Intra-Operative Dermoscopy in Assessment of Melanonychia and as a Guide for Biopsy.

BACKGROUND AND AIMS: Melanonychia can be a manifestation of benign or malignant pathology and often poses a diagnostic challenge on clinical examination. Even with distinguishing dermoscopic features (nail plate), it can be quite difficult to determine the nature of pigmentation as complete assessment of nail bed and matrix is still not possible. Intraoperative dermoscopy (IOD) can serve as a useful tool to appreciate the bed and matrix changes. The aim here is to study the intraoperative dermoscopic features in patients with melanonychia and correlate with histopathology. METHODS: 20 consecutive patients with melanonychia were recruited. Inclusion criteria was melanonychia of sudden onset, progressive nature, irregular width/color/symmetry on dermoscopy, positive Hutchinson sign, solitary nail involvement or associated nail dystrophy. Preoperative dermoscopy was performed and recorded. Patients were planned for nail matrix biopsy, during which IOD was performed over nail matrix and bed after removal of the nail plate. Images were recorded and analyzed and correlated with the histopathology. RESULTS: Out of 20 patients, 12 were females and 8 males. On IOD-histopathological correlation, 2 patients were found to have melanoma of the nail unit, 5had nail lichen planus, 9 had benign melanocytic nevi, and 4 had fungal melanonychia. IOD revealed fine, parallel and regular lines of pigmentation localized to proximal nail bed and matrix in all patients with benign melanonychia, while dark thick bands with irregular borders, dots, globules, streaks and structureless areas in the two patients with melanoma. Fungal melanonychia revealed an unremarkable nail bed and matrix on IOD. CONCLUSION: Intraoperative dermoscopycan help in determining the nature of melanonychia and obviate the need to perform biopsy in certain cases. It can also aid in delineating the most suitable site for biopsy, along with grossly assessing the extent of involvement in case of malignancy.

Treatment of severe refractory erythema nodosum leprosum with tumor necrosis factor inhibitor Etanercept.

Erythema nodosum leprosum (ENL) is a common complication of lepromatous leprosy. Some patients unresponsive to conventional, first-line therapeutics develop recurrent, recalcitrant ENL. Here, we report a case of severe refractory ENL that was successfully treated with Etanercept. Biologics may be considered as therapeutic alternatives in management of severe, recalcitrant ENL.

Keloidal plaque in a patient with pulmonary tuberculosis: A rare morphological variant of tuberculosis verrucosa cutis.

Tuberculosis verrucosa cutis (TVC), also known as warty tuberculosis, anatomist's wart or prosector's wart is characterized by the presence of verrucous plaque-like lesions, resulting from direct inoculation of the causative organism into the skin of a previously infected patient. A 59-year-old man presented with a hyperpigmented plaque on the chest wall which closely mimicked a keloid. He was a case of sputum-positive pulmonary tuberculosis and had repeatedly been applying early morning saliva on the lesion as a part of the indigenous practices for quick healing. There was further progression of the lesion with discharge from several sites. A smear for acid fast bacilli was positive from the discharge and growth on Lowenstein Jensen medium revealed growth of Mycobacterium tuberculosis. Biopsy was compatible with TVC and the patient was started on 6months anti-tubercular therapy. However, the plaque continued to persist with continuing discharge from multiple openings which necessitated surgical intervention, finally leading to near complete resolution of the plaque of TVC.