Common, But Neglected: A Comprehensive Review of Leg Ulcers in Sickle Cell Disease.

OBJECTIVE: To compile available evidence to better understand the management of leg ulcers in sickle cell disease (SCD), as well as describe potential therapeutic steps that may be required to improve the quality of life of patients with SCD leg ulcers. DATA SOURCES: MEDLINE, PubMed, EMBASE, and Web of Science databases. STUDY SELECTION: A comprehensive search was conducted to retrieve relevant studies using the keywords "sickle cell disease and leg ulcer," "ulcer treatments, diagnosis and sickle cell," and "wound sickle cell." Studies published through July 2020 were included. DATA EXTRACTION: Two independent authors selected all studies that assessed the relationship between leg ulcer and SCD identified from online databases. DATA SYNTHESIS: The authors have summarized updated information on pathophysiology (vasculopathy linked to chronic hemolysis and endothelial dysfunction), diagnosis, and available treatment options to unravel the dermohematologic connection between leg ulcers and SCD. CONCLUSIONS: It is the authors' hope that this detailed discussion of the information available on leg ulcers and SCD will lead to a better appreciation of this clinical problem by the clinicians and researchers and in turn have a long-term positive effect on the quality of life of patients with SCD. Researchers should design new trials considering these insights and potential therapeutic approaches based on current knowledge.

Role of Patch Testing in Facial Contact Dermatitis: A Cross-Sectional Study from Central India.

Background: Facial contact dermatitis is an emerging skin disorder due to the use of a large array of materials over the face. It leads to psychological distress in patients, impacting their quality of life. Most of the allergens applied over the face vary as per cosmetic or herbal products' availability, usage, or religious practices. Identifying and discontinuing the implicated allergens will lead to a better prognosis and reduced morbidity in clinical practice. Objectives: To determine the frequency of different allergens responsible for causing facial contact dermatitis, in an urban part of central India, using patch test with the help of Indian standard and cosmetic series. Materials and Methods: All suspected patients (>18 years) of facial contact dermatitis visiting the outpatient department of dermatology were patch tested with both Indian standard and cosmetic series. Results: Out of 38/58 patch-test-positive patients, 71.06% were females, and 28.94% were males. Most patch-test-positive females were housewives. The most common allergens implicated were thiomersal (17.24%), followed by fragrance mix (15.51%), and paraphenylene diamine (12.06%). Conclusion: In our study, forehead and malar areas were most commonly involved indicating fairness creams and perfumes as the important contributors to facial contact dermatitis. Antigen batteries need to be updated with changing social and cultural trends, as many with a consistent history of aggravation with some products tested negative in patch tests.

Pestalotiopsis, a rare cause of mycetoma; A case report.

Pestalotiopsis is an appendage-bearing, well-known plant pathogen, and very few species are associated with human infections. To best of our knowledge, this is first report of Pestalotiopsis spp. isolated from mycetoma patient in India. A 66-year-old male farmer, having a history of twig prick, presented with a swollen foot and multiple discharging sinuses. 10 % KOH mount of tissue and grain showed fragmented fungal elements. White to pale honey-colored colonies with undulated edges and shiny black granules grew on potato dextrose agar. Characteristic fusiform, 5-celled conidia with 2-3 apical appendages seen on LPCB mount. Patient was treated with systemic Itraconazole successfully.

Morphological Index as a Sensitive Marker of Drug Resistance in Leprosy: A Case Series.

Resistance to antileprosy drugs is one of the main contributors for the persistence of leprosy in the present era. In the absence of universal antimicrobial resistance (AMR) surveillance through the national program, the indications for resistance testing remain a important dilemma to clinicians. WHO recommendations mainly focus on clinical relapse, which could be picked up late with continued transmission and repeated leprosy reactions in the patient. We report here a series of eighteen leprosy cases who were tested for AMR in view of the positive morphological index after completion of multidrug therapy, chronic Erythema nodosum leprosum, and clinical relapse.

Penicillamine-induced Stevens Johnson Syndrome-toxic Epidermal Necrolysis (SJS-TEN) Overlap in an HIV-infected Patient with Wilson's Disease and Hepatitis B.

INTRODUCTION: Stevens-Johnson syndrome (SJS) and Toxic epidermal necrolysis (TEN) are severe adverse drug reactions characterized by widespread blistering and mucositis. Wilson's disease is a rare, autosomal recessive disorder that results in excessive copper accumulation in the body, where penicillamine is an effective treatment option for copper chelation. Penicillamineinduced SJS-TEN is a rare but potentially fatal adverse effect. There is increased susceptibility to SJS/TEN in HIV infection due to immunosuppression and chronic liver disease due to impaired hepatic function. OBJECTIVE: To diagnose and manage the occurrence of the rare severe adverse cutaneous drug reactions in the backdrop of immunosuppression and chronic liver disease. CASE REPORT: We are reporting penicillamine-induced SJS-TEN overlap in a 30-year-old male with Wilson's disease, HIV and Hepatitis B who was treated with intravenous immunoglobulins. The patient later developed neurotrophic ulcer in the right cornea as a delayed sequela. CONCLUSION: Our case report emphasizes that there is an increased predisposition to SJS/TEN in immunocompromised and chronic liver disease patients. Physicians should be well aware of the potential danger of SJS/TEN in this subset of patients, even while prescribing a relatively safer drug.

Mycobacterium welchii Vaccine Granuloma - A Cautionary Tale.

BACKGROUND: Mycobacterium welchii (Mycobacterium w) vaccine was one of the many strategies used to both treat and prevent coronavirus disease 2019 (COVID-19) infection. We report the results of a retrospective analysis of 15 cases with vaccine-site granulomas after administration of prophylactic Mycobacterium w vaccine as part of a trial for COVID-19 and our experience in managing those cases. METHODS: This was a retrospective analysis of 15 patients with vaccine-site granulomas who were given the vaccine as a prophylactic measure as part of a trial with informed consent. RESULTS: The mean average age of cases was 37 and the male-to-female ratio was 1:0.87. All of the patients developed erythematous tender nodules over the injection sites within a month of receiving the inoculations. Mycobacterial cultures and cartridge-based nucleic acid amplification tests yielded negative results. Skin biopsy revealed granulomatous dermatitis with acid-fast bacilli positivity. A diagnosis of noninfective granulomatous dermatitis was made. Treatment started with analgesics and anti-inflammatory agents. Systemic antibiotics were required in 9/15 patients. Patients are being followed up with no reported recurrence till date. CONCLUSION: The possibility of injection-site granuloma should be taken into the risk-benefit analysis for the administration of Mycobacterium w vaccine and the patients should be counseled as such. Patients with persistent ulceration respond to combinations of doxycycline, ofloxacin, and clarithromycin.

Biomarkers in Psoriasis: The Future of Personalised Treatment.

Psoriasis is a chronic and complex immune-mediated papulosquamous disease affecting almost 2% of the world population. The interaction between a genetically predisposed individual and environmental triggers leads to a vicious cycle involving autoreactive T cells, dendritic cells, keratinocytes and dermal cells. Up to 40% of the psoriasis cases develop disabling psoriatic arthritis and an equal number of patients also tend to develop metabolic syndrome as well as cardiovascular comorbidities; hence, this is no more considered to be a disease limited to skin only. Being a systemic disease, there is an urgent need to develop potential biomarkers for the assessment of disease severity, prediction of outcome of the therapeutic intervention and association with various systemic comorbidities. Diverse genetic markers not only function as predictors of diseases pathogenesis, but also help to predict development of psoriasis and psoriatic arthritis. Personalised medicine is customising the therapeutic needs of a psoriasis patient and improving the outcome as per the hints we receive from the various biomarkers. This review deals with the list of potential biomarkers proposed to be useful in psoriasis, though there is limited data validating their routine use in clinical practice and the progress so far made in the field of precision medicine for psoriasis.

Small Molecules in the Management of Psoriasis and Psoriatic Arthritis.

Psoriasis is a common chronic, immune-mediated inflammatory skin disease associated with various comorbidities. Managing psoriasis is often challenging as the therapy is decided based on the area of the disease, associated comorbidities and impairment in quality of life, besides the patient's preference. Making progress in the development of new molecules that can be used topically or orally, effectively controlling the disease with minimal side effects and providing long-lasting remissions are the needs of the hour. Recent developments in understanding the complexities of the pathogenesis of psoriasis have resulted in the reinforcement of treatment modalities, leading to the evolution of various biologics and small-molecule inhibitors. In comparison with biologics, both patients and treating physicians prefer small molecules for various reasons such as avoiding injections and side effects that are associated with biologics biologics. Moreover small molecules are economical than biologics. Newer small molecules, both topical and oral, are promising additions to the therapeutic arsenal in the management of psoriasis in the future.

Management of Pustular Psoriasis; The Way Ahead.

Pustular psoriasis is a specialized variant of psoriasis which can be life threatening if not treated at the earliest. The pathogenesis has been recently linked to the role of interleukin 36. Apart from the corticosteroids, systemic antipsoriatics like acitretin, cyclosporine and methotrexate have been used with some success though unpredictable. With recent identification of role of IL-36 in the pathogenesis of pustular psoriasis, biologics targeting the IL-36 receptors have been used to manage the situation with high degree of success. This narrative review deals with the recent concepts of pathogenesis of pustular psoriasis as well as the current management scenario.

A clinicoepidemiological study of pityriasis rosea in South India.

Pityriasis rosea is an acute self-limiting papulosquamous skin disorder of unknown etiology. Although pityriasis rosea is a common dermatologic disorder, information regarding the epidemiology of the disease in India is limited because of inadequate studies. The incidence and presentation of pityriasis rosea varies from one geographical region to another. The objective was to study the various clinical patterns of the disease and epidemiologic factors influencing its occurrence. A cross-sectional study on the clinicoepidemiologic pattern of pityriasis rosea was conducted. A detailed history of illness regarding onset, evolution, duration, symptoms, systemic features, recurrence, history of contact, and associated factors such as socioeconomic status, history of drug intake, and use of new clothing, along with epidemiologic data, was recorded in the performa. The age of the patients ranged from 3 to 47 (mean 20.32) years. Incidence of pityriasis rosea was highest among patients aged 11 to 20 years followed by those 21 to 30 years. There was a male preponderance. Seasonal variation was not evident. History of using new garments or old garments, unwashed for an extended period was elicited in 23% of cases. The average interval of onset of lesions and presentation to physician was 14.45 days. Pruritus was a common symptom (70%). Of 73 patients, 67 had herald patch. The clinical features of most of the cases were in accordance with the classical pattern of pityriasis rosea.

Linezolid: a safer and effective substitute to aminoglycoside in the treatment of actinomycetoma by Nocardia species.

Actinomycetoma is chronic, suppurative, granulomatous infection caused by bacteria and requires prolonged antibiotic therapy preferrably in combinations. Nephrotoxicity is a common side effect of aminoglycosides used in the management of actinomycetoma. We report here two cases of actinomycetoma due to Nocardia species who received linezolid as a substitute to aminoglycosides after developing nephrotoxicity.

Morphological Diagnosis of Blastomycosis Clinically Presenting as Mycetoma in a Young Immunocompetent Indian Patient; A Diagnostic Dilemma.

Primary cutaneous blastomycosis is very rare in non-endemic regions like India. Only few cases have been reported from India. Herein, we are reporting a rare case of chronic cutaneous blastomycosis in a young immunocompetent male presenting as mycetoma with multiple discharging sinuses in the anterior abdominal wall with no significant travel history.

Role of Autoerythrocyte Sensitization Test in the Diagnosis of Recurrent Spontaneous Bruising.

Introduction: Psychogenic purpura, also known as autoerythrocyte sensitization syndrome, is a rare condition which is characterized by spontaneous development of painful purpura, or ecchymoses. Skin lesions are usually preceded by stress and emotional trauma. It is usually a diagnosis of exclusion after ruling out history of trauma, drug intake and other bleeding disorders. Autoerythrocyte sensitization test (AEST) and a psychiatric evaluation helps in the diagnosis and treatment. Objective: To demonstrate the importance of AEST in diagnosing the patient of Gardner Diamond syndrome. Materials and Methods: Five suspected cases of autoerythrocyte sensitization syndrome underwent AEST after ruling out other causes of bleeding. Results: Four out of five patients were positive for AEST while one patient was negative. Psychiatric complaints were present in three patients. One patient was lost to follow up. Rest all patients responded well to vitamin C supplementation. Conclusion: Autoerythrocyte sensitization syndrome is a rare disorder and is a diagnosis of exclusion, so a thorough workup of the patient to rule out common causes of bruising is essential. A high index of suspicion on the clinician's part and a simple OPD-based AEST may help in the diagnosis. Psychiatric consultation is important to find out the stress factor and timely management.

Clinico-Demographic Profiles of Herpes Zoster Cases in Patients With and Without COVID-19 Infection During the Pandemic: A Retrospective Analysis of 32 Cases.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has multiple impacts on the human body. The immunological effect is one of the prominent ones, which is thought to be fundamental in many physical manifestations and disease severity. Herpes zoster (HZ) reactivation has been well-linked to immunity; immunocompromised states predispose a person to HZ. Studies have raised concerns about HZ incidences in COVID-19 patients; however, the clinical characteristics of the HZ cases among patients with and without COVID-19 are another area to be explored. METHODS: In this retrospective analysis, we compared the clinical and demographic characteristics of HZ cases presented to our outpatient department immediately before and during the early second wave of the COVID-19 pandemic (September 2020 to April 2021) in India. The cases were divided into two groups based on the history of COVID-19 infections. The clinico-demographic characteristics were then compared using an unpaired t-test, Fisher's exact test, and analysis of variance as applicable using InStat software; a two-sided p-value <0.05 was considered significant. RESULTS: During the period, 32 cases (17 HZ cases with a history of COVID-19; 15 HZ cases without) were detected. The age and gender distribution were indifferent statistically. Our analysis showed that multi-dermatomal and disseminated involvements were significantly higher in HZ cases having a history of COVID-19. CONCLUSION: The present retrospective analysis of 32 cases indicates that persons who suffered from COVID-19 and presented with HZ were likely to have a higher chance of multi-dermatomal and disseminated involvement. While our analysis cannot establish a true association between COVID-19 infection and HZ reactivation, which will require a large-scale study, clinicians might get a clue of the possible progression of the extent of HZ manifestations from our findings.

An Analysis of Interns' Feedback after Dermatology Posting.

Background: Dermatology knowledge among fresh medical graduates is poor in India as undergraduate medical curriculum and Internship training lack adequate focus on this subject. This contributes to the inappropriate management of Dermatology patients by the medical graduates. Objective: To analyse the expectations, motivations and experience of interns during their dermatology posting. Materials and Methods: This was a retrospective record review of questionnaire-based anonymous validated feedback forms submitted by interns posted in a dermatology department of a tertiary care institute. The feedback form contained nine multiple choice questions some of which allowed multiple responses. Results: A total of 63 completed forms were analysed. The common expectations before the posting were, to learn the management of basic dermatological problems (98.4%), to take an informed decision regarding post-graduation in dermatology (53.9%) and hope that the posting will be useful for the postgraduate entrance test (50.7%). After the posting, 69.87% of them felt that their expectations were fulfilled. After the posting, 84.1% of the interns felt that they would have liked to study dermatology as a separate undergraduate subject with a summative assessment at the end. Limitations: The sample size was less and the feedback form contained limited questions. Conclusion: The majority of the interns were satisfied after dermatology posting. Increased exposure of interns to dermatology inpatients and side laboratory procedures will further enrich their clinical experience. The inclusion of dermatology as a separate subject with examination in the undergraduate curriculum was a felt need.

Relapse of pemphigus foliaceus initiating at the site of irradiation in an elderly male with laryngeal carcinoma: Illustrating the concept of immunocompromised cutaneous district.

Radiotherapy-induced or -aggravated pemphigus is not a common occurrence with only a few cases reported so far. The radiation disrupts the local immune regulation and alters the antigenicity of keratinocytes, but the exact etiology is not clear. We report a case of an elderly man operated for laryngeal carcinoma who presented with recurrence of pemphigus foliaceus lesions starting at the irradiation site. The appearance of vesiculobullous lesions at the site of irradiation should be evaluated thoroughly to rule out immunobullous diseases.

Podophyllin in Dermatology: Revisiting a Historical Drug.

Podophyllin is a cytotoxic material extracted from Podophyllum peltatum and Podophyllum hexandrum and is widely used for the treatment of genital warts. This article reviews the chemistry of podophyllin and its active components along with the mechanism of action in various dermatoses. Furthermore, the documented uses of podophyllin in various dermatological disorders have been described along with the side effects of the drug. Based on the available literature, a clinical guideline is being proposed so as to minimize the side effects. Further studies should be carried out on its use in a lower concentration in other dermatoses, especially premalignant and malignant skin diseases.

Palatal perforation in a patient with borderline lepromatous leprosy: leprosy still not eradicated.

Leprosy was eliminated globally in 2000, but it continues to be endemic in developing countries like India, Brazil and Indonesia, with a prevalence of 0.57/10 000 persons in India (2020). At the end of the year 2020, the prevalence was 129 389, and oral manifestation of the leprosy is luncommon. We hereby report a case of a female patient in her late 30s who presented with palatal perforation. Following a thorough history taking and full body clinical examination, we arrived at a diagnosis of leprosy, and prompt treatment was initiated. Knowledge of cases like this becomes important as the oral lesion is said to form an essential source of leprosy dissemination in the community, and awareness about them becomes crucial, demanding immediate attention.