Actinic keratoses and squamous cell carcinoma limited to photo-exposed skin in vitiligo vulgaris in pigmented skin type.

Vitiligo skin has a lesser number of photoprotective melanocytes-theoretically, there is a higher risk of development of non-melanoma skin cancers in such patients. But most studies in Caucasian patients have shown decreased incidence of non-melanoma skin cancers in patients with vitiligo. In Indian patients, there is a paucity of literature on such adverse events. We report a case of actinic keratoses, cutaneous horn with dysplasia and squamous cell carcinoma developing exclusively over photo-exposed vitiligo lesions in an Indian woman in her 60s (housewife, Fitzpatrick skin type V and average daily photo-exposure time 2-4 hours) of long-standing vitiligo vulgaris without any history of phototherapy. The photoprotected lesional skin was completely normal with no clinically appreciable enlarged regional lymph nodes. Shave and elliptical excision of the suspicious lesions were done, and histopathology showed various degrees of malignant transformation in various lesions. The patient was started on topical imiquimod for the lesions of actinic keratoses and was referred for staging and wide excision of squamous cell carcinoma lesion. We report this case for its rarity and to emphasise the fact that there is a need for counselling for lifestyle modification in patients with vitiligo as the use of sunscreens is often not practised by Indian patients due to financial constraints and physical measures such as using full sleeves, high-collared dresses and scarves should be encouraged.

Profile of Cutaneous Bacterial Flora in Pemphigus Patients.

Objectives Pemphigus, a group of autoimmune bullous diseases, can be fatal, resulting from overwhelming opportunistic infection of lesions secondary to cutaneous bacterial infections. This study aimed to look into the cutaneous bacterial infection profile of pemphigus patients as timely identification and appropriate treatment can play a major role in reducing mortality. Materials and Methods Pus samples/swabs received from patients with pemphigus over a 2-year period from July 2018 to June 2020 were subjected to standard microbiological culture techniques and susceptibility testing. The frequency of isolation and susceptibility profile of the different bacterial pathogens toward various antimicrobial agents were interpreted and analyzed as per the Clinical and Laboratory Standards Institute's guidelines. Results Samples from 315 patients were received during the study period comprising of 203 (64.4%) males and 112 (35.5%) females. Of 211 samples which were culture-positive, a total of 245 bacterial isolates were obtained, comprising of 158 Gram-positive cocci and 87 Gram-negative bacilli. Staphylococcus aureus (138, 56.3%) was the most common isolate followed by Pseudomonas aeruginosa (41, 16.7%) and Escherichia coli (16, 6.5%). Methicillin resistance was observed in 24.6% Staphylococcus aureus isolates and carbapenem resistance in 9.5 to 14.6% Gram-negative bacilli. Conclusions Study findings emphasize the need for continuous monitoring of cutaneous pemphigus lesions for appropriate choice of antimicrobial therapy.

Case Report: Multiple Scalp Abscesses due to Mycobacterium abscessus Infection Following Triamcinolone Injection in an Immunocompetent Person.

Mycobacterium abscessus complex is a group of nontuberculous mycobacteria (NTM). The NTM may involve skin, soft tissue, and other organs like the eye and central nervous system. Clinically may mimic multidrug resistance. Here, we present a case of a 29-year man with a history of multiple scalp swellings with mild symptoms. He had undergone multiple triamcinolone acetonide injections on his scalp to stop hair fall and baldness 2 months prior. As there was a history of injections on the scalp and lesions associated with minimal symptoms, we suspected the possibility of NTM and fungal infections. As a part of treatment and obtaining a sample for investigation, lesions were aspirated with a needle. The swellings contained gelatinous material, which was sent for microscopic examination, and revealed the presence of acid-fast bacilli (AFB). Xpert MTB/RIF assay was negative for mycobacteria (MTB complex), but culture revealed NTM, identified as M. abscessus complex by line probe assay. Based on the diagnosis, the patient was treated with an injection of amikacin, moxifloxacin, and azithromycin. The lesions improved. The patient has completed over a year of follow-up with no recurrence noted. Mycobacterium abscessus, a rapidly growing NTM, has been occasionally reported to cause cutaneous soft tissue infection when injected with nonsterile medicine or needles. Therefore, a high index of suspicion for NTM infection is warranted in patients with cutaneous scalp abscess following scalp injections for hair loss.

Ocular manifestations in moderate-to-severe psoriasis in India: A prospective observational study.

Purpose: Ocular manifestations in psoriasis are due to direct eye involvement with psoriatic plaques or psoriasis-related, immune-mediated inflammatory processes. The commonly reported pathologies are blepharitis, conjunctivitis, keratitis, dry eyes, and uveitis. Limited data is available on the ocular findings in psoriasis patients in India. In this study, we evaluated various ocular changes associated with moderate-to-severe psoriasis. Methods: In this prospective cohort study, treatment-naive psoriasis patients with Psoriasis Area Severity Index (PASI) score of more than 10 were included. The Ocular Surface Disease Index (OSDI) score, Schirmer's score, tear film breakup time (TBUT), corneal and conjunctival staining score, and meibomian gland dysfunction score were noted. All these parameters were re-evaluated at 8 weeks of follow-up after systemic treatment. Results: Sixty-eight patients were enrolled in the study. The most common ocular pathologies observed in this study were tarsal hyperemia and anterior blepharitis in 128 (94.1%) and 64 (47%) eyes, respectively. Mild, moderate, and severe dry eyes were seen in 26 (19.1%), 14 (10.2%), and 34 (25%) eyes, respectively. Thirty-nine (57.3%) patients complained of significant difficulty watching television or digital screen. In 21 patients evaluated on follow-up at 8 weeks, cornea and conjunctiva's ocular surface staining score increased and TBUT decreased significantly. Conclusion: The most common ocular pathologies observed in this study were anterior blepharitis and moderate dry eye, which significantly affected most patients' daily routines. Screening patients with greater severity of psoriasis would help in early management of such problems.

Peeling Skin Syndrome: An Easily Missed Rare Entity.

A 6-year-old boy with Down's syndrome presented with recurrent episodes of asymptomatic peeling of the skin from the trunk, palms, soles, and face since he was 2 years old. He was the first child of a non-consanguineous marriage. There was no history of any seasonal aggravation or variation. The peeling occurred once or twice a month. Several pediatricians and dermatologists diagnosed it to be either a staphylococcal scalded skin syndrome or a drug reaction. A temporal correlation could not be established with any drugs, including cefixime, amoxicillin, and paracetamol.

Neonatal dermatitis neglecta---Neglect by health system: A case report.

A 29 days old female child presented to the general outpatient department of Community Health Center with greenish black crusting over left ear for 7-8days duration without any other signs and symptoms. We report the diagnosis and management of the condition through ad-hoc store and forward tele-dermatology. This is the first reported case of dermatitis neglecta in neo-natal period.

Clinical features of a large chronic ulcer on the genital and perianal region in HIV-infected patients can be a strong clinical clue for the diagnosis of herpes simplex infection.

Herpes simplex infection presents as a large, chronic, genital, and perianal ulcer in immunosuppressed HIV-positive patients. However, the characteristic morphological feature for clinical diagnosis is unclear. This case series illustrates the morphological characteristics of large, chronic, herpes simplex ulcers at the genital and perianal region in four HIV-positive patients. The diagnosis of herpes simplex infection was confirmed by laboratory test and/or rapid response to acyclovir therapy. All four of our patients had consistent morphological features such as uniform depth, punched out edge and arcuate border on the genital and perianal ulcers, along with positive IgM and IgG antibodies to herpes simplex virus and/or rapid response to acyclovir. Such findings suggest that these morphological features may be the characteristic feature of large and chronic herpes simplex ulcer in HIV/ADS positive patients.

Dyschromatosis Universalis Hereditaria with Hypospadias: A Rare Association.

Dyschromatosis universalis hereditaria (DUH) is a rare genodermatosis, which presents as hyper- and hypopigmented macules all over the body. Although a benign condition, rarely DUH is associated with abnormalities of dermal connective tissue, nerve, and systemic conditions. We report a case of DUH associated hypospadias and complicated with hydronephrosis that has not been described earlier.

Adult-Onset Asthma with Periocular Xanthogranuloma (AAPOX), a Variant of Periorbital Xanthogranulomatous Disease: An Uncommon Entity.

Adult orbital xanthogranulomatous disease (AOXGD) is a rare granulomatous disorder. Adult-onset asthma with periocular xanthogranuloma (AAPOX) which is a subtype of AOXGD is very rare and a realtively unknown entity among dermatologists. Very few cases had been reported in literature. Clinically recurrent periorbital swelling and its location may mimic other dermatological conditions like sarcoidosis, necrobiotic xanthogranuloma, dermatomyositis, and rarely amyloidosis. Herein we report a female with recurrent periorbital swelling with brownish yellow papulonodular lesions on periorbital area with adult-onset asthma. Histopathology and immunohistochemistry proved the diagnosis. She was started with systemic methylprednisolone and methotrexate and improved significantly after 4 months. We report this case because of its rarity and to create awareness among dermatologists about this uncommon entity.

Annular Pattern of Pustular Vasculitis: A Case Report of Unusual Morphological Presentation.

Pustular cutaneous vasculitis is a rare entity. Only handful cases are reported from all over the world. They typically present with painful pustules mainly over dorsum of hands and rarely on lower legs. We report a 50-year female who presented with painful pustules arranged in annular pattern predominantly distributed over lower limbs. Laboratory investigation ruled out any systemic associations. Histopathology was suggestive of pustular vasculitis. Final diagnosis of idiopathic pustular vasculitis was made. The patient was successfully treated with oral prednisolone and dapsone without any recurrence on follow up. It is the first report of annular morphological presentation of pustular vasculitis.

Clinical Diagnosis of Herpes Simplex-Infected Pemphigus Erosions.

Clinical diagnosis of Herpes simplex-infected pemphigus erosions is challenging. Pemphigus and Herpes simplex both produce superficial erosions on the skin and mucosa after rupture of vesicles or bullae. Delay in diagnosis of herpes-infected pemphigus patients often causes prolonged morbidity. So far, there has been a paucity of literature describing the characteristic features of Herpes simplex-infected pemphigus erosions. In the present case series, we have illustrated the morphologic features of three Herpes simplex-infected pemphigus erosions and also have suggested characteristic clinical features that were consistently present in all cases.

Penile Horn: A Rare Presentation of Pseudoepitheliomatous, Keratotic, and Micaceous Balanitis Successfully Treated with Oral Acitretin.

Glans penis is an unusual site for horn. Only few cases are reported worldwide in English literature. Pseudoepitheliomatous, keratotic, and micaceous balanitis (PKMB) is a pyodermatitis with pseudoepitheliomatous response to chronic inflammation or infection. Rarely it can develop a horn. There is one case report of PKMB presenting as penile horn and one case with nail-like presentation in the literature. Mode of treatment of PKMB with horn ranged from topical 5-fluorouracil, electrosurgery, and cryosurgery to excision. Use of oral acitretin in PKMB or penile horn is unknown. We are reporting a 60-year-old circumcised male who presented with a penile horn. Histology was suggestive of PKMB. Treatment with topical 5-flurouracil did not work. He was successfully treated with oral acitretin.

Acute Methotrexate Toxicity Due to Overdosing in Psoriasis: A Series of Seven Cases.

Overdosing is the major cause of acute methotrexate toxicity in psoriasis patients. There are no published data regarding the acute cumulative dose causing acute toxicity, duration to achieve acute cumulative toxic dose and various reasons for wrong dosing of methotrexate in Indian patients. We are presenting a series of seven cases of toxicity due to overdosing of methotrexate in psoriasis. The acute cumulative dose of methotrexate ranging from 35 mg to 150 mg, taken over 3-7 days was responsible for acute toxicity in the psoriasis cases. Lack of counselling regarding the disease course, drug dosing, schedule and awareness about possible outcome of high and daily dose were found to be the causes of overdosing and toxicity in our patients. All cases presented with ulceration, bleeding and pain in skin lesions and five cases had oral mucosal ulceration and genital mucosa was involved in two cases. All cases were given injectable folinic acid. Five cases recovered and two cases expired. Authors postulate counselling about the course of disease, regarding dosing schedule of methotrexate and consequences of methotrexate overdosing is mandatory for all patients of psoriasis in country like India where drug regulation is not strict to prevent methotrexate toxicity and its dreaded consequences.

Hemophagocytic lymphohistiocytosis: A rare, potentially fatal complication in subcutaneous panniculitis like T cell lymphoma.

Subcutaneous panniculitis-like T cell lymphoma is a rare subtype of cutaneous lymphomas with distinct clinical, histological and immunophenotypic characteristics, as well as an indolent clinical course. Rarely, it may be complicated with hemophagocytic lymphohistiocytosis: a hyperinflammatory syndrome which, if not diagnosed early, carries a dismal outcome. In this article, we describe a case of subcutaneous panniculitis-like T cell lymphoma in a middle-aged female patient which was complicated with secondary hemophagocytic lymphohistiocytosis with a favorable outcome following etoposide-based therapy. The various histological mimics of subcutaneous panniculitis-like T cell lymphoma and the management options are also briefly discussed.

Efficacy and Safety of Tazarotene 0.1% Plus Clindamycin 1% Gel Versus Adapalene 0.1% Plus Clindamycin 1% Gel in Facial Acne Vulgaris: A Randomized, Controlled Clinical Trial.

BACKGROUND: Acne vulgaris is a multifactorial disorder which is ideally treated with combination therapy with topical retinoids and antibiotics. OBJECTIVES: The present study was conducted to compare the efficacy and safety of tazarotene plus clindamycin against adapalene plus clindamycin in facial acne vulgaris. METHODS: This study is a randomized, open-label, parallel design clinical trial conducted on 60 patients with facial acne at the outpatient dermatology department in a tertiary healthcare center. The main outcome measures were change in the acne lesion count, Investigator's Static Global Assessment (ISGA) score, Global Acne Grading System (GAGS) score, and Acne-Specific Quality of Life Questionnaire (Acne-QoL) at the end of 4 weeks of therapy. After randomization one group (n = 30) received tazarotene 0.1% plus clindamycin 1% gel and another group (n = 30) received adapalene 0.1% plus clindamycin 1% gel for 1 month. At follow-up, all the parameter were reassessed. RESULT: In both treatment regimens the total number of facial acne lesions decreased significantly. The difference in the change in the total count between the two combination regimens was also significant [6.51, 95% confidence interval (CI) 1.91-11.09, p = 0.007]. A ≥50% reduction in the total lesion count from the baseline levels was achieved by 71% of patients in the tazarotene plus clindamycin group and 22% of patients in the adapalene plus clindamycin group (p = 0.0012). The difference in the change of inflammatory (p = 0.017) and non-inflammatory (p = 0.039) lesion counts in the tazarotene plus clindamycin group were significantly higher than the adapalene plus clindamycin group. The difference in change of the GAGS score was also significantly higher in the tazarotene plus clindamycin group (p = 0.003). The ISGA score improved in 17 patients in the tazarotene plus clindamycin group versusnine patients in the adapalene plus clindamycin group (p = 0.04). The change of total quality-of-life score was found to be significantly (p = 0.027) higher in the tazarotene plus clindamycin group. CONCLUSIONS: Both treatment regimens were efficacious, but tazarotene plus clindamycin was found to be superior to adapalene plus clindamycin. The tolerability profile of both regimens was comparable. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02721173.

Attention deficit hyperactivity disorder presenting as dermatitis artefacta.

Dermatitis artefacta, a self-inflicted intentional dermatosis is a very rare diagnosis in childhood. In a large proportion, the underlying psychiatric disorders go unidentified due to lack of collaboration between dermatologist and psychiatrist. The underlying psychological reasons for childhood dermatitis artefacta include emotional distress and interpersonal conflicts. A multitude of psychosocial factors interact to precipitate this disorder. Here, we report a child with dermatitis artefacta who was diagnosed with attention deficit hyperactivity disorder during psychiatric evaluation. Parental expectations and sibling rivalry were further increasing the stress of the index child. Appropriate diagnosis and management lead to treatment compliance and functional improvement in the child.

Halometasone monohydrate (0.05%) in occupational contact dermatitis.

OBJECTIVE: The impact of occupational contact dermatitis (OCD) is often underestimated because of underreporting, and its management is also inadequate, especially in developing countries. Topical corticosteroids have remained the first line treatment but till date, there is no study on efficacy and safety of halometasone in OCD, and there is a paucity of data on its comparative efficacy in allergic and irritant variety. This study aims to evaluate the efficacy and safety of halometasone in OCD and to compare its effect in allergic and irritant types of OCD. METHODS: The present study is a prospective, interventional, single arm clinical study conducted on 150 patients of OCD. Detailed history and clinical examination was done at baseline, and all enrolled patients underwent patch test with the Indian Standard Battery of allergens. Eczema severity was assessed by the Investigator's Global Assessment (IGA) scale, SCORing Atopic Dermatitis (SCORAD) index, and patient-oriented eczema measure (POEM). Change in quality of life was assessed by using the Dermatology Life Quality Index (DLQI). After baseline assessments, they were prescribed halometasone 0.05% ointment and were followed up after 4 weeks, and efficacy variables were evaluated. RESULTS: At follow-up, 19 patients were lost, and data of 131 patients were analyzed. After 4 weeks of halometasone therapy, there was statistically significant (P < 0.001) improvement in SCORAD index, IGA, POEM, and DLQI. Considering improvement in IGA as treatment success criteria, treatment was found to be successful in 87.8%. Subgroup analysis revealed no significant difference in effect of halometasone in allergic and irritant OCD. CONCLUSIONS: Halometasone is efficacious with a good safety profile in patients with OCD, and there is no significant difference in efficacy of the drug in allergic and irritant OCD.