Erythema Nodosum Leprosum Reaction Masquerading as Rheumatoid Arthritis.

Erythema nodosum leprosum is a type 3 hypersensitivity reaction that often presents with transient eruptions of red papules, plaques, and nodules. A 52-year-old female presented with multiple joint pain that was being treated as rheumatoid arthritis (RA), but through clinical examination, she was found to have Hansen's disease with a type 2 reaction. Hence, the importance of a thorough clinical examination is a must for the timely and correct diagnosis of patients suffering from Hansen's disease.

Navigating Treatment Dilemmas: Recalcitrant Pemphigus and the Burden of Multiple Comorbidities.

Pemphigus vulgaris is a chronic autoimmune disease of the skin caused by the production of autoantibodies targeting desmogleins 1 and 3 usually presenting in individuals with an average age of onset of approximately 40 years. A 35-year-old obese, diabetic woman presented with fluid-filled lesions over her body for three months along with erosions and painful ulcers in her mouth and genital area for two months. Based on clinical and histopathological studies, the patient was diagnosed as a case of pemphigus vulgaris. She was started on conventional treatment with oral corticosteroids followed by pulse therapy and mycophenolate mofetil. Rituximab infusion was scheduled but could not be administered due to elevated D-dimer values. The patient underwent screening for deep vein thrombosis (DVT) and received subcutaneous enoxaparin and oral rivaroxaban. She developed severe sepsis for which she was treated with systemic antibiotics. She subsequently developed acute renal failure and underwent hemodialysis. The patient's clinical condition further deteriorated, which necessitated therapeutic plasma exchange (TPE). Collagen, colloidal silver, and silicone foam dressings were done to hasten wound healing. Two distinct approaches were employed to eliminate the pseudomembrane on the wounds. One portion was treated with hydrogen peroxide (H2O2), while the other was with hyaluronidase. The hyaluronidase treatment resulted in considerable improvement of the lesions. Intravenous immunoglobulin (IVIG) infusion was scheduled. However, the treatment could not be administered as the patient succumbed to death due to pulmonary thromboembolism (PTE) secondary to DVT.

Onychoscopic Analysis of Cyclophosphamide-Induced Polydactylic Bluish-Gray Discoloration in a Case of Pemphigus Foliaceus.

Cyclophosphamide, an alkylating agent, has rarely been observed to cause a bluish discoloration of nails, an occurrence that is typically underreported. We describe the case of a middle-aged male undergoing dexamethasone-cyclophosphamide pulse therapy for pemphigus foliaceus, who exhibited bluish-gray discoloration of the nails. It is crucial to differentiate this presentation from other conditions such as nail apparatus melanoma (NAM), which may manifest in a slightly different manner. We also report the onychoscopic findings observed in this case.

Actinomycetoma in a patient with pre-existing sensorineural hearing loss: a linezolid-based treatment paradigm.

Mycetoma is a chronic granulomatous infectious disease with a triad of subcutaneous swelling, discharging sinuses and the presence of granules. The infection may occur following minor trauma or penetrating thorn injury. We report a case of a man in his 40s with a history of thorn prick 9 years ago, followed by the formation of painless discharging sinuses on the right foot for the past 2 years. Clinical, local epidemiological, histopathological examination and Gram stain confirmed the diagnosis of actinomycetoma. Prior to initiating the Welsh regimen, a pretreatment assessment of the patient's auditory function was conducted through pure tone audiometry, indicating the existence of pre-existing high-frequency bilateral sensorineural hearing loss. The patient was treated with linezolid as an alternative to amikacin, at a dosage of 600 mg two times per day, leading to complete resolution within 3 weeks. This underscores linezolid's efficacy as a safe and cost-effective alternative for actinomycetoma, without causing ototoxic side effects.

Prevalence and risk factors of vulvar dermatoses: A hospital-based study.

Background: The overall prevalence of vulvar diseases in the literature is low because of underreporting and is often neglected; thus, its impact on a female's life is often underestimated. Objectives: This study is aimed to determine the prevalence of vulvar diseases and their associated risk factors in patients attending a tertiary care hospital. Materials and Methods: This is a descriptive, cross-sectional, and case-controlled study wherein all female patients attending the dermatology outpatient department (OPD) were screened for the signs and symptoms of vulvar dermatoses and were enrolled after obtaining informed consent and institutional ethics committee approval for 21 months. Out of them, 200 patients who consented and had signs and symptoms of vulvar diseases were selected as cases, and the same number of age-matched females were enrolled as controls with no signs and symptoms of vulvar dermatoses. Results: During the study period, 9431 females attended the dermatology OPD, of which the prevalence was 2.12% (200 patients). The most common infection was genital infection without sexually transmitted infection (57%) (tinea cruris [33.5%]), followed by inflammatory dermatoses (21%) (lichen sclerosus et atrophicus [6%]). The most common risk factor found statistically significant (P ≤ 0.005) were homemakers (49%) and the use of undergarments of mixed fabric (70.68%), followed by nonmenopausal females (63.15%). Conclusion: Our study findings indicated that the prevalence was low, which reflects the tip of an iceberg. Further clinical and population-based studies, a multidisciplinary approach including gynecological consult for diagnostic and therapeutic approach is needed for the optimal management of vulvar diseases.

Systemic Lupus Erythematosus in India: A Clinico-Serological Correlation.

Background and objectives Systemic lupus erythematosus (SLE) is a chronic multisystem disorder exhibiting a wide spectrum of clinical and immunological abnormalities. Skin is the second most affected organ; lesions may precede systemic manifestations and foretell systemic involvement. Correlation between systemic manifestations and immunological profile is known but the interplay between antibodies and cutaneous findings is an area of recent interest. The present study aims to evaluate the demographic differences, pattern and prevalence of skin lesions, and correlation between cutaneous, systemic manifestations, and serological profile in SLE. Methods A total of 40 patients diagnosed with SLE, fulfilling Systemic Lupus International Collaborating Clinics (SLICC) criteria (2012), who visited the Dermatology outpatient department between April 2019 to April 2020 were recruited. Demographic details, evaluation of cutaneous lesions as lupus erythematosus (LE) specific and LE non-specific, systemic examination, hematological tests, and serological profile findings were noted. Results The mean age of onset was 23.3 years with a female to male ratio of 19:1. Common LE-specific lesions were malar rash (77.5%), photosensitivity (70%), and generalized maculopapular rash (20%). Frequently occurring LE non-specific lesions were non-scarring alopecia (60%), oral ulcers (45%), and vasculitis (12.5%). Arthritis (77.5%) and nephritis (30%) were common systemic findings. Among 14 patients with cutaneous manifestations alone, 12 (85%) had antinuclear antibody (ANA), eight (57%) had anti-double-stranded DNA (anti-dsDNA), four (28%) had anti-Smith (anti-Sm) and anti-RO/Sjögren's syndrome antigen A (Anti-RO/SSA), three (21%) had anti-histone, and one (7%) had anti-ribonucleoprotein (anti-RNP) antibodies in serum. Conclusions Lower age at onset, high prevalence of photosensitivity, anemia, and alopecia with a low prevalence of Raynaud's phenomenon suggest environmental influence in the context of the Indian population. A positive immunological profile in patients with cutaneous involvement alone gives an opportunity to the caregiver to identify the disease process much before systemic manifestations are expressed.

Association of Vitamin D Deficiency with Psoriasis and Metabolic Syndrome: A Case-Control Study in Indian Patients.

Background: Substantial evidence suggests a higher risk of metabolic syndrome as a result of persistent inflammation in patients with psoriasis. Psoriasis may also be associated with vitamin D deficiency. Aim: To correlate vitamin D deficiency with psoriasis and metabolic syndrome. Materials and Methods: Serum vitamin D levels were quantified, and metabolic syndrome was assessed in 42 cases whose psoriasis severity had been measured by PASI and in an equal number of age/gender-matched controls. The resultant data were analyzed statistically. The odds ratio was calculated wherever applicable and a two-tailed P < 0.05 was considered statistically significant. Results: Vitamin D deficiency (<20 ng/ml) occurred in 43 subjects [(51.19%); 26 (62%), patients and 17 (40.4%), controls] and was statistically significant in patients (OR: 2.39, P = 0.044) though lacking correlation with disease severity. Metabolic syndrome seen in 25 (30%) subjects-15 (36%) patients and 10 (24%) controls-emerged to be significant (OR: 3.71, P = 0.047) in cases with vitamin D deficiency. Hypertension-observed in 31 (37%) subjects; 18 (43%) cases, 9 each (21.4%) with/without metabolic syndrome and 13 (31%) controls, 7 (16.6%) with and 6 (14.3%) without metabolic syndrome (P = 0.25)-correlated independently with vitamin D deficiency in patients (P = 0.009). Conclusions: Despite limitations of small sample size and observational nature, our study-probably the first such hereto from India-showed statistically significant associations between vitamin D deficiency, metabolic syndrome, and hypertension in patients with psoriasis. Future larger studies are needed for strengthening this evidence prior to the recommendation of its clinical application in the optimum management of patients.

Correlation of Venous Clinical Severity Score With Dermatology Life Quality Index Among Patients With Chronic Venous Insufficiency: A Cross-Sectional Study.

Introduction Chronic venous insufficiency (CVI) is characterized by inadequate functioning of venous valves in the lower limb. CVI is associated with a significant reduction in patient's quality of life (QOL). The severity of CVI was determined by CEAP (clinical, etiological, anatomical, pathophysiological) classification and venous clinical severity score (VCSS). The study is aimed to evaluate and correlate Dermatology Life Quality Index (DLQI) with VCSS, CEAP in patients with CVI. Methods A cross-sectional study of 57 patients with CVI was conducted over a period of 12 months. A sociographic survey, clinical and severity grading using CEAP classification, and VCSS were done for all venous doppler confirmed patients. QOL was evaluated by validated DLQI questionnaires using English and native languages Hindi and Marathi. Results A total of 57 patients with a male to female ratio of 6.1:1 and a mean age of 51.68 years were included in the study. CEAP grading in patients showed 49.12% (C4a), 21.05% (C6), 15.7% (C4b), 7.01% (C3), 3.50% (C2 and C5). Mean VCSS and DLQI were 11.47 and 10.12, respectively; 49.12%, 40.35%, 10.53% of patients had a moderate, very large, and small impact on DLQI respectively, positively correlating to VCSS (P < 0.001). Conclusion From this study, it was observed that VCSS and CEAP positively correlated with DLQI, and the impact increases in proportion with the seriousness of the disease.

Correlation of Cutaneous Manifestations with Body Mass Index, Blood Glucose, and Hormonal Levels in Patients with Polycystic Ovarian Disease.

BACKGROUND: Polycystic ovarian disease (PCOD) is characterized by oligo/anovulation, ultrasonographic evidence of polycystic ovaries and cutaneous features such as hirsutism, acne, acanthosis nigricans, androgentic alopecia, and signs of virilization. AIM: Correlation of dermatological manifestations with body mass index (BMI), blood glucose, and levels of free testosterone, dehydroepiandrosterone sulfate (DHEAS), follicle stimulating hormone (FSH), and luteinizing hormone (LH) in patients of PCOD hailing from Pimpri, Pune. SUBJECTS AND METHODS: This observational study was carried out from November 2015-April 2017 on 102 patients (aged 12-45 years, non-pregnant) of PCOD, attending dermatology/gynecology outpatient departments. After recording socio-demographic/menstrual and medical history, BMI was calculated and examination of cutaneous manifestations were done. Participants were then subjected to pelvic ultrasonography and blood sugar/hormonal estimation. STATISTICAL ANALYSIS: By using statistical package for the Social Sciences 17.0 software, Chi-square test, and Fisher's exact test. RESULTS: Age: 59.80% belonged to the third decade (range,12-40; mean, 26.27 ± 5.05 years); ultrasonography revealed polycystic ovaries in 79.41%. Cutaneous manifestations recorded were - acne (74.50%); acanthosis nigricans (50%); striae (49.02%); hirsutism (40.19%); acrochordons (36.27%); seborrheic dermatitis (32.35%), and androgenetic alopecia (30.39%). Free testosterone (35;34.31%), DHEAS (9;8.82%), LH and FSH (2;1.96% each), and LH: FSH ratio (51;50%) were raised. Statistical association of acanthosis nigricans emerged with free testosterone (P = 0.034), DHEAS (P = 0.016), fasting blood sugar (P = 0.01), and raised BMI (P = 0.002) and of hirsutism with raised DHEAS (P = 0.016), free testosterone (P = 0.012), and BMI (P = 0.022). CONCLUSION: Significant correlations demonstrated were acanthosis nigricans with free testosterone, DHEAS, FBS, and BMI and hirsutism with DHEAS, free testosterone, and BMI.

Improvement in the Quality of Life of a Patient of Ectodermal Dysplasia with Reconstructive Surgeries.

Ectodermal dysplasias are a complex group of heterogenous, heritable disorders entailing two or more developmental abnormalities in ectodermal structures, such as hair, teeth, nails, and/or sweat glands. The most common subtype of these disorders is X-linked hypohidrotic that significantly impairs the quality of life of its sufferers. A 15-year-old boy, who sought the treatment for protuberant lips, saddle nose, dental anomalies, fine sparse hair, decreased sweating, intolerance to heat and photosensitivity, experienced dramatic improvement in his quality of life and confidence with aesthetic correction comprising autologous fat grafting, rhinoplasty, lip reduction, microblading and comprehensive prosthodontic and orthodontic treatments undertaken in collaboration with dental and plastic surgery departments and expert psychological counseling.

Hand eczema in nurses, nursing auxiliaries and cleaners-A cross-sectional study from a tertiary hospital in western India.

BACKGROUND: Healthcare workers have a high risk of developing hand eczema. OBJECTIVES: To determine the prevalence and severity of dermatologist-determined hand eczema among healthcare workers, carry out patch testing, and correlate the findings with impairment in quality of life (QoL) and demographic and vocational factors. METHODS: Seven hundred and ten healthcare workers (279 nurses, 246 cleaners, and 185 nursing auxiliaries) were screened for the presence of hand eczema. Severity of eczema was calculated with the Hand Eczema Severity Index (HECSI), and QoL was measured with the Dermatology Life Quality Index (DLQI). Individuals with hand eczema were also patch tested. RESULTS: The point and 1-year prevalences of hand eczema were 7.2% and 18.9%, respectively. Hand eczema was significantly associated with atopic dermatitis. The mean HECSI score was 9.39; it was significantly higher in patients with atopic dermatitis and those with recurrent hand eczema. The mean DLQI score was 5.37. Cleaning staff had significantly greater impairment in QoL. HECSI and DLQI scores were positively correlated. Patch testing showed that thiuram mix, antibiotics and cleansers as sensitizers were over-represented in healthcare workers as compared with controls. CONCLUSIONS: Hand eczema was particularly common in hospital cleaners and staff with atopic dermatitis. Further studies are needed to address the burden of occupational hand eczema and develop guidelines for its management at a national level.

Acquired angiokeratomas of the vulva.

Angiokeratomas are benign cutaneous lesions consisting of numerous ectatic blood vessels present in the superficial dermis and usually involving the scrotum. Although usually asymptomatic, they may be complicated by sporadic or profuse bleeding. We report the development of multiple vulvar angiokeratomas in a 40-year-old female after undergoing a perineoplasty successfully treated with electrocautery.

Clinicoepidemiological Observational Study of Acquired Alopecias in Females Correlating with Anemia and Thyroid Function.

Alopecia can either be inherited or acquired; the latter, more common, can be diffuse, patterned, and focal, each having cicatricial and noncicatricial forms. This observational study of 135 cases in a semiurban Indian population aimed to detect the prevalence of various forms of acquired alopecia in females and correlate the same with levels of hemoglobin, serum ferritin, triiodothyronine, thyroxin, and thyroid stimulating hormone. The majority (84, 62.2%) of our cases of alopecia had telogen effluvium followed by female pattern alopecia (32, 23.7%). Stress (86, 63.7%), topical application of chemicals (72, 53.3%), systemic medications for concurrent illnesses (62, 5%), and pregnancy (14, 10.3%) were the common exacerbating factors. Neither low hemoglobin (<12 gm%, 73.4%) nor low serum ferritin (<12 µg/L, 6.7%) was found to be statistically significant. A majority (90, 90.9%) of 99 cases with anemia (hemoglobin levels of <12 gm%) had serum ferritin levels >12 µg/L. Though lack of vitamin B12 testing was a limitation of our study, its deficiency could be the probable cause of iron deficiency as the majority (58, 64.4%) of these cases, as indeed majority (89, 65.4%) of our study population, were vegetarians. Thyroid disorders (23, 17%, including 9 newly diagnosed) were not of significance statistically.

Case Report: Whole exome sequencing helps in accurate molecular diagnosis in siblings with a rare co-occurrence of paternally inherited 22q12 duplication and autosomal recessive non-syndromic ichthyosis.

Lamellar ichthyosis (LI), considered an autosomal recessive monogenic genodermatosis, has an incidence of approximately 1 in 250,000. Usually associated with mutations in the transglutaminase gene ( TGM1), mutations in six other genes have, less frequently, been shown to be causative. Two siblings, born in a collodion membrane, presented with fish like scales all over the body. Karyotyping revealed duplication of the chromosome arm on 22q12+ in the father and two siblings. Whole exome sequencing revealed a homozygous p.Gly218Ser variation in TGM1; a variation reported earlier in an isolated Finnish population in association with autosomal recessive non-syndromic ichthyosis. This concurrence of a potentially benign 22q12+ duplication and LI, both rare individually, is reported here likely for the first time.