Serum levels of tumour necrosis factor (TNF-α) and interleukin-17 (IL-17) in patients with nail psoriasis: A cross-sectional study.

Background Psoriasis is a common chronic inflammatory disorder affecting all aspects of a patient's life. Nail involvement is frequent, but little is known about its associated inflammatory biomarker profile, including similarities or differences from cutaneous disease. Aims We conducted this cross-sectional study to evaluate serum levels of inflammatory cytokines [tumour necrosis factor-alpha (TNF-α) and interleukin -17 (IL-17)] in patients with nail psoriasis and compared these to psoriasis patients without nail involvement, as well as in non-psoriatic healthy controls. Methods Adult psoriasis patients with (Group I, n = 30) and without nail involvement (Group-II, n = 30) were sequentially recruited. In addition, non-psoriatic healthy controls (Group-III, n = 20) were recruited. The nail disease severity by NAPSI score was determined for patients in Group I. Cutaneous disease severity (by PASI score) and presence of psoriatic arthritis (through CASPAR criteria) were evaluated for patients in Groups I and II. Serum levels of TNF-α, IL-17, erythrocyte sedimentation rate (ESR), rheumatoid factor (RA factor), and anti-cyclic citrullinated peptide antibody (Anti-CCP) were evaluated for all three groups. Results The median age was significantly higher for Group I as compared to Group II patients (41 ± 12.6 years vs 30 ± 12.4 years, p = 0.017). Group I patients also had higher median PASI score than Group II patients, although the difference was not statistically significant (10 ± 11.41 vs 6.50 ± 5.46, p = 0.275). The mean serum IL-17 levels were significantly higher for Group-I (113.39 ± 251.30 pg/mL) than Group II (27.91 ± 18.22 pg/mL, p = 0.002) and Group III (25.67 ± 12.08 pg/mL, p = 0.005). A weak positive correlation was found between NAPSI and serum IL-17 levels (Spearman's Rho = 0.355) though not statistically significant (p = 0.054). Correlation between serum IL-17 and PASI was poor for Group-I patients (Spearman's Rho = 0.13, p = 0.944) and strongly negative for Group-II patients (Spearman's Rho = -0.368, statistically significant with p = 0.045). The mean serum levels of TNF-α were below the detection threshold of the assay kit, hence no meaningful comparison could be made. Limitations A small sample size and low sensitivity of TNF-α assay kit. Conclusion Our study showed that nail psoriasis could be independently associated with an elevation of IL-17. This can help choose appropriate drugs and estimate drug response in patients with nail psoriasis.

Clinico-epidemiological profile and management outcome of subungual digital glomus tumor-Indian experience.

BACKGROUND: Glomus tumors are rare tumors arising from the mesenchymal smooth muscle cells of the glomus body. They are extremely painful tumors but because of their subungual location, remain mostly underdiagnosed. AIM: To characterize the demographic, clinical, onychoscopic, radiological features and management outcome of subungual glomus tumor. Material & methods- 15 patients with a total of 16 subungual glomus tumors were evaluated and their demographic data, history, clinical features, investigations, treatment, and follow-up were analyzed. RESULTS: Glomus tumors had a female preponderance (11/15) with thumb being the commonest site. All patients presented with intractable pain. Nail discoloration was observed in 11/16 (68.8%) lesions and nail plate deformity in 6/16 (37.5%) lesions. Common features on onychosocpy were pink glow and linear vascular structures. Doppler sonography and/or magnetic resonance imaging confirmed the diagnosis of glomus tumor in all the lesions. Surgical excision was done under local anesthesia using a trans-ungual approach and no recurrence was seen. CONCLUSIONS: High index of suspicion, meticulous clinical assessment along with radiological investigations can help in the early diagnosis. Complete surgical excision is the treatment of choice to prevent recurrence.

Pterygium Complicating Nail Psoriasis and Trachyonychia: Is It Rare?

Pterygium is an irreversible scarring of the nail matrix resulting in a split nail. The deformity is most often post-traumatic, though it can be the end result of aggressive inflammatory diseases involving the nail matrix like nail lichen planus, graft versus host disease, or autoimmune bullous disorders like cicatricial pemphigoid. It is thought to be a result of lymphocytic inflammation-mediated damage to the nail matrix, initiating a fibrotic process which slowly fuses the nail fold with the nail matrix and bed, destroying the nail plate. We report an interesting observation in a series of patients of various ages with nail and/or skin psoriasis, and trachyonychia associated with pterygium formation in multiple nails. Insidious progression to anonychia was also observed despite initiating adequate treatment. This report highlights the potential of irreversible nail damage occurring in reportedly benign nail conditions like psoriasis and trachyonychia, emphasizing the need for early recognition and aggressive management in such cases.

Modulation of mRNA Expression of IL-6 and mTORC1 and Efficacy and Feasibility of an Integrated Approach Encompassing Cognitive Behavioral Therapy Along with Pregabalin for Management of Neuropathic Pain in Postherpetic Neuralgia: A Pilot Study.

OBJECTIVE: This study was designed to explore the efficacy and feasibility of cognitive behavioral therapy (CBT) along with pregabalin and compare it with pregabalin monotherapy for the management of neuropathic pain in post-herpetic neuralgia (PHN) patients and to explore the modulation of messenger RNA (mRNA) expression of interleukin (IL)-6 and mammalian target of rapamycin-1 (mTORC1) genes in these patients. DESIGN: Randomized controlled pilot study. METHODS: The patients aged >18 years of age with an established diagnosis of PHN with evident allodynia and hyperalgesia who had pain for at least 3 months after healing of rash with pain intensity ≥4/10 on NRS-Pain Scale were enrolled. The trial was registered with the Clinical Trials Registry-India (CTRI/2019/03/018014). A detailed baseline assessment regarding type and duration of pain and disability using pain-relevant self-report questionnaires was done. Two mL venous blood samples were collected for gene expression studies at base line and at end of 12 weeks of treatment. Patients were randomized into one of the two groups. Group PR received pregabalin and Group CP received CBT along with pregabalin. The pain intensity was measured using numeric rating scale (NRS)-Pain scale, neuropathic component of the pain by using Neuropathic Pain Symptom Inventory (NPSI) and Pain Detect Questionnaire (PDQ), sleep interference by NRS-Sleep, pain-related catastrophic thoughts by using Pain Catastrophizing Scale (PCS), depression and quality of life using Beck Depression Inventory-II (BDI-II) and Short Form-12 (SF-12), respectively. The research funding was supported by the intramural grant from the institution. RESULTS: A total of 40 patients with 20 in each group were included. Following integrated approach encompassing CBT and Pregabalin, group CP had significant downregulation of mRNA expression of IL-6; however, no such correlation was observed with mTOR expression. A significant decline in the intensity of pain, NPSI scoring for burning, allodynia, and pain-related catastrophizing were observed; also a significant improvement in depressive symptoms and quality of life were observed with the use of CBT. CONCLUSIONS: A significant downregulation of mRNA expression of IL-6 was observed; however, no significant correlation was observed between NRS pain score and ΔCt values of mRNA expression of both mTORC1 gene and IL-6 gene at baseline and at the end of 12th week. In addition, we note a significant decrease in pain intensity, depressive symptoms, and pain-related catastrophizing while improving QOL was observed with the use of CBT as a clinical adjunct along with pregabalin in PHN patients.

Clinico-epidemiological profile of lichen scrofulosorum: a 22-year, single-center, retrospective study.

BACKGROUND: Lichen scrofulosorum (LS) represents immunologic reaction to the Mycobacterium tuberculosis antigen and presents with subtle, asymptomatic, grouped follicular papules over the trunk and shows good therapeutic response to antitubercular drugs. OBJECTIVE: To study the clinical and epidemiological characteristics of patients diagnosed with LS. MATERIALS AND METHODS: A single-center retrospective review of patients diagnosed with LS from 1997 to 2018 was conducted. The data pertained to clinico-epidemiological profile, BCG vaccination, Mantoux positivity, laboratory investigations, coexistent focus of tuberculosis, and response to antitubercular treatment (ATT). RESULTS: LS cases constituted 15.2% (221/1458) of all the patients diagnosed with cutaneous tuberculosis (CTB). Of these, 156 (70.5%) were pediatric patients. All patients presented with multiple follicular and perifollicular grouped papules. The trunk was the most common site involved (98.6%), followed by lower limb (25.33%), upper limb (15.83%), face (5%), and external genitalia (3.6%). Evidence of BCG vaccination and Mantoux test positivity was observed in 52.03 and 83.2%, respectively. Coexistent TB focus was detected in 134 (60.6%) patients in lymph nodes, lungs, abdomen, and unusual sites such as intracranial, endometrium, and eye. Twenty-eight patients (12.66%) had coexistent other clinical forms of CTB. Clinical diagnosis of LS was confirmed on histology that revealed chiefly periappendageal epithelioid cell granuloma. Response to ATT was good with complete resolution of lesion in 8-12 weeks. CONCLUSION: LS appears to be an underdiagnosed entity. Subtle and asymptomatic lesions of LS are often missed, thereby necessitating a high index of suspicion and appropriate evaluation of the underlying TB focus.

Efficacy and Safety of Intralesional Bleomycin in the Management of Ungual Warts.

INTRODUCTION: Ungual warts are common fibroepithelial tumours of the nail unit caused by human papillomavirus. Although various treatment modalities are available, their management is challenging due to high potential for recurrence and treatment-related nail dystrophy. OBJECTIVE: This study evaluates the efficacy and safety of intralesional bleomycin injections in the treatment of ungual warts. METHODS: Medical records of 80 patients with ungual warts, treated by us from 2015 to 2019, were analysed retrospectively with respect to the number of warts, site, morphology, and treatment outcome. Children <5 years of age, and pregnant and lactating women were excluded. All ungual warts were treated with intralesional injections of bleomycin 3 Units/mL, given at 3-4 weeks interval. RESULTS AND CONCLUSIONS: A total of 250 periungual and subungual warts were treated in 80 patients. An average of 2.61 sessions per patient was required for complete resolution. Moderate pain was reported by 65 patients (81.2%), and transitory perilesional hyperpigmentation was observed in 155 lesions (62%). Severe pain and necrosis developed in 3 lesions (1.2%) that were reversible without any residual scarring and deformity. We conclude that intralesional bleomycin is an effective and safe therapeutic modality for ungual warts.

Fox-Fordyce Disease: Dermoscopic Perspective.

Fox-Fordyce disease (FFD) is a rare chronic skin disease of the apocrine unit. It presents chiefly in postpubertal females as grouped, monomorphic, skin-colored follicular papules associated with intense pruritus commonly in axillae but may involve pubic, perineal, areolar, and umbilical areas [An Bras Dermatol. 2018;93(1):161-2]. Diagnosis is mostly clinical as histological features are often nonspecific and variable. However, the lesions at times may be mistaken for irritant contact dermatitis, lichen nitidus, syringoma, etc. [J Dermatol. 2009;36(9):485-90]. Dermoscopy is being increasingly utilized in pigmentary and inflammatory skin disorders. In this communication, we describe the dermoscopic features in FFD, which shows typical light brown to dark brown folliculocentric structureless areas with loss of dermatoglyphics. Some of the lesions also show hyperkeratotic follicular plugging.

Dermoscopic Features of Nail Psoriasis: An Observational, Analytical Study.

INTRODUCTION: Nail involvement in psoriasis occurs in up to 30-50% of patients, and 5-10% may have isolated nail disease. Onychoscopy, a noninvasive tool, might obviate the need for nail biopsy, which is a diagnostic gold standard. OBJECTIVE: The aim of this study was to evaluate onychoscopic features of nail unit in patients with nail psoriasis. METHODS: Fifty-five patients with clinically diagnosed and histologically documented nail psoriasis were recruited. Onychoscopy was performed for each nail (excluding the 5th toenail). Clinically, 443/550 fingernails and 101/440 toenails were involved. The frequency distributions of various onychoscopic features was assessed and compared using the χ2 test (p value <0.05 was considered significant). RESULTS: With onychoscopy, additional 52 fingernails and 64 toenails showed psoriatic involvement. Pitting was the commonest finding in fingernails (60.5%) followed by subungual hyperkeratosis (SUH) (52.8%), onycholysis (40.8%), and dotted capillaries in hyponychium, proximal, and lateral nail folds (38.6 vs. 35.8 vs. 35.8%). In toenails, we observed SUH (85.1%), nail plate thickening (82.1%), onycholysis (77.2%), and dotted capillaries in hyponychium and nail folds (59.4 vs. 53.4 vs. 45.5%). Fuzzy lunula was a novel onychoscopic finding noted in 33.6% fingernails and 4.95% toenails (p < 0.00001). LIMITATIONS: Small sample size. CONCLUSIONS: Onychoscopy may aid in diagnosing nail lesions even before the clinical signs are apparent.

Melanonychia: Etiology, Diagnosis, and Treatment.

Melanonychia is a very worrisome entity for most patients. It is characterized by brownish black discoloration of nail plate and is a common cause of nail plate pigmentation. The aetiology of melanonychia ranges from more common benign causes to less common invasive and in situ melanomas. Melanonychia especially in a longitudinal band form can be due to both local and systemic causes. An understanding of the epidemiology, pathophysiology and clinical details is necessary for adequate patient care and counseling. It not only helps in the early recognition of melanoma but also prevents unnecessary invasive work up in cases with benign etiology. An early diagnosis of malignant lesion is the key to favourable outcome. Though there are no established guidelines or algorithms for evaluating melanonychia, a systematic stepwise approach has been suggested to arrive at a probable etiology. We, hereby, review the aetiology, clinical features, diagnostic modalities and management protocol for melanonychia.

Norfloxacin-Induced Linear IgA Dermatosis.

A 60-year-old cachexic man visited the dermatology outpatient department with fluid-filled lesions on much of his body. He had an intermittent high-grade fever, diarrhea, and vomiting for the past 2 months associated with weight loss and decreased appetite. He admitted to having taken norfloxacin 400 mg twice daily for 3 days for diarrhea, 5 days prior to the onset of the lesions. Physical examination revealed pallor and significant lymphadenopathy (cervical, axillary, and inguinal), and his body mass index (BMI) was 17.67. There were generalized, bizarre-shaped, discrete, as well as coalescing, vesicles and bullae over a diffusely erythematous skin. Characteristic "string of pearls morphology" could be seen over the trunk (Figure 1A and 1B). The trunk exhibited sheets of skin peeling with underlying erosions and Nikolsky sign was positive (Figure 1C), although there was no cutaneous tenderness or mucosal involvement. A Tzanck smear revealed the presence of neutrophils and eosinophils but no acantholytic cells. There was moderate hepatomegaly (7 cm below the costal margins).

Comparison of four softening agents used on formalin-fixed paraffin-embedded nail biopsies with inflammatory disease.

Obtaining high-quality sections of the nail plate poses a significant challenge to histopathology technicians world over. Nail is a heavily keratotic hard tissue that tends to split or tear while sectioning when processed and embedded in a routine manner. Many agents such as phenol, alcohol, and thioglycolate have been tried for the purpose of softening a variety of experimental materials. However, there is no clear consensus on any single agent. The study was conducted with the aim of evaluating and comparing the role of various compounds as softening agents for nail biopsies with inflammatory disease. Thirty paraffin-embedded nail biopsies were subjected to four softening agents: distilled water (DIH20), 30% potassium hydroxide (KOH), hair removal cream, and fabric conditioner. The ease of sectioning, the incidence of juddering (i.e. 'venetian blind' effect), and the shattering of tissue were recorded. Hematoxylin and eosin-stained sections were examined microscopically. Sectioning was very easy after using fabric conditioner, with good quality sections, and hair removal cream produced comparable results. The incidence of juddered, shattered sections after using hair removal cream was considerably higher (63.33%) compared to fabric conditioner-treated nails (16.67%). Microtomy of nail biopsies was found to be easiest after using 30% KOH with moderate section quality. DIH2O could neither allow easier sectioning nor obtain good sections for interpretation. Fabric conditioner and hair removal cream proved to be the effective keratin softeners, while 30% KOH worked effectively when the nail plate alone was submitted for histological examination.

Lymphatic Obstruction as a Rare Complication of Morphea and Response to Intralesional Steroid.

Morphea is a rare sclerosing disorder of the skin. Linear morphea is commonly seen in children and can affect head, neck, trunk, or limbs. It may extend to involve deeper structures such as muscles, bones, and joints. Involvement of lymphatics or the vasculature is very rare. We report a case of a 20-year-old woman presenting with linear morphea involving the nape of the neck and scalp. The lesion gradually developed two linear thick cord-like structures within the lesion of morphea because of secondary lymphatic obstruction causing restriction of neck movements. The patient was given intralesional steroid that led to softening of the skin lesions including that of cords, resulting in improvement of neck movements.

Indurated Dusky Red Swelling on the Forearm of an Infant: Tufted Angioma.

Tufted angioma (TA) is a rare benign vascular tumor that may be congenital or acquired and generally presents as an asymptomatic or painful solitary erythematous to violaceous poorly defined plaque. Hyperhidrosis and hypertrichosis may be associated. The lesions have tendency to resolve spontaneously, in majority, within 2 years of disease onset. However, occurrence of Kassbach-Merritt phenomenon should be looked for. We present a case of 8-months-old infant with TA over the right forearm with classical clinical, histoptahological and immunohistochemistry features.

Precalcaneal congenital fibrolipomatous hamartoma: Rare or under-reported?

Precalcaneal congenital fibrolipomatous hamartoma (PCFH) is a benign under-reported condition of infancy characterized by the presence of soft nodules on precalcaneal plantar surface of the heel. These lesions are usually bilateral solitary and asymptomatic. We present a 2-month-old infant with solitary skin-colored nodules present on precalcaneal plantar aspect of bilateral heels.