Epidermolysis bullosa acquisita and anti-p200 pemphigoid as major subepidermal autoimmune bullous diseases diagnosed by floor binding on indirect immunofluorescence microscopy using human salt-split skin.

BACKGROUND: Subepidermal autoimmune bullous diseases are a diverse group of diseases with overlapping clinical and immunopathological features. Indirect immunofluorescence microscopy on artificially split skin helps to classify these conditions into those with staining on the epidermal side of the split ("roof-binding") and those with staining on the dermal side ("floor-binding"). Epidermolysis bullosa acquisita is the prototype of "floor-binding" subepidermal autoimmune bullous diseases. However, not all floor-binding sera are associated with epidermolysis bullosa acquisita. AIM: The aim of this study was to evaluate the clinical and immunological profile of patients with floor-binding subepidermal autoimmune bullous disease by indirect immunofluorescence microscopy and to identify the target antigens in them. METHODS: Ten patients who showed a floor-binding pattern were studied with regard to their clinical and immunopathological characteristics. Target antigens were identified by modified indirect immunofluorescence microscopy using recessive dystrophic epidermolysis bullosa skin, enzyme linked immunosorbent assay, and immunoblotting. RESULTS: Diagnosis of epidermolysis bullosa acquisita was confirmed in six patients. Three patients with an inflammatory subepidermal autoimmune bullous disease mimicking bullous pemphigoid reacted with a 200 kDa protein on immunoblotting with dermal extract, as is characteristic of anti-p200 pemphigoid. One serum showed both roof and floor binding, and reacted with the BP180 antigen. LIMITATION: We could not perform serration pattern analysis in our patients. CONCLUSION: In this study, we report three cases of anti-p200 pemphigoid from India. These cases, though indistinguishable clinically from bullous pemphigoid, revealed a floor-binding pattern on indirect immunofluorescence using salt-split skin.

Guidelines for bath PUVA, bathing suit PUVA and soak PUVA.

BACKGROUND: The aim of these guidelines is to encourage dermatologists to use bath psoralen plus ultraviolet A (PUVA), bathing suit PUVA and soak PUVA in the treatment of psoriasis vulgaris and other conditions. METHODS: Evidence was collected using searches of the PubMed, MEDLINE and COCHRANE databases using the keywords "bath PUVA," "soak PUVA," "bathing suit PUVA" and "turban PUVA." Only publications in English were reviewed. RESULTS: One hundred and thirty-eight studies were evaluated, 57 of which fulfilled the criteria for inclusion. CONCLUSIONS: Both bath PUVA and bathing suit PUVA are very effective and safe treatments for generalized stable plaque psoriasis (strength of recommendation, A). Soak PUVA is very effective in the treatment of both palmoplantar psoriasis and chronic palmoplantar eczema (strength of recommendation, A).

Hansen's disease associated with erythromelalgia mimicking Lupus erythematosus.

Hansen's disease, though considered to be at the verge of elimination in many countries including India, still continues to surprise patients and dermatologists alike. This is mainly due to its varying and unconventional presentations which may lead to initial misdiagnosis and prolongation of treatment. Here we describe an unusual case presenting with erythematous photosensitive facial lesions associated with erythromelalgia of the finger tips, provisionally diagnosed as SLE. A subsequent histopathology examination proved it to be Hansens' disease Borderline Tuberculoid variety. Hansen's disease can be termed as the modern great imitator, displacing the traditional great imitator, syphilis.

Efficacy and safety of erbium-doped yttrium aluminium garnet fractional resurfacing laser for treatment of facial acne scars.

BACKGROUND: Treatment of acne scars with ablative fractional laser resurfacing has given good improvement. But, data on Indian skin are limited. A study comparing qualitative, quantitative, and subjective assessments is also lacking. AIM: Our aim was to assess the improvement of facial acne scars with Erbium-doped Yttrium Aluminium Garnet (Er:YAG) 2940 nm fractional laser resurfacing and its adverse effects in 25 patients at a tertiary care teaching hospital. METHODS: All 25 patients received four treatment sessions with Er:YAG fractional laser at 1-month interval. The laser parameters were kept constant for each of the four sittings in all patients. Qualitative and quantitative assessments were done using Goodman and Barron grading. Subjective assessment in percentage of improvement was also documented 1 month after each session. Photographs were taken before each treatment session and 1 month after the final session. Two unbiased dermatologists performed independent clinical assessments by comparing the photographs. The kappa statistics was used to monitor the agreement between the dermatologists and patients. RESULTS: Most patients (96%) showed atleast fair improvement. Rolling and superficial box scars showed higher significant improvement when compared with ice pick and deep box scars. Patient's satisfaction of improvement was higher when compared to physician's observations. No serious adverse effects were noted with exacerbation of acne lesions forming the majority. CONCLUSION: Ablative fractional photothermolysis is both effective and safe treatment for atrophic acne scars in Indian skin.Precise evaluation of acne scar treatment can be done by taking consistent digital photographs.

Cutaneous metastases from carcinoma breast: the common and the rare.

Cancer metastasis is quite devastating to the patient as well as the physician and may herald the onset, dissemination or recurrence of malignancy. Breast carcinoma metastasis is the most common carcinoma encountered by dermatologists and it presents in various morphological and histological forms. Here, we present two varied cases, the first being the common nodular metastasis from a previously treated intraductal carcinoma and the second, the rarer variant, carcinoma erysipeloides as a heralder of the invasion of an incompletely treated disease.

Erythema nodosum leprosum as the presenting feature in multibacillary leprosy.

Leprosy is an ancient disease that has survived into the modern ages despite an intense effort to eliminate it worldwide. Here we report a case of a 32-year-old woman who had recurrent painful nodules of six months duration. Because of a lack of lesions suggestive of leprosy, she was initially diagnosed to have cutaneous vasculitis and erythema nodosum. However, because of the persistent nature of her condition she was later detected to have leprosy and erythema nodosum leprosum (ENL) with the aid of simple diagnostic tests.

Epithelioid sarcoma: a diagnostic challenge.

Epithelioid sarcoma is an uncommon slow-growing soft tissue malignancy, associated with a high incidence of local recurrence and metastasis. We report a 26-year-old male with epithelioid sarcoma on the right palm with a long history of over seven years, which was initially misdiagnosed as cutaneous tuberculosis and epithelioid hemangioendothelioma, as a result of which the treatment was delayed. No metastasis was found in our patient. The patient was referred to the oncology centre where he underwent wide excision of the lesion followed by radiotherapy. The review of the literature including clinical and histological differential diagnosis is presented as it mimics inflammatory, benign tumors as well as other malignant conditions.

Minimal erythema response (MED) to solar simulated irradiation in normal Indian skin.

BACKGROUND: Phototesting is an essential tool in the investigation of photodermatoses. AIMS: The main aim was to study the cutaneous response to UVR in terms of minimal erythema dose (MED) to both UVA and UVB in normal Indian subjects with a solar simulator and to study the relationship of skin type to MED. METHODS: One hundred healthy volunteers not on any medication and without any history of photodermatoses were phototested using a solar simulator with whole spectrum irradiation (UVA, UVB and visible light) and only visible and UVA radiation. The tested areas were marked with gentian violet and readings were taken after 24 hrs. RESULTS: Of the 100 volunteers, 48% were males and 52% were females, with a mean age of 36.6 +/- 11.6 yrs. The most common skin type among Indians was type 5 (46%) followed by type 4 (41%). The mean MED for UVB was 61.5 +/- 17.25 J/cm2. The MED for UVA could not be determined as none of the patients showed any erythema after irradiation for 45 minutes. CONCLUSIONS: As the MED is found to be low in idiopathic acquired photodermatoses, the MED in the normal population could serve as a baseline data in the investigation.