Therapeutic implications of dermoscopic findings in acanthosis nigricans: A clinical and histopathological study.

Acanthosis nigricans is associated with numerous systemic disorders. These include endocrinological conditions such as, diabetes, acromegaly, Cushing's syndrome, thyroid dysfunction, as well as metabolic abnormalities like obesity and polycystic ovarian disease. Its association with visceral malignancy is known. Moreover, Acanthosis nigricans is known to be a cutaneous marker of insulin resistance (IR) and hyperinsulinemia. The primary aim of this study was to study clinical and histopathological patterns of acanthosis nigricans and its correlation with dermoscopic patterns and treatment implications. 103 patients clinically diagnosed as acanthosis nigricans were enrolled in the study. Clinical evaluation, dermoscopy, and skin biopsy was done for histopathological evaluation. Consistency was observed in the changes seen on dermoscopy with clinical and histopathological findings. Common dermoscopy findings were Crista Cutis, Sulcus Cutis, Papillary projections, hyperpigmented dots, crypts, and blotching Dermoscopic findings can be correlated with histopathological features. Dermoscopy allows visualization on higher magnification which helps to pick up subtle changes which are not visible to naked eye. Dermoscopy can be a useful tool to distinguish acanthosis nigricans from other pigmentary disorders in patients who are not willing for histopathological examination and helps in treatment making decisions.

Alarming India-wide phenomenon of antifungal resistance in dermatophytes: A multicentre study.

BACKGROUND: An alarming increase in recalcitrant dermatophytosis has been witnessed in India over the past decade. Drug resistance may play a major role in this scenario. OBJECTIVES: The aim of the present study was to determine the prevalence of in vitro resistance to terbinafine, itraconazole and voriconazole in dermatophytes, and to identify underlying mutations in the fungal squalene epoxidase (SQLE) gene. PATIENTS/METHODS: We analysed skin samples from 402 patients originating from eight locations in India. Fungi were identified by microbiological and molecular methods, tested for antifungal susceptibility (terbinafine, itraconazole, voriconazole), and investigated for missense mutations in SQLE. RESULTS: Trichophyton (T.) mentagrophytes internal transcribed spacer (ITS) Type VIII was found in 314 (78%) samples. Eighteen (5%) samples harboured species identified up to the T interdigitale/mentagrophytes complex, and T rubrum was detected in 19 (5%) samples. 71% of isolates were resistant to terbinafine. The amino acid substitution Phe397Leu in the squalene epoxidase of resistant T mentagrophytes was highly prevalent (91%). Two novel substitutions in resistant Trichophyton strains, Ser395Pro and Ser443Pro, were discovered. The substitution Ala448Thr was found in terbinafine-sensitive and terbinafine-resistant isolates but was associated with increased MICs of itraconazole and voriconazole. CONCLUSIONS: The high frequencies of terbinafine resistance in dermatophytes are worrisome and demand monitoring and further research. Squalene epoxidase substitutions between Leu393 and Ser443 could serve as markers of resistance in the future.

Primary Cutaneous Actinomycosis Mimicking Cutaneous Leishmaniasis.

Actinomycosis is a chronic suppurative bacterial infection commonly seen in the tropics, caused by gram-positive, anaerobic bacilli of the genus Actinomyces. There are very few reported cases of primary cutaneous actinomycosis. It can mimic mycetoma, tuberculosis, nocardiosis, and botryomycosis. A high index of clinical suspicion is required for diagnosis in the absence of sinuses. Even with repeated attempts, cultures are mostly negative; and hence, histology reveals the diagnosis in most cases. Here, we report an unusual case of primary cutaneous actinomycosis in a 21-year-old female patient, following a road traffic accident (RTA). A positive Splendore-Hoeppli phenomenon and special stains demonstrated the ray fungus and helped us reach the diagnosis. The patient was started on oral penicillin G and showed good response.

Clinico-epidemiological profile of genital dermatoses in people living with HIV: A shifting paradigm from venereal to nonvenereal dermatoses.

Context: The protean mucocutaneous manifestations of HIV and the resultant opportunistic infections are well documented. Genital dermatoses can be either venereal or nonvenereal in origin. As the presence of HIV infection greatly increases the chances of acquiring another sexually transmitted pathogen, these are often presumed to be venereal in origin. Aims: The aims of the study were to record the different morphologies of genital skin lesions in seropositive patients and to classify them as venereal or nonvenereal in origin. Settings and Design: This was an observational study undertaken in seropositive patients with genital skin lesions attending the outpatient department of dermatology at a tertiary health-care center. Subjects and Methods: One hundred and seventy-seven seropositive patients with genital lesions were enrolled. A detailed history was taken; the genital and dermatological examination was performed. Statistical Analysis Used: None. Results: Males predominated the study population with the majority (79.1%) falling into the reproductive age group of 15-49 years. Nonvenereal genital dermatoses (59%) outnumbered sexually transmitted infections (STIs) (41%) out of which the most frequently encountered were dermatophytosis, scabies, and intertrigo. Other entities recorded were inflammatory dermatoses, cutaneous adverse drug reactions, and tumors. The most common STIs were herpes genitalis (55.4%) and anogenital warts (32.5%). Conclusion: This study showed that nonvenereal genital dermatoses are more common than STIs in people living with HIV. Our findings reiterate the fact that genital lesions should be approached with caution as a presumptive and hasty diagnosis of STI adds greatly to the morbidity of the patient in terms of guilt and shame, and adversely affects the quality of life.

Nail Changes in Immuno-Bullous Disorders: A Cross-Sectional Study.

Context: Autoimmune blistering (AIBD) disorders affect mucosae, skin, and appendages. Appendageal involvement has not been studied extensively to date. However, they are important as nail changes are commonly encountered during a flare-up of the disease. Aims: To determine the prevalence and patterns of nail changes in various Immunobullous disorders and to study the relationship between the nail changes and the disease duration and severity. Settings and Design: A cross-sectional study was conducted at the Department of Dermatology, venerology, and leprosy at a tertiary care center in Mumbai. Materials and Methods: A cross-sectional study including a total of 74 cases of Immunobullous diseases was conducted and the prevalence of nail changes was determined. The association between the mean number of nail changes and the disease duration and severity was analyzed using ANOVA (Analysis of variance) and unpaired t-test. Statistical Analysis: The Statistical Package for Social Studies (SPSS) software was used for statistical evaluation. Results: We found that the prevalence of nail changes was 91%. There was a significant difference in the mean number of nail changes with respect to the severity grades of mucosal involvement in AIBD (P value < 0.05). There was no significant difference in the mean number of nail changes with respect to the severity grades of Pemphigus vulgaris (PV), Pemphigus foliaceous (PF), subepidermal blistering diseases, and the duration of AIBD. Conclusions: Nails are frequently affected in AIBD. The number of nail changes is related to the severity of mucosal disease but not to duration.

Efficacy and Safety Comparison of Basic Fibroblast Growth Factor-Related Decapeptide 0.1% Solution (bFGFrP) Plus Oral PUVA Combination Therapy with Oral PUVA Monotherapy in the Treatment of Vitiligo.

Background: Phototherapy in its different forms, is mainstay of vitiligo management. Combining treatment modalities like topical calcipotriol (for quicker, more intense repigmentation), Low dose azathioprine with PUVA have proven to be beneficial in management of vitiligo due to different mechanisms of repigmentation and their synergistic effects. Topical bFGF-related decapeptide (bFGFrP) application followed by sun exposure/ UVA phototherapy yields effective repigmentation. bFGFrP has shown to aid the targeted phototherapy in smaller lesions and its combinations with other treatment modalities have been very promising. However, there is paucity of studies on combination treatments; especially oral PUVA along with bFGFrP. This study was aimed at evaluating safety and efficacy of combination of bFGFrP with Oral PUVA in vitiligo (larger body surface area 20% or more). Materials and Methods: Phase IV, randomized, multicentre study (N = 120) in adult patients with stable vitiligo of 6 months treatment period with monthly follow up visits. Psoralen (Tab. Melanocyl) dosage 0.6 mg/kg orally 2 h before exposure to UVA phototherapy. Oral PUVA therapy, initially, at an irradiation dose 4 J/cm2 (PUVA group), followed by increments 0.5 J/cm2 every four sittings if tolerated for twice weekly. Primary end point was improvement in extent of repigmentation (EOR) in target lesion (at least 2 cm × 2 cm in greatest dimension, without leukotrichia), while secondary endpoints were improvement in patient global assessment (PGA) and safety at end of 6 months of treatment period in bFGFrP + oral PUVA combination group and Oral PUVA monotherapy group. Results: End of 6 months, significantly greater EOR >50%) was achieved in 61.8% (34 patients, n = 55) from combination group while 30.2% (16 patients, n = 53) from the oral PUVA monotherapy group (n = 53). Regarding Grade of repigmentation (GOR), complete repigmentation was observed 5.5% (3 patients, n = 55) in combination group whereas no patient showed complete repigmentation in monotherapy group (p ≤ 0.05), PGA showed significant overall improvement in combination group (p ≤ 0.05); 6 patients (10.9%) from combination group Vs one (1.9%) showed complete improvement. During treatment period, there were no reported adverse events. Conclusions: Addition of bFGFrP to oral PUVA therapy resulted in intense and faster induction of repigmentation than oral PUVA monotherapy with favorable safety profile.

Anti CD-6 Monoclonal Antibodies in the Management of Generalised Pustular Psoriasis.

Generalised pustular psoriasis (GPP) is an uncommon, severe, life-threatening variant of psoriasis requiring careful therapeutic approach. Conventional treatment modalities have unsatisfactory outcomes, poor side effect profiles and toxicities that have led to an emerging use of biological therapies. Itolizumab, an anti-CD-6 humanised monoclonal IgG1 antibody, is approved for the management of chronic plaque psoriasis in India. We share our experience of using this drug in three cases of GPP that were failing conventional therapies. Its upstream effect on co-stimulatory pathway in disease pathogenesis is the postulated mechanism. Our experience warrants further large-scale exploration of the role of itolizumab in the management of GPP, which would benefit this severely affected population of patients. Although the definite pathogenesis of GPP is unknown fully, molecules blocking CD-6, which plays a role in the interaction between T cells and antigen-presenting cells (APCs), are expected as new promising treatment options for GPP.

Poikilodermatous Mycosis Fungoides with Erosive Lesions.

Mycosis fungoides (MF) is the commonest form of cutaneous T-cell lymphoma. Many clinical subtypes and variants of MF have been described, one of which is poikilodermatous MF variant. Erosions and bullous lesions in a patient with poikilodermatous MF is a rare presentation. We present one such rare case of poikilodermatous MF with erosive lesions in a 40-year-old male.

Acral Acanthosis Nigricans in a Case of Scleroderma.

Acanthosis nigricans (AN) is a dermatosis characterized by velvety, papillomatous, brownish-black, hyperkeratotic plaques, typically on the intertriginous surfaces and neck. The majority (80%) of AN occurs idiopathically or in benign conditions such as endocrinopathies like diabetes mellitus, polycystic ovary syndrome; metabolic syndrome and/or heritable disease. Malignancy-associated AN is rare. AN may rarely be associated with autoimmune diseases including systemic lupus erythematosus, due to antibodies to the insulin receptor, so-called type B insulin resistance. Here we report a case of AN in a case of diffuse progressive systemic sclerosis without evidence of insulin resistance.

Classical Sweet's syndrome.

A 38-year - old female came to us with sudden eruptions of painful edematous lesions which appeared pseudovesicular on cutaneous examination. Histopathology supported the diagnosis of sweet's syndrome and she responded to a combination of dapsone and oral steroids, after having relapsed on self-discontinuation of monotherapy with dapsone.

Solitary superficial acral angiomyxoma: an infrequently reported soft tissue tumor.

Superficial angiomyxomas (SA) are clinically variable, infrequent, benign skin lesions. They are usually located on the trunk, but can also appear on the lower limbs, head, and neck. The present case, hence, is unusual, because the lesion developed on the toe. They are diagnosed histologically, and are characterized by being poorly delimited tumors with the presence of interstitial myxoid material and scanty cellularity. We discuss the clinical and histological features of digital SA as well as a brief outline of other myxoid lesions.

Acute hemorrhagic edema of infancy-a rare entity.

A patient presenting with fever and purpura often presents a diagnostic challenge for the dermatologist. Acute hemorrhagic edema of infancy (AHEI) is a rare acute cutaneous leukocytoclastic vasculitic syndrome of infants leading to this presentation. We present an 18-month-old girl with AHEI who presented with fever, edema, and purpuric lesions involving the face, ears and extremities with uneventful complete recovery.

Disabling pansclerotic morphea of childhood with extracutaneous manifestations.

Disabling pansclerotic morphea (DPM) of childhood is a rare generalized type of localized scleroderma (LS) that is known to follow an aggressive course with pansclerotic lesions leading to severe joint contractures and consequent immobility. Mortality is due to complications of the disease such as bronchopneumonia, sepsis, or gangrene. There is no specific laboratory finding. Treatment protocols are still evolving for this severe recalcitrant disorder. Extracutaneous manifestations are rarely reported in DPM. We present the case of a 7-year-old girl with DPM with severe extracutaneous manifestations in the form of gastrointestinal and vascular disease, whose disease progressed rapidly. In spite of treatment with methotrexate, corticosteroids, and PUVA therapy, she ultimately succumbed to her illness due to sepsis.