Intralesional Vitamin D3 Versus Bleomycin for Difficult-to-Heal Palmoplantar Warts: A Comparative Study.

Introduction: Difficult-to-heal or recalcitrant palmoplantar warts are notoriously resistant to treatment, making treatment difficult and challenging. To improve the outcome and overcome the difficulties, various treatment options have been tried, but none is gold standard. Many comparative studies have been undertaken to assess the efficacy of various drugs; however, none of them are standardized, and no single treatment is effective. Various comparative efficacy studies have been conducted but, to the best of our knowledge, no study has been conducted comparing intralesional (IL) injection (inj) vitamin D3 (Vit D3) with the chemotherapy drug IL inj Bleomycin for difficult-to-heal palmoplantar warts. We conducted a trial to evaluate the efficacy of IL inj Vit D3 versus IL inj Bleomycin in the treatment of difficult-to-heal palmoplantar warts. The purpose of this study was to compare the efficacy of IL inj vitamin D3 versus IL inj Bleomycin as biological response modifier therapy in difficult-to-heal palmoplantar warts. Materials and Methods: A cohort of 48 patients with difficult-to-heal warts were consecutively assigned to one of two groups: Group 1 IL inj Vit D3 (0.2-0.5 mL inj vitamin D3 600,000 IU solution 15 mg/mL) or Group 2 IL inj Bleomycin (0.2-0.4 mL of 1 U/mL solution) for a maximum of four treatments spaced 2 weeks apart, with a maximum of five warts treated at each visit for both groups. Warts were measured at baseline and at each subsequent visit. Wart's resolution was measured as 1-25%, 2-50%, 3-75%, and 4-100% reduction. Patients were followed-up for 3 months after treatment. Results: All the 48 patients completed the study, with 26 receiving IL inj Vit D3 with complete resolution in 88.5%, partial resolution in 11.5%, and side effects in 6.2%. In 22 patients receiving IL inj Bleomycin, 95.5% had complete resolution, 4.5% had partial resolution, and 8.2% had side effects. Maximum resolution was observed in the third session. We found no recurrence after 3 months. Conclusion: IL inj Vit D3 and IL inj Bleomycin are both safe and effective in treating difficult-to-heal palmoplantar warts with better outcomes and patient satisfaction. IL Bleomycin was significantly more effective than IL Vit D3, although the difference was not statistically significant.

Multiple Eruptive Dermatofibromas Masquerading as Cutaneous Lymphoma.

A 34-year-old male came with complaints of multiple firms to hard nontender, nonitchy nodules, measuring 2 cm × 2 cm to 1 cm × 1.5 cm, present predominantly over the lower limbs. This condition started 5 years back as a single nodule over the thigh but gradually increased in number and size with time to involve both lower limbs. A differential diagnosis of cutaneous lymphoma and dermatofibroma was considered. He underwent a biopsy and immunohistochemistry for the same which were consistent with hemosiderotic histiocytoma and positive for vimentin. The patient was advised surgical excision for the same. The occurrence of multiple dermatofibromas although rare has been reported in a few case reports; however, the occurrence of multiple dermatofibromas of the hemosiderotic variant has not been documented yet.

Cutaneous tuberculosis of the pinna: a report of two cases.

BACKGROUND: Cutaneous tuberculosis (TB) is less common than other forms of TB but accounts for 1.5% of all cases of extrapulmonary TB. The source of mycobacterial infection and the immune status of the host determine the presentation of any of a wide spectrum of clinical manifestations. Lupus vulgaris (LV) is a post-primary, paucibacillary form of TB caused by hematogeneous, lymphatic, or contiguous spread from elsewhere in the body. METHODS: We report two recent cases of LV in women presenting with the exclusive involvement of the ear lobe. In Patient 1, clinical presentation appeared as an apparently benign chronic eczematous process. In Patient 2, it appeared as a fulminant ulceronecrotic process. Both women were immunocompetent, and neither had a personal or family history of TB. RESULTS: Both patients were diagnosed with LV and treated with standard antitubercular therapy (ATT). In both patients, mycobacterial culture showed growth of Mycobacterium tuberculosis sensitive to streptomycin, rifampicin, and ethambutol. CONCLUSIONS: Lupus vulgaris is the most common form of cutaneous TB. It is important to diagnose LV because it can result in chronic disfigurement and because 10-20% of LV patients have active pulmonary TB or TB of the bones and joints. In addition, longstanding LV is known to lead to the development of squamous cell carcinoma, which can be avoided by early diagnosis and treatment with ATT.

Role of direct immunofluorescence on Tzanck smears in pemphigus vulgaris.

The Tzanck smear is a simple, sensitive, and rapid test to diagnose pemphigus vulgaris (PV), a life threatening autoimmune blistering disorder. The presence of acantholytic cells in cytology is indicative of but not specific for PV. Hence, a direct Immunofluorescence (DIF) test to demonstrate immunoglobulin deposits on the acantholytic cells would make the Tzanck test more specific, in addition to being a rapid test. Twenty untreated patients with PV confirmed histopathologically were enrolled to evaluate the efficacy of using DIF technique using IgG on Tzanck smear samples. The DIF smears were compared with DIF on skin biopsies in the same patient. This prospective pilot study approved by the institutional ethics committee was carried out in a tertiary health care hospital in a developing country. Of the 15 patients presenting within 3 mo of onset of the illness, 40% (n = 6) showed DIF positivity on Tzanck smear, when compared with 46.67% (n = 7) on skin biopsy. On the other hand, of the five patients presenting beyond 3 mo of their illness, only 20% (n = 2) showed positivity on Tzanck, when compared with all 100% (n = 5) on skin biopsy. The study, thus, suggests that DIF on skin biopsy is comparable to biopsy in diagnosing early PV. This preliminary study proposes that the use of DIF on Tzanck smear is a simple, rapid, painless, and user-friendly out-patient procedure for the diagnosis of early PV, even for relatively inaccessible lesions in the oral cavity and flexural regions. This methodology would be of great help in outlying and rural facilities lacking proper histological equipment, thus avoiding the need for a surgical or punch biopsy or heavy investment in laboratory equipment and expertise. Probable reasons for DIF negativity on Tzanck smears are also discussed.

Pinch skin grafting in non-healing leprous ulcers.

Treatment of leprous ulcers has remained inadequate, owing to the fact that most of these ulcers are still being managed conservatively especially in developing nations, probably due to financial constraints. Pinch skin grafting, though obsolete now (2), tries to bridge this gap between cost and effectiveness. It is a simple office-based technique, not requiring much expertise or investment, and can be done in a simple set-up such as a side room (3). Also, pinch skin grafting has an added advantage over single grafts, in that even if one graft is rejected, there are other grafts, which successfully heal, and epidermize to the surrounding. Moreover, if the ulcer is draining, the discharge flows out in between the grafts, thus preventing the whole graft from being rejected. The only disadvantage to pinch skin grafting is the final cosmetic appearance, which might not be most pleasing. We had very good results with all four patients who underwent this procedure in our institution. The procedure and the final result are described in detail in this report.

Lithium induced hidradenitis suppurativa and acne conglobata.

Lithium is known to cause a variety of dermatological problems, common ones being acneiform eruptions, folliculitis and psoriasis including its pustular form. Hidradenitis suppurativa and acne conglobata are lesser known side effects, with only three reports so far. We report a patient, who had bipolar affective disorder, was on lithium for a long duration and developed hidradenitis suppurativa and acne conglobata during therapy, which subsequently decreased once lithium was stopped. We describe this case for its rarity and analyze its pathogenesis.