Immunotherapy of anogenital warts with measles, mumps, and rubella vaccine.

Anogenital warts, caused by the human papillomavirus, are a cause of significant discomfort and psychological concern for the patients. Despite the availability of multiple treatment options, they are a challenge to manage and may be quite refractory. An easy-to-use therapeutic method with low adverse event profile and low-recurrence rate, therefore, remains highly desirable. In this brief paper, an attempt is made to review the intralesional immunotherapy of anogenital warts with measles, mumps, and rubella vaccine.

Association of Piebaldism with Café-au-Lait Macules.

A 45-day-old infant was brought by his parents to the dermatology outpatient department with chief complaints of asymptomatic, depigmented lesions that had been present on his skin since birth. On mucocutaneous examination, large rhomboid-shaped depigmented macules were noted on the abdomen and lower extremities bilaterally (Figure 1). A depigmented macule was present on the forehead, with white hair (leukotrichia; a "developing forelock") (Figure 2). Three hyperpigmented lesions (café-au-lait macules [CALMs]) were also noted on the chest (Figure 1a). There was no history of consanguinity, and the family history was negative. The infant was otherwise normal for his age. A diagnosis of "piebaldism with CALMs" was made, and his parents were counseled about the disease and its progression, and possible treatment options as the child grew. They were also informed about a currently unquantifiable risk of future development of Legius syndrome or neurofibromatosis type 1 (NF1), and were counseled for regular follow-up.

Epidermodysplasia Verruciformis (Lewandowsky and Lutz's Dysplasia).

A woman in her twenties, with a non-consanguineous marriage, presented to the dermatology clinic with asymptomatic lesions on her face, neck, trunk, and extremities for the past 12 years. The general physical and systemic examination was unremarkable. Cutaneous examination revealed multiple hypopigmented to a few hyperpigmented, slightly scaly tinea versicolor-like macules distributed predominantly on the neck, upper portion of the back, and distal parts of the extremities (Figures 1-5). There were muultiple, slightly erythematous to violaceous flat-topped wart-like papules and plaques were discovered on the arms (Figures 1 and 2), with seborrheic keratosis-like lesions on the face (Figure 5). Baseline investigations, such as complete blood count (CBC), liver function test (LFT), kidney function test (KFT), and plasma glucose levels, were normal. Serologic tests conducted for human immunodeficiency virus (HIV)-1 and HIV-2, and hepatitis B and C were nonreactive. Skin lesion potassium hydroxide (KOH) examination from tinea versicolor-like lesions was negative for fungal elements. Skin biopsies were performed from tinea versicolor-like macules present on the upper portion of the back, flat wart-like plaque on the dorsum of the left hand, and hyperpigmented scaly plaque in the extensor area of the left leg. Histopathologic examination revealed parakeratosis, hyperkeratosis, and acanthosis with swollen keratinocytes, bluish-gray cytoplasm, and rounded nuclei with prominent nucleoli. No dysplastic changes/atypia or mitotic figures (Figures 6 and 7), plus occasional perinuclear halo (a vacuolated area that surrounds the nucleus), were observed. Following clinicopathologic correlation, the patient was diagnosed with epidermodysplasia verruciformis (EV, or Lewandowsky and Lutz's dysplasia).

Ophthalmic Manifestations of Seborrheic Dermatitis.

Seborrheic dermatitis (SD) is a common, chronic inflammatory skin disease that affects the sebaceous tissues of the body. The meibomian glands of the eyelids are modified sebaceous glands. Involvement of the meibomian glands and their dysfunctioning are significant in SD; however, the ophthalmic features of SD have been poorly described in the literature. The ophthalmic manifestations of SD and the significance of ocular examinations in SD patients are discussed in this review.

Predictability of Nailfold Capillaroscopic Score in Diagnosing Retinopathy in Patients with Type 2 Diabetes Mellitus and its Utility as a Non-Invasive Tool for Differentiating from those Not Having Retinopathy: A Pilot Observational Cross-Sectional Analytical Study.

Background: Diabetes mellitus (DM) is a chronic hyperglycaemic state associated with microvascular structural alterations. Nailfold capillaroscopy (NFC) is an in vivo study of microvascular circulation. Aims and Objectives: This study aimed to investigate the diameters of capillary loops and morpho-structural changes using a handheld dermatoscope in patients with type 2 DM (T2DM) with and without diabetic retinopathy (DR) and to establish nailfold capillary changes and NFC score as a non-invasive method to identify microvascular complication in T2DM patients. Material and Methods: A cross-sectional observational study was conducted in AIIMS Rishikesh for 6 months from August 2022 to February 2023. Our study participants were 100 adults more than 18 years of age diagnosed with T2DM, based on the American Diabetes Association (ADA) criteria. All patients were evaluated thoroughly for the presence of microvascular complications in the form of retinopathy. Based on this, they were divided into two groups-group 1 (T2DM with retinopathy) and group 2 (T2DM without retinopathy). Both groups were further subdivided into three subgroups based on haemoglobin A1c (HbA1c): the first group with HbA1c <7%, the second group with HbA1c 7-8.9% and the third group with HbA1c >=9%. For all the study participants, a detailed NFC was done for all 8 fingernails (excluding the thumb), using a handheld dermatoscope. Abnormal capillary shapes (ACS) were recorded by semi-quantitative score (NFC score). Results: A significant association was seen in capillary density (loops/mm) (5.83 ± 0.72 in the DR group and 6.3 ± 0.89 in the no-DR group) (P value = 0.005), capillary density (loops/3 mm) (P value = 0.005), total number of microhaemorrhages/3 mm (P value < .0001), total number of giant capillaries/3 mm (P value = 0.0004), total number of avascular areas/3 mm (P value = 0.0005), enlarged capillaries/3 mm (P value = 0.002), tortuous capillaries/3 mm (P value < .0001), abrogated/bushy capillaries/3 mm (P value = 0.004), number of fingers involved excluding the thumb (P value < .0001) and total nailfold capillaroscopic score (P value < .0001) between the two groups, one with DR and another without DR. Furthermore, the proportion of patients with abnormal nailfold capillaroscopic findings, abnormal NFC score, was significantly higher in patients with DR as compared to patients without DR (51.85% vs 4.35%, respectively) (P value < 0.0001). Conclusion: Our results suggest that NFC could possibly be used as an adjunctive tool in diabetics for diagnosing or monitoring microvascular complications with total NFC score being the significant predictor of DR at a cut-off point of >0 with the area under the curve (AUC) of 0.745 for correctly predicting DR.

Therapeutic Use of Amniotic Membrane Dressing in Toxic Epidermal Necrolysis.

A 45-year-old woman presented with painful erosions and a few dusky vesiculobullous lesions all over the body, including the face, trunk, arms and legs, and oral and genital mucous membranes, for 3 days after consuming tablet diclofenac for fever. There was hemorrhagic crusting on the lips along with conjunctival hyperemia. A clinical diagnosis of toxic epidermal necrolysis (TEN) was made. The Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) was 3 at the time of admission. All routine investigations, including liver function test (LFT), kidney function test (KFT), fasting blood sugar (FBS, 105 mg/dL), and viral serology (Hepatitis B surface antigen [HBsAg], hepatitis C virus [HCV], and Human immunodeficiency virus [HIV]-1, 2), were normal. Blood and urine cultures were sterile. A chest X-ray (posteroanterior [PA] view) and electrocardiogram (ECG) did not reveal any abnormality. The patient was treated conservatively with supportive care, including intravenous fluids, maintenance of ambient temperature, air-fluidized bedding, and appropriate pain and ophthalmic care. For skin lesions, normal saline dressing with paraffin gauge was used; however, after 5 days of treatment, coverage of skin lesions with amniotic membrane dressings was planned due to poor healing. Amniotic membranes are taken from normal delivery patients using aseptic precautions and ensuring negative viral (HBsAg, HCV, and HIV-1, 2) serology. Blood clots were removed from amniotic membranes and stored in buffered normal saline by adding gentamycin. The membranes were applied over the denuded areas (Figures 1 and 2) and wrapped with sterile bandages. The membranes were replaced after 3 days, and removed on day 4 of the second application. More than 90% improvement was observed (Figures 3 and 4) on removal of second application. Supportive treatment was continued, and the patient was discharged on day 20 of admission. (SKINmed. 2022;20:215-217).

Association of Psoriasis With Thyroid Disorders: A Hospital-Based, Cross-Sectional Study.

Background Although numerous studies have been conducted to determine the relationship between psoriasis and thyroid dysfunction, contrasting results have been reported. The link between psoriasis and thyroid disease has not been elucidated well. This study aimed to determine the frequency of thyroid dysfunction and its relationship with gender, age, duration, and severity of psoriasis among patients with psoriasis. Methodology Psoriasis was diagnosed clinically, and the severity of the disease was assessed by the Psoriasis Area Severity Index (PASI) score and the body surface area (BSA) involved, as measured by Wallace's rule of nine. A total of 111 patients with psoriasis were analyzed for thyroid dysfunction, which included thyroid-stimulating hormone, free T3, free T4, and anti-thyroid peroxidase (anti-TPO) antibody levels. SPSS version 23.0 (IBM Corp., Armonk, NY, USA) was used for analysis. Results Out of the 111 analyzed psoriasis patients, deranged thyroid status was observed in 22 patients. Anti-TPO was increased in 19 patients. Patients with thyroid dysfunction had a more severe form of psoriasis (both by PASI score and BSA involvement) than those with mild psoriasis (61.9% vs. 38.1%), whereas patients with increased anti-TPO had a milder disease. Conclusions This study illustrated deranged thyroid status and thyroid autoimmunity in 19.8% and 17.1% of psoriasis patients, respectively, suggesting thyroid dysfunction and autoimmunity. However, further studies are required to expand our knowledge of psoriasis and its association with thyroid dysfunction and thyroid autoimmunity, as well as with age, gender, disease duration, and severity of psoriasis.

Porokeratotic Variant of Lichen Planus.

A 44-year-old woman presented with mildly itchy, brownish-black plaques for the last 2 years. The lesions first appeared on the upper back, followed by involvement of the face and upper arms within 4-5 months. Individual lesions began as small papules that gradually evolved into small, annular, and barely palpable plaques. There were no systemic complaints, photosensitivity, or history of intake of prolonged medication. Cutaneous examination revealed multiple, well-demarcated, and hyperpigmented oval to round plaques on the photo-exposed area, including the face, bilaterally on arms, and upper trunk, measuring about 1 × 1-3 × 3 cm2 in size (Figures 1A and 1B). Dermatoscopic examination established rolled-out, thread, double-marginated border with central atrophy with a brownish reticular background. Multiple brownish to black globules and dark lacunae were also observed (Figures 1C and 1D). No Wickham's striae were viewed. Combination of clinical presentation with dermatoscopic findings indicated a provisional clinical diagnosis of disseminated superficial porokeratosis. Biopsy performed on the upper back revealed hyperkeratotic epidermis with mild lymphocytic exocytosis and spongiosis with pigmentary incontinence. The coronoid lamina was not revealed in any of the pathologic sections examined, including further deeper sections and in a repeat biopsy. Clinical morphology, dermatoscopic features, and pathology were considered compatible with the diagnosis of porokeratotic variant of lichen planus (LP). The patient was counseled and started on topical steroids (fluticasone). She is on regular follow-up.

Psoriasis Alba (White Psoriasis) of the Perianal Region.

A 40-year-old man presented with pruritic perianal lesions existing for 18 months, accompanied by frequent burning sensation on defecating. He had received oral fluconazole 150 mg weekly for a presumptive diagnosis of candidosis earlier. There was no history of other mucocutaneous lesions or comorbidities. The patient denied any unprotected sexual exposure or having anal intercourse. Examination revealed a well-defined perianal, horseshoe-shaped, white-colored macerated plaque with fissures on the gluteal cleft (Figure 1) with tenderness. Examination of scalp, nail, and oral mucosa was unremarkable. Routine investigations, including complete blood counts and chemical profile, were within normal limits. His fasting glucose level was 85 mg/ dL and glycated hemoglobin (HbA1c) was 5.3. The Venereal Disease Research Laboratory (VDRL) test and testing for human immunodeficiency virus (HIV)-1 and 2 were nonreactive. A 10% potassium hydroxide (KOH) examination was negative for fungal elements. Differential diagnoses of flexural psoriasis, Hailey-Hailey disease, and lichen sclerosus were considered, and a skin biopsy for pathology and direct immunofluorescence was performed. The pathologic features showed epidermal acanthosis, hyperkeratosis with elongated rete ridges, and focal hypogranulosis. The upper part of the dermis showed a moderate perivascular mononuclear inflammatory infiltrate with a few melanophages (Figure 2). Direct immunofluorescence was negative. Based on pathologic features, a diagnosis of psoriasis alba was confirmed, and the patient was started on desonide lotion (0.05%) to be applied in the morning and tacrolimus cream (0.1%) at night, plus oral antihistamines. At the follow-up visit 3 weeks later, the lesions diminished to a great extent (Figure 3).

Increased Prevalence of Alcohol Use Disorder (AUD) in Psoriasis and Dermatitis (Eczema).

Inflammatory cutaneous diseases, such as psoriasis, are associated with considerable psychosocial impact and alcohol consumption; however, this association with other skin diseases, such as dermatitis (eczema), is less explored. We examined patients with psoriasis and dermatitis for excessive alcohol consumption using the Alcohol Use Disorders Identification Test (AUDIT). For this cross-sectional, observational study, 385 patients of both genders, aged ≥18 years, who were diagnosed with either psoriasis or dermatitis, were recruited. The primary outcome measure was the AUDIT score. The prevalence of alcohol use disorder (AUD) was 28% in patients with psoriasis and 23% in patients with dermatitis. Men in both groups had statistically significant more hazardous drinking pattern (AUDIT score ≥ 8) when compared with women. The prevalence of the dermatology life quality index (DLQI) ≥ 11 was 57% in psoriasis patients and 51% in dermatitis patients. Accordingly, alcohol consumption behavior in eczema patients was comparable to those with psoriasis. Based upon the research, it is recommended that patients with inflammatory skin diseases must be asked and screened for their alcohol consumption in order to choose appropriate systemic treatment options.

Onychoscopy: a quick and effective tool for diagnosing onychomycosis in a resource-poor setting.

INTRODUCTION: Onychomycosis is the most prevalent nail disease. Although clinical diagnosis of onychomycosis is easy, fungal culture as a confirmatory test requires an equipped laboratory and is time-consuming. Onychoscopy is a simple, quick, and inexpensive technique and may help clinicians increase the diagnostic accuracy of onychomycosis. The aim of this study was to identify common onychoscopic patterns of onychomycosis and correlate them with clinical subtypes of onychomycosis. METHODS: This study was performed in the dermatology outpatient department of a tertiary care hospital in northern India for 6 months. Clinically diagnosed cases of onychomycosis were confirmed by potassium hydroxide (KOH) mount. After obtaining informed written consent, these patients underwent onychoscopy with DermLite II hybrid m, 3Gen, polarized mode, 10× magnification. The common onychoscopic patterns were recorded and the data analyzed. RESULTS: The study included 60 confirmed cases of onychomycosis. The common onychoscopic patterns observed were jagged edges with spikes of the onycholytic area in 65.5% of cases, longitudinal striae in 77.6%, distal irregular termination or a "ruin pattern" in 82.7%, and chromonychia in 62.1%. Clinical types of onychomycosis showed a statistically significant association with chromonychia (p = 0.000), jagged edges with spikes (p = 0.015), and distal irregular termination (p = 0.016). CONCLUSIONS: Onychoscopy can be a complementary tool in clinical diagnosis of onychomycosis to alleviate the need for direct microscopy and culture.