Aastha Gupta

Bilateral lichen striatus: A case report with review of literature

Lichen striatus is a self-limiting dermatosis presenting with sudden eruption of lichenoid papules along the lines of Blaschko. A 5-year-old girl presented with asymptomatic hypopigmented linear lesions over both upper limbs. The histopathological examination revealed spongiosis, vacuolar alteration of the basal layer and lymphocytic exocytosis with a mild-to-moderate perivascular mononuclear infiltrate in the dermis. Lichen striatus was diagnosed based upon the characteristic clinical and histopathological findings. The pathogenetic mechanism of bilateral lichen striatus is unknown at present, however, a somatic mutation in two different clones of cells can be a possibility.

An unusual case of noma caused by Klebsiella pnuemoniae and its management

Noma or cancrum oris is an orofacial gangrene causing progressive mutilating destruction of the infected tissues. It mainly affects malnourished children with poor oral hygiene and concurrent debilitating systemic illnesses. It is a polymicrobial infection and borrelia vincentii and fusobacterium are the most important pathogens known. We present a case of a boy aged 2.5 years with noma where klebsiella was grown and was the initial cause of failure of empiric therapy.

Recalcitrant alopecia areata responsive to leflunomide and anthralin-Potentially undiscovered JAK/STAT inhibitors?

Several treatment modalities are available for the management of alopecia areata (AA); however, no therapy is universally effective and treatment can be frustrating in severe cases, with low response and high recurrence rates. Recent studies show that the JAK/STAT pathway plays a central role in the pathogenesis of this disease by determining the crosstalk between the infiltrating CD8+ T cells and the hair follicles, suggesting a role of JAK inhibitors in the treatment of AA. However, reports on the off‐label use of these more expensive targeted agents have shown variable results. We present a case of a child with recalcitrant ophiasis‐pattern AA who had failed steroid therapy and was treated successfully with leflunomide and anthralin, possibly by the synergistic effect on the JAK/STAT pathway inhibition, and we propose this combination could be a cost‐effective therapeutic option for recalcitrant AA.

Extensive hypopigmented cribriform lesions with fine scaling in a child

A 14-year-old boy presented with multiple asymptomatic hypopigmented lesions present on the trunk for the past 6 months. His past medical history was unremarkable, and he did not have atopic dermatitis or any immunodeficiency. He had received systemic corticosteroids (injection triamcinolone acetonide 40 mg/mL intramuscular monthly for 6 months) and antihistamines from a general physician for a mistaken diagnosis of psoriasis. Cutaneous examination revealed hyperkeratotic hypopigmented lesions involving the trunk, neck, and upper limbs that were discrete and confluent (Figure 1). On close examination, the lesions could be seen to be scaly, which became prominent after scratching with a glass slide. Skin biopsy was taken from the lesions over the trunk and skin scrapings were examined using potassium hydroxide.

Lymphangioma circumscriptum treated with combination of Bleomycin sclerotherapy and Radiofrequency ablation

ABSTRACT Lymphangioma circumscriptum (LC) is a lymphatic malformation presenting with vesiculo-papules or warty lesions, resembling a “frog-spawn”. Many treatment modalities have been described but random excision is still often needed. Bleomycin is a safe sclerosant with specific action on the vascular endothelial cells. It has been used extensively in cystic hygromas but its use in LC of the skin has not been documented previously. We present this case with extensive LC of the flank treated with a combination of intralesional bleomycin and radiofrequency ablation in the same sitting. As the lesion was extensive, treatment was done in three sittings, one to each third. Near complete resolution, with no significant recurrence was achieved with a single sitting to each third.

Description of a new pigmentary demarcation line (Type I)

A 52-year-old man presented with hypopigmented lesions on his chest, which had been present since childhood. The lesions were asymptomatic. They were not scaly, and sensation in the areas was normal. There was no history of any preceding inflammatory skin lesions or topical applications. Physical examination revealed a hypopigmented lesion on the chest, extending laterally along the medial aspect of the arm and posteriorly involving the nape of the neck and the upper back. The lateral border of the lesion and its extension upwards and posteriorly on the back was sharply demarcated, whereas the lower border on the chest merged imperceptibly into the surrounding normal skin (Fig. 1). Potassium hydroxide smear was noncontributory. Histopathological examination revealed decreased basal layer pigmentation in the hypopigmented area compared with the normal skin with normal number of melanocytes on S-100 staining (Fig. 2). A diagnosis of pigmentary demarcation line (PDL) was made. The anterior pattern roughly corresponded with the previously described Miura type A-III PDL, with some variation. The pattern seen over the upper back is previously unreported. We labelled this presentation as Type I PDL. PDLs are physiological, abrupt transitions between darker and lighter pigmented skin areas, and were described initially by Maztumoto in Japanese patients and Futcher in African patients. Miura classified these lines into four groups (lines A to D) based on his observation in Japanese patients; later, line E and lines F, G and H, described in Africans and Indians respectively, were added. Further, these PDLs have been divided into subtypes based on their location and extension. For instance, Group A lines, seen on the anteromedial aspect of upper arms, have been divided into four subtypes based on the variations in the pattern of their transpectoral extension observed among Japanese patients. However, the presence and frequency of transpectoral extension has not been described in other populations (except in an African patient with Type I PDL) and has not been reported previously in the Indian population. The aetiology of PDLs remains unknown. According to some authors, PDLs are atavistic remnants. Racial differences in their frequency suggest the role of genetic factors, and their appearance during pregnancy suggests a role of hormonal factors. Krivo proposed the clonal– Blaschko linear theory, suggesting that PDLs are due to pigmentary mosaicism and follow the lines of Blaschko. Others believe that they correspond to the axial lines of Sherrington. Recently, Maleville proposed the axial neural theory, suggesting that PDLs arise due to different homeobox genes controlling melanogenesis in various neural territories. Our patient presented with a PDL that did not conform to any pattern described previously. It started as a group A line, having a wavy transpectoral extension (corresponding to Muiro group A III line); however, its upward extension towards the neck has not been reported (a)

Multifocal cutaneous Rosai-Dorfman disease masquerading as lupus vulgaris in a child

Dear Editor, A 13-year-old girl presented to us with red plaques and nodules on her chest and ears for the past two years. The lesions gradually increased in size and were asymptomatic. The patient was otherwise healthy and had no significant past medical history. General physical examination was normal, with no lymph node enlargement. Cutaneous examination revealed multiple infiltrative erythematous plaques, nodules and scars on the right breast surrounding an area of central atrophy and hypopigmentation, which occurred due to the intralesional triamcinolone injections received by the patient from a local practitioner (Figure 1). There was a reddish-yellow nodule of 1cm in size on the pinna of the left ear (Figure 2). There was no mucosal involvement. Routine biochemical tests were normal. Histopathological examination revealed a dense pandermal infiltrate composed of histiocytes and admixed plasma cells, neutrophils, lymphocytes and multinucleate giant cells. Histiocytes had abundant eosinophilic to pale cytoplasm and occasionally an inflammatory cell was present within the cytoplasm suggestive of emperipolesis (Figure 3). Mild fibrosis was present intervening the infiltrate. Stain for acid fast bacilli (AFB) was negative. Immunohistochemical staining revealed that the histiocytes were positive for S-100, CD68 and CD163. CD1a staining was negative. Fungal and AFB cultures were negative. Based on the above findings a diagnosis of cutaneous Rosai-Dorfman disease (RDD) was made. Patient was advised excision of the lesions.

Rational for drug dosimetry and duration of terbinafine in the context of recalcitrant dermatophytosis: Is 500 mg better than 250 mg OD or BD?

Drug dosimetry is dependent on three steps before their clinical utility can be assessed.[3] The most basic involves the experimental determination of the pharmacokinetic/ pharmacodynamics (PK/PD) levels of the drug. This is followed by assessing the drug’s skin PK/PD index and then assessing the proper dose and understanding the level of treatment efficacy desired. This is followed by its clinical application.

Looking Beyond the Cyclosporine “Swish and Spit” Technique in a Recalcitrant Case of Erosive Lichen Planus Involving the Tongue

Oral lichen planus is a relatively common autoimmune disease affecting the middle-aged population. Although no treatment is necessary for a benign asymptomatic case, in case of erosive lichen planus, topical corticosteroids form the mainstay of treatment. In case of failure, apart from tacrolimus, cyclosporine, using the “swish and spit” technique, is a valid therapeutic intervention. In our case, though, this therapeutic option had to be replaced by the systemic use of cyclosporine with gratifying results.