Abir Saraswat

Palmoplantar lesions in psoriasis : A study of 3065 patients

Although palmoplantar psoriasis can be severely disabling, there are very few large clinico-epidemiological studies on this condition. Our purpose was to study the morphology and pattern of lesions in Indian patients with palmoplantar psoriasis and to elucidate the role of occupation in the incidence/localization of these lesions. All patients attending our Psoriasis Clinic from 1993 to 2000 were screened for palmoplantar lesions and their demographic characteristics, occupation and the exact localization of the lesions were noted. Out of 3,065 patients screened, 532 had palm and/or sole involvement. Plantar lesions were seen in 91.9% and palmar lesions in 55.6% of these patients. Four distinct patterns of lesion localization were noted on the palms and 5 patterns on the soles. Almost half of the men involved in regular manual labor had palmar lesions restricted to areas exposed to pressure, whereas only a quarter of other men had this type of lesion pattern. All patients with unilateral palmar lesions had them on their dominant hand and these patients were involved in regular manual labor. In our patients, the prevalence of plantar lesions was much higher than that of palmar lesions. The possible role of occupational trauma in lesion localization in Indian patients with palmoplantar psoriasis is discussed.

Rediscovering hydroxyurea: its role in recalcitrant psoriasis

Abstract

Comparison of Calcipotriol and Coal Tar in Conjunction with Sun Exposure in Chronic Plaque Psoriasis: A Pilot Study

This study was a left‐right comparison of the efficacy of 0.005% calcipotriol ointment and 5% coal tar ointment in conjunction with sun exposure in 10 patients with stable plaque psoriasis. After four weeks of therapy, the calcipotriol treated site showed a significantly faster fall in PASI compared to the coal tar treated site. At eight weeks, this difference was not significant with both sides showing comparable improvement in lesions, as shown by PASI values. There were no significant side effects from either therapy. We conclude that both calcipotriol and coal tar ointments have comparable efficacy in treating stable plaque psoriasis when used simultaneously with sun exposure, although the initial response to calcipotriol is faster.

Conventional Cold Excision Combined with Dermabrasion for Rhinophyma

A 65‐year‐old man, farmer by occupation, presented with redness and gradual enlargement of the nose. Examination revealed marked nodular enlargement of the nose and loss of normal nasal contours. Sebaceous material could be expressed from widened pores. The patient was diagnosed as rhinophyma of moderate degree. He was treated with cold knife excision combined with dermabrasion. A literature scan revealed that currently there is no evidence of superiority of much popular laser surgery over conventional cold knife surgery combined with dermabrasion for rhinophyma. Conventional surgery is time‐tested, and it does not require expensive equiment or special training.

Lesions resembling polymorphic eruption of pregnancy several years after pregnancy.

A 53-year-old woman presented to the Gynaecology Department with complaints of vaginal discharge and intermittent mild pain in the lower abdomen for the past 4 months. She had reached menopause 3 years back and had no history of bleeding per vaginum after that. She gave a history of losing 6 kg in the past 4 months. On internal examination, her cervix was bulky and bled on touch. A biopsy was taken and she was diagnosed as having cervical cancer (stage IIb) and was advised to undergo radiotherapy. One day prior to the beginning of radiotherapy, she was referred to the Dermatology Department because of intensely pruritic erythematous lesions on her abdomen which had appeared 10 days before. There was no history of any prior drug intake. On examination, she had numerous erythematous 5to 20-mm papuloplaques localised to the striae distensiae on the lower abdomen. A few lesions were topped with pinpoint excoriations and tiny crusts. She recalled having similar lesions during all 4 prior pregnancies, the last of which was 28 years back. Her haemogram, liver and renal function tests were all within normal limits. Scrapings for scabies and tinea were repeatedly negative. A skin biopsy was advised, but could not be done for fear of non-healing as she was about to start radiotherapy the same day. She was advised to apply topical corticosteroids twice a day for 1 week after which there was marked improvement in the lesions. Polymorphic eruption of pregnancy (PEP) is a common, intensely pruritic dermatosis which occurs in approximately 1 in 240 pregnancies [1]. The lesions usually begin and predominate over the striae distensiae, although they can later spread to the thighs, arms and upper abdomen. PEP most often occurs in primigravidae and rarely re-occurs in subsequent pregnancies [2]. In a recent review it has been classified along with pemphigoid gestationis and cholestasis of pregnancy as a unique dermatosis of pregnancy [3]. Almost all reported cases of PEP have begun in the third trimester and rarely in the post-partum period [4]. A Medline search did not reveal any reported cases in non-pregnant women. In our case, the occurrence of itchy polymorphic lesions localised to the striae combined with a history of similar lesions in all previous pregnancies strongly suggests that these lesions were analogous to her previous episodes of PEP. The rapid disappearance of lesions with topical corticosteroids is also similar to the response seen in most cases of PEP. Although a biopsy could not be done in our patient, histopathological findings in cases of PEP are most often nonspecific [1]. The cause of PEP is still unknown and the only factor reported to be significantly related to its occurrence is twin pregnancy [5], due to excessive stretching of the abdominal skin, although this finding has been disputed [6]. Our patient gave a history of weight loss in the months preceding the onset of the rash, which was probably related to the cervical cancer. A recent study has implicated the phenomenon of ‘microchimerism’ in the pathogenesis of PEP [7]. Fetal DNA was detected in the epidermis of 50% and the dermis of 40% of women with PEP carrying male foetuses, but in none of the controls. It was postulated that the skin lesions may be a reaction to the presence of fetal cells in the epidermis and dermis. In another report, Bianchi et al. [8] have reported the presence of male fetal progenitor cells in maternal circulation for up to 27 years post partum. Our case may represent an analogous situation in which migration of persisting fetal cells to the skin may have elicited a PEP-like eruption 28 years after the last pregnancy. Ectopic production of human chorionic gonadotropin has also been reported in cases of carcinoma of the cervix [9], which can presumably produce a milieu resembling pregnancy thereby including PEP-like lesions. Our patient is the first reported case of recurrent PEP-like lesions in a non-pregnant woman and suggests that this dermatosis considered exclusive to the pregnancy period may rely on mechanisms developing also after delivery.

Acropigmentation of Dohi in an Indian family.

Dyschromatosis symmetrica hereditaria (DSH) is a rare, autosomally dominant genodermatosis, first reported as a clinical entity by Toyama (1, 2). This condition was described by Dohi in 1920 in 12 Japanese patients and reported later by Komaya (3) as “acropigmentation symmetrica of Dohi”. The term (reticulate) acropigmentation of Dohi is now used synonymously with DSH, more so in the Western literature (4). Apart from the skin lesions, there are no commonly associated disorders seen with acropigmentation of Dohi. We report a case associated with psoriasis. The significance of this association is also discussed. The proband was a 12 year-old Indian boy who presented with complaints of itchy, erythematous, scaly lesions over the trunk, extremities, and scalp for a duration of 8 months. On examination, these were found to be plaque-type lesions of psoriasis. In addition, he had multiple, 1–5 mm, hypopigmented and hyperpigmented macules over the hands, forearms, and below the knees on both legs (Fig. 1). These lesions had been present since infancy and had gradually increased with age. A clinical diagnosis of reticulate acropigmentation of Dohi with psoriasis was made. A punch biopsy from the hyperpigmented and hypopigmented macules revealed adjacent areas of basal hypermelanosis and hypomelanosis. This pigmentary disorder in the index case led us to the other affected members in his familyhis brother, aunt and grandmother also had had mottled pigmentation over distal parts of extremities dating back to early childhood (Fig. 2). The palms and soles were spared in all including the index case. None of the other affected members had psoriasis or any other cutaneous or systemic disease. Acropigmentation of Dohi is characterized by the distribution of hyperpigmented and hypopigmented macules on the extremities, especially over the dorsa of hands and feet. The lesions appear in infancy or early childhood over the extremities, slowly extend proximally and may affect the sides of the neck and face. The lesions are found predominantly on photo exposed areas and become more marked after sun exposure, although there is no evidence of photosensitivity. They usually stop spreading before The Journal of Dermatology Vol. 29: 386–388, 2002

Progressive Macular Hemangioma: A New Entity?

We report a 22-year-old man with an extensive cutaneous vascular lesion involving the left arm since the age of 2 months. The lesion was macular and had been growing steadily in extent since its appearance. It had crossed the midline in several places. There was no involvement of any internal organ. Histopathology and immunostaining revealed unmistakable evidence of vascular proliferation. The predominantly macular character of the lesion, even with passage of time, besides the absence of several other features, usually associated with a tufted angioma, led us to the use of the term ‘progressive macular hemangioma’ for this condition.