Amit Kumar Malhotra

Intralesional immunotherapy with killed Mycobacterium w vaccine for the treatment of ano‐genital warts: an open label pilot study

Background  Intralesional immunotherapy with skin test antigens and vaccines has been found to be effective in the management of genital and extragenital warts.

Imiquimod 5% cream for the prevention of recurrence after excision of presternal keloids

Imiquimod 5% cream has been found to be effective and safe in preventing recurrence of keloids on earlobes after excision. We evaluated the efficacy and safety of imiquimod 5% cream in preventing the recurrence of presternal keloids after excision (3 keloids in 2 patients). After excision with radiofrequency, imiquimod 5% cream was applied once daily at bedtime for 8 weeks, and the defect was left to heal by secondary intention. In all the treated keloids, the defect healed in 6–8 weeks, and no recurrence was seen while on imiquimod application; however, all keloids completely recurred within 4 weeks of stopping imiquimod. Side effects were mild and acceptable in the form of burning and pain. Imiquimod did exert an antifibrotic action but it was short-lived.

Chronic arsenic toxicity from Ayurvedic medicines.

Background  Ayurvedic medicines are known to contain arsenic and concentrations up to toxic levels have been reported in certain formulations. However, clinical disease due to arsenic containing ayurvedic medicines has rarely been reported. We seek to highlight the existence of toxic levels of arsenic in certain ayurvedic preparations that can produce serious systemic manifestations.

Osteoma cutis in pseudohypoparathyroidism.

Osteoma cutis is the formation of normal bone in the skin. Primary osteoma cutis occurs de novo, whereas the secondary type develops in association with the underlying inflammatory, tumorous or traumatic conditions. Primary osteoma cutis is also associated with Albrights hereditary osteodystrophy (AHO), which can include hypocalcaemic‐type pseudohypoparathyroidism (also known as pseudohypoparathyroidism type Ia) or normocalcaemic‐type pseudohypoparathyroidism (also known as pseudopseudohypoparathyroidism). We describe a case of osteoma cutis in a 7‐year‐old boy who had cutaneous, biochemical and phenotypic features of pseudohypoparathyroidism type Ia and AHO.

Multiple basal cell carcinomas in xeroderma pigmentosum treated with imiquimod 5% cream.

Abstract:  We report successful treatment of multiple basal cell carcinomas with imiquimod 5% cream in a 16‐year‐old boy with xeroderma pigmentosum and review the possibility of prophylactic role of imiquimod in the disease. Imiquimod cream was applied uniformly over all the basal cell carcinoma lesions and background pigmented skin, once at bedtime on every alternate day for 12 weeks. Besides the basal cell carcinomas, the background hyperpigmentation and keratotic papules also cleared, and the skin texture improved. The lesions did not recur at the treated sites during the follow up of 1 year.

EFFECTIVENESS OF ISOTRETINOIN IN PAPILLON–LEFÈVRE SYNDROME

blood count, erythrocyte sedimentation rate, rheumatoid factor, and antinuclear antibody testing, may be necessary (1,3,7). We present this patient to make dermatologists aware of the MR imaging features of subcutaneous GA. The usefulness of ordering such radiologic studies – especially because biopsy may be necessary in any event – should be considered on a case-by-case basis. However, dermatologists should be familiar with these radiologic features and their general specificity because MR imaging studies may be performed before patients are referred to dermatology (3). Moreover, MR imaging conceivably could be useful in reducing the need for additional biopsy procedures in patients with multiple or recurrent lesions.

Lichen sclerosus: Role of occlusion of the genital skin in the pathogenesis

Lichen sclerosus (LS) is a chronic inflammatory skin disease, which most commonly involves the anogenital region. The etiology of LS is obscure, but genetic susceptibility, autoimmune mechanisms, infective agents like human papillomavirus and spirochaetes, and Koebner phenomenon has been postulated as causative factors. We report our observation in 6 patients (3 males and 3 females) with histologically proven lichen sclerosus that showed relative sparing of the uncovered areas of the genitals, thereby suggesting that the occlusion of the genital skin may be playing a greater role in the causation of LS than is currently thought, in both sexes.

Melkersson–Rosenthal syndrome with diffuse facial swelling and multiple cranial nerve palsies

We report an unusual case of Melkersson–Rosenthal syndrome presenting as diffuse facial swelling with facial, glossopharyngeal and vagus nerve palsies. A skin biopsy revealed non‐caseating epithelioid cell granulomas throughout the dermis. The disease responded poorly to systemic steroids, antihistamines, antibiotics and potassium iodide.

Nerve involvement in Indian post kala-azar dermal leishmaniasis.

Sir,Post kala-azar dermal leishmaniasis (PKDL) is a well-recognized sequel of kala-azar in India, developingin approximately 20% cases after a variable timeinterval of 1–5 years (1). The disease occurs chieflyin the eastern parts of India, an area that also hasa high prevalence of leprosy. PKDL manifests assymmetrically distributed hypopigmented macules,papules, infiltrated plaques and nodules, that bear aclose resemblance to leprosy, with which it is oftenconfused. Clinical and pathological features to differ-entiate the two diseases have been described (2).Nerve inflammation on skin biopsy is considered adiagnostic feature of leprosy. We describe a case ofIndian PKDL with lesional nerve infiltration, histolo-gically mimicking tuberculoid leprosy. The diagnosis ofPKDL was confirmed by serological and gene ampli-fication techniques. Nerve involvement has beenreported in the Sudanese variety of PKDL (3). As faras ascertained, this feature has not been previouslyreported in Indian PKDL.CASE REPORTA 25-year-old migrant labourer from Bihar presentedwith widespread, asymptomatic macular and papularlesions of 2 years duration. It was not associated withtingling, numbness or paraesthesia, fever or constitu-tional symptoms. He had kala-azar 10 years ago andwas treated with 24 intramuscular injections of sodiumantimony stibogluconate, with complete cure.Dermatological examination revealed multiple, dis-crete and coalescent, symmetrically distributed hypo-pigmented macules and papules, distributed on the faceincluding ear lobes, the trunk and extremities (Fig. 1).There was no lesional or glove and stocking anaesthesiaor peripheral nerve enlargement. Mucous membraneswere spared. Examination of the abdomen, cardio-vascular and central nervous systems revealed noabnormality.The haematological and biochemical investigationswere normal. Focal calcifications in the spleen wereobserved on ultrasonography of the abdomen, sugges-tive of previous kala-azar. Slit skin smears from thepapular lesions stained with Giemsa, acridine orangeand Ziehl Neelsen stains failed to demonstrateLeishman-Donovan (LD) bodies or acid-fast bacilli.A skin biopsy obtained from a papule, revealeda superficial and deep dermal, moderately dense,granulomatous infiltrate composed of epithelioid cellsand lymphocytes around the blood vessels, appendagesand nerve twigs. There were no plasma cells ormacrophages; LD bodies could not be demonstrated.On S-100 staining, fibrillar structures, suggestive ofnerve twigs, could be identified within the granulomas(Fig. 2). The histopathological features were suggestiveof tuberculoid leprosy. Enzyme-linked immunosorbentassay (ELISA) for PKDL and a strip test based onrecombinant K39 antigen (4) were positive. A 600-bpfragment of the Leishmania donovani-specific kineto-plast mini-circle DNA was amplified from the skinsample by polymerase chain reaction (PCR) (5).The diagnosis of PKDL was confirmed by serologicaland DNA amplification procedures. However, thepatient refused therapy, as he had to go back to hisvillage for financial reasons.DISCUSSIONThe remarkable clinical similarity between PKDL andleprosy is well known. The differentiating featuresinclude predilection of PKDL lesions for the centro-facial region, absence of neurological deficit bothclinically and histologically and demonstration of LDbodies in slit skin smears or histological sections.However, in various series on PKDL reported fromdifferent parts of the world, the parasite could bedemonstrated by slit smears in only 20–66.6% oflesions and on histopathology, the detection ratewas sometimes as low as 20% (6, 7). Under suchcircumstances, establishing the diagnosis of PKDL and

How useful is the Mantoux test in the diagnosis of doubtful cases of cutaneous tuberculosis

Background  Diagnostic tests are critical to management when the clinical picture is unclear. We analyzed the records of patients in whom the initial diagnosis of cutaneous tuberculosis was doubtful to evaluate the utility of the Mantoux test in this setting.