Anuradha Bishnoi

Phototherapy using narrowband ultraviolet B and psoralen plus ultraviolet A is beneficial in steroid-dependent antihistamine-refractory chronic urticaria: a randomized, prospective observer-blinded comparative study

Literature on the efficacy of phototherapy in steroid‐dependent antihistamine‐refractory chronic urticaria (CRU) is limited.

Dermatoscopic evaluation and histopathological correlation of acquired dermal macular hyperpigmentation

Acquired dermal macular hyperpigmentation (ADMH) is a hypernym encompassing Riehls melanosis, lichen planus pigmentosus, and ashy dermatoses that show significant clinicopathological overlap. We sought to describe the dermatoscopic features of ADMH and correlate them with histopathological findings.

Involvement of flexures in an adolescent patient with dermatomyositis: extension of inverse Gottron papules?

A 16-year-old presented with a 6-month history of poikilodermatous changes on the shoulders, upper back, upper arms and ‘V’ area of the chest, associated with progressive proximal muscle weakness and photosensitivity. Physical examination of the patient’s hands revealed atrophic nontender lichenoid papules with scaling on both the dorsal and ventral aspects of the interphalangeal joints (Fig. 1a). Interestingly, a few erythematous to violaceous, scaly plaques were present on the flexural aspects of the wrists, bilateral cubital fossae, axillae, popliteal fossae and abdominal folds. There was associated pigmentary change in the form of depigmentation in the popliteal fossa (Fig. 1b–d). No dilated capillaries were seen in the nail folds. Muscle power was reduced in both knee and arm extensors. Histological examination of a skin biopsy from the palmar papules showed hyperkeratosis, focal basal cell vacuolization, mild perivascular lymphocytic infiltrate and melanin incontinence (Fig. 2a), while a biopsy from the cubital fossa demonstrated hyperkeratosis, epidermal atrophy, necrotic keratinocytes, extensive basal cell vacuolization, and moderate perivascular and interstitial lymphocytic infiltrate (Fig. 2b). Direct immunofluorescence examination was negative. The findings were consistent with dermatomyositis. Levels of muscle enzymes were raised and electromyography showed myopathic changes. Chest examination and high-resolution computed tomography did not show evidence of interstitial lung disease. Atrophic lichenoid papules on the dorsal aspect of interphalangeal joints, elbows and knees are referred to as Gottron papules (GP) of dermatomyositis, and represent a pathognomonic finding. Hand examination is important in patients with dermatomyositis, as it can reveal GP, mechanic’s hands and nail-fold abnormalities. Our patient had GP on his hands and elbows. Rarely, similar papules may be present over the palmar aspect of the interphalangeal joints, known as inverse GP. The presence of inverse GPs has been shown to correlate with the presence of interstitial lung disease and myositis-specific antibodies. When associated with antimelanoma differentiation-associated antigen-5 antibody, these papules are erythematous and tender, whereas when associated with antitranscriptional intermediary factor-c antibody, they are nontender and nonerythematous. Our patient did not have positive anti-Mi-2 or anti-Jo-1 antibodies. The rest of the myositis-specific antibody panel could not be performed because of the lack of facilities. Antinuclear antibody titre was raised at 1 : 160. Dermatomyositis chiefly involves the extensor aspects of the extremities, notably the extensors of the hands, elbows and knees. The index patient exemplifies unique findings in the form of flexural involvement in addition to characteristic extensor involvement. Although palmar papules have been previously described as inverse GP, those extending to other flexures (with sparing of the intervening skin) are unique and have not been described previously in the literature. In addition, the histopathological findings of the flexural lesions were characteristic, revealing interphase dermatitis consistent with dermatomyositis. The patient is currently receiving prednisolone and methotrexate for his disease, and is under continuing follow-up. There is substantial improvement in the muscle weakness. The lesions on the axillae and cubital fossae have resolved with pigmentary changes suggestive of poikiloderma. Inverse GP are still persistent. The patient is still receiving tapering doses of prednisolone and methotrexate. It is important to identify novel cutaneous manifestations associated with rare disorders as Correspondence: Professor Davinder Parsad, Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh, 160012, India E-mail: parsad@me.com

Teneligliptin-associated bullous pemphigoid in an elderly man with diabetes

Dermatology consultation was sought by a 69-year-old man for complaints of recent-onset erythematous, itchy, fluid-filled lesions that appeared either spontaneously or were incited by minor trauma and tended to rupture within 4–5 days. On examination, there were few (<10 in number) haemorrhagic blisters of variable sizes (maximum up to 2 cm diameter) distributed on the chest, abdomen and upper extremities (figure 1A and B). The bullae had settled down or eroded and had healed with hypopigmentation at few places. No mucosal involvement was seen. His nails were normal. Figure 1 (A,B) Few, scattered haemorrhagic bullae, distributed on the neck, chest, abdomen and upper extremities. Some of the bullae had ruptured and healed, leaving behind hypopigmentation, while many had settled as such. Note the characteristic absence of background urticarial and eczematous lesions, and relatively small-sized bullae. (C,D) Split at the dermoepidermal junction with blister cavity containing eosinophils and neutrophils. The dermis shows moderate inflammatory infiltrate comprising eosinophils and lymphomononuclear …

Comparison of effectiveness and safety of excimer lamp vs topical calcipotriol-clobetasol propionate combination in the treatment of palmoplantar psoriasis

Very few studies have assessed the efficacy of excimer in the treatment of palmoplantar psoriasis (PPP), and none has compared the excimer with calcipotriol‐clobetasol propionate combination.

Paraneoplastic bullous pemphigoid associated with penile squamous cell carcinoma

Editor A 43-year-old farmer presented to us for evaluation of multiple, itchy, tense vesicles and bullae, containing clear to haemorrhagic fluid, surmounting an urticarial background on his thighs and inguinal area for 20 days (Fig. 1a). He was also undergoing evaluation for bilateral metastatic inguinal lymphadenopathy detected 3 months back that had revealed squamous cell carcinoma on cytology. Search for primary was still on. Genital examination incidentally revealed a bright red, welldefined, verrucous plaque on glans penis (Fig. 1b). Inguinal lymph nodes were enlarged (7 9 5 cm on the right and 5 9 5 cm on the left side), hard and non-tender. Per-rectal examination was normal. Patient had noticed the penile lesion about 2 years back, but had been reluctant to consult about this. There were no systemic symptoms except backache. His HIV, VDRL, chlamydia serology, Tzanck smear and gram stain from the genital lesion were non-contributory. Histopathology from the genital lesion revealed dysplastic epithelium and early invasion of basement membrane by atypical squamous cells forming small clusters rendering a diagnosis of microinvasive moderately differentiated penile squamous cell carcinoma (Fig. 2a and b). Histopathology from the bullae showed a subepidermal split with cavity containing eosinophils (Fig. 2c and d). DIF demonstrated homogeneous linear deposition of IgG, IgA and C3 at basement membrane (Fig. 2e, f and g). A diagnosis of bullous pemphigoid (BP) associated with penile squamous cell carcinoma (SCC) was made. PET scan revealed active uptakes in spine and ribs. He received cisplatinand taxane-based chemotherapy and oral prednisolone. Paraneoplastic dermatoses (PD) are the cutaneous manifestations secondary to malignancies, without direct neoplastic infiltration into the skin. To satisfy the criteria, a PD should develop after malignancy and follow a parallel clinical course. But this has some obvious limitations. The malignancy is not always identifiable despite exhaustive efforts. Sometimes, the malignancy is too advanced to determine whether PD responds to its resolution. Lastly, the PD may not respond to the treatment of malignancy, such as paraneoplastic pemphigus (PNP). BP is characterized by formation of autoantibodies against BP antigen 1 (BPAg1) and 2 (BPAg2). Data pertaining to pemphigoid associated with malignancy (PAM) is heterogeneous. Both BP and malignancies primarily affect elderly population. Some studies report an enhanced risk of malignancies (around 5.8–19%) in BP compared to general population, whereas some report that few malignancies (laryngeal cancer, renal cell carcinoma and lymphoid malignancies) herald an increased risk of developing BP. Cross-reaction between tumour and hemidesmosome antigens, tumour-mediated basement membrane damage and subsequent antibody response and a common predisposing genetic background (HLA-B13) are some of the theories proposed for the development of PAM. Unlike PNP, PAM is essentially similar to classical BP, with slightly more mucosal involvement. Balestri and colleagues suggest suspecting PAM in patients having treatment refractory or early-onset disease. We could find only single previous report of BP following metastatic penile SCC. Penile SCC is a flat, infiltrative or papillary growth that can present with phimosis and inguinal lymphadenopathy. BPAg1 upregulation has been observed in penile SCC that correlated with the metastatic potential. We could not obtain BPAg1 ELISA in our patient due to lack of facilities. BP in our patient presented at a relatively younger age, closely following the inguinal lymphadenopathy. There was excellent response of BP to prednisolone, which was tapered and stopped within 2 months (Fig. 1c and d). There has been no relapse of BP, while the patient is on chemotherapy and brachytherapy. We report this case for its classical clinical presentation demonstrating PAM and highlight the delay before active treatment for genital pathologies, because of the associated fear, stigma and/ or embarrassment. Figure 1 (a) Multiple tense vesicles and bullae, containing clear to haemorrhagic fluid, on thighs and inguinal area. Bilateral inguinal lymphadenopathy is apparent. (b) A well-defined erythematous plaque with verrucous surface on dorsal aspect of glans. (c and d) Significant improvement at 1-month follow-up (c) and 2-month follow-up (d). Penile SCC is still present on the glans, albeit the size has reduced.

Velvety Hyperpigmentation on Hands and Feet of a Young Girl: Acral Acanthosis Nigricans

A lean young girl presented with bilaterally symmetrical, hyperpigmented, hyperkeratotic, velvetyplaques on the dorsa of her hands and feet. They were accentuated on knuckles with linear disposition on interphalangeal area. Examination of neck, axillae, groins, palms, soles, and mucosae was normal. There was no evidence of endocrinopathy or prior drug intake. Schwartz has classified acanthosis nigricans (AN) as benign, malignant, obesity associated, acral, unilateral, drug induced, syndromic, and mixed. Acral AN (acral acanthotic anomaly) affects extremities in isolation, is more common in darker skin types, and usually occurs in the absence of systemic features. The concern of the patients is usually cosmetic, and the condition responds to keratolytics.

Task Shifting in Dermatology—A Call to Action

Task Shifting in Dermatology—A Call to Action To the Editor In response to the Evidence Synopsis by Brown et al1 on the practice of task shifting, we would like to highlight how task shifting is currently being successfully implemented in health programs in India, with emphasis on National Leprosy Eradication Program. Task shifting refers to the strengthening of the peripheral health care workforce to provide better health care in the remote geographical areas. India is a large country with a vast population, and most of its people reside in remote rural areas; these people benefit greatly from task shifting.2 Health care workers are voluntary laypeople trained to promote health among their peers. They include accredited social health activists, village health guides, multipurpose health care workers, and many others. They serve a predefined population and are provided performance-based monetary incentives for their services.2 They carry out active surveillance of diseases and provide basic treatment, follow-up, and referral to medical officers, whenever needed. Periodic training helps them to meticulously plan and execute their activities, making it possible to decentralize otherwise centrally sponsored programs for tuberculosis, leprosy, vector-borne diseases, nutritional deficiencies, immunization, sexually transmitted infections, and reproductive, maternal, and child health. Dermatology is a visual specialty and can implement task shifting by training emissaries to diagnose few major skin ailments. The practice has been effectively used in the Indian National Leprosy Eradication Program, where grassroots multipurpose health care workers are trained to identify the hypopigmented patches, skin nodules, and deformities that are so characteristic of leprosy. They are also trained to make slit-skin smears whenever possible. Periodic intensified drives carried out in hyperendemic blocks have increased the new case detection rate by as much as 6 times.3,4 Within 6 days of active case surveillance carried out by trained multipurpose health care workers, 358 hidden cases of leprosy were identified increasing the annual new case detection rate from 21.3 to 28.9 per 100 000 persons and prevalence from 1.37 to 2.09 per 10 000 persons in a targeted block awareness campaign.5 Physical, cultural, and psychosocial proximity of the multipurpose health care workers to the community inspires trust and credibility in the population, resulting in enhanced participation in information, education, and communication activities. This in turn helps in earlier case detection and reduces the rates of disabilities and associated stigma in leprosy. To conclude, task shifting can help provide an earlier diagnosis and timely referral for those living in remote areas, but its implementation requires well-equipped training centers and meticulous strategies. It remains to be seen whether possible task shifting can be used to manage melanoma and basal cell carcinomas, the major dermatological health problems in Western populations.

Clinical and Molecular Aspects of Vitiligo Treatments

Vitiligo is an asymptomatic but cosmetically disfiguring disorder that results in the formation of depigmented patches on skin and/or mucosae. Vitiligo can be segmental or non-segmental depending upon the morphology of the clinical involvement. It can also be classified as progressing or stable based on the activity of the disease. Further, the extent of involvement can be limited (localized disease) or extensive (generalized disease). The treatment of vitiligo therefore depends on the clinical classification/characteristics of the disease and usually comprises of 2 strategies. The first involves arresting the progression of active disease (to provide stability) in order to limit the area involved by depigmentation. The second strategy aims at repigmentation of the depigmented area. It is also important to maintain the disease in a stable phase and to prevent relapse. Accordingly, a holistic treatment approach for vitiligo should be individualistic and should take care of all these considerations. In this review, we shall discuss the vitiligo treatments and their important clinical and molecular aspects.

“Over the Internet” sale of prescription-level topical corticosteroids and dilemma of dermatologists

A young woman recently turned up in our outpatient department with complaint of red face. Examination revealed atrophic skin, acne, hypertrichosis, and numerous telangiectasias on the right side of her face, where she had been applying a “cream” for the previous 1 year to cure a trivial scar. Notably, she had procured the combination cream containing tretinoin, mometasone furoate (a potent topical corticosteroid), and hydroquinone from a prime online shopping website, which claimed it to be an herbal/organic product that could be sold without a valid prescription (Figs. 1 and 2). To our surprise, an online search revealed an unannounced and unforeseen plethora of such formulations. Despite a recently reiterated ban on over-the-counter (OTC) sale of topical corticosteroids in India, a majority of combination formulations (steroid/antifungal/antibacterial combinations and fairness creams containing corticosteroid/hydroquinone/tretinoin combinations) were easily available online, both on the affluent commercial marketing websites and the dedicated e-pharmacies, without the need for a prescription. It was disheartening to see these formulations being promoted miscellaneously as treatments for “acne”/“fungal infections”/“skin infections” or “general purpose” creams (Figs. 3 and 4) and being dispensed without the hassle of a valid medical prescription, just like a bunch of groceries (Fig. 5). In addition to the scant and inaccurate information available online, the drugs were marketed with lucrative offers and significant discounts. Added adjectives/superlatives of “100% natural/ pure herbal/organic/safe” were distasteful. The distressing part about this trend is that these websites might represent the first source of information for many patients who surf and self-medicate. Many of these sites additionally provided medication listing (the costumers who bought this also bought these) and doctor listing (advertisement for teleconsultation in the absence of a valid prescription). Cases of corticosteroid abuse are routinely encountered during dermatology practice in India, where patients end up using topical corticosteroids/combinations as a panacea for every dermatological complaint. An ingrained cultural obsession for a fairer skin coupled with blatantly outrageous endorsement of expensive fairness creams by the celebrities feeds the insecurities of people. In addition, the perceived notion of a general similarity among various dermatoses to an untrained eye makes the laymen (friends, saloons, multimedia), nondermatologist-medical professionals, general practitioners, and pharmacists to think that virtually all dermatoses are trivial, self-treatable “allergies” easily amenable to creams/corticosteroids. The same thought process leads to prescription sharing and needs to be changed for good. Sadly, very few outside the specialty of dermatology are versed with the significant cutaneous and systemic adverse effects these corticosteroid-containing topical medications can cause. Despite being designated as “prescription only medications”, the pursuit for such products is colossal, and Indian markets are flooded with OTC topical steroid-containing products, and an unregulated, uninhibited online availability of these formulations is going to make things further worse. The lineup does not stop here, and medications such as systemic retinoids, immunosuppressants, biologics, botulinum toxin,