Bhavana Doshi

Trichoscopy in alopecias: Diagnosis simplified

Trichoscopy is the term coined for dermoscopic imaging of the scalp and hair. This novel diagnostic technique, both simple and non-invasive, can be used as a handy bed side tool for diagnosing common hair and scalp disorders. Trichoscopic observations can be broadly grouped as hair signs, vascular patterns, pigment patterns and interfollicular patterns. In this article, we have briefly described the trichoscopic findings in the common categories of cicatricial and non-cicatricial alopecias such as androgenetic alopecia, alopecia areata, telogen effluvium, tinea capitis, trichotillomania, lichen planopilaris, discoid lupus erythematosus and hair shaft disorders. Besides diagnosing alopecia, it has the potential for obviating unnecessary biopsies and when a biopsy is still needed it is helpful in choosing an ideal biopsy site. Moreover, trichoscopy is a valuable tool for evaluating the treatment response photographically at each follow-up. The last statement here is deleted as asked.

A study of clinicopathologic profile of 15 cases of hypopigmented mycosis fungoides.

BACKGROUND Mycosis fungoides (MF) is cutaneous lymphoma of the T-cell lineage. Hypopigmented MF is a clinical variant of MF, described mainly in Asians. This is a retrospective clinicopathologic analysis of hypopigmented MF at a tertiary care center. AIMS To describe the clinicopathologic profile of hypopigmented MF. METHODS Records of clinicopathologic notes over a 5-year period ranging from January 2005 up to December 2009 were reviewed over a period of 3 months, of which 15 cases were diagnosed with hypopigmented MF based on clinicopathologic correlation. RESULTS Hypopigmented MF was found to be more common in males, and between second and fourth decades of life. The latent period between onset and diagnosis was around 3.83 years. Most of the patients were asymptomatic 80% (12/15), with skin changes of subtle atrophy in 46.66% (7/15), scaling in 20% (3/15) and focal changes of poikiloderma in 26.66% (4/15) patients. Most common sites of distribution of the lesions were the trunk and extremities. Many of the cases had been clinically mistaken for Hansens disease prior to correct diagnosis. Marked epidermotropism and tagging of epidermis by large lymphocytes characterizes the condition histopathologically. Of the 15 cases, immunohistochemistry was possible in 10 cases, of which 8 showed predominant CD8 positive epidermotropic infiltrates and two cases showed absence of CD8 positive and CD4 positive lymphocytic infiltrate in the epidermis. CONCLUSION Hypopigmented MF presents as hypopigmented asymptomatic patches without any erythema or infiltration in its early stage and mimics Hansens disease. Skin biopsy clinches the diagnosis.

Phenomena in dermatology.

For a better understanding of various dermatoses, it is imperative for any physician practising dermatology to have a good theoretical knowledge of the underlying pathophysiologic processes involved in various systemic diseases involving the skin. For an easy grasp over this topic, we have discussed the various phenomena under three broad categories, like (a) clinical--Meyerson, Meirowsky, pathergy, Renbok, (b) laboratory--LE cell, prozone and (c) histopathology--Splendore-Hoeppli.

Angiolymphoid hyperplasia with eosinophilia with follicular mucinosis.

Follicular mucinosis occurring along with angiolymphoid hyperplasia with eosinophils (ALHE) has been described in a 49-year-old male. The patient presented with pruritic hyperpigmented papules and nodules on the vertex and right parietal scalp. There was no any other complaint. Histopathological examination from one of the papule showed prominent blood vessels in the dermis lined by plump histiocytoid endothelial cells that were surrounded by a dense lymphoid infiltrate with numerous eosinophils; these findings are typical of angiolymphoid hyperplasia with eosinophilia. Features of follicular mucinosis were observed in the same section with 3 hyperplastic follicular infundibula containing pools of mucin in the infundibular epithelium. The concurrent occurrence of these 2 distinct histopathological patterns in the same biopsy specimen has been reported rarely.

Psoriasiform variant of porokeratotic eccrine ostial and dermal duct nevus

dermal duct nevus Sir, A 25-year-old male with no history of consanguinity in parents presented to us with multiple asymptomatic raised linear lesions over the dorsum of the right toe extending up to the dorsum of the right foot since two years of age. On inquiry, none of the family members were similarly affected. The lesions were resistant to various forms of topical treatment. Cutaneous examination revealed hyperkeratotic grouped papules with keratotic plugs over the dorsum of the right foot. The lesions had coalesced over the great toe to form a plaque of size 4 cm · 3 cm with discrete nonfollicular papules in a linear pattern extending up to the foot (Fig. 1). Thus, a differential diagnosis of inflammatory linear verrucous epidermal nevus, lichen striatus, and porokeratotic eccrine ostial and dermal duct nevus (PEODDN) was thought of clinically. Biopsy from one such nonfollicular lesion showed mounds of parakeratosis with neutrophils alternating with orthokeratosis within an epidermal invagination with hypogranulosis and scant spongiosis overlying the eccrine acrosyringium, which was surrounded by lymphocytic infiltrate (Fig. 2). Periodic Acid-Schiff (PAS) stain of a biopsy sample was negative for mycotic infection. Another biopsy carried out from the plaque showed similar histopathologic findings affecting multiple acrosyringia with relative sparing of the intervening epidermis. Hence, a diagnosis of psoriasis selectively involving the acrosyringia suggestive of psoriasiform variant of PEODDN was reached on histopathologic examination. Histopathology of lichen striatus shows hyperkeratosis, parakeratosis with a few necrotic keratinocytes in the epidermis, mild spongiosis with lymphocytic exocytosis, and focal or band-like lichenoid infiltrate. The presence of the inflammatory infiltrate around hair follicles and vessels in the mid-plexus with extension to eccrine glands is a characteristic feature. However, our case is distinct because of the presence of neutrophils in parakeratotic mounds and absence of infiltrate around follicles or eccrine glands. Histopathology of inflammatory linear verrucous epidermal nevus reveals a psoriasiform hyperplasia of the epidermis, stubby zones of parakeratosis without a granular layer alternating with areas of orthokeratosis with a thickened granular layer. Our case, is unique in its selective involvement of eccrine acrosyringia over which mounds of parakeratosis with neutrophils alternating with orthokeratosis were observed. The PEODDN was first reported by Marsden et al. and later described by Abell and Read in 1980. It has been classified as an adnexal tumor with eccrine differentiation, which follows the lines of Blaschko. It presents as asymptomatic, congenital, keratotic papules and 742 Figure 1 Multiple hyperkeratotic grouped papules with keratotic plug over dorsum of foot Figure 2 Hematoxylin and eosin stain ·20 showing exclusive involvement of eccrine ostium with dilatation, plugging and periosteal infiltrate with mounds of parakeratosis topped by neutrophils alternating with orthokeratotic zones

Retrospective study of spectrum of cutaneous lymphoma presenting to dermatology

512 Approximately 40% of women in some geographical areas use hair-coloring agents. The prevalence of PPD sensitivity in various population based epidemiological studies has been estimated to be between 0.1% and 1%.[2] Penchalaiah et al.[3] studied the sensitizers commonly causing contact dermatitis from cosmetics in India.[3] Of 436 patients, 31 (7.1%) were suspected of having cosmetic dermatitis due to hair dye and only 8 (1.8%) showed positivity to 1% PPD.

Ichthyosis associated with rickets in two Indian children

We wish to report two cases of rickets due to vitamin D deficiency secondary to underlying ichthyotic skin disorder. The first case is of an 8-year-old male with history of multiple fluid-filled lesions over the body that would rupture to heal with thickening and scaling of skin, suggestive of epidermolytic hyperkeratosis, and the second is of a 14-year-old female with thick, large, quadrilateral scales over the extremities and back clinically consistent with lamellar ichthyosis. Both showed improvement with parenteral vitamin D3 and oral calcium supplements in addition to topical emollients.

Epidermotropic metastatic melanoma with perilesional depigmentation in an Indian male.

Melanoma is a rare form of cutaneous malignancy encountered in the dark skin population. Epidermotropic metastatic melanoma is a rare form of cutaneous metastatic melanoma which can mimic primary melanoma on histopathology. Hence its differentiation is of immense prognostic importance. The occurrence of rim of depigmentation around the primary cutaneous melanoma has previously been reported to portend a bad prognosis. The occurrence of vitiligo like lesions in patients with metastatic melanoma in comparison has a better prognosis. However the occurrence of depigmentation around the secondaries is rare and its importance is not well known. Hence we wish to report a case of epidermotropic metastatic melanoma with perilesional depigmentation in a 78 year old Indian male.

Intralesional drug therapy in dermatology

Cortisone and hydrocortisone acetate suspensions were used from the early 1950s before introduction of preparations with lower solubility such as triamcinolone acetonide, which is now the most common agent used.[2] Triamcinolone acetonide (2.5–10 mg/ml [1 mg/cm2]), betamethasone sodium phosphate/acetate (1–2 mg/ cm2/site), dexamethasone acetate (0.8–1.6 mg/site), dexamethasone sodium phosphate (170 μg–5 mg/ session), hydrocortisone acetate (5–7.5 mg/session) and methylprednisolone acetate (20–60 mg/session) are used for keloids, alopecia areata, nodulocystic acne, granuloma annulare, granuloma faciale, hidradenitis suppurativa, localized and nail psoriasis, prurigo nodularis, cutaneous lupus erythematosus, vitiligo, lichen simplex chronicus, hypertrophic nail lichen planus, resistant oral pemphigus, hemangiomas, etc.[1] The dose per session is generally 0.1–0.2 ml/cm2 of involved skin (<1–2 ml/dose) with an interval of 3–6 weeks between two consecutive injections. The number of injections depends on the disease, site of lesions, age of the patient and response to previous injections. The maximum dosage of triamcinolone acetonide should not exceed 40 mg/ml/session. Corticosteroids can be injected in full strength or diluted with normal saline or local anesthetic.[2]

Hyperkeratotic palmoplantar lichen planus in a child

Lichen planus (LP) is a common idiopathic inflammatory disorder that affects the flexor aspect of the wrists, the legs, and the oral and genital mucosa. Depending upon the site of involvement, LP can be divided into mucosal, nail, scalp, or palmoplantar types. Palmoplantar LP can pose a diagnostic problem to the clinician as it resembles common dermatoses like psoriasis, verruca, corn, calluses, lichenoid drug eruption, and papular syphilide of secondary syphilis. In this case report, we describe a 4-year-old male child who presented with highly pruritic erythematous to violaceous hyperkeratotic papules and plaques on his palms and soles. Typical LP papules were noted on the upper back. Histopathology of the papular lesion showed features of LP. Dermatoscopy of a papule from the back showed the characteristic Wickham striae. We report this rare involvement of palm and soles in a case of childhood LP.