Biswanath Behera

Dermoscopy of Langerhans cell histiocytosis

CLINICAL PRESENTATION An 11-month-old boy was brought by parents with 2-months’ history of asymptomatic rash over the trunk and neck associatedwith on-and-off fever. Cutaneous examination revealedmultiple discrete and grouped erythematous-to-skin-colored nonscaly papules of size varying from 1 3 1 mm to 3 3 3 mm over the trunk and neck (Fig 1). The child also had scalp scaling and generalized lymphadenopathy.

Generalized lichen planus developing at the healed sites of erythema multiforme in a human immunodeficiency virus-seropositive patient

Dermatol 1998;31:675. 6. Zaias N, Rebell G. A simple and accurate diagnostic method in chromoblastomycosis. Arch Dermatol 1973;108:545‐6. 7. Goette DK, Robertson D. Transepithelial elimination in chromomycosis. Arch Dermatol 1984;120:400‐1. 8. Uribe F, Zuluaga AI, Leon W, Restrepo A. Histopathology of chromoblastomycosis. Mycopathologia 1989;105:1‐6. 9. Queiroz‐Telles F, Santos DW. Challenges in the therapy of chromoblastomycosis. Mycopathologia 2013;175:477‐88. 10. Badgwell Doherty C, Doherty SD, Rosen T. Thermotherapy in dermatologic infections. J Am Acad Dermatol 2010;62:909‐27.

Primary cutaneous plasmablastic lymphoma presenting as perineal ulcero-proliferative growth in a human immunodeficiency virus-seropositive patient.

23. Joshi U, Ceena DE, Ongole R, Sumanth KN, Boaz K, Jeena Priy K, et al. AIDS related Kaposi’s sarcoma presenting with palatal and eyelid nodule. J Assoc Physicians India 2012;60:50-3. 24. Sharma RK, Bhardwaj S. Kaposi sarcoma presenting as an index sign of HIV infection in an Indian. JK Science 2012;14:158-60. 25. Singh AS, Atam V, Das L. Response of ART and chemotherapy in AIDS associated Kaposi’s sarcoma. J Case Rep 2012;2:125-9. 26. Sehgal VN, Verma P, Sharma S. HIV/AIDS Kaposi sarcoma: The Indian perspective. Skinmed 2013;11:375-7. 27. Warpe BM. Kaposi sarcoma as initial presentation of HIV infection. N Am J Med Sci 2014;6:650-2. 28. Agarwala MK, George R, Sudarsanam TD, Chacko RT, Thomas M, Nair S. Clinical course of disseminated Kaposi sarcoma in a HIV and hepatitis B co-infected heterosexual male. Indian Dermatol Online J 2015;6:280-3. 29. Arul AS, Kumar AR, Verma S, Arul AS. Oral Kaposi’s sarcoma: Sole presentation in HIV seropositive patient. J Nat Sci Biol Med 2015;6:459-61. 30. Behera B, Chandrashekar L, Thappa DM, Toi PC, Vinod KV. Disseminated Kaposi’s sarcoma in an HIV-positive patient: A rare entity in an Indian patient. Indian J Dermatol 2016;61:348. 31. Atkinson JO, Biggar RJ, Goedert JJ, Engels EA. The incidence of Kaposi sarcoma among injection drug users with AIDS in the United States. J Acquir Immune Defic Syndr 2004;37:1282-7. 32. Bower M, Dalla Pria A, Coyle C, Andrews E, Tittle V, Dhoot S, et al. Prospective stage-stratified approach to AIDS-related Kaposi’s sarcoma. J Clin Oncol 2014;32:409-14. 33. Biggar RJ, Engels EA, Ly S, Kahn A, Schymura MJ, Sackoff J, et al. Survival after cancer diagnosis in persons with AIDS. J Acquir Immune Defic Syndr 2005;39:293-9. 34. Palmieri C, Dhillon T, Thirlwell C, Newsom-Davis T, Young AM, Nelson M, et al. Pulmonary Kaposi sarcoma in the era of highly active antiretroviral therapy. HIV Med 2006;7:291-3.

Therapeutic Efficacy of Intralesional Steroid With Carbon Dioxide Laser Versus With Cryotherapy in Treatment of Keloids: A Randomized Controlled Trial.

BACKGROUND Keloids are difficult to treat due to their poor response and high recurrence rate. OBJECTIVE We conducted a randomized controlled trial to compare the therapeutic efficacy of intralesional triamcinolone acetonide (ILTA) in combination with carbon dioxide laser (Group 1) versus in combination with cryotherapy (Group 2) in the treatment of keloids. MATERIALS AND METHODS Sixty patients with 101 keloids were randomized into 2 groups. On Day 1, keloids were ablated using either CO2 laser or cryotherapy followed by injection of ILTA at baseline and at 4 weeks interval for 3 months. Patients were followed up for 12 months to assess for therapeutic response and side effects. RESULTS Successful therapeutic response (>50% improvement) between the 2 groups (CO2 vs cryotherapy) were assessed in terms of reduction in thickness, reduction in volume, patients self-assessment, observers assessment, and Vancouver Scar Scale score at the end of 6 months and 12 months (55.55% vs 70.37%; 61.1% vs 77.8%; 75% vs 77.78%; 61.12% vs 85.18%; 52.78% vs 62.96% respectively). The difference in therapeutic response between the 2 groups was not statistically significant at the end of 12 months. CONCLUSION Both CO2 laser and cryotherapy in combination with ILTA were found to be equally effective in the treatment of keloids.

Polymorphous presentation of subcutaneous phaeohyphomycosis: a rare occurrence

To avoid a misleading genetic diagnosis of epidermolysis bullosa Dear Editor, Zeng et al. recently reported a young female patient with epidermolysis bullosa (EB), who showed extensive epidermal exfoliation, subepidermal blisters, and erosions with dystrophy of all her nails. Based on direct sequencing and 100 reference DNAs, a heterozygous c.280G>A mutation of KRT14, which leads to a p.Ala94Thr change in the head domain of keratin 14, was concluded to be the causative mutation in the case, and the Koebner form of EB simplex was diagnosed. However, when I examined mutations for a Japanese case with EB, I noticed that this variant, 17:39742807C/T, was matched to a SNP (RefSNP ID: rs3826550) and the frequency of the minor allele was as high as 0.352 in ID: ss1692775521 of EVA_EXAC [Batch ID: The Exome Aggregation Consortium (ExAC)_0.3] or 0.73 in a report by Chamcheu et al. Therefore, it is unlikely that the SNP reported in KRT14 causes EB simplex. When histological data are limited, we often rely on genetic analysis for the differential diagnosis of EB. Indeed, the detection of such mutations in causative genes is helpful for the diagnosis of EB. However, each mutation should be carefully discriminated from simple polymorphisms for proper genetic diagnosis. Recent public human genome databases, such as ExAC, in which the sample size is as high as 60,706, providing a large human reference database, are useful to exclude common polymorphisms and to narrow down candidate mutations in the analysis of EB. We hope that the report by Zeng et al. will be revised properly by further extensive genetic analysis using whole exome sequencing.

Clinical, dermoscopic and histopathological features of a rare cutaneous neural tumour

A 56-year-old woman presented with a 15-year history of an asymptomatic, slow-growing mass over her right foot. Physical examination revealed a solitary, skin-coloured, nontender, lobulated exophytic growth, 50 9 40 mm in size, over the lateral aspect of the dorsum of the right foot. The surface of the lesion was studded with multiple grain-like protrusions (Fig. 1a). Under nonpolarized contact dermoscopy, the nodule was seen to have a diffuse grey to yellow background, grey to yellow cobblestone-like areas, and a pigmented network-like area. The grain-like protrusions had grey structureless areas within them, and hairpin, linear irregular and twisted vessels around them (Fig. 1b). Magnetic resonance imaging (MRI) of the growth showed a well-defined, lobulated, exophytic, soft-tissue lesion with multiple thin internal septa, confined to the cutaneous and subcutaneous plane without any infiltration of tendon, muscle or bone (Fig. 1c).

Dermoscopy of a solitary verrucous plaque on the back

the Department of Dermatology, Jawaharlal Institute of stgraduate Medical Education and Research, Puducherry, dia. ing sources: None. licts of interest: None declared. spondence to: Munisamy Malathi, MD, DNB, Department of ermatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India. E-mail: mmalathi.dr@live.com. J Am Acad Dermatol 2017;77:e37-9. 0190-9622/

Acute hemorrhagic edema of infancy: Panicked parents and playful child

36.00 a 2017 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2017.01.009

Postsurgical pyoderma gangrenosum successfully treated with cyclosporine

6. Reveille JD, Solomon DH; American College of Rheumatology Ad Hoc Committee of Immunologic Testing Guidelines. Evidence‐based guidelines for the use of immunologic tests: Anticentromere, Scl‐70, and nucleolar antibodies. Arthritis Rheum 2003;49:399‐412. 7. Scalapino K, Arkachaisri T, Lucas M, Fertig N, Helfrich DJ, Londino AV Jr, et al. Childhood onset systemic sclerosis: Classification, clinical and serologic features, and survival in comparison with adult onset disease. J Rheumatol 2006;33:1004‐13.

Wickham's striae-like appearance in a case of nodular Kaposi's sarcoma: A dermoscopic pitfall

Sir, A 67‐year‐old man presented to the surgery department with anorexia, progressive constipation and weight loss for one month. The contrast‐enhanced computed tomography of the abdomen revealed inflammatory swelling of the proximal jejunum extending into the mesentery. The mass was removed surgically, followed by a gastrojejunostomy. On the 5th post‐operative day, he was referred to the dermatology department for low‐grade fever and gaping of the surgical wound, which was associated with rapidly progressive erythema and necrosis. The patient also had a history of multiple ulcers at sites of minor trauma, which used to heal with atrophic scars. He had history of diabetes for last 8 years and was on tablet metformin 500 mg three times per day. There was no history suggestive of inflammatory bowel disease, connective tissue disorders, recurrent infection, bleeding or hepatic disorders. Cutaneous examination revealed extensive necrosis of the midline abdominal surgical incision site with formation of an ulcer that was surrounded by erythematous and edematous unhealthy skin. The floor of the ulcer was covered with purulent slough [Figure 1]. He was pale, febrile (100°F) and had tachycardia (110 beats/min). Biopsies and tissue cultures were taken from the wound edge for suspected postoperative pyoderma gangrenosum. Histopathological examination revealed necrosis of the epidermis with a dense infiltrate of neutrophils. The dermis showed an extensive neutrophilic infiltrate forming microabscesses, perivascular lymphocytic infiltrate and occasional fibrinoid necrosis of the vessel wall [Figure 2]. Cultures of tissue specimens for bacteria, fungus and mycobacteria were negative. Histopathology of the abdominal mass was consistent with an inflammatory growth that developed due to a jejunal stricture after healing of a perforation. The hemogram revealed microcytic hypochromic anemia and neutrophilic leukocytosis. Other investigations were within normal limits. The patient was started on oral cyclosporine 100 mg twice daily (3 mg/kg/day). The wound dressing was done using calcium alginate and debridement was avoided. After two months of follow‐up, the lesion healed almost completely [Figure 3]. The patient was given a maintenance dose of cyclosporine 50 mg dailyand was advised to continue for 3 months and follow‐up regularly.