Garima Dabas

Dermoscopy in disseminated sporotrichosis

We read with interest the article by Slawinska et al1 on dermoscopic features of disseminated cryptococcosis. We would like to highlight the dermatoscopic features of disseminated sporotrichosis and discuss the similarities in the dermatoscopic features of various deep mycosis and cutaneous leishmaniasis. A 41-year-old male, resident of the Kashmir valley, presented for the evaluation of multiple ulcerated skin lesions since past 3 years. This article is protected by copyright. All rights reserved.

A novel scale for measurement of acquired dermal macular hyperpigmentation severity

reassessing formulation suitability. For DLHNL, BBD represents highly accepted quadratic surface models. Optimized formulation SEM micrographs represent duple nail layer structure as presented in Fig. 1. Bovine hoof’s model was employed to simulate dense keratinization akin to be present in mutilated and infected nails and the novel use of thioglycolic acid improved the drug permeability and retention onto the nail plates. The study reportedly elicited percentage cumulative drug release of 71% over a period of 24 h. Microbiological assessment of the released drug also supported its clinical relevance as it demonstrated antifungal activity against T. rubrum which is considered as a predominant causative agent for onychomycosis by giving a zone of inhibition of diameter 38 mm as presented in Fig. 2. Additionally, DNL offers sufficient bioadhesiveness of 1.9 N which is appreciable enough to cause its prolonged retention onto the surface of nail plate when compared with a single layer lacquer film. In conclusion, the proposed DNL formulation offers a high clinical potential in terms of an aesthetically suited treatment tool for a difficult to treat disease onychomycosis.

Inexplicable Purpura in a Female: Gardner-Diamond Syndrome

A 39-year-old housewife presented with recurrent, painful, ecchymotic patches on both legs for the past 1 year (A). There was no history of trauma, fever, joint pain, photosensitivity, or any other systemic illness. A diagnosis could not be reached despite extensive investigation, which raised the suspicion of Gardner-Diamond syndrome (GDS). Autoerythrocyte sensitization test was performed, which showed a positive reaction at the site of erythrocyte injection after 2 hours, while serum and normal saline sites were negative (B). In GDS, patients are sensitized to phosphatidylserine present on the erythrocyte membrane. There is no specific treatment; however, psychiatric consultation is beneficial.

Lichen planus pigmentosus - An appraisal

References 1 Almutairi D, LeBlanc K, Alavi A. Peristomal skin complications: what dermatologists need to know. Int J Dermatol. 2018; 57: 257–264. 2 Lyon CC, Smith AJ, Griffiths CE, et al. The spectrum of skin disorders in abdominal stoma patients. Br J Dermatol 2000; 143: 1248–1260. 3 Lyon CC, Smith AJ, Griffiths CE, et al. Peristomal dermatoses: a novel indication for topical steroid lotions. J Am Acad Dermatol 2000; 43: 679–682. 4 Moriyasu A, Katoh N, Kishimoto S. Psoriasis localized exclusively to peristomal skin. J Am Acad Dermatol 2006; 54: S55–S56. 5 Marshall C, Woodmansey S, Lyon CC. Peristomal psoriasis. Clin Exp Dermatol 2017; 42: 282–286. 6 Friedman BJ, Dasgeb B, Lee JB. Cutaneous Crohn’s disease with superimposed psoriasis: a unique case with overlapping histology. J Cutan Pathol 2017; 44: 588–590. 7 van Rheenen PF, Van de Vijver E, Fidler V. Faecal calprotectin for screening patients with suspected inflammatory bowel disease: diagnostic meta-analysis. Br Med J 2010; 341: c3369. 8 Kallel L, Ayadi I, Matri S, et al. Fecal calprotectin is a predictive marker of relapse in Crohn’s disease involving the colon: a prospective study. Eur J Gastroenterol Hepatol 2010; 22: 340–345. 9 Takeshita J, Grewal S, Langan SM, et al. Psoriasis and comorbid diseases: implications for management. J Am Acad Dermatol 2017; 76: 393–403.

A retrospective study of dermatitis herpetiformis from an immunobullous disease clinic in north India

Indian data on dermatitis herpetiformis (DH) is not available. The aim of this study was to investigate the demographic and clinicopathological characteristics of patients with DH and to study its association with other autoimmune diseases.

Unilateral nipple erosion with acantholysis

A woman in her 40s sought treatment for a painless erosion over the left nipple of 6 months duration. There was no history of oral or genital ulcers, skin blisters, and lesional trauma. The erosion had partially responded to topical steroids but recurred on its discontinuation. On physical examination, a 3 9 3 cm erosion was noted on the left nipple and areola (Fig. 1). The erosion had well-defined, regular margins, and the floor was covered by pink granulation tissue. Clinical examination did not reveal any breast mass or axillary and cervical lymphadenopathy. Examination of the oral cavity, genitalia, and scalp was within normal limits.

Resveratrol-induced thrombocytopenia: Inadvertent side-effect of a commonly used antioxidant

Resveratrol is a polyphenolic antioxidant which has recently shot in vogue due to its free radical scavenging, anticancer, anti-inflammatory, anti-melanogenic, and cardioprotective properties. It has found its place in dermatology owing to its skin lightening (Kim et al., 2002) and anticancer properties (Bhattacharya, Darjatmoko, & Polans, 2011). There are no reports regarding its potential side-effects so far, besides increased risk of bleeding in patients taking it with warfarin. The present study reports a patient who developed thrombocytopenia after taking resveratrol for the treatment of melasma.

Acitretin: a promising therapy for localized childhood lichen myxoedematosus

Localized lichen myxoedematosus (LM) is characterized by lichenoid papules, nodules and plaques with mucin deposition in the dermis and variable amounts of fibroblasts. It is mostly reported in adults and presentation in childhood can pose a diagnostic challenge. We present the case of a child with localised LM who was successfully treated with acitretin. An 11-year-old boy presented with a 3-year history multiple, asymptomatic, skin-coloured lesions on his back. There was no history of fever, joint pain, muscle weakness, cough, corysa or viral illness prior to the onset of lesions. Physical examination revealed closely set, waxcoloured to skin-coloured papules coalescing to form plaques over the patient’s scalp, neck and back (Fig. 1a,b). Systemic examination did not reveal any abnormality. Laboratory investigations, including renal, hepatic, lipid and thyroid profiles, complete blood count, urine analysis, serum and urine protein electrophoresis, serum creatinine kinase, aldolase level and antinuclear antibody testing, were within normal limits. Serology for human immunodeficiency virus and hepatitis B and C virus was negative. Chest radiography and abdominal ultrasonography did not reveal any abnormality. Histopathology of the skin biopsy showed normal epidermis with presence of large amounts of mucin and irregular arrangement of collagen in the upper dermis. There was an increased number of fibroblasts (Fig. 1c). Alcian blue staining (pH 2.5) highlighted dermal mucin (Fig. 1d). Based on the clinical and histological findings, a diagnosis of the localized lichen myxoedematosus was made. The child was counselled regarding the self-limiting nature of the disease and regular follow-up was advised. However, over the next 1 year, the lesions kept increasing in size and number. The patient was prescribed topical mometasone 0.1% cream and topical tacrolimus 0.1% ointment once daily, without any response. Thus, acitretin 25 mg once daily was initiated, and 3 months later, new lesions stopped developing and many of the papular lesions flattened. There was complete clearance of the lesions within 5 months (Fig. 2a,b). The patient was maintained on oral acitretin 10 mg for another 2 months, after which it was stopped. There were no adverse effects and the response was maintained at follow-up 6 months later. The cutaneous mucinoses are a heterogeneous group of disorders characterized by abnormal mucin deposition in the skin. The criteria for diagnosing localized LM requires presence of papular lesions showing deposition of mucin, with variable fibroblast growth in histopathology and an absence of paraproteinaemia or thyroid disease. The newly updated classification has categorized LM into two types: systemic and pure cutaneous. The pure cutaneous type is further classified into forms with localized or limited skin involvement (discrete, acral persistent, self-healing, nodular) and the generalized form with extensive skin involvement. There is often some degree of overlap between these conditions. Classification of primary cutaneous mucinosis occurring in childhood is often difficult and confusing because of the limited number of reported cases and overlapping clinical features. Self-healing juvenile Correspondence: Professor Sanjeev Handa, Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India E-mail: handa_sanjeev@yahoo.com

A retrospective study of lichen planus pigmentosus with focus on palmoplantar involvement

Lichen planus pigmentosus (LPP) is a rare disease characterized by persistent and asymptomatic slate‐grey pigmentation, which mostly affects patients with skin types IV–VI. The face and neck are the most commonly involved sites, followed by the trunk and extremities. LPP is believed to spare the palms, soles and nails. In this report, we describe palmoplantar involvement in 10 (4.65%, 10/215) patients with LPP, and compare its clinicodemographic features with those of classic LPP. LPP lesions on the palms and soles present as asymptomatic, well‐circumscribed, hyperpigmented, brown–black patches without any history of prior lichen planus lesions. They are mostly observed in young patients with rapidly spreading active disease, who often require systemic treatment to control the disease activity. Strikingly, palmoplantar involvement is frequently associated with other atypical LPP variants. It is important to identify palmoplantar involvement in LPP, as it has a different clinical course and associations compared with classic LPP.

Dermoscopic features in two cases of acroangiodermatitis

Acroangiodermatitis (pseudo-Kaposi sarcoma) is a rare vasoproliferative dermatosis that occurs as a result of the reactive proliferation of blood vessels in response to congenital or acquired vascular alterations. The lesions are often indistinguishable from Kaposi sarcoma clinically. Four types of acroangiodermatitis have been described; the Mali type, which is associated with chronic venous insufficiency; the Stewart–Bluefarb type, which is associated with congenital arteriovenous malformations; a third type associated with a first pregnancy; and a fourth type, which is seen in patients with chronic kidney failure and with an iatrogenic arteriovenous fistula. In this report, we describe the dermoscopic appearance of two types of acroangiodermatitis. Patient 1 was a 37-year-old man with chronic kidney disease who presented with painful plaques on the left hand that he had for the previous 8 months. An iatrogenic arteriovenous fistula had been created for haemodialysis on the same limb proximally 2 years earlier. On examination, many violaceous plaques with superficial crusting were seen on the dorsum of his left hand (Fig. 1a). Patient 2 was a 43-year-old man who presented with asymptomatic erythematous lesions on his left leg which he had for the previous 7 months. On examination, many erythematous to violaceous papules coalescing to form plaques were observed on the medial aspect of the left lower leg (Fig. 2a). Dilated varicose veins were seen in the surrounding skin and the saphenofemoral junction was incompetent on the same side. Dermoscopy was carried out in both patients in polarised contact mode with 910 magnification, revealing an irregularly distributed, polymorphous vascular pattern composed of many dots, clods, straight and hairpin blood vessels along with many white structureless areas (Figs 1b,2b). Histopathology in both patients showed a lobular proliferation of small capillaries with plump endothelial cells and extravasated erythrocytes along with a sparse lymphomononuclear infiltrate throughout the dermis. The endothelial cells did not show any atypia (Figs 1c,2c). Immunohistochemical analysis showed CD34 positivity only in the endothelial cells while the stromal cells were negative. Immunohistochemistry analysis for human herpes virus-8 was negative.