Kabir Sardana

Pigmented purpuric dermatoses: An overview

Pigmented purpuric dermatoses are a spectrum of disorders characterized by a distinct purpuric rash, mainly localized to the lower limbs, which are morphologically dissimilar but histopathologically indistinguishable. Their etiology remains obscure. They are rather resistant to treatment. Although diagnosed quite straightforwardly, the disease entity remains an enigma and a therapeutic challenge. The current narration discusses the outline of the epidemiology, etiopathogenesis, clinical features, histopathology and management of these disorders. The current review, hopefully, may once again rekindle interest in the entity, for it has been sparingly reported or discussed for the benefit of under‐ and/or postgraduates and those in practice, including family physicians.

Retinoids: Fascinating Up‐and‐Coming Scenario

Retinoids have been in sharp focus ever since their introduction 30 years ago. They include any drug (s) that bind to retinoid receptors and elicit a biological response. Enormous information on the subject seems to embroil the recent literature. Practically it is impossible to clearly comprehend the undercurrents. The meticulously dispensing text envisages surmounting the perspective readers predicaments. Accordingly, retinoids and their related facets namely retinoid receptors, classification, mode of action, and the pharmacological diversity have been precisely defined. Commonly used systemic retinoids too have been given a substantial fresh look along with their monitoring. Overall, adverse effects and relative and absolute contraindications have been scrupulously incorporated. Human immuno deficiency virus (HIV) and isoretinoid for acne, in particular, have been highlighted. Micronized isotretinoin formulations have also been taken care so also commonly used topical retinoids. Tretinoin and their newer formulation have also been accounted for along with tretinoin polymer cream. Adapalene, a new chemical entity possessing a unique physico‐chemical activity similar to that of tretinoin has also been dealt with. Newer retinoids are likely to be a subject of intrigue. A focus on future potentials of retinoids is its special ingredient. The inclusion of details of rexinoid the most recent introduction in their purview is likely to invoke interest to further consolidate its reckoning in future. All in all the text of the paper should provide an insight into the current rumbling around retinoids.

Diagnosing multibacillary leprosy : A comparative evaluation of diagnostic accuracy of slit-skin smear, bacterial index of granuloma and WHO operational classification

BACKGROUND In view of the relatively poor performance of skin smears WHO adopted a purely clinical operational classification, however the poor specificity of operational classification leads to overdiagnosis and unwarranted overtreatment while the poor sensitivity leads to underdiagnosis of multibacillary (MB) cases with inadequate treatment. Bacilli are more frequently and abundantly demonstrated in tissue sections. AIMS AND METHODS We compared WHO classification, slit-skin smears (SSS) and demonstration of bacilli in biopsies (bacterial index of granuloma or BIG) with regards to their efficacy in correctly identifying multibacillary cases. The tests were done on 141 patients and were evaluated for their ability to diagnose true MB leprosy using detailed statistical analysis. RESULTS A total of 76 patients were truly MB with either positive smears, BIG positivity or with a typical histology of BB, BL or LL. Amongst these 76 true-MB patients, WHO operational classification correctly identified multibacillary status in 56 (73.68%), and SSS in 43 (56.58%), while BIG correctly identified 65 (85.53%) true-MB cases. CONCLUSION BIG was most sensitive and effective of the three methods especially in paucilesional patients. We suggest adding estimation of bacterial index of granuloma in the diagnostic workup of paucilesional patients.

An observational analysis of erythromelanosis follicularis faciei et colli

Erythromelanosis follicularis faciei et colli (EFFC) is characterized by well‐demarcated erythema, hyperpigmentation, and follicular papules. Since the orginal description, < 50 patients have been reported in the literature. Five cases of EFFC have been seen in our outpatient department in the past 5 years. All patients except one presented with the classic triad of erythema, brown pigmentation and follicular papules on the face and keratosis pilaris lesions on the trunk. In all cases, there was no family history for related disorders or history of atopy. Histopathological examination in all cases was consistent with the diagnosis of EFFC. Age at presentation ranged from 11 to 19 years, and the male female ratio was 4 : 1. Patients had the classic lesions of keratosis pilaris on the face (5/5), trunk (2/5) and legs (4/5). All patients except one had a background of erythema. One patient (patient 2) had itching and a history of photosensitivity. Of the patients who were on treatment (4/5), complete clinical regression was seen in one patient. To our knowledge, this is the first case series of EFFC from India, and we believe that EFFC is a common but infrequently reported condition.

A suspected case of primary cutaneous actinomycosis on the buttock.

Primary cutaneous actinomycosis is rare and can mimic mycetoma, tuberculosis and nocardiosis. The results of cultures (aerobic and anaerobic) are not always positive. A high degree of clinical suspicion should be entertained and a combination regimen of penicillins with sulphonamides should be used for treatment. We report a patient with primary cutaneous actinomycosis over the buttock, who was successfully treated with amoxycillin and sulphonamides.

Disseminated infection with Cryptococcus neoformans var neoformans in an 8 years immunocompetent girl.

Disseminated cryptococcosis is a rare and often fatal disease in children. The majority of cases usually occur in individuals with defective cell-mediated immunity, most commonly due to HIV infection. The authors here in report an 8-year-old girl from Nepal who presented with fever, cough, headache, lymphadenopathy, hepatosplenomegaly and cutaneous lesions. Lymph node biopsy revealed multiple granulomas composed of histiocytes and epitheliold cells along with numerous yeast forms of cryptococcus. Cultures of CSF, sputum and urine yielded cryptococcus neoformans. Surprisingly,the immune function in terms of T-cell number, CD4 : CD8 ratio, serum immunoglobulins and HIV serology was normal. After the diagnosis of disseminated cryptococcosis was established, the patient was treated with 5-fluorocytosine (100 mg/kg/day) for initial two weeks and amphotericin B (1 mg/kg/day) for 13 weeks. Patient responded well to the treatment with disappearance of presenting symptoms, cutaneous lesions, and lymphadenopathy, though she still had hepatosplenomegaly, which also decreased. Unfortunately, she developed loss of vision in 10th week of therapy. The patient was discharged on oral fluconazole (6 mg/kg/day) and no recurrence was found during the follow-up period of more than 9 months. This is the first case of disseminated cryptococcosis with no detectable immune deficit, from India.

Perforating folliculitis with jaundice in an Indian male: a rare case with sclerosing cholangitis.

our experience with six patients does suggest several conclusions. Firstly, there does not appear to be an increased frequency of adverse reactions to high-dose tetracycline in patients with localized EBS. Secondly, two-thirds of our patients did indeed experience reduced disease activity while on prolonged tetracycline therapy, based on objective, standardized, lesional counts. Thirdly, the response lasted during at least 4 months of treatment, rather than representing a transient effect seen only at 2 but not at 4 months of treatment. Fourthly, no decreases in lesional counts occurred following treatment with placebo. Although the limited number of patients completing therapy precludes statistical validation of this intervention, based on our encouraging experience in four of our six wellstudied patients, coupled with the lack of any other known effective treatment for this disease, we would recommend empirical treatment with tetracycline of any EBS patient who is willing to risk the known adverse side-effects of this drug and who is sufficiently symptomatic to desire an attempt at systemic therapy. It could even be used in children at risk for tetracycline-induced dental discoloration if the severity and chronicity of their symptoms justified such treatment, given how easily permanent crowns could be placed in these patients if cosmetic dental intervention were necessary and desired at a later age.

An interesting case of colocalization of segmental lichen planus and vitiligo in a 14‐year‐old boy

A 14‐year‐old boy had segmental vitiligo (L3−4) on the right thigh and leg for 4 years, and was advised to apply topical clobetasol propionate, 0.05%, in the night, with daily sun exposure for 10 min, as he refused to comply with topical psoralens. As there was no response to therapy even after 3 months, the patient stopped the steroid cream but continued with the sun exposure. Subsequently, the patient noticed gradual‐onset, itchy, violaceous, pigmented, raised lesions superimposed on the vitiligo macules. Cutaneous examination revealed violaceous, polygonal papules, 0.5 × 0.5 cm in size, some of which coalesced to form discrete violaceous plaques, confined to areas of vitiligo, with a clear‐cut demarcation from normal skin ( Fig. 1 ). The scalp, palms, soles, nails, and mucosa were normal. Histopathology of the polygonal papules revealed hyperkeratosis, wedge‐shaped hypergranulosis, irregular acanthosis with saw toothing of the rete ridges, basal cell liquefaction, and a band‐like lymphocytic infiltrate ( Fig. 2 ), consistent with lichen planus. The patient was subsequently prescribed fluticasone propionate (0.05%) ointment once daily for the lesions of lichen planus. There was a marked improvement in the lesions of lichen planus after 1 month.

Seasonal variation in acne vulgaris--myth or reality.

A traditional opinion proposed by Western dermatologists is that acne improves in summer and worsens in winter. We studied 452 patiens with acne vulgaris and asked them about seasonal variation in their acne. A total of 229 patients (50.67%) complained of a seasonal variation; a significant proportion (56.33%) noticed an aggravation in summer, while 16.16% improved in summer and only 11.35% worsened in winter. Apparently winters did not affect the severity of acne in a majority of patients (64.20%). Significantly, a majority (80.62%) of patients noticed a summer aggravation due to sweating and increased humidity. Thus our study is at variance with the existing literature, with summer aggravation being the predominant complaint. We would like to propose that the increased temperature, marked humidity, and sweating might explain the results seen in our region.

Giant combined dermatofibroma with satellitosis

An unusual giant combined dermatofibroma is reported in a 34‐year‐old man who presented with skin‐coloured swellings on the medial aspect of the left scapula. The plaque was well defined, reddish‐brown and 25–30 cm in diameter. It was also tender and indurated. Several similar smaller lesions (satellites) were present around the plaque. Light microscopy of an incisional biopsy from the main lesion showed architectural features of a deep penetrating type of dermatofibroma, with xanthomatous aggregates, myxoid changes and probable myofibroblastic differentiation. Our case represents an extraordinary example of giant combined dermatofibroma with satellitosis. Despite its benign nature, a wide excision is contemplated because of its unsightly appearance and physical discomfort.