Malcolm Pinto

Two cases of axillary chromoblastomycosis.

Sir, Chromoblastomycosis is a chronic fungal infection of the skin and subcutaneous tissue caused by dematiaceous fungi, the most common causative organisms being Fonsecaea pedrosoi, Phialophora verrucosa, Fonsecaea compacta and Cladophialophora carionni.[1] The hallmark of chromomycosis is sclerotic bodies which can be demonstrated in potassium hydroxide mount and routine hematoxylin and eosin staining.[2] Lower limbs are the most commonly affected sites. Unusual extracutaneous sites of involvement include pleural cavity, ileocecal region, laryngotracheal area and tonsils.[3] Dissemination, though rare, presents with multiple verrucous nodules and plaques over limbs, neck, face, lymph glands and tonsil according to reports.[4] The most frequent complication is secondary bacterial infection but malignancies have also been recorded.[2]

Clinical and epidemiological features of coryneform skin infections at a tertiary hospital

Background: Skin infections caused by coryneform bacteria are common dermatological conditions. However, to the best of our knowledge, no studies are available on the clinical characteristics and epidemiological features of this group of disorders as one entity from India and abroad. Aims: To study the clinical and epidemiological features of coryneform skin infections Methods: A total of 75 patients presenting with clinically distinctive lesions of pitted keratolysis, erythrasma and trichobacteriosis to our hospital were included in the study. Cases were interviewed with particular emphasis on epidemiological features and the various clinical findings were recorded. Investigations like Grams stain, Woods light examination, 10% KOH scrapings, were done in selected cases to ascertain the diagnosis. Results: Pitted keratolysis was more common in the age group of 31-40 years (40%) with a male preponderance (76.7%), most commonly affecting pressure bearing areas of the soles with malodour (86.7%) and frequent contact with water (58.3%) constituting the most important presenting symptom and provocating factor respectively. Erythrasma affected both male and female patients equally and was more commonly detected in patients with a BMI > 23kg/m2 (62.5%) and in diabetics (50%). All patients with trichobacteriosis presented with yellow coloured concretions in the axillae. Bromhidrosis (71.4%) and failure to regularly use an axillary deodorant (71.4%) were the most common presenting symptom and predisposing factor respectively. Conclusion: Coryneform skin infections are common dermatological conditions, though epidemiological data are fragmentary. Hyperhidrosis is a common predisposing factor to all three coryneform skin infections. Asymmetrical distribution of pits has been reported in our study. Diabetic status needs to be evaluated in all patients with erythrasma. Woods lamp examination forms an indispensible tool to diagnose erythrasma and trichobacteriosis.

Dermoscopic features of distal lateral subungual onychomycosis

Background: Onychomycosis is a very common disease and accounts for upto 50% of the diseases affecting the nail apparatus. Diagnosis of onychomycosis is usually confirmed with the help of a potassium hydroxide (KOH) mount and fungal culture. Onychoscopy can be a handy and additional tool for the diagnosis. Aims and Objectives: To determine the dermoscopic findings in distal lateral subungual onychomycosis (DLSO). Materials and Methods: A prospective study of 60 nails with a clinical and mycological diagnosis (KOH with Chicago sky blue positive) of DLSO. Dermoscopic examination was performed using a Heine delta 20 plus dermatoscope and the features were recorded. Results: Longitudinal striae and jagged proximal edges seen in all 60 (100%) patients. Intermittent spiked pattern was seen in 47 nails (78.3%). Chromonychia and distal irregular termination were noticed in 23 (38.3%) and 7 (11.7%) nails, respectively. Conclusions: Onychoscopy can be used as an important diagnostic tool while evaluating nail disease, especially in DLSO. Limitations: Small study sample and lack of comparison with other nail diseases that manifests with distal onycholysis.

Pemphigus foliaceus: A rare case of exfoliative dermatitis

Exfoliative dermatitis (ED) is a dermatological condition necessitating admission as it can sometimes be fatal because of its metabolic burden and complications. Papulosquamous disorders and drug reactions comprise over 75% of all the causes of ED. One must be vigilant for the rarer causes of ED as treatment protocols vary and prompt institution of treatment is lifesaving. We present a case of a 56-year-old man with ED who had a history of developing recurrent crusted lesions over the scalp and trunk over the last 3 years. He was treated with oral steroids which he stopped abruptly 6 months ago. Then, he applied topical herbal medications over the lesions before the skin disease progressed to the present state of ED. We uncovered his old records where the histopathology and direct immunofluorescence studies aided in the diagnosis. Based on the history, examination findings supported by histopathology and immunofluorescence studies we came to a final diagnosis of ED secondary to pemphigus foliaceus. This case has been reported for the rare presentation of a common immunobullous disorder and to highlight its diagnostic difficulties.

Absent skin at birth with blistering: Bart's Syndrome?

Barts Syndrome is a disorder characterised by aplasia cutis congenita and epidermolysis bullosa. We report a case of a 4-day-old baby who had absent skin over the legs along with blistering and nail dystrophy. The diagnosis of Barts Syndrome was made based on history and clinical examination. However, detailed investigations and histopathological confirmation is needed for final diagnosis. The management is conservative and needs multidisciplinary support.

Skin tags are not merely cosmetic: A study on its association with metabolic syndrome

Background: Skin tags (STs) are common benign lesions composed of loose fibrous tissue and occur mainly on the neck and flexures as small, soft protrusions. They are common and are merely considered as a cosmetic problem. However, they have been associated with various clinical conditions and that with metabolic syndrome (MetS) has been a matter of special concern. Objective: To investigate the prevalence of MetS in patients with STs and healthy controls. Materials and Methods: We performed a hospital-based case-control study on 30 adult patients with STs and 30 controls. MetS was diagnosed by the presence of 3 or more of the South Asian Modified National Cholesterol Education Programs Adult Panel III criteria. Results: MetS was significantly more common in STs patients than in controls (70% vs. 30%, P = 0.0019). Psoriatic patients also had a higher frequency of triglyceridemia and abdominal obesity (P < 0.05) There was no significant difference in the fasting blood sugar, high density lipoprotein levels, and presence of hypertension among patients with psoriasis and controls. Conclusion: STs could be considered as a warning sign for MetS and their presence may help in the early detection of at-risk patients for cardiovascular morbidities.

Application of illuminoscope in smartphone micrography

1. Kellett CE. Sir Thomas Browne and the disease called the Morgellons. Ann Med Hist 1935;7:467‐79. 2. Morgellons Research Foundation. Available from: http://www. morgellons.org/. [Last accessed on 2016 Apr 18]. 3. Misery L. Morgellons syndrome: A disease transmitted via the media. Ann Dermatol Venereol 2013;140:59‐62. 4. Middelveen MJ, Bandoski C, Burke J, Sapi E, Filush KR, Wang Y, et al. Exploring the association between Morgellons disease and Lyme disease: Identification of Borrelia burgdorferi in Morgellons disease patients. BMC Dermatol 2015;15:1. 5. Pearson ML, Selby JV, Katz KA, Cantrell V, Braden CR, Parise ME, et al. Clinical, epidemiologic, histopathologic and molecular features of an unexplained dermopathy. PLoS One 2012;7:e29908. 6. Harvey WT, Bransfield RC, Mercer DE, Wright AJ, Ricchi RM, Leitao MM. Morgellons disease, illuminating an undefined illness: A case series. J Med Case Rep 2009;3:8243. 7. Lepping P, Freudenmann RW. Delusional parasitosis: A new pathway for diagnosis and treatment. Clin Exp Dermatol 2008;33:113‐7.

Atherogenic lipid profile in psoriasis: Correlation with severity and duration of the disease

Background: Psoriasis has been considered of late as a dermatological disorder with systemic inflammation that could contribute to various systemic effects like atherogenic dyslipidemia. Materials and Methods: Eighty patients with psoriasis and 80 age and sex matched controls were included in the study for their serum lipid profiles. The lipid values were compared with special emphasis on the duration and severity of the disease. Results: Serum triglycerides were found to be significantly higher in the psoriasis group than in the control group ( P ≤ 0.05). No significant difference was found between serum total cholesterol, low-density lipoprotein-cholesterol (LDL-C), high-density lipoprotein-cholesterol (HDL-C) levels in the two groups. However, Low HDL-C levels were found in patients with disease of more than 2 years ( P ≤ 0.05) and elevated total cholesterol ( P P 12). Conclusion: Atherogenic dyslipidemia is observed in psoriasis, but the degree of change may vary based on the duration and severity of psoriasis. More studies with a higher sample size are required to obtain longitudinal data for conclusive evidence about the systemic effects on lipid profiles in psoriasis.

Giant pigmented Bowen's disease: A rare variant at a rare site

Sir, Bowens disease (BD) is an intraepithelial squamous cell carcinoma (SCC) in situ with a potential for invasive malignancy. Although it has a propensity to occur in sun-exposed areas, other unusual sites are also described.[1] BD is unusual in the pigmented skin and the pigmented variant of BD occurs in less than 2% of cases.[2] Etiology of BD is not clearly understood but various strains of human papilloma viruses, arsenic exposure, and immune suppression have been considered as the risk factors.[3,4] Lesions arising in scars have been described.[5] Three to five percent cases of BD have a risk of developing SCC; metastasis may occur in 1/3 of these invasive tumors.[6] We describe an unusual case of giant pigmented BD over an atypical site. A 68-year-old male presented with a gradually progressing, asymptomatic plaque over the left lower abdomen of 25 years duration. He had applied topical herbal medications with no improvement. There were no medical co-morbidities or excessive sunlight exposure or exposure to arsenic, radiation or underlying immunosuppression. There was history of constant friction at the waistline due to tying of dhoti, a traditional outfit of south India. Cutaneous examination revealed a well defined, hyperpigmented, scaly, verrucous, irregular plaque with a central area of depigmentation measuring about 11 × 5 cm [Figure 1]. Differential diagnoses of Bowens disease, basal cell carcinoma, and lupus vulgaris were considered. An edge biopsy sent for histopathological examination revealed hyperkeratosis, acanthosis, and irregular elongation of rete ridges with thinned out papillae. Scattered dyskeratotic cells having homogenous eosinophilic cytoplasm and hyperchromatic nuclei were noted imparting a windblown appearance [Figure 2]. Focal areas of dysplasia were noted with a few atypical cells having hyperchromatic nuclei with an intact basement membrane. Scattered melanin pigment was observed within the cytoplasm of the atypical keratinocytes. [Figure 3]. The deeper dermis revealed mild to moderate perivascular chronic inflammatory infiltrate. Multiple sections did not reveal features of SCC. A final diagnosis of pigmented type of Bowens disease was thus confirmed. Figure 1 Well-defined, hyperpigmented, scaly, verrucous, irregular plaque with a central area of depigmentation measuring about 11 × 5 cm Figure 2 Scattered dyskeratotic cells having homogenous eosinophilic cytoplasm and hyperchromatic nuclei giving a windblown appearance (H and E ×400) Figure 3 Scattered melanin pigment seen within the cytoplasm of the atypical keratinocytes (H and E ×400) In 1912, John T. Bowen described Bowens disease as a form of in situ SCC, with a potential to progress to invasive carcinoma.[7] Histopathologically, it is characterized by the “windblown” pattern of the epidermis, with loss of polarity and presence of nuclear atypia and mitotic figures.[7] Various treatments including topical imiquimod or 5-fluorouracil, cryotherapy, surgical excision, electrocautery, photodynamic therapy, lasers, and Mohs micrographic surgery have been attempted.[1,2] Excision and primary closure was relatively easy in our patient as a rapid treatment. Cosmetic outcome was not a major consideration for the patient because the lesion was situated in a covered area. Surgical excision was hence chosen ahead of other options such as cryotherapy and topical 5-fluorouracil.[8] BD in sun protected areas of the body is a rare occurrence. It was also a giant lesion (11 × 5 cm) that did not progress to malignancy despite its chronicity. It also occurred at the friction prone site of the waistline due wearing of the dhoti, a traditional garment of south India, hence making it a possible cultural dermatosis. Many waistline dermatoses due to wearing of tight garments such as saree/petticoat have been reported but not Bowens disease,[9] making our case unique. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Leprosy: Chronicles of a disabling disease

The history of leprosy dates back to antiquity.[1] It is a complex disease with multifaceted history ranging from medical-scientific to legal, social, and political.[2] The word leprosy is derived from the Greek word “lepros,” meaning scaly. The disease was named after Gerhard Armauer Hansen as Hansen’s disease following his identification of a bacterium, Mycobacterium leprae as the causative agent of leprosy. Despite the various advances in the field of leprosy management, it is still referred to as “living death.”[1]