Rashmi Sarkar

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.

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.

Three unusual siblings with Harlequin icthyosis in an Indian family.

Harlequin fetuses occurring as three siblings in an Indian family are described here. All three were preterm, low birth weight, and did not survive. There was no history of consanguinous marriage in the parents or in the family. Thus autosomal recessive inheritence appears to be a remote possibility, although not impossible or, as recently described, these recurrent harlequin fetuses could be the result of new dominant mutations with parental mosaicism.

Erythroderma in Children : A Clinico-Etiological Study

Although there are various published studies on erythroderma from western and Asian countries, most of them have only included patients in the adult age groups. As we have an exclusively pediatric dermatology unit, we thought it would be intriguing to study the clinical, etiological and laboratory parameters of erythroderma in children.

Comparative Evaluation of Efficacy and Tolerability of Glycolic Acid, Salicylic Mandelic Acid, and Phytic Acid Combination Peels in Melasma.

BACKGROUND Melasma is acquired symmetric hypermelanosis characterized by light-to-deep brown pigmentation over cheeks, forehead, upper lip, and nose. Treatment of this condition is difficult and associated with high recurrence rates. Chemical peels have become a popular modality in the treatment of melasma. OBJECTIVE To compare the therapeutic efficacy and tolerability of glycolic acid (35%) versus salicylic-mandelic (SM) acid (20% salicylic/10% mandelic acid) versus phytic combination peels in Indian patients with melasma. MATERIALS AND METHODS Ninety patients diagnosed with melasma were randomly assigned into 3 groups of 30 patients each. Group A received glycolic acid (GA-35%) peel, Group B received SM acid, and Group C received phytic combination peels. Each group was primed with 4% hydroquinone and 0.05% tretinoin cream for 4 weeks before treatment. Chemical peeling was done after every 14 days in all groups until 12 weeks. Clinical evaluation using melasma area and severity index (MASI) score and photography was recorded at every visit and follow-up was done until 20 weeks. RESULTS There was a decrease in MASI score in all 3 groups but it was statistically significantly lower in Group A than Group C (p = .00), and it was also statistically significantly lower in Group B than Group C (p = .00) but there was no statistically significant difference between Groups A and B (p = .876). Objective response to treatment evaluated by reduction in MASI scoring after 12 weeks was 62.36% reduction in GA group, 60.98% reduction in SM group, and 44.71% in phytic acid group. CONCLUSION It is concluded that GA (35%) and SM acid peels are both equally efficacious and a safe treatment modality for melasma in Indian skin, and are more effective than phytic acid peels. Salicylic-mandelic peels are better tolerated and more suitable for Indian skin.

Unilateral Nevoid Telangiectasia Syndrome

To the Editor: A one-year-old female child presented to the outpatient department with unilateral erythematous streaky lesions over the right side of the face present since birth and swelling of the right eyelid of one day’s duration. There was no family history of similar lesions. Cutaneous examination revealed a strikingly unilateral distribution of thread-like telangiectasia extending from the medial canthus of the right eye to 2.0 cm anterior to the right tragus. These telangiectasia were distributed over the right periorbital region and forehead (Fig. 1) along the distribution of the left trigeminal nerve. There was no macular erythema in the background. Examination of the right eyelid revealed excoriations and a puncta suggestive of an insect bite (although it gave the lesion an appearance of cavernous haemangioma). The lesions did not blanch on pressure. Eye examination was normal except for chemosis of the right eyelid with haemorrhagic crusting on the surface. The cornea, uvea and retina were normal. A clinical diagnosis of unilateral nevoid telangiectasia was made. The histopathological examination showed dilated capillaries in the subpapillary plexus of the dermis, which was consistent with the diagnosis. Unilateral nevoid telangiaetasia syndrome is a rare congenital (1) or acquired condition characterized by a dermatomal distribution of telangiectasia (2). It is distributed over the trigeminal, C3, C4 (1), or adjacent dermatomes (2) and is reported to be uncommon in females (2). The telangiectasias may vary from erythematous macules to pulsatile spiders with a central puncta (2). Acquired forms are seen in association with elevated estrogen states including puberty, pregnancy, liver disease, or exogeneous estrogen therapy (1, 4). The pathogenesis has been presumed to be a dermatomal defect of increased estrogen receptors. Wilkin et al. proposed that unilateral dermatomal telangiectasia was a more appropriate name and that it was a localized form of generalized essential telangiectasia (3). Other associations include erythema palmare (1), gastric and retinal involvement (1), tuberculosis (3), bronchitis (3), cryptorchidism (3), and scleroderma (5). The condition can be differentiated from hemangioma simplex or nevi simplex by the absence of any background macular eythema which feature these telangiectasias and by the presence of the streaky telangiectasias in the present case in the distribution of the trigeminal nerve. Such hemangiomas on the face usually fade by one year; however, in the present case, they persisted. Angioma serpiginosum was also considered, but the points against the diagnosis were: absence of a family history of similar lesions, absence of a background of diffuse erythema, location of the lesions on the face rather than on the lower limbs and the buttocks, and distribution of the telangiectasias in the distribution of the trigeminal nerve. This is a rare occurrence of telangiectasia in a dermatomal distribution in a pediatric age group; to the best of our knowledge, no other such case has been reported from India. The Journal of Dermatology Vol. 28: 453–454, 2001

Multinodular keratoacanthoma: a rare but definite entity.

A 62-year-old male farmer was seen at the skin outpatient department of the Lady Hardinge Medical College Hospital for evaluation of a large asymptomatic tumor on the right lower limb. It had been present for the last 11 months. The tumor began as a 2 x 1 -cm sized lesion and progressively increased in size with central clearing and the appearance of multiple raised lesions on the periphery of the tumor. There was no history of trauma/ infection at the site, exposure to tar/chemicals or excessive exposure to sunlight. There was no history of tuberculosis in the patient or family. Dermatological examination revealed a hypertrophic, verrucous plaque of size 9 x 5 cm on the right shin with multiple nodules of size 1.5 cm to 2 cm on the periphery of the plaque with central clearing and scarring (Fig. 1). Regional lymph nodes were not enlarged, and remainder of the cutaneous examination was normal. A diagnosis of multinodular keratoacanthoma was made. A wedge biopsy was performed from the periphery of the plaque, and the histopathology confirmed the diagnosis of keratoacanthoma (Fig. 2). Wide (4 mm) excisional surgery was performed and the defect was repaired with a full-thickness skin graft (Fig. 3). The patient was subsequently discharged and has been on regular follow up for the last 3 years with no recurrence.

Hereditary wooly hair in an Indian family.

To theEditor:A thirty-seven-year-old Indian woman and her two daughters, aged eleven and seven years, presented with loss of hair from different parts of the scalp. The hairs were sparse and curly from birth in all of them. There was no history of consanguinity in the parents. Neither the woman nor her two daughters suffered from either photosensitivity or any systemic illnesses. Examination of the scalp revealed tightly coiled, thin, dry, brittle, poorly pigmented, lustreless, sparse hairs with irregular patches of alopecia, as shown in Figure 1. These changes were more severe in the mother and her younger daughter. The nails, teeth, and genitals were normal. Both the sisters had normal IQs. The hairs of the eyebrows, axillary, and pubic regions were very sparse in all three patients. Systemic examination was normal. A clinical diagnosis of hereditary wooly hair was made. The routine laboratory tests were normal. Low power microscopic examination of the hairs showed reduction in hair shaft diameter and cuticular wear and tear. There are many conditions associated with abnormalities of the hair shaft; wooly hair is associated with excessive fragility of the hair. Wooly hair is more or less tightly coiled hair which occurs over the whole or part of the scalp, in an indivudual not of negroid origin (1). Hutchinson et al. have clasLetter to the Editor

Treatment of Postinflammatory Hyperpigmentation With a Combination of Glycolic Acid Peels and a Topical Regimen in Dark-Skinned Patients: A Comparative Study

BACKGROUND Facial postinflammatory hyperpigmentation (PIH) is challenging to manage in patients with skin of color because of the risk of subsequent treatment-related hyperpigmentation. OBJECTIVE To evaluate the safety and efficacy of combining glycolic acid (GA) peels with a modified Kligman formula (MKF) containing hydroquinone 2%, tretinoin 0.05%, and hydrocortisone 1% for the treatment of facial PIH in Indian patients. METHODS Thirty Indian patients (Fitzpatrick skin Types III–V) with facial PIH were randomly assigned to 2 groups of 15 each. One group received serial GA peels combined with an intervening topical regimen containing MKF. The other group received MKF alone. Results were evaluated by a clinical investigator at baseline and at the end of 21 weeks (3 weeks after treatment completion) using an objective scoring system, the Hyperpigmentation Area and Severity Index (HASI) score, and clinical photography. RESULTS The baseline mean HASI scores of the 2 groups were comparable. There was a statistically significant difference in the mean HASI score of the peels group compared with the MKF alone group at 12 weeks (p = .004) and 21 weeks (p < .001). Side effects were observed in both groups and were managed with liberal application of emollients. No patient dropped out of the study as a result of the side effects. CONCLUSION This study demonstrates that serial GA peels in combination with a MKF are efficacious and safe in the treatment of facial PIH in dark-skinned patients.

Lymphangioma circumscriptum masquerading as irritant contact dermatitis.

To theEditor: A ten-year-old girl presented with mildly itchy eruptions over the left upper arm for the previous four years. There was a history of summer exacerbertion. The lesions had first appeared on the left upper arm and then spread to the left foream. She was given some ointment for local application; this aggravated her itching, and the site began to ooze. There was no history of any operative procedure on the arm, family history of similar lesions, or radiation therapy. Cutaneous examination revealed an 8 em x 6 em plaque over the left deltoid region extending on to the medial aspect of the arm and just below the elbow, studded with small deep vesicles resembling frog spawn (Fig. 1). At places, the plaque was crusted (Fig. 2). Clear watery fluid was released when 1)1e lesions were punctured. Systemic examination was normal. A clinical diagnosis of irritant dermatitis was initially made, and the child ws given topical betamethasone valerate cream 0.05% twice a day. Her crusting improved after three days, and a skin biopsy was performed. Histopathology showed multiple irregular cystic spaces lined by a single layer of endothelium containing lymph. The epidermis showed hyperkeratosis at places; at other areas, it was thinned. There was a mild lymphocytic infiltrate in the dermis. A final diagnosis of lymphangioma circumscription was made. A cutaneous lymphangioma can be superficial lymphangioma circumscription or deep lymphangioma cavernosum (I). The classical type of lymphangioma circumscriptum usually manifests at birth or soon afterwards, involves the proximal parts of limbs, and appears in the form of irregular clusters of vesicles (l). The late appearance of this patients leLetter to the Editor