Sathish B Pai

Sutures and suturing techniques in skin closure

A surgical wound never attains the same cutaneous tensile strength as of normal uncut skin. Two weeks after suturing, 3-5% of original strength will be achieved by a surgical wound. By the end of third week, 20% of the ultimate wound strength is achieved, and by one month only 50% of wound strength is attained. All sutures are foreign bodies and produce an inflammatory response in the host dermis. Peak inflammatory response is seen between second and seventh day with abundance of polymorphonuclear leukocytes, lymphocytes, and large monocytes in dermis.[3] Between the third and eighth day, the epithelial cells deeply invade the suture tracts.

Cutaneous metastases from carcinoma breast: the common and the rare.

Cancer metastasis is quite devastating to the patient as well as the physician and may herald the onset, dissemination or recurrence of malignancy. Breast carcinoma metastasis is the most common carcinoma encountered by dermatologists and it presents in various morphological and histological forms. Here, we present two varied cases, the first being the common nodular metastasis from a previously treated intraductal carcinoma and the second, the rarer variant, carcinoma erysipeloides as a heralder of the invasion of an incompletely treated disease.

Efficacy and safety of Erbium-doped Yttrium Aluminium Garnet fractional resurfacing laser for treatment of facial acne scars

BACKGROUND Treatment of acne scars with ablative fractional laser resurfacing has given good improvement. But, data on Indian skin are limited. A study comparing qualitative, quantitative, and subjective assessments is also lacking. AIM Our aim was to assess the improvement of facial acne scars with Erbium-doped Yttrium Aluminium Garnet (Er:YAG) 2940 nm fractional laser resurfacing and its adverse effects in 25 patients at a tertiary care teaching hospital. METHODS All 25 patients received four treatment sessions with Er:YAG fractional laser at 1-month interval. The laser parameters were kept constant for each of the four sittings in all patients. Qualitative and quantitative assessments were done using Goodman and Barron grading. Subjective assessment in percentage of improvement was also documented 1 month after each session. Photographs were taken before each treatment session and 1 month after the final session. Two unbiased dermatologists performed independent clinical assessments by comparing the photographs. The kappa statistics was used to monitor the agreement between the dermatologists and patients. RESULTS Most patients (96%) showed atleast fair improvement. Rolling and superficial box scars showed higher significant improvement when compared with ice pick and deep box scars. Patients satisfaction of improvement was higher when compared to physicians observations. No serious adverse effects were noted with exacerbation of acne lesions forming the majority. CONCLUSION Ablative fractional photothermolysis is both effective and safe treatment for atrophic acne scars in Indian skin.Precise evaluation of acne scar treatment can be done by taking consistent digital photographs.

Cutaneous nocardiosis: an underdiagnosed pathogenic infection

A 35-year-old woman presented with raised red lesions over the elbow at the site of a prior injury from a road traffic accident which had occurred 3 years ago. She gave history of pus discharge from the lesions occasionally. A previous biopsy suggested a diagnosis of cutaneous botryomycosis following which the patient received a course of antibiotics for a week. A culture revealed no bacterial or fungal growth. But the lesions continued to progress with pus drainage. On clinical examination, multiple skin-coloured nodules with erosions and crusting were seen over the extensor …

Childhood epidermolysis bullosa acquisita: Confirmation of diagnosis by skin deficient in Type VII Collagen, enzyme-linked immunosorbent assay, and immunoblotting

Epidermolysis bullosa acquisita (EBA) is an acquired subepidermal bullous disorder characterized by autoantibodies against Type VII collagen. It usually affects adults; childhood EBA is rare. We describe a 10-year-old girl presenting with recurrent tense blisters predominantly on legs, dorsa of hands and feet accompanied by oral erosions since the age of 5 years. Direct immunofluorescence (IF) microscopy showed linear deposition of IgG and C3 along the basement membrane zone (BMZ); indirect IF microscopy on salt-split skin revealed staining of IgG to the dermal side of the split. The patients serum did not show BMZ staining in recessive dystrophic epidermolysis bullosa skin deficient for Type VII collagen, thus confirming autoantibody reactivity against Type VII collagen. Circulating antibodies against the immunodominant noncollagenous 1 domain of Type VII collagen were detected by ELISA and immunoblotting studies. The patient was treated with oral corticosteroids and dapsone with good improvement.

A simple instrument designed to provide consistent digital facial images in dermatology

Photography has proven to be a valuable tool in the field of dermatology. The major reason for poor photographs is the inability to produce comparable images in the subsequent follow ups. Combining digital photography with image processing software analysis brings consistency in tracking serial images. Digital photographs were taken with the aid of an instrument which we designed in our workshop to ensure that photographs were taken with identical patient positioning, camera angles and distance. It is of paramount importance in aesthetic dermatology to appreciate even subtle changes after each treatment session which can be achieved by taking consistent digital images.

Erythema elevatum diutinum associated with scleritis.

Erythema elevatum diutinum (EED) is a chronic and rare variant of leukocytoclastic vasculitis that is being reported nowadays frequently in association with HIV infection. It clinically manifests as asymptomatic to tender erythematous papules, plaques and nodules, usually with acral distribution and is rarely accompanied by systemic complaints other than arthralgia. The reported associations include preceding upper respiratory infections, hematological malignancies, lymphomas and monoclonal gammopathies. Here we report a 45 year old man with multiple joint pains, tender nodules over palms and soles and ocular pain and congestion, who was subsequently diagnosed as a case of EED and scleritis following histopathological examination. Skin as well as ocular complaints completely subsided with Dapsone monotherapy.

Direct Immunofluorescence Microscopy of Skin Biopsy Samples Preserved in Honey

Brachioradial pruritus 9 8.44 (61.01) 3.56 (62.65) 4.89 (62.67) .012 Notalgia paresthetica 3 8.67 (61.53) 5.17 (64.25) 3.50 (63.04) .180 Neuropathic pruritus NOSz 16 9.31 (61.35) 5.23 (63.75) 4.03 (63.6) \.001 Prurigo nodularis 18 9 (61.65) 3.78 (61.96) 5.22 (62.21) \.001 Atopic dermatitis 12 9.08 (61.24) 3.63 (62.33) 5.63 (62.4) .003 Chronic pruritus NOS 14 8.57 (61.79) 4.5 (63.67) 4.07 (63.54) .005 Otherx 36 8.44 (61.76) 3.88 (62.69) 4.81 (62.63) \.001 Total 96 8.63 (61.62) 4.19 (62.9) 4.61 (62.77) \.001

Epidermolysis bullosa acquisita and anti-p200 pemphigoid as major subepidermal autoimmune bullous diseases diagnosed by floor binding on indirect immunofluorescence microscopy using human salt-split skin

Background: Subepidermal autoimmune bullous diseases are a diverse group of diseases with overlapping clinical and immunopathological features. Indirect immunofluorescence microscopy on artificially split skin helps to classify these conditions into those with staining on the epidermal side of the split (“roof-binding”) and those with staining on the dermal side (“floor-binding”). Epidermolysis bullosa acquisita is the prototype of “floor-binding” subepidermal autoimmune bullous diseases. However, not all floor-binding sera are associated with epidermolysis bullosa acquisita. Aim: The aim of this study was to evaluate the clinical and immunological profile of patients with floor-binding subepidermal autoimmune bullous disease by indirect immunofluorescence microscopy and to identify the target antigens in them. Methods: Ten patients who showed a floor-binding pattern were studied with regard to their clinical and immunopathological characteristics. Target antigens were identified by modified indirect immunofluorescence microscopy using recessive dystrophic epidermolysis bullosa skin, enzyme linked immunosorbent assay, and immunoblotting. Results: Diagnosis of epidermolysis bullosa acquisita was confirmed in six patients. Three patients with an inflammatory subepidermal autoimmune bullous disease mimicking bullous pemphigoid reacted with a 200 kDa protein on immunoblotting with dermal extract, as is characteristic of anti-p200 pemphigoid. One serum showed both roof and floor binding, and reacted with the BP180 antigen. Limitation: We could not perform serration pattern analysis in our patients. Conclusion: In this study, we report three cases of anti-p200 pemphigoid from India. These cases, though indistinguishable clinically from bullous pemphigoid, revealed a floor-binding pattern on indirect immunofluorescence using salt-split skin.

Acantholytic Variant of Bowen's Disease with Micro-invasive Squamous Cell Carcinoma: A Case Report of a Unique Variant.

Bowens disease is generally regarded as premalignant dermatoses. The disease affects both skin and the mucosa and has the potential to progress to invasive squamous cell carcinoma. There are descriptions of several histological variants of Bowens disease like psoriasiform, atrophic, pagetoid, etc. Acantholysis of anaplastic keratinocytes with bullae/cleft formation is described in premalignant condition like actinic keratosis and adenoid variant of squamous cell carcinoma, but there is lack of report describing this phenomena in Bowens disease. We present a case of unusual acantholytic variant of Bowens disease with focus of micro-invasive carcinoma.