Sendhil Kumaran

Woolly hair nevus.

To the Editor: Molluscum contagiosum and common warts (verrucae vulgaris) are two cutaneous infections caused by DNA viruses that infect the epidermis: human papillomavirus and poxvirus, respectively. While these infections can occur at any age, the greatest incidence occurs in children. The prevalence of molluscum contagiosum and common warts is especially high in individuals who are immunocompromised. Although skin lesions associated with these infections have different presentations, treatments are similar and have traditionally consisted of topical application of chemicals such as salicylic acid, glycolic acid, silver nitrate, trichloroacetic acid, or podophyllin. Recent anecdotal reports demonstrate limited success with oral or topical cidofovir or oral cimetidine treatment (1–3). Ablative procedures performed during an office or clinic visit include cryotherapy with liquid nitrogen, curettage, laser vaporization, and electrodesiccation. Treatment of molluscum contagiosum and common warts is not benign and is frequently associated with pain. For young children, treatment can be far worse than the skin lesions themselves. Due to the contagious nature of these diseases and the propensity for autoinoculation, the proliferative lesions can be tenacious and resistant to treatment. Recently the efficacy of duct tape was compared to cryotherapy in the treatment of common warts (4). Because treatment of common warts is similar to that of molluscum contagiosum, we opted to try duct tape occlusion in the treatment of recurrent molluscum contagiosum. A 7-year-old Asian girl with a history of atopic dermatitis presented with an eruption of waxy, round, umbilicated, pearl-colored papules extending from the backs of both knees to her thighs. At home, a topical solution of 17% salicylic acid had been applied to the lesions, resulting in significant pain. A compounded topical cream containing glycolic acid was prescribed as an alternative treatment. Toothpick application of this cream, followed by occlusion with paper tape, resulted in slightly less pain. The patient endured this therapy for 3 months. At the next office visit, the lesions were crusted over, with the waxy papules replaced by scabs. The topical cream was discontinued and a triple antibiotic ointment was applied for 5 days to prevent secondary bacterial infection. The lesions gradually disappeared within 2 weeks of discontinuation of the topical glycolic acid therapy. The most severe lesions left scars that faded over time. Molluscum contagiosum lesions reappeared 1 year later. The patient was reluctant to undergo a second course of topical glycolic acid therapy, therefore duct tape occlusion therapy was attempted. Duct tape was applied in a manner similar to that for common warts, with the exception of applying the tape over multiple lesions. Duct tape was cut to the size of each lesion and applied after the patient bathed and towel dried. It was reapplied after each bath or if it fell off. After 3 weeks of therapy, most of the lesions were crusted over. Occlusion therapy continued for 2 months. By the end of therapy the lesions had disappeared. This treatment was very well tolerated, with no reported pain or irritation. Compared to topical salicylic acid or glycolic acid therapy, minimal scarring occurred. The use of duct tape occlusion therapy for molluscum contagiosum has several advantages over conventional treatment. Treatment is nondestructive and painless or minimally painful. Duct tape is widely available and affordable compared to the costs of traditional over-the-counter and prescription medications. The tape is applied at home, obviating office visits. Molluscum contagiosum is selflimiting and can remit spontaneously. However, when lesions persist, the use of duct tape occlusion may be a more acceptable, nontoxic treatment option, especially for young children.

Combination of Follicular and Epidermal Cell Suspension as a Novel Surgical Approach in Difficult-to-Treat Vitiligo: A Randomized Clinical Trial

Importance Epidermal cell suspension (ECS) and follicular cell suspension (FCS) are successful surgical modalities for the treatment of stable vitiligo. However, repigmentation in generalized and acrofacial vitiligo and over acral or bony sites (eg, elbows, knees, iliac crests, and malleoli), which are difficult to treat, is challenging. Objective To study the efficacy of transplanting a combination of autologous, noncultured ECS and FCS (ECS + FCS) compared with ECS alone in stable vitiligo. Design, Setting, and Participants A prospective, observer-blinded, active-controlled, randomized clinical trial was conducted at a tertiary care hospital, with treatment administered as an outpatient procedure. Thirty participants who had stable vitiligo with symmetrical lesions were recruited between October 18, 2013, and October 28, 2016. All of the lesions were resistant to medical modalities with minimum lesional stability of 1 year. Intent-to-treat analysis was used. Interventions ECS + FCS was prepared by mixing equal amounts (in cell number) of FCS with ECS. After manual dermabrasion, ECS was applied to 1 lesion and ECS + FCS was applied to the anatomically based paired lesion of the same patient. No adjuvant treatment was given. Main Outcomes and Measures Patients were followed up at 4, 8, and 16 weeks by a blinded observer and extent of repigmentation, color match, pattern of repigmentation, patient satisfaction and complications were noted. Both the visual and the computerized image analysis methods were used for outcome assessment. Cell suspensions were assessed post hoc for OCT4+ stem cell counts using flow cytometry; expression of stem cell factor and basic fibroblast growth factor was evaluated using quantitative relative messenger RNA expression. Results Of the 30 patients included in the study, 18 (60%) were women; mean (SD) age was 23.4 (6.4) years. Seventy-four percent of the lesions (62 of 84) were difficult-to-treat vitiligo. ECS + FCS showed superior repigmentation outcomes compared with ECS: extent (76% vs 57%, P < .001), rapidity (48% vs 31%, P = .001), color match (73% vs 61%, P < .001), and patient satisfaction (mean [SD] patient global assessment score, 23.30 [6.89] vs 20.81 [6.61], P = .047). Melanocyte stem cell counts (2% in ECS + FCS vs 0.5% in ECS) as well as expression of basic fibroblast growth factor (11.8-fold) and stem cell factor (6.0-fold) were higher in ECS + FCS suspension (P<.05 for both). Conclusions and Relevance The findings from this study establish ECS + FCS as a novel approach in vitiligo surgery for attaining good to excellent repigmentation in a short period with good color match, even in difficult-to-treat vitiligo. Trial Registration ctri.nic.in Identifier: CTRI/2017/05/008692

Comparison of bacillary index on slit skin smear with bacillary index of granuloma in leprosy and its relevance to present therapeutic regimens

Background: As the world moves toward elimination of leprosy, persistence of infective cases in endemic pockets remains a significant problem. The use of clinical criteria to decide the paucibacillary (PB) versus multibacillary (MB) regimens has greatly simplified therapy at the field setting. However, a small but significant risk of under-treatment of so-called “PB” cases which actually have significant bacillary load exists. This study was undertaken to assess this risk and compare two methods of assessment of bacillary load, namely bacillary index on slit skin smear (BIS) versus bacillary index of granuloma (BIG). Aims: To compare BIS with BIG on skin biopsy in consecutive untreated cases of leprosy. Materials and Methods: This prospective study was conducted over a period of 12 months, wherein new untreated patients with leprosy were consecutively recruited. After a thorough clinical examination, each patient underwent slit skin smear (SSS) where the BIS was calculated. The same patient also underwent a skin biopsy from a clinical lesion where, the BIG was calculated. SSS and skin biopsy for BIS and BIG respectively were repeated for all patients at the end of therapy for comparison. All patients received therapy according to World Health Organization-Multidrug Therapy Guidelines. Results: The BIG was positive in all cases where the BIS was positive. Significantly, BIG was positive in three cases of borderline tuberculoid leprosy with <5 lesions who received PB regimen, whereas the BIS was negative in all three cases. Conclusion: This study suggests that BIG may be a better indicator of the true bacillary load in leprosy as compared to BIS. Its role in management is significant, at least in tertiary care centers to prevent “under-treatment” of so called PB cases, which may actually warrant MB regimens.

Noninvasive treatment of keloid using customized Re‐188 skin patch

Keloids are developed as fibrotic scar at the site of surgery or trauma and often enlarge beyond the original scar margins. Re‐188 colloid coated customized patch was superficially fixed onto the lesion for 3 hrs. The same patch was reapplied on the lesion on third day for 3 hrs. The patients were followed up at 1, 3,6 and 12 months post treatment. The size and elevation of the keloid lesion was reduced after treatment. The total radiation dose from the patch (day‐1 and day‐3) was 100 Gy/mCi of Re‐188. The radioactive patch treatment of keloids is noninvasive, painless and safe with prolonged outcome.

Gangrene of the Glans Penis in a Diabetic Patient Due to Calcific Arteriopathy

A 50-year-old man with poorly controlled diabetes mellitus presented with gangrene of the glans penis (A). He had been on haemodialysis for 5 years until he underwent renal transplantation 6 months back. Histopathology revealed fat necrosis and microangiopathy without any calcium deposits (B). Doppler imaging showed dense intimal calcification of the deep arteries of the penis (C, D; arrows) with vascular compromise. He underwent total penectomy. A normal calcium-phosphate product of <70 mg/dL, normal parathyroid hormone levels, absence of calcium deposits in cutaneous vasculature, and lack of response to a therapeutic trial of sodium thiosulfate ruled out a possibility of calciphylaxis in the index case. We could find some reports of penile gangrene in diabetic patients due to calcific arteriopathy. Ischemic penile gangrene is a rare occurrence owing to its abundant blood supply from 3 vessels. References

Spina ventosa—a rare cause of sausage digit

A 21-year-old female presented to us with a 2-month history of painful swelling involving her right index finger with low-grade fever. Examination demonstrated a visibly enlarged index finger with a firm, fusiform swelling that involved the proximal and middle phalanges, with overlying erythema (Fig. 1A). Movements were painful. History of local trauma, cough, bowel or menstrual disturbance and immunosuppression could not be elicited. Serum HIV and VDRL were negative. Serum uric acid concentration and X-rays of chest and spine were normal. X-Ray of the digit showed cortical erosion in the distal part of proximal phalanx, minimal periosteal reaction and soft tissue swelling (Fig. 1B). Biopsy revealed granulomatous inflammation in the dermis and subcutaneous fat, with necrosis and Langhan’s giant cells. Staining and culture for bacteria, fungi and mycobacteria were negative. Mantoux test was strongly positive (34 mm). A diagnosis of tubercular dactylitis/spina ventosa was made. The patient was started on anti-tubercular treatment and had significant improvement in the swelling at a follow-up of 2 months (Fig. 1C). Dactylitis or sausage digit is an inflammatory fusiform digital swelling. Differentials include infections (pyogenic osteomyelitis, tuberculosis, phaeohyphomycosis), PsA, sarcoidosis, reactive arthritis, gout and bone tumours. Spina ventosa is tubercular osteomyelitis of the phalanges that can spread to overlying soft tissues causing sausage digit. Although rare, it is important to consider tuberculosis as cause of sausage digit in an endemic area because of the excellent response to anti-tubercular treatment [1, 2].

Primary cutaneous nodular amyloidosis: A rare disease

© 2017 Indian Dermatology Online Journal | Published by Wolters Kluwer Medknow A 40‐year‐old male presented with a 6‐month history of a gradually progressing, painless, firm, 10 × 8 mm erythematous nodule on his nose [Figure 1]. Skin biopsy showed nodular deposition of eosinophilic, acellular, amyloid material in the entire dermis, which was surrounded by focal plasma cell infiltrate [Figure 2]. This material was congophilic [Figure 3] and demonstrated kappa light chain restriction on immunohistochemistry [Figure 4]. Systemic amyloidosis was ruled out by laboratory investigations, and thus, a diagnosis of primary nodular cutaneous amyloidosis, immunoglobulin light chain (AL) type was made.

Evidence-based review, grade of recommendation, and suggested treatment recommendations for melasma

Treatment of melasma is known to be less satisfactory, often incomplete, and relapse is frequent. Although many treatment options are available, they are either known to be unsafe on long-term use or their long-term safety profile is unknown. Patients often use various drugs, even topical steroid-based preparation without any medical supervision for long period of time, making the skin unsuitable for many of the drugs available. Thus, there has been gross disparity among the treating physician about what drugs and what regimen are best suitable for various categories of melasma patients and in different situations. With this background, numerous newer drugs, mostly combinations of some proprietary molecules or even unknown plant extracts, have flooded the market for the management of melasma. Information on efficacy or safety of these products are almost unknown. Studies on Asian people, especially Indian population, are far less commonly available. Therapeutic guideline for use on Indian patients with melasma is almost missing. Extrapolation of data from Caucasian people for use on Asian people may not be scientifically justifiable because Caucasian and Asian people are known to have inherent difference in their response as well as tolerance to the drugs used for melasma. With this background, we have extensively evaluated, following a strict, scientifically designed protocol, all the available studies on melasma management till May 2016 and prepared this document on level of evidence, grade of recommendation and suggested therapeutic guideline for melasma as per the method proposed by Oxford Centre of Evidence-Based Medicine. Various ethical, social, logical, regional, and economic issues in the context of Indian and similar populations were given due importance while preparing the suggested therapeutic recommendation.