Sudhir Uk Nayak

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.

Laptop induced erythema Ab Igne

Erythema ab igne is a reticular, pigmented dermatosis caused by prolonged and repeated exposure to infrared radiation that is insufficient to produce a burn. The use of laptop computers has increased manifold in the recent past. Prolonged contact of the laptop with the skin can lead to the development of erythema ab igne. We present a case of erythema ab igne secondary to laptop use in an Indian student.

Henoch-Schonlein purpura: yet another disease manifesting the Koebner phenomenon.

Sir, A 60-year-old housewife presented with asymptomatic reddish lesions on extremities of 3 weeks duration. There was a history of abdominal pain with bloodstained diarrhea and joint pain. There was no history of passing high colored urine, history of any prior drug intake, pruritus, or any other systemic complaints. There was no previous history of similar complaints. Examination revealed palpable and non-palpable purpurae over the extremities, gluteal region, and lower abdomen [Figure 1]. Some of the purpurae were arranged in a linear pattern especially over the lower extremities [Figure 2]. A clinical diagnosis of HenochSchonlein purpura (HSP) with Koebner’s phenomenon was made.

Herpetiform pemphigus clinically resembling bullous pemphigoid

Herpetiform pemphigus was first introduced by Jablonska in 1975, as a variant of pemphigus that combines the clinical features of dermatitis herpetiformis with the immunological features of pemphigus.1 Because of its rare and atypical clinical presentation, patients are often initially diagnosed as Dermatitis herpetiformis, Linear IgA bullous disease, Bullous pemphigoid or Pemphigus foliaceus. We report a case of herpetiform pemphigus in an elderly lady which was initially misdiagnosed as bullous pemphigoid, however histology and immunofluorescence helped in clinching the diagnosis. A 75-year-old woman presented with a one year history of an intensely pruritic eruption which began on her extremities and later expanded to involve the trunk with only partial response to topical corticosteroids and antihistamines. She was otherwise healthy with no accompanying constitutional symptoms and not on any other medications. Cutaneous examination revealed a symmetric polymorphous eruption of old and new lesions, comprising of erythematous urticarial papules and plaques studded with clear and cloudy vesicles (Fig. 1), ulcerated and crusted lesions arranged in herpetiform groups. Oral and genital mucosa were normal. Clinically a differential diagnosis of bullous pemphogoid was entertained, however a Tzanck smear from a clear vesicle showed abundant neutrophils, with only few eosinophils. Biopsy for histopathology showed mild epidermal hyperplasia with a subcorneal blister containing neutrophils and few acantholytic cells. Predominant areas of neutrophilic spongiosis with a superficial perivascular infiltrate of eosinophils and neutrophils were seen in the papillary dermis. Direct and indirect immunofluorescence demonstrated strong intercellular deposits of IgG and C3 in the upper epidermis. Based on the histology and immunofluorescence findings, the diagnosis was revised to herpetiform pemphigus and patient was started on oral steroids. Fig. 1 Grouped flaccid vesicles and bullae in a herpetiform distribution Pemphigus herpetiformis (PH) is recognized as a distinct subset of pemphigus by its pruritus, rarity of mucosal involvement, invariable presence of eosinophils on histology and its tendency to respond to sulfones. Various terms that have been used to describe it are acantholytic herpetiform dermatitis, pemphigus controlled by sulfapyridine, mixed bullous disease and eosinophilic spongiosis in pemphigus. Clinically patients present with severe intractable pruritus and erythematous urticarial papules and plaques with occasional vesicles in a herpetiform arrangement. Even though the clinical picture is reminiscent of dermatitis herpetiformis, the histological findings are variable and include eosinophilic spongiosis, subcorneal pustules with minimal or no apparent acantholyis.2 Though eosinophilic spongoisis is classically seen in pemphigus herpetiformis, neutrophilic spongiosis may also be encountered and should be recognized as an important diagnostic clue3 as was seen in our case. Definitive diagnosis is established by immunopathology which shows in vivo bound IgG deposits on the keratinocyte cell surface primarily in the upper epidermis. The auto-antibodies in most patients of PH target desmoglein 1 and because desmoglein 1 is predominantly located in the upper epidermis, there is preferential binding of IgG to the upper epidermis as was seen in our case. Why the auto-antibodies in PH and pemphigus vulgaris give rise to different clinical presentations could be explained by their preferential binding to different epitopes on the same antigen molecule.4 In our case, the presence of severe pruritus in an elderly female with blisters and absence of mucosal involvement made us think of bullous pemphigoid, however, to our surprise the histology and immunofluorescence turned out to be PH. Patient was started on oral steroids along with dapsone and is currently under follow-up.

Conjugal Leprosy: is there a need for active Surveillance in Endemic Areas?

Leprosy is an ancient chronic disease caused by Mycobacterium leprae, primarily residing in skin and peripheral nerves, leading to varied spectrum of clinical manifestations.1 Leprosy has been endemic to India since antiquity.During the 20th century, health authorities and private agencies waged war towards elimination of the disease.The elimination of leprosy as a public health prob-lem was officially declared in India on 31 December 2005.2 This does not mean the disease is eliminated.However, many do not now consider leprosy to be a significant health issue.3–5 We report a case of conjugal leprosy which provides substantial evidence of the continued threat of leprosy in India.

Doxofylline: Another drug causing fixed drug eruption

Our patient had idiopathic pyoderma gangrenosum of 8-year duration. Due to the severity of disease, large area of involvement, and very long-standing nature of the disease, we wanted to start the patient on oral prednisolone. However, in view of her uncontrolled diabetes, adverse effects of cyclosporine on blood pressure and kidney, inconvenience of taking potassium iodide, and biologics being very expensive alternative, we decided to begin the therapy with safer alternatives and hence dapsone and doxycycline were started to which the patient responded very quickly and completely in 45 days and still continues to be in remission. We report an unusually long-standing case of pyoderma gangrenosum and would like to lay emphasis on the fact that older, cost–effective, and relatively safer drugs such as dapsone and doxycycline may be revisited again as first‐line therapy for treating pyoderma gangrenosum, especially in patients with comorbidities rather than steroids, immunosuppressives, and biologics which have greater side effects and are very expensive.

A refractory case of scleromyxedema

A 45-year-old female presented with generalized tightening of skin associated with burning and itching of 2 months’ duration. The tightening of skin was first noticed over the trunk which gradually spread to involve the limbs. There was difficulty in food intake due to restricted mouth opening, but there was no difficulty in swallowing food. Restricted opening of mouth and tightening of skin due to the edema resulted in difficulty in performing day‐to‐day activities which affected her quality of life. There was no history of any previous drug intake or other systemic illness. There was no history suggestive of Raynaud’s phenomenon.

Multiple trichofolliculomas mimicking multiple trichoepitheliomas

Trichofolliculomas are benign hair follicle hamartomas which were initially considered as hair follicle tumors. Usually presenting as a solitary lesion associated with a tuft of vellus hairs, multiple trichofolliculomas are rare. Trichofolliculomas are characterized by a histopathological feature of dermal keratin cyst with cyst wall showing radiating hair follicles. We report this case for the rare presentation of multiple trichofolliculomas on the face which clinically mimicked multiple trichoepitheliomas.

Synopsis of Diet in Dermatology: A one day CME conducted by the Department of Dermatology, Kasturba Medical College,Manipal, March 3, 2013

Food is intricately related to mind and body and is one of the elements sustaining life, in disease as well as in health. There are many myths and misgivings regarding partake of food and its medicinal properties. The Department of Dermatology, Kasturba Medical College (KMC), Manipal organized a continuing medical education (CME) on Diet in Dermatology on 3rd March 2013 focusing on pertinent issues regarding diet and medicinal use of food.

Finger like growth and multiple nodules over right upper back.

Indian J Dermatol Venereol Leprol | September-October 2010 | Vol 76 | Issue 5 Figure 1: Finger-like growth and multiple nodules seen over upper back Figure 3: Storiform pattern of arrangement of spindle cells in dermis (H and E, ×200) Figure 2: Epidermis showing orthokeratosis, mild acanthosis, and effacement of rete ridges. There is diffuse infiltration of spindle cells throughout dermis extending in to subcutaneous fat (H and E, ×40). Finger like growth and multiple nodules over right upper back