Tulika Rai

A rare case of keloidal granuloma faciale with extra-facial lesions

Granuloma faciale (GF) is an uncommon, cutaneous disorder characterized by one to several soft, erythematous to livid papules, plaques, or nodules, usually occurring on the face. Extra-facial lesions occur rarely. We present a case report of 33-year-old male who presented with keloidal lesions on face and left shoulder. The patient didn’t respond with intralesional triamcinolone and showed poor response with the addition of topical tacrolimus. Surgical excision in consultation with plastic surgeons is planned.

Type 2 lepra reaction in an immunocompromised patient precipitated by filariasis

Though patients affected with both acquired immuno deficiency syndrome (AIDS) and leprosy commonly present with type 1 lepra reaction, there are few isolated reports of type 2 lepra reaction in retropositive patients affected with leprosy. We are presenting a case report of 35-year-old male affected with AIDS, tubercular lymphadenitis, and lepromatous leprosy with recurrent episodes of type 2 lepra reaction manifesting as erythema nodosum leprosum (ENL). Dipstick enzyme-linked immunosorbent assay (ELISA) for filarial antigen was also positive. The patient was treated with 100 mg thalidomide daily, 300 mg diethylcarbamazine, and modified multidrug therapy (MDT) for leprosy. He responded well and has not had any further reaction in the last 6 months.

A case of zidovudine induced pigmentation on palms and soles

98 Indian Dermatology Online Journal January-March 2014 Volume 5 Issue 1 No single modality of treatment may suffice to improve outcome in deeper acne scars. Combination of multiple treatment modalities in a less aggressive mode offers substantially better outcomes with less complications. Ramadan et al. studied subcision versus 100% trichloroacetic acid in the treatment of rolling acne scars in a split face trial. This study highlighted two important factors viz; the side with subcision showed significantly greater decrease in scar depth and size than TCA, although more pigmentation was seen with TCA (CROSS) over time decrease in scar depth was better with TCA (CROSS) method.[7]

A rare case of malignant acanthosis nigricans in a lady with ovarian cancer

“Tripe palms” or pachydermatoglyphy is a descriptive term of acanthosis nigricans of the palms and is associated with internal malignancy. It often precedes the diagnosis of a new or recurrent tumor. Malignant acanthosis nigricans is most commonly associated with intra-abdominal malignancies. In patients with both tripe palms and acanthosis nigricans, gastric carcinoma is the most common followed by lung carcinoma. There are very few reports in the literature of malignant acanthosis nigricans associated with gynecological malignancies. We report this case because of its rarity. A 47-year-old lady presented with lower abdominal swelling and progressive hyperpigmentation which preceded the abdominal swelling by 6 months. On investigations, she was found to have ovarian cancer. The presence of acanthosis nigricans in conjunction with tripe palms in a female patient is highly suggestive of an internal malignancy including an ovarian cancer and demands an extensive search for the hidden ovarian cancer.

Papular granuloma annulare of palms and soles

Apart from the complications of ENL, leprosy patients can have other deformities such as foot drop, claw hand, shortening of digits, and non‐healing ulcers. In the present case, the patient had necrotic ENL with painful ulcers over the extremities and buttocks, tender inguinal, and submental lymphadenopathy. The close differential diagnosis of the present case is lucio phenomenon, which occurs in patients with diffuse form of leprosy and presents with purpuric lesions followed by ulcers with irregular margins. Lucio phenomenon is characterized by absence of constitutional and systemic symptoms. On histopathology there is ischaemic epidermal necrosis, necrotizing vasculitis, endothelial proliferation, and presence of a large number of AFB in endothelial cells. Lucio phenomenon responds to MDT.[4] In our case, the patient had systemic symptoms with multiple nodules getting ulcerated and AFB was absent in histopathology. The patient was already on MDT when she developed nodules and ulcers which later responded to oral steroids. After treatment, the ulcers healed with extensive linear hypopigmented and hypertrophic scar formation over extremities. Hypertrophic scar is an abnormal tissue response to injury leading to excess collagen formation and at times can lead to contracture of the affected parts hindering the movement.[5] Extensive linear hypopigmented and hypertrophic scars over the extremities as a sequel of necrotic ENL is cosmetically unappealing for a young girl and can hamper the daily activities. It also adds to the suffering of a patient who is already psychologically handicapped with leprosy. The case is interesting both for necrotic ENL which is rarely found and because of formation of extensive scars as a complication along with significant lymphadenopathy.

Role of folic acid supplementation in reducing side effects of oral methotrexate in patients of psoriasis: A study

Background: Methotrexate (MTX) has been used for the treatment of severe psoriasis for more than 50 years. MTX use can be associated with many side effects, and folic acid is supplemented to reduce these side effects. MTX can be given orally or parenterally. Materials and Methods: In this study, a total of 81 patients of severe psoriasis were given 15 mg/week of MTX orally, and side effects were noted at each visit. Results: A total of 36 patients developed side effects, of which ten patients were discontinued due to the development of serious side effects. Remaining 26 patients developing nonserious side effects were given folic acid 5mg/day on non-MTX days and continued with 15 mg/week of MTX therapy. They were further evaluated for any improvement in side effects. Folic acid supplementation was associated with improvement in gastrointestinal and mucosal side effects in 17 out of 26 patients. Conclusion: Therapeutic effects were not compromised in all these patients after initiation of folic acid therapy. We recommend the supplementation of folic acid 5 mg/day in all patients of psoriasis who are receiving 15 mg/week of MTX therapy.

Papulonecrotic tuberculid in a patient with pulmonary tuberculosis.

A 55-year-old male presented with recurrent crops of crusted papular lesions and boils over buttocks for 1month along with a short history of productive cough. The diagnosis of papulonecrotictuberculid (PNT) with pulmonary tuberculosis was made based on history, clinical features, laboratory investigations, and response to antitubercular treatment.