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   Table of Contents - Current issue
Coverpage
July-December 2021
Volume 5 | Issue 2
Page Nos. 131-263

Online since Thursday, August 26, 2021

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REVIEW ARTICLES  

Dynamic immune status of pregnancy and dermatological diseases: An interplay Highly accessed article p. 131
Navya Parthasarathy, Ajit B Janagond, Arun C Inamadar, Anusha Lingaiah, Meghana Gangadhar, Nazneen Zulfikar Arsiwala, Rintu Merin George, Vartika Ratan
DOI:10.4103/CDR.CDR_47_19  
Dynamic changes of immune system in the various stages of pregnancy affect the course of various diseases afflicting the mother alongside determining how pregnancy affects these diseases. To understand this, a thorough knowledge on how the immune system differs in pregnancy is essential. The complex interplay between the maternal and fetal immune systems via placenta in order to maintain the pregnancy leads to waxing and waning of immune responses in both mother and fetus. This dynamic nature of immune responses can heavily influence the manifestations and severity of several dermatological diseases, whether infectious or noninfectious. Here, we discuss the effect of altered immunity of gestation on a few important dermatological diseases such as psoriasis, systemic lupus erythematosus, syphilis, varicella, leprosy, and TORCH infections and vice versa.
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COVID-19 vaccination in India: Clinical guidance for patients with dermatological diseases Highly accessed article p. 139
Namitha Chathra, Savitha Somaiah
DOI:10.4103/cdr.cdr_48_21  
Since the advent of COVID-19 vaccines, dermatologists have frequently come across patients, especially those receiving immunomodulatory drugs, who express concerns about the safety and efficacy of vaccines. In this review, we aim to provide guidelines to dermatologists with regard to the three COVID-19 vaccines licensed for use in India. All dermatology patients, even the ones on immunomodulatory drugs, need to be encouraged to take the vaccine. COVID-19 vaccines are not contraindicated in individuals afflicted with eczema; atopic dermatitis; psoriasis; vitiligo; lichen planus; urticaria; connective tissue disorders; and bacterial, mycobacterial, viral, or fungal infections. However, those who have been seriously ill requiring hospitalization are advised to wait for 4–8 weeks. For patients on immunomodulatory drugs, when the disease is stable, the drug may be withheld or dosage reduced for 1–2 weeks following vaccination. However, the vaccination may be given without any modification in the drug/biological. People with a history of anaphylaxis/urticaria can receive a COVID-19 vaccine with 30 min postvaccination observation period. Absolute contraindications include a history of immediate hypersensitivity to any component of the vaccination and hypersensitivity following first dose of vaccination. Patients who have received vaccination can undergo procedures such as skin biopsy, cautery, cryotherapy, lasers, chemical peels, excisions, biopsy, and hair transplantation; fillers may be scheduled 2 weeks before or after the vaccination.
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ORIGINAL ARTICLES Top

Importance of dermoscopy in differentiating common urticaria and urticarial vasculitis: A randomized control study p. 144
Mahajabeen Saheb Patel Madarkar
DOI:10.4103/CDR.CDR_82_20  
Background: Urticarial vasculitis is a clinicopathological entity that overlaps with common urticaria, and histopathological diagnosis is required for differentiation between them. Objectives: To determine, for the first time, if skin surface microscopy can aid in the clinical differentiation between common urticaria and urticarial vasculitis in daily practice. Materials and Methods: Lesions in 20 patients with a clinical diagnosis of urticaria were studied. All urticarial lesions were subjected to dermoscopy, skin biopsy, and histopathological examination to confirm the diagnosis. Dermoscopy was performed using Derm Lite 3 dermoscope and images captured were anyalysed. Clinical images were taken. A punch biopsy was performed in all patients. Statistical analysis was done. Results: In 11 patients diagnosed clinically as chronic urticaria, on dermoscopy showed red lines in 9(45%), red dots in 2 (10%) and structureless areas in 8(40%) patients. In 9 patients diagnosed as urticarial vasculitis clinically, on dermoscopy revealed purpuric dots in 8(40%) and purpuric globules in 5(25%) patients. Conclusion: We conclude that in our setting dermoscopy significantly facilitates the detection, diagnosis and differentiation of common urticaria and urticarial vasculitis.
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Skin behind the bars! p. 149
Komal Ramteke, Sumit Kar, Safa Patrick, Ajinkya Sawant, Pooja Manwar, Pratiksha Sonkusale, Subhor Nandwani
DOI:10.4103/CDR.CDR_108_20  
Background: Prisoners fall in the most vulnerable population group, but the health issue of this group is the most understudied. The various dermatological conditions that hamper their overall health and quality of life needs to be identified and serious measures should be undertaken for preventing them. Objectives: This study is one of the rare studies that aim to identify the dermatosis pattern and to relate with its etiological factors and suggest preventive methods to be undertaken for it. Materials and Methods: Total three visits were made to the district jail located in Central India over a period of 8 months, and the prison inmates were clinically examined. The data was recorded and results were drawn. Results: Scabies accounted for 31.51% while dermatophytes accounted for 30.83%. Other dermatoses seen were acne vulgaris (5.17%), allergic contact dermatitis (ACD) in 5.03%, pyoderma (2.71%), urticaria (2.86%), and tinea versicolor (2.62%). These were followed by the other dermatoses such as milia (1.81%), alopecia areata (0.5%), and irritant contact dermatitis (0.5%); viral infections such as herpes labialis (0.45%) and molluscum contagiosum (0.45%); and pigmentary disorders such as vitiligo (0.65%) and melasma (1.16%). Three new cases of Hansen's disease were diagnosed clinically (1.75%). Conclusion: We found that common dermatoses were scabies and fungal infections which are due to the overcrowding and poor hygiene facility in the prison premises. During the subsequent visits, the number of dermatophyte infections declined which may be attributed to patient counseling and awareness regarding hygiene and general cleanliness which was provided by us to the inmates in all previous visits. A detailed look into the matter may improve the overall dermatological health of the inmates.
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A study on pattern of dermatoses affecting periorbital region and its clinicodermoscopic correlation p. 153
Namrata Bhavsar, Pragya Ashok Nair
DOI:10.4103/CDR.CDR_81_20  
Background: The periorbital area may be affected by a vast number of dermatoses such as infectious or noninfectious diseases, inflammatory dermatoses, systemic diseases, drug reactions, benign and malignant lesions, and traumatic lesions, thus poses both diagnostic and therapeutic challenge. Objectives: To study the pattern of dermatoses involving periorbital region and to correlate its clinical and dermoscopic findings. Materials and Methods: A cross-sectional study was carried out in patients with periorbital dermatoses (PODs) attending the Department of Dermatology during April 2018–March 2019 after approval from the ethical committee. A detailed history was taken and investigations including hemoglobin levels, Vitamin B12, serum cholesterol, and wood's lamp examination were done as and when required. A prestructured pro forma was used to collect the data. Data were entered into Microsoft Excel 2010 and analyzed using EPI INFO. Ver7 software (Developed by united states of America centre for disease control. Results: A total of 275 patients were studied of which majority of patients belonged to the age group of 41–60 years (38.5%) with a female-to-male ratio of 1.16:1. The most common group of PODs was skin tumors (25.1%), followed by disorders of pigmentation (17.4%), infections (13.1%), and periorbital dermatitis (11.6%). Most common dermoscopy findings of PODs were as follows: (a) common seborrhoeic keratosis (CSK): comedone-like opening, fissures and ridges, and sharp demarcation; (b) verruca vulgaris: finger-like papilla, red brown dots in center of papilla; (c) periorbital hyperpigmentation: blotches, globules, exaggerated pigment network, and reticular vessels; (d) allergic dermatitis: patchy red dots, pinkish hue, and patchy scale; (e) senile comedone: comedone-like opening; and (f) xeroderma pigmentosus: orange–yellow homogenous structures. Conclusion: Periorbital region is an area of cosmetic concern. Dermoscopy improves the differential diagnosis of common PODs and its knowledge may aid to reduce unnecessary invasive procedures such as shaving or incisional biopsies which may lead to scarring.
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Clinicobacteriological study of pyoderma with trends in antibiotic sensitivity at a tertiary care center in western India p. 161
Kasturi Chavan, Bhavana Ravindra Doshi, Vaishali Dohe
DOI:10.4103/CDR.CDR_67_20  
Background: Pyoderma refers to any pus-forming infection of the skin. Antibiotic resistance has significantly downplayed the utility of established antibiotics and possesses a serious threat to public health. Objective: To study the causative organisms, their trends of antibiotic sensitivity pattern thus helping in prescribing appropriate antibiotics and study the response to the treatment in patients of pyoderma. Materials and Methods: A 2-month prospective study on a cohort of 30 pyoderma patients attending the outpatient and inpatient department in our tertiary care hospital under ICMR short-term studentship was undertaken. Statistical analysis was performed using the SPSS software version 24. Results: Those in 5th–6th decade were more predisposed. Higher incidence was seen in anemics. Staphylococcus spp. (26/30 case 86.66%) was the most common organisms to be isolated in 12/15 (80%) outpatients and 14/15 (93.33%) inpatients. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated equally (33.33%) in both outpatient and inpatients, with increasing trend in MRSA in out-patients. Higher incidence of Pseudomonas aeruginosa in outpatients was noted. MRSA in superficial pyoderma group was sensitive to one first-line drug which was gentamycin, whereas in deep pyoderma, the only first-line drug to which the MRSA was 100% sensitive was ciprofloxacin. All MRSA, MSSA, MR CONS, and MS CONS were sensitive to all second-line drugs. Sixty-percent patients who showed no response to empirical primary line of treatment showed good response on changing the antibiotics according to the reports of culture and sensitivity. Conclusion: An increasing trend in MRSA in outpatients was noticed along with higher incidence of Pseudomonas infection. Limitation: Small sample size.
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A descriptive case-control study on assessment of iron profile in patients with and without melasma p. 168
Megha Prakash, Namrata C Manjunath, BS Deepali
DOI:10.4103/CDR.CDR_90_20  
Background: Melasma or chloasma is a common acquired hyper melanosis, characterized by dark, irregular hyperpigmented macules and patches over the malar areas, lips, nose and forehead. Iron overload manifests with skin hyperpigmentation. Therefore, it is important to understand the role of iron in patients with melasma. Objectives: (1) To assess serum iron profile in non-pregnant women and men with melasma. (2) To assess the same parameters in age and sex matched controls. Materials and Methods: A descriptive case–control study with 35 cases of melasma and 35 age and sex-matched controls was conducted between December 2019 and March 2020, to assess the association between melasma and iron deficiency. Results: Among 35 cases of melasma, 85.7% were females, the most common type was the malar type 68.8%, sunlight was the most-common risk factor and 100% had deranged iron profile. Mean ferritin levels in the melasma group was 15.204 ng/ml while in control group it was 71.717 ng/ml. Mean serum iron levels in melasma group was 28.585 μg/dl while in that of controls were 135.018 μg/dl. Other iron parameters also showed significant iron deficiency in melasma patients. Conclusion: Well-known factors implicated in the etiology of melasma include sunlight, Oral contraceptive pills with oestrogen, pregnancy and smoking. This study indicates that iron deficiency is also an important etiological factor and hence treatment of iron deficiency may be a novel therapeutic approach in patients with refractory melasma.
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A study of cutaneous adverse drug reactions in a tertiary care center in south India p. 173
Lakshmi Rajendran, Anoop Thyvalappil, Rajiv Sridharan, S Ajayakumar, EM Sparshadeep, Binoo Divakaran
DOI:10.4103/CDR.CDR_109_20  
Background: Cutaneous adverse drug reactions (CADRs) are common among adverse drug reactions (ADRs). Early identification of ADRs can reduce the morbidity and mortality rates. Objectives: To know the pattern of various types of CADRs and to find out the causative drugs involved. Materials and Methods: Retrospective analysis was performed from ADR register, kept in Dermatology department in a tertiary care center. Naranjo's algorithm was used to determine the causality assessment. Details regarding drug intake, morphology of eruption, offending drugs, history regarding hospitalization, drug rechallenge or drug dose modifications, and treatment given to the patients were assessed. The data were subjected to descriptive analysis. Results: A total of 216 patients were recruited into the study, of which 118 were male and 98 were female. Antimicrobials (30.1%) were noted to be the most common offending drugs, followed by antiepileptics (18.1%), analgesics and antipyretics (11.1%), and anticancer drugs (11.1%). The most common presentation of CADR was maculopapular drug eruption (31.5%), followed by fixed drug eruption (13.4%). Conclusion: Among the antimicrobials, penicillins (13.9%) were the most common cause of CADR, followed by cephalosporins (8.8%) and fluoroquinolones (6.9%). A total of 28 patients (13%) were found to have severe cutaneous adverse reactions to drugs. It is important to closely monitor the patient, when a new drug is introduced, which will aid in detecting and preventing of CADRs.
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Stressful major life events and chronic urticaria: Its role in induction or exacerbation of the disease p. 178
Preeti Ganesh Choudhari, Ganesh Kamath Hundi, D Sukumar
DOI:10.4103/CDR.CDR_116_20  
Background: The skin and central nervous system are derivatives of embryonic ectoderm. There is an etiological factor of stressful life events in various skin diseases such as chronic urticaria through psychosomatic mechanisms. Many observations and case series are reported in favor of this opinion. Objectives: To evaluate the stressful life events within one year, six months and a month preceding onset or exacerbation of lesions in chronic idiopathic urticaria cases enrolled in this study. Material and Methods: It is an Observational descriptive questionnaire-based study, which included minimum of 50 patients of chronic idiopathic urticaria and important stressful events were noted in these subjects using Gurmeet Singh's presumptive stressful life events (PSLE) scale. Results: Out of 50 cases, stressful life events preceded the exacerbation of the chronic urticaria in 16 (32%) patients. Amongst them 12 (24%) showed slight degree and four (8%) showed moderate degree of stress and none of the cases reported great degree of stress. Among 16 cases, eight (50%) cases noticed exacerbation within six months of experiencing stressful life event with higher degree of severity in older age group (p = 0.004). Financial loss or problem was the most common stressful life event seen in four out of 16 cases (25%) (p = 0.000). Few desirable events were also found as stressors in four cases accounting for 25%. Conclusion: These results support association between psychological factors and exacerbation of the disease. The need for stress management programs in high stress scores to cope up with the stressful events, will further help in reducing the morbidity.
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Apremilast titration: Real-world indian experience p. 183
Abhishek De, Aarti Sarda, Dhiraj Dhoot, Hanmant Barkate
DOI:10.4103/cdr.cdr_123_20  
Background: Apremilast is recommended to titrate in initial period to reduce adverse effects (AE). But inspite of that, in India; many dermatologists experienced a lot of AE resulting in discontinuation of therapy. As a result, many of them have adapted to titrate the dose in different ways. Objectives: To evaluate the AE profile and rate of discontinuation of apremilast during initial titration in different ways. Materials and Methods: A multicentre, retrospective data analysis was done at 121 dermatology clinics across India in the adult patients diagnosed with chronic plaque psoriasis and prescribed at least one dose of apremilast. Patient characteristics and data were obtained from medical records when available. Results: Out of 582 patients, 175 were prescribed apremilast starter pack in licensed dose (Group 1); 202 were prescribed starter pack in OD dosing (Group 2) for 13 days and 205 were prescribed 2 starter packs in OD dosing (Group 3) for 26 days. 45.14% had AE in Group 1 whereas 36.63% and 30.24% had in Group 2 & 3 respectively. Gastrointestinal upset, headache & nausea were most common. In Group 1, 17.71% of patients discontinued apremilast whereas 16.33% and 10.24% discontinued in Group 2 & 3 respectively. On comparison within group, Group 3 had significant difference over Group 1 (p value <0.05). Conclusion: It is concluded that slower titration of apremilast in initial phase leads to lesser AE profile and hence discontinuation of therapy and thus increasing adherence.
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Impact of COVID-19 on Dermatology practice: A cross-sectional study p. 187
Ajit B Janagond, Vartika R Ratan, Indira Potthuri, Vishalakshi S Pandit, Arun C Inamadar
DOI:10.4103/cdr.cdr_15_21  
Background: The sudden outbreak of novel coronavirus has caused confusion, anxiety, and fear not only among the general public but also the health-care system. Considering widespread effects of the disease spilling into all aspects of life in general population and health-care workers alike, we conducted a study regarding the impact of coronavirus disease 2019 (COVID-19) on the functioning of the department of dermatology at a tertiary care hospital during the period of lockdown. Objective: We aimed to study the impact of COVID-19 infection and lockdown due to pandemic on practice of dermatology and workings in the outpatient department (OPD) at a tertiary care center. Materials and Methods: A cross-sectional, observational study was conducted on patients attending the dermatology OPD at a tertiary care center from April 11, 2020, to May 31, 2020. Patients were interviewed on the basis of a simple questionnaire seeking demographic details, complaints, diagnosis, history, and duration of treatment. Data obtained were recorded as numbers and percentages. Results: A total of 1022 individuals participated in the study with 620 (60.6%) males and 402 (39.33%) females. Among them, 625 (61.15%) were localities and 395 (38.64%) were from surrounding rural areas. The age of patients ranged from 6 months to 94 years, and majority were farmers. Eight hundred and twenty-nine (81.1%) were educated and 146 (14.2%) were illiterates. Six hundred and ninety-seven (68.1%) of the participants were new and 325 (31.8%) follow-up cases. Dermatophytosis 194 (27.8%) and psoriasis 15 (4.6%) were the most common diagnoses among new and old cases, respectively. Conclusion: A significant reduction was observed in the number of patients visiting the department seeking treatment. The pandemic necessitated various modifications in the patient examination and management protocols.
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CASE REPORTS Top

Staphylococcal-Scalded skin syndrome: A case series p. 192
Anirudha Gulanikar, Arpita Arghya
DOI:10.4103/CDR.CDR_4_20  
Staphylococcal-scalded skin syndrome (SSSS) is also known as Ritter's disease. The symptoms produced by the strains of staphylococcus occur due to exfoliative toxins. Here, we have presented a case series of four children aged <2 years, who were admitted in MGM Medical College and Hospital, Aurangabad, for fever in association with superficial fluid-filled lesions leaving large denuded areas behind Nikolsky's sign – positive. The mucosal area was spared. Blood culture served as diagnostic test, besides clinical history and examination. All the children were treated with cephalosporin and responded well. Hydration was maintained with topical mupirocin over the eroded areas. A high degree of suspicion has to be there for SSSS. We emphasize the importance of interdisciplinary management, association with dermatologist, pediatrics, and plastic surgeon for better outcome. Although considered rare, we came across four cases of SSSS with classical presentation.
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Morphoeic basal cell carcinoma – an unusual tumor variant at an unusual site p. 197
C Chandrakala, GK Tharini
DOI:10.4103/CDR.CDR_1_20  
Basal cell carcinomas (BCC) are malignant neoplasm arising from the basal layer of epidermis, seen almost exclusively on hair-bearing areas of skin. There are many clinical and histopathological variants in BCC. The tumor commonly seen at the site of excessive sun exposure. It is a locally invasive tumor with rare metastasis. The most common site for the development of morphoeic BCC is over the face. Clinically, morphoeic BCC presents as morphea such as sclerotic plaque and histopathologically as densely hyalinized stroma with angulated strands of neoplastic basaloid cells. Ulceration of the lesion is uncommon in this type. We report a case of morphoeic BCC, an unusual tumor variant occurring over the back.
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Alkaptonuria: A hereditary disease which is usually diagnosed in adulthood p. 200
Mudita Gupta, Rajni Sharma, Ritu Rani
DOI:10.4103/CDR.CDR_63_20  
Alkaptonuria (AKU) is a multisystemic autosomal recessive disease due to deficiency of enzyme homogentisate dioxygenase leading to accumulation of homogentisic acid. Urine becoming dark on oxygenation or alkalinization is the first symptom but is often ignored. The patient usually presents with pigment deposition in connective tissue and cartilage after the third decade. This pigment deposition not only alters the aesthetics but also leads to alteration in the activity of different tissues due to inflammation and subsequent fibrosis or calcification. We are presenting an adult male who was asymptomatic till 5 years back when he started having backache for which he was taking analgesics off and was diagnosed to be having AKU at the age of 58 years.
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Giant cutaneous epithelioid angiomatous nodule: A rare vascular tumor p. 204
Jayati Shailesh Dave, Atul M Dongre, Sunanda Arun Mahajan, Uday S Khopkar
DOI:10.4103/CDR.CDR_48_20  
Cutaneous epithelioid angiomatous nodule (CEAN) is an uncommon benign vascular proliferation that presents as a reddish solitary nodule. Less than 60 cases have been reported in the literature. As it is benign, the prognosis is good, but it is sometimes difficult to differentiate it from other vascular neoplasms. A 16-year-old male presented with a single, large, brownish multinodular swelling over the left pinna. Biopsy showed conglomeration of epithelioid endothelial cells with eosinophilic cytoplasm in the dermis. These cells stained positive for CD31 and CD34. Diagnosis of CEAN was made
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A female with mucocutaneous telangiectases and portal hypertension: A case report of osler-weber-rendu syndrome p. 207
Vidhi S Chandibhamar, Bhagirath R Patel, Ani Patel, Jignaben K Padhiyar
DOI:10.4103/CDR.CDR_58_20  
Osler-Weber-Rendu syndrome, also known as hereditary hemorrhagic telangiectasia, is a rare autosomal dominant disorder manifested by telangiectases of the skin and mucous membranes and arteriovenous malformations of various organ systems. We report a case of 45-year-old postmenopausal woman who presented to dermatology department for evaluation of compressible vascular lesion involving bilateral palms and oral cavity for the past 3 months' duration. On further evaluation, she was found to have portal hypertension and multiple cavernoma formation on place of portal vein.
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Single plaque lepromatous leprosy presenting as granuloma annulare: A rare presentation p. 210
Sudha Rani Chintagunta, Priyanka Jaju
DOI:10.4103/CDR.CDR_56_20  
Leprosy is a chronic infectious disease caused by Mycobacterium leprae, primarily affecting the peripheral nerves and skin. The clinical presentation of leprosy is highly variable, depending on the immune status of the individual. Based on the Ridley–Jopling classification, the clinical spectrum ranges from tuberculoid to lepromatous leprosy (LL). In all its stages, it can mimic various other conditions. Early and accurate diagnosis of leprosy is crucial because late recognition may give rise to permanent deformity resulting from the disease. Here, we report a case of LL clinically presenting as granuloma annulare in a 75-year-old man, which was diagnosed and confirmed by histopathology.
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A case series of disseminated porokeratosis p. 213
J Logeshwari, Nippa Devi A Patel, Sirisha Varala, Ananthula Venkata Krishna
DOI:10.4103/CDR.CDR_94_20  
Porokeratosis is an autosomal dominant disorder of epidermal keratinization resulting from abnormal expansion of latent clones following chronic ultraviolet exposure or immunosuppression. Various clinical and morphological variants of porokeratosis are present, among which disseminated superficial actinic porokeratosis (DSAP) is the most common subtype located predominantly on the sun exposed areas, whereas disseminated superficial porokeratosis (DSP) is present both on the sun exposed and sun protected areas including oral mucosa and genitalia. Porokeratosis is characterized clinically by annular plaques with atrophic center and thready border and histologically by the presence of cornoid lamella. DSAP may be missed because of its inconspicuous nature in dark skinned individuals and may sometimes be mistaken for actinic keratoses in sun-damaged skin. Here, we report a case series of five patients with disseminated porokeratosis with varied presentations.
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An interesting case of synchronous basal cell carcinoma of face successfully treated by surgery p. 217
Sucheta Pathania, Navneet Sharma, Tashi Dolma Bodh
DOI:10.4103/CDR.CDR_96_20  
Basal cell carcinoma (BCC) is the most common type of nonmelanocytic tumor. Multiple BCCs are generally associated with heredo-familial conditions or syndromes, but in sporadic cases, multiple BCCs are relatively rare. They tend to occur in synchronous or metachronous manner, but in our setup, synchronicity is uncommon and metachronous BCCs are attributed mainly to reoccurrence. We present a case of dual BCC of face with synchronicity and different histopathology, treated with wide local excision using full-thickness grafting and V-Y advancement flap.
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Giant subcutaneous granuloma annulare p. 220
MR Harish, BM Shashikumar, Priyanka R Magod, Deepadarshan K Gowda
DOI:10.4103/CDR.CDR_54_20  
Subcutaneous granuloma annulare is an uncommon, benign self-limiting cutaneous disease, almost exclusively seen in young children. We report a case of 31-year-old male patient, presented with asymptomatic firm plaques over the left lateral malleoli and dorsum of the feet. Histopathological examination was done to confirm the diagnosis and the lesions responded well to monthly doses of the combination of rifampicin, ofloxacin, minocycline (ROM) therapy and intralesional steroid therapy. This case is reported for its unusual presentation of very large plaque in an adult male and its resolution after combined ROM and intralesional steroid therapy.
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Intriguing case of porokeratosis of mibelli on gluteal region p. 223
Snehal Balvant Lunge, Vijayalakshmi M Dhorigol, Anisha P Bindagi
DOI:10.4103/CDR.CDR_61_20  
Porokeratosis (PK) is a rare group of heterogeneous disorders of keratinization representing diverse phenotypic expressions of the same genetic defect, which is mainly inherited in an autosomal dominant manner. This report describes the case of a 40-year-old female with PK over the gluteal region. The rarity of this disorder, unusual site of presentation, and involvement of unilateral side of gluteal region, which is unusual in this form of PK, and the occurrence in a female patient motivated to report this case.
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Pemphigus and beyond p. 226
Shital Poojary, Kavya Baddireddy
DOI:10.4103/CDR.CDR_72_20  
A 23-year-old male diagnosed with pemphigus foliaceous presented with multiple asymptomatic hyperpigmented patches and plaques clinically resembling seborrheic keratoses over multiple sites on the body of 1-year duration. There were no fluid-filled lesions, active erosions, or mucosal involvement. Histopathological examination from the hyperpigmented plaque revealed marked acanthosis with intra-epidermal acantholysis. Enzyme linked immunosorbent assay (ELISA) for antidesmoglein-1 antibodies was positive with a titer of 157 units/ml. Treatment with oral azathioprine, dapsone, and topical halobetasol propionate produced a marked response with complete clearance of the lesions. A thorough workup helped us detect the persistence of disease activity and thus prevent a potential relapse. This case report highlights the unusual presentation of a common immunobullous disorder, Pemphigus acanthomata a rare entity with regard to its morphological, histopathological, and immunological features.
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Pleomorphic xanthomas: A clue to rare familial hypercholesterolemia p. 229
Shivangi Singh, Pankaj Kumar Tiwary, Anupama Singh
DOI:10.4103/CDR.CDR_73_20  
Xanthomas are the subcutaneous lipid deposits which can be seen in normolipedemic or hyperlipidemic conditions. Xanathomas are usually of single type and presence of polymorphic xanthomas arise suspicion of dyslipidemia. We report a case of young girl presenting with pleomorphic xanthomas (Xanthelasma palpebrarum, intertriginous Xanthomas, tendon Xanthomas, and eruptive xanthomas), hypothyroidism and multiple cardiac valvular involvements with very high serum total cholesterol and low-density lipoprotein along with deranged lipid profile in both parents. Pleomorphic xanthoma arouses a suspicion and helped in making a diagnosis of rare homozygous familial hypercholesterolemia.
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Blueberry look-alike masson's hemangioma over the thigh p. 233
Yashaswi Rai, AS Savitha, TS Nagesh, Swathy Prasannan, Sneha Manjunath, Tarun Deepak Reddy
DOI:10.4103/CDR.CDR_78_20  
Masson's hemangioma (MH), also known as intravascular papillary endothelial hyperplasia, is a rare benign vascular tumor. Histopathology helps to confirm the diagnosis, wherein a papillary proliferation of thin-walled capillaries is almost always associated with thrombus formation in the lumen of a vessel. We report the case of a 48-year-old female with a purple-colored swelling over the right thigh that was diagnosed as MH with the help of histopathological examination. Dermoscopy was also done, and the findings were reported.
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“What lies beneath” – macrophage activation syndrome unveiled systemic lupus erythematosus p. 236
JP Prathibha, Vivek Pai, P Ishwara Bhat
DOI:10.4103/CDR.CDR_87_20  
Macrophage activation syndrome (MAS) is a potentially fatal condition characterized by massive systemic inflammatory response in the setting of a myriad of systemic disorders such as autoimmune collagen vascular disease, infections, drug-induced, and malignancies. It falls under a group of disorders known as hemophagocytic lymphohistiocytosis of which familial and acquired types have been described. Here, we report a case of acquired MAS secondary to acute systemic lupus erythematosus (SLE). Early diagnosis and timely intervention resulted in a favorable outcome.
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Multiple itchy nodules over the scalp – clinicopathological challenge p. 240
Aditi Dhanta, Gargi Taneja, Neirita Hazarika, Michael Leonald Anthony
DOI:10.4103/CDR.CDR_85_20  
Angiolymphoid hyperplasia with eosinophilia is an uncommon benign vascular proliferation with histologically distinct endothelial cells and a mixed inflammatory infiltrate composed of mainly lymphocytes and eosinophils unknown. It commonly affects middle-aged adults and characterized by flesh/plum-colored pruritic nodules and papules. In our case, it has to be differentiated from other appendageal tumors such as cylindroma, spiradenoma because of similar site involvement. The histopathological examination is a fundamental tool to achieve a correct diagnosis.
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Giant venous malformation of the tongue with macroglossia: A hidden menace p. 242
Reena Kumari Sharma, Archita Makharia, Mudita Gupta, Suresh Thakur
DOI:10.4103/CDR.CDR_98_20  
Venous malformations (VMs) are congenital slow flow vascular malformations that are usually present at birth. They grow proportionate with the age and do not regress with time differentiating them from hemangiomas. VM presents as bluish discoloration of skin/mucosa or as soft subcutaneous masses. It may affect any organ, including viscera-like gastrointestinal tract or brain. VM is generally slowly progressive and asymptomatic as they grow slowly with age. We report the case of asymptomatic giant VM over the tongue for which the patient presented due to herpetic stomatitis.
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RESIDENT PAGE Top

Cobblestone appearances in dermatology Highly accessed article p. 245
Anup Kumar Tiwary, Piyush Kumar
DOI:10.4103/CDR.CDR_95_20  
Dermatology is a visual medical discipline which demands watchful eyes, profound knowledge of different morphologic patterns of various dermatoses, and extensive clinical experience. A meticulous cutaneous examination always helps in generating the close differential diagnoses and incorporation of past visual experience leads to a provisional diagnosis, obviating the need of further investigations in many cases. Although there is a wide spectrum of morphologic presentations, some dermatoses may have characteristic appearances such as cobblestoning, Peau d' orange, umbilication, and Christmas-tree pattern. Identification of these lesional characteristics or patterns can efficiently avoid the misdiagnosis and unnecessary diagnostic workup. In this article, skin diseases showing cobblestone appearances on both clinical and dermoscopic examination have been compiled and outlined in brief.
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DIAGNOSTIC PEARL Top

Diagnostic perplexity in hypertrophic lichen planus: Dermoscopy saves the day! p. 251
Samipa S Mukherjee, Balachandra S Ankad, SV Smitha, Balakrishna P Nikam
DOI:10.4103/CDR.CDR_59_20  
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LETTERS TO EDITOR Top

Acral lentiginous melanoma: Dermoscopic perspective in skin of color p. 253
Balachandra S Ankad, SV Smitha, Balakrishna P Nikam
DOI:10.4103/CDR.CDR_65_20  
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Recurrent Apocrine Hidrocystoma of Scalp: A Rare Case Report p. 255
Hemant Kumar Sharma
DOI:10.4103/CDR.CDR_97_20  
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Dermoscopy of cutaneous lymphangioma circumscriptum: A report of three cases p. 257
Yasmeen Jabeen Bhat, Atiya Yaseen, Sheema Sheikh
DOI:10.4103/CDR.CDR_86_20  
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Co-localization of verruca vulgaris with verrucous epidermal nevus: Role of dermoscopy in diagnosis p. 260
Yasmeen Jabeen Bhat, Sumaya Zeerak, Reeta Devi, Iffat Hassan Shah
DOI:10.4103/CDR.CDR_93_20  
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NOTICE OF RETRACTION Top

Retraction: Efficacy and safety of 88% phenol application versus cryotherapy in repigmentation of idiopathic guttate hypomelanosis: A prospective study p. 263

DOI:10.4103/2542-551X.324588  
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