Botulinum toxin, one of the most poisonous biological substances known, is a neurotoxin produced by the bacterium Clostridium botulinum. C. botulinum elaborates eight antigenically distinguishable exotoxins (A, B, C ₁ , C ₂ , D, E, F and G). All serotypes interfere with neural transmission by blocking the release of acetylcholine, the principal neurotransmitter at the neuromuscular junction, causing muscle paralysis. The weakness induced by injection with botulinum toxin A usually lasts about three months. Botulinum toxins now play a very significant role in the management of a wide variety of medical conditions, especially strabismus and focal dystonias, hemifacial spasm, and various spastic movement disorders, headaches, hypersalivation, hyperhidrosis, and some chronic conditions that respond only partially to medical treatment. The list of possible new indications is rapidly expanding. The cosmetological applications include correction of lines, creases and wrinkling all over the face, chin, neck, and chest to dermatological applications such as hyperhidrosis. Injections with botulinum toxin are generally well tolerated and side effects are few. A precise knowledge and understanding of the functional anatomy of the mimetic muscles is absolutely necessary to correctly use botulinum toxins in clinical practice.

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Chikungunya fever, caused by "Chikungunya virus," is an arbovirus disease transmitted by the bite of infected mosquitoes belonging to the genus Aedes. Chikungunya fever epidemics have been reported from several countries around the world. The disease that was silent for nearly 32 years re-emerged in the October 2005 outbreak in India that is still ongoing. The incubation period ranges from 3 to 12 days. The onset is usually abrupt and the acute stage is characterized by sudden onset with high-grade fever, severe arthralgias, myalgias, and skin rash. Swollen tender joints and crippling arthritis are usually evident. In the chronic stage, relapses that include sensation of fever, asthenia, exacerbation of arthralgias, inflammatory polyarthritis, and stiffness may be evident. Neurological, ocular, and mucocutaneous manifestations have also been described. Chronic arthritis may develop in about 15% of the patients. Viral culture is the gold standard for the diagnosis of Chikungunya fever. Reverse transcription polymerase chain reaction and real-time loop-mediated isothermal amplification have also been found to be useful. Serodiagnostic methods for the detection of immunoglobulin M and immunoglobulin G antibodies against Chikungunya virus are more frequently used. Chikungunya is a self-limiting disease; however, severe manifestations such as meningoencephalitis, fulminant hepatitis, and bleeding manifestations may sometimes be life-threatening. Treatment is symptomatic and supportive. Prevention by educating the community and public health officials, vector control measures appear to be the best approach at controlling Chikungunya fever as no commercially available vaccine is available for public use in India for this condition presently.

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Dengue viral infection is a cause of considerable morbidity and mortality and may be associated with a variety of mucocutaneous manifestations that may provide important early clues to the diagnosis of this condition. Cutaneous and mucosal findings like confluent erythema, morbilliform eruptions, and hemorrhagic lesions may figure prominently in the clinical features of dengue. The differential diagnoses include a large number of bacterial and viral exanthems as well as drug rash.

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Dengue viral infections are one of the most important mosquito-borne diseases in the world. Presently dengue is endemic in 112 countries in the world. It has been estimated that almost 100 million cases of dengue fever and half a million cases of dengue hemorrhagic fever (DHF) occur worldwide. An increasing proportion of DHF is in children less than 15 years of age, especially in South East and South Asia. The unique structure of the dengue virus and the pathophysiologic responses of the host, different serotypes, and favorable conditions for vector breeding have led to the virulence and spread of the infections. The manifestations of dengue infections are protean from being asymptomatic to undifferentiated fever, severe dengue infections, and unusual complications. Early recognition and prompt initiation of appropriate supportive treatment are often delayed resulting in unnecessarily high morbidity and mortality. Attempts are underway for the development of a vaccine for preventing the burden of this neglected disease. This review outlines the epidemiology, clinical features, pathophysiologic mechanisms, management, and control of dengue infections.

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Chikungunya fever (CF) is an arboviral acute febrile illness transmitted by the bite of infected Aedes mosquitoes. After a quiescence of more than three decades, CF has recently re-emerged as a major public health problem of global scale. CF is characterized by an acute onset of high fever associated with a severe disabling arthritis often accompanied by prominent mucocutaneous manifestations. The disease is usually self-limiting, but the joint symptoms and some of the cutaneous features may persist after the defervescence. A wide range of mucocutaneous changes has been described to occur in association with CF during the current epidemic. Besides a morbilliform erythema, hyperpigmentation, xerosis, excoriated papules, aphthous-like ulcers, vesiculobullous and lichenoid eruptions, and exacerbation of pre-existing or quiescent dermatoses had been observed frequently. These unusual features may help in the clinical differential diagnosis of acute viral exanthems mimicking CF.

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Hirsutism is a common clinical condition seen in female patients of all ages. It affects around 5-10% of the women and is a common presenting complaint in the dermatological out patient department for cosmetic reasons. The cause is mainly hyperandrogeneism, which may be ovarian or adrenal. It may be part of a rare metabolic syndrome, drug induced, or just idiopathic. Hirsutism has a huge psychosocial impact, especially in the young females. This article reviews the current evaluation guidelines and management of hirsutism.

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Background: Vitiligo is an acquired pigmentary disorder of the skin. Genetic factors, oxidative stress, autoimmunity, and neurochemical agents might be contributing factors for the development of the disease. Aims: To evaluate the oxidative stress level and tyrosinase activity in vitiligo patients and to compare them with healthy volunteers. Materials and Methods: We used Comet assay to evaluate DNA strand breaks in peripheral blood cells of active vitiligo patients. We then extracted total protein from lesional and nonlesional skin of ten selected patients. Tyrosinase activity was found to play a crucial role in melanogenesis. Results: The basal level of systemic oxidative DNA strand breaks in leukocytes increased in vitiligo patients compared to healthy participants. We observed that tyrosinase activity in lesional skin was lower than in nonlesional skin. Conclusion: Our finding suggests that increased levels of oxidative stress might impact tyrosinase activity and eumelanin synthesis via anabolism pathway of melanin synthesis. In sum, we observed a negative correlation between levels of systemic oxidative stress and of tyrosinase activity.

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Background: In 1769, William Cullen introduced the word "urticaria" (transient edematous papules, plaque with itching). Urticaria affects 15-25% of people at least once in their life time. It is a clinical reaction pattern triggered by many factors causing the liberation of vasoactive substances such as histamine, prostaglandins and kinins. Urticaria is classified according to its duration into acute (<6 weeks duration) and chronic (>6 weeks duration). Various clinical investigations may be initiated to diagnosis the cause. Aims: To evaluate the types of chronic urticaria with reference to etiology from history and investigations . Materials and Methods: A total of 150 patients with chronic urticaria of more than six weeks were studied. Autologous serum skin test (ASST) was performed after physical urticarias were excluded. Standard batteries of tests were performed after ASST in all patients; and other specific investigations were done where necessary. Skin prick test was done in idiopathic urticaria. Results: The study sample consisted of 62 male and 88 female patients with a mean age of 21-40 years. About 50% of patients showed an ASST positive reaction, 3.9% were positive for antinuclear antibody (ANA), IgE titer was elevated in 37%, H. pylori antibodies was positive in 26.7%. Thyroid antibodies were positive in 6.2%. Giardia and entamoeba histolytica was reported in 3.3% on routine stool examination and on urinalysis 8% had elevated WBC counts; 12% showed para nasal sinusitis, with maxillary sinusitis of 7.3%. Random blood sugar was high in 5.3%. Four patients had ASOM, two had positive KOH mount for dermatophytes, abdominal USG showed cholecystitis in two patients. Recurrent tonsillitis was noted in two patients. Urticaria following intake of NSAIDs was observed in four patients and with oral contraceptive pills in one patient. Contact urticaria to condom (latex) was seen in one patient. Cholinergic (4.7%) and dermographic (4.7%) urticaria were the predominant physical urticarias. Prick test was performed in idiopathic urticaria with maximum reactions to food antigens (25%) where brinjal was the commonest, 9% to dust in which spider web was the most common, 8% to pollen where parthenium and amaranthus were the commonest, followed by A. flavus in fungi, pigeon in epithelia and cockroach in insects. Conclusion: Nearly half of the patients had chronic autoimmune urticaria on the basis of ASST. A significant number of them had serological makers of autoimmune activity. ASST provides an easy, inexpensive investigation in CU and helps direct attention to underlying systemic auto immune diseases. The presence of these auto antibodies was significantly associated with more frequent and longer lasting urticarial attacks. Exhaustive work ups with extensive laboratory diagnostics, challenge tests, and prick testing should be reserved for individual cases following detailed history.

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Background: Diabetes mellitus affects individuals of all ages and socioeconomic status. Skin is affected by the acute metabolic derangements as well as by chronic degenerative complications of diabetes. Aims: To evaluate the prevalence of skin manifestations in patients with diabetes mellitus. To analyze the prevalence and pattern of skin disorders among diabetic patients from this region of Western Himalayas. Materials and Methods: One hundred consecutive patients with the diagnosis of diabetes mellitus and having skin lesions, either attending the diabetic clinic or admitted in medical wards were included in this study. Results: The common skin disorders were: x0 erosis (44%), diabetic dermopathy (36%), skin tags (32%), cutaneous infections (31%), and seborrheic keratosis (30%). Conclusion: Skin is involved in diabetes quite often and the manifestations are numerous. High prevalence of xerosis in our diabetic population is perhaps due to cold and dry climatic conditions in the region for most of the time in the year.

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Introduction: The under-five population is a unique and vulnerable component of our society that always demands special attention. Aims: Our present work aimed to study the seasonal variation, age-wise variation and distribution of lesions of common dermatoses of this age group. Materials and Methods: We clinically studied all fresh cases attending the skin OPD of our hospital for one month each from summer, rainy season and winter. Total number of patients was 879. Results: The top six skin diseases in our study were impetigo, miliaria, scabies, furunculosis, seborrheic dermatitis and papular urticaria. On statistical analysis, scabies and seborrheic dermatitis were more prevalent during winter while impetigo, furunculosis and miliaria were more during summer and rainy season. Papular urticaria was more frequent in the rainy season. Seborrheic dermatitis predominantly affected the infants while impetigo, furunculosis, miliaria and popular urticaria were commoner in older age groups. Conclusion: Distribution of lesions of common dermatoses will help diagnose difficult cases and extensive evaluation of the body parts which, by virtue of being commonly affected, are must-examine sites in under-five children.

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Background: In women, the age of 50 is suggested to be the turning point of life at which the development of skin tags comes to a stop. A major event that occurs around this period of life is menopause/andropause. After menopause, estrogen receptors amounts decrease significantly. As skin is considered as the largest nonreproductive target on which estrogens and androgens act, we assume a possible relationship between the pathogenesis of skin tags and sex steroid balance. Another phenomenon is the association of skin tags in obese patients, which may also be explained by the interplay of sex steroids and their receptors in skin tags. Aims: Here we see that in obese patients, hyperandrogenism occurs as a result of hyperinsulinemia as well as peripheral conversion of estrogens into androgens in the excessive adipose tissue. To examine the possible role of androgen and estrogen receptors in etiopathogenesis of skin tags. Materials and Methods: To examine these hypotheses, we measured the level of androgen and estrogen receptors (both α and β) in skin tags compared to control. We also correlated the level of receptors to body mass index, and compared those levels in patients with acanthosis nigricans compared to normal. Results: The level of estrogen receptors (both α and β) was significantly higher in skin tags than in controls with a P value of 0.004 and 0.001, respectively. The same upsurge was found for androgen receptors in skin tags relative to control with a P value of 0.001. No statistically significant difference in receptor level was found either among patients with acanthosis nigricans and those without, or in correlation to body mass index (our participants were overweight non diabetic). Conclusion: These results suggest the possible role of androgen and estrogen receptors in etiogenesis of skin tags, and propose that the neck is an androgen dependent area just similar to the axillae and the groins, though hairless.

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Background: Vitiligo or leukoderma is a chronic skin condition that causes loss of pigment due to destruction of melanocytes, resulting in irregular pale patches of skin. Vitiligo is a polygenic disease and is associated with autoimmunity with an unknown etiology. Aims: One of the candidate genes which has a strong association with several autoimmune diseases is ctla0 -4 gene located in chromosome 2q33 region. We investigated the possible association between ctla0 -4 gene polymorphism in exon 1 (A49G) and vitiligo in patients from South India and compared the distribution of this polymorphism to matched control groups. Patients and Methods: The polymorphism was detected by Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP) method in 175 patients and 180 normal, age/ethnicity matched individuals. Consistency of genotype frequencies with the Hardy-Weinberg equilibrium was tested using a ÷² test. Results: There was no significant difference between the genotype (P=0.93) and allele (P=0 .615) frequencies of CTLA-4 A49G polymorphism in patients and normal healthy individuals. However there was significant association of the CTLA-4 genotype ( P=0.02) and allelic frequency ( P=0.008) between the segmental and non-segmental sub groups within vitiligo. Conclusion: Our results indicate that there is no association between CTLA-4 A49G gene polymorphism and vitiligo in southern Indian population.

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Neurofibromatosis is a genetic disorder of neural crest-derived cells that primarily affect growth of neural tissues. It is broadly divided into three categories: (a) von Recklinghausen's neurofibromatosis or NF-1, (b) bilateral acoustic neuroma (NF-2), and (c) all other neurofibromatoses, including alternate or atypical forms of the disease. The patients with generalized form of NF1 are characterized by multiple café-au-lait spots and neurofibromas and diagnosed easily. But when an individual has small number of lesions in a limited region of the body it could be neglected by the patient or not be recognized by the clinicians as a segmental form of neurofibromatosis. We describe three cases of segmental neurofibromatosis (SNF). These cases have been classified as segmental NF according to Riccardi's definition of SNF and classification of neurofibromatosis. Segmental form of NF may evolve into a complete form over time. Also, this disorder may be transmitted to the offspring's of these individuals. Hence genetic counseling of these individuals must include these facts.

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Background: Oral lesions are common among Human Immuno deficiency Virus (HIV)-positive patients. The pattern of oral features in these persons may differ in separate settings. Aims: To find out the spectrum of oral manifestations among a section of seropositive individuals attending the antiretroviral therapy (ART) centre of a referral hospital. Materials and Methods: A total of three hundred and twenty-one newly diagnosed seropositive patients were enrolled in this study. Of these, ninety-four patients who demonstrated lesions related to the oral cavity were examined intra-orally by a clinician. HIV testing was done with ELISA and CD4 counts were measured with the help of fluorescence activated cell sorter (FACS) system. Results: Fifty-four respondents presented exclusively with oral lesions. Candidiasis patients were the largest group (38.30%). Conclusion: HIV disease presents a plethora of oral manifestations, which provide valuable diagnostic and prognostic information.

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A 40-year-old male presented with a fresh case of pulmonary tuberculosis and itchy oozing rashes distributed characteristically over the sun exposed areas of the skin. These rashes had developed since six days following 10 days of start of antitubercular drugs (streptomycin, isoniazid, rifampicin, pyrazinamide and ethambutol at standard dosages). A possibility of drug-induced reaction was entertained and all the antitubercular drugs were discontinued; subsequently they were reintroduced in a sequential manner starting with small dosages, gradually increasing them to their normal dose. The rashes reappeared after introduction of pyrazinamide. We tried to desensitize this very important antitubercular drug but were not successful as the rashes reappeared. The patient was labeled as having pyrazinamide-induced phototoxicity and was started on a regimen containing streptomycin, isoniazid, rifampicin, ethambutol. Five months following treatment, the patient is now sputum negative for AFB. Pyrazinamide forms the integral part of most of the short course regimens, included in all the three categories of DOTS and with increasing coverage of DOTS therapy these rare cases may well be frequently encountered.

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Ehlers-Danlos Syndrome (EDS) is a rare group of inheritable connective tissue disorder of defective collagen. Skin, joints and blood vessels are most commonly affected. Clinical signs such as Gorlin sign and Metenier sign have been described in this syndrome. We report another new clinical sign called 'Reverse-Namaskar' sign as an important clinical finding in EDS, based on the family pedigree study of the proband.

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Background: The human leukocyte antigen (HLA) system in the skin coordinates the pigmentation and immune response and could be implicated in the pathogenesis of vitiligo. Human leukocyte antigen HLA-G is a nonclassic, major histocompatibility complex class I molecule expressed in the extravillous cytotrophoblast at the feto-maternal interface. It is known to protect the fetus from maternal cellular immunity. Analogically, it could be implicated in the pathogenesis of autoimmune diseases such as vitiligo. Aims: To compare the expression of HLA-G between vitiligo patients and healthy controls. Materials and Methods: In the present study, 22 vitiligo patients and 24 healthy controls were investigated to look for a possible correlation between HLA-G expression and this pathology. Expression of HLA-G in cutaneous biopsy specimens was investigated by immunohistochemical analysis. Results: HLA-G was detected in the biopsy specimens of 3 (13%) out of 22 patients. This number was significantly higher in healthy controls 18 (75%) out of 24 as compared to vitiligo patients ( P < 0.001). Conclusion: There is significant negative correlation between HLA-G expression and vitiligo. In our mind, upregulation of HLA-G expression in lesional skin could be local (superficial expression) or systemic (soluble HLA-G isoforms) compensation to restore normal pigmentation in lesions.

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A family presented to our dermatology clinic with a complaint of white nails. Physical examination revealed clinical feature of leukonychia totalis and the presence of sensorineural hearing loss, palmo plantar keratoderma and knuckle pads (four essential criteria for the diagnosis of Bart Pumphrey syndrome).Three consecutive generations of this family were affected with variable presentations of Bart Pumphrey syndrome in male and female; and autosomal dominant pattern of inheritance.

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In May, 2003, a 28-year-old female presented with large non-healing ulcers on face, trunk and limbs covered with black hemorrhagic crust. There were no other systemic manifestations. Diagnosis of lupus panniculitis was considered on clinical and histopathological grounds. The lesions healed completely, with scarring, with systemic corticosteroid, hydroxychloroquine and topical 2% mupirocin. She came again in November, 2005, with malar rash, joint pain, scarring alopecia of the scalp and albuminuria. Her ANA, AntidsDNA came positive and diagnosed as having systemic lupus erythematosus (SLE). She responded well to systemic corticosteroid, antimalarial and topical antibacterial. The evolution of lupus panniculitis is slow and characterized by regression of the inflammatory lesions when treated with antimalarial drugs. The lupus panniculitis generally has a favorable course.

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Introduction: The use of body donor hair for transplanting to the bald scalp is termed body hair transplant. In recent times, robust body hair has been used as an adjunct to scalp donor hair to augment the donor hair supply. A large percentage of body hair are in telogen and, as single hair units. Aims: To devise a non invasive protocol to identify the body donor hair in anagen phase prior to extraction. Materials and Methods: Hairs are shaved flush with the skin, four days prior to extraction. On fourth day, the actively growing hair follicles as well as non growing hairs were extracted and phase of hair growth determined. Results: Nineteen out 22 extracted hair follicles in nongrowing phase were found to be the telogen phase. Conclusion: Preshaving the body donor areas is a simple non invasive method of isolating the hair in anagen phase.

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Background: Multiple eccrine hidrocystomas pose a significant treatment challenge due to their facial location and tendency to scar after traditional surgical and other destructive modalities. Aims: To compare two frequently used non-destructive therapeutic modalities. Materials and Methods: Thirty patients with multiple eccrine hidrocystomas were enrolled in the study. They used topical 0.03% Atropine cream and 15% AlCl ₃ solution on left and right sides of their face randomly for 4 weeks. All the patients were visited before commencing the therapy as well as two and four weeks later by a dermatologist, blinded to the drugs and the number of lesions. Results: Twenty nine patients (25 females, four males) completed the study. The mean reduction in the number of lesions was significantly higher with Atropine cream in comparison with AlCl ₃ solution, 10.2±7.4 vs. 6.2±5.3 ( P < 0.05). There were no recurrences after three months follow-up in both groups. Conclusion: It seems that both Atropine and AlCl ₃ are useful therapies in eccrine hidrocytomas but the former might be more effective. We think that other randomized clinical trials with larger sample sizes are needed.

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Background: Plantar ulcers commonly occur in leprosy patients, which usually recur and cause morbidity in such cases. Aims: The aim of the study is to find out the bacteriological profile of these ulcers and to find out the antibiotic susceptibility of the isolates so that appropriate drugs may be chosen for treatment and for prevention of recurrence. Materials and Methods: Fifty-six samples from recurrent plantar ulcers of paucibacillary leprosy patients (attending the outpatient department of Calcutta School of Tropical Medicine) were studied for the purpose. Proper sample collection, gram staining, inoculation on culture media, and final identification by biochemical methods were undertaken. Antibiotic susceptibility testing was done for appropriate choice of drugs. Results: Mixed growth of bacteria was seen in 20 (36%) cases while single organism was isolated from the rest. Staphylococcus aureus is the predominant single isolate followed by E. coil, Proteus sp. and Pseudomonas sp. Chloramphenicol and gentamycin are the two drugs that have shown efficacy to the extent of 75 to 100% and 25 to 100% respectively in vitro studies. Conclusion: Bacteriological study of plantar ulcers of leprosy patients has revealed Staphylococcus aureus as the main pathogen. Treatment with chloramphenicol and gentamycin holds good prospect as per our study.

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Tuberculides, the supposedly immunologic reactions to the products of dead Mycobacterium tuberculosis bacilli deposited in the skin from distant foci of tubercular infection, are presently considered to be of two types-papulonecrotic tuberculide and lichen scrofulosorum. Simultaneous occurrence of both the types in the same patient is very rare. We report the case of an adult male without any known internal tubercular focus who showed two types of skin lesions, clinically typical and histopathologically consistent with the diagnoses of papulonecrotic tuberculide and lichen scrofulosorum, occurring simultaneously. Polymerase chain reaction showed the presence of Mycobacterium tuberculosis DNA in papulonecrotic tuberculide type of lesion, and both types of lesions responded promptly to anti-tubercular drugs.

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Riga-Fede disease (RFD) describes a benign, ulcerative lesion resulting from the repetitive trauma of contact of the oral mucosal surface of the tongue with the teeth. Although the name applies primarily to small children, similar clinical and histopathological findings can also be found in adults. We describe here a 70 year-old woman showing a painful tongue ulcer with elevated borders and whitish discoloration for the past four years. Repeated histological investigations revealed a benign leukoplakia without dysplasia. Replacement of an ill-fitting prosthesis led to complete remission within two weeks. RDF-like disease is thus a problem in elderly patients for whom topical treatment is insufficient to induce healing.

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Remittent idiopathic necrotizing acrocyanosis is a very rare condition characterized by persistent systemic cyanotic or erythrocyanotic discoloration of hands and feet. It is associated with pain, tenderness of fingers and toes and may present as ulceration or gangrene of extremities. It is aggravated with cold exposure but persists even in summer. Acrocyanosis is not due to any systemic disease; peripheral arteriolar constriction with secondary vasodilatation due to disordered vascular tone of unknown etiology has been postulated. It responds to peripheral vasodilator drug but usually needs continuous long term therapy along with avoidance of cold exposure. We report the case of a 53-year-old male farmer with remittent necrotizing acrocyanosis.

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A 64-year-old man with generalized papular granuloma annulare of four years duration with frequent relapses and remissions presented with persistent lesions while on 15 mg prednisolone and achieved complete remission with PUVASOL therapy using solarium.

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