Dermatomyositis (DM) is a chronic inflammatory disorder of the skin and muscles. Evidence supports that DM is an immune-mediated disease and 50-70% of patients have circulating myositis-specific auto-antibodies. Gene expression microarrays have demonstrated upregulation of interferon signaling in the muscle, blood, and skin of DM patients. Patients with classic DM typically present with symmetric, proximal muscle weakness, and skin lesions that demonstrate interface dermatitis on histopathology. Evaluation for muscle inflammation can include muscle enzymes, electromyogram, magnetic resonance imaging, and/or muscle biopsy. Classic skin manifestations of DM include the heliotrope rash, Gottron's papules, Gottron's sign, the V-sign, and shawl sign. Additional cutaneous lesions frequently observed in DM patients include periungual telangiectasias, cuticular overgrowth, "mechanic's hands", palmar papules overlying joint creases, poikiloderma, and calcinosis. Clinically amyopathic DM is a term used to describe patients who have classic cutaneous manifestations for more than 6 months, but no muscle weakness or elevation in muscle enzymes. Interstitial lung disease can affect 35-40% of patients with inflammatory myopathies and is often associated with the presence of an antisynthetase antibody. Other clinical manifestations that can occur in patients with DM include dysphagia, dysphonia, myalgias, Raynaud phenomenon, fevers, weight loss, fatigue, and a nonerosive inflammatory polyarthritis. Patients with DM have a three to eight times increased risk for developing an associated malignancy compared with the general population, and therefore all patients with DM should be evaluated at the time of diagnosis for the presence of an associated malignancy. This review summarizes the immunopathogenesis, clinical manifestations, and evaluation of patients with DM.

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Basosquamous carcinoma (BSC) is a rare aggressive epithelial neoplasm with features of both basal cell carcinoma and squamous cell carcinoma, with a tendency toward local recurrence and a propensity for lymph node and distant metastases. The aim of the present study was to report the case of a 63-year-old Caucasian male with BSC in the auricular region.

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Background: Skin is a window to aging changes, a biological reality. There is a dearth of studies regarding the various chronological (intrinsic) aging and photoaging (extrinsic) changes seen in Asians. This study was undertaken to detect the clinical pattern of aging skin changes and dermatoses seen in the elderly. Materials and Methods: This was a descriptive study conducted on 500 consecutive elderly individuals attending the Dermatology out-patient department. The severity of photoaging was graded using Glogau scale. Results: Most of the population had skin type IV and V. Majority (415, 83%) of our cases had chronological aging without photoaging and the remaining 85 (17%) individuals had photoaging along with chronological aging. The common skin changes due to chronological aging were thin skin, fine wrinkles, xerosis, and loss of elasticity. Photoaging changes such as dyspigmentation, freckles, thick skin, deep wrinkles, melasma, citrine skin, senile purpura, pseudostellate scar, acrokeratoelastoidosis marginalis, and lentigines were less frequent in our study. Smoking and prolonged sun exposure was the risk factors aggravating photoaging. The most common dermatosis was pruritus in 248 (49.6%) individuals, of which 149 (29.8%) had pruritus associated with xerosis. Contact dermatitis was more common in males. Fungal infections were frequently seen in females. Seborrhoeic keratosis (253, 50.6%) was the most common benign neoplasm more commonly seen in males. Cutaneous malignancies were less common in our study population. Conclusion: Photoaging changes were less common than chronological aging changes in skin type IV. Chronological changes were more frequent in females than males, while photoaging was more frequent in males.

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Photoprotection by sunscreens, clothing and glasses are important to protect the skin against the detrimental effects of sun exposure. In order to achieve complete protection, topical strategies must shield against the range of solar wavelengths ultraviolet A, ultraviolet B, infrared radiation that can damage the skin. To provide the necessary broad spectrum coverage, combinations of chemical and physical UV filters along with molecules that are capable of interfering with and/or preventing the deleterious effects of sunlight are discussed in this review.

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Ochronosis is a rare disease characterized by speckled and diffuse pigmentation symmetrically over the face, neck, and photo-exposed areas. It is characterized histologically by banana-shaped ochre-colored deposits in the dermis. It can present in exogenous or endogenous form. We report a case of exogenous ochronosis in a 50-year-old Indian woman after prolonged use of topical hydroquinone which is a rare complication with a commonly used drug which is available over the counter.

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Background: Psoriasis is a chronic inflammatory disease of the skin and joints with an increased cardiovascular risk. Previous studies have shown a higher prevalence of metabolic syndrome (MS) in psoriatic patients. Objective: To investigate the prevalence of MS in patients with psoriasis and healthy controls, and to determine the relation between disease severity and the presence of MS. Materials and Methods: We performed a hospital-based case-control study on 118 adult patients with psoriasis vulgaris and 120 controls matched for age, sex and body mass index. MS was diagnosed by the presence of three or more of the South Asian Modified National Cholesterol Education Program's Adult Panel III criteria. Results: MS was significantly more common in psoriatic patients than in controls (44.1% vs. 30%, P value = 0.025). Psoriatic patients also had a higher prevalence of triglyceridemia (33.9% vs. 20.8%, P value = 0.011), abdominal obesity (34.7% vs. 32.5%, P value = 0.035) and elevated blood sugar. There was no difference in the high density lipoprotein (HDL) levels and presence of hypertension among patients with psoriasis and normal controls. There was no correlation between the severity and duration of psoriasis with MS. Conclusion: MS is frequent in patients with psoriasis. We have found no relationship between disease severity and presence of MS. Hence, we suggest that all patients must be evaluated for the MS, irrespective of the disease severity.

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Mal de Meleda is a rare autosomal recessive transgradient palmoplantar keratoderma characterized by transgradient keratoderma with associated scleroatrophy, nail changes, pseudoainhum around digits and perioral erythema, without a tendency for spontaneous resolution. Involvement of the lip by keratoderma has not been reported in the English literature. Here we present two cases of Mal de Meleda with unusual lip involvement. The first case was a 15-year-old girl, born of second-degree consanguineous marriage, who presented with transgradient palmoplantar keratoderma from 6 months of age, with lichenoid papules and plaques on the elbows and knees, conical tapering of the distal digits, flexion deformity of several fingers, digital constriction, knuckle pads and lip involvement. The second case was a 24-year-old male with transgradient palmoplantar keratoderma since birth. He also had scaly plaques on the extensors of bilateral knees and elbows, knuckle pads, pseudosclerodermatous fingers with conical tapering, digital constrictions at various places with mild flexion deformity and lip involvement. Both patients were otherwise normal without any family history.

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Muscle inflammation and weakness are the key features of idiopathic inflammatory myopathies (IIMs). In addition IIMs are frequently associated with cutaneous and pulmonary involvement. In clinical practice the three common inflammatory myopathies we come across are polymyositis (PM), dermatomyositis (DM) and inclusion body myositis (IBM). The Bohan and Peter criteria combine clinical, laboratory, and pathologic features to define PM and DM. They did not recognize inclusion body myositis (IBM) or other inflammatory myopathies, such as granulomatous and eosinophilic myositis. Thus the disease spectrum is wide and IIMs are a heterogeneous group of autoimmune disorders. To address these issues in this article we have discussed the currently developing newer classifications of IIMs.

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Polymyositis (PM) is one of the inflammatory myopathies, disorders characterized pathologically by the presence of inflammatory infiltrates in striated muscle. The principal clinical manifestation of PM is proximal muscle weakness. The cause of PM is unknown, but current evidence suggests that it is an autoimmune disorder. PM can affect people of any age, but most commonly presents between the ages of 50 to 70. PM is rarely seen in people younger than 18 years of age, and is twice as common among females than males. PM is more common in blacks than in whites. The overall prevalence of PM is 1 per 100,000. Muscle weakness may develop suddenly or more insidiously over a period of weeks to months. The classic symptom of PM is proximal weakness, which may manifest as difficulty holding the arms over the head, climbing stairs, or rising from a chair. Weakness of the striated muscle of the upper esophagus may result in dysphagia, dysphonia, and aspiration. The chest wall muscles may be affected, leading to ventilatory compromises. Involvement of cardiac muscle may lead to arrhythmias and congestive heart failure. Dermatomyositis (DM) is closely related to PM, and both are distinguished primarily by the occurrence of characteristic skin abnormalities in the former. PM and DM may be associated with a variety of malignancies. PM may also occur as part of the spectrum of other rheumatic diseases like systemic lupus erythematosus and mixed connective tissue disease. Moreover, inflammatory myopathy may be caused by some drugs (procainamide, D-penicillamine), and viruses, most notably the retroviruses. Corticosteroids and immunosuppressive agents are the mainstays of therapy for PM. The principal goals of therapy are to improve strength and improve physical functioning. Many patients require treatment for several years. The 5-year survival rate for treated patients is in the order of 95%. Up to one-third of PM patients may be left with some degree of residual muscle weakness.

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Necrobiotic xanthogranuloma (NXG) is a very rare, progressive variant of non-Langerhans cell histiocytosis. It is known to be associated with multisystem involvement and paraproteinemias. A 65-year-old female presented with chronic, slowly growing, asymptomatic periorbital nodules. The lesions had recurred after local excision elsewhere. No systemic involvement or paraproteinemias were detected. A provisional diagnosis of isolated cutaneous NXG was made which was confirmed by histopathology and immunohistochemistry staining. The lesions were surgically excised with excellent cosmetic and functional results. There was no recurrence over a period of 9 months. To our knowledge, this is the second case of NXG reported from India and the first without any systemic manifestations.

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Background: Herpes zoster is an intractable painful condition, more severe in elderly patients. The pain during the first 30 days of onset is known as Acute Herpetic Neuralgia. Multiple treatments using non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and tricyclic anti-depressants are available, but their side effects limit their use in geriatric patients. Gabapentin is also used in chronic neuropathic pain; however, its role in acute herpetic neuralgia is less explored. Aim : This study was aimed to determine dose related efficacy and safety of gabapentin in reducing pain of acute herpetic neuralgia in geriatric patients. Materials and Methods: In this placebo-controlled, four-week trial including 56 subjects, 42 patients received gabapentin in the dosage of 300 mg (n=15), 600 mg (n=14), and 900 mg(n=13) per day in divided doses and 14 patients received placebo within 72 hours of onset of herpes zoster. Results: Subjects receiving gabapentin had a statistically significant reduction (P<0.0001) in visual analog scale (VAS) score as compared to placebo, emphasizing the efficacy of gabapentin in the treatment of acute pain associated with herpes zoster on each assessment (weeks 1, 2, 3, and 4). Gabapentin in doses of 600 mg/day and 900 mg/day was better than 300 mg/day in each visit. However, no difference was observed between gabapentin 600 mg/day and 900 mg/day group at any point of time (P>0.05). Conclusion: The results of this study show that gabapentin is effective in acute herpetic neuralgia in different doses with 600 mg/day being the more appropriate dose in terms of safety and efficacy.

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A 63-year-old woman living in the countryside referred to our department with a 2-month history of a red nodule localized on the right breast. Histological examination, immunohistochemical analyses and serologic evaluation conducted with ELISA and Western blot were performed. Clinical diagnosis of borrelial lymphocytoma was not possible solely on the clinical presentation of a classical nodular form without lymphoadenopathy. An absence of a referred prior tick bite and a previous or concomitant erythema migrans at clinical presentation rendered a more challenging diagnosis. The fact that the patient lived in the countryside, the appearance of the breast nodule in September, and serologic, histologic, and immunohistochemical analysis facilitated the diagnosis of borrelial lymphocytoma. We report this case to highlight the importance of an investigation of Lyme borreliosis when a patient living in the countryside presents with a red nodule of the nipple and areola.

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A 35-year-old male presented with multiple discharging sinuses and fluctuant swelling on right side of face which started after a vehicular accident three year back. The lesions did not respond to routine antibiotics treatment but went on increasing. Gram smear showed typical acid fast branching filaments suggestive of nocardiosis, which was confirmed by culture. Patient received co-trimoxazole for three and a half month. When seen again after three years, all the lesions had healed with puckered scarring. Patient had received co-trimoxazole for three and a half months with dramatic improvement.

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Background: Bacterial skin infection especially Pyoderma, commonly caused by Staphylococcus aureus and group A Streptococci, is quite common in Indian dermatology clinics. Despite a number of new antibiotics, the incidence of bacterial resistance is rising. Aim: To find out causative organisms and their latest antibiotic susceptibility patterns in pyodermas. Materials and Methods: All in-patients admitted in the Dermatology wards in Government Medical College, Amritsar were screened over 18 months and those with erosive skin lesions and/or purulent discharge were included in the study and swabs were sent for culture and sensitivity. Results: Majority 49/61 cases (80.33%) comprised of secondary pyodermas while primary pyodermas constituted only 12/61 cases (19.67%). Single organism was isolated in 49 cases (80.33%). More than one type of organism was isolated in 3 cases (4.92%) while none could be isolated from 9 (14.75%) cases. Staphylococcus aureus spp. was the commonest organism isolated in 36 (59.01%) cases and out of these, coagulase positive strains were found to be highly susceptible to amikacin (21cases-100%). Coagulase negative strains were sensitive to amikacin (7 cases-77.7%) and gentamycin (6 cases-66.6%) respectively. Conclusion: This study gives an indication of the present pattern of bacteriological profile of pyodermas in a tertiary care hospital in north-west India. In-vitro testing is essential as knowledge of the causative organisms and resistance patterns can help us select appropriate antibiotics without wasting time in using resistant drugs.

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Xeroderma pigmentosum (XP) is a rare autosomal recessive disorder related to defective deoxyribonucleic acid (DNA) repair. Various cutaneous manifestations related to ultraviolet (UV) damage characterize the clinical course. Primary malignant cutaneous neoplasms like squamous cell carcinoma, basal cell carcinoma and malignant melanoma have been reported. Atypical fibroxanthoma is a rare dermal neoplasm occurring in UV-damaged skin. We report an unusual case of atypical fibroxanthoma in a 20-year-old male with XP.

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Epithelioid hemangioma (EH) or angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon benign disease. We report an unusual case of EH (ALHE) that arose on the lower back in a zosteriform array. The presence of the characteristic histological appearance of plump endothelial cells with hobnail-like protrusions led to the diagnosis of EH (ALHE). Histological examination of the lesion also revealed the existence of arteriovenous shunts, the possible factor contributing to the pathogenesis of EH (ALHE).

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Most varicella-zoster virus (VZV) infections after cord blood transplantation (CBT) present as localized herpes zoster. Here, we report a case of VZV reinfection in an adult patient after CBT that appeared clinically to be varicella. A 50-year-old Japanese man underwent CBT for the management of acute lymphoblastic leukemia. Seventeen months later, he developed a small number of vesicles with umbilicated centers. A skin biopsy showed an intraepidermal blister containing degenerated balloon cells. Subsequently, the skin eruption developed over his entire body. The patient was treated with intravenous acyclovir for 5 days, followed by oral valacyclovir for 9 days. It took more than 3 weeks for most of the skin lesions to scab. Serum levels of anti-VZV IgG on days 3 and 33 after the onset of the skin eruption were negative and 260 mIU/ml, respectively. Serum anti-VZV IgM on days 3 and 33 was not detected. Our patient was diagnosed with VZV reinfection.

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