Demodex mite is an obligate human ecto-parasite found in or near the pilo-sebaceous units. Demodex folliculorum and Demodex brevis are two species typically found on humans. Demodex infestation usually remains asymptomatic and may have a pathogenic role only when present in high densities and also because of immune imbalance. All cutaneous diseases caused by Demodex mites are clubbed under the term demodicosis or demodicidosis, which can be an etiological factor of or resemble a variety of dermatoses. Therefore, a high index of clinical suspicion about the etiological role of Demodex in various dermatoses can help in early diagnosis and appropriate, timely, and cost effective management.

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In this short communication we are providing insight about the regulatory role of the phosphatidylinositol 3-kinase (PI3K)-AKT-mammalian target of rapamycin (mTOR) kinase system in psoriatic disease. This is an upcoming active research field in respect to elucidating the inflammatory and proliferative cascades of psoriatic disease. To provide a new dimension to the understandings of the molecular principles of the pathogenesis of autoimmune diseases, we hypothesized that (i) dysregulation of cytokines and growth factors in autoimmune diseases activate the mTOR signaling system and (ii) the activated mTOR kinase system is a key regulator of the inflammatory/proliferative cascades of the disease process. In support of this hypothesis we have earlier reported that growth factors (nerve growth factor (NGF) and platelet-derived growth factor (PDGF)) and relevant cytokines (interleukin (IL)-17, IL-22) known to be critical for psoriasis, psoriatic arthritis, and rheumatoid arthritis activate the mTOR signaling system. Here, we are providing our latest observations that the mTOR signaling proteins are upregulated in psoriatic skin and further we observed that proliferation of keratinocytes (KC) and synovial cells (synovial fibroblasts (FLS)) of psoriatic arthritis are dependent on the PI3K-AKT-mTOR kinase system. To our knowledge, we are the first to explore whether a double kinase inhibitor of mTOR signal proteins has a therapeutic potential for psoriatic disease. Here we will be sharing our views, our research work in this field and as well we will provide evidences how a double kinase inhibitor of mTOR signal proteins can be an effective therapeutic agent for psoriatic disease.

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Chronic paronychia is an inflammatory disorder of the nail folds of a toe or finger presenting as redness, tenderness, and swelling. It is recalcitrant dermatoses seen commonly in housewives and housemaids. It is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens. Repeated bouts of inflammation lead to fibrosis of proximal nail fold with poor generation of cuticle, which in turn exposes the nail further to irritants and allergens. Thus, general preventive measures form cornerstone of the therapy. Though previously anti-fungals were the mainstay of therapy, topical steroid creams have been found to be more effective in the treatment of chronic paronychia. In recalcitrant cases, surgical treatment may be resorted to, which includes en bloc excision of the proximal nail fold or an eponychial marsupialization, with or without nail plate removal. Newer therapies and surgical modalities are being employed in the management of chronic paronychia. In this overview, we review recent epidemiological studies, present current thinking on the pathophysiology leading to chronic paronychia, discuss the challenges chronic paronychia presents, and recommend a commonsense approach to management.

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Context: Alopecia areata (AA) is a common form of localized, non-scarring hair loss. The etiopathogenesis of the disease is still unclear, but the role of autoimmunity is strongly suggested. AA is commonly associated with various autoimmune disorders; the most frequent among them is autoimmune thyroid disorders. Aim: To determine whether AA is associated with thyroid autoimmunity or thyroid function abnormalities in Egyptian patients. Materials and Methods: Fifty subjects with AA (37 males and 13 females) without clinical evidence of thyroid disorders were selected from Dermatology Outpatient Clinic, Menoufiya University Hospital, Menoufiya Governorate, Egypt, during the period from June 2009 to February 2010. They were divided into 3 groups according to severity of AA. Fifty age and sex-matched healthy volunteers (35 males and 15 females) were selected as a control group. Every case and control were subjected to history taking, complete general and dermatological examination. Venous blood samples were taken from cases and controls after taking their consents for measurement of thyroid stimulating hormone (TSH), free T3, freeT4 and detection of Anti-thyroglobulin Antibody (Tg-Ab) and Anti-thyroid Peroxidase Antibody (TPO-Ab). Results: Subclinical hypothyroidism was detected in 16% of cases. There were statistically significant differences between cases and controls regarding levels of TSH, free T3 and free T4. There were significant differences between cases and controls regarding the presence of Tg-Ab and TPO-Ab. Conclusions: Every patient with AA should be screened for thyroid functions and presence of thyroid autoantibodies even in absence of clinical manifestations suggestive of thyroid affection.

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Background: Onychomycosis of the fingernails and toenails is generally caused by dermatophytes and yeasts. Toenail mycoses involve mainly dermatophytes but when Candida is also involved, the strain most commonly isolated worldwide is C. albicans. Aims: To determine Candida strains prevailing in onychomycosis. Materials and Methods: A retrospective, observational and descriptive study of fungal cultures retrieved from the registry of the microbiology laboratory of the Pontificia Universidad Católica was performed. Specimens obtained from patients attending the healthcare network between December 2007 and December 2010 was analyzed. Statistical Analysis: A descriptive statistical analysis was performed. Results: Candida was retrieved from 467 of 8443 specimens (52% fingernails and 48% toenails). Cultures were negative in 5320 specimens (63.6%). Among Candida-positive cultures, parapsilosis was the most commonly isolated strain with 202 cases (43.3%). While isolates of Candida guillermondii were 113 (24.2%), those of Candida albicans were 110 (23.6%), those of spp. were 20 (4.3%) and there were 22 cases of other isolates (4.71%). Among the 467 patients with positive cultures for Candida, 136 (29,1%) were men and 331 (70,9%) were women. All patients were older than 18 years old. Clinical files were available for only 169 of the 467 patients with positive cultures for Candida. For those, age, gender, underlying illnesses and use of immunossupresive agents during the trial was reviewed. Conclusions: The present study shows that both C. parapsilosis as well as C. guillermondii appear as emerging pathogens that would be in fact taking the place of C. albicans as the most commonly isolated pathogen in patients with Candida onychomycosis. The relative percentage of C parapsilosis increases every year. Identification of Candida strains as etiological agents of nail candidiasis becomes relevant to the management both nail as well as systemic candidiasis, in view of the resistance to conventional treatments readily reported in the literature.

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Background: There are limited data exploring the characteristics of mixed type basal cell carcinoma (BCC). Objectives: To explore different characteristics of mixed type BCC. Design: Cross sectional study. Materials and Methods: 825 patients with BCC enrolled in this study. Results: Among 825 patients, 512 (62%) were male. Three hundred and fifty five (43%) presented with nodular subtype, 267 (32.4%) with mixed subtype, 25 with superficial and the 178 remaining presented with other subtypes. Four hundred and eighty three (58.6%) of the lesions were on the face, 243 (29.5%) on scalp, 52 (6.3%) on ears, 20 (2.4%) on neck, 15 (1.8%) on trunk and 12 (1.4%) on extremities. Anatomic distribution of mixed type was as follows: 137 on face, (51.4%), 100 (37.3%) on scalp, 19 (7%) on ear, 6 (2.1%) on neck, 4 (1.5%) extremity and 1 (0.7%) on trunk, which the difference from non mixed types was statistically significant (P = 0.002). The mean diameter of the mixed types and non mixed type BCCs were significantly different (2.7 ± 2.1 cm vs. 2.2 ± 1.6 cm; P = 0.01. The prevalence of necrosis in mixed type BCC was two times higher than non mixed type BCCs (OR = 2.3, CI 95% 1.3-3.9, P = 0.001). The most frequent combined subtypes were nodular-infiltrative (P < 0.001). Conclusion: Mixed type BCC has differences with other BCC subtypes in anatomical distribution and tumor diameter. Indeed, mixed type BCCs are frequently composed of aggressive subtypes than nonaggressive subtypes.

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Trigeminal trophic syndrome (TTS) is a rare cause of facial ulceration, consequent to damage to the trigeminal nerve or its central sensory connections. We reporta case of TTS in a 48-year-old woman with Bell's palsy following herpes zoster infection. The patient was treated and counseled. There hasnot been any recurrence for 1 year and the patient is being followed-up. The diagnosis of TTS should be suspected when there is unilateral facial ulceration, especially involving the ala nasi associated with sensory impairment.

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Tuberculosis verrucosa cutis (TVC) is a common cutaneous form of paucibacillary tuberculosis in an individual with moderate to high degree of immunity to Mycobacterium tuberculosis infection. Clinical appearance of TVC is mostly very typical with well-defined warty plaques presenting mostly on hands, knees, ankle, and buttocks; however several atypical morphology of the lesions have also been described. We hereby report a case of TVC, masquerading as asymptomatic diffuse keratoderma of left foot for nine months, in an otherwise healthy individual, obstructing easy diagnosis of cutaneous tuberculosis. Diagnosis was confirmed by histopathology.

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A 20-year-old male presented with multiple eruptions on his right leg since birth; these bled and were painful on trivial trauma. Examination revealed dark brown, hyperkeratotic, indurated, verrucous linear plaques with irregular borders. Histopathological evidence of hyperkeratosis, acanthosis, and extensive vascular proliferation in papillary dermis confirmed clinical suspicion of angiokeratoma circumscriptum (AKC). Excision and skin grafting yielded a cosmetically favorable outcome. Angiokeratomas, first described by Mibeli in 1889, are a group of vascular ectasias involving the papillary dermis. Angiokeratomas are more common in males; however, AKC-the rarest of its five variants-exhibits a female preponderance (F:M:3:1). AKC is an extremely rare nevoid disorder, only 100 of its cases having been reported in the world literature until 2006. Herein, we have reported a typical case of AKC in a young male that was previously misdiagnosed, and the patient wrongly counseled about the likelihood of its spontaneous regression.

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Context: Mixed connective tissue disorder is an uncommon disease. Some scientists are reluctant to recognize it as a separate entity. Some others have defined this ailment. Cutaneous features of this condition are unique. Researchers from India have described these features to relate to those described in the studies from other parts of the globe. Aims: This study aims to delineate the skin manifestations of clearly defined mixed connective tissue disease (MCTD) patients, to compare them with those established as overlap syndrome, and to relate them with studies from other parts of the globe. Settings and Design: Successive patients who fulfilled the specific criteria for MCTD presenting in the skin outpatient department of a tertiary care hospital in eastern India were clinically examined from 2009 for 3 years. Materials and Methods: The number of participants was 23 and the dermatological features of these were compared with 22 patients with overlap syndrome. The antibody to uridine-rich U1 ribonucleoprotein was measured for all patients. Statistical Analysis Used: SPSS (Version 17) and MedCalc (Version 11.6). Results: The Male: Female ratio among the MCTD patients was 1:6.67 and that of the overlap syndrome was 1:10. Twenty patients of the MCTD group presented with synovitis as against only seven in the overlap group. Raynaud's phenomenon was present in some of the subjects. Puffy fingers were rare in our study. Facial numbness was reported by four of those suffering from MCTD. Antinuclear antibody (ANA) was essentially of a speckled pattern in this disease Conclusions: Cutaneous indicators of MCTD are distinct from overlap syndrome. Knowledge of these manifestations prevalent in a region may lead to early diagnosis of the disease.

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The term "reticulate" is used for clinical description of skin lesions that are configured in a net-like pattern. Many primary and secondary dermatoses present in such patterns involving specific body sites. Certain cutaneous manifestations of systemic diseases or genodermatoses also present in such manner. This review classifies and describes such conditions with reticulate lesions and briefly, their associated features.

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Background: Early detection of skin cancers by screening could be very beneficial to decrease their morbidity or mortality. There is limited study about skin cancer screening in Iran. Aim: This essay was planned as a pilot skin cancer screening campaign in Tehran, Iran to evaluate its profit and failure and further design large-scale screening program more definitely. Materials and Methods: Thirty one public health centers of Shahid Beheshti Medical University were selected in different areas of Tehran. The project was announced via media and invited all the people above 40 years old to come for the whole-body skin examination in a one-week period. Patients with any suspected lesions were referred to the dermatology clinics of the university. Results: 1314 patients, 194 males (14.8%) and 120 females (85.2%), with mean age of 51.81 ± 10.28 years participated in this screening campaign. Physicians found suspected lesions in 182 (13.85%) of participants. The diagnosis of skin cancer was confirmed in 15 (1.14%) patients. These malignancies included 10 (0.76%) cases of basal cell carcinoma, 2 (0.15%) cases of squamous cell carcinoma and 3 (0.23%) cases of malignant melanoma. Conclusion: Skin cancer screening seems to be valuable to detect skin malignancies in their early course. Regarding the considerable amount of facilities needed to perform skin cancer screening program, it might be more beneficial to perform the targeted screening programs for the high-risk groups or emphasis more on public education of skin cancer risk factors and their early signs.

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Background: Acquired, non-nevoid, apparently idiopathic facial pigmentation are distributed over some specific locations like periorbital area, zygomatic area, malar area, root of nose, perioral and mandibular area. Periorbital pigmentation is the most well known entity in this group. These are bilaterally distributed homogenously diffuse gray to dark gray or slate-gray colored patches showing progressive intensification of pigmentation. These are often considered as physiologic or constitutional pigmentation. Some portions of the margins of these patches were described previously as pigmentary demarcation line (PDL- F, G, H). Aim : To analyze the distributional patterns of acquired, apparently idiopathic facial pigmentations and to evaluate the etiologic aspects of these conditions. Materials and Methods: Spatial patterns, distribution, and orientation were analyzed among 187 individuals with idiopathic non-nevoid, facial pigmentation. Observed patterns were compared with various pigmentary nevi and Blaschko's lines on face. Results: It was found that most of the idiopathic facial pigmentary alterations including periorbital pigmentation and PDL on face had specific patterned distribution that had high similarity to that of the pigmentary nevi and Blaschko's lines on face. Conclusion: It is hypothesized here that phenotypic expression of acquired patterned pigmentation (AIFPFP) is due to genetically determined increased pigmentary functional activity to various known and unknown yet natural factors like UV rays and aging. Mosaicism is a definite possibility. We also consider that these patterns actually reflect the normal patterns of embryological human pigmentation on face.

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Clinical signs are evolved by clinicians through their careful clinical examination. Medical professionals are generally familiar with these signs because of the emphasis given to them by the teaching faculty while they were students. Some of these signs are eponymously named after the clinicians giving credit to their observation. Eponymous signs in vesiculobullous diseases such as Nikolsky sign and Asboe Hansen sign (Bulla spread sign) are well known and were described during the 19th and 20th century, respectively. Cerebriform tongue in pemphigus vegetans was described by Premalatha (1981) three decades ago and is well recognized and cited in several text books and articles in leading journals. All these signs are revisited below with an emphasis on cerebriform tongue in pemphigus vegetans which could eponymously be called as Premalatha sign.

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Lichen sclerosus (LS) is an inflammatory dermatitis of unknown etiology that mostly affects the genital region in both the sexes. In active cases the histopathologic changes differentiate between LS and morphoea though in chronic cases it is very difficult to diagnose with certainty. Coexistence of both the conditions in a single patient indicates that these lesions represent a spectrum of similar pathologic process. Coexistence of both the conditions along Blaschko's lines is so far not described in literature. We report an Indian patient with both LS and morphoea occurring along Blaschko's lines.

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An eccrine poroma is a solitary tumor arising from the eccrine duct epithelium in the epidermis. The lesions commonly occur on the sole of the foot, the hands, and occasionally on the nose, eyelids, neck, and chest. We report a patient who presented with a slow-growing nodular lesion over her left cheek, prompting a diagnosis of basal cell carcinoma or keratoacanthoma. Biopsy from the nodule revealed a well-defined epidermal tumor with uniform small cuboidal cells with rounded deeply basophilic nuclei, few narrow ductal lumina, and occasional cystic spaces confirming the diagnosis of an eccrine poroma.

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A 14-year-old Chinese girl had a 6-year history of recurrent lesions on her head, face, and limbs. Epstein-Barr virus (EBV)-IgM was positive. Histopathological findings revealed focal lymphocyte invasion in subcutaneous panniculus adiposus, mainly surrounding the blood vessels. Immunohistochemistry showed CD3+, CD4+, CD5+, CD8+, TIA-1+, GrB+, CD56-, and L26-. In situ hybridization staining for EBV-encoded small nonpolyadenylated RNA (EBER)-1 was positive. The patient showed significant improvement in clinical symptoms after being treated with acyclovir and IFN-α in this patient.

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Ichthyosis hystrix is a term used to describe an ichthyosiform dermatosis which is characterized by hyperkeratotic spiny scales mainly over extensor aspects of limbs with palmoplantar keratoderma and occasionally associated with deafness and neurological deficit. It is a rare autosomal dominant form of ichthyosis and very few cases are reported in literature. We are presenting a 46 years-old-male patient of ichthyosis hystrix with unusual presentation. He had lesions mainly over the face and scalp with palmoplantar keratoderma and significant nail changes.

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Two cases of infantile perianal pyramidal protrusions (IPPP), one pyramidal in shape and one leaf shaped, are being described by us. Both were notable for coexisting hemangiomas in the close vicinity. To the best of our knowledge we are reporting these two variants of IPPP with the associated neighboring hemangiomas for the first time in Indian dermatologic literature. We suggest that this presentation may be a part of one of the syndromes that comprise anorectal malformations with hemangiomas like PELVIS syndrome and others mentioned in the table.

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Background: Pemphigus has been treated with Dexamethasone Cyclophosphamide Pulse (DCP) Therapy since 1981.Various modifications have been suggested in the original regimen. These include Dexamethasone Azathioprine Pulse (DAP) and Dexamethasone Methotrexate Pulse (DMP) therapies. Aims: To report our experience on the noncomparative study of various Pulse regimens DCP, DAP AND DMP therapies in patients with Pemphigus. Materials and Methods: The patients were put on three regimens depending upon the situation-Conventional DCP, DAP in the reproductive age group, DMP in patients who showed prolonged Phase I more than 12 months while on DCP. Results: 30 patients were put on DCP therapy. The duration of phase I was on an average six months. Relapse was seen in 3 patients in phase IV. 12 patients on DAP therapy were considered. In Phase III 5 patients relapsed in phase IV four patients relapsed. Five patients were put on the DMP. Disease activity was poorly controlled and in three DMP was discontinued. Conclusion: DCP remains the most effective regimen with quickest onset of remission and continuance of remission. In DAP therapy fixation of dose of azathioprine at 50 mgs daily may be counterproductive. DMP does not fulfil the promise of a viable treatment option in recalcitrant pemphigus and this lacunae needs to be plugged.

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