Selective serotonin reuptake inhibitors (SSRI) are the most prescribed antidepressant medications for the treatment of depression and other psychiatric disorders due to their efficacy, tolerability, and safety profile. The dermatological side-effects or cutaneous reactions due to SSRI class of antidepressants is rare. Though there were few case reports of SSRI-induced rash due to fluoxetine, paroxetine, and sertraline, the evidence associated with escitalopram, the highly prescribed antidepressant is comparatively less. The identification and reporting of the drug-related side-effects/adverse drug reactions either serious or non-serious is very important as it will be helpful in understanding, reviewing, and educating the drug-related information before starting medication to the patient.

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Background: Azathioprine is an immunosuppressant used to treat several immunological disorders. As a purine analog, it inhibits DNA synthesis and cell multiplication. However, marrow suppression is a serious complication associated with azathioprine. Aim: To analyze the marrow suppression caused by azathioprine in dermatology patients. Material and Method: This is a retrospective analysis of the records of 18 patients who presented with marrow suppression secondary to azathioprine which was used for the treatment of various dermatological diseases. Results: The analysis includes 18 patients, 15 females and 3 males with the average age being 25.88 years. All except two patients received 1 mg/kg of oral azathioprine once daily. Leukopenia was seen in 13 patients (with severe leukopenia in 7 patients), thrombocytopenia in 8, and low hemoglobin in 14 patients. Isolated low hemoglobin was seen in four patients, isolated leukopenia in four patients, and only one patient presented with isolated thrombocytopenia. Six patients had pancytopenia. The duration from the starting dose to reporting of marrow suppression ranged from 10 days to 1 year. Eight out of 18 patients presented with anagen effluvium, 2 patients with oral ulcers, and 1 patient with an upper respiratory tract infection. All the patients recovered within 1 month. Conclusion: Marrow suppression due to azathioprine can occur with a low dose of 1 mg/kg. Hair loss and oral ulcers serve as early warning signs for marrow suppression.

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Background: Discoid lupus erythematosus (DLE) is chronic dermatosis manifests as scaly indurated plaques with erythema and peripheral hyperpigmentation. Few cases progress to systemic lupus erythematosus. Differentials include lichenoid photo dermatitis, Jessner's lymphocytic infilterate, and polymorphus light eruptions. It is difficult to assess the activity clinically. Histopathology is characteristic and evaluation of disease activity is possible. Dermoscopy is a useful diagnostic method in many dermatoses. Dermoscopy is reflection of histological changes. Hence, dermoscopic features may act as a tool for activity assessment. Here authors have pursued dermoscopic and histopathological correlation in DLE lesions to assess the activity of disease. Aims: To study dermoscopic features in DLE and correlate the patterns with histopathological changes in skin of color. Method: This study was conducted in a tertiary hospital. Clinically suspected and histopathologically proven lesions of DLE were enrolled in this study. The target lesion was marked and sent for biopsy after performing dermoscopy. Activity of the lesion was assessed on the basis of histopathological features. SPSS statistics for windows v20.0 (SPSS Inc, Chicago, USA) was used to analyze data. Chi-square and Fisher's χ² test was used to statistically signify association. Cohen's kappa coefficient was used to determine the agreement. Results: Study included 110 patients with Fitzpatrick skin type IV-V having 120 lesions. Follicular keratotic plug [73 (60.8%)] and peri-follicular whitish halo [65(54.1%)] were commonly found in dermoscopy. Blue-gray and brown dots, telangiectasia, follicular red dots, white rosettes and white areas include other features. Interface dermatitis, peri-appendageal infilterate, melanin incontinence, melanophages and fibrosis were noted in histopathology. Perfect agreement was observed in follicular plugs. Conclusion: Dermoscopy patterns were well correlated with histopathological changes. Thus dermoscopy played an important role in assessing the activity of lesion.

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Background: Vitamin D is thought to play a role in the pathogenesis of acne, and its levels can change in patients with acne vulgaris. Several studies have revealed that serum 25-hydroxy vitamin D levels tend to be low and statistically significant in acne vulgaris patients. However, the relationship between vitamin D levels and acne severity is still poorly understood. Objective: This study aims to identify the correlation between serum 25-hydroxy vitamin D levels and the severity of acne vulgaris. Method: This systematic review study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline based on several studies taken from the PubMed, PMC, Semantic Scholar, and ResearchGate databases until June 2021. Full-text case-control, randomized controlled trial, or cross-sectional study in English or Indonesian language reporting on the serum 25-hydroxy vitamin D levels and the severity of acne vulgaris on human participants were included. Result: From a total of 401 studies, 10 studies met the criteria. Almost all studies (8 of 10) revealed lower serum 25-hydroxy vitamin D levels as the acne severity progresses, although 2 of them were not statistically significant. Conclusion: The evidence of an inverse correlation between serum 25-hydroxy vitamin D levels and the severity of acne vulgaris suggests the need for screening of vitamin D levels in acne patients and offers a new prospect in the field of acne prevention and treatment.

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Background: Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are acute, life-threatening, severe drug reactions. Randomized studies on these diseases are difficult to perform. Aims and Objectives: The purpose of this study was to summarize the demographic and clinical characteristics of patients with SJS and TEN in a tertiary hospital in Turkey. Materials and Methods: We evaluated the records of 33 patients with SJS and TEN who were followed in our clinic or examined between January 2008 and June 2019, retrospectively. Age, sex, time of admission to hospital, causative drug, presence of concomitant disease, skin findings, mucosal involvement, the severity-of-illness score for TEN, the medication used, antibiotic use, transfer to intensive care, development of complications, and death or discharge status were noted. Results: Of the 33 patients, 11 (33.3%) had SJS, 3 (9.1%) had SJS/TEN overlap, and 19 (57.6%) had TEN. The majority (60.6%) of the patients were female. Nineteen (57.6%) patients had one, and 13 (39.4%) had more than one suspected drug exposure in their history. The most commonly suspected drugs were antibiotics. Twelve (36.4%) patients had intensive care unit hospitalization. Ten (30.3%) patients died. Conclusion: The demographic data of our study were consistent with the literature. Similar to the literature, antibiotics were the most common reaction-causing drugs. However, antiepileptic drugs, which were more frequently reported in other studies, were identified as suspicious in only one patient. We believe that our study will contribute to the determination of characteristics of this rare disease with real-life data.

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Background: The use of tumor necrosis factor-α inhibitors (TNFi) has been associated with an increased risk latent tuberculosis (TB) reactivation. The role of TB screening assays in monitoring patients during TNFi therapy remains uncertain. Spontaneous conversions and reversions have been described. Aims: This study aims to determine the conversion and reversion rate of TB screening tests among dermatology patients receiving TNFi in a country with moderate TB incidence. Subjects and Methods: A retrospective single-center study conducted on all patients in whom treatment with TNFi was initiated in our dermatology clinic in a tertiary university hospital, Riyadh, Saudi Arabia, until September 2018. Data were collected from the hospital electronic patient information system. Results: One hundred and eighteen patients were included. Majority (79.9%) of patients used adalimumab. Psoriasis was the most common indication (90%). Among patients with negative baseline TB screening who had been retested during TNFi therapy (n = 65; 55%), conversion to positive was observed in nine patients (13.8%) with a mean duration of exposure of 39.7 months, whereas among patients with positive TB testing result (n = 18), 10 (55.5%) reverted to negative. Conclusions: This study emphasizes the need for prospective large-scale multispecialty studies assessing the significance of TB retesting, which should be considered when designing rescreening protocols.

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Background: Substantial evidence suggests a higher risk of metabolic syndrome as a result of persistent inflammation in patients with psoriasis. Psoriasis may also be associated with vitamin D deficiency. Aim: To correlate vitamin D deficiency with psoriasis and metabolic syndrome. Materials and Methods: Serum vitamin D levels were quantified, and metabolic syndrome was assessed in 42 cases whose psoriasis severity had been measured by PASI and in an equal number of age/gender-matched controls. The resultant data were analyzed statistically. The odds ratio was calculated wherever applicable and a two-tailed P < 0.05 was considered statistically significant. Results: Vitamin D deficiency (<20 ng/ml) occurred in 43 subjects [(51.19%); 26 (62%), patients and 17 (40.4%), controls] and was statistically significant in patients (OR: 2.39, P = 0.044) though lacking correlation with disease severity. Metabolic syndrome seen in 25 (30%) subjects—15 (36%) patients and 10 (24%) controls—emerged to be significant (OR: 3.71, P = 0.047) in cases with vitamin D deficiency. Hypertension—observed in 31 (37%) subjects; 18 (43%) cases, 9 each (21.4%) with/without metabolic syndrome and 13 (31%) controls, 7 (16.6%) with and 6 (14.3%) without metabolic syndrome (P = 0.25)—correlated independently with vitamin D deficiency in patients (P = 0.009). Conclusions: Despite limitations of small sample size and observational nature, our study—probably the first such hereto from India—showed statistically significant associations between vitamin D deficiency, metabolic syndrome, and hypertension in patients with psoriasis. Future larger studies are needed for strengthening this evidence prior to the recommendation of its clinical application in the optimum management of patients.

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Background: Latent tuberculosis infection (LTBI) is a common yet difficult problem to diagnose in tuberculosis endemic countries. Both tuberculin skin test (TST) and interferon-gamma release assay (IGRA) are used for the diagnosis of LTBI. Aims: The aim of the study is to compare TST and IGRA in patients planned for systemic treatment of psoriasis. Methods: It was a diagnostic study conducted in a tertiary care centre during the study period from January 20 to December 20. Patients more than 18 years of age with chronic plaque psoriasis planned for systemic therapy were included. Psoriasis area severity index (PASI), history of tuberculosis in past or family and BCG vaccination were recorded. Complete blood count, radiograph of the chest, tuberculin skin test and interferon-gamma release assay were performed in all patients. Statistical analysis was performed using statistical package for social sciences (SPSS version 20, Chicago). Results: A total of 75 patients, including 48 males and 27 females, were included in the study. The mean age and mean duration of disease were 46.08 (±12.16) and 4.59 (±3.8) years, respectively. Seventy-one (94.6%) patients had BCG scar, and two (2.6%) had a history of tuberculosis in a family member. The TST and IGRA were positive (>10 mm) in 23 (30.6%) and 16 (21.3%) patients, respectively. Either TST or IGRA was positive in 28 (37.3%) patients. Out of these 28 patients, concordance was seen in 11 (39.2%) and discordance in 17 (60.7%). Discordance was TST+/IGRA − in 12 (42.8%) and TST−/IGRA + in five (17.8%) patients. Abnormality in radiograph of the chest and computed tomography (CT) scan of the chest were seen in five (6.6%) and nine (12%) patients, respectively. The patients with either TST or IGRA + were more likely to have abnormal chest radiographs than those who were TST−/IGRA− (OR: 11.3, 95% CI: 1.24–102.3, P = 0.03). The TST and IGRA showed fair agreement ([INSIDE:1] = 0.364, P = 0.003). ROC curve was plotted for the absolute value of TST in mm considering IGRA as the gold standard. The area under the curve was 0.805 (95%CI: 0.655–0.954). For the TST positivity cut-off of 10 and 15 mm, specificity was 77.3% and 95.5%, respectively; the sensitivity was 68.8% irrespective of the cut-off value. Limitation: Small sample size and lack of follow-up are the biggest limitations of the study. The lack of a gold standard in the diagnosis of LTBI is an inherent yet unavoidable flaw in the study. Conclusion: Reactivation of LTBI is a concern in a patient planned for immunosuppressive therapy. We suggest the use of both TST and IGRA rather than two-step testing (TST followed by IGRA) or IGRA alone for the diagnosis of LTBI, especially in patients with a high risk of reactivation. The positivity on either test should prompt further evaluation and treatment decisions should be taken considering the risk-benefit ratio of treatment rather than test results alone.

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Introduction: Of late, immunotherapy has emerged as a promising therapeutic modality for the treatment of recalcitrant and difficult to treat warts. Purified protein derivative of tuberculin (PDD) and mycobacterium w (Mw) vaccine hold promising prospects for the treatment of verruca, especially in a country like ours where a majority of the population is already sensitized to mycobacterium tuberculosis both due to disease endemicity and Bacillus Calmette-Guérin (BCG) vaccination. Aims and Objectives: We aimed at evaluating the treatment outcome of intralesional PPD tuberculin and Mw vaccine in the treatment of recalcitrant extragenital warts in immunocompetent subjects. Materials and Methods: The patients included immunocompetent subjects between the ages of 16 and 65 years with two or more extragenital warts. The patients were randomized into two groups, namely A (PPD Tuberculin) and B (Mw vaccine). In both groups, 0.1 mL of active intralesional immunogen was injected at the base of the largest wart. The doses were repeated at 4 weeks' intervals for a maximum of 5 injections. Additionally, the improvement in quality of life was measured using the Hindi-validated version of the Dermatology Quality of Life Index (DLQI) questionnaire. Results: Ninety-seven patients completed the study, with 46 in group A and 51 in group B. In group A, 24 (52.17%) patients had complete clearance in all warts, and in group B, 32 (62.75%) (P = 0.38). The most common adverse event in patients of group A was transient injection site erythema and swelling, whereas that in group B was mild transient fever. None of the patients showed any signs of recurrence in the ensuing follow-up period. There was a statistically significant improvement in the mean DLQI scores after treatment in both groups (P < 0.0001). Conclusion: Both PPD Tuberculin and Mw vaccine are effective in the treatment of recalcitrant warts with minimal recurrence rate. The safety profile of PPD is superior to Mw vaccine. We suggest both to be used as first-line therapy in the treatment of difficult to treat warts.

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Background: Impact of acne on the psychological aspect among adolescents and young adults is poorly understood and many times goes unnoticeable. Aim: To assess body image disturbance, self-esteem, quality of life among adolescents and young adults with acne. Materials and Methods: A cross sectional survey on 250 adolescents and young adults aged 13-25 years in Dermatology OPD of a tertiary care hospital, was performed. Severity of acne, body image disturbance, self-esteem, and quality of life were assessed using standardized tools like IGA scale, BIDQ, RSES, and TAQOL respectively. Results: A majority of the participants, 163 (65%), were aged 20–25 years, in which 141 (56.4%) were male, 237 (94.8%) were unmarried, 192 (76.8%) were residing in urban area, 142 (56.8%) were graduate/post-graduate, 173 (69.2%) were students and 113 (45.2%) belonged to upper middle class of socio-economic status. More than half, 137 (54.8%), had a family history of acne, 228 (91.2%) had oily skin, 166 (67.4%) had normal nutritional status, 154 (61.6%) had moderate form of acne whereas 80 (32%) had severe acne. The mean BIDQ score was 3.05 (SD = 0.89); 169 (67.60%) had normal self-esteem and 174 (69.64%) had mild impairment in quality of life. Severity of acne had significant association with body image disturbance (P = 0.007) and quality of life (P = 0.001) but not related with self-esteem. Conclusion: The results revealed body image disturbance and impaired quality of life among adolescents and young adults with acne which draws the attention of dermatologists towards unidentified psychological aspects of acne during treatment. However, the majority of them revealed normal self-esteem in the study.

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Objective: This study was performed to determine the genotype and allelic frequencies (polymorphisms) of the four genes of vitamin D receptor (VDR) among Egyptian psoriatic patients and healthy controls to explore their association with disease severity (PASI) score and immune modulation of IL-22 cytokine and to predict the response to topical calcipotriol treatment. Patients and Methods: The frequencies of the four VDR gene polymorphisms (FokI, ApaI, TaqI, and BsmI) in blood samples of 51 adult Egyptian patients with psoriasis vulgaris and 50 healthy controls were evaluated using restriction fragment length polymorphism (RFLP)-PCR. Serum levels of IL-22 were measured by ELISA. Results: The most frequent genotype (wild) in the studied patients was Apa1; AA (88.2%) followed by Fok1; FF (47.1%) and Taq1; TT (47%), while Bsm1; BB genotype was (27.7%). The most frequent allele polymorphisms either in one allele (Bb) or both alleles (bb) in psoriatic patients were 72.5%, followed by Ff, ff (52.9%) and Tt, tt (52.9%). The less frequent allelic polymorphism was Aa, aa (27.7%). Insignificant differences in the frequency of genotype (wild) and allelic polymorphisms were detected between patients and controls (P > 0.05). A significantly higher serum concentration of IL-22 (ng/mL) was detected in patients than controls (P = 0.001). Further, 66.6% of patients displayed a clinical response, while 33.4% were non-responders. A significantly higher expression of TaqI polymorphism was detected in (100%) of non-responders (P < 0.001), which was also correlated with disease severity (r = 0.515, P < 0.01). Conclusion: These results suggest that the VDR TaqI polymorphism is the only gene correlated to psoriasis susceptibility in the Egyptian population, and affects the response to topical calcipotriol treatment but does not affect IL-22 immune modulation.

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Importance: Exact etiopathogenesis of chronic spontaneous urticaria (CSU) remains elusive. Infections, pseudoallergens, autoimmunity, and contact sensitization are various postulated factors. Few studies are available measuring cytokine levels in CSU. Objectives: The aim was to study various etiological factors of CSU and levels of IL-6 and IFN-ϒ in cases and controls, and correlation between various etiologies with the levels of the abovementioned interleukins in the cases. Design: Case-control study performed over 2 years with no follow-up of the participants. Setting: It was a referral-center-based study. Participants: Sixty patients of CSU and equal age and sex-matched healthy controls were recruited on the basis of convenience sampling. Exposures: Biochemical and hematological investigations with hepatitis serology, thyroid function tests, anti-thyroid antibodies, and levels IL-6 and IFN-ϒ were performed in all cases and controls. All cases were subjected to ASST. Cases with all above negative tests were patch-tested with Indian standard series. Urticaria activity score (UAS7) was calculated for all the cases and repeated in patients with positive etiological factor after 3 weeks (improvement after allergen or drug avoidance, treatment of infection). Outcomes: To study the various etiological factors (food, infection, autoimmunity, autoreactivity, and contact sensitization) and the levels of IL-6 and IFN- γ in patients of chronic spontaneous urticaria. Results: Etiology was ascertained in 75% of patients (autoimmunity: 50%, contact sensitization: 21.67%, food and drug allergy: 1.67% each). Mean values of the interleukins and anti-thyroid antibodies were significantly higher in cases versus controls. Levels of IFN-ϒ were significantly elevated in patients with higher UAS7 scores. Conclusion: Antithyroid antibodies, ASST, and patch testing are important tools and should be considered in patients of CSU after a thorough history and history-based workup. Elevated levels of IL-6 and IFN- ϒ in cases suggest that both Th1 and Th2 type of immune responses are implicated in pathogenesis of CSU.

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Introduction: Ectodermal dysplasias (EDs) affect structures derived from the ectoderm such as skin, its appendages, nail, and teeth. In this series, we describe four patients presenting with a clinical phenotype of dysplasia of one or more ectodermal structures who underwent next-generation sequencing for mutational analysis. Case Series: The clinical phenotype of three patients was hypohidrotic ectodermal dysplasia (HED) and one patient was diagnosed with autoimmune polyglandular syndrome (APS) type 1. Two patients with classical clinical features of X-linked HED (XLHED) had mutations in EDA gene; variant c.924+ 8C>G (5′ proximal splice site) and c.760C>T (p.Gln254Ter). Case 3 had clinical phenotype of HED with urticaria pigmentosa, which was confirmed on skin biopsy and immunohistochemistry. This patient was found to have mutation in C1orf172; c.449G>A (p.Arg150Gln) which has not been reported previously. Case 4 was diagnosed to have APS type 1 with cutaneous features of discoloration of teeth and chronic mucocutaneous candidiasis. This patient had a compound heterozygous mutation of AIRE gene. The two variants detected were c.169C>T (p.Gln57Ter) and c.47C>T (p.Thr16Met). Conclusion: The present series highlights the clinic-genetic correlation in four patients with features of ED. Two variants of uncertain significance and two previously unreported variants were also found in this study.

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Background and Objectives: Acanthosis nigricans is characterized by hyperpigmentation and velvet-like thickening of the skin. It symmetrically involves the neck, axilla, groins, antecubital and popliteal fossae, umbilical, and perianal areas. Acanthosis nigricans is a marker for insulin resistance and is increasingly found to be associated with metabolic syndrome. We conducted this study to estimate the frequency of metabolic syndrome in acanthosis nigricans. Methods: In this hospital-based, cross-sectional study, we evaluated 60 patients with acanthosis nigricans with neck involvement. They were examined for other areas of involvement by acanthosis nigricans. Axillary and neck severity was graded based on the scale described by Burke et al. Insulin resistance was interpreted using homeostatic model assessment (HOMA-IR). Metabolic syndrome was diagnosed according to the SAM-NCEP criteria. Collected data were analyzed using IBM SPSS Statistics, Version 22 (Armonk, NY: IBM Corp). Results: Axilla was the most common site involved in 51 patients (85%) followed by knuckles (55%). Metabolic syndrome was found in 78.3% of our patients, and 56.66% had insulin resistance. A statistically significant association of severity grading of axillary acanthosis nigricans with both metabolic syndrome (P = 0.001) and insulin resistance (P = 0.03) was noted. However, no meaningful association was found between the severity grading of neck acanthosis nigricans with both metabolic syndrome (P = 0.4) and insulin resistance (P = 0.08). The association of neck texture grading of acanthosis nigricans with insulin resistance was statistically significant (P = 0.005). Conclusions: Metabolic syndrome was seen in 78.3% of acanthosis nigricans. Axillary severity grading was associated with metabolic syndrome.

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Objective: To integrate evidence and assess the risk factors associated with actinic keratosis (AK). Methods: Unrestricted searches were conducted on five electronic databases, with an end-date parameter of September 2021. We summarized the study characteristics and pooled the results from individual studies by using a random-effects model. The risk of bias was estimated using the Cochrane Risk of Bias Tool, and the quality of evidence was estimated according to the Newcastle–Ottawa Scale. Results: Sixteen studies were included in final analysis, and we assessed the AK risk among a variety of risk factors. Overall, the male sex (odds ratio (OR): 2.51; 95% confidence interval (CI): 1.94–3.25; P < 0.01), age >45 years (OR = 7.65, 95% CI: 2.95–19.86; P < 0.01), light Fitzpatrick skin phototype (OR = 2.32, 95% CI: 1.74–3.10; P < 0.01), light hair color (OR = 2.17, 95% CI: 1.40–3.36; P < 0.01), light eye color (OR = 1.67, 95% CI: 1.03–2.70; P = 0.04), freckles on face/arms (OR = 1.88, 95% CI: 1.37–2.58; P < 0.01), suffered positive history of other types of non-melanoma skin cancer (OR = 4.46, 95% CI: 2.71–7.33; P < 0.01), sunburns in childhood (OR = 2.33, 95% CI: 1.47–3.70; P < 0.01) and adulthood (OR = 1.50, 95% CI: 1.12-2.00; P < 0.01), severe sunburn (OR = 1.94, 95% CI: 1.62–2.31; P < 0.01), and chronic occupational and/or recreational sun exposure (OR = 3.22, 95% CI: 2.16–4.81; P < 0.01) increased the risk of AK. Moreover, sunscreen use (OR = 0.51, 95% CI: 0.34–0.77; P < 0.01) and history of atopy reduced the risk of AK. Sensitivity analysis yielded consistent results. The included studies showed a high risk of bias. Conclusion: We confirm several well-known AK risk factors and their quantitative data, and summarized the uncommon risk factors and protective factors. Our results may inform on the design and implementation of AK screening and educational programs.

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Background: Vaccine-hesitancy is an important obstacle to attain herd-immunity against COVID-19. Undue fears about adverse effects like allergic reactions may be an important reason for vaccine-hesitancy. Objectives: To assess the online information-seeking behavior of Indian internet users regarding 'allergies' and determine its association with COVID-19 vaccine-hesitancy. Methods: We conducted a Google trend analysis to obtain the relative search volume (RSV) for keywords—'skin allergy,' 'drug allergy,' 'food allergy,' 'vaccine allergy,' 'contact dermatitis,' and 'allergy' using a public domain https://trends.google.com/trends. We further obtained state-wise data and statistically analyzed it to assess any association with vaccine-hesitancy. Results: Higher RSV was found for 'vaccine allergy' after the advent of COVID-19 vaccines, showing the steepest peak. 'Skin allergy' showed two peaks. The first peak was after the advent of COVID-19 pandemic and second peak was after introduction of vaccines. RSV of 'contact dermatitis' remained unchanged. Eastern and North-Eastern states showed the highest RSV for 'skin' and 'vaccine' allergies. Literacy rate showed a significant positive correlation with vaccination, whereas vaccine-hesitancy was inversely proportional to RSV for 'allergy.' Conclusion: Increased online information-seeking behavior is demonstrated by Indians regarding various 'allergies,' particularly after the advent of COVID-19 vaccines. Literacy was directly proportional to vaccination status, whereas vaccine-hesitancy was inversely proportional to search-volume for 'allergy.'

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As the popularity of injection lipolysis increases, several side effects of injection lipolysis have been reported. In this case, A 53-year-old woman visited our outpatient clinic with a new round-shaped protruding mass (size: 5.0 cm × 3.0 cm) in the submental area. The patient had received the injection lipolysis treatment before the visit. She had received injections in the submental area at 1-week intervals (i.e., 4, 5, and 6 weeks). We performed contrast-enhanced computed tomography of the neck for differential diagnosis and found a 5.0 cm × 3.7 cm × 2.1 cm rim-enhanced fluid-density lesion in the submental. Hence, surgical removal of the lesion was planned based on the diagnosis of unspecified complicated fluid collection. The removed mass was a 3.0 cm × 2.0 cm × 2.0 cm whitish fibrous tissue. Histological examination revealed mucormycosis infection. Although several side effects of lipolysis have been reported to date, mucormycosis infection in the submental area has not been reported before.

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The basic principle of science is to always think of the simplest explanation for a condition. But in post graduate training, distinguishing a rare case from a common case is a dilemma for the naïve clinician. Often the eager and enthusiastic resident trainees are more prone to fall into this “rare case phenomenon.” Innumerable rare case reports in countless scientific journals may give the false impression to the budding trainee that uncommon cases are encountered every now and then. This article stresses on the importance of applying certain rules that can help in making the diagnostic process systematic and simpler. The chance of encountering rare cases are in fact rare and limited, wherreas in some circumstances, can diagnose life threatening conditions too.

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A novel observation of chronic eczema developing over the skin of adequately treated lesions of tinea cruris/tinea corporis in six atopic individuals is being shared. We propose that the skin of atopic individuals affected by dermatophytosis be observed for secondary changes even after the complete resolution of the lesions. The use of bland emollients with topical antifungal agents should be encouraged in atopic patients. The extent and duration of the compromised epidermal barrier function of the skin of atopic individuals with dermatophytosis need to be studied further.

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Epidermolysis bullosa (EB) is a group of rare inherited conditions that results in blistering of the skin and mucous membranes. Mutations in the PLEC gene cause epidermolysis bullosa simplex (EBS). Mutations in type VII collagen, encoded by COL7A1 lead to epidermolysis bullosa dystrophica (EBD). The report presents three autosomal recessive cases, one with epidermolysis bullosa simplex (EBS) with nail and muscular dystrophy showing heterozygous single base pair deletion in exon 31 (chr8:144998220delC; c. 6288del; p. Arg2097AlafsTer55) and a heterozygous two base pair deletion in exon 27 (chr8:145001693_145001694delCT; c. 4054_4055del; p. Ser1352CysfsTer68) of PLEC gene. Two cases of epidermolysis bullosa dystrophica (EBD), with a novel homozygous, nonsense mutations in exon 54 (c. 5047C > T) and exon 104 (c. 7762C > T) of COL7A1 gene. The findings of the case report, provide evidence for additional molecular heterogeneity, in epidermolysis bullosa and also emphasize the significance of PLEC and COL7A1 gene mutations in epidermolysis bullosa.

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Alopecia neoplastica is a rare type of cutaneous metastasis. The most frequent presentation consists of red-violaceous nodular scarring alopecia located at the parietal area. The most frequent primary tumor locations are the breast and gastrointestinal tract. We report a case of alopecia neoplastica that induced an underlying lytic bone metastasis. After a rigorous literature search, we could not find another case showing this mechanism.

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Anaplastic thyroid carcinoma is a highly aggressive tumor with 100% mortality that constitutes 1%–2% of thyroid malignancies. Cutaneous metastases from thyroid carcinoma are extremely rare. We report a case of a 68-year-old male with anaplastic thyroid carcinoma with cervical lymph node and thoracic cutaneous metastases. Following the diagnosis of anaplastic carcinoma with stage IVB after thorough investigations, he was started on chemotherapy with cisplatin and adriamycin, and also radiotherapy was given subsequently. Dermatological examination showed a single ulcer of size 3 × 2 cm, hard nodules, and plaques of varied sizes present over the anterior chest. Skin biopsy from the nodule showed pleomorphic tumor cells in strands with colloid material and neutrophilic infiltrates in the deep dermis. The present case report demonstrates that thoracic skin metastases can occur from anaplastic thyroid carcinoma with nodules and ulcers and, to our knowledge, this is the first case report of such an extremely rare condition from India.

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