The explosive rise in the incidence of atopic diseases in the Western developed countries can be explained on the basis of the so-called "hygiene hypothesis". In short, it attributes the rising incidence of atopic dermatitis to reduced exposure to various childhood infections and bacterial endotoxins. Reduced exposure to dirt in the clean environment results in a skewed development of the immune system which results in an abnormal allergic response to various environmental allergens which are otherwise innocuous. This article reviews the historical aspects, epidemiological and immunological basis of the hygiene hypothesis and implications for Indian conditions.

Store and forward and real time or videoconferences are the two types of teledermatology services practiced. Dermatology and radio-diagnosis are visual specialties suited for store-and-forward teledermatology (SAFT). Advances in information technology, electronic instruments and biotechnology have revolutionized and brought changes in SAFT. Cellular phone, digital camera, personal digital assistants, Wi-Fi, Wi-Max and computer- aided-design software are incorporated to deliver the quality health care to remote geographic regions. Complete SAFT care equivalent to face-to-face consultation (Gold standard) is essential. Health care providers in rural areas are the 'eyes' for the consultants. Consultants to guide them should have a rapid periodic audit of visual parameters and dimensions of lesions. Given this background, this article reviews advances in 1) capture, store and transfer of images. 2) Computer Aided measurements of generalized and localized lesions and 3) the integration model to meet all the above two requirements in a centralized location. This process enables diagnosis, management, periodic assessment and complete follow-up care to achieve patient and physician satisfaction. Preservation of privacy and confidentiality of digital images is important. Uniform rules and regulations are required. Indian space research organization (ISRO), Government of India has demonstrated telemedicine pilot projects utilizing the satellite communication and mobile telemedicine units to be useful in meeting the health care needs of remote and rural India. we have to join hands with them to meet dermatology problems in rural areas.

Background: Sarcoidosis is a multisystem disease of undetermined etiology. Indian studies on cutaneous sarcoidosis are not many and mainly comprise case reports. Aims: This retrospective study was carried out to assess the clinical profile of sarcoidosis patients presenting with cutaneous lesions. Methods: All histopathologically proven cases of cutaneous sarcoidosis seen consecutively between 1999 and 2004 were studied. Their age, sex, presenting features, evolution of disease and laboratory parameters were analyzed. Results: A total of 23 patients (F:M 15:8) between 31 to 78 years (mean 44.3 years) of age had the mean duration of skin lesions of 1.4 years. Six patients had one to four lesions; two patients each had scar sarcoidosis and angiolupoid and one patient each had recurrent erythema nodosum, leg lymphedema and subcutaneous sarcoidosis. Others showed combination of papules, nodules, plaques and psoriasiform lesions. Peripheral lymph nodes were involved in two patients. Among 10 patients of pulmonary involvement, three had become symptomatic four months to four years after the cutaneous lesions. Routine laboratory investigations including serum calcium estimation were normal in all cases. Serum angiotensin-converting enzyme levels were raised in 3 out of 6 patients. Asymptomatic lytic lesions of digital bones were detected in hand X-ray of one patient. Conclusion: Skin lesions of sarcoidosis are like the tip of an iceberg indicating more changes in other organs. The symptomatology and abnormal laboratory results do not necessarily correlate with the severity of cutaneous involvement in general.

Background: Finding an effective treatment for acne that is well tolerated by the patients is a challenge. One study has suggested the efficacy of tea tree oil in treatment of the acne vulgaris. Aim: To determine the efficacy of tea tree oil in mild to moderate acne vulgaris. Methods: This was a randomized double-blind clinical trial performed in 60 patients with mild to moderate acne vulgaris. They were randomly divided into two groups and were treated with tea tree oil gel (n=30) or placebo (n=30). They were followed every 15 days for a period of 45 days. Response to treatment was evaluated by the total acne lesions counting (TLC) and acne severity index (ASI). The data was analyzed statistically using t-test and by SPSS program. Results: There were no significant differences regarding demographic characteristics between the two groups. There was a significant difference between tea tree oil gel and placebo in the improvement of the TLC and also regarding improvement of the ASI. In terms of TLC and ASI, tea tree oil gel was 3.55 times and 5.75 times more effective than placebo respectively. Side-effects with both groups were relatively similar and tolerable. Conclusion: Topical 5% tea tree oil is an effective treatment for mild to moderate acne vulgaris.

Background: Patients receiving phototherapy for various dermatoses are at increased risk of eye damage due to ultraviolet (UV) rays. They are prescribed UV protective sunglasses by dermatologists but their exact protecting effects are not known. Aim: To study the ultraviolet protective properties of branded and unbranded UV protective sunglasses available in the Indian market, in UV phototherapy chambers. Methods: Sixteen different branded and unbranded UV protective sunglasses were collected from two opticians in Mumbai. Baseline irradiance of the UV chamber was calculated by exposing the photosensitive probe of UV photometer in the chamber. Then, the photosensitive probe of the UV photometer was covered with the UV protective glass to be studied and irradiance was noted. Such readings were taken for each of the UV protective sunglasses. The percentage reduction in the UV rays' penetration of different UV protective sunglasses was calculated. Results: Thirteen sunglasses provided > 80% reduction in UVA rays penetration, of which four were branded (out of the four branded studied) and nine were unbranded (out of the 12 unbranded studied). More than 70% reduction in UVB penetration was provided by 12 sunglasses, which included 10 unbranded and two branded sunglasses. Conclusion: All branded sunglasses provided good protection against UVA penetration, but UVB protection provided by both branded and unbranded sunglasses was not satisfactory. A few unbranded sunglasses had poor efficacy for UVA and UVB spectra; one branded glass had poor efficacy for protection against the UVB spectrum. The efficacy of sunglasses used for phototherapy should be assessed before use.

Background: Alopecia areata is a recurrent, nonscarring type of hair loss. Different modalities of treatment have been used to induce hair re-growth. Aims: To determine the efficacy of topical garlic gel in the treatment of alopecia areata. Methods: Patients were randomly divided into two groups of garlic gel and placebo. The two groups were advised to follow the treatment twice daily, for three months. Both groups received topical application of corticosteroid (betamethasone cream 0.1% in isopropyl alcohol) twice daily. Baseline demographic characteristics and the size of patches, total number of grown hair and number of terminal hair at the end of each month were recorded. Effectiveness was assessed by scoring the results. Statistical analysis was done by means of chi-square and t test. Results: Forty patients met the inclusion criteria and enrolled for the study. The first group (garlic treated) consisted of 20 patients (12 males, 60% and eight females, 40%). The second group (control) consisted of 20 patients (10 males, 50% and 10 females, 50%). At the end of the treatment, good and moderate responses were observed in 19 (95%) and one (5%) patients of the case group respectively, which was significantly better than the control group ( P = 0.001). No complication was observed in the patients under study. Conclusion: The present study showed that the use of garlic gel significantly added to the therapeutic efficacy of topical betamethasone valerate in alopecia areata and that it can be an effective adjunctive topical therapy for alopecia areata.

Background: Kaposi`s varicelliform eruption (KVE) represents widespread cutaneous herpes simplex virus (HSV) infection in patients with preexisting dermatoses. Occasionally, this infection can present as a nosocomial infection in skin wards, if adequate bed-spacing and barrier nursing methods are not followed. We are reporting five cases of KVE; four cases acquired the infection in a makeshift ward after admission of the first case in May 2005, due to the renovation work of the regular skin ward. Aim: The purpose of this study is to create clinical awareness about this uncommon dermatologic entity and to stress upon the importance of bed-spacing and barrier nursing in skin wards. Methods: Five cases of KVE, three females and two males with different primary dermatoses (pemphigus foliaceus - one, pemphigus vulgaris - two, paraneoplastic pemphigus - one and toxic epidemal necrolysis - one) were included in this study. Diagnosis was made clinically and supported with Tzanck smear and HSV serology. All the cases were treated with oral acyclovir. Results: Four out of five cases of KVE recovered with treatment, one case of extensive pemphigus vulgaris with KVE succumbed to death. Conclusion: Mini outbreaks of KVE can occur in skin wards with inadequate bed-spacing and overcrowding of patients. Therefore adequate bed-spacing, barrier nursing and isolation of suspected cases are mandatory to prevent such life-threatening infections.

A four-year-old girl was brought to the dermatology outpatient department with scaling all over the body since birth. She had history of episodic vomiting and abdominal distension. A dermatological diagnosis of lamellar ichthyosis was made. Abdominal examination revealed a nontender hepatomegaly, fatty liver on ultrasonography and deranged liver function tests. Peripheral blood smear showed lipid vacuoles in the granulocytes consistent with Jordans' anomaly. Similar lipid vacuoles were seen in the basal layer in skin biopsy. An inflammatory infiltrate, moderate fibrosis in the portal tract and diffuse severe fatty change in hepatocytes were seen in liver biopsy. The patient was diagnosed as a case of Dorfman-Chanarin syndrome.

Encephalocraniocutaneous lipomatosis is a congenital hamartomatous disorder with unique ocular, cutaneous and neurological features. A 13-year-old boy presented with history of mental retardation and delayed developmental milestones. Bulbar conjunctiva of left eye showed hypertrophy with a soft reddish limbal nodule encroaching on the cornea. Dermatological examination showed multiple patches of alopecia, soft papules in the left perioral and periorbital areas, soft masses over the right axilla, trunk and in the lumbosacral region suggestive of lipomas. The CT scan of the brain revealed well-defined, hypodense lesions in both the cerebellar hemispheres suggestive of lipomas. The constellation of these findings led us to a diagnosis of encephalocraniocutaneous lipomatosis.

Tuberous sclerosis complex (TSC) and hypomelanosis of Ito (HI) are two uncommon neurocutaneous syndromes and their coexistence is extremely rare. An epileptic child presented with progressively increasing multiple hypopigmented macules arranged in a linear and whorled pattern along the lines of Blaschko over the trunk and limbs, characteristic of HI. He also had facial angiofibromas, ash-leaf and confetti macules and shagreen patches. Magnetic resonance imaging of the brain showed cortical tubers and subependymal nodules; which are diagnostic of TSC. The TSC defining loci have been mapped to Chromosome 9q34 (TSC1) and 16 pl3.3 (TSC2). There is no common genetic background for HI, but mosaicism of 9q33 locus has been documented. As per our knowledge, this is the second case of association of TSC with HI in a four-year-old child.

Ectrodactyly, ectodermal dysplasia and cleft palate/lip syndrome (EEC) is a rare autosomal dominant syndrome with varied presentation and is actually a multiple congenital anomaly syndrome leading to intra- and interfamilial differences in severity because of its variable expression and reduced penetrance. The cardinal features include ectrodactyly, sparse, wiry, hypopigmented hair, peg-shaped teeth with defective enamel and cleft palate/lip. A family comprising father, daughter and son presented to us with split hand-split foot deformity (ectrodactyly), epiphora, hair changes and deafness with variable involvement in each family member.

A six-month-old girl who presented with dermatitis was found to have multiple, symmetric, deep, gyrate skin folds involving her trunk and similar circumferential lesions on her extremities since birth. She had a characteristic round face with hypertelorism, depressed nasal bridge, thin, down-turned vermillion border of upper lip and short neck. Skin biopsy demonstrated increased smooth muscle fibers in the deeper dermis. A diagnosis of Michelin tire baby syndrome was made. Clinical features, histopathology, differential diagnosis and prognosis of this rare disorder have been discussed.

Mesotherapy is a technique which involves microinjections of conventional homeopathic medication and/ or vitamins into the mesoderm or middle layer of the skin to promote healing or corrective treatment to a specific area of the body. It is a debatable addition in the therapeutic armamentarium in the management of skin rejuvenation. However, dermatologists have to use this cautiously and judiciously as at present there is a lot of controversy regarding its efficacy and safety despite the fact that mesotherapy is gaining popularity in the West.

Background: No controlled data is available till date comparing topical tazarotene and clobetasol in Indian psoriatic patients. Objective: The aim was to compare the clinical efficacy of 12 weeks of once-daily tazarotene 0.1% cream with that of once-daily clobetasol propionate 0.05% cream in the treatment of patients with chronic plaque psoriasis. Methods: About 36 patients with bilaterally symmetrical lesions were enrolled in this double-blind randomized controlled study. A left-right randomized study was conducted. Results: Clobetasol cream was better than tazarotene cream in reducing the erythema throughout the treatment period with statistically significant differences favoring clobetasol at weeks 2, 4, 6 and 8 ( P <0.05). Tazarotene was better in reducing the induration at weeks 2 ( P <0.05), 4, 10 and 12. Clobetasol cream was better in reducing the scaling throughout the treatment period with statistically significant differences favoring clobetasol over the entire treatment period. Treatment success rate was 100% with clobetasol and 88% with tazarotene at the end of week 12 with clobetasol achieving 100% success rate at the end of week 6. Treatment with tazarotene resulted in uniform reduction of plaque elevation and was not associated with the development of hot spots. Conclusion: Topical tazarotene 0.1% cream is less effective than topical clobetasol propionate 0.05% cream in the treatment of plaque psoriasis. It has more effect on induration than on erythema and scaling of psoriatic lesions.

Kaposi's varicelliform eruption (eczema herpeticum) is the name given to a distinct cutaneous eruption caused by herpes simplex and certain other viruses that infect persons with preexisting dermatosis. Most commonly it is associated with atopic dermatitis. We report a case of a three-year-old atopic child who presented with extensive vesicular eruption suggestive of Kaposi's varicelliform eruption. There was history of fever, malaise and extensive vesicular eruptions. Diagnosis was made based on clinical features and Tzanck smear examination. Patient responded adequately to oral acyclovir therapy.