The pathogenesis of systemic sclerosis (SSc) is complex, and the final story is yet to be elucidated. The clinical heterogeneity of the disease, its various autoimmune and antibody profiles, its long course and tendency for spontaneous cure makes the design of clinical trials difficult. The overwhelming need in this disease is to diagnose it early and identify those patients who will benefit most from early, aggressive treatment. We attempt to review data from recent clinical trials and the lessons derived.

Background: Atopic dermatitis (AD) is a chronic, relapsing, itchy dermatosis of multifactorial origin, which commonly starts in childhood. Defective metabolism of essential fatty acids leading to relative dominance of pro-inflammatory prostaglandins (PGE ₂ and PGF ₂ ) has been reported as an important factor in the pathogenesis of AD. Evening primrose oil (EPO) as a source of gamma-linolenic acid (GLA) has been of interest in the management of AD. Aim: To evaluate the efficacy and safety of EPO in atopic dermatitis in our patients. Methods: Consecutive new out-patient department (OPD) patients of a referral hospital in Kolkata clinically diagnosed as having AD were randomly allocated to two groups. To the first group, evening primrose oil was supplied as 500-mg oval clear unmarked capsules, while placebo capsules identical in appearance and containing 300 mg of sunflower oil were given to the other group. Treatment continued for a period of 5 months. With pre-designed scoring system (based on four major parameters: extent, intensity, itching, and dryness), clinical evaluation was done at baseline and subsequent monthly visits. Data of the first 25 patients from each group who completed the 5 months of trial were compiled and analyzed. Results: At the end of the fifth month, 24 (96%) patients of EPO group and 8 (32%) patients of placebo group showed improvement. There was significant difference in outcome of treatment between two groups (P < 0.00001). No significant adverse effect was reported by any patient/guardian at any point of assessment. Conclusion: Evening primrose oil is a safe and effective medicine in management of AD. However, since not all researchers across the world have found the same good result, further large trials on Indian patients are needed.

Background: Parthenium hysterophorus is the commonest cause of airborne contact dermatitis in India. Azathioprine has been shown to be effective and safe in parthenium dermatitis, but there are no reports of comparison of steroids and azathioprine in this condition. Aims: To study the therapeutic efficacy of azathioprine versus betamethasone in patients having contact dermatitis to parthenium and compare the side effects of the drugs. Methods: Fifty-five patients of airborne contact dermatitis to parthenium were randomly assigned to treatment with azathioprine 100 mg daily (group A) or betamethasone 2 mg daily (group B), for 6 months in a blinded manner. The patients were evaluated every month for 6 months to determine the response to treatment and side effects and then further followed up for another 6 months to determine any relapse. Results: There were 26 patients in group A and 29 in group B, of which 20 patients of group A and 21 of group B completed the study. Nineteen (95%) patients in group A and all 21 (100%) patients in group B had an excellent response (complete remission) to treatment (P = 0.0156 vs. 0.0005). The patients in group B, however, had more adverse effects (Fisher exact, P≤0.05). Nine (45%) patients in group A and 14 (67%) patients in group B relapsed during the post-treatment follow-up. Conclusions: Azathioprine and betamethasone appear to be almost equally effective (P = 0.0156 vs. 0.0005) in the treatment of parthenium dermatitis. However, adverse effects and relapses were observed to be more frequent in patients treated with betamethasone.

Background: The pattern of eczema is altered by geography, habits of people and environmental factors and regional variation in skin structure and function. Aims: Our study was done to estimate frequency and patterns of lower leg and foot eczemas. Methods: A total of 200 patients with various types of lower leg and foot eczemas were recruited over a period of 2 years. Demographic and clinical characteristics were noted. Suspected cases of allergic contact dermatitis were patch tested. Results: The frequency of these eczemas was 2.5 per 1000 out patients. Mean age of patients was 40.49 years. Female to male ratio was 1.6:1. Sixty (30%) patients were farmers, sixty (30%) were housewives, forty (20%) were students, nineteen (9.5%) were daily laborers, nine had sedentary jobs and three were teachers. Most eczemas were bilateral (72%). Mean duration of eczema was 36.6 months. Most common type of eczema was lichen simplex chronicus (36%) followed by discoid eczema (18.5%), allergic contact dermatitis (14.5%) and stasis eczema (7.5%). Other eczemas noted were juvenile plantar dermatosis, cumulative irritant contact dermatitis, infected eczema, hyperkeratotic eczema, asteatotic eczema, pompholyx, infective eczema and unclassified endogenous eczema. Common sites of involvement were dorsa of feet (49.5%), followed by lateral aspect of lower leg (31%), medial aspect of lower leg (17.5%) and ankle (12%). Conclusion : Our study highlights lichen simplex chronicus as the most common eczema affecting the lower legs and feet.

Background: The histologic diagnosis of early mycosis fungoides (MF) and its distinction from inflammatory dermatoses is challenging, owing to the overlap of several features. Aims: 1) To assess the efficacy of histologic criteria to diagnose early MF, 2) to study their utility in differentiating inflammatory mimics of MF. Methods: We retrospectively reviewed slides from 50 cases clinically/histologically suspicious for MF. The diagnoses were established based on response to treatment and follow-up. The slides were analyzed double-blinded by two observers independently. Twenty-eight histologic criteria were assessed and each criterion was graded. Univariate analysis was performed on the results. Results: There were 17 cases of MF and 33 of inflammatory dermatoses. Of the 28 criteria, the following 15 achieved significance on univariate analysis: disproportionate epidermotropism, tagging of lymphocytes along the basal layer, haloed lymphocytes, convoluted lymphocytes, Pautrier's abscesses, larger epidermal lymphocytes, wiry dermal collagen, absence of edema, eccrine infiltration, folliculotropism, follicular mucin, involvement of papillary and reticular dermis, monomorphous infiltrates, and atypia of dermal lymphocytes. The criteria that were 100% specific for MF included convoluted lymphocytes, eccrine infiltration, and follicular mucin. Absence of edema was 100% sensitive and specific in distinguishing MF from its inflammatory mimics. Conclusions: A combination of histologic patterns and cytology of lymphocytes is reliable in distinguishing MF from inflammatory dermatoses. No single criterion is effective in achieving this. Rather than merely recording the presence or absence of a criterion, grading each of them adds objectivity to the diagnosis.

Background: Atopic dermatitis is a major problem among the urban population and it can be aggravated or triggered by various allergens. Atopic patch test can be used as a diagnostic tool in characterizing patients with allergen triggered atopic dermatitis. Aims: 1. Patch testing to reproduce an eczematous reaction by applying prick test allergens under occlussion on intact skin. 2. To find the allergen associated with atopic dermatitis. 3. To find the specific allergen which causes or exacerbates atopic dermatitis in a given subject. Methods: Seventy five subjects with atopic dermatitis were included in our study and patch tests using prick test allergens were applied to the back. Reading was done after 48 and 72hours Results: Out of the 75 subjects tested, 47% showed positive reactions, parthenium accounted for 42% of all positive reactions. Conclusions: Epicutaneous application of prick test antigen on intact skin can produce a reaction. Parthenium is commonest allergen in Bangalore. Counselling based on patch test reports may help to reduce morbidity and improve quality of life.

Background: Topical therapies are the first line of treatment for patients with stable plaque psoriasis affecting a limited body surface area. Though in use for more than a decade, we could not find any reports of studies directly comparing calcipotriol and tazarotene. Aim: To evaluate the comparative efficacy and tolerability of calcipotriol and tazarotene in the treatment of stable plaque psoriasis. Methods: This was a prospective, right-left side intra-individual parallel 8-week study using calcipotriol 0.005% ointment applied twice daily (right side) versus tazarotene (left side) randomized to either 0.05% (group I) or 0.1% gel (group II) once daily in two groups, each of 10 patients. Efficacy was determined by the assessment of target psoriatic lesions under evaluation by using the severity scale (0-3) of erythema, scaling, and infiltration (ESI score). Evaluation was done at baseline (0 week), 4 weeks, and 8 weeks of treatment. At the end of 8 weeks, patients with more than 75% reduction in ESI score were considered to have marked improvement; 51% to 75%, moderate improvement; 26% to 50%, minimal improvement; and less than 25%, non-responders. Results: Seventeen patients (9 in group I, 8 in group II) completed the study. In group I, reduction in ESI score was significantly more at both 4 and 8 weeks on sides treated with calcipotriol, producing moderate-to-marked improvement (P < 0.05). In group II, improvement was comparable in lesions treated with either calcipotriol or tazarotene (0.1%) at the end of 4 and 8 weeks. Adverse effects noted were mild - in the form of burning, pruritus, and irritation - and were observed more often in the lesions treated with tazarotene as compared to those in the lesions treated with calcipotriol, but the difference was not statistically significant. However, none of the patients discontinued the therapy because of adverse events. Conclusion: Topical calcipotriol 0.005% ointment is more effective than tazarotene 0.05% gel; however, its efficacy is comparable to tazarotene 0.1% gel in the treatment of stable plaque psoriasis.

Background : Histamine is responsible for the wheal and flare reaction in various allergic conditions. Classical antihistamines are the drugs which block the H ₁ receptors and are widely used in various allergic conditions, whereas H ₂ blockers are mainly used for acid peptic disease. Although H ₁ receptor-mediated actions of histamine are primarily responsible for vasodilatation, vasopermeability, and itching, it has been observed that combined blocking of both H ₁ and H ₂ receptors may provide better relief. Aim: To compare the efficacy of levocetirizine (H ₁ blocker) versus levocetirizine and ranitidine (H ₂ blocker) in suppressing histamine-induced wheal. Methods: Fifteen volunteers were given a single dose of levocetirizine 5 mg on day 1 and a single dose of levocetirizine 5 mg with ranitidine 150 mg twice a day on day 7. A pretest was performed by intradermal histamine prick test. After administration of the drugs, the prick test was repeated at 1 hour, 2, 3, 6, and 24 hours, and the size of the wheal measured and statistically analyzed. Results: At 1 hour, there was no statistically significant difference in the wheal size between levocetirizine alone and the combination of levocetirizine and ranitidine. Levocetirizine with ranitidine resulted in statistically significant reduction of wheal size at 2, 3, 6, and 24 hours when compared with levocetirizine alone. Conclusion: H2 blocker potentiates the effects of an H1 blocker in suppressing histamine-induced wheal.

Neutrophilic dermatosis of the dorsal hands, a localized form of Sweet's syndrome, was recently described, and can be associated with several diseases including infections. Chronic hepatitis C virus infection has been proposed as a possible triggering factor. The authors present a case in which the clinical and laboratory workup diagnosis only revealed positive serology for hepatitis C virus. Although a cause-effect relation could not be proved, it might be advisable to include serology for this virus in the initial evaluation of patients with neutrophilic dermatosis.

We describe two cases of methotrexate toxicity occurring due to inappropriate self-medication with the drug. The first patient was a 57-year-old man with plaque-type psoriasis on intermittent methotrexate therapy. He discontinued his medications for 2 months and had exacerbation of psoriasis for which he self-medicated with methotrexate following which he developed ulceration of the psoriatic plaques accompanied by bone marrow suppression. The second patient was a 68-year-old man with chronic plaque-type psoriasis for 20 years and was being treated with intermittent methotrexate for 15 years. He also self medicated with oral methotrexate 15 mg daily for 7 days for exacerbation of psoriasis and developed ulceration of the psoriatic plaques with bone marrow suppression and evidence of gastrointestinal erosions.

A 10-month-old female presented with severe progressive wedge-shaped thickening and discoloration of all twenty nails. Further evaluations revealed palmoplantar keratoderma along with recurrent acral blisters causing residual crusted ulcers which were present during the past six months. Other findings included scalp kinky hair and dental caries. Past medical and family history had remarkable findings such as natal teeth and similar skin lesions in her older brother since his infancy. The patients' clinical presentations and history are compatible with pachyonychia congenita presenting with concomitant features of both subtypes 1 and 2.

Neu-Laxova syndrome is a rare lethal congenital disorder involving multiple systems. Intrauterine growth retardation, ichthyosis, microcephaly, abnormal facial findings, and limb contractures are its key features. We present a case of Neu-Laxova syndrome in a male appropriate for gestational age (AGA) newborn with characteristic features including ichthyosis, microcephaly, severe ectropion, rudimentary ears, eclabion, limb contractures, and hypoplastic genitalia. The patient was born at 38 weeks of gestation to consanguinous Turkish parents. The mother was a 20-year-old primi gravida with lack of prenatal follow-up. Therefore, the case was diagnosed postnatally, and he died 5 days later. Because of the autosomal recessive inheritance of Neu-Laxova syndrome, in countries with high rates of consanguineous marriage, such as Turkey, physicians have to know this syndrome, and serial prenatal ultrasound examinations with genetic counseling should be performed on pregnant women at high risk. To the best of our knowledge, this is the first case described in an AGA newborn.

Donovanosis is a slowly progressive, granulomatous ulcerative disease , caused by Klebsiella (Calymmatobacterium) granulomatis. The disease is known to persist for years together, leading to complications. A male patient aged 30 years with underlying HIV-2 infection presented to the department of STD with painful ulceration over the genital region of 5 months duration, with absence of penis. Tissue smear from the ulcer and histopathological examination revealed large histiocytes with intracellular Donovan bodies (Pund cell). A final diagnosis of donovanosis with auto-amputation of penis with HIV-2 infection was made. The old conventional medicines, viz. streptomycin, doxycycline and amoxycillin, were effective. Though HIV-2 infections are milder than HIV-1 infections in all aspects, donovanosis in this HIV-2 infected case presented with complications. However, since the CD4 count was 748 cells/cmm, the severity is attributed to the long standing nature and negligence by the patient, and not to possible immunodeficiency.

Clinicians often receive pathology reports proclaiming a spongiotic dermatitis with little in the form of a cogent differential diagnosis. In some cases, this is a natural consequence of the nonspecific nature of the reaction pattern due to matters of sampling error and/or lesional evolution. Further, some conditions are so synonymous in their histologic presentation that to choose one without mention of the other, purely on a histologic basis, may serve to inadvertently mislead the clinician. Despite the often significant histologic overlap amongst the varying spongiotic dermatitides, there are many subtle, yet detectable, features that may serve as clues to the pathogenetic process. Identification and subsequent communication of these features help to narrow the diagnostic possibilities with the ultimate goal of contributing to effective patient management. This article focuses on the histologic details of the spongiotic reaction pattern and presents some of the more common variations of its manifestation which, in conjunction with ancillary inflammatory elements, may help the histomorphologist to arrive at a more concise list of diagnostic possibilities.

Digital photography has virtually replaced conventional film photography as far as clinical imaging is concerned. Though most dermatologists are familiar with digital cameras, there is room for improvement in the quality of clinical images. We aim to give an overview of the basics of digital photography in relation to dermatology, which would be useful to a dermatologist in his or her future clinical practice.

Online reprint request (ORR) is the standard protocol to obtain the reprints (e-print/hard copy) using the internet (author's e-mail address) when the required literature is not available. The problem of higher cost of surface mail for the author and the reader, as well as the time taken to receive postal reprints, is overcome by ORR. This technique has its limitation in message failure, expiration of mail (e-mail decay), or journal not providing author's e-mail address. This article analyzes the available practical solution to overcome these barriers. This process facilitates the exchange of scientific information. In e-mail decay, reprint request can be sent in the following order: a) search and send to author's latest e-mail address, b) co-author's latest or affiliated institution's e-mail address, c) postal reprint request providing the requestor's e-mail address. This protocol can be practiced when library facilities or required literature is not available. Literature can be pooled and used for residency teaching programs, like group discussions, journal clubs, and e-learning exercises (teleeducation), to update the recent advances for practice and research.

Background: Activated T cells present in psoriatic plaques play a key role in the pathogenesis of psoriasis. CCR7 on T cells plays a crucial role in native immune response and formation of secondary lymphoid organ. Aims: To determine whether differential expression and functions of the CCR7 occur in psoriasis patients in China, we examined CCR7 on T cells from normal and psoriasis subjects. Methods: Skin specimens and T cells from 33 patients and 22 healthy controls were analyzed by immunohistology, flow cytometry, and RT-PCR. Results: Patients with psoriasis had a skewed distribution of T lymphocytes, with an increased level of CCR7 ⁺ T lymphocytes compared to healthy controls (P < 0.01) By flow cytometry, it was found that CCR7 was selectively, frequently, and functionally expressed on CD4 ⁺ (20.5±6.8%)but not on CD8 ⁺ (9.5±3.4%) T cells from patients with psoriasis, whereas this phenomenon was not seen in normal subjects. Through RT-PCR it was also found that CCR7 was highly expressed on T cells in patients with psoriasis than in healthy controls in the level of gene. Conclusions: Patients with psoriasis had a skewed distribution of T lymphocytes, with an increased level of CCR7 ⁺ T lymphocytes compared to healthy controls. CD4 ⁺ CCR7 ⁺ T cells had abnormal expression, which might induce protraction and persistence of psoriasis.

Background: Appendageal skin tumors belong to a heterogenous group of tumors with specific histopathology. The aim of this study is to determine the pattern of appendageal tumors in skin biopsies done in our department. Methods: This is a 3-year retrospective descriptive study of all patients who were diagnosed to have skin appendageal tumors in our department, and the diagnoses were confirmed by histopathology. The tumors were classified as eccrine, hair, sebaceous, and apocrine after a detailed examination of routine hematoxylin and eosin sections. Results: The total number of cases in the study was 33 - 10 males and 23 females. Tumors with eccrine differentiation constituted the maximum, 17 cases (51.5%); followed by tumors with hair differentiation, 12 cases (36.36%); tumors with sebaceous differentiation, 2 cases (6.06%); and apocrine tumors, 2 cases (6.06%). Syringoma constituted the commonest eccrine tumor, 14 cases (42.42%); while trichoepithelioma was the commonest hair tumor, 9 cases (27.27%). The other eccrine tumors were eccrine spiradenoma, 2 cases (6.06%); and nodular hidradenoma, 1 (3.03%). The other hair tumors were pilar cyst, 2 (6.06%); and pilomatricoma, 1 (3.03%). The sebaceous tumors constituted 2 cases (6.06%) of nevus sebaceous. Syringocystadenoma papilliferum, 1 (3.03%); and cylindroma, 1 (3.03%), constituted the apocrine tumors. Conclusions: Appendageal skin tumors are relatively uncommon. Histopathology is mandatory for the diagnosis. No tumor showed malignant change in this study.

Dermatitis artefacta is a disorder in which the skin is the target of self-inflicted injury. We report a case of dermatitis artefacta, in which the patient developed skin lesions, after taking each and every medication. Additionally he also had red coloured urine after taking certain group of medications, which, on further investigations, was found to be associated with glucose 6-phosphate dehydrogenase (G6PD) deficiency. This case illustrates the presence of factitious dermatitis and physical co-morbidity simultaneously, which was missed before psychiatric referral. Every symptom in a patient with a factitious disorder should not be labelled as feigned without a proper workup.