Vitiligo is a psychologically devastating condition. Topical therapy is employed as first-line treatment in localized vitiligo. Currently, several topical agents are available in many forms viz. methoxsalen (solution and cream), trioxsalen (solution), corticosteroids (gel, cream, ointment and solution) and calcineurin inhibitors (ointment and cream). Although topical therapy has an important position in vitiligo treatment, side-effects or poor efficacy affect their utility and patient compliance. Novel drug delivery strategies can play a pivotal role in improving the topical delivery of various drugs by enhancing their epidermal localization with a concomitant reduction in their side-effects and improving their effectiveness. The current review emphasizes the potential of various phospholipid based carriers viz. liposomes, transferosomes, ethosomes, lipid emulsions, solid lipid nanoparticles and organogels in optimizing and enhancing the topical delivery of anti-vitiligo agents, whilst reducing the side effects of drugs commonly used in its topical treatment.

'Invisible dermatoses' is a concept which has not received wide recognition, but is nevertheless very important both clinically and histologically. The term invisible dermatoses has been used in two contexts: a) Diseases, with out definite clinical features, and are therefore "invisible" to the clinician, but yet can be diagnosed by special investigations. b) Dermatoses which present with definite and obvious clinical features, but subtle or hidden histological features and are therefore "invisible" histologically. Diagnosis of such diseases represents a great challenge to both the dermatologist and dermatopathologist. This article discusses such diseases and offers clues and tools for their diagnosis. Diagnosis of such 'Invisible dermatoses' needs proper awareness, recognition of subtle features, special stains, special investigations such as immunofluorescence and histochemistry and proper clinicopathological correlation.

Background: Detergents are used by almost every household in the developed and developing world. Soap and most detergents are anionic surfactants and attack the horny layer of the skin and increase its permeability with little or no inflammatory change and may result in hand eczema, which is very distressing and incapacitating. Aim: To evaluate the irritant potential of common household detergents (laundry and dish wash) used by the Indian population using a 24-hour patch test and to convincingly educate the patients on the detergents less likely to cause irritation in the particular individual. Methods: Seventeen commonly used detergents found in Indian market were included in the study, of which, 12 were laundry detergents (powders - seven, bar soap - five) and five were dish wash detergents (powder - one, liquid - one, bar soap - three). The irritant potential of the 17 detergents were evaluated in 30 volunteers. Thirty microliters of each of the detergent bar solutions, distilled water (negative control), and 20% SDS (positive control) were applied to Finn chambers with a micropipette and occluded for 24 hours. Erythema, scaling, and edema were graded in comparison to the reaction at the negative control site (distilled water) for each volunteer separately. The scoring of erythema / dryness and wrinkling on a 0 - 4 point scale and edema on another 0 - 4 point scale was based on the Draize scale. The pH of each of the detergent solutions was determined using litmus papers (Indikrom papers from Qualigens fine chemicals). Results: The difference between detergents (F value) was significant for erythema / dryness and wrinkling (F = 3.374; p = 0.000), but not significant for edema (F = 1.297; p = 0.194). [Table 2] lists the means for erythema / dryness and wrinkling, and edema. The F value of the totals of the means for erythema / dryness and wrinkling and edema was significant (F = 2.495; p = 0.001). The pH of all the detergents was found to be alkaline except Pril utensil cleaner which tested acidic (pH 6). The positive control, 20% SDS also tested acidic (pH 6). Conclusion : Similar to patch testing in allergic contact dermatitis, 24-hour patch testing with detergent solutions (8% w/v), will educate the patient on what detergent to avoid. This may bring down the total medication requirement and frequent hospital consultations for these patients.

Background: Narrowband UVB therapy is presently one of the most effective therapies for generalized vitiligo. Many topical agents have been used in combination with narrowband UVB therapy to increase its efficacy in causing repigmentation in vitiligo. Placental extract is used topically usually in combination with sun exposure to cause repigmentation of vitiligo lesions. Aims: The present study aims to study whether the efficacy of narrowband UVB therapy would be enhanced by addition of topical placental extract to the treatment regimen. Methods: Ninety patients with vitiligo having more or less bilaterally symmetrical lesions on the face, trunk or limbs and receiving narrowband UVB therapy were enrolled for the study and instructed to apply topical placental extract (placentrex) lotion on their vitiligo lesions on the right side of the body. The other side of the body received narrowband UVB therapy alone and served as the control side. The extent of repigmentation achieved was assessed by VASI scoring and compared between the symmetrical lesions present on the two sides at monthly intervals and at the end of study period. Results: Seventy-eight patients with 218 symmetrically distributed lesions, excluding those present on the hands or feet, were evaluated for study results at the end of treatment period. The time to onset of repigmentation as well as the mean NB-UVB dosage required was the same on the two sides. The mean repigmentation achieved was 63% (VASI score of 3.69) on the right (placental extract) sided lesions in comparison with 62% (VASI score of 3.60) on the left (control) sided lesions. Greater than 90% repigmentation was achieved in 70 symmetrical lesions in 24 patients. Of these 70 lesions, 39 were located on the right side of the body while 31 belonged to the left side of the body. Conclusions: Addition of the topical placental extract was seen to have a modest but a statistically insignificant effect on the efficacy of NB-UVB therapy in causing repigmentation in vitiligo.

Background: Itchy folliculitis are pruritic, folliculo-papular lesions seen in human immunodeficiency virus (HIV)-infected patients. Previous studies have shown that it was impossible to clinically differentiate between eosinophilic folliculitis (EF) and infective folliculitis (IF). Also, attempts to suppress the intense itch of EF were ineffective. Aims: The present study is aimed at correlating clinical, histopathological and immunological features of itchy folliculitis in HIV patients along with their treatment. Methods: The present prospective study lasted for 36 months (September, 2005 to August, 2008) after informed consent, data on skin disorders, HIV status and CD4 count were obtained by physical examination, histopathological examination and laboratory methods. Results: Of 51 HIV-positive patients with itchy folliculitis, the predominant lesion was EF in 23 (45.1%) followed by bacterial folliculitis in 21 (41.2%), Pityrosporum folliculitis in five (9.8%) and Demodex folliculitis in two (3.9%) patients. The diagnosis was based on characteristic histopathological features and was also associated with microbiology confirmation wherever required. EF was associated with a lower mean CD4 count (180.58 ± 48.07 cells/mm ³ , P-value < 0.05), higher mean CD8 count (1675.42 ± 407.62 cells/mm3) and CD8/CD4 ratio of 9.27:1. There was significant reduction in lesions following specific treatment for the specific lesion identified. Conclusion: Clinically, it is impossible to differentiate itchy folliculitis and therefore it requires histopathological confirmation. Appropriate antimicrobial treatment for IF can be rapidly beneficial. The highly active antiretroviral therapy along with Isotretinoin therapy has shown marked reduction in the lesions of EF. Familiarity with these lesions may help in improving the quality of lives of the patients.

A 55-year-old lady presented with a large skin colored growth on her vulva since the age of 15 years, which gradually increased to the present state, with the development of a new lesion on her left thigh. There were no systemic symptoms. Biopsy followed by immunohistochemistry showed features consistent with a granular cell tumor.

Ellis-van Creveld (EVC) syndrome is a rare autosomal recessive congenital disorder characterized by chondrodysplasia and polydactyly, ectodermal dysplasia and congenital defects of the heart. We present here a case of a 16-year-old short-limbed dwarf with skeletal deformities and bilateral postaxial polydactyly, dysplastic nails and teeth, also having left-sided facial hemiatrophy. The diagnosis of EVC syndrome was made on the basis of clinical and radiological features. To the best of our knowledge, this is the first report of EVC syndrome with facial hemiatrophy in the medical literature from India.

Vulvar vestibular papillomatosis is considered an anatomical variant of the vulva. Recognition of this condition enables one to distinguish it from warts and therefore avoid unnecessary therapy. A 29-year-old lady presented to this clinic with a history of 'small growths' in her vulva since two years. Examination identified skin colored translucent papules; some of them appeared digitate and were seen on the vestibule and inner aspect of both labia minora. They were soft to feel and non-tender. Few lesions looked like elongated pearly penile papules. A provisional diagnosis of vestibular papillomatosis was made and a biopsy was done. It showed finger-like protrusions of loosely arranged subdermal tissue with blood vessels and which were covered by normal mucosal epithelium. No koilocytes were seen and the diagnosis of vestibular papillomatosis was confirmed. We believe that this is the first case report of vulvar vestibular papillomatosis in Indian dermatologic literature.

We report a case of 65-year-old male patient who presented with multiple erythematous papules coalescing to form a nodular mass over posterior aspect of right thigh of six months duration. His general and systemic examinations were within normal range except for right inguinal lymphadenopathy. Biopsy from the lesion was done, which showed diffuse infiltrate of nests of atypical melanocytes extending upto reticular dermis. Malignant cells were positive for S100 and human melanin black 45(HMB 45). Hence, a diagnosis of amelanotic melanoma (AM) - Clarke level IV and TNM stage III was reached. MRI of involved leg showed fungating soft tissue mass in the posterolateral aspect of right thigh and metastatic right inguinal adenopathy. Fine needle aspiration cytology (FNAC) from the right inguinal nodes confirmed metastasis of melanoma. The patient was referred to oncosurgery department for further management.

Three unusual clinical forms of sporotrichosis described in this paper will be a primer for the clinicians for an early diagnosis and treatment, especially in its unusual presentations. Case 1, a 52-year-old man, developed sporotrichosis over pre-existing facial nodulo-ulcerative basal cell carcinoma of seven-year duration, due to its contamination perhaps from topical herbal pastes and lymphocutaneous sporotrichosis over right hand/forearm from facial lesion/herbal paste. Case 2, a 25-year-old woman, presented with disseminated systemic-cutaneous, osteoarticular and possibly pleural (effusion) sporotrichosis. There was no laboratory evidence of tuberculosis and treatment with anti-tuberculosis drugs (ATT) did not benefit. Both these cases were diagnosed by histopathology/culture of S. schenckii from tissue specimens. Case 3, a 20-year-old girl, had multiple intensely pruritic, nodular lesions over/around left knee of two-year duration. She was diagnosed clinically as a case of prurigo nodularis and histologically as cutaneous tuberculosis, albeit, other laboratory investigations and treatment with ATT did not support the diagnosis. All the three patients responded well to saturated solution of potassium iodide (SSKI) therapy. A high clinical suspicion is important in early diagnosis and treatment to prevent chronicity and morbidity in these patients. SSKI is fairly safe and effective when itraconazole is not affordable/ available.

Phacomatosis cesioflammea is a rare condition defined by the simultaneous presence of both vascular and pigmentary nevus in the same patient. We report a case of a 4-year-old Indian female child who presented with diffuse dermal melanosis on the upper shoulders, upper anterior chest and lower back and extending to involve both sides of the arms and forearms, generalized port-wine stain on the back, shoulders and both upper limbs with sparing of the right palm. At places, the two types of lesions were superimposed on each other and were also present discretely on the back, but in close proximity to each other. There was the presence of melanosis bulbi on the right side of the eye. She was otherwise normal. She was clinically diagnosed as a case of phacomatosis pigmentovascularis cesioflammea. The nonallelic twin spotting phenomenon has been proposed in the pathogenesis of this disorder.