The aerospace environment is a dynamic interaction between man, machine and the environment. Skin diseases are not particularly significant aeromedically, yet they could permanently affect an aviator's status for continued flying duty. A number of dermatological conditions lend themselves to flying restrictions for the aviator. Aircrew and ground crew are exposed to a myriad of elements that could also adversely impact their flying status. Inflight stresses during flights as well as space travel could impact certain behaviors from a dermatological standpoint. With the advent of space tourism, dermatological issues would form an integral part of medical clearances. With limited literature available on this subject, the review article aims to sensitize the readers to the diverse interactions of dermatology with the aerospace environment.

Lichenoid tissue reaction or interface dermatitis embrace several clinical conditions, the prototype of which is lichen planus and its variants, drug induced lichenoid dermatitis, special forms of lichenoid dermatitis, lichenoid dermatitis in lupus erythematosus, and miscellaneous disorders showing lichenoid dermatitis, the salient clinical and histological features of which are described to facilitate their diagnosis. Background of lichenoid reaction pattern has been briefly outlined to enlighten those interested in this entity.

Epidermolysis bullosa, a genetically determined skin fragility disorder can severely incapacitate the life of the afflicted patient. Although the clinical features are multiple and varied, treatment still remains a major challenge. There have been major changes in the classification of the disease recently. Although there is still a long way to go, good nursing care, and gene therapy could possibly significantly alleviate the suffering of the patients in the future.

Pemphigus is a chronic epidermal immunobullous disease with potentially fatal outcome. The journey of literature on pemphigus in India has come a long way in last five decades. Pemphigus in Indian patients has unique genetic, clinical, and epidemiological differences from those in the Western countries. Corticosteroids remain the mainstay of treatment for pemphigus. Dexamethasone-cyclophosphamide pulse therapy has revolutionized the management of pemphigus in India and abroad for nearly 3 decades now. Corticosteroid-based treatment, along with adjuvants, has significantly brought down the high mortality rates that had been observed in precorticosteroid era. Present day research is largely based on elucidating the pathogenesis beyond the antidesmoglein antibodies, and newer diagnostic and treatment approaches. In this article, we review various aspects of literature on pemphigus in India, on Indians abroad, or literature from other countries that are considered relevant to the topic.

Bullous pemphigoid (BP) is a relatively common autoimmune vesicobullous disease encountered in India. It is a subepidermal bullous disorder most commonly seen in the elderly and manifests as tense blisters on urticarial base, predominantly over flexures, and is associated with pruritus. The diagnosis can be confirmed by histology, direct and indirect immunofluorescence. Several new diagnostic techniques have also been developed. Treatment of BP is based on the extent and rate of progression of the disease. Several topical and systemic anti-inflammatory and immunosuppressive agents have been used with variable results.

Background: Pemphigus, bullous pemphigoid, and epidermolysis bullosa acquisita are autoimmune diseases of skin associated with considerable morbidity and sometimes mortality. There is no cure for these diseases. Aims: To summarize evidence-based treatments for these diseases by performing a systematic review. Methods: The research protocol included the following steps: identification of databases to be searched, defining search strategy, searching the databases for references, first-stage screening of the abstracts, second-stage screening of full texts of articles identified after the first-stage screening, data extraction from the identified articles after second-stage screening, quality appraisal of the studies using the Delphi list, and summarizing the findings. Results: No randomized controlled trials of interventions in pemphigus vegetans, pemphigus erythematosus, and epidermolysis bullosa acquisita could be found. After the second-stage screening, 12 randomized controlled trials were analyzed, which included patients with pemphigus vulgaris or pemphigus vulgaris and pemphigus foliaceus, and 7 which included patients with bullous pemphigoid. Conclusions: Number of high-quality randomized controlled trials conducted on pemphigus and bullous pemphigoid is small. Oral corticosteroid along with a steroid-sparing agent appears to be the most effective treatment for pemphigus. Azathioprine may be most effective as a steroid-sparing agent. Topical corticosteroid therapy (as studied) is effective for bullous pemphigoid and appears to be superior to oral corticosteroid for extensive disease. Some suggestions about future research are made.

Background: The neonatal period is generally regarded as the first 28 days of extrauterine life. Skin disorders are commonly seen in the neonatal period, most of which are transient and limited to the first days or weeks of life. In spite of being so frequent, these transient conditions usually escape dermatologist's observations, and consequently few have been studied. Aims: The study was designed to identify the dermatoses in the first 72 h of life; to report the relationship among the most common dermatoses with the newborn's features; and to verify how often dermatoses are reported by the neonatologist. Methods: The authors carried out a cross-sectional study on newborn's dermatoses in a brazilian public hospital, including 203 healthy neonates, until 72 h of age, with skin disorders. Results: Out of 34 different skin diagnosed conditions, hypertrichosis lanuginosa, Mongolian spot, sebaceous hyperplasia, epidermal hyperpigmentation, erythema toxicum, and salmon patch were the most frequent ones. The dermatoses with statistical significance were: Mongolian spot and epidermal hyperpigmentation with the non-white newborns; erythema toxicum and cutis marmorata with the white newborns; salmon patch with the female sex; physiologic desquamation with the cesarean section; acrocyanosis with the first pregnancy birth and Bohn's nodules with the vaginal delivery. Conclusions: Thirty-four different types of dermatological alterations were identified in the healthy newborn within 3 days of life at the Maternity School of the Federal University of Rio de Janeiro. Underreporting of dermatoses with serious medical significance shows the importance of a dermatologist in the neonatal unit of a hospital.

Background: There is a clear association between autoimmune thyroiditis (AT) and chronic urticaria/angioedema (CUA). However, not all patients with AT demonstrate urticaria. Aims: The aim of the study was to investigate in which patients with AT did CUA become a problem. A sensitive inflammation marker, neopterine (NP) was used to confirm whether the severity of inflammation in the thyroid gland was responsible for urticaria or not. Methods: Neopterine levels were assessed in patients with AT with urticaria and without urticaria. Furthermore, levels were compared in relation to pre and post levothyroxine treatment. Twenty-seven patients with urticaria (Group 1) and 28 patients without urticaria (Group 2) were enrolled in the study. A course of levothyroxine treatment was given to all patients, and urine neopterine levels before and after the trial were obtained. Results: All patients completed the trial. Mean age in Group 1 and Group 2 was similar (35.70 ± 10.86 years and 38.36 ± 10.38 years, respectively) (P=0.358). Pre-treatment urine neopterine levels were significantly higher in Group 1 (P=0.012). Post-treatment levels decreased in each group, as expected. However, the decrease in the neopterine level was insignificant in the patients of Group 2 (P=0.282). In Group 1, a significant decrease in post-treatment neopterine levels (P=0.015) was associated with the remission of urticaria. Conclusion: In patients with CUA and AT, pre-treatment elevated levels of NP, and its decrease with levothyroxine treatment along with symptomatic relief in urticaria, may be evidence of the relationship between the degree of inflammation in thyroid and presence of urticaria.

Background: Even though seborrheic keratoses (SK) have been well characterized clinically and histopathologically, data regarding clinical and dermoscopic correlation of different types of SK are inadequate. Aims: We carried out a study to establish any correlation between the clinical and dermoscopic appearance of SK and its variants. Methods: This was a descriptive study conducted in the Department of Dermatology, a tertiary care institute, from August 2008 to June 2010. Patients with SK were evaluated with respect to age, sex, age of onset, duration, site of lesions, number of lesions, and morphology. Dermoscopy was performed in all cases. Results: A total of 250 cases of SK were recruited. A male-to-female ratio was 1:1.04. The most common age group affected by SK was 60 years and above (40%). The most common clinical variant was common seborrheic keratosis (CSK) (60%). Comedo-like openings (CL) (80%), fissures and ridges (FR) (52%), and sharp demarcation (SD) (83%) were consistent finding on dermoscopy in CSK. Dermatosis papulosa nigra (DPN) and pedunculated seborrheic keratoses (PSK) had characteristic CL and FR in both of them. Fingerprint (FP) (55%) and network-like (NL) (88%) structures were commonly seen in flat SK. Stucco keratoses demonstrated SD (100%) and NL structures (100%). Conclusions: The most common clinical variant of SK was CSK, followed by DPN, PSK, Flat SK, and stucco keratoses. Dermoscopic findings were consistent with those described in the literature.

Background: Alopecia areata (AA) is the most common cause of localized, non-scarring alopecia. Stress and other psychological factors have been implicated in the causation of the disease, and it is also found to alter the course of the disease process. Unfortunately no one has studied the impact of AA on the quality of life, which includes the social life of the patients. Aim: To study the clinical profile and impact of alopecia areata on the quality of life, including the social life of adult patients with severe forms of the disease. Methods: The present study determined the clinical pattern of AA and its impact on the quality of life (QOL) in all the patients with severe forms of alopecia areata attending the Dermatology Outpatient Department. Results: The male : female ratio was 1.86 : 1. Most (58.03%) of the patients were between 21 and 40 years of age. Almost 40% of the patients had associated systemic disease or other dermatological disorders. A family history of AA was found in 593 (20.02%) of the patients. Nail changes were observed in 297 (10%) of the patients. There were significant differences between the mean Dermatology Life Quality Index (DLQI) score in cases with severe forms of AA and controls ( p0 < 0.001). Conclusions: Severe forms of alopecia areata had a major impact on the psychosocial well-being of the patients. These individuals had to be treated early, and they required more than just prescription drugs. Educational and psychological support in addition to medical therapy for AA could improve their long-term physical outcomes.

A middle-aged hypertensive male, with a fatty liver and chronic alcohol intake, relocated to a high altitude of 2100 m above sea level; in the first winter season, he developed bluish skin lesions over the tip of the nose, margins of both ear lobes, both knees, and subungual location. Systemic examination was unremarkable. Skin biopsy showed thrombi in dermal vessels without any evidence of vasculitis; immunofluorescence was negative. Investigations revealed mild elevation in plasma homocysteine levels, weakly positive antinuclear antibodies and elevated antiphospholipid antibodies, methylene tetrahydrofolate reductase C677T heterozygosity, and protein S deficiency. The patient received prednisolone for 2 weeks, aspirin and pentoxyphylline for 3 months, and continues to be on folic acid and vitamin B6. After 3 months, antiphospholipid antibodies and antinuclear antibody levels were normal. Isolated distal cutaneous thrombosis is an uncommon entity and precipitation by extreme cold in a hypertensive male with three thrombophilic states - one transient, one hereditary, and one acquired - is fascinating.

Generalized eruptive histiocytosis (GEH) is a rare cutaneous histiocytosis that mainly affects adults and presents with multiple symmetric papules on face, trunk, and proximal extremities. GEH is included in type IIa (histiocytes involving cells of dermal dendrocyte lineage) of histiocytic disorders. Clinical and pathological correlations are required for differentiating GEH from other histiocytic disorders and from lepromatous leprosy which clinically mimic GEH and is prevalent in India. We report a case of a middle-aged woman who presented with generalized asymptomatic papules and nodules and was treated for leprosy but was finally diagnosed to have GEH after clinical, histopathological, and immunohistochemical correlation. Furthermore, the newer lesions also showed features of progressive nodular histiocytosis.

Ectodermal dysplasia-skin fragility (EDSF) syndrome is a rare and first described inherited disorder of desmosomes. It occurs due to loss-of-function mutations in PKP1 gene resulting in poorly formed desmosomes and loss of desmosomal and epidermal integrity. We report a case of a 2-year-old Indian male child who presented with palmoplantar hyperkeratosis with fissuring, short, sparse, and easily pluckable scalp hair, nail dystrophy, and multiple erosions over the skin. Skin biopsy showed epidermal hyperplasia with widening of intercellular spaces. His developmental milestones were delayed but intelligence was normal. Echocardiography, X-ray chest, and electrocardiogram were normal. Very few cases of this syndrome have been reported in the literature. We consider this as the first case report from India.

Congenital melanocytic nevus (CMN) may rarely regress which may also be associated with a halo or vitiligo. We describe a 10-year-old girl who presented with CMN on the left leg since birth, which recently started to regress spontaneously with associated depigmentation in the lesion and at a distant site. Dermoscopy performed at different sites of the regressing lesion demonstrated loss of epidermal pigments first followed by loss of dermal pigments. Histopathology and Masson-Fontana stain demonstrated lymphocytic infiltration and loss of pigment production in the regressing area. Immunohistochemistry staining (S100 and HMB-45), however, showed that nevus cells were present in the regressing areas.

Background: Studies on the interaction of pemphigus and pregnancy are limited to case reports and small case series. Pregnancy is not rare in Iranian pemphigus patients due to lower age at onset of the disease. Aim: We sought to investigate the outcome of pregnancy and the course of pemphigus in pemphigus patients in a retrospective study. Methods: The files of 779 pemphigus women younger than 50 presenting to our center from 1984 till 2006 were examined for any mention of pregnancy. Data related to outcome of pregnancy and the course of the disease were collected. Results: Sixty-six patients with a history of pregnancy were identified. Forty-eight known pemphigus patients experienced one or more pregnancies during their disease (total pregnancy number: 52). The course of pemphigus was as follows in this group: 28 cases (54%) of exacerbation, 15 cases (31%) with no alteration, and 9 cases (17%) showing improvement. The rate of abortion was 9.6% (5 cases). In 18 cases, the disease had started during pregnancy, 2 of them (11%) ended in an abortion. Overall, postpartum flare was seen in 33 cases (47.1%). Conclusion: Pemphigus may be exacerbated during or after pregnancy, but often to a mild degree. Although the rate of stillbirth was not as high as previously reported, the rate of abortion was considerable. Pregnancy may have an uneventful course, especially in patients in clinical remission; nevertheless, careful monitoring of the high risk mother and fetus is mandatory.

Pellagra is a niacin deficiency disorder characterized clinically by diarrhea, dermatitis, and dementia. However, few drugs also cause pellagroid dermatitis. Recently, we encountered two cases of pellagroid dermatitis; both were on second line of antituberculosis drugs. Case 1 was of multidrug-resistant pulmonary tuberculosis. Patient was on ethionamide since one year before developing pellagroid dermatitis. Case 2 was of central nervous system tuberculoma and was on second line of antitubercular drugs. This patient was on ethionamide and isoniazid (INH) since six months before developing pellagroid dermatitis. This patient had previously taken first line of antituberculous therapy, inclusive of INH, for 1 year without any dermatitis. The skin lesions in both patients were symmetric hyperpigmented thickened plaques with prominent skin markings resembling lichen simplex chronicus. Nicotinamide 300 mg in three divided doses healed the lesions completely within 4 weeks and 3 weeks in first and second patient, respectively.

Dissemination of primary cutaneous nocardiosis is a rare event. A 37-year-old man working as farmer presented with multiple painful suppurative nodular and ulcerative skin lesions over left lower extremities, in a linear pattern, with duration of five months and single painful nodule over right elbow since last three months. We found the presence of beaded filamentous bacteria in Gram stain smear and partial acid fast stain, from the smear taken from pus. Patient responded well to cotrimoxazole therapy. Hence, we confirm our diagnosis of sporotrichoid pattern of cutaneous nocardiosis with dissemination to other cutaneous area.