The deleritious effect of ultraviolet radiation on humans has increased the need for photoprotection. Sunscreens are widely used as photo protective agents. They are divided into chemical sunscreens which absorb high-energy ultraviolet rays and physical blockers which reflect or scatter light. Effectiveness of sunscreens depends upon sun protection factor and its substantivity. Clothing is also important for sun protection and its effectiveness is measured by Ultraviolet Protection Factor. There are many other agents with photo protective properties, which range from antioxidants to plant extracts to DNA repair enzymes. Usage of wide brimmed hats and sunglasses, avoidance of solar exposure at times of peak intensity, use of cover-up garments and sunscreen lotions are effective for photo protection of the skin.

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Background: Although the role of bacillus Calmette Guιrin (BCG) vaccine in the prevention of leprosy was hypothesized as early as 1939, its level of protective effect remained controversial. Aim: As a meta-analysis systematically combines the results from different studies, we summarize the protective effect of BCG vaccine in prevention of leprosy using meta-analytic procedures. Methods: Our search strategy included a computerized literature search, snowballing technique to identify potential studies, review of previously compiled lists of BCG studies and articles, contacting experts on BCG vaccination and manual search to locate articles in non-indexed journals. The present meta-analysis included 22 studies (6 trials, 2 cohort studies and 14 case-control studies) on the role of BCG vaccine in the prevention of leprosy. The random effects model as described by DerSimonian and Laird was used to summarize the effect measures. For each summarization, a Chi-square test of heterogeneity was estimated. To strengthen the viewpoint further additional information from the studies which were not included in meta-analysis, was also utilized. Results: The summary protective effects calculated from trials, cohort studies and case-control studies were 43 (27-55), 62 (53-69) and 58 (47-67)% respectively, which were statistically significant. These estimates confirmed the protective association between BCG vaccination and leprosy. Review of 29 studies focusing on the role of BCG vaccination in the prevention of leprosy revealed that not a single study reported a negative protective effect. Thirteen (44.8%) studies demonstrated greater than or equal to 50% efficacy/effectiveness. Conclusion: There is sufficient and convincing evidence of the protective effect of BCG vaccine against leprosy, as reflected from the meta-analysis and overall review of 29 studies of BCG vaccination and leprosy.

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Awareness of ultraviolet radiation-induced skin damage creates the need for the development of broad-spectrum, safe and cosmetically acceptable sunscreens. Being relatively inert, safe, stable and non-irritating, physical sunscreens are particularly useful for patients with sensitive skin who cannot tolerate chemical sunscreens. However, they form a thick visible pigment layer on the skin. To overcome this drawback, microfine oxides have been developed which made the sunscreens virtually transparent when applied on the skin. This article reviews the rationale for the comeback of physical sunscreens by analyzing data from various sources.

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Fumaric acid esters (FAE) are chemical compounds derived from the unsaturated dicarbonic acid fumaric acid. The usage of FAEs in treatment of psoriasis was introduced in the late 1950's. In the 1980s more standardized oral preparations of FAEs were developed containing dimethylfumarate(DMF) and salts of monoethylfumarate(MEF) as main compounds. In 1994, Fumaderm® an enteric-coated tablet containing DMF and calcium, magnesium, and zinc salts of MEF was approved for the treatment of psoriasis in Germany and since then has become the most commonly used systemic therapy in this country. Fumaric acids have been proven to be an effective therapy in patients with psoriasis even though the mechanisms of action are not completely understood. About 50-70% of the patients achieve PASI 75 improvement within four months of treatment and without any long-term toxicity, immunosuppressive effects, or increased risk of infection or malignancy. Tolerance is limited by gastrointestinal side effects and flushing of the skin. This article reviews pharmacokinetics, uses, contraindications, dosages, and side effects of treatment with FAEs.

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Background: Twenty percent azelaic acid gel is recommended as a topical treatment for acne due to its favorable profile. Aim: Our objective in this study was to evaluate the efficacy of 20% azelaic acid gel in the treatment of mild to moderate acne vulgaris. Methods: This was a double blind, randomized clinical trial. Sixty patients with mild to moderate acne vulgaris were selected randomly to receive either azelaic acid gel or the vehicle gel alone. Patients were followed up every 15 days for a period of 45 days. The number of lesions and the acne severity index (ASI) were recorded and compared using Student's t-test. Results: Total lesion count was reduced by 60.6% and 19.9% by azelaic acid gel and the placebo respectively (P =0.002). ASI was reduced by 65.2% and 21.3% by azelaic acid gel and the placebo respectively (P =0.001), i.e., azelaic acid gel was 3.06 times more effective than the placebo in reducing ASI. Conclusion: Azelaic acid gel can be used as an effective treatment in mild to moderate acne vulgaris.

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Background: During pregnancy profound immunologic, metabolic, endocrine and vascular changes occur, that are responsible for the changes of the skin and its appendages, both physiologic and pathologic. Aims: We undertook a clinical study to find out the frequency and pattern of skin changes in pregnant women. Methods: All consecutive pregnant women were included in the study. Results: A total of 607 pregnant women were included in this study. Of these, 303(49.9%) pregnant women were primigravida and 304(51.1%) were multigravida. Skin changes grouped into: physiological changes (all cases), specific dermatoses (22 cases) and other dermatoses affected by pregnancy (125 cases). Most common physiological changes were pigmentary alterations seen in 555 (91.4%) followed by striae seen in 484(79.7%) cases. Of the various specific dermatoses of pregnancy, pruritic urticarial papules and plaques of pregnancy (PUPPP) was the most common disorder (14 cases) followed by pruritus gravidarum (5 cases). The most common dermatoses affected by pregnancy were candidal vaginitis (17 cases), acne vulgaris (15 cases), skin tags (15 cases), eczemas (14 cases). Conclusion: This study brings into focus various skin changes during pregnancy in south India.

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Background: Minimal erythemal dose (MED) for narrow band-ultraviolet B radiation (NB-UVB) varies with race and skin type. The aim was to estimate the MED for NB-UVB and compare visual readings with those from a Dermaspectrometer^® in a north Indian patients as the available data is sparse. Methods: Forty one patients who visited the dermatology outpatient department were recruited for this study. Skin type was grouped as per Fitzpatrick skin type scale. Patients' upper backs were irradiated after applying a novel template with 8 windows of 2 x 2 cm each, with a test dose ladder of 250-1500 mJ/cm ² in a Waldmann (700K) TL-01chamber. MED and erythema index were read after 24 hours, the latter by using Dermaspectrometer^® . Results: Forty one patients (10 males, 31 females) with mean age of 30.5 (14-65) years were recruited. 23 patients were of skin type 5, 17 of type 4 and one of skin type 3. The estimated MEDs were 1000 mJ/cm ² in 17, 750 mJ/cm ² in 19, 1100 mJ/cm ² in four and 500 mJ/cm ² in one patient. The median and mode MED was 1000 mJ/cm ² .There was an exponential rise in the erythema index with increase in irradiation (17.18-26.25/ 250-1500 mJ/cm ² ). Student's t-test applied to detect differences between the visual and Dermaspectrometer^® readings was found to be statistically not significant. Conclusion: The estimated MED for NB-UVB varied from 500 to 1100 mJ/cm ² , the median MED being 1000 mJ/cm ² . The darker skin types did not have low MED while some patients with lighter skin type displayed lower MED. There was no significant difference in MED determined by visual and Dermaspectrometer® readings.

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Aleukemic leukemia cutis has always been a dermatological curiosity. It is a rare condition characterized by the infiltration of skin by leukemic cells before their appearance in the peripheral blood or bone marrow. A 20 year old man had presented with nodular swelling on the scalp of 6 months duration along with cervical lymphadenopathy. Biopsy and immunohistochemistry revealed myeloid sarcoma. The initial presentation was aleukemic and repeated peripheral blood counts and marrow examinations were normal. However, the outcome was fatal within 3 months of diagnosis of cutaneous lesions.

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The internet is increasingly being used to distribute knowledge in medicine in novel and unconventional ways. In this article, we give a brief introduction into the website www.derm101.com, which was founded by A. B. Ackerman for the purpose of teaching dermatology and dermatopathology. A clinical atlas, online books such as the 3rd edition of his volume "Histologic diagnosis of inflammatory skin diseases", works on clues and differential diagnoses in dermatopathology, a resource on therapeutic strategies in dermatology, a video lecture library on controversial issues in dermatology, the quarterly online journal Dermatopathology: Practical and Conceptual and much more can be found on derm101.com. The site is enriched with new contents biweekly and offers several interactive teaching devices. Currently, www.derm101.com is the most comprehensive online library of dermatology resources.

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Background: Pityriasis lichenoides is a papulosquamous disorder of unknown etiology with remissions and exacerbations. Histopathology helps greatly in the diagnosis of this condition. Aim: We studied clinical and histopathological features of pityriasis lichenoides in our patients. Methods: This is a 3-year retrospective and prospective, descriptive study of all patients clinically diagnosed as pityriasis lichenoides and confirmed by histopathology. All patients were studied clinically and histopathologically. Results: There were 51 (30 males and 21 females) cases of pityriasis lichenoides in the study period. The maximum number of cases, 14 (27.45%) were in their second decade of life. Pityriasis lichenoides chronica was diagnosed in 39 cases (76.47%) and pityriasis lichenoides et varioliformis acuta (PLEVA) in 12 cases (23.53%). Histopathologically, basal cell vacuolation and perivascular infiltrate were seen in all the cases. Exocytosis was seen in 45.1% of the cases. All the cases of PLEVA showed lymphocytic vasculitis albeit without fibrinoid deposition in the vessel walls. Conclusion: Pityriasis lichenoides is not a rare disorder. and is not a true lymphocytic vasculitis as blood vessel damage and fibrinoid deposition in the blood vessel walls were not seen in this study.

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Histiocytosis is a term applied to a group of rare disorders of the reticuloendothelial system. Eosinophilic granuloma, the most benign and localized of the three Langerhans cell histiocytosis entities, may be solitary or multiple. Eosinophilic granuloma can affect almost any bone, but commonly involves the mandible when the jaws are affected. Conventional treatment of LCH is with surgery, radiotherapy, chemotherapy and steroid injections, alone or in combination. Spontaneous regression of localized disease has also been reported. We report a six and a half-year-old patient with Langerhans cell histiocytosis - solitary eosinophilic granuloma of the mandible that initially regressed but rapidly recurred even after radical treatment and had a fatal outcome.

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Cutaneous involvement in renal disease is due to a host of factors ranging from metabolic disturbances to immunosuppressive drugs. Herein we report a series of six cases of renal failure with varied cutaneous manifestations ranging from infections to neoplasms due to prolonged immunosuppression. Our first case had cutaneous cryptococcosis where skin lesions gave a clue to the diagnosis of altered sensorium and underlying meningitis. The second case initially presented with florid warts and was treated successfully but later presented with an explosive recurrence of skin lesions due to malignant transformation. Our third case had basal cell carcinoma over the presternal region that was successfully treated with liquid nitrogen cryotherapy. Our fourth case had diabetic nephropathy that presented with septicemia and purpura fulminans. The last case had cutaneous manifestations of drug therapy because of heparin infusion. To conclude, cutaneous manifestations in patients with renal failure are varied and a high degree of suspicion is needed for early diagnosis and aggressive treatment to effectively combat mortality and morbidity.

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Background: Parthenium dermatitis is a major problem in urban and rural India. Patients with severe allergic rhinitis due to exposure to pollens of parthenium are reported to have parthenium specific IgE and IgG antibodies. Parthenium induces contact dermatitis by Type IV hypersensitivity and allergic rhinitis by Type-I hypersensitivity. Aims: The study was undertaken to detect Type-I and Type-IV hypersensitivity amongst patients with parthenium dermatitis. Methods: Fourteen patients with clinical features of parthenium dermatitis who patch tested positive to parthenium were included in the study. Patch testing was done by standard method and results interpreted as recommended by the ICDRG. Serum IgE was determined by chemiluminescence immuno assay system (CLIA). Prick testing was performed and interpreted by standard method. Results: Twelve out of the 14 patients included, showed a positive prick test. Serum IgE was elevated in all patients to varying degrees (mean IgE-1279.9 IU/ml; N - up to 100 IU/ml). Conclusion: The positive patch test, prick test and elevated serum IgE suggest that both Type-I and Type-IV hypersensitivity may play a role in the induction and perpetuation of parthenium dermatitis in most patients. To date, delayed hypersensitivity was thought to be solely responsible for parthenium dermatitis. This study suggests that a combined type-I and type IV hypersensitivity mechanisms may be operational.

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A 36-year-old young male with multiple heterosexual contacts presented with bilateral inguinal bubo and the classical "sign of groove". A diagnosis of lymphogranuloma venereum (LGV) was made and a three-week course of doxycycline was given. Lack of response prompted us to investigate further. A biopsy of the bubo was consistent with non-Hodgkin's lymphoma (NHL). Immunohistochemistry of the lymph node done at the Regional Cancer Center (RCC), Trivandrum, confirmed the diagnosis as NHL of diffuse large B-cell type. The second patient, a 32-year-old male with two unprotected heterosexual contacts presented with a left-sided inguinal bubo of six weeks duration. An empirical course of doxycycline was given even though investigations did not reveal any STI. Lack of response prompted us to do a lymph node biopsy, which was consistent with NHL, which later with immunohistochemistry was confirmed as NHL, diffuse large cell type. We are reporting here that the "sign of groove" is not specific for LGV as thought earlier, but can occur in NHL also.

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A 9-year-old female, presented with recurrent bilaterally symmetrically distributed flesh colored vegetative plaques, papules and nodules on trunk, and upper and lower extremities since 15 days. Investigations revealed anemia, hypoproteinemia, decreased albumin and positive D-xylose test. Pus swab and biopsy for culture sensitivity showed Enterococci species. Biopsy showed spongiotic psoriasiform dermatitis with subcorneal pustule. She fulfilled criteria for the diagnosis of blastomycosis-like pyoderma viz. presentation of large verrucous plaques with pustules and elevated border, pseudoepitheliomatous hyperplasia with abscess histologically and growth of one pathogenic bacterium on culture or tissue biopsy. She responded to long-term amoxicillin-clavulanic acid therapy.

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We herein describe a case of 55-year-old farmer, who presented with chronic non-healing ulcers over both shins of 4 years duration. Intravenous drug abuse was suspected due to inability to find any venous access and all peripheral veins being found thickened and fibrosed. There were multiple atrophic scars in linear distribution in all limbs as well as in both groins. In addition there were multiple discrete fibrous papules in linear distribution on both hands, which were more obvious on the left side. The patient denied abusing intravenous drugs. However, his relatives confirmed that he abused pentazocine for almost one year before his chronic pain in abdomen was treated by appendicectomy. With subsequent counseling, it was found that he continued to abuse pentazocine at times even after surgery leading to the non-healing of ulcers.

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