Vitiligo, an autoimmune disorder characterized by localized and / or generalized depigmentation of the skin and / or mucous membranes, is a well-recognized entity. The imperatives of its epidemiology both in rural India and in global reckoning have been highlighted frequently. Its morphology is striking and is characterized by asymptomatic ivory / chalky white macule(s) that may be frequently surrounded by a prominent pigmented border, the 'trichrome vitiligo'. However vitiligo may have morphological variations in the form of: trichrome, quadri-chrome, penta-chrome, blue and inflammatory vitiligo. Its current topographical classification into segmental, zosteriform and nonsegmental, areata, vulgaris, acrofacialis and mucosal represent its well acclaimed presentations. Its adult and childhood onset is well appreciated as also its presentation in males and females. Occasionally, it may be possible to identify triggering factors. Vitiligo may be associated with cutaneous, ocular and systemic disorders, the details of which are discussed in this article.

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Background : Recent clinical and animal experimental studies postulate that the pathogenetic mechanisms of vitiligo could be of systemic origin as vitiligo is associated with ocular and auditory abnormalities as well as other autoimmune disorders.Hence, we studied genetic factors, systemic associations, ocular and auditory abnormalities of vitiligo. Methods: The study group included 150 new cases of various types of vitiligo. One hundred age- and sex-matched nonvitiligo cases were included as controls in the study. A complete family history was taken for all patients. Examination was carried out taking note of the type of vitiligo and approximate percentage of body surface involved. All relevant laboratory investigations, a thorough audiological examination including pure tone audiometry and a complete ophthalmologic examination were carried out in all patients and controls. Statistical analysis was done using the Chi square test. Results: Fifty-four vitiligo patients (36%) had a family history of vitiligo. Anemia was present in 30 (20%) vitiligo patients but only in five (5%) controls, a difference that was statistically significant (c² = 15.8, P < 0.001). Diabetes mellitus was present in 24 (16%) vitiligo patients and only 2 (2%) of controls (Chi square, c² = 12.4, P < 0.001). Hypothyroidism and alopecia areata were present in 18 (12%) and 11 (7.4%) vitiligo patients respectively and none of the controls. Hypoacusis was seen in 30 (20%) vitiligo patients and two (2%) controls (c² = 8.19, P < 0.005). Twenty-four vitiligo patients (16%) and five controls (5%) had specific ocular abnormalities like uveitis, iris and retinal pigmentary abnormalities (c² = 7.39, P < 0.001). Conclusion: This study demonstrates statistically significant clinical evidence confirming that vitiligo is a part of systemic autoimmune process.

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Background: Chromoblastomycosis is a chronic fungal infection caused by several pigmented fungi commonly seen in tropical and subtropical climates. Aim: To evaluate the epidemiologic, clinical and pathological characteristics of chromoblastomycosis in our patients. Methods: This retrospective and prospective study was conducted at the Manipal Teaching Hospital, Pokhara, Nepal. Clinical features and histopathology of all the cases diagnosed as chromoblastomycosis during the last eight years were studied. Results: A total of 13 cases of chromoblastomycosis were diagnosed during the period of 1999 - 2006. The disease was seen predominantly in middle-aged male farmers and those from rural areas. The lesions commonly involved the lower extremity and were single or multiple in number. They clinically presented as verrucous or nodular growths. Out of these 13 cases, three were diagnosed clinically as squamous cell carcinoma and one as psoriasis. The histopathological features included sclerotic bodies in 12 cases (92%), microabscess formation in 10 cases (76.9%), pseudoepitheliomatous hyperplasia in nine cases (69.2%) and granuloma in eight cases (61.5%). Conclusion: Farming is the commonest occupation in patients with chromoblastomycosis. Early histological diagnosis helps in effective management of the condition.

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Background: The incidence of uncomplicated psoriasis is 1-3% in the general population. Arthritis is found in increased frequency in psoriatic patients and its incidence is estimated to be 5-7%. Aim: To assess the prevalence of arthritis in psoriatic patients. Methods: Four hundred and seventy-two psoriatic patients were enrolled in the study out of which 40 patients had (psoriatic) arthropathy (PsA). Severity of psoriasis was assessed by the psoriasis area and severity index (PASI). Routine blood investigations were carried out along with radiological investigations. Results: Forty percent of the 40 PsA patients were in the age group of 51-60 years. Seven patients out of the 40 (17.5%) psoriatic arthropathic (PsA) patients had a family history of psoriasis. Nail involvement was observed in 37 cases (92.5%). Rheumatoid factor was present in five out of the 40 (12.5%) PsA patients. Serum uric acid levels were above normal in eighteen out of the 40 (45%) PsA patients. Asymmetric oligoarthropathy was the most commonly observed feature in 42.5% of the 40 PsA patients. Narrowing of joint spaces and erosions were observed in 62.5% and 45% of the 40 PsA patients. Conclusion: There is an association between the duration of skin lesions and duration of arthropathy. Similarly the PASI score is also directly related with arthropathy.

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Background: Efficacy of topical methotrexate in psoriasis is limited by its penetration. Aims: The study involved the preparation of niosomal methotrexate in chitosan gel and to test the same for irritation and sensitization on healthy human volunteers followed by assessing the efficacy of the gel through double-blind placebo-controlled study on psoriasis patients and also comparing its efficacy with a marketed methotrexate gel. Methods: The methotrexate niosomes were prepared by lipid layer hydration method. The characterized niosomes were incorporated in chitosan gel. The gels were tested on 10 human volunteers to check for irritation and skin sensitivity by human repeated insult patch test (HRIPT). The formulations were assessed for efficacy by double-blind placebo-controlled study in 10 psoriasis patients for each formulation. The efficacy was calculated by psoriasis area and severity index scoring method. The global score was used to assess the progress of the disease. Results: The HRIPT test did not produce any significant irritation or sensitization on healthy human volunteers. The placebo and marketed gels were compared with niosomal methotrexate gel. At Week 12, with niosomal methotrexate gel, there was reduction in total score from 6.2378±1.4857 to 2.0023±0.1371. Conclusion: These results suggest that niosomal methotrexate gel is more efficacious than placebo and marketed methotrexate gel.

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A 48-year-old male patient presented to Skin and VD outpatient with multiple granulomatous growths of different sizes all over the body, including numerous subcutaneous swellings mimicking lipomas of 2 years duration. Two and half years back he was operated for a polypoidal growth of left nostril with subsequent recurrence. Fine needle aspiration cytology and histopathology of the cutaneous lesion confirmed the diagnosis as rhinosporidiosis. We report this rare case of disseminated cutaneous rhinosporidiosis.

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Background: Although acute radiation dermatitis (ARD) is a common side-effect of radiotherapy (RT), currently there is no general consensus about its prevention or treatment of choice. Aims: The purpose of this study was to investigate whether prophylactic use of topical betamethasone 0.1% can prevent ARD caused by chest wall irradiation. Methods: Fifty-one patients who underwent modified radical mastectomy for breast cancer and were going to receive RT, were randomly assigned to receive topical betamethasone 0.1%, petrolatum or none during RT. The frequency and severity of ARD (measured using Radiation Therapy Oncology Group acute radiation morbidity scoring criteria) were recorded at the end of each week during RT and two weeks after its completion. Clinical outcomes were analyzed by relevant statistical methods. Results: All patients developed some degree of ARD, the frequency and severity of which increased with time and reached the maximum at the end of the seventh week for all groups. Patients receiving betamethasone had less severe ARD than the other two groups throughout the course of the study, but this difference was significant only at the end of the third week (p =0.027). No significant difference was observed between the petrolatum and control arms. Conclusion: Prophylactic and ongoing use of topical betamethasone 0.1% during chest wall RT for breast cancer delays occurrence of ARD but does not prevent it. Petrolatum has no effect on the prevention of ARD in these patients.

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A 65-year-old male presented with right hemiparesis and skin lesions. On examination, the patient had multiple, discrete, skin-colored papules on the neck and upper chest with wrinkling of the skin. The lateral part of the trunk and medial aspect of both upper arms showed atrophic plaques. A computerized tomography scan of the head showed dilatation of the basilar artery with a frontoparietal infarct. Funduscopic examination showed characteristic angioid streaks. Skin biopsy of the papule and atrophic plaques showed epidermal atrophy, calcium deposits in the mid-dermis and basophilic clumped and fragmented elastic fibers in the mid- and lower dermis, all findings consistent with pseudoxanthoma elasticum. We are reporting here a case of pseudoxanthoma elasticum with cerebrovascular accident.

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Rhinosporidiosis is a chronic granulomatous disease of the mucocutaneous tissue, which clinically presents as polypoidal growths. Cutaneous lesions are infrequent and are generally associated with mucosal lesions. We present a case of cutaneous rhinosporidiosis in association with recurrent nasopharyngeal rhinosporidiosis in a 65-year-old male patient. He presented with dysphagia for solid foods and skin growth on the left side of jaw of 2 years duration. Histopathology of cutaneous and nasopharyngeal lesions revealed numerous thick walled sporangia in a vascular connective tissue along with a granulomatous inflammation confirming the diagnosis of cutaneous and nasopharyngeal rhinosporidiosis. Endoscopic removal of nasopharyngeal polyp was done and he was started on dapsone therapy.

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A case of mucocutaneous nasal histoplasmosis in an immunocompetent host is described below. A 30-year-old male had a broadened nose with swelling and repeated blockage of nasal passages for the past six months. Diagnosis was made on the basis of histological demonstration of characteristic yeast cells of Histoplasma capsulatum var. capsulatum occurring within histiocytes and extracellularly in stained smears of fine needle aspirates and biopsy from the lesions in ala of the nose and perioral region. The patient showed appreciable regression of lesions after three weeks of itraconazole therapy but was not available for re-assessment.

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Background: Atopic dermatitis is a chronic, relapsing disorder associated with significant morbidity. Growth retardation is known to occur in children affected with atopic dermatitis. However, there is not enough Indian data for this disorder. Aims: We conducted a longitudinal study to look for the effect of atopic dermatitis on growth attainment of Indian preschool children. Methods: The growth patterns of 62 children, aged 3-5 years and suffering from atopic dermatitis were studied in terms of body weight, height and head circumference. Sixty-eight normal healthy children matched for age, sex and socioeconomic status were taken as controls. Every child was followed up at intervals of three months following a mixed longitudinal study design for the duration of one year. Severity of the disease was determined by the scoring atopic dermatitis (SCORAD) index. Results: Growth velocities were lower in patients than in controls. Mean changes in body weight of patients of both sexes showed close similarity to controls. Mean values for height and head circumference were found to be significantly lower in girls than in the girls of the control group at majority of the age levels. In contrast, in boys, these values for the patients remained comparable or higher than in the boys of the control group at some of the ages. Girls had comparatively more severe disease than boys and they had lower values than boys for all the growth parameters assessed. Conclusion: Growth retardation was observed among children with a more severe form of the disease. Height of the affected children was compromised mostly, though a tendency for catch-up growth was observed. Severe forms of atopic dermatitis may impair a child's linear growth temporarily.

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Cutaneous sporotrichosis, a subcutaneous mycotic infection is caused by the saprophytic, dimorphic fungus Sporothrix schenckii. It commonly presents as lymphocutaneous or fixed cutaneous lesions involving the upper extremities with facial lesions being seen more often in children. The lesions are polymorphic. The therapeutic response to saturated solution of potassium iodide is almost diagnostic. We describe a culture-proven case of cutaneous sporotrichosis of the face mimicking lupus vulgaris initially and basal cell carcinoma later, who did not tolerate potassium iodide and failed to respond to treatment with fluconazole. The patient had reactivation of infection following an infiltration of the scar with triamcinolone acetonide injection. Various other aspects of these unusual phenomena are also discussed.

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We are reporting a rare case of primary mucocutaneous histoplasmosis. A 47-year-old male with a part-time job of rearing pigeons presented with a non-healing oral ulcer with no associated systemic symptoms. Differential diagnosis of oral ulcerative lichen planus, squamous cell carcinoma and mucocutaneous leishmaniasis was considered. Histopathology showed multiple organisms with a peripheral halo, stained strongly with Gomori methenamine silver stain.

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