Leprosy is unique in terms of the nature of the causative organism (Mycobacterium leprae), the chronicity of the disease, its prolonged treatment and the definitions of "cure" and "relapse." The principal mode of assessing the efficacy of therapeutic regimens in leprosy is the "relapse rate." There are wide variations in estimates of relapse rates after the World Health Organization (WHO) multidrug therapy in different regions. The important predisposing factors for relapse include the presence of "persister" bacilli, monotherapy, inadequate/irregular therapy, presence of multiple skin lesions/thickened nerves and lepromin negativity. The conventional methods of confirming activity or relapse in an infectious disease (demonstration and/or culture of the etiologic agent) have limited utility in leprosy because of the difficulty in demonstrating bacilli in paucibacillary (PB) cases and absence of a method of in vitro cultivation of M. leprae. Bacteriological parameters are useful in multibacillary (MB) leprosy, whereas in PB leprosy, the criteria for relapse depend primarily on clinical features. Although there are no widely available serologic tests for leprosy other than in a research setting, various immunological tests may be useful for monitoring patients on chemotherapy as well as for confirming suspected cases of relapse. The main differential diagnoses for relapse are reversal reactions, erythema nodosum leprosum and reactivation/resistance/reinfection. The most reliable criteria for making an accurate diagnosis of relapse include clinical, bacteriological and therapeutic criteria. Additional ones that may be used, depending on the setting, are histopathological and serologic criteria. Relapsed cases of leprosy should be identified and put back on chemotherapy as soon as possible to prevent further disability and transmission of infection. Factors that should be considered in choosing an appropriate regimen are the type of leprosy (PB or MB), previous treatment and drug resistance. Occasionally, clinicians may need to use their judgement to modify the standard WHO treatment regimens according to the scenario in each patient.

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Histoplasmosis, also called as Darling's disease, is caused by the dimorphic fungus, Histoplasma capsulatum. In India, several cases of histoplasmosis have been reported since 1954, but in only a few cases could the diagnosis be confirmed by fungal culture. Disseminated histoplasmosis in adults is often associated with immunosuppression, as in human immunodeficiency virus (HIV) infection. Oral lesions are seen in 30-50% of the patients. Here, we are reporting two histoplasmosis cases, one with disseminated histoplasmosis with extensive skin and oral lesions in a known HIV-positive patient and the second case presenting with ulcer of the tongue, found to be HIV positive on investigation. It is important to consider histoplasmosis as one of the differential diagnosis of oral lesions in HIV-infected individuals.

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Background: Very few studies have been performed to evaluate the efficacy and safety of narrow-band ultraviolet B (NBUVB) therapy in Indian patients with vitiligo and are of small sample size. Aims: The purpose of this study is to know the efficacy and safety of NBUVB in 150 vitiligo patients of various age groups. Methods: One hundred fifty patients (69 males, 81 females), aged 3-70 years, with vitiligo were treated twice weekly with NBUVB. The starting dose was 250 mJ/cm ² in adults and 150 mJ/cm ² in children, with 20% dose increments at each subsequent visit given for a maximum period of 1 year and were followed-up for 6 months for stability of repigmentation. Statistical methods were employed to establish the relation between the response and the number of exposures, duration of treatment, cumulative dose and the compliance. Results: Analysis of our study showed that a majority of our cases, about 73, achieved 25-75% repigmentation, with an average of 51 ± 19 exposures, 51 had <25% repigmentation, with an average of 19 ± 11 exposures and 26 had >75% repigmentation, with an average of 74 ± 24 exposures. Good response to therapy was directly associated with good compliance, more number of exposures and increasing cumulative dose, which was statistically significant (P < 0.01). Adverse effects were minimal. Only three patients developed depigmentation of repigmented sites during follow-up. Conclusion: Our study proves that NBUVB therapy is an effective and safe tool in the management of vitiligo, with good stability of repigmentation and cosmetic appearance.

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Background: Cutaneous fungal infections are common in Tehran, Iran, and causative organisms include dermatophytes, yeasts and non-dermatophyte molds. The prevalence of superficial mycosis infections has risen to such a level that skin mycoses now affect more than 20-25% of the world's population, making them the most frequent form of infection. Aims: Our aim was to determine the prevalence of superficial cutaneous fungal infections especially dermatophytosis in our Medical Mycology Laboratory in the Pasteur Institute of Iran, Tehran. Methods: A total of 17,573 specimens were collected from clinically suspected tinea corporis, tinea cruris, tinea capitis, tinea faciei, tinea pedis, tinea manuum and finger and toe onychomycosis from 2000 to 2005. Patients were referred to our laboratory for direct examination, fungal culture and identification. The incidence of each species was thus calculated. Results: Dermatophytes remain the most commonly isolated fungal organisms, except from clinically suspected finger onychomycosis, in which case Candida species comprise >7% of the isolates. Epidermophyton floccosum remains the most prevalent fungal pathogen and increased incidence of this species was observed in tinea cruris. Trichophyton tonsurans continues to increase in incidence. Conclusion: This study identifies the epidemiologic trends and the predominant organisms causing dermatophytosis in Tehran, Iran. These data can be used to ascertain the past and present trends in incidence, predict the adequacy of our current pharmacologic repertoire and provide insight into future developments. Consideration of the current epidemiologic trends in the incidence of cutaneous fungal pathogens is of key importance to investigational effort, diagnosis and treatment.

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A 28-year-old man presented with a partially eroded growth on the back of his right thigh for the last 15 years. Tuberculosis verrucosa cutis and pyogenic granuloma were suspected on clinical examination. Histopathological examination revealed syringocystadenoma papilliferum (SCAP). SCAP is rare on the thigh and a review of the English literature revealed eight cases. Non-descript clinical presentation in an unusual location and the rare linear and segmental variants lead to misdiagnosis. Onset at puberty should alert one to the possibility of the unusual location of SCAP.

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Background: The Psoriasis Disability Index (PDI) questionnaire is a widely used instrument to measure psychological morbidity in plaque-type psoriasis patients. Aims: This study aimed to validate the Persian version of the PDI and to evaluate the impact of psoriasis on quality of life (QOL). Methods: The English language version of the PDI was translated into Persian (Iranian official language) and was used in this study. The questionnaire was administered to a consecutive sample of 125 chronic plaque-type psoriasis patients and statistical analysis was performed to evaluate the impact of psoriasis on QOL. The other health-related QOL assessment tool included the Persian version of the Dermatology Life Quality Index (DLQI). Results: Overall, 125 patients who had received the PDI and DLQI completed all the questions. Reliability analysis showed a satisfactory result (Cronbach's a coefficient = 0.92 and 0.79 for PDI and DLQI, respectively). There was a strong statistical correlation between mean PDI and DLQI scores, with mean Psoriasis Area and Severity Index (PASI) (P = 0.005 and 0.02). Also, a significant correlation coefficient existed between DLQI and PDI (r = 0.94). The higher the PASI index, the higher the PDI and DLQI scores, which indicated greater impact on QOL. In the patients with lesions on visible exposed skin areas, the correlation was statistically significant (P = 0.002 and 0.01). Conclusion: The Persian PDI is an acceptable, reliable and valid measure of psychological distress, with more suitable content validity than DLQI for assessment of impact of psoriasis on QOL among psoriasis patients. Data provided may improve the physicians' awareness of the importance of the patients' QOL.

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Phototherapy is one of the most important therapeutic modalities in dermatology. This field has seen several major advances in the recent years, the most recent being targeted phototherapy. Targeted phototherapy, which includes laser and nonlaser technologies, delivers light/laser in the ultraviolet spectrum, of specific wavelength, specifically targeted at the affected skin and thereby avoids many of the side effects of conventional phototherapy. The treatment has been claimed to be effective, quick, and needing fewer treatment sessions. The article reviews this new mode of phototherapy.

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We herein report an 11-year-old girl who came to our clinic with a swelling on the genital area of 2 months duration. Dermatological examination of the patient was performed and a pigmented lesion was found on the inner surface of the labium majus of the mucosa. The lesion was well circumscribed and approximately 1 cm in diameter, with homogenous color distribution. The patient was diagnosed as Spitz nevus on the basis of clinical and histopathological findings. Our case is probably the first reported case of Spitz nevus localized to the genital mucosa in the English literature.

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Background: Electronic medical records (EMRs) can be of great use in dermatological data recording. Unfortunately, not many studies have been carried out in this specific area. Aims: We attempt to evaluate the use of an EMR system in dermatology, comparing it with a conventional paper-based system. Methods: Two hundred patient records of patients attending the dermatology outpatient department were studied over a 3-month period. Half the reports were entered in the conventional paper-based format while the other half was entered in an EMR system. The time taken for each consultation was recorded and the same was carried out for the first subsequent follow-up visit. Results: The average time taken for the completion of the EMR-based consultation for new cases was 19.15 min (range, 10-30 min; standard deviation, 6.47). The paper-based consultation had an average time of 15.70 min (range, 5-25 min; standard deviation, 6.78). The P-value (T-test was used) was 0.002, which was significant. The average time taken for consultations and entering progress notes in the follow-up cases was slightly less than 10 min (9.7) for EMR while it was slightly more than 10 min (10.3) for the paper format. The difference was not statistically significant. The doctors involved also mentioned what they felt were the advantages and disadvantages of the system along with suggestions for improvement. Conclusion: The use of an EMR system in dermatology (or for that matter in any specialty) may overawe most users at the beginning, but once a comfort level is established, EMR is likely to outscore conventional paper recording systems. More time-motion-case studies are required to ascertain the optimal usage of EMR systems.

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Background and Aims: Atopic dermatitis (AD) is a common skin disease. Long-standing, severe AD with repeated scratching and rubbing of the face, which requires continuous dermatologic care, predisposes the patient to various ocular complications. The knowledge of the frequency and significance of these ocular complications may allow their early diagnosis and treatment. The present study assesses the ocular complications in Indian children suffering from AD. Methods: In order to study the ocular complications in AD, 100 patients (61 male and 39 female) between the ages of 1 and 14 years were recruited. All the patients had complete dilated fundus examination with indirect ophthalmoscopy. The lid, conjunctiva and cornea were examined. Also, any evidence of cataract formation and retinal disorders were recorded. Results: The mean age of the children was 5.4 years. Forty-three (43.0%) AD patients showed ocular abnormalities in the form of lid and conjunctival changes. Of these, 18 (41.9%) patients showed only lid involvement, 16 (37.2%) only conjunctival involvement and both conjunctival and lid changes were seen in nine (20.9%) patients. Conjunctival changes were mostly in the form of a cobblestone appearance of the papillae, with mild to moderate papillary reaction and papillary hypertrophy. Variables observed to have a significant impact on the development of ocular abnormalities were age more than 5 years, duration of illness >12 months, positive family history of atopy, presence of palmar hyperlinearity and a combination of both xerosis and Dennie-Morgan fold. Conclusions: The present study is the first of its kind from India to document an association between AD in children and various ocular manifestations. The ocular manifestations observed in our cohort were not associated with significant ocular morbidity or visual impairment possibly because of a less-severe disease in Indians.

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Background and Aims: Elimination of allergens/topical medications causing contact dermatitis in venous eczema, which poses a significant problem in its chronicity and treatment, provides the basis for better therapeutic outcome. Our objective was to determine the pattern of contact sensitization in venous eczema patients in Himachal Pradesh (India). Methods: Thirty-four patients (M:F, 31:3) and 10 controls (M:F, 6:4) were patch tested with Indian standard series and 10 commonly used topical medicaments. Results: Positive patch test results were seen in 50% (M:F, 16:1) of the patients. Common allergens were Fragrance mix (15%), p-phenylendiamine (15%), nickel (9%), wool alcohol (9%), chinoform (9%), balsum of Peru (5%), cobalt chloride (5%), potassium dichromate (3%), epoxy resin (3%), thiuram mix (3%) and formaldehyde (3%). Only sisomycin and miconazole among the topical medications elicited a positive patch test reaction in 3 and 5% patients, respectively. Neomycin contact sensitivity was not seen in any of the patients. One patient who had exacerbation of venous eczema following accidental application of topical diclofenac showed a positive patch test reaction to it. Conclusions: Patch test should be used to identify the topical agents that may be responsible for perpetuation or aggravation of eczema, especially in patients who do not improve despite adequate treatment of other underlying cause(s).

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Lymphadenopathy is known to be associated with lepromatous leprosy and has also been observed as a feature of type-2 lepra reaction. However, nodular lymph node enlargement is not commonly reported in leprosy patients or as a feature of relapse. We herewith are presenting a case of bacteriological relapse in a patient of lepromatous leprosy treated 22 years before till smear negativity with WHO multidrug therapy (MDT) multibacillary type (MB). She presented with prominent nodular swelling of the cervical group of lymph nodes along with generalized lymphadenopathy, which was mistakenly treated as tubercular lymphadenopathy. A diagnosis of late bacteriological relapse of lepromatous leprosy presenting with prominent lymphadenopathy and ENL was made after relevant investigations. The patient was started on treatment with WHO MDT MB (daily dapsone and clofazimine and monthly rifampicin) and thalidomide (200 mg/day). Nerve pain regressed within 2 weeks of therapy. The lymph nodal swelling regressed within 3 months of starting treatment.

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Background: Leprosy is at a low endemic situation in China, the value of house contact survey in case detection of leprosy becoming a dispute. Aims: To evaluate the value of household contact survey in the case detection of leprosy at a low endemic situation in China. Methods: A study was carried out using a designed questionnaire in a retrospective method to analyze the value of household contact survey in case detection in Southwest and East China. Results: A total of 2135 index leprosy patients were collected from January 1, 1996 to December 31, 2005 in six provinces of China. The number of index patients accounted for 22.0 and 14.1% of newly registered patients in the Southwest and East of China, respectively. The household contact survey (36.1%) and the skin clinic (62.0%) ranked first in methods of case detection in Southwest and East China, respectively. Within 5 years after primary leprosy patients were detected, 24.8 and 16.1% of the index patients in Southwest China and East China had been detected, respectively. Conclusion: The authors conclude that at the time of a low leprosy endemic situation, the household contact survey is still a useful method for case detection in China.

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