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Psoriasis is a chronic inflammatory skin disorder that may drastically impair the quality of life of a patient. Among the various modes of treatments for psoriasis, topical therapy is most commonly used in majority of patients. The topical formulations based on conventional excipients could serve the purpose only to a limited extent. With the advent of newer biocompatible and biodegradable materials like phospholipids, and cutting-edge drug delivery technologies like liposomes, solid lipid nanoparticles (SLNs), microemulsions, and nanoemulsions, the possibility to improve the efficacy and safety of the topical products has increased manifold. Improved understanding of the dermal delivery aspects and that of designing and developing diverse carrier systems have brought in further novelty in this approach. Substantial efforts and the consequent publications, patents and product development studies on the subject are the matter of interest and review of this article. However, majority of the work is related to the preclinical studies and demands further clinical assessment in psoriasis patients.

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Psoriasis is a common, chronic, inflammatory disease with a wide range of clinical presentations. The disease severity ranges from mild to severe. Plaque type of psoriasis is the most common. A number of factors like previous treatment history and comorbid conditions influence the treatment of psoriasis in an individual patient. Location of the lesions is also an important consideration. Psoriasis localized to certain areas of the body like scalp, nails, palms and soles remains difficult to treat. These sites have been referred to as the difficult locations in literature. This article covers the management of psoriasis limited to these special areas.

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Psoriasis is a common debilitating disease significantly affecting the quality of life of the patients. Majority of the psoriasis patients have mild disease which can be managed by topical therapies. Around 30% of the psoriasis patients require systemic therapy during the course of their disease. There is a vast array of drugs for the treatment. Methotrexate, cyclosporine and retinoids are the most commonly used conventional systemic drugs. Newer studies provide insight into their more effective and safer use and as combination therapy with biologics. In recent times, many new drugs with novel mechanisms of action other than biologics have been tried in psoriasis. In this article, we have reviewed the current developments and new found role of the conventional drugs as well as the newer nonbiologic systemic drugs in the treatment of psoriasis.

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Hemangiomas are indolent birthmarks of vascular origin, which are known to appear soon after birth, proliferate for 8-18 months, and then slowly regress over the next 5-8 years, leaving behind normal or slightly blemished skin. In rare instances, hemangiomas may encroach upon and endanger vital structures with a mortality of up to 60%. Multiple therapeutic modalities are available for hemangiomas with variable results and associated with side effects. We report two cases of hemangioma, successfully treated with propranolol. Case 1 was a 5-month-old female child who presented with a giant segmental hemangioma since birth. She was unable to open her left eye over the past 7 days. Within 48 hours of administering full dose of oral propranolol (2 mg/kg/day), the lesion decreased considerably, and the patient was able to open her eye. Case 2 was a 1-year-old female child who presented with hemangioma over the danger area of face. Oral propranolol was given for a period of 6 months with monthly follow up. Both the cases showed dramatic response, with more than 80% regression, without any relapse after stopping the treatment.

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Anti-tumor necrosis factor (anti-TNF) agents have revolutionized treatment of psoriasis and many other inflammatory diseases of autoimmune origin. They have considerable advantages over the existing immunomodulators. Anti-TNF agents are designed to target a very specific component of the immune-mediated inflammatory cascades. Thus, they have lower risks of systemic side-effects. In a brief period of 10 years, a growing number of biological therapies are entering the clinical arena while many more biologicals remain on the horizon. With time, the long-term side-effects and efficacies of these individual agents will become clearer and help to determine which ones are the most suitable for long-term care. Golimumab (a human monoclonal anti-TNF-α antibody) and Certolizumab (a PEGylated Fab fragment of humanized monoclonal TNF-α antibody) are the two latest additions to the anti-TNF regimen. Here, we are providing a brief description about these two drugs and their uses.

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Background: Psoriatic nail changes predispose to onychomycosis because it becomes easier for fungi to penetrate an already compromised nail plate. Moreover, some of the psoriatic nail changes closely resemble onychomycosis. Aim: To investigate cases of nail psoriasis for any evidence of onychomycosis. Methods: Seventy-two patients with psoriasis were included in the study. The patients were selected from the psoriasis clinic and dermatology in-patient ward. Direct microscopic examination with 20% KOH and culture were carried out in all patients showing psoriatic nail changes. Histopathological examination with Periodic Acid-Schiff (PAS) stain was done in cases negative by KOH examination and culture. Results: Nail changes were seen in 66.66% (48/72) of psoriasis patients. The most common fingernail changes observed were pitting, onycholysis and subungual hyperkeratosis, and the most common toenail changes were onycholysis and subungual hyperkeratosis. Nail changes were significantly more common in males. The duration of skin lesions of psoriasis and Psoriasis Area Severity Index scores were significantly higher in patients with nail changes. Out of 48 patients with psoriatic nail change, 23 (47.91%) had investigative evidence of onychomycosis. The fungal isolates on culture were non-dermatophytic molds in nine patients (18.75%) and yeast like fungi also in nine patients (18.75%). Conclusion: Coexistent onychomycosis in psoriatic nails does occur.

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Ever since artificial TL-01 lamps were developed, narrowband ultraviolet B (NBUVB) has gained giant strides in dermatology. Psoriasis is one of the common indications for the use of NBUVB in present day dermatology. We discuss here the evolution of NBUVB, its mechanism of action pertaining to psoriasis, indications and contraindications, dosimetry, complications of NBUVB while being used in patients with psoriasis, its merits and demerits in comparison with broadband UVB and psoralen+UVA (PUVA), and recent developments in the delivery system of NBUVB.

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Fetal varicella syndrome is a rare condition of the newborn, presenting with cutaneous scars, limb defects and ocular and central nervous system abnormalities. It is due to varicella or zoster developing in the fetus following maternal varicella infection during early pregnancy. We are reporting one such patient who presented with a linear, depressed, erythematous scar over the left forearm and axillary fold, with a history of maternal chicken pox during the first trimester of pregnancy.

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McCune-Albright syndrome (MAS) is a rare, heterogenous, clinical condition caused by a rare genetic mutation. The disorder is more common in females and is characterized by a triad of cutaneous, bone and endocrine abnormalities. We describe a male patient with MAS having multiple cafι-au-lait macules and deforming polyostotic fibrous dysplasia involving long bones of the limbs, skull and spine without any endocrine abnormality. Severe bone deformities involving almost all bones have not been described previously and this prompted us to present the current case.

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Psoriatic arthritis (PsA) is a chronic inflammatory disease that can be progressive and may be associated with permanent joint damage and disability. Early identification of PsA will enable these patients with progressive disease to be treated early and aggressively. Due to lack of consistent diagnostic or classification criteria in the past, PsA was considered as uncommon. Overall it affects 6-10% of all psoriasis patients during the course of their disease. Both dermatologists and rheumatologists should be involved in the diagnosis and management of this disorder. Interest in PsA has greatly enhanced over the past several years due to many factors including a better understanding of disease mechanisms, improved investigational tools, better clinical trial design and perhaps most importantly, the availability of newer therapeutic agents. Mild forms of PsA can initially be treated with nonsteroidal antiinflammatory drugs (NSAID). In acute as well as oligo- to polyarticular joint involvement, disease-modifying anti-rheumatic drugs (DMARD) are indicated for PsA. The biologics particularly tumor necrosis factor alpha (TNF- a) antagonists are gaining increasing significance as second-line therapy. Treatment choice should also take into consideration the extent of skin involvement.

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Background: There was a recent epidemic of chikungunya (CKG) in Calicut and other northern districts of Kerala, South India, affecting thousands of people. Aims: To study the cutaneous manifestations of CKG and to have a serological and histopathological correlation. Methods: A total of 162 patients (63 males and 99 females) with cutaneous manifestations of CKG were enrolled in the study and serological confirmation was done with capture IgM ELISA for CKG. Skin biopsy was done in all representative cases. Results: Cutaneous manifestations were found more in females. There were 23 children, the youngest being 39 days old. Generalized erythematous macular rash was the most common finding. Vesicles and bullae were also common especially in infants. Localized erythema of the nose and pinnae, erythema and swelling of the pre existing scars and striae and toxic epidermal necrolysis-like lesions sparing mucosae were the other interesting findings. Different types of pigmentation were observed with a striking nose pigmentation in a large number of patients, by looking at which even a retrospective diagnosis of CKG could be made. Hence we suggest this peculiar pigmentation may be called "chik sign". There was flare up of existing dermatoses like psoriasis, lichen planus and unmasking of Hansen's disease with type 1 reaction. Serological tests were positive in 97%. Some hitherto unreported histopathologic findings like melanophages in the erythematous rashes were observed. Conclusion: A spectrum of cutaneous manifestations of CKG with a wide variety of unusual presentations with confirmed serological and histopathological evidence was encountered.

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Background: Psoriasis is a chronic inflammatory disease of the skin and is associated with an increased risk of cardiovascular atherosclerosis. Metabolic syndrome, a conglomerate of various clinical and biochemical parameters is a significant predictor of atherosclerotic disease and the associated risk for cardiovascular events in such patients. Aim: To investigate the prevalence of metabolic syndrome in patients with psoriasis. Methods: The study was a prospective, hospital based case-control study involving 150 adult patients with chronic plaque psoriasis and 150 healthy controls. Venous samples were taken at the enrolment visit after the subjects had fasted overnight (at least 8 h). Serum cholesterol and triglycerides were measured with enzymatic procedures. Plasma glucose was measured using a glucose oxidase method. Metabolic syndrome was diagnosed by the presence of three or more criteria of the National Cholesterol Education Programme's Adult Panel III (ATP III). Statistical analysis of the data was done using statistical processing software (SPSS-17) and epi-info software. Results: Metabolic syndrome was significantly more common in psoriatic patients than in controls 42(28%) vs 9(6%), odds ratio (OR) = 6.09, P<0.05. Psoriatic patients also had a significantly higher prevalence of hypertriglyceridaemia (73/150 among cases vs 24/150 among controls; P<0.05), arterial hypertension (74/150 among cases vs 24/150 among controls; P<0.05) and impaired fasting plasma glucose levels (27/150 among cases vs 04/150 among controls; P<0.05). Psoriatic patients with metabolic syndrome had mean disease duration of 13.67±11.87 years against 6.46±5.80 years in those without metabolic syndrome. Conclusion: There is a significantly higher prevalence of metabolic syndrome in psoriasis patients as compared to general population and so is the risk of having atherosclerotic adversity. While managing the psoriatic plaques of these patients, concerns should extend to the atherosclerotic plaques as well.

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Granulomatous mycosis fungoides (GMF) is a rare type of cutaneous T cell lymphoma. A 38-year-old married male presented with decreased sweating all over the body for last 8 years, progressive redness and scaling over body for 2 years and multiple noduloulcerative lesions over the body for 1 year. Cutaneous examination revealed generalized erythema and scaling with poikilodermatous changes over chest and upper back along with multiple noduloulcerative lesions. Skin biopsy from a nodular lesion revealed dense granulomatous infiltrate of atypical lymphocytes with epidermotropism and sparing of appendages. Diagnosis of GMF was made. Computed tomographic scan of thorax, abdomen and pelvis revealed axillary and inguinal lymphadenopathy. Immunohistochemistry revealed leukocyte common antigen and CD3 positivity suggestive of T cell origin. Patient was started on CHOP (Cyclophosphamide, Hydroxydaunorubicin, Oncovin and Prednisolone) regimen of chemotherapy with marked improvement after three cycles of chemotherapy. This case had some clinical resemblance to lepromatous leprosy.

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Subcutaneous phaeohyphomycosis is an infection of the skin and subcutaneous tissue, caused by dematiaceous fungi. An adult male presented with a history of multiple reddish nodules over the face and hands. Histopathological examination of the skin biopsies showed a dense granulomatous infiltrate of macrophages, containing intracytoplasmic basophilic bodies throughout the dermis. Gomori methenamine-silver stained sections revealed yeast cells within macrophages. Multiple cultures on Sabouraud's dextrose agar grew Cladophialophora boppii. The patient was treated with oral itraconazole for a year and the response monitored with dermal ultrasound. This is the first case report of subcutaneous phaeohyphomycosis caused by Cl. boppii in India.

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Bacillary angiomatosis is a recently described infectious disease that usually affects immunosupressed hosts with a previous history of contact with cats. We report a rare case of bacillary angiomatosis in an immunocompetent 59-year-old woman with no history of previous exposure to cats, and atypical clinical features (fever and subcutaneous nodules with ulceration on the left ankle). Histopathology of the lesion showed extensive ulceration and reactive tumor-like vascular proliferation of the blood vessels with swollen endothelial cells and an inflammatory infiltrate including neutrophils and lymphocytes in the dermis and subcutis. Staining with the Warthin-Starry method demonstrated the presence of clustered bacilli located in the extracellular matrix adjacent to the proliferating endothelial cells. Diagnosis was confirmed with the detection of Bartonella spp. DNA in the affected skin and in bone marrow using polymerase chain reaction.

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Background: Laser hair reduction has become a very popular means to get rid of unwanted hair. Aims: We conducted the current study to evaluate the safety and efficacy of Nd: YAG laser on dark skin. We also evaluated the effect of increasing the gap between sessions on the long term efficacy of hair reduction achieved with long pulsed Nd: YAG laser. Methods: A prospective study was conducted on 200 consecutive female patients who underwent laser hair reduction for unwanted hair over the face, at Kaya skin clinic Delhi, with long pulsed Nd: YAG laser, from May 2006 to May 2009. The gap between sessions was increased from 2 ^nd session itself. Results were evaluated 6 months after 6 sessions. Also a note was made of worsening of hair growth or any side effects experienced the patient during any of the sessions. Results: A total of 200 female patients (160 skin type IV and 40 skin type V) were followed up. Of these, 64 enrolled for lower face, 88 for chin or upper neck and 48 for upper lip. 6 months after 6 sessions, more than 50% improvement was seen in 68.7% of lower face, 89.69% cases of chin and 59% of upper lip cases. None of the patients had any worsening. Conclusions: The current study shows that long pulsed Nd: YAG is a very safe and effective means of hair reduction in skin types IV and V. Adequate fluences and increasing the gap between sessions from the 2 ^nd session could be the key to achieving long term hair reduction with Nd: YAG laser. Adequate cooling and proper shaving are the key factors determining the safety.

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Background: Very few studies using the combination of topical 8-methoxypsoralen (8-MOP) and narrow-band ultraviolet B (NBUVB) have been performed, especially in Indian patients. A combination of oral psoralen with NBUVB has been shown to have a superior efficacy as compared with NBUVB alone in psoriasis. Aims: Comparison of the efficacy of topical psoralen NBUVB (combination) versus NBUVB alone in psoriasis. Methods: Thirty patients with plaque psoriasis were taken up for the study and NBUVB phototherapy was given twice weekly. The target lesions on one side were treated with 0.1% topical 8-MOP 15 min before the irradiation. The treatment period was 12 weeks or 24 exposures. Results: The number of treatment sessions and cumulative NBUVB doses were lower in the combination therapy as compared with NBUVB monotherapy, although the differences were not statistically significant. Conclusion: To conclude, topical 8-MOP enhances the therapeutic effects of NBUVB therapy without increasing the incidence of adverse effects.

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CD4+/CD56+ hematodermic neoplasm, formerly known as blastic NK cell lymphoma, is a rare and aggressive neoplasm with a high incidence of cutaneous involvement, risk of leukemic dissemination and poor prognosis. The characteristic features are expression of the T helper inducer cell marker CD4 and the NK-cell marker CD56 in the absence of other T cell or NKcell specific markers. Because of the rarity of this disease, we describe a 48 year old woman suffering from CD4+/CD56+ hematodermic neoplasm on her cheek without leukemic infiltration.

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