Arsenicosis is a multisystem disorder, with virtually no system spared from its vicious claw; though its predominant manifestations are linked to cutaneous involvement. Cutaneous effects take the form of pigmentary changes, hyperkeratosis, and skin cancers (Bowen's disease, squamous cell carcinoma, and basal cell epithelioma). Peripheral vascular disease (blackfoot disease), hypertension, ischemic heart disease, noncirrhotic portal hypertension, hepatomegaly, peripheral neuropathy, respiratory and renal involvement, bad obstetrical outcome, hematological disturbances, and diabetes mellitus are among the other clinical features linked to arsenic toxicity. The effects are mediated principally by the trivalent form of arsenic (arsenite), which by its ability to bind with sulfhydryl groups present in various essential compounds leads to inactivation and derangement of body function. Though the toxicities are mostly linked to the trivalent state, arsenic is consumed mainly in its pentavalent form (arsenate), and reduction of arsenate to arsenite is mediated through glutathione. Body attempts to detoxify the agent via repeated oxidative methylation and reduction reaction, leading to the generation of methylated metabolites, which are excreted in the urine. Understandably the detoxification/bio-inactivation process is not a complete defense against the vicious metalloid, and it can cause chromosomal aberration, impairment of DNA repair process, alteration in the activity of tumor suppressor gene, etc., leading to genotoxicity and carcinogenicity. Arsenic causes apoptosis via free radical generation, and the cutaneous toxicity is linked to its effect on various cytokines (e.g., IL-8, TGF-β, TNF-α, GM-CSF), growth factors, and transcription factors. Increased expression of cytokeratins, keratin-16 (marker for hyperproliferation) and keratin-8 and -18 (marker for less differentiated epithelial cells), can be related to the histopathological findings of hyperkeratosis and dysplastic cells in the arsenicosis skin lesion.

Diagnosis of arsenicosis relies on both clinical and laboratory criteria, but principally it can be diagnosed on the basis of its cutaneous manifestations. Cutaneous manifestations (melanosis, keratosis, and cutaneous cancers) are essential clues in the diagnosis, and trained dermatologists or arsenic experts are able to clinically confirm a case even without laboratory backup. Although systemic manifestations are not considered as diagnostic hallmarks, yet their presence serves as important telltale signs in arriving at the diagnosis. In countries where laboratory facilities are available, measuring the level of arsenic in drinking water (consumed in the last 6 months), urine, hair, and nails is of immense value. Newer biomarkers of arsenic exposure are being explored to provide early information about arsenic intoxication, of which urinary porphyrin level, blood metallothionein have shown promising results. Controlling the problem of arsenicosis depends on various factors, of which the most important is cessation of intake of arsenic-contaminated water. Deep wells, traditional dug wells, treatment of surface water, rainwater harvesting, and removing arsenic from the contaminated water by arsenic removal plant or arsenic treatment unit are the available options for providing arsenic-free drinking water. The role of nutrition and antioxidants in preventing the onset of symptoms of arsenicosis is also of importance. Nonspecific therapies (e.g., keratolytics for hyperkeratosis) cannot also be ignored and serve as palliative measures. The persons affected need to be followed up at regular intervals to detect the onset of cancers (if any) at the earliest. Role of counseling and education should never be underestimated since absence of public awareness can undermine all efforts of mitigation measures.

Arsenicosis is a global problem but the recent data reveals that Asian countries, India and Bangladesh in particular, are the worst sufferers. In India, the state of West Bengal bears the major brunt of the problem, with almost 12 districts presently in the grip of this deadly disease. Recent reports suggest that other states in the Ganga/Brahmaputra plains are also showing alarming levels of arsenic in ground water. In West Bengal, the majority of registered cases are from the district of Nadia, and the maximum number of deaths due to arsenicosis is from the district of South 24 Paraganas. The reason behind the problem in India is thought to be mainly geogenic, though there are instances of reported anthropogenic contamination of arsenic from industrial sources. The reason for leaching of arsenic in ground water is attributed to various factors, including excessive withdrawal of ground water for the purpose of irrigation, use of bio-control agents and phosphate fertilizers. It remains a mystery why all those who are exposed to arsenic-contaminated water do not develop the full-blown disease. Various host factors, such as nutritional status, socioeconomic status, and genetic polymorphism, are thought to make a person vulnerable to the disease. The approach to arsenicosis mitigation needs be holistic, sustainable, and multidisciplinary, with the 2 main pillars being health education and provision of 'arsenic-free water.' In the state of West Bengal, the drive for arsenic mitigation has been divided into 3 phases using various methods, including new hand pumps/tube wells at alternative deep aquifers, dug wells, arsenic removal plants, arsenic treatment units, as well as piped and surface water supply schemes. The methods have their own limitations, so it is intended that a pragmatic approach be followed in the arsenicosis prevention drive. It is also intended that the preventive measures be operationally and economically feasible for the people living in the affected areas.

Background: The possibility of a causal influence of emotional stress, especially of stressful life events, on the course of various skin diseases has long been postulated. Previous reports addressing its influence on skin psoriasis and chronic urticaria have been mainly anecdotal. Objective: The aim of this study was to evaluate the stressful events of life within 1 year preceding onset or exacerbation of skin disease in patients of psoriasis vulgaris and chronic urticaria. Method: Fifty consecutive clinically diagnosed psoriasis patients and 50 consecutive clinically diagnosed chronic urticaria patients were examined clinically and administered Gurmeet Singh's presumptive stressful life events scale. Results: Stressful life events were seen in 26% of the patients in the psoriasis vulgaris group and 16% of the patients in the chronic urticaria group within 1 year preceding onset or exacerbation of skin disease. In the psoriasis vulgaris group, the most common stressful life event seen was financial loss or problems (8%), followed by death of close family member (4%), sexual problems (4%), family conflict (2%), major personal illness or injury (2%),and transfer or change in working conditions (2%), failure in examinations (2%), family member unemployed (2%), illness of family member (2%), getting married or engaged (2%), miscellaneous (2%). In the chronic urticaria group, the most common stressful life event seen was death of a close family member (6%), followed by family conflict (2%), financial loss or problems (2%), sexual problems (2%), illness of family member (2%), getting married or engaged (2%), trouble at work with colleagues, superiors, or subordinates (2%), going on a pleasure trip (2%) and extramarital relations (2%). Conclusion: Psychological stress plays a significant role in triggering or exacerbating dermatological diseases. Our study indicates the role of relaxation therapies and stress management programs in chronic diseases such as psoriasis and chronic urticaria. Psychological interventions can help individuals to reinterpret events and develop strategies to cope with stressful events, thus decreasing morbidity due to these diseases.

Background: Psoriasis can have a profound impact on a patient's quality of life. Very few Indian studies have examined this aspect of Indian patients of psoriasis. Aims: This study was conducted to assess the clinical severity, as well as physical and psychosocial disability, and stress incurred and to analyze their interrelationship in psoriasis patients aged more than 18 years. Methods: This hospital-based cross-sectional study was conducted in the Department of Dermatology, JIPMER, Pondicherry, India. Clinical severity, physical and psychosocial morbidity, and the stress incurred were measured using psoriasis area severity index (PASI), psoriasis disability index (PDI), and psoriasis life stress inventory (PLSI) respectively, the latter two of which were suitably modified and translated into the local language, viz., Tamil. Appropriate tests were conducted using SPSS for Windows (Release 7.5.1) statistical software. Results: Fifty patients (34 males, 16 females) were included in the study. The clinical PASI scores correlated significantly with the overall physical disability (PDI), individual aspects of the PDI (except the treatment-related activities), and the measurement of stress incurred (PLSI). A PASI score of more than 18 delineated a subgroup of patients with higher overall physical disability and higher stress rating. Among the physical and psychosocial factors investigated, daily activities, employment, and treatment were reported to be affected the most. Psoriasis sufferers are also most likely to feel self-conscious, be disturbed / inconvenienced by the shedding of the skin, live in a constant fear of relapse, and avoid social interactions. Conclusions: The present study provides compelling evidence that psoriasis affects the quality of life, and it highlights the importance of adopting a multidimensional assessment of psoriasis.

Background: Cutaneous manifestations of inflammatory bowel disease are relatively common, although they vary widely. Aims: The aim of this study was to determine the prevalence of cutaneous manifestations in inflammatory bowel disease according to their location, age, gender, activity, and type of underlying disease in an Iranian population during a 10-year period. Methods: The medical records of 404 inpatients with inflammatory bowel disease were extracted retrospectively to detect cutaneous manifestations. Results: In this study, the prevalence of cutaneous manifestations was 5.9%. These manifestations were higher in Crohn's disease (7.29%) than in ulcerative colitis (4.07%), and more frequent in females (52%) than in males (48%). Aphthous stomatitis was observed more frequently in Crohn's disease; however, pyoderma gangrenosum was seen more often in ulcerative colitis. Erythema nodosum was diagnosed only in female patients with Crohn's disease. Manifestations secondary to nutritional deficiency or associated conditions including psoriasis and other autoimmune disorders were less frequent. Conclusions: Aphthous stomatitis, pyoderma gangrenosum, and erythema nodosum were the most common skin disorders related to inflammatory bowel disease (IBD), which mainly occurred in women.

Background: Alopecia areata (AA) is an autoimmune disease mediated by T lymphocytes. Many treatments have been used but their results remain disappointing. There is a need to propose new therapeutic alternatives. Methods: During a period of 3 years, 26 patients with recalcitrant or severe AA (>40% hair loss) were enrolled in an open-label uncontrolled clinical trial. According to the response to sulfasalazine, patients were grouped into 3 categories: no hair regrowth (<10% terminal hair), partial hair regrowth (10%-90% terminal hair), and complete hair regrowth (90%-100% terminal hair). Efficacy evaluation was performed with clinical examination. Results: Twenty-two patients completed the treatment. Overall, 68.2% (15 of 22 patients) responded to therapy: 27.3% (6 of 22 patients) achieved complete hair regrowth, and 40.9% had partial hair regrowth. Seven (31.8%) patients had no hair regrowth. Of the 22 patients with complete and partial remission, 10 (45.5%) suffered a partial or complete relapse. Side effects following treatment were seen in 7 (31.8%) patients. Conclusion: Sulfasalazine could be considered as a therapeutic alternative in the treatment of AA, because of its safety profile, cosmetically acceptable efficacy, and good tolerability.

Background: There are numerous therapeutic modalities available for treatment of molluscum contagiosum. However, the ablative modalities are painful and not suitable for children. Aim: We aimed to evaluate and compare the safety and efficacy of 2 of the painless modalities, viz., 5% imiquimod cream and 10% potassium hydroxide (KOH) solution, in the treatment of molluscum contagiosum. Methods: Out of a total of 40 patients of molluscum contagiosum in the study, 18 patients in the imiquimod group and 19 patients in the KOH group completed the study. The given medication was applied by the patient or a parent to mollusca at night, 3 days per week. Imiquimod was continued till clinical cure; and 10% KOH, till lesions showed signs of inflammation. Assessments of response and side effects were performed at the end of week 4, week 8, and week 12. Significance was tested by Student's t test and Mann-Whitney test. Results: The mean lesion count decreased from 22.39 to 10.75 with imiquimod and from 20.79 to 4.31 with KOH at the end of 12 weeks. We found complete clearance of lesions in 8 (44%) patients with imiquimod and in 8 (42.1%) patients with 10% KOH. Minor side effects were seen in 15 (78.9%) patients on KOH and 10 (55.5%) patients on imiquimod. Conclusions: The results of this study suggest that both 5% imiquimod cream and 10% KOH solution are equally effective in molluscum contagiosum though KOH has a faster onset of action. However, KOH solution is associated with a higher incidence of side effects.

Background: Immune reconstitution inflammatory syndrome (IRIS) is a paradoxical deterioration in clinical status in a patient on antiretroviral treatment (ART) despite satisfactory control of viral replication and improvement of CD4 count. Aim: To study development of IRIS as a part of ART. Methods: Hundred patients on antiretroviral treatment were studied prospectively in the Department of Skin and VD over a period of 2 years. Patients were asked to come if they developed any symptoms or on a monthly basis. They were screened clinically and investigated suitably for evidence of opportunistic infections. Results: Out of 100 patients, 10 patients did not come for follow-up. Twenty (22.2%) out of the 90 patients developed IRIS. Herpes zoster (HZ), herpes simplex virus (HSV), and tuberculosis (TB) were the cases of IRIS seen in the present study. Conclusions: IRIS in terms of HSV/TB is known to accelerate HIV disease progression. Hence early detection and prompt treatment, along with continuation of highly active ART, are of utmost importance.

Background: Various surgical procedures for correcting stable vitiligo exist but these have their own limitations. Autologous, non-cultured, non-trypsinized, melanocyte plus keratinocyte grafting is a new and simple method of vitiligo surgery. Objective: The study aimed to evaluate efficacy of a new grafting technique in vitiligo patches. Methods: Eighteen vitiligo patches underwent this procedure. The upper layer of epidermis was removed by superficial dermabrasion using a dermabrader micromotor until the epidermis appeared wet and shiny. Then, antibiotic ointment was applied and dermabrasion was continued up to the whitish area of the upper dermis. The paste-like material (ointment with entangled epidermal particles) was collected and spread over the dermabraded recipient site. Results: Pigmentation usually started at 4-6 weeks. Complete uniform pigmentation took 16-20 weeks. Conclusion: For smaller vitiligo patches this method gives cosmetically acceptable results. It is easy to perform and does not require specific laboratory setup.

Background: Nevus sebaceus (NS), otherwise designated as 'organoid nevus', involves proliferative changes of the sebaceous glands, sweat glands, and the hair follicles. It displays a range of appearances, depending on the lesion's age. Aims: To study the histopathological features of NS and correlate these with clinical findings. Methods: All skin biopsy specimens over a 12-year period from 1995 to 2007 which had a diagnosis of NS were included. Clinical data with follow-up notes and histopathology were reviewed. Results: Half of the cases had a verrucous clinical appearance, while the rest presented as papules, plaques, or patches. All the cases showed immature hair follicles, and 24% of cases showed immature sebaceous glands. Normal terminal hair follicles were characteristically absent in the lesion. Nineteen percent of the cases showed dilated apocrine glands, and 14% showed hyperplasia of eccrine glands. Epidermal changes in the form of acanthosis, papillomatosis, and hyperkeratosis were seen in 86% of cases. Dilated keratin-filled infundibula were observed in 24% of cases. One case was associated with a squamous cell carcinoma. Conclusions: Nevus sebaceus is a cutaneous hamartoma, consisting of various elements indigenous to the organ. Normal terminal hair follicles are characteristically absent in the lesion although the same may be seen in rest of the epidermis, a feature of diagnostic importance, not usually highlighted in literature. The divergent differentiation observed in NS is consistent with the common embryologic origin of the folliculosebaceous-apocrine unit and should not mislead the pathologist.

Background: Despite recent significant therapeutic advances, vitiligo remains a clinical conundrum. Topical immunotherapy has been extensively tested in the treatment of various dermatologic disorders, especially those believed to have an immunologic basis. Aim: To evaluate the role of topical diphenylcyclopropenone (DPCP) in the treatment of vitiligo. Methods: Nineteen patients with limited vitiligo lesions were enrolled in this study. After sensitization with 2% lotion of DPCP in acetone, progressively higher concentrations beginning at 0.001% up to 2% were applied weekly for 6 months to the depigmented skin lesions. Results: Thirteen of the 19 patients were evaluated at the end of 6 months. Four patients with focal vitiligo, one patient with vitiligo vulgaris, and three patients with segmental vitiligo showed marked (grade 3) repigmentation. Conclusion: Marginal and central repigmentation with hyperpigmented borders was seen in the majority of lesions. Further controlled trials should be undertaken to evaluate the use of topical DPCP in vitiligo.

The Brooke-Spiegler syndrome (BSS) is an uncommon autosomal dominant disorder characterized by a high affinity to form multiple adnexal neoplasia (skin appendage tumors), especially trichoepitheliomas and cylindromas, and occasionally spiradenomas, which usually appear in the second or third decade of life. To date, only a few cases with this syndrome have been reported. This case report describes a 26-year-old woman who presented to the dermatology department of Qaem Hospital with tumoral lesions on her scalp, face, and forearm. Her father and younger brother were also affected. On examination, several round-to-oval skin-colored papules with a smooth pearly surface measuring 2 to 6 mm in diameter were seen on the mid-face, particularly in the nasolabial folds, the upper lip. Tumors and nodules seen on the scalp were pinkish red, dome-shaped, and to some extent, pedunculated with surface telangiectasia and induration. Histopathology of the facial papules showed trichoepithelioma while that of a scalp nodule showed cylindroma.

Nocardia spp are gram-positive, aerobic, acid-fast bacteria which exist as saprophytes in nature. Invasive disseminated infections are particularly common in immunocompromised or debilitated hosts. Superficial infections with Nocardia spp occur as a result of local trauma and contamination of the wound. Clinically, it presents as acute infection (abscesses or cellulitis), mycetoma, or sporotrichoid infection. Differential diagnosis includes eumycetoma, chromomycosis, blastomycosis, coccidioidomycosis, sporotrichosis, tuberculosis, botryomycosis, syphilis, yaws, and neoplasia. Its diagnosis is confirmed by demonstrating the causative organism in exudates (as granules), tissue specimens, or cultures. Early diagnosis will obviate need for drastic surgical measures as early institution of chemotherapy is effective in most patients. However, its diagnosis is often delayed due to diverse clinical presentations and for want of clinical suspicion, particularly in non-endemic areas. This paper presents 4 clinical forms of this not so uncommon disease, emphasizing the importance of high index of clinical suspicion, especially in non-endemic regions; and the significance of repeated examination of exudates for Nocardia granules for an early diagnosis.

Cutaneous leishmaniasis is a disease caused by intracellular protozoal parasites belonging to the genus Leishmania. Immune suppression caused by HIV infection is an important factor for atypical presentation and widespread progression of cutaneous leishmaniasis. Diffuse (disseminated) cutaneous leishmaniasis and HIV co-infection is emerging as an extremely serious new disease. A 38-year-old HIV-positive man presented with a 12-month history of a progressive papule and nodular eruptions on face and extremities with infiltrations of nasal and oral mucosa. We report the case due to its atypical, widespread muco-cutaneous presentation masquerading as lepromatous leprosy.

A 6-year-old boy presented with abnormal habitus since birth, delayed language development, history of frequent falls since 9 months, and fever since 1 week. He was found to have hyperandrogenic features, generalized paucity of fat, generalized muscular overdevelopment, and brownish pigmentation over the flexural creases. Skin biopsy demonstrated features suggestive of acanthosis nigricans with an absence of subcutaneous tissue. After further investigation, a diagnosis of Berardinelli-Seip syndrome with bilateral pneumonia and generalized tonic clonic seizures was made. Clinical features, histopathology, differential diagnosis, and prognosis of this rare disorder have been discussed.

Background and Aims: Vitiligo is known to affect the quality of social and personal life in some countries. This study aims to assess the quality of life (QOL) in vitiligo sufferers among the Iranian population and to evaluate its relation with different variables. Methods: One hundred vitiligo patients answered a questionnaire based on the Dermatology Life Quality Index (DLQI). Results: The mean DLQI score was 8.16. There were statistically significant relationships between DLQI scores and marital status, skin phototype, and disease extension independently. Conclusions: This study shows that vitiligo has a major impact on the QOL of patients in Iran. Hence dermatologists should pay attention to the psychological effects of this cosmetic disease and try to decrease its extension and disfiguring effects by various treatments.

Alkaptonuria is a rare disorder of metabolism characterized by deficiency of homogentisic acid oxidase. Characteristic features include darkening of urine, ochronosis, and arthropathy. Darkening of urine is the only sign of the disorder in the pediatric age group, and it occurs at very early stage of the disorder, as reported by the parents. A 4-year-old boy presented to our clinic with the complaint of dark urine and bluish black staining of clothes. This darkening pointed to a positive physical history of bluish discoloration of sclerae which occurred off and on. We initiated treatment with ascorbic acid and a protein diet with restriction of phenylalanine and tyrosine (1.6 g/kg/d). This case report is significant because of the early diagnosis made.