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   Table of Contents - Current issue
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January-June 2021
Volume 5 | Issue 1
Page Nos. 1-130

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DERMATOLOGY PRACTICE DURING COVID-19 PANDEMIC - EDITORIAL  

Preparedness of dermatologists in disaster management: Learning from present for the future p. 1
Ragunatha Shivanna
DOI:10.4103/cdr.cdr_4_21  
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DERMATOLOGY PRACTICE DURING COVID-19 PANDEMIC - REVIEW ARTICLE Top

Changing the gear of dermatology practice during and after COVID-19 pandemic: Potential problems and their management p. 3
BS Chandrashekar, Preethi B Nayak, C Madura
DOI:10.4103/CDR.CDR_102_20  
COVID-19 since the dawn has changed the way we look at things around us. Medical practice has changed drastically, so is dermatology practice. Clinical and procedural dermatology practice had come to a standstill in India, due to the past COVID-19 situations. With the changing scenario, now it is time for dermatologists as well as dermatology field to sail through these difficult times, with extra care and precautions. According to the latest CDC and ICMR guidelines, we have designed the following proposed guidelines from entrance to exit for the smooth functioning of dermatology institute/hospital/clinic. Potential setbacks related to patient and manpower, their management during COVID-19 pandemic has been reviewed. Potential setbacks related to clinical dermatology practice and procedures, their management during COVID-19 pandemic has been reviewed and briefed. Hard times are usually blessings in disguise; hence, we should utilize this pandemic period to learn and rejuvenate our practice.
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DERMATOLOGY PRACTICE DURING COVID-19 PANDEMIC - ORIGINAL ARTICLES Top

Management of pemphigus vulgaris and bullous pemphigoid in times of COVID-19 pandemic Highly accessed article p. 12
Tejaswini Salunke, Vinay Kulkarni, Dhanashree Bhide, Pradyumna Vaidya
DOI:10.4103/CDR.CDR_100_20  
Background: The pandemic the world is facing today started in the city of Wuhan, central China, in December 2019, and presented as unexplained lower respiratory infections. On February 11, 2020, the World Health Organization announced that the disease caused by the severe acute respiratory syndrome coronavirus 2 virus be called “corona virus disease 2019 (COVID-19).” Since the beginning of the pandemic there has been quite some debate regarding starting or continuing the treatment of diseases requiring immunosuppression. The major issues arise with management of dermatological diseases, such as vesiculobullous disorders, moderate-to-severe psoriasis, acute severe drug reactions, and connective tissue diseases which would require high level of immune-suppression or immune-modulation as treatment. In this article, we discuss the management strategies adopted for the management of pemphigus vulgaris (PV) and bullous pemphigoid (BP) as the prototypical examples. We will discuss the algorithm we evolved in our department for managing such cases during COVID-19 pandemic to give optimum benefit for our patients along with decreasing their risk for increased vulnerability for severe COVID-19 infection. The same principle can be used for other diseases requiring immunosuppressive or immunomodulatory therapies. Objectives: The management of the patients suffering from BP and PV that came to our department during the national lockdown during COVID-19 pandemic. Materials and Methods: It was a prospective study of 30 consecutive patients that came to our outpatient department either previously diagnosed or as fresh cases of PV or BP. Results: Treating patients with BP or PV during the pandemic has been a challenge. Analyzing the risk versus benefit and making a custom-based treatment helped us minimize the risk for severe COVID-19 infection as well as the side effects due to the primary drugs that are used in BP/PV. We were successful in keeping the primary disease in control. None of our patients was infected with symptomatic COVID-19 infection. Conclusion: With rapidly changing scenario of the pandemic it is very difficult to assess the optimal management of complex diseases such as PV and BP. With contradictory data available whether suppressing the immunity will result in a milder form of COVID 19 with less complications or render the patient at higher risk of complicated COVID-19 is unknown. Thus we, as dermato-physicians, need to keep ourselves and our patients updated, educated, and choose the best possible option where in the risk for severe COVID-19 infection minimized while keeping their primary disease in control.
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Teledermatology during COVID era: Our experience Highly accessed article p. 20
Satish A Doddaballapur, Amrutha N Bangera, Radhika V Kaujalgi, Aparna A Dongare
DOI:10.4103/CDR.CDR_83_20  
Background: Telemedicine refers to “remote diagnosis and treatment of patients by means of telecommunication technology.” Dermatology has a unique place in telemedicine as a reasonably accurate diagnosis can be established by history, clinical images, and real-time video consultation. Objectives: The aim was to assess the merits and demerits of teleconsultation in the period of lockdown due to COVID-19. Materials and Methods: An analysis of data of teleconsultation done in 84 patients between April 08, 2020 and May 19, 2020 was assessed. Results: The age group of patients ranged from 1 month to 95 years, with a preponderance of females over males. The most common skin condition in the study was eczema, followed by acne, psoriasis, and vitiligo. Among the total 84 patients, three patients were called for in-person consultation to eliminate the margin of error and six patients voluntarily reported for the follow-up to the clinic. Conclusion: Teledermatology during the COVID era safeguards both patients and health-care workers from exposure to the virus. Although faced with several challenges, teleconsultation when judiciously used can be a boon in the diagnosis of dermatological disorders, especially in susceptible individuals.
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DERMATOLOGY PRACTICE DURING COVID-19 PANDEMIC - CASE REPORTS Top

Bullous pemphigoid: Management during COVID-19 pandemic p. 24
Ajit B Janagond, Anusha Lingaiah, Arun C Inamadar
DOI:10.4103/CDR.CDR_77_20  
Bullous pemphigoid (BP) is an autoimmune blistering disorder with subepidermal split, which predominantly affects the elderly. Here, we report a case of BP with hypertension and bronchial asthma managed during coronavirus disease-2019 national lockdown. A known case of BP in remission for 10 months came with recurrence. The patient was managed with dapsone and topical corticosteroids. Social media application was utilized further to prescribe and monitor the patient due to inconvenience faced during the current pandemic.
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Treating pemphigus foliaceus-a telemedicine way p. 27
Vikrant Saoji
DOI:10.4103/CDR.CDR_76_20  
To control the COVID pandemic, lockdown was ordered by the government, leading to travel restrictions which affected the access to the medical facility. A 63-year-old male staying 200 km away in a remote area without dermatological facility was diagnosed and treated successfully by telemedicine. Diagnosis of pemphigus foliaceus was made on clinical photograph. The patient had extensive involvement. The patient was treated with tablet betamethasone tapered over 4 weeks along with tablet cyclophosphamide 100 mg OD. Clinical photographs along with the laboratory reports were sent by the patient weekly. By the end of the 1st week, the patient started noticing improvement which continued for next 4 weeks. A good clinical improvement was achieved in 4 weeks. No side effects were reported. The improvement achieved in 4 weeks will be maintained with tablet cyclophosphamide. Telemedicine can play an important role in offering medical help to the remote rural area where the health facilities are lacking.
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Management of toxic epidermal necrolysis in an adult patient: Challenges and their management during COVID-19 pandemic p. 30
Ragunatha Shivanna, Gaurav Ramakrishna, Godwin K Mannur
DOI:10.4103/cdr.cdr_125_20  
An adult male patient who underwent neurosurgery for extradural hematoma following road traffic accident presented with toxic epidermal necrolysis (TEN) secondary to phenytoin. The patient was semiconscious and not responding to verbal commands. The patient was admitted and managed with oral cyclosporine and supportive measures. TEN is a dermatological emergency presenting as acute skin failure. The management requires multidisciplinary approach in an intensive care setup. The treatment includes the administration of immunosuppressant drugs and maintenance of hemodynamic stability. However, the COVID-19 pandemic has resulted in a lot of limitations regarding the use of immunosuppressant drugs and in-patient care because of the possibility of transmission of COVID-19 infection among patients, their caretakers and health-care professionals. Here, we are presenting a case of TEN managed successfully during the pandemic of COVID-19. Strict adherence to all the guidelines recommended by concerned authorities related to the prevention of transmission of COVID-19 and judicious use of immunosuppressant drugs based on risk and benefit ratio is very crucial.
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DERMATOLOGY PRACTICE DURING COVID-19 PANDEMIC - LETTER TO EDITOR Top

COVID-19: A wake-up call for teledermatology in India p. 34
S Aarya, Manasa Shettisara Janney, V Sandeep Lal
DOI:10.4103/CDR.CDR_84_20  
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REVIEW ARTICLE Top

Serum biomarkers of vitiligo p. 36
Mohamed Ibrahim ElGhareeb
DOI:10.4103/CDR.CDR_9_19  
The pathogenesis of vitiligo is complex, although the driving factors seem to become gradually clarified. This may help to identify possible targets for both detection of activity as well as discovering new therapeutic agents. In the coming years, new clinical trials are expected based on this scientific progress. Logically, a biomarker that allows an early and accurate determination of treatment response will also be of a considerable value. In contrast to other inflammatory skin disorders such as psoriasis or atopic dermatitis, vitiligo lacks obvious inflammatory signs, which can be easily evaluated by clinical examination. Several clinical activity signs have been described in vitiligo (such as hypochromic areas, blurred borders and confetti-like depigmentation, and Koebners' phenomenon), although these signs are only present in a subset of active vitiligo patients. Moreover, it is unclear whether these signs can be used to evaluate disease activity over time. The hallmark of vitiligo is its unpredictable clinical course, including periods of disease stability and disease flares. This complicates the daily management of vitiligo. Biomarker analysis could be useful to follow patients over time and even predict the chance of future disease progression, allowing to tailor the treatment to the individual biomarker profile.
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ORIGINAL ARTICLES Top

Clinical, dermoscopic, and mycological association in onychomycosis in a tertiary care hospital p. 43
Daksha Vasava, Hita Mehta, Twinkle Patel, Milan Jhavar, Rahul Lakhotia
DOI:10.4103/CDR.CDR_49_20  
Background: Onychomycosis (OM) refers to fungal infection of the nail unit. It is one of the most common nail disorders, accounting for 50% of all nail disorders and about 30% of all cutaneous fungal infections. OM is mostly diagnosed clinically, but Dermoscopic (DS) examination aids in diagnosis. Objectives: The purpose of the study is to study the association between clinical, dermoscopic, and mycological patterns of OM. Materials and Methods: A total of 200 patients with clinical suspicion of OM were included in the study. All patients underwent clinical examination, dermoscopic examination with a handheld dermoscope Dermlite II pro (3 Gen, San Juan, Capistrano, CA, USA) with a ×10 magnification, KOH assessment, and culture analysis. The most frequent dermoscopic patterns were identified and their associations with the clinical subtype of OM were analyzed. Results: Out of the 200 cases, 65 cases were male and 135 cases were female. The most common findings seen on clinical examination of nails were discoloration of nail plates (178) and onycholysis (109). Distal irregular termination (91) was the most common dermoscopic finding seen followed by spike pattern (76). A significant association was seen between dermoscopic patterns such as superficial transverse striation, spike pattern, and different types of OM (P < 0.05). Eighty-two cases were positive for fungal elements by direct microscopy, 68 were positive by culture, and 18 patients showed positive result for both. The most common causative organism found on culture examination was Candida albicans (24). Conclusion: Dermoscopy is an easy-to-perform, noninvasive, and cost-effective method which aids in early diagnosis of OM.
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Efficacy and safety of 88% phenol application versus cryotherapy in repigmentation of idiopathic guttate hypomelanosis: A prospective study p. 49
Harish M Rajegowda, Deepadarshan Kalegowda, Shashikumar B Madegowda, Ambika C Rangarajaiah
DOI:10.4103/CDR.CDR_50_20  
Background: Idiopathic guttate hypomelanosis (IGH) is a common, acquired dermatosis characterized by multiple, round or oval, hypopigmented to depigmented macules. A variety of therapies with variable success are described, despite that, the treatment remains still unsatisfactory and a therapeutic challenge for the treating specialist. Objective: The objective of this study is to compare the safety and efficacy of 88% phenol application and cryotherapy in repigmentation of IGH macules. Materials and Methods: A total of 30 patients with more than 10 IGH macules were selected. For each enrolled patient, 88% phenol was applied to 5 IGH macules and single cryotherapy for 3–5 s was applied for another 5 IGH macules once in a month till the repigmentation for maximum of 3 applications. Patients were assessed monthly for 3 months for the side effects and improvement in pigmentation. The degree of improvement in pigmentation was assessed using a grading system, <25% - no response (Grade-1), 26%–50% - minimal (Grade-2), 51%–75% - good (Grade-3), and >75% - excellent response (Grade-4). Results: A total of 25 patients completed the study. At the end of the treatment period, out of 125 macules treated with short contact cryotherapy 75 (60%) macules showed excellent response and 20 (16%) macules showed good response. In phenol group, out of 125 macules 37 (29.6%) and 29 (23.2%) macules showed excellent and good improvement in pigmentation respectively, with P < 0.05. Side effects such as persistent scabbing, ulceration were more common with 88% phenol application compared to cryotherapy. Conclusion: Short contact cryotherapy of 3–5 s was found to be more efficacious and safe compared to therapeutic wounding with 88% phenol in inducing pigmentation of IGH macules.
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Comparison of purified protein derivative and vitamin D in the treatment of recalcitrant warts p. 54
Leena Raveendra, Belliappa Pemmanda Raju, Kumar K C Dharam, Vinutha Mohan Kumar Yadav
DOI:10.4103/CDR.CDR_51_20  
Background: Viral warts are caused by human papillomavirus. There are various treatment modalities which cause destruction of the warts. Not all of them are very effective on difficult-to-treat warts. For the treatment of difficult-to-treat warts, new and effective treatment includes intralesional immunotherapy. Objectives: The aim was to evaluate and compare the efficacy of intralesional Vitamin D and tuberculin purified protein derivative (PPD) as immunotherapy in difficult-to-treat warts. Materials and Methods: A total of 100 patients with difficult-to-treat viral warts were enrolled in this randomized controlled study. Group A patients were injected intralesionally with 2.5 TU of tuberculin PPD (0.1 ml) and Group B patients were injected with 0.1 ml of Vitamin D3 per lesion to a maximum of ten lesions. The clinical assessment was done by photographic measurements at baseline, before each treatment session, and after the completion of the treatment every 2 weeks for a total of four sessions. Unpaired t-test was used to compare both the treatment modalities. Results: In Group A, a total of 38 (76%) patients showed complete clearance and 12 (24%) showed partial response, while in Group B, a total of 42 (84%) patients showed complete clearance, while 8 (16%) showed partial response. There was no statistically significant difference between both the modalities. Conclusions: Intralesional Vitamin D3 injection and intralesional PPD may be a treatment option for difficult-to-treat warts that are unresponsive to conventional treatments. Both are equally effective with minimal side effects.
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Hair loss severity and its impact on quality of life in patients suffering from androgenic alopecia: A one-year cross-sectional study p. 59
Kriti Lohia, Bhavana Ravindra Doshi, BS Manjunathswamy
DOI:10.4103/CDR.CDR_52_20  
Background: Androgenic alopecia (AGA) is a common form of nonscarring alopecia encountered in daily dermatology practice. Both apparent and imperceptible AGA has a significant impact on an individual's personality, where physical appearance plays an important role in the probable prospects for marriage as well as other social aspects. Hair loss, thus, can severely hamper them for both men and women with clinical severity of alopecia not necessarily correlating with the quality of life (QoL) of the patient. Objectives: The objective is to assess the QoL in patients with AGA attending a tertiary care hospital in western India and compare QoL with hair loss severity (HLS), rated by both dermatologist and patient. Materials and Methods: One hundred and four patients, clinically diagnosed with AGA, consenting for the study over a period of 1 year were included. Demographic data of the patients were recorded. QoL was assessed using skindex-16 questionnaire; HLS was assessed through self-administered questionnaires completed by patients and dermatologists. Data were analyzed using Wilcoxon signed-rank test, Kendall's tau correlation coefficients, and Chi-square test. Results: The mean global score of Skindex–16 was 45.75 ± 16.90, with highest scores from emotions (64.93 ± 23.26). A positive correlation was found between the patients' HLS rating (r = 0.33, P < 0.0001) and the clinical HLS rating. However, patient rated the extent of their hair loss as more severe than the dermatologist. Patient-related HLS significantly correlated with the mean global score of Skindex–16 (P < 0.0001) as well as with all the subdomain scores (P < 0.0001), whereas dermatologist-rated HLS only significantly correlated with the global score of Skindex–16 (P = 0.04) but not with the subdomain scores. Limitations: As Skindex-16 is a self-reported questionnaire, there may be a recall bias. Another limitation of our study is the sample size; a study with a bigger sample size is required to vindicate our findings. Conclusion: The study demonstrates that AGA patients perceived their HLS as more severe than the dermatologist. Both patient-related HLS and dermatologist-rated HLS showed statistical correlation with the total global Skindex-16 score. Hence, dermatologists need to be more alert and should address the psychosocial and QOL issues, when treating patients with AGA.
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Dermatoscopy and clinicopathological correlation in different spectrum of leprosy p. 65
Amrit Singh Bhatia, Ambresh Badad, Ashok S Hogade, M Spoorthy
DOI:10.4103/CDR.CDR_53_20  
Background: Leprosy is a chronic granulomatous infection with varied clinical presentations. Dermatoscopy is a noninvasive technique that allows rapid and magnified in vivo observation of the skin with the visualization of morphologic features that are invisible to the naked eye. In our study, we aim to describe the dermatoscopic features of all types of leprosy and correlate with clinical and histopathological findings. Materials and Methods: A prospective observational study was done on all the leprosy patients attending OPD over a period of 1 year. The study patients were categorized as per Ridley–Jopling classification. The lesions of different types of leprosy were photographed and evaluated by dermatoscopy and biopsied. Results: A total of 60 patients (34 males and 26 females) were taken under the study. Of 60 patients, 6 cases of tuberculoid leprosy, 22 cases of borderline tuberculoid (3 with Type 1 reaction), 16 cases of borderline lepromatous, 12 cases of lepromatous leprosy (5 with Type 2 reaction), and 4 cases of Histoid leprosy. The dermatoscopic features seen are yellowish-orange areas and vascular structures such as linear branching vessels and crown vessels. Broken pigment network and white chrysalis like areas are also seen. Absence or diminished hair follicles and eccrine duct openings are seen in tuberculoid spectrum. Scaling and follicular plugs are seen in type 1 reaction. Conclusion: Yellowish-orange areas and vascular structures are the common dermatoscopic features seen in leprosy. Broken pigment network and paucity of appendageal structures are other features seen.
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A clinicoepidemiological study of adult acne among females: Is it surpassing the adolescent acne? p. 71
Harish Muddanahalli Rajegowda, BS Suman, Shashi Kumar Basavapura Madegowda, Deepadarshan Kalegowda, Bhagya Shree Shettar Rajendra
DOI:10.4103/CDR.CDR_55_20  
Background: Acne is usually recognized as an adolescent skin disorder, but recently prevalence among adults is increasing. There are not many studies on adult acne in Indian population. Objectives: To study the various clinico-epidemiological factors and assess laboratory investigations for underlying hormonal imbalance in patients with adult acne. Objectives: To study the impact of adult acne on psychological stress and patients quality of life. Materials and Methods: In our prospective observational study, female patients over the age of 25 years presenting with acne in a tertiary care hospital were included. All patients were assessed for hormonal imbalances both clinically and with laboratory investigations. Patients were asked to fill questionnaires to assess stress and impairment in quality of life. Statistical analysis used: Descriptive statistics like percentage ,mean, range were used. Inferential statistics like chi square test was used. The statistical significance was evaluated at 95% confidence level (P<0.05). Results: Out of 150 female patients included in the study, the mean age of the patients was 30.19 years. Persistent acne was observed in 77.3%, while it was late onset in 22.7%, with inflammatory acne (76%) being most common. Most patients showed clinical signs of hyperandrogenism but raised total testosterone levels was seen in only 1.3%. Scarring was observed in a majority of patients (76%), and psychological stress in 46.7% patients. Conclusions: Adult acne is predominant in women which can be of late onset or persistent type, is usually inflammatory with predominant distribution involving cheeks, mandible and chin as compared to adolescent acne. Psychological stress assessment and dermatological quality of life index helps in assessing the severity and providing appropriate treatment.
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A study on clinical patterns of nonvenereal male genital dermatoses at a rural-based tertiary care center p. 78
Rochit R Singhal, Pragya Ashok Nair
DOI:10.4103/CDR.CDR_60_20  
Background: All dermatoses affecting genitalia are not sexually transmitted. Wrongly labeling a patient as a case of venereal disease can have great psychosocial implications, apart from the resultant wrong treatment. It is necessary to have detailed knowledge and broader view while approaching genital lesions as it can be a nonvenereal disease. Objectives: The aim was to study the clinical patterns of nonvenereal male genital dermatoses. Materials and Methods: It was a cross-sectional observational study of male patients having nonvenereal genital dermatoses attending the Department of Dermatology for a period of 1 year from June 2016 to May 2017. Male patients with genital lesions were included in the study after taking their written consent in vernacular language. A detailed history and examination was carried out according to a prestructured pro forma. Investigations were done as and when required. Patients diagnosed with sexually transmitted disease were excluded from the study. Results: The study included 200 male patients having forty different nonvenereal genital dermatoses. Most patients belong to the age group of 19–40 years (46%), with a mean age of 36.47 years. Most of them were students (32%), were graduate (38.5%), and belonged to middle socioeconomic class (60.5%). Sixty percent of the patients were married. Common dermatoses encountered were scabies (27 [13.5%]), dermatophytoses (19 [9.5%]), scrotal dermatitis (16 [8%]), lichen planus (15 [7.5%]), vitiligo (12 [6%]), and psoriasis and pearly penile papules each with 10 (5%) cases. Other rare dermatoses were median raphe cyst, genital lentigenosis, granuloma annulare, nevus, cutaneous tuberculosis, and lichen sclerosus. Conclusions: Scabies was the most common nonvenereal genital dermatosis found in this study.
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Varying trends in geographical distribution and patterns of dermatophytosis and its antifungal susceptibility: A descriptive cross-sectional study in a tertiary care hospital of South India p. 85
Pranami Kashyap, Yadalla Hari Kishan Kumar, PR Belliappa, R Prakash
DOI:10.4103/CDR.CDR_64_20  
Background: Dermatophytosis is seen worldwide, causing severe physical, mental, and psychosocial morbidity to the patient. Owing to indiscriminate, inadequate and irregular use of various drugs, cases of anti-fungal resistance have emerged in recent times, leading to ineffective treatment needing multiple drugs over longer treatment durations. Hence, this study was taken up to evaluate the changing geographical trends in the clinico-mycological profile of dermatophytosis and its antifungal susceptibility patterns. Materials and Methods: Two hundred and eleven patients with clinically diagnosed dermatophytosis were evaluated with history, examination followed by a Potassium Hydroxide wet mount. Skin scrapings were also taken for fungal culture and antifungal susceptibility tests against ten commonly used antifungal agents using the Broth Microdilution method as per CLSI M38-A2 guidelines. Results: Tinea incognito was the most common presentation, and Trichophyton rubrum was the predominant dermatophyte isolated. Recurrent dermatophytosis was seen in 11.84% subjects. Terbinafine was the most effective systemic agent, while Luliconazole was the most effective topical agent. Itraconazole and Luliconazole were the most effective systemic and topical agents, respectively, at their lowest minimum inhibitory concentrations inhibiting T. rubrum isolates in vivo. Fluconazole, followed by Griseofulvin, showed the least efficacy. In vitro microbiological resistance to Griseofulvin was found in 15.3% of cases (P < 0.00001). Conclusion: The rapidly evolving geographical trends in clinico-epidemiological profiles of dermatophytosis and its varying antifungal susceptibility patterns highlight the need for updating the knowledge of this disease in the global scenario as well as counseling the rural populations with behavioral and lifestyle modifications.
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CASE REPORTS Top

Ulcerated subcutaneous nodules: The first presenting sign of gastric adenocarcinoma p. 92
Tulika Rai, Sermili Rini Singnarpi, Vijay Kumar, Shailesh Singh
DOI:10.4103/CDR.CDR_35_19  
Cutaneous metastasis from internal malignancies is rare and represents about 2% of all skin tumors. Cutaneous metastasis occur in about 0.2%–0.4% of gastric carcinoma cases, most commonly affecting the abdomen with neck, head, eyebrow, axilla, chest, and fingertips being the other sites. Here, we present a case in which cutaneous metastases presenting as multiple crateriform nodules were the first presenting signs of gastric adenocarcinoma.
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Mixed connective tissue disorder in a patient with retroviral disease: A rare case report p. 95
Farhana Tahseen Taj, Monika Singh
DOI:10.4103/CDR.CDR_37_19  
Connective tissue disorders are a group of disorder of unknown etiology. Mixed connective tissue disorder is a distinct syndrome with combination of features of Systemic lupus erythematosus, systemic sclerosis,dermatomyositis/polymyositis and rheumatoid arthritis. We report a case of mixed connective tissue disorder in a patient with acquired immune deficiency syndrome which is to the best of our knowledge is very rare presentation.
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Knife cut fissures: A clue for vulval crohn's disease!! p. 98
ML Ranjitha, Kanathur Shilpa, Budamakuntla Leelavathy, DV Lakshmi
DOI:10.4103/CDR.CDR_41_19  
Crohn's disease is an inflammatory bowel disorder with various extraintestinal manifestations. Vulva is rarely involved in Crohn's disease and occasionally may constitute the only sign of the disease. It is often unrecognized and can be confused with various disorders involving the vulva. Vulval Crohn's disease is often refractory to treatment. We describe a case of 30-year-old female presented with labial swelling, discharging sinuses and knife cut fissures and diagnosed as a case of vulval Crohn's without intestinal involvement, that was managed with oral steroids, sulfasalazine, and metronidazole.
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Scar sarcoidosis: A dermatologic masquerader p. 101
Seema Rani, Sweta Singh, Minakshi Bhardwaj
DOI:10.4103/CDR.CDR_39_19  
Cutaneous sarcoidosis has varied clinical presentation and is a great mimicker, which requires an initial work-up for systemic involvement, followed by periodic screening. Recognition of cutaneous lesions is important because they provide a visible clue to the diagnosis and serve as an easily accessible source of tissue for histologic examination. Scar sarcoidosis is a rare clinical entity and often missed, and clinical diagnosis is made on subsequent biopsy after excluding other causes. We report a rare presentation of cutaneous sarcoidosis.
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A case of lichen planus pigmentosus in blaschkoid pattern in a 10-year-old female p. 104
Tulika Rai, Ayushi Bohara, Prasanna Kumar Jha
DOI:10.4103/CDR.CDR_42_19  
We describe a rare case of lichen planus pigmentosus (LPP) involving a 10-year-old female child with the involvement of the anterolateral aspect of the left thigh following the lines of Blaschko. LPP is a rare pigmented variant of lichen planus. Lines of Blaschko are lines of normal cell development. Histopathology showed melanophages in the papillary dermis with perivascular lymphocytic infiltrate and focal vacuolar change in basal layer consistent with a diagnosis of LPP.
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Treatment for syphilis unraveling gluten-sensitive linear IgA dermatosis p. 107
Ani Prakashbhai Patel, Jignaben Krunal Padhiyar, Vidhi Sanjay Chandibhamar, Nayankumar Harshadkumar Patel
DOI:10.4103/CDR.CDR_43_19  
Linear IgA bullous dermatosis (LAD) is an acquired autoimmune blistering disorder which can develop following various drugs but not after banzathine penicillin injection. LAD has lower prevalence of associated gluten-sensitive enteropathy (GSE). We describe the case of a 20-year-old male with homosexual behavior who presented with multiple pruritic maculopapular lesions over the trunk, extremities, and palms for 2 months. Rapid plasma reagin (1:1280 titer) and treponema pallidum hemeagglutination tests were positive. A diagnosis of syphilis was made. The patient developed vesicular lesions following benzathine penicillin injection with histopathological and immunofluorescent features characteristic of LAD. Despite treatment, the patient continued developing new vesicles. Gluten-free diet (GFD) was advised, and the patient was further investigated for GSE. The patient responded well to GFD. We conclude that the prevalence of drug-induced LAD and associated GSE is quite low, but possibility exists. Hence, a diagnosis of GSE must be sought as patients might respond to GFD.
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Involvement of palms in leprosy: An unusual clinical manifestation p. 110
C Divyalakshmi, Naveen Kumar Kansal, Prashant Pranesh Joshi, Divya Singh
DOI:10.4103/CDR.CDR_44_19  
Leprosy (Hansen's disease), a chronic granulomatous infection caused by Mycobacterium leprae, frequently affects the areas of skin, which have a relatively low temperature and/or are prone to trauma. Several zones of skin, for example, scalp, palms and soles, groins, genitalia, axillae, eyelids, and perineum, have usually been described as “immune” to lesions of leprosy. However, clinical, bacteriological, and pathologic evidence of involvement of these so-called “immune zones” has rarely been documented. Therefore, now many workers have proposed that these “immune zones” should be called “relatively immune,” rather than “absolute immune.” Hereby, we report a rare case of leprosy with palmar involvement.
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Adenoid basal cell carcinoma: A rare variant and a diagnostic dilemma p. 114
Neha Sethi, Anjali Sharma, Chaitali Singh, Kirti Pandia, Anil Gupta
DOI:10.4103/CDR.CDR_46_19  
Basal cell carcinoma (BCC) constitutes the most common malignancy of the skin, accounting around 70% of all skin malignancies, especially in sun-exposed areas. The adenoid variant is a very uncommon subtype which accounts for approximately 1.3% of all BCCs. A 65-year-old male presented with ulcer and swelling on the left side of the nose and cheek with rolled borders for the past 2 years. Based on the histopathology and immunohistochemistry, the diagnosis of the adenoid type of BCC was made. One should be aware of its close mimics such as primary cutaneous adenoid cystic carcinoma before diagnosing adenoid BCC as they differ in prognosis and treatment modalities.
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Arsenical keratoses: Case report from nonendemic area of Amritsar p. 117
Tejinder Kaur, Jyoti Budhwar
DOI:10.4103/CDR.CDR_49_19  
Arsenic occurs naturally in the earth's crust, widely distributed in the environment, in drinking water, used in various industrial, agricultural & medicinal substances & is a occupational hazard for miners and glass workers. Arsenic impairs nucleotide excision repair, affect DNA methylation. Chronic exposure of arsenic leads to arsenical keratosis, which usually presents as multiple hyperkeratotic, punctuate lesions, occurs at sites of friction and trauma especially on palms and soles and on chronically light exposed skin. They resemble Bowen's disease microscopically and may progress to squamous cell carcinoma or basal cell carcinoma. Topical 5-FU, 5% Imiquimod and oral retinoids may be helpful in treating arsenic induced cutaneous lesions. Arsenical keratosis in a patient of non endemic area of Amritsar region, makes this case worth reporting.
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Alopecia totalis successfully treated with modified platelet-rich plasma therapy in a patient recalcitrant to traditional treatment modalities p. 120
Sumit Gupta, Priyanka Borde Bisht, Charisma Kannan
DOI:10.4103/CDR.CDR_50_19  
Alopecia areata (AA) is an autoimmune, nonscarring, inflammatory disorder of the scalp and/or body resulting in hair loss. Extensive AA such as alopecia totalis is increasingly unresponsive to conventional treatment modalities. We report a case of alopecia totalis showing a promising response with the application of platelet-rich plasma therapy modified with triamcinolone acetonide.
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Syringoma: A rare presentation at an unusual site p. 123
Anitha Bhakthavatsalam, Ragunatha Shivanna
DOI:10.4103/CDR.CDR_52_19  
Syringomas are benign adnexal tumors arising from the lower intraepidermal and upper dermal eccrine sweat ducts, manifesting as asymptomatic, multiple tiny firm skin-colored papules, commonly over the lower eyelid and malar area of the face. A case of syringoma in an adult female patient presenting with asymptomatic lesions occurring exclusively on the vulva with an unusual presentation as a polypoidal growth is reported. Vulvar syringomas may not be recognized if they are asymptomatic or they may be misdiagnosed. Examination of the vulvar region should not be missed when syringoma is found outside the genital area. Syringomas should be considered in the differential diagnosis of vulvar pruritus, vulvar pain syndrome, and papulonodular lesions or polypoidal mass over the vulva.
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Congenital ichthyosiform erythroderma: A report in two siblings p. 126
Tulika Rai, Najuma Subba, Sri Rupa
DOI:10.4103/CDR.CDR_36_19  
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A painless bump on scalp p. 129
Seetharampura Ramamurthy Radhika, Kanathur Shilpa, Leelavathi Budamakuntla
DOI:10.4103/CDR.CDR_2_20  
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