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   Table of Contents - Current issue
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July-December 2020
Volume 4 | Issue 2
Page Nos. 69-190

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SYMPOSIUM: BASICS OF DERMOSCOPY AND DERMOSCOPIC PATTERNS  

Basic science of dermoscopy Highly accessed article p. 69
Balachandra S Ankad, SV Smitha, Varsha R Koti
DOI:10.4103/CDR.CDR_71_20  
Introduction: Dermoscopy is a non-invasive tool which demonstrates characteristic patterns in many dermatoses. To understand dermoscopy, basic elements, vascular structures and pigment netwrok should be dealt with. One needs to understand the concept of basic physics of dermoscopy and cross polarization. Non-polarized and polarized lights show particular patterns in prominence. Hence both are complementary to each other. It is recommended to use both lights in clinical practice. Essentially, dermoscopic features should be analyzed and interpreted in terms of pattern of dermoscopic changes, predominant color and any specific clues present in the lesion. This is basic approach to a given lesion to arrive at accurate diagnosis dermoscopically. Aim: To understand the basic principles of dermoscopy and the types of dermoscopy. Summary: Dermoscopy is a rapid method that involves the use of a hand-held device with a built-in illumination and magnification systems. It is an in-vivo technique to observe the surface and subsurface structures in the skin layers. In the past, it was employed exclusively to diagnose and rule out melanoma in a given pigmented lesion. Its confirmed utility in inflammatory and infective dermatoses has enhanced its popularity as dermatologist's stethoscope.
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Dermoscopic approach to inflammatory lesions in skin of color p. 74
Balachandra S Ankad, Varsha R Koti
DOI:10.4103/CDR.CDR_69_20  
Introduction: Dermoscopy is an in vivo and non-invasive tool that assists as an adjunctive method in the diagnosis of many dermatoses. Dermoscopic studies and research in the field of inflammatory and infective lesions are limited to case series or case reports without definitive criteria. Authors have attempted to describe a very basic approach to dermoscopic diagnosis of inflammatory conditions like psoriasis, eczema, lichen planus, pityriasis rosea, prurigo nodularis, and discoid lupus erythematosus. Aim: To propose basic dermoscopic guidelines in terms of approach to an inflammatory lesion.Summary: Dermoscopy of inflammatory conditions is referred to as 'inflammoscopy'. Basic approach in inflammoscopy is based on 5 dermoscopic parameters which include; i) background colour, ii) vessels, iii) scales, iv) follicular findings and v) specific clues. Dermoscopy helps in the differentiation of many inflammatory lesions by demonstrating characteristic patterns thus aiding in its diagnosis. Uniform and regular dotted vessels are seen in psoriasis. Wickham striae, adherent fabric fibre sign, yellow clod sign and white rosettes are respectively a special clue for the diagnosis of lichen planus, prurigo nodularis, eczema and early DLE lesion. Collarette scales over brownish yellow background are seen in P. rosea. Dermatologist dealing with skin lesions in patients with skin types IV, V, and VI should be aware that there are slight variations in the dermoscopic pattern owing to amount of melanin.
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Dermoscopic approach to hypopigmentary or depigmentary lesions in skin of color Highly accessed article p. 79
Balachandra S Ankad, Varsha R Koti
DOI:10.4103/CDR.CDR_68_20  
Introduction: Hypopigmented or depigmented lesions are considered as important dermatoses in daily practice. Their accurate diagnosis is very much crucial because of social stigma attached to these diseases in Indian subcontinent. Authors have proposed basic guidelines for dermoscopic assessment in terms of approach to a given hypopigmented/depigmented lesion. The following conditions are dermoscopically described here, they are vitiligo, idiopathic guttate hypomelanosis, lichen sclerosus, pityriasis alba, leprosy, pityriasis versicolor and nevus depigmentosus. Aim: To propose basic dermoscopic guidelines in terms of approach of a hypopigmented/ depigmented lesion in skin of color. Summary: Dermoscopic patterns highly depend on melanin skin layers and thus analysis of dermoscopic patterns in hypopigmented/depigmented lesions is difficult owing to the reduction or absent melanin in the epidermis. All hypopigmented/depigmentary conditions are described based on the 5 dermoscopic parameters which include; i) background colour, ii) vessels, iii) scales, iv) follicular findings and v) specific clues. Glowing white color in vitiligo and pale or dull white color in IGH and white with little brownish color in PA and PV are the different shades of color in the background in dermoscopy. In leprosy, PMH and ND, background color is brownish-white rather white. LSEA, color is white with bluish or pinkish hue is observed. Furthermore, dermoscopic diagnosis should be based on every parameter visible in a given lesion and not in isolation as each pattern or parameter is immensely contributory to the final diagnosis. Conclusion: Thus, dermoscopy aids in the distinction of hypopigmented/depigmentary lesions by demonstrating characteristic and definitive patterns.
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Dermoscopic approach to hyperpigmented lesions in skin of color Highly accessed article p. 84
Balachandra S Ankad, Nicholas R Drago, Varsha R Koti, Balkrishna P Nikam
DOI:10.4103/CDR.CDR_74_20  
Hyperpigmented skin lesions are common presentation of Indian patients. It causes cosmetic disfigurement, as well as has immense psycho social impact. Most of the lesions are diagnosed clinically but some of them are difficult to diagnose because of overlapping features. To form basic dermoscopic guidelines to approach a hyperpigmented lesion. LPP and EDP demonstrate brownish background with bluish gray hue and brown to gray globules, which is also seen in PCD with superimposition of brown globules. Linear cristae cutis and sulci cutis forms a special clue in AN. Frictional melanosis displays bluish gray globules with patulous follicles with plugs and perifollicular scaling. Patulous follicular opening with whitish yellow excrescences on pseudopigment network is seen in seborrheic melanosis. PDL displays peri-follicular brown globules with no vasculature changes or scales. Melasma shows prominent brown background with reticular or reticulo-globular pigment pattern. Exogenous ochronosis demonstrates grayish brown globules with obliteration of follicular openings. Brown polygonal globules with scales along skin lines and over the globules are noted in CRP. Hub and spoke pattern of pigmentation is a feature of macular amyloidosis. Hyperpigmented pityriasis versicolor demonstrates accentuated pigment network with scaling in diffuse or perifollicular or along skin lines seen. Dermoscopic diagnosis should be based on amalgam of all parameters identified in a given lesion and not in isolation. Dermoscopy is of great importance for assessment of hyperpigmentation disorders in dark-skinned patients as they may clinically look similar due to the natural brownish background.
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Nail disorders in skin of color: Approach to onychoscopic diagnosis Highly accessed article p. 92
Balachandra S Ankad, Yasmeen Jabeen Bhat, Sakshi S Gaikwad
DOI:10.4103/CDR.CDR_70_20  
Onychoscopy provides a better understanding of nail lesions in terms of diagnosis, monitoring of progression and response to treatment. Author have put forward a simplified way to approach to a nail lesion by onychoscopy. Onychoscopy of pigmentary, inflammatory, infections, neoplastic and connective tissue diseases affecting the individual of skin of color are described to construct a basic outline for onychoscopic approach to a nail lesion. Onychoscopy shows homogenous dark band in longitudinal melanocytic nevus (LMN), irregular black pigment with irregular longitudinal lines in melanoma, multi-colored pigmented patches in fungal melanonychia, purplish-black in subungual hematoma, transverse bands in the under surface of plate in true leukonychia, whitish- yellow patches in pseudoleukonychia. In psoriasis, irregular pits, salmon spots are seen whereas in lichen planus onychorrhexis, whitish linear splits and pterygium are observed. Eczema shows pits with lusterless surface. In Darier's disease, characteristic alternate white and red bands are present. Lichen striatus shows longitudinal erythematous bands and ridging. Red dots with white halos are characteristics in warts. Onychomycosis shows 'aurora borealis' pattern and white opaque and friable spots. Bowen's disease shows white scales with red dots. 'Woodworm appearance' and keratotic mass are seen in onychomatricoma and respectively. Squamous cell carcinoma reveals destruction of nail plate and glomus tumor demonstrates pinkish blush. In connective tissue diseases, characteristic changes are present nail fold capillaries. Onychoscopy assists in the analysis and differentiation of many dermatoses which affect nail unit with similar clinical manifestations.
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Trichoscopy in hair disorders in darker skin: An approach to diagnosis p. 102
Balachandra S Ankad, Samipa Mukherjee, SV Smitha
DOI:10.4103/CDR.CDR_79_20  
Introduction: Trichoscopy is a non-invasive technique that shows promising results in the diagnosis and assessment of response to treatment in various types of alopecias. Besides diagnosing alopecia, it is helpful in choosing an ideal biopsy site. Here authors have attempted to describe trichoscopic findings of healthy scalp and compare hair shaft abnormalities, follicular and interfollicular features and vascular patterns of common non-cicatricial and cicatricial alopecias in skin of color. Summary: Trichoscopy of androgenetic alopecia shows hair diameter diversity, brown and white peripilar sign. Exclamatory hairs and coudability hairs are characteristics of alopecia areata. 'i' hair and pigtail hair indicates good prognosis in alopecia areata. Mace hair sign and burnt matchstick sign are newer findings of trichotillomania. Tinea capitis shows comma hairs, corkscrew hairs. Morse-code like hairs, zigzag hairs and bent hair are specific for tinea capitis. Traction alopecia shows anisotrichosis and hair casts with follicular drop outs in severe disease. Trichoteiromania shows trichoptilosis and broom hairs. Lichen planopilaris (LPP) and discoid lupus erythematosus show 'targetoid' and speckled patterns of blue-grey dots respectively. Perifollicular tubular scaling is characteristic in LPP. Frontal fibrosing alopecia presents as absent follicular openings and follicular plugging. Follicular tufting with starburst fibrotic bands is definitive of folliculitis decalvans. Pseudopelade of Brocq presents with loss of follicular ostia with prominent honeycomb pigmentation.
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REVIEW ARTICLE Top

Thymic stromal lymphopoietin in dermatological diseases p. 115
Mohamed Ibrahim ElGhareeb
DOI:10.4103/CDR.CDR_8_19  
Thymic stromal lymphopoietin is an epithelial cell-derived cytokine expressed in gut, lungs, skin, and thymus. It affects both the local dermal dendritic cells (DCs) and the circulating myeloid DCs. It has important roles in the pathogenesis of many dermatological diseases and may be correlated with disease activity. In this review, its role in the pathogenesis of some dermatological diseases was illustrated.
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ORIGINAL ARTICLES Top

Trichoscopic evaluation of alopecia areata of the scalp and clinical correlation of these findings with disease activity and severity p. 118
Anita Vijay, Pramila Kumari, Alpana Mohta, Kapil Vyas, Ramesh Kumar Kushwaha, Suresh Kumar Jain
DOI:10.4103/CDR.CDR_3_20  
Background: Alopecia areata (AA) is a common, chronic inflammatory disease characterized by nonscarring hair loss on the scalp or any hair-bearing area of the body. Recently, trichoscopy has emerged as a noninvasive method for the evaluation of AA. Aim: Evaluating trichoscopic patterns in AA and correlating these with the disease activity and severity. Materials and Methods: Noncontact trichoscopy was performed on AA patients using polarized mode of DermLite dermatoscope. The trichoscopic patterns were recorded and analyzed to cognize their correlation with the disease activity and severity. Results: In our study, we observed 10 distinct types of hair under dermascope in 260 cases of AA. The most common type of AA was localized patch type. On trichoscopy, the most common finding was yellow dots (YDs) in 189 (72.71%) cases and other findings were short vellus hair (SVH), broken hair (BH), tapering hair (TH), black dot (BD), and trichoptilosis. Statistically significant positive correlation was observed between YDs, BD, BHs, TH, CD, and T and disease activity (r = 0.204, 0.389, 0.568, 0.683, 0.504, and 0.347 and P = 0.001, 0.000, 0.000, 0.000, 0.000, and 0.000, respectively). Statistically significant positive correlation was observed between TH, BH, and T and disease severity (r = 0.276, 0.250, and 0.146 and P = 0.000, 0.000, and 0.019, respectively). SVHs were correlated negatively with the disease activity and severity (r = −0.111, P = 0.075 and r = −0.141, P = 0.075, respectively). Conclusion: Our study has proved the utility of trichoscopy in evaluating AA. It has emerged as a useful noninvasive tool for evaluating classical and novel patterns and their correlation with the different determinants of the disease and assessing disease severity.
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A study of clinical and investigational profile of hirsute women at a tertiary care center in Western India p. 123
Priyanka G Dhanotia, Bela J Shah, Suyog S Dhamale
DOI:10.4103/CDR.CDR_34_18  
Background: Hirsutism is defined as a male pattern of hair distribution in a female. The interplay of androgens as well as other non androgenic hormones has an important role in the causation of hirsutism. Objectives: The objective of this study was to investigate the prevalent causes for hirsutism and to study the clinical profile of patients presenting with hirsutism. Methodology: Patients who came with features of hirsutism were screened by the modified Ferriman–Gallwey (mFG) scale and those with mFG ≥8 were included in the study. Patient's clinical history, family history, body mass index, general examination, dermatological examination, and systemic examination were carried out. Serum total testosterone, serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), LH: FSH ratio, dehydroepiandrosterone sulfate (DHEAS), thyroid-stimulating hormone, blood sugar levels (fasting and postprandial), and abdomino-pelvic ultrasound were performed for all patients. Serum prolactin, free testosterone, 17 hydroxyprogesterone, T3level, T4level, serum cortisol level, and serum fasting insulin levels were performed in selected patients depending on the clinical scenario. Results: A total of 44 patients were studied during the study. About 95.45% of patients were categorized under mild mFG, whereas 4.55% of patients had moderate mFG score. Idiopathic hirsutism (IH) was the most common cause in our patients which accounted for 43.18% of patients followed by polycystic ovarian syndrome (PCOS) which was the reason for hirsutism in 38.64% of patients. Total testosterone was raised in 25% of patients. Free testosterone levels were performed for 25 patients and found to be raised in six patients. Five patients had elevated DHEAS levels of which four had PCOS and one had late-onset congenital adrenal hyperplasia. Conclusion: IH was the most common cause of hirsutism in our patients which was followed by PCOS.
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A study to evaluate various upcoming therapies for acne scars: Head on comparison p. 128
Suyog S Dhamale, Amita H Sutaria, Bela J Shah
DOI:10.4103/CDR.CDR_34_19  
Background: Scarring is a most common complication of acne vulgaris which has negative psychosocial implications. Multiple surgical modalities are available for the management of scars. Very few studies are available in literature which compares these modalities head-on and in a comprehensive way. Aims and Objectives: The objective is to analyze and compare the efficacy of subcision alone as well as combination of subcision with other therapeutic modalities. Materials and Methods: The study was carried out in 95 patients with postacne scars. Patients were divided into four groups as follows: Group I (S): Subcision; Group II (S + M): Subcision + microneedling; Group III (S + P): Subcision + platelet-rich plasma (PRP); Group IV (S + T): Subcision + trichloroacetic acid (TCA) peeling; all patients were followed up with photographs at 2, 6, and 9 months after start of treatment. Goodman-Baron's qualitative score assessment was performed at the start and end of the study. In addition, we also appointed independent blinded dermatologist for evaluating clinical improvement in terms of % improvement based on serial clinical photographs. Results: Among all modalities, subcision alone group showed the least improvement while subcision plus microneedling group showed the best response. Difference in final response of (S + P) and (S + T) groups was not statistically significant, but it was better than subcision alone group. Conclusion: Subcision plus microneedling showed the best response in our study while subcision plus PRP efficacy is comparable to that of subcision plus TCA peeling.
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Dermoscopic differentiation of pustular psoriasis and tinea incognito p. 136
Balachandra S Ankad, Apoorva S Reshme, Balakrishna P Nikam, Nicholas D Drago
DOI:10.4103/CDR.CDR_19_19  
Introduction: Dermoscopy is a rapid diagnostic method in many inflammatory dermatoses which are diagnosed accurately by dermoscopy. Clinically, pustular psoriasis (PP) and tinea incognito (TI) look similar, and sometimes, TI is an invader into PP. Hence, it is important to differentiate each to manage them properly. Thus, a tool to distinguish both TI and PP is necessary for the correct diagnosis and management. Dermoscopy of PP is well-documented but not in TI. Here, we describe the dermoscopic differentiation of TI from PP with histopathological correlation. Materials and Methods: This was a cross-sectional study. Cases of PP and TI were included. DermLite 3 was employed. Potassium hydroxide (10%) mount and histopathological examination were done to confirm the diagnosis. Statistical analysis was done using “z” test. Results: A total of 20 TI and ten PP patients were in the study. Micropustules and scales were seen in all (100%) patients of PP and TI. Brown and black globules and hair changes were seen only in TI (100%), not in PP (0.0%). Red dots were observed in all PP patients (100%), not in TI (0.0%). Erythematous background in PP (100%) and in TI (70%) was statistically significant with P < 0.001. Conclusion: Dermoscopy is an in vivo tool to visualize the deeper structures of the skin. It demonstrates characteristic and different patterns in PP and TI as well, thus aiding in the differentiation of both the conditions. It would help treating physician to manage correctly and avoid unnecessary delay in the accurate diagnosis and treatment.
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Retrospective analysis of a cohort of 16 patients with drug reaction with eosinophilia and systemic symptoms p. 141
Varadraj V Pai, Simantini Sakardhande, Pankaj Shukla, Karla Nadine Faleiro
DOI:10.4103/CDR.CDR_30_19  
Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe adverse drug-induced reaction characterized by a triad of fever, skin rash, and symptomatic or asymptomatic internal organ involvement. Aims: The aim of this study is to determine the study of varied clinical manifestations and their therapeutic outcome in patients with DRESS. Materials and Methods: A hospital-based retrospective case series was conducted in the department of dermatology. The medical records of patients with DRESS syndrome, drug reaction with eosinophilia, and drug hypersensitivity syndrome within 3 years were reviewed and were entered into a specially prepared pro forma. Results: A total of 16 patients fulfilled the criteria and were studied with equal involvement in males and females. The latency period of 4–6 weeks was the most common duration for drug exposure. Anticonvulsants were associated with more than 50% of the cases. Other than skin, hematological and hepatic involvement was noted. The topical steroids with moisturizers reduced scaling and erythema in 62.5% of the patients. Conclusion: The manifestations in DRESS can be diverse ranging from cutaneous lesions such as maculopapular rash to systemic involvement. Anticonvulsants are the most commonly implicated drug. Topical steroids are effective in patients with limited skin involvement.
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Uncommon cutaneous manifestations in buffalopox p. 146
Sanjay Gore, Anirudha Gulanikar, Chetan Rajput, Shubhangini Sharma, Shailesh Malani
DOI:10.4103/CDR.CDR_28_18  
Context: Buffalopox is a zoonotic disease caused by buffalopox virus. The natural host being buffaloes, it has been known to infect cows and humans as well. Recent trends suggest that increasing numbers of outbreaks in the Indian subcontinent are being recorded, but awareness about diagnosis, treatment and preventive measures in humans is much less. Aim: To report the rare occurrence of lesions in humans at atypical sites like face and eyes and also indirectly involving non-milkers. Methods and Material: The study was carried out in Dhule, Maharashtra where twenty-eight patients were diagnosed with the condition based on history and clinical examination. The diagnosis was confirmed by viral nucleotide sequencing by polymerase chain reaction. Results: Total twenty-eight patients were diagnosed with buffalopox with a male predominance. Most of them were milkers but two children who were not directly involved in milking were also affected. Lesions were mostly present over hands and forearms. We found involvement of atypical sites like face and eyes in some patients. Prophylactic antibiotic treatment was given, draining of pus and debridement done and hygienic practices like use of gloves were promoted. Conclusions: Early interventions in such conditions help limit the disease itself; however, the involvement of children and presentation of atypical sites may indicate increased virulence of the virus. This may lead to a severe epidemic in the future. Atypical presentations, and new sites of development of clinical lesions should be kept in mind. Awareness should be created regarding the emergence of poxvirus infections in future.
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A study on the role of footwear as a cause of foot eczema using patch test p. 149
Neema Sandra Dias, B Nanda Kishore, D Sukumar
DOI:10.4103/CDR.CDR_7_20  
Background: Foot eczema is an allergic contact dermatitis which runs a chronic course due to the ignorance of the causative agent. Patch test is a safe and simple outpatient diagnostic procedure for all kinds of allergic contact dermatitis. Aims and Objectives: This study was done to find the role of footwear as a cause of foot eczema and to know the most common allergen in the footwear causing foot eczema by Patch testing. Materials and Methods: A total of 71 patients were enrolled in the study who presented with foot eczema. Meticulous history was taken and clinical examination was done on all patients. A patch test using Indian footwear series containing 15 allergens was performed, and results were recorded after 48 h. Results: In our study comprising 71 patients, age of the patients ranged from 13 to 70 years with a slight female preponderance. Plantar surface of foot was the most common site involved (35.2%) with a winter aggravation (21.1%). A total of 63.4% of patients were tested positive for one or more allergens present in the footwear. Footwear was reported to be an inciting agent in 36.4% patients, and 82.6% of these were tested positive. Black rubber mix (22.53%), nickel (14.08%), and colophony (12.67%) were the most common sensitizers. Conclusion: A significant incidence of footwear as a causation of foot eczema was concluded, with rubber and metals being the most common allergens. It is noteworthy to consider employing patch test routinely to know the causation of footwear in the foot eczema so that appropriate footwear can be used. However, it would be helpful if we could detect the specific allergen in a footwear to help these patients suffering a relapsing chronic dermatitis.
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Changing allergen pattern in allergic contact dermatitis p. 155
Neethu Mary George, Narendra Gangaiah, Veena Thimmappa, Amruthavalli Potlapati
DOI:10.4103/CDR.CDR_27_19  
Background: Allergic contact dermatitis (ACD), a T-cell mediated type 4 hypersensitivity reaction, occurs when skin get exposed to exogenous allergens. True incidence of ACD is difficult to estimate. Common sensitizers also vary with place, patient profile and time. With increasing complexity of human life, our skin gets exposed to a large spectrum of chemical and biological products, thereby increasing allergic sensitisation. Aim and objectives: To identify the common allergens causing allergic contact dermatitis in a tertiary health centre and to determine the clinical profile of patients presenting with the same. Settings and Design: A cross sectional study was conducted in a tertiary health centre in Tumkur. Materials and methods: Fifty patients with suspected allergic contact dermatitis were enrolled. Demographic data, clinical history, examination and patch testing with Indian standard series containing 19 allergens was done after subsidence of active eczema. Statistical analysis used: Descriptive statistics were reported using mean and standard deviation for continuous variables, number and percentage for categorical variables. The Chi-Square test was used and a 'p' value of 0.05 proportion or less was considered statistically significant. Results: Out of the 50, 35 were patch test positive. There was a slight male predominance(4:3) and majority belonged to the age group 31-50 years. The common allergens in decreasing frequency were parthenium, fragrance mix, PPD, potassium dichromate and chlorocresol. Conclusions: With changing lifestyle and urbanization, the allergens keep on varying. The clinical pattern also varies with the causative allergen/s. Such studies help to detect the common prevalent allergens in a locality and thereby avoid misdiagnosis and also in creating awareness.
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Comparative analysis of serum lipid profile in adults with and without acne vulgaris in a tertiary care center in South India p. 160
Halaguru Narayanaswamy Veena, Kanathur Shilpa, Budamakuntla Leelavathy, Dammaningala Venkataramaiah Lakshmi
DOI:10.4103/CDR.CDR_40_19  
Background: Acne is a chronic inflammatory disease of the pilosebaceous unit, affecting most teenagers during adolescence and at times may persist into adulthood also. Sebum analysis in some studies has shown increased triglycerides and wax/cholesterol esters in acne patients. Whether there is local alteration of surface lipids and seborrhea associated with any alteration of serum lipid profile in acne patients is not yet known. However, few studies in acne patients have shown definitive variations in lipid profile providing insights into plausibility of role of altered serum lipid levels in acne. Aims: The aim was to evaluate serum lipid profile in adults with and without acne vulgaris and to study the correlation between lipid profile and severity of acne in Indian patients. Materials and Methods: Fifty male and female adults presenting with acne aged between 18 and 40 years along with age- and sex-matched healthy adults without acne were subjected for serum lipid level analysis. Results: In this study, there was no significant difference in lipid levels in acne patients compared to control. Limitations: The limitation of the study was small sample size. Conclusions: There is no statistically significant increase in total cholesterol, very low-density lipoprotein, and low-density lipoprotein in acne patients compared to control.
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CASE REPORTS Top

Scalp micro-needling: A new tool in the treatment of alopecia totalis p. 164
Savitha L Beergouder, Apoorva Reshme
DOI:10.4103/CDR.CDR_29_19  
Alopecia areata is the most common form of nonscarring alopecia. It may vary from a single round patch to that involving large surface area termed as alopecia totalis (AT). Pediatric age of onset, more extensive disease, and recalcitrance to initial therapies are more challenging to treat and require the synergy of two or more established therapy. Here, we have treated a case of AT with scalp micro-needling with topical steroids.
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Basal cell carcinoma arising in a tattoo p. 167
Nicole Edmonds, Thomas Cropley, Mary M Noland, Richard Hal Flowers
DOI:10.4103/CDR.CDR_24_19  
Cutaneous malignancies may uncommonly arise in the setting of injury to the skin from a variety of etiologies. While melanoma, squamous cell carcinoma, and basal cell carcinoma (BCC) have all been reported at tattoo sites, BCC is the least common, with the present case being only the 12th such case reported in the literature. We present a case of a large BCC of 15 years duration arising within a blue/black tattoo on the patient's left upper arm. The patient was treated with 6 weeks of imiquimod cream with promising results and started a second 6-week regimen to clear residual tumor. Of the 12 reported cases of BCC arising within tattoo sites, the majority of patients have been male (7/12 patients) and the majority of the BCCs developed within the blue or black pigment of the tattoo (8/12 patients) on sun-exposed skin (9/12 patients). The average age at the diagnosis is 53.5 years, and the average duration between tattoo placement and BCC onset is 18.3 years. It has been hypothesized that tattoo ink may be related to the development of malignancies as either a primary carcinogen or cocarcinogen with ultraviolet exposure. Nevertheless, the link between tattoo ink and malignancy may also be coincidental considering the number of tattooed individuals worldwide and the extreme rarity of BCCs that have developed in tattoos. Our purpose is to raise the awareness of the development of cutaneous malignancies within tattoo sites and encourage the physicians to include cutaneous malignancy in the differential diagnosis of “rash” arising in a tattoo.
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Segmental cherry angiomas with microtia and hepatomegaly: A case report p. 170
Niral K Sheth, Mohabat D Baria, Nilam K Damor, Rahul S Bhabhor
DOI:10.4103/CDR.CDR_17_19  
Cherry angioma or Campbell de Morgan spots or senile hemangioma is an acquired, well-circumscribed vascular lesion, occurring in adulthood and increasing in number with age. We report the case of a 60-year-old male patient with segmental cherry angioma, hepatomegaly, and ear abnormality.
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Maffucci syndrome with multiple soft-tissue hemangiomas: A rare case report p. 173
Chandraprakash Chouhan, Rao Pankaj, Dilip Kachhawa
DOI:10.4103/CDR.CDR_25_19  
Maffucci syndrome, a congenital mesodermal dysplasia, characterized by multiple enchondromas and hemangiomas was first described in 1881, and 200 cases have been reported in the literature since then. Here, we report the case of a 30-year-old male who presented with multiple soft, compressible swellings present on the back and right feet for 15 years and swelling of the right knee joint with difficulty in walking for 2 years. Roentgenogram of the right foot and hand showed multiple, small radiolucent (osteolytic lesions) areas at 1st metatarsal, distal phalanges, cuneiforms, talus bones, and 1st metacarpal bone suggestive of enchondromas. Doppler study showed venous malformation. Computed tomography (CT) scan of the right lower limb extending up to mid abdomen was suggestive of Maffucci syndrome with soft-tissue hemangioma and intraosseous enchondromas in the tibia and femur. This case is being reported for its rarity. These patients have a possibility of malignant transformation in about 30% of cases thus requiring early detection and management if required.
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Multicentric reticulohistiocytosis with pure cutaneous involvement p. 176
Basavapura Madegowda Shashi Kumar, Somaiah A Savitha, Katwe Kirti
DOI:10.4103/CDR.CDR_23_19  
Multicentric reticulohistiocytosis is a rare type of non-Langerhans cell histiocytosis. The typical lesions include skin involvement with erosive arthritis. Diagnosis is confirmed by the presence of histiocytes and multinucleated giant cells. About 15%–30% of cases are associated with malignancy. Here, we report a case of an 18-year-old boy who presented with sudden onset of brown asymptomatic lesions on the face and back of 2 months' duration, which on biopsy showed dense infiltrate of histiocytes and giant cells. However, he did not have any symptoms of systemic involvement and all routine investigations were normal. The lesions have not progressed on 1 year of follow-up.
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Cutaneous metastasis as a presenting feature of adenocarcinoma of lung p. 179
Rashmi Mahajan, Srishti Jain, Kishan Ninama, Yogesh S Marfatia
DOI:10.4103/CDR.CDR_28_19  
Metastasis is a neoplastic lesion which arises from another neoplasm with which it is no longer in continuity. Cutaneous metastasis is the spread of malignant cells from a primary malignancy to the skin. Skin metastases occur in about 5.3% of patients with internal malignancies and represent 2% of all skin tumors. Breast cancer, in women, and lung cancer, in men, are the most common origins of cutaneous metastasis. It mostly occurs late in the course of disease. Herein, we report the case of a 97-year-old male who presented with asymptomatic, hyperpigmented, indurated plaques with crusting and few overlying tense bullae over the right side of the chest extending to the right axilla for 4 months. On evaluation, he was diagnosed as a case of metastatic adenocarcinoma, the primary being from the lung. He succumbed to his illness within 2 months of diagnosis.
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Eumycetoma caused by Alternaria alternata in an immunocompetent host: A rare case report p. 182
Vasudha A Belgaumkar, Ravindranath Brahmadeo Chavan, Vijay Vidyadhar Raut, Pallavi Prataprao Patil
DOI:10.4103/CDR.CDR_26_19  
Mycetoma is a chronic granulomatous subcutaneous infection caused by either true fungi (eumycetoma) or filamentous anaerobic bacteria (actinomycetoma). Herein, we report a case of mycetoma foot due to a rare opportunistic fungus in a male farmer. He presented with swelling and sinuses discharging pus and bloodstained black granules on the right foot for 6 years. A final diagnosis of eumycetoma (caused by Alternaria alternata) with bone involvement in immunocompetent patient was confirmed on the basis of histopathology and culture. Opportunistic fungi most commonly cause infection in immunocompromised hosts. Although mycetoma caused by opportunistic and saprophytic fungi responds relatively well to systemic antifungal treatment, few cases such as ours might require amputation. Clinically, it is difficult to comprehend the exact etiological agent. Proper diagnosis and radiological investigation are necessary for the precise identification of the etiological agent and extent of spread which in turn dictate choice of treatment.
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Co-localization of alopecia areata and discoid lupus erythematosus p. 186
Keshavmurthy A Adya, Arun C Inamadar, Aparna Palit
DOI:10.4103/CDR.CDR_48_19  
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Acquired onychoheterotopia with acquired digital fibrokeratoma p. 189
Elreema Fernandes, Varadraj Pai, Pankaj Shukla
DOI:10.4103/CDR.CDR_20_19  
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