In the recent past, there has been an alarming rise in patients presenting with atypical clinical types of dermatophytosis. These patients require prolonged treatment with systemic and topical antifungal agents. In majority of patients, close household contacts are affected. Frequent relapses and extensive disease affect the quality of life of the patient significantly. The emergence of such a challenging scenario is attributed to complex interplay of host, environment, and agent factors. The change in prevalence of dermatophytes causing the disease; host factors such as comorbidity and immunosuppression; and hot and humid climate, lifestyle changes, and poor hygiene are responsible for atypical dermatophytosis. Several atypical clinical types such as psoriasis-like, eczematous dermatitis-like, seborrheic dermatitis-like, and rosacea-like have been reported. Hence, dermatophytosis has been suggested to be included in the list of great imitators. The collaborative effort involving dermatologists, microbiologists, and public health professionals is required to address this emerging public health problem.

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Superficial dermatophytosis caused by dermatophytes belonging to the three genera, “Trichophyton, Microsporum and Epidermophyton” is the most common fungal infection seen in human beings, worldwide. Medical fraternity in India has been observing an increase in the prevalence of dermatophytosis and that too of the difficult to treat recalcitrant, recurrent and chronic dermatophytosis, over the last 3-4 years. This change in the clinical scenario with increasing frequency of treatment failures has given rise to innumerable treatment options mainly based on individual's experience, as the therapeutic regimens given in the standard textbooks, both Western and Indian, have ceased to result in a good clinical response. With this background, this article will focus on the treatment schedule given in standard textbooks and the current modifications that have evolved to treat dermatophytosis of the glabrous skin.

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Dermatophytosis, caused by dermatophytes is becoming difficult to treat due to various reasons. Accurate diagnosis is essential for the accurate management of this infection and prevention of relapse or recurrence. Although this condition is easy to diagnose clinically, due to overlapping signs and symptoms of few dermatological conditions it may be misdiagnosed necessitating laboratory confirmation. Isolation, identification of the dermatophytes and the antifungal susceptible profile may further help to initiate appropriate antifungal agent. The classical conventional techniques such as direct microscopic examination and isolation of fungi from the clinical specimens are still considered as an important modality of diagnosis. With the rise of the molecular era, molecular techniques are increasingly being applied to diagnose dermatophytosis and identify the dermatophytes. The present review provides an overview and update on the laboratory diagnosis of dermatophytosis.

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We hereby describe a case series of eczematous dermatitis in a peculiar clinical setting. The cases presented with eczematous dermatitis at the site of surgical incision and adjoining skin after a varying lag period. Clinically, all patients presented with xerosis and eczematous rashes around the surgical sites. In our observation, the time taken to develop skin rashes around the surgical sites ranged from 6 months to 3 years. We believe that denervation injury due to dermal nerve transections may lead to autonomic disturbance in the involved area and contribute to the development of dermatitis. Treatment is essentially medical with topical emollients and judicious use of topical corticosteroids. Through this case series, we propose to introduce a new dermatological entity - “autonomic denervation dermatitis” in postsurgical patients.

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Background: Patients attending the dermatology outpatient department (OPD) come with varied presentations. It is a challenge for a dermatologist to make a right diagnosis in a short time noninvasively. Hence in such conditions, dermoscope provides a rapid handy diagnostic aid. Objectives: The aim is to evaluate and compare the dermoscopic features of common dermatological conditions in an Indian population with brown skin. Materials and Methods: A total of 475 dermatoses including inflammatory, infectious, vesiculobullous, vascular, benign face tumors, hypopigmentary, drug reactions and miscellaneous conditions attending the OPD between March 2011 and January 2013 were enrolled in the study after obtaining informed consent. Detailed history and thorough dermatological examination were conducted to reach the final diagnosis. Dermlite II PRO dermoscope was used for the study. Data collected was analyzed by frequency and percentage. P value for each dermoscopic parameter in three groups was calculated using Chi-square test for independence using graph pad where the value of P < 0.05 was considered statistically significant. Results: Red dotted vessel was a prominent feature in inflammatory conditions (P < 0.0003), which was found to be regular in a pattern in psoriasis (100%). The unique feature of lichen planus was Wickham's striae (P < 0.0001). Collarette scales were observed in 93% of cases of pityriasis rosea. Live nymphs depicting as brown oval structure (46.67%) were observed. Scabies mites head was characterized using “Triangular sign” (93%). Red brown dots and papilla-like structure were observed in most of the cases of warts. Comedo-like opening (P = 0.024) and milia-like cyst (P = 0.0495) are typical features of seborrheic keratosis. Conclusion: Dermoscopy findings provide an extra clue for the diagnosis of common dermatoses and it also helpful in prognostic evaluation and monitoring response to treatment.

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Autoimmune inflammatory rheumatic diseases, also termed as autoimmune collagen vascular diseases, as the name suggests are the group of illness arising from a combination of loss of tolerance to self-antigens and shifting of the immune system into self-destructive overdrive. These are commonly classified under six mutually exclusive diseases which include systemic lupus erythematosus (SLE), systemic sclerosis (SSc), dermatomyositis, polymyositis, rheumatoid arthritis (RA), and primary Sjögren syndrome, the so-called definitive connective tissue diseases. Undifferentiated and mixed connective tissue disease and overlap syndrome have also been added to the classification. An initially undifferentiated connective tissue disease may later evolve into a differentiated connective tissue disease. Here, we define the various connective tissue diseases and elaborate more upon SLE and its overlap, including the overlap of RA (RHUPUS).

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Background: Vitiligo is a common skin disorder causing depigmented macules that can impair a patient's quality of life. There are number of treatment modalities are available but at the present, there are no studies compairing betamethasone pulse therapy versus azathioprine daily therapy in treatment of vitiligo. Objectives: To compare the safety and efficacy of Azathioprine daily and Betamethasone pulse therapy in the treatment of in vitiligo. Materials and Methods: We included two vitiligo patient groups. namely group A and group B Patients of group A were given oral Azathioprine to be given 50mg twice daily and those of second group B, Betamethasone were given as a single oral dose of 5 mg on two consecutive days per week. Therapy in both groups was given for a total of 6months with follow up at 1, 3 and 6th month. Clinical photographs were taken at each visit. Side-effects if any were noted. Results were calculated with help of VASI score (vitiligo area severity index). Results: At the baseline: The patients to group A (SD 3.81± 2.3) and of group B (SD 3.76± 2.28) were having depigmented patches (P = 0.90). At the first follow up: Although there was significant improvement with perifollicular repigmentation started in both groups but the patients are of group B (SD 3.38±2.06) were showing slower response as compared to oral group A (SD 3.70± 2.28). At the second follow up: Remarkable improvement is seen in both groups compared (P = 0.17). At the third follow up: Significant improvement is seen in both groups compared (P = 0.09). Conclusions: Azathioprine and betamethasone pulse therapy are equally effective in treatment of vitiligo.

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Topical antifungals are an important adjuvant in treatment of dermatophytosis. Also specific situations such as dermatophytoses in pregnancy and infants often warrant topical therapy. Several new topical antifungals and newer formulations hold out the promise of enhanced effectiveness of topical therapy in dermatophytosis. This article reviews the entire spectrum of topical antifungals and formulations and their role in management of dermatophytosis.

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Background: Various modalities of treatment have been used in the treatment of acne and nowadays, clinicians seek to employ new technologies in acne care like chemical peeling. Objectives: The objective of this study is to compare the efficacy of salicylic acid and mandelic acid peel in the treatment of mild to moderately severe acne vulgaris. Methodology: A total of fifty patients with mild to moderately severe acne graded based on Global Acne Grading System were divided randomly into two groups of 25 patients each. Group A patients were treated with 20% salicylic acid and Group B patients were treated with 30% mandelic acid every 15 days for six sessions. Pre- and post-peel sunscreen and moisturizer were prescribed. Percentage of improvement in inflammatory and noninflammatory lesions at the end of six sessions was the primary endpoint measure. The improvement was graded as mild, moderate, good, and significant. Results: All the patients showed improvement of acne at the end of the treatment. The mean improvement of inflammatory acne in Group A was 73.3% and in Group B was 65.4%. The mean improvement of noninflammatory acne in Group A was 39.4%, and Group B was 27.9%. In both groups, the improvement in both inflammatory and noninflammatory lesions was found to be statistically significant (P < 0.05). Conclusion: Salicylic acid peel was found to be more efficacious than mandelic acid peel. However, the side effects were less common with no postinflammatory hyperpigmentation with mandelic acid peel.

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Background: Facial melanosis in tropics presents as a diagnostic and therapeutic challenge. We report characteristic patterns of facial pigmentation following vigorous rubbing or cleaning of the face in Indian patients. Awareness of the condition shall guide the clinician to a specific diagnosis. Objective: To study clinicohistopathological profile and patterns of facial frictional melanosis (FFM). Materials and Methods: A multicenter clinicohistopathological hospital-based cross-sectional case descriptive study of sixty patients with characteristic patterned facial melanosis underwent a detailed history taking and clinical examination over a period of 5 years. Biopsy specimens of thirty patients were analyzed for histopathology with hematoxylin-eosin stain. Ten biopsy specimens were also processed for both Fontana Mason and Congo red staining. Results: Sixty patients (males n = 48, females n = 12) with typical clinical features of FFM were studied. Ages of patients varied from 16 to 68 years. Patients on direct questioning confirmed history of vigorous rubbing with hand/handkerchief to clear the face of sweat and grime. Pigmentation was distributed symmetrically over the bony prominences with several characteristic patterns. Histology showed epidermal hypermelanosis, dermal melanin incontinence, and consistent absence of amyloid deposits. Conclusion: We present characteristic facial melanosis in Indian patients due to friction as a specific type of benign friction melanosis. We aim to bring to notice; friction as a distinct etiology of patterned facial hyperpigmentation.

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Background: Diabetes mellitus is a metabolic disorder characterized by raised fasting and postprandial blood glucose levels and a variety of multisystem complications. The prevalence of skin manifestations seems to be similar between type 1 and type 2 diabetes mellitus patients. Cutaneous manifestations usually develop following the diagnosis of diabetes, but in some patients, they are the initial presenting signs, thereby helping in the early diagnosis of diabetes mellitus. Objectives: The objective of this study is to describe the cutaneous lesions in patients with type 2 diabetes mellitus and to compare the pattern of skin manifestations in diabetics and nondiabetics in coastal Karnataka and neighboring districts of Kerala. Methodology: This case-control study included 400 patients with type 2 diabetes mellitus and cutaneous manifestations attending the outpatient Departments of Dermatology and General Medicine and those admitted under these departments. A total of 400 age and sex-matched nondiabetic patients were included as controls. Results: Cutaneous infections were noted in 148 (37%) diabetics of which fungal infections were the most common seen in 106 (26.5%) patients, followed by xerosis in 121 (30.25%) and acrochordons in 71 (17.75%) patients. Other dermatoses associated with diabetes mellitus noted were acanthosis nigricans (5.5%), scleredema diabeticorum (0.25%), diabetic bullae (0.5%), and Kyrle's disease (1%). Cutaneous changes associated with neurovascular complications included diabetic foot in 3%, diabetic dermopathy in 2%, and pigmented purpuric dermatosis in 0.25% of the diabetics. Conclusion: A joint effort between dermatology and general medicine is necessary for the early recognition and treatment of the skin conditions and also to ensure adequate metabolic control.

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Context: Foot eczema is a common complaint encountered in dermatology outpatient department. Footwear dermatitis forms an important exogenous cause of foot eczema. Patch testing helps in identifying possible allergens causing footwear dermatitis. Aims: This study aims to study the clinical profile of foot eczema and to evaluate patch test results in these patients. Subjects and Method: Fifty patients with foot eczema were included in the study and underwent patch testing with Indian standard series and footwear series. Patch test results were read as per International Contact Dermatitis Research Group guidelines. Statistical Analysis Used: Descriptive data are given as mean standard deviation. Differences between patients were assessed by unpaired “t”-test and frequency of parameters by the Chi-square test. Linear regression analysis was used, and correlation coefficients were calculated by Pearson's method. P <0.05 was considered statistically significant. Results: Foot eczema was most common in the 18–29 years of age group (48%), with a male:female ratio of 1.78:1. Office workers (50%), followed by students (24%) were the common occupational groups affected. Allergic contact dermatitis (ACD) (60%), followed by discoid (10%) and forefoot eczema (10%) were the common morphological types. Parthenium (13.8%), diphenylguanidine (10.3%), and potassium dichromate (10.3%) were common allergens seen. Parthenium was the most common allergen identified by patch testing in our study. Conclusion: Patch testing may be used as a valuable and safe additional tool to aid the clinician's diagnosis and help in the treatment of ACD.

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Acne vulgaris (acne) is a common chronic skin disease and affects over 90% of teenagers worldwide. Despite its prevalence, acne vulgaris is shrouded in multiple misconceptions that are widespread in the general public, among acne patients, and even in health-care professionals. This article reviewed six common misconceptions about acne vulgaris: (1) acne is a trivial condition and does not require medical attention; (2) acne is a transitory disease of adolescence; (3) dietary factors cause acne; (4) acne is caused by uncleanliness; (5) acne improves rapidly upon treatment; and (6) acne can be treated by sunlight. These misconceptions span across the natural history, etiology, and treatment of acne vulgaris. The paucity of knowledge about acne has potentially severe consequences and should not be overlooked. Underestimating the severity and progression of acne may delay treatment, while misinterpreting the etiology of acne could lead to unnecessary and disruptive lifestyle changes. Unrealistic expectations about therapy will lead to dissatisfaction, which may decrease treatment compliance. Actions in public health, medical education, and research are warranted to eradicate these misconceptions about acne vulgaris.

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Various factors unique to elderly patients such as physical, physiological, psychological, and socioeconomic factors affect the outcome of dermatophytic infection and its management. The associated comorbidities such as renal and hepatic failure and polypharmacy influence the pharmacological properties of antifungal agents. These drugs are potent inhibitors of hepatic enzymes involved in drug metabolism leading to accumulation and subsequent toxicity of various classes of drugs. All these factors are considered in the management of dermatophytosis in elderly especially with comorbidities.

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Bowenoid papulosis (BP), a rare disease with malignant potential, is a distinct clinicopathological entity strongly associated with human papillomavirus (HPV) infection. We described an adult male presenting with well defined, purplish papules of varying size with verrucous to smooth surface distributed discretely over medial side of the left thigh, scrotum, and penile shaft. Histopathology showed focal areas of full thickness epidermal atypia comprising irregularly arranged nuclei which are large, hyperchromatic, and crowded at few places. Pap smear from spouse showed inflammatory infiltrate with moderate-to-severe dysplasia. The patient was treated with topical 5-fluorouracil. Excellent response was noticed at the end of 2 weeks. A patient with BP should be thoroughly educated regarding HPV infection and emphasis should be on prevention. Female patients or sexual partners of male patient with BP are at the risk of developing cervical cancer and hence should be followed with regular cytologic, colposcopic, and histologic examinations.

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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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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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Background: Pellagra is due to deficiency of niacin or its precursor tryptophan and is characterized by four Ds: The Dermatitis, Dementia, Diarrhea, and eventually Death if it is untreated. Not long ago, the disease was endemic in several parts of the world; including India. Over the past two decades, only a few pellagra cases have been reported. By the year 2011, Pellagra had almost disappeared due to public distribution system but, the clinical features still prevail in the Indian subcontinent to some extent. Objective: The study was carried out to report our experience with pellagra in a tertiary care hospital. Materials and Methods: We undertook a retrospective study of 335 clinically diagnosed pellagra cases attending the Nutrition Unit of tertiary care hospital from 1992 to 2012. Results: In a total of 335 patients of pellagra studied, there were 316 males and 17 females. Majority of patients were in 30–40 years with mean age 42.76 ± 11.6 years. Chronic energy deficiency was seen in 63.8% of patients. Chronic alcoholism and tuberculosis were noted in 3.88% and 1.19% of patients, respectively. Conclusion: Pellagra is a complex and multisystem disease that occurs due to varied etiological factors. Of these, inadequate diet is the best-recognized cause in the developing countries like India. This study clearly recommends that general ration should be regularly distributed, especially in areas where maize and sorghum are cultivated and consumed.

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Introduction: Dermoscopy has gained tremendous importance in the recent past. It helps in the visualization of subsurface structures, whereby details of skin lesion are studied in depth. Nailfold capillaries are involved early in the course of disease process in connective tissue diseases. Videocapillaroscopy is used to examine the patterns in the nailfold capillaries. However, training, cost, and skilled technique limits the use of it. Dermoscopy, being handheld and easy to perform, is best alternative to videocapillaroscopy. Authors evaluated the utility of dermoscopy in the study of nailfold capillaries in connective tissue diseases in patient with the skin of color. To the best knowledge of authors, this is the first study from the Indian subcontinent. Materials and Methods: The study was conducted in a tertiary care hospital from January 2017 to June 2017. It was a cross-sectional pilot study. Sixteen consecutive patients with connective tissue diseases were included in the study. Connective tissue diseases comprised of systemic sclerosis, lupus erythematosus, mixed connective tissue disease, dermatomyositis, and rheumatoid arthritis. DermLite 3 dermoscope with Sony camera was employed. Polarized mode and ultrasound gel were used. Results: Of 16 patients, three, two, and three had systemic sclerosis, systemic lupus erythematosus, and discoid lupus erythematosus, respectively. Mixed connective tissue disease, dermatomyositis, and rheumatoid arthritis were seen in one, one, and five patients, respectively. One patient had Rowell syndrome. Scleroderma and nonspecific scleroderma patterns were observed in 75% and 12.5% of patients, respectively. In two patients, the nailfold capillaries appeared normal. Conclusion: Dermoscopy is an in vivo cost-effective method for studying nailfold capillaries in connective tissue diseases. Results obtained using handheld dermoscope were comparable to that of a videocapillaroscope. Authors recommend further studies involving large sample size of the population with skin of color to affirm the nailfold capillaries pattern observed in this study.

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Background: Cancer is a leading cause of mortality and morbidity in both developed and developing parts of the world with the disease burden projected to grow exponentially in future. Over the past several decades great advances have been made in the area of cancer chemotherapy. Objectives: To study the various cutaneous adverse events associated with cancer chemotherapy. Methodology: 100 patients diagnosed with cancer attending the departments of a tertiary hospital who underwent chemotherapy and satisfied the inclusion and exclusion criteria were included in this study. It is a hospital based observational study. All patients were counselled about the study and informed written consent was obtained. Patients were examined before start of chemotherapy treatment and after every cycle of chemotherapy. Data collected was analysed using SPSS version 16.0. Results: In this study, 100 patients including 37 females and 63 males were included in this study. Majority (56%) of the patients belonged to the age group of 41-60 years. The common indications for chemotherapy were carcinoma oropharynx (24%), carcinoma breast (18%), tongue and stomach. Among the cutaneous adverse events noted, hair changes were the most common presentation and were reported in 68 patients. Skin changes were seen in 65 cases, nail changes in 30 cases and mucosal changes in 12 patients. Xerosis (26%) and hyperpigmentation (22%) were the most commonly observed adverse event affecting skin. Cisplatin, cyclophosphamide, 5 fluorouracil, carboplatin, paclitaxel and doxorubicin were the most frequently prescribed chemotherapeutic drugs. Conclusion: Our observations necessitate a joint effort between dermatology and oncology for the early recognition and adequate treatment of the cutaneous adverse effects associated with cancer chemotherapy which may help in reducing morbidity and improving compliance.

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Context: Lichen planus (LP) is an idiopathic T-cell-mediated inflammatory disorder. Chronic inflammation may result in derangement of lipid metabolism. Some studies have shown that prevalence of dyslipidemia is more among patients with LP, whereas other studies have not supported this hypothesis. Aims: The aim of this study is to find out if there is any association between LP and dyslipidemia. Settings and Design: The study was conducted at the dermatology outpatient department of a tertiary care hospital; this was a comparative, cross-sectional study. Subjects and Methods: Forty-seven patients with LP aged 20 years or more attending the dermatology department of a tertiary care hospital were recruited for the study. Comparison group consisted of 47 age- and sex-matched patients with skin infections of <1 month duration. Fasting lipid profile of all participants was estimated. Proportion of patients with dyslipidemia in both groups was compared using Chi-square test. Student's t-test for equality of means and Levene's test for equality of variances were used to compare the lipid profile values in both groups. Statistical Analysis Used: Chi-square test, Student's t-test for equality of means, and Levene's test for equality of variances. Results: Dyslipidemia was observed among 30 (63.8%) patients in the LP group and among 23 (48.9%) patients in the comparison group (P = 0.145; odds ratio = 1.84; 95% confidence interval = 0.81–4.2). There was no significant difference in mean serum cholesterol (P = 0.096), triglycerides (P = 0.318), high-density lipoprotein (HDL) (P = 0.901), and low-density lipoprotein (LDL) (P = 0.077) between the two groups. Levene's test of equality of variances showed that differences in the variability between patients in the LP and in the comparison group were significant for serum cholesterol values (P = 0.036), but not for serum triglycerides (P = 0.821), HDL (P = 0.343), and LDL (P = 0.841). Conclusions: Although the prevalence of dyslipidemia was more among patients with LP, it was not significant at 5% level.

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Background: Acne vulgaris is a common skin disease seen primarily in adolescents and young adults. As the treatment involves long-term therapy with antibiotics, an agent with a long half-life can be very useful in increasing the compliance. Objectives: The objective of this study was to evaluate the efficacy of a pulse dose of azithromycin and compare it with daily dose of minocycline in the treatment of acne vulgaris. Materials and Methods: This prospective, randomized, open-label, comparative study was conducted on sixty patients with moderate-to-moderately severe (Grade II and III) acne vulgaris. Patients were randomly assigned to two treatment groups, A and B. Patients in Group A received 50 mg minocycline orally daily whereas patients in Group B were given 500 mg azithromycin orally once a day for 3 consecutive days/week. Both the groups were advised topical application of 2.5% topical benzoyl peroxide gel in the night. The total duration of treatment was 3 weeks. All the patients were evaluated at the end of 3 weeks. Statistical analysis was done using Wilcoxon signed-rank test and Mann–Whitney U-test. Results: Group A showed a reduction in lesional count of 39.7% for noninflammatory papules, 65.11% for inflammatory papules, and 52.22% for pustules. Similarly, Group B showed 30.39%, 54.69%, and 57.76% reduction in lesional count for noninflammatory papules, inflammatory papules, and pustules, respectively. Conclusions: Both minocycline and azithromycin were equally effective and safe for the treatment of acne vulgaris.

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