Issue 2015.1

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 I, congratulate Zonunsanga for taking pain in conducting this trial. This research under taken by Zonunsanga et al is a step forward in the field of targeted phototherapy showing efficacy of  excimer light therapy in the treatment of  alopecia areata; opening a field of further research before this modality is offered / recommended as a good therapeutic option for AA. From the present evidence available corticosteroids being the most popular and minoxidil being the least preferred treatment in the management of AA. The same conclusions have been documented in this study also. Addition of certain criteria in results section [ like Salt scoring tool, AGS six point scale, statistical analysis between the groups, flow diagram of the intervention, discussion of adverse effects in all the groups, relapse/ failure during follow-up period, age criteria in material and methods, maximum and minimum doses used in the excimer and steroid group]  of this article would have made this article more comprehensive and elaborate.  Dr Rakesh Tilak Raj (India) 

  Excimer laser has been regarded by some authors as a ‘‘super-narrowband’’ UVB light source which is postulated to induce T cell apoptosis. The role of T cell in the pathogenesis of alopecia areata has been proposed to play a crucial role in the developing of this entity [1]. The present study shows how excimer laser can be a safe and effective option in our therapeutic armamentum when treating this disease.   References:  1. McMichael AJ. Excimer laser: a module of the alopecia areata common protocol. J Investig Dermatol Symp Proc. J Investig Dermatol Symp Proc. 2013;16:S77-9.    Dr Manuel Valdebran (República Dominicana)

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 This is a valuable study because of importance that pure neural leprosy, a rare form of leprosy, is mostly seen in India with a percentage of %18. Assesment of relationship between bacillary load and neuritis in an endemic region makes results more reliable.  Dr Seval Boyraz Karasat (Turkey) 

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 We congratulate Dobrev and Nocheva [1] for their excellent depiction on the use of videodermatoscopy (VD) on pearly penile papules. We entirely agree that VD and its static counterparts non-digital (ED) and digital epiluminescence dermoscopy/dermatoscopy (DED) are highly effective in substantiating the diagnoses of many non-pigmented cutaneous conditions. We strived to share our experience to echo the findings of Dobrev and Nocheva, and inserted a review of the underlying biophysical principles. For the use of dermatoscopy in pearly penile papules, we were actually the first in reporting such [2]. However, this previous article was focused on sexually transmitted infections, and the terms dermoscopy or dermatoscopy are not listed in the title or abstract in Medline or other indexes. We have found that DED can be helpful in diagnosing pityriasis rosea, through magnification of the lesions and the elimination of other epidermal details such as skin creases and excoriation [3,4]. For pediculosis pubis, VD could identify the nits and moving lice [5]. As the imaging was performed in real time projection on the computer monitor, the experience was thrilling for the patient, who subsequently modified his sexual behaviour desirably. For pseudofolliculitis barbae, we depicted inverted-U-shaped ingrowing hairs through DED [6]. Upon providing the patient with solid proof that the over-enthusiastic use of triple-bladed razors did lead to ingrown hairs, pseudofolliculitis, and subsequent hypertrophic scars, we achieved therapeutic success by behavioural modifications alone.  Lastly, for focal vitiligo, DED revealed the sparing of perifollicular pigments while the interfollicular pigments were destroyed by the autoimmunity at the border of the lesions [7]. This pattern is pathognomonic for all types of urticaria, and VD and DED should play tremendous roles in reaching a definite diagnosis particularly for patients with marginal findings on examination with bare eyes or with magnifying lens. A number of trainees have indicated to us that they do not understand the underlying biophysical principles of ED, DED, and VD. We thus take the liberty to cover such briefly here. These devices incorporate two filters at 90° to each other, one for light emitting from and the other for light returning to the scope. The emitting light passes through the first filter, and becomes polarised.  Some of the polarised light is reflected from the skin surface. As only one reflection occurs, the returning light is still polarised, and is blocked by the second filter.  Some of the polarised light passes through the skin surface to lower layers of the epidermis and superficial dermis. Through repeated refractions, the returning light becomes non-polarised, and is not blocked by the second filter. The viewer thus sees the light from deeper layers of the epidermis and upper dermis only, which is free from details of the skin surface such as skin creases and excoriations. We congratulate Dobrev and Nocheva again for their outstanding article with VD images of unsurpassed quality, and look forward to seeing further reports broadening the utilisations of ED, DED and VD.    References: 1. Dobrev HP, Nocheva DG. Videodermatoscopy of pearly penile papules – Case reports. Our Dermatol Online. 2014;5:29-31.  2. Chuh AAT, Wong WCW, Lee A. Ten common myths in sexually transmitted diseases. Aust Fam Physician. 2006;35:127-9.  3. Chuh AAT. Collarette scaling in pityriasis rosea demonstrated by digital epiluminescence dermatoscopy. Australas J Dermatol. 2001;42:288-90.  4. Chuh AAT. The use of digital epiluminescence dermatoscopy to identify peripheral scaling in pityriasis rosea. Comput Med Imaging Graph. 2002;26:129-34.  5. Chuh A, Lee A, Wong W, Ooi C, Zawar V. Diagnosis of pediculosis pubis – a novel application of digital epiluminescence dermatoscopy. J Eur Acad Dermatol Venereol. 2007;21:837-8.  6. Chuh A, Zawar V. Pseudofolliculitis barbae – epiluminescence dermatoscopy enhanced patient compliance and achieved treatment success. Australas J Dermatol. 2006;47:60-2.  7. Chuh AAT, Zawar V. Demonstration of residual perifollicular pigmentation in localized vitiligo – a reverse and novel application of digital epiluminescence dermoscopy. Comput Med Imaging Graph. 2004;28:213-7.  Ass. Prof. Antonio Chuh (Hong Kong) and Prof. Vijay Zawar (India) 

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 A very interesting case report. Thanks to authors. Epidermodysplasia verruciformis (EV) is a rare genodermatosis, first described by Lewandosky and Lutz in 1922 [1]. This premalignant lesion has occurred de novo, as well as in patients with impaired cell-mediated immunity, including those infected with HIV, systemic lupus erythematosus [2], or lymphoma [3], or those who have received a solid organ transplant [4]. In immunocompromised and immunocompetent populations, typical clinical findings are similar, and include pityriasis versicolor-like macules, as well as flat papules and lesions resembling verruca plana. Characteristic histologic features of the disease are the coexistence of epidermal thickening, a loose horny layer with a basketweave–like appearance, and the presence of large cells in the spinous and granular layers of the skin, presenting with a large blue-gray cytoplasm often associated with a perinuclear halo [5].   References:  1. Lewandowsky F, Lutz W. Archives of dermatology and syphilology. Berlin: 1922:141(193).  2. Tanigaki T, Kanda R, Sato K. Epidermodysplasia verruciformis (L-L, 1922) in apatient with systemic lupus erythematosus. Arch Dermatol Res. 1986;278:247-8.  3. Barr BB, Benton EC, McLaren K, Bunney MH, Smith IW, Blessing K, et al. Papillomavirus infection and skin cancer in renal allograft recipients. Lancet. 1989;2:224-5.  4. Gross G, Ellinger K, Roussaki A, Fuchs PG, Peter HH, Pfister H. Epidermodysplasia verruciformis in a patient with Hodgkin’s disease: characterization of a new papillomavirus type and interferon treatment. J Invest Dermatol. 1988;91:43-8.  5. Majewski S, Jablonska S. Epidermodysplasia verruciformis as a model of human papillomavirus-induced genetic cancer of the skin. Arch Dermatol. 1995;131:1312-8.  Dr. Yugandar Inaks (India)  

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 The authors describe an interesting case report of Tinea faciei highlighting the practical aspects in daily activity. Adequately written, very well documented and updated the article focuses on what is known and what is new in a clinical problem frequently seen by dermatologists. It is an educative paper, well illustrated and presented. Prof. Anca Chiriac (Romania) 

 Thanks to authors for posting rare case report. Dermatophytoses are the most common fungal infections of the skin. In the clinical practise, tinea pedis is most common clinical form of dermatophytosis. Other clinical forms are tinea cruris, tinea capitis, tinea corporis and tinea faciei. Tinea faciei is a rare form of dermatophytosis of glabrous skin, characterized by a well- circumscribed erythematous patch, and is more commonly misdiagnosed with some dermatologic diseases as seborrheic dermatitis, contact dermatitis, polymorphic light eruption and lymphocytic infiltrations.   Dr. Yugandar Inaks (India) 

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 Thanks to author for posting an interesting case report. Cheilitis is a general term that refers to an inflammation of the vermilion border of the lips. Cheilitis is classified into various types: angular cheilitis, actinic cheilitis, contact cheilitis, plasma cell cheilitis, cheilitis glandularis, cheilitis granulomatosa, exfoliative cheilitis and factitious chelitis. Exfoliative cheilitis, a rare, localized condition, is a chronic superficial inflammatory condition that is characterized by regular peeling of a superficial excessive layer of keratin. In most cases, a good history, thorough clinical examination and relevant investigations will help the clinician arrive at a diagnosis.  Dr. Yugandar Inaks (India) 

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 Thanks for presenting these case report. Lupus miliaris disseminatus faciei (LMDF) is a benign condition characterized by a papular eruption located in the central face. Histologic studies of the papules show granulomatous infiltrates with central necrosis. The condition is self-limited and usually resolves within 1 to 2 years yet can be cosmetically debilitating, given the location and potential for scarring.  Dr. Yugandar Inaks (India) 

 This case corresponds to the facial granulomatous dermatosis, a group of disorders characterized by facial papules with the common histological feature of epithelioid granulomas. LMDF is a  a diagnosis  supported  by  the  poor  response  to  tetracyclines and the good response to steroids, in addition to the signs of  rosacea  (facial  redness)  that  she  presented  during  the course  of  the  disease. All  this  lead in the presente time  to  consider  LMDF, granulomatous rosacea, perioral granulomatous dermatitis, and  the  nodular  cutaneous  form  of  sarcoidosis  to  be  in the  same  diagnostic  category,  the  facial  granulomatous dermatoses.   Prof. Beatriz Di Martino Ortiz (Paraguay) 

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 Thanks to authors for presenting rare disease. Moniletherix is a rare hereditary condition with variable expressivity characterized by the presence of beaded or spindle-shaped shafts of scalp hair.It is usually inherited as an autosomal-dominant trait but rarely can be autosomal-recessive. It shows considerable variations in age of onset, severity, and course. Hair is usually normal at birth and is progressively replaced by abnormal hair during first few months of life. Dr. Yugandar Inaks (India) 

 This is yet another case report of monilethrix. It is of interest to note that in this case it is associated with Keratotic horny papules on the nape of the neck. Had skin biopsy been taken from that site it would have keratosis pilaris. Though topical minoxidil 2% will be useful, we cannot predict the growth of hairs with similar monilethrix features on other unwanted areas like cheeks, chin and arms at a younger age which will not be welcome. It required lot of research to decipher the genetic mutations in affected families. Congratulations to the authors for the nice presentation.   Prof. Sundaramoorthy Srinivasan (India) 

 The article is very comprehensive and accurate. Monilethrix is a picture of hypotrichosis of childhood. The differential diagnosis should consider: woolly hair, ectodermal dysplasia, Hereditary hypotrichosis simplex of the scalp, Marie Unna hypotrichosis, generalized hypotrichosis simplex, among others.   Dra. María Bibiana Leroux (Argentina)  

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 Localized scleroderma causes one or more patches of hard skin. There are different types. The linear type can cause problems to underlying tissues such as muscles and bones. En coup de sabre or morphea en coup de sabre is a type of linear scleroderma characterized by a linear band of atrophy and a furrow in the skin that occurs in the frontal or fronto-parietal scalp. Only few cases have been documented in literature related to late onset variety. For ex. 1. Yamanaka CT, Gibbs NF. Trauma-induced linear scleroderma. Cutis. 1999;63:29–32;  2. Mohan SV, Nittur V, Stevens KJ. Late-onset en coup de sabre of the skull.Skeletal Radiol. 2013;42:1447-50. This phenomenon can be categorized as a recently introduced Post traumatic isotopic response: (the occurrence of a new skin disease at the site of previous trauma). Please refer- Proposed classification for koebner, wolf isotopic, renbok, koebner nonreaction, isotopic nonreaction & other related phenomen. Kannangara, Ajith P; Yosipovitch, Gil; Fleischer Jr., Alan B. Dermatology Online Journal, 20(11) November 16, 2014. According to our experience for severe form of disease oral mini pulse steroids or methotrexate and topical Calcipotriol and Tacrolimus ointment would be the most suitable treatment for early cases.  Dr Ajith Prasanna Kannangara (Sri Lanka) 

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 An Interesting case report with peerless association. Thanks to authors. Ledderhose disease is a relatively rare foot disorder of unknown etiology. Although it is listed as a “rare disease” by the Office of Rare Diseases (ORD). It is characterized by local proliferation of abnormal fibrosis tissue in the plantar fascia. The nodules are typically slow growing and most often found in the central and medial portions of the plantar fascia. This tissue is locally aggressive and progressively replaces the normal plantar aponeurosis. LD may occur at any age with the greatest prevalence at middle age and beyond. This disorder is more common in men than woman and it is sometimes associated with other forms of fibromatosis, such as Dupuytren’s disease in the hand, Peyronie’s disease, or knuckle pads. Only 25 percent of patients have bilateral involvement.  Dr. Yugandar Inaks (India) 

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 Thanks to Author for an interesting case report. Cervical cancer rarely metastasizes to the skin; this occurs in less than 2% of patients.2–5 Patients with cutaneous metastatic disease may present at the time of diagnosis or up to 10 years later [1-3]. The presence of metastatic disease in the skin signals a poor prognosis, because skin metastasis is usually associated with local or regional recurrence [2,4]. The treatment is usually palliative [1,4]. The mechanism of metastasis can be understood as a series of steps providing three basic patterns of distribution: 1) mechanical (arising from anatomical proximity and lymphatic draining), 2) site-specific (arising from the selective attachment of tumour cells to a specific organ), 3) non-selective (independent of these distribution factors) [4].  The proposed mechanism of cutaneous metastasis is radiationinduced endothelial cell damage, leading to tumour cell trapping [5,6]. It is usually confined to the irradiation fields, appearing months to years after treatment completion [5]. Another probable mechanism described is alteration of the lymphatic flow by tumour [2]. In most cases, it probably results from the obstruction of deep lymphatic pathways by tumour with shunting of the lymphatic flow to the cutaneous lymphatics [2,3].   References:  1. Malfetano JH. Skin metastasis from cervical carcinoma: a fatal event. Gynecol Onco.l 1986;24:177–82.  2. Tharakaram S, Rajendran SS, Premalatha S, Yesudian P, Zahara A. Cutaneous metastasis from carcinoma cervix. Int J Dermatol. 1985;24:598–9.  3. Freeman CR, Rozenfeld M, Schopflacher P. Cutaneous metastases from carcinoma of the cervix. Arch Dermatol. 1982;118:40–1.  4. Schwartz RA. Cutaneous metastatic disease. J Am Acad Dermatol. 1995;33:161–82.  5. Diehl LF, Hurwitz MA, Johnson SA, Butler WM, Taylor HG. Skin metastases confined to a field of previous irradiation; report of two cases and review of the literature. Cancer. 1984;53:1864–8.  6. Yamamoto T, Ohkubo H, Nishioka K. Cutaneous metastases from carcinoma of the cervix resemble acquired lymphongioma. J Am Acad Dermatol. 1994;30:1031–2.  Dr. Yugandar Inaks (India) 

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 Thanks to authors for nice brief report. Mycosis fungoides (MF), a low-grade lymphoproliferative disorder, is the most common type of cutaneous T-cell lymphoma. Typically, neoplastic T cells localize to the skin and produce patches, plaques, tumours or erythroderma. Diagnosis of MF can be difficult due to highly variable presentations and the sometimes nonspecific nature of histological findings. Molecular biology has improved the diagnostic accuracy. So Mycosis Fungoides is a Dermatological Masquerader. Table shows differential diagnosis of mycosis fungoides [1-3]. References: 1. Kikuchi A, Shimizu H, Nishikawa T. Mycosis fungoides with marked hyperpigmentation. Dermatology. 1996;192:360–3.  2. Co´rdoba S, Ferna´ndez-Herrera J, Sa´nchez-Perez J, Fraga J, García-Díez A. Vesiculobullous mycosis fungoides. Br J Dermatol. 1999;141:164–5.  3. Kodama K, Fink-Puches R, Massone C, Kerl H, Cerroni L. Papular mycosis fungoides: a new clinical variant of early mycosis fungoides. J Am Acad Dermatol. 2005;52:694–8. Dr. Yugandar Inaks (India) 

 This very interesting article highlights the skin as  mirror to internal disease. In every dermatologist, there should be something of the detective. Keen observation, intense inspection of the subject, attention to details and apparent trifles  are particularly pertinent to dermatologist. Recent overenphasis of dermatology on cosmiatric subjects may lead to lack of interest on investigative aspects. In fact, lucrative aspects of cosmiatric procedures is the prime suspect of this new behavior that leads dermatology to dangerous directions. Various systemic  illnesses manifest in the skin and  skin offers the advantage of easy access for biopsy. This  case also  stresses the importance of close inspection with ” eye of eagle ”  – as the authors wisely  quote – of every otherwise unimportant lesions and subsequent biopsy for that skin lesions often represent just the tip of the iceberg. The precoce diagnosis can be of substantial benefit to the patients avoiding progression of many diseases.   Dr César Bimbi (Brasil) 

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 Congratulations to Author. An interesting up-to-date review of Hepatitis B virus association with dermatological changes. By improving awareness about screening among dermatologists regarding the risks of HBV reactivation and its prevention for patients receiving following drugs seems warranted. 1) Interleukin receptor antagonists: Ustekinumab, anakinra, tocilizumab. 2) Tumor necrosis factor (TNF) inhibitors: Infliximab, etanercept, adalimumab. 3) Antineoplastic agents: methotrexate. 4) Glucocorticoids, follow abrupt discontinuation. 5) Anti-CD20 antibodies: Ofatumumab, rituximab.  Dr. Yugandar Inaks (India)