2014.1

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The paper by Ambika et al deals with an issue that every dermatologist has faced in his/her career. The uncontrolled use of topical steroids is due to 2 major reasons in my personal opinion:    1) easily can be obtained- there are many agents that are OTC drugs. In some countries you can even get stronger ones without prescription,    2) the good initial effect in many facial dermatoses.    On the other hand, the prolonged and uncontrolled use can result in adverse effects. That in turn, augmented by media, social networks, etc, results in the phenomenon of corticophobia. Assuming these arguments, the present paper os of actuality. Dr Razvigor Darlenski (Bulgaria)

Very good work! It is interesting to know like these findings in a country like India. TCS misuse is a nationwide problem especially in the developing countries. From my experience in Yemen, the first reason for TCS use on the face is using it in popular lightening preparations which include many ingredients; some of them are hazardous such as clobetasol propionat (Dermovate), which are commonly used in rural and suburban communities for fairness purpose and self-treatment of chloasma and melasma. The major complication I commonly see is steroid induced rosacea. I agree with you that patients and doctors education about the correct usage of steroids is essential. Dr Mohamed Ahmed Al-Kamel (Yemen)

I find this paper titled ” Topical corticosteroid abuse on the face: a prospective, study on outpatients of dermatology” interesting. We have been encountering these patients often in our clinic. From this article this becomes rather apparent that the problem of topical steroid abuse is widespread and not limited to one odd place. Dr. Vikram K. Mahajan (India)

This is an interesting article regarding a very common issue observed in outpatients in most of Departments of Dermatology in hospitals in our region (Spain). The misuse of topical corticosteroids on face is one of main problems dermatologists have to deal with. To assess the factors of this misuse and the potential secondary adverse effects is of great help to reduce and control this habit. Authors have performed a study with a considerable sample size leading to conclusions of great interest. More articles on this focus are warranted. Dr. Husein Husein-El Ahmed (Spain)

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Melasma is certainly a therapeutic challenge especially in patients with phototypes V and VI, where further irritation from agents such as hydroquinone or retinoids could worsen the pigmentation process. That is why there is a need for research in alternative agents less irritant to sensitive skin types prone to hyperpigmentation. Licorice extract preparations are available as an alternative treatment for melasma however there are very few in vivo studies published in peer reviewed journals that demonstrate its effectiveness, stressing the validity of this article. The article also remind us that we should conduct more clinical research and development of alternative anti pigmentation agents especially in geographical regions where melasma is more prevalent. Dr. Manuel Valdebran – Dominican Republic

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Genital herpes, is one of the most common sexually transmitted diseases in humans. By contrast, intrauterine HSV-2 infections have been described rare. But there are cases concerning ex. neonate who delivered by cesarean section presented with respiratory distress syndrome and broncho-pulmonary dysplasia, 6 weeks later: chorioretinal scar, and later – recurrent HSV-2 infection with nasal lesions – as a result of mother prenatal HSV-2 infection (confirmed with retrospective type-specific serologic test) [1]. Or neonatal HSV- 2 infection presenting with supraglottitis. followed HSV-2 encephalitis in spite of treatment [2]. The Hala Mohamed Majeed Hassan et al. article have confirmed also that the HSV-infection in pregnant woman can influence on the pregnancy (bad obstetric history). This means that HSV infection can change the course of the pregnancy as well as the life of born child in the future and the HSV-type specific serologic methods should be considered during pregnancy, if you think about neonate also. The other problem is – how to help the future mother and new born baby? What about the anti-HSV2 vaccines? Is there still a place for them if woman plan the pregnancy or the vaccines will just relief the mucosal symptoms [3]? Future research and clinical trials are necessary. During the 4th month of age, the. The retrospective type-specific serologic diagnosis revealed previous HSV-2 infection of the mother resulting in prenatal HSV-2 infection of the infant. In conclusion, intrauterine HSV-2 infections may be underrepresented since they may not be associated with severe congenital malformations and the diagnosis requires the use of HSV type-specific serologic methods not widely applied in microbiological laboratories. Ass. Prof. Małgorzata Sokołowska-Wojdyło (Poland).    References:    1. Bentley J, Neubauer AP, Sauerbrei A. Value of herpes simplex virus type-specific serology: a case report. J Clin Virol. 2012;54:269-71.    2. NW, Morgan D, Turner AJ, Lipshen G, Arkwright PD. Neonatal herpes simplex 2 infection presenting with supraglottitis. Arch Dis Child. 2013;98:611-2.    3. Wizel B, Persson J, Thörn K, Nagy E, Harandi AM. Nasal and skin delivery of IC31(®)-adjuvanted recombinant HSV-2 gD protein confers protection against genital herpes. Vaccine. 2012;30:4361-8.  

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I found the proposal of Martini and Solime very charming as many of like me should do. The reflectance spectrophotometry is a non-invasive technique to evaluate the response of skin lesions to therapeutics quantatively. The instrument illuminates the surface to be analyzed with a light of a known spectrum and records the spectral response of the surface. Statistically comparisons can be made between not only normal and lesional skin but also lesional skin before and after treatment. On the other hand, the contact dermatitis is one of the most common skin problems that both primary care physicians and dermatologists have to deal with. It is also most common form of occupational skin diseases which not only affects the patients but also has a significant economic impact for the countries. Therefore it seems to have a priority for research and prevention. In addition, it is undeniable that patients generally prefer natural drugs which have pharmacological or biological activity that can be of therapeutic benefit in treating diseases. To be prescribed by physicians widely as an evidence based practice, more trials should be done. I would like to praise both authors also for accomplishing the trial without any funding and financial support. I am looking forward to read their future article about the subject and hoping they would use clinical before-after pictures and graphics for the readers like me. Dr Luna Tanrikulu (Turkey)

Why the authors did not use a positive control (applied a reference drug for one group of volunteer) to validate their test? Dr Metowogo Kossi (Togo)    Answer: Before to decide to make official experiments with Desmodium Ads. Dr. Solimé has had the chance to test the drug directly on his patients (being he a naturalist and doctor in Naturopathic Medicine) and observed by the first impact the real efficay of Desm.Ads. with regards to allergic external diseases, exceptionally better than by the use of other plants and drugs!so we reputed it was supervacaneus to compare efficacy of D.A. with other plants in some other group of patients for this it is clear that we have not used a positive control, I think, this is our fault and we apologise for this! (Authors)

Knowing that there are several mechanisms involved in asthma further histamine release, why the authors say that it is a asthma drugs instead of talking of antiallergic drug? Dr Metowogo Kossi (Togo)    Answer: Desmodium efficacy towards asthma is well ascertained in scientific literature at all!!!!perhaps we have introduced it as an anti-asthmathic, since its real nature is that!but we have tried to justify its use in allergic and external diseases, indeed! (Authors)

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Tumid lupus erythematosus (lupus erythematosus tumidus) consists of erythematous, urticaria-like, non-scarring plaques and sometimes papules on the face, neck, and upper trunk. They are usually in sun-exposed areas. Monolateral severe eyelid erythema and edema are unique manifestations of this variant. Lesions may have a fine scale and be pruritic. It usually occurs in a setting of DLE but sometimes systemic lupus erythematosus has been present or rarely develops subsequently. Tumid lupus is part of a spectrum that includes the papulonodular type. A study of 80 patients with this disease concluded that on the basis of specific histopathological features, this condition should be considered a separate entity of cutaneous lupus erythematosus. There is usually a good response to antimalarials with this form of the disease. In tumid lesions there is increased dermal mucin in all cases, often accompanied by subepidermal edema. Some cases have only a sparse inflammatory cell infiltrate, while others have a heavy infiltrate of lymphocytes and less mucin. A few scattered neutrophils may be present. Epidermal involvement is uncommon; in one study of 80 cases, epidermal atrophy and alterations at the dermoepidermal junction were absent in all cases. In a blinded comparison of tumid lupus and Jessner’s lymphocytic infiltrate there were only slight differences between the two. Slight epidermal atrophy and focal thickening of the dermoepidermal junction were more common in tumid lupus and the lymphocytic infiltrate was less dense in tumid lupus than in Jessner’s lymphocytic infiltrate, supporting a continuous spectrum for these two disorders. Ass. Prof. Beatriz Di Martino Ortiz (Paraguay)

This presentation of a case of LET is timely for several reasons. It is an uncommon and usually under-diagnosed. It is indistinguishable from what Jessner’s lymphocytic infiltrate was called. Moreover, at present, their inclusion in the classification of cutaneous lupus as dermal LE variant is being reviewed. Dr Maria Bibiana Leroux MD, PhD (Argentina)

Thanks alot to the authors of this manuscripts, they direct our attention to this special type of lupus erythematosus and how can we treat. Ass. Prof. Nagat Sobhy Mohamad (Egypt) 

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This It is a very rare case, from the way you came to diagnosis to treatment. Being a lesion with clinical and unusual location (is in a covered area) in addition to direct methods such as direct examination of the sample (obtained by scraping the edges of the lesion) and biopsy (the picture of granulomas is not clear an no amastigots are in there) and subsequent Wright or Giemsa staining to observe amastigots, the culture in Novy-MacNeal-Nicolle media and indirect methods such as intradermal Montenegro (Leishmania) chain reaction polymerase should be used. The pentavalent antimonials are the drugs of first choice. Meglumine antimonate and sodium stibogluconate are used in almost all countries. Why were used in this patient clarithromycin and aureomycin? Ass. Prof. Beatriz Di Martino Ortiz (Paraguay)

Erysipeloid type is a rare and unusual presentation of cutaneous leishmaniasis. It’s an interesting case, but I can’t confirm the diagnosis! You didn’t mention the area from where the patient came and the laboratory serological tests! Histopathological image with x40 magnification is not clear and the „before” photo was missed. Molecular diagnostic option may be confirmatory. Dr Mohamed Ahmed Al-Kamel (Yemen)

Erysipeloide form of leishmaniasis is a very rare and unusual presentation of CL. In Syria with the eruption of the disease nowadays, many cases are seen, none of which in my personal carrier follow-up, are manifested with the atypical erysipeloide form as such. CL. is usually manifested with an erythematous and indurated diffuse plaque that appears not only in the face, the nose and cheeks but in any exposed part of the body as well. CL is usually seen in limbs, arms, face and neck. In this case in particular, most likely during some kind of skin exposure activity in a contaminated location, the patient was exposed to the vector (Sand fly) bite. In fact, beside the different types of immune response, the skin fragility due to senility, hormonal changes at menopause and trauma, which are the main factors that cause and could explain such atypical appearance of the lesion, the general and local application of the corticosteroids in this particular case in away, can not be excluded and may have contributed later to the exaggeration of this unusual manifestation presented with erythematous squamous and indurated plaque type of lesion. Dr. Mohamed Wael Daboul (Syrian Arab Republic)     References:    1. Alvar J,Velez ID, Bern C, Herrero M, Desjeux P, Cano J, et al/ . Leishmaniasis worldwide and globalestimatesofitsinci- dence. PLoSONE. 2012;7:e35671.    2. Daboul MW. Cutaneous Leishmaniasis- A New Concept. Lap Lambert Academic Publishing 2012. ISBN: 978-3-659-21092-1  

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Although not appreciated granulomas in first case (the second biopsy was not done) is essential in all cases, a culture because of the high risk of an associated infectious process are, especially thinking about the possibility of atypical mycobacteriosis. Ass. Prof. Beatriz Di Martino Ortiz (Paraguay)

– It would be desirable to review the histological images. – There are many recent references on this topic. It would convenient compare cases presented with any of them, for exemple: 1. Sanghavi SA, Dongre AM, Khopkar US. Tattoo reactions–an epidemic on the surge: a report of 3 cases. Indian J Dermatol Venereol Leprol. 2013;79:231-4. 2. Garcovich S, Carbone T, Avitabile S, Nasorri F, Fucci N, Cavani A. Lichenoid red tattoo reaction: histological and immunological perspectives. Eur J Dermatol. 2012;22:93-6. – The references is not orderer. Dr José López-López (Spain)

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Very interesting article, dermoscopy can be considered as a diagnostic tool in many skin diseases other than melanocytic lesions. Dr. Rania Mounir Abdel Hay (Egypt)

There are many recent references on this topic. It would conveninete compare cases presented with any of them. Dr José López-López (Spain)

It is a very interesting case where the diagnosis of lichen planus pigmentosus inversus (LPPI) is proposed in association with lichen planus in the trunk. It is important to establish differential diagnosis with pigmented contact dermatitis, frictional dermatosis, fixed drug eruption and postinflammatory macule as hystopathological features are not specific however its association with lichen planus of the trunk and the finding of many melanophages in the specimen orient us more with the diagnosis of LPPI. It is possible that LPPI could arise from either lichen planus or lichen planus pigmentosus however there is a need of more reports that validate this finding to establish its association. It is plausible the use of dermoscopy images to study this case as dermoscopy is useful to study inflammatory lesions as lichen plannus as it address the magnitude of the pigmentary incontinence. Dr. Manuel Valdebran (Dominican Republic)

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We read with great interest the article Unusual presentation of granuloma annulare restricted over the palms: a rare case presentation signed by Snehal Lunge et colab. Granuloma annulare is a common cutaneous disorder, with still an obscure etiology , despite systemic associations reported during last years: diabetes mellitus, malignancy, thyroid disease, dyslipidemia, drug intake. The clinical picture is the hallmark of the disease but the confirmation is based on the histopathological report, as it is stated in the mentioned article. Beside localized form of GA (lesions on the dorsal hands) there are variants (not rare): generalized (generalized annular GA, disseminated papular GA, atypical generalized GA), subcutaneous, and perforating GA. The localized type on the palms, as the case described by Snehal Lunge et colab, is indeed rarely reported in the literature, or perhaps under diagnosed, different pathological entities could have been taken into consideration; in the present case the differential diagnosis highlighted very well this aspect. In localized GA good results can be achieved by using topical or intralesional steroids, demanded by esthetic reasons mostly, although spontaneous resolution have been reported. The administration of Hydroxicloroquine in GA localized type, with complete remission of the lesions, is of interest and further studies must follow the idea. We thank for the case presentation and for short update of the disease, granuloma annulare being a frequent clinical condition in daily practice. Ass. Prof. Anca Chiriac (Romania)

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Our credits goes to Beatriz Di Martino and others, to publishing this case because this entity is frequently overlooked and therefore inadequately treated leading to a poor prognosis. Suspicion of such lesions should be raised in chronic wounds demonstrating characteristic changes. If the goal is to eradicate this clinical entity, all of the chronic ulcers that fail to heal require biopsies at regular intervals. Early recognition and definitive treatment are the mainstays ensuring the best prognosis. Dr. Ajith Prasanna Kannangara (Sri Lanka)

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About sringomas excellent case report, well dscribed and diagnosed. Ass. Prof. Beatriz Di Martino Ortiz (Paraguay)

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Kaposi’s sarcoma is a cancer that causes patches of abnormal tissue to grow under the skin, in the lining of the mouth, nose, and throat or in other organs. The patches are usually red or purple and are made of cancer cells and blood cells. The red and purple patches often cause no symptoms, though they may be painful. If the cancer spreads to the digestive tract or lungs, bleeding can result. Lung tumors can make breathing hard. Before the HIV/AIDS epidemic, KS usually developed slowly. In HIV/AIDS patients, though, the disease moves quickly. Treatment depends on where the lesions are and how bad they are. Treatment for HIV itself can shrink the lesions. Agrawal and colleagues had reported a young healthy lady with a chronic asymptomatic pigmented plaque over the thigh. So, in an asymptomatic pigmented chronic plaque one should consider KS, otherwise one could be neglected with KS. Ass. Prof. Shahin Aghaei (Iran)