Issue 2015.3

since 03. July 2015

C O N T E N T S   3.2015

 

 

 


ORIGINAL ARTICLES                                                                                                               


Zoran Vrucinic, Biljana Jakovljevic, Ljubisa Preradovic
Pruritus in hemodialysis patients: Results from Fresenius dyalisis center, Banja Luka, Bosnia and Herzegovina
      Our Dermatol Online 2015; 6(3): 252-256         DOI: 10.7241/ourd.20153.70

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Vladimír Bartoš, Milada Kullová
Immunohistochemical evaluation of E-cadherin expression in basal cell carcinoma of the skin
      Our Dermatol Online 2015; 6(3): 257-264          DOI: 10.7241/ourd.20153.71

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Khalifa E. Sharquie, Ammar F. Hameed, Waqas S. Abdulwahhab
Pathogenesis of Molluscum Contagiosum: a new concept for the spontaneous involution of the disease
      Our Dermatol Online 2015; 6(3): 265-269          DOI: 10.7241/ourd.20153.72

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 This work is focused on one of the most common condition observed in paediatric population. Since some cases are quite challenging and difficult to manage, it's worthy to have some new data about the spontaneous involution. On my experience, this involution is not so common as the authors state. The hypothesis of a regression process similar to that of follicular regeneration might be of interest to investigate in further researches.  Dr Husein Husein-ElAhmed (Spain)  

 The authors deserve appreciation. More information have been given regarding the pathogenesis of MC. Other pathogenic factors such as inflammation pathways needs to be more clearly understood. Molluscum contagiosum is a virus of the Molluscipox genus, which produces characteristic skin lesions. Only humans are known to be affected except for one report each of molluscum contagiosum occurring in chimpanzees and a horse. In immune-competent patients, spontaneous regression of MCV-induced lesions is commonly preceded by clinical signs of inflammation (Epstein, 1992; Brown et al., 2006). The cellular mechanisms underlying this event are still incompletely  understood. Histological features of ongoing regression were tightly correlated with the occurrence of a composite local immune reaction (here referred as I-MC).   Ass. Prof. Mohammad S. Nayaf (Iraq)   

 
Mariusz Jaworski
Doctors' Support – An important part of medical therapy and quality of life
      Our Dermatol Online 2015; 6(3): 270-275          DOI: 10.7241/ourd.20153.73

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 Psoriasis is a persistent, long-lasting  chronic disease caused by an overactive immune system. There may be times when psoriasis symptoms get better alternating with times worsens. Psoriasis is a common skin condition that changes the life cycle of skin cells. It causes cells to build up rapidly on the surface of the skin. The extra skin cells form thick, silvery scales and itchy, dry, red patches that are sometimes painful. Psoriasis is most common in adults. But children and teens can get it too. While there isn't a cure, psoriasis treatments may offer significant relief. Lifestyle measures, such as using a nonprescription cortisone cream and exposing skin to small amounts of natural sunlight, are among factors that may improve psoriasis symptoms. The importance of the level of doctors’ support in psoriasis in the other hand could help to improve the overall functioning of these patients which may affect their quality of life. The study is an interesting one highlighting in-depth the importance of doctor's support and hens its effect on improving patient's quality of life.   Dr Mohammed Wael Daboul (Syrian Arab Republic)  

Ahmed Abdul-Aziz Ahmed, Mohammad S. Nayaf, Kholood J. Maulood
The relationship of body mass index and hirsutism in adult females
      Our Dermatol Online 2015; 6(3): 276-279        DOI: 10.7241/ourd.20153.74

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 It is of a particular interest the results of this study, more than 1.1 billion adults worldwide are overweight, of these 312 million are obese [1]. Conditions such as hirsutism are seen more frequently in this population as properly exposed by the authors. The association between hirsutism and obesity is worth to study specially due to the significant impact in the quality of life that these conditions have on affected patients and very importantly because these findings may reflect an underlying metabolic and endocrine alterations. Hirsutism has been commonly associated with an excess in androgen secretion in about 75-85% of hirsute patients. Disorders that cause this excessive androgenic levels include most commonly polycystic ovary syndrome (PCOS) (70-80%). Less common disorders are: hyperandrogenic insulin-resistant acanthosis nigricans syndrome, 21-OH–deficient nonclassic adrenal hyperplasia and ovarian or adrenal androgen-secreting neoplasms [2]. In particular PCOS has been described to be part of a complex endocrine environment which involve the presence of insulin resistance and hyperinsulinemia in the setting of overweight or obese patients. This factors may influence the development of glucose intolerance states and type 2 diabetes (T2D) [3]. Patients coming to the clinics seeking attention for hirsutism may benefit for proper counseling and workup for the metabolic and endocrine alterations as exposed by the authors. Interventions leading to decrease their BMI may be counseled in order to decrease insulin resistance, prevention of T2D, and to address other gynecological associated disorders.   References:   1. Hossain P, Kawar B, El Nahas M. Obesity and diabetes in the developing world — a growing challenge. N Engl J Med. 2007;356:213-5.   2. Azziz R. The evaluation and management of hirsutism. Obstet Gynecol. 2003;101:995-1007.   3. Conway G, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Franks S, Gambineri A, et al. The polycystic ovary syndrome: a position statement from the European Society of Endocrinology. Eur J Endocrinol. 2014;171:P1-29.  Dr Manuel Valdebran (Dominican Republic)  

 This is another piece of work that supports an association between hirsutism and BMI. Boustani et al 2012 have also reported a higher prevalence of hirsutism and menstrual disorders among obese adolescent girls. The possibility of looking into hirsutism among different age groups, those having abnormal androgen profiles, effects of appropriate glycemic control on hirsutism among T1DM patients are recommended as well.   Dr Rajesh Jeewon Ph.D. (Mauritius)   

Muhammad Uzair, Ghazala Butt, Khawar Khurshid, Sabrina Suhail Pal
Comparison of intralesional triamcinolone and intralesional verapamil in the treatment of keloids
      Our Dermatol Online 2015; 6(3): 280-284          DOI: 10.7241/ourd.20153.75

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 None of therapeutic options for the treatment of keloids has been found completely effective and satisfactory.Intralesional injection with corticosteroid remains the mainstay of therapy for keloids, however some lesions are unresponsive or may result in skin atrophy. Intralesional bleomycin injection is an alternative therapy that has been widely reported but unfortunately, hyperpigmentation was the major side effect in darker skin type. Success with interferon varies and systemic side effects may occur, including flu-like symptoms and other unfavorable reactions such as pain at the injection site, local erythema. Intraregional 5-fluorouracil has reported wound ulceration and hyperpigmentation, atrophy, erythema, tissue sloughing, swelling, pain, and telangiectasia as complications. There are some studies of combination surgical methods and oral methotrexate. I would like to suggest intraregional methotrexate as another option for this problematic issue. Dr. Ajith P Kannangara (Sri Lanka) 

 This is a valuable study because of importance of treatment of keloid, The authors deserve appreciation.   Ass. Prof. Mohammad S. Nayaf (Iraq)   

 The authors have done a great report of their experience with intralesional injections of verapamil in keloids in the present study. The mechanism of action of verapamil has been exposed in the past; it acts specifically on the L-type calcium channels, blocking the influx of calcium from the extracellular matrix to the cytoplasm. On skin it is thought to inhibit the synthesis/secretion of extracellular matrix, induce fibroblast procollagenase synthesis and inhibit IL-6, VEGF, TGF-β1andcellular proliferation of fibroblasts, resulting in depolymerization of actin filaments, alteration of cell shape, apoptosis and reduction of fibrous tissue production [1,2]. It would be good that the same group of investigators organize a second study which could include a placebo group, a longer treatment period and perhaps an increased frequency of application of verapamil (due to its short half-life).  Combination with topical verapamil should also be investigated.   References:   1. Wang R, Mao Y, Zhang Z, Li Z, Chen J, Cen Y. Role of verapamil in preventing and treating hypertrophic scars and keloids. Int Wound J. 2015 May 12,    2. Giugliano G, Pasquali D, Notaro A, Brongo S, Nicoletti G, D'Andrea F, et al. Verapamil inhibits interleukin-6 and vascular endothelial growth factor production in primary cultures of keloid fibroblasts. Br J Plast Surg. 2003; 56:804-9.   Dr. Manuel Valdebran (Dominican Republic) 

 I have gone through the article:„Comparison of intralesional triamcinolone and intralesional verapamil in the treatment of keloids“. I think it is nicely written by the authors and this study is one more contribution to research related to the treatment of keloids. Also, this study is one more confirmation that intralesional triamcinolone acetonide is the first-line therapy for the treatment of keloids. But we must remember that intralesional corticosteroid injections, when used alone, have the most effects on younger keloids. In older keloids corticosteroides can provide symptomatic relief. And as the authors concluded, further large randomized controlled studies are needed to establish the role of intralesional verapamil in the treatment of keloids.   Dr. Nermina Ovčina-Kurtović, MD MS (Bosnia and Herzegovina) 

 
Shahla Babaei Nejad, Hamideh Herizchi Ghadim, Abolfazl Ezzati, Sina Nobahari, Esmail Emami Khatib, Sima Masoudnia
Comparison between the effects of Daivonex cream alone and its combination with narrowband ultraviolet B in treatment of psoriasis
      Our Dermatol Online 2015; 6(3): 285-288        DOI: 10.7241/ourd.20153.76

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BRIEF REPORTS                                                                                                                      


Virendra Saoji, Amit Achliya
Balanoposthitis as a cutaneous marker of diabetes mellitus in an apparently healthy male
      Our Dermatol Online 2015; 6(3): 289-291          DOI: 10.7241/ourd.20153.77

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 “Balanoposthitis as a cuteaneous marker of diabetes mellitus in an apparently healthy male” is an interesting article. In our experience, in male patients with diabetes mellitus either type 1 (T1DM) or type 2 (T2DM), balanitis and balanoposthitis are common conditions, mostly when their glycemic control is inadequate, so good glucose control is the foundation for treatment of Candida spp., balanitis. In the Study to Help Improve Early Evaluation and management of Risk Factors leading to Diabetes (SHIELD) survey of men in the United States (886 with T2DM, 2766 without T2DM, circumcision status not presented) the rate of self-reported genital fungal/yeast infection was significantly (2.2-fold) higher in men with T2DM [1-2]. Hirji et al [2] determined the adjusted risk of balanitis to be 2-8 fold higher in patients with diabetes compared with those without diabetes [3]. We have observed more fungal than bacterial infections, and we isolate Candida albicans as the first etiologic agent (almost 60%). It’s important to mention that we isolate Candida glabrata in 13 to 18% of vulvovaginitis and balanitis, because even tough is considered less pathogenic than Candida albicans and may cause milder symptoms; it is often resistant to antifungal agents like fluconazole (an alternative to topical treatment) and   may cause recurrent infections. It is well known that balanitis and balanophosthitis is more common in uncircumcised men, so it would have been interesting to know how many patients in the study where circumcised, because of anatomical reasons and poor hygiene. As the article suggest it is important to screen for diabetes mellitus in all patients with balanitis and balanoposthitis.   References:   1. Nyirjesy P, Sobel J. Genital Mycotic Infections in Patients With Diabetes. Postgraduate Med. 2013;125:33-46.  2. Lisboa C, Santos A, Diaz C, Azevedo F, Pina-Vas C, Rodriguez A. Candida balanitis: risk factors. J Eur Acad Dermatol Venerol. 2010;24:820-6.  3. Hirji I, Andersson SW, Guo Z, Hammar N, Gomez-Caminero A. Incidence of genital infection among patients with type 2 diabetes in the UK. General Practice Research Database. J Diabetes Complications. 2012;26:501-5.  Dr Pilar Simón-Diaz and Dr Alexandro Bonifaz (México)  

 Thanks to authors for enlighten the association. Candida balanoposthitis is a known feature of diabetes mellitus. Diabetes mellitus is often diagnosed for the first time by many dermatologists. Fissuring along with balanoposthitis was found to be more common in sexually active males. In conclusion, we must bear in mind that balanoposthitis may be first clinical sign in uncircumscribed males. Therefore it is important that appropriate tesing should be carried out when assessing men with balanoposthitis.   Dr Yugandar Inacs (India)   

Mehdi Amirnia, Effat Khodaeiani, Sima Masoudnia, Sina Nobahari, Esmaeil Emami Khatib, Abolfazl Ezzati 
Study of Cryotraphy results in warts in patients referring to Dermatology Department of Sina Hospital, Iran
      Our Dermatol Online 2015; 6(3): 292-295         DOI: 10.7241/ourd.20153.78

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 This study conducted by Dr Amirnia and coworkers is very is very important, as warts are common dermatological condition. Although cryotherapy is one of the methods of treatment of warts even in refractory warts, electro coagulation should also be tried in particular in the case of plantar and foot warts. One may also suggest the systematic vaccination against HPV to reduce infection in children.   Dr. Laouali Salissou (Niger)  


CASE REPORTS                                                                                                                       


Chiharu Tateishi, Kulsupa Nimmannitya, Hisayoshi Imanishi, Daisuke Tsuruta
Ustekinumab successfully treated a patient with severe psoriasis vulgaris with primary failure to infliximab and secondary failure to adalimumab
      Our Dermatol Online 2015; 6(3): 296-298          DOI: 10.7241/ourd.20153.79

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Ana Maria Abreu Velez, Billie L. Jackson, Michael S. Howard
Intraepidermal and subepidermal blistering with skin necrosis, possibly caused by etanercept in treatment of a patient with psoriasis
      Our Dermatol Online 2015; 6(3): 299-303          DOI: 10.7241/ourd.20153.80

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Kalegowda Deepadarshan, Manjunath Kavya, Muddanahalli Rajegowda Harish, Basavapura Madegowda Shashikumar
Embolis cutis medicamentosa, a rare preventable iatrogenic complication
      Our Dermatol Online 2015; 6(3): 304-306          DOI: 10.7241/ourd.20153.81

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 Sindrome Nicolau, as is commonly known, differs from other livedos for its evolution. In the early days, another medication useful is  oral cilostazol, as it has great vasodilator capacity. This article helps us not forget this entity.   Dra. Maria Bibiana Leroux (Argentine)  

Beatriz Di Martino Ortiz, Tatiana Moreno, Silvia Mancia, Gloria Galeano
Manifestaciones mucocutáneas debidas a la infección por Mycoplasma pneumoniae. Reporte de 3 casos
[Muco-cutaneous manifestations due to Mycoplasma pneumoniae infection. Report of 3 cases]
      Our Dermatol Online 2015; 6(3): 307-312          DOI: 10.7241/ourd.20153.82

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 Gracias a los autores para resaltar manifestaciones pulmonares extra de micoplasma. La neumonía por micoplasma es una de las causas más comunes de neumonía atípica. 25-33 % de los pacientes infectados puede mostrar algunas manifestaciones cutáneas más notablemente exantemas, urticaria,y SJS. Se produce una variedad de manifestaciones pulmonares adicionales, incluyendo neurológica, hepática, cardíaca y enfermedades dermatológicas antes, durante, o después de afectación pulmonar. Por otra parte, existe un vínculo interesante con eritema multiforme que merece una mayor investigación………………………………………………………………………………………Thanks to authors for highlighting extra pulmonary manifestations of mycoplasma. Mycoplasma pneumonia is one of the commonest causes of atypical pneumonia. 25–33% of infected patients may show some cutaneous manifestations most notably exanthemas, urticaria, and SJS. It produces a variety of extra pulmonary manifestations, including neurological, hepatic, cardiac, and dermatological diseases before, during, or after pulmonary involvement. Furthermore, there is an intriguing link with erythema multiforme that deserves further investigation.   Dr Yugandar Inacs (India) 

Loai Sami, Huang Changzheng
O’Brien’s granuloma in a 50-year-old Chinese male
      Our Dermatol Online 2015; 6(3): 313-316          DOI: 10.7241/ourd.20153.83

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Snehal Balvant Lunge, Pradeep Mahajan, Vishwas Naik
Miescher granulomatous macrocheilitis: A case report
      Our Dermatol Online 2015; 6(3): 317-320          DOI: 10.7241/ourd.20153.84

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Salsabil Attafi, Ines Chelly, Alia Zhani, Ines Zarraa, Slim Haouet, Nidhameddine Kchir
Un lymphome cutané déroutant
[A confusing cutaneous lymphoma]
      Our Dermatol Online 2015; 6(3): 321-324          DOI: 10.7241/ourd.20153.85

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Yugandar Inakanti, Thimmasarthi Venkata Narsimha Rao
An interesting uncommon side effect of topical corticosteroids-hidradenitis suppurativa
      Our Dermatol Online 2015; 6(3): 325-327          DOI: 10.7241/ourd.20153.86

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Nadeem Toodayan
Hidradenitis suppurativa in Down’s syndrome: A case report
      Our Dermatol Online 2015; 6(3): 328-330          DOI: 10.7241/ourd.20153.87

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Shivanand Gundalli, Balachandra S Ankad, Ashwin PK, Rutuja Kolekar
Dermoscopy of shagreen patch: A first report
      Our Dermatol Online 2015; 6(3): 331-333          DOI: 10.7241/ourd.20153.88

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 Thanks to authors for enlighten one more innovative uses of dermoscopy. Dermoscopy is a non-invasive method that allows the in vivo evaluation of colours and microstructures of the epidermis, the dermoepidermal junction, and the papillary dermis not visible to the naked eye. These structures are specifically correlated to histologic features. The identification of specific diagnostic patterns related to the distribution of colours and dermoscopy structures can better suggest a malignant or benign pigmented skin lesion. Dr. Yugandar Inacs (India) 

 

Balachandra S Ankad, Vijay Domble, Lakkireddy Sujana
Dermoscopy of apocrine hydrocystoma: A first case report
      Our Dermatol Online 2015; 6(3): 334-336          DOI: 10.7241/ourd.20153.89

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Mrinal Gupta, Vikram K Mahajan, Suman Singh
Nevoid acanthosis nigricans: a rare case with late onset
      Our Dermatol Online 2015; 6(3): 337-338          DOI: 10.7241/ourd.20153.90

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 Achantosis nigricans (AN) – the classical form –  is a very common condition today  since the problem of  obesity  is  growing more and more due to fast-food habits, especially and mostly among young people in prosperous countries.  Also, insulin resistance and rarely malignancy are associated with classical AN. Regarding Nevoid-AN , that is a rare form of NA,  it is not associated with any endocrine abnormalities or malignancies. Instead, it is inherited as an irregularly autosomal dominant trait that may first become evident at birth, in childhood, or during puberty. This case-report with well taken photos is very interesting for showing one of that cases that deserves the saying “ once seen is never forgotten “. Moreover it is a  late-onset Nevoid-AN, which rarer still.   This case-report with well taken photos is very interesting for showing one of that cases that deserves the saying “ once seen is never forgotten “. Also, offers an treatment option of retinoic acid.   Dr Cesar Bimbi (Brasil) 

Yugandar Inakanti
Pachyonychia Congenita type 1 – A peerless entity
      Our Dermatol Online 2015; 6(3): 339-342          DOI: 10.7241/ourd.20153.91

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Yugandar Inakanti, Thimmasarthi Venkata Narsimha Rao
Infantile Haemangioma – An nnusual location
      Our Dermatol Online 2015; 6(3): 343-346          DOI: 10.7241/ourd.20153.92

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 The authors describe, well documented and in details, a “classic” IH with a rare location, reviewing briefly new data regarding IH. IH usually manifest during the first or second week of life, but not later than 12 weeks of, although precursor lesions are observed at birth in up to 65 %1. IH should be named also “birth marks”? making the differential diagnosis with vascular malformations which are always present at birth. Due to its location, the presence of ulceration, the indication of a biopsy was done to elucidate the diagnosis. A surgical excision would not have been better resolving the diagnosis and the therapeutical approach? We congratulate the authors for presenting this case, which proves to be helpful in dealing with IH in daily practice.    Reference: 1. Munden A, Butschek R, Tom WL, Marshall JS, Poeltler DM, Krohne SE, et al. Prospective study of infantile haemangiomas: incidence, clinical characteristics and association with placental anomalies. Brit J Dermatol. 2014;170:907–13.     Prof. Anca Chiriac (Romania) 

Tasleem Arif, Iffat Hassan, Parvaiz Anwar, Syed Suhail Amin
Slim belt induced morphea-Price paid for a slimmer look
      Our Dermatol Online 2015; 6(3): 347-349         DOI: 10.7241/ourd.20153.93

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REVIEW ARTICLE                                                                                                                   


Zonunsanga
Melanocytes and melanogenesis
      Our Dermatol Online 2015; 6(3): 350-355          DOI: 10.7241/ourd.20153.94

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 It is so  rare and uncommon to find a so clear explication attempting  to demonstrate  how a biochemical path can drive to the diverse types of melanines, depending on human races or other mammals possessing melanines, idest how a simplest reaction comprising  the co-presence of co-enzymes and the alternative metabolic shifting can induce the formation of  eumelanin and/or pheomelanin. And I do precisely  refer to the following excerptum: When Cysteine is depleted, the Dopaquinone forms Leucodopachrome which ultimately forms eumelanin. The ratio of these two types of Melanin determines visible pigmentation. The variation in skin color among various races is determined mainly by the number, melanin content and distribution of melanosomes produced and transferred by each melanocyte to a cluster  of keratinocytes surronding it. This sort of exhaustive  treatise is excellent since it detours from the banality and commonplace of whichever Handbook of Dermatology or Cosmetic Dermatology.     Lorenzo Martini, M.Sc. (Italy) 


CLINICAL IMAGES                                                                                                                    


Salsabil Attafi, Olfa Khayat, Aschraf Debbiche
A case of Hailey-Hailey disease
      Our Dermatol Online 2015; 6(3): 356-357          DOI: 10.7241/ourd.20153.95

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Ines Smichi, Salsabil Attafi, Mariem Bel Haj Salah
Carcinoma sebace palpebral: un dilemme diagnostique [Palpebral sebaceous carcinoma: a diagnostic dilemma]
      Our Dermatol Online 2015; 6(3): 358-359          DOI: 10.7241/ourd.20153.96

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Salsabil Attafi, Ines Smichi, Wafa Rkik
Tubular apocrine adenoma of the axilla: a rare adnexal tumor
      Our Dermatol Online 2015; 6(3): 360-361          DOI: 10.7241/ourd.20153.97

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LETTER TO THE EDITOR  –  Observation                                                                           


Patricia Chang, Tyson Meaux, Gylari Calderon
Solitary Neurofibroma
      Our Dermatol Online 2015; 6(3): 362-364          DOI: 10.7241/ourd.20153.98
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LETTERS TO THE EDITOR                                                                                                      


Gayatri Khatri, Vikram K. Mahajan, Rashmi Raina
Escherichia coli: an uncommon cause of severe urticarial vasculitis
      Our Dermatol Online 2015; 6(3): 365-366          DOI: 10.7241/ourd.20153.99

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Tomoko Hiraiwa, Toshiyuki Yamamoto
Superficial thrombophlebitis mimicking cutaneous polyarteritis nodosa as an early and sole cutaneous manifestation of Behçet’s disease
      Our Dermatol Online 2015; 6(3): 367-368          DOI: 10.7241/ourd.20153.100

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Ahu Yorulmaz, Seray Cakmak, Burcu Hazar Tantoglu, Ferda Artuz, Elcin Kadan, Elif Sen
Inflammatory linear verrucous epidermal nevus syndrome
      Our Dermatol Online 2015; 6(3): 369-371          DOI: 10.7241/ourd.20153.101

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 I would like to refer this entity as inflammatory verrucous epidermal nevus syndrome instead of Inflammatory linear verrucous epidermal nevus syndrome. As we know there are several morphology for this interesting skin condition. Here, the mentioned picture could be classified as Inflammatory zosteriform verrucous epidermal nevus. Other documented forms (sub groups) are bilateral or unilateral linear, bilateral or unilateral segmental, hemisided, multisegmental, mucosal and generalized.     Dr. Ajith P Kannangara (Sri Lanka) 

Ahu Yorulmaz, Ferda Artuz, Sezer Kulacoglu, Elif Sen
A case of pityriasis rosea of vidal accompanied by neurofibromatosis type 1
      Our Dermatol Online 2015; 6(3): 372-374          DOI: 10.7241/ourd.20153.102

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Comment by: Ass. Prof. Antonio Chuh and Prof. Vijay Zawar 
      Our Dermatol Online 2015; 6(3): 375-377
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Patricia Chang, Tyson Meaux, Marisol Gramajo Rodas
Tuberous sclerosis associated with a renal angiomyolipoma
      Our Dermatol Online 2015; 6(3): 378-381          DOI: 10.7241/ourd.20153.103

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Tasleem Arif, Syed Suhail Amin
Tasleem's water jet sign – A new sign in dermatology
      Our Dermatol Online 2015; 6(3): 382-383          DOI: 10.7241/ourd.20153.104

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 We read with great interest an article published into the current issue of your journal, “Tasleem’s water jet sign”[1].  Although it sounds interesting and eye-catching title may be good enough to attract the readers, may we make a few comments as follows:  1. The water jet sign that the authors presented has been already published under the title, “ Fountain sign” described by Dhar S in hypertrophic lichen planus [2]. Thus, the sign is neither new nor rare. The authors might have missed this publication.  2. The ‘fountain sign’ has been said to be due to the hydropic degeneration of the hair follicular wall in addition to the basal cell degeneration. It was speculated by Dhar S [2] that as a result of degeneration of hair follicular wall, the injected drug passes through the pilosebaceous canal easily and is ejected out forcefully through the follicular openings during intralesional injection [2]. The author further stated that some degree of degeneration of the hair follicular wall also occurs in cases of DLE. However, this phenomenon is not seen while injecting in hypertrophic DLE. This is probably because of the fact that the follicular openings in DLE lesions remain blocked by greasy scales responsible for "carpet tack sign". Perhaps perifollicular scarring is also responsible for prevention of entry of the drug into the pilosebaceous canals [2]. There is no basal cell degeneration neither follicular wall damage in a typical case of warts. There is neither an explanation nor speculation in cases described by Arif T and Amin S [1].  3. On this background and considering several histopathological features of classic and atypical warts, we believe, in the current article, observations by Arif T and Amin S are interesting. However, there appears something having been missed or misinterpreted.  4. The significance of the described sign as the authors mention is limited to protection of physician’s eyes. We believe, they mean, the protection from the physical spillage of anaesthetic solution to avoid injury and irritation to eyes if we correctly understood. However, more importantly, the patient suffering from warts may also be co- infected with HIV, hepatitis B virus , hepatitis C virus, syphilis, and other infective disorders. Therefore, we recommend that patients might be screened for these infections before injecting the local anaesthetic, as there may a risk of transmitting infections to the healthcare provider, including dermatologists. This is much more serious than a trauma of spillage jet or simple irritation to the eyes of health care providers [3-55].   It is also important from safety point of view to defer procedures in such infected and risky patients. Thus, wearing protecting glasses alone may not help to prevent spread of infection.  The “church spire” papillomatosis in warts is actually characteristic of hyperplastic seborrheic keratosis and acrokeratosis verruciformis of Hopf [6], though this may rarely be present in warts. If the authors have noted “Church-spire appearance” so frequently in the histopathology of biopsies of their patients of warts, there may be a likelihood of misdiagnosis. The “church spire” appearance should be exception in classical warts, not the rule.  We would advocate that for postgraduate dermatology departments, clinical and histological training should be of higher priority than procedural skills, at least during some stages of the postgraduate dermatology specialist training.  5. It would be more prudent if authors study their cases carefully with more in depth analysis of histopathological features and subsequently corroborating these with clinical phenomenon of “jet sign” observed in their cases of warts. This might prove to be more useful.  We do hope that our comments help to prevent the spread of inappropriate academic information, which may be detrimental to students of dermatology, who may access free online material as a part of their studies.  May we humbly request the authors to please take our comments in good spirit, as there is no intention of hurting them. We, in fact, would like to encourage them to keep exploring new clinical signs with continued zest.  References: 1. Arif T, Amin SS. Tasleem's water jet sign – A new sign in dermatology. Our Dermatol Online. 2015;6:382-3.  2. Dhar S. "Fountain sign" in lichen planus hypertrophicus. Indian J Dermatol Venereol Leprol; 1997;63:210.  3. Henderson DK, Fahey BJ, Willy M, Schmitt JM, Carey K, Koziol DE, et al. Risk for occupational transmission of human immunodeficiency virus type 1 (HIV-1) associated with clinical exposures: a prospective evaluation. Ann Intern Med. 1990;113:740-6.  4. Mashoto KO, Mubyazi GM, Makundi E, Mohamed H, Malebo HM. Estimated risk of HIV acquisition and practice for preventing occupational exposure: a study of healthcare workers at Tumbi and Dodoma Hospitals, Tanzania. BMC Health Serv Res. 2013;13:369.  5. Kermode M. Healthcare worker safety is a pre-requisite for injection safety in developing countries. Int J inf Dis. 2004;8:325-27.  6.  Madke B, Doshi B, Khopkar U, Dongre A. Appearances in dermatopathology: The diagnostic and the deceptive. Indian J Dermatol Venereol Leprol. 2013;79:338-48.   Prof. Vijay Zawar (India) and  Dr Antonio Chuh (Hong Kong)  





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