Ophthalmic Manifestations of Seborrheic Dermatitis

Seborrheic dermatitis (SD) is a common, chronic inflammatory skin disease that affects the sebaceous tissues of the body. The meibomian glands of the eyelids are modified sebaceous glands. Involvement of the meibomian glands and their dysfunctioning are significant in SD; however, the ophthalmic features of SD have been poorly described in the literature. The ophthalmic manifestations of SD and the significance of ocular examinations in SD patients are discussed in this review.

Predictability of Nailfold Capillaroscopic Score in Diagnosing Retinopathy in Patients with Type 2 Diabetes Mellitus and its Utility as a Non-Invasive Tool for Differentiating from those Not Having Retinopathy: A Pilot Observational Cross-Sectional Analytical Study

Background

Diabetes mellitus (DM) is a chronic hyperglycaemic state associated with microvascular structural alterations. Nailfold capillaroscopy (NFC) is an in vivo study of microvascular circulation.

Aims and Objectives

This study aimed to investigate the diameters of capillary loops and morpho-structural changes using a handheld dermatoscope in patients with type 2 DM (T2DM) with and without diabetic retinopathy (DR) and to establish nailfold capillary changes and NFC score as a non-invasive method to identify microvascular complication in T2DM patients.

Material and Methods

A cross-sectional observational study was conducted in AIIMS Rishikesh for 6 months from August 2022 to February 2023. Our study participants were 100 adults more than 18 years of age diagnosed with T2DM, based on the American Diabetes Association (ADA) criteria. All patients were evaluated thoroughly for the presence of microvascular complications in the form of retinopathy. Based on this, they were divided into two groups-group 1 (T2DM with retinopathy) and group 2 (T2DM without retinopathy). Both groups were further subdivided into three subgroups based on haemoglobin A1c (HbA1c): the first group with HbA1c <7%, the second group with HbA1c 7-8.9% and the third group with HbA1c >=9%. For all the study participants, a detailed NFC was done for all 8 fingernails (excluding the thumb), using a handheld dermatoscope. Abnormal capillary shapes (ACS) were recorded by semi-quantitative score (NFC score).

Results

A significant association was seen in capillary density (loops/mm) (5.83 ± 0.72 in the DR group and 6.3 ± 0.89 in the no-DR group) (P value = 0.005), capillary density (loops/3 mm) (P value = 0.005), total number of microhaemorrhages/3 mm (P value < .0001), total number of giant capillaries/3 mm (P value = 0.0004), total number of avascular areas/3 mm (P value = 0.0005), enlarged capillaries/3 mm (P value = 0.002), tortuous capillaries/3 mm (P value < .0001), abrogated/bushy capillaries/3 mm (P value = 0.004), number of fingers involved excluding the thumb (P value < .0001) and total nailfold capillaroscopic score (P value < .0001) between the two groups, one with DR and another without DR. Furthermore, the proportion of patients with abnormal nailfold capillaroscopic findings, abnormal NFC score, was significantly higher in patients with DR as compared to patients without DR (51.85% vs 4.35%, respectively) (P value < 0.0001).

Conclusion

Our results suggest that NFC could possibly be used as an adjunctive tool in diabetics for diagnosing or monitoring microvascular complications with total NFC score being the significant predictor of DR at a cut-off point of >0 with the area under the curve (AUC) of 0.745 for correctly predicting DR.

Therapeutic Use of Amniotic Membrane Dressing in Toxic Epidermal Necrolysis

A 45-year-old woman presented with painful erosions and a few dusky vesiculobullous lesions all over the body, including the face, trunk, arms and legs, and oral and genital mucous membranes, for 3 days after consuming tablet diclofenac for fever. There was hemorrhagic crusting on the lips along with conjunctival hyperemia. A clinical diagnosis of toxic epidermal necrolysis (TEN) was made. The Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) was 3 at the time of admission. All routine investigations, including liver function test (LFT), kidney function test (KFT), fasting blood sugar (FBS, 105 mg/dL), and viral serology (Hepatitis B surface antigen [HBsAg], hepatitis C virus [HCV], and Human immunodeficiency virus [HIV]-1, 2), were normal. Blood and urine cultures were sterile. A chest X-ray (posteroanterior [PA] view) and electrocardiogram (ECG) did not reveal any abnormality. The patient was treated conservatively with supportive care, including intravenous fluids, maintenance of ambient temperature, air-fluidized bedding, and appropriate pain and ophthalmic care. For skin lesions, normal saline dressing with paraffin gauge was used; however, after 5 days of treatment, coverage of skin lesions with amniotic membrane dressings was planned due to poor healing. Amniotic membranes are taken from normal delivery patients using aseptic precautions and ensuring negative viral (HBsAg, HCV, and HIV-1, 2) serology. Blood clots were removed from amniotic membranes and stored in buffered normal saline by adding gentamycin. The membranes were applied over the denuded areas (Figures 1 and 2) and wrapped with sterile bandages. The membranes were replaced after 3 days, and removed on day 4 of the second application. More than 90% improvement was observed (Figures 3 and 4) on removal of second application. Supportive treatment was continued, and the patient was discharged on day 20 of admission. (SKINmed. 2022;20:215-217).

Porokeratotic Variant of Lichen Planus

A 44-year-old woman presented with mildly itchy, brownish-black plaques for the last 2 years. The lesions first appeared on the upper back, followed by involvement of the face and upper arms within 4-5 months. Individual lesions began as small papules that gradually evolved into small, annular, and barely palpable plaques. There were no systemic complaints, photosensitivity, or history of intake of prolonged medication. Cutaneous examination revealed multiple, well-demarcated, and hyperpigmented oval to round plaques on the photo-exposed area, including the face, bilaterally on arms, and upper trunk, measuring about 1 × 1-3 × 3 cm² in size (Figures 1A and 1B). Dermatoscopic examination established rolled-out, thread, double-marginated border with central atrophy with a brownish reticular background. Multiple brownish to black globules and dark lacunae were also observed (Figures 1C and 1D). No Wickham's striae were viewed. Combination of clinical presentation with dermatoscopic findings indicated a provisional clinical diagnosis of disseminated superficial porokeratosis. Biopsy performed on the upper back revealed hyperkeratotic epidermis with mild lymphocytic exocytosis and spongiosis with pigmentary incontinence. The coronoid lamina was not revealed in any of the pathologic sections examined, including further deeper sections and in a repeat biopsy. Clinical morphology, dermatoscopic features, and pathology were considered compatible with the diagnosis of porokeratotic variant of lichen planus (LP). The patient was counseled and started on topical steroids (fluticasone). She is on regular follow-up.

Psoriasis Alba (White Psoriasis) of the Perianal Region

A 40-year-old man presented with pruritic perianal lesions existing for 18 months, accompanied by frequent burning sensation on defecating. He had received oral fluconazole 150 mg weekly for a presumptive diagnosis of candidosis earlier. There was no history of other mucocutaneous lesions or comorbidities. The patient denied any unprotected sexual exposure or having anal intercourse. Examination revealed a well-defined perianal, horseshoe-shaped, white-colored macerated plaque with fissures on the gluteal cleft (Figure 1) with tenderness. Examination of scalp, nail, and oral mucosa was unremarkable. Routine investigations, including complete blood counts and chemical profile, were within normal limits. His fasting glucose level was 85 mg/ dL and glycated hemoglobin (HbA1c) was 5.3. The Venereal Disease Research Laboratory (VDRL) test and testing for human immunodeficiency virus (HIV)-1 and 2 were nonreactive. A 10% potassium hydroxide (KOH) examination was negative for fungal elements. Differential diagnoses of flexural psoriasis, Hailey-Hailey disease, and lichen sclerosus were considered, and a skin biopsy for pathology and direct immunofluorescence was performed. The pathologic features showed epidermal acanthosis, hyperkeratosis with elongated rete ridges, and focal hypogranulosis. The upper part of the dermis showed a moderate perivascular mononuclear inflammatory infiltrate with a few melanophages (Figure 2). Direct immunofluorescence was negative. Based on pathologic features, a diagnosis of psoriasis alba was confirmed, and the patient was started on desonide lotion (0.05%) to be applied in the morning and tacrolimus cream (0.1%) at night, plus oral antihistamines. At the follow-up visit 3 weeks later, the lesions diminished to a great extent (Figure 3).

Tuberculous verrucosa cutis with a sporotrichoid distribution

Tuberculosis verrucosa cutis (TBVC) is a common paucibacillary form of cutaneous tuberculosis caused by exogenous reinfection in previously sensitized individuals. The typical morphology is usually observed as a single verrucous plaque with inflammatory borders mostly on the hands, knees, ankle, and buttocks; however, several atypical morphologies of the lesions have also been described. TBVC occurring in sporotrichoid pattern is relatively rare. We report a case of a rare sporotrichoid presentation of TBVC in a 38-year-old male patient in the absence of any primary tuberculous focus.

Increased Prevalence of Alcohol Use Disorder (AUD) in Psoriasis and Dermatitis (Eczema)

Inflammatory cutaneous diseases, such as psoriasis, are associated with considerable psychosocial impact and alcohol consumption; however, this association with other skin diseases, such as dermatitis (eczema), is less explored. We examined patients with psoriasis and dermatitis for excessive alcohol consumption using the Alcohol Use Disorders Identification Test (AUDIT). For this cross-sectional, observational study, 385 patients of both genders, aged ≥18 years, who were diagnosed with either psoriasis or dermatitis, were recruited. The primary outcome measure was the AUDIT score. The prevalence of alcohol use disorder (AUD) was 28% in patients with psoriasis and 23% in patients with dermatitis. Men in both groups had statistically significant more hazardous drinking pattern (AUDIT score ≥ 8) when compared with women. The prevalence of the dermatology life quality index (DLQI) ≥ 11 was 57% in psoriasis patients and 51% in dermatitis patients. Accordingly, alcohol consumption behavior in eczema patients was comparable to those with psoriasis. Based upon the research, it is recommended that patients with inflammatory skin diseases must be asked and screened for their alcohol consumption in order to choose appropriate systemic treatment options.

Onychoscopy: a quick and effective tool for diagnosing onychomycosis in a resource-poor setting

INTRODUCTION

Onychomycosis is the most prevalent nail disease. Although clinical diagnosis of onychomycosis is easy, fungal culture as a confirmatory test requires an equipped laboratory and is time-consuming. Onychoscopy is a simple, quick, and inexpensive technique and may help clinicians increase the diagnostic accuracy of onychomycosis. The aim of this study was to identify common onychoscopic patterns of onychomycosis and correlate them with clinical subtypes of onychomycosis.

METHODS

This study was performed in the dermatology outpatient department of a tertiary care hospital in northern India for 6 months. Clinically diagnosed cases of onychomycosis were confirmed by potassium hydroxide (KOH) mount. After obtaining informed written consent, these patients underwent onychoscopy with DermLite II hybrid m, 3Gen, polarized mode, 10× magnification. The common onychoscopic patterns were recorded and the data analyzed.

RESULTS

The study included 60 confirmed cases of onychomycosis. The common onychoscopic patterns observed were jagged edges with spikes of the onycholytic area in 65.5% of cases, longitudinal striae in 77.6%, distal irregular termination or a "ruin pattern" in 82.7%, and chromonychia in 62.1%. Clinical types of onychomycosis showed a statistically significant association with chromonychia (p = 0.000), jagged edges with spikes (p = 0.015), and distal irregular termination (p = 0.016).

CONCLUSIONS

Onychoscopy can be a complementary tool in clinical diagnosis of onychomycosis to alleviate the need for direct microscopy and culture.

Immunotherapy of anogenital warts with measles, mumps, and rubella vaccine

Anogenital warts, caused by the human papillomavirus, are a cause of significant discomfort and psychological concern for the patients. Despite the availability of multiple treatment options, they are a challenge to manage and may be quite refractory. An easy-to-use therapeutic method with low adverse event profile and low-recurrence rate, therefore, remains highly desirable. In this brief paper, an attempt is made to review the intralesional immunotherapy of anogenital warts with measles, mumps, and rubella vaccine.

Polymorphic Eruption of Extensive Cutaneous Sarcoidosis

A 40-year-old man presented with a 1-year history of asymptomatic multiple raised reddish lesions that started on the face and gradually progressed in size and number to involve the neck, trunk, and arms. There was no history of fever, fatigue, weight loss, arthralgia, cough, dyspnea, or ocular complaints. Past and family history was insignificant, and no significant drug history could be elicited. On examination, multiple reddish brown, shiny, firm papuloplaques and nodules were present over the face, neck, and arms. There was a reddish brown plaque with central depression and overlying prominent telangiectasia over the left perioral area. The lesions over the posterolateral aspects of the arms were atrophic with peripheral reddish brown papules and central clearing, assuming an annular configuration. There were multiple large indurated subcutaneous and atrophic plaques over the arm and back. The palms, soles, hair, nail, and mucosal areas were not involved.

Dermatitis Artefacta: An Update

Dermatitis artefacta is a specific psychocutaneous illness, in which the patient creates skin lesions to satisfy the unconscious need to presume a sick role. It is more common in women and in patients with a diagnosis of psychiatric illness/personality disorder (usually borderline) or external stressor. The clinical signs are characteristic and usually present with typical psychiatric manifestations. This diagnosis is by exclusion, and possible organic causes of cutaneous lesions must be ruled out. Treatment of dermatitis artefacta is taxing, both on the physician as well as on relatives, and it needs to involve a multidisciplinary approach consisting of dermatologists and mental health professionals.

Nevus Depigmentosus: An Update

Nevus depigmentosus, a disorder of hypopigmentation, occurs in both sexes and all races. It most commonly presents in early infancy and childhood as a nonprogressive hypomelanotic macule. It is considered a form of cutaneous mosaicism due to somatic mutation in pigmentary genes, which results in functional impairment of melanocytes. Clinical forms include localized, segmental, and systemized. Rare cases of nevus depigmentosus may be associated with systemic features. Treatment is usually not required, although certain techniques such as suction-blister grafting, excimer laser, and cosmetic camouflage have been tried with variable results. Counseling of parents plays a significant role to allay apprehension and anxiety.

Aceclofenac-Induced Erythema Annulare Centrifugum

Erythema annulare centrifugum (EAC) is characterised by slowly enlarging annular erythematous lesions and is thought to represent a clinical reaction pattern to infections, medications, and rarely, underlying malignancy. Causative drugs include chloroquine, cimetidine, gold sodium thiomalate, amitriptyline, finasteride, etizolam etc. We present a case of 40-year-old woman who presented to us with a 10 days history of nonpruritic, peripherally growing annular erythematous eruption. She had a history of recent onset of joint pain, for which she was taking aceclofenac 90 mg once a day for 5 days prior to the onset of the rash. This was confirmed on biopsy as EAC. The rash promptly subsided after stopping the drug. We report this case as there was no previous report of aceclofenac induced EAC.

H Syndrome: A Case Report and Review of Literature

H syndrome is a rare autosomal recessive syndrome characterised by constellation of clinical features and systemic manifestations including cutaneous hyperpigmentation, hypertrichosis, hepatosplenomegaly, hearing loss, heart anomalies, hypogonadism, hyperglycaemia, low height, and hallux valgus. We report a case of this syndrome with typical clinical findings. We report this case citing the rarity of this uncommon entity.

Association of Piebaldism with Café-au-Lait Macules

A 45-day-old infant was brought by his parents to the dermatology outpatient department with chief complaints of asymptomatic, depigmented lesions that had been present on his skin since birth. On mucocutaneous examination, large rhomboid-shaped depigmented macules were noted on the abdomen and lower extremities bilaterally (Figure 1). A depigmented macule was present on the forehead, with white hair (leukotrichia; a "developing forelock") (Figure 2). Three hyperpigmented lesions (café-au-lait macules [CALMs]) were also noted on the chest (Figure 1a). There was no history of consanguinity, and the family history was negative. The infant was otherwise normal for his age. A diagnosis of "piebaldism with CALMs" was made, and his parents were counseled about the disease and its progression, and possible treatment options as the child grew. They were also informed about a currently unquantifiable risk of future development of Legius syndrome or neurofibromatosis type 1 (NF1), and were counseled for regular follow-up.