Topical Ciclopirox Olamine 1%: Revisiting a Unique Antifungal

The injudicious use of antifungals, indiscriminate use of corticosteroids for instant relief, persistence of predisposing factors like sweat retention and uncontrolled diabetes, and emerging resistance to antifungals across the globe have rendered the management of an erstwhile simple infection, the superficial cutaneous mycoses highly complicated and tricky. Ciclopirox is an old yet efficacious, versatile, and safe topical antifungal of the hydroxypyridone family. Despite its numerous beneficial properties over the majority of other topical antifungals, it remains underutilized.

CLINICAL PATTERN OF VITILIGO AMONGST INDIANS

Vitiligo incidence in the series was 14 per thousand. The affliction of the younger subjects was frequent, the mean value of age at onset being 24.25 years. Both the sexes were affected and there was no significant difference between the two. The duration of the disease had wide variations, majority reporting in the course of one year. The emotional undertones and the ocurrence of the disease amongst family links were observed as provocating factors in some cases. Ivory white macules associated sometimes with erythematous tinge, leucotrichiae and islets of pigmentation were classic. The lower extremities were frequently involved, followed by face and other parts of the body. The disease was largely progressive, though in a few it was stationary. Vitiligo vulgaris was its commonest variant, followed by areata, zosteriformis, mucosae and acrofacialis. The associations namely diabetes mellitus, liver diseases and others were recorded. The occurrence of myasthenia gravis and trigeminal neuralgia in vitiligo was interesting. Its association on the basis of autoimmunity is brought out. The importance of the clinical parameters in anticipating the prognosis after psoralen therapy are discussed.

Plexiform neurofibroma affecting the upper parietal scalp, with cerebellar hamartoma: role of histopathology, colour Doppler imaging and magnetic resonance imaging

We report a patient with plexiform neurofibroma, which is pathognomonic for neurofibromatosis type 1 (NF1) affecting the upper parietal region of the scalp. Cerebellar hamartoma was present, a finding that, to our knowledge, has not been reported previously. We highlight the role of histopathology, ultrasonography, colour Doppler imaging and magnetic resonance imaging, in addition to the seven existing criteria, for the diagnosis of NF1.

Male pattern androgenetic alopecia in an Indian context: a perspective study

BACKGROUND

Androgenetic alopecia (AGA) has received scant attention, despite it being a common entity that may result in significant psychosocial morbidity. There are some patients who do not fit into any of the proposed types. Moreover, there have been no published studies of pattern and prevalence of AGA in males in an Indian context. Hence, the present study was an attempt to classify AGA in males with the aim of producing a simple, effective and easily reproducible classification.

METHODS

In total, 150 male patients were clinically diagnosed as AGA. After obtaining informed consent from all patients, a detailed history/examination was carried out, including a hair pull test, a trichogram investigation and a biopsy. Classification of AGA was subsequently attempted across Norwood guidelines.

RESULTS

A gradual shift in the type of AGA from the earlier types (II and III) to more severe types (VI) with increasing age was significant. Twenty-seven patients did not fit into specific patterns according to Hamilton and Norwood classifications. In addition, type 'a' variant was recorded in 20% of patients, clearly indicating limitations of the existing classifications.

CONCLUSIONS

It was possible to classify 80% of the AGA, with II (28%) and III (15%) being the most common types of AGA. Twenty-seven patients (18%) could not be classified as a significant finding. There was considerable overlap in types IV, V and VI in the Norwood classification with the 'a' variants further confusing the picture.

Trichotillomania +/- trichobezoar: revisited

Trichotillomania is an intriguing psychosomatic entity in which there is an irresistible desire to pull out the hair from the scalp, eyelashes, eyebrows and other parts of the body. The process results in an instant release of tension, a sense of relief and security. However, non-scaring alopecia is its clinical presentation. The development of trichobezoar following ingestion of the pulled hair is its salient complication in a few cases. Subsequently, it may cause symptoms pertaining to the gastrointestinal tract culminating in intestinal obstruction, perforation, pancreatitis and obstructive jaundice. The Rapunzel syndrome (trichobezoar) may occur when gastrointestinal obstruction is produced by a rare manifestation of a trichobezoar with a long tail that extends to or beyond the ileocecal valve. In most cases in children, trichotillomania +/- trichobezoar is a habit disorder and thus has a better prognosis. However, in adults the psychopathology is usually deeper and thus entails a poor prognosis. The diagnosis is made after taking a thorough history, noting the clinical features and evaluating a hair-root examination, where telogen hair is (almost) completely lacking, which distinguish trichotillomania from other hair disorders. Treatment modalities vary in childhood and adult varieties. Apart from psychotherapy, the drug treatment involves several agents including selective serotonin reuptake inhibitors (SSRIs) and domipramine. Trichobezoar/Rapunzel syndrome requires surgical intervention.

Giant combined dermatofibroma with satellitosis

An unusual giant combined dermatofibroma is reported in a 34-year-old man who presented with skin-coloured swellings on the medial aspect of the left scapula. The plaque was well defined, reddish-brown and 25-30 cm in diameter. It was also tender and indurated. Several similar smaller lesions (satellites) were present around the plaque. Light microscopy of an incisional biopsy from the main lesion showed architectural features of a deep penetrating type of dermatofibroma, with xanthomatous aggregates, myxoid changes and probable myofibroblastic differentiation. Our case represents an extraordinary example of giant combined dermatofibroma with satellitosis. Despite its benign nature, a wide excision is contemplated because of its unsightly appearance and physical discomfort.

Itraconazole versus terbinafine in the management of onychomycosis: an overview

Ever since the introduction of itraconazole and terbinafine in the management of onychomycosis, there has been a revival of interest in the latter. In order to comprehend the intricate emerging scenario, an endeavor has been made to form a distinct outline in the shape of an overview on several of their facets. The review, therefore, envisages forming and facilitating instant decision-making.

Lichen planopilaris

P, a 20-year-old laborer displayed initial symptoms of the disease in question when he was 10 years old. Initially he had an asymptomatic progressive loss of hair on the scalp. A couple of years later he had mild to moderate pruritus, and the appearance of slate-blue eruptions on the scalp and elsewhere on the body. This resulted in a complete loss of hair on the vault of the scalp, which led him to seek specialist opinion. Skin surface examination revealed the presence of grayish-blue acuminate follicular papules, disposed singly and in groups (plaques). The pilo-sebaceous orifices were conspicuously obliterated and filled by keratin plugs. Perifollicular erythema was a predominant feature on the scalp. The lesions were present over the scalp, around the neck, chest, back, axillae, groin and legs. Shiny atrophied scalp skin depicting scarring alopecia mimicking male-type baldness was a salient feature. In addition, it was studded with conspicuous acuminate papules in its center (Fig. 1a). The known nonhairy (glabrous) skin had classic lichen planus lesions (Fig. 1b). Hemotoxylin-eosin stained microsections prepared from typical lichen planus (LP) lesions over the abdomen and those of lichen planopilaris (LPP) of the scalp were simultaneously studied. The former revealed changes in the epidermis comprising of hyperkeratosis, increase in thickness of stratum granulosum, hydropic degeneration of the basal cell layer and band-like lympho-histiocytic infiltrate pressing against and invading the epidermis, while the latter revealed uniform atrophy of the epidermis and vacuolization of basal cells. The hair follicles were dilated and were filled with keratin plugs. In addition to fibrosis of the dermis, pigment laden microphages and lympho-histiocytic infiltrate was prominent. The follicles and the sebaceous glands were absent. However, arrectores pilorum and sweat glands were preserved (Fig. 2a,b).

Hereditary palmoplantar keratoderma (four cases in three generations)

A 39-year-old man reported with progressive thickening of the skin of the hands and feet and an inability to flex his hand. It was largely asymptomatic; however, brisk walking caused excessive sweating, pain, and widening of the fissures on the soles of the feet. He was unable to walk barefooted. According to his mother, the first episode presented with blistering at 7 days of age. Ever since, the condition has steadily worsened to acquire the current status. He was married at the age of 18 years, and had a stillborn child 18 months afterwards. Presently, he has three children, two girls aged 14 and 12 years and a son aged 10 years. Both the daughters are similarly affected. While cataloguing the details of the pattern of inheritance, the mother of the index case was also found to be affected (Fig. 1). The natural history of the disease was identical. Examination of the palms was marked by pronounced thickening of the skin resulting in the masking of palmar creases. The thickening was well demarcated and its margins were prominent and surrounded by an erythematous halo. The color of the skin was yellow and waxy (Fig. 2a). Contractures were present on all the fingers; nevertheless, the deformity of the middle and distal interphalangeal joints of the little finger was prominent. The soles of the feet had a similar morphology. In addition, marked fissuring was obvious (Fig. 2b). His daughters had an identical affliction of the palms and soles. The texture and morphology of the nails were normal. Light microscopy performed on scrapings from the fissures, mounted on 10% potassium hydroxide, revealed mycelia (hyphae) and spores. Hematoxylin and eosin-stained microsections from the palms and soles showed exquisite changes in the epidermis characterized by considerable uniform orthohyperkeratosis. Hypergranulosis and acanthosis were other associated changes. In addition, perinuclear vacuolization and keratohyalin granules of varying sizes and shapes were located at the periphery of the cells. A sparse mononuclear infiltrate was located at the dermo-epidermal junction. Hyphae and spores of fungi were also identified in the stratum corneum (Fig. 3). Itraconazole, 400 mg/day in two equally divided doses, was administered with major meals for 7 days. In addition, high doses of vitamin A (100,000 IU) were given daily for 2 weeks, supplemented by 12% salicylic acid (Salicylix SF12) ointment for daytime application and an ointment containing 6% coal tar and 3% salicylic acid (Salytar) for night-time application. This treatment is useful in recalcitrant cases.

Nail changes in Langerhans cell histiocytosis

Nail changes in Langerhans cell histiocytosis are distinctly uncommon. Paronychial erythema, swelling and subungual pustules of the fingernails and toenails were cardinal, and were supported by diffuse as well as dense collections of mononuclear Langerhans cells evidenced by microscopic investigation. Oral administration of co-trimoxazole (800 mg sulphamethoxazole + 160 mg trimethoprim) every 12 h, 50 mg/d cyclophosphamide and 80 mg/d predinisolone were the mainstay of treatment, supported by scalp tar shampoo and local betamethasone lotion application.

Pityriasis rubra pilaris (PRP): report of four cases

Four patients with pityriasis rubra pilaris are reported. The diagnosis in each was based upon well-recognized clinical features. Two of them, a mother and son, had the disease since childhood and were marked by relative remission in spring and exacerbation in autumn. Moderate to severe pruritus was a common dominator. Erythroderma was a presenting feature in one case. Although histopathology was considered imperative, it only supplemented the clinical expression. Vitamin A in heavy dosage, supplemented by vitamin E and stanozolol in tandem, was the mainstay of treatment.

Typical varicella zoster (ophthalmicus) in an HIV-infected person

A typical varicella zoster (ophthalmicus) in an incidentally HIV-infected person is reported in a young man. It was characterized by tense, grouped, vesiculobullous eruptions on a brick-red base. The diagnosis was substantiated by demonstration of swollen epidermal (balloon) cells with a nucleus/several nuclei containing inclusion bodies. Reticular degeneration was apparent.

Solitary cellular schwannoma (neurilemmoma) showing malignant changes: evaluation through magnetic resonance imaging (M.R.I.), surgical intervention, and histopathology

Schwannoma (neurilemmoma) are common benign tumors arising from the peripheral nerve sheath. Malignant transformation is uncommon. A unique case showing such a transformation is reported highlighting the roles of magnetic resonance imaging, surgical intervention, and histopathology. The case was thoroughly investigated by learning the details of the sequence of events leading to the current status. The evaluation was made through magnetic resonance imaging. In addition, computed tomography and conventional radiography were used to locate any foci of calcification. Subsequently, the tumor's gross and microscopic morphology was defined by surgical intervention and histopathology. Malignant schwannoma of the left leg occupying the entire calf is extremely uncommon. Only ten cases have been reported thus far, including the current one from the Indian subcontinent. Malignant transformation in a schwannoma differs significantly from malignant nerve sheath tumors (erroneously called malignant schwannomas). An endeavour has been made to differentiate malignant transformation in schwannoma from other malignant peripheral nerve sheath tumors. An innovation in this direction is magnetic resonance imaging. This investigate procedure is imperative in such situations, along with surgery and histopathology, which may also help in classifying the condition.

Knowledge, attitude, belief and practice (K.A.B.P) study on AIDS among senior secondary students

A cross-sectional survey was done among students of four senior secondary schools including two boys and two girls schools of rural Delhi to know the knowledge, attitude, belief and practices regarding AIDS. A large majority (83.0%) of students though had heard about AIDS, yet majority of them did not know the possible methods for prevention of AIDS. There were only 27.1% girls who knew about regular condom usage. Half of them had permissible attitude for pre-maritial sex, while sexual activity was observed in one-fourth students. Students were less reluctant to discuss about AIDS than sex, and teachers were preferred as compared to parents in this regard. School is an ideal setting to educate adolescents regarding HIV/AIDS transmission and safer sex behaviour.

Inoculation cutaneous tuberculosis

Two cases of inoculation cutaneous tuberculosis are presented. As commonly occurs, the diagnosis could not be confirmed bacteriologically due to the small numbers of organisms present. However, both patients responded to antituberculosis chemotherapy.