Background Discoid lupus erythematosus (DLE) on the scalp can be confused with various scarring alopecias. There is no large-scale trichoscopic study on scalp DLE, and the trichoscopic features in skin of colour are underreported. Objective This study aimed to analyse the clinical and trichoscopic features of DLE on the scalp in skin of colour. Methods This retrospective cross-sectional study analysed the clinical and trichoscopic images of all the biopsy and direct immunofluorescence-proven cases of scalp DLE. Results The prevalent trichoscopic features encompassed follicular, perifollicular, and interfollicular findings. Follicular features included follicular plugs (87%) and yellow dots (53%). Perifollicular findings comprised white scales (92%), white (94%) and brown structureless areas (87%), shiny white structures (SWSs; 75%), and erythema (74%). Interfollicular features included white to pinkish-white structureless areas (90%), white scales (88%), brown structureless areas (81%), shiny white structures (75%), and erythema (72%). Vascular patterns observed were linear irregular, linear, arborising, and polymorphous vessels. Limitations The study's limitations were small sample size, and a retrospective design. Conclusion Scalp DLE presents as two distinct clinical morphologies in skin of colour, and the trichoscopic features can vary depending on the clinical morphology.

Background Livedoid vasculopathy, characterised by painful ulcers and atrophie blanche, significantly affects the quality of life of patients. Data pertaining to the efficacy of various available treatment options for this condition is limited, especially in India. Aim The study aimed to evaluate the treatment outcomes, clinicodemographic features, and associated laboratory abnormalities in patients with livedoid vasculopathy at a tertiary care centre. Methods This retrospective observational study analysed the case records and clinical photos of all clinically and histologically proven cases of livedoid vasculopathy who received antithrombotic treatment and were followed up for a minimum of 6 months. The primary endpoint was the proportion of patients who achieved a pain visual analogue (VAS) score of zero and complete healing of livedoid vasculopathy ulcers at 3 months. The secondary endpoint was the proportion of patients who achieved a pain VAS score of zero and complete healing of livedoid vasculopathy ulcers at 6 months. Side-effects, improvements in the dermatological life quality index (DLQI), clinicodemographic features, and associated laboratory abnormalities were also analysed. Results Of the 26 patients who satisfied the inclusion and exclusion criteria, 20 were males. At 3 months, 65.3% (17) of patients achieved the primary endpoint. Of these, 11 had received rivaroxaban (10mg) once daily and six had received aspirin (150mg) once daily. At 6 months, 96.1% (25) of patients had complete ulcer healing and achieved a VAS pain score of 0. Of these, 11 patients had received rivaroxaban, eight had received a combination of rivaroxaban and aspirin, and six had received aspirin. The improvements in VAS and DLQI at 3 months and 6 months were significant. None of the patients had any adverse effects from the therapy. Limitations The small sample size and its retrospective nature were limitations of the study. Conclusion Monotherapy with rivaroxaban or aspirin can effectively heal the ulcers, successfully achieve pain control, and improve the quality of life in livedoid vasculopathy. However, a fraction of patients may need a combination of the two to achieve these therapeutic goals. Both monotherapy and combination therapy are safe and not associated with significant side effects.

Onychocytic matricoma (OCM) is a benign tumor of the onychocyte. It clinically presents as localized longitudinal pachyonychia and melanonychia. It has many clinical and histopathological differential diagnoses. A 54-year-old male presented with a 2-year history of melanonychia on the left thumb. Local examination revealed a 2 mm skin colored papule over the proximal nail fold. The proximal nail plate showed longitudinal melanonychia with subungual hyperkeratosis. Histopathological examination of the nail bed revealed proliferation of basaloid epithelial cells. There were many organized spheres composed of prekeratogenous and keratogenous layers. No nuclear atypia was noted. The nail plate biopsy showed septate, thin-walled fungal hyphae, which were highlighted by periodic acid Schiff (PAS) stain. We report an additional case of the acanthotic subtype of onychocytic matricoma in skin of color. Additionally, this case also showed onychomycosis. We also discuss the literature review and diagnostic approach. Knowledge about this rare tumor will help to arrive at the correct diagnosis.

BACKGROUND:Small cell lung cancer (SCLC) constitutes about 15% of lung cancers and is an aggressive disease with uveal metastasis. An isolated iris lesion in such patients may or may not be a manifestation of disseminated disease. We report two cases - one patient with SCLC and another with non-small cell lung cancer, each with varied presentation. CASE SUMMARY:The first case was a 49-year-old female who presented with redness in the left eye. She was a known case of SCLC with multi-organ involvement. The best corrected visual acuity (BCVA) was 20/100. Slit-lamp bio-microscopy showed an iris mass with neovascularization. Cytology from anterior chamber paracentesis was suggestive of malignancy. Subsequently she received whole-brain radiotherapy followed by six cycles of platinum doublet chemotherapy. On follow-up, the iris lesion subsided with BCVA of 20/50. The second case was a 54-year-old female with lung adenocarcinoma and brain metastasis. She presented with pain and redness in the right eye (BCVA 20/200). Slit lamp bio-microscopy showed multiple iris nodules in the affected eye. Trabeculectomy was done due to raised intraocular pressure (IOP). Aqueous tap and tissue biopsy for cytology and histopathology respectively, were negative for secondaries. Postoperatively, BCVA improved to 20/70, with an IOP of 12 mmHg and resolution of the nodules. CONCLUSION:Iris lesions in lung carcinoma patients may not necessarily be metastases. Sometimes they can be reactive nodules mimicking secondaries.

ABSTRACT:Pediatric dermatoses presenting as follicular papules are common entities encountered in clinical practice. These are a heterogeneous group of disorders of infectious or noninfectious origin that commonly present as regularly spaced, small papules with or without perifollicular inflammation. Inflammatory causes include follicular eczema, pityriasis rubra pilaris, lichen nitidus, follicular seborrheic dermatitis, keratosis pilaris and its variants, keratosis circumscripta, follicular psoriasis, lichen spinulosus, follicular lichen planus, follicular mucinosis, perforating folliculitis, follicular porokeratosis, and follicular dermographism. These conditions may arise due to filaggrin mutations, keratinization defects, autoimmunity, or microbial triggers. Nutritional causes include phrynoderma and scurvy, while connective tissue diseases such as dermatomyositis and chronic cutaneous lupus erythematosus are autoimmune. Additional categories include infectious, genetic, hormonal, environmental, frictional, malignant, nevus-related, iatrogenic, and idiopathic entities. An early and accurate diagnosis is essential for proper management and reducing disease-associated apprehension in children and/or their parents. This review attempts to describe the role of history taking and clinical examination, including morphology, location, pattern of distribution, and associated features, while dealing with a child with follicular-based papules. In addition, it delineates the role of dermoscopy and pathological examination in reaching a correct diagnosis. Furthermore, it describes the available treatment options and disease course of various follicle-based dermatoses.

Introduction Erythema Nodosum Leprosum (ENL), a multisystemic disease, can significantly impair patients' quality of life due to its chronic and recurrent course. Systemic corticosteroids and thalidomide are the mainstay of therapy in the management of severe ENL. However, the role of thalidomide as a steroid-sparing agent is limited by its adverse effects and high cost. No interventional trial has evaluated azathioprine's efficacy in ENL. This study aimed to compare the safety and efficacy of thalidomide versus azathioprine as a steroid-sparing agent in severe ENL. Methodology This assessor-blinded randomized controlled trial was conducted on 48 patients with severe ENL who were randomly allocated to receive either thalidomide or azathioprine with prednisolone. The outcome measures were to compare the proportion of patients achieving remission at the end of 6 months between the groups, cumulative dose of prednisolone, number of ENL flares, side effects, change in Dermatology Life Quality Index (DLQI) from baseline, and correlation between change in ENL International Study Group (ENLIST) Severity Scale (EESS) score and serum IFN-gamma level. Results In the azathioprine group, 20/22 participants and in the thalidomide group, 21/22 achieved remission (p = 0.5). The median cumulative dose of steroids received (p = 0.44) and change in DLQI score (p = 0.44) between the two groups were not significantly different. The azathioprine group had more flares (8/22) as compared with the thalidomide group (2/22). There was no statistically significant correlation between EESS score change and serum IFN-gamma level change at three months (correlation coefficient-0.24). Conclusion Azathioprine, a steroid-sparing agent, is an effective alternative to thalidomide to control ENL and improve patients' quality of life without significant adverse effects.

Background Pemphigus is a rare autoimmune blistering disorder characterized by involvement of the skin and mucous membranes, primarily due to autoantibodies targeting desmogleins. Emerging evidence has pointed to a potential pathogenic role of antimuscarinic acetylcholine receptor (anti-M-AChR) antibodies and reported a correlation between their titers and pemphigus disease activity. However, data on this association, particularly in relation to different phases of pulse therapy in the Indian context, remain limited. Aim This study aimed to evaluate the correlation between anti-M-AChR antibody titers and pemphigus disease activity at baseline and after Phase I of dexamethasone-cyclophosphamide/azathioprine pulse therapy. Materials and methods This prospective longitudinal observational study included newly diagnosed cases of pemphigus confirmed through histopathology and direct immunofluorescence from April 2019 to March 2021. Pemphigus Disease Area Index (PDAI) scores were recorded, and eligible patients received dexamethasone-cyclophosphamide or dexamethasone-azathioprine pulse therapy as appropriate. Results A total of 29 patients were enrolled: 23 (79%) with pemphigus vulgaris, five (17%) with pemphigus foliaceus, and one (3.4%) with pemphigus erythematosus. Patient ages ranged from 21 to 69 years, with a male-to-female ratio of 0.7:1. By the end of Phase I therapy, 20 patients (69%) completed follow-up. The mean baseline anti-M-AChR antibody titer was 76.48 ± 48.12 U/mL, which decreased to 53.61 ± 30.97 U/mL after Phase I. At that point, PDAI scores showed a moderate correlation with anti-M-AChR antibody levels (r = 0.51, p = 0.02). The reduction in antibody titers from baseline to the end of Phase I was statistically significant (p = 0.05). Conclusions While serum anti-M-AChR antibody titers may not reliably indicate disease activity at the time of diagnosis, their levels appear to reflect changes in disease activity following treatment. This suggests their potential use as a prognostic marker during the course of therapy.

BACKGROUND:Tall cell subtypes of papillary carcinoma thyroid (T-PTC) are defined as tumour cells with a height: breadth ratio of > 3. The tall cell subtype of papillary thyroid carcinoma is known for its poor outcomes and aggressive nature. Its definitive preoperative recognition would be advantageous and would help the surgeon to plan a more effective treatment regimen. We aim to determine if the cytomorphological features are sufficiently characteristic to enable their distinction from classic subtypes of PTC on FNAC. METHODOLOGY:We compared the cytological features of 20 cases of histologically proven T-PTC with 20 cases of the classic PTC (C-PTC). The presence of tall cells (Height: breadth ratio > 3) was confirmed by image morphometry. Thirty-six parameters, pertaining to architectural, cytological, nuclear and background characteristics, were analysed using a semi-quantitative scoring system. The statistical significance of the data was determined using Fisher's probability test and Chi-square test. RESULTS:Tall cells, spindle cells, tail-like cells, and isolated tumour cells were seen in a significantly higher number of cases of T-PTC than C-PTC (p value < 0.05). These features' sensitivity, specificity, PPV and NPV in identifying T-PTC range from 90% to 100% and approach 100% when all four features are present in a given case. DISCUSSION:The cytomorphological characteristics of T-PTC are distinct. Key features distinguishing T-PTC from C-PTC include tall cells, spindle-shaped cells and tail-like cells with irregular nuclear contours. CONCLUSIONS:These distinctive cytomorphological attributes can aid cytopathologists in differentiating T-PTC from the classic subtype during preoperative FNAC.

Diagnosing a case of patchy alopecia in the setting of lupus erythematosus (LE) can be clinically challenging. Of the various causes of LE-specific alopecias, lupus panniculitis of the scalp is rarely reported. A 40-year-old woman presented with a nonscarring patch of alopecia over the scalp. Trichoscopy showed multiple follicular plugging, multiple thin and dystrophic hair shafts, empty follicles, and regularly distributed pinpoint white dots within the lesion. The clinical diagnoses of alopecia areata or early discoid LE were considered. However, the histopathological examination of the scalp biopsy showed typical hyaline-type fat necrosis of the subcutis along with moderate perivascular and perifollicular inflammatory infiltrate without any interface dermatitis. On direct immunofluorescence, staining for IgG, IgA, IgM, and C3 was negative. A diagnosis of lupus panniculitis of the scalp, presenting as patchy nonscarring alopecia, was rendered. Treatment with oral prednisolone and methotrexate led to complete recovery of alopecia. In conclusion, we report a rare case of lupus panniculitis of the scalp and discuss its differential diagnosis in the setting of LE.

BackgroundFine-needle aspiration cytology (FNAC) has been used as the first line approach to lymphadenopathy, which is a common presentation in pediatric age group. The Sydney system for reporting of lymph node (LN) cytology has been proposed to assess the reliability, performance, and accuracy of the aspiration procedure. This study intends to assess the role of FNAC in the pediatric population according to the Sydney system.MethodsThis was a retrospective observational study from a tertiary care center in Eastern India. All the patients in the age group of 0-18 years evaluated during years 2016-2024 were reclassified according to the Sydney system. Based on the cytology and histology diagnoses, the cases were categorized into true-negative, true-positive, false-negative, and false-positive. The overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and risk of malignancy (ROM) was calculated for each category.ResultsOf 803 cases of pediatric LN-FNACs, 35 (4.35%) cases were reported as inadequate (L1), 689 (85.8%) cases as benign (L2), four (0.49%) cases as atypical cells of undetermined significance (L3), 22 cases as suspicious for malignancy (L4), and 53 (6.6%) cases as malignant (L5). The sensitivity, specificity, PPV, NPV, and accuracy was 72.34%, 98.48%, 97.14%, 83.33%, and 87.61%, respectively. The ROM was 16.67% for L2 and 100% for both L4 and L5 categories.ConclusionsFNAC is a highly accurate and specific test for LN pathology, especially in the pediatric population. The incorporation of the Sydney system helps to achieve uniformity and reproducibility in LN cytology diagnosis.

BACKGROUND Conjunctival plasmacytoma is an exceedingly uncommon form of extramedullary manifestation of multiple myeloma, with only a handful of cases reported so far. CASE SUMMARY A 66-year-old male of Indian origin with multiple myeloma presented with a 1-year history of progressive pink mass associated with itching in his left eye. Examination revealed a pinkish conjunctival mass with telangiectasia extending up to the temporal limbus, mimicking ocular surface squamous neoplasia. The patient underwent successful excision of the mass and amniotic membrane grafting. Histopathological examination after excision revealed plasma cell infiltration, confirming an unusual extramedullary manifestation of multiple myeloma. The patient was followed up for one year, with no evidence of recurrence. CONCLUSION This case report highlights the importance of considering multiple myeloma in the differential diagnosis of ocular masses, particularly in patients with a known history of the disease. The presentation of a conjunctival mass in a patient with multiple myeloma is rare, but it is essential to recognize this possibility to ensure timely and appropriate management.

Angiolymphoid hyperplasia with eosinophilia (ALHE) and Kimura disease were previously considered the same entities and are now considered a distinct disorder clinically and histologically. ALHE is a benign vasoproliferative disorder with unclear etiology. The clinical presentation of ALHE includes the involvement of skin and vascular structures sparing lymph nodes. It predominantly involves the head and neck region, extremities, and rarely orbit, oral mucosa, bones, and colon. On the other hand, Kimura disease is a rare benign chronic inflammatory disorder of unknown etiology that predominantly involves subcutaneous lymphoid masses and regional lymph nodes of the head and neck region. Both disorders are classified under hypereosinophilia (HE); however, Kimura disease is more associated with peripheral eosinophilia. It is tough to differentiate both the disorders clinically from each other and also from other HE syndromes including eosinophilic granulomatosis with polyangiitis and systemic HE syndromes. However, tissue diagnosis is the key to differentiation. Here, we describe a female at her 50s without any prior comorbidities, presented to our OPD with atypical multiple symmetrical soft tissue swellings which were of diagnostic dilemmas. She showed features of both ALHE and Kimura disease in investigations. As there is no specific recommendation for treatment, she was started with oral glucocorticoid and weekly methotrexate showing a good response in follow-up visit.