Background:Current trend of rising drug-resistant dermatophyte infection is alarming and fretted by dermatologists. Dilemma prevails regarding use of the same or different class of antifungal agents topically and systemically. The aim was to study the efficacy of oral itraconazole 200 mg with 1% terbinafine cream versus oral itraconazole 200 mg with 2% sertaconazole cream in dermatophytosis. Methods:This within-person open-label pilot study enrolled 50 patients with dermatophytosis. Two lesions of comparable size within each patient were randomly allotted to group A and B and treated with 2% sertaconazole and 1% terbinafine cream, respectively. Both groups received itraconazole 200 mg once daily for 4 weeks. The remaining lesions received 1% terbinafine cream. Response and adverse effects were assessed at 2 and 4 weeks. Reduction in erythema, scaling, pruritus and clinical, and mycological cure constituted efficacy outcomes. Results:The mean duration of lesions was 2.82 ± 1.35 months. Complete clinical cure was observed in 50% and 48%, whereas mycological cure was attained in 56% and 52% patients in groups A and B, respectively, after 4 weeks, which was statistically insignificant. Reduction in erythema, scaling, and pruritus after 4 weeks when compared between the two groups, was also statistically insignificant. Conclusion:Same class of oral and topical antifungal agents has comparable efficacy with different classes of oral and topical antifungal agents in dermatophyte infection.

Dear Editor, Lichen planopilaris is an uncommon follicular variant of lichen planus that presents as scarring alopecia of the scalp. It is an idiopathic autoimmune disease that involves lymphocytic inflammatory response targeting the hair follicle antigens.[1] Alopecia areata is also an acquired autoimmune disorder; however, it causes a non-scarring alopecia and may involve sites other than the scalp. It is often considered a T-cell mediated disorder with loss of immune privilege in the hair follicles.[2] The co-existence of all three disorders i.e., lichen planus, lichen planopilaris, and alopecia areata in an individual is rare and has not been described previously. A 38-year-old male presented with multiple patches of scarring alopecia predominantly over the frontoparietal scalp, for one year [Figure 1a]. He also noticed multiple itchy violaceous atrophic plaques over the right mandibular region [Figure 1b], eight months following the scalp lesions. Simultaneously, he developed gradually progressive multiple non-scarring alopecia patches over both the forearms [Figure 1c]. No other body sites were involved, nails, mucosa, and trunk were normal. Hair-pull test over the scalp and forearms was positive indicating active disease. Dermoscopy of the scalp revealed significantly diminished follicular ostia and pigment network, predominantly perifollicular violaceous pigment, blue-grey dots, minimal perifollicular scaling, and multiple white dots [Figure 1d]. Dermoscopy of the facial lesions revealed brown to violaceous background, Wickham’s striae, diminished hair follicles, and blue-grey dots [Figure 1e], and the forearms revealed multiple black dots, pohl-pinkus constriction, and short vellus hairs [Figure 1f]. Histopathology of the scalp showed hypergranulosis, follicular plugging, dense bandlike perifollicular lymphocytic infiltrate with an hourglass-like configuration of the follicle, and pigment incontinence. An interface pattern of inflammation characteristic of lichen planopilaris was also noted [Figure 2a and b]. Histopathology of the face revealed epidermis showing compact orthokeratosis with wedge-shaped hypergranulosis, irregular acanthosis, dense band-like lymphocytic inflammatory infiltrate at the dermo-epidermal junction, vacuolar alteration of the basal layer, and few civatte bodies and pigment incontinence [Figure 2c]. A possibility of Graham-Little-Picardi-Lasseur syndrome was ruled out as there were no hyperkeratotic papules over the body, and the examination of the axilla and perineum was normal. He was diagnosed as a case of atrophic lichen planus of the face with lichen planopilaris of the scalp and co-existing alopecia areata of the forearms, and was started on oral cyclosporine at 5 mg/kg/day with a favorable response of the forearm and facial lesions; however, suboptimal response of the scalp lesions at 3-month follow-up.Figure 1: (a) Scarring alopecia predominantly over the frontoparietal scalp; (b) Violaceous atrophic plaques over right mandibular region; (c) Non-scarring alopecia patches over both the forearms; (d) Dermoscopy (Illuco IDS-1100, Polarized, 10X) of the scalp showing significantly diminished follicular ostia and pigment network, predominantly perifollicular violaceous pigment, blue-grey dots (black circle), minimal perifollicular scaling (red circle) and multiple white dots; (e) Dermoscopy of the facial lesions showing diffuse brown to violaceous background, Wickham’s striae (black circle), diminished hair follicles, and blue-grey dots (red circle); (f) Dermoscopy of the forearms showing multiple black dots (black circle), short vellus hair (black arrow), broken hair (red circle), and pohl-pinkus constriction (red arrow)Figure 2: Histopathology showing (a) Epidermis with hypergranulosis, follicular plugging (arrow), and dense bandlike infiltrate with an hourglass-like configuration of the follicle (star). The dermis shows lymphocytic infiltrate, pigment incontinence (triangles) (40x, H and E) (a); (b) Perifollicular lymphocytic infiltrate (star) (400x, H and E); (c) Facial lesion showing epidermis with compact orthokeratosis (arrow), wedge-shaped hypergranulosis (triangles), and irregular acanthosis. Dense band-like lymphocytic inflammatory infiltrate is seen at the dermo-epidermal junction and the superficial dermis with pigment incontinence (star). Vacuolar alteration of the basal layer is seen along with a few civatte bodies in the inset (triangle) (100x, H and E)Histopathology plays an integral role in diagnosing both scarring and non-scarring alopecias. In scarring alopecia, the lymphocytic infiltrates affect the bulge and the isthmus region with loss of sebaceous glands. The destruction of the stem cells in the bulge area of the follicle along with fibrous scar tissue leads to irreversible hair loss. The non-scarring alopecias like androgenetic and alopecia areata show progressive miniaturization of terminal hair follicles, sebaceous pseudo-hyperplasia, and/or intrabulbar inflammation with several follicles in the biopsy in the same phase of the hair cycle.[3,4] Lichen planus, lichen planopilaris, and alopecia areata are all considered autoimmune disorders of unknown etiology and hence, their coexistence may point towards a similar pathophysiological mechanism or alteration in immune regulation. Individuals with one or more autoimmune disorders are more predisposed to develop other related or associated autoimmune disorders.[5] The occurrence of either two of these disorders has been described rarely of which lichen planopilaris existing with alopecia areata is rare; however, the three existing together is even rarer.[6-8] All three conditions involved hair-bearing areas in our patient. Hair follicle is an immune-privileged site and there are multiple mechanisms to ensure this, which may include the downregulation of major histocompatibility complex (MHC) and local generation of immunosuppressants.[9] Loss of this privilege invites various autoimmune disorders of the hair follicles, as seen in our patient. We describe this rare occurrence which emphasizes the fact that having one or more autoimmune disorders predisposes to others, and loss of hair follicle immune privilege may predispose to autoimmune disorders involving multiple hair-bearing areas of the body. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Mucormycosis is a rare angioinvasive fungal infection commonly found in immunocompromised individuals, especially in an intensive care setting. Rhino-orbito-cerebral (ROCM) form is the most common presentation in patients with diabetes mellitus in India. A high index of clinical suspicion in picking up early subtle clinical signs such as periorbital edema, sinusitis, and ophthalmoplegia coupled with an aggressive management plan including systemic antifungals and surgical debridement of invaded tissue can often avert an otherwise fatal outcome in susceptible patients. We report a case of ROCM in a 37-year-old male with diabetic ketoacidosis.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe adverse cutaneous drug reaction with mortality up to 10%. It is a rare condition with risk varying between 1 in 1000 and 1 in 10 000 drug exposures. The aim of the study was to describe clinical features, management and drugs responsible for causing DRESS. The study was retrospective, observational study. The data of patients admitted to hospital with diagnosis of DRESS during study period (March 2018 to February 2020), were retrieved and analyzed. The descriptive data of patients were summarized. The continuous variables were summarized as mean +/- SD and/or median, depending on the skewness of the data. The categorical variables were expressed as absolute numbers, frequency, and proportions (%). The data was tabulated and analyzed in Microsoft Excel 2019 version. A total of 20 patients who met inclusion criteria (probable or definite DRESS as per RegiSCAR criteria) were included in the study. The mean age of the patients was 41.2 +/- 15.7 years. The average latency period was 26.45 +/- 5.65 days (range: 7-60). The commonest culprit drugs were dapsone and phenytoin, each in five (25%) patients. Commonest morphology of rash was morbilliform in 13 (65%) patients. One patient with targetoid rash had multi-organ involvement. Facial edema, periorbital edema, and conjunctival injection were seen in 17 (85%), seven (35%), and six (30%) cases, respectively. Eosinophilia was present in 18 (90%) patients with mean (+/- SD) value of 1976 +/- 840 cells/mu l. Liver was the commonest internal organ involved in 14 (70%) patients and kidney in three (15%) patients. The initial dose of prednisolone for treatment varied from 0.75 to 2 mg/kg/day. The mean duration of steroid treatment was 64 +/- 21 days. Two patients were treated with intravenous methylprednisolone and one with intravenous immunoglobulin. Two patients (10%) had recurrence of adverse drug reaction >6 months after completion of initial treatment and two (10%) developed autoimmune thyroiditis during follow-up. Small sample size and retrospective nature of the study were main limitations. Selection bias is a possibility as study was carried out in tertiary care center. Tests for incriminating culprit drugs such as patch test, intradermal test, and lymphocyte transformation test were not performed. DRESS is a rare disease that can be diagnosed early with high index of suspicion and treated successfully with steroids. The internal organ involvement is common in DRESS and requires a thorough evaluation.

Leprosy has a wide range of clinical manifestations, which sometimes imposes a clinical challenge and may lead to misdiagnosis. Interactions between leprosy and human immunodeficiency virus (HIV) have been little studied and poorly understood to date. However, coinfection still poses dilemmas in leprosy as to the occurrence of the immune reconstitution inflammatory syndrome manifesting as clinical leprosy and reversal reactions, higher chances of relapse after the successful completion of the multidrug therapy (MDT) and drug interactions between MDT and antiretroviral therapy. Furthermore, coinfection can lead to atypical clinical manifestations of leprosy. Herein, we describe a rare presentation of leprosy in a patient of HIV infection who reported with papulosquamous lesions over both upper and lower limbs histopathologically consistent with Hansen's disease.

Background: Leprosy is a chronic communicable disease caused by Mycobacterium Leprae. Despite the multidrug regimen against this formidable pathogen for nearly four decades, leprosy remains a public health scourge. The World Health Organization has intensified its efforts to eliminate leprosy by launching “Global Leprosy Strategy 2016–2020. Notwithstanding, India had accounted for 60% of new cases globally in 2016. Aims: The aim of this study is to describe the clinical and epidemiological spectrum of leprosy patients encountered at a tertiary care center in Western Maharashtra. Settings and Design: Record-based, retrospective, descriptive study. Methods: Case records of leprosy patients treated at a tertiary care hospital over 10 years were studied. Two hundred and thirteen cases that fulfilled the World Health Organization's 1998 case definition of leprosy and whose case records were replete with a basic demographic, case history, examination, and treatment details were included in the study. Statistical Analysis: Data were compiled in MS Excel and analyzed with the SPSS statistical software version 20. Results: Majority (87.3%) cases were multibacillary leprosy. A significant number of patients had borderline tuberculoid leprosy (71.5%). Meantime taken for the diagnosis, i.e., time taken from the onset of symptoms to diagnosis was 271.74 days. Contact tracing could be elicited in only 1.4% of cases. A light-colored numb patch was the most common clinical presentation in 79% of patients. 96.7% of patients had peripheral nerve thickening, of which, the ulnar nerve was the most frequently involved (93.5%). Ninety-nine (46.5%) cases had documented leprosy reactions. Grade 2 disability accounted for 23% cases with claw hand as the most common deformity in17.4%. Conclusions: The present study provides an insight into disease burden as well as the effectiveness of health services at a tertiary care hospital in Western Maharashtra. The study also highlights the importance of early diagnosis and management of leprosy and reactions, thereby minimizing deformities and disabilities.

Introduction: Skin biopsy is an indispensable tool in dermatological diagnosis.Various factors that influence the outcome of a biopsy include information recorded on the histopathology request form by the treating dermatologist to the reporting pathologist. Conversely, a good biopsy report is vital for the clinician to arrive at a diagnosis. Materials And Methods: The present study was conducted at a tertiary care hospital in the form of a retrospective investigation of histopathology requisition forms and reports of skin and mucosal biopsies done over a period of one year.If the pathological diagnosis was definite and matched one of the clinical diagnoses, it was grouped under the category definite and consistent. If the pathologist gave a descriptive diagnosis that matched one of the clinical diagnoses, it was grouped under the category descriptive and consistent. If the pathologist gave a definite diagnosis that did not match any of the clinical diagnoses, it was grouped under definite and inconsistent and if the pathological diagnosis was descriptive and did not match any clinical diagnoses, it was grouped under descriptive and inconsistent. Data analysis was done using R Statistical Software v3.6.0 (R Statistical Corp, Vienna, Austria). Level of significance was set at p<0.05. Results: A total of 403 skin biopsy requisition forms and their reports were analysed. 46.5% were given a definite pathological diagnosis consistent with the clinical diagnosis, 21% were given a descriptive pathological diagnosis consistent with the clinical diagnosis, 6% had a definite pathological diagnosis inconsistent with clinical diagnosis and 26.5% had a descriptive pathological diagnosis inconsistent with the clinical diagnosis. Conclusion: The present study has shown that clinicopathological consistency in diagnosing skin diseases is 67.5%. Providing comprehensive clinical description and repeat biopsy increases the diagnostic accuracy rate.

Background:Verruca vulgaris is a viral infection with high recurrence rates and is very difficult to treat. It occurs due to the ability of the virus to evade immune recognition. This immune evasion by the human papillomavirus (HPV) can be circumvented by injecting HPV antigens subcutaneously and inducing inflammation and a systemic immune response. Falkner technique is an approved technique for the treatment of warts. In this observational study, we analyzed the recovery rate among patients undergoing this technique as part of their routine treatment. The aim of this study is to study the clinical outcome of Falkner's needling technique that is being used for the treatment of verruca vulgaris. Methods:Under local anaesthesia, only a single wart was vertically punctured using a 26-gauge needle up till the subcutis multiple times till bleeding was observed. No treatment was done for other warts. Patients were advised not to take any anti-inflammatory medications for pain and were observed for responses after 1 week as well as 1 and 3 months. Results:Of 41 patients included in this study, the total resolution of both the punctured and distant warts occurred in 28 patients (68.29%) and partial response in 7 patients (17.1%) by the end of 3 months. Interestingly, individual warts that were subjected to needling showed complete resolution in 35 patients (85.4%). Conclusion:Falkner's needling method provides a high rate of complete resolution of multiple warts at both the needled and distant sites after a single treatment session of only a single lesion. This modality has a high cure rate, is easy to perform, requires minimal infrastructure support, is cost-effective, and can be undertaken at most peripheral settings with minimal training.

Hansen's disease is a chronic infectious granulomatous disease with varied clinical presentation. Histoid Hansen's disease is an important emerging lepromatous subset of Hansen's disease known to mimic varied dermatoses. Occurrence of reactions, especially erythema nodosum leprosum (ENL), is rare in this form of leprosy. We report a case of Histoid Hansen's disease with initial presentation of ENL while undergoing management for infertility.

Hansen's disease is caused by Mycobacterium leprae. The disease is known to involve the visceral organs including the testis apart from the skin and nerves in the lepromatous pole of leprosy due to widespread hematogenous dissemination of lepra bacilli. Furthermore, there can be testicular pain during the type 2 reaction in Hansen's disease. Filariasis is a disease caused by the parasitic nematode, Wuchereria bancrofti. This infection most commonly results in lymphedema and secondary vaginal hydrocele with an associated epididymo-orchitis. Acute epididymo-orchitis is either seen in the acute phase or as a part of secondary bacterial infections. The particular interest of this paper is to report the case of Hansen's disease who presented with testicular pain and posed a diagnostic dilemma when his pain did not respond to the standard mode of treatment and an alternate rare diagnosis was sought. This case report also emphasizes the need of reconsideration of diagnosis when the patient is not responding to standard therapy.

A 55-year-old female patient who presented with asymptomatic, small, dark coloured, raised lesions over the right forearm of eight years duration. These lesions gradually increased in size and number to the present state. There was no associated itching, pain or discharge from the lesions. There was no history of any other skin or mucosal lesions or any systemic symptoms. Examination revealed multiple discrete hyperpigmented to dark brown linear plaques and nodules distributed over middle third of right forearm, predominantly over extensor aspect [Figure 1]. An excisional biopsy was performed from a nodule on the right forearm. The histological picture was as seen in Figure 2.Figure 1: (a) Multiple hyperpigmented to dark brown nodules on right forearm (b) Close up view of the clinical lesionsFigure 2: Histopathology revealing (a) Hyperplastic epidermis with a grenz zone and mid dermis lesion composed of spindle cells with elongated hyperchromatic nuclei arranged in interwoven fascicles (H and E, ×10) (b) High power view of the same (H and E, ×40)WHAT IS YOUR DIAGNOSIS? ANSWER Diagnosis: Dermatofibroma Histopathlogy revealed a well-circumscribed lesion composed of fibroblast-like spindle cells arranged in interwoven fascicles in the mid-dermis. At the periphery, the spindle cells characteristically were wrapped around normal collagen bundles. The cells had eosinophilic cytoplasmic processes with elongated hyperchromatic nuclei with inconspicuous nucleoli. Large numbers of capillaries were present in the stroma. The epidermis was hyperplastic with elongated rete ridges and a grenz zone was present. DISCUSSION Dermatofibroma is a benign fibrohistiocytic tumor characterized by proliferation of spindle cells resembling fibroblasts and oval cells resembling histiocytes. It is also known as fibrous histiocytoma, histiocytoma cutis, subepidermal nodular fibrosis and sclerosing angioma. The precise pathomechanism giving rise to these cutaneous nodules is unknown. Recent studies suggest clonal proliferative growth as the main pathogenesis.[1] Clinically, the lesions are usually asymptomatic firm papules and nodules ranging from 1 to 15 in number, developing more commonly on extremities. Pruritus and pain may be present. On squeezing of the overlying epidermis, there is dimpling due to tethering of skin ("dimple sign"). This sign although not unique to dermatofibroma, is useful in clinical diagnosis. An eruptive form of the disease has been described in immunocompromised hosts, familial cases, malignancies and autoimmune diseases.[2] Dermoscopy is a useful clinical tool and most commonly reveals a peripheral pigment network and central white area.[3] On histopathology, there is epidermal hyperplasia and increased pigmentation may at times be seen. Dermis shows focal proliferation of cells that resemble histiocytes and fibroblasts with storiform pattern focally. The spindle cell proliferation is seen in whorling fascicles. Excessive collagen deposition with hyalinization may also be seen. Different clinicopathological variants of dermatofibroma have been described. These include cellular, aneurysmal, pseudosarcomatous and epithelioid. The most common cellular variant has larger lesions and can extend into subcutis mimicking dermatofibrosarcoma protruberans. The aneurismal variant can mimic vascular tumors and on histopathological examination (HPE) has cavernous like pseudovascular spaces. The pseudosarcomatous variant can have various morphologies and may have mitotic figures on HPE. The epithelioid variant can again mimic vascular tumors and have myxoid changes on HPE. An atrophic form has also been described.[4] The rarer ones include ulcerated, erosive and lichenoid forms. Treatment is warranted only for cosmetically unacceptable or symptomatic lesions. Deep excision, cryosurgery and ablative lasers are the present options.[5] We had considered a differential diagnosis of scar sarcoid, fibroxanthoma, leoimyoma and histoid Hansen's disease. Dimpling sign was present and histopathology confirmed the diagnosis of dermatofibroma, probably a lichenoid or sarcoid-like form with classical histopathological features. Excision biopsy was done for all lesions.

Toxic epidermal necrolysis (TEN) is a rare, idiosyncratic, unpredictable drug reaction. It is potentially a life threatening dermatological disorder. At present there is no definite consensus regarding the management of TEN. Treatment of TEN with etanercept has shown promising results in the recent literature where conventional systemic therapies are either contraindicated or have failed. We report a case of nevirapine induced TEN treated successfully by administering single dose of 50 mg etanercept given subcutaneously that resulted in complete re-epithelialization and without any complications.

A 4 year old boy presented with history of itchy raised lesions on body of 2 years duration. Though parental consanguinity was not present, his elder brother had similar complaints. Dermatological examination revealed multiple hyperpigmented papules with a central keratotic plug distributed mainly over face and extensors of upper and lower extremities. Koebnerisation was present. Skin biopsy revealed perforating collagen bundles in the upper dermis and epidermis which was confirmed by Van Gieson staining. Patient was being treated with topical retinoids and intralesional corticosteroids with minimal relief.

A 50-year-old man, a known case of human immunodeficiency virus infection for the past 1 year, was on antiretroviral therapy in the form of stavudine, lamivudine, and nevirapine. Three days after replacing stavudine with tenofovir, he developed redness on the face and neck and within 48 h the rash became generalized. Dermatological examination revealed involvement of photoexposed areas of the face in the form of erythema and ill-defined hyperpigmented plaques, with mild periorbital edema. There was specific involvement of V and nape of the neck. Extensive erythema and scaling were also present on buttocks, thighs, and upper third of legs. A diagnosis of photoallergic dermatitis to tenofovir was considered and confirmed by histopathology and photopatch test. He responded well to the stoppage of the drug and oral corticosteroids. This is the first report of a photoallergic reaction to tenofovir in the literature.