RFP Journal of Dermatology

Case Details

Clinical - Observe the clinical image of a 40-year old Indian lady who developed gradually progressive asymptomatic dark brown to greyish-blue pigmentation with ill-de ned margins involving her forehead, lateral aspect of cheeks, preauricular region extending down till middle neck over the past 3 years. [Fig. 1A]. As a home maker, her sun-exposure was minimal and she denied being very fond of or frequent user of cosmetics and fragrances. She gave history of having used Indian gooseberry (amla) oil over her scalp for many years; and had started using an ammonia-free propriety hair color around 4-5 years back. Being unmarried, she did not use vermillion powder in the scalp parting line. There were no other lesions elsewhere, and examination of mucosae, scalp and hair, and nails was unremarkable. No treatment had been sought or taken till now. A patch and photopatch test with the Indian Standard series and cosmetic series revealed 2+ and 3+ positive allergic reactions to paraphenylenediamine (PPD) and fragrance mix respectively.

Dermoscopy – Dermoscopic image taken from the pre-auricular area (marked with white solid arrow in Fig. 1A] using E-scope

Minoxidil (MNX), the first drug approved for androgenetic alopecia (AGA) in both genders by the US-FDA is most commonly prescribed as 2% or 5% minoxidil topical solution (MTS) for local scalp application. However, the cosmetic unacceptability and other local adverse effects including allergic contact dermatitis associated with the conventional alcoholic MTS often results in markedly reduced patient compliance. Although a patch test is essential to differentiate between allergic reaction to the solvents, namely ethanol and/or propylene glycol (PG) versus MNX molecule, the most common source of the allergic reactions and flaking of scalp with MTS is the alcoholic solvent vehicle. Alcohol-free MTS formulations have been launched but brands with tall claims need to be scrutinized before prescription. Shifting to the aerosolized foam preparation is one viable option, albeit a little costlier. Low dose oral MNX may be tried in patients recalcitrant to topical MNX or developing intolerable local adverse effects. Nanoxidil 5%, the new congener with a lower molecular weight and expectedly better penetration and tolerance may offer a leap over MNX but needs to be validated in large randomized controlled trials.

Keywords: Minoxidil topical solution; Androgenetic alopecia; Female pattern hair loss; Male pattern hair loss; Hair loss; Allergic contact dermatitis; Alcoholic solution; Propylene glycol; Patch Test; Minoxidil foam; Oral minoxidil; Nanoxidil

Chronic non healing ulcer (NHU), especially over the legs pose a management conundrum to the doctor. Etiology of NHU over the legs is predominated by diabetes, leprosy, venous stasis, arterial insufficiency, decubitus ulcer, vasculitis and certain infections. The ulcer may not heal for a long time despite the diagnosis and treatment of the underlying disease. The problem becomes compounded in idiopathic NHU of the legs. Various approaches, including skin grafting have been used with variable results. We describe for the first time, the use of the Jodhpur Technique, our innovation synonymous with autologous non-cultured non-trypsinised keratinocyte and melanocyte grafting to attempt healing of a chronic NHU over the lower leg of a 52-year old man with treated leprosy. The patient’s persistent and treatment-refractory NHU of 3 years duration healed completely within 5-6 weeks of the procedure. No adverse effects were observed. We propose the use of JT as an extremely low cost and simple procedure to induce healing of chronic NHU, especially on the leg.

Keywords: Jodhpur technique Non-healing ulcer Diabetes Leprosy Venous stasis Vasculitis Skin grafting Autologous non-cultured non-trypsinised keratinocyte and melanocyte grafting.

Background: Reconstructing defect is the goal of the plastic surgeon which is done on the principle of reconstruction ladder but certain defect needs coverage requiring improvising on the principles, once such is crane principle. In this study, we would like to highlight the use of crane principle in reconstructing defect of hand and protecting vital structures. Methods: 18 year male with full thickness defect of a volar and dorsal aspect of wrist post electrical burn injury underwent flap cover for the defect. Results: Marginal necrosis of flap noted, flap debrided, healthy wound bed noted. Conclusion: Covering of defect employing crane principle though described in earlier days is still relevant in the management of defect with limited donor site.

Keywords: Crane principle; Defect; Hand

Background: Chronic urticaria is a distressing condition which affects the quality of life of patients. Majority of chronic urticaria patients have no external cause and termed as chronic idiopathic urticaria. Approximately 30-40% of patients with chronic idiopathic urticaria have autoimmune urticaria. Asst is a simple inexpensive test which helps to classify chronic urticaria into idiopathic urticaria and autoimmune urticaria. Aims: To identify autoimmune urticaria amongst the chronic idiopathic urticaria. Methods: A total of 100 cases of chronic urticaria, attending the skin opd from march to February were taken up for the study. After a detailed clinical history and examination laboratory investigations like Complete haemogram, Blood sugars, Erythrocyte Sedimentation Rate (ESR), Absolute eosinophil count (AEC) was sent for all the patients. ASST was done. A positive test was defined as a serum-induced wheal response with a diameter of 1.5 mm or more than the saline induced response at 30 minutes. Results: Of all the patients studied 41% of the patients showed a positive reaction. Most of whom were females and in the age group of 21-30 years. The mean urticaria activity score was 5.11 in the ASST positive patients compared to 4.39 in the ASST negative group. In the ASST positive group, 80.48% had daily occurrence of lesions while 62.71% of the asst negative group got lesions daily. Patients with positive ASST had larger extent of body involvement. Conclusion: We concluded that autoimmune urticaria has greater frequency and larger extent and higher urticarial activity score than other types of urticaria.

Keywords: Chronic urticaria; ASST; Autoimmune urticaria.

Chronic Urticaria remains a major problem in terms of etiology, investigation, and management. Chronic spontaneous urticaria affects 0.5-1% of individuals (lifetime prevalence) and significantly reduces quality of life (QOL). Aims of the Study: 1) To evaluate the types of chronic urticaria with reference to etiology from history and investigations. 2) To identify the specific cause of urticaria by thorough history and investigations. Materials and Methods: Out of 300 patients with chronic spontaneous urticaria were enrolled. Autologous serum skin test (ASST) was performed after excluding physical urticaria. Routine laboratory tests were performed after ASST in all patients; and other specific investigations were done where necessary. Skin prick test was done in idiopathic urticaria. Results: Out of 300 patients, 100 (33%) had history of angioedema. Out of 300 patients, auto-immune condition was present in 48 (16%) patients. Provocating factors were present in 81 (27%) patients. In our study 123 (41%) patients showed infective focus on routine screening investigation. ASST was positive in 60% of patients. Physical urticaria were found in 47 (15.66%) patients by challenge test, most common was dermographism. In prick test, maximum number of patients reacted positively to food allergens followed by pollen, dust, fungus in decreasing frequency. Conclusion: Nearly half of the patients had chronic autoimmune urticaria on the basis of ASST. Chronic spontaneous urticaria requires extended diagnostic measures based on the patient’s history.

Keywords: Auto antibodies; Autoimmune disease; ASST; CSU; Skin prick test.

Palmoplantar keratodermas (PPK) constitute a diverse group of disorders characterized by thickening of the skin of palms and soles. They are often hereditary, but acquired non-familial forms are also common. Acquired PPK are relatively less common in children compared to adults. There is paucity of published literature on this subject with no review article at present. In this systematic review, we discuss the epidemiology and different kinds of acquired PPK in children. An approach towards treatment appropriate for the pediatric age group is also detailed. There is an urgent need for other investigators, especially Pediatric Dermatologists to document and generate more evidence on the epidemiology and clinical presentation of acquired variants of PPK in children.

Keywords: Palmoplantar; Keratoderma; Hyperkeratosis; Children; Pediatric; Acquired; Childhood psoriasis; Childhood eczema Aquagenic PPK; Keratolytics; Retinoids