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Trichostasis spinulosa is a disorder of hair follicles characterized by the retention of vellus telogen club hair, leading to the formation of comedo-like lesions. It usually presents over the face and is frequently asymptomatic. We report a 53-year-old female who presented with multiple itchy, discrete, bluish-black, 2-3 mm comedo-like follicular papules and pustules on her breast and lower abdomen for the past 2 years. In-vivo dermoscopy showed keratotic plugs with a tuft of hair. Extraction dermoscopy yielded a cystic structure filled with keratin and multiple vellus telogen club hairs. Histology showed a cyst lined by squamous epithelium containing abundant laminated keratinous debris and a vellus hair shaft. Truncal or breast involvement, as seen in the present case, is relatively rare, and can be pruritic, causing significant morbidity due to itching and secondary bacterial infections. Dermoscopy, especially ex-vivo extraction dermoscopy, can show diagnostic features and obviate the need for abiopsy., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Indian Dermatology Online Journal.)

Background: Tinea incognito presents with atypical, widespread, and recurrent lesions. Dermoscopy can aid its rapid diagnosis., Aim and Objectives: This study aimed at assessing dermoscopic features and response to treatment in patients with tinea incognito., Materials and Methods: An evaluation of 62 patients with tinea of glabrous skin (Group A (cases)-31 steroid modified and Group B (controls)-31 treatment naïve) was done. Clinical, dermoscopic, and mycological evaluations were done for both groups at baseline, 2, and 4 weeks of terbinafine therapy. Clinical severity (Clinical Assessment Severity Score (CASS) and Visual Analogue Scale (VAS)) and frequency of various dermoscopic changes were compared at 0 and 4 weeks between cases and controls, using unpaired Student's t -test, Mann-Whitney U-test, and Wilcoxon signed-rank test., Results: Baseline dermoscopic features for both groups were significantly different with respect to frequency of broken hair, bent hair, micropustules and Morse code hair. Earliest feature to resolve with treatment was micropustules at 2 weeks. Significant reduction in frequency of morphologically altered hair was evident at 4 weeks. Telangiectasia, dotted vessels, I-hair, and broken hair persisted for a longer period of time. Terbinafine for 4 weeks was an effective treatment, producing complete cure in 73% of cases and 93% of controls. Persistent dermoscopic changes at 2 weeks were found to be associated with treatment failure at 4 weeks, highlighting the role of dermoscopy in identifying patients requiring prolonged treatment., Conclusions: Dermoscopy can be used as a diagnostic and monitoring tool for tinea of glabrous skin., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Indian Dermatology Online Journal.)

Onychomycosis (OM) is a difficult-to-treat condition, especially considering the limited armamentarium of antifungal drugs, need for prolonged treatment, and poor compliance. This problem is further confounded while treating OM in special populations such as children, elderly, immunosuppressed patients, pregnant or lactating women, and patients with chronic liver or kidney disease. In the absence of standardized treatment guidelines, the antifungal therapy is either withheld or compromised, as it is largely governed by personal preferences or based on anecdotal reports. Hence, an expert group of the Nail Society of India worked towards drafting guidelines based on established literature and inputs from experts, with practical recommendations for the treatment of onychomycosis in special population groups. An extensive analysis of available English language literature on onychomycosis in special populations, published during a 10-year period (2014-2023 until date) was done. The available studies and reports were evaluated, cross-references read, and evidence compiled, graded, and discussed by the expert group to derive consensus recommendations for practice. The evidence and recommendations based on it are presented in a narrative format to guide treatment choices when dealing with population groups with special considerations., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Indian Dermatology Online Journal.)

Background: Onychomycosis (OM) is the most common nail disorder accounting for 40-50% of all onychopathies. Onychomycosis is caused by dermatophytes in majority, mostly Trichophyton ( T. ) rubrum followed by T. mentragrophytes var . interdigitale . However, there is a variation in the etiological profile with the subset of population, time, and geographical location. In immunocompromised hosts, non-dermatophytic molds (NDMs) and yeasts like Candida albicans and Candida parapsilosis are the main causative agents. Diabetes mellitus (DM) is a well-established risk factor for OM., Aim and Objectives: This study was conducted to determine the clinical and mycological characteristics of OM in diabetic patients and to evaluate the clinico-etiological correlation, if any., Materials and Methods: Three hundred consecutive diabetic patients were screened, of whom 102 (34%) patients were diagnosed with OM based on clinical, mycological, dermoscopic, and histological criteria., Results: Distal lateral subungual onychomycosis was the most common clinical variant seen in 80 (78.43%) patients. Fungal culture was positive in 57 (55.88%) of which NDMs constituted approximately half (47.61%) of the isolates, followed by Candida species (30.15%) and dermatophytes (22.22%). The clinico-mycological correlation was performed to look for the association of various fungi with the clinical type of OM. Distal lateral subungual onychomycosis was majorly caused by NDMs (51.02%), followed by Candida species (28.57%), and dermatophytes (20.40%)., Conclusion: Non-dermatophytic molds are increasingly incriminated as the causative organisms for OM in DM and must be considered as potential pathogens in the present scenario, thus necessitating the change in the treatment options accordingly., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Dermatology Online Journal.)

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Onychomycosis (OM) is the commonest cause of dystrophic nails, responsible for upto 50% of cases. Apart from significantly damaging the nails, quality of life, and self-image of the sufferer, it also acts as a reservoir of fungal infections carrying important implications for emerging recalcitrant dermatophytoses. Treatment of OM is based on guidelines released almost a decade back, in addition to published literature and personal preferences. Hence, an expert group of nail society of India (NSI) worked towards drafting these guidelines aimed at compiling recommendations for pharmacologic treatment of OM, based on scientific evidence, along with practical experience. The group did an extensive analysis of available English language literature on OM published during the period 2014-2022. The evidence compiled was graded and discussed to derive consensus recommendations for practice. Special focus was placed on combination therapies and adjunct therapies, including experience of members, to improve treatment outcomes., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Dermatology Online Journal.)

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We have seen that radiological techniques like digital x-ray, high-frequency ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) have their unique roles in assessing a complex anatomical structure like the nail unit. Broadly speaking, USG and MRI help evaluate soft tissue components well; while, radiographs and CT scans help assess bony lesions better. In the second part of this review, salient radiological features of various nail disorders, as seen on these modalities are detailed. The radiological features mostly play a supportive role and help rule out differential diagnoses. However, in some diseases like retronychia and some nail tumors, radiological findings help clinch the diagnosis. The diagnostic features as well as the investigative modality of choice for a particular disease are highlighted based on the best level of evidence (LoE) available. This narrative review includes both infectious and non-infectious nail unit diseases, with special emphasis on nail unit tumors., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Dermatology Online Journal.)

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As we were on the road to recovery from the coronavirus disease-19 (COVID-19) pandemic, the world is waking up to yet another potential adversary. Monkeypox (or human monkeypox) caused by monkeypox virus (an orthopox virus) is fast emerging in more than 80 countries worldwide, where it has never been historically reported. We in India, have already seen the advent of this outbreak since July 2022, with a progressive rise in number of cases being seen. Though the virus is not a novel virus; it is presenting with atypical manifestations as compared to our conventional knowledge of the disease. Through this document, the Indian Association of Dermatologists, Venereologists, and Leprologists Academy aims to sensitize dermatologists toward recognizing the clinical features and responding promptly, to contain the outbreak at the earliest. In view of the non-availability of specific antiviral drugs as well as vaccines; early detection, isolation, and prevention of spread form the mainstay of our approach towards the outbreak, which has been declared to be a "Public Health Emergency of International Concern" by the World Health Organization., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Dermatology Online Journal.)

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The nail unit is a unique skin appendage, capable of mounting only a limited number of reaction patterns to a variety of insults. This makes it difficult to diagnose many nail conditions based on clinical features alone. Thus, diagnostic modalities have an important role to play in nail disorders. Emphasis is placed on non-invasive diagnostic methods, of which, radiological imaging forms an important part; however, it is a field largely under-explored with very few studies and reports available in the literature. This could be due to the problems encountered in nail unit radiology including its small size, complex anatomy, requirement for special high-frequency probes to reliably evaluate superficial structures, and non-familiarity with nail unit radiological features even amongst trained radiologists. Nevertheless, it plays a useful role in diagnosing nail disorders (especially tumors), localizing the changes, exploring differential diagnoses, estimating prognosis, and planning management. This article is aimed at collating scientific data pertaining to various radiological modalities used in the diagnosis of nail diseases. The advantages and limitations of various imaging techniques used for evaluating the nail unit, including digital radiographs, high-frequency ultrasound, ultrasound doppler (USD), computed tomography (CT), and magnetic resonance imaging (MRI), are discussed in the first part. The second part will discuss the features of common and uncommon nail diseases., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Dermatology Online Journal.)

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Background: Various nail manifestations have been reported with COVID-19; mostly in the form of isolated reports., Objective: This cross-sectional study was carried out to assess nail changes in hospitalized patients with moderate to severe COVID-19., Methods: Nail findings in 43 adults being treated for COVID-19, were evaluated after obtaining informed written consent. Nail changes involving fingernails and toenails were documented as new-onset or pre-existing changes. Disease status, hematological and biochemical tests, inflammatory markers, treatment administered and outcomes were also recorded. The frequency of changes in fingernails and toenails were statistically compared., Results: The red half-moon sign (32.5%) and nail bed erythema (34.8%) were the commonest changes seen in fingernails; while apparent leukonychia (46.5%) and distal brown discoloration (51.1%) were commonest changes in toenails. The difference in frequency of changes seen between fingernails and toenails was statistically significant (p < 0.05). Nail changes correlated with systemic involvement in these patients., Limitations: Single-center evaluation in a limited number of patients, without using augmented examination techniques like onychoscopy, nail fold capillaroscopy, or fluoroscence. Those with less severe disease or with rapid fatality could not be studied., Conclusion: Nail changes in COVID-19 are common and reflect the systemic nature of illness, being a harbinger of underlying complications., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Dermatology Online Journal.)

In dermatology, "pseudo" is often used as a prefix for entities resembling another standard condition, either morphologically or histopathologically. Correspondingly, "pseudotumor" is a term encompassing dermatological conditions which are not true proliferations, but either have a clinical resemblance to a known tumor ( e.g. , Pseudokaposi's sarcoma is actually a non-neoplastic condition) or a histopathological resemblance to one ( e.g. , pseudo-myogenic hemangioendothelioma named due to a histopathological resemblance between myocytes and tumor cells). Often such a nomenclature can create confusion and unnecessary alarm for both the physicians and the patients. Through this article we attempt to summarise "pseudotumors" in dermatology and classify them into clinical and histopathological "pseudotumors", so as to produce a ready reckoner for this confusing nomenclature., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Dermatology Online Journal.)

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In dermatology, the word "molluscum" is used as a prefix for infective and non-infective conditions. The term is used to describe soft papules or nodules with or without central umbilication, which is not a necessary qualification. This article attempts to summarise the conditions in dermatology with the epithet "molluscum" and discuss them in brief., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Indian Dermatology Online Journal.)

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Introduction: Systemic sclerosis (SSc) is characterized by fibrosis and intimal proliferation of cutaneous and visceral small vessels. These architectural abnormalities can be visualized with nailfold capillaroscopy (NFC); the changes being quite characteristic. At the same time, morphological alterations in retinal vascular bed are expected but sparsely described., Aim: We aimed to characterize the frequency and type of retinal microvascular changes in patients with SSc and to analyze any association with NFC changes., Patients and Methods: With institutional ethical committee approval, we recruited 45 consecutive patients with SSc (diagnosed based on American College of Rheumatology and European League against Rheumatism [ACR/EULAR-2013] criteria). NFC was done for all of them with a Universal Serial Bus (USB) dermatoscope; additionally, fundoscopy, fundus photography, and optical coherence tomography (OCT) were analyzed. Disease characteristics in patients with and without retinal disease were compared., Results: Among the 45 SSc patients, 12 (26.67%) had limited cutaneous SSc (lSSc) while 33 (73.33%) had diffuse cutaneous disease (dSSc). Retinal microvascular changes seen as mild arteriolar alteration and arteriovenous crossing changes were recorded in 13 patients (28.89%); mostly in those with dSSc (12/13). The NFC architectural changes were more severe in patients with retinal disease, though the difference was not statistically significant., Conclusion: Patients with SSc can often have retinal microvascular abnormalities commensurate with the vascular changes characteristic of SSc. The severity of retinal changes correlates with changes in NFC. NFC, which is now an essential tool for the management of SSc, could be a surrogate marker for retinal involvement in these patients., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Dermatology Online Journal.)

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Nail unit is a complex skin appendage offering natural barrier to drug penetration by virtue of its unique anatomy. This is the reason why topical as well as oral therapies can be largely ineffective when dealing with nail diseases. Intralesional (injectable therapies) offer a practical solution in this scenario. This review aims to summarise the role of different injectable drugs in various nail unit disorders. Various types of intralesional therapies in the nail unit, their techniques of administration, appropriate drugs to be used and optimum treatment protocols are summarised., Competing Interests: There are no conflicts of interest.

Competing Interests: There are no conflicts of interest.

Nail biopsy is a procedure not routinely resorted to; but when indicated, it is often the only clue left for diagnosis. At such times, it pays to be conversant with it. It is an investigation that not only provides etiologic, diagnostic, and prognostic information but also aids in understanding the pathogenesis of nail diseases. It can be of therapeutic value, especially with respect to nail tumors. This article compiles the procedural techniques for nail biopsy of various types and attempts to summarize the evidence available in the literature. The objective of nail biopsy is to clinch a precise diagnosis of nail pathology with a simple and safe surgical procedure, avoiding pain or permanent nail damage. Patient selection is of utmost importance, wherein, the patient does not have typical skin lesions, yields inadequate information on routine nail investigations, and has no peripheral vascular compromise. The patient needs to be explained about the risks associated, the expected functional handicap, the time required for regrowth, a possibility of permanent nail dystrophy, and a possibility of not achieving a diagnosis even after the biopsy. Techniques and types of various nail biopsies are being discussed in this article. The specimen could be collected as an excision biopsy, punch biopsy, shave biopsy, or longitudinal biopsy. The trick lies in choosing the appropriate area for biopsy. Various biopsy types discussed in this article include nail plate biopsy (easiest and least scarring); nail bed biopsy (elliptical excision or punch); nail matrix biopsy (elliptical excision, punch excision (≤3 mm) or tangential/shave excision); and nail fold biopsy. Complications reported along with means to minimize them are also discussed., Competing Interests: There are no conflicts of interest.

Subungual melanoma (SUM) is an uncommon form of acral melanoma that arises within the nail matrix. The incidence for acral melanomas is similar worldwide, however, the proportion is higher in dark-skinned individuals. The subungual form represents approximately 2% of cutaneous non-sun-induced melanomas in the western world and up to 75% in Africans, 10% in Japanese, and 25% in the Chinese. No specific figures are available from the Indian subcontinent; however, the authors could trace three anecdotal case reports published over the last two decades. A general reluctance to biopsy a nail lesion to confirm the diagnosis may be contributing to the missed diagnosis. We report four cases of SUM of the big toenails seen over a period of 2.5 years. They were three women and one man with an age ranging from the 4 th to 7 th decade and disease duration of 6-18 months. The lesion involved the big toe in all and two patients had liver and lymph node metastasis at the time of presentation. Awareness among dermatologists regarding clinical manifestations, high index of suspicion for acral pigmented lesions, and nail bed biopsy may help in the early diagnosis and management and can prevent mortality., Competing Interests: There are no conflicts of interest.

Competing Interests: There are no conflicts of interest.

Background: There is no uniform grading scale for objective assessment of premature canities that can serve as a reference. The aim of the study was to devise an objective and reproducible scoring system to assess the severity of premature canities., Materials and Methods: A cross-sectional study conducted from November 2011 to April 2013 in a tertiary care setup with 52 apparently healthy individuals with onset of premature graying of scalp hair before the age of 20 years. A new scoring system (Graying Severity Score, GSS) was devised to evaluate the extent of graying taking into account five representative sites from the scalp by two independent investigators and analysed for agreement. GSS ranged from 0 to 15 that was further graded as mild, moderate, and severe., Results: The highest total GSS attained was 13 and lowest was 4 (mean = 6.6 ± 1.97). Of the 52 patients 17 (32.69%) had mild, 32 (61.54%) moderate, and only 3 (5.77%) had severe GSS. Scores of both investigators were found to have good agreement. The intraclass correlation calculated by the two-way mixed model using the absolute agreement definition for the GSS was 0.967 (CI = 0.944-0.981; P = 0.000) and for GSS grade was 0.962 (P = 0.000). In the study subjects the frontal and the vertex regions were found to be the worst affected., Conclusion: GSS is a novel, numeric, objective, and reproducible tool for evaluation of premature canities that can be used to follow up and assess therapeutic response. Further large scale studies are recommended to optimize its utility.