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Background Melasma is a common, recurrent, and refractory cause of facial pigmentation resulting in cosmetic disfigurement. Tranexamic acid (TA) has been used systemically and locally for clearance of pigmentation. Objective To assess the clinical efficacy of topical TA (10%) with microneedling in melasma. Methods A split face, prospective, randomized, open-label study with a sample size of 40. Left or right side of the face was chosen randomly and microneedling was done on both the sides, followed by 10% TA solution application on one side of the face (test side) and distilled water on the other side of face (control). The procedure was done at 2 weekly intervals (0, 2, 4, and 6 weeks). Clinical images were taken at each visit including modified Melasma Area and Severity Index (mMASI) scoring of each half of the face to assess the clinical response along with patient satisfaction scores and side effects. Results On the test side, there was 65.92% improvement in the mean mMASI score compared with 20.75% on the control side of the face at the end of 8 weeks. Conclusion Tranexamic acid may be a promising therapeutic agent in melasma and the topical solution along with microneedling seems to be efficacious.

Background: Vitiligo is the most prevalent pigmentary disorder occurring worldwide. In most cases, the diagnosis is made by clinical examination alone. The disease status (active/stable) needs to be assessed to make appropriate therapeutic decisions. Objective: The aim of the present study was to evaluate the histopathological and immunohistochemical features in active and stable lesions. Materials and Methods: Biopsies from vitiliginous areas from 50 patients (25 each of clinically active and stable vitiligo); with hematoxylin and eosin, Masson Fontana (MF), S-100, and human melanoma black-45 (HMB-45) stained sections were studied. Results: Age of the patients ranged from 7 to 69 years (mean age: 33.6 ± 15.73 years). Of 50 patients, 27 (54%) were male and 23 (46%) were female. All the cases showed variable degree of basal hypopigmentation. Histopathological findings, epidermal spongiosis, basal vacuolar degeneration, dermal melanophages, and dermal lymphomononuclear cells were commonly observed in active lesions as compared to the stable ones. On MF staining, 23/25 cases (92%) of active vitiligo showed complete loss of basal melanin. Quantitative analysis of HMB-45 immunostaining in stable and active vitiligo revealed mean number of positive melanocytes as 2.52 ± 1.0/high power field (hpf) and 0.08 ± 0.28/hpf, respectively, while on S-100 immunostaining the mean values of positive Langerhans cells were 1.70 ± 0.38/hpf and 7.78 ± 4.11/hpf, respectively. Conclusion: The demonstration of overall reduction in the number of HMB-45-positive melanocytes and increase in S-100-positive Langerhans dendritic cells in the active vitiligo lesions is facilitated by immunohistochemistry. The technique is of immense help in differentiating active and stable stages of vitiligo, thus guiding therapy.

To study and compare the therapeutic efficacy and side effects of a 35% glycolic acid (GA) full face peel alone or in combination with a 10% or 20% trichloroacetic acid (TCA) spot peel for facial melasma.Thirty patients with facial melasma were randomly divided into 3 equal Groups A, B, and C. Group A was treated with a 35% GA full-face peel, Group B and C with 35% GA full-face peel followed by a 10% and 20% TCA spot peel respectively once every 15 days. Four peels were performed once every 15 days. The response to the treatment was evaluated by the percentage reduction in melasma area severity index (MASI) scoring.All 3 groups had significant reduction of MASI, but there was no significant difference between the groups. Group A had minimum side effects.Chemical peels with GA alone or in combination with TCA do result in a significant improvement in melasma, but the combination of the peels in the same sitting does not seem to have any additive or synergistic effect while they may increase the side effects.

Background: There has been an alarming increase in recalcitrant dermatophytosis in recent years. The standard treatment guidelines no longer seem effective in achieving clearance and results in hig...

INTRODUCTION Platelet-rich plasma (PRP) is an autologous blood product which has recently been used in multiple spheres of dermatology including facial rejuvenation, androgenetic alopecia, acne scars, and wound healing. Its use in melasma is comparatively an understudied topic. MATERIAL AND METHODS An extensive systematic literature search of the PubMed electronic database and Cochrane central register of controlled trials was done using the keywords "platelet rich plasma" and "melasma" in the title. Relevant studies were selected and data were analyzed by two different authors. Four articles were excluded as they did not adhere to the inclusion criteria of this review and a total of 6 articles were reviewed.The relevant references of the included articles were also traced and included. DISCUSSION These studies showed that PRP has been used effectively not only as an adjuvant therapy but also as a standalone treatment for melasma. PRP contains about 30 growth factors, transforming growth factor beta (TGF-β) being one of the growth factors having a predominant role in treatment of melasma. TGF-β decreases signal transduction of microphthalmia-induced transcription factor and thus decreases tyrosinase and tyrosinase-related proteins. In addition to this, PRP also has an additional benefit of inducing collagen synthesis thus improving the quality and texture of the skin. But there is a scarcity of data and large randomized controlled trials. This review is an effort to highlight and upscale the use of this excellent blood product for melasma which is quite a treatment refractory disorder.

Verruca vulgaris (VV) acquired through direct contact or autoinoculation of human papilloma virus (HPV). Treatment of VV are challenging as destructive modalities have variable efficacy and recurrence rates. Various immunotherapies attempt to stimulate the cell-mediated host immune response against HPV. We have assessed efficacy of intralesional tuberculin in patients with verruca vulgaris and to see the long term follow-up at 12 months. Forty patients were enrolled in the study. All patients received intralesional tuberculin injections (5 Tuberculin U/mL) in a dose of 0.1 mL/lesion every fortnightly. Patients were followed up for 12 months duration, and response to treatment assessed. Thirty patients (75%) showed complete resolution, 5 (12.5%) patients showed partial response, 3 (7.5%) showed minimal response and 2 (5%) were non-responders. Irrespective of tuberculin sensitivity test response the majority of patients showed grade 3 response. Five (12.5%) patients had a recurrence of lesions. Two had a recurrence on the same site, and three had recurrences over distant sites. Intralesional tuberculin immunotherapy is an effective modality for VV. Immunotherapy of warts is a potential area of research, and exact method and agents are still under investigation.

Background and aims. Sarcoidosis is a multisystem granulomatous disease of unknown etiology and cutaneous involvement is the second most frequent manifestation in systemic sarcoidosis. The aim of the present study is to evaluate the clinical and pathological spectrum of cutaneous sarcoidosis and compare the same with literature available. Methods. The present retrospective study was conducted from January 2010–March 2015 and fifteen cases diagnosed as cutaneous sarcoidosis on biopsy were reviewed. The histological spectrum of cutaneous sarcoidosis was evaluated. Results. The mean age at diagnosis was 46 years. Nine (60%) cases out of 15 were females. Most common cutaneous lesions were nodules (46.6%) followed by papules (40%). Classically, lymphocyte-poor, non-caseating epithelioid cell granulomas, was the most common histologic finding. Inclusion bodies were seen in 20% cases with occasional presence of fibrinoid necrosis (13.3%). Peri-adnexal granuloma, seen in one case, raised the possibility of tuberculoid leprosy. Foreign body was seen in one case supporting the opinion that sarcoidosis and granulomatous foreign body reaction are not mutually exclusive. Epidermal changes including atrophy, loss of rete pegs, acanthosis, papillomatosis, hyperkeratosis, parakeratosis and basal cell vacuolation were seen in 46.6% cases. Reticulin was positive in all the cases while special stains for acid fast bacilli and fungi were negative. Conclusion. The clinical presentation of cutaneous sarcoidosis may be variable. Presence of naked, reticulin-rich granulomas is the most characteristic histopathological finding. Correlation of clinical history with histologic examination is essential to exclude other granulomatous diseases including leprosy, syphilis, other infectious granulomatous diseases and foreign body reaction.

BACKGROUND Diffuse hair loss (DHL) is a common problem in adult women and has a major impact on quality of life. Ascertaining the etiological diagnosis is a challenging task in such patients. Satisfactory treatment can only be instituted after ascertaining the cause of hair loss. OBJECTIVE To study the clinico-epidemiological profile of nonscarring DHL in females and to ascertain its underlying etiological factors. STUDY DESIGN Of a total of 110 females, who presented with nonscarring DHL to the outpatient dermatology department, 100 qualified for inclusion in the study. A detailed history, clinical examination, and laboratory investigations were performed in all the patients. Statistical analysis was performed on the data collected. RESULTS Of 100 cases of DHL which were included in the study, commonest was chronic telogen effluvium (CTE) (62%), followed by female pattern hair loss (FPHL) (22%) and acute telogen effluvium (ATE) (16%). Incidence of hair loss was highest in 21-40 years age group. Psychological stress was seen to be a precipitating factor in 18 patients and found most commonly in women belong to CTE group (n-16, 25.8%). Hemoglobin levels ranged from 80 to 142 gm/L (mean: 119 ± 110). Low hemoglobin level (

Trichothiodystrophy (TTD) is characterized by the common feature of sulfur-deficient brittle hair associated with a constellation of neuroectodermal symptoms. There is a wide phenotypic variation in the severity; ranging from isolated hair defect to multiple neuroectodermal symptoms such as photosensitivity, ichthyosis, intellectual impairment, decreased fertility, and short stature. This case report describes TTD in two sisters with only hair fragility and no other associated feature. This case highlights the variable clinical presentation of TTD and the need for regular follow-up in such patients for an early detection of any neurological, physical, and sexual impairment.

Background Venous lakes are asymptomatic, cosmetically unacceptable vascular malformations commonly present over the lips. Most of the lesions do not warrant any therapeutic intervention. Objective We herein report a 20-year-old male patient with venous lake who was treated using intralesional radiofrequency (RF) by modified insulated intravenous cannula as an extended probe. Methods An RF ablation was performed under local infiltration anesthesia using intravenous infusion cannula as an extended insulated probe to deliver current. Results The venous lake was obliterated immediately post-procedure with minimal inflammatory change. It showed good cosmetic results with minimal scarring and no recurrence at 18 months of follow-up. Conclusions Intralesional RF using modified insulated probe is a useful alternative treatment and may be considered to treat small venous lakes.

BACKGROUND Microdermabrasion (MDA) is a recently introduced noninvasive, nonsurgical, office-based esthetic procedure for revitalizing and rejuvenating the skin. It is a closed-loop vacuum-assisted abrasive procedure, which uses the physical action of inert crystals to exfoliate the skin. OBJECTIVE The aim was to evaluate the procedure of MDA in postacne scarring, melasma, and facial rejuvenation, and review the relevant literature. METHODS Ten patients each of postacne scarring, melasma, and facial rejuvenation were treated by a series of weekly MDA sittings alone or in conjunction with a topical retinoid. The results were assessed by patient questionnaire and an objective assessment by two independent observers. The literature was reviewed to find indications and efficacy of MDA. RESULTS All the patients of postacne scarring, melasma, and facial rejuvenation reported a mild but definite improvement, which increased when MDA was performed in conjunction with a topical retinoid. Most of the literature based on subjective and patient-dependent assessment parameters points toward a marginal improvement in the skin appearance following repeated procedures. CONCLUSION Reappraisal of this potentially useful procedure points toward a need for well-designed clinical trials and studies with a long follow-up based on objective assessment parameters.

BackgroundMicropigmentation, also known widely as tattooing, is being commonly used esthetically to camouflage various medical conditions related to dermatology and plastic surgery.ObjectiveThe aim was to review the procedure of tattooing and its various latest medical indications.MethodsPeer review

Topical antibacterials are being widely used for the treatment or prevention of superficial bacterial infections. Emergence of drug resistant mutant strains of microorganisms and development of irritant and allergic contact dermatitis is a common problem with many of the topical antibacterials. Topical antibacterials are being reviewed with special emphasis on their spectrum of activity, resistance patterns, contact sensitivity potential and clinical uses. Factors which help the physician to choose a particular antibacterial for the specific indication in order to have the maximum efficacy and minimum adverse effects are discussed.

Tuberculosis (TB) of the ribs is extremely rare and its diagnosis is often delayed due to the late appearance of radiologic signs. Although antituberculous drugs are the mainstay of treatment, surgery has a definite therapeutic role in recalcitrant or recurrent cases. A 5-year-old boy with scrofuloderma of the chest wall due to underlying TB of the rib, who responded partially to antituberculous treatment is reported. Surgical resection of the affected rib led to complete resolution. Early diagnosis of TB of this rare site and the role of surgical intervention in such cases is emphasized.

Summary Lichen sclerosus is a depigmenting mucocutaneous disorder that most frequently affects the female genitalia. Lichen sclerosus affecting the oral mucosa is extremely rare. Oral lesions are asymptomatic but cosmetically unacceptable. We report here a case of lichen sclerosus presenting with a linear lesion over the nose that extended to involve the philtrum and the upper lip with intraoral extension up to the gingiva. Treatment with a short course of oral and intralesional corticosteroids resulted in partial resolution of the lesions.

Crude coal tar has been used in the treatment of dermatoses for many decades. In the last few years its use has been limited to skin diseases such as psoriasis and chronic dermatitis. Newer topical modalities for psoriasis are being used increasingly for treatment, but have failed to replace crude coal tar as a first-line treatment of psoriasis. We review the pharmacology, chemistry and use of crude coal in order to reappraise its role as a therapeutic agent in dermatology.

Lichen sclerosus et atrophicus is an uncommon disease of skin and genital mucosa in both sexes. Involvement of the male genital mucosa is usually complicated by recurrent balanoposthitis, ulceration, phimosis, and meatal stenosis. The development of a squamous cell carcinoma is extremely rare in genital lichen sclerosus et atrophicus in males as compared with females. We report a 70-year-old male with a squamous cell carcinoma of the glans superimposed on long-standing lichen sclerosus et atrophicus of glans and prepuce. The patient in addition had a basal cell carcinoma on his face. Awareness of this rare complication of lichen sclerosus et atrophicus in males is emphasized.

Aim: The present study was designed to categorize alopecia areata (AA) into various stages based on histopathology and further study the direct immunofluorescence (DIF) pattern. Materials and Methods: The current study is noninterventional, prospective study on 25 consecutive patients suspected of AA based on clinical assessment. Histomorphologic features and immunoreactivity for IgG, IgM, IgA, and C3, was studied on biopsy material. Results: Age of the patients ranged from 6 years to 48 years with a mean age of 28.56 ± 21.8 years. Majority of patients, 9 (36%) were in the age group of 21-30 years. Of 25 patients, 13 (52%) were males and 12 (48%) were females. Male: female ratio was 1.1:1. On histopathology majority of cases were in subacute stage 9 (36%), followed by chronic 7 (28%), acute 5 (20%) and recovery stages 4 (16%). Three (12%) of 4 cases showed characteristic swarm of bees appearance. Two (8%) of the cases showed presence of giant cells. Increased numbers of catagen hair were seen in 12 (48%) cases. Of 25 cases, 9 (36%) cases showed positive DIF with granular deposits. The most common immunoreactant was IgG in 7 (28%) cases, followed by IgA in 4 (16%), C3 in 6 (24%) and IgM in 3 (12%) cases. Of 9 cases showing positive staining, 3 (12%) were in acute stage and 2 (8%) each in subacute, chronic and recovery stages. Conclusion: The observations further reiterate that immune mechanisms play a role in the pathogenesis of AA.

A 22-year-old female presented to the dermatology department with a 8-month history of blistering lesions over the left forearm and face. Most of the bullae and erosions were perfectly round and of nearly the same size. In absence of any obvious etiological, precipitating or aggravating factor, a provisional diagnosis of dermatitis artefacta (self-inflicted dermatological lesions) was made. A detailed anamnesis revealed that stress caused by her ex-boyfriend’s threats and apprehension of consequences prompted her to create the lesions using a hot spoon. The patients of dermatitis artefacta usually present to dermatologists as their pathology manifests as unexplained and variable cutaneous lesions which may go undiagnosed for a long time. It is important for the dermatologist to have a high index of suspicion to recognise the underlying psychopathology.

Cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis seen in children in developing countries. We report a 5-year-old child with cutaneous tuberculosis with involvement of lymph nodes, lungs, and the musculoskeletal and central nervous systems, which was not clinically obvious. Antituberculous treatment led to marked clinical improvement. The importance of a thorough search for internal organ involvement in patients presenting with cutaneous tuberculosis is emphasized.

Sarcoidosis is a rare disease among children, manifesting differently in children below and above 4-5 years of age. Although the exact incidence and prevalence of childhood sarcoidosis is not known, the cutaneous involvement is frequent in both children and adults. Infiltration of old cutaneous scars with sarcoid granuloma in the active phase of disease, known as scar sarcoidosis is one of the uncommon cutaneous manifestations of sarcoidosis. We report a case of scar sarcoidosis in an 11-year-old child along with a brief review of the literature.

Hair transplantation, a generally regarded as a safe surgical modality for the treatment of androgenetic alopecia, is not without its potential risks and complications. A case of an extensive keloid formation at donor site following follicular unit extraction is discussed. Hair transplant surgeons should be aware of this significant potential complication, especially in patients having previous keloidal tendencies to avoid such disastrous outcomes.

A reduced level or complete cessation of sweating can be caused by a variety of factors affecting sweat glands directly or indirectly through alterations in their nerve supply. The most common presentation is the syndrome of heat intolerance with or without features of dysautonomia. An acquired idiopathic form of generalized anhidrosis is characterized by loss of sweating in the absence of any neurological features or destruction of sweat glands. Cholinergic urticaria has been associated with some cases of this acquired idiopathic form of generalized anhidrosis. A case of generalized absence of sweating without a neurological deficit is described, and the implications of heat intolerance are discussed.

Necrotizing infections of the skin and subcutaneous tissue are usually bacterial in origin. Rarely, fungi of the class Zygomycetes, which cause deep mycoses, may be responsible for acute necrotizing infections of these areas. Several local and systemic predisposing factors have been associated with such acute necrotizing infections. Surgical debridement and amphotericin B remain the mainstay of treatment. In this report we describe a patient with post-surgical necrotizing subcutaneous infection caused by Absidia corymbifera, 2 weeks following appendectomy. Successful management with surgical debridement, topical amphotericin B and oral potassium iodide is reported.

Author(s): Dhingra, M; Kaistha, N; Bansal, N; Solanki, LS; Chander, J; Thami, GP; Sande, WW van de

Annular erythemas are distinct cutaneous eruptions associated with a variety of causes. Occurrence of erythema annulare centrifugum, a variant of annular erythemas, in the immediate post-operative period in a patient with surgical intervention in the gall bladder and pancreas region is being described for the first time. Its probable association with surgical trauma is discussed.

A 70-year-old male with a superficial granulomatous ulcer is reported. Histopathological findings were the same as those described for superficial granulomatous pyoderma, a recognized variant of classic pyoderma gangrenosum. The differences between pyoderma gangrenosum and its variant superficial granulomatous pyoderma are highlighted.

Chondroid syringoma (CS) is a relatively rare cutaneous tumor arising from sweat glands. It usually presents in the head and neck area as an asymptomatic nodule. Although usually it presents in middle aged or older patients, we here present two much younger patients with CS, located over the nose and cheek areas, respectively.

Patterned transient pigmentation along lines of creases occurring in a newborn is rare. A case report of this entity is described, along with a review of all six cases described in the literature so far.

Background: Panniculitides are well-recognized clinicopathologic entities but the non-specificity of their clinical and pathological features often troubles the diagnostician. Methods: This study retrospectively evaluates the clinical overlaps and the significance of histological findings among various panniculitides. Results: The clinical evaluation in 55 panniculitides cases suggested the diagnosis of typical erythema nodosum (EN) in 26 cases, atypical EN in 17 cases, atypical nodular vasculitis (NV) in two cases, soft tissue infection in five cases and five cases remained unclassified. Skin biopsy evaluation provided definite panniculitis diagnosis in 53 cases including EN (28 cases), leukocytoclastic vasculitis (seven cases), NV (four cases), superficial thrombophlebitis (ST) (two cases), eosinophillic panniculitis (EP) (three cases), infection-related panniculitis (five cases), and one case each of erythema nodosum leprosum (ENL), lupus panniculitis (LP), pancreatic fat necrosis and acne conglobata with two cases remaining unclassified. Histologically, ‘predominantly septal’ and ‘mixed panniculitis' were the chief inflammatory patterns in EN cases, while mixed panniculitis was seen in most LCV cases and predominantly lobular and mixed panniculitis in NV cases. Conclusions: Biopsy evaluation of a panniculitis lesion is usually significant, and the application of a combination of histologic features rather than of a single biopsy finding or an inflammatory pattern is helpful in the diagnosis of panniculitis.

Background: Obtaining deeper sections or step sections is a common practice for small skin biopsies. Much of the available literature highlights the importance of step sections in neoplastic diseases of skin. However, the routine dermatopathology practice in developing countries shows a predominant burden of nonneoplastic diseases, and the utility of step sections in this context has not been much reported. Objective: The study was aimed to evaluate the utility of prospective step sections in routine dermatopathology practice. Materials and Methods: The present study comprising 200 consecutive skin biopsies was carried out in a prospective manner. Three slides were prepared in each case: Slide 0 was prepared from the ribbon of tissue obtained from untrimmed block, step sections 1 and 2 were obtained at 50 μm and 100 μm depth, respectively. The diagnosis was rendered on slide 0 and subsequently reviewed after examining step section 1 and 2. Results: Of the 200 cases, additional findings on step sections were found in 18 cases (9%) which led to change in diagnosis in 10 (5%) cases. Step section 1 led to correct diagnosis in 6 cases (3%). Step section 2 led to correct diagnosis in 10 cases (5%); however, this was statistically not significant (P ≥ 0.065) when comparing to step section 1. Additional findings which led to diagnosis was most commonly found in the cases of borderline tuberculoid leprosy (5 out of 10 cases) followed by bullous disorders. Conclusion: We therefore believe that step sections improve the diagnostic accuracy in skin biopsies and they are, especially useful in suspected cases of Hansen's disease. There is no statistical advantage of step section 2 versus step section 1; although, step section 2 had shown to include all the additional findings which led to a change in diagnosis.

Lindane (gamma-benzene-hexachloride) has been widely used as an antiscabetic and a pediculicidal agent for the past 50 years with reasonably good efficacy. After its initial use as a first-line therapy, there have been several reports of its neurotoxicity, especially among infants and young children. Literature review reveals that the risk of its neurotoxicity is minimal if used properly and strictly according to the prescribed recommendations. However, following availability of other safer and equally efficacious alternatives, it is now being regarded as a second-line therapy for scabies and pediculosis.

Background and Aims: Langerhans cell histiocytosis (LCH) is a rare proliferative disorder of histiocytes characterized by a proliferation of abnormal and clonal Langerhans cells. We retrospectively studied clinicopathologic features of this disorder in five cases. Methods: Clinical and histopathological findings of five cases of cutaneous LCH were reviewed based on the hospital records. Results: The age of patients ranged from 28 days to 5 years and M: F ratio was 1:1.5. Clinically, the diagnoses suggested were histiocytosis, varicella, transient neonatal pustular melanosis, keloid, sarcoidosis, seborrheic keratosis and LCH. The most common type of skin lesion was a generalized papular lesion. Histologically, all cases showed aggregates of large mononuclear histiocytes (Langerhans cells) with reniform, irregular, cleaved nuclei and abundant eosinophilic cytoplasm. There was multi-systemic involvement in two patients and single-system involvement in three patients. Conclusion: Cutaneous lesions may be the sole presenting feature of LCH. Diagnosis is based on demonstration of S-100 positive histiocytes.

Lucio phenomenon is a peculiar reactional state associated with Lucio leprosy; both exhibit a restricted global distribution. The exact underlying pathomechanism of Lucio phenomenon, which may be fatal at times, still needs further elaboration. A case of relapse of partially treated nodular lepromatous leprosy presenting with Lucio phenomenon is reported, along with a brief review of the literature.

S urgical procedures like dermabrasion, salabrasion, microdermabrasion, dermasanding, dermaplaning, etc, have been used to remove different depths of skin in order to rejuvenate the layered structure of skin. Various instruments or materials are required to achieve the different levels of cutaneous abrasion. The most superficial form of dermabrasion, using chemically inert crystals, has been termed microdermabrasion and has recently become very common. Because of its innate nature, the procedure of microdermabrasion can only be used on dry and intact skin surfaces. Wet areas, like chronic non-healing ulcers, may also require the removal of superficial layers of slough and dead necrotic tissue debris. The deeper layers of slough and necrotic tissue requiring wider excision may be replaced immediately by superficial necrotic slough, which harbors infection and thus retards granulation tissue formation. These wounds with recurrent superficial slough formation need to be treated with chemical desloughing agents like hydrogen peroxide, hypochlorite solution, hydrocolloid gel, and enzymatic agents like fibrinolysins, streptokinase, streptodornase, trypsin, and collagenase, etc. We have been usingmechanicalmethods of desloughing these ulcers by abrading (gauzabrasion) them with simple dressing gauze.

Eugenol is a para-substituted phenolic compound that is commonly used in various cosmetics, foods and dental materials (1). In dentistry eugenol is used as an impression material, in periodontal packs, and in various sealers. As a primary irritant and sensitizer it is known to cause contact urticaria as well as chronic urticaria (1, 2). A 32-year-old woman presented with severely pruritic, erythematous wheals of 12 h duration that were all over her body. She had been fitted with a temporary dental bridge on the previous morning, and developed an urticarial rash in the evening. Cutaneous examination revealed extensive blanchable wheals of various shapes and sizes. There was no angioedema or mucosal involvement. A provisional diagnosis of acute urticaria due to dental material was made. Treatment with chlorpheniramine maleate 8 mg 6-hourly and prednisolone 1 mg/kg bodyweight per day failed to control the urticaria for next 2 days until the dental bridge and sealer were removed. There was temporary exacerbation of urticaria at the time of removal of the dental bridge, which gradually subsided over 3–4 days. Her dentist revealed that the dental intervention included fixing a polymethyl methacrylate bridge with zinc oxide–eugenol sealer. No local anesthetics or any other drugs or chemicals were used. A skin prick test (SPT) done 2 weeks later was positive for eugenol (10%) and negative for zinc oxide (10%) and polymethyl methacrylate (10%). She was advised not to have eugenol in future dental treatments. No relapse or recurrence was observed during 3 months follow-up. SPT in another two subjects undergoing similar dental interventions with eugenol showed negative results. Eugenol (4 allyl-2-methoxy phenol; C10H12O2) is naturally present in different concentrations in oil of carnation (80%), pimento oil (80%), oil of bay (60%), oil of cloves (85%) and oil of cinnamon (10%) (1). Cements and liners have antiseptic and anesthetic properties with a palliative action on the dental pulp (3). These sealers may also be used as lubricants or as fillers in teeth. Zinc oxide and eugenol undergo a combination of chemical and physical reactions to yield a hardened mass of zinc eugenate. Small amounts of free zinc oxide and eugenol remain trapped in the matrix of the long sheath of eugenate and are released slowly during setting over a period of several days. Zinc eugenate can also be slowly decomposed by water to release minute quantities of zinc oxide and eugenol (3). Eugenol is known to cause contact urticaria, characterized clinically by development of an immediate wheal-andflare response on intact skin coming into direct contact (2). Acute urticaria has rapid onset and disappearance and is usually regarded as an allergic rection (4). Eugenol has an inhibitory action on the cyclooxygenase pathway of arachidonic acid metabolism and may cause urticaria by its direct pharmacological action similar to other cyclooxygenase inhibitors (e.g. aspirin and other nonsteroidal antiinflammatory drugs) (5). Strong temporal correlation of onset of urticaria with dental intervention, continued presence of urticaria despite therapy, its resolution after removal of the dental bridge and sealer, and positive SPT to eugenol confirmed the etiological role of eugenol in acute urticaria in this case. The immunological mechanism in this patient was apparently an immediate-type IgE-mediated hypersensitivity reaction, so it was considered unsafe to rechallenge orally. Although contact and chronic urticaria have previously been described with eugenol, this is the first report of acute urticaria.

Human bite on genitalia is a rare cause of penile ulceration, but is increasingly being reported, probably due to the increasing frequency of orogenital sex. The great morbidity associated with it brings it under the category of high-risk bite wounds, similar to those on hands, feet and joints. We report a case and review the literature on human bite-induced penile ulceration.

Kaposi's varicelliform eruption (KVE) or eczema herpeticum is characterized by disseminated papulovesicular eruption caused by a number of viruses like Herpes simplex virus I and II, Coxsackie virus, and Vaccinia and Small pox viruses in patients with pre-existing skin disease. The occurrence of KVE with psoriasis has been reported recently as a new entity psoriasis herpeticum. The rare causation of psoriasis herpeticum due to Varicella zoster virus in a patient with underlying psoriasis is being reported for the first time.

Acrodermatitis enteropathica which is a manifestation of zinc deficiency, is rarely seen in breast-fed infants. A child with typical acral rash, zinc deficiency and low breast milk zinc levels is described. The importance of awareness of this entity in breast-fed infants along with differential diagnosis is being emphasized.

Rarely, different variants of porokeratosis may coexist in an individual patient or their family members. A patient with the linear form of porokeratosis present since birth subsequently developed the disseminated superficial actinic form at a later age. A review of the literature pertaining to the coexistence of variants of porokeratosis suggests a significant association between the linear and disseminated superficial actinic forms. Genetic linkage between different variants and the basis for their association is discussed.

Background: Corticosteroids are used as a daily oral therapy or in a pulse form with or without various adjuvant drugs for the treatment of pemphigus. Our long-term experience with the use of dexamethasone-cyclophosphamide pulse therapy as a first-line treatment modality for pemphigus is presented. Methods: A retrospective analysis of records of pemphigus patients treated by dexamethasone-cyclophosphamide therapy was carried out. The treatment regimen consisted of the monthly administration of intravenous dexamethasone (136 mg) for 3 consecutive days with addition of intravenous cyclophosphamide (500 mg) on the second day. Oral cyclophosphamide (50 mg) daily and oral corticosteroids (low tapering doses) were given in the intervals between the pulses, till partial remission was achieved. Pulse therapy was then continued for another 6 months followed by daily oral cyclophosphamide (50 mg) for 1 year, which produced a complete remission. Results: A total of 36 patients, 32 with pemphigus vulgaris and 4 with pemphigus foliaceus, were treated with this regimen. Two to 8 pulses were required to achieve a partial remission, while the total number of pulses given for complete remission ranged from 8 to 32. The duration of pulse therapy correlated with both the disease severity and the time to achieve remission. All patients are now in complete remission with a follow-up of 0.5–12 years. Four patterns of remission were observed, related to the severity of disease. The response to pulse therapy was faster in the milder form of disease. The severe form of disease required more pulses as well as higher doses of intervening oral corticosteroids. Conclusions: Dexamethasone-cyclophosphamide pulse therapy is an effective form of treatment in pemphigus and results in long-lasting remissions.

A case of plasma cell mucositis is described for its rarity. A probable aetiological correlation with periodontitis is discussed. The patient showed good response to intralesional and topical steroids.

Kikuchi disease, or histiocytic necrotizing lymphadenitis, is a benign illness characterized by fever and cervical lymphadenopathy predominantly in young women. It has a self-limiting course. Skin changes occur in about one-third of patients and are of a nonspecific nature. A case of Kikuchi disease with cutaneous involvement in the guise of erythema multiforme and a facial rash is reported. The differential diagnosis with systemic lupus erythematosus and Rowell syndrome is discussed.

Laugier-Hunziker syndrome is a benign pigmentary disorder which manifests as macular hyperpigmentation of the lips and buccal mucosa. Some patients have longitudinal pigmented bands of nails. The syndrome has no systemic associations. Two patients of this rare syndrome are reported. Disorders producing similar pigmentary changes which must be differentiated are discussed.