Indian Journal of Dermatology
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   Table of Contents - Current issue
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January-February 2020
Volume 65 | Issue 1
Page Nos. 1-84

Online since Monday, January 13, 2020

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REVIEW ARTICLES  

Chloronychia: The goldman–fox syndrome - Implications for patients and healthcare workers Highly accessed article p. 1
Robert A Schwartz, Nicole Reynoso-Vasquez, Rajendra Kapila
DOI:10.4103/ijd.IJD_277_19  
Nail coloration has many causes and may reflect systemic disease. White nails (leukonychia) are common; rubronychia is rare, whereas green (chloronychia) is occasionally evident. Chloronychia, the Fox–Goldman syndrome, is caused by infection of an often damaged nail plate by Pseudomonas aeruginosa. P. aeruginosa is an opportunistic pathogen known for localized and systemic infections. It can spread cryptically in a variety of ways, whether from an infected nail to a wound either autologously or to a patient as a surgical site infection, and many represent a threat to elderly, neonatal, or immunocompromised patients who are at increased risk of disseminated pseudomonas infection. We will review the Goldman–Fox syndrome as an occupational disorder of homemakers, nurses, plumbers, and others often with wet hands. At a time when hand washing is being stressed, especially in healthcare settings, examination of nails should be emphasized too, recalling the possibility of surgical site infection even with a properly washed and gloved medical care provider. Pseudomonasmay be a community-acquired infection or a hospital or medical care setting-acquired one, a difference with therapeutic implications. Since healthcare workers represent a threat of nosocomial infections, possible guidelines are suggested.
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The role of sunscreen in melasma and postinflammatory hyperpigmentation Highly accessed article p. 5
Sakeena Fatima, Taylor Braunberger, Tasneem F Mohammad, Indermeet Kohli, Iltefat H Hamzavi
DOI:10.4103/ijd.IJD_295_18  
Photosensitive conditions such as melasma and postinflammatory hyperpigmentation (PIH) are exacerbated by exposure to ultraviolet (UV) rays and visible light making sunscreen use an essential component of treatment. This is especially true in skin of color patients who are less likely to use photoprotection, even if diagnosed with these photoexacerbated conditions. We aimed to evaluate the body of literature to provide evidence for the use of sunscreen in the treatment of melasma and PIH. We reviewed English articles from PubMed, Journals@Ovid Full Text, and Embase using the search terms “sunscreen” and either “melasma” “PIH,” or “post-inflammatory hyperpigmentation.” Nine relevant publications provide evidence that a broad spectrum of protection, including UVA, UVB, and visible light within sunscreens can play an adjuvant role in therapy for melasma and PIH by stabilizing and improving these pigmentary disorders in skin of color patients. This review illustrates the advantages and limitations of sunscreen use, as well as practice gaps in photoprotection in the skin of color patients with melasma and PIH.
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ORIGINAL ARTICLES Top

Clinical observation and follow-up of subungual splinter hemorrhages of toenails in Chinese adults p. 11
Jing Gao, Changbing Shen, Randy Ko, Yajun Guo, Xue Shen, Yong Cui, Chunjun Yang
DOI:10.4103/ijd.IJD_193_18  
Background: Subungual splinter hemorrhage (SSH) is a common nail disorder and is difficult to differentiate from other nail diseases because of their similar characteristics. The epidemiological study of SSH is lacking and it is unclear whether SSH needs treatment or not. Aims: The aims of this study were to observe the clinical characteristics of SSH of toenails in Chinese adults and to provide a reference for the diagnosis and prognosis of patients with SSH. Materials and Methods: We collected and followed up 63 SSH patients who were diagnosed through dermoscopic examination. The clinical and dermoscopic characteristics, disease course, and recovery results were recorded. Data sets were analyzed through the use of SPSS 16.0. Literature concerning SSH were reviewed and compared with the results in this study. Results: Sixty-three SSH patients were included with an age range of 17–58 years. Nearly 93.7% of SSH patients occurred in the right, left, or right and left first toenails; 66.7% of SSH patients occurred only in one toenail; there were 60.3% of SSH patients with a clear stimulus causing it and 31.8% of SSH patients with five types of comorbidities. The common characteristics of dermoscopy showed a reddish brown or brown stain with a clear boundary visible under the nail in which the color gradually faded outward from the center, with no blue or white structure. After following up for 24 weeks, the disappearance of hemorrhage was observed in 95.2% of SSH patients. For the recovered SSH patients, data analysis showed no significant difference in the course of SSH in males and females (P = 0.645); the statistical analysis showed that there was no significant correlation (r2 = −0.002) between age and course in recovered SSH patients (P = 0.986). Conclusions: It is unnecessary to do any special treatment during the 1st year. Measures ought to be taken for SSH patients if the course of the disease exceeds more than 1 year.
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Is itch intensity in atopic dermatitis associated with skin colonization by staphylococcus aureus? Highly accessed article p. 17
Leszek Blicharz, Paulina Usarek, Grażyna Młynarczyk, Krzysztof Skowroński, Lidia Rudnicka, Zbigniew Samochocki
DOI:10.4103/ijd.IJD_136_19  
Background: Atopic dermatitis (AD) is a highly pruritic skin condition of unclear pathogenesis. Patients with AD are predisposed to colonization by Staphylococcus aureusdue to deficiencies in the mechanical and immunological functions of the skin barrier. Recent studies indirectly show that S. aureus may aggravate disease flares in AD. Aims: The aim was to assess the relationship between S. aureus skin colonization and itch intensity in patients with AD. Materials and Methods: The SCORAD index components reflecting itch intensity (excoriations, subjective evaluation of pruritus, and sleep loss) were assessed in 33 adult patients with AD. Swabs were taken from lesional and nonlesional skin. The prevalence and abundance of S. aureus were assessed. Statistical analysis was performed to correlate the microbiological results with the clinical parameters. The control group consisted of 36 healthy volunteers. Results: Lesional and nonlesional skin showed a high frequency of S. aureus colonization when compared with controls (81.8% and 57.6% vs 5.6%, respectively, P< 0.0001). The mean concentration (points) of S. aureus was 2.01 ± 1.25, 1.06 ± 1.14, and 0.11 ± 0.46, respectively (P< 0.0001). S. aureus abundance on lesional/nonlesional skin positively correlated with excoriations and sleep loss (rho = 0.69, P< 0.00001; rho = 0.44, P< 0.01; rho = 0.41, P< 0.02; and rho = 0.34, P< 0.05, respectively). The mean values of excoriations were higher in patients colonized by S. aureus than in patients without S. aureus carriage. Conclusion: S. aureus skin colonization may be one of the factors aggravating itch in AD. It may be hypothesized that restoring the natural composition of the skin microbiome may reduce pruritus intensity.
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Clinicopathological and immunological profile of patients with cutaneous manifestations and their relationship with organ involvement in systemic lupus erythematosus attending a tertiary care center of Eastern India p. 22
Arghya P Ghosh, Falguni Nag, Saugato Biswas, Raghavendra Rao, Abhishek De
DOI:10.4103/ijd.IJD_282_19  
Background: Lupus erythematosus (LE) is an autoimmune disorder with diverse clinical manifestations ranging from mild cutaneous disorder to life-threatening systemic illness and associated with varying immunological parameters. Aim: We conducted a study in a tertiary care center of eastern India to determine the clinical pattern, immunological profile of patients with cutaneous manifestations of systemic LE (SLE) and their relationship with organ involvement. Materials and Methods: Fifty-five consecutive patients attending dermatology OPD having features consistent with cutaneous LE and fulfilling the criteria of SLE were included. After proper history taking and clinical examination, routine blood and antinuclear antibody (ANA) profile, histopathological examination, and direct immunofluorescence test were undertaken. Results: Among 55 patients, 49 were female. ANA positivity was the most common association, followed by photosensitivity, malar rash, arthritis, oral ulcer, immunological markers, renal system involvement, discoid rash, serositis, central nervous system (CNS) involvement, and least common being the hematological involvement. Vacuolar basal cell degeneration was the commonest epidermal change and upper dermal periappendageal and perivascular lymphocytic infiltration was the commonest dermal change observed on histopathological examination. On direct immunofluorescence (DIF) granular pattern was seen in majority of patients. Statistically significant risk of kidney involvement was present both when patient had bullous lesions and DIF positivity of unexposed (DIF-UE) skin. CNS involvement was seen in five patients and it was found to be significantly associated with purpuric lesions. Conclusion: This study reveals cutaneous lesions and DIF testing could be reliable predictors of systemic involvement and strongly suggests DIF testing, routinely in all patients of SLE.
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The Relationship between Tissue Thioredoxin Reductase Activity and the Psoriasis Area and Severity Index p. 29
Bita Kiafar, Maryam Moradi Binabaj, Amir Hossein Jafarian, Zahra Khazan, Seyed Isaac Hashemy
DOI:10.4103/ijd.IJD_327_18  
Introduction: Psoriasis is an autoimmune disease. The important role of oxidative stress in the pathogenesis of psoriasis had been investigated in different studies. Thioredoxin reductase (TrxR) is a selenocysteine-containing enzyme which is involved in the protection of cells against oxidative stress. Here, we investigated the TrxR activity in skin lesions of psoriatic patients and the possible correlation between this activity and the severity of the disease that was scored based on the Psoriasis Area and Severity Index (PASI). Materials and Methods: TrxR activity was determined using TrxR colorimetric method based on the reduction of 5,5'-dithiobis-(2-nitrobenzoic acid) to 5-thio-2-nitrobenzoic acid by TrxR using nicotinamide adenine dinucleotide phosphate in 20 psoriatic patients (11 men and 9 women) aged 38.9 ± 12.6 years. For evaluating the disease severity, PASI score system (mild [PASI <10], moderate [PASI 10–20], or severe [PASI >20]) was utilized that was based on three factors including thickness, erythema, and scaling of lesions. Results: Our results revealed that the TrxR activity between different groups of psoriatic patients (according to the PASI score) was statistically significant and it was higher in psoriatic patients with mild disease (correlation coefficient = −0.85). Conclusion: These results further strengthen the association between psoriasis and oxidative stress. The increased level of TrxR could be due to the protective effect of this enzyme against the inflammatory process and oxidative stress. Moreover, TrxR could be used as a novel marker for evaluating psoriasis severity.
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Antimelanocyte antibodies: A possible role in patients with vitiligo p. 33
Maha A El-Gayyar, Manal E Helmy, Eman R Amer, Moustafa A Elsaied, Mohammad A Gaballah
DOI:10.4103/ijd.IJD_344_18  
Background: Vitiligo is an acquired depigmenting skin disorder with multifactorial pathogenesis including genetic, autoimmune, and neuronal factors. Both humoral- and cell-mediated immunities are supposed to have a role in the pathogenesis of vitiligo. Patients with vitiligo have an increased concentration of circulating autoantibodies that are specific to melanocyte cytoplasm and surface antigens that related to the extent of the disease. Aims and Objectives: The aim of the present study was to evaluate the role of antimelanocyte antibodies (AMAs), complement 3 and 4 (C3 and C4), and antinuclear antibodies (ANAs) in the pathogenesis of vitiligo. Materials and Methods: This study included 49 patients with nonsegmental vitiligo and 36 healthy individuals as a control group. All participants were subjected to detailed history, general examination, and detailed dermatological examination of the skin, hair, nails, and oral mucosa. The severity of vitiligo was assessed according to the Vitiligo Area Scoring Index (VASI). AMA, C3 and C4, and ANA serum levels were measured for patients and controls. Results: ANA, AMA, and C4 levels were significantly higher in the sera of patients than in controls. ANA, AMA, and C4 serum levels showed significant positive correlations with VASI score. Conclusion: Our results support the role of AMA in the pathogenesis of nonsegmental vitiligo, correlating with the disease extent and severity. However, a longitudinal study in a large cohort of patients to evaluate the clinical and predictive value of AMA is warranted.
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Therapeutic efficacy of the combination therapy of corticosteroids and 5-aminosalicylic acid for treatment of pyoderma gangrenosum with ulcerative colitis p. 38
Wei Chen, Lijuan Xiang, Li Li
DOI:10.4103/ijd.IJD_505_18  
Background: Pyoderma gangrenosum (PG) in inflammatory bowel disease (IBD) is a rare cutaneous condition and its treatment remains controversial due to limited data. Aims and Objectives: The purpose of this study was to investigate the characteristics and treatment response to specific therapies of IBD-associated PG. Methods: In this retrospective study, we reviewed a series of cases of IBD-associated PG patients who presented at our institution, and collected clinical data, such as demographics, characteristics, subtype, and disease activity of IBD and specific therapies used and their treatment response. Results: In total, 42 cases were identified: 69% female and 92.9% with ulcerative colitis (UC). At PG diagnosis, 93% had active and 7% inactive IBD. PG ulcers occurred predominantly on the legs (33.3%); 14.3% had multiple lesions. In total, 20/39 UC patients received the combination therapy of systemic corticosteroids and 5-aminosalicylic acid (5-ASA) with a good response in 19 patients (95%). Seven patients received the monotherapy of 5-ASA with a response rate of 43%. Five patients were successfully treated with systemic corticosteroids alone. Other patients were treated with intravenous immunoglobulin, infliximab, or cyclophosphamide alone or in combination with corticosteroids and all showed a good response. Conclusion: Our study indicates the therapeutic efficacy of corticosteroids in combination with 5-ASA, which may be considered as the first-line therapy for UC-associated PG.
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A quality of life study of patients with leprosy attending the dermatology OPD of a tertiary care center of Eastern India p. 42
Nirmalya K Das, Abhishek De, Biswanath Naskar, Amrita Sil, Sudip Das, Aarti Sarda, Gobinda Chatterjee
DOI:10.4103/ijd.IJD_729_18  
Background: Leprosy is a chronic infectious disease caused by Mycobacterium leprae affecting the skin, peripheral nervous system, and other tissues. The disease is associated with social stigma, and the patients sometimes suffer social discrimination because it often leads to visible physical deformities. Hence, leprosy may have severe impact on the quality of life (QoL) of patients. Aims and Objectives: The aim of this study was to assess the effect of leprosy on the QoL of the affected patients and to find out whether there is some association with certain demographic and clinical factors. Materials and Methods: The Dermatology Life Quality Index (DLQI) questionnaire was used to assess the QoL of 114 patients with leprosy who attended dermatology outpatient department of a tertiary care center of eastern India. This was a cross-sectional study. Results: Among a total of 114 patients, leprosy had no impact on the QoL of 15 (13.16%) patients. There was a mild impact in 23 (20.18%) of the patients. There was moderate impact in 37 (32.46%) of the patients. The disease had severe impact in the QoL of 39 (34.21%) patients. None of the patients had a very severe impact. Several of the clinical aspects such as nerve involvement, systemic features, deformity, disability grade, and type of leprosy have significant impact on QoL. Among the demographic factors, gender had some effects on QoL. Conclusion: Leprosy adversely affects the QoL of those affected. Although it is considered a social disease, at least in our part of the country, demographics have minimal effect on the QoL. Rather, important clinical aspects such as systemic features, nerve involvement, reaction, deformity, and disability have profound impact on the QoL of the patients.
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CASE REPORTS Top

Lichen simplex chronicus secondary to scald injury and skin flap transplantation p. 47
Jia Li Xu, Guo Xin Song, Zhi Qiang Yin
DOI:10.4103/ijd.IJD_88_19  
A 50-year-old woman had suffered from chronic pruritic plaque located on right retroauricular area for around 16 years, which was diagnosed as lichen simplex chronicus. Seventeen years ago, patient had multiple scalded areas distributed throughout the body and underwent autologous skin flap transplantation for the right retroauricular wound. After the wound healed, patient started experiencing paresthesia continuously on the skin grafted area and could not resist scratching. To our knowledge, this is the first reported case of lichen simplex chronicus secondary to scald injury and skin flap transplantation. We successfully treated this patient with dyclonine hydrochloride cream 1% and desonide cream 0.05%.
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A rare case of lichenoid sarcoidosis mimicking papular amyloidosis p. 50
Preema Sinha, Saikat Bhattacharjee, Deep Kumar Raman, Aradhana Sood
DOI:10.4103/ijd.IJD_501_18  
Cutaneous lesions in sarcoidosis are seen in nearly 20–30% and include lesions like papules, nodules, plaques, infiltrated scars, and erythema nodosum. Lichenoid variants of cutaneous sarcoidosis, a type of papular variant is quite rare. Herein we report a case of lichenoid sarcoidosis in a 40-year-old male who presented with raised itchy lesions over his legs and lower back of 8 years duration.
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Lipoid Proteinosis with Esotropia: Report of a Rare Case and Dermoscopic Findings p. 53
Hera Tabassum, Sabha Mushtaq, Syed Suhail Amin, Mohammad Adil, Mohammad Mohtashim, Kafil Akhtar
DOI:10.4103/ijd.IJD_523_18  
Lipoid proteinosis (LP) is a rare progressive autosomal recessive disorder caused by mutations in the extracellular matrix protein 1 gene present on chromosome 1q21. It is characterized by infiltration of hyaline material into the skin, mucosae, and internal organs. Patients present with a classical history of repeated blistering, skin scarring, beaded eyelid papules, waxy papules over the body, and laryngeal and tongue infiltration leading to hoarseness of voice and restricted tongue movement. A variety of ocular manifestations have been described in association with LP. We report a case of a 10-year-old female child with typical features suggestive of LP associated with unilateral esotropia. The case is reported here for its rarity and uncommon association with esotropia hitherto not documented. Dermoscopic findings of the case are also discussed.
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Mycosis fungoides, lymphomatoid papulosis and Hodgkin's lymphoma in the same patient: Apropos of a possible monoclonal origin p. 57
Montserrat Molgó, Leonardo Espinoza-Benavides, Patricio Rojas, Sergio González
DOI:10.4103/ijd.IJD_16_19  
A 59-year-old man with Hodgkin's lymphoma was referred by a hematologist for consultation for cutaneous issues. Physical examination revealed generalized scaling and erythematous scaly patches located in the groin, abdomen, and arms. The biopsy was compatible with mycosis fungoides (MF). At his next medical visit, painful nodules with erythematous halo and scabby surface were noted, and a subsequent biopsy was compatible with lymphomatoid papulosis (LyP). Mycosis fungoides, the most common primary cutaneous T-cell lymphoma, is usually defined in its classic form as a CD4+ non-Hodgkin lymphoma; LyP corresponds to a CD30+ lymphoproliferative disorder; and Hodgkin's lymphoma (HL) constitutes a lymphoid neoplasia characterized by the presence of Reed–Sternberg cells and its variants. Although these entities have been defined independently, evidence suggests the possibility of a common monoclonal origin. To our knowledge, this is the first case of MF, LyP, and HL in a single patient.
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SHORT COMMUNICATION Top

Metastatic basal cell carcinoma: case report and review of the literature p. 61
Jose-Francisco Millan-Cayetano, Nuria Blazquez-Sanchez, Ines Fernandez-Canedo, Juan Bosco Repiso-Jimenez, Rafael Funez-Liebana, María Dolores Bautista, Magdalena de Troya-Martin
DOI:10.4103/ijd.IJD_302_18  
Basal cell carcinoma (BCC) is the most commonly occurring carcinoma among humans. However, despite their overall frequency, cases of BCC featuring metastases are extremely rare. We present the case of a male patient with BCC located in the chest, measuring 10 cm and with an evolution of 15 years. After several years, an axillary recurrence developed as a tumor mass affecting the lymph nodes. After 14 months, a further lymph node recurrence was observed and resected. Six months later, a pulmonary nodule was detected, which was resected with tumor-free margins. Histopathological report revealed infiltration by BCC. After 13 years of follow-up (after the removal of the primary tumor), the patient remained alive and received close clinicoradiological monitoring. Taking advantage of this opportunity, we also provide a brief review of the corresponding literature.
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CORRESPONDENCES Top

NPY gene polymorphism in vitiligo: A case–control study in Egyptian patients p. 65
Ola Bakry, Alaa Mariee, Iman Badr, Nermin Tayel, Samar El Gendy
DOI:10.4103/ijd.IJD_104_18  
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Combinatorial assessment of serum inflammation reactants in patients with acute urticaria accompanied by systemic symptoms p. 67
Ming Zeng, Songke Shen, Yuanjing Zhang, Shengxiu Liu
DOI:10.4103/ijd.IJD_286_18  
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Black maculae between the toes: A rare form of Laugier–Hunziker syndrome? p. 69
Jing Guo, YingYing Hu, Jie Tu, Zhi Qiang Yin
DOI:10.4103/ijd.IJD_18_19  
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Periumbilical acanthosis nigricans along the surgical site of umbilical hernia operation p. 70
Tubanur Çetinarslan, Kamer Gündüz, Peyker Temiz
DOI:10.4103/ijd.IJD_127_19  
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Paraneoplastic erythroderma as a protean manifestation of adenocarcinoma prostate p. 72
Geo Celestin Danny, Adikrishnan Swaminathan, Gayathri Rajesh, Mahalakshmi Veeraraghavan
DOI:10.4103/ijd.IJD_189_18  
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Sexual abuse in children and relevance of POCSO act—A report of four Cases p. 74
Sudip Das, Abhishek De, Nidhi Sharma, Sujata Sinha, Arnab Dutta, Sampriti Nanda
DOI:10.4103/ijd.IJD_673_18  
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Tinea corporis bullosa secondary to trichophyton verrucosum: A newer etiological agent with literature review p. 76
Priyadarshini Sahu, Surabhi Dayal, Pdiangty Giri Mawlong, Parul Punia, Rajeev Sen
DOI:10.4103/ijd.IJD_483_19  
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Successful therapy with 5-ALA photodynamic therapy for bowen's disease in a single lobulated nodule mimicking genital warts p. 78
Qin Yi, Xian Jiang, Hong-Jie Liu, Rong Mei, Jia-yan Liu
DOI:10.4103/ijd.IJD_484_18  
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Paraneoplastic dermatomyositis in association with poorly differentiated esophageal carcinoma – A rare association and a brief review of literature p. 80
Swaroopa Subhash, S Pradeep Nair, K Abdul Samad, Sheena Ann Simon, Mini Gomathy
DOI:10.4103/ijd.IJD_617_18  
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Neurofibromatosis type 1 with Becker's nevus and nevus of ota p. 81
Hai-En Wu, Tie-Nan Li, Chun-Lin Jin, Yong-Bin Liu
DOI:10.4103/ijd.IJD_645_18  
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Unusual periungual nodulocystic lesions leading to the diagnosis of extranodal marginal zone lymphoma p. 83
Spyridon Gkalpakiotis, Petr Arenberger, Eva Sticova, Ivana Karlova, Monika Arenbergerova
DOI:10.4103/ijd.IJD_485_18  
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