Indian Journal of Dermatology
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   Table of Contents - Current issue
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January-February 2019
Volume 64 | Issue 1
Page Nos. 1-84

Online since Monday, January 7, 2019

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BASIC RESEARCH  

Pathogenesis of alopecia areata based on bioinformatics analysis Highly accessed article p. 1
Zhigang Zhang, Xiaoli Wang, Rongqiang Zhang
DOI:10.4103/ijd.IJD_68_18  
Background: Alopecia areata (AA) describes a sudden localized patchy alopecia. The cause of AA is not completely clear and its incidence may be related to genetic, autoimmune, and environmental factors. Aim: To explore the possible mechanisms of AA and to provide a basis for the early diagnosis and treatment of AA. Methods: Gene microarray data from 122 scalp skin biopsy tissue samples from patients with AA or healthy controls from the Gene-Cloud of Biotechnology Information database were analyzed using bioinformatics analysis methods. Molecular network analysis of the differentially expressed genes (DEGs) was conducted by Cytocluster using the Molecular Complex Detection (MCODE) algorithm. Results: The gene expression profile of skin lesions from patients with AA was significantly altered, with 111 DEGs found in the skin lesions of AA, compared with that of the healthy skin. The DEGs were mainly related to biological processes such as the development of the epidermis and inflammatory reaction. The protein–protein interaction network analysis of DEGs revealed bone morphogenetic protein 2 (BMP2) as a core protein interaction network. BMP2 acted not only via the inflammatory response but also via the signaling pathways in epithelial cell development and epidermal cell differentiation to affect the epidermal development. MCODE analysis further showed that keratins (KRTs) and keratin-associated proteins (KRTAPs) can affect the epidermal development via the epidermal development pathway. Conclusions: The abnormal development of the epidermis and inflammatory reactions in skin tissue play important roles in the pathogenesis of AA and are closely related to BMP2, KRTs, and KRTAPs genes. Limitations: Our study was limited by experimental verification.
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ORIGINAL ARTICLES Top

Alopecia areata different view; Heavy metals Highly accessed article p. 7
Goknur Ozaydin-Yavuz, Ibrahim Halil Yavuz, Halit Demir, Canan Demir, Serap Gunes Bilgili
DOI:10.4103/ijd.IJD_137_18  
Background: Alopecia areata (AA) is a noncicatricial alopecia affecting any hair-bearing area. Although AA is considered to be an autoimmune disease, oxidative stress has been shown to be an important factor in the etiology of AA. Trace elements are highly essential for humans since they form the building blocks of large molecules, function as the cofactors of enzymes, and have some key biological functions. The aim of this study was to investigate serum levels of heavy metals like iron (Fe), zinc (Zn), manganese (Mn), copper (Cu), magnesium (Mg), cobalt (Co), cadmium (Cd), and lead (Pb) in patients with AA. Materials and Methods: The study included a patient group of 30 with AA and a control group of 31 healthy individuals. Serum levels of heavy metals were measured using atomic absorption spectrophotometry. Results: The 30 patients included 17 (56.7%) men and 13 (43.3%) women with a mean age of 33.8 (range, 19–48) years. Serum Zn and Mn levels were significantly lower and serum Cd, Fe, Mg, Pb, Co, and Cu levels were significantly higher in the patient group compared to that of the control group (P < 0.05 for all). Conclusion: The results indicated that low levels of Zn and Mn are associated with AA while other metals were normal. So Zn supplementation may have some beneficial effect in AA while Fe prescription is fruitless.
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Assessment of metabolic profile and ischemia-modified albumin level in patients with alopecia areata: A case–control study p. 12
Pinar Incel-Uysal, Neslihan Akdogan, Nuran Alli, Ayse Oktem, Tuba Candar, Canan Topcuoglu, Turan Turhan
DOI:10.4103/ijd.IJD_238_18  
Background: Alopecia areata (AA) is an autoimmune-mediated hair follicle disorder. In the literature, there is no study evaluating metabolic syndrome and levels of ischemia-modified albumin (IMA) which is proposed as an oxidative stress biomarker in patients with AA. Aims: The aim was to investigate the presence of metabolic syndrome and the levels of IMA, small dense low-density lipoprotein (sd-LDL), and visfatin levels in AA patients. Settings and Design: A hospital-based cross-sectional study was undertaken among AA patients and controls. Subjects and Methods: Thirty-five patients with AA and 35 sex-, age-, and body mass index-matched healthy controls were enrolled. Clinical and laboratory parameters of metabolic syndrome were examined in all participants. Furthermore, IMA, sd-LDL, and visfatin levels were assessed and analyzed with regard to disease pattern, severity and extent, severity of alopecia tool score, duration, and recurrence. Results: The median IMA and adjusted IMA levels were significantly increased compared with controls (P < 0.05 and P =0.002, respectively). Patients with pull test positivity displayed higher levels of adjusted IMA levels (P < 0.05). In AA group, there was a positive correlation between adjusted IMA and waist circumference (r =0.443, P =0.008), adjusted IMA and triglyceride levels (r =0.535, P =0.001), and adjusted IMA and sd-LDL levels (r =0.46, P < 0.05). We observed no statistically significant difference in fasting blood glucose and lipid profile, sd-LDL, and visfatin levels of the patients and healthy controls. Conclusions: AA patients and controls have similar metabolic profile. Raised levels of adjusted IMA levels may be associated with antioxidant/oxidant imbalance and with risk of cardiovascular disease.
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Clinical profile of androgenic alopecia and its association with cardiovascular risk factors p. 19
Rita V Vora, Rahul Krishna Suresh Kumar Kota, Rochit R Singhal, Gopikrishnan Anjaneyan
DOI:10.4103/ijd.IJD_526_16  
Context: Androgenic alopecia (AGA) is a hereditary androgen-dependent disorder, characterized by gradual conversion of terminal hair into miniaturized hair and defined by various patterns. Common age group affected is between 30 and 50 years. Metabolic syndrome (MetS) is a cluster of cardiovascular risk factors that include diabetes and prediabetes, abdominal obesity, dyslipidemia, and hypertension. The relationship between androgenic alopecia and MetS is still poorly understood. Aim: The aim was to study the clinical profile of androgenic alopecia and its association with cardiovascular risk factors. Materials and Methods: This was a hospital-based cross-sectional study done on men in the age group of 25–40 years. Fifty clinically diagnosed cases with early-onset androgenic alopecia of Norwood Grade III or above and fifty controls without androgenic alopecia were included in the study. Data collected included anthropometric measurements, blood pressure, family history of androgenic alopecia, history of alcohol, smoking; fasting blood sugar, and lipid profile were done. MetS was diagnosed as per the new International Diabetes Federation criteria. Chi-square and Student's t-test were used for statistical analysis. Results: MetS was seen in 5 (10%) cases and 1 (2%) control (P =0.092). Abdominal obesity, hypertension, and lowered high-density lipoprotein were significantly higher in patients with androgenic alopecia when compared to that of the controls. Conclusion: A higher prevalence of cardiovascular risk factors was seen in men with early-onset androgenic alopecia. Early screening for MetS and its components may be beneficial in patients with early-onset androgenic alopecia.
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The association of metabolic syndrome and insulin resistance in early-onset androgenetic alopecia in males: A case–control study p. 23
Mukunda Ranga Swaroop, B Manohara Kumar, BD Sathyanarayana, D Yogesh, JC Raghavendra, Priyanka Kumari
DOI:10.4103/ijd.IJD_724_16  
Background: Men with premature androgenetic alopecia (AGA) are found to be susceptible to cardiovascular diseases, metabolic syndrome (MS), diabetes mellitus and hypertension, and also premature baldness can have a definite negative impact on self-image and self-esteem in these patients. The aim of this study was to assess the strength of association between MS and/or insulin resistance (IR) in males with early-onset AGA. Methods: A total of 50 male patients with premature AGA and equal number of age-matched controls were enrolled in the study. Anthropometric measures, blood pressure, fasting glucose, fasting insulin, high-density lipoprotein cholesterol, and triglycerides were measured for all the participants. Association of IR and MS was evaluated. Results: Most common grade of hair loss was Grade IIIa (32%) of Hamilton–Norwood Scale of hair loss. Five out of 50 cases (10%) and 2 out of 50 controls (4%) had shown association with IR and the difference between the groups was statistically insignificant (P =0.23). Fifteen out of 50 cases (30%) and 4 out of 50 controls had shown association with MS and the difference between the groups was statistically significant (P =0.005). Conclusion: Male patients with early-onset AGA were not associated with IR. MS was associated with male patients with early-onset AGA. The results observed in our study may raise awareness in susceptible individuals that lifestyle changes in early life can reduce the risk of coronary heart diseases in the long term.
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Clinicopathological study of primary cutaneous amyloidosis in a tertiary care center of Eastern India reveals insignificant association with friction, scrubbing, and photo-exposure: How valid is the “keratinocyte hypothesis”? p. 28
Projna Biswas, Dayamay Pal, Abhishek De, Gobinda Chatterjee, Arghyaprasun Ghosh, Sudip Das, Pijush Kanti Das, Aarti Sarda, Sumit Sen
DOI:10.4103/ijd.IJD_149_18  
Introduction: Primary cutaneous amyloidosis (PCA) can be classified into four principal categories: macular amyloidosis, lichen amyloidosis, biphasic, and nodular amyloidosis. Some unusual variants such as widespread diffuse hyperpigmentation without papules, poikiloderma like involvement, lesions following Blaschko's line, etc., have also been reported. However, not much data are available regarding the demography, epidemiology, clinical patterns, and distribution and histopathological findings, especially from the eastern part of India. Aims: We conducted a cross-sectional, institution-based study to evaluate clinicopathological pattern and factors of PCA in eastern India. Materials and Methods: We recorded clinical and histopathological findings of 100 consecutive patients of PCA presenting to a tertiary care institution of Kolkata in eastern India. Results: We found female patients of PCA outnumber male (M:F =1:1.9) with majority of patients being young adults (56%) between 20 and 40 years of age. More than half (54%) of the patients were pruritic. The severity of pruritus is significantly more associated with lichenoid and biphasic variants over macular amyloidosis. Positive family history was recorded in 17% of cases. Macular variant was the most common variant constituting 48% of the total PCA. We also found that the association with history of friction and scrubbing and photo-exposure were statistically insignificant. However, duration of the disease has statistically significant association with the disease morphology. Congo red stain showed these deposits as reddish orange substance in 28 patients out of 64 patients' samples on which Congo red could be performed. Conclusion: Our study revealed that many concepts of pathogenesis of PCA including friction and photoexposure might have lesser importance. However, morphological types were significantly associated with the duration of the disease and symptom severity.
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Evaluation of peripheral blood eosinophilia in adolescent and adult patients suffering from atopic dermatitis and the relation to the occurrence of allergy to aeroallergens p. 34
Jarmila Celakovska, Josef Bukac, Karel Ettler, Jaroslava Vaneckova, Irena Krcmova, Kvetuse Ettlerova, Jan Krejsek
DOI:10.4103/ijd.IJD_509_17  
Background: Eosinophils play an important pathogenic role in atopic dermatitis (AD), but its exact function remains to be determined. Aims and Objectives: The aim of this study was to correlate the eosinophil count with the manifestations such as asthma bronchiale, rhinitis, level of total IgE, sensitization to mites, animal dander, bird feather, dust, mixture of grass, mixture of trees, mixture of fungi, duration of lesions (persistent or occasional during last year), family history about atopy, and onset of AD (under or above 5 year of age). Materials and Methods: Two hundred and seventy-two patients suffering from AD at the age of 14 year or older were examined – 100 men and 172 women with the average age of 26.7±9.5 years and with the average SCORAD index of 32.9±14.1. Complete dermatological and allergological examinations were performed in all patients with the evaluation of monitored manifestations. Mann–Whitney test for difference in medians was used for statistical evaluation. Results: The count of eosinophils in peripheral blood was significantly higher in patients with total IgE ≥200 IU/ml, with sensitization to dust, with persistent eczematous lesions and in patients with the onset of AD under 5 year of age. The count of eosinophils above 5% was recorded as well in patients suffering from asthma bronchiale, rhinitis, sensitization to mites, and in patients with positive family history about atopy, but the difference was not significant. On the other hand, the count of eosinophils was under 5% in patients with sensitization to animal dander, bird feather, mixture of grass and trees. Conclusion: Our results demonstrated the difference in the count of eosinophils in peripheral blood according to different manifestations in patients suffering from AD.
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SHORT COMMUNICATION Top

Expression of cluster of differentiation 1a-positive langerhans cells in oral lichen planus p. 41
Thankanadar Arul Kumar, Veeran Veeravarmal, Ramdas Madhavan Nirmal, Ramamoorthy Amsaveni, Mohamed Hanifa Mohamed Nassar, Ganesan Kesavan
DOI:10.4103/ijd.IJD_350_16  
Background/Purpose: Lichen planus is a T-cell-mediated mucocutaneous disorder characterized histopathologically by a band of chronic inflammatory cells in the subepithelial zone and degeneration of basal layer. The present study was aimed to evaluate the distribution and quantitative assessment of cluster of differentiation 1a (CD1a)-positive Langerhans cells (LCs) in oral lichen planus (OLP), thus to determine the role of LCs pertaining to the changes occurring in OLP. Materials and Methods: Five cases of normal oral mucosa and 20 cases of OLP were immunostained with CD1a antibody; the positive cells were counted manually in the photomicrographs and statistically analyzed using t-test, Mann–Whitney test, and Wilcoxon signed-rank test. Results: The average percentage of CD1a-positive LCs in normal subjects was 0.9%, and in the OLP cases higher percentage was observed (3.93%). The statistical comparison of these two parameters was significant (P =0.018). The degree of basal cell degeneration and density of subepithelial infiltrate on statistical comparison with the concentration of CD1a-positive LCs showed significant results. Conclusion: LCs play a pivotal role in the recruitment of CD4+ and CD8+ cells to the subepithelial region and basal keratinocytes apoptosis. A small number of study subjects, assessment of only CD1a molecule and LCs in the epidermis only were a few of the drawbacks of the study.
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DERMATOPATHOLOGY ROUND Top

A study of the histopathological features of alopecias on transverse sections of scalp biopsies p. 47
Mankul Goyal, Sujay Khandpur, M Ramam, Vinod Kumar Sharma, Manoj Kumar Singh
DOI:10.4103/ijd.IJD_477_17  
Background: Transverse sections of scalp biopsies are performed for the assessment of alopecias and are considered advantageous over vertical sections. Aim: The aim was to study the histopathological features of alopecias on transverse sections of scalp biopsies. Methods: It was a descriptive study. Clinically confirmed cases of noncicatricial and cicatricial alopecias were subjected to 4 mm scalp biopsies, which were sectioned transversely and analyzed. Biopsies obtained from occipital region of androgenetic alopecia (AGA) cases were taken as controls. Results: Biopsies from 41 cases were assessed, including male and female AGA, alopecia areata (AA), trichotillomania, lichen planopilaris (LPP), discoid lupus erythematosus (DLE), and folliculitis decalvans (FD). Normal scalp (control) biopsies showed the median total number of hair follicles of 35 (32–37), anagen:telogen/catagen ratio of 17.5 (16.5–31), and terminal:vellus ratio of 15 (10.7–17.5). In AGA and AA, miniaturization and shift toward telogen and catagen hair were consistently observed. Peribulbar inflammation was seen in two-third of AA. Trichotillomania showed increased catagen hair and numerous pigment casts. In DLE, besides perifollicular inflammation, prominent peri-arrector pili and peri-eccrine inflammation were observed. Type of inflammatory infiltrate was similar in DLE and LPP (lymphocytic), whereas FD showed neutrophilic and plasma cell infiltrate, both around follicles and interstitially. Basal cell damage in the follicles and pigment incontinence were seen in majority of DLE and LPP patients. DLE also showed basement membrane thickening, mucin deposition, and telangiectasia. Reduction/absence of sebaceous glands and perifollicular fibrosis were observed in almost all cicatricial alopecias. Conclusion: Transverse sectioning may be a useful tool in the diagnosis of alopecias.
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CASE REPORTS Top

Acquired localized cutis laxa: A case report and the role of plastic surgery p. 55
Guru Prasad Reddy, Brijesh Mishra, Divya Narain Upadhyaya
DOI:10.4103/ijd.IJD_14_18  
Cutis laxa is an uncommon connective tissue disorder affecting the elastin fibers leading to lax and pendulous skin and in generalized form can present with systemic involvement. Congenital cutis laxa is common in comparison to acquired cutis laxa and has varied inheritance patterns. Treatment is chiefly observation in congenital cutis laxa, and there is a paucity of literature on surgical management in acquired cutis laxa. We report a rare case of acquired localized cutis laxa with a review of literature on the role of plastic surgery in this condition.
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Generalized livedo reticularis: A rare variety p. 59
Pallavi Goyal, Surabhi Dayal, Priyadarshini Sahu
DOI:10.4103/ijd.IJD_246_18  
Livedo reticularis can present with progressive ischemia and diffuse cutaneous involvement with or without any evidence of systemic diseases. Livedo reticularis (LR) is a livedoid discoloration of the skin in a reticular pattern. We report the case of a 30-year-old male who presented with an asymptomatic, red-colored, net-like rash all over the body for 4 years. Laboratory investigations were performed to rule out any systemic involvement. Biopsy showed perivascular mononuclear cell infiltrate and occasional arteriole showed thickening of the wall with obliteration of the lumen and extensive collagenization in dermis, suggesting a diagnosis of LR. The patient was advised oral pentoxifylline 400 mg thrice daily with oral nifedipine 10 mg twice daily, and mild improvement was seen after 6 weeks of therapy.
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Linear lichen nitidus with onychodystrophy in a child p. 62
Vineet Relhan, Jaspriya Sandhu, Vijay Kumar Garg, Nita Khurana
DOI:10.4103/ijd.IJD_754_16  
Lichen nitidus is a common dermatosis described classically as shiny, skin-colored, nonfollicular, flat-topped papules. A number of variants have been described in literature including localized, generalized, actinic, vesicular, perforating, hemorrhagic, palmar/plantar, purpuric, and linear forms. Here, we report an unusual case of linear lichen nitidus in an 11-year-old boy mimicking lichen striatus along the left thumb with isolated nail involvement of the affected digit. Nail involvement in lichen nitidus is very rare; there are only seven cases of lichen nitidus associated nail changes reported in the literature. To the best of our knowledge, this is the first such case reported from India.
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Giant and extensive localized xanthoma associated with primary lymphedema p. 65
Reena Kumari Sharma, Mudita Gupta
DOI:10.4103/ijd.IJD_150_18  
Lymphedema is extravasation of lymphatic fluid into extracellular spaces and may be primary or secondary. Primary lymphedema may be caused by truncular lymphatic malformation. Long-standing lymphedema may result in various complications due to increased porosity of lymphatics, defective valves, and increased lymphatic pressure. There are few reports of normolipidemic xanthoma in association with lymphedema. We report a case of giant xanthoma associated with primary lymphedema.
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Systemic retinoids and scar dehiscence p. 68
Hasan Mete Aksoy, Berna Aksoy, Emel Çalikoglu
DOI:DOI: 10.4103/ijd.IJD_148_18  
Systemic retinoids such as isotretinoin and acitretin are associated with numerous side effects but are therapeutically valuable in dermatological practice. Several studies have reported the wound-healing effects of treatment with concurrent systemic retinoids in addition to surgical treatments. Herein, we describe two patients with scar dehiscence that developed after initiation of systemic retinoid treatment following cutaneous surgery. In Case 1, isotretinoin was thought to decrease collagen production to a greater degree than did degradation during the wound remodeling phase, which resulted in wound dehiscence. In Case 2, acitretin was thought to decrease fibroblast proliferation and collagen production during the proliferation phase of wound healing, which resulted in wound dehiscence. Based on the two presented cases, it is advisable to postpone systemic retinoid treatment for 6 months to 1 year following cutaneous surgery, located especially in cosmetically important sites.
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The curious cases of burn by fig tree leaves p. 71
Mohammad Sajjad Imen, Ali Ahmadabadi, Seyed Hassan Tavousi, Alireza Sedaghat
DOI:10.4103/ijd.IJD_442_17  
Phytophotodermatitis is a condition which is caused by contact with some plants containing furocoumarins. Furocoumarins in sap of fig tree are the main cause of its irritability when come in contact with the skin. The main symptoms are burning sensation and pain, itchy erythema, and edema, which usually begin 24 h after exposure. The leaf and root sap of the fig tree are the most potent parts causing irritant reaction. We report four children who were playing with fig tree leaves during a family picnic. They were referred to a burn center with second-degree burn in about 10% of total body surface area, due to phytophotodermatitis. Most people are not aware of the potential adverse effect of the plant. The improvement in general knowledge about the dangers of contacting fig tree leaves and sap and the benefits of suitable coverage at the time of harvesting or contacting fig tree may prevent such adverse effects.
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CORRESPONDENCES Top

An unusual case of erythropoietic protoporphyria mimicking lipoid proteinosis p. 74
Sarabjit Kaur, Parul Aggarwal, Ankita Sangwan, Kamal Aggarwal, Surabhi Dayal, Vijay Kumar Jain
DOI:10.4103/ijd.IJD_441_17  
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Exacerbation of psoriasis with pustulation by sorafenib in a patient with metastatic hepatocellular carcinoma p. 75
Takenobu Ohashi, Toshiyuki Yamamoto
DOI:10.4103/ijd.IJD_16_17  
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Erythema gyratum repens as a manifestation of drug reaction with eosinophilia and systemic symptoms p. 77
Sarita Sasidharanpillai, Saleem Rahima, Manikoth Payyanadan Binitha, Ettapurath N Abdul Latheef, Aparna Govindan, Dhanya Prashant, Rajwa Rahman
DOI:10.4103/ijd.IJD_19_17  
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Primary mucinous adenocarcinoma of skin in axilla: A case report and review of literature p. 80
Vibhuti Dayanand Ambawade, Swati Bipin Ghanghurde, Madhuri S Kate
DOI:10.4103/ijd.IJD_320_17  
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Cutaneous abscess: An isolated manifestation of disseminated anaplastic large-cell lymphoma in a child p. 83
Latha M Sneha, Sunitha Ramaswamy, Sai Shalini, Julius Scott
DOI:10.4103/ijd.IJD_514_16  
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