Background: It is a challenge to treat onychomycosis due to frequent treatment failures and relapses. Systemic and topical therapies need to be combined to improve cure rates. Antifungal susceptibility might play a role in the treatment resistance of onychomycosis. Aims: To compare the safety and effectiveness of amorolfine 5% nail lacquer + oral fluconazole versus only oral fluconazole in the treatment of fingernail onychomycosis. Methodology: In this double-blind trial (CTRI/2015/02/005369), patients were randomized (1:1) into amorolfine 5% nail lacquer + fluconazole and dummy lacquer + fluconazole. Treatment was given for 3 months with monthly follow-ups. Antifungal sensitivity was carried out for Candida. Effectiveness was assessed by reduction in the number and percentage area of nails involved and mycological cure. At the end of 3-month treatment period, the association between drug sensitivity and treatment response was explored for the Candida infections. Results: Among 30 study participants, the combination group showed significantly lower number of nail involvement (P = 0.004) and percentage nail involvement (P = 0.005) than only fluconazole group. Pretreatment fungal culture showed a comparable number of dermatophytes, Candida, Aspergillus in both the groups. Sensitivity testing was done for the isolated Candida species. Antifungal sensitivity for Candida (n = 11) was tested, and 8 (72.7%) of the organisms were sensitive to fluconazole (minimum inhibitory concentration [MIC] 1.25 ± 1.19 μg/ml), 100% were sensitive to itraconazole (MIC 0.0726 ± 0.021 μg/ml), and 3 (27.3%) were susceptible-dose dependent (S-DD) to fluconazole (MIC 16 μg/ml). Fluconazole only group patients with Candida who showed resistance to fluconazole did not respond to therapy; however, patients in the combination group showed moderate improvement (reduction in area involvement = 55.56 ± 35.36%). Conclusion: The combination of amorolfine/fluconazole achieved a higher cure rate not only for sensitive fungus but also for those which were S-DD to fluconazole.

Background: Superficial mycosis is the commonest infections affecting human globally. Though they do not cause mortality, their clinical significance lies in their morbidity, recurrence, and cosmetic disfigurement, thus creating a major public health problem. The infections are more prevalent in the tropical regions. The etiological agents are also seen to vary with time and geographical location. Aim: This study was carried out to find out the trend of superficial mycosis in Assam, along with a clinicomycological correlation. Materials and Methods: A total of 130 clinically diagnosed cases of superficial mycoses attending the outpatient department (OPD) of a tertiary hospital in Assam for a period of 1 year were taken up for the study. After taking the informed consent and a proper history, the clinical materials like skin scrapings, nail clippings, and infected hair were sent for mycological examination. Results: The infection was found to be more prevalent among males than females (M:F, 3:2) and among the farmers and laborers (24.61%). Tinea corporis was the commonest clinical type (21.5%). Among the fungal isolates, dermatophytes were the most frequent isolates (43.54%), out of which Trichophyton rubrum was commonest. nondermatophyte moulds like Fusarium, Aspergillus, Scopulariopsis, Trichosporon, and Penicillium spp. were isolated. Conclusion: The epidemiology of fungal infection and the causative fungi is seen to vary geographically and with time. This study reflects the changing trend of fungal infection in the north eastern region with a high rate of isolation of nondermatophyte moulds as the causative agent.

Background: The incidence of dermatophytosis is increasing over the last few years and there are many cases which are recurrent and chronic. Aim: The aim was to study the host and pathogen factors in dermatophytosis, to identify the species responsible, and to study the histopathological features of chronic dermatophytosis. Materials and Methods: It was a descriptive study conducted in the Department of Dermatology for a period of 1 year and all patients who were clinically diagnosed as dermatophytosis were included. Isolated hair, and nail involvement were excluded from the study. Epidemiological parameters and treatment history were analyzed, scrapings, and fungal culture were done in all patients. Histopathological examination was done in patients with chronic dermatophytosis who had applied topical steroids. Results: Chronic dermatophytosis was seen in 68%; tinea corporis was the most common presentation; topical steroid application was seen in 63%; azoles were the most common antifungals used; varied morphologies such as follicular and nonfollicular papules, arciform lesions, pseudoimbricata were seen in steroid modified tinea. Trichophyton rubrum and Trichophyton mentagrophytes were the most common species isolated in culture, but rare species such as Trichophyton tonsurans, Trichophyton schoenleinii, Epidermophyton floccosum, and Microsporum audouinii were also isolated from chronic cases. Histopathology showed perifolliculitis in steroid modified tinea. Minimal inhibitory concentration was lowest for itraconazole in susceptibility studies. Conclusion: Chronicity in dermatophytosis is due to various factors such as topical steroid application, noncompliance, and change in predominant species.

Background: Onychomycosis (OM) is a fungal infection of the finger or toenails caused by dermatophytes, yeasts, or nondermatophyte molds (NDMs) and can involve any component of the nail unit. OM, apart from being asymptomatic, is a chronic disease and warrants long-term treatment. Aims: The aim was to study the clinicoepidemiological features of OM and to evaluate the mycological and histopathological features among patients attending the dermatology outpatient department. Subjects and Methods: A cross-sectional hospital-based study was performed in 500 patients with symptoms related to the nails and nail folds. OM was confirmed in 284 patients by potassium hydroxide (KOH) mount, fungal culture, or biopsy. Descriptive analysis of the data was undertaken. Results: The study included 284 confirmed cases of OM of which 117 (41.1%) were positive for fungal elements by KOH mount, 168 (59.1%) samples showed positivity in fungal culture, and 62 (21.8%) samples had positive nail biopsy results. Distolateral subungual OM was the most common clinical type (47.6%). Among the fungal isolates, a predominance of dermatophytes was observed followed by yeasts and NDMs. The most common dermatophytic fungal isolate in the culture was Trichophyton rubrum (45%). Conclusion: Our study implies the importance of laboratory diagnosis of OM as it can mimic diverse nail disorders. As the role of NDMs and yeasts is on the rise for etiology of OM, investigations such as KOH examination, culture, or nail biopsy becomes essential for correct diagnosis and management.

Background: Recent years have seen an alarming rise in the prevalence of recalcitrant and relapsing dermatophyte infections in India associated with lack of clinical response to standard antifungal regimens. Aims and Objectives: A study was undertaken to identify the antifungal susceptibility patterns of dermatophyte species isolated from lesions of dermatophytoses in patients examined at our center. Materials and Methods: A total of 85 patients with clinically diagnosed dermatophytoses were subjected to skin scrapings for potassium hydroxide mount (microscopic examination) and culture using Sabouraud's agar medium containing chloramphenicol and cycloheximide (incubated at 30°C). Antifungal susceptibilities [minimum inhibitory concentration-90 (MIC-90)] of the identified dermatophytes were tested for seven systemic and topical antifungal agents (terbinafine, griseofulvin, itraconazole, fluconazole, sertaconazole, ketoconazole, and clotrimazole) using Clinical and Laboratory Standards Institute broth microdilution method (M38-A). Results: Trichophyton rubrum (50%) and Trichophyton mentagrophytes complex (47.2%) were the two major species isolated. Isolates of both showed downy and granular forms (61.11%, 38.89% and 32.35%, 67.65%, respectively). The overall in-vitro susceptibility profiles (MIC-90 ranges in μg/mL) of the seven drugs for T. rubrum and T. mentagrophytes complex respectively were as follows: terbinafine (0.008–0256, 0.016–0.256), griseofulvin (0.03-1, 0.06–1), itraconazole (0.125-2, 0.25–2), fluconazole (0.125–1, 0.25–32), sertaconazole (0.03-1, 0.03-1), ketoconazole (0.06–1, 0.125–1), and clotrimazole (0.03–2, 0.06–1). Conclusions: This study indicates a rising proportion of T. mentagrophytes complex with increased proportion of granular form (T. mentagrophytes var. mentagrophytes). This study represents the current antifungal susceptibility profile of dermatophytic infections in a tertiary care medical center in western India with rising MICs to terbinafine and itraconazole.

Background: Currently, the studies related to hair loss in children showed the variable prevalence of different clinical patterns and causes of scalp hair loss, that had regional variation. Aims: The aim of this study is to evaluate the epidemiology and clinical pattern of scalp hair loss in children (0–18 years age group). Materials and Methods: A total of 300 children presenting with scalp hair loss were studied during a period of 1 year from April 2015 to March 2016. The results were recorded and analyzed. Results: The most common disorder found in this study was tinea capitis seen in 166 (55.33%) cases followed by alopecia areata, seborrheic dermatitis, pediculosis with secondary infection. Other uncommon causes were lichen planopilaris, tractional alopecia, telogen effluvium, nevus sebaceous, occipital neonatal alopecia, ectodermal dysplasia, scalp psoriasis, trichotillomania, and alopecia due to nutritional deficiency. Several other rare causes were identified in this study. Conclusion: This study showed that hair loss in children in our region is not an uncommon problem and results from a variety of causes. Early diagnosis and treatment are needed to prevent further hair loss and to avoid irreversible hair loss and scarring alopecia. As has been observed in this study, hair problem may be due to important nutritional deficiency. We should be aware of such presentation. These may be a clue to the diagnosis of systemic illness.

Background: Corticosteroids are the most common agents used in the treatment of alopecia areata (AA), however, their long-term use is associated with severe side effects. Therefore, other immunosuppressive agents have been tried and azathioprine appears to be an effective and promising alternative. Objective: The main objective of this study was to compare the efficacy of 300 mg once weekly azathioprine pulse (WAP) and 5 mg betamethasone on 2 consecutive days every week in the management of AA. Materials and Methods: In this open-label, randomized comparative study, 50 patients of AA with >10% scalp area involvement were treated with either 300 mg WAP or 5 mg betamethasone on 2 consecutive days every week for 4 months or till complete scalp hair regrowth and followed up for next 5 months. Primary efficacy parameters were average percentage scalp hair regrowth and change in average Severity of Alopecia Tool (SALT) score at 4 months. Results: Twenty patients in WAP group and 21 patients in betamethasone group completed the study. The median percent scalp hair regrowth and the median change in SALT score was 44.52 and 9.5 in WAP group compared to 71.43 and 14 in betamethasone group at 4-month, respectively, which were statistically similar in two groups, however, side effects were significantly higher in betamethasone group. On further follow-up at 9 months, 10 (50%) patients in WAP group and 13 (62%) patients in betamethasone group achieved complete hair regrowth. Lack of control group was a limitation of our study. Conclusion: WAP and betamethasone therapy, both appear to be effective in the treatment of AA. However, betamethasone caused several side effects; therefore, WAP can be used as a better alternative to corticosteroids in AA.

Background: Chronic inflammatory diseases take an important place in dermatology and their effects range from mild itching to grave metabolic complications. In psoriasis, association with metabolic syndrome (MS) has been proved in many studies. Chronic inflammation is a trigger of MS, and in turn, the components of MS, namely obesity and dyslipidemia, promote a pro-inflammatory milieu. Thus, chronic inflammation causes MS and vice versa. Hence, the study focuses on association of MS with lichen planus (LP), another chronic inflammatory disease. Aim: The aim of this study is to find the association of MS with all variants of LP. Materials and Methods: An observational study for MS in all patients with LP who attended skin outpatient department (OPD) for 6 months from February 2016. International Diabetes Federation criteria 2005 were used. The confounding variables of MS such as smoking, alcohol, and physical activity were assessed for its significance in the association of LP with MS. Results: Out of 113 cases, 21 cases were found to be associated with MS. Among them, 8 cases (38.09%) were of eruptive LP, which showed significant association with MS when compared to other variants. MS cases were significantly high in females and in the age group of 41–50 (57.1%). Due to unequal distribution of smoking and alcohol habits, they were not taken into account for analysis. Physical activity had no significant association with MS in our study population. Waist circumference (WC) being the mandatory criterion in all variants associated with MS, dyslipidemia was the next frequently encountered criteria except in eruptive LP. High BP was less commonly noted criteria. Conclusion: Eruptive LP showed significant association with MS. Further studies with large sample size in each variant and control group are needed to confirm it which are the limitations in our study.

Background: Lichen planus (LP) is an inflammatory skin disease of unknown etiology associated with chronic inflammation, oxidative stress induction, and cardiovascular risk factors. Objectives: To document the prevalence of metabolic syndrome (MetS), dyslipidemia, and associated factors in Nigerian patients with LP. Methods: A cross-sectional design was made to evaluate 90 patients with LP and 90 controls for MetS and dyslipidemia in two Nigerian teaching hospitals. Diagnosis of LP was made with the aid of histology, and MetS and dyslipidemia were diagnosed using the National Cholesterol Education Program Adult Treatment Panel III criteria. Results: The prevalence of MetS was insignificantly higher in LP than in control (18.9% vs. 13.5, P = 0.311), and dyslipidemia was significantly associated with LP (60% vs. 40%, P = 0.007). LP was associated with higher mean of serum triglyceride (1.21 ± 0.34 vs. 1.08 ± 0.32 mmol/L, P = 0.003), low-density lipoprotein cholesterol (3.47 ± 0.89 vs. 3.12 ± 0.77 mmol/L, P = 0.007), and T-cholesterol (5.32 ± 0.88 vs. 4.92 ± 0.86, P = 0.002). LP patients with MetS were older (P < 0.001) and less likely to have Wickham's striae (P = 0.028) compared to those without MetS. Female LP patients were older (P = 0.047), obese (P = 0.043), and had insignificant increase in MetS prevalence compared to the males. Hypertrophic LP was more frequent in patients with dyslipidemia (63.0% vs. 27.8%, P = 0.002), and the family history of diabetes mellitus (DM) was an independent predictor of MetS in LP patients (odds ratio: 4.4, confidence interval: 1.0–19.1, P = 0.047). Limitation: Availability of fund is a significant factor that limited the sample size to the minimum required as always in a poor-resource setting. Conclusions: LP has an insignificant association with MetS and a significant association with dyslipidemia among Nigerians. The family history of DM is an independent predictor of MetS in LP patients. LP patients should be routinely screened for MetS and its components.

Background: The current upsurge of complicated dermatophytosis in India and other parts of the world has necessitated the development of rapid and accurate diagnostic techniques. Conventional methods such as potassium hydroxide (KOH) mount lack color contrast and require a trained eye, whereas fungal culture is laborious and costly. Chicago sky blue 6B (CSB) a new contrast stain promises to be a reliable and rapid diagnostic method. It contains 1% CSB stain and is used with 10% KOH as clearing agent. Aims and Objectives: The objective of this study is to compare the efficacy of a novel contrast stain (CSB) and KOH mount in the diagnosis of dermatophytoses with culture as the reference method. Methods: The infected skin scrapings, nail clippings, and hair specimens from 100 patients, with clinically diagnosed dermatophytoses, were subjected to KOH mount, CSB stain, and culture on Sabouraud's dextrose agar. Using fungal culture as the reference standard, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CSB stain and KOH mount were determined. An inter-rater reliability analysis was performed using the Cohen's κ statistic to determine agreement amongst the different diagnostic modalities. Results: Of the 100 cases, the CSB stain and KOH mount were positive in 85 (85%) and 70 (70%) cases, respectively. Cultures on Sabouraud's agar yielded growth in 59 (59%) cases. The sensitivity, specificity, PPV, NPV, and accuracy of CSB stain were 98%, 34%, 68%, 93%, and 72%, respectively. The same for KOH mount were 71%, 32%, 60%, 43%, and 55%, respectively. Conclusion: CSB stain is a simple, rapid, sensitive, accurate, and inexpensive office-based method with qualitatively superior demonstration of dermatophytes compared to KOH mount.

Disseminated infection with Scedosporium apiospermum is an emerging opportunistic infection in immunocompromised individuals. A 41-year-old male farmer presented with a diffuse swelling in the right foot with discharge of whitish material from the swelling for 1 year. He also had multiple cystic swellings of varying sizes in the right ankle, left leg, left foot, and right forearm for 6 months. There was a history of diabetes and steroid therapy for joint pain which had increased the risk of dissemination of fungi in our patient. Early recognition of this infection and treating the patients with systemic antifungal drugs such as voriconazole and local surgical debridement help in resolution of the lesion.

Deep mycosis of the scalp caused by Rhizopus oryzae mimicking kerion is rare. Herein, we report a case of such infection in a 5-year-old immunocompetent boy who presented with multiple painful boggy swellings with discharging sinuses on the scalp of 4 months' duration. Purulent discharge from the swelling cultured on Sabouraud's dextrose agar yielded R. oryzae species which was confirmed by molecular analysis by polymerase chain reaction. The child was managed with parenteral liposomal amphotericin-B which helped in clearance of infection.

Wilson's disease is an inherited disorder of copper metabolism that results in excessive accumulation of copper in various organs, with liver being the primary site of involvement. D-penicillamine (DPA) as a chelating agent forms the mainstay of therapy; however, it can cause a myriad of adverse effects on long-term use. The major adverse effects reported with DPA include disorders of collagen synthesis, such as pseudoxanthoma elasticum-like lesions, autoimmune blistering diseases, and urticarial lesions. Here, we report a young girl who developed extensive pompholyx-like blisters within a few months of starting DPA which on histopathology showed a spongiotic reaction. The lesions improved on stopping DPA and initiation of oral steroids.

Graft-versus-host disease (GVHD) is a frequent and potentially life-threatening complication of hematopoietic stem cell transplantation (HSCT). Although skin involvement is common, generalized follicular eruption as the major clinical manifestation is rare. However, it is important for clinicians to recognize it at the earliest to initiate an appropriate therapy. We report a case of a patient with multiple myeloma who developed extensive hyperkeratotic, lichenoid folliculocentric papules with perifollicular erythema on day 53 following an allogeneic HSCT. The overall clinical and histological findings were consistent with the overlap subtype of chronic follicular GVHD.

Introduction: Pemphigus comprises of a group of autoimmune bullous disorders with intraepithelial lesions involving the skin and mucous membranes. Pemphigus is characterized histologically by an intraepidermal blister and immunopathologically by the finding of in vivo bound immunoglobulin G (IgG) antibodies against desmosomal adhesion proteins on the surface of keratinocytes. Indirect immunofluorescence for IgG is considered as a gold standard method for diagnosis of this group of bullous disorders on the condition that fresh frozen tissue is accessible. Aim: We designed a new diagnostic method by immunohistochemistry (IHC) for IgG4 on paraffin sections instead of fresh frozen tissue and evaluated sensitivity, specificity, and positive and negative predictive values of this method. Materials and Methods: We searched our pathologic archive of pemphigus of 35 patients, including 29 cases of pemphigus vulgaris (PV) and 6 patients with pemphigus foliaceus (PF). In all cases, the diagnosis was confirmed by indirect immunofluorescence studies. Thirty-five specimens served as controls, including 31 specimens of safe margins of basal cell carcinoma and 4 specimens of normal skin. Sections with condensed and continuous immunoreactivity localized to the intercellular junctions of keratinocytes were considered as positive. Results: Sensitivity of IgG4 was estimated to be 72.4% in PV group and 83.3% in PF group. The overall sensitivity and specificity of IgG4 IHC for diagnosis of pemphigus were 74.2% and 82.8%, respectively, in PV and PF groups. Furthermore, positive predictive value and negative predictive value were 81.2% and 76.3%, respectively. Conclusion: Immunohistochemical labeling for IgG4 on paraffin-embedded tissue provides a sensitive and specific test for diagnosing pemphigus in a situation when fresh frozen tissue is unavailable.

Background: Calmodulin (CaM) is a multifunctional intermediate messenger protein that plays important role in cell motility, proliferation, and apoptosis. Therefore, it is thought to be involved in various ways in the apoptotic processes which are implicated in the pathogenesis of lichen planus. Objective: The aim of this study was to evaluate the immunohistochemical expression of CaM in lichen planus lesions in comparison to normal control skin to throw light on its possible role in disease pathogenesis. Patients and Methods: This case–control study was conducted on 50 patients with lichen planus, in addition to 20 age- and sex-matched healthy individuals. Skin biopsy specimens were taken from lesional skin of lichen planus patients as well as normal skin of controls. All were examined for immunohistochemical expression of CaM antibody. Results: There was statistically significant increase of the immunohistochemical expression of CaM in lesional skin of lichen planus patients compared with normal skin of controls (Chi-square test, P < 0.001). No significant correlation could be detected between CaM expression in lesional skin and the studied clinical parameters of lichen planus patients. Limitations: Tha main limitation of this study is its small sample size. Conclusion: CaM is upregulated in cutaneous lichen planus lesions suggesting a possible role in disease pathogenesis. Targeting CaM is expected to be a novel strategy for treatment of lichen planus.

Erythema gyratum repens (EGR) is a rare paraneoplastic dermatosis known to be associated with internal malignancy. Herein, we report a case of EGR with diffuse large B-cell lymphoma (DLBCL) in a young farmer who presented with generalized massive lymphadenopathy and wood-grain pattern dermatosis. Lymph node biopsy with immunohistochemistry established the diagnosis of DLBCL. He was managed by the oncologist with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen which alleviated his symptoms considerably after completion of three cycles and was under follow-up.