Indian Journal of Dermatology, Venereology & Leprology Journal indexed with SCI-E, PubMed, and EMBASE

| | VVolo l 7744 IIssues s u e 2 MMar-Apra r- A p r 220080 0 8 C O N T E N T S

EDITORIAL Management of autoimmune urticaria Arun C. Inamadar, Aparna Palit ...... 89

VIEW POINT Cosmetic dermatology versus cosmetology: A misnomer in need of urgent correction Shyam B. Verma, Zoe D. Draelos ...... 92

REVIEW ARTICLE Psoriasiform dermatoses Virendra N. Sehgal, Sunil Dogra, Govind Srivastava, Ashok K. Aggarwal ...... 94

ORIGINAL ARTICLES A study of allergen-specific IgE antibodies in Indian patients of atopic dermatitis V. K. Somani ...... 100 Chronic idiopathic urticaria: Comparison of clinical features with positive autologous serum skin test George Mamatha, C. Balachandran, Prabhu Smitha ...... 105

Autologous serum therapy in chronic urticaria: Old wine in a new bottle A. K. Bajaj, Abir Saraswat, Amitabh Upadhyay, Rajetha Damisetty, Sandipan Dhar ...... 109 Use of patch testing for identifying allergen causing chronic urticaria Ashimav Deb Sharma ...... 114

Vitiligoid lichen sclerosus: A reappraisal Venkat Ratnam Attili, Sasi Kiran Attili ...... 118 C O N T E N T S (Contd.)

BRIEF REPORTS Activated charcoal and baking soda to reduce odor associated with extensive blistering disorders Arun Chakravarthi, C. R. Srinivas, Anil C. Mathew ...... 122

Nevus of Ota: A series of 15 cases Shanmuga Sekar, Maria Kuruvila, Harsha S. Pai ...... 125

Premature ovarian failure due to cyclophosphamide: A report of four cases in dermatology practice Vikrant A. Saoji ...... 128

CASE REPORTS Hand, foot and mouth disease in Nagpur Vikrant A. Saoji ...... 133

Non-familial multiple keratoacanthomas in a 70 year-old long-term non-progressor HIV-seropositive man Hemanta Kumar Kar, Sunil T. Sabhnani, R. K. Gautam, P. K. Sharma, Kalpana Solanki, Meenakshi Bhardwaj ...... 136

Late onset isotretinoin resistant conglobata in a patient with acromegaly Kapil Jain, V. K. Jain, Kamal Aggarwal, Anu Bansal ...... 139

Familial dyskeratotic comedones M. Sendhil Kumaran, Divya Appachu, Elizabeth Jayaseelan ...... 142 C O N T E N T S (Contd.)

Nasal NK/T cell lymphoma presenting as a lethal midline granuloma Vandana Mehta, C. Balachandran, Sudha Bhat, V. Geetha, Donald Fernandes ...... 145

Childhood sclerodermatomyositis with generalized morphea Girishkumar R. Ambade, Rachita S. Dhurat, Nitin Lade, Hemangi R. Jerajani ...... 148

Subcutaneous panniculitis-like T-cell cutaneous lymphoma Avninder Singh, Joginder Kumar, Sujala Kapur, V. Ramesh ...... 151

LETTERS TO EDITOR Using a submersible pump to clean large areas of the body with antiseptics C. R. Srinivas ...... 154

Peutz-Jeghers syndrome with prominent palmoplantar pigmentation K. N. Shivaswamy, A. L. Shyamprasad, T. K. Sumathi, C. Ranganathan ...... 154

Stratum corneum findings as clues to histological diagnosis of pityriasis lichenoides chronica Rajiv Joshi ...... 156

Author’s reply S. Pradeep Nair ...... 157 Omalizumab in severe chronic urticaria K. V. Godse ...... 157 Hypothesis: The potential utility of topical eflornithine against cutaneous leishmaniasis M. R. Namazi ...... 158

Nodular melanoma in a skin graft site A. Gnaneshwar Rao, Kamal K. Jhamnani, Chandana Konda ...... 159 C O N T E N T S (Contd.)

Palatal involvement in lepromatous leprosy A. Gnaneshwar Rao, Chandana Konda, Kamal Jhamnani ...... 161

Unilateral nevoid telangiectasia with no estrogen and progesterone receptors in a pediatric patient F. Sule Afsar, Ragip Ortac, Gulden Diniz ...... 163

Eruptive lichen planus in a child with celiac disease Dipankar De, Amrinder J. Kanwar ...... 164

Xerosis and pityriasis alba-like changes associated with zonisamide Feroze Kaliyadan, Jayasree Manoj, S. Venkitakrishnan ...... 165 Treatment of actinomycetoma with combination of rifampicin and co-trimoxazole Rajiv Joshi ...... 166

Author’s reply M. Ramam, Radhakrishna Bhat, Taru Garg, Vinod K. Sharma, R. Ray, M. K. Singh, U. Banerjee, C. Rajendran ...... 168 Vitiligo, psoriasis and imiquimod: Fitting all into the same pathway Bell Raj Eapen ...... 169 Author’s reply Engin Şenel, Deniz Seçkin ...... 169 Multiple dermatofibromas on face treated with carbon dioxide laser: The importance of laser parameters Kabir Sardana, Vijay K. Garg ...... 170 Author’s reply D. S. Krupa Shankar, A. Kushalappa, K. S. Uma, Anjay A. Pai ...... 170 progressing to totalis/universalis in non-insulin dependent mellitus (type II): Failure of dexamethasone-cyclophosphamide pulse therapy Virendra N. Sehgal, Sambit N. Bhattacharya, Sonal Sharma, Govind Srivastava, Ashok K. Aggarwal ...... 171

Subungual exostosis Kamal Aggarwal, Sanjeev Gupta, Vijay Kumar Jain, Amit Mital, Sunita Gupta ...... 173 C O N T E N T S (Contd.) Clinicohistopathological correlation of leprosy Amrish N. Pandya, Hemali J. Tailor ...... 174

RESIDENT’S PAGE Dermatographism Dipti Bhute, Bhavana Doshi, Sushil Pande, Sunanda Mahajan, Vidya Kharkar ...... 177

FOCUS Mycophenolate mofetil Amar Surjushe, D. G. Saple ...... 180

QUIZ Multiple papules on the vulva G. Raghu Rama Rao, R. Radha Rani, A. Amareswar, P. V. Krishnam Raju, P. Raja Kumari, Y. Hari Kishan Kumar ...... 185

E-IJDVL Net Study Oral isotretinoin is as effective as a combination of oral isotretinoin and topical anti-acne agents in nodulocystic acne Rajeev Dhir, Neetu P. Gehi, Reetu Agarwal, Yuvraj E. More ...... 187 Net Case Cutaneous diphtheria masquerading as a sexually transmitted disease T. P. Vetrichevvel, Gajanan A. Pise, Kishan Kumar Agrawal, Devinder Mohan Thappa ...... 187

Net Letters Patch test in Behcet’s disease Ülker Gül, Müzeyyen Gönül, Seray Külcü Çakmak, Arzu Kõlõç ...... 187 Cerebriform elephantiasis of the vulva following tuberculous lymphadenitis Surajit Nayak, Basanti Acharjya, Basanti Devi, Satyadarshi Pattnaik, Manoj Kumar Patra ...... 188

Net Quiz Vesicles on the tongue Saurabh Agarwal, Krishna Gopal, Binay Kumar ...... 188

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Watanabe K. Predictive value of acetylcholine stimulation testing for oligohidrosis caused by zonisamide. Pediatr Neurol 2000;23:59-61. 3. Knudsen JF, Thambi LR, Kapcala LP, Racoosin JA. Oligohydrosis and fever in pediatric patients treated with zonisamide. Pediatr Neurol 2003;28:184-9. 4. Low PA, James S, Peschel T, Leong R, Rothstein A. Zonisamide and associated oligohidrosis and . Epilepsy Res 2004;62:27-34. 5. de Carolis P, Magnifico F, Pierangeli G, Rinaldi R, Galeotti M, Cevoli S, et al. Transient hypohidrosis induced by topiramate. Epilepsia 2003;44:974-6. 6. Shimizu T, Yamashita Y, Satoi M, Togo A, Wada N, Matsuishi T, et al. Heat -like episode in a child caused by zonisamide. Brain Dev 1997;19:366-8. Figure 1: Pityriasis alba like lesions on face 7. Cerminara C, Seri S, Bombardieri R, Pinci M, Curatolo P. Hypohidrosis during topiramate treatment: A rare and alternative anti-epileptic treatment, following which the reversible side effect. Pediatr Neurol 2006;34:392-4. 8. Vinod S, Singh G, Dash K, Grover S. Clinico epidemiological dryness and the skin lesions improved. study of pityriasis alba. Indian J Dermatol Venereol Leprol 2002;68:338-40. Zonisamide is a relatively newer anti-epileptic drug that acts by the inhibition of carbonic anhydrase.[1] Both zonisamide and topiramate (another anti-epileptic that is also a carbonic anhydrase inhibitor) have been documented to TTreatmentreatment ooff aactinomycetomactinomycetoma cause hypohidrosis.[2-5] Zonisamide has also been implicated wwithith ccombinationombination ofof rrifampicinifampicin in the causation of heat stroke in children secondary to oligohidrosis.[6] However, hypohidrosis is considered to aandnd co-trimoxazoleco-trimoxazole be completely reversible after cessation of the drug.[6,7] The exact mechanism of oligohidrosis due to these drugs Sir, remains conjectural, although it has been postulated that I read with interest the article ‘A modified two-step carbonic anhydrase blockage at the level of the sweat treatment for actinomycetoma’, which appeared in the July- [7] gland may be a major factor. In our case, we assume August 2007 issue of the IJDVL.[1] that hypohidrosis induced by zonisamide contributed to the sudden development of xerosis and pityriasis alba-like The article illustrates vividly the difficulty in definitive changes. Pityriasis alba itself is known to be precipitated by microbiological diagnosis of mycetomas faced by clinicians [8] dryness of the skin. This report highlights the point that in practice as even the authors could demonstrate in patients on zonisamide or topiramate presenting with actinomycetes in only half of their cases and that too in a sudden onset of dryness of the skin, the possibility of drug- premier teaching institute. induced hypohidrosis should be considered. The choice of antibiotics used in such cases is, therefore, FFerozeeroze KKaliyadan,aliyadan, JayasreeJayasree Manoj,Manoj, often based on reports of previous clinical studies or SS.. VVenkitakrishnanenkitakrishnan reports of laboratory studies of in vitro sensitivity of human Department of Dermatology, Amrita Institute of Medical Sciences, isolates of actinomycetes. Combinations of two or more Kochi, India drugs are often used to prevent resistance and persistence of AAddressddress fforor ccorrespondence:orrespondence: Dr. Feroze Kaliyadan, Department of infection. However, no single regimen has given consistent Dermatology, Amrita Institute of Medical Sciences, Kochi - 682 026, good results, and successful treatment of actinomycetomas Kerala, India. E-mail: [email protected] in general remains really speaking ‘a matter of chance’. RREFERENCESEFERENCES Of the 16 patients reported by the authors, 7 patients 1. Leppik IE. Zonisamide: Chemistry, mechanism of action and were lost to follow-up before complete healing had pharmacokinetics. Seizure 2004;13:5-9. occurred, indicating a very high rate of drop-outs and 2. Okumura A, Ishihara N, Kato T, Hayakawa F, Kuno K, possible waste of intensive therapy that they had received

166 Indian J Dermatol Venereol Leprol | March-April 2008 | Vol 74 | Issue 2 Letters to the Editor

he underwent 1 year back to remove the affected tissue. Six months after the surgery, he started developing new sinuses and induration of the surrounding tissue.

A biopsy from one of the new sinuses revealed suppurative- granulomatous nodules within the dermis, one such area of suppuration had at its centre a collection (grain) of actinomycetes. The patient was investigated; complete haemogram, tests for G6PD function, liver and renal functions, blood sugars, urine routine and chest X-rays were found to be within normal limits. The patient had no past history of tuberculosis.

Figure 1: Actinomycetoma with sinuses on instep of right foot He was started on rifampicin 600 mg daily and cotrimoxazole at presentation double strength tablets (DS 1-1 or 2-2 320/1600) twice daily along with multivitamins and folic acid supplements.

He was instructed to repeat all investigations at monthly intervals at his home town and follow up for clinical examination after 2 months or earlier if he experienced any side-effects from the medication. At the first follow-up at 2 months, the lesions had started healing and by end of 4 months all lesions had healed and no new sinuses had developed [Figure 2]. Therapy was continued for a further 6 months for a total treatment period of 10 months, at the end of which he was symptom-free and continued to be so for a further follow-up period of 6 months. No adverse effects of the medication were seen.

Figure 2: Complete healing at 4 months with previous surgery Rifampicin is a highly bactericidal antibiotic and has been scar shown to be the most effective antibiotic in terms of lowest MIC amongst 13 antibiotics tested for in vitro studies earlier. Of the other 9 who did follow-up, one patient against Streptomyces somaliensis, which is a cause of human relapsed later with development of new lesions. Because actinomycetoma.[2] Rifampicin has also been used along with mycetoma affects predominantly poor people from rural amikacin and co-trimoxazole in the successful treatment of communities who often are daily wage earners, admission nocardiosis of the chest wall that developed 10 years after to hospital for intensive intravenous regimens puts them untreated mycetoma of the right hand.[3] under great financial strains and results in high levels of drop-outs. I would like to report the efficacy of the Therefore, in my opinion, rifampicin along with cotrimoxazole combination of rifampicin and cotrimoxazole in a case of for extended periods of time may be a rational initial choice actinomycetoma. for treatment of actinomycetomas, as this combination is fairly cheap and can be used at home by the patient without A 58-year-old shopkeeper from a semi-rural region, about the need for admission to a hospital. 100 km north of Mumbai, presented with swelling and induration of the right foot with discharging sinuses on the Most patients do not receive therapy for adequate period instep and the dorsum of the right foot [Figure 1]. He had of time (several months to even years of treatment may be been diagnosed clinically with mycetoma of the right foot needed), and for patients who do not improve even after 5 years back and was treated with several courses of various a reasonable trial with these two drugs, intensive therapy antibiotics (details of treatment were not available with the with intravenous penicillin and gentamicin or amikacin may patient), and due to lack of response to medical treatment, be attempted.

Indian J Dermatol Venereol Leprol | March-April 2008 | Vol 74 | Issue 2 167 Letters to the Editor

RRajivajiv JJoshioshi It is true that admission to a hospital places financial P. D. Hinduja National Hospital, Veer Savarkar Road, Mahim, strain on patients and may lead to drop-outs. However, Mumbai, India in our study, all the drop-outs occurred after discharge AAddressddress fforor ccorrespondence:orrespondence: P. D. Hinduja National Hospital, Veer from hospital. Nevertheless, admission can be avoided Savarkar Road, Mahim, Mumbai - 400 016, India. if gentamicin is injected intramuscularly in the intensive E-mail: [email protected] phase of the schedule described in our paper.[3] The RREFERENCESEFERENCES pharmacokinetics of gentamicin after intravenous and intramuscular administration appear to be similar.[4] Since 1. Ramam M, Bhat R, Garg T, Sharma VK, Ray R. A modified administration of the drug and monitoring for toxicity is two step treatment for actinomycetomas. Indian J Dermatol familiar to medical practitioners, it may be possible for the Venereol Leprol 2007;73:235-9. patient to receive injections from any medical facility near 2. Nasher MA, Hay RJ, Mahgoub ES, Gumaa SA. In vitro studies his home. After 4 weeks, the patient can be switched to of antibiotic sensitivities of Streptomyces somaliensis: A the maintenance phase, which requires oral medications cause of human actinomycetoma. Trans R Soc Trop Med Hyg 1989;83:265-8. alone. 3. Saarinen KA, Lestringant GG, Czechowski J, Frossard PM. Cutaneous nocardiosis of chest wall and pleura: 10 year The response to combination therapy with rifampicin consequences of a hand actinomycetoma. Dermatology and co-trimoxazole in the reported patient is impressive. 2001;202:131-3. If results are similar in a larger number of patients, it would be a useful addition to the treatments available for this neglected disease. Careful clinical evaluation and AAuthor’suthor’s replyreply a chest X-ray to exclude concurrent tuberculosis would, of course, be mandatory to avoid inadvertently administering rifampicin monotherapy for tuberculosis in people who Sir, have both infections.[5] We thank Dr. Joshi for his interest in our paper and his thoughtful comments about the management of actinomycetomas. There is a great need for more sensitive MM.. RRamam,amam, RRadhakrishnaadhakrishna Bhat,Bhat, TTaruaru GGarg,arg, 1 1 diagnostic tests that will confirm the presence of mycetoma. VVinodinod K.K. SSharma,harma, RR.. RRayay , MM.. KK.. SSinghingh , 2 3 Although the clinical presentation is characteristic in many UU.. BBanerjeeanerjee , CC.. RRajendranajendran Departments of Dermatology and Venereology, 1Pathology, cases, laboratory diagnosis is required to know if mycetoma 2Microbiology, 3Mycology, All India Institute of Medical Sciences, is eumycotic or actinomycotic. In addition, identification of New Delhi, India the organism causing actinomycetoma may lead to better- AAddressddress fforor ccorrespondence:orrespondence: M. Ramam, Department of Dermatology directed therapy using drugs effective against the isolated and Venereology, All India Institute of Medical Sciences, New Delhi - bacterium. 110 029, India. E-mail: [email protected]

Fortunately, many of the different organisms causing RREFERENCESEFERENCES actinomycetoma are susceptible to the same drugs, making it possible to embark on treatment even if the antibiotic 1. Mahgoub ES. Medical management of mycetoma. Bull WHO 1976;54:303-9. sensitivity of the causative organism is not known. While 2. Desai SC, Pardanani DS, Kher YR, Mehta RS, Sreedevi N, there are no randomized studies comparing monotherapy Wagle UD, et al. Therapeutic investigations on actinomycetomas. with combination therapy, observational studies show Indian J Surg 1970;32:448-61. that the latter is more effective.[1] The usefulness of 3. Ramam M, Bhat R, Garg T, Sharma VK, Ray R, Singh MK, combination treatments was demonstrated in a fairly large et al. A modified two-step treatment for actinomycetomas. group of 144 patients with actinomycetoma. In that study, Indian J Dermatol Venereol Leprol 2007;73:235-9. the most effective combinations were streptomycin plus 4. Gemer O, Harari D, Mishal J, Segal S. Comparative pharmacokinetics of once daily intravenous and co-trimoxazole and streptomycin plus daspone.[1] Other intramuscular gentamicin in patients with post partum studies in smaller groups of patients have also identified endometritis. Arch Gynecol Obstet 2001;265:34-35. [2] treatments useful in this disorder; these combinations 5. Fahal AH, Azziz KA, Saliman SH, Galib HV, Mahgoub S. Dual are likely to be effective in most patients. But clearly, more infection with mycetoma and tuberculosis: Report of two work is necessary. cases. East Afr Med J 1995;72:749-50.

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