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Onychomycosis (OM) is a difficult-to-treat condition, especially considering the limited armamentarium of antifungal drugs, need for prolonged treatment, and poor compliance. This problem is further confounded while treating OM in special populations such as children, elderly, immunosuppressed patients, pregnant or lactating women, and patients with chronic liver or kidney disease. In the absence of standardized treatment guidelines, the antifungal therapy is either withheld or compromised, as it is largely governed by personal preferences or based on anecdotal reports. Hence, an expert group of the Nail Society of India worked towards drafting guidelines based on established literature and inputs from experts, with practical recommendations for the treatment of onychomycosis in special population groups. An extensive analysis of available English language literature on onychomycosis in special populations, published during a 10-year period (2014–2023 until date) was done. The available studies and reports were evaluated, cross-references read, and evidence compiled, graded, and discussed by the expert group to derive consensus recommendations for practice. The evidence and recommendations based on it are presented in a narrative format to guide treatment choices when dealing with population groups with special considerations.

Background: Onychomycosis (OM) is the most common nail disorder accounting for 40–50% of all onychopathies. Onychomycosis is caused by dermatophytes in majority, mostly Trichophyton (T.) rubrum followed by T. mentragrophytes var. interdigitale. However, there is a variation in the etiological profile with the subset of population, time, and geographical location. In immunocompromised hosts, non-dermatophytic molds (NDMs) and yeasts like Candida albicans and Candida parapsilosis are the main causative agents. Diabetes mellitus (DM) is a well-established risk factor for OM. Aim and Objectives: This study was conducted to determine the clinical and mycological characteristics of OM in diabetic patients and to evaluate the clinico-etiological correlation, if any. Materials and Methods: Three hundred consecutive diabetic patients were screened, of whom 102 (34%) patients were diagnosed with OM based on clinical, mycological, dermoscopic, and histological criteria. Results: Distal lateral subungual onychomycosis was the most common clinical variant seen in 80 (78.43%) patients. Fungal culture was positive in 57 (55.88%) of which NDMs constituted approximately half (47.61%) of the isolates, followed by Candida species (30.15%) and dermatophytes (22.22%). The clinico-mycological correlation was performed to look for the association of various fungi with the clinical type of OM. Distal lateral subungual onychomycosis was majorly caused by NDMs (51.02%), followed by Candida species (28.57%), and dermatophytes (20.40%). Conclusion: Non-dermatophytic molds are increasingly incriminated as the causative organisms for OM in DM and must be considered as potential pathogens in the present scenario, thus necessitating the change in the treatment options accordingly.

Onychomycosis (OM) is the commonest cause of dystrophic nails, responsible for upto 50% of cases. Apart from significantly damaging the nails, quality of life, and self.image of the sufferer, it also acts as a reservoir of fungal infections carrying important implications for emerging recalcitrant dermatophytoses. Treatment of OM is based on guidelines released almost a decade back, in addition to published literature and personal preferences. Hence, an expert group of nail society of India (NSI) worked towards drafting these guidelines aimed at compiling recommendations for pharmacologic treatment of OM, based on scientific evidence, along with practical experience. The group did an extensive analysis of available English language literature on OM published during the period 2014.2022. The evidence compiled was graded and discussed to derive consensus recommendations for practice. Special focus was placed on combination therapies and adjunct therapies, including experience of members, to improve treatment outcomes.

Mycetoma is a chronic, suppurative, localized, and destructive infection involving skin, subcutaneous tissue, fascia, muscle and sometimes invade the underlying bone. The infection is prevalent in tropical countries and involves chiefly adults. Etiologically, it is classified into eumycetoma and actinomycetoma caused by fungus and bacteria respectively. Clinically, mycetoma presents as a triad of firm to soft swelling with multiple sinuses and discharging grains of different colors. Mycetoma is reported rarely in children. We report an 11-year-old boy diagnosed with actinomycetoma of the left foot with classical clinical, histological, and radiological features.

Background: The epidemic-like scenario of superficial fungal infections in India has been complicated by the prescription of systemic and topical potent steroids. As a result, alarming number of patients are presenting with exogenous Cushing's syndrome. Methods: This cross-sectional study involved 23 patients of superficial dermatophytosis on steroids who presented with clinical features like that of Cushing's syndrome. Their clinical details and laboratory investigations including fungal culture and serum cortisol, were recorded on a pre-designed proforma. Results: There were 23 patients (14 males and 9 females) with mean age of 29.47 ± 15.5 years, majority with extensive tinea cruris and corporis. All of them received oral (Betamethasone) or parenteral corticosteroids along with potent topical steroids (clobetasol propionate and betamethasone valerate) for at least two months. In majority (56.5%), treatment was prescribed by unqualified medical practitioners and in the rest by alternative medical practitioners. Striae, buffalo hump, hirsutism were observed in 16 (69.5%), 15 (65.2%), 13 (56.5%) patients, respectively. Serum cortisol estimation revealed low levels and ranged from 0.66 to 6 μg/ml with a mean of 1.53 ± 1.27 μg/ml (normal 7-25 μg/ml). Conclusions: Corticosteroids are life saving for many dermatological diseases; their injudicious use (topical, oral, and parenteral) for prolonged periods in the treatment of superficial dermatophytosis can lead to Cushing's syndrome.

Fabry's disease is a rare X-linked dermatosis, resulting from alpha-galactosidase deficiency and presents with both cutaneous (angiokeratoma, acral paresthesia, and hypohidrosis) and extracutaneous manifestations (ocular, cardiac, renal, and neurological). We report two brothers age 16 and 14 years that presented with multiple angiokeratoma in a bathing suit distribution on the trunk and the scrotum. The younger brother had acral paresthesia too. On systemic screening, ocular involvement was noted in both. Alpha-galactosidase assay in both brothers, revealed a deficiency of 19.2 nmol/h/mg (reference value

Introduction: Systemic sclerosis (SSc) is characterized by fibrosis and intimal proliferation of cutaneous and visceral small vessels. These architectural abnormalities can be visualized with nailfold capillaroscopy (NFC); the changes being quite characteristic. At the same time, morphological alterations in retinal vascular bed are expected but sparsely described. Aim: We aimed to characterize the frequency and type of retinal microvascular changes in patients with SSc and to analyze any association with NFC changes. Patients and Methods: With institutional ethical committee approval, we recruited 45 consecutive patients with SSc (diagnosed based on American College of Rheumatology and European League against Rheumatism [ACR/EULAR-2013] criteria). NFC was done for all of them with a Universal Serial Bus (USB) dermatoscope; additionally, fundoscopy, fundus photography, and optical coherence tomography (OCT) were analyzed. Disease characteristics in patients with and without retinal disease were compared. Results: Among the 45 SSc patients, 12 (26.67%) had limited cutaneous SSc (lSSc) while 33 (73.33%) had diffuse cutaneous disease (dSSc). Retinal microvascular changes seen as mild arteriolar alteration and arteriovenous crossing changes were recorded in 13 patients (28.89%); mostly in those with dSSc (12/13). The NFC architectural changes were more severe in patients with retinal disease, though the difference was not statistically significant. Conclusion: Patients with SSc can often have retinal microvascular abnormalities commensurate with the vascular changes characteristic of SSc. The severity of retinal changes correlates with changes in NFC. NFC, which is now an essential tool for the management of SSc, could be a surrogate marker for retinal involvement in these patients.

Melanonychia is a very worrisome entity for most patients. It is characterized by brownish black discoloration of nail plate and is a common cause of nail plate pigmentation. The aetiology of melanonychia ranges from more common benign causes to less common invasive and in situ melanomas. Melanonychia especially in a longitudinal band form can be due to both local and systemic causes. An understanding of the epidemiology, pathophysiology and clinical details is necessary for adequate patient care and counseling. It not only helps in the early recognition of melanoma but also prevents unnecessary invasive work up in cases with benign etiology. An early diagnosis of malignant lesion is the key to favourable outcome. Though there are no established guidelines or algorithms for evaluating melanonychia, a systematic stepwise approach has been suggested to arrive at a probable etiology. We, hereby, review the aetiology, clinical features, diagnostic modalities and management protocol for melanonychia.

Nail disorders in infants and children do not contribute to substantial pediatric consultations as they are relatively uncommon. Nail changes are often missed as specific nail examination is not routinely done in this age group. The presentation and management of nail disorders in children are different from adults; few being specific to the children. Physiological alterations are common in infants and pediatric age. These should be known to a clinician so as to differentiate from pathological conditions, to reassure parents, and to avoid unnecessary medical intervention. The congenital nail disorders can be a part of major hereditary syndromes requiring further evaluation. Several acquired causes may cause nail dystrophy. Some of them are self-limiting while others may require long-term management. Meticulous and careful nail examination is, therefore, important in neonates, infants and children for early diagnoses, management and to prevent complications. There are few epidemiological studies delineating nail changes in infants and children. In this script, we have comprehensively reviewed nail conditions seen in pediatric population through all stages, i.e., neonates, infants, and children.

Background: Pityriasis versicolor (PV) is a superficial mycosis caused by Malassezia yeast; a lipophilic fungus. Dermoscopy may be a value addition in the diagnosis of PV in some cases, where results of KOH (potassium hydroxide) examination are ambiguous. There is paucity of Indian data on dermoscopy of PV. Materials and Methods: Thirty consecutive patients diagnosed clinically with pityriasis versicolor were recruited in this pilot cross sectional study.Patients were subjected to KOH mount of the skin scrapings from the lesions which were positive in all the patients.Dermoscopy was performed in all using Universal Serial Bus (USB) dermoscope [Dinolite AMZT 73915, Edge 3] and features were recorded for analysis. Results: Hypopigmented variant was the most common type (80%). Dermoscopic analysis revealed altered pigmentary network as most common finding (100%) followed by scaling seen in 25 cases (83.33%). Folliculocentric pattern was appreciated in 20 cases (66.67%). A characteristic contrast halo ring around the primary altered pigmentation was observed in 20 cases (66.67%). Invasion of hair follicles by yeast was evident in 6 patients (20%). Conclusion: Dermoscopy with characteristic features such as folliculocentricity, contrast halo sign, and yeast invasion of hair follicles can be a very useful aid in contributing towards diagnosing pityriasis versicolor.

Background: Tinea pseudoimbricata, characterized by concentric scaly rings simulating Tinea imbricata is caused by dermatophytes other than Trichophyton concentricum. It is reported to occur in patients with steroid abuse and in immunocompromised individuals. Aim: To study the clinico-mycological profile and dermoscopic features of T. pseudoimbricata in immunocompetent patients. Methods: We have evaluated 14 consecutive, clinically diagnosed patients of T. pseudoimbricata with positive 10% potassium hydroxide (KOH) examination and culture, seen over a period of 6 months. Dermoscopy was performed in all patients. The demographic, clinical, and mycological features of each patient were recorded on a predesigned proforma. Results: There were seven male and seven female patients with a mean age of 27.6 years and a mean disease duration of 3.8 months. All patients gave a history of application of potent or super-potent topical steroid with or without oral/injectable steroid for varying duration. Culture isolates were Trichophyton mentagrophytes complex and Trichophyton rubrum in 11 and 3 patients, respectively. Dermoscopic analysis showed features of steroid abuse in majority of the patients. Limitation: A small sample size was the limitation of our study. Conclusion: T. pseudoimbricata is a special subset of Tinea incognito caused by injudicious and inappropriate use of topical steroid. The typical appearance should alert the dermatologists regarding the possible abuse of steroids. Most common species isolated on culture was T. mentagrophytes complex.

Congenital Erythropoetic Porphyria (CEP) also called the “Günther disease”, is a rare variant of porphyria. It is caused by the deficiency of uroporphyrinogen III synthase (URO-III-synthase), an enzyme in the heme biosynthetic pathway. Clinically, CEP presents with blistering over face and extremities, scarring, hypertrichosis and dyspigmentation. Acral blistering leads to mutilation of the fingers with acro-osteolysis of distal phalanx We, hereby, report an 8-years-old boy with classical clinical features and porphyrin assays.

Tufted angioma (TA) is a rare benign vascular tumor that may be congenital or acquired and generally presents as an asymptomatic or painful solitary erythematous to violaceous poorly defined plaque. Hyperhidrosis and hypertrichosis may be associated. The lesions have tendency to resolve spontaneously, in majority, within 2 years of disease onset. However, occurrence of Kassbach-Merritt phenomenon should be looked for. We present a case of 8-months-old infant with TA over the right forearm with classical clinical, histoptahological and immunohistochemistry features.

Morphea is a rare sclerosing disorder of the skin. Linear morphea is commonly seen in children and can affect head, neck, trunk, or limbs. It may extend to involve deeper structures such as muscles, bones, and joints. Involvement of lymphatics or the vasculature is very rare. We report a case of a 20-year-old woman presenting with linear morphea involving the nape of the neck and scalp. The lesion gradually developed two linear thick cord-like structures within the lesion of morphea because of secondary lymphatic obstruction causing restriction of neck movements. The patient was given intralesional steroid that led to softening of the skin lesions including that of cords, resulting in improvement of neck movements.

Introduction: Ingrown toenail is one of the most commonly encountered nail disorders that adversely affect the quality of life. The common surgical intervention includes partial nail avulsion with chemical matricectomy but it has a relatively longer recovery period. We attempted to study the efficacy and safety of radio frequency (RF) for matricectomy. Materials and Methods: Eight patients with total 10 ingrown toenails (grade 2) were recruited. Partial nail avulsion with RF ablation of matrix was performed. The radio-frequency electrode was placed over the lateral matrix horn for the duration of 3–5s, two to three times. Patients were followed up at regular interval. Outcome was measured in terms of ooze, erythema, pain, and swelling of the lateral nail folds. Results: Of the eight patients, six were males and two were females. Total 10 nails were treated as two patients had bilateral toenail involvement. Average number of days required for postprocedural healing was 7.5 days. Significant improvement was observed in terms of erythema, pain as well as swelling within 4 days of surgery. None of the cases showed any adverse effects or relapse within 3–5 months of follow-up. Conclusion: Matricectomy by radio-frequency ablation is a safe and effective method in the management of ingrown toenail with significant reduction in downtime.

Dermatophyte infections are common worldwide, and dermatophytes are the prevailing causes of fungal infection of the skin, hair, and nails. These infections lead to a variety of clinical manifestations; nail infection known as onychomycosis (OM) and hair infection as Tinea capitis. The diagnosis and treatment of dermatophyte infections of the Nail and hair will be reviewed here.

Cutaneous basal cell carcinoma (BCC) is a slow growing locally aggressive malignant tumor. It is usually diagnosed on histopathological examination of the excised biopsy. Recently, fine needle aspiration cytology (FNAC) is emerging as a simple alternative technique for rapid diagnostic work of nodular and plaque-like skin lesions. We report the cytomorphological features of two cases of cutaneous BCC having unusual clinical presentation and mixed histology (MH); emphasizing the diagnostic difficulties encountered on cytology, the plausible explanation and the precautions to keep in mind to avoid misdiagnosis.

Subungual melanoma (SUM) is an uncommon form of acral melanoma that arises within the nail matrix. The incidence for acral melanomas is similar worldwide, however, the proportion is higher in dark-skinned individuals. The subungual form represents approximately 2% of cutaneous non-sun-induced melanomas in the western world and up to 75% in Africans, 10% in Japanese, and 25% in the Chinese. No specific figures are available from the Indian subcontinent; however, the authors could trace three anecdotal case reports published over the last two decades. A general reluctance to biopsy a nail lesion to confirm the diagnosis may be contributing to the missed diagnosis. We report four cases of SUM of the big toenails seen over a period of 2.5 years. They were three women and one man with an age ranging from the 4th to 7th decade and disease duration of 6–18 months. The lesion involved the big toe in all and two patients had liver and lymph node metastasis at the time of presentation. Awareness among dermatologists regarding clinical manifestations, high index of suspicion for acral pigmented lesions, and nail bed biopsy may help in the early diagnosis and management and can prevent mortality.

Mycosis fungoides (MF) is the most common type of primary cutaneous lymphomas. Several clinical variants of MF have been described. Purely, hypopigmented variant of MF (HMF) is rare. Phototherapy, especially photochemotherapy (Psoralen and ultraviolet), is the most widely used method and is recommended as the first-line treatment for HMF. However, there are no standard guidelines for phototherapy as the disease is uncommon. We, hereby, report a 30-year-old woman with HMF in whom clinical, histopathological, and immunohistochemical remission was achieved following narrow-band ultraviolet B therapy.

Background: There is no uniform grading scale for objective assessment of premature canities that can serve as a reference. The aim of the study was to devise an objective and reproducible scoring system to assess the severity of premature canities. Materials and Methods: A cross-sectional study conducted from November 2011 to April 2013 in a tertiary care setup with 52 apparently healthy individuals with onset of premature graying of scalp hair before the age of 20 years. A new scoring system (Graying Severity Score, GSS) was devised to evaluate the extent of graying taking into account five representative sites from the scalp by two independent investigators and analysed for agreement. GSS ranged from 0 to 15 that was further graded as mild, moderate, and severe. Results: The highest total GSS attained was 13 and lowest was 4 (mean = 6.6 ± 1.97). Of the 52 patients 17 (32.69%) had mild, 32 (61.54%) moderate, and only 3 (5.77%) had severe GSS. Scores of both investigators were found to have good agreement. The intraclass correlation calculated by the two-way mixed model using the absolute agreement definition for the GSS was 0.967 (CI = 0.944–0.981; P = 0.000) and for GSS grade was 0.962 (P = 0.000). In the study subjects the frontal and the vertex regions were found to be the worst affected. Conclusion: GSS is a novel, numeric, objective, and reproducible tool for evaluation of premature canities that can be used to follow up and assess therapeutic response. Further large scale studies are recommended to optimize its utility.

Basal cell carcinoma (BCC) is the most common skin cancer worldwide. Surgical excision is considered to be the primary therapeutic modality wherever possible. For inoperable cases, 5% imiquimod seems to be a good alternative. We present two cases of nodular pigmented BCCs on the face in elderly women successfully treated with 5% imiquimod cream application resulting in complete clinical clearance of lesion as well as on histology and dermatoscopy. There was no recurrence of the lesion on 2 years follow-up for the first and 1.5 years for the second patient.

Collagenomas are connective tissue nevi representing hamartomatous proliferation of collagen. Isolated collagenomas are of rare occurrence. They are sporadically acquired, and lesions are often localized to a single body region. We described a case of solitary collagenoma in a 23-year-old woman, confirmed on histopathology and special stains for collagen, involving an uncommon site such as labium majus. A high index of suspicion for a skin-colored circumscribed solitary growth and a low threshold for biopsy often help to arrive at a final diagnosis.

Introduction: There is a constant need to define the epidemiological and mycological characteristics of onychomycosis (OM) for optimal management strategies. Objectives: To define the epidemiological and mycological characteristics of patients with dermatophyte toenail OM in a tertiary care hospital. Materials and Methods: Hundred consecutive patients of KOH and culture-positive dermatophyte toenail OM were subjected to detailed history, clinical examination and investigations. Results: Maximum number of patients (40%) belonged to 31-45 years age group and there was a male preponderance (M:F = 6.7:1). The mean duration of disease was 54 months. Thirty-three patients had fingernail involvement in addition to the toenail OM and 37% had co-existent cutaneous dermatophyte infection. Discoloration was the most common symptom (98%). Ninety-four (94%) patients had distal lateral subungual onychomycosis (DSLO) while two had superficial onychomycosis (SO) and only one had proximal superficial onychomycosis (PSO). Trichophyton interdigitale was the most common etiological agent (61%) followed by Trichophyton rubrum and Trichophyton verrucosum. Conclusions: Toenail OM is more common in males. DSLO was the most common clinical variant and T. interdigitale the most common etiological fungus responsible for toenail OM in our region. The importance of early diagnosis and treatment is highlighted as long-standing toenail OM predisposes to fingernail onychomycosis and recurrent tinea pedis.

Background: Leprosy has been officially eliminated from India since December, 2005; still, there are districts and blocks reporting high prevalence indicating ongoing transmission. The present study aimed at determining the current clinical profile of leprosy from a tertiary level hospital in Delhi. Materials and Methods: A retrospective, record-based study was carried out on patients diagnosed and registered in the leprosy clinic of a tertiary level teaching hospital in East district of Delhi (April 2007 to March 2012). Data regarding demographic details, clinical features, treatment started and complications was analyzed. Results: A total of 849 patients were registered over a 5-year period, with M: F ratio of 2.3:1. 9.3% were children (ͳ14 years). 54.3% patients were immigrants from adjoining states. Multibacillary leprosy was the most common clinical type (86.9%). Borderline tuberculoid leprosy was the most frequent morphologic type, seen in 56.3% followed by borderline-borderline (1.5%), borderline lepromatous (24.9%), lepromatous leprosy (8.1%), pure neuritic (8.1%), histoid and indeterminate leprosy (0.5% each). 37.4% patients presented in reaction (Type I in 30.4% cases and Type II in 7% cases). WHO grade II deformities were diagnosed in 37.9% with claw hand being the most common paralytic deformity (23.3% cases). Conclusion: Our study offers insight into the current status of the disease in an area of otherwise low prevalence. It is seen that despite statistical elimination, multibacillary disease, leprosy reactions and deformities are commonly seen as presenting manifestations, in contrast to national projected trends. Delhi′s unique demography with a high degree of migrant workers, presenting to our center (near border location) could be a possible contributing factor towards these aberrations. It highlights the need for continuation of targeted leprosy control activities and active case detection.

Certain nail changes are specific for various dermatological disorders. In addition, examination of nails may also provide an insight into more sinister systemic manifestations in the form of both subtle as well as specific changes. These findings may present as a defect of various anatomical components of the nail unit; nail matrix, nail plate and/or nail bed or vasculature. This article is an attempt to equip the dermatologists with a foresight to suspect and diagnose the unapparent systemic connotations that may be possible by a simple but detailed nail examination.

Psoriasis patients are often susceptible to cardiovascular diseases (CVD), including atherosclerosis. Traditional markers (biochemical and inflammatory) and diagnostic tools could detect occlusive but not subclinical atherosclerosis. Carotid intima-media thickness (CIMT), has recently been recognised as a non invasive diagnostic tool for identification of premature atherosclerosis. Therefore we evaluated 80 psoriasis patients and 80 age sex matched healthy controls for serum leptin levels and apolipoprotein B/apolipoprotein A-I ratio (apoB/apoA-I ratio) in relation with CIMT of carotid artery. Carotid intima-media thickness and carotid plaques were simultaneously measured by carotid sonography. Serum concentration of leptin and apolipoprotein were measured using enzyme-linked immuno sorbent assay (ELISA) and nephelometry respectively. Raised CIMT correlated to age of onset of the disease, serum leptin and apoB/apoA-I ratio in psoriasis patients. Taking into account, values that were above the 75 percentile of the three markers (leptin, apoB/apoA-I ratio and CIMT) the odds ratio was 4.26 (2.06–8.80 CI). Leptin and apoB/apoA-I ratio showed significant cumulative association with CIMT. Results of predictive analysis supports measurement of CIMT along with estimation of serum leptin and apoB/apoA-I ratio for prediction of premature atherosclerosis in psoriasis patients.

Leprosy is a chronic inflammatory disease of skin and peripheral nerves. Elimination of leprosy as a public health problem was reached at the global level in the year 2000 and by India on 31 st December, 2005. Thereafter, leprosy services in India have been integrated with General Health-Care System resulting in reduced focus and funds. Sustaining the gains made so far in controlling leprosy is a big challenge and there is no time for complacency. Pockets of high endemicity with prevalence rate of > 1 still exist in many states. Our data from a tertiary care center indicates poor epidemiological control and ongoing disease transmission. To combat this, dermatologists all over India should continue to play a central role in capacity building and training of undergraduate and post-graduate students, medical officers, and field workers.

Cutaneous sarcoidosis presents with a wide range of clinical presentations. An uncommon cutaneous manifestation is infiltration of old cutaneous scars with non-caseating granulomas known as scar sarcoidosis. Most of the patients with this clinical entity have other systemic manifestations, particularly pulmonary changes. We report a case of a 50 years old man, presenting with cutaneous sarcoidosis overlying scars of healed herpes zoster.

We report a case of chemical leucoderma (CL) in a 15-year-old girl, who developed patterned depigmentation at the back of both ear lobules after contact with plastic ear-ring stoppers made of polyvinyl chloride (PVC) after continuous use for 6-7 months. Patch test with Indian standard series and cosmetic series was negative after 48 h, but she refused patch testing for extended duration as the possibility of induced depigmentation at the test site was unacceptable to her. To the best of our knowledge, this is the first report of plastic ear-ring stopper induced CL.

Lupus vulgaris (LV) is a common form of cutaneous tuberculosis in India, mostly involving the lower half of the body. Facial involvement is uncommon. Untreated disease may lead to significant morbidity due to atrophic scarring, mutilation, and deformity. We report a case of multi-focal LV in a 10-year-old boy affecting the nose and cheek that resulted in perforation of the nasal septum, a rarely reported complication.