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Background The Indian ITS genotype VIII T. mentagrophytes population shows a high amount of different erg1 (ergosterol) mutants encoding for squalene epoxidase, which catalyzes the first step of ergosterol biosynthesis. Objectives Illumination of the implication of point mutations at position Ala448Thr in single and double erg1 T. mentagrophytes mutants because mutants of this type were abundantly found within the Indian fungal population. Methods Growth in fluconazole or terbinafine containing medium was analyzed using a microplate-laser-nephelometry (MLN)-based growth assay. Results Ala 448 Thr erg1 single mutants were terbinafine sensitive but about 50% of isolates showed an increased fluconazole resistance, whereas 95% of the double mutants (Phe 397 Leu, Ala 448Thr) demonstrated combined terbinafine and increased fluconazole resistance. Conclusion The new Indian T. mentagrophytes populations show several point mutations in erg1. Point mutations at position 397 were previously described and cause terbinafine resistance. A large part of the double mutants exhibit resistance to terbinafine and fluconazole, demonstrating a selective advantage of the combination of both mutations.

Background Nail psoriasis can pose diagnostic difficulties as there are several close clinical mimickers, including onychomycosis, lichen planus, and even squamous cell carcinoma. In view of differing treatment and prognostic implications, it is important to make an accurate diagnosis, especially in cases with isolated nail involvement. Methods Sixty consecutive patients with nail changes suggestive of psoriasis were included. A nail punch biopsy was performed and histopathological features were recorded for each case and percentage positivity of each individual feature was calculated. Periodic acid-Schiff (PAS) stain was performed to detect any fungal colonization or invasion. Results The most common clinical nail change was distal onycholysis (93.3% patients), followed by subungual hyperkeratosis (80%). On histological examination, the feature found most frequently was hyperkeratosis with parakeratosis (78% of biopsies), followed by neutrophilic infiltration of nail bed epithelium (63%), and hypergranulosis (58%). Unlike psoriasis elsewhere, nail bed and matrix histopathology revealed hypergranulosis in more than half of the cases. PAS stain was positive for fungal elements in 16 of 60 (26%) cases. Conclusion This study provides a careful, detailed histopathological description of nail unit psoriasis in a large number of cases. The histopathologic features described, which are somewhat different from psoriasis elsewhere on the body, are of utility to pathologists who may receive nail biopsy specimens of hyperkeratotic lesions.

Phacomatosis pigmentovascularis is characterized by coexistent extensive cutaneous vascular (capillary) and pigmentary anomalies. We describe a 2-month-old infant presenting with classic features of phacomatosis pigmentovascularis 2b (phacomatosis cesioflammea). He was also found to have hitherto unreported associations in the form of extensive venous anomalies presenting as striking abdominal wall varicosities and persistent left superior vena cava and natal tooth.

Precalcaneal congenital fibrolipomatous hamartoma (PCFH) is a benign under-reported condition of infancy characterized by the presence of soft nodules on precalcaneal plantar surface of the heel. These lesions are usually bilateral solitary and asymptomatic. We present a 2-month-old infant with solitary skin-colored nodules present on precalcaneal plantar aspect of bilateral heels.

Deposition of smegma in the subpreputial region is common in young uncircumcised boys. Although the term "smegma pearls" has been used colloquially for this entity, there is an apparent lack of reference to smegma pearls and their characteristics in the extant scientific literature. We present a series of six Indian boys with smegma pearls and discuss their possible origin, course, and management.

Background Leishmaniasis is a protozoal disease caused by species of Leishmania. Mucocutaneous leishmaniasis (MCL) involves the skin and mucosa. India is endemic for species such as Leishmania donovani and Leishmania major, which are responsible for visceral and cutaneous leishmaniasis, respectively. Although MCL has been reported from India previously, the implicated pathogen was identified as L. donovani in only one case. Case report A 55-year-old man presented with a nasal ulcer of four years' duration. He had been treated for borderline lepromatous (BL) leprosy 25 years earlier. Differential diagnoses of MCL, lupus vulgaris, and subcutaneous mycosis were considered. Leishman–Donovan bodies were seen on tissue imprints, and histopathology showed epidermal thinning with loss of appendages and dense pandermal infiltrate. Polymerase chain reaction was positive for L. donovani-specific DNA amplification. A diagnosis of MCL with treated BL leprosy was made. The patient was treated with sodium stibogluconate and achieved complete healing of the ulcer. Conclusions The coexistence of manifestations of disease from opposite ends of the spectrum (a hyperergic form of leishmaniasis with an anergic form of leprosy) is difficult to explain. However, the development of MCL after the cure of BL leprosy may reflect the loss of the inhibitory effect of Mycobacterium leprae antigen on interferon-γ production, and delayed persistence and the gradual clearance of the antigen from the body may account for the 20-year time lag. Further research centered on the immunological interactions between leishmaniasis and leprosy is warranted, particularly with respect to different Leishmania species.

Lichen planus (LP) is infrequently seen in children and the clinical presentation is often atypical. We conducted a retrospective analysis of clinical features and treatment response in childhood LP to date. The clinical profile and treatment response data of patients younger than 14 years old with LP (entered in a predesigned pro forma study) from January 1997 to June 2011 were analyzed. The treatment was administered according to a predetermined departmental protocol and was comprised of topical steroids with or without oral dapsone or corticosteroids. Patients were evaluated for response, adverse effects, and relapse. The study population consisted of 316 children (166 boys, 150 girls), or 18.7% of the total registered patients in the LP clinic. The mean age was 10.28 years (range 2-14 years). Cutaneous lesions were seen in 96.2%. Involvement of the oral mucosa was detected in 18%, nails in 13.9%, scalp in 8.2%, and genitalia in 4.4%. Classic LP was most prevalent (53.8%), followed by eruptive (16.5%), hypertrophic (8.2%), linear (6.9%), and lichen planopilaris (6.3%). LP pigmentosus, annular, and atrophic variants were encountered infrequently. Topical corticosteroids were the most common treatment used in 69.5% of patients, 28.8% of whom had excellent response at 6 months, although 38.8% failed to follow up. Dapsone was prescribed in 20% and systemic steroids in 9.8% of patients. We report the largest series to date of LP in childhood, with a more varied clinical presentation than in previous series. The course and response to treatment were similar to those in adults.

Hypomelanosis of Ito and naevoid hypertrichosis are both uncommon disorders and their coexistence in the same patient is rarely described. Most previously reported patients, in addition to cutaneous lesions, had multiple neurological, musculoskeletal and other organ system involvements. We present the case of a 3-year-old girl with these two naevoid disorders at sites completely exclusive of each other and without any severe associated defects.

Oral lichen planus (OLP) is a common disease of the oral mucosa with worldwide distribution and overall prevalence of 0.5-2.2%. Its etiology remains unclear, although the role of autoimmunity is supported by its association with other autoimmune diseases and the presence of auto-cytotoxic T cell clones in the lesions. Although many options for treating symptomatic OLP are available, no therapy is curative. This trial compared treatments with topical tacrolimus 0.1% ointment and topical clobetasol propionate 0.05% ointment. Forty patients with histologically proven symptomatic OLP were divided into two groups of 20 to receive clobetasol propionate (0.05%) ointment or tacrolimus (0.1%) ointment for eight weeks. Follow-up for all patients included three visits during the treatment course and one post-treatment visit. At each visit, objective improvement in the lesions was assessed by two independent investigators. The primary outcome measure was defined as the percentage of patients attaining complete response at eight weeks. Secondary outcome measures were the percentages of patients attaining complete or partial response at 8 and 12 weeks. Patient-observed improvement was evaluated at each visit. Demographic parameters and pretreatment disease characteristics were comparable between the groups. The mean net clinical score (NCS) declined progressively from baseline at each follow-up visit in both groups. In the clobetasol group, the mean NCS declined from 8.00 ± 2.65 at baseline to 2.00 ± 1.49 at 12 weeks. In the tacrolimus group, the mean NCS declined from 7.78 ± 3.25 at baseline to 1.31 ± 1.06 at 12 weeks. At each visit, the decline in mean NCS from baseline was statistically significant (P 0.05). No severe adverse events were reported. Tacrolimus 0.1% ointment is an effective alternative to topical steroid and may be considered as a first-line therapy in OLP.

Background Mycobacterial isolation from cutaneous tuberculosis on Lowenstein–Jensen (L–J) medium has been reported to be low. The radiometric BACTEC 460 TB culture system (BACTEC system) has shown better isolation rates in pulmonary tuberculosis. There has been a progressive increase in the prevalence of multidrug resistance in pulmonary tuberculosis, but similar studies are lacking for cutaneous tuberculosis. Therefore, this study was undertaken to compare mycobacterial isolation on conventional L–J medium vs. the BACTEC system, and to determine the prevalence of multidrug resistance in cutaneous tuberculosis. Methods Thirty-five untreated, clinically diagnosed, and histopathologically documented patients with cutaneous tuberculosis constituted the study material. Lesional skin biopsy specimens were cultured on both L–J medium and the BACTEC system. The isolates obtained were identified and subjected to sensitivity to rifampicin, isoniazid, ethambutol, and streptomycin using the BACTEC system. Results Twenty-six mycobacterial isolates were recovered from 35 patients. Nine isolates (25.7%) grew on L–J medium after a mean period of 31.5 days, and 22 (62.8%) on the BACTEC system in 17.3 days. All of the isolates were identified as Mycobacterium tuberculosis. Drug susceptibility testing demonstrated 12 isolates to be resistant, seven multidrug resistant. Discussion The BACTEC system demonstrated an improved mycobacterial isolation rate and substantially reduced detection time when compared with L–J medium. The combined isolation rate on both media was 74.3% (26/35), greater than that of either used separately. Drug resistance was observed in 46.2% of isolates. Conclusion Radiometric liquid culture medium together with conventional L–J medium may be recommended in practice to enable the institution of appropriate antituberculous therapy modifications in drug-resistant cases of cutaneous tuberculosis.

A 10-year-old immunocompetent boy presented with multiple, verrucous, disseminated pheohyphomycotic lesions caused by Exophiala spinifera. The patient was not responsive to combination antifungal therapy (itraconazole, terbinafine, fluconazole) and cryotherapy. As antifungal susceptibility is known to be variable for Exophiala spinifera, in vitro sensitivity testing is recommended before medical treatment. This article reviews, in brief, all cases documented so far in the English literature.

Two cases of linear nevus sebaceus syndrome (LNSS) are described in which ipsilateral facial nevus of Jadassohn was associated with complex ocular choristoma. One patient also had scleral osteomas, a rare occurrence in LNSS.

A rare case of a child with multiple keratoacanthoma (KA) on the lower half of the body successfully treated with topical and intralesional 5-fluorouracil (5FU) is described to confirm the therapeutic efficacy of 5FU in such cases.

Treatment of perniosis with topical nitroglycerin ointment is reported in a 6-month-old boy.

Cutaneous mosaicism has always been an intriguing subject. A 15-year-old boy presented to us with a unilateral band of lesions of pityriasis rosea and lichen striatus. The case is discussed in the light of the concept of genetic mosaicism.