The Aestheticians Journal August'23 issue

Platelet-Rich Plasma in Non-Healing

Diabetic Foot Ulcer : A Case Report

Genital Haemangioma with Ulceration: A Case Report

Tattoo Reaction: A Case Report

Combined Treatment with Isotretinoin, Salicylic Acid Peels and CO2 Laser for Acne Grade 3: A Case Report

Reticular Erythematous Mucinosis or Lupus

Erythematosus Tumidus : A Diagnostic Dilemma!

Glow Up for a Better Appearance

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Published for the period of August - 2023

Good skin care and adopting a healthy lifestyle are key factors in maintaining the appearance and health of our skin. Healthy skin always helps delay natural aging and prevent various skin problems. Establishing a regular skincare routine tailored to our skin type can make a significant difference in achieving and maintaining healthy, radiant skin. Our body’s largest organ is our skin and it performs a variety of important and complex functions from regulating our body temperature to protecting against germs. The skin barrier, which is primarily composed of lipids, plays a crucial role in protecting our skin from external elements and maintaining its moisture balance. Nourishing and maintaining a healthy skin barrier is essential for all skin types.

It's important to recognize that everyone's skin is unique, and different skin types have different needs. Oily skin, for example, requires products that provide hydration without clogging pores or triggering breakouts. A gentle, foaming cleanser can effectively remove dirt, excess oil, and impurities, while a lightweight, oil-free, and non-comedogenic moisturizer can provide the necessary hydration for oily skin.

Achieving radiant, healthy-looking skin and a glow-up is a personal journey, and there's no one-size-fits-all approach. It's important to focus on self-care, take small steps, and be consistent in our skincare routine. By doing so, we can enhance our natural beauty and radiance while feeling good about ourselves. Remember to also consider other lifestyle factors that can contribute to skin health, such as eating a balanced diet, staying hydrated, protecting our skin from the sun, managing stress levels, and getting enough sleep. All of these factors play a role in overall skin health and appearance.

In this issue we have a clinical articles on Platelet-Rich Plasma in Non-Healing Diabetic Foot Ulcer, Combined Treatment for Acne Grade 3, Granulomatous Tattoo Reaction, Genital Haemangioma with Ulceration, Reticular Erythematous Mucinosis or Lupus Erythematosus Tumidus : A Diagnostic Dilemma!

HOPE YOU HAVE A GREAT READ

Thanks & Cheers

- Dom Daniel Executive Editor & Publisher

Platelet-Rich Plasma in Non-Healing Diabetic Foot

Ulcer : A Case Report

Dr. Kinnor Das, MBBS, MD (Dermatology, Venereology and Leprosy)

Granulomatous Tattoo Reaction: A Case Report

Dr. Anuja A. Sutar, Resident

Dr. Ashish V. Naik, Assistant Professor

Dr. Anamika G. Wagh, Resident

Dr. Ashwinikumar J. Tripathi, Resident

Dr. Vishal A. Indurkar, Professor & Head

Combined Treatment with Isotretinoin, Salicylic Acid

Peels and CO2 Laser for Acne Grade 3: A Case Report

Dr. Nitika Nijhara, MBBS, MD (Dermatology)

Genital Haemangioma with Ulceration: A Case Report

Dr. Ch. Saritha, DDVL

Reticular Erythematous Mucinosis or Lupus

Erythematosus Tumidus : A Diagnostic Dilemma!

Dr. Priyanka Thakur, Junior Resident

Dr. Reena Sharma, Assistant professor

Dr. K . S. Mehta, Professor and Head

Dr. P. S. Chauhan, Associate Professor

Dr. Anju Lath, Assistant Professor

Dr. Anuj Sharma, Assistant Professor

Dr. Sujaya Manvi, Senior Resident

Dr. Amisha, Junior Resident

August

Haemangioma Ulceration: Report develops an ulcer or break in the surface layer the or mucous membrane. This can happen when orhaemangiomabecomeslarge located an that subjecttotraumaorpressure. Genital haemangioma can vary size, shape, location anditcanbeeithersuperficial singledeep.Theycanappearasa lumpormultiplelumpsandtheycanbe orpurple in color. It relatively rarecondition,but affect both males and females, with higher incidence females. They may be asymptomatic associated with pain, bleeding andinfection.Thecauseofgenital haemangioma is not well understood, but thought to be a congenital disorder of abnormal proliferation of bloodvessels.Ulceration a complication that can occur the andlocationItthehaemangioma. toshowscharacteristicssimilar neoplasm in true sense that consist of epithelial cells which continuously being dividing spreading while its multiplication there are new vessel channel is being formed. typically

their overtime. Another type haemangioma is the "cavernous haemangioma," which made up of larger blood vessels called cavernous vessels often located internal organs such as the liver, brain spinalcord. Genital haemangioma with ulceration a condition that occurs when a benign tumour build up of blood vessels the genitals,

Dr.PriyankaThakur DepartmentResidentDepartmentofDVL,DrRajendraPrasadGovernment MedicalCollege,Tanda,Kangra, HimachalPradesh

11TH WORLD CONGRESS

THE

It is with great enthusiasm and pleasure to proudly announce the 11th annual meeting of the Dermatologic & Aesthetic Surgery International League (DASIL) to take place in Bangkok this year, from October 25 - 27, 2023.

As president for the DASIL 2023 meeting, I am reaffiming the goals of DASIL to create a global community for the open exchange of knowledge and innovation by physicians specializing in Dermatologic & Aesthetic Surgery.

The DASIL 2023 curriculum will offer outstanding symposia, workshops and live patient demonstrations. Dasil will aslo continue in the tradition of creating networking opportunities among physicians and industry through numerous planned social events that will take place during the course of the meetings.

We welcome all of our colleagues and are looking forward to seeing you at DASIL 2023 in Bangkok

It promises to be one of the most prominent and educational conferences in 2023, and an opportunity to remember.

Tatjana Pavicic, MD DASIL PRESIDENT

BANGKOK WELCOMES YOU

DASIL (The Dermatologic & Aesthetic Surgery International League) is a worldwide organization with a unique and innovative mission: to bring the latest academic advancements in Clinical, Surgical, and Aesthetic Dermatology all over the world.

To accomplish this goal, DASIL members integrate a Faculty of dozens well known experts from more than 80 countries, whom altruistically contribute with their time.

Atchima Suwanchinda, MD DASIL WORLD CONGRESS PRESIDENT

WWW.DASIL.ORG

DASIL is a true non-profit international dermatology and dermatologic surgery organization. We pride ourselves on the openness of the group, the transparancy of our activities, and abiding by our mission of Mentors Teaching Mentors — as we ensure that dermatology and dermatologic surgery are practiced and taught at the highest of levels. Our initiatives, set out by our members, continue to inspire and bring new members into the organization — which is what teaching and education is all about. We encourage everyone to join DASIL and to become part of the best dermatology group in the world.

So, plan on attending DASIL Bangkok 2023 — we look forward to welcoming the world to this outstanding Congress.

The Aestheticians Journal and Paradigm Infocom Group are the sole and exclusive booking agency in India for Drs from India for DASIL Bangkok' 2023 For Bookings Contact: + 91 8779515551

INTERNATIONAL CONGRESS OF DERMATOLOGY, AESTHETICS AND SURGICAL TECHNIQUES.

Editorial Board

Dr. Kinnor Das MBBS, MD (Dermatology, Venereology and Leprosy) Consultant Dermatologist, Apollo Clinic Silchar, Assam, India

Dr. Nitika Nijhara MBBS, MD (DERMATOLOGY) Visiting Consultant BLK-MAX Super Speciality Hospital, New Delhi Consultant-Fortitude Skin and Hair Clinic, Dermaworld Skin and Hair Clinic, New Delhi

Dr. Ch. Saritha DDVL Consultant Dermatologist Vishwa Skin Clinic Siddipet, Telangana

Dr. Priyanka Thakur Junior Resident

Dr. Reena Sharma Assistant professor

Dr. K . S. Mehta Professor and Head

Dr. P. S. Chauhan Associate professor

Dr. Anju Lath Assistant Professor

Dr. Anuj Sharma Assistant professor

Dr. Sujaya Manvi Senior Resident

Dr. Amisha Junior Resident Dr. Rohit Negi Junior Resident Department of DVL, Dr Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh

Dr. Anuja A. Sutar Resident Dermatology Department of Dermatology, DVVPFs Medical College & Hospital, Ahmednagar

Dr. Ashish V. Naik Assistant Professor Department of Surgery, DVVPFs Medical College & Hospital, Ahmednagar

Dr. Anamika G. Wagh Resident Dermatology Department of Dermatology, DVVPFs Medical College & Hospital, Ahmednagar

Dr. Ashwinikumar J. Tripathi Resident Dermatology Department of Dermatology, DVVPFs Medical College & Hospital, Ahmednagar

Dr. Vishal A. Indurkar Professor & Head Department of Dermatology, DVVPFs Medical College & Hospital, Ahmednagar

Platelet-Rich Plasma in Non-Healing Diabetic Foot Ulcer : A Case Report

Dr. Kinnor Das

MBBS, MD (Dermatology, Venereology and Leprosy)

Consultant Dermatologist, Apollo Clinic Silchar

Assam, India

Introduction

Diabetic foot ulcer (DFU) is one of the most costly and devastating complications of diabetes mellitus, affecting around 15% of diabetic patients during their lifetime. It is the most prevalent and harmful diabetes side effect and is responsible for a significant percentage of diabetes-related hospitalizations. A diabetic foot ulcer can lead to severe complications, including preventable amputations and even mortality, particularly if they become infected or fail to heal properly. Effective management of diabetic foot ulcers is crucial, and early intervention can significantly reduce the severity of these complications.1, 2

A non-healing diabetic foot ulcer can be a major source of morbidity and disability for affected individuals. A nonhealing diabetic foot ulcer is a type of wound that is characterized by a breakdown of the skin and underlying tissue on the foot.2 A diabetic ulcer often develops in three stages called a callus

(which forms as a result of neuropathy), deformity of the foot and sensory loss that causes trauma. Finally, the trauma caused by the callus induces subcutaneous bleeding until it erodes and becomes an ulcer.3 People with diabetes are at a higher risk of developing foot ulcers due to a combination of factors, such as peripheral neuropathy (loss of sensation in the feet), peripheral vascular disease (poor blood flow to the feet), poorly controlled blood sugar levels and sometimes due to neuropathy (nerve damage). These factors make it difficult for the ulcers to heal and can also increase the risk of amputation.2

There are several risk factors associated with foot ulcers in patients with diabetes, including previous lower extremity amputation, history of a foot ulcer, anatomic foot deformity, peripheral vascular disease, diabetic nephropathy in those on dialysis, poor glycemic control, and smoking. These risk factors can increase the likelihood

of developing foot ulcers in patients with diabetes. Patients with one or more of these risk factors should be monitored closely for the development of foot ulcers, and appropriate preventive measures should be taken to minimize the risk of ulceration. Regular foot exams, patient education about proper foot care, and appropriate medical management of underlying conditions such as poor glycemic control and peripheral vascular disease are all important components of preventing foot ulcers in patients with diabetes.4 Both retrospective and prospective investigations have demonstrated that increased plantar pressure causes many plantar ulcers to form in diabetic patients and that ulceration frequently precedes lower extremity amputation.5

Case report

A 72-year-old, male patient presented to our outpatient department with non-healing ulceration over the right heel and calf for five months. He had a medical history of uncontrolled type 2 diabetes mellitus and was on oral hypoglycaemic medicines and subcutaneous insulin for 24 years. On examination the edges of ulcers were firm, and the floor of ulcer was covered with purulent discharge. The temperature of surrounding skin was bit elevated and the surrounding skin was taught. There was no tenderness though. Regional lymph nodes were palpable and tender. The dorsalis pedis artery pulsation of right

feet was feeble. Some basic laboratory and radiographic investigations were conducted. The serum creatinine was slightly raised. X-ray didn’t reveal any bony abnormality. On the initial day patient was given basic wound care by changing daily dressing and wound debridement along with some general antibiotics. The conservative treatment did not show a satisfactory result. Platelet-rich plasma (PRP) therapy was suggested looking at the condition. Few other therapies like wound care, systemic medication along with PRP treatment was given as well. The patient was kept on regular follow up to check the reduction in wound size and to avoid any adversity of the wound. PRP was injected at the base and the margins of the ulcer at an interval of two weeks. All diabetic foot ulcers responded positively with no adverse reaction. The ulcers were healed within 3 months of treatment. No ulceration or swelling was found with complete skin epithelialisation.

Before treatment

After 3 months of treatment

Figure 1: Ulcerated surface along with swollen border and mild tenderness on the inner skin of the right calf

Before treatment

After 3 months of treatment

Figure 2: Non–healing ulceration, on the right heel

Diagnosis of diabetic ulcer

Although the diagnosis of a diabetic foot ulcer is straight forward, a thorough evaluation of the patient's medical history and a physical examination of the feet should be done.6 The history should cover the onset and duration of the condition, glycaemic control, other preexisting problems of diabetes, such as sensory neuropathy, history of peripheral vascular disease, callus formation, past ulcers, prior treatments, and the results. The location of the ulcer, any anatomical anomalies, symptoms of vascular insufficiency, and the peripheral pulses of the foot are all examined during the clinical examination.3

With Semmes-Weinstein monofilament, diabetic peripheral neuropathy can be evaluated. For the diagnosis of peripheral neuropathy and unusual presentations, nerve and skin biopsy are additional means of examination. Plain X-rays are used to assess osteomyelitis or any other bone involvement. The probeto-bone - test can be done that involves using a sterile metal probe to probe the ulcer. The probability of osteomyelitis is minimal after a negative test in an outpatient or lowrisk scenario. After a positive test in a high-risk or inpatient environment, the chance of osteomyelitis is high. 3, 6

Treatment

The primary goal of treatment for non-healing diabetic foot ulcers is to promote healing and prevent infection, which may include off-loading or redistributing weight from the affected area, wound

care and debridement, antibiotics to treat or prevent infection, treatment of underlying conditions such as diabetes or peripheral vascular disease and regular follow-up with a wound care specialist or foot care specialist.2 The management of diabetic foot ulcers typically requires a multidisciplinary team approach, as a holistic approach to wound management is necessary to address the various factors that contribute to the development and progression of diabetic foot ulcers. Blood sugar control, wound debridement, advanced dressings, and offloading modalities are generally considered key components of diabetic foot ulcer management. In some cases, surgery may also be necessary to promote healing and prevent the recurrence of chronic ulcers. Additionally, adjunct therapies such as hyperbaric oxygen therapy, electrical stimulation, negative pressure wound therapy, bioengineered skin, and growth factors may be used to expedite the healing process.1

It appears that people with diabetes must practise the right self-care behaviours in order to prevent diabetic foot ulcers, including wearing offloading footwear, exercising, eating a healthy diet, checking their blood sugar levels, taking medicine, and taking care of their feet.7

Patient education and regular foot care are also essential in preventing diabetic foot ulcers and their complications. Patients should be educated

about proper foot care, including daily inspections, proper footwear and foot hygiene. They should also be advised to seek prompt medical attention for any signs of foot injury or infection. Overall, a comprehensive and individualized approach to diabetic foot ulcer management is necessary to achieve optimal outcomes.1 Wound care typically involves cleaning the wound and removing any dead tissue, as well as controlling any infection that may be present. Topical or oral antibiotics may be prescribed, and a dressing may be applied to the wound to help promote healing.2, 3 Off-loading of the affected limb is also important in the management of nonhealing diabetic foot ulcers. This may involve the use of special shoes, inserts, or bracing to redistribute weight and pressure away from the ulcer.2 Additionally, blood sugar levels should be well controlled before and during the treatment.3

Treatment of a non-healing diabetic foot ulcer with platelet-rich plasma (PRP) is a minimally invasive option that utilizes a patient's own blood platelets to promote healing and tissue regeneration. The growth factors in the PRP help to reduce inflammation, promote blood flow, and stimulate the growth of new cells and tissue, which can aid in the healing process and reduce the risk of amputation in patients with diabetic foot ulcers. These growth factors have a crucial role in regulating the recruitment, proliferation,

and production of extracellular matrix by mesenchymal cells during the healing process. A polypeptide called plateletderived angiogenesis factor is known to promote endothelial cell migration, which in turn promotes the formation of new capillaries.8 PRP has been shown to be effective in promoting healing in nonhealing diabetic foot ulcers. It can be used in conjunction with other treatments such as off-loading, wound care and antibiotics to treat or prevent infection.8 It has been found to improve wound healing rate and reduce wound size, compared to standard wound care alone.9 Platelets are rich in growth and healing factors an injured individual can get back to a pain-free life in four to six weeks. The use of PRP could help a patient avoid joint replacement surgery, and potentially back surgery. The main advantages of PRP is use of autologous blood, which eliminates the risk of allergic reactions or rejection and low cost and limited resource requirement in its preparation and lack of manpower resources.9, 10

Activated platelet-rich plasma (aPRP) is a treatment option that has been studied for its potential role in the treatment of diabetic foot ulcers. The treatment process is similar to traditional PRP, but it involves activating the platelets before they are applied to the wound.

Activation can be done using various methods such as thrombin or calcium chloride.9

Activation of platelets leads to the release of more growth factors and enzymes, which

can enhance the healing process of the wound. aPRP has been shown to improve wound healing rate and reduce wound size in some studies.9, 10 The treatment may be repeated multiple times, depending on the severity of the ulcer and the patient's response to treatment.9

It is important to consult with a healthcare professional who is trained and experienced in the use of PRP to determine if this treatment is right for the patient and to ensure safe and appropriate administration.

Figure 3 ulcer; HB PAD, per Discussio

Discussion

3: Algorithm BO, hyperba ripheral arter on lcer is a pred ulcers won' on raises a v op a major a economical ends a range betes, early managemen the overall q ses of diabe ed to be hig o elevated p ns that can s fload, the hea mall blood ve

m for prevent aric oxygen rial disease; disposing fa 't get well, variety of p amputation. T l use of heal of strategies recognition nt. Effective quality of lif

ion and car ; MRI, mag PTB, probe ctor in abou and up to 2 ossible poin Thus, develo thcare resou for managi and referra manageme e for diabeti

e of the diab gnetic resona to bone; Tc ut 80% of di 8% could d nts where an ping diabet rces. 2 The N ing diabetic l of suspect nt can not o c patients.1

Figure 3 : Algorithm for prevention and care of the diabetic foot. ABI, Ankle-brachial index; DFU, diabetic foot ulcer; HBO, hyperbaric oxygen; MRI, magnetic resonance imaging; NPWT, negative pressure wound therapy; PAD, peripheral arterial disease; PTB, probe to bone; TcPO2, transcutaneous oxygen pressure; XR, radiography.2

A foot ul of these amputatio could sto the most recomme with diab infection improve The caus discovere linked to condition taken off of the sm lead

and

etic foot ulc gher local fo plantar press seriously dam aling proces essels in the ventually,

ers are num ot pressures sure. Claw-t age the str s may be ha e legs and fe

merous. 3 On s. There are oe deformit ructure of th mpered.5 An et, which is develop.3

betic foot. A ance imagin PO2, transcu iabetes-relate emand an interventio tic foot care National Ins foot ulcers, ted diabetic nly reduce t ne of the p e numerous ties and Cha he foot. Acco nother reaso s also seen i

BI, Ankle-b g; NPWT, n utaneous ox d lower ext amputation. n based on recommend titute for He including re foot ulcers, the risk of a precursors in structural is arcot neuroa ording to re on for diabeti n diabetes p

A foot ulcer is a predisposing factor in about 80% of diabetesrelated lower extremity amputations. At least 25% of these ulcers won't get well, and up to 28% could demand an amputation.2 This process from foot ulcer to amputation raises a variety of possible points where an intervention based on evidencebased recommendations could stop a major amputation. Thus, developing diabetic foot care recommendations is essential to guaranteeing the most economical use of healthcare resources.2 The National Institute for Health and Care Excellence (NICE) recommends a range of strategies

rachial inde negative pre ygen pressu remity amp 2 This proce evidence-ba ations is es ealth and Ca egular foot a , and approp mputations the forma sues with th arthropathy esearch, if th ic foot infec patients. Vas

x; DFU, di ssure woun re; XR, radi utations. At ss from fo ased recomm sential to gu are Excellen ssessments f riate woun and mortali tion of foo he foot that are the mos he ulcerated tions is athe cular compr

ography. ot m d s r

Platelet-Rich Plasma in Non-Healing Diabetic Foot Ulcer : A Case Report

for managing diabetic foot ulcers, including regular foot assessments for patients with diabetes, early recognition and referral of suspected diabetic foot ulcers, and appropriate wound care and infection management. Effective management can not only reduce the risk of amputations and mortality but also improve the overall quality of life for diabetic patients.1

The causes of diabetic foot ulcers are numerous.3 One of the precursors in the formation of foot ulcers is discovered to be higher local foot pressures. There are numerous structural issues with the foot that have been linked to elevated plantar pressure. Claw-toe deformities and Charcot neuroarthropathy are the most frequent conditions that can seriously damage the structure of the foot. According to research, if the ulcerated foot is not taken offload, the healing process may be hampered.5 Another reason for diabetic foot infections is atherosclerosis of the small blood vessels in the legs and feet, which is also seen in diabetes patients. Vascular compromise can lead to necrosis and eventually, gangrene can develop.3

PRP is a non-operative; permanent solution utilizing the body’s natural healing process. In the case of nonhealing diabetic foot ulcers, PRP can be injected below and around the ulcers at a definite interval.8 These concentrated platelets contain platelet-derived growth factors, fibroblast

growth factor, vascular endothelial growth factor, epidermal growth factor and transforming growth factor and other cytokines that promote healing and tissue regeneration.8,9

Several studies found that the use of PRP in the treatment of diabetic foot ulcers was associated with a significant reduction in wound size and an increase in wound healing rate. Factors such as the severity of the ulcer, the patient's overall health, and the presence of underlying conditions may affect the outcome of treatment.9

Conclusion

A non-healing diabetic foot ulcer is a very complicated condition seen in uncontrolled diabetic patients. A multidisciplinary approach to therapy is necessary to ensure the successful and rapid healing of diabetic foot ulcers. Wound debridement and the use of advanced dressings are necessary to facilitate healing and prevent infection. Surgery or some advanced therapies may be necessary in some cases to promote healing and prevent the recurrence of chronic ulcers. Overall, a rational and multidisciplinary approach to therapy is necessary to reduce the high morbidity and risk of serious complications resulting from diabetic foot ulcers. By utilizing these management strategies whenever feasible, the risk of amputation and other serious complications can be reduced, and patients can achieve optimal outcomes. PRP has been studied as a

treatment option for diabetic foot ulcers and has shown promising results. PRP is believed to work by promoting the formation of new blood vessels and the growth of new tissue, which can help to speed up the healing process. It is also thought to have antiinflammatory and antioxidant properties that can help to reduce inflammation and prevent further damage to the wound. It is crucial to note that PRP should be used as adjunctive therapy, and not as a replacement for standard wound care and management of underlying diabetes.

Reference

1. Yazdanpanah L, Nasiri M, Adarvishi S. Literature review on the management of diabetic foot ulcer. World J Diabetes. 2015 Feb 15;6(1):37-53. doi: 10.4239/wjd. v6.i1.37. PMID: 25685277; PMCID: PMC4317316.

2. Hingorani, Anil; LaMuraglia, Glenn M.; Henke, Peter; Meissner, Mark H.; Loretz, Lorraine; Zinszer, Kathya M.; Driver, Vickie R.; Frykberg, Robert; Carman, Teresa L.; Marston, William; Mills, Joseph L.; Murad, Mohammad Hassan (2016). The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. Journal of Vascular Surgery, 63(2), 3S–21S. doi:10.1016/j. jvs.2015.10.003.

3. Oliver TI, Mutluoglu M. Diabetic Foot Ulcer. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https:// www.ncbi.nlm.nih.gov/books/ NBK537328/

4. Aumiller, Wade D. PhD; Dollahite, Harry Anderson MD. Pathogenesis and management of diabetic foot ulcers. JAAPA 28(5):p 28-34, May 2015. | DOI: 10.1097/01. JAA.0000464276.44117.b1

5. Peter R. Cavanagh; Sicco A. Bus (2010). Off-loading the diabetic foot for ulcer prevention and healing. , 52(3-supp-S), 0–43. doi:10.1016/j. jvs.2010.06.007

6. Amin, N., & Doupis, J. (2016). Diabetic foot disease: From the evaluation of the "foot at risk" to the novel diabetic ulcer treatment modalities. World journal of diabetes, 7(7), 153–164. https:// doi.org/10.4239/wjd.v7.i7.153.

7. Joseph Ngmenesegre Suglo, Kirsty Winkley, Jackie Sturt, "Prevention and Management of Diabetes-Related Foot Ulcers through Informal Caregiver Involvement: A Systematic Review", Journal of Diabetes Research, vol. 2022, Article ID 9007813, 12 pages, 2022. https://doi. org/10.1155/2022/9007813

8. Goda, Asser A. MDa,; Metwally, Mohamedb; Ewada, Ashrafb; Ewees, Hossama. Platelet-rich plasma for the treatment of diabetic foot ulcer: a randomized, doubleblind study. The Egyptian Journal of Surgery 37(2):p 178-184, Apr–Jun 2018. | DOI: 10.4103/ejs. ejs_139_17

9. Del Pino-Sedeño T, TrujilloMartín MM, Andia I, AragónSánchez J, Herrera-Ramos E, Iruzubieta Barragán FJ, SerranoAguilar P. Platelet-rich plasma for the treatment of diabetic foot ulcers: A meta-analysis. Wound Repair Regen. 2019 Mar;27(2):170182. doi: 10.1111/wrr.12690. Epub 2018 Dec 21. PMID: 30575212.

10. Steed DL, Goslen JB, Holloway GA, Malone JM, Bunt TJ, Webster MW. Randomized prospective double-blind trial in healing chronic diabetic foot ulcers. CT-102 activated platelet supernatant, topical versus placebo. Diabetes Care. 1992 Nov;15(11):1598-604. doi: 10.2337/diacare.15.11.1598. PMID: 1468291.

Platelet-Rich Plasma in Non-Healing Diabetic Foot Ulcer : A Case Report

Granulomatous Tattoo Reaction: A Case Report

Resident Dermatology

Department of Dermatology, DVVPFs Medical College & Hospital, Ahmednagar

Assistant Professor

Department of Surgery, DVVPFs Medical College & Hospital, Ahmednagar

Resident Dermatology

Department of Dermatology, DVVPFs Medical College & Hospital, Ahmednagar

Resident Dermatology

Department of Dermatology, DVVPFs Medical College & Hospital, Ahmednagar

Abstract

Professor & Head

Department of Dermatology, DVVPFs Medical College & Hospital, Ahmednagar

Tattooing is a popular activity, secondary to growing interest of young generation for recent fashion trends, but recently it is also associated with increased cases of tattoo reactions too due to lack of awareness in general population and no strict supervision to prevent them in India. The most frequent skin reactions to tattoos are an acute inflammatory reaction, superficial to systemic infections, allergic contact dermatitis etc. We report a case, 21-year-old male presented with heart shaped firm well demarcated keratotic plaque, which was developed over heart shaped

tattoo area made with red ink. Histopathology confirmed the diagnosis of granulomatous tattoo reaction.

Keywords

Tattoo, Tattoo pigment, Tattoo granuloma

Introduction

Tattooing is an age old procedure that includes injecting the desired colour of ink pigment into the dermis. Most societies around the world have it, and it is getting more and more prevalent in developing nations. In addition, it is spreading more quickly among Indian rural youth because of their

Dr. Anuja A. Sutar

Dr. Ashish V. Naik

Dr. Anamika G. Wagh

Dr. Ashwinikumar J. Tripathi

Dr. Vishal A. Indurkar

growing interest for new fashion trends.

The Tahitian word "tattau," which meaning "to mark something," is the source of the English word tattoo.[1] Tattoos can be broadly categorised as either permanent (which lasts a lifetime) or temporary (which lasts for a few weeks). There are three different types of permanent tattooing: traumatic, cosmetic (decorative tattoos and permanent makeup), and medical/therapeutic.

[1] In dermatology, vitiligo is mostly treated by therapeutic tattooing. Young people enjoy getting cosmetic tattoos, which are mostly worn as decorative art. In India there are no laws governing these facilities, and the sterility of the procedures performed is in doubt. As a result, there are more unpleasant effects following tattooing. The most frequent skin reaction is a transient acute inflammatory reaction at the tattoo location, which manifests quickly and lasts a few days. Other reactions include systemic infections, allergic reactions, superficial and deep local infections, and skin conditions that are localised to the tattooed region, such as eczema, psoriasis, lichen planus and morphea.[1, 2]

Case Report

A 21-year-old male patient made a permanent tattoo of his name with green colored ink and a heart with red colored ink over left forearm. (Figure

1) After 4-months of tattoo he started itching and pain over red colored heart tattoo and gradually developed

elevated lesion. (Figure 2) On local examination, single 2 × 2 cm heart shaped firm well demarcated keratotic plaque over heart shaped tattoo area which was made with red ink while remainder tattoo made with green ink was unaffected. On palpation, it was indurated, non-tender and did not exude any fluid. All routine blood investigations including HbsAg, HCV and HIV were unremarkable. Then performed an excisional biopsy of lesion for histopathological examination by keeping tattoo granuloma as provisional diagnosis. Histopathology confirmed the clinical diagnosis of Granulomatous tattoo reaction, with following findings such as foci of palisading granulomas showing central necrobiosis and peripheral granulomatous infiltrate consisting of lymphocytes, histiocytes and foreign body giant cells. Granular tattoo material is seen interspersed within the granulomatous infiltrates. (Figure 3) On follow up after 3 weeks of surgical excision the excised area shows cosmetically acceptable outcome. (Figure 4)

Granulomatous Tattoo Reaction: A Case Report

Figure 1: Before granulomatous reaction

Figure 2: Granulomatous tattoo reaction

Figure 3: Histopathology showing granulomatous tattoo reaction

Figure 4: Post surgical excision

Granulomatous Tattoo Reaction: A Case Report

Discussion

Despite the fact that tattoos have been there for thousands of years, there use has been increased and have now become a fashion statement. The students between the age group of 18-25 have a 20%–25% frequency rate.[1]

According to numerous research, tattoo complications occur in 2%–3% of cases and can vary from infections to cancer.[1] The infection can be localised or systemic and can be caused by bacteria like methicillin-resistant Staphylococcus aureus, nontuberculous mycobacteria, viruses such as hepatitis B and C, HIV, and human papilloma virus.[2] The other side effect includes allergic contact dermatitis to several pigments and additives.[4-6]

The majority of inks are made up of water-based additives like formulants, dispersants, and preservatives along with nearly insoluble pigments.

The allergens linked to hypersensitive reactions in various inks are mercury salt in red, dichromate in green, cobalt in blue and cadmium in yellow ink. One of the previous research, about 53.9% patients had an allergy to red colour. Mercury has been substantially superseded by contemporary substitutes including siennaferric hydrate, cadmiumselenide, organic vegetable dyes, sandalwood, and brazilwood.[7, 8]

The dye particles other than the red dye are smaller in size and hence they are less likely to trigger an inflammatory

reaction. In the constrained red tattoo region, it is likely that the oil solvent used to blend tattoo ingredients could produce a synergistic granulomatous reaction.[9,10]

The use of acrylic paints by some of the tattooist may be the cause of the increased reactions among amateur tattoos that were done on the side of the road. It is quite challenging to identify the precise chemicals in action or the specific components of a given type of ink, particularly with the development of new mixes. There seems to be a general lack of knowledge regarding the dangers of toxic substances in tattoo ink.

The tattoo granuloma can be managed with either medical, surgical or laser modalities. In medical management for tattoo granuloma one can use potent topical or intralesional steroids, Allopurinol (it reduces the production of free radicals involved in granulomas formation), Tetracyclines (decreases the release of tumor necrosis factor alpha (TNF-a)) and Antimalarials (prevents granuloma formation by inhibiting antigen processing and presentation by antigen-presenting cells to CD4 T cells).[2,3]

In our case we have opted surgical excision with successful outcome.

Conclusion

We must understand the hazards associated with getting tattoos in potentially unsterile settings. Hence, in order to keep the enthusiasm of tattooing alive, the tattoo artists and fellow citizen must

be vigilant about the strict infection control measures that has to be followed at the time of tattooing.

References

1. Shashikumar BM, Harish MR, Shwetha B,Kavya M, Deepadarshan K, Phani HN. Hypersensitive reaction to tattoos:A growing menace in rural India. Indian J Dermatol 2017;62:291-6.

2. Valbuena MC, Franco VE, Sánchez L, Jiménez HD. Sarcoidal granulomatous reaction due to tattoos: report of two cases. An Bras Dermatol. 2017;92(5 Suppl 1):138-141. doi: 10.1590/abd18064841.20175860. PMID: 29267473; PMCID: PMC5726704.

3. Syed N, Indurkar V, Gosavi R, Gadekar M, Marwale J, Revanwar S, Chate A. Keratoacanthomatous Tattoo Reaction: A Case Report. VIMS Health Science Journal. 2018 Jun 13;5(2):85-7.

4. Incel Uysal, Pinar MD, Gurel, Mehmet Salih, Behzatoglu, Kemal MD. A Tattoo-Associated Complication: Foreign Body Granulomatous Reaction. The American Journal of Dermatopathology 38(12):p 936937, December 2016. | DOI: 10.1097/DAD.0000000000000570

5. Petrochko, Jameson, et al. "Tattoo-associated complications and related topics: A comprehensive review." International Journal of Academic Medicine, vol. 5, no. 1, Jan.-Apr. 2019, p. 19.

6. Madden J F. Reactions in tattoo. Arch Dermatol Syphilol 1939; 40: 256.

7. Andrea Bassi, PieroCampolmi, Giovanni Cannarozzo, Rossana Conti, Nicola Bruscino, Massimo Gola, Stefano Ermini, Daniela Massi, Silvia Moretti, "Tattoo-Associated

Skin Reaction: The Importance of an Early Diagnosis and Proper Treatment", BioMed Research International, vol. 2014, Article ID 354608, 7 pages, 2014. https://doi. org/10.1155/2014/354608

8. Sanghavi SA, Dongre AM, Khopkar US. Tattoo reactions-An epidemic on the surge: A report of 3 cases. Indian J Dermatol Venereol Leprol 2013;79:231-4.

9. Seok J, Choi SY, Kwon TR, Kim JH, Park KY, Li K, Kim HS, Kim BJ. Tattoo Granuloma Restricted to Red Dyes. Ann Dermatol. 2017 Dec;29(6):824-826. doi: 10.5021/ ad.2017.29.6.824. Epub 2017 Oct 30. PMID: 29200786; PMCID: PMC5705379.

10. Ravits H G. Allergic Tattoo Granuloma. Arch Dermatol. 1962;86 (3) :287–289. doi:10.1001 /archderm.1962.015900900

Granulomatous Tattoo Reaction: A Case

Common fatty acid contributes to temperature and pain sensitivity in psoriasis plaques

A common fatty acid found in the Western diet breaks down into compounds that contribute to increased temperature and pain but not itch sensitivity in psoriatic lesions. The finding could lead to better understanding of how lipids communicate with sensory neurons, and potentially to improved pain and sensitivity treatments for psoriasis patients. Linoleic acid is a fatty acid found in vegetable oils, nuts and seeds, and is one of the predominant fatty acids found in the Western diet. Metabolites from linoleic acid (the products formed when the body breaks it down through digestion) play a role in skin barrier function.

Researchers noticed high levels of two types of lipids derived from linoleic acid in psoriatic lesions. That led them to wonder whether the lipids might affect how sensory neurons in these lesions communicate. Researchers decided to investigate whether their presence could be related to the temperature or pain hypersensitivity that many psoriasis patients report. The research team used mass spectrometry to create lipid profiles of skin from psoriatic lesions. They focused on two types of linoleic acid-derived lipids, or oxylipids: 13-hydroxy-9,10-epoxy octadecenoate (9,13-EHL) and 9,10,13-trihydroxy-octadecenoate (9,10,13-THL). The first form, 9,13-EHL, can convert into the more stable 9,10,13THL form via interaction with certain enzymes.

The researchers found that while both forms bind to receptors on sensory neurons within the skin, the more stable form 9,10,13-THL had a longer lasting effect than 9,13-EHL. They also found that once the lipids bind to the neuronal receptor, they activate the neurons expressing TRPA1 and TRPV1 receptors that are involved in temperature and pain hypersensitivity, opening communications channels to the central nervous system. Interestingly, the lipids did not have any effect on itch.

It was surprising that these lipids could create hypersensitivity but not impact itch sensation, which is usually the most troublesome symptom associated with psoriasis. This most likely has to do with how the neuron is activated a mechanism they still haven't uncovered. Now that an association between linoleic acid and hypersensitivity to temperature and pain has been established, the researchers want to further explore exactly how this response is being created. They hope that the answers may lead to solutions that can relieve these symptoms in psoriasis patients.

They know that this lipid moves from one form to another, but don't yet know what causes that. They also know what protein the lipids are binding to, but not where the bond occurs. Answering these questions may hopefully lead to new therapies or dietary solutions for some psoriasis sufferers.

FDA adds safety-related information to its dermal filler webpage

Dermal fillers are a type of cosmetic treatment used to enhance and restore volume in the face and other areas of the body. They are typically injected under the skin to address various aesthetic concerns and to reduce the signs of aging. The primary purpose of dermal fillers is to plump up areas with lost volume, smooth out wrinkles and lines, and improve overall facial contours.

Recently, Food and Drug Administration updated its informational webpage on dermal fillers to reflect the risk of delayedonset inflammation near dermal filler treatment sites. Along with a list of common reactions such as bruising, redness, swelling, and pain, the webpage now includes language to inform the public and health care providers about reports of delayed-onset inflammation that have been reported to occur near the dermal filler treatment site following viral or bacterial illnesses or infections, vaccinations, or dental procedures. According to an FDA spokesperson, the update is based on several sources of information, including post marketing data from adverse event–reporting databases, such as the Manufacturer and User Facility Device Experience (MAUDE) for devices and the Vaccine Adverse Event Reporting System (VAERS) for vaccines, published literature, and recommendations from federal agencies and professional societies.

More specifically, the site was updated to include certain risks of using dermal fillers such as swelling and bruising as well as some less common risks such as inflammation swelling or redness near the dermal filler injection site following viral or bacterial illnesses or infections, vaccinations, or dental procedures. Other less common risks from dermal filler use listed on the website include bumps in or under the skin (nodules or granulomas) that may need to be treated with injections, oral antibiotics, or surgical removal; infection; open or draining wounds; a sore at the injection site; allergic reactions; or necrosis.

Meanwhile, rare risks from dermal filler use that have been reported to the FDA include severe allergic reactions (anaphylactic shock) that require immediate emergency medical assistance; migration (movement of filler material from the site of injection); leakage or rupture of the filler material at the injection site or through the skin (which may result from a tissue reaction or an infection); the formation of permanent hard nodules; and injury to the blood supply after an unintentional injection into a blood vessel, resulting in necrosis, vision abnormalities (including blindness), or stroke.

Combined Treatment with Isotretinoin, Salicylic Acid Peels and CO2 Laser for Acne Grade 3: A Case Report

Dr. Nitika Nijhara

MBBS, MD (DERMATOLOGY)

Visiting Consultant

BLK-MAX Super Speciality Hospital, New Delhi

Consultant-Fortitude Skin and Hair Clinic, Dermaworld Skin and Hair Clinic, New Delhi

Introduction

Acne is a common skin condition that affects millions of people worldwide. It is a disease of the pilosebaceous units, clinically characterized by seborrhea, comedones, papules, pustules, nodules and, in some cases, scarring.

1 It is a disorder of the skin caused by inflammation of the skin glands and hair follicles. Acne vulgaris is the most common type of acne, which occurs when hair follicles are blocked with dead skin cells, bacteria and oil (sebum).2,3,4

Nodulocystic acne is a severe form of acne that can cause nodules and cysts that typically resolve with scarring.1 Acne vulgaris can be graded using different grading systems. One of the grading systems used by Indian authors is a simple grading system that classifies acne vulgaris into four grades. Grade 1 includes comedones and occasional papules, grade 2 includes papules, comedones, and few pustules, grade 3 includes predominant pustules, nodules, abscesses and grade 4 includes mainly

cysts, abscesses, widespread scarring.1 Acne grade 3, also known as moderately severe or nodulocystic acne, is characterized by numerous papules and pustules, along with occasionally inflamed nodules. Lesions occur primarily on the face, but the back and chest may also be affected. It is more severe than grade 1 and grade 2. 5

The etiology of acne is multifactorial, with the hypersensitivity of the sebaceous glands to a normal circulating level of androgens being the primary cause. Environmental exposures are important exogenous factors in the etiologies of acne, which leads to a group of environmental factorsinduced acne. Research found that the occurrence of acne was strongly attributed to the exposure of skin in the natural environment, obesity and other built environment characteristics for transport. However, the correlation between environmental factors and acne has yet to be fully investigated.

Peels and CO2 Laser for Acne Grade 3: A Case Report

Other factors that can aggravate acne include P. acnes and inflammation, food with a high glycemic number like dairy products, junk food and chocolates, which cause insulin-like growth factors that stimulate follicular epidermal hyperproliferation. 5,6,7,8 Hormonal changes, particularly during puberty, can cause the sebaceous glands to enlarge and make more sebum, leading to acne. Other possible triggers of an acne flare-up include friction or pressure on the skin, certain medications and some cosmetic products. However, most of the biological reactions that trigger acne occur beneath the skin, not on the surface, so having dirty skin and poor hygiene is not a direct cause of acne.3

Acne vulgaris lesions are studied in two groups: noninflammatory (blackheads and whiteheads or comedones) and inflammatory (papules, pustules, nodules and cysts). Histologically, acne vulgaris is characterized by hyperkeratosis, follicular plugging and inflammation. The closed comedo can rupture and form a pustule. Inflammatory acne lesions are characterized by the presence of neutrophils, lymphocytes and macrophages. The inflammatory response is triggered by the release of pro-inflammatory cytokines, chemokines and other mediators. 9,10,11

Case Report

A 20-years-old male patient who has presented the complains of acne with the

painful comedones, papules, pustules, nodules and scars and the major involvement of cheeks. Patient history revealed he had acne since long time and still had this presentation. There was a strong family history of acne. After the physical examination and all the detailed history of his clinical presentation, considering his case to be grade 3 acne. After made the diagnosis of grade 3 acne, the oral treatment of isotretinoin 20mg was prescribed for 6 months along with salicylic acid peels 20% 4 sessions was done and 4 sessions of fractional CO2 laser was done. Asked patient to follow the daily skincare to avoid any side effects or skin complications. Combined treatment of these 3 showed significant result and it was really helped the patient to clear his acne and minimise scars. The pictures are taken before treatment and after the treatment effects on patient.

Diagnosis

The diagnosis of acne is based on the history and physical examination. It is always important to ask about the patient's medical history, including any medications they are taking and their family history of acne, the onset, duration, and progression of the acne, as well as any associated symptoms such as pain or itching. The physical examination will involve a thorough inspection of the skin to identify the type and

Combined Treatment with Isotretinoin, Salicylic Acid Peels and CO2 Laser for Acne Grade

Figure 1: acne with the painful comedones, papules, pustules, nodules and scars

severity of acne lesions. An acne grading system may be helpful in patient care. Acne grade 3 or nodulocystic acne, is characterized by numerous papules and pustules, along with occasionally inflamed nodules. Acne grade 3 primarily occurs on the face, but the back and chest may also be involved. The histopathology of acne is important for understanding the pathogenesis of the disease and for developing effective treatments.12,13,14,15,16

Limited information is available on the histopathology of acne grade 3. However, nodulocystic acne, which is a severe form of acne characterized by nodules and cysts that typically resolve with scarring, may be similar to acne grade 3. Histopathologically, noninflammatory lesions (comedones) are a kind of follicular retention cysts. These tiny cysts may consist of cornified cells, hair shafts, sebum, and bacteria. In early nonpustular lesions, telangiectasia is in the foreground and perifollicular and perivascular mixed type inflammation (lymphocytes, plasmocytes, macrophages, eosinophils, and polymorphonuclear leucocytes) draw attention. Abnormal keratinization, sebaceous gland hyperplasia, and inflammation are the main histopathological features of acne vulgaris. The severity of acne is correlated with the degree of inflammation and scarring can occur in severe cases of acne, particularly in nodulocystic acne.9

Treatment

Treatment options for acne depends on the severity of the condition. It may include prescription medications such as topical or oral antibiotics, isotretinoin or hormonal therapy, as well as overthe-counter treatments like benzoyl peroxide or salicylic acid. Mild acne can be treated with over-the-counter topical agents such as benzoyl peroxide, salicylic acid and topical retinoids. Topical antibiotics and medications with bacteriostatic and antiinflammatory properties are effective for treating mild to moderate acne. Moderate to severe acne may require prescription-strength topical or oral medications, such as antibiotics, hormonal therapy, isotretinoin, corticosteroids or procedures like chemical peels, lasers or combination of treatment. Acne treatment can take several weeks or months to show results and it may worsen before it gets better. 3,4,12,17

Topical treatment is usually ineffective for nodulocystic acne or grade 3 acne. So the treatment for acne grade 3 may require different lines of treatment. Different therapeutic options are available, including oral antibiotics, hormonal antiandrogens for female patients, oral isotretinoin and other combination therapies. Oral antibiotics such as tetracycline, doxycycline, minocycline and erythromycin can be effective in controlling surface bacteria that aggravate and cause acne. Isotretinoin is

a vitamin A derivative that reduces sebum production and prevents the formation of new acne lesions. It is the most effective treatment for nodulocystic acne. 5,12,14, 18,19,20,21,22 Isotretinoin is a highly effective treatment for severe acne, including acne grade 3. The recommended dose of isotretinoin is based on the patient's weight and it is usually started at a low dose of 0.5 mg/kg/day for 4 to 6 months. A study found that 20 mg/day of isotretinoin was effective in the treatment of moderate to severe acne vulgaris and both isotretinoin regimens were well tolerated and found to be an effective treatment for moderate to severe acne vulgaris. The efficacy of isotretinoin in the treatment of moderate to severe acne vulgaris was found to be 90%. Low-dose isotretinoin (20 mg/day) was found to be effective in the treatment of moderate to severe acne vulgaris. Treatment with isotretinoin often results in prolonged clearance of acne, which can be permanent for some patients. However, isotretinoin is a strong medicine that has the potential for serious side effects, including birth defects, depression and liver damage. It is important to follow the prescribing guidelines and to monitor patients closely for adverse effects. Patients taking isotretinoin should also avoid sun exposure and use effective contraception to prevent pregnancy. The use of isotretinoin in acne is recommended for severe acne as well as many cases of more moderate disease

Combined Treatment with Isotretinoin, Salicylic Acid Peels and CO2 Laser for Acne Grade 3:

that are unresponsive to other treatments. The appropriate use of isotretinoin also includes patients with moderate-to-severe acne or lesser degree of acne producing physical scarring or psychological distress and unresponsive to adequate conventional therapy. The safety and efficacy of lowdose isotretinoin in the treatment of moderate to severe acne vulgaris have been studied and it has been found to be an effective and safe treatment option.

23,24,25,26,27,28,29

Chemical peels, including glycolic acid, salicylic acid, Jessner's solution, retinoic acid, lactic acid, mandelic acid and pyruvic acid are effective for mild to moderate acne. Salicylic acid peels are effective in treating acne. Salicylic acid is a Beta Hydroxy Acid (BHA) that powerfully penetrates pores deep, making it an effective treatment for people prone to acne breakouts. Salicylic acid peels are available in different strengths, including 3%, 15%, and 25%, and are perfect for at-home usage. Salicylic acid is an oil-soluble type of acid that works nicely on acne and oily skin types to accelerate the exfoliation process. A study found that glycolic acid and salicylic acid peels not only clear the acne lesions but also show improvement in post-acne scar and hyperpigmentation to some extent. Salicylic acid 20% peel is a medium-strength peel that can help with acne and acne scarring as well as fine lines and wrinkles. 30, 31,32

Lasers are effective in treating acne. Fractional CO2 laser treatment is effective in treating acne scars. The fractional CO2 laser works by poking microscopic holes into the deep layers of the skin, which regenerates collagen growth and evens out pitted acne scars. Fractional CO2 laser works very well for acne scars and typically needs at least 1 to 3 treatments, depending upon the severity of acne scars. Fractional CO2 laser skin resurfacing is an internationally recognized technique to improve acne scars. As the name suggests, only a fraction of the skin is treated, leaving the surrounding tissue intact for faster healing. Fractional CO2 laser is a non-invasive procedure that uses laser, specially made of carbon dioxide, to remove the outer layers of damaged skin. It is a type of skin treatment used by dermatologists or physicians to reduce the appearance of acne scars, deep wrinkles and other skin irregularities. Fractional CO2 laser is a game-changer for aesthetic dermatology and can help to nix acne scars for good. 33,34,35

Discussion

Acne is a common dermatological condition, which can present with inflammatory and noninflammatory lesions chiefly on the face but can also occur on the upper arms, trunk and back. Acne is classified into four grades, with grade 3 (moderately severe or nodulocystic acne) showing numerous papules and pustules, along

with occasionally inflamed nodules.5 Acne can cause significant embarrassment and anxiety in affected patients. It can affect an individual's self-esteem and both cystic and nodular acne can lead to permanent skin damage in the form of scarring. The treatment and prevention of acne depend on the severity of the condition. It is important to follow a consistent skincare routine, avoid picking or squeezing acne lesions and protect the skin from sun damage. Acne prevention involves washing the face twice a day with mild soap-free wash, warm water and a soft face cloth, using sun protection, such as a widebrimmed hat and avoiding oily or greasy cosmetics. Good basic skin care and other selfcare techniques can also help to avoid or control mild or moderate acne. 12,15,36,37

An acne grading system may be helpful in patient care. To facilitate therapeutic decisions and assess treatment response, clinicians can use a consistent method of grading and classifying acne using the characteristics such as number of acne lesions, type of acne lesions, disease severity, anatomical sites, scarring, quality of life and microbiologic and endocrinologic testing.1 Limited information is available on the epidemiology of acne grade 3. A study conducted on males found that 15 (45.5%) had grade 2 acne, 5 (15.2%) had grade 3 acne and 12 (36.4%) had grade 4 acne. Another study found that 5.5% of acne cases had

Treatment with Isotretinoin, Salicylic Acid Peels and CO2 Laser for Acne Grade

grade 3/4 scarring. Acne vulgaris is the most common type of acne and it affects up to 85% of people at some point in their lives. Acne is more common in adolescents and young adults, but it can affect people of all ages and ethnicities. Family history, age, BMI, skin type, and certain lifestyle factors like diet and stress have been associated with acne presentation and severity. It is important to consult a dermatologist for proper diagnosis and treatment of acne. A dermatologist can help determine the best treatment plan for an individual based on their skin type, acne severity, and medical history.

6,13,15,16,38

Conclusion

Acne is a commonly-seen skin disease with a considerable impact on the quality of life. It can have a devastating physical and psychological effect on the lives of vulnerable adolescents. It is a common inflammatory disorder of the pilosebaceous unit, which runs a chronic course and is self-limiting. It can present with inflammatory and non-inflammatory lesions with the range from mild pimples, through blackheads, whiteheads and papules, to deep, inflamed, pus-filled cysts and nodules. Acne is graded by dermatologists based on its severity, with grade 3 or nodulocystic acne being a severe form of acne that can cause numerous papules and pustules, along with occasionally inflamed nodules. There have been a growing number of

epidemiological, medical, demographic and sociological researches focusing on various influencing factors in the occurrence of acne. Treatments include lifestyle modifications and medications. Effective and safe treatments for acne are available. Treatment of acne should be started early to prevent scarring and the most effective agent with the minimum risk of adverse effects should be chosen. Health education should ensure that patients have accurate information about the causes of acne and also that they have realistic expectations about the time for treatment to work.

References

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2. Genebriera J, Davis M. Acne. Pharmacology and Therapeutics, 2009.

3. AskMayoExpert. Acne. Mayo Clinic; 2019.

4. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Acne: Overview. 2013 Jan 16 [Updated 2019 Sep 26]. Available from: https://www.ncbi.nlm. nih.gov/books/NBK279211/

5. Kraft J, Freiman A. Management of acne. CMAJ. 2011 Apr 19;183(7):E430-5. doi: 10.1503/ cmaj.090374. Epub 2011 Feb 28. PMID: 21398228; PMCID: PMC3080563.

6. Sutaria AH, Masood S, Schlessinger J. Acne Vulgaris. [Updated 2023 Feb 16]. In: StatPearls [Internet]. Treasure

Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https:// www.ncbi.nlm.nih.gov/books/ NBK459173/

7. Suh, D. H. (Ed.). (2021). Acne. Updates in Clinical Dermatology. doi:10.1007/978-3-030-68996-4

8. Yang J, Yang H, Xu A, He L. A Review of Advancement on Influencing Factors of Acne: An Emphasis on Environment Characteristics. Front Public Health. 2020 Sep 17;8:450. doi: 10.3389/fpubh.2020.00450. PMID: 33042936; PMCID: PMC7527424.

9. Alper, M., & Khurami, F. A. (2017). Histopathologic Evaluation of Acneiform Eruptions: Practical Algorithmic Proposal for Acne Lesions. Acne and Acneiform Eruptions. doi:10.5772/65494

10. Lynch FW. Acne Vulgaris: Review Of Histologic Changes Observed In Early Lesions. Arch Derm Syphilol. 1940;42(4):593–606. doi:10.1001/ archderm.1940.01490160053008

11. John L. Bezzant, Histology of acne lesions https://library.med.utah. edu/kw/derm/pages/ac04_8.htm

12. Feldman S, Careccia RE, Barham KL, Hancox J. Diagnosis and treatment of acne. Am Fam Physician. 2004 May 1;69(9):2123-30. PMID: 15152959.

13. Shah, N., Shukla, R., Chaudhari, P., Patil, S., Patil, A., Nadkarni, N., & Goldust, M. (2021). Prevalence of acne vulgaris and its clinico-epidemiological pattern in adult patients: Results of a prospective, observational study. Journal of Cosmetic Dermatology. doi:10.1111/jocd.14040

14. Zaenglein, A. L., Pathy, A. L., Schlosser, B. J., Alikhan, A., Baldwin, H. E., Berson, D. S., … Bhushan, R. Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology, (2016), 74(5), 945–973. e33. doi:10.1016/j.jaad.2015.12.037

Combined Treatment with Isotretinoin, Salicylic Acid Peels and CO2 Laser for Acne Grade 3: A Case Report

15. Heng, A.H.S., Chew, F.T. Systematic review of the epidemiology of acne vulgaris. Sci Rep 10, 5754 (2020). https://doi.org/10.1038/ s41598-020-62715-3

16. Loria K. Study: Family History May Factor in Acne Presentation, Severity, and Scarring. Dermatology Times, July 2022 (Vol. 43. No. 7)

17. Thiboutot DM, Dréno B, et al. “Practical management of acne for clinicians: An international consensus from the Global Alliance to Improve Outcomes in Acne.” J Am Acad Dermatol 2018;78:S1-23.

18. Johnson BA, Nunley JR. Use of systemic agents in the treatment of acne vulgaris. Am Fam Physician. 2000 Oct 15;62(8):1823-30, 1835-6. Erratum in: Am Fam Physician 2001 Apr 1;63(7):following 1295. PMID: 11057839.

19. Al-Kathiri L, Al-Najjar T. Severe Nodulocystic Acne not Responding to Isotretinoin Therapy Successfully Treated with Oral Dapsone. Oman Med J. 2018 Sep;33(5):433-436. doi: 10.5001/omj.2018.79. PMID: 30210724; PMCID: PMC6131924.

20. American Academy of Dermatology. Guidelines of care for the management of acne vulgaris. https://doi.org/10.1016/j. jaad.2015.12.037.

21. Eichenfield DZ, et al. Management of acne vulgaris: A review. JAMA. 2021; doi:10.1001/jama.2021.17633.

22. Titus S, Hodge J. Diagnosis and treatment of acne. Am Fam Physician. 2012 Oct 15;86(8):734-40. PMID: 23062156

23. Rao PK, Bhat RM, Nandakishore B, Dandakeri S, Martis J, Kamath GH. Safety and efficacy of lowdose isotretinoin in the treatment of moderate to severe acne vulgaris. Indian J Dermatol. 2014 May;59(3):316. doi: 10.4103/0019-

5154.131455. PMID: 24891681; PMCID: PMC4037971.

24. Goldsmith LA, Bolognia JL, Callen JP et al. “American Academy of Dermatology Consensus Conference on the safe and optimal use of isotretinoin: summary and recommendations.” J Am Acad Dermatol 2004; 50: 900-6.

25. Layton A. The use of isotretinoin in acne. Dermatoendocrinol. 2009 May;1(3):162-9. doi: 10.4161/ derm.1.3.9364. PMID: 20436884; PMCID: PMC2835909.

26. Dhaked, Daulat Ram; Meena, Ram Singh; Maheshwari, Anshul; Agarwal, Uma Shankar; Purohit, Saroj. A randomized comparative trial of two low-dose oral isotretinoin regimens in moderate to severe acne vulgaris. Indian Dermatology Online Journal 7(5):p 378-385, Sep–Oct 2016. | DOI: 10.4103/2229-5178.190505

27. Mehra T, Borelli C, Burgdorf W, Röcken M and Schaller M. Treatment of Severe Acne with Low-dose Isotretinoin. Acta Derm Venereol 2012; 92: 247–248

28. American Academy of Dermatology and AAD Association, “Position Statement on Isotretinoin, (last update November 13, 2010).

29. Hafeez L, Khan A N, Aslam A, Tahir R, Shafi A, Akhta A. Comparison of safety and efficacy of low dose isotretinoin versus the conventional dosing regime in the treatment of acne vulgaris. Journal of Pakistan Association of Dermatologists. 2020;30(3):423-427.

30. Lee KC, Wambier CG, Soon SL, Sterling JB, Landau M, Rullan P, Brody HJ, on behalf of the International Peeling Society(IPS), Basic chemical peeling-superficial and medium depth peels, Journal of the American Academy of Dermatology (2019), doi: https://doi.org/10.1016/j.

jaad.2018.10.079

31. Angela Palmer.Treating Acne With Light-Duty Chemical Peels. September 30, 2021

32. Sharma P, Shah A, Dhillon AS. Study of glycolic acid and salicylic acid peels as a sole therapy in treatment of acne vulgaris. Int J Med Res Rev 2016;4(12):2205-2210.doi:10.17511 /ijmrr. 2016.i12.21.

33. Handler, MZ, Bloom BS, et al. “Energy-based devices in treatment of acne vulgaris.” Dermatol Surg. 2016 May;42(5):573-85.

34. Jih MH, Kimyai-Asadi A. Laser treatment of acne vulgaris. Semin Plast Surg. 2007 Aug;21(3):167-74. doi: 10.1055/s-2007-991185. PMID: 20567668; PMCID: PMC2884837.

35. Nicholas Brownstone, Update on New Laser Treatments for Acne. Dermatology Times, November 2022 (Vol. 43. No. 11).

36. Graber E. Treatment of acne vulgaris. https://www.uptodate.com/ contents/search. Accessed July 9, 2020.

37. The Australasian College of Dermatologists (Acne vulgaris), Australasian College of Dermatologists (Adult Acne), The Royal Children's Hospital Melbourne (Acne), Skin Health Institute (Acne), Therapeutic Guidelines Ltd (Acne)

38. Say, YH., Heng, A.H.S., Reginald, K. et al. Modifiable and nonmodifiable epidemiological risk factors for acne, acne severity and acne scarring among Malaysian Chinese: a cross-sectional study. BMC Public Health 21, 601 (2021). https://doi. org/10.1186/s12889-021-10681-4

Combined Treatment with Isotretinoin, Salicylic Acid Peels and CO2 Laser for Acne Grade 3: A Case Report

Genital Haemangioma with Ulceration: A Case Report

Dr. Ch. Saritha

DDVL

Consultant Dermatologist

Vishwa Skin Clinic

Siddipet, Telangana

Introduction

Haemangioma are benign proliferative tumour, often referred to as vascular malformations. It can be classified based on the location and depth of the tumour, as well as the types of blood vessels that are involved.1 It often breaks out at birth and develops later on in childhood.2 The most common type of haemangioma is the "capillary haemangioma," which is made up of small blood vessels called capillaries. These haemangioma are also known as "strawberry marks" because of their bright red colour. Capillary haemangioma typically occur in infants and young children and tend to disappear on their own over time.2 Another type of haemangioma is the "cavernous haemangioma," which is made up of larger blood vessels called cavernous vessels often located in internal organs such as the liver, brain or spinal cord.2

Genital haemangioma with ulceration is a rare condition that occurs when a benign

tumour build up of blood vessels on the genitals, develops an ulcer or a break in the surface layer of the skin or mucous membrane. This can happen when a haemangioma becomes large or is located in an area that is subject to trauma or pressure. Genital haemangioma can vary in size, shape, location and it can be either superficial or deep. They can appear as a single lump or multiple lumps and they can be red or purple in color.1,3, 4 It is a relatively rare condition, but it can affect both males and females, with a higher incidence in females. They may be asymptomatic or associated with pain, bleeding and infection. The cause of genital haemangioma is not well understood, but it is thought to be a congenital disorder of abnormal proliferation of blood vessels. Ulceration is a complication that can occur due to the size and location of the haemangioma.1, 4 It shows characteristics similar to a neoplasm in true sense that it is consist of epithelial cells which is continuously being dividing and spreading while its multiplication there

are new vessel channel that is being formed.5 It typically consist of three phases which includes emergence at birth followed by its proliferation for approximately 6 months and then slowly regresses towards the involution period.3 In its growing phase elevated levels of pro-angiogenic factors mainly vascular endothelial growth factors (VEGF) and the fibroblast growth factors (FGF) are observed.6

There is an elevated levels of mast cell observed which is indirectly linked with new vessel generation via heparin synthesis.5 Early diagnosis and appropriate management are essential to prevent complications and improve quality of life.

Symptoms of a genital haemangioma with ulceration can include raised, red or purplish lump on the genitals, pain or discomfort in the area of the lump, bleeding or discharge from the ulcerated area, swelling or tenderness in the affected area.

Hereby we are presenting a case of 3-months-old child who has a genital haemangioma with ulceration and he was treated successfully.

Case Presentation

A 3 months old baby was presented to our department with complaints of red, raised lesions over the genitalia. No similar ulceration could be detected anywhere else in the body. The baby was then treated with mild steroid with antibiotics topically over the ulcer for a week along with topical timolol drops with

one drop twice daily application for 15 days then gradually increased the dose to 5 -6 drops daily twice till the whole haemangioma got cleared. After the therapy the lesions slowly turned pale from pink and eventually disappeared.

Before treatment After treatment

Diagnosis

The diagnosis of genital haemangioma is typically made based on the physical appearance of the lesion and confirmed by ultrasound, echographic or magnetic resonance imaging (MRI).1 In few severe and unsure cases biopsy are performed.6 In few cases angiography is done to examine the presence of any bruits or any deep involvement of any organs.2 On physical examination solitary lesions near the scrotum was found. Other examination carried out include identifying the type of haemangioma and its stage, location, underlying complications and ulceration (present or absent).6 Based on the evaluation made tailored treatment modalities have been selected like for proliferating lesions steroids have been proved to be best choice and non proliferating lesions can be treated by observation and care.2

Treatment

The management of genital haemangioma depends on the type, location, size and symptoms. Observation and monitoring of the present condition is one such option that can be implemented to ensure that it is not spreading or damaging the body. The treatment options include topical therapy and oral therapy. The other treatment options include surgical excision, cryotherapy, sclerotherapy and laser therapy. Steroid injection can be used to reduce inflammation and also shrink the size of the haemangioma.2

Oral therapy

Corticosteroids : Prednisolone is the preferred drug of choice in this class of drugs. Main action exhibited by it is repressing effect on section of vascular endothelial growth factor A (VEGF-A). Steroids have been proven to be effective in early stages of haemangioma and should be taken until

Genital Haemangioma with Ulceration: A Case Report

Figure 1: Ulcerated haemangioma involving penis and scrotum

any deflation is observed or cessation of the lesion. On chronic use many side effects are associated like cushingoid faces and in rare case adrenal insufficiency was observed.6

Propranolol: It’s a safe, efficient and good alternative to traditionally used drugs; it is a non-selective betaadrenergic receptor blocker. It acts by blocking the receptor and thereby counteracting the release of nitric oxide which is a vasodilator resulting in vasoconstriction of the capillaries adjoining in the haemangioma. Down regulation of pro-angiogenic factors are seen. It can also be used in treating ulcerated and painful cases. Relapse of the condition is observed in little case after completion of the therapy. Negative inotropic and also chronotropic effects has been observed on the heart as it is beta blocker.3,6

Topical Therapy

Timolol: It is non-selective beta-blocker and has successfully emerged as an alternative to systemic corticosteroids in treating haemangioma. It has been used in localized, superficial and non-ulcerative cases. It cannot penetrate deeply hence cannot be used in deep haemangioma. 1 drop usually contains 0.25mg of the drug. It is found to works better in proliferative phase rather than involution phase. No major and significant side effect reported yet and no systemic drugs needed.4, 6

Imiquimod: It is basically an immune response modifier useful in superficial healing

with added antiangiogenic action. Some inflammatory changes were seen as a side effect.6

Systemic drugs like interferon alpha, vincristine and cyclophosphamide are reserved for life threatening cases.2,6

Surgical excision of the haemangioma, which can be done under local or general anaesthesia. Here significant loss of tissue is a major issue observed.2

Embolotherapy, which deals with embolization that is blocking of the vessel by some foreign substance.2

Cryotherapy, which involves freezing the haemangioma using liquid nitrogen and often associated with scaring.2

Sclerotherapy, which involves injecting a solution into the haemangioma to shrink it.2 Sodium tetradecyl sulfate, sodium morrhuate, sodium psylliate are few secreting agents used.2

Steroid injection, used to reduce inflammation in the area and also to shrink the size of the haemangioma.

Laser therapy, have gained a lot of popularity due to photothermolysis of the target rather than non – selective tissue damage caused due to surgical therapy.2

Pulsed Dye Laser (PDL) is proven efficacious in treating ulcerated haemangioma and causes rapid healing. It also helps in removal of residual dilated capillaries.6

Other lasers used are Nd:YAG

laser and KTP (PotassiumTitanyl-Phosphate) laser but found to be less efficient as compared to PDL.

Discussion

Haemangioma being a vascular disorder, which originates usually during birth and involves later in the childhood years. Their occurrence in the genital areas is a rare presentation, which may be painful, distressing or functional impairment to the child and even great concern to their parents. In few instances of haemangioma is subjected to ulceration.3,4 Some harmful consequence associated with severity of diseases include rectal bleeding, haemorrhage, affecting spermatogenic activity, even spreading of lesion and ulceration to lower pelvic areas. Hence proper medication plan is must to prevent further spreading, pain and scarring of the skin. The main etiology associated in the emergence of the condition are unknown, at times it is observed to be originated due to decreased oxygenation and ulceration are thought to be caused due to diaper as it covers 75% of the surface of hemangioma.1 Some cases can be observed and monitored if they are small and asymptomatic, while others may require treatment. The most common treatment options for genital haemangioma include surgical excision, cryotherapy, sclerotherapy, steroid injection and laser therapy. Surgical excision is often the treatment of choice for larger or symptomatic

haemangioma and it's done under local or general anaesthesia. Cryotherapy, sclerotherapy and laser therapy are used for smaller haemangioma and those located in sensitive areas. Steroid injection can be used to reduce inflammation and also shrink the size of the haemangioma.2 Sometimes, a combination of medications such as corticosteroids may be used to help shrink the haemangioma and control any associated symptoms.6

Genital haemangioma can lead to serious complications if left untreated. They can cause severe bleeding, infection and scarring, which can result in the need for multiple surgeries and also can affect sexual activity, pregnancy and delivery. Hence, it is important to seek medical attention and to be evaluated and treated by a medical professional specializing in this condition, such as a paediatric surgeon, a dermatologist, a plastic surgeon or an obstetrician/ gynecologist.1, 3

Conclusion

In conclusion, a genital haemangioma with ulceration is a rare condition that can cause significant discomfort and complications if not treated promptly and effectively. It is more prevalent in immature infants, especially girls. It disappears spontaneously and proper management may be necessary to prevent the haemangioma from causing complications such as bleeding, ulceration or pain. Consultation with a specialized practitioner such as a

vascular surgeon, oncologist is important to determine the best treatment approach. In addition, patient education is important regarding possible risks, benefits and possible complication of the treatment that will be chosen. Furthermore, doctors should be aware that not all haemangioma require treatment and they should choose the best approach depending on the location, size and symptoms of the haemangioma. Close monitoring is crucial to check for any changes or new symptoms that may occur and prompt follow-up is recommended to ensure the most effective treatment and management of the condition.

Reference

1. Patoulias, Ioannis; Farmakis, Konstantinos; Kaselas, Christos; Patoulias, Dimitrios (2016). Ulcerated Scrotal Hemangioma in an 18-Month-Old Male Patient: A Case Report and Review of the Literature. Case Reports in Urology, 2016(), 1–4. doi:10.1155/2016/9236719

2. Ahuja Tarun, Jaggi Nitin, Kalra Amit, Bansal Kanishka, Sharma Shiv Prasad. Hemangioma: Review of Literature. The Journal of Contemporary Dental Practice, September-October 2013;14(5):1000-1007

3. Christine Tran, Joan Tamburro, Audrey Rhee, Alex Golden, Propranolol for Treatment of Genital Infantile Hemangioma, The Journal of Urology, Volume 195, Issue 3, 2016,Pages 731-737, ISSN 00225347, https://doi.org/10.1016/j. juro.2015.09.069.

4. Mutyala, Priyanka; Bommakanti, Janardhan. Ulcerated Infantile Genital Hemangioma Treated with

Timolol. Indian Journal of Paediatric Dermatology 22(1):p 92-93, Jan–Mar 2021. | DOI: 10.4103/ijpd. IJPD_36_20

5. Gary J. Alter; Guy TrengoveJones; Charles E. H Jr. (1993). Hemangioma of penis and scrotum. , 42(2), 205–208. doi:10.1016/00904295(93)90649-u

6. Sethuraman, Gomathy; Yenamandra, VamsiK; Gupta, Vishal (2014). Management of infantile hemangiomas: Current trends. Journal of Cutaneous and Aesthetic Surgery, 7(2), 75–. doi:10.4103/0974-2077.138324

Genital Haemangioma with Ulceration: A Case Report

Reticular Erythematous Mucinosis or Lupus Erythematosus Tumidus : A Diagnostic Dilemma!

Dr. Priyanka Thakur

Junior Resident

Department of DVL, Dr Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh

Dr. Reena Sharma

Assistant professor

Department of DVL, Dr Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh

Dr. K . S. Mehta

Professor and Head

Department of DVL, Dr Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh

Dr. P. S. Chauhan

Associate Professor

Department of DVL, Dr Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh

Dr. Anju Lath

Assistant Professor

Department of DVL, Dr Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh

Abstract

Reticular erythematous mucinosis (REM) is an idiopathic cutaneous mucinosis characterized by erythematous macules, papules and plaques which amalgamate to form specific reticular pattern. It typically involves the midline of the chest or back. Lupus erythematosus tumidus (LET) is an uncommon and highly photosensitive form of chronic

Dr. Anuj Sharma

Assistant Professor

Department of DVL, Dr Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh

Dr. Sujaya Manvi

Senior Resident

Department of DVL, Dr Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh

Dr. Amisha

Junior Resident

Department of DVL, Dr Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh

Dr. Rohit Negi

Junior Resident

Department of DVL, Dr Rajendra Prasad Government Medical College, Tanda, Kangra, Himachal Pradesh

cutaneous lupus erythematosus (CCLE). It has been classically defined as annular erythematous, succulent, plaques involving face and trunk. Although REM and LET share similarities but distribution of lesions together with histopathological features may aid in distinction between these two entities.

Introduction

Reticular erythematous mucinosis is a disorder of dermal mucin accumulation affecting women in third and fourth decade of life although men can be affected.(1) Lupus erythematosus tumidus occur in photodistributed pattern in the form of urticarial plaques or papules without scaling, dyspigmentation and scarring.

(2) The distinction between REM and LET has been a subject of debate. REM needs to be distinguished from LET, since REM does not involve internal organ and procures good prognosis.

Case report

A 47 year- male presented with progressive asymptomatic, multiple reddish flat to raised lesions over the central part of chest and forehead involving hairline and associated with lesional loss of hair for last four years. The lesions become prominent on exposure to sunlight. The patient denied history of prior drug intake. There was history of smoking tobacco for last 20 years. Family history was non contributory.

On clinical examination of frontal aspect of scalp revealed single well defined erythematous band like plaque measuring 9×4 cm with alopecia with atrophy. There was symmetrical involvement of chest in the form of well defined erythematous reticulated plaques of size ranging from 14×6 cm on the right side and 15× 5 cm on the left side with smooth surface and partial loss of hair. The aforementioned lesion blanched incompletely on pressure. The back, extremeties and mucosa were spared. The systemic involvement was non

contributory. The possibilities of REM and LET were kept clinically. Routine lab investigations including complete blood count, serum biochemistery, urine analysis, thyroid function test, chest X-ray and abdominal ultrasonography were essentially normal. Antinuclear antibodies and direct immunofluroscence test was negative. A 4mm punch biopsy from lesional skin of chest showed flattened epidermis. There was superficial to mid perivascular and periadenexial inflammatory cell infiltrate predominantly of lymphocytes. Alcian blue staining showed homogenous deposition of mucin in the superficial dermis.

Diagnosis of REM syndrome was made on the basis of history, characteristic morphology and corroborating histolopathology. After clearance by an ophthalmologist, he was given tab hydroxychloroquine 200 mg twice daily, topical tacrolimus 0.1% once daily application at night, broad spectrum sunscreen and photoprotection was advised. Smoking cessation and effect of smoking on the disease thoroughly discussed with the patient. The patient showed remarkable improvement after 6-8 weeks and is under follow up.

c

Discussion

Amongst the diverse group of cutaneous mucinosis, REM is a rare form of primary cutaneous mucinosis which was first described by Steigleder in 1974.(3) It most often involve

the midline of upper chest or back in middle aged women although men and children are not spared. Hallmark features are erythematous macules and indurated papules or plaque having reticular configuration. They lack surface changes or scaling. The typical site is midline of chest or back ergo known as midline mucinosis, but atypical areas such as arms, abdomen, face and legs are occasionally involved. The disease have relapsing and remitting course and the disease is limited to skin. Prognosis of this entity is favourable. (4)

The pathogenesis of this entity is unclear, however associations with certain disorders such as haematological malignancies, solid organ malignancies (e.g. breast, lung, colon), thyroid disorders, diabetes, idiopathic thrombocytopenic purpura and systemic lupus erythematosus have been sometimes associated. There is upswing of the disease by menses, oral contraceptives, pregnancy, heat and smoking. Sun exposure can flare or ameliorate the disease course. Viral infections (e.g. HIV) and immunological disturbances have been conjectured to be linked with the induction of REM syndrome.(5)

Within the heterogenous group of cutaneous mucinosis, REM endure clinical and histologic resemblance to LET.(6)

Lupus erythematos tumidus dermal form of lupus erythematosus, which is commonly evident with non scarring, bright red or voilaceous, urticarial plaques with no surface changes such as follicular plugging.(1) They involve face, neck, upper back, extensor aspects of arms, and shoulders. The mean age of onset is fourth or fifth decade with almost equal sex incidence.(7) There are association of LET with SLE and discoid lupus erythmatosus anecdotally reported. It is an extremely photosensitive form of CCLE with negative ANA pattern.(1) Biopsy findings of REM show more superficial inflammatory infiltrate around the adenexa and vessels, but in case of LET the perivascular and perifollicular lymphocytic infiltrate is more dense and is situated deeper the infiltrate is more intense in LET. The mucin deposition in the dermis is more abundant and present in deep dermis in LET, whereas in REM it is present in superficial dermis. (8)

Antimalarials improve the skin lesions of REM patients significantly. They are the first line of treatment for the disease. The lesion generally heal within 1-2 months. Topical calcineurin inhibitors, topical and systemic corticosteroids are the 2nd line treatment. Topical and systemic agents can be combined for better results.(9)

REM should be considered in the differential diagnosis of any erythematous maculopapular or plaque like eruption on the upper

Figure 2: Near complete regression of lesions after 2 months of treatment

Reticular Erythematous Mucinosis or Lupus Erythematosus Tumidus : A Diagnostic Dilemma!

Figure 3: Flattened epidermis, red arrow- empty spaces in the dermis (mucin)

Figure 4: Black arrow-dilated blood vessels, yellow arrow –mild to moderate lymphocytic infiltrate around blood vessels and appendageal structures

chest and upper back. Though it may simulate LET, REM is a distinct entity. Clinicopathologic correlation is pivotal in entertaining the diagnosis of REM, as prognosis is certainly favorable of this entity.

Bibliography

1) Cinotti E, Merlo V, Kempf W, Carli C, Kanitakis J, Parodi A et al Reticular erythematous mucinosis: histopathological and immunohistochemical features of 25 patients compared with 25 cases of lupus erythematosus tumidus. J Eur Acad Dermatol and Venereol. 2015; 4:689- 97.

2) Sontheimer RD. The lexicon of cutaneous lupus erythematosus--a review and personal perspective on the nomenclature and classification of the cutaneous manifestations of lupus erythematosus. Lupus. 1997;6(2):84-95

3) Moulin G, Bouchet B, Poupon P. Erythème réticulé avec mucinose (R. E. M. syndrome de Steigleder) [Reticulate erythema with mucinosis (R. E. M. Steigleder syndrome) (author's transl)]. Ann Dermatol Venereol. 1977 Apr;104(4):309-1

4) Rongioletti F, Merlo V, Riva S, Cozzani E, Cinotti E, Ghigliotti G, Parodi A, Kanitakis J. Reticular erythematous mucinosis: a review of patients' characteristics, associated conditions, therapy and outcome in 25 cases. Br J Dermatol. 2013 Dec;169(6)

5) Thareja S, Paghdal K, Lien MH, Fenske NA. Reticular erythematous mucinosis--a review. Int J Dermatol. 2012 Aug;51(8):903-9

6) Rongioletti F, Rebora A. cutaneous mucinosis:microscopic criteria for diadnosis. Am J Dermatopathol. 2001; 23 : 257-67.

7) Vieira V, Del Pozo J, Yebra-Pimentel MT, Martínez W, Fonseca E. Lupus erythematosus tumidus: a series of 26 cases. Int J Dermatol. 2006 May;45(5):512-7.

8) Fernandez-Flores A, Saeb-Lima

M. Mucin as a diagnostic clue in dermatopathology. J Cutan Pathol. 2016 Nov;43(11):1005-1016.

9) Verma P, Sharma S, Yadav P, Namdeo C, Mahajan G. Tumid lupus erythematosus: an intriguing dermatopathological connotation treated successfully with topical tacrolimus and hydroxyxhloroquine combination. Indian J Dermatol. 2014 Mar;59(2):210.

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