The term “acral” means the distal portions of the limbs (hand, foot) and the head (ears, nose). The term acral melanosis is loosely applied to an increase in melanin pigmentation, in a diffuse, reticulate, or focal pattern over the distal parts of the arms and legs. There are various causes of acral pigmentation varying from genetic to acquired, benign to malignant, autoimmune to infectious, drug-induced, nutritional deficiencies, postinflammatory, and even exogenous reasons. The pigmentation may be occurring in isolation or associated with various systemic features. An earlier age of the onset of pigmentation, a positive family history, and a reticulate or mottled pattern usually point to a genetic cause. The diffuse pattern of pigmentation is usually seen in racial, endocrine diseases, and nutritional deficiencies. Postinflammatory acral pigmentation may follow both infectious and autoimmune diseases and may even be drug induced. A correct diagnosis is important to decide on the management which varies from reassurance and counseling to active treatment. This review paper is an attempt to classify acral pigmentation based on its diverse etiological causes.

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Skin color is determined by melanin and other chromophores and is influenced by physical factors (ultraviolet radiation) and other endocrine, autocrine, and paracrine factors. Being the largest organ of the body, any aberration in skin color (hyperpigmentation and hypopigmentation) can have impact on the patients’ quality of life. Hyperpigmentation may be circumscribed or diffuse. Diffuse hyperpigmentation can be multifactorial in origin; hence, a multipronged approach is needed in such cases. First, the cause (systemic or cutaneous) needs to be ascertained, and then disease-specific management needs to be performed. The biggest challenge in such cases is to treat the hyperpigmentation itself; hence, counseling and general treatment (the use of broad-spectrum sunscreen, the avoidance of sun exposure, etc.) play crucial role, and an interdisciplinary approach may be required, especially when the hyperpigmentation is due to a systemic cause.

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Background: Periocular darkening, popularly known as “dark circles,” is a common condition globally. Pigment deposition, shadowing due to laxity, superficial location of vasculature and prominent nasojugal groove are recognized causative factors. Very few studies exist on its clinicopathological correlation, especially in the Asian population. Materials and Methods: Eighty-two consecutive patients attending skin outpatient department (OPD) with periocular hyperpigmentation (POH) who agreed to follow the study protocol were included in this descriptive study, conducted in Maharashtra, India. They were evaluated clinically and also investigated with histopathology, special staining and immunohistochemistry of the periocular skin to study the various factors involved in the pathogenesis. Results: 19.51% of the patients had a positive family history of POH, 90% gave history of exhaustion of periocular muscles, 41.46% had anemia, 8.54% gave history of aggravation during pregnancy and 7.32% had menstrual irregularities. Laxity of skin was present in 82.92% patients, visible veins in 50%, and sunken eyes with prominent infraorbital rim and shadowing in 26.82%. Periocular darkening due to pigment was present in only 17% patients, with mixed dermoepidermal pigmentation being present in majority (70.73%). Clinicopathological concordance was significant in case of dermal pigmentation (Fisher’s exact test P-value <0.05) in contrast to epidermal. Conclusion: Periocular darkening was predominantly not due to pigment, but rather due to cutaneous laxity and vascular visibility through thin skin. Most of them with pigment had it in the dermis. Clinical dermal pigmentation correlated well with histology, unlike epidermal pigmentation. Iron and amyloid were not significant as etiological factors in our patients.

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A 2-year-old male child born of third degree consanguineous marriage was brought to dermatology outpatient department with multiple dark colored flat lesions over body and one large dark colored flat lesion over right side of body since birth. Another prominent feature was proptosis of left eye since 1 month. Cutaneous examination revealed multiple café au lait macules (CALMs) over lower limbs and back and large CALM over right side of back, chest, and upper limb with proptosis of left eye. Histopathological examination of large patch findings was suggestive of CALM. Magnetic resonance imaging (MRI) brain plain and contrast findings were suggestive of plexiform neurofibroma. Based on clinical features and investigations a diagnosis of giant CALM in segmental distribution in a case of neurofibromatosis 1 (NF1) was made. It can be explained on basis of type II segmental manifestation in NF1.

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Menkes disease is an X-linked lethal multisystem disorder caused by the disturbances of copper distribution in different tissues due to the mutation of ATPA7 gene. The estimated prevalence of the disease is 1 in 100,000 to 1 in 250,000 (Kirodian et al., 2002).

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Even though seborrheic keratosis (SK)-like histopathological change has been reported within verrucous epidermal nevi (VEN), SKs developing over epidermal nevi has not been described in the past, hence this report. A 50-year-old female presented with asymptomatic pigmented skin lesions over the right half of the body since birth and the appearance of new itchy raised lesions on these of 3 months duration. On examination, multiple verrucous pigmented papules and plaques, along the Blaschko’s lines, were seen involving the right side of the body. Multiple discrete hyperpigmented plaques with a rough surface were seen scattered overlying the linear lesions. There were no similar lesions on the normal skin elsewhere. Investigations for internal malignancy were negative. Biopsy from the linear lesions was suggestive of VEN, while that from the new onset verrucous plaques was consistent with SK. Activating fibroblast growth factor receptor 3 mutations have recently been detected in SKs and VEN. This might explain the colocalization of these in our patient.

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Context: Vitiligo is a cosmetically disfiguring condition especially in dark-skinned individuals, thereby adversely affecting their quality of life (QOL). Studies have reported higher psychiatric morbidity in patients with vitiligo, but a comparative study between patients with stable and unstable vitiligo has not been reported. Aims: To compare the psychiatric morbidity, perceived stress, and QOL in patients suffering from stable versus unstable vitiligo. Settings and Design: This was a clinical observational, cross-sectional liaison study conducted over a period of 2 years and included 100 consecutive patients with vitiligo, who came for treatment to the dermatology clinic of a tertiary care hospital. Materials and Methods: A dermatologist clinically assessed the patients and calculated their vitiligo area severity index score and dermatology life quality index. A psychiatrist evaluated the patients on the basis of the perceived stress scale (PSS), hospital anxiety and depression scale (HADS), and clinically established diagnosis using International Classification of Diseases (ICD-10). Statistical Analysis: The aforementioned variables between the two groups were compared using chi-square test and independent t test. Results: High psychiatric morbidity (65%) was reported in patients with vitiligo, with adjustment disorder being the most common morbidity. The most common reported stress was grief or emotionally significant loss. Psychiatric morbidity, scores on HADS, and PSS were significantly higher in patients with unstable vitiligo in comparison to patients with stable vitiligo. The quality of life (QOL) was mildly affected among the patients in both the groups. Conclusions: There is higher psychiatric morbidity in patients with unstable vitiligo along with a worse QOL in comparison to those with stable vitiligo. Patients with vitiligo should be assessed for stability as well as psychiatric morbidity, because it will have significant management implications.

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