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Review Article

THE DERMATOSES OF PREGNANCY

Silonie Sachdeva
Abstract

The skin changes in pregnancy can be either physiological (hormonal), changes in pre-existing skin diseases or development
of new pregnancy specific dermatoses. Pregnancy-specific skin dermatoses include an ill-defined heterogeneous group
of pruritic skin eruptions which are seen only in pregnancy. These include Atopic eruption of pregnancy, Polymorphic
eruption of pregnancy, Pemphigoid gestationis and intrahepatic cholestasis of pregnancy. Atopic eruption of pregnancy
is the most common of these disorders. Most skin eruptions resolve postpartum and require only symptomatic treatment.
Antepartum surveillance is recommended for patients with pemphigoid gestationis and intrahepatic cholestasis of
pregnancy as they carry fetal risk. This article deals with the classification, clinical features and treatment of the specific
dermatoses of pregnancy.

Key Words: Dermatoses, pregnancy, skin

Indian J Dermatol 2008:53(3):00-00******

Introduction the most common pruritic skin condition in pregnancy in

Pregnancy is characterized by many physiological skin
changes as striae gravidarum, melasma accompanied by hair,
nail and vascular changes which are due to hormonal effects.
Along with this, the pre-existing skin conditions may either
improve or exacerbate in pregnancy due to immunological
changes in pregnancy. As cell mediated immunity is
depressed during normal pregnancy, this accounts for
increased severity and frequency of skin infections as
candiadiasis. There are however few inflammatory skin
dermatoses which are specific to pregnancy and are seen
only in pregnancy. Though most of these skin dermatoses
are benign and resolve in post partum period, a few can
risk fetal life and require antenatal surveillance.
Classification
The first classification of dermatoses of pregnancy was
proposed by Holmes and Black1 in 1983 and included four
skin conditions 1. Pemphigoid gestationis (PG, syn. herpes
gestationis) 2. Polymorphic eruption of pregnancy (PEP) (syn.,
pruritic urticarial papules and plaques of pregnancy [PUPPP])
3. Prurigo of pregnancy (PP) and 4. Pruritic folliculitis of
pregnancy (PF). The second, proposed by Shornick2 in
1998 included intrahepatic cholestasis of pregnancy (ICP)
in addition to PG, PEP and PP. The most recent rationalized
classification has been proposed by Ambros-Rudolph et al,3
in 2006 after their retrospective two-center study on 505
pregnant patients. They introduced a new entity “Atopic
eruption of pregnancy (AEP)” as AEP was observed to be
From Jalandhar, Punjab, India Address correspondence
to: Dr. Silonie Sachdeva, 1312, Urban Estate, Phase-1,
Jalandhar - 144 022, Punjab, India. E-mail: siloniesachdeva@
yahoo.com
their study. It was noted in almost 50% of patients affected
with pregnancy specific dermatosis. They included three
conditions- eczema in pregnancy (EP), prurigo of pregnancy
and pruritic folliculitis of pregnancy under AEP due to their
overlapping features. Therefore they presented four main
conditions 1. Atopic Eruption of Pregnancy 2. Polymorphic
eruption of Pregnancy 3. Pemphigoid Gestationis and 4.
Intrahepatic cholestasis of Pregnancy under dermatoses of
pregnancy. While AEP starts significantly earlier, PEP, PG,
and ICP present in late pregnancy.
1. Atopic eruption of pregnancy (AEP) (Syn. early -
onset prurigo of pregnancy)
Eczema in pregnancy: Vaughan-Jones et al,4 in a PE
prospective study on pruritic skin diseases in pregnancy
in 1999 reported a high prevalence of atopic eczema in
pregnancy for first time. This finding was not reflected in the
previous classifications1-2 which had concluded poymorphic
eruption of pregnancy as the most common dermatoses in
pregnancy. The reason for increased incidence of atopic
eczema in pregnancy was cited due to immunological
changes in pregnancy. Pregnancy is characterized by a lack
of strong maternal cell-mediated immune function and T-
helper 1 (Th1) cytokine production (eg, IL-12, interferon
gamma) and a dominant humoral immune response and
T-helper 2 (Th2) cytokine production (e.g., IL-4, IL-10)
to prevent fetal rejection.5 The Th2 shift associated with
pregnancy may favor the exacerbation of atopic dermatitis.
Ambros-Rudolph et al,3 confirmed these findings in a
retrospective two-center study on 505 pregnant patients.
In their study it was revealed that 80% of the affected
patients experienced first episode of atopic eczema during
pregnancy. These patients had an atopic background with

103 Indian J Dermatol 2008; 53(3)

 Sachdeva: Running title missing???
raised total serum IgE levels. The eruption was seen more
commonly in primigravida with single gestation pregnancy
and skin lesions started during early pregnancy in first and
second trimester. The skin eruption affected all parts of the
body, including face, palms, and soles.
Prurigo of pregnancy: Prurigo of pregnancy has been
reported to occur in approximately one in 300 pregnancies.6
It is characterized by pruritic, often excoriated papules and
nodules on the extensor surfaces of the legs and upper
arms. The abdomen can also be involved. The time of
onset is variable and it has been reported to occur in all
trimesters. The etiology and pathogenesis is not known,
although there is sometimes a history of atopy.4 There are
no recognized adverse effects for the mother or fetus.
Pruritic folliculitis: This rare dermatosis occurs in the
second and third trimester of pregnancy and affects an
estimated one in 3,000 pregnancies.7 Contrary to its name,
pruritus is not a major feature and it may be mistaken
for acne or microbial folliculitis.8,9 It is characterized by
an acneiform eruption consisting of multiple, pruritic,
2- to 4-mm, follicular papules or pustules typically on
the shoulders, upper back, arms, chest, and abdomen.
The diagnosis is made clinically after excluding other,
more common rashes. The skin lesions usually resolve
spontaneously one to two months following delivery. Small
case series have failed to implicate immunologic dysfunction
or elevated androgen levels.10-12 On histopathology, an acute
sterile folliculitis is evident and direct immunofluorescence
stains are negative. The disorder is not associated with any
maternal or fetal morbidity, although one small series of
patients showed a reduction in fetal birth weight.12
2. Polymorphic eruption of pregnancy (Syn. late -
onset prurigo of pregnancy)
Polymorphic eruption of pregnancy also known as pruritic
urticarial papules and plaques of pregnancy (PUPPP),
occurs with an incidence of one in 160 pregnancies4 and
is the second most common skin dermatosis in pregnancy
after atopic eczema. It is associated with multiple gestation
and increased maternal weight gain. The exact etiology
is not known. It has been proposed that stretching of the
skin damages the connective tissue causing subsequent
conversion of nonantigenic molecules to antigenic ones,
leading to skin eruption.13-14 PUPPP usually occurs in
primigravidas in the third trimester and recurrence in
subsequent pregnancies is unusual. The eruption may first
appear in postpartum period. PUPPP has a marked pruritic
component and the onset of pruritis coincides with the skin
lesions which are seen as polymorphous, erythematous,
nonfollicular papules, plaques, and sometimes vesicles. The
eruption begins over the abdomen, commonly involving
striae gravidarum with sparing of the periumbilical region.
It may spread to the breasts, upper thighs, and arms.
The face, palms, soles, and mucosal surfaces are usually
spared. Histopathologic findings are nonspecific and the
Indian J Dermatol 2008; 53(3)
immunoflourosecence studies are negative. The lesions
resolve near term or in the early postpartum period. The
maternal and fetal prognosis is excellent.14,15
3. Pemphigoid gestationis (herpes gestationis)
Pemphigoid gestationis is a rare autoimmune disorder
occurring in approximately one in 50,000 pregnancies,
and begins in the second or third trimester. The condition
has been linked to the presence of HLA-DR3 and HLA-
DR4 and has a rare association with molar pregnancies and
choriocarcinoma has been reported.16 It has been suggested
that the disease could be triggered by a placental antigen
that causes cross-reaction with skin antigens. This explains
the onset of the disease in the periumbilical region. The
skin lesions are pruritic, urticarial and vesiculobullous.
Histologically, it is characterized by subepidermal vesicle
formation, and immunopathologically by deposition
of complement 3 along the basement membrane zone.
These features are shared by another skin disease bullous
pemphigoid which suggests that herpes gestationis may
be a related entity.17 The condition may resolve late in
pregnancy, but classically flares up again at delivery. Fetal
risk has not been substantiated, although immunoglobulin
G autoantibodies cross the placenta, and 5 to 10 percent
of newborns have urticarial, vesicular or bullous lesions.18
Mild placental failure has been associated with premature
deliveries and newborns that are small for gestational
age. Therefore, antenatal surveillance is advised. Affected
patients may have nongestational recurrences triggered by
oral contraceptives and menstrual cycles.6
4. Pruritus gravidarum (intrahepatic cholestasis of
pregnancy) (ICP)
The two terms term pruritus gravidarum and intrahepatic
cholestasis of pregnancy (ICP) have been used
interchangeably in the literature.7 While pruritus gravidarum
is classically associated with itching, without any skin lesions
and occurs in the first trimester, ICP also called obstetric
cholestasis is seen in third trimester and is characterized by
pruritus with or without jaundice, absence of primary skin
lesions, and with laboratory markers of cholestasis.19 The
skin lesions are usually secondary linear excoriations and
excoriated papules, which are caused by scratching and are
localized on the extensor surfaces of the limbs, abdomen and
back. The severity of skin lesions correlates with the duration
of pruritus.3 The etiology of ICP remains controversial.
A family history of the condition is common, and there
is an association with the presence of human leukocyte
antigen-A31 (HLA-A31) and HLA-B8. The condition tends
to recur in subsequent pregnancies.7,19 Patients may have a
family history of cholelithiasis and a carry higher risk of
gallstones.20,21 Laboratory markers include elevated serum
bile acid levels (4.08 mcg per mL [10 μmol per L] or more)
and alkaline phosphatase levels with or without elevated
bilirubin levels. The condition is associated with a higher risk
of premature delivery, meconium-stained amniotic fluid, and
104
 Sachdeva: Running title missing???
intrauterine demise due to anoxia caused by decreased fetal
elimination of toxic bile acids.22 A statistically significant
increase in adverse fetal outcomes has been reported in
patients with bile acid levels of 16.34 mcg per mL (40 μmol
per L) or more.20 Cholestasis and jaundice in patients with
severe or prolonged intrahepatic cholestasis of pregnancy
may cause vitamin K deficiency and coagulopathy.19
Therefore, early diagnosis, prompt treatment, and close
obstetric surveillance are mandatory in cases of ICP.
Treatment
Atopic eruption of pregnancy and Polymorphic eruption
of Pregnancy are benign skin conditions and do not carry
any fetal risk.3,6 They usually resolve in early post partum
period. During pregnancy they respond well to topical
emollients and moderately potent steroids in combination
with oral antihistamines. Systemic steroids may be used for
severe cases of PUPPP.14,15 Pruritic follicullitis responds well
to topical benzoyl peroxide8,9 and also has been treated with
narrowband (TL-01) ultraviolet B phototherapy.23 Patients
with pemphigoid gestationis and intrahepatic cholestasis of
pregnancy carry fetal risk and require specific treatment.
The mild pruritus can be treated with oral antihistamines
but patients with more severe cases of PG require systemic
corticosteroids.16,19 PG has also been treated with high-dose
intravenous immunoglobulins.24 For ICH, ursodeoxycholic
acid is considered to be the drug of choice, as it is the only
therapy that has been shown to decrease both maternal
pruritus and fetal mortality.25,26
References
1. Holmes RC, Black MM. The specific dermatoses of pregnancy.
J Am Acad Dermatol 1983;8:405-12.
2. Shornick JK. Dermatoses of pregnancy. Semin Cutan Med Surg
1998;17:172-81.
3. Ambros-Rudolph CM, Mullegger RR, Vaughan-Jones SA, Kerl H,
Black MM. The specific dermatoses of pregnancy revisited and
reclassified: Results of a retrospective two-center study on 505
pregnant patients. Am Acad Dermatol 2006;54:395-404.
4. Vaughan Jones SA, Black MM. Pregnancy dermatoses. J Am
Acad Dermatol 1999;40:233-41.
5. Wilder RL. Hormones, pregnancy, and autoimmune disease. Ann
N Y Acad Sci 1998;840:45-50.
6. Kroumpouzos G, Cohen LM. Dermatoses of pregnancy. J Am
Acad Dermatol 2001;45:1-19.
7. Roger D, Vaillant L, Fignon A, Pierre F, Bacq Y, Brechot JF,
et al. Specific pruritic diseases of pregnancy: A prospective study
of 3192 pregnant women. Arch Dermatol 1994;130:734-9.
8. Kroumpouzos G, Cohen LM. Pruritic folliculitis of pregnancy.
J Am Acad Dermatol 2000;43:132-4.
9. Fox GN. Pruritic folliculitis of pregnancy. Am Fam Physician
Author Query??????
PE Please confirm the style given for heading level three is fine throughout the issue.
105
1989;39:189-93.
10. Zoberman E, Farmer ER. Pruritic folliculitis of pregnancy. Arch
Dermatol 1981;117:20-2.
11. Wilkinson SM, Buckler H, Wilkinson N, O’Driscoll J,
Roberts MM. Androgen levels in pruritic folliculitis of pregnancy.
Clin Exp Dermatol 1995;20:234.
12. Vaughan Jones SA, Hern S, Nelson-Piercy C, Seed PT,
Black MM. A prospective study of 200 women with dermatoses
of pregnancy correlating clinical findings with hormonal and
immunopathological profiles. Br J Dermatol 1999;141:71-81.
13. Rudolph CM, Al-Fares S, Vaughan-Jones SA, Mullegger RR,
Kerl H, Black MM. Polymorphic eruption of pregnancy:
Clinicopathology and potential trigger factors in 181 patients. Br
J Dermatol 2006;154:54-60.
14. Matz H, Orion E, Wolf R. Pruritic urticarial papules and plaques
of pregnancy: Polymorphic eruption of pregnancy (PUPPP). Clin
Dermatol 2006;24:105-8.
15. Brzoza Z, Kasperska-Zajac A, Oles E, Rogala B. Pruritic urticarial
papules and plaques of pregnancy. J Midwifery Womens Health
2007;52:44-8.
16. Engineer L, Bhol K, Ahmed AR. Pemphigoid gestationis:
A review. Am J Obstet Gynecol 2000;183:483-91.
17. Morrison LH, Anhalt GJ. Herpes gestationis. J Autoimmun
1991;4:37-45.
18. Shimanovich I, Brocker EB, Zillikens D. Pemphigoid gestationis:
New insights into pathogenesis lead to novel diagnostic tools.
BJOG 2002;109:970-6.
19. Kroumpouzos G, Cohen LM. Specific dermatoses of pregnancy:
An evidenced-based systematic review. Am J Obstet Gynecol
2003;188:1083-92.
20. Glantz A, Marschall HU, Mattsson LA. Intrahepatic cholestasis
of pregnancy: Relationships between bile acid levels and fetal
complication rates. Hepatology 2004;40:467-74.
21. Kaaja RJ, Greer IA. Manifestations of chronic disease during
pregnancy. JAMA 2005;294:2751-7.
22. Lammert F, Marschall HU, Glantz A, Matern S. Intrahepatic
cholestasis of pregnancy: Molecular pathogenesis, diagnosis and
management. J Hepatol 2000;33:1012-21.
23. Reed J, George S. Pruritic folliculitis of pregnancy treated with
narrowband (TL-01) ultraviolet B phototherapy. Br J Dermatol
1999;141:177-9.
24. Rodrigues Cdos S, Filipe P, Solana Mdel M, de Almeida LS, de
Castro JC, Gomes MM. Persistent herpes gestationis treated with
high-dose intravenous immunoglobulin. Acta Derm Venereol
2007;87:184-6.
25. Palma J, Reyes H, Ribalta J, Hernandez I, Sandoval L,
Almuna R. Ursodeoxycholic acid in the treatment of cholestasis
of pregnancy: A randomized, double-blind study controlled with
placebo. J Hepatol 1997;27:1022-8.
26. Kondrackiene J, Beuers U, Kupcinskas L. Efficacy and safety
of ursodeoxycholic acid versus cholestyramine in intrahepatic
cholestasis of pregnancy. Gastroenterology 2005;129:894-901.
Received: December, 2007. Accepted: March, 2008.
Source of Support: Nil, Conflict of Interest: Nil.
Indian J Dermatol 2008; 53(3)
Original Article

COMPARISON OF PLASMA MALONDIALDEHYDE, GLUTATHIONE,

GLUTATHIONE PEROXYDASE, HYDROXYPROLINE AND SELENIUM
LEVELS IN PATIENTS WITH VITILIGO AND HEALTHY CONTROLS
Cetin Ozturk, Kadir Batcioglu1, Fikret Karatas2, Ersoy Hazneci3, Metin Genc4
Abstract

Background: The etiology and pathophysiologic mechanism of vitiligo are still unclear. The relationship between
increased oxidative stress due to the accumulation of radicals and reactive oxygen species and the associated changes in
blood and epidermal component of vitiliginous skin have been reported many times. We investigated the possible changes
of plasma malondialdehyde, glutathione, selenium, hydroxyproline and glutathione peroxidase activity levels in patients
with vitiligo in order to evaluate the relationship between oxidative stress and etiopathogenesis of vitiligo. Materials and
Methods: Plasma malondialdehyde, glutathione, hydroxyproline and glutathione peroxidase activity levels were measured
by spectrophotometric methods, and HPLC was used for measurement of selenium concentrations. Results: Our results
showed increased malondialdehyde, hydroxyproline and glutathione peroxidase activity levels in plasma of vitiligo group
(P < 0.05). Conclusion: Support of antioxidant system via nonenzymatic antioxidant compounds and antioxidant enzymes
may be useful to prevent of melanocyte degeneration which occur due to oxidative damage in vitiligo.

Key Words: Free radicals, oxidative damage, selenium, vitiligo

Indian J Dermatol 2008:53(3):00-00******

Introduction and associated changes in blood and epidermal component

Vitiligo is an acquired idiopathic, and in the majority of
cases, a progressive, unpredictable disorder of the skin.
The family history is positive in approximately 30-40%
of cases, and there is no gender or racial bias.1 The onset
is mostly early in life, and it has an estimated worldwide
incidence of 0.5-4%. The etiology and pathogenic
mechanism of vitiligo is still unclear. Several hypotheses
have been proposed for the loss of functioning melanocytes
in the skin of these patients. These include the presence of
autoantibodies against various tissues; cytotoxic T-cells;
autodestruction of melanocytes by intermediates of the
melanogenesis pathway; the presence of intrinsic/extrinsic
metabolic defects in the melanocytes themselves or in the
epidermal melanin unit, leading to oxidative stress; and
the neural hypothesis. Recently, a “convergence theory”
has been suggested, combining all hypotheses of this
disease.1,2 The role of free radicals and oxidative damage
in the pathophysiology of vitiligo has been shown.3,4 The
relationship between increased oxidative stress due to the
accumulation of radicals and reactive oxygen species (ROS)
From Department of Biochemistry, Inonu University, Faculty of
Medicine, Malatya/Turkey. 1Department of Biochemistry, Inonu
of vitiliginous skin have been reported many times.4-7 An
increased epidermal H2O2 level has been described both
in vivo and in vitro in the active phase of vitiligo. High
H2O2 level is possibly associated with reduced catalase,
glutathione peroxidase activities and selenium levels.3,8
The tripeptide glutathione (GSH) is essential for metabolic
and cell-cycle related functions in virtually all cells. Its
ability to directly scavenge free radicals and to act as a co-
substrate in the glutathione peroxidase catalyzed reduction
of H2O2 and lipid hydroperoxides makes GSH central
to defense mechanisms against intra- and extracellular
oxidative stres.9
Malondialdehyde (MDA), the end product of lipid
peroxidation (LPO), arising from the free radical
degradation of polyunsaturated fatty acids, can cause cross-
linking in lipids, proteins and nucleic acids.10,11 Human
body is equipped with various antioxidants superoxide
dismutase (SOD), glutathione peroxidase (GSHPx) and
catalase (CAT) which can counteract the deleterious action
of ROS and protect from cellular and molecular damage.12,13
Hydroxyproline (HyPro) is a product of nonenzymatic
hydroxylation reaction of proline made by ROS and Q1

University, Faculty of Pharmacy, Malatya/Turkey. 2Department
of Chemistry, Firat University, Faculty of Science, Elazig/Turkey.
3
Department of Dermatology, Acibadem Hospital, Bursa/Turkey.
4
Inonu University, Faculty of Medicine, Public Health Department,
Malatya/Turkey. Address correspondence to: Dr. Kadir Batcioglu,
Inonu University Faculty of Pharmacy, Biochemistry Dep., 44280
Malatya/Turkey. E-mail: kadirbatci@inonu.edu.tr
possible degradation of collagen caused by ROS in vitiligo
diseases hence we measured hydroxyproline levels in blood
samples with vitiligo patients.
In this study, we investigated the possible changes of plasma
MDA, GSH, GSSG, Se, hydroxyproline and glutathione
peroxidase activity levels in patients with vitiligo in order

Indian J Dermatol 2008; 53(3) 106

 Ozturk et al.: Running title missing???
to evaluate the relationship between oxidative stress and
etiopathogenesis of vitiligo.
Materials and Methods
Experiment groups
Thirty (19 male, 11 female) patients with generalized stable
vitiligo, and thirty (12 male, 18 female) healthy controls
were included in this study. The ages of the patients ranged
from 16 to 43 years old (23.6 ± 7.4). The control group
consisted of healthy volunteers, whose ages ranged from
16 to 52 (27.9 ± 7.1). The Ethic Committee approved the
protocol for this study; all subjects gave his/her protector
informed consent. They were not under a therapeutic
regimen for the previous 2 months and had not received
drugs containing iron and/or vitamins. All individuals with
any history of smoking and alcohol habits were excluded.
Chemicals
All chemicals were purchased from Sigma Chemical
Company (St. Louis, MO, USA).
Preparation of plasma samples
All blood samples were drawn at the same time. Ten ml
blood was drawn from cubital median vein of the patients
and control group into tubes that were washed with heparin.
The blood samples were centrifuged at 1000 × g for 10 min
at +4°C, and upper plasma phase was drawn with pipette
Q2 and transferred to into polypropilen tubes, and stored at
−40°C.
Determination of protein levels
Protein determinations in plasma were done according to
modified micro method of Lowry et al.,14 using BSA as
standard.
Estimation of glutathione peroxidase enzyme activity
GSHPx activity measurements were conducted according
to Lawrence and Burk.15 900 μL of 50 mM PBS solution
(pH 7.4), including 5 mM EDTA, 2 mM NADPH, 20 mM
GSH, 10 mM NaN3 and 23 mU of GSSG reductase
were incubated at 37°C for 5 min. Fifty μL of 0.25 mM
H2O2 solution and 50 μL of samples were added to the
assay mixture. The change in absorbance at 340 nm was
Q3 monitored for 3 min. A blank with all ingredients except
supernatant was also monitored. Specific activity was
calculated as U/mg protein for plasma samples.
Measurement of MDA levels
Lipid peroxidation products were quantified by the
thiobarbituric acid (TBA) method.16 Malondialdehyde is
formed as an end product of lipid peroxidation which reacts
with TBA reagent under acidic conditions to generate a
pink-colored product. Plasma (0.5 ml) was made up to
1 ml with saline and an equal volume of trichloroacetic
acid (TCA) was added and incubated at 378C for 20 min
107
and centrifuged at 500 g. To 1 ml of TCA extract (the
supernatant) 0.25 ml TBA was added and heated in a water
bath at 958C for 1 h till a faint pink color appeared. After
cooling, the color was extracted in 1 ml butanol and the
intensity was read at 532 nm. 1,1,3,3 tetra ethoxypropane
(1-100 nmol/ml) was used as the standard.
Measurement of glutathione levels
Total glutathione: Glutathione was assayed according to
modified Owens17 method. Previously, plasma treated with
meta phosphoric acid and centrifuged at 4000 g. to obtained
deproteinized samples. Then, supernatants mixed with 5,5’-
dithiobis-2-nitrobenzoat, NADPH2 and oxidized glutathione
reductase in a sodium potassium phosphate buffer. The
samples were incubated in a water bath at 30 °C for
15 min, and absorbance was read spectrophotometrically at
412 nm.
Oxidized glutathione: Previously, supernatants were
treated with 2-vinylpyridine to prevent present reduced
glutathione interference. Then, each sample was mixed
with high concentrations of NADPH2 and GSSG reductase
in the sodium potassium phosphate buffer. The change in
absorbance was observed spectrophotometrically at 340 nm.
When all the GSSG was run out, a constant absorbance
was recorded.
Measurment of selenium levels
Plasma samples were digested in a teflon bomb according
to Breyer and Gilbert.18 Each sample was diluted with (v/
v:1/3) 1.00 N HNO3/1.00 N HClO4 and left in the teflon
bomb at 120°C for 12 h. After coolin to room temperature,
Se6+ was reduced to Se4+ by addition of HCl to a final
concentration of 4N and the samples kept at 90°C in
a water-bath for 15 min. After returning to the room
temperature, to each sample 5 ml of 0.1 M EDTA was added
and mixed thoroughly. Two ml of 2.5 M HCOOH and 2 ml
of 1500 ppm. 3,3-diaminobenzidine (DAB) were added to
each sample and the mixtures were left in a dark place for
60 min. The pH was adjusted to 7.0 with 4N NH3 and the
Se-DAB complex was extracted with 5 ml of of toluene.
These samples were analysed according to Watkinson19 and
Whetter and Ullrey20 using a Perkin Elmer 100 Flouresans Q4
Spectrophotometer with excitation at 420 nm and emission
at 570 nm.
Measurment of hydroxyproline levels
Hydroxyproline (HyPro) levels were measured by the
method described by Bergman and Loxley.21 One mililiter
of plasma samples were sealed in small Pyrex test tubes and
hydrolyzed for 12 hours at 110°C by adding 5 mL of 6N
HCl. The hydrolysates were neutralized by 2.5 N NaOH and
0.25 mL was used for analyses. Hydroxyproline oxidation
was initiated by adding chloramine T and the tube content
were kept at room temperature for 5 min. Chloramine T
was then removed by adding 3.15 M perchloric acid. After
Indian J Dermatol 2008; 53(3)
 Ozturk et al.: Running title missing???
5 min, 3.25 mL of Ehrlich’s reagent was finally added;
the mixture was shaken, and the tubes were placed in a
60°C water bath for 25 min. They were then cooled in tap
water for 5 min. The absorbance values of the solutions
were determined at 558 nm. The hydroxyproline values
calculated from L-hydroxyproline standard curve.
Results and Discussion
Results are tabulated in Table 1. All results were expressed
as mean + SD.
The skin is the largest tissue of the human body with
an approximate size of 1.8 m2, where numerous fine-
tuned mechanisms act in a concerted action to keep the
homeostasis in place. Recently, it has been shown in vivo
and in vitro that patients with the pigmentation disorder
vitiligo accumulate mM levels of hydrogen peroxide
(H2O2) in their epidermis.22 It is well established that as
high as millimolar levels of hydrogen peroxide lead to
the inactivation of catalase and glutathione peroxidase
despite normal mRNA expression.3,23,24 Possible sources of
endogenous H2O2 production are increased the activities
of epidermal monoamine oxidase A, NADPH-oxidases,
inducible nitric oxide synthase, increased levels of
TNFα and photo-oxidation of epidermal 6-biopterin and
sepiapterin.25 Increased generation or decreased removal
of hydrogen peroxide has been shown to lead to lipid
peroxidation, protein oxidation and DNA damage in skin
and blood. H2O2 itself is a rather weak oxidizing agent
incapable to induce these effect directly. It is generally
believed that free metal ions, mostly Cu and Fe are involved
in the transmission of H2O2 induced cell toxicity by Fenton-
like reactions.26 H2O2 has a longer half-time than other
reactive oxygene molecules singlet oxygen, superoxide
or hydroxyl radicals and may diffuse other compartment
of body from place of generation. We reported at our
preceding study; the erythrocyte glutathione peroxidase,
catalase and Cu/Zn superoxide dismutase activities and
plasma nitrite/nitrate levels were changed in patients with
vitiligo.27 Wu SC et al.28 reported an increased skin blood
flow and skin temperature in vitiligonous lesions. At these
conditions, increased shear stress may be the cause of free
radical production in blood.
In our study, we found increased MDA, HyPro and GSHPx
activity levels in plasma of vitiligo group. Catalase and
glutathione peroxidase catalyze the decomposition of
hydrogen peroxide. Cohen and Hochstein,29 using the H2O2
diffusion technique, offered evidence that catalase does
Table 1: Activity of GSHPx, and MDA, GSH,GSSG, Se and HyPro levels in vitiligo and control samples
MDA GSHPx Se
(nmol/mL) (U/mg prot) (ppb)
Vitiligo (n = 30) 0.642 ± 0.110a 0.550 ± 0.077a 122.333 ± 30.173
Control (n = 30) 0.494 ± 0.085 0.439 ± 0.075 120.766 ± 21.802
P < 0.05, vitiligo group was compared to control group
a
Indian J Dermatol 2008; 53(3) 108
not play an important role in protecting blood cells against
endogenous H2O2. Rather, thay concluded glutathione
peroxidase is the major route for disposing of H2O2. We
know that concentration of H2O2 is high in vitiligonous
area, and the diffusion of H2O2, which is thought to be
in high concentration in the lesion area, into plasma
will be more limited, but significant; but significantly as
statistically GSHPx activity elevated in response to possible
low concentration of H2O2 in plasma will be able to lead to
the detoxification of H2O2. Ines et al.30 reported decreased Q5
GSHPx activities of erythrocytes in vitiligo patients. One
of the sourches of plasma antioxidant enzymes is lysis of
erythrocytes. Increased plasma GSHPx activities may be
result of lysis of erythrocytes due to decreased GSHPx
activity and increased ROS levels in erythrocytes. On the
other hand, as the activity of GSHPx is high in plasma, it
led us to consider those antioxidant enzymes or molecules
that may lead to synthesis of mRNA for antioxidants
that are likely to be transported to blood from the other
components of body.
The consequence of increased free radicals via H2O2
generation and imbalances in oxidant/antioxidant balance
is oxidative stress, which leads to oxidative damage,
resulting in increased MDA levels, which is the end
product of lipid peroxidation. Koca et al.31 has reported
increased serum MDA levels in vitiligo. Similar findings
have been reported by Ines et al.30 and Yildirim et al.32. Our
results support the findings of these articles. On the other
hand, we found increased plasma HyPro levels in vitiligo
patients. Possible reasons of high HyPro levels may be the
damage of collagen tissue and nonenzymatic oxidation of
proline via free radicals. There is no study that evaluates
the relationship HyPro levels and vitiligo. However, it is
known that both of free and constitutional amino acids may
be oxidized by free radicals.
In our study we observed a slight but not significant increase
in plasma Se levels. Beazley et al.24 reported increased
serum Se levels in vitiligo. Similar results were reported
by Garsaud et al.33. Recently, Picardo et al.34 have claimed
that a cocktail containing various antioxidants, including Q6
selenomethionine, is beneficial in the repigmentation
process in vitiligo. Selenium, which is a crucial factor
for the function of the selenium-dependent isoenzyme of
glutathione peroxidase, has been shown to be elevated in
the serum of patients with vitiligo by other authors.24,35,36 In
addition, our results showed that plasma GSH and GSSG
levels did not change significantly. GSH is a component of
GSH GSSG HyPro
(nmol/mL) (nmol/mL) (mg/L)
4.497 ± 0.486 4.45 × 102− ± 0.6 × 102− 16.841 ± 1.856a
4.567 ± 0.497 4.66 × 10 ± 0.55 × 10
2− 2−
15.013 ± 2.231
 Ozturk et al.: Running title missing???
nonenzymatic antioxidant system and substrate for GSHPx.
Passi et al.37 showed that the epidermal GSH levels of active
vitiligo patients were significantly lower when compared
with the controls. Park et al.38 reported that glutathione
prevented dopamine-induced apoptosis of melanocytes.
In conclusion, vitiligo effects not only skin but also
other components of organism such as blood. However,
the effects on plasma is lower than skin. In addition,
we believe that the support of antioxidant system via
nonenzymatic antioxidant compounds and antioxidant
enzymes may be useful in the prevention of melanocyte
degeneration, which occurs due to oxidative damage in
vitiligo.
Acknowledgement
This research was generously supported by Inonu University
Research Fund.
References
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Schallreuter KU. Melanocytes are not absent in lesional skin of
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2. LePoole IC, Das PK, van den Wijngaard RM, Bos JD,
Westerhof W. Review of the etiopathomechanism of vitiligo: A
convergence theory. Exp Dermatol 1993;2:146-53.
3. Schallreuter KU, Wood JM, Berger J. Low catalase levels
in the epidermis of patients with vitiligo. J Invest Dermatol
1991;97:1081-5.
4. Maresca V, Roccella M, Roccella F, Camera E, Del Porto G,
Passi S, et al. Increased sensitivity to peroxidative agents as a
possible pathogenic factor of melanocyte damage in vitiligo.
J Invest Dermatol 1997;109:310-3.
5. Moellmann G, Klein-Angerer S, Scollay DA, Nordlund JJ,
Lerner AB. Extracellular granular material and degeneration of
keratinocytes in the normally pigmented epidermis of patients
with vitiligo. J Invest Dermatol 1982;79:321-30.
6. Bhawan J, Bhutani LK. Keratinocyte damage in vitiligo. J Cutan
Pathol 1983;10:207-12.
7. Courtney B, Casp Jin-Xiong S, Wayne T. Genetic association of
the catalase gene (CAT) with vitiligo susceptibility. Pigment Cell
Res 2002;15:62-6.
8. Schallreuter KU, Moor JM, Wood JM, Beazley WD, Gaze DC,
Tobin DJ, et al. In vivo and in vitro evidence for hydrogene
peroxide accumulation in the epidermis of patients with vitiligo
and its syccesfull removal by a UVB-activated pseudocatalase.
J Invest Dermatol Symp Proc 1999;4:91-6.
9. Micke P, Beeh K, Buhl R. Effects of long-term upplementation
with whey proteins on plasma glutathione levels of HIV-infected
patients. Eur J Nutr 2002;41:12-8.
10. Freeman BA, Crapo JD. Biology of disease: Free radicals and
tissue injury. Lab Invest 1982;47:412-26.
11. Flohe L, Beckmann R, Giertz H, Loschen G. Oxygen-centered
free radicals a mediators of inflammation. In: Sies H, editor.
Oxidative stress. New York: Academic Press; 1985. p. 405-37.
12. Kensler TW, Bush DM, Kozumbo WJ. Inhibition of tumor
promotion by a biomimetic superoxide dismutase. Science
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13. Ray G, Batra S, Shukla NK, Deo S, Raina V, Ashok S, et al.
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Lipid peroxidation, free radical production and antioxidant status
in breast cancer. Breast Cancer Res Treat 2000;59:163-70.
14. Lowry OH, Rosebrough NJ, Farr AL, Randall RI. Protein
measurement with the folin phenol reagent. J Biol Chem
1951;193:265-75.
15. Lawrence RA, Burk RF. GSHPX activity in rat liver. Biochem
Biophys Res Commun 1976;71:952-8.
16. Gavino VC, Miller JS, Ikharebha SO, Milo GE, Cornwall DG.
Effects of polyunsaturated fatty acids and antioxidants on lipid
peroxidation in tissue cultures. J Lipid Res 1981;22:763-9.
17. Owens CW, Belcher RV. A colorimetric micro-method for the
determination of glutathione. Biochem J 1965;94:705-10.
18. Breyer PH, Gilbert BP. Determination of selenium differantial
pulse voltametry of the 3,3’-diaminobenzidine piazselenol. Anal
Chem Acta 1987;201:23-32.
19. Watkinson JH. Flourometric determination of traces of selenium.
Anal Chem 1960;32:981-4.
20. Whetter PA, Ullrey DA. Improved flourometric method for
determining of selenium. J Assoc Anal Chem 1978;61:927-30.
21. Bergman I, Loxley R. New spectrophotometric method for the
determination of proline in tissue hydrolyzates. Anal Chem
1970;42:702-6.
22. Rokos H, Beazley WD, Schallreuter KU. Oxidative stress in
vitiligo: Photo-oxidation of pterins produces H2O2 and pterin-
6-carboxylic acid. Biochem Biophys Res Commun 2002;292:
805-11.
23. Aronoff S. Catalase: Kinetics of photo-oxidation. Science
1965;150:72-3.
24. Beazley WD, Gaze DC, Panske A, Panzig E, Schallreuter KU.
Serum selenium levels and glutathione peroxidase activities in
vitiligo. Br J Dermatol 1999;41:301-3.
25. Schallreuter KU, Elwary S. Hydrogen peroxide regulates the
cholinergic signal in a concentration dependent manner. Life Sci
2007;80:2221-6.
26. Ozben T. Free radicals and antioxidants in physical exercises. In:
Ozben T, editor. Free radicals, oxidative stres and antioxidants.
1st ed. London: Plenum Press; 1997. p.168-77.
27. Hazneci E, Karabulut AB, Ozturk C, Batcioglu K, Dogan G,
Karaca S, et al. A comparative study of superoxide dismutase,
catalase, and glutathione peroxidase activities and nitrate levels
in vitiligo patients. Int J Dermatol 2005;44:636-40.
28. Wu CS, Yu HS, Chang HR, Yu CL, Wu BN. Cutaneous blood
flow and adrenoceptor response increase in segmental-type
vitiligo lesions. J Dermatol Sci 2000;23:53-62.
29. Cohen G, Hochstein P. Generation of hydrogen peroxide in
erythrocytes by hemolytic agents. Biochemistry 1964;3:895-900.
30. Ines D, Sonia B, Riadh BM, Amel EG. A comparative study of
oxidant-antioxidant status in stable and active vitiligo patients.
Arch Dermatol Res 2006;298:147-52.
31. Koca R, Armutcu H, Altinyazar C, Gurel A. Oxidant-antioxidant
enzymes and lipid peroxidation in generalized vitiligo. Clin Exp
Dermatol 2004;29:406-9.
32. Yildirim M, Baysal V, Inaloz HS, Kesici D, Delibas N. The role
of oxidants and antioxidants in generalized vitiligo. J Dermatol
2003;30:104-8.
33. Garsaud AM, Garsaud P, Boisseau HL, Robert M. Increase
in total blood antioxidant status and selenium levels in black
patients with active vitiligo. Int J Dermatol 2002;41:640-2.
34. Picardo M, Camera E, Maresca V. Antioxidant treatment in
vitiligo. Pigment Cell Res 1997;10:360-3.
Indian J Dermatol 2008; 53(3)
 Ozturk et al.: Running title missing???

35. Halliwell B, Gutteridge JM. Ischemia/reoxygenation injury. In:
Halliwell B, Gutteridge JM, editors. Free radicals in biology
and medicine, 2nd ed. Oxford: Clarendon Press; 1985. p.
163-78.
36. Teherani DK, Nagy-Vezekenyi K. Neutron activation analysis
of some trace elements (selenium, chromium, cobalt and
nickel) in the blood of vitiligo patients. J Radioanal Nucl Chem
1986;104:53-8.
37. Passi S, Grandinetti M, Maggio F, Stancato A, De Luca C.
Epidermal oxidative stress in vitiligo. Pigment Cell Res
1998;2:81-5.
38. Park ES, Kim SY, Na IM, Ryu SH, Youn SW, Kim DS,
et al. Glutathione prevented dopamine-induced apoptosis of
melanocytes and its signaling. J Dermatol Sci 2007;47:141-9.
Received: December, 2007. Accepted: January, 2008.
Source of Support: Inonu University Research Fund,
Conflict of Interest: Nil.

Author Queries??????
Q1 check change
Q2 polypropylene?
Q3 a control?
Q4 flourescent?
Q5 This will statistically correspond to the elevation of GSHPx activity in response to the possibly low concentration
of H2O2 in plasma, which in turn will lead to the detoxification of H2O2. Please check if we can revise the
sentence like this.
Q6 misture of?

Indian J Dermatol 2008; 53(3) 110

Original Article

HIRSUTISM: CLINICO-INVESTIGATIVE PROFILE OF 50 INDIAN PATIENTS

Nand Lal Sharma, Vikram K Mahajan, Rashmi Jindal, Mudita Gupta, Anju Lath
Abstract

Background: Despite worldwide prevalence of hirsutism studies on hirsutism in Indian patients are not many. Aims: This
retrospective study was carried out to assess the clinico-investigative profile of patients presenting with hirsutism.
Materials and Methods: Medical records of 82 hirsutism patients diagnosed consecutively during July 2005 to October
2007 were analyzed. Results: The complete data of 50 patients aged between 13 and 47 years were available. Fifty
percent patients were aged 20 to 30 years. The average F-G score was 10.3 ± 2.46. Associated signs of hyperandrogenism
were acne (64%), oligomenorrhea or menstrual irregularities (36%), androgenetic alopecia (16%), acanthosis nigricans
(6%) and seborrhea (4%). Polycystic ovaries were detected in 30% patients and 22% patients had elevated serum free
testosterone levels. Family history of hirsutism was present in 18% patients. Conclusion: Hirsutism in Indian patients is
not uncommon. Adolescent patients appear to be more concerned about hirsutism as compared to those in the older age
group who were more often worried of late onset acne. All patients, however, were more concerned for facial hair than
those on other body areas signifying that facial hair need be given higher than current value in F-G score.

Key Words: Acne, hyperandrogenism, polycystic ovarian disease

Indian J Dermatol 2008:53(3):00-00******

Introduction poor self esteem, and psychological distress for women

Hirsutism is defined as male-pattern growth of terminal
body hair in women in androgen-stimulated locations such
as face, chest, and areolae. Hirsutism can be classified
broadly into 2 groups viz. androgen induced and non-
androgen induced. Androgen induced can either be due
to excessive endogenous androgen production (ovarian/
adrenal) or exogenous due to drugs. Central over production
of androgens, increased peripheral conversion of androgens,
decreased metabolism and enhanced receptor binding
are potential causes of hirsutism. Non-androgen induced
hirsutism can be idiopathic, familial or drug induced.
Other accompanying signs and symptoms of
hyperandrogenism include acanthosis nigricans, obesity,
pelvic mass, signs or symptoms of virilization, features of
Cushing’s syndrome, acne, increased sebaceous activity
and alopecia. The modified Ferriman-Gallwey (F-G) score1
is used to determine the severity of hirsutism by assessing
the extent of hair growth in 9 key anatomical sites. Simple
laboratory measurement of total and free testosterone,
dehydroepiandrosterone sulfate, and androstenedione
identifies about half of the patients with hyperandrogenism.
Hirsutism is a frequent reason of cosmetic embarrassment,
From the Departments of Dermatology, Venereology and
Leprosy, Indira Gandhi Medical College, Shimla, India.
Address correspondence to: Dr. N. L. Sharma, Departments
of Dermatology, Venereology and Leprosy, Indira Gandhi
Medical College, Shimla - 171 001, Himachal Pradesh, India.
E-mail: nandlals@hotmail.com
world over. However, hirsutism has rarely been studied in
Indian patients. In this communication, we report clinico-
investigative profile of 50 patients of hirsutism diagnosed
in the Dermatology Outpatient Department during July
2005 to October 2007.
Materials and Methods
Medical records of 82 patients of hirsutism maintained in
the department were analyzed retrospectively for age, family
history of hirsutism, medications and systemic diseases,
menstrual and obstetric history, and associated signs of
hyperandrogenism. Quantification of hirsutism was done
using modified F-G score [Table 1]. Investigations included
were estimation of thyroid hormones, free testosterone,
luteinizing hormone (LH), follicular stimulating hormone
(FSH) and serum prolactin levels and ultrasonography
(USG) for adrenals and ovaries. Polycystic ovarian
syndrome (PCSO) was diagnosed by Rotterdam criteria:
presence of two of the three elements viz. clinical or
biological hyperandrogenism, polycystic ovaries and chronic
anovulation.2 Polycystic ovaries (PCO) were diagnosed
on pelvic USG by presence of ≥12 follicles measuring
2-9 mm in diameter and/or ≥10 ml ovarian volume.3
Clinical hyperandrogenism was defined by presence of
hirsutism, acne or androgenetic alopecia.4 Oligomenorrhea
was defined as fewer than nine menses per year.5
Results
Data of only 50 patients was complete and could be analyzed
[Table 2]. Age of these patients was between 13-47 (Mean

111 Indian J Dermatol 2008; 53(3)

 Sharma et al.: Running title missing???

Table 1: Modified ferriman-gallwey semiquantitative scoring for hirsutism1

Sites Grade-1 Grade-2 Grade-3 Grade-4
Upper lip Few hairs at the Small moustache at Moustache extending Moustache extending
outer margin outer margin halfway from outer margin to mid-line
Chin Few scattered Scattered hairs with Complete cover, Complete cover,
hairs small concentrations light heavy
Chest Circumareolar hairs Circumareolar hairs with Fusion of circumareolar Complete cover
mid-line hair hairs with mid-line hair
giving three-quarter cover
Upper back Few scattered More than a few scattered Complete cover, light Complete cover,
hairs hair but still scattered heavy
Lower back Sacral tuft of hair Sacral tuft of hair with Three-quarter cover Complete cover
some lateral extension
Upper Few mid-line hairs Rather more but Half cover Complete cover
abdomen still mid-line
Lower Few mid-line Mid-line streak Mid-line band of hair An inverted
abdomen hairs of hair V-shaped growth
Upper arm Sparse hair growth More than a Complete cover, Complete cover,
and thigh affecting not more than quarter coverage but light heavy
a quarter of limb surface still incomplete
Forearm - - - Complete cover,
and legs heavy
Forearm and hand, lower leg and feet are not included in the ‘hormonal’ score and only single value is added even when hirsutism
involves these extremities bilaterally. Minimum score is zero and maximum is 36. A score of <8 = no hirsutism, 8-16 = mild hirsutism,
17-25 = moderate hirsutism, >25 = severe hirsutism. Values may vary in different ethnic groups

25.84 ± 8.30) years, 25 (50%) of them were in age group
of 20-30 years. The maximum hirsutism F-G score was
17 with an average of 10.3 ± 2.46. Acne was found to be
associated in 32 (64%) patients aged between 15-41 years.
Other signs of hyperandrogenism were acanthosis nigricans
in 3 (6%) and seborrhea in 2 (4%) patients respectively.
Oligomenorrhea or irregular menstrual cycles was reported
by 18 (36%) patients; 10 of them had PCO as well.
Androgenetic alopecia was observed in 8 (16%) patients.
Nine (18%) patients had history of hirsutism in first degree
relatives; 2 of them showed no investigative abnormality.
Eleven (22%) patients had no investigative/menstrual
abnormality except for a family history of hirsutism in first
degree relatives of 2 of these patients. None of the patients
was obese, hypertensive, diabetic or had clinical/laboratory
evidence of adrenal, thyroid or Cushing’s disease. No
patient had history of any drug intake.
Serum free testosterone levels were elevated in 11 (22%)
patients and 10 (20%) patients had elevated serum prolactin
levels. LH/FSH ratio was increased in 17 (34%) patients, 9 of
them had normal serum free testosterone levels and menstrual
cycles. Fifteen (30%) patients revealed polycystic ovaries on
pelvic USG. In total 17 (34%) patients fulfilled Rotterdam
criteria2 for hyperandrogenism of polycystic ovarian syndrome
origin and 9 of them also had anovulatory menstrual cycles.
Discussion
Hirsutism affects 5-10% of women of reproductive age.1
It can be classified as androgenic and non-androgenic
hirsutism. Hirsutism can be caused by abnormally high
androgen levels or by hair follicles which are more
sensitive than usual to normal androgen levels. Biologically
active free testosterone is responsible for hair growth and
is regulated by sex hormone-binding globulin. The causes
of androgenic hirsutism can be exogenous due to drugs
(testosterone, dehydroepiandrosterone sulfate, danazol,
corticotropin, high-dose corticosteroids, metyrapone,
phenothiazine derivatives, anabolic steroids, androgenic
progestin, and acetazolamide) or excess endogenous
androgen of adrenal or ovarian origin. Various causes of
ovarian hyperandrogenism are PCOS and virilizing ovarian
neoplasia (Luteoma of pregnancy, arrhenoblastomas, leydig
cell tumors, hilar cell tumors, thecal cell tumors, etc.).
However, PCOS alone accounts for 75-80% cases of
hyperandrogenism.4,6 Clinically the most common sign of
hyperandrogenism in PCOS is hirsutism. The prevalence
of hirsutism in PCOS varies between 17% and 83%.7
Polycystic ovaries were detected in our 30% patients.
However by using Rotterdam criteria for diagnosing PCOS,2
17 (64%) of our patients had clinical hyperandrogenism.
Acne appears another consistent feature and was found
in 64% patients across all age groups followed by
oligomenorrhea in 18% and androgenetic alopecia in
16% patients respectively. Acanthosis nigricans (6%) and
seborrhea (4%) appear other but less common signs of
hyperandrogenism in our patients. Since gonadotrophins
are released in a pulsatile manner their concentration varies

Indian J Dermatol 2008; 53(3) 112

 Sharma et al.: Running title missing???

Table 2: Clinico-investigative profile of 50 hirsutism patients

Case Age F.G. Acne Menstrual Family Free testosterone LH: FSH Serum Pelvic
No. (yrs) score history history of (N = 0.7-3.6 ng/ml) N < 2:1 prolactin USG
hirsutism N < 24ng/ml
1. 21 8 − Regular − Normal Normal Normal PCO
2. 38 8 − Regular − Normal Normal Normal PCO
3. 41 11 − Oligomenorrhea − Normal Normal Normal Normal
4. 24 14 − Regular − Normal Normal Normal Normal
5. 15 14 − Regular − Normal Increased Normal Normal
6. 19 12 + Regular + Normal Normal Normal Normal
7. 30 11 + Oligomenorrhea + Increased Normal Increased PCO
8. 23 9 − Regular − Normal Normal Normal Normal
9. 19 11 − Irregular − Increased Normal Increased PCO
10. 27 9 − Regular − Normal Increased Normal Normal
11. 24 11 − Regular − Normal Normal Normal PCO
12. 27 8 − Regular − Normal Increased Normal PCO
13. 25 13 + Regular + Increased Normal Increased Normal
14. 22 11 + Oligomenorrhea + Normal Normal Normal PCO
15. 31 12 − Regular − Increased Increased Increased PCO
16. 23 9 + Regular − Normal Normal Normal Normal
17. 20 8 − Regular − Normal Normal Normal PCO
18. 31 9 − Oligomenorrhea − Normal Normal Normal Normal
19. 18 9 − Regular − Normal Normal Normal PCO
20. 19 17 − Regular − Normal Normal Normal PCO
21. 18 9 + Oligomenorrhea + Normal Increased Normal Normal
22. 14 11 − Regular − Increased Increased Normal PCO
23. 38 9 − Regular − Normal Increased Normal Normal
24. 29 14 − Oligomenorrhea − Increased Normal Normal Normal
25. 21 9 − Irregular − Normal Increased Normal Normal
26. 47 11 − Regular − Normal Normal Normal Normal
27. 36 8 − Regular − Increased Normal Normal Normal
28. 22 15 − Regular − Normal Increased Normal Normal
29. 42 9 − Regular − Increased Increased Normal Normal
30. 40 9 − Regular − Normal Normal Normal Normal
31. 14 12 − Regular − Normal Increased Increased Normal
32. 30 12 − Regular − Normal Normal Normal Normal
33. 30 6 + Regular − Normal Increased Normal PCO
34. 27 11 + Oligomenorrhoea − Normal Normal Normal Normal
35. 18 16 + Irregular − Normal Normal Normal Normal
36. 24 8 − Oligomenorrhoea − Normal Normal Increased Normal
37. 17 11 − Regular − Increased Normal Normal Normal
38. 13 8 − Irregular − Normal Normal Normal Normal
39. 26 8 + Regular + Increased Normal Normal Normal
40. 34 12 − Regular − Normal Increased Normal Normal
41. 38 6 − Irregular − Normal Normal Increased Normal
42. 16 8 + Irregular − Normal Increased Normal Normal
43. 20 11 + Oligomenorrhoea − Normal Normal Increased PCO
44. 29 8 + Irregular + Normal Increased Normal Normal
45. 21 11 + Regular − Normal Increased Normal Normal
46. 15 13 + Regular + Normal Normal Normal Normal
47. 28 11 + Regular − Increased Normal Normal Normal
48. 36 8 + Irregular − Normal Normal Increased Normal
49. 29 7 + Irregular − Normal Increased Normal PCO
50. 23 10 − Regular + Normal Increased Increased Normal
F.G. Score - Ferriman-Gallwey score, + Present, − Absent, PCO - polycystic ovary, USG - ultrasonography, LH: FSH - Leutinising hor-
mone: Follicular stimulating hormone

113 Indian J Dermatol 2008; 53(3)

 Sharma et al.: Running title missing???
over the menstrual cycle and a single measurement of LH
and/or FSH may not be a sensitive method for diagnosis.5
This is also evident in our17 patients having abnormal LH
to FSH ratio but elevated serum free testosterone levels and
abnormal menstrual cycles, features of hyperandrogenism,
were observed in 11 and 9 patients only.
Adrenal hyperandrogenism is uncommon and seen
in congenital adrenal hyperplasia, late-onset adrenal
hyperplasia, Cushing’s syndrome, pituitary adenomas that
produce excess corticotropin or prolactin and acromegaly.
None of our patients had adrenal abnormality. Hirsutism
in 8 of 10 patients having raised serum prolactin levels
appears to be more of PCOS associated hyperandrogenism
in view of additional features such as elevated free
serum testosterone, LH-FSH ratio, oligomenorrhea and/or
polycystic ovaries.
The non-androgenic causes of hirsutism may be familial,
idiopathic or due to drugs like cyclosporine, phenytoin,
diazoxide, triamterene-hydrochlorothiazide, minoxidil,
hexachlorobenzene, penicillamine and psoralens. Other less
common causes include anorexia nervosa, hypothyroidism
and porphyria. Idiopathic hirsutism, also called simple or
peripheral hirsutism, is diagnosable in women who have
normal ovulatory function and normal androgen profile.
Only 5-15% of hirsute women qualify for this diagnosis
by these criteria.4,7,8 Except for our two patients who had
hirsutism in first degree relatives other 4 patients with
normal investigative profile can be considered to be of
idiopathic origin.
Despite limitations of small number of patients and lack of
long-term follow-up in most patients, the study indicates
that hirsutism in Indian women is not uncommon. Although
its clinical presentation does not differ from its description
in the literature, hirsutism of adrenal or thyroid origin does
not appear to be common in our patients. Interestingly,
Indian J Dermatol 2008; 53(3)
while patients in the adolescent group showed more concern
for their facial hair than acne, the patients in the older age
group had worries more often for late onset acne signifying
a varied perception of the same problem. However, all
patients were more concerned for facial hair than those on
other body areas. We feel that facial hair be given higher
than current value in F-G scoring system in view of the
psychological/cosmetic embarrassment it causes.
References
1. Hatch R, Rosenfield RL, Kim MH, Tredway D. Hirsutism:
implications, etiology and management. Am J Obstet Gynecol
1981;140:815-30.
2. Rotterdam ESHRE/ASRM sponsored PCOS consensus workshop
group 2004 revised 2003 consensus on diagnostic criteria and
long term health risk related to polycystic ovary syndrome. Hum
Reprod 2004;19:41-7.
3. Balen AH, Laven JS, Tan SL, Dewally D. Ultrasound assessment
of the polycystic ovary: International consensus definition. Hum
Reprod Update 2003;9:505-14.
4. Carmina E, Rosato F, Janni A, Risso M, Longo RA. Relative
prevalence of different androgen excess disorders in 950 women
referred because of clinical hyperandrogenism. J Clin Endocrinol
Metab 2006;91:2-6.
5. Ehrmann DA. Polycystic ovary syndrome. N Engl J Med
2005;32:773-7.
6. Azziz R, Sanchez LA, Knochenhauer ES, Moran C, Lazenby
J, Stephens KC, et al. Androgen excess in women: Experience
with over 1000 consecutive patients. J Clin Endocrinol Metab
2004;89:453-62.
7. Carmina E. Prevalence of idiopathic hirsutism. Eur J Endocrinol
1998;139:421-3.
8. Azziz R, Carmina E, Sawaya ME. Idiopathic hirsutism. Endocr
Rev 2000;21:347-62.
Received: November, 2007. Accepted: April, 2008.
Source of Support: Nil, Conflict of Interest: Nil.
114
 Original Article

RANDOMIZED COMPARATIVE CLINICAL TRIAL OF ARTEMISIA

SIEBERI 5% LOTION AND CLOTRIMAZOLE 1% LOTION FOR THE
TREATMENT OF PITYRIASIS VERSICOLOR
Farrokh Rad, Farzad Aala1, Naser Reshadmanesh2, Roksana Yaghmaie3
Q1 Abstract

Context: Tinea versicolor is a common fungal disease. Many topical and systemic drugs have been used for the treatment
of Tinea versicolor. But more or less the treatment results had been similar with high recurrence rates. Aims: The aim
of this study was to compare the therapeutic effects of topical Artremisia sieberi 5% lotion with topical clotrimazole 1%
lotion in the treatment of pityriasis versicolor. Settings and Design: This was a descriptive study which was conducted
in Sanandaj. Materials and Methods: This was a double-blind clinical trial. 100 patients with pityriasis versicolor and
microscopic identification of Malassezia furfur were randomly assigned to treatment with either topical Artemisia sieberi
5% lotion (group 1) or topical clotrimazole 1% lotion (group 2) for 2 weeks. Group 1 and group 2 consisted of 51 and 49
patients respectively. The patients were evaluated both clinically and mycologically at baseline and every 2 weeks for a
period of 4 weeks. Statistical Analysis Used: The data were processed with SPSSwin13 software and data analysis was
performed by means of independent t test, X2, and Fisher’s exact test. Results: In this study, at the end of the second
week, clinical cure rates were 86.3% and 65.3% for group 1 and group 2 respectively (P < 0.01), but at the same time
mycological cure rate was 92.2% for group 1 and 73.5% for group 2 (P < 0.05), which revealed significant differences
clinically and mycologically. At the end of the fourth week (2 weeks after cessation of the treatments), clinical cure
rates were 86.3% and 59.2% for group 1 and group 2 respectively (P < 0.01), and at the same time mycologic cure rate
was 96.1% for group 1 and 65.3% for group 2 (P < 0.01), which demonstrated significant differences, clinically and
mycologically. Conclusions: The results of this study demonstrated that Artemisia sieberi 5% lotion was more effective
than clotrimazole 1% lotion in the treatment of pityriasis versicolor and the recurrence rate with clotrimazole lotion was
high but in the Artemisia sieberi group no recurrence was detected.

Key Words: Artemisia sieberi lotion, clotrimazole lotion, pityriasis versicolor, recurrence ratre

Indian J Dermatol 2008:53(3):00-00******

Q2 Introduction treatments with ketoconazole, itraconazole or fluconazole

Pityriasis versiclor (tinea versicolor) is a common
superficial fungal infection of the stratum corneum caused
Q3 by the fungus Malassezia furfur taht classically affecting
young people around the pubertal time.1,2 The pale type
of pityriasis versicolor is thought to be due to a chemical
produced by Malassezia that diffuses down and impairs
the function of the pigment cells in the underlying skin.3
There are numerous ways of treating pityriasis versicolor
topically and systemically. However the recurrence rate
is very high4 and different studies have shown different
therapeutic results.5-7 However, relapse is very common and
researchers are working to produce more effective drugs.8
Propylene glycol 50% in water, imidazole and the older
antidandruff shampoos as well as ciclopiroxolamine
and terbinafine are effective topically. Short-term oral
From the Departments of 1Parasitology, 2Health and
3
Dermatology, Kurdistan University of Medical Sciences,
Iran. Address correspondence to: Dr. Farrokh Rad,
Keshavarz Ave, Besat hospital, Sanandaj, Kurdistan, Iran.
E-mail: dr_farokh_rad@yahoo.com
are very effective and the risk for side-effects minimized
with short treatment regimen.4 In a double-blind clinical
trial therapeutic effect of Artimisia sieberi 5% lotion
was compared with that of clotrimazole 1% lotion in the
treatment of pityriasis versicolor.9 In the microscopic study,
negative direct smears observed in Artimisia sieberi group
and clotrimazole group were 87.1% and 69% in the second
week, and 100% and 61.5% in the fourth week (2 weeks
after cessation of therapy) respectively.9
Artimesia sieberi is a native shrub growing in northern
Iran.10,11 Alpha- and beta-thujones are important herbal
medicines and food additives.12 Alpha-thujone generally is
considered to be the principal active ingredient of worm
wood oil.13-15
LD50 of alpha-thujone in rats is 500 mg/kg by oral route
and 5000 mg/kg in rabbits by way of dermal contact. At a
concentration of 4% alpha-thujone was negative in dermal
irritation and maximization tests in humans.16 The aim
of the present study was to compare efficacy of topical
Artemisia sieberi 5% lotion with that of clotrimazole 1%
lotion in the treatment of pityriasis versicolor.

115 Indian J Dermatol 2008; 53(3)

 Rad et al.: Artemisia sieberi 5% lotion and clotrimazole 1% lotion for the treatment of pityriasis versicolor
Materials and Methods
The study was a randomized, double-blind clinical trial.
After informed consent, 102 patients with pityriasis
versicolor were enrolled in the study. The diagnosis
was made on clinical examination and confirmed with
microscopic examination of scales soaked in 10-15%
potassium hydroxide.
This study was approved by Ethical Review Committee of
Kurdistan University of Medical Sciences and conformed to
the ethical guidelines of the 1975 Declaration of Helsinki.
Inclusion criteria were as follows: clinical diagnosis of
pityriasis versicolor and its confirmation with microscopic
examination in patients between 15 and 45 years of age,
and involvement of less than 10% of the total body surface
by skin lesions.
Pregnant and lactating women were excluded from the
study. The patients were randomly divided into two groups.
Group 1 used 1-2 ml of Artimisia sieberi 5% topical lotion
produced by Barij Essence Pharmaceutical Company in
Iran, twice daily and group 2 applied 1-2 ml of clotrimazole
topical lotion on the lesions twice daily, for two weeks.
Of 102 patients, 100 completed the treatment course
(51 patients in group 1 and 49 patients in group 2 respectively).
Two patients were lost to follow-up and excluded from the
study. Disappearance of all skin lesions on inspection was
our criterion for clinical cure and negative direct smear in
microscopic study was regarded as mycological cure.17
Skin assessment and microscopic examination of skin
smears were performed at baseline, after completion of the
two-week treatment course, and two weeks after cessation
of the topical agents. The phone numbers and addresses
of the patients were recorded in their files. One of our
colleagues was responsible to call the patients to remind
them of the follow-up visits, but in the event they did not
come, he referred to them to take skin smear and evaluate
the patients for clinical cure rate (assessment of the
clinical cure rate for all of the patients was performed by
the same person). Results of the clinical and microscopic
examinations and demographic data of the patients were
recorded in a check- list for each of the patients.
The data were processed with SPSS Win13 software and
data analysis was performed by means of independent t test,
Chi- square tests, and Fisher’s exact test.
Results
Analysis of the two treatment groups at baseline, as
explained in the following paragraphs revealed no significant
differences between the group 1 and group 2 patients in
relation to age, sex distribution, number of weekly baths,
distribution and location of the skin lesions, occupation,
disease duration, and family history of the patients;
suggesting that the randomized arms were equivalent.
Indian J Dermatol 2008; 53(3)
There were 27 (27%) female and 73 (73%) male patients;
sex distribution was similar in both groups (70.6% male in
group 1 and 75.5% male in group 2) (P = 0.65).
The mean age of the patients was 26.5 ± 9.8 (range
15-45 years) (P = 0.26). The mean numbers of weekly
baths were 1.5 ± 0.2 and 1.8 ± 0.25 for group 1 and
group 2 respectively. The mean values for disease duration
in group 1 and group 2 were 3.09 ± 0.43 and 3.61 ± 0.51
months respectively.
From the occupational point of view, no significant
difference was noted between the two groups (P = 0.31).
Distributions of lesions over different parts of the body
(Neck, chest, abdomen, back arms…) was similar in both
groups (P = 0.67).
19.6% of the patients of group 1 and 16.3% of the patients
of group 2 had positive family history of pityriasis
versicolor (P = 0.76).
Clinical assessment of the patients, after two weeks
revealed that 86.3% of the patients of group 1 and 65.3%
of the patients of group 2 achieved success, which was
statistically significant (P < 0.05). Mycological examination
of the skin smears at the same time demonstrated cure rates
of 92.2% and 73.5% for group 1 and group 2 respectively,
which showed a significant difference (P < 0.05).
After four weeks (2 weeks after cessation of the treatments)
clinical cure rates were 86.3% and 59.2% (P < 0.01) and
mycological cure rates at the same time were 96.1% and
65.3% (P < 0.01) for group 1 and group 2 respectively
[Table 1].
Among the cured patients, the recurrence rates clinically
(assessed only by inspection of the skin) and mycologically
(assessed by microscopic examination of the skin smears)
were 9.4% and 11.1% respectively, in the patients of
group 2. However we noticed no recurrence of the skin
lesions, clinically and mycologically in the patients of the
group 1, which was statistically significant (P < 0.01).
Discussion
At the end of the second week of this study, clinical
assessment demonstrated a higher cure rate in Artemisia
sieberi group than clotrimazole group (P < 0.05). At the
same time, in microscopic study, rate of negative direct
smears was higher in group 1 (P < 0.05).
After four weeks from the start of the treatment regimens
clinical re-evaluation of the patients revealed a higher cure
rate in group 1 than group 2 (P < 0.01). At the same time
a higher number of the patients of group 1 had negative
direct smears, compared with group 2 patients (P < 0.01). In
this study the results of clinical evaluation and microscopic
examination showed that Artemisia sieberi lotion was
superior to clotrimazole lotion in the treatment of pityriasis
versicolor. It is likely that active antifungal constituent(s)
116
 Rad et al.: Artemisia sieberi 5% lotion and clotrimazole 1% lotion for the treatment of pityriasis versicolor

Table 1: Comparison of the therapeutic effects of Artemisia sieberi lotion with clotrimazole lotion based on clinical
examination and skin smear after 2 and 4 weeks of the treatment regimens
Group Improvement N (%) Lack of improvement N (%) X2 P
Clinical examination
2 weeks
Artemesia 44 (86.3) 7 (13.7) 6.1 0.01
Clotrimazol 32 (65.3) 17 (34.7)
4 weeks
Artemesia 44 (86.3) 7 (13.7) 9.3 0.002
Clotrimazol 29 (59.2) 20 (40.8)
Skin smear
2 weeks
Artemesia 47 (92.2) 4 (7.8) 6.43 0.01
Clotrimazol 36 (13) 13 (26.5)
4 weeks
Artemesia 49 (96.1) 2 (3.9) 15.3 0.000
Clotrimazol 32 (65.3) 17 (34.7)

of Artemisia sieberi persisted in the superficial layer of skin
for a longer period than did clotrimazole and prevented
early recurrence of pityriasis versicolor.
In a similar double-blind clinical trial, by Mansouri and
her colleague’s significant clinical improvement, after two
weeks was observed in 77.4% and 60.7%, and after 4 weeks
in 93.5% and 57.1% of the patients in Artemisia sieberi
group and clotrimazole group respectively. After two weeks
Mansouri found negative direct smears in 87.1% and 69%,
and after four weeks in 100% and 61.5% of the patients
in Artemisia group and clotrimazole group respectively.9 In
the above mentioned study the results of clinical assessment
and microscopic examination were compatible with those
of our study.
Clinical cure rates after two and four weeks were lower
variety of plants including Artemisia species, sage and
the Thuja tree.14,16 Alpha- thujone has also antihelminthic,
insecticidal, and antinociceptive properties.14,18,19
Conclusion
This double- blind clinical trial shows that Atremisia sieberi
5% lotion is more effective than clotrimazole 1% lotion
in the treatment of pityriasis versicolor. According to the
results of our study, recurrence rate is expected to be much
lower with Artemisia sieberi 5% lotion than clotrimazole
1% lotion after cessation of the therapeutic agents. This
study emphasizes the need for definitive studies to address
this issue in the future.
References Q4

than mycological cure rates at the same time periods.
Therefore accuracy of the laboratory- based care rates was
higher than that of clinically- assessed cure rates.
Occasionally in the pale type of pityriasis versicolor white
marks are permanent for unknown reasons, persisting long
after the scaling and yeasts have gone and despite exposure
to the sun.3
In such cases results of the direct smear of the
hypopigmented lesions are negative and clinically these
patients may be misdiagnosed as cases of untreated pityriasis
versicolor. Therefore sometimes clinical assessment and
laboratory results may be incompatible. It is very likely
that antifungal effect of Artemisia sieberi lotion is due to
alpha- thujone.
The mechanism by which alpha- thujone is of therapeutic
benefit in pityriasis versicolor is unclear at present. Alpha-
thujon is a constituent of essential oils derived from a
1. Savin R. Diagnosis and treatment of tinea versicolor. J Fam Pract
1996;43:127-32.
2. Faergemann J. Management of seborrheic dermatitis and
pityriasis versicolor. Am J Clin Dermatol 2000;1:75-80.
3. Thoma W, Krämer HJ, Mayser P. Pityriasis versicolor alba. J Eur
Acad Dermatol Venereol 2005;19:147-52.
4. Faergemann J. Pityrisis versicolor. Semin Dermatol 1993;12:276-9.
5. Montero-Gei F, Robles ME, Suchil P. Fluconazole vs itraconazole
in the treatment of tinea versicolor. Int J Dermatol 1999;38:601-3
6. Farshchian M, Yaghoobi R, Samadi K. Fluconazole versus
ketoconazole in the treatment of tinea versicolor. J Dermatol
Treat 2002;13:73-6.
7. Chu AC. Comparative clinical trial of bifonzole solution versus
selenium sulphide shampoo in the treatment of pityriasis
versicolor. Dermatologica 1984;169:81-6.
8. Vander Straten, Hossain MA, Ghannom MA. Cutaneous infection,
dermatophytosis, onychomycosis and tinea versicolor. Infect Clin
North Am 2003;17:87-112.
9. Mansouri P, Kashanian M, Bekhradi R, Hakmat H. Artemesia

117 Indian J Dermatol 2008; 53(3)

 Rad et al.: Artemisia sieberi 5% lotion and clotrimazole 1% lotion for the treatment of pityriasis versicolor

sieberi lotion 5% compared with clotrimazole lotion in the
treatment of tinea versicolor. Iran J Pharma Res 2004;2:38.
10. Habibi R, Shakoei M. Ecological regions of Iran vegetation
types of Tehran area. 1382. Available from: http:/www.rifr-ac.ir/
English/books/details.aspx?id=1000019.
11. Tavili A, Jafari M. Comparing artemisisa sieberi besser and
artemisia scoparia waldst and kit: Elemental content grown on
crusted and uncrusted soils. Pak J Nutr 2006;5:10-3.
12. Sirisoma NS, Höld KM, Casida JE. Alpha- and beta- Thujones
(herbal medicines and food additives): Synhthesis and analysis
of hydroxy and dehydro metabolites. J Agric Food Chem
2001;49:1915-21.
13. Arnold WN. Absinthe. Sci Am 1989;260:112-7.
14. Lachenmeier DW, Walch SG, Padosch SA, Kroner LU. Absinthe:
A review. Crit Rev Food Sci Nutr 2006;46:365-77.
15. Weisbord SD, Soule JB, Kimmel PL. Poison on line- acute
renal failure caused by oil of worm wood purchased through the
internet. N Engl J Med 1997;337:825-7.
16. FEMA. FEMA Database: Thujone. Washington, DC: Flavor and
Extract Manufacturer’s Association; 1997. p. 12.
17. Delescluse J. Itraconazole in tinea vesicolor: A review. J Am
Acad Dermatol 1990;23:551-4.
18. Lee s, Tsao R, Peterson C, Coats JR. Insecticidal activity
of monoterpenoids to western corn rootworm (Coleoptera:
Chrysomelidae), twospotted spider mite (Acari: Tetranychidae),
and house fly (Diptera: Muscidae). J Econ Entomol 1997;90:
883-92.
19. Rice KC, Wilson RS. (-)-3-Isothujone, a small nonnitrogenous
molecule with antinociceptive activity in mice. J Med Chem
1976;19:1054-7.
Received: October, 2007. Accepted: April, 2008.
Source of Support: Nil, Conflict of Interest: Nil.

Author Queries??????
Q1 Approximately 250 words
Q2 Include why this study was conducted, what were the aims and objectives of the study.
Q3 Should this be deleted?
Q4 Follow the punctuation marks carefully. Do not include unnecessary bibliographic elements such as issue number,
month of publication, etc. Include names of six authors followed by et al if there are more than six authors.

Indian J Dermatol 2008; 53(3) 118

Original Article

UNDIAGNOSED DIABETES MELLITUS IN PATIENTS WITH HERPES

ZOSTER
Mohammad Nassaji-Zavare, Ramin Taheri1, Raheb Ghorbani2, Maryam Aminian
Abstract

Background and Aim: Herpes Zoster (HZ) is reactivation of latent varicella-zoster virus that involves dermatomes. Aging
and immunosupressed states are among the main risk factors. Some investigations showed that HZ is more common in
diabetic patients than in normal population. Aim: To determine whether undiagnosed DM is more common in patients
with HZ than in those without it. Materials and Methods: In this study 103 patients with HZ (cases) and 142 as control
participated. They had no history of DM. Both groups were matched according to age, gender and family history of DM.
Fasting plasma glucose was checked for all participants. DM was defined when the fasting plasma glucose was equal
or more 126 mg/dl. Results: 35.9% of patients with HZ and 19.7% of the control group had DM. There was significant
association between HZ and undiagnosed DM (OR = 2.28, 95% CI: 1.28-4.06). Conclusion: Our findings indicate that
the prevalence of undiagnosed DM is more common in HZ patients and supports the policy to investigate patients with
HZ for the presence of undiagnosed DM.

Key Words: Diabetes mellitus, fasting plasma glucose, herpes zoster

Indian J Dermatol 2008:53(3):00-00******

Introduction this include abnormality in cell mediated immunity and

Herpes zoster (HZ) is the reactivation of Varicella-Zoster
virus (VZV) that becomes latent after primary infection
within the dorsal root ganglia. It affects about 20% of
the population mainly the elderly. The factors that are
responsible for reactivation are not well known, but appear
to be dependent on a balance between virus and host
factors. During reactivation, VZV overwhelms immune
control and spreads in the affected ganglia and sensory
nerves to the skin.1
Immune dysfunction in certain diseases and states is a
potent trigger for HZ. Most commonly, advanced age,
which acts as a surrogate for waning of cell-mediated
immunity, is an important recognized risk factor.2 In patients
with impaired immunity, both the incidence and severity of
HZ are increased.3 This is seen in malignancies especially
lymphoma, patients receiving immunosuppression therapy
and HIV infection.4
Diabetes mellitus (DM) comprises a group of metabolic
disorders that share the phenotype of hyperglycemia. The
incidence of DM has increased in the past two decades.
Individuals with DM have a greater frequency and
severity of infections. Several rare infections are seen
almost exclusively in diabetic population. The reasons for
From Departments of Infectious Diseases, 1Dermatology and
2
Social Medicine, Semnan University of Medical Sciences,
Semnan, Iran. Address correspondence to: Dr. Mohammad
Nassaji Zavareh, Department of Infectious Diseases, Fatemieh
hospital, Semnan University of Medical Sciences, Semnan, Iran.
E-mail: hnassaji@yahoo.com
phagocyte functions associated with hyperglycemia.5
Undiagnosed DM especially type 2 is common, with an
estimated lag of five to seven years between the onset of
the disease and diagnosis. It is estimated that up to fifty
percent of people are unaware of their disease. Incidence
of undiagnosed DM increase with age. The size of the
undiagnosed fraction of adults with diabetes is a major
public health concern, heightened by the evidence that the
latent stage is likely to be long, and that diabetes-related
complications may develop.6
Early detection of DM and intervention improve long-
term outcome, therefore it is important for the physicians
to screen for DM in subjects who demonstrate major risk
factors. Identification of such individuals may also be a
worthwhile objective.7
The revised criteria for the diagnosis of DM emphasize the
fasting plasma glucose (FPG) as a reliable and convenient
test for diagnosis of DM in asymptomatic individuals.5
However, little is currently known concerning the clinical
and socio-demographic characteristics of those individuals
that they should constitute a target for the screening and
management of impaired glucose level.
There are some reports indicating that HZ occurs more
frequently in patients with diagnosed DM rather than
normal population.8-10 Although suspected of being a
marker of undiagnosed DM, information on this subject is
scarce, and there are a few studies for evaluation of HZ
as a marker of undiagnosed DM. If it could be proven

119 Indian J Dermatol 2008; 53(3)

 Nassaji-Zavare et al.: Running title missing???

that HZ is an indicator of DM, this could alert clinician to

screening these patients for undiagnosed DM. This study Table 1: Characteristics of two groups
was designed to evaluate the probable relationship between Factor Study group P-value
HZ and undiagnosed DM. On the other hand the objective Herpes zoster Control
was to answer this question; is undiagnosed DM more n% n%
common in HZ patients than in those without it? Age
<50.0 48 46.6 71 50 NS*
Materials and Methods ≥50.0 55 53.4 71 50
In this case-control study, patients that visited dermatology Gender
and infectious diseases clinics with HZ enrolled as cases. Female 53 51.5 64 45.1 NS
HZ was diagnosed for them by dermatologist and infectious Male 50 48.5 78 54.9
specialist based on clinical findings. Patients that visited for
Family history
other diseases in the same clinics, in the same duration and of DM
had no history of previous HZ enrolled as controls. In both
+ 1 1.0 2 1.4 NS
groups, individuals with past history of DM or symptoms
suggestive of DM (Polyuria, Polydypsia, Weight loss), those - 102 99.0 140 98.6
with known immunosuppressive disorders (HIV infections, *NS: Not significant
chemotherapy, transplantation, neoplastic disorders) and
those receiving drugs that increase blood glucose level approved in some immunosuppressed states. In a study,
(Corticosteroids, beta-blockers, thyroid hormones, thiazides, 28.4% of 67 patients with HZ were immunocompromised.
etc) were excluded. The presence of diagnosed diabetes Nine patients had malignancy and 13 patients had been on
was based on the patient’s history and/or if they used cytotoxic and/or steroid therapy.12
hypoglycemic agents. Two groups were matched for age and
gender. Family history of DM was recorded for both groups. In Donahue et al, study, from 1075 cases with HZ, HIV
infection was documented in 5% and cancer in 6%.13
After informed consent, for each individual after twelve
hours fasting blood sample was taken for measurement of DM can cause abnormalities in various parts of immunity
FPG using standard laboratory test. For overcoming stress- system and can increase risk and severity of infections.
induced hyperglycemia, FPG of cases was measured after Our study showed significant association between HZ and
healing of vesicular eruption and subsiding pain. If control undiagnosed DM. The estimated odds ratio of HZ group
subjects had any acute disease, their FPG was measured was 2.28 in relation to control group. In McCulloch study
after subsiding problem. Subjects were considered as 12.7% 0f 1017 diabetic patients had past history of HZ
having undiagnosed diabetes when FPG level was equal or and 61% of these patients developed HZ before the onset
over 126 mg/100 ml.11 of DM.14 In accordance with our study, Neu and Rodiek
detected disorder of glucose utilization in 16 of 28 HZ
Kolmogrov-Smirnov, Independent samples t, Chi-square, patients.8
Fisher exact tests, Odds Ratio (OR) and 95% Confidence
Interval (CI) were used for the statistical evaluation of the In another study it was found that among 140 patients
data. P-value less than 0.05 were considered statistically with HZ, 13.5% of patients had DM, which is significantly
significant. Statistical analysis was performed by SPSS higher than general incidence of 2%. When patients over
version 9.0 for windows. 50 years old were considered separately, the incidence goes
up to 17%.15 In Cerny study 12 patients with recurrent HZ
Results were evaluated. Three of the patients had DM.16 In 31 cases
of HZ with neurological complications; smoking with
103 patients with HZ and 142 patients without HZ fulfilled diabetes was the putative risk factors in 53%.9
inclusion criteria. Mean (±SD) age of cases was 51.9
(±16.6) and for controls was 50.2 (±14.3), that difference In contrast to our finding in a prospective study on
was not significant (P = 0.407). The case group included 590 patients with HZ, the clinical spectrum of the disease
53 (51.5%) and controls 64 (45.1%) female (P = 0.233). was not different from general population. They concluded
Family history of DM was positive in 1% of HZ patients that HZ is not a risk factor for DM and diabetes was not a
and 1.4% of those without HZ [Table 1]. risk factor for HZ.17
35.9% of patients with HZ and 19.7% of controls had Our study has several limitations. First, the number of
FPG ≥ 126. There was a significant association between patients is relatively small.
HZ and undiagnosed DM (OR = 2.28, CI 95%: 1.28-4.06) Secondly, our patients were from same province. Study
in other areas is recommended. Based on our finding
Discussion
we conclude that undiagnosed DM is more common in
Increased incidence and severity of HZ have been HZ patients than in patients without this disease. It may

Indian J Dermatol 2008; 53(3) 120

 Nassaji-Zavare et al.: Running title missing???
be related to deterioration of immunity. We therefore,
recommend that HZ can be considered as a criterion for
screening of undiagnosed DM. More research is needed to
test this hypothesis.
References
1. Whitley R. Varicella-Zoster virus. In: Mandell G, Bennett J,
Dolin R, editors. Principles and practice of infectious disease.
6nd ed. Philadelphia: Churchill- Livingstone; 2005. p. 1781-5.
2. Mandal BK. Herpes zoster in the immunocompromized
populations. Indian J Dermatol 2006;51:235-43.
3. Burns T, Breathnach S, Cox N, Christopher G. Rook’s textbook of
dermatology, 17th ed. Massachusetts: Blackwell; 2004. p. 22-8.
4. Mazur MH, Dolin R. Herpes zoster at the NIH: A 20 year
experience. Am J Med 1978;65:738-44.
5. Powers A. Diabetes mellitus. In: Kasper DL, Fauci AS, Longo D,
et al, editors. Harrison’s principles of internal medicine. 16th ed.
New York: McGraw-Hill; 2005. p. 2169-70.
6. Wilder RP, Majumdar SR, Klarenbach SW, Jacobs P. Socio-
economic status and undiagnosed diabetes. Diabetes Res Clin
Pract 2005;7026-30.
7. Buse J, Polansky K, Burant C. Disorders of carbohydrate and
lipid metabolism. In: Larsen R, Kronenbrey H, Melmed S,
Polansky K, editors. Williams textbook of endocrinology, 10th ed.
Philadelphia: Saunders; 2003. p. 1427-9.
8. Neu I, Rodiek S. Significance of diabetes mellitus in the
activation of the varicella zoster virus. MMW Munch Med
Wochenschr 1977;119:543-6.
121
9. Guidetti D, Gabbi E, Motti L, Ferrarini G. Neurological
complications of herpes zoster. Ital J Neurol Sci 1990;11:
559-65.
10. Najadawi F, Faouri M. Frequency and types of skin disorders
and associated diabetes mellitus elderly Jordanians. East Mediterr
Health J 2002;8:574-8.
11. The Expert Committee on the Diagnosis and Classification
of Diabetes Mellitus: Report of the Expert Committee on the
Diagnosis and Classification of Diabetes Mellitus. Diabetes Care
1997;20:1183-97.
12. Oh HM, Ho AY, Chew SK, Monteiro EH. Clinical presentation
of herpes zoster in a Singapore hospital. Singapore Med J
1997;38:471-4.
13. Donahue JG, Choo PW, Manson JE, Platt R. The incidence of
herpes zoster. Arch Intern Med 1995;155:1605-9.
14. McCulloch DK, Fraser DM, Duncan LP. Shingles in diabetes
mellitus. Practitioner 1982;226:531-2.
15. Brown GR. Herpes zoster: Correlation of age, sex, distribution,
neuralgia and associated disorders. South Med J 1976;69:
576-8.
16. Cerny Z. Recurrent eruptions of herpes zoster. Bratisl Lek Listy
1999;100:515-8.
17. Ragozzio MW, Melton LJ, Kurland LT,. Herpes zoster and
diabetes mellitus: An epidemiological investigation. J Chronic
Dis 1983;36:501-5.
Received: April, 2007. Accepted: April, 2008.
Source of Support: Nil, Conflict of Interest: Nil.
Indian J Dermatol 2008; 53(3)
Original Article

BACTERIAL RESISTANCE TO ANTIBIOTICS IN ACNE VULGARIS: AN

IN VITRO STUDY
Parvin Hassanzadeh, M Bahmani1, Davood Mehrabani2
Abstract

Background: Acne vulgaris is one of the most common skin disorders in youth especially during the puberty. Objective: This
in vitro study was performed to determine the antibiotic resistance and sensitivity in acne vulgaris. Materials and
Methods: Samples were collected from normal skin and nodulocystic and pustular skin lesions of one hundred youngsters
(64 girls, 36 boys) among college students in the age range of 18-24 years old. The specimens were cultured individually
on blood agar and Muller-Hinton media. The cultures were then incubated under both aerobic and anaerobic conditions for
2 to 7 days. Bacteria were identified and their resistance to common antibiotics was evaluated according to the standard
procedures. Results: In aerobic culture of pustular and nodulocystic skin lesions, Staphylococcus aureus was present in
41% of subjects, Staphylococcus epidermidis in 53% and Micrococcus spp in 45% of subjucts. In anaerobic bacterial
culture of pustular and nodulocystic skin lesions, Staphylococcus aureus was present in 39%, Propionibacterium acne
in 33% and Staphylococcus epidermidis in 21% of subjects. The results of present study revealed that clindamycin and
erythromycin were the least effective antibiotics for Propionibacterium acne while tetracycline was the least effective for
Staphylococcus aureus in vitro. A synergic effect of benzoyl peroxide, erythromycin or clindamycin was noticed. Rifampin
was the most effective antibiotic in vitro. Conclusion: Our results showed that rifampin was the most sensitive antibiotic
in vitro for acne vulgaris. To achieve a better treatment, a combination of rifampin with other antibiotics may be more
efficient. We suggest in vivo studies for better evaluation and treatment of acne patients with rifampin.

Key Words: Acne vulgaris, antibiotic resistance, southern Iran, rifampin

Indian J Dermatol 2008:53(3):00-00******

Introduction acne, Staphylococcus epidermidis and Malasezia furfur.3

Depending on the severity of the disease, the acne patients
Acne vulgaris is a chronic inflammatory disorder of
receive topical or systemic therapy, or a combination.7,8
pilosebaceous follicles that affects more than 85 percent
Pathogenesis of microorganism originates from production
of adolescents and young adults.1,2 Four major factors are
of proinflammatory mediators (e.g. IL-1, TNFα) as well as
involved in the pathogenesis including increased sebum
many lipases. Increased number of Propionibacterium acne
production, hypercornification of the pilosebaceous duct, an
was reported in acne patients, but their number was not
abnormality of the microbial flora especially colonization of
correlated with the clinical severity.9 Due to development
the duct with Propionibacterium acnes), and the production
of a resistance in microorganisms causing acne to common
of inflammation.3 It seems that several factors influence acne
antibiotics and the differences in species and strains of
including diet, menstruation, sweating, stress, ultra violet
the microorganisms in different regions, a research in the
radiation and occupation.4 Positive association between
method of therapy seems indispensable.10,11 This study was
intake of milk and acne was reported and this findings
undertaken to determine bacteria involved in acne vulgaris
support earlier studies and suggests that the metabolic
in Shiraz, southern Iran and to clarify the in vitro antibiotic
effects of milk are sufficient to elicit biological responses in
sensitivity in acne vulgaris.
consumers.5 It was also reported that a low-glycemic-load
diet improves symptoms in acne vulgaris patients.6 Acne is Materials and Methods
not an infectious disease, but three major organisms were
isolated from the surface of the skin and the pilosebaceous Samples from the normal skin and pustular and nodulocystic
duct of patients with acne including Propionibacterium skin lesions were provided in 100 youngsters (64 girls,
36 boys) among college students, in the age range of
18-24 years. The subjects were asked to refer to Department
From the Department of Biology, School of Sciences, Shiraz
of Biology of School of Sciences, Shiraz University from
University, Shiraz, Iran; 1Departments of Dermatology and
Pathology, Faghihi Hospital, 2Gastroenterohepathology Research
October 2004 to March 2005. The samples were immediately
Center, Nemazee Hospital, Shiraz University of Medical Sciences, cultured individually on blood agar and Muller-Hinton media.
Shiraz, Iran. Address correspondence to: Parvin Hasanzadeh, The cultures were then incubated at 37°C under both aerobic
Department of Biology, School of Sciences, Shiraz University, and anaerobic conditions for 2 to 7 days. The colonies
Shiraz, Iran. E-mail: hassanzadeh@susc.ac.ir species were determined morphologically by specific culture Q1

Indian J Dermatol 2008; 53(3) 122

 Hassanzadeh et al.: Acne and antibiotic resistance

Table 1: Analysis of bacteria in samples obtained from youngsters [n = 100]

Cultures Samples S. aureus S. epidermidis P. acne Micrococcus spp
Aerobic Pustular and nodulocystic skin lesions (n) 51 53 - 45
Microflora of normal skin (n) 30 73 - 32
Anaerobic Pustular and nodulocystic skin lesions (n) 39 21 33 -
Microflora of normal skin (n) 33 48 11 -
Q2 n: number; Percentages were calculated based on one hundred persons

media such as mannitol, indole and sorbitol media and

Table 2: The effects of different antibiotics on isolated
specific standard microbial tests such as oxidase, catalase,
bacteria of acne vulgaris
and coagulase tests.12 The sensitivity of bacteria to antibiotics
was determined according to the method of Kirbauy.12 Name of antibiotic Sensitivity % Resistance %
Clindomycin 50 50
Results Amikacin 70 30
The microorganisms in the microflora of the normal skin Amoxycillin 60 40
and pustular and nodulocystic skin lesions were grown Cephalexin 40 60
both aerobically and anaerobically as presented in Table 1. Tetracycline 65 35
A significant higher percentage of Staphylococcus aureus Erythromycin 48 52
was observed in normal skin of both girls and boys Cephalothin 50 50
compared to Propionibacterium acne in pustular and
Gentamicin 50 50
nodulocystic skin lesions (P < 0.05). The different bacteria
in pustular and nodulocystic skin lesions in both genders Kanamycin 38 62
were grown aerobically and anaerobically. Aerobically, Cloxacillin 0 100
Staphylococcus aureus, Staphylococcus epidermidis, Rifampin 83 17
Propionibacterium acne and Micrococcus spp were Neomycin 20 80
detected in 41%, 53%, 0%, 45% of samples respectively Benzoyl-Peroxide 75 25
while these figures anaerobically were 39%, 21%, 33% and Clindamycin + Benzoyl-Peroxide 63 27
0% respectively. When the effects of different antibiotics on
Erythromycin + Benzoyl-Peroxide 67 23
Propionibacterium acne, Micrococcus spp, Staphylococcus
epidermidis, and Staphylococcus aureus were tested
[Table 2], Propionibacterium acne, Staphylococcus conventional antibiotics such as erythromycin and tetracycline
epidermidis and Staphylococcus aureus were more sensitive were reported to have an increasingly trend,10 research on
to rifampin compared to other drugs (P = 0.004). As shown finding the effective antibiotics seems indispensable. In vitro
in Table 2, the combined inhibitory effect of clindamycin or inhibition of Propionibacterium acne by a bacteriocin-like
erythromycin with benzoyl peroxide was less than rifampin inhibitory substance (BLIS-Like substance) produced by
alone. Table 2 shows the effects of different antibiotics Streptococcus salivarius was previously reported and in some
on isolated bacteria from pustular and nodulocystic skin studies BLIS was suggested for its anti-Propionibacterium
lesions. The diameter of inhibition zone (mm) by each acne activity in the treatment of acne patient.18 In this
antibiotic was studied. According to the manual instruction geographical area with Staphylococcus aureus as primary
of Padtan Tab Co., inhibition zone less than 17 mm® was casual agent in acne development, Staphylococcus aureus
considered as resistance to antibiotic. was resistant to tetracycline, erythromycin and clindamycin
which is consistent to reports by some other investigators,19-21
Discussion but was highly sensitive to Rifampin. On the basis of these
In this study, more Staphylococcus aureus and Micrococcus results, we suggest that rifampin is a suitable antibiotic for
spp were found in aerobic cultures while more Staphylococcus acne patients, but to achieve a better result, combination of
aureus and Propionibacterium acne responsible for acne, rifampin with other antibiotics seems necessary. Also we
were found in anaerobic cultures. Since the most frequent suggest an in vivo study to be performed for better evaluation
bacteria isolated from acne patients were Staphylococcus acne vulgaris treated by rifampin.
aureus, it is possible that acne acne vulgaris is mainly caused
by Staphylococcus aureus rather than Propionibacterium Acknowledgment
cane.13,14 This is in contrast to some reports which implicated We would like to thank the Office of Vice Chancellor for research
both Staphylococcus epidermidis and Propionibacterium of Shiraz University for financial support.
acnes as bacteria causing acne vulgaris.15-17 It may be
concluded that geographical regions affect the bacteria References
involved in acne vulgaris.10 Since bacterial resistance to 1. Hanna S, Sharma J, Klotz J. Acne vulgaris: More than skin deep.

123 Indian J Dermatol 2008; 53(3)

 Hassanzadeh et al.: Acne and antibiotic resistance
Dermatol Online J 2003;9:8.
2. Webster GF, Leyden JJ, Nilsson UR. Complement activation in
acne vulgaris: Consumption of complement by comedones. Infect
Immun 1979;26:183-6.
3. Simpson NB. Disorders of the sebaceous glands. In: Burn T,
Breathnach S, Cox N, Grifiths C, editors. Rook’s Textbook of
Dermatology. 7th ed. Oxford Blackwell Science; 2004. p. 43.15.
4. Firooz A, Sarhangnejad R, Davoudi SM, Nassiri-Kashani M. Acne
and smoking: Is there a relationship? BMC Dermatol 2005;24;5:2.
5. Adebamowo CA, Spiegelman D, Berkey CS, Danby FW, Rockett
HH, Colditz GA, et al. Milk consumption and acne in adolescent
girls. Dermatol Online J 2006;12:25.
6. Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA.
A low-glycemic-load diet improves symptoms in acne vulgaris
patients: A randomized controlled trial. Am J Clin Nutr
2007;86:107-15.
7. Gollnick HP, Krautheim A. Topical treatment in acne: current
status and future aspects. Dermatology 2003;206:29-36.
8. Stein RH, Lebwohl M. Acne therapy: Clinical pearls. Semin
Cutan Med Surg 2001;20:184-9.
9. Zaenglein AL, Thiboutot DM. Acne vulgaris. In: Bolognia JL,
Jorizzo JL, Rapini RP, editors. Dermatology. 2nd ed. Toronto:
Mozby; 2003. p. 532.
10. Ashkenazi H, Malik Z, Harth Y, Nitzan Y. Eradication of
Propionibacterium acnes by its endogenic porphyrins after
illumination with high intensity blue light. FEMS Immunol Med
Microbiol 2003;35:17-24.
11. Ross JI, Snelling AM, Eady EA, Cove JH, Cunliffe WJ,
Leyden JJ, et al. Phenotypic and genotypic characterization of
antibiotic-resistant Propionibacterium acnes isolated from acne
patients attending dermatology clinics in Europe, the USA, Japan
and Australia. Br J Dermatol 2001;144:225-7.
12. Baron EJ, Finegold SM. Methods for testing antimicrobial
Author Queries??????
Q1 Is this usage correct?
Q2 Please confirm if the foot note “Percentage..... persons” should be retained here.
Indian J Dermatol 2008; 53(3)
effectiveness. In: Diagnosis microbiology. 8th ed. The CV Mosby
Company; 1990. p. 171-94.
13. Toyoda M, Morohashi M. An overview of topical antibioticforacne
treatment. Dermatology 1998;196:130-4.
14. Rodriguez-Cavallini E, Vargas-Dengo P. Etiologyia bacteriana y
susceptiblidad a antibioticos en pacientes con acne. Rev Biomed
2004;15:101-6.
15. Thiboutot D. New treatments and therapeutic strategies for acne.
Arch Fam Med 2000;9:179-87.
16. Leyden JJ. Effect of topical benzoyl peroxide-clindamycin
versus topical cindamycin and Propionibacterium acnes. Cutis
2002;69:475-80.
17. Ross JI, Eady EA, Cove JH, Ratyal AH, Cunliffe WJ. Resistance
to erythromycin and clindamycin in cutaneous propionibacteria
is associated with mutations in 23S rRNA. Dermatology
1998;196:69-70.
18. Bowe WP, Filip JC, DiRienzo JM, Volgina A, Margolis DJ.
Inhibition of propionibacterium acnes by bacteriocin-like
inhibitory substances (BLIS) produced by Streptococcus
salivarius. J Drugs Dermatol 2006;5:868-70.
19. Cunliffe WJ, Baron SE, Coulson IH. A clinical and therapeutic
study of 29 patients with infantile acne. Br J Dermatol
2001;145:463-6.
20. Noyon V, Legallou F, Richet H, Dreno B. The resistance of
Propionibacterium acnes and Staphylococcus epidermidis to
cyclones. Ann Dermatol Venereol 1998;125:885-7.
21. Tan HH, Goh CL, Yeo MG, Tan ML. Antibiotic sensitivity of
Propionibacterium acnes isolates from patients with acne vulgaris
in a tertiary dermatological referral centre in Singapore. Ann
Acad Med Singapore 2001;30:22-5.
Received: November, 2007. Accepted: April, 2008.
Source of Support: Nil, Conflict of Interest: Nil.
124
Original Article

COMPARISON OF THE ACTIVITIES OF FOUR ANTIFUNGAL AGENTS IN

AN IN VITRO MODEL OF DERMATOPHYTE NAIL INFECTION
Hossein Nowrozi, Golrokh Nazeri1, Parvaneh Adimi2, Mohsen Bashashati3,
Masood Emami2
Abstract

Background: Onychomycosis is a difficult condition to treat and cure rates are disappointing. Moreover fungicidal action
of antifungal agents in NCCLS assays and their rapid accumulation in nails in vivo are not compatible with the duration
of treatment. Aims: This study aimed to find the effectiveness of 4 different antifungal agents in an in vitro model with
some similarities to in vivo conditions. Materials and Methods: Strains of Trichophyton rubrum I-III, Trichophyton
mentagrophytes (usual form), Trichophyton mentagrophytes 73, Epidermophyton Flucosom, Microsporum Canis, and
Trichophyton Schoenleini which were isolated from the nails of patients, were hired. Inocula suspensions were prepared
from 7 to 14 day-old cultures of dermatophytes. Antifungal agents including fluconazole, ketoconazole, terbinafine, and
griseofulvin were obtained as standard powders. For each antifungal agent, initial MIC was calculated by registering the
optical density for 10 two-fold serially diluted forms which was incubated with diluted fungal suspensions with RPMI
1640. Human nail powder inoculated with different strains and incubated in RPMI 1640 and different concentrations of
antifungal drugs for 4 weeks. Final MIC at different steps of 1, 2, 3 and 4 weeks were investigated. Results: The final
MIC that resulted from the incubation of dermatophytes with nail powder was much more than the initial which was
concluded from conventional MIC assay. Terbinafine had the lowest rate of initial and final MICs. Conclusion: The
model described here may present more similar conditions to clinical fungal infections; therefore the results such as MIC
may be more helpful for hiring the most effective antifungal agent.

Key Words: Antifungal, culture media, nail, onychomycosis

Indian J Dermatol 2008:53(3):00-00******

Introduction We decided to investigate on the antifungal drug response

Onychomycosis (OM) is fungal infection of the toenails
or the fingernails. It is not life-threatening, however it
can cause pain, discomfort, and deformity and may have
a significant effect on the quality of life.1 Half of all
nail disorders are due to OM. Moreover, 30 percent of
patients with a cutaneous fungal infection also have OM.
Additionally, the incidence of OM has been increasing, on
account of increasing in the incidence of diabetes mellitus,
immunosuppression and increasing age.2
Despite fungicidal effect of anti-fungal drugs (e.g. terbinafine)
in National Committee for Clinical Laboratory Standards
(NCCLS) assays and their rapid accumulation in nails in vivo,
onychomycosis patients require prolonged treatment to be
cured.3 Therefore, an in vitro model with some similarities
with in vivo conditions might help us to assess this dilemma.
In addition, since this infection is very common, especially
in elderly patients, effective topical therapy would provide
an outstanding treatment for such patients.4
From the Iran University of Medical Sciences, Tehran, 1Gom Azad
University, Gom, 2Tehran University of Medical Sciences, Tehran,
3
Karaj Azad University, Karaj, Iran. Address correspondence to:
Dr. Hossein Nowrozi, Department of Medical Mycology, Faculty
of Health, Iran University of Medical Sciences, Hemmat Highway,
Tehran, Iran. E-mail: nowrozi@usa.com
of 4 different agents in an in vitro model of dermatophyte
nail infection. To investigate this, as introduced by Osborne
et al.3 and Yazdanparast et al,5 we used a more clinically
relevant onychomycosis in vitro test. To provide this
condition, human nail powder inoculated with growth
media and provided an extensive and invasive fungal
growth media.
Materials and Methods
Standard methods were used for preparation of the stock
organisms, stock solution of antifungal agents, and MIC
determination.6-9
Organism: A total of 3 strains of Trichophyton (T) rubrum
(I,II,III), 2 strains of Trichophyton mentagrophytes (usual
form and, T. mentagrophytes 73), Epidermophyton (E)
Flucosom, Microsporum (M) Canis, M. Gypseum and
T. Schoenleini which were isolated from the nails of
patients, were hired from the department of mycology and
Health Research Institute in Tehran University of Medical
Sciences.
Stock Inocula preparation: Inocula suspensions were
prepared from 7 to 14-day-old cultures of dermatophytes
grown on Potato Dextrose Agar at 30°C. Briefly, colonies
were covered with 2 ml of sterile saline, and then rubbed

125 Indian J Dermatol 2008; 53(3)

 Nowrozi et al.: Running title missing???
carefully with the tip of a Pasteur pipette. Heavy particles
of the suspension were allowed to settle for 3 to 5 min. The
final inoculum size was adjusted with a spectrophotometer
at a wavelength of 530 nm to a transmittance of 95%.
These suspensions were diluted in RPMI 1640 test medium
(1:50) to obtain a cell number ranging from 0.5 × 104 to
5 × 104 CFU/ml.
Antifungal agents: They were obtained as standard
powders. The powder of fluconazole 99.7% (Pars Daru,
Iran), ketoconazole 98.43% (Rooz Daru, Iran), terbinafine
99.6% (Behvarzan, Iran), and griseofulvin 99.3%
(Daroopakhsh, Iran) were used in this study.
Stock solutions were prepared by dissolving and two-fold
serially dilution of drugs in Methanol 0.1 percent, by using
Broth microdilution method. 10× dilutions were prepared
for each drug Tested concentrations for fluconazole ranged
from 0.187-96.0 μg/ml, and for ketoconazole, terbinafine
and griseofulvin from 0.125-64.0 μg/ml. Stock solutions
were prepared by dissolving and two-fold serially dilution
of drugs in Methanol 0.1 percent.
Determination of initial MIC: For each fungal strain
13 tubes with the volume of 10 ml, were prepared. 0.1 cc of
each antifungal agent dilutions were added to tubes 1 to 10.
Then 0.9 cc of diluted fungal suspensions with RPMI 1640
was added to each tube. The eleventh tube contained a 0.9 ml
volume of inoculum suspension and a 0.1 ml volume of drug-
free medium (To assess the inhibitory effect of medium on
fungal growth). The twelfth tube (growth control) consisted
of fungal suspensions with RPMI 1640. A sterility control
(the thirteenth tube) was run in parallel by including a 1 ml
volume of uninoculated, drug-free medium.
Tubes were incubated at 30°C for 48h. Growth control
tubes were observed for the presence or absence of visible
growth. When growth was visible, the growth in each tube
was compared with that of the growth control tube. Optical
density (OD) of each tube which was obtained from a
spectrophotometer at a wavelength of 530 nm was used to
Table 1: Initial MIC* for different antifungal agents according to the type of dermatophytes
Ketoconazole
Dermatophytes
T. rubrum I 32
T. rubrum II 16
T. rubrum III 32
T. mentagrophytes 16
T. mentagrophytes73 32
T. schoenleini 0.5
E. flucosom 1 48
M. canis 8 24
M. gypseum 16
MIC range 0.5-32
*μg/ml
Indian J Dermatol 2008; 53(3)
find the amount of reduction in turbidity as compared to
that of the drug-free control tube. MIC at which 50% of
the isolates are inhibited (MIC50) was determined.
Preparation of nail powder:5,10 Human nail Clippings
from several healthy volunteers previously found free from
fungi when examined in 10% KOH were used. The samples
were cleaned with 70% ethanol, dried in a sterile Petri dish
at 37°C, and ground with using a stainless steel peppermill.
The powder was autoclaved at 121°C for 20 min.
Nail model culture: After finding the primary MIC for each
microorganism, 6 tubes containing MIC tube, 2 tubes with
higher dilution and 2 tubes with lower dilution, respectively
plus another tube as the control tube were selected.
Autoclaved nail powder was added, at approximately
10 mg per tube. 0.9 cc of Inocula suspensions were added
directly onto the nail powder. The tubes were left at 37°C
for 10 days. After 10 days the mycelium were attached
to nail particles which established the sufficiency of the
growth time. 0.1 cc of antifungal agents were added to the
culture according to the calculated MIC, and the cultures
were returned to 37°C. Final MIC 4 weeks after incubation
with nail powder was investigated.
Statistical analysis
Initial and final MICs were assessed 2 times for each
sample and presented as means. ANOVA besides Tukey
test was hired to analyze MICs in each subgroup. Pearson
correlation was used in order to find any correlation
between initial and final MICs. Paired t-test was used for
comparing between initial and final MICs.
Results
Initial MICs [before culturing on nail powder] for each
subgroup are presented in Table 1.
Grisofulvin and ketoconazole had the same rate of initial
MICs, which were statistically different from fluconazole
with the highest rate of initial MIC and terbinafine with
Fluconazole Terbinafine Grisofulvin
48 2 32
24 4 16
48 2 32
48 0.125 8
48 1 32
48 4 0.5
2 16
8 16
24 8 64
24-48 0.125-8 0.5-32
126
 Nowrozi et al.: Running title missing???
Table 2: Final MIC for different antifungal agents according to the type of dermatophytes
Ketoconazole
Dermatophytes
T. rubrum I 64
T. rubrum II 16
T. rubrum III 64
T. mentagrophytes 64
T. mentagrophytes73 - 96
T. schoenleini 2 96
E. flucosom 2 96
M. canis 16
M. gypseum 32
the lowest rate of initial MIC respectively (ANOVA,
P = 0.0001).
After incubation with nail powder we found that final MICs
statistically increased in comparison with initial MICs
(Initial MIC: 19.42 ± 17.21 μg/ml, final MIC 36.72 ± 33.77
μg/ml, paired t-test, P value = 0.0001) [Table 2].
There was a direct correlation between initial and final
MICs which was statistically significant (R = 0.95,
P value = 0.0001).
Discussion
Griseofulvin and newer antifungal drugs such as
ketoconazole, fluconazole and terbinafine, are the major
systemic drugs applied to treat onychomycosis.11 Griseofulvin
was the first systemic antifungal drug but nowadays it is
not used in a widespread way.12 Ketoconazole was the first
orally active imidazole but it is known for its hepatotoxicity
as well.7 Terbinafine is highly effective against dermatophyte
infections and acts by blocking ergosterol synthesis.10
Studies which compared the effectiveness of different
antifungal agents in treatment of onychomycosis at the
same time7 are scarce. Moreover, treatment of OM is a
problematic issue in clinical practice.1,10
Santos et al,7 tried to study in vitro susceptibility of
52 isolates of Trichophyton rubrum and 40 of Trichophyton
mentagrophytes to griseofulvin, terbinafine, itraconazole,
ketoconazole, fluconazole and cyclopiroxolamine. They
used modified NCCLS approved procedure M38-A. Finally,
they concluded that terbinafine was the most effective
in vitro against all isolates, followed by itraconazole,
cyclopiroxolamine, ketoconazole and fluconazole.
Conidial suspensions or mixed suspension of mycelial
fragments and conidia growing in a rich medium are used
in the NCCLS methodology for antifungal testing makes
use of.13,14 Employing nail powder for antifungal testing,10
mimics the course of a natural nail fungal infection, with
antifungal treatment starting only after mycelial growth.
In this method the fungi must use the nails as their only
127
Fluconazole Terbinafine Grisofulvin
96 4 32
48 8 32
96 4 32
96 1 16
4 32
16 1
2 32
48 16 16
- 32 -
nutrition by activation of keratinases secretion. In this
in vitro model, using its natural substrate, the dermatophytes
act with more similarity to in vivo clinical condition.5,10,15,16
Therefore, response to antifungal agents which is normally
reported as MIC reached form NCCLS models would reach
more relevant and practical result.
Due to our findings, the final MIC which resulted after
the incubation of dermatophytes beside nail powder was
much more than the initial which was concluded from
conventional MIC assay. In addition Osborne et al,10 found
that terbinafine Nail-MFCs obtained from in vitro method
using nail powder were much higher than MFC values
obtained after conventional assays. Also, they found that
the cidal action of terbinafine was much slower than in
conventional assays. Therefore the current model of culture
may show the needs for high dose and long duration of
antifungal treatment for OM.
On the other hand, by comparing the efficacy of the
assessed antifungal drugs, we found that terbinafine
inhibited the growth of dermatophytes in the in vitro model
more effectively. Osborne et al, concluded similarly.10
The higher activity of terbinafine in comparison to other
tested antifungal drugs has been established during in vitro
studies.7,17 Therefore our finding in this regard is not new
rather than higher MIC which had been also achieved by
Osborne et al.10
In conclusion, the model described here offers a clinically
mimicking condition for measuring the efficacy of different
antifungal drugs for the treatment of onychomycosis. Future
studies on dermatophytes using other biomaterials such as
hair powder as a part of culture medium may be useful for
other clinical conditions.
References
1. Blumberg M, Kantor GR. (Internet): Onychomycosis. Available
from: http://www.emedicine.com/derm/topic300.htm.
2. Faergemann J, Baran R. Epidemiology, clinical presentation and
diagnosis of onychomycosis. Br J Dermatol 2003;149:1-4.
3. Osborne CS, Leitner I, Favre B, Ryder NS. Antifungal drug
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4. Len J, Chem W, Buchta R, et al. A multi-model approach for the
evaluation of topical antifungal agents and formulation for the
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5. Yazdanparast SA, Barton RC. Arthroconidia production in
Trichophyton rubrum and a new ex vivo model of onychomycosis.
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in vitro activities of voriconazole and five established antifungal
agents against different species of dermatophytes using a broth
macrodilution method. J Clin Microbiol 2001;39:385-8.
7. Santos DA, Hamdan JS. In vitro antifungal oral drug and
drug-combination activity against onychomycosis causative
dermatophytes. Med Mycol 2006;44:357-62.
8. Espinel-Ingroff A, Dawson K, Pfaller M, Anaissie E, Breslin B,
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response in an in vitro model of dermatophyte nail infection.
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Med Mycol 2004;42:159-63.
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combination of approaches. Br J Dermatol 2001;145:3-8.
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Wayne, PA: NCCLS; 2000.
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in vitro activities of 17 antifungal drugs against a panel of 20
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15. Rashid A, Scott EM, Richardson MD. Inhibitory effect
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Received: November, 2007. Accepted: April, 2008.
Source of Support: Nil, Conflict of Interest: Nil.
128
Original Article

ISOLATION OF BACTERIA CAUSING SECONDARY BACTERIAL

INFECTION IN THE LESIONS OF CUTANEUS LEISHMANIASIS
Hengameh Ziaie, G Sadeghian1
Abstract

Background: Cutaneous Leishmaniasis (CL) is a parasitic disease characterized by single or multiple ulcerations.
Secondary bacterial infection is one of the complications of the disease that can increase the tissue destruction and
the resulting scar. Objective: To effectively determine the incidence of real secondary bacteria infection in cutaneous
leishmaniasis, we designed the current study. Methods and Materials: This was a cross-sectional study performed in
Skin Diseases and Leishmaniasis Research Centre, Isfahan, Iran. In this study, 854 patients with confirmed CL were
enrolled. Samples were taken from all the patients. Sterile swaps were achieved for the ulcer exudates and scraping was
used for nonulcerated lesions. All the samples were transferred to tryptic soy broth medium. After 24 h of incubation in
37°C, they were transferred to eosin methylene blue agar (EBM) and blood agar. Laboratory tests were used to determine
the species of bacteria. All of the collected data were analyzed by SPSS software and chi-square. Results: Among
854 patients with confirmed cutaneous leishmaniasis, 177 patients (20.7%) had positive cultures for secondary bacterial
infection. Bacteria isolated from the lesions were as follows: Staphylococcus aureus - 123 cases (69.4%), coagulase
negative Staphylococcus - 41 cases (23.1%), E. coil - 7 cases (3.9%), Proteus - 3 cases (1.7%) and Klebsiella - 3 cases
(1.7%). Conclusions: The incidence of secondary bacterial infection in lesions of CL was 20.7%. The most common
isolated pathogen was Staphylococcus aureus. The incidence of secondary bacterial infection was significantly more in
the ulcerated lesions as compared with nonulcerated lesions (P = 0.00001).

Key Words: Bacteria, cutaneous leishmaniasis, infection

Indian J Dermatol 2008:53(3):00-00******

Introduction factors, including parasite load and virulence, host immune

Leishmaniasis is a parasitic disease transmitted by sand
flies. It is characterised by a spectrum of cutaneous,
mucocutaneous and visceral clinical manifestations that
depend largely on the species of parasite involved and
the host immune response. According to recent estimates,
1.5 million new cases of cutaneous leishmaniasis (CL)
occur each year. More than 90% of cases occur in five
countries in the Old World (Afghanistan, Algeria, Iran,
Iraq and Saudi Arabia) and two countries in the New
World (Brazil and Peru).1 Cutaneous leishmaniasis in the
Old World is caused by L major, L. tropica, L infantum
and L. aethiopica, which are found in southern Europe,
the Mediterranean basin, the Middle-East and Africa.2
Cutaneous leishmaniasis in the New World is mainly caused
by members of the L. braziliensis complex (L. braziliensis
and L. peruviana), L. mexicana, L. amazonensis and the
L. guyanensis complex (L. guyanensis and L. panamensis).
Cutaneous leishmaniasis of the Old World eventually
heals. The rate of spontaneous healing depends on several
From Medical School of Isfahan University of Medical Science,
Isfahan, Iran. 1Skin Disease and Leishmaniasis Research Centre
(SDLRC), Isfahan University of Medical Science, Isfahan, Iran.
Address correspondence to: Dr. Hengameh Ziaei, Medical
School, Isfahan University of Medical Science, Isfahan, Iran.
E-mail: hengameh65_ziaie@yahoo.com
response, location of the lesion and the presence or absence
of secondary bacterial infection. Lesions caused by L. major
heal spontaneously after approximately 18 weeks.3
An important part of therapy for CL is local care along with
antileishmania therapy. The treatment of secondary bacterial
infection is essential for healing. On the other hand, the
secondary bacterial infection of the CL will increase the
tissue destruction and the resulting scar.4 To effectively
determine the incidence of real secondary bacteria infection
in CL, we designed the present study.
Materials and Methods
This was a cross-sectional study performed at Skin Disease
and Leishmaniasis Research Centre (SDLRC), Isfahan, Iran.
The patients enrolled in this study with clinical and
parasitological diagnosis of CL and referred to SDLRC
from August 2006 to 2007. The patients belonged to both
sex and different age groups and had different clinical form
of CL. The use of topical or systemic antibiotics in recent
weeks was not included in the study.
The skin areas surrounding the lesions were thoroughly
cleaned using cotton wool moistened with alcoholic iodine.
After appropriate cleaning, the specimens of the ulcers were
obtained by rubbing sterile saline solution over the edge of

129 Indian J Dermatol 2008; 53(3)

 Ziaie and Sadeghian: Bacterial infection in cutaneous leishmaniasis
Table 1: Distribution frequency of bacteria in positive cultures
Clinical forms of lesion Ulcerated plaque
Staphylococcus aureus 117 (66.1)
Coagulase negative Staphylococcus 41 (23.1)
E. coli 7 (3.9)
Proteus 3 (1.7)
Klebsiella 3 (1.7)
Total positive culture 171 (96.6)
Figures in parenthesis are in percentage
ulcerated lesions and samples were collected aseptically
by scraping the nonulcerated lesions. All the samples
were transferred to tryptic soy broth medium. After 24-h
incubation in 37°C, the samples were transferred to eosin
methylene blue agar (EMB) and blood agar.
Gram staining, oxidase test, indole test, urease test, catalase
test and coagulase test were used to determine the species
of bacteria.
Statistical analysis
All of the collected data were analysed by SPSS and Chi-
squared test.
Results
In this study, 854 patients who confirmed CL were enrolled.
The age range of patients was 2 months to 85 years and the
mean age of the patients was 27.21 years. Among them,
320 patients (37.5%) were women and 534 (62.5%) were
men. The results of the culture were positive in 20.7%
of the patients (177 patients). Bacteria isolated from the
lesions were as follows: Staphylococcus aureus - 123 cases
(69.4%), coagulase negative Staphylococcus - 41 cases
(23.1%), E. coil - 7 cases (3.9%), Proteus - 3 cases (1.7%)
and Klebsiella - 3 cases (1.7%).
The distribution frequency of the isolated bacteria by the
clinical from of the leishmaniasis lesions are shown in
Table 1.
Discussion
Secondary bacterial infection is one of the complications
of CL. Although some authors emphasize on the rarity of
this finding,3 our clinical findings are in contrast to this.
In our practice, we encounter many cases of the infected
leishmaniasis ulcers. In fact, secondary bacterial infection
can exacerbate the disease and the final scar because it will
increase the tissue destruction and necrosis. In these cases,
painful ulcers with purulent discharges and with surrounding
inflammation may occur. In addition, the duration of disease
would be prolonged.4 The appropriate use of antibiotics will
decrease the resultant infection in these cases. One study in
Sudan has shown the prevalence of the secondary infection
to be 18% of the 736 evaluated patients. The pathogenic
organism was not identified in this study.5
Indian J Dermatol 2008; 53(3)
Nonulcerated plaque Ulcerated papule or nodule Total
3 (1.7) 3 (1.7) 123 (69.4)
- - 41 (23.1)
- - 7 (3.9)
- - 3 (1.7)
- - 3 (1.7)
3 (1.7) 3 (1.7) 177 (100)
In the another study, bacteria including Proteus
valguries, Pasteurella multisided, Staphylococcus aureus, Q1
Staphylococcus albus, E. coli and Pseudomonas aurogenosa Q2
were isolated from clinically infected lesions.6
In another study that was performed in the impetiginized
forms of leishmaniasis, Staphylococcus aureus was
recognized to be the responsible pathogen.4
In a study performed in the Yucantan peninsula of
Mexico, some pathogenic bacteria were detected from
the skin lesions of patients with chiclero’s ulcers (a form
of cutaneous leishmaniasis due to Leishmania mexicana)
reluctant to antimonial treatment, and the results of
this study suggested the need to eliminate bacterial
infections by antibiotic therapy before starting antimonial
administration.7
In our study, out of the 854 patients with confirmed
cutaneous leishmaniasis, 177 patients (20.7%) had
confirmed secondary bacterial infection.
The most common bacterial isolate was Staphylococcus
aureus. Other pathogens included coagulase negative
Staphylococcus, E. coli, Proteus vulgaris and Klebsiella.
There was no significant association between the prevalence
distribution of the isolated bacteria with the age, sex,
location, number and duration of the disease (P > 0.05).
However, there was a significant association between
the clinical form of the disease and the isolated bacteria
(P = 0.00001).
All the lesions that had secondary bacterial infection were
ulcerated. There was no bacterial isolates from the lesions
that were not ulcerated. With regard to these facts, we can
conclude that destruction of the epidermis in the ulcerated
lesions had predisposed the patients to the secondary
bacterial infection.
Regarding the results of our study, we suggest that topical
antiseptic solutions are need for ulcerated lesions of the
cutaneous leishmaniasis to prevent the secondary bacterial
infection that may accelerate tissue destruction.
In addition in the case of secondary bacterial infection
symptoms and signs, the use of antibiotics particulary
against staphylococcus would be logical.
130
 Ziaie and Sadeghian: Bacterial infection in cutaneous leishmaniasis

References 5. el-Safi SH, Peters W, el-Toam B, el-Kadarow A, Evans DA.

1. Desjeux P. Worldwide increasing risk factors for leishmaniasis.
Med Microbiol Immunol 2001;190:331-6.
2. Addy M, Nandy A. Ten years of kala-azar in west Bengal, Part I:
Did postkala-azar dermal leishmaniasis initiate the outbreak in
24-Parganas? Bull World Health Organ 1992;70:341-6.
3. Alrajhi AA, Ibrahim EA, De Vol EB, Khairat M, Faris RM,
Maguire JH. Fluconazole for the treatment of cutaneous
leishmaniasis caused by Leishmania major. N Engl J Med
2002;346:891-5.
4. Bryceson AD, Plotikir N. Diffuse cutaneous leishmaniasis in
Ethiopia: The clinical and histological features of the disease.
Tranc Royal Soc Trop Med Hyg 1971;63:708-37.
Studies on leishmaniasis in the Sudan: Clinical and parasitological
studies on cutaneous leishmaniasis. Trans Royal Soc Trop Med
Hyg 1991;85:457-64.
6. Sneirt R, Elias E. Leishmaniasis major bacterial contamination
of cutaneous lesions in experimental animals. Isr J Med Sci
1992;28:847-51.
7. Isaac-Marquez AP, Lezama-Davila CM. detection of pathogenic
bacteria in skin lesions of patients with chiclero’s ulcer: Reluctant
response to antimonila treatment. Mem Inst Oswaldo Cruz Rio
de Janeiro 2003;98:1093-5.
Received: September, 2007. Accepted: December, 2007.
Source of Support: Nil, Conflict of Interest: Nil.

Author Queries??????

Q1 vulgaris?
Q2 Pseudomonas aeruginosa?

131 Indian J Dermatol 2008; 53(3)

 Original Article

OUTBREAK OF TINEA GLADIATORUM IN WRESTLERS IN TEHRAN (IRAN)

Shahindokht Bassiri Jahromi, Ali Asghar Khaksar
Abstract

Background: In recent years, skin diseases in wrestling have finally received the attention they deserve. Outbreaks of tinea
corporis are often associated with sports involving extensive bodily contact; such sports include wrestling. Tinea corporis
gladiatorum is primarily caused by Trichophyton tonsurans, infecting wrestlers at alarming rates. The management of
skin infections in wrestlers and other athletes in sports involving skin-to-skin contact entails numerous challenges, from
making an accurate diagnosis to determining eligibility for playing the sports. To control outbreaks, we conducted an
epidemiologic investigation. The purpose of this article is to determine the prevalence of tinea corporis gladiatorum in
wrestlers in Tehran, Iran. Materials and Methods: A study of dermatophytosis was carried out during the period of
March 2004 to December 2005 on 612 mycological proven cases of dermatophytosis found in male wrestlers in Tehran.
Mycological examination consisted of culturing of pathologic material followed by direct microscopic observation.
Diagnosis was based on macroscopic and microscopic characteristics of the colonies. Result: T. tonsurans was the
predominant dermatophyte, accounting for >90% of all tinea corporis gladiatorum isolates during the 2 year analysis. Tinea
corporis gladiatorum was found to be more frequent in individuals between the ages of 10 and 20 years of age (72.7%).
Wrestlers with tinea corporis gladiatorum were predominantly from wrestling clubs in southern and southeastern Tehran.
Transmission of tinea corporis is primarily through skin-to-skin contact. Conclusion: Rapid identification and treatment
of tinea corporis gladiatorum is required to minimize the disruption of team practices and competitions. Infection with
dermatophytes can disqualify a wrestler from competing in matches, and thus, vigilant surveillance and rapid initiation of
treatment is important to prevent the suspension of team practices and competitions.

Key Words: Dermatophytosis, infection control, Iran, tinea corporis, tinea gladiatorum, trichophyton tonsurans, wrestling

Indian J Dermatol 2008:53(3):00-00******

Introduction hairbrushes, combs, pillowcases, other bedding material

One of the most common types of infections that can occur
in wrestlers is a fungal infection known as tinea corporis
gladiatorum. Characterized by well-defined, red, scaling
plaques located on the head, neck and upper extremities,
tinea corporis gladiatorum epidemics have been reported in
numerous wrestling teams ranging in prevalence from 24%
to 77%.1
Q1 Tinea corporis is extremely common in wrestling and other
sports involving extensive skin-to-skin contact and can
result in outbreaks. Wrestlers acquire tinea corporis from
direct skin-to-skin contact; thus, the predilection for the
head, neck and upper extremities. Wrestling as a part of
the National Collegiate Athletic Association (NCAA) ranks
number one in the frequency of cutaneous infections.2
Lesions often occur on the arms, torso, head and neck,
corresponding to the areas of greatest contact between
combatants. Wrestling requires close body contact and
often results in skin abrasions that are a perfect opportunity
for person-to-person transmission. However, dermatophytes
have been isolated from several inanimate objects, including
From Department of Medical Mycology, Pasteur Institute of Iran.
Tehran, Iran. Address correspondence to: Dr. Shahindokht Bassiri-
Jahromi, Medical Mycology Department, Pasteur Institute of Iran,
Pasteur st. No.69 Tehran Iran. E-mail: basiri@pasteur.ac.ir
and dormitory floors.3 Inanimate objects or fomites may
be responsible for prolonged transmission of ringworm
infections;4 the competitive wrestling environment includes
many omits as possible source of contagion. Tinea corporis
gladiatorum is caused by dermatophytes, usually of the
genus Trichophyton, affecting both humans and animals.
The fungus causes a characteristic lesion which is often
clear in the center with a rough, scaly circular border.
Lesions vary in size from very small circular patches to
large patches.5
The primary mode of transmission in wrestlers is to person-
to-person contact. Clinical features of tinea gladiatorum
may or may not be consistent with those found in the
general population.6
The aim of this study is to determine the prevalence of tinea
corporis gladiatorum and identify the primary causative
agents of dermatophytosis and other related factors in
wrestlers in Tehran, Iran.
Materials and Methods
This study was conducted from March 2004 to December
2005. We have published a leaflet showing the clinical
characteristics and methods of diagnosis of tinea gladiatorum.
These leaflets were distributed to the wrestler clubs all

Indian J Dermatol 2008; 53(3) 132

 Jahromi and Khaksar: Tinea Gladiatorum in Iran
over Tehran and around Tehran via the wrestler federation,
asking the members to participate in the survey. Directing
managers or coaches of the wrestler clubs who agreed to
participate in the survey were asked to complete application
forms describing the location of the club and the number of
club members who agreed to participate in the survey. The
clinical examination of self-referred athletes was performed.
Wrestlers who showed suspected lesions were referred to
Medical Mycology Pasteur Institute of Iran.
Demographic information requested in the questionnaire
included age, number of family, members and residence
conditions and history of cutaneous infection in the family
members. The participants were also monitored for current
or previous possible tinea gladiatorum eruptions.
The clinical diagnosis and detailed history of each wrestler
were recorded. Specimens from suspected lesions were
collected in sterile Petri dishes. All collected specimens
Q2 were carried out in potassium hydroxide solution in
order to examine characteristic fungal elements. The
specimens were cultured on sabouraud glucose agar
(oxoid, Basingstoke, United Kingdom) supplemented with
0.05 mg/l chloramphenicol and 0.5 mg/l cyclohexamide.
Cultures were incubated for 4 weeks at 25°C. The
identification of dermatophytes was performed on the basis
of both macroscopic and microscopic appearance. Slide
cultures and other confirmatory tests such as Trichophyton
agar slants, urea agar slant, potato glucose agar, cornmeal,
rice grain medium and an in vitro hair perforation test
were performed when necessary.7-8
Results
A total of 893 male wrestlers, aged 6-42 years, from 173
active clubs in Tehran were examined, most of whom were
members of wrestling clubs in southern or southeastern
Tehran. The mean age of the wrestling team was 18.2 years.
Tinea corporis in 64 cases was documented among the
family members of infected wrestlers. Most of the patients
came from wrestling clubs in southern and southeastern
Tehran.
The most frequently isolated etiological agent was
Trichophyton tonsurans (92.6%), followed by Trichophyton
rubrum (2.8%), Trichophyton mentagrophytes (1.75%),
Epidermophyton floccosum (1.75%), Trichophyton
violaceum (0.43%) and Trichophyton verrucosum (0.43%).
Microsporum canis (0.2%) infections occurred sporadically
among patients.
Tinea corporis gladiatorum was found to be more prevalent
between the ages of 10 to 30 years [Table 1]. In 64 cases
(10.8%), tinea corporis was present among the family
members of infected wrestlers.
Discussion
Contact sports provide an excellent setting for the
transmission of communicable disease. Outbreaks of fungal
133
Table 1: Dermatophyte isolation with respect to
wrestlers infected with tinea gladiatorum according to
wrestler age
<10 year 10-20 21-30 31-40 >40 year Total
years years year
7 242 137 25 1 612
1.2 72.7 22.4 4 0.2 %100 Q3
infections are common in contact sports such as wrestling,
judo and kung fu because of the close physical contact
and trauma to the skin involved in these sports. Several
outbreaks of tinea corporis or ringworm have recently been
reported in high school and college wrestling.9-17
Tinea gladiatorum outbreaks have been caused by
Trichophyton tonsurans. The primary mode of transmission
in wrestlers is to the person-to-person contact.18 Q4&5
Dermatophytosis is extremely common in wrestling
and other sports with extensive skin-to-skin contact.
Asymptomatic carriers may be an important source of
fungal organisms.18,19 Risk factors for becoming a carrier
include active infection during the sporting season, history
of head and neck tinea infection, failure to wear headgear
and failure to wash practice clothes at least once a week.20
By promptly identifying the infected athletes and excluding
them from direct contact with other wrestlers can help to
reduce tinea occurrences.21
To our knowledge, this is the largest reported series of
patients with tinea gladiatorum and the only one to describe
such infections in Iran. There are more than 90 wrestling
clubs and 25,000-30,000 wrestlers in Tehran. Wrestling is a
national sport in Iran and plays an important role in Iranian
entertainment. Subsequently, the practicing of wrestlers can
lead to direct and indirect exposures to and transmission
of dermatophytes between wrestlers along with positive
observers.
T. tonsurans is an anthropophilic dermatophyte and was the
main cause of tinea corporis in wrestlers in this study. The
incidence of T. tonsurans infection is dynamically changing
in various parts of the world.22 Although T. tonsurans rarely
occurred in Iran,23 in 1995, it began to spread sporadically
in Tehran and since then it has dramatically increased
throughout Iran. This study demonstrates a high occurrence
of T. tonsurans infection in wrestlers (92.6%). In recent
years it has become the predominant cause of tinea corporis
in adolescents.24-25 T. tonsurans is one of the main causes
of dermatophytosis in Iranian wrestlers. Skin infections
due to T. tonsurans have become a significant health
problem affecting children, adolescents and sometimes
adults. Therefore, correct diagnosis and treatment of
the active disease is important. Infection can also be
reduced by screening of possible carriers and treatment of
asymptomatic carriers and their environment.3 T. tonsurans
remains the predominant causative agent in North America
Indian J Dermatol 2008; 53(3)
 Jahromi and Khaksar: Tinea Gladiatorum in Iran

and currently accounts for >95% of tinea capitis in the We need to study all aspects of this infection in this
United States.18-19 population in order to develop strategies to deal with it.
Because infection with dermatophytes can disqualify a
Since the 1950s, T. tonsurans has spread to North America.19
wrestler from competing in matches, vigilant surveillance,
A rapid increase in the incidence of T. tonsurans resulting
prevention, rapid identification and treatment of tinea
in tinea capitis has been noted in Canada. Canadian studies
gladiatorum is vital to reduce the suspension of a team’s
reported an incidence of 9% in 1985 and 76% in 1996.26 In
practice and competition.
Europe, an increasing number of T. tonsurans infections in
recent years suggest its return to this area. In 1999, Fitowski Good personal hygiene helps prevent the spread of
and Ratka27 reported an epidemic outbreak of T. tonsurans ringworm. Showering thoroughly after practices and
in 23 village children in Poland. In 1995, an outbreak of competitions and washing uniforms after they are used with
tinea corporis occurred in members of a wrestling team antibacterial detergent is an effective means in achieving
in Sweden. Wrestlers from a USA team visiting Sweden appropriate hygiene.6,35 Furthermore, uniforms and practice
were the suspected source of this epidemic.28 Recently, clothing should not be shared among wrestlers.35
T. tonsurans was also reported to occur in the United
Tinea corporis gladiatorum can be found quite frequently
Kingdom and was found to be the predominant cause of
among high school wrestlers. Without a thorough knowledge
tinea capitis, accounting for 72% of the observed infections
of tinea gladiatorum, wrestling is compromised as a sport.
in Birmingham.29 Other outbreaks of T. tonsurans were also
Vigilant surveillance and rapid initiation of therapy is
reported in southeastern London (United Kingdom) 30 and
important to prevent suspension of team practices and
among school children in Spain.31
competitions due to infection with dermatophytes. Awareness
This particular study focuses on its occurrence in wrestlers of these infections may facilitate the implementation of
in Tehran during recent years. In this study, incidence of early treatment and preventive measures.35
tinea corporis gladiatorum occurred in males between the
We suggest focusing our efforts on studying the
ages of 10and 20 years. Occlusion has been postulated to
person-to-person transmission, studying when return to
increase hydration of the underlying skin and emission
competition techniques such as the use of skin barriers34
of carbon dioxide from the skin, which could favor
and pharmacologic prophylaxis.37,38 We would suggest
dermatophyte growth.32,33 Tinea corporis in 64 cases (10.8%)
the continuation of common-sense hygiene measure,
was documented among the family members of infected
including showering after very encounter, washing practice
wrestlers. Most of our patients came from wrestling clubs
clothes daily and disinfecting mats daily.36 Until we have
in southern and southeastern Tehran. This is the first and
more definitive answers about ringworm in wrestlers,
largest outbreak of tinea corporis gladiatorum to be reported
it is impossible to have sufficient infection control and
in Tehran. Appropriate control measures have not yet been
prevention plans.
established.
Attention should be focused on primary and secondary
Tinea corporis is spread through direct contact with
prevention as well as treatment. Educating wrestlers,
infected individuals and may also occur due to contact with
coaches, parents and members of the medical community
infectious spores on inanimate objects such as clothing,
about skin infections and their prevention, recognition and
mats, etc. However, the presence of a dermatophyte on
treatment is crucial and a part of our continuing effort. The
a fomite or as part of a carrier sate does not affirm it
prevention of tinea should be a major priority in wrestling.
as the definitive source. The principles of an infectious
Prevention begins with cleaning all the mats before and
disease require a viable organism, a susceptible host
after practices with a hospital grade disinfectant. Secondly,
and an appropriate environment for clinical infection to
wrestlers should be educated on symptoms and trained
occur. Several authors suggest that some wrestlers may
to inspect their own bodies daily. Thirdly, wrestlers must
be asymptomatic carriers and act as reservoirs.6-34-35 Tinea
wash all workout equipment daily and be sure to wash
gladiatorum is highly contagious and is a result of the
knee pads and headgear twice a week. Fourth, wrestlers
presence of T. tonsurans. As infection with dermatophytes
should shower and use an antibacterial soap and selenium
can disqualify a wrestler from competing in matches,
shampoo immediately after workouts. It is also important to
vigilant surveillance, prevention, rapid identification;
avoid drying of skin as it is more susceptible to infection.
further, treatment of tinea gladiatorum is vital to reduce the
Finally, when a lesion is noticed, the individual must consult
suspension of team practice and competition. Appropriate
their physician or allelic trainer and use the appropriate
treatment can mitigate an infection and potentially prevent
medication. The lesion should be covered prior to wrestling
recurrence. In addition, physicians must know when
according to NCAA guidelines outlined below.39
to disqualify a wrestler and how to prevent an outbreak
through appropriate hygienic and immediate diagnostic Hygienic measures, such as mandatory showers before and
measures.36,37 In recent decades, the improvement of after practice, use of antibacterial soaps and daily washing
hygiene standards and earlier treatment may have decreased of practice gear, may be the most effective means in
widespread infections. preventing skin infections.

Indian J Dermatol 2008; 53(3) 134

 Jahromi and Khaksar: Tinea Gladiatorum in Iran
This study highlights a common problem in many areas
of the world and suggests that further measures regarding
public health and personal hygiene must be undertaken
in order to reduce the risk of tinea gladiatorum.5,40 In
particular, greater and more efficient sanitary control
should be implemented in communal environments such
as gymnasia, farms, factories, swimming pools, changing
rooms of sports clubs and public showers.
More research concerning different treatment regimens in
the wrestling environment is needed to define the optimal
treatment to quickly return wrestlers to competitions
without placing other wrestlers at risk of infection.
Intuitive hygiene practices have been suggested to
prevent the spread of infection, but have not yet been
substantiated.36
Knowledge of the most common agents producing infectious
disease outbreaks in specific sports can be used to guide
targeted prevention efforts. Surveillance of the frequency
of infections per team each season will also allow athletic
staff to identify outbreaks.1
In conclusion, these data reiterate the continued predominance
of T. tonsurans as the principal pathogens in cutaneous fungal
infections in Tehran. Trichophyton tonsurans remain the most
prevalent pathogen as tinea gladiatorum in wrestlers. The
most prevalent fungal pathogen was T. tonsurans (92.6%),
followed by T. rubrum, T. mentagrophytes, E. floccosum,
T. violaceum and T. verrucosum and M. canis.
Acknowledgment
The authors are grateful to Miss Nazanin Hakimzadeh-Jahromi
for her help during this research.
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2005;46:99-103.
15. Hirose N, Shiraki Y, Hiruma M, Ogawa H. An investigation of
Trichophyton tonsurans in university students participating in
sports clubs. Nippon Ishinkin Gakkai Zasshi 2005;46:119-23.
16. Nishimoto K, Honma K, Shinoda H, Ogasawara Y. Survey of
Trichophyton tonsurans infections in the Kyushu, Chugoku
and Shikoku areas of Japan. Nippon Ishinkin Gakkai Zasshi
2005;46:105-8.
17. Himura M, Shiraki Y, Nihei N, Hirose N, Sugunami M.
Questionnaire investigation of incidence of Trichophyton
tonsurans infection in Dermatology Clinics in the Kanto area.
Nippon Ishinkin Gakkai Zasshi 2005;46:93-7.
18. Babel DE, Baughman SA. Evaluation of the adult carrier state
in juvenile tinea capitis caused by Trichophyton tonsurans. J Am
Acad Dermatol 1989;21:1209-12.
19. Grissey JT, Martin R. A new form of scalp ringworm in western
New York. N Y State J Med 1960;60:679-82.
20. Shiraki Y, Hiruma M, Hirose N, Sugita T, Ikeda S. A nationwide
survey of Trichophyton tonsurans infection among combat sport
club members in Japan using a questionnaire form and the
hairbrush method. J Am Acad Dermatol 2006;54:622-6.
21. Rebell G, Taplin D. Dermatophytes. Their recognition and
identification. 2nd ed. Coral Gables, University of Miami Press.
22. Bobel DE, Rogers AL, Benede ES. Dermatophytosis of the scalp:
Incidence, immune response and epidemiology. Mycopathologia
1990;109:69-73.
23. Jahromi ShB, Khaksar AA. Aetiologic agents of tinea capitis in
Tehran, Iran. Mycoses 2006;49:65-7.
24. Shiraki Y, Soda N, Hirose N, Hiruma M. Screening examination
and management of Dermatophytosis by Trichophyton tonsurans
in the judo club of a university. Nippon Ishinkin Gakkai Zasshi
2004;45:7-12.
25. Hedayati MT, Afshar P, Shokohi T, Aghili R. A study on tinea
gladiatorum in young wrestlers and dermatophyte contamination
of wrestling mats from Sari, Iran. Br J Sports Med 2007;41:
332-4.
26. Gupta AK, Summerbell RC. Increased incidence of Trichophyton
tonsurans tinea capitis in Ontario, Canada between 1985 and
1986. Med Mycol 1998;36:55-60.
27. Fitowski JA, Ratka P. An epidemic of superficial dermatophytosis
caused by trichophyton tonsurans in 23 village children. Pediatr
Dermatol 1992;9:314-5.
28. Haradil E Hersle, Nordin P, Faergemann J. An epidemic of tinea
Indian J Dermatol 2008; 53(3)
 Jahromi and Khaksar: Tinea Gladiatorum in Iran

corporis caused by Trichophyton tonsurans among wrestler in
Sweden. Acta Dermatol Venerol 1995;75:305-6.
29. Leeming JG, Elliott TS. The emergence of Trichophyton
tonsurans tinea capitis in Birmingham, UK. Br J Dermatol
1995;133:929-31.
30. Fuller LC, Child FC, Higgins EM Tinea capitis in South-East
London: An outbreak of Trichophyton tonsurans infection. Br J
Dermatol 1997;136:139.
31. Cuctara MS, Del Palacio A, Percito M, Noricga AR. Prevalence
of undetected tinea capitis in a prospective survey in Madrid:
Emergence of new causative fungi. Br J Dermatol 1998;138:
658-60.
32. King RD, Cunico RL, Maibach HI, Greenberg JH, West ML,
Jeppsen JC. The effect of occlusion carbon dioxide emission
from human skin. Acta Dermatol Venereol 1978;58:135-8.
33. Ripen JW. Medical mycology. 2nd ed. WB Saunders:
Philadelphia, A; 1982. p. 154-248.
34. Nenoff P, Handrick W, Haustein UF. Sport-induced infections.
Wien Med Wochenschr 2002;152:574-7.
35. Kohl TD, Martin DC, Nemth R, Hill T, Evans D. Fluconazole
for the prevention and treatment of tinea gladiatorum. Pediatr
Infact Dis J 2000;19:717-22.
36. Hand JW, Wroble RR. Prevention of tinea corporis in collegiate
wrestlers. J Athl Train 1999;34:350-2.
37. Hazen PG, Weil ML. Itraconazole in the prevention and
management of dermatophytosis in competitive wrestlers. J Am
Acad Dermatol 1997;36:481-2.
38. Kohl TD, Martin DC, Nemeth R, Evans DL. Wrestling mats:
Are they a source of ringworm infections? J Athl Train 2000;35:
427-30.
39. Stiller MJ, Klein WP, Dorman RI, Rosenthal S. Tinea corporis
gladiatorum: An epidemic of Trichophyton tonsurans in student
wrestlers. J Am Acad Dermatol 1992;27:632-3.
40. Adams BB. Tinea corporis gladiatorum. J Am Acad Dermatol
2002;47:286-90.
Received: October, 2007. Accepted: December, 2007.
Source of Support: Nil, Conflict of Interest: Nil.

Author Queries??????

Q1 tinea corporis gladiatorum - Please check if we shuld use the full name throughout
Q2 Should this be ‘submerged’?
Q3 100%?
Q4 Should this part be deleted?
Q5 or skin-to-skin?

Indian J Dermatol 2008; 53(3) 136

Original Article

CLINICOPATHOLOGICAL EVALUATION OF RADIATION INDUCED BASAL

CELL CARCINOMA
Naser Tayyebi Meibodi, Masood Maleki1, Zari Javidi1, Yalda Nahidi1
Abstract

Development of skin neoplasms is one of the most important chronic complications of radiation therapy. Basal
cell carcinoma (BCC) is the most frequent carcinoma occurring at the region of the body to which radiotherapy was
delivered. The aim of this study was to evaluate clinical and histological aspects of basal cell carcinoma in patients with
a history of radiotherapy. Materials and Methods: Medical records and microscopic slides of 80 patients with basal cell
carcinoma who had received radiotherapy (1996-2006) were reviewed in pathology department of Imam Reza hospital
of Mashhad, Iran. Collected data were analyzed statistically using descriptive test. Results: 60 men and 20 women were
included, majority of them in their sixties. Plaque was the most common clinical pattern of basal cell carcinoma. Fift one
percent of the patients had pigmented and 42.5% had multiple lesions. Scalp was the most common site of involvement.
Histologically, macronodular and pigmented carcinoma were the most predominant forms of basal cell carcinoma.
Discussion: Majority of patients had scalp involvement and multiple lesions. Nodular and pigmented forms were the
most common histological findings. We suggest the need for close supervision in patients with a history of radio therapy
in the past.

Key Words: Basal cell carcinoma, basal cell epithelioma, radiotherapy

Indian J Dermatol 2008:53(3):00-00******

Introduction is known as a late complication of ionizing radiation.3,4

Evidence that ionizing radiation is carcinogenic first came
from reports of nonmelanoma skin cancers on the hands
of workers using early radiation devices. An increase in
relative risk of basal cell carcinoma has also been found
among uranium workers, radiologists and children irradiated
for an enlarged thymus gland or tinea capitis.1
Radiotherapy has acute and chronic damages on skin.
Chronic radiation damage has common manifestations such
as telangiectasia, irregular hyperpigmentation, atrophy, and
scar formation. It is well known that radiation-induced
skin cancer may appear at sites of prior radiation, even if
there is no evidence of chronic radiation damage, as in the
present case. Several studies reported in the last decade also
supported the issue that variable factors such as anatomic
location, radiation type and dosage, age at exposure, post-
treatment time, sun exposure, and ethnic and genetic factors
have considerable effects on the incidence and type of skin
cancers in the irradiated population.2
Skin neoplasms especially basal cell carcinoma (BCC)
and then squamous cell carcinoma (SCC) are the main
complications of radiotherapy.3 Incubation periods of post-
radiation skin malignancies are very long. Skin cancer
From the Departments of Pathology and 1Dermatology of
Mashhad University of Medical Sciences, Mashhad, Iran. Address
correspondence to: Dr. Zari Javidi, Dermatology Department,
Imam-Reza Educational Hospital, Mashhad University of Medical
Sciences (MUMS), Mashhad, Iran. E-mail: zari_javidi@yahoo.com
Radiation-induced skin cancer may develop any time from
2 to 65 years after exposure, with an estimated median
latency of 20 to 45 years.2,4-7 Total dose of radiation
and irradiated site exposed to sunlight can lead to short
incubation period.6 BCC occurs in irradiated areas usually in
elderly and less frequently at young ages. Incubation period
between exposure to ionizing radiation and BCC symptoms
is shorter in young patients.8,9 Radiation exposures to the
scalp during childhood for tinea capitis were associated
with a four-fold increase in skin cancer, primarily basal
cell carcinomas, and a three-fold increase in benign skin
tumors.2,10
Relative risk of BCC is higher in patients who had received
low dose radiation to head and neck area.2
This study is performed to evaluate clinical and histological
aspects of basal cell carcinoma in patients with a history of
radiation.
Materials and Methods
This study was carried out at the dermatology ward of
Imam-Reza hospital of Mashhad. During a 10-year period
(1996-2006), a total of 648 cases of BCC were admitted.
Regarding to their medical records, 80 cases were selected.
All of them had a history of radiotherapy for treatment
of tinea capitis during childhood. The files of all patients
were collected and the following data were recorded: age,
gender, clinical form, number and size of lesions, age at
onset of radiation and sample number. Parameters such as

137 Indian J Dermatol 2008; 53(3)

 Meibodi et al.: Running title missing???
ulcer, histologic pattern and pigmentation were reviewed
using microscopic slides.
Collected data were analyzed statistically by SPSS software
(version 13) using qui-square, T-student and Man-Whitney
tests with 95% confidence interval.
Results
Among 80 patients with positive history of radiation
therapy, 60 (75%) were men and 20 (25%) were women
(male: female ratio was 3:1). Predominantly, BCC had been
developed in 5th (28/75%), 6th (42.5%) and 7th (18.75%)
decades of age. Average age of our cases was 56 years.
Plaques (74%), papules (13%), nodules (10%) and patches
(3%) were the most common clinical patterns of basal cell
carcinoma. Fifty one percent of the patients had pigmented
lesions and clinical ulcer was detected in 53%. Forty six
cases had only one lesion but 18 cases had two, 8 cases
had three and 8 cases had five lesions. The mean of lesions
Q1 number was 1.83 per patient. Scalp (71%), forehead (6%),
nose (5%) and periorbital area (5%) were the most common
sites of involvement.
Histologically, nodulocystic (60%) and micronodular
(17.5%) carcinoma were the most predominant forms of
BCC. 37.5% had ulcers and 72% had pigmentation.
Discussion
Different types of neoplasms such as skin cancers,
angiosarcoma, malignant fibrous histiocytoma, thyroid
carcinoma and brain tumors may occur following
radiotherapy.2,4 BCC (70-100%)11 and then SCC are the most
common malignancies in patients receiving radiation.3,4
Karagas suggests that exposure to therapeutic radiation is
associated with BCC but not with SCC.1 These neoplasms
usually occurs after radiation therapy for treatment of tinea
capitis, hypertrophic tonsillitis4 acne vulgaris,1,4 atopic
dermatitis and hyperthyroidism4 and rarely following
cancer of cervix and nasopharynx,12 neck lymph node
tuberculosis,5 medulloblastoma,13 ankylosing spondylitis,14
hemangioma15,16 and hirsutism.7 A recent report suggested
an increased risk of nonmelanoma skin cancer among the
latest Japanese atomic bomb survivors.1
Arai et al, defined radiation-associated second cancer using
the following criteria:1 difference of histologic type from
the primary cancer2 latency period of at least 2 years after
radiation therapy and3 development site in the irradiated
field.4
Regarding to Maalej and colleagues report the average
latency period between irradiation and cancer occurrence
was 36 ± 14 years.3 Meseddi’s report suggests that the
interval between irradiation and the onset of carcinoma
varied between 21 and 51 years.11
The time between receiving radiation therapy and onset of
Indian J Dermatol 2008; 53(3)
BCC was 30 to 70 years in our cases. The average patients’
age at the time of irradiation was 12 ± 6 years and 5 to
17 years in Maalej’s and Mseddi’s studies respectively.3,11
Majority of our cases were irradiated at less than 12 years
of age. Among all 648 patients suffering from BCC,
80 cases (12.5%) had a history of radiation therapy. This
was 41% in Akhyani’s study17 which can be explained by
the professional aspects of Razi hospital and also division of
our patients in 2 major dermatologic centers in Mashhad.
Ron and colleagues reported that the average radiation dose
for treatment of tinea capitis was 7GY. The relative risk of
radiogenic skin cancer did not differ significantly between
men or women or by time since exposure but was greatest
following exposures in early childhood. The estimated
excess relative risk was 0.7 per Gy.10
Shore’s study showed a relative risk of 3.6 (95% confidence
interval, 2.3-5.9) for BCC of the head and neck among
irradiated Caucasians in response to a dose of about 4.8Gy to
scalp. Children irradiated at young ages had the highest BCC
risk. He also mentioned that low ages at the time of exposure
and UV radiation increase the relative risk of BCC.18
Radiation induced BCC usually occurs with low to
moderate doses of radiation for treatment of tinea capitis,
hypertrophic tonsillitis, acne vulgaris, atopic dermatitis and
hyperthyroidism. But SCC seems to develop after high-
dose radiation.2,4,7
In 1987 Vloten et al, examined 605 patients treated by
irradiation for benign diseases in the head and neck region.
They reported 30 skin tumors mainly BCC and mentioned
that severity of radiodermatitis is associated with a higher
prevalence of skin cancer and the number of radiation-
induced skin cancers rises with the post-treatment time.2
The mean age of our cases was 56 years (ranged 40 to 80)
that is higher than Maalej’s cases in which patient’s age at
diagnosis of malignancy varied from 20 to 83 years with
an average of 47 years.3
Among 98 patients of Maalej’s study, in 61 patients (62%),
the scalp appeared normal and in 38% radio dermatitis was
noted. Basal cell carcinomas were the most frequent tumors
arising on chronic radiodermatitis.3 The radiogenic BCCs
tend to be multiple and they manifest as conventional
nodular BCC, superficial BCC and rarely, fibroepithelioma
Pinkus and keloidal types.7 Also, linear BCC can develop
rarely in the irradiated areas.19
Majority of our cases were men (75%) similar to Mseddi’s
study.11 It can be due to higher prevalence of tinea in
leading to higher radiation therapy in men. Moreover,
occupation and sunlight exposure are also important
risk factors. In Mseddi’s study 40% of BCC occurred on
the occipital area and 65% were in the scalp site. The
number of lesions varied from 1 to 5 and the size from
2 to 45 mm.11 About 41% of Akhyani’s cases had a positive
138
 Meibodi et al.: Running title missing???
history of irradiation. This rate was 90% in patients with
BCC on head, ear helices and neck. Also number of lesions
was higher in cases having received previous radiation.17
Scalp was the main area of involvement in our cases (71%)
and 42.5% had multiple lesions varying from 3 mm to
8 × 4 cm.
Also Shore reported several cancers in irradiated patients.9,18
About 40% of his irradiated cases have had multiple
BCCs.18 The average of lesions number was 1.8 per patient
in our study, 1.5 per patient in Maalej’s study and 1.76 per
patients in Mseddi’s study.3,11 In Mseddi’s study, nodular
BCC and pigmentation was detected in 51% 64% of cases
clinically but histological study showed a nodular pattern
in 76% and pigmentation in 63% of cases.11 Despite of
Akhyani’s report in which noduloulcerative BCC was the
main clinical from (30.5%),17 the most common forms
in our study were plaque (74%) and pigmented (51%).
The most frequent histological type in both Akhyani’s
and Malekzadeh’s studies was solid tumors (53.5% and
30%).17,20 Microscopic study revealed 72% pigmentation
in our study which was higher than Mseddi’s (62%)11 and
Malekzadeh’s (44%) reports.20
Conclusion
Periodical lifetime examination of irradiated areas in
addition to scalp and ear helices is indicated for patients
with a history of radiation. Moreover, it is very important to
create awareness in patients of referring to their physician
for any suspicious lesions.
References
1. Karagas MR, McDonald JA, Greenberg ER, Stukel TA,
Weiss JE, Baron JA, et al. Risk of basal cell and squamous cell
skin cancers after ionizing radiation therapy. J Natl Cancer Inst
1996;88:1848-53.
2. Ekmekçi P, Bostanci S, Anadolu R, Cengizhan Erdem C,
Gürgey E. Multiple basal cell carcinomas developed after
radiation therapy for tinea capitis: A case report. Dermatol Surg
2001;27:667-9.
3. Maalej M, Frikha H, Kochbati L, Bouaouina N, Sellami D,
Benna F, et al. Radio-induced malignancies of the scalp about 98
patients with 150 lesions and literature review. Cancer Radiother
2004;8:81-7.
4. Handa Y, Miwa S, Yamada M, Ono H, Suzuki T, Tomita Y.
Multiple pigmented basal cell carcinomas arising in the normal-
appearing skin after radiotherapy for carcinoma of the cervix.
Dermatol Surg 2003;29:1233-5.
5. Misago N, Ogusu Y, Narisawa Y. Keloidal basal cell carcinoma
after radiation therapy. Eur J Dermatol 2004;14:182-5.
Author Query??????
Q1 Should this be: ‘mean number of legions’?
139
6. Iwamoto I, Endo M, Kakinuma H, Suzuki H. Multiple basal cell
carcinoma developing two years after 60Co irradiation. Eur J
Dermatol 1998;8:180-2.
7. Misago N, Ogusu Y, Narisawa Y. Keloidal basal cell carcinoma
after radiation therapy. Eur J Dermatol 2004;14:182-5.
8. Marín-Gutzke M, Sánchez-Olaso A, Berenguer B, González B,
Rodríguez P, De Salamanca JE, et al. Basal cell carcinoma in
childhood after radiation therapy: Case report and review. Ann
Plast Surg 2004;53:593-5.
9. Shore RE, Albert RE, Reed M, Harley N, Pasternack BS. Skin
cancer incidence among children irradiated for ringworm of the
scalp. Radiat Res 1984;100:192-204.
10. Ron E, Modan B, Preston D, Alfandary E, Stovall M, Boice JD.
Radiation-induced skin carcinomas of the head and neck. Radiat
Res 1991;125:318-25.
11. Mseddi M, Bouassida S, Marrekchi S, Khemakhem M,
Gargouri N, Turki H, et al. Basal cell carcinoma of the scalp after
radiation therapy for tinea capitis: 33 patients. Cancer Radiother
2004;8:270-3.
12. Badri T, Zeglaoui F, Kochbati L, Kooli H, El Fekih N, Fazaa B,
et al. Multiple basal cell carcinomas following radiation therapy
for nasopharyngeal cancer. Presse Med 2006;35:55-7.
13. Atahan IL, Yildiz F, Ozyar E, Uzal D, Zorlu F. Basal cell
carcinomas developing in a case of medulloblastoma associated
with Gorlin’s syndrome. Pediatr Hematol Oncol 1998;15:187-91.
14. Beswick SJ, Garrido MC, Fryer AA, Strange RC, Smith AG.
Multiple basal cell carcinomas and malignant melanoma
following radiotherapy for ankylosing spondylitis. Clin Exp
Dermatol 2000;25:381-3.
15. Eggers G, Flechtenmacher C, Kurzen H, Hassfeld S. Infiltrating
basal cell carcinoma of the neck 34 years after irradiation
of an haemangioma in early childhood: A case-report.
J Craniomaxillofac Surg 2005;33:197-200.
16. Bucher S, Guerra M, Corrias F, Ribuffo D. Basal cell carcinoma
of the nose requiring amputation arising after irradiation for
childhood hemangioma. Anticancer Res 2006;26:4767-70.
17. Akhyani M, Ghaninezhad Ahary H, Safaie Naraghi Z, Rezaie A.
An epidemiologic clinical and pathological study of basal cell
epithelioma (BCE) in Razi Dermatological Hospital. J Tehran
Faculty Med 1977;5:48-52.
18. Shore RE, Moseson M, Xue X, Tse Y, Harley N, Pasternack BS.
Skin cancer after X-ray treatment for scalp ringworm. Radiat Res
2002;157:410-8.
19. Chopra KF, Cohen PR. Linear basal cell carcinomas: Report of
multiple sequential tumors localized to a radiotherapy port and
review of the literature. Tex Med 1997;93:57-9.
20. Malek Zadeh F. The comparison of pathological BCC variation
with previous history of radiotherapy versus patients without
history of radiotherapy. Sci J Hamadan Univ Med Sci Health
Services 1978;14:16-8.
Received: August, 2007. Accepted: April, 2008.
Source of Support: Nil, Conflict of Interest: Nil.
Indian J Dermatol 2008; 53(3)
Case Report

PIGMENTED BASAL CELL CARCINOMA SUCCESSFULLY TREATED WITH

5% IMIQUIMOD CREAM
Vandana Mehta, C Balachandran
Abstract

Basal cell carcinoma (BCC) is the most common malignant skin tumor, amongst which the nodular, nodulo ulcerative
and superficial types comprise nearly 80% of all BCCs. Topical Imiquimod, an immune response modifier has been found
to be effective in superficial and nodular types of BCC with histological clearance rates of up to 100%. We report our
experience of treatment a large pigmented BCC on the face with topical Imiquimod 5% cream.

Key Words: Pigmented BCC, Imiquimod

Indian J Dermatol 2008:53(3):00-00******

Introduction lesion, which subsided in due course. At 12 weeks there

Basal cell carcinoma (BCC) is the most common malignant
skin tumor. Though surgical excision, curettage with
or without electrocautery, cryotherapy and intralesional
interferons are all available as potential treatments for BCC,
they are painful and require a skilled medical practitioner.
Topical imiquimod, an immune response modifier has been
found to be effective in superficial and nodular types of
BCC with histological clearance rates of up to 100%. We
report our experience of treatment a large pigmented BCC
on the face with topical Imiquimod 5% cream.
Case History
A 37-year-old male presented with an asymptomatic,
hyperpigmented plaque on his left cheek of 8 years
duration. The lesion was small at onset and had gradually
increased to its present state. There was no history of
exposure to radiation other than routine sun exposure.
There were no systemic symptoms. Cutaneous examination
revealed a solitary well-defined hyperpigmented plaque
measuring 3 × 4 cm with raised pigmented margins near
the left ear [Fig. 1]. There was no ulceration or regional
lymphadenopathy. Systemic examination was normal.
A clinical diagnosis of pigmented basal cell carcinoma
was made. Biopsy from the edge of the plaque showed
multiple nests of basaloid cells with peripheral palisading
in the papillary dermis in continuity with the overlying
epithelium [Figs. 2 and 3]. Our patient was started on
Imiquimod 5% cream to be applied three times a week
on alternate days. After four weeks of application, he
developed mild erythema with burning sensation over the
From the Department of Skin and STD, Kasturba Medical
College, Manipal. Address correspondence to: Dr. Vandana
Mehta, Department of Skin and STD, Kasturba Medical College,
Manipal - 576 104, Karnataka, India. E-mail: vandanamht@
yahoo.com
was near complete resolution of the pigmentation from
the periphery with only some central activity [Fig. 4]. The
treatment was further continued for four weeks after which
there was complete clearance. A repeat biopsy done at this
stage showed no residual tumor on multiple sections.
Discussion
Imiquimod, a heterocyclic imidazoquinoline amide, is an
immune response modifier that has both antitumor and
antiviral activity. It was first approved by the US Food
and Drug Administration in 1997 for the treatment of
external genital and perianal warts, and in 2004 for the
treatment of actinic keratoses and superficial basal cell
carcinoma.1 Besides these there are also reports of its use
in non genital warts, molluscum contagiosum, Bowen’s
disease, squamous cell carcinoma, extra mammary
Paget’s disease, keratoacanthoma, Mycosis fungoides,
morphea, prevention of keloids after surgery, infantile
hemangiomas, porokeratosis of Mibelli, cutaneous
leishmaniasis, actinic cheilitis, recurrent genital herpes
and eccrine poroma.2
Imiquimod as a monotherapy has shown cure rates ranging
from 70% to 100% with twice daily, once daily and thrice
weekly regimens for both superficial and nodular BCC.3
Clinical and histological cure rate of 100% was seen with
twice daily application of Imiquimod for a period of six
weeks.4
The precise mechanism of action of Imiquimod in BCC is
unknown. It has been postulated that ultraviolet radiation
induces mutations in the tumor suppressor genes and
alters the immunosurveillance, so that tumor cells escape
from apotosis and cytotoxic T cells. The Th2 cytokines
that down regulate tumor surveillance are raised in BCC.
Imiquimod is a Toll like receptor (TLR) 7 agonist that
acts on the immune system by stimulating the monocytes,

Indian J Dermatol 2008; 53(3) 140

 Mehta and Balachandran: Running title missing???
Fig. 1: Hyperpigmented plaque with raised borders
Fig. 2: Photomicrograph showing nests of basaloid cells in continuity with
the epidermis 20×
macrophages and dendritic cells to produce interferon
alpha, Th1 cytokines (IL-1, IL-6, IL-10, IL-12), tumor
necrosis factor α and G-CSF, thereby counteracting Th2
cytokines and promoting tumor surveillance.5 It also
enhances the activity of natural killer cells and epidermal
Langerhan’s cells.
Although imiquimod is considered safe, both systemic and
local side-effects have been reported.6 Most of the local side-
effects have been application site reactions such as burning,
itching, pain, erythema, erosions and hypopigmentation
which may be seen with any dosing regimen, but typically
increase in frequency and severity as the frequency of
application increases. Systemic side-effects are usually mild
and include headache, fever, malaise, myalgia, arthralgia,
nausea and diarrhea. Our patient continued treatment for
16 weeks and experienced only minimal application site
reactions which subsided is due course.
For patients who have failed to respond to other therapeutic
modalities or who have had recurrence following standard
therapy or who are medically unfit for surgery, Imiquimod
may be beneficial.
141
Fig. 3: Photomicrograph showing close up of basaloid cells with peripheral
palisading 40×
Fig. 4: Post-treatment photograph showing resolution of pigmentation
from the periphery
References
1. Jobanputra KS, Rajpal AV, Nagpur NG. Imiquimod. Indian J
Dermatol Venereol Leprol 2006;72:466-9.
2. Navi D, Huntley A. Imiquimod 5 percent cream and the treatment
of cutaneous malignancy. Dermatol Online J 2004;10:4.
3. Geisse JK, Rich P, Pandya A, Gross K, Andres K, Ginkel A,
et al. Imiquimod 5% cream for the treatment of superficial basal
cell carcinoma: A double blind, randomized vehicle controlled
study. J Am Acad Dermatol 2002;47:390-8.
4. Marks R, Gebauer K, Shumack S, Amies M, Bryden J, Fox TL,
et al. Imiquimod 5% cream in the treatment of superficial basal
cell carcinoma: Results of a multicenter 6 week dose response
trial. J Am Acad Dermatol 2001;44:807-13.
5. Tyring S, Conant M, Marini M, Van Der Meijden W, Washenik K.
Imiquimod: An International update on therapeutic uses in
dermatology. Int J Dermatol 2002;41:810-6.
6. Sterry W, Ruzicka T, Herrera E, Takwale A, Bichel J, Andres K,
et al. Imiquimod 5% cream for treatment of superficial and
nodular basal cell carcinoma: Randomized studies comparing
low frequency dosing with and without occlusion. Br J Dermatol
2002;147:1227-36.
Received: May, 2007. Accepted: July, 2007.
Source of Support: Nil, Conflict of Interest: Nil.
Indian J Dermatol 2008; 53(3)
Case Report
MANAGEMENT OF ENL BY MYCOPHENOLATE MOFETIL
Kalyan Banerjee, Raghubir Banerjee
Abstract
Mycophenolate Mofetil has been tried in 20 cases of chronic relapsing ENL reaction where long use of systemic steroid
produce complications or are contraindicated. Excellent results have been observed in all the cases to arrest the reaction
followed for a period of six to eight months duration.
Key Words: ENL, mycophenolate mofetil
Indian J Dermatol 2008:53(3):00-00******
Introduction
Progressive knowledge of leprosy over the last few decades
sometimes fall short in the understanding of many a
subsequent complication and aftermath of this disease even
after a full MDT schedule. Treatment of reactional and post
reactional episodes often pose a therapeutic challenge to
leprologists of our country and some times drug therapy
with routine anti-inflammatory and immunomodulator
agents fail to produce desired response.1
The present study attempts to evaluate the role of a yet not
so routinely used agent Mycophenolate Mofetil in reactions
in leprosy where systemic corticosteroid therapy is not
viable.
Materials and Methods
In this study profile 20 patients of ENL between the age
group of 30 to 50 years were selected out which 16 patients
were of LL type and 4 patients of BL type. These patients
had intractable ENL reactions of severe grade refractory to
routine conservative treatment and having contraindications
for systemic corticosteroid therapy like hypertension,
diabetes mellitus and peptic ulcer and history of melaena.
All the patients had erythematous evanescent, tender skin
nodules with pyrexia and joint pains as the commonest
clinical findings.2 Routine laboratory tests showed
leucocytosis and raised ESR. In four patients skin biopsy
was done for confirmation of the diagnosis. Fever and
nodules and erythema subsided within 48 to 72 h of
commencement of therapy.
These patients were started with Mycophenolate Mofetil
at dose of 1 gram per day and in a few cases dosage
increment to 2 grams per day were necessary for control
From the University College of Medicine, Goenka Hospital,
Calcutta, India. Address correspondence to: Dr. Kalyan Banerjee,
120, Apcar’s Garden Asansol - 713 304, India. E-mail:
drkalyanbanerjee@yahoo.com
Indian J Dermatol 2008; 53(3)
and subsequent maintenance. The liver function, kidney
function and routine blood counts were done during the
course of therapy. These patients were monitored for a
period of six to eight months. In two patients treatment
was discontinued within a month due to the systemic side-
effects of the drug like nausea and vomiting and other
gastro intestinal symptoms and drug did not produce
desired results. Maintenance dosages of 500 mg per day
was effective to control the ENL in most cases.
Results
Out of the 20 cases under going treatment 14 cases were
males and 6 females mostly of the middle age group.
Most of the cases (18) showed significant subsidence of
lesions within a month although low dose maintenance
with 0.5 gram per day was necessary for 4 to 6 months for
complete remission Table 1.
Discussion
The name ENL given by Japanese Dr. Murata 1912 is
used in most parts of Asia alternatively lepromatous
lepra reaction is also used as it commonly occurs at the
bacilliferous end of the leprosy spectrum. It is common in
treated lepromatous patients 50% developing by the end of
the first year of treatment.3
Mycophenolate Mofetil is used. In dermatology and
documented in the treatment of SLE, pemphigus, steroid
resistant idiopathic thrombocytopenic purpura and other
autoimmune diseases. Its use in ENL as a steroid sparing
agent has not so commonly being put to test. Efficacy
of Mycophenolate Mofetil in diffuse proliferative lupus
nephritis and in stable renal transplant recipients has been
commonly put to practice by the medical fraternity.4
Immunopharmacology of Mycophenolate Mofetil is vital
in understanding its clinical usage. Prodrug Mycophenolic
acid acts as a inhibitor of inosine mono phosphate
dehydrogenase (IMPDH) which is the rate limiting enzyme
in denovo synthesis of guanosine nucleotide. T and B
142
 Banerjee and Banerjee: Running title missing???

by which MPA exerts immunosuppressive effects).

Table 1: Showing number of patients with different
contra indication to systemic steroid therapy Efficacy of MPA occurs mainly due to induction of
Contraindications No of patients apoptosis of activated T cells, eliminating clones of cells
Hypertension 7
responding to antigenic stimulation. Depleting guanosine
nucleotides, MPA suppresses glycosylation and expression
Diabetes mellitus 5
of some adhesion molecules. By depleting guanosine
Peptic ulcer 6 nucleotides, MPA also depletes tetrahydrobiopterin (cofactor
Melaena 2 for inducible form of nitric oxide synthetase - INOS).
The common dosage schedule followed was the routine
0.5 gram twice in a day with dosage reduction over period of
4 to 6 months and further follow-up for another two months.

Conclusion
Mycophenolate Mofetil may be an important steroid
sparing agent for ENL reactions where systemic cortisone
is contraindicated for producing quick control of symptoms
and remission lasting over 6 to 8 months.

References
1. Karat AB. Complications of leprosy, a window on leprosy. In:
Chatterjee BR, editor. Calcutta: Statesman Commercial Press;
1978. p. 128-32.
2. Thangaraj RH. Reactions in leprosy, A manual of leprosy. South
Asia: The Leprosy Mission; 1983. p. 160-5.
Q1 Fig. 1: Missing???
3. Waters MF. A window on leprosy. In: Chatterjee BR, editor.
Calcutta: Statesman Commercial Press; p. 124-7.
4. Schnuelle P, van der Heide JH, Tegzess A, Verburgh CA, LC,
lymphocytes are more dependent on this path way that van der Woude FJ, et al. Open randomized trial comparing early
alters cell types. MPA is five times more potent inhibitor of withdrawal of either cyclosporine or Q2

type (ii) isoform of IMPDH which is expressed in activated

lymphocytes than type (i) isoform. MPA has cytostatic Received: February, 2007. Accepted: October, 2007.
effect on lymphocytes than on other cell types (mechanism Source of Support: Nil, Conflict of Interest: Nil.

Author Query??????

Q1 Please provide Figure caption and citation.

Q2 Sentence incomplete

143 Indian J Dermatol 2008; 53(3)

Case Report

ANGIOLYMPHOID HYPERPLASIA WITH EOSINOPHILIA: ATYPICAL

APPEAREANCE IN AN OLDER PATIENT
Ozlem Karabudak, Oktay Taskapan, Onder Bozdogan1, Bilal Dogan
Abstract

We describe a 76-year-old man presenting with a chronic, non-healing ulcer of six-year duration on his left zygomatic
area. The skin biopsy specimen taken from the lesion, showed increased vascular proliferation, edematous endothelial
cells in the dermal blood vessels and perivascular eosinophilic/lymphocytic infiltration. The routine and specific blood
tests were unremarkable. On the basis of these features, the patient was diagnosed as having angiolymphoid hyperplasia
with eosinophilia (ALHE). We present the case because of its rarity in older people, atypical clinical appearance; and
stress the consideration of ALHE in the differential diagnosis of chronic non-healing superficial ulcers confined to face
and neck.

Key Words: Angiolymphoid hyperplasia with eosinophilia, non-healing ulcer

Indian J Dermatol 2008:53(3):00-00******

Introduction eosinophil count and serum total Ig E level were within

Angiolymphoid hyperplasia with eosinophilia (ALHE) is
an uncommon idiopathic condition characterized isolated
or grouped papules, plaques, or nodules in the skin of
the head and neck. ALHE is a benign neoplasm, but may
be persistent and difficult to eradicate. It presents most
commonly in patients aged 20-50 years and rarely in
elderly people.
Case History
A 76-year-old man presented with a chronic, non-healing
ulcer of six-year duration on his left zygomatic area. His
medical history was unremarkable except hypertension
controlled with anti-hypertensive medication (amlodipine,
5mg/day). No abnormality was detected in general physical
examination. Dermatological examination revealed an
asymptomatic, atrophic, partly crusted and ulcerated
plaque of 8 × 3 cm in diameter in the left zygomatic area
[Fig. 1].
A biopsy specimen was obtained from the lesion [Figs. 2, 3].
Histopathologic examination of the skin biopsy specimen
showed increased vascular proliferation, edematous
endothelial cells in the dermal blood vessels and perivascular
eosinophilic/lymphocytic infiltration. All routine laboratory
investigations including whole blood count, sedimentation
rate, renal and liver function tests, peripheral blood
From Department of Dermatology, GATA Teaching Hospital,
Tibbiye Street 81327 Kadikoy, Istanbul, Turkey. 1Department of
Pathology, Kırıkkale University Faculty of Medicine, Istanbul,
Turkey. Address correspondence to: Dr. Ozlem Karabudak, GATA
Teaching Hospital Department of Dermatology, Tibbiye Street
81327 Kadikoy, Istanbul, Turkey. E-mail: okarabudak@yahoo.com
normal limits. Craniography was also found to be normal.
On the basis of clinical and histopathological features, the
patient was diagnosed as having ALHE. He was treated
with cryotherapy. However, there was a recurrence in a
few months. The patient didn’t come to regular follow-up
examinations.
Discussion
Angiolymphoid hyperplasia with eosinophilia, first
described by Wells and Whimster in 1969, is a rare
benign vascular tumor.1 It is characterized by one or more
purplish, brownish papules and subcutaneous nodules
with a predilection for the head and neck regions. Other
tissues such as orbit, heart, bone, liver and spleen may also
be involved. It is more common in middle-aged females.
Contrary the name suggests, peripheral blood eosinophilia
is not a constant finding in ALHE.2 Histopathologically,
ALHE is characterized by numerous thick and thin-walled
vessels lined with characteristic edematous endothelial cells
(“hobnail” or “tombstone” appearance) associated with
variable lymphocytic and eosinophilic infiltrate.3
The etiopathogenesis of ALHE is not well known.
Trauma, hormonal changes and infections (HTLV or
HHV 8) have been suggested to play a role in the
pathogenesis.4 Association of ALHE with nephrotic
syndrome and pregnancy have been described.4,5 Over-
expression of estrogen and progesterone receptors
was detected in pregnant women.6 Interleukin 5 and
vascular endothelial growth factor were also found to be
increased in some cases.7 Since they share many clinical
and histopathological similarities, ALHE should be
differantiated from Kimura’s disease. Kimura’s disease
occurs in younger patients, the lesions show deeper

Indian J Dermatol 2008; 53(3) 144

 Karabudak et al.: Running title missing???

The clinical appearance of the lesion in our patient

resembles sclerosing (morpheaform) basal cell carcinoma
(BCC) which is characterized by a yellowish-whitish
sclerotic plaque with poorly defined margins and induration.9
Our patient’s lesion had no signs regarding sclerosis and
induration. In addition, ALHE and sclerosing BCC show
completely different histopathological patterns.
The most common therapeutic options are surgical excision
and pulsed dye laser. Cryotherapy, irradiation, intralesional
steroid injection, carbon dioxide laser have also been
reported as therapeutic options with variable levels of
success.10
The older patient of ALHE presented here had an atypical
appearance. We suggest that ALHE should be considered in
Fig. 1: Ulcerated plaque in the left zygomatic area
the differential diagnosis of chronic non-healing superficial
ulcers confined to face and neck.

References
1. Wells GC, Whimster IW. Subcutaneous angiolymphoid
hyperplasia with eosinophilia. Br J Dermatol 1969;81:1-14.
2. Zarrin-Khameh N, Spoden JE, Tran RM. Angiolymphoid
hyperplasia with eosinophilia associated with pregnancy:
A case report and review of the literature. Arch Pathol Lab Med
2005;129:1168-71.
3. Olsen TG, Helwig EB. Angiolymphoid hyperplasia with
eosinophilia: A clinicopathologic study of 116 patients. J Am
Acad Dermatol 1985;12:781-96.
4. Hollo P, Marschalko M, Sikos G, Harsing J, Horvath A.
Angiolymphoid hyperplasia with eosinophilia in pregnancy. J Eur
Acad Dermatol Venereol 2005;19:645-6.
5. Azizzadeh M, Namazi MR, Dastghaib L, Sari-Aslani F.
Fig. 2: Dense chronic inflammation and vascular network in dermis. Angiolymphoid hyperplasia with eosinophilia and nephrotic
(H&E, ×20) syndrome. Int J Dermatol 2005;44:242-4.
6. Moy RL, Luftman DB, Nguyen QH, Amenta JS. Estrogen
receptors and the response to sex hormones in agiolymphoid
hyperplasia with eosinophilia. Arch Dermatol 1992;128:825-8.
7. Aoki M, Kimura Y, Kusunoki T, Tahara S, Kawanah S.
Angiolymphoid hyperplasia with eosinophilia associated with
anomalous dilation of occipital artery: IL-5 and VEGF expression
of lesional mast cells. Arch Dermatol 2002;138:982-4.
8. Calonje E, MacKie RM. Soft-tissue tumors and tumor-like
conditions. In: Breathnach S, Cox N, Griffiths C, editors.
Textbook of dermatology, 7th ed. Oxford: Blackwell Publishing;
2004. p. 20.
9. David J, Leffell L. A fitzgerald basal cell carsinoma Fitzpatrick’s
Dermatology in General Medicine. In: Freedberg IM, Eisen ZA,
Wolff K, Austen KF, Goldsmith LA, Katz SI, et al, editors.
Fitzpatrick. 5th ed. New York: McGraw Hill Company; 1999.
p. 857-64.
10. Meyerle CH., Glusac E.: Angiolymphoid hyperplasia with
Fig. 3: Prominent histiocyte-like endothelial cells and chronic inflammatory eosinophilia. eMedicine. [cited on 2006]. Available from:
cells (eosinophils and neutrophils) around vessels. (H&E, x40) http://www.emedicine.com/derm/topic30.htm. [last accessed on
2006 Dec 14].
localization and association with lymphadenopathy.
Histologically, it contains sclerosis at any stage, but does Received: July, 2007; Accepted Date: October, 2007.
not have epithelioid endothelial cells.8 Source of Support: Nil, Conflict of Interest: Nil.

145 Indian J Dermatol 2008; 53(3)

Case Report

METASTATIC CROHN’S DISEASE OF EXTERNAL GENITALIA

Charles Panackel, Joseph John, Devadas Krishnadas, Kattoor R Vinayakumar
Abstract

Metastatic Crohn’s disease is an uncommon extraintestinal manifestation of Crohn’s disease. Its hallmark features include
the presence of cutaneous noncaseating granulomas that are noncontiguous with the gastrointestinal tract or fistula. We
report a rare case of metastatic Crohn’s disease involving the external genitalia in a 14-year-old girl. Diagnosis was based
on skin biopsy. Patient had complete recovery on treatment with oral and topical steroids along with azathioprine.

Key Words: Extraintestinal manifestation of IBD, metastatic Crohn’s disease, noncaseating granuloma

Indian J Dermatol 2008:53(3):00-00******

Introduction was in remission (CDAI-146) when she developed pain,

itching of external genitalia followed by papular eruptions
Metastatic Crohn’s disease is an uncommon extraintestinal
and ulceration [Fig. 1]. There was no fever, constitutional
manifestation of Crohn’s disease. Its hallmark features
symptoms or vaginal discharge. She had no aggravation
include the presence of cutaneous noncaseating granulomas
of her bowel symptoms. A skin biopsy was done which
that are noncontiguous with the gastrointestinal tract or
was inconclusive and clinical diagnosis of herpes simplex
fistula. We report a rare case of metastatic Crohn’s disease
infection was made. Patient was started on acyclovir
involving the external genitalia in a girl with Crohn’s
with no relief of symptoms. A repeat skin biopsy was
disease and discuss the various manifestations and treatment
done which showed noncaseating epitheloid granulomas,
options.
multinucleated giant cells, and perinuclear cuffing with
Case History lymphocytes [Figs. 2 and 3]. Gram, Zeil Nielson and period
acid Schiff stain were negative. A diagnosis of metastatic
A 14-year-old girl presented with history of pain, itching, Crohn’s disease was made and oral prednisolone 40 mg and
swelling and ulceration of external genitalia of three topical steroids were added to azathioprine. Steroids were
weeks duration. Patient was diagnosed to have pulmonary continued for four weeks and tapered. She had complete
tuberculosis in 2000 for which she took Antitubercular relief of symptoms. All throughout her present illness her
treatment for six months. In 2002, she presented with chronic Crohn’s disease remained in remission.
diarrhea and was diagnosed as intestinal tuberculosis. She
was re-treated with antitubercular drugs with no relief of Discussion
symptoms. One year later she presented with perianal abscess
Cutaneous manifestations occur in 22-44% of patients
and erythema nodosum when a repeat colonoscopy showed
with Crohn’s disease.1 Three distinct patterns of cutaneous
apthoid ulcers, cobble stone appearance, fissuring ulcers
involvement are seen in Crohn’s disease. The most
and pseudopolyps in ascending, transverse, descending and
common is the peristomal or perianal disease where the
sigmoid colon. Ileum, ileocaecal valve and Caecum were
gastrointestinal tract disease encroaches on the adjacent
normal. A barium meal follow through was normal. Colonic
skin. Second pattern includes a variety of conditions
biopsy showed evidence of Crohn’s disease and a diagnosis
associated with Crohn’s disease like erythema nodosum,
of extensive Crohn’s disease with moderate activity was
pyoderma gangrenosum, neutrophilic dermatosis, steven
made (CDAI-260). She was initiated on treatment with
Johnson syndrome, erythema multiforme, acrodermatitis
antibiotics and mesalamine followed by steroids. In 2005,
enteropathica, and epidermolysis bullosa acquista.2 The
she presented with recurrent relapse of symptoms while
third type is the metastatic Crohn’s disease. The disease
on steroids. She was diagnosed to have steroid refractory
was first described by parks et al, in 1965.3 It was Mountain
Crohn’s and was started on azathioprine(100mg/day). She
who coined the term metastatic Crohn’s disease in 1970.4
Metastatic Crohn’s disease is characterized by noncaseating
From the Department of Medical Gastroenterology, Medical
College Trivandrum, Kerala, India - 695 004 Address
granulomatous involvement of skin noncontiguous from
correspondence to: Dr. Charles Panackel, Department of the gastrointestinal tract in a patient with Crohn’s disease.5
Gastroenterology, Medical College Trivandrum, Kerala - 695 004, Metastatic Crohn’s disease of the external genitalia is
India. E-mail: charlespanackel@hotmail.com exceedingly rare, with few documented cases in the literature.

Indian J Dermatol 2008; 53(3) 146

 Panackel et al.: Metastatic Crohn’s Disease

these lesions show multinucleated giant cells, noncaseating

granulomas, perivascular lymphocytes, monocytes and
necrobiosis.5,7-9 Metastatic Crohn’s disease appears to be
more common in patients with colonic involvement. There
is no relation between presence of metastatic Crohn’s and
activity of intestinal disease. Metastatic Crohn’s disease can
precede or occur along with gastrointestinal disease. Our
case had papules, nodules and ulcers of external genitalia.
She had Crohn’s colitis which was in remission.
Other conditions that can be mistaken for metastatic
Crohn’s include syphilis, tuberculoid leprosy, sarcoidosis,
tuberculosis, fungal infections, foreign body granulomas
and erysipelas. A definite diagnosis requires a thorough
evaluation including biopsy and cultures.
Fig. 1: Multiple papules, nodules and ulcers on the external genitalia and
surrounding skin
There are no definite guidelines for treatment of metastatic
Crohn’s. Drugs tried include topical agents, oral steroids,
aminosalicylates, immunosuppressive agents, oral
antibiotics, hyperbaric oxygen10 and surgery.11 Infliximab an
antitumor necrosis factor-α chimeric monoclonal antibody is
used for the treatment of Crohn’s disease. Till date there are
six case reports where Infliximab was used to successfully
treat metastatic Crohn’s disease.12-17 Infliximab has been
successfully used to treat other cutaneous manifestations
of Crohn’s disease like pyoderma gangrenosum and
hidradenitis suppurative. Our patient was continued on
azathioprine and both topical and oral steroids were added.
Oral steroids were continued in a dose of 1 mg/kg for four
weeks and taper gradually till complete healing occured.

Conclusion
Metastatic Crohn’s disease is a disfiguring illness and often
Fig. 2: Skin biosy showing multinucleate giant cell and epitheloid cells
(H&E, ×400)
refractory to treatment. A thorough evaluation including
biopsies is required to make a definite diagnosis. Ours is
a case of metastatic Crohn’s disease involving external
genitalia and it responded to oral and topical steroids along
with azathioprine.

References
1. Goyal A, Mansel RE, Young HL, Douglas-Jones A. Metastatic
cutaneous Crohn’s disease of the nipple: Report of a case. Dis
Colon Rectum 2006;49:132-4.
2. Burgdorf W. Cutaneous manifestations of Crohn’s disease. J Am
Acad Dermatol 1981;5:689-95.
3. Parks AG, Morson BC, Pegum JS. Crohn’s disease with
cutaneous involvement. Proc R Soc Med 1965;58:241-2.
4. Mountain JC. Cutaneous ulceration in Crohn’s disease. Gut
1970;11:18-26.
5. Guest GD, Fink RL. Metastatic Crohn’s disease: Case report
Fig. 3: Skin biopsy showing noncaseating granuloma (H&E, ×100) of an unusual variant and review of the literature. Dis Colon
Rectum 2000;43:1764-6.
6. Sangueza OP, Davis LS, Gourdin FW. Metastatic Crohn’s
Metastatic Crohn’s disease can have a varied presentation. disease. South Med J 1997;90:897-900.
It can present as cutaneous ulcerations, plaques, papules 7. Hackzell-Bradley M, Hedblad MA, Stephansson EA. Metastatic
and nodules.6 Lesions usually have a predilection for skin Crohn’s disease: Report of 3 cases with special reference to
folds, infra-mammary area and the limbs. Biopsies from histopathologic findings. Arch Dermatol 1996;132:928-32.

147 Indian J Dermatol 2008; 53(3)

 Panackel et al.: Metastatic Crohn’s Disease
8. Burgdorf W, Orkin M. Granulomatous perivasculitis in Crohn’s
disease. Arch Dermatol 1981;117:674-5.
9. Perret CM, Bahmer FA. Extensive necrobiosis in metastatic
Crohn’s disease. Dermatologica 1987;175:208-12.
10. Brady CE 3rd, Cooley BJ, Davis JC. Healing of severe perineal
and cutaneous Crohn’s disease with hyperbaric oxygen.
Gastroenterology 1989;97:756-60.
11. Williams N, Scott NA, Watson JS, Irving MH. Surgical
management of perineal and metastatic cutaneous Crohn’s
disease. Br J Surg 1993;80:1596-8.
12. van Dullemen HM, de Jong E, Slors F, Tytgat GN, van
Deventer SJ. Treatment of therapy-resistant perineal metastatic
Crohn’s disease after proctectomy using anti-tumor necrosis
factor chimeric monoclonal antibody, cA2: Report of two cases.
Dis Colon Rectum 1998;41:98-102.
13. Miller AM, Elliott PR, Fink R, Connell W. Rapid response
Indian J Dermatol 2008; 53(3)
of severe refractory metastatic Crohn’s disease to infliximab.
J Gastroenterol Hepatol 2001;16:940-2.
14. Escher JC, Stoof TJ, van Deventer SJ, van Furth AM. Successful
treatment of metastatic Crohn disease with infliximab. J Pediatr
Gastroenterol Nutr 2002;34:420-3.
15. Rispo A, Lembo G, Insabato L, Cozzolino A, Pesce G,
Castiglione F. Successful treatment of therapy-resistant metastatic
Crohn’s disease with infliximab. Br J Dermatol 2004;150:1045-6.
16. Graham DB, Jager DL, Borum ML. Metastatic Crohn’s disease
of the face. Dig Dis Sci 2006;51:2062-3.
17. Konrad A, Seibold F. Response of cutaneous Crohn’s disease to
infliximab and methotrexate. Dig Liver Dis 2003;35:351-6.
Received: October, 2007. Accepted: December, 2007.
Source of Support: Nil, Conflict of Interest: Nil.
148
Case Report

CONCOMITANT CUTANEOUS METASTATIC TUBERCULOUS ABSCESSES

AND MULTIFOCAL SKELETAL TUBERCULOSIS
Betul Sezgin, Ulviye Atilganoglu1, Ozgul Yigit, Selma Sonmez Ergun2, Nevin Cambaz,
Cuyan Demirkesen3
Abstract

Tuberculosis, one of the oldest diseases known to affect humans is caused by the bacteria mycobacterium tuberculosis. The
disease usually affects the lungs, although, in up to one third of cases, other organs are involved. Metastatic tuberculosis
abscess is a rare form of skin tuberculosis. It is characterized by nodule and abscess formation throughout the body
after hematogenous spread of mycobacterium tuberculosis from a primary focus during a period of impaired immunity.
Tuberculosis osteomyelitis is also a rare form of extrapulmonary tuberculosis in pediatric age group. Skeletal tuberculosis
pathogenesis is related to reactivation of hematogenous foci or spread from adjacent paravertebral lymph nodes. Weight-
bearing joints are affected most commonly. Bilateral hand and foot bone involvement is rarely reported. We present a
five-year-old girl with two very rare presentations of the disease such as osteomyelitis and metastatic skin abscess.

Key Words: Cutaneous metastatic tuberculous abscess, skeletal tuberculosis, treatment

Indian J Dermatol 2008:53(3):00-00******

Introduction We present a five-year-old girl with both metastatic

Although tuberculosis is an ancient disease that is
known to have existed in prehistoric times, it remains
one of the most important infectious diseases today in
terms of morbidity, mortality, and economic impact. The
development of resistance to antituberculosis drugs and
conditions associated with immunodeficiency such as AIDS
and chemotherapy are responsible for the recent increase.
As a result unusual presentations of tuberculosis have been
encountered more frequently such as cutaneous tuberculosis,
skeletal tuberculosis, tuberculous meningitis, tuberculous
lymphadenitis and abdominal tuberculosis. In the last
decade, a 50% increase in admissions for extrapulmonary
tuberculosis was reported.1-7
subcutaneous skin abscesses in multiple sites and
tuberculosis osteomyelitis of tarsal and carpal bones treated
successfully by antituberculosis agents.
Case History
A five-year-old malnourished female patient was admitted
to our hospital with multiple subcutaneous abscesses
on her neck, right elbow, left fourth finger, left lateral
malleolus, left and right dorsum of the foot and right
great toe, which had been present for seven months
[Figs. 1-3]. After she received courses of antibiotics, the
lesions, initially pea-sized, failed to heal; on the contrary,
they enlarged.

Skin tuberculosis, a form of the extrapulmonary
tuberculosis, occurs in 1% of all tuberculosis cases.
Metastatic tuberculosis abscess is a rare form of cutaneous
tuberculosis resulting in single or multiple cutaneous and
subcutaneous lesions on trunk, extremities, or head.3,8,9
Skeletal involvement occurs in approximately 1-3% of
patients with tuberculosis. The most frequently involved
site is vertebrae followed by pelvis and knee joints. Few
cases are reported in the literature that showed involvement
of tarsal and carpal bones.3,8,10-12
From Departments of Pediatry, 1Dermatology, 2Plastic and
Reconstructive Surgery and 3Pathology, Cerrahpasa Medical
School, Istanbul, Turkey. Address correspondence to: Dr.
Selma Sönmez Ergün, Bahçeşehir Emlak Bankası Konutları,
B 18 D3 C020403 34 900, Büyükçekmece/Istanbul/Turkey.
E-mail: selmasonmezergun@yahoo.com
Dermatologic examination revealed widespread dusky
red nodules. The lesions were fluctuating and non-tender
without redness or local warmth on the overlying skin.
The left fourth finger, right elbow, left ankle and bilateral
dorsal foot regions were swollen and painful. Regional
lymphadenopathy was not detected. The other physical
findings were normal.
Her weight and height were 15 kg and 100 cm respectively
(both below the third percentile). There was history of
progressive weight loss. She had no previous history of
skin injury or immunosuppressive therapy. The family
history revealed a past occurrence of treated pulmonary
tuberculosis in one of the house members. She did not
have BCG vaccine. A quantative reading of PPD (purified
protein derivate) skin test was positive with 22 × 29 mm of
induration at the 72nd hour. Erythrocyte sedimentation rate
was 102 mm/hr. Blood count showed signs of pancytopenia

149 Indian J Dermatol 2008; 53(3)

 Sezgin et al.: Running title missing???
(HGB: 9.2 gr/dl, WBC: 3260/mm³, PLT: 100 000/mm³).
CRP was 4.05 mg/dl (usual value 0-1 mg/dl). Serology for
antibodies to HIV was negative.
The chest roentgenogram was normal. The roentgenograms
of the extremities showed a periosteal reaction in the left
fourth metacarpal bone, right proximal ulna, right proximal
Fig. 1: Cutaneous metastatic skin abscess on the neck
Fig. 2: Cutaneous metastatic skin abscess on right elbow
Fig. 3: Bilateral cutaneous metastatic skin abscess on dorsum of the
foot
Indian J Dermatol 2008; 53(3)
humerus, left distal fibula and tibia and bilateral calcaneus
[Figs. 4-6]. The findings on the bone scan were suggestive
of osteomyelitis.
Skin biopsy specimen was taken from the margin of the
active skin lesion. Large areas of necrosis, surrounded
by palisading epithelioid histiocytes, Langhans-type
multinucleated giant cells and lymphocytes were detected
in this skin biopsy [Fig. 7]. Using Ehrlich-Ziehl-Neelsen
stain, acid-fast bacilli were not seen.
On the basis of clinical-pathological findings, positive
tuberculine skin test, and history of close contact with
tuberculosis patient in her family, a final diagnosis of
extrapulmonary tuberculosis was made.
Abscesses were drained and treatment with isoniazid (INH)
15 mg/kg/day, rifampicin (RMP) 15 mg/kg/day, ethambutol
(EMB) 15 mg/kg/day and pyrasinamid (PZA) 20 mg/kg/
day were started. The lesions regressed within two months.
After two months EMB and PZA were discontinued. INH
and RMP were given for 16 more months.
Fig. 4: Fusiform, expansive heterogenous material filling the diaphysis of
the fourth metacarpal bone describing spina ventosa
Fig. 5: “Bone in bone” pattern describing calcaneal bony expansion
with sclerotic changes in the center surrounded by a radiolucent ring
representing secondary changes due to medullary involvement of
tuberculosis
150
 Sezgin et al.: Running title missing???
Fig. 6: Increased medullary intensity resulting from subperiostal expansion
in the area between metaphysis and diaphysis in ulna consistent with
tuberculosis osteomiyelitis
Fig. 7: Skin biopsy revealing large areas of necrosis, surrounded by
palisading epitheloid histiocytes (H&E, x100)
Three months later, her symptoms waned, and the abnormal
results on laboratory tests and findings on extremity
roentgenograms markedly improved. Complete resolution
occurred by nine months. At the end of 60 months follow-
up, the patient was clinically very healthy.
Dıscussıon
Tuberculosis has been known to affect mankind since
the dawn of human civilization and still remains a major
problem in the developing countries. Extrapulmonary
tuberculosis accounts for up to one third of all cases.
Children show a higher predisposition to the development
of extrapulmonary tuberculosis.3,8,9
The overall incidence of cutaneous tuberculosis among
all forms of tuberculosis is approximately 1-2%.
M. tuberculosis, m.bovis and under certain conditions the
attenuated BCG organism cause all forms of cutaneous
tuberculosis. Classification has been attempted according
to morphology, and more recently the mode of infection
or the immunologic state of the host. Although primary
151
inoculation tuberculosis and tuberculosis verrucosa cutis
are exogenous infections; lupus vulgaris, scrofuloderma,
metastatic tuberculous abscess, acute miliary tuberculosis
and orificial tuberculosis are endogenously spread
cutaneous tuberculosis forms. Kumar et al, reported that
lupus vulgaris was the most common clinical presentation,
followed by scrofuloderma, tuberculosis verrucosa cutis
and cutaneous metastatic tuberculous abscess (tuberculous
gumma) in their series.1,3,6,8,13
Metastatic tuberculous abscesses may occur along with
progressive organ tuberculosis or in miliary tuberculosis,
however there are reports showing that it may occur
without any underlying tuberculous focus as occurred in
our patient. It usually occurs in undernourished children
of low socioeconomic status or immunodeficient or
severely immunosuppressed patients. Our patient had a
lower socioeconomic status, too, her general condition was
consistent with failure to thrive and she had manifestations
of malnutrition.3,8,9,14
The differential diagnosis includes staphylococcal abscess,
other mixed bacterial infections, spirotrichosis, nocardiosis,
chromomycosis, leishmaniasis, atypical mycobacterial
infections, deep fungi infections, syphilitic gumma, leprosy
and all forms of panniculitis. Confirmation of the clinical
diagnosis is obtained by histopathology, and bacterial or
fungal culture.8,15,16
Tuberculin sensitivity is usually lower than in other forms
of skin tuberculosis and may be absent in severely ill
patients.1,5,6,8,13,14 There was strong tuberculine positivity
in our patient that could be attributed to concomitant
tuberculosis osteomyelitis.
Skeletal tuberculosis accounts for 10-15% of cases of
extrapulmonary tuberculosis.15,17,18 Recently, the proportion
of bone or joint tuberculosis has progressively increased to
27%.19 Although they are highly specific in the presented
case, the clinical findings may not be specific, and in many
cases, the radiographic appearance is similar to pyogenic
osteomyelitis; therefore, the disease is frequently neglected
or misdiagnosed. The symptoms are those usually seen in
musculoskeletal disorders; pain, stiffness, and swelling. The
tuberculin test is positive in up to 90% of cases.2,7,12,15,20
Multifocal bone involvement can occur but it is occasionally
reported in children. The spine and hip are the most
common sites of osteoarticular tuberculosis. On the other
hand, tuberculosis of the hand and foot is less common.
The spine is involved in half the cases, whereas dactylitis
contributes only to 4% of cases.2,7,12,18,19,21
Tuberculous involvement of the short, tubular bones of the
hands and feet is termed tuberculous dactylitis. Fusiform
soft-tissue swelling and periostitis are the most common
radiographic findings. As underlying bone is destroyed, a
cyst-like cavity forms and the remaining bone appears to be
ballooned out. This appearance is termed spina ventosa. In
Indian J Dermatol 2008; 53(3)
 Sezgin et al.: Running title missing???
children, tuberculous dactylitis can produce spina ventosa
like our patient, a pattern of chronic osteitis characterized
by central defect, soft tissue swelling, and exuberant
periosteal reaction.
The most common radiologic finding is that of osteoporosis,
which may be intense cancellous bone involvement
and may present as a cystic lesion with or without
sequestrum.7,10,12,15
Roentgenograms, CT or MRI reveal the characteristic lesion
and suggest its etiology, although the differential diagnosis
includes other infections and tumors. Aspiration of the
abscess or bone biopsy confirms the tuberculous etiology,
as histologic findings are highly typical and cultures are
usually positive; however skeletal and skin tuberculoses are
paucibacillary lesions and it is difficult to demonstrate or
culture acid-fast mycobacteria from these lesions like our
patient.22
The incidence of active pulmonary tuberculosis associated
with skin or skeletal tuberculosis is reported as 50-65%
in the literature. The concomitant presentations of skin
and skeletal tuberculosis is a very rare condition. Kıvanc-
Altunay et al, reported that 61% of skin tuberculosis cases
had pulmonary involvement whereas no skeletal tuberculosis
was encountered. Kumar et al, reported that four patients
out of 75 with skin tuberculosis had skeletal tuberculosis
and only one had tuberculous dactylitis. Although active
pulmonary tuberculosis was not present in our case, two
rare presentations of tuberculosis, skin tuberculosis and
skeletal tuberculosis were concomitantly observed.4,6
The histological findings of metastatic tuberculous abscess
involve massive necrosis and abscess formation with or
without acid fast bacilli. No bacilli were shown among
typical necrotising granulomas in our case. The culture
and PCR results were also negative for tuberculosis in our
case. In endemic regions, the clinical features, radiological
appearance and elevated ESR are sufficient to diagnose
tuberculosis and begin treatment.10,15,23,24 Considering
positive family history with a patient having cavernous
tuberculosis in the same home environment, strong positive
PPD results, X-ray findings and necrotising granulomas in
histology, metastatic tuberculous abscesses and tuberculous
osteomyelitis were diagnosed in our case. Immune
suppression due to malnutrition was the explanation for the
clinical situation.
In conclusion, tuberculosis incidence has increased in
industrialized countries, which is attributed to several factors
such as immigration from countries with a high prevalence
of tuberculosis, infection with HIV, emergence of multi-drug
resistant tuberculosis, and social problems such as poverty,
homelessness and drug abuse.22 Rare extrapulmonary
tuberculosis cases are seen more frequently as a result of this.
The possibility of tuberculosis must always be kept in mind
in subcutaneous abscess and nodule cases non-responsive to
non-spesific therapy, and drainage. Awareness of the unusual
Indian J Dermatol 2008; 53(3)
presentations of tuberculosis is essential for early diagnosis
and proper therapy. Therefore physicians must have a high
index of suspicion with regard to tuberculosis.
References
1. Braun-Falco O, Plewing G, Wolff HH, Winkelman R.
Dermatology. 4th ed. Berlin: Springer-Verlag; 2000.
2. Munoz FM, Starke JR. Mycobacterial infections. In: Behrman
RE, Kliegman RM, Jenson HB, editors. Nelson’s texbook of
pediatrics.17th ed. Philadelphia: WB Saunders Company; 2004.
p. 958-78.
3. Mert A, Tabak F, Dumankar A, Öztürk R, Aktuğlu Y. Derialtı
abseleri gelisen dissemine tüberküloz olgusu. Turk J Infect
1997;11:157-8.
4. Kivanç-Altunay I, Baysal Z, Ekmekçi TR, Köslü A. Incidence of
cutaneous tuberculosis in patients with organ tuberculosis. Int J
Dermatol 2003;42:197-200.
5. Maltezou HC, Spyridis P, Kafetzis DA. Extra-pulmonary
tuberculosis in children. Arch Dis Child 2000;83:342-6.
6. Kumar B, Rai R, Kaur I, Sahoo B, Muralidhar S, Radotra BD.
Childhood cutaneus tuberculosis: A study over 25 years from
northern India. Int J Dermatol 2001;40:26-32.
7. Starke RS. Tuberculosis. In: Gerson AA, Hotez PJ, Katz SL,
editors. Krugman’s infectious diseases of children. 11th ed.
Philadelphia: Mosby Co; 2004. p. 731-65.
8. Tappeiner G, Wolff K. Tuberculosis and other mycobacterial
infections. In: Fitzpatrick TB, Freedberg IM, Eisen AZ, Wolff
K, editors. Dermatology in general medicine. 4th ed. New York:
McGraw-Hill Company; 1999. p. 2274-92.
9. Darmstadt GL, Sidbury R. The skin. In: Behrman E, Kliegman
RM, Jenson HB, editors. Nelson Texbook of Pediatrics. 17th ed.
Philadelphia: WB Saunders Company; 2004. p. 2153-250.
10. Mittal R, Gupta V, Rastogi S. Tuberculosis of the foot. J Bone
Joint Surg Br 1999;81:997-1000.
11. Ray M, Kataria S, Singhi P. Unusual presentation of disseminated
tuberculosis. Indian Pediatr 2002;39:88-91.
12. Engin G, Acunaş B, Acunaş G, Tunaci M. Imaging of
extrapulmonary tuberculosis. Radiographics 2000;20:471-88.
13. Baykal C, Deri Tüberkülozu: 64 olgunun retrospektif
değerlendirilmesi. Türkderm 2001;35:103-7.
14. Kumar B, Muralidhar S. Cutaneous tuberculosis: A twenty-year
prospective study. Int J Tuberc Lung Dis 1999;3:494-500.
15. Vanmarsenille JM, de Berg B, Houssiau FA, de Selys J. Unusually
prolonged course of tuberculous dactylitis with osteitis. Joint
Bone Spine 2003;70:535-7.
16. McNally L, Al-Ansari H, Novelli V. Mycobacterial infections
of the skin. In: Haiper J, Orange A, Prose N, editors. Text book
of pediatric dermatology. Oxford: Blackwell Science; 2000.
p. 401-10.
17. Combalia A, Sastre S, Esteban P. Tuberculous osteomyelitis of
the knee. Arch Orthop Trauma Surg 2004;124:708-10.
18. Martinez SF, Canale ST. Tuberculosis and other unusual infections.
In: Canale ST editor. Campbell’s operative orthopaedics. 10th ed.
Philadelphia: Mosby Company; 2003. p. 713-27.
19. Lin YS, Huang YC, Chang LY, Lin TY, Wong KS. Clinical
characteristics of tuberculosis in children. J Pediatr Orthop
1999;19:151-5.
20. Wang MN, Chen WM, Lee KS, Chin LS, Lo WH. Tuberculous
osteomyelitis in young children. J Pediatr Orthop 1999;19:151-5.
152
 Sezgin et al.: Running title missing???
21. Çaksen H, Arslan S, Oner AF, Kuru M, Karakök M, Odabaş
D. Multiple metastatic tuberculous abscesses in a severly
malnourished infant. Pediatr Dermatol 2002;19:90-1.
22. Raviglione MC, O’Brien RJ. Tuberculosis. In: Braunwald E,
Hauser SL, Fauci AS, Longo DL, Kasper DL, Jameson JL,
editors. Harrison’s Principles of Internal Medicine. 15th ed.
Philadelphia: McGraw-Hill; 2001. p. 1024-35.
23. Ramesh V, Misra RS, Beena KR, Mukherjee. A study of cutaneous
153
tuberculosis in children. Pediatr Dermatol 1999;16:264-9.
24. Uzel M, Garipardic M, Cetinus E, Bilgic E, Karaoguz A,
Boran C, et al. Tuberculosis of knee in a child. J Trop Pediatr
2004;50:182-4.
Received: May 2007. Accepted: July 2007.
Source of Support: Nil, Conflict of Interest: Nil.
Indian J Dermatol 2008; 53(3)
Case Report

ALLERGIC CONTACT DERMATITIS MIMICKING MAMMARY

PAGET’S DISEASE
Kaliyadan Feroze, Jayasree Manoj, S Venkitakrishnan
Abstract

A 55-year-old female patient presented to our outpatient department with complaints of persistent erythema, oozing and
crusting restricted to the left breast over the last 6 months. The patient underwent investigations to rule out the possibility
of mammary Paget’s disease, all of which were negative. A possibility of contact dermatitis to topical medication was
considered and confirmed by patch testing.

Key Words: Allergic contact dermatitis, patch testing, topical steroids, Paget’s disease

Indian J Dermatol 2008:53(3):00-00******

A 55-year-old lady, a college professor, presented to us

with a history of persistent itching, erythema, oozing and
crusting over the nipple, areola and periareolar region
on the left breast of more than 6 months duration. The
lesions had been localized to the nipple and immediate
periareolar region initially but had started extending
recently. She had been using various topical medications
for the same including steroids of varying potency. The
patient had good response to topical steroids initially but
on further use the lesion appeared to be getting worse.
The patient had no other significant co-morbidity and was
in otherwise good health. On examination we found an
ill-defined area of scaling, erythema and minimal crusting
over the over the nipple, areola and peri-areolar region
on the left breast [Fig. 1]. There was minimal induration
Fig. 1: Lesion restricted to the left breast showing erythema with oozing,
over the nipple and immediate peri-areolar area and no crusting and scaling
significant tenderness or bleeding on touch. Patient had
no significant lymphadenopathy. The unilateral nature
of the central lesions and the apparent lack of response
to topical steroids made us consider a possibility of
mammary Paget’s disease, for which the patient was
evaluated. Routine blood and urine investigation were
within normal limits. Potassium hydroxide smears and
cytology findings were normal. Mammography showed
no evidence of any micro calcification or significant
breast tissue involvement suggestive of malignancy.
A skin biopsy was taken form two sites and both
the specimens showed features of a dermatitis with
spongiosis and moderate lymphocytic infiltration. Based
on the investigation results we ruled out the possibility

From the Department of Dermatology, Amrita Institute of

Medical Sciences and Research Centre, Kochi, Kerala,
India. Address correspondence to: Dr. Feroze Kaliyadan,
Department of Dermatology, Amrita Institute of Medical
Sciences and Research Centre, Kochi, Kerala - 682 026, India.
E-mail: ferozkal@hotmail.com
Fig. 2: Lesion after 2 weeks of stopping all topical applications
of Paget’s disease and considered an alternative
possibility of a primary non-specific dermatitis with a
persistent contact dermatitis to topical applications. We

Indian J Dermatol 2008; 53(3) 154

 Feroze et al.: Allergic contact dermatitis mimicking Paget’s
initially patch tested the patient with the commercial
products she was using, including brands of fluticasone
and betamethasone. Interestingly all the products showed
a strong positive reaction after 48h. We then patch-tested
the patient with multiple antigens including topical
antibiotics, preservatives and bases. The patch tests
showed a strongly positive reaction to propylene glycol,
parabens and chlorocresol and a moderate reaction to
both neomycin and gentamycin. We also carried out an
intradermal test with hydrocortisone and betamethasone
solutions in saline, which gave a negative result. Based
on the patch test findings we asked the patient to stop
all topical preparations and started the patient on saline
compresses and plain Vaseline along with a short course
of systemic steroids. The lesions improved and by the
end of two weeks had subsided almost entirely with only
a mild residual hyperpigmentation [Fig. 2].
Discussion
Contact dermatitis of the breast area can be due to a number
of factors including topical applications of various types.1-3
In our case the unilateral presentation and the apparent lack
of response to topical steroids made us think on the lines of
mammary Paget’s. Most eczematous lesions of the breast
tend to be bilateral like seborrheic and atopic dermatitis
though there have been reports of chronic unilateral
dermatitis of the nipple areolar complex.4 The diagnosis of
mammary Paget’s was excluded in our case based on the
cytology, mammography and histopathology findings. The
history of apparent worsening of the lesions after an initial
improvement made us think of a possibility of an allergic
contact dermatitis to the topical applications used by the
patient. Ointment bases and vehicles are known to cause
various kinds of contact allergies, prominent among them
being those due to chlorocresols, parabens and propylene
glycol.5,6 Topical corticosteroids per se can also cause an
allergic contact dermatitis, especially tixocortol pivalate and
Author Query??????
Q1 Matter missing?
155
budesonide and need to be tested in suspected cases, either
as a patch test in an ethanol base or as an intradermal test
in saline.7-9 Nonhalogenated topical steroids are considered
to be more frequent sensitizers than halogenated molecules.7
This case was published to highlight the importance of
thinking of an allergic contact dermatitis to topical agents Q1
in lesions stimulating a chronic eczematous dermatitis.
References
1. García M, del Pozo MD, Díez J, Muñoz D, de Corrès LF.
Allergic contact dermatitis from a beeswax nipple-protective.
Contact Dermatitis 1995;33:440-1.
2. McGeorge BC, Steele MC. Allergic contact dermatitis of the
nipple from Roman chamomile ointment. Contact Dermatitis
1991;24:139-40.
3. Lamb SR, Ardley HC, Wilkinson SM. Contact allergy to
propylene glycol in brassiere padding inserts. Contact Dermatitis
2003;48:224-5.
4. Novick NL. Unilateral, circumscribed, chronic dermatitis of
the papillary-areolar complex: Case report and review of the
literature. Mt Sinai J Med 2001;68:321-5.
5. Krupa Shankar DS, Shrestha S. Relevance of patch testing in
patients with nummular dermatitis. Indian J Dermatol Venereol
Leprol 2005;71:406-8.
6. Dogra A, Minocha YC, Sood VK, Dewan SP. Contact dermatitis
due to cosmetics and their ingredients. Indian J Dermatol
Venereol Leprol 1994;60:72-5.
7. English JS. Corticosteroid-induced contact dermatitis: A pragmatic
approach. Clin Exp Dermatol 2000;25:261-4.
8. Seukeran DC, Wilkinson SM, Beck MH. Patch testing to
detect corticosteroid allergy: Is it adequate? Contact Dermatitis
1997;36:127-30.
9. Isaksson M, Andersen KE, Brandão FM, Bruynzeel DP, Bruze
M, Camarasa JG, et al. Patch testing with corticosteroid mixes in
Europe: A multicentre study of the EECDRG. Contact Dermatitis
2000;42:27-35.
Received: August, 2007. Accepted: October, 2007.
Source of Support: Nil, Conflict of Interest: Nil.
Indian J Dermatol 2008; 53(3)
Correspondence

MULTIFOCAL BULLOUS FIXED

DRUG ERUPTION DUE TO
FLUCONAZOLE
Amiya Kumar Nath, Balaji Adityan,
Devinder Mohan Thappa
Indian J Dermatol 2008:53(3):00-00******
From the Department of Dermatology and STD, Jawaharlal
Institute of Postgraduate Medical Education and Research
(JIPMER), Pondicherry - 605 006, India. E-mail: dmthappa@
satyam.net.in/dmthappa@gmail.com

Fixed drug eruption (FDE) due to fluconazole is extremely

rare. We recently had a 35-year-old female patient who
presented with multifocal bullous FDE due to fluconazole
hitherto not reported in the literature.
A 35-year-old female, a known case of carcinoma stomach,
operated and initiated on post-operative chemotherapy
with cisplatin and adriamycin, presented with multiple
itchy hyperpigmented elevated oval patches over the
face, neck, trunk, upper limbs and lower limbs of three
days duration following some medications for sore throat
problem (details of the medication were not available at
that time). On physical examination, she had multiple
(200 in number) asymmetrically distributed, rounded to
oval, hyperpigmented, edematous lesions of variable sizes
surrounded by a rim of erythema over the body. Many
lesions were bullous. She had a similar episode six months
ago but at that time had developed only three lesions on
the face and neck following oral medication for mouth
problem. A diagnosis of multifocal bullous FDE was made.
The skin lesions subsided over next one week leaving
behind hyperpigmented macules without any intervention.
Patch testing with cisplatin and adriamycin was negative.
Oral rechallenge test to paracetamol and diclofenac sodium
was negative. Subsequently, she was diagnosed to have
oral candidiasis in our hospital and was prescribed oral
fluconazole 200 mg on day one followed by 50 mg daily
for two weeks. Within half an hour of intake of first dose,
she developed itching in the skin lesions and in a couple of
hours, developed reactivation of FDE lesions [Fig. 1]. She
was managed with systemic corticosteroids to control the
reaction. Thus, a diagnosis of multifocal bullous FDE due
to fluconazole was established.
Fluconazole is a triazole antifungal. It is fungisatic and is
effective against many yeasts and dermatophytes.1 It acts
by inhibiting 14 α-demethylase, a microsomal cytochrome
P450 enzyme, in the fungal cell membrane.1 Despite it’s
widespread use, side-effects due to fluconazole are rarely
reported. Side-effects are common when used in high doses
Fig. 1: Multifocal fixed drug eruption due to fluconazole
(400 mg/day for months), especially in HIV individuals.2
Reported side-effects are nausea, vomiting, abdominal
pain, diarrhea, elevated liver enzymes, mild to fatal hepatic
necrosis, thrombocytopenia, agranulocytosis, leucopenia,
eosinophilia, headache, dizziness, seizures, paresthesia,
anaphylaxis, acute adrenal insufficiency, hypokalemia,
teratogenicity, menstrual irregularities, and various
cutaneous side effects like pruritus, exanthems, erythema
multiforme, Stevens-Johnson syndrome, toxic epidermal
necrolysis, exfoliative dermatitis, fixed drug eruption,
angioedema, oral ulcers, purpura, and reversible alopecia.2
Most of the cutaneous side-effects due to fluconazole exist
in isolated or a limited number of case reports. Fixed drug
eruption due to fluconazole is extremely rare. To the best of
our knowledge, there are only eight earlier reports of fixed
drug eruption due to fluconazole in the literature.3-5
FDE is characterized by sudden onset of round and/
or oval edematous, dusky-red, macules/plaques on the
skin and/or mucosa arising precisely over the area of an
earlier reaction due to the same drug.6 However, with
subsequent exposure to the culprit drug, a few to numerous
new lesions may appear and sometimes may become
generalized. Acute lesions usually develop 30 min to eight
hours after re-administration of the incriminating drug.6
After the initial acute phase lasting days to weeks, residual
grayish or slate-colored hyperpigmentation develops.6
Various morphological types of lesions that may occur
are morbiliform, scarlatiniform, erythema multiforme-like,
Stevens-Johnson syndrome-like, eczematous, urticarial,
nodular, vesicular, bullous (may become toxic epidermal
necrolysis-like in severe cases), non-pigmenting and diffuse
hypomelanosis.6 Confirmation of diagnosis requires re-
challenge by topical provocation (in the form of patch test)
and/or oral provocation test, of which oral provocation test
is considered superior but unsafe.6

Indian J Dermatol 2008; 53(3) 156

 Correspondence

Our literature search on FDE due to fluconazole revealed in tapering doses which resulted in complete healing of the
that all cases reported so far had limited cutaneous or erosions within a month.
mucosal lesions. In contrast, our patient had extensive
Localized bullous pemphigoid (LBP) is a rare autoimmune
generalized lesions with many bullous lesions, a unique
subepidermal blistering disease of the elderly characterized
presentation of fixed drug eruption due to fluconazole
by chronic intermittent eruptions affecting only a restricted
which has not been described in the literature so far. With
area of the body. Though it accounts for 16% to 29%
widespread use of any drug, new adverse effects come to
of all cases of bullous pemphigoid, the true incidence
light and hitherto unknown adverse effect may become
may be greater as it is often misdiagnosed and is highly
more common occurrence. We recommend that fluconazole
responsive to topical steroids. LBP has got similar clinical,
be included in the list of drugs causing multifocal bullous
histopathological and immunofluorescence features to
FDE so that similar cases may be diagnosed more often.
generalized bullous pemphigoid.1 Three types have been
References identified which include: 1.) mucous membrane pemphigoid
or cicatricial pemphigoid 2.) localized scarring pemphigoid
1. Konnikov N, Raynham H. Oral antifungal agents. In:
or Brunsting Perry pemphigoid affecting the head and
Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA,
Katz SI, editors. Fitzpatrick’s Dermatology in General Medicine, neck 3.) localized non scarring pemphigoid usually seen
6th ed. New York: McGraw-Hill; 2003. p. 2443-8. over the pretibial region, vulva, breast and the soles. The
2. Amichai B, Grunwald MH. Adverse drug reactions of the new diagnosis of this last entity tends to be delayed because
oral antifungal agents-terbinafine, fluconazole and itraconazole. it can mimic other localized vesicobullous diseases and
Int J Dermatol 1998;37:410-5. dyshidrotic eczema.2 While the pathogenesis of generalized
3. Mahendra A, Gupta S, Gupta S, Sood S, Kumar P. Oral fixed bullous pemphigoid is well elucidated, it is unknown why
drug eruption due to fluconazole. Indian J Dermatol Venereol patients with LBP have limited disease. The pathogenesis
Leprol 2006;72:391. most likely could be similar to that of generalized bullous
4. Ghislain PD, Ghislain E. Fixed drug eruption due to fluconazole: pemphigoid because patients in both the groups recognize
A third case. J Am Acad Dermatol 2002;46:467.
5. Shukla P, Prabhudesai R. Fixed drug eruption to fluconazole.
Indian J Dermatol 2005;50:236-7.
6. Sehgal VN, Srivastava G. Fixed drug eruption (FDE): changing
scenario of incriminating drugs. Int J Dermatol 2006;45:897-908.

LOCALIZED FLEXURAL BULLOUS

PEMPHIGOID
Vandana Mehta, C Balachandran
Indian J Dermatol 2008:53(3):00-00******
From the Department of Skin and STD, Kasturba Medical College,
Manipal, Karnataka, India. E-mail: Vadanamht@yahoo.com
Fig. 1: Tense vesicles and bullae in the axilla Q1
A 63-year-old male agriculturist presented with a
spontaneously appearing bullous eruption localized to the
axillae and groins, with intense pruritus of 3 weeks duration.
He was also a known hypertensive, diagnosed with renal
failure on treatment with ACE inhibitors and amlodepin
since 1 year. On examination there were tense vesicles and
bullae associated with crusting and erosions in the axillae,
upper medial aspect of arms and groins bilaterally. The rest
of the skin including the mucous membranes, palms, soles,
genitalia were normal. Histopathology revealed subepidermal
blisters, direct immunofluorescence assay of perilesional skin
showed linear deposits of IgG and C3 along the basement
membrane zone and the indirect immunofluorescence
demonstrated antibasement membrane antibodies bound to
the epidermal side of the salt split normal human skin thus
confirming our diagnosis of localized bullous pemphigoid.
Patient was accordingly started on prednisolone 60 mg daily Fig. 2: Tense vesicles and bullae in the groins

157 Indian J Dermatol 2008; 53(3)

 Correspondence
the same BP antigens.3 LBP has been documented following
radiotherapy,4 PUVA therapy, trauma,5 sunexposure,6
split skin grafting for burns,7 around peristomal lesions8
and several authors have thus postulated that these local
factors might play a role in the induction of lesions in
immunologically susceptible individuals. In a study on the
distribution of bullous pemphigoid antigens in normal human
skin the greatest expression was seen in the skin obtained
from the flexor aspect of arms, legs and thighs9 which
probably explains the predominant flexural localization of
lesions in our case. Whether the ACE inhibitors contributed
in triggering the bullous eruption here is not clear as the
patient had been taking the above medications for almost a
year. Nevertheless this case emphasizes the need to follow-
up such patients regularly as they are at risk of developing a
generalized eruption later in life.
References
1. Tran JT, Mutasim DF. Localized bullous pemphigoid:
A commonly delayed diagnosis. Int J Dermatol 2005;44:942-5.
2. Scola F, Telang GH, Swartz C. Dyshidrosiform pemphigoid.
J Am Acad Dermatol 1995;32:516-7.
3. Soh H, Hosokawa H, Miyauchi H, Izumi H, Asada Y. Localized
bullous pemphigoid shares the same target antigen as bullous
pemphigoid. Br J Dermatol 1991;125:73-5.
4. Leconte-Boulard C, Dompmartin A, Verneuil L, Thomine E,
Joly P, Rogerie MJ, et al. Localized bullous pemphigoid
following radiotherapy. Ann Dermatol Venereol 2000;127:70-2.
5. Vermeulen C, Janier M, Panse I, Daniel F. Localized bullous
pemphigoid induced by thermal burn. Ann Dermatol Venereol
2000;127:720-2.
6. Lee CW, Ro YS. Sun induced localized bullous pemphigoid.
Br J Dermatol 1992;126:91-2.
7. Hafejee A, Coulson IH. Localized bullous pemphigoid 20 years
after split skin grafting. Clin Exp Dermatol 2005;30:187-8.
8. Torchia D, Caproni M, Ketabchi S, Antiga E, Fabbri P. Bullous
pemphigoid initially localized around a urostomy. Int J Dermatol
2006;45:1387-9.
9. Hamm G, Wozniak KD. Bullous pemphigoid antigen
concentration in normal skin: relation to body area and age. Arch
Dermatol Res 1988;280:416-9.
MANGO DERMATITIS
Viroj Wiwanitkit
Indian J Dermatol 2008:53(3):00-00******
From Health Unit, Chulalongkorn University; Department of
Laboratory Medicine, Faculty of Medicine, Chulalongkorn
University, Bangkok, Thailand - 10330. E-mail: wviroj@yahoo.com
Mango, Mangifera indica, is a common tropical fruit. It is
a favorable sweet for millions of people living in several
tropical countries.1 Mango Dermatitis’ is the common term
given to allergic contact dermatitis to the sap or skin of the
fruit of mango. This type of allergic reaction is rare but has
become increasingly important.2 Here, the author reported a
Indian J Dermatol 2008; 53(3)
case of mango dermatitis. A 42-year-old female presented
to the physician at a health unit with a one-day history of
patchy pruritic erythema of the face, and extremities with
periorbital edema. Periorbital edema was present without
intraoral abnormalities or laryngeal changes. The patient
denied any history of contact urticaria or new household
or personal hygiene contactants. She gave the history of
this illness as a common episode after ingestion of peeled
mangoes. In the Health Unit, the patient was administered
a single 50 mg dose of oral prednisone. She continued
treatment with a five-day course of prednisone, 50 mg
daily, with chlorphemiramine, 8 mg daily. Symptomatic
improvement was seen over seven days. Patch testing
using mango skin and mango flesh gave positive reactions.
Complete avoidance of mango is suggested to this patient.
Adding to the previous report of Weinstein et al,1 this is the
second reported positive patch test to the mango flesh.
References
1. Weinstein S, Bassiri-Tehrani S, Cohen DE. Allergic contact
dermatitis to mango flesh. Int J Dermatol 2004;43:195-6.
2. Paschke A, Kinder H, Zunker K, Wigotzki M, Steinhart H,
Wessbecher R, Vieluf I. Characterization of cross-reacting
allergens in mango fruit. Allergy 2001;56:237-42.
IN HERPETIFORM PEMPHIGUS
CLINICALLY RESEMBLING
BULLOUS PEMPHIGOID
Vandana Mehta, C Balachandran,
Sudhir Nayak
Indian J Dermatol 2008:53(3):00-00******
From the Department of Skin and STD, Kasturba Medical College,
Manipal, Karnataka, India. E-mail: vandanamht@yahoo.com
Herpetiform pemphigus was first introduced by Jablonska in
1975, as a variant of pemphigus that combines the clinical
features of dermatitis herpetiformis with the immunological
features of pemphigus.1 Because of its rare and atypical
clinical presentation, patients are often initially diagnosed as
Dermatitis herpetiformis, Linear IgA bullous disease, Bullous
pemphigoid or Pemphigus foliaceus. We report a case of
herpetiform pemphigus in an elderly lady which was initially
misdiagnosed as bullous pemphigoid, however histology and
immunofluorescence helped in clinching the diagnosis.
A 75-year-old woman presented with a one year history of
an intensely pruritic eruption which began on her extremities
and later expanded to involve the trunk with only partial
response to topical corticosteroids and antihistamines. She
was otherwise healthy with no accompanying constitutional
symptoms and not on any other medications. Cutaneous
examination revealed a symmetric polymorphous eruption
of old and new lesions, comprising of erythematous
urticarial papules and plaques studded with clear and
158
 Correspondence
cloudy vesicles [Fig. 1], ulcerated and crusted lesions
arranged in herpetiform groups. Oral and genital mucosa
were normal. Clinically a differential diagnosis of bullous
pemphogoid was entertained, however a Tzanck smear from
a clear vesicle showed abundant neutrophils, with only
few eosinophils. Biopsy for histopathology showed mild
epidermal hyperplasia with a subcorneal blister containing
neutrophils and few acantholytic cells. Predominant areas
of neutrophilic spongiosis with a superficial perivascular
infiltrate of eosinophils and neutrophils were seen in the
papillary dermis. Direct and indirect immunofluorescence
demonstrated strong intercellular deposits of IgG and
C3 in the upper epidermis. Based on the histology and
immunofluorescence findings, the diagnosis was revised
to herpetiform pemphigus and patient was started on oral
steroids.
Pemphigus herpetiformis (PH) is recognized as a distinct
subset of pemphigus by its pruritus, rarity of mucosal
involvement, invariable presence of eosinophils on histology
and its tendency to respond to sulfones. Various terms that
have been used to describe it are acantholytic herpetiform
dermatitis, pemphigus controlled by sulfapyridine, mixed
bullous disease and eosinophilic spongiosis in pemphigus.
Clinically patients present with severe intractable pruritus
and erythematous urticarial papules and plaques with
occasional vesicles in a herpetiform arrangement. Even
though the clinical picture is reminiscent of dermatitis
herpetiformis, the histological findings are variable and
include eosinophilic spongiosis, subcorneal pustules with
minimal or no apparent acantholyis.2 Though eosinophilic
spongoisis is classically seen in pemphigus herpetiformis,
neutrophilic spongiosis may also be encountered and
should be recognized as an important diagnostic clue3 as
was seen in our case. Definitive diagnosis is established by
immunopathology which shows in vivo bound IgG deposits
on the keratinocyte cell surface primarily in the upper
epidermis. The auto-antibodies in most patients of PH target
desmoglein 1 and because desmoglein 1 is predominantly
located in the upper epidermis, there is preferential binding
Q2 Fig. 1: Caption missing??????
159
of IgG to the upper epidermis as was seen in our case. Why
the auto-antibodies in PH and pemphigus vulgaris give rise
to different clinical presentations could be explained by
their preferential binding to different epitopes on the same
antigen molecule.4
In our case, the presence of severe pruritus in an elderly
female with blisters and absence of mucosal involvement
made us think of bullous pemphigoid, however, to our
surprise the histology and immunofluorescence turned out
to be PH. Patient was started on oral steroids along with
dapsone and is currently under follow-up.
References
1. Jablonska S, Chorzelski TP, Beuther EH, Chorzelska J.
Herpetiform pemphigus: A variable pattern of pemphigus. Int J
Dermatol 1975;14:353-9.
2. Robinson ND, Hashimoto T, Amagai M, Chan LS. The new
pemphigus variants. J Am Acad Dermatol 1999;40:649-71.
3. Huhn KM, Tron VA, Nguyen N, Trotter MJ. Neutrophilic
spongiosis in pemphigus herpetiformis. J Cutan Pathol
1996;23:264-9.
4. Ishii K, Amagai M, Komai A, Ebihara T, Chlorzelski TP,
Jablonska S, et al. Desmoglein 1 and desmoglein 3 are the
target autoantigens in herpetiform pemphigus. Arch Dermatol
1999;135:943-7.
IDIOPATHIC VULVAR CALCINOSIS:
THE COUNTERPART OF
IDIOPATHIC SCROTAL CALCINOSIS
Vandana Mehta, C Balachandran
Indian J Dermatol 2008:53(3):00-00******
From the Departments of Skin and STD, Kasturba Medical College,
Manipal, Karnataka, India. E-mail: Vandanamht@yahoo.com
Calcinosis cutis is characterized by the deposition of
hydroxyapatite crystals of calcium phosphate in the skin. It
is commonly encountered as a consequence of connective
tissue disease or metabolic abnormalities but sometimes
could be idiopathic. We report a case of idiopathic
calcinosis cutis of the vulva in a healthy woman.
A 35-year-old woman presented with multiple asymptomatic
yellowish nodules on the external genitalia of one year
duration. A few of the nodules broke down spontaneously
discharging a chalky white material. She was otherwise
healthy and had no systemic complaints. There was
neither a history of trauma nor any inflammatory process
in the vulvar skin prior to the development of lesions.
The hematologic and biochemistry panel such as liver and
renal function, serum calcium, phosphorous, electrolytes,
uric acid and parathyroid hormone levels were normal. An
excision biopsy of the nodule showed features suggestive
of calcinosis cutis.
Indian J Dermatol 2008; 53(3)
 Correspondence
Q3 Fig. 1: Caption missing??????
Cutaneous calcification may be divided into four
major categories: dystrophic, metastatic, iatrogenic and
idiopathic.1 Though dystrophic calcinosis is fairly common,
idiopathic calcification is rare, and usually no underlying
cutaneous cause can be identified. It commonly presents as
painless, firm papules and nodules that appear in childhood
and adolescence and gradually increase in number and
size. Lesions may be solitary or pedunculated and are
initially skin-colored, but as they grow larger they become
yellowish and lobulated breaking down spontaneously
or when compressed to produce a chalky white material.
Microscopic examination typically shows large granular
deposits of deeply basophilic material which stains black
with Von Kossa stain for calcium.2
The pathogenesis of idiopathic vulvar calcinosis is highly
disputed. The principle debate concerning the cause
is whether calcium is deposited at the site of inflamed
epidermal cysts or whether the calcific nodules are truly
idiopathic. Although several authors have suggested that
vulvar calcinosis results from dystrophic calcification of
Author Queries??????
Q1 Figures not cited in text.
Q2 Figure caption missing
Q3 Please provide figure caption and citation
Indian J Dermatol 2008; 53(3)
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the inflammed epidermal cysts, several others have refuted
the above facts and found it to be truly idiopathic.3
Idiopathic calcinosis cutis of the vulva is rare with only
seven cases reported worldwide. Besides, it has also been
reported over the neck after rhytidectomy,4 the sctotal wall5,
shaft of the penis6 and the areola of the breast.7 Cornelius
et al, have postulated that tiny apatite crystals seen only
on electron microscopy in cases of idiopathic calcinosis
cutis might act as a source of injury leading to secondary
deposition of acid mucopolysaccharides, which become
a matrix for crystal formation and calcification. What
initiates the deposition of these crystals is not yet known.8
In our case no predisposing cause for calcification could be
identified and since the patient was asymptomatic and not
keen on surgical removal the lesions were not excised.
References
1. Angamuthu N, Pais AV, Chandrakala SR. Calcinosis cutis:
A report of four cases. Trop Doct 2003;33:50-2.
2. Walsh JH, Fairley JA. Calcifying disorders of the skin. J Am
Acad Dermatol 1995;33:693-706.
3. Ozçelik B, Serin IS, Başbuğ M, Oztürk F. Idiopathic calcinosis
cutis of the vulva in an elderly woman: A case report. J Reprod
Med 2002;47:597-9.
4. Aksoy HM, Ozdemir R, Karaaslan O, Tiftikcioglu YO, Oruç M,
Kocer U. Incidental idiopathic calcinosis cutis in a rhytidectomy
patient. Dermatol Surg 2004;30:1145-7.
5. Sánchez-Merino JM, Bouso-Montero M, Fernández-Flores A,
García-Alonso J. Idiopathic calcinosis cutis of the penis. J Am
Acad Dermatol 2004;51:S118-9.
6. Oh CK, Kwon KS, Cho SH. Idiopathic calcinosis of the areola
of the nipple. J Dermatol 2000;121-2.
7. Yahya H, Rafindadi AH. Idiopathic scrotal calcinosis: A report
of four cases and review of the literature. Int J Dermatol
2005;44:206-9.
8. Cornelius CE, Tenenhouse A, Weber JC. Calcinosis cutis.
Metabolic, sweat, histochemical, X- Ray diffraction and electron
microscopic study. Arch Dermatol 1968;98:218.
160