Letters to the Editor 2.
Kurklinsky AK, Miller VM, Rooke TW. Acrocyanosis: The Flying Dutchman. Vasc Med 2011;16:288‑301.
3.
Di Lucca J, Mahe E, Saiag P. Severe acrocyanosis in carcinoid syndrome. Ann Dermatol Venereol 2007;134:895‑6.
4.
Poszepczynska‑Guigné E, Viguier M, Chosidow O, Orcel B, Emmerich J, Dubertret L. Paraneoplastic acral vascular syndrome: Epidemiologic features, clinical manifestations, and disease sequelae.
Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.131139
J Am Acad Dermatol 2002;47:47‑52.
A study of the prevalence and precipitating factors of pruritus in pityriasis versicolor Sir, Pityriasis versicolor (PV), also referred to as Peter Elam’s disease, is one of the most common infectious skin diseases that is seen in abundance during summer. In tropical areas, PV is found in up to 50% of all patients consulting a dermatologist.[1] Patients can present with symptoms ranging from hypopigmented to hyperpigmented patches associated with erythema, scaling, and itching. Malassezia species yeasts are a part of the normal flora in seborrheic areas, but some contributing factors, such as the application of oily preparations, creams, an increase in ambient humidity, corticosteroid abuse, or genetic predisposition can cause Pityrosporum to change from saprophytic to pathogenic form.[2] Exposure to sunlight stimulates the production of azelaic acid, which causes the appearance of hypopigmented spots.[3] Pruritus in patients with PV has been inconsistently described. Surprisingly, even though it is a common disorder, the prevalence and the factors responsible for this symptom are not properly documented. Hence, we conducted this study to know the prevalence and factors responsible for itching in PV. A total of 200 cases aged between 15 and 60 years were selected for the study. The patients were recruited from March 2012 to September 2012. All cases were diagnosed on the basis of clinical suspicion and confirmed by the demonstration of Malassezia furfur on KOH (potassium hydroxide) examination of skin scraping and Wood’s lamp examination. Parameters considered to precipitate itching were type of pityriasis versicolor (hypopigmented or hyperpigmented), extent of involvement (localized or extensive), site of the lesion, and association with sweating, sun exposure, and following bathing. The extent of involvement was calculated using the rule of Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
nine. Patients were asked regarding the association of itching with sweating, sun exposure, and following bathing. Patients with serious concurrent medical conditions and other fungal infections were excluded. Statistical analysis was done using the Chi‑squared test and Fisher’s exact test. Out of 200 patients, itching was an associated complaint in 44 (22%) patients (39 with hypopigmented macules and 5 with hyperpigmented macules). Itching was noticed in patients with lesions predominantly distributed over the neck (69%) and chest and back (87.2%), following sweating (100%), sun exposure (78%), and bathing (7%). Localization of the lesions reflected the distribution of sebaceous glands. We did not find any significant association between the extent of involvement and prevalence of itching. Morais et al.,[4] in a study of 116 patients with pityriasis versicolor who presented at a referral center in Brazil, observed itching in 48.3% of the patients. In another study, Rao et al.[5] noted mild itching as a presenting complaint in 30% which is consistent with the findings of this study. Krishnan et al.[3] found that severe itching was associated with combined and hyperpigmented types. However, in our study, itching was also reported following bathing, sweating, and sun exposure, commonly over the hypopigmented lesions. Krishnan et al.[3] in their study found that itching was mainly present during sweating. The literature suggests that the lipoperoxidation process by Pityrosporum accounts for the clinical hypopigmented lesions[6] and the theory proposed for hyperpigmented lesions is the increased thickness of the keratin layer and more pronounced inflammatory cell infiltrate acting as a stimulus for melanocytes.[5] However, there is no scientific explanation for itching associated with these hypopigmented and hyperpigmented lesions. So, we hypothesized that a humid and moist environment enhances the virulence of the fungus, which manifests as itching immediately after sun exposure, sweating, and bathing. To conclude, according to our study, the prevalence of itching in PV does not depend on the extent of involvement. Perhaps, it depends on the areas of involvement (seborrheic areas) and predisposing factors like sun exposure, bathing, and sweating. However, this requires to be further investigated and substantiated.
223
Letters to the Editor
Ankita Kaushik, Hyacinth P. Pinto, Ramesh M. Bhat, Sukumar D., Srinath M. K. Department of Dermatology, Father Muller Medical College, Mangalore, Karnataka, India Address for correspondence: Dr. Ramesh M. Bhat, Department of Dermatology, Father Muller Medical College, Kankanady, Mangalore - 575 002, Karnataka, India. E‑mail: [email protected]
REFERENCES
4.
5.
6.
tinea versicolor in south Indian patients. Indian J Dermatol 2003;48:83‑6 Morais PM, Cunha MG, Frota MZ. Clinical aspects of patients with P. Versicolor seen at a referral center for tropical dermatology in Manaus, Amazonas, Brasil. An Bras Dermatol 2010;85:797‑803. Rao GS, Kuruvilla M, Kumar P, Vinod V. Clinico‑epidermiological studies on tinea versicolor. Indian J Dermatol Venereol Leprol 2002;68:208‑9. Sunenshine PJ, Schwartz RA, Janniger CK. Tinea versicolor. Int J Dermatol 1998;37:648‑55.
Access this article online Quick Response Code: Website: www.idoj.in
1. 2. 3.
Mayer PA, Preuss J. Pityriasis versicolor: New aspects of an old disease. Hautarzt 2012;63:859‑67. MendezTovar LJ. Pathogenesis of dermatophytosis and tinea versicolor. Clin Dermatol 2010;28:185‑9. Krishnan A, Thapa DM. Morphological and pigmentary variations of
Idiopathic cutaneous pseudolymphoma: An enigma Sir, Pseudolymphoma is not a specific disease but an inflammatory response to known or unknown stimuli that results in a lymphomatous‑appearing picture, mimicking lymphoma but in fact a benign accumulation of inflammatory cells. However, the terminology of pseudolymphoma should be reserved for idiopathic cases where inciting cause is unknown. The enigma stems from the fact that the condition has to be differentiated from cutaneous lymphoma which would change the outcome of the disease. This case presented as a pigmented nodule just above left ala of nose since 2 years resembling a nevus in a middle‑aged male which was asymptomatic [Figure 1]. The patient gave a history of recent increase in size since 2 months with no pain, discharge, and itching. On examination, it was a firm red‑brown nodule, non‑tender with no regional lymph nodes palpable. There was no history of insect bite, trauma, and infection at that site in the past. There was no history of drug ingestion. A wide excision was done; the histopathology was reported as cutaneous pseudolymphoma. At 6‑month follow‑up, patient was asymptomatic. Immunohistochemistry revealed negative CD3, CD10, leucocyte common antigen (LCA), and CD20 panel, which are markers for lymphoma. After ruling out all etiological factors mentioned above and the histological evidence of top heavy dermal, mixed cellular infiltrate, absence of pigmentation and blast cells, with no necrotic areas, it was labeled as idiopathic pseudolymphoma.
224
DOI: 10.4103/2229-5178.131141
Pseudolymphoma, also called as cutaneous lymphoid hyperplasia, is a skin lesion having lymphomatous appearance mimicking lymphoma that results from known or unknown stimulus like insect bites, vaccination, trauma, folliculitis, drugs, jewelry, and contactants.[1,2] This results in accumulation of inflammatory cells that not only mimics lymphoma histologically but clinically as well. Nodular lesions resemble B‑cell lymphomas, whereas plaque forms resemble T‑cell lymphomas. It is essential to differentiate pseudolymphomas from malignant lymphomas, which involves clinical, histological, and immunohistochemistry evidences as even in benign lesions, malignant histological picture may be seen. Pseudolymphomas are classified according to histological components into B‑cell and T‑cell variants. Commonly occurring etiological causes have been tabulated along with salient
Figure 1: Nodular lesion over left ala of nose
Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
Copyright of Indian Dermatology Online Journal is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Kurklinsky AK, Miller VM, Rooke TW. Acrocyanosis: The Flying Dutchman. Vasc Med 2011;16:288‑301.
3.
Di Lucca J, Mahe E, Saiag P. Severe acrocyanosis in carcinoid syndrome. Ann Dermatol Venereol 2007;134:895‑6.
4.
Poszepczynska‑Guigné E, Viguier M, Chosidow O, Orcel B, Emmerich J, Dubertret L. Paraneoplastic acral vascular syndrome: Epidemiologic features, clinical manifestations, and disease sequelae.
Access this article online Quick Response Code: Website: www.idoj.in DOI: 10.4103/2229-5178.131139
J Am Acad Dermatol 2002;47:47‑52.
A study of the prevalence and precipitating factors of pruritus in pityriasis versicolor Sir, Pityriasis versicolor (PV), also referred to as Peter Elam’s disease, is one of the most common infectious skin diseases that is seen in abundance during summer. In tropical areas, PV is found in up to 50% of all patients consulting a dermatologist.[1] Patients can present with symptoms ranging from hypopigmented to hyperpigmented patches associated with erythema, scaling, and itching. Malassezia species yeasts are a part of the normal flora in seborrheic areas, but some contributing factors, such as the application of oily preparations, creams, an increase in ambient humidity, corticosteroid abuse, or genetic predisposition can cause Pityrosporum to change from saprophytic to pathogenic form.[2] Exposure to sunlight stimulates the production of azelaic acid, which causes the appearance of hypopigmented spots.[3] Pruritus in patients with PV has been inconsistently described. Surprisingly, even though it is a common disorder, the prevalence and the factors responsible for this symptom are not properly documented. Hence, we conducted this study to know the prevalence and factors responsible for itching in PV. A total of 200 cases aged between 15 and 60 years were selected for the study. The patients were recruited from March 2012 to September 2012. All cases were diagnosed on the basis of clinical suspicion and confirmed by the demonstration of Malassezia furfur on KOH (potassium hydroxide) examination of skin scraping and Wood’s lamp examination. Parameters considered to precipitate itching were type of pityriasis versicolor (hypopigmented or hyperpigmented), extent of involvement (localized or extensive), site of the lesion, and association with sweating, sun exposure, and following bathing. The extent of involvement was calculated using the rule of Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
nine. Patients were asked regarding the association of itching with sweating, sun exposure, and following bathing. Patients with serious concurrent medical conditions and other fungal infections were excluded. Statistical analysis was done using the Chi‑squared test and Fisher’s exact test. Out of 200 patients, itching was an associated complaint in 44 (22%) patients (39 with hypopigmented macules and 5 with hyperpigmented macules). Itching was noticed in patients with lesions predominantly distributed over the neck (69%) and chest and back (87.2%), following sweating (100%), sun exposure (78%), and bathing (7%). Localization of the lesions reflected the distribution of sebaceous glands. We did not find any significant association between the extent of involvement and prevalence of itching. Morais et al.,[4] in a study of 116 patients with pityriasis versicolor who presented at a referral center in Brazil, observed itching in 48.3% of the patients. In another study, Rao et al.[5] noted mild itching as a presenting complaint in 30% which is consistent with the findings of this study. Krishnan et al.[3] found that severe itching was associated with combined and hyperpigmented types. However, in our study, itching was also reported following bathing, sweating, and sun exposure, commonly over the hypopigmented lesions. Krishnan et al.[3] in their study found that itching was mainly present during sweating. The literature suggests that the lipoperoxidation process by Pityrosporum accounts for the clinical hypopigmented lesions[6] and the theory proposed for hyperpigmented lesions is the increased thickness of the keratin layer and more pronounced inflammatory cell infiltrate acting as a stimulus for melanocytes.[5] However, there is no scientific explanation for itching associated with these hypopigmented and hyperpigmented lesions. So, we hypothesized that a humid and moist environment enhances the virulence of the fungus, which manifests as itching immediately after sun exposure, sweating, and bathing. To conclude, according to our study, the prevalence of itching in PV does not depend on the extent of involvement. Perhaps, it depends on the areas of involvement (seborrheic areas) and predisposing factors like sun exposure, bathing, and sweating. However, this requires to be further investigated and substantiated.
223
Letters to the Editor
Ankita Kaushik, Hyacinth P. Pinto, Ramesh M. Bhat, Sukumar D., Srinath M. K. Department of Dermatology, Father Muller Medical College, Mangalore, Karnataka, India Address for correspondence: Dr. Ramesh M. Bhat, Department of Dermatology, Father Muller Medical College, Kankanady, Mangalore - 575 002, Karnataka, India. E‑mail: [email protected]
REFERENCES
4.
5.
6.
tinea versicolor in south Indian patients. Indian J Dermatol 2003;48:83‑6 Morais PM, Cunha MG, Frota MZ. Clinical aspects of patients with P. Versicolor seen at a referral center for tropical dermatology in Manaus, Amazonas, Brasil. An Bras Dermatol 2010;85:797‑803. Rao GS, Kuruvilla M, Kumar P, Vinod V. Clinico‑epidermiological studies on tinea versicolor. Indian J Dermatol Venereol Leprol 2002;68:208‑9. Sunenshine PJ, Schwartz RA, Janniger CK. Tinea versicolor. Int J Dermatol 1998;37:648‑55.
Access this article online Quick Response Code: Website: www.idoj.in
1. 2. 3.
Mayer PA, Preuss J. Pityriasis versicolor: New aspects of an old disease. Hautarzt 2012;63:859‑67. MendezTovar LJ. Pathogenesis of dermatophytosis and tinea versicolor. Clin Dermatol 2010;28:185‑9. Krishnan A, Thapa DM. Morphological and pigmentary variations of
Idiopathic cutaneous pseudolymphoma: An enigma Sir, Pseudolymphoma is not a specific disease but an inflammatory response to known or unknown stimuli that results in a lymphomatous‑appearing picture, mimicking lymphoma but in fact a benign accumulation of inflammatory cells. However, the terminology of pseudolymphoma should be reserved for idiopathic cases where inciting cause is unknown. The enigma stems from the fact that the condition has to be differentiated from cutaneous lymphoma which would change the outcome of the disease. This case presented as a pigmented nodule just above left ala of nose since 2 years resembling a nevus in a middle‑aged male which was asymptomatic [Figure 1]. The patient gave a history of recent increase in size since 2 months with no pain, discharge, and itching. On examination, it was a firm red‑brown nodule, non‑tender with no regional lymph nodes palpable. There was no history of insect bite, trauma, and infection at that site in the past. There was no history of drug ingestion. A wide excision was done; the histopathology was reported as cutaneous pseudolymphoma. At 6‑month follow‑up, patient was asymptomatic. Immunohistochemistry revealed negative CD3, CD10, leucocyte common antigen (LCA), and CD20 panel, which are markers for lymphoma. After ruling out all etiological factors mentioned above and the histological evidence of top heavy dermal, mixed cellular infiltrate, absence of pigmentation and blast cells, with no necrotic areas, it was labeled as idiopathic pseudolymphoma.
224
DOI: 10.4103/2229-5178.131141
Pseudolymphoma, also called as cutaneous lymphoid hyperplasia, is a skin lesion having lymphomatous appearance mimicking lymphoma that results from known or unknown stimulus like insect bites, vaccination, trauma, folliculitis, drugs, jewelry, and contactants.[1,2] This results in accumulation of inflammatory cells that not only mimics lymphoma histologically but clinically as well. Nodular lesions resemble B‑cell lymphomas, whereas plaque forms resemble T‑cell lymphomas. It is essential to differentiate pseudolymphomas from malignant lymphomas, which involves clinical, histological, and immunohistochemistry evidences as even in benign lesions, malignant histological picture may be seen. Pseudolymphomas are classified according to histological components into B‑cell and T‑cell variants. Commonly occurring etiological causes have been tabulated along with salient
Figure 1: Nodular lesion over left ala of nose
Indian Dermatology Online Journal - April-June 2014 - Volume 5 - Issue 2
Copyright of Indian Dermatology Online Journal is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
