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   Table of Contents - Current issue
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October-December 2020
Volume 21 | Issue 4
Page Nos. 255-355

Online since Wednesday, September 30, 2020

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REVIEW OF CURRENT LITERATURE  

Hot topics in pediatric dermatology Highly accessed article p. 255
Shirin Bakshi, Dipankar De
DOI:10.4103/2319-7250.296850  
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ORIGINAL ARTICLES Top

Effectiveness, safety, and tolerability of itraconazole oral solution in pediatric dermatophytosis p. 259
M Ramesh Bhat, Durga Satheesh, Jyothi Jayaraman
DOI:10.4103/ijpd.IJPD_34_20  
Introduction: Cutaneous mycosis is one of the most common dermatological conditions seen in children. In the recent past, there has been an increased incidence and unresponsiveness to various antifungal agents. Itraconazole is an effective and safe antifungal agent used, especially in adults; however, there are only a few studies in the literature for the treatment of dermatophytosis in children with oral itraconazole solution. Objective: The objective of this study is to assess the safety, effectiveness, and tolerability of oral itraconazole solution in children with recurrent and extensive dermatophytoses. Methods: This is a hospital-based prospective, longitudinal, open-labeled study conducted in a tertiary care hospital over a period of 3 months at the Department of Dermatology Venerology and Leprosy. A total of 30 children with recurrent and extensive dermatophytoses were recruited for the study. All were assessed for history, clinical features, and potassium hydroxide (KOH) mount for fungus. Itraconazole oral solution was given at a dosage of 5 mg/kg body weight for a duration of 4 weeks and evaluated for safety, effectiveness, tolerability, and mycological cure (KOH mount) after 4 weeks. Results: There were 30 cases in the study comprising 18 males and 12 females. The age group 6–10 years constituted a maximum number of cases. All of these cases had more than 10% body surface area involvement. Twenty-six patients had both clinical and mycological cure, whereas four patients still demonstrated fungal elements on KOH examination. All patients demonstrated excellent safety and tolerability except one who complained that the preparation was unsavory. Conclusion: Oral itraconazole solution is effective in chronic and recurrent dermatophytoses in children.
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Clinical pattern of superficial fungal infection and steroid use among pediatric patients: Our experience from a tertiary care hospital in Northern India p. 264
Neerja Saraswat, Ajay Chopra, Pooja Shankar, Sushil Kumar, Shekhar Neema, Parul Kamboj
DOI:10.4103/ijpd.IJPD_159_18  
Background: Fungal infections are increasingly encountered in the pediatric age group for the past few years. Majority of children at some point in time suffer from one or other clinical form of these infections. Although encountered in healthy patients also, an increase in immunocompromised patients is thought to be the major reason responsible for its increased prevalence world over. Indiscriminate use of irrational over-the-counter steroid combination has increased the menace of dermatophytes in children. Aims: The aim of the study was to describe the common clinical types of superficial fungal infections in children and to assess the use of topical steroid and its source. Materials and Methods: An observational study was done over a 5-month duration, wherein all children in the age group of 3–14 years with superficial fungal infection were examined and the data regarding the use of any topical steroid, and its source was accessed. Results: A total 313 children were included. One hundred twenty-nine (41.2%) children were between the age of 7–10 years, 194 (61.9%) were male, while 119 (38%) were female. Ninety-seven (30.9%) children were in the class 4th–6th. The duration of infection ranged from 30 to 60 days in 86 (27.4%) children. There was no significant association between steroid use and duration of infection as well as steroid use and gender (P value + 0.845 and 0.567, respectively). Conclusion: This study aims to highlight the common clinical type of superficial fungal infection. Type of topical steroid used and its source in these children was inquired.
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Clinico-epidemiological profile of patients with traumatic anserine folliculosis: A retrospective study from a tertiary care center in North India p. 270
Ramesh Kumar, Arti Singh, Rozy Badyal, Suresh Kumar Jain, Devendra Yadav
DOI:10.4103/ijpd.IJPD_11_19  
Background: Traumatic anserine folliculosis (TAF) is an uncommon follicular dermatosis. It is characterized by multiple closely set grouped follicular papules with goose skin appearance. There are few publications about this condition, and little is known about the incidence and peak age and sex groups. Aims and Objectives: The aim of this study is to describe the various pattern of TAF in children of 6 years to 18 years of age group. Methods: A retrospective study was conducted to identify cases of TAF in 26 patients at the dermatology department of our tertiary care hospital. The study population was 6–18 years age group children. History, variables, cutaneous and systemic examination, and routine laboratory investigations data were collected from previously recorded forms. Results: Twenty-six patients with TAF were identified. Of these, 19 were male and 7 were female. The mean age was 12.11 ± 2.2 years, ranging from 8 to 16 years. Only four patients were older than 14 years. The mean duration of lesions was 10.23 ± 7.2 months. We classified the clinical patterns as mental, mandibular, and malar according to anatomic location. The most common lesion locations were the chin in 20 (76.7%) followed by the body of mandible in 4 (15.38%) and cheek in 2 (7.69%) cases. Friction and pressure were the predisposing factors in most of the cases. Conclusion: The most commonly affected age group was 8–14 years in 22 (84.6%) children, and the most common predisposing factors were friction and pressure. Therefore, early diagnosis with proper counseling and lifestyle modification of TAF provides rapid relief for patients and avoid unnecessary tests and treatments.
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Pattern of common skin diseases among school going children in Semi-Urban Area of Jaipur: A cross-sectional study p. 275
Manisha Nijhawan, Manmohan Bagri, Shivi Nijhawan, Subhash Bishnoi, Savita Agarwal, Sandeep Nijhawan
DOI:10.4103/ijpd.IJPD_119_19  
Aims: Skin disorders are a common health problem in pediatric age group, and a school-based survey seems to be a good screening tool for estimating the prevalence of cutaneous disorders among children. Subjects and Methods: A cross-sectional prospective study was conducted in three schools of semi-urban area of Jaipur. A total of 576 children including 218 boys and 358 girls of age group 4–18 years were examined for the study, and laboratory investigations were also done for all the children. Results: Out of 576 students, 349 students were found to have a skin disorder. Of all the affected children, 69.7% (370) had noninfectious dermatoses, 19.8% (105) had infectious dermatoses, and 10.5% (56) had nutritional dermatoses. Conclusions: In our study, the prevalence of skin infection was found to be associated with low socioeconomic status and poor personal hygiene. Hence, awareness regarding skin-related health problems in children as well as in their parents seems to be of utmost importance.
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Prevalence of dermatoses among jenukuruba tribal children p. 279
HS Rajani, D Narayanappa, K Jagadish Kumar, VG Manjunath
DOI:10.4103/ijpd.IJPD_124_18  
Introduction: Dermatoses are common among schoolgoing children, more so in a tribal area and cause significant morbidity. Objective: The present study was conducted to study the point prevalence and pattern of dermatoses in Jenukuruba tribal children in Mysore district. Materials and Methods: A cross-sectional study was conducted on 4207 Jenukuruba tribal children in Mysore district. Diagnosis of various dermatoses was made on the basis of detailed clinical examination. Results: The point prevalence of dermatoses was 71.5%. Majority had single skin lesion. Nearly 43% had more than one skin lesion. Among skin infections and infestations, pyoderma (33.4%) and scabies (19.8%) were most prevalent. Among the noninfective conditions, xerosis (71.5%), pityriasis alba (16.7%), acne (8.6%), and hyperpigmentation (54.5%) were most prevalent. Conclusions: The point prevalence of dermatoses in tribal schoolchildren in Mysore district is very high. Health education of children and caregivers regarding the signs and symptoms of dermatoses is warranted for early detection, timely intervention, and prevention.
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Efficacy of fluticasone propionate ointment 0.005% in childhood lichen planus p. 283
Abhinav Kumar, Vibhu Mendiratta, Sarita Sanke, Ram Chander
DOI:10.4103/ijpd.IJPD_149_18  
Background: Treatment of childhood lichen planus (LP) is challenging owing to high rate of relapses. Moreover, majority of treatment options for LP have been extrapolated from studies done in adults. Topical corticosteroid remains the first line of treatment in localized classic form of LP, but till date, no consensus exists regarding standardized therapy in children. Hence, we conducted this study to evaluate the efficacy of mid-potent topical steroid fluticasone propionate 0.005% in childhood LP. Aims and Objectives: The aim of this study was to evaluate the therapeutic efficacy of fluticasone propionate ointment 0.005% in childhood LP. Materials and Methods: Thirty-one patients (6 months to 18 years of age) with clinical and histopathologically confirmed diagnosis of LP were subjected to routine baseline severity assessment, patient/parent assessment, pretreatment photographic record of the fixed anatomical site under treatment, and then received topical mid-potent steroid therapy (fluticasone propionate ointment 0.005%) twice daily and cetirizine dihydrochloride in predefined doses for 8 weeks. Follow-up was done at the end of 2 weeks, 4 weeks, 6 weeks, and 8 weeks. After 8 weeks, a proportion of patients achieving clinical improvement and side effects were assessed. Observation and Results: The difference between pre- and posttreatment induration was not statistically significant (P = 0.336). The mean number of lesions before the start of treatment was 50.29, which reduced to 14.77 (P = 0.000) after treatment, and the mean of patients' itching score before treatment was 6.74 ± 1.6, which reduced to 2.61 ± 2.3 (P = 0.000) following treatment, which was statistically significant. Clinical improvement was seen in 67.7%, whereas 32.3% showed no improvement over a period of 8 weeks. Conclusion: Mid-potency steroid fluticasone propionate ointment twice daily is an effective therapeutic agent for localized childhood LP, with minimal side effects.
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The epidermal growth pattern in human fetuses p. 287
Shivani Dhingra, Jayant Kumar Verma, Adil Asghar
DOI:10.4103/ijpd.IJPD_42_19  
Background: The estimation of fetal epidermal thickness has clinical significance for dermatological investigation and diagnosis of fetal prematurity. Objective: We aimed to collect baseline data of fetal epidermal thickness and secondarily to study the correlation of gestational age (GA) from epidermal thickness. Materials and Methods: Thirty fetuses were selected for the study aged from 11 to 40 weeks. They were divided into six groups at a 4-week interval. The mean epidermal thickness was measured at four sites such as the abdomen, interscapular region, scalp, and palm. The histometric analysis was done with the help of amscope 5MP Aptina MT9P001. Results: The mean age of gestation was 25.67 ± 8.45 weeks. The mean epidermal thickness of the abdominal, interscapular, scalp, and palmar region was 21.9 ± 12.9 μm (3.41–42.48), 111.21 ± 74.39 μm (7.9–214.51), 27.58 ± 13.26 μm (11.7–46.2), and 139.73 ± 96.40 μm (7.3–280.51), respectively. The growth pattern of the epidermis of the different region was significantly variable based on the ANOVA (P = 1.98E-13 P < 0.05 significant) and paired t-test of interregion comparison. Conclusions: The epidermal thickness has a significant positive correlation with GA and anatomical sites. We emphasize that epidermal thickness is a newborn maturity marker at birth.
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Lichenoid eruptions in children: A retrospective study p. 294
Manjyot Gautam, Parag Chaudhari, Shuchi Priya, Vasundhara Singh, Nitin Nadkarni, Sharmila Patil
DOI:10.4103/ijpd.IJPD_48_19  
Background: Lichenoid eruptions are a diverse group of inflammatory dermatoses, characterized clinically by flat-topped papules which resemble lichen planus (LP) and histologically by a lichenoid tissue reaction. There are many lichenoid dermatoses, of which some are seen predominantly in the pediatric age group. The knowledge of these lichenoid eruptions is essential for the dermatologists for early diagnosis, timely treatment, and also to predict their course. Aims: Our aim was to study the clinicoepidemiological features of lichenoid dermatoses in children and to differentiate between various lichenoid dermatoses and classify them accordingly. Materials and Methods: This was a retrospective, hospital-based, cross-sectional study of 52 children with a clinical diagnosis of lichenoid eruptions from January 2017 to December 2017. Results: Of the 986 children who visited the dermatology outpatient department 52 children (5.27%) were diagnosed with lichenoid dermatoses, with the male: female ratio being 1: 1.48 and a mean age of 7.25 years. LP was the most common lichenoid dermatosis reported in our study (48%), followed by lichen striatus (37.6%), lichen nitidus (5.8%), lichen sclerosus (5.8%), pityriasis lichenoides (3.2%), and Gianotti Crosti syndrome (1.9%). Limitations: It was a retrospective data analysis involving only 1 year of study with limited sample size, without study of long term evolution. Conclusions: Some lichenoid dermatoses (lichen straitus and lichen nitidus) are self-limiting and undergo spontaneous resolution without any sequelae, whereas LP and lichen sclerosus can be associated with varying degrees of morbidity. Proper diagnosis helps in allaying the fears of parents.
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The pattern of mucocutaneous disorders in pediatric HIV patients in a tertiary care center p. 301
Sanjith Saravanabhavan, Seethalakshmi Ganga Vellaisamy, Kannan Gopalan, Muthusamy Kandasamy
DOI:10.4103/ijpd.IJPD_13_19  
Background: Dermatological manifestations constitute one of the most common clinical features in HIV-infected children. An early recognition of such features is important for an early diagnosis and also to assess the prognosis of HIV infection. Objective: The present study was conducted to determine the prevalence and pattern of mucocutaneous manifestations in HIV-infected children and also to assess the association between those manifestations and degree of cellular immune deficiency. Materials and Methods: This was a cross-sectional study conducted in the Outpatient Department of SKIN and STD between April 2017 to March 2018. A total of 100 HIV patients <18 years of age were included in the study. After screening, skin diseases were classified under four broad categories: (i) Infectious dermatoses, (ii) inflammatory dermatoses, (iii) neoplastic conditions, and (iv) drug-related dermatoses. Data were coded and analyzed. Results: The prevalence of cutaneous manifestation in our study was found to be 82% among the HIV-infected children. In toto, inflammatory disorders (58%) were more common, followed by nail disorders (40%), infectious dermatoses, (36%) and drug-related conditions (23%). Among the individual disorders, diffuse pigmentation of nails (24%) was the most common condition and zidovudine was the most common implicated drug in 22% of children. Conclusion: Due to antiretroviral therapy (ART), the occurrence of infectious dermatoses has come down, but we are encountering adverse effects due to drugs. Due to the ability of ART to reconstitute the immune system, there have been undoubtedly significant changes in the nature and prevalence of skin disorders.
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CASE REPORTS Top

Hay-wells syndrome with selective immunoglobulin a deficiency p. 307
Bhupathi Sharanya, Rajendran Narayanan, Manobalan Karunanandhan
DOI:10.4103/ijpd.IJPD_26_20  
Hay-Wells syndrome or ankyloblepharon-ectodermal dysplasia-cleft lip/palate (AEC) syndrome is a rare form of ectodermal dysplasia. It is an autosomal dominant disorder with various congenital abnormalities involving the skin, hair, teeth, nails, and sweat glands. We report a case of a 7-year-old boy who presented with scaly lesions all over the body that was noticed since birth. The child had scalp erosions and fusion of the eyelids at birth. The child even had patchy scaring alopecia with scaling over the vertex, decreased sweating, and poor formation of nails since birth. We also noted frontal bossing in the child. Epiphora and sparse eye lashes were noted in both eyes. Ear-nose-throat examination revealed rudimentary bifid uvula, aural polyp in the right ear, and abnormal dentition. In view of these clinical signs and symptoms, we arrived at a clinical diagnosis of ankyloblepharon-ectodermal dysplasia-cleft palate (AEC). Due to recurrent scalp pyodermas and seborrheic dermatitis in infancy, the child was suspected and confirmed to have selective immunoglobulin A (IgA) deficiency. We report this case in view of its rare association, i.e., AEC, with selective IgA deficiency.
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Mixed immunobullous disease in infants: Falls in bullous pemphigoid-linear IgA spectrum? p. 310
Sruthi Mohanan, Sebastian Criton, Usha Mary Abraham
DOI:10.4103/ijpd.IJPD_40_20  
Bullous pemphigoid (BP) and linear immunoglobulin A bullous dermatosis (LABD) are common immunobullous diseases affecting both adults and children, with minor differences in clinical presentation. The only test for a definitive diagnosis is direct immunofluorescence (DIF) study, with linear deposits of immunoglobulin G (IgG) (mainly) at the dermoepidermal junction (DEJ) being diagnosed as BP and linear deposits of IgA at DEJ, diagnosed as LABD. Mixed immunobullous disease is the term given for immunobullous diseases with equal IgA/IgG deposits at the DEJ. Through this case report, a mixed immunobullous disease with clinical diagnosis of LABD and DIF findings of BP is being discussed. Furthermore, the presence of a BP-LABD spectrum of disease that can progress in either direction and present with features of both diseases is discussed.
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Ecthyma gangrenosum in a neonate p. 313
Bishnupriya Sahoo, Himani Bhasin, Shikhar Ganjoo, Pankaj Abrol
DOI:10.4103/ijpd.IJPD_132_19  
Ecthyma gangrenosum (EG) is pathognomonic of invasive Pseudomonas infection or septicemia. It is characterized by pustules that rapidly evolve into hemorrhagic blister with central necrosis with the surrounding erythema. It is more often seen in immunocompromised patients but can be seen in healthy neonate also. We report the case of a 4-day-old neonate presenting with Pseudomonas bacteremia and EG.
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The use of immunofluorescence antigen mapping in the diagnosis of junctional epidermolysis bullosa in a 15-year-old female p. 316
Ankita Choudhary, Deval Mistry, Rima Joshi, Bela Shah
DOI:10.4103/ijpd.IJPD_90_20  
Epidermolysis bullosa (EB) comprises a group of genetically determined skin fragility disorders, characterized by blistering of the skin and mucosae following mechanical trauma, which includes four major forms (EB simplex, junctional EB [JEB], dystrophic EB, and Kindler syndrome) with various distinctive clinical phenotypes. We report a rare case of a 15-year-old female diagnosed as JEB (generalized intermediate), with the help of immunofluorescence antigen mapping.
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Fabry's disease manifesting as familial angiokeratoma corporis diffusum in an indian family – A rare occurrence! p. 319
Ishmeet Kaur, Archana Singal, Deepak Jakhar, Deepika Pandhi
DOI:10.4103/ijpd.IJPD_38_19  
Fabry's disease is a rare X-linked dermatosis, resulting from alpha-galactosidase deficiency and presents with both cutaneous (angiokeratoma, acral paresthesia, and hypohidrosis) and extracutaneous manifestations (ocular, cardiac, renal, and neurological). We report two brothers age 16 and 14 years that presented with multiple angiokeratoma in a bathing suit distribution on the trunk and the scrotum. The younger brother had acral paresthesia too. On systemic screening, ocular involvement was noted in both. Alpha-galactosidase assay in both brothers, revealed a deficiency of 19.2 nmol/h/mg (reference value <60), confirming the diagnosis of Fabry's disease. Cutaneous manifestations such as angiokeratoma and acral paraesthesia can be clues to the diagnosis of Fabry's disease. The case report is accompanied by a brief review of the literature.
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Subcorneal pustular dermatosis: An unusual presentation in pediatric age group p. 323
Shivani Saini, Devendra Yadav, Akshy Kumar
DOI:10.4103/ijpd.IJPD_24_20  
Subcorneal pustular dermatosis (SPD), first described by Sneddon and Wilkinson, represents a rare chronic and relapsing sterile pustular eruptions generally involving the trunk and flexor aspect of limbs. Usually, it affects middle-aged or elderly women. Histologically, it is characterized by the accumulation of subcorneal neutrophils with an absence of spongiosis and acantholysis. Here, we are reporting a rare case of SPD in the pediatric age group, which was diagnosed based on clinical and histological findings. We gave dapsone in treatment with a positive outcome. To the best of our knowledge, there has not been any case report in the pediatric age group from India so far.
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Addisonian hyperpigmentation in a case of late onset familial glucocorticoid deficiency and dramatic improvement with glucocorticoid supplementation p. 326
Sunanda Mahajan, Siddhi Chikhalkar, S Rajasekar
DOI:10.4103/ijpd.IJPD_104_19  
Addison's disease is a chronic endocrine disorder in which the adrenal glands do not produce enough steroid hormones mostly both glucocorticoid and mineralocorticoid. Most common causes of primary adrenal insufficiency are due to autoimmune adrenalitis in developed world, and tuberculosis in developing world. Here we present a rare case of primary adrenal insufficiency with addisonian pigmentation secondary to familial glucocorticoid deficiency.
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Multiple bouncy balls in an adolescent girl p. 329
Nidhi Kamra, Ankita Tuknayat
DOI:10.4103/ijpd.IJPD_106_19  
Pilomatricoma is a benign hair follicle hamartoma presenting as a single hard dermal or subcutaneous nodule on the head and neck in children. A 15-year-old girl with multiple bullous pilomatricomas is being presented and the importance of ruling out underlying genetic defects in such patients is being discussed.
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Uncombable hair syndrome with loose anagen syndrome: A rare association p. 332
Divya Agrawal, Syed Suhail Amin, Mohammad Adil, Annu Priya
DOI:10.4103/ijpd.IJPD_128_18  
Uncombable hair syndrome presents with dry, coarse, silvery hairs that stand straight from the scalp surface. Loose anagen syndrome is characterized by easy pluckability of the hair due to impaired adhesion between the cuticle of the inner root sheath and the cuticle of the hair shaft. We report the case of a 7-year-old female who presented with features of both these conditions. She had difficulty in combing hair for 4 years. Her hairs did not grow and were dry and frizzy. Hairs were easily pluckable, and microscopy showed predominantly dystrophic anagen hair, with the shaft having undulations and longitudinal groove.
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Lichenoid reaction to red-inked tattoo – A known but forgotten problem p. 335
Niharika Dixit, Sameer Sarswat, Purnima Paliwal
DOI:10.4103/ijpd.IJPD_136_18  
Permanent tattooing has become a huge fascination among youngsters, and with increasing popularity, a wide variety of adverse reactions have been encountered. Herein, we report a case of lichenoid reaction localized to red-inked tattoo.
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Aplasia cutis congenita with hypocalvaria in a neonate p. 337
Rajendra Prasad Anne, Suresh Kumar Angurana, Renu Suthar, Akshay Kumar Saxena, Venkataseshan Sundaram
DOI:10.4103/ijpd.IJPD_39_19  
We report a neonate presenting with a large scalp defect with hypoplasia of underlying frontal and parietal bones. It fits into the description of a severe form of aplasia cutis congenital with hypocalvaria.
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Vaccine–induced childhood pemphigus vulgaris: A case report in a 5-year-old female child p. 340
Rajni Sharma, Mudita Gupta, Geeta Ram Tegta, Ritu Rani
DOI:10.4103/ijpd.IJPD_61_19  
Pemphigus vulgaris (PV) is an immunobullous disease affecting the skin and mucosa. It is a disease most commonly manifesting in the third–fifth decades of life. Pediatric PV is rare and usually seen at a mean age of 12 years. Early childhood PV is extremely rare with only few cases reported. There are various inducers of PV in children. Diphtheria toxoid (DT) has rarely been reported as an inducer of PV. We report a 5-year-old female child who developed vesiculobullous mucocutaneous lesions after DT vaccination. The diagnosis was confirmed by histopathology and immunofluorescence. She was treated with pulse methylprednisolone therapy and daily dose azathioprine.
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RESIDENT CORNER Top

Mount the Menace! – Potassium hydroxide in superficial fungal infections p. 343
Manjyot Gautam, Saloni Bhatia
DOI:10.4103/2319-7250.296851  
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LETTERS TO EDITOR Top

Herpes zoster in a 3-month-old infant p. 347
Rini Makhija, Lalit Kumar Gupta, Ashok Kumar Khare, Asit Mittal
DOI:10.4103/ijpd.IJPD_20_19  
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Promising results with secukinumab in refractory pediatric psoriasis p. 349
Sukriti Baveja, Anwita Sinha, Deepak Vashisht, Prince Yuvraj Singh
DOI:10.4103/ijpd.IJPD_102_18  
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Chronic primary mucocutaneous candidiasis in a child p. 351
Aastha Gupta, Sinu Rose Mathachan, Pooja Arora, Purnima Malhotra
DOI:10.4103/ijpd.IJPD_47_19  
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H syndrome: A rare case with homozygous mutation in SLC29A3 gene p. 354
Sahana M Srinivas, Sowjanya G Thimmaiah, Radha Venkatesan, Raghupathy Palany
DOI:10.4103/ijpd.IJPD_58_20  
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