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   2021| January-March  | Volume 22 | Issue 1  
    Online since December 31, 2020

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Cosmetic Procedures in Adolescents: What's Safe and What Can Wait

January-March 2021, 22(1):12-20
Teenagers between 13 and 19 years are increasingly seeking cosmetic procedures. They are suffering from anxiety, depression, and low self-esteem as a result of an obsession with body image and celebrity culture, fueled by social networking sites. Teenagers seek cosmetic procedures most commonly for traumatic scars, acne and acne scars, pigmentary abnormalities, hypertrichosis, hirsutism, and tattoo removal. They demand plastic surgery for nose deformities, breast asymmetry, ear abnormalities, and congenital deformities. The physical, emotional, psychological, social, ethical, and legal aspects must be considered while counseling adolescents. Not every teenager seeking cosmetic surgery is well suited for a procedure, and teens must demonstrate emotional maturity and an understanding of the limitations of these procedures and the risks involved. There should be a 3-month cooling-off period, followed by another consultation, which should be done in the presence of a parent. Only very essential surgery should be performed, giving realistic expectations on the outcome of procedures, as they rely too much on physical appearance to gain confidence. A psychiatric evaluation is essential to rule out body dysmorphic disorders in those repeatedly seeking treatment for minor defects. Sometimes, procedures are necessary to avoid social withdrawal and loss of self-esteem. Proper informed consent should be taken, explaining the benefits, limitations, and risks involved. Ideally, teenagers should not receive cosmetic or surgical procedures unless there are compelling medical or psychological reasons to do so. A successful aesthetic procedure in a mature teenager can have a positive influence, whereas surgery on an immature, psychologically unstable adolescent can have an adverse impact. This review discusses what is safe and what can wait, still there is limited evidence. There is a strong need for guidelines for the use of cosmetic surgery on children and teenagers.
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Genetics of Vascular Malformations: Current Perspectives
Kin Fon Leong
January-March 2021, 22(1):1-11
For decades, vascular anomalies are categorized as either vascular tumors or malformations based on their onset, clinical course, radiologic, and histologic features. Owing to the heterogeneity of vascular anomalies, they are frequently misdiagnosed. With the advent of massively parallel next-generation sequencing, the molecular landscape of vascular anomalies is rapidly evolving and recent discoveries have shed light on the genetic basis and classification of these vascular disorders. The genotype-phenotype correlation will provide a more precise classification of vascular anomalies and form the basis for future targeted pharmacologic therapy. Thus far, inhibitor of mTOR, AKT1, and PIK3CA (sirolimus, miransertib, and alpelisib) have promising clinical results. In vascular malformations, majority of sporadic cases are due to somatic mutations that disrupt the main endothelial receptor intracellular signaling pathways, i.e., PIK3CA-AKT-mTOR, RAS - MAPK – ERK, and SMAD signaling pathways. Most of the sporadic vascular malformations are caused by somatic mutations that are acquired after fertilization, instead of being inherited from his parents. In general, this type of mosaicism is not inherited, except when the mutation affects the gonads.
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Role of Elimination Diet in Atopic Dermatitis: Current Evidence and Understanding

January-March 2021, 22(1):21-28
Atopic dermatitis (AD) is a fairly common dermatosis of childhood. In many cases, parents are concerned that food allergy plays a role in their child's symptoms and they ask whether practicing elimination diets would help in controlling the symptoms. In this review, we try to provide concise answers to the questions raised by the parents, apart from addressing the myths associated with elimination diets in AD and provide scientific evidence in favor of or against the common notions. A comprehensive English-language literature search for the role of elimination diet in AD across multiple databases (PubMed, EMBASE, MEDLINE, and Cochrane) for keywords (alone and in combination) was performed. MeSH as well as non-MeSH terms such as “AD,” “diet elimination,” “treatment,” “prevention,” “evidence,” “blanket elimination,” and “specific exclusion diet” were taken into consideration. There is level I evidence to support specific exclusion diets in preselected and screened patients, but there is insufficient evidence to recommend strict (blanket) elimination diets.
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Pattern of Dermatoses in Small Children in a Tertiary Care Hospital

January-March 2021, 22(1):29-36
Aims: The aim of the study was to study the pattern of dermatoses in children up to 5 years of age. Settings and Design: It is an observational study done in a tertiary care hospital. Subjects and Methods: A total of 505 patients, aged up to 5 years, attending the department of dermatology, venereology, and leprosy for a duration of 18 months from January 2017 to June 2018 were included in the study. Statistical Analysis Used: All results were statistically analyzed by IBM SPSS software and Chi-square test was used to compare the associations. Results: Preschoolchildren (75.44%) formed the majority. Males (54.65%) outnumbered females. Infections constituted the most (45.94%) followed by eczema (21.98%), hypersensitivity disorders (14.25%), nevi (4.55%), papulosquamous (3.76%), pigmentary (3.76%), physiological and transient noninfective neonatal conditions (3.56%), sweat gland (2.97%), hair disorders (0.59%), and other dermatoses (2.97%). Conclusions: Infections/infestations constituted the most among the dermatoses in children up to 5 years of age. As they are preventable, educating the parents, guardian, care takers, and teachers in the preschool about communicable diseases can limit their transmission and improve the well-being of children.
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Clinical Spectrum of Cutaneous Adverse Drug Reactions in Pediatric Population in East Coast of Andhra Pradesh: An Observational Study
VV V Satyanarayana, Suruthi Purushothaman, Bonu Chandipriya
January-March 2021, 22(1):37-42
Context: Cutaneous adverse drug reaction (CADR) among pediatric population is underappreciated and often misdiagnosed in clinical settings. Furthermore, epidemiologic data on only cutaneous adverse reactions among this population are limited. Aim: The aim of this study is to analyze the CADRs with reference to the pattern, causative drugs, its subgroup analysis, and other clinical characteristics among children. Settings and Design: This was an observational, hospital-based study over a period of 12 months. Materials and Methods: The CADRs occurring and referred to the inpatient and outpatient department of dermatology were actively monitored and the collected reports were analyzed for CADR pattern, drug groups, clinicodemographic profile, and severity of adverse drug reaction (ADR). Statistical Analysis Used: Data were documented in Microsoft Excel and analyzed using SPSS Version 20.0. Results: A total of 33 CADRs were documented. Most of the ADRs (40%) occurred between the age of 11 and 15 years. Antimicrobials comprised the major group of drugs causing ADRs (42.4%). Maculopapular rash (54.5%) and urticaria (15.2%) were the most common type of ADR. A single case of death due to anticonvulsant-induced toxic epidermal necrolysis had been observed in the study period. There were more occurrences of ADRs with multiple drugs compared to single-drug therapy. About 80% of reactions were of mild to moderate. Conclusion: Knowledge of the pattern and the offending drug helps in better diagnosis, management, reduced complications in this population, and also helps in preventing recurrences, thereby helps in promoting the safe use of drugs, which can overall impact the quality of health care among children positively.
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Acne Fulminans: A Case Report and Review of Literature

January-March 2021, 22(1):43-47
Acne fulminans (AF), a variant of acne vulgaris, is a rare disease that occurs after treatment of AF with oral isotretinoin. Less than 200 cases of AF have been reported in literature, mostly in young men and all with varying clinical presentations. A thorough search of literature was performed for AF using PubMed, MEDLINE, EMBASE, and UK PubMed Central electronic databases. Pathogenesis is not clearly established. However, it is most likely due to hypersensitivity reactions to sebum or bacterial antigens. It presents as sudden eruption of friable, hemorrhagic crusting overlying the ulcers, plaques, and tender nodules, usually on the trunk, with or without systemic symptoms such as malaise, fever, and arthralgia a few days after initiation of oral isotretinoin therapy. Laboratory abnormalities including raised erythrocyte sedimentation rate, altered hematological profile, and radiological evidence of osteolytic bone lesions may be found. Treatment involves the use of oral steroids with subsequent addition of oral isotretinoin. Many other immunosuppressive therapies have been tried.
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Sweet Syndrome in Early Infancy

January-March 2021, 22(1):77-79
Sweet syndrome (SS), also known as acute febrile neutrophilic dermatosis, is an uncommon inflammatory disease in pediatrics. It presents with fever, blood neutrophilia, and painful erythematous plaques with a dermal neutrophilic infiltrate. In general, it is associated with infections, hematologic and solid tumor, immunodeficiency, and certain drugs. It can easily be mistaken for infection and can lead to prescribe antibiotics or antiviral agents. Here, we describe a case of a 6-week-old infant who developed SS following a pulmonary infection. The patient presented with ocular manifestations and fully recovered after 1 week of corticosteroids.
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Clinical and Dermoscopic Spectrum: Novel Findings in Interesting Cases

January-March 2021, 22(1):48-51
Uncommon, interesting clinical entities presenting in dermatological practice often challenges the diagnostic skills of a trained dermatologist. A non-invasive tool for recognition of these conditions is especially relevant in the paediatric population and dermoscopy plays a pivotal role in diagnosing these cases. A spectrum of novel clinical and dermoscopic findings is reported in four interesting cases. (vitiligo ponctue, cutaneous larva migrans, zosteriform angiokeratoma, linear milia en plaque).
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Norwegian (Crusted) Scabies Involving Eyelids and Conjunctiva

January-March 2021, 22(1):52-55
Scabies is a parasitosis caused by the mite sarcoptes scabiei var. hominis, with crusted scabies being more contagious than classic scabies because of a larger mite burden. It can lead to an epidemic of classic scabies if not diagnosed early and treated accordingly. We report a 10-year-old boy who presented with a complaint of an inability to open his left eye and irritation in the right eye. Examination showed the presence of multiple crusted lesions throughout the body, including face and eyelids, and a yellowish patch in the right bulbar conjunctiva. The histopathological evaluation of the specimen of the conjunctival lesion confirmed it to be sarcoptes infestation. Face and eyelids involvement are very rarely in crusted scabies and only a few cases have been reported in the past. Our report demonstrates conjunctiva as an unusual site of involvement in these cases.
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Psoriasiform Fixed-Drug Eruption to Ibuprofen: A Rare Variant of Fixed-Drug Eruption in a Child
Annie Raizada, Maitreyee Panda, Nibedita Dixit, Abhishek Lachure
January-March 2021, 22(1):96-98
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Isotretinoin Hepatotoxicity or Isotretinoin Induced Autoimmune Hepatitis?

January-March 2021, 22(1):70-72
While isotretinoin, a drug used for the treatment of severe nodulocystic acne, is known to be hepatotoxic, an association with autoimmune hepatitis (AIH) has not been suggested so far. A 17-year-old girl diagnosed with AIH following isotretinoin use for acne vulgaris is presented, and the differences between isotretinoin hepatotoxicity and isotretinoin triggered AIH were discussed. To conclude this case, we want to underline that induction of an AIH by isotretinoin, even though so far unreported, is possible and thus the drug should be used with care, especially in patients with another autoimmune disease.
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Cutaneous Manifestations of Juvenile Dermatomyositis: A Case Series

January-March 2021, 22(1):80-84
Juvenile Dermatomyositis (JDM) is an idiopathic inflammatory myopathy characterized by the weakness of skeletal muscle and pathognomonic skin rashes. Studies focusing on the cutaneous manifestations of JDM are sparse. The objectives of the study were (1) to describe cutaneous changes seen in JDM and (2) to observe nailfold capillaroscopy (NFC) changes in patients with JDM. This was a retrospective case series. All children under the age of 15 years who were diagnosed to have dermatomyositis according to the Bohan and Peter criteria and on histopathology presenting to the dermatology outpatient department during a period of 1.5 years (January 2017–June 2018) were included in the series. Details including clinical features and finding from investigations such as NFC, muscle magnetic resonance imaging, electromyography, muscle enzymes, and biopsy were noted. Statistical analysis was performed on the basis of measures such as percentage and frequency of cutaneous manifestations. A total of eight cases of JDM were included, with average age at presentation being 7.62 years. Among the cutaneous manifestations, the most common presenting features were heliotrope rash and Gottron's papule. Facial telangiectasias, calcinosis cutis, and hypertrichosis were seen in 37.5% of cases. Other cutaneous features seen were confluent and reticulate violaceous erythema, cutaneous ulcer, and periungual telangiectasia with cuticular overgrowth. NFC was suggestive of scleroderma-dermatomyositis pattern in all six patients in whom it was conducted. JDM has classic, pathognomonic skin manifestations that may or may not correspond with muscle inflammation. To avoid complications, early diagnosis and prompt treatment is the mainstay. NFC acts as an important diagnostic tool and also helps to characterize the phase of disease.
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Localized Pseudoxanthomatous Mastocytosis of Vulva

January-March 2021, 22(1):56-58
Cutaneous mastocytosis (CM) is a mast cell proliferative disorder that is common in the pediatric age group. Common entities are urticaria pigmentosa, solitary mastocytoma, telangiectasia macularis eruptive perstans. and diffuse CM. Pseudoxanthomatous mastocytosis presents in the form of yellowish nodular lesion resembling xanthoma and is a rare variant and not reported much in the literature. We, hereby report a rare case of localized vulvar pseudoxanthomatous mastocytosis in a 10-year-old female child.
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Subcutaneous Fat Necrosis of the Newborn Secondary to Sepsis: A Case Report

January-March 2021, 22(1):73-76
Subcutaneous fat necrosis of the newborn (SCFN) is a rare noninfectious type of panniculitis, which primarily affects term and postterm infants. It is usually a benign, self-limiting condition, but in rare cases can be complicated by hypercalcemia, hypoglycemia, thrombocytopenia, etc. We report a case of SCFN in a 4-week-old male infant, treated successfully without complications.
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A Challenging Case of Toxic Epidermal Necrolysis in a 2 Year Old Child With Review of Literature

January-March 2021, 22(1):62-65
Toxic epidermal necrolysis (TEN) is a rare, severe, life-threatening, mucocutaneous adverse drug reaction characterized by widespread blistering and sloughing of the epidermis and mucositis with fatal complications such as sepsis and multiorgan failure. In most cases, drugs are implicated, but occasionally, vaccination and infection can be the triggers of TEN. TEN is very rare in infants and young children and usually has a fatal outcome due to sepsis or multiorgan failure due to large body surface area. Till now, only a few reports have been documented in the literature. We hereby report a challenging case of TEN in a 2-year-old boy who had had a turbulent course during his hospital admission. He was successfully treated with intravenous immunoglobulin followed by systemic steroid along with high-end systemic antibiotics in a dedicated dermatology intensive care setup taking care of his fluid, electrolytes, calories, protein demand, and care of skin and mucosa.
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Ulcerated Infantile Genital Hemangioma Treated with Timolol
Priyanka Mutyala, Janardhan Bommakanti
January-March 2021, 22(1):92-93
  387 52 -
Cutaneous Lesions Presenting as Recurrent Annular Erythema in a Child with Juvenile Myelomonocytic Leukemia, Coeliac Disease, and CALMs: The Myriad Manifestations of RASopathy
Bishnupriya Sahoo, Shikhar Ganjoo, Mohinder Pal Singh Sawhney, Seema Nagger
January-March 2021, 22(1):66-69
In neurofibromatosis type 1 (NF-1), a Ras-pathway mutation disorder both celiac disease and juvenile myelomonocytic leukemia (JMML) have been found in association. A 3-year-old male child presented to us with annular erythema and cafe-au-lait macules (>6 in number). On investigation, he was found to have JMML and celiac disease. A child with early manifestation of NF1 in association with JMML and celiac disease is an even rarer presentation.
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Bilateral Systematized Inflammatory Linear Verrucous Epidermal Nevus Treated with Topical and Systemic Retinoids: A Case Report
Sandeep Sidhu, Niharika Mittal, Tejinder Kaur
January-March 2021, 22(1):94-95
  382 46 -
Curious Subcutaneous Swellings: A Case of Pediatric Myocysticercosis

January-March 2021, 22(1):59-61
Cysticercosis is a parasitic infection caused by the larval stage of the tape worm, Cysticercus cellulosae, chiefly affecting the subcutaneous tissue, central nervous system, orbit, and the skeletal muscles. It occurs in human due to ingestion of contaminated water or raw meat of pig. We hereby present a case of a 6-year-old female presenting with multiple subcutaneous swellings of 3 months' duration, associated with painful movement and associated with a history of on and off fever and malaise. Local part ultrasonography revealed multiple cystic lesions in the muscular plane, with peripheral streak of calcification indicative of scolex. Fine-needle aspiration cytology of the lesions showed revealed degenerated and viable polymorphs, macrophages, few lymphocytes, and foreign body giant cells with foci of necrosis, with occasional hooklets of parasite, with findings suggestive of parasitic infection in neck with acute on chronic inflammation. Computed tomography (CT) scan of brain was normal. Thus, clinical, radiological, and cytological findings confirmed the diagnosis of myocysticercosis. This case is presented because of the rareness of its occurrence.
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Benign Cephalic Histiocytosis with Unique Dermoscopic Pattern
Sarita Sasidharanpillai, Anza Khader, Aparna Govindan, Nina Paul, Nimmi John
January-March 2021, 22(1):85-86
  348 44 -
Acrodermatitis Enteropathica with Complicated Tubercular Meningitis in a Child with a Novel Mutation of SLC39A4 gene
Anupama Manohar Prasad, Sahana M Srinivas
January-March 2021, 22(1):90-91
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Barraquer–Simons Lipodystrophy Syndrome in an Otherwise Normal Child: A Rare Case of Acquired Partial Lipodystrophy
Kananbala Sahu, Swetalina Pradhan
January-March 2021, 22(1):87-89
  306 31 -