Dermatophytosis due to the Trichophyton mentagrophytes-Trichophyton interdigitale complex is being increasingly reported across India. Reports of therapeutic failure have surfaced recently, but there are no clinical break points (CBP) or epidemiological cutoffs (ECVs) available to guide the treatment of dermatophytosis. In this study, a total of 498 isolates of the T. mentagrophytes-interdigitale complex were collected from six medical centers over a period of five years (2014 to 2018). Antifungal susceptibility testing of the isolates was carried out for itraconazole, fluconazole, ketoconazole, voriconazole, luliconazole, sertaconazole, miconazole, clotrimazole, terbinafine, amorolfine, naftifine, ciclopirox olamine, and griseofulvin. The MICs (in mg/liter) comprising >95% of the modeled populations were as follows: 0.06 for miconazole, luliconazole, and amorolfine; 0.25 for voriconazole; 0.5 for itraconazole, ketoconazole, and ciclopirox olamine; 1 for clotrimazole and sertaconazole; 8 for terbinafine; 16 for naftifine; 32 for fluconazole; and 64 for griseofulvin. A high percentage of isolates above the upper limit of the wild-type MIC (UL-WT) were observed for miconazole (29%), luliconazole (13.9%), terbinafine (11.4%), naftifine (5.2%), and voriconazole (4.8%), while they were low for itraconazole (0.2%). Since the MICs of itraconazole were low against the T. mentagrophytes-interdigitale complex, this could be considered the choice of first-line treatment. The F397L mutation in the squalene epoxidase (SE) gene was observed in 77.1% of isolates with a terbinafine MIC of ≥1 mg/liter, but no mutation was detected in isolates with a terbinafine MIC of <1 mg/liter. In the absence of CBPs, evaluation of the UL-WT may be beneficial for managing dermatophytosis and monitoring the emergence of isolates with reduced susceptibility.

Background:Papulonecrotic tuberculid (PNT) is said to be a hypersensitivity reaction to M. tuberculosis. Some reports indicate that organisms are demonstrable by polymerase chain reaction (PCR).Methods:We describe 12 patients with PNT over 6 years. We reviewed the histopathologic features, clinical data and follow-up. PCR for M. tuberculosis DNA was done in all cases.Results:There were 7 men and 5 women. The ages ranged from 3–58 years. Upper limbs were commonly involved (8 cases). All patients had multiple papulonodular lesions, 5 showed ulceration and scarring. Mantoux test was strongly positive in all. Seven patients had systemic tuberculosis.On microscopy, necrosis was seen in 11 cases, varying from minimal to extensive. Epithelioid granulomas were common, except for 1 case with palisading and interstitial patterns. The infiltrate showed mostly lymphocytes, while 3 cases showed eosinophils. Vasculitis was seen in 8 cases. Two cases had dermal mucin, one also with interface dermatitis. This patient had concurrent LE. Mycobacterial DNA was detectable by PCR in 3 cases. Seven patients showed improvement/resolution of lesions on treatment.Conclusions:PNT is a rare disease. A positive PCR reiterates the question whether these are “tuberculids”. PNT may be better classified as true cutaneous tuberculosis and patients screened for systemic disease.

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Background:Follicular Mycosis Fungoides (FMF) is an under-recognized disease in India. Its clinical mimics include Hansen’s disease and Sarcoidosis.Aims:To describe the clinical and pathological features of FMF.Materials and Methods:All cases of FMF between January and December 2007 were retrieved. Cases of conventional epidermotropic MF with a minor follicular component were excluded. Slides were reviewed by two observers. The following criteria were assessed: degree and density of folliculotropism of lymphocytes, location of folliculotropism (infundibular / isthmic / bulbar), follicular mucin, eosinophils, granulomas, and conventional epidermotropism. Each feature was assigned a semi-quantitative grade.Results:There were four cases of FMF, with an equal gender distribution and a mean age of 17.5 years. All lesions were on the face. They presented as: hypopigmented patches (2) and erythematous plaques (2). Alopecia was seen in two cases. The clinical diagnosis was Hansen’s disease in all four, with a differential of Alopecia mucinosa / Sarcoidosis in two cases.The histological features seen were: disproportionate folliculotropism, lymphocyte tagging with haloes, follicular mucin, and nucleomegaly / convolution in all four cases, prominent eosinophils (2), epithelioid granulomas (1), eccrine infiltration (4), parakeratosis at the follicular ostia (2), and sebaceotropism (1). The infiltrate was bulbar (4) and isthmic (2). The rest of the epidermis showed no hint of conventional MF.Conclusion:The preferential features for FMF were involvement of face, dominant folliculotropism, nuclear atypia and convolution, and follicular mucin. Presence of granulomas and eosinophils necessitated exclusion of infectious causes. The absence of findings of MF in the rest of the epidermis should not deter pathologists from rendering this diagnosis.

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Histopathology is a dependable tool in identifying the underlying cause in SA. Even in cases that show a complete loss of follicles, it is possible to suggest the etiology based on epidermal and connective tissue changes.

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