In 1995, I graduated from high school and got accepted as a student at faculty of Medicine University of Indonesia, Jakarta. After graduated as a doctor, I worked as a general practitioner in several hospital and clinics, such as Dr.Cipto Mangunkusumo Hospital, Jalan Baja Primary Health Care Facility, Kebayoran Lama Primary Health Care Facility, and Bulungan Clinic. In 2011, I continue my study in Dermatology and Venereology at faculty of Medicine University of Indonesia, Jakarta. In 2015, I graduated as dermatovenereologist and started to work in Pasar Minggu Regional Hospital, Jakarta until now.

Introduction Leprosy is a chronic granulomatous infection caused by Mycobacterium Leprae. There are two types of Lepra reaction, Reversal Reaction (type 1 lepra reaction) and Erythema nodosum leprosum (type 2 lepra reaction). Skin lesions in type 2 lepra reaction manifest as numerous erythematous and tender nodules and plaques in different parts of the body. Bullous lesions are rarely found in type 2 lepra reaction. Case Report A 31 years old male, with multiple painful reddish swelling and fluid filled lesions in his face, trunk and extremities. He has been diagnosed as lepromatous leprosy on WHO multidrug therapy (MDT) for the past 13 months. There were several history of type 2 lepra reaction, which manifest as multiple painful reddish swelling without any fluid filled lesions before. They were usually managed by high doses of corticosteroids result in improvement. For the first time, on this occasion he had also developed multiple fluid filled lesions. Dermatological examinations revealed multiple erythematous tender nodules and plaques on face, trunk and extremities. He also had multiple bullous lesions on upper and lower extremities. Nikolsky sign was negative. Bilateral ulnar nerves were thickened and tender. Laboratory results revealed anemia, polymorphonuclear leukocytosis and increased ESR. Slit skin smear examination showed solid and fragmented acid fast bacilli with bacteriological index (BI) of 2 2/3 + and morphological index (MI) of 8%. Skin biopsy of bullous lesion show subcorneal bullae with diffuse polymorphonuclear cell infiltrate in the dermis, a few foamy histiocytes, vasculitis, and neutrophilic panniculitis. He was treated with a high dose systemic corticosteroid, intravenous injection of methylprednisolone starting at 62,5mg/day and tappered off over one month period. Anti leprosy drugs were continued. Topical treatments consist of normal saline wound dressing and application of topical antibiotic. He showed good response to the treatment. Discussion Lepra reactions caused by an alteration of immunological balance in a leprosy patient. Erythema nodosum leprosum is an immune complex reaction and seen mostly in lepromatous type. Antibodies reacts to M.leprae antigen to form the immune complex which circulated and deposited in various tissues. This process will lead to activation of complement and causing damage of the tissues. Bullous lesions in type 2 reactions are very rare. There were only a few reports of bullous erythema nodosum leprosum. They have been associated with very high bacillary load in lepromatous leprosy patients.

Al-Moatasem Al-Mamari graduated from the medical college at Sultan Qaboos University (SQU), in Oman, in 2014. Then joined the psychiatry residency program in Oman Medical Specialties Board (OMSB) in Oman. Currently, he is the deputy chief resident, in his third residency year.

Background – Various studies have suggested that depression is more prevalent among patients with skin disorders than in the general population. Most of the studies addressing this subject involve Euro-American populations. Objectives –The present study aimed to estimate the prevalence of depressive symptoms among patients with dermatological disorders and, then, to decipher the clinical–demographic factors associated with depressive symptoms. Methods – A cross-sectional analytical study was conducted among a random sample of patients attending a dermatology clinic in Muscat. The Patient Health Questionnaire-9 (PHQ-9) was used to screen for depressive symptoms. A logistic regression model was used to find the adjusted and unadjusted odds ratios (ORs). Results – A total of 260 patients participated in this study, with a response rate of 81%. The prevalence of depression symptoms was 24%. According to regression analysis, family history of depression, comorbid medical disorders, and treatment with topicals or isotretinoin were significant predictors of depression (OR = 9.41, 95% confidence interval [CI]: 2.27–39.05, P = 0.002; OR = 2.0, 95% CI: 1.2–3.21, P = 0.05; OR = 2.28, 95% CI: 1.09–4.76, P = 0.028; and OR = 2.78; 95% CI: 1.08–7.19, P = 0.035, respectively). Conclusion – This study indicates that depressive symptoms are common among patients with dermatological disorders in Oman, particularly in those with a family history of depression and medical comorbidities, and those who use a specific dermatological medication. Screening for depression in patients attending dermatology clinics is essential in order to detect and promptly treat patients suffering from depression.

Vilashini. V has completed her undergraduate M.B.B.S., in PSG IMSR, Coimbatore and is currently pursuing first year post graduation in M.D., Dermatology in Chettinad hospital and research institute, Kelambakkam, Tamil Nadu, India.

Introduction: Lichen planus is a common inflammatory dermatoses that presents in a variety of morphologic patterns. Lichen planus pigmentosus, a disease of unknown etiology runs a insidious prolonged course, characterized by small dark brown macules on sun exposed areas that merge to form large hyper pigmented patches. Lichen planus pigmentosus inversus is characterized by hyper chromic , asymptomatic to mildly pruritic well defined macules and plaques affecting intertriginous areas , most commonly axilla and groin in Caucasian patients. Herein I report a 45 year old female diagnosed with lichen planus pigmentosus inversus mimicking intertrigo. Materials and Methods: Case Report – A 45 year old married woman, a known case of epilepsy and optic neuritis on treatment, presented with chronic itchy dark brown macules which then merged to form dark hyper pigmented lichenified plaques in intertriginous areas of groin for the past one year. Woods lamp was done to exclude erythrasma .Patients’s thyroid levels were normal. . Based on the clinical presentation diagnosis of intertrigo was done and patient was treated with anti fungals and emollients. But the patient failed to show any clinical improvement. Hence skin biopsy was done. Histopathology findings were consistent with Lichen planus pigmentosus. Discussion: Hence Lichen planus pigmentosus inversus also should be considered a differential diagnosis of cutaneous pigmentation exclusively located in the flexural and intertriginous areas .

Wina completed the education of a dermatologist at the age of 31 from Sriwijaya University in Palembang, Indonesia. Now she is taking a doctoral education at Airlangga University in Surabaya, Indonesia. She is the head of the Department of Dermatovenerology at the Medical Faculty of Nahdlatul Ulama University in Surabaya / Jemursari Islamic Hospital Surabaya.

Introduction: Pemphigus foliaseus (PF) is a group of autoimmune blistering disease with blisters on the stratum granulosum or at the base of stratum corneum. PF is commonly found in women with an average age 40-60 years. Clinical symptoms of PF are erosions, crusts, scales, with an erythematous base and located in seborrheic areas. Primary PF lesions, flaccid blisters, are usually difficult to find. Systemic corticosteroids, usually oral prednisone, are standard treatments with an initial dose 60 mg daily. Osteoporosis, derived from the word osteo which means bone and porosis means thinning or becoming porotic. Pharmacologic treatment of osteoporosis includes calcium supplements, vitamin D, and anti-resorbsi medications such as estrogen, calcitonin and bisphosphonates. Case: A 64-year-old female patient with preexisting crusts and scales increasing in quantities and also blisters on all over the body since a month ago. Flaccid blisters were found on extremities. Histopathology revealed PF. Radiologic examination of thoracolumbar supported osteoporosis and thoracolumbar spondylosis. Treatment with prednisone tablets 60 mg daily, and Risedronate tablets 5 mg daily made clinical improvement. Discussion. This was the first case report of PF with osteoporosis in Dr. Mohammad Hoesin General Hospital Palembang Indonesia. The diagnosis of PF with osteoporosis was based on history taking, physical examination, histopathological features and radiologic examination. Treatment was oral and topical corticosteroid for PF and oral biphosphonate for osteoporosis. Combination of treatment made clinical improvement.

Born in 1955, graduated from Ahvaz University of Medical sciences as Gp and Dermatology. I am associated professor in dermatology department .and work with Center for Research and Training of Skin diseases and Leprosy.

Background: Surgery is used for stable vitiligo lesions which did not respond to medical treatment. Non cultured melanocyte-keratinocyte cell suspension is one of the surgical modalities available for restoring melanocytes on the recipient site. There are two donor sources for obtaining epithelial cells: follicular unit extraction (FUE) and thin skin split sample (TSS).Follicular source has the advantage of nearly not leaving scars and presumed higher density of melanocytes compared to skin. However, there are few clinical trials comparing these two methods and to our knowledge, none have been controlled studies. Objective: We sought to compare the efficacy of noncultured cell suspensions prepared from thin split skin and follicular extraction on repigmentation of stable vitiligo, in a placebo controlled trial. Methods: Fifteen patients with stable vitiligo were randomized into three groups of follicular extract, split skin, and placebo. Following transplantation of cell suspensions, they followed up monthly until 6 months and again at 1-year. .Repigmentation area, side effects and quality of life were outcomes of interest at 6 months and 1 year follow-up post-transplantation. Data were analysed by SPSS version 16(SPSS Inc., Chicago.IL,USA). Results: Repigmentation occurred in both groups of follicular (F) and split skin cell (C). Surface area change of repigmentation was greater in group C (p=0.02). Side effects were minimal. At 1-year follow-up, no patient had relapsed. Limitations: The main limitation was the small sample size in each group. Conclusions Overall noncultured cell suspensions seem to be promising for patients with stable vitiligo who have not previously responded to medical treatment; however a follicular source seems to be less effective. Further research is needed.

Nancy completed the education of dermatologist at the age of 30 from University of Sumatera Utara in Medan, Indonesia. Now she is working as dermatovenereologist at Abdul Wahab Sjahranie General Hospital in Samarinda, Indonesia.

Introduction: Radiodermatitis or radio-induced dermatitis (RD) is one of the most important side-effects of radiotherapy (RT) and radiation-based imaging techniques. It is defined as cutaneous reaction to the inflicted cellular injury, which occurs once the threshold level of exposure has been exceeded. RD is most common in patients treated for breast, head and neck, anal and vulvar cancer. The higher incidence is due to the fact that the irradiation target in these anatomical regions is closer to the skin and therefore it receives a high RT dose. Acute RD starts with red rashes and dry desquamation, become bright erythema with patchy moist desquamation, and develops confluent moist desquamation. In some rare cases a very painful necrosis with hemorrhage and ulceration can occur and affects greatly the patients’ quality of life. Treatment with daily hygiene practices such as gentle washing with water with or without mild soap, application of wound dressings that absorb the wound exudate and protect the wound from environmental damage and bacteria to prevent secondary infections. For infected wounds, silver-containing dressings can be used. Nasopharyngeal carcinoma (NPC) is a rare malignancy worldwide, but it is endemic in a few areas. It is one of the Epstein-Barr virus (EBV) associated malignancies. The symptoms and signs include neck masses, epistaxis, nasal obstruction and discharge, headache, and other non specific indicators. NPC is very sensitive to RT resulting in 3-year disease-free and overall survival of approximately 70% and 80%, respectively. Case: A 39-years-old male patient with multiple painful necrosis with hemorrhage, erosions, ulceration, and crusted skin on the neck since 10 days ago. History taking revealed previous RT for 21 times since 3 weeks ago due to NPC std.IV. Treatment with wound dressings, topical corticosteroid, mupirocine cream 2 times daily, and Mefenamic acid tablets 500 mg 3 times daily made clinical improvement. Discussion: The diagnosis of RD with NPC was based on history taking, physical and radiologic examination. Treatment was given wound dressings, topical corticosteroid, mupirocine cream, and oral mefenamic acid for RD and series of RT for NPC. Combination of treatment made clinical improvement.

Dr. Jacqueline Chen graduated from Monash University in 2013 and completed her fellowship examinations with the RACGP in 2018 and is a general practitioner in South Australia with an interest in Dermatology.

Dermatology is a highly dynamic field. Clinical research remains vital in the diagnosis and management of skin diseases to improve patient outcomes. Australia has among the highest skin cancer rates globally. With many researchers being dermatologists, there is a limited workforce shortage due to a projected deficit of 90 dermatologists by 2030 recently reported by our Department of Health. There are 508 registered dermatologists in 2015 versus a total of 36,938 general practitioners (GPs) in 2017.Hence, general practitioners can play a role to increase dermatology research as patients often present to GPs first seeking initial advice. One of the possible ways to cultivate this is to increase awareness within dermatology and its potential for research even amongst undergraduate programs as dermatology teaching is limited in Australian Higher Education Institutions. Only 4/17 medical schools had compulsory dermatology clinical attachments. Research should be encouraged and this should stem from the curriculum itself. Regular clinical meetings to bridge the gap between dermatologists and primary care providers can be implemented to increase awareness and enhance patient recruitment for clinical trials. Furthermore, establishing standardised courses in the methodology of monitoring response to therapy would aid GP involvement in the assessment of outcomes in various clinical trial scenarios. With the rise in tele-dermatology, patients in rural regions have newfound opportunities to access current clinical trials, more so than ever before. This can be utilised as a tool by rural GPs in patient recruitment, treatment commencement and the communication of results to their fellow researchers.

Ruby Gibson is currently a fourth year medical at the Long School of Medicine at the University of Texas Health San Antonio applying for dermatology residency.

Atypical squamous proliferation (ASP) is a descriptive term used for a specimen when pathologists are unable to exclude a variant of squamous cell carcinoma. The objective of this study was to retrospectively review the current management, differential diagnosis, and histopathologic features of ASPs. A multicenter retrospective chart review was performed for skin biopsies reported as “atypical squamous proliferation” (ASPs) between 2004 and 2014. A total of 771 ASP specimens were identified. The most common location was head and neck region (53%). Management strategies for ASPs included excision (42.5%) followed by repeat biopsy (18.4%), observation (16%), and Mohs micrographic surgery (15.9%). The original pathologist solely favored a benign process such as actinic keratosis in 40.52% of cases. The retrospective dermatopathologist favored malignant diagnosis over an ASP diagnosis more frequently than the general pathologist. Of the biopsies, 183 (24%) were labeled as inadequate biopsies. Of all the cases that were rebiopsied, the lesion was upgraded to malignant 22% of the cases. ASP present a diagnostic and therapeutic challenge for both pathologists and dermatologists. Inadequate superficial biopsies and overlapping histopathologic features prevent a definitive histopathologic diagnosis. Our study emphasizes the importance of taking adequate biopsies when squamous cell proliferation is in the differential.

Dr. Palki Sharma has completed her MBBS at the age of 24 years from Jammu University, India. Due to her compassion in serving the underprivileged she worked as a medical officer with Government of India for 4 years in rural parts of India. She completed her Masters in Clinical Dermatology in 2019 with a distinction from Cardiff University, School of Medicine UK.

Hidradenitis suppurative is a chronic inflammatory skin condition. It is characterized by recurrent, painful inflammatory nodules and abscess in the intertriginous parts of the body, leading to extensive scarring and disfigurement. The exact pathogenesis of HS is unknown. The primary defect in HS is believed to cause occlusion and subsequent inflammation of the pilosebaceous unit under the influence of genetic, hormonal, immune, smoking, obesity, and mechanical frictional factors. A sizeable body of research demonstrates obesity as one of the most common comorbidities associated with HS. Moreover, obesity is considered to be one of the risk factors for the development of metabolic syndrome and cardiovascular abnormalities, which are commonly associated with HS. Presently, there is a lack of data on there being a direct association between HS and obesity and none data available showing a cause and effect relationship between weight or BMI and the disease severity. Therapeutic studies in HS have shown a decreased efficacy of patients towards various treatment modalities, including biologics. Studies evaluating the efficacy of biologics in autoinflammatory diseases have suggested obesity to have a negative impact on anti-TNF therapy. Unfortunately, at present, there are no studies conducted on HS that can verify this theory, chiefly due to imprecise knowledge linking obesity and HS. Thus, for this paper, the scientific studies surrounding the multifaceted association between HS and obesity have been reviewed, suggesting that obesity might be a severity factor of HS. Therefore, opting a different course of treatment may help in the management of overweight and obese HS.

Laura Pauline Kosasih has completed her Bachelor degree of Medicine in Hang Tuah University Indonesia and Master degree in Clinical Dermatology in Cardiff University. She has utmost interest in both medical research and clinical skill. Educating and learning about Aesthetic and Clinical Dermatology are some of her core values.

Nodular prurigo is a rare, intractable chronic skin disease, characterized by intensely pruritic nodules. Its aetiology is still under debate; however, it is theorized that multifactorial pruritic-related aetiologies are deemed as the most probable factors that lead to the vicious itch-scratch cycle. It can occur in any age group and race; however, elderly and African-descendents are in the higher risk. Owing to its hallmark’s symptoms and signs, nodular prurigo can greatly affect one’s physical and mental well-being. Various diseases have been linked to nodular prurigo, either dermatological or non-dermatological conditions, with atopic dermatitis being most frequently linked disease with the incidence of nodular prurigo. In fact, 80% of individuals with nodular prurigo may have a history of atopic dermatitis. The precise pathogenesis of nodular prurigo is still unclear. However, innate and adaptive immune cascades with neuronal sensitization are postulated to orchestrate the journey to nodular prurigo. Additionally, many itch-related immune complexes and pathways that have been found in atopic dermatitis are also found in nodular prurigo. Dupilumab is a fully human IgG4 monoclonal antibody that targets the IL4 receptor α subunit to inhibit the signaling of both Th2 cytokines: IL-4 and IL-13. The two cytokines: IL4 and IL13 are implicated in the immunopathology of nodular prurigo. Dupilumab has been established as a successor biologic treatment options in treating atopic dermatitis. Several case series may have shown a successful outcome in treating nodular prurigo with dupilumab, however, efficacy has not been proven by RCT. This study proposes a multi-centered, prospective, phase 3, open-label, randomised controlled crossover trial of dupilumab in recalcitrant nodular prurigo in patients with prior failure of one systemic therapy. This study aims to assess the efficacy of dupilumab in treating recalcitrant nodular prurigo patients and also assess the non-pharmacological aspect of the effect of dupilumab such as the quality of life and psychiatric comorbidities of the patients after intervention. Furthermore, the study will determine whether dupilumab is equally efficacious in patients with and without co-existent atopic dermatitis. It is expected that dupilumab will give same level of efficacy in patients who have and do not have a history of atopic dermatitis.

Kerasia-Maria Plachouri has completed her studies in medicine at the age of 24 from the University of Patras, Greece. She completed her doctoral thesis and her specialty in dermatology in Westfaelische-Wilhelm’s University, Muenster, Germany, at the age of 31. She has published more than 15 papers in reputed journals.

Introduction The mixed type of localized scleroderma (mLS), which combines linear LS and plaque type LS or linear LS and generalized LS, is seen in children quite often, but is frequently misdiagnosed. Objectives We describe the case of a child that presented with an mLS, manifesting with a brown patch on the left zygomatic area, linear lichen-sclerosus-like lesions on the face, and scattered morphea patches distributed among the four extremities. Methods A 13-year old Caucasian girl presented in our Department for the evaluation of an irregular brown patch on the left zygomatic region, that had first appeared 3 years ago and was gradually progressing in size. Previous evaluations were in favor of a ‘’harmless naevus’’. Also noted were a slightly depressed porcelain-white plaque, with an atrophic epidermis on the left upper lip and the left nasofacial angle. Furthermore, four shimmering livid-brown patches with atrophic epidermis were documented on all extremities. Results and Discussion A deep biopsy of the brown patch of the left zygomatic lesion and the lip and left hand revealed an atrophic epidermis with thickened bundles of collagen fibers and focal loss of elastin fibers in the reticular dermis. These findings were compatible with LS. A therapy with systemic prednisolone and methotrexate was initiated, combined with a local treatment of methylprednisolone acetonate and tacrolimus 0,1% ointments Conclusion This report is a reminder of the atypical features of this entity to the physicians, and underlines the fact that high level of suspicion, careful monitoring and prompt treatment are necessary, in order to avoid disease-related complications.

Harshita Jain has completed her MBBS at the age of 23 years from Peoples University and Ongoing Postdoctoral studies from Teerthankar Mahaveer University in batch of 2018, and complete Dermatology degree by 2021.

Darier Disease: A very rare Genodermatosis. Darier disease (DD) or Darier-white disease, also known as Keratosis follicularis, is an autosomal dominant inherited genodermatosis caused by mutations of ATP2A2 gene. It is characterized by greasy hyperkeratotic papules in seborrheic regions, nail abnormalities and sometimes mucous membrane changes. Oral manifestations primarily affect the palatal and alveolar mucosa. A 24 year old girl presented with greyish coloured warty plaques scattered on the face, neck, ears, trunk, hands, legs, and groins. The lesions were foul smelling. Characteristic V-shaped nicking of the nails with longitudinal ridges parallel to the long axis were seen. Palmer pits were also present. On examining oral mucosa, multiple white papules over the palate giving cobblestone appearance was seen. Patient was also complaining of Photophobia, redness, lacrimation and pain. On slit lamp examination, ulcer of 2x3 mm with Fluorescent stain positive and few anterior chamber cells present. No family history was there of similar illness. Biopsy was taken from hyperkeratotic papules of hand, which shows hyperkeratosis along with central keratin plug, the epithelial rete ridges associated with the lesions appear narrow and elongated. DD is a rare keratinization disorder with skin involvement and oral mucosal lesions. We wanted to present this case because of its rarity. On the basis of Clinical and histopathological finding patient was diagnosed as a case of Darier disease. General measures were advised and genetic counselling was done, including information of inherited condition and risk of transmission to offspring.