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Published for the period of May -2025
RESIDERM: A LAUNCHPAD FOR YOUNG DERMATOLOGY PROFESSIONALS
Dermatology continues to be one of the most soughtafter and competitive specialties in medicine today. With a strong academic foundation, dermatology residents are among the most intelligent, skilled, and capable minds in the field. When provided with the right opportunities early in their careers, they have the potential to achieve remarkable milestones.
RESIDERM is one such platform—designed to empower residents to express their ideas, share experiences, and grow without limitations. This initiative aims to support young dermatologists as they navigate the early stages of their professional journey, shaping both their personal identity and their contributions to the field.
We understand that dermatology can be an intricate and sometimes overwhelming subject for new residents. The goal of RESIDERM is to offer meaningful guidance and mentorship—helping residents make informed decisions that foster their growth and enhance the learning environment for peers, medical students, and the wider healthcare system.
In this issue, we feature valuable insights and advice from experienced faculty, designed to inspire and guide. We also bring you engaging clinical case discussions, including Infantile Hemangioma and Terra Firma-Forme Dermatosis: A Rare Presentation in Dermatology.
We hope you find this issue both enjoyable and enriching. Your journey in dermatology is just beginning, and we are excited to be a part of it.
We look forward to your contributions for the next edition.
Warm Regards,
Team RESIDERM
- Dom Daniel Executive Editor & Publisher
brown-black papules and plaques that typically appear on the neck, trunk, face, and abdomen, including the umbilicus. These plaques may exhibit a papillomatous surface. The condition has been observed around surgical sites, such as after total knee replacement or median sternotomy, and in rare cases, it can present with extensive involvement over the chest, abdomen, and thighs.2 Despite their appearance, these areas are not actually dirty but appear so due to abnormal keratinization. It commonly occurs in areas of the body that experience friction or rubbing, such as the neck, trunk, or extremities.1 Terra firma-forme dermatosis is considered a disorder of keratinization characterized by abnormal and delayed maturation of skin cells. This condition involves prolonged adhesion between keratinocytes, leading to the retention of melanin, sebum, and microorganisms, which results in the formation of brown patches and thickened plaques. It is hypothesized that terra firma-forme dermatosis may represent a ‘forme fruste’(an atypical or incomplete manifestation of another condition) of confluent and reticulated papillomatosis of Gougerot and Carteaud.2
Physical factors influencing the development of terra firma-forme dermatosis (TFFD) include its occurrence near surgical wounds, poor hygiene in disabled individuals, and areas under jewelry, as well as over flexures. Prolonged sun exposure, xerosis, and accumulation of sweat also contribute to its pathogenesis.2 Additionally, genetic factors such as a disorder of delayed keratinization may explain the higher incidence in children aged 0 to 10 years, and although there is no racial predilection, mutations in the filaggrin gene play a minor role.2 Individuals suffering from terra firma-forme dermatosis (TFFD) often face significant challenges due to the persistent and conspicuous nature of the condition. The emotional and psychological burden of dealing with a visibly persistent dermatological issue can impact quality of life, contributing to feelings of embarrassment and isolation.2 Maintaining a balanced diet and adequate hydration is essential for overall skin health and can play a supportive role in managing Terra Firmaforme dermatosis (TFFD). In managing Terra Firma-forme dermatosis (TFFD), lifestyle
modifications, particularly in diet and hydration, play a supportive role. A diet rich in essential nutrients—such as vitamins A, C, E, and zinc—is beneficial for skin repair and overall function. Incorporating a variety of fruits, vegetables, lean proteins, and whole grains into the diet can enhance skin resilience and promote a healthy complexion. Staying well-hydrated by drinking ample water is also crucial, as it helps maintain skin moisture and elasticity, which is important for managing the dryness and flakiness associated with TFFD. While dietary changes alone cannot cure TFFD, they can significantly contribute to improved skin health and complement other treatment strategies, ultimately enhancing the quality of life for those affected by the condition.2
Case Report
A 14-year-old female patient presented with terra firmaforme dermatosis (TFFD), which had been persistent for the past 6 months. Upon physical examination, multiple discrete papules were observed in the pubic region. These papules were distinctively raised, with a brownish-black coloration and a rough texture. They were clustered
together, forming larger plaques. Notably, the patient maintained good hygiene practices, and the lesions showed no signs of inflammation, tenderness, or discharge. Given the clinical appearance and characteristic features of the lesions, a diagnosis of TFFD was confirmed. Dermoscopic examination further supported this diagnosis by revealing exaggerated skin markings and accentuated skin lines, which are typical findings in TFFD. To address the condition, treatment commenced with the topical application of 70% isopropyl alcohol. This approach is aimed at cleansing the
affected area by removing the accumulated debris that contributes to the lesions. TFFD usually responds very well to this treatment, with a complete resolution of symptoms and a low likelihood of recurrence. The patient and her family were reassured that TFFD is a benign and self-limiting condition. They were advised on the use of alcohol wipes to manage any potential recurrence of lesions, emphasizing that ongoing good hygiene can help prevent future episodes. This approach ensures that the patient is well-informed about managing her condition effectively.
Diagnosis
Terra firma-forme dermatosis is primarily a clinical diagnosis characterized by lesions
on any area of the body that cannot be removed with soap. Wiping affected areas with a pad soaked in 70% isopropyl
alcohol will completely remove the lesions and is simultaneously diagnostic and therapeutic.3, 4.
Dermoscopy of terra firmaforme dermatosis reveals characteristic surface features of the lesions, such as a rough, irregular texture and a gritty appearance. The examination may show areas of hyperpigmentation with a mottled or patchy brownish color, corresponding to the dirty or soil-like appearance observed clinically.3, 4 Additionally, large brown polygonal areas arranged in a mosaic-like pattern are often seen. Dermoscopy helps in visualizing these texture and color patterns, which are indicative of the condition, and can assist in distinguishing TFFD from other dermatological disorders. A skin biopsy is rarely performed in terra firma-forme dermatosis (TFFD), as the findings are mostly nonspecific, including papillomatosis, acanthosis, and orthohyperkeratosis. Occasionally, keratin whorls may be observed and can be somewhat specific for the diagnosis. While the biopsy provides valuable insights, especially in ruling out other potential diagnoses, it is most effective when correlated with
Figure 1: Brownish- black papules on pubic region
Before treatment
After treatment
visually conspicuous skin condition can lead to anxiety, low self-esteem, and social withdrawal.6
Psychosocial distress associated with Terra Firma-forme dermatosis (TFFD) often stems from its dirty appearance, which may be misinterpreted as poor personal hygiene.1 This can lead to significant psychiatric impacts, including emotional strain and stigma related to the condition’s appearance. Patients frequently experience heightened anxiety and depression due to the social implications and frustration with ineffective treatments.2 The persistent and resistant nature of TFFD can further intensify these psychological challenges, making effective management and support crucial for improving patient well-being. Several other dermatological conditions can mimic Terra Firmaforme dermatosis, and distinguishing them is crucial for accurate diagnosis and treatment.5 Dermatitis neglecta results from inadequate skin cleansing and responds to washing with soap and water. Acanthosis nigricans appears as velvety, symmetrically distributed lesions in intertriginous areas, often
linked to obesity, metabolic syndrome, or, less commonly, internal malignancies. Confluent and reticulated papillomatosis of Gougerot and Carteaud is characterized by brown papules that coalesce into plaques with a net-like periphery, and remains resistant to vigorous rubbing with alcohol. Atopic dirty neck is an acquired hyperpigmentation of the neck seen in individuals with atopic dermatitis, particularly in Asian populations. Symmetrical acrokeratoderma presents as dirt-like hyperkeratotic areas on the upper and lower limbs, notably the wrists, ankles, and dorsum of hands and feet. Seborrhoeic keratosis involves benign growths of keratinocytes that may resemble Terra Firmaforme dermatosis but do not vanish with alcohol rubbing.6 Other conditions to consider include pityriasis versicolor, which presents with discolored patches of skin, epidermal naevus, a congenital lesion with a warty surface, and postinflammatory ....... hyperpigmentation, which results from skin inflammation leading to darkened areas.6 Preventive measures for terra firmaforme dermatosis primarily
involve maintaining good skin hygiene and minimizing friction or rubbing on affected areas. Regular bathing and gentle exfoliation can help remove excess keratinized skin cells, reducing the appearance of dirty patches. Wearing loose-fitting clothing may also help prevent friction-induced lesions from forming. Since the condition is benign and asymptomatic, no specific preventive measures are typically required beyond basic skin care practices.5 Future treatment strategies may involve advancements in topical therapies, such as novel formulations and enhanced exfoliation techniques, including new chemical peels and improved keratolytics. Additionally, exploring systemic treatments and preventive measures could offer more comprehensive management options for TFFD, aiming to address the condition more effectively and improve patient outcomes.
Conclusion
Terra Firma-forme dermatosis (TFFD) poses a distinct dermatological challenge due to its resemblance to other conditions like dermatitis neglecta and seborrheic
A Case Report on Infantile Hemangioma
a central focal point and represent the most common type, accounting for 68% of infantile hemangiomas cases. Multifocal infantile hemangiomas are focal lesions affecting multiple anatomical sites. Segmental infantile hemangiomas involve extensive areas of skin in a plaque-like manner, following patterns associated with embryonal developmental units. Infantile hemangiomas that do not fit the criteria for focal or segmental classification are termed indeterminate and constitute 17% of cases.1 Infantile hemangiomas typically undergo rapid postnatal growth followed by slow involution, often resulting in complete regression. However, certain cases may pose life- or functionthreatening risks or be associated with structural congenital anomalies.3
The pathogenesis of infantile hemangioma remains challenging and not fully comprehended, with various theories proposed to explain its onset. Immunohistochemical ...... studies have confirmed the vascular nature of these tumors, demonstrating the presence of specific markers like CD31, von willebrand factor, VEGF,
and urokinase in endothelial cells. Dysfunctions in angiogenesis and vasculogenesis pathways, affected by genetic factors, hormonal changes, and placental abnormalities, are implicated in the formation of these tumors.2
The factors associated with an elevated risk and heightened occurrence of infantile hemangiomas include prematurity, multiple gestation, elderly primigravida, placenta previa and pre-eclampsia.4 It is predominantly observed among Caucasian infants at a rate of approximately 10%, IH exhibits a notable female predominance with a ratio of 3:1. The progression of infantile hemangioma can be elucidated by delineating its clinical stages, facilitating a comprehensive understanding of its natural course. These distinctive features aid in distinguishing infantile hemangioma from congenital hemangiomas, which manifest fully at birth without subsequent postnatal growth.5
A collaborative, multidisciplinary approach involving pediatricians, dermatologists, and vascular anomalies specialists is paramount for optimizing the management
of infantile hemangioma. Through an understanding of its complex pathogenesis and personalized treatment strategies, favorable longterm outcomes can be achieved for affected infants.
Clinical presentation
Infantile hemangiomas follow a distinct pattern of development, typically characterized by two main phases: proliferation and involution. Proliferation occurs during early infancy, with gradual regression starting around 1 year of age. Between these phases, there may be a temporary balance called the "plateau" phase, where some cells continue to proliferate while others undergo involution and apoptosis. The involution process can take several years and varies in duration.2
During the proliferative phase (up to 12 months of age), early signs may include localized blanching or redness of the skin. As endothelial cells multiply, the Infantile hemangiomas grow larger, become more elevated, and feel rubbery. This growth phase may also be marked by surrounding paleness and dilated veins, with occasional ulceration leading to pain and scarring.2
Infantile hemangiomas typically appear before 4 weeks of age and grow rapidly, with most reaching 80% of their size by 3 months and completing most of their growth by around 5 months. Deep infantile hemangiomas tend to develop later and persist longer than superficial ones.2 Involution typically begins between 6 and 12 months of age, with the majority of regression occurring before age 4. During this phase, Infantile hemangiomas flatten and shrink, often starting from the centre and spreading outward. Superficial lesions may also show a graying or clearing of the central area.2
Reddish pink patches:
Infantile hemangioma often start as faint red marks or patches on the skin. As they grow, they can become raised, firm, and more intensely red or purple in colour. Some may have a bluish tint due to underlying blood vessels.2
Ulceration and Bleeding:
Infantile hemangioma can sometimes lead to ulceration, where the overlying skin breaks down, leaving an open sore. This can occur due to the pressure exerted by the hemangioma on the skin
or as a result of trauma. Ulceration may cause pain, discomfort, and in some cases, bleeding.2
Feeding impairment:
Infants with infantile hemangioma, particularly those affecting the perioral region or airway, may experience feeding difficulties. Ulcerated lip infantile hemangiomas can cause pain, making it challenging for infants to latch onto a nipple.2
Airway Involvement and Obstruction:
Airway hemangioma may manifest with or without concurrent skin manifestations. Symptomatic obstructive airway hemangioma, such as supra- and subglottic lesions, typically exhibit a biphasic inspiratory and expiratory stridor that worsens progressively within the initial 6 to 12 weeks of life during the proliferation phase of the lesion. Infants affected by these hemangiomas may also quickly develop noisy breathing or a hoarse cry.2
It is important to note that the clinical presentation of infantile hemangiomas can be highly variable, and not all hemangiomas will exhibit the same features. Additionally, the natural
history of these lesions can also differ from one individual to another, with some spontaneously regressing without treatment while others may require intervention to manage complications or aesthetic concerns.
Case Report
A 9-month old healthy child presented with a large vascular plaque with crusting and bleeding over right temporal area of scalp, pre and post auricular area since birth with gradual increase in size over the months, the size was around 10×10cm. Diagnostic imaging via MRI brain with contrast revealed extracalvarial altered signal intensity lesions with tortuous voids and a dilated tortuous feeding artery entering the lesion, suggestive of a vascular malformation. Laboratory findings, including Random Blood Sugar (RBS), Serum Calcium, and Electrocardiogram (ECG), were within normal limits. Clinical diagnosis confirmed an infantile hemangioma. The treatment plan involved systemic medication, including Syrup Prednisolone sodium phosphate solution (10mg/5ml) in tapering dose for 10 days, Tab Propranolol
A Case Report on Infantile
therapy, surgical excision, and interventional radiologic procedures.6, 7, 8
Among the spectrum of hemangiomas, various differential diagnoses warrant consideration to ensure accurate diagnosis. These include congenital hemangiomas, pyogenic granulomas, kaposiform hemangioendotheliomas,.... tufted hemangiomas, venous malformations, capillary malformations such as port wine stains, macrocystic lymphatic malformations, and malignant tumors such as sarcomas, cutaneous neuroblastomas, or lymphomas. Each differential necessitates careful evaluation to differentiate and accurately diagnose the underlying condition.5
Treatment
The treatment options for infantile hemangiomas include:
a. Beta-Blockers: Oral
Propranolol is the most commonly used betablocker for the treatment of hemangiomas.3 It helps inhibit the growth of the blood vessels within the hemangioma, leading to shrinkage and resolution of the lesion. Propranolol is usually administered orally in a liquid formulation,
with dosing tailored to the patient's weight and response. Propranolol helps reduce the size and redness of the hemangioma.4 Close monitoring of vital signs, particularly heart rate and blood pressure, is required during treatment.6
b. Corticosteroids:
Systemic corticosteroids, such as prednisolone, may be prescribed for large or problematic hemangiomas. Corticosteroids help reduce inflammation and suppress the growth of the hemangioma.3 They are typically administered in tapering doses over several weeks, with close monitoring for side effects.6
c. Topical Timolol:.....
Timolol is a common topical treatment for infantile hemangiomas, showing safety and efficacy, especially for small and superficial infantile hemangiomas.5
d. Vincristine:.............
Vincristine, derived from plants, is a vinca alkaloid that interferes with mitosis by affecting microtubule formation. Its antiangiogenic properties stem from its ability to induce endothelial cell apoptosis and inhibit endothelial cell growth, migration, and capillary-like tube
formation. While primarily used in vascular lesions associated with kaposiform hemangioendothelioma..... (KHE) or tufted angiomas (TAs) linked to KasabachMerritt phenomenon (KMP), vincristine has also shown efficacy in managing life-threatening or function-threatening infantile hemangiomas affecting the airway, orbit, or liver. Administered weekly through a central catheter due to its vesicant nature.5
e. Interferon-α:...........
Interferon-α 2a........ and 2b, has been efficacious in treating infantile haemangiomas in children. It is administered subcutaneously, starting with an initial dose of 1 million IU/m2, which is gradually increased to 3 million IU daily over the first month of treatment. Throughout therapy, monitoring of neurologic status, white blood cell count, and liver function is essential. Treatment duration typically ranges from 2 to 12 months.5
f. Imiquimod: A 5% Imidazoquinoline topical agent, acts as an immuneresponse modifier by stimulating the innate immune system. It enhances cytokine production, including interferons (α, β, and γ), IL-10, IL-12, IL-18,
and tumor necrosis factor. These cytokines bolster cell-mediated immunity and induce apoptosis. Imiquimod's therapeutic effect on infantile hemangiomas may involve inhibition of angiogenesis by these cytokines. Additionally, it down regulates proangiogenic factors like bFGF and MMP-9 while upregulating endogenous angiogenesis inhibitors such as interferoninducible protein 10, tissue inhibitor of MMPs, and thrombospondins. Topical imiquimod application has demonstrated significant inhibition of tumor cellinduced angiogenesis in human keratinocyte models.5
2. Laser Therapy:
Lasers have become a keystone for treating various cutaneous lesions, including infantile hemangiomas, following the development of the theory of selective photothermolysis. The pulsed dye laser (PDL) stands as the most frequently utilized laser for managing infantile hemangiomas.5, 8
Another commonly employed laser for vascular lesion treatment is the Neodymium-Doped Yttrium Aluminium Garnet (ND laser) operating at mid-
infrared wavelengths (1064 nm), it corresponds to an additional infrared absorption peak of oxyhemoglobin around 1000 nm. With its ability to penetrate deeper (5–6 mm) compared to PDL (0.75–1 mm), it finds indication in treating deep or mixed hemangiomas, particularly when both laser types are combined. However, a notable drawback is the pain experienced during laser sessions.5, 8
3. Surgical Excision:
Surgical removal of the hemangioma may be considered for lesions that are large, disfiguring, or causing functional impairment.4, 6 It is typically reserved for hemangiomas that do not respond to other treatment modalities or pose a significant risk to the patient's health.6, 8 Close follow-up care is necessary to monitor for recurrence and ensure optimal wound healing.5, 8
4. Interventional.........
Inselect cases, interventional radiologic procedures such as embolization or sclerotherapy may be employed to treat hemangiomas.4 These techniques involve injecting
a substance into the blood vessels supplying the hemangioma to block blood flow and induce shrinkage.4 Interventional radiologic procedures are often reserved for complex or deep-seated hemangiomas that are difficult to treat by other means.6
Discussion
Infantile hemangioma, while not typically lifethreatening, can profoundly affect a patient's quality of life and mental well-being. Therefore, a comprehensive understanding of its occurrence, development, potential mechanisms, and treatment options is essential. Various risk factors have been identified, including low birth weight (LBW), preterm birth, female sex, Caucasian race, progesterone therapies, multiple gestations, and a family history of infantile hemangioma. Additionally, emerging research suggests associations with in vitro fertilization (IVF), advanced maternal age, placental anomalies and maternal tobacco use.9
Local hypoxia plays a pivotal role in infantile hemangioma development by suppressing the hypoxiainducible factor pathway (HIF-pathway), leading to dysregulated proliferation.
MUMBAI 202
MUMBAI 2025
1 Day Conference, Hands on Workshop and Exhibition
AESTHETICCON Mumbai 2025 is just the event for you with practical insights shared in the Conference, tips while training in the Hands on workshop and interaction
AESTHETICCON Mumbai 2025 is just the event for you with practical insights shared in the Conference, tips while training in the Hands on workshop and interaction with product manufacturers.
Spend the day catching up and meeting with your fellow Dermatologists colleagues.
