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plaques, and multiple pits, which display comedo like keratotic plugs. The lesions tend to have an acral predisposition though a few cases have also been reported with lesions over the forehead, neck, and trunk.7 Histopathology of PEODDN shows hyperkeratosis, acanthosis, and cornoid lamellae-like columns of parakeratosis arising at the level of the mid-dermis and lying within the epidermal invaginations with a thinned granular layer and underlying dilated eccrine ducts.6,7 Vacuolated and dyskeratotic keratinocytes are also typically present within the epidermal invagination. This parakeratotic column is nearly always found overlying an eccrine duct with a dilated acrosyringium; often the eccrine duct is tortuous and hyperplastic as well.6 An orthokeratotic variant of this condition, showing orthokeratotic keratin plugs overlying dilated acrosyringia, has also been reported previously.8 The similarities between PEODDN and our case were the occurrence of lesions in a blaschkoid pattern over the acral region as well as histology showing parakeratotic mounds overlying the acrosyringia with absence of granular layer.1,4 However, our case is distinct from PEODDN in that it had histopathology showing epidermal invagination containing keratotic plug of alternating mounds of orthokeratosis and parakeratosis with entrapped neutrophils overlying a dilated acrosyringium resembling the findings seen in psoriasis. Hence, on clinicopathologic correlation, we propose our case to be a psoriasiform variant of PEODDN. Bhavana R. Doshi, MD Department of Dermatology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India E-mail:
[email protected]
Conflict of interest: The authors have no conflict of interest to declare.
References 1 Mobini N, Toussaint S, Kamino H Non infectious erythematous, papular and squamous diseases. In: Elder DE, ed. Lever’s Histopathology of the Skin, 9th edn. Philadelphia, Lippincott Williams and Wilkins, 2005: 201–202. 2 Lee SH, Rogers M. Inflammatory linear verrucous epidermal naevi: a review of 23 cases. Australas J Dermatol 2001; 4: 252–256. 3 Marsden R, Fleming K, Dawber R. Comedo naevus of the palm – a sweat duct naevus? Br J Dermatol 1979; 101: 717–722. 4 Abell E. Read. Porokeratotic eccrine ostial and dermal duct naevus. Br J Dermatol 1980; 103: 435. 5 Van de Kerkhof P, Steijlen P, Happle R. Co-occurrence of linear psoriasis with porokeratotic eccrine ostial and dermal duct nevus. Acta Derm Venereol 1993; 73: 311–312. 6 Sassmannshausen J, Bogomilsky J, Chaffins M. Porokeratotic eccrine ostial and dermal duct nevus: a case report and review of literature. J Am Acad Dermatol 2000; 43: 364–367. 7 Rasi A, Tajziechi L. Late-onset porokeratotic eccrine ostial and dermal duct nevus associated with sensory polyneuropathy and hyperthyroidism. Arch Iranian Med 2008; 11: 218–220. 8 Parera E, Gallardo F, Gilaberte M, et al. Epidermal naevus with eccrine duct changes: an orthokeratotic variant ofeccrine ostial and dermal duct naevus? Acta Derm Venereol 2007; 87: 84–85.
Uday Khopkar, MD, DNB Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India
Pillar knocker’s callosities
Editor, The American Medical Association defined occupational skin disease as ‘work-related skin disease … a disease to which occupational exposure is a major causal or contributing factor’.1 Occupational skin diseases encompass a wide array of conditions ranging from acne to contact dermatitis to neoplasms.2 Occupational hand dermatitis is reportedly the most frequent occupational skin disease, with an incidence of 0.7–1.5 cases per 1000 population per year in some societies.3 Numerous studies have
ª 2012 The International Society of Dermatology
reported not only purely occupational dermatoses, such as knuckle pads in boxers and Russell’s sign in bulimics, but also culturally determined occupational dermatoses such as the yoga sign in cross-legged squatters and prayer nodules in Muslim males.4–7 This reported case of occupational dermatosis is unique as it is determined by a peculiar occupation of knocking pillars at a historically renowned religious site of World Heritage repute. The group of monuments located at Hampi in Karnataka province in India is listed in the United Nations
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hyperkeratotic plaques on the skin overlying the proximal interphalangeal joints of the third fingers of the dorsa of both hands (Fig. 2). It is presumed that repeated blunt trauma suffered over the years while knocking on the stone pillars and the resultant mechanical forces acted on the skin overlying the bony prominences to produce these callosities. As type IV and V individuals are prone to develop post-inflammatory hyperpigmentation, these callosities turned into ‘pigmented callosities’. This case is reported in order to highlight the singular peculiarity of this occupational dermatosis and to underscore the unique opportunity-driven educational value offered by dermatology in serendipity. Figure 1 Vijaya Vitthala Temple Complex, showing the
richly carved musical pillars
Educational, Scientific and Cultural Organization (UNESCO) World Heritage List.8 Hampi was the final capital of the last great Hindu Kingdom of Vijayanagar, the princes of which built temples and palaces in the city during the 16th century AD. Vijaya Vitthala Temple Complex is one of the most popular monuments in this group. The temple stands on a strong stone basement and consists of 56 richly carved stone pillars (Fig. 1). When tapped, these pillars produce musical sounds. The pillars are popularly known as the ‘‘musical pillars’’ or ‘‘SaReGaMa pillars’’ after the saptha swaras (seven notes) of Indian classical music.9 This 41-year-old man had been working as a guide at the temple complex at Hampi for the last 16 years. During the course of his duties, he would repeatedly knock on the pillars of the temple and demonstrate the different musical notes emanating from different pillars. He had developed firm, circumscribed, non-tender, hyperpigmented, and
Sanjiv Grover, MD Department of Dermatology, Air Force Hospital Jorhat Assam India E-mail:
[email protected] Conflicts of interest: None.
References 1 Slodownik D, Nixon R. Occupational factors in skin diseases. In: Tur E, ed. Environmental Factors in Skin Diseases. Basel: Karger Publishers, 2007: 173–187. 2 Elsner P. Skin protection in the prevention of skin diseases. In: Schliemann S, Elsner P, eds. Skin Protection: Practical Applications in the Occupational Setting. Basel: Karger Publishers, 2007: 1–10. 3 Diepgen TL. Occupational skin disease data in Europe. Int Arch Occup Environ Health 2003; 76: 331–338. 4 Kanerva L. Knuckle pads from boxing. Eur J Dermatol 1998; 8: 359–361. 5 Daluiski A, Rahbar B, Meals RA. Russell’s sign. Subtle hand changes in patients with bulimia nervosa. Clin Orthop Relat Res 1997; 343: 107–109. 6 Verma SB, Wollina U. Callosities of cross-legged sitting: ‘‘yoga sign’’ – an under-recognized cultural cutaneous presentation. Int J Dermatol 2008; 47: 1212– 1214. 7 Kahana M, Cohen M, Ronnen M, et al. Prayer nodules in Moslem men. Cutis 1986; 38: 281–282. 8 UNESCO. Group of Monuments at Hampi, UNESCO World Heritage Centre. Available at: http://whc.unesco. org/en/list/241/ [accessed November 12, 2009]. 9 Hampi Travel Guide. Hampi India – Hampi Vijaya Vitthala Temple. Available at: http://www.hampi.co.in/ article.php/vijaya-vitthala-temple [accessed November 12, 2009].
Figure 2 The guide knocking on the pillar of the temple. The
inset shows the callosities over the third fingers of both hands International Journal of Dermatology 2012, 51, 742–754
ª 2012 The International Society of Dermatology
