IntroductionProbiotics exhibit widespread effects on homeostasis and immunomodulation of both mucosal and systemic immunity. Probiotics counter weight aggressive commensals in the body and reinforce the barrier function of the epithelium while also contributing to the regulation of innate and adaptive immune responses of the host under healthy or pathogenic conditions. Probiotics could be used for prevention or treatment of chronic allergic and inflammatory diseases, such as inflammatory bowel disease (IBD) and atopic dermatitis. We describe a case of pustular psoriasis where probiotics were used for the treatment successfully. Case ReportA 47yr old female, presented with crops of pustules all over her body since 20 days. The rashes started over the leg and rapidly progressed to the whole body. The rashes were associated with pain. Patient had fever and arthritis of both knees. There was no photosensitivity. Patient was a known case of psoriasis since 15 years. She was on treatment with different medications both topical and systemic. She was given Methotrexate 2yrs back for 6 months and since then she was on irregular treatment. The patient was anxious, looked very ill and was febrile. General physical examination showed bilateral pedal edema. On cutaneous examination there was diffuse erythema with areas of pustules over extensor aspect of upper and lower limbs, abdomen and chest ( Fig. 1, 2). Multiple scaly plaques were present over the scalp. Axilla and groins had no lesions. Nails showed pitting with subungual hyperkeratosis. Palms and soles were normal. Systemic examination was within normal limits.Her random blood sugar was 220mg/dl, triglycerides were 344mg/dl, C-Reactive Protein was positive, total protein was 5.6g/dl and albumin was 3g/dl. Ultrasonography of the abdomen did not show any significant abnormality. On the basis of history, clinical examination a diagnosis of pustular psoriasis was made. The patient was admitted and put on steroids, dapsone and as she was already on methotrexate, it was continued with supplementation of analgesics and antipyretics. But even after two weeks she did not respond and her lesions kept increasing and her blood sugar increased. She started developing signs of steroid toxicity. We were forced to withdraw steroids. As she could not afford biologics we had to look for alternative medicines.With anecdotal reference [4] of probiotics helping palmoplantar pustular psoriasis and their usefulness in atopic dermatitis, we thought of trying the regimen after obtaining consent from the patient. The patient was put on Lactobacillus, one sachet thrice daily with biotin 10mg once daily. All the other drugs were stopped forthwith. In fifteen days the fever subsided, lesions started involuting and no new lesions appeared (Fig. 3, 4). The patient's general condition also showed improvement. Blood sugar level dropped. She was continued with the same treatment and after six months follow up she is free of lesions and she is being followed up for possible recurrence. Her plaque psori...

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Terra firma-forme dermatosis is a cutaneous discoloration. 'Dirty' brown grey cutaneous patches and plaques that can be rid off by forceful swabbing with alcohol pads characterize it. The pathogenesis has been attributed to abnormal and delayed keratinization. It poses no medical threat. A 40-year-old male patient presented to the Department of Dermatology with a 2-3 month history of persistent pigmented patches on both upper arms. The lesions were not associated with itching or burning sensation. He gives no history of exacerbation on exposure to the sun.

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Introduction Porokeratosis is an assorted group of five genetic disorders. These include porokeratosis of Mibelli, DSAP, punctate porokeratosis, porokeratosis palmaris et plantaris disseminata, and linear porokeratosis [1]. They are disorders of abnormal keratinization characterized by the appearance of atrophic patches. Porokeratosis of Mibelli is referred to the more localized form of this disorder usually manifesting as solitary or a small group of lesions. It was first described by Mibelli in 1893 who described atrophic patches surrounded by a clinically and histologically unique ridge like border termed the cornoid lamella. The cornoid lamella is formed by rapidly proliferating atypical keratinocytes that expands peripherally to form a raised boundary at the junction of abnormal and normal cells. These lesions are most commonly found on the extremities, but can also be found on genitalia, face, oral mucosa and cornea [2]. Though the patches are generally asymptomatic they can often lead to ulcerative, verrucous, giant, and malignant lesions [3]. We describe a case of Porokeratosis of Mibelli at an unusual site in a 22 yr old male. The presenting history, clinical findings, biopsy results and available literature are reviewed. Case Report A 22 year old male patient came with complaints of a white rash over his nose since 6 months. It was confined to the left ala of the nose (Fig. 1). The lesion started as a small papule and gradually spread peripherally. There was central clearing with hypo pigmentation and a raised border. The patient's history was otherwise insignificant. There was no similar history in the family. He was born of a non consanguineous marriage. There was no history suggestive of photosensitivity. His systemic examination was within normal limits. The differential diagnosis of Discoid Lupus Erythematoses, Basal Cell Carcinoma, Lupus Vulgaris and Porokeratosis were considered. Routine blood investigations were normal. HIV 1 and 2 was non reactive. A full depth skin biopsy was taken from the outer part of the lesion with a 2mm disposable skin biopsy punch and subjected to histopathology. The histopathology revealed foci of epidermal invagination filled with keratin and parakeratotic coronoid lamella. Dermis showed a mild to moderate infiltrate of lymphocytes (Fig. 2). On the basis of history, clinical examination and histopathology, a diagnosis of Porokeratosis of Mibelli was made. Topical tretinoin was prescribed for the management of the lesion.