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a 22 years male developed fever, pain abdomen, vomiting, and painful swelling of both ankle and wrist joints. Two days later, he noticed multiple red raised lesions symmetrically over all extremeries. Nasopharyneal swab for Coronavirus disease 2019 (COVID-19) PCR testing was positive at admission. He had no respiratory symptoms. Examination revealed fever (100.8 F), edema with tenderness over both wrist, hand and ankle joints. Cutaneous examination revealed multiple, discrete to confluent palpable purpura with few central vesicles distributed symmetrically over all extremities, gluteal region, and lower abdomen (Figure 1A-D). He denied history of any drug intake prior to onset of symptoms.The patient was investigated on the lines of IgA vasculitis and systemic involvement of COVID-19. Urinalysis revealed a proteinuria of 2 g/day. Remaining investigations were as in Table 1. Skin biopsy from thigh lesion revealed features of leukocytoclastic vasculitis (Figure 2A,B). Direct immunofluorescence (DIF) from lesion was negative which could be due to biopsy from a lesion >48 h duration or sample processing error. PCR for SARS-CoV-2 from skin sample could not be done due to nonavailability. Because of the proteinuria, a kidney biopsy was done which showed features of focal necrotizing, mesangial, and focal endocapillary proliferative IgA nephropathy with mesangial granular deposits of IgA (Figure 3). Patient was promptly started on injection dexamethasone equivalent to 1 mg/kg of prednisolone for 10 days and shifted to oral prednisolone subsequently. Presence of poor prognostic findings on kidney biopsy with glomerular segmental tuft necrosis and cellular crescent formation prompted us to plan long-term immunosuppressants for at least three months duration. Hence, mycophenolate mofetil as steroid sparing agent was added to be continued for three months and oral prednisolone tapered off in one month. His cutaneous lesions, joint involvement and abdominal symptoms resolved, liver function tests, and urinalysis normalized over 2 weeks. The patient is under follow-up to look for long-term renal complications.

households of patients who experienced relapse, suggesting that they were exposed to the same trigger event.We observed a relatively high frequency of relapses in our chilblain-like cohort. These relapses were contemporary with the second wave of the COVID-19 pandemic in our region. Recent data suggested that recurrent pernio could be linked to exposure to cold temperature. 6 In our area, the mean minimum and maximum temperatures ranged from 12Á7°C and 19Á6°C in October 2020 to 5Á3°C and 14Á6°C in January 2021. We cannot exclude that those relapses were caused by the return of the cold season triggering relapse on a previously altered microcirculation. Recurrent pernio occurs after cold exposure in genetic interferonopathies, supporting a seasonal explanation for the relapses. However, one-third of the patients who had relapses were exposed to possible or proven cases of COVID-19 within the household, and infections in the household were observed in 75% of cases within 2 weeks of the relapse of chilblain-like lesions. Conversely, COVID-19 infection was not reported in any patients or their households in the no-relapse group. Only one patient with relapse had a positive PCR test. Despite proven circulation of the virus in the household, virological confirmation of infection is lacking in most patients.Chilblain-like lesions associated with the COVID-19 pandemic have been suggested as interferon type I-related skin manifestations due to an efficient antiviral response in those patients. 4,7 Efficient antiviral immune response has been proposed to explain the absence of virological confirmation in children exposed to This probably explains the difficulties in proving a causal link based on a positive RT-PCR and/ or serology between chilblain-like lesions and COVID-19.Taken together, our results suggest an eventual high risk of relapses in patients who have had a previous episode of chilblains in the context of COVID-19 infection. Our data suggest that re-exposure to SARS-CoV-2 infection might trigger a relapse in chilblain-like lesions, although we cannot exclude that an initial insult from SARS-CoV-2, followed by subsequent cold exposure, could trigger these relapses in some cases.

Background: Dermatophytosis is a common, superficial fungal infection of the skin. In developing countries like India, casual attitude toward seeking medical attention and lax drug control policies lead to indiscriminate use of irrational over-the-counter (OTC) medications. Studies on OTC topical medication abuse in dermatophytosis are lacking despite its frequent occurrence. Aims: To assess the magnitude of OTC topical medication use in dermatophytosis by studying the demographic variables, source of prescription, and their adverse effects. Materials and Methods: This cross-sectional, observational, questionnaire-based pilot study was carried out in a tertiary care center. One hundred consecutive, mycologically confirmed dermatophytosis patients were questioned about the use of OTC medications and examined for adverse effects of the preparations used. Results were documented in a predesigned pro forma and the data were expressed in terms of means and proportions. Results: The study population consisted of 75 males and 25 females. Tinea cruris was the most common pattern observed. Only 32% of the patients consulted a dermatologist on developing a rash, whereas the majority (68%) used medicines suggested by others. Clobetasol-based preparations were commonly misused, and 63.23% of the study population experienced adverse effects. Furthermore, majority (89%) of the study population were unaware of steroids and their adverse effects. Conclusions: The growing threat of OTC drug abuse in India is evident from this study. Stringent drug control policies and awareness of adverse effects of OTC topical medication abuse are truly the need of the hour to control this menace.

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