Case study A man, 18 years of age, presented with a 6-month history of a widespread itchy rash, more intense at night, which had appeared 1 month after returning from a holiday to the Dominican Republic. The rash initially appeared as white patches affecting the fingers. The patient reported unprotected heterosexual intercourse while on holiday. There was no previous or family history of atopic dermatitis, however, the patient's sister had recently begun to experience similar symptoms. Clinical examination revealed scattered excoriated papules over the trunk (Figure 1), limbs and hands (Figure 2). Intensely itchy nodules were observed on the scrotum (Figure 3). A prolonged course of oral antihistamine in addition to topical corticosteroids did not improve the symptoms. 

A 51-year-old man presented with a 12-year history of an expanding, irritable rash on his buttocks, groin and scrotum. He gradually developed erythematous, annular plaques with ridged borders and depressed centres. He also had a verruciform eruption in his perianal area. A clinical diagnosis of porokeratosis confined to the genitogluteal area was confirmed histopathologically. Oral acitretin resulted in symptomatic and cosmetic improvement. He continues to be followed up to evaluate treatment outcomes.

Reiter disease (RD) is characterized by a triad of sterile arthritis, urethritis and conjunctivitis. The conditions occur concomitantly or sequentially, and are associated with mucocutaneous features such as circinate balanitis and stomatitis. Arthritis usually occurs in attacks followed by recovery, but it sometimes progresses to permanent damage of the affected joints. Because the symptoms of this disorder are attributable to activated neutrophils, we assessed the efficacy of granulocyte and monocyte adsorption apheresis (GCAP) in a 73-year-old man with RD who had skin rashes on his penis, scrotum and right hand, with severe arthralgia. The patient's skin rash and joint pain responded dramatically to five sessions of GCAP delivered at intervals of 5 days. We present a detailed description of the patient and discuss the mechanisms of GCAP, and suggest that GCAP may be useful for treating RD.

Edema is a well-known feature of juvenile dermatomyositis (JDM). However, to our knowledge localized penile and scrotum swelling was not previously reported. During a 27-year period, 5,506 patients were followed up at the Pediatric Rheumatology Unit of our University Hospital and 157 patients (2.9%) had JDM. One of them (0.6%) had concomitant localized penile and scrotum swelling. He had severe disease activity since he was 7-year-old, manifested by diffuse cutaneous vasculitis, recurrent localized edema (limbs or face) and only one episode of generalized edema. At the age of 10, he presented edema of the genitalia associated with mild skin erythema. Penis, scrotum and testicular ultrasound as well as magnetic resonance imaging showed skin edema without testicular involvement. He was taking prednisone, methotrexate, cyclosporin, hydroxychloroquine and thalidomide. Improvement of skin rash, penile and scrotum swelling was noticed only with rituximab therapy. No adverse event was observed during anti-CD20 infusions and after six months of follow up. Penile and scrotum edema was a rare manifestation of JDM which improved with anti-CD20 monoclonal antibody treatment.

Rickesttsial diseases are a group of diseases caused by obligate intracellular gram negative bacilli and transmitted to man by arthropod vectors (except Q fever). It is increasingly realised that rickesttsial diseases are underdiagnosed. It is now well documented that rickettsial disease is prevalent all over India, in pockets. The hallmark of rickettsial infection is microvasculitis, causing microinfarcts in various organs. Usually the patients present with classical triad of Fever, Headache & Rash. Apart from this, pain in legs, oedema, Gastro-intestinal symptoms, hepato-splenomegaly, anaemia, necrotic rash, gangrene of digits, toes, earlobes, scrotum, painless eschar and lymphadenopathy are other manifestations. Complications include encephalitis, ARDS, pneumonia, Myocarditis, Renal failure and Vascular collapse. Endocarditis is seen in Q fever. Gold standard test for confirmation of diagnosis is I.F.A. Weil felix test is widely available but unacceptable for accurate diagnosis. Weil Felix test can be used in developing countries where other tests are not available. ELISA Should be preferred and is now available in India. The drug of choice for all age group is doxycycline. Rickettsia are potentially dangerous pathogens and unfortunately, specific serological tests are available in only a few specialized laboratories. Hence, it is imperative to have a high index of suspicion for Rickettsial diseases and make a clinical diagnosis based on prudent history taking and appropriate physical findings. A therapeutic trial with a specific agent in these patients is justified because a delay in initiating treatment may prove fatal. A rapid and favorable response is suggestive of a correct diagnosis.

Scrotal pain and swelling are common presentations in children and are usually secondary to torsion of the testis, hydatid of Morgagni or epididymo-orchitis. Fournier's gangrene is a rare, but life-threatening disease, that can present in a similar fashion. We present a rare case of Fournier's gangrene in a 5-year-old boy associated with a preceding varicella rash.

An epidemic of chikungunya disease occurred in India during late 2005 through 2006 affecting nearly 1,400,000 people.To study the cutaneous manifestations in suspected cases of chikungunya disease.Patients who attended our outpatient departments from January 2006 to September 2006 were prospectively included if they had symptoms of chikungunya disease according to the 'case definition' of the National Institute of Communicable Diseases, Directorate General of Health Services, Government of India. The criteria were an acute illness characterized by the sudden onset of fever and several symptoms such as joint pain, headache, backache, photophobia, and eruption during an epidemic of chikungunya fever in the absence of confirmatory serological tests.A total of 115 patients (65 men and 50 women) who satisfied the above criteria were enrolled for the study.An erythematous maculopapular rash subsiding without any sequelae in 3-4 days was the most common cutaneous finding in our patients. Genital ulcers distributed predominantly over the scrotum and base of the penile shaft in men and labia majora in women were the second most common manifestation. Other manifestations included tenderness/edema of hands and feet, grouped hyperpigmented macules over the nose and cheeks, fixed drug eruptions, erythema nodosum, erythema multiformae, generalized urticarial eruptions, and flare up of pre-existing psoriasis and lichen planus.To conclude, a plethora of cutaneous manifestations were noted in suspected cases of chikungunya disease. Genital ulcers, to the best of our knowledge, have not been reported during the earlier epidemics but have been reported by others during the present one.

Acute erythema and oedema of the genitalia is an alarming complaint for any patient. Diagnosis can be complicated by atypical presentation and the use of concurrent immuno-modulatory drugs.We present a case report of a man on anti-TNF therapy for rheumatoid arthritis presenting with an acutely red, swollen, non-tender penis and scrotum presumed to be infective. The discovery of erythematous plaques in both antecubital fossae alerted the clinicians to consider alternative dermatological diagnoses.The accepted adjuncts to confirming or excluding infectious aetiology were complicated by the use of immuno-modulatory medication in this case. This patient's unusual presentation may have been associated with and was complicated by the use of etanercept. The case illustrates the need to consider other diagnoses and obtain appropriate advice when the clinical course is not progressing as anticipated.

An 82-year-old man presented with an itching rash on his scrotum that he had had for several years. Histopathological examination revealed a normal epidermis with multiple atypical cells, organised both solitary and group-wise within the epidermis. The diagnosis of extra-mammary Paget's disease (EMPD) was made. Further investigation showed no signs of underlying malignancy. The man was operated upon and the lesion was completely removed. EMPD is an intra-epidermal adenocarcinoma, found in areas with apocrine sweat glands. Primary EMPD (75%) probably arises from pluripotent stem cells in the epidermis. Over time it can invade the dermis and deeper tissues and metastasize. In secondary EMPD (25%) there is epidermal invasion of malignant cells of skin adnexal adenocarcinomas, or there is an association with adenocarcinomas of nearby internal organs. Immunohistochemical investigation may help to discriminate between primary and secondary EMPD. Average mortality is 26%. Treatment depends on the presence of an underlying malignancy, but surgery is the preferred option. The risk of relapse varies from 8 to 61%, which makes a long-term follow-up necessary.