Clinical study on antifungal drug resistance among cases of dermatophytosis in patients reporting to multiple tertiary care hospitals.

Background: In a tropical country like India, the warm and humid climate plays an important role in the increased incidence of superficial fungal infections. This is a study to identify the causative fungi of dermatophytosis and their in vitro antifungal susceptibility pattern among patients reporting to multiple tertiary care hospitals. Methods: Skin scrapping, nail clipping, and hair follicles were processed for microscopy, culture, and antifungal susceptibility testing as per standard guidelines. Antifungal susceptibility was performed as per published by Clinical Laboratory Standards Institute for yeasts (M27-A3) and filamentous fungi (M38-A2). Result: The study sample had a predominantly male population with the commonest age group being 21-30 years (39.57%) followed by 31-40 years (31.46%). Tinea corporis (57.30%) was the most common clinical presentation followed by tinea cruris (20.85%) and onychomycosis (14.73%). Microscopy positivity was 43.19%, while culture positivity was 23.97%. Dermatophytes accounted for the majority of isolates. All fungal isolates had high minimum inhibitory concentration (MIC) to fluconazole, suggesting that dermatophytes are possibly resistant to this drug. Conclusion: Trichophyton mentagrophytes is confirmed as the dominant pathogen of dermatophytosis in all three tertiary care hospitals.

Vitamin D Deficiency After Oral Retinoid Therapy for Ichthyosis.

Oral retinoids are being increasingly used to treat ichthyotic disorders in children. We report on two children with ichthyotic disorders who developed unusual manifestations after they were started on oral retinoids. The first case is a 10-year-old girl with nonbullous ichthyosiform erythroderma and the second is a 2-year-old girl with lamellar ichthyosis. The child with ichthyosiform erythroderma developed features of rickets within months of initiation of systemic retinoids. Her baseline examination before initiation of oral retinoids was normal. The second patient with lamellar ichthyosis was found to have low vitamin D levels after 6 months of retinoid therapy, and prompt supplementation reversed the levels in 2 months. These cases are being reported to bring attention to the probable need for initiation of vitamin D supplementation with systemic retinoid therapy in ichthyotic disorders in children.

A comparative study of efficacy of cultured versus non cultured melanocyte transfer in the management of stable vitiligo.

BACKGROUND: Replenishing melanocytes by autologous melanocytes selectively in vitiliginous macules is a novel and promising treatment. With expertise in culturing autologous melanocytes, it has now become possible to treat larger recipient areas with smaller skin samples. To determine the relative efficacy of cultured versus non cultured melanocyte transfer in the management of stable vitiligo. METHODS: The melanocytes were harvested as an autologous melanocyte rich cell suspension from a donor split thickness graft. Cultured or non cultured melanocytes were then transplanted to the recipient area that had been superficially dermabraded. 100 patches of vitiligo in patients reporting to this hospital were randomly allocated into 2 groups to receive either of the interventions. RESULTS: An excellent response was seen in 62.17% cases with the autologous melanocyte rich cell suspension technique and in 52% with the melanocyte culture technique. CONCLUSION: Autologous melanocyte transplantation can be an effective form of surgical treatment in stable but recalcitrant lesions of vitiligo. Large areas of skin can be covered with a smaller donor skin using melanocyte culture technique; however culture method is more time consuming, and a labour intensive process, requiring state of the art equipments with a sterile lab setup.

Trichophyton: Changing Nomenclature and Practical Implications.

Trichophyton interdigitale had been regarded as anthropophilic, mainly causing non-inflammatory tinea unguium and tinea pedis. T. mentagrophytes, thought to be zoophilic, were regarded as responsible for more inflammatory dermatophytosis. Indian terbinafine-resistant strains, identified with ribosomal internal transcribed spacer as 'genotype VIII', have recently been termed Trichophyton indotineae based on clinical and mycological features. Some of these have shown selective azole resistance as well. Phenotypic studies have shown some similarities and some differences between Trichophyton indotineae, T. mentagrophytes, and T. interdigitale, which are optimally distinguished with HMG locus analyses as three main genotypic groups containing the type strains of T. indotineae (CBS 146623), T. interdigitale (CBS 428.63), and T. mentagrophytes (IHEM 4268) and having approximate differences in geographic distribution. Trichophyton interdigitale was prevalently isolated from superficial infections on exposed body sites such as the scalp and face, while also feet and nails. Trichophyton mentagrophytes has a similar predilection but are also often found on the trunk and genitals. Trichophyton indotineae is mostly restricted to the trunk and groin. T. indotineae lesions are generally highly inflammatory, strongly associated with tinea cruris, corporis, and faciei and less commonly with fingernail onychomycosis and tinea pedis. They cause papulosquamous, pustular, pseudo-imbricata (tinea faciei), lichenoid, and pityriasis rosea (tinea corporis of the neck) types of lesions and spread rapidly to multiple sites and cause painful lesions with itching or burning. Lipolytic abilities of T. mentagrophytes and T. interdigitale are very similar and are higher than those of T. indotineae, which is associated with a higher prevalence of T. mentagrophytes on the human scalp, which is relatively rich in lipids. Keratin degradation is significantly larger in T. interdigitale due to location (tinea pedis and tinea unguium). Identification of T. indotineae through culture alone may not be sufficient for effective treatment decision-making; genetic analysis for resistance profiles is needed for optimum treatment selection. In India, steroid-induced suppression of local cellular immunity as well as an altered cutaneous microbiome provided a window of opportunity for the unique, multidrug-resistant species Trichophyton indotineae.

Oral Tranexamic Acid for the Treatment of Melasma: Evidence and Experience-Based Consensus Statement from Indian Experts.

Melasma, a chronic pigmentary skin condition mainly affecting the face, remains a challenge despite the availability of several options for treatment. Many melasma patients are not satisfied with treatment outcomes. Tranexamic acid (TXA), an anti-fibrinolytic drug has shown promising results in patients with melasma. Evidence from several clinical studies has surfaced on efficacy and tolerability of TXA in these patients. It can be used as monotherapy or adjuvant with other therapies. Currently, there is no published consensus or guideline document for its use in the treatment of melasma. TXA is available for oral use, topical use as well as an injection. In this article, a consensus of Indian experts is prepared based on the available literature and experience with use of oral TXA in melasma. This review article might help clinicians for use of oral TXA appropriately while treating melasma.

Proposal for a Severity Score (DeASI, Dermatophytosis Area and Severity Index) for the Evaluation of Dermatophyte Infections - A Delphi Consensus Study.

Background: There has been a significant increase in the incidence of recurrent, resistant, and extensive dermatophyte infections worldwide recently. This menace has spurred the need for more well-designed randomized controlled trials to optimize the treatment of dermatophyte skin infections. One of the limitations in designing such studies is the limited availability of standard and validated score, to measure the severity of dermatophyte infections. Aims: To create a severity score for the evaluation of dermatophyte infections. Materials and Methods: A Delphi consensus model was used to frame a severity scoring tool for superficial dermatophyte skin infections. Fourteen experts participated in the first round and twelve experts participated in the second round. Results: Based on the expert consensus, a final scoring system proposed was: Final Severity Score (FSS) = Sum total of Body Surface Area (BSA) in hand units for each patch multiplied by the sum of the scores for pruritis (P), lichenification (L), and actively raised borders (A) for each patch (FSS = BSA in hand units × (P + E + L + A) of patch 1 + BSA in hand units × (P + E + A) of patch 2 …etc.). For measuring hand units more accurately fractional values of 0.25 can be used (0.25 corresponding to an approximate 1/4th of a hand unit). A score of +1 will be added in case of the following - 1) Close contact/family member affected, 2) History of at least one recurrence in the previous 6 months after a course of oral antifungals, 3) History of immunosuppression (on immunosuppressive medication or having underlying immunosuppressive disease). The scores will be valid only if the patient has not used any treatment topical or systemic, for at least 2 weeks before enrolment. Conclusion: The proposed Dermatophytosis Area and Severity Index (DeASI) score will help the physicians and researchers standardize the treatment protocol for dermatophytosis, henceforth, assessing the response to therapy. This will also help to standardize the parameters of effectiveness while designing any clinical trial.

Unusual sites with variable presentation of de novo syringocystadenoma papilliferum: A case series.

Syringocystadenoma papilliferum (SCAP) is an uncommon, benign adnexal neoplasm that occurs de novo or in an organoid nevus. It usually presents as a skin-coloured to pink, solitary, smooth, hairless plaque, verruca or nodule frequently on the scalp and forehead. SCAP may be present at unusual sites including the arm, forearm, trunk and chest. Diagnosing SCAP arising on uncommon sites is difficult owing to its varied presentation. Mostly, they are wrongly diagnosed clinically and found to be SCAP only on histopathology. We present this study of cases of SCAP with unusual location and varied presentations, which were clinically misdiagnosed. The five cases included in this study were patients attending the dermatology outpatient department in a tertiary care centre in North India. The clinical presentation and the involved sites were noted by the dermatologist, and a clinical diagnosis was made. Biopsy of the lesions was sent for histopathological examination. There are five patients in the series - four are male and one female, with age ranging from 28 to 48 years. Locations included the forearm, arm, anterior chest wall and lateral abdominal wall. The lesions clinically appeared as warty papule or nodules and one lesion appeared within a plaque, with the average duration being 5.3 years. In all five patients, the lesions were clinically suspected to be either tuberculosis verruca cutis or nodular basal cell carcinoma or dermatofibroma sarcoma protuberans (DFSP) or verruca or fibroma or pyogenic granuloma. A confirmatory diagnosis of SCAP was made for all the patients on histopathology. We are presenting five cases which were misdiagnosed clinically due to the unusual location and varied presentation to emphasise the importance of histopathology in diagnosing SCAP arising de novo, which was clinically misdiagnosed. Also, we present this case series to alert the clinicians about the likelihood of SCAP on unusual locations with varied clinical presentation.

A Joint Consensus of Rheumatologists and Dermatologists on Early Detection and Effective Management of Psoriatic Arthritis: India's Perspective.

Psoriatic arthritis (PsA) is a chronic inflammatory disease with clinical manifestations, including inflammatory arthritis and the presence of psoriasis (PsO). The present consensus statement evaluated the early diagnosis and treatment approaches in the management of psoriasis and psoriatic arthritis by rheumatologists and dermatologists. For PAN India representation, a panel of eight rheumatologists and five dermatologists from different institutes in India were constituted. These thirteen experts were divided into two groups (rheumatologists group and dermatologist group) who received a set of questionnaires each for diagnosis and treatment approaches in the management of psoriasis and psoriatic arthritis. Based on the responses received, a panel discussion took place, where the experts identified the early diagnostic criteria for PsA considering: Clinical signs and symptoms, and questionnaire-based PsA screening, which includes Psoriasis Epidemiology Screening Tool (PEST) for dermatologists and Classification Criteria for Psoriatic Arthritis (CASPAR) for rheumatologists. The experts also recommended shift from conventional disease-modifying anti-rheumatic drugs (DMARDs) to biologics like secukinumab, when there is extensive skin involvement and TNF inhibitors when there is extensive joint involvement. Overall, the objective of the consensus was to assist rheumatologists and dermatologists in the early diagnosis and management of patients of PsA and PsO in their clinical practice.

International Dermoscopy Society criteria for non-neoplastic dermatoses (general dermatology): validation for skin of color through a Delphi expert consensus.

BACKGROUND: The International Dermoscopy Society (IDS) recently released a set of five basic dermoscopic parameters (vessels, scales, follicular findings, "other structures," and specific clues) encompassing a total of 31 subitems to standardize the use of dermoscopy in non-neoplastic dermatoses, yet they have been developed taking into account Caucasian/Asian skin, with consequent possible limitations if used in dark skin. OBJECTIVES: To validate the abovementioned criteria for the use in dark-skinned patients (phototypes IV-VI) through an expert consensus. METHODS: The two-round Delphi method was adopted, with an iterative process consisting of two rounds of email questionnaires. Potential panelists were recruited via e-mail from all over the world based on their expertise on dermoscopy of non-neoplastic dermatoses in skin of color. RESULTS: Twenty-two panelists took part in the validation process. All of the five originally proposed parameters and subitems reached agreement during the first round, aside from "follicular red dots." Additionally, during round 1, five new subitems were proposed (perifollicular scales distribution, follicular openings obliteration, broken hairs, eccrine pigmentation, and eccrine ostia obliteration), along with the possibility to change the denomination of parameter 3 (from "follicular findings" to "follicular/eccrine findings") and split it into two subparameters ("follicular findings" and "eccrine findings"). All such proposals reached agreement during the second round and therefore were included in the final list, for a total of 37 items. CONCLUSIONS: Although nearly all the dermoscopic criteria originally proposed by the IDS are applicable even to darker phototypes, several additional variables need to be assessed.

Dermatoscopy of Infections and Infestations.

Dermoscopy is a non-invasive tool for the diagnosis of skin diseases. Entomodermoscopy is a branch of dermoscopy that deals with infections and infestations. The use of dermoscopy for diagnosis of infections and infestations is rapidly increasing as it can provide useful clues related to diagnosis and effectiveness of treatment. It serves as a useful adjunct to microbiological and histopathological examination. In some cases, like scabies dermoscopy can even clinch the diagnosis.

Management of Vitiligo Amidst the COVID-19 Pandemic: A Survey and Resulting Consensus.

BACKGROUND: COVID-19 pandemic has changed the approach of dermatologists, with respect to management of numerous conditions, vitiligo being one of them. However, there is a lack of consensus on how to deal with patients of vitiligo, as we battle this pandemic. AIM: To conduct a questionnaire-based survey, amongst expert dermatologists; in order to understand the impact of COVID-19 on the management of vitiligo. MATERIALS AND METHODS: An online semi-structured English questionnaire was prepared and the link was circulated among 50 pan-Indian expert dermatologists, through various platforms (snowball sampling). Confidentiality and anonymity were strictly maintained. Responses were analyzed at the end of the study and a consensus statement was generated. RESULTS: 42.22% of the respondents believed that teleconsultation is adequate for the diagnosis and management of most cases of vitiligo. 64.44% were found to be comfortable in prescribing oral medications, even during the COVID-19 pandemic; of which 62% would prefer to prescribe systemic steroids; followed by 17%, 11%, 7%, and 3% who would prefer cyclosporine, azathioprine, mycophenolate mofetil, and methotrexate, respectively. 64.44% respondents would recommend phototherapy in their office and 80% would prefer home-based phototherapy (PUVAsol or handheld NBUVB devices). 86.67% would prefer to stop the oral immunosuppressive drugs, till the COVID-19 RTPCR positive patients are tested negative. LIMITATIONS: The results are based on a survey of a small albeit selected group of dermatologists who decided on the currently available information on COVID-19. The same may change depending on the nature of further available information on the virus and its effect on how we manage the patients. CONCLUSIONS: Cases for initial consultation may be seen physically, and those for follow-up may be scheduled for teleconsultation. Topical therapy may be used without any hesitation. Phototherapy may be best advised with either PUVAsol or home-based phototherapy units (handheld NBUVB devices). With regards to systemic immunosuppressives, oral minipulse therapy may be preferable in view of lesser requirement of monitoring. Surgery for vitiligo should be performed only if the psychological well-being is severely affected.

A randomized controlled pilot study of a proprietary combination versus sunscreen in melasma maintenance.

BACKGROUND: Melasma is the commonest cause of facial hypermelanosis in skin type IV-VI. First-line treatment includes a triple combination containing topical corticosteroid and hydroquinone which have side effects on prolonged use. Chemical peels are a second-line management option with the laser being used in refractory cases, but the worsening of hyperpigmentation in darker skin types can occur following laser therapy. Sunscreen is a must to prevent relapses. AIMS AND OBJECTIVES: (i) To compare the effects of treatment with a proprietary combination (phenyl ethyl resorcinol, nonapeptide-1, aminoethyl phosphinic acid, antioxidants and sunscreen) versus sunscreen alone in limiting or reducing, melasma and preventing recurrence as a maintenance regimen after the initial use of triple combination,(ii) to evaluate the safety of the formulation studied, and (iii) to study the improvement of the quality of life of the patients after using the study formulation versus placebo. METHODS: It was a prospective double-blinded parallel-group randomized controlled pilot study. A total of 46 subjects were recruited by consecutive sampling methods and randomized to 23 each in case and control groups. The study period was eight months with three phases. Phase 1 constituted the application of triple combination for eight weeks by both groups followed by phase 2 with the case group applying proprietary medicine and the control group applying sunscreen. Phase 3 was a follow-up period to see the sustenance of results in both groups as well as any evidence of relapses. Sunscreen was applied in all three phases. RESULTS: Case group in the study showed improvement in the melasma severity score and mean melanin index as measured by mexameter but it did not attain statistical significance as compared to the control group. The melasma area and severity index score showed a consistent reduction in the case group, whereas it increased in the control group from baseline. LIMITATIONS: Small sample size and a short follow-up period of our study were major limitations. CONCLUSION: The proprietary combination, which has sunscreen as one of its constituents, is more effective in maintaining remission after triple combination without any added inconvenience of application of two separate preparations as compared to sunscreen alone.

Clinical Dermatology and COVID-19 Pandemic: Narrative Review.

The coronavirus disease of 2019 (COVID-19) pandemic has radical repercussions on every aspect of medical science, including dermatology. The magnitude of the impact on clinical dermatology cannot be overemphasized. Dermatologists have been forced to modify and reconsider the way they consult patients. Teledermatology has come up in a big way, with most of the clinicians resorting to technology and software-based consultations. Management of different dermatological conditions like papulosquamous disorders, vesiculobullous disorders, malignancies, etc., needs to be modified as per the different recommendations proposed by expert panels. This review is an attempt to highlight the impact of this destructive pandemic on various aspects of clinical dermatology.

Systemic Management of Psoriasis Patients in Indian Scenario: An Expert Consensus.

BACKGROUND: Psoriasis is a common inflammatory disease with significant comorbidities, and regardless of its extent, it affects the patients' quality of life. The various modalities of treating psoriasis comprise topical or systemic medications, phototherapy, and an array of biologic agents. There is a lack of Indian recommendations on the management of psoriasis with these different modalities and challenges faced by the clinicians in day-to-day practice. AIM: To develop India-specific consensus for systemic management of patients with moderate-to-severe psoriasis. METHOD AND RESULTS: A panel of dermatology experts, based on the evidence and international recommendations, coupled with their own clinical experience, developed recommendations for systemic management of patients with moderate-to-severe psoriasis. CONCLUSION: These recommendations are meant to provide guidance in terms of choice of systemic therapies, dosing, effectiveness, and safety. It also addresses clinical challenges that may be experienced during psoriasis management.

A Comparative Study of Elongation of Earlobe Following Two Different Modalities for Repair of Posttraumatic Split of Earlobe: Simple Side-to-Side Closure and Closure with Anterior Posterior Flap Modification.

Context: Ear piercing is a common practice in women seen in the Asian and African subcontinents. Traumatic elongation of ear lobe cleft is seen following long-standing use of heavy jewellery on the ear, or a tug on the earring. These inadvertent tears of the lobe have resulted in patients seeking earlobe repairs, which are routinely performed as an outpatient procedure. Various surgical methods exist for earlobe repair from the simple closure to modified flaps and Z-plasty. Certain methods with excessive tissue loss can result in elongation of the earlobe postprocedure. Aims and Objectives: This study aimed to compare the elongation of earlobe post repair with simple side-to-side closure versus closure with anterior-posterior flap modification. Settings and Design: A cohort study conducted at the outpatient department in a tertiary care hospital of Mumbai. Materials and Methods: A total of 30 women with bilateral, equal, or almost equal earlobe clefts were enrolled in this study. After informed consent, simple side-to-side closure was performed on one earlobe and closure with anterior-posterior flap modification was carried out on the other side in the same patient under strict aseptic precautions. Patients were followed up two weekly till 12 weeks postoperative for any possible elongation of earlobe. Statistical Analysis Used: The data were analyzed using Statistical Package for the Social Sciences (SPSS, IBM, New York, USA) software package for windows, version 20.0. Quantitative and qualitative variables were presented as mean ±standard deviation (SD) and as frequency with percentages. The comparison was done with paired t-test. Results: It was seen that earlobe repairs led to significant elongation of the lobe with simple closure, which did not occur with flap modification irrespective of cleft sizes. Conclusion: It is imperative to choose a correct method to avoid postprocedure elongation of earlobe.

Dermoscopy in general dermatology (non-neoplastic dermatoses) of skin of colour: a comparative retrospective study by the International Dermoscopy Society.

BACKGROUND: Dermoscopy has been shown to be a useful supportive tool to assist the diagnosis of several non-neoplastic dermatoses (i.e. inflammatory, infiltrative and infectious skin diseases), yet data on skin of colour is still limited. OBJECTIVES: To characterize dermoscopic features of non-neoplastic dermatoses in dark-skinned patients in order to identify possible clues that may facilitate the differential diagnosis of clinically similar conditions. MATERIALS & METHODS: Members of the International Dermoscopy Society were invited to submit cases of any non-neoplastic dermatosis developing in patients with Fitzpatrick Phototypes V-VI whose diagnosis had been confirmed by the corresponding gold standard diagnostic test. A standardized assessment of the dermoscopic images and a comparative analysis according to clinical presentation were performed. Seven clinical categories were identified: (I) papulosquamous dermatoses; (II) facial hyperpigmented dermatoses; (III) extra-facial hyperpigmented dermatoses; (IV) hypopigmented dermatoses; (V) granulomatous dermatoses; (VI) sclerotic dermatoses; and (VII) facial inflammatory dermatoses. RESULTS: A total of 653 patients (541 and 112 with Phototype V and VI, respectively) were recruited for the analysis. Thirty-six statistically significant dermoscopic features were identified for papulosquamous dermatoses, 24 for facial hyperpigmented disorders, 12 for extra-facial hyperpigmented disorders, 17 for hypopigmented disorders, eight for granulomatous dermatoses, four for sclerotic dermatoses and 17 for facial inflammatory diseases. CONCLUSION: Our findings suggest that dermoscopy might be a useful tool in assisting the diagnosis of clinically similar non-neoplastic dermatoses in dark phototypes by revealing characteristic clues. Study limitations include the retrospective design, the lack of a direct dermoscopic-histological correlation analysis and the small sample size for less common diseases.

Dermoscopy of Pigmentary Disorders in Brown Skin.

Dermoscopy is a noninvasive technique for the diagnosis, prognosis, and monitoring of pigmentary disorders in brown skin. It can be used for the diagnosis of various facial melanoses, which can avoid the need for biopsy in many cases. It can also help in early identification of the adverse effect of topical steroids and hydroquinone when they are used for the treatment of these disorders. Dermoscopy can also reliably differentiate vitiligo from other disorders of hypopigmentation. It can also help in assessing the stability of vitiligo before surgery.