Clinical Use of Super-Bioavailable Itraconazole for the Management of Dermatophytosis: Consensus Statement by Dermatologists from India via the Modified Delphi Technique.

Super-bioavailable itraconazole (SB ITZ) overcomes the limitations of conventional itraconazole (CITZ) such as interindividual variability and reduced bioavailability. It has been approved for systemic mycoses in Australia and Europe as 50 mg and the USA as 65 mg and in India as 50 mg, 65 mg, 100 mg, and 130 mg. However, data on the ideal dose and duration of SB ITZ treatment in managing dermatophytosis are insufficient. This consensus discusses the suitability, dosage, duration of treatment, and relevance of using SB ITZ in managing dermatophytosis in different clinical scenarios. Sixteen dermatologists (>15 years of experience in the field and ≥2 years clinical experience with SB ITZ), formed the expert panel. A modified Delphi technique was employed, and a consensus was reached if the concordance in response was >75%. A total of 26 consensus statements were developed. The preferred dose of SB ITZ is 130 mg once daily and if not tolerated, 65 mg twice daily. The preferred duration for treating naïve dermatophytosis is 4-6 weeks and that for recalcitrant dermatophytosis is 6-8 weeks. Moreover, cure rates for dermatophytosis are a little better with SB ITZ than with CITZ with a similar safety profile as of CITZ. Better patient compliance and efficacy are associated with SB ITZ than with CITZ, even in patients with comorbidities and special needs such as patients with diabetes, extensive lesions, corticosteroid abuse, adolescents, and those on multiple drugs. Expert clinicians reported that the overall clinical experience with SB ITZ was better than that with CITZ.

Platelet rich plasma in treatment of topical steroid damaged face: A retrospective analytical study.

Topical steroid damaged face (TSDF) is an entity caused by unsupervised and prolonged use of topical corticosteroids (TC) on the face. There is currently no definite treatment that can partially or completely reverse the changes seen in the facial skin in TSDF. Platelet rich plasma (PRP) is a biological product that is obtained from autologous centrifuged blood and it contains multiple growth factors for the skin and other body tissues. PRP has been employed as a treatment option in patients with steroid induced rosacea. We hereby report the results from 34 cases of TSDF who had been treated with PRP at our institute. Retrospective analysis of the data and digital photographs of these cases was carried out in October 2021 and the data analysis revealed a significant therapeutic benefit in most of the cases with excellent results in 76% (26/34) cases. Improvement was noticed after the first session only in majority of cases and in all the clinical parameters in the study patients. No adverse effects were reported in any patient in this series.

Sweet syndrome after Oxford-AstraZeneca COVID-19 vaccine (AZD1222) in an elderly female.

Vaccination for COVID19 infection is in full swing all around the world and while the vaccines are considered overall safe, many cutaneous and extracutaneous adverse effects have been reported after their use. Local injection-site reactions are the commonest adverse effect described with the use of these vaccines. We describe a case of Sweet syndrome in an elderly female after the first dose of Oxford-AstraZeneca COVID-19 vaccine (AZD1222).

Is targeted UVB as effective as excimer light phototherapy in treatment of vitiligo?

Excimer light (EL) and targeted UVB (TUVB) devices have been used successfully in repigmenting vitiligo. To compare the repigmenting efficacy and safety of EL with TUVB device in vitiligo. The study was conducted retrospectively on patients of vitiligo who had received either EL (Group A) or TUVB (Group B) from year 2015 to 2020. Data pertaining to 40 such age and sex matched patients from each group was retrieved with almost similar sites of involvement. Only patients whose phototherapy sessions had been given twice weekly for minimum of 30 sessions or until 90%-100% repigmentation were included in the study. The study was retrospective in nature and the principles outlined in the Declaration of Helsinki were followed during the study. The primary endpoint compared between the two groups was the extent of repigmentation achieved on different sites of body and adverse effects from treatment. Secondary endpoints compared included total number of doses, cumulative dose needed for complete repigmentation and number of doses needed for onset of repigmentation. There were 82.6% responders in Group A and 76.3% in Group B who had achieved at least 50% repigmentation. Excellent response (75%-100% repigmentation) was achieved in 68.1% lesions in Group A and 46.4% lesions in Group B. Patients in Group A needed less number of doses (13.75 vs. 19.37) and less cumulative dose (6.14 vs. 7.69 J/cm2 ) to achieve complete or near complete repigmentation. Adverse effects were negligible in both groups. Targeted phototherapy with EL demonstrated better repigmenting efficacy than TUVB in vitiligo.

Excimer light therapy in childhood segmental vitiligo: Early treatment gives better results.

Segmental vitiligo (SV) is considered to be relatively less responsive form of vitiligo to medical treatment. While excimer light (EL) has shown great promise in treating localized vitiligo especially on face and neck, its efficacy in SV is not reported so commonly. We conducted a retrospective study on patients of childhood SV who had received EL therapy from January 2016 to December 2018 at our institute. Data of all such cases who had received at least 10 doses of EL treatment or achieved complete repigmentation were selected for analysis. Records of 26 children with SV satisfied the selection criteria. Excellent response (>75% repigmentation) was documented in 65.4% (17/26) patients with 7.7% (2/26) patients showing partial (50%-75%) repigmentation. Response to treatment was seen to correlate inversely with the duration of SV. Patients with SV of <6 months reported better results with all 10 cases achieving complete or near complete (>75%) repigmentation. In contrast, only 44% patients (7/16) with disease duration of >6 months were seen to have achieved >75% repigmentation.

Apremilast is effective in controlling the progression of adult vitiligo: A case series.

There are limited treatment options available to control the progression of vitiligo and most of these treatment options carry the risk of both short-term as well as long-term adverse effects. Apremilast has emerged as a promising treatment option in psoriasis and many other cutaneous disorders. We report herein the successful use of oral apremilast therapy in controlling the progression of adult onset vitiligo in 13 patients. The patients had not responded to other systemic treatments earlier. In addition to the control of progression, eight patients (61.5%) showed some evidence of repigmentation after apremilast therapy. Gastrointestinal adverse effects and headache were the commonest adverse effects reported that led to cessation of treatment in two cases.

Fractional Carbon Dioxide Laser Resurfacing in Combination With Potent Topical Corticosteroids for Hypertrophic Burn Scars in the Pediatric Age Group: An Open Label Study.

BACKGROUND: Lasers and potent topical corticosteroids are used as therapeutic options in hypertrophic burn scars. OBJECTIVE: To assess the therapeutic effect of fractional CO2 laser resurfacing in combination with potent topical corticosteroids on hypertrophic burn scars in pediatric age group. METHODS: Ten children (5-12 years) with postburn hypertrophic scars were treated with 3 to 5 sessions of fractional CO2 laser resurfacing at 1-month intervals, and triamcinolone suspension was applied immediately after each laser session. Patients were also instructed to apply clobetasol propionate gel for 1 week after each laser session. Response to treatment was assessed using Vancouver Scar Scale (VSS) and Physician Global Assessment (PGA). Tolerability for the procedure and adverse effects were also assessed. RESULTS: Laser sessions were well tolerated under the effect of topical or local anesthesia. At the time of final assessment, there was mean reduction of 4.2 (range: 2.8-7) in VSS. Reduction of VSS by ≥4 points was observed in 8 of 10 cases, whereas PGA revealed excellent response in 6 of 10 cases. No significant adverse effects were reported by any patient. CONCLUSION: Fractional CO2 laser resurfacing in combination with potent topical steroids leads to significant therapeutic benefits in children with postburn hypertrophic scars.

Contact sensitivity in patients with venous leg ulcer: A multi-centric Indian study.

Venous leg ulcers are the most common form of non-healing leg ulcers. They are subjected to treatments such as topical medications, dressings, and compression therapies. This can lead to exposure to a number of allergens with subsequent sensitisation and contact dermatitis of the regional skin. This may contribute to the poor ulcer healing. To detect the various contact sensitisers in patients with venous leg ulcers through patch testing, patients from 6 centres across India with venous leg ulcers of longer than 6 weeks duration were enrolled for the study. They were patch tested using a special parch test kit with 27 antigens. A total of 172 patients were included in the study; 82 (48.2%) tested positive for at least 1 antigen. Among them, polyvalent sensitisation was noted in 71% of patients. Wood tar mix (10.4%) and the framycetin (8.7%) were the most common allergens. There is a high frequency of allergic sensitisation to various ingredients of topical therapies used in the venous ulcer management, which may interfere with wound healing. Avoiding them can help obtain a better therapeutic outcome.

Ultrathin Skin Grafting in Resistant Stable Vitiligo: A Follow-up Study of 8 Years in 370 Patients.

BACKGROUND: Ultrathin skin grafting (UTSG) is a tissue grafting technique used in resistant stable vitiligo. OBJECTIVE: To assess long-term follow-up results achieved with UTSG in vitiligo. METHODS: Over a span of 8 years, a total of 415 patients with stable vitiligo were treated with UTSG at the authors' institute. Retrospective analysis of results achieved in these patients was performed, and primary end points assessed included the extent and quality of repigmentation achieved and adverse effects from the procedure. Results were correlated with the site, morphological type of vitiligo, duration of stability, postprocedure treatment used, and the age and sex of the patient. RESULTS: Follow-up results were available with 554 lesions in 370 patients. Excellent response (≥90% repigmentation) was documented in 78.9% (437/554) lesions whereas 8.67% (48/554) lesions demonstrated poor results. Pigmentation was retained in >98% (112/114) cases over 4-year follow-up. The commonest adverse effect noted was "perigraft halo" in 12.3% (68/554) lesions. Site and morphological type of vitiligo as well as the postoperative use of phototherapy showed statistically significant correlation with response. Age and sex of the patient and duration of stability beyond 1 year did not influence the outcome. CONCLUSION: Ultrathin skin grafting provides long-term beneficial results in stable resistant vitiligo.

Depigmentation with Q-switched Nd:YAG laser in universal vitiligo: a long-term follow-up study of 4 years.

Q-switched (QS) lasers are used for depigmentation in universal vitiligo, but there is limited data on long-term results after laser treatment. This study was conducted to assess the safety and long-term follow-up results of QS Nd:YAG laser treatment in combination with need-based topical depigmentation therapy for universal vitiligo. A retrospective study was performed on patients with universal vitiligo who had received QS Nd:YAG laser treatment from 2010 to 2013. All patients were contacted and called for follow-up. Patients who reported were assessed clinically and information regarding adverse effects and relapse (repigmentation) in the follow-up period were obtained. Any need for topical depigmenting creams or other interventions and overall satisfaction to treatment were also documented. Records of 34 patients were retrieved, out of whom 28 cases reported for the follow-up visit. Duration of follow-up ranged from 2 to 5 years (mean, 2.78). No long-term adverse effects were reported and the majority of patients were highly satisfied with treatment. Satisfactory results with >90% clearance of pigment was reported by 89.3% (25/28) of patients, out of whom 72% (18/25) had retained the therapeutic effect with the use of sunscreens with/without intermittent topical depigmentation therapies. In seven cases, partial to complete relapse was observed. QS Nd:YAG laser is an effective tool for treating residual pigmentation in universal vitiligo, and the therapeutic effect can be maintained in most cases with regular sunscreen use and need-based topical therapies.

The Safety and Effectiveness of Decapeptide in Patients With Vitiligo: A Real-World Study.

Background Vitiligo, a chronic autoimmune depigmenting skin disease, affects a significant portion of the global population. One of the topical treatment options for vitiligo is basic fibroblast growth factor (bFGF)-related decapeptide (bFGFrP) 0.1% solution. This study aimed to assess the real-world effectiveness and safety of decapeptide in treating vitiligo. Methods This retrospective analysis utilized data collected from routine clinical practice in the management of vitiligo, focusing on patients treated with topical decapeptide lotion (Melgain™, manufactured by Zydus Healthcare Ltd., Ahmedabad, India). The primary outcome measures included the extent of re-pigmentation (EOR) and the grade of re-pigmentation (GOR) assessed at each follow-up visit. Results The analysis included data from 65 patients (24 males and 41 females) with an average age of 30.83 years. Segmental vitiligo was present in 52.31% of cases, with the face being the most commonly affected site. Among the patients, 33 received decapeptide as monotherapy, while 32 received decapeptide alongside adjuvant drug/phototherapy. The mean duration of treatment was five months. The first, second, and final follow-ups were observed to be at a mean of 45 days, two months, and five months, respectively. During the second and final follow-up, a significant response (>75% re-pigmentation) was observed in 12% (eight) and 71% (46) of the patients. A mild response (<50% re-pigmentation) was noted in 45% (29) of the patients during the first follow-up visit, 15% (10) during the second follow-up visit, and 6% (four) during the final follow-up visit. Grade 6 and 7 re-pigmentation occurred in a higher number of patients at the final visit, indicating treatment effectiveness. Overall, nearly all patients (96.92%) reported excellent tolerability of the decapeptide lotion based on the global assessment of tolerability. Conclusion This real-world study demonstrates that decapeptide promotes re-pigmentation and improves patient outcomes in vitiligo. Both decapeptide regimens, as monotherapy or in combination with other therapies, were effective and well tolerated by most patients. Thus, decapeptide represents a safe and effective therapeutic option for vitiligo treatment.

Development of Consensus Recommendations on the Management of Vitiligo and the Role of Decapeptide in Vitiligo by the Delphi Method.

Background: Treatment of vitiligo is still a challenge in dermatology. Literature is sparse on the definitive clinical role of basic fibroblast growth factor (bFGF) in vitiligo patients. Aims: We decided to generate a consensus in an attempt to answer some critical questions related to the management of vitiligo and the role of bFGF. Materials and Methods: A Delphi method among 21 experts across India was conducted. A consensus (agreement was 75% or greater) was taken on 27 statements on the prevalence, epidemiology, and treatment of vitiligo and the role of bFGF in the management of vitiligo. The consensus process was completed after two rounds. Results: Topical corticosteroid therapy is the first-line therapy for vitiligo; however, its adverse effects are widely known, especially in sensitive areas. Topical calcineurin inhibitors are preferred in stable vitiligo of the face, neck, genitals, or intertriginous regions as an alternative to topical corticosteroids. Topical bFGF is a relatively newer therapy with a promising role in stable vitiligo. bFGF is safe and effective in inducing repigmentation of vitiligo lesions. Combination therapy of bFGF with other topical therapies, phototherapy, and surgical procedures can be beneficial in patients of vitiligo. Conclusion: This consensus would complement the currently available literature on bFGF and help the practitioner to recognize the unmet need in the treatment of vitiligo.

Androgen receptor coregulator long noncoding RNA CTBP1-AS is associated with polycystic ovary syndrome in Kashmiri women.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is one of the most common reproductive, endocrine, and metabolic disorder in premenopausal women. Even though the pathophysiology of PCOS is complex and obscure, the disorder is prominently considered as the syndrome of hyperandrogenism. C-Terminal binding protein 1 antisense (CTBP1-AS) acts as a novel androgen receptor regulating long noncoding RNA (lncRNA). Therefore, the present study was aimed to establish the possible association of androgen receptor regulating long noncoding RNA CTBP1-AS with PCOS. METHODS: A total of 178 subjects including 105 PCOS cases and 73 age-matched healthy controls were recruited for the study. The anthropometric, hormonal, and biochemical parameters of all subjects were analyzed. Total RNA was isolated from peripheral venous blood and expression analysis was done by quantitative real-time PCR. The correlation analysis was performed to evaluate the association between and various clinical parameters and lncRNA CTBP1-AS expression. RESULTS AND CONCLUSION: The mean expression level of CTBP1-AS was found to be significantly higher in the PCOS women than in the healthy controls (-lnCTBP1-AS, 4.23 ± 1.68 versus 1.24 ± 0.29, P < 0.001). Furthermore, subjects with higher expression level of CTBP1-AS had significantly higher risk of PCOS compared to subjects with low levels of CTBP1-AS expression (actual OR = 11.36, 95% CI = 5.59-23.08, P < 0.001). The area under receiver operator characteristic (ROC) curve was 0.987 (SE 0.006, 95% CI 0.976-0.99). However, lncRNA CTBP1-AS was found to have no association with different clinical characteristics of PCOS. In conclusion, androgen receptor coregulating lncRNA CTBP1-AS is associated with PCOS women and high expression of CTBP1-AS is a risk factor for PCOS in Kashmiri women.

Alopecia areata severity index (AASI): A reliable scoring system to assess the severity of alopecia areata on face and scalp-a pilot study.

BACKGROUND: All scoring systems used in Alopecia Areata (AA) focus mainly on scalp and cannot assess the severity or treatment response when AA involves the beard hair, eyebrows, or eyelashes. AIM: This study describes and assesses the reliability of a new scoring system "Alopecia Areata Severity Index" (AASI) for measuring the severity of AA of scalp, beard, and upper face. METHODS: Scalp hair, beard hair, upper face (eyebrows and eyelashes) were individually assessed and the severity of AA was scored from 0 to 100 (0-50 in case of upper face). AASI score was then calculated as a sum of all these individual scores as AASI = AASI (scalp) + AASI (upper face) + AASI (beard)+. To test the inter-observer reliability of AASI score, 25 patients with varying severity of AA were scored by 4 trained dermatologists. Repeat scoring was performed after one week to test for intra-observer reliability. RESULTS: Excellent inter-rater, as well as intra-observer reliability, was observed with Chronbach's alpha value of 0.999 (CI = 0.989-1.000). The intra-observer correlation coefficient with average measure was 0.999 (CI = 0.990-1.000) with statistically significant F test <0.005. CONCLUSION: AASI score is a reliable scoring system to assess the severity of AA in patients with involvement of one or more areas of the body. LIMITATIONS: Sample population belonged to single ethnic group.

Does topical tacrolimus ointment enhance the efficacy of narrowband ultraviolet B therapy in vitiligo? A left-right comparison study.

BACKGROUND: Narrowband ultraviolet B (NB-UVB) therapy has emerged as one of the most favored treatment options in patients with generalized vitiligo. The aim of combining topical agents is to improve the efficacy of NB-UVB in causing repigmentation in vitiligo. AIMS AND OBJECTIVES: The present study aims to study the effect of combining topical tacrolimus to NB-UVB therapy in causing repigmentation in vitiligo lesions. METHODS: This prospective single-blind study was performed on 80 patients of generalized vitiligo above 12 years of age who had symmetrically distributed vitiligo lesions on the face, trunk or limbs. The patients applied topical tacrolimus 0.1% ointment twice daily on selected symmetrically distributed lesions on the left side of the body. No topical agent was applied on the corresponding lesions on the right side. The patients also received whole-body NB-UVB exposure three times every week on non-consecutive days according to a set protocol. Lesions selected for the comparison analysis were photographed serially and assessed by a single-blinded observer for the extent or repigmentation achieved. The extent of repigmentation achieved was calculated on the basis of VASI scoring. The time taken for the initial repigmentation to start, the overall repigmentation achieved as well as any adverse effects were noted down and compared between the selected lesions on the two sides. RESULTS: Seventy-four patients with 234 symmetrical vitiligo lesions were available for comparison analysis at the end of study period. The mean repigmentation achieved on the left-sided study lesions was approximately 71% (VASI score of approximately 4.0) as compared with 60.5% on the symmetrically distributed right-sided lesions (VASI score of 3.4). Moreover, the repigmentation started earlier on the study lesions on left side than on the right-sided ones. No significant adverse events were reported with the combination treatment. CONCLUSIONS: Addition of topical tacrolimus increases the extent of overall repigmentation achieved with NB-UVB therapy in vitiligo and also reduces the cumulative NB-UVB dose needed to achieve a therapeutic benefit in affected patients.

Unconventional Uses of Laser Hair Removal: A Review.

Laser hair removal since its availability has been primarily used for aesthetic purposes. Over the years, it has emerged as an important therapeutic modality in various dermatological and surgical disorders, both as an adjuvant and as a monotherapy. Depending on the skin type, all laser hair removal systems have been used with good results and minimal complications. We hereby review the diverse range of unconventional indications of laser hair removal.

Methods to overcome poor responses and challenges of laser hair removal in dark skin.

Conventional and advance technologies are available for laser hair removal. Complete and permanent hair reduction is not yet possible by treatment with lasers. Ideal patient for any conventional laser hair removal treatment is one who has thick, dark terminal hair, light skin and normal hormonal status. Factors that contribute to variable outcomes in laser hair removal can be broadly divided into patient related ones and the technology related ones. Skin type, hair color, thickness and density, degree of tan, hormonal dysfunction etc., constitute the patient related factors. The wavelength, fluence, spot size and pulse duration of the laser system are the technology related factors. There are some patients who respond variably, unpredictably or poorly to laser hair removal despite ensuring that indication for treatment is appropriate with adequate parameters of the laser system. This article reviews various patient related and technology related factors which lead to variable-to-poor outcomes in laser hair removal; and various challenges and limitations of laser hair removal technology in patients with dark skin types.

Fractional Carbon Dioxide Laser in Combination with Topical Corticosteroid Application in Resistant Alopecia Areata: A Case Series.

INTRODUCTION: Intradermal steroid injections are used as treatment option in resistant alopecia areata. However, it is difficult and quite painful to treat large areas of alopecia with this modality. OBJECTIVE: To assess the efficacy and safety profile of a combination of fractional carbon dioxide (CO2) treatment followed by topical corticosteroid application in resistant alopecia areata. MATERIALS AND METHODS: Ten cases of resistant alopecia areata who had not responded to multiple treatment modalities were treated with fractional CO2 laser followed by topical application of triamcinolone spray (10mg/mL) on the resistant lesions. Patients received 4-8 sessions that were repeated at an interval of 3-4 weeks. Response to treatment was assessed on a quartile physician assessment scale and labeled as excellent (>75% regrowth), good (50%-75% regrowth), fair (26%-50% response), and poor (<25% regrowth). RESULTS: Eight of these ten cases completed the treatment process. Seven of these eight patients had complete recovery of the area treated. One patient however did not show good response even after four sessions. No significant adverse effects were noted in any of the patients. CONCLUSION: Fractional CO2 laser in combination with topical triamcinolone can prove to be an effective treatment option in resistant alopecia areata.