Microvascular changes on nailfold capillaroscopy in acute stage of Kawasaki disease: a new diagnostic paradigm for an enigmatic condition.

OBJECTIVES: Kawasaki disease (KD) is a medium vessel vasculitis with a predilection to involve coronary arteries. However, there is a paucity of literature on microvascular changes in patients with KD. METHODS: Children diagnosed with KD based on American Heart Association guidelines 2017 were enrolled prospectively. Demographic details and echocardiographic changes in coronaries were recorded. Nailfold capillaries were assessed using Optilia Video capillaroscopy and data were analysed using Optilia Optiflix Capillaroscopy software at acute (prior to IVIG administration) and subacute/convalescent phase. RESULTS: We enrolled 32 children with KD (17 boys) with a median age of 3 years. Nailfold capillaroscopy (NFC) was performed in 32 patients in the acute phase (compared with 32 controls) and in 17 during the subacute/convalescent phase at a median follow-up of 15 (15-90) days after IVIG treatment. The following findings were seen in NFC in the acute phase of KD: reduced capillary density (n = 12, 38.6%), dilated capillaries (n = 3, 9.3%), ramifications (n = 3, 9.3%) and capillary haemorrhages (n = 2, 6.2%). Capillary density was reduced significantly in the acute phase of KD (38.6%) as compared with the subacute/convalescent phase (25.4%) (P-value <0.001) and controls (0%) (P-value = 0.03). We observed no correlation between coronary artery involvement and mean capillary density (P = 0.870). CONCLUSION: Results show that patients with KD have significant nailfold capillary changes in the acute phase. These findings may provide a new diagnostic paradigm for KD and a window to predict coronary artery abnormalities.

Midfacial Toddler Excoriation syndrome (MiTES): case series, diagnostic criteria and evidence for a pathogenic mechanism.

BACKGROUND: PRDM12 polyalanine tract expansions cause two different disorders; Midfacial Toddler Excoriation Syndrome (MiTES) - itch with normal pain sensation associated with homozygous 18 alanines (18A), and congenital insensitivity to pain (CIP) with normal itch with homozygous 19A. Knowledge of the phenotype, genotype, and disease mechanism of MiTES is incomplete. Why PRDM12 18A versus 19A can cause almost opposite phenotypes is unknown; no other poly-alanine or poly-glutamine tract expansion disease causes two such disparate phenotypes. METHODS: We assessed the genotype and phenotype of 9 new, 9 atypical, and 6 previously reported patients diagnosed with MiTES. Using cell lines with homozygous PRDM12 of 12A (normal), 18A (MiTES) and 19A (CIP) we examined PRDM12 aggregation and subcellular localisation by image separation confocal microscopy and sub-cellular fractionation western blotting. RESULTS: MiTES presents in the first year of life, and in all cases the condition regresses over the first decade leaving scarring. The MiTES phenotype is highly distinctive. Features overlapping with PRDM12-CIP are rarely found. The genotype-phenotype study of PRDM12 polyalanine tract shows that 7A -15A are normal; 16A -18A are associated with MiTES; 19A leads to CIP; and no clinically atypical MiTES cases had an expansion. PRDM12 aggregation and sub-cellular localisation differ significantly between 18A and normal 12A cell lines and between 18A and 19A cell lines. MiTES is a new protein aggregation disease. CONCLUSION: We provide diagnostic criteria for MiTES, and improved longitudinal data. MiTES and CIP are distinct phenotypes despite their genotypes varying by a single alanine in the PRDM12 polyalanine tract. We found clear distinctions between the cellular phenotypes of normal, MiTES and CIP cells.. We hypothesise that the developmental environment of the trigeminal ganglion is unique and critically sensitive to prenatal and postnatal levels of PRDM12.

Whole-body and targeted narrowband ultraviolet B phototherapy effectively stabilize acral vitiligo with negligible repigmentation beyond wrists and ankles: Results from a split-body randomized controlled trial.

BACKGROUND: Narrowband ultraviolet B (NB-UVB) phototherapy promotes stability and repigmentation in vitiligo. No studies have compared targeted NB-UVB with whole-body NB-UVB in treatment of acral vitiligo. OBJECTIVES: This randomized split-body study compared whole-body NB-UVB with targeted NB-UVB in inducing stability and repigmentation in acral vitiligo. METHODS: Thirty-two patients with bilaterally symmetrical acral vitiligo lesions (distal to elbows and knees) were recruited. Patients received whole-body NB-UVB treatment, with one hand and one foot shielded until elbow and knee, followed by targeted NB-UVB treatment on the shielded side. Patients were assessed at 4-week intervals for 24 weeks using Vitiligo Disease Activity (VIDA) score, Vitiligo Skin Activity Score (VSAS), Vitiligo Area Scoring Index (determined through fingertip method, using the method to calculate facial-VASI) and degree of repigmentation. RESULTS: After 12 weeks, 87.5% of patients achieved a VIDA score of 3, with none having active disease at 24 weeks. Over 50% repigmentation was observed in 42.2% and 37.5% of limbs in whole-body and targeted groups, respectively (p = .95). No improvement in F-VASI scores of hands and feet (distal to wrist and ankles) was noted with either modality over the 24-week period. CONCLUSION: Our study showed comparable repigmentation rates between whole-body and targeted NB-UVB groups. Limited effectiveness of phototherapy in repigmentation of hands and feet underscores an important therapeutic gap.

Clinical, immunological and molecular profiles of DOCK8 deficiency in six patients from a tertiary care centre in North India.

BACKGROUND: Dedicator of cytokinesis protein 8 (DOCK8) deficiency is an autosomal recessive form of combined immunodeficiency. This rare disorder is characterized by an increased predisposition to allergy, autoimmunity and malignancies. OBJECTIVES: To analyse clinical, immunological and molecular profiles of patients with DOCK8 deficiency. METHODS: Clinic records of all patients attending the primary immunodeficiency clinic from 2018 to 2021 were reviewed. Six patients from five families were found to have DOCK8 deficiency. RESULTS: Median age at diagnosis was 7.5 years (range 2-13), with a male/female ratio of 5 : 1. Among the six patients, recurrent eczematous skin lesions were the predominant cutaneous manifestation, present in five patients (83%). Warts and molluscum contagiosum were evident in two patients (33%) and one patient (16%), respectively. Two patients had recalcitrant prurigo nodularis lesions and two had epidermodysplasia verruciformis-like lesions. Food allergies and asthma were reported by one patient each. Of the six patients, recurrent sinopulmonary infections were detected in five (83%). Epstein-Barr virus-driven non-Hodgkin lymphoma with liver metastases was the only case of malignancy, in a 4-year-old boy. IgE was elevated in all patients. Lymphopenia and eosinophilia were observed in three patients (50%) and five patients (83.3%), respectively. Genetic analysis showed DOCK8 pathogenic variants in all patients: homozygous deletion mutations in two patients, compound heterozygous deletion mutations in one, and homozygous nonsense mutations in two. A novel pathogenic homozygous missense variant in the DOCK8 gene was identified in one patient. CONCLUSIONS: DOCK8 deficiency should be considered as a possibility in any patient with early onset eczema, cutaneous viral infections and increased predisposition to allergy, autoimmunity and malignancy.

Delay in diagnosis is the most important proximate reason for mortality in hereditary angio-oedema: our experience at Chandigarh, India.

BACKGROUND: Hereditary angio-oedema (HAE) is a rare autosomal dominant disorder characterized clinically by recurrent episodes of nonpruritic subcutaneous and/or submucosal oedema. Laryngeal oedema is the commonest cause of mortality in patients with HAE. Prior to the availability of first-line treatment options for the management of HAE, mortality was as high as 30%. Mortality has significantly declined in countries where first-line treatment options are available and patients can access these therapies. There is a paucity of literature on the outcomes of patients with HAE in developing countries where availability of and access to first-line treatment options are still a challenge. OBJECTIVES: To report our experience on mortality in patients with HAE and to report factors associated with the death of these patients. METHODS: We carried out a record review of all patients diagnosed with HAE between January 1996 and August 2022. Families with HAE who had reported the death of at least one family member/relative from laryngeal oedema were studied in detail. RESULTS: Of the 65 families (170 patients) registered in the clinic, 16 families reported the death of at least one family member/relative from laryngeal oedema (total of 36 deaths). Of these 16 families, 14 reported that 1 or more family members had experienced at least 1 attack of laryngeal oedema. One patient died during follow-up when she was taking long-term prophylaxis with stanozolol and tranexamic acid, while the remaining 35 patients were not diagnosed with HAE at the time of their death. At the time of death of all 36 patients, at least 1 other family member had symptoms suggestive of HAE, but the diagnosis was not established for the family. CONCLUSIONS: To our knowledge, this is the largest single-centre cohort of patients with HAE in India reporting mortality data and factors associated with death in these families. The delay in diagnosis is the most important reason for mortality.

Efficacy of generic forms of itraconazole capsule in treating subjects with chronic pulmonary aspergillosis.

BACKGROUND: Itraconazole capsules have variable and unpredictable bioavailability. OBJECTIVE: Whether the generic brands are as effective as the innovator itraconazole in treating subjects with chronic pulmonary aspergillosis (CPA) remains unclear. METHODS: In this retrospective study, we treated CPA subjects with 6-month itraconazole capsule and measured itraconazole levels at 2 weeks, 3 months and 6 months. Our primary outcome was to compare the proportion of subjects achieving therapeutic drug levels (≥0.5 mg/L) with the generic and the innovator itraconazole after 2 weeks. We performed a multivariate logistic regression analysis to ascertain whether trough itraconazole levels affected treatment outcomes. We categorised treatment response as favourable or unfavourable based on improvement (or worsening) in clinical symptoms, microbiology and imaging. We also performed morphometric analysis of different brands of itraconazole by video-dermoscopy. RESULTS: We included 193 (generic brands [n = 94] and innovator itraconazole [n = 99]) CPA subjects. A higher proportion of subjects achieved therapeutic levels at 2 weeks with the innovator than with the generic brands (72/99 [73%] vs. 27/94 [29%], p < .0001). The median trough level at 2 weeks was higher with the innovator than the generic brands (0.8 vs. 0 mg/L). The mean trough itraconazole levels achieved (average of three values measured over 6 months) independently predicted a favourable treatment response after adjusting for age, gender and CPA severity. On morphometric analysis, the generic brands had variable pellet numbers and sizes, and dummy pellets. CONCLUSION: At 2 weeks, a significantly higher proportion of CPA subjects achieved therapeutic drug levels with the innovator than the generic itraconazole. The mean serum itraconazole levels independently predicted a favourable treatment response in CPA.

A randomized prospective study to assess the role of topical tacrolimus as preventive therapy in unstable acral vitiligo.

BACKGROUND: Acral vitiligo is a significantly distressing condition and tends to be treatment-resistant. The occurrence of new lesions on acral areas further causes greater psychological trauma. Topical tacrolimus has been widely used in the management of vitiligo and its role in preventing flares in other dermatoses such as atopic dermatitis has been well documented. OBJECTIVES: To assess the role of topical tacrolimus as preventive therapy in unstable acral vitiligo. MATERIALS AND METHODS: In this single-centre randomized prospective study, 60 patients aged 16-60 years having unstable acral vitiligo with symmetrical lesions were enrolled and randomized (1:1) into two groups. Patients in group A were instructed to apply topical tacrolimus 0.1% ointment on both vitiliginous and normal skin while patients in group B were instructed to apply topical tacrolimus 0.1% ointment only on vitiliginous skin for 6 months. Only the distal hand till the wrist joint was chosen for observation. Vitiliginous patches were assessed monthly for 6 months for a change in the number of lesions and total area involved, extension of preexisting lesions and adverse effects if any. RESULTS: A reduction in the number of lesions was observed in both groups. The decrease in the number of lesions in group A was 5.6% as compared to 2.3% in group B (p-0.001). The decrease in depigmented area in group A was 10.5% as compared to 4.6% in group B (p-0.048). Treatment failure was seen in 11 out of 60 (18.3%) patients. CONCLUSION: Tacrolimus 0.1% ointment application showed effectiveness in preventing the appearance of new lesions in unstable acral vitiligo and hastening the repigmentation when applied on both lesional and perilesional skin in vitiligo.

Dermoscopic Features of Actinic Cheilitis and Other Common Inflammatory Cheilitis: A Multicentric Retrospective Observational Study by the International Dermoscopy Society.

BACKGROUND: Clinical differentiation between different cheilitis variants may be difficult. Application of mucoscopy, in addition to clinical background, could provide additional diagnostic clues facilitating initial patient management. OBJECTIVES: To determine mucoscopic clues differentiating actinic cheilitis from the main forms of inflammatory cheilitis, including eczematous cheilitis, discoid lupus erythematosus, and lichen planus of the lips. METHODS: This was a retrospective, multicenter study being a part of an ongoing project "Mucoscopy - an upcoming tool for oral mucosal disorders" under the aegis of the International Dermoscopy Society. Cases included in the current study were collected via an online call published on the IDS website (www.dermoscopy-ids.org) between January 2019 and December 2020. RESULTS: Whitish-red background was found in actinic cheilitis as well as in cheilitis due to discoid lupus erythematous and lichen planus. Polymorphous vessels were more likely to be seen in actinic cheilitis compared to other causes of cheilitis. White scales, ulceration, and blood spots predominated in actinic cheilitis and lichen planus, whereas yellowish scales typified eczematous and discoid lupus erythematous cheilitis. Radiating white lines although most common in lichen planus patients were also seen in actinic cheilitis. CONCLUSION: Despite differences in the frequency of mucoscopic structures, we have not found pathognomonic features allowing for differentiation between analyzed variants of cheilitis.

A multicentric study on dermoscopic patterns and clinical-dermoscopic-histological correlates of basal cell carcinoma in Indian skin.

BACKGROUND: Literature on the dermoscopic patterns of basal cell carcinoma (BCC) in India is limited. AIM: To describe the dermoscopic pattern and dermoscopic-histopathological correlation in a large cohort of patients with BCC from India, with a particular focus on skin of colour (SOC). METHODS: This retrospective study was conducted under the aegis of the Dermatoscopy Society of India. Clinical details were collected, and two lead authors independently analysed dermoscopic images of BCC for a predefined set of characteristics. Histopathological slides/blocks were reviewed, and dermoscopic-histological correlation attempted. RESULTS: In total, 143 patients with BCC and skin phototypes IV-VI were included. The mean largest BCC diameter was 3.10 ± 3.68 cm and there was a significant but weak association between duration and largest dimension of the lesion (Spearman ρ = 0.33, P < 0.01). Nearly half of the cases were diagnosed with pigmented BCC and the most common histological subtype was nodular BCC (37.9%). Dermoscopically, blue-grey dots and arborizing vessels were the most common features (60.0%). Pigmentary changes were found in the majority of cases, and included blue-white veil, blue-grey ovoid nests and maple leaf-like areas. A third of our patients had short linear telangiectasia, polymorphic vessels and regular dotted vessels, and another third exhibited a dermoscopic rainbow effect. Arborizing vessels were significantly more common with micronodular (78.9%) and nodular variants (74.1%, P = 0.05), whereas regular dotted vessels (68.4%, P = 0.04), blue-white veil (84.2%, P = 0.02) were significantly associated with micronodular variant. CONCLUSION: The dermoscopic patterns of blue-white veil and regular dotted vessels are indicators towards micronodular BCC in SOC and can help in prioritizing treatment.

Quality of life assessment in childhood vitiligo in a tertiary care center in India.

The impact of vitiligo on quality of life (QOL) of children is not well studied. In this cross-sectional study, QOL in the form of Children's Dermatology Life Quality Index (CDLQI) was assessed in 114 children with vitiligo over a year. The mean CDLQI was 2.72 ± 3.35. There was a significant correlation of body surface area involved with the DLQI and the impairment was higher in older children. The psychosocial burden of vitiligo in children cannot be ignored and must be tackled early on in order to prevent an ever lasting impact on young minds.

Clinical, biochemical, and serologic predictors of drug reaction with eosinophilia and systemic symptoms syndrome: A prospective case-control study.

BACKGROUND: Detailed scoring systems such as the European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) score for validating a diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome are available, but there is no rapid, easy tool to identify DRESS at presentation. OBJECTIVE: To identify the clinical, biochemical, and serologic markers predicting the DRESS syndrome and its severity. METHODS: In this prospective observational study, 25 patients with the DRESS syndrome and 25 control patients with maculopapular drug rash were recruited. Baseline clinical, biochemical, and serologic markers, such as high-sensitivity C-reactive protein (hsCRP), erythrocyte sedimentation rate, and thymus and activation-regulated chemokine (TARC) levels, were recorded and their utility in identifying the DRESS syndrome at presentation and predicting severity was analyzed. RESULTS: The effectiveness of TARC level (>613.25 pg/mL), total body surface area (TBSA, >35%), hsCRP (>5 mg/L), eosinophils (>6%), absolute eosinophil count (>450 cells/mm3), and aspartate transaminase (>92 U/L) were statistically similar to the effectiveness of the RegiSCAR DRESS validation score (≥2) in diagnosing the DRESS syndrome. A combination model (TBSA at baseline, eosinophil count, and hsCRP) at the cutoff of 6.8 had a sensitivity of 96% and a specificity of 100%. Baseline serum TARC levels did not predict the DRESS severity or outcome. LIMITATIONS: Small sample size. CONCLUSION: The combination of TBSA involvement, eosinophil count, and hsCRP levels can predict the DRESS syndrome at presentation.

A prospective, randomized clinical study to compare the efficacy of recipient site preparation using dermabrasion, cryoblister, and dermaroller in autologous noncultured epidermal cell suspension in stable vitiligo.

Noncultured epidermal cell suspension (NCES) is a well-established surgical treatment modality for stable vitiligo. The outcome of this procedure significantly depends on the method of recipient site preparation, a critical step to achieve cosmetically acceptable repigmentation. To compare the efficacy of recipient site preparation using three methods namely, dermabrasion, cryoblister, and dermaroller followed by NCES in stable vitiligo. In this single-center, prospective, intra-patient, randomized clinical trial; 36 participants having at least three vitiligo patches in same anatomic region with minimum lesional stability of 1 year were randomized 1:1:1 for recipient site preparation using manual dermabrasion, cryoblister, and dermaroller followed by NCES. Patients were followed up at 4, 8, and 12 weeks and assessment of extent and pattern of repigmentation, color match and patient satisfaction were done. Among 36 patients, 22 (61.1%) were females; mean (SD) age was 28.33 (9.4) years. Dermabrasion and cryoblister techniques showed equal efficacy with respect to extent of repigmentation (>75% repigmentation; 55.6% vs 47.2%; P = .63) and patient satisfaction score (20.2 ± 9.6 vs 19.9 ± 7.9, P = .194). However, dermabrasion was superior to cryoblister in terms of rapidity (65% vs 32.5% at 4 weeks, P = .04) and color match (47.2% vs 19.4%, P = .004). Dermaroller had poor repigmentation outcomes compared to both dermabrasion and cryoblister. Cryoblister as a method of recipient site preparation is equally effective as manual dermabrasion in NCES for attaining good to excellent repigmentation, but with risk of hyperpigmentation. However, dermaroller is inferior to both dermabrasion and cryoblister.

Oral cyclosporine is effective in stabilizing active vitiligo: Results of a randomized controlled trial.

Oral dexamethasone mini pulse (OMP) is an established treatment modality for active vitiligo. Cyclosporine may have therapeutic role in active vitiligo but current evidence supporting its role is scarce. The objective of study was to compare the efficacy and safety of oral cyclosporine with OMP in patients of active vitiligo. Fifty patients with active vitiligo were randomized into two groups of 25 patients. Group 1 was treated with OMP (2.5 mg dexamethasone) on two consecutive days/week for 4 months while group 2 was treated with cyclosporine (3 mg/kg/day) for 4 months. Laboratory monitoring was performed as per the prevalent protocol. The patients were followed up for another 2 months after stopping treatment. Arrest of disease progression (ADP) was defined as change of vitiligo disease activity score from 4+ to 3+ (time elapsed since last disease activity being more than 6 weeks upto 3 months) during the study period (6 months). ADP was attained in 21 patients in group 1 and 22 patients in group 2 (84% vs. 88%, p = 1.00) at the end of 6 months. However, mean time to achieve ADP was significantly lower in group 2 as compared to group 1 (10.92 [4.12] weeks vs. 13.90 [3.92] weeks, p = 0.01). Extent of repigmentation, improvement in patient assessment score, vitiligo quality of life and clinical markers of disease activity were marginal and comparable in both groups. Cyclosporine leads to earlier disease stabilization in active vitiligo as compared to OMP. Although considered a rescue drug in dermatology, low dose cyclosporine can be an effective therapeutic alternative in vitiligo patients.

Clinico-epidemiological profile and long term follow up in melasma.

Melasma is a disorder of hyperpigmentation that is frustratingly resistant to therapy with a high recurrence rate on treatment discontinuation. With the scarcity of melasma epidemiological studies from India, we conducted this study to see clinico-epidemiological trends and therapeutic response. Totally 957 melasma patients were studied during the 5-year period between October 2014 and September 2019. A female preponderance was seen. Patients were classified as early, moderate, and late responders if they had more than 80% clinical improvement within 8, 8-12, and 12-16 weeks rest classified as nonresponders. Six hundred and forty-eight patients with mMASI of ≤5 had been prescribed non-hydroquinone-based therapies who had overall response rate of 40.9% by end of 16 weeks, 309 with mMASI >5 received hydroquinone based triple combination with a response rate of 33.6% at end of 16 weeks. A total of 33.65% responded to triple combination compared to 40.1% in the non-hydroquinone group. All nonresponders received oral tranexamic acid 250 mg twice daily. Most patients on oral tranexamic acid group developed recurrence by 6 weeks post discontinuation, compared with triple combination therapy group who had relapsed by 2 months post discontinuation and 4 months to relapse with non-hydroquinone-based therapies. Side effects experienced were 0.83% in hydroquinone group reporting erythema and burning. 0.57% in non-hydroquinone group perceived stinging sensation and none from tranexamic acid group. The longest follow up available in our study was for 18 months. The emergent need of the hour is a long, safe, and effective therapy for melasma.

Dermatoscopic assessment of treatment response in patients undergoing autologous non-cultured epidermal cell suspension for the treatment of stable vitiligo: A prospective study.

There is lack of literature on serial dermatoscopic assessment in patients undergoing non-cultured epidermal cell suspension (NCES) for treatment of stable vitiligo. This prospective study was conducted to evaluate the role of serial dermatoscopy in assessing disease stability and predicting repigmentation rates in vitiligo patients undergoing NCES. Dermatoscopic assessment of target lesions were done at baseline and post-NCES at week 4, 8, 12, 16, and 24. Patches obtaining >90% repigmentation at 24 weeks were categorized to have obtained excellent repigmentation. The dermatoscopic features of target lesions that showed clinical signs of disease activity anytime during the follow-up period were compared to those maintaining clinical stability throughout. Twenty-six vitiligo patients with 52 patches, clinically stable for atleast 1 year were recruited. At follow-up, six patches showed clinical signs of instability. Five patches in the unstable group developed satellite lesions by week 16, compared to none in the stable group (p < 0.05). Excellent repigmentation was achieved in 29 out of 52 patches. Appearance of normal reticular pigment network at 8 weeks was a positive predictor of excellent response (OR = 10.5, CI 1.2-89.7), whereas, altered pigment network at 12, 16, and 24 weeks and telangiectasias at 12 and 16 weeks significantly reduced the odds of excellent repigmentation.

Teledermatology during the COVID-19 pandemic: Experience at a tertiary care centre in North India.

BACKGROUND: Teledermatology has evolved as a valuable option to outpatient visits during the current pandemic. We set up a smartphone-based hybrid model of teledermatology services providing direct care to patients at our center. To analyse patient and physician-experience and acceptability for teledermatology over a 6-month-period, along with clinicodemographic profile of patients. METHODOLOGY: Single-center, retrospective study conducted from May 20, 2020 to October 31, 2020. Patient satisfaction level for teledermatology was assessed on a 4-point scale and compared with the satisfaction level during their previous physical visits prior to COVID-19 pandemic. A physician assessment form was utilised to record the experience of dermatologists while providing teledermatology services. RESULTS: Of 7530 patients registered, a successful consult was provided to 6125 patients (81.34%). Average number of teleconsultations/day rose from 23.60 in May 2020 to 77.96 in October 2020. Mean age of patients availing teledermatology services was 33.60 ± 16.99 years. Average distance to care and travel time were 100.90 ± 171.77 km and 135 ± 222.32 min, respectively. A definitive diagnosis could be ascertained in 5724 patients (93.45%) and in-person visit was recommended to 133 patients (2.2%). Out of 6125 patients, 5229 could be contacted for feedback, 935 (18.18%), 2230 (42.65%), 1749 (33.45%), and 300 patients (5.70%) reported being very satisfied, satisfied, partially satisfied, and unsatisfied, respectively. Of 1914 patients, who had availed in-person OPD facilities prior to the pandemic, 914 patients (49.62%) preferred in-person visits. Of 34 dermatologists surveyed, 88.2% felt comfortable providing teleconsultations and 82.4% felt the need to continue teledermatology services in the upcoming months. CONCLUSIONS: Overall, teledermatology is a valid alternative for in-person dermatology visits during the current crisis; helping with initial triage and further patient management. Further refinement of the process could lead to even more acceptability.

Application of mucous membrane dermoscopy (mucoscopy) in diagnostics of benign oral lesions - literature review and preliminary observations from International Dermoscopy Society study.

Dermoscopy of mucosal surface termed "mucoscopy" is an upcoming offshoot of dermatological imaging. However, the literature on mucoscopy is limited to individual cases and small case series. An organized review or systematic analysis of mucoscopy is lacking. The aim of this review was to summarize the published literature on mucoscopic features of benign conditions affecting the oral mucosa and semi-mucosa. Additionally, the results of mucoscopic features of diseases, which have not been described before have been presented.

Oral mycophenolate mofetil in the treatment of acquired dermal macular hyperpigmentation: An open-label pilot study.

BACKGROUND: Literature on treating acquired dermal macular hyperpigmentation is sparse. AIMS AND OBJECTIVES: To assess treatment response of mycophenolate mofetil in patients having acquired dermal macular hyperpigmentation. MATERIAL AND METHODS: In this open-label, pilot study, patients of acquired dermal macular hyperpigmentation affecting at least the face and/or neck were included. Each participant was treated with mycophenolate mofetil 2 g/day for 24 weeks, with a follow-up of 12 weeks. Two aspects of disease severity were measured: activity (appearance of new lesions/extension of existing lesions), and degree of hyperpigmentation (measured using 'dermal pigmentation area and severity index'). Patient satisfaction was assessed on a scale of 0-10. RESULTS: Forty-three of 46 patients who were prescribed mycophenolate, completed the study (40 females, 6 males; mean disease duration 2.8 ± 1.4 years). Amongst 20 (43.5%) patients with active disease, stability was achieved in 17, after a mean duration of 6.1 ± 2.5 weeks (range 4-12 weeks; median 4; IQR 4 weeks). Mean dermal pigmentation area and severity index at baseline was 18.8 ± 7.1 and decreased to 13.7 ± 6.3 at 24th week (27.5 ± 14.7%; P < 0.001). A significant decreasing trend in dermal pigmentation area and severity index (P < 0.001) was observed, and first significant difference from baseline was noted at the 16th week (P 0.008). Less than 10%, >10-20%, >20%-30%, >30%-40%, >40%-50%, and >50% reduction in dermal pigmentation area and severity index was observed in 8, 5, 4, 15, 10 and 1 patients/patient respectively. The maximum mean grade of pre-treatment dermatoscopic severity was 3 ± 0.7, and decreased to 2.1 ± 0.8 on the face (P < 0.001) and 2.4 ± 0.7 on the neck (P < 0.001) post-treatment. There were 9 (20.1%) non-responders. Self-assessment scores of the rest of the patients fell in the range of moderate/fair improvement (>5 to 7). No significant correlation was seen between patient satisfaction score and degree of reduction in dermal pigmentation area and severity index (r -0.39). Three developed adverse effects (leucopenia, n = 1; transaminitis and hyperbilirubinemia, n = 2) that resolved following discontinuation of mycophenolate. CONCLUSION: Mycophenolate mofetil appears to be a promising treatment option in acquired dermal macular hyperpigmentation.

Changing paradigms of dermatology practice in developing nations in the shadow of COVID-19: Lessons learnt from the pandemic.

At present, routine dermatology practices stay mostly disrupted worldwide owing to the ongoing COVID-19 pandemic. However, dermatology services need to be resumed in future and dermatologists especially in developing countries face a mammoth task of devising plans to tackle the upcoming surge of patients while still maintaining the precautions to avoid risk of infection to health care workers and our patients. Teledermatology practice is a viable alternative and there is need of starting functioning teledermatology centers at primary health care centers and training health care workers in telemedicine. Several steps like increasing the working hours of outpatient clinics, posting dermatologists and health staffs in shifts, encouraging online registration and payment, providing time slots to patients should be taken to prevent overcrowding at outpatient departments in hospitals of developing countries like India where the usual patient turnover during summers maybe around 600 to 800 per day. Once diagnosed by the dermatologist, a subsequent meticulous use of teledermatology can limit the number of follow-up visits. To avoid student gatherings, the undergraduate and postgraduate teaching schedule should be replaced by online or virtual teaching in form of webinars and video conferencing. Above all, intense upgradation of health care infrastructure, recruitment, training of new health care staffs on mass level and huge investment in health care sector is required in all the developing countries.

Intralesional sclerotherapy for the treatment of acne cysts: A case series.

Acne cysts are a common dermatological problem that often leads to scarring and a significant negative impact on patients' psyche. The aim of the study was to evaluate the usefulness of intralesional foam sclerotherapy for the treatment of cystic acne. Patients with cystic acne treated with intralesional foam sclerotherapy between June 2018 and May 2019 were identified. Treatment response and adverse effects were assessed during follow-up. Twelve patients (10 men and 2 women) with cystic acne with a median age of 21 years were treated during the study period. Of these 12 patients, eight (66.7%) showed complete resolution within 48 hours and two (16.7%) experienced complete resolution within 1 week. Two patients failed treatment at the end of the 4-week follow-up. Of the two patients with more than one acne cyst, response was noted only at the treated site. All patients who showed improvement sustained the effects at the 12-week follow-up. No adverse effects were observed and the treated sites healed with good cosmesis and minimal scarring. To conclude, single-session percutaneous polidocanol sclerotherapy is useful for the treatment of acne cysts. Future controlled studies are required to compare the efficacy of intralesional sclerotherapy with intralesional corticosteroids.