Prescribing practices of tranexamic acid for melasma: Delphi consensus from the Pigmentary Disorders Society.

Introduction There is ambiguity regarding usage of tranexamic acid for melasma in India, be it in its pre-administration evaluation, administration route, dosing or monitoring. Hence, we conducted this study to understand various tranexamic-acid prescribing patterns and provide practical guidelines. Materials and methods A Google-form-based questionnaire (25-questions) was prepared based on the key areas identified by experts from the Pigmentary Disorders Society, India and circulated to practicing dermatologists across the country. In rounds 2 and 3, the questionnaire was re-presented to the same group of experts and their opinions were sought. The results of the practitioners' survey were denoted graphically alongside, to guide them. Consensus was deemed when at least 80% of respondents chose an option. Results The members agreed that history pertaining to risk factors for thromboembolism, cardiovascular and menstrual disorders should be sought in patients being started on oral tranexamic-acid. Baseline coagulation profile should be ordered in all patients prior to tranexamic-acid and more exhaustive investigations such as complete blood count, liver function test, protein C and S in patients with high risk of thromboembolism. The preferred oral dose was 250 mg orally twice daily, which can be used alone or in combination with topical hydroquinone, kojic acid and sunscreen. Repeated dosing of tranexamic-acid may be required for those relapsing with melasma following initial tranexamic-acid discontinuation. Coagulation profile should ideally be repeated at three monthly intervals during follow-up, especially in patients with clinically higher risk of thromboembolism. Treatment can be stopped abruptly post improvement and no tapering is required. Limitation This study is limited by the fact that open-ended questions were limited to the first general survey round. Conclusion Oral tranexamic-acid provides a valuable treatment option for melasma. Frequent courses of therapy may be required to sustain results and a vigilant watch is recommended for hypercoagulable states during the course of therapy.

Clinical Profile and Diagnostic Accuracy of Patient-submitted Photographs in Teledermatology.

Background: The COVID-19 pandemic has shifted healthcare from physical in-person patient visits to teleconsultations in order to curtail the spread of this virus. Dermatology, being a visual science, lends itself amenably to teleconsultation. Objective: This study was performed to assess the basic dermatological diseases which are more easily diagnosable and managed through teleconsultation, distinguishing them from diseases for which a face-to-face consultation may be a better option and to delineate the factors affecting the image quality which is the cornerstone of a teledermatology consultation. Methods: A retrospective observational study was conducted over a three-month period during the pandemic. Store and forward, video conferencing, and hybrid consultations were included. Two dermatologists of different clinical experience independently assessed the clinical photographs of the patients and gave each photograph an objective score (Physician Quality Rating Scale) and a diagnosis. The diagnostic concordance between the two dermatologists as well as the correlation of this score with the certainty of diagnosis was calculated. Results: A total of 651 patients completed the study. Mean PQRS score of Dermatologist 1 was 6.22 while the mean score of Dermatologist 2 was 6.24. Patients in whom both the dermatologists were absolutely certain about their diagnosis had a higher PQRS score and interestingly had a higher education level than the rest. There was 97.7 percent diagnostic concordance between the two dermatologists. Infections, acne, follicular disorders, pigmentary disorders, tumors, and STDs had the largest proportion of cases wherein both the dermatologists were in total agreement with each other. Conclusion: Teledermatology might be best for the care of patients with characteristic clinical presentation or for follow-up of already diagnosed patients. It can be used in the post-COVID era to triage patients requiring emergency care and reduce patient wait times.

Brachial artery flow-mediated dilation in patients with systemic sclerosis: an experience from tertiary care center from North India.

Role of flow-mediated dilatation (FMD) testing in the assessment of the macrovascular dysfunction in systemic sclerosis (SS) and correlation of FMD values with disease severity. Twenty-five patients of SS and 25 healthy age-matched controls were recruited. Modified Rodnan skin thickness score (MRSS) was used for skin thickness assessment. FMD values were measured in the brachial artery. FMD values done at baseline before the initiation of treatment were lower in SSc patients (4.044 ± 2.742) compared to the healthy controls (11.076 ± 5.896) (P < 0.05). Comparison of FMD values between patients with limited cutaneous systemic sclerosis (LSSc) and diffuse cutaneous systemic sclerosis (DSSc) showed a trend toward lower in LSSc (3.182 ± 2.482) as compared to DSSc patients (5.111 ± 2.711); however, the difference was not statistically significant. Patients with lung manifestations on high-resolution CT chest showed lower FMD values (2.66 ± 2.23) compared to those without HRCT changes (6.45 ± 2.56) (P < 0.05). We demonstrate that FMD values in SSc patients were lower when compared to healthy controls. Patients with SS having pulmonary manifestations showed a lower value of FMD. Key Points • FMD is a simple non-invasive tool to assess the endothelial function in patients with systemic sclerosis. • Lower values of FMD in systemic sclerosis suggest that the endothelial dysfunction and values can also be correlated with other organ involvement such as lung and skin involvement. So, lower FMD values might be a useful marker for disease severity.

Species Distribution and Antifungal Susceptibility Profile of Dermatophytes from a Tertiary Care Centre in North India.

Objective Dermatophytoses, one of the most ancient diseases, is becoming a menace in recent times. This has made the knowledge of antifungal susceptibility a priority in today's times. Material and Methods This is a prospective study conducted over 18 months including all dermatophytes isolated during the period. Dermatophytes were identified by routine phenotypic methods. Antifungal susceptibility testing was performed for griseofulvin, terbinafine, and itraconazole as per the Clinical Laboratory Standard Institute M38 A2, and minimum inhibitory concentrations (MICs) were read after 5 days. Results Patient details and associated risk factors were recorded. Fixed dose combinations with steroids were associated with 79.3% (46 out of 58) of patients with dermatophytosis of skin. Among the 72 dermatophytes isolated during the study period, 58 (80.5%) were isolated from skin scrapings and 14 (19.4%) from nail samples. Tinea corporis with cruris was the most common presentation. The most common dermatophyte isolated from skin scrapings was Trichophyton mentagrophytes complex (70.6%, 41 out of 58), while from nail samples it was Trichophyton rubrum complex (78.57%, 11 out of 14). Based on the MIC 50 and MIC 90 results, itraconazole showed the lowest MICs, followed by terbinafine and then griseofulvin. Conclusion With the changing epidemiology of species distribution and antifungal resistance, there is a need for continuous surveillance of these parameters of dermatophytes.

Comparative Efficacy of Injection Triamcinolone Acetonide given Intralesionally and through Microneedling in Alopecia areata.

Introduction: Alopecia areata (AA) manifests as patchy hair loss and intralesional corticosteroid (ILCS) is usual therapeutic choice in limited disease. Microneedling is used for uniform delivery of topical agent to relatively larger areas may prove to be more efficacious than traditional ILCS. The present study prospectively compared microneedling to traditional intralesional delivery of triamcinolone acetonide (TA). Materials and Methods: Prospective randomized comparative study in 60 patients of AA restricted to scalp not requiring systemic treatment randomly divided into two equal groups. Group 1 patients underwent microneedling with local application of injectable TA and Group 2 patients were given injectable TA intradermally for a total of three sessions at 3 weeks interval. Results: A mean regrowth of 66.36% in Group 1 and 69.75% in Group 2 at week 9 was seen which was comparative with no significant statistical difference between the two groups (P = 0.664). Thirteen patients achieved 100% regrowth at week 9 in Group 1 and 16 patients achieved 50%-99% regrowth in Group 2. Discussion and Conclusions: ILCSs have been cornerstone in the treatment of limited AA, but depth of injecting drug cannot be controlled, microneedling whereas is an effective drug delivery system and also causes release of growth factors. In this study, injectable TA used intralesionally and topically with microneedling had nearly similar efficacy in causing regrowth of hair with microneedling resulting in a more uniform but less dense regrowth of hair with lesser adverse effects.

Platelet-rich plasma is a promising therapy for melasma.

INTRODUCTION: Platelet-rich plasma (PRP) is an autologous blood product which has recently been used in multiple spheres of dermatology including facial rejuvenation, androgenetic alopecia, acne scars, and wound healing. Its use in melasma is comparatively an understudied topic. MATERIAL AND METHODS: An extensive systematic literature search of the PubMed electronic database and Cochrane central register of controlled trials was done using the keywords "platelet rich plasma" and "melasma" in the title. Relevant studies were selected and data were analyzed by two different authors. Four articles were excluded as they did not adhere to the inclusion criteria of this review and a total of 6 articles were reviewed.The relevant references of the included articles were also traced and included. DISCUSSION: These studies showed that PRP has been used effectively not only as an adjuvant therapy but also as a standalone treatment for melasma. PRP contains about 30 growth factors, transforming growth factor beta (TGF-ß) being one of the growth factors having a predominant role in treatment of melasma. TGF-ß decreases signal transduction of microphthalmia-induced transcription factor and thus decreases tyrosinase and tyrosinase-related proteins. In addition to this, PRP also has an additional benefit of inducing collagen synthesis thus improving the quality and texture of the skin. But there is a scarcity of data and large randomized controlled trials. This review is an effort to highlight and upscale the use of this excellent blood product for melasma which is quite a treatment refractory disorder.

Aspergillus candidus eumycetoma with review of literature.

OBJECTIVE: Mycetoma is a slowly progressive, chronic granulomatous infection of skin and subcutaneous tissues with involvement of underlying fasciae and bones, usually affecting extremities. In India, among mycetoma, the eumycetoma constitutes about 35% of cases. Hereby, we report the first case of eumycetoma caused by uncommon fungus, Aspergillus candidus. CASE REPORT: A 61 year old female presented to the Department of Dermatology with history of swelling of right foot associated with multiple firm nodules of approx. 1.5 × 1.5 cm each over dorsum of foot with discharging sinus containing white color granules. Biopsy of lesion on right foot on direct KOH examination revealed septate hyphae. Histopathology examination showed a histiocytic granuloma with fungal elements. Culture on Sabouraud Dextrose Agar grew white mycelial colonies which were identified to be Aspergillus species phenotypically. Genetic sequencing using Internal transcribed spacer gene, beta tubulin gene and Calmodulin gene was done and the isolate was identified to be Aspergillus candidus. Lesion was excised and patient was started on itraconazole. CONCLUSION: Timely identification and starting of antifungal treatment can help in reducing morbidity due to eumycetoma to a large extent. As newer and newer species of fungi are emerging as significant causative agents of human infections, it is pertinent to report such findings from epidemiological point of view.

Autologous intralesional platelet rich plasma improves melasma.

Platelet rich plasma (PRP) is an upcoming interventional therapy for the treatment of melasma. Its efficacy is due to the multiple growth factors present in it which decrease melanogenesis by various signal transduction pathways. The present study evaluated the efficacy of PRP as a standalone agent in treatment of melasma. This is an open labeled prospective trial. Forty patients were given intralesional PRP at once monthly interval. Three such PRP sessions were carried out and the patients were followed up for 3 months. Assessment was done by calculating the modified melasma area severity index score (mMASI) for each patient. Patients were also asked to self-evaluate their improvement based on a scale. There was an average 54.5% reduction in the mMASI score at the end of the study. There was no relapse in any patient. This reduction was irrespective of the skin type, gender, and type of melasma. Patients self-evaluation showed that more than 90% of the patients were pleased or very pleased with the results. There were no significant side effects. PRP appears to be a potential new therapy with significant efficacy in improving pigmentation of melasma, standalone as monotherapy.

Efficacy of tuberculin immunotherapy in verruca vulgaris: Our experience from single center from North-West India and review of literature.

Verruca vulgaris (VV) acquired through direct contact or autoinoculation of human papilloma virus (HPV). Treatment of VV are challenging as destructive modalities have variable efficacy and recurrence rates. Various immunotherapies attempt to stimulate the cell-mediated host immune response against HPV. We have assessed efficacy of intralesional tuberculin in patients with verruca vulgaris and to see the long term follow-up at 12 months. Forty patients were enrolled in the study. All patients received intralesional tuberculin injections (5 Tuberculin U/mL) in a dose of 0.1 mL/lesion every fortnightly. Patients were followed up for 12 months duration, and response to treatment assessed. Thirty patients (75%) showed complete resolution, 5 (12.5%) patients showed partial response, 3 (7.5%) showed minimal response and 2 (5%) were non-responders. Irrespective of tuberculin sensitivity test response the majority of patients showed grade 3 response. Five (12.5%) patients had a recurrence of lesions. Two had a recurrence on the same site, and three had recurrences over distant sites. Intralesional tuberculin immunotherapy is an effective modality for VV. Immunotherapy of warts is a potential area of research, and exact method and agents are still under investigation.

A Rare Case of Congenital Vitiligo in a Neonate.

BACKGROUND: Vitiligo affects one percent of general population and usually manifests in the second and third decades of life. Vitiligo is believed to be an acquired condition, though a positive family history is seen in 30 to 40 percent of cases. Few cases of vitiligo at birth have been reported. We report a case of congenital vitiligo in a neonate and discuss disease course and pathogenesis. CASE REPORT: A 27- days-old female neonate patient presented with multiple, rapidly progressing, depigmented patches over the body that had been present since birth. The lesions showed chalky white accentuation under Wood's lamp. There was positive history of vitiligo in the mother. The child was started on topical fluticasone propionate 0.05% cream in the morning and tacrolimus 0.03% ointment at night. At the one-year of follow-up period, there were no new lesions, and partial repigmentation was noticed in the existing lesions. CONCLUSION: Manifestation of vitiligo at birth is a very rare occurrence. The presentation at birth in this case suggests a genetic link, as opposed to acquired factors, and supports the in-utero hypothesis, adding to the scant literature available on congenital vitiligo.

Clinical Efficacy of Topical Tranexamic Acid With Microneedling in Melasma.

BACKGROUND: Melasma is a common, recurrent, and refractory cause of facial pigmentation resulting in cosmetic disfigurement. Tranexamic acid (TA) has been used systemically and locally for clearance of pigmentation. OBJECTIVE: To assess the clinical efficacy of topical TA (10%) with microneedling in melasma. METHODS: A split face, prospective, randomized, open-label study with a sample size of 40. Left or right side of the face was chosen randomly and microneedling was done on both the sides, followed by 10% TA solution application on one side of the face (test side) and distilled water on the other side of face (control). The procedure was done at 2 weekly intervals (0, 2, 4, and 6 weeks). Clinical images were taken at each visit including modified Melasma Area and Severity Index (mMASI) scoring of each half of the face to assess the clinical response along with patient satisfaction scores and side effects. RESULTS: On the test side, there was 65.92% improvement in the mean mMASI score compared with 20.75% on the control side of the face at the end of 8 weeks. CONCLUSION: Tranexamic acid may be a promising therapeutic agent in melasma and the topical solution along with microneedling seems to be efficacious.

Familial Dermatophytosis in India: A Study of the Possible Contributing Risk Factors.

Background: Dermatophytes are keratinophilic fungi responsible for skin, nail, and scalp infections. Chronic dermatophytosis, defined as persistent infection for six months or more, was very rare in the 1980s and mostly limited to patients with nail involvement, but this is no longer true. Currently, patients with chronic dermatophytosis are increasing, and about 50 percent of patients with dermatophytosis have at least one other member of their family infected at the same time, sometimes with entire families being affected at once. Objective: We sought to study the possible risk factors associated with familial dermatophytosis. Methods: The present questionnaire-based study was conducted from May 2017 to July 2017. Patients with a clinical diagnosis of dermatophytosis and at least one other family member affected were included. A proforma was filled and history was taken, including number of family members affected, site of infection in the index case, site(s) of infection of all other subsequent family members affected, and use of over-the-counter drugs. Results: Out of the 113 families surveyed, which included 673 subjects, a little over half (55.4%) were affected by dermatophytosis. In 103 families, the initial site of infection in the subsequent family member affected was the same site as that affected in the first member. All families reported a history of using an irritant soap and over-the-counter drugs. Washing all the family's clothing together was a common factor. All families had a single bathroom and used the same soap and stool for bathing. Conclusion: Through our survey, we identified possible risk factors that might be responsible for the increasing epidemic of familial dermatophytosis in India, including sharing of soaps and towels, washing clothes in the same vessel, sharing of lavatories, abuse of topical steroids and over the counter topicals, and use of antiseptic soaps that kill normal flora.

Evaluation of efficacy and safety of oral terbinafine and itraconazole combination therapy in the management of dermatophytosis.

Background: There has been an alarming increase in recalcitrant dermatophytosis in recent years. The standard treatment guidelines no longer seem effective in achieving clearance and results in high failure rates.Objective: To evaluate the efficacy and safety of oral terbinafine and itraconazole combination therapy in the management of dermatophytosis.Methods: Clinically diagnosed and KOH positive patients of tinea corporis/cruris/faciei were randomly divided into three groups and given terbinafine 250 mg, itraconazole 200 mg and a combination of both once daily taken on the same day respectively for 3 weeks. Partial responders at the end of the therapy were given same treatment for additional 3 weeks. Clinical parameters namely itching, erythema, and scaling were evaluated at baseline, 3, 6, and 9 weeks. Adverse effects were noted at the end of therapy.Results: Maximum clinical and mycological cure was achieved in group III (receiving combination therapy) (90%) followed by group II (receiving itraconazole) (50%) and group I (receiving terbinafine) (35%). The combination therapy of oral terbinafine and itraconazole was found to be as safe as monotherapy without any significant adverse effects.Conclusions: The combination of systemic terbinafine and itraconazole therapy may be an effective and safe therapeutic strategy in the management of dermatophytosis.

Comparative Efficacy of a 35% Glycolic Acid Peel Alone or in Combination With a 10% and 20% Trichloroacetic Acid Spot Peel for Melasma: A Randomized Control Trial.

BACKGROUND: To study and compare the therapeutic efficacy and side effects of a 35% glycolic acid (GA) full face peel alone or in combination with a 10% or 20% trichloroacetic acid (TCA) spot peel for facial melasma. METHODS: Thirty patients with facial melasma were randomly divided into 3 equal Groups A, B, and C. Group A was treated with a 35% GA full-face peel, Group B and C with 35% GA full-face peel followed by a 10% and 20% TCA spot peel respectively once every 15 days. Four peels were performed once every 15 days. The response to the treatment was evaluated by the percentage reduction in melasma area severity index (MASI) scoring. RESULTS: All 3 groups had significant reduction of MASI, but there was no significant difference between the groups. Group A had minimum side effects. CONCLUSION: Chemical peels with GA alone or in combination with TCA do result in a significant improvement in melasma, but the combination of the peels in the same sitting does not seem to have any additive or synergistic effect while they may increase the side effects.

Lithium-induced Linear Psoriasis: A Rare Presentation.

Atypical forms of psoriasis are frequently seen. However, linear psoriasis precipitated by drugs is extremely rare. We report a case of an adult woman who presented with lithium-induced unilateral psoriasis arranged in Blaschko lines on the left leg. A brief discussion on etiology and differential diagnosis is included, as well as treatment methods.

NonScarring Diffuse Hair Loss in Women: a Clinico-Etiological Study from tertiary care center in North-West India.

BACKGROUND: Diffuse hair loss (DHL) is a common problem in adult women and has a major impact on quality of life. Ascertaining the etiological diagnosis is a challenging task in such patients. Satisfactory treatment can only be instituted after ascertaining the cause of hair loss. OBJECTIVE: To study the clinico-epidemiological profile of nonscarring DHL in females and to ascertain its underlying etiological factors. STUDY DESIGN: Of a total of 110 females, who presented with nonscarring DHL to the outpatient dermatology department, 100 qualified for inclusion in the study. A detailed history, clinical examination, and laboratory investigations were performed in all the patients. Statistical analysis was performed on the data collected. RESULTS: Of 100 cases of DHL which were included in the study, commonest was chronic telogen effluvium (CTE) (62%), followed by female pattern hair loss (FPHL) (22%) and acute telogen effluvium (ATE) (16%). Incidence of hair loss was highest in 21-40 years age group. Psychological stress was seen to be a precipitating factor in 18 patients and found most commonly in women belong to CTE group (n-16, 25.8%). Hemoglobin levels ranged from 80 to 142 gm/L (mean: 119 ± 110). Low hemoglobin level (<120 gm/L) was observed in 57% patients. Total serum ferritin <10 ng/mL was seen in 20 patients, vitamin B12 < 211 pg/mL in 76 cases, vitamin D3 < 30 ng/mL in 81 cases. Subclinical hypothyroidism was present in 11% cases. CONCLUSIONS: Nonscarring DHL is a multifactorial condition with highest incidence in 21- to 40-year age group. Serum ferritin, serum vitamin B12, and D3 levels seem to have a contributing role in the pathogenesis of hair loss, and their supplementation may be needed for a faster regrowth of hair in all cases of hair loss irrespective of the pattern.

Evaluating the Unusual Histological Aspects of Granuloma Annulare: A Study of 30 Cases.

BACKGROUND: Granuloma annulare (GA) is an uncommon dermatologic disorder that presents as annular, skin-colored to erythematous plaques. Histopathologically, it is characterized by palisaded histiocytic granulomas. A definitive diagnosis of GA is based on clinicopathologic correlation. OBJECTIVE: The aim of this study was to study the histomorphologic spectrum of GA. MATERIALS AND METHODS: A total of 30 cases reported as GA over 6 years (2012-2017) were retrieved. The detailed clinical profile and histomorphologic findings on the skin biospies were reviewed. RESULTS: Majority of the cases (40%) presented in the 6th decade of life with a mean age of 48.3 ± 16.5 years and with a female predominance (77%). The lesions were localized in 22 cases (73%). Asymptomatic to erythematous, annular plaques was the most frequent presentation (60%). GA was not suspected clinically in two cases. Histopathologically, interstitial pattern of infiltrate was most common (44%), whereas granuloma formation and palisaded histiocytes were seen in 4 (13%) and 3 cases (10%), respectively. A mixed pattern was observed in 10 (33%) cases. Collagen degeneration was universal finding (100%) and presence of dermal mucin was noted in 24 cases (80%), both of which were important clues to the diagnosis of GA. Additional features such as presence of plasma cells, eosinophils, and vasculitis were noted in 10 (33%), 6 (20%), and 6 (20%) cases, respectively. CONCLUSION: The diagnosis of GA may be challenging owing to its diverse morphology. Acquaintance with the varied histomorphology of GA is of utmost importance to render a correct diagnosis and understand the pathogenesis.