Uncommon toxic epidermal necrolysis -like presentation of cutaneous lupus erythematosus: A series of 6 cases.

TEN like Lupus erythematosus is an uncommon life-threatening variant of Lupus erythematosus. It is usually associated with flares of systemic lupus erythematosus and also because of widespread skin erosions, it can cause acute skin failure. It is often confused with drug induced TEN, however the management of both the diseases is different and hence correct diagnosis becomes crucial. In this study we aimed to assess the clinical characteristics and outcome of TEN like LE in the Indian population. All patients satisfying ACR/EULAR 2019 criteria for SLE and clinically diagnosed with TEN like LE were retrospectively reviewed. A total of 6 patients were identified. All patients were female. Except 1 patient who presented de-novo, the others had pre-existing symptoms of connective tissue disease. Half of the patients had palmoplantar involvement. Mucosal involvement was only mild. Majority had systemic involvement in the form of nephritis followed by arthralgia, autoimmune hepatitis and autoimmune hemolytic anemia.

Identification of novel step-up regimen of intralesional triamcinolone acetonide in scalp alopecia areata based on a double-blind randomized controlled trial.

Although intralesional triamcinolone acetonide (TA) is the most commonly prescribed treatment for localized alopecia areata (AA), the literature regarding the optimal concentration for attaining better efficacy with the most acceptable side effects is scarce. To compare hair regrowth and local side effects of various concentrations of intralesional TA in scalp AA using clinical and dermoscopic parameters. A double-blind randomized control trial with four treatment groups (10, 5, 2.5 mg/ml TA and normal saline [NS]) was conducted between March 2018 and August 2019. After recruitment, each AA patch was divided into quadrants and randomized before first injection. Injections were given and outcome parameters were analyzed every 4-weekly till 12-weeks. Statistical analysis was done by the R software employing generalized estimation equation. P-value <.05 was considered significant. Out of 105-patients (168-AA patches), 75-patients (121-patches) completed the study. Hair regrowth scale of all TA concentrations was better than NS group (P < .001). Other parameters such as quadrants with poor clinical response and dermoscopic disease activity signs were also favorable in TA groups in comparison to NS. However the evidence of atrophy and telangiectasia was maximum in 10 mg/mL group. 10 mg/mL TA showed a comparatively better response at the cost of increased adverse effects. Based on the clinical benefit and adverse risk assessment from our study, it may be better to start with 2.5 mg/mL intralesional TA in limited scalp AA patients. It can be implied that the concentration of TA can be increased as a step-up regimen based on the serial clinical and dermoscopic response.

A Randomized Comparative Study of Oral Corticosteroid Minipulse and Low-Dose Oral Methotrexate in the Treatment of Unstable Vitiligo.

BACKGROUND: Despite continued progress towards elucidation of the biochemical, genetic and immunopathological pathways in vitiligo, a definitive cure remains elusive. The initial therapy must be directed to arrest disease progression. Oral minipulse therapy (OMP) with betamethasone/dexamethasone has been tried and shown to be an effective modality to arrest the disease progression in vitiligo. OBJECTIVES: Methotrexate (MTX) is a time-tested effective treatment extensively used in various autoimmune disorders with good efficacy, safety and tolerability on a long-term basis. We intended to compare the efficacy of MTX with that of OMP in patients with unstable vitiligo vulgaris. PATIENTS AND METHODS: In a prospective randomized open label study, 52 patients with vitiligo were divided into two groups. Patients in group 1 received 10 mg methotrexate weekly. Group 2 patients received corticosteroid OMP which comprised tablets of dexamethasone 2.5 mg (5 tablets), taken on 2 consecutive days in a week (total weekly dose of 5 mg dexamethasone). RESULTS: In the MTX group, among 25 patients analyzed, during the course of treatment for 24 weeks, overall 6 patients developed new vitiliginous lesions. In the OMP group, 7/25 patients developed new lesions. Statistical correlation between the two groups showed no significance in the number of patients who developed new lesions (increasing disease activity) in either of the groups. At the end of the study, it was demonstrated that patients in both groups had a similar reduction in the vitiligo disease activity score. CONCLUSION: Our study demonstrated that both drugs are equally effective in controlling the disease activity of vitiligo. MTX can be used in patients with active vitiligo, wherever corticosteroids are contraindicated.

Efficacy of apremilast in hyperkeratotic hand and foot dermatitis: results from a randomized observer-blinded comparative study.

BACKGROUND: Hyperkeratotic hand and foot dermatitis significantly affects quality of life. Some patients respond suboptimally to topical corticosteroids and have multiple recurrences. OBJECTIVE: Our aim was to compare the efficacy and safety profile of apremilast and topical corticosteroid versus corticosteroid alone in hyperkeratotic hand and foot dermatitis. METHODS: This randomized controlled study involved 77 patients treated for 3 months. Group A (39 patients) received mometasone furoate 0.1% cream with oral apremilast 30 mg twice daily, and Group B (38 patients) received mometasone alone. They were assessed monthly using the Hand Eczema Clinical Severity Index (HECSI) and Visual Analogue Scale (VAS) scores for pruritus. Investigator Global Assessment (IGA) and Quality of Life in Hand Eczema Questionnaire (QOLHEQ) were conducted at the end of 3 months. RESULTS: The HECSI, VAS score, and QOLHEQ showed a significant decrease in both groups from baseline to the third month. Intergroup comparisons of HECSI failed to reach the significance level. When compared, patients receiving apremilast had significantly better improvement in the third month according to the Patient Global Assessment (PGA) and Investigator Global Assessment (IGA). They also had a smaller number of flares. CONCLUSION: Adding apremilast to topical corticosteroid leads to better patient and physician-perceived improvement and reduces the number of flares in hyperkeratotic hand eczema.

Efficacy and safety of diode laser for facial hair reduction in hirsutism-a clinico-trichoscopic evaluation.

Background: Hirsutism is the presence of excessive terminal hair on androgen-dependent sites of the body. Lasers like Alexandrite, diode, and Nd:Yag lasers have been used for hair reduction with varying efficacy. Trichoscopy of hair is a simple noninvasive method of hair assessment. However, it has not been used in the assessment of diode laser hair reduction. Objectives: This study aimed to assess the efficacy and safety of diode laser hair reduction in skin color with the help of clinical and trichoscopic assessment. Materials and Methods: This prospective observational study included 73 patients of hirsutism recruited in 18-month period. All participants received sessions of 805 nm diode laser at monthly intervals up to six sessions. Clinical and trichoscopic evaluation along with photographs were obtained at each visit. Side effects, if any, were noted in every sitting. Results: All patients were females of Fitzpatrick skin types III-V. All clinical parameters showed statistically significant hair reduction when compared with baseline. Trichoscopic parameters of hair reduction like total hair count, terminal hair count, and terminal/vellus hair ratio showed reduction compared to baseline which was statistically significant (P < 0.05). The most common side effect noted in our study was pain followed by erythema and perifollicular edema. Conclusions: Diode laser is an effective and safe procedure for the reduction of unwanted facial hair, even in darker skin types. We also wish to emphasize that trichoscopy for the assessment of laser hair reduction is a recent, noninvasive, simple, and underutilized tool. No serious adverse events were noted in our study.

Clinical triad with multi-biopsy histopathology as a reliable diagnostic marker of mycetomas: a retrospective review from a tertiary care center.

BACKGROUND: Mycetoma is a neglected tropical infectious disease which runs a prolonged and protracted course. Microbiological confirmation is diagnostic yet unreliable due to poor sensitivity and variable availability of culture facilities in resource poor settings. METHODS: A retrospective review was performed on electronic records (histopathology, microbiology, and radiology) of all patients who underwent skin biopsies with mycetoma as one of the clinical differential diagnoses from year 2016 to 2020. RESULTS: Out of 73 patients biopsied with a differential of mycetoma, 42 fit the clinical triad of swelling-sinuses-granules. After clinical, microbiological, pathological, and radiological correlation, 31 cases were of eumycetoma and seven were of actinomycetoma. Mean patient age was 37.58 ± 13.8 years with a male to female ratio 2.45 : 1 and mean disease duration of 11.31 ± 10.9 years. Histopathological findings revealed fungal hyphae in 18 cases and gram-positive bacteria in six cases. Fungal culture was positive in 13 cases with the three commonest organisms being Madurella mycetomatis in five cases, Fusarium and Aspergillus nidulans in two cases each. X-ray changes of soft tissue, bones, and joints were seen in 25 cases, and "dot-in-circle" sign was seen in eight of nine MRIs. CONCLUSION: Eumycetoma was more common than actinomycetoma in our setup, ratio being 4.43 : 1. A clinical triad of swelling, multiple sinuses and grainy discharge with any one diagnostic support (histopathology/radiology) is sufficient to make a definitive diagnosis of mycetoma in the absence of microbiological identification.

Teledermatology Services during COVID-19 Pandemic: Experience of a Tertiary Care center in Western India.

Background: Telemedicine has emerged as an important tool in providing patient care during the COVID-19 pandemic. Hence, we aimed to study the clinico-epidemiological profile of patients seen in the teledermatology outpatient department (OPD) during the COVID-19 pandemic. Material and Methods: Retrospective data analysis of records of patients, who consulted in telemedicine OPD from 20 April 2020 to 5 Feb 2021 was done. Results: Out of 2524 patients registered for teledermatology consultation, 2117 completed the process of teleconsultation. The mean age of patients was 35.59 ± 15.60 years. There was a male preponderance with 1372 (64.81%) patients while females were 745 (35.19%). 1773 (83.75%) patients were managed on telemedicine alone and 344 (17.42%) patients required face to face physical consultation. The most common disorder was dermatophytosis seen in 316 (17.82%) followed by hair disorders like androgenetic alopecia and telogen effluvium in 239 (13.48%), acne in 238 (13.42%) and dermatitis in 196 (11.05%). Blood investigations were advised in 365 (17.24%) patients and skin biopsy was advised in 23 (1.09%) patients. The major causes for incomplete teleconsultation procedure were no response to telephone calls in 207 (8.2%), 76 (3.01%) patients had taken a prior consultation and 60 (2.37%) patients didn't give consent for teleconsultation. Conclusion: Common dermatological diseases like tinea, acne, hair disorders and dermatitis can be managed on telemedicine alone. In India, there are fewer dermatologists per population, therefore telemedicine can be continued even after the pandemic is over in cases where diagnoses and treatment are straight forward.

Ichthyosis Follicularis, Alopecia, and Photophobia (IFAP) Syndrome: A Case Report and Review of Cases Reported from India.

Ichthyosis follicularis, alopecia, and photophobia (IFAP) syndrome is characterized by the triad of follicular keratotic papules, total to subtotal alopecia, and photophobia. We hereby report a case of IFAP syndrome in a 1-year-old boy who presented with all these classical features along with hyperkeratotic plaques over knees, plantar keratoderma, and umbilical hernia. Also, literature review of cases reported from India is being presented.