Topical and Systemic Therapies in Melasma: A Systematic Review.

Introduction: Melasma is an acquired disorder, which presents with well-demarcated, brown-colored hyperpigmented macules, commonly involving the sun-exposed areas such as the face. It is a chronic and distressing condition, affecting the patients' quality of life, and has been conventionally treated with "first-line" agents including hydroquinone (HQ) alone or as a part of a triple combination cream (TCC), while "second-line" options include chemical peels, and third line options include laser therapy. Materials and Methods: A systematic search was performed for all topical and systemic treatments for melasma up till May 4, 2021, using the PubMed and EMBASE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The search terms "melasma" and "treatment" were used to search for the relevant articles on both these databases, and a total of 4020 articles were identified. After removing the duplicate entries and screening the titles, abstracts, and full-text articles, we identified 174 randomized controlled trials (RCTs) or controlled clinical trials. Results: Based on our review, HQ, TCCs, sunscreens, kojic acid (KA), and azelaic acid receive grade A recommendation. Further large-scale studies are required to clearly establish the efficacy of topical vitamin C, resorcinol, and topical tranexamic acid (TXA). Several newer topical agents may play a role only as an add-on or second-line drugs or as maintenance therapy. Oral TXA has a strong recommendation, provided there are no contraindications. Procyanidins, Polypodium leucotomos (PL), and even synbiotics may be taken as adjuncts. Discussion: Several newer topical and systemic agents with multimodal mechanisms of action have now become available, and the balance seems to be tipping in favor of these innovative modalities. However, it is worth mentioning that the choice of agent should be individualized and subject to availability in a particular country.

De Sanctis-Cacchione Syndrome with Subdural Effusion: A Rare Case from India with Review of Literature.

De Sanctis-Cacchione syndrome (DCS) formerly known as xerodermic idiocy is characterised by cutaneous photosensitivity, microcephaly, mental retardation, short stature, hypogonadism, spasticity, peripheral neuropathy and sensorineural deafness. Here in, we present the case of a four and half years old male child with features of severe acute malnutrition (SAM) with a typical bird like facies and sunken eyes who had history of photosensitive pruritic pigmentary skin lesions on sun exposed areas from a very early age of six months. Gross developmental delay, ataxia, microcephaly, short stature, hypogonadism and cachectic wasting were identified on examination and hypertransaminasemia and hypothyroidism were recorded from biochemical profile. Subsequent visual evoked response and brainstem evoked response audiometry revealed anterior visual pathway dysfunction and bilateral profound sensorineural hearing loss. Magnetic resonance imaging of brain yielded subdural effusion with mass effect in addition to cerebro-cerebral atrophy and demyelination. Skin biopsy further detected dysplastic changes and early signs of squamous cell carcinoma (SCC). Although few cases are reported sporadically throughout the world, to our best of knowledge till date only 11 such cases have been reported completely in Indian medical literature which makes our case report the 12th one with distinctive novel association of subdural effusion.

Psoriatic Arthritis: A Comprehensive Update for Dermatologists with Review of Literature.

Psoriatic arthritis (PsA), an inflammatory seronegative spondyloarthropathy is the most common co-morbidity of psoriasis (PsO), in almost 30% of cases. Delayed diagnosis and treatment of PsA may result in irreversible joint damage, significant morbidity, impaired quality of life, and several cardiometabolic and cerebrovascular co-morbidities. Dermatologists are uniquely privileged to be able to diagnose latent PsA at an early stage, as almost 80% of these patients present with pre-existing cutaneous PsO. This review provides a detailed overview of PsA along with its salient clinical features, classification criteria, screening tools, simple physical examination maneuvers, imaging findings, and therapeutic options to acquaint dermatologists and other clinicians with this morbid musculoskeletal disorder. We hope to generate awareness about this condition among dermatologists to enable proactive screening of all PsO patients for early diagnosis, initiation of appropriate treatment, and prompt referral to a rheumatologist; thus, helping to arrest PsA disease progression, irreversible joint damage, and subsequent permanent disability.

Clinico-Epidemiology and Histopathologic Spectrum of Primary Scarring Alopecia: A Cross-Sectional Study.

Background: Primary scarring alopecias (PSAs) are a rare group of dermatological disorders with overlapping clinical features. They result in permanent hair loss and significant psychological morbidity. Aims: To analyze the clinico-epidemiology of PSAs of the scalp, along with clinico-pathological correlation. Methods: We conducted a cross sectional, observational study including 53 histopathologically confirmed cases of PSA. Clinico-demographic parameters, hair care practices, and histologic characteristics were noted and statistically analyzed. Results: Among 53 patients (mean age 30.9 ± 8.1 years, M: F 1:1.2, median duration 4 years) with PSA, lichen planopilaris (LPP) was most common (39.6%, 21/53), followed by pseudopelade of Brocq [30.2%, 16/53], discoid lupus erythematosus (DLE) [16.9%, 9/53], and non-specific scarring alopecia (SA) (7.5%, 4/53), while central centrifugal cicatricial alopecia (CCCA), folliculitis decalvans, and acne keloidalis nuchae (AKN) accounted for 1 case each. Forty-seven patients (88.7%) demonstrated predominant lymphocytic inflammatory infiltrate, while basal cell degeneration and follicular plugging were the commonest histological changes. Perifollicular erythema and dermal mucin deposition were noted in all patients with DLE (both P < 0.05). Nail involvement (P = 0.004) and mucosal involvement (P = 0.8) were more common in LPP. Single alopecic patches were characteristic of DLE and CCCA. Hair care practices (non-medicated shampoo > oil) had no significant association with the subtype of PSA. (P = 0.4). Conclusion: PSAs are a diagnostic challenge for dermatologists. Thus, histology and clinico-pathological correlation should be performed in all cases for proper diagnosis and treatment.

Clinical Dermatology and COVID-19 Pandemic: Narrative Review.

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

Sex Hormones, Metabolic Status, and Obesity in Female Patients with Acne Vulgaris Along with Clinical Correlation: An Observational Cross-Sectional Study.

BACKGROUND: Acne vulgaris is a common dermatological disorder. Several hormones are suspected to play a role in its etiopathogenesis. AIMS AND OBJECTIVES: The aim of this study was to analyze the role of sex-hormones, metabolic status, and obesity in acne vulgaris and correlate with its severity and symptom load. MATERIALS AND METHODS: This cross-sectional observational study included 89 female patients with acne vulgaris and certain phenotypic markers such as prepubertal onset, late-onset, persistent course, hirsutism, acanthosis nigricans, acrochordons, premenstrual flare, and diminished response to isotretinoin; suggestive of an underlying hormonal pathology. All patients were subjected to physical examination to rule out obesity and metabolic syndrome along with serum biochemistry to detect sex hormones (testosterone, progesterone, estrogen), serum insulin and insulin resistance (HOMA-IR) and lipid profile. RESULTS: Among 89 patients (mean age 21.3 ± 5.3 years), 34.8% presented with late-onset/persistent/pre-pubertal acne, 33.7% presented with premenstrual flare and 28.2% presented with hirsutism. Hormonal analysis revealed elevated testosterone and progesterone with low estrogen across all categories of patients. Testosterone was significantly elevated even in mild acne. Serum lipid profile was altered significantly only in hirsute females. In total, 36% and 20.2% patients presented with metabolic syndrome and obesity, respectively; however, neither was associated with severity of acne. CONCLUSION: Sex-hormones, serum lipids, metabolic status, and body mass index are altered in acne vulgaris. All acne patients with endocrine markers should be evaluated for sex-hormones irrespective of severity and symptom load, whereas hirsutism may be regarded as clinical marker of lipid abnormalities. Metabolic syndrome and obesity do not seem to be directly correlated with acne severity. Thus, anti-androgens may be considered as adjuvant therapy in these patients, not responding to conventional therapy.

Rosacea in skin of color: A comprehensive review.

Rosacea is a relatively common inflammatory dermatosis in persons with fair skin. It is uncommonly reported in people with skin of color (darker skin tone; Fitzpatrick skin types IV, V or VI). Apart from reduced incidence, underreporting due to decreased awareness might also be a probable explanation. Rosacea commonly presents with telangiectasias and persistent facial erythema on the sun-exposed parts, which can be distressing to the patient and affect the quality of life. The diagnosis is made clinically, in the absence of any confirmatory investigation. Several treatment modalities have been employed to date with varying results. Light-based therapies should be used cautiously in the colored skin to avoid distressing pigmentation. This article focuses on the pathogenesis, clinical features, treatment recommendations and other aspects of this uncommon disorder along with a review of the literature.

Safety of the current drug treatments for vitiligo.

Introduction: Vitiligo is an acquired depigmenting skin disorder adversely affecting the patient's quality of life. Despite the presence of several treatment modalities, ranging from medical to physical to surgical options, none is curative. Each modality has its own drawbacks and side effects. Thus, the treatment modality needs to be tailored for each individual patient taking into consideration the disease characteristics and also its efficacy and safety to obtain a favorable risk-benefit ratio.Areas covered: This review highlights the different treatment modalities utilized in vitiligo up until 4 November 2019 along with their adverse effects and contraindications, if any.Expert opinion: All the medications have their own adverse effects and contraindications. We have included the most commonly used topical corticosteroids, which may result in striae, cutaneous atrophy, and tachyphylaxis, to the recently introduced biologics, which may induce hypersensitivity reactions, systemic toxicities, and even malignancies. However, more long-term studies are needed to assess the safety of these medications, especially the newer ones, to provide a safe and effective treatment for this disorder.

Anatomy and Applications of the #15 Scalpel Blade and Its Variations.

Scalpels have been used to make skin incisions since the advent of "modern" dermatosurgery. #15 Scalpel blade and #3 handle (Bard-Parker handle) are most frequently used by a dermatosurgeon. Besides the proper equipment, appropriate technique is mandatory to ensure a "precise" incision. In this article, we discuss about the anatomy, variations, and different uses of the #15 scalpel blade and the ideal method of making a "precise" skin incision.

Clinical and Histopathological Response to Multidrug Therapy in Paucibacillary Leprosy at the end of 6 Months: A Prospective Observational Study from Eastern India.

BACKGROUND: At present, the WHO recommends fixed duration multidrug therapy (FD-MDT) for the treatment of leprosy, in which treatment is provided for a fixed duration regardless of clearance of skin lesions or bacterial status of the patient. There is divided opinion regarding the efficacy of FD-MDT; especially for paucibacillary Hansen's disease, in which treatment is provided for 6 months. In addition, there is a paucity of literature on clinical and histopathological features of treated leprosy. OBJECTIVES: The objectives of this study were to prospectively observe the effects of MDT on clinical and histopathological features in paucibacillary leprosy and to assess the efficacy, safety and tolerability of MDT-paucibacillary (PB) regimen. MATERIALS AND METHODS: A total of 52 new cases of PB leprosy diagnosed by clinicopathological correlation and slit skin smear were administered standard WHO PB-MDT for 6 months. Patients were reviewed at 3rd month and 6th month of therapy and 3 months posttherapy for their clinical and histopathological assessment. RESULTS: Among 52 new cases of PB-leprosy 43 patients (mean age 31.74 ± 12.2 years, m:f 1.53:1) completed the study as per protocol. Fourteen percent patients recovered completely, 76.7% patients had a residual patch at the end. Number of lesions reduced significantly 2nd follow-up onwards while the lesional size showed significant decrease 1st follow-up onward. Nerve palpability also reduced significantly at treatment completion. Histological improvement was appreciable; lymphocytic infiltration reduced significantly 2nd follow-up onward and presence of granuloma 1st FU onward. Only four patients complained of occasional, uneventful epigastric pain during the study. CONCLUSION: Although the frequency of persistence of lesions after completion of therapy was high, histological evidence of activity was present in a minority (7%). Thus, the standard WHO MDT-PB regimen was found to be effective, safe and well-tolerated.

Calcified Keratoacanthoma with Tumoral Calcinosis in a 10-year-old Boy: A mere Co-incidence?

Keratoacanthoma (KA) is a rapidly evolving benign cutaneous tumor, occurring in elderly individuals with a tendency towards spontaneous regression and histopathologic similarity to squamous cell carcinoma. Tumoral calcinosis is an uncommon condition, associated with the deposition of painless calcific masses. The occurrence of these two conditions in the same patient is a rarity itself, whereas deposition of calcium within the KA lesion in our 13-year-old patient makes it even more intriguing. Such an association has been seldom reported in the literature, and this prompted the current report.

CD8-positive Mycosis Fungoides Masquerading as Pyoderma Gangrenosum.

Mycosis fungoides (MF), a primary cutaneous T-cell lymphoma, accounts for <1% of non-Hodgkin lymphomas. The diagnosis of classic MF is based on a constellation of typical clinical presentation, histopathology, immunohistochemistry, and T-cell monoclonality detected by molecular studies. Rarely, atypical clinical presentation may occur. The typical immunohistochemical phenotype is, CD2 +ve, CD3 +ve, CD5 +ve, CD4 +ve, and CD8 - ve. Here, we report a rare case of CD8 +ve MF in a 43-year-male patient who was clinically diagnosed as pyoderma gangrenosum initially. The atypical presentation and rarity of such case have prompted this report.

A Weeping Tumor in a Young Girl: An Unusual Presentation of Nodular Hidradenoma.

A 10-year-old girl presented with a swelling on her left thigh that was associated with dripping of serous fluid from the lesion. Based on histological features of the excised tumor, a diagnosis of nodular hidradenoma was made. Atypical features including large size of the tumor, location on the lower limb, a weeping presentation, and histological finding of a nodular hidradenoma with an unusually large cystic cavity discharging fluid prompted us to report the case.