Review of facial acanthosis nigricans: Easy to diagnose and difficult to treat marker of hyperinsulinemia/metabolic syndrome.

Facial acanthosis nigricans (FAN) is an increasingly discussed anatomical variation of acanthosis nigricans (AN). Its presentation as brown to black pigmentation with ill-defined blurred margins with varying degree of textural changes commonly over forehead, temporal, and malar regions of the face predominantly in dark-skinned individuals with a male predilection can be confused with other common facial melanoses. Its pathogenesis, clinical features, and management are in many ways similar to in the commonly described areas like neck and major flexural areas. Understanding of FAN has gained momentum in the past decade with studies highlighting its association with various metabolic abnormalities particularly insulin resistance and obesity. It is now being considered to be a cutaneous marker of metabolic syndrome. While there is uniformity in its clinical description, there appears to be scope for further in depth biochemical and histopathological studies to link the pigmentation, altered texture and microscopic changes in individuals presenting with FAN and hyperinsulinemia with or without other features of metabolic syndrome. It awaits a consensus on grading its severity and correlating it with histological features as patients often hesitate to be subjected to a biopsy of the face. This is a review of current literature pertaining to FAN. Newer clinical, dermoscopic, histopathological, and biochemical insights will help to understand this relatively new entity.

Marking nut dermatitis: A case series on factitious dermatitis.

Marking nut or Bhilawa is the fruit of plant Semecarpus anacardium Linn (Family; Anacardiaceae). It belongs to Semecarpus genera which also includes cashew nuts. It is closely related to Rhus and Toxicodendron genera, which includes poison ivy and poison sumac and causes similar skin reaction due to the presence of compound urushiol. Marking nut dermatitis is an uncommon problem but has special importance in military dermatology. Individuals can get exposed to this plant during camping which can result in an irritant or allergic contact dermatitis. It can also be applied deliberately to cause factitious dermatitis. We present 5 cases of factitious dermatitis resulting from application of marking nut.

Infrared thermography in the diagnosis of palmar hyperhidrosis: A diagnostic study.

Background: Primary hyperhidrosis is a common condition affecting 1-3% of the general population. Excessive sweating leads to reduced surface temperature due to evaporation that can be captured using a thermal camera. We performed this study to find the utility of thermography in the diagnosis of palmar hyperhidrosis. Methods: This was a cross-sectional diagnostic study conducted in a tertiary care dermatology center during the study period Apr 20-Mar 21. Adult patients with palmar hyperhidrosis diagnosed by expert dermatologists were recruited. The severity was assessed using the hyperhidrosis disease severity scale (HDSS). The measurements were done using a FLIR™ thermal camera. A pilot study, including 30 patients and 30 controls were performed. The results of the pilot study were used for the calculation of sample size. Result: The study included 55 patients and 110 controls. The mean age of the patients and controls was 22.4 (±3) years and 21.7 (±2.5) years, respectively. The mean temperature difference in the patient and control group was found to be 19.6 (±3.3)0 F and 5.8 (±2.9)0 F, respectively (p < 0.001). A receiver operating characteristics curve (ROC) to assess the discriminatory ability of mean temperature difference in diagnosis of hyperhidrosis found the area under the curve (AUC) to be 0.995 and a temperature difference of 11.5 °F provides sensitivity and specificity of 98.2% and 97.3% for the diagnosis of hyperhidrosis. Conclusions: Thermal imaging is a simple, noninvasive, and objective tool for the diagnosis of hyperhidrosis. It has potential utility in monitoring the effect of the treatment.

An observational study of severe cutaneous adverse reactions at a tertiary care teaching hospital.

Background: The term severe cutaneous adverse reactions to drugs (SCAR) comprises of acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms complex (DRESS), Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS-TEN) and drug-induced erythroderma or exfoliative dermatitis (ED). The present study aims at describing the epidemiological and clinical profile, probable cause and the extent of morbidity and mortality in patients with severe cutaneous adverse drug reactions. Methods: An observational study of all cases of SCAR presenting to our centre during the period from Jun 2018 to July 2019 was carried out. Results: A total of 24 SCAR patients were studied. Most of the patients were in the age group of 11-20 years. The commonest reactions observed were SJS-TEN (54.2%) followed by DRESS (42%). Antibiotics are the most common cause of SJS-TEN, whereas almost all the drug groups were implicated equally in DRESS. No causative drug could be found in two of the SJS-TEN patients. These patients had raised atypical targetoid lesions as well as evidence of viral reactivation which could have been the probable trigger for the SCAR. A total of five patients (20.8%) died during treatment in hospital, and the percentage mortality was highest in SJS-TEN. Conclusion: Nondrug aetiologies for SJS-TEN are on the rise, and this was observed in this study too. Viral reactivation may be the commonest aetiology in such cases, and the morphology of the rash can give a clue to such cases.

Resurgence of syphilis, the great imitator.

Syphilis, one of the earliest diseases to be discovered in humans, still remains an enigma when it comes to its myriad manifestations and changing epidemiological profiles. There has been a surge in cases in the last few decades due to various factors. The human immunodeficiency virus (HIV) epidemics, global travel, increased incidence of male to male sexually transmitted diseases, online relationships culminating in casual sex are few of the important factors. Increased awareness could also be a factor for increased diagnosis. The multitude of clinical features especially when it comes to secondary syphilis and the rare tertiary manifestations, which can mimic various systemic disorders still pose a diagnostic challenge to the best of venereologists and physicians. This review aims to discuss the causes of resurgence in syphilis and few recent developments in pathogenesis, which could have led to this resurgence.

Literature search: Simple rules for confronting the unknown.

Literature search forms the foundation of most clinical decisions about patient management and is the starting point for all bedside/bench-side research. Despite being an essential tool in the armamentarium of all medical professionals and researchers, literature search remains a challenge, often resulting in frustration and waste of time (and resources). This article aims to provide a beginner's guide to information seekers for a step-wise approach to literature search on web-based databases.

Precision medicine: Concept and tools.

Precision medicine is the new age medicine and refers to tailoring treatments to a subpopulation who have a common susceptibility to a particular disease or similar response to a particular drug. Although the concept existed even during the times of Sir William Osler, it was given a shot in the arm with the Precision Medicine Initiative launched by Barack Obama in 2015. The main tools of precision medicine are Big data, artificial intelligence, the various omics, pharmaco-omics, environmental and social factors and the integration of these with preventive and population medicine. Big data can be acquired from electronic health records of patients and includes various biomarkers (clinical and omics based), laboratory and radiological investigations and these can be analysed through machine learning by various complex flowcharts setting up an algorithm for the management of specific subpopulations. So, there is a move away from the traditional "one size fits all" treatment to precision-based medicine. Research in "omics" has increased in leaps and bounds and advancements have included the fields of genomics, epigenomics, proteomics, transcriptomics, metabolomics and microbiomics. Pharmaco-omics has also come to the forefront with development of new drugs and suiting a particular drug to a particular subpopulation, thus avoiding their prescription to non-responders, preventing unwanted adverse effects and proving economical in the long run. Environmental, social and behavioural factors are as important or in fact more important than genetic factors in most complex diseases and managing these factors form an important part of precision medicine. Finally integrating precision with preventive and public health makes "precision medicine" a complete final product which will change the way medicine will be practised in future.

Precision medicine: Uses and challenges.

Precision medicine has brought in many changes to the practise of medicine. The omics-based development of biomarkers and pharmaco-omics-based drug development programmes are evidences for the advancement. However, the field where it has proved to be most useful is in the development of various modalities of treatment in oncology. Various drugs targeting vascular endothelial growth factor, epidermal growth factor, tyrosine kinase receptor and rat sarcoma mutations have come to the forefront proving to be beneficial in many cancers. Some of the classic drugs developed using this concept include trastuzumab, bevacizumab, cetuximab and panitumumab among others. Precision medicine has been put to best use in the COVID-19 pandemic through use of various biomarkers such as IL-6 and c-reactive protein in assessing severity of disease, for development of various therapies and also to judge efficacy of vaccines. Precision medicine is also finding its place in management of infectious diseases, chronic diseases such as asthma, connective tissue diseases, cardiovascular diseases, diabetes and obesity. India has also made its presence felt in the field by launching various initiatives such as the Indian genome project and Indian cancer genome atlas. Numerous challenges still exist to the future of precision medicine such as cost involved, ethics, security of the Big data, merger of various platforms to integrate data and also availability of trained manpower to manage the data and algorithms. This new age medicine is a big step forward for mankind and hopefully it will bring more benefits for both patients and the caregivers in the near future.

Hair transplantation by follicular unit extraction for male androgenetic alopecia: A retrospective observational study from two centers.

BACKGROUND: Follicular unit extraction (FUE) is the most popular method of hair transplantation in today's world. Hair transplantation in androgenetic alopecia (AGA) in males can restore the frontal hairline and provide hair density in alopecic areas to the satisfaction of most patients. METHODS: Consecutive male patients of AGA who underwent hair transplantation by FUE method in two centers between the period of January 2016 and June 2017 have been included in this study based on inclusion and exclusion criteria. Photographic images, trichoscopy and Likert's scale were used to assess patient's improvement in hair density after the transplantation procedure. Statistical methods using SPSS software was used to analyze the results. Institutional ethical clearance and patients' written consent for procedure and images was obtained. The study was an observational retrospective study using data and images from records for which consent and ethical clearance was obtained from patients and the institution. RESULTS: Average number of follicular units transplanted in patients was 1290 (improvement in hair density: of 30.61 follicular units/sq cm). There was a statistically significant difference in improvement in hair density in patients younger than 33 years and in patients with Norwood classification below stage 4a. Forty-nine patients were satisfied with the results after assessment by the Likert scale. CONCLUSION: Hair transplantation by follicular extraction method provides good hair cover in AGA in males. This modern dermatosurgical technique with its many innovations is a very helpful technique to improve quality of life in male pattern baldness.

Bullous erythema nodosum leprosum manifesting in the post partum period with unusual features.

A 30 year old woman who presented with multiple numb patches on the body was initially diagnosed as borderline lepromatous leprosy and started on multidrug therapy for leprosy. She had an episode of Type 1 reaction during the fifth month of pregnancy. After delivery, she stopped therapy fearing harm to her child and developed an episode of Type 2 reaction. The reaction was unusual in that bullous lesions developed over previous leprosy patches which had initially become indurated, with associated neuritis. Histopathology revealed bullae with intense neutrophilic reaction and strong positivity for acid fast bacilli. There was no response to steroid therapy which was started for the reaction. Thalidomide had to be prescribed after stopping lactation by medical means. She responded dramatically to Thalidomide with regression of cutaneous lesions and neuritis. This patient is being reported as a very unusual manifestation of bullous erythema nodosum leprosum in the postpartum period responding dramatically to thalidomide.

A unique association of unilateral idiopathic calcinosis cutis with ipsilateral porokeratotic eccrine ostial and dermal duct nevus.

An 11-year-old boy presented with complaints of multiple skin-colored hard lumps on the right side of his body and progressive deformity of the right leg of 7-years duration. His parents had also noticed multiple asymptomatic pits over his right arm, palms, and soles since childhood. Examination revealed skin-colored nontender nodules on the right half of his body and shortening of his right leg. The multiple hyperpigmented pits over the right arm, palm, and sole raised diagnostic difficulties, but histopathologic, radiologic, and biochemical investigations confirmed the features of idiopathic calcinosis cutis and porokeratotic eccrine ostial and dermal duct nevus. Unilateral idiopathic calcinosis cutis has not been previously reported in the literature, and the association with ipsilateral porokeratotic eccrine ostial and dermal duct nevus makes this case unique. Diagnostic difficulties and limited options for treatment make this case interesting academically.

Vitamin D Deficiency After Oral Retinoid Therapy for Ichthyosis.

Oral retinoids are being increasingly used to treat ichthyotic disorders in children. We report on two children with ichthyotic disorders who developed unusual manifestations after they were started on oral retinoids. The first case is a 10-year-old girl with nonbullous ichthyosiform erythroderma and the second is a 2-year-old girl with lamellar ichthyosis. The child with ichthyosiform erythroderma developed features of rickets within months of initiation of systemic retinoids. Her baseline examination before initiation of oral retinoids was normal. The second patient with lamellar ichthyosis was found to have low vitamin D levels after 6 months of retinoid therapy, and prompt supplementation reversed the levels in 2 months. These cases are being reported to bring attention to the probable need for initiation of vitamin D supplementation with systemic retinoid therapy in ichthyotic disorders in children.

Utility of absolute lymphocyte count as a surrogate marker of CD4 cell counts: Is it useful?

BACKGROUND: Human immunodeficiency virus (HIV) management has witnessed paradigm changes over the past decade. In the early era, Absolute lymphocyte counts (ALC) were used as an inexpensive, indirect marker of immunity status. With time, CD4 lymphocyte counts and HIV RNA levels have become a standard of care for follow up of people living with HIV/AIDS (PLHA). Wide disparities between resource rich and poor countries, rekindles the need for an inexpensive surrogate marker for CD4 lymphocyte counts. Multiple studies in the past including one by Sen S et al, in 2011 did not validate ALC as a surrogate marker of CD4 lymphocyte counts and had recommended a similar study at another centre to validate the same.(1) Recently few publications have suggested that ALC may be used as a proxy marker to CD4 lymphocyte counts in resource poor areas.(2) With this backdrop we decided to evaluate the association if any, of ALC as a surrogate marker to CD4 lymphocyte counts. METHODS: ALC and CD4 lymphocyte counts measurements of 241 patients at our HIV/AIDS referral centre were assessed over a period of 13 months. RESULTS: Pearson correlation coefficient, coefficient of determination and standard statistical methods revealed modest linear correlation between ALC and CD4 lymphocyte counts which was statistically significant but did not have clinical significance. CONCLUSION: We recommend that time has come to call curtains down on ALC as a surrogate marker for CD4 lymphocyte count.

A comparative study of efficacy of cultured versus non cultured melanocyte transfer in the management of stable vitiligo.

BACKGROUND: Replenishing melanocytes by autologous melanocytes selectively in vitiliginous macules is a novel and promising treatment. With expertise in culturing autologous melanocytes, it has now become possible to treat larger recipient areas with smaller skin samples. To determine the relative efficacy of cultured versus non cultured melanocyte transfer in the management of stable vitiligo. METHODS: The melanocytes were harvested as an autologous melanocyte rich cell suspension from a donor split thickness graft. Cultured or non cultured melanocytes were then transplanted to the recipient area that had been superficially dermabraded. 100 patches of vitiligo in patients reporting to this hospital were randomly allocated into 2 groups to receive either of the interventions. RESULTS: An excellent response was seen in 62.17% cases with the autologous melanocyte rich cell suspension technique and in 52% with the melanocyte culture technique. CONCLUSION: Autologous melanocyte transplantation can be an effective form of surgical treatment in stable but recalcitrant lesions of vitiligo. Large areas of skin can be covered with a smaller donor skin using melanocyte culture technique; however culture method is more time consuming, and a labour intensive process, requiring state of the art equipments with a sterile lab setup.

Severe cutaneous adverse drug reactions.

Severe cutaneous drug reactions are one of the commonest medical challenges presenting to an emergency room in any hospital. The manifestations range from maculopapular rash to severe systemic symptoms like renal failure and cardiovascular compromise. Toxic epidermal necrolysis, erythroderma, drug rash with eosinophilia and systemic symptoms, acute generalised exanthematous pustulosis and drug induced vasculitis are the common cutaneous drug reactions which can have severe morbidity and even mortality. Careful history taking of the lag period after drug intake and associated symptoms, along with detailed examination of the skin, mucosa and various systems, help in early diagnosis of these reactions. Early stoppage of the incriminating drug, specific therapy including corticosteroids, cyclosporine and intravenous immunoglobulin depending on the case along with supportive therapy and local measures help in salvaging most patients. An overview of these important cutaneous drug reactions along with their management is being reviewed in this article.