Chemical Peels for Melasma: A Systematic Review.

BACKGROUND: Melasma is a common chronic, relapsing pigmentary disorder that causes psychological impact. Chemical peels are a well-known therapeutic modality used for accelerating the treatment of melasma. OBJECTIVE: To review the published evidence on the efficacy and safety of chemical peels in the treatment of melasma. METHODS: A systematic review was done. A meta-analysis could not be done due to the heterogeneity of data. RESULT: The authors conducted a PubMed search and included prospective case series of more than 10 cases and randomized controlled trials (RCTs) that have studied the safety and/or efficacy of chemical peel in melasma. Out of 24 studies, 9 were clinical/comparative trials and 15 were RCTs. The total sample size was 1,075. The duration of the study varied from 8 to 36 weeks. Only 8 studies were split face. All studies used self-assessment, physician global assessment, and Melasma Area and Severity Index (MASI) for quantifying the results. Glycolic acid was found to be the most safe and effective in melasma. CONCLUSION: Chemical peels were found to be safe and effective in the management of melasma.

Emerging role of topical Janus kinase inhibitors in dermatological disorders: a review.

Janus kinase (JAK) refers to a family of tyrosine kinases that are involved in the production of proinflammatory mediators in response to various extracellular signals. The JAK-signal transducer and activator of transcription (STAT) pathway is an appealing target in many inflammatory illnesses as this pathway modulates immune cell activation and T-cell-mediated inflammation in response to several cytokines. The practical considerations of prescription for topical and oral JAK inhibitors (JAKis) in atopic dermatitis, vitiligo and psoriasis have been covered in prior publications. Currently, the US Food and Drug Administration has approved the topical JAKi ruxolitinib for atopic dermatitis and nonsegmental vitiligo. None of the remaining first- or second-generation topical JAKis have been approved for topical application in any dermatological indications so far. For this review, the PubMed database was searched using 'topical' and 'JAK inhibitor' or 'Janus kinase inhibitor' or the names of individual drug molecules as the keyword in the title with no date limits. The description of topical JAKi usage in dermatology from the literature was evaluated in each abstract. The current review concentrates on emphasizing the rising use of topical JAKis in both approved and off-label dermatological applications for both old and novel conditions.

Microneedling in Combination With 15% Trichloroacetic Acid Peel Versus 25% Pyruvic Acid Peel in the Treatment of Acne Scars.

BACKGROUND: Acne scars are a permanent disfiguring sequel of acne. OBJECTIVE: To compare the efficacy of microneedling with 15% trichloroacetic acid (TCA) peel versus microneedling with 25% pyruvic acid peel in the management of postacne scars. MATERIAL AND METHODS: Thirty patients with atrophic acne scars were randomized into 2 groups receiving microneedling on both sides of the face at 0,6, and 12 weeks and 15% TCA on one side and 25% pyruvic acid on other side at 3,9, and 15 weeks. Acne scar scoring performed using the Echelle D'Evaluation Clinique des Cicatrices D'Acne (ECCA) and visual analogue scales by patient and physician were used to grade improvement at all visits and at 21 weeks. RESULTS: The mean ECCA score on the TCA side declined from 151.17 ± 26.90 to 138.83 ± 30.56 and on the pyruvic side declined from 151.83 ± 27.53 to 141.33 ± 28.92 after 21 weeks (statistically significant: p-value <.05). Comparing the ECCA on the TCA and pyruvic sides at 21 weeks was not significant. VAS showed moderate-to-marked improvement after 3 months in both groups. CONCLUSION: In our study, the combination modality showed early reduction in rolling and boxcar compared with icepick scars. These peels led to improvement in overall texture of the skin, hence more patient satisfaction. On comparing ECCA, a significant difference was not observed.

Platelet-Rich Plasma in Melasma-A Systematic Review.

BACKGROUND: Melasma is a common relapsing hyperpigmentation disorder, which is often difficult to treat. Platelet-rich plasma (PRP) is a novel modality often used to treat acne scars, androgenic alopecia, chronic wounds, and skin rejuvenation. Recently, it has had a promising role in the treatment of melasma. OBJECTIVE: To review the published evidence on the efficacy and safety of PRP in the treatment of melasma. MATERIALS AND METHODS: A systematic review was performed. A meta-analysis could not be performed because of methodological differences across studies and data heterogeneity. RESULTS: Seven studies were fulfilled and analyzed. Most studies used intradermal injections of PRP and have shown significant improvement in melasma. Microneedling mediated delivery of PRP has been tried in melasma with good results. A single study showed no additional benefit of PRP in patients treated with topical tranexamic acid. Another study showed no benefit of intense pulsed light in patients treated with intradermal PRP. CONCLUSION: Platelet-rich plasma inhibits the melanin synthesis through its various components acting through several mechanisms. It demonstrates a moderate grade of recommendation according to the Oxford Center for Evidence-Based Medicine 2011 standards.

Role of Platelet-Rich Plasma Therapy as an Adjuvant in Treatment of Melasma.

BACKGROUND: The management of melasma is an ongoing challenge. Platelet-rich plasma (PRP) therapy has been reported to be beneficial, but there is paucity of studies on PRP therapy in melasma. OBJECTIVE: To compare the efficacy of PRP therapy and hydroquinone versus hydroquinone alone in melasma. MATERIALS AND METHODS: Thirty patients were randomized to receive PRP microinjections on one side and normal saline on the other in a total of 3 sittings. Patients were concurrently advised 4% hydroquinone (HQ) cream application on both sides of the face. Efficacy was evaluated with hemi-modified Melasma Area Severity Index (MASI) scoring and a 4-scale patient satisfaction grading. RESULTS: Majority of the subjects (53.3%) in PRP + HQ group and 76.7% in HQ group had 25% to 50% improvement in their MASI scores. However, 40% in the PRP + HQ group and only 3.3% in the HQ group had 51% to 75% improvement. The difference in the percentage improvement was statistically significant. There was a greater percentage of subjects reporting a good response among the HQ + PRP group (53.3%) as compared with the HQ group (27%). CONCLUSION: Microinjections of PRP combined with topical HQ has better efficacy than topical HQ alone.

Dermatological therapies with relevance to COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel single-stranded RNA virus that has gripped humanity all over. It affects primarily the respiratory system, but is not limited to it, causing widespread involvement of many organ systems. The cases are still rising at an exponential rate and manifold trials are on to test different agents with the hope for potential limitation of spread and control of symptoms. Various classes of drugs have been tried; some with moderate success while many are yet to be proven to be of definite benefit. We have observed that the drugs used in dermatology practice are featured in more than a few of such studies. Here, we wish to highlight the ones that we are familiar with, which has featured at some point, in the management of this very challenging pandemic.

Mental distress in dermatologists during COVID-19 pandemic: Assessment and risk factors in a global, cross-sectional study.

There is a sparsity of data regarding the mental health status of dermatologists during COVID-19 pandemic. Evaluate the effects of pandemic on mental health of dermatologists on a large scale and identify risk factors for mental distress. 733 dermatologists were included in this cross-sectional, web-based survey. Mental distress was reported by 77.2% of responders. Considerable percentages of participants experienced stress (73.9%), irritation (33.7%), insomnia (30%), or depression (27.6%), and 78.6% were overwhelmed with the amount of pandemic information they were receiving. Mental distress was significantly associated with practice years, volume of patients seen per week before pandemic, personal protective equipment availability at hospital (P = .001 for each), practice location (continent; P < .001), and participant's assessment that the healthcare system was not equipped for the pandemic (P = .003). Stress was associated with hospital service (P = .003), and depression with being overwhelmed with the amount of pandemic information received (P = .004). In a logistic model, teledermatology use was the most powerful predictor of mental distress (OR, 1.57 [95% CI, 1.07-2.32]). Mental distress was common among dermatologists during this pandemic. Teledermatology use was the most powerful predictor of mental distress. Preventative strategies and psychosocial interventions should be implemented.

Childhood atopic dermatitis-An Indian perspective.

Developing countries such as India can offer unique perspectives on and contributions to knowledge of and the literature on atopic dermatitis, including information on epidemiology, the role of environmental factors, clinical features, and treatment strategies in resource-poor settings using indigenous methodologies. This report will help in understanding atopic dermatitis in the Indian diaspora as well.

Treatment of Postinflammatory Hyperpigmentation With a Combination of Glycolic Acid Peels and a Topical Regimen in Dark-Skinned Patients: A Comparative Study.

BACKGROUND: Facial postinflammatory hyperpigmentation (PIH) is challenging to manage in patients with skin of color because of the risk of subsequent treatment-related hyperpigmentation. OBJECTIVE: To evaluate the safety and efficacy of combining glycolic acid (GA) peels with a modified Kligman formula (MKF) containing hydroquinone 2%, tretinoin 0.05%, and hydrocortisone 1% for the treatment of facial PIH in Indian patients. METHODS: Thirty Indian patients (Fitzpatrick skin Types III-V) with facial PIH were randomly assigned to 2 groups of 15 each. One group received serial GA peels combined with an intervening topical regimen containing MKF. The other group received MKF alone. Results were evaluated by a clinical investigator at baseline and at the end of 21 weeks (3 weeks after treatment completion) using an objective scoring system, the Hyperpigmentation Area and Severity Index (HASI) score, and clinical photography. RESULTS: The baseline mean HASI scores of the 2 groups were comparable. There was a statistically significant difference in the mean HASI score of the peels group compared with the MKF alone group at 12 weeks (p = .004) and 21 weeks (p < .001). Side effects were observed in both groups and were managed with liberal application of emollients. No patient dropped out of the study as a result of the side effects. CONCLUSION: This study demonstrates that serial GA peels in combination with a MKF are efficacious and safe in the treatment of facial PIH in dark-skinned patients.

Aquagenic cutaneous disorders.

Aquagenic cutaneous disorders, which include aquagenic urticaria, aquagenic pruritus, and aquagenic acrokeratoderma, are a group of rare diseases characterized by skin lesions or discomfort induced by brief contact with water. Aquagenic urticaria is characterized by pruritic wheals that occur at the sites of water contact, either immediately or within minutes, and disappear within 30-60 min after water removal. Aquagenic pruritus presents with severe pruritus or a stinging, tingling, or burning sensation without any visible skin changes. These symptoms occur immediately or within minutes after the skin is exposed to water, lasting for one hour or longer. Aquagenic acrokeratoderma usually presents with whitish papules and plaques, edema, and hyperwrinkling within 2-20 min after brief exposure to water; symptoms disappear within minutes to one hour after drying. The pathomechanisms of these diseases are not yet fully understood, and their diagnosis is primarily based on clinical features. Treatment remains a challenge. Herein, we review the literature regarding these unusual disorders.

Comparative Evaluation of Efficacy and Tolerability of Glycolic Acid, Salicylic Mandelic Acid, and Phytic Acid Combination Peels in Melasma.

BACKGROUND: Melasma is acquired symmetric hypermelanosis characterized by light-to-deep brown pigmentation over cheeks, forehead, upper lip, and nose. Treatment of this condition is difficult and associated with high recurrence rates. Chemical peels have become a popular modality in the treatment of melasma. OBJECTIVE: To compare the therapeutic efficacy and tolerability of glycolic acid (35%) versus salicylic-mandelic (SM) acid (20% salicylic/10% mandelic acid) versus phytic combination peels in Indian patients with melasma. MATERIALS AND METHODS: Ninety patients diagnosed with melasma were randomly assigned into 3 groups of 30 patients each. Group A received glycolic acid (GA-35%) peel, Group B received SM acid, and Group C received phytic combination peels. Each group was primed with 4% hydroquinone and 0.05% tretinoin cream for 4 weeks before treatment. Chemical peeling was done after every 14 days in all groups until 12 weeks. Clinical evaluation using melasma area and severity index (MASI) score and photography was recorded at every visit and follow-up was done until 20 weeks. RESULTS: There was a decrease in MASI score in all 3 groups but it was statistically significantly lower in Group A than Group C (p = .00), and it was also statistically significantly lower in Group B than Group C (p = .00) but there was no statistically significant difference between Groups A and B (p = .876). Objective response to treatment evaluated by reduction in MASI scoring after 12 weeks was 62.36% reduction in GA group, 60.98% reduction in SM group, and 44.71% in phytic acid group. CONCLUSION: It is concluded that GA (35%) and SM acid peels are both equally efficacious and a safe treatment modality for melasma in Indian skin, and are more effective than phytic acid peels. Salicylic-mandelic peels are better tolerated and more suitable for Indian skin.

Lipoid Proteinosis: a case report in two siblings.

Lipoid proteinosis was first reported by Urbach and Wiethe in 1929. It is also known as hyalinosis cutis et mucosae or Urbach-Wiethe disease. It is a rare autosomal recessive disorder and characterized by the infiltration of hyaline material in the skin, oral cavity, larynx, and internal organs. Lipid proteinosis presents early in life. Hoarseness develops in infancy. The classic sign is beaded eyelid papules along the lid margin, also known as 'Monilform Blepherosis'. In India about 30 cases have been reported to date. We report the following case because of its rarity in the Indian literature.

Fever with Rash in a Child: Revisited.

Rash and fever are some of the most common chief complaints present in paediatric dermatology emergencies. The spectrum of differential diagnosis is broad, including many different infectious and some non-infectious agents. A systematic approach involving detailed history taking, careful clinical examination along with particular attention to epidemiological features are the most important factors to make a diagnosis. This article reviews the morphological patterns of various causes of fever with rash in children, including infectious as well as non-infectious causes, with special emphasis on the Indian scenario. We intend to highlight the clinical characteristics of each cause, which will not only help make a clinical diagnosis but also distinguish benign versus life-threatening causes of skin rash in febrile paediatric patients and provide early medical intervention.

Probiotics in Dermatology: An Evidence-based Approach.

Probiotics are viable microorganisms that confer health benefits when administered to the host in adequate amounts. Over the past decade, there has been a growing demand for the use of oral and topical probiotics in several inflammatory conditions such as atopic dermatitis, psoriasis, acne vulgaris, etc., although their role in a few areas still remains controversial. The objective of this article is to shed light on understanding the origin and implications of microbiota in the pathophysiology of these dermatological conditions and the effect of probiotic usage. We have conducted a comprehensive search of the literature across multiple databases (PubMed, EMBASE, MEDLINE, and Google Scholar) on the role of probiotics in dermatological disorders. Commensal microbes of the skin and gastrointestinal tract play an important role in both health and disease. Increased use of probiotics has asserted a good safety profile, especially in this era of antibiotic resistance. With the advent of new products in the market, the indications, mechanism of action, efficacy, and safety profile of these agents need to be validated. Further studies are required. Oral and topical probiotics may be tried as a treatment or prevention modality in cutaneous inflammatory disorders, thus facilitating decreased requirement for topical or systemic steroids and antimicrobial agents. Tempering microbiota with probiotics is a safe and well-tolerated approach in this era of antimicrobial resistance.

Clinical Spectrum of Dermatological Disorders at an Urban Health Center in East Delhi.

Dermatological disorders constitute a significant proportion of primary health care (PHC) setups. The pattern of dermatological disorders varies among different countries and different parts of the same country owing to climatic and geographical variations, level of education, access to health care, etc. To study the clinical spectrum of patients presenting with dermatological disorders at an urban health center (UHC) in East Delhi. To identify the various risk factors associated with dermatological disorders in study subjects. A total of 1,148 patients who reported skin diseases for the first time at the Dermatology Outpatient Clinic at UHC in East Delhi were recruited. Detailed demographic data, history, and examination and potential risk factors of skin diseases (socioeconomic status, level of education, occupation, comorbidities, and addictions) were recorded on a predesigned proforma. A total of 616 (53.7%) patients had infectious dermatoses and 532 (46.3%) had non-infectious dermatoses. Among the infectious dermatoses, fungal diseases (44.8%) were the most common followed by parasitic infections (31.17%) and bacterial infections (9.74%). Among the non-infectious group, eczematous disorders (28.01%) were the most common, followed by pigmentary disorders (21.62%) and acne (19.55%). A significant association between level of education, occupation, and comorbidities with the distribution of infectious and non-infectious dermatoses was found. As a significant proportion of patients with a vivid spectrum of dermatological disorders present at the PHC setups, therefore dermatologists supervise that specialty clinics should be held regularly at these centers along with the availability of all the basic investigations to aid diagnosis and management.

The Key Areas and Unmet Need of Mentorship Programs in Indian Dermatology: A Survey Based Analysis.

Background: Mentorship programs for dermatologists have been in vogue in the West for many years, but have been on a hiatus in India. Recently, there is renewed interest, and mentorship programs are gaining momentum across the country to guide and nurture young dermatologists to attain their full potential. However, what constitutes an ideal mentorship program is still an enigma. Materials and Methods: We developed a multiple-choice questionnaire (Google-form), enquiring post graduates and dermatologists about their general opinion of mentorship, its key areas and what constituted an ideal mentorship-program. These were distributed via email and WhatsApp and responses were collected over a month's period. The statistical analysis was carried out using Statistical Package for Social Sciences (SPSS) for Windows. Results: We received 202 responses and majority of the respondents were private practitioners (32.2%) and post graduate students (29.7%). Respondents felt that mentorship should be undertaken at the beginning of postgraduation (37.1%) or just after its completion (23.8%), and should focus on academic and research related issues (55.0%). Communication (95.5%) was an important factor for the program to be successful, and on an average, must be of seven weeks duration, with a mentor : mentee ratio of 1:2. We found a significant association between the designation of the respondent and their perceived ideal time for a mentorship program (P<0.001, Chi Square Test), seeking of mentorship beyond the program duration (P<0.01, Chi Square Test) and the type of mentorship program (P=0.01, Chi square test). Conclusion: Our survey concluded that a well-planned short mentorship program of six to eight weeks duration with a low mentee to mentor ratio with an informal style of mentoring in the formative years of one's career would be suitable in the Indian Dermatology scenario. Communication and availability emerged as important elements for a successful mentor mentee relationship. The positive effects of a well-planned mentorship program extend beyond its duration and enrich both the mentor and mentee.

Efficacy of 15% trichloroacetic acid peel versus 35% glycolic acid peel in acanthosis Nigricans: A randomized open-label study.

Introduction: Acanthosis Nigricans (AN) is an acquired disorder of keratinization. It presents as hyperpigmentation, velvety texture of skin that can involve any part of the body including the face. Different topical, systemic therapies, or physical therapies including laser have been explored. However, there are not many randomized controlled studies for the majority of therapy alternatives besides lifestyle modifications and weight reduction. Objectives: The aim of this study was to compare the effectiveness of 15% trichloroacetic acid (TCA) and 35% glycolic acid (GA) peel for AN. Materials and Methods: Forty participants were included and randomized into two groups. In groups A and B, peeling with 15% TCA and 35% GA was done, respectively. The effectiveness of each peel was assessed using changes in the Acanthosis Nigricans Area and Severity Index Score (ANASI) and Physician Assessment Score. Statistical analysis included Wilcoxon-Mann-Whitney test, Friedman test, and generalized estimating equations. Results: The overall change in ANASI over time was compared in the two groups using the generalized estimating equations method. A significant difference was observed in the trend of ANASI over time between the two groups (P < 0.001). TCA peel group showed more change in ANASI as compared with GA peel group. Conclusion: In our research, 15% TCA has a better efficacy when compared with 35% GA peel after three sessions of chemical peeling. We therefore recommend the use of 15% TCA peel in AN as a safe and effective treatment option. However, more comprehensive randomized control studies are required for supporting data.

Glutathione as a skin-lightening agent and in melasma: a systematic review.

Hyperpigmentary disorders, including melasma, are challenging to treat. Glutathione has anti-melanogenic and antioxidant properties, which led to its use as a skin-lightening agent. Our objective was to review the published evidence and literature on the efficacy and safety of glutathione as a skin-lightening agent and in the treatment of melasma. A literature search was done in the PubMed, Embase, and Cochrane library databases using the search terms "glutathione as a skin-lightening agent" and "glutathione in melasma" for the past 10 years. The level of evidence, strength of recommendation, and risk of bias assessment were evaluated. Among various forms of topical glutathione, glutathione 0.5% was significantly more effective compared to glutathione 0.1% and placebo. For glutathione alone versus glutathione plus microneedling, more improvement was seen. Five randomized controlled trials and a single open-arm clinical study on oral glutathione at doses of 250 mg once a day, 250 mg twice a day, and 500 mg once a day showed a significant reduction in the melanin index compared to placebo. The combination of topical 2% glutathione plus oral glutathione was superior to monotherapy alone. There was only one placebo-controlled study on intravenous (IV) glutathione [6/16 (37.5%) vs. 3 (18.7%), (p0.054)]. The risk of bias assessment showed that almost an equal number of studies have low and high risk of bias. Topical versus oral glutathione both provide moderately efficacious skin-lightening outcomes that are localized versus generalized and have minimal versus substantial adverse effects, but they are unsustainable, with variable costs. IV glutathione is contraindicated due to lack of efficacy and side effects. It may work more as an antioxidant in melasma.

Comparative study of flip-top transplantation and punch grafting in stable vitiligo.

BACKGROUND: Because of limitations of medical treatment in vitiligo, various surgical techniques have been devised. There is a scarcity of comparative studies of surgical techniques in vitiligo. OBJECTIVE: To compare the effectiveness and side-effect profile of flip-top transplantation (FTT) and punch grafting (PG) in patients with stable vitiligo. MATERIALS AND METHODS: Twenty patients with stable vitiligo were treated using PG and FTT on 26 lesions; 156 grafts were taken (78 PG, 78 flip-top grafts). They were graded for response in the form of repigmentation as excellent (91-100%), very good (76-90%), good (51-75%), fair (31-50%), poor (<30%). Onset and maximum pigment spread were observed. RESULTS: Sixty-five percent of our patients showed excellent repigmentation with FTT, versus 50% with PG (p = .44). Thirty percent of patients with FTT and 40% with PG had side effects. The differences in onset of repigmentation, completion, and pigment spread between the two techniques were statistically significant (p < .001). CONCLUSIONS: Flip-top transplantation was equally effective as PG for treating vitiligo, although graft uptake rate was higher with FTT, with more pigment spread, and cost less.