Photodermatoses in the Pigmented Skin.

Skin colour (specifically in relation to its melanin content and composition) has a marked influence on its interaction with ultraviolet light. Eumelanin has mainly photoprotective properties while pheomelanin has the ability to cause formation of reactive oxygen species. This difference is responsible for the difference in incidence and presentation of various idiopathic photodermatoses in dark skinned patients compared to those with lighter skin types. Certain conditions are peculiar to darker skins including pin point popular variant of polymorphous light eruption. These differences are discussed in this chapter while also highlighting the challenges faced in performing phototesting in patients with dark skin.

Cutaneous Mucormycosis: A Fatal Complication of Immunosuppressant Therapy for Pemphigus Vulgaris.

A 62-year-old man with no comorbidities presented to the outpatient department of our Institute with a history of extensive vesiculobullous and erosive skin lesions and oral erosions for 2 months and fever for 1 week. A diagnosis of pemphigus vulgaris was made based on histopathology and direct immunofluorescence of a skin biopsy specimen, and the patient was started on oral prednisolone 40 mg per day along with intravenous antibiotics (amoxicillin-clavulanic acid, gentamicin, and metronidazole) empirically, pending blood and skin swab culture and sensitivity reports. His biochemical and hematologic investigations revealed no abnormalities (hemoglobin 12.4 g/dl, leukocyte count 6500/mm3, platelet count 250,000/mm3), and blood and skin cultures were sterile. When the fever had subsided and while he was receiving antibiotics, he was administered intravenous dexamethasone-cyclophosphamide pulse therapy over 3 days. After this, he was discharged on oral amoxicllin/clavulinc acid 625 mg tid, prednisolone 40 mg daily, and cyclophosphamide 50 mg daily. At the time of discharge, the erosions on the anterior region of the chest were reepithelializing without any evidence of eschar.

Repigmentation of leukotrichia due to retrograde migration of melanocytes after noncultured epidermal suspension transplantation.

BACKGROUND: Although leukotrichia in vitiligo is troublesome, no study has been performed with a large number of patients undergoing surgical or medical vitiligo treatment giving importance to its improvement. OBJECTIVE: To evaluate retrospectively the improvement of leukotrichia after a modified procedure of autologous noncultured epidermal suspension transplantation. METHODS: Individuals with stable vitiligo (N = 31) were included, and 42 lesions with leukotrichia were treated. Autologous noncultured epidermal suspension was prepared from split skin graft and transplanted to the dermabraded recipient area using a new modified procedure. Patients were given methylcobalamin and advised to get daily sun exposure after dressing removal. Follow-up ranged from 6 months to 1 year. Retrospective assessment was based on percentage improvement of leukotrichia according to photographs. RESULTS: There was improvement of leukotrichia in 37 of 42 (88.1%) treated lesions. Improvement was faster in body hairs than pubic hairs and hair on the face and scalp. No significant adverse events were reported. CONCLUSION: Although retrograde migration of melanocytes in the improvement of leukotrichia was observed in surgical management of vitiligo, this is the first study with a large number of patients using noncultured epidermal suspension transplantation.

Photodermatoses in pigmented skin.

Photodermatoses are a group of skin diseases primarily caused by, or exacerbated by exposure to ultraviolet and or visible radiation. The effect of sunlight on skin depends on a number of factors including skin colour, skin phototype and the content and type of melanin in the skin. There are only a few studies describing photodermatoses in populations with dark skin. A PubMed search was conducted to summarize currently available information on differences in biology of melanin in dark and light skin and photodermatoses in dark skin. Dark skin is characterised by higher content of melanin, higher eumelanin to pheomelanin ratio, lower tyrosinase activity, and more effective distribution of melanin for protection against ultraviolet light. Photodermatoses are common in dark skinned patients with some variation in the spectrum of photodermatoses. Polymorphous light eruption (PMLE) is the commonest, followed by chronic actinic dermatitis. Pin-point papular and lichenoid variants of PMLE and actinic lichen planus are more frequent in dark skin whereas actinic prurigo, solar urticaria and hydroa vacciniforme are uncommon. Photodermatoses are common in dark skinned patients despite better natural photoprotection. It is proposed that lichenoid photodermatoses may be added to the classification of photodermatoses in dark skin.

Procedural dermatology and its unmet need.

Procedural dermatology includes invasive conventional dermatologic surgeries which involve significant use of knife and suture, minimally invasive procedures and device-based procedures. Device-based procedures are the easiest to learn and are less prone to human errors due to automation but can lead to monotony, while conventional surgeries require significant skill, craftsmanship and interest. There has been a recent shift in the approach to procedural dermatology as a therapeutic option with complementary and combination models replacing the conventional hierarchical model in which procedures were last in the step-ladder approach. The demand for both conventional dermatologic surgeries and minimally invasive cosmetic procedures is increasing. Unfortunately, this demand has not been met with adequate supply. Consequently, the number of trained professionals with expertise in these procedures is very limited; they are far outnumbered by unqualified practitioners. A limited number of dermatologic surgeons practicing conventional surgeries has resulted in huge waiting lists for vitiligo surgeries, inappropriate excisions for skin cancers and poor cosmetic outcomes of excisions without proper knowledge of flaps and grafts. Increasingly procedures are being performed by inadequately trained personnel, resulting in complications. There is also an absence of good quality research on the subject of procedural dermatology, which has resulted in a lack of standardisation of various procedures and knowledge about the efficacy of various drug-procedure and procedure-procedure combinations. An increasing variety of gimmicky but costly procedures are being offered to the public without much evidence of efficacy. Individual institutional and broad policy directives are needed to address these issues. Special emphasis is required on formal hands-on procedural dermatology training during residency and beyond it.

Symmetrical Centrofacial Erythematous Plaques and Papules: A Clinicopathological Challenge.

Facial papular eruptions remain a diagnostic dilemma for the dermatologist with a wide range of inflammatory and infectious conditions manifesting in this manner. Here, we present a case of a 29-year-old, otherwise healthy man from North India with asymptomatic well-defined normoaesthetic symmetrical papules and plaques over the upper and mid-face of 3 months duration. Skin biopsy showed perivascular and periappendageal well-defined collections of foamy macrophages and epithelioid cells in superficial and deep dermis, characteristic of borderline lepromatous leprosy. Though acid-fast stain for lepra bacilli was negative both on lesional biopsy specimen and lesional and ear lobe slit skin smear, a 16s ribosomal ribonucleic acid (16s-r-RNA) polymerase chain reaction on skin biopsy specimen was found to be positive for lepra bacilli. A final diagnosis of borderline lepromatous leprosy in type I reaction was made and the patient received World Health Organization (WHO) multibacillary (MB) multidrug therapy along with oral steroids. This case highlights the unusual localized involvement in a case of MB leprosy lacking all the three cardinal features of leprosy, i.e. sensory loss, peripheral nerve involvement, and acid-fast bacilli positivity on biopsy or slit skin smear but diagnosed on the basis of characteristic histology and positive polymerase chain reaction results.

Disease Stability in Segmental and Non-Segmental Vitiligo.

INTRODUCTION: Some therapeutic decisions in vitiligo depend on the likelihood of the disease remaining stable and inactive. AIM: To determine a period of disease stability in vitiligo following which reactivation was unlikely. MATERIALS AND METHODS: This cross-sectional descriptive study was carried out in 200 patients where a detailed clinical history of the disease activity and stability over the course of vitiligo was recorded. RESULTS: There were 167 (83.5%) patients with non-segmental vitiligo and 33 (16.5%) with segmental vitiligo. For every 1-year increase in the duration of the disease, stable and active periods increased by 0.7 and 0.3 years, respectively in non-segmental vitiligo and by 0.9 and 0.1 years in segmental vitiligo (P < 0.01). When segmental vitiligo was stable for at least 2 years, it was five times less likely to re-activate than the disease that was stable for less than 2 years (P = 0.16). However, in non-segmental vitiligo, we found no association between the duration of stability and risk of reactivation. CONCLUSIONS: Segmental vitiligo usually becomes inactive after the disease has been stable for 2 years. Non-segmental vitiligo is prone to reactivation even after prolonged periods of stability.

Seroprevalence of Strongyloides infection among steroid recipients in a tertiary care centre in North India.

Background: Strongyloides stercoralis (S. stercoralis), a unique parasite, can cause mortal disease even years after the exposure. Iatrogenic use of steroids can complicate asymptomatic infections to a life-threatening hyperinfection and/or disseminated infection. Data regarding seroprevalence of strongyloidiasis remains scarce and this knowledge gap needs due attention in many endemic countries including India. Aim: The present study is aimed at assessing the seroprevalence of Strongyloides infection and the need for routine screening among individuals receiving steroid therapy. Methodology: Eighty patients receiving steroid therapy and thirty healthy volunteers who had not received any immunosuppressive drugs and/or anthelminthic therapy in last six months were enrolled as cases and controls respectively and they were screened by Strongyloides IgG ELISA. Results: Among the 80 patients on steroids, the mean cumulative prednisolone equivalent dose received was 8.2 g (±11.2 g) for a mean duration of 184 days, 16 patients (20%, 95% CI 11.9-30) had a positive Strongyloides IgG serology. Only 4 controls (4/30, 13.3%, CI 3.8-30.7) tested positive (p=0.4). Conclusions: Our study demonstrated a Strongyloides seroprevalence of 20% in the study population emphasizing the need for screening for Strongyloides infection prior to immunosuppressive therapy in order to prevent hyperinfection or possible dissemination.

Autologous noncultured melanocyte transplantation for stable vitiligo: can suspending autologous melanocytes in the patients' own serum improve repigmentation and patient satisfaction?

BACKGROUND: Vitiligo is a cosmetically disfiguring acquired depigmenting disorder caused by the loss of functional melanocytes from the epidermis. Various approaches that have been used for the treatment of vitiligo can be classified as medical and surgical therapies. Noncultured autologous melanocyte transplantation is a new and effective surgical treatment for stable vitiligo. OBJECTIVES: To compare the repigmentation results in stable vitiligo of transplantation of autologous noncultured melanocytes suspended in normal saline with that of those suspended in the patient's own serum. METHODS AND MATERIALS: Twenty-five patients with 36 lesions of stable vitiligo were randomized into two groups for noncultured melanocyte transplantation. Patients in Group A received melanocytes suspended in normal saline, and those in Group B received melanocytes suspended in their own serum. RESULTS: Statistically significant difference in repigmentation results and reduction in Dermatology Life Quality Index (DLQI) score was observed between the two groups 16 weeks after surgery. Repigmentation results were excellent (>90%) and very good to excellent (>75%) in 44.4% and 66.7% of lesions, respectively, in Group A and 88.8% and 94.4% of lesions, respectively, in Group B. There was also a significant (p=.002) decline in DLQI score in both groups, with the mean reduction being significantly greater in Group B than Group A (p=.005). CONCLUSION: Results of noncultured melanocyte transplantation can be improved significantly more by suspending the melanocytes in the patients' autologous serum than in normal saline. This could be an important innovation in the surgical management of patients with stable vitiligo.

Efficacy of NB-UVB in Progressive Versus Non-Progressive Non-Segmental Vitiligo: A Prospective Comparative Study.

INTRODUCTION: Narrow-band (NB) ultraviolet B (UVB) phototherapy has been shown to halt disease progression in vitiligo, but whether there is any difference in the response to NB-UVB seen in patients with progressive vitiligo versus non-progressive vitiligo has not been evaluated. OBJECTIVES: To evaluate the effect of NB-UVB on progressive versus non-progressive non-segmental vitiligo. STUDY DESIGN: Prospective observational comparative study. DURATION: April 2016-November 2017. METHODS: Adult patients having non-segmental vitiligo involving 2-50% body surface area were divided into two subsets; patients developing >5 lesions in the last 1 month or >15 lesions in the last 3 months (progressive vitiligo, Group I) and patients with static disease for the last 6 months (non-progressive vitiligo, Group II). Both groups were treated with NB-UVB for 6 months (26 weeks) cumulatively and its efficacy in halting disease progression, re-pigmentation, side effects and psychosocial impact were evaluated. RESULTS: Nineteen out of 24 patients with progressive vitiligo had arrest of disease progression. Rest five patients developed lesions at a slower pace. Group II had earlier onset of re-pigmentation, while Group I had more NB-UVB fluence (34.73 J/cm2 vs 25.2 J/cm2, P value = 0.034), more time for the fluence to be fixed (P value = 0.001) and more pruritus (P value = 0.001). CONCLUSIONS: NB-UVB has the potential to halt disease progression in some patients with progressive vitiligo; but is associated with more total NB-UVB fluence and time taken for fixing it. Progressive vitiligo patients have more pruritus as compared to patients with non-progressive vitiligo.

Oral Isotretinoin Combined with Oral Terbinafine Versus Oral Terbinafine Alone to Treat Recurrent Dermatophytosis: An Open-Label Randomised Clinical Trial.

BACKGROUND: Recurrent dermatophytosis is becoming arduous to treat. Recently, oral itraconazole with oral isotretinoin was successful in a patient suffering from recurrent dermatophytosis. OBJECTIVES: To evaluate if oral isotretinoin confers any added benefit over oral terbinafine in the treatment of recurrent dermatophytosis. MATERIALS AND METHODS: This was an open-label randomized clinical trial including 100 adult patients with recurrent tinea cruris and/or tinea corporis randomized into two groups; Group A (oral isotretinoin 0.5 mg/kg/day and oral terbinafine 250 mg twice daily) and Group B (oral terbinafine 250 mg twice daily) for 4 weeks, and followed up for 3 months. Fungal culture and antifungal susceptibility testing against terbinafine, fluconazole, amphotericin B, itraconazole, and griseofulvin were performed. RESULTS: Out of the 100 patients, 91 patients (44 in Group A and 47 in Group B) completed the trial. Complete cure was seen in 19/44 (43.18%) patients in Group A and 20/47 (42.55%) patients in Group B (P = 0.951). Recurrence occurred in 12/19 (63.1%) patients in Group A and 13/20 (65%) patients in Group B (P = 0.904). Cheilitis and dryness of lips were the most common adverse effects seen in 32/44 (72.73%) patients in Group A. A total of 50 cultures were grown. The commonest species isolated was Trichophyton interdigitale in 36 (72%) patients, having a mean minimum inhibitory concentration of 3.13 µg/mL for terbinafine. However, for itraconazole, it was 0.13 µg/mL, and varied minimum inhibitory concentration (MIC) values were seen for fluconazole, griseofulvin, and amphotericin B. CONCLUSION: The addition of isotretinoin to terbinafine has no added benefit in treating patients with recurrent dermatophytosis.

A cross-sectional study of spontaneous repigmentation in vitiligo.

BACKGROUND: Spontaneous regression is well documented in several chronic skin diseases such as psoriasis, alopecia areata, and atopic dermatitis. However, information on vitiligo is scarce. AIMS: We studied the frequency, extent, and factors affecting spontaneous repigmentation in vitiligo. METHODS: A cross-sectional descriptive study was undertaken in 167 patients with vitiligo with an emphasis on history of spontaneous repigmentation. Where available, photographs documenting spontaneous repigmentation were also obtained. Repigmentation was defined as spontaneous if it occurred when the patient was off treatment for at least 3 consecutive months. RESULTS: Spontaneous repigmentation occurred in 36 (21.5%) patients with complete repigmentation in 6 (3.6%) patients. The extent varied from 0.5% to 100% (mean, 35.4 ± 37.9%) of vitiliginous skin. It occurred after 3 months to 47 years (mean, 8.7 ± 9.5 years) of onset of vitiligo and persisted for 2 months to 27 years (mean, 4.4 ± 6.2 years). Diffuse repigmentation was the most common pattern observed in 20 (55.6%) patients and there was a good color match in 26 (72.2%) patients. Likelihood of spontaneous repigmentation was 3.5 times greater in patients with more than 3 years of stable disease (P = 0.001). LIMITATIONS: The chief limitation was the dependence on patient recall for the data, except when documented by images. CONCLUSION: Spontaneous repigmentation occurs in one-fifth of patients with vitiligo. In some patients, the repigmentation is clinically significant and long-lasting. Considering its frequency and extent, spontaneous repigmentation should be taken into account both when evaluating novel interventions and counselling patients about the course of the disease.

A split face randomized controlled trial comparing 1,064 nm Q-switched Nd-YAG laser and modified Kligman's formulation in patients with melasma in darker skin.

BACKGROUND: No randomized studies compared the efficacy and safety of modified Kligman's triple combination (TC) with 1,064 nm Q-switched Nd-YAG laser (QSNYL) in melasma in darker skin. OBJECTIVES: To compare the efficacy and safety of QSNYL and TC in the treatment of melasma in Fitzpatrick skin types IV and V. METHODS: In this split face randomized controlled trial, participants' cheeks were randomized to receive either weekly QSNYL (group A) or daily TC (group B) for 12 weeks, followed by 12 weeks of follow-up. RESULTS: Twenty-eight patients completed the intervention, and 21 of them completed follow-up. We found a significant but modest reduction in mean melanin index, modified Melasma Area Severity Index (MASI), and photographic and patient's assessment in both modalities (P < 0.01). No significant differences were detected between the groups. All patients had reappearance of pigmentation by the end of follow-up. Adverse reactions were significantly more in group B (P < 0.001). LIMITATION: The desired sample size could not be achieved. CONCLUSION AND RELEVENCE: No statistically significant differences were observed between QSNYL and TC as monotherapy in melasma. Reappearance of melasma is inevitable after stopping treatment.

Comparison of efficacy of noncultured hair follicle cell suspension and noncultured epidermal cell suspension in repigmentation of leukotrichia and skin patch in vitiligo: a randomized trial.

BACKGROUND: Vitiligo manifests as hypo- to de-pigmented macules, which are sometimes associated with leukotrichia. For complete cosmetic improvement, the repigmentation of leukotrichia is an important component. METHODS: This randomized controlled trial included patients with stable vitiligo with leukotrichia. Two vitiligo patches in each patient were randomized to receive either of the two procedures. The patients were followed up for 9 months posttransplantation. The efficacy of hair follicle cell suspension (HFCS) with epidermal cell suspension (ECS) in repigmentation of leukotrichia and skin in vitiligo was compared. RESULTS: A total of 20 patients underwent the procedure, and 19 completed the follow-up. The area of the vitiligo patch and the number of leukotrichia in the patches were comparable between the two groups. There was a significant difference in the mean ± S.D. number of cells transplanted between the two groups (5.06 × 105 in HFCS vs. 39.8 × 105 in ECS, P < 0.0001). The percentage viability of cells and proportion of melanocytes were comparable between the two groups. A total of 10 patients in HFCS and eight patients in ECS had repigmentation of leukotrichia. The mean ± S.D. percentages of depigmented hair showing repigmentation at nine months were 7.42 ± 11.62% in HFCS and 11.42 ± 17.90% in ECS (P = 0.4195), whereas the mean ± S.D. percentage repigmentation of vitiligo patches was 61.58 ± 42.68% in HFCS and 78.68 ± 30.03% in ECS (P = 0.1618). CONCLUSIONS: The mean number of cells transplanted in the HFCS group was about eight times less than those in ECS. ECS was better than HFCS in repigmentation of leukotrichia and vitiligo, although the difference was not statistically significant.

Congenital symmetrical circumscribed patterned non-scarring alopecia of eyebrows: a variant of congenital triangular alopecia or an anatomical variation?

Triangular alopecia presents as a unilateral triangular-shaped non-scarring alopecia usually involving the temporal scalp. There are few reports of occipital scalp involvement and bilateral disease. Usually it is seen at 2-3 years of age but occasionally can be present at birth. Here we present a unique case of triangular alopecia involving the eyebrows in a 23-year-old man. He had bilateral symmetrical involvement since birth. Points in favour of triangular alopecia in our case were non-scarring alopecia, oval-to-triangular shape, fringe of terminal hair at superior margin; trichoscopy showing significant decrease in hair diameter diversity with increased number of vellus and intermediate hair and histopathology showing normal hair follicle density and increased vellus and intermediate hair (miniaturisation) with absence of inflammation on histopathology. Other differential diagnoses kept were partial duplication of eyebrows, congenital alopecia areata and mild form of ectodermal dysplasia.