Clinico-Laboratory Profile of Tuberculides: An Experience at a Tertiary Care Centre from Chandigarh, India.

Background: Tuberculides are characterised by delayed-type of immunologic reactions to Mycobacterium tuberculosis or its products in immuno-competent individuals. We herein describe clinico-epidemiological features and response to treatment in patients with tuberculides from a tertiary care centre from North India. Methods: This was a retrospective analysis of the clinical records of all the cutaneous tuberculosis (TB) patients (year 2000-2019) enrolled in the TB clinic. The patient records fulfilling the diagnostic criteria of tuberculides were considered for analysis. Results: A total of 225 patients attended the tuberculosis clinic; out of this, 34 were diagnosed as tuberculides. Out of these 34 cases, 21 were identified as LS, 2 erythema induratum of Bazin, 1 papulonecrotic tuberculide, and 10 erythema nodosum. History of contact to open cases of TB was present in 15/34 (44.1%) patients. History of BCG vaccination was found in 15/34 (44.1%) patients. The focus of underlying TB could be identified in 20/34 (58.8%) patients. Skin biopsy was performed in all patients. In all patients, the diagnosis was confirmed by clinico-pathological correlation, positive TST, and the underlying focus of TB. All patients received 6 months regimen of anti-tubercular therapy with first-line drugs. Conclusion: In this study, we demonstrated various forms of tuberculides; lichen scrofulosorum was the most common form. We also included erythema nodosum cases also, which responded well to ATT. Observation from our study showed that tuberculides are important cutaneous markers for underlying tuberculosis infection, which helps in early detection of occult tuberculosis and timely management.

Clinical Profile and Diagnostic Accuracy of Patient-submitted Photographs in Teledermatology.

Background: The COVID-19 pandemic has shifted healthcare from physical in-person patient visits to teleconsultations in order to curtail the spread of this virus. Dermatology, being a visual science, lends itself amenably to teleconsultation. Objective: This study was performed to assess the basic dermatological diseases which are more easily diagnosable and managed through teleconsultation, distinguishing them from diseases for which a face-to-face consultation may be a better option and to delineate the factors affecting the image quality which is the cornerstone of a teledermatology consultation. Methods: A retrospective observational study was conducted over a three-month period during the pandemic. Store and forward, video conferencing, and hybrid consultations were included. Two dermatologists of different clinical experience independently assessed the clinical photographs of the patients and gave each photograph an objective score (Physician Quality Rating Scale) and a diagnosis. The diagnostic concordance between the two dermatologists as well as the correlation of this score with the certainty of diagnosis was calculated. Results: A total of 651 patients completed the study. Mean PQRS score of Dermatologist 1 was 6.22 while the mean score of Dermatologist 2 was 6.24. Patients in whom both the dermatologists were absolutely certain about their diagnosis had a higher PQRS score and interestingly had a higher education level than the rest. There was 97.7 percent diagnostic concordance between the two dermatologists. Infections, acne, follicular disorders, pigmentary disorders, tumors, and STDs had the largest proportion of cases wherein both the dermatologists were in total agreement with each other. Conclusion: Teledermatology might be best for the care of patients with characteristic clinical presentation or for follow-up of already diagnosed patients. It can be used in the post-COVID era to triage patients requiring emergency care and reduce patient wait times.

Comparative Efficacy of Injection Triamcinolone Acetonide given Intralesionally and through Microneedling in Alopecia areata.

Introduction: Alopecia areata (AA) manifests as patchy hair loss and intralesional corticosteroid (ILCS) is usual therapeutic choice in limited disease. Microneedling is used for uniform delivery of topical agent to relatively larger areas may prove to be more efficacious than traditional ILCS. The present study prospectively compared microneedling to traditional intralesional delivery of triamcinolone acetonide (TA). Materials and Methods: Prospective randomized comparative study in 60 patients of AA restricted to scalp not requiring systemic treatment randomly divided into two equal groups. Group 1 patients underwent microneedling with local application of injectable TA and Group 2 patients were given injectable TA intradermally for a total of three sessions at 3 weeks interval. Results: A mean regrowth of 66.36% in Group 1 and 69.75% in Group 2 at week 9 was seen which was comparative with no significant statistical difference between the two groups (P = 0.664). Thirteen patients achieved 100% regrowth at week 9 in Group 1 and 16 patients achieved 50%-99% regrowth in Group 2. Discussion and Conclusions: ILCSs have been cornerstone in the treatment of limited AA, but depth of injecting drug cannot be controlled, microneedling whereas is an effective drug delivery system and also causes release of growth factors. In this study, injectable TA used intralesionally and topically with microneedling had nearly similar efficacy in causing regrowth of hair with microneedling resulting in a more uniform but less dense regrowth of hair with lesser adverse effects.

Platelet-rich plasma is a promising therapy for melasma.

INTRODUCTION: Platelet-rich plasma (PRP) is an autologous blood product which has recently been used in multiple spheres of dermatology including facial rejuvenation, androgenetic alopecia, acne scars, and wound healing. Its use in melasma is comparatively an understudied topic. MATERIAL AND METHODS: An extensive systematic literature search of the PubMed electronic database and Cochrane central register of controlled trials was done using the keywords "platelet rich plasma" and "melasma" in the title. Relevant studies were selected and data were analyzed by two different authors. Four articles were excluded as they did not adhere to the inclusion criteria of this review and a total of 6 articles were reviewed.The relevant references of the included articles were also traced and included. DISCUSSION: These studies showed that PRP has been used effectively not only as an adjuvant therapy but also as a standalone treatment for melasma. PRP contains about 30 growth factors, transforming growth factor beta (TGF-ß) being one of the growth factors having a predominant role in treatment of melasma. TGF-ß decreases signal transduction of microphthalmia-induced transcription factor and thus decreases tyrosinase and tyrosinase-related proteins. In addition to this, PRP also has an additional benefit of inducing collagen synthesis thus improving the quality and texture of the skin. But there is a scarcity of data and large randomized controlled trials. This review is an effort to highlight and upscale the use of this excellent blood product for melasma which is quite a treatment refractory disorder.

Efficacy of tuberculin immunotherapy in verruca vulgaris: Our experience from single center from North-West India and review of literature.

Verruca vulgaris (VV) acquired through direct contact or autoinoculation of human papilloma virus (HPV). Treatment of VV are challenging as destructive modalities have variable efficacy and recurrence rates. Various immunotherapies attempt to stimulate the cell-mediated host immune response against HPV. We have assessed efficacy of intralesional tuberculin in patients with verruca vulgaris and to see the long term follow-up at 12 months. Forty patients were enrolled in the study. All patients received intralesional tuberculin injections (5 Tuberculin U/mL) in a dose of 0.1 mL/lesion every fortnightly. Patients were followed up for 12 months duration, and response to treatment assessed. Thirty patients (75%) showed complete resolution, 5 (12.5%) patients showed partial response, 3 (7.5%) showed minimal response and 2 (5%) were non-responders. Irrespective of tuberculin sensitivity test response the majority of patients showed grade 3 response. Five (12.5%) patients had a recurrence of lesions. Two had a recurrence on the same site, and three had recurrences over distant sites. Intralesional tuberculin immunotherapy is an effective modality for VV. Immunotherapy of warts is a potential area of research, and exact method and agents are still under investigation.

Autologous intralesional platelet rich plasma improves melasma.

Platelet rich plasma (PRP) is an upcoming interventional therapy for the treatment of melasma. Its efficacy is due to the multiple growth factors present in it which decrease melanogenesis by various signal transduction pathways. The present study evaluated the efficacy of PRP as a standalone agent in treatment of melasma. This is an open labeled prospective trial. Forty patients were given intralesional PRP at once monthly interval. Three such PRP sessions were carried out and the patients were followed up for 3 months. Assessment was done by calculating the modified melasma area severity index score (mMASI) for each patient. Patients were also asked to self-evaluate their improvement based on a scale. There was an average 54.5% reduction in the mMASI score at the end of the study. There was no relapse in any patient. This reduction was irrespective of the skin type, gender, and type of melasma. Patients self-evaluation showed that more than 90% of the patients were pleased or very pleased with the results. There were no significant side effects. PRP appears to be a potential new therapy with significant efficacy in improving pigmentation of melasma, standalone as monotherapy.

Secondary Cutaneous Mantle Cell Lymphoma.

Mantle cell lymphoma is a rare form of B-cell non-Hodgkin's lymphoma that presents as a low-grade lymphoma and has a different prognosis than other types of lymphoma. Mantle cell lymphoma is an aggressive tumor that can manifest as nonspecific symptoms, such as nasal obstruction, dyspnea, and erythematous indurated cutaneous plaques. Diagnosis can be established with confidence using immunohistochemistry. In this report, a case of nasopharyngeal mantle cell lymphoma metastasizing to the skin is discussed.

Comparative Efficacy of a 35% Glycolic Acid Peel Alone or in Combination With a 10% and 20% Trichloroacetic Acid Spot Peel for Melasma: A Randomized Control Trial.

BACKGROUND: To study and compare the therapeutic efficacy and side effects of a 35% glycolic acid (GA) full face peel alone or in combination with a 10% or 20% trichloroacetic acid (TCA) spot peel for facial melasma. METHODS: Thirty patients with facial melasma were randomly divided into 3 equal Groups A, B, and C. Group A was treated with a 35% GA full-face peel, Group B and C with 35% GA full-face peel followed by a 10% and 20% TCA spot peel respectively once every 15 days. Four peels were performed once every 15 days. The response to the treatment was evaluated by the percentage reduction in melasma area severity index (MASI) scoring. RESULTS: All 3 groups had significant reduction of MASI, but there was no significant difference between the groups. Group A had minimum side effects. CONCLUSION: Chemical peels with GA alone or in combination with TCA do result in a significant improvement in melasma, but the combination of the peels in the same sitting does not seem to have any additive or synergistic effect while they may increase the side effects.

NonScarring Diffuse Hair Loss in Women: a Clinico-Etiological Study from tertiary care center in North-West India.

BACKGROUND: Diffuse hair loss (DHL) is a common problem in adult women and has a major impact on quality of life. Ascertaining the etiological diagnosis is a challenging task in such patients. Satisfactory treatment can only be instituted after ascertaining the cause of hair loss. OBJECTIVE: To study the clinico-epidemiological profile of nonscarring DHL in females and to ascertain its underlying etiological factors. STUDY DESIGN: Of a total of 110 females, who presented with nonscarring DHL to the outpatient dermatology department, 100 qualified for inclusion in the study. A detailed history, clinical examination, and laboratory investigations were performed in all the patients. Statistical analysis was performed on the data collected. RESULTS: Of 100 cases of DHL which were included in the study, commonest was chronic telogen effluvium (CTE) (62%), followed by female pattern hair loss (FPHL) (22%) and acute telogen effluvium (ATE) (16%). Incidence of hair loss was highest in 21-40 years age group. Psychological stress was seen to be a precipitating factor in 18 patients and found most commonly in women belong to CTE group (n-16, 25.8%). Hemoglobin levels ranged from 80 to 142 gm/L (mean: 119 ± 110). Low hemoglobin level (<120 gm/L) was observed in 57% patients. Total serum ferritin <10 ng/mL was seen in 20 patients, vitamin B12 < 211 pg/mL in 76 cases, vitamin D3 < 30 ng/mL in 81 cases. Subclinical hypothyroidism was present in 11% cases. CONCLUSIONS: Nonscarring DHL is a multifactorial condition with highest incidence in 21- to 40-year age group. Serum ferritin, serum vitamin B12, and D3 levels seem to have a contributing role in the pathogenesis of hair loss, and their supplementation may be needed for a faster regrowth of hair in all cases of hair loss irrespective of the pattern.

Extensive Multisystemic Disseminated Tuberculosis in an Immunocompetent Patient.

Extrapulmonary tuberculosis is uncommon and has an insidious onset with slow evolution and a paucibacillary nature. Here, we present a case of disseminated tuberculosis in an adult immunocompetent man presenting with morphologically different types of cutaneous lesions (i.e., multiple subcutaneous abcesses and multiple noduloulcerative lesions with discharging sinuses with seropurulent fluid). Extensive screening in the form of routine blood investigations, serologies, skin biopsy, Montoux test, sputum examination, chest and skull roentgenogram, noncontrast computed tomography chest and abdomen, contrast-enhanced computed tomography of the skull, and magnetic resonance imaging of lumbosacral spine with screening of the whole spine revealed extensive involvement of the skin, subcutaneous tissue, lungs, lymph nodes, skull bone, mandible, ribs, scapula, pelvis and Pott's spine, and thyroid.

Trichothiodystrophy without Associated Neuroectodermal Features in Two Siblings.

Trichothiodystrophy (TTD) is characterized by the common feature of sulfur-deficient brittle hair associated with a constellation of neuroectodermal symptoms. There is a wide phenotypic variation in the severity; ranging from isolated hair defect to multiple neuroectodermal symptoms such as photosensitivity, ichthyosis, intellectual impairment, decreased fertility, and short stature. This case report describes TTD in two sisters with only hair fragility and no other associated feature. This case highlights the variable clinical presentation of TTD and the need for regular follow-up in such patients for an early detection of any neurological, physical, and sexual impairment.

Extensive Donor Site Keloids in Follicular Unit Extraction Hair Transplantation.

Hair transplantation, a generally regarded as a safe surgical modality for the treatment of androgenetic alopecia, is not without its potential risks and complications. A case of an extensive keloid formation at donor site following follicular unit extraction is discussed. Hair transplant surgeons should be aware of this significant potential complication, especially in patients having previous keloidal tendencies to avoid such disastrous outcomes.

An innocent giant.

A cutaneous horn (cornu cutaneum) is a protrusion from the skin composed of a cornified material. It may be associated with a benign, premalignant, or malignant lesion at the base, masking numerous dermatoses. In a 24-year-old female, a giant cutaneous horn arising from a seborrheic keratosis located on the leg is presented. This case has been reported to emphasize that a giant cutaneous horn may also occur in young patients, even in photoprotected areas, and are not always associated with malignancy.

Direct immunofluorescence pattern and histopathological staging in alopecia areata.

AIM: The present study was designed to categorize alopecia areata (AA) into various stages based on histopathology and further study the direct immunofluorescence (DIF) pattern. MATERIALS AND METHODS: The current study is noninterventional, prospective study on 25 consecutive patients suspected of AA based on clinical assessment. Histomorphologic features and immunoreactivity for IgG, IgM, IgA, and C3, was studied on biopsy material. RESULTS: Age of the patients ranged from 6 years to 48 years with a mean age of 28.56 ± 21.8 years. Majority of patients, 9 (36%) were in the age group of 21-30 years. Of 25 patients, 13 (52%) were males and 12 (48%) were females. Male: female ratio was 1.1:1. On histopathology majority of cases were in subacute stage 9 (36%), followed by chronic 7 (28%), acute 5 (20%) and recovery stages 4 (16%). Three (12%) of 4 cases showed characteristic swarm of bees appearance. Two (8%) of the cases showed presence of giant cells. Increased numbers of catagen hair were seen in 12 (48%) cases. Of 25 cases, 9 (36%) cases showed positive DIF with granular deposits. The most common immunoreactant was IgG in 7 (28%) cases, followed by IgA in 4 (16%), C3 in 6 (24%) and IgM in 3 (12%) cases. Of 9 cases showing positive staining, 3 (12%) were in acute stage and 2 (8%) each in subacute, chronic and recovery stages. CONCLUSION: The observations further reiterate that immune mechanisms play a role in the pathogenesis of AA.

Photoletter to the editor: Bullous dermatitis artefacta induced with a hot spoon.

A 22-year-old female presented to the dermatology department with a 8-month history of blistering lesions over the left forearm and face. Most of the bullae and erosions were perfectly round and of nearly the same size. In absence of any obvious etiological, precipitating or aggravating factor, a provisional diagnosis of dermatitis artefacta (self-inflicted dermatological lesions) was made. A detailed anamnesis revealed that stress caused by her ex-boyfriend's threats and apprehension of consequences prompted her to create the lesions using a hot spoon. The patients of dermatitis artefacta usually present to dermatologists as their pathology manifests as unexplained and variable cutaneous lesions which may go undiagnosed for a long time. It is important for the dermatologist to have a high index of suspicion to recognise the underlying psychopathology.

Exogenous insulin-derived acanthosis nigricans: could it be a cause of increased insulin requirement?

Acanthosis nigricans is a cutaneous manifestation of insulin resistance. We herein present a case of localized acanthosis nigricans over the abdomen in a 14-year-old boy with type 1 diabetes mellitus. The acanthosis nigricans appeared secondary to repeated insulin injection over same site. After advising the patient about rotating the injection site there was better disease control along with drop in insulin requirement and a significant reduction in the size of the lesion.