Water quality assessment using synchrotron-based TXRF.

The pollutants released from pharmaceutical, steel, paper, and battery industries into water cause stress on the natural ecosystems, may mix with soil and water, enter into human food chain, and hence cause irreparable damage to the biotic system. Hence, the appropriate monitoring of water along with determination of heavy metals is very important for human beings. In present paper, total reflection X-ray fluorescence (TXRF) spectrometry technique is employed to determine the level of different contaminants in the water samples gathered from the various sites of an identified industrial area. Experimentation is carried out at Raja Ramanna Centre for Advanced Technology (RRCAT), Indore-India by using TXRF, which is one the advance techniques of element determination up to ppb levels. The elemental concentration of Cl, K, Ca, Fe, Cu, Zn, Ga, Br, Sr, As, Pb, and Ni is quantified and compared with the limits established by the WHO (World Health Organization) and BIS (Bureau of Indian Standard) guidelines regarding drinking water use. The levels of the Pb, Fe, As, Ni, Cr, Co, and Mn exceeded the values suggested by WHO and BIS at some locations/sites. To better understand the situation, water quality parameters such as Water Quality Index (WQI), Heavy metal Pollution Index (HPI), Contamination Index (CI), Metal Enrichment Index (MEI), and Heavy Metal Evaluation Index (HEI) have also been assessed for all the sites close to industrial hub. Among all sites except at A3 and A6, WQI is found to be much greater than WHO and BIS established limit. Level of arsenic in the water at A1 location was found 73 ppb. However, lead metal in water was found to be very high at all the six studied locations, and at A1 location, it is found extremely high 2613 ppb. Therefore, water at A1 and A2 sites is found to be unfit for drinking. PRACTITIONER POINTS: Total reflection X-ray fluorescence (TXRF) spectrometry technique is employed to determine the level of different contaminants in the water samples The elemental concentration of Cl, K, Ca, Fe, Cu, Zn, Ga, Br, Sr, As, Pb, and Ni is quantified and compared with the limits prescribed by the WHO Water Quality Index (WQI), Heavy metal Pollution Index (HPI), Contamination Index (CI), Metal Enrichment Index (MEI), and Heavy Metal Enrichment Index (MEI) have also been assessed for all the sites Water at some sites is found unfit for drinking purpose. Based on the observations, some remedial measures are suggested to reduce the level of water contaminants up to desired levels.

Enhanced Feature Extraction-based CNN Approach for Epileptic Seizure Detection from EEG Signals.

One of the most common neurological disorders is epilepsy, which disturbs the nerve cell activity in the brain, causing seizures. Electroencephalography (EEG) signals are used to detect epilepsy and are considered standard techniques to diagnose epilepsy conditions. EEG monitors and records the brain activity of epilepsy patients, and these recordings are used in the diagnosis of epilepsy. However, extracting the information from the EEG recordings manually for detecting epileptic seizures is a difficult cumbersome, error-prone, and labor-intensive task. These negative attributes of the manual process increase the demand for implementing an automated model for the seizure detection process, which can classify seizure and nonseizures from EEG signals to help in the timely identification of epilepsy. Recently, deep learning (DL) and machine learning (ML) techniques have been used in the automatic detection of epileptic seizures because of their superior classification abilities. ML and DL algorithms can accurately classify different seizure conditions from large-scale EEG data and provide appropriate results for neurologists. This work presents a feature extraction-based convolutional neural network (CNN) to sense and classify different types of epileptic seizures from EEG signals. Different features are analyzed to classify seizures via EEG signals. Simulation analysis was managed to investigate the classification performance of the hybrid CNN-RNN model in terms of different achievement metrics such as accuracy, precision, recall, f1 score, and false-positive rate. The results validate the efficacy of the CNN-RNN model for seizure detection.

A randomized, placebo and active controlled, split scalp study to evaluate the efficacy of platelet-rich plasma in patchy alopecia areata of the scalp.

Platelet-rich plasma (PRP) is a new modality of treatment in the field of dermatology. There are paucity of studies evaluating the effects of PRP in nonscarring alopecia especially alopecia areata (AA). To compare the efficacy and safety of PRP in patchy AA of the scalp in a placebo and active controlled trial. This was a randomized, placebo and active controlled, split scalp study. Fifty patients of patchy AA of the scalp were recruited and allocated to two treatment groups. Left side of the scalp received placebo (intralesional normal saline), right side of the scalp received intralesional PRP in one group and intralesional triamcinolone acetonide in second group. Three treatment sessions were given at 4-week interval and final follow-up was done at 8 weeks later. SALT scoring, dermoscopy were the parameters used to assess the efficacy. The SALT score showed statistically significant improvement from baseline in both the treatment groups (P value <.001). The maximum absolute regrowth was shown by the steroid group followed by PRP followed by placebo group (P value .016). Improvement in dermoscopic findings were similar in both the PRP and steroid groups followed by placebo (P value .448). PRP is a promising therapy in AA as an adjuvant in those with minimal response and those not tolerating steroids or have developed adverse effects to it.

Comparative Study of 35% Glycolic Acid, 20% Salicylic-10% Mandelic Acid, and Phytic Acid Combination Peels in the Treatment of Active Acne and Postacne Pigmentation.

BACKGROUND: Acne is a commonly encountered disorder in the dermatological practice. Chemical peeling is one of the treatment modalities in acne and postacne pigmentation. Although various peeling agents are available, studies comparing their efficacy are lacking. Moreover, there is a paucity of studies comparing the efficacy of combination peels in Asian population. MATERIALS AND METHODS: Forty-five patients with mild to moderate acne were divided into three groups of fifteen each. Groups A, B, and C underwent peeling sessions biweekly with 35% glycolic acid, 20% salicylic-10% mandelic acid, and phytic acid peels, respectively, for a total of six sessions. All other anti-acne treatments were stopped. Lesion count was carried out at baseline and at each follow-up visit. Acne scoring and postacne hyperpigmentation index were noted at each visit. Photographic record was maintained. RESULTS: Significant reduction in inflammatory and noninflammatory lesion count was noted at 12 weeks in all the three study groups. Reduction in acne score at the end of 12 weeks in the three study groups was 70.55%, 74.14%, and 69.7%, respectively. A significant decline was observed in the postacne hyperpigmentation index in all the three study groups at the end of 12 weeks (P = 0.034). CONCLUSION: All three chemical peels are effective in the treatment of mild to moderate acne in Asian population. No significant adverse effects were noted.

A cross-sectional study of the histopathology and immunology of alopecia areata: Unearthing the role of the Janus kinase-signal transducer and activator of transcription pathway.

BACKGROUND: Alopecia areata is an autoimmune disease that occurs as a result of the loss of the inherent immune privilege of the hair follicle. It has been recently demonstrated that the interferon-γ/interleukin-15 feedback loop that signals via the Janus kinase-signal transducer and activator of transcription pathway is critical to the breakdown of this immune privilege. AIMS: To evaluate the immunological distribution of CD4+ T-cells, CD8+ T-cells, phosphorylated signal transducer and activator of transcription 1 and study its relation with the clinical and histopathological findings of the disease. MATERIALS AND METHODS: A total of 30 patients of alopecia areata were included in the study. Following a detailed history and clinical examination, a scalp biopsy was performed. Histopathology was studied and immunohistochemistry was done to demonstrate the positivity and distribution of CD4+ T-cells, CD8+ T-cells and phosphorylated signal transducer and activator of transcription 1. RESULTS: The follicular count, number of anagen and terminal hair were found to be decreased, whereas the catagen, telogen and vellus hair were found to be increased in number. A peribulbar CD4+ T-cell infiltrate was seen in 70% cases, whereas a CD8+ T-cell infiltrate was seen in 83.3% cases. An intrabulbar CD4+ T-cell infiltrate was seen in 26.7% cases, whereas a CD8+ T-cell infiltrate was seen in 70% cases. Among the 25 hair follicles dermal papilla identified, 36.8% cases were found to be positive for phospho-signal transducer and activation of transcription-1. LIMITATIONS: The drawbacks of our study included a small sample size and the use of only vertical sectioning for the scalp biopsy samples. CONCLUSION: Phosphorylated signal transducer and activator of transcription 1 positivity as an indicator of signalling via the Janus kinase-1/2 pathway was seen in 36.8% of our cases highlighting the integral role of this pathway in the pathogenesis of alopecia areata.

Linear Lichen Nitidus with Onychodystrophy in a Child.

Lichen nitidus is a common dermatosis described classically as shiny, skin-colored, nonfollicular, flat-topped papules. A number of variants have been described in literature including localized, generalized, actinic, vesicular, perforating, hemorrhagic, palmar/plantar, purpuric, and linear forms. Here, we report an unusual case of linear lichen nitidus in an 11-year-old boy mimicking lichen striatus along the left thumb with isolated nail involvement of the affected digit. Nail involvement in lichen nitidus is very rare; there are only seven cases of lichen nitidus associated nail changes reported in the literature. To the best of our knowledge, this is the first such case reported from India.

Direct immunofluorescence findings in cicatricial alopecia: A retrospective study of 155 cases.

OBJECTIVES: To study the direct immunofluorescence (DIF) in cicatricial alopecia (CA) patients. MATERIALS AND METHODS: Approximately, 155 skin biopsies from CA patients examined over 7 years (2009-2015). Special stains and Hematoxylin and Eosin were performed, and final histopathological diagnosis was made. DIF (against anti-IgG, IgM, C3, IgA, and fibrinogen) on all these cases and patterns were noted. The descriptive statistics were applied along with ANOVA test. RESULTS: Approximately, 155 patients with Male: Female = 1.24:1, age 7-65 years. In total, 57 cases were of Lichen planopilaris (LPP; 36.7%), 22 Lichen planus (LP; 14.2%), 22 Psuedopalade of Brocq (PPB; 14.2%),16 discoid lupus erythematosus (DLE; 10.3%), 8 end-stage scarring alopecia (ESSA; 5.2%), 2 cases each of Fungal folliculitis (FF), and Folliculitis decalvans (FD; 1.3% each), and in 26 cases, no specific diagnosis could be reached were collectively kept in the category of non-specific findings (NSP; 16.7%). On DIF: LPP positive for IgG = 4 cases (7%), IgM = 26 (45%), IgA = 11 (19.3%), C3 = 16 (28.1%), and fibrinogen = 11 (19.3%). LP positive for IgG = 2 (9%), IgM = 18 (81%), IgA = 2 (9.1%), C3 = 10 (45%), and fibrinogen = 1 (4.5%). DLE positive for IgG = 6 (37%), IgM = 8 (50%), IgA = 1 (6.3%), C3 = 9 (56%), and fibrinogen = 1 (4.5%). LIMITATIONS: Because this was a retrospective study, clinical follow-up and treatment history of the patient could not be retrieved. CONCLUSIONS: IgG positivity helps significantly in differentiating LPP from DLE (P 0.004) and NSP from DLE (P 0.005). IgM positivity helps significantly in differentiating LPP from LP (P 0.04), LP from PPB (P 0.00) and NSP (P 0.00). C3 positivity helps significantly in differentiating PPB from DLE (P 0.02).

A randomized study to evaluate the efficacy and effectiveness of two sunscreen formulations on Indian skin types IV and V with pigmentation irregularities.

BACKGROUND: Regular exposure to ultraviolet rays is high in India, where most Indians present Fitzpatrick skin phototypes IV and V. AIMS: To evaluate the efficacy and compare the effectiveness of two sunscreen products on Indian skin types IV and V with pigmentation irregularities. METHODS: A randomized, uncontrolled and investigator-blinded, single-center study enrolled adult men and women (18-45 years) with Fitzpatrick skin phototypes IV (28° < individual typological angle <10°) and V (10° < individual typological angle < -30°) with pigmentary abnormalities seen on the face in adults (actinic lentigines and postinflammatory hyperpigmentation), who did not use sunscreens. Participants were randomized (1:1) to either of the two marketed sunscreen products, Product A (sun protection factor 50 PA+++) or Product B (sun protection factor 19 PA+++), applied twice daily before sun exposure for ≥2 h. Primary objectives aimed at assessing possible improvement in hyperpigmented spots and overall skin appearance after 12 weeks of use. Evaluation of skin radiance and skin color was done by means of L'Oréal color chart and colorimetric measurements (Chromameter®). RESULTS: Among the 230 enrolled participants, 216 (93.91%) completed the study. The clinical assessment of the density of pigmented spots and skin radiance showed significant (P < 0.001) improvement in both groups during all visits. The qualitative (participant perception) and quantitative (Chromameter®) data indicated improvement in pigmentation from Week 0 to Week 12. Both products were well-tolerated. LIMITATIONS: The study was conducted over a rather short period of time (12 weeks) at a single location. CONCLUSIONS: This is the first study conducted on Indian skin phototypes IV and V under real-life conditions. It demonstrated the effect of regular sunscreen usage in the prevention of certain signs of skin photoaging such as increased pigmentation or pigmentary abnormalities, thus providing support and assistance to clinicians in suggesting the use of efficient sun-screening products to patients.

Autologous noncultured melanocyte-keratinocyte transplantation in stable vitiligo: A randomized comparative study of recipient site preparation by two techniques.

BACKGROUND: Accurate preparation of recipient area is a critical step in melanocyte-keratinocyte transplantation procedure for vitiligo. It is an important potential step for adaptation in the quest to achieve better results and ablative lasers potentially offer excellent precision over margin and depth control in achieving that. OBJECTIVE: To compare between the two techniques used for recipient site preparation: Er:YAG laser ablation and mechanical dermabrasion for melanocyte-keratinocyte transplantation procedure in terms of re-pigmentation achieved and adverse effects seen. METHODS: A randomized comparative trial was performed among 32 patients of stable vitiligo undergoing melanocyte-keratinocyte transplantation procedure. In Group A (n = 15), recipient site preparation was done with Er:YAG laser, and in Group B (n = 17), it was done with a motorized dermabrader. Patients of both groups were objectively assessed for re-pigmentation at 1, 3 and 6 months. RESULTS: A total of 253.696 cm2 of depigmented surface was operated upon and re-pigmentation of 125.359 cm2 (49.4%) was achieved. On comparison between two groups, no statistical difference was found with respect to total re-pigmentation achieved (Group A: 54.67% vs Group B: 48.841%, P = 0.663) and grades of re-pigmentation achieved (P = 0.796). Occurrence of adverse events was also statistically similar in both the groups. CONCLUSION: This study did not reveal any statistically different outcome (in terms of re-pigmentation and adverse effects) between the two methods of recipient site preparation - motorized dermabrasion and Er:YAG ablation. LIMITATIONS: This study is small and larger studies are needed to ascertain the benefit of Er:YAG for recipient site preparation. Future studies may also ascertain variables such as time taken to prepare the recipient area, nature of bleeding, postoperative healing, difficulties in specific area, cost of the procedure, patient comfort and ease of the surgeon, rather than comparing the re-pigmentation alone.

Childhood Leprosy: A Retrospective Descriptive Study from Delhi.

BACKGROUND: Childhood leprosy is an important marker of the status of the ongoing leprosy control programme, as it is an indicator of active disease transmission in the community. Despite achievement of elimination status of leprosy in 2005, the reported prevalence of childhood cases continue to be high. METHOD: A retrospective analysis of 11 year records of leprosy patients aged less than 15 years in a tertiary care hospital of central Delhi was carried out from 2005-2015. Data were analysed using SPSS 22.0 system. RESULT: A total of 113 (7.6%) cases of childhood leprosy were reported during the 11 year period from 2005-2015. Multibacillary cases constituted a total of 57 (50.4%), while paucibacillary constituted 56 (49.6%) cases. The M:F ratio noted was 2.5:1. Signs of reaction were found in 15% cases, while deformity was noted in 24.7% cases. CONCLUSION: The rate of childhood leprosy continues to be high. Lack of proper access to health facilities, ignorance among the general population, high susceptibility due to immature immune system etc make this population highly vulnerable. LIMITATIONS: Limited data of 11 years from an urban center were analyzed.

Palmoplantar Lesions of Lichen Planus.

INTRODUCTION: Palmoplantar lesions of lichen planus (LP) are uncommon and may not always have classical clinical features of LP. A variety of morphological types has been described in literature. AIM AND OBJECTIVES: The aim was to study and classify the clinical variants into distinct easily recognisable categories for quick recognition and early treatment initiation. METHODS: All patients diagnosed with LP over a period of 5 years were evaluated for palmoplantar lesions in our hospital. The clinical and histopathological features of the palmoplantar lesions were then studied. RESULTS: Out of 424 patients of LP, 55 (12.9%) had palmoplantar lesions. Histopathology was consistent or at least compatible with LP in 44/55 patients. For the purpose of assessment, only patients with histopathology consistent with LP were included (n = 44) in the study. Just over half of the patients were male, with most patients (43.2%) having had LP lesions elsewhere for 6 months before palmoplantar lesions were noticed. Soles were more frequently involved than palms. The sites most often involved were the centre of the palms (45.2%), and the instep of the soles (63.9%). The predominant morphological presentation was psoriasiform (47.7%). One patient had ulcerative lesions of LP on both his soles which is a very rare variant. Notably, nearly half of the patients (20/44) had mucosal (mostly oral) lesions characteristic of LP. This was significant as typical oral lesions of LP help in identifying palmoplantar lesions that do not have classical lichenoid morphology. CONCLUSION: LP lesions on palms and soles need to be identified keeping a high index of suspicion and differentiated from other papulosquamous conditions so that specific treatment can be initiated early.

Mycetoma: An Update.

Mycetoma is a localized chronic, suppurative, and deforming granulomatous infection seen in tropical and subtropical areas. It is a disorder of subcutaneous tissue, skin and bones, mainly of feet, characterized by a triad of localized swelling, underlying sinus tracts, and production of grains or granules. Etiological classification divides it into eumycetoma caused by fungus, and actinomycetoma caused by bacteria. Since the treatment of these two etiologies is entirely different, a definite diagnosis after histopathological and microbiological examination is mandatory, though difficult. Serological test exists but is not so reliable; however, molecular techniques to identify relevant antigens have shown promise. The disease is notoriously difficult to treat. Eumycetoma may be unresponsive to standard antifungal therapy. Actinomycetoma responds to antibiotic therapy, but prolonged treatment is necessary. This review focuses on the etiopathogenesis, clinical features, laboratory diagnosis, and treatment of mycetoma.

Transcriptome wide identification and characterization of starch branching enzyme in finger millet.

Starch-branching enzymes (SBEs) are one of the four major enzyme classes involved in starch biosynthesis in plants and play an important role in determining the structure and physical properties of starch granules. Multiple SBEs are involved in starch biosynthesis in plants. Finger millet is calcium rich important serial crop belongs to grass family and the transcriptome data of developing spikes is available on NCBI. In this study it was try to find out the gene sequence of starch branching enzyme and annotate the sequence and submit the sequence for further use. Rice SBE sequence was taken as reference and for characterization of the sequence different in silico tools were used. Four domains were found in the finger millet Starch branching enzyme like alpha amylase catalytic domain from 925 to2172 with E value 0, N-terminal Early set domain from 634 to 915 with E value 1.62 e-42, Alpha amylase, C-terminal all-beta domain from 2224 to 2511 with E value 5.80e-24 and 1,4-alpha-glucan-branching enzyme from 421 to 2517 with E value 0. Major binding interactions with the GLC (alpha-d-glucose), CA (calcium ion), GOL (glycerol), TRS (2-amino-2-hydroxymethylpropane- 1, 3-diol), MG (magnesium ion) and FLC (citrate anion) are fond with different residues. It was found in the phylogenetic study of the finger millet SBE with the 6 species of grass family that two clusters were form A and B. In cluster A, finger millet showed closeness with Oryzasativa and Setariaitalica, Sorghum bicolour and Zea mays while cluster B was formed with Triticumaestivum and Brachypodium distachyon. The nucleotide sequence of Finger millet SBE was submitted to NCBI with the accession no KY648913 and protein structure of SBE of finger millet was also submitted in PMDB with the PMDB id - PM0080938. This research presents a comparative overview of Finger millet SBE and includes their properties, structural and functional characteristics, and recent developments on their post-translational regulation.

A Comparative Analysis of Polymerase Chain Reaction and Direct Fluorescent Antibody Test for Diagnosis of Genital Herpes.

OBJECTIVE: To compare laboratory tests that can simultaneously detect and type herpes simplex virus (HSV) directly from the genital ulcer specimens in clinically suspected cases of genital herpes. MATERIALS AND METHODS: A study was conducted over 10 months and 44 adult male and female patients clinically suspected with genital herpes were recruited. Genital ulcer swab specimens were subjected to glycoprotein-G gene-based conventional polymerase chain reaction (PCR) and commercially available direct fluorescent antibody (DFA) test and the results were compared. RESULTS: PCR for HSV was positive in 82% (36/44) cases. DFA was positive in 68.2% (30/44) cases. There was 100% agreement between HSV types detected by DFA and PCR. The strength of agreement between the results was better in primary genital herpes than recurrent cases. CONCLUSION: PCR was found to be better in the detection of HSV in recurrent genital herpes patients. It is a better modality, especially when genital herpes clinically presents with ulcerative or crusted lesions, and is also a cheaper alternative as compared to DFA.

Clinico-Epidemiological Profile of Viral Sexually Transmitted Infections in Seropositive Patients Attending a Tertiary Care Hospital in North India.

Sexually transmitted diseases are a major public health problem both in developing and in developed countries, and especially with the co-synergy with HIV infection, there is an increasing need to have a proper understanding of the clinicodemographic patterns of sexually transmitted infections (STIs) for planning and implementing control strategies. Worldwide, there is an increased preponderance of viral STIs. Increasing incidence and altered clinical presentation of viral STIs in patients with HIV pose a diagnostic challenge; thereby, we studied the demographic profile of HIV-seropositive patients and compared clinical manifestations of viral STIs in HIV-seropositive patients to those in seronegative individuals. Twenty-seven HIV-seropositive patients with viral STI (herpes/molluscum/warts) and same number of age-, sex-, and STI-matched seronegative patients were studied for variability in clinical profile. There were significant differences in the demographic factors (education, income, and migration) and sexual practices (number of contacts and source of infection) in the 2 groups. Lesional symptoms, increased extent of lesions, and resistance to treatment were significantly more common in HIV-seropositive patients.

Pityriasis Rosea: An Update on Etiopathogenesis and Management of Difficult Aspects.

Pityriasis rosea (PR) is a benign papulosquamous disorder seen commonly in clinical practice. Despite its prevalence and benign nature, there are still times when this common disorder presents in an uncommon way or course posing diagnostic or management problems for the treating physician. The etiopathogenesis of PR has always been a dilemma, and extensive research is going on to elicit the exact cause. This review focuses mainly on the difficult aspects of this benign common disorder such as etiopathogenesis, atypical manifestations, recurrent cases, differential diagnosis, therapy and pregnancy considerations. Although we could not find a black and white solution to all these problems, we have tried to compile the related literature to draw out some conclusions.

A Comparative Study of Two Modalities, 4% Hydroquinone Versus 30% Salicylic Acid in Periorbital Hyperpigmentation and Assessment of Quality of Life Before and After Treatment.

BACKGROUND: Periorbital hyperpigmentation (POH) is a common hyperpigmentary problem of the face, which can be psychologically distressing and it can influence an individual's quality of life. However, this condition has received less attention in literature. AIMS AND OBJECTIVES: To study the clinico-etiological features and the effect of two therapeutic modalities on the quality of life in patients of POH before and after treatment. MATERIALS AND METHODS: Fifty patients attending the outpatient clinic of Dermatology Department, with clinically evident POH were included. All patients were divided randomly into two groups of 25 each and one group was treated with 4% hydroquinone and another group with 30% salicylic acid for 12 weeks. Assessment with visual analog scale (VAS) was done at 4, 6, and 12 weeks, and outcome of the patients was analyzed statistically. RESULTS: Majority of the cases, i.e. 26 (52%) were in the age group of 20-30 years. Females comprised 74% of the study population. On VAS, most of the patients showed mild improvement (10-30%) at 12 weeks of treatment in both the groups. Separately, both the treatments significantly improved the dermatological life quality index of the patients although there was no significant difference found between the two groups. CONCLUSION: POH is less responsive to standard treatments due to its multifactorial etiology and deposition of melanin in both dermis and epidermis. However, even the mild to moderate improvement in appearance can cause an improvement in the quality of life of the patients.

Imatinib induced melasma-like pigmentation: Report of five cases and review of literature.

Imatinib mesylate is a cytotoxic agent that targets tyrosine kinase. Common side effects of this drug include nausea, edema and maculopapular rash. Hypopigmentation is a commonly reported side effect of this drug while hyperpigmentation has rarely been described. We describe five cases of melasma-like pigmentation induced by this anti-cancer drug. Four of the patients were diagnosed with gastrointestinal stromal tumor while one had chronic myeloid leukemia. Patients received imatinib mesylate in a dose of 400 mg daily. Over an average period of 3 months, well defined hyperpigmented macules appeared over the convexities of the face. One of the patients also developed similar pigmentation on the forearm. Other causes of hyperpigmentation were excluded in each patient.