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

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

Clinical Use of Super-Bioavailable Itraconazole for the Management of Dermatophytosis: Consensus Statement by Dermatologists from India via the Modified Delphi Technique.

Super-bioavailable itraconazole (SB ITZ) overcomes the limitations of conventional itraconazole (CITZ) such as interindividual variability and reduced bioavailability. It has been approved for systemic mycoses in Australia and Europe as 50 mg and the USA as 65 mg and in India as 50 mg, 65 mg, 100 mg, and 130 mg. However, data on the ideal dose and duration of SB ITZ treatment in managing dermatophytosis are insufficient. This consensus discusses the suitability, dosage, duration of treatment, and relevance of using SB ITZ in managing dermatophytosis in different clinical scenarios. Sixteen dermatologists (>15 years of experience in the field and ≥2 years clinical experience with SB ITZ), formed the expert panel. A modified Delphi technique was employed, and a consensus was reached if the concordance in response was >75%. A total of 26 consensus statements were developed. The preferred dose of SB ITZ is 130 mg once daily and if not tolerated, 65 mg twice daily. The preferred duration for treating naïve dermatophytosis is 4-6 weeks and that for recalcitrant dermatophytosis is 6-8 weeks. Moreover, cure rates for dermatophytosis are a little better with SB ITZ than with CITZ with a similar safety profile as of CITZ. Better patient compliance and efficacy are associated with SB ITZ than with CITZ, even in patients with comorbidities and special needs such as patients with diabetes, extensive lesions, corticosteroid abuse, adolescents, and those on multiple drugs. Expert clinicians reported that the overall clinical experience with SB ITZ was better than that with CITZ.

Post Herpetic Itch Leading to Frictional Alopecia of Eyebrow and Scalp-A Hitherto Undescribed Phenomenon.

Post herpetic itch (PHI) is a less commonly reported sequela of herpes zoster. It can begin upon the resolution of the lesions or several weeks later. PHI is neuropathic in nature and is said to be caused by neural injury in the form of demyelination of itch-transmitting nerve fibers in the skin. The majority of PHI resolves over weeks to months with symptomatic treatment. We report a case of PHI resulting in frictional alopecia of eyebrows and scalp due to frequent rubbing of the skin and hairs secondary to bothersome neuropathic itch.

Trichophyton indotineae-An Emerging Pathogen Causing Recalcitrant Dermatophytoses in India and Worldwide-A Multidimensional Perspective.

Trichophyton (T.) indotineae is a newly identified dermatophyte species that has been found in a near-epidemic form on the Indian subcontinent. There is evidence of its spread from the Indian subcontinent to a number of countries worldwide. The fungus is identical to genotype VIII within the T. mentagrophytes/T. interdigitale species complex, which was described in 2019 by sequencing the Internal Transcribed Spacer (ITS) region of ribosomal DNA of the dermatophyte. More than 10 ITS genotypes of T. interdigitale and T. mentagrophytes can now be identified. T. indotineae causes inflammatory and itchy, often widespread, dermatophytosis affecting the groins, gluteal region, trunk, and face. Patients of all ages and genders are affected. The new species has largely displaced other previously prevalent dermatophytes on the Indian subcontinent. T. indotineae has become a problematic dermatophyte due to its predominantly in vitro genetic resistance to terbinafine owing to point mutations of the squalene epoxidase gene. It also displays in vivo resistance to terbinafine. The most efficacious drug currently available for this terbinafine-resistant dermatophytoses, based on sound evidence, is itraconazole.

Chronic Eczema Developing Over Skin Treated for Dermatophytosis in Atopic Patients -Importance of Treating Gently and Intelligently.

A novel observation of chronic eczema developing over the skin of adequately treated lesions of tinea cruris/tinea corporis in six atopic individuals is being shared. We propose that the skin of atopic individuals affected by dermatophytosis be observed for secondary changes even after the complete resolution of the lesions. The use of bland emollients with topical antifungal agents should be encouraged in atopic patients. The extent and duration of the compromised epidermal barrier function of the skin of atopic individuals with dermatophytosis need to be studied further.

Impact of Red Complex Bacteria and TNF-α Levels on the Diabetic and Renal Status of Chronic Kidney Disease Patients in the Presence and Absence of Periodontitis.

Scientific evidence shows a positive association in the etiopathogenesis of periodontitis and chronic kidney disease (CKD). Various confounding factors, such as obesity, diabetes, and inflammation, also play a significant role in the progression of CKD, which remains unexplored. We hypothesise the role of red complex bacteria with various confounding factors associated with chronic kidney disease. The study comprised a total of 120 participants categorised into 4 groups: the control group (C), periodontitis subjects without CKD (P), periodontally healthy chronic kidney disease subjects (CKD), and subjects having both periodontitis and CKD (P + CKD), with 30 subjects in each group. Demographic variables, and periodontal, renal, and diabetic parameters were recorded. Tumour necrosis factor (TNF)-α levels and those of red complex bacteria such as Prophyromonas gingivalis (P.g), Treponema denticola (T.d), and Tonerella forsythia (T.f) were assessed, and the obtained results were statistically analysed. Among the various demographic variables, age showed a level of significance. Mean PI, GI, CAL, and PPD (the proportion of sites with PPD ≥ 5 mm and CAL ≥ 3 mm) were elevated in the P + CKD group. Diabetic parameters such as fasting blood sugar (FBS) and HbA1c levels were also greater in the P + CKD group. Renal parameters such as eGFR and serum creatinine levels were greater in CKD patients. The estimation of red complex periodontal pathogens such as Pg, Td and Tf levels were significantly greater in the P and P + CKD groups. Pearson correlation analysis revealed significant correlation of red complex bacteria with all variables. Greater levels of P.g, T.d and T.f were found in the P groups, thus indicating their important role in the initiation and progression of inflammation of periodontitis and CKD, with diabetes as one of the confounding factors. The study also confirmed a log-linear relationship between TNF-α levels and red complex bacteria, thereby demonstrating the role of inflammatory biomarkers in periodontal disease progression that could contribute to the development of systemic inflammation such as CKD.