The Use of Botulinum Toxin-A as an Adjunctive Treatment for Facial Atrophic and Hypertrophic Scars After Surgical Correction.

Background: Facial wounds, especially the ones lying perpendicular to the Lines of Langer, heal poorly. Several methods have been attempted to rectify this, but most of them do not target the underlying pathological process of scarring. Botulinum Toxin-A (BTA) has been successfully used for atrophic and hypertrophic scars. Materials and Methods: This is a prospective study, where 30 patients who were operated for facial scar revision were divided into two equal groups: The first group was injected with BTA, but the second group was not. They were followed up for three months, and the results were analyzed. Results: Manchester scar scale (MSS) was used to assess the scars. In all the cases, the MSS score reduced after surgical correction, which further reduced after the injection of BTA in the first group of patients. The results are statistically significant (P < 0.01). Conclusion: The BTA plays an important role in the treatment of scars after scar revision surgeries.

Hair Follicle Grafting Therapy Promotes Re-Emergence of Critical Skin Components in Chronic Nonhealing Wounds.

An exploding public health crisis is the exponential growth in the incidence of chronic nonhealing ulcers associated with diseases such as diabetes. Various modalities have been developed to stimulate wound closure that is otherwise recalcitrant to standard clinical treatments. However, these approaches primarily focus on the process of re-epithelialization and are often deficient in regenerating the full spectrum of structures necessary for normal skin function. Autologous hair follicle grafting is a recent therapy to stimulate the closure of such nonhealing wounds, and we observed effects beyond the epidermis to other important components of the dermis. We found that hair follicle grafting facilitated the reappearance of various undifferentiated and differentiated layers of the epidermis with the restoration of epidermal junctions. In addition, other important structures that are critical for cutaneous health and function such as the blood and lymph vasculature, nerve fibers, and sweat gland structures were restored in postgrafted wounds. Interestingly, both immune cells and inflammatory signals were substantially decreased, indicating a reduction in the chronic inflammation that is a hallmark of nonhealing wounds. Our observation that punch wounds created on the postgrafted area likewise healed suggests that this is a self-sustaining long-term therapy for patients with chronic wounds.

A Nationwide, Multicentric Case-Control Study on Vitiligo (MEDEC-V) to Elicit the Magnitude and Correlates.

BACKGROUND: Vitiligo is an acquired, idiopathic, and common depigmentation disorder. The values of various epidemiologic parameters are often doubtful due to the methodological weaknesses of the studies. AIMS: To elicit the magnitude of various epidemiological parameters and important correlates of vitiligo. MATERIALS AND METHODS: Every vitiligo patient attending the outpatient department of medical colleges spread over most of the Indian states were examined over a period of 1 year. Various epidemiological and clinical variables were examined and compared with age and sex-matched controls (registered in the Clinical Trial Registry of India CTRI/2017/06/008854). RESULTS: A total of 4,43,275 patients were assessed in 30 medical colleges from 21 Indian states. Institutional prevalence of vitiligo was 0.89% (0.86% in males and 0.93% in females, P < 0.001). The mean age at presentation and mean age at onset were 30.12 ± 17.97 years and 25.14 ± 7.48 years, respectively. Head-neck was the most common primary site (n = 1648, 41.6%) and most commonly affected site (n = 2186, 55.17%). Most cases had nonsegmental vitiligo (n = 2690, 67.89%). The disease started before 20 years of age in more than 46% of cases. About 77% of all cases had signs of instability during the last 1 year. The family history, consanguinity, hypothyroid disorders, and depressed mood were significantly (P < 0.001) higher among the cases. First, second, and third-degree family members were affected in 269 (60.04%), 111 (24.78%), and 68 (15.18%) cases, respectively. Work-related exposure to chemicals was significantly higher among cases (P < 0.008). Obesity was less common among vitiligo cases [P < 0.001, odds ratio (OR) 0.78, 95% confidence interval (CI): 0.71-0.86]. CONCLUSION: This is one of the largest studies done on vitiligo in India. The prevalence of vitiligo was found to be 0.89% among hospital attendees. Prevalence of vitiligo was higher among females than in males and prevalence of family history, consanguinity, hypothyroid disorders were higher in vitiligo than among controls.

To Study the Outcome of Three-Flap Technique in the Management of Pincer Nail.

CONTEXT: Pincer nail deformity is a transverse overcurvature of the nail. Though various conservative and surgical techniques have been described in the literature, very few studies are based on objective measurements. This study was undertaken to evaluate the outcome of three-flap technique in the management of pincer nail. AIM: To study the outcome of three-flap technique in the management of pincer nail. SETTINGS AND DESIGN: Prospective interventional study. SUBJECTS AND METHODS: Fifteen patients with pincer nail deformity, fulfilling inclusion and exclusion criteria were enrolled for the study. Routine X-ray was carried out for all patients to detect underlying bony abnormalities such as exostoses. Width and height indices were calculated before the procedure. A three-flap technique was performed on all affected toe nails and outcome was assessed at the end of 6 months and 1 year. STATISTICAL ANALYSIS USED: Paired t-test and P value. RESULTS: Satisfactory cosmetic outcome and statistically significant improvement (P < 0.0001) were achieved in all patients. CONCLUSIONS: Three flap technique is an useful technique in the management of pincer nail.

Spotlight on itolizumab in the treatment of psoriasis - current perspectives from India.

Psoriasis is a chronic, debilitating, immune-mediated, systemic inflammatory disease affecting mainly skin, nails, and joints. Several therapeutic modalities are available depending on the severity of the disease. Long-term use of these drugs results in unwanted effects and toxicities. Recently, itolizumab, a humanized monoclonal immunoglobulin G1 antibody to CD6, has shown appreciable clinical effects and safety profile in patients with moderate-to-severe chronic plaque psoriasis. A literature search was conducted using the keywords "anti-CD6", "psoriasis", "phase trials", "case series", and "case reports". The data from all studies conducted in India on efficacy of itolizumab in psoriasis and published before September 2017 were collected. This article provides an overview of the clinical data obtained in these published articles. Itolizumab has immunomodulatory and anti-inflammatory effects. It is efficacious and provides a good duration of remission, and hence represents a new biological agent that could be added to the therapeutic armamentarium of psoriasis.

Scalp Defect Reconstruction with Triple Rotation Flap: A Case Report.

Scalp surgeries are some of the surgeries frequently performed in dermatosurgery department. These surgical procedures may leave large defects, especially when performed for malignant condition in which wide margin has to be excised. Such large defects are difficult to close primarily when reconstruction with local flap is essential. Here we report a case of epithelioid angiosarcoma of the scalp in a 24-year-old man where excision and reconstruction were performed using triple rotation flap.

Comparative Study of Efficacy and Safety of Botulinum Toxin a Injections and Subcutaneous Curettage in the Treatment of Axillary Hyperhidrosis.

BACKGROUND: Primary focal axillary hyperhidrosis is a chronic distressing disorder affecting both the sexes. When the condition is refractory to conservative management, we should go for more promising therapies like intradermal botulinum toxin A (BtxA) injections in the axilla, and surgical therapies like subcutaneous curettage of sweat glands. AIMS AND OBJECTIVES: The aim of this study is to compare the efficacy, safety and duration of action of intradermal BtxA injections in one axilla and subcutaneous curettage of sweat glands in the other axilla of the same patient with axillary hyperhidrosis. MATERIALS AND METHODS: Twenty patients (40 axillae) received intradermal BtxA injections on the right side (20 axillae) and underwent tumescent subcutaneous curettage of sweat glands on the left side (20 axillae). Sweat production rate was measured using gravimetry analyses at baseline and at 3 months after the procedure. Subjective analyses were done using hyperhidrosis disease severity scale (HDSS) score at baseline, at 3rd and 6th month after the procedure. RESULTS: At 3 months post-treatment, the resting sweat rate in the toxin group improved by 80.32% versus 79.79% in the subcutaneous curettage method (P = 0.21). Exercise-induced sweat rate in the toxin group improved by 88.76% versus 88.8% in the subcutaneous curettage group (P = 0.9). There was a significant difference in the HDSS score after treatment with both the modalities. There were no adverse events with BtxA treatment compared to very minor adverse events with the surgical method. CONCLUSION: Both intradermal BtxA injections and tumescent subcutaneous curettage of sweat glands had a significant decrease in the sweat rates with no significant difference between the two modalities. Hence, in resource poor settings where affordability of BtxA injection is a constraint, subcutaneous curettage of sweat glands can be preferred which has been found equally effective with no or minimal adverse events.

Follicular Unit Grafting in Chronic Nonhealing Leg Ulcers: A Clinical Study.

INTRODUCTION AND OBJECTIVES: The restoration of the epithelium after injury takes place by migration of epithelial cells adjoining a wound or by centrifugal migration from hair follicles. To evaluate the feasibility and potential healing capacity of scalp follicular unit grafts transplanted into the wound bed of chronic leg ulcers. MATERIALS AND METHODS: Patients with chronic nonhealing ulcers of more than 6 weeks duration were selected for the study. Those with infected ulcers and uncontrolled diabetes were excluded from the study. Fifteen patients were included in the study. Follicular unit grafts were harvested under local anesthesia using small-diameter (1 mm) circular punches. A density of 5 follicular grafts/cm2 was implanted into the ulcer bed. The ulcer was dressed with Vaseline gauze and elastic bandage for 24 h. The wound area and volume were calculated by length × width × 0.7854 and length × width × depth × 0.7854, respectively. The treatment outcome was defined as the percentage in change of area and volume of the ulcer, 18 weeks after intervention. RESULTS: A total of 15 patients with 17 ulcers were treated with the above method. Of these 17 ulcers, 11 were venous ulcers, 2 were pyoderma gangrenosum associated with varicose veins, 2 were traumatic ulcers, and 2 were trophic ulcers. The baseline mean area of the ulcer was 6.72 cm2 (SD 5.65) and baseline volume was 2.87 cm3 (SD 2.9). The final area of the ulcer at the end of 18 weeks after the procedure was 3.84 cm2 (SD 5.43) and the final volume was 1.21 cm3 (SD 2.45), which was statistically significant. The mean percentage improvement in the area and volume of the ulcer was 48.8% and 71.98%, respectively. Two patients did not respond to the treatment. There were no adverse events after the procedure. CONCLUSION: We conclude that follicular unit grafting into wound beds is feasible and represents a promising therapeutic alternative for managing nonhealing chronic leg ulcers.

Nevirapine induced toxic epidermal necrolysis and non-Hodgkin lymphoma in a Human Immunodeficiency Virus positive patient.

Nevirapine, a non-nucleoside reverse transcriptase inhibitor (NNRTI) is one of the important components of highly active antiretroviral therapy. It is sometimes associated with life-threatening adverse reactions. Here we report one such patient who developed toxic epidermal necrolysis (TEN), leucopenia and hepatotoxicity secondary to intake of nevirapine. This patient was also diagnosed to have non-Hodgkin lymphoma grade IV of anal canal for which he was given radiotherapy and two cycles of chemotherapy. The treating physicians should carefully monitor patients on NNRTI-based antiretroviral therapy so that fatalities due to adverse drug reactions can be prevented with timely intervention.

Efficacy and safety of itolizumab, a novel anti-CD6 monoclonal antibody, in patients with moderate to severe chronic plaque psoriasis: results of a double-blind, randomized, placebo-controlled, phase-III study.

BACKGROUND: Itolizumab, a humanized monoclonal antibody to CD6, is a novel therapeutic agent evaluated in chronic plaque psoriasis. OBJECTIVE: We sought to assess the safety and efficacy of itolizumab in moderate to severe chronic plaque psoriasis. METHODS: A total of 225 patients were randomized (2:2:1) to 2 different itolizumab arms (A or B; A = 4-week loading dose of 0.4 mg/kg/wk followed by 1.6 mg/kg every 2 weeks; B = 1.6/mg every 2 weeks) or placebo. At week 12, the placebo arm was switched to 1.6 mg/kg itolizumab every 2 weeks. The primary end point was the proportion of patients with at least 75% improvement in Psoriasis Area and Severity Index score at week 12. RESULTS: At week 12, 27.0% in arm A (P = .0172 vs placebo), 36.4% in B (P = .0043 vs placebo), and 2.3% in the placebo arm had at least 75% improvement in Psoriasis Area and Severity Index score. At week 28, the proportion with at least 75% improvement in Psoriasis Area and Severity Index score was comparable: 46.1%, 45.5%, and 41.9% for A, B, and placebo, respectively. In weeks 1 to 12, the incidence of all adverse events was comparable across arms (A, 43%; B, 38%; placebo, 47%) and the incidence of infections was not greater than placebo (11.1%, 8.9%, and 18.6% for A, B, and placebo). LIMITATIONS: No active comparator is a limitation. CONCLUSIONS: Itolizumab is an effective and well-tolerated novel biological therapy in moderate to severe psoriasis.

A Randomised, Open-label, Comparative Study of Tranexamic Acid Microinjections and Tranexamic Acid with Microneedling in Patients with Melasma.

BACKGROUND: Melasma is a common cause of facial hyperpigmentation with significant cosmetic deformity. Although several treatment modalities are available, none is satisfactory. AIM: To compare the therapeutic efficacy and safety of tranexamic acid (TA) microinjections versus tranexamic acid with microneedling in melasma. MATERIALS AND METHODS: This is a prospective, randomised, open-label study with a sample size of 60; 30 in each treatment arms. Thirty patients were administered with localised microinjections of TA in one arm, and other 30 with TA with microneedling. The procedure was done at monthly intervals (0, 4 and 8 weeks) and followed up for three consecutive months. Clinical images were taken at each visit including modified Melasma Area Severity Index MASI scoring, patient global assessment and physician global assessment to assess the clinical response. RESULTS: In the microinjection group, there was 35.72% improvement in the MASI score compared to 44.41% in the microneedling group, at the end of third follow-up visit. Six patients (26.09%) in the microinjections group, as compared to 12 patients (41.38%) in the microneedling group, showed more than 50% improvement. However, there were no major adverse events observed in both the treatment groups. CONCLUSIONS: On the basis of these results, TA can be used as potentially a new, effective, safe and promising therapeutic agent in melasma. The medication is easily available and affordable. Better therapeutic response to treatment in the microneedling group could be attributed to the deeper and uniform delivery of the medication through microchannels created by microneedling.

Extensive morphea profunda with autoantibodies and benign tumors: A rare case report.

The term deep morphea describes a variant of morphea (localised scleroderma) in which inflammation and sclerosis are found in the deep dermis, panniculus, fascia or superficial muscle. It is sometimes associated with autoantibodies. We report the case of a 49 year-old male who had morphea profunda (radiologically and histopathologically confirmed) affecting mainly the left side of the body with face, trunk and limb involvement, along with autoantibody production and associated neurofibromas and lipomas.