An updated clinico-investigative approach to diagnosis of cutaneous hyperandrogenism in relation to adult female acne, female pattern alopecia & hirsutism a primer for dermatologists.

INTRODUCTION: Hyperandrogenism is a clinical state consequent to excess androgen production by the ovary, adrenals, or increased peripheral conversion of androgens. The varied manifestations of hyperandrogenism include seborrhea, acne, infertility, hirsutism, or overt virilization of which adult female acne, hirsutism, and female pattern hair loss are of clinical relevance to dermatologists. AREAS COVERED: We limited our narrative review to literature published during period from 1 January 1985 to Dec 2022 and searched PubMed/MEDLINE, Web of Science (WOS), Scopus, and Embase databases with main search keywords were 'Hyperandrogenism,' 'Female,' 'Biochemical,' 'Dermatological', and 'Dermatology.' We detail the common etiological causes, nuances in interpretation of biochemical tests and imaging tools, followed by an algorithmic approach which can help avoid extensive tests and diagnose the common causes of hyperandrogenism. EXPERT OPINION: Based on current data, total testosterone, sex hormone binding globulin, DHEAS, prolactin, free androgen index, and peripheral androgenic metabolites like 3-alpha diol and androsterone glucuronide are ideal tests though not all are required in all patients. Abnormalities in these biochemical investigations may require radiological examination for further clarification. Total testosterone levels can help delineate broadly the varied causes of hyperandrogenism. Serum AMH could be used for defining PCOM in adults.

Time to revisit the purported link of leprosy reactions with infective triggers: An unnecessary economic burden for patients.

Existing literature on factors triggering leprosy reactions is based only on case reports and case series, and thus probably gives a biased view. We undertook a case-control study to investigate such purported trigger factors in 42 leprosy reaction patients and 40 non-reactional controls, and the cost of investigations required for the same. Detailed history, clinical evaluation and investigations for triggers were carried out. Infections (typhoid, dental caries) were the most common triggers found, followed by pregnancy. Trigger factors were commoner in the type 2 reaction (T2R) group compared to type 1 (T1R) reaction group. There was however no statistical difference between the two groups. The average estimated cost of investigations was higher in the reactional group and this difference was statistically significant. Hence, except for essential investigations required for initiating steroids, an extensive battery of investigations is unjustified unless the medical history suggests a definitive infective trigger.

JAK inhibitors in vitiligo: what they hit and what they miss - an immunopathogenesis based exposition of existing evidence.

INTRODUCTION: Vitiligo is an autoimmune disorder which presents as depigmented macules due to selective loss of melanocytes. Heightened expression of Janus Kinase Signal transducers and activators of transcription (JAK STAT) pathway, which mediate cytokines action, suggest that targeting this signaling pathway may be an effective option. AREAS COVERED: A PubMed search was carried out with the broad key words 'JAK,' 'vitiligo' from 2016 to 2023. We also analyzed papers where tissue-based JAK expression was studied, with or without concomitant treatment with JAK inhibitors. We address the role of JAK inhibitors in vitiligo and their effect on repigmentation of lesions. EXPERT OPINION: While JAK inhibitors help in cessation of disease progression, they have no in vivo action on melanocyte proliferation and hence cannot result in re-pigmentation as a monotherapy. There is a need for tissue-based JAK and cytokine-based studies with post-treatment expression data to validate the role of this class of drugs in vitiligo. There is as yet no data to suggest that selective JAK inhibitors are superior to pan JAK inhibitors for vitiligo. JAK inhibitors are useful in active disease and effectively modulate the cytokine mediated autoimmune dammage and makes them singularly superior to oral glucocorticosteroids.

JAK inhibitors in dermatology: the road travelled and path ahead, a narrative review.

INTRODUCTION: Numerous cutaneous dermatoses mediated by cytokines depend on the JAK STAT pathway for intracellular signaling. JAK inhibitors form a useful therapeutic approach in treating these conditions. The literature on effectiveness of JAK inhibitors in treatment of alopecia areata, vitiligo, atopic dermatitis, psoriasis and several other inflammatory and autoimmune diseases is growing although very few conditions have sufficiently well performed studies to their credit and, barring a few indications, their use in rest remains empirical as yet. AREAS COVERED: A search of the PubMed database was made using the keywords Janus kinase inhibitors OR JAK inhibitors AND dermatology with the time duration limited to the last 5 years. Here, we review the JAK STAT pathway, the various conditions in which JAK inhibitors are currently used in dermatology, and other conditions their use is being explored in. EXPERT OPINION: The pathology of a large number of dermatological disorders is mediated via inflammatory cytokines which signal via the JAK STAT pathway. JAKinibs have shown great promise in treating cutaneous disorders refractory to conventional therapy. Their current clinical use in dermatology is based on robust evidence (for some), and anecdotal evidence for most other dermatoses.

Psoriasiform Drug Eruption to Finasteride: Uncommon Side Effect of a Commonly Used Drug.

Finasteride, a 5-α reductase inhibitor, is generally well tolerated on long-term use and cutaneous adverse events have rarely been observed with the drug. We present the case of a 25-year-old male who developed an extensive psoriasiform eruption within a week of starting finasteride 1 mg for androgenetic alopecia.

Severe type 2 leprosy reaction with COVID-19 with a favourable outcome despite continued use of corticosteroids and methotrexate and a hypothesis on the possible immunological consequences.

Type 2 leprosy reaction (T2LR), or Erythema Nodosum Leprosum (ENL), often poses a therapeutic challenge to clinicians and commonly requires long courses of steroids for control. While immunosuppressants are known to achieve control and lower steroid dependence in T2LR, the prospect of managing a severe T2LR in conjunction with COVID-19, with the concern of worsening COVID-19 with long-term immunosuppression has not previously been encountered. We report a case of severe T2LR treated with oral steroids and methotrexate, with COVID-19 infection acquired during hospital stay, and a favourable outcome achieved despite the continued use of immunosuppressants. We discuss the possible reasons for this both in terms of the drug pharmacodynamics and the immunological profile of T2LR.