Estimating the burden of vitiligo: a systematic review and modelling study.

BACKGROUND: Vitiligo is a chronic autoimmune disease characterised by depigmented skin patches, which can pose substantial psychosocial challenges particularly in individuals with dark skin tones. Despite its impact on quality of life, there is an absence of standardised global epidemiological data. We sought to address this gap with the present study. METHODS: In this study we did a systematic review and modelling analysis to estimate the global, regional, and national prevalence and incidence of vitiligo. We did a comprehensive search of nine digital libraries (PubMed, Embase, Web of Science, Scientific Electronic Library Online, KCI Korean Journal Database, Russian Science Citation Index, Western Pacific Region Index Medicus, Informit, and Health Research and Development Information Network) from inception up to May 25, 2023. We included cross-sectional or cohort studies reporting the incidence rate or prevalence of vitiligo, or data from which incidence rate or prevalence could be calculated, in the general population of a country or area of a country. Summary estimate data were extracted. A main outcome was to estimate the worldwide, regional, and country-specific lifetime prevalence of vitiligo diagnosed by physicians or dermatologists among the general population and in adults and children (as per age groups defined in included studies). We used a Bayesian hierarchical linear mixed model to estimate prevalence, and calculated number of affected individuals using the UN population structure in 2022. In estimating lifetime prevalence, studies reporting point or period prevalence were excluded. Our other main outcome was to estimate incidence rates of vitiligo, but due to a small number of studies, the data on incidence were presented in a descriptive summary. This study was registered on PROSPERO, CRD42023390433. FINDINGS: Our search identified 22 192 records, of which 90 studies met our inclusion criteria. Of these studies, six focused on the incidence of vitiligo, 79 reported on the prevalence of vitiligo, and five provided data on both incidence and prevalence. 71 studies reported on lifetime prevalence. In the most recent years studied, incidence rates in the general population ranged from 24·7 cases (95% CI 24·3-25·2) per 100 000 person-years in South Korea in 2019, to 61·0 cases (60·6-61·4) in the USA in 2017. In individual studies, incidence rates showed an increasing trend over the periods studied. The global lifetime prevalence of vitiligo diagnosed by a physician or dermatologist was estimated at 0·36% (95% credible interval [CrI] 0·24-0·54) in the general population (28·5 million people [95% CrI 18·9-42·6]), 0·67% (0·43-1·07) in the adult population (37·1 million adults [23·9-58·9]), and 0·24% (0·16-0·37) in the child population (5·8 million children [3·8-8·9]). Vitiligo prevalence was higher in adults than in children across all regions. Central Europe and south Asia reported the highest prevalence (0·52% [0·28-1·07] and 0·52% [0·33-0·82], respectively, in the general population). INTERPRETATION: This study highlights the need for standardised epidemiological data collection globally to inform public health policies and improve vitiligo diagnosis and management. Emphasis on the impact on individuals with darker skin tones is crucial to reducing stigma and improving quality of life. Furthermore, our study highlights the need to conduct more research in regions and populations that have been historically under-represented, to effectively address the worldwide burden of vitiligo. FUNDING: None.

Exogenous Progestogen Hypersensitivity and its Increasing Association with Assisted Reproductive Techniques (ART)/in vitro Fertilization (IVF).

Progestogen hypersensitivity (PH) also known as autoimmune progesterone dermatitis is a rare clinical entity that may be triggered by endogenous progesterone (menstrual cycles and pregnancy) or exogenous progestin exposure (examples: contraceptive medicines, in vitro fertilization treatments). It is a poorly recognized syndrome due to its heterogeneous clinical presentation. The pathomechanism of PH is believed to be primarily IgE mediated but less commonly other immune responses may be involved. Management is usually focused on symptomatic control with medications. Recently, with the increasing use of exogenous progestins for in vitro fertilization more cases of hypersensitivity to exogenous progestins have been reported. Progesterone is an essential drug in the luteal phase support improving chances of implantation and pregnancy rates, and hence, PH is an important and difficult challenge to manage in these patients. Because patients require IVF and there is no alternative to progesterone, desensitization is suggested as an approach to endure fertility treatments and provides symptom control in refractory cases. Here, we will review the different aspects of PH.

Prescribing practices of tranexamic acid for melasma: Delphi consensus from the Pigmentary Disorders Society.

Introduction There is ambiguity regarding usage of tranexamic acid for melasma in India, be it in its pre-administration evaluation, administration route, dosing or monitoring. Hence, we conducted this study to understand various tranexamic-acid prescribing patterns and provide practical guidelines. Materials and methods A Google-form-based questionnaire (25-questions) was prepared based on the key areas identified by experts from the Pigmentary Disorders Society, India and circulated to practicing dermatologists across the country. In rounds 2 and 3, the questionnaire was re-presented to the same group of experts and their opinions were sought. The results of the practitioners' survey were denoted graphically alongside, to guide them. Consensus was deemed when at least 80% of respondents chose an option. Results The members agreed that history pertaining to risk factors for thromboembolism, cardiovascular and menstrual disorders should be sought in patients being started on oral tranexamic-acid. Baseline coagulation profile should be ordered in all patients prior to tranexamic-acid and more exhaustive investigations such as complete blood count, liver function test, protein C and S in patients with high risk of thromboembolism. The preferred oral dose was 250 mg orally twice daily, which can be used alone or in combination with topical hydroquinone, kojic acid and sunscreen. Repeated dosing of tranexamic-acid may be required for those relapsing with melasma following initial tranexamic-acid discontinuation. Coagulation profile should ideally be repeated at three monthly intervals during follow-up, especially in patients with clinically higher risk of thromboembolism. Treatment can be stopped abruptly post improvement and no tapering is required. Limitation This study is limited by the fact that open-ended questions were limited to the first general survey round. Conclusion Oral tranexamic-acid provides a valuable treatment option for melasma. Frequent courses of therapy may be required to sustain results and a vigilant watch is recommended for hypercoagulable states during the course of therapy.

Oral Tranexamic Acid for the Treatment of Melasma: Evidence and Experience-Based Consensus Statement from Indian Experts.

Melasma, a chronic pigmentary skin condition mainly affecting the face, remains a challenge despite the availability of several options for treatment. Many melasma patients are not satisfied with treatment outcomes. Tranexamic acid (TXA), an anti-fibrinolytic drug has shown promising results in patients with melasma. Evidence from several clinical studies has surfaced on efficacy and tolerability of TXA in these patients. It can be used as monotherapy or adjuvant with other therapies. Currently, there is no published consensus or guideline document for its use in the treatment of melasma. TXA is available for oral use, topical use as well as an injection. In this article, a consensus of Indian experts is prepared based on the available literature and experience with use of oral TXA in melasma. This review article might help clinicians for use of oral TXA appropriately while treating melasma.

Cosmetic gynecology-An emerging field for the dermatologist.

INTRODUCTION: Cosmetic gynecology is an expanding field with a steep rise in awareness and demand for procedures to enhance the aesthetic appearance of female genitalia. AIM: This article aims to provide an overview of aesthetic gynecology for a practicing dermatologist. METHODS: A study conducted in India showed a rising trend in the demand of aesthetic vaginal procedures from 3.9% in 2012 to 28.97% in 2015. CONCLUSION: Several aesthetic modalities such as peels, platelet rich plasma, and energy-based devices and surgical modalities have been in use, though serious evidence for efficacy of many of these procedures is lacking.

Dermatologic and Cosmetic Procedures in Pregnancy.

Background: Patients may develop a need to undergo procedures while being pregnant and this requires a certain risk-benefit profiling to be done by the clinician. Skin changes during pregnancy such as melasma, striae, varicose veins, hirsutism, and increased skin growths may raise concerns for the lady. Although pregnancy-induced physiologic changes may prompt a surgeon to delay nonessential procedures until after delivery, certain skin conditions may require urgent intervention. Others that may be nonurgent, elective, or cosmetic may need careful analysis. Materials and Methods: Data were extracted from available literature through a PubMed search for the following keywords: "dermatological procedures in pregnancy," "dermatosurgical procedures during pregnancy," "aesthetic procedures in pregnancy," "safety in pregnancy," "teratogenicity of drugs," "local anesthesia during pregnancy," "physiological changes in pregnancy," "cosmetic procedures during pregnancy," and "lasers in pregnancy." Results: Only procedures which are safe and necessary should be carried out in a pregnant woman. Electrocautery, radiofrequency, cryotherapy, and lasers for warts, particularly genital, surgical interventions for skin malignancies, and other small growths should be performed. Safe but cautious outlook is required for intralesional steroid injections, aesthetic procedures such as chemical peeling, botulinum toxin, microdermabrasion, and biopsies for questionable lesions. Absolutely contraindicated procedures include fillers, sclerotherapy, and liposuction.

Hair Oils: Indigenous Knowledge Revisited.

Hair oils are used all over the world since time immemorial; however, their exact effect on the hair and scalp remains obscure. They are usually easily accessible and are inexpensive. A wide variety of oils have been used and newer ones are coming up every day. The primary function of most of the hair oils is to act like an emollient but the unique characteristics of various hair oils suggests its action just more than emollient action. This article focuses on the different types of hair oils and their possible beneficial effects on the hair. Dermatologists need to be aware of the effects of hair oils and their usage.

Role of Smoking in Androgenetic Alopecia: A Systematic Review.

Smoking and its role in Androgenetic Alopecia has long been debated. Smoking may lead to hair loss by vasoconstriction, by forming DNA adducts, free radical damage to hair follicle, by enhancing senescence and hormonal effects. We have reviewed the available literature on AGA and smoking. Data available show that there is a significant association between smoking and AGA. However, studies demonstrating the benefit of avoidance of smoking in improving hair loss are lacking. Furthermore, large controlled studies with histological documentation are still unavailable to affirm the findings.

Oral clonidine as a pre-anesthetic medication in hair transplantation surgery-A pilot study.

BACKGROUND: Hair transplantation (HT) is a safe and rewarding procedure for a patient as well as the surgeon. Clonidine may be a good adjuvant in HT because of its analgesic, anxiolytic, and sedative effects. OBJECTIVE: To study efficacy of Clonidine as a preoperative medication in HT. METHODS & MATERIALS: The study was a prospective trial of 46 consecutive patients who underwent HT between January and May 2017. Patients with normal vital parameters on arrival were given Tab clonidine (0.1 mg) 30 min before starting of the procedure [Clonidine group (n = 30)]; rest were included in the control group (n = 16). Vitals were monitored every 30 min during surgery until the end. Patients were assessed for pain, level of sedation during surgery and for postoperative analgesia. RESULT: All patients who received clonidine, except one, were comfortable and experienced no pain throughout the duration of surgery; nine went into deep sleep. Of the 16 patients in the control group, no patients reported deep sleep, 3 felt restless, and 4 had mild pain. There were no untoward effects in both groups. CONCLUSION: Our study suggests that clonidine is useful as a pre-anesthetic medication in HT. However, this is a pilot study and further larger studies are needed.

The Role of Adipose Tissue in Hair Regeneration: A Potential Tool for Management?

Human adipose tissue (AT) is a rich and easily harvestable source of stem cells and various growth factors (GFs). It has been widely used hitherto for facial rejuvenation and volumization. Increasing evidence shows that dermal adipocytes are intricately associated with hair follicles (HFs) and may be necessary to drive follicular stem cell activation. Early published data have shown encouraging preliminary results for the use of adipocytes and their stem cells as a treatment option for hair growth. The aim of this review study is to analyze published literature on the effect of fat on hair growth and to summarize the current evidence.

Role of vitamin D in hair loss: A short review.

BACKGROUND: Vitamin D, a vitamin and hormone, plays an important role in dermatology and dermatotherapeutics, due to its anti-inflammatory and immunomodulatory properties, and regulation of keratinocyte differentiation and proliferation. It also affects the hair cycle, and its role in hair loss is under constant research. OBJECTIVES: This review aims to give a brief overview of vitamin D biology within the hair follicle, role in the etiopathogenesis, and rationale for supplementation in various alopecias. METHODS: A PubMed literature search was performed to review relevant current literature and studies investigating the role of vitamin D in the etiopathogenesis, as a supplement and a potential therapeutic modality in hair loss. RESULTS AND CONCLUSION: Vitamin D is intricately involved in various signaling pathways of growth and differentiation of hair follicles. Most studies show an inverse relationship between serum vitamin D levels and non-scarring alopecias such as telogen effluvium, androgenetic alopecia, alopecia areata, and trichotillomania. Vitamin D deficiency is also associated with scarring alopecia. However, conclusive studies to demonstrate the benefit of vitamin D administration in correcting hair loss and managing these conditions are lacking. Hence, further studies are needed before vitamin D can be routinely recommended as a treatment modality in these conditions.

9 Tips and Pearls for Safer Performance of Dermatological Procedures during Covid-19 Pandemic.

SARS-CoV2 pandemic has affected dermatologypractice greatly. In view of the risk of transmission, physicians need to devise methods to perform procedures in a safer way. Our institute has adopted a number of innovative safety precautions steps, which are being outlined here.

Role of Low-Level Light Therapy (LLLT) in Androgenetic Alopecia.

Androgenetic alopecia (AGA) is the commonest type of alopecia affecting over half of men and women. Only two drugs have been approved so far (minoxidil and finasteride), and hair transplant is the other treatment alternative. Low-level laser therapy (LLLT) has been claimed to be a new safe devise-based modality for stimulating hair growth in men and women in AGA. Searches of PubMed and Google Scholar were carried out using keywords alopecia, hair loss, and LLLT. Fifteen studies were found to be strongly relevant and were analyzed. Studies have shown that LLLT stimulated hair growth in both men and women. Studies with largest randomized controlled trials demonstrated statistically significant hair regrowth by terminal hair count in both males and females. One study also showed that LLLT and minoxidil had similar efficacy in hair growth and that combination therapy was even more effective. LLLT represents a non-invasive, safe, and potentially effective treatment option for patients with AGA who do not respond or are not tolerant to standard treatment of AGA. Moreover, combining LLLT with topical minoxidil solution and oral finasteride may act synergistic to enhance hair regrowth. However, the level of evidence of the studies is still low and hence more controlled large studies are needed.

Optimal Hair Transplant Recipient Site Slit Design: Minimizing Vascular Damage.

An often overlooked aspect of hair transplantation is the art of recipient site design and slit creation. There is also a lack of consensus on which technique provides the optimum coverage while minimizing vascular damage. This paper aims to provide logical arguments to determine the optimal instrument and method of slit creation, in order to ensure maximum density, optimal survival, minimal pop-out, and minimal damage to scalp vascularity. The use of semiconical blades reduces the damage to the dermis and vascular plexus as compared with rectangular blades and needles, as the depth of penetration required is lower. The use of acute angle reduces the depth of penetration for the same length of slit and decreases damage to deep plexus. Coronal slits produce less vascular damage than that of sagittal slits with the same size blades. We believe that these recommendations provide the optimum volume slits while causing minimal vascular damage.

Regenerative Medicine Treatments for Androgenetic Alopecia.

Regenerative medicine and the role of stem cells are being studied for applications in nearly every field of medicine. The pluripotent nature of stem cells underlies their vast potential for treatment of androgenic alopecia. Several advances in recent years have heightened interest in this field, chief among them are the evolution of simpler techniques to isolate regenerative elements and stems cells. These techniques are easy, outpatient procedures with immediate injection, often single session with harvest, and minimal manipulation (usually physical). This paper seeks to critically review the existing data and determine the current evidence and their role in practice.

Importance of Choke Vessels in Injectable Fillers.

Knowledge of facial anatomy is indispensable for dermatologists and plastic surgeons practicing aesthetic medicine, especially for those using fillers, as injection of fillers may be associated with serious complications such as vascular occlusion and blindness. Angiosome and choke vessels play an important role in vascular incidents occurring after filler injections. The objective of this article was to outline the anatomy and pathophysiology of choke vessels, a concept which is not well known to dermatologists.

Recommendations for Cutaneous and Aesthetic Surgeries during COVID-19 Pandemic.

BACKGROUND: Amid the coronavirus disease 2019 (COVID-19) pandemic, dermatologists must be prepared to restructure their practice of procedural dermatology and cutaneous aesthetic surgeries. The COVID-19 pandemic has presented several challenges and has ushered in several changes in practice such as teledermatology, with many physicians adopting virtual consultations and treatments. Performing procedures in the times of COVID-19 pandemic presents challenges such as risk of transmission to doctors and staff due to potential aerosolization, release of virus droplets during the procedures, and risk of virus transfer through the instruments both in the peri- and postoperative period. This can have several medical, administrative, and legal implications. OBJECTIVES: This document aimed to outline best practices that can be followed in this scenario to perform cutaneous surgeries and procedures to ensure safer skin surgery. RECOMMENDATIONS: Standard precautions include social distancing of at least 1 m, hand hygiene, appropriate use of personal protective equipment (PPE), safe injection practices, sterilization and disinfection of medical devices, environmental cleaning, and respiratory hygiene. It is generally advisable to see patients only by appointments. Each clinic should have a special area at entry for screening patients and providing sanitizers and masks. Procedures, which are of short duration, performed on nonfacial areas are considered as low risk and require donning surgical mask. Procedures involved with minimal invasiveness and bleeding, short duration procedures on the face such as injectables, chemical peels, and aerosol-generating procedures on nonfacial areas are considered moderate risk. These procedures need apron with head cover, N95 mask, face shield, double gloves, and smoke evacuator with high-efficiency particulate air (HEPA) or ultralow particulate air (ULPA) filter. Aerosol and plume-regenerating procedures (such as ablative lasers on the face), prolonged surgeries on head (such as hair transplantation), intraoral, and intranasal procedures are considered high risk. These procedures must be carried out with full body cover with surgical gown, head cover, N95 mask, face shield, double gloves, and smoke evacuator. Physicians should be aware of local epidemiological situation and adhere to the relevant guidelines issued by the relevant governmental agencies.