A Potpourri of Trichoscopic Findings: Unique Presentation of Hyperthyroidism-Induced Hair Changes.

Hyperthyroidism is known to cause thin, brittle hair, and premature graying. Hair shaft abnormalities in hyperthyroidism have not been described in the literature. A visible and microscopic change in the hair shaft due to cosmetic procedures and environmental factors is known as hair weathering. Herein, we report a case of hair weathering in an adult female with hyperthyroidism with unique dermoscopic features.

Evaluation of the Efficacy and Safety of Apremilast in the Management of Lichen Planus.

Introduction: Lichen planus is a chronic disease with often disappointing and less than optimal treatment options. Apremilast modulates inflammatory signalling pathways which play a central role in the pathogenesis of lichen planus, thus making it useful in the management of such patients. Materials and Methods: The present study was an investigator-initiated, single-centre, non-randomized, open-label, pilot study of the efficacy and safety of Apremilast in the treatment of lichen planus. All the patients were prescribed Apremilast 30mg, twice daily, for 12 weeks. Patients were evaluated for improvement in their lesions, based on the physician's global assessment (PGA), subject global assessment (SGA), and target area lesion symptom score (TALSS). Results: A total of 34 patients were included in the study; 26 patients completed the study duration and were considered for the final analysis. After 12 weeks, 34.61% (n = 9/26) patients showed 2 or more grade improvement in their disease as per PGA. About 42.30% (n = 11/26) patients achieved more than 50% improvement in their lesions based on the subject global assessment of their disease. There was a significant improvement in TALSS during the study period (p < 0.0001). Only 23.07% (n = 6/26) patients developed one or more adverse events because of Apremilast with headache being the commonest side effect. Conclusion: The results obtained in our study justify that Apremilast is efficacious and safe in the management of patients with lichen planus. Based on these results, Apremilast can be considered as a promising alternative treatment option in patients with lichen planus.

An Open-Label, Randomized, Prospective, Comparative, Three-Arm Clinical Trial to Evaluate the Safety and Effectiveness of Apremilast with Three Different Titration Methods in Patients with Chronic Plaque Psoriasis in India.

Purpose: To minimize adverse effects (AEs), apremilast is recommended to titrate at the initiation of therapy. But still, many patients experience AEs, resulting in discontinuation of therapy. As a result, many dermatologists have adapted to further titrate apremilast in different ways. The present study was planned to evaluate the safety and effectiveness of apremilast in different dose titration methods as initiation therapy in the treatment of plaque psoriasis. Patients and Methods: In this open-label, randomized, prospective, comparative, three-arm, single center study, 128 plaque psoriasis patients were included. Patients were randomized into three groups. Group I received standard titration for the first 6 days; Group II received all tablets in a starter pack as once a day (OD) total for 13 days; and Group III received two starter packs as 8 tablets each of apremilast 10 mg and 20 mg as OD and 10 tablets of 30 mg as OD, in total for 26 days. All groups received apremilast 30 mg as twice a day after initial titration. The total duration of apremilast therapy in all groups was 16 weeks. Results: In safety assessment, AEs were reported in 50%, 41.3% and 25% in Groups I, II and III, respectively (p <0.05) with nausea being the most common AE. In Group I, 10.53% of patients discontinued apremilast whereas 6.52% and 2.27% discontinued in Groups II and III respectively. Maximum number of AEs were seen in Group I in first week only (74.19%) compared with other groups. At week 16, on the Psoriasis Area and Severity Index, PASI 75 was achieved in 31.43%, 42.4% and 33.3% of patients in Groups I, II and III, respectively with no statistical difference between any groups. Conclusion: It can be concluded that slower titration is a useful strategy for minimizing AEs while at the same time maintaining effectiveness of apremilast.

Multiple Koenen Tumors, a Rare Entity: Combination Treatment with 1% Topical Sirolimus Electrofulguration and Excision.

INTRODUCTION: Koenen tumors are benign, cutaneous manifestations of tuberous sclerosis. These are disfiguring, painful, and challenging to treat as they frequently recur. We report a case of long-standing, multiple Koenen tumors affecting all twenty nails in an elderly female who was successfully treated with a combination of topical sirolimus 1%, surgical excision, and electrofulguration. CASE REPORT: A 57-year-old lady presented with multiple, asymptomatic periungual, and subungual tumors affecting all twenty nails since 27 years. Cutaneous examination revealed confetti macules, ash-leaf macule, and shagreen patch over trunk. Nail biopsy was compatible with Koenen's tumor. Computerized tomography of brain showed diffuse patchy sclerosis. The tumors were treated with topical sirolimus 1% ointment for 10 months with excellent regression. Electro-fulguration for both great toenails and surgical excision of right thumbnail periungual fibroma was done. 1% sirolimus was advised after the surgical treatment. There were no adverse effects or recurrence of tumors over a 2-year follow-up. DISCUSSION: Topical sirolimus 1% was effective in tumor regression and preventing new tumor formation. Larger tumors that interfered in daily chores were treated with excision and electrofulguration. Thus, a combination treatment for this rare presentation of tuberous sclerosis provided optimum results.

A Quality of Life Study in Patients with Leprosy Using DLQI and WHOQOL-BREF Questionnaires.

CONTEXT: India accounts for 60% of the global leprosy burden. Deformities lead to a negative impact on the quality of life (QoL). There is a paucity of Indian studies evaluating the QoL in patients with leprosy. AIMS: This study was undertaken to assess QoL in leprosy patients with two different questionnaires, correlate QoL with demographic and clinical profile and evaluate the impact on health-related QoL scores. SETTINGS AND DESIGN: A cross-sectional study to evaluate the QoL was conducted in the dermatology OPD of a tertiary center in Maharashtra, India. MATERIALS AND METHODS: Demographic and clinical profile along with evaluation of QoL using DLQI and WHOQOL-BREF questionnaires was conducted in 60 leprosy patients. STATISTICAL ANALYSIS USED: Parametric test, R test, Chi-square test, Z test, Student's t-test (t), and Pearson's correlation coefficient (r) were used. RESULTS: The mean DLQI score was 8.4 ± 4.4 and 40% of patients had moderate impact on QoL, and the mean WHOQOL-BREF score was 3.13 ± 0.9. The demographic profile, type of leprosy and reactions did not have a statistically significant correlation with DLQI. Presence of deformity had significant impact on DLQI and a statistically significant impact on physical, psychological, and environmental domain in WHOQOL-BREF analysis. CONCLUSIONS: Deformities have a profound impact on QoL in leprosy patients on evaluation with DLQI and WHOQOL- BREF questionnaires. The social domain was least affected, whereas severe impact was noted in psychological domain. DLQI is a practical and simple questionnaire, whereas WHOQOL- BREF provides a comprehensive approach on all domains.

Contact sensitivity in patients with venous leg ulcer: A multi-centric Indian study.

Venous leg ulcers are the most common form of non-healing leg ulcers. They are subjected to treatments such as topical medications, dressings, and compression therapies. This can lead to exposure to a number of allergens with subsequent sensitisation and contact dermatitis of the regional skin. This may contribute to the poor ulcer healing. To detect the various contact sensitisers in patients with venous leg ulcers through patch testing, patients from 6 centres across India with venous leg ulcers of longer than 6 weeks duration were enrolled for the study. They were patch tested using a special parch test kit with 27 antigens. A total of 172 patients were included in the study; 82 (48.2%) tested positive for at least 1 antigen. Among them, polyvalent sensitisation was noted in 71% of patients. Wood tar mix (10.4%) and the framycetin (8.7%) were the most common allergens. There is a high frequency of allergic sensitisation to various ingredients of topical therapies used in the venous ulcer management, which may interfere with wound healing. Avoiding them can help obtain a better therapeutic outcome.

A retrospective study of the utility of targeted phototherapy in vitiligo.

BACKGROUND: Targeted phototherapy is a recent advance in the treatment of vitiligo, involving selective treatment of vitiligo patches with no effect on surrounding areas. Although it has been in use for a few years, little data is available regarding its safety and efficacy. AIMS: A retrospective study to determine efficacy and safety of targeted phototherapy in vitiligo. METHODS: One hundred and thirty four patients (male: 53, female: 81) who received targeted phototherapy and completed 11 or more sittings were included. Treatment was given once a week using the Lumera phototherapy system, a broadband ultraviolet B source, starting at 150 mJ/spot and after excluding a sunburn reaction, with increments of 50 mJ every week up to a maximum of 1000 mJ/patch. Chi-square test for linear trends was used for statistical analysis. RESULTS: The most common sites involved were the legs and a majority (70.9%) had non-segmental vitiligo. Response was mild in 78 (58.2%) patients, moderate in 50 (37.3%) and excellent in 6 (4.5%) patients. Response was directly proportional to the number of sittings with more patients showing moderate and excellent responses with an increase in the number of sittings. The most common site for an excellent response was the trunk while the lower limbs were involved in most cases with a moderate or mild response. Side effects were seen in 27 (20.2%) patients, the commonest being erythema. LIMITATIONS: This is a retrospective uncontrolled study. Further, the effects of adjuvant treatment were not assessed. CONCLUSIONS: Targeted phototherapy is a useful treatment for vitiligo with mild adverse effects, though response is mild or moderate and appears to be directly proportional to the number of treatments received.

Standard Guidelines of Care: Performing Procedures in Patients on or Recently Administered with Isotretinoin.

BACKGROUND: Currently, the standard protocol regarding the performance of procedures on patients receiving or having recently received isotretinoin (13-cis-retinoic acid) states that the procedures should not be performed. The recommendations in standard books and drug insert require discontinuation of isotretinoin for 6 months before performing cosmetic procedures, including waxing, dermabrasion, chemical peels, laser procedures, or incisional and excisional cold-steel surgery. These recommendations have been followed for over two decades despite little evidence for the stated increased risk of scarring. OBJECTIVE: The Association of Cutaneous Surgeons (I) constituted a task force to review the evidence and to recommend consensus guidelines regarding the safety of skin procedures, including resurfacing, energy-device treatments, and dermatosurgical procedures in patients with concurrent or recent isotretinoin administration. MATERIALS AND METHODS: Data were extracted from the literature through a PubMed search using the keywords "isotretinoin," "safety," "scarring," "keloids," "hypertrophic scarring," and "pigmentation." The evidence was then labeled and circulated to all members of task force for review. RESULTS: The task force is of the opinion that there is insufficient evidence to support the current protocol of avoiding and delaying treatments in the patient group under consideration and recommends that the current practice should be discontinued. The task force concludes that performing procedures such as laser hair removal, fractional lasers for aging and acne scarring, lasers for pigmented skin lesions, fractional radio-frequency microneedling, superficial and medium-depth peels, microdermabrasion, dermaroller, biopsies, radio-frequency ablation, and superficial excisions is safe in patients with concurrent or recent isotretinoin administration.