Randomized controlled trial to compare the effectiveness and safety of low dose dexamethasone oral mini-pulse versus diphenylcyclopropenone contact sensitisation in severe pediatric alopecia areata.

Oral mini pulse (OMP) corticosteroids and diphencyclopropenone (DPCP) contact sensitisation are commonly used treatment modalities in severe cases of Alopecia areata (AA) in children but with scarce studies comparing the two modalities in children. In this study we aimed to compare the effectiveness and safety of dexamethasone OMP with DPCP contact sensitization in severe non progressive AA in children. This randomized open label study was undertaken in 30 children less than 18 years of age with extensive non progressive AA divided in two groups. Group I included 15 patients who received dexamethasone (5 mg/week) OMP as five tablets of 0.5 mg dexamethasone (i.e., 2.5 mg dexamethasone) on two consecutive days in a week. Group II included 15 patients who were treated with DPCP contact sensitization. The treatment was continued in all patients for 24 weeks. Patients were followed up every 4 weeks and records were maintained. Response rate was 100% in OMP group and 53.3% in DPCP group at 24 weeks. In Group I, complete regrowth was seen in 20% patients, and cosmetically acceptable regrowth in 66.7% while in Group II, complete regrowth was not seen in any of the patients, and cosmetically acceptable regrowth in 20% (p = 0.001). Hair regrowth started at mean duration of 7.7 weeks in Group I, while 11.3 weeks in Group II. Response rate of treatment with dexamethasone OMP leads to a significantly faster and better hair regrowth compared to DPCP contact immunotherapy in non-progressive extensive AA in children.

Pachyonychia congenita responding favorably to a combination of surgical and medical therapies.

Pachyonychia congenital (PC) is a rare genetic disorder of cornification and is classified into five types on the basis of keratin gene involved. There are no established treatment options available for PC. Sirolimus in both topical and oral form has been studied in management of PC. We report a young female with a novel genetic mutation in KRT6A gene who presented with painful palmoplantar hyperkeratosis and onychogryphosis, which was cosmetically disfiguring. She was prescribed oral sirolimus after all investigations. There was significant improvement in pain within a week. Pain relief was sustained at 1 year follow-up with topical treatment only. Serial nail avulsion surgeries were also done with showed significant cosmetic improvement in the nails. Medical therapies can be combined with surgery for a better cosmetic outcome and improvement in patient quality of life.

Efficacy and safety of topical calcipotriol in management of alopecia areata: A pilot study.

Reports have highlighted serum vitamin D deficiency and reduced 1,25-dihydroxyvitamin D(3) receptors(VDR) expression on hair follicles of alopecia areata(AA) patients. Very few studies have demonstrated efficacy of topical calcipotriol (vitamin D analogue) in AA. We intended to study the efficacy of calcipotriol lotion 0.005% in AA and correlate its outcome with serum vitamin D levels. We conducted a prospective study, in which 22 patients with AA were treated with calcipotriol lotion 0.005% twice daily for 3 months. Clinico-epidemiological parameters including severity of AA and SALT score were calculated at baseline and at 12 weeks. Hair regrowth was assessed monthly at 4, 8, 12 weeks. Serum vitamin D levels were measured at baseline. After 12 weeks of treatment, hair regrowth was observed in 13 (59.1%) patients. Mean period for onset of disease stabilization and hair regrowth was 4 weeks and 4.21± 2.13 weeks, respectively. Among these 13 patients, SALT50 and SALT100 was observed in 6(46.2%) and 2(9%) patients, respectively. Response to treatment was better in patients with lower vitamin D levels (p < .009). Topical calcipotriol can be an alternative treatment in AA and it could prove to be more useful in patients who are vitamin D deficient.

Pustular lesions in the neonate: Focused diagnostic approach based on clinical clues.

Pustules in a neonate can be due to various causes. Though the majority of conditions causing pustules in a neonate are benign, it is essential to clearly differentiate these from serious ones. A systematic approach based on detailed history and clinical examination of the neonate along with basic laboratory evaluation narrows down diagnostic possibilities and aids in the correct diagnosis. This review outlines a step-by-step approach so as to avoid clinical dilemmas and unnecessary intervention.

Extrafacial Melasma: A Scenario Less Explored.

Background: Extrafacial melasma is a rare presentation, commonly occurring in postmenopausal women with a poor etiological insight and nature of its course. We planned to decipher the natural course of extrafacial melasma based on history questionnaire. Materials and Methods: Patients with diagnosis of extrafacial melasma were recruited. After informed consent, complete history including age of onset, duration, progression, sites of involvement (initial site as well as current site of pigmentation), treatment history, history of drug intake, family history, associated other diseases, and clinical photography and dermoscopy were done. Results: Fifteen extrafacial melasma patients were recruited. All were females with mean age of 51.2 years. History of facial melasma in past was given by 93% of recruited patients. Mean total duration of melasma was 23 years. Ten (66%) patients had centrofacial melasma to begin with, 4 (26%) patients had malar melasma, and 1 (6.6%) had extrafacial melasma as initial presentation. Currently all patients had extrafacial melasma. Mean time for clearance of central face melasma was 18.2 years and appearance of melasma at extrafacial sites was 20 years. Conclusions: We infer that different clinical patterns of melasma occur sequentially over the natural course of disease and centrofacial melasma as the initial presentation in majority of our patients, progressed to involve extrafacial sites with time.

Clinico-Dermoscopic Features and Treatment Responsiveness in Pediatric Alopecia - Experience from a Tertiary Care Pediatric Dermatology Clinic.

BACKGROUND: Data on clinical and epidemiologic profile on pediatric alopecia is relatively scarce. AIMS AND OBJECTIVES: We aimed to study the clinical, epidemiological, and dermoscopic profile of children presenting with alopecia, and assess the responsiveness to different treatment modalities in a real-life setting. MATERIALS AND METHODS: This cohort study involved analyzing children presenting with hair loss during the study period. After a detailed history, clinical, and trichoscopic examination, treatment offered to patients and follow-up response to treatment along with relapse of symptoms were noted. RESULTS: Around 119 children were included. Nearly 90% were of acquired etiology. The most common cause of alopecia was alopecia areata (AA) in 85 (71%) patients followed by tinea capitis 9 (7.5%), lichen planopilaris 4 (3.3%), and other less common causes. In patients of AA, dermoscopy showed the presence of black dots in 68% cases, exclamation mark hair in 54% of patients followed by off-white dots, yellow dots, and vellus hair. Patients with an acute course and black dots on dermoscopy responded better to treatment. Relapse was common in patients with early age of onset and longer disease duration. CONCLUSIONS: Hair loss is frequently seen in pediatric dermatology clinics. Dermoscopy of pediatric AA shows scarce yellow dots while off-white dots are more frequent; the presence of black dots is a good prognostic indicator.

Correlation of vitamin D and vitamin D receptor expression in patients with alopecia areata: a clinical paradigm.

BACKGROUND: Vitamin D (Vit.D) deficiency has been reported in alopecia areata (AA). Downregulation of Vitamin D receptor (VDR) on hair follicles is associated with reduced hair growth. OBJECTIVE: To correlate serum Vit.D levels with severity, pattern, and duration of AA, and density of VDR expression over hair follicles in AA patients. METHODS: Prospective study including 30 AA patients and 30 healthy controls. Clinical details and serum Vit.D measurement and scalp biopsy for histopathology and VDR expression was performed in patients and controls at baseline and after 6 months of treatment of AA. RESULTS: Mean age of patients and controls was 28.9 ± 9.96 and 31.17 ± 9.43 years, respectively. Mean SALT score in patients was 35.8 ± 27.5 with a median disease duration of 48 weeks. Mean serum Vit.D levels was 7.65 ± 4.50 ng/ml and 15.8 ± 11.47 ng/ml in patients and controls, respectively. Twenty-nine (96.7%) patients were Vit.D deficient (<20 ng/ml), compared to 22 (73.3%) controls (P = 0.001). Serum Vit.D levels inversely correlated with severity of the disease (r = -256), P = 0.17, and duration of disease but did not correlate with pattern of AA and VDR expression in tissue samples. VDR expression was reduced in all patients and was normal in controls. Inverse correlation of VDR was noted with presence of inflammation on histology (P = 0.02). VDR upregulation post treatment was seen only in 13% of patients and demonstrated no correlation with response to treatment. CONCLUSION: Vit.D deficiency in AA correlates inversely with disease severity and duration. VDR expression is reduced in AA and inversely correlate with inflammation histologically but does not correlates with serum Vit.D levels, severity, pattern, or duration of illness.