Kanika Sahni

Dermafrac ™ : An innovative new treatment for periorbital melanosis in a dark-skinned male patient

Periorbital melanosis (under eye dark circles) is an often idiopathic cosmetically disturbing condition that is poorly responsive to currently available treatment modalities. We present the case of a 48-year-old man (skin phototype V) with significant idiopathic periorbital melanosis and who had good to excellent reduction in periorbital melanosis with the new DermaFrac™, which combines microneedling with simultaneous infusion of a serum containing active ingredients. The possible mechanisms of benefit are discussed. DermaFrac™ may be an innovative and effective new treatment option for patients with periorbital melanosis.

Stability in vitiligo: Is there a perfect way to predict it?

Stability is a hard-to-define concept in the setting of vitiligo, but is nonetheless extremely crucial to the planning of treatment regimens and also in prognosticating for the patient. There are several ways to judge stability in vitiligo, which include clinical features and, recently, many biochemical, cytological and ultrastructural correlates of the same. These recent advances help in not only in prognosticating individual patients but also in elucidating some of the mechanisms for the pathogenesis of vitiligo, including melanocytorrhagy and oxidative damage to melanocytes.

Clinical efficacy of rituximab in the treatment of pemphigus: A retrospective study.

Background: Pulsed corticosteroids have been used successfully for the management of pemphigus. However, prolonged use of glucocorticoids may be associated with adverse effects and some patients show a poor response to conventional therapy. Biologics have shown a promising role in such cases; however, there is limited data from the Indian subcontinent. Objective: The primary objective was to assess the efficacy and adverse effects of rituximab in pemphigus. The secondary objective was to measure the cumulative doses of corticosteroids required for these patients. Methods: We undertook a retrospective review of records of 25 pemphigus patients (pemphigus vulgaris: 21, pemphigus foliaceus: 4) who had received rituximab infusion (rheumatoid arthritis protocol in 21 patients, modified in 4). Oral prednisolone was administered in dosages up to 0.5 mg/kg of body weight and tapered over the next 3–4 months according to the disease activity. However, other immunosuppressive agents such as cyclophosphamide and azathioprine were continued for one year after clinical remission was achieved. Results: Complete remission was observed in 22 (88%) patients. The mean time to disease control and complete remission was 1.10 and 4.36 months, respectively. Four (16%) patients experienced relapse after a mean duration of 11.75 months. The mean total dose of oral steroids administered was equivalent to 3535.64 mg of prednisolone. Exacerbation of disease was noted in two patients after the first dose of rituximab and infectious complications, pneumonia and cellulitis, developed in one patient each. Limitations: A small sample size, the retrospective nature of the study and unavailability of follow-up anti-desmoglein autoantibodies levels were limitations. Conclusion: Rituximab is an effective agent in the treatment of pemphigus. The use of rituximab enabled use of a lower initial dose of oral prednisolone in pemphigus and hence reduced its total cumulative dose. Severe side effects were rare.

A novel point-of-care in vivo technique for preparation of epidermal cell suspension for transplantation in vitiligo

SURGICAL CHALLENGE We describe a new technique for preparation of noncultured epidermal cell suspension for transplantation in stable vitiligo, in which cell separation and harvesting is performed inside sterile blisters induced by suction on the patient’s thigh. This technique has the advantage of being simple, easy to learn, and inexpensive, and it requires minimal processing and handling of the tissue outside the body.

Extracted hair follicle outer root sheath cell suspension for pigment cell restoration in vitiligo

Vitiligo surgery has come up a long way from punch skin grafts to epidermal cell suspension and latest to the extracted hair follicle outer root sheath cell suspension (EHF-ORS-CS) transplantation. The progressive development from one technique to the other is always in a quest for the best. In the latest development- EHF-ORS-CS, which is an enriched source of follicular inactive melanocyte (melanocyte stem cells), seems to be a good addition to the prevailing cell-based therapies for vitiligo; however, need to be explored further in larger, and preferably randomized blinded studies. This review discusses the principle, technical details, and stem cell composition of hair follicular outer root sheath cell suspension.

Hyperpigmentation in photo exposed patches of vitiligo following tacrolimus therapy

Vitiligo is an acquired pigmentary disorder, clinically characterized by depigmented macules caused by destruction of melanocytes in the affected skin. Half of all patients develop the disease in childhood and adolescence before the age of 20 years, making vitiligo an important skin disease of childhood. There are numerous studies in the literature that suggest the efficacy of topical tacrolimus in vitiligo, without serious adverse effects. We describe a case of vitiligo in a pediatric patient who developed hyperpigmentation in the periorbital lesions of vitiligo with the use of topical tacrolimus. To the best of our knowledge, this is only the second such reported occurrence in a patient with vitiligo.

Basal cell carcinoma overlying vitiligo attributable to phototherapy

dose-dependent effect because it usually occurs when using unfractionated heparin or low-molecular-weight heparin at therapeutic doses.[1] Bullous hemorrhagic dermatosis usually appears some days after heparin injection although, rarely, it may occur weeks later. Clinically, it is characterised by tense hemorrhagic bullae distant from the heparin injection sites without any inflammatory signs in the adjacent skin. There are no other symptoms or signs. The key histopathological features of this entity are intraepidermal bullae with lack of thrombosis, vasculitis or inflammatory changes in vessels or dermis. These features are essential to exclude other cutaneous side effects of heparin injection.[1] Treatment for this condition is not necessary since the prognosis is usually favorable with spontaneous remission. Treatment with enoxaparin can be continued despite the eruption of hemorrhagic bullae. In conclusion, this case adds to the evidence from other reports that these drugs can probably cause skin reactions at sites distant from subcutaneous injections.[4,5] Till date, there are less than 20 cases reported in the literature.[3] This disease is usually self-limited despite continuing the offending medication; hence, it may be an under-diagnosed phenomenon. Since enoxaparin is a drug frequently used in medical practice, dermatologists should be aware of these side effects so that their patients can be appropriately informed.

An open label prospective randomized trial to compare the efficacy of coal tar-salicylic acid ointment versus calcipotriol/betamethasone dipropionate ointment in the treatment of limited chronic plaque psoriasis

Background: Chronic plaque psoriasis is a common papulosquamous skin disorder, for which a number of topical agents are being used including coal tar, topical steroids and more recently topical calcipotriol/betamethasone dipropionate. There is no study comparing purified coal tar preparation with calcipotriol/betamethasone dipropionate ointment in limited chronic plaque psoriasis. Aims and Objectives: A prospective randomized open label controlled trial to compare the efficacy and safety of topical application of coal tar-salicylic acid ointment with calcipotriol/betamethasone dipropionate ointment applied once at night for 12 weeks for the treatment of limited chronic plaque psoriasis. Materials and Methods: A total of 62 patients of limited chronic plaque psoriasis (body surface area <10%) were randomized into two treatment groups: Group A received topical application of 6% coal tar with 3% salicylic acid ointment and Group B received calcipotriol/betamethasone dipropionate, once at night for 12 weeks. Results were assessed based on psoriasis area severity index (PASI) scores and patient global assessment (PGA) at each visit. Results: Mean PASI was significantly lower at week 2 (P = 0.01) and week 4 follow-up (P = 0.05) and the mean reduction in PASI was significantly higher at week 2 (P = 0.02) with calcipotriol/betamethasone than coal tar-salicylic acid, but this difference was not sustained at subsequent follow-up visits. Similarly, PGA scores at weeks 2 and 4 were significantly lower with calcipotriol/betamethasone dipropionate ointment (P = 0.003 and P = 0.007 respectively). There was no significant difference in any parameter during subsequent follow-up visits or at the end of the treatment phase (12 weeks). Conclusion: Topical nightly application of calcipotriol/betamethasone dipropionate ointment leads to an initial, more rapid reduction in disease severity, but the overall outcome parameters are comparable in the two treatment groups.

Photodermatoses in the Pigmented Skin

Skin colour (specifically in relation to its melanin content and composition) has a marked influence on its interaction with ultraviolet light. Eumelanin has mainly photoprotective properties while pheomelanin has the ability to cause formation of reactive oxygen species. This difference is responsible for the difference in incidence and presentation of various idiopathic photodermatoses in dark skinned patients compared to those with lighter skin types. Certain conditions are peculiar to darker skins including pin point popular variant of polymorphous light eruption. These differences are discussed in this chapter while also highlighting the challenges faced in performing phototesting in patients with dark skin.

Bleeding erythematous papules over nose in a middle-aged man

A 38-year-old man presented with a 11⁄2-year history of multiple, asymptomatic, erythematous, crusted papules over the left ala of the nose. The lesions were slowly progressive, and there was a history of bleeding on minor trauma. The patient was systemically well. One session of radiofrequency ablation performed 3 months before from a local practitioner had led to no significant improvement. Figure 2 Hematoxylin and eosin staining of skin biopsy shows the presence of well-formed epithelioid cell granulomas located in both upper (a, 9200) and lower dermis (b, 9100) with a large area of caseous necrosis (c, 9200, arrow). Granulomas are composed of Langhans and multinucleated giant cells along with multiple epithelioid histiocytes (d, 9400, arrow)