Muhammed Razmi T

Combination of Follicular and Epidermal Cell Suspension as a Novel Surgical Approach in Difficult-to-Treat Vitiligo: A Randomized Clinical Trial

Importance Epidermal cell suspension (ECS) and follicular cell suspension (FCS) are successful surgical modalities for the treatment of stable vitiligo. However, repigmentation in generalized and acrofacial vitiligo and over acral or bony sites (eg, elbows, knees, iliac crests, and malleoli), which are difficult to treat, is challenging. Objective To study the efficacy of transplanting a combination of autologous, noncultured ECS and FCS (ECS + FCS) compared with ECS alone in stable vitiligo. Design, Setting, and Participants A prospective, observer-blinded, active-controlled, randomized clinical trial was conducted at a tertiary care hospital, with treatment administered as an outpatient procedure. Thirty participants who had stable vitiligo with symmetrical lesions were recruited between October 18, 2013, and October 28, 2016. All of the lesions were resistant to medical modalities with minimum lesional stability of 1 year. Intent-to-treat analysis was used. Interventions ECS + FCS was prepared by mixing equal amounts (in cell number) of FCS with ECS. After manual dermabrasion, ECS was applied to 1 lesion and ECS + FCS was applied to the anatomically based paired lesion of the same patient. No adjuvant treatment was given. Main Outcomes and Measures Patients were followed up at 4, 8, and 16 weeks by a blinded observer and extent of repigmentation, color match, pattern of repigmentation, patient satisfaction and complications were noted. Both the visual and the computerized image analysis methods were used for outcome assessment. Cell suspensions were assessed post hoc for OCT4+ stem cell counts using flow cytometry; expression of stem cell factor and basic fibroblast growth factor was evaluated using quantitative relative messenger RNA expression. Results Of the 30 patients included in the study, 18 (60%) were women; mean (SD) age was 23.4 (6.4) years. Seventy-four percent of the lesions (62 of 84) were difficult-to-treat vitiligo. ECS + FCS showed superior repigmentation outcomes compared with ECS: extent (76% vs 57%, P < .001), rapidity (48% vs 31%, P = .001), color match (73% vs 61%, P < .001), and patient satisfaction (mean [SD] patient global assessment score, 23.30 [6.89] vs 20.81 [6.61], P = .047). Melanocyte stem cell counts (2% in ECS + FCS vs 0.5% in ECS) as well as expression of basic fibroblast growth factor (11.8-fold) and stem cell factor (6.0-fold) were higher in ECS + FCS suspension (P<.05 for both). Conclusions and Relevance The findings from this study establish ECS + FCS as a novel approach in vitiligo surgery for attaining good to excellent repigmentation in a short period with good color match, even in difficult-to-treat vitiligo. Trial Registration ctri.nic.in Identifier: CTRI/2017/05/008692

Combined epidermal and follicular cell suspension as a novel surgical approach for acral vitiligo

based on the assumption that increased search queries for itch, and thus interest, serves as a proxy of increased itch symptoms in the public. That SVI for pain did not correlate with temperature further validates our observations for itch. The rise in itch SVI with increasing temperatures during the summer months is likely a result of the increased incidence of pruritic skin disorders, such as poison ivy and insect bites, during the summer seasons. In addition, although the seasonality of itch has not explicitly been previously studied, it is known that heat or warmth sensations are major factors that provoke the itch response. The transient receptor potential vanilloid type 1 protein is involved in the induction of histaminergic-associated pruritus and is activated by heat. The calcitonin gene-related peptide has also been implicated in heat-induced pruritus, as selective ablation of calcitonin generelated peptide alpha primary sensory neurons in mice can attenuate histamine-induced scratch behaviors. Furthermore, skin inflammation has been shown to reduce the temperature threshold for transient receptor potential vanilloid type 1 activation, allowing itch induction at lower temperatures. Increased environmental heat stimuli is not only an independent trigger for itch in healthy skin, but can also exacerbate pre-existing pruritus at a lower heat threshold. A limitation of this study is that the population is limited to only Google users and extrapolates Google queries to the prevalence of pruritus. This research letter serves as an initial investigation of the seasonal variation of itch.

Clinical, dermoscopic, and trichoscopic analysis of frontal fibrosing alopecia associated with acquired dermal macular hyperpigmentation: A cross sectional observational case-control study

Intervention group 50 95 (91-100) \.0001 58 (51-65) .4551 70 (65-76) .0105 Nonintervention group 56 72 (63-81) 55 (47-62) 61 (54-67) Intervention, aged 11-30 y 26 97 (94-100) \.0001 62 (53-70) .0458 74 (68-79) .0005 Nonintervention, aged 11-30 y 37 69 (58-81) 55 (46-64) 60 (52-67) Intervention, aged 31-50 y 15 96 (90-100) .0009 60 (47-73) .534 72 (64-80) .2416 Nonintervention, aged 31-50 y 13 82 (66-98) 53 (34-71) 62 (47-78) Intervention, aged 51-70 y 9 89 (67-100) \.0001 44 (21-68) .0214 59 (39-79) .7922 Nonintervention, aged 51-70 y 6 67 (33-100) 58 (35-82) 61 (48-75)

Giant variant of acquired reactive perforating collagenosis in diabetic nephropathy

A woman in her 60s, with diabetic nephropathy (chronic kidney disease stage: 4/5), presented with 2 months history of intensely itchy papules over extensor aspects of her limbs, especially legs. Her serum creatinine levels had shown a rise from 2.7mg/dL to 3.5mg/dL during 2 months of the lesion onset. Her fasting blood sugar and glycated haemoglobin levels were 152mg/dL and 7.8%, respectively. Cutaneous examination revealed multiple crusted papules and plaques, largest measuring 2.5cm, with well-defined keratotic plugs at the centre (figure 1A). Histopathology of the lesion demonstrated cup-shaped invaginations in the epidermis enabling elimination of degenerated collagen fibres from the dermis (figure 1B). A diagnosis of acquired reactive perforating collagenosis …

Secondary syphilis: lest we forget it

A 30-year-old man presented with 1-month history of asymptomatic, reddish, scaly plaques over his palms and soles for which he was being treated for palmoplantar psoriasis. On examination, a painless indurated ulcer (primary chancre) was noted on the upper labial mucosa. Oral mucosa had snail track ulcers and mucous patches. There were split papules at the angles of mouth and alar creases. Erythematous papules were also present over the body, coalescing at flexures to form moist plaques (condyloma lata). In …

Blepharochalasis: ‘drooping eyelids that raised our eyebrows’

A 20-year-old woman presented with drooping of both the eyelids (left>right). She had intermittent upper eyelid oedema for 3 years. There was no diurnal variation or fatiguability. The neuro-ophthalmic examination was normal including the extraocular movements. Serum anti-acetylcholine receptor antibodies, CT of the orbit and electromyography were unremarkable. Loose overhanging skin changes were highlighted on clinical reassessment (figure 1A). Atrophy of nasal fat pad causing ‘pseudo-epicanthic fold’ was noted (figure 1B). A diagnosis of blepharochalasis was confirmed on histopathology by demonstrating markedly reduced elastic fibres in the dermis (figure 2). Oral doxycycline (200 mg/day) in combination with topical tacrolimus 0.1% gel was given for 3 months with partial improvement. She disregarded a future plan of blepharoplasty. Figure 1 Clinical presentation of blepharochalasis. …

Recent Advances in Pathogenesis and Medical Management of Vitiligo

Vitiligo is a common pigmentary disorder characterised by the loss of functioning melanocytes from the basal layer of epidermis, leaving behind depigmented patches on the skin. It has a complex aetiopathology. Even though there are various theories describing the pathomechanisms of melanocyte loss, the initial trigger for melanocyte directed attack and the final steps causing melanocyte destruction is still speculative. The poor understanding of a common pathway causing melanocyte loss reflects in the lack of a targeted therapy in the medical management of vitiligo in this era of biologicals. The unravelling of interferon (IFN)-γ/CXCL10 axis in the causation of melanocyte directed attack and the observation of clinical usefulness of tofacitinib, which blocks the same pathway, give new hope in the direction of targeted therapy in vitiligo. In vitiligo, unlike psoriasis, the physician needs to address not only the issue of halting the inflammatory cascade causing the overt manifestation of the disease but also that of reviving the lost melanocytes, to regain normal skin colour. This chapter discusses the recent advances in the understanding of vitiligo pathogenesis and includes an update on the conventional and newer modalities in the medical management of vitiligo. A brief overview of the approach to the medical management of vitiligo is given at the end of the chapter.

Gangrene of the Glans Penis in a Diabetic Patient Due to Calcific Arteriopathy

A 50-year-old man with poorly controlled diabetes mellitus presented with gangrene of the glans penis (A). He had been on haemodialysis for 5 years until he underwent renal transplantation 6 months back. Histopathology revealed fat necrosis and microangiopathy without any calcium deposits (B). Doppler imaging showed dense intimal calcification of the deep arteries of the penis (C, D; arrows) with vascular compromise. He underwent total penectomy. A normal calcium-phosphate product of <70 mg/dL, normal parathyroid hormone levels, absence of calcium deposits in cutaneous vasculature, and lack of response to a therapeutic trial of sodium thiosulfate ruled out a possibility of calciphylaxis in the index case. We could find some reports of penile gangrene in diabetic patients due to calcific arteriopathy. Ischemic penile gangrene is a rare occurrence owing to its abundant blood supply from 3 vessels. References

Cellular transplantation procedures in vitiligo: what is in a name?

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Vitiligo surgery: a journey from tissues via cells to the stems!

Depigmented patches in vitiligo, a common dermatosis, cause a great psychological distress to the patients. Hence, apart from halting the disease process, the strategies to impart normal skin colour to these white patches carry an important role in the management of vitiligo. Surgical procedures are often required for stable vitiligo lesions not responding to medical therapies. It involves “shuffling” of melanocytes from the pigmented skin to the depigmented areas. During the last fifty years, the vitiligo surgery has evolved from tissue transplantation via cellular transplantation to reach a stage where the use of stem cells or immunomodulatory cells is contemplating. We would like to depict this wonderful journey of vitiligo surgery through this viewpoint.