Prashant Verma

Melasma: Treatment strategy

Abstract Melasma, a hypermelanosis of the face, is a common skin problem of middle-aged women of all racial groups, especially with dark complexion. Its precise etio-pathogenesis is evasive, genetic influences, exposure to sunlight, pregnancy, oral contraceptives, estrogen-progesterone therapies, thyroid dysfunction, cosmetics, and drugs have been proposed. Centro-facial, malar, and mandibular are well-recognized. Epidermal pigmentation appears brown/black, while dermal is blue in color, and can be distinguished by Woods lamp illumination. The difference may be inapparent with mixed type of melasma in skin types V and VI. An increase in melanin in epidermis: basal and suprabasal layers and/or dermis is the prime defect. There is an increased expression of tyrosinase related protein-1 involved in eumelanin synthesis. The use of broad-spectrum sunscreen is important, lightening agents like retinoic acid (tretinoin), azelaic acid, and combination therapies containing hydroquinone, tretinoin, and corticosteroids, have been used in the treatment of melasma, and are thought to have increased efficacy as compared with monotherapy. Quasi-drugs, placental extracts, ellagic acid, chamomilla extract, butylresorcinol, tranexamic acid, methoxy potassium salicylate, adenosine monophosphate disodium salt, dipropyl-biphenyl-2,2′-diol, (4-hydroxyphenyl)-2-butanol, and tranexamic acid cetyl ester hydrochloride, in addition to kojic and ascorbic acid have been used. Chemical peeling is a good adjunct. Laser treatment is worthwhile.

Acrodermatitis continua of Hallopeau: evolution of treatment options

Ever since its inception, acrodermatitis continua of Hallopeau, has been recognized as an uncommon clinical entity which has been sparingly reported from across the globe. The attempt to have cumulative information on prevalent nomenclature, definition, reminiscences, and clinical overtures has brought differential diagnosis and diagnosis in sharp focus, the highlights of which are outlined. Hence, it was considered important to review the evolution of treatment options available thus far including use of biologics.

Nail avulsion: Indications and methods (surgical nail avulsion)

The nail is a subject of global importance for dermatologists, podiatrists and surgeons. Nail avulsion is a frequently undertaken, yet simple, intriguing procedure. It may either be surgical or chemical, using 40% urea. The former is most often undertaken using the distal approach. Nail avulsion may either be useful for diagnostic purposes like exploration of the nail bed, nail matrix and the nail folds and before contemplating a biopsy on the nail bed or for therapeutic purposes like onychocryptosis, warts, onychomycosis, chronic paronychia, nail tumors, matricectomy and retronychia. The procedure is carried out mostly under local anesthesia with or without epinephrine (1:2,00,000 dilution). Besides the above-mentioned indications, the contraindications and complications of nail avulsion are briefly outlined.

Leflunomide: dermatologic perspective

Abstract Leflunomide, an isoxazole derivative, is a disease-modifying antirheumatic drug. It has successfully been used for the treatment of rheumatoid arthritis as a feasible alternative to methotrexate. Recently, leflunomide has been used in certain dermatologic conditions. Medline/PubMed search revealed only 201 articles of its application in dermatologic conditions, of which 21 were relevant for inclusion. Prime mode of action of leflunomide is through the inhibition of dihydroorotate dehydrogenase, a key enzyme in the de novo pyrimidine synthesis pathway used by lymphocytes for clonal expansion. The current level of evidence and strength of recommendation suggest its use in psoriasis and psoriatic arthritis. However, the use of leflunomide in severe atopic dermatitis, systemic lupus erythematosus, Wegeners granulomatosis, primary Sjögrens syndrome, bullous pemphigoid, dermatomyositis, sarcoidosis and systemic sclerosis still requires further evaluation.

Juvenile, insulin-dependent diabetes mellitus, type 1-related dermatoses.

Juvenile insulin‐dependent diabetes mellitus type 1 (IDDM) is a well‐recognized worldwide entity, the significance of which has increased because of its recent upsurging trends, warranting attention on variety of its clinical expressions, in particular, pertaining to skin, an aspect seldom taken cognizance of. Hence an endeavour to recap the related dermatoses, such as limited joint mobility syndrome including sclerodermoid (scleroderma–like) changes, xerosis, necrobiosis lipoidica diabeticorum, granuloma annulare, diabetic foot syndrome, has been made. Complexities relating to the recently explored issues of atopic dermatitis and drug hypersensitivity syndrome have also been covered adequately. In addition, the current concepts of the physiopathology of type 1 diabetes‐related dermatoses are briefly recapitulated for clarity.

Anthralin/dithranol in dermatology

Anthralin (1,8‐dihydroxy‐9anthrone, dithranol) was first synthesized as a derivative of chrysarobin, prepared from the araroba tree in Brazil over a century ago. Drawbacks to the use of anthralin include irritation and discoloration of the skin. This property of the molecule prompted workers to investigate details of its pharmacology, mode of action, and indications. The major point of this article is to highlight and revisit these aspects for pertinent future use. Therefore, it is worthwhile to consider that the drug is relatively innocuous, yet effective, and is devoid of any systemic side effects in contrast to a wide variety of systemic and topical therapies available for psoriasis and other dermatoses.

Alterations in T-lymphocyte sub-set profiles and cytokine secretion by PBMC of systemic lupus erythematosus patients upon in vitro exposure to organochlorine pesticides.

Chronic exposure to organochlorine pesticides (OCP) has been suspected of causing immunoregulatory abnormalities that eventually lead to development and progression of Systemic Lupus Erythematosus (SLE), but the role of these non-genetic stimuli has remained poorly understood. The objectives of the study were to quantify the levels of different OCP residues in the blood of SLE patients and to study the effects of in vitro treatment of peripheral blood mononuclear cells (PBMC) from these patients and healthy controls with OCP. Levels of different OCP residues in the blood were measured by gas-liquid chromatography. Isolated PBMC were treated in vitro with hexachlorocyclohexane (HCH), o,p’-dichlorodiphenyltrichloroethane (DDT), or phytohemagglutinin-M (PHA-M) for 72 h, then stained with different dye-labeled monoclonal antibodies to analyze alterations in T-lymphocytes using flow cytometry. Levels of different TH1 and TH2 cytokines were also estimated by ELISA. Significantly higher levels of p,p’-DDE and β-HCH were detected in the blood of SLE patients than in healthy controls. HCH exposure markedly increased the percentages of CD3+CD4+ T-lymphocytes and expression of CD45RO+ on CD4+ and CD8+ T-lymphocytes, but decreased CD4+CD25+ T-lymphocytes in SLE patients. DDT exposure increased the percentages of CD3+CD4+ T-lymphocytes and decreased those of CD4+CD25+ T-lymphocytes in SLE patients as compared to healthy controls. No significant responsiveness of patient PBMC to PHA-M stimulation was observed indicating suppression of T-lymphocytes by these OCP. Further, both HCH and DDT decreased the levels of IL-2 and IFNγ but had no effect on IL-4 levels in SLE patients. DDT also increased significantly the levels of IL-10 in patients. It is likely that higher levels and prolonged durations of exposure to HCH and DDT may significantly influence T-lymphocyte sub-sets and cytokine expression in vivo that could lead to the development or exacerbation of SLE.

Exogenous ochronosis after prolonged use of topical hydroquinone (2%) in a 50-year-old Indian female

Ochronosis is a rare disease characterized by speckled and diffuse pigmentation symmetrically over the face, neck, and photo-exposed areas. It is characterized histologically by banana-shaped ochre-colored deposits in the dermis. It can present in exogenous or endogenous form. We report a case of exogenous ochronosis in a 50-year-old Indian woman after prolonged use of topical hydroquinone which is a rare complication with a commonly used drug which is available over the counter.

Contemporary surgical treatment of hidradenitis suppurativa (HS) with a focus on the use of the diode hair laser in a case

Abstract Hidradenitis suppurativa, a chronic recurrent disorder, characterized by painful, deep-seated nodules and abscesses commonly affecting the pilosebaceous-apocrine unit of the axillary, inguinal and mammary region in females, while the perianal area and buttocks are the prevalent sites in males. Its onset is after puberty, and may persist thereafter. Its exact aetiology is speculative. Follicular occlusion is the primary event leading to secondary inflammation, infection and destruction of the unit, ultimately affecting the adjoining subcutaneous tissue. Smoking and obesity may trigger or aggravate the condition. Stage of disease determines the mode of treatment. Medical treatment is valid in the early stage, but the results are transient. The early stage may warrant incision, and drainage of abscesses coupled with limited excision for locally recurring draining sinuses. While radical excision and healing with secondary intention, skin grafting, and flaps is recommended in advanced stages, laser therapy including the diode laser may prove a promising and innovative alternative.

Lichenoid tissue reaction/interface dermatitis: Recognition, classification, etiology, and clinicopathological overtones

Lichenoid tissue reaction or interface dermatitis embrace several clinical conditions, the prototype of which is lichen planus and its variants, drug induced lichenoid dermatitis, special forms of lichenoid dermatitis, lichenoid dermatitis in lupus erythematosus, and miscellaneous disorders showing lichenoid dermatitis, the salient clinical and histological features of which are described to facilitate their diagnosis. Background of lichenoid reaction pattern has been briefly outlined to enlighten those interested in this entity.