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Catecholamines (epinephrine, norepinephrine and dopamine) are considered toxic to the melanocytes and may play an important role in the development of depigmented patches on the skin. This study was done to evaluate the levels of catecholamines in skin and plasma samples of active vitiligo patients' and gene expression changes in catecholamines' metabolism regulatory genes (COMT and GTPCH1), immunoregulatory genes (CTLA4 and PTPN22), and Catalase in active vitiligo patients. In this single-centre, prospective, case-control study, 30 patients with active vitiligo were recruited and skin biopsies from the perilesional site and plasma samples were collected. Skin biopsies from the normal site in vitiligo patients and healthy controls (n = 15) and plasma samples from controls were also obtained. Catecholamines' estimation was done via high-performance liquid chromatography. Gene expression variations were investigated via reverse transcription-polymerase chain reaction (PCR) and real-time PCR. Epinephrine, norepinephrine and dopamine levels were significantly higher in perilesional skin biopsies as compared to controls (P = 0.035, 0.024, and 0.006, respectively). However, epinephrine, norepinephrine and dopamine levels observed in patients' plasma samples were comparable to controls. The mRNA expression level of the Catalase gene was found to be upregulated at the perilesional site of patients as compared to the non-affected site of same patients (P 0.001) and healthy controls (P = 0.037). Transcriptional expression of GTPCH1 and COMT were observed to be increased significantly at the perilesional site of patients in comparison to controls (P = 0.004 and P = 0.046, respectively). Our results support the presence of oxidative stress, inflammation and induced immune response in vitiligo patients at the perilesional sites. The increased inflammatory response may lead to catecholamines upregulation resulting in oxidative stress and melanocyte damage.

Opportunistic fungal infections account for a significant amount of morbidity associated with diabetic patients. Oral thrush is a condition in which the fungus Candida albicans accumulates on the lining of mouth. It is well known that Candida species are normal commensals of oral cavity in up to 50% of the healthy population but these commensals can cause opportunistic infection of the oral cavity, specially when person is having co-morbid disease that reduces the immune strength of patient as like in diabetes. Keywords: Oral thrush, Oral candidiasis, Diabetes, Anti-fungal, Poor Oral Hygiene.

Onychocryptosis, or ingrown toenail, is a frequent, painful condition affecting young individuals. Controversies still exist regarding its etiopathogenesis and treatment options, including conservative and surgical techniques. The choice of treatment method depends on the stage of disease as conservative measures are mostly effective in early stages and surgical procedures are required in the later stages. Among surgical techniques, phenol cauterization of lateral nail matrix has been the most effective, safe, and commonly performed method. Other more destructive surgical procedures are rarely done nowadays. In this review, we briefly discuss the etiopathogenesis, clinical features, and different treatment options of ingrown toenail.

Catecholamines (epinephrine, norepinephrine, and dopamine) have been proposed as a possible cause of melanocyte loss. Dopamine has been observed to cause apoptosis in melanocytes via reactive oxygen species development, but the effect on melanocyte adhesion and proliferation still remains to be elucidated. Thus, we explored the dose- and time-dependent toxicity of catecholamines and the effect of dopamine on the proliferation and adhesion potential of melanocytes.Primary culture of melanocytes was investigated in vitro for toxic effects of epinephrine, norepinephrine, and dopamine on metabolic activity via MTT [3-(4,5-dimethylthiazol-2-yl)-2,5 diphenyl tetrazolium bromide) assay. Cells were observed microscopically for any phenotypic changes. Further cell proliferation, cell adhesion, and cell death pathway were explored under dopamine toxicity in dose- and time-dependent manner with RNase/PI method of cell cycle analysis, cell adhesion assay, and Annexin V-FITC/PI assay, respectively. Altered gene expressions were confirmed with a real-time polymerase chain reaction.Metabolic activity of cells varied with time and different doses of epinephrine, norepinephrine, and dopamine. Dopamine was observed to be more toxic than epinephrine and norepinephrine. Melanocytes were observed to follow different cell death pathways at comparatively lower and higher concentrations of dopamine. Persistent exposure to dopamine resulted in decreased cell proliferation and adhesion potential with apoptotic changes. Gene expression changes also confirmed the weak adhesion and survival potential of cells under the toxic effects of dopamine.Dopamine can alter melanocytes' adhesion and survival potential, leading to apoptotic cell death or melanocytorrhagic loss.

Mixed vitiligo (MV) is the coexistence of segmental vitiligo (SV) and non-segmental vitiligo (NSV). The literature on MV is sparse.To assess the clinicodemographic and treatment parameters in MV and compare them with SV.Clinical data of MV and SV patients enrolled in our pigmentary clinic from July 2015 to December 2019 were reviewed retrospectively and compared.Out of a total of 4,371 vitiligo patients, 293 (6.7%) were SV while 74 (1.69%) were MV. As compared to SV, MV had significantly lower mean age of onset of segmental component (SC) (13.33 ± 9.01 vs. 15.70 ± 8.60 years, P = 0.03) and significantly higher proportion of patients with more than 1% body surface involvement by SC (66.2% vs. 51.5%, P = 0.03) and presence of leukotrichia in the SC (66.2% vs. 51.5%, P = 0.03). Topical agents and systemic immunosuppressive agents were significantly more effective in non-segmental component (NSC) as compared to SC of MV. Surgical modalities were the only effective treatment modality for SC.Retrospective design, heterogeneity of treatment regimens.Early age of onset, larger (1%) body surface area involvement, and leukotrichia in SV predict its progression into MV with time. Treatment response to different modalities varies significantly between SC and NSC of MV.

Management of chronic/recurrent erythema nodosum leprosum (ENL) is challenging. The majority of these patients become steroid-dependent and suffer from the adverse effects of long-term corticosteroid use. Minocycline has shown promising results in a small series of chronic/recurrent ENL patients. The aim of this study was to compare the efficacy and safety of minocycline and clofazimine in patients with chronic/recurrent ENL. In this prospective randomized clinical trial, 60 participants with chronic/recurrent ENL were randomized (1:1) to receive either minocycline 100 mg once daily or clofazimine 100 mg thrice daily for 12 weeks along with prednisolone according to WHO protocol and followed up for 6 months. The outcome measures were mean time for initial control of ENL, proportion of patients having a recurrence of ENL, mean time for recurrence after initial control, additional prednisolone requirement, and frequency of adverse events. Initial control of ENL was achieved earlier in the minocycline group as compared to the clofazimine group (2.97 ± 1.9 weeks vs. 4 ± 1.96 weeks, respectively; p-0.048). The number of participants having ENL flares/recurrences during the study period was comparable in both groups (71.4% in clofazimine vs. 55.2% in minocycline group; p-0.2). The participants in the minocycline group remained in remission for a longer duration after initial control of ENL as compared to the clofazimine group (p-0.001). Mean additional prednisolone dose required for control of ENL flares/recurrences was also comparable in both groups (p-0.09). The minocycline group had fewer side effects than the clofazimine group (p-0.047). Minocycline led to a rapid and sustained improvement of ENL episodes with fewer adverse events showing a superior efficacy to clofazimine.

BACKGROUND Leprosy relapse/recurrence is a serious concern particularly in a leprosy-endemic nation such as India. It is believed that bacilli persisting even after multidrug therapy can cause relapse; recently, however, drug resistance as a cause for recurrences and chronic erythema nodosum leprosum (ENL) has been speculated. AIM To study drug-resistance patterns in cases of leprosy relapse and chronic/recurrent (c/r)ENL. METHODS This cross-sectional study conducted over a period of 1 year included patients diagnosed as having leprosy relapse and those with c/rENL. Skin biopsy specimens were examined by conventional PCR for resistance testing for rifampicin, dapsone and ofloxacin, respectively targeting the rpoB, folP and gyrA genes of Mycobacterium leprae. RESULTS In total, 61 patients (25 smear-negative) were included in the study. Of these, 37 were diagnosed as having leprosy relapse and 24 as having c/rENL. Drug resistance to at least one drug was identified in 10 cases (16.4%). Rates of drug resistance were 5.4% (2 of 37) for dapsone, 10.8% (4 of 37) for rifampicin and 2.7% (1 of 37) for ofloxacin among cases of relapse, whereas it was 12.5% (3 of 24) and 8.3% (2 of 24) for dapsone and rifampicin respectively among those with c/rENL. Multidrug resistance was seen in 3.3% patients (2 of 61). CONCLUSION Drug-resistance rate among those with c/rENL was almost equalled that of relapse. Smear-negative leprosy relapse cases also had resistance to bactericidal drugs. These findings call for modifications in criteria for testing under leprosy drug-resistance surveillance and all cases of relapse and those with recalcitrant c/rENL should be tested.

This is an exciting phase of vitiligo research with the current understanding of vitiligo pathogenesis and its translation to successful treatment. The pathogenetic origin of vitiligo revolves around autoimmunity with supporting role from many other factors like oxidative stress, inherent melanocyte defects, or defective keratinocytes and fibroblasts. Vitiligo can be classified into segmental or non-segmental depending upon the clinical presentation, or it can be classified as progressing or stable based on the activity of the disease. Vitiligo treatments need to be stratified depending upon which type of vitiligo we are treating and at which phase the vitiligo patient presents to us. There are two different aims of treatment of vitiligo. The first involves rescuing the melanocytes from the damage to arrest the depigmentation. The second strategy focuses on replenishing the melanocytes so that successful repigmentation is achieved. It is also important to maintain the disease in a stable phase or prevent relapse. As stability in non-segmental vitiligo is a dynamic process, maintenance of the stability of repigmentation is also an important consideration in the management of vitiligo. In this review, we shall briefly discuss the current options and future insight into the management of vitiligo.

Placebo-controlled studies have reported the efficacy of apremilast in the management of palmoplantar psoriasis but studies comparing efficacy with a conventional agent are lacking. The objective of this article was to compare the efficacy and safety of apremilast and methotrexate in patients with palmoplantar psoriasis. In this prospective, randomized, active-controlled, observer-blinded clinical trial, conducted at a psoriasis clinic of a tertiary care institute in India from 1 July, 2019 to 1 June, 2020, 84 patients with palmoplantar psoriasis were randomized (1:1) to receive either methotrexate (0.4 mg/kg/week orally) or apremilast (30 mg twice daily). The treatment protocol was continued for 16 weeks or until achieving a ≥ 75% improvement in the Modified Palmoplantar Psoriasis Area and Severity Index (m-PPPASI 75), whichever was earlier. Changes in m-PPPASI and Dermatology Life Quality Index scores from baseline, the proportion of patients achieving m-PPPASI 75, and adverse events were assessed. Eighty-four patients were included (76 palmoplantar psoriasis and 8 palmoplantar pustulosis). The mean age (standard deviation) was 44.5 (12.9) years and 53 (63%) were women. The m-PPPASI score [median (interquartile range)] after 16 weeks of treatment showed a significant improvement from baseline in both apremilast [− 6.3 (10.9), p < 0.001] and methotrexate groups [− 8.5 (9.9), p < 0.001]. The estimated median difference between the groups was − 1.2 (p = 0.39, 95% confidence interval − 4.2 to 2.1). At 16 weeks, m-PPPASI 75 was achieved by 14/42 (33%) and 17/42 (41%) patients in the apremilast and methotrexate groups, respectively (p = 0.49). A significant reduction in the Dermatology Life Quality Index score [median (interquartile range)] was observed in both groups [apremilast: − 3.0 (6.0), p < 0.001; methotrexate: − 3.0 (6.3), p < 0.001] with an estimated median difference of 0.0 (p = 0.99, 95% confidence interval − 1.0 to 2.0). The proportion of patients experiencing adverse events was comparable (p = 0.49). Apremilast showed a comparable efficacy and safety profile to methotrexate in the management of palmoplantar psoriasis. CTRI/2019/06/019830, date of registration: 24 June, 2019; trial registered prospectively.

Noncultured epidermal cell suspension (NCES) is a well-established surgical treatment modality for stable vitiligo. The outcome of this procedure significantly depends on the method of recipient site preparation, a critical step to achieve cosmetically acceptable repigmentation. To compare the efficacy of recipient site preparation using three methods namely, dermabrasion, cryoblister, and dermaroller followed by NCES in stable vitiligo. In this single-center, prospective, intra-patient, randomized clinical trial; 36 participants having at least three vitiligo patches in same anatomic region with minimum lesional stability of 1 year were randomized 1:1:1 for recipient site preparation using manual dermabrasion, cryoblister, and dermaroller followed by NCES. Patients were followed up at 4, 8, and 12 weeks and assessment of extent and pattern of repigmentation, color match and patient satisfaction were done. Among 36 patients, 22 (61.1%) were females; mean (SD) age was 28.33 (9.4) years. Dermabrasion and cryoblister techniques showed equal efficacy with respect to extent of repigmentation (>75% repigmentation; 55.6% vs 47.2%; P = .63) and patient satisfaction score (20.2 ± 9.6 vs 19.9 ± 7.9, P = .194). However, dermabrasion was superior to cryoblister in terms of rapidity (65% vs 32.5% at 4 weeks, P = .04) and color match (47.2% vs 19.4%, P = .004). Dermaroller had poor repigmentation outcomes compared to both dermabrasion and cryoblister. Cryoblister as a method of recipient site preparation is equally effective as manual dermabrasion in NCES for attaining good to excellent repigmentation, but with risk of hyperpigmentation. However, dermaroller is inferior to both dermabrasion and cryoblister.

Smokeless tobacco keratosis is a condition that causes thick white patches to form on mucosa with common sites are inner check , in between teeth & gums , appear wrinkled in texture usually develops in between 1-5 years of tobacco use. Educating and motivating a patient is very important in the prevention as well as cure of STK.

A subset of leprosy patients has clinical and histopathological activity in the form of persistent plaques and granulomas after completion of multidrug therapy (MDT) which can have significant impact on their quality of life. In the absence of clear guidelines regarding management of such patients, majority of the times they are treated either as late reversal reaction with corticosteroids or no active treatment is offered. We observed 11 patients of leprosy with persistent plaques after completing the 6/12-months MDT who were treated favorably with minocycline 100 mg once daily for 16 weeks. Complete clinical resolution was observed in 9/11 patients while two patients had partial improvement. Histopathological improvement in the form of disappearance of granulomas corroborated with the clinical improvement. All the patients tolerated the treatment well and hyperpigmentation was the only adverse effect noted. Minocycline may be considered as a useful and well tolerated therapeutic option for this subset of leprosy patients due to its immune modulatory and anti-inflammatory effects.

Background Despite advances in surgical management of vitiligo, lesions on acral areas and bony prominences remain treatment refractory. There is lack of literature on the treatment efficacy of various surgical modalities over these treatment refractory sites. Objective To compare the efficacy of three common methods of grafting in vitiligo in known resistant areas. Methods A single-center interventional clinical trial involving 30 patients of stable vitiligo (disease stability ≥1 year) located over bony prominences and acral areas. All patients were treated with noncultured epidermal cell suspension (NCES), suction blister epidermal grafting (SBEG), and mini punch grafting (MPG) on three separate patches. Extent of repigmentation was assessed at 12 and 24 weeks, color matching and patient satisfaction were evaluated at 24 weeks. Results Among 30 participants, 22 (73%) were females, mean age was 27.4 (±10.7) years, and the majority (93.3%) had nonsegmental vitiligo. At 12 weeks, repigmentation >75% was noted in 56.6, 60, and 16.6% of patches treated by NCES, SBEG, and MPG, respectively. At 24 weeks, results remained the same in both the NCES and SBEG groups, while the number of patches with >75% repigmentation increased to 23.3% in the MPG group. The difference in repigmentation rate between NCES and MPG as well as between SBEG and MPG achieved statistical significance. Color matching of treated area and patient satisfaction were better in NCES and SBEG groups compared to MPG. Conclusion NCES and SBEG are superior to MPG with reasonably good efficacy and can be offered as a therapeutic modality for stable vitiligo patches over these sites.

Tumour necrosis factor-alpha (TNF-α) inhibitors have been successfully used in the treatment of various immune-mediated inflammatory diseases. However, these agents are frequently associated with mucocutaneous adverse effects.1 Anti-TNF-α-induced lupus erythematosus (LE) represents an uncommon adverse effect and has implications on patient management.2 Herein, we report a female patient who developed cutaneous LE after treatment with adalimumab for her rheumatoid arthritis (RA). A woman aged 40 years presented with photosensitivity and painless oral ulcers of 1-month duration. On examination, ill-defined erythema was present over her nose extending to malar area. Well-defined erythematous ulcers were present over buccal mucosae, lips and hard palate (figure 1A,B). Chillblain-like lesions were present over both ears (figure 1C). Her medical history was significant for the presence of RA, for which she had received four doses of …

Dermatology consultation was sought for a middle-aged man with multiple asymptomatic skin nodules all over the body. The patient was admitted with neurology inpatient services for altered sensorium and loss of vision for the last 2 days. He also suffered from hyperaesthesia and weakness of limbs for the last 2 years. On physical examination, hepatosplenomegaly was also detected along with neurological and visual abnormalities. Multiple cutaneous erythematous to skin-coloured, dome-shaped, exophytic, sessile as well as pedunculated, soft to firm asymptomatic nodules were observed on trunk, limbs and scalp (figure …

An elderly woman presented with 6 months history of skin coloured to erythematous papules in annular pattern over extremities, upper back and neck. The patient was diagnosed with granuloma annulare (GA) and started on hydroxychloroquine (HCQ) 300 mg daily. After 4 months of treatment, she developed bluish grey pigmentation within the plaques of GA with normal surrounding skin (figure 1A,B). There was no pigmentation at other body sites. Biopsy from the plaque showed necrobiotic collagen with intradermal mucin and perivascular lymphohistiocytic infiltrate accompanied by brown coarse pigment in the dermis …