Search

Oral lichen planus (OLP) is a common disease of the oral mucosa with worldwide distribution and overall prevalence of 0.5-2.2%. Its etiology remains unclear, although the role of autoimmunity is supported by its association with other autoimmune diseases and the presence of auto-cytotoxic T cell clones in the lesions. Although many options for treating symptomatic OLP are available, no therapy is curative. This trial compared treatments with topical tacrolimus 0.1% ointment and topical clobetasol propionate 0.05% ointment. Forty patients with histologically proven symptomatic OLP were divided into two groups of 20 to receive clobetasol propionate (0.05%) ointment or tacrolimus (0.1%) ointment for eight weeks. Follow-up for all patients included three visits during the treatment course and one post-treatment visit. At each visit, objective improvement in the lesions was assessed by two independent investigators. The primary outcome measure was defined as the percentage of patients attaining complete response at eight weeks. Secondary outcome measures were the percentages of patients attaining complete or partial response at 8 and 12 weeks. Patient-observed improvement was evaluated at each visit. Demographic parameters and pretreatment disease characteristics were comparable between the groups. The mean net clinical score (NCS) declined progressively from baseline at each follow-up visit in both groups. In the clobetasol group, the mean NCS declined from 8.00 ± 2.65 at baseline to 2.00 ± 1.49 at 12 weeks. In the tacrolimus group, the mean NCS declined from 7.78 ± 3.25 at baseline to 1.31 ± 1.06 at 12 weeks. At each visit, the decline in mean NCS from baseline was statistically significant (P 0.05). No severe adverse events were reported. Tacrolimus 0.1% ointment is an effective alternative to topical steroid and may be considered as a first-line therapy in OLP.

To assess the profile and describe the clinical presentations, clinico-histopathological profile, complications and treatment compliance of childhood leprosy at a tertiary care hospital in north-east district of Delhi during 2000-2009.A retrospective institutional study of children less than 14 years of age diagnosed with leprosy and registered in a leprosy clinic during 2000-2009. Demographic, clinical, investigative and treatment data was extracted from a pre-designed proforma.A total of 1790 cases of leprosy were registered during this period, of which 172 (9.6%) were children. The majority of patients (70.3%) were more than 11 years of age with a male preponderance. History of contact was present in 25 (14.5%) patients. Borderline tuberculoid (BT) was the commonest clinical type (70.3%) followed by tuberculoid (TT) seen in 5.8%, mid-borderline (BB) in 1.2%, borderline lepromatous (BL) in 9.9%, lepromatous (LL) in 4.1%, pure neural (PNL) in 4.6% and indeterminate in 4.1% cases. More than half (52.9%) patients had a single lesion. Nerve thickening was detected in 70% cases. Slit skin smears were positive in 34 (19.8%) patients. Eighty-nine (51.7%) children were classified as multibacillary (MB) and 83 (48.3%) as paucibacillary (PB) disease by NLEP criteria. Of the available biopsy records, clinico-histological correlation was observed in 130/151 (86.1%) patients. Lepra reactions were observed in 32 patients (18.6%), Type I in 29 cases and Type II in three cases. Neuritis occurred in 11 (6.4%) and deformities in 22 (12.8%) patients. Thirty-four (19-8%) children defaulted from treatment. Two patients relapsed.Despite the statistical elimination of leprosy in this region, childhood leprosy cases continue to present in alarming numbers. Our study confirmed that multibacillary disease and the complications of lepra reactions and deformities remain common in children. Early detection, treatment and contact tracing may be important reducing the burden of leprosy in the community. There is a need to continue leprosy control activities with full vigour even in areas where, statistically, it has been eliminated.

The diagnostic and pathological relevance of anti-desmoglein autoantibodies in common forms of pemphigus has been well established, and T cells have been shown to play a role in the onset and progression of these diseases. The role of superantigens in provoking polyclonal activation of T cells with many different fine specificities, possibly including autoreactive T cells and T-cell mediated autoantibody response, is unknown. Further, abnormal T-cell function may lead to opportunistic infections particularly with Candida. The response of T cells of pemphigus patients to recall antigens of these opportunists is not clear. The aim of this study was to investigate the in vitro response of T lymphocytes from pemphigus patients to common bacterial superantigens such as streptococcal pyrogenic exotoxin A and staphylococcal enterotoxin B, and recall antigens such as Candida antigen. Changes in CD3(+) CD4(+) and CD3(+) CD8(+) T-cell sub-populations and expression of naive/memory markers (CD45RA(+) /RO(+)) on different T cells were analyzed by flow cytometry. Significant elevation in CD3(+) CD4(+) and expression of the memory (CD45RO(+)) markers on these cells was observed both in pemphigus vulgaris and pemphigus foliaceus patients, as compared to healthy controls, upon stimulation with streptococcal pyrogenic exotoxin A and staphylococcal enterotoxin B. However, only memory T cells (CD45RO(+)) were significantly increased upon Candida antigen stimulation. Our study suggests that CD4(+) memory T lymphocytes may modulate the pathogenic autoantibody response in pemphigus patients, and also emphasizes the possibility that the superantigen-reactive T cells participate in the triggering of autoimmunity in pemphigus.

Objective: To sensitize patients, physicians, and aestheticians about the possibility of spread of cutaneous warts during cosmetic procedures, especially following temporary hair removal methods, such as shaving, waxing, threading, and using depilatory creams, so they practice the requisite safety measures. Cutaneous warts caused by human papilloma virus are highly contagious. They tend to spread locally with even the trivial trauma of scratching, resulting in autoinoculation or “pseudo-Koebnerization.” Other than isolated case reports, there is a paucity of literature on pseudo-Koebnerization of warts by temporary hair removal methods. Design, setting, and participants: The authors present their observations from five patients—two men and three women (Cases 1 to 5)—in whom, after a single or a few episodes of a specific temporary hair removal method, either pre-existent warts spread locally at a rapid pace or surfaced clinically for the first time and then started spreading locally. An attempt was made to study the temporal relationship between the cosmetic procedure and the eruption or exacerbation of warts. Results: All five cases showed warts in a linear or local distribution, suggesting pseudo-Koebnerization and the possible use of unclean material used for temporary hair removal methods. One male (Case 1) and two female (Cases 3 and 4) patients already had pre-existent warts, which spread locally following the temporary hair removal procedures. The clinically naive other two patients may have acquired human papilloma virus due to cross-infection from unsterilized razor blades (possibly in Case 2) or from a spouse’s infected towel pressing against freshly waxed skin (Case 5). Treatment with radiofrequency ablation or topical tretinoin was successful in all patients. Conclusion: Despite the widely prevalent practice of temporary hair removal cosmetic procedures around the globe, such pseudo-Koebnerization-induced “cosmetic warts” remain under-reported. Through this case series, the authors wish to inculcate the practice of more hygienic measures by patients, barbers, aestheticians, and beauticians to prevent such cosmetic mishaps.

Nocebo effect, originally denoting the negative counterpart of the placebo phenomenon, is now better defined as the occurrence of adverse effects to a therapeutic intervention because the patient expects them to develop. More commonly encountered in patients with a past negative experience, this effect stems from highly active processes in the central nervous system, mediated by specific neurotransmitters and modulated by psychological mechanisms such as expectation and conditioning. The magnitude of nocebo effect in clinical medicine is being increasingly appreciated and its relevance encompasses clinical trials as well as clinical practice. Although there is hardly any reference to the term nocebo in dermatology articles, the phenomenon is encountered routinely by dermatologists. Dermatology patients are more susceptible to nocebo responses owing to the psychological concern from visibility of skin lesions and the chronicity, unpredictable course, lack of 'permanent cure' and frequent relapses of skin disorders. While finasteride remains the prototypical drug that displays a prominent nocebo effect in dermatologic therapeutics, other drugs such as isotretinoin are also likely inducers. This peculiar phenomenon has recently been appreciated in the modulation of itch perception and in controlled drug provocation tests in patients with a history of adverse drug reactions. Considering the conflict between patients' right to information about treatment related adverse effects and the likelihood of nocebo effect stemming from information disclosure, the prospect of ethically minimizing nocebo effect remains daunting. In this article, we review the concept of nocebo effect, its postulated mechanism, relevance in clinical dermatology and techniques to prevent it from becoming a barrier to effective patient management.

Background Tinea indecisiva is characterized by concentric scaly rings simulating tinea imbricata but caused by dermatophytes other than Trichophyton concentricum. Objective Tinea indecisiva has been rarely reported. We report a unique case and review of the previously reported cases, pathogenesis, and management. Methods An adult Indian man developed extensive tinea cruris and tinea corporis with concentric rings of scaly lesions over the groin, buttocks, and thighs following the use of oral corticosteroids and antifungal-steroid cream for 3 months. Mycologic and immunologic studies were performed for diagnosis. Results Diagnosis of tinea indecisiva was confirmed on the appearance of “ring-within-a-ring”; lesions clinically and isolation of Trichophyton mentagrophytes var. interdigitale as the etiologic agent on mycologic testing. Intradermal testing with Trichophyton extract showed fluctuating hypersensitivity responses. Four-week treatment with daily oral terbinafine resulted in complete resolution. Conclusion Tinea indecisiva should be considered in a patient with tinea imbricata-like lesions with local immunosuppression caused by a non-concentricum dermatophyte.

Hair loss is one of the most commonly encountered problems for dermatologists. Hair have a huge impact on a person’s looks and selfesteem. Needless to say, hair loss and/or reduction of scalp hair density and thinning of hair have a profound negative impact on one’s quality of life. Several studies have shown show that balding patients develop a negative self-perception, which appears to be consistent between Western and Asian cultures

Melasma is an acquired pigmentary disorder characterized by symmetrical hyperpigmented macules on the face. Its pathogenesis is complex and involves the interplay of various factors such as genetic predisposition, ultraviolet radiation, hormonal factors, and drugs. An insight into the pathogenesis is important to devise treatment modalities that accurately target the disease process and prevent relapses. Hydroquinone remains the gold standard of treatment though many newer drugs, especially plant extracts, have been developed in the last few years. In this article, we review the pathogenetic factors involved in melasma. We also describe the newer treatment options available and their efficacy. We carried out a PubMed search using the following terms "melasma, pathogenesis, etiology, diagnosis, treatment" and have included data of the last few years.

Lasers have come up as the newest therapeutic modality in dermatological conditions including melasma. In this article, as a group of experts from Pigmentary Disorders Society in collaboration with South Asian Pigmentary Disorders Forum (SPF), we have tried to discuss the lasers which have been used in melasma and formulate simple consensus guidelines. Following thorough literature search, we have summarised the rationale of using the lasers and the supporting evidences have also been provided. It is clear that laser cannot be the first line treatment for melasma. However, it can be used as an adjuvant therapy in resistant cases, provided the selection of patient and counselling has been done properly.

Mondor’s disease is a rare condition characterised by superficial thrombophlebitis of subcutaneous veins, most commonly over the anterior chest wall. Penile Mondor’s disease is rarer, arising out of thrombophlebitis of the penile veins. It typically involves the dorsal vein of the penis and presents with a cord-like indurated lesion with a beaded feel, palpable along the length of the involved vein. Though penile Mondor’s disease involving the dorsal vein of the penis has been reported by many authors, we report a peculiar case of penile Mondor’s disease in a 26-year-old sexually active man with thrombophlebitis of the circumflex vein of the penis with sparing of the dorsal vein. Diagnosis was confirmed on Doppler ultrasonography of the penile venous system. Despite exhaustive history taking, no cause could be elicited. The lesion completely subsided within three days with daily local hot fomentation. We propose the term ‘atypical penile Mondor’s disease’ for such a case.

A 10-year-old boy presented with 3-year history of erythema and brown-coloured pigmentation over bilateral preauricular and malar areas, studded with tiny whitish papules giving a rough texture (figure 1). Follicular keratotic papules with perifollicular erythema of keratosis pilaris (KP) were also present on the arms. KP lesions were observed over the arms of his brother and parents. A facial lesion biopsy revealed hyperkeratosis, follicular plugs, increased basal pigmentation and …

Oral lichen planus (OLP) is a common disease of the oral mucosa with worldwide distribution and overall prevalence of 0.5-2.2%. Its etiology remains unclear, although the role of autoimmunity is supported by its association with other autoimmune diseases and the presence of auto-cytotoxic T cell clones in the lesions. Although many options for treating symptomatic OLP are available, no therapy is curative. This trial compared treatments with topical tacrolimus 0.1% ointment and topical clobetasol propionate 0.05% ointment. Forty patients with histologically proven symptomatic OLP were divided into two groups of 20 to receive clobetasol propionate (0.05%) ointment or tacrolimus (0.1%) ointment for eight weeks. Follow-up for all patients included three visits during the treatment course and one post-treatment visit. At each visit, objective improvement in the lesions was assessed by two independent investigators. The primary outcome measure was defined as the percentage of patients attaining complete response at eight weeks. Secondary outcome measures were the percentages of patients attaining complete or partial response at 8 and 12 weeks. Patient-observed improvement was evaluated at each visit. Demographic parameters and pretreatment disease characteristics were comparable between the groups. The mean net clinical score (NCS) declined progressively from baseline at each follow-up visit in both groups. In the clobetasol group, the mean NCS declined from 8.00 ± 2.65 at baseline to 2.00 ± 1.49 at 12 weeks. In the tacrolimus group, the mean NCS declined from 7.78 ± 3.25 at baseline to 1.31 ± 1.06 at 12 weeks. At each visit, the decline in mean NCS from baseline was statistically significant (P0.05) in both groups. Complete response rates of 40% and 70%, respectively, were achieved in the clobetasol and tacrolimus groups (P = 0.057). The percentages of patients reporting "good" or "very good" treatment responses at week 8 were 74% in the clobetasol group and 100% in the tacrolimus group (P0.05). No severe adverse events were reported. Tacrolimus 0.1% ointment is an effective alternative to topical steroid and may be considered as a first-line therapy in OLP.

We report a case of ulcerated lupus vulgaris occurring in 1.5-year-old boy at the Bacille Calmette-Guerin vaccination site within 6 months, which was diagnosed using histology and polymerase chain reaction. The lesion resolved with isoniazid and rifampicin therapy.

Genital human papillomavirus (HPV) infection is the most common sexually transmitted infection with an estimated worldwide prevalence of 9-13% and approximately 6 million people being infected each year. Mostly acquired during adolescence or young adulthood, HPV presents clinically as anogenital warts and may progress to precancerous lesions and cancers of the cervix, vagina, vulva, penis and anus, and oropharynx. HPV infection is considered to contribute to almost 100% cervical cancers and at least 80% of anal and 40-60% of vulvar, vaginal, and penile cancers. At present, two prophylactic HPV vaccines are commercially available and both are prepared from purified L1 structural proteins. These proteins self-assemble to form virus-like particles that induce a protective immunity. Gardasil(®) is a quadrivalent vaccine against HPV types 6, 11, 16, and 18 and is recommended for use in females 9-26 years of age, for the prevention of cervical, vulvar, and vaginal cancers and intraepithelial neoplasia and condyloma acuminata and recently for vaccination in boys and men 9-26 years of age for the prevention of genital warts. Cervarix™ is a bivalent vaccine approved for the prevention of cervical cancer and precancerous lesions caused by HPV 16 and 18, in females 10-25 years. HPV vaccines are safe and efficacious against type-specific HPV-induced anogenital warts, precancerous lesions, and cervical cancer. The vaccines are most effective when given before the onset of sexual activity and provide long-term protection. Effective vaccination coverage in young adolescent females will substantially reduce the incidence of these anogenital malignancy-related morbidity and mortality. There is need to generate India-specific data on HPV epidemiology and HPV vaccination efficacy as well as continue worldwide surveillance and development of newer vaccines.

A 75-year-old man presented with a peculiar facial appearance, having a diffuse yellowish hue, atrophic skin, and deep wrinkles and furrows involving the entire face, most prominently the forehead, zygomatic, and malar areas [Figure 1]. Multiple large comedones and numerous 2-6 mm sized yellow-to-brown colored papules and nodules were present, clustered in the periocular region and over the dorsum of a patulous nose. The lesions had been present for at least 15 years with gradual coarsening of facial features. Lateral madarosis of both eyebrows was evident, but leprosy was clinically ruled out based on absence of history suggestive of any sensory or motor impairment and lack of cutaneous lesions suggestive of leprosy, Hypoesthesia, thickening of peripheral nerves, any motor deficit or deformity on examination. He also had depigmentation of lower lips but was not bothered by it and did not seek any treatment for the same. The patient was a farmer by occupation with history of significant daily sun exposure and had never followed any specific sun-protection measures or used sunscreens. He had been a chronic heavy smoker with 50 smoking pack years (25 cigarettes per day for 40 years). The patient was totally unconcerned about the facial disfigurement and wanted to consult regarding itching in his groin region, which on examination revealed tinea cruris. Histopathology from the cheek revealed grossly solar damaged epidermis with abundant grey-blue ribbon-like elastotic fibers in upper- and mid-dermis, agglomerating to form elastic globules at places. The upper dermis shows an increased number of thin-walled capillaries and sparse superficial perivascular lymphohistiocytic infiltrate with thinning of reticular dermis [Figure 2]. We diagnosed him as a case of Favre-Racouchot syndrome (FRS) with tinea cruris. Special stains were not done as the histopathology on hematoxylin and eosin staining was characteristic of this syndrome. He was prescribed a 2-week course of twice daily terbinafine cream that completely cleared the fungal infection when examined on follow-up. He refused any treatment for the facial skin. Figure 1 Deeply wrinkled, furrowed, and atrophic facial skin with multiple comedones, papules, and nodules over the nose, cheeks, and forehead Figure 2 Histopathology from the cheek revealing sparse superficial perivascular lymphohistiocytic infiltrate with abundant grey blue ribbon like elastotic fibers in upper- and middermis, agglomerating to from elastic globules at places. Overlying epidermis is ... FRS, also referred to as senile comedones, solar comedones, and nodular elastosis with cysts and comedones, was originally described in 1932 by Favre and later reviewed in detail by Favre and Racouchot in 1951.[1] Though mostly reported in Caucasian men (with an estimated prevalence of 6% in adults older than 50 years), cases have also been reported in dark-skinned people including Indians, albeit rarely.[2] Cases occurring as early as the second decade of life have also been documented.[3] Males clearly outnumber females, presumably due to more sun-exposure and the effect of smoking. Clinically, this peculiar syndrome is characterized by a diffuse yellowish hue with the presence of large, open, black comedones symmetrically distributed on the temporal and periorbital areas, and deep wrinkles and furrows over a background of actinically damaged and atrophic skin.[3] In severely affected patients, multiple small papules, nodules and cystic lesions develop, especially involving the periocular region and the nose. Uncommonly, the lateral neck, retroauricular areas, earlobes, and forearms may also be involved. The eruption is usually bilaterally symmetrical. The differential diagnosis includes acne comedones, milia, colloid milium, syringomas, trichoepitheliomas, and sebaceous hyperplasia.[3] Conditions closely linked to FRS include cutis rhomboidalis nuchae which it often accompanies and the actinic comedonal plaque, which is considered to be a variant of FRS.[3] Other conditions reported to be associated with FRS include cutaneous myxoma, actinic keratosis, basal and squamous cell carcinoma, trichostasis spinulosa, keratoacanthoma, and eyelid papilloma.[4] Diagnosis is primarily clinical and histopathology is rarely required. However, the histologic features of FRS are very characteristic with presence of dilated pilosebaceous openings, atrophic sebaceous glands and large, round cyst-like spaces lined by a flattened epithelium and filled with layered horny material.[5] Evidence of significant solar elastosis is often present with presence of epidermal atrophy and massive basophilic degeneration of the upper dermis.[3] Vellus hair shafts, copious amounts of bacteria, sebum, and eosinophilic laminated horny material have been demonstrated within the cyst-like spaces, suggesting that they actually represent oblique histologic cuts of closed comedones rather than true infundibular cysts.[3,5] The comedones are colonized with Propionibacterium acnes, Corynebacterium acnes, Staphylococcus albus, and Malassezia yeasts. Inflammation is conspicuously absent. Though the precise pathogenesis of FRS remains unclear, implicated factors include chonic exposure to ultraviolet radiation and heavy smoking, which may act synergistically. Additionally, radiation therapy has been linked to development of FRS in at least three reported cases till now.[3,5] Measures to halt the progression of the disease include meticulous sun-protective measures like avoiding outdoors activities during peak hours of sun-exposure and the use of broad spectrum sunscreens.[4] Cessation of smoking is strongly advised. Isolated use of pharmacologic treatments or surgical techniques has so far resulted in unsatisfactory results. For best therapeutic outcome, one needs to target the solar elastosis, nodulocystic lesions, and the small as well as large comedones that require mechanical removal. Thus, combining medical and surgical treatments seems to be the best approach at present. Owing to their exfoliative and collagen remodeling properties, topical retinoids constitute the mainstay of medical treatment. Their regular use results in expulsion of small comedones and improvement in photodamaged skin. Daily oral Isotretinoin (0.05-0.1 mg/kg/day) used in conjunction with topical tretinoin has also been found effective.[3] Surgical techniques include comedone extraction, curettage, simple or multiple-stage excision, dermabrasion, and laser resurfacing.[4] The most recent addition to the therapeutic armamentarium of FRS is the combination of superpulsed carbon dioxide laser to vaporize the epidermis followed by extraction of cystic and comedonic material with a pair of forceps, with the entire procedure performed without anesthesia. After an initial encouraging outcome observed in two cases of unilateral FRS, Mavilia et al.,[6] reported excellent cosmetic results, rapid recovery, and good safety profile of this combination therapy in 50 patients of FRS with Fitzpatrick skin type III, and have suggested that it may become the treatment of choice for FRS in future. The prognosis of this condition is excellent if the patient is properly counseled and treated.

Cutaneous tuberculosis continues to be a significant medical problem even with the advent of highly effective antituberculous drugs. It constitutes about 1.5% of all extra pulmonary tuberculosis. The prevalence in children varies from 18 to 54% in India. There is no gender predilection and the infection occurs with increased frequency in 10-14 year age group. Intrafamilial source of TB has been observed very frequently. A concomitant TB lymphadenitis is most common while involvement of other systemic organs like lung, bone and abdomen has also been observed. Protective efficacy of BCG is debatable and not yet fully defined. Of all the clinical types, scrofuloderma (SFD) is the most commonly encountered variant followed by lupus vulgaris (LV) and tuberculosis verrucosa cutis (TBVC). Lichen scrofulosorum (LS) is generally found to be associated with systemic TB focus in about 72% of cases. The impact of HIV on childhood cutaneous TB seems to be minimal. Similar to adults, the diagnosis of cutaneous tuberculosis relies mainly on histopathology, culture on LJ medium or radiometric BACTEC 460 TB culture system and PCR. In addition Mantoux positivity and a positive therapeutic trial with anti-tubercular drugs may be a good pointer to tubercular infection. A thorough clinical evaluation and exhaustive investigations to pin-point associated systemic focus is advocated as the latter has an impact on the duration of treatment. Cutaneous TB in children is treated as per the recommendations of therapy for extrapulmonary TB.

Sarcoidosis is a systemic disorder with prominent cutaneous component. Skin lesions are of diverse morphology, of which few are specific for the disease. We describe a 30-year-old woman with polymorphic skin lesions including papules, plaques, and nodules, as well as uncommon variants like eyelid papules, palmar and digital nodules, tattoo sarcoid, as well as scar sarcoid. The patient also had stage II pulmonary sarcoidosis, and articular as well as reticulo-endothelial system involvement manifested by enlarged mediastinal and abdominal lymph nodes and hepatosplenomegaly. The presentation of polymorphic skin lesions with involvement of multiple extra-cutaneous systems is uncommon in a single patient.

Melasma is a notoriously recidivist condition with yet unclear etiopathogenesis. It seems to have a multifactorial origin with both genetics and environment playing an important role. A genetic predisposition is suggested by a high reported incidence in family members in certain racial groups. Among the environmental factors, exposure to ultraviolet and visible light constitutes the biggest risk factor. Onset or worsening of melasma during pregnancy and during or following intake of hormonal oral contraceptive pills suggest the involvement of hormonal factors. The role of cutaneous vasculature in its pathogenesis is suggested by presence of clinically appreciable telangiectatic erythema confined to the melasma lesional skin in many patients, a finding reinforced by dermatoscopic evaluation and detection of upregulated expression of vascular endothelial growth factor, in the lesional skin. Various other factors such as thyroid disorder, drugs, cosmetics, stress may exacerbate existing melasma in a subset of patients. Although the precise molecular pathogenesis of melasma remains mysterious, up regulation of inducible nitric oxide synthase and many melanogenesis-related genes and melanocyte markers such as TYR, MITF, SILV, and TYRP1, Wnt pathway modulator genes, genes of prostaglandin metabolic processes, and those regulating lipid metabolism seem to be operative. In summary, though the exact etiopathogenesis of melasma remain appalling, newer studies have provided corporeal evidence in favor of certain previously suspected and some novel factors. Further research in this area will not only provide more evidence for their involvement in the pathophysiology of melasma, but also offer attractive targets for development of newer treatment modalities. This article exhaustively reviews the validity of the previously postulated etiological factors based on hitherto-accrued evidence, and explores the newer suggested pathogenetic mechanisms, which may pave way for development of novel therapeutic strategies.

Dermoscopy is a simple noninvasive technique that aids in the diagnosis of disorders of hyperpigmentation. However, its role in diagnosis of vitiligo is relatively infantile with only few published reports. We report the case of a young man who sought consultation for diffuse facial hyperpigmentation suggestive of photomelanosis. Dermoscopy from a pigmented forehead lesion revealed perifollicular depigmentation (PFD) without leukotrichia, in a background of reticular hyperpigmentation. There was no clinical evidence or past history of vitiligo. Family history of early-onset recalcitrant vitiligo was positive in mother. The patient developed rapidly progressive vitiligo with leukotrichia within the next 4 weeks. Dermoscopic re-evaluation from the same region revealed a reduction in hyperpigmentation, widening of PFD, leukotrichia of few hairs and rarefaction and pigment reduction of other hair shafts suggestive of impending leukotrichia. He developed the treatment-refractory disease over the next 6-8 months. Therefore, though perifollicular pigmentation is preserved in the lesional skin in most cases of vitiligo, PFD seen on dermoscopy may paradoxically indicate impending vitiligo especially in a high-risk case e.g. positive family history. This case has been documented to highlight the role of dermoscopy and the sign of PFD in early detection of vitiligo.

Leprosy is a chronic inflammatory disease of skin and peripheral nerves. Elimination of leprosy as a public health problem was reached at the global level in the year 2000 and by India on 31(st) December, 2005. Thereafter, leprosy services in India have been integrated with General Health-Care System resulting in reduced focus and funds. Sustaining the gains made so far in controlling leprosy is a big challenge and there is no time for complacency. Pockets of high endemicity with prevalence rate of > 1 still exist in many states. Our data from a tertiary care center indicates poor epidemiological control and ongoing disease transmission. To combat this, dermatologists all over India should continue to play a central role in capacity building and training of undergraduate and post-graduate students, medical officers, and field workers.