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Background Nailfold capillaroscopy (NFC) is useful in the diagnosis and assessment of various connective tissue diseases. In this study, NFC findings were studied in patients of systemic sclerosis (SS), systemic lupus erythematosus (SLE) and dermatomyositis. Aims To study the nailfold capillaroscopic findings in patients with connective tissue disorders, their correlation with disease severity, and changes in findings following treatment or disease progression. Methods This observational prospective time-bound clinico-epidemiological study was conducted in 43 patients over 20 months at Topiwala National Medical College and BYL Nair Ch. Hospital, Mumbai. NFC was performed using the polarising mode of a USB 2.0 video-dermatoscope in all 10 fingernails at 50X and 200X. It was repeated at three follow-up visits to look for changes in findings. Results Among SLE patients, eleven (52.4%) had non-specific NFC patterns and eight (38.1%) had SLE patterns. Among systemic sclerosis patients, eight (42.1%) cases had active and late SS patterns respectively, while one (5.3%) each had SLE, non-specific and early SS patterns. After three follow-ups, 10 out of 11 (90.9%) cases with improvement in NFC also showed clinical improvement; this figure was significantly more than 11 out of 23 (47.8%) cases who had no change in NFC but showed clinical improvement. Two of the three dermatomyositis patients showed a non-specific pattern while one showed a late SS pattern at baseline. Limitations A larger sample size would have yielded results with more validity. Standardisation of the interval between baseline and last follow-up to equal to or more than six months would have yielded results with more accuracy. Conclusion Capillary findings change significantly over time and reflect changes in the clinical status of patients of both SLE and systemic sclerosis, and hence are an important prognostic marker. Rather than an overt change in NFC pattern, reduction or increase in abnormal capillaries is a better predictor of change in disease activity.

IL-9‒producing T cells are present in healthy skin as well as in the cutaneous lesions of inflammatory diseases and cancers. However, the roles of IL-9 in human skin during homeostasis and in the pathogenesis of inflammatory disorders remain obscure. In this study, we examined the roles of IL-9 in metabolic reprogramming of human primary keratinocytes (KCs). High-throughput quantitative proteomics revealed that IL-9 signaling in human primary KCs disrupts the electron transport chain by downregulating multiple electron transport chain proteins. Nuclear magnetic resonance-based metabolomics showed that IL-9 also reduced the production of tricarboxylic acid cycle intermediates in human primary KCs. An integration of multiomics data with systems-level analysis using the constraint-based MitoCore model predicted marked IL-9-dependent effects on central carbohydrate metabolism, particularly in relation to the glycolytic switch. Stable isotope metabolomics and biochemical assays confirmed increased glucose consumption and redirection of metabolic flux toward lactate by IL-9. Functionally, IL-9 inhibited ROS production by IFN-γ and promoted human primary KC survival by inhibiting apoptosis. In conclusion, our data reveal IL-9 as a master regulator of KC metabolic reprogramming and survival.

In situ squamous cell carcinoma (SCC) of male and female genitalia can present as Bowen's disease (BD), erythroplasia of Queyrat, Bowenoid papulosis, Paget's disease, pseudoepitheliomatous keratotic, and micaceous balanitis. BD is SCC in situ. It affects both skin and mucous membranes and has the potential to progress to invasive SCC. BD can be found on any body site, including both sun-exposed and non-sun-exposed regions of the body. However, BD presenting on the genitalia is rare. Here, we present a report of three cases of in situ genital malignancies. Two females had BD, and one male had erythroplasia of Queyrat.

Rhinophyma is the most common form of phymatous rosacea, typically seen in men. It may appear de novo (without preceding inflammatory changes) or occur in patients with preexisting papulopustular rosacea. It is characterized by slow, bulbous, reddish-purple, painless enlargement of lower two-third of nose with rugose peau d’orange surface resulting from the enlargement of the sebaceous glands and subcutaneous tissue, which does not resolve spontaneously. Though benign, it causes lot of cosmetic and psychological concern. Commonly used treatment modalities include debulking by surgical excision, electrosurgery, carbon dioxide laser ablation, cryosurgery, or dermabrasion. Here we report a case series of three patients with Grade 3 rosacea as per National Rosacea Society grading, treated by radio frequency with good improvement.

High numbers of autologous human primary keratinocytes (HPKs) are required for patients with burns, wounds and for gene therapy of skin disorders., High numbers of autologous human primary keratinocytes (HPKs) are required for patients with burns, wounds and for gene therapy of skin disorders. Although freshly isolated HPKs exhibit a robust regenerative capacity, traditional methodology fails to provide a sufficient number of cells. Here we demonstrated a well characterized, non-cytotoxic and inert hydrogel as a substrate that mimics skin elasticity, which can accelerate proliferation and generate higher numbers of HPKs compared to existing tissue culture plastic (TCP) dishes. More importantly, this novel method was independent of feeder layer or any exogenous pharmaceutical drug. The HPKs from the hydrogel-substrate were functional as demonstrated by wound-healing assay, and the expression of IFN-γ-responsive genes (CXCL10, HLADR). Importantly, gene delivery efficiency by a lentiviral based delivery system was significantly higher in HPKs cultured on hydrogels compared with TCP. In conclusion, our study provides the first evidence that cell-material mechanical interaction is enough to provide a rapid expansion of functional keratinocytes that might be used as autologous grafts for skin disorders.

Immune dysregulation is critical in vitiligo pathogenesis. Although the presence and roles of numerous CD4+ T-cell subsets have been described, the presence of Th9 cells and more importantly, roles of IL-9 on melanocyte functions are not explored yet. Here, we quantified the T helper cell subsets including Th9 cells in vitiligo patients by multicolor flowcytometry. There was an increased frequency of skin-homing (CLA+ ) and systemic (CLA- ) Th9 cells in vitiligo patients compared to healthy donors. However, there was no difference in Th9 cell frequency in vitiligo patients with early and chronic disease. There was negligible IL-9 receptor (IL-9R) expression on human primary melanocytes (HPMs); however, IFNγ upregulated IL-9R expression on HPMs. Functionally, IL-9/IL-9R signaling reduced the production of IFNγ-induced toxic reactive oxygen species (ROS) in HPMs. There was no effect of IL-9 on expression of genes responsible for melanosome formation (MART1, TYRP1, and DCT), melanin synthesis (TYR), and melanocyte-inducing transcription factor (MITF) in HPMs. In conclusion, this study identifies the presence of Th9 cells in vitiligo and their roles in reducing the oxidative stress of melanocytes, which might be useful in designing effective therapeutics.

Actomyosin contractility, crucial for several physiological processes including migration, is controlled by the phosphorylation of myosin light chain (MLC). Rho-associated protein kinase (ROCK) and Myosin light chain kinase (MLCK) are predominant kinases that phosphorylate MLC. However, the distinct roles of these kinases in regulating actomyosin contractility and their subsequent impact on the migration of healthy and malignant skin cells is poorly understood. We observed that blockade of ROCK in healthy primary keratinocytes (HPKs) and epidermal carcinoma cell line (A-431 cells) resulted in loss of migration, contractility, focal adhesions, stress fibres, and changes in morphology due to reduction in phosphorylated MLC levels. In contrast, blockade of MLCK reduced migration, contractile dynamics, focal adhesions and phosphorylated MLC levels of HPKs alone and had no effect on A-431 cells due to the negligible MLCK expression. Using genetically modified A-431 cells expressing phosphomimetic mutant of p-MLC, we show that ROCK dependent phosphorylated MLC controls the migration, focal adhesion, stress fibre organization and the morphology of the cells. In conclusion, our data indicate that ROCK is the major kinase of MLC phosphorylation in both HPKs and A-431 cells, and regulates the contractility and migration of healthy as well as malignant skin epithelial cells.

Candida, a commensal dimorphic fungus, is the most common microorganism that causes opportunistic fungal infections worldwide. It can cause diseases ranging from superficial mucosal infections to disseminated, systemic life-threatening infections. Among Candida species, Candida albicans is the most common infectious agent. Nowadays, non- albicans Candida species are also emerging as significant pathogens. Candida dubliniensis has been implicated as a causative agent of oral candidiasis in HIV-infected individuals but has also been recovered from HIV non-infected individuals with oral candidiasis and rarely from the genital tract of women with vaginitis. Such cases have been under-reported due to phenotypic resemblance to C. albicans. The majority of C. dubliniensis clinical isolates tested to date have been susceptible to fluconazole, but they tend to develop resistance rapidly. Here, we report a case of chronic vulvovaginitis due to C. dubliniensis not responding to standard doses of fluconazole.

The incidence of penile squamous cell carcinoma (SCC) varies widely in different parts of the world. It is rare in Western countries but common in developing countries like India. The glans and foreskin are the most commonly affected sites. It can occur in two forms which have different evolution and prognosis. Exophytic papillary lesions have late and rare lymphatic spread and ulcero-infiltrating lesions are associated with rapid lymph node invasion and a poorer prognosis. Human immunodeficiency virus (HIV) is an aggravating factor for penile cancer and accelerates the progression of the disease. Cutaneous metastasis from penile SCC is rarely reported. Here, we report a case of metastatic SCC of the penis in a 51-year-old HIV-infected man who presented with cutaneous metastases in the inguino-pubic region with a hidden penile SCC.

Syphilis and human immunodeficiency virus (HIV) infections are both transmitted sexually. Co-infection of HIV and syphilis alters the course of both diseases. Clinical presentation of syphilis in patients of HIV may be atypical. HIV-infected individuals are at risk of developing lues maligna, which is characterized by nodulo-ulcerative lesions associated with severe constitutional symptoms. Erythroderma secondary to generalized papulo-squamous lesions of secondary syphilis is also uncommon. Here we report two cases of atypical presentations of secondary syphilis in HIV-positive patients.

Background: Lichen planus (LP) is an immune_mediated, chronic inflammatory disease involving skin, oral and genital mucosa, nails, and hair with several morphologic variants. The exact etiology remains unclear, but several factors have been implicated. Purpose: To study the clinico-epidemiological profile of patients of LP and its clinical variants and to find out whether LP is relatively uncommon in children. Methods: This prospective, cross-sectional, descriptive, time-bound, clinico-epidemiological study was conducted in the outpatient department of dermatology at a tertiary care hospital during the period of June 2017 to October 2018. A total of 170 patients were included in the study. Microsoft Excel and SPSS 23 software packages were used for data entry and statistical analysis. The results were averaged for each parameter for continuous data and numbers and percentage for categorical data. Statistical tests were applied wherever necessary. Results: The overall prevalence of LP was 0.4% (n = 170) out of 42,127 patients who attended the OPD during the study period. The gender-wise prevalence of LP was 41% among females and 59% among males, and the difference was not statistically significant (P = 0.3). The male-to-female ratio was 1.5:1. The highest prevalence among the variants of LP was of classical form (29%) and lowest was of inverse LP (0.6%). Overall, the mean age of the patients was 36 years, with a standard deviation of 17. There was one instance of LP occurring in both father and son. Conclusion: The most common age group of LP was 18 -40 years. Most patients came to seek health care within 1 year of beginning of disease. More than one variant of LP can coexist in the same individual. Childhood LP is not uncommon in the Indian subcontinent.

Behcet's disease (BD) is a chronic multisystem disorder characterized by a triad of oral ulcers, genital ulcers, and uveitis. Association between BD and other autoimmune disorders is not well documented. BD with idiopathic thrombocytopenic purpura has rarely been reported. Here, we present the case of a 16-year-old female presenting with recurrent oral and genital ulcers with a low platelet count diagnosed as BD with idiopathic thrombocytopenic purpura based on clinical and laboratory findings. The patient showed an excellent response to systemic corticosteroids.

Skin pigmentation is one of the most strikingly variable phenotypes in humans, therefore making cutaneous pigmentation disorders frequent symptoms manifesting in a multitude of forms. The most common among them include lentigines, postinflammatory hyperpigmentation, dark eye circles, and melasma. Variability of skin tones throughout the world is well-documented, some skin tones being reported as more susceptible to pigmentation disorders than others, especially in Asia and India. Furthermore, exposure to ultraviolet radiation is known to trigger or exacerbate pigmentation disorders. Preventive strategies for photoprotection and treatment modalities including topical and other medical approaches have been adopted by dermatologists to mitigate these disorders. This review article outlines the current knowledge on pigmentation disorders including pathophysiology, molecular profiling, and therapeutic options with a special focus on the Indian population.

Background: Adapalene a synthetic retinoid analogue, is an addition to the arsenal of topical retinoids developed for the topical treatment of acne vulgaris. The study was designed to compare the clinical efficacy and safety of topical adapalene gel 0.1% and tretinoin cream 0.025% in the treatment of acne vulgaris. Methods: A total of 80 patients with grade I-III acne vulgaris seen in the out-patient department of a tertiary care center were randomized to 8 weeks of daily treatment with either adapalene gel 0.1% or tretinoin gel 0.025%. Counts of total lesions, inflammatory lesions and non-inflammatory lesions were made at baseline and again at treatment weeks 2, 4, 6 and 8. Global assessment ratings, based on percent lesion reduction from baseline were also made. Side-effects like erythema, burning, pruritus, scaling and dryness were rated on a 0-3 severity scale. Results: Out of 80 patients there were 8 dropouts in the study; the 72 patients who completed the study were evaluated for efficacy and safety. Both adapalene and tretinoin produce dramatic reductions in total, inflammatory and non-inflammatory lesion counts, on an average. Cutaneous side-effects were limited to a mild retinoid dermatitis occurring in both treatment groups however patients treated with adapalene gel tolerated this therapy significantly better than those treated with tretinoin cream. Conclusions: Adapalene gel 0.1% offers comparable efficacy to tretinoin cream 0.025 % cream, but is less irritating. Adapalene gel 0.1% is a safe and effective topical agent in the treatment of mild to moderate acne vulgaris in Indian patients.

Phaeohyphomycosis is a chronic infectious condition caused by dematiaceous fungi which usually involve the skin and subcutaneous tissue. Subcutaneous phaeohyphomycosis is characterised by papulonodules, verrucous, hyperkeratotic or ulcerated plaques, cysts, abscesses, pyogranuloma, non-healing ulcers or sinuses. In India, commonly associated genera are Exophiala, Phialophora, Cladosporium, Curvularia, Fonsecaea and Alternaria. This condition involves the presence of brown-walled hyphal structures in the dermis and epidermis. Here, we are reporting a rare case series of three patients of phaeohyphomycosis with lesions on finger and dorsum of the hand.

There has been an increasing prevalence of dermatophytosis among the females in India, over the last 5-6 years. Similarly an increase in the occurrence of vulvovaginal infections has also been observed. The recommendations from existing guidelines do not focus on these infections in females and provide optimal outcomes in real world setting. Hence, the aim of the present consensus was to formulate recommendations based on current clinical experience to address these infections. A multispecialty panel of 12 members consisting of 7 gynecologists and 5 dermatologists participated in the pursuit of obtaining consensus by modified Delphi process. All the panelists formulated questionnaire after critical review of literature. Four rounds of questionnaires containing a total of 63 questions were floated through Google docs survey and responses were marked by all the panelists. Agreement for a given question/statement as ≥75% was set to achieve consensus. Out of the 63 questions/statements, consensus was obtained on diagnosis and treatment of dermatophytosis and VVI in non-pregnant and pregnant females, in 61 statements. The panel also formulated treatment algorithm for dermatophytosis and VVI. The present consensus will provide a guidance to the clinicians in India regarding management of dermatophytosis and VVI in pregnant and non-pregnant females in the current scenario of therapeutic challenges in both the infections.

The incidence of lymphangioma is 1.2 to 2.8/1000 newborns. They present at birth/before 2 years, with predilection for the head and neck (50%–70%). The buccal mucosa is the second most common site reported (14 cases reported) after the anterior two-thirds of tongue. The scrotum is a rare site with less than 50 cases reported (till 2002). Involvement of vital structures, aesthetic, and functional requirements may necessitate treatments such as surgical excision, radiation, cryotherapy, electrocautery, sclerotherapy, embolization, ligation, and laser. Two rare cases – the first being primary, late-onset buccal lymphangioma, with vesicular presentation, and the second being genital lymphangioma involving the right side of scrotum, thigh, and groin with extension to the left groin – are highlighted.

Background: Post-inflammatory hyperpigmentation (PIH), also has psychosocial implications. Hydroquinone containing preparations though effective, have unacceptable side effects. Molecules like kojic acid, arbutin, vitamins C and E, niacinamide and many others have depigmenting effect, singly or in combination. The objective of this study was to assess the effectiveness and tolerability of a cream containing a combination of niacinamide-4.0%, glycolic acid-2.0%, vitamin E acetate-0.1%, kojic acid dipalmitate-2.0%, soy isoflavones-0.5%, arbutin-2.0%, pterowhite-0.12%, licorice-40% CA-0.12%, ascorbyl glucoside-0.1% (Melaglow-Rich, Abbott Healthcare Pvt. Ltd.) in treatment of PIH. The specific objectives were to evaluate the changes in pigmentation, safety of the cream and patient opinion regarding the cream after 90 days of use.Methods: After IEC approval, adult males and non-pregnant, non-lactating females aged upto 50 years with PIH were included. Those with endocrinopathies who received systemic steroid therapy in the preceding month were excluded. 114 participants who were enrolled in this open-label, non-comparative study, applied study medication (b.i.d) and sunscreen (SPF-30; q.d). Effectiveness was assessed by PIH severity scale, Mexameter assessment, Patients’ and Physicians’ Global Assessment Scale and clinical photographs. Adverse events were documented.Results: Mean PIH score and mean mexameter reading for melanin and erythema in the hyperpigmented and non-hyperpigmented skin reduced by day 90 (p=0.0009, pConclusions: Melaglow rich cream was found to be effective and well-tolerated in the treatment of PIH.

T cells mediate skin immune surveillance by secreting specific cytokines and regulate numerous functions of keratinocytes, including migration during homeostasis and disease pathogenesis. Keratinocyte migration is mediated mainly by proteolytic cleavage of the extracellular matrix and/or by cytoskeleton reorganization. However, the cross-talk between T cell cytokines and actomyosin machinery of human primary keratinocytes (HPKs), which is required for cytoskeleton reorganization and subsequent migration, remains poorly examined. In this study, we describe that IL-9 profoundly reduced the actin stress fibers, inhibited contractility, and reduced the cortical stiffness of HPKs, which resulted in inhibition of the migration potential of HPKs in an adhesion- and MMP-independent manner. Similarly, IL-9 inhibited the IFN-γ–induced migration of HPKs by inhibiting the actomyosin machinery (actin stress fibers, contractility, and stiffness). IL-17A increased the actin stress fibers, promoted cellular contractility, and increased proteolytic collagen degradation, resulting in increased migration potential of HPKs. However, IL-9 inhibited the IL-17A–mediated HPKs migration. Mechanistically, IL-9 inhibited the IFN-γ– and IL-17A–induced phosphorylation of myosin L chain in HPKs, which is a major regulator of the actomyosin cytoskeleton. Finally, in addition to HPKs, IL-9 inhibited the migration of A-431 cells (epidermoid carcinoma cells) induced either by IFN-γ or IL-17A. In conclusion, our data demonstrate the influence of T cell cytokines in differentially regulating the actomyosin cytoskeleton and migration potential of human keratinocytes, which may have critical roles in skin homeostasis and pathogenesis of inflammatory diseases as well as skin malignancies.

Background: Lichen planus (LP), a T-cell-mediated inflammatory disorder, wherein inflammation produces lipid metabolism disturbances, is linked to increase in cardiovascular (CV) risk with dyslipidemia. Increased reactive oxygen species and lipid peroxides have also been implicated in its pathogenesis. Aim and Objective: The aim of the study was to evaluate the status on lipid disturbances, oxidative stress, and inflammation in LP patients. Materials and Methods: The study was initiated after obtaining Institutional Ethics Committee permission and written informed consent from participants. The study included 125 patients (74 LP patients and 51 age and sex-matched controls) visiting the outpatient clinic in the dermatology department of our hospital. Variables analyzed included lipid profile, C-reactive protein (CRP), malondialdehyde (MDA), and catalase (CAT) activity. Results: Analysis of lipid parameters revealed significantly higher levels of total cholesterol (TC), triglycerides, and low-density lipoprotein cholesterol (LDL-C) along with decreased levels of high-density lipoprotein cholesterol (HDL-C) in LP patients as compared to their respective controls. LP patients also presented with a significantly higher atherogenic index that is, (TC/HDL-C) and LDL-C/HDL-C ratios than the controls. A significant increase in CRP levels was observed among the LP patients. There was a statistically significant increase in the serum levels of the lipid peroxidation product, MDA and a statistically significant decrease in CAT activity in LP patients as compared to their respective controls. A statistically significant positive correlation (r = 0.96) was observed between serum MDA levels and duration of LP whereas a significantly negative correlation (r = −0.76) was seen between CAT activity and LP duration. Conclusion: Chronic inflammation in patients with LP may explain the association with dyslipidemia and CV risk. Our findings also suggest that an increase in oxidative stress and imbalance in the antioxidant defense mechanisms in LP may play a role in the pathogenesis of LP.

Background Hydroquinone is the preferred topical bleaching agent used in the treatment of melasma. The adverse effects of its chronic use are confetti-like depigmentation and exogenous ochronosis. Exogenous ochronosis manifests clinically with gray-brown or blue-black hyperpigmentation, as well as pinpoint hyperchromic caviar-like papules over the malar region. Dermatoscopic findings of ochronosis are unique and point towards a clue for its diagnosis. Methods Three cases of suspected hydroquinone-induced exogenous ochronosis while treating melasma were subjected to dermatoscopy and histopathology studies. Results Dermatoscopy in the areas of caviar-like hyperpigmentation revealed accentuation of the normal pseudo-rete of the facial skin with amorphous densely-pigmented structures obliterating some follicular opening and multiple thin, short arciform structures. On histopathological examination, curved ochre-colored structures, 'banana-shaped' fibers, were seen in the dermis of all patients. Conclusion Exogenous ochronosis is difficult to treat. Dermatologists should be able to differentiate it from melasma and immediately discontinue hydroquinone. Exogenous ochronosis has characteristic features on dermatoscopy which may obviate the need for an invasive procedure of biopsy for its diagnosis.