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Melasma is a notorious dermatosis, often resistant to treatment. Chemical peeling constitutes an acceptable option of management of melasma (of any type and duration). In this article, as a group of experts from Pigmentary Disorders Society (PDS) in collaboration with South Asian Pigmentary Forum (SPF), we have tried to elaborate the various chemical peeling agents for the treatment of melasma. Besides, we have reviewed the indications, mechanism of action, rationality and the detailed procedure of peeling. The evidence in favor of various peeling agents have been summarized as well.

Chronic spontaneous urticaria (CSU) affects 1% of the world population and also their quality of life, and 50% of these patients are refractory to H1-antihistamines. Omalizumab is a humanized monoclonal anti-IgE antibody that binds with free IgE antibodies and reduces the circulating levels of free IgE. This reduction in free IgE prevents mast-cell degranulation. The EAACI/GA2LEN/EDF/WAO guidelines recommend omalizumab as the third-line of therapy as an add-on to antihistamines. The recommended dose of omalizumab is 300 mg, 4 weekly in the management of CSU refractory to standard of care with H1-antihistamines in adults and adolescents ≥12 years of age. In some patients, a dose of 150 mg may be acceptable. Omalizumab has a good safety profile. However, due to the biologic nature of the drug, all patients administered omalizumab must be observed for 2 h after administration for anaphylactoid reactions. There have been no studies on the effect of impaired renal or hepatic function on the pharmacokinetics of omalizumab. While no particular dose adjustment is recommended, omalizumab should be administered with caution in these patients.

Melasma is one of the most common hyperpigmentary disorders found mainly in women and dark-skinned patients. Sunlight, hormones, pregnancy, and genetics remain the most implicated in the causation of melasma. Although rather recalcitrant to treatment, topical agents such as hydroquinone, modified Kligman's Regime, azelaic acid, kojic acid, Vitamin C, and arbutin still remain the mainstay of therapy with sun protection being a cornerstone of therapy. There are several new botanical and non botanical agents and upcoming oral therapies for the future. There is a lack of therapeutic guidelines, more so in the Indian setup. The article discusses available evidence and brings forward a suggested treatment algorithm by experts from Pigmentary Disorders Society (PDS) in a collaborative discussion called South Asian Pigmentary Forum (SPF).

BACKGROUND: We have been observing that a significant proportion of our patients, especially females, have certain pigmentary demarcation lines (PDL) over the face. However, systematic studies of the subject are lacking. AIMS: We categorized the different clinical patterns of facial PDLs in the Indian subpopulation and assessed their prevalence in this study. METHODS: About 4000 consecutive patients, both males and females, attending our skin clinic were examined for the presence of any pigmentary demarcation lines on the face, from October 1998 to February 2000. RESULTS: Out of the study population of 4037 patients, 243 (6%) were found to have demarcation lines on the face. The demarcation lines were far more common in women (9%) than in men (0.75%). These lines could be classified into three patterns that we would like to label as F, G, H as PDLs A to E have already been described. CONCLUSIONS: Pigmentary demarcation lines are fairly common in the Indian population especially amongst the females. Hormonal influences could possibly explain the female preponderance. Aggregation of cases within families or among close relatives suggests a genetic background.

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.

A rare case of hereditary motor and sensory neuropathy in a 45 year old man with glove and stocking hypoaesthesia, bilateral clawing, foot drop and thickening of the peripheral nerves mimicking Hansen's disease is reported.

Histiocytoses are a heterogeneous group of disorders that are not clearly understood. The unifying aspect of the entire spectrum lies in the accumulation of histiocytes in various tissues. Two cases are being presented for their rarity and the importance of histological features and marker studies in the diagnosis is emphasized.

Background: Atopic dermatitis (AD) is a chronic, relapsing, pruritic dermatitis frequently associated with the hyperproduction of IgE to various allergens. Identification of these allergens is possible by various laboratory investigations. Aim: The present study was designed to assess these allergen-specific antibodies in the diagnosis of AD in the Indian context. Methods: This prospective study comprised 50 patients of AD. The diagnosis was made clinically after satisfying Hanifin and Rajka's criteria. Serum IgE levels were estimated and specific IgE antibodies were measured for 20 food allergens and aeroallergens. Results: Serum IgE was elevated in 88% of the patients. The highest elevation of mean IgE levels was seen in the 10-20 years age group. Sixty five percent of the children under the age of ten years were positive to one or more food allergens. Food allergens were more often positive in the ≤10 years age group and specific antibodies to inhalants were seen more frequently in the older age groups. Specific antibodies to apples were found in all age groups. Conclusion: Antibodies against apples and hazelnuts were the more commonly seen specific antibodies in children. Incidence of positivity was much higher in children when compared to earlier studies. Identification of food allergens can be an important factor in the diagnosis of AD in children in India. Positivity to inhalant allergens in the older age groups was lower in this study. The allergen profile with regard to inhalants in Indian patients was similar to that of earlier studies.

A 28-year-old man presented to the Dermatology Outpatient Department with a complaint of a burning sensation and soreness over his left cheek and left ear of 10 days duration. It had started suddenly one morning when he woke up from sleep. He noticed a large blister with intense redness over his left cheek, associated with a burning sensation. There was a history of similar episodes over the past year, and all were sudden in onset, involved the cheeks, and were noticed after waking up from sleep. The patient volunteered that the episodes were always associated with a drinking spree the previous night. The individual was a healthy man with a wife and two children. The patient had been dependent on alcohol for the past year, and had been consuming alcohol for many years. On examination, there was an eschar occupying almost the entire cheek, with a few scattered lesions over the left tragus and left external ear. Peripheral scarring was noted with hyperpigmentation. While the angle of the mouth was superficially involved on the left side, the oral mucosa was normal. The right cheek also showed a few areas of scarring with patches of alopecia. There were no similar lesions elsewhere on the body. The peculiar history and the morphology of the lesion, that defied any classical diagnosis description, prompted us to interrogate both the man and his wife with regard to any serious differences. After much persuasion and on assurance of secrecy, the wife admitted that her husband was an alcoholic and was neglecting his family. When her efforts to prevent his drinking failed, she resorted to this drastic measure. Each time he passed out after a drinking bout, she poured acid on his cheek, hoping that the sequelae would frighten him from drinking. The acid was readily available to her as she used it for domestic cleaning. The couple were sent for psychiatric evaluation as Munchausen's syndrome by proxy (MSBP) or witchcraft's syndrome (WS) was suspected. Detailed psychiatric evaluation, together with psychometric assessment, revealed that the patient had an alcohol dependence (Axis-I diagnosis) and had a cyclothymic personality. Severe marital discord due to alcohol dependence had been present for the past 2 years. Evaluation of the patient's wife revealed that she was under significant psychologic distress. She showed major depressive symptoms with a histrionic personality. She revealed that she had resorted to using the corrosive out of frustration and anger over the behavior of the patient while he was in an inebriated state. The couple are currently undergoing psychiatric treatment.

Background Melasma is one of the most common pigment disorders seen by a dermatologist and often occurs among women with darker complexion (skin type IV–VI). Aims The present study aimed to investigate the epidemiology of melasma in the Indian population and to focus on the regional variability in the demographics, clinical manifestations and factors that precipitate this condition. Methods The present multicentric study conducted across four regions in India enrolled patients (>18 years) diagnosed with melasma on Wood’s light examination. Patients were examined to identify the distribution of melasma. Various precipitating and etiological factors for melasma were documented. Results The mean age of the 331 enrolled patients with melasma was 37.2 ± 9.3 years. The prevalence of melasma was higher in females with a female to male ratio of approximately 4:1. The overall population with family history was 31%, highest in the northern region (38.5%) and lowest in the eastern region (18.2%). The two prominent patterns of distribution were centrofacial (42%) and malar (39%). Only 35% of the patients were using sunscreens. Of these, 10% of the patients used sunscreen with SPF >50. The usage of sunscreens was observed to be highest in the north (69%). About 51% of women with multiple pregnancies had a history of melasma when compared with single women (25%) or with no pregnancy (24%). Conclusions In conclusion, the result of the study showed that there was a regional variability in the demographics, clinical manifestations and factors that precipitate melasma among patients in India. There was a strong correlation between the family history and prevalence of melasma. Sun exposure is a major precipitating factor in melasma, but only 10% of the patients used sunscreen with SPF >50. Other factors such as concomitant medication, chronicity of disease, multiple pregnancies and use of oral contraceptives might precipitate melasma. Electronic supplementary material The online version of this article (doi:10.1007/s13555-014-0046-1) contains supplementary material, which is available to authorized users.