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   Table of Contents - Current issue
May-August 2022
Volume 9 | Issue 2
Page Nos. 67-145

Online since Friday, August 12, 2022

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Cover till you recover: breaking the stigma of pigmentary diseases in India p. 67
Namrata Singh, Tarun Narang
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Newer indications of tranexamic acid in dermatology beyond melasma: a review p. 70
Astha Arora, Mala Bhalla
Tranexamic acid (TXA) is an antifibrinolytic agent approved for use to control bleeding during surgery and after trauma. It has been used in dermatology as a therapeutic and prophylactic agent in angioedema since 1970s but its recently discovered role in melasma has made it the current molecule of interest. At present TXA is being widely researched for multiple indications in view of its role in reducing melanogenesis and angiogenesis in skin. Various case reports and clinical trials have been published over the last few years describing its role in postinflammatory hyperpigmentation, dermal melanosis, rosacea, telangiectasia, and even as an antiaging agent. We present this review here summarizing the various publications for the aforementioned indications.
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Drug-induced pigmentation p. 82
Arunachalam Narayanan, Laxmisha Chandrashekhar
Around 10% to 20% of all cases of acquired hyperpigmentation are drug-induced. The underlying pathogenesis for drug-induced pigmentation includes melanin accumulation, drug accumulation, toxic effects on melanocytes, and hypersecretion of adrenocorticotropic hormone and melanocyte-stimulating hormone among others. A step-by-step approach might help the dermatologist to diagnose a case of drug-induced pigmentation. Initial history should include a list of drugs taken, duration of intake of each drug, dose of the drug, and latency between drug intake and the onset of pigmentation. Examination findings might reveal specific patterns of pigmentation such as fixed drug eruption, serpentine supravenous pigmentation, flagellate pigmentation, melasma-like pigmentation, or reticulate pigmentation. The color of the pigment also helps in making a diagnosis. Besides, examination of the mucosa, hair, nails, and teeth is also essential. The histopathological examination might reveal whether the color is due to the drug itself, melanin, lipofuscin, or hemosiderin. Special staining, examination under polarized light, and electron microscopy are useful adjuncts in making a diagnosis. Often, drug-induced pigmentation is a diagnosis of exclusion and requires evaluation for other causes of pigmentation. Treatment options for drug-induced pigmentation include lowering the dose or replacing the drug with an effective alternative. Photoprotection and sunscreens also play an important role in treatment. Knowledge of the various patterns of drug-induced pigmentation is essential for all dermatologists to manage this condition.
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Role of dermoscopy in the assessment of difficult to diagnose cases of pigmentary dermatoses: study from a tertiary care hospital p. 93
Yasmeen J Bhat, Faizan Y Shah, Insha Latif, Najm-u Saqib, Aaqib A Shah, Yaqzata Bashir, Rita Devi, Uzair K Dar, Masarat Naushad, Iffat Hassan, Kewal Krishan
Background: Pigmentary disorders are a common skin affliction causing great distress and anguish among those affected. Dermoscopy is a noninvasive diagnostic modality which has great potential in the diagnosis of these disorders. Objectives: To assess the dermoscopic features relevant to the diagnosis of pigmentary dermatoses in patients presenting to our tertiary care hospital. Methods: This was a cross-sectional study conducted in patients presenting to pigmentary dermatoses clinic of our hospital over a period of 1 year. A comprehensive evaluation with special emphasis on dermoscopy was performed in all patients. The dermoscope used was DL3N Dermlite (10X). Additional investigations were carried out as deemed necessary to clinch a final diagnosis. Results: The study included a total of 200 cases with 90 males and 110 females, with age ranging from 6 months to 69 years and a mean age of 24.43 ± 17.07 years. The pigmentary dermatoses encountered were divided into three groups − disorders of hypopigmentation, facial melanoses, and other pigmentary disorders. Dermoscopic findings most relevant to diagnosis were compiled and tabulated. Conclusion: Dermoscopy played a significant role to rule out ominous diagnosis with accuracy comparable to histopathology, when carried out by an expert. The need for an invasive procedure such as skin biopsy was evaded in a number of cases.
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Efficacy of autologous melanocytic transplantation by flip-top technique in patients of stable vitiligo p. 107
Jyoti Budhwar, SK Malhotra
Background: Vitiligo is an acquired disorder of depigmentation. Various surgical modalities are recommended for quicker resolution of lesions in stable cases. Aim and objectives: To study the efficacy of flip-top technique of autologous melanocytic transplantation in a series of 30 patients with stable vitiligo. Materials and Methods: Thirty patients with stable vitiligo, not responding to adequate trial of medicines were taken in this prospective study. After doing complete investigations, including coagulogram, they were subjected to Flip-top technique of autologous melanocytic transplantation, then 15 patients were put on PUVASOL and 15 patients were exposed to sunlight alone for 3 months. Digital photographs were taken at every sitting. An analysis was performed using the Wilcoxon signed-rank test and Mann--Whitney tests and grading was done for response. Results: Satisfactory cosmetic results were obtained in all cases with 26 patients achieving more than 25% of repigmentation and only 4 patients achieving less than 50% or above repigmentation. Colour match was good with minimal complications. Conclusion: Flip-top technique of autologous melanocytic transplantation appears to be a promising option for patients with stable recalcitrant vitiligo.
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Clinico-dermatoscopic study of facial melanosis at a tertiary care hospital p. 115
Dhruv R Patel, Jinal J Tandel, Rutoo V Polra, Jaishree Ganjiwale, Pragya A Nair
Introduction: Facial pigmentary disorders are a group of heterogeneous disorders with clinical features of hyper- or hypopigmentation. They cause a great degree of psychosocial impact on patients’ quality of life due to their easy visibility. Aims and objectives: To find out different clinical and dermatoscopic patterns in facial melanosis. Materials and methods: Patients with hyperpigmentation or hypopigmentation over the face attending the skin OPD were recruited after taking their written consent in vernacular language. A detailed history was taken to collect demographic data. Clinical examination and dermatoscopy were done in all patients. Relevant investigations and biopsy were carried out as and when required. The descriptive statistics has been used to describe the quantitative data. Qualitative data were presented as frequency and percentage for clinical and dermatoscopic patterns. Results: The study included 180 patients having 20 different facial melanoses. Maximum number of patients (99; 55%) belonged to the age group of 19 to 40 years with female:male ratio of 1.72:1. The most common precipitating factor was sunlight in 66 (36.7%) patients followed by seasonal variation in 27 (15%) cases. Cheek was the most common site involved in 101 (56.1%) cases. Melasma was reported as the most common dermatosis including epidermal melasma 40 (22.2%), dermal melasma 26 (14.4%), and mixed melasma 4 (2.2%) cases followed by postinflammatory pigmentation (18; 10%), acanthosis nigricans (13; 7.2%), and vitiligo (11; 6.1%). In dermatoscopy, the most common pattern seen was reticuloglobular pattern in 68 (37.3%) cases, followed by black-brown globules in 47 (25.6%) cases. Conclusions: Melasma was reported as the most common cause of facial melanosis. The most common dermatoscopic pattern was the reticuloglobular pattern. The study is useful in understanding the different clinical and dermatoscopic patterns of facial melanosis, thereby help the physician to effectively manage the conditions and reduce the need of biopsy. Limitation: Histopathological correlation was not done.
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A retrospective evaluation of patient profiles, investigations, and treatment modalities used within a pigmentary disorders clinic in Australia p. 122
Brent J Doolan, Janice Yeon, Michelle Weaich, Monisha Gupta
Background: Pigmentary disorders are a common presentation in dermatology practice and can be challenging to manage and require expert intervention. Currently, there are limited data on Australian patients presenting with pigmentary disorders. Aims: The aim of the study was to undertake a review of patients presenting with pigmentary disorders and to compare serology, treatment, and quality of life data to global data. Methods: A retrospective, observational study was undertaken in patients attending the pigmentary disorders clinic at The Skin Hospital, Sydney from June 2012 to March 2020. Data collection included demographics, disease duration, baseline nutritional and autoimmune serology, quality of life scores, and treatments undertaken. Results: 776 patients were identified, with 600 patients (54.3%, female) attending for management of pigmentary disorders. The mean age at time of clinic attendance was 34.5 ± 17.0 years. Vitamin D deficiency, anemia, and abnormal thyroid serology were present in 36.5%, 8.4%, and 6.6% of patients, respectively. Among vitiligo patients, a positive family history of vitiligo and autoimmune disease was present in 17.0% and 20.1% of patients, respectively. Serological testing revealed a 29.5% prevalence of thyroid autoimmunity. A mean treatment time of 1.04 ± 0.62 years was required to decrease dermatology life quality index (DLQI) scores from severe to mild (P < 0.001). Based on DLQI scores, 59% of severe and 18% of patients with moderate scores reduced their baseline scores to mild at follow-up (mean follow-up time of 1.21 ± 1.01 years). Conclusion: This study is the first to investigate the profile and management of patients with pigmentary disorders and highlights the need for such a clinic in an increasingly multiracial Australia.
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Association between vitiligo and risk of suicide and suicidal ideation: systematic review and meta-analysis p. 127
Kevin Phan, Stephen Shumack, Monisha Gupta
Background: Vitiligo is an autoimmune skin disorder characterized by patches of depigmentation due to loss of melanocytes. Vitiligo is associated with significant psychosocial burden, with prior studies showing links with psychiatric comorbidities such as depression. Few studies have evaluated the relationship between vitiligo and suicidal ideation and suicide attempts. We aimed to investigate the underlying prevalence and risk of suicidal ideation or suicide attempts among patients with vitiligo. Materials and Methods: A systematic search of PubMed, MEDLINE, Embase, and the Cochrane Library was conducted. Cross‐sectional, case–control or cohort studies that assessed the prevalence of suicidal ideation or suicide attempts among patients with vitiligo were included. DerSimonian and Laird random‐effects models were utilized to calculate the pooled prevalence and odds ratios. Results: From systematic review, we identified seven studies included for analysis. A total of 12,043 vitiligo cases were compared with 87,053,333 controls. The pooled proportion of suicidal ideation in vitiligo was 15.2% compared to 2.0% in the control group (P < 0.001). The proportion of suicide attempts/suicides was also higher for vitiligo compared to controls (3.2% vs. 2.1%, P < 0.001). Moderate‐to‐high heterogeneity was observed between the studies. Conclusion: Our data further provide evidence of the significant impact vitiligo has on self-esteem and psychological burden. Patients with vitiligo were significantly more likely to have suicidal ideation. Clinicians should actively evaluate patients with vitiligo for signs/symptoms of suicidal ideation and provide appropriate referrals to manage their psychiatric symptoms accordingly.
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The mystery of brown shawl over back: a rare case of giant plexiform neurofibroma underlying a giant café-au-lait macule p. 131
Kinjal D Rambhia, Sumit A Hajare, Jayesh I Mukhi, Rajesh Pratap Singh
Neurofibromatosis is a rare autosomal dominant disorder characterized by café-au-lait macules and cutaneous neurofibromas. Café-au-lait spots are sharply defined, light-brown colored homogenous macules observed in more than 90% of cases. Plexiform neurofibromas are benign tumors originating from nerve sheath cells, subcutaneous or visceral peripheral nerves involving multiple fascicles often described on palpation as a bag of worms. We describe a case of 25-year-old male who presented with a giant plexiform neurofibroma underlying a giant café-au-lait macule.
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Tamoxifen-induced lichen planus pigmentosus − case report p. 134
Azra Ferheen Chaudhary, Shitij Goel, Tunika Arora
Lichen planus pigmentosus is characterized by slaty-gray pigmentation, predominantly on sun-exposed sites. It is considered to be a type IV hypersensitivity reaction to unknown antigen with lichenoid inflammation which may lead to melanin incontinence and superficial dermal pigmentation. This report presents a rare case of lichen planus pigmentosus caused due to tamoxifen intake.
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Mosaic neurofibromatosis type 1 or segmental neurofibromatosis: what is in the name? p. 137
Kakar Shruti, Suggu Sree Ramu, Bhalla Mala
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Sunitinib-induced localized depigmentation over melasma in an elderly woman p. 139
Sambasiviah Chidambara Murthy, Megha Shankar, Niveditha Nagaraj, Megha Srikantaiah
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Midline nevoid acanthosis nigricans p. 141
Priyanka A Kowe, Shashank K Agrawal, Vaishali H Wankhade
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Current best evidence in pigmentary dermatology p. 143
Sheenam Sethi, Vishal Thakur
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