Artificial Intelligence (AI) has surpassed dermatologists in skin cancer detection, but dermatology still lags behind radiology in its broader adoption. Building and using AI applications are becoming increasingly accessible. However, complex use cases may still require specialized expertise for design and deployment. AI has many applications in dermatology ranging from fundamental research, diagnostics, therapeutics, and cosmetic dermatology. The lack of standardization of images and privacy concerns are the foremost challenges stifling AI adoption. Dermatologists have a significant role to play in standardized data collection, curating data for machine learning, clinically validating AI solutions, and ultimately adopting this paradigm shift that is changing the way we practice.

Randomized control trialsare the gold standard for testing the efficacy of new interventions. Historically, superiority trials were methods of choice as reference (standard) interventions were not established for many disease conditions. However currently, reference interventions are available for most of adverse conditions. Despite this, many investigators are using superiority trials in comparison to more suitable noninferiority and equivalence trials. The application of noninferiority and equivalence trials is on the rise, but by and large, these trials are poorly understood, ill-conceived, inappropriately analyzed, and reported and misinterpreted.

Introduction: Dermatologists in India are trained and qualified to treat leprosy and there is evidence to suggest that they are involved in the diagnosis and management of a significant number of leprosy patients in the country. The present study evaluated the access to quality leprosy services at their clinics and hospitals to understand the extent of their role in providing comprehensive care to people affected by leprosy and how it can be organized further. Methods: The DermLep Study was a pan-India questionnaire-based survey carried out to evaluate the role that dermatologists play in leprosy management in the country. It included as part-2 of the survey, 11 questions on the access of the dermatologist to various quality leprosy services available at the clinic or institution including skin smears, skin biopsy, multidrug therapy (MDT) blister packs, basic physiotherapy services, and reporting to the national program (NLEP). Results: The dermatologists who participated in the survey included 101 private practitioners and 100 working in Government or private medical institutions. The key findings of the survey were that 78% of the participating dermatologists still encounter leprosy patients frequently in their clinics; 81.0% of them had access to skin smears; and 93.4% to skin biopsy. The World Health Organization (WHO) MDT regimen was followed by 79.0% of the dermatologists in the study, majority of whom were those working in medical colleges (88%); however overall, 87.4% extended the regimen beyond the fixed duration, mostly on a case to case basis. Thalidomide was available for 61.1% of them to treat type 2 reactions. Basic physiotherapy services were available with 70.2% of dermatologists surveyed; 58.9% dermatologists had access to MCR footwear; and RCS facility access known to 45.5% of them. About 83.5% of the dermatologists working in institutions were reporting their leprosy cases to the NLEP, whereas from a high percentage (71.4%) of dermatologists in private practice, cases were not captured in routine under NLEP. Conclusion: Dermatologists in India have the clinical skill, expertise, and access to most of the basic services, including skin smear and skin biopsy facilities needed to provide comprehensive care to leprosy patients in post-elimination era of integration of leprosy services. While dermatologists are already managing leprosy patients both at medical institutes and private clinics across India, their “structured” involvement at all levels in the national program will facilitate improved reporting and cataloging of cases seen by them. It will also elevate standards of leprosy care; create an effective public-private partnership and disease expertise; and assist develop a comprehensive, patient-tailored approach in the leprosy program in India.

Background and Aims: Biological agents are being used as treatment of psoriasis for years. However, autoimmunity can develop after the using of these agents. Antinuclear antibody (ANA) status changes during biological therapy can be affected by certain factors including the presence of immunosuppression. We aimed to evaluate the effect of antitumor necrosis factor agents and ustekinumab on ANA status, as well as other factors leading to change in ANA status such as history of phototherapy and methotrexate combination therapy. Methods: In this study, the laboratory findings of thirty-one patients with psoriasis who received biological agents including infliximab, etanercept, adalimumab, and ustekinumab from 2016 to 2018 managed at the department of dermatology were reviewed. The ANA status of the patients was evaluated every 2–3 months. Results: Twelve (38.7%) out of the thirty-one patients developed ANA positivity during treatment. Nine patients receiving infliximab, two patients receiving etanercept, and one patient receiving adalimumab developed ANA positivity. The nuclear homogeneous, nuclear fine speckled, and nuclear large/coarse speckled were the most common patterns of ANA. A patient receiving infliximab also developed anti-dsDNA positivity. None of the patients developed drug-induced lupus erythematosus or any autoimmune diseases. Concomitant methotrexate use and phototherapy history had no effect on ANA status statistically (P = 0.240 and 0.717, respectively). Conclusion: The emergence of ANA positivity during infliximab therapy among all biological agents was more common. ANA positivity during biologic agents does not cause any signs and symptoms of autoimmune diseases in patients with psoriasis; thus, it can be suggested that biological agents are not major risk factors for autoimmunity.

Objective: To analyze the accuracy of Tibot artificial intelligence (AI) application tool in predicting the diagnosis of dermatological conditions. Material and Methods: In this prospective, observational study photographs of dermatological lesions with other details of patients having different skin conditions were fed in the AI application for the diagnosis. Predictions given by the Tibot AI application were compared with diagnosis done by the dermatologist. The performance of AI application was evaluated using accuracy, precision, and recall. Results: Data of 398 patients were included in the application of whom 159 (39.9%) had fungal infections. Other conditions included eczema 36 (9%), alopecia 28 (7%), infestations 27 (6.8%), acne 25 (6.3%), psoriasis 19 (4.8%), benign tumors 7 (1.8%), bacterial infection 19 (4.8%), viral infection 15 (3.8%), and pigmentary disorders 20 (5%). The prediction accuracy (ability to get diagnosis in top three conditions) for alopecia, fungal infections, and eczema was 100%, 95.6%, and 91.7%, respectively. Mean prediction accuracy for correct diagnosis in the predicted top three diagnoses was 85.2%, and for correct diagnosis was 60.7%. Sensitivity and specificity of the application were approximately 86% and 98%, respectively. The sensitivity and positive predictive value of the application to diagnose alopecia was 100% and for fungal infections it was 96.85% and 90.05%, respectively. Conclusion: In the preliminary stages, AI application tool showed promising results in diagnosing skin conditions. The accuracy and predictive value of the test may improve with the expansion of the database.

Background: Autoimmune bullous diseases (AIBD) are a heterogeneous group of diseases characterized by autoantibodies against desmosomal proteins in the pemphigus group of disorders and adhesion molecules of the dermal-epidermal junction in pemphigoid group of diseases. Direct immunofluorescence (DIF) establishes the diagnosis of AIBD by demonstrating intercellular deposits of IgG and C3 in case of pemphigus and linear deposits of IgG and C3 along the basement membrane zone (BMZ) in bullous pemphigoid (BP). BIOCHIP mosaic-based indirect immunofluorescence (IIF), a novel diagnostic approach employs detection of characteristic staining pattern and target antigens in a single miniature incubation field. Aim: To compare the BIOCHIP mosaic-based IIF with DIF in the diagnosis of AIBD. Materials and Methods: A total of 40 patients of AIBD in the active phase of the disease were included in the study. Skin biopsy was done in these patients for DIF study and serum was subjected to BIOCHIP mosaic-based IIF assay. The results were then compared. Results: DIF revealed a diagnosis of Pemphigus in 18 patients and BP in 22 patients. BIOCHIP showed a diagnosis of pemphigus in 18 patients, BP in 18 patients and floor pattern staining in four patients, which could be attributed to any of the floor pattern staining subepidermal blistering disease. Limitations: Small sample size, lack of control group and no comparison made with ELISA. Conclusion: This study concludes that the result of BIOCHIP showed a significant correlation with the DIF and can be used as a first line-screening tool in the diagnosis of AIBD.

Background: Alopecia areata (AA) is a chronic nonscarring alopecia that involves hair follicles and is characterized by patchy areas of hair loss without any signs of clinical inflammation. Platelet-ri-ch plasma (PRP) has a high platelet concentration. Anti-inflammatory effect of PRP may be of great help in AA. Aims and Objectives: Study was conducted to compare the outcome of treatment and side effects of intralesional PRP versus triamcinolone in AA. Materials and Methods: 40 patients with alopecia areata were allocated into 2 groups and treated with triamcinolone and PRP injections. The response was analyzed by SALT score (severity of alopecia tool score) and hair regrowth grade (HRG) scale. Inferential statistical tools such as t-test, Mann–Whitney U test, and Chi-square test were used. Results: 16 patients in each group completed the study. While comparing the decrease in SALT score at different intervals of time, there was a significant difference in SALT score reduction during the second review between PRP group and triamcinolone group (P = 0.028). After the first and final review, results did not show any statistically significant difference between the two groups. While comparing the hair regrowth scale between treatments, there was no statistical significance. 12.5% patients in PRP group reported excellent response after final review (HRG scale 4), compared to none in triamcinolone group. Conclusions: Platelet-rich plasma is a safe, effective, steroid sparing, and suitable alternative in AA. Only side effect noted was pain during injections in both the groups.

Background: Many factors have been implicated in the pathogenesis of atopic dermatitis (AD) and recently the role of oxidative damage has been postulated. Objectives: To study the levels of oxidants and antioxidants including melatonin in the blood of children with AD and their association with the severity of AD. Methods: Thirty patients with atopic dermatitis, aged 6 months to 12 years, and equal number of age and sex-matched controls were included. Clinical characteristics and baseline severity assessment using SCORAD (scoring atopic dermatitis) severity index were noted. Blood superoxide dismutase, blood glutathione peroxidase, serum malondialdehyde, and serum melatonin levels were measured in cases and controls and results were compared. Results: The serum levels of malondialdehyde and melatonin were significantly higher among the cases compared to controls. The blood levels of superoxide dismutase and glutathione peroxidase were higher in cases but the difference with controls was not statistically significant. There was no significant correlation between these markers and the severity of the disease. Conclusions: Oxidative stress was increased in cases of childhood AD compared to the control group in this study. No correlation between oxidative stress and the severity of the disease was found. Larger studies are warranted.

Context: Surgical correction of scars may not be an ideal solution in all cases and hence it is desirable to have a nonsurgical option available. Autologous platelet-rich plasma (PRP) and fractional carbon dioxide laser (FCL) offer an alternative treatment modality. Aims: To compare the efficacy and safety of FCL and intradermal PRP with FCL in the management of postburn and posttraumatic scars. Settings and Design: A prospective, randomized, observer-blinded, comparative study was conducted at a hospital skin centre from Oct 2016 to Sep 2018. Subjects and Methods: A total of 67 patients with scars were randomly divided into two groups; Group I was treated with four sessions of monthly FCL and Group II was treated with four sessions of PRP and FCL. The patients were assessed using the Patient and Observer Scar Assessment Scale (POSAS) at baseline and 4 weeks after each session. Statistical Analysis Used: For continuous variables, the summary statistics of mean ± standard deviation was used; for categorical data, number and percentage were used. Chi-square (χ2) test was used for association between two categorical variables. P value <0.05 was considered to be statistically significant. Results: Thirty cases in each group completed the study. There was a significant improvement in the total score of POSAS (p < 0.001) in both groups, but the final difference between the two groups was not statistically significant (p = 0.793 and P = 0.278, respectively). Conclusions: Fractional CO2 laser causes significant improvement in scar appearance. PRP in combination with FCL offers no additional advantage.

The aim of every academician and clinical dermatologist is to publish their research in reputed biomedical journals. But from conceptualization to completion, myriad shortcomings creep into the article and by the time it is ready for publication, by default and certainly not by design, the article discourse gets flawed, sometime fatally so. The endeavor of this article is to discuss these pitfalls from conceptualization, statistical machinations, authorial misconcepts, article structuring, and final journal selection. The article can function as a prophylactic checklist, albeit not comprehensive, by any prospective author and is an appreciation of the most oft repeated fallacies usually detected in publication submissions.

Introduction: The COVID-19 pandemic has disrupted clinical teaching in medical schools. Direct patient interaction, especially in groups, in out-patient departments or wards, was also made difficult. Institutes have adapted to the changed circumstances by increasing the use of online learning. We share our experience with a module of online Dermatology for undergraduate students. Methods: An online module, aligned with the existing course objectives was designed and applied for two cohorts (year 4 and year 5). The module included student manuals, Powerpoint- presentations, videos, and quizzes uploaded on dedicated online management systems. There were live interactive sessions in small groups also. The small group session included student-led case presentations and faculty-led simulated case discussions. Feedback was taken from both the students and the faculty regarding the module using a structured questionnaire. Results: A total of 45 students and 4 faculty responded to the respective questionnaires. A majority of the students felt that the module covered the planned content adequately. The faculty and the majority of the students were also satisfied with the technical aspects of the module. Student and faculty concerns were mainly in the area of assessment and practical skills. While faculty were concerned about the validity of the assessment, students were concerned mainly about difficulty and the need for more orientation regarding the assessment. Conclusions: The students and faculty were satisfied with the online Dermatology module in our study. However, the validity of assessment and the training of practical skills are major limitations.

Introduction: Lupus Vulgaris (LV) is the chronic, progressive, tissue destructive form of cutaneous tuberculosis. LV should be diagnosed and treated to prevent scaring and deformities. Histopathology is the gold standard for the diagnosis. Dermoscopy is helpful tool in diagnosing different dermatological condition. Here, dermoscopic and histopathogical correlation in LV was attempted. Materials and Methods: It was a cross sectional, observational study done from February 2019 to October 2019. Nineteen patients of LV were included. Dermlite 4 with attached smart phone (iphone) was employed. LV lesions were subjected to skin biopsy to confirm the diagnosis. Results: Study enrolled 19 patients, with 8males, 5 female and 6 children. Dermoscopy showed yellowish-white globules, white structureless areas and white scales were noted in 19 (100%) patients. Telangiectasias were seen in 16 (84.21%) patients as long linear, branching and short linear vessels. Pinkish-red background was noted in all patients (100% n=19). Newer observations included white shiny streaks, white rosettes and bluish hue. Age, sex, duration of lesions had no influence in the dermoscopic patterns. Discrepancy in dermoscopic-histopathologic correlation was noted. Facial lesions showed increased frequency of follicular plugs, patulous follicles and white rosettes. Conclusion: Dermoscopy is widely gaining importance in the realm of dermatology. In this study, dermoscopy demonstrated characteristic patterns in LV. Thus, dermoscopy a non-invasive procedure can be used as diagnostic tool in many infective dermatoses.

Background: The nail changes caused by chemotherapy in cancer patients are difficult to assess and often overlooked by clinician. The present study was undertaken to study nail changes caused by various chemotherapeutic agents and various drug protocols most commonly associated with them. Materials and Method: Five hundred patients with malignancies receiving chemotherapy in the oncology ward and skin outpatient department were screened in this cross-sectional observational study from November 2018 to October 2019. Results: Nail changes due to chemotherapy were observed in 37.6% patients. The most common condition observed was melanonychia (84.04%), followed by half and half nails (6.91%), erythronychia (5.31%), longitudinal grooves (2.12%), leukonychia (2.12%), Mees’ lines (1.59%), Beau's lines (0.53%), pitting (0.53%), and subungual hyperkeratosis (0.53%). The usual protocol to cause melanonychia was platinum analogues + taxanes based combinations, half and half nails by platinum analogues + taxanes + 5 fluorouracil (5FU) based polypharmacy, and erythronychia by cisplatin-based adjuvants. Conclusion: The knowledge of the nail changes caused by chemotherapy will help in counseling of already worried patients with malignancy. It will also improve patient compliance and enrich the clinicians’ knowledge pertaining to chemotherapy-induced nail changes.

Introduction: Leprosy or Hansen's disease poses a drastic impact on the quality of life in affected patients even after successful completion of treatment. The involvement of the endocrine system in leprosy is usually insidious, silent, and under-reported, especially the testicular dysfunction. Aims and Objectives: The present study was aimed at evaluating the abnormalities of the primary testicular hormone testosterone and the gonadotrophins LH and FSH in male patients affected with lepromatous leprosy and assessing the impact of the disease on quality of life (QOL). Materials and Methods: The study included 43 married male patients diagnosed with lepromatous leprosy. Careful history taking and examination for symptoms of testicular dysfunction were done. Serum concentrations of total testosterone, FSH, and LH were noted. The QOL was evaluated using the WHO Quality of Life-BREF (WHOQoL-BREF). Results: The most common clinical manifestation of testicular dysfunction was reduced or loss of libido reported in 12 (27.9%) patients followed by gynaecomastia in 7 (16.3%). Ultrasonographic (USG) analysis revealed reduced testicular volume in 31 (72.1%) patients, and average testicular volume was 11.9 ± 4.9 mL each. Seventeen (39.5%) patients had low serum testosterone levels, 9 (20.9%) had high serum FSH level, and 11 (25.6%) high LH levels. There was a significant negative correlation between testosterone level and FSH as well as LH. There was also a significantly positive correlation between testicular volume and testosterone level. Symptomatic patients with gynaecomastia/gynaecothelia had higher hormonal derangement than those who had other symptoms. On QOL, most patients scored lowest on the domain of “social relationships” (including sexual wellbeing) followed by “psychological health”. Conclusion: We found a high rate of USG diagnosed testicular atrophy in lepromatous leprosy patients. Therefore, every leprosy patient should be thoroughly examined clinically to rule out features of testicular dysfunction. Testicular function tests should be routinely carried out in all leprosy patients to arrive at an early diagnosis. Leprosy is found to affect all domains of a patient's quality of life.

Introduction: Alopecia areata (AA) is a chronic, non-scarring type of alopecia that presents as patchy hair loss over the scalp and other parts of the body. The diagnosis of AA can sometimes be challenging. Trichoscopy can be used to observe certain follicular patterns, shaft changes, and interfollicular pattern which help in diagnosing and determining the disease activity in AA. Materials and Methods: This study was a 1-year hospital-based observational cross-sectional study consisting of 60 patients clinically diagnosed with AA. Trichoscopic examination of the scalp and hair was performed using a videodermatoscope—Dinolite premier AM4113ZT model, trichoscopic images were recorded, and results were analyzed statistically. Results: AA was more common in males 39/60 cases (65%) with male to female ratio of 1.85:1. Scalp was the most frequently involved site, seen in 52/60 cases (86.67%) and patchy alopecia was the most frequent clinical pattern of presentation (83.33%). The characteristic follicular features noted were black dots, yellow dots, and empty hair follicles. Black dots were the commonest finding (63.33%) and represented a marker for active disease. The characteristic hair patterns noted were broken hair, micro-exclamation mark hair, coudability hair, all of which were commonly seen in active cases. 72% of cases that had clinically inactive disease showed active disease on trichoscopy. Conclusion: Trichoscopic features of AA are characteristic and they not only provide an important clue to the diagnosis in doubtful cases but also help in assessing disease activity in AA.

Context: Repeated trauma involving extremities (in the setting of peripheral neuropathy) and poor vascularity that impairs wound healing are important causes of disability and deformity in leprosy patients. Nail changes can serve as indicators of trophic changes due to leprosy. Aims: To describe the onychoscopy findings in leprosy cases and to identify any specific findings in leprosy patients in comparison to controls. Settings and Design: The first 30 leprosy patients and 30 age and sex-matched controls who attended our tertiary care center from 1 August 2018 were included in this cross-sectional study. Materials and Methods: Onychoscopy examination of all fingernails was performed at 50× magnification using dinolite dermoscope AM4113ZT under non-polarizing light to document surface changes and under polarizing light to document pigmentation and vascular changes. Statistical Analysis: The observed nail changes in cases and controls were compared using Pearson's Chi-square test. Results: Statistically significant association with leprosy was found for pitting, onycholysis, melanonychia, transverse lines, nail pallor, and onychauxis. Nail pallor was unique to leprosy patients. Limitations: Small sample size and not evaluating toenails were the major limitations of the study. Conclusions: Studies with large sample size are needed to assess the significance of nail pallor as a specific onychoscopy finding in leprosy.

Phaeohyphomycosis encompasses many clinical syndromes occurring due to a wide variety of dematiaceous fungi. It can manifest as superficial, cutaneous, subcutaneous, or systemic forms involving the skin, subcutis, paranasal sinuses, or the central nervous system. Subcutaneous phaeohyphomycosis is the most common subtype and occurs due to wound contamination or traumatic inoculation of the saprophytic fungus from soil and vegetation. Multiple cases of subcutaneous phaeohyphomycosis involving the extremities in the form of cystic lesions and abscesses have been reported. However, involvement of the face in the form of a progressive ulcerative and disfiguring lesion in an immunocompetent person is extremely rare. We report a rare case of subcutaneous phaeohyphomycosis presenting as a slowly progressive disfiguring lesion of face.

Wells syndrome or eosinophilic cellulitis is an idiopathic inflammatory dermatitis characterized by a benign but recurrent evolution. It often causes edematous urticarial plaques on the extremities. Herein, we report two rare cases of Wells syndrome with marked swelling in the hands. Both cases exhibited various clinical features. Case 1 was Wells syndrome with collagen disease-like sclerotic edema in the fingers and annular erythema on the trunk. Case 2 was Wells syndrome with diffuse plate-like hardening of the forearm mimicking cellulitis, which required fasciotomy due to suspected compartment syndrome at the emergency room. Wells syndrome should be included in the differential diagnosis of patients presenting with marked diffuse swelling in the hands.

Giant porokeratosis (PK) is a rare entity. Many consider it as a variant of PK of Mibelli, while others describe it as a separate variant. The diameter may range between 10 and 12 cm and the wall of hyperkeratotic ridge may be upto 1 cm. High tropical temperature and long duration of outdoor activities without adequate clothing are known influencing factors of PK. To the best of our knowledge, only five cases of solitary giant PK and a case of disseminated giant PK have been documented from India. We report three cases of giant PK for their rarity.

Graft versus host disease (GVHD) is a unique entity wherein the donated marrow cells (graft) view the hosts as foreign and attack various body organs. Skin is the most frequently affected organ followed by mucosa, eyes, gastrointestinal, respiratory, musculoskeletal system, and other organs. The incidence of GVHD varies from 25 to 80%. Cutaneous involvement can present as exanthem, epidermolysis, lichenoid eruptions, erythroderma, ichthyosis, pityriasis rubra pilaris like lesions, psoriasiform lesions or just pruritus. Asymptomatic truncal follicular eruptions as the major presentation is rare. We report a case of aplastic anemia that developed extensive truncal folliculocentric papules 10 months following an allogeneic hematopoietic stem cell transplantation. Histopathological examination of the follicular lesions revealed perifollicular inflammatory infiltrate comprising of lymphocytes, plasma cells and histiocytes at the dermo-epidermal junction. Basal cell vacuolization, pigment incontinence in the upper dermis and few apoptotic keratinocytes in the follicular epidermis were also seen. The patient responded satisfactorily to tapering doses of steroids.