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Itraconazole, is the most commonly prescribed oral antifungal agent in India, and has a low minimum inhibitory concentration as compared to other oral antifungals, and in conjunction with the markedly high skin levels, the drug should have a predictably good clinical response which is not the consistent experience of clinicians . Probably the variation in pelletization parameters might affect the bioavailability of the drug and consequently affect the serum levels. The maximum bioavailability of conventional itraconazole is 55 percent, which is neither consistent nor predictable. However, the novel itraconazole (Super bioavailable Itraconazole) with targeted drug release in the small intestine has predictable serum levels with minimum interindividual variability, which could make it a potentially useful drug in recalcitrant dermatophytosis.

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Eyebrows have been known to be an importance aspect of facial aesthetics and eyebrow restoration is now a part of anti-ageing procedures too. Microblading is a new technique in the field of permanent cosmetics for eyebrow restoration. Currently, it is one of the most sort after treatment in aesthetic procedures due to the curiosity and awareness raised by social media. Microblading is a form of superficial micropigmentation, wherein pigment is deposited till the papillary dermis, with the help of a manual device and a blade consisting of stacked needles. The resultant crisp, discrete hair like incisions simulate the eyebrow hair to give a natural look. The results are semi-permanent and last only 12-18 months. In the recent years, with the advancement in the instrumentation of microblading there have been several modifications in this procedure. Microblading has now found its applications not only in cosmetic treatments but also in dermatological conditions such as alopecia totalis, hypothyroidism, chemotherapy induced madarosis etc. It is a vital tool in any dermatology or cosmetic practise for its extensive applications. But with the rise in popularity of microblading, there is also a rise of untrained professionals performing it leading to a rise in its side-effects. This article aims at not only guiding on the instrumentation and procedure of microblading but also its pre and post procedure care, interaction with other aesthetic procedures and treating its complications.

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Dermatoscopy is a non-invasive, handy tool, which is increasingly being used in diagnosis and prognostication of pigmentary dermatoses. Dermatoscopic changes in pigmentary pattern, scaling, and vasculature help us to differentiate among the myriad of hypo and hyper pigmentary diseases. This review gives a brief overview of the dermatoscopic features of pigmentary diseases, which are commonly encountered in clinical practice. We also provide a diagnostic approach based on salient dermatoscopic features.

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Dermoscopy is a non-invasive tool for the diagnosis of skin diseases. Entomodermoscopy is a branch of dermoscopy that deals with infections and infestations. The use of dermoscopy for diagnosis of infections and infestations is rapidly increasing as it can provide useful clues related to diagnosis and effectiveness of treatment. It serves as a useful adjunct to microbiological and histopathological examination. In some cases, like scabies dermoscopy can even clinch the diagnosis.

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Background: Confluent and reticulate papillomatosis (CRP) is an uncommon benign, acquired keratinization disorder. Studies on this disorder are lacking except for a few case reports and there is a paucity of Indian literature on the condition. Objectives/Methods: To study and describe the various morphological patterns and histopathological findings, as well as assess the response to treatment of 30 patients diagnosed with CRP. Results: Thirtypatients with a diagnosis of confluent and reticulate papillomatosis were included in the study. The male to female ratio was 1:1.5. Mean age at onset of skin eruptions was 27.3 years and mean duration of skin eruptions was 8.2 months. Most of the patients (60%) were asymptomatic. The majority (66.7%) had lesions distributed over upper trunk. Two-thirds of patients had typical brown macules in confluent and reticulate pattern.KOH mount was done in 24 cases and was positive in three cases (12.5%) for yeast-like hyphae. Biopsy demonstrated variable degrees of hyperkeratosis, papillomatosis, and moderate acanthosis. Thirteen out of eighteenpatients on minocycline showed complete clearance within 3 weeks andthreepatients had more than 50% improvement at the end of 3 weeks. Doxycycline showed satisfactory response but results were less satisfactory with azithromycin. Conclusion: CRP is an uncommon condition. There is a paucity of large studies in Indian literature.The present study highlightssuch a large cohort of cases. Prevalence of CRP was more in female in contrast to western studies. Association of CRP with hyperthyroidism was described in many studies but the present study highlights the association with hypothyroidism. Morphological variants like shiny atrophic lesions, verrucous lesions, and involvement of atypical sites like forearm have been described. Role of minocycline in the management of chronic and recurrent cases has been reinforced.

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Background: Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening mucocutaneous drug reactions with a high morbidity and mortality that require immediate medical care. Several immunomodulatory drugs are used for the treatment but evidence of their efficacy is limited. Cyclosporine has recently been found to have a promising role in SJS/TEN owing to its potent antiapoptotic activity. Aims: This open label prospective study was conducted to determine the efficacy, safety, and tolerability of cyclosporine in patients with SJS/TEN. Methods: This study was conducted at a tertiary care teaching hospital of South Rajasthan during a period of 4 years (August 2015 to July 2019). Data regarding clinical profile, causative drug(s), disease severity, associated comorbidities, treatment received, and outcome were recorded in a predesigned proforma. SCORTEN prognostic score was calculated for each patient at the time of admission. Cyclosporine was administered in a dose of 5 mg/kg body weight in two divided dosage until reepithelization. Results: Out of 16 patients 10 were males and 6 were females. Mean age of patients was 30.62 ± 16.98 years (range: 7–63). Most of the patients, i.e., 8 out of 16 had TEN, 5 patients had SJS, and 3 patients had SJS/TEN overlap. Mean ± SD delay between onset and admission was 3.812 ± 1.377 days (range: 2–7). Among the suspected drugs, antiepileptics (43.7%) formed the major group. Mean duration of reepithelization was 10.5 ± 3.46 days (range: 7–15). Based on the SCORTEN, the expected mortality was 2.55 with mean predicted mortality rate of 16.43% with SD of 19.3. Limitations: 1) Sample size was small. 2) Placebo control trial could not be done due to the severity of the disease. Conclusion: We recommend cyclosporine (5 mg/kg/day) as the first line-specific immunomodulatory agent in SJS/TEN on account of its efficacy, safety, rapid reepithelization, decrease hospital stay, and reduced morbidity and mortality.

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Dermatoscopy is a relevant in vivo diagnostic tool for inflammatory diseases of the skin that aids not only in diagnosis, but also in monitoring the response to treatment. The inflammatory diseases show dermoscopic patterns involving the vessels, scales, follicles, background hue, and special clues. This review aims to provide an overview on the use of dermoscopy in inflammatory dermatoses based on the available literature and the deviation from it in the skin of color (SOC) as there is paucity of literature in dermoscopy of inflammatory disorders in SOC. The dermatoscopic patterns in most of the inflammatory diseases in SOC are similar to that of white skin, with pigmentary changes being the prominent dermoscopic findings while vascular patterns and erythema being less evident.

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Cutaneous granulomatous disorders represent diseases with underlying granulomas on histology and are broadly divided into infectious and noninfectious disorders. Although histology is sine qua non in diagnosis of granulomatous disorders, lately dermoscopy has come up as a useful tool assisting in diagnosis of granulomatous disorder. Dermoscopy of granulomatous disorder is characterized by localized or diffuse, structureless yellowish-orange areas, along with vessels. Dermoscopic features of granulomatous disorders can be overlapping among various disorders, but detailed accurate assessment of various findings and their pattern may be useful in differentiating among them. In addition to this, peculiar dermatoscopic findings seen can also prove useful in distinguishing between various disorders. Hereby, we discuss dermatoscopic findings of various granulomatous disorders.

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Context: Early diagnosis is the mainstay in the management of severe cutaneous adverse reactions (SCARs) to drugs. Aims: To study the role of frozen section in the rapid diagnosis of SCARs and the impact on outcome of the affected patients. Settings and Design: A single-blind, hospital-based study was conducted from December 2014-July 2016. Methods and Material: We biopsied 32 adults with SCARs diagnosed by clinical features and standard criteria. The histopathological features seen on frozen sections were compared to that of paraffin blocks. The impact of rapid diagnosis on the clinical outcome was studied in toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS), drug rash with eosinophilia and systemic symptoms (DRESS) and acute generalized exanthematous pustulosis (AGEP). Statistical Analysis: Z test was used to compare two proportions. Kappa statistic, sensitivity, specificity, positive predictive value, and negative predictive value of the frozen section diagnosis were calculated in TEN/SJS and DRESS using MedCalc software. Results: Frozen and paraffin sections were done in TEN/SJS spectrum (13), DRESS (17), and AGEP (2). The sensitivity, specificity and kappa values for frozen section diagnosis in SJS/TEN and DRESS were 91.7%, 95%, 0.867 and 94.4%, 100%, 0.937 respectively. The concordance between frozen and paraffin section diagnosis was 100% in TEN, SJS, DRESS and AGEP. All the 6 patients with TEN and 2 with AGEP survived. Taking the worst-case scenario, the mortality in SJS was 28.6%. The mortality among patients with DRESS was 11.8%. Conclusions: Frozen section helps in the rapid diagnosis and early treatment of SCARs and differentiates it from diseases that mimic it.

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Background and Aims: Cutaneous lesions are the defining features of several neurocutaneous syndromes like neurofibromatosis1(NF1), tuberous sclerosis complex (TSC), and Sturge Weber syndrome to name a few. With this background, we explored the possibility of identifying congenital and nevoid cutaneous markers that may help in the early recognition of autism spectrum disorders (ASD) in Indian children. The objective of this study was to measure the strength of association between congenital and nevoid cutaneous lesions and ASD among Indian children. Methods: A case-control study was conducted from January 2018 to June 2018. 132 children (18 months-16 years of age) with ASD and equal number of age and sex-matched children without autism were studied. Diagnosis of ASD was based on DSM-5 criteria. All the children were examined for cutaneous lesions with special attention to nevoid and congenital conditions. The strength of association was measured using the diagnostic odds ratio (OR). Results: The prevalence of congenital and nevoid lesions were higher in ASD group (OR = 3.12, P = 0.0001). Among them, pigmentary mosaicism of hyperpigmented type (OR = 2.76, P = 0.02) and café-au-lait macules (CALMs) (OR = 2.40, P = 0.001) were the most prevalent with hyperpigmented pigmentary mosaicism showing a higher association with autism. Atypical CALMs (OR = 2, P = 0.09) were also more prevalent in the ASD group though not statistically significant. Conclusion: The presence of hyperpigmented pigmentary mosaicism and CALMs warrant closer surveillance by the caregivers and physicians for evolving features of autism. Larger multicentric studies are required to validate these findings.

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Vascular disease is frequent in patients with systemic lupus erythematosus, which can be related to the disease process, or can develop as an accompanying co-morbidity and represents the most frequent cause of death in established disease. However, at times the presentations can be uncommon and subtle, and warrants a thorough examination both clinically and radiologically.We report a case of a young female with photosensitive malar rash, oral ulcers, intermittent fever with joint pains, history of two abortions, and unilateral absent radial and brachial artery pulses on clinical examination. The evaluation revealed positive antinuclear antibody (4+), anti-Smith antibody (2+), direct Coomb's test (2+), and antiphospholipid antibody panel was negative. Color doppler flow imaging of right upper limb (arterial) revealed irregular wall thickening with a narrow lumen and mildly reduced peak systolic volume. Computed tomography aortogram revealed wall thickening and luminal narrowing involving the entire length of the right brachial and radial artery. We report this case for its rarity and unique presentation of medium vessel vasculopathy.

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Introduction: Cutaneous leishmaniasis (CL) is a vector-borne protozoal infection of the skin with variable clinical manifestations. In Rajasthan, western Thar desert is endemic for this disease. Aim: The present study was aimed to describe clinico-epidemiological features of cutaneous leishmaniasis cases from a non-endemic area of South Rajasthan.Materials and Methods: A hospital-based prospective study was carried out during a period of 3 years (2017-2019). Data regarding clinical profile and treatment outcome were recorded in a predesigned proforma for analysis. Diagnosis of CL was made clinically and confirmed by demonstration of amastigotes in microscopic examination of Giemsa stained tissue smear of lesions.Results: Out of 24 patients, 16 (67%) were females and 8 (33%) were males. The age ranged from 3 months to 68 years (median-25). Face (67%) and extremities (29%) were the common sites affected. The most common morphological form was crusted plaques (54%) followed by nodular lesions (38%). Slit skin smear for Leishmania donovani bodies was positive in all patients (100%).Conclusion: This study highlights a focus of CL in non-endemic areas of South Rajasthan. Of late leishmaniasis is breaking out of its classical boundaries and is increasingly being reported from new geographic locations with a possibility of a novel parasite variant. Therefore, a high clinical suspicion of CL should be kept in non-endemic area.

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Background: Association between alcohol consumption, alcohol use disorder, and clinical features of psoriasis patients has not been adequately studied in the Indian context. Objectives: To study the frequency of alcohol consumption, alcohol use disorder, and its association with age, gender, duration, and severity of psoriasis. Materials and Methods: One hundred and forty-six (M: F 6.3:1) patients completed the Alcohol Use Disorder Identification Test (AUDIT) questionnaire by World Health Organization (WHO). Excessive drinkers, occasional drinkers, and abstainers were defined. AUDIT provided a measure of alcohol consumption, its dependence, and its impact on daily life. The severity of psoriasis was graded as mild, moderate, and severe. Results: Seventy-four (50.7%) patients were aged ≤40 years and 51.4% of patients had the disease for <5 years. Psoriasis was mild in 48.6% and moderate to severe in 51.4% of patients, respectively. Only males (32.9%) were consuming alcohol in varying amounts; 19.9% were occasional drinkers (AUDIT score <8). Other 67.1% of patients completely abstained from alcohol consumption (AUDIT score 0). The remaining 13% were regular drinkers (AUDIT score >8) and had more severe psoriasis compared to patients having AUDIT score <8 (P < 0.05). A high level of alcohol use disorder and alcohol dependence was present in one patient each. Limitations: Few patients, particularly females may not have disclosed their alcohol consumption due to fear of stigmatization. Small number of patients, hospital-based cross-sectional study design, and no follow-up for clinical improvement after cessation of alcohol are other limitations. Conclusions: Alcohol consumption was associated with alcohol use disorder in 32.9% of patients (AUDIT score >8) and significantly severe psoriasis compared to 67.1% abstainers. Whether increased alcohol consumption is a consequence or a risk factor for chronicity of psoriasis needs large linear studies for confirmation.

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Research funding is defined as a grant obtained for conducting scientific research generally through a competitive process. To apply for grants and securing research funding is an essential part of conducting research. In this article, we will discuss why should one apply for research grants, what are the avenues for getting research grants, and how to go about it in a step-wise manner. We will also discuss how to write research grants and what to be done after funding is received.

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Background: Psoriasis is a chronic inflammatory dermatosis associated with psychological morbidity. Like mental illness, it is also associated with stigma. Very few studies from India have evaluated stigma experienced by patients with psoriasis. Aim of the Study: To study stigma in patients with psoriasis (in the form of internalized stigma, perceived stigma, and social-participation-restriction stigma) and its relationship with demographic and clinical variables. Methodology: 104 patients with psoriasis assessed on the internalized stigma of mental illness scale (ISMIS), explanatory model interview catalogue stigma scale, participation scale (P-scale), perceived social support, total score of Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7) scale, Dermatology Life Quality Index, and Psoriasis disability index. Results: On ISMIS, overall, 27.9% had experienced stigma. On domains, majority of the participants experienced discrimination (52.9%) followed by stigma resistance (51.9%), stereotype (26.0%), social withdrawal (24.1%), and alienation (23.1%). Majority of them reported mild restriction. As per the evaluation by a qualified psychiatrist, about 30% of the participants had at least one psychiatric diagnosis. On comparison, those with the presence of co-morbid psychiatric illness experienced a higher level of stigma on each domain of ISMIS except discrimination and stigma resistance. Lower social support was associated with higher stigma in all the domains. All the domains of ISMIS except discrimination and stigma resistance were associated with a higher level of anxiety and depression, poor quality of life, and higher disability. Conclusion: The patients with psoriasis experience a significant amount of stigma and stigma is associated with the presence of psychiatric morbidity, lower social support, higher restriction, and more disability.

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Pyogenic granuloma (PG), also called a lobular capillary hemangioma, is a benign vascular proliferation of skin or mucous membrane. It classically presents as a solitary friable nodule over the face or distal extremities. Multiple disseminated PG is a rare form generally reported after trauma such as burn injury. We report two cases of spontaneous development of multiple localized PGs in immunocompetent individuals.

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Introduction: Health care workers form an important occupational group with a high risk of hand eczema. All health care professionals are exposed to a variety of allergens and irritants which can cause hand dermatitis, resulting in significant morbidity. Aims and Objectives: To assess the clinical profile of hand eczema in hospital employees, to perform patch test in relevant cases and to find out the most common sensitizers in them. Materials and Methods: This was a cross-sectional, hospital-based study in which the staff was screened for features of hand eczema and patch testing was done in the suspected cases of allergic contact dermatitis. Results: Out of 340 employees screened, 46 employees (13.5%) suffered from hand eczema. The most common type was wear and tear dermatitis accounting for 17 (36.9%) cases, followed by discoid eczema, pompholyx, focal palmar peeling, finger-tip eczema, hyperkeratotic eczema, ring eczema, and unspecified types. Patch testing was positive in 15 (32.6%) cases. The most common allergen was paraphenylene diamine, followed by fragrance mix, nitrofurazone, mercaptobenzothiazole, potassium bichromate, black rubber mix, and thiuram mix. A statistically significant association (0.001) was found with an underlying history of atopy. Conclusion: Hand eczema is a commonly encountered dermatological complaint in many hospital employees. Proper counseling, work, up, patch testing, and treatment can mitigate the symptoms in such employees.

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Hidradenitis suppurativa is a chronic relapsing disease with multiple abscesses, nodules, and scars in the apocrine bearing areas. Dowling-Degos is a rare autosomal dominant genodermatosis characterized by multiple hyperpigmented macules or papules in reticulate pattern, affecting mainly the flexures. We report a case of coexisting hidradenitis suppurativa and Dowling-Degos disease in a 31-year-old male in whom PSENEN mutation analysis revealed a splice site mutation c.62-1G>T.

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Background: There is a huge spectrum of skin tumors which can be confused clinically with malignancies, particularly when they are pigmented or inflamed, and histopathological examination of a biopsy specimen is required to establish a definitive diagnosis and to facilitate appropriate intervention and follow up. Aim: To evaluate all skin tumors and categorize them according to their origin. Methods: The present study was conducted over a period of 4 years (July 1, 2013 to June 31, 2017) comprising of 1.5 years prospective and 2.5 years retrospective analysis in the departments of Dermatology and Pathology, at a tertiary hospital in North India. All specimens of skin tumors were analyzed grossly and microscopically. Immunohistochemistry was done wherever possible. Results: A total of 232 skin tumors were seen; of which 123 cases were benign (53.0%) and 109 cases were malignant (47.0%). The mean age of patients with benign and malignant skin tumors was 40.3 ± 19.9 and 60.8 ± 14.8 years, respectively. The most common site was face (n = 106; 45.7%) followed by limbs (n = 44; 19.0%). The male:female ratio of benign and malignant tumors was 1.01:1 and 1.31:1, respectively. Among the benign tumors, keratinocytic tumors were the commonest (n = 57; 46.3%) followed by the melanocytic tumors (n = 37; 30.1%) and appendageal tumors (n = 29; 23.6%). The most common malignant skin tumors were the keratinocytic tumors (n = 87; 79.8%) followed by 12 cases (11%) of hematolymphoid tumors and five cases (4.6%) each of melanocytic and appendageal tumors. Limitations: The lack of clinical and dermatoscopic correlation and inclusion of retrospective data are the limitations of this study. Conclusions: Skin tumors affect people of all ages. The benign tumors are seen in the younger age group as compared to malignant tumors. Face is the most common site and keratinocytic tumors are the most common skin tumors in both benign and malignant categories.

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Background: Psoriasis is a chronic inflammatory dermatosis associated with psychological morbidity. Very few studies have evaluated stigma among caregivers of patients with psoriasis. Objective: This study aimed to evaluate the prevalence of stigma and its correlates among the caregivers of patients with psoriasis. Methodology: Forty-nine caregivers of patients with psoriasis were evaluated on psoriasis adapted version of caregiver of people with mental illness (CPMI) to assess internalized stigma, Explanatory Model Interview Catalogue Stigma Scale, Family Burden Inventory (FBI), Multidimensional aspect of perceived social support scale (PSS), Cognitive behavioral avoidance scale (CBAS), and Coping checklist. Results: Majority of the caregivers were either spouse (42.8%) or parents (36.7%) of the patients. The caregivers were involved in the care of the patients for a mean duration of 6.5(SD; 4.8) years. On CPMI, the mean score was highest for the affective domain (3.1), this was followed by affective (2.9), and behavioral (2.9) domain. Very few (12.2%) caregivers reported significantly high caregiver burden. A higher level of stigma was associated with more often use of avoidance coping. Presence of higher social support was associated with higher level of stigma as assessed by using CPMI. A higher level of caregiver burden in all the domains of FBI was associated with higher level of stigma. Conclusion: Stigma is highly prevalent among the caregivers of patients with psoriasis. These findings suggest that there is an urgent need to identify the stigma and address the same.

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Cutaneous malignant melanoma is a rapidly progressing skin tumor accounting for most deaths from skin malignancies. Four morphological variants (nodular, superficial spreading, lentigo maligna, and acral lentiginous) are described in the literature. Here we are reporting malignant melanoma in a 35-year-old male who presented with depigmented plaques with few hyperpigmented areas and extensive overlying scaling. The patient progressed to the nodular stage within 2 weeks and succumbed to death during chemotherapy. We are reporting such rare presentation of malignant melanoma to create awareness among dermatologists to avoid misdiagnosis and delayed treatment which can lead to rapid progression and fatal outcome.

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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 shows correlation with the DIF and can be used as a first line-screening tool in the diagnosis of AIBD.

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