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Background: Alopecia areata is an autoimmune disease that occurs as a result of the loss of the inherent immune privilege of the hair follicle. It has been recently demonstrated that the interferon-γ/interleukin-15 feedback loop that signals via the Janus kinase-signal transducer and activator of transcription pathway is critical to the breakdown of this immune privilege., Aims: To evaluate the immunological distribution of CD4+ T-cells, CD8+ T-cells, phosphorylated signal transducer and activator of transcription 1 and study its relation with the clinical and histopathological findings of the disease., Materials and Methods: A total of 30 patients of alopecia areata were included in the study. Following a detailed history and clinical examination, a scalp biopsy was performed. Histopathology was studied and immunohistochemistry was done to demonstrate the positivity and distribution of CD4+ T-cells, CD8+ T-cells and phosphorylated signal transducer and activator of transcription 1., Results: The follicular count, number of anagen and terminal hair were found to be decreased, whereas the catagen, telogen and vellus hair were found to be increased in number. A peribulbar CD4+ T-cell infiltrate was seen in 70% cases, whereas a CD8+ T-cell infiltrate was seen in 83.3% cases. An intrabulbar CD4+ T-cell infiltrate was seen in 26.7% cases, whereas a CD8+ T-cell infiltrate was seen in 70% cases. Among the 25 hair follicles dermal papilla identified, 36.8% cases were found to be positive for phospho-signal transducer and activation of transcription-1., Limitations: The drawbacks of our study included a small sample size and the use of only vertical sectioning for the scalp biopsy samples., Conclusion: Phosphorylated signal transducer and activator of transcription 1 positivity as an indicator of signalling via the Janus kinase-1/2 pathway was seen in 36.8% of our cases highlighting the integral role of this pathway in the pathogenesis of alopecia areata., Competing Interests: None

Background: Regular exposure to ultraviolet rays is high in India, where most Indians present Fitzpatrick skin phototypes IV and V., Aims: To evaluate the efficacy and compare the effectiveness of two sunscreen products on Indian skin types IV and V with pigmentation irregularities., Methods: A randomized, uncontrolled and investigator-blinded, single-center study enrolled adult men and women (18-45 years) with Fitzpatrick skin phototypes IV (28° < individual typological angle <10°) and V (10° < individual typological angle < -30°) with pigmentary abnormalities seen on the face in adults (actinic lentigines and postinflammatory hyperpigmentation), who did not use sunscreens. Participants were randomized (1:1) to either of the two marketed sunscreen products, Product A (sun protection factor 50 PA+++) or Product B (sun protection factor 19 PA+++), applied twice daily before sun exposure for ≥2 h. Primary objectives aimed at assessing possible improvement in hyperpigmented spots and overall skin appearance after 12 weeks of use. Evaluation of skin radiance and skin color was done by means of L'Oréal color chart and colorimetric measurements (Chromameter ® )., Results: Among the 230 enrolled participants, 216 (93.91%) completed the study. The clinical assessment of the density of pigmented spots and skin radiance showed significant (P < 0.001) improvement in both groups during all visits. The qualitative (participant perception) and quantitative (Chromameter ® ) data indicated improvement in pigmentation from Week 0 to Week 12. Both products were well-tolerated., Limitations: The study was conducted over a rather short period of time (12 weeks) at a single location., Conclusions: This is the first study conducted on Indian skin phototypes IV and V under real-life conditions. It demonstrated the effect of regular sunscreen usage in the prevention of certain signs of skin photoaging such as increased pigmentation or pigmentary abnormalities, thus providing support and assistance to clinicians in suggesting the use of efficient sun-screening products to patients., Competing Interests: None

Background: Accurate preparation of recipient area is a critical step in melanocyte-keratinocyte transplantation procedure for vitiligo. It is an important potential step for adaptation in the quest to achieve better results and ablative lasers potentially offer excellent precision over margin and depth control in achieving that., Objective: To compare between the two techniques used for recipient site preparation: Er:YAG laser ablation and mechanical dermabrasion for melanocyte-keratinocyte transplantation procedure in terms of re-pigmentation achieved and adverse effects seen., Methods: A randomized comparative trial was performed among 32 patients of stable vitiligo undergoing melanocyte-keratinocyte transplantation procedure. In Group A (n = 15), recipient site preparation was done with Er:YAG laser, and in Group B (n = 17), it was done with a motorized dermabrader. Patients of both groups were objectively assessed for re-pigmentation at 1, 3 and 6 months., Results: A total of 253.696 cm 2 of depigmented surface was operated upon and re-pigmentation of 125.359 cm 2 (49.4%) was achieved. On comparison between two groups, no statistical difference was found with respect to total re-pigmentation achieved (Group A: 54.67% vs Group B: 48.841%, P = 0.663) and grades of re-pigmentation achieved (P = 0.796). Occurrence of adverse events was also statistically similar in both the groups., Conclusion: This study did not reveal any statistically different outcome (in terms of re-pigmentation and adverse effects) between the two methods of recipient site preparation - motorized dermabrasion and Er:YAG ablation., Limitations: This study is small and larger studies are needed to ascertain the benefit of Er:YAG for recipient site preparation. Future studies may also ascertain variables such as time taken to prepare the recipient area, nature of bleeding, postoperative healing, difficulties in specific area, cost of the procedure, patient comfort and ease of the surgeon, rather than comparing the re-pigmentation alone., Competing Interests: None

Acitretin, a synthetic retinoid has gradually replaced etretinate in today's dermatologic practice because of its more favorable pharmacokinetics. Acitretin over the past 20 years has proven useful in a number of difficult-to-treat hyperkeratotic and inflammatory dermatoses and nonmelanoma skin cancers. It is effective both as monotherapy and in combination with other drugs for hyperkeratotic disorders. It is considered to be an established second line treatment for psoriasis and exerts its effect mainly due to its antikeratinizing, antiinflammatory, and antiproliferative effect. Its antineoplastic properties make it a useful agent for cancer prophylaxis. Evidence-based efficacy, side-effect profile, and approach to the use of acitretin would be discussed in this review. In addition to its approved uses, the various off label uses will also be highlighted in this section. Since its use is limited by its teratogenic potential and other adverse effects, including mucocutaneous effects and hepatotoxicity, this review would summarize the contraindications and precautions to be exercised before prescribing acitretin.

Paget's disease of the breast is an uncommon form of breast cancer presenting as an eczematous eruption over the nipple and/or areola. The diagnosis remains elusive with varied presentations, mimicking many benign skin diseases, the awareness of which is indispensable for diagnosis and minimizing morbidity. Most of the cases have an associated malignancy of the underlying breast tissue. There have been very few reports wherein the disease has occurred independent of any underlying malignancy. Since, the initial presentation is limited to skin; it is the dermatologist who plays a key role in making a diagnosis, thus, facilitating proper management. We report a rare presentation of mammary Paget's disease with a wide cutaneous spread probably attributed to a significantly delayed diagnosis without any associated underlying malignancy.

Melasma is one of the most common and distressing pigmentary disorders presenting to dermatology clinics. The precise cause of melasma remains unknown; however, there are many possible contributing factors. It is notably difficult to treat and has a tendency to relapse. The existing and most tried topical therapy is hydroquinone and the triple combination with tretinoin and corticosteroids, which is considered the gold standard for melasma. Besides that, azelaic acid, kojic acid, arbutin, ascorbic acid, glycolic acid and salicylic peels have also been tried with limited success. However, multiple novel topical agents are being investigated for their potential as hypopigmenting agents with unique mode of action. But, further trials are required to study their efficacy and safety before they can be further recommended. The article highlights these newer formulations and also briefly mentions about the newer chemical peels and the much hyped lasers in treating this difficult and frustrating condition.

Fever with rash is common among children and are seen by both dermatologists and pediatricians. Most of them are benign viral exanthems without much clinical significance. This article gives an overview of the infectious and noninfectious causes of fever with rash in children and how to diagnose them, with special emphasis on the Indian scenario as well. It also differentiates them from fever with rash caused by drugs. This review emphasizes that although benign in many cases, it is necessary to identify the signs of serious illnesses to prevent mortality or sequelae.

Punctate palmoplantar keratoderma (Brauer-Buschke-Fischer syndrome) is a rare entity. Among punctate keratoderma, the linear presentation is much rarer, and exact incidence is not known. Unilateral linear punctate palmoplantar keratoderma is not yet reported in the literature. Here we report a case 12-year-old child presented with asymptomatic linear punctate plaque on the left sole and hand; histology revealed hyperkeratotic epidermis without columns of parakeratosis or cornoid lamella.

We report a case of a 58-year-old female patient who presented with multiple, asymptomatic, slowly-growing, raised pigmented lesions all over her body for the past 10 years with ulceration in one of the lesions on the trunk for the past five months. Histopathology of the lesion revealed features consistent with melanoacanthoma. Here, we report the first case of cutaneous melanoacanthoma presenting with an ulcerated plaque and the third case of cutaneous melanoacanthoma with multiple lesions. To the best of our knowledge, ulceration has not yet been reported as a feature of cutaneous melanoacanthoma in the medical literature.

Epidermolysis bullosa, a genetically determined skin fragility disorder can severely incapacitate the life of the afflicted patient. Although the clinical features are multiple and varied, treatment still remains a major challenge. There have been major changes in the classification of the disease recently. Although there is still a long way to go, good nursing care, and gene therapy could possibly significantly alleviate the suffering of the patients in the future.

Mesotherapy is a controversial cosmetic procedure which has received publicity among the lay people, in the internet and in the media. It refers to minimally invasive techniques which consist of the use of intra- or subcutaneous injections containing liquid mixture of compounds (pharmaceutical and homeopathic medications, plant extracts, vitamins and other ingredients) to treat local medical and cosmetic conditions. This position paper has examined the available evidence and finds that acceptable scientific evidence for its effectiveness and safety is lacking. IADVL taskforce, therefore would like to state that the use of this technique remains controversial at present. Further research and well-designed controlled scientific studies are required to substantiate the claims of benefit of this mode of therapy.

Although erythroderma is a well-recognized entity in the adult age groups and has been studied by various authors, there is a paucity of studies on erythroderma in the pediatric age group. It poses a greater challenge to the dermatologist and pediatrician because of its potential life threatening nature. In a study conducted by us in a large Indian hospital to delineate the causes of neonatal and infantile erythroderma, the causes identified were infections (40%), ichthyosiform erythroderma (25%), atopic dermatitis (15%), infantile seborrheic dermatitis (10%) and unidentified (10%). In another study of childhood erythroderma, etiologically, drugs (29%) showed the highest incidence, followed equally (18%) by genodermatoses, psoriasis and staphylococcal scalded skin syndrome (SSSS). The management of childhood erythroderma is mainly supportive with correction of the hematologic, biochemical and metabolic imbalance if required. In this review, the causes of childhood erythroderma, the clinical features useful to the diagnosis and management are discussed.

Low-dose isotretinoin (0.5 mg/kg/day) is a mode of therapy for mild to moderate grades of acne. We analyzed the various trials of this mode of therapy with or without combination with topical agents. We also statistically analyzed the results, efficacy and relapse rates of standard therapy in comparison with the low-dose therapy. Our analysis of the data revealed that the efficacy and relapse rates of low-dose isotretinoin in mild to moderate grades of acne is comparable with the standard regimen (1 mg/kg/day), which is given in the severe grade of acne vulgaris. Thus, the grade of acne vulgaris should dictate the dose of administration of isotretinoin and the standard dose of 1 mg/kg/day is an unnecessary overtreatment for mild to moderate grades of acne.

The pathogenesis of systemic sclerosis (SSc) is complex, and the final story is yet to be elucidated. The clinical heterogeneity of the disease, its various autoimmune and antibody profiles, its long course and tendency for spontaneous cure makes the design of clinical trials difficult. The overwhelming need in this disease is to diagnose it early and identify those patients who will benefit most from early, aggressive treatment. We attempt to review data from recent clinical trials and the lessons derived.

The clinico-histopathological features of 75 patients of lichen planus were studied. The male to female ratio was 1:13. The largest number of patients (30.6%) fell into the 31-40 year age group. Two patients had systemic hypertension. There was no history of lichen planus in the family. All patients presented with severe itching within 1-2 months of onset. Papular lesions were seen in 72% and papules with plaques were seen 16%. Lower limbs were involved in 38% of cases. Mucosal involvement was seen in 24% in addition to skin involvement ; nail involvement hypertrophicus (17.3%). Lichen planopilaris and oral lichen planus were uncommon. Clinico-histopathological discrepancies were observed in 7 patients. Civatte bodies were seen in only 37% of cases.