Rosacea is a relatively common inflammatory dermatosis in persons with fair skin. It is uncommonly reported in people with skin of color (darker skin tone; Fitzpatrick skin types IV, V or VI). Apart from reduced incidence, underreporting due to decreased awareness might also be a probable explanation. Rosacea commonly presents with telangiectasias and persistent facial erythema on the sun-exposed parts, which can be distressing to the patient and affect the quality of life. The diagnosis is made clinically, in the absence of any confirmatory investigation. Several treatment modalities have been employed to date with varying results. Light-based therapies should be used cautiously in the colored skin to avoid distressing pigmentation. This article focuses on the pathogenesis, clinical features, treatment recommendations and other aspects of this uncommon disorder along with a review of the literature.

Humans have been anointing their skin with natural colorants since antiquity. Before the advent of modern cosmetics, tattoos and hair dyes, the spectacular colors in plants served as a palette for humanity's fascination with color. Skin, hair, nails, teeth and clothing have been altered with botanical colorants for centuries. Understanding the relevance of botanical colorants is an important part of cultural competency. Substitution or adulteration of plant colorants with synthetic colorants has played a role in varied dermatoses (eg. black henna, kumkum, and Holi dermatoses). Safety concerns over synthetic colorants have led to a resurgence of natural colorants. However, some plant colorants have produced adverse reactions. Plant colorants have also played an integral role in medicine. Ingested plant colorants are an indispensable part of our diet, playing crucial roles in the maintenance of health and prevention of disease. Excessive intake of some pigments can alter skin color (carotenoderma, lycopenemia, and the golden tan of canthaxanthin). We have relied on the colors of hematoxylin and alizarin red, derived from the logwood tree and madder roots, respectively, to study and diagnose disease in pathology. We briefly review the uses, cultural relevance, and adverse effects of the common botanical colorants on the skin, hair, and mucosa. We also describe their relevance in our diet, and in the diagnosis and description of dermatological diseases.

Background: Autologous serum therapy aims to supplement the existing pharmacotherapy in chronic urticaria by decreasing the antihistamine pill-burden and maintaining symptom-free interval. Subcutaneous autologous serum therapy further modifies the amount of serum (2 mL to 1 mL) and gauge of a needle (24G to 31G) to improve compliance and facilitate ease of application. Objectives: To assess clinical effectiveness and safety of subcutaneous autologous serum therapy versus conventional intramuscular autologous serum therapy and to compare the quality of life in the two treatment arms. Methods: Institution-based, assessor-blind, prospective, randomized, parallel-group, active-controlled trial with 32 patients in each treatment arm and analyzed on a modified intention to treat principle. After baseline autologous serum skin test, autologous serum was injected as per randomization every week for 9 consecutive weeks. Results: Among the study population, conventional intramuscular autologous serum therapy and subcutaneous autologous serum therapy had a comparable duration of disease (P = 0.164, Mann-Whitney U test), autoreactive status (P = 0.796), urticaria total severity score (P = 0.637) and urticaria activity score summed up over 7 days (P = 0.982). Both urticaria activity score summed up over 7 days and total severity score along with antihistamine pill-burden reduced significantly (P < 0.001, Friedman's analysis of variance) in both subcutaneous autologous serum therapy and conventional intramuscular autologous serum therapy from first follow-up onwards (P < 0.05, Post hoc Dunn's test). Significant improvement was noted in patient's as well as physician's global assessment of disease activity improvement scale (P < 0.001, Friedman's analysis of variance). Intergroup analysis showed that there was no significant difference in urticaria activity score summed up over 7 days either at baseline (P = 0.982, Mann-Whitney U test) or at study end (P = 0.398, Mann-Whitney U test). Similar comparable results were found in the total severity score at the end of the study (P = 0.345, Mann-Whitney U test). Dermatology life quality index showed marked improvement with both types of treatment (P < 0.0001, Wilcoxon test), and the intergroup comparison showed comparable dermatology life quality index values (P = 0.994, Mann-Whitney U test). The pain score at the injection site was more with conventional intramuscular autologous serum therapy than subcutaneous autologous serum therapy (P = 0.0115, Mann-Whitney test). Younger age and lower baseline total severity scores were associated with a better therapeutic response. Baseline urticaria activity score added up over a period of 7 days and total severity scores and the diameter of lesions showed a positive correlation with response pattern. Limitation: Basophil histamine release assay not done. Logistics could not support follow-up beyond the end of treatment. Conclusion: Subcutaneous autologous serum therapy is not inferior to conventional intramuscular autologous serum therapy with the additional advantage of less pain and operational feasibility.

Background: Alopecia areata is a disease of uncertain, probably autoimmune etiology. The role of growth factors like platelet-derived growth factor and C-kit (CD117) in alopecia areata is unknown. Aims: To compare the expression of CD117 and platelet-derived growth factor receptor α in tissue samples of alopecia areata and normal controls. Methods: Thirty biopsy samples of alopecia areata and eighteen normal control samples were included in this cross-sectional study. Immunohistochemistry was done to detect the expression of CD117 and platelet-derived growth factor receptor α in cases and controls. The mean percentage of follicles expressing CD117 and platelet-derived growth factor receptor α was compared among cases and controls. Results: The mean number of follicles expressing CD117 in anagen and catagen hairs differed significantly among cases and controls. The extent and intensity of staining with platelet-derived growth factor receptor α correlated significantly with the severity of alopecia areata based on the severity of alopecia tool score. Limitations: Confirmation of the expression pattern of molecules observed in immunohistochemistry with western blot or polymerase chain reaction would have strengthened the report. Conclusions: The expression of CD117 varied in cases and controls. The expression of platelet-derived growth factor receptor α correlated with the severity of the disease. This could explain how platelet-rich plasma works in the treatment of alopecia areata. Further studies are required to explore the role of these molecules in autoimmune pathogenesis.

Background: Many international guidelines on psoriasis management have emphasized upon the need to identify risk factors for liver fibrosis and that the risk may be increased after a certain total cumulative dose of methotrexate. Methods: Consecutive patients with moderate-to-severe psoriasis were assessed for liver fibrosis using transient elastography and noninvasive scores. Based on the presence of significant liver fibrosis, the Odds ratio associated with various factors was calculated using logistic regression analysis. Receiver operating characteristic curves were calculated to find maximal cutoff values of noninvasive tests to detect fibrosis. Results: In this cross-sectional study, 134 patients completed the study. Significant fibrosis (liver stiffness measurement ≥7, corresponding to F2 fibrosis or higher) was seen in 33 (24.6%) patients. Neither methotrexate exposure nor total cumulative dose of ≥1.5 was associated with significant fibrosis. Female sex (P = 0.024) and the presence of metabolic syndrome (P = 0.034) were the two variables associated with significant liver fibrosis. On logistic regression analysis, the odds ratio for the female gender and metabolic syndrome was estimated to be 2.51 (95% confidence interval - 1.09–5.81) and 2.33 (95% confidence interval - 1.03–5.27), respectively. Aspartate transaminase to platelet ratio index, nonalcoholic fatty liver disease score and the fibrosis-4 index had low sensitivity in comparison to transient elastography. Limitations: These included small sample size, small number of patients with a total cumulative methotrexate dose of >3–4.5 g, and lack of control group consisting of healthy persons. Another is the absence of liver biopsies considered as the gold standard in the diagnosis of liver fibrosis. Conclusions: Metabolic syndrome and female sex are associated with the development of significant liver fibrosis in patients with psoriasis. Methotrexate exposure does not seem to be significantly associated with significant liver fibrosis.

Background: Segmental vitiligo has a different clinical course and prognosis as compared to nonsegmental vitiligo, which necessitates its correct diagnosis. It may be difficult to distinguish segmental vitiligo from the limited or focal types of nonsegmental vitiligo. Objective: To validate the previously proposed diagnostic criteria for segmental vitiligo. Methods: This was a cross-sectional validation study involving patients with limited vitiligo. The diagnostic criteria were used to classify vitiligo lesions as segmental or nonsegmental, and was compared with the experts' diagnosis, which was considered as the “gold standard”. Results: The study included 200 patients with 225 vitiligo lesions. As per the diagnostic criteria, 146 vitiligo lesions were classified as segmental and 79 as nonsegmental. The experts classified 147 vitiligo lesions as segmental and 39 as nonsegmental, while the diagnosis either was labeled “unsure” or could not be agreed upon for 39 lesions. As compared with the experts' opinions (“for sure” cases, n = 186), the sensitivity and specificity of the diagnostic criteria was 91.8% (95% confidence interval [CI]: 86.2%–95.7%) and 100% (95% CI: 91%–100%), respectively. The positive predictive value was 100% (95% CI: 97.3–100%), while the negative predictive value was 76.5% (95% CI: 62.5%–87.2%). There was a 93.5% agreement between the clinical criteria and experts' opinions (k = 0.83, P < 0.001). Limitation: The diagnostic criteria were compared with the experts' opinion in the absence of an established diagnostic “gold standard”. Conclusions: The proposed diagnostic criteria for segmental vitiligo performed well, and can be used in clinical practice, as well as in research settings.

Background: The high incidence, chronicity, frequent recurrences and severity of hand eczema leads to a massive impact on the quality of life. Despite great medical and socioeconomic importance, there is a paucity of data that addresses the cost of illness and economic factors associated with hand eczema. Most of the studies have originated from Europe and none have been reported from India. Aim: To analyze the clinical subtype, the pattern of contact sensitization and the impact of severity of disease on the quality of life and cost of illness in patients of hand eczema. Methods: Hundred patients of hand eczema were recruited and evaluated for morphological patterns of the condition, hand eczema severity index and quality of life (Dermatology Life Quality Index questionnaire). All patients were subjected to patch tests with Indian standard series, cosmetic series and personal or work-related products. The economic burden of hand eczema was measured by both its direct and indirect costs. Results: Morphologically, chronic dry fissured eczema 36 (36%) was the most common pattern followed by mixed type 19 (19%), hyperkeratotic palmar eczema 15 (15%), vesicular eczema with recurrent eruption 9 (9%), nummular eczema 7 (7%) and wear and tear dermatitis 7 (7%). Seventy nine patients gave positive patch test results. Etiological profile of the most common allergens, as established with a patch test, include potassium dichromate 18 (18%) followed by cetrimonium bromide 17 (17%), nickel 16 (16%), gallate 14 (14%), garlic 9 (9%) and patient's own product 8 (8%). Allergic contact dermatitis was the most common clinical pattern of hand eczema seen in 45 (45%) patients, followed by an irritant 14 (14%) and a combination of both 13 (13%). The average total cost of illness was INR 13,783.41 (0–93,000) per individual per year with an average direct cost of INR 2,746.25 ± 1,900 and indirect cost of INR 4911.73 ± 13237.72, along with a positive correlation with the Dermatology Life Quality Index (P = 0.00). The hand eczema severity index was marginally correlated with direct costs (P = 0.07) and highly correlated with indirect costs (P = 0.024). Conclusion: Hand eczema has a huge impact on the quality of life and economic consequences. Limitations: In our study, parameters like Dermatology Life Quality Index and hand eczema severity index could have been affected by the chronicity of disease as being a tertiary referral centre, most of the recruited patients had severe and persistent hand eczema at the time of visit. Also, cost of illness was based on retrospective calculations on recall basis.

A 19-year-old man with granulomatosis with polyangiitis (Wegener's disease) presented with hemorrhagic facial nodules mimicking severe inflammatory acne (acne fulminans) as one of the first symptoms of the disease. The lesions were earlier treated as nodulocystic acne with isotretinoin without any benefit. Complete resolution was seen with pulsed methylprednisolone and oral prednisolone and mycophenolate mofetil thereafter. He also developed acute onset of severe pustular eruption of the face and a destructive ulcer of the auricle on two separate occasions. Facial lesions mimicking severe inflammatory acne, not responsive to standard treatment, may be a marker for more severe systemic disease such as Wegener's disease/granulomatosis with polyangiitis.

Background: Approximately 18% of infantile hemangiomas are segmental. These are larger than other infantile hemangiomas, associated with higher rate of complications and developmental anomalies, and often require treatment. They follow nonrandom patterns on the head and neck as well as extremities which are probably related to embryologic development. Aims: Our study aimed to describe segmental patterns of infantile hemangiomas in Indian children, with associated anatomical abnormalities if any. Methods: Over a 9-year period, 59 infants presenting with lesions classified as segmental infantile hemangiomas were evaluated and analyzed. Associated developmental anomalies were assessed and recorded. In addition, patterns of “indeterminate” infantile hemangiomas in another 43 patients were analyzed. Results: There were 14 male and 45 female infants with an average birth weight of 2.7 ± 0.726 kg in our study; the average age at onset was 1 ± 1.25 months with most (50.8%) lesions localized to the head and neck area. Mapping of lesions showed that the most common facial segments involved were mandibular (33%) and maxillary (30%). However, additional repetitive patterns not previously described (such as an “inverted comma” pattern on the chest, bilateral neck involvement and unilateral labium involvement) were seen in our patients. Common local complications were ulceration (27%), amblyopia and nasal obstruction (3% each). Mapping of the additional 43 patients with indeterminate infantile hemangiomas also showed repetitive though incomplete patterns. Limitations: Relatively small number of patients. Conclusion: Segmental infantile hemangiomas present as large, distinctively patterned lesions, even on the trunk and genitalia. These patterns are probably based on embryologic developmental patterns. In addition, indeterminate lesions also showed distinctive repetitive patterns. Our study suggests that additional segments may need to be defined, particularly on the trunk and genital area.

Background: The biophysical and ultrasonographic properties of the skin change in papulosquamous diseases. Aims: To identify biophysical and ultrasonographic properties for the differentiation of five main groups of papulosquamous skin diseases. Methods: Fifteen biophysical and ultrasonographic parameters were measured by multiprobe adapter system and high-frequency ultrasonography in active lesions and normal control skin in patients with chronic eczema, psoriasis, lichen planus, pityriasis rosea and parapsoriasis/mycosis fungoides. Using histological diagnosis as a gold standard, a decision tree analysis was performed based on the mean percentage changes of these parameters [(lesion–control/control) ×100] for differentiation of the diseases. Results: The accuracy of the decision tree model for differentiation of five diseases was 67% which developed based on changes in stratum corneum hydration, epidermal thickness, skin pH, melanin index, R0 (reciprocal of firmness) and erythema. Among the flowcharts for pairs of diseases, three models for differentiation had high accuracy (> 95%): those of psoriasis from lichen planus, pityriasis rosea, and parapsoriasis/mycosis fungoides. Limitations: Validation studies on a larger sample size in situations where the diagnosis is unclear are needed to confirm the accuracy and applicability of decision trees. Conclusion: Skin biophysical and ultrasonographic properties may help in the differentiation of papulosquamous diseases as simple and non-invasive tools.