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.

Head louse infestation, or pediculosis capitis, caused by Pediculus humanus var. capitis, is a common health concern in pediatric age group. An itching of the scalp is the chief symptom, whereas presence of viable nits confirms the diagnosis of head louse infestation. Secondary bacterial infection with impetignization with cervical and occipital lymphadenopathy can complicate the clinical scenario with physician misdiagnosing pediculosis to a primary bacterial infection. Screening and treatment of all close contacts is necessary for an adequate management of pediculosis. Medical management of head louse infestation requires proper application of topical pediculicidal agents', chiefly permethrin lotion and wet combing with a fine toothcomb. Severe cases with high parasitic load justify the use of either oral cotrimoxazole or Ivermectin. Other described technique involves a single application of hot air for 30 minutes. Radical but culturally unacceptable method would be shaving of scalp in resistant cases. Environmental fogging with insecticides is neither necessary nor recommended.

Background: Transverse nasal groove is a condition of cosmetic concern which awaits due recognition and has been widely described as a shallow groove that extends transversely over the dorsum of nose. However, we observed variations in the clinical presentations of this entity, hitherto undescribed in literature. Aims: We conducted a clinicoepidemiological study of transverse nasal lesions in patients attending our outpatient department. Methods: We conducted a prospective observational study. We screened all patients attending our out-patient department for presence of transverse nasal lesions, signs of any dermatosis and associated other skin conditions. Results: One hundred patients were recruited in the study. Females (80%) predominated over males. Most patients were of 15-45 years age group (70%). Majority of the transverse nasal lesions were classical transverse nasal groove (39%) and others included transverse nasal line (28%), strip (28%), ridge (4%) and loop (1%). Seborrhoeic diathesis was the most common condition associated with transverse nasal lesion. Conclusions: Occurrence of transverse nasal line, strip, ridge and loop, in addition to classical transverse nasal groove implies that latter is actually a subset of transverse nasal lesions. Common association of this entity with seborrheic dermatitis, seborrhea and dandruff raises a possibility of whether transverse nasal lesion is a manifestation of seborrheic diathesis.

Background: Chlamydia trachomatis is the most common bacterial etiology of sexually transmitted infection. Aim : A pilot study was designed using PCR for amplification and detection of a specific 517 bp sequence of the common endogenous plasmid of C. trachomatis from clinical swab specimens obtained from symptomatic female patients attending STD clinics of AIIMS and Regional STD Teaching, Training & Research Center, Safdarjang Hospital, New Delhi. Methods: 97 patients were recruited in the study, and endocervical swabs were collected following standard procedures. The samples were analyzed by PCR and direct fluorescence antibody (DFA) for detection of C. trachomatis, and the sensitivity, specificity, PPV and NPV of PCR were calculated taking DFA as gold standard. Results: Out of 97 samples tested, 9 were positive for C. trachomatis by PCR. 1 PCR positive patient was negative by DFA although a total of 11 patients were positive by DFA. The sensitivity, specificity, PPV and NPV of PCR with reference to DFA was 72.73%, 98.84%, 88.89% and 96.59%, respectively. This PCR had high specificity and NPV for detection of C.trachomatis. Conclusions : In light of the introduction of enhanced syndromic approach, which involves the use of laboratory techniques (wherever possible) to confirm clinical diagnosis, a diagnostic PCR with high specificity and NPV is particularly valuable for determination of etiological diagnosis and hence contribute to judicious use of antimicrobials in the community.

Background: Organ transplant recipients (OTR) are at high risk of developing cutaneous neoplasms. Topical photodynamic therapy (PDT) has been used for the treatment of actinic keratosis (AK) in OTR. Aims: The objective was to evaluate the efficacy of PDT with methylaminolevulinate (MAL) in the treatment of facial AK in OTR. As a secondary objective, we wanted to evaluate the usefulness of topical PDT in the reduction of photodamage in OTR. Methods: A prospective, single center, single arm study was made. 16 OTR were included. Topical PDT was applied for 1 or 2 cycles depending on the patient's characteristics. An evaluation of AK was made at visits pre-treatment, at 12 weeks and at 24 weeks. Photodamage was measured with multispectral image technique (SkinCare^®). Results: A complete response rate of 100% was achieved for AK in all patients; it persisted without change at 12 and 24 weeks of follow-up. 62.5% of patients improved their photodamage as measured by SkinCare^®, but this result was not statistically significant (P = 0.12). All patients had high level of satisfaction at the end of the therapy. Conclusions: MAL-PDT is an effective therapy for the treatment of AK in OTRs. It can reduce photodamage in this group of patients, but these results were not statistically significant.

Background: Acne is a common problem in adolescent children and has a considerable impact on their quality of life. Aims: The purpose of this study was to assess health-related quality of life (HRQoL) among Serbian adolescents with acne, using 2 questionnaires: The Children's Dermatology Life Quality Index (CDLQI) and the Cardiff Acne Disability Index (CADI) and to provide a cross validation of 2 scales. Methods: This cross-sectional study was conducted among the pupils of the secondary railway-technical school in Belgrade, Serbia. 478 pupils (aged 15 - 18 years) completed 2 HRQoL questionnaires: CDLQI and CADI. We used t-test for differences between mean values of CDLQI and CADI and Spearman's rho coefficient for correlation between 2 questionnaires. Results: Self-reported acne was present in 71.6% of pupils (64.3% boys and 35.7% girls). The overall mean CDLQI score (4.35 of max. 30) and the overall mean CADI score (3.57 of max. 15) were low, indicating a mild impairment of HRQoL among adolescants. There was good correlation between the 2 questionnaires (Spearman' rho = 0.66). Conclusion: The CADI and the CDLQI questionnaires represent simple and reliable instruments for the assesment of HRQoL among schoolchildren with acne. In this study, we identified 17% of boys and 18% of girls perceived their acne as a major problem. It is important to detect and treat such adolescents on time to reduce the psychosocial burden associated with acne.

Background: Acne vulgaris is a very common skin disease with a significant detrimental effect on the quality of life of the patients. Aims: To assess the comparative efficacy and safety of a nano-emulsion gel formulation of adapalene and clindamycin combination with its conventional formulation in the treatment of acne vulgaris of the face. It was a prospective, randomized, open label, active-controlled, multicentric, clinical trial. Methods: Eligible patients suffering from acne vulgaris of the face were randomized to receive once-daily treatment with a nano-emulsion gel or conventional gel formulation of adapalene 0.1% and clindamycin (as phosphate) 1% combination for 12 weeks. Total, inflammatory and noninflammatory lesion counts, with grading of acne severity were carried out on a monthly basis. Safety assessments were done to determine the comparative local and systemic tolerability. Two-tailed significance testing was carried out with appropriate statistical tests, and P-values < 0.05 were considered as significant. Results: 209/212 patients enrolled in the study were eligible for efficacy and safety assessments in both nano-emulsion gel (118/119 patients) and conventional gel (91/93 patients) groups. Significantly better reductions in total (79.7% vs. 62.7%), inflammatory (88.7% vs. 71.4%) and noninflammatory (74.9% vs. 58.4%) lesions were reported with the nano-emulsion gel as compared to the conventional gel (P < 0.001 for all). Mean acne severity score also reduced significantly more with the nano-emulsion formulation (1.9 ± 0.9 vs. 1.4 ± 1.0; P < 0.001) than the comparator. Significantly lower incidence and lesser intensity of adverse events like local irritation (4.2% vs. 19.8%; P < 0.05) and erythema (0.8% vs. 9.9%; P < 0.05) were recorded with the nano-emulsion gel. Conclusions: The nano-emulsion gel formulation of adapalene and clindamycin combination appears to be more efficacious and better tolerated than the conventional formulation for the treatment of acne vulgaris in Indian patients. Further studies can elucidate the comparative treatment benefits of this nano-emulsion gel formulation.

Background : Granuloma annulare (GA), a common dermatological condition of unknown etiology, affecting all ages. Involvement of the palms appears rare, posing a diagnostic challenge. This study was conducted to document various clinical and histopathological features of GA on the palms. Aims: To study clinical and histopathological variations in granuloma annulare on palms. Methods : A total 7 patients from our outpatient department with lesions of GA, exclusively on the palms, were studied over a period of 6 months from March 2011 to August 2011. Total of 8 biopsies were studied. In each patient, diagnosis was made on clinico-pathological correlation. Various clinical and histopathological features were analyzed. Results: An average age of onset was 47 years, male: female ratio was 1.33: 1, and average disease duration was 9 months. Pain was the most common symptom. Clinically, the most common presentation was pseudovesicles. Histologically, both classic palisading and interstitial pattern were seen. Perineural granulomas, perieccrine granulomas, elastophagocytosis were seen additionally. In 5 out of 7 patients, diagnosis was missed clinically. Conclusion: GA on palms poses a diagnostic challenge due to variable presentations. Histopathology is of vital importance for correct diagnosis and treatment. GA should be considered in differential diagnosis of papular lesions on palms.

Mucous membrane pemphigoid (MMP) is a chronic, recurrent, progressive, subepidermal blistering disorder, mainly affecting the mucous membranes. Anti-laminin 332 MMP is a distinct subset of MMP with antibodies, mainly targeted against α3 or γ2 subunit. Antibodies exclusively against β3 subunit are rarely seen. An internal malignancy is frequently associated with anti-laminin 332 MMP. This disorder usually responds poorly to treatment, requiring multidisciplinary approach. Herein, we describe the first case of anti-laminin-332 MMP from India, which showed antibodies exclusively to β3 subunit.

Epidermal nevus syndrome (ENS) is a rare disease, the pathogenesis of which is largely elusive. We, hereby, report an exclusive case of a 20-year-old man with verrucous ENS presented with dark colored papules and plaques along the Blaschko's lines present over the head and neck area along with fleshy growth in both eyes since birth. Limb length discrepancy and kyphoscoliosis were remarkable. Skin biopsy was compatible with verrucous epidermal nevus while the biopsy of the ocular lesion confirmed complex choristoma. MRI brain revealed calcification in the right temporal lobe. Bilateral arachnoid cyst in the middle cranial fossa, scleral osteoma in the posterior part of the right eyeball, and deformed calvarium were evident on CECT skull and orbit. The present illustration emphasizes the importance of a punctilious work up of the case.

Pilomatricoma is an uncommon hamartomatous tumor of the hair matrix. Bullous and anetodermic changes over pilomatricoma are rare. We report an 18-year-old male with an asymptomatic nodule with overlying cystic changes on the left arm of 6-month duration with clinical and histological features of both bullous and anetodermic modifications. We also reviewed the associated literature to conclude that there is sufficient overlap in these two entities. Both variants show a bullous or pseudobullous appearance clinically and loss of elastin, sparse collagen bundles separated by intense edema, and dilated lymphatics/blood vessels in the dermis overlying the tumor mass histologically. We therefore propose that bullous, pseudoampullary, anetodermic, and lymphangiectatic forms should be considered as synonymous or transitional to the ultimate scar-like anetodermic appearance.

Background: Dermatology is a minor subject in undergraduate medical curriculum in India. The dermatology clinical postings are generally poorly attended, and the clinical acumen of an average medical graduate in this specialty is quite low. Aims: To develop and implement Computer Assisted Objective Structured Clinical Examination (CA-OSCE) as a means of end of dermatology posting evaluation. Also, to assess its effectiveness in improving the motivation, attendance and learning of undergraduate students with respect to their visual recognition skills and problem solving ability. Methods: We designed and introduced CA-OSCE as a means of end of posting assessment. The average attendance and assessment scores of students undergoing CA-OSCE were compiled and compared using 'independent t test' with the scores of previous year's students who had undergone assessment with essay type questions. Results: The average attendance and average assessment scores for the candidates undergoing CA-OSCE were found to 83.36% and 77.47%, respectively as compared to 64.09% and 52.07%, respectively for previous years' students. The difference between the two groups was found to be statistically significant. Student acceptability of the technique was also high, and their subjective feedback was encouraging. Conclusion: CA-OSCE is a useful tool for assessment of dermatology undergraduates. It has the potential to drive them to attend regularly as well as to test their higher cognitive skills of analysis and problem solving.

Background: High-frequency ultrasound is a noninvasive tool that offers characteristic markers, quantifying the cutaneous changes of the physiological senescence process. Aims: The aim was to assess the changes in skin thickness, dermal density and echogenicity, as part of the ageing process, with different age intervals. Methods : The study was performed on 160 patients, aged 40.4 ± 21.2, divided into four age categories: <20, 21-40, 41-60, 61-80. Ultrasonographic images (Dermascan device) were taken from three sites: dorsal forearm (DF), medial arm (MA), zygomatic area (ZA). We assessed the thickness of epidermis and dermis (mm), number of low, medium, high echogenicity pixels, the ratio between the echogenicity of the upper and lower dermis (LEPs/LEPi), and SLEB (subepidermal low echogenicity band). The statistical analysis was performed using SPSS 15.00. A P value <0.05 was considered significant. Results: On all examined sites, it was found that the dermal thickness increases in the 21 to 40 year interval (P<0.0001). After the 21 to 40 year interval, the number of low echogenic pixels increases significantly, especially on photoexposed sites. High-echogenic pixels follow the same pattern on all examined sites: they increase in the 21 to 40 year interval and decrease in the 3rd and 4th age category. The LEPs/LEPi ratio increases significantly with age, at all sites (P<0.05), due to an increase of hypoechogenic pixels in the upper dermis. Conclusions: High-frequency ultrasound is a noninvasive "histological" tool that can assess the cutaneous structure and age-related changes. It offers imagistic markers, comparable to the histological parameters and also characteristic ultrasonographic markers. Histology remains the gold standard for the investigation of the integumentary system.