Background: Stevens–Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening mucocutaneous adverse drug reactions with a high morbidity and mortality that require immediate medical care. The various immunomodulatory treatments include systemic corticosteroids, cyclosporine, intravenous immunoglobulin, cyclophosphamide, plasmapheresis and tumor necrosis factor-α inhibitors. Aim: The ideal therapy of Stevens–Johnson syndrome/toxic epidermal necrolysis still remains a matter of debate as there are only a limited number of studies of good quality comparing the usefulness of different specific treatments. The aim of this article is to comprehensively review the published medical literature and frame management guidelines suitable in the Indian perspective. Methods: The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) assigned the task of preparing these guidelines to its special interest group on cutaneous adverse drug reactions. The group performed a comprehensive English language literature search for management options in Stevens–Johnson syndrome/toxic epidermal necrolysis across multiple databases (PubMed, EMBASE, MEDLINE and Cochrane) for keywords (alone and in combination) and MeSH items such as “guidelines,” “Stevens–Johnson syndrome,” “toxic epidermal necrolysis,” “corticosteroids,” “intravenous immunoglobulin,” “cyclosporine” and “management.” The available evidence was evaluated using the strength of recommendation taxonomy and graded using a three-point scale. A draft of clinical recommendations was developed on the best available evidence which was also scrutinized and critically evaluated by the IADVL Academy of Dermatology. Based on the inputs received, this final consensus statement was prepared. Results: A total of 104 articles (meta-analyses, prospective and retrospective studies, reviews [including chapters in books], previous guidelines [including Indian guidelines of 2006] and case series) were critically evaluated and the evidence thus gathered was used in the preparation of these guidelines. Recommendations: This expert group recommends prompt withdrawal of the culprit drug, meticulous supportive care, and judicious and early (preferably within 72 h) initiation of moderate to high doses of oral or parenteral corticosteroids (prednisolone 1-2 mg/kg/day or equivalent), tapered rapidly within 7-10 days. Cyclosporine (3-5 mg/kg/day) for 10-14 days may also be used either alone, or in combination with corticosteroids. Owing to the systemic nature of the disease, a multidisciplinary approach in the management of these patients is helpful.

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Background: Trichoscopy is an office tool used in the diagnosis of alopecia but its utility has not been assessed. Objectives: To compare the trichoscopic characteristics of different types of alopecia, identify features of diagnostic value, and to determine the utility of trichoscopy in the diagnosis of alopecia. Methods: A descriptive cross-sectional study was performed in patients with alopecia. After clinical assessment and relevant investigations, trichoscopy was performed using a non-polarized trichoscope (×10). The utility of trichoscopy in difficult cases of alopecia was assessed statistically. Results: One hundred and twenty patients of alopecia (90 non-cicatricial, 30 cicatricial) were recruited. The diagnosis was made on the basis of a detailed history and clinical examination, and confirmed by biopsy and relevant investigations in difficult cases. Yellow dots (63.3%) were the most common trichoscopic feature followed by thin hair (40.8%). Among the 21 difficult cases of alopecia, trichoscopy was diagnostic in 19 (90.5%). Statistically significant features on intergroup comparison included black dots (Fischer's exact test, P< 0.001), cadaverized hair (P = 0.024), exclamation mark hair (P < 0.001) in alopecia areata; diameter diversity more than 20% (P < 0.001) and thin hair (P < 0.001) in androgenetic alopecia; broken hair of different lengths (P < 0.001), frayed hair (P < 0.001), split ends (P < 0.001) in trichotillomania; comma hair (P < 0.001) in tinea capitis and arborizing blood vessels in discoid lupus erythematosus (P = 0.012). Limitations: The small number of patients in some types of alopecia was a limiting factor. Conclusions: Trichoscopy is useful in the differential diagnosis of alopecia. Among the various trichoscopic findings, those of diagnostic value were identified.

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Anticoagulants are the cornerstone of treatment of venous thromboembolism associated with various medical conditions and surgical procedures. They act on different steps of the coagulation pathway and are broadly categorized into heparins, vitamin K antagonists, and inhibitors of thrombin and factor Xa. The classification is evolving as newer and better oral and parenteral anticoagulants are being added. Anticoagulants in dermatology are important not only for their therapeutic application in cutaneous thrombotic dermatoses such as livedoid vasculitis, purpura fulminans, superficial and deep venous thrombosis and others but also for their use in non-thrombotic dermatoses such as lichen planus, recurrent oral aphthosis, chronic urticaria and several others. Further, the use of anticoagulants for any indication is associated with various adverse effects with dermatologic manifestations including specific reactions such as warfarin-induced skin necrosis, heparin-induced thrombocytopenia and anticoagulant-associated cholesterol embolization syndrome.

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Background: Progressive macular hypomelanosis is an acquired disorder characterized by hypopigmented macules mostly on the trunk and upper extremities. Although many treatment modalities have been proposed for this condition with variable success rates, there are few reports comparing their efficacy and relapse rates. Aim: To compare the efficacy and relapse rates of different treatment modalities for progressive macular hypomelanosis. Methods: Case records of patients diagnosed with progressive macular hypomelanosis and treated in National Skin Centre for a six year period between 2008 and 2014 were reviewed. Patient demographics, distribution of hypopigmented macules, treatment efficacy and relapse rates were noted. Results: A total of 108 patients were seen for progressive macular hypomelanosis over the study period; of these, 40 opted for no treatment but were followed up. Thirty-six were treated with topical antimicrobials and 32 with phototherapy. Of those untreated, 23% recovered spontaneously while 38% in the antimicrobial group and 90% in the phototherapy had remission of their hypopigmentation. After 2 years of follow-up, relapse occurred only in the phototherapy group. Limitations: The main limitation is the retrospective design whereby diagnosis is dependent on the attending dermatologist. Conclusions: Narrow-band ultraviolet B therapy appears to be the most effective treatment for progressive macular hypomelanosis but also has the highest potential for relapse. Response rates for antimicrobial therapy are lower and slower, but patients who responded did not relapse. A combination of topical/systemic antimicrobials with narrow-band ultraviolet B therapy might be the best option to hasten recovery and minimize relapse.

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Background: Earlobe keloids are usually recalcitrant to treatment and have a high rate of recurrence. Verapamil is a calcium channel antagonist that has been shown to inhibit the synthesis/secretion of extracellular matrix molecules and increase collagenase. Objectives: This prospective study was designed to evaluate the results of treatment of recurrent earlobe keloids using keloidectomy with core fillet flap and intralesional verapamil injection. Methods: Nineteen keloids in 16 patients were treated using this technique with intralesional verapamil injection given intraoperatively, then every 2 weeks for 3 months, with postoperative follow-up for 18 months. Results: Fourteen patients completed the study. Ten patients (71.4%) showed response to treatment. Four (28.6%) cases showed recurrence, two (14.2%) at the wound bed and another two (14. 2%) at the incision line. Eighty percent of responders were highly satisfied with their treatment. Conclusion: Keloidectomy with core fillet flap and intralesional verapamil injection is a reliable and cost-effective method in the treatment of recurrent earlobe keloids with a low rate of recurrence and high patient satisfaction.

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Background: Hair dye is one of the most common causes of allergic contact dermatitis. The main allergen has been identified as para-phenylenediamine. To prevent the recurrence of contact dermatitis to para-phenylenediamine, patients should discontinue the use of para-phenylenediamine-containing hair dye products. However, many patients are unable to discontinue their use for cosmetic or social reasons. Sometimes, they continue to have symptoms even after switching to so-called “less allergenic” hair dyes. Objectives: To evaluate the safety of 15 commercially available hair dye products in patients with allergic contact dermatitis due to para-phenylenediamine. Methods: We performed patch tests using 15 hair dyes that were advertised as “hypoallergenic,” “no para-phenylenediamine” and “non-allergenic” products in the market. Results: Twenty three patients completed the study and 20 (87.0%) patients had a positive patch test reaction to at least one product. While four (26.7%) hair dye products contained para-phenylenediamine, 10 (66.7%) out of 15 contained m- aminophenol and 7 (46.7%) contained toluene-2,5-diamine sulfate. Only one product did not elicit a positive reaction in any patient. Limitations: Small sample size and possibility of false-positive reactions. Conclusions: Dermatologists should educate patients with allergic contact dermatitis to para-phenylenediamine about the importance of performing sensitivity testing prior to the actual use of any hair dye product, irrespective of how it is advertised or labelled.

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Anagen effluvium, the shedding of anagen hair, leads to diffuse non-scarring alopecia. We report two cases of anagen effluvium in the same family secondary to the ingestion of tubers of Gloriosa superba, which contains the antimitotic alkaloid colchicine. Both patients developed anagen effluvium and gastroenteritis 1–2 weeks after consuming the tubers. In addition, one of them had bicytopenia, pleural effusion, hematuria and altered liver function tests. Both were managed conservatively and counseled regarding the reversible nature of the hair loss. Follow-up at 3 months showed regrowth of hair in both the cases.

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Background: 8-oxoguanine, a major product of DNA oxidation, is considered a key parameter in measuring the carcinogenic effects of ultraviolet radiation. Objective: To assess and compare the carcinogenic potential of different photo (chemo) therapeutic modalities in photoresponsive skin diseases by measuring the levels of 8-oxoguanine in dark-skinned individuals before and after photo (chemo) therapy. Methods: A prospective, randomized controlled pilot study was conducted in 63 patients of skin types III–V with photo-responsive dermatoses including vitiligo, psoriasis and mycosis fungoides. Patients were divided into three groups; Group 1 (received narrowband ultraviolet-B), Group 2 (received psoralen plus ultraviolet-A) and Group 3 (received broadband ultraviolet-A). Biopsies were taken before and after phototherapy to measure 8-oxoguanine levels using enzyme-linked immunosorbent assay. Biopsies were also taken from the sun-protected skin in 21 controls subjects who had no dermatological disease. Results: Regardless of the disease, a significantly higher level of 8-oxoguanine was found after treatment when compared to the pre-treatment baseline levels; however, these levels were comparable to those in control subjects. A weakly significant positive correlation was found between cumulative dose and 8-oxoguanine levels following psoralen plus ultraviolet-A therapy. In controls, comparing the 8-oxoguanine levels between skin types III and IV showed significantly lower 8-oxoguanine in skin type IV. Conclusion: Therapeutic doses of ultraviolet radiation are relatively safe in dark skinned patients; however, minimizing the cumulative dose of phototherapeutic modalities (particularly psoralen plus ultraviolet-A) is recommended.

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