Melasma is a common hypermelanotic disorder affecting the face that is associated with considerable psychological impacts. The management of melasma is challenging and requires a long-term treatment plan. In addition to avoidance of aggravating factors like oral pills and ultraviolet exposure, topical therapy has remained the mainstay of treatment. Multiple options for topical treatment are available, of which hydroquinone (HQ) is the most commonly prescribed agent. Besides HQ, other topical agents for which varying degrees of evidence for clinical efficacy exist include azelaic acid, kojic acid, retinoids, topical steroids, glycolic acid, mequinol, and arbutin. Topical medications modify various stages of melanogenesis, the most common mode of action being inhibition of the enzyme, tyrosinase. Combination therapy is the preferred mode of treatment for the synergism and reduction of untoward effects. The most popular combination consists of HQ, a topical steroid, and retinoic acid. Prolonged HQ usage may lead to untoward effects like depigmentation and exogenous ochronosis. The search for safer alternatives has given rise to the development of many newer agents, several of them from natural sources. Well-designed controlled clinical trials are needed to clarify their role in the routine management of melasma.

Chronic urticaria has a wide spectrum of clinical presentations and causes. Still, despite our best efforts no cause may be found in the majority of cases. The treatment options are: Primary prevention in the form of avoidance of aggravating factors; counseling; antihistamines; leukotriene receptor antagonists; prednisolone; sulfasalazine and a host of immunosuppressives like methotrexate, cyclosporine, omalizumab etc.

Repigmentation of vitiligo depends on available melanocytes from three possible sources: from the hair follicle unit which is the main provider of pigment cells, from the border of vitiligo lesions, and from unaffected melanocytes within depigmented areas; pigment cells at these locations originate a perifollicular, border spreading and a diffuse repigmentation pattern. In order for repigmentation to take place under stimulation with diverse therapies, melanocytes should be present in appropriate numbers. Melanocyte tissue stem cells located in the niche at the bulge region of the hair follicle are the most important sources for providing immature pigment cells that undergo terminal differentiation and originate repigmentation, but cytokines, UVR and other molecules acting in melanogenesis with adequate regulation mechanisms contribute to successful recovery in vitiligo. The presence of keratinocyte stem cells in the interfollicular epidermis raises the question on the possibility of melanocyte stem cells in a similar location and the development of future strategies for therapeutic purposes.

Background: Skin tags are common benign skin tumors usually occurring on the neck and major flexors of elder people. Aims: The aim of this study is to perform quantitation of mast cells and collagen fibers in skin tags and normal skin in diabetics and nondiabetics, to find a possible correlation between mast cells and collagen fibers in the pathogenesis of skin tags. Methods: Thirty participants with skin tags were divided into two groups (15 diabetic and 15 nondiabetic). Three biopsies were obtained from one anatomical site: A large skin tag, a small skin tag, and adjacent normal skin. Mast cells stained with Bismarck brown were counted manually in ten different fields of each section with magnification Χ1000 and the average count was correlated with the percentage of mean collagen area in five fields done by the image analyzer. Results: A statistically significant correlation between mast cell count and percentage of collagen mean area was detected in both studied groups (except in large skin tags of the nondiabetic group). Conclusion: The positive correlation between mast cell count and percentage of collagen mean area suggests the critical role of mast cells in the etiogenesis of skin tags through its interaction with fibroblasts.

Background: Generally, the significances of laser photo stimulation are now accepted, but the laser light facilitates wound healing and tissue repair remains poorly understood. Aims: We have examined the hypothesis that the laser photo stimulation can enhance the collagen production in diabetic wounds using the excision wound model in the Wistar rat model. Methods: The circular wounds were created on the dorsum of the back of the animals. The animals were divided into two groups. The study group (N = 24) wound was treated with 632.8 nm He-Ne laser at a dose of 3-9J/cm ² for 5 days a week until the wounds healed completely. The control group was sham irradiated. Result: A significant increase in the hydroxyproline content and reduction in the wound size were observed in the study group. The pro-healing actions seem to be due to increased collagen deposition as well as better alignment and maturation. Conclusion: The biochemical analysis and clinical observation suggested that 3-6 J/cm ² laser photo stimulation facilitates the tissue repair process by accelerating collagen production in diabetic wound healing.

Background: Reactive perforating collagenosis (RPC) is one of the rare forms of transepidermal elimination in which genetically altered collagen is extruded from the epidermis. This disease usually starts in early childhood as asymptomatic umbilicated papules on extremities, and the lesions become more conspicuous with age. Aims: The objective of our study was to determine the clinico-pathological features of RPC and the response to various treatment modalities. Methods: Ten patients of RPC, belonging to five different families, were studied clinically. Various laboratory investigations were carried out and diagnosis was made by histopathology of the lesions. Patients were given various topical and oral treatments. Results: RPC is familial in most cases without any definite inheritance pattern. It begins in childhood and the lesions are usually recurrent and become profuse and large with age. Systemic diseases have no role in the onset of lesions. Conclusion: Oral and topical retinoids in combination with emollients is the best treatment option.

Background: Cutaneous disorders during HIV infection are numerous and skin is often the first and only organ affected during most of the course of HIV disease. Some Cutaneous disorders reflect the progression of HIV disease; though the relation is still controversial. Aims : The objective of this study, conducted at a tertiary care centre in Bastar, Jagdalpur, is to estimate the status of cutaneous manifestation in HIV-infected patients and its relationship with CD4 cell counts. Methods: We enrolled 137 HIV positive subjects. Demographic information such as age, gender, weight, height, socioeconomic status, and educational status were recorded. Laboratory parameter (CD4 counts) and treatment regimen were noted. Patients were examined for skin disorders by a dermatologist. Data were analyzed using chi-square test for categorical variables. Results: Majority of the patients were from rural area (65.69%) and belonged to a low socioeconomic and educational status. 30.65% of the patients were housewives, 23.35% drivers, and 16.78% labourers. Predominant mode of transmission was heterosexual contact (94.16%). Most common HIV-related dermatological manifestations were seborrheic dermatitis (74.16%), xerosis (52.5%), generalized skin hyperpigmentation 56 (46.67%), onychomycosis 53 (44.16%), pruritic papular eruption 27 (22.5%), oral candidiasis 21 (17.5%), photo dermatitis 21 (17.5%), and scabies 4 (3.33%). Significant correlation with low CD4+ cell counts was found for oral candidiasis (P < 0.0001) and Kaposi's sarcoma ( P = 0.03), while other disorders such as seborrheic dermatitis ( P = 0.22), xerosis ( P = 0.25), and onychomycosis (P = 0.08) were not statistically significant. Conclusion : This study showed high prevalence of dermatological manifestations in HIV-infected subjects, and they occur more frequently with progression of HIV and decline in immune functions. Therefore, early diagnosis and management of skin disorders can improve the quality of life of HIV-infected subjects.

Background: The spectrum of skin cancer in Kashmir valley is drastically different from the rest of the country. Maxwell was the first to report skin cancer of lower extremities in Kashmiri population, developing on/over erythema ab igne, and attributed it to the use/or exposure of Kangri. These tumors have an aggressive biological behavior with a substantial risk of loco-regional metastasis in 30-50% cases.Because of unique geographical distribution of Kangri cancer, there is dearth of literature regarding the natural history, loco-regional and distant metastatic pattern and treatment recommendations in these tumors. Aims: To study the metastatic pattern of these skin tumors and to assess the impact of various treatment modalities and use of prophylactic nodal treatment in this clinical entity. Methods: The retrospective study (study period 1993-2005) included 266 patients of squamous cell carcinoma of skin of lower extremities and abdominal wall. Two hundred and forty-four cases with a follow-up of 2-7 years were included for final analysis with stress on loco-regional relapse pattern and methods of treatment evolved and used at our institute from time to time. Statistical analysis was done using yates corrected Chi-square test and odds ratio analysis. Results: Our results favor the use of post operative radiotherapy to primary and prophylactic treatment of regional nodes on the lines of head and neck tumors in these cases. Conclusion: Post operative radiotherapy significantly decreases the loco-regional recurrences and a trial of prophylactic nodal irradiation is justified in a selected group of such patients.

Background: The prevalence of sexually transmitted infections (STI) varies widely from region to region in our country. Aims: To highlight the pattern of STIs and the profile of patients with HIV infection in STD patients as seen at our hospital. Methods: A retrospective chart analysis of clients attending STI clinic, JIPMER, Puducherry, from June 2004 to June 2006 was done. Results: A total of 866 clients attended our STI clinic, out of whom 435 (50.2%) had proven STI. STIs were more common in men, with a male (290): female (145) ratio of 2:1. Their age ranged from 1 year to 75 years (mean age = 32.38 years) with the maximum number of patients in the age group of 21-30 years, while children constituted only 2.8%. Herpes genitalis (107 patients, 32.8%) was the most common ulcerative STI, while genital wart was the most common nonulcerative STI (56 patients, 17.1%). Non-gonococcal urethritis (46 patients, 14.1%) was more common than gonococcal urethritis. HIV infection was the most common STI in our study, at an alarmingly high rate of 34.5% (151/435). HIV seropositivity was more common in patients who presented with ulcerative STIs than with nonulcerative STIs. Conclusions: Herpes genitalis was the most common ulcerative STD, while genital wart was the most common nonulcerative STI in our study. The prevalence of HIV among STI clients in India has been on the rise, but has quite alarmingly become the most common STI in our study.

Background: Uncomplicated skin and skin structure infections (uSSSI) are commonly encountered community-acquired infections and are typically confined to the superficial layers of the skin. Hence, they seldom lead to the destruction of skin structures. Aims: To evaluate the efficacy and tolerability of cefditoren pivoxil in uSSSI in Indian patients. Methods: One hundred and seventy-eight patients diagnosed with uncomplicated SSSI were enrolled in this randomized, comparative, multicentric study. Patients received either cefditoren pivoxil or cefdinir for ten days. Efficacy was assessed both clinically and microbiologically. Safety evaluation consisted of reporting of type, frequency, severity, and causal relationship of adverse events. Results: One hundred and fifty-one patients completed the study. Clinical and bacteriological efficacy of cefditoren pivoxil was comparable to that of cefdinir in the treatment of uSSSI. One hundred and five patients were eligible for per protocol (PP) analysis of bacteriological outcome and clinical efficacy. Clinical cure or improvement was achieved in 98.00% patients treated with cefditoren pivoxil and 98.18% patients treated with cefdinir. In the modified Intent to Treat (mITT) patient population, clinical cure or improvement was recorded in 97.33% patients treated with cefditoren pivoxil and 96.20% patients treated with cefdinir. Microbiological eradication (or presumed eradication) was recorded in 88.00% patients treated with cefditoren pivoxil and 94.55% patients treated with cefdinir. The above differences in the outcome rates between the two drugs were not statistically significant. Six adverse events (AEs) (two in cefditoren group and four in cefdinir group) were reported in this study. Conclusion: Cefditoren pivoxil 200 mg b.i.d. was effective and well tolerated in the treatment of uSSSI.

Background: Mammalian pigmentation results from the synthesis and accumulation of photo protective epidermal melanin. Melanin was formed from the amino acid precursor L-tyrosine within specialized cells, the melanocytes. Oxidative stress has been suggested to be the initial pathogenetic event in melanocyte degeneration with H ₂ O ₂ accumulation in the epidermis of patients with active disease. Auto immunity has been also suggested as another hypothesis in the pathogenesis of depigmentation disorders. Topical corticosteroids and phototherapy as common treatment modalities have been prescribed in patients with vitiligo. However, they are often not effective and safe (epidermal atrophy). Therefore, research for alternative therapies continues. Aims: To evaluate the beneficial effects of a supplementation with antioxidant vitamins (A, C, E) and minerals (zinc, selenium) for vitiligo treatment. Methods: Forty experimental autoimmune vitiligo mice C57BL6, aged from 5 to 12 months showing visible signs of induced vitiligo, were sequentially randomized into five parallel groups (8 mice per group). Each group mice was allocated an identical pre coded cage. the first group (SZV) received the ED+1,4 g zinc (Zn)+0.04 g selenium (Se)+vitamins (A 118 UI, C 8,5 mg, E 5,4 UI) /kg diet, the second group (PSZV) received the ED+1,4 g zinc (Zn)+0.04 g selenium (Se)+vitamins (A 118 UI, C 8.5 mg, E 5,4 UI)/kg diet+Polyphenol orally, the group 3 (PSZ ) received the ED+green tea decoction prepared from 100 g/l (polyphenol orally)+1,4 g Zn+0.04 g Se, the 4 (P) received the ED+green tea decoction prepared green tea decoction prepared from 100 g/l, the control group 5(C) received the ED++ distilled water. Cure was defined as repigmentation of treated sites. Photographic and optical techniques were used both at the baseline and on weekly basis. Results: By the end of the study, mices showed visible repigmentation. Using the investigator's global assessment, therapeutic success in terms of a clear repigmentation documented in 70% of treated mice. Conclusion: Our findings suggest that an antioxidant supplementation is significantly beneficial in contributing superior clinical efficacy to cure vitiligo.

Background: Periocular hyperpigmentation is a condition in which skin of eyelids become darker in color than the normal surrounding skin. Lead and other heavy metals produce increased pigmentation because of deposition of metal particles in the dermis and increased epidermal melanin production. Aims: This study was conducted to evaluate the dual effect of chelation therapy in treating periocular hyperpigmentation and lead toxicity. Methods: The study population consisted of nine females complaining from dark coloration of their eyelids. The nine females were continuously using kohl as eyeliner. Lead levels in conjunctiva and serum before and after D-penicillamine (D-PCN) oral administration were estimated in relation to vertical, horizontal length, and degree of hyperpigmentation score. Results: Highly significant P values (0.000) were obtained as regard to the conjunctival lead levels, serum lead levels, horizontal length, and degree of darkness score before and after D-PCN therapy. A less significant P value (0.040) was recorded as regard to the vertical length. Conclusion: Regardless other causes, this study spots the light on a new concept for periocular hyperpigmentation from lead toxicity in adult females using kohl and suggests D-PCN in a low divided dose (750 mg/day) for its treatment.

Background: Existing remedies for controlling pseudofolliculitis barbae (PFB) are sometimes helpful; however the positive effects are often short lived. The only definitive cure for PFB is permanent removal of the hair follicle. Aims: Our aim was to compare the efficacy of the Alexandrite laser with the intense pulsed light system in the treatment of PFB and to follow up the recurrence. Methods: Twenty male patients seeking laser hair removal for the treatment of PFB were enrolled in this study. One half of the face was treated with the long-pulse Alexandrite laser and the other half was treated with the IPL system randomly. The treatment outcome and any complications were observed and followed up for one year. Results: All patients exhibited a statistically significant decrease in the numbers of papules. Our results showed that the Alexandrite-treated side needed seven sessions to reach about 80% improvement, while the IPL-treated side needed 10-12 sessions to reach about 50% improvement. During the one year follow up period, the Alexandrite-treated side showed recurrence in very minimal areas, while the IPL-treated side showed recurrence in bigger areas. Conclusions: Our results showed that both systems might improve PFB but Alexandrite laser was more effective at reducing PFB than IPL.

Diffuse plane xanthomas are characterized by the presence of yellowish plaques on the eyelids, neck, upper trunk, buttocks, and flexural folds. Histology shows foamy histiocytes in the dermis. Approximately half of the cases are associated with lymphoproliferative disorders. Budd-Chiari syndrome is an uncommon condition induced by thrombotic or nonthrombotic obstruction of hepatic venous outflow. We present a case of diffuse plane xanthoma in a 62-year-old man who developed normolipemic plane xanthomas coinciding with Budd-Chiari syndrome and monoclonal gammopathy. We review the English-language literature regarding the rare association of xanthomas and Budd-Chiari syndrome.

Hyper IgE syndrome (HIES) is a rare immunodeficiency syndrome characterized by a triad of cutaneous abscesses, mostly caused by Staphylococus aureus; pneumonia; and raised IgE levels. Nonimmunological associations include course facial features, multiple bone fractures, joint hyperextensibility, and retained primary dentition. Patients require long-term antibiotic therapy. We report here a classical case of HIES with rare associations of natal teeth, bilateral cervical ribs, and conductive deafness. The patient was being treated with monteleukast and dapsone.

Cutis marmorata telangiectatica congenita (CMTC) is a rare congenital disorder with persistent cutis marmorata, telengiectasia, and phlebectesia, which may be associated with cutaneaus atrophy and ulceration of the involved skin. We herewith report a full-term newborn female baby with CMTC at birth with ulceration over the extensor aspects of both the knee joints and right elbow joint. CMTC is a benign vascular anomaly representing dilatation of capillaries and veins of dermis and is apparent at birth. The baby had a reticulated bluish purple skin changes all over the body including the face and limb. Although it resembled physiological cutis marmorata, it was strikingly pronounced and definitely was unvarying and permanent. A variety of vascular malformation has been described along with this disorder. Etiology is not very clear and may be multifactorial, teratogens and genes are also been suggested. Prognoses in uncomplicated cases are good.

Hyper IgE Syndrome (HIES) is a rare multi system genetic immunodeficiency disorder, with immunological and non-immunological features. Immunolgical features are 1) Recurrent cutaneous abscesses, 2) Atopic dermatitis like lesions, 3) Sino pulmonary infections, 4) Elevated serum IgE levels and 5) Abnormal neutrophil chemotaxis. Non immunological features include cranio facial and skeletal abnormalities. We are reporting a girl with classical features of HIES with umbilical hernia with her younger brother suffering from right sided inguinal hernia, as both herniae are hitherto unreported in patients with HIES.

Cutaneous metastasis from ovarian carcinoma is relatively uncommon in clinical practice. We report the case of the woman who presented to us with clitoral nodules and skin nodules. Histopathological examination of nodules confirmed the diagnosis of metastasis of an ovarian carcinoma. Despite poor prognosis, the patient responded and survived well beyond the expected four months survival of similar cases.

Saksenaea vasiformis is an emerging zygomycete species, most often associated with cutaneous, subcutaneous and rhino- orbito-cerebral infections. Herein, we report a case of cutaneous zygomycosis of face caused by Saksenaea vasiformis in a 54-year-old immunocompetent female. The diagnosis was carried out by microscopy using KOH mount, Gram staining, Gomori's methenamine silver staining, hemotoxylin and eosin staining and culture on Sabouraud's Dextrose agar without actidione. Slide cultures were put up on Czapek Dox agar, which showed typical flask-shaped sporangium with rhizoids. The patient was treated successfully with intravenous amphotericin B.

A total of 60 patients suspected to have AIDS with oral lesions suggestive of oral candidiasis were studied. Candida species were isolated from 50 patients. Candida albicans was the commonest isolate (70 %) followed Candida parapsilosis (15%), Candida glabrata (7.5%) and Candida tropicalis (5%) respectively. Candida dubliniensis was isolated from a single case only. Though the reports from developed countries show more prevalence of the novel species Candida dubliniensis, in our study it was isolated in a single case. All the patients were treated successfully with oral fluconazole for 7 days except for the patients from which Candida glabrata was isolated, who were treated with Amphotericin B.