Background: Atopic dermatitis (AD) is a common and chronic, pruritic inflammatory skin condition that affects all age groups. There was a dearth of consensus document on AD for Indian practitioners. This article aims to provide an evidence-based consensus statement for the management of AD with a special reference to the Indian context. This guideline includes updated definition, etiological factors, classification, and management of atopic dermatitis. Methodology: The preparation of guidelines was done in multiple phases. Indian Dermatology Expert Board Members (DEBM), recommended by the Skin Allergy Society of India, prepared 26 evidence-based recommendations for AD. An extensive literature search was done in MEDLINE, Google scholar, Cochrane, and other resources. Articles published in the past 10 years were reviewed and recommendations were graded based on the quality of evidence as per GRADE. After forming the initial structure, DEBM met in Mumbai and gave their decisions on an agree and disagree scale with an Indian perspective. Finally, their suggestions were compiled for preparing the article. After DEBM finalized the draft, a treatment algorithm was formulated for the management of AD. Results: DEBM suggested a working definition for AD. The panel agreed that moisturizers should be used as mainstay of therapy and should be continued in all lines of therapy and in maintenance phase. Topical corticosteroids and topical calcineurin inhibitors should be considered as the first line of treatment. Among systemic therapies, cyclosporin should be considered first line, followed by azathioprine, methotrexate, and mycophenolate mofetil. Phototherapy can be an effecive alternative. Empirical food restriction was recommended against. Conclusion: These guidelines should form a reference for the management of patients with AD in an evidence-based manner.

Background: Genetic variations associated with nonprogression of HIV infection to AIDS are enriched in psoriasis patients. HCP5 gene 335 T > G and chemokine C receptor type 5 (CCR5) gene Δ32 polymorphisms are associated with HIV nonprogression phenotype. Aim: The aim of this study was to determine the association of HCP5 gene 335 T > G (rs2395029) and CCR5 gene Δ32 (rs333) polymorphisms with psoriasis vulgaris (PV). Materials and Methods: Genotype of HCP5 gene 335 T > G and CCR5 gene Δ32 polymorphisms were determined by polymerase chain reaction (PCR)-restriction fragment length polymorphism and allele-specific PCR methods, respectively. Results: The frequency of HCP5 gene 335 T > G SNP was ~7 times higher in PV patients than in the control group (P = 1.49 × 10^–8; odds ratio [OR] = 10.2; 0.95 confidence interval [CI]: 3.9–26.8). OR for the occurrence of HCP5 335 G allele in either homozygous or heterozygous genotype in PV patients was 13.1 (0.95 CI: 4.7–36.1). The strength of association was higher with moderate-to-severe subgroup (P = 3.29 × 10^–9; OR = 18.4; 0.95 CI: 6.2–54.9) than with mild subgroup (P = 2.1 × 10^–4; OR = 8.3; 0.95 CI: 2.6–23.3). In addition, the strength of association was higher with Type I (P = 9.53 × 10^–8; OR = 15.3; 0.95 CI: 5.1–46.5) than with Type II subgroup (P = 6.8 × 10^–6; OR = 11.0; 0.95 CI: 3.6–33.9). Type I gene Δ32 polymorphism was observed neither among psoriatic nor among healthy individuals. Conclusions: Our results indicate that HCP5 gene 335 T > G polymorphism and not CCR5 gene Δ32 polymorphism is associated with the increased risk of developing PV.

Background: Psoriasis is a chronic, inflammatory skin disease. The etiology of the disease is unknown. It is a polygenic and multifactorial disease, which interacts with genetic and environmental factors. Genetic factors (polymorphism/mutation) can alter the immune system and normal physiologically functioning keratinocytes to pathological or predisposition levels. Aims: We aimed to investigate psoriasis at a different and novel window by searching for vascular and immunological variations and intersections in psoriasis. We investigated the main vascular and hypoxic controlling factors, which are vascular endothelial growth factor (VEGF) and hypoxia inducible factor 1 alpha (HIF-1α), as well as immunological and serotonergic factors, such as TNF-α, IL-10, and 5HT2A, which could connect each other to the pathogenesis of psoriasis. Subjects and Methods: Nine single nucleotide polymorphisms (SNPs) in five genes were genotyped by mini-array format in 300 subjects: VEGF (rs2010963, rs833061, and rs1570360), HIF-1α (rs11549465), TNF-α (rs361525, rs1799964, and rs1800629), IL-10 (rs1800896), and 5HT2A (rs6311). Results: An association was found between rs1800629 (TNF-α) and Type I psoriasis, and rs833061 (VEGF) and Type II psoriasis. Haplotype analysis suggests that the coexistence of the polymorphisms rs1799964 (TNF-α), rs2010963 (VEGF), rs833061 (VEGF), and rs6311 (5HT2A) may be a protective factor for psoriasis. Conclusion: Our results suggest that the vascular component of the studied vasculo-immunologic variation is more relevant in the pathogenesis of psoriasis.

Background: Psoriasis is a common dermatologic disease with multifactorial etiology in which genetic factors play a major role. Peroxisome proliferator-activated receptor (PPAR)-γ is expressed in keratinocytes and is known to affect cell maturation and differentiation in addition to its role in inflammation. Aim: To study the association between PPAR-γ gene polymorphism and psoriasis vulgaris in Egyptian patients to explore if this polymorphism influenced disease risk or clinical presentation. Methods: Forty-five patients with psoriasis vulgaris and 45 age, sex and body mass index matched healthy volunteers who have no present, past or family history of psoriasis as a control group were enrolled. Selected cases included obese and nonobese participants. Detection of PPAR-γ gene polymorphism was done with restriction fragment length polymorphism polymerase chain reaction. Narrow-band ultraviolet B (NBUVB) was given for every case three times/week for 12 weeks. Results: Homopolymorphism, heteropolymorphism, and Ala allele were significantly associated with cases (P = 0.01, P = 0.01, and P = 0.004, respectively) and increased risk of occurrence of psoriasis by 5.25, 3.65, and 3.37 folds, respectively. Heteropolymorphism was significantly associated with nonobese cases compared to obese ones (P = 0.01). Ala allele was significantly associated with obese cases (P = 0.001) and increased risk of occurrence of psoriasis in obese participants by 1.14 folds. Homopolymorphism, heteropolymorphism, and Ala allele were more prevalent among obese cases without metabolic syndrome (MS) than obese cases with MS but without statistical significance. Percentage of decrease of mean Psoriasis Area and Severity Index score before and after 3 months of treatment with NBUVB was higher in cases with heteropolymorphism with no significant difference between homo- and heteropolymorphism. Conclusion: PPAR-γ gene polymorphism is associated with and increased the risk of psoriasis and its associated obesity in Egyptian patients. It has no role in NBUVB response in those patients. Future large-scale studies on different populations are recommended.

Context: Advanced glycation end products (AGEs) promote oxidative stress and inflammation by altering structure and function of proteins. They are excessively produced mainly in hyperglycemia, chronic inflammation and are involved in the development of atherosclerosis and cardiovascular disease. Aims: The aim of this study was to investigate whether skin AGEs levels were increased and had relation to premature atherosclerosis in patients with psoriasis. Subjects and Methods: Fifty-two psoriasis patients and 20 healthy controls (HC) were included. AGEs were determined by skin autofluorescence (SAF) analysis. High-sensitive C-reactive protein (hsCRP) and carotid intima-media thickness (CIMT) were also investigated. Physical activity and dietary patterns were determined. Statistical Analysis Used: Fisher's exact test, two-sample t-tests, Mann–Whitney-U test, Pearson correlation, Spearman correlation, and Wilcoxon test. Results: SAFs were increased in psoriasis patients (1.8 arbitrary units [AUs]) compared to that in HC (1.6 AUs) (P = 0.057). Median CIMT values of HC and psoriasis groups were 0.43 (0.28–0.79), and 0.59 (0.44–0.98) respectively and the differences were significant (P = 0.001); hsCRP levels were not different between groups. Conclusions: Skin AGE accumulation was found to have a correlation with CIMT in psoriasis patients providing evidence for the role of AGEs in premature atherosclerosis.

Background: Adenosine deaminase (ADA) is an enzyme involved in purine metabolism and it is a marker of nonspecific T-cell activation. Few studies have shown high levels of ADA in the epidermis and sera of psoriatic patients. Other inflammatory markers such as high-sensitive C-reactive protein (hsCRP), erythrocyte sedimentation rate (ESR), and serum uric acid (SUA) have shown correlations with psoriasis area severity index (PASI) score. The correlation between ADA and PASI score is still a matter of debate. Aims: The aim of this study was to evaluate serum ADA, hsCRP, SUA, and ESR in psoriatic patients and their correlation with PASI score. Patients and Methods: This study included 60 psoriatic patients divided according to PASI score into three groups (mild, moderate, and severe) each containing 20 patients. PASI score <10 was defined as mild, (10–20) moderate, and >20 severe. Twenty healthy subjects of matched age and sex were included as control. Serum ADA, hsCRP, SUA, and ESR were evaluated for patients and controls. Correlations of ADA, hsCRP, SUA, and ESR with PASI scores were done. Results: While ADA, hsCRP, SUA, and ESR showed a significant increase in psoriatic patients compared with that of the controls (P<001), they showed no significant difference between different psoriatic groups (P>0.05) and no correlations with PASI score (P>0.05). The frequency of joint affection increased with increasing severity of psoriasis (5%, 10%, and 25% in mild, moderate, and severe psoriasis, respectively). Conclusion: Serum ADA, hsCRP, SUA, and ESR showed higher levels among psoriatic patients than in controls. The increased ADA in psoriatic patients supports the role of T-cell activation and proliferative disorder in the pathogenesis of psoriasis. No significant correlations were found between these biomarkers and PASI score. Further studies are needed to validate these biomarkers as diagnostic and prognostic factors in psoriasis.

Background: Acitretin is a widely used systemic retinoid in the treatment of psoriasis. Dosage of acitretin in not weight adjusted due to certain interindividual variations. Objective: To evaluate the clinical efficacy and effects on biochemical parameters of fixed tapering dosage of acitretin in patients with psoriasis administered over a period of 4 weeks. Materials and Methods: This was an observational study. The study included patients of psoriasis vulgaris in the age group of 18 and 65 years with a psoriasis area severity index (PASI) score of >10 which was not responsive to topical therapy and phototherapy. Patients were given oral acitretin daily at a dose of 25 mg BD for 2 weeks, which was later tapered to 25 mg OD for another 2 weeks. The clinical efficacy and biochemical parameters were assessed. Results: Out of the 18 patients, PASI 75 was achieved in 66% of the patients by the end of the third week. Significant elevations were noted in serum lipids during 4 weeks, which returned to normal limits or near baseline levels at the end of 4 weeks. Conclusion: Fixed tapering dose of acitretin is effective in psoriasis with minimal clinical and biochemical adverse events

Introduction: Phakomatosis pigmentovascularis (PPV) is a rare congenital syndrome characterized by the simultaneous presence of capillary malformation and pigmentary nevi. The objective of our study was to describe the clinical characteristics of a series of Indian patients presenting with this rare entity. Materials and Methods: It was a record-based descriptive case series. Results: A total of 11 patients with PPV (9 females, 2 males, age range: 7 days to 45 years; mean 11.6 years) were studied. Port wine stain was present in 10 (91%) patients and one patient (9%) had cutis marmorata telangiectatica congenita. Isolated nevi of Ota and Mongolian spots were seen in 4 (36%) patients each. Simultaneous presence of both Mongolian spots and nevus of Ota was present in 1 (9%) patient. The combination of Mongolian spots and bilateral palatal hyper-melanosis was noticed in 2 (18%) patients. Café au lait macule was present in one patient. Bilateral ocular melanosis was found in 3 (27%) patients. Unilateral ocular melanosis was noticed in 4 (36%) patients. Two patients (18%) had history of seizure disorder and intracranial vascular anomalies on MRI imaging. Two patients (18%) had features of Klippel-Trenaunay syndrome. According to the traditional classification, three patients had PPV type 2b, one patient had PPV type 5b, and seven patients had PPV type 2a. According to the Happle's classification, 10 patients had PPV of cesio flammea type, and one patient had PPV of cesio marmorata type. Limitations: We could not perform genetic study of the patients. Conclusion: Our findings emphasize the importance of detailed systemic evaluation including ocular examination and brain imaging in every patient of PPV.

Background: Copper and zinc are important trace elements involved in the development of psoriasis. However, reports regarding changes in serum copper and zinc levels in patients with psoriasis have been inconsistent. Aims: This meta-analysis was designed to analyze changes in serum copper and zinc levels between patients with psoriasis and a healthy population. Materials and Methods: English and Chinese literature from international and national electronic databases from 1988 to May 2016 was analyzed. Studies that performed a comparative analysis of serum copper and zinc levels between patients with psoriasis and healthy controls were included in the meta-analysis. The random-effects model was used to calculate the overall combined estimates of serum copper and zinc levels between patients with psoriasis and healthy individuals. Results: Fifteen references were included in this study, including 1324 patients with psoriasis and 1324 healthy controls. Compared with healthy controls, serum copper levels were significantly increased (Z = 4.02, P < 0.0001; standardized mean difference [SMD], 1.23; 95% confidence interval [CI], 0.63 to 1.82), and serum zinc levels were significantly decreased (Z = 2.95, P < 0.0001; SMD, −1.35; 95% CI, −2.25 to − 0.45) in patients with psoriasis. Conclusions: In conclusion, increased serum copper and decreased serum zinc levels were generally observed in patients with psoriasis. Treatments to normalize the serum copper and zinc levels may improve the outcome of psoriasis patients.

Acanthosis nigricans (AN) describes clinically hyperpigmented skin, which most commonly affects the flexural areas such as axilla, groin and neck. It is usually a benign condition associated with obesity, insulin resistance, and hyperinsulinemia; endocrinopathy; or malignancy, in particular, gastrointestinal adenocarcinoma. It can also occur in association with various genetic syndromes involving various organ systems. Few such known syndromes are Berardinelli-Seip syndrome, Alström syndrome, Leprechaunism, and Bardet-Biedl syndrome. MORFAN syndrome, which associates mild mental retardation, pre- and post-natal overgrowth, remarkable facies and diffuse and widespread AN, is a rare entity.

Naegeli–Franceschetti–Jadassohn syndrome is a rare autosomal dominant form of ectodermal dysplasia affecting sweat glands, nails, teeth, and skin. We report a case of 16-year-old female who had generalized reticulate pigmentation, dental changes, nail changes, and absence of dermatoglyphics and hypohydrosis.

Psoriasis is a chronic immune-mediated inflammatory condition, affecting 2–3% of the population. In recent years, advent of biologics, including secukinumab, have been a major advancement in the management of difficult-to-treat plaque psoriasis. However, high cost of biologics is often a deterrent, especially for Indian socioeconomic condition. Apremilast is an oral phosphodiesterase 4 inhibitor that is safe for use along with many other systemic therapies of psoriasis, including biologics. We report two cases of psoriasis on secukinumab therapy for long duration with good response to therapy. Later, addition of apremilast, allowed halving the dose of secukinumab with maintenance of improvement.

Psoriasis is a chronic papulosquamous skin disease that involves immune-mediated cutaneous inflammation and keratinocyte hyperproliferation. The associated immunosuppression in people living with HIV (PLHIV) with psoriasis poses a challenge to the clinician as therapeutic options are limited. Until now, there have been no documented case of apremilast therapy for HIV-associated psoriasis in India. Here, we report a case of HIV-associated psoriasis who achieved Psoriasis Area and Severity Index (PASI) 100 with apremilast therapy.

Background: Vascular endothelial growth factor (VEGF) is significantly elevated in psoriatic patients and is associated with the severity of the psoriasis. Due to the effect of inhibiting production of VEGF, acitretin can effectively treat psoriasis. Semaphorin 3A (Sema3A) restrain tumor growth and angiogenesis by partially reversing VEGF effects on tumor. However, the role of Sema3A in the pathogenesis of psoriasis is unclear. Aims and Objectives: This study aimed to investigate the effect of VEGF, Sema3A, and acitretin on HaCaT cells, to see whether Sema3A could be a beneficial factor in psoriasis, as well as acitretin. Materials and Methods: Functional analysis of VEGF, Sema3A, and acitretin was carried out using HaCaT cells cultured under different treatments. Cell counting kit-8 method, colony formation assay, flow cytometry, transwell migration, reverse transcription-polymerase chain reaction, and Western blot test were performed to measure proliferation, colony formation, migration, apoptosis, and the expression of Bcl2, Bax, Caspase 3, and Caspase 9 of HaCaT cells. Results: Sema3A and acitretin inhibited the proliferation, colony formation, and migration of HaCaT cells, while induced the apoptosis of HaCaT cells by inhibiting the expression of Bcl2, and promoting the expression of Bax, Caspase 3, and Caspase 9, which were opposite to VEGF. Sema3A and acitretin partially reversed the function of VEGF. Conclusions: Like acitretin, exogenous supplement of Sema3A may correct the abnormal proliferation and apoptosis procedure of HaCaT cells, and partially reverse the function of VEGF.

Background: Chronic urticaria is a common dermatological disorder that causes a great deal of distress in patients and affects daily life. Narrow band ultraviolet B (NBUVB) has been shown to be an effective treatment in chronic urticaria in few studies. However, the data regarding its role in chronic urticaria are limited. Aims and Objectives: The aim of this study was to determine the role of NBUVB in the treatment of chronic urticaria in combination with antihistamine. Materials and Methods: A total of 80 patients of chronic urticaria were recruited, out of which 40 were allocated to NBUVB-loratadine group and 40 to loratadine group. Patients were assessed using urticaria activity score (UAS) at same point of time, i.e. after 4 weeks (8 sessions), 8 weeks (16 sessions) and at follow up of 4 weeks after stopping the treatment. Results: On comparing the two groups, the mean UAS was significantly lower after 8 and 16 sessions in NBUVB-loratadine group (12.03 v/s 21.43 and 3.54 v/s 17.16, respectively). The difference in reduction of UAS7 in two groups was seen to be statistically significant (P value < 0.01). Conclusion: Thus we conclude that NBUVB may be useful in the treatment of chronic urticaria.

Introduction: Skin is one of the major target organ for adverse drug reactions (ADRs). The incidence of dermatological ADRs among indoor patients in developed countries ranges from 1–3%, whereas in developing countries such as India, it is 2–5%. Aims: To analyze the clinical spectrum, seriousness, outcome, causality, severity, and preventability of the cutaneous ADRs. Material and Methods: All cutaneous ADRs reported at the Regional Adverse Drug Reaction Monitoring Center between January 2013 to May 2016 were identified and evaluated. A retrospective analysis was carried out for clinical presentation, causality (as per the WHO–UMC scale and the Naranjo'a reactions (ADRs) Severity (Hartwig and Seigel scale), and preventability (Schumock and Thornton criteria) of a said drug. Results: Out of 2171 ADRs reported during study period, 538 were cutaneous ADRs (24.78%). The most common clinical presentation was maculopapular rash (58.92%) followed by itching (10.59%), and Stevens–Johnson syndrome (4.83%). The time relationship of cutaneous ADRs to drug therapy revealed that they can develop within 1 week to 1 year of treatment. Most common causal drug groups were antimicrobials (46%), non-steroidal anti-inflammatory drugs (NSAIDs) (18%), and antiepileptics (10%). Polypharmacy was observed in 7% of the cases. Most of the cutaneous ADRs were non-serious (91%), however, 10 were life-threatening and 1 was resulted in death due to the Stevens–Johnson syndrome. Causality category for majority of cutaneous ADRs was possible. Although majority of cutaneous ADRs were moderately severe (81%), however, not preventable (89%). Conclusion: The occurrence of cutaneous ADRs is common and they developed within 1 week of therapy. Antimicrobial agents and NSAIDs are the most common implicated drug class. Hence, physicians should closely monitor the patient in the first week while using such therapy for early detection and prevention of cutaneous ADRs.

Background: Chronic plantar ulcers are common problems for leprosy patients with numb feet due to their prolonged healing time. Chronic plantar ulcers affect the quality of life of patients and can lead to more serious complications, such as disability and deformity, if not handled appropriately. Wound-care products in the market, however, give unsatisfactory results. One factor in the delayed healing of chronic plantar ulcers due to leprosy is the lack of growth factors and cytokines in the wound due to reduced blood supply. We speculated that application of human amniotic membrane stem cell (hAMSC) secretome, which contains growth factors and cytokines, could improve wound healing. Aim: To evaluate the effect of topical application of a hAMSC secretome gel on wound healing of chronic plantar ulcers due to leprosy. Materials and Methods: We recruited 11 patients after leprosy treatment with chronic plantar ulcers due to leprosy. hAMSC secretome gel was applied topically to ulcers every 3 days for up to 2 months. Ulcer size and possible side effects or complications from gel application were evaluated weekly. Results: The ulcers of 8 of 11 patients (72.7%) completely healed, the ulcers of 2 patients (18.2%) partially healed, and the ulcers of 1 patient (9.1%) persisted. No ulcers became worse. Conclusion: hAMSC secretome was found to be an efficacious and well-tolerated alternative therapy for chronic plantar ulcers due to leprosy.

Background: Herpes zoster (HZ) is identified to induce postherpetic neuralgia (PHN) which is difficult to cure. PHN-related pain brings patients not only physical discomfort but also mental depression and anxiety. Currently, the main purpose of PHN treatment is to reduce patients' pain. Now treatment combining some international pain management and drug therapy has come up. Aims and Objective: This study aims to evaluate the effect of interventional management through meta-analysis. Materials and Methods: Interventional pain management was defined as a direct strategy on nerve through physical or chemical method. Drug therapy was always regarded as control. Potentially relevant articles were searched in PubMed, EMBASE, and the Cochrane Library through key words by consensus. Pain severity was evaluated by a validated visual analog scale (VAS). Moreover, the weighted mean difference was used to calculate pain intensity. Some trails recorded the efficiency rate and odds ratio was used to calculate the effectiveness. Statistical heterogeneity was measured by the value of I², and when statistical I² > 50%, subgroup analysis was used to seek for the source of heterogeneity. Results: Pulsed radiofrequency (PRF) combined with medication reduced the VAS scores at 1, 2, 4, and 8 weeks after treatment. The nerve block combined with medication reduced VAS scores at 8 weeks after treatment, but there is no difference between the results of medication alone at 1, 2, and 4 weeks after treatment. Conclusion: The interventional mean of PRF combined with medication has a good effect on PHN. The effect of nerve block combined with medication on PHN seems to be the same as that of medication alone. Besides, a long period with high-quality randomized controlled trial should be done to verify the results.

Renal cell carcinoma (RCC) is the most frequent cancer of the kidney and it accounts for 3% of all solid malignancies. Although rare, cutaneous metastases can be an important manifestation of RCC. We present a case of a 56-year-old male with a history of RCC, followed by the development of cutaneous metastases 4 years later with an uncommon clinical presentation. RCC is the most common genitourinary cancer to metastasize to the skin and accounts for 6.8% of cutaneous metastases. These patients have a poor prognosis. It is essential for these patients to perform a complete periodic dermatologic examination for proper restaging and treatment.

Mycosis fungoides (MF) is the commonest form of cutaneous T-cell lymphoma. Many clinical subtypes and variants of MF have been described, one of which is poikilodermatous MF variant. Erosions and bullous lesions in a patient with poikilodermatous MF is a rare presentation. We present one such rare case of poikilodermatous MF with erosive lesions in a 40-year-old male.

Primary cutaneous neuroendocrine carcinoma (PCNC), previously known as Merkel cell carcinoma (MCC), is a rare tumor of the skin with aggressive behavior and poor prognosis. Typically, PCNC is positive for Cytokeratin-20 (CK20) and negative for Thyroid Transcription Factor-1 (TTF-1). Rarely, CK-20 negative and TTF-1 positive PCNC have been described. We present the case of two patients with skin lesions histologically compatible with MCCs and a behavior characteristic of this disease, but with expression of TTF-1 instead of CK-20. In conclusion, there are increasing reports of TTF1+ CK20− skin lesions without signs of systemic disease which behave clinically and prognostically like a PCNC. The origin of these TTF1 tumors are, to date, unknown.