Background: Although acne is principally a disorder of adolescence, the number of adult patients with acne is increasing. Adult acne is defined as the presence of acne beyond the age of 25 years. There is relatively few data on the prevalence and studies of acne in adult population. Aim and Objectives: To analyze the various factors that aggravate or precipitate acne vulgaris in Indian adults. Materials and methods: The study was done at the Department of Dermatology at a tertiary care center in Kerala for a period of 1 year. A total of 110 patients above the age of 25 year diagnosed clinically as acne vulgaris were included in the study. A detailed history regarding age of onset, duration, type of acne, family history, whether there was any exacerbation related to food, cosmetics, drugs, emotional stress, seasonal variation, sunlight, sweating, pregnancy, menstruation and smoking was taken. Results: Majority of patients with adult acne were in the age group 26-30 years and there was a clear female preponderance. Persistent acne was more common than late onset acne. Food items and cosmetics were attributed to exacerbation by 47.3% and 40% of patients respectively; 32.7% patients had exacerbations during stress, 26.4% following sun exposure and 23.6% after sweating. About 48% patients had first degree relatives with present or past history of acne. Most of the female patients had premenstrual flare of acne, which was much more common among patients with persistent acne. Pregnancy had no effect on acne in majority of patients. Seasonal variation was observed in 44.5% patients, most of them showing exacerbation in summer months. Conclusion: Acne as a disease lasts longer, persists into adulthood and requires treatment well into the forties. Unlike teenage acne, where males tend to be affected more commonly, post adolescent acne mainly affects females. It is therapeutically rewarding to identify the concerned triggers and aggravating factors and be able to deal with them.

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Background: Vitiligo is an idiopathic acquired progressive de/hypopigmentary disorder of skin and mucosae. In Indian skin depigmentaion is very much obvious and can cause psychological distress, low self esteem and social stigmatization. Aims: The primary objective of this study was to evaluate the psychiatric morbidity in vitiligo patients and secondary objective was to assess the morbidity in all eight dimensions of psychosocial and physical aspects, i.e. cognitive, social, discomfort, limitations, depression, fear, embarrassment and anger. Materials and Methods: An institution based case-control study with sixty-one patients of vitiligo and equal number of healthy age and sex matched controls was undertaken. The self-reporting questionnaire-24 (SRQ-24) and skindex (A 61-item survey questionnaire) were used to assess the psychiatric morbidity in both the groups. Results: The SRQ-assessed psychiatric morbidity in the study group was 63.93%, compared with 24.59% in the control group (P<0.0001). Acral vitiligo had maximum association with psychiatric morbidity (86.67%) followed by vitiligo vulgaris (68%), mucosal vitiligo (62.5%) and others. According to the skindex, the most common psychiatric morbidity in vitiligo patients was depression (62.29%) followed by embarrassment (55.73%), social problem (54.09%), cognitive impairment (50.81%), physical limitation (47.54%), discomfort (40.98%), anger (36.06%) and fear (24.59%). The difference in Skindex scoring that marked the psychiatric morbidity among the case and control groups was statistically significant for depression, discomfort, social problem, cognitive impairment, embarrassment (P<0.0001) and physical limitation (P=0.0044). Conclusion: Vitiligo has a high degree of psychiatric morbidity.

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Background: A fixed-drug eruption (FDE) is a unique cutaneous adverse drug effect in the form of recurrent lesions at the same site after re-exposure to the offending agent. Aim: The aim of the study was to identify changes in trends in fixed drug eruptions with regard to causative drug or patient risk factors. Methods: Cases of FDEs encountered between March 2014 to May 2017 during routine pharmacovigilance activities were analyzed. Results: FDEs made up 8.4% of total adverse drug reactions and 11.1% of cutaneous reactions. Majority of the patients were adults between 18 and 45 years old. The average lag period between drug intake and appearance of FDE was 2.04 days. Commonly affected sites were extremities, lips, head and neck, and genitalia. Number of FDE lesions varied from 1 to > 6, with nearly half the patients (46%) presenting with a single lesion. Antimicrobials (80.6%) and nonsteroidal anti-inflammatory drugs (20.8%) were most frequent drugs implicated. Route of administration was oral for all causative drugs. History of an FDE was positive in 26 (50.2%) of the cases. Majority of the patients (21 out of 25 or 84%) whose lesions appeared within minutes to hours of suspected drug intake had a history of FDE. Furthermore, 66.7% of patients with multiple lesions had a history of FDE while only 34.8% of patients with a single lesion had such a history. Conclusion: FDEs are common cutaneous reactions with antimicrobials and anti-inflammatory agents, with increased likelihood of extensive and multiple lesions in patients with a history of FDE.

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Background: Atopic dermatitis is a dermatological disease characterized by chronic inflammation. In recent years, systemic inflammation is also mentioned along with local inflammation for its pathogenesis. Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and mean platelet volume (MPV) are nonspecific indicators of systemic inflammation, and they were shown to be associated with the disease and its prognosis in allergic or nonallergic diseases. Aims and Objectives: The aim of this study was to evaluate the values of NLR, PLR, and MPV in atopic dermatitis patients and also to investigate the associations of them with the atopic dermatitis disease severity and duration. Materials and Methods: Two hundred and fifty-two atopic dermatitis patients and 75 control group individuals were included in the study. Mean/median values of NLR, PLR, and MPV were compared among patients and controls, severity groups classified according to SCORing Atopic Dermatitis (SCORAD) and intrinsic and extrinsic groups. Correlation of disease duration and SCORAD with NLR, PLR, and MPV values were examined. Disease duration and its association with NLR were evaluated by correlation and linear regression analysis. Results: Mean NLR and median PLR values of atopic dermatitis patients were higher than those of controls (0.97 ± 0.69 and 80.86 [59.86–108.23], respectively). NLR and PLR values were found to be positively correlated with disease duration and NLR was positively associated with disease duration after adjustment. NLR value was also higher in the extrinsic group than the intrinsic group. Conclusion: Presence of systemic inflammation in the pathogenesis of atopic dermatitis was considered to be associated with increased NLR and PLR values. These parameters were also associated with disease duration and might vary between subtypes of atopic dermatitis. NLR and PLR were cheaper and easily accessible alternatives to the systemic inflammation biomarkers that were expensive and not accessible for all laboratories, particularly in economically disadvantaged countries.

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Background: Sun exposure causes extensive intrinsic as well as extrinsic changes in the skin. Pathogenic effects of sun exposure such as tanning, melasma, skin cancer, and aggravation of various photodermatoses such as systemic lupus erythematosus (SLE) may be prevented by the use of sunscreens. We conducted the present study to assess the knowledge and attitudes regarding sun exposure and use of sunscreens. Methods: Two thousand and thirty-seven volunteers answered the questionnaire over a period of 2 years. All adults aged 18 years and above who voluntarily agreed to participate in the study after written informed consent were included. Results: Out of 2037 volunteers, 1242 volunteers had no knowledge of sunscreens. Sixty-eight percent of the volunteers from the upper class of society knew about sunscreens, and 86% of the volunteers from the lower middle class did not know about sunscreens. Eight-one percent of the volunteers did not suffer from sunburns. Eight-four percent of the volunteers were aware that sun exposure caused darkening, but awareness about other effects of sun exposure such as wrinkling, melasma, allergy, and photo-induced cancers was less. Most of the volunteers agreed that sunscreens protected against sun damage and tanning. Fifty-eight percent of the volunteers applied sunscreen before venturing out, and 78% of the volunteers applied sunscreen only on the face. Prevention of tanning was the most common reason for the usage of sunscreens. Cosmetic appeal and irritant potential were the prominent deciding factors in choosing sunscreens. Conclusion: Awareness about protective spectrum of sunscreens, their correct method of application, and misconceptions need to be focused on. Better product development keeping in mind the Indian conditions would help in increasing the usage of sunscreens.

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Background: Pemphigus is an autoimmune blistering disease. The common cause of death in pemphigus is septicemia which is usually secondary to cutaneous bacterial infection. Aim: The aim was to study the cutaneous bacteriological profile in patients with pemphigus. Materials and Methods: Pus for culture and sensitivity was collected from clinically infected lesions of pemphigus patients in the Department of Dermatology, St. John's Medical College Hospital, Bengaluru, from June 2013 to June 2014. Results: Of the 49 patients included in the study, 44 were suffering from pemphigus vulgaris, 4 from pemphigus foliaceus and one had pemphigus vegetans. There were 31 male and 18 female patients. The mean age of the group was 35.51 year. Mean Autoimmune Bullous Disorder Intensity Score was 17.36. About 32.7% were diabetic. About 40.81% showed the growth of Staphylococcus aureus, 12.24% of Pseudomonas aeruginosa, 6.12% of Proteus mirabilis, 4.08% of β-hemolytic streptococci and nonfermenting Gram-negative bacilli, and 2.04% of Proteus vulgaris, Staphylococcus saprophyticus, Enterococcus species, and Klebsiella species. S. aureus showed 100% sensitivity to antibiotics – tetracycline, amikacin, chloramphenicol, and netilmicin; 90% resistance was found for penicillin and 55% resistance was found for ciprofloxacin and erythromycin. Methicillin-resistant S. aureus was 30%. P. aeruginosa showed 100% sensitivity to ciprofloxacin, amikacin, gentamicin, piperacillin, piperacillin + tazobactam, and netilmicin. Conclusion: S. aureus was the most common organism showing sensitivity to tetracycline, amikacin, chloramphenicol, and netilmicin and resistance to penicillin, ciprofloxacin, and erythromycin.

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Lipedematous scalp (LS) and lipedematous alopecia (LA) are both rare conditions with an unknown etiology. LS is characterized by boggy swelling under the skin as a result of hyperplasia of subcutaneous layer. LA is basically LS associated with hair growth abnormalities such as alopecia and short broken hair. Herein, we present two patients who were diagnosed with LS and LA where case with LA had a new diagnosis of systemic lupus erythematosus.

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Background: The relationship between impaired quality of life (QoL) due to melasma and its clinical severity remains equivocal despite several studies. Aim: The aim was to study the correlation, if any, between the clinical severity and the impairment in QOL due to melasma. Methods: This cross-sectional, questionnaire-based study was conducted on a cohort of 141 patients of melasma attending the outpatient department of our referral hospital. A physician measured the severity of melasma using the melasma area and severity index (MASI), while melasma-related QoL (MELASQOL) score was calculated utilizing the validated Hindi version of the MELASQOL questionnaire filled by the patients. Correlations of these two scores with each other and with components of the demographic data were attempted using the Statistical Package for the Social Sciences, version 20. Results: Significantly greater impairment in QoL was found in patients with a history of prior use of triple combination therapy and in patients with hirsutism and/or polycystic ovarian disease. The severity of melasma was found to be significantly higher in patients with a history of recurrence and tobacco chewing. Limitations: The sample size could have been larger. Ultrasonography could have been carried out in all cases of hirsutism. Conclusion: The severity of melasma does not correlate with the impairment in QoL.

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Background: In adult patients suffering from atopic dermatitis (AD), studies investigating the co-prevalence of AD and food allergy are still scarce, and exact data are not available. Aims and Objectives: To evaluate the occurrence of food allergy to peanuts in significant relation to food hypersensitivity, inhalant allergy and to asthma bronchial and rhinitis. Materials and Methods: Altogether 332 patients of AD 14 year or older were included in the study. The complete dermatological and allergological examinations were performed in all included patients (including examination of specific immunoglobulin E, skin prick test to different food and inhalant allergens, anamnestic data about food reactions, evaluation of allergic rhinitis, and allergic asthma bronchiale). We evaluated whether there was some relation between the food allergy to peanuts and followed parameters. Pairs of these categories were entered in the contingency tables, and the Chi-square test for the relationship of these variables was performed with the level of significance set to 5%. Results: Altogether 332 persons suffering from AD were included in the study of which 120 were male and 212 were female; the average age was 27.2 year. The significant relation between the allergy to peanuts and the occurrence of food hypersensitivity (FH) reactions to tomatoes, kiwi, apples, oranges, carrot and to the sensitization to grass, trees, mites, and the occurrence of rhinitis was found. Conclusion: The significant relation between the allergy to peanuts and the occurrence of FH reactions and the sensitization to inhalant allergens and rhinitis was found. The future studies may show if the decrease in food allergy to peanuts can lead to the decrease of the occurrence of other FH reactions and sensitization to inhalant allergens and rhinitis in AD patients.

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Background: Vitiligo is a depigmenting cutaneous disorder with complex pathogenesis. Thiol compounds are well-known organic structures that play a major role in melanogenesis. Aim: The aim of this study was to determine the association between plasma thiol level and disease severity in patients with nonsegmental vitiligo. Methods: A total of 73 patients with nonsegmental vitiligo (57 generalized and 16 localized type) and age- and sex-matched 69 healthy controls were enrolled in the study. Plasma levels of native thiols, disulfides, and total thiols were measured by a novel and automated assay. Disease severity of vitiligo was assessed with Vitiligo Area Scoring Index (VASI) score. The extent, stage, and spread of vitiligo of patients were evaluated according to the Vitiligo European Task Force (VETF) system. Results: The native and total thiol levels of vitiligo patients were higher than those of healthy control group (P≤0.001 and 0.001, respectively). The median VASI score of patients was 0.7 (0.02–28.30). Univariate analyses showed that plasma native thiol levels, VETF spread score, disease duration, and vitiligo type significantly correlated with VASI scores (r=0.237, P=0.043; r=0.458, P<0.001; and P<0.001, respectively). Stepwise multivariate analysis revealed that disease duration (β=0.017; P=0.005) and spread score (β=1.301; P=0.001) were found statistically significant as independent factors on VASI score. Conclusion: Although plasma native thiol level significantly correlated with VASI scores of patients, it is not a predictive factor for vitiligo severity.

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Objective: Identification of allergens by intradermal test in patients with asthma, allergic rhinitis, and eczema. Materials and Methods: Intradermal test was performed in 100 patients of Ambala over an 8-year period to identify the common allergens. A total of 197 allergens including 50 types of pollen, 19 fungi, 17 insects, 14 types of dust, 6 animal dander, 7 types of fabric and feather and 82 types of foods, dust mite, and parthenium were tested. Results: In this study, the major allergens were pollen (51%) followed by foods (28.9%), insects (26.9%), fungus (12.6%), dusts (6.7%). Among pollen allergens, Brassica campestris (8%) was a major allergen followed by Ageratum conyzoides (7%) and Artemisia scoparia (6%) Cannabis sativa, Cynodon dactylon and Maerua arenaria (5%). Among the fungal group, Alternaria tenuis, Aspergillus flavus, Aspergillus fumigates, Candida albicans, Penicillium sp., Rhizopus nigricans (3%), Fusarium solani (2%) were found. In the insect group, mosquito (7%), ant (6%), grasshopper (5%), locust (male), moth, and house fly (4%) were the major allergens. Among the dust allergens, grain dust rice (3%), straw dust, house dust, and grain dust bajra (2%) were found. Among the food allergens, prawn (5%), almonds, Baker's yeast, Bengal gram (3%) and mushroom, mango ripe, rajma, cinnamon, chocolate, beans fresh, and areca nut (2%) were found. Conclusion: It can be said that the knowledge may help to create a mapping of allergens in this area and help to treat patients by immunotherapy or avoidance strategy.

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Background: Lichen planus is a common mucocutaneous inflammatory skin disease with a multifactorial etiology. Cytokines have a key role in its pathogenesis. In our study, we aimed to investigate the relationship between the disease severity and levels of the tumor necrosis factor alpha (TNF-α) cytokine which was considered as a primary cytokine that initiates the cytotoxicity. Materials and Methods: A total of 34 patients with lichen planus who were 18 year or older and gender-matched healthy controls were included in the study. Serum TNF-α levels were measured by human TNF-α enzyme-linked immunosorbent assay test kits and the values in the two groups were statistically compared. Results: The mean serum TNF-α levels were higher in the patient group than that in the control group. Serum TNF-α levels were not associated with oral mucosal involvement and gender. However, it was observed that the level of TNF-α was higher in older ages, both in patient and in control groups. Conclusion: It is thought that TNF-α, a proinflammatory cytokine, may have an important role in the pathogenesis of lichen planus.

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Crohn's disease (CD) is a type of inflammatory bowel disease that can affect any part of the gut from mouth to anus. It also may occur at contiguous sites, like, lip, perineal or peristomal regions or may occur at sites separated from the bowel by normal tissue referred to as metastatic CD. The condition is relatively rare and may mimic or coexist with other dermatoses. The presence of noncaseating granuloma on histopathological examination confirms the diagnosis. Here, we report a case of metastatic CD with cutaneous symptoms of long duration and presenting with vegetating plaques in the lower abdomen, groins, and vulva. The gastrointestinal disease was under remission. The diagnosis was confirmed by histopathological examination and patient responded well to topical as well as systemic steroids.

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A lady presented with indolent slowly spreading erythematous nodule on the left external ear which on histopathology showed dense monomorphic lymphoid cells in the dermis. No epidermotropism or angioinvasion was seen. Immunohistochemistry showed that the infiltrating lymphoid cells were CD8+ but CD4-. Majority of the cases of cutaneous T-cell lymphomas have a CD4+, CD8− T-cell expression. Few cases have been reported with similar CD8-positive lymphoid proliferation with a curious ear tropism.

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There are very few published studies in the literature examining the association between vitiligo and skin cancers and only some anecdotal reports about phototherapy-associated nonmelanoma skin carcinoma (NMSC) in patients with vitiligo. Herein, we report a case of an 84-year-old male with widespread vitiligo with concurrent onset of two primary cutaneous malignancies in sun-exposed vitiligo skin. The association between vitiligo and NMSC deserves further assessment. Chronic sun damage might be a possible causative factor for the development of NMSC in the vitiligo patient.

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