Pigment International

How to limit medicolegal “scarring” in dermatology? Madhulika Mhatre, Aseem Sharma Pigment International 2019 6(1):1-3 The field of dermatology, and pigmentary disorders, specifically, has undergone a sea of positive changes since the turn of this millennium. The flip side to this change has been the influx of law into the realms of dermatology. Ego medicolegal issues are on the rise, caused by a variety of factors: the rise of interventional procedures, overpromising and underdelivering by physicians, quackery, and Internet awareness, to name but a few. Needless to say, a dermatology practitioner today will most likely be introduced to the medicolegal world, given the increased incidence of the aforementioned. And it is common knowledge that medical schools and residency colleges do not cater to these specific needs of medicolegal education even though serious efforts are being made to bridge this gap.

Current understanding of lichen planus pigmentosus, erythema dyschromicum perstans (ashy dermatosis), and idiopathic eruptive macular pigmentation Michelle Rodrigues, Amit G Pandya, Marcel Bekkenk, Davinder Parsad, Sujith P Kumarasinghe Pigment International 2019 6(1):4-8 Lichen planus pigmentosus, erythema dyschromicum perstans and idiopathic eruptive macular pigmentation are the three most commonly accepted subtypes of acquired dermal hyperpigmentary disorders. While some patients fit easily into one of these subtypes, others do not. Overlapping features of several subtypes may also be seen in the one patient. This paper covers these three entities in detail and highlights the diagnostic and classification challenges.

Animal models in disorders of skin color − utilizing evolution and demystifying mysteries Kiruthika Subburaj, Seema Manjunath, Muthu Sendhil Kumaran Pigment International 2019 6(1):9-17 Disorders of pigmentation are commonly encountered in dermatology outpatient clinics. Among hypopigmentary conditions, vitiligo is the most common disorder whereas hyperpigmentation can be attributed to multiple etiologies. The pathogenesis of these disorders in humans are still poorly understood. Animal models have been extensively studied and analyzed to pave way for understanding pathology as well as employ targeted treatment. In this study, we will discuss about the animal models that provide insight about pigmentation disorders.

A comparative study of topical 5% tranexamic acid and triple combination therapy for the treatment of melasma in Indian population Sandeep Khuraiya, Dilip Kachhawa, Bharti Chouhan, Mitali Dua, Pankaj Rao Pigment International 2019 6(1):18-23 Introduction Melasma is an acquired hyperpigmentary disorder and poses great therapeutic challenge and has a high recurrence rate. Topical 5% tranexamic acid (TA) is a novel and safe alternative therapy for melasma. The aim of our study was to evaluate the efficacy of topical solution of 5% TA and compare it with triple combination therapy (hydroquinone, tretinoin, fluocinolone) in Indian population. Materials and Methods This was a prospective comparative study of 12 weeks. A total number of 25 patients between 18 and 50 years of age were included in the study. Patient’s face was divided into two halves (split face), and on one half of the face (i.e., on left), topical 5% TA and on the other half of the face (i.e., on right), topical triple combination therapy were applied. The melasma area severity index (MASI) and side effects were evaluated at baseline and every 15 days. Photographs were taken at alternate visits (i.e., 30 days) and compared with earlier one by an independent observer. Results The study was completed on 23 patients. The mean MASI scores decreased significantly in both the groups (P < 0.05), but there was no significant difference between them (P > 0.05). However, the side effects of triple combination therapy were significant compared with TA. At the end of 12 weeks, in group 1, photographic evaluation showed excellent response in 26%, good response in 60.1%, fair response in 8.6%, and poor response in 4.3%. In group 2, there was excellent response in 34.7%, good response in 56.5%, fair response in 4.3%, and poor response in 4.3%. Conclusion This study revealed that the topical 5% TA is a safe effective, and better alternative with good patient acceptance for the treatment of melasma. The study revealed improved pigmentation in both tested sides, but topical 5% TA has less side effects such as erythema, irritation, and telangiectasia as compared to triple combination.

Pigmentary adverse effects of chemotherapeutic agents Neerja Saraswat, Shekhar Neema, KPS Sengar Pigment International 2019 6(1):24-28 Introduction: Skin and mucosa are most susceptible to the adverse effects of chemotherapeutic agents due to rapid rate of proliferation. A wide array of these adverse effects has been reported in patients undergoing chemotherapy. Although mostly of cosmetic significance, few of these side effects may require alteration or suspension of therapy and reduce the likelihood of therapy completion. This study was undertaken to know the spectrum of skin pigmentary issues seen in these patients. Material and Methods: A total of 153 patients on chemotherapy for various malignancies from oncology department of the hospital were screened for cutaneous adverse effects over a period of 3 months. Relevant details and chemotherapy protocol followed were assessed. Cutaneous examination was done in daylight and photographs were taken. The data was analyzed at the end of 3 months. Results: Ninety-one (59.4%) patients had cutaneous adverse effects due to chemotherapeutic agents. Colorectal carcinoma was most common malignancy seen in 27 (29.6%) patients. Hand–foot hyperpigmentation was most common adverse effect seen in 67 (73.6%) patients followed by supravenous hyperpigmentation in 14 (15.3%), oral hyperpigmentation in four (4.3%), and flagellate hyperpigmentation and melisma-like pigmentation in three (3.2%). Capecitabine was most common drug resulting in hand–foot hyperpigmentation in 29 (43.2%) patients whereas docetaxel resulted in supravenous hyperpigmentation in five (35.4%) patients. Flagellate hyperpigmentation was seen with bleomycin and oral pigmentation exclusively noticed with capecitabine. Conclusion: Cutaneous adverse effects of chemotherapy are common but rarely reported. It is important to understand the entire spectrum of these side effects and allay the anxiety associated with them.

Keloids coexisting with vitiligo − A rare case series Rayna T Velurethu, Murugesh B Shamanur, Viswanath K Belluli Pigment International 2019 6(1):29-32 Background Hypertrophic scars and keloid scars are a result of abnormal wound healing, in which the key feature is the excess collagen fiber secretion by fibroblasts that have been stimulated by α-melanocyte-stimulating hormone, produced by the melanocytes. Vitiligo is a common depigmenting skin disorder characterized by a total absence of the melanocytes microscopically. The observation that keloids do not occur in albinous or vitiligo patches has consolidated the theory that the melanocytes are linked to the proliferation of fibroblasts, which are central to the development of keloids. To the best of our knowledge, there is only one previous report of keloids arising over vitiligo patch. Case Series We observed three patients with keloids arising from a pre-existing vitiligo patch. All keloids were preceded by trauma. Two out of the three patients showed leucotrichia in the patch where keloid had developed. In two of our patients, we observed both a reduction in the size of the keloids as well as the repigmentation of the patches at a shorter span of time on using 5-fluorouracil as a treatment modality. Discussion According to a few studies, the number and activity of the melanocytes in the skin can be postulated to play a dominant role in pathological scar formation. However, we found three patients in whom keloids had developed on vitiligo patches. This suggests that fibroblast proliferation in keloids may not be completely dependent on just stimulation by αMSH secreted by the melanocytes, and that several other pathways may be at play to stimulate the FGF and TGF factors, which are considered central to the development of keloid.

Exogenous ochronosis in an elderly Indian male: A case report Chapalamadugu S Sindhu, Cordelia Babitha, Anuradha Priyadarshini, Mahalakshmi Veeraraghavan Pigment International 2019 6(1):33-36 Exogenous ochronosis (EO) is an infrequent cutaneous disorder characterized by blue-black hue in the skin due to the deposition of small ochre-colored pigment in the dermis secondary to prolonged skin lightening agents or unprotected sun exposure. We describe a case of a 65-year-old male who presented to our hospital with a history of hydroquinone application for melasma and was diagnosed to have acquired ochronosis after subsequent extensive history taking, clinical, dermoscopic, and histopathological assessment. EO is not frequently reported as it is misdiagnosed as melasma in most of the Asian population. In such a situation, histopathological examination of the skin lesion remains a gold standard for diagnosis of the condition. EO is a cosmetic disfigurement over the face with unsatisfying treatment options.

Mucocutaneous hyperpigmentation as presentation of vitamin B12 deficiency: A case report and brief review Prachi V Agrawal, Yugal K Sharma, Kirti S Deo, Rahul H Ranpariya, Pallavi Singh Pigment International 2019 6(1):37-42 Vitamin B12 deficiency presents usually with hematologic, gastrointestinal, neurologic, and less commonly, psychiatric, cardiovascular, and dermatological manifestations. A 20-year-old female presented with palmoplantar hyperpigmentation, accentuated over creases and knuckles. She also had intertriginous, perioral/intraoral hyperpigmentation, and gray, thin, lustreless hair. She consumed nonvegetarian diet occasionally. Histopathology revealed increased pigmentation of stratum malpighii. Hemoglobin, vitamin B12, and folate levels were reduced; RBC indices, deranged and parietal cell antibodies, weakly reactive. Pernicious anemia was diagnosed; the patient responded to intramuscular cobalamin injections. Review of Indian and global cases/case series of this deficiency with mucocutaneous presentation iterates knuckle hyperpigmentation to be its prime clinical marker. However, the nonvegetarians comprising a majority of participants in case series from India of vitamin B12 deficiency presenting with hyperpigmentation is confounding and necessitates reassessment with larger future studies. Moreover, increased awareness of the mucocutaneous signs—often nonspecific, subtle, or asymptomatic—of this widely pervasive deficiency among Indians may facilitate prompt management and rectify underreporting.

Risperidone-induced hyperpigmentation Pooja Bains, Simplepreet Kaur, Tanreet Kaur Pigment International 2019 6(1):43-45

Enhanced repigmentation of vitiligo by topical minoxidil and excimer lamp treatment Vangelis George Kanellis, Monisha Gupta Pigment International 2019 6(1):46-47