Background An alarming increase in recalcitrant dermatophytosis has been witnessed in India over the past decade. Drug resistance may play a major role in this scenario. Objectives The aim of the present study was to determine the prevalence of in vitro resistance to terbinafine, itraconazole and voriconazole in dermatophytes, and to identify underlying mutations in the fungal squalene epoxidase (SQLE) gene. Patients/Methods We analysed skin samples from 402 patients originating from eight locations in India. Fungi were identified by microbiological and molecular methods, tested for antifungal susceptibility (terbinafine, itraconazole, voriconazole), and investigated for missense mutations in SQLE. Results Trichophyton (T.) mentagrophytes internal transcribed spacer (ITS) Type VIII was found in 314 (78%) samples. Eighteen (5%) samples harboured species identified up to the T interdigitale/mentagrophytes complex, and T rubrum was detected in 19 (5%) samples. 71% of isolates were resistant to terbinafine. The amino acid substitution Phe397Leu in the squalene epoxidase of resistant T mentagrophytes was highly prevalent (91%). Two novel substitutions in resistant Trichophyton strains, Ser395Pro and Ser443Pro, were discovered. The substitution Ala448Thr was found in terbinafine‐sensitive and terbinafine‐resistant isolates but was associated with increased MICs of itraconazole and voriconazole. Conclusions The high frequencies of terbinafine resistance in dermatophytes are worrisome and demand monitoring and further research. Squalene epoxidase substitutions between Leu393 and Ser443 could serve as markers of resistance in the future.

Melasma is a localized, chronic acquired hypermelanosis of the skin. Despite several treatments available, melasma can often be refractory to treatment. Also recurrences are common. Tranexamic acid is a new addition in treatment of melasma and is effective in dosage of 250 mg BD for atleast 4 to 8 weeks. Tranexamic acid acts mainly via the plasminogen activator-plasmin system to prevent UV radiation induced pigmentation in melasma. This article reviews the mechanism of action of tranexamic acid in melasma and current evidence in literature for use of tranexamic acid in melasma.

Background Umbilical granuloma is an overgrowth of granulation tissue following the separation of umbilical cord. Treatment options for this common entity are limited and have side effects such as chemical burns. In this study, we present a novel modification of the salt application method to treat infants with umbilical granuloma. Methods Seventeen infants were recruited in our study after institutional ethics committee approval and consent from the parents. The area of application was cleaned, and common table salt was carefully applied over the lesion. The granuloma was then occluded with surgical adhesive tape for 24 hours. Cases were followed up the next day to remove the occlusive tape and for assessment of improvement. Results All seventeen cases responded well to this approach with complete resolution of lesions at 24 hours. Small clotlike shrunken tissue was found at the site of granuloma, which was easily scraped off during gentle cleansing. No major complication or recurrence was noted in 3 months of follow‐up. Conclusion Complete resolution of umbilical granuloma can be achieved with a single, clinic‐based application of salt under occlusion for 24 hours. Salt causes shrinkage of granuloma inside occluded hyperosmolar chamber by desiccant effect. The salient features of this method include ease of application, low cost of treatment, accurate one‐time physician‐controlled application, and complete and rapid resolution without complication.

Treatment of melasma is known to be less satisfactory, often incomplete, and relapse is frequent. Although many treatment options are available, they are either known to be unsafe on long-term use or their long-term safety profile is unknown. Patients often use various drugs, even topical steroid-based preparation without any medical supervision for long period of time, making the skin unsuitable for many of the drugs available. Thus, there has been gross disparity among the treating physician about what drugs and what regimen are best suitable for various categories of melasma patients and in different situations. With this background, numerous newer drugs, mostly combinations of some proprietary molecules or even unknown plant extracts, have flooded the market for the management of melasma. Information on efficacy or safety of these products are almost unknown. Studies on Asian people, especially Indian population, are far less commonly available. Therapeutic guideline for use on Indian patients with melasma is almost missing. Extrapolation of data from Caucasian people for use on Asian people may not be scientifically justifiable because Caucasian and Asian people are known to have inherent difference in their response as well as tolerance to the drugs used for melasma. With this background, we have extensively evaluated, following a strict, scientifically designed protocol, all the available studies on melasma management till May 2016 and prepared this document on level of evidence, grade of recommendation and suggested therapeutic guideline for melasma as per the method proposed by Oxford Centre of Evidence-Based Medicine. Various ethical, social, logical, regional, and economic issues in the context of Indian and similar populations were given due importance while preparing the suggested therapeutic recommendation.

Association of vitiligo with other autoimmune diseases emphasizes autoimmune aetiology of vitiligo. This study also emphasizes the need to actively look for, and if necessary, investigate patients with vitiligo for other autoimmune diseases.

A 12-day-old neonate presented with ill-defined dark pigmentation over the centrofacial area with flagellate pigmentation on the trunk and patchy pigmentation on the extremities. The mother had a history of fever starting a week before delivery and continuing for 3 days in the postpartum period. Together these led to consideration of a possible diagnosis of congenital chikungunya, which was confirmed according to the immunoglobulin M antibodies to chikungunya in the mother and child. The rare occurrence of cutaneous pigmentation was the only clue to the retrospective diagnosis of neonatal chikungunya. Chikungunya is an emerging viral disease that can be transmitted maternally during pregnancy and in the peripartum period. It can be added to the list of viral infections that can lead to fetal demise or, when present during labor and delivery, can cause neonatal disease with cutaneous signs.

Background: Recent years have seen an alarming rise in the prevalence of recalcitrant and relapsing dermatophyte infections in India associated with lack of clinical response to standard antifungal regimens. Aims and Objectives: A study was undertaken to identify the antifungal susceptibility patterns of dermatophyte species isolated from lesions of dermatophytoses in patients examined at our center. Materials and Methods: A total of 85 patients with clinically diagnosed dermatophytoses were subjected to skin scrapings for potassium hydroxide mount (microscopic examination) and culture using Sabouraud's agar medium containing chloramphenicol and cycloheximide (incubated at 30°C). Antifungal susceptibilities [minimum inhibitory concentration-90 (MIC-90)] of the identified dermatophytes were tested for seven systemic and topical antifungal agents (terbinafine, griseofulvin, itraconazole, fluconazole, sertaconazole, ketoconazole, and clotrimazole) using Clinical and Laboratory Standards Institute broth microdilution method (M38-A). Results: Trichophyton rubrum (50%) and Trichophyton mentagrophytes complex (47.2%) were the two major species isolated. Isolates of both showed downy and granular forms (61.11%, 38.89% and 32.35%, 67.65%, respectively). The overall in-vitro susceptibility profiles (MIC-90 ranges in μg/mL) of the seven drugs for T. rubrum and T. mentagrophytes complex respectively were as follows: terbinafine (0.008–0256, 0.016–0.256), griseofulvin (0.03-1, 0.06–1), itraconazole (0.125-2, 0.25–2), fluconazole (0.125–1, 0.25–32), sertaconazole (0.03-1, 0.03-1), ketoconazole (0.06–1, 0.125–1), and clotrimazole (0.03–2, 0.06–1). Conclusions: This study indicates a rising proportion of T. mentagrophytes complex with increased proportion of granular form ( T. mentagrophytes var. mentagrophytes ). This study represents the current antifungal susceptibility profile of dermatophytic infections in a tertiary care medical center in western India with rising MICs to terbinafine and itraconazole.

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