IADVL SIG Pediatric Dermatology (Academy) Recommendations on Hemangioma of Infancy (HOI).

Hemangioma of infancy (HOI) is a benign vascular proliferation. Though resolution is the norm, potential complications make an accurate diagnosis and early management of importance. The Indian association of dermatologists, venereologists and leprologists (IADVL) special interest group (SIG) paediatric dermatology in association with IADVL academy did an extensive analysis of the literature on the clinical features, diagnosis, and management of HOI published between 2010 and 2021. Online meetings were conducted from February 2021 to March 2022 to reach a consensus on these recommendations which are made from an Indian perspective.

IADVL SIG Pediatric Dermatology (Academy) Recommendations on Childhood Alopecia Areata.

Alopecia areata (AA) is a chronic inflammatory disease characterized by nonscarring alopecia. In contrast to adult onset AA, the epidemiology, clinical characteristics, and therapy of childhood AA are less explored. This study aims at providing recommendations for the management of childhood AA. The special interest group (SIG) in pediatric dermatology under the Indian Association of Dermatology, Venereology and Leprosy (IADVL) conducted online meetings from February 2021 to September 2021, intending to identify the critical aspects in the diagnosis and treatment of AA. The classification, diagnosis, and tools for assessment of disease activity of childhood AA have been described in this study, along with recommendations for topical and systemic therapy, including newer therapeutic options.

Recommendations for Management of Childhood Psoriasis.

Childhood psoriasis is recognized as a potential multisystem disorder and hence it is imperative to optimize disease management to arrest progression, minimize psychological burden and evolution of metabolic syndrome. Clinical practice recommendations are necessary to assist practitioners in appropriate decision making based on available evidence. Owing to the lack of Indian recommendations on childhood psoriasis, the SIG Pediatric Dermatology under IADVL Academy undertook an evidence-based approach based on published literature on the topic, between January 2000 and July 2020 to frame the recommendations.

Cutaneous manifestations of chikungunya fever.

Chikungunya fever, a re-emerging RNA viral infection produces different cutaneous manifestations in children compared to adults. 52 children with chikungunya fever, confirmed by positive IgM antibody test were seen during 2009-2010. Pigmentary lesions were common (27/52) followed by vesiculobullous lesions (16/52) and maculopapular lesions (14/52). Vesiculobullous lesions were most common in infants, although rarely reported in adults. Psoriasis was exacerbated in 4 children resulting in more severe forms. In 2 children, guttate psoriasis was observed for the first time.

Evaluation of Five Different Regimes For the Treatment of Vitiligo.

Response of vitiligo patients to five different regimes was evaluated taking only those patients who had either static or progressively increasing lesions. Selection of the regimen depended upon the clinical characteristics of the disease. Each regime was tried for at least 4 months and if a patient didnot improve with one regime, he was shifted to another regime. A patient was considered to have improved, if the lesions started regimenting or the previously progressive lesions stopped increasing further. Regime I consisted of 150 mg levamisol orally on two consecutive days per week, given to 13 cases, it resulted in improvement in 7 (53.80/o). Regime II consisted of levamisole in the same dose combined with once a day topical massage with 0.1% fluocinolone acetonide acetate cream; it led to improvement in 27 (81.8%) of the 33 cases. Regime III consisted of 3 mg betamethasone orally on alternate days combined with levamisole and topical fluocinolone; given to 32 cases, it was successful in 28 (87.50/o). A combination of 2 mg betamethasone orally alternating with 20 mg 8-methoxypsoralen and sun exposure (regime IV) caused improvement in 17 (85%) of the 20 cases. An oral mini pulse consisting of 5 mg betamethasone orally twice a week combined with 50 mg cyclophosphimide daily orally (regime V) was successful in 20 (90.9%) of the 22 cases, the remaining two cases showed unprovement when the dose ofbetamethasonc .was increased from 5 mg to 7.5 mg twice a week. Thus ultimately each one of the 91 patients responded to one or the other regime. The side effects were minimal and insignificant.The degree of improvement at the time of analysis was 100% in 23.3% cases, 50-100% in 44.2'Yo cases and less than 50% in 32.5%, after 4-14 months of treatment. It is felt that the results may be better after a longer follow-up although all patients are not expected to get complete repigmentation.

Further Studies on Pemphigus Patients Treated with Dexamethasone.

Our regime for the treatment of pemphigus consists of 100mg dexamethasone dissolved in 5% glucose given by a slow intravenous drip over 1-2 hours and repeated on 3 consecutive days. On the first day, 500 mg cyclophosphamide is also given in the same drip. Such dexamethasone cyclophosphamide pulses (DCP) are repeated once a month. In between the (DCP), the patient is given only 50 mg cyclophosphamide daily orally. During the first few methods of starting this treatment, most patients continue to get relapses of pemphigus lesions in between the DCP (phase I). After a variable period however, almost all patients stop having such relapses, but we continue to give once monthly DCP for atleast 6 months (phase II), After which the DCP is stopped and the patient continues to take 50 mg cyclophosphamide daily orally for a further period of one year (phase III). At the end of thos phase all treatment is stopped and the patients followed-up for any relapse (phase IV). Follow up of the first 100 patients, pemphigus vulgaris (92), pemphigus follaccus (6) and pemphigus erythematosus (2), has.

Passively Transferred Pemphigus in a Newborn.

A 24 yew old patient having pemphigus for the last 1 year delivered a female baby after 36 weeks of gestation. The baby had pemphigus like lesions on the skin and a single ulcer on the hard palate. The serum antibody titres of intercellular antibodies in the mother and the baby at the time of delivery were 1:80 and 1: 40 respectively. 1 The lesions in the baby healed completely by the 9th day after birth, without any specific treatment. Three months later the antibody titre in the mother was 1: 40, while in test became negative The baby the baby, the has since shown no recurrence of the lesions.

Nuts As a Cause of Contact Dermatitis of the Hands.

To evaluate contact hypersensitivity to some of the commonly used Indian nuts, patch tests were undertaken with cashew nuts, ground nuts, almonds and pistachio in 3 groups of individuals: (1) patients exposed to the corresponding nut and having dermatitis on their fingertips, (2) controls having no dermatitis, but exposed to the nut, and (3) unexposed group. A paste prepared by Cushing the nut and used as such gave positive patch test 'reactions in, all the 6 patients tested with cashew - nut, ground - nut and almonds, and these looked to be irritant reactions. Further patch tests with these three nuts were therefore done with 1:1 dilution of the paste with distilled water. The number of patients showing positive patch tests out of the total number.

Eosinophilic Spongiosis in Vesiculo-bullous Diseases.

A retrospective review of the skin biopsies of 93 patients having various vesiculo-bullous diseases seen between 1983 and 1985 revealed eosinophilic spongiosis (ES) in 31 cases. of these, 19 (36.5%) out of 52 patients having pemphigus vulgaris 2(20%) of 10 patiens having pemphigus foliaceous, one patient having pemphigus vegetans, 3 (15%) of 20 patients with bullous pemphigoid, and 3 (50%) of 6 patients with dermatitis herpetiformis had ES. The severity of eosinophilic spongiosis graded on an arbitrary scale, was 3 + in 2 cases of pemphigus vulgaris, 2 + in 7 cases of pemphigus vulgaris, 1 case of pemphigus vegetans and 2 cases of dermatitis herpetiformis, while in the remaining it was only 1 +. Only 3 patients of pemphigus vulgaris showed distinctive atypical clinical features in the form of erythema multiforme like lesions in 2 cases and erythema annulare centrifugum like lesions in 1 case. In the remaining cases the clinical presentation was not different from those who did not have ES.

Condiments and Contact Dermatitis of the Finger - Tips.

Patch tests were undertaken with 16 condiments in 4 groups of patients which included exposed patients, exposed controls, unexposed patients and unexposed controls. As the interpretation of the positive patch test reaction was similar in both the unexposed patients and unexposed controls, these two were combined into one (unexposed groups). Positive reactions were obtained in a variable number of individuals in each of these groups but the tests were generally more frequently positive and more severe in the exposed patients and exposed controls, compared to the unexposed groups. The number of patients showing positive patch tests out of the total number tested in the 3 groups respectively, with each of the agents were, cinnamon 1 (9), 0 (11), 1 (7): coriander 3 (8), 4 (12), 1 (5); clove 2 (8), 3 (16), 0 (1); cumin seeds 3 (8), 4 (11), 1 (6); fennel 3 (9), 4 (16), 0 (1); small cardamom 1 (8),6 (17), 0 (0); large cardamom 3 (8) 3 (11), 0 (7); asafoetida 1 (5), 3 (7), 5 (13); Indian cassia 0 (2), 3 (16), 1 (8); mustard seeds 5 (8), 4 (15) 0 (2); red chillies 2 (7), 6 (21), 0 (0); turmeric 3 (6), 8 (15) 1 (5); tamarind 0 (3), 0 (6), 3 (16); dried mango powder 0 (2), 3 (6), 1 (17); Jaggery 0 (1), 2 (4), 2 (20) and ginger 7 (22), 0 (4), 0 (0). These were considered unikely to be irritant reactions, because in the case of irritant reactions, the frequency of positive reaction is expected to be much more. However, this could not be excluded completely without further studies with standardized antigens and their dilutions.

Low Dose Cyclophosphamide Therapy in Lichen Amyloidosis.

Nine patients (5 males and 4 females) with lichen amyloidosis were treated with 50 mg cyclophosphamide orally daily for 6 months to 1 year. Itching was decreased by 80 - 90% in all the 9 patients within 4 months, and 4 patients showed 50-75% improvement at the end of,6 months but subsequently there was no further improvement. In the other 3 patients, ,there 'was no change, in the papules during a follow - up of 6 months. The side effects possibly attributable to cyclophosphamide included a reversible leucopenia. (less than 4000-mm3) in one patient and transient diffuse alopecia in 3. 3.