Background: Vitiligo is a dermatological challenge with a major socio-psychological concern. Despite the availability of numerous medical and surgical treatment options, a single universally reliable therapeutic modality is yet to emerge due to the variability of response rate in different patients. Purpose: The objective of this study was to assess the safety and efficacy of microneedling along with topical 5-fluorouracil (5-FU) solution application in localized stable vitiligo. Methods: This open, nonrandomized, single-arm study was enrolled with 100 patients with localized stable vitiligo. Microneedling with topical 5-FU solution application was performed on 204 patches. The procedure was performed fortnightly for maximum 6 months. Results: At the end of 3 months, good to excellent (Grade IV) repigmentation was noted in 106 patches (51.96%) and Grade I to Grade II repigmentation was seen in 56 (27.45%) patches whereas at the end of follow-up, 128 (62.74%) patches showed good to excellent response. Conclusion: In conclusion, the results of this study showed that needling with 5-FU is a simple, cost-effective, and well-tolerated procedure which can be used as an alternative or additive modality in the treatment of localized stable vitiligo.

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Background: Atopic dermatitis (AD) is associated with increased burden and reduced health-related quality of life (HRQoL); however, there is no available Bengali questionnaire assessing the same. Purpose: We aimed to develop the Bengali version of the questionnaire and examine its cross-cultural adaptability considering linguistic equivalence. Methods: A multicentric, mixed methods, cross-sectional study was conducted through the consecutive sampling at the outpatients of three homeopathy hospitals in West Bengal. The Bengali version of the questionnaire was produced by standardized forward-backward translations. Psychometric analysis was run to examine its factor structure, validity, and reliability. Reliability was examined using internal consistency (n = 230). Construct validity was examined by the exploratory factor analysis (EFA; n = 115) using the principal component analysis (PCA; varimax rotation). Subsequently, confirmatory factor analysis (CFA; n = 115) was performed to verify the model fit. Results: The internal consistency (Cronbach's α =0.876 (95% confidence interval 0.851–0.898)), test-retest reliability and concurrent validity – all were within the acceptable limits. The Kaiser-Meyer-Olkin (KMO = 0.793) and Bartlett's test of sphericity (Chi-square: 1038.981 at 153° of freedom, P < 0.001) both suggested adequacy of the sample. In factor analysis using varimax, all the items loaded above the prespecified value of 0.4 and identified five components, explaining 68.3% of the variation. The goodness-of-fit of the 5-components model in CFA was also acceptable (comparative fit index = 0.858, Tucker Lewis index = 0.823, root mean square error of approximation = 0.102, and standardized root mean square residual = 0.188). Conclusion: The Bengali version of the questionnaire consisting of 18 items and framed within five components appeared to be a valid and reliable instrument measuring disease burden and HRQoL in adults suffering from AD.

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Background: Knowledge and positive attitude toward vitiligo would foster support for affected individuals, improving their sense of well-being and possibly treatment outcome. Purpose: To evaluate the levels of public knowledge and attitude toward vitiligo among Saudis. Methods: A cross-sectional study among 12,181 participants. Data were collected using a self-administered questionnaire enquiring about knowledge, attitude, and perceptions in vitiligo. Results: The response rate was 95.4%. Most respondents had heard about vitiligo (96.9%). The median knowledge score was four out of eight and median attitude score was six out of eight. Social media/Internet was the most commonly reported source of information (34.7%), followed by family/friends/acquaintances (30%). Higher proportions of correct responses were recorded regarding the noninfectious nature of vitiligo (85.0%) and whether vitiligo was dangerous or connected to skin cancer (63.4%). However, unsatisfactory responses were found regarding the immunological basis of the condition: only 24.3% knew that vitiligo was an immune disease and 24.5% knew about the role of heredity in vitiligo. The majority of respondents did not mind employing patients with vitiligo (89.0%). Only 40.6% responded that they would marry someone with vitiligo. Positive attitude was significantly common in respondents aged 31–50 years (P < 0.01), women (P < 0.01), and those who had a university degree or higher (P < 0.05). Conclusion: Although overall attitude toward vitiligo patients was positive, there were gaps in the knowledge, particularly regarding the nature of the disease. More awareness and education are required to improve attitude toward vitiligo patients, with an aim to improve their overall well-being.

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Background: Misuse of topical corticosteroids (TCS) is common and constitutes a serious problem in many parts of the world where they can be obtained without prescription. Limited studies have been performed in Saudi Arabia to address this issue. Purpose: We aim to study the prevalence, predisposing factors, and adverse consequences of TCS use without prescription in Saudi Arabia. Methods: A cross-sectional study was performed using an Arabic questionnaire distributed through social media applications in May 2020 in Saudi Arabia. Individuals aged 18 years and above who used TCS within the last 2 years were included. The questionnaire consisted of detailed questions about TCS use and demographic information. Results: A total of 720 participants completed the questionnaire. TCS were used without prescription by 43.1% of respondents. Being female was the only identified risk factor for the use of TCS without prescription. The main reason for purchasing TCS without prescription was that the problem seemed too trivial to consult a physician (36.6%). The most common conditions for which TCS were used were treatment of pruritus without skin disease (23.7%) and cosmetic reasons (19.9%). Side effects were reported in 25.6% of participants. The most common side effects were hypopigmentation, itching, redness, and skin sensitivity. Conclusion: The use of TCS without prescription is prevalent in Saudi Arabia. We recommend that local health authorities regulate the use of TCS.

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Janus kinase (JAK) inhibitors have been identified as an effective treatment option for severe alopecia areata (AA), but response is variable among patients. Intramuscular triamcinolone acetonide (IMTA), which has a greater bioavailability than other forms of steroids, has been used effectively to treat refractory AA with very few side effects. However, the use of IMTA in combination with JAK inhibitors is not well characterized. We present two patients with severe patch type AA and alopecia totalis who failed to achieve substantial regrowth after at least 6 months of oral tofacitinib and were treated with a single dose of IMTA 60 mg. Both patients had more than 50% increase in hair regrowth in areas of hair loss that had persisted on tofacitinib with no reported adverse effects.

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Immunocompromised patients, including those with acquired immunodeficiency syndrome (AIDS), are susceptible to a variety of opportunistic infections, cutaneous malignancies, and other skin lesions, which can present with nonspecific cutaneous findings. Herein, we present the case of a 28-year-old male with AIDS who presented with fatigue, left axillary lymphadenopathy, and a necrotic, red papule on the left upper arm. This case reviews the differential diagnosis of this presentation in an immunosuppressed patient including the key pathological findings.

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Prurigo pigmentosa (PP) was originally reported in Japan. It is an uncommon inflammatory skin disorder that usually involves the neck and trunk and characterized by a sudden eruption of pruritic indurated macules, papules, and Vescio papules that involute, leaving a reticulated pigmentation. It commonly affects young adult females. PP was initially thought to have a predilection for the Asian race, however several cases have been reported worldwide. The exact etiology of PP is yet unclear. However, it has been associated with ketosis and a ketogenic diet. Oral antibiotic is a major treatment in this disorder, while topical steroid and antihistamines are not successful.

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Background: Viral cutaneous infections have impact globally due to several factors, including changing rates of atopic dermatitis (AD), vaccination rates, and access to trained dermatologists. Furthermore, advancements in treatments and access to vaccinations suggest an association between the wealth of countries and the burden of their disease. Purpose: The overall purpose of this study is to better understand the global impact of viral skin disease across differing demographics and time periods, as well as the burden in relation to national wealth. Methods: In this article, the prevalence, incidence, and years lived with disability (YLDs) were analyzed for viral cutaneous infections in 195 countries from 1990 to 2019, using the global burden of disease dataset. Furthermore, the disease burden was assessed as a function of gross-domestic product (GDP) and AD. Results: The prevalence of individuals affected by viral skin diseases is approximately 154 million globally. Young children (1–9 years old) were more likely to be affected. The age-standardized prevalence rates per 100,000 in the Americas and Asia decreased between 1990 and 2019 from 2819 to 2650 and from 2074 to 1906, respectively. This decrease was outside the 95% uncertainty interval. Increased GDP predicted increased prevalence and YLD (P < 0.0001). There was a relationship between 1 year lived with disability per capita of AD and an increase of 0.14 (0.07, 0.21) cases of viral skin diseases (P = 0.002). Conclusion: The increase in disease burden with increased GDP may be correlated to decreased access to dermatologists in developing countries. An increased burden with AD is likely due to skin barrier and immune regulatory dysfunction. The morbidity of skin diseases demonstrates the need for increased access to vaccination campaigns and dermatologic care across developing nations.

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Background: Androgenic alopecia (AGA) is a common type of chronic progressive hair loss that affects both males and females. AGA was shown to be associated with metabolic syndrome (MS) in many studies; the correlation between the AGA grade and MS, however, is still debatable. Purpose: The objective of the study was to assess the severity of AGA in a sample of patients suffering from this condition and its association with MS. Methods: This case–control study included 319 patients attending a dermatology clinic at a tertiary care hospital. Anthropometrics, blood pressure, lipid profile, and fasting blood sugar were collected from patients' records. Patients with AGA were allocated to the case group and were stratified based on severity using the Ludwig hair loss scale for females and the Norwood scale for males. The control group was composed of patients free of any hair condition. Data were analyzed using version 25 of SPSS. Results: MS was seen in 26.4% and 10.2% in cases and controls, respectively (P < 0.05). In terms of severity, MS was found in 21.6% of Grade I, 30.5% of Grade II, and 42.9% of Grade III patients. Although the findings showed no statistical significance (P > 0.05), the burden of MS was associated with the severity of AGA. Conclusion: Our findings suggest an association between MS and AGA and that burden of MS is associated with the severity of AGA, although the analysis showed no statistical significance. Based on our results, we think that early screening for MS might be beneficial to patients with AGA, as this will encourage early lifestyle modification to hopefully prevent future complications.

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Background: Vitiligo is a common, acquired, idiopathic, depigmenting disorder with a profound effect on the patient's quality of life (QoL). Purpose: The objective of the study was to measure the QoL of patients with vitiligo using the dermatology life quality index (DLQI) and to assess psychiatric comorbidity in vitiligo patients using the General Health Questionnaire-28 (GHQ-28). Methods: Sixty patients above 16 years of age with vitiligo were enrolled. Age, sex, occupation, marital status, duration of disease, extent of involvement, visibility of lesions, details of treatment, duration of treatment, and response to treatment were collected. Independent t-test and ANOVA were used to test for significance of continuous variables and Chi-square test for categorical variables. Correlation between DLQI and GHQ-28 was assessed using Spearman's rho correlation coefficient. Results: Females scored higher than males on overall GHQ-28 scores and in individual domains of anxiety/insomnia, social dysfunction, and severe depression. Unmarried participants had higher scores compared to married subjects in all dimensions of DLQI and GHQ-28, indicating worse QoL and mental health. Conclusion: More than half of vitiligo patients had psychiatric comorbidity. There was a strong correlation between DLQI and GHQ-28 score, indicating strong association of QoL impairment with psychological problems. Proper counseling of patients of vitiligo along with specific treatment may be prudent.

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Background: Nail is an important structure both functionally and cosmetically. Nail examination is an integral part of a complete dermatological examination and can provide a clue in the diagnosis and severity of skin diseases. Purpose: The aim of the study is to study the pattern of nail changes in various dermatoses. Methods: The present study was a cross-sectional study conducted among 550 patients attending dermatology outpatient department in a tertiary care center in North India. A prestructured pro forma captured detailed demographic profile, clinical examination related to various dermatoses, and associated nail changes. KOH examination, fungal or bacterial culture, nail biopsy, and radiographic studies were done when indicated. The data analysis was done using the Statistical Package for Social Sciences (SPSS) version 21.0. Results: Majority of patients had onychomycosis (48%) followed by psoriasis (29%), paronychia (5%), vitiligo (4.7%), lichen planus (4%), and alopecia areata (2.3%). Twenty-nail dystrophy was noticed in three patients. The most common type of onychomycosis was distal lateral subungual onychomycosis (89%). Pits were seen in all psoriatic patients. Longitudinal ridges were the most frequent nail change in lichen planus (83%) and vitiligo (80%). Conclusion: Nails, in spite of being easily accessible for examination, are often overlooked. A variety of nail changes occur in various dermatological conditions and may be helpful in achieving a diagnosis.

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Background: Isotretinoin causes dryness of the mucous membranes. Medications altering the salivary flow are a risk factor for dental caries. Purpose: To prospectively assess caries and salivary flow in patients taking systemic isotretinoin. Methods: Twenty-four patients treated with 0.5 mg/kg of isotretinoin every day for 8 months were studied. The control group was the same patients before start taking oral Isotretinoin. Salivary flow, buffer capacity, bacterial tests, and caries status based on the decay, missing, and filled teeth (DMFT) index were assessed. Results: At baseline, there was slight to moderate calculus on the teeth. DMFT index, stimulated saliva flow, and bacterial tests for Streptococcus mutans increased during isotretinoin treatment (P < 0.05). There was no significant difference (P > 0.05) in buffering capacity or Lactobacillus. Conclusion: Systemic isotretinoin increased the DMFT index and bacteria rate and decreased salivary flow that might lead to dental caries.

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Background: Finasteride, a type II 5-α reductase inhibitor, is approved for the management of benign prostate hyperplasia and male pattern hair loss. Finasteride is used off-label for female pattern hair loss. In utero fetal exposure to finasteride might lead to external genital anomalies in males. Purpose: The aim of this study is to assess the outcomes of in utero finasteride exposure. Methods: We report seven pregnant women with maternal exposure to finasteride. A detailed history was obtained from patients after delivery. Results: In one woman who was pregnant with twin boys, one boy died at the 16^th week of gestation and the other delivered at the 34^th week of gestation with hypospadias. Another woman had threatened abortion and delivered a normal healthy baby girl. A third had induced elective abortion in the 9^th week of gestation. The outcomes of the other four pregnancies were completely healthy, three girls and one boy. Conclusion: External genital anomalies may occur in male fetuses exposed in utero to finasteride depending on the timing of exposure.

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Background: Dermatologic surgical procedures are expanding. Residents' training in procedural dermatology must evolve with the changes in the field. Purpose: We assessed the current status of surgical dermatology training in all Saudi Commission for Health Specialties (SCFHS)-accredited dermatology residency programs in Saudi Arabia. Methods: The survey was mailed to all 4^th-year dermatology residents who completed the full 4 years of training at 5 SCFHS-accredited dermatology residency programs in December 2020. Statistical software SPSS (Version 22) was used to analyze responses. Results: A total of 26 4^th-year residents participated, with a response rate of 89.6%. About 53.8% of the participants were equally assigned as the primary surgeons in laser for acne scar treatment and botulinum toxin for hyperhidrosis. Most of residents reported higher levels of nonexposure, especially for hair transplant procedures at 88.5%, fat transfer at 84.6%, fillers injection, and chemical peels at 65.4%. Regarding Mohs surgery, 73.1% of them are only knowledgeable through lectures and observations, without any hands-on training. The majority of residents (92.3%) were not satisfied with their dermatologic surgery training during residency. Conclusion: Residents express dissatisfaction with procedural and surgical dermatology training. Exposure in important areas of dermatologic surgery training could be better.

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Background: Hidradenitis suppurativa (HS) is a chronic recurrent painful auto-inflammatory skin disease of the terminal hair follicle, causing nodules, abscesses, sinus tracts, and scars on intertriginous areas. Purpose: This study aims is to determine the effect of HS on patients' psychology and quality of life in the Makkah population. Methods: This is a cross-sectional, multi-center study conducted on HS patients who visited the dermatology clinic during 2017−2020. A total of 165 patients participated in the study by completing a questionnaire consisting of demographic data, the dermatology life quality index, depression, anxiety, and stress score. Results: In total, 147 patients were included in the final analysis, and the mean age of the participants was 32.0 ± 10.6. HS had a very large effect on the quality of life of 32% of the participants. Quality of life was worse with the number of flares per year (P < 0.003) and with axillary and perianal involvement, (P < 0.018 and P < 0.024, respectively). Moreover, a higher level of depression was associated with a higher body mass index (P < 0.020). Conclusion: HS had a large effect on the quality of life regardless of Hurley stage and was correlated with the number of flares per year and area of disease involvement.

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Background: Collagen induction therapy is a form of microneedling. It is cheap and effective and has less side effects than other alternative therapies. Purpose: It is done using dermaroller for the treatment of scars, wrinkles, stretch marks, hair growth, and transdermal delivery of substances like lipopeptides and antiaging products. Methods: It acts by stimulating collagen production, produces microwounds and thus release of various inflammatory mediators. It also increases electric potential, thus inducing cellular activity with release of cytokines and growth factors leading to wound healing with collagen induction. Results: There are various new modified instruments, and combination with other modalities of treatment increases its utility in different dermatological and cosmetic conditions. Conclusions: Microneedling is a simple, inexpensive procedure with no down time and good results in acne scars, hair loss and wrinkles.

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Background: Primary cutaneous gamma delta T cell lymphoma (PCGD TCL) is a rare and rapidly progressive cutaneous malignancy that can be diagnostically challenging. Purpose: To improve characterization of the clinical and histologic features of PCGD-TCL. Methods: We present two patients with PCGD TCL and review an additional 97 PCGD TCL cases from the English literature. Results: A 51 year old male with biopsy proven psoriasis and a previously healthy 31 year old male with vitiligo developed PCGD-TCL. Initial biopsy specimens in both patients suggested tumor stage mycosis fungoides (MF), but subsequent histopathology confirmed PCGD TCL. Ninety-seven patients were identified in the literature, mostly males (53%) with a mean age of 55.2 years. Lesions most commonly involved the lower (60%) and upper (30%) extremities and existed a mean of 26 months before diagnosis. The most common immunohistochemical markers were EBV(-), CD3(+), CD4(-), CD5(-), CD7(-), CD8(-), CD30(-), CD56(+), granzyme-B(+), perforin(+), and βF1(-). Radiation and CHOP chemotherapy were the most common interventions and 52% of patients died. Conclusion: PCGD TCL is a devastating disease that can clinically and histologically mimic more common dermatologic conditions, such as psoriasis and MF, and its diagnosis may require multiple biopsies and review by a multi specialty pathology team.

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