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The patient comes with erythema and papules on facial convexities (central face), a characteristic feature of acne rosacea.

It is triggered by exposure to sunlight, spicy food, alcohol, or emotional disturbances. Patients also develop telangiectasia later. They also have a tendency for developing rapid flushing due to temperature change. Rosacea is more common in women of age 30-50 years.

The innate immune response in rosacea appears to be altered. There is increased Tolllike receptor 2 (TLR2) activity and increased protease activity.

Demodex mite proliferation in the pilosebaceous follicles of the face has also been suggested as a possible aetiological factor in cutaneous and ocular inflammation. The pathogenesis of ocular rosacea seems to be closely associated with meibomian gland dysfunction.

The table below shows the 4 subtypes and the corresponding treatment options. The subtypes are not equivalent to the progression of the disease.

The image below shows rosacea.

Subtype

Erythematotelangiectatic ros acea (ETTR)

Treatment

Sun avoidance and protectio nTopical ° receptoragonists

- brimonidine or oxymetazoli ne

Subtype Treatment

Papulopustular rosacea (PPR) Active inflammatory lesions:

Topical metronidazoleAzelaic acidIvermectinSodium sulfa cetamideSulfurPerilesional er ythema:BrimonidineOxymeta zoline

Phymatous rosacea Topical skinpeeling agent if there are large occluded folli clesElectrocautery or laser fo r telangiectases

Ocular rosacea Daily lid hygieneOily tearsu bstitute lubricating eye drops or aqueous gels

Drug-induced acne (acneiform eruptions) are associated with the following:

• Topical or systemic steroids (most common)
• Anabolic steroids - danazol, stanozolol
• Anticonvulsants - carbamazepine, phenytoin, phenobarbitone
• Antituberculosis drugs- isoniazid, pyrazinamide

Clinically, acneiform eruptions are characteristically monomorphic. Drugs most commonly implicated in acneiform eruptions:

• Worldwide- steroids
• India- isoniazid (INH)

This given image shows acné excoriée on the chin of a male with compulsive picking of the face using nail pliers and tweezers.

Acné excoriée is regarded as a selfinflicted skin condition in which the sufferer compulsively picks real or imagined acne lesions predominantly on the face. It is mostly seen in adolescent girls.

Other psychiatric disorders associated with acne are:

• Body dysmorphic disorder - Some patients have acne as their prime symptom. The perceived acne is out of proportion to physical signs.
• Eating disorders - reported in anorexia nervosa. Acne itself may be a predisposing factor for anorexia in vulnerable teenaged age groups who adopt a diet in an attempt to control their acne.

Option B: Acne fulminans or acne maligna is a rare and severe destructive form of acne presenting primarily in adolescent males. It most frequently affects the trunk but can affect the face and presents acutely in association with systemic symptoms.

Options C: Acne conglobata represents a rare and severe form of acne characterized by multiple and extensive inflammatory papules, tender nodules, and abscesses which commonly coalesce to form malodorous draining sinus tracts.

Option D: Acne mechanica describes acne that occurs at the site of repeated mechanical trauma and/or frictional obstruction of the pilosebaceous outlet resulting in comedo formation. Examples include ‘fiddler’s neck’, which may occur on the neck of violin players, and is characterized by welldefined plaques with the presence of comedones, lichenification, and pigmentation

Glycolic acid is the preferred chemical peel agent in dark-skinned individuals.

Dark skin (Fitzpatrick type IV to VI) has a tendency for post-inflammatory hyperpigmentation (PIH) after procedures like lasers and chemical peel. Deep chemical peels cannot be used in dark-skinned patients. Even medium-depth peels need to be used with extreme caution.

Chemical peels are believed to promote desquamation which reduces corneocyte cohesion and keratinocyte plugging, so enabling the extrusion of inflammatory contents. Light chemical peels are used with the aim of helping to remove comedones as well as superficial scarring and hyperpigmentation.

Other peeling agents are:

• Pyruvic acid
• Lactic acid
• Maleic acid
• Citric acid
• Tartaric acid
• Mandelic acid
• Jessener's Solution - lactic acid + salicyclic acid + resorcinol

Rhinophyma (also known as potato nose) is a slowly progressive condition due to hypertrophy and hyperplasia of the sebaceous glands of the tip of the nose.

It is often seen in cases of long-standing rosacea called phymatous rosacea. It is not a neoplasm.

It presents as a pink, lobulated mass over the nose with superficial vascular dilation. It mostly affects men past middle age. Patients seek advice because of the distorted appearance of the enlarged nose, or obstruction in breathing and vision.

Rhinophyma may be diagnosed clinically, but a skin biopsy can confirm the diagnosis. On histology, rhinophyma shows sebaceous gland hypertrophy, hyperplasia and fibrosis.

The most common indication for treatment is cosmetic. Ablation using CO2 laser or surgical resection of excess tissue with remodelling of nose can be performed.

The image shows acne rosacea. Comedones are pathognomonic features of acne vulgaris, not rosacea.

The absence of comedones helps in differentiating rosacea from acne vulgaris.

Option A: Photosensitivity is a feature of rosacea. It may be triggered/exacerbated by exposure to sunlight.

Option B: Ocular rosacea is associated with involvement of eye due to meibomian gland dysfunction, which causes gritty sensation in the eye, blepharitis, recurrent chalazion, and conjunctivitis.

Option C: Erythemato telangiectatic rosacea (ETT) is associated with facial vascular changes –

redness (flushing) and telangiectasia on central cheeks.

Fordyce spots occur most commonly on the upper lip gt;buccal mucosa.

The image shows pearly, penile papules. These are exclusively found in males. They consist of flesh-coloured, smooth papules most commonly on the coronal margin of the glans penis. They are benign and asymptomatic and treatment involves reassuring the patient.

Note: Pearly, penile papules are commonly mistaken for Fordyce spots (Tyson's glands). Fordyce spots are commonly seen on the shaft of the penis and are ectopic sebaceous glands. Image below depicts Fordyce spots on the penile shaft:

The image shows clear, thinwalled, superficial vesicles 1–2 mm in diameter, without associated erythema, resembling drops of water in a newborn. It is suggestive of miliaria, a disorder

of eccrine sweat glands.

The given image shows hidradenitis supurativa or inverse acne. Surgical excision is the best treatment that offers a cure.

Hidradenitis suppurativa is a chronic, inflammatory, recurrent, debilitating, follicular disease that usually presents after puberty.

There are painful, deepseated inflamed lesions in the apocrine glandbearing areas of the body, most commonly the axillary, inguinal, and anogenital regions.

This definition is based on the San Francisco modification of the Dessau criteria. The following three criteria must be met for the diagnosis to be made:

• Typical lesions - deepseated, painful nodules or ‘blind boils’; abscesses, draining sinuses, bridged scars, and paired or multiheaded open pseudocomedones in secondary lesions.
• Typical topography - axillae, groin, perineal and perianal region, buttocks and infra and intermammary folds.
• Chronicity and recurrence of lesions.

More common in young women of ages 20-29 years. Obesity and smoking are the two main factors associated with hidradenitis suppurativa.

Treatment includes:

• Antibiotics - tetracycline, clindamycin
• Intralesional corticosteroids
• Immunosuppressants
• Acitretin
• Anti-TNF alpha therapy
• Surgery

Arrector pili demarcates the upper and lower hair follicles. The portion above arrector pili constitutes the upper hair follicle while the portion below constitutes the lower hair follicle.

Option A: Sebaceous gland divides the upper segment into infundibulum and isthmus

Option B: Apocrine sweat glands open into the hair follicle above the opening of the sebaceous gland.

Option D: Adamson's fringe is an inverted V-shaped area in the upper keratogenous zone of the hair follicle and divides the lower segment into stem and bulb.

80-90 of hair follicles at a given time are in the anagen phase. The hair cycle has three phases:

Anagen:

It refers to the period of active hair growth. Anagen can continue for several years and the duration of this phase is responsible for determining the final length of the hair. Normally,

80–90 of hair follicles on the human scalp are in anagen at any one time. It can be identified by the presence of angulated roots.

Catagen:

At the end of anagen, epithelial cell division slows and stops, and the follicle enters an involutionary phase known as catagen. The proximal end of the hair shaft keratinizes to form a club-shaped structure and the lower part of the follicle involutes by apoptosis. It lasts for about

weeks.

Telogen:

It is the resting phase between catagen and the next anagen. Clubbing becomes more prominent. It lasts for about 3 months. Club hair is eventually shed through an active process called exogen.

In the human scalp, hair follicles may remain in a state of latency, also known as kenogen, for a prolonged period after the club hair is shed.

Vellus hair extends to the dermis and not the subcutis.

Lanugo refers to the fine, soft, unmedullated and usually unpigmented hair of the prenatal period. It is normally shed in utero in the eighth to ninth months of gestation.

Postnatal hair is of two kinds: vellus and terminal.

This man has male-pattern hair loss. Finasteride selectively inhibits type 2 5° reductase within the hair follicle. Hence, it is used in the treatment of male-pattern hair loss.

The 5° reductase enzyme converts testosterone to the more potent form of dihydrotestosterone (DHT). 5° Reductase exists in 3 isoforms. Type 1 and 3 are widely distributed in the skin and not involved in hair growth.

Type 2 is present in androgen-responsive tissues such as the dermal papillae of the hair follicle, prostate, epididymides, and seminal vesicles. Type 2 5° reductase also plays a key role in regulating androgen-dependent hair growth.

Hair growth in the following areas is androgen dependent:

• Beard, chest, and extremity hair in males
• Scalp, pubic, and axillary hair in both sexes
• Male-pattern hair loss:

Male-pattern hair loss causes thinning of the vertex and an M-shaped receding hairline, as shown below. High levels of circulating androgens stimulate hair loss in certain sites by a process called miniaturization. Finasteride reverses this process.

The dermal papilla is the primary target of the action of androgen in the hair. This is because the dermal papillae have two important features, namely

• Androgen receptors which are present only in dermal papillae
• Expression of 5° reductase type 2 which regulates androgen-dependent hair growth.
• Androgens have the following effects on hair growth.
• It increases the number of cells in the dermal papilla which causes hair follicle growth and results in pubertal hair growth.
• It causes miniaturization of the follicle in other susceptible sites which leads to male pattern
• hair loss.

Finasteride inhibits conversion of testosterone to dihydrotestosterone in the dermal papillae. This prevents miniaturization and further development of alopecia.

This clinical scenario is suggestive of male pattern androgenetic alopecia. Finasteride is not the first line treatment in women.

Finasteride use in pregnancy can lead to teratogenic effects on male fetuses.

Androgenetic alopecia is a disorder characterized by a reduction of hair fiber production by follicles and miniaturization. It is of two types , male pattern and female pattern hair loss. Male pattern hair loss may occur in female amp; vice versa is also true. Male pattern hair loss causes frontal hairline recession and thinning of the vertex.

Miniaturization refers to a reduction in the size of follicles until it leaves behind a remnant called stelae or streamers. Elastic staining of the stelae shows Arao-Perkin's bodies.

DHT is a more potent form of testosterone. It is responsible for follicular regression and thus causes androgenic alopecia. Finasteride inhibits the enzyme that converts testosterone to DHT and hence is used for treatment.

Minoxidil is a potent vasodilator. It is used orally to treat severe hypertension. When used as a hair lotion, it prolongs the anagen phase and slows down or prevents hair loss. Drugs used to treat male pattern baldness:

• Minoxidil lotion
• 5-alpha reductase antagonist - Finasteride
• Drugs used to treat female pattern baldness:
• Minoxidil lotion
• Anti-androgens - spironolactone, flutamide, and cyproterone acetate

Female pattern hair loss (FPHL) presents with diffuse thinning of hair over the midfrontal scalp with minimal or no bitemporal recession. Usually, vertex baldness is absent and frontal hairline is maintained.

Male pattern hair loss (MPHL) involves vertex baldness and frontal hairline recession. There is no entity called mixed pattern hair loss.

Currently, the Hamilton-Norwood classification system for MPHL and the Ludwig system for FPHL are most commonly used to describe patterns of hair loss.

The above picture shows female pattern hair loss with frontoparietal thinning and maintenance of the frontal hairline. Female pattern hair loss staging is done using the Ludwig staging.

Option B: Hamilton Norwood staging is used for male pattern hair loss (MPHL).

Option C: Tanner staging is used to assess sexual maturity.

Option D: Batts-Ludwig staging is used for staging chronic hepatitis.

Chemotherapy causes hair loss known as anagen effluvium.

It is due to the disruption of the anagen or proliferating phase of the hair cycle. Hair shedding typically occurs within 1–3 weeks and it is complete within 1–2 months after the initiation of chemotherapy.

Most important drugs implicated in the order of decreasing frequency of association causing anagen effluvium:

• Anti-microtubule agents (e.g., paclitaxel)
• Topo-isomerase inhibitors (e.g., doxorubicin)
• Alkylating agents (e.g., cyclophosphamide)
• Anti-metabolites (e.g., 5-fluorouracil)

Option A: Alopecia areata causes patchy, well-circumscribed hair loss, as shown below.

Option B: Telogen effluvium is an acute-onset diffuse hair loss that occurs 2–3 months after a triggering event such as high fever, surgical trauma, sudden starvation or haemorrhage.

Option D: Trichotillomania is a behavioural disorder characterised by compulsive hair pulling which causes patchy hair loss. It shares some features with obsessive-compulsive disorder and may be associated with other psychiatric conditions.

The pattern of hair loss in this clinical scenario is telogen effluvium. It is an acute-onset scalp hair loss that occurs 2–3 months after a triggering event such as high fever, surgical trauma, sudden starvation, or hemorrhage.

It refers to an increase in the shedding of telogen club hairs due to premature termination of the anagen (proliferative) phase of the hair cycle following a period of stress.

Chronic diffuse telogen hair loss refers to telogen hair shedding persisting gt; 6 months. Causes of chronic diffuse telogen hair loss are:

• Thyroid disorders (Both hyper- and hypothyroidism)
• Severe iron deficiency anemia, acrodermatitis enteropathica, and malnutrition.

Telogen gravidarum refers to telogen hair loss seen 2–3 months after childbirth. The circulating placental estrogen during pregnancy prolongs anagen phase. After delivery, the estrogen withdrawal pushes all the hair simultaneously into catagen and then telogen phase.

This patient has alopecia areata. The characteristic finding described in this vignette is called exclamation mark hair.

Alopecia areata is a chronic inflammatory disease that causes non-scarring patches of hair loss. It is a T-cell mediated inflammatory disease that occurs in genetically predisposed patients.

The lesions of alopecia areata are characterized by a smooth circumscribed patch of alopecia. Exclamation mark hair refers to short extractable broken hairs which are thinner towards the base, as shown in the image below.

Hair loss over the back of the head is called ophiasis because it creeps like a snake towards both ears.

Alopecia areata causes non-scarring hair loss in well-circumscribed patches. It peaks between 20-40 years but can occur at any age.

In case of limited patchy hair loss present for lt; 1 year, spontaneous remission is seen in 80 of patients. Sometimes the patches can coalesce to cause complete loss of hair.

Alopecia totalis means loss of all scalp hair and alopecia universalis means loss of all body hair.

The given scenario suggests alopecia areata in which geometric fine-stippled pitting of the nail is the most likely expected finding, as shown below.

Option B: Thinning of the nail with dorsal pterygium is seen in lichen planus.

Option C: V-shaped nicks on the distal edge of the nail are a feature of Darier disease. Option D: Green nails are associated with Pseudomonas infection.

This patient has limited alopecia areata as seen by the well-circumscribed patch of hair loss. Intra-lesional steroids are the first-line treatment.

The following treatment options are used in alopecia areata.

• First line: Intra-lesional corticosteroids - Depot steroid (hydrocortisone acetate 25 mg/mL or triamcinolone acetonide 5–10 mg/mL)
• Second line: Oral corticosteroids are used if initial treatment fails.
• Third line: Contact immunotherapy. It works by inducing mild contact dermatitis on the scalp by applying an allergen.

The finding described is called going white overnight and is characteristic of alopecia areata.

Alopecia areata preferentially targets pigmented hair. Older patients with grey hair have a mixture of white and pigmented hair. If the disease progresses rapidly, only pigmented hair will be affected, sparing the white hair. This leads to a dramatic change in overall hair color that is called going white overnight.

The following image shows patches of hair loss with sparing of white hair.

Option A: Hyperthyroidism can cause weight loss and diffuse hair thinning but a change in hair color is not a feature.

Options C and D: Telogen effluvium and psychological stress (which also causes telogen effluvium) lead to diffuse hair loss that affects all hair equally, not just pigmented hairs. So, overall hair color will not be affected.