'Substantial clinical benefit' and 'substantial clinical worsening' cut-off of Vitiligo Impact Scale (VIS)-22 change scores

Patient-centric outcome measures focus on clinically meaningful change in various aspects of disease, including severity, quality-of-life, and psychological distress. The minimal important change (MIC) is a commonly used threshold of patient-reported outcome measures, representing the smallest difference that is considered significant by the patient and/or physician. However, it has been suggested that MIC is too low a bar for determining treatment success, and alternative thresholds such as substantial clinical benefit (SCB) and patient acceptable symptom state (PASS) may be preferred.

Evaluation of a paraffin-based moisturizer compared to a ceramide-based moisturizer in children with atopic dermatitis: A double-blind, randomized controlled trial

BACKGROUND

Moisturizers are first-line therapy for treatment of atopic dermatitis (AD). Although there are multiple types of moisturizers available, head-to-head trials between different moisturizers are limited.

OBJECTIVE

To evaluate if a paraffin-based moisturizer is as effective as ceramide-based moisturizer in children with AD.

MATERIALS AND METHODS

In this double-blind, randomized comparative trial of pediatric patients with mild to moderate AD, subjects applied either a paraffin-based or ceramide-based moisturizer twice daily. Clinical disease activity using SCOring Atopic Dermatitis (SCORAD), quality of life using Children/Infants Dermatology Life Quality Index (CDLQI/IDLQI), and transepidermal water loss (TEWL) were measured at baseline and at follow-up at 1, 3, and 6 months.

RESULTS

Fifty-three patients were recruited (27 ceramide group and 26 paraffin group) with a mean age of 8.2 years and mean disease duration of 60 months. The mean change in SCORAD at 3 months in the ceramide-based and paraffin-based moisturizer groups was 22.1 and 21.4, respectively (p = .37). The change in CDLQI/IDLQI, TEWL over forearm and back, amount and days of topical corticosteroid required, median time to remission and disease-free days at 3 months were similar in both groups. As the 95% confidence interval (CI) of mean change in SCORAD at 3 months in both groups (0.78, 95% CI: -7.21 to 7.52) was not within the predefined margin of equivalence (-4 to +4), the conclusion of equivalence could not be proven.

CONCLUSION

Both the paraffin-based and ceramide-based moisturizers were comparable in improving the disease activity in children with mild to moderate AD.

International eDelphi Study to Reach Consensus on the Methotrexate Dosing Regimen in Patients With Psoriasis

Importance

A clear dosing regimen for methotrexate in psoriasis is lacking, and this might lead to a suboptimal treatment. Because methotrexate is affordable and globally available, a uniform dosing regimen could potentially optimize the treatment of patients with psoriasis worldwide.

Objective

To reach international consensus among psoriasis experts on a uniform dosing regimen for treatment with methotrexate in adult and pediatric patients with psoriasis and identify potential future research topics.

Design, Setting, and Participants

Between September 2020 and March 2021, a survey study with a modified eDelphi procedure that was developed and distributed by the Amsterdam University Medical Center and completed by 180 participants worldwide (55 [30.6%] resided in non-Western countries) was conducted in 3 rounds. The proposals on which no consensus was reached were discussed in a conference meeting (June 2021). Participants voted on 21 proposals with a 9-point scale (1-3 disagree, 4-6 neither agree nor disagree, 7-9 agree) and were recruited through the Skin Inflammation and Psoriasis International Network and European Academy of Dermatology and Venereology in June 2020. Apart from being a dermatologist/dermatology resident, there were no specific criteria for participation in the survey. The participants worked mainly at a university hospital (97 [53.9%]) and were experienced in treating patients with psoriasis with methotrexate (163 [91.6%] had more than 10 years of experience).

Main Outcomes and Measures

In a survey with eDelphi procedure, we tried to reach consensus on 21 proposals. Consensus was defined as less than 15% voting disagree (1-3). For the consensus meeting, consensus was defined as less than 30% voting disagree.

Results

Of 251 participants, 180 (71.7%) completed all 3 survey rounds, and 58 participants (23.1%) joined the conference meeting. Consensus was achieved on 11 proposals in round 1, 3 proposals in round 2, and 2 proposals in round 3. In the consensus meeting, consensus was achieved on 4 proposals. More research is needed, especially for the proposals on folic acid and the dosing of methotrexate for treating subpopulations such as children and vulnerable patients.

Conclusions and Relevance

In this eDelphi consensus study, consensus was reached on 20 of 21 proposals involving methotrexate dosing in patients with psoriasis. This consensus may potentially be used to harmonize the treatment with methotrexate in patients with psoriasis.

Patient perception and satisfaction with a smartphone-based teledermatology service initiated during the COVID-19 pandemic at a tertiary care hospital in North India

BACKGROUND

Telemedicine is being increasingly used to provide healthcare to patients, particularly during the COVID-19 pandemic.

AIMS

The study aimed to study patient perception and satisfaction with a smartphone-based hybrid teledermatology service initiated during the COVID-19 pandemic.

METHODS

This was a cross-sectional telephonic survey including patients ≥18 years of age who had received a teledermatology consultation. After noting the demographic, clinical and teleconsultation details, patients were administered the Telemedicine Satisfaction Questionnaire and an additional 6-item questionnaire. Patients were also asked to give qualitative feedback and suggestions for improvement using a semi-structured interview guide.

RESULTS

We interviewed 201 subjects. The most common diagnoses were pemphigus (27, 13.4%), superficial fungal infections (24, 11.8%), psoriasis (22, 10.9%) and dermatitis (21, 10.4%). The overall mean Telemedicine Satisfaction Questionnaire score was 4.20± 0.71. One hundred seventy-one (85.1%) patients responded that they would use teledermatology services again, while 168 (83.6%) reported satisfaction with the quality of services. A majority of the patients were largely satisfied with the various components involved, though some concerns were raised about the care perceived as not at par with physical consultations, difficulty in procuring medicines, lack of confidence in photographic diagnoses and the lack of a personal touch. Patients with urticaria (P=0.020), those who were advised a change in treatment (P=0.029) and those with improvement in their skin disease (P=0.026) were more likely to be satisfied.

LIMITATIONS

Our study was conducted during the COVID-19 pandemic when patient acceptability was likely to be higher. Only follow-up patients were included in the study.

CONCLUSION

Patient satisfaction levels were generally high with teledermatology. Addressing lacunae that negatively impact patient perception and satisfaction will help in greater acceptance of teledermatology services.

Assessment of body image disturbance, self-esteem and quality of life among adolescents and young adults with acne in a tertiary care facility of India

Background:

Impact of acne on the psychological aspect among adolescents and young adults is poorly understood and many times goes unnoticeable.

Aim:

To assess body image disturbance, self-esteem, quality of life among adolescents and young adults with acne.

Materials and Methods:

A cross sectional survey on 250 adolescents and young adults aged 13-25 years in Dermatology OPD of a tertiary care hospital, was performed. Severity of acne, body image disturbance, self-esteem, and quality of life were assessed using standardized tools like IGA scale, BIDQ, RSES, and TAQOL respectively.

Results:

A majority of the participants, 163 (65%), were aged 20–25 years, in which 141 (56.4%) were male, 237 (94.8%) were unmarried, 192 (76.8%) were residing in urban area, 142 (56.8%) were graduate/post-graduate, 173 (69.2%) were students and 113 (45.2%) belonged to upper middle class of socio-economic status. More than half, 137 (54.8%), had a family history of acne, 228 (91.2%) had oily skin, 166 (67.4%) had normal nutritional status, 154 (61.6%) had moderate form of acne whereas 80 (32%) had severe acne. The mean BIDQ score was 3.05 (SD = 0.89); 169 (67.60%) had normal self-esteem and 174 (69.64%) had mild impairment in quality of life. Severity of acne had significant association with body image disturbance (P = 0.007) and quality of life (P = 0.001) but not related with self-esteem.

Conclusion:

The results revealed body image disturbance and impaired quality of life among adolescents and young adults with acne which draws the attention of dermatologists towards unidentified psychological aspects of acne during treatment. However, the majority of them revealed normal self-esteem in the study.

Disease stability in segmental and non-segmental vitiligo

Introduction:

Some therapeutic decisions in vitiligo depend on the likelihood of the disease remaining stable and inactive.

Aim:

To determine a period of disease stability in vitiligo following which reactivation was unlikely.

Materials and Methods:

This cross-sectional descriptive study was carried out in 200 patients where a detailed clinical history of the disease activity and stability over the course of vitiligo was recorded.

Results:

There were 167 (83.5%) patients with non-segmental vitiligo and 33 (16.5%) with segmental vitiligo. For every 1-year increase in the duration of the disease, stable and active periods increased by 0.7 and 0.3 years, respectively in non-segmental vitiligo and by 0.9 and 0.1 years in segmental vitiligo (P < 0.01). When segmental vitiligo was stable for at least 2 years, it was five times less likely to re-activate than the disease that was stable for less than 2 years (P = 0.16). However, in non-segmental vitiligo, we found no association between the duration of stability and risk of reactivation.

Conclusions:

Segmental vitiligo usually becomes inactive after the disease has been stable for 2 years. Non-segmental vitiligo is prone to reactivation even after prolonged periods of stability.

Lymphocyte-Peppered Sclerotic Collagen: An Additional Histological Clue in Lichen Sclerosus, Morphea, and Systemic Sclerosis

BACKGROUND

"Line sign," "cookie cutter sign," "square biopsy sign," "high eccrine glands sign" have been previously described in morphoea and lichen sclerosus. We found focal areas of thickened collagen bundles with lymphocytes interspersed between them in several biopsies of these conditions.

MATERIALS AND METHODS

We reviewed slides of sclerosing disorders obtained from the archives of the pathology department in our hospital for the period 2013-2019.

RESULTS

A total of 73 slides including 40 of lichen sclerosus, 24 of morphea, 2 of lichen sclerosus-morphea overlap, and 7 of systemic sclerosis were evaluated. Lymphocytes were noted between sclerotic collagen bundles in 46 (63%) slides, being most common in lichen sclerosus (80%, 32/40) followed by morphea (50%, 12/24), whereas it was seen in one case each of lichen sclerosus with morphea overlap (50%, 1/2) and systemic sclerosis (14.3%, 1/7). The finding was noted in the upper dermis in 20 of 32 (62.5%) slides of lichen sclerosus and in both the superficial and deep dermis in 11 (91.7%) of 12 slides of morphea.

CONCLUSION

Lymphocyte-peppered sclerotic collagen may be a useful histological clue to the diagnosis of lichen sclerosus, morphea, and systemic sclerosis.

Family vitiligo impact scale: A scale to measure the quality-of-life of family members of patients with vitiligo

BACKGROUND

Vitiligo places a significant psycho-social burden on caregivers and family members.

AIMS

The aim of the study was to develop and preliminarily validate a scale to measure the psychosocial impact of vitiligo on adult family members.

METHODS

Themes that emerged from qualitative interviews and a focus group discussion with family members were used to generate items for a preliminary scale, followed by pre-testing and scale development. The new scale was then tested with two comparator scales and a global question.

RESULTS

A preliminary scale with 32 items was pilot tested on 30 participants. Following this, the scale was condensed to 16 items in 12 domains that were administered to 159 participants. Scale scores ranged from 0 to 48 with a mean of 19.75 ± 12.41. The scale had excellent internal consistency with Cronbach's alpha coefficient of 0.92 (0.70-0.95) and also showed good test-retest reliability at two weeks (r = 0.946). The scale showed criterion, convergent and known group validity.

LIMITATIONS

It was conducted in a large teaching hospital which may have resulted in selection of patients with persistent or progressive disease and more worried family members. Vitiligo is highly stigmatized in our country and the performance of the scale may need to be evaluated in other communities and cultures as well where stigma is less oppressive.

CONCLUSION

Family Vitiligo Impact Scale appears to be an easy-to-complete, reliable and valid instrument to measure the psychosocial impact of vitiligo in family members of patients. It may be useful as an outcome measure in both clinical and research settings.

Pseudolipomatosis Cutis: A Retrospective Case Series of Skin Biopsies Showing a Distinctive Vacuolar Artifactual Change

Pseudolipomatosis cutis is a distinctive artifact characterized by the presence of adipocyte-like vacuoles in the biopsy specimens. We describe this change in a series of skin biopsies clustered over 2 periods, November 2017-December 2017 and February 2019. Hematoxylin and eosin-stained sections from 21 skin biopsies were examined by 2 dermatopathologists. Variable-sized vacuoles were noted in the epidermis, dermis, and/or subcutaneous fat in all biopsies. Vacuoles were seen in the stratum corneum in 2 biopsies, epidermis in 15 biopsies, papillary dermis in 19 biopsies, reticular dermis in 20 biopsies, and subcutis in 9 biopsies. The vacuoles resembled a true histological change in many biopsies: vacuolated keratinocytes (n = 6), basal cell vacuolization (n = 6), foamy histiocytes (n = 12), and adipocytes (n = 20). Other changes included dermal collagen sclerosis and empty ectatic vascular channels. The clustering of this peculiar change in biopsies from patients with unrelated skin diseases that stopped on changing the formalin solution in both instances suggests that it is an artifactual change due to improper tissue fixation.

Psychosocial burden of lichen planus pigmentosus is similar to vitiligo, but greater than melasma: A cross-sectional study from a tertiary-care center in north India

BACKGROUND

Lichen planus pigmentosus can have a negative impact on the quality of life; however, this has not been studied in detail.

OBJECTIVES

To study the quality of life in patients with lichen planus pigmentosus and compare it with patients with vitiligo and melasma.

METHODS

This was a cross-sectional study conducted in a tertiary-care center in north India from January 2018 to May 2019. Patients ≥ 18 years of age with lichen planus pigmentosus (n = 125), vitiligo (n = 113) and melasma (n = 121) completed the Dermatology Life Quality Index (DLQI) questionnaire and answered a global question on the effect of disease on their lives. In addition, patients with vitiligo completed the Vitiligo Impact Scale (VIS)-22 questionnaire, while those with lichen planus pigmentosus and melasma filled a modified version of VIS-22.

RESULTS

The mean DLQI scores in patients with lichen planus pigmentosus, vitiligo and melasma were 10.9 ± 5.95, 9.73 ± 6.51 and 8.39 ± 5.92, respectively, the difference being statistically significant only between lichen planus pigmentosus and melasma (P < 0.001). The corresponding mean modified VIS-22/VIS-22 scores were 26.82 ± 11.89, 25.82 ± 14.03 and 18.87 ± 11.84, respectively. This difference was statistically significant between lichen planus pigmentosus and melasma, and between vitiligo and melasma (P < 0.001 for both). As compared to vitiligo, patients with lichen planus pigmentosus had a significantly greater impact on "symptoms and feelings" domain (P < 0.001) on DLQI, and on "social interactions" (P = 0.02) and "depression" (P = 0.04) domains on VIS-22. As compared to melasma, patients with lichen planus pigmentosus had significantly higher scores for "symptoms and feelings," "daily activities," "leisure" and "work and school" domains of DLQI, and all domains of VIS-22. Female gender was more associated with impairment in quality of life in patients with lichen planus pigmentosus, while lower education, marriage, younger age and increasing disease duration showed a directional trend.

LIMITATIONS

Use of DLQI and modified version of VIS-22 scales in the absence of a pigmentary disease-specific quality-of-life instrument.

CONCLUSION

Patients with lichen planus pigmentosus have a significantly impaired quality of life. The psychosocial burden of lichen planus pigmentosus is quantitatively similar to that of vitiligo, but significantly greater than melasma.

Histopathology of Post Kala-azar Dermal Leishmaniasis

The various lesions seen in the clinical presentation of post kala-azar dermal leishmaniasis (PKDL) are reflected in the histopathology of the type of lesion biopsied. The cells that form the dermal infiltrate include lymphocytes, histiocytes, and plasma cells in varying proportions. The infiltrate, which is mild and confined to the superficial dermis in macular lesion becomes denser with the increasing severity of the lesion. Leishman–Donovan bodies (LDB) in general are rarely demonstrable in macules and somewhat infrequently in the rest, though at times they may be numerous; mucosal lesions offer a greater chance of visualizing LDB than biopsies from the skin. A characteristic histomorphology in nodules is prominent follicular plugging with a dense plasma cell-rich lymphohistiocytic dermal infiltrate that shows an abrupt cut-off in the lower dermis, an appearance highly suggestive of PKDL even in the absence of LDB. Russell bodies within plasma cells, vascular changes, and xanthoma-like hue have been seen in plaques from chronic PKDL. The histopathologic picture in some may also mimic that seen in tuberculoid and lepromatous leprosy, and other granulomatous dermatoses. In contrast to Indian PKDL, epithelioid cell granulomas with giant cells are more common in African PKDL, and vascular changes are rare though neuritis showing LDB has been described.

Validation of the diagnostic criteria for segmental vitiligo

Background

Segmental vitiligo has a different clinical course and prognosis as compared to nonsegmental vitiligo, which necessitates its correct diagnosis. It may be difficult to distinguish segmental vitiligo from the limited or focal types of nonsegmental vitiligo.

Objective

To validate the previously proposed diagnostic criteria for segmental vitiligo.

Methods

This was a cross-sectional validation study involving patients with limited vitiligo. The diagnostic criteria were used to classify vitiligo lesions as segmental or nonsegmental, and was compared with the experts' diagnosis, which was considered as the "gold standard".

Results

The study included 200 patients with 225 vitiligo lesions. As per the diagnostic criteria, 146 vitiligo lesions were classified as segmental and 79 as nonsegmental. The experts classified 147 vitiligo lesions as segmental and 39 as nonsegmental, while the diagnosis either was labeled "unsure" or could not be agreed upon for 39 lesions. As compared with the experts' opinions ("for sure" cases, n = 186), the sensitivity and specificity of the diagnostic criteria was 91.8% (95% confidence interval [CI]: 86.2%-95.7%) and 100% (95% CI: 91%-100%), respectively. The positive predictive value was 100% (95% CI: 97.3-100%), while the negative predictive value was 76.5% (95% CI: 62.5%-87.2%). There was a 93.5% agreement between the clinical criteria and experts' opinions (k = 0.83, P < 0.001).

Limitation

The diagnostic criteria were compared with the experts' opinion in the absence of an established diagnostic "gold standard".

Conclusions

The proposed diagnostic criteria for segmental vitiligo performed well, and can be used in clinical practice, as well as in research settings.

Follicular Becker's Nevus: A New Clinical Variant

Becker's nevus, also known as pigmented hairy epidermal nevus, is characteristically described as a unilateral, hairy, light to dark brown macule with sharply outlined but irregular border. The etiopathogenesis of Becker's nevus is still not clearly understood. Perifollicular pigmentation has been described earlier by some authors. But, Becker's nevus presenting exclusively with follicular lesions has not been described. We are reporting a series of patients of Becker's nevus with follicular lesions. The diagnosis in all the patients was made after clinicopathological correlation. Follicular epithelium may hold a significant role in the etiopathogenesis of Becker's nevus.

Lichenoid pseudovesicular papular eruption on nose: A papular facial dermatosis probably related to actinic lichen nitidus or micropapular polymorphous light eruption

Background

Facial papules are a feature of several clinical conditions and may present both diagnostic and therapeutic challenges.

Aim

To describe a grouped papular eruption on the nose and adjoining cheeks that has not been well characterized previously.

Materials and Methods

A series of consecutive patients with a papular eruption predominantly involving nose and cheeks were evaluated, treated and followed up prospectively at tertiary care centers. Demographic details, clinical features, histopathology and response to treatment were recorded.

Results

There were five men and six women (mean age 29.9 ± 6.9 years) who had disease for a mean duration of 17.3 ± 11.1 months. All patients presented with a predominantly asymptomatic eruption of monomorphic, pseudovesicular, grouped, skin colored to slightly erythematous papules prominently involving the tip of nose, nasal alae, philtrum and the adjoining cheeks. A total of 15 biopsies from 11 patients were analyzed and the predominant finding was a dense, focal lymphoid infiltrate restricted to the upper dermis with basal cell damage and atrophy of the overlying epidermis. The eruption ran a chronic course from several months to years.

Limitations

Direct immunofluorescence could not be performed except in one case. Immunohistochemical stains for CD4 and CD8 could not be done owing to nonavailability. Phototesting was undertaken in one patient only.

Conclusion

Small grouped papules on the nose and adjoining skin with a lichenoid histopathology appear to represent a distinct clinicopathological entity. It may be related to actinic lichen nitidus/micropapular variant of polymorphous light eruption.

A cross-sectional study of spontaneous repigmentation in vitiligo

Background

Spontaneous regression is well documented in several chronic skin diseases such as psoriasis, alopecia areata, and atopic dermatitis. However, information on vitiligo is scarce.

Aims

We studied the frequency, extent, and factors affecting spontaneous repigmentation in vitiligo.

Methods

A cross-sectional descriptive study was undertaken in 167 patients with vitiligo with an emphasis on history of spontaneous repigmentation. Where available, photographs documenting spontaneous repigmentation were also obtained. Repigmentation was defined as spontaneous if it occurred when the patient was off treatment for at least 3 consecutive months.

Results

Spontaneous repigmentation occurred in 36 (21.5%) patients with complete repigmentation in 6 (3.6%) patients. The extent varied from 0.5% to 100% (mean, 35.4 ± 37.9%) of vitiliginous skin. It occurred after 3 months to 47 years (mean, 8.7 ± 9.5 years) of onset of vitiligo and persisted for 2 months to 27 years (mean, 4.4 ± 6.2 years). Diffuse repigmentation was the most common pattern observed in 20 (55.6%) patients and there was a good color match in 26 (72.2%) patients. Likelihood of spontaneous repigmentation was 3.5 times greater in patients with more than 3 years of stable disease (P = 0.001).

Limitations

The chief limitation was the dependence on patient recall for the data, except when documented by images.

Conclusion

Spontaneous repigmentation occurs in one-fifth of patients with vitiligo. In some patients, the repigmentation is clinically significant and long-lasting. Considering its frequency and extent, spontaneous repigmentation should be taken into account both when evaluating novel interventions and counselling patients about the course of the disease.

Hemi Masticatory Spasm: Series of 7 Cases and Review of Literature

Background

Hemi masticatory spasm (HMS) is a rare movement disorder affecting muscles of mastication attributed to dysfunction of motor branch of trigeminal nerve and is characterized by painful spasm of masticatory muscles. Microvascular compression leading to focal demyelination of motor branch of trigeminal nerve is the most speculated on mechanism of HMS. Treatment options range from medical to surgical approaches, but botulinm toxin (BTX) has now become the preferred treatment.

Cases

We report a retrospective review of 7 cases of HMS, supported by electrophysiological and clinical findings. All the cases had excellent response to BTX therapy.

Discussion and Conclusion

In this article, we highlight the delay in diagnosis of HMS attributed to rarity, long course of illness, association with hemiatrophy, "Lichen Sclerosus et Atrophicus," and scleroderma/morphea. Considering the favorable outcome to BTXs, surgical treatment can be avoided or delayed in majority except secondary cases.

Necrobiotic Xanthogranuloma as the Presenting Manifestation of Smouldering Myeloma

Necrobiotic xanthogranuloma is a rare dermatological manifestation of underlying hematological malignancies, in particular, when associated with paraproteinemia. These patients who are clinically symptomatic with chronic papules, nodules or plaques which demonstrate a histopathological pattern suggestive of extensive and frequently confluent areas of necrobiosis with granulomatous infiltration, warrant evaluation for an underlying monoclonal gammopathy.

Macular hypopigmentation, hair loss and follicular spongiosis: A distinct clinicopathological entity

Background

Hypopigmented macules are seen in a variety of disorders and the diagnosis rests on clinicopathological correlation. However, some cases are difficult to classify and pose a diagnostic challenge.

Aim

To describe the clinical and histopathological features of patients with hypopigmented macules and follicular spongiosis on histopathology.

Materials and Methods

We undertook a retrospective analysis of clinical and histopathological findings in 12 patients who presented with clinically nondiagnostic hypopigmented macules and showed follicular spongiosis on skin biopsy, at All India Institute of Medical Sciences, New Delhi, India between January 2015 and October 2016. The findings were compared with 12 patients with "unclassified" hypopigmented macules, who did not show follicular spongiosis on skin biopsy.

Results

A total of 12 patients with hypopigmented macules showed spongiosis affecting the follicular epithelium on histopathology. There were eight men and four women, most in their second decade (mean age 19.1 ± 8.05 years), presenting with hypopigmented macules most commonly on the upper limbs, for a mean duration of 6.33 ± 5.10 months. Clinically evident lesional hair loss was seen in all patients, and follicular prominences in seven (58%) patients. Histological features suggestive of other diagnosis, namely leprosy, mycosis fungoides or sarcoidosis were not seen in any biopsy. Alcian blue stain revealed an minimal amount of mucin in one biopsy. Clinically apparent hair loss and follicular prominences were found to be statistically significantly associated with histological evidence of follicular spongiosis (P < 0.001 and 0.003, respectively).

Limitations

Our study is limited by its retrospective design and small sample size.

Conclusions

Patients with hypopigmented macules and follicular spongiosis on histopathology may represent a distinct clinicopathological entity that is associated with lesional hair loss and follicular prominences. It is probably a variant of an endogenous dermatitis similar to pityriasis alba.