A Dissertation on CLINICO EPIDEMIOLOGICAL STUDY of FACIAL DERMATOSES AMONG ADULTS

A Dissertation on CLINICO EPIDEMIOLOGICAL STUDY OF FACIAL DERMATOSES AMONG ADULTS

Dissertation submitted to THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY CHENNAI-600032

With partial fulfillment of the requirements for the award of M.D.DEGREE IN DERMATOLOGY, VENEREOLOGY AND LEPROLOGY (BRANCH - XX) REG. No. 201730201

COIMBATORE MEDICAL COLLEGE AND HOSPITAL COIMBATORE MAY 2020 DECLARATION

I Dr . MANIVANNAN . M solemnly declare that the dissertation entitled “CLINICO EPIDEMIOLOGICAL STUDY OF FACIAL

DERMATOSES AMONG ADULTS ” is a bonafide work done by me at

Coimbatore Medical College Hospital during the year June 2018 to May 2019 under the guidance & supervision of Dr. M. KARUNAKARAN M.D.,

(DERM) Professor& Head of Department, Department of Dermatology,

Coimbatore Medical College & Hospital. The dissertation is submitted to Dr.

MGR Medical University towards partial fulfillment of requirement for the award of MD degree branch XX Dermatology, Venereology and Leprology.

PLACE: Dr. MANIVANNAN .M

DATE:

CERTIFICATE

This is to certify that the dissertation entitled “CLINICO EPIDEMIOLOGICAL STUDY OF FACIAL DERMATOSES AMONG ADULTS” is a bonafide original work done by Dr. MANIVANNAN.M. Post graduate student in the Department of Dermatology, Venereology and Leprology, Coimbatore Medical College Hospital, Coimbatore under the guidance of Dr. M. KARUNAKARAN M.D., (DERM), Professor and HOD of Department, Department of Dermatology, Coimbatore Medical College Hospital, Coimbatore in partial fulfillment of the regulations for the Tamilnadu DR.M.G.R Medical University, Chennai towards the award of MD., degree (Branch XX.) in Dermatology, Venereology and Leprology.

Date : GUIDE Dr. M. KARUNAKARAN M.D., (DERM) Professor & HOD, Department of Dermatology, Coimbatore Medical College & Hospital.

Date : Dr. M. KARUNAKARAN M.D., (DERM) Professor & HOD, Department of Dermatology, Coimbatore Medical College & Hospital.

Date : Dr. B. ASOKAN, M.S., Mch., Dean, Coimbatore Medical College & Hospital, Coimbatore. COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that The Tamilnadu DR.M.G.R Medical University,

Chennai shall have the rights to preserve, use and disseminate this dissertation/thesis in print or electronic format for academic/research purpose.

PLACE: COIMBATORE Dr. MANIVANNAN .M

DATE:

PLAGIARISM CERTIFICATE

This is to certify that this dissertation work titled "CLINICO

EPIDEMIOLOGICAL STUDY OF FACIAL DERMATOSES" of the candidate Dr. M. MANIVANNAN with Registration number for the award of

M.D.DERMATOLOGY, VENEREOLOGY AND LEPROSY in the branch of XX. I personaly verfied the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion pages and results shows 1% of plagiarism in the dissertation.

Signature of the Guide

ACKNOWLEDGEMENT

I solicit my humble thanks to the Dean Dr. B. Asokan, M.S., Mch., Coimbatore Medical College Hospital, for allowing me to conduct the study in this hospital.

I am also immensely thankful to my guide Prof. Dr.M.Karunakaran M.D., (DERM) Professor Head of the Department, Dermatology and Leprology for his invaluable guidance, motivation and help throughout the study.

I express my earnest gratitude to Dr. Muthukumaran M.D., Prof. and Head of the Department, Department of Venerealogy, all the Assistant Professors, Department of Dermatology Dr.B.Eswaramoorthy M.D., Dr.R.Madhavan M.D., Dr.S.Bharathi M.D., Dr.Swarnalakshmi M.D., Dr.pradeepa M.D , Dr. Ranjani M.D and Dr. Arul D.D.V.L without their help and guidance this work would not have been possible.

I owe a lot to my parents and other family members who have always

been my pillar of support in all stages of my life.

My sincere thanks to my seniors Dr.A.Amutha, Dr.M.S.Krishnameera, Dr.Divya, Dr.Dhineshkumar and my fellow post graduate colleagues Dr.Vijayalakshmi, Dr.Neikhrielie Khro, Dr.Manipriya, Dr.Aravind and Dr.Kiruthika who have been of immense help throughout the study period.

I am very grateful to all patients for their co-operation and participation in the study.

TABLE OF CONTENTS

S.NO CONTENTS PAGE NO.

1. INTODUCTION 1

2. REVIEW OF LITERATURE 2

3. AIM AND OBJECTIVES OF THE STUDY 51

4. MATERIALS AND METHODS 52

5. OBSERVATION AND RESULT 54

6. DISCUSSION 89

7. SUMMARY 95

8. CONCLUSION 97

9. BIBLIOGRAPHY 102

10. ANNEXURES

PROFORMA

CONSENT FORM

KEY TO MASTER CHART

MASTER CHART

LIST OF TABLES

S.No. TABLES PAGE NO.

1. CLASSIFICATION OF FACIAL DERMATOSES 3

2. CLINICAL GRADING SYSTEM OF ACNE 10 (PILLSBURRY’S CLASSIFICATION)

3. SUBTYPES OF ROSACEA AND THEIR CLINICAL 14 FEATURES

4. FITZPATRICK SKIN TYPES 15

5. TYPES OF MELASMA 17

6. BORDEAUX VITILIGO GLOBAL ISSUES 22 CONSENSUS CONFERENCE CLASSIFICATION

7. CLASSIFICATION OF SEGMENTAL VITILIGO OF 22 FACE

8. CLASSIFICATION OF PHOTODERMATOSES 27

9. AGE WISE DISTRIBUTION OF FACIAL 55 DERMATOSES

10. SITES OF DISTRIBUTION OF FACIAL DERMATOSES 58

11. AGE AND SEX WISE DISTRIBUTION OF ACNE 59

12. SITES OF DISTRIBUTION OF ACNE 61

13. GRADING OF ACNE 61

14. AGGREVATION FACTORS OF ACNE 62

15. AGE WISE DISTRIBUTION OF PIGMENTARY 63 DISORDERS

16. AGE WISE DISTRIBUTION OF INFECTIONS 70

17. AGE WISE DISTRIBUTION OF ECZEMATOUS 73 DISEASES

18. AGE GROUP WISE DISTRIBUTION OF SKIN 77 TUMOURS

19. INCIDENCE OF SKIN TUMOURS OF FACE 78

LIST OF CHARTS

S.No. CHARTS PAGE NO.

1. SEX DISTRIBUTION IN FACIAL DERMATOSES 54

2. OCCUPATIONAL DISTRIBUTION OF FACIAL 55 DERMATOSES

3. SEASONAL VARIATIONS IN FACIAL 56 DERMATOSES

4. SYMPTOMS IN FACIAL DERMATOSES 57

5. INCIDENCE OF VARIOUS FACIAL DERMATOSES 57

6. GENDER DISTRIBUTION OF ACNE 59

7. OCCUPATIONAL DISTRIBUTION OF ACNE 60

8. OCCUPATIONAL DISTRIBUTION OF 64 PIGMENTARY DISORDERS

9. SEASONAL DISTRIBUTION OF PIGMENTARY 65 DISORDERS

10. SEX DISTRIBUTION OF MELASMA 66

11. OCCUPATIONAL DISTRIBUTION OF MELASMA 67

12. DISTRIBUTION PATTERN OF MELASMA 68

13. OCCUPATIONAL DISTRIBUTION OF INFECTIONS 70

14. INCIDENCE WISE DISTRIBUTION OF 71 INFECTIONS

15. OCCUPATIONAL DISTRIBUTION OF ECZEMAS 74 AFFECTING FACE

16. OCCUPATIONAL DISTRIBUTION OF SKIN 77 TUMOURS

COLOUR PLATES

S.No COLOUR PLATES PAGE NO.

1. ACNE VULGARIS 80

2. NODULO CYSTIC ACNE 80

3. MELASMA 81

4. HERPES LABIALIS 81

5. ACNE SCARS 82

6. PERIORAL DERMATITIS 82

7. TINEA FACIEI 83

8. VITILIGO 83

9. MOLLUSCUM CONTAGIOSUM 84

10. PHOTO SENSITIVE ECZEMA 84

11. DERMATOSIS PAPULOSA NIGRA 85

12. HERPES SIMPLEX 85

13. ROSACEA 86

14. HANSEN’S DISEASE 86

15. XANTHELASMA 87

16. SYRINGOMA 87

17. TRICHOEPITHELIOMA 88

18. TUBEROUS SCLEROSIS 88

LIST OF ABBREVIATIONS

DPN : Dermatosis Papulosa Nigra

SCC : Squamous Cell Carcinoma

BCC : Basal Cell Carcinoma

SLE : Systemic Lupus Erythematosus

PMLE : Polymorphic Light Eruption.

TLR : Toll Like Receptors

PAMPs : Pathogen Associated Molecular Patterns.

MITF : Melanocyte Inducing Transcription Factor.

ABSTRACT

TITLE :

CLINICO EPIDEMIOLOGICAL STUDY OF FACIAL DERMATOSES

AMONG ADULTS

BACKGROUND AND PURPOSE OF STUDY :

Face is cosmetically important area of the body. Any change in skin colour or appearance of rash over the face affects an individual both in psychological and social aspects. Each facial dermatoses have its own clinical presentations and also own demographic variations. Therefore detailed knowledge about the dermatoses affecting the face is important.

AIM

To study the clinical features and different pattern of involvement of various facial dermatoses and their epidemiological aspects like age , sex distribution and occupation.

MATERIALS AND METHODS

200 patients with facial dermatoses were selected from OPD of dermatology, Coimbatore Medical College Hospital, for a period of 1 year. In each patient, the details of name, age , sex and occupation were noted. A detailed history of symptoms and their duration were recorded. Complete general and dermatological examination was carried out in all the patients. Investigations like KOH examination , woods lamp examination and skin biopsy was carried out in relevant patients.

RESULTS

Among the 200 patients enrolled in this study 63% were females and

37% were males. Most common age group affected was 26-32 years. Majority of them were housewives (27.5%.). Seasonal variation was reported in 60% of cases. Among the various facial dermatoses , most commonly reported in this study was pilosebaceous diseases , followed by pigmentary disorders and infections.

CONCLUSION :

Most of the studies in the facial dermatoses were focused on the specific diseases, this study highlights the need for comprehensive studies in facial dermatoses.

KEYWORDS : ACNE, MELASMA, Skin Tumors INTRODUCTION

Face is an important area of concern in aspects of health and disease.

Facial appearance of an individual provides primary identity to a person.

Facial skin is more prone to UV rays , allergens , infections and cosmetics usage than any other parts in our body. Any lesions on the face provoke more anxiety and seeks early medical need.

The various dermatological conditions that affect the face are pilosebaceous diseases, pigmentary disorders , infections , eczema , connective tissue diseases and immune bullous disorders. Some of them pertaining to face only and some of them are early manifestation of systemic diseases as well.

Hence early identification of these diseases are helps in proper management.

REVIEW OF LITERATURE

CLINICO EPIDEMIOLOGICAL STUDY OF FACIAL DERMATOSES

AMONG ADULTS

Facial appearance is a primary identity for an individual. Facial skin is differ from other regions of the skin because of its rich vascular supply and abundant sebaceous glands. The dermo epidermal junction of facial skin have a flattened profile with consequent reduction in prominence of the papillary dermis compared to limb or trunk.

Facial skin is affected by various dermatological diseases. They can be classified as diseases of pilosebaceous unit, pigmentary disorders , infections , eczematous disorders , photo dermatoses , skin tumours and papulo squamous disorders.

TABLE 1 : CLASSIFICATION OF FACIAL DERMATOSES

CONDITIONS DISEASES Diseases of Acne , Rosacea. Pilosebaceous Unit Pigmentary Disorders Melasma,, Lentigines ,Ephelides , Lichen planus pigmentosus, Riehl’s melanosis, Acanthosis nigricans, Nevus of Ota, Vitiligo. Eczematous Disorders Allergic contact dermatitis , Seborrheic dermatitis. Photo Dermatoses Polymorphic light eruptions, Chronic actinic dermatitis, Photo allergic , Photo toxic, Xeroderma pigmentosum. Infections Bacterial – Erysipelas , Folliculitis, Hansen’s disease, Lupus vulgaris . Viral – Herpes simplex, Herpes zoster, Molluscum contagiosum, Wart. Fungal – Tinea faciei , Tinea barbae, Tinea versicolor. Papulo Squamous Psoriasis , Lichen planus. Disorders Immuno Bullous Pemphigus vulgaris, Pemphigus foliaceous, Disorders Pemphigus erythematosus. Connective Tissue SLE, Scleroderma , Dermatomyositis Diseases Skin Tumours Seborrheic keratosis, DPN, SCC, BCC , Malignant melanoma Syringoma, Trichoepithelioma, Pilomatricoma. Geno Dermatoses Neurofibromatosis , Tuberous sclerosis. Miscellaneous Milia , Epidermoid cysts, Xanthelasma palpebrarum Conditions

DISEASE OF PILOSEBACEOUS UNIT

ACNE VULGARIS

It is a chronic inflammatory disease of pilosebaceous unit, manifesting generally in adolescence with pleomorphic lesions like comedones , papules, pustules, nodules and cysts and these may lead to scarring.

Acne affects approximately 85% of young people between ages of 12 and 24 years.1 Typically it starts between 12 to 14 years of age group in girls and 14 -16 years in boys. Males tends to develop acne later in adolescence with greater severity. Females have a less severe but chronic course.

Acne vulgaris is multifactorial in origin and the factors that affect the severity of acne are,

1. Altered cornification and differentiation

2. Androgens induced seborrhea.

3. Colonization of the pilosebaceous duct by Propionibacterium acnes.

4. Inflammation and immune response. 2

1. ALTERED CORNIFICATION AND DIFFERENTIATION

The primary change observed in the sebaceous follicle is the alteration in the pattern of keratinization within the follicle. Initial alteration takes place in the lower portion of the infundibulam , where there is hyperproliferation.

The excess keratin is also qualitatively altered as it tends to become densely packed along with monofilaments and lipid droplets. Comedogenesis results from accumulation of abnormally desquamated keratinocytes in the sebaceous follicle and formation of a keratinous plug. When the keratinous plug enlarges below a very small follicular pore at the skin surface, it becomes visible as a closed comedone (whitehead). An open comedone (blackhead) occurs if the follicular pore dilates. Subsequent proliferation of P. acnes generates inflammatory mediators and formation of inflammatory lesions.

Immunohistochemical studies have shown an increase in the proliferation rate of the basal keratinocytes and abnormal differentiation of the follicular keratinocytes in the follicle wall of microcomedones and comedones. Follicular hyperproliferation is also results from abnormal lipid inclusions. High levels of biologically active interleukin-1α (IL-1α) have been detected in comedones, believed to be expressed by follicular keratinocytes and triggered by changes in sebum composition and secretion. IL-1α may compromise follicular barrier and thus induce inflammation.

2. ANDROGENS INDUCED SEBORRHEA.

Abnormally high levels of sebum secretion could result from high overall androgen production; or increased availability of free androgen, due to deficiency of sex hormone binding globulin (SHBG); or because of amplified target response mediated either through 5α-reduction of testosterone or an increased capacity of the intracellular receptor to bind the hormone. Sebocytes and follicular keratinocytes are capable of metabolizing androgens through enzymes 5-a reductase (type 1), and 3b and 17b hydroxysteroid dehydrogenase.

In the facial skin of acne prone individual , type1 5α-reductase enzyme activity in sebaceous glands is greater than other body areas. In contrast, the oxidative activity of the type 2 17ß-HSD enzyme is greater in sebaceous glands from other areas compared to sebaceous glands of facial skin. The net effect of the activity of these 2 enzymes is the greater production of potent androgens such as testosterone and DHT within the sebaceous glands of facial areas, that may results in development of acne in these areas.

3. COLONIZATION OF THE PILOSEBACEOUS DUCT BY

PROPIONIBACTERIUM ACNES

P. acnes, a Gram-positive anaerobic bacteria normally found in the sebaceous follicle, plays an important role, both directly and indirectly, in the development of inflammatory acne. Others that may have a role include

Propionibacterium granulosum and Propionibacterium avidum. P. acnes

releases many enzymes such as proteinases, lipases, hyaluronidases and chemotactic factors that are integral in the inflammatory cascade. It directs immune reactions by modulation of the T helper 1/T helper 2 response and induction of monocyte-derived dendritic cell maturation. P. acnes stimulates the host innate immune response by activating toll-like receptors (TLR) and recognizing pathogen-associated molecular patterns (PAMPs).

4. INFLAMMATION AND IMMUNE RESPONSE

The inflammatory process in acne involves both humoral and cell- mediated immunity. Immunoglobulins G, M, and A and C3 are found within and surrounding inflammatory acne lesions. P. acnes activates both complement pathways. C5a is produced, which attracts neutrophils. The dermal inflammation is not caused by bacteria in the dermis but probably results from biologically active mediators that diffuse from the follicle where they are produced by P. acnes. The early inflammation is due to pro- inflammatory mediators moving through the duct wall into dermis. In vitro P. acnes may produce many enzymes, including three proteases - lipase, phosphatases and hyaluronate lyase all of which might be implicated. Ductal corneocytes produce interleukins (IL1α and IL1ß) and TNFα and these may be involved in inflammation. In papules, helper T cells are the first inflammatory cells to be seen. P. acnes, in particular its cell-wall fraction, is a potent chemoattractant for polymorphonuclear leucocytes and mononuclear cells. In

moderate and severe inflammation, there is disruption of the duct and a macrophage - giant cell foreign body reaction.

Other factors responsible for acne are

Hot and humid climate, High glycaemic load carbohydrate diet, stress ,

UV light, drugs like anabolic steroids, corticosteroids, phenytoin, lithium, isoniazid, anticancer drugs , cosmetics and hormonal factors - 70% of females have aggravation of acne before or during menstruation. 3 In adult and persistent acne in females > 25 years, polycystic ovarian syndrome (PCOS) 4 and other endocrine disorders play a major role.

Acne affects the areas of skin with the densest population of sebaceous follicles; the prevalence and severity on the face, chest and back being 92%,

45% and 61%,respectively. 5 On the face, acne occurs mostly on the cheeks and also on the nose, forehead and chin. The ears may be involved, with large comedones in the concha, cysts in the lobes, and sometimes preauricular and retro auricular comedones and cysts. Large cystic lesions may predominate on the neck, especially in the nuchal area.

Groins and pubic region usually not affected because acne lesions generally occur in the sebaceous glands connected with vellus hair.

Important clinical signs of acne are excess greasiness of the skin , seborrhea and the presence of Comedones. 6 Comedones are the characteristic

early non inflammatory lesions of acne. It is a plug of sebaceous and keratinous material lodged in the opening of hair follicle. Open comedones are a dilated pore filled with black keratinous material. Black colour is due to melanin deposited within the cellular debris. Closed comedones are small , flesh coloured, dome shaped papule.

There are two types of adult acne , Persistent acne and late-onset acne.

Adolescent acne persisting beyond the age of 25 years is called persistent adult acne and acne developing for the first time after the age of 25 years is called late-onset adult acne. 7

Various types of comedones are

 Open comedones.

 Closed comedones.

 Macrocomedones.

 Sand paper comedones.

 Submarine comedones.

 Secondary comedones .8

TABLE 2 : CLINICAL GRADING SYSTEM OF ACNE

(PILLSBURRY’S CLASSIFICATION) 9

GRADING DESCRIPTION

Grade 1 (mild) Comedones (open or closed), occasionally

pustules or papules; no scarring.

Grade 2 (moderate) Papules, comedones, few pustules; mild

scarring.

Grade 3 (severe) Predominant pustules, nodules and abscesses ,

moderate scarring.

Grade 4 (very severe) Mainly cysts, abscesses, scars; severe scarring.

SEQUELAE OF ACNE

The inflammatory lesions of acne are destructive and results in various types of scars. Acne scars which occurs due to collagen loss are atrophic, rolling, box car, linear and irregular and those occurs with increased collagen are hypertrophic and keloidal.

The lesions may leave behind pigmentation called post inflammatory hyperpigmentation. 10

Some of the clinical variants of acne are

 Infantile acne.

 Preadolescent acne.

 Adolescent acne .

 Post adolescent acne.

 Acne fulminans.

 Acne necrotica.

 Cosmetic acne.

 Acne excoriee.

 Acne conglobate.

 Comedone nevus.

 Occupational acne.

 Tropical acne .

 Acne estevalis.

 Steroidal acne.

Steroidal acne distinguish from acne vulgaris by its sudden onset usually within 2 weeks of starting topical or systemic corticosteroids and appearance of monomorphic, red , firm , papules and pustules on the face.

Rosacea

Rosacea is characterized by a persistent erythema of the convex surfaces of the face, most frequently affected were cheeks and nose, followed by involvement of the brow and chin. Most common age group affected were 30 to 50 yrs11. More common in women but the severity is more in men. More frequently occurs in those with fair and sensitive skin. 12

The triggering factors for rosacea were

 Sun exposure.

 Hot beverages.

 Spicy foods.

 Alcohol consumption.

 Wind blow.

 Emotional disturbances.

 Temperature variation.

 Topical irritants like soap and cosmetics. 13

ETIOPATHOGENIC FACTORS

VASCULAR HYPOTHESIS– Constitutional predisposition to flushing and blushing, vasomotor lability pronounced during menopause and microcirculatory disturbances. 14 .

EXAGGERATED INNATE IMMUNE RESPONSES – Increased cathelicidin peptides mediated inflammation of epidermis. Degenerated changes of matrix and connective tissue leads to small vessel dilatation with perivascular leakage of inflammatory mediators. Release of NO, gastrin, TNF alpha and IL 8 by helicobacter pylori leads to increased flushing. Demodex folliculorum also a etiological factor for rosacea. 15

Guideline for diagnosis of rosacea by National Rosacea Expert

Committee 16 are Presence of one or more of the following primary features

 Flushing

 Non transient erythema

 Papules and pustules

 Telangiectasia

Graded as mild, moderate or severe (0 – 3)

Presence of one or more of the following secondary features

 Burning or stinging .

 Plaque.

 Dry appearance .

 Edema.

 Ocular manifestations.

 Peripheral location.

 Phymatous changes.

Graded as absent or present.

TABLE 3 : SUBTYPES OF ROSACEA AND THEIR CLINICAL FEATURES 17

SUBTYPES PREDOMINANT CLINICAL FEATURES

Erythemato telangiectatic Flushing and persistent erythema pertaining to centro facial area.

Papulopustular Facial erythema with papules, pustules over the centro facial area.

Phymatous Localised swelling of facial soft tissue develop over many years due to increase in connective tissue, sebaceous gland hyperplasia, ectatic veins and chronic deep inflammation. Most commonly involve the nose,

 Rhinophyma – nose.

 Gnathophyma -chin.

 Metophyma – forehead.

 Otophyma – ears.

 Blepharophyma – eyelids.

Ocular rosacea Presented with foreign body sensation, blurred vision, conjunctival telangiectasia, blepharitis and chalazion.18

PIGMENTARY DISORDERS

MELASMA

Melasma is an acquired disorder of symmetrical hyperpigmentation commonly affects women with Fitzpatrick skin types 4 to 6 in areas where intense UVR. 19 It presents as light to dark brown to muddy brown macules of the face, commonly over the malar region and also involves forehead, chin in a symmetrical distribution pattern.

TABLE 4 : FITZPATRICK SKIN TYPES

Type I Always burns Never tans

Type II Usually burns Tans poorly

Type III Sometimes mild burn Tans after initial burn

Type IV Burns minimally Tans easily

Type V Very rarely burns Tans darkly easily

Type VI Never burns Always tans darkly

Chloasma is derived from the word chloazein. The literal meaning is green , also known as mask of pregnancy. Melasma in Greek as melas meaning black. Most commonly seen in the people of south east asian and Hispanic

origin. The prevalence of melasma varies between 1.5% and 33.3% depending on the population. 20

ETIOLOGICAL FACTORS

Genetic predisposition, Sunlight exposure causes generation of free radicals that stimulate melanogenesis, Pregnancy, Hormonal – stimulation of melanocytes by female sex hormones Estrogens and Progesterone ,Oral contraceptives 21 and hormone replacement therapy, Upregulation of melanocyte markers such as MITF, Increased vascularity and increased response of cutaneous vessels of face to sun exposure, Phototoxic medications,

Thyroid disorders and emotional – overstimulation of MSH by stress. 22

They presents as are dark, irregular patches of pigmentation. They can be guttate or confetti like, linear or confluent.

Three common clinical distribution pattern of melasma are

1. Centro facial – most common pattern involving forehead , nose , upper

lip and chin.

2. Malar – mainly involves cheeks.

3. Mandibular – involving skin over the ramus of mandible. 23

Depends upon the depth of pigment melasma divided into 3 types

1. Epidermal – melanin pigmentation mainly present over the basal and

supra basal layers of epidermis.

2. Dermal – in this type perivascular melanophages with less prominent

epidermal pigmentation are seen.

3. Mixed – melanin deposition seen in both epidermis and dermis

But based on the reflectance confocal microscopy all melasma

considered as mixed.

TABLE 5 : TYPES OF MELASMA

WOOD’S TYPE COLOUR HISTOLOGY LAMP

Melanin increases in EPIDERMAL Light brown Enhancement epidermis

Ashen or bluish- DERMAL No enhancement Melanophages in dermis gray

Melanin increases in Enhancement in MIXED Dark brown epidermis & Melanophages spotty areas in dermis

Ashen gray or INDETERMI unrecognized, Not conclusive Melanin deposits in dermis24 NATE Skin types 5 & 6

Severity assessment of melasma

Scoring system that commonly used for melasma is melasma area severity index. It was proposed by kimbrough green et al. 24

Face is divided into four areas.

Forehead , Right malar area, Left malar area and Chin.

In the above areas first three are given weightage of 30% each ,while chin given weightage of 10%. Scoring for darkness of pigment D compared with normal skin and homogenicity of the pigment H in the specified area is then performed.

The range of score is 0 – 48.

Impact of quality of life can be assessed by MELASQoL index. In this 3 important life domains being assessed social life, recreation leisure, emotional well being. 25 It is a 10 question scale that ask patients , how they feel about each on a scale of 1 to 7. Highest score indicating worst quality of life .

LENTIGO

These are persistent , benign ,discrete , hyperpigmented macules of round to oval in shape presents over the forehead , cheeks and back of the hands. They often results from increased number of melanocytes in the basal layer of epidermis. Simple lentigines starts often from childhood and solar lentigines occurs during middle age. It can be associated with some syndromes

like Peutz Jeghers syndrome , Cronkhite Canada syndrome and LEOPARD syndrome. 26

EPHELIDES

These are small , discrete macules of size 1 to 2mm present over the nose and malar areas of light skinned individuals. 27

RIEHL ‘S MELANOSIS

Otherwise called as pigmented contact dermatitis. It is due to allergens present in the fragrances, cosmetics and Kumkum. Diffuse grey brown pigmentation seen over the scalp, forehead , temple areas of face and neck. 28

Mostly seen in middle aged women.

LICHEN PLANUS PIGMENTOSUS

This is a rare variant of lichen planus , characterized by insidious onset of hyperpigmented dark brown macules mainly over the sun exposed areas especially on the face, upper limb and occasionally on the trunk. 29 It usually seen in 30 to 40 years age group , predominantly in women.

ACANTHOSIS NIGRICANS OF FACE

Acanthosis nigricans are brown to black velvety thickening of skin ,seen over the neck, axilla and groin. Facial acanthosis nigricans seen over the malar

and zygomatic region of the face with rough and verrucous overlying skin. It is commonly seen in obese and hyper insulinemic patients. 30

NEVUS OF OTA

Also known as nevus “Fuscoceruleus Ophthalmomaxillaris”. This is a dermal melanocytic hamartoma that presents as bluish brown patchy hyperpigmentation on the face along the first or second branches of trigeminal nerve. 31 On the face they are commonly seen over the periorbital region, temple, malar eminence , nose and forehead. Ocular involvement seen in 60 % of cases. Women are 5 times more commonly affected than men. Onset is usually at or after birth or 1to 10 years of age group. 15

PERIOCULAR MELANOSIS

Various synonyms of this condition are dark circles, periorbital hyperpigmentation or idiopathic cutaneous hyperchromia of orbital origin. This is an ill defined , round or semicircular homogenous dark brown pigmented macules in the periocular region. 32 This is more prevalent in females with age group between 16 – 25 years. It has multifactorial etiology. This may be due to thin and translucent eyelid skin leading to vascular prominence, periorbital edema, shadowing effect due to lax skin and ageing, post inflammatory pigmentation and environmental conditions such as UV radiation, lack of sleep, stress, alcohol and smoking.

HYPOPIGMENTARY DISORDERS

VITILIGO

Vitiligo is one of the most common depigmentary disorder of skin affecting approximately 0.5 to 1% of population. 33 Vitiligo affected patients having psychological and cosmetical devastating effects. This is derived from a lathin word vitium which means “a defect”. Highest incidence of vitiligo has been noted in india from Indian subcontinent. Vitiligo affects all races and both sexes equally. Majority of the people affected are in the age groups between 20 and 30 yrs.

Various theories has been proposed for etiopathogenesis. They are Auto immune theory, Neural hypothesis, Defective free radical defense theory, Self- destructive theory, Genetic ,Defective melanocyte growth factor theory,

Melano-cytorrhagy. Among the various proposed theories autoimmune destruction of melanocytes is the leading hypothesis. Grave’s disease , alopecia areata, type 1 diabetes and pernicious anemia are some of the autoimmune diseases associated with vitiligo.

This is characterized by asymptomatic ,well circumscribed amelanotic macules, which are symmetrical or asymmetrical in distribution surrounded by normal skin. Lesions enlarge centrifugally overtime, although the rate may be slow or rapid.

CLASSIFICATION OF VITILIGO 34

TABLE 6 : BORDEAUX VITILIGO GLOBAL ISSUES CONSENSUS

CONFERENCE CLASSIFICATION.

NONSEGMENTAL VITILIGO Acrofacial, mucosal -more than one mucosal site, generalized , universal , mixed.

SEGMENTAL Uni or bi or pluri segmental.

UNDETERMINED / Focal , mucosal (one site in isolation). UNCLASSIFIED VITILIGO

TABLE 7 : CLASSIFICATION OF SEGMENTAL VITILIGO OF FACE35

TYPES DISTRIBUTION

1a Lesions starts from the right side of the forehead and crosses midline of face and spreads down to eyelids, cheeks and nose on the left side.

1b Mainly over the forehead and scalp.

2 Starts between nose and lip and arches towards the preauricular area.

3 Starts from lower lip and spread towards the chin and neck.

4 Starts from forehead, goes downwards involving eyelids, nose and cheeks on the same side.

5 Around the right orbital area.

ECZEMATOUS DISORDERS

ALLERGIC CONTACT DERMATITIS

ACD is a delayed hypersensitivity reaction. It is due to T cell mediated immune response to a defined allergen that results in dermatitis. Exposure to a particular allergen can occur years before developing a delayed hypersensitivity reactions. After sensitization occurs , subsequent exposure to allergens may result in allergic contact dermatitis, even if small concentrations.

They divided into the three categories – Scalp dermatitis, Aerosolized allergens and Directly applied allergens. Females are more commonly affected than males. The common sources of allergens for both sexes includes moisturizers, sunscreens, hair products and fragrances. In general, cosmetic related dermatitis favors a bilateral facial distribution. It is often patchy and diffuse. Predilection for periphery of the face involving the pre auricular , submental and mandibular region results from scalp applied allergens like shampoos , conditioners , hair dyes and facial cleansers . Predominant central facial distribution suggests make up and moisturizers.

In India Bindi dermatitis is most common and it is due to thiomersal , colophony, PTBP or nickel. 36

PARTHENIUM DERMATITIS

It is an allergic contact dermatitis to Parthenium hysterophorus. It is the most common cause of plant dermatitis in India.

In India Parthenium hysterophorus commonly known as congress grass or congress weed. It was referring to the US congress, which allocated the contaminated wheat shipment containing the herb for Pune in 1956. The first case of Parthenium hysterophorus induced hypersensitivity was reported from

Pune in 1968. 37

Parthenium dermatitis caused by airborne dry and friable plant particles, especially sesquiterpene lactones and trichomes. It contains allergen parthenin predominantly and some of the allergens present in these are Hymenin ,

Ambrosin and Coronophilin.

Parthenium dermatitis has a chronic course with exacerbation during summers and some remission noted during winter.

Males are more commonly affected than females with male to female ratio of 5.5:1 and 20 : 1. Patients presented with persistent erythema , swelling, papules in moderate cases and extensive vesiculation and exudation in severe cases.

Classical pattern of airborne contact dermatitis (ABCD)pattern which affects the face specially eyelids ,V area of chest and cubital fossa. It is also called as pseudo photo dermatitis as the skin of the upper eyelids, retro auricular areas and sub mental areas which spared in photo dermatitis, are involved in parthenium dermatitis. 38

SEBORRHEIC DERMATITIS

This is an inflammatory disorder of the skin, characterized by erythema which is well marginated and accompanied by greasy scales over the scalp, face , chest, back and flexural regions. It affects 1 to 3 % of adult population. It has been suggested that, SD arises from an interaction between yeasts from the

Malassezia genus with the immune system. M. Globasa , M. Furfur and M .

Restricta are the most commonly implicated pathogens. 39 Two types of seborrheic dermatitis are infantile and adult SD.

Fine flaking of the skin with mild to moderate erythema present over the alar creases and nasolabial folds with scaling over the external ear canals. In scalp and beard areas they presents as persistent yellowish greasy scaly, plaques with indistinct margins and mild to moderate erythema present . Mild form can present with dandruff over the scalp. Adult form may occur along with acne , rosacea or pityriasis versicolor. Infantile form usually starts at 3 months of age and spontaneous resolution at 8 months. SD sometimes associated with neurological disorders and psychiatric diseases, including

Parkinson’s disease, neuroleptic induced parkinsonism and tardive dyskinesia.40

Main DD for SD is psoriasis , in which thick and sharply delineated plaques with silvery white scales ,tends to extend beyond the margin with less facial involvement.

PHOTODERMATOSES

These are group of disorders affected by sunlight. All these photosensitive reactions are results from UV radiation of wavelength 290 to

400nm. Various wavelength of UV spectrum are,

 UVA – wavelength (320 – 400nm), they penetrate into deep layers of

dermis and these one are responsible for photoaging. It can passes

through9 wind glass and may promote skin cancers.

 UVB – wavelength (290 – 320nm), effectively screened out by

window glasses and responsible for cutaneous reactions of sunlight.

 UVC – (<290nm) these are shorter wavelengths filtered out by the

atmosphere.

TABLE 8 : CLASSIFICATION OF PHOTODERMATOSES

TYPES DISEASES

GENETIC DISEASES Xeroderma pigmentosum, Cockayne syndrome, Bloom syndrome, porphyria,

Trichothiodystrophy

PHOTOTOXIC AND Medications (tetracyclines)

PHOTOALLERGIC REACTIONS Plants (Giant hogweed, Meadow grass) Chemicals (Psolarens , Eosin, Acridine)

IDIOPATHIC DERMATOSES Polymorphic light eruption, Solar urticaria, Chronic actinic dermatitis,

Actinic prurigo.

POLYMORPHIC LIGHT ERUPTION

PMLE is an idiopathic eruption caused by UV exposure which appears

in hours to days with a varying morphology between patients. It is triggered by

both wavelengths UVA and UVB. Commonly affects young women less than

30 years of age, in temperate regions with a prevalence of 10 to 20%. 41

ETIOPATHOGENESIS

It is believed to be an cell mediated /type 4 delayed Hyper sensitivity

response to endogenous cutaneous photo antigen. 42 UVR causes a natural skin

constituent to change into allergen , to which immune response get activated.

Glutathione depletion leads to free radical mediated injury results in development of skin lesions.17beta estradiol in females prevents UV radiation induced suppression of contact hypersensitivity response.

Typical sites of involvement are nasal bridge, malar areas of cheeks, chin of the face, sides and V area of the neck, dorsal aspect of hands, feet and extensor aspect of extremities.

The lesions are vary in morphology. The skin lesions are itchy and they are confined to sun exposed areas. The most common type is papular type which is an erythematous papules appear on a patchy erythematous base. The second most common type is plaque type in which superficial urticarial plaques are seen. In third type, the urticarial plaques develop into vesicles.

CHRONIC ACTINIC DERMATITIS

It is a rare chronic eczematous photo dermatosis involving mainly over the sun exposed areas. Usually affects the middle aged or older people. 43 It is a persistent photoallergic dermatitis that follows prior sensitization without further antigen exposure. It also been called as persistent light reaction photo sensitive eczema, Photosensitivity dermatitis and actinic reticuloid .

Photohaptens induced autoimmune response is a suggested pathogenesis of this disease.

Confluent eczematous patches associated with infiltrated plaques seen over the face scalp, back, side of neck and dorsa of the hands. In this sparing of the submental area, retro auricular and upper eye lids is a striking feature. In actinic reticuloid patients presented with lichenified indurated plaques over the face giving a leonine appearance.

SOLAR URTICARIA

Solar urticaria is a rare photo dermatoses characterized by recurrent episodes of wheals, erythema and pruritus over the sun exposed areas. It develops within minutes of exposure to sunlight and subsides within an hour or more.

Occurs in 4th or 5th decade with a female predominance. Primary form is

IgE mediated. 44 and secondary form is drug induced . It usually affects the face, trunk and hands.

XERODERMA PIGMENTOSUM

It is an autosomal recessive disorder due to defect in DNA repair.

Patients presents with marked photosensitivity, develop solar lentigines by the age of 2 and have freckles, atrophy, scaring, telangiectasia , mottled hypo and hyperpigmentation. Early onset of malignancies like BCC, squamous cell carcinoma, actinic keratosis and malignant melanoma 45 occurs mainly over the head and neck region.

Xeroderma pigmentosum divided into 7 groups A to G. Among these

A,C,D and G groups have severe cutaneous manifestations. Standard diagnostic method is unscheduled DNA synthesis assay following UV radiation of skin fibroblasts and lymphocytes.

INFECTIONS

BACTERIAL INFECTIONS

ERYSIPELAS

This is an acute superficial infection involving dermal lymphatics caused by group A Beta hemolytic streptococci. Also known as St. Anthony’s fire. Mostly affected age group were 4th and 6th decade with female predominance. Most common site affected is lower legs followed by face. They presents as bright red , sharply demarcated, rapidly spreading erythematous patch with indurated border. On the face lesions starts from the cheeks near the nose or in front of ears and goes upwards to the scalp. Patients usually treated with penicillin or macrolides with dramatic improvement.

SYCOSIS BARBAE

This is a chronic bacterial infection of the hair follicle over the beard area caused by staphylococcus aureus characterized by tender ,erythematous papulo nodules ,often with a central pustules.

LUPUS VULGARIS

This is a rare chronic infection with tubercle bacilli spread by underlying foci of infection or lymphatic or hematogenous route. Lower extremities are the primary site of involvement. On the face commonly seen over the nose , cheeks followed by ear involvement. These are slowly spreading granulomatous plaques and group of papules. On diascopy they appear translucent but have a central opaque yellowish brown center called as apple jelly nodules.

VIRAL INFECTIONS

HERPES SIMPLEX INFECTIONS

These are infections caused by viruses HSV type 1 or type 2. HSV type

1 is responsible for orofacial infections whereas type 2 are commonly associated with genital infections. Primary infection usually affects children within age group of 1 to 3 years. The infection starts off as a pyrexial gingiva stomatitis. They develop white patches on the oral mucosa studded with vesicles and often ulcerate. After resolution the virus remains latent in the sensory ganglia. Recurrences taken place when patient have fever, trauma, emotional stress sun exposure and reduction in immune status.

Recurrent attacks present as inflamed patches surrounded by clusters of vesicles on the lips, around the mouth , chin, cheeks and peri orbital region.

These vesicles often ulcerate and patients develop painful neuralgia.

HERPES ZOSTER

This is a segmental painful skin disease caused by reactivated varicella zoster virus. 46 After initial chicken pox infection, the virus becomes dormant in dorsal root ganglia and reactivation results in herpes zoster. Also known as shingles. The term zoster literally means as girdle. Middle age people are most commonly affected with slight female predominance. Among the various dermatomes involved trigeminal is seen in 15% of cases. It usually starts with pain and paraesthesia followed by erythematous patches along the nerve root involved. This followed by rapid development of vesicles which become purulent and crusted. Vesicle on the side of nose indicate nasocilliary involvement. Patient develops ocular complications along with unilateral fore head involvement seen in Herpes Zoster Ophthalmicus.

WART

These are benign epithelial tumors caused by human papilloma virus.

There are more than 100 serotypes has been identified. The most common clinical type of facial wart is flat wart which is caused by serotypes 3,10,28 and

49. They are more common in adolescence and early adults. Face and neck are commonest affected sites. These are smooth , slightly elevated, skin colored, flat topped papules are commonly seen over periorificial , mandibular and lower jaw area. In men it may frequently spread by shaving [ auto inoculation].Spontaneous resolution can be expected in 6 months.

FUNGAL INFECTIONS

DERMATOPHYTES

Dermatophytes lives as a parasite in tissue containing keratin. They are divided into

Anthropophilic – found in humans.

Zoophilic - in animals

Geophilic – in soil.

Three groups of dermatophyte fungi causing tinea infections are

Trichophyton – affects skin , hair and nail.

Epidermophyton – skin and nails

Microsporum – skin and hair.

The word tinea comes from the Latin word which means “worm”.

TINEA BARBAE

Also known as tinea sycosis , barber’s itch. This is the ring worm infection of beard and moustache areas of face. This is exclusively found in male adults. The organisms responsible for this infection are trichophyton mentagrophytes and trichophyton Verrucosum.

Autoinoculation from finger nails or tinea pedis is frequently the source of infection. Sometimes animals like cats , dogs and horses may transmit the

infection. Pathogenic fungi produce several keratinases that may invade the keratins. Some patients presented with superficial , crusted , bald patches with folliculitis and some presented with deep , nodular suppurative lesions.

Commonly involves the upper lip, chin ,cheeks and sometimes it may spread to eyelids , forehead also. Hair is loose and broken , and easily pulled off without pain. This is in contrast to bacterial folliculitis where it is very painful. Patient may have fever and lymphadenopathy. Diagnosis by KOH examination, culture, wood lamp examination.

TINEA FACIEI

This is an infection of the glabrous skin of the face excluding moustache and beard areas of adult males. The organisms responsible for Tinea Faciei are trichophyton mentagrophytes and T. rubrum . Infections spread by directly from the organisms or by secondarily from the preexisting lesions from other areas of the body. Patients presented with erythematous patches and minimal scaling with indistinct borders. Typical annular lesions are may or may not be present. There has been mild photosensitivity of the lesional area present. 47

This photosensitivity property it is often confused with LE and PMLE.

Because of its varied morphology over the face it is diagnosed by KOH examination and biopsy.

TINEA VERSICOLOR

This is a common fungal infection caused by Malassezia , a dimorphic fungi. It is also known as Pityriasis versicolor, Tinea flavea , Liver spots,

Chromophytosis.

It is more commonly seen in young adults and mostly during the months of summer and in tropical zones. More apparent in dark skinned people.

Usually caused by M. globosa and also by M. furfur and M. sympodialis. 48

These normal flora , after converting into mycelial form ,spread into superficial epidermis, results in appearance of rash.

These are confluent , scaly, discoloured or depigmented areas , mainly over the upper trunk ,neck , face and scalp. The color of the lesions vary from white to reddish brown to tan coloured. Hypopigmentation is due to tyrosinase inhibitors secreted by the fungus and hyperpigmentation due to fungi induced melanosomes enlargement. KOH examination of the scales shows fungal hyphae and numerous spores referred to as spaghetti and meatballs appearance.

In vitiligo, there has been complete pigment loss , no scaling or surface changes.

AUTOIMMUNE CONNECTIVE TISSUE DISEASES

These are group of polygenic disorders that involving complex autoimmune responses targeting collagen or ground substances. These disorders have heterogenous and overlapping clinical features.

The disorders comes under this group are

1.systemic lupus erythematosus

2.dermatomyositis

3.scleroderma.

LUPUS ERYTHEMATOSUS

Lupus erythematosus is an autoimmune disorder with a varying clinical spectrum ranging from mild cutaneous lesions to life threatening systemic involvement with nephritis, arthritis, serositis and CNS.

Lupus erythematosus divided into 2 types

. Cutaneous lupus erythematosus

. Systemic lupus erythematosus

Cutaneous lupus erythematosus has 3 types

1. Acute cutaneous lupus erythematosus

2. Subacute cutaneous lupus erythematosus

3. Chronic cutaneous lupus erythematosus. 49

SYSTEMIC LUPUS ERYTHEMATOSUS

SLE is a multifactorial autoimmune disease involving multiple organs and characterized by presence of antinuclear antibodies.

Females are more commonly affected than males with a ratio between

7:1 and 15:1.most of the females are around the reproductive age group.

Skin is affected in up to 80% of the patients at some point in their disease and face is affected in large majority of the cases. Other areas of skin affected are the v area of the neck ,dorsum of the hands and forearm.

Involvement of facial skin usually occurs early in the course of the disease alongside systemic symptoms before development of arthropathy.

In some patients the condition develops after an episode of exposure to sunlight, after some minor infective disorders like upper respiratory tract infection, emotional stimuli, stress, pregnancy, drugs such as isoniazid, procainamide, hydralazine and phenytoin.

60% of SLE patients develop malar rash. They classically presented with localized transient erythema in a butterfly shaped distribution over the malar area within hours or weeks following sun exposure. It involves nasal bridge, bilateral malar eminence, sparing the melolabial folds which is commonly involved in facial erythema of dermatomyositis. It may also involves forehead, periorbital areas and sides of the neck. 50 Morphology of the

lesions varying from erythema to edematous lesions. They may develop into papules , scaling , erosions, poikiloderma, atrophy or dyspigmentation.

Malar rash sometimes associated with generalised photo distributed eruption involving v area of the neck , upper back , extremities , dorsal hands sparing the knuckles.

CHRONIC DISCOID LUPUS ERYTHEMATOSUS

This is a chronic remittent destructive and scarring disorder of the sun exposed skin. Discoid lupus accounts for majority cases of chronic cutaneous lupus erythematosus. Females are affected more than males. 5% of localised

DLE and 20% of disseminated DLE patients progress into SLE .

The lesions are start as red macules or irregularly thickened red plaques with well defined margins that develop on the face, concha of the ear ,neck, scalp and occasionally over the forearms. The lesions develop into scales, atrophy and scarring with central hypopigmentation and peripheral hyperpigmentation. Follicular orifices may become dilated and filled with horny plugs called “carpet tack sign” or tin tack sign or cat tongue sign.

SCLERODERMA

Scleroderma is an umbrella term that used for conditions that includes localised forms also known as Morphea and systemic forms that are presented with internal organs involvement with vascular manifestations.

Scleroderma divided into localised forms and systemic forms.

Localised forms morphea

Systemic forms divided into 2 types

 Limited cutaneous systemic sclerosis

 Diffuse cutaneous or progressive systemic sclerosis

MORPHEA

Morphea is characterized by sclerosis, fibrosis and atrophy of the skin and subcutaneous tissue and progress into muscle ,bone and brain sometimes.

More common in females than males with ratio of (2.6 : 1). 52

Kreuter et al classified morphea into,

Limited type , Generalised type , Linear type , Deep type.

Face is not often involved in ordinary types but it is affected by a special somewhat curious linear type of head and neck variant known as “en coup de sabre”. 53 It often involves the frontoparietal regions of the forehead and scalp in a paramedian distribution. Varying degrees of sclerosis, atrophy and hyperpigmentation observed over that area in a pattern likened to the effects of a sabre blow. They can be associated with scarring alopecia of the scalp, eyebrows and eyelashes.

SYSTEMIC SCLEROSIS

This is a multiorgan disease with diffuse sclerosis of connective tissue favouring skin, lungs, GIT and kidneys. There is marked patient to patient variability in clinical and laboratory manifestations and its course. Commonly occurs in third and fifth decades. Female to male ratio 5:1.but worse prognosis noted in males. The pathogenesis of SS is autoreactive T cells produce types 1 ,

3 and 4 collagen and also fibronectin and proteoglycans which gets deposited in affected tissues . TGF beta is the main cytokine responsible for fibrosis. 51

Systemic sclerosis divided into two types

 Limited cutaneous systemic sclerosis

 Diffuse cutaneous systemic sclerosis

In limited form skin thickening confined to distal extremities (distal to

MCP and MTP joints) and face. In progressive systemic sclerosis skin thickening involves proximal and distal extremities as well as face and trunk.

Facial features of fully developed scleroderma patients shows mask like facies due to diminished expression lines. Facial skin is taut and hidebound.

Microstomia, bird like thinning of nose with hollowing of cheeks. Star like telangiectasias occurs over the forehead and cheeks. Diffuse hyperpigmentation also seen over the face.

Limited form have less severe involvement of renal and pulmonary system. Progressive form presented with involvement of pulmonary , cardiovascular, GIT, renal and musculoskeletal manifestations. Limited form positive for anti centromere antibodies whereas diffuse one are anti topoisomerase positive.

DERMATOMYOSITIS

This is an uncommon auto immune disease characterized by a combination of proximal muscle weakness and inflammatory skin changes. It is also known as “Wagner Unverricht disease”.

Females are more commonly affected than males. It has a bimodal distribution with children 5 to 14 years of age groups and in adults 40 to 65 years of age.

Dermatomyositis divided into 2 groups

 Adult onset dermatomyositis

 Juvenile dermatomyositis

Genetic susceptibility, induction by UV light , viral infections

(coxsackie virus, EBV, parvo virus) and loss of immune regulation are pathogenic factors.

The myositis predominantly involves the proximal limb girdle muscles and it is first noted as weakness and tenderness over the affected muscles. In skin involvement face is affected in majority of the patients. Bilaterally symmetrical confluent macular violaceous erythema involving both the malar region of the face including melolabial folds. Erythema around the periorbital area known as heliotrope rash and it occurs due to inflammation of orbicularis oculi muscle. Erythema over the lateral thigh holster sign. Pathognomonic feature of dermatomyositis is Gottron papules 54 which are lichenoid papules present over the PIP, DIP, MCP joints.

SKIN TUMOURS

Skin tumours are diverse group of disorders that occurs due to proliferation of group of cells with differentiation into single or multiple components of the skin. The face is a target for solar damage and neoplasms that develop after prolonged exposure to UV radiation.

CLASSIFICATION OF SKIN TUMOURS

 BENIGN CONDITIONS - Seborrheic keratosis, Nevi

 MALIGNANT – SCC, BCC , Malignant melanoma

 ADNEXAL TUMOURS - Syringoma, Trichoepithelioma,

Pilomatricoma,

BENIGN TUMOURS

SEBORRHEIC KERATOSIS

This is a benign epithelial tumour and commonly seen in people with those exposed to sunlight. 55 Also known as basal cell papilloma, seborrheic wart. Usually starts from the age of 40 years or more and it has familial predisposition with autosomal dominant inheritance.

Seborrheic keratosis can occur anywhere in the body but most commonly seen over the face , trunk and backs of the hands. On the face, it often seen over the forehead, temple and preauricular area. A distinctive stuck on appearance is the classical. It can be flat , raised , filiform , pedunculated and the surface smooth , or verrucous. The surface may have greasy scaling and scattered keratin plugs. It can be differentiated from the nevi by the non reflecting nature of light. Patterened fine fissures over the surface of the SK , distinguish it from lentigo maligna and actinic keratosis.

Variants 56

 Dermatosis papulose nigra.

 Inverted follicular keratosis.

 Stucco keratosis .

DERMATOSIS PAPULOSE NIGRA

In this variant multiple black or dark brown , pigmented , flat or cupuliform papules appear on the face and trunk but it may extend into trunk also. The cheek and forehead are the common site affected on the face. More common in women than in men with dark skin complexion. 57

NEVI

These are benign neoplasm of uniform melanocytes. They can be congenital or acquired. Common acquired nevus may appear at puberty or early adulthood and equal in both sexes. White skinned people are more commonly affected than black skinned individuals. UV exposure and BRAF gene mutations are suggested etio pathogenic factors.

Based on the histological pattern they are classified as

 Junctional nevi – melanocytes at DEJ

 Dermal nevi – melanocytes in the dermis.

 Compound nevi – melanocytes in both sites.

Junctional nevi are light to dark brown macule of 2 to 10 mm size located usually on the trunk and extremities. Compound nevi mildly elevated oval or round papule with symmetrical shape. Dermal nevi are smooth surfaced , flesh coloured dome shaped nodules with sprouting of hair from

surface present over the head and neck areas. On the face commonly seen over the nasolabial folds and perioral area.

BCC

Most common form of skin cancer seen on the face in the middle age or elderly males. It is a locally invasive , does not metastasize and also called as

“Rodent ulcer”. It grows slowly and become locally destructive. Prolonged sun exposure , fair skinned individuals , ionizing radiation are the some of predisposing factors. 58 The pathogenesis related to altered regulation of sonic hedgehog pathway. Most common type is Nodulo ulcerative type 59 ,which appears as a glistening, translucent , skin coloured papules leads to central necrosis that forms an ulcer with an adherent crust and a rolled out edge seen over the nose and also over the forehead , cheeks , and periocular areas.

SCC

SCC is the second most common malignant skin tumour of skin. This is more common in black individuals and organ transplant patients. More common in males after 50 years of age. UVA induced mutation of p53 gene,

HPV 16,18, arsenic exposure ,chronic inflammation and scars are the various etiological factors considered. 60 Most commonly seen over the sun exposed areas like face , forearms and back of hands. On the face lower lip is most common site followed by tongue, nose and lower lids. SCC presents as

ulcerated plaques or nodules. Very indolent lesions presents as cutaneous horns from pink thickened plaques.

MALIGNANT MELANOMA

This is an epidermal neoplasms of melanocytes. Peak age is around 60 yrs. Most common type is superficial spreading 61 , followed by lentigo maligna , nodular and acral lentiginous. LM presents as slowly enlarging pigmented patch on the face. It often have a mixture of pigmentation that helps to distinguish it from senile lentigo. NM present as irregularly shaped and irregularly pigmented raised nodule over the face. Prognosis depends on the depth of invasion.

ADNEXAL TUMOUR

TRICHOEPITHELIOMA

This is also known as epithelioma adenoids cysticum . These are uncommon benign epithelial tumours of hair follicles 62 which may be solitary or multiple. Mostly affect young adults with female predominance. They are small ,skin coloured or pearly nodules. They can be single or multiple. Solitary lesions occurs anywhere on the face and it may resemble nodulocystic bcc. If they are multiple they occur over the both cheeks. It may resemble syringomas but trichoepithelioma , do not cluster around the eyes.

SYRINGOMA

These are benign sweat gland tumours , usually multiple. They are more common in women and seen predominantly on the face especially over the eyelids, cheeks and neck. It may also occur over the trunk and limbs.

Syringomas are small 2 to 4mm ,skin coloured ,white or pink papules which may appear lichenoid. These are usually asymptomatic and nonhereditary. 63

PILOMATRICOMA

These are benign tumours of skin arise from hair follicle matrix. These are more common in young adults. They are single , firm or hard , skin coloured or slightly bluish nodules occurring over the face, neck and shoulders.

BULLOUS DISEASES

PEMPHIGUS VULGARIS

The word pemphigus derived from Greek means blister or bubbles.

These are caused by auto antibodies formed against Desmosomal proteins ,

Desmogleins 1 and 3. Most common age group affected are 4th and 6th decade.

64 Both sexes are affected equally. Oral blisters and erosions are the earliest manifestation seen in 50 to 70 % of patients. Patients develops fluid filled flaccid vesicles and bullae over the scalp , face and axillae in an normal or erythematous skin. Blisters easily rupture into erosions which have low tendency to heal. Resolves with hypopigmentation.

PEMPHIGUS FOLIACEOUS

This is characterized by small flaccid bullae with crusting and scaling in the seborrhoeic distributed areas of scalp , face , chest and upper back . Blisters not obvious because cleavage is superficial.

PEMPHIGUS ERYTHEMATOSUS

This is a localized variant of pemphigus foliaceous. Also known as Senear

Usher syndrome. 65 This is characterized by erythematous scaly plaques, thin walled bullae and denuded areas predominantly over the face in a butterfly like distribution and also over the chest and back areas. Exacerbations following sun exposure is common. patients have immunopathologic features of both pemphigus and lupus erythematosus (LE).

PAPULO SQUAMOUS DISORDERS

PSORIASIS

Psoriasis is a chronic inflammatory skin condition that can affect any skin site. The prevalence of psoriasis is 2 to 3 % in total population. It is very rare for psoriasis that occurs solely over the face. Most of the affected patients associated with either scalp psoriasis or moderate to severe plaque psoriasis in other sites. Three clinical subtypes of facial psoriasis are Hairline psoriasis, sebo psoriasis and true facial psoriasis.

Hairline psoriasis are extension of scalp psoriasis beyond the margins of hairlines and extend into forehead. Sebopsoriasis have salmon pink , thin plaques with bran like scales involving eyebrows , eyelids , nasolabial folds and beard areas. 66 True facial psoriasis are symmetrical sharply demarcated scaly plaques , affect any area of face. Treatment for facial psoriasis are challenging one due to thin and sensitive skin of face.

LICHEN PLANUS

LP is an immunologically mediated chronic inflammatory disease involving skin hair , nail and mucous membranes. Flexural extremities are the most common site for LP. Over all incidence of LP is less than 1%. Actinic LP is a variant of LP seen mainly in tropical countries. Usually seen in children and young adults. It involves sun exposed areas like face , dorsum of hands and neck. These are blue brown annular plaques with atrophic centre and peripheral hypopigmentation. 67

PORTWINE STAIN

These are capillary malformations present at birth. Most common site is face. On the face it presents as flat , dark red or crimson patches occurs along the distribution of 5th nerve. On increasing with age , these lesions are more prominent by developing hypertrophy and warty papillomatous areas.

SPIDER NEVUS

Mostly occurs on the face especially over the cheeks. They have central red spot with radiating legs.

CYSTS

MILIA

These are small subepidermal keratin cysts. They common on the face in all age groups and appears as a small white millet seed like papules of 0.5 mm to 2 mm in diameter. They also occurs following subepidermal blistering e.g epidermolysis bullosa.

EPIDERMOID CYSTS

These are horn filled epidermis lined cavities commonly seen over the face especially over the forehead and ears.

NEUROFIBROMATOSIS

These are benign hamartomatous growth of peripheral nervous system.

Inherited as autosomal dominant. 68 Two types of neurofibromatosis are there.

Type 1 is due to mutation of neurofibromin in chromosome 17 , whereas type 2 is due to mutation of merlin in chromosome 22. Incidence of NF 1 is 1 in 3000.

90% met the diagnostic criteria by the age of 8. Rapid enlargement of neurofibromas noticed during puberty. Cutaneous neurofibromas presented as asymptomatic , skin colored to pink tan , soft papulonodules present over the trunk , limbs and face which invaginate with gentle pressure(button hole sign).

AIMS AND OBJECTIVES OF THE STUDY

AIM :

To study the dermatoses affecting the face and their epidemiological aspects like age, sex and occupational distribution and clinical presentation of these conditions.

OBJECTIVES OF THE STUDY :

1. To study the epidemiology of facial dermatoses .

2. To study the clinical presentation of various facial dermatoses.

MATERIALS AND METHODS

STUDY DESIGN

Observational study.

STUDY POPULATION

A total of 200 patients who presented to the Department of dermatology,

Coimbatore medical college and hospital, during the period of June 2018 to

May 2019 were included in this study.

INCLUSION CRITERIA

Patients were with dermatological complaints pertaining to facial region with age group of 18 to 45 years were included in this study.

EXCLUSION CRITERIA

1. Age less than 18 years and more than 45 years.

2. Patients who had already been diagnosed and treated for facial skin

disorders.

3. Patients with mucosal involvement only (oral or conjunctival).

4. Patients who refused to give consent.

METHODOLOGY

A total of 200 patients with facial dermatoses were recruited in this study. Demographic details such as age, sex, occupation were recorded in all the participants. A detailed history regarding duration of illness, previous treatment, similar illness in the family and any relevant comorbidities also recorded. General and dermatological examinations were done for all patients.

Investigations like 10% potassium hydroxide examination, woods lamp examination and skin biopsy were done for relevant cases.

OBSERVATION AND RESULTS

SEX DISTRIBUTION

Out of the 200 patients in our study, 74 (37%) were males and

126(63%) were females. The female to male ratio was 1.7:1.

CHART 1 : SEX DISTRIBUTION IN FACIAL DERMATOSES

MALE FEMALE

37%

63%

AGE DISTRIBUTION

The maximum number of patients in both sexes were observed in age group of 26 to 32 years (33%) and the next group observed were of 33 to 39 years (26.5%).

TABLE 9 : AGE WISE DISTRIBUTION OF FACIAL DERMATOSES

AGE GROUP MALE FEMALE TOTAL PERCENTAGE (IN YEARS)

18 – 25 16 28 44 22%

26 – 32 21 45 66 33%

33 – 39 14 39 53 26.5%

40 – 45 23 14 37 18.5%

OCCUPATION

Majority of the patients with facial dermatoses were housewives 55

(27.5%), followed by students 43 (21.5%).

CHART 2 : OCCUPATIONAL DISTRIBUTION OF FACIAL

DERMATOSES

27% housewives 14% students manual workers field workers 13% self employees govt servants 21% 16%

SEASONAL VARIATIONS

About 55% patients of facial dermatoses have no seasonal variation.

Summer exacerbation was observed in 40% of patients whereas winter exacerbation was observed in 5% of patients.

CHART 3 : SEASONAL VARIATIONS IN FACIAL DERMATOSES

40% SUMMER WINTER 55% NO RELATION

SYMPTOMS

Patients with pigmentary changes were observed in 52 (26%) followed by pruritus in 45 (22.5%) , pain /burning sensation in 22 (11%) and photosensitivity in 36 (18%) of patients. About 32(16%) patients were asymptomatic.

CHART 4 : SYMPTOMS IN FACIAL DERMATOSES

60 52 50 45

40 36 32 30 22 20

0 pigmentary pruritus pain/ burning photosensitivity asymptomatic changes sensation

INCIDENCE OF VARIOUS FACIAL DERMATOSES

Diseases of pilosebaceous unit were the most common facial dermatoses seen in 27% , followed by pigmentary disorders in 26% of patients.

CHART 5 : INCIDENCE OF VARIOUS FACIAL DERMATOSES

30% 27% 26% 25%

20% 14% 15%

10% 7.50% 8.50% 3.50% 3.50% 4% 5% 5% 2% 0%

DISTRIBUTION OF FACIAL DERMATOSES

The most commonly affected site of involvement was cheeks (90%) followed by forehead (55%) . The least common site of involvement was perioral area (13%).

TABLE 10 : SITES OF DISTRIBUTION OF FACIAL DERMATOSES

SITES PERCENTAGE

Forehead 55 %

Temple 22%

Cheeks 94%

Periocular 28%

Nose and nasolabial folds 32%

Chin 22%

Perioral area 13%

DISEASE OF PILOSEBACEOUS UNIT

Among the 54 patients 52 had acne and 2 had rosacea.

ACNE

Total number of patients affected by acne were 52. Out of 52 cases

63.46% were females and 36.53% were males. Females out numbers males with a ratio of 1.7 :1.

CHART 6 : GENDER DISTRIBUTION OF ACNE

0% 0%

MALE 37%

FEMALE 63%

The maximum number of patients belonged to the age group of 18 – 25 years (59%), followed by 26-32 years (25%).

TABLE 11 : AGE AND SEX WISE DISTRIBUTION OF ACNE

NUMBER AGE PERCENTAGE MALE FEMALE OF GROUP PATIENTS 18-25 years 10 21 31 59.61%

26 – 32 years 5 9 13 25%

>32 years 4 3 7 13.46%

In this study majority were housewives (50%), followed by students

(19.23%), field workers (13.46%) and govt servants (7%).

CHART 7 : OCCUPATIONAL DISTRIBUTION OF ACNE

60%

50% 50%

40%

30%

19.23% 20% 13.46% 9% 10% 7%

0% HOUSEWIVES STUDENTS FIELD WORKERS MANUAL GOVT SERVANTS LABOURERS

MORPHOLOGICAL DISTRIBUTION IN ACNE

In patients with acne most of them had papules (38%), followed by pustules (25%), comedones (19%) , scars (13%) and nodules and cysts (3%).

SITES OF DISTRIBUTION OF ACNE

Most common site affected were cheeks followed by forehead. Least common site affected was chin.

TABLE 12 : SITES OF DISTRIBUTION OF ACNE

SITES NUMBER OF PERCENTAGE CASES Forehead 35 67.30%

Cheeks 50 96.15%

Chin 16 30.76%

Mandibular 22 42.30%

Nose 18 34.61%

Duration of acne ranges from 2 weeks to 5 years.

Majority of the patients had grade II acne (38.46%) followed by grade

III (25%) , Grade I (19.23%) and grade IV (17.30%) .

TABLE 13 : GRADING OF ACNE

GRADE MALE FEMALE TOTAL PERCENTAGE

Grade 1 3 7 10 19.23%

Grade 2 7 13 20 38.46%

Grade 3 3 10 13 25%

Grade 4 6 3 9 17.30%

Comedones were seen in 10 patients. Open comedones were more commonly observed than closed comedones.

Majority of the acne patients were in grade 2 group. Inflammatory acne

(grade II,III,IV) were more common than noninflammatory acne (Grade I).

Scars were present in 9 cases. Out of this, 4 had atrophic scars and 3 had icepick Scars. In 2 patients, they had both atrophic and icepick scars.

TABLE 14 : AGGREVATING FACTORS OF ACNE

FACTORS PERCENTAGE

Seasonal aggrevation 44.23%

Family history 23.07%

Premenstrual flare 28.84%

Topical cosmetics 55.76%

Stress 28.84%

Menstrual irregularities 19.23%

Topical steroid 17.03%

Family history was observed in 18% of patients. Association with hirsuitism was noted in 4 patients and androgenic alopecia in 5 patients.

Rosacea was observed in 2 patients. Both were males. One was field worker and the other one was manual labourer. Exacerbation following sun exposure was observed in both cases. Both of them had papulopustular type of rosacea involving both malar areas , nose and forehead.

PIGMENTARY DISORDERS

Out of 200 patients pigmentary changes were observed in 26%. Most common pigmentary disorder seen in our study was melasma (67%), followed by periocular melanosis (9%), post inflammatory pigmentation 9% , vitiligo 7% and ephelides 5%.

Females (73%) were more commonly affected than males (29%).

Pigmentary changes was the primary symptom in all the cases.

Female to male ratio was 2.7 : 1.

Majority of the patients belong to the age group of 33 to 39 years (46%) followed by 26 to 32 years accounting for 28%.

TABLE 15 : AGE WISE DISTRIBUTION OF PIGMENTARY

DISORDERS

AGE GROUP MALE FEMALE TOTAL PERCENTAGE

18 – 25 years 2 4 6 11%

26 – 32 years 5 10 15 28%

33 – 39 years 3 21 24 46%

40 – 45 years 4 3 7 13%

OCCUPATION

Majority of the cases were Housewives(54%) followed by Manual labourers (27%) , Self employees (13%) and Govt. servants(6%).

CHART 8 : OCCUPATIONAL DISTRIBUTION OF PIGMENTARY

DISORDERS

housewives manual labourers self employees govt servants

13%

54%

27%

Mean duration of pigmentary changes observed between 1 month to 10 years.

SEASONAL VARIATION

CHART 9 : SEASONAL VARIATION OF PIGMENTARY DISORDERS

SUMMER+ WINTER NO VARIATION

44% 47%

Summer exacerbation was observed in 47% of patients whereas winter exacerbation was observed in 9% of cases. In 44% of cases there were no seasonal variation.

Among the 52 cases, 28 were found using cosmetics were noted between 6 months to 3 year duration.

In 5 cases topical steroids were used for <1 year duration.

MELASMA

Out of 52 cases of pigmentary disorders , 67% were melasma . Among them 82% were females and 17% were males with a ratio of 4.8:1.

Pigmentary changes was the primary complaint. In about 14% also had pruritus.

CHART 10 : SEX DISTRIBUTION OF MELASMA

0% 0%

MALE 17%

FEMALE 83%

Majority of the patients belong to the age group between 26 years to 40 years , with peak incidence was observed at 34 years.

Majority of them were Housewives (60%) followed by Field workers

(22.85%) and Manual labourers (17.14%).

OCCUPATIONAL DISTRIBUTION

CHART 11 : OCCUPATIONAL DISTRIBUTION OF MELASMA

HOUSEWIVES FIELD WORKERS MANUAL LABPURERS

17%

22% 61%

 Mean age of onset of melasma was 25 years and the average duration

was 3 years.

 Relation with sun exposure was found in 71.42% of cases (25).

 Among the 35 cases , 15 were found using cosmetics with the duration

of 6 months to 2 years.

 In about 5 cases of melasma gave positive history of taking OCP while

4 were under medication for hypothyroidism.

 Most common clinical pattern of melasma , observed in our study was

malar pattern (57.14%) , followed by centrofacial pattern (37.14%) and

the least common was mandibular pattern (5%).

CHART 12 : DISTRIBUTION PATTERN OF MELASMA

60.00%

50.00%

40.00%

30.00%

20.00%

10.00%

0.00% MALAR PATTERN CETROFACIAL PATTERN MANDIBULAR PATTERN

On woods lamp examination 19 patients had epidermal type of pigmentation , 7 patients had mixed type of pigmentation and 7 patients had dermal pigmentation.

Periocular melanosis was observed in 5 cases. Among them 3 were females and 2 were males. Positive family history was found in 2 cases.

Ephelides were observed in 4 cases. Among them 2 were females and 2 were males.. One of them was house wife and the other 2 were field workers.

One of them had given positive family history.

VITILIGO

Out of 52 patients of pigmentary disorders, vitiligo was observed in 4 cases. All of them were males. Mean duration of vitiligo was 7 months to 8 years. Average age was 29.25 years. Among the 4 cases, one had generalized vitiligo and the other 3 had acrofacial vitiligo. In about 75% cases of vitiligo periocular , nasolabial involvement were observed whereas one case showed segmental vitiligo of right side of face involving mandibular area. Family history was present in 25%. Positive history of thyroid disease was observed in

25%.

INFECTIONS

 Out of 200 cases, 14% were affected by infections.

 Males (60.7%) were predominantly affected than females (39.28%).

 Majority of them belong to the age group of 33 to 39 years (39.28%),

followed by age group 26 to 32 years (32.14%).

TABLE 16 : AGE WISE DISTRIBUTION OF INFECTIONS

AGE GROUP MALE FEMALE TOTAL PERCENTAGE

18 – 25 years 3 2 5 17.85%

26 – 32 years 5 4 9 32.14%

33 – 39 years 7 4 11 39.28%

40-45 years 2 1 3 10.71%

OCCUPATION - Majority of them were manual labourers (53%) , followed by field workers (29%), self employees (11%) and students (7%).

CHART 13 : OCCUPATIONAL DISTRIBUTION OF INFECTIONS

manual labourers field workers self employees students

11%

53% 29%

 Duration of symptoms ranges from 5 days to 1 year.

 Most common symptom was pruritus (50%) followed by pain (25%).

 Most common infections were fungal infections(64.28%) followed by

viral infections (28.5%) and bacterial infections (7%).

CHART 14 : INCIDENCE WISE DISTRIBUTION OF INFECTIONS

70.00% 64.28%

60.00%

50.00%

40.00%

28.50% 30.00%

20.00%

10.00% 7%

0.00% fungal infections viral infections bacterial infections

Among the fungal infections ,Tinea faciei was seen in 77% cases whereas tinea versicolor was 23%. Most common site of tinea faciei was mandibular area (50%), followed by involvement of forehead (28.5%) , cheek

(14.28%)and chin (7%). Majority of them were males 71.42%(10) and females were 28.57%(4). Majority of them were Manual labourers (78.57%). Out of 14 cases of tinae faciei , 10 cases also had other body areas of involvement .

Pruritus was the commonest symptom observed in all the patients.

In tinea versicolor 75% were males and 25% were females. Mandibular area involvement was observed in all the patients whereas one patient had both forehead and mandibular involvement.

Most common viral infections in this study was herpes simplex (62.5%) followed by herpes zoster (25%) and molluscum contagiosum (12.5%) . In herpes simplex infections majority of them were females (80%) and age group commonly affected were 26 to 32 years. Pain was predominant symptom .

Most common site of involvement was lower lip and chin (80%) followed by cheeks (20%).

Herpes zoster was found in 2 cases. Both of them were males and they belong to age group of 42 to 45 years. Both of them had unilateral involvement of forehead , nose and eyes.

Hansen’s disease was observed in 2 cases of this study. Among them , one was male and the other one was female. One patient had hypopigmented and hypoanaesthetic patch involving right side of the cheek and forehead and in another patient involvement of forehead was observed. One patient had 6 month duration of the disease and other one had 8 months.

ECZEMA

Out of 200 patients eczematous disorders were observed in 15 cases.

Among them males were 66% and females were 34%.

Most common age group affected were 40 – 45 years (53%). The next age group affected were 33 – 39 years (26%).

TABLE 17 : AGE WISE DISTRIBUTION OF ECZEMATOUS

DISEASES

AGE GROUP MALE FEMALE TOTAL PERCENTAGE

26-32 1 2 3 20%

33-39 3 1 4 26%

40-45 6 2 8 53%

OCCUPATION

Among the 15 cases , 80% were Manual labourers followed by field workers (13%) and Housewives (7%).

CHART 15 : OCCUPATIONAL DISTRIBUTION OF ECZEMATOUS

DISORDERS AFFECTING FACE

7% 0 13%

80%

MANUAL LABOURERS FIELD WORKERS HOUSEWIVES

Contact allergic dermatitis (60%)was the most common eczematous disorder in this group , followed by seborrheic dermatitis (26% ) and perioral dermatitis (13%).

Pruritus was the most common symptom observed in majority of the patients.

Among the contact allergic dermatitis 66% had airborne contact dermatitis and 34% had contact allergic dermatitis to hair dye and Kumkum. In

ABCD most of them belong to the age group of 40 -45 years with peak incidence was seen at 44 years. Summer exacerbation was observed in 26% cases.

Perioral dermatitis was observed in 2 cases . Both of them were females and they were belong to the age group of 33- 36 years.

PHOTODERMATOSES

The total no of cases with PMLE were 7 . Among them , 28.5% were males and 71.4% were females. Majority of them were manual workers

(57.14%). Most common age group affected were 26 – 32 years (87.71%).

Duration of PMLE was observed between 2 weeks to 3 months. Most common symptom was pruritus (71.42%) followed by burning sensation

(28.5%) . Most common site affected was temple (57.14%) followed by cheeks (42.8%)

CONNECTIVE TISSUE DISEASES

Total number of cases comes under this group were 8 . Majority of the cases were SLE (75%) , followed by scleroderma (25%).

Among the 6 cases of SLE , 5 were females and one was male. Most common age group affected was 26 – 32 years (66%) , followed by 18 – 25 years (34%) . Majority of them were housewives 83.3% . Most common symptom was burning sensation (83.3%). Summer exacerbation was observed in 83% of cases. Malar rash was observed in majority of the cases.

Scleroderma was found in 2 cases . Both of them were females. One of them was housewife and other one was field worker. They belong to age group of 39- 42 years. Duration of illness varying from 3 – 5 years.

IMMUNOBULLOUS DISEASES

Total no of cases were 7 (3.5%). Among them 5 (71.42%) were pemphigus vulgaris , 2 (28.5) were pemphigus foliaceous. Majority of them were females (71.42% ). Most common age group affected were 40 – 45 years

(57.14). Most common symptom was pain (71.42% ), followed by itching (

28.5%) . Majority of them were housewives (71%) followed by Manual labourers (29%). Age of onset of pemphigus vulgaris was observed in this study was 31 years. Among the pemphigus vulgaris patients 4 had bullae over the mandibular area, forehead and chin while 3 cases had erosions over the temple, forehead and chin. All the cases of pemphigus vulgaris had oral lesions.

SKIN TUMOURS

Total no. of cases in this study was 17 (8%). Among them 58% were males and 42% were females. Most common age group affected were belong to 40-45 years (88%) .

Peak incidence was noted at 44 years.

TABLE 18 : AGE GROUP WISE DISTRIBUTION OF SKIN TUMOURS

AGE MALE FEMALE TOTAL PERCENTAGE GROUP

26 – 32 - 1 1 5%

33-39 - 1 1 5%

40 -45 10 5 15 88.23%

OCCUPATIONAL DISTRIBUTION

CHART 16 : OCCUPATIONAL DISTRIBUTION OF SKIN TUMORS

MANUAL LABORERS HOUSEWIVES FIELD WORKERS

24%

47%

29%

Most of them were manual laborers (47%) followed by housewives

(29%) and field workers (24%).

TABLE 19 : INCIDENCE OF SKIN TUMOURS OF FACE

CONDITIONS MALE FEMALE TOTAL PERCENTAGE

Seborrheic keratoses 2 1 3 17.64%

DPN 8 4 12 70.58%

Syringoma - 1 1 11.76%

Trichoepithelioma - 1 1 5%

Among the 12 cases of DPN, 66% were males and 34% were females.

Among the DPN cases , most of them were manual laborers. Duration

varying from 6 months to 3 years. Majority of them were asymptomatic. Most

common site of involvement was cheeks followed by temple.

Genodermatoses were observed in 3 cases . One case was tuberous

sclerosis and the other 2 were neurofibromatosis. They belong to age group of

39 – 44 years. Patient with tuberous sclerosis had adenoma sebaceum ,

involving the nasolabial area and cheeks. Among the 2 cases of

neurofibromatosis , one was male and the other one was female. Both of them

had cutaneous neurofibromas involving the face. One patient , also had

plexiform neurofibromas involving face and neck .

Milia was observed in 4 cases. Among them 3 were females and one of

them was male. They were belong to the age group of 28 – 35 years.

Xanthelasma palpebrarum was observed in 3 cases . Among them , one was male and 2 were females. They belong to the age group of 39 – 45 years.

History of diabetes mellitus was observed in 2 cases.

Dariers disease was seen in 2 cases. One of them was male and the other one was female. They belong to age group of 29 – 38 years.

COLOUR PLATES

FIGURE 1 : ACNE VULGARIS

FIGURE 2 : NODULO CYSTIC ACNE

FIGURE 3 : MELASMA

FIGURE 4 : HERPES LABIALIS

FIGURE 5 : ACNE SCARS

FIGURE 6 : PERIORAL DERMATITIS

FIGURE 7 : TINEA FACIEI

FIGURE 8 : VITILIGO

FIGURE 9 : MOLLUSCUM CONTAGIOSUM

FIGURE 10 : PHOTO SENSITIV+E ECZEMA

FIGURE 11: DERMATOSIS PAPULOSE NIGRA

FIGURE 12 : HERPES SIMPLEX

FIGURE 13 : ROSACEA

FIGURE 14 : HANSEN’S DISEASE

FIGURE 15 : XANTHELASMA

FIGURE 16 : SYRINGOMA

FIGURE 17 : TRICHOEPITHELIOMA

FIGURE 18 : TUBEROUS SCLEROSIS

DISCUSSION

DEMOGRAPHIC DETAILS COMPARISON

SEX INCIDENCE

Totally 200 patients were enrolled in this study , out of these majority of them were females (63%) . A similar female preponderance was also observed by Mayuri Jain et al. 69 In contrast to our study , Pradeep et al. 70 observed male preponderance.

AGE COMPARISON

In our study ,majority of the patients belong to age group of 26 – 32 years (33%). Similar finding was observed in Pradeep et al. 70 study also.

OCCUPATIONAL COMPARISON

In our study majority of them were house wives followed by students which was similarly observed in Pradeep et al. 70 study.

SEASONAL VARIATION

In our study Seasonal variation was observed in 45% cases , which was higher than the study conducted by Mayuri Jain et al . 69

SYMPTOMS

Most common symptom reported in our study was pigmentary changes

(26%).

SITES AFFECTED

Most common site affected in our study was cheeks 74% and the least common site affected was perioral area (13%).

PATTERN OF INVOLVEMENT

Most common facial dermatoses in our study were pilosebaceous diseases 27% , followed by pigmentary disorders (26%) and infections (14%).

PILOSEBACEOUS DISEASES

Acne (96%) was the most common dermatoses encountered in this group followed by rosacea (4%).

Among the acne patients majority of them were females (63%) with a ratio of 1.7 :1, similar finding was observed in Arjun Singh et al. 71 study. In

Swathi et al. 72 study females were much more common than males in the ratio

4.5 :1.

Most common age group reported in this study was 18 -25 years

(59.6%) ,similar to studies of Arjun Singh et al. 71 and M Jain et al. 69

Majority of them were housewives (50%) followed by students (19%) which was similar to Lakshminarayana et al study.

In our study most common site was cheeks (96.15%) , followed by forehead (67.3%). A similar study was done by Laksminarayana et al. 73 where they found cheeks was the most common site involved followed by perioral area. Swathi et al also found that cheeks was the most common site followed by chin involvement.

Majority of them belongs to grade II acne (40.38%) followed by grade

3 acne (25%) which was similar to Lakshminarayana et al study. 73 But Swathi et al study showed grade 2 acne was the most common followed by grade 1 acne.

In our study most common aggravating factor was use of cosmetics

(55.76%), followed by seasonal variations (44.28%), premenstrual flare

(28.84%) and topical steroids (17.3%). This is in contrast to Lakshminarayana et al. 73 study where stress was the most common aggravating factor followed by cosmetics use.

In our study, hirsuitism was associated with acne in 7 % and AA with acne in 9 % which was comparable to Swathi et al study. In our study inflammatory acne was more common than non inflammatory acne which was in concordance with the study conducted by Jain et al. 69

PIGMENTARY DISORDERS

In our study majority of the patients with pigmentary disorders were females with F : M ratio 2.7:1 which is comparable to Avula Rajamma et al. 74 and Jain et al. 69 studies. Most common age group reported was 33 – 39 years, majority of them were housewives (54%) , similar to Avula Rajamma et al. 74 study.

Most common pigmentary disorder reported in our study was melasma

(69%) followed by POM (9%) , PIH (4%), ephelides 4% and vitiligo. While

Avula Rajamma et al74 study reported melasma was the most common pigmentary disorder followed by PIH , POM and ephelides.

In melasma, majority of them were females with F : M ratio 4.8 :1. Most common age group affected was 26 – 40 years with peak incidence at 34 years of age and majority of them were housewives (60%). All the above findings were comparable to kavya et al. 75 study. Aggrevation following sun exposure in our study was 71% which is comparable to Sabina et al. 76 study.

In our study, majority of them were asymptomatic (71%) , followed by photosensitivity (22% ), and itching (5%) which is similar to kavya et al. 75 study.

Most common clinical pattern of melasma seen in our study was malar type. A similar finding was observed in Sabina et al. 76 study. Other studies reported centro facial pattern as common presentation.

Majority of the PIH were sequelae of acne similar to finding observed in Avula

Rajamma et al.

VITILIGO

All the vitiligo patients were males in our study but in hassan et al study showed equal distribution of vitiligo in both sexes. In our study , 50% of vitiligo patients had early age of onset and 25% of patients had h/o thyroid disorder which is in concordance with the study of hassan et al. 77

INFECTIONS

In our study, infections (14%) was the third commonest entity after acne and melasma which was similar to Jain et al. 69 study. Majority of them were fungal infections (64%) followed by viral infections (28.5%) and bacterial infections. Majority of the patients were manual laborers. Most common symptom was itching. Above findings were similar to Pradeep et al. 70 In Jain et al study , viral infection was the most common infection followed by fungal and bacterial infections.

ECZEMAS

Eczematous disorders were seen in 7% of facial dermatoses in our study.. Most common was contact allergic dermatitis 60%, followed by seborrheic dermatitis. Majority of them were males 66%. Most common age group affected was 40 -45 years.

Above findings were comparable with study of Pradeep et al. 70

Kumkum was the commonest allergen reported in our study similar to study of

Jain et al. 69

SKIN TUMOURS

Skin tumors were seen in 8% of facial dermatoses in our study. Majority of them were males. They belong to age group of 40 - 45 years. DPN (70.5%) was the most common skin tumour in our study which is comparable to Jain et al study. 69

Our study also found that connective tissue diseases (4%) and immune bullous diseases (3.5%) involving the face were more common than Jain et al study. 69

SUMMARY

Facial dermatoses are classified into pilosebaceous disorders, pigmentary disorders, infections, eczematous disorders, photo dermatoses, connective tissue diseases, immunobullous disorders and skin tumors.

 200 cases of facial dermatoses from June 2018 to May 2019 were

included in this study.

 Most of the patients belong to age group of 26 – 32 years.

 There was female preponderance in this study , with a female to male

ratio of 1.7:1.

 Pigmentary changes were the commonest symptom in facial dermatoses.

 Majority of them were housewives.

 45% of cases had seasonal variations.

 Cheeks were the most common site involved in facial dermatoses of this

study.

 Pilosebaceous diseases , pigmentary disorders and infections were the

three most common facial dermatoses.

PILOSEBACEOUS DISEASES

 Female preponderance was observed.

 Most common age group affected were 18 – 25 years.

 Majority of them were housewives.

 Acne was the commonest entity in this study.

 Inflammatory acne was more common than noninflammatory acne.

 Cheeks involvement was commonest site of involvement.

PIGMENTARY DISORDERS

 Female preponderance was observed.

 Most common age group affected were 33 – 39 years.

 Majority of them were housewives.

 Melasma was the commonest pigmentary disorder.

 Malar pattern was the commonest clinical presentation.

INFECTIONS

 Male preponderance was observed.

 Most common age group affected were 33 -39 years.

 Majority of them were manual labourers.

 Fungal infections were the commonest.

 Mandibular area was the most common site involved in this study.

CONCLUSION

This study was undertaken to assess the various dermatoses affecting the face and their different presentations. Comparing with other skin disorders early identification and characterization of facial skin disorders were difficult.

Many of the studies explained individual dermatoses of face. In this study provides insight into various facial dermatoses that encountered in a day to day practice.

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PATIENT PROFORMA

NAME : ADDRESS

AGE :

SEX :

OCCUPATION :

PHONE NO. :

CHIEF COMPLAINTS,

Duration :

Site :

Associated with itching/pain/fever/joint pain :

Any loss of sensation :

Progression :

Photosensitivity :

Atopy :

Drug history/Topical application :

Family history :

Past history :

Personal history :

Treatment history :

EXAMINATION

GENERAL EXAMINATION

Pallor/ cyanosis/ clubbing/ pedal edema.

SYSTEMIC EXAMINATION

CVS :

RS :

ABDOMEN:

CNS:

DERMATOLOGICAL EXAMINATION OF FACE :

Skin lesion :

macule/ patch/ papule /plaques/ pustules/ nodules/ comedone.

Site :

Cheek/ forehead/ nose / chin/ periocular/ perioral

Size :

Shape :

Colour :

Edge :

Associated secondary lesions :

Lesions elsewhere in the body :

INVESTIGATIONS

KOH mount

WOOD’S lamp

Biopsy for relevant cases.

CONSENT FORM

I Mr/Mrs hereby volunteer to participate in the study CLINICO EPIDEMIOLOGICAL STUDY OF

FACIAL DERMATOSES AMONG ADULTS. I was explained about the nature of the study by the doctor, knowing which I fully give my consent to participate in this study. I also give consent to take clinical photographs for the purpose of the study.

Date :

Place :

Signature of the patient

ஒப்ꯁதல் ஧羿வம்

ப஧னர் :

வன鏁 :

஧ா஬ி஦ம் :

믁கவ쎿 :

அப毁 ககாவவ ந쏁த்鏁வக் கல்쯂쎿னில் கதால் ந쏁த்鏁வத்

鏁வ஫னில் ஧ட்ட கநற்஧羿ப்ꯁ ஧னி쯁ம் நாணவர்

ந쏁.கநா.நணிவண்ணன் அவர்கள் கநற்பகாள்쯃ம் "믁கம் சார்ந்த

கதால் க஥ாய்கள்" பசய்믁வ஫ பதாடர்஧ா஦ அவ஦த்鏁

வி஧பங்கவ஭뿁ம் ககட்翁 எ஦鏁 சந்கதகங்கவ஭ பத஭ிퟁ஧翁த்திக்

பகாண்கடன்.

஥ான் இந்த ஆய்வில் என்வ஦ ஧쎿கசாதவ஦ பசய்ன 믁폁

ந஦鏁டꟁம், 毁ன சிந்தவ஦뿁டꟁம் சம்நதிக்கிக஫ன்.

என்ꟁவடன க஥ாய் ஧ற்஫ின இந்த ஆய்வில் எ஦鏁 அவ஦த்鏁

வி஧பங்க쯃ம் ஧ா鏁காக்கப்஧翁வ鏁டன், க஥ாய் ஧埁தினின் ꯁவகப்஧டம்

நற்쟁ம் இதப ஆய்ퟁ 믁羿ퟁகள் பவ஭ினிடப்஧翁வதில் ஆட்கச஧வ஦

இல்வ஬ என்஧வத பத쎿வித்鏁க் பகாள்கிக஫ன்.

எந்த க஥பத்தி쯁ம் இந்த ஆய்வில் இ쏁ந்鏁 வி஬கிக்பகாள்஭

எ஦க்埁 உ쎿வந உண்翁 என்஧வத뿁ம் அ஫ிகவன்.

இடம் :

஥ாள் : வகபனாப்஧ம்

KEY TO MASTER CHART

MA Male CAD Contact allergic dermatitis

FE Female POD Perioral dermatitis

ML Manual labourer SD Seborrheic dermatitis

HW House wife PMLE Polymorphic light eruption

ST Student PV Pemphigus vulgaris

SE Self employees PF Pemphigus foliaceus

FW Field worker SLE Systemic lupus erythematosus

GS Government service SCL Scleroderma

ROS Rosacea SK Seborrheic keratosis

MEL Melasma DPN Dermatosis Papulosa Nigra

VIT Vitiligo SYR Syringoma

PIH Post inflammatory TRI Trichoepithelioma hyperpigmentation

POM Periocular melanosis MIL Milia

EPH Ephelides TS Tuberous sclerosis

TF Tinea faciei NF Neurofibromatosis

TV Tinea versicolor XP Xanthelasma palpebraurem

HS Herpes simplex DAR Dariers disease

HZ Herpes zoster SUM Summer

LEP Leprosy WIN Winter

MC Molluscum Contagiosum NO No relation

H/O

TOPICAL

SYMPTOMATIC LESIONAL MORPHOLOGY SITE

APPLICATIO

SEX

AGE

S.NO

SEASONAL

DURATION

DIAGNOSIS

VARIATION

FAMILY FAMILY H/O

OCCUPATION

THYROID H/O

ASYMPTOMATIC

CHIN

HYPO HYPO

SCARS

HYPER HYPER

PATCH

LABIAL

PHOTO

BULLAE

CHEEKS

PAPULE

OTHERS

PLAQUE

NODULE

PUSTULE VESICLES

CHANGES

MACULES

STEROIDS

PRURITUS

PERI PERI ORAL

FOREHEAD

COSMETICS

SENSITIVITY

NOSE/NASO

COMEDON

PIGMENTORY

OTHERAREAS

MANDIBULAR

PERI PERI OCCULAR

PAIN/BURNING

PIGMENTATION PIGMENTATION 1 19 MA ST ACNE     3 WEEKS                        2 19 FE ST ACNE     6 MONTHS                        3 21 MA ST ACNE     1 YEAR SUM                       4 22 FE HW ACNE     5 MONTHS SUM                       5 29 MA ML ACNE     2 WEEKS                        6 20 MA ST ACNE     8 MONTHS SUM                       7 31 MA ML ACNE     4 YEARS                        8 24 FE HW ACNE     2 MONTHS SUM                       9 21 MA ST ACNE     2 YEARS                        10 30 MA SE ACNE     4 MONTHS SUM                       11 34 MA ML ACNE     9 MONTHS                        12 22 FE HW ACNE     2 MONTHS SUM                       13 27 FE HW ACNE     4 MONTHS                        14 22 MA FW ACNE     1 MONTH                        15 34 MA ML ACNE     3 YEARS WIN                        16 19 FE ST ACNE     2 MONTHS                         17 33 FE HW ACNE     3 YEARS SUM                       18 29 FE HW ACNE     2 WEEKS                        19 21 FE HW ACNE     5 YEARS SUM                        20 24 FE HW ACNE     7 MONTHS                        21 21 MA FW ACNE     3 WEEKS SUM                       22 22 MA ML ACNE     2 YEARS                        23 18 FE ST ACNE     2 MONTHS                        24 20 MA FW ACNE     4 YEARS WIN                       25 19 FE ST ACNE     3 WEEKS                         26 23 FE HW ACNE     6 MONTHS                        27 19 MA ST ACNE     5 MONTHS SUM                      

28 21 FE HW ACNE     1 YEAR SUM                        29 35 FE HW ACNE     5 YEARS                        30 28 FE HW ACNE     11 MONTHS SUM                        31 32 MA ML ACNE     2 YEARS                        32 23 FE HW ACNE     7 MONTHS SUM                        33 27 FE GS ACNE     5 YEARS                        34 21 FE HW ACNE     2 YEARS                        35 31 MA SE ACNE     2 WEEKS SUM                       36 24 FE HW ACNE     1 MONTH                        37 31 FE HW ACNE     2 YEARS                        38 19 FE ST ACNE     2 MONTHS SUM                       39 32 FE HW ACNE     4 YEARS                        40 36 MA SE ACNE     2 WEEKS SUM                       41 34 FE HW ACNE     10 MONTHS                        42 22 FE HW ACNE     11 MONTHS WIN                        43 21 MA FW ACNE     2 MONTHS                        44 35 MA SE ACNE     1 YEAR SUM                       45 23 FE HW ACNE     6 MONTHS                         46 29 FE HW ACNE     3 WEEKS SUM                        47 21 FE HW ACNE     5 YEARS                        48 24 FE HW ACNE     3 MONTHS                        49 21 FE HW ACNE     1 MONTH                        50 28 FE GS ACNE     4 MONTHS SUM                       51 19 FE HW ACNE      6 WEEKS                         52 27 FE HW ACNE      2 MONTHS                        53 29 MA FW ROS      1 MONTH SUM                        54 32 MA ML ROS      2 WEEKS SUM                        55 28 MA ML MEL      2 MONTHS SUM                         56 34 FE HW MEL      4 MONTHS WIN                         57 27 FE HW MEL      3 MONTHS                         58 32 FE ML MEL      7 MONTHS SUM                        59 29 FE HW MEL      1 YEAR SUM                         60 34 FE HW MEL      6 MONTHS SUM                        61 36 MA ML MEL      5 MONTHS                        

62 35 FE HW MEL      7 MONTHS SUM                        63 31 FE HW MEL      1 YEAR                          64 28 FE HW MEL      4 MONTHS SUM                        65 29 MA ML MEL      6 MONTHS                          66 34 FE HW MEL      1 YEAR SUM                        67 45 FE HW MEL      1 MONTH                         68 30 FE HW MEL      6 MONTHS SUM                         69 34 FE HW MEL      7 MONTHS SUM                        70 40 FE HW MEL      5 MONTHS SUM                        71 35 FE HW MEL      6 MONTHS WIN                         72 39 FE ML MEL      5 MONTHS SUM                        73 37 FE HW MEL      1 YEAR SUM                        74 27 FE ML MEL      6 MONTHS SUM                        75 38 FE HW MEL      7 MONTHS SUM                         76 44 MA FW MEL      5 MONTHS SUM                        77 38 FE HW MEL      6 MONTHS SUM                        78 29 MA FW MEL      3 MONTHS SUM                         79 33 FE HW MEL      3 MONTHS                          80 34 FE FW MEL      6 MONTHS SUM                        81 30 FE FW MEL      8 MONTHS SUM                        82 37 FE HW MEL      6 MONTHS WIN                         83 28 FE FW MEL      7 MONTHS                         84 36 FE FW MEL      1 YEAR SUM                         85 41 FE HW MEL      6 MONTHS SUM                        86 45 FE HW MEL      8 MONTHS SUM                        87 36 FE HW MEL      7 MONTHS SUM                         88 34 MA FW MEL      2 MONTHS SUM                         89 34 FE FW MEL      1 YEAR SUM                         90 31 MA SE VIL      5 YEARS                        91 30 MA GS VIL      1 YEAR                        92 28 MA SE VIL      10 MONTHS                        93 28 MA GS VIL      3 YEARS                        94 22 FE FW PIH      10 YEARS                        95 26 FE FW PIH      2 YEARS                       

H/O

TOPICAL

SYMPTOMATIC LESIONAL MORPHOLOGY SITE

APPLICATIO SIS

SEX

AGE

S.NO

SEASONAL

DURATION

DIAGNO

VARIATION

FAMILY FAMILY H/O

OCCUPATION

THYROID H/O

ASYMPTOMATIC

CHIN

HYPO HYPO

SCARS

HYPER HYPER

PATCH

LABIAL

PHOTO

BULLAE

CHEEKS

PAPULE

OTHERS

PLAQUE

NODULE

PUSTULE VESICLES

CHANGES

MACULES

STEROIDS

PRURITUS

PERI PERI ORAL

FOREHEAD

COSMETICS

SENSITIVITY

NOSE/NASO

COMEDONES

PIGMENTORY

OTHERAREAS

MANDIBULAR

PERI PERI OCCULAR

PAIN/BURNING

PIGMENTATION PIGMENTATION 96 28 FE ML PIH      8 YEARS                        97 24 FE HW PIH      5 YEARS                        98 28 FE ML POM      1 YEAR SUM                       99 32 MA FW POM      9 MONTHS                        100 21 FE SE POM      2 MONTHS SUM                       101 24 MA FW POM      4 MONTHS SUM                       102 28 FE HW POM      7 MONTHS                        103 24 MA FW EPH      3 YEARS                        104 25 FE HW EPH      4 YEARS                        105 22 MA FW EPH      2 YEARS                        106 36 FE HW EPH      1 YEAR                        107 18 MA ML TF      1 MONTH                          108 28 MA ML TF      3 MONTHS                          109 34 MA ML TF      4 WEEKS                         110 31 FE SE TF      6 WEEKS                          111 37 MA ML TF      4 MONTHS                          112 34 FE SE TF      3 MONTHS                          113 35 MA ML TF      5 MONTHS                         114 20 MA ML TF      2 MONTHS                          115 19 FE ST TF      6 MONTHS                          116 38 MA ML TF      4 WEEKS WIN                         117 36 FE ML TF      1 WEEK                          118 29 MA ML TF      2 MONTHS                          119 36 MA ML TF      1 MONTHS                          120 27 MA ML TF      6 MONTHS                          121 31 MA FW TV      3 MONTHS WIN                        122 29 FE ML TV      5 MONTHS SUM                       

123 22 MA FW TV      2 MONTHS SUM                        124 38 MA ML TV      6 MONTHS SUM                        125 35 FE ML HS      4 DAYS SUM                         126 45 FE FW HS      5 DAYS                         127 27 MA FW HS      3 DAYS WIN                         128 29 FE FW HS      5 DAYS WIN                         129 30 FE FW HS      6 DAYS WIN                         130 42 MA ML HZ      8 DAYS WIN                         131 45 MA FW HZ      6 DAYS                          132 36 MA SE LEP      6 MONTHS                         133 39 FE FW LEP      8 MONTHS                         134 21 FE ST MC      2 MONTHS                         135 33 MA ML CAD      3 WEEKS SUM                        136 42 MA ML CAD      4 MONTHS                          137 27 MA ML CAD      4 WEEKS SUM                        138 40 FE ML CAD      3 MONTHS                          139 35 MA ML CAD      1 MONTH SUM                         140 29 FE FW CAD      2 MONTHS SUM                        141 43 MA ML CAD      6 WEEKS                         142 44 FE HW CAD      4 WEEKS                         143 36 MA FW CAD      5 MONTHS SUM                        144 31 FE ML POD      3 WEEKS                         145 42 MA ML POD      2 WEEKS                         146 45 MA ML SD      6 MONTHS SUM                         147 35 FE ML SD      7 MONTHS SUM                         148 43 MA ML SD      6 MONTHS SUM                         149 41 MA ML SD      7 MONTHS SUM                         150 27 FE ML PMLE      2 WEEKS SUM                        151 31 FE HW PMLE      4 WEEKS SUM                         152 30 MA ML PMLE      3 MONTHS SUM                        153 28 FE FW PMLE      1 MONTH SUM                         154 25 FE ML PMLE      2 MONTHS SUM                        155 29 MA ML PMLE      1 WEEK SUM                         156 31 FE SE PMLE      2 MONTHS SUM                        

157 42 FE HW PV      4 WEEKS                          158 41 FE HW PV      2 MONTHS                          159 45 FE HW PV      1 MONTH                         160 37 FE HW PV      3 WEEKS                          161 41 MA ML PV      3 MONTHS                         162 38 MA ML PF      5 WEEKS WIN                        163 36 FE HW PF      2 MONTHS                         164 21 MA FW SLE      3 WEEKS SUM                        165 29 FE ML SLE      2 WEEKS SUM                        166 31 FE HW SLE      1 MONTH SUM                        167 22 FE ML SLE      2 MONTHS WIN                        168 30 FE HW SLE      1 MONTH SUM                        169 28 FE HW SLE      5 WEEKS SUM                        170 39 FE HW SCL      6 MONTHS                         171 42 FE FW SCL      1 YEAR                         172 41 MA ML SK      1 YEAR                          173 45 MA ML SK      2 YEARS                         174 32 FE HW SK      2 YEARS                          175 44 MA FW DPN      6 MONTHS                          176 42 MA ML DPN      1 YEAR                          177 44 MA ML DPN      2 YEARS                         178 45 MA ML DPN      7 MONTHS                         179 39 FE HW DPN      9 MONTHS                         180 42 FE HW DPN      1 YEAR                         181 42 FE HW DPN      2 YEARS                         182 41 FE ML DPN      1 YEAR                          183 40 MA FW DPN      6 MONTHS                         184 43 MA ML DPN      10 MONTHS                         185 45 MA FW DPN      9 MONTHS                         186 41 MA ML DPN      7 MONTHS                          187 40 FE HW SYR      1 YEAR                         188 39 FE FW TRI      8 MONTHS                         189 40 MA FW MIL      4 MONTHS                          190 35 FE ML MIL      3 MONTHS                         

191 32 FE ML MIL      5 MONTHS                          192 42 FE HW MIL      5 MONTHS                          193 38 MA ML TS      20 YEARS                         194 42 MA ML NF      10 YEARS                          195 39 FE ML NF      14 YEARS                         196 42 MA ML XP      6 MONTHS                         197 39 FE FW XP      7 MONTHS                         198 45 FE HW XP      8 MONTHS                         199 29 MA SE DAR      10 YEARS WIN                        200 38 FE FW DAR      12 YEARS WIN                       