The Aestheticians Journal December'2023 issue by The Aestheticians Journal

Total Pages : 36 December 2023 Vol 16* Issue - 12 100

Boosted Minoxidil – Recent Advancement in Management of Androgenetic Alopecia Skin Oedema with Rashes and Burning: A Case Presentation Micro-needling with 5 -Flourouracil- Innovative Approach for Resistant Vitiligo Mole Removal with Radiofrequency Cautery

Risks of Winter Skin Diseases EXECUTIVE EDITOR & PUBLISHER Dom Daniel

CORPORATE OFFICE 22, Shreeji Bhavan, 275-279, Samuel Street, Masjid Bunder (W), Mumbai-4000 03, INDIA. EMAIL: theaestheticiansjournalindia@gmail.com Website: theaestheticiansjournal.com TEL: +91 22 2345 1404 +91 22 2345 5844

Printed, Published, Edited and Owned by Dom Daniel Printed at Swastik Printer, Gala No.9 & 10, Vishal Industrial Estate, Bhandup (West), Mumbai- 400078. Published at 22 Shreeji Bhavan, 275/279, Samuel Street, Masjid Bunder (West), Mumbai - 400003. India. “The Aestheticians Journal” takes no responsibility for unsolicited photographs or material ALL PHOTOGRAPHS, UNLESS OTHERWISE INDICATED, ARE USED FOR ILLUSTRATIVE PURPOSE ONLY.

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Winter can be a challenging season for the skin and there are several risks associated with skin issues during this time. Low temperature, low air humidity makes the skin vulnerable, prone to dryness and increase the risk of many diseases. Treating dry skin in winter requires special care because the cold, dry air can deplete the skin's moisture, leading to issues like flakiness, itching and discomfort. Some of the common risks of winter skin diseases and conditions include eczema or dermatitis, rosacea, psoriasis, xerosis, urticaria, bacterial skin infections or fungal infections etc. To mitigate these risks, it's important to take steps to protect the skin during the winter months. These preventive measures include moisturizing products with ingredients like ceramides, hyaluronic acid, and glycerin, which help lock in moisture. Exfoliating can help remove dead skin cells and allow moisturizers to penetrate better. Incorporate foods rich in omega-3 fatty acids can help support healthy skin. A humectant serum with ingredients like hyaluronic acid can help attract and retain moisture in the skin and using humidifiers to maintain indoor moisture levels. For pre-existing skin conditions like eczema or psoriasis, it's crucial to follow the dermatologist's recommendations and treatment plans to manage and prevent flareups during the winter. Dermatologists can recommend specific products or treatments tailored to the skin's needs. In this issue we have clinical articles on Boosted Minoxidil in Management of Androgenetic Alopecia, Mole Removal with Radiofrequency Cautery, Micro-needling with 5-Flourouracil- Innovative Approach for Resistant Vitiligo and Skin Oedema. HOPE YOU HAVE A GREAT READ

Thanks & Cheers - Dom Daniel

Published for the period of December - 2023

Executive Editor & Publisher

Boosted

Minoxid

il – Recent

Advance

Boos Advanc ted Minoxidil emen – Re Androg t in Managemcent enetic Al en opecia t of Dr. ment in

Manage

ment of

Androge

netic Alopecia

Anil Gos

Boosted Minoxidil – Recent Advancement in Management of Androgenetic Alopecia Dr. Anil Gosavi, M.D. (SKIN)

08 8 Decem

ber 2023

Skin Oedema

with Rashes

and Burning

Skin Oe Burnin dema with Ra g: A Ca se Pres shes and entatio n Dr. K. Lak shm : A Case

14 Skin Oedema with Rashes and Burning: A Case Presentation 14 14 Decem

ber 2023

An Micro-needling with 5 -Flourouracil- Innovative Approach for Resistant Vitiligo

tion

Introduct ion Oedema condition is a medi cal the accu characteriz ed by coagulation (DIC) fluid in mulation of DIC is or vascu exces a medi the body cal emer litis. Skin oede 's tissue s which can s. by be chara gency, abnormal ma refers abno cterized to an accu fluid in bleeding, rmal clottin g and the tissuemulation of surface purpuric which can s below of cause skin lesion the skin the skin, caus the other symptoms s, among ing and also to appear . Vasc swollen is an inflam ulitis mation can be leads to puffin blood pitting or vessels of ess. It nature. to the that can the This can non-pitting in formation lead part of of purpu the body occur in any skin lesions, ric limbs, , includ symptoms as well as ing hands, face, and feet, anklethe aches and such as other joint weak s, have manylungs. Oede ma can the cases, imme ness. In both caus heart or attention es, includ diate medi disease, kidney failure ing diagnose is necessary cal , liver to the inflammatiomalnutrition, cause unde of the injury, rlying medicatio n, and lesions purpuric certain and to skin be caus ns. Oedema appropriate implement ed by variou can treatment. such as essen s facto It's rs many tial to note that systemic trauma, medi there other cation, illnes some skin lesion causes of purpuare cases s, etc. ric accompan , it could In thorough s and oede ma; medi be is symptoms ied by variou necessary cal evaluationa s other warmth, , such as redne the to rlying caus determine ss, case.unde or Oedema 5, 6 tenderness e in each chronic can be temporary . and could or The epide part of the body 1,2,3,4affect any can differ miology of . depending oedema Purpuric specific on the type of associated skin the popu oede lesions lation being ma and be a sign with oedema to studi subje es. Gene can is underlying of a more rally, oedected a comm ma on condition, severe affec dissemina ts peop condition and ted le of intravasculike groups. all age The lar oede ma is prevalence of usually higher

Micro-ne

edling

with 5

Microneedlin Innova g with 5 -Flou tive ro Resista Approach foruracilnt Vitil igo -Flourou

racil- Innovati

ve approac

h for Resistan

t Vitiligo

Dr. Trupti

M.D. (DVD B. Shah ) Consultan t Dermatolo Haribhakti gist and Cosmetolo Clinic, Ahmedaba gist d

Dr. Palak

D. Makawa MBBS, MD (Skin na & VD), Consultan DNB (Derm t Dermatolo atology) Haribhakti gist, Clinic and Ahmedaba South Bopa d l Skin Clini c

Dr. Trupti B. Shah, M.D. (DVD) Dr. Palak D. Makawana, MBBS, MD (Skin & VD), DNB 22 22 Decem

ber 2023

Abstract Backgrou nd Vitiligo procedure is was perfo of great a chronic disea every 2 rmed presenting cosmetic conc se Clinic weeks for 3 ern asses al improveme months. with depig macules nt was sed and patch mented often recalc by serial monthly till 6 es. treatment. itrant to mediIt is and gradi clinical photomonths graphs cal ng score . Aim Results The aim Initiation of repig study the of the study mentation was to started at 1 mont of topic efficacy and (70% h in 7 ). patie safety al Excellent with need 5% 5-fluo (>75% improvements ling in stable rouracil repigment nt vitiligo. noted in 4 patie ation) was Materials nts (40% and Meth Conclusio ). This interv ods n entional study prospective Needling was April 2022 conducted 5-fluoroura with from to April 5% cil appe of 10 ars to patients, 2023. Total simple, safe be vitiligo and with stable treatment of age in vitiligo effective older years, . It can were includ than 15 used in poor study. responders be convention ed in All the the al thera to treated patients py. with need were Introduct by topic ling follow ion al 5% over vitiligo 5-fluorouraed Vitiligo is cil acquired, a comm patches. idiopa only The depig mentary thic, heritable disorder

Mole Remov

al with

Presenta

MBBS, iprasad DDVL Consultan t Dermatolo Aditya gist Polly Hyderabad Clinic Attapur,

Dr. K. Lakshmiprasad, MBBS, DDVL

avi

M.D. (SKI

Associate professor Departmen t of Derm BJ Govt atology Medical College, Pune Abstract Since deca as a first des minoxidil used in andro line topical treatm weak genetic ent SULT hair regrowth.I moderate alope to good cia with follicl 1A1 activity ncreasing Usually in the outco e could takes 3 to see to 4 montme. minoxidil increase hair There is visible hair grow hs researcherresponse. Rece the ntly, th. a s spite of group of patie novel topic have developed regular nts in al formu minoxidil, use of increases la which topic scalp to topic getspoor respo al activity SULT1A1 nse altera in studies al minoxidil. tions to patients via than 40 mention that Few of the intercellula more Outer r pH respond % patients (ORS). Root Shea do th even after to topical mino not 1 year xidil Many usage. Minoxidil of consistent clinical experimental and it is is a pro-d studi and conv rug SULT1A1 es revealed form, mino erted to its that enzyme active the hair activity sulfotransf xidil sulphate, follicle in corre erase by minoxidil in the response lates with enzym outer hair follicl root shea es treatment of for AGA. Now the sulfotransf es. Endo th of novel compound the genous sulfot ransferase s modulating (SULT1A1 erase isoform ) is the domi 1A1 scalp is availa activity in the ble of sulfot nant effect of responsible minoxidil.to boost the ransferase for conversio Introduct mino xidil ion Studies n in the scalp. Androgenetic there is have showed alopecia is the a that comm direc (AGA between t relatio onest ) cause nship hair loss affec and mino SULT1A1 of activity of men and ting around 50% are clinic xidil response. 40% of There Nowadays, that Lowal studies conc topical women. is well minoxidil SULT1A1 luded estab occurs activity treatment in lished exter in nal of the popuapproximately men and 60% and it is also wom lation and predicts drug used the most popu en of AGA. for the treatm lar Topical minoxidil ent is

Radiofr

equenc

y Cauter

Mole Radiof Removal wi th requen cy Caut ery Dr. Amit Mur

An Mole Removal with Radiofrequency Cautery

kute MBBS, DDVL, DNB Consultan t Dermatolo Cosmetolo gist, gist & Hair Founder Transplant of Elite Surgeon Skin & Hair Clini c, Pune Introductio

Dr. Amit Murkute, MBBS, DDVL, DNB

n Moles, also know clusters moles n as nevi, are: 2,3,4,5 of are • can appea pigmented Congenita r as small, cells that on the l nevi: skin. They dark spots moles are These present brown can be are typica or large and at birth and lly also be black in colou r, but can shape. They pink, red irregular Medically or skin-c have in of becom ing cance a higher risk confined nevus is descr olored. impor rous, of skin and persistent ibed as by a tant to have them so it is or muco dermatologi growth checked be flat or sa. 1 Moles st. can • Acquired or rough raised; it can be smooth develop later nevi: These in textur vary in moles in life and size, shapee. Moles can common are more texture. 2 , colou They are than conge nital nevi. and do Most moles are r and typically not benign have a round smaller it is impor cause any and or oval harm, but have a lower risk shape. They or chang tant to have cancerous, any of becom a derma ing moles check new but it is ing to have tologist ed still by impor possible to them tant checked skin cancerule out any dermatologi cases by a st. r. 1 In some it has • Dysp that on been observed moles lastic histological nevi: diagnosed study are These times, either to be malig , it was atypical moles also know n as or squam melanomas nant at larger than . They are usuall or basal and was detec ous cell carcin have irregucommon molesy ted. 1 omas colou rs. They lar shapes The most and have of becom comm ing cancea higher risk on types is also rous, of check important to have so it ed by a dermatologi them st.

30 Decem

ber 2023

December 2023

Figure

1: Class

ification

of melan

ocytic nevi

17th December'2023 Venue: Hotel Ginger, Near Domestic Airport, Vile Parle (East) Mumbai

1 Day Hands on Workshop Training by Masters in Aesthetic Dermatology

with International Certificate by

FACULTY

Dr. Satish Bhatia

Dr. Farida Modi

MD Dermatologist and Cutaneous Surgeon Dermdestination, Mumbai

MD Dermatologist and Cosmetologist Dermacare Skin Clinic & Cosmetic Center, Mumbai

MUMBAI'2023 REGISTRATION FEES & DETAILS

HANDS ON WORKSHOP on Aesthetic Dermatology Procedures with DASIL CERTIFICATE Rs.20,000/- + 18% GST

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For further details and to register for the conference and hands on workshop call us at+91 98205 07771 Terms & Conditions: 1. Only for Dermatologist.Please share your PG in Dermatology Credentials while registering.

Editorial Board Dr. Anil Gosavi

M.D. (SKIN) Associate Professor Department of Dermatology BJ Government Medical College, Pune

Advisory Board DR. PAVAN KUMAR DR. GIRISH HANUMATIHA DR. NEELIMA RAVIPATHI DR. HARITHA RAVIPATHI DR. KARTHIK R. DR. ROOPA SHREE

Dr. K. Lakshmiprasad MBBS, DDVL Consultant Dermatologist Aditya Polly Clinic Attapur, Hyderabad

DR. DEEPTHI BALUSU DR. SUDHIR DR. ASHWINI RAVISHA Dr. ARCHANA GULUR DR. ANKITA RAMESH

Dr. Trupti B. Shah

M.D. (DVD) Consultant Dermatologist and Cosmetologist Haribhakti Clinic, Ahmedabad

Dr. Palak D. Makawana

MBBS, MD (Skin & VD), DNB (Dermatology) Consultant Dermatologist, Haribhakti Clinic and South Bopal Skin Clinic Ahmedabad

Dr. Amit Murkute

MBBS, DDVL, DNB Consultant Dermatologist, Cosmetologist and Hair Transplant Surgeon Founder of Elite Skin and Hair Clinic, Pune

December 2023

Boosted Minoxidil – Recent Advancement in Management of Androgenetic Alopecia

Boosted Minoxidil – Recent Advancement in Management of Androgenetic Alopecia Dr. Anil Gosavi

M.D. (SKIN) Associate Professor Department of Dermatology BJ Government Medical College, Pune Abstract Since decades minoxidil used as a first line topical treatment in androgenetic alopecia with moderate to good outcome. Usually takes 3 to 4 months to see visible hair growth. There is group of patients in spite of regular use of topical minoxidil, gets poor response to topical minoxidil. Few studies mention that more than 40 % patients do not respond to topical minoxidil even after 1 year of consistent usage. Minoxidil is a pro-drug and it is converted to its active form, minoxidil sulphate, by sulfotransferase enzymes in the outer root sheath of hair follicles. Endogenous sulfotransferase 1A1 (SULT1A1) is the dominant isoform of sulfotransferase responsible for minoxidil conversion in the scalp. Studies have showed that there is a direct relationship between SULT1A1 activity and minoxidil response. There are clinical studies concluded that Low SULT1A1 activity occurs in approximately 60% of the population and 8

December 2023

predicts weak hair regrowth. Increasing SULT1A1 activity in the hair follicle could increase the minoxidil response. Recently, researchers have developed a novel topical formula which increases scalp SULT1A1 activity in patients via alterations to intercellular pH of the Outer Root Sheath (ORS). Many experimental and clinical studies revealed that SULT1A1 enzyme activity in the hair follicle correlates with minoxidil response for the treatment of AGA. Now the novel compounds modulating sulfotransferase activity in the scalp is available to boost the effect of minoxidil. Introduction Androgenetic alopecia (AGA) is the commonest cause of hair loss affecting around 50% of men and 40% of women. Nowadays, topical minoxidil is well established external treatment in men and women and it is also the most popular drug used for the treatment of AGA. Topical minoxidil is

Boosted Minoxidil – Recent Advancement in Management of Androgenetic Alopecia

clinically approved treatment of androgenetic alopecia since long. Minoxidil has a good safety profile and less adverse effects, the overall efficacy is relatively low. For significant clinical improvement in hair growth, minoxidil should be used daily for a period of minimum 3-4 months. There are few formulations available where minoxidil with other molecules like tretinoin, azelaic acid, finasteride which act by enhancing the penetration of minoxidil or independent mechanism. The novel and innovative solution has recently introduced to address the low response rate of topical minoxidil treatment for hair loss. Minoxidil is a pro-drug and it is converted to its active form, minoxidil sulphate, by sulfotransferase enzymes in the outer root sheath (ORS) of hair follicles. Endogenous sulfotransferase 1A1 (SULT1A1) is the dominant isoform of sulfotransferase responsible for minoxidil conversion in the scalp.1,2,3,4

growth and improves the response rate to topical minoxidil treatment.1,2,3,4 There is study of a SULT1A1 activity assay demonstrates 95% sensitivity and 73% specificity in predicting minoxidil treatment response for AGA. There are other studies mentioning SULT1A1 enzyme activity in the hair follicle correlates with minoxidil response for the treatment of AGA. Studies have showed that there is a direct relationship between SULT1A1 activity and minoxidil response. SULT1A1 activity has been used as a diagnostic to predict the likelihood of minoxidil response for individuals to help guide treatment for alopecia. A large variability in sulfotransferase enzyme expression in hair is observed among people. This difference in expression explains the varied clinical response to topical minoxidil treatment. Low follicular SULT1A1 activity occurs in approximately 60% of the population leading to weak hair regrowth. The treatment which can increase the SULT1A1 enzyme activity and thereby increases the minoxidil conversion to its active form will increase minoxidil efficiency. Minoxidil booster is a hair enzyme accelerator for use before minoxidil. It increases the activity of Sulfotransferase Enzyme (SULT1A1 Enzyme Booster) in the hair - creating a healthier, more boosted environment for hair to thrive.5,6 Roberts et al. observed that women with a score slightly above the cut-off value of 0.4 AU exhibited only minor improvements in hair growth compared with women with scores over 0.6 AU. This would suggest that there may be a continuum of minoxidil response directly proportional to sulfotransferase activity in the hair follicle. Extending this logic, this finding implies that upregulation of sulfotransferase could potentially be an effective adjunctive therapy to topical minoxidil.5,6

To overcome the minoxidil efficacy related limitation, the newly developed topical formula that increases the activity of SULT1A1 enzymes in hair follicles. Clinical studies have shown that the minoxidil booster can increase the sulfotransferase enzymes needed for minoxidil to work by up to 7x over a two-week period. The minoxidil booster is a promising solution for individuals struggling with hair loss. By increasing the activity of SULT1A1 enzymes, Figure 1: SULT1A1 Activator the booster creates a healthier environment for hair December 2023

Boosted Minoxidil – Recent Advancement in Management of Androgenetic Alopecia

Minoxidil Booster Formulation The minoxidil booster formulation contains the following ingredients: • Purified water

to improve the solubility and bioavailability of active ingredients and prevent the growth of microorganisms.1,5,7 Test for prediction of action of minoxidil for hair growth The expression of SULT1A1 in the scalp varies greatly between individuals and this difference in expression explains the varied clinical response to topical minoxidil treatment.

support SULT1A1 activity in the hair follicle as a strong predictor of minoxidil response in AGA patients. SULT1A1 enzyme activity in the hair follicle plays a crucial role in the conversion of minoxidil to its active form, minoxidil sulphate and is correlated with minoxidil response for the treatment of AGA. The novel enzymatic assay can predict responders to minoxidil therapy with a high sensitivity and specificity, making it a valuable tool for personalizing hair loss treatments.5

• Sultaboost blend (mixture of tetra sodium EDTA, sodium metabisulphate (preservative), PEG-6 caprylic/capric glyceride (moisturizer), polysorbate-80, glycerin, TRIS base and TRIS HCl (buffer), Phospholipon 90G (carrier) and aqua) A novel enzymatic assay has been developed to measure • Tocopheryl acetate SULT1A1 activity in the hair At present this enzymatic • Phospholipon 90G (Lipoid) root of a plucked human hair. assay not commercially The expression of SULT1A1 available in india. On clinical • Fragrance has been localized in the grounds AGA patients outer root sheet. In the assay, not responding to regular • EUXYL PE 9010 the conversion of minoxidil use of topical minoxidil for The sultaboost blend is a to minoxidil sulphate is recommended period can mixture of ingredients that coupled with the conversion be considered for booster includes a carrier, buffer and of p-nitrophenyl sulphate treatment. moisturizer, among others. to p-nitrophenyl, which can The blend is designed to be quantified by optical increase the activity of absorbance at 405 nm. SULT1A1 enzymes in hair follicles, which are responsible In one study, the assay was for converting minoxidil to able to predict responders its active form, minoxidil to minoxidil therapy with sulfate. Tocopheryl acetate a sensitivity of 95% and a is a form of vitamin E that specificity of 73% based on has antioxidant properties a cut-off value of less than Figure 2: SULT1A1 catalyzed and is often used in skincare 0.4 OD 405. These results sulfation of minoxidil5 products. Phospholipon 90G is a carrier that helps to improve the solubility and bioavailability of active ingredients. EUXYL PE 9010 is a preservative that helps to prevent the growth of bacteria and other microorganisms in the formulation. Minoxidil booster formulation contains a blend of ingredients designed to increase the activity of SULT1A1 enzymes in hair follicles, as well as other ingredients that help Figure 3: Minoxidil booster accelerate the response of minoxidil 10

December 2023

Boosted Minoxidil – Recent Advancement in Management of Androgenetic Alopecia

in hair growth and boosting its activity can improve the response rate to topical minoxidil treatment. The novel formula that uses a liposomal encapsulated alkalizing agent to change the pH of the ORS can increase the activity of Role of sulfotransferase SULT1A1 enzymes in hair enzyme SULT1A1 in Hair follicles, leading to improved growth and boosting of hair regrowth outcomes. SULT1A11,3,5,9 Sulfotransferase enzyme Clinical Evidence SULT1A1 plays a crucial 1. High prevalence of patients role in hair growth and the having low levels of follicular boosting of SULT1A1 activity sulfotransferase activity can improve the response in the Indian population. rate to topical minoxidil Study raised strong doubts treatment. Here are some key on the prescription of points regarding the role of minoxidil as monotherapy for SULT1A1 in hair growth and patterned hair loss. 40.8% the boosting of SULT1A1: of patients had low levels of sulfotransferase activity.10 • SULT1A1 activity in the outer root sheath (ORS) of 2. 75% of subjects treated the hair follicle is required for with the SULT1A1 adjuvant minoxidil efficacy. responded to minoxidil treatment after 60 days of use • Sulfotransferase has versus 33% of those treated been demonstrated to be with a placebo adjuvant (p = a biomarker of keratinocyte 0.023). Novel topical formula differentiation. (Minoxidil Booster) increases • Intracellular pH is a key the activity of SULT1A1 regulatory mechanism in the scalp and improves contributing to cell the likelihood of minoxidil differentiation in a number of response. SULT1A1 inducing topical formula is an effective stem cells. adjuvant for improving • Research has suggested minoxidil response. No that increasing intercellular pH patient reported any adverse would lead to an upregulation reaction to treatment in either of SULT1A1. arm.1 • The novel formula uses a liposomal encapsulated alkalizing agent (sodium bicarbonate) to change the pH of the ORS, which can increase the activity of SULT1A1 enzymes in hair follicles. 10. The minoxidil booster formulation is designed to increase the activity of SULT1A1 enzymes in hair follicles, which are responsible for converting minoxidil to its active form, minoxidil sulfate.

Figure 4: Mechanism of action of minoxidil booster Usage of Minoxidil Booster 1, 7, 8

To use the minoxidil booster formulation, follow these steps: 1. Ensure the hair is completely dry before applying the booster. 2. Applied daily to the base of the hair before minoxidil application. 3. Apply 10 minutes before application of minoxidil topical solution to activate and accelerate hair enzymes. 4. Booster formula requires at least 10 minutes to activate and accelerate hair enzymes. 5. Do not apply at the same time with minoxidil solution. 6. After applying the booster, apply minoxidil to the hairs. 7. Spray 7-9 times over the hair scalp (1 spray releases approx. 0.12 ml) 8. Do not shampoo hair for 4 hours after applying minoxidil.

9. Stick to the recommended minoxidil dosage for hair loss • SULT1A1 plays a crucial role and apply it twice a day.

December 2023

Boosted Minoxidil – Recent Advancement in Management of Androgenetic Alopecia

Figure 5 : Treatment- 5% topical minoxidil + novel formula or minoxidil + placebo

Figure 8 : Percentage of patients with hair growth

3. Evaluation of the efficacy of AB-103 as an adjuvant therapy to 5% topical minoxidil solution in the treatment of MPHL. Significantly higher percentage of patients reported hair growth with minoxidil booster + minoxidil treatment vs minoxidil treatment alone. No adverse events were reported in either arm. (Innovator Data on Figure 9 : Expert Assessment File) 5. Remarkable Hair Regrowth: Improving hair growth in 75% of patients in combination with minoxidil, compared to minoxidil alone (33%). (Innovator Data on File)

Figure 6 : Percentage of patients with hair growth 0 (no change), + 1 (slightly improved), + 2 (moderately improved) + 3 (significantly improved)

Figure 7 : Expert Assessment 4. Evaluation of the efficacy of AB-103 as an adjuvant therapy to 5% topical minoxidil solution in the treatment of FPHL. Significantly higher percentage of patients reported Hair growth with minoxidil booster + minoxidil treatment vs minoxidil treatment alone. No adverse events were reported in either arm. (Innovator Data on File) 12

December 2023

Advantages of Minoxidil Booster1,5 Minoxidil booster is a patent-protected formula designed to enhance hair regrowth in patients with androgenetic alopecia (AGA) by addressing low SULT1A1 activity and non-responders. The advantages of minoxidil booster include: 1. Bridging the Need Gap: Minoxidil booster is a unique innovation that aims to improve hair regrowth in AGA patients who do not respond well to traditional minoxidil treatment. 2. Patent Protected Formula: The formula is protected by a patent, ensuring its exclusivity and advancement in hair regrowth treatments. 3. Addressing Low SULT1A1 Activity & Non-Responders: Minoxidil booster is designed to address the issue of low SULT1A1 activity, which is associated with poor response to minoxidil treatment, and non-responders to traditional minoxidil. 4. Increased SULT1A1 Activity: Minoxidil booster is formulated to increase the activity of SULT1A1 enzymes in hair follicles, enhancing the clinical response of minoxidil and improving

Boosted Minoxidil – Recent Advancement in Management of Androgenetic Alopecia

hair regrowth. 5. Clinically Proven Efficacy in Indian Patients with AGA: The efficacy of minoxidil booster has been demonstrated in a small cohort of Indian men with AGA, where adding the SULT1A1 adjuvant to their daily minoxidil treatment regimen improved hair regrowth.

shown to significantly improve hair regrowth compared to daily minoxidil alone in men with AGA. Clinical trials have established the efficacy of the booster formula in Indian patients with AGA. It has a excellent safety profile and noadverse events have been reported with the use of the booster formula. Promoting treatment compliance i.e. enhancing minoxidil response with the booster formula can positively impact treatment compliance, leading to improved efficacy. The combination of the booster formula with minoxidil will have a synergistic effect, further enhancing the treatment outcome.

6. In a study conducted on 24 males with AGA, 75% of the subjects who used the SULT1A1 adjuvant with their daily minoxidil treatments for 60 days regrew hair, compared to 33% of those using a placebo adjuvant. This indicates that minoxidil booster can significantly improve hair regrowth in AGA patients In summary, the limited who do not respond well to efficacy of minoxidil in AGA traditional minoxidil treatment. treatment can be attributed to low SULT1A1 activity Conclusion Minoxidil is the cornerstone of and non-responders. The androgenetic alopecia (AGA) novel booster formula, by SULT1A1 treatment, but its efficacy rate upregulating activity, has demonstrated remains relatively low. The key enzyme responsible for the potential to address converting minoxidil to its active these issues and improve the form is endogenous SULT1A1, clinical response to minoxidil which is the dominant isoform treatment. of the enzyme that plays a References crucial role in the conversion 1. Dhurat R, Daruwalla S, Pai S, et al. of minoxidil. Studies have SULT1A1 (Minoxidil Sulfotransferase) consistently shown a direct enzyme booster significantly improves correlation between SULT1A1 response to topical minoxidil for activity and minoxidil response. hair regrowth. J Cosmet Dermatol. 2022;21(1):343-346. doi:10.1111/ Research efforts have focused jocd.14299 on increasing SULT1A1 activity in the hair follicle to 2. Buhl, A. E., Waldon, D. J., Baker, C. A., enhance minoxidil response. & Johnson, G. A. (1990). Minoxidil sulfate is the active metabolite that stimulates A novel booster formula has hair follicles. J Invest Dermatol.95(5), demonstrated the ability to 553–557. Accessed May 2023 at upregulate the enzymes, https://doi.org/10.1111/1523-1747. leading to increased SULT1A1 ep12504905 activity and improved clinical 3. Roberts, J., Desai, N., McCoy, J. response to minoxidil. This and Goren, A. (2014), Sulfotransferase adjuvant therapy has been activity in plucked hair follicles predicts

response to topical minoxidil in the treatment of female androgenetic alopecia. Dermatol Ther, 27: 252-254. https://doi.org/10.1111/dth.12130 4. Goren A, Castano JA, McCoy J, Bermudez F, Lotti T. Novel enzymatic assay predicts minoxidil response in the treatment of androgenetic alopecia. Dermatol Ther. 2014;27(3):171-173. doi:10.1111/dth.12111 5. Pietrauszka, Kornelia, and Beata Bergler-Czop. “Sulfotransferase SULT1A1 activity in hair follicle, a prognostic marker of response to the minoxidil treatment in patients with androgenetic alopecia: a review.” Postepy dermatologii i alergologii vol. 39,3 (2022): 472-478. doi:10.5114/ ada.2020.99947 6. Singh, S., Patil, A., Kianfar, N., Wakiel-Burnat, A., Rudnicka, L., Sinclair, R. and Goldust, M. (2022), Does topical minoxidil at concentrations higher than 5% provide additional clinical benefit?. Clin Exp Dermatol, 47: 1951-1955. https://doi.org/10.1111/ced.15338 7. Kwon, Oh Sang et al. “Promotive effect of minoxidil combined with alltrans retinoic acid (tretinoin) on human hair growth in vitro.” Journal of Korean medical science vol. 22,2 (2007): 2839. doi:10.3346/jkms.2007.22.2.283 8. Nestor, Mark S et al. “Treatment options for androgenetic alopecia: Efficacy, side effects, compliance, financial considerations, and ethics.” Journal of cosmetic dermatology vol. 20,12 (2021): 3759-3781. doi:10.1111/ jocd.14537 9. Ramos, P.M., McCoy, J., Wambier, C., Shapiro, J., Vañó-Galvan, S., Sinclair, R. and Goren, A. (2020), Novel topical booster enhances follicular sulfotransferase activity in patients with androgenetic alopecia: a new strategy to improve minoxidil response. J Eur Acad Dermatol Venereol, 34: e799-e800. https://doi.org/10.1111/jdv.16645 10. Chitalia J, Dhurat R, Goren A, et al. Characterization of follicular minoxidil sulfotransferase activity in a cohort of pattern hair loss patients from the Indian Subcontinent. Dermatol Ther. 2018;31(6):e12688. doi:10.1111/ dth.12688

December 2023

Skin Oedema with Rashes and Burning: A Case Presentation

Skin Oedema with Rashes and Burning: A Case Presentation Dr. K. Lakshmiprasad MBBS, DDVL Consultant Dermatologist Aditya Polly Clinic Attapur, Hyderabad

Introduction Oedema is a medical condition characterized by the accumulation of excess fluid in the body's tissues. Skin oedema refers to an abnormal accumulation of fluid in the tissues below the surface of the skin, causing the skin to appear swollen and also leads to puffiness. It can be pitting or non-pitting in nature. This can occur in any part of the body, including the limbs, hands, feet, ankles, face and lungs. Oedema can have many causes, including heart or kidney failure, liver disease, malnutrition, injury, inflammation and certain medications. Oedema can be caused by various factors such as trauma, medication, systemic illness, etc. In some cases, it could be accompanied by various other symptoms, such as redness, warmth or tenderness. Oedema can be temporary or chronic and could affect any part of the body.1,2,3,4 Purpuric skin lesions associated with oedema can be a sign of a more severe underlying condition, like disseminated intravascular coagulation (DIC) or vasculitis. DIC is a medical emergency, which can be characterized by abnormal clotting and 14

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bleeding, which can cause purpuric skin lesions, among other symptoms. Vasculitis is an inflammation of the blood vessels that can lead to the formation of purpuric skin lesions, as well as other symptoms such as joint aches and weakness. In both the cases, immediate medical attention is necessary to diagnose the underlying cause of the purpuric skin lesions and to implement appropriate treatment. It's essential to note that there are many other causes of purpuric skin lesions and oedema; a thorough medical evaluation is necessary to determine the underlying cause in each case.5, 6 The epidemiology of oedema can differ depending on the specific type of oedema and the population being subjected to studies. Generally, oedema is a common condition and affects people of all age groups. The prevalence of oedema is usually higher in older adults, people with chronic medical conditions, and those who are sedentary or immobile. Certain factors, such as heart failure, liver disease, kidney disease, venous insufficiency and use of certain medications, may lead to increase in the

Skin Oedema with Rashes and Burning: A Case Presentation

risk of developing oedema in patients. Oedema cases can occur anywhere in the world, although certain types of oedema, such as lymphatic filariasis, are more common in specific regions. On gender basis, women have higher chances than men to experience oedema mostly caused due to hormonal changes, such as premenstrual syndrome (PMS). Some studies have also indicated differences in the prevalence of oedema among different racial groups, although more research is needed in order to better understanding of these differences.7, 8 There are several types of oedema, including:9 1. Peripheral Oedema: This is the most common type of oedema, characterized by swelling in the legs, ankles, and feet.8

be a sign of a more serious there is presence of a bacterial underlying medical condition, skin infection, which can such as heart or kidney failure. causes redness, swelling and pain. Each type of oedema has its own specific causes Deep vein thrombosis and treatment options, so (DVT): This happens due to it is important to carry out the presence of a blood clot or a thorough evaluation and thrombus in a deep vein that examination for each type and may cause swelling, pain and it’s associated symptoms. redness. While encountering skin oedema with rashes and burning, it is essential to evaluate the pattern, distribution and symptoms associated with them. Skin oedema with rashes and burning can be indicative of various underlying skin conditions, ranging from allergic reactions to inflammatory skin disorders. Thus, the presence of these symptoms may suggest an immune response or irritation within the skin. Skin rashes with burning due to oedema can be caused by various underlying conditions like:10, 11

2. Pulmonary Oedema: This type of oedema involves fluid accumulation in the lungs, Allergic reactions: Allergies to certain substances such as making it difficult to breathe. foods, medications, cosmetics 3. Cerebral Oedema: This or environmental factors can type of oedema involves fluid trigger skin oedema, rashes accumulation in the brain, and burning. The immune which can lead to increased system reacts to the allergen pressure on the brain and can and releases histamines be life-threatening. along with other chemicals 4. Macular Oedema: This that cause inflammation and type of oedema involves fluid irritation in the skin. accumulation in the macula, Contact dermatitis: This the central part of the retina in occurs when direct contact the eye, causing vision loss. between skin and irritant 5. Lymphedema: This is a or allergen takes place, chronic condition that occurs which leads to a localized response. when the lymphatic system inflammatory is not able to properly drain Commonly occurring irritants certain soaps, fluid from the body, leading to include 8 detergents, cosmetics, metals swelling in the arms or legs. (e.g. nickel) and plants (e.g. 6. Pedal Oedema: This type poison ivy). of oedema involves swelling in the feet and legs and can Cellulitis: This is seen when

Lymphedema: It is a type of oedema which occurs due to obstruction of the lymphatic vessels or nodes, while angioedema is a rapid swelling of the dermis, subcutaneous tissue and mucosa. Eczema (atopic dermatitis with oozing condition): Eczema is a chronic inflammatory skin condition that can be characterized by red, itchy rashes. Skin oedema, as well as the presence of rashes and burning, is a common manifestation. It is usually triggered by allergens, irritants, or underlying genetic factors. Insect bites or stings: Allergic reactions to insect bites or stings may cause localized oedema, redness, rashes and a burning sensation. This reaction can vary in severity depending on sensitivity of the individual. Autoimmune disorders: Certain autoimmune disorders like lupus or dermatomyositis, these can lead to skin manifestations, including oedema, rashes and a burning sensation. These conditions are characterized by a hyperactive immune response targeting healthy tissues. The treatment of oedema depends on its underlying cause and may involve lifestyle changes, medications, compression therapy, or December 2023

Skin Oedema with Rashes and Burning: A Case Presentation

medical procedures. In some cases, oedema can be a sign of a serious underlying medical condition.1 In severe cases, treatment may involve medical procedures such as drainage of excess fluid.1, 3, 4 A thorough medical history, physical examination and if needed, diagnostic tests can aid in identification of the underlying cause and be helpful for guiding in treatment decisions. Case Presentation A 42 year old female patient Before Treatment visited in our clinic with the chief complaints of skin swelling, puffy ankles and feets, red rashes on hands and palms with the changes in skin colour and severe burning sensation. Due to stretched skin she had a difficulty moving certain parts of the body. Past history revealed that she has completed both the doses of Covid-19 vaccination 2 years back. She had a fever after 7 months of vaccination. The fever subsided with administration of antibiotics and general course within a week. Three weeks later she After Treatment developed these lesions and rashes with lot of burning Figure 1: Red skin lesions and rashes on hands with fluid filled oedema sensation, but temperature was found to be normal. The diagnosis of skin oedema was made. After further investigations the reports showed that the Covid antibodies were 89, D-Dimer test results came out to be 800 mg/ml, White blood cell (WBC) count results were 11500 microlitre and C - reactive protein (CRP) test resulted 124mg/ml. All these results suggest that the Covid-19 vaccination was not full proof and due to this she got the oedema. Before Treatment 16

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Skin Oedema with Rashes and Burning: A Case Presentation

Inspection: Is swelling present in the affected area? Is the swelling symmetrical or asymmetrical in appearance? Palpation: Is the swelling soft and compressible or firm and non-compressible to touch? Can the patient press down on the swelling and have the skin stay indented for a short amount of time (pitting or nonpitting)?

After Treatment Figure 2: Rashes with redness on palms

Before Treatment After Treatment Figure 3: Red rashes and severe swelling, puffiness on ankles and feets

Observing for other signs: Is the skin over the swelling stretched or shiny? Are there any signs of skin breakdown or ulceration present? Measurement: The extent and severity of oedema can be measured by weighing the affected limb before and after elevation, by measuring the circumference of the affected limb or by using a pneumatic compression device. Diagnostic tests: Depending on the suspected cause behind the oedema, conducting additional diagnostic tests may be ordered, including blood tests, imaging studies (such as X-rays, CT scans, or ultrasounds), or biopsy of the affected area.

In the case of oedema, the histopathology of affected tissues would show accumulation of fluid in the Diagnostic Assessment and Medical Evaluation interstitial spaces between The assessment of oedema involves evaluation of the cause, cells.13,14 extent and severity of the swelling along with its impact on the Under the microscope, the patient's health and quality of life. A thorough medical evaluation tissues that are affected would typically consists of the following steps:12 appear to be swollen and Patient history: Taking a detailed medical history to detect any underlying conditions or contributing factors. The history and physical examination are necessary components of the evaluation of oedema. The history should focus on timing and progression of symptoms, associated symptoms, medical history, family history etc.

distended, with an increased in size of the interstitial spaces. The cells themselves would mostly appear normal, but can show signs of stress or damage due to the fluid build-up.14

some cases, the Physical examination: A physical examination to perform In assessment of the presence, location and type of oedema. The accumulation of fluid in the interstitial spaces can also be physical examination should focus on: December 2023

Skin Oedema with Rashes and Burning: A Case Presentation

accompanied by inflammation (inflammatory infiltrate include neutrophils, lymphocytes and monocytes) and the histopathology would reveal the presence of inflammatory cells, such as leukocytes.14 It is crucial to understand the histopathology of oedema in order to better understand the underlying mechanisms of this condition and to formulate more effective prevention and treatment strategies. However, a definitive diagnosis of oedema and its underlying causes usually needs a combination of clinical, laboratory and imaging tests, in addition to histopathology.14 Treatment Skin oedema, rashes and burning can be associated with various skin conditions like allergic reactions, contact dermatitis, eczema or insect bites. The treatment for these symptoms may undergo changes depending on the underlying cause. Lifestyle changes can turn out to be beneficial in treatment. Making changes in diet and exercise routine, as well as elevating legs or the swollen part, can help reduce swelling and improve circulation. Leg oedema which can be related to congestive heart failure or liver disease can be treated with a diuretics (sometimes called a ''water pill'') like furosemide.9 Compression therapy i.e. wearing compression stockings or using compression pumps can help improve circulation and reduce swelling of the area. Cool compresses can be helpful in management of burning sensation and oedema. Applying cool compresses or taking cold showers can be helpful to soothe the burning sensation and reduce 18

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inflammation.Identifying and avoiding triggers is important, if patient suspect that a specific allergen or irritant is causing the symptoms try to identify and ask them to avoid it. This might involve avoiding certain foods, cosmetics, fabrics or environmental factors. Topical corticosteroids are anti-inflammatory medications that can help in reduction of swelling, alleviate itching and relieve burning sensations. Oral antihistamines can provide relief by blocking the histamine response system and also reduce itching and allergic reactions. Applying moisturizers helps in keeping the skin hydrated and alleviate dryness, reducing discomfort.2

of an infection that should be treated promptly.4

Treating any underlying medical conditions contributing to the oedema is essential for long-term management. If the symptoms persist, worsen, or are accompanied by other concerning symptoms, it is strongly advisable to consult a healthcare professional or dermatologist for a proper evaluation and diagnosis; who can provide a more targeted and specific treatment plan based on the underlying cause of symptoms. In severe cases or when an underlying condition is diagnosed, prescriptionstrength medications is usually necessary to manage the symptoms effectively.11

Oedema can be divided into several types depending on its region and affected organ or system. Major types of oedema based on this are peripheral oedema, pulmonary oedema, cerebral oedema, macular oedema, lymphedema and pedal oedema. Every individual type of oedema has definite cause and treatment options, making it necessary to carry out a thorough evaluation and examination for each type and symptoms associated with it.

Discussion Oedema is characterized by swelling within or beneath the skin and can be pitting or non-pitting in nature. The consistency and texture of the swelling can help differentiate it from other conditions, such as the presence of a foreign body. If the affected area shows symptoms like redness and warmth, it may be an indicative

From epidemiological studies it was found that although oedema can affect anyone irrespective of age group, health status, lifestyle, region or gender these factors may affect its prevalence. The chances of developing oedema is higher in elderly or geriatric population, patients suffering with abnormality or failure of organs like heart, kidney or liver, individuals more prone to sedentary lifestyle, regions with prevalence of diseases like filariasis and women especially while they are undergoing premenstrual syndrome (PMS).7,8

Skin oedema along with rashes and burning can be an indication of various underlying skin conditions, ranging from allergic reactions to inflammatory skin disorders. The presence of these symptoms may suggest an immune response or irritation within the skin. Some possible causes and their implications are allergic reactions, contact dermatitis, atopic dermatitis, cellulitis, deep vein thrombosis (DVT), lymphedema, insect bites or stings, autoimmune disorders like lupus or dermatomyositis and hives.10,11

Skin Oedema with Rashes and Burning: A Case Presentation

The most safe and effective treatment for edema depends on the underlying cause and severity of the swelling. However, some common treatments that are considered safe and effective like topical corticosteroids, antihistamines, moisturizers etc. Avoidance of triggers, known allergens or irritants can help prevent recurrence of these episodes.11 Peripheral oedema, which is swelling that, occurs when fluid accumulation takes place in the tissues of the arms or legs. The symptoms that are usually typical early signs of peripheral oedema include feelings of fullness or heaviness, visible swelling, the ability to leave a dent when pressed, tight or uncomfortable clothing or jewellery, tight or warm skin near the swelling, finding difficulty in moving affected joints, and a sensation of tautness or pain in the surrounding area.7 Conclusion A skin rash with burning and purpuric skin associated with oedema can be a sign of a serious underlying condition, such as disseminated intravascular coagulation (DIC) or vasculitis. Prompt medical evaluation is necessary to diagnose the underlying cause and to implement appropriate treatment. A thorough medical evaluation typically includes taking a patient history, performing a physical examination, ordering diagnostic tests, and developing a treatment plan. It's important to note that there are many other potential causes of a skin rash with burning and purpuric skin associated with oedema and a healthcare provider should determine the most appropriate course of action based on the

individual patient's needs and circumstances. It is crucial to understand the epidemiology of oedema in order to improve prevention and treatment strategies and to reduce the burden of this condition on affected individuals and society.

References 1. Lent-Schochet D, Jialal I. Physiology, Edema. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih. gov/books/NBK537065/ 2. Sterns RH et al. Patient education: Edema (swelling). Jun 2023. 3. Simon EB. Leg edema assessment and management. Medsurg Nursing. 2014 Jan 1;23(1):44-53.

Dec 16;16(12):e0260742. doi: 10.1371/journal.pone.0260742. PMID: 34914717; PMCID: PMC8675752. 8. Goyal A, Cusick AS, Bhutta BS. Peripheral Edema. [Updated 2023 Feb 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https:// www.ncbi.nlm.nih. gov/books / NBK554452/ 9. Loscalzo J, et al., eds. Edema. In: Harrison's Principles of Internal Medicine. 21st ed. McGraw Hill; 2022. https://accessmedicine. mhmedical.com. Accessed Nov. 29, 2022. 10. American Family Physician: “Edema: Diagnosis and Management.” 11. Sterns RH et al. General principles of the treatment of edema in adults. Jun 2023.

4. King M. Management of Edema. J Clin Aesthet Dermatol. 2017 Jan;10(1):E1-E4. Epub 2017 Jan 1. PMID: 28210383; PMCID: PMC5300735.

12.Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. American family physician. 2013 Jul 15;88(2):10210.

5. Perera TB, Murphy-Lavoie HM. Purpura Fulminans. [Updated 2022 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih. gov/books / NBK532865/

13. Gurcan MN, Boucheron LE, Can A, Madabhushi A, Rajpoot NM, Yener B. Histopathological image analysis: a review. IEEE Rev Biomed Eng. 2009;2:147-71. doi: 10.1109/ RBME.2009.2034865. Epub 2009 Oct 30. PMID: 20671804; PMCID: PMC2910932.

6. Singh P, Schwartz RA. Disseminated intravascular coagulation: A devastating systemic disorder of special concern with COVID-19. Dermatol Ther. 2020 Nov;33(6):e14053. doi: 10.1111/ dth.14053. Epub 2020 Sep 4. PMID: 32700813; PMCID: PMC7404500. 7. Besharat S, Grol-Prokopczyk H, Gao S, Feng C, Akwaa F, Gewandter JS. Peripheral edema: A common and persistent health problem for older Americans. PLoS One. 2021

14. Chirasuthat P, Chirasuthat S, Suchonwanit P. Acute Inflammatory Edema: A Case Report with Histopathological and Immunohistochemical Findings. J Inflamm Res. 2021 Sep 21;14:4877-4880. doi: 10.2147/ JIR.S334051. PMID: 34584442; PMCID: PMC8464357.

December 2023

Micro-needling with 5 -Flourouracil- Innovative approach for Resistant Vitiligo

Micro-needling with 5 -FlourouracilInnovative Approach for Resistant Vitiligo Dr. Trupti B. Shah

M.D. (DVD) Consultant Dermatologist and Cosmetologist Haribhakti Clinic, Ahmedabad

Dr. Palak D. Makawana

MBBS, MD (Skin & VD), DNB (Dermatology) Consultant Dermatologist, Haribhakti Clinic and South Bopal Skin Clinic Ahmedabad Abstract Background Vitiligo is a chronic disease of great cosmetic concern presenting with depigmented macules and patches. It is often recalcitrant to medical treatment.

procedure was performed every 2 weeks for 3 months. Clinical improvement was assessed monthly till 6 months by serial clinical photographs and grading score.

Results Initiation of repigmentation Aim started at 1 month in 7 patients The aim of the study was to (70%). Excellent improvement study the efficacy and safety (>75% repigmentation) was of topical 5% 5-fluorouracil noted in 4 patients (40%). with needling in stable vitiligo. Conclusion Materials and Methods Needling with 5% This interventional prospective 5-fluorouracil appears to be study was conducted from simple, safe and effective April 2022 to April 2023. Total treatment in vitiligo. It can be of 10 patients, with stable used in poor responders to vitiligo of age older than 15 conventional therapy. years, were included in the Introduction study. All the patients were treated with needling followed Vitiligo is a commonly by topical 5% 5-fluorouracil acquired, idiopathic, heritable disorder over vitiligo patches. The depigmentary 22

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Micro-needling with 5 -Flourouracil- Innovative approach for Resistant Vitiligo

affecting skin and/or mucous membrane. It is a chronic disease with great social and cosmetic concern having prevalence of 0.1% to 8.8% in India.[1] Vitiligo is diagnosed clinically with characteristic of depigmented macules due to the selective destruction of melanocytes.[2] Although there is no definitive treatment still several treatment options have shown relative satisfactory results.[3] Routinely used options include the following: topical corticosteroids, topical calcineurin inhibitors, phototherapy, laser, graft surgeries and micro[4-7] pigmentation. Though a lot of surgical treatment modalities are available for vitiligo, patients are often apprehensive to undergo extensive procedure such as grafting. Micro-needling, also known as collagen induction therapy, is a new minimally invasive procedure that uses fine miniature needles to create superficial tiny holes in the skin without damaging the surface.[8] These superficial scratches cause minor bleeding and trigger the repair and release of growth factors such as platelet-derived growth factor (PGF), transforming growth factor-alpha & beta, as well as fibroblast growth factor (FGF).[9] Needling also causes trauma-induced inflammation in the skin, stimulating the migration and mechanical transfer of keratinocytes and melanocytes from the hair follicle and the healthy edge of the lesion during the healing phase.[10] In addition, needling facilitates the penetration of other drugs into the

skin by creating a kind of dermabrasion, enhancing the effect of other topical medications. 5-Fluorouracil (5-FU), an antimitotic agent that promotes melanocyte proliferation and migration, has known side effect of localised hyperpigmentation in cancer therapy.[11] It is being studied topically as well as intradermally with other modalities, including NB-UVB, dermabrasion and Erbium:YAG laser ablation for the treatment of vitiligo.[10] These modalities, however, often require a special setup with a deep learning curve and the cost tends to deprive the patients from lower socioeconomic strata, of these modalities. So here we present study of efficacy of 5-FU with microneedling in vitiligo patients. Patient Selection Patients with disease stability of at least one year duration were included whereas patients with active Koebner's phenomenon, pregnant women, age less than 10 years, coagulation disorder, patients with an active infection, patients at high risk of keloid and patches on the face, genitalia, and intertriginous areas were excluded from the study. Informed written consent was obtained from each patient. Method Total 10 patients fulfilling inclusion criteria and ready to give consent were included in the study. Topical anaesthetic cream was applied on the patch 40 min before the procedure followed by

cleaning and sterilization the affected area using betadine solution. A thick paste of 5% 5-FU cream was applied on the patch followed by microneedling with dermapen from one border to the next using several parallel side-to-side and top-down scratches till several small, punctate bleeding spots develop. A lag period of few seconds between the time of needling and appearance of pin point bleed indicates that the needle has reached the dermo-epidermal junction. Haemostasis was achieved by applying a normal salinesoaked piece of gauge on the treated area and then wipe off cream with betadine gauze. Mixture of 5% 5-FU and topical antibiotic cream (1:1 ratio) was applied on the treated area and done dressing for 24 hours. All the patients were advised to apply the mixture of 5-FU and antibiotic cream twice daily for the next 13 days. Maximum of six sessions of therapy done at 2-week interval. Postoperative Care In the immediate post operative phase, patients advised to avoid any irritating chemical exposures and to administer sunscreens. Patients were followed up monthly and assessed using clinical photograph and subjective score of repigmentation. Erythema, discomfort, ulceration, burning sensation, ecchymosis, infection or allergic symptoms can be observed but generally subsides with topical antibiotic. December 2023

Micro-needling with 5 -Flourouracil- Innovative approach for Resistant Vitiligo

Result Mean age was 28.4 years in our study. We found vitiligo to be more prevalent in females comprising 7 (70%). Mean duration of vitiligo was 4 years. Most common morphological type in our study was focal vitiligo (6 out of 10, 60%) followed by vitiligo vulgaris (4 out of 10, 40%). After 1 month of therapy, initiation of repigmentation was noted in 7 (70%) patients. At the end of 6 months, 40 % patients had excellent response (>75% Repigmentation), 50 % patients had very good response (5075% repigmentation) and 10% patients had poor response (<25% repigmentation). Loss of pigmentation was not observed in any patient. Pain, erythema and itching were most common (70% patients) side effect. Ulceration of lesion was not seen in any patient. Koebner’s phenomenon was observed in 1 patient. Excellent response was most often seen over the trunk followed by limbs.

Before Treatment

3 months After Treatment

Figure 2: Pigmentation on chest right side

Pre-treatment

Immediate post procedure

After 1 session

Figure 1: Depigmented macules on the leg

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After 3 sessions

Immediate Pre post treatment proedure

After 3 Setting

Figure 3: Pigmentation on left leg medial malleolie

Micro-needling with 5 -Flourouracil- Innovative approach for Resistant Vitiligo

The process of needling in vitiligo treatment induces a robust inflammatory response and local edema, which results in increased intercellular spaces within the basal layer of the skin. This creates a pathway for active melanocytes to migrate from pigmented areas of the epidermis. Inflammatory After 3 sessions mediators such as leukotrienes Baseline After 1 session Figure 4: Pigmentation on left leg lateral malleolie and lateral C4 and D4, as well as matrix metalloproteinases released part of leg by keratinocytes, play a role in promoting melanocyte Discussion migration and proliferation. Vitiligo is an autoimmune disease characterized by the Combining microneedling with destruction of melanocytes, resulting in depigmented macules other treatment modalities on the skin. The condition is influenced by environmental, in various clinical trials has genetic and neural factors and can have a significant shown improved effectiveness psychosocial impact on individuals, leading to lowered selfin achieving repigmentation esteem and potential mental health issues. A study conducted in vitiligo. Additionally, these in India revealed that a portion of vitiligo patients experienced trials have demonstrated depression, anxiety and even suicidal ideation. It is therefore shorter treatment durations crucial to provide these patients with appropriate and effective and reduced side effects treatment options while offering support to cope with the compared to other condition. The choice of therapy for vitiligo depends on various approaches. This combination factors, including the nature and stability of the disease, extent therapy approach holds of involvement, and the patient's age. Treatment options range promise for enhancing the from medical to surgical modalities and the selection should outcomes of vitiligo treatment, be tailored to each individual's specific needs.12 offering a potentially more Tsuji and Hamada introduced a novel treatment method for efficient and well-tolerated vitiligo involving the application of 5-fluorouracil (5-FU) after option for patients. 12 therapeutic wounding. While topical 5-FU has been previously Our study constituted patients used alone or in combination with dermabrasion and lasers, of age varying from 15 to 48 Tsuji and Hamada's approach showed promising results. years, and the mean age of 5-FU exhibits selective cytotoxicity towards epidermal cells, patients was 28.4 years. A with melanocytes being less vulnerable than keratinocytes. female predominance was The proposed mechanism of repigmentation suggests observed in our study (70%). that 5-FU overstimulates melanocytes in follicles, leading Similar study conducted by to their migration during epithelialization and subsequent George et al. noted female pigmentation. In vitro studies have demonstrated that low predominance in their study. concentrations of 5-FU selectively destroy keratinocytes A higher number of female over a three-week period, while melanocytes continue to patients have been found multiply and contribute to pigment formation. This innovative in clinico-epidemiological treatment approach may offer a potential therapeutic option studies of vitiligo conducted by for vitiligo patients, promoting repigmentation while minimizing Handa and Dogra and Gandhi damage to melanocytes. Further research and clinical studies et al. This probably reflects are necessary to validate the effectiveness and safety of this the increased social stigma of method. 12 vitiligo in female patients and December 2023

Micro-needling with 5 -Flourouracil- Innovative approach for Resistant Vitiligo

thus early treatment-seeking A study conducted by George behavior.12 et al. on the efficacy of laser dermabrasion followed by At the end of 1 month, topical 5-FU in the treatment initiation of repigmentation of stable vitiligo found nearly in the form of erythema complete repigmentation in over the patches started in 40% patients.12 7 patients (70%). However, Mina et al. reported a start of Santosh et al. found that repigmentation within 6 weeks after 3 months of treatment in 44% patches of vitiligo of vitiligo with 5-FU after treated with 5-FU combined microneedling of the lesion, with microneedling. The approximately 60% of patients response to needling appears (30) had hyperpigmentation in to be faster than effect of the vitiligo lesions. There was fluorouracil combined with almost complete pigmentation microdermabrasion as studied in very small patches; larger by Garg et al. who noted the ones had less pigmentation start of repigmentation in 50% and 40% (20) did not have patches within 2 months. The any pigmentation from the faster response after needling previous state.12 could be due to the better Only one patient of 27 penetration of the topical drug (3.7%) showed excellent after needling.12 improvement in vitiligo patch At the end of 6 months, treated with microneedling excellent repigmentation with dermapen after 5-FU (>75% repigmentation) application in an Egyptian was noted in 40% study. Approximately patients, whereas <25% 70% patients showed repigmentation was seen in some improvement in the 10%. The results of our study color of lesions. These are comparable to a study patients showed 18.5% conducted by Shashikiran et improvement when treated al. in which more than 75% with microneedling alone. repigmentation was reported Ghiya et al. reported excellent in 49% of the patches. response in 60% children However, they noticed of stable localized vitiligo <50% repigmentation in treated with 5-FU solution 25% patches in their study. followed by dermaroller. The Mina et al. noted excellent high response rate can be repigmentation in 48% attributed to the fact that patches treated with patients received treatment combined microneedling and every 15 days for 6 months.12 5-FU.12 In our study, maximum Similar result was reported number of truncal lesions by Yones et al. in a study of showed the best response, efficacy of dermabrasion plus and acral lesions were the topical 5-FU in stable vitiligo, least responsive. This was in which they found excellent consistent with the results of repigmentation in 45% Shashikiran et al. Leukotrichia .12 patients and bony locations have been 26

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linked to the poor response of treatment in literature.12 In our study, pain was experienced by 7 (70%) patients, whereas erythema, itching and ulceration were observed in few patients. The adverse effects of erythema, itching and ulceration were in accordance with a study by Shashikiran et al. However, they recorded pain during the procedure in all the patients (100%). The lesser occurrence of pain in our study can be attributed to the use of topical anesthetic sprayed before the procedure. Mina et al. observed ulceration in 4% patients, while no patient observed ulceration in our study Sethi et al. reported erythema and serous discharge in all patients, formation of pseudomembrane, and hypertrophic scarring in their study. Loss of pigmentation was not seen in any of our patients probably due to the short follow-up period after the intervention. No systemic side effect was reported in our study, thereby making use of topical FU along with needling safe and effective therapeutic modality in the treatment of vitiligo.12 Limitations of our study included an unblinded design and a short follow-up period. This study also did not evaluate the efficacy of the intervention on mucosal vitiligo. Further, we did not use any tool that measures changes in vitiligo from the patient’s perspective. The use of a 26-gauge needle might be economically convenient but it is prone to produce an inferior

Micro-needling with 5 -Flourouracil- Innovative approach for Resistant Vitiligo

wound than a dermaroller or a with 5-Fluorouracil (5-FU) is dermapen.12 an innovative approach that holds promise as a potential We found that needling treatment for resistant followed by topical application vitiligo. This technique of 5-FU has much higher combines the benefits efficacy than 5-FU alone of micro-needling, which in vitiligo. It is a useful enhances the penetration therapy in poor responders of topical medications, with to conventional therapy. the application of 5-FU, However, the stability of a medication that inhibits repigmentation has to be melanocyte activity. While analyzed with longer period of early research suggests follow up.12 the potential efficacy of this Limitations of our study approach, it is important to included an unblinded note that more studies are design and a short follow-up needed to determine its safety, period. This study also did long-term effectiveness and not evaluate the efficacy of optimal treatment parameters. the intervention on mucosal Standardization of treatment vitiligo. Further, we did not dosing protocols and further use any tool that measures randomized clinical trials changes in vitiligo from the are necessary to establish a patient’s perspective. The use consensus regarding the use of a 26-gauge needle might be of micro-needling with 5-FU in economically convenient but it vitiligo treatment. is prone to produce an inferior References wound than a dermaroller or a 1. Sehgal VN, Srivastava G. Vitiligo: dermapen.12 While this approach shows promise, it is important to note that the research on micro-needling with 5-FU for vitiligo is still in its early stages and more studies are needed to determine its safety and efficacy. Clinical trials are necessary to evaluate the optimal concentration of 5-FU, the number of treatment sessions required, and the long-term outcomes of this approach. Additionally, potential side effects and risks associated with micro-needling, such as skin irritation, infection, or scarring, need to be carefully considered.12,13,14,15,16 Conclusion In conclusion, micro-needling

compendium of clinico-epidemiological features. Indian J Dermatol Venereol Leprol. 2007;73:149–56 2. Glassman SJ. Vitiligo, reactive oxygen species and T-cells. Clin Sci (Lond) 2011;120:99–120

3. Nicolaidou E, Antoniou C, Stratigos AJ, Stefanaki C, Katsambas AD. Efficacy, predictors of response, and long-term follow-up in patients with vitiligo treated with narrowband Uvb phototherapy. J Am Acad Dermatol. 2007; 56(2): 274- 278. 4. Adelekun A, Onyekaba G, Lipoff JB. Skin color in dermatology textbooks: an updated evaluation and analysis. J Am Acad Dermatol. 2021; 84(1): 194- 196. 5. Taieb A, Alomar A, Böhm M, et al. Guidelines for the management of vitiligo: the European dermatology forum consensus. Br J Dermatol. 2013; 168(1): 5- 19. 6. Baltas E, Nagy P, Bonis B, et al. Repigmentation of localized vitiligo with the xenon chloride laser. Br J Dermatol. 2001; 144(6): 1266- 1267.

7. Mulekar S, Isedeh P. Surgical interventions for vitiligo: an evidencebased review. Br J Dermatol. 2013; 169: 57- 66. 8. Orentreich DS, Orentreich N. Subcutaneous incisionless (Subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg. 1995; 21(6): 543- 549. 9. Singh A, Yadav S. Microneedling: advances and widening horizons. Indian Dermatol Online J. 2016; 7(4): 244. 10. Gauthier Y, Anbar T, Lepreux S, Cario-André M, Benzekri L. Possible mechanisms by which topical 5-fluorouracil and Dermabrasion could induce pigment spread in vitiligo skin: an experimental study. Int Sch Res Notices. 2013; 2013: 1- 7. 11. Mohamed HA, Mohammed GF, Gomaa AH, Eyada MM. Carbon dioxide laser plus topical 5-fluorouracil: a new combination therapeutic modality for Acral vitiligo. J Cosmet Laser Ther. 2015; 17(4): 216- 223. 12. Zahra, Fatima T et al. “Efficacy of Topical 5% 5-Fluorouracil with Needling versus 5% 5-Fluorouracil Alone in Stable Vitiligo: A Randomized Controlled Study.” Journal of cutaneous and aesthetic surgery vol. 13,3 (2020): 197203. doi:10.4103/JCAS.JCAS_12_20

13. Pazyar N, Hatami M, Yaghoobi R, Parvar SY, Radmanesh M, Hadibarhaghtalab M. The efficacy of adding topical 5-fluorouracil to microneedling in the treatment of vitiligo: A randomized controlled trial. J Cosmet Dermatol. 2023 May;22(5):15131520. doi: 10.1111/jocd.15616. Epub 2023 Jan 31. PMID: 36718813. 14. Shashikiran A R, Gandhi S, Murugesh S B, Kusagur M, Sugareddy. Efficacy of topical 5% fluorouracil needling in vitiligo. Indian J Dermatol Venereol Leprol 2018;84:203-205 15. Attwa EM, Khashaba SA, Ezzat NA. Evaluation of the additional effect of topical 5-fluorouracil to needling in the treatment of localized vitiligo [published online September 16, 2019]. J Cosmet Dermatol. doi:10.1111/jocd.13152 16. Jha AK, Sonthalia S. 5-Fluorouracil as an adjuvant therapy along with microneedling in vitiligo. J Am Acad Dermatol. 2019 Apr;80(4):e75-e76. doi: 10.1016/j.jaad.2018.12.008. Epub 2018 Dec 7. PMID: 30529709. December 2023

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Mole Removal with Radiofrequency Cautery

Mole Removal with Radiofrequency Cautery Dr. Amit Murkute

MBBS, DDVL, DNB Consultant Dermatologist, Cosmetologist and Hair Transplant Surgeon Founder of Elite Skin & Hair Clinic, Pune Introduction Moles, also known as nevi, are clusters of pigmented cells that can appear as small, dark spots on the skin. They are typically brown or black in colour, but can also be pink, red or skin-colored. Medically nevus is described as confined and persistent growth of skin or mucosa.1 Moles can be flat or raised; it can be smooth or rough in texture. Moles can vary in size, shape, colour and texture.2 Most moles are benign and do not cause any harm, but it is important to have any new or changing moles checked by a dermatologist to rule out any possible skin cancer.1 In some cases it has been observed that on histological study, it was diagnosed to be malignant at times, either melanomas or basal or squamous cell carcinomas was detected.1

The most common types of moles are: 2,3,4,5

• Congenital nevi: These moles are present at birth and can be large and irregular in shape. They have a higher risk of becoming cancerous, so it is important to have them checked by a dermatologist. • Acquired nevi: These moles develop later in life and are more common than congenital nevi. They are typically smaller and have a round or oval shape. They have a lower risk of becoming cancerous, but it is still important to have them checked by a dermatologist. • Dysplastic nevi: These moles are also known as atypical moles. They are usually larger than common moles and have irregular shapes and colours. They have a higher risk of becoming cancerous, so it is also important to have them checked by a dermatologist.

Figure 1: Classification of melanocytic nevi 30

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Mole Removal with Radiofrequency Cautery

The pathophysiology of skin moles involves the growth and accumulation of pigmented cells (melanocytes) in the skin. Melanocytes are cells that produce the pigment melanin, which gives colour to the skin, hair and eyes. Normally, melanocytes are distributed evenly throughout the top layer of the skin (epidermis). Due to mutations of these cells there is activation of a gene called BRAF (proto-oncogene) which causes the proliferation of cells hence forming moles.6 The exact cause of moles is not fully understood, but it is believed to be related to a combination of genetics and sun exposure. Genetic factors can influence the number, distribution and development of melanocytes in the skin.3 While environmental factors such as sun exposure can cause an overproduction of melanocytes or an accumulation of melanocytes in one area.4 In addition, UV radiation can cause an increase in the number of moles on the skin, it can cause existing moles to become darker and can damage the DNA of melanocytes, leading to mutations that can cause them to become cancerous.4

malignant and if it is malignant, what type of skin cancer it is.9

Diagnosis Nevi cells are mainly melanocytes on adaptive modification who have lost dendritic process. These cells have clusters of cells lying intradermally or dermally having junction nests arranged in various shapes like round, ovoid etc. Some clinical features observed are these melanocytic nevi or moles are confined to limited area, with some circular lesions with well defined border and hypertrichosis.2 Improper There are several risk factors that can increase a person's diagnosis are assumed to chances of developing skin moles. Some of the most common lead to poor prognosis of the risk factors include: diseases.4 • Genetics: A family history of moles or a genetic predisposition A history and physical to developing moles can increase a person's risk.3 examination is an important

• Sun exposure: People who have had a lot of sun exposure, step in the diagnosis of skin particularly during childhood and adolescence, have an increased moles. Healthcare provider will look for any new or changing risk of developing moles.3 moles on the skin, as well as • Fair skin: People with fair skin are more susceptible to any signs of abnormal growth developing moles than people with darker skin.7 or changes in colour, shape or • UV radiation: Exposure to UV radiation, whether from the sun size. They will also check for or tanning beds, can increase the risk of developing moles and any signs of bleeding, itching or pain. They will also examine the skin cancer.3 skin for any signs of other skin • Pregnancy: Hormonal changes that occur during pregnancy conditions, such as eczema or can cause moles to darken or change in appearance.8 psoriasis.9 Some types of moles have a higher risk of becoming cancerous. These moles, such as dysplastic nevi and congenital nevi have abnormal melanocytes, which can grow and divide uncontrollably, forming a malignant tumour.1,3 It's important to note that having one or more of these risk factors does not mean that a person will definitely develop skin moles because most moles are benign. However, it's important to be aware of these risk factors and to have any new or changing moles checked by a healthcare provider to rule out any possible skin cancer. The diagnosis of skin moles typically begins with a physical examination by a dermatologist or other qualified medical professional. During the examination, the dermatologist will look for any new or changing moles on the skin and will check for any signs of abnormal growth or changes in colour, shape or size.4, 9 If the dermatologist suspects that a mole may be cancerous or precancerous, they may recommend a biopsy. A biopsy is a procedure in which a small sample of tissue is taken from the mole and examined under a microscope by a pathologist. This allows the dermatologist to determine if the mole is benign or

During the history taking, the healthcare provider will ask about any new or changing moles on the skin, family history of moles and any past history of skin cancer. They may also ask about any recent sun exposure, any use of tanning beds and any medications or medical conditions.9 The provider will also use the ABCDE criteria to evaluate the moles:9 • Asymmetry: One half of the mole is different from the other half • Border: Irregular border, scalloped or poorly defined December 2023

Mole Removal with Radiofrequency Cautery

• Colour: Uneven colour, shades of tan, brown, black, white, red or blue • Diameter: Larger than a pencil eraser or 6mm • Evolving: Any changes in size, shape, colour or symptoms

skin-colored, commonly found in children and usually dome shaped. Reticular pattern seen with vertically arranged nests of epetheloid cells. Blue nevi, blue-gray nodule are observed with irregular borders. These usually consist of dermal divisions of melanocyte.3 Case Report A 34 years old male patient was presented to our dermatology department with a pigmented mole near his nose with some hair growth on it. There was no family history for such mole or any melanoma. On physical observation, a large solitary nodule near nose was noticed. Biopsy and on histological examination, no malignancy was found. Radiofrequency (RF) curettage technique was used to remove the mole.

Figure 2: Algorithm for determination of diagnosis and biopsy of pigmented lesions9 Before treatment The histopathological examination of the mole can help to determine the type of mole and the risk of malignancy, which is essential to make a proper diagnosis and treatment plan. A biopsy of a mole is taken, typically by cutting or shaving off a small piece of the mole and then it is examined under a microscope by a pathologist.4 In histopathology, moles are classified into different types, depending on their characteristics under the microscope.

Common acquired moles (nevi) appear as a collection of benign melanocytes in the epidermis and dermis. The melanocytes are arranged in a single or multiple nests and have a normal cytological appearance. Dysplastic nevi, also known as atypical moles, have abnormal melanocytes that are larger than normal, have irregular nuclei and are less organized. They also tend to extend deeper into the dermis and have increased number of mitotic figures, which After treatment are cells in the process of dividing. Congenital nevi, which are present at birth, tend to be larger in size and have more complex Figure 3: Mole removal with structures. They tend to have more atypical cells and have a RF cautery greater tendency to become malignant. Spitz nevi, pink to red or December 2023

Mole Removal with Radiofrequency Cautery

Treatment If the mole is malignant, the treatment will depend on the type of skin cancer and the stage of the cancer. It may involve surgical removal of the mole, radiation therapy or chemotherapy.1 There are various methods used like surgical excision, lasers, curettage, liquid nitrogen (cryotherapy) and sometimes no therapy (only observation).1 The most common methods for mole removal include: • Observation: For small, benign moles that are not causing any symptoms, the healthcare provider may recommend simply monitoring the mole for any changes over time.1 • Excision: This involves cutting out the mole with a scalpel and closing the wound with sutures. These are most commonly used as it removes more cells compared to other techniques and most commonly used in removal of congenital nevi.1 Some disadvantage like re-pigmentation and re-occurrence of nevi.1 a. Shave excision: This method involves shaving off the mole with a small blade.2 b. Round excision: Total removal of all nevi in all types of cases.2 c. Deep excision: Incomplete excision observed with few recurrence cases.2

Excision and shave excision are considered effective methods for removing moles. Excision is typically used for larger moles that are raised or have irregular borders, while shave excision is typically used for smaller, flat moles. Both methods involve cutting or shaving off the mole and are typically performed under local anesthesia.1 Cryotherapy and electrodessication and curettage (ED&C) are also reliable method for removing moles, but they may have a slightly higher risk of complications, such as infection or scarring.1 Laser surgery on the other hand may be more expensive and may require more than one treatment.2

Discussion • Cryotherapy: This method involves freezing the mole with Moles are pigmented or nonliquid nitrogen.1 Cosmetically it is found to have good outcome pigmented tumours containing but hypo pigmentation of the skin is major disadvantage.1 nevus cells. They may appeared to be papillomatous, • Laser surgery: This method involves using a laser to vaporize the mole.2 Various types of lasers like pigment-specific to ablative hair follicle containing, smooth, flat and lasers are used.2 They do not necessarily target melanin cells but pedunculated, 1 sometimes non-hair bearing cause thermal damage due epidermal area. In order to prevent damaging effect of heat the pulse time of laser must be under Nevi or mole are common benign neoplasm found and controlled limits.2 often wrongly diagnosed skin • Electrodessication and curettage (ED&C): This method condition.2,8 The incidence of involves using a small electric needle to burn off the mole and moles also varies by location then scraping it off with a curette.10 and culture, with higher incidence in people living Radiofrequency (RF) cautery is generally considered safe and in areas with intense sun effective for the removal of moles. The procedure is minimally exposure or high UV radiation.3 invasive and usually leaves a small scar that fades over time. The prevalence of moles varies Radiofrequency cautery is a medical procedure that uses highamong different populations, frequency electrical energy to remove tissue. The process the average adult has between involves numbing the area around the mole with local anaesthesia 10 and 40 moles on their body. and then using a handheld device that emits a high-frequency The number of moles a person electrical current to burn and remove the mole by smooth strokes has can also increase with with the head pointing at an acute angle to skin. RF cautery can age.1 Individuals with fair skin, be used for removing moles that are benign or non-cancerous. red or blond hair, blue or green The device cauterizes the area around the mole as it removes it, eyes are more likely to develop which helps to minimize bleeding.10 moles than those with darker After the procedure, the area may be covered with a bandage and skin.7 the patient is advised to keep the area clean and dry. Over time, Mole removal can be done for the skin in the treated area will heal and any scarring will typically cosmetic or medical reasons. fade with time. Additionally, the suitability of this procedure can Several mole removal methods depend on the size, location and type of mole being removed, as are available including cutting, well as other individual factors.10 burning, freezing and laser December 2023

Mole Removal with Radiofrequency Cautery

surgery. There are many treatment options available by which they can be removed or treated like surgery, laser, radiofrequency (RF) and in few cases only observation. Excision and shave excision are considered safe methods for removing moles and they have a high success rate. Both methods involve cutting or shaving off the mole and they are typically performed under local anesthesia.1 Curettage is similar to electro-surgery. This technique is mostly used in removal of benign melanocytic nevi. The process of mole removal with RF cautery is relatively quick and minimally invasive. The site is prepared by applying some local anaesthetics like 1% lidocaine along with epinephrine and then clear out the moles with the help of curette and then apply cautery to avoid bleeding and charring of the skin While radiofrequency removal of moles is generally considered safe and effective, there are some risks associated with the procedure, such as infection, scarring and changes in skin pigmentation. This technique overcomes necrosis which is caused due to cryotherapy.10 It is thought to have similar efficacy and cure rates as compared to other methods stated above with comparatively lesser side effects and minimal equipment requirement. Also cost effective and not much after care requirement.10 Even though, if any treatment is considered to be effective, it carries a risk of scarring and infection, hence one must follow the instructions after the mole removal treatment, to ensure the best healing and minimize the risk of scarring or complications. Conclusion 34

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In the conclusion, the pressure for good appealing look has reached heights in recent times. External beauty plays an important role to play in one’s life to boost its self esteem. Moles are aesthetically unappealing causing individual to feel depressed. Various innovation and research in the cosmetic industry has empowered humans to look smarter and attractive by using various modifying or removal techniques available in the market. Hence mole removal techniques have gained a lot of demand in recent years for good aesthetic appearance of skin. Skin mole removal is a common procedure that can be performed for cosmetic or medical reasons. The treatment method will depend on the size, location and type of mole. Before performing any procedure, one must be aware about the potential risks and benefits of each treatment and what to expect during and after the procedure. This will help ensure that the patient makes an informed decision and that the procedure is performed safely and effectively. References 1. Reddy Bandral M, Gir PJ, Japatti SR, Bhatsange AG, Siddegowda CY, Hammannavar R. A Comparative Evaluation of Surgical, Electrosurgery and Diode Laser in the Management of Maxillofacial Nevus. J Maxillofac Oral Surg. 2018 Dec;17(4):547-556. doi: 10.1007/s12663-018-1081-8. Epub 2018 Feb 6. PMID: 30344399; PMCID: PMC6181846. 2. Sardana K, Chakravarty P, Goel K. Optimal management of common acquired melanocytic nevi (moles): current perspectives. Clin Cosmet Investig Dermatol. 2014 Mar 19;7:89103. doi: 10.2147/CCID.S57782. PMID: 24672253; PMCID: PMC3965271.

3. Rogers T, Marino ML, Raciti P, Jain M, Busam KJ, Marchetti MA, Marghoob AA. Biologically distinct subsets of nevi. G Ital Dermatol Venereol. 2016 Aug;151(4):365-84. Epub 2016 Apr 27. PMID: 27119653; PMCID: PMC5445663. 4. Navarro-Fernandez IN, Mahabal GD. Congenital Nevus. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi. nlm.nih.gov/books/NBK559270/ 5. Baigrie D, Tanner LS. Dysplastic Nevi. 2022 Oct 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 29489189. 6. Ruiz-Vega R, Chen CF, Razzak E, Vasudeva P, Krasieva TB, Shiu J, Caldwell MG, Yan H, Lowengrub J, Ganesan AK, Lander AD. Dynamics of nevus development implicate cell cooperation in the growth arrest of transformed melanocytes. Elife. 2020 Oct 13;9:e61026. doi: 10.7554/ eLife.61026. PMID: 33047672; PMCID: PMC7553774. 7. Aalborg J, Morelli JG, Mokrohisky ST, Asdigian NL, Byers TE, Dellavalle RP, Box NF, Crane LA. Tanning and increased nevus development in very-light-skinned children without red hair. Arch Dermatol. 2009 Sep;145(9):989-96. doi: 10.1001/ archdermatol.2009.193. PMID: 19770437; PMCID: PMC2924169. 9. Tran, K. T., Wright, N. A., & Cockerell, C. J. (2008). Biopsy of the pigmented lesion—When and how. Tran, K. T., Wright, N. A., & Cockerell, C. J. (2008). Biopsy of the pigmented lesion—When and how. Journal of the American Academy of Dermatology, 59(5), 852–871. doi:10.1016/j. jaad.2008.05.027 10. Goldman G. The current status of curettage and electrodesiccation. Dermatol Clin. 2002 Jul;20(3):569-78, ix. doi: 10.1016/s0733-8635(02)000220. PMID: 12170889.

RNI No. MAHENG/2010/44622