Total Pages : 36 June 2022 Vol 15* Issue-4 100
Lactosporin – A Postbiotic Revolution in Acne Management Management of Acne Scars: Microneedling versus Microneedling with Platelet Rich Plasma. Does It Make A Difference?
Clinically Modified Tinea: A Menace for Dermatologists Chronic Urticaria Responded to Anti Tuberculosis Treatment : A Case Report
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Fungal Infection: A Biggest Challenge to Treat 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. Views expressed in this Journal are those of the contributors and not of the publisher. Reproduction in whole or in parts of texts or photography is prohibited. Manuscripts, Photographs and art are selected at the discretion of the publisher free of charge (advertising excluded). Whether published or not, no material will be returned and remains the property of the publishing house, which may make use of it as seen fit. This may include the withdrawal of publication rights to other publishing houses.
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Published for the period of June-2022
Fungal infections of the orbit can lead to grave complications. Due to tropical climate, Asia has a high incidence of fungal infections. The data on the burden of opportunistic mycoses in India is not clear though the climate in this country is well suited for a wide variety of fungal infections. Fungal infections are more prevalent than previously appreciated, partly because of missed diagnosis, new risk factors and the emergence of new and mutidrug resistant pathogens. Fungi causing skin and subcutaneous diseases, endemic fungal infections, fungal rhinosinusitis and fungal keratitis mostly affect people without any preexisting conditions, living and working closely in certain environmental niches. Due to its varied and nonspecific clinical features, especially in the early stages, patients are frequently misdiagnosed and even treated with steroids which worsen the situation leading to dire consequences. In recent years fungi have been flourishing in immunocompromised patients. Antifungal resistant and recalcitrant dermatophyte infection is nowadays considered as one of the most difficult to treat conditions in dermatology clinical practice. Cases are complicated with the widespread use of topical corticosteroids in combination with antifungal agents. The steroid combinations cost much lesser than pure potent antifungal creams, which make these popular. These are used often only for symptom control without any instructions or supervision and patients often stop using them when the itching and redness are mitigated and reapply when the symptoms reappear. Thus there is need of good diagnostic mycology laboratories, rapid diagnosis, and refinement of antifungal strategies in India. This issue has articles on Clinically Modified Tinea, Lactosporin – A Postbiotic Revolution in Acne Management, Chronic Urticaria, Management of Acne Scars with Microneedling and PRP. . - Dom Daniel Executive Editor & Publisher
June 2022
3
07 Lactosporin – A Postbiotic Revolution in Acne Management Dr. Abir Saraswat, MBBS, MD
07
Chronic
Urticaria
Respond
Chroni c Anti Tu Urticaria Resp berculos onded to A Case is Treatment : Report ed to Anti
Tubercu
losis Treatme
nt : A Case
16
Chronic Urticaria Responded to Anti Tuberculosis Treatment : A Case Report
Report
Dr. Digamb
ar R.
MD (Derm Dashatwar atology) Consultan t Dermatolo Chandrapu gist, r, Maha rashtra, India
Dr. Digambar R. Dashatwar, MD (Dermatology) 16
16 June 2022
Case Repor t A 6 year old boy has been from almost sufferin g He genera reddish, lized has no swollen stigmata hives daily itchy, afebrile about 4 years. , his parana of atopy. He is The timing since non frequency sal sinuse tender. of appea and s are Eyes, nose, do not teeth, rance follow any oral cavity, gums, of oropha set pattern rash lips rynx, tongue are norma He had . l. Scalp, an , normal. hair, ears anal region episode of swellin Axillae, are palms, g of nails are soles and after which (Angioedema normal. ) he started in 2018, itchy rash getting He has asymp almost The appea on a daily tomatic, basis. enlarged, non multiple corresponde rance of itchy lymph nodes tender non d rash matted to cool the day in neck on both hours i.e at of evenin sides. This has been bother g and night. Systemic patient examination some and parent to the CVS, RS : s as well. are within His normal Abdom parents limits. en Inspec consulted doctor tion : no no tender after anothe distension, one ness, pathies r of no hepato : allopat different megaly. spleno hy, homeo allergologist pathy, and sustain ed benefi so on with no Investigatio ts. n: CBC : His WNL, allergen Thyroid reactivity tests Functi showed to : mango Chest radiog on test : WNL, produc , ginger ts, sour raphy : , milk ESR foods. WNL , Ig E Levels : 25 mm His serum at end were raised double of first hour. to almost of high normal was 25 Manto values, mm at ux ESR the end induration test : 21 of first In the mm firm hour. with erythe physical positive. ma : Strong examin in 2021 ation done ly it was observ young The clinica ed that boy l the itchy rash had reddish, suggested and laboratory swollen, findings over trunk clinical diagno and limbs. lymphadenit sis of is in neck. TB
Clinicall
y Modified
Tinea:
A Menace
for Dermato
Clinica A Menac lly Modified Tine e for De rmatol a: ogists logists
18 Clinically Modified Tinea: A Menace for Dermatologists
Dr. Swa
ti Garg
MD (DVL ) Departmen t of Derm Smart Skin atology, Solutions, Panchkula , Haryana Abstra
ct
Dr. Swati Garg, MD (DVL) 18 18 June 2022
Backg round: with whole infectio Dermatophyt ns have body ic presen never critical were tations. been such arena for The majorit unusual a patients derma last few y of these had years when tologists until preparations used over the atypica the myriad l presen counte containing r of of topica tations rise. Unsup combination are on l ervised the or antiba steroids, antifun use of and irration gal and/ cterial topical agents al default cortico further . Relaps ers and steroid complicated s steroid e, to occurr the situatio has appeared to be more modified tinea ence of n due treatm relapsing modifie common ent- naïve d tinea steroid than cases. to almost propor tions. Conclusion: epidem ic Inappropriate of topica Aims: l cortico To use steroid to modify and clinica study epidem s appea clinical iological l rs making course dermatophyt profile of patien it more of tinea ts with and treatment on cortico osis with an relapsing recalcitrant empha steroid sis presen with misuse polymorphic tations . Metho and therap posing a great ds: We studied clinical eutic challen and 205 500 (295 practic females) ge for ing derma consecutive males with derma the tologists. patients Index tophytosis centre, in this terms: crossis single section tinea; Clinically-mod study. al, observ cortico The ified steroid clinico-demo ational dermatophyt profile of patien misuse osis; graphic tinea ; ts, nature tinea medications cruris corpor of topica and effect is, l clinical thereof presen on the Introduction tations and analyz were record ed statisti ed Superf cally. icial fungal Results: never infectio The major been ns have was tinea such a clinical cruris critical type for dermatologis et corpor (53.6% arena ts years ) patien until last when ts. Uncom is in 266 pattern the myriad few mon clinica s resem presen tations of atypica bling subac l erythematos l ute lupus Unsupervised are on us, the rise. atopic nummular and irration eczema, of over eczema, al use the counte dermatitis, seborrheic topical r availab depigm cortico majocchi entatio steroid le n, and complicated s has granuloma. further of scrotu the situatio Involve m, penis, ment occurrence n due of relapsi and face to ng steroid along modified tinea to almost -
Manage
ment of
28
Acne Scars:
Microne
Man Micron agement of Ac eedlin ne Sc with Pl g versus Micr ars: at on Does It elet Rich Plas eedling Make A m Differe a. nce? Dr.
Management of Acne Scars: Microneedling versus Microneedling with Platelet Rich Plasma. Does It Make A Difference?
edling
versus
Microne
edling
Kindy D.
with Platelet
Rich Plasma.
Does It
Make A
Differen
A. S. New
MD (Derm mai atology) Consultan t, Olive Christian Dimapur, Hospital Nagaland and Rese
arch Centr
Dr. Raghun
atha Red MD (Derm dy atology), Roots Instit DNB, FRG UHS Bangalore ute of Dermatolo gical Scien
ces,
Dr. Aneesh
Dr. Kindy D. A. S. Newmai, MD (Dermatology)
Samaya
MD (Derm atology) Professor
m
Departmen t of Derm East Point atology Medical College, Bangalore INTRO
DUCTION
Dr. Raghunatha Reddy, MD (Dermatology), DNB, FRGUHS
28 28
Dr. Aneesh Samayam, MD (Dermatology)
4
June 2022
ce?
June 2022
Acne can of the be define skin by self-lim rolling iting, inflam d as a chroni with c, fine needle of pilose matory s.Micropunc miniature baceous disease create d using tures genera unit, manife are lly micron sting produce in with a contro eedles which adolescence withou pleomorphic lled skin t actual comed injury lesions ones, ly damag like epidermis. cysts. Extens papules, nodule ing These microinjuries the s, and to minim as a sequa ive scarring lead can occur set up al superficial lae. bleeding a wound and healing release Micron cascade eedling of with invasive such as various growth is a minim factors platelet ally factor superficial procedure derived (PGF), involvi and contro growth lled punctu ng factor alpha transforming growth ring TGF-ß and beta (TGF), conne and ctive tissue activating
e,
Editorial Board Dr. Abir Saraswat
Dr. Kindy D. A. S. Newmai
Dr. Swati Garg
Dr. Raghunatha Reddy
Dr. Digambar R. Dashatwar
Dr. Aneesh Samayam
MBBS, MD Dermatologist and Cosmetologist Indushree Skin Clinic, Lucknow, India
MD (DVL) Department of Dermatology, Smart Skin Solutions, Panchkula, Haryana
MD (Dermatology) Consultant Dermatologist, Chandrapur, Maharashtra, India
6
June 2022
MD (Dermatology) Consultant, Olive Christian Hospital and Research Centre, Dimapur Nagaland
MD (Dermatology), DNB, FRGUHS Roots Institute of Dermatological Sciences, Bangalore
MD (Dermatology) Professor Department of Dermatology East Point Medical College, Bangalore
Lactosporin – A Postbiotic Revolution in Acne Management
Lactosporin – A Postbiotic Revolution in Acne Management Dr. Abir Saraswat
MBBS, MD Dermatologist and Cosmetologist Indushree Skin Clinic, Lucknow, India
Abstract Postbiotics are the by-products of probiotic bacteria which are a great source of antioxidants, which protect the skin and act as humectants keeping skin moisturized. Recent evidence suggests that inflammation may be the first step in acne development, leading to the initial clogged pore. Due to colonization of bacteria, existing inflammation gets worsened. Using antibiotics alone to kill bacteria is not as beneficial in acne treatment as controlling inflammation and restoring skin balance. Postbiotics have certain advantages over antibiotics and antimicrobial in general: they reduce sebum production, control inflammation and restore skin microbiome by allowing friendly bacteria to grow. LactoSporin is an extracellular metabolite produced by B. coagulans MTCC 5856. LactoSporin is stable at an acidic pH and at temperatures up to 70 to 90°C. It demonstrates antimicrobial activity against various pathogenic bacteria, including Cutibacterium acnes and is a potent inhibitor of 5-alpha reductase enzyme.
Introduction Acne is a chronic skin condition that occurs primarily at puberty with a prevalence of almost 95%.1 The majority of people are affected by acne between the onset of puberty and 30 years of age.2 Reasons which could give rise to, or aggravate acne could be hyperkeratinization of sebaceous follicles, androgen-induced excessive sebum production, inflammation and bacterial colonization of hair follicles by Cutibacterium acnes.3,4 Skin microbiome and host immunity play important roles in acne with perturbed microbial composition and activity found in acne patients.5,6 The microbiome is emerging as a major contributor to protect the skin from inflammatory conditions. A microbial imbalance or ‘dysbiosis’, compared with the normal distribution in healthy tissues, has been suggested to be involved in the pathophysiology of inflammatory acne.7 This perturbation of the skin microbiome can cause skin diseases such as acne, eczemas, allergies, autoimmune diseases, and aging.8 Various treatment strategies are becoming popular to preserve the skin microbiota. June 2022
7
Lactosporin – A Postbiotic Revolution in Acne Management
Topical and systemic drugs like retinoids and antibacterials are commonly used, but have certain adverse events such as peeling of skin, redness, irritation and dryness or flaking of the skin. Apart from probiotics and prebiotics which are used in acne treatment for its rejuvenation and improving skin immunity9, recently the chemical byproducts of bacterial fermentation such as antimicrobial peptides and fragments of dead bacterial cells, termed “Postbiotics,” have attracted attention for their beneficial physiological effects. Postbiotics in Acne: Postbiotics, also known as microbial metabolites are known for their anti-inflammatory, immunomodulatory, antiobesogenic, antihypertensive, hypo-cholesterolemic, antiproliferative and antioxidant benefits.10 Constituents of postbiotics include short-chain fatty acids, extracellular metabolites, functional proteins, cell lysates and other products derived from a probiotic that can influence the microbiome composition.8 Antimicrobial proteins produced from useful bacteria are one of the expanding fields of research due to conventional antibiotic resistance and are reported to be less toxic than other chemical antimicrobial agents. Benefits and advantages of Postbiotics Postbiotics are reported to provide health benefits similar to that of probiotics, although they do not contain live organisms.11 They possess several practical advantages over probiotics and prebiotics: • Biological activity in non-viable state • Lower 8
chance
for
June 2022
microbial
translocation • Lower chance infection
for
microbial
• Improved inflammatory defence • Favourable physiochemical properties (solubility) • Favourable pharmacokinetic properties (absorption, distribution, metabolism, and excretion) Important advantage over the antibiotics and chemicals Reduce sebum and inflammation Restore skin microbiome by allowing friendly bacteria to grow.12 LactoSporin – Postbiotic for Skin care Bacillus coagulans MTCC 5856 (LactoSpore) is a non-pathogenic Gram-positive, endospore forming patented probiotic strain. It is a facultative anaerobe, grows optimally at a slightly acidic pH range of 5.5 to 6.2 and a temperature of 37°C. The strain produces L (+) lactic acid as a primary product after germination and prevents the growth of pathogenic microbes in the GI tract and has received the Generally Regarded as Safe (GRAS) status from USFDA.13,14 LactoSporin is an extracellular metabolite produced by B. coagulans MTCC 5856 under specific growth conditions.15 LactoSporin is reported to have anti-microbial activity and has been evaluated in a clinical study for efficacy against acne.17 LactoSporin is found to be safe as a cosmetic ingredient and has been successfully registered as per the Cosmetics Regulation (Regulation (EC) No 1223/2009). Benefits of LactoSporin on skin microbiome16,17 LactoSporin is a promising
ingredient in maintaining the healthy skin by balancing the skin microbiome. LactoSporin is a postbiotic that is thermostable and stable at an acidic pH. It can maintain the skin microbiome balance by acting as an antimicrobial agent – by inhibiting C. acnes proliferation, reducing noninflammatory lesions, improving the signs of inflammation, reducing sebum secretion (inhibiting 5-alpha reductase enzyme) thereby helping in preserving skin structure. LactoSporin is highly suitable for mild-to-moderate acne vulgaris treatment. Studies have shown the efficacy of bacteriocin (antimicrobial proteins) in inhibiting the inflammatory skin bacteria, such as S. epidermidis, S. aureus, S. pyogenes and C. acnes. Bacteriocin activity depends upon its amphiphilic nature, selectivity, and ability to disrupt the bacterial cytoplasmic membrane while preserving the natural skin homeostasis by altering the skin microflora, skin lipids and immune system, leading to a significant reduction in inflammatory lesions and pustules. LactoSporin showed antimicrobial activity against various skin pathogens like P. aeruginosa, an opportunistic pathogen, and S. aureus and S epidermidis, the two most important skin pathogens. Most importantly, it is found to be effective against C. acnes, the acne-causing bacteria, showing a minimum inhibitory concentration of 4%. Clinical evidence 116 A randomized, open-label, comparative
clinical
trial
was
performed to treat acne in 68 subjects with LactoSporin 2% for 21 days. It was compared to benzoyl peroxide 2.5 %. The antimicrobial
Lactosporin – A Postbiotic Revolution in Acne Management
activity, thermostability, pH stability and the 5-alpha reductase inhibitory activity were evaluated in vitro to
understand
the
mechanism
of action of LactoSporin. The dermatological safety evaluation of LactoSporin cream was performed on healthy volunteers by a 24 h primary skin irritation patch test before the efficacy trial.
Results In-Vitro Antimicrobial, pH Stability, Thermostability and 5-Alpha Reductase Inhibition Studies: The MIC50 ranged from 0.5% to 4% for the pathogens tested. LactoSporin was active against p. aeruginosa, S. aureus, S. epidermis and C. acnes. LactoSporin is stable and active in highly acidic pH. LactoSporin was found to be temperature-stable up to 90°C for 30 min. LactoSporin at various concentrations inhibited the 5-alpha reductase enzyme. The percentage inhibition was highest (17.17) at 0.5% v/v of LactoSporin (Figure 1).
Healthy male and female subjects of 18–65 years having Fitzpatrick skin type III to V and willing to maintain the patch for 24 h and who did not participate in a similar investigation in the past two weeks were enrolled in the study. Study outcome assessments The study’s primary outcome measures were the mean reduction in acne lesions as observed by the reduction in elevation and redness by Antera measurement, the mean reduction of sebum secretion through Sebumeter measurement and the mean reduction in noninflammatory and inflammatory lesions by dermatologists’ image assessments using VISIA image. The dermatological assessment was performed by counting both the inflammatory and noninflammatory lesions recorded using the assessment form on the baseline (day 0) and days 3, 7, 14 and 21.
Figure 1. In-vitro studies of LactoSporin. (a) Minimum inhibitory concentration (MIC50) of LactoSporin to inhibit the bacterial species, i.e., Pseudomonas aeruginosa, Escherichia coli, Salmonella abony, Streptococcus mutans, Cutibacterium acnes, Staphylococcus aureus, Staphylococcus epidermidis and Bacillus cereus. (b) Table showing the effects of pH on the antibacterial activity of LactoSporin. (c) Table showing the effects of temperature on the antibacterial activity of LactoSporin. (d) 5-alpha reductase inhibitory activity of LactoSporin. Values are expressed as mean ± SD.
Primary Skin Irritation Patch Test LactoSporin 2 % cream was deemed a non-irritant and dermatologically safe for the study population compared to the positive control (Table 1).
Localized skin irritation was recorded by dermatological evaluation based on the parameters such as erythema, dryness, edema, urticaria, allergic reactions, etc. For the patch test of LactoSporin, test sites were assessed for erythema, dryness, wrinkles and oedema, as per the Draize scale for scoring. June 2022
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Lactosporin – A Postbiotic Revolution in Acne Management
Assessment Based on the Instrumental Counting of Acne Lesions Antera 3D Assessment It is the measure of inflammation and was performed on inflamed acne by dermatologists. Both LactoSporin and benzoyl peroxide showed a reduction in inflammation as early as three days after application. At the beginning of the study, the mean redness in the LactoSporin and benzoyl peroxide groups was 43.89 ± 3.76 and 44.08 ± 2.87, which was subsequently reduced to 39.54 ± 4.55 and 39.18 ± 2.97, respectively. (Figure 2)
Figure 2. Antera analysis was conducted at day 0, day 3, day 7, day 14 and day 21. (a): Redness (Hb-index—% hemoglobin hyper-concentration) in the inflammatory response. (b) Elevation (small) in the inflammatory response. (c) Elevation (medium) in the inflammatory response. Values are expressed as mean _ SE. (d) Antera Images Subject No. 21—benzoyl peroxide: (i) redness, (ii) small elevation and (iii) medium elevation. (e) Antera Images Subject No.47—LactoSporin: (i) redness, (ii) small elevation and (iii) medium elevation.
Sebumeter MPA 580 Assessment—Sebum Secretion The assessment on the sebum secretion measured via Sebumeter showed a mean value of 106.74 ± 9.78 μg/cm2 and 108.13 ± 9.32 μg/cm2 in the LactoSporin and benzoyl peroxide groups, respectively, at the beginning of the study. The same was significantly reduced at the end of the study period (61.41 ± 7.91 μg/cm2 and 61.11 ± 7.16 μg/cm2, p < 0.001 for both groups) (Figure 3). A significant reduction in sebum secretion was observed at all time points after product application in both the LactoSporin and benzoyl peroxide groups. The percentage of reduction was 42.4% and 43.4% in the LactoSporin and benzoyl peroxide groups, respectively, on day 21 compared to the baseline.
10
June 2022
Lactosporin – A Postbiotic Revolution in Acne Management
Figure
4.
Dermatological
Assessment:
total number of open comedones, closed comedones, papules and pustules were counted by a dermatologist at day 0, day 3, day 7, day 14 and day 21. (a) Count of open comedones. (b) Count of closed comedones. (c) Count of papules. (d) Count of pustules. Values are expressed as mean ± SE.
Figure 3. Analysis of sebum secretion (µg /cm2) by Sebumeter was done at day 0, day 3, day 7, day 14 and day 21. Values are expressed as mean ± SE, * p < 0.05 in comparison to benzoyl peroxide
Dermatological Assessment The dermatological assessment was performed by counting the inflammatory (papules and pustules) and noninflammatory (open and closed comedones) lesions. The mean number of open comedones reduced from 1.03 ± 1.82 to 0.38 ± 0.75 with a 63.11% reduction for LactoSporin and 1.00 ± 1.74 to 0.50 ± 1.16 with a 50.0% reduction for the benzoyl peroxide group (Figure 4a). Similarly, closed comedones reduced by 50.02% for LactoSporin and 49.50% for the benzoyl peroxide group (Figure 4b). The significant reduction in open comedones was observed as early as day 7 in the LactoSporin group, while in the benzoyl peroxide group it was on day 14. The count of papules reduced following application of LactoSporin (69%, p<0.001) and benzoyl peroxide (73.86%, p <0.001) for three weeks at all the time points (Figure 4c). The count of pustules reduced from 0.53 ± 1.41 (baseline) to 0.09 ± 0.39 in LactoSporin and from 0.06 ± 0.25 (baseline) to 0.03 ± 0.18 in the benzoyl peroxide group. The resulting percentage reduction was 83.02% in the LactoSporin and 50% in the benzoyl peroxide groups, respectively (Figure 4d).
Safety Outcomes There was no serious adverse event (SAE) or local intolerance with the test products, and both test products were deemed overall safe. None of the subjects reported skin irritations, as assessed by the subject self-assessment questionnaire. Conclusion Postbiotic is a relatively new term used to describe the metabolites and cell components derived from a probiotic that can influence the microbiome composition. They are bioactive, soluble, non-living microbial cell products that possess several practical advantages over the probiotic itself, as they show biological activity in the nonviable state and are easier to formulate with favourable physicochemical properties. LactoSporin shows antimicrobial activity at acidic pH conditions. Skin pH ranges from 4 to 6 (acidic), which suggests that LactoSporin could be highly effective as a topical formulation. Further, it is thermostable and is water-soluble and can be adapted for different formulations with ease. Study results suggest that LactoSporin, the postbiotic from B. coagulans MTCC 5856, shows a significant efficacy against pimples, acne spots and erythema by its antimicrobial activity, as well as by reducing sebum secretion, with a potential role in controlling seborrheic conditions like acne vulgaris.
Figure 4 June 2022
11
Lactosporin – A Postbiotic Revolution in Acne Management
Clinical evidence 217 Skin protective activities of the extracellular metabolite (LactoSporin) of a spore-forming probiotic Bacillus coagulans MTCC 5856 in vitro was studied and reported. Methods LactoSporin was evaluated for antioxidant activity by free radical scavenging activity and reactive oxygen quenching activity in human dermal fibroblast cells. Protection of fibroblasts from UVinduced apoptosis and cell death was studied by flow cytometry and neutral red uptake assays. Enzyme inhibition assays were carried out for collagenase, Elastase, and Hyaluronidase. Gene expression studies were carried out using polymerase chain reaction. Results 1. Antioxidant activity: Antioxidant activity of the extracellular metabolite LactoSporin was evaluated by DPPH free radical scavenging assay and inhibition of intracellular reactive oxygen species. DPPH, a water-soluble free radical, reacts with antioxidants to dissipate the color in the reaction mixture. It measures the capacity of the extract to scavenge free radicals in the solution. A dose-dependent reduction in the free radical activity was observed with 50% inhibition (IC50) at 0.43% v/v. 2. UV Protection effect: Treatment with LactoSporin at varying concentrations before UV exposure resulted in 48.6–54.9% protection from UV-A radiation and 18.7–32.46% against UV-B exposure, respectively. 3. Anti-collagenase activity: Aging is associated with an increased collagenase activity, resulting in the depletion of 12
June 2022
collagen in the skin. The anticollagenase activity of LactoSporin was assessed by the percentage inhibition of collagenase activity at different concentrations (0.5–2% v/v). LactoSporin showed a dosedependent inhibition of collagenase activity in vitro with a 56.61% reduction in activity at 2% v/v. The IC50 of LactoSporin was calculated to be 1.8% v/v. 4. Anti-elastase activity: Skin fibroblast elastase plays a crucial role in wrinkle formation through the degeneration of elastic fiber. LactoSporin shows moderate activity in inhibiting the activity of elastase with 32.55 inhibition at 2% v/v. 5. Anti-hyaluronidase activity: Hyaluronidase is the proteolytic enzyme in the dermis responsible for hyaluronan/ Hyaluronic acid (HA) degradation on the extracellular matrix. HA is responsible for skin moisture retention. Dose-dependent reduction in hyaluronidase activity was observed with an IC50 value of 2.95% v/v.
the activity of collagenase and suppress glycation while increasing EGF expression, suggesting its potential to prevent premature aging by multiple mechanisms. LactoSporin inhibited collagenase, elastase, and hyaluronidase activity and upregulated the expression of hyaluronan synthase, transforming growth factor and epidermal growth factor, which are associated with extracellular matrix integrity. These findings suggest that LactoSporin may reduce the appearance of wrinkles and sagging of skin. Overview: LactoSporin in acne management LactoSporinis a very useful and safe mode of acne management because of the following 16,17 benefits: • Reduces the sebaceous secretion by its 5-alpha reductase inhibitory & antimicrobial properties • Provide protection against photo-toxicity that is induced by UV-A and UV-B radiation, and reduces inflammation • Safe without any irritancy
6. Anti-Glycation effect: Glycation, the process of undesired cross-linking of collagen proteins with sugar molecules, impairs the collagen fibers function by making the skin hard and aged. The antiglycation effect of LactoSporin was studied by using ribose sugar and bovine serum albumin. Treatment with LactoSporin at 0.5%, 1%, and 2% v/v concentration showed a dose-dependent inhibition of Advanced Glycation End Products (AGEs) by 24.95%, 54.55%, and 93.06%, respectively. Conclusion Skin aging is characterized by the loss of elastin and collagen fiber network, leading to wrinkling. LactoSporin was able to inhibit
• A potent antioxidant and shows activity in reducing both free radical generation and oxidative stress • Inhibits glycation and collagenase activity, so helps maintain youthful skin • Beneficial on conditions characterized by seborrhea • Offers clinical efficacy, patient satisfaction
and
•
Suitable for mild-to-moderate acne vulgaris treatment
•
Reduces oiliness greasiness from the face
•
Efficacious in reducing acne, acne spots, and redness
and
Lactosporin – A Postbiotic Revolution in Acne Management
•
•
Reduce non-inflammatory lesions viz. both open and closed comedones and improves the signs of inflammation, viz. redness and skin elevation Controls closed comedones because of its Anti-DHT activity by inhibiting the 5-alpha reductase enzyme, thus reducing the secretion of sebum
Pre- and Probiotics. Nutrients 2020, 12, 2189 12. Jeremy AH et al. Inflammatory events are involved in acne lesion initiation. J. Invest. Dermatol.121, 20-27 (2003) 13.
1. Indian J Dermatol. 2018 Jul-Aug; 63(4): 328–331
M.;
Nagabhushanam,
K.;
Natarajan, S.; Arumugam, S.; Pande, A.; Majeed, S.; Ali, F. A Double-Blind, PlaceboControlled, Parallel Study Evaluating the Safety of Bacillus coagulans MTCC 5856 in Healthy Individuals. J. Clin. Toxicol. 2016, 6, 283 14.
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2019;181(4):691–9
Acne: A Randomized, Comparative Clinical Study to Evaluate its Efficacy, Tolerability and Safety. Cosmetics 2020, 7, 70 17. Majeed M, Majeed S, Nagabhushanam
8. Majeed et al. Novel topical application of postbioitic, Lactosporin. Cosmetics 2020, 7(3), 70
K, Lawrence L, Arumugam S, Mundkur L. Skin Protective Activity of LactoSporin® the Extracellular Metabolite from Bacillus Coagulans MTCC 5856. Cosmetics. 2020;
9. Majeed et al. Skin protective activity of
7(4):76
lactosporin. Cosmetics 2020, 7, 76 10. Aguilar-Toalá, J.; Garcia-Varela, R.; Garcia, Córdova,
H.;
Mata-Haro, A.;
V.;
González-
Vallejo-Cordoba,
B.;
Hernández-Mendoza, A. Postbiotics: An evolving term within the functional foods field. Trends Food Sci. Technol. 2018, 75, 105–114 11. Zolkiewicz, J.; Marzec, A.; Ruszczynski, M.; Feleszko, W. Postbiotics-A Step Beyond June 2022
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News
FDA warns companies selling OTC skin lighteners The Food and Drug Administration ( FDA) issued warning letters to 12 companies selling over-thecounter (OTC) skin lightening products. All the products contain hydroquinone as the active ingredient which does not meet the requirements to be sold legally over the counter. The 12 products with hydroquinone are unapproved drugs and are not generally recognized as safe and effective, the FDA said. Among the side effects associated with hydroquinone products reported to the FDA are skin rashes, facial swelling, and skin discoloration or ochronosis. The discoloration can be permanent, the FDA said. The lighteners are marketed for use on age or dark spots on the skin associated with melasma. Hydroquinone is a very effective medication, and that’s exactly what it is, a medication,” said dermatologist, who supports the FDA action. It’s very effective and very safe to use in the right hands, but when it is overused or used in the wrong situation, it can cause problems. Those problems often occur, when there is no health care professional overseeing the use of the OTC products, and when people use them over the long term. The FDA action to ban the OTC products is “very appropriate,” said dermatologist. “We know patients pick this up [an OTC product] and use it without physician oversight.” When patients use the products longer than is appropriate, which is also common, it can worsen the initial skin issue. The action follows reforms finalized under the CARES Act (Coronavirus Aid, Relief and Economic Security Act), which included not only COVID-19 response efforts but also updated the method in which certain OTC drugs are regulated. Manufacturers of the skin lightening products that don’t have FDA approval had been told to remove the products from the market by September 2020. The recent letters were sent to a dozen companies still marketing their products without an FDA new drug approval. The agency asked the companies to take prompt action and respond with 15 days, stating what they have done to correct the violations.
Sunscreen doesn’t protect as well as it should: Here is what is missing Sunscreen, also known as sunblock, sun cream or suntan lotion, is a photoprotective topical product for the skin that absorbs or reflects some of the sun's ultraviolet (UV) radiation and thus helps protect against sunburn and most importantly prevent skin cancer. A new study finds a strong link between the actions of free radicals and free iron in the skin -- a link that causes skin to age prematurely after exposure to the sun. The researchers have also identified antioxidants that can be added to skin products to mop-up the harmful iron, thereby minimizing sun damage. A key ingredient is missing from all sunscreens and anti-aging creams, and our skin will be far better protected from the damaging effects of the sun once this rich source of natural photoprotection has been added. The missing ingredient is a class of antioxidant (a type of stable molecule) commonly found in nature. Experiments have shown that these antioxidant molecules eliminate excess iron in cells, thereby helping cells maintain a healthy level of free radicals (a type of unstable molecule). Free radicals and free iron are strongly linked to skin damage. By including these potent antioxidants in skin-care products and sunscreen formulations, and therefore trapping free iron, we can expect to get an unprecedented level of protection from the sun. Scientists have known for some time that iron deposits promote the appearance of aging, but the latest study highlights the interplay between free iron and free radicals in the skin. As a result of their findings, skin-care manufacturers look more closely at opportunities to include iron-trapping extracts in their products. Though the antioxidants they have identified work well in laboratory conditions, they don't necessarily remain stable once they've been added to a cream. These extracts come from plants, and environmental factors affect their stability and long-term effectiveness -- anything from the season in which they are grown, soil type, latitude and the time of harvest can change the strength by which they can neutralise free radicals as well as work as iron traps. 14
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News
Photoprotection strategies for melasma are increasing
Melasma is a common skin condition in which brown patches appear on the skin. Melasma most often affects the skin on the face. According to researchers, untinted chemical sunscreens on the market are not sufficient to protect the skin from the effects of visible light, complicating sun protection efforts for patients with melasma and other conditions aggravated by sun exposure. A sensible alternative for patients with melasma are tinted sunscreens with an SPF of 30 or greater, which offer both UV and blue light protection. Tinted sunscreens contain iron oxides; some also contain pigmentary titanium dioxide. Black, red, and yellow iron oxide all reflect visible light, noting that currently, there are no regulations as to how tinted sunscreens are marketed, making it difficult for practicing clinicians to advise patients about what products to choose. However, “unlike ‘SPF’ and ‘broad spectrum’ labeling, there is no specific guidance on tinted sunscreens. “ ‘Universal’ shade is a good start but might not be ideal for users with very fair or deep skin tones,” reserchers noted. In December 2021, a guide to tinted sunscreens, recommending that consumers choose a product that contains iron oxides, is labeled as broad spectrum, and has an SPF of at least 30. A comprehensive list of 54 tinted sunscreens with an SPF of 30 or greater that contain iron oxide is also available. Sunscreens with biologically active antioxidants may be another option for patients with melasma. A proof-of-concept study that researchers conducted in 20 patients found that application of a blend of topical antioxidants (2%) was associated with less erythema at the application sites among those with skin phototypes I-III and less pigmentation at the application sites among those with skin phototypes IV-VI after exposure to visible light and UVA-1, compared with controls.Certain antioxidants have been added to sunscreens currently on the market, including niacinamide (vitamin B3), licochalcone A, carotenoids (beta-carotene), vitamin E, vitamin C, glycyrrhetinic acid, and diethylhexylsyringylidenemalonate. A recently published data demonstrated a significant reduction in visual light–induced hyperpigmentation on skin with sunscreen that contained the antioxidants vitamin E, vitamin C, diethylhexylsyringylidenemalonate, licochalcone A, and a glycyrrhetinic acid, compared with sunscreen that had noantioxidants.
Anti-ageing technique makes skin cells act 30 years younger Skin aging is a complex biological process influenced by a combination of endogenous or intrinsic and exogenous or extrinsic factors. Skin aging is a part of a natural human “aging mosaic” which becomes evident and follows different trajectories in different organs, tissues and cells with time. Now researchers have developed a method that can turn back the biological clock on skin cells by 30 years, creating stem cells from mature ones, which could be used to treat skin conditions in the future. A technique that could transform adult skins cells into stem cells by inserting four specialist molecules, dubbed “Yamanaka factors”, that reverse cell development. It takes around 50 days of exposure to these molecules for normal cells to be reprogrammed into what are known as induced pluripotent stem cells (iPSCs). When you turn to a cell into an iPSC, you lose the original cell type and its functionality. A technique that uses Yamanaka factors to rejuvenate skin cells without losing their previous functionality. The researchers collected skin cell samples from three human donors that had an average age of around 50, then exposed these to the Yamanaka factors for just 13 days to partially anti-age the cells. They then removed the Yamanaka factors and left the cells to grow. As we age, our DNA gets tagged with chemicals, so tracking these markers can help us determine how old our bodies are. This is known as our epigenetic clock. Over time, some of our genes will either turn on or off, the collection of which is known as the transcriptome. The researcher team found that the epigenetic clock and transcriptome profiles of the partially reprogrammed cells matched the profiles of skin cells that belonged to people who were 30 years younger. The rejuvenated cells also functioned like younger ones, too, creating more collagen than those that didn’t undergo reprogramming. And when placed onto an artificial wound, the reprogrammed cells moved to close the gap much quicker than the older ones did. In young people, if you cut yourself, it’ll take quicker to heal the wound, while it would take me longer to heal, says team member. It’s very exciting – not only the molecular read-outs that are younger, but the cell also functions more like young cells. The key advance in this study is that we are now able to substantially rejuvenate cells without changing their identity or functionality. The technique may one day be useful in treating skin conditions, such as burns and ulcers. There is also the added bonus that the cells wouldn’t be rejected by an individual’s body, because they would be their own cells. So far, we’ve only tested this technique in skin cells. We’re excited to see if we can translate it across other cell types. June 2022
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Chronic Urticaria Responded to Anti Tuberculosis Treatment : A Case Report
Chronic Urticaria Responded to Anti Tuberculosis Treatment : A Case Report Dr. Digambar R. Dashatwar MD (Dermatology) Consultant Dermatologist, Chandrapur, Maharashtra, India
Case Report A 6 year old boy has been suffering from almost generalized itchy, reddish, swollen hives daily since about 4 years. The timing and frequency of appearance of rash do not follow any set pattern. He had an episode of swelling of anal region (Angioedema) in 2018, after which he started getting itchy rash almost on a daily basis. The appearance of itchy rash corresponded to cool hours of the day i.e at evening and night. This has been bothersome to the patient and parents as well. His parents consulted one doctor after another of different pathies : allopathy, homeopathy, allergologist and so on with no sustained benefits. His allergen tests showed reactivity to : mango, ginger, milk products, sour foods. His serum Ig E Levels were raised to almost double of high normal values, ESR was 25 mm at the end of first hour. In the physical examination done in 2021 it was observed that the young boy had reddish, swollen, itchy rash over trunk and limbs. 16
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He has no stigmata of atopy. He is afebrile, his paranasal sinuses are non tender. Eyes, nose, oral cavity, teeth, gums, oropharynx, tongue, lips are normal. Scalp, hair, ears are normal. Axillae, palms, soles and nails are normal. He has asymptomatic, multiple enlarged, non tender non matted lymph nodes in neck on both sides. Systemic examination : CVS, RS are within normal limits. Abdomen Inspection : no distension, no tenderness, no hepatospleno megaly. Investigation : CBC : WNL, Thyroid Function test : WNL, Chest radiography : WNL , ESR : 25 mm at end of first hour. Mantoux test : 21 mm firm induration with erythema : Strongly positive. The clinical and laboratory findings suggested clinical diagnosis of TB lymphadenitis in neck.
Chronic Urticaria Responded to Anti Tuberculosis Treatment : A Case Report
Management The Urticarial symptomatology is controlled with ketotifen. For TB lymphadenitis neck : He was started on rifampicin 10mg/ kg + INH 5mg/kg daily single dose on empty stomach preferably in the night before going to sleep to overcome the side effects. Urticarial rash – Frequency of appearance and extent of severity of rash and sensation of itch slowly started reducing over 4 months of regular treatment. By the end of 6 months of regular treatment patient is free of urticarial rash and itching. The enlarged lymph nodes in neck regressed. There is an overall improvement in general condition, appetite increased, more fairness of complexion is apparent, there is increased - playfulness and physical activities.
latent TB infection. This is very significant in presence of bilateral lymphadenopathy in neck. This prompted us to start the patient on Rifampicin + INH. Ethambutol was not prescribed because the patient is younger than 8 years. The above treatment worked, the lymph nodes in the neck regressed in size and to our pleasant surprise his urticarial rash started to respond and reduce in severity of itching and symptoms as well as extent of rash reduced significantly and almost stopped appearing by the end of 6 months of treatment. Take home message : Young children with chronic severe urticaria should be thoroughly examined and investigated appropriately for identifying the cause of urticaria. They should be treated accordingly…. as in this case : TB Lymphedenitis in neck.
Discussion Chronic urticaria can be caused by many bacterial, fungal, viral, parasitic infections. Chronic spontaneous urticaria is labeled when no cause is obvious. In the case of this boy – Severe, almost daily appearing rash with severe debilitating, bothering itch was the main and significant clinical presentation. He was extensively investigated – Allergen testing, serum IgE levels and so on. Unfortunately bilateral significant lymphadenopathy in neck was missed. Under 5 year children are susceptible to TB infection, in spite of BCG vaccination. The Mantoux test (intradermal injection of purified protein derivative – PPD) was very strongly reactive in this boy indicating June 2022
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Clinically Modified Tinea: A Menace for Dermatologists
Clinically Modified Tinea: A Menace for Dermatologists Dr. Swati Garg
MD (DVL) Department of Dermatology, Smart Skin Solutions, Panchkula, Haryana Abstract Background:
Dermatophytic infections have never been such a critical arena for dermatologists until last few years when the myriad of atypical presentations are on the rise. Unsupervised and irrational use of topical corticosteroids has further complicated the situation due to occurrence of relapsing steroidmodified tinea to almost epidemic proportions.
Aims:
To study epidemiological and clinical profile of patients with dermatophytosis with an emphasis on corticosteroid misuse.
Methods:
We studied 500 (295 males and 205 females) consecutive patients with dermatophytosis in this is single centre, cross- sectional, observational study. The clinicodemographic profile of patients, nature of topical medications and effect thereof on the clinical presentations were recorded and analyzed statistically.
Results: The major clinical type was tinea cruris et corporis in 266 (53.6%) patients. Uncommon clinical patterns resembling subacute lupus erythematosus, atopic eczema, nummular eczema, seborrheic dermatitis, depigmentation, and majocchi granuloma. Involvement 18
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of scrotum, penis, and face along with whole body were unusual presentations. The majority of these patients had used over the counter preparations containing combination of topical steroids, antifungal and/ or antibacterial agents. Relapse, defaulters and steroid- modified tinea appeared to be more common than treatment- naïve cases. Conclusion: Inappropriate use of topical corticosteroids appears to modify clinical course of tinea making it more treatment recalcitrant and relapsing with polymorphic presentations posing a great clinical and therapeutic challenge for the practicing dermatologists.
Index
terms:
Clinically-modified tinea; corticosteroid misuse; dermatophytosis; tinea corporis, tinea cruris
Introduction Superficial fungal infections have never been such a critical arena for dermatologists until last few years when the myriad of atypical presentations are on the rise. Unsupervised and irrational use of over the counter available topical corticosteroids has further complicated the situation due to
Clinically Modified Tinea: A Menace for Dermatologists
occurrence of relapsing steroidmodified tinea to almost epidemic proportions. A need is being felt to analyze epidemiological and clinical profile of these patients and understand factors for topical corticosteroid misuse. The overall paucity of relevant data has prompted this study.
Methods This is a single centre, crosssectional, and observational study carried out after informed written consent in an urban primary skin care center. The study subjects comprised 500 (M:F = 295:205) consecutive patients with clinically diagnosed dermatophytosis enrolled between Jan to Oct 2021. Patients with onychomycosis were excluded. Results are documented in a predesigned pro forma and the data are expressed in the
form of means and proportions. Demographic variables, family history of dermatophytosis and reasons for present consultation were noted. Details for nature of topical or systemic medication, its duration of usage, source and reason for using it, response to previously prescribed medications, relapses and remissions were recorded. Samples of skin scrapings, nail clippings, and hair were examined microscopically for fungus in 10% potassium hydroxide (KOH) mount. Cases demonstrating fungal hyphae/spores in KOH mounts or showing therapeutic response to antifungal therapy were included for final analysis. All categorical variables were expressed as frequencies and means.
The patients were aged between 2.5 and 81 (mean 28.4) years and the mean duration of infection was 3.2 months and it varied between 3 months and >1 year in 268 (54%) patients. There were 72 (14.4%) children <14 years of age. Among majority, 288 (57.6%) patients, 154 (30.8%) patient had relapsed from the previous episodes and 134 (26.8%) patients were treatment defaulters after initial improvement. Only 123 (24.6%) patients were treatmentnaïve cases. In 263 (52.6%) patients at least one other family member was also infected similarly. Fungal hyphae/ spores were visualized in KOH mounts in 408 (81.6%) patients while other 92(18.4%) patients had been enrolled after therapeutic response to systemic and topical antifungals.
Results The clinico-epidemiological profile of 500 patients is depicted in Table-1.
Table-1: Baseline clinico-demographic profile of patients Baseline characteristics Gender
Age
Duration
Number of patients (%) n =500 Males (M)
295 (59)
Females (F)
205 (41)
M: F
1.4:1
Range
2.5-81 years
Mean
28.4 years
≤14 years
72 (14.4%)
>14-45 years
286 (57.2%)
>45 years
142 (28.4%)
Range
3 months- >1 year
Mean
3.2 years
≤2 weeks
65 (13%)
>2weeks - 3 months
Cases based on Treatment
113 (22.6%)
>3months -1 year
268 (53.6%)
> 1year
54(10.8%)
Naïve cases
123(24.6)
Defaulters
134(26.8)
June 2022
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>3months -1 year Clinically Modified Tinea: A Menace for Dermatologists
268 (53.6%)
> 1year
54(10.8%)
Naïve cases
123(24.6)
Defaulters
134(26.8)
Relapsed cases
154(30.8)
Missed cases
89 (17.8)
KOH mounts
Positive
408 (81.6)
Family history of fungal infection
Present
263(52.6)
Cases based on Treatment
Other cases
Clinically, tinea cruris et corporis in 266 (53.6%) patients was the commonest presentation. Tinea cruris in 64 (12.8%), tinea corporis in 59 (11.8%), tinea faciei/barbae in 44 (8.8%), tinea manuum in 32 (6.4%), tinea pedis in 19 (3.8%), and tinea capitis in 16 (3.2%) patients, respectively, were other clinical presentations in order of frequency (Fig-1 to 3). Tinea imbricata and majocchi’s granuloma were diagnosed in 27 and 18 patients, respectively. The 47 patients showed uncommon clinical presentations mimicking various other dermatoses and diagnosis was only due to strong clinical suspicion [Table-2, Fig-4 to 6].
Fig-1: Clinical diagnosis (a) Tinea capitis with “ear sign”, (b) Tinea barbae/faciei, (c) Tinea corporis (dorsal foot), (d) Tinea cruris et corporis, (e) Tinea dorsal hand, (f) Inframammary tinea corporis
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Clinically Modified Tinea: A Menace for Dermatologists
Table-2: Uncommon clinical presentations (N=47) Uncommon clinical presentations
No. of patients
Eczema-like
13
Seborrheic dermatitislike
9
Depigmentation
7
Subacute lupus erythematosus-like
5
Erythema- multiformelike
3
Pityriasis rosea-like
3
Erythroderma
2
Erythema annulare centrifugum-like
1
Pustular lesions
1
Squamous cell carcinoma-like
1
Fig-2: Tinea faciei in children
Fig-3: (a) Classic annular lesions with central clearing. (b) and (c) arciform lesions, (d) double edged or geographic lesions
A
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Clinically Modified Tinea: A Menace for Dermatologists
Fig-4: Atypical lesions of tinea lacking the classical central clearing and showing chronic eczematous changes surrounded by erythematous borders.
Fig-5: Adult type of tinea capitis with involvement of glabrous skin with lesions in the scalp extending on to the (a & b) nape of neck, (a) upper back, (c) face, and (d) ear pinna. 22
June 2022
Clinically Modified Tinea: A Menace for Dermatologists
Fig-6: Clinical presentations mimicking various dermatoses; (a) Nummular eczema-like, (b) Majocchi granuloma, (c) Erythema annulare centrifugatum-like, (d) Seborrheic dermatitis-like, (e) Majocchi granuloma-like, (f) Tinea pseudoimbricata, (g) Pustular variant, (h) Lupus erythematosus-like, (i) Squamous cell carcinoma- like.
Only 123 (24.6%) patients had taken prescribed antifungals medication. The majority, 377 (75%) patients were using one or the other topical preparation recommended by registered medical practitioners (RMPs, in 97), dispensing chemists (in 92), quacks (in 68), dermatologists (in 66) and friends/relatives/neighbours in 54 patients in that order and comprised topical steroids alone or in combination with tretinoin, hydroquinone, antifungal and/ or antibacterial agents for a mean duration of is 1.8 months. [Table-3]
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Clinically Modified Tinea: A Menace for Dermatologists
Table-3: Nature and duration of usage of topical medications (N=500) Contents of the topical 377 medications (75%) Antifungal with steroids (Candid-B, Keto-B, etc.)
178
Home remedies (Camphor, Coconut oil, Neem leaves)
146
Antifungals (Clotrimazole, ketoconazole, Lulliconazole, etc.)
123
Steroid alone or in combination (Panderm plus, Skinshine, Skinlite)
78
Antibacterials preparations
35
Others (Neosporin powder, Zalim lotion, other irritants)
28
Unlabelled preparations
8
Duration of topical medications ≤1 week
56
>1 week to 3 months
185
>3 months to ≥1 year
136
Being cost effective (in 204) and quick relief of symptoms in 178 patients, respectively, were the major reasons for using topical corticosteroids.[Table-4]. Interestingly, some of the patients also used them for popularity of the product and associated benefit of fairness cream. Table-4: Stated reasons for topical corticosteroids usage (N=256) Reasons
No. of patients
Cost-effectiveness
204 (80%)
Quick relief in symptoms
178 (70%)
Belief on provider
88 (34%)
Popularity of the product
68 (26.5%)
Previously prescribed 34 (13%) for other indication(s) As a fairness face cream 24
25 (10%)
June 2022
Table-5 depicts various reasons for seeking expert consultation. Dermatologist’s consultation was sought by 272 (54%) patients only after experiencing exacerbation of symptoms and skin rash on discontinuation of topical preparation while 90 (18%) patients consulted on experiencing some adverse effects. Table 5: Reason for present consultation to dermatologist (N=500) Reasons for dermatological consultation
No. of patients
Flare of the disease on discontinuation of topical preparation
272 (54%)
Side-effects to topical preparation (sensitization, striae 90 (18%) formation, recurrent folliculitis, inability to discontinue the drug) Second opinion for treatment
75 (15%)
Casual consultation
63 (12%)
Discussion In dermatology practice superficial dermatophytosis is one of the commonest diagnoses surpassing acne and pigmentation in last few years due to multifold increase in its prevalence across all regions in India. A distinct variation in morphology of lesions and therapeutic poor response is also notable leading to treatment beyond the standard guidelines. Men were slightly outnumbered women affecting most during 14-45 years of age. Tinea cruris et corporis in 53.6%, tinea cruris in 12.8%, tinea corporis in 11.8%, tinea faciei/barbae in 8.8%, tinea manuum in 6.4%, tinea pedis in 3.8%, and tinea capitis in 3.2% patients were the common presentations. The demographic and clinical features in our patients did not differ from those described across studies.[1-4] Pathania et al [1] observed multiple sites in 64.4% patients while tinea corporis and tinea cruris were the major clinical types in other studies.[2,3] Besides inguinal folds inframammary fold in women is common site of infection as occlusion, heat, friction and maceration provide conducive environment to the fungus. Dermatophytosis affected 14.4% children aged <14 years with tinea faciei followed by tinea
corporis and tinea capitis being the common presentations. Presence of other affected family member in our 52.6% of patients and acting as a source of reinfection has been reported in 16.6% to 72% patients previously.[1,3,4] KOH mounts demonstrated fungal elements in 81.6% patients in this study and corroborated an overall positivity between 64% and 92% reported in previous studies.[1,5,6] Annular lesions with central clearing and scaling are classic of tinea infection in treatment naïve cases and were noted as multiple, large, anular or arciform lesions over trunk in our patients as well. However, lesions with pustular borders and erythematous centres observed in this study are uncommon and suggest infection with high inflammatory host reaction. Glabrous type of adult tinea capitis of glabrous skin in our 6 patients has been highlighted in a study by Verma and Madhu.[6] The clinical diagnosis of tinea was difficult in our 18.4% patients difficult due to their resemblance to eczema, lupus erythematosus, erythema annulare centrifugatum, squamous cell carcinoma, depigmentation and diffuse scaling. Dermatophytosis mimicking eczema, psoriasis,
Clinically Modified Tinea: A Menace for Dermatologists
seborrheic dermatitis, rosacea and lupus erythematosus have been reported as tinea incognito in the literature.[1,5-9] Other atypical presentations resembling impetigo, scutula, molluscum, purpura, rosacea, pseudomemberanous, blepharo cliliaris, cystic granuloma trichophyticum reported in the literature were not observed by us perhaps due to small number of cases.[10] Tinea incognito/ incognita, tinea atypica and steroid- modified tinea are the most commonly accepted examples for such cases.[8,9] On the other hand, patches of tinea involving large skin areas almost in bathing trunk distribution pseudo circinate pattern, and increase prevalence of tinea faciei in younger age group has been attributed to increased steroids abuse, if not the sole determining factor in the emergence of recalcitrant tinea in a recent consensus statement.[11] Other factors identified for relapses and recalcitrant nature of infection have been defaulting on treatment, inadequate treatment, drug resistance, reinfection, misdiagnosis and under treatment apart from poor hygiene, overcrowding, etc. and were also noted in a fair number of our patients.[10,11] The majority, 256 (51.2%) patients were using topical steroids preparation alone or in combination with antifungal and/or antibacterial agents, tretinoin, or hydroquinone often considering them being cost effective and providing immediate relief as few of the cited reasons. It seems possible as none of them used or was prescribed topical calcineurin inhibitors, another cause of tinea incognito along with antipsoriatic medications.[12-15] Further, home remedies still constitute a sizable proportion of users in this study. While 54 patients were self-medicating following advice
by family, relatives, friends and neighbours, RMPs in 97, and chemists in 92 patients form major prescribers of these cocktail creams in this study corroborating previous observations by Kim et al[6] wherein ≥59% patients were self-medicating or being treated by non- dermatologists. Only 24.6% patients in this study had been prescribed proper antifungals treatment previously compared to 32% in an earlier study.[16] Most patients perceived their problem being trivial and self-limiting and did not consider the need to consult dermatologist. Moreover, the symptomatic relief from continuous use of topical medication prescribed earlier for some other dermatosis like melasma further delayed appropriate dermatological consultation until flare up in 54% or their adverse effects in 18% became evident to them. Interestingly, only 15% resorted to second dermatological opinion. The vicious circle of immediate relief in symptoms remains, cost effectiveness and unrestricted availability remain the major derive for prolonged use of corticosteroid containing topical medications for >2 years in our study. This highlights the need to restrict over the counter availability of corticosteroids and pivotal role mass media can play in generating awareness for importance of timely and accurate treatment that may be needed for a longer duration than usually recommended to achieve mycological cure after obvious clinical cure. This is particularly true in the current perspective of increasing number of resistant and recalcitrant cases of tinea. [17-19] Nevertheless, to blame only the corticosteroids-antifungal combinations for the current scenario of chronic, recalcitrant and extensive disease even in immune
competent individuals may not be justifiable in the absence of scientific evidence.[20] Limitations Small number of cases, cross sectional study design, lack of identification of fungal species by culture, and no follow up for therapeutic outcome/development of disease remain some of the limitations. Conclusions Inappropriate use of topical corticosteroids at various levels have altered the morphology and clinical presentation of tinea to more profuse, widespread, ill-defined, atypical, chronic and treatment recalcitrant. Delayed diagnosis, lack of adequate treatment; and unrestricted availability and use of topical corticosteroids, alone or in combination preparations are common denominators for clinically modified tinea posing a diagnostic and therapeutic challenge for the practicing dermatologists.
Financial support and sponsorship: Nil.
Conflicts..of..interest: None declared References 1. S. Pathania, S. M. Rudramurthy, T. Narang, U. N. Saikia, S. Dogra, “A prospective study of the epidemiological and clinical patterns of recurrent dermatophytosis at a tertiary care hospital in India,” Indian J. Dermatol. Venereol. Leprol., Vol. 84, pp. 678-684, NovDec 2018. 2. V. Ramaraj, R. S. Vijayaraman, S. Rangarajan,
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Clinically Modified Tinea: A Menace for Dermatologists
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S. Arora, V. S. Lal, N. Donaparthi, “Use of
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18. M. Rajagopalan , A. Inamadar , A. Mittal ,
“Dermatophyte infections mimicking other
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of an antipsoriatic gel,” Skin Appendage
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Leprol., vol. 83, pp. 281-284, May-Jun 2017.
News
Questions about optimal dosing of isotretinoin persist, expert says Systemic isotretinoin remains the most efficacious treatment for severe acne as well as many cases of more moderate disease that are unresponsive to other treatment modalities. Although the Food and Drug Administration approved isotretinoin for severe recalcitrant acne 40 years ago, many questions about its optimal dosing remain to this day. These include, what is the ideal daily dose of isotretinoin? What is the ideal cumulative dose of isotretinoin to minimize relapse of acne? What is the ideal duration of isotretinoin therapy? More recently, investigators who conducted a single-center study of 1,453 patients treated with isotretinoin defined relapse as the need for a second course of isotretinoin. They found that neither daily nor cumulative dosages influenced relapse of acne vulgaris in patients treated with varying doses of isotretinoin as long as treatment was continued for 2 or more months after the acne had completely resolved. The current evidence underpinning the 120-150 mg/kg cumulative threshold–dosing regimen is equivocal and is based on two low-grade studies. Cumulative doses required for clearance appear lower for acne of mild to moderate severity and higher for more severe acne. Future investigations should use clinically relevant endpoints as end of treatment criteria and define treatment success in acne accurately. Other studies have looked at whether higher doses of isotretinoin could reduce treatment failures in patients with acne. In a retrospective chart review of 102 patients with acne who had been treated with isotretinoin for at least 4 consecutive months and followed for over a year, 45.1% required further treatment and 15.7% received a second course of isotretinoin. Cumulative dose (mg/kg), follow-up period, duration of treatment, and daily dose during the last month of treatment were not significantly different between those who relapsed and those who did not relapse. However, “while the cumulative dose of isotretinoin did not significantly impact acne relapse, patients who received a higher cumulative dose were less likely to require a second course of treatment. According to researcher, variables to consider in selection of a daily dose include the presence of intense inflammation, cysts, nodules, potential difference in side-effect profiles with ethnicity, and an individual’s degree of side effects and their level of comfort. What are some of the concerns with higher doses? Those of us who have treated a lot of acne patients have had the unfortunate occurrence where you start someone on isotretinoin and their acne explodes, as do their cysts and nodules. Once that happens it’s a bad situation and it takes you a while to get past it.
Detailed molecular map of skin layer creates pathways for treatments The skin is the largest organ of the body, it protects from microbes and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and cold. It has three main layers, the epidermis, the dermis and the subcutaneous layer. Current research finding shows the scientists have accurately analysed the tough barrier layer of the skin giving the most detailed molecular map of its structure that will help in the development of new skin products and treatments. Researchers used the latest three-dimensional mass spectrometry imaging technique to analyse human skin tissue from the stratum corneum to reveal its molecular chemistry in unprecedented detail. These new findings provide increased fundamental understanding in skin biology and enable the development of new skin products and treatments. The technology facilitates an unprecedented level of molecular analysis for a range of materials including biological tissues, such as human skin. Importantly, its high mass resolving power, chemical specificity and high sensitivity allow it to be used to analyse in situ human skin samples to accurately map the molecular structure of the skin. Researchers used ex vivo full-thickness human skin tissue samples and a single gas cluster ion beam to both sputter through the skin and generate secondary ions, which were analysed using the OrbitrapTM to generate a depth profile. This process showed the range of chemistries and 3D distributions within the stratum corneum and indicate how these relate to fundamental biological processes such as the cholesterol sulphate cycle. This research gives the chemical structure detail of the stratum corneum never seen before. The information they were able to gather on the complex chemistry of this tough barrier layer has the potential to benefit research into fundamental biological processes, such as those associated with ageing and disease in addition to improving the efficacy of topical delivery.The team were able to accurately track the penetration of No7's peptide blend and detected the peptides responsible for targeting invisible photo-damage that occurs early in the ageing process. June 2022
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Management of Acne Scars: Microneedling versus Microneedling with Platelet Rich Plasma. Does It Make A Difference?
Management of Acne Scars: Microneedling versus Microneedling with Platelet Rich Plasma. Does It Make A Difference? Dr. Kindy D. A. S. Newmai
MD (Dermatology) Consultant, Olive Christian Hospital and Research Centre, Dimapur, Nagaland
Dr. Raghunatha Reddy
MD (Dermatology), DNB, FRGUHS Roots Institute of Dermatological Sciences, Bangalore
Dr. Aneesh Samayam MD (Dermatology) Professor Department of Dermatology East Point Medical College, Bangalore
Introduction Acne can be defined as a chronic, self-limiting, inflammatory disease of pilosebaceous unit, manifesting generally in adolescence with pleomorphic lesions like comedones, papules, nodules, and cysts. Extensive scarring can occur as a sequalae. Microneedling is a minimally invasive procedure involving superficial and controlled puncturing of the skin by rolling with miniature fine needles. 28
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Micropunctures are created using microneedles which produce a controlled skin injury without actually damaging the epidermis. These microinjuries lead to minimal superficial bleeding and set up a wound healing cascade with release of various growth factors such as platelet derived growth factor (PGF), transforming growth factor alpha and beta (TGF-ɑ and TGF- ), connective tissue activating protein, connective tissue growth factor,
ᵦ
Management of Acne Scars: Microneedling versus Microneedling with Platelet Rich Plasma. Does It Make A Difference?
and fibroblast growth factor (FGF). The needles also breakdown the old hardened scar strands and allow it to revascularize.1, 2
informed consent was taken. Digital photographs were taken. At the end of the treatment duration the scars were graded using Goodman and Baron Quantitative grading system as used in the beginning, photographs of the face were compared.
PRP is an effective concentration of multiple fundamental growth factors (GFs) by virtue of platelets alone (stored as granules in platelets) and plasma proteins, namely fibrin, fibronectin and vitronectin. This cocktail of GFs is pivotal in modulation of tissue repair and regeneration, whereas the plasma proteins act as a scaffold for the bone, connective tissue and epithelial migration.3, 4
For PRP, 10 ml of autologous whole blood was collected into tubes containing acid citrate dextrose (ACD) and centrifuged at 2000 rpm for 10 minutes in order to get PRP at the top of the test tube. Then, the PRP was further centrifuged at 4000 rpm for 10 minutes at room temperature of 22°C in order to obtain a platelet count 4.5 times higher than the base line (i.e., 8-9 lakhs/µl). Platelet-poor plasma (PPP) was partly removed and partly used to resuspend the platelets.
Materials and Methods
Assessments Treatment efficacy during follow up was determined by Goodman and Baron Quantitative Score as well as percentage of acne scar counts of Icepick, Rolling scar, Boxcar scars and linear scars at follow up were compared.
Inclusion criteria: 1) Patients with atrophic facial acne scars. 2) Aged 18-40 years Exclusion criteria 1) Patients with atrophic facial scars due to other causes 2) Patients on oral isotretinoin treatment. 3) Patients with active acne.
Calcium chloride was added as an activator.0.3 ml of 10% Calcium chloride for 1 ml of PRP. Microneedles with 1.5 mm length and 192 needles on roller drum were used.
Statistical Analysis All the collected data was entered in Microsoft Excel Sheet 2010 and then transferred to SPSS software after typographic corrections. Statistical analysis was done by SPSS software ver.17. The Acne Score grades between the groups were compared with baseline score by using Man Whitney U test. P value of <0.05 was considered as significant.
4) Patients with recurrent herpes simplex 5) Patients with keloidal tendency 6) Patients with hematological and endocrinological disorders Forty patients with facial atrophic acne scars were offered four sittings of microneedling (dermaroller) treatment of 4 weeks apart in one group and microneedling with Platelet-rich plasma in another group. The patients were randomly assigned to each group. The patients were explained about the dermaroller and PRP therapy, the cost factor involved, benefits, duration of the Graph 1: Percentage of improvement in Boxcar scars treatment, possible side effects and e of improveement in Boxxcar scars the prognosis of the treatment. An Graph 1: Percentage June 2022
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Management of Acne Scars: Microneedling versus Microneedling with Platelet Rich Plasma. Does It Make A Difference?
Graph 2: Percentage of improvement in Rolling scars
Graph 2 2: Percentagee of improveement in Rollling scars
Graph 3: Percentage of improvement in Icepick scars
Graph 3 : Percentag ge of improvement in Iceepick scars
Graph 4: Percentage of improvement in Linear scars 30
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Graph 4: Percentagee of improveement in Linnear scars
Graph 4: 4 Percentagee of improveement in Linnear scars Management of Acne Scars: Microneedling versus Microneedling with Platelet Rich Plasma. Does It Make A Difference?
Graph 5: Adverse effects
Graph 5: 5 Adverse efffects
Graph 6: Man Whitney U Test
Results • On Comparing the clinical was noted when compared in improvement of Acne scar grading percentages of individual acne between the groups by Man scars. 66: Man Whitn Whitney UGraph test: first sitting p ney = U Test th 0.447, 8 week p=0.522, 16th week p= 0.283. • Between the groups there was no improvement statistically. However, the clinical improvement
Graph 66: Man Whitn ney U Test
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Management of Acne Scars: Microneedling versus Microneedling with Platelet Rich Plasma. Does It Make A Difference?
Group A-Microneedling + PRP
Baseline
8 weeks
16 weeks
8 weeks
16 weeks
1 month after the first treatment session (P = 0.15) or 4 months after the second (P = 0.23).5
Summary and Conclusion • On comparing the clinical improvement of patients on subsequent follow up among both groups, we found no difference in grades of scar between groups at baseline, first and second follow up statistically.
Group B-Microneedling Alone
Baseline Discussion The present study was conducted to compare the efficacy between microneedling versus microneedling and platelet rich plasma on atrophic acne scars. In a study done by Gita Faghihi et al, Sixteen patients underwent splitface therapy with ablative fractional carbon dioxide laser combined with intradermal platelet-rich plasma treatment on one half of their face and ablative fractional carbon dioxide laser with intradermal normal saline on the other half. Scars were graded according to Goodman and Baron qualitative scale. Overall clinical improvement of acne scars was higher on the platelet-rich plasma-fractional carbon dioxide laser treated side but the difference was not statistically significant either 32
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In a study done by Imran Majid, thirty-seven patients of atrophic facial scarring were offered multiple sittings of microneedling treatment and their scars were evaluated and graded clinically by Goodman and Baron qualitative grading and by serial photography at the start as well as at two months after the conclusion of the treatment protocol. Out of these 36 patients, 34 achieved a reduction in the severity of their scarring by one or two grades (88.7%). Excellent response was seen in rolling or boxcar scars, while moderate response was seen in pitted scars.6
• Clinically, in respect to percentages of individual acne scar grades, improvement was found. In group A (microneedling+PRP), percentage of ice pick scars at 8 weeks and 16 weeks as compared to baseline was 24.50% and 47.65% respectively. Whereas in group B (microneedling), the improvement rate at 8 weeks and 16 weeks compared to baseline were 23.77% and 45.58% respectively.
Management of Acne Scars: Microneedling versus Microneedling with Platelet Rich Plasma. Does It Make A Difference?
• In Boxcar scars, group A showed 39.74% and 64.42% improvement at 8 weeks and 16 weeks compared to baseline respectively. Group B showed 31.50 % and 54.27% improvement from baseline at 8 weeks and 16 weeks respectively.
References
• In rolling scars, group A showed 34.50% and 59.39% improvement as compared to baseline at 8 weeks and 16 weeks respectively. Group B showed 36.87% and 52.53%improvement at 8 weeks and 16 weeks as compared to baseline respectively.
2. Satish D. Microneedling with Dermaroller.
• In Linear scars, Group A showed 24.49 % and 47.83 % improvement at 8 weeks and 16 weeks as compared to baseline respectively. No patient allotted to Group B had linear scars. This study confirms the efficacy of microneedling in acne scarring treatment as a stand-alone treatment. However, since there was an improvement in percentages of individual acne scars, as compared to baseline, platelet rich plasma may add a synergistic role in the efficacy of microneedling by improving healing time and regeneration.It should also be noted that patients treated with microneedling and platelet rich plasma showed marked patient satisfaction.
1. Liebl
H.
Abstract
reflections
about
Collagen Induction Therapy. A Hypothesis for the mechanism of action of collagen induction therapy using microneedles, January 2-7. http://dermaroller.de/us/science/abstractrefections-26.html February
Journal of Cutaneous and aesthetic surgery .July-dec 2009,volume 2 : Issue 2 3. Marx RE. Platelet-rich plasma: Evidence to support its use. J Oral MaxillofacSurg 2004;62:489-96 4. Arshdeep, Kumaran MS. Platelet-rich plasma in dermatology: Boon or a bane? Indian J DermatolVenereolLeprol 2014;80:514 5. Faghihi
G,
Keyvan
S,
Asilian
A,
NouraeiS,Behfar S, Nilforoushzadeh MA. Efficacy of autologous platelet-richplasma combined with fractional ablative carbon dioxide resurfacinglaser in treatment of facial atrophic acne scars: A split-face randomized clinical trial. Indian J DermatolVenereolLeprol 2016;82:162-8. 6. Imran.Majid.Microneedling
Therapy
in Atrophic Facial Scars: An Objective Assessment Journal of Cutaneous and Aesthetic Surgery - Jan-Jun 2009, Volume 2, Issue 1
Although there have been multiple such similar studies done in the past, there are sparse studies that have used Goodman and Baron’s Quantitative scoring system as opposed to the more popular Qualitative scoring system and represents an interesting tool for further in-depth research and additional experimentation on the use of PRP in association with other techniques in treatment of acne scars.
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