Total Pages : 24 May 2022 Vol 15* Issue-4 100
Needling with 5FU-Safe and Cost Effective Treatment for Stable Vitiligo Acne Scarring – Brief Review with Focus on Atrophic Scarring Tick √ Yourself to Never Ignore Any Skin Lesion Microneedling with GFC – Modified PRP If Undelivered, return to Paradigm Infocom Pvt. Ltd. 22, 2nd floor, Shreeji Bhavan, 275-279 Samuel Street, Masjid Bunder (W), Mumbai-4000 03
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EXECUTIVE EDITOR & PUBLISHER Dom Daniel
Advances In Clinical Dermatology
ADVISORY BOARD Dr. Manjunath Hulmani Dr. Harini Thummuluri Dr. Shayan Haq Dr. Niranjana Yogiraj Dr. Priya K.S Dr. Sohan Das Shetty Dr. H. Girish Dr. Sanath Posavanike Dr. Vidya T.S Dr. Ashwini K.R.
Dermatology is the branch of medicine dealing with the skin. It is a specialty with both medical and surgical aspects. Dermal diagnosis is a challenging fact for the dermatologists to combat the diseases and disorders of skin, hair and nails. The new advances and developments in the field of medical dermatology is lead to improved patient care. The recent advances are playing key role in diagnostic options, novel treatment, primary prevention, technology tools, better skin protection, prevent many damaging skin conditions etc., ultimately it shows there is no shortage of options to bring the best solutions to improved patient care.
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.
All rights reserved. Reproducing in any manner without prior written permission prohibited.
Published for the period of May-2022 4
May 2022
The advance technology provides most practical and comprehensive information on the treatment and care of skin disorders. Psoriasis, fungal infection, bacterial infection, atopic dermatitis, acne, melasma, urticaria, alopecia areata, vitiligo has become an immensely burdensome disease with increasing focus from the best dermatological minds. But the new therapeutic options with existing medications achieved some success to control the disease. The innovative treatments and techniques in clinical dermatology providing a great satisfaction to patients. Many new pharmacologic therapies for skin disorders is continued to grow in importance as compared to traditional therapy. Newer medications have a substantially higher safety profile with greater efficacy and faster cure rate. In this issue we got the articles on Microneedling with GFC – Modified PRP, Tick Yourself to Never Ignore Any Skin Lesion, Acne Scarring – Brief Review with Focus on Atrophic Scarring, Needling with 5FU-Safe and Cost Effective Treatment for Stable Vitiligo. . - Dom Daniel Executive Editor & Publisher
Acne Scarring
– Brief
Review
with Focus
on Atrophic
Scarring
Acne Brief Re Scarring – vi on Atro ew with Focu s phic Sc arring Dr. San dee
p Gupta MD (DVL ) Consultan t Dermatolo Balaji Skin gist Clinic, Bhagat Alive Welln Hospital, ess Clini New Delh cs i
08 Acne Scarring – Brief Review with Focus on Atrophic Scarring 08
Dr. Sandeep Gupta, MD (DVL) 8
June 2022
Introduction Scar is defined as a mark skin or left within body tissue on the wise wound , burn, summary where a completely or sore has not healed description. The rather than full therapies tissue has and fibrous conne are more detailed for skin developed. ctive of color. Acne is important Impac t of acne scars because it leaves scars of the • Psych ; not only ologically but more on face distres and emotio importantly sing; Although nally a percep on psyche. 1 • Depression, developing tion of anxiety, esteem poor self, embar adolescence as a consequenc acne rassment, e of image alterat is widely has clear body long lasting prevalent, it interactions; ions, altered and physic social psychologic • Lower al effects al ed acade . mic anger, It is consid and unemp performance , factor for of derma ered bread and loyment; suicid tology butter • risk practic of individ Negatively e; e as >80% uals shall relationships affects profes lifetime . It affects suffer it in their sional employment and chances 80% of 90% boys of future 16-17 ; and year old recove girls. Acne Predi rs in the sposing majority years of age. factorsafter 25 factor s assoc In appro 1% of iated withRisk increa males ximate sed likelih and 5 persists % of female ly Not ood of until age everyo scarring ne shall it grade of 40. develo Scarring of acne scarring. p same occurs severity early in As the of Indian of acne acne. 29% has no patients correla direct have scars tion with were found psychosocia post acne to affection, observ similarly l in a recent ation scarring develop acne scars. study in this can in all grade 2 review s of acne. on Scarring occurs The impac early and both its t, risk relates severity factors overview to and delay and brief treatment. of acne before is highlig scar treatm hted. Focus ent is on point
Tick Yourself
to Never
Ignore
Any Skin
Tick Yo Ignore urself to Neve Any Sk in Lesio r n Dr. Mah ajab
14 Tick √ Yourself to Never Ignore Any Skin Lesion
Lesion
een S. Mad
MD
arkar
Associate Professor Departmen t of Derm SNMC atology and HSK Hospital Bagalkot, Navanagar Karnataka ,
Dr. Tanuja
Rajagopal MBBS Junior Resid ent Departmen t of Derm SNMC atology and Bagalkot, HSK Hospital Navanagar Karnataka ,
Dr. Mahajabeen S. Madarkar, MD Dr. Tanuja Rajagopal, MBBS, Junior Resident 14
14 June 2022
Abstra ct Ticks are ectopa blood rasites sucking belong class of topica ing to Arachn l applica ida. the cutane tion of ous manife It may cause medications any native or drug transm was it various stations and also past no similar complintake. There tick-bo rne diseas or no signific We are aints e. reporting ant family in the bite with a rare case On cutane history. live tick of tick ous examin under the buried ation, its head tick which had skin. a live embed stuck ded its firmly Introduction and head under (Figure 1- A & the skin. Ticks crusting B) are was seen Erythema and ectopa blood rasites at the sucking attachment. site of belong class ing to Arachn ida. the Removal cutane ous manife It may cause of tick radiofr was done transm equency it various stations and using probe also care was tick-bo and specia rne diseas taken to They can l e. completely remove cause the local and complication withou tick mouth system part which t damaging ic the and manag s. Hence its was intact skin. diagno ement sis under plays a key role. Dermo Case Repor scopy was illuco A 35-yea t done dermoscope r-old female using 110 to the dermatology presented magni Dermatoscop (IDSdepartment e) with fication outpatient which 10x legged with of skin tick (Figure revealed live compl lesion 8 itching, 2- C & associated aints may be correla D) which burning ted to with tick which pain over sensat ixodid has a the abdom ion and shield. 1 15 days. body protechard en since No history tion constitutiona fever or Labora l sympt tory any oms. No investigation history normal and s were system reveale d no abnorm ic examination alities.
Microne
edling
with GFC
– Modified
PRP
Micron
eedling Modifi with GFC – ed PRP
16 Microneedling with GFC – Modified PRP
Dr. Kanu
Verma MBBS, MDSenior Cons SKIN &VD ultant Derm Aastha atologist Medicare, & Cosm Dwarka, Visiting etologist, Delhi Consultan t, Aakash Dwarka, Healthcare Delhi Hospital,
Dr. Kanu Verma, MBBS, MD-SKIN &VD 16 16 June 2022
18 Needling with 5FU-Safe and Cost Effective Treatment for Stable Vitiligo
Abstract Facial rejuvenation common is the treatment most a derma enquired tologist in Also known usually clinic. ask for Patients INDUC as “COLL minim TION THER pain less AGEN APY” as and minim um invasive, to treat treatment skin conce it is used um downt for their rns via ime production. face rejuve Micron collagen eedling nation. or collag therapy, en induct is a Discussion rejuvenation minimum invasiv ion e skin Microinjury pigmentation procedure, to skin, for healing sets up a wound fine wrinkle , photo damag facial cascade e skin, of variou with and aged minimum s growth release skin, with releas disruption factors ed and no . The growth of epider adverse factors mis Platelet derive effects. d growth mainly (PDGF), Epidermal factorIntroduction (EGF), growth Vascular Micron endothelial factor factor eedlin (VEGF), growth procedure g is an Fibroblast aesthetic factor (FGF) growth involving or Derma Dermapen growth factor- and Transforming Roller beta (TGF-b or Micron Radio stimulate Frequency eedling eta), can proliferation (MNRF needles epidermal of fibrobl ) with to create asts, cells micro chann tiny synthe skin. and sis. collagen els in These In additio needles n, the skin at punctu Transforming re the growth factor– various beta, has depths a contro to create inhibit melan proved lled skin to punctu skin pigme ogenesis or injury. re create reverse ntation s a chann Each stimulates . el that Effects neovascular neocollagen of the ization osis. and can also micron eedling be enhan It helps –modified ced by to bright adding PRP the skin, Hyperpigme (Platelet-Ric helps with Plasma), ntation GFC h Tone, , Melas concentrate (growth Scars, factor Fine lines ma, Skin )-Yuskin. and Pore & Wrinkl size and Yuskin–GFC Acne Scars. es , formulation high concentratio has factors n of naturally growth promoting healing
Needling
with 5FU-Saf
e and Cost
Effective
Treatme
nt for Stable
Vitiligo
Needlin Safe an g with 5FUTreatm d Cost Effec ent for tive Stable Vitiligo Dr. Man
mohan
MD, DVL Senior Resid ent AIIMS, Rishi Uttarakhan kesh d
Dr. Manmohan Bagri, MD, DVL
18 18 June 2022
Bagri
Introduction Vitiligo is a chronic autoim mune acquired disorder, depigm Mater presen ented ts as Five ial and metho macules, total or ds patients in which partial with total loss vitiligo occurs 1 . Its preval of melanocytes 12 stable patche s (>1 selected, world’s ence is year) 1-2% of popula who had were tion irrespe and photo any age taken or sex. 2 medical ctive of therapy For repigm 7-8 month treatment medical entatio for last s exclud treatment n, active therapy Koebner’s ing patients with but in stable is primar y less phenomenon surgical vitiligo than 10 options various , age are availab face, genita years, patche with medic s on the le al therap along areas. lia, and ies. 3 intertriginous The duratio Topica l 5% presen n of each fluorou ce of commonly patch, racil is other factors used in less progn including but it vitiligo has leukotrichia, ostic patients and the treatment combination been tried earlier were record taken previo site in and lasers with ed. dermabrasio usly . As it’s n effective and easy a safe, cost Proce the treatm modality dure ent of for After stable disease explain vitiligo stability ing the with patien of at least duratio proced t conse n. 5FU ure to one year along were photo nt was taken, leads lesions to strong with Needling 1 graphed. precau reactio Under tions, inflammator n causin aseptic y with betadi affected area g local increase cleansed ne then edema Local in , normal basal layer Intercellular lignocaine space saline. was injecte of patch over stimul due to which after AST. d over there is 5% ation and A thick melanocytes fluorou migrat paste of from pigme ion of the patch racil cream achrom applie ic epider followe nted to d by needli d on close as mis resulti pigmentation ng as ng in outsid possible to each . e to inside other from with needle. A lag period a 26-G sterile between of few secon the ds appearance time of needli ng and of pin point bleed
Editorial Board Dr. Sandeep Gupta
Dr. Manmohan Bagri
Dr. Mahajabeen S. Madarkar
Dr. Tanuja Rajagopal
MD (DVL) Consultant Dermatologist Balaji Skin Clinic, Bhagat Hospital New Delh
MD Associate Professor Department of Dermatology SNMC and HSK Hospital Navanagar, Bagalkot, Karnataka
Dr. Kanu Verma
MBBS, MD-SKIN &VD Senior Consultant Dermatologist & Cosmetologist, Aastha Medicare, Dwarka, Delhi Visiting Consultant, Aakash Healthcare Hospital, Dwarka, Delhi
6
May 2022
MD, DVL Senior Resident AIIMS, Rishikesh Uttarakhand
MBBS Junior Resident Department of Dermatology SNMC and HSK Hospital Navanagar, Bagalkot, Karnataka
Complete Post Procedure care solution
Non Comedogenic Face Moisturiser
May 2022
7
Acne Scarring – Brief Review with Focus on Atrophic Scarring
Acne Scarring – Brief Review with Focus on Atrophic Scarring Dr. Sandeep Gupta
MD (DVL) Consultant Dermatologist Balaji Skin Clinic, Bhagat Hospital New Delhi
Introduction Scar is defined as a mark left on the skin or within body tissue where a wound, burn, or sore has not healed completely and fibrous connective tissue has developed. Acne is important because of the scars it leaves; not only on face but more importantly on psyche.1 Although a perception of acne developing as a consequence of adolescence is widely prevalent, it has clear long lasting psychological and physical effects. It is considered bread and butter of dermatology practice as >80% of individuals shall suffer it in their lifetime. It affects 90% boys and 80% girls of 16-17 years age. Acne recovers in the majority after 25 years of age. In approximately 1% of males and 5 % of females it persists until age of 40. Scarring occurs early in acne. 29% of Indian patients were found to have scars post acne in a recent observation study in this review on acne scars.2 The impact, risk factors and brief overview of acne scar treatment is highlighted. Focus is on point 8
May 2022
wise summary rather than full description. The therapies detailed are more for skin of color. Impact of acne scars • Psychologically and emotionally distressing; • Depression, anxiety, poor selfesteem, embarrassment, body image alterations, altered social interactions; • Lowered academic performance, anger, and unemployment; risk factor for suicide; • Negatively affects professional relationships and chances of future employment. Predisposing factors- Risk factors associated with increased likelihood of scarring Not everyone shall develop same grade of acne scarring. As the severity of acne has no direct correlation with psychosocial affection, similarly scarring can develop in all grades of acne. Scarring occurs early and relates to both its severity and delay before treatment.
Acne Scarring – Brief Review with Focus on Atrophic Scarring
Acne severity 5.1-9 times increase in severe/ very severe acne, though risk in all severities.
crater, undulation, tunnel, shallow type and hypertrophic scars.4
Relapsing acne Time between acne onset and first effective treatment- 2.4 to 3.3 times increase. This relates to time elapsed since the onset of inflammation.
2001- Jacob et al classified acne scars into atrophic and hypertrophic. Former was sub classified into ice pick, boxcar and rolling. It allows physicians to easily assess patients with acne scarring and determine the best approach to treatment.6
Male gender Family history-1.3-1.8 times increase when ≥1 relative with scars. Increased incidence on face vs back and chest.3
1999- Langdon- type 1-shallow small, type 2- ice pick scars type 3distensible scars.5
Table 1: March 2006 Goodman and Baron qualitative scar grading system Level of Disease Characteristics
Examples
Macular disease
Erythematous, hyper-or hypopigmented flat marks visible to patient or observer irrespective of distance
Erythematous hyper or hypopigmented flat marks
Mild disease
Mild atrophy or hypertrophy Mild rolling, small soft that may not be obvious at papular social distance of 50 cm or greater and may be covered adequately by makeup or the normal shadow of shaved beard hair in males or normal body hair if extrafacial
Preexisting scars- Increase with number of scars at baseline. Pathogenesis Scars normally proceed through the specific phases of wound healing: inflammation, granulation and remodeling. Histologically, scars have thicker, abundant collagen and aligned in the same plane as epidermis. Scarring indeed occurs as a consequence of deep inflammation. Abnormal keratinization of follicular epithelium leads to comedones. Lymphocytes and neutrophils affect the attenuated follicular wall of closed comedones. The breach of this wall leads to the extravasation of hair, lipids, keratin and bacteria into dermis. A foreign body inflammation is induced. The absence of development of scars is associated with a low expression of proinflammatory markers, remodeling markers and the immunosuppressive cytokine.
Moderate disease Moderate atrophic or hypertrophic scar that is obvious at social distance of 50 cm or greater and is not covered easily by makeup or the normal shadow of shaved beard hair but is still able to be flattened by manual stretching of the skin
More significant rolling, shallow “boxscar”, mild to moderate hypertrophic or opular scars
Severe disease
Punched out atrophic (deep “boxscar”), “icepick”, bridges and tunnels, gross atrophy, dystrophic scars significant hypertrophy or keloid
Severe atrophic or hypertrophic scar that is obvious at social distance of 50 cm or greater and is not covered easily by makeup or the normal shadow of shaved beard hair in males or body hair (if extrafacial) and is not able to be flattened by manual stretching of the skin
Table 2: Goodman and Baron Quantitative scoring
Various scoring systems to grade scarring Time and again, various attempts have been made to standardize severity assessments and treatment modalities. 1987- Ellis and Mitchell- ice pick, May 2022
9
Acne Scarring – Brief Review with Focus on Atrophic Scarring
Table 3: Global Scale for Acne Scar Severity (SCAR-S)
From: Tan JKL, Tang J, Fung K et al. Development and Validation of a Scale for Acne ScarSeverity (SCAR-S) of the Face and Trunk. J Cutaneous Medicine and Surgery 2010; 14: 156-60
Treatment Topical treatment Evidence for efficacy of topical preparations in atrophic acne scarring came in 1991 from a case report. A 25 year female had significant improvement in acne scars after 4 months of tretinoin 0.025% cream daily nightly.7 Topical retinoic acid 0.025% and glycolic acid 12% - in 35 patients, >15 patients showed more than moderate improvement.8 Retinaldehyde 0.1% and Glycolic acid 6% in 145 patients over 3 months-remarkable improvement in macular erythema and hyperpigmentation was noticed.9 Adapalene 0.1 % and benzoyl peroxide 2.5% combination- these have been shown to improve overall severity of atrophic scars as well as reducing occurrence of new scars (prevention).10 Minimally invasive Microdermabrasion– It helps improve superficial rolling scars. It is relatively quick, inexpensive, noninvasive and low risk procedure which contributes to its persistent popularity among patients and providers. To reduce acne scars, more than 6 treatments are generally needed. However, to obtain good to excellent results, 15, and sometimes more than 36 treatments are needed.11 10
May 2022
Superficial Chemical Peel Superficial peels done, in many sessions, help a lot in superficial scarring especially TCA, 10 to 20%. Advantages of TCA include low cost, easy end point and homogeneity of application. 2530% TCA is indicated for boxcar scars without active lesions, rolling scars. Average of 4 to 7 sessions are required for scars at interval of 3040 days. The choice of superficial peeling agent depends on the type of scar, skin type and skin thickness. Suggestions are: TCA (Trichloroacetic acid) - Boxcar scars Glycolic acid- Macular scars Pyruvic acid- Macular lesions and / or very superficial boxcar scars Salicylic acid- Active acne lesions and /or macular scars Jessner’s solution followed by TCASuperficial boxcar and macular scars Medium and deep peels have to be done in experienced hands, especially in skin of color as these entail a higher risk of complications like post inflammatory hyperpigmentation and persistent hypo or depigmentation or erythema. CROSS (Chemical Reconstruction
of Skin Scars) by TCA is a very useful economic way of treating icepick scars, and deep boxcar scars. It has been found very safe in our Indian skin types.12,13 It is as effective as 1550 nm fractional non ablative laser in ice pick scars.14 Fillers- Though expensive, these can be a good alternative for short term management of atrophic acne scars-boxcar and rolling types. Hyaluronic acid is most commonly used temporary filler. Calcium hydroxyapatite and Poly L Lactic acid are semipermanent fillers with biostimulatory effect. These increase collagen production and useful for a greater extent of dermal atrophy. Polymethyl methacrylate is the only dermal filler approved for acne scars. Fat (autologous) is a less used modality which has a long duration of action and can replenish large volume deficits. Skin Needling (micro needling/ percutaneous collage induction therapy)- It is an inexpensive form of scar reduction treatment. It is well suited for Asian skin as chances of PIH are almost nil.15 It is effective at improving depressed acne scarring. It is either performed by skin (derma) roller or dermapen. Results generally start after about 6 weeks. Complete improvement can take at least 3 months to occur and new collagen and texture shall keep improving over a 12 month period. 50 to 90% improvement is expected in different individuals. Most shall require approximately 3 sessions at 4 weekly intervals. My experience with Dermapen™ 4 has been gratifying over last few years. Few before and after pictures from my collection.
Acne Scarring – Brief Review with Focus on Atrophic Scarring
Before
After
Before After Figure 1: 4 sessions of dermapen 4 at 2 months interval
Platelet Rich Plasma Therapy (PRP) – It is an autologous concentration of human platelets in a small volume of plasma. Numerous growth factors stimulate stem cells proliferation and replication of mesenchymal cells, fibroblasts, osteoblasts and endothelial cells. It can be combined with microneedling for better results. Normally three sessions are done a month apart though can vary depending on individual collagen response. Dermabrasion- It is the gold standard for facial acne scarring. It has to be done under local or general anesthesia. Good results for superficial atrophic scars but the chances of complications and downtime has reduced its use to few centers. The advent of fractional ablative lasers almost replaced dermabrasion, which has a lower recovery time and lesser complication rate.16 Surgical Techniques As treatment approach of an individual patient is primarily determined by morphology (type) of scars, surgical interventions are indispensable in most, if not all, individuals.
Before After Figure 2: Depressed scars - 2 sessions of dermapen 4 at 2 months interval
Before After Figure 3: 1 session of dermapen 4 at 6 weeks
Subcision– The word is a combination of subcutaneous incision. It is touted to be most helpful in long term improvement of rolling scars. Adequate local anesthesia, optimal placement of needle in superficial fat and anatomy of facial nerves helps in patient’s best comfort and result. Several sessions may be needed for optimal results in conjunction with other scar reduction procedures. Results depend on the unique wound healing property of the individual.
May 2022
11
Acne Scarring – Brief Review with Focus on Atrophic Scarring
Dermal Grafting– A donor site, usually post auricular, is deepitheliased. A
References
scalpel or laser is used to harvest linear or punch sized grafts depending
1. Baldwin HE The interaction between acne
on scar shape. After undermining the recipient area (scar), grafts are placed in pocket created. It is a useful technique for correcting deep contour
vulgaris and the psyche. Cutis 2002;70:1339.
defects. The prepackaged injectable soft tissue augmenting procedures
2. Budamakuntla L, Parasramani S, Dhoot
has resulted in lesser interest in this procedure.
D, Deshmukh G, Barkate H, Acne in Indian
Excision, Punch Elevation and Punch Grafting
evaluating multiple factors. IP Indian J Clin
Table 4: Global Scale for Acne Scar Severity (SCAR-S)
population:
An
epidemiological
study
Exp Dermatol 2020;6(3):237-242
Technique
Indicated scar types
3. Tan JK, Tang J, Fung K, Gupta AK,
Punch excision
Ice pick scars; deep boxcar scars <3.5 mm in diameter
Y, Gulliver W, Sebaldt RJ. Development and
Elliptical excision and suturing Ice pick scars; deep boxcar scars ≥3.5 mm, scars with bridges, cysts or tunnels Punch grafting
Ice pick scars; deep boxcar scars
Punch elevation
Deep boxcar scars with vertical walls and scar bases that match surrounding skin in texture and pigmentation
Richard Thomas D, Sapra S, Lynde C, Poulin validation of a Scale for Acne Scar Severity (SCAR-S) of the face and trunk. J Cutan Med
Surg.
doi:
10.2310/7750.2010.09037.
2010
Jul-Aug;14(4):156-60. PMID:
20642983. 4. Ellis DA, Michell MJ. Surgical treatment of acne scarring: non-linear scar revision.
Fat Grafting- Efficacy is related to adipose derived stem cells that have potential to differentiate, synthesize collagen and stimulate angiogenesis. Fat graft is harvested and small parcels of fat are injected into multiple tunnels for maximum blood supply.
The
Journal
of
Otolaryngology.
1987
Mar;16(2):116-119. PMID: 2955129. 5. Langdon, R.C. Regarding Dermabrasion for Acne Scars(letter). Dermatologic Surgery. 1999; 25: 919-920. https://doi.org/10.1046/
Ablative Laser- It uses light-based energy to destroy columns of skin. Surrounding zone is a zone of thermally coagulated tissue. A reparative process follows that produces new collagen, elastin fibers and epidermis. Ablative Fractional photothermolysis has overall higher improvement range compared to non-ablative counterpart, though more side effects were noted informer.17
j.1524-4725.1999.99186-11.x
Radiofrequency- Acne scars is the most commonly treated condition by micro needling radiofrequency as per a review.
7. Harris DW, Buckley CC, Ostlere LS, Rustin
6. Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification system and review of treatment options. J Am AcadDermatol. 2001
Jul;
45(1):109-17.
doi:
10.1067/
mjd.2001.113451. PMID: 11423843.
MH. Topical retinoic acid in the treatment of fine acne scarring. Br J Dermatol. 1991
12
Camouflage- It has a significant role in the journey of a scarred patient (more so mentally). Though less prescribed, it should be stressed upon in first encounter with patient as any modality takes months to a year to show significant improvement (except fillers). It does not interfere with any pharmacologic therapy of acne scars. It is used as a temporary cover for post procedure erythema.
Jul;125(1):81-2.
Conclusion A patient of atrophic scarring almost invariably has all types of scars. A consensus of multiple modalities combined, in significantly improving the acne scars, has emerged over a period of time. Ice pick scars improve best with cross and punch excision. Rolling scars improve best with fillers and Subcision. Boxcar scars shallow type respond best to punch elevation and deeper ones suboptimally to multitude of strategies.
9. Dreno B, Katsambas A, Pelfini C,
May 2022
doi:
10.1111/j.1365-
2133.1991.tb06048.x. PMID: 1831384. 8. Chandrashekar B S, Ashwini K R, Vasanth V, Navale S. Retinoic acid and glycolic acid combination in the treatment of acne scars. Indian Dermatol Online J 2015;6:84-8
Plantier D, Jancovici E, Ribet V, Nocera T, Morinet P, Khammari A. Combined 0.1% retinaldehyde/ 6% glycolic acid cream in prophylaxis and treatment of acne scarring. Dermatology.
2007;214(3):260-7.
10.1159/000099593. PMID: 17377389
doi:
Acne Scarring – Brief Review with Focus on Atrophic Scarring
10. Dreno B, Tan J, Rivier M, Martel P, Bissonnette R. Adapalene 0.1%/benzoyl peroxide 2.5% gel reduces the risk of atrophic scar formation in moderate inflammatory acne: a split-face randomized controlled trial.
J
EurAcadDermatolVenereol.
2017
Apr;31(4):737-742. doi: 10.1111/jdv.14026. Epub 2016 Dec 7. PMID: 27790756.
Suggested reading Acne scars: classification and treatment 2nd edition, edited by A. Tosti, M. P. De Padova, G. Fabbrocini, and K. R. Beer, Florida, CRC Press, 2018, 179 pp.
11. Tsai RY, Wang CN, Chan HL. Aluminum oxide crystal microdermabrasion. A new technique
for
treating
facial
scarring.
Dermatol Surg. 1995 Jun;21(6):539-42. doi: 10.1111/j.1524-4725.1995.tb00258.x. PMID: 7773601. 12. Khunger N, Bhardwaj D, Khunger M. Evaluation of CROSS technique with 100% TCA in the management of ice pick acne scars in darker skin types. J CosmetDermatol 2011;10:51–7. 39. 13. Agarwal N, Gupta LK, Khare AK, Kuldeep CM, et al. Therapeutic response of 70% trichloroacetic acid CROSS in atrophic acne scars. DermatolSurg 2015;41:597–604.) 14. Kim HJ, Kim TG, Kwon YS, Park JM, et al. Comparison of a 1,550 nm Erbium: glass fractional laser and a chemical reconstruction of skin scars (CROSS) method in the treatment of acne scars: a simultaneous splitface trial. Lasers Surg Med 2009;41:545–9 15. Cachafeiro T, Escobar G, Maldonado G, Cestari T, et al. Comparison of nonablative fractional erbium laser 1,340 nm and microneedling for the treatment of atrophic acne scars: a randomized clinical trial. DermatolSurg 2016;42:232–41. 16. Christophel J, Elm C, Endrizzi BT, Hilger PA, et al. A randomized controlled trial of fractional laser therapy and dermabrasion for
scar
resurfacing.
DermatolSurg
2012;38:595–602. 17. Ong MW, Bashir SJ. Fractional laser resurfacing for acne scars: a review. Br J Dermatol. 2012 Jun;166(6):1160-9. doi: 10.1111/j.1365-2133.2012.10870.x.
Epub
2012 May 8. PMID: 22296284.
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Tick √ Yourself to Never Ignore Any Skin Lesion
Tick √ Yourself to Never Ignore Any Skin Lesion Dr. Mahajabeen S. Madarkar MD Associate Professor Department of Dermatology SNMC and HSK Hospital Navanagar, Bagalkot, Karnataka
Dr. Tanuja Rajagopal
MBBS Junior Resident Department of Dermatology SNMC and HSK Hospital Navanagar, Bagalkot, Karnataka Abstract Ticks are blood sucking ectoparasites belonging to the class Arachnida. It may cause cutaneous manifestations and also transmit various tick-borne disease. We are reporting a rare case of tick bite with live tick buried its head under the skin. Introduction Ticks are blood sucking ectoparasites belonging to the class Arachnida. It may cause cutaneous manifestations and also transmit various tick-borne disease. They can cause local and systemic complications. Hence diagnosis and management plays a key role. Case Report A 35-year-old female presented to the dermatology outpatient department with complaints of skin lesion associated with itching, burning sensation and pain over the abdomen since 15 days. No history fever or any constitutional symptoms. No history 14
May 2022
of topical application of any native medications or drug intake. There was no similar complaints in the past or no significant family history. On cutaneous examination, a live tick which had stuck firmly and embedded its head under the skin. (Figure 1- A & B) Erythema and crusting was seen at the site of attachment. Removal of tick was done using radiofrequency probe and special care was taken to remove the tick completely without damaging its mouth part which was intact under the skin. Dermoscopy was done using illuco dermoscope (IDS110 Dermatoscope) with 10x magnification which revealed live 8 legged tick (Figure 2- C & D) which may be correlated to ixodid hard tick which has a body protection shield.1 Laboratory investigations were normal and systemic examination revealed no abnormalities.
Tick √ Yourself to Never Ignore Any Skin Lesion
Ehrlichiosis, Recurrent Tularemia, Babesiosis.
fever,
Any tick found should be completely removed alive to avoid the complications and has to follow up the patients for further complications. 3
A
B
Figure 1: A & B-Clinical image showing live tick embedded under the skin
In our case, tick we found may belong to the family Ixodidae and patient had immediate reactions. After removing patient was prescribed oral doxycycline and was followed to observe for late reactions and tick-borne disease. Conclusion Ticks can be very tiny and can be missed in diagnosis. Therefore, one has to carefully assess tick bite and, in such cases, dermoscopy acts as adjunct to the diagnosis. References 1. Jayasree P, Kaliyadan F, Ashique KT. Dermoscopy of tick bite. J Skin Sex Transm Dis 2021;3(1):103-4.
C
D
Figure 2: C & D- Dermoscopy with 10x magnification revealing 8 legged live tick, hard tick which has a chitineous shield (body protection shield). Both dorsal and ventral surface.
2. Haddad Jr, Haddad MR, Santos M, Cardoso JL. Skin manifestations of tick bites in humans. Anaisbrasilerios de dermatolgia. 2018Mar;93:251-5.
Discussion Ticks are arthropod ectoparasites belonging to the class Arachnida. They usually feed on host’s blood. So far 850 species are known and only 10% has importance in human medicine. They are natural hosts of wild and domesticated animals and cause infestations in humans accidentally.2 Ticks possess mouth parts known as capitulum, an unsegmented body and four pairs of legs in adult. It has two major families, Ixodidae (hard ticks) and the Argasidae (soft ticks). Ticks from Ixodidae family has a chitineous shield or scutum which refers to hard tick. The mouth part (capitulum) project forwards and are easily visible from above.
These hard ticks attach to their hosts, without causing pain and remain unchanged till the next phase of their cycle.
3. Liu CC, Landeck L, Zheng M. Tick bite.
Indian
J
DermatolVenereolLeprol
2014;80:269-270.
Tick bites can cause cutaneous manifestations in humans. They can cause immediate and late reactions together called primary lesions and secondary lesions.2 Immediate reactions can be due to toxins and irritants in saliva causing firm papules and intense pruritis and tick can be attached. Late reactions may be due to fragments of the mouth part and includes chronic edematous nodules. Secondary lesions are Lyme Borreliosis, Rocky Mountain spotted fever, Tick paralysis, May 2022
15
Microneedling with GFC – Modified PRP
Microneedling with GFC – Modified PRP Dr. Kanu Verma
MBBS, MD-SKIN &VD Senior Consultant Dermatologist & Cosmetologist, Aastha Medicare, Dwarka, Delhi Visiting Consultant, Aakash Healthcare Hospital, Dwarka, Delhi
Abstract Facial rejuvenation is the most common treatment enquired in a dermatologist clinic. Patients usually ask for minimum invasive, pain less and minimum downtime treatment for their face rejuvenation. Microneedling or collagen induction therapy, is a minimum invasive skin rejuvenation procedure, for facial pigmentation, photo damage skin, fine wrinkle and aged skin, with minimum disruption of epidermis and no adverse effects. Introduction Microneedling is an aesthetic procedure involving Dermapen or Derma Roller or Microneedling Radio Frequency (MNRF) with tiny needles to create micro channels in skin. These needles puncture the skin at various depths to create a controlled skin injury. Each puncture creates a channel that stimulates neovascularization and neocollagenosis. It helps to bright the skin, helps with Hyperpigmentation, Melasma, Skin Tone, Scars, Fine lines & Wrinkles and Pore size and Acne Scars. 16
May 2022
Also known as “COLLAGEN INDUCTION THERAPY” as it is used to treat skin concerns via collagen production. Discussion Microinjury to skin, sets up a wound healing cascade with release of various growth factors. The released growth factors mainly Platelet derived growth factor(PDGF), Epidermal growth factor (EGF), Vascular endothelial growth factor (VEGF), Fibroblast growth factor (FGF) and Transforming growth factor-beta (TGF-beta), can stimulate proliferation of fibroblasts, epidermal cells and collagen synthesis. In addition, the Transforming growth factor–beta, has proved to inhibit melanogenesis or reverse skin pigmentation. Effects of the microneedling can also be enhanced by adding –modified PRP (Platelet-Rich Plasma), GFC (growth factor concentrate)-Yuskin. Yuskin–GFC, formulation has high concentration of growth factors naturally promoting healing
Microneedling with GFC – Modified PRP
and enhances damaged tissue regeneration. It needs to be injected intradermally or can be massaged over the skin after microneedling, hence supplying the under skin layers with collagen and Tenascin, stimulated by transforming growth factors in it. These growth factors also promote formation of new blood vessels that in some cases results in disappearance of spider veins. Addition of GFC-Yuskin to microneedling speeds up the recovery/healing process and stimulates the skin renewal with potential better results than microneedling alone. Patients usually see excellent results after 2-3 sessions. Results Clinically results of GFC with microneedling are natural looking and subtle and can last for as long as more than 18 months. It is ideal to undergo treatment sittings with a gap of 4-6 weeks to get maximum output of GFC on skin pigmentation and rejuvenation. The good thing about this treatment is that GFC-Yuskin is an autologous, ready to use kits and won’t make condition worse unlike other treatment, so one can do treatment confidently without worry, giving natural facial treatment that has lots of benefits. It has no allergic reaction. Recovery from microneedling is usually quick. People may experience some soreness and tenderness immediately after treatment. The area may also have redness and there may be some bruising, which clears up in 4-5 days.
Figure 1: Pre and post treatment of microneedling with GFC
Microneedling with PRP may not be suitable during pregnancy or people with following conditions: -Active acne -History of scarring / bruising easily -Platelet or blood disorder -HIV -Infection on face eg. herpes
3. Ankita Tuknayat , Mala Bhalla , Gurvinder Pal Thami .Platelet-rich plasma is a promising therapy for melisma . J Cosmet Dermatol . 2021 Aug;20 (8): 2431 - 2436.
Financial support and sponsorship Nil
References 1. Sthalekar B, Agarwal M,Sharma V, PatilCY , Desai M. Prospective study of growth facetor concentrate therapy for treatment of melisma. Indian Dermatol Online J2021;12:549-54 2. Safety and Efficacy of Growth Factor Concentrate in the Treatment of Nasolabial Fold Correction: Split Face Pilot Study Satish M Totey ,Gema P Sevilla, Rachita S Dhurat, Geetanjali Shetty, Prashant P Kadam and Satish M Totey May 2022
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Needling with 5FU-Safe and Cost Effective Treatment for Stable Vitiligo
Needling with 5FUSafe and Cost Effective Treatment for Stable Vitiligo Dr. Manmohan Bagri MD, DVL Senior Resident AIIMS, Rishikesh Uttarakhand
Introduction Vitiligo is a chronic acquired autoimmune disorder, presents as depigmented macules, in which total or partial loss of melanocytes occurs.1 Its prevalence is 1-2% of world’s population irrespective of any age or sex.2 For repigmentation, medical treatment is primary therapy but in stable vitiligo various surgical options are available along with medical therapies.3 Topical 5% fluorouracil is less commonly used in vitiligo patients but it has been tried earlier in combination with dermabrasion and lasers. As it’s a safe, cost effective and easy modality for the treatment of stable vitiligo with disease stability of at least one year duration. 5FU along with Needling1 leads to strong inflammatory reaction causing local edema, increase in Intercellular space of basal layer due to which there is over stimulation and migration of melanocytes from pigmented to achromic epidermis resulting in pigmentation.
18
May 2022
Material and methods Five patients with total 12 stable vitiligo patches (>1 year) were selected, who had taken medical and phototherapy treatment for last 7-8 months excluding patients with active Koebner’s phenomenon, age less than 10 years, patches on the face, genitalia, and intertriginous areas. The duration of each patch, presence of other prognostic factors including leukotrichia, site and the treatment taken previously were recorded. Procedure After explaining the procedure to patient consent was taken, lesions were photographed. Under aseptic precautions, affected area cleansed with betadine then normal saline. Local lignocaine was injected over patch after AST. A thick paste of 5% fluorouracil cream applied on the patch followed by needling as close as possible to each other from outside to inside with a 26-G sterile needle. A lag period of few seconds between the time of needling and appearance of pin point bleed
Needling with 5FU-Safe and Cost Effective Treatment for Stable Vitiligo
suggests needle has reached the dermo epidermal junction. Following this, area is cleaned with betadine and equal quantity of 5% fluorouracil and topical antibiotic cream (fusidic acid) applied on the treated area and dressing was done.
once a month for 3 consecutive months; serial photographs were taken; and the patients were followed up for 6 months and evaluated for erythema, pigmentation and any adverse reaction.
Patients were advised to apply a mixture of 5% fluorouracil and antibiotic cream twice daily for 15 days and reviewed every 4 weeks. 5% fluorouracil needling was done
Repigmentation was categorized as 75% (excellent G4), 50-75% (very good-G3), 25-50% (good-G2) and < 25% (poor response-G1) grades were considered as the desirable outcomes.
Pre treatment
After 2 sessions
Result Table 1: Repigmentation category Response
Results (Repigmentation)
Excellent (G4, > 75%)
58 %
Very good (G3, 50-75%)
25 %
Good (G2, 25-50%)
16%
Poor (G1, < 25%)
-
After 3 months
Figure 1: Vitiligo patch over left eye Depigmented patch over left eye after successive treatments repigmentation categorized as G3 after 3 months.
Pre treatment
After 2 sessions
After 4 months
Figure 2: Vitiligo patch over left knee
In the above case of vitiligo patch over left knee improvement were seen after the follow up and categorized as G3. Side effects such as pain (100%) during procedure, erythema (100%), ulceration (30%), itching (54%) were noted in patients.
May 2022
19
Needling with 5FU-Safe and Cost Effective Treatment for Stable Vitiligo
Discussion Tsuji and Hamada in 1983 introduced application of 5FU after therapeutic wounding as vitiligo treatment.4 Now a days various techniques has been used for therapeutic wounding like derma abrasion, cryosurgery, trichloroacetic acid, local application of phenol, laser ablation and needling, but in all above methods needling is the simplest and cost effective technique.3,4 Needling produce strong inflammatory reaction which leads to release of inflammatory mediators such as leukotrienes , C4, D4, MMP-2 (Matrix Metalloproteinase-2) which stimulate melanocyte proliferation and migration from pigmented to achromic area.3,5 Study done by shashikiran et al. showed >75% repigmentation in 49% of patches, in 26% patches 50-75% repigmentation was seen, 25-50% repigmentation developed in 11% patches whereas less than 25% repigmentation seen in 14% cases.1 This showed topical 5% fluorouracil with needling is a safe, easy, cost effective method for repigmentation in stable vitiligo. Conclusion Result of topical 5FU with needling is a simple, safe and cost effective method for stable vitiligo patches in cases where medical and topical treatments are not effective with no major side effects. Reference 1. Shashikiran A R, Gandhi S, Murugesh S B. Efficacy of topical 5% fluorouracil needling in vitiligo. Indian J DermatolVenereolLeprol 2018;84:203-5 2. Santosh SK, Sushantika, Mohan L, Gupta AK. Treatment of Vitiligo with 5-Fluorouracil after Microneedling of the lesion.Int J Sci Stud 2018;5(11):125-127.
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3. Vedamurthy M, Moorthy A, Samuel S (2016) Successful Treatment of Vitiligo by Needling with Topical 5 Fluorouracil. Pigmentary
Disorders
3:242.DOI:
10.4172/2376-0427.1000242. 4. Y. Gauthier, T. Anbar, S. Lepreux,“Possible Mechanisms by Which Topical 5-Fluorouracil and Dermabrasion Could Induce Pigment Spread in Vitiligo Skin: An Experimental Study,” ISRN Dermatology, vol. 2013, Article ID 852497, 7. 5. Sethi S, Mahajan BB, Gupta RR, Ohri A “Comparative evaluation of the therapeutic efficacy of dermabrasion, dermabrasion combined with topical 5% 5-fluorouracil cream, and dermabrasion combined with topical placentrex gel in localized stable vitiligo” Int J Dermatol 2007 Aug;46(8):875-9.
News
Study provides new analysis of isotretinoin and risk for adverse neuropsychiatric outcomes Acne is an inflammatory disorder of the skin, which has sebaceous (oil) glands that connects to the hair follicle, which contains a fine hair.It is a common skin condition that happens when hair follicles under the skin become clogged. The recently published study shows the use of isotretinoin to treat acne was not associated with an increase in adverse neuropsychiatric outcomes, compared with the use of oral antibiotics. Although severe neuropsychiatric effects associated with isotretinoin therapy in patients with acne have been reported. The study results suggest that isotretinoin is conferring protection against adverse neuropsychiatric outcomes, particularly when compared with using oral antibiotics to treat acne, researcher said. In the study, the investigators reviewed electronic health records (2013-2019) from a primarily United States–based dataset (TriNetX) of patients with acne aged 12-27 who had been followed for up to 1 year after their prescriptions had been dispensed.There were four arms: those prescribed isotretinoin (30,866), oral antibiotics (44,748), topical anti-acne treatments (108,367), and those who had not been prescribed any acne treatment (78,666). The primary outcomes were diagnoses of a neuropsychiatric disorder (psychotic, mood, anxiety, personality, behavioral, and sleep disorders; and non-fatal self-harm) within one year of being prescribed treatment. After using propensity score matching to adjust for confounders at baseline, the investigators determined that the odds ratio for any incident neuropsychiatric outcomes among patients with acne treated with isotretinoin was 0.80 (95% confidence interval, 0.74-0.87), compared with patients on oral antibiotics; 0.94 (95% CI, 0.871.02), compared with patients on topical anti-acne medications; and 1.06 (95% CI, 0.97-1.16), compared with those without a prescription for anti-acne medicines.Side effects of isotretinoinsuch as headache, dry mouth, and fatigue were higher among those on isotretinoin than in the other three groups. The researcher concluded that isotretinoin was not independently linked to excess adverse neuropsychiatric outcomes at a population level. They observed a consistent association between increasing acne severity as indicated by anti-acne treatment options and incidence of adverse neuropsychiatric outcomes, but the findings showed that isotretinoin exposure did not add to the risk of neuropsychiatric adverse outcomes over and above what was associated with oral antibiotics.
FDA approves topical tapinarof for plaque psoriasis Psoriasis is a chronic, multisystem inflammatory disease with predominantly skin and joint involvement. Mild to moderate psoriasis can be treated topically with a combination of glucocorticoids, vitamin D analogues, and phototherapy. Moderate to severe psoriasis often requires systemic treatment. Recently the Food and Drug Administration has approved tapinarof cream, 1%, a steroid-free topical cream applied once a day, for the treatment of mild, moderate, or severe plaque psoriasis in adults. Tapinarof is an aryl hydrocarbon receptor agonist and is the first FDA-approved steroid-free topical medication in this class. Approval was based on results of three studies in a phase 3 clinical trial program (PSOARING 1, PSOARING 2), and an open-label extension study, (PSOARING 3). In PSOARING 1 and 2, approximately 1,000 adults aged 18-75 years (median age, 51 years) with plaque psoriasis were randomized to once-daily topical tapinarof or placebo for up to 12 weeks; 85% were White and 57% were men. The primary endpoint for both trials was the proportion of patients who achieved Physician Global Assessment (PGA) scores score of “clear” (0) or “almost clear” (1) and improvement of at least two grades from baseline. After 12 weeks, 36% of the patients in PSOARING 1 and 40% in PSOARING 2 who received tapinarof met the primary outcome, compared with 6% of patients on placebo (P < .001 for both studies). Of these, a total of 73 patients from both studies who achieved PGA scores of 0 were entered in PSOARING 3, a 40-week open-label extension study, in which they stopped tapinarof treatment and retained PGA scores of 0 or 1 for approximately 4 months off treatment. In addition, patients who received tapinarof in the PSOARING 1 and 2 studies showed significant improvement from baseline, compared with patients on placebo, across a range of secondary endpoints including a 75% or greater improvement in Psoriasis Area and Severity Index score (PASI 75). At the end of the PSOARING 3 study (at either week 40 or early termination), 599 participants responded to satisfaction questionnaires. Of these, 83.6% said they were satisfied with the results of tapinarof treatment, and 81.7% said it was more effective than previous topical treatments they had used. Tapinarof cream can be used on all areas of the body, including the face, skin folds, neck, genitalia, anal crux, inflammatory areas, and axillae. May 2022
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