The Aestheticians Journal May'24 Digital Issue

EXECUTIVE EDITOR & PUBLISHER

Dom Daniel CORPORATE OFFICE

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Published for the period of May -2024

Embracing Skin Wellness

Welcome to this issue! As we navigate the complexities of modern life, it's easy to overlook the profound impact our daily habits have on the health and appearance of the skin. However, by embracing a holistic approach that addresses both internal and external factors, we can unlock the secret to radiant, resilient skin. From diet and hydration to stress management and sleep hygiene, every aspect of daily routine plays a crucial role in nurturing the skin from within. The impact of lifestyle factors such as stress, sleep and environmental exposure on skin health. In today's fast-paced world, chronic stress and sleep deprivation have become all too common, taking a toll on the skin's barrier function, elasticity and resilience.

As the body's largest organ, the skin relies on a steady supply of essential nutrients to maintain its integrity and function. From antioxidants and omega-3 fatty acids to vitamins and minerals, the foods we eat can either fuel inflammation and premature aging or support cellular repair and rejuvenation.

Through dermatologist’s expert always provide insights and practical tips for mindfulness practices, relaxation techniques and sleep hygiene strategies. Dermatologists are always there to address specific concerns or simply enhance natural radiance, they guide how to cultivate a sense of balance and restore harmony to body and mind, promoting optimal skin health in the process.

Remember that small changes can yield significant results over time. By prioritizing self-care, embracing healthy habits and nurturing the skin from within, we'll be well on our way to achieving the glowing complexion we deserve.

In this issue we have clinical articles on Facial Rejuvenation for Acne Scars, Ear Lobe Repair with Punch Excision Technique and Pityriasis Lichenoides Chronica.

HOPE YOU HAVE A GREAT READ

Thanks & Cheers

- Dom Daniel Executive Editor & Publisher

Facial Rejuvenation for Acne Scars:

A Case Report

Dr. Vijay Kakkar, M.S (General Surgery), M. Ch. (Plastic Surgery)

Ear Lobe Repair with Punch Excision Technique and Vertical Mattress Suturing: Preserving Aesthetics and Saving Ear Piercing Area

Dr. Priyanka Talari, MBBS, MD (DVL)

Pityriasis Lichenoides Chronica –A Rare Dermatologic Disorder

Dr. Dharmin Mehta, MD (Dermatology)

Dr. Kopal Mehta, MD, DNB (Dermatology)

Editorial Board

Dr. Vijay Kakkar

M.S (General Surgery), M. Ch. (Plastic Surgery)

Diploma in Practical Dermatology- Cardiff University,UK

Sr. Consultant, Saroj Hospital, Mata Chanan

Devi Hospital, Janakpuri, New Delhi

Cosmetic & Plastic Surgeon, IRAC Multispeciality Clinic and Physiotherapy Center, Dubai

Dr. Priyanka Talari

MBBS, MD (DVL)

Dermatologist and Cosmetologist Hyderabad

Dr. Dharmin Mehta

MD (Dermatology)

Dermatologist, Dermakulture Clinic, Surat

Dr. Kopal Mehta

MD, DNB (Dermatology)

Dermatologist, Dermakulture Clinic, Surat

Advisory Board

DR. ARUN KUMAR

DR. SHASHIDHAR TALWAR

DR. RAMESH A. C.

DR. K.S. UPADYA

DR. SAVITHA T G

DR. AKHILESH A.

DR. ABDUL SAMAD

DR. VENKATESH VINAYAK

DR. SATISH K M

DR. HAFSA ERAM

DR. NARENDRA

DR. POORNIMA

DR. MANJUNATH HULMANI

DR. ASHISH SHETTY

Hands on Workshop on Aesthetic Dermatology

Hands on Workshop on Aesthetic Dermatology Excellence in Aesthetic Dermatology Education!

In continuation with its commitment to provide Excellent education in Aesthetic Dermatology procedures AESTHETICCON the "DASIL Certified One Day Hands-on Workshop was held in Mumbai on April 28th,2024.

Overall Rating: With a 100% rating of good and above AESTHETICCON Mumbai 2024 emerged as a resounding success.

Meeting Expectations: All the participants agreed that AESTHETICCON Mumbai far exceeded their expectations .

Practical Learning Impact: Every participant was confident of starting or enhancing their injectables practice post this workshop.

Faculty Performance: The guidance provided by the faculty member Dr.Satish Bhatia (M.D) was unanimously found to be of the highest level with 75% of participants deeming it excellent and the remaining 25% giving it a rating of very good.

Recommending to their Colleagues : All the participants stated that they were going to recommend AESTHETICCON workshops to their Dermatology colleaguesfor the genuine handson experience , efficient event arrangements and execution.

The word-of-mouth from this event is sure to amplify within the aesthetic dermatology community.

Feedback of some of the Participants

• Dr. Jagriti Gandhi (New Delhi) – The program was executed very well. Advanced indications were taught. Being small batches, Dr. Satish Bhatia made us feel more confident about starting injectables in our private practice. It was nice experience.

• Dr. Aswathy (Goa) - I really liked hands on given for each delegate and also the faculty guiding us at each stage. Arrangement was so nice and the staff was very cooperative and excellent.

• Dr. Swami Das Mehta (Punjab) – The workshop was well organised and the faculty was excellent.

• Dr. BhavyaValsalan (Kerala) – The detailed explanation by the faculty and the way they patiently responded to our doubts ...... Excellent faculty and would like to attend more such AESTHETICCONF workshop.

• Dr. Baddam Swarupa Charles (Hyderabad) – The proper area markingsand the practical aspects was explained very well. Everything was Excellent.

• Dr. Farida Kapadia (Mumbai) – Very interactive with student friendly faculty. The sessions were very much informative and has provided confidence in me to start botulinum toxin, fillers, threads in my clinic.

Stay Tuned: The pursuit of excellence in Aesthetic Dermatology education continues! Stay tuned for future AESTHETICCON events, where innovation and knowledge converge with AESTHETICCON HAIR 2024.

Practical Hands on Workshop

Faculty Guiding at the Hands on Workshop

Attentive Audience during the Lecture

Facial Rejuvenation for Acne Scars: A Case Report

Dr. Vijay Kakkar

M.S (General Surgery), M. Ch. (Plastic Surgery)

Diploma in Practical Dermatology- Cardiff University,UK

Sr. Consultant, Saroj Hospital, Mata Chanan Devi Hospital

Janakpuri, New Delhi

Cosmetic & Plastic Surgeon, IRAC Multispeciality Clinic and Physiotherapy Center, Dubai

Introduction

Skin rejuvenation refers to a range of cosmetic treatments and procedures that aim to improve the appearance of the skin and reverse the effects of aging, sun damage and other environmental factors with the goal to restore a more youthful, refreshed and healthy-looking complexion. Facial rejuvenation for acne scars refers to a variety of cosmetic procedures that are designed to improve the appearance of the skin and reduce the visible signs of acne scars. Acne scars can be a source of self-consciousness for many people, which can eventually lead to anxiety and depression. Acne scars, commonly results from the healing acne lesions, is a chronic inflammatory condition of the hair follicles and sebaceous glands, which typically occurs during puberty but can also affects the people with all age group. Acne lesions can be mild blackheads, whiteheads, severe nodules, cysts and the severity of acne can vary widely among individuals.

Etiology being not completely understood, complex involvement of hormones, genes and environmental factors can contribute to the development of acne. Hormonal changes can stimulate sebaceous glands to produce more sebum, which can clog the hair follicles and lead to the formation of acne lesions. Genetic factors can be more predisposed to developing acne due to the family history in some individuals. Environmental factors, such as diet and stress, may also contribute to the development of acne.

The epidemiology of acne scars is difficult to determine, as not all individuals with acne will develop scarring, and the severity of scarring can vary widely among individuals. The pathophysiology of acne scars involves the disruption of normal skin healing processes, leading to the formation of abnormal collagen fibers and scar tissue. When an acne lesion heals, the body's natural response is to produce collagen to

repair the damaged skin. However, in some cases, the collagen fibers produced during the healing process are irregularly shaped and can result in the formation of raised or depressed scars. The type and severity of acne scars can vary depending on the type and severity of the acne lesions and the individual's healing response. Acne scars can be atrophic or hypertrophic depending on whether there is a net loss or gain of collagen. Atrophic scars, which are more common, occur due to a loss of collagen and can be further categorized into icepick, boxcar or rolling scars. The pathogenesis of acne scars is complex and involves various factors such as inflammation, altered matrix remodelling and abnormal wound healing responses. It is essential to diagnose and evaluate the type and severity of scars before selecting the appropriate treatment. Various treatment modalities, such as CO2 FX lasers, hyaluronic acid skin boosters and retinol peels, can be used individually or in combination to achieve optimal results that can help to reduce the appearance of acne scars and restore a more youthful, refreshed appearance to the skin. Facial rejuvenation procedures can be broadly categorized as either surgical or non-surgical. Surgical options, such as face lift surgery or rhytidectomy, are more invasive and involve repositioning or removing excess skin, fat and muscle to restore a more youthful appearance. Non-surgical options, such as fillers or

botulinum toxin injections, are less invasive and involve the injection of substances to smooth out wrinkles or add volume to the face. Surgery can be considered as most direct method, the optimal approach varies depending on patient's individual needs and goals. This may include surgical procedures such as facelifts or brow lifts, minimally invasive treatments such as injectables or lasers or a combination of both. Hence plastic surgeons must carefully evaluate each patient's unique anatomical characteristics, including the condition of their skin and underlying bone structure, when determining the most appropriate treatment plan to achieve the most natural-looking and effective results. Proper knowledge of the anatomical aspects of the aging process is essential for achieving optimal results with these procedures. The severity of the aging process and the areas of major involvement can vary among patients e.g. some patients may experience more significant wrinkling around the eyes or mouth, while others may experience more sagging in the midface or jowls. Additionally, individual factors such as a patient's expectations, recovery time and economic status can all influence the choice of rejuvenation method. Proper patient selection, counseling, and management are crucial to achieving the desired outcomes.1,2,3,4

Case Report

A 26 years female patient was presented to our clinic. After examination she was diagnosed with acne scars. She wanted a clear skin before her wedding. After going through medical history no genetic predisposition was present. No evidence of hormonal imbalance was seen. She didn’t had any disease or was not on any medication as well. Considering all factors and treatment options available she was advised for Fractional Carbon Dioxide Laser, chemical peels & skin boosters as facial rejuvenation techniques. Hyaluronic acid skin booster and yellow peel (retinol) peel combination was used. The clinical pictures before and after treatment as shown as follows:

Figure 1: Before treatment

Facial Rejuvenation for Acne Scars: A Case Report

Diagnosis

The diagnosis of acne scars typically involves a visual examination of the skin as the appearance and location of the scars can provide the type and severity of the scarring. These acne scars are classified as atrophic scars which appear as depressions or indentations in the skin and are caused by the loss of tissue during the healing process and are further classified into ice pick, boxcar or rolling scars based on their shape and depth or can be hypertrophic/ keloid scars which appear as raised, thickened areas of skin and are caused by the overproduction of collagen during the healing process. Sometimes areas of skin get darkened after an acne lesion has healed. This is called as post-inflammatory hyperpigmentation (PIH) that occurs due to the increase in melanin production in response to inflammation. In some cases skin biopsy or other diagnostic tests are done to confirm the diagnosis of acne scars.2,3,4,5

Treatment

A typical stepwise approach that targets each component of scarring i.e. first to address any underlying active acne and then prevent scarring is required for the management of acne scars. Once active acne is under control, treatment can be

focused on addressing scarassociated erythema and atrophic scarring. Various treatment options being available, choice to be made depending on type and severity of the scarring, as well as the patient's individual needs and goals. Topical or oral medications, chemical peels, laser resurfacing or surgical procedures such as dermabrasion/subcision or combination treatment is the most effective approach for treating acne scars, as multiple components of scarring can be targeted simultaneously. A patient-specific approach is important, as the type and severity of scarring can vary widely from patient to patient.

Figure 2: 3 week after MNRF and yellow peel

Figure 3: 6 week after facial hydration with hyaluronic acid skin booster

The several facial rejuvenation techniques of acne scars includes microneedling that encourages the body to produce more collagen by puncturing the skin with a needle-studded roller, laser resurfacing which helps to remove the top layer of skin with a laser instrument, dermabrasion which removes the top layer of skin with a rapidly rotating brush or other device and using dermal fillers; injections like steroids or other medications into raised scars to help soften and flatten them can be used as effective treatment options. Using chemical peels involve application of chemical solution to skin which exfoliates the top layers of dead skin cells and stimulates the growth of new, healthy skin. Thus improving the tone, texture of skin, reducing the appearance of fine lines and wrinkles and minimize the visibility of age spots and sun damage. Microdermabrasion involves use of special device to exfoliate the top layers of the skin, removing dead skin cells and promoting the growth of new, healthy skin. In some cases botox i.e. injecting purified form of the botulinum toxin into the skin to relax the muscles that cause wrinkles and other facial expressions can help to smooth out fine lines and wrinkles and create a more youthful, refreshed appearance.5,6,7

A combination of CO2 fractional lasers, hyaluronic acid skin boosters and retinol peels can be used for both acne scar treatment and facial rejuvenation. CO2 fractional

lasers work by delivering short pulses of high-energy light to the skin, creating thousands of microscopic treatment zones that penetrate deep into the skin. This stimulates the production of new collagen and elastin, which can improve the appearance of acne scars and help to rejuvenate the skin. Hyaluronic acid (HA) skin boosters work by injecting HA into the skin in small amounts to improve skin texture and tone and to reduce the appearance of fine lines, wrinkles and acne scars. Retinol peels work by exfoliating the outer layers of the skin, which can help to reduce the appearance of acne scars, improve overall skin texture and tone and stimulate collagen production. When used together, these treatments can provide a comprehensive approach to acne scar treatment and facial rejuvenation.8,9

CO2 fractional lasers being the popular treatment option for acne scars and facial rejuvenation that stimulates the production of new collagen and elastin, which can improve the appearance of acne scars and help to rejuvenate the skin. These lasers work by delivering short pulses of high-energy light to the skin, creating thousands of microscopic treatment zones that penetrate deep into the skin which can be customized to target specific depths and areas of the skin, allowing for a precise and individualized treatment approach. It typically require several sessions, spaced several weeks apart, to

achieve the desired results. Recovery time can vary depending on the depth and intensity of the treatment, but most patients experience some redness, swelling and peeling for several days after each session. Other factors, such as skin type, medical history and individual goals and expectations, should also be taken into account when determining the most appropriate treatment approach.8

Retinol peels/ yellow peels, can be used for both acne scar treatment and facial rejuvenation. Retinol is a type of vitamin A that is known to improve the appearance of fine lines, wrinkles, uneven skin tone and stimulates collagen production and promoting cell turnover, which can help to reduce the appearance of acne scars and improve overall skin texture. Retinol can be applied topically as a cream or serum or it can be used in higher concentrations in chemical peels. Yellow peels are a type of chemical peel that contains a combination of salicylic acid, lactic acid and citric acid, as well as other ingredients such as retinol, kojic acid and arbutin. The specific formulation of a yellow peel can vary depending on the provider and the individual patient's needs. Yellow peels work by exfoliating the outer layers of the skin, which can help to reduce the appearance of acne scars, improve overall skin texture and tone and stimulate collagen production. When used together, retinol and yellow

Facial Rejuvenation for Acne Scars: A Case Report

peels can be an effective treatment option for acne scars and facial rejuvenation. The retinol helps to promote collagen production and cell turnover, while the yellow peel exfoliates the skin and helps to improve its texture and tone. Hyaluronic acid skin boosters can be used for acne scar treatment and facial rejuvenation. HA is a naturally occurring substance in the body, HA skin boosters can also be used for overall facial rejuvenation, as they can help to restore volume and hydration to the skin and stimulate collagen production. For acne scars HA skin boosters work by filling in the depressions caused by the scarring, which can help to improve the overall appearance of the skin. The treatment is generally performed in a series of sessions, with results becoming noticeable after the first session and continuing to improve with subsequent treatments. HA skin booster that contains a mix of different-sized HA molecules, which can provide more natural-looking results and longer-lasting effects. It is typically injected into the skin using a fine needle or cannula and the procedure is generally well-tolerated with minimal downtime. However, as with any injectable treatment, there is a risk of side effects such as swelling, bruising and infection and it is important to work with a qualified and experienced provider to ensure safe and effective treatment. The combination of CO2 fractional lasers, hyaluronic acid skin boosters

and retinol peels can be an effective treatment for acne scars and facial rejuvenation. Each of these treatments works in a different way to improve the appearance of the skin and together they can provide comprehensive improvement. 2,10,11

Discussion

Facial rejuvenation refers to the various procedures or treatments that aim to restore a youthful and vibrant appearance to the face. These treatments can address a range of concerns related to aging, such as wrinkles, sagging skin, loss of volume and uneven skin tone or texture. Facial rejuvenation for acne scars typically involves a combination of treatments that target different aspects of scarring, including atrophic scars, hyperpigmentation and erythema. The various approaches to facial rejuvenation, including surgical and non-surgical options. Surgical procedures such as facelifts, brow lifts and eyelid surgery involve incisions and the removal or repositioning of excess skin tissue, gives dramatic results but requires significant recovery time and carry a higher risk of complications. Non-surgical options for facial rejuvenation include injectables, fillers, lasers, and peels can be performed in-office and typically have little to no downtime. Injectables such as botox can temporarily smooth wrinkles and fine lines by relaxing the muscles responsible for facial expressions. Dermal fillers can add volume to areas of the

face that have lost fullness, such as the cheeks or lips. Laser treatments can improve skin texture and tone, while chemical peels can remove damaged outer layers of skin to reveal smoother, fresherlooking skin underneath. Combining multiple nonsurgical treatments can often produce the best results for facial rejuvenation. For example, a combination of injectables and fillers can help smooth wrinkles and restore volume to the face, while laser treatments or chemical peels can improve the overall texture and tone of the skin. CO2 fractional lasers are commonly used to treat atrophic scars by promoting collagen production and remodelling. Hyaluronic acid skin boosters are used to improve skin hydration, texture and elasticity, which can also help reduce the appearance of acne scars. Retinol peels can be used to address hyperpigmentation and improve skin texture. Combination of these treatments can provide a comprehensive approach to addressing acne scarring and improving overall skin quality.8,12,13,14,15

The safety and efficacy of the combination of CO2 fractional lasers, hyaluronic acid skin booster and retinol peel for acne scars and facial rejuvenation have been studied in various clinical trials. CO2 fractional lasers have been shown to be safe and effective in improving the appearance of acne scars but has also shown to carry potential risks such

as hyperpigmentation, hypopigmentation, scarring and infection. These risks can be minimized by proper patient selection, appropriate laser settings and post-treatment care. Hyaluronic acid skin boosters has also shown adverse effects which are rare, with the most common being mild swelling, redness and bruising at the injection site. The use of retinol peels carries a lower risk of adverse effects compared to CO2 lasers and hyaluronic acid injections, with mild redness and flaking being the most common side effects. The combination of all three has shown promising results however, as with any aesthetic procedure, it is important to consult with a qualified healthcare provider to determine the most appropriate treatment plan based on individual factors such as skin type, severity of scarring and overall health status. It's also important to manage expectations regarding the results of facial rejuvenation for acne scars. While significant improvements can be achieved, complete elimination of scarring may not be possible and multiple sessions may be required for optimal results. Patients should also be prepared for some downtime and potential side effects such as redness, swelling and temporary changes in skin texture.8,16

Conclusion

Facial rejuvenation for acne scars requires a comprehensive approach that targets each component of scarring. The first step is to

target erythema, followed by addressing atrophic scarring, which is more common than hypertrophic scars and keloids. Different treatment modalities are available for acne scars, including CO2 fractional lasers, hyaluronic acid skin boosters and retinol peels. Combining these treatments in a patientspecific way can offer the best chance of significant improvement. However, proper diagnosis, evaluation and patient selection are critical to achieving optimal outcomes. Additionally, active acne should be treated before addressing scars to prevent a cycle of scarring in already treated areas. Ultimately, facial rejuvenation for acne scars requires a personalized approach that takes into account the patient's individual characteristics, expectations and recovery time. CO2 fractional lasers are commonly used to treat atrophic scars by promoting collagen production and remodelling. Hyaluronic acid skin boosters are used to improve skin hydration, texture and elasticity, which can also help reduce the appearance of acne scars. Retinol peels can be used to address hyperpigmentation and improve skin texture. Combining these treatments can provide a comprehensive approach to addressing acne scarring and improving overall skin quality. However, it's important to note that not all patients are suitable candidates for these procedures, and a consultation with a qualified dermatologist or

plastic surgeon is necessary to determine the most appropriate treatment plan. The best acne scar removal methods include laser skin resurfacing, chemical peels, microdermabrasion, microneedling and filler.

References

1. Kim BJ, Choi JH, Lee Y. Development of Facial Rejuvenation Procedures: Thirty Years of Clinical Experience with Face Lifts. Arch Plast Surg. 2015 Sep;42(5):521-31. doi: 10.5999/aps.2015.42.5.521. Epub 2015 Sep 15. PMID: 26430622; PMCID: PMC4579162. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4579162/

2. Brownstone Nicholas ,Explore New Tactics for Acne Scars, Dermatology Times, June 2022,Volume 43, Issue number 6, pages 38 https://www. dermatologytimes.com/view/ explore-new-tactics-for-acne-scars

3. JOUR, Berg, Daniel et al, Acne Scars: Pathogenesis, Classification and Treatment PY - 20102010/10/14, 893080, 2010, 1687-6105https://doi. org/10.1155/2010/893080 https:// www.hindawi.com/journals/ drp/2010/893080

4. Kravvas G, Al-Niaimi F. A systematic review of treatments for acne scarring. Part 1: Nonenergy-based techniques. Scars, Burns & Healing. 2017;3, doi:10.1177/2059513117695312 https://journals.sagepub.com/ doi/10.1177/2059513117695312

5. Fabbrocini G, Annunziata MC, D'Arco V, De Vita V, Lodi G, Mauriello MC, Pastore F, Monfrecola G. Acne scars: pathogenesis, classification and treatment. Dermatol Res Pract. 2010;2010:893080. doi: 10.1155/2010/893080. Epub 2010

Facial Rejuvenation for Acne Scars: A Case Report

Oct 14. PMID: 20981308; PMCID: PMC2958495. https://www. ncbi.nlm.nih.gov/pmc/articles/ PMC2958495/

6.Connolly D, Vu HL, Mariwalla K, Saedi N. Acne ScarringPathogenesis, Evaluation, and Treatment Options. J Clin Aesthet Dermatol. 2017 Sep;10(9):1223. Epub 2017 Sep 1. PMID: 29344322; PMCID: PMC5749614. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5749614/

7. Khunger N. Standard guidelines of care for acne surgery. Indian J Dermatol Venereol Leprol 2008;74:28-36

8. Zhang J, Xu F, Lin H, et al. Efficacy of fractional CO2 laser therapy combined with hyaluronic acid dressing for treating facial atrophic acne scars: a systematic review and meta-analysis of randomized controlled trials. Lasers Med Sci. 2023;38(1):214. Published 2023 Sep 19. doi:10.1007/s10103-02303879-y

9. Mahamoud WA, El Barbary RA, Ibrahim NF, Akmal EM, Ibrahim SM. Fractional carbon dioxide laser combined with intradermal injection of autologous platelet-rich plasma versus noncross-linked hyaluronic acid in the treatment of atrophic postacne scars: A split face study. J Cosmet Dermatol. 2020;19(6):13411352. doi:10.1111/jocd.13427

10. Ypiranga, S., Fonseca, R. (2017). Hyaluronic Acid Filler for Skin Booster on the Face. In: Issa, M., Tamura, B. (eds) Botulinum Toxins, Fillers and Related Substances. Clinical Approaches and Procedures in Cosmetic Dermatology. Springer, Cham. https://doi.org/10.1007/978-3319-20253-2_23-1

11. Mukherjee, Siddharth et al. “Retinoids in the treatment of skin

aging: an overview of clinical efficacy and safety.” Clinical interventions in aging vol. 1,4 (2006): 327-48. doi:10.2147/ciia.2006.1.4.327

12. Ganceviciene, Ruta et al. “Skin anti-aging strategies.” Dermatoendocrinology vol. 4,3 (2012): 30819. doi:10.4161/derm.22804

13. Beaty MM. Guiding the Facial Rejuvenation Journey: Fulfilling the Complete Role of Surgeon and Aesthetic Practitioner. Facial Plast Surg 2021;37:140–148.

14. Goldman, Alberto, and Uwe Wollina. “Facial rejuvenation for middle-aged women: a combined approach with minimally invasive procedures.” Clinical interventions in aging vol. 5 293-9. 23 Sep. 2010, doi:10.2147/cia.s13215

15. Jie Zhu, Xi Ji, Min Li, Xiao-e Chen, Juan Liu, Jia-an Zhang, Dan Luo, Bing-rong Zhou, "The Efficacy and Safety of Fractional CO2 Laser Combined with Topical Type A Botulinum Toxin for Facial Rejuvenation: A Randomized Controlled Split-Face Study", BioMed Research International, vol. 2016, Article ID 3853754, 7 pages, 2016. https://doi. org/10.1155/2016/3853754

16. Zhang DD, Zhao WY, Fang QQ, et al. The efficacy of fractional CO2 laser in acne scar treatment: A meta-analysis. Dermatol Ther. 2021;34(1):e14539. doi:10.1111/ dth.14539

Risk for COVID-19 Infection in Patients With Vitiligo

Vitiligo is a depigmentation disorder that results from the loss of melanocytes in the epidermis. The most widely accepted pathophysiology for melanocyte destruction in vitiligo is an autoimmune process involving dysregulated cytokine production and autoreactive T-cell activation. Individuals with cutaneous autoinflammatory conditions currently are vital patient populations warranting research, as their susceptibility to COVID-19 infection may differ from the general population. Our research team previously found a small increased risk for COVID-19 infection in patients with psoriasis, which suggests that other dermatologic conditions also may impact COVID-19 risk. The risk for COVID-19 infection in patients with vitiligo remains largely unknown. In this retrospective cohort study, we investigated the risk for COVID-19 infection in patients with vitiligo compared with those without vitiligo utilizing claims data from the COVID-19 Research Database. The vitiligo and nonvitiligo cohorts included 40,363 and 161,452 patients, respectively (Table 1). Logistic regression analysis with adjustment for confounding variables, including high comorbid risk factors revealed that patients with a diagnosis of vitiligo had significantly increased odds of COVID-19 infection compared with patients without vitiligo (adjusted odds ratio [AOR], 1.47; 95% CI, 1.37-1.57; P<.001). Additionally, subgroup logistic analyses for sex, age, and exclusion of patients who were HIV positive revealed that females with vitiligo had higher odds of contracting COVID-19 than males with vitiligo. Our results showed that patients with vitiligo had a higher relative risk for contracting COVID-19 than individuals without vitiligo. It has been reported that the prevalence of COVID-19 is higher among patients with autoimmune diseases compared to the general population. Additionally, a handful of vitiligo patients are managed with immunosuppressive agents that may further weaken their immune response. Moreover, survey results from dermatologists managing vitiligo patients revealed that physicians were fairly comfortable prescribing immune suppressants and encouraging in-office phototherapy during the COVID-19 pandemic. As a result, more patients may have been attending in-office visits for their phototherapy, which may have increased their risk for COVID-19. Although these factors play a role in ¬COVID-19 infection rates, the underlying immune dysregulation in vitiligo in relation to COVID-19 remains unknown and should be further explored.

Our findings are limited by the use of ICD-10 codes, the inability to control for all potential confounding variables, the lack of data regarding the stage of vitiligo, and the absence of data for undiagnosed COVID-19 infections. In addition, patients with vitiligo may be more likely to seek care, potentially increasing their rates of COVID-19 testing. The inability to identify the stage of vitiligo during enrollment in the database may have altered our results, as individuals with active disease have increased levels of IFN Increased secretion of IFN also potentially helps in the clearance of COVID-19 infection.1 Future studies should investigate this relationship via planned ¬COVID-19 testing, identification of vitiligo stage, and controlling for other associated comorbidities.

Study Demonstrates Faster Recovery, Less Pain After Facial Resurfacing With 2910-nm Laser

A 2910-nm erbium-doped fluoride glass fiber laser, approved 2 years ago by the US Food and Drug Administration (FDA), has demonstrated a high degree of improvement for facial photoaging and rhytides along with relatively high rates of patient satisfaction — while causing less discomfort and downtime compared with conventional fractional lasers, a small single-center study showed.

In the study enrolled 15 patients who had three treatment sessions with the 2910-nm laser. It has a really fast time in healing compared to traditional abatable lasers; the healing time is 5-7 days vs several weeks. The 2910nm erbium-doped fluoride glass fiber laser is a mid-infrared ablative fractional device that operates at peak water absorption. It’s designed to cause minimal residual thermal damage, resulting in less discomfort, shorter downtime, and potentially fewer side effects than conventional ablative lasers.

Because of the way the pulses are delivered, “it’s far less painful than traditional fractional ablative lasers, so you can use mainly topical numbing; you don’t need nerve blocks, you don’t have to infiltrate lidocaine, you don’t have to put the patient under anesthesia,” author said.

Because of the wavelength, how pulses are delivered and how customizable the settings are, it’s safer to use in darker skin types,” and the density, depth, and the amount of coagulation applied into the skin are customizable.

The laser also delivers pulses in a different way than the conventional 2940-nm erbium and CO2 lasers, resercher explained. Traditional lasers do it all in one pulse. This laser uses micropulses with relaxation time in between pulses, so the body interprets it as less painful and allows pressure and steam to escape out of the channel, which results in faster healing.

The study patients had topical anesthetic cream applied to their faces 45-60 minutes before the procedure. Multiple passes were made using both superficial and deep laser modes. The average patient age was 65.7 years, and Fitzpatrick skin types included I (n = 3), II (n = 3), III (n = 7), and IV (n = 2). On a scale of 0-10, the average level of discomfort was 4.9, and the average patient satisfaction after three treatments was 4.8. For cosmetic improvement, the study used the 5-point Global Aesthetic Improvement Scale (GAIS). Blinded reviewers evaluated digital images and determined an average GAIS score of 3.2 for overall appearance, 2.9 for wrinkles, 3.6 for pigment, 3.1 for skin texture, and 2.6 for skin laxity. When the patients themselves reviewed the digital images, the average GAIS score was 3.8 for overall appearance.

Lidocaine & Prilocaine Cream

Acid (AHA) 6% Lactic Acid(BHA) 2% Retinyl Palmitate 0.001% Ceramide-2.

Procapil Redensyl

Glycolic

Ear Lobe Repair with Punch Excision Technique and Vertical Mattress Suturing: Preserving Aesthetics and Saving Ear Piercing Area

Dr. Priyanka Talari MBBS, MD (DVL)

Dermatologist

and Cosmetologist

Hyderabad

Introduction

Ear lobe repair is a surgical procedure performed under local anesthesia, aimed at correcting deformities, injuries, or elongation of the earlobes. The earlobes are susceptible to damage due to factors such as trauma, wearing heavy earrings, or gauging. When the earlobe is torn, stretched, or otherwise damaged, it can affect the aesthetic appearance of the ear and cause discomfort or difficulty in wearing earrings. This procedure aims to restore the natural appearance and shape of the earlobes with several steps to reconstruct the damaged or stretched tissue having any irregularities or asymmetries. Such procedures are commonly performed by plastic surgeons or dermatologists with expertise in cosmetic procedures.

The primary goal of ear lobe repair is to restore a natural-

looking and well-contoured earlobe. Various techniques can be employed during the surgical intervention, depending on the specific needs of the patient. These techniques may include direct closure, repositioning of the tissue, or using advanced suturing techniques to ensure proper healing and minimize scarring. While ear lobe repair is generally considered quick, safe, and effective, the individual results may vary as the success rate depends on various factors, including the severity of the earlobe deformity, the patient's overall health, and their adherence to post-operative care instructions.

Sharma et al.'s classification distinguish between congenital and acquired clefts, with acquired clefts further subcategorized into partial or complete defects based on the extent of lobe margin

involvement. The choice of surgical technique depends on the specific deformity/ defects present which can be either partial, characterized by a wide aperture, or total, that involves the complete splitting of the lobe. In conventional repair techniques, with or without preserving the earring orifice, the resulting skin scar is either located at the center of the lobule or just beneath it. Flap techniques can result in a central dimple due to a deficiency in central connective tissue and fat. Placing future earrings in the central lobule or scar may not be aesthetically pleasing to some patients. The "Step advancement flap" technique offers an alternative approach were, the flap is elevated and advanced either anteriorly or posteriorly, thereby moving the scar away from the center of the lobule. This helps to maintain the thickness of the lobule and allows the future earring to be placed in the center, avoiding the skin scar and reducing the risk of recurrence.1

Punch excision technique is a simple new innovative technique with vertical mattress suturing helps in preventing notching along the scar and preserves the shape of the ear lobule giving good aesthetic appearance helps in ear piercing in the future.

Case Presentation

A 38 year female patient visited our clinic with the concern of ear lobe repair. She was diagnosed with an elongated earlobe. We opted for the ear lobe repair procedure. After obtaining

consent, we administered a test dose of local anesthesia, injection lidocaine HCl. The ear lobe repair was performed using the punch method with the assistance of a chalazion clamp. Under aseptic precautions and local anesthesia, the skin was punched to create raw areas and sutured using vertical mattress sutures. A punch size 1mm larger than the torn area was selected, and the chalazion clamp was used to secure hemostasis and stability during punch excision surgery.

Following the procedure, the patient was briefed about the process and post-operative care instructions. The patient was prescribed a course of medication including Amoxicillin (500mg), Clavulanic Acid (125mg), Acetaminophen or Paracetamol, Mupirocin ointment to be applied twice a day, and Chymotrypsin to be taken thrice a day for one week. Antiseptic dressing was advised every alternate day.

Figure 1: Ear lobe surgical instruments

Figure 2: After earlobe surgery

Figure 3: One month after earlobe surgery

Ear Lobe Repair with Punch Excision Technique and Vertical Mattress Suturing:

Treatment

The typical treatment procedure performed in an outpatient setting often involves local anesthesia, where the type of surgery depends on multiple factors. This approach is welltolerated, and most patients can resume their regular activities relatively quickly. At the start of the surgery, the area to be treated along with the surrounding region is cleaned, sterilized, and then numbed with anesthesia. Usually, a numbing cream is applied to avoid the prick pain of local anesthetic.

Precise incisions are made along the edges of the damaged earlobe with a punch, which may follow the original tear, or the size may be adjusted based on the desired outcome. Further tissue realignment is achieved by carefully repositioning the torn or stretched tissue, ensuring that the edges align properly. If necessary, excess tissue can be removed to achieve symmetry and balance. Specialized suturing techniques are employed to close the incisions and secure the newly aligned tissue. The sutures may be placed internally or externally, depending on the specific case. Once the sutures are in place, a dressing or bandage is applied to protect the incisions and care for the earlobes post-surgery. This includes keeping the area clean, avoiding certain activities, and managing any discomfort to ensure proper healing and minimize the risk of complications.2, 3

Torn earlobes/ split earlobes or cleft earlobes are indeed a common aesthetic concern that can be repaired through surgical procedures. The incidence of torn earlobes is estimated to be around 1-2% of the general population. This means that a small percentage of individuals may experience a tear or cleft in their earlobes at some point in their lives. The actual prevalence may vary based on factors such as cultural practices, fashion trends, and individual habits. The steps involved during the surgery are typically the same and include numbing the affected area with anesthesia, doing debridement (i.e., torn edges of the earlobe to be carefully cleaned and trimmed to create fresh, healthy tissue for proper healing), performing suturing, and then applying a protective dressing to safeguard the repair site. The composite technique for repairing split earlobe offers several potential advantages. It aims to maintain the natural contour of the lower pole of the earlobe, ensuring that the repaired earlobe looks aesthetically pleasing. By utilizing an upper triangular flap, the composite technique allows for the preservation of the original perforation site. This eliminates the need for re-piercing, which can be beneficial for patients who wish to continue wearing earrings. The undermining technique used in the composite technique helps prevent the formation of grooves, which can occur when the repaired tissue is under tension. This contributes to a smoother and more natural

appearance. The L-plasty component helps to prevent the development of inferior notching, which can affect the overall shape and symmetry of the repaired earlobe.The cuff of normal tissue at the lower pole, created through the composite technique, provides better support for the weight of earrings. This reduces the risk of recurrence compared to a full-length scar. It can be particularly useful for repairing incomplete cleft lobes, eliminating the need to convert them into complete clefts for repair. Additionally, this technique is easy to master and reproduce, which can be learned and performed consistently and reliably.

DISCUSSION

3,4,5,6

Ear piercing and the wearing of ornaments have been longstanding cultural traditions which can sometimes lead to complications such as dilated or torn earlobes which can be addressed using various surgical techniques. Such techniques have their own advantages and disadvantages. The choice of technique depends on individual preferences, the type of defect (partial or total), categorizing the type of cleft, the desired outcome, making decisions regarding intra- or postoperative earlobe repiercing etc are some key considerations being the minimization of recurrence. In some cases, the preservation of the earring orifice may be a factor to consider during the repair process. This preserves the existing piercing hole, allowing the patient to continue wearing earrings

without the need for repiercing. The aim of the study conducted at the Karwar Institute of Medical Sciences Hospital in Karnataka, India, was to present and discuss a novel technique for repairing both partial and complete cleft ears. The details and specifics of this technique were likely discussed in the study. 1

The first step in repairing an earlobe cleft is to categorize it correctly, whether it is a complete or partial cleft, as well as assessing the specific characteristics of the cleft, such as the distance between the original piercing and the lower margin of the earlobe which guides the choice of repair technique. Some common repair techniques include direct closure, rotation flap, transposition flap, Z-plasty and composite graft. Each technique has its own advantages and limitations, and the surgeon should consider factors such as the size and shape of the cleft, tissue quality and patient preferences when selecting the most appropriate technique. Another decision the surgeon needs to make is whether to re-pierce the earlobe intraoperatively (during the repair procedure) or postoperatively (after the healing process) as intraoperative re-piercing may be preferred to ensure proper alignment and positioning of the piercing whereas postoperative re-piercing may be recommended to allow for optimal healing and reduce the risk of complications. Some previous retrospective studies from the 1970s reported an

incidence rate of 1% to 2% for torn earlobes in patients wearing earrings. However, with the increasing popularity of multiple piercings in today's population, the true incidence rate is likely higher. BlancoDavila and Vasconez have proposed a subclassification for partial clefts based on the distance between the original piercing and the lower margin of the earlobe. This subclassification helps in determining the appropriate technique for closing the partial or complete earlobe cleft.3

Conclusion

Earlobe repair is a common procedure performed by cosmetic surgeons to address torn or cleft earlobes. The incidence of torn earlobes is likely higher than previously reported, given the popularity of multiple piercings in today's population. There are various techniques available for repairing earlobe clefts which are multifactorial based.

The surgeon should be familiar with categorizing the cleft, distinguishing between complete and partial clefts and assessing specific features of the cleft. This categorization helps in selecting the most suitable repair technique. Common techniques include direct closure, rotation flap, transposition flap, Z-plasty and composite graft, each with its own advantages and limitations.

Additionally, the decision of whether to re-pierce the earlobe intraoperatively or postoperatively depends on several factors, including

the repair technique used and individual patient considerations. Ultimately, earlobe repair aims to restore both the function and aesthetics of the earlobe. Consulting with a qualified cosmetic surgeon is crucial to determine the most appropriate technique and achieve satisfactory outcomes in terms of the repair's longevity, symmetry and patient satisfaction.

References

1. Harish MO, Chethana R. Step advancement flap technique of ear lobe repair. Int J Otorhinolaryngol Head Neck Surg 2018;4:154-8.

2. Sadasivan, Kalesh, and Ajayakumar Kochunarayanan. “A Revised Classification and Treatment Algorithm for Acquired Split Earlobe, With a Description of the Composite Technique and its Outcome.” Cureus vol. 12,9 e10422. 13 Sep. 2020, doi:10.7759/ cureus.10422

3. Vujevich, Justin & Goldberg, Leonard & Obagi, Suzan. (2007). Repair of partial and complete earlobe clefts: a review of 21 methods. Journal of drugs in dermatology : JDD. 6. 695-9.

https://www.researchgate.net/ publication/6076006_Repair_of_ partial_and_complete_earlobe_ clefts_a_review_of_21_methods

4. Reed, Kenneth L et al. “Local anesthesia part 2: technical considerations.” Anesthesia progress vol. 59,3 (2012): 127-36; quiz 137. doi:10.2344/0003-3006- 59.3.127

5. Kirchhoff, P., Clavien, PA. & Hahnloser, D. Complications in colorectal surgery: risk factors and preventive strategies. Patient Saf Surg 4, 5 (2010). https://doi. org/10.1186/1754-9493-4-5

6. Vathulya, Madhubari et al. “Simple Tips for Ear Lobule Reconstruction"Lobuloplasty Revisited".” Indian journal of otolaryngology and head and neck surgery: official publication of the Association of Otolaryngologists of India vol. 71, Suppl 2 (2019): 1096-1098. doi:10.1007/s12070-017-1186-2

Pityriasis Lichenoides Chronica –A Rare Dermatologic Disorder

Dr. Dharmin Mehta

MD (Dermatology)

Dermatologist,

Dermakulture Clinic, Surat

Dr. Kopal Mehta

MD, DNB (Dermatology)

Dermatologist, Dermakulture Clinic, Surat

Introduction

Pityriasis lichenoides (PL) encompasses a range of cutaneous disorders, including acute pityriasis lichenoides et varioliformis acuta (PLEVA) and pityriasis lichenoides chronica (PLC) forms, with approximately 20% of cases occurring in children. Despite ongoing investigations, the exact etiology of PL remains uncertain, but there is an observed proliferation of immune cells (T-cells) in the skin. Genetic susceptibility is believed to trigger an inappropriate immune response to foreign agents, such as viruses or medications, leading to skin inflammation. Pityriasis lichenoides has been linked to various illnesses and medications, with no identifiable cause in many cases. Pityriasis lichenoides

et varioliformis acuta and pityriasis lichenoides chronica are considered part of a continuous spectrum with overlapping presentations. In pityriasis lichenoides et varioliformis acuta, characteristic features include abrupt crops of vesicular to necrotic erythematous macules and papules, often accompanied by systemic symptoms. In contrast, lesions of pityriasis lichenoides chronica are milder, exhibit a gradual onset and tend to heal with postinflammatory hypo(PIHy) or hyperpigmentation (PIH). Notably, the varioliform scarring seen in pityriasis lichenoides et varioliformis acuta is absent in pityriasis lichenoides chronica. Dermoscopy of pityriasis lichenoides chronica, as

detailed by Errichetti et al. in seven Caucasian patients, commonly reveals orangeyellowish structureless areas, with focally distributed non-dotted and dotted vessels, along with scattered hypopigmented areas. Pityriasis lichenoides can affect individuals of all ages, but it is more commonly seen in children and young adults. Both pityriasis lichenoides et varioliformis acuta and pityriasis lichenoides chronica can have a chronic course with periods of remission and exacerbation. Dermoscopy may reveal features such as orange-yellowish structureless areas, punctate or glomerular vessels, and erythematous globules surrounding a homogeneous orange or crusty central area.1,2,3

Dermoscopy of pityriasis lichenoides chronica in individuals with darker skin tones revealed an additional “brownish hue” over the yellowish-orange areas. While fewer vessels were noted, multiple scattered dark-brown-black granules, globules and clods were observed. Although speculative, we interpret these pigmented structures as indicative of post-inflammatory hyperpigmentation, a dermoscopic finding commonly described in inflammatory dermatoses in individuals with darker skin types. The challenge in observing vascular structures may be attributed to the predominant pigmented background. Histologically, Errichetti et al. correlated

the orange-yellowish structureless areas of pityriasis lichenoides chronica to hemosiderin degradation products from extravasated red blood cells and attributed the vascular components to dilatation of superficial dermal vessels.4

Pityriasis lichenoides is an uncommon skin disorder that manifests in three distinct forms: pityriasis lichenoides et varioliformis acuta, pityriasis lichenoides chronica and febrile ulceronecrotic Mucha-Habermann disease. These variations represent a spectrum of disease presentations, with the possibility of one form evolving into another. Occurring at a rate of approximately 1 in 2000 individuals annually, pityriasis lichenoides affects males slightly more frequently and typically emerges in late childhood to early adulthood. The condition can manifest across all age groups and ethnicities.5

In pityriasis lichenoides et varioliformis acuta, the onset involves bright red, flat to slightly raised oval spots (2-10 mm) that evolve, developing blisters, pustules and eventually ulceration and crusting. Lesions may appear individually or in groups, with successive crops emerging over weeks. The rash commonly appears on the trunk, thighs, upper arms and flexural areas, occasionally affecting the face, palms, soles and genitals. While there may be mild itching or burning, pityriasis lichenoides et varioliformis acuta typically presents without other

symptoms. The rash can persist for 1.5 to 18 months, with the potential for scarring and skin discoloration.6

Patients with pityriasis lichenoides chronica typically undergo a disease course characterized by relapses and remissions, lasting for months to years. In a retrospective study involving 46 children with pityriasis lichenoides chronica, the median duration of the disease was 20 months (range 3 to 132 months). Individual lesions heal over several weeks, leaving behind hypopigmented or hyperpigmented macules or patches. Notably, scarring is absent. On occasion, patients may present with widespread, hypopigmented macules as the predominant clinical manifestation of the disease. Pityriasis lichenoides chronica, being more common and milder than pityriasis lichenoides et varioliformis acuta, presents with subtle, flat, red to brown oval spots on the trunk, thighs and upper arms. Fine scale peels at the lesion edges and adheres to the center. Pityriasis lichenoides chronica may relapse and remit over an extended period, generally without scarring. Febrile ulceronecrotic Mucha-Habermann disease is exceptionally rare and considered a dermatologic emergency. It presents abruptly with widespread, ulcerated, necrotic plaques ranging from red to black. Systemic symptoms include high fever, abdominal pain, diarrhea, joint pain, breathing difficulties and altered mental

Pityriasis

status. Hospitalization is necessary, with a 25% mortality rate associated with febrile ulceronecrotic MuchaHabermann disease.1,2,3,4,5,6

Case Report

A 10-year-old male child presented with a chronic skin rash characterized by numerous red-brown papules, primarily distributed on the trunk and extremities. The lesions had been present for several months, with occasional pruritus reported by the child. On examination, the patient exhibited multiple oval-shaped papules, some showing a characteristic mica-like scale. Lesions were predominantly located on the trunk and proximal extremities. The clinical presentation raised suspicion of pityriasis lichenoides. A skin biopsy was performed to confirm the diagnosis. Histopathological examination revealed a lichenoid lymphocytic infiltrate in the dermis, supporting the diagnosis of pityriasis lichenoides chronica.

The patient was started on a therapeutic regimen comprising of oral methotrexate 5 mg per week and narrowband UVB phototherapy. Methotrexate was stopped 3 weeks after starting the treatment because of four-fold rise in ALT from the baseline investigation. After that oral mini-pulse therapy with betamethasone 2 mg per week was given for 3 months along with antacids, calcium and vitamin D3 supplements. Beclometasone lotion was given for 2 months with tapering applications. Patient was maintained on

NBUVB therapy for one year. Regular follow-up appointments were scheduled to monitor treatment response and assess potential side effects.

This case report underscores the importance of considering pityriasis lichenoides chronica as a potential diagnosis in pediatric patients presenting with persistent skin lesions. Timely biopsy and accurate diagnosis facilitate appropriate management strategies. The successful use of narrowband UVB phototherapy and oral immunosuppressives in this case highlights the efficacy of a combined treatment approach.

Before treatment

After 6 months of treatment

Figure 1: Red-brown papules on the trunk and extremities.

Diagnosis

Diagnosis involves a dermatologist conducting a biopsy to examine the characteristic skin inflammation pattern. Blood tests may be performed to rule out other causes or identify triggering infections. pityriasis lichenoides et varioliformis acuta and pityriasis lichenoides chronica are not typically associated with abnormal blood tests, but febrile ulceronecrotic MuchaHabermann disease may show increases in white blood cell count and inflammatory markers. Given the similarity of pityriasis lichenoides et varioliformis acuta to certain cutaneous lymphomas, it is crucial to exclude malignant or premalignant conditions during diagnosis.7, 8

Diagnosis is typically based on the clinical appearance of the lesions and may be confirmed through a skin biopsy. The diagnosis of pityriasis lichenoides et varioliformis acuta relies on recognizing the characteristic lesion patterns at various stages, encompassing erythematous maculopapules evolving into papules with a crusted and/or necrotic center. However, the resemblance of these lesions to those of other conditions often necessitates skin biopsies for accurate diagnosis, even in infants.7, 8,9

Treatment

Pityriasis lichenoides presents with a distinctive clinical profile. It is a rare skin disorder characterized by the development of small, red, scaly papules (bumps) on the skin. Most studies employed ultraviolet (UV) phototherapy (narrow-band UVB, broadband UVB, UVA1, or PUVA). Clearance rates across different modalities varied, ranging approximately between 70% and 100%. Narrow-band UVB demonstrated efficacy comparable to PUVA, as did the combination of UVA and UVB vs. PUVA. Oral erythromycin exhibited clearance rates ranging from 66% to 83%, while methotrexate demonstrated up to 100% clearance but in limited and dated studies. Evidence for other treatments was limited. The absence of high-level evidence studies on PL treatment was noted, with potential bias from disease auto-resolution, sample heterogeneity (children vs. adults) and short follow-up periods. Few studies explored the durability of results posttherapy cessation and assessments of quality of life and treatment impact were lacking. Based on the review results, narrowband UVB phototherapy is recommended as a first-line treatment, followed by oral erythromycin with or without topical corticosteroids and low-dose methotrexate as second-line therapies. While pityriasis lichenoides et varioliformis acuta and pityriasis lichenoides chronica may resolve without treatment

over months or years, antibiotics like erythromycin or tetracycline are often prescribed to expedite recovery. Oral steroids may accompany antibiotics for lesion clearance. Light therapy is effective for pityriasis lichenoides et varioliformis acuta and pityriasis lichenoides chronica. Febrile ulceronecrotic Mucha-Habermann disease requires hospital treatment with medications like IV gamma globulin, dapsone, cyclosporine and methotrexate. Methotrexate, a medication that inhibits the proliferation of certain cells, is sometimes used in the treatment of pityriasis lichenoides chronica, a type of skin disorder. However, the use of methotrexate for pityriasis lichenoides chronica is not universally established and the decision to prescribe this medication is typically based on the severity of the condition, the patient's response to other treatments and the overall health of the individual.10,11,12

The evidence supporting the use of methotrexate in pityriasis lichenoides chronica is limited and often comes from small studies or individual case reports. The choice of methotrexate or any other treatment should be made by a dermatologist or healthcare professional after a thorough evaluation of the patient's medical history, the extent of the skin lesions and the response to previous treatments. It's important to note that methotrexate, like any medication, may have

potential side effects and risks. Regular monitoring and follow-up with a healthcare provider are crucial during methotrexate treatment to ensure its safety and effectiveness.13,14

Narrowband UVB (NBUVB) phototherapy is a treatment option that has been used in some cases of pityriasis lichenoides chronica. UVB phototherapy involves exposing the skin to ultraviolet B light of a specific wavelength and narrowband UVB uses a more focused range of wavelengths. The use of narrowband UVB for pityriasis lichenoides chronica is based on the idea that exposure to UVB light can help modulate the immune response and reduce inflammation in the skin. It is important to note that the response to phototherapy can vary from person to person and not all individuals with pityriasis lichenoides chronica may benefit from this treatment. Phototherapy is generally considered when other treatment options, such as topical steroids or oral medications, have not been effective or are not suitable. The decision to use narrowband UVB or any other form of phototherapy should be made by a dermatologist or healthcare professional based on a thorough evaluation of the individual's condition, medical history and response to other treatments.

During phototherapy sessions, the patient's skin is exposed to controlled amounts of UVB light for a prescribed duration and frequency. Regular monitoring and follow-up

Pityriasis Lichenoides

are essential to assess the response to treatment and manage any potential side effects.

As with any medical treatment, it is crucial to consult with a healthcare professional to determine the most appropriate course of action for treating pityriasis lichenoides chronica, taking into consideration the individual's specific circumstances and medical history.15,16,17

Discussion

Pityriasis lichenoides chronica is a rare skin disorder that falls within the spectrum of pityriasis lichenoides, a group of inflammatory skin diseases. Pityriasis lichenoides chronica is characterized by the gradual development of numerous red-brown papules, often accompanied by a characteristic mica-like scale.

Pityriasis lichenoides chronica is rare and affecting a small percentage of the population. It is more commonly observed in late childhood to early adulthood, with a slightly higher prevalence in males. The exact cause of pityriasis lichenoides chronica is not well understood, but it is believed to involve a proliferation of immune cells, specifically T-cells, in the skin. Genetic susceptibility may play a role, triggering an inappropriate immune response to foreign agents such as viruses or medications. Diagnosis is typically made through a skin biopsy to examine the characteristic pattern of inflammation in the skin. Blood tests may be conducted to

rule out other causes of skin rash or identify triggering infections. Differential diagnosis is crucial to exclude malignant or premalignant conditions, given the similarity of pityriasis lichenoides chronica to certain cutaneous lymphomas. Pityriasis lichenoides chronica may resolve without treatment, but the course can be prolonged. Antibiotics like erythromycin or tetracycline are often prescribed to expedite recovery. Oral steroids may be used alongside antibiotics to speed up lesion clearance. Light therapy, specifically narrowband UVB phototherapy, has shown effectiveness in treating pityriasis lichenoides chronica. Pityriasis lichenoides chronica is generally considered a benign condition. The disease may have a prolonged course, but it tends to resolve over time. Scarring is uncommon, and the overall impact on quality of life is often minimal.1,2,3,18,19

The combination treatment of pityriasis lichenoides chronica using methotrexate and narrowband UVB (nbUVB) phototherapy has shown promise in certain cases, offering a comprehensive approach to manage the condition. Methotrexate, an immunosuppressive medication, has demonstrated efficacy in controlling the symptoms of pityriasis lichenoides chronica by modulating the immune response. Narrowband UVB phototherapy has been effective in treating various skin disorders, including pityriasis

lichenoides chronica, through its immunomodulatory effects and promotion of skin healing. The combination of methotrexate and nbUVB is based on the rationale of addressing the dual aspects of immune modulation and targeted light exposure. Combining these treatments may enhance therapeutic efficacy and potentially allow for lower methotrexate dosages, reducing the risk of side effects associated with long-term use. The combination therapy of methotrexate and nbUVB appears to be a promising and well-tolerated treatment option for pityriasis lichenoides chronica, particularly in cases where other treatments may be less effective. This approach acknowledges the multifactorial nature of pityriasis lichenoides chronica, targeting both the underlying immune dysregulation and the skin lesions.18,19

Individual responses to treatment can vary and the decision to use this combination should be made based on the specific circumstances of each patient. Factors such as the severity of the condition, the patient's overall health and the potential risks and benefits of the treatments should be considered. Regular clinical monitoring and follow-up are crucial during combination therapy to assess treatment response, manage potential side effects, and make adjustments to the treatment plan as needed. Dermatologists or healthcare professionals play

a pivotal role in overseeing the treatment course and ensuring optimal outcomes. While the combination of methotrexate and nbUVB appears promising, further research, including larger clinical trials, is needed to establish standardized protocols, assess longterm efficacy and determine safety profiles. Continued research will contribute to refining treatment guidelines for pityriasis lichenoides chronica, providing evidencebased recommendations for healthcare practitioners.17,18,19

Conclusion

In conclusion, pityriasis lichenoides chronica is a rare but distinctive skin disorder with a characteristic clinical presentation. The understanding of its causes and optimal treatment approaches continues to evolve and healthcare professionals play a crucial role in managing and providing personalized care for individuals with pityriasis lichenoides chronica. The treatment of pityriasis lichenoides chronica using a combination of methotrexate and narrowband UVB (NBUVB) phototherapy has shown promise in certain cases. Methotrexate, an immunosuppressive medication, has been used in the treatment of pityriasis lichenoides chronica in some cases. Limited evidence suggests that methotrexate can be effective in controlling the symptoms of pityriasis lichenoides chronica, potentially reducing the number and severity of

skin lesions. Narrowband UVB phototherapy involves exposing the skin to ultraviolet B light of a specific wavelength and it has been used as a treatment for pityriasis lichenoides chronica. UVB phototherapy, including narrowband UVB, has immunomodulatory effects, helping to reduce inflammation and promote healing of the skin lesions. Narrowband UVB has been found to be effective in treating various skin disorders and some studies suggest its benefit in pityriasis lichenoides chronica. The combination of methotrexate and narrowband UVB phototherapy represents a hopeful and comprehensive therapeutic approach for pityriasis lichenoides chronica.

References

1.Teklehaimanot F, Gade A, Rubenstein R. Pityriasis Lichenoides Et Varioliformis Acuta (PLEVA) [Updated 2023 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi. nlm.nih.gov/books/NBK585135/

2. Kim JE, Yun WJ, Mun SK, et al. Pityriasis lichenoides et varioliformis acuta and pityriasis lichenoides chronica: comparison of lesional T-cell subsets and investigation of viral associations. J Cutan Pathol. 2011;38(8):649-656. doi:10.1111/ j.1600-0560.2011.01717.x

3. Nair PS. A clinical and histolopathological study of pityriasis lichenoides. Indian J Dermatol Venereol Leprol 2007;73:100-102

4. Kothari, Rohit et al. “Dermoscopy of Actinic Lichen Planus in Skin of Color.” Indian dermatology online journal vol. 14,6 929-930. 10 Jul. 2023, doi:10.4103/idoj.idoj_616_22

5. Chauhan P, Behera B, Ding DD, et al. Dermoscopy of Infectious Dermatoses (Infectiouscopy) in Skin of Color – a systematic review by the International Dermoscopy Society “Imaging in Skin of Color” Task Force. Dermatol Pract Concept. 2023;13(4):e2023309S. DOI: https://doi.org/10.5826/ dpc.1304S1a309S

6. Tahir, Muhammad et al. “Pityriasis Lichenoides Chronica of Esophagus: A Rare Case Report.” Cureus vol. 14,12 e32290. 7 Dec. 2022, doi:10.7759/cureus.32290

7. Teklehaimanot F, Gade A, Rubenstein R. Pityriasis Lichenoides Et Varioliformis Acuta (PLEVA) [Updated 2023 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi. nlm.nih.gov/books/NBK585135/

8. Khachemoune, A., Blyumin, M.L. Pityriasis Lichenoides. Am J Clin Dermatol 8, 29–36 (2007). https://doi.org/10.2165/00128071200708010-00004

9. Ankad, Balachandra S, and Savitha L Beergouder. “Pityriasis lichenoides et varioliformis acuta in skin of color: new observations by dermoscopy.” Dermatology practical & conceptual vol. 7,1 2734. 31 Jan. 2017, doi:10.5826/ dpc.0701a05

10. Musiek Amy, Zic John A, Levy Moise L et al. Pityriasis lichenoides chronic. Feb 2024.

11. Bellinato F, Maurelli M, Gisondi P, Girolomoni G. A systematic review of treatments for pityriasis lichenoides. J Eur Acad Dermatol Venereol. 2019;33(11):2039-2049. doi:10.1111/jdv.15813

12. Zang JB, Coates SJ, Huang J, Vonderheid EC, Cohen BA. Pityriasis lichenoides: Long-term

Pityriasis Lichenoides Chronica – A Rare Dermatologic Disorder

follow-up study. Pediatr Dermatol. 2018;35(2):213-219. doi:10.1111/ pde.13396

13. Lynch PJ, Saied NK. Methotrexate treatment of pityriasis lichenoides and lymphomatoid papulosis. Cutis. 1979;23(5):634.

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