The Aestheticians Journal Feb'23 Digita Edition

Mimicker of Tinea Faciei

How to Optimize the Outcome of Subcision in Acne Scars?

Videodermoscopy

Evaluation in Nonscarring Alopecia of Scalp Part-2

Congenital Nasal Dermoid and Sinus Cysts: A Case Report

Systemic Lupus Erythematosus

Masquerading as Gangrene- an Infrequent Presentation

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Published for the period of February-2023

The Year of Our Healthiest Skin

Ever

Skin is the largest organ in the human body, and it plays an important role in protecting us from the environment. Skin also contains various cells and structures, such as melano cytes, which produce the pigment melanin, which gives color to the skin and also protects the skin from sun damage. Skin is also able to regenerate, meaning it's able to recover from injuries, such as cuts and burns. However, factors such as sun exposure, smoking, and poor diet can damage the skin and lead to conditions such as aging, wrinkles and skin cancer. Therefore, it is important to take care of the skin by maintaining a healthy lifestyle and skincare routine.

Having healthy skin involves maintaining a consistent skincare routine that includes cleansing, moisturizing, protecting our skin from the sun, use non-comedogenic and hypoallergenic skincare products. This routine should be tailored to our specific skin type (oily, dry, combination, etc.). Additionally, we should aim to eat a balanced diet, stay hydrated, and avoid smoking and excessive alcohol consumption. Maintain a consistent skincare routine and be patient, as results may take time to show.

It's also important to see a dermatologist if we have any specific concerns or issues with our skin. They can provide personalized recommendations and possibly prescribe any necessary medication or treatment.

- Dom Daniel

Executive Editor & Publisher

Systemic Lupus Erythematosus Masquerading as Gangrene- an Infrequent Presentation

Dr. Aditi Singh, MBBS, DDVL

How to Optimize the Outcome of Subcision in Acne Scars?

Dr. Neha Chaitanya Shukla, MBBS, MD

Videodermoscopy Evaluation in Non-scarring Alopecia of Scalp Part-2

Dr. Palak Garg, MD (DVL)

Dr. Gaurav Rajauria, PharmD (Doctor of Pharmacy)

Congenital Nasal Dermoid and Sinus Cysts: A Case Report

Dr. Sheetal Dandale, MBBS, MD, DDV, FCPS

A Mimicker of Tinea Faciei

Dr. Dr. Rathish T. Pillai, MD

Dr. Shahnaz A. S., Junior Resident

Dr. Sana Shams, Junior Resident

Editorial Board

Dr. Neha Chaitanya Shukla

MBBS, MD

Consultant Dermatologist, Cosmetologist and Laser Surgeon

EYE and SKIN Plus Advance Hospital

Gandhinagar, Gujarat

Dr. Palak Garg MD (DVL)

Consultant Dermatologist

Dr. Talwar's Skin, Hair and Laser Clinic

Chandigarh, India

Dr. Aditi Singh

MBBS, DDVL

Consultant Dermatologist and Aesthetician

Dr Aditi Singh's Skin Clinic, Raipur Government District Hospital, Raipur

Dr. Gaurav Rajauria

PharmD (Doctor of Pharmacy)

Assistant Professor

Department of Pharmacy

Dr. Bhimrao Ambedkar University, Chhalesar Agra, Uttar Pradesh,

Dr. Rathish T. Pillai

MD

Head of Department

Department of Dermatology

Azeezia Medical College, Kollam, Kerala

Dr. Shahnaz A. S.

Junior Resident

Department of Dermatology

Azeezia Medical College, Kollam, Kerala

Dr. Sheetal Dandale

MBBS, MD, DDV, FCPS

Consultant Dermatologist, Trichologist and Laser Surgeon Skinconsult Clinic, Mumbai

Dr. Sana Shams

Junior Resident

Department of Dermatology

Azeezia Medical College, Kollam, Kerala

Systemic Lupus Erythematosus

Masquerading as Gangrene- an Infrequent Presentation

Dr. Aditi Singh

MBBS, DDVL

Consultant Dermatologist and Aesthetician

Dr Aditi Singh's Skin Clinic, Raipur

Government District Hospital, Raipur

Abstract

Systemic lupus erythematosus (SLE) is an auto-immune disease affecting multiple organs. Among the cutaneous features, digital gangrene is considered to be very rare, occurring in only 1.3% of SLE patients.[1] It is considered to be due to compromised perfusion of digits secondary to vasculitis, vasospasm and thomboembolism. This is the case report of a 35 year old female who presented with acute blackish discoloration of toes of both feet associated with pain. She had no other features of SLE. But serology came out positive for SLE. The patient responded well to steroids, hydroxychloroquine, anti-platelet and anticoagulant medications and is currently under follow-up.

This case report basically shows us that SLE should be considered as a possible differential diagnosis whenever there is a young patient presenting with digital gangrene without any other medical history.

Keywords: digital gangrene, systemic lupus erythematosus, infrequent

Introduction

Systemic lupus erythematosus is an auto-immune disease of unknown etiology wherein auto-antibodies are formed against various tissues of the body, leading to inflammation. Cutaneous manifestations include malar rash, photosensitivity, livedo reticularis, alopecia, discoid lupus erythematosus and digital gangrene. Out of these, digital gangrene is considered to be very rare, occurring in only 1.3% of SLE patients.[1] Furthermore, peripheral digital gangrene as the first presenting symptom of SLE is seldom reported.

Here we describe a case of a 35 year old female, who presented initially as an acute peripheral digital dry gangrene. She was then evaluated and showed positive ANA. We diagnosed her as a case of SLE and started her on Hydroxychloroquine, anti-platelet and anti-coagulant medications and she is currently under follow up.

Case report

A 35-year old female presented with painful blackish discoloration of toes of both feet since ten days. There was a history of exacerbation of this pain on exposure to cold, with diminution on rewarming. There was no history of smoking, facial rash, photosensitivity, oral ulcers, joint pains, fever prior to onset of symptoms. There was no history of recurrent spontaneous abortions. On examination, there was blackish discoloration of distal half of all toes on right side, and similar discoloration till mid-dorsum of left foot, and locally reduced temperature on both sides. Right anterior and posterior tibial arteries were palpable, dorsalis pedis was feeble. Left anterior tibial artery was palpable, posterior tibial was feeble, and dorsalis pedis artery was not palpable. On investigating, total leucocyte counts (TLC) were normal, with a neutrophilic shift and haemoglobin was 7g/ dL. Erythrocyte sedimentation rate (ESR) was elevated, Anti Nuclear Antibodies (ANA), Double stranded DNA (dsDNA) were positive. Bilateral lower limb arterial Doppler studies were normal. Computerised Tomography (CT) angiography showed left dorsalis pedis artery occlusion and hypoplastic left posterior tibial artery. Hepatic transaminases were mildly elevated. Anti-beta-2 glycoprotein and anti-cardiolipin antibodies were negative. A diagnosis of Systemic Lupus Eythematosus (SLE) was made and patient was started on intravenous Methylprednisolone 500mg in 100 ml normal saline once daily (OD) along with Hydroxychloroquine 200mg

twice a day (BD), anti-platelet and anti-coagulant medications.

Discussion

This case has been reported in view of the sporadic presentation of systemic lupus erythematosus as gangrene. Peripheral digital gangrene has been described as a rare manifestation of SLE. It occurs only in 1.3% of SLE patients.[1] Furthermore, peripheral digital gangrene as the first presenting symptom of SLE is rarely reported. Only 0.2% of patients with SLE present initially as digital gangrene.[1] Former reports declared that it is seen mostly at a late stage of the disease. Rosato et al. claimed that acute digital gangrene is never the first presentation of SLE.[2] Here, this patient presented with digital gangrene as the first presentation of SLE. In 2009 Rajasekhar et al described that, out of 344 patients, 20 cases of digital lupus gangrene had been reported among the Indian population.[3]

According to a study conducted by Liu et al on 2684 lupus patients, a history of Raynaud’s phenomenon is a predictive factor for developing digital necrosis.[1] In this case too, the patient gave a prior history of Raynaud’s phenomenon prior to developing digital gangrene.

As per literature, the suggested treatment of digital gangrene includes corticosteroids, immunosuppressants, anticoagulants and hypolipidemic drugs.[4] This patient too responded well with corticosteroids and hydroxychloroquine, besides anticoagulants.

This case report enlightens us to consider SLE as a possible differential diagnosis whenever we encounter a young patient presenting with digital gangrene, without any other medical history and think of auto-immune etiology as a distinct possibility, so that

Figure 1: Painful blackish discoloration of toes of both feet

Systemic Lupus Erythematosus Masquerading as Gangrene- an Infrequent Presentation

References

1. Alalawi ZM, Alkenany S, Almahroos F, Albloushi B. Peripheral Gangrene as the Initial Presentation of Systemic Lupus Erythematosus in Emergency Department. Cureus. 2020;12(1).

2. Rosato E, Molinaro I, Pisarri S, Salsano F. Digital ulcers as an initial manifestation of systemic lupus erythematosus. Intern Med. 2011;50(7):767-9.

3. Rajasekhar L, Jayachandran NV, Prabu VN, Narsimulu G. Comment on: Prevalence, serological features, response to treatment and outcome of critical peripheral ischaemia in a cohort of lupus patients. Rheumatology (Oxford). 2009 Apr;48(4):451-2.

4. Liu A, Zhang W, Tian X, Zhang X, Zhang F, Zeng X. Prevalence, risk factors and outcome of digital gangrene in 2684 lupus patients. Lupus. 2009 Oct;18(12):1112-8.

Acknowledgement: Horizon Hospital

timely intervention may be done and the limbs can be salvaged.

Systemic Lupus Erythematosus Masquerading as Gangrene- an Infrequent Presentation

Age-related atopic dermatitis phenotypes evaluated in study

Atopic dermatitis, also known as eczema, is a chronic skin condition characterized by itching, redness, and the formation of rashes and blisters. It is often seen as a long-term, recurrent skin disease and is more common in children, but can also occur in adults. Pediatric patients with atopic dermatitis (AD) are more likely to experience symptoms at classical sites such as the knees and have more associated and severe signs of AD, while older adults tend to present with less flexural eczema and the fewest associated signs. Those are key findings from a study conducted which aimed to identify the age-related clinical phenotypes of AD. Previous studies have found differences in the clinical characteristics of AD depending on age of AD onset, ethnic background, and AD severity. However, none have prospectively compared the clinical characteristics and associated signs by age group. Improved understanding of the clinical phenotypes of AD may help guide choice of treatment and improve health outcomes.

The reserchers reviewed self-reported questionnaires that were completed by 380 patients prior to their visit at clinic. Questions included age of AD onset, sociodemographics, Visual Analog Scale (VAS) itch and sleep for Scoring AD, and Numeric Rating Scale (NRS) for skin pain and itch. The researchers used the Eczema Area Severity Index to assess AD severity and a dermatologist conducted full body skin exams, noting the distribution of AD involvement as well as associated signs. Of the 380 patients, 6.1% were younger than aged 18 years, 46.3% were young adults aged 18-39 years, and 47.6% were older adults 40 years of age and older. Compared with pediatric patients, both young and older adults were less likely to experience AD on the ankles, moderate to severe AD lesions on flexures, pityriasis alba, oozing lesions, and moderate to severe excoriations.

In children, severe itch was more common, reported in 47.1%, compared with 43.4% of the young adults and 38.6% of the older adults, and itch was less severe among the young and older adults. Interestingly, despite increased itch in pediatric patients, reserchers found no difference in the severity of skin pain across all age groups, the researchers wrote. Moreover, pediatric patients reported skin pain less often than adult patients. This may be due to age-related differences of pain perception.

In other findings, compared with pediatric patients, young adults were more likely to experience AD around the eyes, while older adults were less likely to experience AD on elbows, nipples, knees, and less likely to have keratosis pilaris, and lichenification. The reserchers used latent class analysis to identify four classes for distribution of AD lesions. In this model, class 1 had low probabilities of AD involvement at all sites examined and class 2 had low probabilities of scalp, face, and foot involvement, and intermediate probability of all other AD sites. Class 3 had low probabilities of hand and foot involvement, high probability of facial erythema, and intermediate probability of all other AD signs, while class 4 had intermediate probability of postauricular and foot involvement, and high probability of all other AD sites examined.

Pigmentary disorder experts welcome research explosion

Atopic Pigmentary disorders typically indicate an increased amount of melanin, leading to darker color of the skin, called hypermelanosis or hyperpigmentation. Decreased or absent pigment makes the skin appear lighter or white, known as hypomelanosis or hypopigmentation. The disorders can be genetic or acquired. Research on pigmentary disorders has entered an overdue era of increased attention, resulting in more treatment options and the promise of improved quality of life for patients.

The arrival of ruxolitinib cream, a topical JAK inhibitor – and oral JAK inhibitors, including ritlecitinib, a JAK3/TEC (tyrosine kinase expressed in hepatocellular carcinoma) inhibitor in clinical trials – is a welcome development for treatment of vitiligo. Also in the pipeline is a kit for melanocyte-keratinocyte transplantation, which involves transplanting epidermal cells from one part of the body to another. This can be a challenging procedure but a kit would make it easier for a wider range of practitioners. (Topical ruxolitinib was approved by the Food and Drug Administration for treating nonsegmental vitiligo in July, 2022.) In the last 10 years, it’s just blown up and people care about vitiligo now, noting that vitiligo is more than a cosmetic issue, like gray hair or wrinkles. Vitiligo is an autoimmune disease and now is being treated as such.

The experts said that the increasing availability of treatment options for hyperpigmentation, aside from hydroquinone, which is associated with an increased risk of adverse effects. We have more and more nonhydroquinone agents which is really nice because it expands our treatment armamentarium and what we can use to cycle people off of hydroquinone. Some of these options include tranexamic acid and products containing azelaic acid or vitamin C. The hyperpigmentation has “profound effects on quality of life” for patients. Patients are often more bothered by the darkening of the skin than the primary process that caused it.

The experts offered suggestions for managing hyperpigmentation patients. Among experts tips for hyperpigmentation, physicians should not be afraid to biopsy the face – but suggested small, 2-millimeter specimens. In addition, “you can get common conditions in uncommon places, if you see something that looks like melasma off the face, it actually could be, so keep that in your differential. Clinicians need to use an algorithm for diagnosis, considering features such as localized or diffuse, scale or no scale, as well as patient history, and other factors. For instance, a hypopigmented area that is localized and has a reddish central papule might lead a clinician to a diagnosis of hypopigmented sarcoidosis.

How to Optimize the Outcome of Subcision in Acne Scars?

Dr. Neha Chaitanya Shukla

MBBS, MD

Consultant

Dermatologist, Cosmetologist and Laser Surgeon

EYE and SKIN Plus Advance Hospital

Gandhinagar, Gujarat

Introduction

Acne scars are the most common sequele of the inflammatory process of acne and affects almost 95 percent of the patients with acne vulgaris.

Hypertrophic scars and keloid scars result from excessive tissue formation; atrophic scars are characterized by loss or damage of tissue, which are further categorized into ice pick, rolling, and boxcar scars. Sometimes the skin loses its underlying support and develops fibrous bands of tissue between the skin and subcutaneous layer, which pull on the epidermis and cause a wavy texture called as rolling scar.

The principle of subcision is to break the fibrotic strands, which tether the scar to the underlying subcutaneous tissue. The depression is lifted by the releasing action of the procedure, as well as from connective tissue that forms during the course of normal wound healing.

Objectives

3 groups of patients with predominantly rolling atrophic acne scars treated with

• 18 gauge nokor needle subcision

• 18 gauge blunt cannula subcision

• Combination of both

The three groups were evaluated thereafter to

• Compare efficacy

• Compare safety

• Compare patient comfort

30 patients with predominantly rolling atrophic acne scars were divided into 3 groups of 10 patients each for 3 sessions of treatment at intervals of 6 weeks-

• Group A- needle subcision

• Group B-Cannula subcision

• Group C –Combination subcision

Assessment of results and adverse effects in each group was done at end of 6 weeks.

How to Optimize the Outcome of Subcision in Acne Scars?

Preoperative requirements

Eutectic Mixture of Local Anesthetic, Marker,Normal Saline, Lignocaine With Adrenaline, Blunt Cannula, Insulin Syringe, 18 Gauge Needle, 2.5 Cc Syringe, Sterile Water, Moisturizing Cream, Topical Antibiotic Cream.

Patients were evaluated using the following scores at end of 6 weeks.

Grade Level of disease

Clinical features

1 Macular Erythematous, hyper-or hypo-pigmented flat marks, with no contour issues.

2 Mild

Mild atrophic or hypertrophic scars that may not be obvious at a social distance of 50 cm or more, and maybe covered adequately with makeup, or the normal shadow of shaved beard hair in men or normal body hair if extrafacial.

3 Moderate

Moderate atrophic or hypertrophic scarring that is obvious at social distance of 50 cm or more, not covered easily by make-up, or normal shadow of shaved beard hair in men or normal body hair if extrafacial, but is still able to be manually flattened by skin stretching if atrophic.

4 Severe

Severe atrophic or hypertrophic scarring that is obvious at social distance of 50 cm or more, not covered easily by make-up, or normal shadow of shaved beard hair in men or normal body hair if extrafacial, and is unable to be manually flattened by skin stretching.

Grade (type)

1-10

A Milder scarring-macular erythematous, pigmented, mildly atrophic, dish like 1 pts

B Moderate scarring-moderately atrophic dish like, punched out small scars with, shallow bases but atrophic areas (<5mm>) 2 pts

C Severe scarring-punched out with deep but normal bases, punched out with deep abnormal bases, linear or troughed dermal scarring, deep and broad atrophic areas

D Hyperplastic papular scars

3 pts

sq-6

VISUAL ANALOG SCORE

Area

sq-12 pts Area >20 cm sq–18 pts

Table 1: Goodman and Baron’s qualitative score

Number of lesions

Results

At the end of treatment, improvement qualitative acne scar grades, Goodman and Baron’s quantitative acne scar scores, physician global assessment and visual analogue scale were significantly higher in patients treated with a combination of nokor needle subcision and blunt cannula subcision as compared to the remaining two groups, while the post procedure side effects were minimal in the group treated with blunt cannula subcision.

These findings were in concordance with previous studies published regarding blunt cannula subcision, mentioned in refrences during my presentation, which concluded that Cannula subcision appears to be a safe and practical technique that can enhance the efficacy of subcision without considerable complications.

One such study was done by Nilforoushzadeh MA, Lotfi E, HeidariKharaji M, Nickhah N, Alavi S, Mahmoudbeyk M. Comparing cannulabased subcision with the common needle method: A clinical trial.

Skin Res Technol. 2020 Jan;26 (1):39-44. doi: 10.1111/srt.12761.

Epub 2019 Aug 1. PMID: 31373077.

Its results showed that Subcision using the cannula showed good and very good improvement in about 83% of patients (n = 50, P < .05) based on dermatologists investigation and almost no side effects were observed in compared with needle subcision.

Table 3: Visual Analog Score

4: PHYSICIAN’S GLOBAL ASSESSMENT SCORE

Adverse effects of subcision with blunt cannula-Post procedure edema

Adverse effects of subcision with nokor needle-Post procedure Crusting, erythema, echhymosis

mean/avera difference b

grou A(no need subcis

p kor le ion)

grou (bl can subc

up B unt nula ision)

Considerin needle su

g the compli bcision for ac

ications and s cne scar treat

atisfaction ra ment

group noko and can sub tes, Blunt Ca

C (both r needle blunt nula cision) nnula Subcis

treatment a scores efficient tha

t ment

Considering the complications and satisfaction rates, Blunt Cannula Subcision was more efficient than needle subcision for acne scar treatment

Figure 1:

Goodman’s B

Baron’s quant

itative score

improvemen

t after treatm

ion was more ent

ge of the etween pos nd pre treat n

Figure 1: Goodman’s Baron’s quantitative score improvement after treatment

verage of the

visual ana

log scores

B (blunt nnula cision) gr n Axis Title

avera

oup C (both okor needle and blunt cannula subcision)

oup C (both okor needle and blunt cannula subcision)

score

for t

ee groups the improve

ana 3 ) group C (b needle a cannula

.8 oth nokor nd blunt subcision)

average of scores groups

he three

.8 oth nokor nd blunt subcision)

average of scores groups average three g

he three hree groups

average three g

the visual ana of the scor roups

the visual ana of the scor roups

log e for the

log e for the

Figure 4: Physician’s global assessment score for the improvement in the three groups

ment in the t

Figure 2: Goodman and Baron’s qualitative score-improvement after

V

Figure 3: V

How to Optimize the Outcome of Subcision in Acne Scars?

group A (Nokor needle Subcision)

group B (Blunt cannula subcision

group C ( Both nokor needle and blunt cannula subcision

formation

group A (Nokor needle Subcision)

group B (Blunt cannula subcision

group C ( Both nokor needle and blunt cannula subcision

edema erythema echhymosis nodule formation

group A (Nokor needle subcision

group B (blunt cannula subcision group C (both nokor needle and blunt cannula subcision

pain during the procedure

burnin sensation immediately towards the end of the procedure

feeling of heaviness during and immediately post procedure

group A (Nokor needle subcision

average recovery period (in days)

group B (blunt cannula subcision group C (both nokor needle and blunt cannula subcision

group A (nokor needle subcision group B (blunt cannula subcision group C (both nokor needle and blunt cannula subcision

pain during the procedure

overall poor patient cooperation

burnin sensation immediately towards the end of the procedure

feeling of heaviness during and immediately post procedure

overall poor patient cooperation

average recovery period (in days)

Figure 5: Adverse effects in the three groups

Figure 6: Procedure comfort and patient cooperation

Figure 5: Adverse effects in the three groups

Figure 5: Adverse effects in the three groups

Figure 6: Procedure comfort and patient cooperation

Figure 6: Procedure comfort and patient cooperation

Figure 7: Recovery period post procedure

Figure 7: Recovery period post procedure

How to Optimize the Outcome of Subcision in Acne Scars?

Discussion

NEEDLE CANNULA BOTH

Useful in shallow rolling/ box scars.

Useful for very deep rolling scars, by releasing the tethering fibres from the subcutaneous tissue.

Multiple entry points for anesthesia as well as subcision. Single entry point for anesthesia as well as subcision.

4-5 days downtime. Almost no downtime.

Useful for all kinds of rolling scars, deep as well as superficial, as double layer subcision focuses on subcutaneous as well as dermal component of the scar.

Single entry point for anesthesia and blunt cannula subcision, but multiple entry points for needle subcision.

4-5 days downtime.

Painful due to multiple pricks. Almost painless. Almost painless.

Multiple hematomas, crusting after the procedure, redness and swelling made the number of side effects higher in the needle subcision group.

Conclusion

The cannula based subcision could be performed safely in the temples and marionette regions. The needle can not be used safely on the temples or on the marionette region, due to the risk of injuring the blood vessels, being therefore used only in the cheeks.

• The combination approach for subcision using both needle and cannula gave better results compared to any of them used alone, though the safety profile was better for the group treated with blunt cannula.

• Subcision is a safe, simple, cost effective, quick, gratifying and time tested technique that provides significant long-term improvement in the "rolling scars" of acne scar patients.

• Patients who went only for blunt cannula subcision had the minimal side effects, only 10% had bruising, 20% had erythema and 80% had transient post treatment edema. Whereas in the group which was treated with both nokor needle and blunt cannula had faced post procedure redness, swelling

Patients who had both needle and cannula subcision consistently reported experiencing less severe side effects after cannula subcision. Specifically, patients who underwent both types of subcision tended to develop hematomas after needle subcision but not after cannula subcision.

and hematoma in 100%, 90% and 30% patients respectively.

• Group A had almost 80100% patients experiencing pain during the procedure and burning sensation immediately post procedure, making the overall patient cooperation during the procedure poor. On the other hand, usage of blunt cannula made the procedure more comfortable to the patients with just a feeling of heaviness experienced by them after the treatment

• Adding cannula to the equation enhances the results, the patient comfort and physician’s access to the sites like temples and marionettes where high vascularity keeps us vary of using a needle. Subcision with the Cannula appears to be a safe method with high

efficacy in the treatment and high satisfaction in patients as we observed an interesting cure rate (more than 50% after 2 sessions). It demonstrates to be a safe procedure because it performed by single perforation in each side instead of multiple perforations that helps to reduce the patients' pain and risk of scars. In other hand Cannula-based Subcision needs considerable fewer sessions of surgery and also less recovery time.

Limitations-

1. Long-term follow-up was not done as scars usually modulate over a long period.

2. There were a limited number of sessions.

3. Larger sample size and longer follow-up are needed that would

References

1. Chandrashekar B, Nandini A. Acne scar subcision. J CutanAesthet Surg. 2010 May;3(2):125-6. doi: 10.4103/0974-2077.69029. PMID: 21031076; PMCID: PMC2956956.

2. 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.

3. Pravangsuk J, Udompataikul M, Cheyasak N, Kamanamool N. Comparison of Normal Saline Injection with Pneumatic Injector to Subcision for the Treatment of Atrophic Acne Scars. J ClinAesthetDermatol. 2021 May;14(5):50-55. Epub 2021 May 1. PMID: 34188750; PMCID: PMC8211335.

4. Kravvas G, Al-Niaimi F. A systematic review of treatments for acne scarring. Part 1: Non-energy-based techniques. Scars Burn Heal. 2017 Mar 30;3:2059513117695312. doi: 10.1177/2059513117695312. PMID: 29799567; PMCID: PMC5965325.

5. Nilforoushzadeh MA, Lotfi E, Heidari-Kharaji M, Nickhah N, Alavi S, Mahmoudbeyk M. Comparing cannulabased subcision with the common needle method: A clinical trial. Skin Res Technol. 2020 Jan;26(1):39-44. doi: 10.1111/srt.12761. Epub 2019 Aug 1. PMID: 31373077.

6. Rajan M B, Bhardwaj A, Singh S. Luer-lock cap for tackling acne scar subcision-related blood spill. J Am AcadDermatol. 2021 Jan 10:S01909622(21)00142-0. doi: 10.1016/j. jaad.2020.12.084. Epub ahead of print. PMID: 33440216.

How to Optimize the Outcome of Subcision in Acne Scars?

Nickkholgh E, Salehi B, Shokrani M. Can Subcision with the Cannula be an Acceptable Alternative Method in Treatment of Acne Scars? Med Arch. 2015 Dec;69(6):384-6. doi: 10.5455/ medarh.2015.69.384-386. PMID: 26843730; PMCID: PMC4720458.

8. Gheisari M, Iranmanesh B, Saghi B. Blunt cannula subcision is more effective than Nokor needle subcision for acne scars treatment. J CosmetDermatol. 2019 Feb;18(1):192-196. doi: 10.1111/ jocd.12523. Epub 2018 Mar 9. PMID: 29524284.

9. Mohammed GF, Al-Dhubaibi MS. Triple steps acne scar revision technique: A new combination therapeutic modality for atrophic acne scars. J CosmetDermatol. 2022 Mar 29. doi: 10.1111/jocd.14944. Epub ahead of print. PMID: 35348282.

7. Nilforoushzadeh M, Lotfi E,

probably put more light on the outcome of acne scars.

Videodermoscopy Evaluation in Non-scarring Alopecia of Scalp Part-2

Dr.

Dr.

Table 6: Association of yellow dots among the cases between- Alopecia areata, Androgenetic alopecia and Telogen effluvium groups

Non-scarring Alopecia of Scalp

$ 6 cells (50.0%) have expected count less than 5. ^ Column data pooled and Chi-Square Test reapplied.

$ 6 cells (50.0%) have expected count less than 5. ^ Column data pooled and Chi-Square Test reapplied.

Table 7: Association of black dots among the cases between- Alopecia areata, Androgenetic alopecia and Telogen effluvium groups

Table 8: Association of Brown Peripilar Sign among the cases between- Alopecia areata, Androgenetic alopecia and Telogen effluvium groups

$ 5 cells (41.7%) have expected count less than 5. ^ Column data pooled and Chi-Square Test reapplied.

In our study alopecia areata 93.3% had yellow dots and 6.7%. In alopecia areata subjects 50% had black dots. In alopecia areata 56.6% had small vellous hairs. In Alopecia areata 60% of the subjects had exclamation mark hair. In alopecia areata 16.6% had brown peripilar sign.

In another study byLacarrubba F et al the first group consisted of 200 patients affected by acute (140 patients) and chronic (60 patients) AA, and the second group of 100 patients affected by AGA. In both groups, the clinical diagnosis was confirmed by pull tests and trichograms. The third group consisted of 50 patients with clinically undifferentiated hair loss. In all groups, videodermatoscopy was performed at magnifications ranging from 20x to 600x.[13,14,15]

Videodermoscopy Evaluation in Non-scarring Alopecia of Scalp

In our study alopecia areata 93.3% had yellow dots and 6.7%. In alopecia areata subjects 50% had black dots. In alopecia areata 56.6% had small vellous hairs. In Alopecia areata 60% of the subjects had exclamation mark hair. In alopecia areata 16.6% had brown peripilar sign.

In another study by Lacarrubba F et al the first group consisted of 200 patients affected by acute (140 patients) and chronic (60 patients) AA, and the second group of 100 patients affected by AGA. In both groups, the clinical diagnosis was confirmed by pull tests and trichograms. The third group consisted of 50 patients with clinically undifferentiated hair loss. In all groups, videodermatoscopy was performed at magnifications ranging from 20x to 600x.[13,14,15]

The study results in acute AA (n = 140), three videodermatoscopy patterns were identified, characterized by: (i). 'exclamation point' and/or 'cadaveric' hairs (n = 62); (ii). 'vellus' hairs, in some cases with increased proximal shaft thickness and pigmentation (n = 38); and (iii). coexistence of all the features from (i). and (ii). [n = 40]. In chronic AA (n = 60), in those cases who were recently converted to chronic form from acute AA (n = 35), videodermatoscopy showed a scalp skin that appeared smooth and thin, with evident follicular openings. In cases of long-standing chronic AA (n = 25), hair follicle openings appeared to be obstructed by keratotic plugs. However, whether the two follicular patterns were related to disease duration or to some unknown factors is unclear. In some patients with chronic AA, videodermatoscopy also revealed hair regrowth, which appeared either as homogeneous, indicating early disease remission (upright

'vellus' hairs), or as sparse, thin, and twisted vellus hairs that were usually lost in a few weeks time. In AGA patients, videodermatoscopy observation allowed an accurate assessment of the ratios of miniaturized to normal hairs, a finding that was interpreted as a prognostic feature. Interestingly, videodermatoscopy clearly demonstrated the hair abnormalities corresponding to both diseases in those patients with concomitant causes of hair loss, as we observed in five patients simultaneously affected by AA and AGA. In the third group, videodermatoscopy allowed identification of early or minimal forms of AA (n = 20), AGA with mild hair loss of the centro-parietal area of the scalp (n = 20), and scarring alopecia (n = 10).

The study concluded that the results indicate that videodermatoscopy represents a very useful tool in the evaluation of hair loss, both for differential diagnosis (especially in early, transitional and mild forms) and for prognostic evaluation. It allows rapid, detailed, and noninvasive observation of the scalp skin and hair, and it provides highresolution quality imaging.

In our study a total of 140 subjects were studied, 30 alopecia areata, 40 androgenetic alopecia, 30 telogen effluvium and 40 controls.

Of the total 140 subjects, the cases were divided into alopecia areata 30 (21.4%), androgenetic alopecia 40 (28.6%), telogen effluvium 30 (21.4%) and control cases 40(28.6%).

In alopecia areata 93.3% had yellow dots. In androgenetic alopecia 57.5% had yellow dots. In telogen effluvium 16.7% had yellow dots. In controls 7.5% had yellow dots.

In alopecia areata subjects 50%

had black dots. In androgenetic alopecia 5% had black dots. In telogen effluvium and controls none of the subjects had black dots. The p-value was significant with a value of 5.64E-08 where E stands for 10 to the power of minus.

In alopecia areata 56.6% had small vellous hairs. Androgenetic alopecia and telogen effluvium did not have any significant association with the small vellous hairs.

In alopecia areata 60% of the subjects had exclamation mark hair. Exclamation mark hair was not seen in androgenetic alopecia, telogen effluvium and control subjects. p-value was significant with a value of 7.55E-12 (where E stands for 10 to the power of minus) showing a clear relationship of alopecia areata and exclamation mark hairs.

In another study by Inui S, Itami S et al dermoscopic examination of areas of hair loss on the scalp of 300 Asian patients with AA was performed using a DermLite II pro, which can block light reflection from the skin surface without immersion gels. Using the Spearman rankorder correlation coefficient by rank test, correlations between the incidence of each dermoscopic finding and the severity of disease and disease activity were examined. The sensitivity and specificity of the findings as diagnostic clues for AA were evaluated.[16]

The results showed characteristic dermoscopic findings of AA included black dots, tapering hairs, broken hairs, yellow dots, and clustered short vellus hairs (shorter than 10 mm) in the areas of hair loss. Black dots, yellow dots, and short vellus hairs correlated with the severity of disease, and black dots, tapering hairs, broken hairs, and short vellus hairs correlated with disease activity. For diagnosis,

Videodermoscopy Evaluation in Non-scarring Alopecia of Scalp Part-2

yellow dots and short vellus hairs were the most sensitive markers, and black dots, tapering hairs, and broken hairs were the most specific markers.

It was concluded in the study that dermoscopic characteristics, such as black dots, tapering hairs, broken hairs, yellow dots, and clustered short vellus hairs, are useful clinical indicators for AA.

In another study by Ihm w et al it was shown that exclamation mark (EM) hair can lead to the misdiagnosis of alopecia areata (AA) because it is widely considered as pathognomonic for AA. Typical EM hairs were also found in trichotillomania. EM hairs collected from 2 cases of trichotillomania and 9 cases of AA were compared under light microscopy. There were two sorts of EM hairs, one with frayed distal ends and the other with blunt distal ends. The majority (77.8%) of the EM hairs from AA had frayed distal ends, while the majority (82.2%) of that from trichotillomania had blunt distal ends. EM hairs, even with frayed distal ends, are not pathognomonic of AA.[17]

In our study in alopecia areata 60% of the subjects had exclamation mark hair. Exclamation mark hair was not seen in androgenetic alopecia, telogen effluvium and control subjects. p-value was significant with a value of 7.55E12 (where E stands for 10 to the power of minus) showing a clear relationship of alopecia areata and exclamation mark hairs.

In another study by Ozlem Karadag Kose et al 144 subjects of alopecia were involved with similar control subjects. The follicular features showed yellow dots, black dots, and broken hairs that was significantly more common in AA than in the other alopecias. Tapering hairs

were detected only in AA. Short vellus hairs were noted in all types of alopecia, without a significant difference in frequency. Circular hairs and trichorrhexis nodosa were observed in AA or PCAs without a significant difference between the two groups. Hair diameter diversity was found in all subjects with AGA, and was significantly more common in this group than the others. Empty follicles, and peripilar sign were noted only in AGA. In AGA yellow dots were seen in 30.5%, black dots in 1.7%, hair diameter diversity in 100% of the patient’s empty follicles in 52.5% and peripilar sign in 59.3% white dots were seen in 15.3% of the patients. In AA yellow dots were seen in 83.7%, black dots in 63.3%, tapering hairs in 42.9%, broken hairs in 57.1%, short vellous hairs in 46.9% and hair diameter diversity in 32.7%. In telogen effluvium yellow dots were seen in 21.1%, short vellous hairs were seen in 47.7% and hair diameter diversity were seen in 10.5%. Black dots, tapering hairs and broken hairs were not seen in telogen effluvium. [8,18]

In our study alopecia areata 93.3% had yellow dots. In alopecia areata subjects 50% had black dots and 56.6% had small vellous hairs. In alopecia areata 60% of the subjects had exclamation mark hair. In alopecia areata 16.6% had brown peripilar sign.

In our study brown peripilar sign were seen in androgenetic alopecia in 95% of subjects compared to 42.5% in control volunteers, 43.3% in telogen effluvium and 16.6% in alopecia areata, showing a significant association of brown peripilar sign in androgenetic alopecia. Yellow dots were seen in alopecia areata in 93.3%. In androgenetic alopecia 57.5% had yellow dots. In telogen effluvium 16.7% had yellow dots. In controls

7.5% had yellow dots.

In another study Inui S the characteristic trichoscopic features of common hair loss diseases are described using a DermLite II pro or Epilight eight. Characteristic trichoscopic features of alopecia areata are black dots, tapering hairs (exclamation mark hairs), broken hairs, yellow dots and short vellus hairs. In androgenetic alopecia (AGA), hair diameter diversity (HDD), perifollicular pigmentation/ peripilar sign and yellow dots are trichoscopically observed. In all cases of AGA and female AGA, HDD more than 20%, which corresponds to vellus transformation, can be seen. In cicatricial alopecia (CA), the loss of orifices, a hallmark of CA, and the associated changes including perifollicular erythema or scale and hair tufting were observed. Finally, an algorithmic method for trichoscopic diagnosing is proposed.[4]

In our study a videodermoscope of 50*magnification from medicam company with a LED light and connectable to the computer hard disk drive with a USB cable through which videodermoscopic pictures can be recorded is used.

In another study by Rakowska A et al female androgenetic alopecia and telogen effluvium was studied. They compared to the healthy controls, hair thickness of patients with female AGA was significantly reduced in the frontal, occipital left temporal and right temporal area. The largest percentage of thin hairs was observed in female AGA in frontal area (20.9 + 12%) and it was significantly different compared to patients with telogen effluvium (10.4+ 3.9%) and healthy volunteers (6.15+ 4.6%, p<0.001).

The percentage of single-hair, double-hair and triple-hair units was

Videodermoscopy Evaluation in Non-scarring Alopecia of Scalp Part-2

evaluated. In patients with female AGA the mean percentage of single-hair pilosebaceous units was highest in the frontal area (65.2+ 19.9%). This was significantly more than in telogen effluvium (39.0 + 13.4%, p< 0.001) and healthy controls (27.3 + 13%, p<0.001).

Perifol liculardis coloration was significantly more often in female AGA as compared to healthy controls or patients with chronic telogen effluvium. The mean percentage of hair follicles with surrounding disco louration in female AGA was 32.4+4.7% in the frontal area and 6.6+2% in the occipital area p<0.001.[19]

In another study by Inui S, Nakajima T et al, they investigated the dermoscopic features and their incidence of androgenetic alopecia (AGA; n = 50 men) and female AGA (FAGA; n = 10 women) in Asian people. More than 20% hair diameter diversity (HDD), which reportedly is an early sign of AGA and corresponds to hair follicle miniaturization, was observed in the affected area of all AGA and FAGA cases, suggesting that HDD is an essential feature to diagnose AGA and FAGA. Peripilar signs, corresponding to perifollicular pigmentation, were seen in 66% (33/50) of AGA and 20% (2/10) of FAGA women. This incidence in the present study was lower than previously reported in white subjects possibly because the Asian skin color conceals slight peripilar pigmentation. Yellow dots were observed in 26% (13/50) of AGA and 10% (1/10) of FAGA cases and the number of yellow dots in AGA and FAGA was limited to 10 on the overall hair loss area. Yellow dots possibly indicate the coincidence of AGA and enlargement of the sebaceous glands caused by common end-organ hypersensitivity to androgen. In conclusion, dermoscopy is useful to diagnose

AGA and FAGA and provides insights into the pathogenesis of AGA.[20]

In our study brown peripilar sign were seen in androgenetic alopecia in 95% of subjects compared to 42.5% in control volunteers, 43.3% in telogen effluvium and 16.6% in alopecia areata, showing a significant association of brown peripilar sign in androgenetic alopecia. Yellow dots were seen in alopecia areata in 93.3%. In androgenetic alopecia 57.5% had yellow dots. In telogen effluvium 16.7% had yellow dots. In androgenetic alopecia 95% had brown peripilar sign compared to 42.5% in controls, 16.6% in alopecia areata and 43.3% in telogen effluvium. In controls 7.5% had yellow dots. P–Value was significant with a value of 6.37E where E stands for 10 to the power of minus. Relationship of yellow dots was 93.3% in alopecia areata and 7.5% in control subjects.

Conclusion

Videodermoscopy is an effective non-invasive tool of considerable potential in dermatological practice. It is gaining popularity as an accessory tool in differential diagnosis of hair loss. videodermoscopy has proved to represent a useful tool for differentiating between different types of alopecia, thus avoiding scalp biopsy in most of the cases, which is particularly important in patient compliance. Use of videodermoscopy in the clinical evaluation of scalp and hair disorders improves diagnostic capability beyond simple clinical inspection and reveals novel features of disease, which may extend clinical and pathogenetic understanding. Nowadays, they represent an important and relatively simple aid in daily clinical practice.

Figure 1: Exclamation mark hair in alopecia areata

Figure 2: Tapering hair in alopecia areata

Figure 3: Yellow dots in alopecia areata

Figure 4: Black dots in alopecia areata

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.

References

1.Ohyama M. Management of hair loss diseases. Dermatologica Sinica.2010 28; 139–145

2.Van neste, d. female patients complaining about hair loss: documentation of defective scalp hair dynamicswith contrastenhanced phototrichogram. Skin res technol. 12, 83-88 (2006)

3. Inui S. Trichoscopy for common hair loss diseases: algorithmic method for diagnosis. J Dermatol. 2011 Jan; 38(1): 71-5.

4. Kossard S, Zagarella S. Spotted cicatricial a lopecia in dark skin:a clue to fibrous tracts. Australas J Dermatol 1993;34:49-51

5. Strumia R, Califano A. Le molteplici applicazioni dermato logichedella video- microscopia a sondaottica. G Ital Dermatol Venereol 1996;131:397-402

6. Tosti A, Duque-Estrada B. Dermoscopy in Hair Disorders. J Egypt Women Dermatol Soc 2010; 7: 1-4.

7. D’AmicoD,Vaccaro M, Guarneri F, Borgia F, Cannavo SP, Guarneri B. Phototrichogram using videomicroscopy: a useful technique in the evaluation of scalp hair. Eur J Dermatol 2001;11:17-20.

8. De Lacharrie`re O, Deloche C, Misciali C, et al. Hair diameter diversity: a clinical sign reflecting the follicle miniaturization. Arch Dermatol 2001; 137:641-6.

9. Hoffmann R. TrichoScan: combining epilumine scence microscopy with digital image analysis for the measurement of hair growth in vivo. Eur J Dermatol 2001; 11:362-8.

10. Micali G, Lacarrubba F. Possible applications of videodermoscopy

beyond pigmented lesions. Int J Dermatol 2003;42: 430-3.

11. Lacarrubba F, Dall’Oglio F, Nasca MR, Micali G. Videodermoscopy enhances diagnostic capability in some forms of hair loss. Am J ClinDermatol 2004;5:205-8.

12. Deloche C, de Lacharrie`re O, Misciali C, Piraccini BM, VincenziC, Bastien P, et al. Histologic features of peripilar signs associated with androgenetic alopecia. Arch Dermatol Res 2004;295:422-8.

13. Rakowska A, Slowinska M, Kowalska - Oledzka E, Rudnicka L. (2008). Trichoscopy (hair and scalp videodermoscopy) in the healthy female. Method standardization and norms for measurable parameters"J Dermatol Case Rep3 (1): 14–19.

14. Rudnicka, Lidia; Olszewska, Malgorzata; Majsterek, Magdalena; Czuwara, Joanna; Slowinska, Monika (2006). "Presence and future of dermoscopy".Expert Review of Dermatology1 (6): 769.

15. Rakowska A, Slowinska M, Kowalska-Oledzka E, Rudnicka L. (2008). "Trichoscopy in genetic hair shaft abnormalities".J Dermatol Case Rep2 (2): 14–20

16. William stolz, Peter bilek, Micheallandchaer, Amandcogneta. Basis of dermatoscopy and skin surface microscopy. William stolz, Peter bilek, Micheallandchaer, Amandcogneta color atlas of dermatoscopy. 1st ed. Germany .Blackwell publications; 1994. P 7-10

17. Haneke e. terminology in dermatology: logical or arbitrary? Arch dermatol 2000; 136: 1061

18. Anderson RR. Polarized light examination and photography of the skin. Arch. Dermatol 1991.127.10001005

19. Rudnicka L, Olszewska M, Rakowska A, Kowalska-Oledzka E, Slowinska M. (2008). "Trichoscopy: a

new method for diagnosing hair loss". J Drugs Dermatol7 (7): 651–654. PMID18664157.

20. Bowling J, Argenziano G, Azenha A, et al. Dermoscopy key points: recommendations from the international dermoscopy society. Dermatology.2007; 214:3-5.

Videodermoscopy Evaluation in Non-scarring Alopecia of Scalp Part-2

Common fatty acid contributes to temperature and pain sensitivity in psoriasis plaques

Psoriasis is a chronic autoimmune skin condition that causes cells to build up rapidly on the surface of the skin. The excess skin cells form scales and red patches that are sometimes itchy and painful. The exact cause of psoriasis is unknown, but it is believed to involve a combination of genetic and environmental factors.

According the recent study findings showed a common fatty acid found in the western diet breaks down into compounds that contribute to increased temperature and pain but not itch sensitivity in psoriatic lesions. The finding could lead to better understanding of how lipids communicate with sensory neurons, and potentially to improved pain and sensitivity treatments for psoriasis patients. Linoleic acid is a fatty acid found in vegetable oils, nuts and seeds, and is one of the predominant fatty acids found in the western diet. Metabolites from linoleic acid - the products formed when the body breaks it down through digestion - play a role in skin barrier function.

The researchers noticed high levels of two types of lipids derived from linoleic acid in psoriatic lesions. That led us to wonder whether the lipids might affect how sensory neurons in these lesions communicate. They decided to investigate whether their presence could be related to the temperature or pain hypersensitivity that many psoriasis patients report. The research team used mass spectrometry to create lipid profiles of skin from psoriatic lesions. They focused on two types of linoleic acid-derived lipids, or oxylipids: 13-hydroxy-9,10-epoxy octadecenoate (9,13-EHL) and 9,10,13-trihydroxy-octadecenoate (9,10,13-THL). The first form, 9, 13-EHL, can convert into the more stable 9,10,13-THL form via interaction with certain enzymes.

The researchers found that while both forms bind to receptors on sensory neurons within the skin, the more stable form -9,10,13-THL - had a longer lasting effect than 9,13-EHL. They also found that once the lipids bind to the neuronal receptor, they activate the neurons expressing TRPA1 and TRPV1 receptors that are involved in temperature and pain hypersensitivity, opening communications channels to the central nervous system. Interestingly, the lipids did not have any effect on itch. It was surprising that these lipids could create hypersensitivity but not impact itch sensation, which is usually the most troublesome symptom associated with psoriasis. This most likely has to do with how the neuron is activated - a mechanism we still haven't uncovered. Now that an association between linoleic acid and hypersensitivity to temperature and pain has been established, the researchers want to further explore exactly how this response is being created. They hope that the answers may lead to solutions that can relieve these symptoms in psoriasis patients.

Researchers know that this lipid moves from one form to another, but don't yet know what causes that. They also know what protein the lipids are binding to, but not where the bond occurs. Answering these questions may hopefully lead to new therapies -or dietary solutions -for some psoriasis sufferers.

In cells, UV-emitting nail polish dryers damage DNA and cause mutations

The ultraviolet nail polish drying devices used to cure gel manicures may pose more of a public health concern than previously thought. Researchers studied these ultraviolet (UV) light-emitting devices, and found that their use leads to cell death and cancer-causing mutations in human cells. The devices are a common fixture in nail salons, and generally use a particular spectrum of UV light (340-395nm) to cure the chemicals used in gel manicures. While tanning beds use a different spectrum of UV light (280-400nm) that studies have conclusively proven to be carcinogenic, the spectrum used in the nail dryers has not been well studied.

If we look at the way these devices are presented, they are marketed as safe, with nothing to be concerned about. But to the best of our knowledge, no one has actually studied these devices and how they affect human cells at the molecular and cellular levels until now.

Using three different cell lines -adult human skin keratinocytes, human foreskin fibroblasts, and mouse embryonic fibroblasts - the researchers found that the use of these UV emitting devices for just one 20-minute session led to between 20 and 30 percent cell death, while three consecutive 20-minute exposures caused between 65 and 70 percent of the exposed cells to die. Exposure to the UV light also caused mitochondrial and DNA damage in the remaining cells and resulted in mutations with patterns that can be observed in skin cancer in humans.

Researchers saw multiple things: first, they saw that DNA gets damaged, they also saw that some of the DNA damage does not get repaired over time, and it does lead to mutations after every exposure with a UV-nail polish dryer. Lastly, they saw that exposure may cause mitochondrial dysfunction, which may also result in additional mutations. Researchers looked at patients with skin cancers, and we see the exact same patterns of mutations in these patients that were seen in the irradiated cells.

The researchers caution that, while the results show the harmful effects of the repeated use of these devices on human cells, a long-term epidemiological study would be required before stating conclusively that using these machines leads to an increased risk of skin cancers. However, the results of the study were clear: the chronic use of these nail polish drying machines is damaging to human cells.

Congenital Nasal Dermoid and Sinus Cysts: A Case Report

Dr. Sheetal Dandale

MBBS, MD, DDV, FCPS Consultant Dermatologist, Trichologist and Laser Surgeon Skinconsult Clinic, Mumbai

Introduction

Congenital nasal dermoid and sinus cysts (NDSCs) are rare congenital malformations. They are the most common type of congenital nasal midline lesions.1

Other types include nasal meningoencephaloceles and gliomas. The incidence of dermoid cysts and fistulas in the midline of the nose is 1/20,000 to 1/40,000.1 NDSCs constitute approximately 11% of dermoid cysts in the head and neck, 1% of dermoid cysts in the whole body, and 61% of median lesions in children.

Herewith we describe a rare case of NDSC in an Indian adult female.

Case Report

An otherwise healthy 41-yearold female presented with an asymptomatic swelling over her nasal dorsum of 10 years duration. She reported a life-long history of a dorsal nasal pit, from which she also noted the growth of hair from within the pit.

The patient denied a history of nasal infection or abscess. She had never sought any type of medical attention for the pits.

On examination, the area around the middle nasal vault was skin coloured and swollen. A midline punctum and a sinus was present without any discharge. On probing, the sinus tract was ending on the nasal bone.

Based on this clinical presentation, the diagnosis of nasal dermoid sinus cyst was made.

In this case, we successfully performed the external rhinoplasty approach. This approach offers a good surgical exposure and an excellent cosmetic effect.2 1 (a)

Discussion

In 1817, Cruvelier first described a nasal dermoid cyst when he identified a hair-containing sinus tract of the nasal dorsum in a child.

A nasal dermoid typically presents as a midline mass, and may be located anywhere from the base of the collumella, along the nasal dorsum, to the nasoglabellar region.3 It is typically a noncompressible mass that does not transilluminate and has a negative Furstenberg sign (i.e. there is no enlargement with compression of the jugular veins).

A sinus opening with intermittent discharge of sebaceous material is frequently encountered. Local infection is common, but infection related to intracranial extension (e.g. meningitis and brain abscess) is rare. Hair protruding through a cutaneous punctum over the nasal dorsum is pathognomonic for a nasal dermoid.4 The mean age of presentation varies from 14 to 34 months,3,5 but reports of nasal dermoids presenting in adults exist in the literature.6,7,8

There are some reports about male predominance.9

Intracranial extension varied from 5 to 45% in several recently published series.3,4, 9, 10

Nasofrontal dermoid sinus cysts have a unique embryological origin. A midline basal frontal dermoid associated with a dimple or sinus opening on the nasal dorsum with or without protruding hair and sebaceous discharge is the classical presentation.

The first report about NDSC was published by Bramann in 1890.11

There are lots of theories like sequestration, trilaminary and prenasal, about NDSCs.

The most accepted theory is Pratt’s prenasal theory.12

Pratt described the common embryologic pathway of gliomas, encephaloceles and nasofrontal dermoid sinus tract.11,5

The nasal bones are separated from the adjacent cartilaginous nasal capsule by a Prenasal space (Fig. 1).

1 (b)

Figure 1 (a&b): Asymptomatic swelling over nasal dorsum

Figure 2: Successfully performed the external rhinoplasty

Figure 3: Removed dermoid sinus cyst

Figure 5: After surgery completely cured with excellent cosmetic effect

Figure 1: Prenasal space — a potential space extending from the brain to the nasal tip

Congenital Nasal Dermoid and Sinus Cysts: A Case Report

Faulty regression of the embryologic neuroectodermal tract pulls skin elements into the prenasal space, resulting in a dermoid cyst or sinus. The sinus tract may form anywhere along the course of the diverticulum, from the columella to the anterior cranial fossa. The lesion may be extranasal, intranasal, or a combination of the two. The majority of nasal dermoids are confined to the superficial nasal area. Intracranial extension most often communicates through the foramen cecum or the cribriform plate to the base of the frontal fossa with extradural adherence to the falxcerebri. There are rare reported cases of involvement of the brain parenchyma.3

Imaging is a crucial component in the evaluation of nasal dermoids since intracranial extension has been reported in up to 45% of cases.

Computed tomography (CT) and magnetic resonance imaging (MRI) scans are the gold standards in radiographic evaluation of nasal dermoids.

Complete surgical excision of nasal dermoid cyst and any associated sinus tract is essential for cure. Recurrence rates of 50–100% have been reported in cases in which dermal components were incompletely removed.4,13 Any surgical approach for removal of nasal dermoid cysts should adhere to the following four tenets: permit access to all midline lesions and allow for medial and lateral osteotomies; allow repair of skull base defects or cerebrospinal fluid leak; facilitate reconstruction of any nasal deformity; and result in a cosmetically acceptable scar.13

The midline vertical incision continues to be the most popular and straightforward technique for removal of the cyst.

Conclusion

Although nasal dermoids are rarely encountered, their potential for local bony atrophy and distortion of the nose, as well as serious infections such as meningitis and brain abscess, warrant early recognition, accurate diagnosis, and prompt treatment. A thorough understanding of the embryogenesis of midline nasal congenital lesions is important when the diagnosis is not obvious on physical examination alone. Manipulation of a midline nasal mass prior to excluding or confirming any central communication may result in cerebrospinal fluid leak or infection. Imaging of the midface and brain is essential for accurate diagnosis, assessment for any intracranial extension, and appropriate surgical planning. Complete excision of the cyst and its tract is the only cure. Any residual ectodermal elements result in a high rate of recurrence and complicated infections.

References

1. Hughes GB, Sharpino G, Hunt W, et al. Management of the congenital midline nasal mass—a review. Head Neck Surg 1980;2:222–33

2. Locke R, Kubba H. A case of a nasal dermoid presenting as a median upper lip sinus. Int J Oral MaxiofacialSurg 2011;40:985–7. [PubMed] [Google Scholar]

3. Rahbar R, Shah P, Mulliken JB, et al. The presentation and management of nasal dermoid: a 30-year experience.

4. Wardinsky TD, Pagon RA, Kropp RJ, et al. Nasal dermoid sinus cysts:

association with intracranial extension and multiple malformations. Cleft palate Craniofac J 1991; 28:87–95

5. Penslar JM, Bauer BS, Naidich TP. Craniofacial dermoids. PlastRenconstrSurg 1988; 82:953–959

6. Hacker DC, Freeman JL. Intracranial extension of a nasal dermoid sinus cyst in a 56-year-old man. Head Neck 1994; 16:366–371.

7. Vaghela HM, Bradley PJ. Nasal dermoid sinus cyst in adults. J LaryngolOtol 2004; 118:955–962.

8. Post G, McMains KC, Kountakis SE. Adult nasal dermoid sinus cyst. Am J Otolaryngol 2005; 26:403–405

9. Denoyelle F, Ducroz V, Roger G, Gara-bedian EN. Nasal dermoid sinus cysts in children. Laryngoscope 1997;107:795-800

10. Van Aalst JA, Luerssen TG, Whitehead WE, Havlik RJ. ‘Keystone’ approach for intracranial nasofrontaldermoid sinuses. PlastReconstrSurg 2005; 116:13–19. Excellent discussion of the intracranial/ extracranial approach to dermoids pathology

11. Hanikeri M, Waterhouse N, Kirkpatrick N, et al. The management of midline transcranial nasal dermoid sinus cysts. Br J PlastSurg 2005;58:10431050.

12. Emel CT, Ömer TS, Güleser SAO, Hakan K. The management of rare nasal mass – nasal dermoid sinus cysts: open rhinoplasty. Rare Tumors. 2009 Dec 28;1(2):e40.

13. Posnick JC, Bortoluzzi P, Armstrong DC, Drake JM. Intracranial nasal dermoid sinus cysts: computed tomographic scan findings and surgical results. PlastReconstrSurg 1994; 93:745–754.

Congenital Nasal Dermoid and Sinus Cysts: A Case Report

New treatment for moderate to severe atopic dermatitis shows promising long-term results

Atopic dermatitis, the most common type of eczema, is a debilitating chronic inflammatory skin disease that affects millions of people worldwide. It often develops at a very young age, causing the skin to become inflamed, red, extremely itchy, painful, and very dry -all symptoms that greatly affect a patient's quality of life.

According to recent clinical trial, patients sustained significant improvement in signs and symptoms up to 20 weeks after medication was stopped. Patients with moderate to severe atopic dermatitis who participated in a clinical trial of rocatinlimab - a novel, patient-tailored monoclonal antibody therapy - showed promising results both while taking the drug and up to 20 weeks after the therapy was stopped.

The researchers said the results indicate that rocatinlimab has the potential to change the genetic makeup of a person's atopic dermatitis for the long term, and possibly help sustain lasting results without continued use. Rocatinlimab inhibits OX40 -- an immune molecule involved in activating inflammatory cells that play a key role in the development of atopic dermatitis and other inflammatory diseases.

Researchers are very optimistic about the results of this trial and the potential for disease modification and long-lasting effects to improve patients' quality of life. In this phase 2b multicenter, double-blind, placebo-controlled study, 274 patients were recruited and (rocatinlimab: n=217; placebo: n=57) randomly assigned 1:1:1:1:1 to rocatinlimab every four weeks (150 mg or 600 mg) or every two weeks (300 mg or 600 mg) or subcutaneous placebo up to week 18, with an 18-week active-treatment extension and 20-week follow-up.

Percent change from baseline in the Eczema Area and Severity Index (EASI) score was assessed as the primary endpoint at week 16, and significance versus placebo was achieved with all active rocatinlimab doses (-48% to -61%) doses compared to placebo (-15%). All active dose cohorts also continued improving after week 16, and most patients maintained the response for at least 20 weeks off treatment.

The results support rocatinlimab as a safe and effective treatment for moderate to severe atopic dermatitis, with potentially long-lasting efficacy and disease modification. At week 36, all participants had been on the treatment for at least 18 weeks, by this time, researchers saw that while the drug achieved the primary endpoints in all doses versus the placebo, it's also a drug that improves over time, which is really unusual and unique among currently available treatment options.

Oral minoxidil improves anticancer treatment–induced alopecia in women with breast cancer

Oral minoxidil is a medication that was initially developed to treat high blood pressure, but was later discovered to have the side effect of promoting hair growth. Topical minoxidil is widely used to treat hair loss, but new findings suggest that a combination of oral and topical minoxidil could be effective for women with breast cancer who have experienced alopecia from anticancer treatment.

In a retrospective cohort study of women with breast cancer and anticancer therapy–induced alopecia, researchers found that combining low-dose oral minoxidil (LDOM) and topical minoxidil achieved better results than topical minoxidil alone and that the treatment was well tolerated. A total of 5 of the 37 patients (13.5%) in the combination therapy group achieved a complete response, defined as an improvement of alopecia severity from grade 2 to grade 1, compared with none of the 19 patients in the topical therapy–only group.

In contrast, none of the patients in the combination group experienced worsening of alopecia, compared with two (10.5%) in the topical monotherapy group. Topical minoxidil is approved by the Food and Drug Administration to treat androgenetic alopecia. Oral minoxidil is not approved for treating hair loss but has been receiving increased attention as an adjunctive therapy for hair loss, particularly for women. Oral minoxidil is approved for treating hypertension but at much higher doses.

An increasing number of studies have been conducted on the use of oral minoxidil for the treatment of female pattern hair loss, dating back to a pilot study in 2017, with promising results. The findings suggest that LDOM might be more effective than topical therapy, well tolerated, and more convenient for individuals to take.

A Mimicker of Tinea Faciei

Dr. Rathish T. Pillai

MD

Head of Department

Department of Dermatology

Azeezia Medical College, Kollam, Kerala

Dr. Shahnaz A. S.

Junior Resident

Department of Dermatology

Azeezia Medical College, Kollam, Kerala

Dr. Sana Shams

Junior Resident

Department of Dermatology

Azeezia Medical College, Kollam, Kerala

Introduction

Leprosy, also known as Hansen’s disease, is a chronic granulomatous disease caused by the bacteria Mycobacterium leprae. It primarily affects the peripheral nerves and skin. According to the World Health Organization (WHO), individuals having one of the following three features have leprosy: (i) definite loss of sensation in a pale (hypopigmented) or reddish skin patch; (ii) a thickened or enlarged peripheral nerve with loss of sensation; and (iii) the presence of acid-fast bacilli in a slit-skin smear.(1) Clinically this neglected tropical infectious condition has

a variable clinical presentation in reference to the patient's immune status. The Ridley and Jopling/WHO classification criteria, is based totally on; scientifically clinical symptoms, pathological, bacilloscopic, and immunological components of the disorder, thus, allowing for a radical characterization or instead categorization of six leprosy class: the polar tuberculoid leprosy (TT), borderline tuberculoid (BT), the intermediate borderlineborderline (BB), borderline lepromatous 6 (BL) and lepromatous leprosy (LL) form.(2)

The goal of the WHO and CDC is to completely eradicate leprosy. Eradication efforts have included free treatment, close monitoring, and education of family members.(3)

Case Description

A 56 year old female presented to the Department of Dermatology due to erythematous annular skin lesion over the left side of face since 3 months. She had no history of pruritus. She consulted a general practitioner for the same and was diagnosed with tinea faciei and was prescribed systemic and topical antifungals. The patient took the treatment for 2 months with no improvement. Since there was no improvement and the lesion became more severe she presented to the Department of Dermatology. On examination, a single well defined erythematous plaque with raised margin and central clearing about 7cmx5cm size was observed on the left side of face. Sensations were decreased over the lesion.

Skin biopsy was taken in view of suspicion of hansen’s disease, which revealed hansen’s disease- borderline tuberculoid type. The patient along with family members were educated about the risk of transmission and the associated signs and symptoms of the condition. The patient was referred to the nearest leprosy center to start MDT.

Discussion

Leprosy is one of the oldest diseases known to man. Despite advances in all spheres of medical science, leprosy continues to be a public health challenge in countries like India.(4) Leprosy is the great imitator, therefore Dermatologists should always consider leprosy as a differential diagnosis in suspicious cases. A histopathological examination can help to differentiate leprosy skin lesions from skin lesions of other diseases.

References

1. Shiva Raj KC, Geetika KC, Gyawali P, Singh M, Sijapati MJ. LeprosyEliminated and forgotten: A case report. Journal of Medical Case Reports. 2019 Sep 1;13(1).

2. Malumani M, Malan M, Kaseya COR, Quan SJ. NF-KB Single Nucleotide Polymorphism View project Hansen’s Disease: A Neglected Tropical Infectious Condition 1 2 *3 [Internet]. Available from: https://www.researchgate.net/ publication/338455925

3. Luchtefeld W. Clinical Case Report

[Internet]. Vol. 38, The Nurse Practitioner •. 2013. Available from: www.tnpj.com

4. RaoPn, Suneetha S. Current situation of leprosy in India and its future implications. Indian Dermatology Online Journal. 2018;9(2):83.

Figure 1: Erythematous lesion with raised margin and central clearing