The Aestheticians Journal July'2023 issue

Topical Retinoid in Dermatology: A Clinical Review

Application of Artificial Intelligence

In Identifying Antioxidants for Aging Part-II

A Study of Comparison of Fractional CO2 Laser Alone Vs Sequential Fractional CO2 Laser with Dermaroller in Acne Scars

Hair Transplant with Combination of FUE and PRP for Hair Loss: A Case Report

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Published for the period of July - 2023

Beware of Skin Disorders during Monsoon

Monsoon season, characterized by increased humidity and rainfall, can indeed lead to various skin allergies and infections. Monsoon season is the time when due to the high humidity there are various bacteria, fungi, viruses and other microorganisms become active, which can harm the skin and cause skin problems. A few chronic skin disorders like atopic eczema, acne and psoriasis tend to worsen in this season. The biggest complaint during monsoon is the fungal infection. The change in weather and humidity during the monsoons can disrupt the skin barrier, making it more susceptible to external contaminants and triggering eczema flare-ups.

The monsoons are especially harsh on people with oily skin. This type of skin may experience an outbreak of red and raised bumps. The season promotes the growth of bacteria on blackheads, transforming them into full-fledged inflamed acne. During monsoons especially, one tends to get skin allergies and fungal infections in covers like underarms, groins, and buttock area and it is important to meet a dermatologist to treat these as this may lead to chronic infections. To diagnosing and treating skin infections, dermatologists always play a role in preventive care and patient education. They provide guidance on maintaining healthy skin, recommend appropriate skincare products, and educate patients about the importance of skin care.

In this issue we got articles on Topical Retinoid for Acne, CO2 Laser and Dermaroller in Acne Scars, Hair Transplant with Combination of FUE and PRP for Hair Loss and Application of Artificial Intelligence in Identifying Antioxidants for Aging.

- Dom Daniel Executive Editor & Publisher

Topical Retinoid in Dermatology: A Clinical Review

Dr. Kanu Verma, MD-Skin & VD

Application of Artificial Intelligence In Identifying Antioxidants for Aging Part-II

Dr. Saad Sami AlSogair, MD

A Study of Comparison of Fractional CO2 Laser Alone Vs Sequential Fractional CO2 Laser with Dermaroller in Acne Scars

Dr. Tejansu Samir Dalal, MBBS, MD (DVL)

Hair Transplant with Combination of FUE and PRP for Hair Loss: A Case Report

Dr. Kiran Joshy, Dermatologist and Hair Transplant Surgeon

AStudy of Comparison of Fractional CO2 LaserAlone Vs Sequential Fractional CO2 Laser with Dermaroller in Acne Scars

11TH WORLD CONGRESS

THE

It is with great enthusiasm and pleasure to proudly announce the 11th annual meeting of the Dermatologic & Aesthetic Surgery International League (DASIL) to take place in Bangkok this year, from October 25 - 27, 2023.

As president for the DASIL 2023 meeting, I am reaffiming the goals of DASIL to create a global community for the open exchange of knowledge and innovation by physicians specializing in Dermatologic & Aesthetic Surgery.

The DASIL 2023 curriculum will offer outstanding symposia, workshops and live patient demonstrations. Dasil will aslo continue in the tradition of creating networking opportunities among physicians and industry through numerous planned social events that will take place during the course of the meetings.

We welcome all of our colleagues and are looking forward to seeing you at DASIL 2023 in Bangkok

It promises to be one of the most prominent and educational conferences in 2023, and an opportunity to remember.

Tatjana Pavicic, MD DASIL PRESIDENT

BANGKOK WELCOMES YOU

DASIL (The Dermatologic & Aesthetic Surgery International League) is a worldwide organization with a unique and innovative mission: to bring the latest academic advancements in Clinical, Surgical, and Aesthetic Dermatology all over the world.

To accomplish this goal, DASIL members integrate a Faculty of dozens well known experts from more than 80 countries, whom altruistically contribute with their time.

Atchima Suwanchinda, MD DASIL WORLD CONGRESS PRESIDENT

WWW.DASIL.ORG

DASIL is a true non-profit international dermatology and dermatologic surgery organization. We pride ourselves on the openness of the group, the transparancy of our activities, and abiding by our mission of Mentors Teaching Mentors — as we ensure that dermatology and dermatologic surgery are practiced and taught at the highest of levels. Our initiatives, set out by our members, continue to inspire and bring new members into the organization — which is what teaching and education is all about. We encourage everyone to join DASIL and to become part of the best dermatology group in the world.

So, plan on attending DASIL Bangkok 2023 — we look forward to welcoming the world to this outstanding Congress.

The Aestheticians Journal and Paradigm Infocom Group are the sole and exclusive booking agency in India for Drs from India for DASIL Bangkok' 2023 For Bookings Contact: + 91 8779515551

INTERNATIONAL CONGRESS OF DERMATOLOGY, AESTHETICS AND SURGICAL TECHNIQUES.

Editorial Board

Dr. Saad Sami AlSogair

MD

Dermatologist & Anti-aging Consultant

Vice President of the Middle East International Dermatology & Aesthetic Medicine Conference & Exhibition - MEIDAM

Dr. Kanu Verma

MBBS, MD-SKIN &VD

Senior Consultant Dermatologist & Cosmetologist, Aastha Medicare, Dwarka, Delhi

Visiting Consultant, Aakash Healthcare Hospital, Dwarka, Delhi

Dr. Tejansu Samir Dalal

MBBS, MD (DVL)

Consultant Dermatologist and Cosmetologist Naranpura Skin, hair and Aesthetic Laser Clinic, Ahmedabad, Gujarat

Dr. Kiran Joshy

Dermatologist and Hair Transplant Surgeon

Joshy’s Medical Center, Bangalore

Topical Retinoid in Dermatology: A Clinical Review

Dr. Kanu Verma

MBBS, MD-SKIN &VD

Senior Consultant Dermatologist & Cosmetologist, Aastha Medicare, Dwarka, Delhi

Visiting Consultant, Aakash Healthcare Hospital, Dwarka, Delhi

Introduction

Topical retinoids are highly effective medicine that plays an important role in treatment of both comedonal and inflammatory acne.1 Topical retinoids are a type of medication that is derived from vitamin A and can be applied to the skin to help improve the appearance of acne scars.2 They work by promoting the shedding of the top layer of the skin and increasing collagen production.2 This can help to reduce the appearance of scars and improve the overall texture and tone of the skin.3 Some examples of topical retinoids include tretinoin, adapalene and tazarotene.2

They are available in various forms, such as creams, gels and liquids and often used in combination with other acne treatments such as topical antibiotics or benzoyl peroxide.4 Use of retinoids, tretinoin, topically was an accidental invention, in late 1960 s, while studying the effect of tretinoin-retinoid on epidermal differentiation and keratinization. They, then realized the effect of topical retinoids on acne.4

Classification of Retinoid

Retinoids are classified as follows:2

1st generation: Retinol, tretinoin and isotretinoin. These are modifications of natural retinoids.

2nd generation: Etretinate, acitretin

3rd generation (synthetic): Tazarotene, adapelene, baxarotene.

4th generation: Trifarotene, highly sensitive for skin retinoid {RAR-y} receptor.

Among these retinol, tretinoin, adapelene and tazarotene, bexarotene, alitretinoin are topically available.

These come in cream, gel and liquid formulations. The medication is usually applied to the skin once a day, evening time, about 20 to 30 minutes after cleansing the face. They are commonly prescribed for mild to moderate acne.1 Sunscreen and moisturizers are to be prescribed along with during day time.5

Mechanism of Action

Retinoids act at a cellular level. They activate genes involved in the physiology of keratinocytes by binding to specific nuclear receptors, retinoic acid receptor (RAR) and retinoid X receptor (RXR).2 When applied topically, any deficiency in collagen that exists in the skin is partially improved.2

Topical tretinoin plays a role in preventing further degradation of the dermal matrix damaged by UV exposure. Therefore, topical retinoids are very effective at slowing and preventing photoaging due to UV exposure. This mechanism is explained through its interaction with the retinoic acid (RAR) and retinoid X receptors (RXR) located in the nucleus of the cell. These nuclear receptors increase the production of pro collagen and function to block the release of inflammatory mediators.2

Retinoids also act as comedolytic agents and work by unclogging blocked pores. They work synergistically with topical antibiotics to allow them to enter the pore and eradicate the underlying bacteria causing the acne breakout.2, 4

4. Antimicrobial effects: Some studies have suggested that retinoids may have antimicrobial effects, which could help to reduce the growth of P. acnes, a bacteria associated with acne.4

5. Stimulation of collagen production: Retinoids have been shown to stimulate collagen production, which can help to improve the overall appearance of the skin.2

Retinoids can take several weeks to start showing a visible improvement, and that longterm use is often necessary to maintain the results.

Uses

Retinoids have a variety of uses in dermatology. Some of the most common uses include:

1. Acne treatment: Topical retinoids are commonly used to treat acne by unclogging pores, reducing inflammation and preventing new comedones from forming.4

Figure 1: Biological pathway of natural retinoids and target sites of synthetic retinoids

Topical retinoids such as retinol and retinaldehyde are commonly added to cosmetics.5

The mechanism of action of topical retinoids in treating acne is not fully understood, but it is thought to involve several mechanisms:

1. Normalization of keratinization: Retinoids help to normalize the process of keratinization, which is the process by which cells in the hair follicles and sebaceous glands mature and are shed. This helps to unclog pores and reduce the formation of comedones.5

2. Anti-inflammatory effects: Retinoids have been shown to have anti-inflammatory effects, which can help to reduce redness and inflammation associated with inflammatory acne.4

3. Modulation of sebum production: Retinoids may also help to modulate sebum production, which can help to reduce the amount of oil on the skin and decrease the chances of clogging of pores.4

2. Anti-aging: Retinoids can help to improve the appearance of fine lines, wrinkles and age spots by stimulating collagen production and increasing cell turnover.4, 5

3. Psoriasis: Topical retinoids can be used to treat mild to moderate psoriasis by reducing inflammation and slowing the growth of skin cells.5

4. Hyperpigmentation: Retinoids can help to reduce the appearance of hyperpigmentation by inhibiting the production of melanin, the pigment responsible for skin color.2, 5

5. Warts: Topical retinoids can be used to treat warts by causing the skin cells to mature and die

more rapidly.

6. Keratosis pilaris: Retinoids can help to reduce the rough, bumpy texture of keratosis pilaris by exfoliating the skin and unclogging pores.5

7. Photoaging: Retinoids have been shown to improve the appearance of photoaged skin by increasing collagen production, reducing fine lines, wrinkles, improving skin texture and tone.5

8. Scarring: Retinoids can be used in combination with other treatments to reduce the appearance of scarring caused by acne or other skin conditions.3

9. Melasma: Retinoids can help to reduce the appearance of melasma by inhibiting the production of melanin.2

10. Basal Cell Carcinoma (BCC): Retinoids can be used as a treatment option for BCC.5

The following are some of the dermatologic uses for each topical retinoid.2, 4, 5

Retinol – Acne, keratosis pilaris, fine lines, hyperpigmentation.

Tretinoin – Acne, keratosis pilaris, fine wrinkles, hyperpigmentation.

Adapalene – Acne.

Tazarotene – Acne, chronic plaque psoriasis, post inflammatory hyperpigmentation, photo damage.

Alitretinoin – Kaposi’s sarcoma.

Bexarotene – Cutaneous T-cell lymphoma.

Trifarotene – Ichthyosis

Topical retinol and tretinoin, are effective first line treatment for comedonal and inflammatory

acne. Also helps in preventing recurrences. They help in reducing the severity of existing scarring and subsequent acne scarring.2

Topical retinoids are effective in post inflammatory hyper pigmentation, as they inhibit melanosome transfer and facilitate melanin dispersal.2

Side Effects

The irritation side effects from topical retinoids occur mainly from prolonged, high dose use. Side effects occur in a dose and concentration dependent fashion, with higher doses and concentrations contributing to the negative effects of these medications.

Topical tretinoin doesn’t cause any birth defects due to its rapid metabolism by the skin; however few fetal defects have been reported. Topical tretinoin in pregnant female should be used cautiously in acne, calculating risk verses benefit ratio. They should not be advised in pregnancy for fine lines, wrinkles and hyperpigmentation or skin roughness.2

It is advised to consult with a board-certified dermatologist before starting treatment with topical retinoids.

Retinoids can cause a range of side effects, some of which are more common than others. The most common side effects of topical retinoids include:5

> Retinoid dermatitis, which includes

• Excessive dryness of the skin

• Skin redness and swelling

• Scaling of the skin

• Pruritus (Itching)

> Sun sensitivity

> Allergic contact dermatitis (rare)

> Teratogenic, particularly with widespread tazarotene use. {pregnancy category X }

Other commonly observed adverse events are as follows:

1. Skin irritation: Retinoids can cause dryness, redness, itching and peeling of the skin. These side effects are more common when starting treatment, but usually subside with time.5

2. Sun sensitivity: Retinoids can make the skin more sensitive to sun exposure, so it is important to use a sunscreen when using topical retinoids.4

3. Photosensitivity: Retinoids can cause increased sensitivity to sunlight, leading to sunburns or rashes.4

4. Burning sensation: Some people might experience a burning sensation on the skin after applying retinoids.4

5. Erythema: Retinoids can cause redness or inflammation on the skin.5

6. Stinging or itching: Some people may experience stinging or itching after applying retinoids.4

7. Allergic reactions: In rare cases, people may experience an allergic reaction to retinoids, such as hives, rash or difficulty breathing.4

Discussion

Acne is a very common complaint in the youngsters today owing to their modern lifestyle; around 80-85% of individual worldwide is facing acne problem.3 Topical retinoids

compete with components implicated in the acne inflammation response. The production of comedones and follicular occlusion is decreased by retinoids' ability to regulate follicular keratinization and reduce keratinocyte cohesion.1 Retinoids bind to a variety of protein groups inside the body, including retinoid binding proteins and retinoid nuclear receptors. This eventually results in the activation of particular DNA regulatory areas known as retinoic acid response elements that control cell proliferation, differentiation and apoptosis.5

There are four generation of retinoid available with varied action and advantages. The efficacy and tolerance of topical retinoids vary, although they are all useful as single agents in the treatment of mild to moderate acne. Among all the topical retinoids, tretinoin is the most potent and widely used therapy for photo-aging.5

Topical retinoids can be used as maintenance therapy for patients who respond to initial treatment, which can reduce the need for protracted antibiotic use.1 Topical retinoid monotherapy is less effective than topical retinoid combination therapy with an antibacterial agent.1 Retinoids are currently employed widely in many clinical uses and ongoing research is still exploring their untapped potential.5

It is advised to start with a lowstrength retinoid and gradually increase the strength as the skin becomes accustomed to the medication. It is also observed that retinoids can cause side effects such as dryness, itching, redness and peeling, but these side effects usually subside with

time.4 It is also recommended to use a moisturizer and sunblock to protect our skin as retinoids make the skin more sensitive to sun exposure.4,5 The dermatologist may recommend the appropriate strength, frequency of application for individual case as well as monitor the progress of the treatment and adjust the treatment according to the severity of the acne.

Conclusion

Retinoids is an acceptable and reliable choice for first-line treatment of acne. They have been extensively studied and have been shown to be effective in the treatment of acne by unclogging pores, reducing inflammation and preventing new comedones from forming. Retinoids also have been found to be effective in treating psoriasis, hyperpigmentation, warts, keratosis pilaris and photoaging by reducing inflammation and slowing the growth of skin cells, inhibiting the production of melanin and exfoliating the skin. They can be used in combination with other treatments to reduce the appearance of scarring caused by acne, surgery or other causes. Moreover, topical retinoids boost the penetration of other topical acne treatments and hasten the healing of postinflammatory hyperpigmentation brought on by acne. Adapalene has a higher tolerability profile than other topical retinoids, which may make it easier for acne sufferers to use it as a longterm maintenance medication. Designing novel retinoids and its analogues with therapeutic value continues to be a difficulty today and are in progress. Overall, topical retinoids are considered

to be a safe and effective treatment option for various skin conditions.

Reference

1. Kolli, Sree S.; Pecone, Danielle; Pona, Adrian; Cline, Abigail; Feldman, Steven R. (2019). Topical Retinoids in Acne Vulgaris: A Systematic Review. American Journal of Clinical Dermatology, (), –. doi:10.1007/s40257-019-00423-z

2. Motamedi, M., Chehade, A., Sanghera, R., & Grewal, P. (2022). A Clinician's Guide to Topical Retinoids. Journal of cutaneous medicine and surgery, 26(1), 71–78. https://doi.org / 10.1177 / 12034754211035091

3. Thielitz A, Abdel-Naser MB, Fluhr JW, Zouboulis CC, Gollnick H. Topical retinoids in acne--an evidence-based overview. J Dtsch Dermatol Ges. 2008 Dec;6(12):1023-31. English, German. doi: 10.1111/ j.16100387.2008.06741.x. Epub 2008 May 13. PMID: 18479477.

4. Rusu A, Tanase C, Pascu GA, Todoran N. Recent Advances Regarding the Therapeutic Potential of Adapalene. Pharmaceuticals (Basel). 2020 Aug 28;13(9):217. doi: 10.3390/ ph13090217. PMID: 32872149; PMCID: PMC7558148.

5. Khalil S, Bardawil T, Stephan C, Darwiche N, Abbas O, Kibbi AG, Nemer G, Kurban M. Retinoids: a journey from the molecular structures and mechanisms of action to clinical uses in dermatology and adverse effects. J Dermatolog Treat. 2017 Dec; 28(8):684696. doi: 10.1080 / 09546634.2017. 1309349. Epub 2017 Apr 2. PMID: 28318351.

Application of Artificial Intelligence

In Identifying Antioxidants for Aging Part-II

Dr. Saad Sami AlSogair MD

Dermatologist & Anti-aging

Consultant

Vice President of the Middle East International Dermatology & Aesthetic Medicine Conference & Exhibition - MEIDAM

Results

A. Machine Learning

Zuvuela at al established quantitative structure-activity relationships models for flavonoids' oxygen radical absorbance capacity prediction. The criteria of two well-known antioxidant activity mechanisms, the hydrogen atom transfer (HAT) mechanism defined by the minimum bond dissociation enthalpy and the sequenced proton-loss electron transfer (SPLET) mechanism defined by proton affinity and electron transfer enthalpy, were used to construct both linear (PLS) and nonlinear (ANNs) models. The results of the ANN-based QSAR simulations are consistent with the findings. Finally, a series of 115 flavonoids were created combinatorially employing flavone as a template, and the highly predictive ANN-QSAR model was utilized to predict antioxidant activities. 23

Shen et al presented AOP-HMM, a computational model that extracts selective evolutionary characteristics from hidden Markov model (HMM) profiles to predict antioxidant proteins. The HMM profiles were first transformed into fixed-length feature vectors using auto crosscovariance (ACC) variables. Then,

to decrease the dimensionality of the raw feature space, they used the analysis of variance (ANOVA) approach. Finally, a support vector machine (SVM) classifier was used to predict AOPs. AOPHMM outperformed the majority of current approaches in the trials, demonstrating that it may be used to swiftly annotate AOPs and steer the experimental process.24

DrugAge (http://genomics. senescence.info/drugs/) is a curated library of medications and substances that may help people live longer lives. DrugAge now has 1316 entries with 418 distinct chemicals from investigations in 27 different model species, including worms, flies, yeast, and mice. 324 papers were manually selected for data. A functional enrichment study of targets of lifespan-extending medicines were run using druggene interaction data. Functional categories relating to glutathione and antioxidant properties, intracellular transport, and metabolic functions are among the enriched phrases. DrugAge is a free online resource for scientists and will be a valuable resource for biogerontologists.25

SeqSVM is a computational technique for predicting antioxidant proteins based on their basic sequence properties. By using the max relevance max distance approach, the features are deleted to decrease duplication. Finally, antioxidant proteins are identified using a support vector machine (SVM). The results of the experiments showed that the technique outperforms current methods, with an overall accuracy of 89.46 percent. Although the suggested computational method achieves a promising classification result, the experimental findings are confirmed using biochemical methods such as wet biochemistry and molecular biology.26

Garcia-Perez et al. reported on the research of phytocompounds in Bryophyllum sp., the application of plant tissue culture methods as a reliable instrument for the valuation of bioactive chemicals, and the use of machine learning techniques to model and maximize Bryophyllum spentire .'s phytochemical potential. Bryophyllum species may be a prospective source of plant bioactive chemicals with high antioxidant and anticancer potential, which might be exploited in cosmetic, food, and pharmaceutical sectors on a big scale. 27

Chen et al. designed quantitative structure-activity relationship (QSAR) models based on 91 antioxidant tripeptides. They used the stepwise regression (SWR) method to select critical variables without autocorrelation, and then developed predictive QSAR models based on the screened variables using multiple linear regression, support vector machine, random forest, and partial least square regression.19 antioxidant tripeptides were generated using SWR-MLR models, and their antioxidant activity in free radical systems was

tested using three antioxidant tests. The developed QSAR models may be utilized to find and test new highactivity antioxidant tripeptides.28

ANPrAod is a model that may be used to find antioxidant proteins. Xi et al computed 673 amino acid reduction alphabets to identify the best feature representation method in order to minimize possibly duplicate features and increase prediction accuracy. The resulting model had a five-fold crossvalidation accuracy of 87.53 percent and a ROC of 0.7266, which was better than the prior techniques. The findings of the independent dataset further revealed ANPrAod's good resilience and dependability, suggesting that it might be a useful tool for identifying antioxidant proteins and contributing to hypothesis-driven experimental design.29

Ho Thanh Lam et al created a machine learning-based model for prediction of antioxidant proteins. The studies were carried out using 10-fold cross-validation on the training process, and three separate independent datasets were used to verify the results. On an ideal collection of sequence characteristics, several machine learning and deep learning techniques were assessed. Random Forest was shown to be the best model for identifying antioxidant proteins with the greatest performance among them. On the training dataset, the optimum model identified antioxidant proteins with an accuracy of 84.6 percent and a balance of sensitivity (81.5 percent) and specificity (85.1 percent). The importance of this approach was further shown by the performance findings from several independent datasets when compared to previously published efforts on antioxidant protein identification.30

The Antioxidant Database (AOD)

was created to aid researchers in understanding and revealing the biological roles of antioxidant proteins. The AOD database may be found at http://lin.uestc.edu. cn/AODdatabase/index.aspx. AOD currently has 710 antioxidant proteins in its current release. AOD extracts categorization, source organism, subcellular localization, gene products, catalytic properties, and functionality of antioxidant proteins from UniProtKB/SwissProt. In addition, AOD now includes two web-based tools for doing sequence similarity searches and computationally identifying antioxidants.31

In the context of a biomarker selectively produced by lipid peroxidation (a result of oxidative stress), such as F2-isoprostanes, Idowu et al developed an AI-based machine learning (ML) model to link a polyphenol's antioxidant action as an output variable to molecular descriptors (factors governing in vivo antioxidant activity) as input variables. Support vector machines, artificial neural networks, and Bayesian probabilistic learning are some of the main approaches that might be applied. This model will be a solid predictor of biorelevant antioxidant capacity of polyphenols, making antioxidant compound identification and design simpler. The method will also help to satisfy the 3Rs criteria when using animals in scientific research (replacement, reduction, and refining).32

IDAod is a user-friendly web server for antioxidant protein identification and can be found at http://bigroup. uestc.edu.cn/IDAod/. Based on a mixed g-gap dipeptide component feature vector, Shao et al developed a deep learning-based classifier to detect antioxidant proteins. To extract nonlinear model from raw input, the classifier employs a deep autoencoder. To minimize

dimensionality, the t-Distributed Stochastic Neighbor Embedding (t-SNE) method was applied. Lastly, the data was classified using a support vector machine. In 10fold cross validation, the classifier received a F 1 score of 0.8842 and an MCC of 0.7409. Their suggested technique outperformed standard machine learning methods in experiments, indicating that it might be a useful tool for identifying antioxidant proteins.33

Bai et al used the Tox21 challenge dataset to build and validate a series of predictive models that used deep learning algorithms like deep neural networks, convolution neural networks, recurrent neural networks, and highway networks to determine whether the compounds are ARE activators or inactivators. With accuracy of 0.992, 0.914, and 0.917 for the training set, test set, and validation set, respectively, the DNN prediction model based on fingerprint characteristics has the best prediction ability. As a result, these robust models may be used to predict the ARE response of molecules quickly and precisely, which is critical for assessing the safety of drugs throughout the drug discovery and development process. 34

A new dataset was built by Guardado et al utilizing databases that gather the flavonoid content of various foods. A structuraltopological technique termed TOPological Sub-Structural Molecular Analysis was used to collect structural information (TOPSMODE). Various artificial intelligence techniques, including Machine Learning (ML) methodologies, were used. Using structural-topological features of dietary flavonoids, they were able to show the efficacy of the models. Except for the Multi-Layer Perceptron (MLP) technique, the

models presented may be regarded successful in estimating new values of Oxygen Radical Absorption Capacity (ORAC) without generalization. The Random Forest (RF) method produced the most ideal model. By incorporating new structural-topological qualities and choosing those that most impact the class variable, the in silico approach they devised enabled them to validate the usefulness of the produced models.35

Using large and diverse pharmacological and natural chemical data, Yoo et al created a deep learning-based strategy for identifying the therapeutic applications of natural compounds. Deep learning can efficiently use heterogeneous characteristics to relieve incomplete information, which is the motivation for this technique. They produced 686 dimensional characteristics for 4,507 natural chemicals and 2,882 authorized and experimental pharmaceuticals based on latent knowledge, molecular interactions, and chemical property aspects. The produced features and confirmed pharmacological indication data were used to train the deep learning model. Potential efficacies were accurately predicted with high sensitivity, specificity, and accuracy when natural compound characteristics were used as inputs to the trained model.36

AOPs-SVM is a model based on sequence characteristics and a support vector machine that was constructed using machine-learning methods. The creators ran a jackknife crossvalidation test using the suggested AOPs-SVM classifier using a testing dataset and got 0.68 in sensitivity, 0.985 in specificity, 0.942 in average accuracy, 0.741 in MCC, and 0.832 in AUC. Existing classifiers were outperformed by this. The findings of the experiment

show that the AOPs- SVM is a useful classifier that adds to antioxidant protein research. To allow open access, a web server was established at http://server. malab.cn/AOPs-SVM/index.jsp.37

Kennedy et al identified peptide RTE62G (pep RTE62G), a naturally occurring, unaltered peptide with ECM modulatory properties, using an artificial intelligence (AI) technique.In vitro, vivo, and proof of concepts clinical trials were used to evaluate pep RTE62AI-predicted G's antiaging capabilities. Pep RTE62G was extracted from a plant source, Pisum sativum, using a deep learning approach (pea). The in vitro impact of pep RTE62G was next assessed using human dermal fibroblasts (HDFs) and keratinocytes (HaCaTs) cell culture assays. ELISA tests were usedto assess various activities such as cell proliferation and ECM protein production properties. A wound healing assay was used to measure cell migration, while immunofluorescence imaging and PCR were used to study ECM protein synthesis and gene expression, respectively. To investigate the induction of ECM proteins by pep RTE62G ex vivo, immunohistochemistry was used on human skin explants. Finally, the clinical efficacy of pep RTE626 was assessed in a 28-day proofofconcept pilot study.38, 39

Pep RTE62G is an effective multi-functional anti-aging ingredient, according to in vitro testing. In HaCaTs, Pep RTE62G administration promotes both cellular proliferation and migration. Pep RTE62G also reliably stimulated the neosynthesis of the ECM proteins elastin and collagen in HDFs, which was verified in human skin explants. Finally, pep RTE626 shown antiwrinkle and collagen stimulatory potential during a 28day period in our proof-of-concept clinical research. pep RTE62G is a

pure, unmodified peptide with antiaging properties predicted by AI and experimentally validated.39

With a focus on peptides, Doherty et al. proposed for complementing, if not replacing, the conventional sequence of functional food ingredients (FFI) structural characterization with an AIpowered solution by integrating AI at the start of the process. To describe functional food components, in silico bioinformatics, in vitro, and HTP screening approaches have substantially enhanced the procedure (FFIs). Bioinformatic tools that perform similarity searches, such as the Basic Local Alignment Search Tool, may be used to mine proteomes in silico (BLAST). These methods, on the other hand, usually analyze and extrapolate on previously collected data and are unable to anticipate molecular entities and functions from scratch.

Artificial intelligence (AI) methods, particularly deep learning approaches, could and should be used to speed up de novo algorithmic identification of bioactive components and their functions, resulting in true innovation at an unprecedented speed in areas like functional ingredients and small molecules, and providing novel insights for a variety of questions. In other words, AI shifts the paradigm away from screening and retroactive benefit assignment and towards design based on predefined benefits.40

Bioactive peptides derived from food have fantastic potential in treating and maintenance of a variety of health conditions, including chronic inflammation. A rice-derived functional component termed a natural peptide network (NPN) significantly reduced Tumour Necrosis Factor (TNF) production in human macrophages in vitro in response to lipopolysaccharides.

Rice NPNs were characterized using AI, and liquid chromatography tandem mass spectrometry was utilized to confirm the presence of seven potentially active peptides. In vitro, the anti-inflammatory capabilities of the network's component peptides were confirmed.40

To forecast whether a chemical substance would lengthen the lifespan of Caenorhabditis worms, Kapsiani et al created a machine learning technique based on information from the DrugAge database. Chemical fingerprints and molecular descriptors were employed as features in five prediction models built using the random forest technique. For classifying the substances in the test set, the top-performing classifier, which was created using molecular descriptors, obtained an area under the curve score (AUC) of 0.815. The Gini significance measure of the random forest technique was used to rank the model's features. Atom and bond count descriptors, as well as topological and partial charge features, were among the top 30 traits. In an external database of 1738 small compounds, the model was utilized to predict the substance. In the screening database, chemical compounds with a prediction probability of 0.80 for increasing Caenorhabditis elegans longevity were classified as (1) flavonoids, (2) fatty acids and conjugates, and (3) organooxygen compounds.41

Deep learning is used in the AnOxPePred program and webserver to predict the antioxidant properties of peptides. Olsen et al's model was trained using an experimentally tested dataset of antioxidant and non-antioxidant peptides. This technique outperforms a k-NN sequence identity-based approach in

prediction on a range of measures. In addition, the new approach will serve as a suitable standard for future antioxidant peptide predictors. The tool is available at http://services.bioinformatics.dtu. dk/service.php?AnOxPePred-1.042

B. Artificial Neural Networks

Ferulic acid ester has been shown to be more efficient in treating several clinical conditions and reducing lipid oxidation. To model and improve the solvent-free and low pressure water evaporation in the lipasecatalyzed synthesis of 2-ethylhexyl ferulate (2-EF) from ferulic acid and 2-ethylhexanol, a Box-Behnken design integrating response surface methodology (RSM) and artificial neural network (ANN) was used. ANN surpassed RSM in data fitting based on residual values and coefficient of determination (R2) obtained from the design data. Overall, in a reduced pressure evaporation environment, the current lipase-catalyzed 2-EF synthesis technique yields a high yield of 2-EF at low reaction temperature. This technique, in particular, has the potential to reduce enzyme denaturation and ferulic acid oxidation, two prominent side effects of long-term biosynthetic activity at high temperatures.43

Liu et al extracted Rosa sterilis flavonoids using an ultrasonic technique, and the extraction conditions were modeled and adjusted using response the surface approach and artificial intelligence. The findings reveal that the ultrasonic approach can successfully extract total flavonoids, and the extraction rate is near to the ANN-GA algorithm's forecast value, demonstrating the model's logic. Material liquid ratio > extraction power > extraction duration > ethanol concentration were the factors that had the most impact

Application of Artificial Intelligence In Identifying Antioxidants for Aging Part-II

on the experiment. Furthermore, the scavenging effects of flavonoids on DPPH, O2-, and OH were investigated, indicating that flavonoids have potent antioxidant properties. Using the data from the extraction process, the kinetics of the extraction process was investigated, and it was discovered that the extraction process followed Fick's first law.44

Using Artificial Neural Networks (ANNs) technology, Golpour et al investigated the total phenolic compounds and antioxidant activity of strawberries under various experimental extraction circumstances. The trial data was used to train ANNs utilizing Levenberg-Marquardt (LM) and Bayesian Regulation techniques to feed- and cascade-forward backpropagation models. Total phenolic compounds, DPPH, and ABTS antioxidant activity were employed as ANN outputs, while three independent variables (solvent concentration, volume/mass ratio, and extraction duration) were used as ANN inputs. The 3-9-1, 3-4-41, and 3-13-10-1 structures, with the learning algorithms of trainlm, trainbr, trainlm, and threshold functions of tansig-purelin, tansigtansig-tansig, and purelin-tansigtansig, respectively, were the best cascade- and feedforward backpropagation topologies of ANNs for the estimation of total phenolic compounds, DPPH, and AB. The best R2 values were 0.9806 (MSE = 0.0047), 0.9651 (MSE = 0.0035), and 0.9756 (MSE = 0.00286, respectively, for total phenolic compounds, DPPH, and ABTS antioxidant activity factors.

According to the ANN comparison results, the cascade-forward backpropagation network beat the feed-forward backpropagation network in predicting TPC, whereas the FFBP network outperformed the cascade-forward backpropagation

system in predicting DPPH and ABTS antioxidant activity parameters. The artificial neural network (ANN) technology can be used to estimate total phenolic compounds and antioxidant activity in strawberries.45

Conclusion

To summarize, AI has the potential to help in a variety of antioxidant identification discovery fields. As with any concept, it is unlikely to be a panacea, but its use should be expanded to help scientists in their various roles and specialties throughout the process. Domainspecific AI applications in industry are just getting started. We are unlikely to see seismic changes overnight; as supplement discovery remains a slow business based on risk management and the development of novel science within the constraints of patient and shareholder responsibility.

However, combining these approaches has the potential to significantly increase efficiency in some parts of the pipeline, giving researchers more time to focus on different problems by offloading simple tasks to AI and robotics combinations. Furthermore, AI provides potentially useful insights to seasoned scientists through its extensive "working memory," which is essentially a new perspective. Nonetheless, there will be setbacks and duplications of effort in the process ofimplementing these changes. We are confident, however, that AI will alter certain drug discovery processes and advance innovative bioactives research and development.

References

23. Žuvela, P., David, J., Yang, X., Huang, D., & Wong, M. W. (2019). NonLinear Quantitative Structure Activity Relationships Modelling, Mechanistic Study and In-Silico Design of Flavonoids

as Potent Antioxidants. International journal of molecular sciences, 20(9), 2328. https://doi.org/10.3390/ ijms20092328

24. Shen Z, Liu T, Xu T. Accurate Identification of Antioxidant Proteins Based on a Combination of Machine Learning Techniques and Hidden Markov Model Profiles. Comput Math Methods Med. 2021 Aug 7;2021:5770981. doi: 10.1155/2021/5770981. PMID: 34413898; PMCID: PMC8369162.

25. Barardo D, Thornton D, Thoppil H, Walsh M, Sharifi S, Ferreira S, Anži A, Fernandes M, Monteiro P, Grum T, Cordeiro R, De-Souza EA, Budovsky A, Araujo N, Gruber J, Petrascheck M, Fraifeld VE, Zhavoronkov A, Moskalev A, de Magalhães JP. The DrugAge database of agingrelated drugs. Aging Cell. 2017 Jun;16(3):594597. doi: 10.1111/acel.12585. Epub 2017 Mar PMID: 28299908; PMCID: PMC5418190.

26. Xu L, Liang G, Shi S, Liao C. SeqSVM: A Sequence-Based Support Vector Machine Method for Identifying Antioxidant Proteins. Int J Mol Sci. 2018 Jun 15;19(6):1773. doi: 10.3390/ ijms19061773. PMID: 29914044; PMCID: PMC6032279.

27. García-Pérez P, Lozano-Milo E, Landin M, Gallego PP. From Ethnomedicine to Plant Biotechnology and Machine Learning: The Valorization of the Medicinal Plant Bryophyllum sp. Pharmaceuticals (Basel). 2020 Dec 4;13(12):444. doi: 10.3390/ ph13120444. PMID: 33291844; PMCID: PMC7762000.

28. Chen N, Chen J, Yao B, Li Z. QSAR Study on Antioxidant Tripeptides and the Antioxidant Activity of the Designed Tripeptides in Free Radical Systems. Molecules. 2018 Jun 10;23(6):1407. doi: 10.3390/molecules23061407. PMID: 29890782; PMCID: PMC6100293.

29. Xi Q, Wang H, Yi L, Zhou J, Liang Y, Zhao X, Zuo Y. ANPrAod: Identify Antioxidant Proteins by Fusing Amino Acid Clustering Strategy and N-Peptide Combination. Comput Math Methods Med. 2021 Apr 8;2021:5518209.

doi: 10.1155/2021/5518209. PMID: 33927782; PMCID: PMC8049822.

30. Ho Thanh Lam L, Le NH, Van Tuan L, Tran Ban H, Nguyen Khanh Hung T, Nguyen NTK, Huu Dang L, Le NQK. Machine Learning Model for Identifying Antioxidant Proteins Using Features Calculated from Primary Sequences. Biology (Basel). 2020 Oct 6;9(10):325.

doi: 10.3390/biology9100325. PMID: 33036150; PMCID: PMC7599600.

31. Feng P, Ding H, Lin H, Chen W. AOD: the antioxidant protein database. Sci Rep. 2017 Aug 7;7(1):7449. doi: 10.1038/s41598-017-08115-6. PMID: 28784999; PMCID: PMC5547145.

32. Idowu SO, Fatokun AA. Artificial Intelligence (AI) to the Rescue: Deploying Machine Learning to Bridge the Biorelevance Gap in Antioxidant Assays. SLAS Technol. 2021 Feb;26(1):16-25. doi: 10.1177/2472630320962716.

Epub 2020 Oct 15. PMID: 33054529; PMCID: PMC7838339.

33. Shao L, Gao H, Liu Z, Feng J, Tang L, Lin H. Identification of Antioxidant Proteins With Deep Learning From Sequence Information. Front Pharmacol. 2018 Sep 20;9:1036. doi: 10.3389/fphar.2018.01036. PMID: 30294271; PMCID: PMC6158654.

34. Bai F, Hong D, Lu Y, Liu H, Xu C, Yao X. Prediction of the Antioxidant Response Elements' Response of Compound by Deep Learning. Front Chem. 2019 May 31;7:385. doi: 10.3389/fchem.2019.00385. PMID: 31214568; PMCID: PMC6554289.

35. Guardado Yordi E, Koelig R, Matos MJ, Pérez Martínez A, Caballero Y, Santana L, Pérez Quintana M, Molina E, Uriarte E. Artificial Intelligence Applied to Flavonoid Data in Food Matrices. Foods. 2019 Nov 14;8(11):573. doi: 10.3390/

foods8110573. PMID: 31739559; PMCID: PMC6915672.

36. Yoo S, Yang HC, Lee S, Shin J, Min S, Lee E, Song M, Lee D. A Deep Learning-Based Approach for Identifying the Medicinal Uses of Plant-Derived Natural Compounds. Front Pharmacol. 2020 Nov 30;11:584875. doi: 10.3389/ fphar.2020.584875. PMID: 33519445; PMCID: PMC7845697.

37. Meng C, Jin S, Wang L, Guo F, Zou Q. AOPs-SVM: A SequenceBased Classifier of Antioxidant Proteins Using a Support Vector Machine. Front Bioeng Biotechnol. 2019 Sep 18;7:224. doi: 10.3389/fbioe.2019.00224. PMID: 31620433; PMCID: PMC6759716.

38. Kennedy K, Cal R, Casey R, Lopez C, Adelfio A, Molloy B, Wall AM, Holton TA, Khaldi N. The anti-ageing effects of a natural peptide discovered by artificial intelligence. Int J Cosmet Sci. 2020 Aug;42(4):388-398. doi: 10.1111/ ics.12635. PMID: 32453870.

39. Kennedy K, Roi, Cal1, et al. pep_35E7UW, a natural peptide with cutaneous anti-ageing effects discovered within the Oryza Sativa proteome through machine learning. J Dermat Cosmetol . 2020;4(5):109-116 DOI: 10.15406/jdc.2020.04.00162

40. Doherty, A., Wall, A., Khaldi, N., & Kussmann, M. (2021). Artificial Intelligence in Functional Food Ingredient Discovery and Characterisation: A Focus on Bioactive Plant and Food Peptides. Frontiers in genetics, 12, 768979. https://doi.org/10.3389/ fgene.2021.768979

41. Kapsiani, S., Howlin, B.J. Random forest classification for predicting lifespan-extending chemical compounds. Sci Rep 11, 13812 (2021). https://doi.org/10.1038/s41598-02193070-6

42. Olsen TH, Yesiltas B, Marin FI, Pertseva M, García-Moreno PJ, Gregersen S, Overgaard MT,Jacobsen C, Lund O, Hansen EB, Marcatili P. AnOxPePred: using deep learning for

the predictionof antioxidative properties of peptides. Sci Rep. 2020 Dec 8;10(1):21471. doi: 10.1038/s41598020-78319-w. PMID: 33293615; PMCID: PMC7722737.

43. Huang KC, Li Y, Kuo CH, Twu YK, Shieh CJ. Highly Efficient Synthesis of an Emerging Lipophilic Antioxidant: 2-Ethylhexyl Ferulate. Molecules. 2016 Apr 12;21(4):478. doi: 10.3390/ molecules21040478. PMID: 27077838; PMCID: PMC6274311.

44. Liu J, Li C, Ding G, Quan W. Artificial Intelligence Assisted Ultrasonic Extraction of Total Flavonoids from Rosa sterilis. Molecules. 2021 Jun 23;26(13):3835. doi: 10.3390/ molecules26133835. PMID: 34201870; PMCID: PMC8270336.

45. Golpour I, Ferrão AC, Gonçalves F, Correia PMR, Blanco-Marigorta AM, Guiné RPF. Extraction of Phenolic Compounds with Antioxidant Activity from Strawberries: Modelling with Artificial Neural Networks (ANNs). Foods. 2021 Sep 20;10(9):2228. doi: 10.3390/foods10092228. PMID: 34574338; PMCID: PMC8472351.

FDA warns of tattoo ink tied to dangerous infections

Tattoo ink is the colored substance that is injected into the skin during the process of tattooing to create permanent designs or artwork. Tattoo inks are typically made up of a combination of pigments, carrier liquids, and sometimes additives. While most tattoo inks are generally considered safe, there is always a potential risk of adverse reactions or complications. Some individuals may experience allergic reactions, skin sensitivities, or infections related to tattoo ink. It's crucial to choose a reputable and professional tattoo artist who follows strict hygiene practices, including using sterile equipment and high-quality tattoo inks.

The Food and Drug Administration draft guidance released recently on possible contamination of tattoo ink was not concerning. There are several different infections from tattooing, and they are from organisms that tend to contaminate things in damp, liquid-type environments. The FDA released the new draft guidance aiming to reduce the use of pathogen-contaminated tattoo ink, which can cause stubborn infections that are especially hard to treat.

Tattooing involves puncturing the epidermis about 100 times per second with needles and depositing ink 1.5 to 2 millimeters below the surface of the skin, deep into the dermis, the guidance states. Contaminated tattoo ink can cause infections and serious injuries. Because these inks are injected, pathogens or other harmful substances in these inks can travel from the injection site through the blood and lymphatic systems to other parts of the body.

Commonly reported symptoms of tattoo ink–associated infections include rashes, blisters, painful nodules, and severe abscesses. One of the most common bacteria found in contaminated tattoo ink is nontuberculous mycobacteria, which is related to the bacteria that causes tuberculosis and can be found in soil and water.

Between 2003 and 2023, there were 18 recalls of tattoo inks that were contaminated with various microorganisms, according to the FDA. In May 2019, the FDA issued a safety alert advising consumers, tattoo artists, and retailers to avoid using or selling certain tattoo inks contaminated with microorganisms. Reputable ink manufacturers use a process called gamma radiation, which refers to electromagnetic radiation of high frequencies to kill microorganisms in the ink and its packaging. Because tattoo ink is considered a cosmetic product, there is not much regulatory oversight involved, which means the sterility and quality of ingredients vary. Cosmeceuticals aren’t regulated by the FDA like prescription medication.

FDA passes on olorofim despite critical need for antifungals

Fungal infections, also known as mycoses, are caused by various types of fungi. Fungal infections can affect different parts of the body, including the skin, nails, hair, and internal organs. Treatment for fungal infections depends on the type and severity of the infection. It often involves the use of antifungal medications, which can be in the form of topical creams, oral tablets, or, in some cases, intravenous injections. Good hygiene practices, such as keeping the affected area clean and dry, can also help prevent and manage fungal infections. The FDA’s says fungal infections are becoming increasingly common and resistant to treatment. There are only four antifungal classes currently available, and there are few new candidates in the pipeline. No new classes of antifungals have been developed in 2 decades. Now Olorofim, (formerly known as F901318) is the first in the orotomide class of antifungals to be evaluated clinically for the treatment of invasive mold infections. Some of the early results were really exciting, of this molecule. “People are enthusiastic about the compound because it has a novel mechanism of action, and it is active against a group of fungi that we have limited to no options for.

Olorofim is the first antifungal agent to be granted breakthrough therapy designation, which the FDA granted in November 2019 for the treatment of invasive mold infections for patients with limited or no treatment options, including patients with refractory aspergillosis or those who are intolerant of currently available therapy. It is also indicated for infections due to Lomentospora prolificans, Scedosporium, and Scopulariopsis species.

Olorofim received a second breakthrough therapy designation in October 2020. The second designation was granted for treatment of central nervous system coccidioidomycosis that is refractory or for cases that cannot be treated with standard-of-care therapy.

NEW CONFERENCE VENUE - Sheikh Rashid Hall, Dubai World Trade Centre, UAE

SCIENTIFIC ORGANISER SCIENTIFIC PARTNER CONFERENCE ORGANISER

HONORARY GLOBAL HUMANITARIAN PARTICIPANT

SCIENTIFIC COLLABORATORS

ENDORSED BY IN COLLABORATION WITH

A Study of Comparison of Fractional CO2 Laser Alone Vs Sequential Fractional CO2 Laser with Dermaroller in Acne Scars

Dr. Tejansu Samir Dalal

MBBS, MD (DVL)

Consultant Dermatologist and Cosmetologist

Naranpura

Skin, hair and Aesthetic Laser Clinic, Ahmedabad, Gujarat

Introduction

Acne is a chronic condition of pilosebaceous unit.1 Impediment of the sebaceous gland due to change in keratinisation and colonisation. Propionobacterium acnes are the crucial reasons for acne production.2 It is caused by the overproduction of oil in the skin, as well as the buildup of dead skin cells and an overgrowth of the bacteria propionibacterium acnes.2 It mainly starts in the adolescent stage during puberty.3 Pilosebaceous unit being immunodominant organ consist of keratinocytes and sebocytes which on attack by propionibacterium acnes gets activated resulting in cytokines secretion resulting in acne. Hormones like androgen also play a major role in acne production. Hyperkeratinisation in the infundibulum is also responsible for acne lesions.1

Acne is a common skin condition characterized by the appearance of pimples, blackheads, whiteheads on the

face, neck, chest and back.3 Pilosebaceous units can unfold into blackheads, other lesions like papules, nodules and cysts.2 In chronic condition these papules agglutinate and lead to drains which eventually cause scarring.2 Acne scars are the result of the inflammatory response to acne. They can appear as depressed or raised areas of skin, it can be caused by a variety of factors, including genetics, skin type and the severity of the acne.2,4 During the process of curation of an active acne results in some impairment to skin and hence scars are generated.5 Scarring is a common consequence of acne and may occur in up to 90% of patients.3 Delay in appropriate management is most likely to result in significant scarring.2

Pathology of scarring involves inflammation, granulation tissue formation, wound contracture and tissue remodeling.5 The depth and extent of inflammation determines the degree of the scar. Acne scars may show

increased collagen (hypertrophic scars) or loss of collagen (atrophic scars).1

Acne scars are the result of severe or untreated acne. They can take the form of deep pits or raised discoloured marks on the skin. Procedural treatments can help to smooth out the skin's texture and reduce the appearance of scars. However, it is important to note that the treatments may not completely remove the scars and may require multiple sessions. Other treatment options for acne scars vary depending on the type, severity of the scars and may include topical creams, chemical peels, micro needling, laser therapy and dermabrasion. Surgery such as subcision and punch excision is also an option for treating deep acne scars.5

The mechanism of action of CO2 laser is collagen tightening, where as derma roller works through natural response to wounding of the skin.5,6

The aim of our study was to compare fractional CO2 laser alone with sequential fractional CO2 laser with derma roller.

Types of acne scar

Acne scarring occurs when the skin is damaged during an acne breakout. There are two preliminary types of acne scars, which include atrophic scars (deprivation of collagen) and hypertrophic or keloidal scars (additional collagen dumping and reduced activity of collagenase enzyme).5

Atrophic scars can further be classified based on depth and size of damage: 5,6

1. Ice pick scars: These are deep, narrow scars that

resemble a small hole in the skin. They are typically caused by severe acne and are difficult to treat.5,6

2. Boxcar scars: These are round or oval scars with sharp edges. They can be shallow or deep and are typically found on the cheeks and temples.5,6

3. Rolling scars: These are broad, shallow scars that give the skin a wavy appearance. They are typically caused by a loss of tissue and can be difficult to treat.5,6

Hypertrophic scars: These are raised scars that are caused by excessive collagen production. They can be itchy, uncomfortable and can occur as a result of picking at acne.5 These are thick hyalinised bundles of collagen fibres which appears to be pink in colour and often seen within the borders of scars.5

Apart from those mentioned above hyperpigmented scars are also observed: These scars are darker in colour than the surrounding skin. They can occur as a result of acne or as a side effect of certain acne treatments.

Treatment for acne scars

Treatment options for acne scars vary depending on the type and severity of the scars. Some common options include:

1. Topical creams: Topical creams containing retinoid, hydroquinone or kojic acid can help to reduce the appearance of hyperpigmented scars.1

2. Chemical Peels: Chemical peels are used to remove the top layers of skin, elevating the healing process, revealing smoother and clearer skin. They can help to reduce the appearance of hyperpigmented scars, as well as improve skin texture. Different types of chemical peels include alpha-hydroxy acids (AHAs),

Figure 1: Types of acne scars

beta-hydroxy acids (BHAs) and trichloroacetic acid (TCA) peels.5

3. Microneedling:

Microneedling is a device with fine needles to create microscopic injuries in the skin, which stimulate collagen production and can help to improve the appearance of acne scars. It can be used alone or in combination with other treatments such as topical creams or platelet-rich plasma (PRP).5

4. Lasers: Lasers can be used to resurface the skin, stimulate collagen production and reduce the appearance of acne scars. Carbon dioxide (CO2) laser and Erbium: Yttrium - AluminiumGarnet (Er:YAG) laser are two types of laser that can be used to treat acne scars. CO2 laser can be used for deep scars, while Er:YAG laser can be used for shallow scars. It is important to note that multiple treatment sessions may be necessary for optimal results.5,6

5. Dermabrasion: Dermabrasion uses a rotating wire brush or diamond-tipped wand to remove the top layers of skin, which can help to reduce the appearance of acne scars. It can be effective for treating rolling and boxcar scars.5,6

6. Surgery: Surgery such as subcision and punch excision is options to treat deep scars. Subcision is a surgical procedure that involves breaking up the fibrous bands that are pulling down the skin, causing the depression in the scar. It is typically used for rolling and boxcar scars.5,6

7. Punch Techniques: Punch excision or punch elevation is a

surgical dermatology method that effectively treats acne scarring. Punch excision is a surgical procedure that involves removing the scar and closing the wound with sutures or a skin graft. Punch elevation is also surgical procedure that involves removing the scar, lifting the surrounding tissue and closing the wound with sutures. These techniques are typically used for deep ice pick scars.6

Main mechanism of action of collagen induction therapy (CIT) includes:5,6

1. Inflammation

2. Proliferation

3. Tissue remodelling

In some cases, a combination of treatments may be recommended for optimal results.

It is very crucial to follow the aftercare instructions given by the practitioner, like avoiding sun exposure and use of sunscreen, avoiding picking or scratching the treated area and avoiding certain skincare products.

Materials and Method

Aim

The main aim of the study is to compare fractional CO2 laser alone with sequential fractional CO2 laser with dermaroller (microneedling) in acne scars under the following:

1. To evaluate objective and subjective outcomes based on clinical improvement, photographic evidence.

2. To observe any untoward events or side effects, if any.

Method

The study was conducted for duration of two years by allotting patients into two groups. Group A was given 2 sessions of fractional carbon dioxide laser at an interval of 1 month. Group B was given 2 sessions consisting of sequential treatment of fractional carbon dioxide laser and dermaroller at an interval of 1 month.

Methodology

• Study Design: Open interventional study

• Duration: 24 months

• Sample size: 50

Figure 2 : CO2 laser and dermaroller

Fractional CO2 Laser Alone Vs Sequential Fractional CO2 Laser with Dermaroller in Acne Scars

Inclusion Criteria

• Age group between 18-35 years

• Giving written and informed consent

• All type of atrophic facial acne scars

Exclusion Criteria

• With keloidal tendency or any active infection on face.

• On immunosuppressive therapy.

• History of photosensitivity or photosensitive disorders.

• With bleeding disorders and on antiplatelet drugs.

The patients were sequentially allotted into group A and Group B. Group A

Patients underwent total of 4 sessions of fractional CO2 laser over a period of 4 months at an interval of 1 month.

Results were evaluated on the basis of:

• Objective assessment using Goodman Barron Score (Qualitative).

• Clinical improvement (Physician assessment) in % was documented by standardized photographs at the end of 6 months. (2 months after the last session).

• Subjective assessment using 6-point Visual Analogue scale (each patient was asked to grade between 0 to 6 as per his/ her satisfaction with 0 being no satisfaction at all and 6 being complete satisfaction).

* The study was conducted in 50 patients. The study showed that the most common age group involved was between 2130 years (88%).

* The male to female ratio was 1.9:1

* Among other factors, like duration of scars and grade of scars have no statistically significant impact on the final outcome.

* GBS score: Group A showed mean improvement from baseline 3.12+0.43 to 2.12+0.53 after 6 months.

* Group B showed mean improvement from baseline 3.56+0.51 to 2.84+0.62 after 6 months.

* Physician assessment: Physician assessment of group A, 12% patients showed 5175% improvement, 80% patients showed 26-50% improvement and 8% patients showed 0-25% improvement of acne scars.

* Group B, 8% patients showed 51-75% improvement, 68% patients showed 26-50% improvement and 24% patients showed 0-25% improvement of acne scars.

* Visual Analogue Score: Visual Analogue Score of group A, 12% patients were highly satisfied (excellent response), 84% were moderately satisfied (good response) and 4% patients were not satisfied (poor response).

Patients had one session of fractional CO2 Laser followed by one session of dermaroller after 1 month to follow same sequence making total of 4 sessions (2 sessions each) over 4 months.

Patients were followed up regularly till 6 months (2 months after the last session)

* Significant clinical improvement was present in both the groups but group A showed better results than group B which is statistically significant.

* Acne scars were predominantly seen on cheeks followed by forehead, temples, chin and nose.

* Group B, 12% patients were highly satisfied (excellent response), 84% were moderately satisfied (good response) and 4% patients were not satisfied (poor response).

Figure 3: Post CO2 laser Group B

Figure 4: Post dermaroller Result

Study of Comparison of Fractional CO2 Laser Alone Vs Sequential Fractional CO2 Laser with Dermaroller in Acne Scars

Group A

Group B

Figure 5 : Group A pre and post treatment

Figure 6 : Group B pre and post treatment

Study of Comparison of Fractional CO2 Laser Alone Vs Sequential Fractional CO2 Laser with Dermaroller in Acne Scars

Discussion

Acne is a multifactorial disease caused due to hormonal change; genetic, excess sweat production and stress all contribute in aggravating or induction of the condition.3 In this study two groups of patients were selected for treatment of acne scars, each group were treated independently and comparison of the treatments were made based on evaluation of results. Group A was treated with fractional carbon dioxide laser alone whereas group B was treated with fractional carbon dioxide laser combined with dermaroller (sequential), both of these techniques are known to be used in treatment of acne scars. A study comparing the two treatments specifically in terms of their effectiveness in treating acne scars would be useful in determining which treatment is more effective or if the combination of the two treatments is more effective. Such study would have to be conducted in a controlled environment, with a large sample size and a long-term follow-up.

Fractional CO2 laser therapy uses a laser to create microscopic columns of injury in the skin, which triggers the skin's natural healing process and stimulates collagen production. This can help to improve the appearance of acne scars by smoothing out the skin's texture and reducing the depth of the scars. The goal is to resurface the skin and improve the appearance of the scars. Studies have shown that it can be effective in treating both atrophic (indented) and hypertrophic (raised) acne scars. The treatment typically involves applying a numbing cream to the

area to be treated and then using the laser to target the affected areas. The procedure can take anywhere from 30 minutes to an hour, depending on the size of the area being treated.5, 6

It is important to note that multiple treatments may be necessary to achieve the desired results. It is also important to note that not all types of acne scars respond well to fractional CO2 laser therapy and other treatment options such as subcision, punch excision and dermal fillers may be needed for more severe cases.

Dermaroller, also known as microneedling, is a procedure in which a device with fine needles is used to create microscopic punctures in the skin. This also triggers the skin's natural healing process and stimulates collagen production, which can help to improve the appearance of acne scars. The dermaroller, on the other hand, creates micro-injuries in the skin which encourages the production of collagen and elastin fibers. Studies have shown that fractional CO2 laser therapy can improve the appearance of acne scars by smoothing out the skin's texture and reducing the depth of the scars. Similarly, studies have also shown that microneedling (dermaroller) can also be effective in improving the appearance of acne scars.5, 6

It's worth noting that the combination of these two treatments may be more effective than either treatment alone, as the laser can target the deeper layers of the skin, while the dermaroller can target the surface layers. However, it's important to note that more

research is needed to confirm the effectiveness of these treatments in combination and to determine the optimal treatment protocol.

Conclusion

Acne vulgaris is the common problem experienced worldwide today mainly affecting the facial area and in some instances leads to scars formation depending on adversity of the condition which corresponds to the acne grade. Hence treatment of acne must begin on early basis to avoid the scar formation. Treatment option include a variety of methods which can be adopted for scar healing, as there is no particular rules and guidelines that needs to be followed. Various strategies are implemented in treating acne scars which include both medical and surgical or laser options.

In conclusion, the use of a sequential fractional CO2 laser with a dermaroller is a commonly used treatment for acne scars that can be very effective in reducing the appearance of scars by smoothing out the skin and making it appear more even. The CO2 laser resurfaces the skin and stimulates collagen production, while the dermaroller creates micro-injuries in the skin to promote collagen growth. Though both the modalities, fractional carbon dioxide laser alone and fractional carbon dioxide laser combined with dermaroller (sequential) are very effective in the treatment of atrophic acne scars with easily manageable transient side effects, fractional carbon dioxide laser alone gives better results than combining it sequentially with dermaroller. Along with the appropriate treatment plans, proper care and follow up is must for any wound healing and

its best result.

References

1. Kurokawa I, Danby FW, Ju Q, et al. New developments in our understanding of acne pathogenesis and treatment. Exp Dermatol. 2009;18(10):821-832. doi:10.1111/ j.1600-0625.2009.00890.x

2. Ayer J, Burrows N. Acne: more than skin deep. Postgrad Med J. 2006;82(970):500-506. doi:10.1136/ pgmj.2006.045377

3. Tan A.U, Schlosser B.J, Paller A.S. A review of diagnosis and treatment of acne in adult female patients. International Journal of Women's Dermatology, 2017;4(2):56-71.https:// doi.org/10.1016/j.ijwd.2017.10.006.

4. Ghodsi SZ, Orawa H, Zouboulis CC. Prevalence, severity, and severity risk factors of acne in high school pupils: a community-based study. J Invest Dermatol. 2009;129(9):2136-2141. doi:10.1038/jid.2009.47

5. Fabbrocini G, Annunziata MC, D'Arco V, et al. Acne scars: pathogenesis, classification and treatment. Dermatol Res Pract. 2010;2010:893080. doi:10.1155/2010/893080

6. Connolly D, Vu HL, Mariwalla K, Saedi N. Acne Scarring-Pathogenesis, Evaluation, and Treatment Options. J Clin Aesthet Dermatol. 2017;10(9):1223.

A Study of Comparison of Fractional CO2 Laser Alone Vs Sequential Fractional CO2 Laser with Dermaroller in Acne Scars

Oxymetazoline Efficacious in Reducing Rosacea-Associated Facial Erythema

When compared to a vehicle treatment, patients with rosacea being treated with oxymetazoline had a more significant reduction facial erythema. In patients with rosacea-associated facial erythema, oxymetazoline proved to be more efficacious in reducing redness than vehicle treatment. In a recent meta-analysis, researchers sought to investigate the drug’s overall safety and efficacy, citing a lack of conclusion or consensus on the effectiveness and adverse events stemming from treatment. Currently, the a1-andrenergic receptor agonist is approved for the treatment of persistent facial erythema associated with rosacea in adult populations.

Research papers included in the meta-analysis were randomized controlled trials limited to English wherein eligible patients were assigned on a random basis to be treated either with oxymetazoline hydrochloride 1.0% or a vehicle treatment. Researchers extracted all relevant data for each paper, including study author, year, study area, research type, number of cases, and disease-specific indicators, such as Clinician Erythema Assessment (CEA) success rate, Subject Self-Assessment for rosacea facial redness (SSA) success rate, satisfaction rate, and rate of treatment-emergent adverse events (TEAEs).

As a result, researchers found significantly higher CEA and SSA success and improvements in patients being treated with oxymetazoline. However, patients being treated with oxymetazoline reported significantly higher incidence of treatment-emergent adverse events (TEAEs) than their vehicle group counterparts. Researchers found, though, that the only TEAE reported in this patient group that was significantly higher than in the vehicle group was application-site dermatitis. Other TEAEs, such as worsening inflammatory lesions of rosacea, application-site pruritus, application-site papules, headache, upper respiratory tract infections, nasopharyngitis, and vomiting, did not have significant differences in incidence rates between treatment groups. Oxymetazoline is effective and can be selected for the treatment of persistent facial erythema of rosacea,” researcher wrote. Additionally, application-site dermatitis was the most important one. Additionally, that most of the TEAEs of oxymetazoline were considered mild or moderate in severity, of which application-site dermatitis was the most important one.

Metformin and Doxycycline Demonstrate Equal Efficacy in Acne Treatment

Researchers said doxycycline, however, was more efficacious in reducing inflammatory lesions. Drugs metformin and doxycycline demonstrated equal levels of efficacy in treating patients with acne vulgaris, according to a recent study. The assessor-blind, add-on, randomized, controlled clinical trial sought to compare the effectiveness of the 2 drugs, particularly in reducing inflammatory and non-inflammatory lesions. Researchers cited metformin’s role in reducing insulin-like growth factor 1 (IGF-1) levels and insulin resistance to explain why the drug may be effective in targeting the pathogenesis of acne vulgaris. Patients ages 15 to 40 years old with moderate acne vulgaris were eligible for participation in the trial. In order to further qualify for study participation, patients could not have received either systemic treatment during the past month or topical treatment during the past 2 weeks leading up to the start of the trial.

Exclusion criteria included history of systemic disease, pregnancy, lactation, polycystic ovarian syndrome, reluctance to continue the study, history of allergy to either of the drugs involved in the trial, use of drugs with known reactions to the drugs involved in the trial, or use of contraceptive medications containing either estrogen or progesterone. Furthermore, patients presenting with acne conglobata or acne fulminans were ineligible to participate.

Upon selecting trial participants (n=40), researchers assigned participants to either the doxycycline or metformin group using random allocation. Participants in the doxycycline group were instructed to take a 100 mg capsule by mouth on a once-daily basis. Members of the metformin group were asked to take a 500 mg tablet by mouth twice daily. In both groups, researchers instructed participants to apply a 5% benzoyl peroxide gel over all affected acne vulgaris lesions each evening before washing the gel off after 30 minutes. In some cases, participants were advised to refrain from taking certain medications, such as betamethasone, bupropion, captopril, cimetidine, or retinoid drugs like isotretinoin.

Researchers collected participant data over the span of 2 months in which the participants were evaluated and treated. They instructed a blinded dermatologist to collect demographic data and disease-specific data, such as acne vulgaris severity and lesion counts. These measures included the Global Acne Grading System (GAGS) score, Investigator Global Assessment for Acne (IGA) score, Cardiff Acne Disability Index (CADI), and Total Acne Lesion Count (TLC). The dermatologist also used the TLC to specify whether lesions were inflammatory or non-inflammatory in nature. Researchers noted that both drugs led to a reduction in acne severity, an increase in patient satisfaction and quality of life, an overall reduction in acne vulgaris lesions.

Hair Transplant with Combination of FUE and PRP for Hair Loss: A Case Report

Dr. Kiran Joshy

Dermatologist and Hair Transplant Surgeon

Joshy’s Medical Center, Bangalore

Introduction

Hair loss, also known as alopecia, can have many causes, including genetics, hormones, medical conditions and certain medications.1 This hair loss is thought to be caused by an autosomal dominant genetic linkage.2 The most prevalent causes of hair loss is due to testosterone and dihydrotestosterone.3 Androgenetic alopecia (AGA) is the most common type of alopecia in both men and women. In men, AGA is characterized by a receding frontal hairline with bitemporal hair loss that merges with vertex thinning. In women, the anterior hairline is preserved and thinning occurs primarily at the crown, as depicted by the Ludwig pattern. Hair loss occurs because of the conversion of terminal hairs into vellus. Although AGA is a physiological condition, the psychological impact of hair loss can be profound.4 Baldness typically begins clinically in both men and women between the ages of 30 and 40.2

Hair growth cycle: An active

growth phase (anagen phase) is followed by a brief involution stage, which is a morphological transition (catagen phase). The next stage is a stage of rest (telogen phase).2 Every time a hair follicle is replaced, one of the three stages of its growth cycle is in progress.2 Following a phase of increased shedding, the process results in the miniaturisation of normal scalp hair follicles; this shortens the length of the hair cycle, which makes more telogen transformation visible.5 To organise the different causes into focal (patchy) and diffuse etiologies, it is practical to do so. Alopecia areata, tinea capitis and trichotillomania are frequently to blame for patchy hair loss. The most common causes of diffuse hair loss are telogen or anagen effluvium.1

Some common causes of hair loss include:

1. Genetics: Male and female pattern baldness, also known as androgenetic alopecia, is the most common cause of hair loss.

It is caused by a combination of genetics and hormones.1, 6

2. Hormonal changes: Hormonal changes in the body can lead to hair loss. For example, pregnancy, childbirth and menopause can cause temporary hair loss.1

3. Medical conditions: Certain medical conditions, such as thyroid disorders, iron-deficiency anemia and autoimmune disorders can cause hair loss.1, 6, 7

4. Medications: Certain medications, such as blood thinners, antidepressants and high blood pressure medications can cause hair loss as a side effect.8

5. Stress: Physical or emotional stress can cause hair loss as a temporary condition called telogen effluvium.1, 6, 7

6. Nutritional deficiencies: Lack of certain nutrients like protein, iron and vitamins can lead to hair loss.1

There are several types of hair loss and baldness. Gradual thinning on the top of the head is the most common type of hair loss, affecting people as they age. In men, hair often begins to recede at the hairline on the forehead, while women typically have a broadening of the part in their hair. Circular or patchy bald spots are another type of hair loss, which can occur on the scalp, beard or eyebrows.

Following are different types of hair loss and baldness: 1, 6, 7, 9, 10

• Androgenetic alopecia: This is the most common type of hair loss, also known as male or female pattern baldness, caused

by a combination of genetics and hormones.

• Alopecia areata: An autoimmune disorder that causes hair loss on the scalp and other parts of the body.

• Tinea capitis: Children are most commonly affected by this dermatophyte infection. Transmission can happen between individuals or from asymptomatic carriers. Patchy alopecia with or without scaling is seen in the clinical presentation, albeit the entire scalp may be affected.

• Telogen effluvium: A temporary condition caused by stress or hormonal changes that results in hair loss. It is a non-inflammatory, non-scarring alopecia. Three to five months following a physiological or mental stressor, it happens when a substantial number of hairs reach the telogen phase and fall out.

• Traction alopecia: Hair loss caused due to tension that is applied to hair repeatedly by tight hairstyles, such as braids or ponytails, that pull on the hair.

• Scarring alopecia: Hair loss caused by scarring on the scalp, which can be caused by a variety of conditions including autoimmune disorders.

• Anagen Effluvium: It is a type of hair loss caused by damage to the hair follicles, typically as a side effect of certain medications.

1: Hair growth cycle Case Report

A 30 year-old youth patient who presented with a chief complaint of hair loss at numerous sites across the scalp. Medical and family history was taken into consideration for identifying the cause. Blood test can be suggested to determine any comorbidities. The clinical examination revealed a marginal alopecia in the frontal region. Sometimes even biopsy is recommended for histopathological examination. Looking at the condition it is possible to diagnose that he may be experiencing initial frontal fibrosing alopecia with concurrent androgenic alopecia. Based on the patient condition and requirement the patient was suggested to undergo a combination

Figure

Hair Transplant with Combination of FUE and PRP for Hair Loss: A Case Report

of treatment which involves single session of Hair Transplant (FUE) combined with Platelet-Rich Plasma (PRP) injections at regular intervals for 6 months. New hair growth was visible after 6 months of treatment.

hair growth.9

3. Low-level laser therapy: A non-invasive treatment that uses low-level laser light to stimulate hair growth.9

4. Hormone therapy: In some cases where hormonal imbalances are causing the hair loss, hormone therapy may be used for such cases.3

5..Surgery: Hair replacement surgery, such as hair transplantation, can be used to restore hair growth. This procedure involves transplanting hair follicles from one area of the scalp to another.3, 9

Diagnosis

The diagnosis of hair loss typically begins with thorough medical history and physical examination, along with scalp examination, blood tests and sometimes a biopsy.1, 6 In the medical history, always important to ask any medical conditions, medications and recent changes in weight or hormonal status.1, 3 Physical examination involves the examination of the scalp for signs of inflammation, infection or other abnormalities.1 In scalp examination, there is a need to examine the scalp for any signs of pattern baldness, scarring or other abnormalities.7 In the pull test gently pull on a small sample of hair to test for hair loss.3, 7 Blood tests can be done to check for underlying medical conditions that may be causing hair loss. Tests like serum iron, thyroid profile, Vitamin D3 & B12, and hormone levels can be performed.1 In some cases, a small sample of scalp tissue may be taken for examination under a microscope.3

Treatment options

Based on the examination, lab test results and other diagnostic tools, the healthcare professional will recommend a treatment plan. Treatment options for hair loss vary depending on the underlying cause of the hair loss. Some common treatments include:

1. Medications: Possible treatments for AGA are minoxidil and finasteride, these are medications that can be used to treat male pattern baldness. Minoxidil is a topical solution that is applied to the scalp, while finasteride is a pill that is taken orally.1, 3, 9

2. Platelet-Rich Plasma (PRP) therapy: It's a non-surgical treatment that involves injecting a patient's own platelet-rich plasma into the scalp. The platelets release growth factors that stimulate

Hair transplant technology is constantly evolving and there are several newer techniques that have been developed in recent years. Some of the latest hair transplant technologies include:

1. Follicular Unit Transplantation (FUT) : This is a traditional hair transplantation technique. In this procedure, a strip of skin is removed from the back of the scalp and divided into individual hair follicles which are then transplanted to the bald or thinning areas of the scalp. The strip of skin is then sutured closed and the transplanted hair follicles will begin to grow in the new location.3

2. Follicular Unit Extraction (FUE): In this procedure, individual hair follicles are removed from the back of the scalp and transplanted to the bald or thinning areas of the scalp. Individual hair follicles are removed from the scalp using a small punch tool. This method was less invasive and resulted in minimal scarring, allowing people to wear their hair short

Figure 2: Hair loss in the frontal region of the head

Before treatment After 6 months of treatment

Hair Transplant with Combination of FUE and PRP for Hair Loss: A Case Report

without revealing the surgical scars.3, 11

3. Robotic Hair Transplantation: This technology uses robots to assist in the precise and efficient extraction of hair follicles during an FUE procedure. It can increase the speed and accuracy of the procedure and also reduce the chances of transection (damage to the hair follicles during extraction).3

4. Stem cell therapy: This treatment is used to improve the growth of hair follicles and it is done by injecting stem cells into the scalp. The procedure is done in combination with hair transplantation to improve the growth of the transplanted hair.9, 12

5. Biofibre Hair Implant: This is a non-surgical hair replacement procedure that involves the implantation of synthetic hair fibers into the scalp. It is a fast, painless and long-lasting solution for hair loss.12

6. Laser-Assisted Hair Transplantation: This technique combines the use of laser technology with traditional hair transplantation methods to improve the accuracy of hair follicle extraction and reduce the recovery time.13

Each technique has its own set of advantages and disadvantages and the choice of which one to use will depend on the individual's specific needs, goals and the stage of hair loss. It is important to consult a qualified and experienced surgeon to determine which technique is best according to the condition.

Hair transplant for hair loss

A hair transplant is a surgical procedure that is used to treat hair loss by transplanting hair follicles from one area of the scalp to another. This procedure can be used to treat male and female pattern baldness, as well as other types of hair loss.3,14 The recovery time can vary depending on the type of procedure and the individual's healing process, but most people can return to their normal activities within a few days.3

These surgical procedures are continuously being evolved significantly over the past years. In the early days of hair transplantation, the procedure was known as "hair plugs" and involved transplanting large clumps of hair that resulted in an unnatural and "plugged" appearance.3, 11 In the 1980s and 1990s, the technique of Follicular Unit Transplantation (FUT) was developed. In the early 2000s, Follicular Unit Extraction (FUE) was developed as a more advanced method of hair transplantation.15

FUE/FIT: The procedure involves aligning the punch with the follicular unit's hairs' angle and using the punch to score the skin. When there are few donor hairs available, the technique is especially beneficial. A problem that can occur in addition to transections is capping, which happens when the epidermis is pulled away from the dermis in an effort to remove the grafts. Sometimes, grafts may appear to be anchored to the underlying tissue, making it challenging for the surgeon to free the grafts.11

PRP: PRP is frequently used in the treatment of wounds.

Numerous stimulatory and growth factors are connected to platelets.11 According to the theory, PRP shortens the time between telogen and anagen, prolongs anagen and prevents catagen by releasing growth factors that promote "cell survival, proliferation and differentiation." Enhancing vascularization and extending anagen through "growth factor mediated increased activation of wingless (Wnt)/-catenin, extracellular signal-regulated kinase (ERK) and protein kinase B (Akt) signalling pathways".9

More recent advancements in hair transplantation include the use of robotic technology, which has made the procedure more precise and efficient.11 Additionally, the development of newer techniques like Direct Hair Implantation (DHI) and Body Hair Transplant (BHT) have made it possible to transplant hair from other parts of the body, such as beard and chest.16

Overall, the evolution of hair transplantation has led to more natural-looking results and less invasive techniques, making it a more accessible treatment option for people experiencing hair loss. The transplanted hair will typically fall out within the first few weeks, but new hair growth should begin to appear within a few months.11

Prevention

Prevention of hair loss can be achieved by maintaining a healthy diet. Eating a diet rich in protein, iron and other nutrients can help promote hair growth.1 Reducing stress is one of the preventive measures of hair loss because stress can cause temporary hair loss, so

it's important to find ways to manage stress.7 It’s always important to avoid harsh hair treatments, such as using heating tools, which can help prevent damage to the hair and scalp. Tying hair tightly or using hair extensions can cause hair loss, so it is best to avoid tight hairstyles.7 Protecting hair from sun and pollution, exposure to UV rays, pollution and chemicals can damage the hair, so it is important to protect the hair from these environmental factors.6 It is important to remember that hair loss can be a complex issue and not all cases can be prevented. If patients are experiencing hair loss, it is important to consult a healthcare professional for proper diagnosis and treatment.

Discussion

Alopecia areata is a disease that develops when the body's immune system attacks hair follicles, causing hair loss. Scarring alopecias result in permanent loss of hair. Hereditary pattern baldness or androgenic alopecia, is the most common cause of baldness, affecting both men and women. Traumatic alopecia is caused by hairdressing techniques, exposure to extreme heat, twisting or damage with strong chemicals. Hair loss may be defined as, an increase in the rate of shedding, including telogen effluvium, anagen effluvium, and whole hair loss or ageing hair (anagen effluvium proper). Diffuse hair thinning includes a decline in hair pigmentation and a reduction in the diameter of the hair shaft in all or a portion of the hairs. It is believed to be a multifactorial disease, with genetic, environmental and autoimmune facets. There are

many different patterns and degrees of severity for hair loss. 1, 6, 7

Since human hair growth is non-synchronous, with constant shedding and regrowth throughout life, what is meant by hair growth or lack of it can vary even among patients in seemingly similar groups.5 In order to achieve optimal results, it is important to use a systematic and practical classification system for hair loss patterns in men. One such classification system is the Norwood-Hamilton Scale, which categorizes the different stages of male pattern baldness based on the distribution of hair loss on the scalp. This scale ranges from stage 1 (mild hair loss) to stage 7 (advanced hair loss).5 Another classification system is the Ludwig Scale, which focuses more on the hair loss patterns on the crown and vertex area of the scalp.5 Once the stage of hair loss has been determined, the appropriate hair transplantation technique can be chosen.

In PRP, the stem cells in the hair bulge were found to be stimulated by the growth factors released by activated platelets, which resulted in folliculogenesis, neovascularization and an extension of the anagen phase.12 Hair transplantation is a surgical procedure that is used to treat hair loss by transplanting hair follicles from one area of the scalp, called the "donor area," to another area, called the "recipient area." 3,14 There are various steps involved in hair transplantation which include preoperative preparation, preparation of the donor area, harvesting, graft preparation,

preparation of the recipient area, graft insertion and postoperative care.2

The two main techniques used in men are Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE).3, 14 However, as with any surgical procedure, there are risks and potential complications that should be considered. Some of the possible risks and complications associated with hair transplantation are infection,3 excessive bleeding during the procedure,3 and scarring at the donor site. However, the scarring is usually minimal and can be hidden by the hair.11 There may be some temporary numbness or tingling around the surgical site, but this usually resolves within a few weeks.3 In some cases, the results of the hair transplantation may not be as desired and a revision surgery may be required.14

Conclusion

In conclusion, alopecia becomes more prevalent, as patient anxiety is constant, psychological (and occasionally psychiatric) assessment is crucial in development of alopecia. A multidisciplinary approach to management is necessary and it must be tailored to each patient's expectations, financial situation, age and degree of hair loss. Normally, the hair will grow back after the precipitating cause has been treated. Hair transplantation entails shifting the patient's existing hair from the donor zone to the recipient zone. One of the advantages of hair transplantation is that it can achieve natural-looking results and also help to restore a patient's confidence and self-esteem.

Hair Transplant with Combination of FUE and PRP for Hair Loss: A Case Report

Additionally, hair transplantation can be used in combination with other treatments for hair loss, such as medication or laser therapy, to achieve optimal results. Hair transplantation is generally considered to be a safe and effective treatment for hair loss, with a high satisfaction rate among patients.

Reference

1. Phillips TG, Slomiany WP, Allison R. Hair Loss: Common Causes and Treatment. Am Fam Physician. 2017 Sep 15;96(6):371-378. PMID: 28925637.

2. Khanna M. Hair transplantation surgery. Indian J Plast Surg. 2008 Oct;41(Suppl):S56-63. PMID: 20174544; PMCID: PMC2825128.

3. Zito PM, Raggio BS. Hair Transplantation. [Updated 2023 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.Available from: https://www.ncbi. nlm.nih.gov/books/NBK547740/.

4. Qi J, Garza LA. An overview of alopecias. Cold Spring Harb Perspect Med. 2014 Mar 1;4(3):a013615. doi: 10.1101/cshperspect.a013615. PMID: 24591533; PMCID: PMC3935391.

5. Dawber RP. Aetiology and pathophysiology of hair loss. Dermatologica. 1987;175 Suppl 2:238. doi: 10.1159/000248896. PMID: 3319730.

6. Qi J, Garza LA. An overview of alopecias. Cold Spring Harb Perspect Med. 2014 Mar 1;4(3):a013615. doi: 10.1101/cshperspect.a013615. PMID: 24591533; PMCID: PMC3935391.

7. Xu L, Liu KX and Senna MM (2017) A Practical Approach to the Diagnosis and Management of Hair Loss in Children and Adolescents. Front. Med. 4:112. doi: 10.3389/fmed.2017.00112.

8. Etminan, Mahyara; Sodhi, Mohitb; Procyshyn, Ric M.c; Guo, Michaela;

Hair Transplant with Combination of FUE and PRP for Hair Loss: A Case Report

Carleton, Bruce C.d,e,f. Risk of hair loss with different antidepressants: a comparative retrospective cohort study. International Clinical Psychopharmacology 33(1):p 4448, January 2018. | DOI: 10.1097/ YIC.0000000000000191

9. Wall D, Meah N, Fagan N, York K, Sinclair R. Advances in hair growth. Fac Rev. 2022 Jan 12;11:1. doi: 10.12703/ r/11-1. PMID: 35156098; PMCID: PMC8808739.

10. Jadesola (Jadé) Temitope Olayinka;Jillian M. Richmond; (2021). Immunopathogenesis of alopecia areata . Current Research in Immunology, (), –.doi:10.1016/j.crimmu.2021.02.001.

11. Rose, Paul (2011). The Latest Innovations in Hair Transplantation. Facial Plastic Surgery, 27(4), 366–377. doi:10.1055/s-0031-1283055.

12. Shivakumar, S., Kassir, M., Rudnicka, L., Galadari, H., Grabbe, S., & Goldust, M. (2021). Hair Transplantation Surgery Versus Other Modalities of Treatment in Androgenetic Alopecia: A Narrative Review. Cosmetics, 8(1), 25. https:// doi.org/10.3390/cosmetics8010025.

13. Villnow MM, Feriduni B. Update on laser-assisted hair transplantation. Dermatol Surg. 1998 Jul;24(7):74954. doi: 10.1111/j.1524-4725.1998. tb04244.x. PMID: 9693669.

14. Unger, Walter P. (2005). Hair Transplantation: Current Concepts and Techniques. Journal of Investigative Dermatology Symposium Proceedings, 10(3), 225–229. doi:10.1111/j.10870024.2005.10111.x.

15. Jimenez, F., Alam, M., Vogel, J. E., & Avram, M. (2021). Hair transplantation: Basic overview. Journal of the American Academy of Dermatology, 85(4), 803–814.doi:10.1016/j.jaad.2021.03.124.

16. Sethi P, Bansal A. Direct hair transplantation: a modified follicular unit extraction technique. J Cutan Aesthet Surg. 2013 Apr;6(2):100-5. doi:

10.4103/0974-2077.112672. PMID: 24023433; PMCID: PMC3764754.

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