The Aestheticians Journal Nov'23 issue by The Aestheticians Journal

Total Pages : 32 November 2023 Vol 16* Issue - 11 100

Microneedling Fractional Radiofrequency- A Game Changer

An Unusual Presentation of Addisonian Pigmentation: A Case Report

Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan

Skin Pigmentation EXECUTIVE EDITOR & PUBLISHER Dom Daniel

CORPORATE OFFICE 22, Shreeji Bhavan, 275-279, Samuel Street, Masjid Bunder (W), Mumbai-4000 03, INDIA. EMAIL: theaestheticiansjournalindia@gmail.com Website: theaestheticiansjournal.com TEL: +91 22 2345 1404 +91 22 2345 5844

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Skin pigmentation refers to the natural coloration of a person's skin, which is determined by the presence and distribution of a pigment called melanin. Skin pigmentation is influenced by a combination of multiple factors. Some of the conditions such as albinism, melasma, vitiligo, addison's disease and post-inflammatory hyperpigmentation, are well-recognized and can have significant impacts on individuals' lives. Skin pigmentation is indeed a complex and variable trait influenced by genetics, UV exposure, hormonal changes and other environmental factors and the management of skin pigmentation is very challenging. The available treatments for pigmentation, including anti-inflammatory medications, antioxidants and tyrosinase inhibitors, is also relevant. These treatments can be used to manage various skin pigmentation disorders, although their effectiveness may vary depending on the specific condition. Maintaining healthy skin and protecting it from excessive UV exposure are essential for maintaining even and healthy skin pigmentation. Proper skincare, including the use of sunscreen can help protect the skin and prevent issues like sunburn, premature aging and pigmentation disorders. Dermatologists are the one who plays a crucial role in the management of pigmentation. It's important to highlight the importance of consulting a dermatologist, before starting any new treatment plan for skin pigmentation disorders. The choice of treatment should be based on a proper diagnosis and individual considerations. In this issue we have clinical articles on Microneedling Fractional Radiofrequency for Acne Scars, Non-Venereal Genital Dermatoses in Geriatric Population and Addisonian Pigmentation. HOPE YOU HAVE A GREAT READ Thanks & Cheers

- Dom Daniel Published for the period of November - 2023

Executive Editor & Publisher

Microne

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Fraction

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Micr Radiof oneedling Fr requen actiona cy for Ac l ne Scar Dr. C. P. Tha s jud

Microneedling Fractional RadiofrequencyA Game Changer

for Acne

Scars

MD heen CEO and Chief Laser Dr. Thaj -Dermatosu Laser Skin Thalasserry Hair Clini rgeon c

Dr. Jyothy

.K MD, DVD Consultan t Dermatolo Dr.Thaj Laser Skin gist Hair Clini Coimbator c e

Dr. C. P. Thajudheen, MD Dr. Jyothy K, MD, DVD

08 8 Novem

ber 2023

Abstract Scarring affecting is a common issue as ablative laser patients over 100 derm treatment annually, million inject abrasion and and causes the ables or ranging with inflammato dermal use of from post- recent fillers. In years, Scar tissue ry acne to traum (Mn) micro aesthetic, can have phys a. popu therapy has needling larity ical, gaine and socia psychologic for variou as a treatm d al ent s derm patients. l implication atolo s for conditions, characteriz Atrophic including gical scars, tissue. Micro ed by scar in the needling skin, often depressions stimulates proce ss the destr the relea result from growth se of factors, following uction of collag promote which en the The severinflammatory acne. collagen and production of ity and of acne the lining elasti durat , of derm n from treatment,as well as delay ion vesse al blood can contr s in can ls. to the be perfoMicroneedling ibute developm atrophic manual rmed ent or moto using treatmentscars. Currently, of or rized devic in the of atrop es scars radiofrequ combination hic pose ency with and there s a challeacne Fract techn ional nge ology accepted is no unive a treatm radiofrequency . ent used the most standard optio rsally and is in clinic cosmetic Various effective treatmn for for dermatolo al rhytides, approache ent. been s have cellulite, acnestriae, scarr gy explored, ing, surgical including tissue, facial vulgaris, scar subcision techniques abnormal rejuvenatio n, non-ablativand punch grafti like alope cia, and pigmentation, resurfacing e laser treatm ng, drug trans techniques ents, found delivery. Many dermal such studies radiofrequ that fracti onal ency treatment

Pattern

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Geriatric

Populati

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Rajastha

Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan

awan MBBS, MD, DNB (Skin, VD Assistant Professor & Lepro sy) Mahatma Gandhi Medical Jaipur College and Hosp ital

Dr. Shivi Nijhawan, MBBS, MD, DNB (Skin, VD & Leprosy)

18 18 Novem

ber 2023

Abstract Backgrou nd Dermatose s involv genital ing not sexuaregion which the disorders, lly trans are histo sexual known mitted ry, obste expo tric histo sure dermatose as Non-vener are treatment ry and history eal Exam genitalia. s of was taken The incide external genit ination . such of alia external nce of non dermatose venereal sites for as well as genit other lesions s are elderly elsew common al the body people. was done here in in with . Patie vener Aim excluded eal diseases nts were from the To ascer study. Results of non tain the preva lence In dermatose venereal the study genital period, population s in geriatric of 3000 patie a total attending nts belon dermatolo to the geriatric ging evaluate gy OPD and the our OPD group visited , out of the spec to patie various which nts trum non of comp presented with 1750 dermatosis venereal laints. genital genital . After proper Materials taking histo and releva ry, exam and meth ination A prosp ods patients nt investigatio ective, ns, 5 were study observatio was carrie nal having a venerdiagnosed as the Derm d out Thus eal departmenatology outpa in geria , our study includ disease. tient tric patie t of our ed 1745 over a nts with vener hosp period of 6 mont ital The eal genital total of non 1750 hs. A incidence derrmatose and abov patients aged s. of non e, who venereal 60 genial with presented the geriadermatoses genital amon tric popu attending complaints found lation wasg to be clinic were the outpatient were 58.1%. male taken as 1000 group. a study females. s, and 745 The study were pertainingA detailed history a total conc to assoc iated skin venereal of 28 types luded of non genital dermatose s

An Unus Addiso ual Presenta nian Pi tion of A Case gmentation: Report Dr. An Unusual

Presenta

tion of

Addison

ian Pigment

ation: A

An Unusual Presentation of Addisonian Pigmentation: A Case Report Dr. Atul Singhania, MBBS, DVD 27

Introductio Addison’s n as prima disease, also of melan ry ocyte is a condi adrenal insuffi known the synthesis s, increase glands, tion where the ciency, melan in located in granu and storag adrenal kidney, on top pigmentatio les. 5 Addis e of do not onian n is more produce of each occur of the hormo likely to aldosterone nes cortisenough stand in individuals ing, 1 untreated with longto symp . This canol and insuffi toms such adrenal lead cause ciency. 4 The muscle as weak underlying low blood ness, weighfatigue, vary, of Addison’s but autoim disease t loss, can changes. 2 pressure mune and skin infections and Addison’s The incide tumors disease, most nce of 5the common are among , 6 depending disease may Intraoral cause 3, on vary cause and the the underlying common oral pigmentation s. popul studied. the disea manifestati is a Addison’s ation being a rare sign of se and may be on of disease endocrine the condi the first is affects tion. 3, 5 disorder about that The epide people 1 in miolo and 100,000 pigme and femal affects both ntation gy of Addisonian males docum es equal is all age not ented ly acros well groups. that affect , but it is a was first The condi s condition s tion and impai the adrenal Addison described by glands Thomas of cortis rs the in the under 1855 and since produ and aldos ction then, hormones.ol has changstanding of the 1, 6 terone cause to ed from an disease the adrenal ACTH stimu infect lates cortex primarily pathology, an autoim ious cortisol, increases to produce although mune produ remains melanin tuberculosis muco ction in the the diseaa leading us cause membranesskin and 7 countries. 3 se in develo of pigmentatio . n The appears ping patches pigmentatio as on the Addis skin, oral brown of Addis n is a hallma onian conjunctiva cavity, on’s disea rk sign oral cavity and genita result se. 4 It , the pigme lia. In the of the of the overstimulais a seen on the ntation melanogeni gingival, is tion border or vermilion c pathw of the ays mucosa, lips, bucca response beta-lipotropin palate l and tongu in some cases (adrenocortito increased e. , oral ACTH may be cotrop pigmentatioIn levels. the first This overs ic hormo n ne) disease, makin sign of Addis to an increase timulation leads denta on’s l profes g it important in the siona number of this for manifestati ls to be aware on. 3 Novem

ber 2023 27

November 2023

Case Report

Atul Sin

ghania MBBS, DVD Skin Spec ialist, Vene Shreekrupa reologist , Lepro Skin and logist, and Akola, Hair Care Maharasht cosmetolo Clinic, ra gist

November 2023

Editorial Board Dr. C. P. Thajudheen

Dr. Shivi Nijhawan

Dr. Jyothy .K

Dr. Atul Singhania

MD CEO and Chief Laser-Dermatosurgeon Dr.Thaj Laser Skin Hair Clinic Thalasserry

MD, DVD Consultant Dermatologist Dr.Thaj Laser Skin Hair Clinic Coimbatore

MBBS, MD, DNB (Skin, VD & Leprosy) Assistant Professor Mahatma Gandhi Medical College and Hospital Jaipur

MBBS, DVD Skin Specialist, Venereologist , Leprologist, and cosmetologist Shreekrupa Skin and Hair Care Clinic, Akola, Maharashtra

Advisory Board Dr. Ashwini K.R.

Dr. Roopa Shree Kurnool

Dr. Pawan Kumar

Dr. Deepthi Balusu

Dr. Karthik Ramappa

Dr. Neelima Ravipathi

Dr. H. Girish

Dr. Haritha Ravipathi

Dr.Sudhir

November 2023

Microneedling Fractional Radiofrequency- A Game Changer

Microneedling Fractional Radiofrequency- A Game Changer Dr. C. P. Thajudheen

MD CEO and Chief Laser-Dermatosurgeon Dr. Thaj Laser Skin Hair Clinic Thalasserry

Dr. Jyothy K

MD, DVD Consultant Dermatologist Dr.Thaj Laser Skin Hair Clinic Coimbatore Abstract Scarring is a common issue affecting over 100 million patients annually, with causes ranging from postinflammatory acne to trauma. Scar tissue can have physical, aesthetic, psychological and social implications for patients. Atrophic scars, characterized by depressions in the skin, often result from the destruction of collagen following inflammatory acne. The severity and duration of acne, as well as delays in treatment, can contribute to the development of atrophic scars. Currently, the treatment of atrophic acne scars poses a challenge and there is no universally accepted standard option for the most effective treatment. Various approaches have been explored, including surgical techniques like subcision and punch grafting, non-ablative laser treatments, resurfacing techniques such 8

November 2023

as ablative laser treatment and dermabrasion and the use of injectables or dermal fillers. In recent years, microneedling (Mn) therapy has gained popularity as a treatment for various dermatological conditions, including scar tissue. Microneedling process stimulates the release of growth factors, which promote the production of collagen and elastin from the lining of dermal blood vessels. Microneedling can be performed using manual or motorized devices or in combination with radiofrequency technology. Fractional radiofrequency is a treatment used in clinical and cosmetic dermatology for rhytides, striae, scarring, cellulite, acne vulgaris, scar tissue, facial rejuvenation, abnormal pigmentation, alopecia, and transdermal drug delivery. Many studies had found that the fractional radiofrequency treatment

Microneedling Fractional Radiofrequency- A Game Changer

was more effective than laser treatment for acne or acne scars. The combination of microneedling and fractional radiofrequency technology synergistically promote collagen production and tightens the skin which helps in overall skin improvement enhancing the skin texture and tone. This microneedling fractional radiofrequency (MnRF) can also be used in various conditions like atrophic scars, open pores, seborrhoea, axillary hyperhidrosis etc and benefits the overall skin condition. Introduction Radio Frequency energy is a form of electromagnetic energy. This source of heat has extensively been used in surgery for haemostasis and tissue ablation (electrosurgery), it has also been applied as a means of shrinking redundant or lax connective tissues through the mechanism of collagen denaturation. Collagen molecules are produced by fibroblasts. Heated fibroblasts are also implicated in new collagen formation and subsequent tissue remodelling which can also contribute to the final clinical result. The precise heat-induced behaviour of connective tissues is dependent on several factors which include the maximum temperature reached, exposure time, tissue hydration and tissue age.1,2,3 Microneedling was described in 1995 by

first

Orentreich and Orentreich for the treatment of atrophic

scars and wrinkles. The local injury induced by dermal penetration of microneedles causes release of growth factors such as transforming growth factor (TGF)-α, TGF-β, and platelet-derived growth factor (PDGF). This stimulates collagen and elastin fiber production as well as capillary formation, ultimately leading to tissue remodeling. Since its inception (in 2009, By Hantash and colleagues), microneedling technology has evolved from manual roller devices to automated devices, some of which have radiofrequency technology. In microneedling fractional radiofrequency the needles become the delivery point and return electrodes and the electric power and current is divided among the needles. The device fractionates the radiofrequency energy among the needles or electrodes, hence the name fractional radiofrequency. Water, collagen, melanin and other dermal tissues offer resistance to radiofrequency energy leading to bulk heating, this causes release of cellular mediators and growth factors and heat shock proteins like HSP47, 70, 72 etc which stimulates collagen remodelling. Newly formed collagen and elastin will help to rejuvenate the skin, improve scars and wrinkles. It also increases the hyaluronic acid levels in the epidermis. The needle insertion causes vertical scar disruption which provide added benefit while treating scars. It has a sebosuppressive effect as the needles can reach upto the sebaceous glands and sweat

glands.4,5 Fractional radiofrequency system is one of novel fractional resurfacing techniques which creates controlled thermal damage in the dermis and stimulates wound healing response, initiating collagen remodelling process by using thermal production from tissue impedance and subsequent heat diffusion to deeper tissue. An advantage of fractional radiofrequency (collagen induction therapy) is that it causes less epidermal disruption by only 5%, compared with 10–70% of that of fractional ablative laser system. The healing process is faster with minimal downtime. Therefore, this technique may be an alternative choice of facial rejuvenation and atrophic scars, especially in patients with darker skin complexion.6,7,8,9 The radiofrequency energy is delivered using insulated or non-insulated (or uninsulated) needles (34G). These needles are made of surgical stainless steel coated with gold for increased conductivity. Usually the needles are approximately 200 um in diameters with a point diameter of 20 um. The needles can penetrate for a depth of 0.5- 3.5 mm depending on the machine used. This helps the user to treat multiple layers of the dermis. With uninsulated needle electrodes, the entire needle conducts heat and wounds are created along the entire length of the needle. These needles can cause more pain especially when November 2023

Microneedling Fractional Radiofrequency- A Game Changer

power is kept high. It can be cause downtime of 2-3 days at times. But even though the entire needle conducts radiofrequency energy, epidermal injury is minimal as the electric current follows the path of least resistance and 80 % of the energy will be delivered at the tip of the needle. By using insulated microneedle electrodes RF energy is directly delivered at the upper dermal level while sparing the epidermis. This technique has shown to provide equivalent efficacy with less side effects, comparing with traditional ablative fractional resurfacing procedures. Insulation is done with silicone compound along the length sparing only 300um close to the tip. So there is nonthermal penetration of the epidermis. Efficacy wise there is not much difference between insulated and non insulated needles. But it can cause pinpoint bleeding as coagulation happens only at the tip. The needle cartridges are available as 25 or 69 pins. There are also devices which use ultra-thin electrodes (0.15mm) which create microchannels via radiofrequency ablation to induce controlled very superficial micro wounds (100-300um) and thermal damage. Following the radiofrequency ablation phase, Galvanic current emission deep within the dermis creates a chemical reaction around each ultrathin electrode tip inside the dermis.1,10,11 Radiofrequency Zone (RTZ) Radiofrequency 10

Zone (RTZ) is a term used in the context of radiofrequency (RF) treatments. Radiofrequency treatments use radiofrequency energy to heat up tissues and create a thermal effect. The RTZ is the area of tissue that is heated up by the radiofrequency energy. Fractional delivery of radiofrequency creates confined zone of denatured collagen or radiofrequency thermal zone (RTZ or RFTZ) similar to MTZ of fractional lasers. Longer radiofrequency conduction time produce larger area of coagulation where as higher radiofrequency energy will lead to tissue destruction. Within the first 24 hours after treatment, predominant neutrophils infiltration around RFTZ occurs followed by lymphocytic infiltration as early as 3 days after treatment which can persist up to 1 month. The well-formed elastic fibers and collagen fibres can be observed after 1 month which continues to persist for several months (neocollagenesis and 12,13,14 elastogenesis). Indications • Atrophic scars – post acne, post surgical /post traumatic • Skin rejuvenation • Photodamaged skin • Open pores • Seborrhoea • Striae • Axillary hyperhidrosis • Transepidermal drug delivery

Thermal In most of these indications microneedling fractional Thermal radiofrequency alone or in

November 2023

combination with fractional lasers, PRP, sublative radiofrequency etc gives excellent results with less down time. As radiofrequency produces electrothermal effect it doesn’t require a chromophore and is colour blind, hence it can be used in all skin types. Thus the combination provides skin tightening, collagen production and remodelling, tissue remodelling, enhancing skin texture giving smooth, firm, reduced fine lines, wrinkles, pigmentation and scars on skin forming an overall rejuvenation of skin. This advantages can be used in the treatment of atrophic scars (post acne, post surgical /post traumatic) were acne, trauma, uneven skin texture and tone are generally observed. Thus the use of microneedling fractional radiofrequency improves the appearance of these scars.15 Open or enlarged pores are a common concern, often resulting from factors such as genetics, oily skin, sun damage and aging. Excessive sebum production can contribute to the enlargement of pores. Here microneedling fractional radiofrequency helps collagen production, skin tightening and elasticity improvement, deep cleansing of the pores, removal of debris, excess oil, impurities and regulate sebum production by targeting the sebaceous glands enhancing in improvement of open pore. All these helps to reduce the visible open pores thus having a smooth skin texture. Additionally, combining microneedling fractional radiofrequency with other

Microneedling Fractional Radiofrequency- A Game Changer

complementary treatments, such as chemical peels or topical skincare products, may enhance the outcomes for open pores.4,16, 17 In some cases like seborrhea (a skin condition characterized by excessive oil production, often resulting in flaky skin) microneedling fractional radiofrequency is a potential treatment that targets the underlying causes and promotes overall skin health. It regulate sebum production, causes deep cleansing and unclogging of pores. It sometimes shows anti-inflammatory properties thus helps to alleviate the redness, irritation, and discomfort and provides overall skin rejuvenation and normalization. Moreover microneedling fractional radiofrequency can be combined with other treatments, such as topical medications or skincare products for enhanced effect.15,16,18 Striae (stretch marks) occur when the skin undergoes rapid stretching or contraction, leading to the disruption of collagen and elastin fibers in the dermis. Microneedling fractional radiofrequency promote skin collagen remodelling, improve skin rejuvenation by enabling the delivery of targeted ingredients, such as vitamin C, hyaluronic acid thus enhancing the results and improve the colour and texture of stretch marks. It also provides minimally invasive procedure that typically involves minimal downtime which is generally

well-tolerated and most individuals can resume their regular activities shortly after the procedure.17 Photo-damaged skin is condition caused by prolonged sun exposure especially to the UV rays, resulting in the development of fine lines, freckles, wrinkles, uneven pigmentation, rough texture and loss of elasticity. General protection can be done by using sunscreen, wearing protective clothing and avoiding prolonged sun exposure. Microneedling fractional radiofrequency stimulates collagen production, improves skin texture, pigmentation, promotes skin remodelling, reduces wrinkles thus provides an overall skin rejuvenation. The use of other methods like laser, surgery or topical tretinoin (improves the appearance of mild to moderate photodamage on the face and forearms) can also be done. Multiple sessions of microneedling fractional radiofrequency maybe required for optimal results, whereas the downtime associated is generally minimal, with mild redness and swelling that typically resolve within a few days.19, 20, 21,22,23 Microneedle fractional radiofrequency systems can be used in skin rejuvenation to assess its impact on the skin barrier function, particularly in skin sensitivity and the exacerbation of conditions such as melasma. The skin barrier plays a crucial role in protecting the underlying tissues thus

maintaining overall skin health. Disruption of the skin barrier can lead to increased skin sensitivity, compromised defense mechanisms and the potential exacerbation of existing skin conditions. Microneedling fractional radiofrequency system is a promising technique for facial skin rejuvenation. In some context microneedling fractional radiofrequency system treatments may lead to transient skin sensitivity and erythema immediately after the procedure, which can be resolved within a short period. However, there is limited evidence to suggest that microneedling fractional radiofrequency system treatments exacerbate melasma specifically. Microneedling fractional radiofrequency can include temporary redness, swelling, bruising and mild discomfort during and after the treatment. The number of treatment sessions required and the downtime associated can vary depending on the individual's skin condition and treatment goals.5,16,17,18 Axillary hyperhidrosis (excessive sweating in the armpits) shows primary focus on non-invasive methods, topical treatments or more invasive procedures. Microneedling fractional radiofrequency is not a commonly used treatment for axillary hyperhidrosis. Non-invasive options include antiperspirants containing aluminum chloride, which can help reduce sweating when applied to the affected area. Prescription antiperspirants November 2023

Microneedling Fractional Radiofrequency- A Game Changer

with higher concentrations of aluminum chloride may be recommended for more severe cases. Topical treatments such as botulinum toxin injections when injected in armpit reduces sweat by blocking nerve signalling that trigger sweat production. This treatment typically provides temporary relief and may need to be repeated periodically. Microneedling fractional radiofrequency has shown effectiveness for axillary hyperhidrosis.24, 25 Microneedling fractional radiofrequency can be used for transepidermal drug delivery (TDD) that enhances the permeability of the skin barrier, allowing for improved absorption and penetration of topical medications or cosmetic substances like growth factors, vitamins, hyaluronic acid etc. it can be used in treatment of acne, scars, hyperpigmentation and aging skin. The effectiveness and safety of microneedling fractional radiofrequency for transepidermal drug delivery can vary depending on the specific drugs or substances being delivered, their formulation and the characteristics of the patient's skin. Further research is needed to optimize the parameters and protocols for microneedling fractional radiofrequency -assisted TDD and to assess the longterm effects and potential risks associated with this technique. As radiofrequency produces electrothermal effect it doesn’t require achromophore and is colour blind, hence it can be used in all skin types.4,17, 23 12

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Procedure The procedure is done under topical anaesthesia after cleaning the area. The depth of the needle insertion can be selected from 0.5mm to 3mm. Power and exposure time is selected depending on the indication and the area to be treated. When the foot switch is pressed the microneedles will penetrate the skin and deliver radiofrequency in to the dermis. We can treat the dermis at different depths in the same sitting. First treat the lower dermis with 3mm or 2.5 mm tip use less power and exposure time while using lower depths. Multiple passes may be needed especially if the needles are non insulated. Bleeding can be stopped by pressure. Ice packs can be used post procedure if the patient has discomfort. Subsequent sessions are done after 4-6 weeks and on an average 4-6 sessions may be required.15, 26, 27 Post procedure instructions include strict sun avoidance or use of sunscreens, Even though the chances of PIH are less compared to fractional lasers, patient should be taught about the importance of post procedure skin care as in any laser procedure which includes no picking or rubbing the skin and avoidance of parlour treatments for a week.15, 26 Result Patient 1

Before Treatment

After Treatment

Patient 2

Before Treatment

After Treatment

Microneedling Fractional Radiofrequency- A Game Changer

Patient 3

Before Treatment

After Treatment

Contraindications Microneedling fractional radiofrequency is a combination cosmetic procedure which is generally safe and welltolerated. There are certain contraindications or situations where the procedure may not be suitable like active infection at the site, history of herpes simplex infection, patients with pacemakers / facial metal implanter, unrealistic expectation/ in-cooperative patient.27 Whereas the common complications associated are erythema (redness), edema (swelling), and crusting that are temporary and can usually last for 12-24 hours. Crusting occurs due to noninsulated needles that can cause superficial injury to the skin hence insulated needles are designed to minimize this risk. There is a potential risk of developing secondary infections following microneedling fractional radiofrequency treatment if the skin is not properly cleansed before the procedure or if proper aftercare instructions are not followed hence good hygiene and follow the post-treatment care guidelines has to be

followed to minimize the risk of infection. Post-inflammatory hyperpigmentation (darkening of the skin) and scarring can occur if aggressive treatment or incorrect technique is used during microneedling fractional radiofrequency. In some cases, a acne can get temporary triggered due to the stimulation of the skin during the procedure or even temporary needle track marks can be noted, typically mild and fade within a few days as the skin heals. Occasional development of milia (small white or yellowish cysts) is seen after microneedling fractional radiofrequency treatment due to accumulation of dead skin cells or sebum trapped beneath the surface of the skin. Individuals with a history of keloid or hypertrophic scarring may be more prone to scarring after microneedling fractional radiofrequency.15,28 Discussion Microneedling also known as percutaneous collagen induction therapy, has gained popularity in dermatology for various purposes such as skin rejuvenation, scar remodelling and hair growth. It is particularly favoured for its minimal risk of post-inflammatory

hyperpigmentation, making it a suitable alternative to laser procedures, especially for individuals with darker skin phototypes. Microneedling devices come in different forms, including rollers, stampers, and pens, with or without electrical power. Some devices are also combined with radiofrequency technology, known as fractional radiofrequency microneedling (FRF-MN). The addition of radiofrequency allows for energy delivery beneath the epidermal surface without causing damage to the epidermis, reducing the risk of dyspigmentation. The characteristics of microneedling devices can vary, including needle length, diameter, density and material. Disposable needle tips are considered safer due to the risk of bloodborne diseases, particularly with the concern of disease transmission associated with procedures like "vampire facials." Home-use devices that are reusable should be used with caution. Devices that offer adjustable needle length are advantageous as different areas of the face or body may require varying penetration depths. For instance, areas with more sebaceous glands may require deeper needle penetration compared to the forehead or periocular areas. Previous studies have suggested that a needle length of 1 mm is desirable and accurate, while longer needle lengths, such as 3 mm, may only penetrate to a depth of 1.5 to 2.0 mm.29 Microneedling and fractional November 2023

Microneedling Fractional Radiofrequency- A Game Changer

radiofrequency microneedling have gained popularity as minimally invasive aesthetic techniques for various skin concerns, including aging, scarring, stretch marks, and hair loss. In the United States, the FDA has classified microneedling devices as class II medical devices with special controls and they are approved for the treatment of microdermabrasion, scarring and wrinkles. Studies have shown that microneedling and fractional radiofrequency microneedling are well tolerated by patients and can lead to significant clinical improvement in different types of scars, including acne scars, hypertrophic scars, keloid scars and postoperative or traumatic scars. Patients often report high levels of satisfaction with the results. Compared to laser resurfacing procedures such as CO2, Er:glass and diode lasers, microneedling and fractional radiofrequency devices are generally better tolerated by patients and have shorter reported downtime. Microneedling and fractional radiofrequency can also be combined with other surgical therapies such as laser resurfacing, chemical peels, platelet-rich plasma (PRP), dermal fillers and botulinum toxin injections to enhance the overall results. The combination of these treatments can provide synergistic effects and improve the outcomes for patients.29

microneedling are effective and well-tolerated treatments for various skin concerns. They can be combined with other therapies for enhanced results. Microneedling fractional radiofrequency combines the principles of microneedling and radiofrequency energy to stimulate collagen production and improve the overall texture and appearance of the skin. It offers a minimally invasive approach with a lower risk of post-inflammatory hyperpigmentation, making it suitable for individuals with darker skin phototypes. Several variables need to be considered when determining the appropriate treatment regimen for microneedling , including the type of scar, duration of the scar, skin type, age and cost. The number of sessions required for significant improvement can vary, but a minimum of 4-6 sessions is often recommended. The depth of the microneedles used can also vary, the duration of follow-up after treatment is crucial, as the deposition of new collagen progresses slowly over time. Longer follow-up periods allow for a more accurate assessment of the effects of microneedling . This microneedling fractional radiofrequency method can be used in various indications like atrophic scars, skin rejuvenation, striae, open pores, seborrhoea, photodamaged skin which helps to get an overall rejuvenated skin which is Conclusion smooth, fine with reduced In conclusion, microneedling wrinkles and improved and fractional radiofrequency skin texture. Complications 14

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like erythema, edema, crusting, secondary infections, post-inflammatory hyperpigmentation (PIH), scarring, temporary needle track marks and acne flare-up, Milia-Like lesions can be seen after microneedling fractional radiofrequency treatment. References 1. Ihnát P, Ihnát Rudinská L, Zonca P. Radiofrequency energy in surgery: state of the art. Surg Today. 2014 Jun;44(6):98591. doi: 10.1007/s00595-013-0630-5. Epub 2013 Jun 1. PMID: 23728491. 2. Horstman CL, McLaughlin RM. The use of radiofrequency energy during arthroscopic surgery and its effects on intraarticular tissues. Vet Comp Orthop Traumatol.

2006;19(2):65-71.

PMID:

16810347. 3. Anderson, S.R., Faucett, S.C., Flanigan, D.C. et al. The history of radiofrequency energy and Coblation in arthroscopy: a current concepts review of its application in chondroplasty of the knee. J EXP ORTOP 6,

(2019).

https://doi.org/10.1186/

s40634-018-0168-y 4. Jiang L, Liang G, Li Y, et al. Does microneedle

fractional

radiofrequency

system inactivate botulinum toxin type A? J Cosmet Dermatol. 2023;00:1-10. doi:10.1111/jocd.15826 5. Singh, Aashim, and Savita Yadav. “Microneedling:

Advances

and

widening horizons.” Indian dermatology online journal vol. 7,4 (2016): 244-54. doi:10.4103/2229-5178.185468 6. Cucu C, Butacu A-I, Niculae B-D, Tiplica G-S. Benefits of fractional radiofrequency treatment in patients with atrophic acne scars - Literature review. J Cosmet Dermatol. 2021;20:381–385. https://doi. org/10.1111/jocd.13900 7. Eubanks, Stephen W, and James A Solomon. “Safety and efficacy of fractional radiofrequency for the treatment and reduction of acne scarring: A prospective study.” Lasers in surgery and medicine vol. 54,1 (2022): 74-81. doi:10.1002/ lsm.23453

Microneedling Fractional Radiofrequency- A Game Changer

8. M. Elman, I. Frank, H. Cohen-Froman and

and Coagulation—Phantom and Porcine

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Y. Harth, "Effective Treatment of Atrophic

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Radiofrequency Treatment with Smooth

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Ablative Radiofrequency and Multisource Fractional RF Skin Resurfacing," Journal of Cosmetics, Dermatological Sciences and Applications, Vol. 2 No. 4, 2012, pp. 267272. doi: 10.4236/jcdsa.2012.24051. 9. Vejjabhinanta, V., Wanitphakdeedecha, R., Limtanyakul, P., & Manuskiatti, W. (2013). The efficacy in treatment of facial atrophic acne scars in Asians with a fractional

radiofrequency

microneedle

system. Journal of the European Academy of Dermatology and Venereology, 28(9), 1219–1225. doi:10.1111/jdv.12267 10. Stevenson, W. G., Tedrow, U. B., Reddy, V., AbdelWahab, A., Dukkipati, S., John, R. M., … Sapp, J. L. (2019). Infusion Needle Radiofrequency Ablation for Treatment of Refractory Ventricular Arrhythmias. Journal of the American College of Cardiology, 73(12), 1413–1425. doi:10.1016/j.jacc.2018.12.070

a standard radiofrequency energy delivery system to facilitate transseptal puncture. Cardiovasc

Electrophysiol.

2009

Feb;20(2):238-40. doi: 10.1111/j.15408167.2008.01323.x. Epub 2008 Oct 13. PMID: 19175842.

JH, Baek JH, Kim HJ, Koh JS, Lee MH. Characterization of microthermal zones by

fractional

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using reflectance confocal microscopy: a preliminary study. Lasers Surg Med. 2013 Oct;45(8):503-8. doi: 10.1002/lsm.22175. Epub 2013 Aug 31. PMID: 23996648. 13. Dong Y, Chen Y, Yao B, Song P, Xu R, Li R, Liu P, Zhang Y, Mu L, Tong X, Ma L, Yu J, Su L. Neuropathologic damage induced by radiofrequency ablation at different temperatures. Clinics (Sao Paulo). 2022 Apr 15;77:100033. doi: 10.1016/j. clinsp.2022.100033. PMID: 35436702; PMCID: PMC9035646. 14. Goldberg, S. N., Ahmed, M., Gazelle, G. S., Kruskal, J. B., Huertas, J. C., Halpern, E. F., … Lenkinski, R. E. (2001). Radio-Frequency

Radiofrequency

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in Chinese Patients? A Prospective Clinical

24. Chilukuri S, Robb CW, Weiner

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10.1080/14764172.2016.1228981

Efficiency and safety of microneedling

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photodamaged skin. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD001782. doi: 10.1002/14651858.CD001782.pub2. Update in: Cochrane Database Syst Rev. 2015;6:CD001782. PMID: 15674885. 20. Ana Torres, Liliana Rego, Márcia S. Martins, Marta S. Ferreira, Maria T. Cruz, Emília Sousa, Isabel F. Almeida, How to Promote Skin Repair? In-Depth Look at Pharmaceutical and Cosmetic Strategies, Pharmaceuticals, 10.3390/ph16040573, 16, 4, (573), (2023).

doi:10.5978/islsm.27_18-OR-26 28. Gowda, Asha et al. “A Systematic Review Examining the Potential Adverse Effects of Microneedling.” The Journal of clinical and aesthetic dermatology vol. 14,1 (2021): 45-54. 29. Juhasz, Margit L W, and Joel L Cohen. “Microneedling for the Treatment of Scars: An Update for Clinicians.” Clinical,

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21. O’Connor K, Kandula P, Kaminer M. Non-surgical skin tightening. Plastic and Aesthetic Research. 2021; 8:64. http:// dx.doi.org/10.20517/2347-9264.2021.60

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Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan

Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan Dr. Shivi Nijhawan

MBBS, MD, DNB (Skin, VD & Leprosy) Assistant Professor Mahatma Gandhi Medical College and Hospital Jaipur

Abstract Background Dermatoses involving the genital region which are not sexually transmitted are known as Non-venereal dermatoses of external genitalia. The incidence of such non venereal genital dermatoses are common in elderly people. Aim To ascertain the prevalence of non venereal genital dermatoses in geriatric population attending the dermatology OPD and to evaluate the spectrum of various non venereal genital dermatosis. Materials and methods A prospective, observational study was carried out in the Dermatology outpatient department of our hospital over a period of 6 months. A total of 1750 patients aged 60 and above, who presented with genital complaints attending the outpatient clinic were taken as a study group. A detailed history pertaining to associated skin 18

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disorders, sexual exposure history, obstetric history and treatment history was taken. Examination of external genitalia as well as other sites for lesions elsewhere in the body was done. Patients with venereal diseases were excluded from the study. Results In the study period, a total of 3000 patients belonging to the geriatric group visited our OPD, out of which 1750 patients presented with genital complaints. After taking proper history, examination and relevant investigations, 5 patients were diagnosed as having a venereal disease. Thus, our study included 1745 geriatric patients with non venereal genital derrmatoses. The incidence of non venereal genial dermatoses among the geriatric population was found to be 58.1%. 1000 were males, and 745 were females. The study concluded a total of 28 types of non

Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan

venereal genital dermatoses were Tinea cruris and Scabies were the most common non venereal genital dermatoses in both males and females, followed by lichen simplex chronicus in females and candidal balanoposthitis in males. Conclusion A wide range of non venereal genital dermatoses were seen in our study. Non venereal genital dermatoses are quite common in geriatric population. These should be differentiated from venereal conditions by careful history, complete dermatological examination and relevant investigations. Introduction Genital dermatoses are skin conditions that affect the genital region and are not caused by sexually transmitted infections. These are also known as Non-venereal dermatoses of external genitalia. These conditions can be caused by a range of factors, including inflammatory, autoimmune, infectious, infestations, systemic diseases, exogenous factors, cysts and tumors. Some examples of genital dermatoses include inflammatory cutaneous disorders like psoriasis, lichen planus, lichen sclerosus et atrophicus; autoimmune diseases like vitiligo; infections and infestations like folliculitis, bartholin gland abscess, tinea cruris and scabies; multisystem diseases like behcet’s disease; exogenous like contact dermatitis; cysts and benign and malignant tumors. These conditions

are more common in the elderly population which are an increasing segment of Indian population, exceeding almost 9% and can cause discomfort, itching, pain, and may interfere with normal daily activities, including sexual function which can hamper the quality of life. It is important for individuals experiencing genital dermatoses to seek medical attention from a healthcare professional who can accurately diagnose the condition and provide appropriate treatment. These conditions are often underreported due to embarrassment or lack of awareness. People may mistakenly assume that any genital lesions or related chronic symptoms are sexually transmitted, leading to misconceptions and unnecessary anxiety, mental distress or depression.1,2,3 The recognisation and diagnosis of nonvenereal dermatoses can be challenging as they have diverse etiologies and varied presentations due to the wide range of potential diseases. This complexity emphasizes the importance of a comprehensive evaluation and understanding of the various parameters involved. The evaluation includes complete body examination and relevant investigations. The nonvenereal dermatoses is classified into five groups based on pathogenesis (inflammatory diseases, infections and infestations, congenital disorders, benign abnormalities, and premalignant/malignant

lesions) which helps to understand different types of disorders that can affect genital area.4 It is important to recognize that not all dermatoses involving the female external genitalia are sexually transmitted, and differentiating between venereal and non-venereal conditions is crucial for accurate diagnosis and management. The International Society for the Study of Vulvovaginal Disease (ISSVD) acknowledges the classification of vulvar dermatoses as inclusion of both venereal and nonvenereal conditions; however the classification of nonvenereal dermatoses of the female genitalia is not as wellestablished. Non-venereal dermatoses of the female external genitalia encompass a range of inflammatory cutaneous disorders, autoimmune conditions, multisystem diseases, exogenous factors, benign and malignant neoplasms. The conditions such as psoriasis, seborrheic dermatitis, lichen planus, lichen sclerosus, vitiligo, Behcet syndrome, Reiter syndrome, Crohn disease, contact dermatitis, corticosteroid abuse, fixed drug eruption, and extramammary paget disease, exemplify the diverse etiology and clinical presentation of these dermatoses.5 The presented study was conducted in geriatric population who visited a tertiary care hospital in Northern Rajasthan with the aims to ascertain the November 2023

Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan

prevalence of non venereal genital dermatoses in geriatric population attending the dermatology outpatient department and to evaluate the spectrum of various nonvenereal genital dermatosis.

In the study period, a total of 3000 patients belonging to the geriatric group visited our OPD, out of which 1750 patients presented with genital complaints. After taking proper history, examination and relevant investigations, 5 patients were diagnosed as having a venereal disease. Thus, our study included 1745 geriatric patients with non venereal genital dermatoses. The prevalence of non venereal genital dermatoses among the geriatric population was found to be Material and Methods 58.1%. The sex ratio was 1.34:1, and 1000 (57%) were males, A prospective observational and 745 (43%) were females. study in geriatric patients attending the Skin & VD department for a period of 6 months (from April 2018 to October 2018). 3000 patients belonged to the geriatric group. Out of 3000 patients aged 60 and above, a total of 1750 patients, who presented with genital complaints attending the outpatient clinic were screened. After getting informed consent, detailed history regarding demographic data, chief Figure 1: Percentage of non venereal genital dermatoses complaints with duration, among the geriatric population history pertaining to associated skin disorders and medical conditions, sexual exposure history, obstetric history and treatment history was taken. Examination of external genitalia as well as other sites for lesions elsewhere in the body was done. Clinical photographs were taken. Laboratory investigations like gram stain, KOH examination, pus culture and sensitivity, rapid plasma reagin test, Figure 2: Percentage of gender distribution HIV testing and skin biopsy wherever indicated was done The median age of the study population was 72.5 years, to establish the diagnosis. ranging from 60 to 85 years. The data were recorded and Sixty eight percent (68%) were married while 28% were analysed. widowed and 4% were unmarried. Exclusion Criteria Most patients (51%) had primary education, 29 % had gone • Patients with venereal beyond primary school while 21% had no formal education. diseases were excluded from the study. Results 20

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Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan

A Figure 3: Percentage of area distribution A total of 25 types of non venereal genital dermatoses were noted in our study. Groups• Infections and infestations – 1012 (58%) • Inflammatory and Autoimmune- 630 (36.1%) Figure 5: (A&B) T. cruris • Drug reactions- 45 (2.5%) • Benign and Premalignant conditions- 50 (3%) • Miscellaneous – 8 (0.4%)

Figure 6: Candidal balanoposthitis Figure 4: Percentage of groups of non venereal genital dermatoses

Group 1- Infections and infestations Table 1: Infections and infestations (n=1012; 58%)

Figure 7: Vulval candidiasis

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Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan

Figure 8: Herpes zoster

Figure 9: Molluscum contagiosum

Figure 10: Furuncle / pyoderma

Group 2- Inflammatory and Autoimmune Table 2: Inflammatory and Autoimmune (n= 630; 36.1%)

Figure 15: Apthous ulcers

Figure 16: Zoon’s balanitis Figure 11: Lichen planus

Figure 13: Intertrigo

Figure 12: Contact dermatitis Figure 14: Lichen simplex chronicus 22

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Figure 17: Behcet’s disease

Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan

Figure 18: Hailey hailey disease

Figure 19 : (A&B) Vitiligo

Group 3- Drug reactions Table 3: Drug reactions (n= 45; 2.5%)

Figure 22 : Angiokeratoma

Figure 20 : Fixed drug eruptions

Figure 21 : SJS-TEN overlap

Group 4 - Benign tumors and premalignant lesions

Table 4: Benign tumors and premalignant lesions (n=50; 3%)

Figure 23 : (A&B) Lymphangioma circumscriptum November 2023

Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan

Group 5 – Miscellaneous Table 5: Miscellaneous (n=8; 0.4%)

genital area can contribute to the constant itch-scratch cycle and exacerbate these conditions. It is noteworthy Figure 24:Bowenoid papulosis that premalignant conditions, such as lichen sclerosus et atrophicus (LSA), are more commonly observed in females, especially postmenopausal women. The hormonal theory, involving changes in estrogen levels and their influence on the Figure 27 : Pearly penile genital skin, may play a role in papules the development of LSA and Discussion other premalignant conditions There are varied manifestations in this population.6 and symptoms associated Understanding these factors with nonvenereal genital and manifestations associated dermatoses, ranging from with nonvenereal genital asymptomatic to chronic dermatoses is crucial for disabling conditions. Itching, accurate diagnosis, appropriate predominant infections and management, and the wellinfestations, followed by being of affected individuals. inflammatory conditions being By recognizing the underlying the most common symptom, causes and implementing thus highlights, aligns with effective treatment strategies, the previous studies and healthcare professionals emphasizes the importance of can alleviate symptoms and considering these etiologies Figure 25 : (A&B) Lichen improve the overall quality of life during diagnosis. Factors such sclerosis et atrophicus for patients with nonvenereal as old age, lack of hygiene, lack genital dermatoses.1,4,7 of genital education, decreased immunity and diabetes can The importance of contribute to the development distinguishing between of the disease as well as venereal and nonvenereal may increase susceptibility genital dermatoses. It is to infections or exacerbate crucial to recognize that not inflammatory conditions in the all lesions on the genitalia genital area. These factors are sexually transmitted, and among the inflammatory group, differentiating between these intertrigo and neurodermatitis two categories is essential were identified as the leading for appropriate diagnosis and dermatoses. The reduced management. Nonvenereal Figure 26 : Erythroplasia of barrier function and decreased genital dermatoses can indeed Querat threshold for itching in the cause considerable concern

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Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan

to patients, leading to mental distress and feelings of guilt. The challenging nature of these disorders further complicates the diagnostic process for treating physicians. Therefore, gaining a comprehensive understanding of the various presentations and their underlying etiology is essential for accurate diagnosis and effective management. Genital dermatoses, whether venereal or nonvenereal, can often be perplexing to various specialists involved in their diagnosis and treatment. The unique characteristics of the genital area can make the diagnosis even more difficult, as the typical features of common diseases may be altered or absent in this specific region. This complexity underscores the need for expertise in dermatology to properly evaluate and manage dermatoses affecting the genitalia.5, 6, 8,9,10 When it comes to differentiating nonvenereal genital dermatoses from venereal ones, several factors should be taken into consideration:A thorough medical history should be obtained, including any previous or current sexual practices, that indicate presence of any sexually transmitted infections or any relevant exposures, nonvenereal dermatoses may be more common in individuals who are not sexually active or who engage in sexual practices that do not involve the transmission of sexually transmitted infections, environmental triggers like potential irritants, allergens, or other environmental factors, application of topical agents such as creams, ointments,

or powders, in the genital area can help identify possible causes or exacerbating factors for nonvenereal dermatoses, the presence of other skin conditions or dermatoses in addition to the genital lesions can provide valuable information in distinguishing between nonvenereal and venereal dermatoses. For proper diagnosis and appropriate treatment a thorough examination of the genital area, including the skin and mucous membranes, should be conducted. This examination may involve inspection, palpation, and assessment of any associated symptoms such as itching, pain or discomfort. It is important to note the characteristics of the lesions, such as their appearance, color, texture, distribution and any associated signs such as scaling, erythema or ulceration. Further relevant investigations like skin biopsy (A small sample of the affected skin or lesion may be taken for histopathological examination), microbiological testing (Swabs or samples may be obtained to test for the presence of specific infectious agents, such as bacteria, fungi or parasites) blood tests (to assess for underlying systemic conditions or autoimmune diseases that can manifest as nonvenereal genital dermatoses) allergy testing (in cases suspected of allergic reactions, patch testing or other allergy tests may be performed to identify potential allergens) imaging studies (ultrasound or MRI may be needed to evaluate specific conditions or assess the extent of involvement) to be conducted if necessary.4,6,9

Male patients with nonvenereal dermatoses may initially seek care from genitourinary experts or physicians who may not have specialized training in dermatological diagnosis and treatment. This further highlights the importance of interdisciplinary collaboration by having a multidisciplinary approach involving dermatologists, genitourinary specialists, and other healthcare professionals to ensure accurate diagnosis, appropriate treatment, and support for patients experiencing dermatoses in the genital region. The limited number of comprehensive studies and scarcity of such studies on nonvenereal dermatoses of the male external genitalia, highlights the need for further research and understanding in this area. The studies conducted by Acharya et al. and Karthikeyan et al. on the pattern of nonvenereal dermatoses in males, as well as the study by Khoo and Cheong in Singapore, contribute to the knowledge base regarding these conditions. These studies likely provide valuable insights into the prevalence, etiology, and clinical characteristics of nonvenereal dermatoses in male patients. The age range, age distribution and mean age in study if are similar to the study by Karthikeyan et al. indicates that nonvenereal dermatoses of the male external genitalia can affect individuals across a wide age range predominantly of patients in the 21-30 years age group is consistent with their findings as well. If the observation of 16 different nonvenereal dermatoses in found in the study with genital November 2023

Pattern of Non-Venereal Genital Dermatoses in Geriatric Population: A Study in North Western Rajasthan

vitiligo being the most common disorder then it aligns with the findings of previous studies. The prevalence of pearly penile papules and fixed drug eruption (FDE) in one study corresponds to the findings of other studies as well. The distribution of patients from urban and rural backgrounds, as well as the marital status, provides additional demographic information about the population under study. The presence of genital vitiligo in various age groups, including both young adults and older individuals, highlights the importance of considering this disorder in the differential diagnosis of nonvenereal dermatoses. The association of genital vitiligo with generalized vitiligo, as well as the duration of illness, are important clinical observations.4 Conclusion A wide range of non venereal genital dermatoses were seen in our study. Non venereal genital dermatoses are quite common in geriatric population which can be sometimes mistaken for venereal dermatoses hence proper differentiation needs to done for proper diagnostic and treatment management. Significant knowledge about the prevalence, clinical characteristics, and etiology plays crucial role. Patients with genital lesions often have concerns and anxieties about potentially having a sexually transmitted infection. The stigma associated with sexually transmitted infections can further contribute to these concerns. It is important to note that nonvenereal dermatoses can affect not 26

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only the genitalia but also the dealing with these conditions. surrounding skin and mucous References membranes. These should be 1. Shim T N, Ali I, Muneer A, Bunker differentiated from venereal C B. Benign male genital dermatoses BMJ 2016; 354 :i4337 doi:10.1136/ conditions by thorough medical bmj.i4337 history, understanding about 2. Kaur, Karamjot et al. “Vulval the individual sexual practices, dermatoses (venereal and nonvenereal) environmental factors, among female patients presenting to tertiary care hospital in North India.” application of topical agents aIndian journal of sexually transmitted and presence of any cutaneous diseases and AIDS vol. 43,2 (2022): disease history, complete 141-145. doi:10.4103/ijstd.ijstd_18_22 dermatological examination 3. Sharanbasava V, Babu PSS, Patil and relevant investigations. The C S. A clinico-epidemiological study of non venereal dermatoses involving male relevant investigations included and female genitalia. IP Indian J Clin Exp skin biopsy, microbiological Dermatol 2021;7(3):237-242. testing, blood tests, allergy 4. Saraswat, P K et al. “A study of pattern testing, and imaging studies. of nonvenereal genital dermatoses of male attending skin OPD at a tertiary This combination helps in care center.” Indian journal of sexually reaching an accurate diagnosis transmitted diseases and AIDS vol. 35,2 129-34. doi:10.4103/0253and formulating an appropriate (2014): 7184.142408 treatment plan for nonvenereal 5. Singh, N., Thappa, D. M, Jaisankar, genital dermatoses. TJ, & Habeebullah, S. (2008). Pattern By explaining the true and benign nature of the lesions, misconceptions and fears associated with genital conditions can be alleviated, removing venerophobia and promoting open discussions about these issues. Early diagnosis of premalignant and malignant conditions in nonvenereal genital dermatoses is particularly important. Timely identification allows for less invasive surgical interventions, leading to lower morbidity and improved outcomes for patients. The study has provided valuable insights into the various patterns of presentations observed in nonvenereal dermatoses. Overall, the findings from the study will contribute to improved diagnosis, management, and patient education regarding non-venereal genital dermatoses and provide proper knowledge to improve and bring awareness of the disease thus making a positive difference in the lives of those

of non-venereal dermatoses of female external genitalia in South India. Dermatology Online Journal, 14(1). http://dx.doi.org/10.5070/D35hs3f52v Retrieved from https://escholarship. org/uc/item/5hs3f52v 6. Vinay N, Ranugha PSS, Betkerur JB, Shastry V, Ashwini PK. Non-venereal genital dermatoses and their impact on quality of life—A cross-sectional study. Indian J Dermatol Venereol Leprol 2022;88:354-9. 7. Kumar PS, Ramatulasi S, Darla S, Acharya A, A clinical study on non venereal genital dermatoses in adult males at a tertiary care center. Indian J Clin Exp Dermatol 2019;5(2):98-102 8. Narasimha Rao T.V and Kumar M S. A Clinical and Etiological Study of Non venereal Genital Dermatoses In Male Patients-A Descriptive Study Pattern In 100 Cases Attending To SKIN & STD OPD. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 22790861.Volume 18, Issue 7 Ser. 5 (July. 2019), PP 55-63. DOI: 10.9790/08531807055563 9. Hogade AS, Mishra S. A study of pattern of nonvenereal genital dermatoses of male attending skin OPD of tertiary centre in Kalaburagi. Int J Res Dermatol 2017;3:407-10. 10. Sujana, L., Beergouder, S. L., Rallapalli, A., Chidipudi, P., & Alla, S. (2022). A clinical study of venereal and non venereal genital dermatoses in women. European Journal of Molecular & Clinical Medicine, 9(4), 2663-2676. https://ejmcm.com/article_19123.html

An Unusual Presentation of Addisonian Pigmentation: A Case Report

An Unusual Presentation of Addisonian Pigmentation: A Case Report Dr. Atul Singhania

MBBS, DVD Skin Specialist, Venereologist , Leprologist, and Cosmetologist Shreekrupa Skin and Hair Care Clinic, Akola, Maharashtra Introduction Addison’s disease, also known as primary adrenal insufficiency, is a condition where the adrenal glands, located on top of each kidney, do not produce enough of the hormones cortisol and aldosterone.1 This can lead to symptoms such as fatigue, muscle weakness, weight loss, low blood pressure and skin changes.2 The incidence of Addison’s disease may vary depending on the underlying cause and the population being studied. Addison’s disease is a rare endocrine disorder that affects about 1 in 100,000 people and affects both males and females equally across all age groups. The condition was first described by Thomas Addison in 1855 and since then, the understanding of the disease has changed from an infectious cause to primarily an autoimmune pathology, although tuberculosis remains a leading cause of the disease in developing countries.3 Addisonian pigmentation is a hallmark sign of Addison’s disease.4 It is a result of the overstimulation of the melanogenic pathways or beta-lipotropin in response to increased ACTH (adrenocorticotropic hormone) levels. This overstimulation leads

to an increase in the number of melanocytes, increase in the synthesis and storage of melanin granules.5 Addisonian pigmentation is more likely to occur in individuals with longstanding, untreated adrenal insufficiency.4 The underlying cause of Addison’s disease can vary, but autoimmune disease, infections and tumors are among the most common causes.3, 5,6 Intraoral pigmentation is a common oral manifestation of the disease and may be the first sign of the condition.3, 5 The epidemiology of Addisonian pigmentation is not well documented, but it is a condition that affects the adrenal glands and impairs the production of cortisol and aldosterone hormones.1,6 ACTH stimulates the adrenal cortex to produce cortisol, increases melanin production in the skin and mucous membranes.7 The pigmentation appears as brown patches on the skin, oral cavity, conjunctiva and genitalia. In the oral cavity, the pigmentation is seen on the gingival, vermilion border of the lips, buccal mucosa, palate and tongue. In some cases, oral pigmentation may be the first sign of Addison’s disease, making it important for dental professionals to be aware of this manifestation.3 November 2023

An Unusual Presentation of Addisonian Pigmentation: A Case Report

Due to its slow progression, often unrecognized symptoms and a severe illness or accident can worsen the condition and lead to a life-threatening crisis, known as an Addisonian crisis or adrenal crisis. Early recognition and treatment of Addison’s disease is important to prevent complications and maintain good health. 3 Case Report A 46-years old female patient was presented to our outpatient department with complaints of skin pigmentation. Patient noticed dark pigmentation 15 years ago on face, neck which gradually increased on abdomen and back to develop diffuse hyperpigmentation as shown in figure 1&2. It was asymptomatic. There was no history of drug ingestion, chemical exposure, artificial ultraviolet light, Ionising radiation using hair dye, nicotine use, Arsenical exposures (drinking water) etc. An eruptive onset of new neavi on skin may be an early sign of Addison’s disease. Based on the physical examination and observation, the diagnosis of Addisonian pigmentation was made.

Figure 1: Hyperpigmentation in the neck region

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increase in melanin is observed in both epidermal and dermal melanophages, with a higher concentration in the latter.7

Figure 2: Diffuse hyperpigmentation of abdomen and buttock Diagnosis The history and physical examination are essential components in the evaluation of patients with Addisonian pigmentation. During the history taking, it is important to determine the duration, distribution and pattern of pigmentation, as well as other symptoms that may suggest an underlying cause. In the physical examination, a thorough evaluation of the skin should be performed to assess the extent and type of pigmentation. Hyperpigmentation is often more noticeable in areas exposed to sun such as the neck, arms, face and legs.8 In addition to the assessment of pigmentation, a complete physical examination should be performed to assess the presence of other symptoms, such as weight loss, fatigue, hypotension, abdominal pain and joint pain that may be associated with Addison’s disease.8 Diagnosis of Addison’s disease can be confirmed by measuring cortisol levels in the blood and ACTH stimulation test. In some cases, adrenal biopsy may be required to confirm the diagnosis.8 Histologically, there is an increased number of melanocytes and increased melanin granules in the basal layer of the epidermis. The

Treatment The treatment and medical management of Addisonian pigmentation typically involves treating the underlying cause of the Addison’s disease. The main aim of treatment is to replace the hormones (glucocorticoids and mineralocorticoids) that the adrenal glands are not producing enough amounts and to normalize the levels of cortisol and aldosterone.1,6 This helps to compensate for the lack of cortisol and aldosterone and helps to regulate the pigment-producing cells to improve the skin's appearance. Additionally, avoiding triggers such as infections or stress that may cause an adrenal crisis can help prevent exacerbation of the pigmentation.6,9 Cortisol replacement therapy is the mainstay of treatment for Addison’s disease and is usually given in the form of oral hydrocortisone (cortisol) or prednisolone. The dose of cortisol replacement may need to be adjusted based on the patient's symptoms, response to treatment and other medical conditions.1, 6 In addition to cortisol replacement , miner alocorticoid replacement therapy may also be necessary in some cases to replace the aldosterone that the adrenal glands are not producing. This is usually given in the form of oral fludrocortisone acetate.1,6 Treatment with immunosuppressive or immunomodulatory agents may be necessary in cases where Addison’s disease is caused by an autoimmune disorder.10 In such cases, medications such as glucocorticoids, azathioprine, or methotrexate

An Unusual Presentation of Addisonian Pigmentation: A Case Report

may be used.11 In few individuals, other medications such as melanocyte-stimulating hormone (MSH) antagonists may be used to help reduce the appearance of pigmentation.12 Sometimes, lightening creams or cosmetic procedures such as chemical peels, laser therapy may be used to improve the appearance of the skin.9 However, these are considered secondary treatments and the primary focus should be on correcting the adrenal insufficiency. However, these treatments should only be performed under the supervision of a dermatologist or other healthcare professional.9 In some critical responses, like an addisonian crisis, the patient requires immediate hospitalization and treatment with intravenous hydrocortisone and fluids.10 With the optimal hormone replacement medication, the pigmentation may occasionally go away on its own. In other circumstances, skin-lightening depigmenting drugs like hydroquinone or kojic acid may be applied topically. In addition to hormone replacement, sun protection measures, such as using a broad-spectrum sunscreen and wearing protective clothing, can also help to reduce the visibility of hyperpigmentation.13 Patients with Addison’s disease should also receive regular monitoring of their adrenal function, including monitoring of cortisol levels, to ensure that their treatment is effective and to adjust their cortisol dose as needed.1,6 The prognosis of Addison’s disease is good with proper management and replacement therapy. However, in case of underlying tuberculosis, the prognosis may be guarded and treatment may involve anti-tubercular therapy

as well. Early recognition and management of Addison’s disease is essential to prevent life-threatening Addisonian crisis and to improve the quality of life of the affected individuals.9 Discussion An uncommon endocrine condition called Addison’s disease is brought on by the adrenal glands dysfunction.1,3 When the adrenal glands are damaged, it leads to decreased production of these hormones and subsequent Addison’s disease. The most common causes of Addison’s disease are autoimmune and tuberculosis.1,6 Addison’s disease is usually the result of autoantibody destruction of adrenocortical tissue, however infection, haemorrhage or infiltration may be the cause of adrenal insufficiency. Addison’s Disease (Hypocortisolism) is due to insufficient secretion or supply of adrenocortical hormones mainly glucocorticoids and mineralocorticoids. Hyperpigmentation (diffuse) is the cardinal sign of Addison’s disease in skin. Pregnancy and oestrogen therapy can cause hyperpigmentation usually on nipples and anogenital skin. Additionally a masklike pigmentation called melasma can develop on forehead, temple, cheek, nose in pregnant women receiving oestrogen therapy.14 Other causes include fungal infection, hemochromatosis, metastatic cancer and X-linked adrenoleukody strophy.6 The exact etiology of Addison’s disease is still unknown, but it is believed to be related to the disturbance in the electrophysiological, electrolyte and metabolic activity.3 A common sign of the condition is hyperpigmentation, which

is sometimes described as "bronzing" and is especially noticeable on pressure points like the elbows, knees and skin that has been exposed to the sun.3 Symptoms of Addison’s disease include dysphagia, fatigue, weight loss, hypotension, abdominal pain, amenorrhea, nausea, vomiting, thin and brittle nails, scanty body hair, mood disturbances, decreased motivation and behaviour changes. One of the classic symptoms of Addison’s disease is hyperpigmentation of the skin and mucous membranes due to ACTH melanogenesis.3 Hyperpigmentation of the mucous membranes and skin usually precedes other symptoms by months to years. In some cases, vitiligo may also occur in association with hyperpigmentation in idiopathic Addison’s disease due to autoimmune destruction of melanocytes. Clinical features of hypoadrenocorticism do not appear until at least 90% of the glandular tissue has been destroyed.3 In developing countries and tropical inhabitants due to dark skin hyperpigmentation is usually missed by patients in beginning and when generalized hyperpigmentation develops patients awakens and takes doctors opinions, then the condition progress and worsens already. The treatment for this pigmentation typically involves managing the underlying cause, which may involve cortisol replacement therapy, oral medications and lifestyle modifications.6 In some cases, cosmetic procedures such as laser therapy or topical lightening agents may be used to improve the appearance of the affected skin. 9 November 2023

An Unusual Presentation of Addisonian Pigmentation: A Case Report

Conclusion Adrenalitis in Addison’s disease causes a deficiency of cortisol. One of the characteristic physical findings of Addison’s disease is hyperpigmentation, which occurs due to an increase in the pigment melanin in the skin. Melanogenesis stimulated by ACTH is linked to hyperpigmentation. Tyrosinase, an enzyme in melanocytes, is stimulated by ACTH, causing pigmentation. In patient with darker skin tones, it may be ignored and left untreated. Addison’s disease should be taken into consideration as part of the differential diagnosis when freckles begin to appear or gradually darken. Prior to any therapy, it's critical to recognise and handle any underlying disease that is causing cutaneous pigmentation. Obesity, diabetes, and osteoporosis can all be induced by overusing glucocorticoids. Hypertension may result after using mineralocorticoids excessively. A lifetime of care for concomitant autoimmune illnesses is required since 50% of people with addison disease, which is brought on by autoimmune adrenalitis, develop another autoimmune problem. Apart from these medications there are some cosmeceuticals which can used to reduce the visibility of hyperpigmention. Early diagnosis of Addison’s disease is essential for proper medical management. Delay in diagnosis carries substantial risk of morbidity and fatality. It is important to maintain regular follow-up with a healthcare provider and take the medication as prescribed to manage the condition effectively and prevent complications like addisonian crisis.

November 2023

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9. Desai S. R. (2014). Hyperpigmentation therapy: a review. The Journal of clinical and aesthetic dermatology, 7(8), 13–17. 10. Napier C, Pearce SH. Current and emerging therapies for Addison’s disease. Curr Opin Endocrinol Diabetes Obes. 2014 Jun;21(3):147-53. doi: 10.1097/MED.0000000000000067. PMID: 24755997. 11. Belgi G, Friedmann PS. Traditional therapies: glucocorticoids, azathioprine, methotrexate, hydroxyurea. Clin Exp Dermatol. 2002 Oct;27(7):546-54. doi: 10.1046/j.1365-2230.2002.01146.x. PMID: 12464149. 12. Brenner M, Hearing VJ. Modifying skin pigmentation - approaches through intrinsic biochemistry and exogenous agents. Drug Discov Today Dis Mech. 2008;5(2):e189-e199. doi: 10.1016/j. ddmec.2008.02.001. PMID: 19578486; PMCID: PMC2678743. 13. Sarkar, R., Arora, P., & Garg, K. V. (2013). Cosmeceuticals for Hyperpigmentation: What is Available?. Journal of cutaneous and aesthetic surgery, 6(1), 4–11. https://doi. org/10.4103/0974-2077.110089. 14. Mudur G. Endocrine disorders remain undetected and untreated in India. BMJ. 1999 Jan 23;318(7178):216. doi: 10.1136/bmj.318.7178.216. PMID: 9915725; PMCID: PMC1114720.

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