The Aestheticians Journal September'23 issue

Low Dose Oral Minoxidil Treatment for Hair Loss: A Case Report

A Case Report on Removal of Verruca Warts Using Radiofrequency Excision

Microneedeling RF for Acne Scars with Hyperpigmentation –A Case Presentation

Venous Ulcer in Rheumatoid Arthritis (RA) Patient: A Case Presentation

Sensitive Skin & Skin Diseases

EXECUTIVE EDITOR & PUBLISHER

Dom Daniel CORPORATE OFFICE

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Published for the period of September - 2023

Sensitive skin and skin diseases are two distinct but related topics in dermatology. Sensitive skin is a common issue in dermatology, which is generally used to describe skin with reduced tolerance to the application of cosmetics and personal care products. The various factors and mechanisms associated with sensitive skin and its potential links to other dermatological and systemic conditions. A number of the skin diseases and conditions linked to sensitive skin include acne, eczema, psoriasis and rosacea etc. Sensitive skin can sometimes be a symptom or manifestation of underlying cutaneous or extracutaneous disorders. People with sensitive skin may be more likely to experience skin inflammation, irritation and discoloration. It's crucial for dermatologists to be cautious and thorough when evaluating individuals with sensitive skin because it can be associated with a range of conditions.

Sensitive skin can be a sign of broader health concerns is essential for providing comprehensive care. Tailoring diagnostic and screening approaches based on individual risk factors and symptoms is a prudent strategy and dermatologists should remain vigilant in assessing and managing patients with sensitive skin to ensure their overall health and well-being. Treatment for sensitive skin diseases varies depending on the specific condition. Dermatologists are trained to diagnose and manage these conditions, often using a combination of topical treatments, oral medications, lifestyle changes and sometimes surgical procedures.

Dermatologists are the one who can provide a professional guidance, proper diagnosis and recommend the most appropriate treatment and skincare regimen for specific needs.

In this issue we have clinical case reports on Low Dose Oral Minoxidil Treatment for Hair Loss, Removal of Verruca Warts Using RF Excision, Microneedeling RF for Acne Scars with Hyperpigmentation, Venous Ulcer in Rheumatoid Arthritis Patient.

HOPE YOU HAVE A GREAT READ

Thanks & Cheers

- Dom Daniel

Executive Editor & Publisher

Low Dose Oral Minoxidil Treatment for Hair Loss: A Case Report

Dr. Shalu Savla, MBBS, DDV

A Case Report on Removal of Verruca Warts

Using Radiofrequency Excision

Dr. G Harish, MBBS, DDVL

Microneedeling RF for Acne Scars with Hyperpigmentation – A Case Presentation

Dr. Shireen Poonawala, MBBS, DDV

Venous Ulcer in Rheumatoid Arthritis (RA) Patient: A Case Presentation

Dr. Madhavi Pudi, MBBS (Gold Medallist), DNB, DVD

Dr. Sudhir Pudi, MBBS, DNB, McPhleb

Editorial Board

Dr. Shalu Savla

MBBS, DDV Dermatologist and Cosmetologist

Dr. Shalu Savla Skin, Hair and Cosmetology Clinic Mumbai

Dr. G Harish

MBBS, DDVL Consultant Dermatologist

Khammam, Telangana

Dr. Abhishek Shetty

Dr. Harish Prasad

Dr. Haritha

Dr. K. Nirupama

Dr. Karthik

Dr. Kiran Raju

Dr. Poornima Santosh

Dr. Shireen Poonawala

MBBS, DDV

Dermatologist, Trichologist and Laser Surgeon Skinvibbes Clinic, Pune

Dr. Shamanth Murthy

Dr. Shashidhar T

Dr. Uma Shree Anee

Dr. Usha Kiran

Dr. Madhavi Pudi

MBBS (Gold Medallist), DNB, DVD

Dr Madhavi’s Advanced Skin Hair and Laser Clinic, Hyderabad

Dr. U.R.S Raju

Dr. Syed Salahuddin

Dr. Srinivas Dasari

Dr. Sudhir Pudi

MBBS, DNB, McPhleb Interventional Radiologist

Dr Sudhir's Scan Center and Varicose Vein Clinic, Hyderabad

Dr. Akhilesh

Dr. P. Narendra

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

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

INTERNATIONAL CONGRESS OF DERMATOLOGY, AESTHETICS AND SURGICAL TECHNIQUES.

Low Dose Oral Minoxidil Treatment for Hair Loss: A Case Report

Dr. Shalu Savla

MBBS, DDV

Dermatologist and Cosmetologist

Dr. Shalu Savla Skin, Hair and Cosmetology Clinic

Mumbai

Introduction

Hair loss is a common topic of interest for people of all ages while considering today’s lifestyle and habits. It has almost affected more than 50 % of male and female population. Hair loss is often saddening and can have significant impact on patients self–esteem and life.1 Scarring and non scarring alopecia are included in the differential diagnosis of alopecia.2 Patients may appear with isolated areas of hair loss or with more diffuse hair loss, which may involve predominant hair thinning or increased hair shedding.3

Main causes may be classified as focal or diffuse hair loss (Table 1). Focal hair loss occurs as a result of subordinate underlying disorder which may eventually lead to scarring and nonscarring alopecia’s. Tinea capitis or alopecia areata causes non scarring focal alopecia; traction alopecia or trichotillomania causes patchy hair loss and discoid lupus erythematosus usually leads to scarring alopecia. Diffuse hair loss

further can be branched into hair shedding caused due to telogen effluvium and hair thinning due to androgenetic alopecia.3

Androgenetic alopecia, also known as male or female pattern hair loss, is a common cause of hair loss in both men and women. The condition is caused by a combination of genetic and hormonal factors and is characterized by a gradual thinning of the hair on the scalp, as well as a receding hairline in men.3 Compared to their adult counterparts, paediatric patients' patterns of hair loss frequently differ from those of adults.

Hair follows a typical hair cycle for its growth which majorly involves three phases: anagen (growing), catagen (degeneration) and telogen (resting). Hair shedding which takes place is mainly when hair enters the telogenic phase and is well described by the phenomenon telogen effluvium.1 Hypothyroidism and hyperthyroidism may also increase the number of hairs entering to telogenic phase, although condition can be

reversed when thyroid is under control.3

Other possible causes of hair loss may include such as irondeficiency anaemia, genetic factors, concurrent diseases, environmental exposure, hormonal imbalances and autoimmune diseases, can also be ruled out if laboratory results are normal.4 Some auto immune diseases which plays major role may include thyroid disease, vitiligo and atopy.4 Physical examination is usually confined to hair and scalp but any comorbid disease associated with patient must also be taken into care. From physical examination one can manifest whether the hair loss is diffused or localised. Some test like hair pull test, tug test, hair mount is performed for identifying hair loss condition.1 Sometimes even scalp biopsy is done to understand its clinical features.1 Trichoscopy is also used for identification of hair loss as it confirms the various pattern involved like loss of follicular ostia highlights scarring alopecia’s and preserved ostia may highlight non-scarring alopecias.5

There are various approaches and strategies followed by various treatment for minimizing hair loss includes amplifying hair rate of growth, enlargement of hair diameter and various tailoring in hair cycle.6 Sometimes surgical methods are also adopted like micrografts, minigrafts etc. Various non-surgical methods adopted include vitamins, nutrients and minerals, anti-androgen therapy, heterocyclics like minoxidil, pyridine derivatives, benzothiazide derivative, steroids and some natural products.6

Case Presentation

In the case of the four patients in their mid-30s who presented with the chief complaints of hair loss and hair thinning, a diagnosis of androgenetic alopecia was made. This diagnosis was likely based on a combination of the patients' symptoms, medical history, physical examination and investigation. On examination, chronic hair loss on the frontal and crown area was observed which directed towards differential diagnosis of androgenetic alopecia. Other examinations like dermoscopy/trichoscopy which are one of the recent tools for diagnosis of hair loss which has been adapted by many dermatologist for aiding in diagnosis of specific condition.

Investigation

When a patient presents with hair loss, it is important to perform a thorough evaluation to determine the underlying cause. In addition to a physical examination, medical history and laboratory investigations are often performed to help identify any underlying medical conditions that may be contributing to the hair loss. In such cases, the physician may suggest a hair and scalp examination with a dermatologist or trichologist, to determine if there's any other cause for the hair loss and suggest a treatment plan for hair loss.7 Sometimes physician may also refer the patient to a specialist or to another department for further evaluation if needed. A detailed medical history and physical examination

Table 1: Differential diagnosis of alopecia3

Low Dose Oral Minoxidil Treatment for Hair Loss: A Case Report

by a qualified healthcare professional, including a scalp examination, a examination of the hair shaft and hair roots can also help to identify the cause of hair loss and determine the best course of treatment.2 However, it is important to note that these laboratory tests are not comprehensive, and there may still be other potential causes of the hair loss that have not been ruled out. The physician may also recommend other tests or investigations to further evaluate the patient's hair loss. Such as blood test for iron, ferritin, vitamin D etc.7

Some common tests that may be performed in cases of hair loss include:8

• Thyroid function tests: These tests are used to evaluate the function of the thyroid gland, which plays a role in hair growth. Abnormal results may indicate that the patient has a thyroid disorder, such as hypothyroidism or hyperthyroidism, which can cause hair loss.

• Iron and ferritin levels: Iron is essential for hair growth and a deficiency can cause hair loss. Ferritin is a protein that stores iron in the body, so measuring ferritin levels can help to determine the patient's iron stores.

• Vitamin D levels: Low levels of vitamin D may be linked to hair loss.

• Hormonal tests: Hormones play a role in hair growth, so hormonal imbalances can contribute to hair loss. Tests for hormones such as testosterone, estrogen, and dehydroepiandrosterone

sulfate (DHEAS) may be performed.

• Blood cell counts: Abnormalities in the number or function of blood cells can contribute to hair loss. A complete blood count (CBC) may be performed.

• Other tests depending on the symptomatology and the physician's discretion. However, other medical conditions can also cause hair loss, and it is crucial to rule out those possibilities before making a diagnosis of androgenetic alopecia. Other causes of hair loss that may need to be ruled out include genetic condition, familial predisposition, hormone metabolism (androgen) hair follicle inflammation and environmental factors.8 In addition, a trichogram or a scalp biopsy may also be performed to evaluate the hair and scalp. Trichogram is a diagnostic tool that provides detailed information about the hair growth cycle, the number of hairs in different growth phases and the number of hair that are in the telogen (resting) phase.7 In this case, the patient's laboratory investigations like thyroid function and ECG, indicated normal results.

From the patient’s normal laboratory investigation, one can confer that cause of the hair loss is not related to an underlying hormonal or cardiovascular condition. In such cases, the hair loss may be caused by a condition such as androgenetic alopecia, which is a common cause of hair loss that is inherited

and caused by the effects of hormones on the hair follicles.

Treatment

Androgenetic alopecia is an autosomal dominant disorder. It may be caused due to hormonal imbalance of dihydrotestosterone (DHT) along with some genetic or environmental factors. DHT causes hair shaft to become less dense, thin and weaker until complete shrinkage and production is stopped. Despite the fact that topical minoxidil, light-based and oral finasteride are the only approved therapies by FDA to treat androgenetic alopecia. Apart from these there are many therapies which has been adopted by various dermatologist all over such as nutraceuticals, hair transplantation, PRP and exosome treatments are undertaken to reverse or slow down its further progression.9

Minoxidil has been the preferred treatment of choice over the years. Topical minoxidil has been used for many years as treatment for different hair disorders. Even though it is an effective therapy, many patients show poor compliance due to the cosmesis, cost and side-effects. During the last few years, low-dose oral minoxidil has proven to be an alternative for patients with alopecia. It is typically used twice a day and should be applied to a clean, dry scalp in the area of hair loss. It was originally developed as an oral medication to treat high blood pressure, but was found to have a side effect of increased hair growth, fluid retention,

weight gain and heart palpitations. Additionally, it should be noted that minoxidil is not recommended for people under the age of 18 or pregnant and lactating women. Some common side effects associated with it are hypertrichosis and sometimes allergic contact dermatitis is also observed. And other hair loss treatments such as finasteride, dutasteride, hair transplantation, etc. may also be considered for treating hair loss.7 Dutasteride is an oral medication that is used to treat hair loss by inhibiting and block the conversion of testosterone to dihydrotestosterone (DHT). Dutasteride is not approved by the FDA for use in the treatment of hair loss, but it is approved in some other countries for this purpose. However, it is widely used offlabel for hair loss treatment in many countries. Dutasteride can have various side effects, such as decreased libido, impotence and breast tenderness or enlargement and it should only be taken under the guidance of a qualified healthcare professional. Additionally, it is not recommended for women.7,9 It's very crucial monitor blood pressure at every visit as oral dutasteride and minoxidil can cause hypotension (low blood pressure) as a side effect.

PRP therapy is another nonsurgical treatment that uses a patient's own blood plasma, which is rich in platelets and growth factors, to stimulate hair growth. These plasma are rich in growth factors

and is injected deep into the subcutaneous tissue. Multipeptide serum is a product that contains a combination of peptides, which are small chains of amino acids that can help to stimulate collagen production and improve hair growth. Hormonal therapies are also been in use in recent times in which antiandrogens are given to male patient and cyproterone acetate along with oral contraceptive estradiol in female patients. Not much efficacy has been noticed yet.7, 9, 10 Various surgeries like hair transplantation are also adopted. Its efficacy again depends on donor hair individuals. Hair is taken from donor individual either by follicular unit extraction, strip method or its combination.9 Combining dutasteride with PRP and multi-peptide serum is a possible treatment option for hair loss, particularly androgenetic alopecia.

In this case, patients were counselled on starting oral minoxidil 2.5mg and dutasteride along with PRP and multi-peptide serum.3 sessions of PRP were given at an interval of 30 days. Blood pressure was monitored at every visit to avoid potential risks of hypotension.

Discussion

Alopecia or hair loss is a disorder which can be either congenital or acquired. It is a common problem appearing to a dermatologist in recent times and sometimes can turn out to be quite distressing to the patients. Various environmental factors, genetically

predisposed individual and other interactions between various genes are commonly observed causes for androgenic alopecia. It is a slow progressive condition, where conversion of hair shaft to vellus hair is seen. This condition is characterized by a gradual thinning of the hair on the scalp and a receding hairline in men. It is also known to cause alterations in hair cycle by elongation of telogen phase and reduction of time span of anagen phase resulting in slow balding. Sequential steps must be followed for proper identification, controlling its spread, proper cure and maintenance of its condition. Clinical steps that should be adapted must include history of patient, clinical and external examination, trichoscopy and other laboratory findings must be done.2 When investigating hair loss in patients, detailed medical history, including information about any medications the patient is currently taking and any family history of hair loss. A physical examination should also be performed, including a thorough examination of the scalp and hair. It is important to note that hair loss can be caused by a variety of factors, and a detailed evaluation is necessary to determine the underlying cause and the best course of treatment.

Minoxidil is a medication that is most commonly used topically to the scalp to stimulate hair growth in people with androgenetic alopecia. The exact way that minoxidil promotes hair growth is not

entirely understood, but it is thought to work by increasing blood flow to the hair follicles, which allows more oxygen, blood and nutrients to reach the hair follicles, which can help to revive dormant hair follicles and promote new hair growth. 7, 9

Treatment for androgenetic alopecia typically includes medications such as minoxidil and finasteride, which can slow or stop the progression of hair loss and even promote regrowth. Other treatments such as hair transplantation, scalp micropigmentation, or laser therapy can also be options. During the last few years, low-dose oral minoxidil has proven to be an alternative for patients with alopecia.

Before prescribing any medication patients was checked for its comorbidites and other medical history was taken into considerations. On having an overview of their medical condition minoxidil 2.5 mg was prescribed along with dutasteride. Along with oral medication other therapy was started in combination for effective therapy like plateletrich-plasma therapy and multi peptide serum. During every visit the patient’s blood pressure was measured to avoid any hypotension which is one of the side effects of minodoxil as it is a vasodilator. It's also important to consider a complete clinical evaluation, review of the medical history, family history and physical examination to come up with a proper diagnosis and management plan.

Result

Here patients got the good result with oral minoxidil 2.5mg and dutasteride along with PRP and multi-peptide serum. At the six-month, all the patients reported an increase in hair density and satisfactory hair growth.

Patient 1

Patient 3

Conclusion

Minoxidil has been used as preferred drug of choice to stimulate hair growth in people with androgenetic alopecia. It is considered to be an effective treatment option, with an estimated 40% of men and 30% of women experiencing moderate-to-good hair regrowth. It is typically used as a last resort in people who have not responded to topical minoxidil or other hair loss treatments. It must be taken into consideration that minoxidil treatment usually takes several months to see results, if you stop using the medication, any new hair growth will be lost and the hair loss will return to its pre-treatment state. Hair growth typically begins within 2 to 4 months of starting minoxidil treatment, but it can take up to a year for the full effects to be visible. While oral minoxidil can be effective in promoting hair growth, it is important to use it only under the close supervision of a healthcare professional. One must weigh the potential benefits and risks of oral treatment for hair loss before starting the treatment. It is always recommended to consult a qualified dermatologist or trichologist for an accurate diagnosis and treatment plan for hair loss and to determine the best course of treatment for each individual case.

References

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. https://pubmed.ncbi.nlm.nih.

gov/28925637/

2. Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part I. History and clinical examination. J Am Acad Dermatol. 2014 Sep;71(3):415.e1-415.e15. doi: 10.1016/j. jaad.2014.04.070. PMID: 25128118.

3. Mounsey AL, Reed SW. Diagnosing and treating hair loss. Am Fam Physician. 2009 Aug 15;80(4):356-62. PMID: 19678603.

4. Pratt CH, King LE Jr, Messenger AG, Christiano AM, Sundberg JP. Alopecia areata. Nat Rev Dis Primers. 2017 Mar 16;3:17011. doi: 10.1038/nrdp.2017.11. PMID: 28300084; PMCID: PMC5573125. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5573125/

5. Xu Liwen, Liu Kevin X., Senna Maryanne M. A Practical Approach to the Diagnosis and Management of Hair Loss in Children and Adolescents. Frontiers in Medicine. VOLUME=4, 2017.DOI=10.3389/ fmed.2017.00112 https://www.frontiersin. org/articles/10.3389/fmed.2017.00112/full

6. Semalty, Mona; Semalty, Ajay; Joshi, Geeta Pant; Rawat, Mohan Singh Maniyari (2011). Hair growth and rejuvenation: An overview. Journal of Dermatological Treatment, 22(3), 123–132. doi:10.3109/09546630903578574

7. Kaliyadan F, Nambiar A, Vijayaraghavan S. Androgenetic alopecia: An update. Indian J Dermatol Venereol Leprol 2013;79:613-625

8. Ho CH, Sood T, Zito PM. Androgenetic Alopecia. [Updated 2022 Oct 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK430924/

9. Nestor MS, Ablon G, Gade A, Han H, Fischer DL. Treatment options for androgenetic alopecia: Efficacy, side effects, compliance, financial considerations, and ethics. J Cosmet Dermatol. 2021 Dec;20(12):3759-3781. doi: 10.1111/ jocd.14537. Epub 2021 Nov 6. PMID: 34741573; PMCID: PMC9298335.

10. Sadgrove NJ, Simmonds MSJ. Topical and nutricosmetic products for healthy hair and dermal antiaging using "dual-acting" (2 for 1) plant-based peptides, hormones, and cannabinoids. FASEB Bioadv. 2021 Jun 6;3(8):601-610. doi: 10.1096/ fba.2021-00022. PMID: 34377956; PMCID: PMC8332470.

Low Dose Oral Minoxidil Treatment for Hair Loss: A Case Report

A Case Report on Removal of Verruca Warts Using Radiofrequency Excision

Dr. G Harish

MBBS, DDVL

Consultant Dermatologist

Khammam, Telangana

Introduction

Verruca warts, also known as plantar warts, are benign growths on the skin caused by the human papillomavirus (HPV).1 They typically appear on the soles of the feet, but can also appear on other parts of the body. They are usually small, hard and have a rough surface with black dots (which are small clotted blood vessels).2 There are more than 100 varieties of HPV and each subtype might result in a distinct kind of wart. Verruca warts are brought on by HPV types 1, 2, 4, 27 and 57.3 These types of HPV infect the epidermal cells of the skin and cause them to grow in an abnormal way, leading to the formation of warts.4 The HPV virus enters the skin through small cuts, scrapes or other breaks in the skin. Once inside the skin, the virus infects the basal cells in the epidermis, which are the cells that make new skin. The virus then causes the cells to grow and divide at an accelerated rate, forming a wart.3

Verruca warts are highly contagious and can be spread through direct contact

with the wart or by coming into contact with surfaces that have been contaminated with the virus, such as gym floors or communal showers.4 They may cause discomfort and pain when pressure is applied to them, such as when walking or standing.3 In addition to the dermal papillae stretching its capillaries up into the wart, hypertrophy of the granular and prickle cell layer also takes place.3 Individuals with plantar warts frequently experience pain, a sensation of lump in their shoe or swelling under their foot when they first acquire them.2 The epidemiology of verruca warts varies depending on factors such as age, gender and lifestyle.2,4 In terms of age, verruca warts are most common in children and young adults. However, they can occur in people of any age.4 They are also more common in males than females. In terms of lifestyle, individuals who have a higher risk of contracting HPV, such as those who have a compromised immune system, regular skin-toskin contact with others or

a history of warts are at a higher risk of getting verruca warts.2 Additionally, people who frequently use shared showers, go barefoot in public or have a high risk of foot trauma, such as athletes, are more likely to get verruca warts. It's worth mentioning that the prevalence of verruca warts may vary depending on the population and the geographic location.2

Risk factors that may increase the likelihood of contracting HPV and developing verruca warts include:2

• Having frequent skin-toskin contact with others

• Having a weak ened immune system

• Having a history of warts

• Having a history of foot trauma

• Walking barefoot in public places - using communal showers or locker rooms

Case Report

A 11-years-old girl suffering from verruca warts on facial and neck region. Patient complained about gradually enlarging wart on the forehead area and below the eye. Since she did not experience any pain or irritation she did not opted for any therapy. On gross inspection, these warts appeared as solitary or grouped rough, greybrown, hyperkeratotic, cobblestoned black dots. Main clinical characteristic features include destruction of normal skin tissues, tiny blood clots formed by thrombosed capillaries within the papules. Few pathological investigations were carried out. Biopsy can be done for

diagnosis and evaluation of warts. Histopathologic analysis hypergranulomatosis along with rapid proliferation of cell leading to papillomatous epidermis in the infected area by the HPV virus.

Based on the diagnosis we decided to exclude the warts using radio frequency ablation technique for excision under local anaesthesia. Warts and moles can be cauterised using radiofrequency using low-temperature, high-frequency energy radio waves. A uniform pink backdrop with no red or black specks, brown pigment or haloes were observed at the end indicated complete clearance.

Before treatment

After treatment

Figure 1: Presence of grouped brown- grey fleshy warts on the forehead region

Figure 2: Verruca warts showing elevated hyperkeratotic projection with localized flat-topped papules

Figure 3: Occurrence of skin-colored to brownish papillomas with pinpoint black dots below the eye area

A Case Report on Removal of Verruca Warts Using Radiofrequency Excision

Diagnosis

A practical approach to the diagnosis and management of verruca warts, typically includes a combination of clinical examination, patient history and possibly a biopsy.4

During the patient's history, the healthcare provider will ask about the duration of the wart, any pain or discomfort associated with it and any previous treatments that have been attempted. It's crucial to be aware, if the patient has a history of warts, if they have a weakened immune system and if they have any history of foot trauma. Also, any risk factors that may increase the likelihood of contracting HPV and developing verruca warts.4 During the physical examination, the healthcare provider will visually inspect the affected area. Verruca warts usually appear as small, hard, rough-surfaced growths on the skin, most commonly on the soles of the feet.4

The healthcare provider may also perform a biopsy of the wart to confirm the diagnosis and to rule out any other conditions that may have similar symptoms. Under the microscope, verruca warts appear as thickened, hyperkeratotic (thickened surface layer of skin) stratum corneum (the outermost layer of the epidermis) and an increased number of keratinocytes (the main cell type found in the epidermis) in the lower epidermis.2

Once the diagnosis is confirmed, the healthcare provider will recommend the appropriate treatment

based on the size, location and number of warts, as well as the patient's individual preferences and medical history. Also regular followup to monitor the progress of the treatment and to take into consideration any new symptoms is mandatory. The differential diagnosis for verruca warts includes other skin conditions that may present with similar symptoms. Some of the conditions that may be considered in the differential diagnosis include:3, 4

1. Calluses: These are thickened areas of skin that develop in response to repetitive friction or pressure. They may have a similar appearance to verruca warts but are typically painless.3

2. Corns: These are similar to calluses but are typically smaller and develop on the toes rather than the soles of the feet. They may also have a similar appearance to verruca warts but are typically painless.3

3. Molluscum contagiosum: This is a viral infection that causes small, raised, fleshcolored or pearly bumps on the skin. They may be confused with verruca warts, but they do not have the characteristic black dots seen in verruca warts.4

4. Seborrheic keratoses: These are benign skin growths that are often described as "stuck-on" or "waxy" in appearance. They may be confused with verruca warts, but they do not typically cause pain or discomfort.4

5. Acrochordons: These are small, soft, skin-colored or brown, benign tumors that are often found on the neck, armpits or groin area and have a small stalk. They may be confused with verruca warts, but they do not typically cause pain or discomfort.5

Treatment

Treatment options include:

Topical medications: Over-the-counter topical medications, such as salicylic acid or cantharidin, can be applied directly to the wart to soften and break down the thickened skin. By chemically eliminating excess keratin from the wart and triggering a local inflammatory reaction, it encourages wart shrinkage.1, 2

1. Cryotherapy: This involves freezing the wart using liquid nitrogen. This treatment causes the wart to peel off after several days. It functions by producing cell damage and local inflammation by freezing the plantar wart. This technique is not suggested for young children due to the pain involved. It is regarded as a secondary treatment for plantar warts.1, 2

2. Cantharidin: It is a blistercausing substance that, after 24-48 hours of exposure, promotes intra-epidermal skin blistering, breaks down the Desmosomal connection and exfoliates tissue that contains viruses.1, 3

3. Bleomycin : It is a strong inhibitor of protein and DNA synthesis. It is used as a treatment for resistant warts because it causes tissue necrosis that triggers an

immunological response.3

4. Surgical methods: In some cases, a healthcare provider may use surgical methods, such as curettage (scraping), electrosurgery (burning) or laser therapy to remove the wart.1, 3

5. Immune response modifiers: These are medications that help the body's immune system to fight the virus, such as imiquimod, cimetidine or levamisole3 enhancing the immunological response of the host to the wart antigen.6

6. Combination therapy: A combination of different treatments may be more effective in some cases, such as topical medication and cryotherapy.3

RF Excision for verruca warts

RF (Radiofrequency) excision is a method used to treat verruca warts, by using a highfrequency electrical current to remove the wart. This method is considered a minimally invasive surgical procedure that can be done under the guidance of dermatologist or healthcare professional. The procedure is done by using a small needle-like probe that delivers a highfrequency electrical current to the wart. The current causes the cells in the wart to heat up and coagulate, effectively killing the cells and causing the wart to fall off.7 The procedure is usually done under local anaesthesia and is relatively painless. It may take several sessions to completely remove the wart, depending on the size

and location of the wart.7 RF excision is considered a safe and effective treatment option for verruca warts and it has the advantage of being less painful than other surgical methods, such as cryotherapy and curettage. With cure rates ranging from 80–90%, it has been demonstrated that the treatment has a good success rate for eradicating warts.8

The operation is typically well-tolerated and there is little chance that it will result in infections or scars. During the procedure, some patients may feel some mild pain or discomfort, but this is typically manageable with local anaesthetic. It's critical to remember that the results of RF excision may not be immediate and it may take several weeks for the wart to fall off completely.8 RF excision can be an effective treatment option for patients with verruca warts that are resistant to other treatments or for patients who are not good candidates for other treatments, such as those with diabetes or a compromised immune system.

By treating the plantar wart and changing one's behaviour, one can lessen the spread of the virus and the likelihood of developing warts. The best, but still elusive, strategy for treating plantar warts is to prevent the lesion entirely by decreasing potential risk factors for HPV infection, preserving the integrity of the cutaneous barrier and enhancing the immune system's capacity to clear early infections.2

Discussion

The warts are composed of an overgrowth of the epidermis, verruca warts have a characteristic appearance; they often appear as a small, hard, raised bump with a rough surface. They can be flesh-colored or have a grey or white appearance. They can be single or grouped together, and they may be painful, especially when they occur on weight-bearing areas of the foot. It's worth mentioning that verruca warts are benign and do not invade the deeper layers of the skin. However, they can be a source of discomfort, pain and can be unsightly.2,3 The genesis of warts depends heavily on the immune system. A weaker immune system may make people more prone to developing warts. In addition, although the immune system is in charge of keeping warts in control, the HPV virus is also responsible for the development of warts, which may enlarge and multiply if the immune system is weak. Plantar wart incidence has been linked, in particular, to cell-mediated immunodeficiency, including primary, secondary and iatrogenic forms.2 The virus infects the epidermal cells of the skin and causes them to grow in an abnormal way, leading to the formation of warts. When there is trauma or damage to the skin, a pathway is created for the virus to penetrate and infiltrate the third layer of skin, known as the stratum spinosum.3 Once inside the skin, the virus infects the basal cells in the epidermis, then causes the

cells to grow and divide at an accelerated rate, forming a wart. After being established, a plantar wart releases HPV through exfoliating epithelial cells. The viral particles can then spread to additional carriers and places.2

Verruca warts can be treated with over-the-counter medications such as salicylic acid or cantharidin, which are applied directly to the wart. Cryotherapy (freezing) with liquid nitrogen is also a common treatment option. In some cases, a healthcare provider may use surgical methods such as curettage (scraping) or electrosurgery (burning) to remove the wart.3 It's vital to remember that some warts might not respond to treatment and might come back after it. In order to prevent the virus from spreading to other parts of the body or to other individuals, it is also critical to practise proper hygiene and refrain from sharing personal objects like towels or shoes.2 Verruca warts are extremely contagious, so it's critical to take preventative measures to stop the virus from spreading. Some of these precautions include avoiding direct contact with warts and keeping the affected region dry and clean.2

Conclusion

A skin lesion with a distinctive morphology can be brought on by an HPV subtype. The cutaneous indications of the human papillomavirus are warts (HPV). Although it infects the stem cells and basal portion of the epithelium, viral sporulation

only occurs in fully developed keratinocytes, or cells from the stratum spinosum and stratum granulosum. The warts are composed of an overgrowth of the epidermis. Clinically speaking, plantar warts are well-circumscribed lesions with underlying hyperkeratosis that can disrupt the skin's lines and promote pinpoint bleeding when they are excised. Cell-mediated immunity is crucial for the decline in viral load. There are a variety of techniques, including tissue keratolysis (salicylic acid), immunotherapy (bleomycin) and tissue invasive techniques (cryotherapy, surgical excision). Immunotherapy has produced positive results in treating resistant patients and preventing their condition from returning.

Reference

1. Nofal A, Elmonsef E, Elkholy B. An Overview of Various Lines in The Treatment of Warts: Review Article. The Egyptian Journal of Hospital Medicine (January 2022) Vol. 86, Page 570-573

2. Witchey, D., Witchey, N., Roth-Kauffman, M. & Kauffman, M. (2018). Plantar Warts: Epidemiology, Pathophysiology, and Clinical Management. Journal of Osteopathic Medicine, 118(2), 92-105. https://doi.org/10.7556/ jaoa.2018.024.

3. Vlahovic, Tracey C.; Khan, M. Tariq (2016). The Human Papillomavirus and Its Role in Plantar Warts. Clinics in Podiatric Medicine and Surgery, (), S0891842216300155–. doi:10.1016/j.cpm.2016.02.003

4. Al Aboud AM, Nigam PK. Wart. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL):

StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi. nlm.nih.gov/books/NBK431047/

5. Belgam Syed SY, Lipoff JB, Chatterjee K. Acrochordon. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi. nlm.nih.gov/books/NBK448169/

6. Jaiswal A, Gupta K, Sharma R, Bedi G, Immunotherapy with PPD in treatment of warts: An open labelled study from western Uttar Pradesh. IP Indian J Clin Exp Dermatol 2019;5(1):41-45.

7. Sachdeva S, Dogra A. Radiofrequency ablation in dermatology. Indian J Dermatol [serial online] 2007 [cited 2023 Mar 30];52:134-7. Available from: https://www.e-ijd.org/text. asp?2007/52/3/134/35091

8. Jaiswal P, Dhali TK, D'Souza P. Comparative study of efficacy of radiofrequency ablation, electrodesiccation, and cryosurgery in the treatment of cutaneous warts. J Dermatol Dermatol Surg [serial online] 2019 [cited 2023 Mar 30];23:24-9. Available from: https://www.jddsjournal.org/text. asp?2019/23/1/24/250825

Case Report on Removal of Verruca Warts Using Radiofrequency Excision

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

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

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

The researchers found that while both forms bind to receptors on sensory neurons within the skin, the more stable form 9,10,13-THL had a longer lasting effect than 9,13-EHL. They also found that once the lipids bind to the neuronal receptor, they activate the neurons expressing TRPA1 and TRPV1 receptors that are involved in temperature and pain hypersensitivity, opening communications channels to the central nervous system. Interestingly, the lipids did not have any effect on itch.

It was surprising that these lipids could create hypersensitivity but not impact itch sensation, which is usually the most troublesome symptom associated with psoriasis. This most likely has to do with how the neuron is activated a mechanism they still haven't uncovered. Now that an association between linoleic acid and hypersensitivity to temperature and pain has been established, the researchers want to further explore exactly how this response is being created. They hope that the answers may lead to solutions that can relieve these symptoms in psoriasis patients.

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

FDA adds safety-related information to its dermal filler webpage

Dermal fillers are a type of cosmetic treatment used to enhance and restore volume in the face and other areas of the body. They are typically injected under the skin to address various aesthetic concerns and to reduce the signs of aging. The primary purpose of dermal fillers is to plump up areas with lost volume, smooth out wrinkles and lines, and improve overall facial contours.

Recently, Food and Drug Administration updated its informational webpage on dermal fillers to reflect the risk of delayedonset inflammation near dermal filler treatment sites. Along with a list of common reactions such as bruising, redness, swelling, and pain, the webpage now includes language to inform the public and health care providers about reports of delayed-onset inflammation that have been reported to occur near the dermal filler treatment site following viral or bacterial illnesses or infections, vaccinations, or dental procedures. According to an FDA spokesperson, the update is based on several sources of information, including post marketing data from adverse event–reporting databases, such as the Manufacturer and User Facility Device Experience (MAUDE) for devices and the Vaccine Adverse Event Reporting System (VAERS) for vaccines, published literature, and recommendations from federal agencies and professional societies.

More specifically, the site was updated to include certain risks of using dermal fillers such as swelling and bruising as well as some less common risks such as inflammation swelling or redness near the dermal filler injection site following viral or bacterial illnesses or infections, vaccinations, or dental procedures. Other less common risks from dermal filler use listed on the website include bumps in or under the skin (nodules or granulomas) that may need to be treated with injections, oral antibiotics, or surgical removal; infection; open or draining wounds; a sore at the injection site; allergic reactions; or necrosis.

Meanwhile, rare risks from dermal filler use that have been reported to the FDA include severe allergic reactions (anaphylactic shock) that require immediate emergency medical assistance; migration (movement of filler material from the site of injection); leakage or rupture of the filler material at the injection site or through the skin (which may result from a tissue reaction or an infection); the formation of permanent hard nodules; and injury to the blood supply after an unintentional injection into a blood vessel, resulting in necrosis, vision abnormalities (including blindness), or stroke.

Microneedeling RF for Acne Scars with Hyperpigmentation –A Case Presentation

Dr. Shireen Poonawala

MBBS, DDV

Dermatologist, Trichologist and Laser Surgeon Skinvibbes Clinic, Pune

Abstract

Acne vulgaris is a common skin condition affecting 80 percent of people aged 11 to 30 years, with many patients experiencing some degree of scarring. Scarring occurs due to a fibrous process in which new collagen is laid down to heal a full-thickness injury, affecting 30% of those with moderate to severe acne vulgaris. Atrophic scars are the most common type of acne scars and may be caused by inflammatory processes that lead to the degradation of subcutaneous fat and collagen fibers under the skin. Microneedling fractional radiofrequency (MnRF) has been found to be efficacious for the treatment of moderate and severe acne scars. Fractional microneedling radiofrequency treatment has also been found to be effective for acne-related post-inflammatory erythema.

Introduction

Acne is a very common condition that affects a large proportion of the population, particularly adolescents and young adults. Acne is

caused by a combination of factors, including increased oil production, clogged pores, and the presence of the bacteria Propionibacterium acnes (P. acnes). Acne can have significant psychological and social implications due to its visible nature and the potential for acne scars to develop. Acne can lead to the development of acne scars, which are caused by the destruction of collagen and elastin in the skin. As for the scars, it's estimated that about 20-30% of people who have had acne will develop scars. However, the prevalence of acne scars can vary depending on the population studied and the severity of the acne. Acne scars with hyperpigmentation are a common complication of acne, it can be caused by a combination of factors. The main cause of acne scars is the inflammation that is associated with acne. The pathogenesis of acne scarring is not fully understood, but it is believed to involve abnormal collagen deposition during the healing process of acne lesions. However, in some

cases, the collagen produced is excessive or abnormal, leading to the formation of scars. Additionally, picking or squeezing pimples can cause damage to the skin, leading to scarring. There are two basic types of scars depending on whether there is a net loss or gain of collagen (atrophic and hypertrophic scars). The histopathology of acne scars with pigmentation can vary depending on the type of scar and the underlying cause of the pigmentation. With atrophic scars, the ice pick type represents 60%–70% of total scars, the boxcar 20%–30%, and rolling scars 15%–25%.1,2,3

1. Icepick scars are characterized by deep, narrow scars that resemble the shape of an icepick. They are caused by the destruction of collagen and elastin in the skin. Histologically, these scars are characterized by a loss of elastic fibers and a decrease in the number of collagen fibers in the dermis.3

2. Boxcar scars are round or oval scars that have sharp edges. They are caused by a loss of collagen and elastin in the skin. Histologically, these scars are characterized by a loss of elastic fibers and a decrease in the number of collagen fibers in the dermis.3

3. Rolling scars are broad, shallow scars that have a wave-like appearance. They are caused by a loss of collagen and elastin in the skin. Histologically, these scars are characterized by a loss of elastic fibers and a decrease in the number of

collagen fibers in the dermis.3

Hypertrophic and keloidal scars are characterized by excessive collagen deposition and reduced collagenase activity, leading to the thickening and raised appearance of the scars. Hypertrophic scars are typically pink or red, raised, and firm. They remain within the boundaries of the original injury or wound site. Histologically, hypertrophic scars show similarities to other types of dermal scars. They are composed of thick bundles of collagen fibers, often arranged in a disorganized manner. These collagen fibers are denser and more hyalinized compared to normal skin. On the other hand, keloid scars extend beyond the boundaries of the original wound or injury. They are characterized by an overgrowth of collagen and can be firm, raised, and rubbery in texture. Keloids often have a shiny and smooth surface. Histologically, keloid scars show an excessive proliferation of collagen fibers that extend into the surrounding healthy tissue.4,5

Hyperpigmentation is caused by an excess of melanin, the pigment that gives color to the skin, in a specific area. This can be caused by a variety of factors, including:6

Inflammation: Inflammation associated with acne can cause hyperpigmentation.

Sun exposure: UV radiation from the sun can cause an increase in melanin production, leading to

hyperpigmentation.

Hormonal changes: Hormonal changes, such as those that occur during pregnancy, can cause an increase in melanin production, leading to hyperpigmentation.

Genetics: Hyperpigmentation can also be inherited, and people with darker skin tones are more susceptible to hyperpigmentation.

Medications: Certain medications, such as birth control pills, can cause hyperpigmentation.

The epidemiology of acne scars varies depending on the population studied. To determine the underlying cause of acne scars with hyperpigmentation is crucial to develop an appropriate treatment plan. Treatment options for acne scars include topical creams, chemical peels, microneedling, lasers, and fillers. The choice of treatment depends on the individual's specific situation and should be determined by a healthcare professional experienced in scar management.

Case Reports Case 1

A 25 year old male patient presented with the chief complaint and history of acne since long time. His history was notable and there was no new active acne present. On the basis of physical and clinical examination the patient was diagnosed as grade 1-4 acne scars with hyperpigmentation. Fractional microneedling RF was used

Microneedeling RF for Acne Scars with Hyperpigmentation – A Case Presentation

to treat the condition. The 3 sessions of microneedling RF were performed at interval of 6 weeks. The procedure done at level 5 with the depth 2.8 mm, 2.1 mm, 1.4 mm, one pass each. There was considerable improvement of the condition and patient was happy. The result was compared 2 months after the 3rd treatment session.

Post treatment

and the scars were reduced and the erythema along with inflammation was removed.

Post pictures clicked and after 3 sessions there was good result.

Pre treatment

Case 2

A 22 year old female patient presented acne grade 3-4 and acne scars grade 3 with erythema. On examination patient was diagnosed as acne scars grade 3 with erythema. Microneedling R F was performed in this case, 3 sessions performed once every 6 weeks. Topical anesthesia was performed using lidocaine and prilocaine cream. The procedure done at level 5 with the depth 2.4 mm, 1.4 mm, two passes and RF time 500. Patient started to show improvement after 1 session

Post treatment

Figure 1: Acne scars with hyperpigmentation

Diagnosis

Histologically, hyperpigmentation is characterized by an increase in the number of melanocytes, the cells that produce melanin, and an increase in the amount of melanin in the skin. It's important to note that these are general descriptions of the histopathology of acne scars with pigmentation and the underlying pathology can vary depending on the cause and severity of the condition. A history and physical examination are important tools for a healthcare professional to use when assessing a patient with acne scars with hyperpigmentation. During the history, it is always important to ask the patient about the onset, duration, and progression of the acne and the scars, as well as any associated symptoms, about any medical conditions, medications, and recent life events that may have contributed to the acne and the scars, sun exposure, skincare routine, and any previous treatments they have received for their acne and acne scars. 1, 3, 7,8

The physical examination will involve a thorough examination of the skin, including the face, neck, chest, and back. The healthcare professional will examine the skin for the presence of pimples, blackheads, and whiteheads, as well as for the presence and type of scars (icepick, boxcar, rolling, or hyperpigmentation). Also examine other areas of the body, such as the nails, skin, and endocrine organs, to look for signs of any underlying medical conditions that may be contributing to the acne. It is also important to consider the patient's family history, as some types of acne and acne scarring can be inherited. The information gathered during the history and physical examination will help the healthcare professional to determine the type and cause of the acne and the scars, which will guide the choice of treatment. Additional diagnostic tests, such as blood tests or a skin biopsy, may also be performed

to confirm the diagnosis or rule out other conditions.

Overall, the history and physical examination are essential for the diagnosis and management of acne scars with hyperpigmentation and should be performed by a qualified healthcare professional such as a dermatologist. 1, 3, 7,8

Treatment

There are several treatment options available for acne scars with hyperpigmentation, including topical creams, such as hydroquinone, kojic acid, and tretinoin, can help to lighten dark spots and improve overall skin tone. Chemical peels use a solution to remove the top layer of damaged skin, revealing new, smoother skin. They can also help to lighten dark spots. Lasers, such as Fraxel, can be used to target specific areas of hyperpigmentation and improve the overall appearance of scars. Platelet-rich plasma (PRP) has been used to improve the appearance of acne scars, it may be used alone or in combination with other treatments. Dermabrasion is a procedure that involves removing the top layer of skin with a rotating brush, it can be helpful to improve the appearance of acne scars. Surgical procedures such as punch excision, subcision or punch grafting may be helpful for some types of acne scars. Injectable dermal fillers can be used to improve the appearance of depressed acne scars. Microneedling involves creating tiny punctures in the skin using

Figure 2: Acne scars with erythema

RF for Acne Scars with Hyperpigmentation

a device that contains fine needles. This can stimulate collagen production and improve the appearance of scars. 7, 9

Microneedling for acne scars

Microneedling fractional radiofrequency (MnRF) is a treatment modality that combines the principles of microneedling and radiofrequency energy to address grade 1-4 acne scars with hyperpigmentation. Let's discuss how MnRF works and its mode of action (MOA): 10,11,12,13

Microneedling : Microneedling involves creating microchannels in the skin using fine needles. These microchannels trigger the body's natural wound healing response, stimulating collagen production and remodeling of the scar tissue. The controlled micro-injuries induce the formation of new collagen and elastin fibers, leading to improved skin texture and reduced scar appearance.

Radiofrequency Energy: In MnRF, radiofrequency energy is delivered through the microneedles into the deeper layers of the skin. Radiofrequency energy generates heat, which further stimulates collagen production and tightening of the skin. It promotes neocollagenesis (production of new collagen) and elastogenesis (production of elastin fibers), resulting in skin rejuvenation and improvement of the acne scars. The combination of

microneedling and radiofrequency energy in MnRF offers several advantages for the treatment of grade 1-4 acne scars with hyperpigmentation: 10,11,12,13

Scar Remodeling: The micro-injuries caused by microneedling trigger the release of growth factors and cytokines, stimulating the production of new collagen and remodeling of the scar tissue. This helps to fill in the depressions, improve the texture, and reduce the depth of the acne scars.

Collagen Induction : Radiofrequency energy enhances the effects of microneedling by delivering controlled heat energy to the deeper layers of the skin. This stimulates the fibroblasts, the cells responsible for collagen synthesis, leading to increased collagen production and overall skin tightening.

Hyperpigmentation............

Treatment: MnRF also addresses hyperpigmentation associated with grade 1-4 acne scars. The microchannels created by the microneedles allow for better penetration of depigmenting agents, such as vitamin c, glutathione, PRP etc into the skin. This helps to lighten the hyperpigmentation and even out the skin tone.

Minimal Downtime: MnRF has the advantage of minimal downtime compared to more invasive procedures like ablative laser resurfacing. The micro-injuries created by the microneedles are less traumatic to the skin, resulting in a faster recovery period.

MnRF treatments for grade 1-4 acne scars with hyperpigmentation should be performed by trained professionals, such as dermatologists or aesthetic specialists. They will determine the appropriate treatment parameters, including the needle depth, energy levels, and the number of sessions, based on individual patient needs and the severity of the scars. Overall, MnRF offers a comprehensive approach to treating grade 1-4 acne scars with hyperpigmentation by combining microneedling and radiofrequency energy. It stimulates collagen production, remodels scar tissue, tightens the skin, and addresses hyperpigmentation, leading to improved skin texture and a more even complexion. Microneedling fractional radiofrequency (MnRF) has been found to be a safe and effective treatment option for grade 1-4 acne scars with hyperpigmentation. Here is some information on its safety and efficacy: 10,11,12,13

1. Controlled Treatment: MnRF allows for precise control over the depth of penetration and energy delivery, minimizing the risk of adverse effects.

2. Minimal Epidermal Damage: The fractional nature of the treatment means that only a fraction of the skin is treated at a time, leaving healthy tissue surrounding the micro-injured areas. This helps to reduce the risk of complications and aids in faster healing.

3. Reduced Risk of Hyperpigmentation: MnRF has been shown to have a lower risk of postinflammatory hyperpigmentation compared to some other laser treatments. This is particularly important when treating hyperpigmented acne scars, as the procedure aims to improve the overall skin tone and texture.

4. Scar Remodeling: MnRF stimulates collagen production and remodeling of the scar tissue, leading to improvements in the appearance of grade 1-4 acne scars. Over a series of treatments, the scars become less prominent, and the skin texture becomes smoother.

5. Hyperpigmentation Reduction: The combination of microneedling and radiofrequency energy helps to address hyperpigmentation associated with acne scars. The controlled micro-injuries created by the microneedles facilitate the penetration of depigmenting agents, leading to a more even skin tone.

6. Skin Tightening: Radiofrequency energy promotes the production of new collagen and elastin fibers, resulting in improved skin elasticity and tightening. This can help to reduce the appearance of sagging or lax skin commonly associated with severe acne scarring.

Clinical studies have shown promising results with MnRF for treating grade 1-4 acne scars with hyperpigmentation. However, it is also important to manage expectations, as complete scar removal

may not always be possible. Multiple treatment sessions are typically required, spaced several weeks apart, to achieve optimal results. Overall, MnRF offers a safe and effective treatment option for grade 1-4 acne scars with hyperpigmentation. 10,11,12,13

Microneedling with radiofrequency (RF) treatment can be considered as a potential option for improving acne scars of grade 3 with associated erythema. The combination of microneedling and RF energy helps stimulate collagen production and remodel the skin, leading to a reduction in scar appearance and improvement in skin texture. The microneedles create controlled microinjuries in the skin, promoting the production of new collagen and elastin fibers. This process helps to remodel the scarred tissue and improve the overall texture of the skin. The addition of radiofrequency energy further enhances the collagen-stimulating effects, as it delivers heat energy to the deeper layers of the skin, promoting additional tissue remodeling and tightening. In the case of grade 3 acne scars with erythema, microneedling with RF can help address both aspects of the condition. The microneedles can help improve the appearance of the scars by inducing collagen production and remodeling, while the RF energy can target the underlying blood vessels that contribute to the erythema, helping to reduce redness and inflammation.10,11,12,13

Additionally, it's worth mentioning that posttreatment care, including sun protection and proper skincare, is crucial for optimizing the outcomes and minimizing potential side effects. Overall, microneedling with RF treatment can be considered as a viable option for improving grade 3 acne scars with associated erythema or hyperpigmentation.

Discussion

10,11,12,13

Acne scars are the result of inflammation and damage to the skin caused by acne lesions. They can vary in appearance and severity, and may be classified into different types, including atrophic scars (depressed or pitted scars) and hypertrophic or keloid scars (raised scars). Studies have found that the prevalence of acne scars is higher in individuals with severe acne compared to those with mild or moderate acne. Additionally, certain ethnic groups may be more susceptible to developing acne scars. Studies have found that individuals with darker skin tones are more likely to develop hyperpigmentation, a form of acne scarring. Overall, acne and acne scars are common conditions that can have a significant impact on a person's quality of life.

11,12,13

Microneedling fractional radiofrequency (MnRF) has emerged as a promising treatment modality for grade 1-4 acne scars with hyperpigmentation. MnRF combines the benefits of microneedling and

Microneedeling RF for Acne Scars with Hyperpigmentation – A Case Presentation

radiofrequency energy to target both the textural irregularities of the scars and the associated hyperpigmentation. One of the advantages of MnRF for grade 1-4 acne scars with hyperpigmentation is its ability to address both the scar texture and the associated skin discoloration simultaneously. Studies evaluating the efficacy of MnRF for grade 1-4 acne scars with hyperpigmentation have shown promising results. They have reported significant improvements in scar texture, reduction in scar depth, and lightening of hyperpigmentation. Additionally, MnRF has demonstrated a good safety profile with minimal downtime and minimal risk of postinflammatory hyperpigmentation, which is particularly important for patients with darker skin types. 11,12,13

MFR (Microneedling Fractional Radiofrequency) treatment can be considered an effective modality for the treatment of moderate to severe acne scars. It offers several advantages, including minimal downtime and effective improvement of the scars. The studies mentioned in the discussion showed positive results in terms of scar improvement and patient satisfaction. MFR combines the benefits of microneedling and radiofrequency energy, which work synergistically to stimulate collagen production and remodeling in the dermis. The microneedles create controlled micro-injuries in the

skin, promoting the release of growth factors and triggering the body's natural healing response. The addition of radiofrequency energy further enhances collagen stimulation and tissue remodeling. 11,12,13

Microneedling fractional radiofrequency (MnRF) is a new technology that uses extra sharp microneedles to heat the depths of the dermis, promoting dermal collagen remodeling. MnRF has been shown to be effective in reducing the appearance of acne scars, including atrophic (depressed) scars, which are the most common type of acne scars. MnRF can also help with hyperpigmentation, which is a common concern for people with acne scars. A study has evaluated the efficacy and safety of microneedling fractional radiofrequency in the treatment of acne scars and found it to be effective and safe. However, it is important to note that the effectiveness and safety of MnRF for acne scars can vary depending on the severity of the scars, the patient's skin type, and other factors. 11,12,13

However, it is worth noting that the optimal treatment parameters, such as the number of sessions, depth of penetration, and energy levels, may vary depending on individual patient characteristics and the severity of the scars. Combination therapies with other modalities, such as chemical peels or topical treatments, may also be employed to further enhance the outcomes.11,12,13

Conclusion

In conclusion, MnRF holds promise as an effective treatment option for grade 1-4 acne scars with hyperpigmentation. It addresses both the textural irregularities and the accompanying skin discoloration, offering a comprehensive approach to scar improvement. Nonetheless, further research and larger-scale studies are warranted to establish standardized treatment protocols and evaluate long-term outcomes. The advantage of MnRF treatment is that it can effectively improve acne scars while minimizing downtime compared to more invasive procedures. This means that patients can resume their normal activities relatively quickly after the treatment. The minimal downtime is particularly beneficial for individuals who prefer a nonsurgical approach or have busy lifestyles. Overall, MnRF treatment offers a promising option for improving moderate to severe acne scars with the added benefits of minimal down time and effective results.

References

1. Connolly, Deirdre et al. “Acne Scarring-Pathogenesis, Evaluation, and Treatment Options.” The Journal of clinical and aesthetic dermatology vol. 10,9 (2017): 1223.

2. Werschler, W Philip et al. “Critical Considerations on Optimizing Topical Corticosteroid Therapy.” The Journal of clinical and aesthetic dermatology vol. 8,8 Suppl (2015): S2-8.

3. Fabbrocini, Gabriella et al. “Acne scars: pathogenesis, classification and treatment.” Dermatology research and practice vol. 2010 (2010): 893080. doi:10.1155/2010/893080

4. Ogawa, Rei. “Keloid and Hypertrophic Scars Are the Result of Chronic Inflammation in the Reticular Dermis.” International journal of molecular sciences vol. 18,3 606. 10 Mar. 2017, doi:10.3390/ijms18030606

5. Carswell L, Borger J. Hypertrophic Scarring Keloids. [Updated 2023 Mar 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih. gov/books/NBK537058/

6. Desai, Seemal R. “Hyperpigmentation therapy: a review.” The Journal of clinical and aesthetic dermatology vol. 7,8 (2014): 13-7.

7. Kravvas G, Al-Niaimi F. A systematic review of treatments for acne scarring. Part 1: Nonenergybased techniques. Scars, Burns & Healing. 2017;3. doi:10.1177/2059513117695312

8. Saedi N and Uebelhoer N. Management of acne scars.Jan 07, 2022.

9. Ramesh M et al. “Novel Technology in the Treatment of Acne Scars: The Matrix-tunable Radiofrequency Technology.” J Cutan Aesthet Surg. 2010 May;3(2):97-101.

10. Chandrashekar, Byalekere Shivanna et al. “Evaluation of microneedling fractional radiofrequency device for treatment of acne scars.” Journal of cutaneous and aesthetic surgery vol. 7,2 (2014): 93-7. doi:10.4103/09742077.138328

11. Huang L, Liu Y, Fang W, Liu L, Sun Q, Lin X, Xu H, Yang Y. Efficiency and safety of microneedling fractional radiofrequency in the

Microneedeling RF for Acne Scars with Hyperpigmentation – A Case Presentation

treatment of Chinese atrophic acne scars: A retrospective study of 3 consecutive treatments with 1-month intervals. J Cosmet Dermatol. 2023 Feb;22(2):497-504. doi: 10.1111/jocd.15454. Epub 2022 Dec 2. PMID: 36217740.

12. Elawar, Anwar, and Serge Dahan. “Non-insulated Fractional Microneedle Radiofrequency Treatment with Smooth Motor Insertion for Reduction of Depressed Acne Scars, Pore Size, and Skin Texture Improvement: A Preliminary Study.” The Journal of clinical and aesthetic dermatology vol. 11,8 (2018): 41-44.

13. Chandrashekar BS, Sriram R, Mysore R, Bhaskar S, Shetty A. Evaluation of microneedling fractional radiofrequency device for treatment of acne scars. J Cutan Aesthet Surg. 2014 Apr;7(2):93-7. doi: 10.4103/09742077.138328. PMID: 25136209; PMCID: PMC4134659.

Venous Ulcer in Rheumatoid Arthritis (RA) Patient: A Case Presentation

Dr. Madhavi Pudi

MBBS (Gold Medallist), DNB, DVD

Dr Madhavi’s Advanced Skin Hair and Laser Clinic, Hyderabad

Dr. Sudhir Pudi

MBBS, DNB, McPhleb

Interventional Radiologist

Dr Sudhir's Scan Center and Varicose Vein Clinic, Hyderabad delayed healing. The presence of underlying RA can complicate the management of leg ulcers, as the chronic inflammation and immune system dysfunction associated with the disease can impede the healing process. Treatment requires a comprehensive approach, addressing the underlying causes, managing inflammation, promoting wound healing, and preventing infection with a multidisciplinary team, including rheumatologists, dermatologists, wound care specialists, and vascular surgeons, may also be involved in the management of complex cases.

Abstract

Rheumatoid arthritis (RA) patients can develop leg ulcers which causes due to venous disease, infection and inflammation such as vasculitis or pyoderma gangrenosum. Vasculitis is an inflammation of blood vessels that affect the blood supply to the legs and lead to ulceration. Pyoderma gangrenosum is a rare inflammatory condition characterized by painful ulcers that typically occur on the legs. Since RA patients, especially those receiving immunosuppressive medications have a weakened immune system, making them more susceptible to infections thus any infection occurring in the leg area, can impair wound healing and lead to the formation of ulcers. The leg ulcer in such patients can involve multiple factors simultaneously, example a venous stasis ulcer may become infected, leading to increased inflammation and

Introduction

Rheumatoid arthritis (RA) is an autoimmune condition which usually attacks joints and causes inflammation in affected parts of body. RA patients can develop leg ulcers which are challenging to heal and may persist for extended periods. There are multiple underlying etiologies,

including venous disease, infection, and inflammation such as vasculitis or pyoderma gangrenosum. Venous disease refers to impaired blood flow in the veins, leading to conditions like venous insufficiency or venous stasis ulcers whereas the chronic inflammation and damage to blood vessels can contribute to venous disease and increase the risk of leg ulcers. Management and appropriate treatment can be provided by addressing the specific etiological factors as example venous disease typically requires compression therapy. Compression helps improve venous blood flow and reduce swelling, promoting healing in venous stasis ulcers. This therapy is often a key component of managing venous disease-related leg ulcers. In cases where deep compartment infection is present, systemic antimicrobial therapy is essential, it may require systemic antibiotics to effectively treat the underlying infection and promote wound healing. For slow healing wounds a beneficial treatment is the new oxidized regenerated cellulose and collagen dressing which provides a moist environment that promotes wound healing and can help to manage superficial inflammation. Hence it is important to clinically distinguish superficial inflammation from critical colonization or frank infection to assess proper and appropriate treatment. For leg ulcers associated with inflammatory processes extending beyond the superficial wound base, disease-specific systemic anti-inflammatory agents are necessary. 1

Ulceration in rheumatoid arthritis (RA) is indeed associated with long-standing erosive and seropositive disease. Patients with more severe and

longstanding RA, characterized by erosive joint damage and positive serological markers such as rheumatoid factor or anti-cyclic citrullinated peptide (anti-CCP) antibodies, have a higher risk of developing ulcers. The introduction of biologic agents and the trend towards more aggressive use of diseasemodifying antirheumatic drugs (DMARDs) in the 1990s has shown a significant decline in other extra-articular vasculitic manifestations of RA. These therapeutic advancements have had a positive impact on reducing systemic inflammation and improving the management of RA, including its vasculitic manifestations. Biologic agents, such as tumor necrosis factor (TNF) inhibitors and other targeted immunomodulators, have revolutionized the treatment of RA. These medications specifically target key inflammatory molecules involved in RA pathogenesis, leading to better disease control and a reduced risk of systemic complications. The aggressive use of DMARDs with combination therapy has effectively suppressed inflammation, slow progression of disease reduce the occurrence of extra-articular manifestations, including vasculitis and ulceration thus improving the outcome.1,2

Lower extremity ulcers are indeed a recognized complication of rheumatoid arthritis (RA). The development of these ulcers is influenced by various factors, and their pathogenesis is multifactorial. Some factors like vasculitis (inflammation of blood vessels) affects the blood supply to the lower extremities, causing tissue damage and ulceration, Felty's syndrome (enlarged spleen and decreased white blood cell count) a rare complication of RA, trauma related to deformity,

such as joint deformities or pressure points, can lead to chronic skin breakdown and ulcer formation. RA-related joint damage and deformities can create areas of increased pressure or friction, making the skin more susceptible to ulceration, neuropathy, (nerve damage) leads to lower extremity ulcers were even nerve damage can impair sensation, leading to a reduced ability to perceive pain or pressure, which increases the risk of skin damage and ulceration, venous insufficiency, leads to the development of venous stasis ulcers, particularly in the lower extremities, arterial disease, such as atherosclerosis or peripheral artery disease, lead to decreased blood flow to leg and feet, can impair wound healing and increase the risk of lower extremity ulceration. Historical cohorts have reported a point prevalence of leg ulceration in RA of approximately 8-9%. However, a more recent postal survey conducted in West Yorkshire, England, involving 1,130 RA patients, revealed a lower point prevalence of foot ulceration in RA of 3.39%. It's important to note that this lower prevalence may be due to the survey's specific focus on foot ulcers and the exclusion of other lower limb ulcers from the analysis.2

The clinical presentation of venous ulcers in rheumatoid arthritis (RA) is similar to individuals without RA hence distinguishing is important. The general clinical representation can be given is that they found on the inner side of the leg typically occur on the lower legs, usually around the ankle area having a shallow, irregularly shaped wound with sloping edges with base in typical red or pink which may be covered with yellow or fibrinous slough. The size varies from small superficial

Venous Ulcer in Rheumatoid Arthritis (RA) Patient: A Case Presentation

ulcers to deep wounds. Clinical skin changes like discoloration (brownish or reddish), thickening (lipodermatosclerosis), and dermatitis are often a result of long-standing venous insufficiency. Patients having venous ulcers have associated edema and pain which can worsen after prolonged periods of standing or seating. Sometimes these patients may have signs of venous hypertension as dilated veins (varicosities) or chronic venous eczema. It's important to differentiate venous ulcers from other types of leg ulcers, such as arterial ulcers, neuropathic ulcers, or ulcers related to other underlying conditions. Ulceration in RA is a complex condition influenced by various factors, and its management requires a multidisciplinary approach, including rheumatologists, dermatologists, wound care specialists, and other healthcare professionals. The overall use of biologic agents and aggressive DMARD therapy has been associated with a decline in extra-articular vasculitic manifestations of RA. These therapeutic advancements have improved disease control and reduced the incidence of systemic complications.2,3,4,5

Case Report

A 38 year old female patient referred by a rheumatologist presented to our OPD having rheumatoid arthritis with nonhealing leg ulcers on both sides since 1 year. She is diabetic patient since 7 years, hypertensive since 6 years, hypothyroid since 5 years . But luckily all her ailments were under control. History of usage of multiple antibiotics - oral as well as topical with no improvement from various doctors. History of use of compression bandages on and off with partial relief as

advised by us 6 months back. The ulcer was healed with compression but recurred following cessation of compression having severe pain and discharge from ulceration. Ulcers were larger than previous and more in number. She had applied some ayurvedic powder on them. Ulcers were located over malleoli and dorsum of foot. The general and local examination showed:

• Moderately obese - BMI 30, well built and well nourished

• Has signs of chronic steroid use - central obesity, striae

• Local exam - ulcers 2 in number, each about 3cm in size. Rounded in shape. Yellow slough present.

• Few reticular veins in the legs

• Pigmentation in lower legs

Investigations report of CBP (complete blood count)-normal, ESR (Erythrocyte sedimentation rate) – 60, TSH (Thyroid stimulating hormone) – 2, HBA1c (Hemoglobin A1C)– 6, LFT (Liver Function Tests) – normal, serum creatinine – normal, RA (Rheumatoid arthritis) – normal, PUS for C/S (Pus Swab culture and sensitivity) - proteus species sensitive to linezolid, Colour doppler studies of both lower limbs - venous and arterial. Before

After 1 week of treatment

After 2 months of treatment

Figure 1: Non-healing leg ulcers

Management

The primary focus of treatment for leg ulcers in patients with rheumatoid arthritis aims to address the underlying causes were the specific treatment approach which may vary depending on the individual patient and the characteristics of the ulcer. Regular cleansing, dressing changes to provide clean and moist wound environment, debridement of nonviable tissue, use of specialized dressings to promote healing to facilitate wound healing, such as hydrocolloid or foam dressings. Offloading or pressure redistribution techniques helps to promote wound care. Compression therapy like compression bandages or stockings are used to manage venous ulcers to help improve venous circulation and reduces edema, promoting healing. Anti microbial techniques to be given in deep compartment infection by using antimicrobial dressings or topical agents, disease-modifying antirheumatic drugs (DMARDs), NSAIDS can be used for symptomatic relief and decrease inflammation. In some cases, surgical interventions like skin grafting or flap reconstruction may be considered for chronic or non-healing ulcers that have failed conservative management. Addressing comorbidities, such as diabetes or peripheral arterial disease, is essential in optimizing wound healing. Topical tacrolimus ointment has been shown to help in the complete healing of chronic leg ulcers in RA patients. A retrospective case review was performed to describe the epidemiology, clinical features, and outcome of chronic leg ulcers in adult patients with rheumatological diseases. Pinch grafting seems to be a good alternative to conservative treatment

for minor leg ulcers for these patients, regarding both wound healing and pain relief.2,5,6,7,8

In our case, we felt that because there were some reticular veins clinically and there was healing with compression, there was a possibility of venous etiology. Thorough counselling was done. Laser ablation of great saphenous veins was done with help of a radiologist. Foam sclerotherapy was done using sodium tetradecyl sulphate for reticular veins and further was given crepe bandage compression along with antibiotics and debridement. The use of laser ablation to treat leg ulcers in RA is limited as its efficacy and safety in this specific context have not been extensively studied. Since it has shown promising effects in certain wound healing applications as chronic diabetic ulcers or venous ulcers, its use in RA-associated leg limited.3, 6

Laser ablation of the great saphenous veins primarily aimed at venous insufficiency (a factor responsible for the development and persistence of leg ulcers) is specifically used to treat leg ulcers in RA patients. As venous ulcers, impaired venous circulation and venous insufficiency can hinder proper wound healing this method is a minimally invasive procedure that involves using laser energy to seal and close off the affected vein. This treatment improves venous circulation, reduce venous reflux, to enhance blood flow, alleviate venous congestion and promote better wound healing. A consultation to be done before approaching this treatment as limited studies are present on this method.3,9,10,11

Endovenous laser ablation (EVLA) uses hemoglobinspecific laser wavelengths (810,

Figure 2: Arterial doppler report

Figure 3: Venous doppler report

940, and 980 nm) and waterspecific laser wavelengths (1319, 1320, and 1470 nm) to destroy incompetent veins. The 1320-nm neodymium-doped yttrium aluminum garnet laser and 1470-nm diode laser have been found to be effective with minimum side effects. EVLA has the advantage of nil or minimum hospital stay, less pain and discomfort, early return to work, minimum surgical hazards thus lesser chance of adverse effects like bleeding or abrasion. Short-term efficacy of EVLA in saphenous incompetence was assessed in many randomized controlled trials (RCTs), which achieved occlusion of the SSV after 3 months in 98-95.9% at 1 year. 12,13,14,15,16,17,18

Another method that aims to improve venous circulation, alleviate venous congestion and promote wound healing is foam sclerotherapy using sodium tetradecyl sulfate (STS) primarily used for venous insufficiency in patients with leg ulcers, with rheumatoid arthritis (RA). It involves injecting a foam solution, typically made by mixing STS with air or a gas, directly into the affected veins was the foam displaces blood in the vein, allowing the sclerosant (STS) to come into direct contact with the vein wall. The sclerosant causes inflammation and scarring of the vein, leading to its closure. The use and approach to this treatment should be made after thorough research as it has limited scientific evidence and clinical data supporting its effectiveness in this specific context. 7,9,19,20,21,22

Some important points regarding foam sclerotherapy and its potential complications are that during the process the limb is typically elevated at a 30° angle and then foam solution is injected into the target vein. Intra-

operative ultrasonography can be used to guide the injection and monitor the movement of the foam. It carries certain risks and complications which are usually dose-dependent and can include pigmentation (discoloration of the skin), pain, allergy, and urticaria (hives). However, serious complications like thrombophlebitis (inflammation of the vein with the formation of a blood clot), pulmonary emboli (blood clots that travel to the lungs), stroke, skin necrosis (tissue death in the treated area), nerve damage (to the saphenous or sural nerves), deep vein thrombosis, anaphylactic reaction, visual disturbances, migraine-like headache, confusion (rare symptoms), death; extremely rare but reported in isolated cases. These serious complications are rare, and the overall risk of complications can be minimized by ensuring that the procedure is performed by a skilled and experienced healthcare professional. Additional pre treatment including compression bandages and the use of thromboembolusdeterrent stockings, may be recommended for a specific duration to optimize the outcomes and minimize complications.18

However, crepe bandage compression, antibiotics, and debridement are commonly used in the management of leg ulcers. Crepe bandage compression known as compression therapy is a key component that helps improve venous circulation, reduce swelling, and promote wound healing. Crepe bandages are applied in a spiral pattern, providing graduated compression from the ankle to the calf. Antibiotics may be prescribed to avoid infections. The choice of antibiotic and

duration of treatment will depend on the severity of the infection and the specific pathogens involved. Hence it is essential to follow the prescribed antibiotic regimen and complete the full course of treatment. Debridement involves the removal of dead or non-viable tissue from the ulcer bed to promote wound healing by creating a clean wound bed and removing barriers to tissue regeneration. It can be performed using techniques like, surgical debridement, mechanical debridement, enzymatic debridement, or autolytic debridement were the choice of method depends on the characteristics of the ulcer.1,2,4,6,7,23

Discussion

The study findings indicate that leg ulcers remain an important clinical problem in patients with rheumatoid arthritis (RA), despite the advent of more effective therapies for RA. The period prevalence of leg ulcers in the cohort was 4.37%, and after a mean follow-up of 22.76 months, only 31.25% of the ulcers had healed. Thus although the prevalence of ulcers has improved with better RA therapies, there is still a significant proportion of patients who experience non-healing ulcers. The study also highlights that the presence of vasculitis, as evidenced by pathological features on tissue biopsy, is not always evident in RA ulcers, even in a center experienced in managing autoimmune ulcers. However, all the patients in the cohort had radiographic evidence of erosive disease and a majority (63%) were seropositive, indicating that extra-articular rheumatoid disease contributes to the development of these ulcers. A multidisciplinary approach is required in RA associated leg ulcer for the

Venous Ulcer in Rheumatoid Arthritis (RA) Patient: A Case Presentation

management and treatment approach. In this study, a comprehensive evaluation for venous and arterial disease was performed, and aggressive management of diabetes was undertaken. While some patients had concomitant venous or arterial disease, interventions targeting these vascular conditions alone did not lead to ulcer healing. Additionally, the presence of diabetes alone was not considered the sole cause of the ulcers, as the patients had well-controlled hemoglobin A1c levels. It is seen that lower extremity ulcers can also be seen in other autoimmune diseases, and antiphospholipid antibodies and prothrombotic states have been associated with such ulcers. However, in this particular cohort of RA-associated ulcers, the presence of significantly elevated antiphospholipid antibody titers was not observed, and the frequency of genetic prothrombotic states was similar to that reported in the general population. Concerns about infection risk often make clinicians cautious about aggressive immunosuppression in patients with active leg ulcers. In the study, less than half of the patients were in clinical remission from RA at the time of leg ulcer presentation. However, no ulcerations resulting from infection related to anti-TNFa or other DMARD therapy were observed among the 366 patients followed with RA. One patient developed a wound infection while receiving anti-TNFa therapy, leading to discontinuation of the therapy. This relatively low incidence of infection may be attributed to the multidisciplinary approach to wound care in the center conducting the study, and it may not necessarily reflect the experiences of communitybased practices.2

To manage chronic leg ulcers in patients with RA is a challenging task; hence underlying etiology should be targeted. Systematic reviews have shown that there is no significant difference in the healing of venous ulcers when comparing different types of dressings. However, compression therapy has been found to be effective in increasing the healing rates of venous ulcers. In cases of recalcitrant lower limb ulcers, other treatment options can be considered. Hyperbaric oxygen therapy has shown short-term benefits in healing diabetic foot ulcers, but its effects on chronic wounds with other underlying causes remain uncertain. Skin grafting is another option, which can involve autografts, allografts, or xenografts, and various surgical techniques have been attempted, such as pinch grafts, punch grafts, full-thickness skin grafts, and split-thickness skin grafts. In a research study, two patients with refractory ulcers underwent autologous cellular skin grafting, resulting in reepithelialization of the ulcers. However, in one patient, new ulcers appeared after a month, and in the other patient, there was a relapse of the ulcer 1 week after reepithelialization. Hence ongoing monitoring of these patients is crucial as they can experience recurrent leg ulcerations as a significant percentage of patients developed concomitant or recurrent leg ulceration. Key strategies for management include sustained immunosuppression, broad-spectrum antibiotics, compression therapy, and aggressive wound bed preparation. Individualized approaches, multidisciplinary collaboration, and continuous monitoring are necessary to optimize the management and improve outcomes for these

patients.5

Conclusion

Rheumatoid arthritis (RA) being an autoimmune can develop leg ulcers which are challenging to heal and can persist for extended periods. Leg ulcers can present as a clinical dilemma. Investigations may show no conclusive evidence to etiology. In such cases a therapeutic trial of compression after ruling out arterial compromise can help to lead clinical decision making regarding definitive treatment for venous etiology. Arterial, venous, vasculitic ulcers may be mixed up. Opinion of multiple specialists may be required. Thorough counselling regarding success and failure of procedure must be done.

References

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Venous Ulcer in Rheumatoid Arthritis (RA) Patient: A Case Presentation

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6. R. F. Öien and others, Leg ulcers in patients with rheumatoid arthritis—a prospective study of aetiology, wound healing and pain reduction after pinch grafting, Rheumatology, Volume 40, Issue 7, July 2001, Pages 816–820, https://doi.org/10.1093/ rheumatology/40.7.816

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Venous Ulcer in Rheumatoid Arthritis (RA) Patient: A Case Presentation

Critopic