Each of us on several occasions in day to day practice , face several dilemmas regarding treatment protocols. Herein are a few tips and tricks in cosmetic dermatology in my 25 years of experience:
- Avoid aggressive parameters or invasive treatment protocol in DRY SKIN, THIN SKIN AND DARK SKIN to avoid complications.
- Always commence with 50% power of any machine inthe first session increasing gradually by 10% in each session or until desirable result is obtained. Always reduce the parameters incase of any patient discomfort or any visible complication.
- Macular or lichenoidamyloidosis have been relative contraindications for most invasive and ablative techniques. Avoid any invasive procedure or aggressive parameter of lasers as chances of post inflammatory hyperpigmentation and rebound are very high.
- Filler granulomas resulting as a complication of permanent( PMMA or polyacrylamide gel ) or semi permanent fillers can be dissolved by 3 or 4,5 mm probe of HIFU(High intensity focused ultrasound).
- Always prescribe oral isotretinoin in a cumulative dose, as short course or early tapering induces partial and temporary shrinkage of sebaceous glands with faster return to pretreatment morphology. Permanent apoptosis of sebaceous gland requires a cumulative dose of 120 mg/kg for facial and a 150 mg/ kg for truncal acne.Grade 4nodulocystic acne and acne keloidalis having recurrence necessitates 2 to 3 full course of isotretinoin as per body weight.
- Always refrain prescribing high or therapeutic dose of isotretinoin in the first visit in those with SUBMARINEcomedones , as chances of aggravation of acne is high. Low dose isotretinoin with comedoextraction with the use of CO2 laser or RF cautery will give excellent clearance.
- Recurrence of keloid can be minimized or delayed by combining injection triamcinolone with injectionbleomycin given intralesionally . Same combination preceded by 2or 3 bursts of vascular IPL over keloid gives far superior results.
- Combining laser hair removal with cryotherapy and intralesional steroid alongside methodical use of pressure garment and silicon gel sheet heightens results in keloids over chest in hirsute men.
- Injection triamcinolone intralesional or intramuscular always disrupts menstrual cycle in women. If need be use depo-medrole instead of triamcinolone in women of the reproductive age group .
- For any severe drug reaction addition of cyclosporine 2 to 3 mg/kg alongside corticosteroid for 5 days give quick relief in symptoms.
- Amongst alllight devices complications following the use of IPL are highly perplexing. Recovery is very slow, leaving behind permanent hypo or hyperpigmentation
- 90% usage of Q switched ND Yagin India is merely for laser toning as opposed to FDA approved indications of Nevus of Ota and tattoo removal.
- For comprehensive tattoo removal always combine Q switched Ndyag with fractional CO2 laser . This precludes theghost effect and reduces number of sessions.
- Avoid temptation of increasing parameters of Q switched Ndyag laser in patients with nevus of ota, tattoo removal and freckles in order to prevent the development of hypopigmentation
- Do not attempt removingmulticoloured tattoo with Q switched NdYaglaser .Excision with split grafting is the only solution in Indian scenario.
- Other than hirsutism diode laser can be used in :faun tail naevus, hair growth in buccal mucosa following skin grafting – post oral cancer surgery, acne keloidalisnuche, keratosis pilaris,pilonidal sinus,backer naevus,compound melanocytic naevus and pseudofolloiculitis .
- Post, ablative procedures like fractional Co2,needle RF, and dermaroller,electroporation with Vitamin C and hyaluronic acid provides good brightening effect and reduces chances of complications.
- Quick and heightened effect of topical anesthetic creams (EMLA) can be achieved with electroporation.
- In repetitive nose granuloma intralesional injection triamcinolone 10 mg/ml on day 1, 21 and 45 days gives excellent results. Nose piercing following this protocol reduces recurrence in those with a previous history . Advice the patient to not change nose ring for 1 year to prevent recurrence.
- Treating melasma has been every dermatologists nightmare. Use of oraltranexemic acid 250 mg bd for 4 months, in combination with Qswitched NdYag laser(always stick to lower parameters) and localized burst of vascular filter of IPL gives faster clearance with longer period of remission.
- Tranexemicacid is known to worsen MIGRANE headaches, always probe for the underlying history, and notify patient to follow up in the event of any precipitation.
- Treating trichoepithelioma with RF cautery gives superior results when compared to ultrapulse CO2 laser.
- Milia recurrence may be prevented by systematic usage of sunscreen and overnight application of salicylic gel1 or 2%.
- If patient forehead slop more than 15 degree deviation from normal 90 degree than chance of developing early androgenic alopecia is more as compared to normal.
- Laser hair removal in hirsuites with or without underlying PCOD requires rendering double pass over cheeks & chin, one each in superpulsed and auto mode to prevent paradoxical hypertrichosis owing to varying thickness of hair.
A few observation with no scientific data in my experience include :
–Patients with seborrhea over 35 years of age have higher chances of underlying dyslipidemia. Always investigate before starting isotretinoin
–Scalp seborrhea at an early age, patient has higher probability of premature greying of hair .
Though there is no clinical and scientific data to substantiate these findings, you may find these tips and tricks helpful in your day to day clinical practice.
