The use of this technique provides a valuable aid in diagnosing pigmented skin lesions; hair disorders, inflammatory and others skin diseases. Dermatoscopic evaluation shows specific or non specific pattern of diseases which can be co-related with clinical history and examination to reach final diagnosis.

Need for dermatoscope is not a novel approach in dermatology. Hand lens has been used by dermatologist from hundreds of years for the same purpose. Dermatosope has advantage for having image proof with better resolution thus becomes the essential instrument in dermatology clinic. Commercially different types of dermatoscope are available and one has to be wise in purchasing the device.

Types of device: – (a) The dermatoscope: – It is the simplest and best-recognized piece of equipment used to perform a dermoscopy examination. It is easy to operate with minimal technical support.  The price varies according to manufacturing companies, types of device, power of lens used and use of assisting device. A dermatoscope can be connected with anything among TV monitor, computer, camera, mobile or USB device.  Power of lens varies among dermatoscope, 50-200x magnification is sufficient enough for routine clinical practice.

Components: – Achromatic lens, Inbuilt illuminating system, Power supply, image analyzer.

 (b) Stereomicroscope: – It allows an accurate binocular observation with different magnifications (X6-80). The illumination system includes a halogen lamp (12 V/50 W). The stereomicroscope is expensive, large and bulky. It is not indicted for routine clinical practice and only advantage is of better visualisation then dermatoscope.

The videodermatoscope include a polarized or nonpolarized video probe that transmits images of the skin lesion to a color monitor.

Nonpolarized v/s polarized light.

The polarized system allows a better visualization of vessels and red areas. Nonpolarized dermoscopy requires the application of a liquid or a gel in the interface between the instrument and the skin surface. Furthermore, the study of vascular pattern may be compromised by excessive pressure of the instrument resulting in compression of vessels. Thus, vascular patterns cannot properly be examined in their real shape. On the other hand, structures such as pseudocysts, multiple gray-blue dots and blue-white veil are more accurately evaluated by non polarized dermoscopy.

Indications:

1.      Hair and scalp disorder- Dermatoscopy or trichoscopy helps in visualisation of hair shaft, texture, cuticle, hair follicle opening, cutaneous microvessels,  intrafollicular, interfollicular and perifollicular skin changes. Congenital hair shaft abnormalities like as monilethrix, trichorrhexis nodosa, trichorrhexis invaginata, pili torti or pili annulati are more evident on dermoscopy. Acquired hair shaft abnormalities;- micro-exclamation mark hairs, tapered hairs and tulip hairs (in alopecia areata and trichotillomania), regrowing upright or pigtail hairs (in various diseases), comma hair or corckscrew hairs (in tinea capitis). Both scarring and non scarring allopecia can be easly differentiated and at times reduce the need for scalp biopsies.  Trichoscopy also allows use for assessing the number of hairs in one follicular unit. In healthy individuals 2-3 hairs emerge from one follicular unit. The number is decreased in non-cicatricial alopecia and increased above 4 in tufted folliculitis, folliculitis decalvans or lichen planopilaris.

Dermoscopy can also be used for prognosis of scalp disorders following treatment. Hair shaft number per follicle, thickness of hair and interfolliclar distance, all can be measured and compared further with the use of dermatoscope.

2.   Pigmentory disorder:–  Dermoscopy helps in visualisation of by specific or nonspecific pattern of pigmented skin disorder. The identification of specific diagnostic patterns related to the distribution of colors and dermoscopy structures can better suggest a malignant or benign pigmented skin lesion. There are specific and non-specific guide criteria for pigmentory skin disorder. Specific guide criteria are further classified as primary and secondary criteria.

Primary guide criteria: – pigment network, pseudopigmneted network, radial streaming and pseudopodes, pigmented globules.

Fig 3. A. pigment network (melanoma), B. radial streaming (melanoma),

C. Pseudopodes (melanoma) , D. pigmented globules (melanocytic neavus).

(adapted from [4]).

Secondary criteria: – Pigmented dots, blue-white veil, blue grey areas, steel blue areas, depigmnetation.

Secondary criteria: – Pigmented dots, blue-white veil, blue grey areas, steel blue areas, depigmnetation.

Conclusion:- 

Among all the dermatological disorder, majority of them rely on careful observation and examination with naked eye. Dermatoscope enhance the optical resolution with image proof of skin disorder thus helps in diagnosing and  further evolution of skin disorder. Several dermatoscopes are available in market and choice should be made on power of lens, image quality, polarized and/or nonpolarized light, assisting device like mobile, computer, and camera. Many research article been published recently and has become area of interest for dermatologist. More research is required for the best use of dermoscope.

1.     Sar-Pomian M, Kurzeja M, Rudnicka L, Olszewska M, The value of trichoscopy in the differential diagnosis of scalp lesions in pemphigus vulgaris and pemphigus foliaceus. An Bras Dermatol. 2014;89(6):1007-12.

2.      Francesco Lacarrubba, Anna Elisa Verzì and Giuseppe Micali*. Dermatoscopy and Video Dermatoscopy in the Diagnosis and Therapeutic Monitoring of Plaque Psoriasis: A Review.  2014; 1(6).

3.     Lidia Rudnicka, Małgorzata Olszewska, Adriana Rakowska, Monika Slowinska. Trichoscopy update 2011. J Dermatol Case Rep 2011 4, pp 82-88.

4.     Ignazio Stanganelli, Maria Antonietta Pizzichetta, Dermoscopy; www.http://emedicine.medscape.com/article/1130783-overview;

•       LLLT was discovered serendipitously in the 1960s when mice irradiated with a low fluence red laser grew hair.

•       It traditionally uses infrared rays which are non-invasive and cause non-thermal biostimulation of the hair.

•       Light source used here is an LED device or light energy below a specific energy threshold with a specific wavelength

•       Since it does not produce heat (cold laser), the therapy is safe and does not cause a burn.

•       Various lasers that have been tried for hair loss management include- Excimer (308nm) helium, neon (632nm) and fractional erbium glass laser (1550nm)

•       LLLT uses devices with diode that emit red light (630-670nm). It is available in the form of :-

1. Hoods / overhead panels
2. Bonnet or laser head caps
3. Hand held device

HOW DOES LLLT WORK ?

1. LLLT increases the blood flow to the scalp and stimulates the metabolism in telogen and catagen hair.
2. LLLT is proposed to act by stimulation of mitochondria to produce more ATP and cyclic AMP, with activation of response to oxidative stress, displacing nitric oxide from the cells and allowing more oxygen to enter. Released nitric oxide also induces vasodilatation and improves blood flow to the hair roots.
3. Induction of transcription factors such as nuclear factor kappa B and hypoxia-inducible factor-1 occurs which in return causes protein synthesis that triggers further effects down-stream, such as increased cell proliferation and migration, alteration in the levels of cytokines, growth factors and inflammatory mediators, and increased tissue oxygenation. (6-8)
4. Weiss and coworkers, by using RT-PCR and microarray analysis, demonstrated that depending on the treatment parameters, LLLT modulates 5-α reductase expression (which converts testosterone into DHT), alters vascular endothelial growth factor gene expression as wells as matrix metalloproteinase (MMP-2) which have significant roles in hair follicle growth. (9)
5. LED uses broader beam of light to cover wider area of the scalp.
6. LLLT has been demonstrated to modulate inflammatory processes and immunological responses, which may also have an effect in hair regrowth thus it may also be used in hair transplant patients post operatively to promote wound healing and expedite hair growth.

BENEFITS OF LASER THERAPY

• Effective in both men and women
• Can be used in a variety of non-scarring alopecias- AA, AGA, alopecia occurring after chemotherapy.
• Non-surgical and non-invasive method of hair restoration.
• No major adverse effects reported
• Painless, no chances of burns.
• Relatively inexpensive
• Minimal time commitment
• Portable device

REFERENCES:

1. Kalia S, Lui H. Utilizing electromagnetic radiation for hair growth: a critical review of phototrichogenesis. Dermatol Clin. 2013 Jan;31(1):193-200.
2. McElwee KJ and Shapiro J. Promising Therapies for treating and/or preventing androgenic alopecia . Skin Therapy Lett. 2012 Jun; 17(6):1-4.
3. Schweiger ES, Boychenko O, Bernstein RM. Update on the pathogenesis, genetics and medical treatment of patterned hair loss. J Drugs Dermatol. 2010 Nov;9(11):1412-9.
4. Castex-Rizzi N, Lachgar S, Charveron M, Gall Y. Implication of VEGF, steroid hormones and neuropeptides in hair follicle cell responses. Ann Dermatol Venereol. 2002;129(5 Pt 2):783–786.
5. Weiss R, McDaniel DH, Geronemus RG, Weiss M. LED photomodulation induced hair growth stimulation. 2005;36(S17):27.
6. Yano K, Brown LF, Detmar M. Control of hair growth and follicle size by VEGF-mediated angiogenesis. J Clin Invest. 2001;107:409–417.
7. Yamazaki M, Tsuboi R, Lee YR, Ishidoh K, Mitsui S, Ogawa H. Hair cycle-dependent expression of hepatocyte growth factor (HGF) activator, other proteinases, and proteinase inhibitors correlates with the expression of HGF in rat hair follicles. J Investig Dermatol Symp Proc. 1999;4(3):312–315.
8. Low level laser (light) therapy (LLLT) for treatment of hair loss: Laser Surg Med: 2014,Feb; 46(2): 144-151

Anti-androgen medications are used to treat signs of hyperandrogenism, including skin and hair disorders like acne, seborrhoea,  hirsutism,  androgenic alopecia and hidradenitis suppurativa. Anti-androgen therapy may bock androgen receptor, reduce adrenal androgen production, reduce ovarian androgen production, reduce pituitary production of prolactin, inhibit 5-alpha reductase or reduce insulin resistance.

Current Anti-Androgen Therapies

Cyproterone acetate is a synthetically derived steroid that acts as a potent anti-androgen. It also possesses progestational properties and can be used to assist conception in subfertile females.  Flutamide/nilutamide/bicalutamide are all non-steroidal, pure anti-androgens. Bicalutamide is the newest agent and has the fewest side effects. Finasteride/dutasteride are inhibitors of 5-alpha reductase, an enzyme that prevents the conversion of testosterone into the active form ihydrotestosterone (DHT). They are specific anti-androgens in that they only counteract the effects of testosterone and not other androgens. Spironolactone, a synthetic 17-spironolactone corticosteroid, is commonly used as a competitive aldosterone antagonist and acts as a potassium sparing diuretic. It used to treat low-renin hypertension, hypokalemia, and Conn’s syndrome. It has recognized anti-androgen effects. Ketoconazole is a derivative of imidazole that is used as a broad spectrum antifungal agent. Recognized effects are severe liver damage, but there is also an adrenolytic function. Ketoconazole reduces androgen production in the testes and the adrenal glands. It is a relatively weak anti-androgen, but is used with good effect in patients with Cushing’s syndrome.

Herbal Anti-Androgens

There is an ever-increasing demand for complementary therapies, or those that are perceived as being more natural. The presence of anti-androgenic chemicals in plants, herbs, and foodstuffs provides an alternative to modern synthetic pharmaceuticals. It is also commonly believed that there are fewer adverse effects of such alternative therapies. While this group of treatments may be slow to find favor and may not be used first line, it does at least appear to be more acceptable to patients because of its perceived more natural origins (29). Herbal remedies to block testosterone come in a variety of forms, including capsules, powders, teas and tinctures, or alcohol extracts.

Saw Palmetto (Serenoa repens)

Saw palmetto is a small palm tree native to eastern regions of the United States. Its extract is believed to be a highly effective anti-androgen as it contains phytoesterols. This has been the subject of a great deal of research with regards to the treatment of BPH (19, 20), androgenic alopecia (21), and PCOS (22). In the context of BPH, there have been 2 reasonably sized clinical trials that found that saw palmetto extract use showed no difference in comparison to placebo (23, 24). In meta-analyses, it has been shown to be safe and effective in mild to moderate BPH when compared to finasteride, tamsulosin, and placebo (25, 26).

Saw palmetto is likely safe for most people. Side effects are usually mild. Some people have reported dizziness, headache, nausea, vomiting, constipation, and diarrhea. Saw palmetto is likely unsafe when used during pregnancy or breast-feeding. Saw palmetto might decrease the effects of estrogen in the body, hence taking it along with birth control pills might decrease the effectiveness of birth control pills. It may slow blood clotting and increase the chances of bruising and bleeding. It should be stopped at least 2 weeks before a scheduled surgery. Established dosages for BPH is 160 mg twice daily or 320 mg once daily and for androgenic alopecia is 200 mg twice daily combined with beta-sitosterol 50 mg twice daily.

Reishi mushrooms (Ganoderma lucidum)

Red reishi, commonly known as LingZhi in Chinese, is a mushroom thought to have many health benefits. In a research study exploring the anti-androgenic effects of 20 species of mushrooms, reishi mushrooms had the strongest action in inhibiting testosterone (3). That study found that reishi mushrooms significantly reduced levels of 5-alpha reductase, preventing conversion of testosterone into the more potent DHT. Oral reishi extract is possibly safe for up to one year, but possibly unsafe when taken in a powdered form for more than one month as it might be hepatotoxic. Reishi can also cause other side effects including dryness of the mouth, throat, and nasal area along with itchiness, stomach upset, nosebleeds, dermatitis and bloody stools. There is not enough reliable information about the safety of taking reishi

mushroom if you are pregnant or breast feeding. Reishi mushroom might decrease blood pressure. High doses of reishi mushroom might increase the risk of bleeding in some people with certain bleeding disorders. Anticoagulant / antiplatelet drugs and antihypertensives interact with this medication. Stop using reishi at least 2 weeks before a scheduled surgery.

White Peony (Paeonia lactiflora)

Chinese peony is a widely grown ornamental plant with several hundred selected cultivars. Many of the cultivars have double flowers with the stamens modified into additional petals. White peony has been important in traditional Chinese medicine and has been shown to affect human androgen levels in vitro. In a 1991 study in the American Journal of Chinese Medicine Takeuchi et al described the effects of paeoniflorin, a compound found in white peony that inhibited the production of testosterone and promoted the activity of aromatase, which converts testosterone into estrogen (7). To date, there have been no studies that translate or explore the clinical effects. Peony has been used safely for up to 4 weeks. It can cause stomach upset and dermatitis. Peony is possibly unsafe when taken by mouth during pregnancy and lactation. Some developing research suggests that peony can cause uterine contractions. Peony may increase the risk of bleeding in some people with certain bleeding disorders. Anticoagulant / antiplatelet drugs and phenytoin (it may decrease the amount of phenytoin) interact with this medication.  It has to be stopped at least 2 weeks before a scheduled surgery.

Chaste Tree (Vitex agnus-castus)

Chaste tree (or chasteberry) is a native of the Mediterranean region and is traditionally used to correct hormone imbalances. In ancient times, it was believed to be an anaphrodisiac, hence the name chaste tree. Clinical studies have demonstrated effectiveness of medications produced from extract of the plant in the management of premenstrual syndrome (PMS) and cyclical mastalgia (14). The mechanism of action is presumed to be via dopaminergic effects resulting in changes of prolactin secretion from the anterior pituitary. At low doses, it blocks the activation of D2 receptors in the brain by competitive binding, causing a slight increase in prolactin release. In higher concentrations, the binding activity is sufficient to reduce the release of prolactin (15). Reduction in prolactin levels affects FSH and estrogen levels in females and testosterone levels in men. There is as yet no information regarding its efficacy in endocrine disease states such as PCOS, however, one small-scale study has demonstrated this prolactin reducing effect in a group of healthy males, and the implication is that it could be of use in mild hyperprolactinemia (16, 17). One could also theorize that it could be refined for use as a male contraceptive, because testosterone reduction should reduce libido and sperm production. This topic is further explored in a review by Grant & Anawalt (18). Vitex agnus-castus  is likely safe for most people when taken by mouth and applied to skin. Uncommon side effects include upset stomach, nausea, itching, rash, headaches, acne, trouble sleeping, and weight gain. Use during pregnancy or breast-feeding is possibly unsafe. It should be avoided in hormone-sensitive condition such as endometriosis; uterine fibroids; or cancer of the breast, uterus, or ovaries, during IVF procedures. It may decrease effectiveness of contraceptive pills. It has dopamine agonist like actions, hence might affect therapy for Parkinson’s disease, Schizophrenia or other psychotic disorders. Crude herb extracts are typically used in doses of 20-240 mg per day up to 1800 mg per day in 2-3 divided doses.

Green Tea (Camellia sinensis)

In addition to supporting the cardiovascular system and somewhat reducing the risk of cancer and type 2 diabetes (8), green tea may also have an important anti-ndrogen effect because it contains epigallocatechins, which inhibit the 5-alpha-reductase conversion of normal testosterone into DHT. As previously noted, this anti-androgen mechanism may help to reduce the risk of BPH, acne, and baldness. As yet, no randomized controlled trials of green tea for these androgen dependent conditions have been conducted. Green tea is likely safe for most adults when consumed in moderate amounts. Green tea extract is possibly safe for most people when taken by mouth or applied to the skin for a short time. In some people, green tea can cause stomach upset and constipation. Green tea extracts have been reported to cause hepatotoxicity in rare cases. Drinking more than five cups per day is possibly unsafe because of the caffeine. These side effects can range from ild to serious and include headache, nervousness, sleep problems, vomiting, diarrhea, irritability, irregular heartbeat, tremor, heartburn, dizziness, ringing in the ears, convulsions, and confusion. Green tea seems to reduce the absorption of iron from food. The fatal dose of caffeine in green tea is estimated to be 10-14 grams (150-200 mg per kilogram).  During pregnancy and lactation about 2 cups per day is possibly safe. It may make anemia worse, the caffeine in it may affect nxiety disorders, bleeding disorders, heart conditions, diabetes, irritable bowel syndrome, glaucoma, blood pressure. Some reports have linked it to osteoporosis (caffeine increases amount of urinary calcium excretion) and hepatic diseases. It interacts with stimulant drugs, some quinolone antibiotics, birth control pills, antidepressants, nticoagulants, nicotine, theophylline, verapamil etc. Doses of green tea vary significantly, but usually range between 1-10 cups daily (three cups approximately rovides 240-320 mg of the active ingredients, polyphenols). To make tea, people typically use 1 teaspoon of tea leaves in 8 ounces boiling water.

Spearmint (Mentha spicata [Labiatae]) 

Spearmint, usually taken in the form of tea, has been thought for many years to have testosterone reducing properties. It is commonly used in Middle Eastern regions as an herbal remedy for hirsutism in females. Its anti-androgenic properties reduce the level of free testosterone in the blood, while leaving total testosterone and DHEAS unaffected, as demonstrated in a study from Turkey by Akdogan and colleagues, in which 21 females with hirsutism (12 with polycystic vary syndrome and 9 with idiopathic hirsutism) drank a cup of herbal tea steeped with M. spicata twice daily for 5 days during the follicular phases of their menstrual cycles. After treatment with the spearmint tea, the patients had significant decreases in free testosterone with increases in luteinizing hormone, follicle-stimulating hormone, and estradiol (9). There were no significant decreases in total testosterone or DHEAS levels. This study was followed by a randomized clinical trial by Grant (10), which showed that drinking spearmint tea twice daily for 30 days (vs. chamomile tea, which was used as a control) significantly reduced plasma levels of gonadotropins and androgens in patients with hirsutism associated with polycystic ovarian syndrome. There was a significant change in patients’ self-reported dermatology-related quality of life indices, but no objective change on the Ferriman-Gallwey scale. It is possible that sustained daily use of spearmint tea could result in further abatement of hirsutism. Avoid using in large amounts of spearmint during pregnancy and lactation. In theory, using large amounts of spearmint tea might worsen kidney and liver disorders.

Licorice (Glycyrrhiza glabra)

Licorice is a flavorful substance that has been used in food and medicinal remedies for thousands of years. It is also known as “sweet root,” licorice root contains a compound that is about 50 times sweeter than sugar. It has been used in both Eastern and Western medicine to treat a variety of illnesses ranging from the common cold to liver disease. Licorice affects the endocrine system because it contains isoflavones (phytoestrogens), which are chemicals found in plants that may mimic the effects of estrogen and relieve menopausal symptoms and menstrual disorders. Licorice may also reduce testosterone levels, which can contribute to hirsutism in women. A small clinical trial published in 2004 by Armanini and colleagues found that licorice root significantly decreases testosterone levels in healthy female volunteers. Women taking daily licorice root experienced a drop in total testosterone levels after 1 month and testosterone levels returned to normal after discontinuation. It is unclear as to whether licorice root affects free testosterone levels (4). The endocrine effect is thought to be due to phytoestrogens and other chemicals found in licorice root, including the steroid glycyrrhizin and glycyrrhetic acid, which also have a weak anti-androgen effect (5, 6). Consuming licorice daily in large doses for more than 4 weeks may cause side effects. In Pregnancy and breast-feeding it is not safe to take oral licorice. It can raise blood pressure, can decrease potassium levels in the blood, can cause water retention hence should be used with caution in heart disease, hypertension, hypertonia, hypokalemia, kidney disease. It should be avoided in hormone-sensitive conditions such as breast cancer, uterine cancer, ovarian cancer, endometriosis, or uterine fibroids. It may cause loss of libido in men and also worsen erectile dysfunction (ED). It could interact with many drugs like digoxin, OCPs, anticoagulants, ethacrynic acid, medications metabolized by the liver, antihypertensive drugs, corticosteroids, diuretics, etc.

Black Cohosh (Actaea racemosa)

Black cohosh (Actaea racemosa) is a plant of the buttercup family. Extracts from these plants are thought to possess analgesic, sedative, and anti-inflammatory properties. Black cohosh preparations (tinctures or tablets of dried materials) are used to treat symptoms associated with menopause, such as hot flashes, although the efficacy has been questioned (11). The inhibitory effects of black cohosh extracts (Cimicifuga syn. Actaea racemosa L.) on the proliferation of human breast ancer cells has been reported recently (12), and Hostsanka. et al (13) have examined the plant’s effects on prostate cancer, another androgen hormone-dependent, pidemiologically important tumor. In that study, the inhibitory effect of an isopropanolic extract of black cohosh (iCR) on cell growth in androgen-sensitive LNCaP and androgen-insensitive PC-3 and DU 145 prostate cancer cells was investigated. The authors found that regardless of hormone sensitivity, the growth of prostate cancer cells was significantly and dose- dependently down regulated by iCR. At a concentration between 37.1 and 62.7 μg/ml, iCR caused 50% cell growth inhibition in all cell lines after 72h. Increases in the levels of the apoptosis-related M30 antigen of approximately 1.8-, 5.9-, and 5.3-fold over untreated controls were observed in black cohosh- treated PC-3, DU 145, and LNCaP cells, respectively, with the induction of apoptosis being dose- and time-dependent. Black cohosh extract was therefore shown to kill both androgen-responsive and non- responsive human prostate cancer cells by induction of apoptosis and activation of caspases. This finding suggested that the cells’ hormone responsive status was not a major determinant of the response to the iCR, and indicated that the extract may represent a novel therapeutic approach for the treatment of prostate cancer. Black cohosh can cause some mild side effects such as stomach upset, cramping, headache, rash, a feeling of heaviness, vaginal spotting or bleeding, and weight gain. It is possibly unsafe when used during pregnancy or breast-feeding. There is some concern that black cohosh might worsen existing breast cancer. It should be avoided in hormone-sensitive conditions (like endometriosis, fibroids, ovarian cancer, uterine cancer, and others) and liver diseases. It might also increase the risk of blood clots in people with preexisting conditions like Protein S deficiency. It may interact with drugs like atorvastatin , cisplatin , medications metabolized by the liver, blood thinners, OCPs, etc.

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The gold standard for diagnosis in dermatology is histopathologic examination of tissue. Although cutaneous biopsies are associated with a relatively low morbidity, there is always a risk for infection, bleeding, and scarring. Biopsies also destroy the site of interest and the dynamic changes over time cannot be observed. Moreover, it consumes time! The search to overcome the drawbacks of the traditional skin biopsy and to provide high resolution images has led to the development of non-invasive techniques such as dermoscopy and in-vivo confocal microscopy.

Confocal scanning laser microscopy(CSLM), often referred as reflectance confocal microscopy, is a novel non-invasive imaging technique that enables the identification of cells and tissues with nearly histologic resolution. The confocal microscope was originally designed by Marvin Minsky (1955), which has further undergone decades of improvisation in structure. With the presently available ones, it is possible to image the skin in vivo, in real time and display on a monitor the 3D morphology and dynamic events. Skin can also be imaged by a confocal microscope in freshly biopsied (in vitro) specimens without processing and staining that is required for routine histopathology. The maximum depth of visualization by CSLM is 200-350µm below the stratum corneum covering the epidermis, papillary dermis and superficial reticular dermis. It allows a horizontal scanning of the imaged tissue, with the advantage of exploring a larger field of view compared with vertical sectioning.

In conventional microscopy, a tissue section is placed on the microscope stage and the entire field of the specimen is simultaneously illuminated by light and visualized. The illumination of other parts of the sample surrounding the point of interest, results in a “background noise,” which compromises the quality of the image.

However, in CSLM, a beam of light (generated by a laser medium) is focused on a small spot inside the tissue through the microscope objective via a dichroic mirror. The mirror is capable of reflecting the light as well as allowing it to pass through. The same objective gathers the reflected light coming back from the tissue, and is projected on a screen. Confocal microscopy overcomes the problem of “background noise” using a small pinhole aperture in a screen that allows only the light emitting from the desired focal spot to pass through. Any light outside of the focal plane (the scattered light) is blocked by the screen. In optical terms, the pinhole is placed in a conjugate focal plane as the tissue specimen (hence the designation “confocal”). A sensitive light detector, such as a photomultiplier tube, on the other side of the pinhole is used to detect the confocal light. (See figure) This technique allows the specimen to be imaged one “point” at a time. Because the sample is not actually sectioned, it is possible to image a “stack” of virtual, confocal image planes that can later be used to make tomographic images, similar to the reconstructions of magnetic resonance imaging or computed tomography scanners in medicine.

Applications of CSLM in dermatology:

• Microscopic analysis of skin structures (including hairs and nails) and their composition at different anatomic sites.
• Detection of premalignant changes in pigmented skin conditions.
• Identification of fungal hyphae and Sarcoptes scabiei mite.
• Monitoring number and activity of inflammatory cells in diseases like psoriasis, lichen planus etc.
• Visualizing intradermal tattoo pigments for laser treatment.
• Defining margins in Mohs surgery.

Limitations of confocal microscopy include the depth of imaging within thick samples and cost compared with conventional microscopes. Nevertheless, technologies for microscopy are promising and are still being improved.

to repigmentation. Antioxidants such as 0.5% ascorbic acid (vitamin C) and retinoid as well as a-hydroxy acids are used as additives to increase penetration and enhance efficacy. Cook- Bolden and Hamilton [7] conducted a 12-week, open-label study of microencapsulated 4% hydroquinone and 0.15% retinol with antioxidants in the treatment of 21 patients (17 PIH, 4 melasma). Significant decreases in lesion size, pigmentation, and disease severity were noted as early as 4 weeks after initiating treatment and remained significantly decreased throughout the study (all p<0.032). The majority of patients (63%) experienced either marked improvement (75% overall improvement) or complete clearing  (95%  or  greater  overall  improvement),  and      reflectance

*Corresponding author: Dr. Shuba Dharmana, Le’Jeune Medspa, 52, Vittal Mallya Road, 1st floor, Bangalore, 560 001, India, Tel: +91 9845104890; E-mail: [email protected]

Received:  September  05,  2014;  Accepted:  October  20,  2014;    Published:

October 24, 2014

Citation: Dharmana S (2014) Review of Topical Lightening Agents. Pigmentary Disorders 1:145. doi: 10.4172/JPD.1000145

Copyright: © 2014 Dharmana S. The terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Retinoids

Tretinoin (all-trans retinoic acid), a vitamin A analog, used to  treat hyperpigmentation of photo aged skin, post inflammatory hyperpigmentation, and melasma. Tretinoin 0.1% has been used to successfully treat melasma in Black patients; improvements of up to 73% were seen after 40 weeks of treatment [5]. Erythema and peeling in the area of application are adverse effects of tretinoin 0.05 to 0.1%; post inflammatory hyperpigmentation can also occur.

Concentrations range from 0.01% to 0.1%. However, irritant dermatitis can be a frequent adverse effect, and caution should be used when prescribing higher concentrations of tretinoin in darker skin types, since the irritation can lead to further PIH. To determine the safety  and  efficacy  of  0.1%  tretinoin  in  the  treatment of PIH, a randomized, double-blind, vehicle-controlled clinical trial was conducted in 54 Black patients [5]. Patients applied either tretinoin   or vehicle cream to the face, arms, or both areas daily for 40 weeks.  At the study endpoint, the PIH lesions of the tretinoin-treated group were significantly lighter than those of the vehicle-treated group as assessed by clinical (p<0.001) and colorimetric (p=0.05) examinations. However, it is important to note that patients treated with tretinoin experienced minimal lightening of normal skin and 50% of these patients also developed retinoid dermatitis. It is possible to reduce  this irritation by reducing dose and titrating to higher doses gradually or by using cream based formulations [15] or even diluting it with a moisturizer.

Other retinoid compounds are also available including isotretinoin, adapalene, and tazarotene. Isotretinoin is available in both oral and topical formulations and is widely used in the treatment of acne.

Azelaic acid

Topical azelaic acid 15 to 20% can be as efficacious as hydroquinone, but is less of an irritant.

Azelaic acid is a dicarboxylic acid isolated from Pityrosporum ovale, the organism responsible for pityriasis versia color [9].

Studies have shown that 20% azelaic acid cream produces significantly greater decreases in pigmentary intensity than the vehicle [16] and, when combined with 15–20% glycolic acid, is as effective as 4% hydroquinone in the treatment of facial hyperpigmentation including melasma and PIH [17]. Azelaic acid is generally well tolerated with only mild adverse effects reported, such as pruritus, transient erythema, scaling, and irritation, which disappear in a few weeks [18].

Kojic Acid

Kojic acid has recently been used as a 2% cream, alone or in combination with glycolic acid or hydroquinone, due to its inhibitory action on tyrosinase. In a comparative study in Chinese women with epidermal melasma, half of the face was treated with kojic acid 2% gel plus glycolic acid 10% and hydroquinone 2%, and the other half of  the face with just glycolic acid 10% and hydroquinone 2% [19]. Better results were obtained on the half of the face treated with the cream