India with population of 1.25 billon people are passing through a transitional phase of desemination of knowledge and service in the field of health care facilities. In this article I only try to draw your attention on a very important issue related to our specialty i.e. Topical Cortico-Steroid misuse.

Abuse of topical steroids has increased alarmingly and an increasing number of cases of Topical Steroid Damaged Face (TSDF) is being confronted by our member dermatologists all across our country.

An alarming concern is the use of these creams as fairness creams in beauty clinics and self medication by patients themselves.

A multicentric study at 12 centres conducted in a cross-section of the Indian populace it was found that 59.3% of patients using TC on the face without any doctor’s prescription. Of the remainder only 26.7% patients had used TC prescribed by a dermatologist.

The sale of topical steroid  in India accounts for 82% of sale all topical drugs in India.   The financial stakes can be easily gauged from the sales figures of TC in 2013 which stood at Rs 1400 crore (approximately $233 million)

A special Task Force titled IADVL Task force Against Topical Steroid Abuse (ITASTA) has recently been constituted. Most of our members have taken pledge to fight this menace by minimizing use of these cocktail steroid combinations.

We have approached the pharma industry

1)        To increase awareness among General Practitioners about this scourge and to motivate and facilitate them in discontinuing their indiscriminate prescriptions.

2)        To minimize and avoid if possible  manufacture , sales and promotion  of  irrational  steroid based cocktail combinations

3)        To avoid and discourage  organizing camps where samples of such preparations are dispensed free in guise of fairness creams.

4)        To educate your retail vendors to avoid dispensing such potentially harmful preparations without valid prescriptions

5)        To limit potent steroid promotion  only to dermatologists

6)        Avoid promoting these products to alternative medical practitioners

7)        helping us in preparing   health education posters, pamphlets and  videos- such posters need to be put up in all medical shops and in clinics

8)        Insert an advisory in bold letters on all tubes that it is meant for  prescription by dermatologist only

9)        Insert a special advisory in all drug  brochures in the tubes  on the  side effects of this menace- we can help you in preparing such advisory

Topical corticosteroids are the backbone of the dermatology therapeutic armamentarium. Rampant & injudicious use has lead to a lot of side effects and topical steroid dependence. Most of these side effects are seen with long-term use, but some may be noticed within days.

Adverse effects of topicalsteorids on skin

1.        Steorid atrophy                                            11.      Pharmacological side effects

2.        Telangiectasia                                                12.      Steroid rebound phenomenon

3.        Striae                                                                13.      Steroid addiction

4.        Purpura                                                            14.      Tachyphylaxis

5.        Stellate pseudoscars                                  15.      Steroid acne

6.        Ulceration                                                       16.      Perioral dermatitis

7.        Easy bruisability                                            17.      Steroid rosacea

8.        Infections                                                        18.      Hirsutism

9.        Tinea incognito                                             19.      Hyperpigmentation

10.      Granuloma gluteale infantum                20.      Hypopigmentation

Systemic Side Effects of Topical Steroid

In addition to local side effects, prolonged use of topical steroids can cause systemic side effects which are less common than those due to systemic corticosteroids. These occur especially in infants and elderly patients. The documented adverse effects are :

• Suppression of the hypothalamic-pituitary-adrenal axis
• Iatrogenic Caushing’s syndrome
• Growth retadation in infants and children
• Ocular: Glaucoma and loss of vision
• Avascular necrosis of femoral head
• Severe disseminated cytomegalovirus infection resulting in death in infants.

I have no personal knowledge & experience about The Global Scenario of Topical Steroid Abuse in the community but in our country the situation definitely calls for urgent attention of the Government, Pharmaceutical Industry, Professional bodies of doctors and pharmacists.

We should also take up the matter with Advertising council of India so that the products containing topical steroids in different so called over the counter products must be stopped to safe guard the public interest.

Due to lack of space, I restrain from elaborating the difficulties that as dermatologists we face to treat the fall out conditions or complications out of this menace. All the stakeholders must join hands in this fight for justice for skin, the largest organ in the body before it is too late.

Academic Supports from:

Prof. R. N. Dutta, Ex-HOD, SSKM MC&H, Kolkata

Dr. Koushik Lahiri, Chairperson, ITATSA/IADVL

Dr. Avijit Mondal, Assistant Professor, Dermatology, Kalyani, Nadia

Introduction

Skin Lightening has a controversial background, ideas equating skin lightness with desirability, beauty and even class. The marketing of skin lightening products is wide spread, as is their use worldwide. This is a billion dollar industry once with a lot of critics.

As a health professional I see my role as encouraging & supporting patients autonomy & decision making by providing credible, unbiased evidence based scientific information to support treatment decision. Our roles are built on a common foundation: Science.

Glutathione – formed from the amino acids, cysteine, glutamate & glucine.

Why is Glutathione critical for health?

–          Herbert T Nagasawa, Ph.D.

Executive research scientist research shows –

Glutathione molecule –

1)      The most important antioxidants that is naturally synthesized in the body so called as “the superhero of antioxidants” mother of all antioxidants.

2)      The only antioxidant that recycles itself.

3)      Maintains cellular redox homeostesis.

4)      Maintains oxidational level of cells.

5)      Reduces hemoglobin, enabling it to accept oxygen & carry it to the cells.

6)      Protects against oxidative stress of the immune system.

7)      Allows newly formed immune cells to proliferate to attract germs & viruses.

8)      Is the master of sequestering free radicals.

9)      Is important to protect the nucleus of the cell & the DNA of the cell.

10)  Most important in protecting the mitochondrial DNA of the cell.

11)  Important in protein biosynthesis process.

12)   Transports amino acids into the cell where protein biosynthesis tates place.

13)  First line of protection against environmental chemicals of toxins.

Function

Glutathione is primarily responsible for reducing the level of cystine on the surface of proteins & helps protect your body from free radical damage. Glutathione also helps synthesize & repair DNA. It helps in recycling of vit C & E. impairs platinum build up in purging your body of toxic compounds such as heavy metals by helping your body detoxify. It helps reduce your risk of developing cancer, slows body’s aging process.

The evidence

Glutathione is an oxidant that is naturally synthesized in the body. Glutathione seems to be darling of alternative medicine industry so called as the superhero of antioxidants, mother of all antioxidants. There have been preliminary studies of its molecule for a number of uses such as Parkinson disease along with chemotherapy to reduced cancer therapy side effects etc.

When it comes to skin whitening Glutathione may have anti-melanogenic effect there have been some studies conducted on oral & topical lotion. The trails have been small but generally positive.

I could located no published evidence that demonstrates that I.V. Glutathione is an effective skin lightening agent. I could locate no clinical traits that have studied the injection or established its efficacy.

Safety

Its supported Glutathione injection are not only safe they are beneficial for your health. Glutathione helps eliminate toxins from the body, supports the central nervous system. Aids in-fertility & supports a healthy & strong immune system.

Are there negative long term effects? There are no known side effects or interaction with I.V. administration of Glutathione

What are the side effects? No known side effects with respect to the skin brightening I.V.

Looked to the medical literature for safety studies and statement. There is very little published safety information on iv Glutathione. The natural medicines comprehensive database says the tablets & injections are “possibly safe”.

There are some clinical traits of i.v. Glutathione published for other purposes and no serious safety signals have been identified.

The most authoritative safety statement seems to be from the “Phillipines food & drug administration” which notes: the alarming increase in the unapproved use of Glutathione administered i.v. as a skin whitening agent at very high doses is unsafe & may result in serious consequences to the health users. There is inadequate safety documentation on the use of high doses of Glutathione administered at 600mg to 1.2 gms. Once weekly or even up to twice likely. The only approved indication of iv Glutathione is as an adjunctive treatment of reduce neurotoxicity associated with cisplatin chemotherapy.

Adverse drug reaction resulting from the use of iv Glutathione for skin whitening have been reported and includes the following –

1)      Adverse drug reaction ranging from skin rashes to the serious sys & TEN

2)      Derangements in thyroid function

3)      Suspected kidney dysfunction potential resulting in kidney failure.

4)      Severe abdominal pain in a patient receiving twice daily IV regimen.

5)      Incorrect techniques by untrained persons can result in following –

Introduction of harmful micro – organism that can result in serious infection including potential fetel sepsis.

Counterfeiting of glutathione has been reported & may lead to infections.

Conclusion

There is very little evidence that establishes either the safety or efficacy of glutathione injection for skin lightening based on the limited information that exists, glutathione’s effects on skin tone are plausible but haven’t been well established the same can be said for safety.

There’s a lack of good safety information when used for this purpose and same international reports of serious harms given this product appears to be prepared by naturopaths directly. Ensuring the final product as sterile of high quality is essential but may be difficult for consumers to confirm. Given the nuclear benefits, risks of harm and the overall lack of medical need in going to recommend consumers think carefully before undertaking skin lightening with glutathione injections.

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:

1. Avoid aggressive parameters or invasive treatment protocol in DRY SKIN, THIN SKIN AND DARK SKIN to avoid complications.    ​
2. 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.                  
3. 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.  
4. 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).
5. 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.                                                                                                                                                                                                                       
6. 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.                                   
7. 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.                                                                                                              
8. 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.
9. 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 .
10. For any severe drug reaction addition of cyclosporine 2 to 3 mg/kg alongside corticosteroid for 5 days give quick relief in symptoms.
11. Amongst  alllight devices complications following the use of IPL are highly perplexing.  Recovery is very slow, leaving behind permanent hypo or hyperpigmentation                                                                                                                                                                                                     
12. 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.          
13. For comprehensive tattoo removal always combine Q switched  Ndyag with fractional CO2 laser . This precludes theghost effect and reduces number of sessions.                                                                                                                                                                                                                
14. 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
15. Do not attempt removingmulticoloured tattoo with Q switched NdYaglaser .Excision with split grafting is the only  solution in Indian scenario.
16. 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 .                                                  
17. 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.                                                                                                                                                            
18. Quick and heightened effect of topical anesthetic creams (EMLA) can be achieved with electroporation.
19. 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.                         
20. 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.         
21. 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.
22. Treating trichoepithelioma with RF cautery gives superior results when compared to ultrapulse CO2 laser.                                                                     
23. Milia recurrence may be  prevented by systematic usage of sunscreen and overnight application of salicylic gel1 or 2%.                                                
24. 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.                                                                                                                                                                                                              
25. 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. 

There is a desperate attempt being made to strike a balance between the environmental ecology with that of the biome within. With the evidence that probiotics may be efficient in restoring the ecology of the skin thereby lowering the incidence and severity of cutaneous disorders has been greeted with a mixture of excitement and skepticism.

What are probiotics?

Probiotics can be defined as live microbial food supplements that are beneficial to the host health when administered in adequate quantities. Emerging research is finding that the benefits of probiotics may be extending beyond the digestive system. Evolving theory suggests that the organisms used as a probiotic may help in forming an effective protective barrier thereby resisting the pathogenic microbes from taking over.

The Science behind probiotics effect on skin:

Most bacterial cells that live inside or on the body are harmless and studies have shown that infact they may be protective and extremely beneficial to the body’s normal functioning. Researches are on to investigate how oral administration or topical application of these bacteria may be beneficial in cutaneous conditions. These researches are based on the gut-brain-skin axis theory which was introduced almost about 80 years back.

Topical probiotics act by the mechanism of bacterial interference where they protect the skin and interfere with the ability of a pathogenic bacteria to evoke an immune response.

Indications in dermatology:

1.      Atopic dermatitis

2.      Eczema

3.      Acne vulgaris

4.      Acne rosacea

5.      Photosensitive dermatoses

6.      Skin and soft tissue infections

7.      Anti-ageing

It has been noted that probiotic initiation during the third trimester of pregnancy in atopic mothers has been efficient in delaying the onset and reducing the severity of the disease in the child (1). So the question is why are we not treating all atopic mothers with probiotic supplementation? Initial studies of different strains of oral lactobacillus for both prevention and treatment of atopic dermatitis were encouraging, but follow-up reviews and meta-analyses have been conflicting (2-6). However having said that newer researches show that topical and oral probiotic administration has helped to increase ceramide levels in the skin barrier thereby reducing the severity of atopic dermatitis and ensuring longer remissions (7).

In these patients the living bacteria on the skin surface is identified as foreign and the body launches an immune response against them thereby causing inflammation. The probiotics act by bacterial interference thereby suppressing this immune sensitization. It has also been postulated that the bacteria in probiotics have a capacity to produce chemical substance which may be lethal to the pathogenic bacteria thereby reducing their load on the skin. This is probably one of the rationale behind using them in combination with antibiotics in cases of skin and soft tissue infections. Stress alone or along with increased intake of processed food can slow digestion and motility of the gasto intestinal tract thereby leading to proliferation of unhealthy bacteria .people who are predisposed to acne or rosacea can experience flares as a result of this shift in microbiome and subsequent inflammation. Parodi and colleagues showed in 2008 that patients with rosacea had a ten-fold greater incidence of small intestinal bacterial overgrowth as compared to healthy controls (8). Further studies examining the therapeutic benefit of oral and topical probiotic administration in mild acne patients within the last decade have been promising, with proposed theories including decreased release of inflammatory mediators as well as increased production of ceramide and skin barrier restoration(9,10).  We in cohesion with the studies opine that although probiotics may not stand as a monotherapy for acne and rosacea it can be definitely considered as a safe and effective adjuvant therapy for the same with some effect on maintenance and long term remission in these patients.

The usage of probiotics in combination with antibiotics also seem beneficial due to modification of the gut microbiome thereby combating the adverse effects like diarrhea associated with consumption of few antibiotics. Wong and colleagues suggested that probiotics may help to normalize disruptions in human microbial communities and bacteria-host interactions that contribute to non-healing wounds (11).

Photoprotection and antiageing properties of probiotics, although the mechanism of action still remains elusive may be attributed to the reduction of inflammatory response and immune modulation. It is hypothesised that bifidobacterium attenuated the damage to the tight junction structure and basement membrane induced by chronic UVB irradiation, possibly via measurably-decreased interleukin-1-beta production in the skin.

The controversies:

The sceptics in usage of probiotics have been fuelled by disappointing results with probiotics in the treatment of eczema as evidenced by the Cochrane Database system in 2008. Selection of the right probiotic for adequate effectiveness is crucial. It has been found that the usage of same probiotic agent in two different population groups have given variable results.

Future perspectives:

Probiotics is an open arena with multiple possibilities. It has stimulated world wideinterest to carry out multi centric well designed larger population based studies so as to validate its use in dermatology and expand the therapeutic horizons.

Conclusion:

Any new venture when undertaken must not be met with prejudice or scepticism. A wider and open eye view of probiotics would help us in providing a more promising and safe, therapeutic and preventive modality in times to come for the chronic cutaneous disorders. While it is tempting and adventurous to embark on the broad utility spectrum of probiotics, such enthusiasm must be tempered with careful study and consideration.

References:

1.      Lee J, Seto D, Bielory L: Meta-analysis of clinical trials of probiotics for prevention and treatment of pediatric atopic dermatitis. J Allergy ClinImmunol 121:116-121.e111, 2008

2.      Kalliomäki M, Salminen S, Arvilommi H, Kero P, Koskinen P, Isolauri E. Probiotics in primary prevention of atopic disease: a randomised placebo-controlled trial. Lancet. 2001; 357(9262):1076-9.

3.      Weston S, Halbert A, Richmond P, Prescott SL. Effects of probiotics on atopic dermatitis: a randomised controlled trial. Arch Dis Child. 2005;90(9):892-7.

4.      Van der aa LB, Heymans HS, Van aalderen WM, Sprikkelman AB. Probiotics and prebiotics in atopic dermatitis: review of the theoretical background and clinical evidence. Pediatr Allergy Immunol. 2010;21(2 Pt 2):e355-67.

5.      Pelucchi C, Chatenoud L, Turati F, et al. Probiotics supplementation during pregnancy or infancy for the prevention of atopic dermatitis: a meta-analysis. Epidemiology. 2012; 23(3):402-14.

6.      Boyle RJ, Bath-hextall FJ, Leonardi-bee J, Murrell DF, Tang ML. Probiotics for treating eczema. Cochrane Database Syst Rev. 2008;(4):CD006135.

7.      Di marzio L, Cinque B, Cupelli F, De simone C, Cifone MG, Giuliani M. Increase of skin-ceramide levels in aged subjects following a short-term topical application of bacterial sphingomyelinase from Streptococcus thermophilus. Int J Immunopathol Pharmacol. 2008; 21(1):137-43.

8.      Parodi A, Paolino S, Greco A, et al. Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication. Clin Gastroenterol Hepatol. 2008;6(7):759-64.

9.      Muizzuddin N, Maher W, Sullivan M, Schnittger S, Mammone T. Physiological effect of a probiotic on skin. J Cosmet Sci. 2012; 63(6):385-95.

10.  4. Di marzio L, Cinque B, De simone C, Cifone MG. Effect of the lactic acid bacterium Streptococcus thermophilus on ceramide levels in human keratinocytes in vitro and stratum corneum in vivo. J Invest Dermatol. 1999;113(1):98-106.

11.  Wong VW, Martindale RG, Longaker MT, Gurtner GC. From germ theory to germ therapy: skin microbiota, chronic wounds, and probiotics. Plast Reconstr Surg. 2013; 132(5):854e-861e.

Fractional CO2 has always been my favourite laser and also my first laser!Although it’s a laser where there is a long learning curve,I am everyday amazed at the versitality of it.Having used it for more than 5 years I have used this laser for various conventional and unconventional uses and still feel there is more to be explored as everyday i learn something new and I am understating the skin better and better.

Non-ablative lasers (ex:Erbium-glass,Erbium-Pixel,ResurFX 1565, Micro-Needle Fractional RF System,etc) will guarantee a minimal downtime yields and good results but in my opinion even though a Fractional CO2 has a longer downtime and chances of PIH is higher,the results are anyday better.If the idea is to treat a burn scar,or extensive scarring we need some ablation as that helps in remodeling of the scar in a more controlled way,along with the growth and healing factors ultimately giving better results.Offcourse if one has the luxury of various lasers to treat certain areas selectively offcourse that would be the best.As a Dermatologist one must  try out various  combinations as there is never a ready made solution to all the problems we face,especially when it comes to facial rejuevation,pigmentations and scars.

In a CO2 laser, vast majority of treatment is done under the  principle that Collagen denaturing  leading to remodelling.The heat denatures the proteins,helping in the remodeling,which makes it essential to have a powerfull laser ,which is very precise too and deliveres more than 5j/cms Fluence  and has a Thermal relaxation time less than 0.1ms.The more the TRT,more the chances of complications,PIH and Pain. The CO2 fractional laser pokes tiny microscopic holes in the skin down past the epidermis and into the dermis. These holes cause new collagen to be generated which fills in the acne scars and creates rejuvenated smoother skin.(1-3)The intact dermis and epidermis allows the use of high fluencies to be delivered as they provide the structural and nutritional support for recovery.This is the principle which we use to treat acne,chicken pox and traumatic  scars,burns,rhytids,facial rejuvenation and skin laxity.

When it comes to pigmented lesions,photothermolysis seems to be the likely cause of the results.Although selective photothermolysis doesn’t occur here,destruction of the tissue and melanin does occur which leads the macrophage actions, healing and removal of the debris.This principle works well when treating Freckles,Lentigines,Melasma ,Lentigo Maligna,Actinic chelitis,etc.

When it comes to cases such as Neurofibroma,Cutaneous horns,Actinic and Seborrheic keratoses,Milia,Syringoma,Trichoepitheliomas,Xanthelasma palpebrarum,Rhinophyma reduction,Corns,Verruca Vulgaris,Epidermal Nevi,Keloid excision including Acne Keloidalis nuchae,even to some extend tattoo removal,ablation,excision,helps a lot and probably play a major role in improvement along with the natural wound healing process of the body.Especially simple things like removing a  Verruca Vulgaris becomes more precise,hence faster healing and lesser patient discomfort when done with a Fractional CO2 laser.Bleeding is also less when excised with a CO2 laser.Infact defocusing and firing the laser does cauterize and minimmise the bleeding. (3-22)

When it comes to Dyschromia,Melasma,Riehl’s Melanosis or Post Inflammatory hyperpigmentation due to various causes,its essential to combine the treatment with various combination of lasers and peels too and management of the treatment area post procedure with essential medication and topical application.(13-18)

The limitations of a Fractional CO2 come down to the fact that most Aesthetic or Cosmetic procedures are done to enhance the aesthetic appearance rather than a necessity. This gets us to the point or rule number one that even if we can’t improve, never worsen. One must know the limitations and also have the knowledge to acknowledge the fact that certain conditions never can be improved beyond a certain limit. The conditions I have mentioned above have been tried, tested and delivered to satisfying results of the patients by me with the help of a Fractional CO2 while probably there are more conditions which could be treated with the  AcuPulse Fractional CO2 laser that i use from Lumenis Inc.,Santa Clara, which is yet to be explored and  learnt by me even after using it for 5 years and speaking about it in various National and International Podiums!I always find something new about it and many a times we all are stuck up upon an idea imprinted in a mind by an article or speaker which mind have been relevant to them but yet to be tested by us.A proper knowledge of the physics of every laser will let us explore and understand the functioning and capability of it although seldom does many of us try to do that.  And this should be the case with any surgeon who should be able to acknowledge his limitations. A proper training with an experienced senior would be advisable before one resort to an ablative laser. In case there is difficulty in getting to know the parameters, which we all do face, it’s always better to start with a lower energy and density and take it a step up in the following sittings.The rule is simple and no secret,the more the energy,lesser the density and Vice versa.

It’s not possible to really come to a gold standard protocol when one comes to treating various conditions because as we all know protocols evolve as one learns to master his skills. Never try to copy what’s right for another person as it’s always better to consider every individual as an individual rather than classifying skin types.One should understand what works best for a reputed senior Cosmetic /surgeon in USA or India or wherever may not work for you as given any laser,they would make it work as they have a thorough understanding of the physics and condition they are treating.

The most common treatment that a Fractional CO2 is used is usually for scar reduction.Never buy a Fractional CO2 hoping to treat pigmentation the way a Q-swtiched Nd-YAG would work.Dont go by the world companies write that FDA approved for so many number of conditions! FDA approved means its can be used to treat with satisfactory results ,it need not mean gold standard results as the criteria for FDA approval for lasers and medication is entirely different! Always a good submission few days earlier or on the day of the procedure is beneficial. In real life practice it’s not always possible to prepare the patient few days before the procedure. It’s also very necessary to rule out a history of keloids,connective tissue disorders as this may lead to scarring and also if the patient is on any photosensitive or blood thinning medications or any other ongoing infection or history of Herpes Labialis. It’s probably advisable to do procedures only on patients who haven’t had any procedures done on the area which might have disrupted the epidermis in the near past and it’s better to treat an undisturbed skin for better results and lesser complications.(20-29)

Procedures commonly is done under topical anesthesia.Most patients tolerate it.Many surgeons do nerve blocks,regional blocks and even general anaesthesia  for an Ablative procedure as this makes the job of a surgeon more comfortable though not all patients agree to this. Many patients want to feel like an outpatient procedure and not like a big surgery was done on them as most times this is a voluntary procedure as mentioned above out of desire rather than necessity. Local Anaesthesia infiltration into certain areas during the procedure is a good way of treating certain sensitive areas.

During the procedure  avoid repeated stamping or overlap as this may lead to bulk heating which may not be visualised  immediately, only in few hours time to days post procedure when PIH is the result!Do not leave gaps between the treatment areas as this will effect the long term results.Dont overtreat ,never involve areas which isn’t essential.Be specific of the pit or scar you are treating.Its better if one gives more energy to the main pit and minimal on the sides, Its always better to ‘feather’ the nearby areas as this  gives a more even texture once the wound has healed. A cooler or Zimmer helps to reduce the patient discomfort, but maintaining the room temperature at about 24degree centigrade and cold compresses helps, along with not hurrying up the procedure and talking to the patient, which will give the patient more confidence and reassurance that all is fine.

Now when it comes to post procedure care,counselling is the most important fact.Sunscreen has to be applied 3 times a day mimimum,along with the application of moisturisers and if neccesory a topical steroid till the erythema ,edema has subsided,after which the patient can continue on sunscreens alone.As for me I prefer the use of occlusive emollients to start of with.Gentle cleansers are essential to remove the scab and serosanguinous discharge.A course of systemic antibiotics is essential and some surgeons also give systemic steroids for few days or a stat dose.(23)The better the patient handles the post procedure care,the faster is the recovery and downtime.(24-29)

Post operative crusting,edema,erythema,oozing,pin point hemmoraghic spots are quite common.The possibility of scarring and a post inflammatory hyperpigentation lasting longer than expected are the dreaded complications for an Aesthetic Surgeon.On a darker skin type,even experienced surgeons can end up burning ones fingers!(29)

Combination therapy with the help of Er-YAG, chemical peels or the use of good Cosmeceutical products post procedure could be beneficial.

In conclusion a Fractional CO2 has changed the role of a Dermatologists-Cosmetologists ,given opportunities to explore more into Aesthetic Surgery as I truly believe that no one knows the skin better than a Dermatologist and has helped him deliver better results with minimal downtime for various conditions,at times in a single sitting alone unlike many Non-ablative lasers or traditional Ablative CO2 lasers. With the cumulative knowledge of Dermatology and Aesthetic Surgery one can surely deliver satisfying results to  the patients.As for Acne scars and rejuvenation which may require multiple sittings clinical improvement is seen right from the 10th day and it might go on to improve till 6 months. When it comes to pigmentary problems usually it’s a single sitting and results are seen by the end of of the first week itself.
While the potential risks are always there like in any other procedure so its essential to understand the laser you have with you before you go aggressive. Offcourse I do agree to the  opinion that an Ablative Fractional CO2 is not for novice laser surgeons but rather for a trained Aesthetic surgeon who has preferably had experience with lesser aggressive devices.

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Fractional CO2 treatment for scars,

Day 1 and Day 70,2 sittings done

Accident injury patient treated with Acupulse ,

on day 1 and Day192

Fractional CO2 day 1 and 120 after 2 sittings

Fractional CO2 Day 1 and Day 120 after 2 sittings

Melasma,Day1,15,382,720

Scar treatment after two sittings of AcuPulse