Hand Rejuvenation: Restoring Youth and Beauty to The Hands

Abstract:

Following the trend in facial cosmetic procedures, patients are now increasingly requesting hand rejuvenation treatments. Intrinsic ageing of the hands is characterized by loss of dermal elasticity and atrophy of the subcutaneous tissue. Thus, veins, tendons and bony structures become apparent. There are various treatment options for cosmetic rejuvenation of the hands, including microdermabrasion, chemical peeling, intense light sources (IPL) ,laser treatments including pigment lasers and ablative resurfacing and non invasive rejuvenation. The soft tissue atrophy of the aging hand can be best addressed with fillers. In this article we share our clinical experience of rejuvenating the hand with combination treatment with peels and fillers.

Introduction

The old saying “ if you want to know a woman’s age, look at her hands” is still valid now.  Intrinsic ageing and photoageing combine to loss of soft tissue, wrinkling, prominence of the dorsal veins, pigmentary changes such as darkening and lead to the appearance of premature ageing of the hands. The aged hand is characterized by cutaneous and dermal atrophy, with deep intermetacarpal spaces, prominent bones and tendons, and bulging reticular veins. Epidermal changes include solar lentigines, seborrheic keratoses, actinic keratoses,(more commonly seen in skin types I-III) skin laxity, rhytides, tactile roughness, hyperpigmentation and telangiectasia. This is often worse in smokers and those with hobbies or occupations which have prolonged outdoor exposure. Especially in our Indian population, with skin type IV to VI, the epidermal changes are that of pigmentation and tactile roughness, associated with the dermal changes including loss of elasticity and skeletonisation of the hand with prominent veins and tendons.

Next to the face, the hands are the most conspicuous part of the human body.1As hands are frequently noticed in social gatherings, this becomes a quality of life issue to the person. Patients with premature ageing frequently request help in improving the aesthetic appearance of their hands. Therefore,many therapies which are used in facial rejuvenation including  microdermabrasion, chemical peels, laser resurfacing, IPL and pigment lasers have been also used for rejuvenation of the hands. The soft tissue atrophy and skeletonisation has been addressed by fat transfers and the use of various fillers.

We designed a study to determine the efficacy and safety of combination treatment of medium depth peels with hyaluronic acid fillers for the rejuvenation of the hand. 20 womenbetween the ages of 35-60, who requested rejuvenation of the hands were enrolled into the study. Informed consent and pre and post treatment photographs were obtained for all patients. All subjects received 2 ml of hyaluronic acid ( 1 ml per dorsum of each hand) and 2 modified Jessner’s peels in 2 weekly intervals. Patients were also advised to use regular sunscreen, and emmolients on the hand during the study period, and advised to avoid excessive contact with detergents during the study period. All patients were evaluated at the end of 1 month, 2 months and 3 months after the last treatment. Results were obtained by comparison of pre and post photographs and by subjective patient feedback.

Chemical Peel: We chose a medium depth peel, Modified Jessner’s peel from Mediderma. The peel was applied in two layers over the dorsa of the hands, with feathering over the forearm area. It was then left on for 8 hours, without washing off.

Method of injection of filler in the dorsum of hand: The dorsa of the hands was anesthetized with a topical anesthetic (5% lidocaine + tetracaine ) cream under occlusion for 45 mins. The treatment area was the cleaned with betadine and alcohol swabs and draped. The dorsa of the hands were iced prior to injection, to increase patient comfort, and to reduce the chances of bruising. The skin was then pinched between the index and thumb  fingers of the non dominant hand and raised above and hyaluronic acid injected intradermally.( Figure 1) Around 8 to 10 sites were injected on the dorsa of each hand. After completing the injections, the dorsa of each hand was gently massaged to allow even distribution of the product.

Results: All 20 patients completed the study. All patients reported satisfaction with the end result. They graded their satisfaction on a scale of one to ten, and the scores varied from 6.5 to 9. There was significant improvement in the texture of the skin as well as reduced appearance of the veins and the guttering of the hands was considerably reduced subjectively as well as observed on photography. There was improvement of the colour of the skin, the appearance of the dorsal veins was reduced. Patients also commented on the hydrated appearance of the skin post procedure. Results lasted till the end of follow up, at 3 months after the last procedure.

Complications were seen secondary to the injectable only. Edema and pain were observed in 4 clients, one of them went on to develop bruising, which resolved in a week.

Discussion:

With patients achieving a younger appearance from facial rejuvenation treatments, a discrepancy betweena youthful face and aged hands often becomes apparent. This drives patients to seek therapies and treatments which bestow youthful appearance on the hands.

There are various options for the rejuvenation of the hands, as listed in the table below.

Microdermabrasion
Chemical Peels
Intensive Pulsed Light IPL
Q switched lasers
Photodynamic therapy
Ablative fractional resurfacing
Non ablative resurfacing
Sclerotherapy
Fat transfer
Injectables – Hyaluronic acid/ PLLA/ Calcium Hydroxy apatite

 

 

 

 

 

 

 

 

Chemical peels: Chemical peels have been a commonly used modality for skin rejuvenation. Based on the depth of penetration, they are classified into superficial, medium or deep peels. For the rejuvenation of Indian skin types, superficial and medium depth peels are recommended, and deep peels are generally avoided due to possible complications of hyperpigmentation and scarring.  Especially in the rejuvenation of the dorsal hands, where the skin is thin and the adnexae are relatively sparse,2 it is prudent to stick with the superficial and medium depth peels.

As Chemical peels are quite economical, these can be the first line for rejuvenation of the hands. Usually 2 – 4 sessions are needed before one can appreciate the improvement in the colour and texture. Mild feathering of the peel into the forearm area is required to avoid creation of a demarcation line between the treated hands and untreated forearms. There are only few reports regarding peeling of the hands in literature. These studies show use of Salicylic acid,3 Jessners solution,4 TCA (30%) and glycolic acid in concentrations upto 70%.

Chemical peels may yield significant improvement, but they must be performed conservatively and serially over time until the results are satisfactory. The results are dependent on concentration and contact time with the skin.

Hyaluronic Acid (HA) Fillers:

The use of HA fillers for the correction of intrinsic signs of ageing of the hands was described by Man et al.5 They described using HA injections to improve the appearance of hand rhytides, prominent veins, bony prominence and dermal subcutaneous atrophy. Typically two vials of HA (one vial per hand) is often required.  Their technique was to place the patient in the Trendelenburg position to reduce vein pressure, with the injector holding the hand loosely in a resting position, HA was injected subcutaneously at an oblique angle adjacent to the dorsal veins using a threading technique. Although Man et al used no anesthesia or cooling, in our practice, we use topical anesthesia and cooling to increase patient comfort. We also prefer to elevate the skin above, and then inject bolus of HA. We then massage the HA over the entire dorsal hand to ensure uniform dispersion.

Various other options are available for rejuvenation of aging hands. The appearance of the skin can be improved with IPL,6 Q switchedlasers,7 ablative and non ablative resurfacing lasers.8 The prominent veins can be treated with slerotherapy 9and endovenous vascular ablation.10 Volume loss can be restored by autologous fat injection11 and injectable  PLLA 12or Calcium hydroxyapatite13 injections.

Any rejuvenation process must address two factors; the epidermal component (which comprises of pigmentary changes, actinic keratosis ) and the sub dermal component of volume loss. This is why as in rejuvenation of the face, a combination of techniques yield a better result that any one procedure. There is sufficient data available to document favorable results with HA and chemical peels, and both procedures are associated with miminal adverse events, making them useful for the dermatologist to address hand rejuvenation.

References

1. Inglefield C. Nonsurgical hand rejuvenation with Dermicol-P3530G. Aesthet Surg J 2009;29:S19–21.

2. Campbell TM, GoldmanMP. Adverse events of fractional CO2laser, a review of 373 treatments. Dermatol Surg 2010;36:1645–50.

3. Landau M. Chemical peels. Clin Dermatol 2008;26:200–8.

4. Collins PS. The chemical peel. Clin Dermatol 1987;5:57–74.

5. Man J, Rao J, Goldman M. A double-blind, comparative studyof nonanimal-stabilized hyaluronic acid versus human collagen

for tissue augmentation of the dorsal hands. Dermatol Surg2008;34:1026–31.

6. Butterwick KJ. Rejuvenation of the aging hand. Dermatol Clin

7. Todd MM, Rallis TM, Gerwels JW, Hata TR. A comparison of3 lasers and liquid nitrogen in the treatment of solar lentigines:

a randomized, controlled, comparative trial. Arch Dermatol2000;136:841–6.

8. Goldberg DJ. New Collagen Formation After Dermal Remodelingwith an intense pulsed light. J Cut Laser Ther 2000;2:59–61.

9. Bains RD, Thorpe H, Southern S. Hand aging: patients’opinions. Plast Reconstr Surg 2006;117:2212–8.

10. Shamma AR, Guy RJ. Laser ablation of unwanted hand veinsPlast Reconstr Surg 2007;120:2017–24.

11. Fournier P. Fat grafting: my technique. Dermatol Surg2000;26:1117–28.

12. Redaelli A. Cosmetic use of polylactic acid for hand rejuvenation:report on 27 patients. J Cosmet Dermatol 2006;5:233–8.

13. BussoM, Applebaum D. Hand augmentation withRadiesse (calcium hydroxylapatite). Dermatol Ther 2007;20:385–7.

Handling Party and Corridor Consultation

It was a busy Friday for Surgeon Rakesh Desai (name changed) and he was aching to reach home as the time neared 10:30 p.m. As he swerved his car into his residential parking slot, a familiar face waved out from the second floor balcony. Avoiding any conversation, Dr. Desai waved back and rushed into the building entrance. About 15 minutes later as he was digging into his dinner-plate, the calling bell rang. Aha, it was the neighbour, Mrs. & Mr. Shah who had earlier waved at him. They took their seats while calling out, “Doctorsaab, we are

in no hurry; you can finish your meal!”

While Mrs Desai frowned at her husband for the unwanted interruption, the generous surgeon whispered to calm her down saying that it may be emergency and that he is duty-bound to help. They hurriedly finished their dinner and Dr. Desai was beside the couple in a few minutes. Mr. Shah began by pointing to his wife saying that his wife is troubled by a severe pain in the foot and that there is a lump. As Dr. Desai awkwardly examined the lady’s foot on the sofa, he came to an instant diagnosis: corns. Dr. Desai politely requested them to come to the consulting room the next day. However, the next thing they uttered made him blow his top. Most of us can guess the obvious question that Mrs. Shah would have asked: “Can you do something now?”

This is definitely a common scene for most of us. Be it a cardiologist, a surgeon, ophthalmologist or a dermatologist a home consultation during the odd hours of the day or night is unavoidable. When there is a genuine emergency, no physician irrespective of his speciality would hesitate to do his duty willingly. Doctors do not have to be reminded of their Hippocratic Oath in such a situation and they understand their responsibility to society. On occasions they may even miss their consulting hours (causing discomfort to regular patients waiting in the clinic) while tackling a neighbourhood emergency. Yet, what disturbs every physician is the neighbour who takes the doctor for granted and abuses his leisure time.

There are numerous examples like Mrs. Shah who barge into doctors’ homes, at unearthly hours, for corns that have troubled them for weeks together, for a child running high temperature for several days or a mole on the face which has been growing since childhood! They force themselves on the physician and point to the face, eyes, nose, throat, arms, fingers, toes, feet, nails and even the teeth.

In the early days of practice the beginner is blinded by his desire to develop enough goodwill so as to build up a modest clientele. Besides, the young doctor is badly inexperienced to deal with a neighbouring chipko aunty.  He or she feels that it is rude to refuse help to a troubled patient. Sometimes the financial necessity during the initial years makes the physician ignore the intrusion into his personal space and time.

Party Scene

There is another scene enacted when a doctor attends a social function or bumps into a patient at a theatre, shopping mall, car park or the corridor of a building. Even before the poor physician recognises the patient the latter greets him with: “Doctor, how are you? Recognise me?”  Depending on the situation the physician may or may not remember the patient in detail. Quite often the physician remembers the face but not the diagnosis and therefore any clinical questions that are showered on the unsuspecting physician is met with confusion. The physician then has to wriggle out of the situation so as to avoid embarrassment in front of other family members who are also attending the party.

As they say. doctors and lawyers never retire! And even more than that, a doctor is a ‘healer’ for all 24 hours of the day – whether he is at home, on the road or at the clinic. While it is a flattering thought and the doctor tries to live up to this reputation, he is sometimes hounded by people even when there is no urgency. It is this fact that troubles the physician the most.

Worst hit

General practitioners, consulting physicians and dermatologists are pestered the most by patients at places outside the clinic. Sometimes the dermatologist has to face the embarrassing scene of a lady delicately lifting up her saree to reveal some ugly eczematous patch on the ankle even as others look on.

Dermatologists often complain that people expect them to “just write me an ointment for this itchy patch” as he gets into his car to rush to his clinic.  Little does the patient realise that the doctor may need some minutes of time to explain what the condition is and how long the treatment has to continue for recovery.

There have been instances where an elderly relative visits a dermatologist at home and points to a classical, hairless, hypopigmented patch on the arm while the poor doctor is petrified to give away the diagnosis. After all, a diagnosis of Hansen’s disease cannot be made casually in front of other family members while sipping tea. With the stigma surrounding the disease, the specialist needs to be careful how such news is broken and he has the added responsibility to counsel her about its cure only on completion of the entire course of multi-drug therapy.

Dealing With Nuisance Makers

Tackling such situations requires a great deal of tact and skill which comes only with experience. The physician gradually learns that once his practice grows there is no need for him to pamper people who do not respect his privacy. That is the time he actually learns to put his foot down when patients make unreasonable demands. Also, as he gains in seniority the commitment of his time to his spouse and children increases. The family too pressurises the physician to refuse unnecessary consultations at home.

In the final analysis, there is no shortcut to avoiding an irritating patient who intrudes into the physician’s home late at night. A few solutions, some of which may not be easy to put in practice, are presented here:

  • It is quite perturbing for a physician to face a query concerning medical science when he is at leisure or when his mind is on something else. The physician may be enjoying his favourite newspaper column when a neighbour barges in with a health complaint. One of the simplest ways to avoid a non-emergency consultation is to politely state that it is not the right time. Yet this is not easy when facing a well known neighbour. An alternative approach would be to say, “I do not have the necessary instruments to examine you. Why don’t you come to the clinic this evening?” It would be a simple way to invite him to the clinic.
  • I know a senior doctor who bluntly says, “I would surely have examined you but unfortunately I have not brought my spectacles along.”
  • Some stubborn neighbours can be put in place with a careless examination of the affected part followed by: “This thing may require a biopsy.”
  • Dermatologists are hounded very often at home and at social occasions and one of the ways of escaping from the scene is with the remark, “oh! the lighting is so poor that I can barely see anything.”

Suggesting a home remedy which is well known to everybody is another way of ticking off the offender. For example: “Why don’t you apply some coconut oil over the patch. It may disappear.” Or “try some saltwater gargle for the sore throat”

  • If the patient is smart enough to tell you that the he or she has already tried the home remedy and that it does not work, tell him/her: “Do it for one more week, your stratum corneum needs more persuasion!”
  • Another way to put him off is to ask: “What are you applying? And if she says, “Soframycin” (or something harmless) respond with “Oh yeah, that’s good…just continue applying for 10 more days…and let me know.” The response should not change irrespective of the disorder or name of the cream/ointment applied!”
  • However not many people can do what one smart chest physician once did. He was once confronted with an acquaintance at a wedding reception. The acquaintance appeared very friendly and bombarded the physician with questions relating to his heart and blood circulation problems. As the ‘patient’ started talking, the physician slowly started walking towards his car. Finally, the physician neared the car; he quickly sat in the driver’s seat,
    his right foot planted on the accelerator and before the
    unsuspecting patient realised it, he went Vrrroooooom!!!
  • At a public event, a gentle hint by a physician that the patient needs to undress for further examination usually takes care of some queries.
  • The award for the best response to a corridor consultation goes to a gastroenterologist who once retorted to a outstation neighbour who pointed to some discoloration on his neck and queried, what it was? He barked, “Oh you have poststreptococcal glomerulonephritis! The shocked neighbour was not prepared for such a ‘big’ disease appearing so innocuously on his neck!!! Consequently, he never dared to question him again!

Are all physicians equally troubled by such demands from their friends and neighbours? No, not everyone. The fortunate doctors are the ones who deal with highly personal matters, private parts of the body etc. They are the sexologist, STD specialists, Proctologist, Gynaecologist, Psychiatrist etc. from whom people may actually stay away in a public place so as to avoid a situation where someone would ask the patient, “How does the doctor know you?”

What a practicing doctor needs to do when faced with an unreasonable enquiry is to prepare a frank and forthright reply without getting irritated. Only a smiling face with a quick, witty response would help one to win back the patient the next day. And umm…by the way, I can spot my Ophthalmologist neighbour, Dr. Hema, entering her residence. Let me quickly drop in before her dinner and find out why my eyes are looking red!

Dermoscopy Facts for All Dermatologists

Dermoscopy Facts for All Dermatologists By Dr. Rahul Kumar Sharma 

Ø  Dermoscopy is an indispensable tool to the clinical examination which is increasingly being used in general dermatology.

Ø  Dermoscopy allows the in vivo evaluation of colors and microstructures of the epidermis, the dermoepidermal junction, and the papillary dermis not visible to the naked eye.

Ø  An interface medium such as ultrasound gel or oil is applied to the skin to make the stratum corneum transparent, while the objective of the dermoscope is placed against the skin surface.

Ø  The instrument makes it possible to observe a vast new range of dermatological signs.

 

Quick facts in dermoscopy, trichoscopy and nail fold microscopy-

 

Scabies

1.      Triangle sign”, which represents the “head” portion of the mite.

2.      Delta wing jet with contrail” sign, corresponding to the head of the mite and the trailing burrow.

 

Sarcoidosis

1.      Yellow nodules (grains of sands), similar to diascopy sign.

2.      Yellow-brown discoloration (apple jelly sign), similar to diascopy sign.

Lichen planusà Wickham striae

Lymphangioma circumscriptumà Yellowish lacunes

Psoriatic lesions and psoriatic balanitisà “Bushy” capillaries at higher magnification and dotted vessels are seen throughout the entire lesion at lower magnification.

 

Angioma serpiginosum à Multiple, scattered, sharp lagoons

 

Dermatofibroma à

1.      Chrystalline structures

2.      Central white patch and peripheral pigment network

 

Clear cell acanthoma à Dotted vessels arranged in line like a string of pearls.

Seborrheic keratosis à

1.      Fingerprint pattern

2.      Fissures and ridges

3.      Milia like cysts

4.      Sharp demarcation

 

Acral nevi à Parallel furrow pattern

 

Hemangiomaà Well-demarcated dark red lacunae

 

Basal cell carcinoma

1.      Arborizing vessels

2.      Ulceration

 

Melanomaà

1.      Ugly duckling sign ,which means that nevi in the same individual tend to resemble one another, and that malignant melanoma often deviates from this nevus pattern

2.      Beauty and the beast sign

 

Androgenetic Alopecia

1.      Terminal to vellus hair ratio can be calculated without skin biopsies

2.      Predominance of hair follicle units with single hairs

3.      Hyperkeratotic plugs

4.      Variable hair shaft diameter

5.      Perifollicular pigmentation

 

Alopecia areata

1.      Yellow dots

2.      Cadaverized hairs

3.      Dystrophic hairs

4.      Micro-exclamation point hairs

 

Cicatricial Alopecia

1.      Fibrosis of follicular ostia visible as white dots

2.      Dots may coalesce to form bony white areas without visible ostia

 

Scleroderma

1.      Pearly shining areas, sclerosis “cotton balls”.

2.      Thin loops, megacapillaries.

3.      Rarefied capillaries (less than 6 loops per mm)

 

Systemic lupus erythematosus

1.      Considerable variation of loops, branching, twisted

2.      Microhemorrhage

Micro-Hutchinson’s sign à Pigmentation of the cuticle that can only be seen clearly with dermoscopy

 

19 Jan 2016 A TO Z OF CO2 LASER IN DERMATOLOGY AND AESTHETICS

The CO2 laser is the most resourceful laser in the management of cutaneous lesions. It is the gold standard amongst all ablative lasers. Potential applications of this laser in day to day dermatological practice are boundless.

Introduction

The CO2 laser is the most resourceful laser in the management of cutaneous lesions. It is the gold standard amongst all ablative lasers. Potential applications of this laser in day to day dermatological practice are boundless. Advances in both power and delivery have made CO2 laser a flexible device, which is progressively more effective in dermatology and aesthetic practice. It has found use in both incisional and excisional procedures along with fractional resurfacing. This article gives a brief overview of the laser physics and its limitless indications in dermatology.

Laser physics:

The CO2 laser emits invisible far infrared light at 10,600nm either in a continuous wave or/ pulsed/ superpulsed /ultrapulsed mode. The laser light energy is absorbed within 20-500µm in the soft tissue and 90% of it is selectively absorbed by water which is its target chromophore. Based on the principle of selective thermolysis the absorption of this energy results in rapid heating and tissue vaporisation. Use of CO2 laser requires alertness of the power distribution within the impact spot, referred to as transverse electromagnetic mode (TEM).  The most basic (TEM0) represents normal distribution i.e. 86% of power within the spot of impact. This TEM highlights the significance of adjoining thermal damage zones and importance of laser setting to avoid tissue injury.

The parameter setting for the CO2 laser relies on its delivery mode whether pulsed or continuous. For continuous mode power is the primary setting.

Excision /cutting mode:

A higher irradiance is required for tissue excision. Irradiance /Power density (W/cm2) = Power output / impact spot size. Hence the beam is focussed to a small diameter (0.1-0.2 mm) with high output (1-30 W) in order to achieve a higher irradiance (between 50,000 – 1, 00, 000W/cm2). Additionally the hand piece can be operated in a focused mode, yielding high irradiance and excellent cutting properties or it may be used in a defocused mode, yielding lower irradiance and better coagulative properties.

Indications

CO2 laser has found its use in limitless indications(benign and malignant lesions) in dermatology , when used  individually or in combination with other procedures(Table1).With the advent of the fractional CO2 laser the results in aesthetic practice have been impressive.

Table1 : Common, uncommon and CO2 laser assisted indications

CommonSyringomasLaser assisted
 Acne

·         Closed comedones

·         Open comedones

·         Senile comedones

Acne keloidalis nuchae

Steatocystoma multiplexBasal cell carcinoma
Acne scar resurfacingSebaceous hyperplasiaBlepharoplasty
AngiokeratomasSebaceous cystClear cell acanthoma
AngiomasTrichoepitheliomaFrenuloplasty
AngiofibromasVerruca

·         Plana

·         Palmoplantar

·         Sub/periungual

Hypertrophic scar
AchrocordonsXanthelasmaKeloid
 Condyloma acuminataMatrixectomy(ingrown toe nails)
Cutaneous hornRhinoplasty
CallosityRhinophyma
CornSquamous cell carcinoma
Darier diseaseLess commonStable vitiligo
Dermatosis papulosa nigricansActinic chelitisSmall tattoo removal
Epidermal nevi

·         Compound nevus

·         Verrucous epidermal nevus

·         Nevus sebaceous

Bowens diseaseScar revision

·         Post trauma

·         Post surgery

·         Post burn

EphilidesCylindromas
Fordyce spotsCalcinosis cutis
Fox Fordyce diseaseCollagenomas
HemangiomasDigital mucus cyst
LentiginesErythroplasia of Queyert
Lichen simplex chronicusElastosis perforans serpiginosa
Lichenoid amyloidosis Favre racouchot syndrome
MiliaGranuloma faciale
Molluscum contagiosumHailey hailey disease
MelasmaHidradenitis suppurativa
NeurofibromasLichen sclerosus et atrophicus
Oral leukoplakiaLupus pernio
Pearly penile papulesLymphangioma circumscriptum
Pyogenic granulomasPorokeratosis
Prurigo nodularisPrimary hyperkeratosis of nipple
RhytidesTrichofolliculoma
Seborrheic keratosis

Contraindications:

History of keloid or hypertrophic scar, active bacterial or viral infection? Use of isotretinoin in the last 6 months, collagen vascular disease, atrophic hairless scars of burns and trauma.

Pre operative Procedures:

Informed consent: Proper Informed consent to be obtained , specifically mentioning the possible appearance of the post treated area , including possible pigmentory changes and need for post operative care.

Anaesthesia: Co2 laser being ablative laser anaesthesia is a pre requirement. Depending on the type of lesion these can range from topical anaesthetics i.e. EMLA(eutectic mixture of local anaesthesia) to local infiltration and ring or field blocks. Superficial epidermal lesions can be treated under topical anaesthetics   with minimal discomfort. Care should be taken to avoid lignocaine with adrenaline while locally infiltrating areas with end arteries including ear lobes, fingers, toes, nose and penis.

Intraoperative:

Being ablativeCo2 lasers pose a fire hazard. Presence of oxygen further increases the risk. Hair sprays and alcohol based gels are highly inflammable and hence moistened towels and sponges should be used to drape the perimeter of laser treatment areas. It produces plume of smoke due to thermal interaction with human tissue that may contain chemicals, portions of intact DNA, bacteria and viruses. Mechanical smoke evacuator system with a high-efficiency particulate air (HEPA) or an ultra-low penetration air (ULPA) filter should be used to capture the plume, nozzle of which should be placed possibly within 1-2 cm of the lasing site. Patient’s eye should be protected with an eye shield or wet gauze.

Postoperative:

It is vital to discuss postoperative care with the patient at initial consultation to establish if he /she are amenable and thus a candidate for laser: Post operative care includes:

·         Topical antibiotics for a week for superficial epidermal lesions post procedure.

·         Instructions to avoid picking the scabs.

·         Sun protection for lesions treated on face and neck.

·         Occlusive dressing in case of deeper lesions.

Complications:

Minor complications include, post inflammatory hyper and hypopigmentation,  erythema,  acne and rosacea  exacerbations. More serious complication include, hypertrophic scarring, delayed healing and ectropion formation.

Conclusion: Co2 laser has satisfactory outcomes with minimal side effects in various aesthetic and dermatology procedures. It is one of the most resourceful tools in dermatology practice.

References:

1. Krupa Shankar D, Chakravarthi M, Shilpakar R. Carbon dioxide laser guidelines. J Cutan Aesthet Surg.2009;2:72–80

2. Savant S. Textbook of dermatosurgery and cosmetology. 2nd ed. India: ASCAD-Mumbai; 2008. The carbon dioxide (CO2) and erbium: YAG (Er: YAG) lasers; pp. 462–76.

3. Hruza GJ. Laser treatment of epidermal and dermal lesions. Dermatol Clin. 2002;20:147–64.

Tranexemic Acid – A New Ray of Hope for Melasma

Introduction:

Melasma is a very common complaint presented to Dermatologists and Cosmetologists in India where obsession for white color is phenomenal.

Melasma is a chronic acquired bilaterally symmetrical, circumscribed hyperpigmentation of the face.

Pathogenesis of melasma is not yet clear and it has a very high rate of recurrence. These two factors pose a challenging problem to treating clinician. Lack of safe and highly effective treatment and high rate of recurrence is clearly reflected by new brand or formulation of depigmenting cream introduced on day to day basis  in the market.

It has highest prevalence in 3rdand 4th decade in women and in Fitzpatrick skin type III to V. However   it can also be seen in 26% men as reported in an Indian study.

Etiology:

The most important risk factor is Sun Exposure (UV Radiation) in a genetically susceptible individual.

The other factors are Pregnancy, Oral Contraceptive Pills, Hormonal Imbalance, and other drugs like Phenytoin and Spironolactone.

Clinical Features:

Melasma is classified in various ways.

It can be classified on the basis of level of pigment distribution as Epidermal, Dermal and Mixed. However the consensus of opinion is there is no clear distinction and almost all the cases fall in the category of Mixed pattern.

The anatomical classification is Centrofacial(63%), Malar(21%0 and mandibular(10%) pattern.

In India, the malar pattern (23%) is most often seen.

Before we discuss various therapeutic strategies, let us understand the newer insights in the study of pigmentation and their therapeutic repercussions.

Melanogenesis:

Melanogenesis implies the conversion of Tyrosine to Dopaquinone in a two-step reaction controlled by enzyme tyrosinase. Melanin biosynthesis occurs in organelles situated in the melanocytes. These melanosomes are then transferred to keratinocytes and impart the color to skin. Pigmentation is a complex process regulated by various intrinsic and extrinsic factors. The intrinsic factors are hormones like MSH, ACTH and corticosteroids. Various other cellular factors are endorphins, endothelins, prostaglandin and stem cell factor.

Ultraviolet rays are the major extrinsic factor in regulating pigmentation.

Ultraviolet rays induced pigmentation is mediated through keratinocytes and fibroblasts. UV Rays induce melanogenic factor in both these cells and stimulate melanosome transfer and distribution within keratinocytes.

Refer to the diagrammatic representation of Melanogensis

In melisma, number of melanocytes remains the same. However, there is increase in deposition of melanin in the epidermis due to hyperactive melanocytes. Melasma skin also shows features of photodamage like solar elastosis, collagen degeneration and increased vascularity. Affected skin also shows defective barrier function.

Knowledge of these pathophysiological changes can help us device better treatment strategy.

Target of therapy for Melasma is

1)            to prevent formation of melanin

2)            to reduce the transfer of melanosomes to keratinocytes

3)            to destroy melanosomes/melanosome laden keratinocytes

Treatment strategy:

1)            To find out the underlying cause and treat or avoid it. Measurement of endocrine parameters have shown elevated levels of leutinizing hormone and decreased levels of estradiol suggesting mild subclinical ovarian dysfunction. Therefore hormonal evaluation in case of persistent melasma becomes important.

2)            Sun Protection: is the main therapeutic component and counseling the patient for total sun protection is the most effective  therapeutic approach.

3)            Antioxidants: have an important role to play.  Chronic sun exposure causes inflammation and damage to keratinocytes which in turn stimulate melanin synthesis as a protective measure.

4)            Bleaching agents: Many bleaching agents are available and newer ones are entering the market as they form the main stay of treatment. However, evidence based drug still remains Hydroquinone. It inhibits the enzyme tyrosinase. The other molecules in this category are KojicAcid, Tetrahydrocurcumin, arbutin, liquorice and many more.

5 )     Retinoids have dual mode of action. They act by inhibiting the tyrosinase and increase epidermal cell turnover, thus eliminating melanin containing keratinocytes.

6)            Azelaic Acid : also has dual mode of action. It inhibits tyrosinase and has toxic effect on melanocytes.

In order to get better results and reduce the adverse effects, all these drugs are used in combinations.

Oral Treatment:

Tranexamic Acid  is a new entrant in this field of depigmenting agents.

It (trans-4-aminomethylcyclonexane carboxylic acid) is a synthetic derivative of amino acid Lysine. It is used as a hemostatic agent in surgical field and in menorrhagia due to its fibrinolytic action.

Njor in 1979, first studied and reported the action of TXA on melasma.

It has a novel and different mode of action than the drugs used so far.

Mode of action of TXA

Following UV exposure, there is an increase in melanosomes, their melanin content and their transfer to keratinocytes. UV exposure stimulated keratinocyte In turn stimulates  melanin synthesis as shown in the diagram.

TXA down regulates the conversion of plasminogen to plasmin, by attaching to the lysine binding system of plasminogen. This step down regulates the synthesis of melanin.

TXA also reduces vascularization, and therefore, proves useful in melasma.

Various clinical studies have been conducted to determine the effective dose.

Suggested dose of TXA is 250 mg two to three times a day. This dose is much lower than the hemostatic dose. It is the duration of the treatment and not the dose, which makes the treatment effective.

One study done on 260 patients suggested the dose of 250 mg for three months.

Adverse Reactions: Venous thromboembolism, Myocardial Infarct, Cerebrovascular Accidents and pulmonary embolism

Contraindications: Defective Color vision and Hypersensitivity to TXA.

Proper patient selection and ruling out potential risk factors resulting in hyper coagulability is essential.

Considering the safety profile, low rate adverse reactions and effectivity Tranexamic acid can prove useful in treatment of Melasma in combination with other local therapy.

References:

1.            Manoj k tembhre,SomeshGupta,StepheneCommo.Physiology of Pigmentation:New Biological Concepts associated with Skin and Hair pigmentation. In: Modern Cosmetic Dermatology (1stEdn). New Delhi:JaypeeBrothers Medical Publishers 2015; 62-71

2.            HurleyME,GueveraIL,GonzalesRM,etal.Efficacy of glycolic acid peels in the treatment of melasma.Arch Dermatol.2002;138:1578-82.

3.            TseTW,Hui E. Tranexamic acid: an important adjuvant in the treatment of melisma.CosmetDermatol. 2013;12:57-66

4.            Leslie Baumann,InjaBogdanAllermann.Depigmenting Agents. In : Cosmetic Dermatology Principles and Practice(2ndEdn). New York: Macgraw-Hill Medical publishing Division; 2009;279-292

5.            GodseKV,SakhiaJ. Triple combination and glycolic acid peels in melisma in Indian patients.JCosmet Dermatol.2011;10:68-9.

6.            KarnD,KC S, AmatyaA,et al .Oral Tranexamic Acid for the Treatment of Melasma.kathmanduUniv med J 2012;10(4): 40-43

7.            Cho HH,ChoiM,ChoS,etal.Role of oral Tranaxemic acid in melisma patients treated with IPL and low fluence QS Nd:YAGlaser.JDermatolog Treat.2013;24:292-6

8.            TseTW ,Hui E, Tranexamic acid an important adjuvant in the treatment of melasma.CosmeDermatol. 2013;12:57-66

How to Choose a Sunscreen?

Introduction:

Sunscreens are an important component of the therapeutic armamentarium of a dermatologist, cosmetologist and aesthetician. With the ever increasing demands in the patients for a more cosmetically acceptable sunscreen with lesser frequencies of application and its safety issues being a concern the quest for an ideal continues. Selecting a sunscreen for a patient is an art and should not be practised as a blanket regime. This article focuses on the basics of the mechanism of action of sunscreens, the suggested selection criterias and basic principles that should be followed while making a choice for the best possible sunscreen for a patient.

Indications for use of sunscreens:

The primary function of a sunscreen is to prevent damage of the skin following exposure to ultraviolet radiations. The common indications for usage of sunscreens include cutaneous conditions like(1):

1. Sunburn

2. Freckling, discoloration

3. Photoaging

4. Skin cancer

5. Phototoxic/ photoallergic reactions

6. Photosensitivity diseases

– Polymorphous light eruption (290-365 nm)

– Solar urticaria (290-515 nm)

– Chronic actinic dermatitis (290 nm-visible)

– Persistent light reaction (290-400 nm)

– Lupus erythematosus (290-330 nm)

– Xeroderma pigmentosum (290-340 nm)

– Albinism

7. Photoaggravated dermatoses

8. Post-inflammatory hyperpigmentation (postprocedure)

Classification:

Sunscreens are classified into organic and inorganic sunscreens.

Organic sunscreensInorganic sunscreens
UVB filters-

a. PABA derivatives – Padimate O

b. Cinnamates – Octinoxate, Cinoxate

c. Salicylates – Octisalate, Homosalate, Trolamine

salicylate

d. Octocrylene

e. Ensulizole

Titanium dioxide
UVA filters-

a.Benzophenones (UVB and UVA2 absorbers) –

Oxybenzone, Sulisobenzone, Dioxybenzone

b. Avobenzone or Parsol 1789 (UVA1 absorber)

c. Meradimate (UVA2 absorber)

Zinc oxide
Newer filters-

Ecamsule (Mexoryl SX), Silatriazole

(Mexoryl XL), Bemotrizinol (Tinosorb S),

Bisoctrizole (Tinosorb M)

Kaolin, calamine

Basic definitions:

UVB sunburn protection factor is defined as the minimal erythema dose of photoprotected skin divided by the minimal erythema dose of unprotected skin. It is noteworthy that a sunscreen with an SPF of 15 blocks about 93% of UVB radiation, while one with an SPF of 30 blocks about 97% of UVB radiation (2).

The most commonly used UVA protection indice is the Boots star rating. In vitro measurement of the ratio of a product’s UVA (320-400 nm) absorbance over its UVB (290-320 nm) absorbance is used to calculate its Boots star rating.

Broad spectrum sunscreen: Critical wavelength > 370 nm AND UVA protection factor > 4 (1).

Water-resistant sunscreen: Maintains the label SPF value after two sequential immersions in water for 20 min (40 min)(1).

Very water-resistant sunscreen: Maintains the label SPF value after four sequential immersions in water for 20 min (80 min).

The application of sunscreen is important both in quantity and in frequency for maintaining its affectivity. The recommendations include every 3-4 hourly application of sunscreen over the sun exposed areas. It is worthwhile to repeat the application of sunscreens in cases of photosensitive and pigmentary disorders or in cases of sensitive skin. The exact amount of sunscreen required to be applied on the skin for optimal protection should be recommended by the manufacturer based on the method and quantity of the sunscreen formulation used for determination of the SPF(3). When using physical sunscreens, it is advisable not to rub them too hard as they work best on the surface of the skin. They leave the surface of the skin with a milky glaze which can be quite useful for gauging which skin areas you are covering and which one may have missed.

The quantity to be applied is determined by the tea spoon rule which states:

“Teaspoon rule”(4)

3 mL (slightly more than half a teaspoon)

• for each arm

• for the face and neck

6 mL (slightly more than a teaspoon)

• for each leg

• for the chest

• for the back

The choice of sunscreens is determined by various patient related factors, environmental factors and by the quality of a sunscreen itself.

The patient factors which need to be considered while administering the sunscreens include the following:

1.       Nature of disease/ skin condition– conditions like photosensitive dermatoses and pigmentary disorders would require a sunscreen with a higher SPF and substantivity than while recommending sunscreens to patients with skin tanning.

2.       Age of the patient– it is better to choose inorganic sunscreens in children less than ten years of age and better to choose chemical sunscreens for an older patient as the use of sunscreens in neonates and children still remain debatable.

3.       Affordability– newer sunscreens with both UVA and UVB filters with newer technologies like sunspheres, nanospheres and with a higher substantivity have a higher pricing thus increasing the cost burden on the patient. Choosing a sunscreen which a patient can afford and whilch serves to benefit the disease increases patient compliance

4.       Skin type– while selecting a sunscreen the skin type of the patient based on Fitzpatrick grading helps to determine the choice. Apart from this knowing the nature of the skin of patients as to dry or oily or sensitive helps in choosing the formulation. A gel or gel cream based formulation is preferred in cases of oily skin whereas a lotion is preferred in dry skin conditions

5.       Site of sunscreen application– Although sunscreens are applied on photoexposed areas it is worthwhile to divide the areas on the basis of cosmetic appeal of the sunscreen. For example a gel based or powder touch sunscreen would be of choice while choosing the face area whereas an oily formulation or physical blocker may be acceptable for the hands and feet. Dividing the areas and choosing sunscreens improves patient compliance and reduces cost burden on the patient.

6.       Cosmetic acceptability– sunscreens by default have an oily feel as the active ingredients are in an oily form, however newer formulations use various technologies to give a better texture to the preparations while maintaining Synergy between UV filters and photostability. This is of immense importance while prescribing sunscreens for cosmetic reasons.

7.       Ease of application– Patient compliance is a problem with respect to application as sunscreens demand to be reapplied frequently atleast every 3-4 hourly. Choosing a sunscreen which has a higher substantivity helps in reducing the frequency of application and thereby improving patient compliance.

8.       Nature of job/ work profile of the patient- a general idea regarding the nature of job of the patient is important as it gives a fair idea regarding the amount of sun exposure as well as the ease of application of sunscreens

Environmental factors:

The choice of sunscreens especially the formulation and SPF selection to a certain extent depends on the environmental condition. Choosing a gel based or cream based sunscreen is better in places of higher humidity whereas an oily formulation is preferable in cold and dry places. Sunscreens need to be applied every two hourly in places of higher altitude with a cooler climate than on the plains. Sunrays are the strongest between 9am -4pm, when it is worthwhile to avoid direct sun exposure, use physical barriers in combination with chemical sunscreens.

Sunscreens quality:

1.       Substantivity of the sunscreen- sunscreens that are long acting require less frequent application and may be used in patients who cannot apply sunscreens regularly.

2.       Texture of sunscreen- A sunscreen which has a powdery feel or a sheer touch or a dry touch is more cosmetically acceptable thereby making it easy to use on areas like face.

3.       Hypoallergenic properties- in cases of sensitive skin a sunscreen with least potential for irritation may be chosen like physical sunscreens as opposed to chemical sunscreens.

Conclusion:

Choosing a sunscreen is not anymore a blanket therapy in dermatology. It is an art which needs to be mastered by combining years of experience with patient handling and a thorough knowledge of the range of products available in the market. This article tries to summarize the practical points that need to be considered while selecting a sunscreen which aims at reducing the cost burden, improving compliance and increasing the aesthetic well-being in a patient.

References:

1.       Kaimal S, Abraham A. Sunscreens. Indian J Dermatol Venereol Leprol 2011;77:238-43.

2.       Draelos ZD. Compliance and sunscreens. Dermatol Clin 2006;24:101-4.

3.       More BD. Physical sunscreens: On the comeback trail. Indian J Dermatol Venereol Leprol 2007;73:80-5.

4.       Schneider J. The teaspoon rule of applying sunscreen. Arch Dermatol 2002;138:838-9.