Dermatology Venereology Leprology

Cosmetic dermatology: An integral part of current dermatology curriculum Jasleen Kaur Sandhu Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):1-2

Methods to overcome poor responses and challenges of laser hair removal in dark skin Shehnaz Zulfikar Arsiwala, Imran M Majid Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):3-9 Conventional and advance technologies are available for laser hair removal. Complete and permanent hair reduction is not yet possible by treatment with lasers. Ideal patient for any conventional laser hair removal treatment is one who has thick, dark terminal hair, light skin and normal hormonal status. Factors that contribute to variable outcomes in laser hair removal can be broadly divided into patient related ones and the technology related ones. Skin type, hair color, thickness and density, degree of tan, hormonal dysfunction etc., constitute the patient related factors. The wavelength, fluence, spot size and pulse duration of the laser system are the technology related factors. There are some patients who respond variably, unpredictably or poorly to laser hair removal despite ensuring that indication for treatment is appropriate with adequate parameters of the laser system. This article reviews various patient related and technology related factors which lead to variable-to-poor outcomes in laser hair removal; and various challenges and limitations of laser hair removal technology in patients with dark skin types.

Optimizing Q-switched lasers for melasma and acquired dermal melanoses Sanjeev Jayanth Aurangabadkar Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):10-17 The Q-switched Nd:YAG laser is an established modality of treatment for epidermal and dermal pigmented lesions. The dual wavelengths of 1064nm and 532nm are suited for the darker skin tones encountered in India. Though this laser has become the one of choice for conditions such as nevus of Ota, Hori's nevus and tattoos, its role in the management of melasma and other acquired dermal melanoses is not clear. Despite several studies having been done on the Q-switched Nd:YAG laser in melasma, there is no consensus on the protocol or number of sessions required. Acquired dermal melanoses are heterogenous entities with the common features of pigment incontinence and dermal melanophages resulting in greyish macular hyperpigmentation. This article reviews the current literature on laser toning in melasma and the role of the Q-switched Nd:YAG laser in stubborn pigmentary disorders such as lichen planus pigmentosus. As the pathology is primarily dermal or mixed epidermal-dermal in these conditions, the longer wavelength of 1064nm is preferred due to its deeper penetration. Generally multiple sessions are needed for successful outcomes. Low fluence Q-switched Nd:YAG laser at 1064nm utilizing the multi-pass technique with a large spot size has been suggested as a modality to treat melasma. Varying degrees of success have been reported but recurrences are common on discontinuing laser therapy. Adverse effects such as mottled hypopigmentation have been reported following laser toning; these can be minimized by using larger spot sizes of 8 to 10mm with longer intervals (2 weeks) between sessions.

Isotretinoin and dermatosurgical procedures Venkataram Mysore, HM Omprakash, Gayatri Nagindas Khatri Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):18-23 Several early reports suggested that performance of dermatosurgical procedures in patients on oral isotretinoin is associated with abnormal skin healing, keloid or hypertrophic scar formation. However, this association has been recently questioned in some studies. This review examines this issue, analyzes the studies published and concludes that the recommendation made earlier about the need to avoid dermatosurgical procedures in patients on isotretinoin is based on inadequate and insufficient evidence and hence needs revision. The review also suggests that recent studies on the subject establish that performing such procedures is safe.

Complications of laser and light-based devices therapy in patients with skin of color BS Chandrashekar, Chaithra Shenoy, C Madura Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):24-31 Lasers and light-based devices are indispensable to an aesthetic dermatology practice. The growing popularity of lasers has been matched by a sharp increase in the incidence of complications. The Indian skin with its high melanin content is more prone to injury and careful setting of laser parameters, early detection of complications and immediate therapy are vital to avoiding permanent sequelae. We review the various complications that occur during laser procedures and their management.

Autologous noncultured melanocyte-keratinocyte transplantation in stable vitiligo: A randomized comparative study of recipient site preparation by two techniques Sumit Gupta, Vineet Relhan, Vijay Kumar Garg, Bijaylaxmi Sahoo Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):32-38 Background: Accurate preparation of recipient area is a critical step in melanocyte-keratinocyte transplantation procedure for vitiligo. It is an important potential step for adaptation in the quest to achieve better results and ablative lasers potentially offer excellent precision over margin and depth control in achieving that. Objective: To compare between the two techniques used for recipient site preparation: Er:YAG laser ablation and mechanical dermabrasion for melanocyte-keratinocyte transplantation procedure in terms of re-pigmentation achieved and adverse effects seen. Methods: A randomized comparative trial was performed among 32 patients of stable vitiligo undergoing melanocyte-keratinocyte transplantation procedure. In Group A (n = 15), recipient site preparation was done with Er:YAG laser, and in Group B (n = 17), it was done with a motorized dermabrader. Patients of both groups were objectively assessed for re-pigmentation at 1, 3 and 6 months. Results: A total of 253.696 cm2 of depigmented surface was operated upon and re-pigmentation of 125.359 cm2 (49.4%) was achieved. On comparison between two groups, no statistical difference was found with respect to total re-pigmentation achieved (Group A: 54.67% vs Group B: 48.841%, P = 0.663) and grades of re-pigmentation achieved (P = 0.796). Occurrence of adverse events was also statistically similar in both the groups. Conclusion: This study did not reveal any statistically different outcome (in terms of re-pigmentation and adverse effects) between the two methods of recipient site preparation – motorized dermabrasion and Er:YAG ablation. Limitations: This study is small and larger studies are needed to ascertain the benefit of Er:YAG for recipient site preparation. Future studies may also ascertain variables such as time taken to prepare the recipient area, nature of bleeding, postoperative healing, difficulties in specific area, cost of the procedure, patient comfort and ease of the surgeon, rather than comparing the re-pigmentation alone.

A randomized, open-label, comparative study of oral tranexamic acid and tranexamic acid microinjections in patients with melasma Vinod K Khurana, Rachita R Misri, Swati Agarwal, Akhilesh V Thole, Sachin Kumar, Tanu Anand Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):39-43 Background: Melasma poses a great challenge as its treatment modalities are unsatisfactory. Treatment using tranexamic acid is a novel concept. Aim: This study aimed to compare the therapeutic efficacy and safety of oral tranexamic acid and tranexamic acid microinjections in patients with melasma. Methods: This is a prospective, randomized, open-label study with a sample size of 64, 32 in each treatment arm. Thirty-two patients were administered localized microinjections (4 mg/ml) of tranexamic acid monthly in 1 arm, while in the other arm, 32 were given oral tranexamic acid 250 mg twice a day. Patients were followed up for 3 consecutive months. Clinical photographs were taken at each visit, and a modified melasma area and severity index scoring was performed at the beginning and end of treatment. Results: Improvement in melasma area and severity index score in the oral group was 57.5% as compared to 43.5% in the intralesional group. All 32 patients in the oral group (100%) showed >50% improvement, out of which 8 showed >75% improvement. In the intralesional group, 17 (53%) patients had >50% improvement, of which 3 had >75% improvement. The remaining 15 patients in this group had <50% improvement. Thus, the oral group showed a more significant response as compared to the intralesional group. No major adverse effects were observed in both the groups. At 6-month follow-up, two patients (6.2%) in the oral group had recurrence as compared to three patients (9.4%) in the intralesional group. Limitations: A small sample size was one of the limitations in this study. The dose of tranexamic acid in microinjections and the frequency of injections could have been increased. Conclusion: Tranexamic acid provides rapid and sustained improvement in the treatment of melasma. It is easily available and affordable. Oral route is undoubtedly efficacious, but the results of microinjections, while encouraging, can probably be enhanced by either increasing the frequency of injections or increasing the concentration of the preparation.

Safety and efficacy of autologous noncultured dermal cell suspension transplantation in the treatment of localized facial volume loss: A pilot study Alok Kumar Sahoo, Savita Yadav, Vinod K Sharma, Anita Singh Parihar, Surabhi Vyas, Somesh Gupta Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):44-50 Background: Available options for correction of facial volume loss, such as synthetic fillers, autologous fat and cultured fibroblasts, have limitations viz. temporary effect and high cost. Aim: To assess the use of a novel technique, autologous non-cultured dermal cell suspension transplantation, for correction of localized facial volume loss due to inflammatory pathologies. Methods: It was a pilot study conducted in the Dermatology Outpatient Department, All India Institute of Medical Sciences (AIIMS), New Delhi, India. Autologous non-cultured dermal cell suspension was transplanted in a total of 10 patients, out of which 5 had predominantly dermal loss and the rest had predominantly lipoatrophy. The donor tissue from the gluteal region was digested into a single cell suspension using collagenase-1 and injected into the recipient area. The outcome was assessed subjectively by patients and investigators and objectively using ultrasonography. Cell count, viability testing and measurement of mesenchymal stem cells were also done. Results: On assessment of patients, the median improvement in the predominantly dermal atrophy group at 3 and 6 months was 70% (range: 10–90%) and 80% (range: 0–90%), respectively, and in the predominantly lipoatrophy group, 0% (range: 0–40) and 0% (range: 0–50), respectively. Mean thickness of dermis + subcutis at the baseline was 1.835 mm (range: 0.89–6.04 mm), which increased to 2.912 mm (range: 0.88–7.07 mm, P = 0.03) at 6 months. Limitations: Our pilot study has some limitations such as small sample size and heterogeneity of the recruited patients. Conclusions: Autologous non-cultured dermal cell suspension transplantation appears to be safe and effective in localized facial dermal defects because of inflammatory pathologies, but not effective in deeper defects.

Toenail concentrations of zinc, selenium and nickel in patients with chronic recurrent warts: A pilot two-group comparative study Mohamed El-Komy, Vanessa Hafez, Rania Abdel Hay, Dina Mehaney, Iman Hafez Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):51-55 Background: Normal immune functioning requires sufficient levels of trace elements including zinc and selenium, while elements such as nickel can be immunotoxic. Aim: To assess long-term abnormalities in zinc, selenium and nickel levels in patients with chronic recurrent warts. Methods: Toenail samples were taken from 28 patients with chronic recurrent warts and 30 apparently healthy matching controls were analysed. Toenail concentrations of zinc, selenium and nickel were measured using inductively-coupled plasma-optical emission spectroscopy. Results: Selenium levels were significantly higher in patients than in controls (P = 0.03). Levels of trace elements did not correlate with the number or duration of warts. Toenail nickel levels in all subjects were higher than globally reported values. Limitations: A small sample size and the absence of regional reference ranges for concentrations of trace elements in toenails. Conclusion: Zinc does not seem to be involved in the chronicity of warts, and it is unclear if selenium has a protective role against warts. Our finding of high concentrations of nickel in both patients and controls raises concerns about environmental exposure.

Successful treatment of metastatic extramammary Paget's disease with pemetrexed monotherapy systemically and 5-fluorouracil topically Kexu Chen, Hanlin Liang, Jiewen Peng, Yanfang Zheng Indian Journal of Dermatology, Venereology, and Leprology 2019 85(1):56-59 Advanced extramammary Paget's disease does not have a standardized treatment guideline as its incidence is low and has been rarely reported in literature. Here we describe a case of metastatic extramammary Paget's disease successfully treated with topical 5-fluorouracil (5-FU) and systemic pemetrexed. The therapy was safe without any appreciable adverse effects like diarrhea, rash, neutropenia or fatigue; maintaining remission for more than 6 months. Thus, we propose 5-FU and pemetrexed as the first-line therapy for advanced extramammary Paget's disease, especially for aged patients with unresectable skin lesions.