Ethicare Remedies

Listening to Your Patients Well -Your Exceptional Competitive Point Why and How?

It’s vital even with a prolific practice. Learn the art of saving your time.

In the initial phase of a doctor’s career, he/she tends to listen to each and every patient carefully and empathetically. Factors such as limited number of patients, the desire to get rapidly established, less experience, the attitude to learn and desire to serve better than anybody else encourage him/her to listen to patients attentively. Gradually, as the number of patients grows, the doctors become more experienced and knowledge expands, paucity of time becomes a constraint. Even if he/she wants to, he/she finds him/herself unable to listen to the patients the way he/she used to in early days of his/her practice.

With the passage of time, as a result of the experience and knowledge of years, the doctor starts diagnosing the problem within a moment without listening to the full complaint list of the patient. Of course, the diagnosis and the treatment are generally accurate and the results are also effective but the patients, at times, begin to feel ignored and develop the impression that the doctor has grown indifferent. The doctor’s practice is not affected by this beyond a point because he is top-notch in his diagnosis and treatment, but it does affect the satisfaction level of the patient.

At present, most of the doctors face a similar situation. They are, at times, not fully aware of the shortcoming that has crept into their practice. They may continue to believe that they listen and attend to patients in the same manner and yet their patients may not be happy. At some deeper level, they do ponder over this however that ‘How can I devote so much time in listening to each patient while I have such a large number of patients to attend to?’ It may be a good idea to pause and ponder for each doctor. Is it not everyone’s experience as a doctor in present times?

On one hand, you are required to attend to a large number of patients every day and on the other hand you also wish to satisfy your patients by giving them your focused attention. Before we dig deep into ‘How to overcome this situation?’, let us get clarity on ‘Why is it important to listen to your patients?’

Why?

You attend to a number of similar types of patients every day.However, this is a fact only you are aware of! Your patient doesn’t know that.
Your patients perceive their illness as unique. But for you, he is just one more patient with similar symptomsand established treatments.
If you start writing a prescription immediately after listening to one or two complaints only, he feels that your prescription addresses only those two complaints, because he/shefeels you have not listened to his full list of complaints. He/she believes that the remaining complaints are not dealt with in the prescription, even if your diagnosis is based on your knowledge of the full list of complaint associated with described symptoms.
Many a timeyou would have observed in many ailments, a good listener is all a patient needs in addition to his treatment, and listening to the patient dramatically impacts his health.
By listening to your patients, you can unravel many hidden fixations which may be a part of their illness as well as their socio-economic status and psychological factors.

Now as we have cleared the ‘Why’, let us explore ‘How to listen to your patients carefully and still save your time?’

How?

The first and foremost way is that history should be taken thoroughly by a counselor or a receptionist. Your counselor should educate the patients that this is for the patients’ Before the doctor interacts with the patient, he will have the complete case history of the patient on his table. This will save the doctor’s time and all the complaints will be addressed properly.
Keep some brochures in the waiting room. Having patients’ awareness brochures of different diseases along with the common symptoms, and a TV presentation running on the television to educate patients on different diseases and symptoms will help save your time. Many a time some of you may perceive TV presentation and brochures are just sales tool meant to boost your revenue, but it is not so. It also helps in patient satisfaction and in saving your time.
As the patient starts talking about symptoms of his disease, you should start adding more relevant symptoms of the disease. It will be easier for you to note additional symptoms which will save your time. As you add the relevant symptoms, he perceives that you are totally aware of the complete scenario and you understand the disease Hence, not only does he get due satisfaction but you are saving your time too and you are perceived as an expert.
You should give an impression to your patient that you are aware of the prevailing contagion.Convey to the patient that this ailment is widespread currently, and that you treat numerous patients for the same disease every day. When you communicate in this fashion, you win the confidence of your patient and he perceives that you are aware about all the existing health issues. Again you save time and patient satisfaction would be high.

Another way of keeping balance between patient satisfaction and saving time is to give them the example of your immediate previous patient who may have been suffering fromthe same illness, or your past patients with similar This would also help patients relate to this and gain confidence about your treatment.
Avoiding unnecessary conversation on irrelevant topic will allow you to focus more on the patient’s problem and listen to him/hercarefully which again will save your time.

Useful Tips For Budding Derms: 2 Consolidating Your Practice

“Genuine warmth, empathy and a positive body language are more important prerequisites than mere knowledge of dermatology!”

In the early days of practice, the struggle is to get patients coming. The bigger battle is to retain those patients for a reasonably long period. Once the dermatologist is popular among the people and one touches the magic figure of, say, 1000 patients in the vicinity that becomes a treasure trove to generate new patients. They would not only come for their own problems but also refer family members and friends, provided the intensity of faith is strong.

Quite often their neighbors may be consulting other dermatologists and not getting results or the desired answers. These neighbors can get redirected for second opinion if the bond with the original patient is strong. Thus the art of consolidating the practice has to be carefully cultivated. Based on inputs from several senior medical practitioners here are some points to be borne in mind.

Be honest

In chronic, recurrent eczema, psoriasis, lichen planus, urticarial etc. it is quite possible that treatment does not produce long-term remission. Treatment with immunosuppressive drugs too may be unsuccessful despite the patient following up regularly for several months. In these cases, it is a good idea to tell the patient honestly that they could try out alternative options or seek a second opinion. Most of them will be willing to give you more time in such a situation.

Two possibilities can occur if s/he goes to some other consultant: If the condition improves, he will thank you mentally for being truthful and happy that a ‘cure’ is found. Conversely, if he does not get any better s/he may return to the original doctor saying: “I have realized how difficult my case is, so doctor, why don’t you give it another try.”

Another probability may occasionally occur, wherein the patient will seek your opinion on whom to go for advice. In this scenario, you could refer him to your mentor or senior whom you have worked with. In all these situations, it is imperative that the work-up and documentation is complete so that the dermatologist giving the second opinion is very clear how well you have managed the case, prompting him to apprise the patient that you have given him the best treatment possible!

Do not fall in love!

While one would like to keep trying to help patients of autoimmune or other disorders, do not stop them from going for a second opinion if they hint at such a likelihood. Letting them go will only indicate that you’re okay to get your prescription validated by someone else. If the patient has a strong bond with you, they will definitely come back in the future. On the contrary if they don’t return, you have one patient less who doesn’t have full trust in you.

A patient with a chronic, unremitting disease who does not have sufficient faith in you despite your best efforts is better off sitting in someone else’s clinic and chewing up the new dermatologist’s brain. Moreover, it makes more economic sense that he or she is not seated in your waiting room and de-motivating those who are eager to see you!

Choose your patients

This title may be perturbing at first glance making one wonder whether one can really choose the people who come for consultation. While it is not possible to know what kind of person comes for treatment the first time, it is certainly up to the doctor to encourage or discourage the patient to return for repeat visits.

Most patients are indeed patient in the waiting rooms and wait for their turn quietly. Yet there will be some trouble makers who keep irritating the receptionist and wanting to be taken out of turn or to know how much more time it will take for his turn. Or some may walk over to the receptionist’s and leaf through the appointment list. Such patient’s disturb the privacy of the receptionist and also her peace of mind which finally affects her work.

It would be wise to deal firmly and curtly with such patients so that the smooth functioning of the clinic is not disturbed. Politely telling the patient not to irritate the girl is necessary even though it may displease the former.

Also there is another category of patients who will instigate others in the waiting room about “lousy appointment system” or having to wait for long despite having an appointment. Many times the irritating person is just one but s/he manages to provoke others creating chaos outside. Deftly, control that one!

That way the annoying ones will go somewhere else and disturb another doctor’s peace! It is very important that while in the clinic the consultant’s mood is not spoilt by one miscreant as it could affect the doctor’s interaction with the rest of the patients who remain to be seen.

Perform procedures with discretion

Although patients may be willing to spend large amounts or get themselves ‘peeled’ or ‘derma-rolled’ on the first consultation, beware. It is better to let the patient be counselled about the pros and cons of the procedure in advance and allow them to go home and sleep with that information, before turning up another day with specific appointment for the procedure. This way s/he will be in a better frame of mind to go through with it even if there is slight discomfort.

Moreover, on the appointed day, they will be well prepared with the procedure fees to be paid as compared to day one when they may be short of funds, potentially leading to embarrassment for all concerned.

A major advantage of not doing procedures rightaway is the minimal “adverse reaction” from family members who may not agree with their son or daughter in-law undergoing certain procedures. This situation arises very often in the case of teenagers (even if they are over 18 years of age) who may get a bashing at home if they reach home with a red face and empty pockets! Some of them may not return subsequently for repetition of glycolic peels etc. if their pocket money is stopped. What is even worse is when their parents turn up the next day to question and make the doctor feel uncomfortable.

While performing procedures where the opinions are subjective e.g. fairness, whitening, glow, shine, wrinkling, fine lines, loose skin, prominent ‘pores,’ etc. there is high possibility of the expectations not being met 100%. In such cases, the consultant should carefully, clearly and correctly mention to the patient and the parent what outcome is to be genuinely expected.

Train the patient

Patients who have to follow up with the doctor for several months, will gradually learn the pattern of the dermatologist’s prescription. He will understand for which lesion a particular cream is to be applied during a relapse.

For example, in a case of plaque type of Psoriasis vulgaris who shows good recovery, while stepping down topical corticosteroid from Clobetasol propionate to Mometasone furoate the patient could be made to understand the thought process involved. If the patient is educated and possesses average level of understanding, he can then be taught to reverse the order for a short while if there is an aggravation.

Obviously this kind of ‘education’ should be provided with a warning and time limits about hazards of overuse. Such a training relieves the patient the tedium of booking an appointment, finding transport and finally reaching the clinic etc. just to get a small advice. Such a consultation also holds up the busy dermatologist’s precious time which could, instead, be allotted to a more rewarding procedure! Obviously, such training to the patients could rob the dermatologist of a “consultation opportunity!” Yet, the convenience provided to the patient will make him thank the dermatologist at all times. This attitude will motivate the patient to recommend the consultant’s name to several friends and relatives. Thus the “consultation opportunity” lost will be rewarded in multiples through new patient visits!

Surprise element: it’s FREE!

Doctor’s consulting room interaction is usually very predictable after the first visit. The doctor as well as the patient knows the sequence of events in the doctor’s clinic. The consultation will end with the patient paying fees to the doctor. Most dermatology patients have to keep visiting the doctor several times. In chronic dermatoses the visits continue monthly for more than a year.

In all these cases the patient will end up paying and paying fees each time. It would be a good idea to refuse to take fees during an occasional consultation. The surprise and relief that you get to see on the patient’s face when they understand that the doctor has not charged for his advice is more than money can buy!

The genuineness of the doctor’s empathy with the patient is evident with this masterstroke. The thought of the patient that his doctor has given adequate time and not charged for his treatment further consolidates their bond.

In addition to the above, each one of us can further find novel opportunities in their practice that allows your practice to take off!

In the third and concluding part, the author writes on ‘Widening the base’.

Deoxycholic Acid for Double Chin

Deoxycholic acid is a bile acid formed by bacterial action from cholate. Bile acids are also steroidal amphipathic molecules derived from the catabolism of cholesterol. Bile acids are physiological detergents that facilitate excretion, absorption, and transport of fats and sterols in the intestine and liver. The unique detergent properties of bile acids are essential for the digestion and intestinal absorption of hydrophobic nutrients. Bile acids have potent toxic properties (e.g., membrane disruption) and there are a plethora of mechanisms to limit their accumulation in blood and tissues.

Deoxycholic acid acts as a detergent to emulsify and solubilize fats for intestinal absorption, is reabsorbed itself, and is used as a choleretic and detergent. When injected subcutaneously, it disrupts cell membranes in adipocytes and destroys fat cells in that tissue. In April 2015, deoxycholic acid was approved by the FDA for the treatment submental fat to improve aesthetic appearance and reduce facial fullness or convexity, allowing for a safer and less invasive alternative than surgical procedures.

It is rapidly absorbed following SC injection, peak plasma time being 18 minutes.

Deoxycholic acid is excreted along with the endogenous deoxycholic acid in the feces with levels return to the endogenous range within 24 hours.

Deoxycholic acid is injected into subcutaneous fat tissue in the submental area using an insulin syringe, 30G needle and 13 mm of length. The needle should be held tangential to the skin or the skin needs to be pinched away from the underlying structures before injecting. The treatment is divided into points spaced 1 cm apart and 0.1 to 0.2 ml of the medicine is used in each point. The number of points depends upon the area and fat content. Up to 5 to 10 ml may be used in a given session. The number of sessions depends upon the extent of double chin but the treatment should only be repeated a month apart. Use of Deoxycholic acid outside the submental region has not been established and is not recommended.

Injections cause edema at injection sites, pain, erythema, induration and pruritus and may also cause hematoma, numbness, paresthesia nodule or ulceration (intradermal injection) in rare circumstances.

Presence of infection at the injection site or pre-existing dysphagia is a strong deterrent for the treatment. Patients shouldn’t be on anticoagulants or have bleeding abnormalities. Do not inject above the inferior border of the mandible. Do not inject within a region defined by a 1- to 1.5-cm line below the inferior border (from the angle of the mandible to the mentum). Avoid injection into the platysma. Prior to each treatment session, palpate the submental area to ensure sufficient submental fat. Use of ice/cold packs, topical and/or injectable local anaesthesia (eg, lidocaine) may enhance patient comfort.

Patients with excessive skin laxity may not appreciate the results unless the laxity isn’t addressed. Such patients should be adequately counselled about the same. Radio frequency or thread lifting can be done for such patients.

Photographs courtesy Geosmatic C & C

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Practice Challenge: How To Price Your Treatments Right!

Introduction:

During our dermatology training, no time is spent on business issues. Cosmetic services pricing is very different from other medical specialties. While other specialties are governed by insurance / reimbursement rules for which there are guidelines from Medicare and insurance companies, our cosmetic procedures are under different tax structure. Setting the right price for aesthetic procedures is critical to successful cosmetic practice and a boost to practice as well as the team morale. However, this seemingly easy task can be very daunting due to crisis management and temporary price adjustments to overcome a short-term crisis. Also with the introduction of GST on cosmetic services, it is not an east scenario. So how does one arrive at those magic numbers? When to relook at the figures and modify? Here are few tips for the same from Dr Apratim Goel, Cutis Skin Studio, Mumbai:

1. Basic pricing structure:

Despite the common sentiment that it’s cash cow, cosmetic practice can be more time-consuming and stressful than the non-aesthetic alternative, starting with pricing. The first steps to consider are what percentage of your practice will be medical versus cosmetic, services you plan to offer patients, and how will you increase footfalls. It also may be a good idea to start with fewer services that the practice can provide efficiently and then add others. Once you’ve defined your practice parameters, then it’s time to do calculations.

2. Identify similar practices:

One can never compare apples with oranges. Isn’t it. So what dermatologists and aesthetic physicians should not worry about is to drop their prices to match salons and spas. Even if they provide a similar service like yours, the level of competency and margin of error and crisis management will be very different. So, don’t compete on price here even at the cost of losing some clients. Instead identify practices similar to yours and of course it is a good idea to be aware of the prices they are offering.

3. Services:

Calculate the amount of effort, consumables, time and follow-up efforts needed in a service and calculate the profitability. Make the prices of the services competitive that are higher profit generating. Don’t do a blanket drop for all the services you offer. There could be 2 services you offer that are money churners and others could be low profits. Try to manipulate the cost of high profit low effort services and with low consumables.

4. Calculate your cost:

It is funny that we doctor hardly know how to calculate the cost of each treatment. We feel that the cost to us is what we pay to but the product. But what about the other costs? What about staff, place rent, cost of electricity, breakdown of the laser etc. Also, the cost of consumables is to be considered as most of the technologies these days are with consumables and disposables. Well friends, that’s the reason most of the times we feel our business is booming and figures are good, but then there is no money in the bank.

5. Who performs the treatment: you or your staff:

Whether it is a treatment that the primary doctor (you) perform, or your assistant doctors or a therapists or other ancillary staff. The charges would be affected by this factor as well. In fact, just how in a salon a senior hair stylist charges are always higher than the junior or trainee, the charges must be similarly decided in your practice.

6. Location:

Treatment charges are hugely impacted by the local clientele and geographic location of the practice. In case you run 2 clinics and one is in a posh location and other somewhere in interiors and in suburbs, the prices can’t be the same. Your rents, maintenance costs etc. all are more in the posh locality and hence the charges need to be modified. Its ok to have different charges in your different clinics.

7. Popularity and availability of the treatment:

When we bought HIFU (high intensity focused ultrasound) 4 years back in Cutis, no one had even heard of HIFU. In fact, we were the first ones in Mumbai to have the technology and so were the trendsetters in deciding the prices. After that the technology gained popularity. However chemical peels for example are provided at almost all dermatology clinics. So, price your treatments depending on the availability and your unique USP in treatment.

8. Would you talk to a colleague?

Why not. If it is going to benefit everyone it is a healthy practice to talk to your friends and colleagues and not keep too much variations in prices. In the long run, we all realize that it is not only a price war. There are doctor shoppers and crooks amongst us too. Very often a patient quotes a ridiculous price being offered at a colleague’s clinic. It would be a good idea to ask the clients to get this statement in written to believe it’s true. Lastly never give away your prices on phone or display the price list on website.

9. Do not underprice:

Value your experience, skill and degrees also when you decide the prices of your services. Don’t compare your prices with a salon offering similar service at half the price. However impress upon the patient your credibility and skills. Very often patients doctor shop and sticking to your prices is best. Every practice has its takers. An effective way of giving patients value added from your knowledge and expertise is to explain them the difference with effective counseling. However it is easier said. Undervaluing is a common trend in our industry practice and I have faced it too. I remember telling a patient once “ I am Dr Apratim Goel, not a vegetable shop around the corner” !!

10. Prices inclusive or exclusive of taxes GST?

Well we all can have our own reasons for the way we do this. You can have the prices quoted to your patients inclusive or exclusive of GST, but for the purpose of your accounts, it is advisable to quote the prices exclusive of taxes. Also it gives the patient fair idea about the amount of taxes and your tax compliance.

Innovative And Conventional Uses Of Q Switch Laser

Introduction

Q Switched (QS) lasers – Treatment of choice for pigmented lesions and tattoos
QS Alexandrite 755nm & QS Ruby 694nm-shorter wavelength (WL) have high epidermal melanin absorption-hence not used in darker patients QS Nd: YAG 1064nm-longer WL, less absorption in epidermal melanin hence safe in darker patients

Indications-

Benign pigmented lesions

Epidermal lesions

Lentigens
Freckles
Café au lait macules
Nevus spilus
Seb Keratosis

Dermal lesions

Nevus of Ota
Nevus of Ito
Blue nevus
Hori’s nevus
Tattoos
Decorative, traumatic, cosmetic, medical
Professional or amateur
Black, blue, blue-black, green, red

OFf Label Indications

Laser Bleach
Periorbital hyperpigmentation
Onychomycosis
Perioral pigmentation
LPP
FDR
Schaumberg disease
Macular amyloidosis
Residual pigmented patch of vitiligo universalis

Dermal-Epidermal lesions

Melasma
PIH
Becker’s Nevus
Compound Nevus
Melanocytic nevi

Mechanism of Action:

Reduced size of melanocytes, cut down dendrite tributaries, fragmentation of melanosomes, removes melanin embedded in dermal macrophages. Melanin dilution, subcellular collagen stimulation, Tyndale effects, improve tone and texture of skin, global facial aesthetic look,
Thinning of epidermis, thickening of dermis, neovascularisation, neocollagen elastic fibre and ground substance formation, removal of dead cells and stimulate neoepidermal cell formation (melanin dilution)

Based on selective photothermolysis Also produce a photoacoustic effect Q switched laser pulses (nanoseconds) fracture ink particles & melanosomes into smaller fragments Some fragments eliminated trans epidermally Cleared by scavenger cells/resident macrophages

1064nm QS Nd: YAG

Longer WL – Deeper penetration
Poor absorption by epidermal melanin
Large spot size – less tissue splatter and purpura
Ideally suited for treatment of dermal melanosis and tattoos in darker patients

532nm FD QS Nd: YAG

Shorter WL-High affinity for epidermal melanin
Useful for treating epidermal lesions like nevus spilus, lentigens, solar lentigo, freckles, CALMs etc.
Risk of hyper and hypo pigmentation in darker skin

Protocol

Consent
Pretreatment photo
Test patches-followed up for 6-8 weeks
Anesthesia-EMLA cream
Sunscreens & Bleaching agent post-op

Treatment technique- dermal

Average of 6 sessions for dermal lesions and tattoos (Range 2-20)
6-8 weeks interval between each session
Amateur tattoos require fewer sessions than professional tattoos
Serial photographs taken to access improvement
Sunscreens and topical antibiotics post-op
Treatment technique-epidermal
1-3 sessions for epidermal lesions
Good clearing in most patients
Chance of recurrence high
Sun protection-mandatory and use of bleaching agents beneficial
Patients can be re-treated safely if lesions recur

Complications

Post-inflammatory hyperpigmentation
Post-inflammatory hypopigmentation
Textural changes and scarring
Allergic reactions to tattoo pigment
Darkening of skin-colored cosmetic tattoos

Key Points

1064nm QS Nd: YAG-treatment of dermal lesions and blue-black tattoos
532nm FD QS Nd: YAG-Epidermal lesions, red tattoo ink
Epidermal lesions clear in 1-3 sessions
Dermal lesions and tattoos-5-20 sessions
Longer WL preferable while treating darker patients (safer in darker skin)
Try to use a large spot size-less tissue splatter and purpura
Narrow margin of safety when using shorter WL like 532nm, 694nm in dark patients
Need for multiple sittings in dermal lesions and tattoos

Approach for treating pigmentary disorders with lasers

A tattoo is a form of body modification, made by inserting indelible ink into the dermis layer of the skin to change the pigment. Multicolor and professional tattoo respond poorly.

R20 Method

The new method of tattoo removal (called the “R20 Method”) is now being employed at Schweiger Dermatology in midtown Manhattan.
Rather than using only a single pass of the Q-Switched laser to remove tattoos, 4 passes of the laser are completed over the tattoo.
There is a 20-minute resting period between passes, so the individual treatments will be a little longer.
This allows for the whitening that forms on the tattoo (produced by tiny bubbles) to dissipate.
This whitening limits penetration of the laser, which is why the 4 passes of the Q switched laser cannot be performed within a shorter amount of time than the 20minute interval.
The R20 Method of tattoo removal produces tattoo pigment changes at greater skin depth than traditional one pass treatment.
However, the incidence of side effects was not increased with the more aggressive R20 treatment.

R0 Method

R 20 method has limitation of waiting time of 60-80 min.
In R0 METHOD, perflurodecaline (liquid perflurodecaline) is used to reduce frosting immediately so as to apply laser in quick succession without waiting for 20 min. frosting observed during tattoo removal is because of release of gas bubbles in stratum corneum.
When perflurodecaline is applied larger frosted area it absorbs release of gas and clears frosting with 3-5 second so next laser pass can be given immediately without waiting for 20 min.
Perflurodecaline has advantage of increase gas clearance from tissue, high optical clarity,it saturates air spaces when applied and thus increase depth of penetration of laser treatment, reduced collateral thermal tissue injury.
R0 method is as effective as R 20 method with reduced treatment time of 5mins.

PIH

What is post inflammatory hyperpigmentation?

Post inflammatory pigmentation is temporary pigmentation that follows injury (e.g. thermal burn) or inflammatory disorder of the skin (e.g. dermatitis, infection). It is mostly observed in darker skin types, thin skin and dry skin. Post inflammatory pigmentation is also called acquired melanosis.
More severe injury results in post inflammatory hypopigmentation, which is usually permanent.

Who gets post inflammatory pigmentation?

Post inflammatory hyperpigmentation can occur in anyone, but is more common in darker skinned individuals, in whom the color tends to be more intense and persist for a longer period than in lighter skin colors. Pigmentation tends to more pronounced in suninduced skin conditions such as phytophotodermatitis and lichenoid dermatoses (skin conditions related to lichen planus, such as erythema dyschromicum perstans).
Some medications may also darken post inflammatory pigmentation. These include antimalarial drugs, clofazimine, tetracycline, anticancer drugs such as bleomycin (flagellate erythema), doxorubicin, 5-fluorouracil and busulfan.

Tips

Take conservative approach while treating melasma. Avoid invasive or aggressive parameter.
The risk of post-inflammatory hyperpigmentation (PIH) is high during Melasma and Freckles treatment in Indian skin.
Textural changes and scarring occur rarely.
To diagnose and to treat melasma and freckles are very easy but recurrence is rule rather than exception. Always counsel patient about protective measures and maintenance sessions.
PIH resolves with time, some patients may need bleaching agents such as hydroquinone along with sunscreens.
Depigmented macules may persist for several weeks to months and may be difficult to treat. Due to multiple passes in same session or repetitive lasing within short span can cause this depigmentation. To prevent this, give enough time between two sessions or combine with fractional device in same session. Phototherapy/excimer light may be used to treat the hypopigmentation.
combination therapy of molecules, procedures and devices is the key to success
Avoid invasive or aggressive parameter in dark skin, dry skin, and thin skin (DDT approach)
Avoid invasive or aggressive approach for patient having h/o of lichen or macular amyloidosis and keloid.
Sun protection and topical therapy is must for each patient undergoing procedural therapy.
Don’t treat any patient who is reluctant or doubtful about follow-up of post procedure protocol.
Combination of various procedures and devices will reduce number of treatment sessions, overall treatment duration and will reduce chances of complications.
Always give first pass with larger spot size on entire face, then give localized lasing with small spot size.
Start with 50% energy of highest and then gradually increase 10% in each session until desirable result.

Why laser in melisma?

Dermal and mix melasma
If patient wants instant results
Patient not tolerating triple combination-irritation, contact dermatitis
Already sensitive skin
Melasma with active acne or pustular acne
For long lasting result
Patient of melasma with hirsutism or hypertrichosis
Can combine Q Switch with MD CP in melasma patient in same session

Cosmetic Warts: An Under-recognized Entity!

Cutaneous warts caused by human papilloma virus (HPV) constitute one of the most common viral infections of the skin and mucosae. After acquisition, the virus remains in the skin indefinitely and may give rise to recurrent lesions, the frequency of which depends upon the HPV serotype and host immunity against the virus. Warts also tend to spread locally around the site of original lesion by autoinoculation induced by trauma-like scratching, called “pseudo-Koebner” phenomenon). Most of the procedures employed for temporary hair removal (THR) such as shaving, threading, waxing, or using depilatory creams result in trivial unnoticeable trauma to the skin. In a patient with pre-existent viral warts, these may seed and spread, whereas in patients not yet exposed to HPV, THR procedures breach the protection of the epidermis and allow viral inoculation from an external infected source, such as a non-sterile razor blade or an infected thread or towel, resulting in fresh eruptions.

Case Description

Case 1: Verrucae Barbae

A 26-year-old man presented with multiple light brown-colored asymptomatic discrete flat papular lesions over the upper and lower neck (Figure 1), which he noticed within two weeks of getting his beard shaved from a local barber to whom he had gone for the first time. He had no history of similar lesions elsewhere in the past. He continued to shave regularly thereafter and noticed a gradual increase in number of lesions in the beard area of the neck. A clinical diagnosis of verruca plana (with spread due to shaving-induced pseudo Koebnerization) was made and lesions were successfully ablated with a bipolar radiofrequency device under topical anesthesia.

Figure 1: Verrucae Barbae: Multiple firm warty papules (verruca vulgaris) over the beard area of a 26-year-old man.

Case 2: Threading Warts

A 35-year-old woman presented with multiple skin-colored 2 to 4 mm sized flat-topped papules localized linearly as a cluster just below the left eyebrow for the last six months (Figure 2). She gave a history of noticing two such lesions below the left eyebrow six months earlier, which had appeared within 15 days of getting threading done at a beauty salon. Although she started doing threading herself instead of going to the salon, the lesions increased in number following each episode of brow-threading. There were no lesions elsewhere. Keeping a differential diagnosis of verruca plana and lichen planus, punch biopsy was performed, which confirmed the diagnosis of verruca plana. Lesions were carefully ablated under topical anesthesia with a bipolar RF device.

Figure 2: Threading Warts: Multiple skin-colored to violaceous, 2-4mm sized, flat-topped papules arranged linearly near the left eyebrow developed following eyebrow threading.

Case 3: Waxing Warts

A 23-year-old woman presented with a one-month history of multiple, skin-colored, flat, asymptomatic papules over the left shin (Figure 3). She had only three to four such lesions over the upper left thigh region for the past few months. However, numerous new similar-looking lesions suddenly spread over the left shin and lower thigh area within three weeks of waxing the leg. On closer examination of the legs, the lesions were present discretely as well as in a linear distribution suggestive of spread due to pseudo-Koebnerization. There were no similar lesions elsewhere on the body. The patient was unwilling to undergo lesional biopsy. Treatment with tretinoin 0.1% cream recommended for 6 to 8 weeks resulted in good improvement.

Figure 3: Waxing Warts: Skin-colored to pinkish flat asymptomatic papules clustered unilaterally over the shin of a 23-year-old woman that spread following waxing.

Comments:

First described by Heinrich Koebner in 1877, Koebner’s isomorphic phenomenon is the development of isomorphic pathologic lesions in the traumatized uninvolved skin of patients who have a pre-existing dermatosis. It may occur due to trauma induced by 1) mechanical or thermal trauma and allergic or irritant reactions (e.g., scratching, surgical incisions, needle-punctures, tattooing, shaving, insect-bites, vaccination, tuberculin testing, etc.); 2) dermatoses (e.g., dermatitis, folliculitis, zoster, etc.); or 3) therapy (e.g., radiotherapy, ultraviolet light, laser hair removal, etc.). Boyd and Neldner have classified Koebner’s phenomenon into the following three different groups: 1) true Koebnerization, described in psoriasis, lichen such as warts and molluscum contagiosum; 2) occasional localization (e.g., in Darter’s disease, lichen sclerosus); and 3) questionable Koebnerization in disorders with anecdotal reports (e.g., lichen nitidus, vasculitis, pemphigus vulgaris, etc.). While immunologic factors have been implicated in true Koebnerization, pseudo-Koebnerization represents seeding of surrounding tissues by trauma-like scratching or shaving and recently, threading. Warts are known to spread by seeding into surrounding areas in the beard area of men due to shaving or after tattooing and in women who shave their legs. Shaving has been the standard practice for men for ages to remove their beards and moustaches as well as remove hair from other parts of the body. Despite the use of best quality razors, the process of shaving entails inadvertent breach into the shaved skin allowing for HPV to inoculate from a pre-existing lesion over the face or due to exposure to an infected fomite (e.g., a hand towel). An electrical trimmer is less likely to result in seeding of virus and thus a preferred alternative to razor blade for men with multiple and/or recurrent beard warts.

Threading is the preferred THR used by women themselves at home or more commonly done by beauticians at beauty salons for removal of unwanted hair and eyebrow shaping and enhancing the cosmetic appearance of the upper lip. In this simple procedure, a double-stranded thread is held between both hands and one hand is twisted 5 to 6 times while tightly holding the other section of the thread tightly. Then the thread is converted to a figure 8 with two triangles and one triangle of the thread being placed over the eyebrow from where hair needs to be plucked. Keeping the thread juxtaposed to the hairline, quick opposing scissors-like movements against the direction of hair growth removes the hair. Threading may contribute to the spread of warts in the following two ways: 1) cross-infection from a client who had HPV infection and her thread was re-used for another person, or 2) spread of pre-existing warts if they are located in the threading territory. The snappy scissors-like movements of threading are sufficient enough to breach the protective epidermal barrier and allow HPV inoculation and seeding. To avoid warts due to threading, ideally, ablative removal of the pre-existing warts should be done as soon as possible and threading attempted only after complete healing of lesions occurs. Additionally, a fresh thread should always be used, the area which already contains some lesions should not at all be touched and any fomite suspected to be infected should not be allowed to come in contact with the depilated skin.

Waxing is another popular THR among both the sexes as it provides longer-lasting hair removal. Warm wax is applied to the area and after some time, it is removed (stripping the wax) in the opposite direction of the hair growth, pulling hairs out at the root. Apart from the pain, this THR method also abrades the skin during the stripping of wax.

All of these procedures are causes for inadvertent skin trauma creating a portal for infection. Another unrelated cosmetic practice that is well-known to cause eruption of warts is cosmetic tattooing. An infected tattoo needle is the most likely to inoculate the skin directly through penetration and implant the wart. A few such cases have been reported. Thus, I proposed the broad term “cosmetic warts” for all cases arising out of a cosmetic procedure including THR methods and tattooing.

Treatments commonly employed for these lesions include destructive, chemotherapeutic, virucidal, immunologic, and alternative modalities. Destructive treatments include cryotherapy, radiocautery, topical acids, cantharidin, surgical excision, laser ablation, and electrosurgery. Chemotherapeutic and virucidal therapies include salicylic acid, topical tretinoin, imiquimod, interferons, bleomycin, cidofovir, acyclovir, 5-fluorouracil, formaldehyde, and glutaraldehyde. Immunologic therapies include topical sensitizers, intralesional sensitizers, and cimetidine. Alternative therapies include radiation, acupuncture, ultrasound, hypnosis, localized heat therapy, folk therapies, and homeopathy.

Prevention is always better than cure. Deferring the procedure until pre-existing warts are ablated, or if the procedure cannot be delayed, strictly avoiding that area during the procedure, are of paramount importance. Secondly, beauty salon personnel should be educated about avoiding reuse of threads or blades during threading or shaving, respectively, and to use freshly laundered and hygienic towels on every new client. Tattooing should be carried out in a proper hygienic environment with fresh unused needles.

Moreover, all instruments (e.g., scissors, forceps, and razors) used for threading, shaving, and facials should be properly sterilized to avoid infection. Further, aestheticians should defer such procedures in individuals with vitiligo, psoriasis, lichen planus, bacterial infections, warts, or molluscum.

This article emphasizes the need to educate and sensitize patients, dermatologists and aestheticians about Cosmetic Warts that spread via pseudo-Koebnerization, especially because it is not uncommon and is easily preventable. Further, early ablation of visible warts may substantially reduce the overall burden of further spread of infection.

DISCLAIMER: This article is an informative synopsis of the detailed original article published as: Sonthalia S, Rahul A, Rashmi S. Cosmetic Warts: Pseudo-Koebnerization of Warts after Cosmetic Procedures for Hair Removal. J Clin Aesthet Dermatol. 2015 Jul;8(7):52-6.