The Rising Menace of Fungal Infections: Newer Problems and How to Deal with Them

Fungal infections are not unfamiliar to a dermatologist. They, in fact, comprise the bread and butter for us. However, what is new is a multitude of challenges that every Dermatologist these days faces at present:

  1. Resistance to topical and systemic antifungals
  2. Varied/not-so-classical presentation of lesions due to a number of reasons (mentioned below)
  3. Recurrences/relapses despite completion of antifungal regimen/complete compliance by patient

Let’s delve a little deeper into each of these issues:

1. Resistance to topical and systemic agents:

Q.When can we say that the patient has developed resistance to a particular agent?

A.In common practice, we can presume that the patient has become resistant to the topical/systemic drug when after 2-4 weeks of consistent and correct use, there is no clinically apparent or symptomatic improvement.

Q.How does resistance occur?

A.Resistance occurs when the fungus adapts itself to the fungistatic/cidal agent being used through some intrinsic genetic/biochemical mechanisms.

In practice, it develops as a consequence of

  • incorrect/inconsistent use by the patient
  • rampant abuse of antifungals by patient/medical practitioners
  • many over-the-counter preparations especially in India comprise a cocktail of unnecessary drugs, which modifies the growth of the fungus, causing it to temporarily cease its metabolic activity/reproduction, but thereafter a resurgence occurs leading to undue and aggressive fungal growth.
  • an infection with a drug-resistant species of fungus, in which case patient does not show the slightest sign of clinical improvement and it maybe advisable to consider doing a fungal culture/sensitivity.
Q.How can resistance be prevented?

A.On the part of the treating doctor:

– The Dermatologist should always start prescribing from the basic/lower antifungal molecule. Just as in case of antibiotics we start from Azithromycin/Amoxicillin, likewise we need to start from the lower molecule and then move up the ladder if we feel the former is not working, rather than directly prescribing the “latest molecule in the market”.

  •  Explain the correct usage of the drug to the patient in detail.
  • topical drug should to be applied 1 cm beyond the visible margins of lesions
  • dusting powder is particularly advised in intertriginous areas
  • treatment regimens should last at least 1month for extensive lesions.
  • topicals should be applied at least two weeks beyond clinical resolution
  • follow-up is quite important
  • Impress upon the patient the need for correct usage/ dangers of incorrect usage.

On part of the patient:

– Strict adherence to the treatment regimen is advised

– Non-usage of any other concurrent medications that he/she might have “used     earlier” and “got relief”

– It is advisable to consult a doctor rather than a chemist, for “some itch relief”

– It is advisable to a Dermatologist rather than a BAMS/BHMS doctor.

Q.Once it occurs, how to deal with resistance?

A.The ideal solution or the first step in the management of resistance is to acquire a confirmation microbiologically. But in case that is not possible, as is the case most of the times in practice, following methods can be used:

– Avoid monotherapy, ie, Combine a topical and systemic antifungal concurrently

– Both should preferably belong to different classes of drugs, so that if resistance occurs to one class of drugs, the other still works.

Prescribe Soap/Dusting powder for extensive lesions/ recurrent cases

– Prescribing combination drugs should be avoided.

– If a patient develops resistance while on systemic therapy, the patient should be asked to complete that regimen and then shift to a new drug rather than stopping the previous one mid-way and starting another one abruptly.

2. Varied/not-so-classical presentation of lesions:
  • Many a time, the varied/unpredictable presentations of superficial dermatomycoses pose a diagnostic challenge to the Dermatologist
  • Unusual/atypical infections are particularly common in following settings:
  • Patient has been treated by multiple doctors previously, including non-dermatologists
  • Use/abuse of over-the-counter drugs especially steroid-containing medications
    • Differential diagnoses to be kept in the mind while considering a patient to have Tinea:
      • Granuloma Annulare
      • Erythrasma
      • Inverse Psoriasis
      • Erythema Annulare Centrifugum
      • Contact Dermatitis
      • Frictional Dermatitis
      • Atopic Dermatitis
      • Eczema
  • Diagnosis and management become a difficult task and one has to tread with great caution and some basic bedside investigations might have to be performed to be able to come to the correct diagnosis. Eg. A simple KOH mount can help come to the correct diagnosis of fungal infections.

3. Recurrences/relapses despite completion of antifungal regimen/complete compliance by patient:

We often encounter patients in our practice who come and share with us that “rashes subsided and got cleared off but now it has begun again”.

What we should NOT do:
  • Prescribe yet another antifungal regimen
  • Add an oral antibiotic and continue both regimens for a longer time period (1 month instead of previously recommended 2 weeks)
  • Add a potent topical steroid to “counter the inflammation”
What we SHOULD do:
  • Check the compliance of the patient by taking a detailed history of usage of medications
  • Check for any underlying comorbidities that might be predisposing the patient for recurrence, eg, rule out Diabetes, Obesity, Type of Occupation (involving working in hot humid conditions, like cooking, working in factories), any underlying immunosuppressed states
  • Check for personal habits (frequency of bathing and use of fresh clean clothes, practice of personal hygiene, patient’s surroundings)
    • Check for any concurrent medications which might be causing reduced efficacy of the antifungal regimen due to potential drug interactions
    • Explain inter-personal transmission by fomites, advice patient to use separate towels, soaps, clothes
    • Educate and counsel patient to STOP using over-the-counter medications for the “ring worm”
    • Advise patients to be particularly careful during the hot/humid summer/monsoon seasons as fungal infections are on the rise during the said time periods.Check for family history of similar complaints and advice for concurrent treatment of other members if they have similar complaints.
    • Check for any concurrent medications which might be causing reduced efficacy of the antifungal regimen due to potential drug interactions
    • Explain inter-personal transmission by fomites, advice patient to use separate towels, soaps, clothes
    • Educate and counsel patient to STOP using over-the-counter medications for the “ring worm”
    • Advise patients to be particularly careful during the hot/humid summer/monsoon seasons as fungal infections are on the rise during the said time periods.
    In Summation:
    • The rising menace of fungal infections can be a massive challenge for dermatologists.
    • Going deep into the cause and avoidance of rampant abuse of antifungals can help curb the problem of resistance.
    • The importance of hygiene and simple home-measures can not be undermined and go a long way in preventing the spread/treating fungal infections.
    • Dermatologist plays a pivotal role in preventing and fighting the epidemic of fungal infections.

Non-energy Based Treatments of Acne Scaring: A Review

Introduction:

Acne Scars are the troublesome manifestation following acne, causing depression, social outcast, and most importantly cosmetic discomfort. They commonly affect those areas which are rich in pilosebaceous glands like face, back and shoulder. Genetic factors, disease severity and delay in treatment are the main factors influencing scar formation. A British study showed that 1% of the population reported having acne scars, 14% of which thought their scars to be disfiguring.

The acne scars are broadly classified as macular, atrophic & hypertrophic or keloidal scars. Atrophic acne scar are further divided into Ice Pick, Box, and Rolling Scars. Atrophic acne scars are more common than keloids and hypertrophic scars with a ratio 3: 1. The ice pick type represented 60%–70% of total scars, the box scar 20%–30%, and rolling scars 15%–25% in one clinical trial. Hypertrophic scars are typically raised and firm scars that remain within the borders of the original site of injury. In contrast, keloid scars form as reddish-purple papules and nodules that extend beyond the borders of the original wound.

Scar classification is important as it can help guide treatment options. Ice pick scars can extend deep into the dermis, which makes them resistant to conventional skin-resurfacing options. Rolling scars are wider and have fibrous anchoring to the subcutis, thus necessitating treatment at a subdermal level. Shallow boxcar scars are more amenable to skin resurfacing treatments whereas deeper boxcar scars are more resistant to such superficial treatments.

Treatment options can be broadly categorised into energy-based and non-energy-based. Commonly used energy-based technologies include ablative and non-ablative lasers, fractional radiofrequency, intense pulsed light and plasma skin regeneration. Non-energy-based devices include subcision, (micro) dermabrasion, microneedling, dermal fillers and chemical peels.

acne scaring 2

Subcision:

It is a non-operative technique that involves a needle being inserted subcutaneously and handled in a fanning motion in order to untether the fibrous strands within the scar, and stimulate new connective tissue formation that will help elevate the depressed surface of scars.

The treatment of post-acne scarring with subcision was assessed in many studies. The scars treated were mainly of the rolling type, with some studies including a combination of the other types. In a few papers, subcision was used in isolation; in one it was used in conjunction with subsequent suctioning; in one with either dermaroller or cryoroller application; in one with 15% trichloroacetic acid (TCA) peel; and in one study with 50% TCA peel. TCA Cross technique followed by subcision is also recommended for Ice pick scar.

In a randomised split-face study of ten patients, the effects of subcision with an 18-gauge Nokor needle were compared with those of collagen fillers in the treatment of different types of depressed acne scars. Assessment at six month follow-up for global improvement was graded as 2.95 and 3.05 and mean patient rating as 3.9 and 2.9 for subcision and fillers, respectively.1

Another study reported the results of a novel technique that included subcision with subsequent suctioning for a two-week period. They treated patients using mainly 23-gauge needles and applying suctioning with the hand piece of a MDA (Micro dermabression) device. The aim behind suctioning was the avoidance of scar re-depression. In patients with subcision and suctioning they observed a 60–90% scar improvement in respect to only 30-60% improvement among patients treated without subcision alone.2

A split-face study on 30 patients with multiple types of acne scarring assessed subcision followed by dermaroller on one side and subcision followed by cryoroller on the other. On the subcision and cryoroller side, mean percentage improvement was documented as 57% while, on the subcision and dermaroller side, mean percentage improvement was 40%.3

Subcision is one of the best treatments for acne scars. It is an outpatient department procedure, which is quick, cost effective and highly efficacious in acne scar management. It can be combined with other non-energy or energy based treatments to increase final outcomes. Yet a few adverse effects may occur like bruising, bleeding and acne flare up. Pre-treatment with Vitamin K, antiseptic cleaning and post treatment antibiotics may minimise the adverse effects.

Dermabrasion and microdermabrasion:

Dermabrasion (DA) and microdermabrasion  (MDA) are facial-resurfacing techniques that mechanically ablate damaged skin in order to promote re-epithelialisation. DA completely removes the epidermis and penetrates to the level of the papillary or reticular dermis, while MDA is a much more superficial treatment and only removes the stratum corneum, accelerating the natural process of exfoliation.

In a study, patients with moderate to severe post-acne atrophic scarring of various types underwent a series of eight weekly treatment sessions. They used suction powers in the range of 40–60 kpa and four to six passes in each direction were performed (directed horizontally, vertically and obliquely). The average treatment lasted approximately 15 min. Following eight sessions of MDA, 27.3% patients achieved no improvement, 45.4% mild improvement, 18.2% moderate improvement and 9.1% good improvement. No patients were found to have achieved very good improvement in scar appearance.4

MDA alone is not a promising technique for the treatment of acne scars. It could be used to treat all kind of scars to a limited extent and I propose to combine it with other existing treatment options.

Microneedling:

Microneedling has become an important treatment modality for atrophic acne scars. The principle of using microneedling is to initiate collagen induction. This is achieved by causing minute injury to the dermis with the use of micro needles.

In a few papers, microneedling was used in isolation, in one it was compared with glycolic acid (GA) peeling and in another it was used in conjunction with platelet-rich plasma (PRP).

A split-face study was done to access the effects of microneedling with PRP versus microneedling with vitamin C application. Result shows better response in patients treated with PRP compared with patients who received treatment with vitamin C.5

Another study compared the effects of PRP versus the CROSS peeling technique with 100% TCA versus combined microneedling and PRP in the treatment of atrophic acne scars. There was no statistically significant difference in the degree of improvement between all the treatments.6

Microneedling is considered equivalent to energy based treatments and it is best when it comes to treat rolling scars, while in other types of scars combination techniques should be preferred. There are a few adverse effects associated with microneedling like Post Inflammatory Hyperpigmentation, acne flare up, bruising, or milia formation. All adverse effects are usually transient and wouldn’t require stoppage to the treatment.

Platelet Rich Plasma

Platelet rich plasma had been used successfully in wound healing in several studies. Higher amount of platelet derived growth factors make it suitable to use in several other indications  such  as  treatment  of  androgenic  alopecia,  acne  scar,  graft  survival  in  hair transplantation, skin rejuvenation, better wound healing, face lifting and several other cosmetic procedures.

In our split-face study with 50 patients, the effects of microneedling along with topical application and intradermal injections of PRP were compared with those of microneedling and intradermal administration of distilled water. After treatment, PRP treated patients showed 62.20% improvement in acne scars and 45.84% improvement of acne scars in patients treated with microneedling with distilled water.7

Platelet rich plasma contains several growth factors needed for proper wound healing and collagen induction. It could be combined with both energy based or non energy based treatments.  PRP alone is not effective and is not worth trying, and should always be used in combination. Autologus PRP is cost effective, easy, and safe to treat acne scars without much adverse effects.

acne scaring

Fig A. 24 years female treated with three sessions of PRP with Microneedling

Dermal fillers:

Dermal fillers involve the injection of foreign body gels into the dermal or subdermal tissue in order to provide localised volume gain.  A few studies assessed the effects of dermal fillers, mainly in patients with rolling type scars. One can utilise poly-L-lactic acid (PLLA), collagen, polymethyl methacrylate (PMMA) and hyaluronic acid (HA).

In one study, patients with severe scarring from acne or varicella treated with injectable PLLA fillers. They achieved a maximum cumulative scar severity reduction of 46.4% at the seventh treatment visit.8

Another study assessed the effects of PMMA versus placebo for the treatment of atrophic rolling acne scars. The overall proportion of scars that improved by at least two points was 50% for PMMA and 21% for the control.9

In a different study, PLLA fillers were used to treat 22 participants with facial rolling scars. A satisfactory response was achieved in 63.6% of patients when assessed by physicians, 68.2% when assessed by blinded evaluators and 45.5% when assessed by the patients themselves.10

Fillers are still having a limited role in the acne scar management as most of them used are not long lasting, expensive. Though fat grafting could help in some cases, still durability is in question here. Adverse effects associated with fillers also make them less useful in acne scars management.

Chemical Peeling:

Chemical peeling is the process of applying chemicals to the skin in order to destroy the outer damaged layers, thus accelerating the normal process of exfoliation, leading to tissue remodelling, thereby decreasing scar appearance.

In a study, patients with post-acne scarring were treated using a modified phenol deep peel. Results were assessed using a four-point scale. 64% patients improved by 51% or more.11

In another study, ten patients were treated using 100% with the TCA CROSS technique. The improvement was assessed using a four-point scale and results were  interpreted as excellent if >70% reduction was observed, good if 50–70%, fair if 30–50% and poor if <30% improvement was observed.

A comparative study between Jessner’s peel and 20% TCA versus 20% TCA peel in isolation was done. Results showed no significant difference in improvement among both the peels.12

Conclusion:

Post-acne scarring is a very common and challenging condition with no easy and definitive solution. Subcision, microneedling, MDA, dermal fillers and chemical peels have all been used with varying degrees of efficacy but an overall positive outcome. Each technique has pros and cons. Some are suited for specific types of scars, others need to be applied repeatedly, and all carry a potential risk of adverse reactions. 

References
  1. Sage RJ, Lopiccolo MC, Liu A, et al. Subcuticular incision versus naturally sourced porcine collagen filler for acne scars: a randomized split-face comparison. Dermatol Surg 2011; 37: 426–431.
  2. Harandi SA, Balighi K, Lajevardi V, et al. Subcision-suction method: a new successful combination therapy in treatment of atrophic acne scars and other depressed scars. J Eur AcadDermatol Venereol 2011; 25: 92–99.
  3. Gadkari R and Nayak C. A split-face comparative study to evaluate efficacy of combined subcision and dermaroller against combined subcision and cryoroller in treatment of acne scars. J Cosmet Dermatol 2014; 13: 38–43.
  4. El-Domyati M, Hosam W, Abdel-Azim E, et al. Microdermabrasion: a clinical, histometric, and histopathologic study. J Cosmet Dermatol 2016; 15: 503–513.
  5. Chawla S. Split face comparative study of microneedling with PRP versus microneedling with vitamin C in treating atrophic post acne scars. J Cutan Aesthet Surg 2014; 7: 209–212.
  6. Nofal E, Helmy A, Nofal A, et al. Platelet-rich plasma versus CROSS technique with 100% trichloroacetic acid versus combined skin needling and platelet rich plasma in the treatment of atrophic acne scars: a comparative study. Dermatol Surg 2014; 40: 864–873.
  7. Asif M, Kanodia S and Singh K. Combined autologous platelet- rich plasma with microneedling verses microneedling with distilled water in the treatment of atrophic acne scars: a concurrent split-face study. J Cosmet Dermatol 2016; 15: 434–443.
  8. Beer K. A single-center, open-label study on the use of injectable poly-L-lactic acid for the treatment of moderate to severe scarring from acne or varicella. Dermatol Surg 2007; 33 (Suppl. 2): S159–167.
  9. Karnik J, Baumann L, Bruce S, et al. A double-blind, randomized, multicenter, controlled trial of suspended polymethylmethacrylate microspheres for the correction of atrophic facial acne scars. J Am Acad Dermatol 2014; 71: 77–83.
  10. Sapra S, Stewart JA, Mraud K, et al. A Canadian study of the use of poly-L-lactic acid dermal implant for the treatment of hill and valley acne scarring. Dermatol Surg 2015; 41: 587–594.
  11. Park JH, Choi YD, Kim SW, et al. Effectiveness of modified phenol peel (Exoderm) on facial wrinkles, acne scars and other skin problems of Asian patients. J Dermatol 2007; 34: 17–24.
  12. Puri N. Efficacy of modified Jessner’s peel and 20% TCA versus 20% TCA peel alone for the treatment of acne scars. JCutan Aesthet Surg 2015; 8: 42–45.
  13. Fabbrocini G, Annunziata MC, D’Arco V, et al. Acne scars: pathogenesis, classification and treatment. Dermatol Res Pract2010; 2010: 893080.

Prescribing a Shampoo: Making The Right Choice

Dermatologists are routinely solicited advice by the patients regarding which shampoo to use. With the wide plethora of options available and extensive marketing of individual products, it is essential to know the basic chemistry of a shampoo. The primary ingredients of any shampoo include surfactants, conditioners, thickeners, sequestering agents, pH adjusters and preservatives. Surfactants in shampoos are used primarily for cleaning hair which involves removing sebum and dirt from the hair. Hair conditioners are added to improve hair manageability, decrease hair static electricity and add lustre. The choice of surfactant in a shampoo greatly affects how the shampoo performs as a whole. The challenge is to remove just enough sebum to allow the hair to appear clean and leave behind enough conditioning agents to leave the hair soft, shiny and manageable.1

Types of Shampoos:

Shampoos are classified based on the chemical nature of the primary surfactant/ detergent. Surfactant is an amphiphilic molecule with both lipophilic and hydrophilic ends. The lipophilic sites help bind sebum and oily dirt while hydrophilic end binds to water, allowing removal of the sebum while washing with water.

  1. Anionic Surfactants: Anionic surfactants carry a negative charge when ionized. It provides a lot of the lather and detergency in the shampoo. This leads to excellent cleaning, foaming, and solubility properties. However, the excessively cleaned hair is harsh, rough, dull with frizz and prone to tangling. Frequently, other surfactants and ingredients are added to reduce skin irritation.2The most commonly used anionic surfactants are sodium laurethsulphate, sodium lauryl sulphate and sulfosuccinates.
  2. Cationic Surfactants: Cationic surfactants carry positive charge when ionized. They are poor cleansers and do not lather well and are not compatible with anionic detergents, limiting their utility. Cationic molecules have the ability to cling to wet surfaces by static attraction. Consequently they are not easily removed during the rinsing process and form the basis of conditioning. As a result, they are useful in imparting softness and manageability to chemically damaged hair and so are primarily used as daily shampoo for damaged hair such as in case of permanently dyed or chemically bleached hair.2Polyquarternium-10 is one of the most common cationic conditioners.
  3. Nonionic Surfactants: Nonionic surfactant has no charge to the molecule. These are not used as a cleaning agent, but rather used in combination with the primary cleanser to modify its actions, they aid in solubility, modifying foam, and in some instances conditioning. These include cocamide DEA or coco glucosides.
  4. Amphoteric Surfactants: This class of surfactants contains both positive and negative charges when ionized in water.They are quite useful in decreasing the irritancy of a formulation while increasing the active contents level of the product and quality of the lather produced. Most amphoteric shampoo surfactants are used in baby shampoos, because they are gentle and will not burn the eyes. By far the most used is cocamido propyl betaine, or occasionally cocamido betaine.
  5. Natural detergents: The fruit pulp of Sapindus, contains saponins which are a natural surfactant and creates a lather which leaves the hair soft, shiny and manageable. After the advent of synthetic detergents, use of natural detergents has declined. Recently, botanically based hair care products have made resurgence. The cleansing of hair offered by these products is poor and their addition is only for marketing purposes.

The anionic surfactants have the greatest cleaning power with the sulfates probably being at the top. Cationic surfactants are not always used but they can provide added conditioning to the hair.  Shampoos for damaged, dry or colored hair will often contain the cationic surfactants as well. The Nonionic and Amphoteric Surfactants are not particularly great for cleansing hair but they are often used in mild shampoos.

Depending on the type and relative concentrations of the surfactants along with the added conditioners, the shampoos are marketed as following:

Clarifying / Deep Cleansing Shampoo:

A clarifying shampoo is formulated to remove product build up from the hair and scalp, leaving it fresh and clean. This is for people who frequently use styling products, such as hair spray, gel, and mousse. These contain a lot of anionic detergents and often leave the hair dry.

Everyday Shampoo:

This is for people who want to wash their hair daily. They generally contain mild detergents and typically do not incorporate the conditioners. However, an instant stand-alone conditioner is recommended which can be applied immediately after wash.

Volumizing Shampoo:

Volumizing shampoo works to add humectants, which are non-oily substances that attract and pull in moisture from the surrounding environment. These humectants help swell a person’s hair shafts to create the illusion of thicker, fuller hair. The major ingredients found in volumizing shampoo include panthenol, wheat protein, rice protein, silk protein and witch hazel.

Moisturizing Shampoo/ Conditioning Shampoo:

A moisturizing shampoo is a type of shampoo that not only cleans the hair but that also adds a moisturizing layer to the hair. Thus, moisturizing shampoos have a hair conditioning element. These generally contain only one anionic surfactant as the cleanser with added conditioners.

Baby Shampoos:

Baby shampoo is for babies where mild detergent is used which is non-irritating to the eyes and achieves mild cleansing, as babies produce limited sebum. They contain the amphoteric group detergents, such as the betaines which actually numb the eye tissues to prevent stinging and irritation.

Medicated Shampoo:

This is used for people with scalp problems like seborrheic dermatitis, psoriasis, bacterial or fungal infections. In addition to regular cleansers, they contain active agents such as Tar derivatives, corticosteroids, salicylic acid, sulfur, selenium sulphide etc.

Keratin Shampoo:

Keratin shampoo is a hair cleaning product that has keratin protein added to it. Manufacturers assert that it will make the cortex stronger. They also claim that it will coat the cuticle, adding protection to the cortex. The result is sleeker hair that is less prone to frizzing and breaking.

pH Balanced Shampoo:

This is a shampoo that tries to keep the pH of the hair at about its natural level, around 5.0 or so. When the pH of the hair gets too high, the hair becomes too alkaline, and the cuticles open, the hair becomes dry and brittle, and the shine disappears. If the pH of the hair gets too low, on the other hand, it will become hard and rough. The pH is balanced by the addition of citric, lactic or phosphoric acid.  A pH-balanced shampoo will help close the hair cuticle and is recommended for color-treated or lightened hair.

References
  1. Draelos ZD. Shampoos, Conditioners, and Camouflage Techniques. DermatolClin. 2013;31:173–8.
  2. Draelos ZD. Essentials of hair care often neglected: Hair cleansing. Int J Trichology. 2010;2:24–9.

Periorbital Rejuvation

Guideline for local anesthesia in use of injectable fillers in perorbital region
  • Historically anesthesia protocol constituted the pre-treatment part of the injecting regimen
  • Recently some physicians have started to combine anesthesia such as lido caine with injectable dermal fillers itself
  • The combined solution of dermal fillers and anesthesia is administer together
Nerve Blocks
  • Nerve blocks total anesthetic to the area being treated by anesthetizing the main trunk of nerve.
  • In tissue infiltration anesthesia is injected just below the skin in the surrounding area that is to be treated with dermal filler.
Physical Aids
  • Physical aids include vibrating, icing and cooling (Zimmer chiller) provide a temporary anesthetic condition so that the pain of injection is somewhat mitigated.
Environmental Aids
  • Finally, environmental aspects can be modulated so that anxieties of the patient are lessened. These include soothing music and talking softly (talkesthesia) with patient throughout the injection period.
Treatment Supplies for Dermal Fillers Injection  
  • Protocols for pretreatment anesthesia & dermal fillers
  • 27G 1 ¼ Inch and ½ inch needles
  • 30 G 1-inch or 27 G 1¼  inch or ½ inch needle for numbering
  • Non –latex-Gloves
  • Mirror
  • 4×4or 3×3 gauze pads
  • Sharps container
  • Camera for before and after photos
  • Signed consent form
  • White eyeliner pencil for marking
  • Alcohol pads for cleansing area
  Injection Technique for Facial Beauty   
  • The technique focuses on trying to decipher objective parameters in creating a template to maximize each individual’s facial beauty.
  • The technique offered is personal and as is evidence below not a unique concept.
  • It in no way represents the best or sole method to non-surgically release the patient’s facial beauty potential.
Injection Techniques
  • Kane’s Technique – After evaluation and marking of the tear trough topical anesthetic ointment is applied to lower eyelids at least 30 minutes before the injection.
  • After preparation of skin with alcohol, a 30 or 32 gauge needle is inserted for injection.
  • The skin of the lower lid is spread and held at some tension with the non injection hand.
  • The skin is inspected carefully for visible vessels before catching needle stick.
  • The deepest portion of the middle tear trough is treated first.
  • The needle is threaded below the surface of the skin above orbicularis oculi.
  • The parallel threads of the filler are injected cephalad and caudal to the tear trough.
  • At least, the junction of the middle and lateral 3rd of the inferior of the rim. If the tear trough is deep the direction of the middle if change throughout the injection so that the filler is applied to cross has fashion.
  • Stutman And Codner Technique – After the marking confirmed by the patient, HA is injected deep in the pre-periosteal plane, to reduce visibility of the product.
  • The HA is placed beneath the insertion of the middle orbicularis muscle at the maxilla and continues laterally needle with care not to inject super facial.

A variety of HA injection technique may be utilized depending on the indications including antigrade or retrograde.

1 linear threading 2 serial puncture 3 crosshatching and sub cutaneous 4 epi-periosteal

In tear through region inject along the inferior orbital rim in pre-periosteal plan and massage the area.

  1. The Kenneth and Samantha Steinsapir Technique-The goal was to place allquots of the filler in the pre-periosteal tissues just inferior to the orbital rim.
  2. The bony orbital rim is free of significant vascular structures from the base of the anterior lacrimal crest to the lateral canthal tendon.
  3. The filler was introduced by using a serial puncture technique.
  4. The orbital rim was digitally palpated and needle rotated so that the bevel was parallel to the skin an advanced to flush on the periosteum.
  Key Point for Tear Trough Injection
  • Low- viscosity HA can be safely injected to correct tear trough deformity.
  • High- viscosity HA and non-biodegradable agents should not be injected in the tear trough.
  • Injections must be at a supra-periosteal level of the orbital rim under defect.
  • One should be cautious around the infraorbital foramen.
  • The HA filler should be gently massaged for even distribution; strong massage should be avoided.
  • Overcorrection should be avoided, HA is hydrophilic and may cause a swelling due to its properties of attraction water. There is a study which shows that HA can also cause stimulation of de novo production of collagen. Hence, it is best to under correction the tear trough area to prevent bulges under the eye. A touch can always be done if necessary when the patient comes for a follow up.
  Post Procedure Care
  • Face down sleeping should be avoided.
  • Refrain from strenuous activity for one or two days.
  • Apply ice periodically for 24 hrs to 48 hrs.
  • If any correction for touch up, call after one week.
  • If any plane lumpiness in treated area, give the finger massage itself.
Conclusions
  • Tear trough deformity can be corrected with an HA filler.
  • It is less invasive and there may be minimal downtime due to swelling and bruising.
  • The volume injected varies from patient to patient and over correction should be avoided.
  • Better results will be achieved if the patient is reassessed in two or four weeks and then additional treatment is performed to achieve complete correction.
  • Care should be taken to avoid injection through the orbital septum, to avoid accentuating pseudoherniation.

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Cleansers: An Essential Part of My Prescription

There is one thing, without which my prescription is never complete. It’s clensers. Whether it is dermatological disease or cosmetic patient, I never forget to advise him/her regarding appropriate clensers or soaps according to their condition.

Why?
  • Most important part of skin care routine.
  • If not advised by dermatologist, patient will end up buying commercial product which may worsen the skin condition or reduces responsiveness of other dermatological treatments.
  • Important part of post procedure advice in cosmetic patient to enhance effect of various cosmetic treatments and to prevent post procedural irritation.
  • Different types of formulations are recommended for different types of skin.

The art of cleansing has progressed immensely over several thousand years from simply scraping the skin to an exercise in relaxation and improvement in the skin’s health and appearance in the present day. Soaps – the basic cleansing agent has also undergone a sea change in its evolution with many variants and newer constituents being incorporated into it.

The constituents of skin cleansers
  1. Water
  2. Surfactants (emulsifiers)
  3. Moisturizers (for hydration)
  4. Binders (stabilizers)
  5. Lather enhancers (in some)
  6. Fillers (hardeners)
  7. Preservatives (ingibit microorganisms)
  8. Fragrance (mask surfactant odour)
  9. Dyes or Pigments (in some)
Dermatological disorders in which cleansers may have a beneficial role
  1. Atopic dermatitis
  2. Acne
  3. Rosacea
  4. Photoages skin
  5. Occupational dermatitis
  6. Xerotic skin
  7. Sensitive skin
  8. Retinoid induced dermatitis and post peel
  9. Idiopathic Perianal Pruritus
Cleanser Composition

Surfactants are the principal constituents of most cleanser formulas and are mainly responsible for its cleansing action. The type and amount of surfactant in a cleansing agent has a bearing on its drying and irritancy potential.

Soaps

Soaps are composed of long chain fatty acid alkali salts with a pH of between 9 and 10.

Soap Subsets

Glycerin bars/transparent bars:

Used rampantly in our country in winter. They contain humectant–glycerine to counter the drying effects of soap.

Superfatted soaps:

Contain greater amount of lipids such as triglycerides, lanolin, paraffin, stearic acid, or mineral oils which provide a protective film on the skin.

Deodorant soaps/antibacterial soaps:

Contain antibacterial agents such as triclosan, triclocarban or carbanile to inhibit the growth of bacteria and thereby odor.

Harsh cleansers such as soaps are known to cause:

⦁ After wash tightness: it is a sensation of tightness perceived 5–10 min after washing with a soap. Rapid evaporation of water from the skin surface causes this tightness.

⦁ After wash tightness: it is a sensation of tightness perceived 5–10 min after washing with a soap. Rapid evaporation of water from the skin surface causes this tightness.

⦁ Skin dryness, scaling and roughness-lipid solvents such as acetone, alcohols and even nonionic surfactants can cause dryness of the skin. Cold weather and low humidity can aggravate these effects.

⦁ Skin irritation–skin irritation along with erythema and itching following the use of harsh soaps are mainly due to damage to the skin barrier.⦁ Allergic contact dermatitis to the fragrances, preservatives, or dyes present in some soaps.

Solution
Lipid free cleansing lotions

These contain fatty alcohols and are suitable for people with sensitive or dry skin. They can be wiped off without water. The fatty alcohols in these lotions facilitate evaporation and so rinsability is high. When used on the face, there is less facial residue which is an advantage of these lipid free-cleansing lotions. These agents also contain emollients (e.g., fatty alcohols) and/or humectants (e.g., propylene glycol) which counter the irritancy or drying potential of the surfactant.

Liquid body washes

These offer a different sensation, are more convenient as well as more hygienic than the wash bar. They employ milder surfactants and incorporate more emollients, thus can actually improve skin overtime.

Cold creams

They combine the effect of a lipid solvent, such as wax or mineral oil, with detergent action from borax.

Factors causing dryness and irritation in cleansers

The major factors affecting the drying and irritancy potential of cleansers include type and rinsability of surfactant ingredients and to a lesser degree pH.

– Surfactant ingredients:

Surfactants after binding to keratin cause protein denaturation, thus leading to damage to the cell membrane of keratinocytes. This in turn leads to adverse cutaneous responses. Surfactant chain length is also an important factor in determining the irritant potential with Kellum opining that the most noticeable irritant reactions developed with fatty acids having chain lengths from C8 to C12 coming in contact with the skin. Although anionic surfactants are considered to have the greatest irritancy potential, their proportion in a cleansing agent and their combination with cationic acrylate polymers or nonionic surfactants and humectants like propylene glycol modifies the irritation potential.

– Skin cleanser residue or rinsability factor:

The irritancy potential of a cleansing agent may increase the longer it is left on the skin. Residual levels of different products on the skin vary, and these levels correlate with irritation reactions.

– pH of cleansing agent:

Although controversial, but still many Dermatologists believe that maintaining the skin surface at its physiological pH (4–6.5) during cleansing prevents overgrowth of certain microorganisms, like Propionibacterium acnes. Soaps with an alkaline pH have also been said to cause damage to the lipid bilayer of the stratum corneum thus causing dryness of the skin. However, other workers have shown that the pH of a cleanser appears to have little effect on its role in damaging the skin. Present day synthetic detergents and lipid free cleansers have a neutral or slightly acidic pH which closely matches the skin pH.

cleansers

MODERN FORMULAS AND CONCEPTS

Cleansing milks, lotions and creams

These are all oil and water emulsions, made to different consistencies depending on how thick a texture you are looking for. They are especially good at cleansing as the oil part removes the make-up, at the same time taking away as little of the natural oils from the skin as possible, while the water carries away the water-soluble waste.

Cleansing gels

Foaming gels that lather up contain detergents, as soap does, and can have the same effect, so are best suited to oilier skins. There are also gels that are suited to dry or sensitive skins and these should not lather up. Gels are often removed by just splashing with water.

Cleansing oil

Although there is not as vast an array of cleansing oils or cleansing balms on the market as other cleansing products, in my opinion they are the best thing to use. Also going under the name of Pre-Cleanser, these are an oil formula that you massage into the skin using fingertips, and then remove with (preferably) a face cloth. Oil formulas are more efficient at removing excess oil and grime from the skin, without stripping or drying it. Even if you have an oily skin, one of these cleansers is still going to remove sufficient grease!

Cleansers have evolved significantly from just serving as cleaning agents for removal of sebum, dirt, dead cells, and microorganisms from skin mainly because of the challenge of meeting the ever changing consumer expectations. With the advent of advanced technologies, newer cleansers are now being manufactured which are mild, provide moisturizing benefits and can be easily washed off. In various dermatological disorders, all these properties of modern cleansers enable them to be used concomitantly with topical therapeutic measures thus influencing the outcome of treatment and progression of the disorders. Dermatologists can enhance the overall management of various skin disorders by advising their patients how to adjust their cleansing regimen to best suit their needs and achieve optimal results with therapy.

Toner

A toner for oily skin will contain up to 70% alcohol and is astringent; it will be effective at removing the oils but cannot stop the skin from producing more – such oil production is down to your hormones and your diet. If you do use astringent products on oily skin to the extent that they remove the natural oils, your body will just produce more to make up for the deficiency, so by removing all the oil, you are not always doing your skin a favour. If you have not removed your cleanser properly, the toner is necessary to remove the last traces.

Micellar water

Micellar water is made of microscopic oil molecules that are suspended in purified water. These gentle oil molecules are called micelles. It is applied using a cotton pad or cloth and wiped over the skin to remove makeup, excess oil and build up. Tiny micelles form in the product and cling onto particles resting on the surface of your skin, wiping them off. It is suitable for both dry and combination/oily skin types, however if your skin is dry, you will need a rich moisturiser to follow this cleansing product.

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Non-surgical Office Time Face Lift

Aging is a natural process in which wrinkles, loosening of skin and dryness are common symptoms. Skin loses fat to become slack leading to uneven descent and laxity. Skin becomes more fragile due to the thinning of the epidermis. Thus, aging changes the shape, texture, and color of the face.

Recently, there has been an increase in trend for patients to pursue minimally invasive treatments with reduced risk of side effects and downtime to correct wrinkles and laxity.

Many patients dislike the idea of insertion of non-absorbable threads that remain permanently in the facial soft tissue and so new, absorbable, barbed suture designs have entered the market.

Classification of threads according to:

A) Mode of Absorption

1. Absorbable threads

a)Polydioxanone thread (PDO),

b)Silhouette Soft thread (Poly-I-lactic acid or sculptra in solid form), and fine thread with bi-directional absorbable cone

B) Barbed and Non-Barbed Thread (Smooth Threads)

1. Barbed Thread

There are 3 types of barbed thread [9]-[11]:

  1. Bi-directional thread (Long suture) are inserted into a hollow needle and then placed in the treated area.
  2. Uni-directional barbed threads (Long sutures) are designed to be anchored to a fixed structure, such as the deep temporal fascia.

Examples include

The value of bi-directional thread over uni-directional thread, and non-barbed thread, is that bi-directional thread cannot move in either direction because of the two-way fixation provided by the barbs. However, if there is asymmetry of the face from the thread insertion, uni-directional threads or non-barbed threads allow easier postoperative correction.

C) Length of threads

  1. Short suture is defined by any thread shorter than 90 mm in length.
  2. Long suture is defined by any thread longer than 90 mm in length.

Indications for use:

Site & Number of threads:

Mechanism of Action:

The axis of lift depends on the direction of insertion and the direction of the cones. The thread material can also create new collagen; for example Poly lactic acid (PLLA). Stimulating threads are made of PDO (polydiaxanone). These threads initiate growth factor release through tissue trauma. Fibroblast activation commences new collagen formation, which is remodeled at four weeks. New collagen has a tendency to shrink as it is remodeled. The effect is one of volume and shrinkage due to the sheer number of threads inserted. Stimulating threads should be considered as micro fillers and lifters, providing a meshwork of new collagen, with initial tissue support.

Depth for Insertion

The correct tissue plane for the insertion of PDO threads is the subcutaneous tissue for barbed threads (superficial musculoaponeurotic system or SMAS layer). If the threads are placed too superficially in the dermal plane then they could be felt and may even be visible in the skin. In this plane, they will not achieve the correct degree of lifting of the tissues or stimulate collagen production. If the PDO threads are placed too deeply, there is a greater risk of damage to the facial artery and vein, the facial nerve and other anatomical structures. Aesthetic practitioners should familiarise themselves with a detailed knowledge of the anatomy of the face and neck.

Side Effects

It includes swelling, bruising, infection (usually due to poor technique), and thread migration. Post-operative skin folds may also occur. Most of these side effects are transient and resolve over several days. Threads can also move away from the site of insertion but this is more common with uni-directional or bi-directional threads. In my experience, the newer 3D multi-direction cog threads do not migrate. Small mono and spiral threads may protrude from the skin and have to be cut back. This is usually due to poor technique, but can also occur spontaneously some days after insertion. More serious complications include facial nerve damage, which may result in facial paralysis and blood vessel damage, especially when needle threads are used.

Length of results

However, short-term clinical studies have shown that the results of the PDO thread lifts were maintained, on the whole, for six months with a little loss of facial elasticity. However results may last 12, or sometimes up to 18 months.

Conclusion

According to the collected data that has been summarized in this review, several techniques of the thread lift procedure have been indicated. However, positive results depend on the process of patient selection (good candidates) as well as selection of the most appropriate technique for the patient. A holistic approach to patient management is also proposed to ensure the patient receives optimal results. This technique can also be combined with other treatments, such as the placement of fillers, platelet rich plasma or other products.

Patient Based Algorithm

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