Cosmetic dermatology

1. Cosmetic dermatology

2. Cosmetic problems • Acne • Pigmentation • Ageing • Benign tumor / nevi / birthmarks • Hair – Alopecia, hirsutism • Nails

3. Acne Surgery in acne is indicated for • active lesions • management of scars

4. Management of active acne • Microdermabrasion (Gr I) • Evacuation surgery (Gr II and III) • Draining of cysts (Gr IV) • Intralesional steroids : large cysts (Gr IV) • Cryoslush – cystic and nodular (Gr IV) • Chemical peels : GA 20-35%, SA 20-30% , TCA 10-25% (Gr II and III) • IPL and blue light lasers (400-420nm): (Grade I, II, III, IV )

5. Acne scars Acne scars can be classified as : • Depressed • Hypertrophic • Keloids

6. Management of acne scars • Laser • Ablative • Non-ablative Non-surgical • Chemical peel • Cryo peel • Microdermabrasion Surgical • Subcision • Dermabrasion • Punch elevation • Punch graft • Punch excision

7. Pigmentation • May be epidermal (brown), dermal (bluish-black) or mixed • Wood’s lamp examination determines the level of pigmentation

8. Pigmentary disorders • Melasma • Post inflammatory hyperpigmentation secondary to acne, lichen planus, fixed drug eruption • Macular amyloidosis • Lichen planuspigmentosus • Toxic melanoderma • Addisonian pigmentation • Drug induced pigmentation

9. Management of Epidermal pigmentation • Use of a broad-spectrum sunscreen • Topical lightening agents Various combinations of hydroquinone (2-10%), arbutin(5%), kojic acid (2 - 4%), azelaic acid (10-20%) • Kligman’s formula: Tretinoin 0.05% + Hydroquinone 4% + dexamethasone 0.5% • Modified Kligman: the steroid component is substituted with fluocinolone, mometasone or hydrocortisone • Chemical peels

10. Management of dermal and mixed pigmentation • Sunscreen • Chemical peels: Glycolic, lactic, salicylic, koj • ic, retinol etc. peels at repeated intervals • Topical retinoids to hasten the cell turnover and the expulsion of pigment granules • IPL (Intense Pulse Light), Erbium and Q-switched Nd-YAG lasers • Possibility of an increase in pigmentation or hypopigmentation in darker skin types

11. Ageing Ageing process results in: • Wrinkles • Rough dry skin with a yellow hue • Loss of tone and elasticity • Loss of subcutaneous tissue • Development of freckles, and lentigenes (sun spots), senile comedones, sebaceous hyperplasia, seborrhoeic warts, rosacea, telangiectases.

12. Management • Sunscreens • Retinoids • Chemical peels • Microdermabrasion • Lasers - ablative and non-ablative • Botox and Fillers • Fat lysis and transfer • Surgery-thread lifts, face lifts • Implants

13. Benign tumors/nevi/birthmarks • Facial angiofibromas, syringomas, Becker’s nevus, nevus of Ota, café au laitmacules, hemangiomas . May be congenital/acquired. Following treatment modalities can be used: • Surgical excision, electrocautery, radiofrequency • Lasers- CO2, vascular, pigmented • Camouflague

14. Hair-Alopecia Treatment depends on scarring/non-scarring • Scarring: surgical excision, scalp reduction, hair transplants • Non-scarring: topical minoxidil, topical steroids, oral vitamins and finasteride, hair transplant

15. Hair Transplantation • Re-distribution/re-arrangement of existing hair follicles in a particular pattern to cover the bald areas Types: • Punch grafting - Standard, Mini and Micro grafting • Follicular unit grafting (most recent) • Synthetic hair grafting

16. Indications and contraindications Indications: • Male pattern alopecia • Female pattern alopecia • Cicatricial alopecia Contraindications: • Large bald area, small donor area • Low hair density • Age-group between 15-25 years • Unrealistic expectation

17. Procedure • Occipital area commonest donor site, others are temporal and parietal area • After anaesthetising the area, single elliptical donor strip is harvested from the donor site • Follicular unit grafts are dissected from the strip • Grafts then inserted at recipient site into tunnels made with needles • Grafts taken up by tenth day • Minoxidil application advised to promote hair growth

18. Post operative course • Interval of three months required for transplanted hair to enter anagen phase • Hair growth continues for 6-8 months

19. Hirsutism • Distribution of thick dark terminal hair in the male distribution pattern in females Hair removal: • Temporary measures: plucking, threading, waxing, bleaching, shaving • Permanent measures: electrolysis • Permanent reduction : Laser hair removal • Topical eflornithine 12.5% as an adjuvant

20. Nails • Treatment of primary condition causing dystrophy eg: treat infections or skin disease • Surgical avulsion • Artificial nails • Nail extensions • Nail paint

21. Cosmetic dermatology Topical agents: Cosmetics, cosmeceutical Procedures : • Chemical peels • Botox • Dermal fillers • Camouflage creams • Tattooing • Microdermabrasion • Dermabrasion • Electrosurgery • Radiosurgery • Cryosurgery • Lasers

22. Cosmetics • A cosmetic is any article intended to be rubbed, poured, sprinkled, or sprayed on, introduced into, or otherwise applied to the human body for cleansing, beautifying, or altering the appearance • Commonly used cosmetics: Soaps, shampoos, moisturizers, anti aging products, eye and lip cosmetics, bleaching and highlighting hair products • Adverse reactions to cosmetics have been recorded

23. Moisturizers • Moisturizers are agents which hydrate the stratum corneum by either providing water or helping to draw water from the deeper layers of the skin • Oil-in water or water in oil preparations • Sunscreens , anti-ageing products like retinols, alpha or beta hydroxy acids and skin-lightening agents may be added

24. Moisturizers - types Oil- in- water: • More cosmetically acceptable by patients • Not very effective for very dry skin conditions • Exists as a cream or lotion Water-in-oil: • Create an occlusive film on the skin surface; reduce water loss and traps moisture in the skin • Stickier, less cosmetically acceptable • More effective for dry skin and ichthyotic conditions

25. Sunscreens • Sunscreens protect from the harmful rays mainly UVA and UVB • Reflects, absorbs or scatters harmful rays • Most sunscreens have a SPF label. • SPF: ability of a sunscreen to delay sun-induced skin erythema

26. Types of sunscreens • Physical: Form an opaque layer which totally blocks out the sunrays e.g zinc oxide, titanium dioxide and calamine • Chemical: Absorb the rays and convert the energy to heat which is diffused. These may selectively protect against UVA or UVB UVA blockers: Benzophenones, dibenzoylmethanes, Mexoryl UVB blockers: P-aminobenzoic acid (PABA) derivatives, salicylates, cinnamates

27. Proper sunscreen rules • 2mg/cm2 of sunscreen needs to be applied • Use half hour before exposure • Repeat every 2 hours if sweating or swimming

28. Adverse reactions to cosmetics • Soaps: Repeated use may strip the skin of its protective lipid layer • Shampoos: Daily washing with harsh shampoos can dry the shaft and make it brittle • Moisturizers: Comedogenic ingredients like isopropyl myristate irritate the pilosebaceous follicles • Fragrances: May cause photocontact dermatitis • Hair colors: Frequent hair lightening or coloring can cause irreversible damage to the hair shaft. Cosmetic alopecia may follow. Contd…

29. Adverse reactions to cosmetics • Sunscreens: Vehicle may exacerbate or induce acne; contact folliculitis may occur • Skin lightening agents: Excessive and prolonged use may cause exogenous ochronosis

30. Cosmeceuticals • Pharmacological agents which have an effect intermediate between cosmetics and drugs • Cosmeceutical botanicals • Retinoids, bleaching agents, sunscreens, chemical peels, minoxidil

31. Cosmeceutical botanicals • Cosmeceutical botanicals are obtained from plant sources • Aloe vera, soya, ginkobiloba, tea tree oil, mulberry etc • Aloe vera: increases blood flow, reduces inflammation, enhances wound healing and decreases bacterial colonization

32. Cosmeceutical botanicals Green tea: • Contains flavanoids : anti-inflammatory against • UVB-induced erythema Soy: • A rich source of flavanoids (genestein and daidzein) • Genestein: potent topical radical scavenger and promotes collagen synthesis

33. Topical retinoids • Tretinoin: comedolytic • Adapalene: anti-inflammatory, comedolytic • Tazarotene: comedolytic, anti-inflammatory • Isotretinoin: comedolytic Used in: • Acne • Photoaging • Pigmentation • Combined with minoxidil in alopecia

34. Topical retinoids Adverse effects: • Redness, burning, • Dryness • Post inflammatory pigmentation • Acne flare up

35. Chemical peels • Controlled application of one or more exfoliating agents to improve photoaging, pigmentation or scarring • Single peel - skin smoothening • Repeated peels - collagen and elastic remodelling • Performed every 2 to 3 weeks • Agents used: glycolic acid, trichloroacetic acid, salicylic acid, mandelic acid, phenol

36. Indications of Chemical Peels • Acne • Ageing skin • Photodamage • Freckles • Melasma • Scars • Fine lines and wrinkles • Xanthelasma • Dilated pores • Improving complexion

37. Botulinum toxin (BTX) • Produced by the bacterium Clostridium botulinum ( Serotype A ) • Inhibits release of acetylcholine at the neuromuscular junction • Temporary flaccid paralysis of muscle • Re-innervation and recovery in 3 to 4 months

38. Aesthetic use of BTX For dynamic wrinkles: • Upper face: frown lines, forehead lines, crows feet • Lower face: Perioral, smile and frown lines, neck lines and folds Advanced use: • Post-herpetic neuralgia, migraine

39. Dermal fillers • Specialized materials injected into the dermis and subcutaneous tissue to replace the lost tissue during aging or injury Types of filers : • Temporary- gets absorbed in 3 to 6 months • Semi-permanent: absorbed within 2 years • Permanent: lasts longer than 2 years

40. Sources of fillers • Heterograft/Xenograft: Bovine collagen, porcine collagen, hyaluronic acid • Allografts: Human-derived collagen • Autografts: Autologous fat, collagen,fibroblasts • Synthetic: Silicone, polytetrafluoroethylene

41. Indication for fillers • Wrinkles • Scars • Augmentation • Lipoatrophy • Enhancement of facial contour

42. Cosmetic camouflage • Concealing of unsightly marks on the skin with specially matched opaque creams and powders • Contents: • Calamine, zinc oxide, bentonite • Colour pigments • Setting powder

43. Indications for cosmetic camouflage • Vitiligo • Freckles • Melasma, post inflammatory pigmentation • Hemangiomas • Nevi • Scars

44. Tattooing • To mask the vitiligomacules especially over the lips, areola • Localized small macules of vitiligo resistant to conventional treatment • Vitiligo lesions should be stable for at least two years

45. Material • Electrical tattooing gun or manually operated punch holding multiple needles (optimal depth 1.5 mm) • Pigment paste: mixture of various ferric oxides (yellow, brown, red and black in colour) in normal saline and glycerine

46. Advantages • Immediate results • Inexpensive, safe and simple office procedure • Useful in sites difficult for grafting • Can be repeated if required

47. Electrosurgery The frequency of electric current used in hyfrecator is 50kHz (50000 cycles/sec), whereas in the operating room devices, it is between 500 and 2000 kHz. In these devices, the electrode becomes hot and acts more like true cautery.

48. Mode of action • The heat generated by the electrical current at the tip of an electrode, destroys the tissue. (Thermal damage) • Moderate heat causes evaporation of the water content of the tissue (Dessication)

49. Radiofrequency When the frequency is raised to 3000kHz (3.0MHz), the electrode itself does not get heated. The instrument, which operates at a frequency of 3.8 Mhz is also known as Radio-frequency (RF) or Radio-surgical unit

50. Mode of action As the current passes through the tissues impedance to the passage of current generates heat → boils the tissue-water creating steam → cutting or coagulation of tissue