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Vol.:Three October:2008

IN HOUSE JOURNAL ON COSMETIC DERMATOLOGY


2 Vol.:Two July:2008

IN HOUSE JOURNAL ON COSMETIC DERMATOLOGY

Dear Kayazens This is the second edition of our rejuvenated skinknowledge.In the present issue we've tried our best to present the most relevant and informative articles and case studies which we came across. I hope to get your sincere feedback regarding the content of the

Kaya Advisory, Kaya skin Care Ltd. (Volume : 2, October 2008)

journal. Our aim will be to continuously keep abreast with the latest technology

Editor

and to review the fallouts of the available

Dr. Ruchi Agrawal

technology . Editoral Board

For the journal to be well received we need active contribution from you all. Your

Dr. Snehal Sriram Dr. Madhuri Agarwal Dr. Preeti Savardekar

Dr. Hema Pant Dr. D. Banerjee Dr. Mansi Mukherjee

participation will maintain a dialogue between kaya doctors and contitue the learning process which will enhance our expertise in the feild of cosmetology I am sure kaya doctors have lots to contribute

Scientific Committee

Dr. Narmada Bharia Dr. Soni Nanda Dr. Piali Chatterjee Dr. Rajeshree Mayekar Dr. Pakhi Pereira Dr. Ishwari Kulkarni Dr. Purvi Shah

to make our journal look more pan India Address for Correspondence:

Very few clinics have sent across the feedback

Ms. Venita Sharma Medical Coordinator Kaya Limited C-10, Dalia Industrial Estate, Off Link Road, Andheri (W), Mumbai $ 400058 Ph: 267020501/2/3; Extn 319, 9819153824

forms and the cme questionnaire. I hope in our subsequent issue the doctors will contribute unhesitantly Hope you all enjoy the October 2008 issue Happy reading Ruchi 9869113561 drruchi@hotmail.com

SKINKNOWLEDGE

Designed for Kaya Skin Care by Dhote Offset Technokrafts Pvt. Ltd. Mumbai - 400 060 Tel. : 28216851/28376401/28240075 E-mail : info@dhoteoffset.net Website : www.dhoteoffset.net

An Inhouse Journal on Cosmetic Dermatology


3

pg 4 1. CME ARTICLE : Lasers In Photorejuvenation and Antiageing

pg 11

2. NEW TECHNOLOGY : Fractional Photothermolysis

pg 14 3. DRUG MOLECULE OF THE MONTH : Esapeptide : B

pg 16

4. CLINICAL STUDY : The Aesthetic Approach To Nonsurgical Brow Lift pg 18

5. CASE REPORT : Treatment of Severe Acne Vulgaris With Topical Tazarotene 1% pg 20

6. SYNOPSIS OF INTERESTING ARTICLES pg 23

8. PHOTO QUIZ

October 2008

SKINKNOWLEDGE


4

CME Article

Lasers In Photorejuvenation and Antiageing -Dr. Rajeshree A. Mayekar, Kaya Training Center, Andheri, Mumbai CME learning objectives: 

Classification of lasers used in Photorejuvenation and Anti-ageing Comparative Analysis of Ablative / Nonablative / Minimally Ablative Lasers in terms of efficacy and safety Newer advances in Photorejuvenation and Anti-ageing



Introduction to Lasers:



C

osmetic physicians continue to search for innovative ways to improve ageing skin. It has been estimated that we loose 1% of our dermal collagen each year after the age of 20 and this rate doubles in sun exposed skin. The best approach to tackle ageing is to stimulate collagen in the papillary dermis with non- ablative, minimally ablative or ablative devices. The new collagen plumps up the surface of the skin, thereby reducing the fine lines and wrinkles.

Non-ablative

Ablative

IPL (550-1100 nm) concerned CO 10600 nm PDL (585 nm) Nd: YAG (1084 nm) with the Nd: YAG (1320 nm) laser light Diode 1450 nm Er. Glass (1540 nm) in the o p t i c a l 300 400 500 600 700 800 900 1000 1500 2000 3000 4000 5000 7500 10000 20000 Wavelength (nm) region of Fig: 2: Electromagnetic spectrum of ablative and the EM nonablative laser. spectrum. This includes infrared (700nm 1) Ablative - Co2 (10600nm) and Erbium (2940nm) and 1mm), ultraviolet (180 and 400nm) and visible light 2) Non ablative – Nd: YAG (400and 700nm). Most lasers 1064nm &1320nm, Pulsed operate in one or more of dye 585nm-595nm, Diode these wavelength regions. 1450nm, Erbium: glass (FIG: 1&2) 1540nm, Intense Pulsed 2

Er:. YAG 2940 nm

Light (550nm to 1100nm). Laser skin rejuvenation is an umbrella term that 3) Minimally ablative – The word laser is an acronym encompasses treatment of the Fractional lasers, Plasma, for Light Amplification by following conditions: Wrinkles, YSGG (2790nm) Stimulated Emission of pigmented lesions, vascular Radiation. The electromagnetic Part 2: Details and lesions, laxity and scars. spectrum (EM) includes energy Comparative Analysis of PART 1: Classiffication of ranging from gamma rays Various Lasers to electricity. For Cosmetic Lasers 1. Ablative Lasers dermatology we are mainly Lasers and light based Indications: technology useful Ultraviolet light Gamma rays Microwaves for rejuvenation and  Acne scars. antiageing effects are Radio, TV waves Infrared light X-rays  Fine or moderate grouped into three wrinkles. Frequency in Hz major categories Visible light Red Orange Yellow Green Blue Violet based on the level of  Photo damaged skin. effect and the amount  Post surgical or traumatic 700 600 550 500 400 (7.5 x 10 Hz) (4.3 x 10 Hz) Wavelength in nm of downtime incurred scars. with each modality. FIG 1: The electromagnetic spectrum and  Pigmentation irregularities wavelengths of the various regions 104

106

106

14

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1010

1012

1014

1016

1018

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An Inhouse Journal on Cosmetic Dermatology


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CME Article

Types



Persistent erythema

Ablative lasers were introduced in the 1980s and early 1990s. They include



Post inflammatory hypo and hyper pigmentation especially in Type IV and V skin



CO2 (10600nm)



Erbium (2940nm)

Working Principle 







CO2 and Erbium 2940 laser systems are termed as Ĺ“ablativeB laser skin resurfacing techniques as they target both the epidermis and dermis.

Indications: Mild to moderate photodamaged skin including:

Side effects



Dyspigmentation



Infection



Fine wrinkles



Itching, swelling and pain



Coarse texture



Erythema (redness) will last from several weeks to 6 months



Prominent pores



Telangiectasias



Scarring, milia

Contraindications

Types Nonablative lasers can be classified in two groups based on their wavelengths: (Flow chart 1)

Mechanism of action involves the targeting and vaporization of fluid-containing tissue, inducing necessary thermal injury for sufficient vascular coagulation, and consequent destruction of the epidermis.



Keloids



Herpes infection (active or past history of recurrent herpes)

Introduction

Working Principle

Ablative lasers work by removing the most superficial damaged tissue allowing new skin to grow over the surface thereby improving the appearance of ageing skin.





Photothermal induction of procollagen III expression resulting in subsequent collagen remodeling.



Vascular activation and endothelial disruption have also been considered to induce cytokine activation and subsequent collagen remodeling.

Although the depth of penetration of CO2 is more than Erbium, the latter produces energy in the mid infrared invisible light spectrum and this energy is10-15 times better absorbed by water in the skin than the energy from CO2 lasers such that the surrounding skin is hardly affected.

Disadvantage 

lasers and requires frequent treatments.

Long period of wound healing



Impetigo (active)



Isotretinoin treatment



Lasers emitting light in the visible range ie .VLL (Visible Light Lasers)



Lasers in range.

1

2. Nonablative Lasers





The trend towards minimally invasive rejuvenation techniques has led to the widespread use of nonablative lasers. Treatments using nonablative lasers and light -based systems are usually described by cosmetic clinics as photo rejuvenation These lasers aim at improving the appearance of the skin without damaging the surface, hence it can be done with minimal risk and limited down time. This gives a good safety profile to the services, but reduces the effectiveness as compared to ablative

the

infrared

Advantage 

Minimal discomfort and downtime as compared to Ablative. The infrared sources are most painful of non ablative lasers.



More client friendly



Side effects are rare as compared to ablative lasers.

October 2008

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CME Article





Telangiectasia, varicose veins, spider veins, hemangiomas, port wine stains Tattoos

Disadvantage One of the major limitations of today’s IPL technology is the short duration (2-5msec), high peak-power pulses which increases the likelihood of adverse effects especially in darker skin types. Side effects

FLOW CHART: 1 Classification of Nonablative Lasers and light based system.

Disadvantages  Multi ple sessions and maintenance is required  Less effective than the ablative lasers Further discussion is confined to Newer Technologies pertaining to Light-based systems in Photorejuvenation LIGHT BASED SYSTEMS (Non ablative, non laser systems) Intense pulsed light (IPL) QUANTUM TM (Lumenis) Intense pulsed light (IPL) is a broadband light source that emits noncoherent light from visible to infrared spectrum (550 to 1100 nm). Filters are mani pulated to block emission of certain wavelength to optimize treatment of different conditions. Newer flashlamp

SKINKNOWLEDGE

systems of the second generation use circulating water to filter out the infrared portion of longer wavelengths, significantly reducing the side effects.



Blistering



Hypo or hyper pigmentation.



Hypertrophic scarring, as a sequelae to burns.

Sessions required The

procedure

may

be

Working Principle Intense Pulsed Light systems, although technically not lasers, use flashes of light of several milliseconds that work in a similar way to nonablative lasers by causing heat damage to dermal tissues without disruption or removal of the outer epidermal layers of the skin.

BEFORE

AFTER 3 SESSIONS (FIG: 3) IPL

repeated every few weeks for 4 or 5 courses to achieve the desired effect. Later every 6 months for maintenance or as required. (Fig 3) The Light Energy Optimization technology (LEO) ARIATM (Alma Lasers)

Indications:  Actinic keratosis / liver Working principle: spots / freckles  AFT (Advance Fluorescence  Fine wrinkles Technology): AFT converts  Facial flushing, rosacea, unused UV lights into a redness. clinically optimal spectrum

An Inhouse Journal on Cosmetic Dermatology


CME Article

Fluence

Increased risk of adverse effects

Therapeutic range

Under treatment

AFT

IPL

Time

Sessions required:



The treatment involves a series of two to five sessions, four weeks apart. Follow-up treatments may be desired once a year to maintain results.

The addition of direct heat increases overall effectiveness and lowers fluence to ultra safe levels.



Lowering fluence eliminates the need for skin cooling techniques, simplifies the treatment process and minimizes the risk of harmful side effects, making it safer, easier and more cost effective, thus resulting in higher client tolerability and satisfaction. (FIG:4)

Graph : 1 Comparison of AFT Pulse With IPL Pulse.

for a range of treatment applications like hair removal, acne clearance, skin rejuvenation, and vascular and pigmented lesions.2AFT utilizes a two step filtering technology to deliver this optimal spectrum. This enables to utilize lower energy levels, resulting in visible clinical improvement while protecting the epidermis.

Light Heat Energy (LHE): DUETTM (RADIANCYTM)

Working Principle LHE advances the princi ples of selective photothermolysis

Light Emitting Diode (LED) : OMNILUXTM (PHOTO THERAPEUTICS)

BEFORE AFTER 3 LHE SESSIONS FIG:4 RADIANCYTM

by utilizing the dual energy pathways of light and heat. Oxy-hemoglobin in vascular lesions and melanin in pigmented lesions are coagulated. The coagulated cells are eliminated by a natural process and replaced by new cells at the same time; LHE creates a mild thermal  Thus AFT delivers optimal, insult to the dermo-epidermal effective and a long, junction. The insult triggers a continous pulse duration wound-healing process and new collagen remodels under unlike the IPL an undamaged outer layer. Advantage As collagen rebuilds, fine  Safer for dark skin and lines and wrinkles reduce. ensures even greater safety Benefits with lighter skin tones.  Since LHE uses very low  It obviates the need for the fluences which emits integrated cooling systems wavelengths of 400that are generally required 1200nm, this natural fusion with IPL systems- Editors of light and heat creates a comments (This needs to far more efficient photo be validated in darker thermal technique. skin) 

AFT pulse shape- The Equally Distributed Fluence (EDF) of AFT pulse (GRAPH:1) is an innovation in electronics which enables continous square $ shaped pulses with moderate peak power throughout the entire pulse, for efficacious, safer results

Light-emitting diodes (LED) are other nonablative devices that emit narrow bands of low-intensity light.LED stimulates cell activities and cell proliferation i.e photobiomodulation to regulate cellular production of collagen and elastin. Narrow band 830 nm and 633 nm are effective for non-ablative skin rejuvenation. PHOTOPNEUMATIC TECHNOLOGY: ISOLAZTM (AESTHERA) It is a unique combination of pneumatic energy and broadband light IPL 5101200nm. Here positive energy builds in treatment ti p, targets are elevated closer to skin surface, blood and melanin concentration are reduced. Broadband light is delivered to elevated targets then the skin is returned to normal position. Benefits 

It is painless, and is claimed to be 5 times

October 2008

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CME Article

more effective in delivering energy to target, and 7 times faster than the traditional light based treatment. 

Entire face can be done in 10 minutes, requires no pre-treatment topical anesthetic.



Vacuum activation exerts mechanical pressure on pores removing sebaceous blockage.



Skin is stretched 25-35 % dramatically increasing the light delivered.



Reduction in pore size and improvement in skin texture.

Radiofrequency and LightBased Treatment (IPL) eLIGHTTM (SR Applicator) (SYNERON)

BEFORE

AFTER FIG: 5 ELOSTM

can be used to treat facial skin laxity where it volumetrically heats the collagen which will subsequent cause collagen Table: 1 Indication For Nonablatve Laser And Light Based System remodeling and neocollagen synthesis.  Nonablative treatment is The procedure is associated also a good modality for with minimal downtime and is saucerized acne scars. safe for use in dark skin types.  Nonablative lasers are More Information will be covgood for maintenance ered in next issue along with following the ablative laser newer advances in Skin Tightprocedures. ening. Table-1 will help to choose Synopsis: Non Ablative a laser or light based system Laser depending on the indication.  Nonablative lasers are useful 3. Minimally Ablative Lasers modalities for reduction (Refer Flow Chart 2) of scars and superficial While ablative laser resurfacdyschromias. ing still remains a key compo Ideal for younger nent in the armamentarium of clients who wish to laser resurfacing, the nonablaimprove the quality, tive lasers especially fractiontone and texture of al laser is rapidly gaining acceptance for skin resurfacing. their skin.

3 SESSIONS

This device uses Bi-Polar radio frequency and light energies or laser to precisely heat the dermal tissue within the targeted treatment area. This combination of technologies is called ELOSTM (Electro optical Synergy) This stimulates collagen production, resulting in tightening and reduction of wrinkles. (Fig. 5)

 Treatment of choice for clients with early photoaging, not for one with class III rhytides.

Minimally ablative lasers can be classified as follows: (a) Fractional laser (b) PLASMA (c) YSGG (2790)

INFRARED TIGHTENING Infrared light 780nm-1000nm

SKINKNOWLEDGE

FLOW CHART 2: CLASSIFICATION OF MINIMALLY ABLATIVE LASERS

An Inhouse Journal on Cosmetic Dermatology


CME Article

FIG: 6

zones within it perfectly intact; hence only causing fractional damage through the heat of the light source. (Ref FIG: 6)

Pixelated Pattern of fractional photothermolysis

 This allows the skin to heal much faster than if the whole area was treated, as the 4healthy’ untreated tissue surrounding the treated zones helps to fill in the damaged area with new cells.

Before After FIG: 7 (Er: YAG 2940nm)

Before

After

FIG: 8 PIXELTM

Before Be Bef B efo ef orrre ore e

Af A After fter te te err FIG: FIIG FIG F IG: 8 PIXELTM PIIX XEL E ELTM ELLTM TM

Before After FIG: 9 PIXELTM: 4 weeks after 1 Pixel Treatment.

 Fractional lasers produce columns of burnt tissue (without vaporization) called Micro Epithelial Necrotic Debris (M.E.N.D.). The body rids off this debris over the course of 7-10 days, only then can the empty spaces be filled with new healing tissue

procedures usually require a single treatment, while fractional resurfacing requires between three to five treatments as only 10% of the area is covered with single pass. Recovery period Post procedure there may be a sunburn-like sensation that reduces with a moisturizer. Make-up can be applied immediately. Some flaking will be experienced for one or two days with full recovery in about five days. Side effects Mild-to-moderate swelling and redness which usually subsides within few days. (b) PLASMA (PORTRAITTM (RHYTEC)

Plasma is the 4th state of matter. If sufficient energy is put into a gas,it undergoes another  Ablative lasers like state transition becoming Before After CO2 and 2940nm plasma. The best example of FIG: 10 FRAXEL Erbium can be used with plasma is the light seen with lightning which is not electricity, fractional technology. but rather plasma. Plasma Indications devices use nitrogen to deliver (ref FIG 7,8,9,10,11) plasma. Plasma is technically  Wrinkles not a resurfacing laser. It Before After FIG: 11 FRAXEL 1550nm erbium fiber laser  Acne scars coagulates the epidermis (a) Fractional Laser:  Melasma across the entire surface area of the tissue without the need Fractional lasers are the new  Telangiectasis for wound care. Treatments addition in minimally ablative  Rosacea that reach dermoepidermal Advantage segment.  Faster wound healing, junction are painful and Working Principle require nerve block. The reduced downtime social downtime is 4-6 days  Ĺ“Fractional Photothermo-  Lower complication rate. lysisB seeks to only dam-  Safer mode for the ablative with residual erythema for 1-2 weeks.1-2 treatments may be age certain zones within lasers like Co2 and Erbium required. the selected target area, 2940. (producing tiny dot, or (c) YSGG 2790nm pixel-like treated areas on Disadvantage (PEARL TM)(CUTERA) the skin), leaving the other The traditional Ablative Yttrium Scandium Gallium  Fractional laser can be ablative or non ablative.

TM

TM

3

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CME Article

options for rhytides and atrophic scars. 



532 nm laser has proved to be risky in skin of color and conservative guidelines should be followed when using it.



1064 nm laser may offer greater safety when treating ethnic skin but still risky in type VI skin.



IPL is a safe option for treating skin of color although it is advisable to limit its use for skin types V and VI.

SUMMARY4



Laser procedures in darker skinned patients are challenging but can be successfully achieved if certain treatment guidelines are followed.

Although there are few studies on LED treatments in skin of color, this type of treatment can be used either as a primary or adjunctive treatment modality with apparently low risk. However more studies are warranted.

TABLE:2 Potential adverse effects and downtime of ablative, minimally ablative and non- ablative laser/light treatments



Discussions of risks and patients expectations are essential in treating the darker-skinned patient population.



Pre- and post laser cooling can be helpful to minimize side effects and improve patients' comfort.



Fractional technology has increased treatment

SKINKNOWLEDGE



Finally, radiofrequency and newer tightening technologies are safe and highly reliable to use for ethnic skin. However, it is prudent to use conservative settings to achieve the desired results when treating darker skinned patients.

SAFETY5 

For comparative analysis

An Inhouse Journal on Cosmetic Dermatology

High EFFECTIVENESS

treatments of sundamaged skin. YSGG vaporizes 1030 microns of epidermis immediately; thereby removing the most damaged skin layer. Coagulation generated in the remaining epidermis creates a natural protective dressing on the skin that remains intact during the restorative process. This peels off in 3-4 days revealing the freshly restored and healthy skin. Residual heat in the dermis stimulates new collagen growth further refining and smoothing the skin over the next several weeks.

Minimally Ablative

Ablative

Non-ablative

Low

SAFETY

High

GRAPH 2 :Comparative Safety and efficacy of skin rejuvenation Technologies.

of safety and efficacy between ablative,minimally ablative and non ablative laser (ref GRAPH: 2 and TABLE: 2). REFERENCES 1.

Nonablative Lasers Journal of Cosmetic Dermatology Volume 5 Issue 2 Page 107-114, June 2006, Keyvan Nouri MD, Maria Patrica Rivas MD, Navid Bouzari

2.

Nonablative and Ablative Modular Laser and Pulsed- light system for the treatment of Cutaneous Abnormalities. Professor Arei Orenstein and Dr Joseph Lepselter $ Department of Plastic Surgery and Class Clinic, Sheba Medical Center. Tel Hashomer, Israel. www. msq.co.il

3.

Fractional Laser Treatment for Pigmentation and Texture Improvement. Skin therapy letter. Editor Dr. Stuart Maddin. Vol 11. Number 9. Nov 2006.Z. Rahman, MD; M. Alam, MD

4. Latest laser and light- based advances for ethnic skin rejuvenation Indian Journal of Dermatology Vol: 53 Issue:2 Page 49-53,year:2008, Mohamed Lofty Elaise, heather Woolery Lloyd, MSCI; J. S. Dover, MD, FRCPC, FRCP 5.

Fractional Ablative Skin resurfacing with the Pixel laser. Pixel wp c 16/8/06 10: 18 Page 1 Gregory S. Keller,MD,FACS, Clinical Associate Professor, David Geffen School of Medicine. University California, Los Angeles, California


Overview: New technology

Fractional Photothermolysis -Dr. Ameet Dandale , Kaya Training Center, Andheri, Mumbai INTRODUCTION:



A

few years back only ablative modalities of treatment were available for acne scars and aging skin. Fractional resurfacing was developed to meet the goals of minimal downtime and reduced risk profile of the nonablative systems, while increasing the efficacy of laser. In 2005,Khan et al reported on the use of the first fractional resurfacing device, a 1550-nm erbium laser.



PRINCIPLE: What is Fractional Photothermolysis? 

Ĺ“Fractional PhotothermolysisB seeks to only damage certain zones within the selected target area, (producing tiny dot, or  pixel-like treated areas on the skin unlike with selective photothermolysis, where the whole of the selected target area is  damaged);leaving the other zones within it perfectly intact; hence only causing fractional damage through the heat of the light source. (as seen in Fig 1 & Fig 2) This is comparable to digital photography that we are able to do nowadays; pixel by pixel.

Fractional photothermolysis manufacturing companies allows the skin to heal much make the lasers fractional. faster than if the whole The difference lies in the area was treated, as Ablative resurfacing Nonablative dermal remodeling Fractional photothemolysis laser laser laser the healthy untreated epidermis epidermis epidermis a r e a s surrounding dermis dermis dermis each column hair folicle hair folicle hair folicle of thermal damage subcutaneous fat subcutaneous fat subcutaneous fat provide a Fig 1. Diagrammatic representation of difference between reservoir ablative and non- ablative lasers from which regeneration may take placement of the filter. The 1,2 place. filter which fractionalizes the laser beam can be Each treatment session present in the gaining covers approximately 20% medium of laser or it can of the targeted skin. A be placed in hand piece. complete course of treatment therefore consists of at  least 4-5 treatment sessions, spaced 2-4 weeks apart. The laser emission is absorbed primarily by water. As the stratum corneum contains little water it is spared. There are two different ways in which the laser

Fractional technology can be used with ablative or minimally non ablative wavelengths. This will depend upon the lasing medium used in laser.

TYPE: (Refer Table-1) Fractional lasers can be ablative or nonablative (ref fig 3).

Fig. 2 Histopathology changes post fractional laser.LDH staining of treated skin shows healing response at 1 hour (A), 1 week (B) and 3 months (C) post-exposure. Clear areas represent loss of cell viability. Note minimal epidermal damage.

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Overview: New technology

delivers an array of small beams creating a periodic lattice of isolated hyperthermic Fig 3: fractional lasers ablative and nonablative columns 1.5 to 3.0 mm in (A) Reliant: Fraxel 1550-nm depth to the erbium fiber laser, reticular dermis. The laser beam is deliv- • Lux 2940 ered through an optically Hand-piece delivers tracked microprocessorerbium laser resulting in controlled hand piece to 3 deep ablative columns. produce an array of microscopic thermal zones, (C) Affirm: Sequentially emits 100 Um in diameter and 1320-nm and 1440400 to 700 Um deep,Treatnm wavelengths at fixed

Post inflammatory erythema resulting from acne vulgaris, Poikiloderma of Civatte, Disseminated superficial actinic porokeratosis, Striae distensae

Fig 3 Prior to fractional laser

Fig 3 After 1st session

Fig 3 Table 1. Fractional lasers commercially available

ment can be performed with a topical anesthetic.

intervals. A micro lens array is employed to diffuse the laser light into a lattice of micro beams targeting superficial and deeper penetration depths through the two wavelengths.4

(B) Palomar StarLux 500: pulse light and laser system. This fractional photothermolysis system can have the following hand piece attachments. •

INDICATIONS: FDA approved:

 

Lux IR Fractional Noncoherent infrared light source, which generates pulses of light in the 825to 1350-nm range of the spectrum. This technology

SKINKNOWLEDGE

Fig 4

Depending upon the manufacturer the different variants of fractional lasers available commercially are summarized in table 1.

Palomar Lux 1540 Contains a hand piece that divides pulsed light into micro beams which penetrate up to 1mm. Advantagepracticality and versatility of a hand piece, and painless.

After 3rd session Fig. 3 Result of fractional laser (Non ablative) on acne scars



Acne scarring (ref. fig. 3) Correction of wrinkles around the eyes (ref. fig. 4) Skin resurfacing (ref. fig. 5, 6) Melasma, Freckles

Fig 4 Fig. 4 Result of fractional laser (Non ablative) on crow’s feet after 4 sessions Fig. 5 Result of fractional laser (Non ablative) on nasolabial folds after 4 sessions

Non FDA approved:

Surgical scars,

An Inhouse Journal on Cosmetic Dermatology

Fig 5


Overview: New technology

Fig. 6 Result of fractional laser (Non ablative) on forehead lines after 4 sessions

traumatic scars a spot size of 10mm and photo rejuvenation a spot size of 15mm is preferred.

Maintenance:  Acne scars: As the the Fig 6 effect lasts lifelong there is no need of maintenance Contraindications: in acne scars. Melanocytic nevi  Photorejuvenation: maintePermanent tattoos, nance sessions once in 6$ 12 months are advisable Suspicious pigmented lesions or history of skin cancer in the COMPLICATIONS: 5-6 treatment area; Infection at or near the Common: Dry skin, Flaking, Pruritis, treatment area, Superficial scratches, Keloid, Poor wound healing Acneiform eruptions (often with poorly controlled Uncommon: diabetes), Pregnancy or breast feeding, Herpes simplex, post inflamarrhythmias or heart failure, matory hyperpigmentation in pacemaker, Liver failure or darker skin, Bronzing. diseaseh/o Photosensitivity Why to choose non Clients with unrealistic ablative fractional laser expectations (table2) PROCEDURE:  Ablative laser modalities though remain the gold • Fluence: Depending upon standard for the treatment the client’s skin type of photo aging, most settings of fluence should patients cannot tolerate the be adjusted. For scars 1$2 weeks of downtime fluence of 25mJ/cm2 required with these increasing by 5-10mJ/ procedures. cm2 with each session. For photo rejuvenation start  Advantages of minimally ablative / fractional laser with fluence of 20mJ/cm2 are that they can combine increasing by 5mJ/cm2 the efficacy of ablative gradually. and safety of non-ablative lasers. • Spot size: acne scars,

References

1. Geronemus RG. Fractional photothermolysis: current and future applications. Lasers Surg Med. 2006; 38:169176. 2. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med. 2004;34:426-438 3. Rahman Z, Tanner H, Tournas J,Jiang K,Kelly K M,Berkowitz L, Zachary C. Ablative fractional resurfacing for the treatment of photo damage and laxity. Lasers Surg Med. 2007 4. Dierickx,C,Khatri K,Alshuler G, et al. Fractionated delivery of Er:YAG laser light to improve efficacy and safety of ablative resurfacing procedure. Lasers Surg Med. 2007 5. Graber E.M, Tanzi E.L, Alster T.S. Side Effects and Complications of Fractional Laser Photothermolysis: Experience with 961 Treatments. Dermatologic Surgery Volume 34 Issue 3 6. Fisher GH, Geronemus RGShort-term side effects of fractional photothermolysis. Dermatol Surg. 2005 Sep;31(9 Pt 2):1245-9

Table 2: Comparison between fractional and ablative lasers

October 2008

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Drug Molecule of the Month

Drug Molecule of the Month: Esapeptide B Dr. Madhuri Agarwal, Kaya Mulund, Mumbai. 

signal peptides,



neurotransmitter-affecting peptides



Carrier peptides.

Esapeptide B: Introduction: The common indicators of skin ageing is the increasing intensity of frown and wrinkle lines of the forehead, glabella, lateral periorbital area as well as the intensity of chin,upper li p wrinkling,nasolabial folds and platysma bands increase1. This can occur naturally over time and is identified by certain biochemical, histological and physiological changes that are enhanced by environmental exposure. There are, however, other secondary factors that can cause characteristic folds, furrows and creases of the face, such as the constant pull of gravity, frequent and constant positional pressure of the skin of the face (e.g. during sleep)or repeated facial movements caused by the contraction of the muscles of facial expression1,2.Botulinum toxin is a known safe therapy for dynamic wrinkles. One of the new options to treat ageing skin are peptide cosmeceuticals.

SKINKNOWLEDGE



(Acetyl hexapeptide-3 i.e.ACgly glu-met-gln-argarg-NH2) Esapeptide B is neurotransmitter-affecting peptides Mechanism of action of Esapeptide B : 

neuropeptidess that are currently incorporated into cosmeceutical products are developed as topical mimics of the botulinium neurotoxins.



intracellular target of BTX-A (Botulinum Toxin) is the synaptosome-associated protein of molecular weight 25 kDa (SNAP-25),which is a protein essential for the successful docking and release of acetylcholine from the presynaptic (ref fig 1 and 2) acetylcholine laden vesicles

Classification: There are three main categories of cosmeceutical peptides:

BTX-A light chain (protease component) cleaves SNAP-25 and interferes with the fusion process required for vesicular docking

Figure 1 Neuro muscular junction with acetylcholine vesicles

An Inhouse Journal on Cosmetic Dermatology

The SNARE complex consists of three proteins (Vamp, Syntaxin and SNAP-25). It is essential to stimulate muscles.(ref fig 3)

Point of action esapeptide B

for



Esapeptide B is a synthetic peptide patterned from the N-terminal end of the protein SNAP25 that inhibits SNARE complex formation and catecholamine release. Esapeptide-B is in competition with the SNAP-25 for a position in the SNARE complex.



The competition destabilizes the complex and consequently the excessive muscular contraction.

Thus the topical neurotransmitter affecting peptides that are currently marketed in cosmeceuticals reportedly function to decrease facial muscle contraction and thus reduce lines and wrinkles by raising the threshold for minimal muscle Figure 2 internalization of activity, requirbotulinum toxin protein at the neural end ing more signal


Drug Molecule of the Month

Side Effects: No systemic adverse reactions have been reported. In rare cases, hypersensitivity reactions may occur. Drug Interactions Figure 3 figurative depiction of the various receptors required for release of acetylcholine in the neuromuscular junction

to achieve movement and reducing subconscious muscle movement over time3.

No drug interactions have been studied or reported till date. Advantages of Esapeptide B



Indications This peptide is currently marketed as Argireline† (McEit [Tianjin] International Trade Co., Ltd.)4. Esapeptide B, being a cosmeceutical neurotransmitter peptide can be used to improve the signs of ageing. It acts by enhancing collagen production, relaxing mimetic wrinkling, improving hydration and barrier function, or by a combination of these benefits. Ref (Fig 4&5). Contraindications:  

not to use on exposed or broken skin surface. discontinue use if allergic reaction immediately.



Esapeptide B is a next generation safe peptide with antiwrinkle activity that could be used in cosmetic preparations. Esapeptide B exhibits the advantage of its insignificant acute toxicity (2000 mg kg-1) as compared with Botulinum toxin A (20ng kg-1)

Conclusion: The studies used to justify the incorporation of these ingredients into skin care products are in vitro.

to suggest that they are beneficial and may have a place in a comprehensive skin care protocol for aging skin3. Although their benefits currently may not be as rigorously tested as most FDA regulated drugs, the evidence to support their use is growing3. Esapeptide is not a substitute or an alternative for Botox treatment for dynamic lines. References: 1. Benedetto, A.V. Environment and skinaging. Clin.Derm.16, 129139 (1998). 2. Stegman, S.J., Tromovitch, T.A. and Glogau, R.G. Theskin of

As dermatologists well know, these results do not always translate into in vivo actions.

the aging face in cosmetic

For any active ingredient to work, it must be absorbed in a stable form into the viable dermis. It is not an easy task to penetrate the barrier of the skin.

year book, St. Louis. MO,

Double-blinded, placebo controlled drug study data is lacking, as it is with all cosmeceuticals as a result of regulatory concerns by industry. before after Fig 4 cosmeceutical peptide treatment

before after Fig 5 cosmeceutical peptide treatment

There is, however, soft clinical data and anecdotal evidence

dermatologic Surgery, 2nd

edn. Mosby

pp. 515(1990). 3. Mary

P.L.,

Anna

Cosmeceutical

L.C...

peptides.

Dermatologic Therapy, Vol. 20, 2007, 343$349. 4. Blanes-Mira C, Clemente J, Jodas G, et al. A synthetic hexapeptide with

(argireline)

anti-wrinkle

activity.

Int JCosmet Sci 2002: 24: 303$310.

October 2008

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16

Clinical Study

The Aesthetic Approach To Nonsurgical Brow Lift Dr Madhuri Agarwal, Kaya Mulund, Mumbai and Dr Malini Girish , Kaya Thane.

INTRODUCTION:

B

otulinum toxin type A (BTX-A) has an impressive safety and efficacy record for the treatment of dynamic facial rhytides, particularly in the upper face. Numerous reports have reported an associated brow lift with BTX-A injections in the glabellar complex, probably caused by deactivation of the brow depressor muscles.

examination, eyebrow droop was also noticed for which she was advised BTX-A. On the day of procedure, under cover of local anesthesia, she was administered 20units in the glabella and 5 units each side (the recommended three points were treated) on the inferolateral aspect of eyebrows away from midpupillary line (Fig 1).

client had satisfactory results after another 10 days (Fig 2). Case 2: (Fig 3&4) A 36-year-old female client presented with frown lines, forehead lines and crows feet. BTX-A for the concern areas and a brow lift for better aesthetic results were recommended. 14

Case1: (Fig 1&2) A 43-yr-old female presented with concerns of crow’s feet and skin dullness. After a detailed age analysis, she was recommended BTX-A for her concern along with microdermabrasion and photo facial treatments. On

After 10 days, an additional touchup of 5 units in each inferolateral aspect of eyebrows was administered for the desired shape. The

Fig 1: Pre chemical brow lift. The white circles indicate injection sites of Botox for brow lift

Fig 2: Post chemical brow lift. Results seen after 20 days of initial injection

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Fig 3: Pre chemical brow lift. The white circles indicate injection sites of Botox for brow lift.

An Inhouse Journal on Cosmetic Dermatology

Fig 4: Post chemical brow lift. The results seen after 15 days of initial injection.

units BTX-A were utilized for the glabella complex. Her forehead lines were tackled by administering 16 units in the frontalis (Fig3). The crow’s feet were treated with 6 units on each side. The client came in for a follow up after 2 weeks. There was optimum softening of the dynamic lines in all three areas where BTX-A was administered. In addition there was a remarkable brow lift, which the client appreciated (Fig 4).


Clinical Study

Discussion: The

Muscles Responsible For Eyebrow Movement

Brow Depressors  Procerus  Orbicularis oculi  Corrugator supercilii muscles Brow Elevators

 Frontalis The Muscles Treated By BTX-A For Brow lift

Case 1: Medial and Lateral Brow Depressors were targeted for Brow Lift With BTX-A

Recommendations brow lift:

for



C/o Crow Feet/Frown with Brow Droop/Straight Brows



Medial and Lateral Brow Depressors Treated with BTX-A



C/o Frown/ Forehead Rhytids desiring Brow Enhancement



Combination of Medial Brow depressors and Brow Elevators Treated with BTX-A

Conclusion: A pleasing brow lift can be achieved with BTX-A. 1. In both the cases we tried two different recommended methods of administering BTX-A for brow lift with satisfactory results. 2. However, client selection

Case 2: Medial Brow Depressors and Brow Elevators both were targeted for Brow Lift With BTX-A

and alignment is extremely vital with regards to aesthetic results, the extent of brow lift elevation and the duration of results.

senior dermatologists. We would like to thank the Kaya advisory board for being a source of encouragement and support.

3. Both the clients didn’t report any side effects and appreciable results were achieved within 1215 days of treatment.

We specially wish to thank Dr. Snehal Sriram for her valuable inputs and suggestions.

4. In cases 1& 2, the BTX-A dose utilized was 40 and 30units respectively.

References: 1. Huilgol SC, Carruthers A, Carruthers JD. Raising eyebrows with botulinum toxin. Dermatol Surg. 1999

May; 25(5): 373-5. Thus BTX-A is an excellent tool for achieving an aesthetically, 2. Carruthers A, Carruthers JD. Eyebrow Height after Botulinum pleasing brow lift by a Toxin Type A to the Glabella. painless method. Dermatol Surg

Editors Note: Brow Lift, an advanced application of BTX-A is not done as a routine practice in KAYA. These 2 cases were taken up as challenge cases in consultation with the zonal

2007; 33:S26$S3 3. Kokoska MS, Amato JB, Hollenbeak CS, Glaser DA. Modifications of eyebrow position with botulinum exotoxin A. Arch Facial Plast Surg 2002; 4:244$7.

October 2008

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18

Case Study

Treatment of Severe Acne Vulgaris With Topical Tazarotene 1%: A Case Report Dr Madhuri Agarwal, Kaya Mulund, Mumbai

Case Report:

Examination

History

The entire face was covered with nodulocystic and papular acne with underlying pigmentation (Fig.1&2).

A

24-year-old female client presented with severe nodulocystic acne vulgaris. The

Management Investigations including a hormonal profile were normal.

Fig.1: Left Side

Fig.2: Right Side

Before Tazarotene Therapy

client gave history of perioral melanosis and few acne for which she took medication with relief. However, after application of lightening creams containing hydroquinone 1% and with mild steroids (details not known) there was acute exacerbation of acne and it reached the present state. It was extremely traumatic for the client and she was severely depressed about it. Hop up on the table and I'll have those wrinkles gone before you know it.

After counseling the patient and aligning her about the concern all her medications were stopped and she was started on tazarotene gel 1% (maximum for 5 mins every night) along with mild cleansing face wash and lacto calamine lotion for sun protection. After 15 days, there was increase in pustular lesions. Hence oral azithromycin pulse dose was added for 2 pulses. After 4-6 weeks of starting tazarotene, there was drastic decrease in the acne and pigmentation. The acne had completely settled down in 8 weeks with reduction of pigmentation as seen in Fig.3 & 4.

H Plastic Surgery

U M O U R

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Yes, Mr Wilson, Face

Transplants are a theoretical po ssibility...and No. Yo u can't Have Brad Pitt's


Case Study

and mean levels of dryness were no more than mild in both groups. In this study, tazarotene cream was effective and well tolerated in the treatment of PIH in patients with darker skin 5. Conclusion:

Fig.1: Left Side Fig.2: Right Side After Tazarotene Therapy

Discussion 

Acne vulgaris is a common adolescent skin concern which may lead to cutaneous as well as emotional scars.

Therefore,client alignment,counseling and topical retinoids are good alternative therapy especially for clients with insufficient funds and skin abused by incorrect therapy. References:



Numerous psychological problems stem from acne, even resulting in decreased employability in adulthood 3.

1. Webster GF. Inflammation in acne vulgaris. J Am Acad Derm. 1995; 33:247$253.



Tazarotene 0.1% gel was more effective than tretinoin 0.025% gel in reducing the open comedo count the total noninflammatory lesion count and the total inflammatory lesion count (not statistically significant) 4.

3. Cunliffe WJ. Acne and unemployment. Br J Derm. 1984; 115:386.



2. Kligman AM. An overview of acne. J Invest Derm. 1974; 62:268$287.

4. Webster GF, Berson D, Stein LF, Fivenson DP, Tanghetti EA, Ling M. Efficacy and tolerability One study assessed tazarotene 0.1% of once-daily tazarotene 0.1% gel versus oncecream for the treatment of post inflammatory daily tretinoin 0.025% gel in the treatment of hyperpigmentation (PIH) in a double-blind, randomized, vehicle-controlled study of facial acne vulgaris: a randomized trial. Cutis . 74 patients of darker racial ethnic groups 2001 Jun; 67(6 Suppl): 4-9.

who had acne. Once-daily application of 5. Grimes P, Callender V. Tazarotene cream for tazarotene cream was shown to be effective post inflammatory hyperpigmentation and against PIH. Mean levels of erythema, acne vulgaris in darker skin: a double blind, burning, and peeling were no more than randomized, vehicle-controlled study. Cutis. trace in both groups throughout the study, 2006 Jan; 77(1): 45-50.

H A New YOU! -Free Make Over

U

Sis...I'm not sure If you' re surprised, shocked, upset or just in a botox state of mind!

M O U

"First, we'll need a sample of your DNA."

R October 2008

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20

Synopsis of Interesting articles

It’s All in How You Inject -Dr.Madhuri Agarwal, Kaya Mulund

Introduction: Hyaluronic acid fillers have an excellent long-term safety profile, but local adverse events in the immediate post injection period are quite frequent. Materials and Methods:

Fig1: The Serial puncture technique for fillers

In this industry-sponsored, prospective, blinded, 17-center, controlled study, 283 patients were randomized to receive either Restylane or Perlane hyaluronic acid fillers for nasolabial folds and oral commissures. The injecting investigators used the injection technique that they preferred, and the injection technique and all local adverse events were recorded. Results: No significant differences between fillers were noted in adverse events. In the pooled data, 20% of patients had bruising, 5% had edema, 4% had tenderness, and 1% had pain after injection.

Fig 2: The Linear threading technique for fillers

(Fig.2), and subcutaneous injections were not associated with increased risk for adverse events. Comment: 

Careful attention to technique is important to reduce the rate of temporary # but to cosmetic patients, distressing # local adverse events.



The least traumatic injection techniques should be used: low volume per site, slow injection, and avoidance of fanlike injection.



Linear threading and multi ple puncture techniques are clearly preferable to fanlike injections.



Another option proposed by some dermatologists for dramatically reducing bruising is the addition of lidocaine with epinephrine to the hyaluronic acid filler.

Adverse events mostly resolved by 2 weeks.

Source:

Local reactions were significantly correlated with use of higher total injection volumes, the fanlike injection technique, and rapid injection (flow rates greater than 0.3 mL/min).

George J. Hruza, MD, published in Journal Watch Dermatology July 11,2008. Glogau RG and Kane MAC, effect of injection techniques on the rate of local adverse events in patients implanted with nonanimal hyaluronic acid gel dermal fillers, Dermatol Surg 2008 Jun; 34:S105

Flow rate was the most important risk factor. Single

puncture

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(Fig.1), linear

threading

An Inhouse Journal on Cosmetic Dermatology


Synopsis of Interesting articles

Human papillomavirus and skin tag- is there any association? -Dr.Madhuri Agarwal, Kaya Mulund

Background: Skin tag (Fig.1), or soft fibroma, is a common benign condition, which consists of a bit of skin which projects from the surrounding skin. Fibroepithelial polyps, or acrochordons, often develop in areas of skin friction. Human papillomavirus (HPV) (Fig.2) is known to be the most ubiquitous of the human viruses. Over Fig1: Skin Tags 100 HPV types have been identified till date. In healthy population, most of these HPV types appear to establish a latent infection of the skin, mostly as normal flora residing in hair follicles.

methodology and restriction fragment length polymorphism (RFLP) assays was done for the detection of low risk HPV types 6 and 11. Results: The results revealed the presence of HPV DNA 6/11 in 48.6% of the skin tags examined by PCR-RFLP (Fig.3).

Figure 3: Representative picture of 1.5% agarose gel electrophoresis showing post-PCR products in normal skin tissue and skin tags from different patients [positive band is of amplified HPV DNA of 526-594 base pairs (bp)]. Lane 1: DNA marker (100-bp ladder); lane 2: negative control; lane 3: normal skin from patient 1; lane 4: skin tag from patient 1; lane 5: normal skin from patient 2; lane 6: skin tag from patient 2; lane 7: normal skin from patient 3; lane 8: skin tag from patient 3; lane 9: plasmids DNA containing the HPV genome types 6 and 11 (positive control); lane 10: DNA marker (100-bp ladder)

Low risk human papillomavirus (HPV) infections are related to the genesis of various benign Fig2: lesions. In an isolated report Papillomavirus available, HPVs has been implicated in the causation of skin tags too.

Conclusion: 

This result corroborates the hypothesis that HPV plays a part in the aetiology of benign lesions like cutaneous soft fibromas.

Objective:



The present study was designed to detect the existence of low risk HPV 6 and 11 in cutaneous soft fibromas (skin tag) in North Indians.

The identification of HPV 6/11 in these lesions, which are benign proliferation of the skin, further expands the spectrum of HPV linked lesions

Source:

Methods:



A total of 37 cases of skin tags from various sites were analysed. Highly sensitive and comprehensive polymerase chain reaction (PCR)

Department of Immunopathology, PGI, Chandigarh, India.



Department of Dermatology, All India Institute of Medical Sciences, New Delhi, India

October 2008

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21


CME Questionnaire

22

CME Questionnaire 1.

Name the lasers and light sources for photorejuvenation?

2.

What are the side effects of ablative lasers?

3.

What is the working princi ple of Fractional thermolysis ?

4.

What is the advantage of Ablative Fractional lasers over traditional ablative lasers?

5.

What is the advantage of Advanced flourence technology pulse over Intense pulsed light?

What's your diagnosis for the Photo Quiz? Views and Suggestions

Kindly Send the Questionnaire and suggestions at the following address:

Ms. Venita Sharma, Medical Coordinator Kaya Limited C-10, Dalia Industrial Estate, Off Link Road, Andheri (W), Mumbai $ 400058 Ph: 267020501/2/3; Extn 319, 9819153824

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An Inhouse Journal on Cosmetic Dermatology


Photo Quiz

23

What’s your diagnosis? Dr Shweta Sawalka - Kaya Lokhandwala, Mumbai.

History: 43 year old female presented

Examination:

with mildly itchy,red colored lesions in both

lesions with granulomatous appearance,

the underarms since 21/2 years gradually

two to three such lesions in each axilla.

increasing in area. Client consulted 2-3

No localized lymphadenopathy, sensation

dermatologists with partial relief with topical

normal.

steroids. There was no history of lesions

Histopathology:

any where else on the body no systemic

superficial and deep perivascular and

Erythematous,

Moderately

annular

dense

complaints, no history suggestive of contact periappendageal lymphocytic infiltrate irritation to perfumes or deodorants or with focal infiltration of dermoepidermal clothes.

junction.rete ridges flattened.focal basal cell vacuolization. single focus of mild spongiosis in the epidermis.

Figure 1 lesions in right axilla

Figure 2 lesions in the left axilla

October 2008

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Skin Knowledge - October 2008