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Total Pages : 40 August-September 2021 (Combined Issue) Vol 14* Issue 6

Pincer Nail Deformity Treated with Haneke’s Procedure Platelet Concentrates In Aesthetic Dermatology Atopic Dermatitis: A Rising Trend Rational Treatment of Dermatophytic Infection

COVID-19 and Issues Related To Dermatological Care: A Case Report Utility of Autologous Platelet Rich Fibrin (PRF) Therapy in the Treatment of Chronic Non-healing Trophic Ulcers Secondary to Hansen’s Disease

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August - September 2021

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EXECUTIVE EDITOR & PUBLISHER Dom Daniel

CORPORATE OFFICE 22, Shreeji Bhavan, 275-279, Samuel Street, Masjid Bunder (W), Mumbai-4000 03, INDIA.

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Increasing Incidence of COVID-19-Associated Dermatological Manifestations The COVID-19 pandemic has directly or indirectly affected every human being on this planet. In this pandemic the increasing incidence of COVID-19-associated cutaneous manifestations have been increasingly reported, their exact incidence has yet to be estimated, their pathophysiological mechanisms are largely unknown, and the role, direct or indirect, of SARS-CoV-2 in their pathogenesis is still debated. Furthermore, evidence is accumulating that skin manifestations associated with COVID-19 are extremely polymorphic. Various types of cutaneous manifestations have been observed in patients with COVID-19 infection. The variability of skin findings seen is substantial compared with other viral infections that typically present with characteristic skin patterns. Recently reported COVID-19-associated dermatological manifestations with various clinical presentations such as urticarial rash, confluent erythematous/maculopapular/morbilliform rash, papulovesicular exanthem, chilblain-like acral pattern, livedo reticularis/racemosa-like pattern, purpuric vasculitic pattern etc. The dermatologist should have a thorough knowledge about the atypical presentations of skin lesions in COVID-19 so that they can lend a helping hand in the early diagnosis of the disease, which is of utmost importance in preventing the disease spread, morbidity, and mortality. In this issue we got the articles on COVID-19 and issues related to dermatological care, rational treatment of dermatophytic infection, platelet concentrates in aesthetic dermatology, atopic dermatitis, PRF therapy in the treatment of chronic non-healing trophic ulcers secondary to hansen’s disease, pincer nail deformity treated with haneke’s procedure.

- Dom Daniel All rights reserved. Reproducing in any manner without prior written permission prohibited.

Published for the period of August-September 2021

4

August - September 2021

Executive Editor & Publisher


Platele

t Concen

trates

In Aesthe

Platelet

tic Dermat

ology

Conce ntra Dermat tes In Aesth etic ology Dr. Niti

Khunge

r

MD, DDV , DNB

Head, Profe Vardhman ssor and Cons ultant Derm New Delh Mahavir Med atologist, ical Colle i, India ge and Safdarjun g

Dr. Khu

Hospital,

shpree

MBBS, t Kaur MD, DNB Mann Senior Resi Vardhman dent Mahavir New Delh Medical i, India College and Safd arjun

08 Platelet Concentrates In Aesthetic Dermatology

g Hosp

Dr. Niti Khunger, MD, DDV, DNB

08 8

Dr. Khushpreet Kaur Mann, MBBS, MD, DNB

ital,

Platele t described concentrate for hemo s, initially multitu Types stasis, de of applic of Plate have derma ations let conce tology in aesthe . They ntrate bioact tic There are s ive functio variou regen n as conce s types Autolo ntrates, gous plateleerative of platele therap based ies. content, t retriev t conce on the ed from leukoc ntrates platele yte conte patien t are via centri t’s whole nt and Platelet-ric fugatio fibrin. blood n. Activa release h plasm ted platele key growt a (PRP) affect ts It is autolo h factor healin gous blood s that can concentratio inflammatio g, matrix plasm depos a with n of platele ition, baseline a cell migra n, angiogenesis ts well (4 to tion, and above , 7 times) Hence cell prolife stem definition of . Worki they PRP was ration. as 1,000 ng rejuvenation help in tissue given ,000 by repair platele Marx and of plasm i of platele . There are ts /μL a. It variou in 5 mL t conce can be s types (L-PR on the ntrates, P) or leukoc mode depen of prepa ding PRP (P-PR leukocyte poor yte rich utilization ration. P). or pure in aesthe Their depen tic Platelet ds on the indica dermatology poor plasm rich plasm tions. a a Platele and studie is the most t Platelet-poor well known d, but Plasm residu increa a (PPP) other al plasm singly types is the becom a once are extracted. article ing popul the PRP aims to ar. This give an is variou overview s types Platelet of platele of the gel and their t conce role in ntrates If a platele aesthe tic derma t activa tology tor such . or calcium as throm chlorid bin e is added to the

Augus

t 2021

Atopic

Dermatit

is: A Rising

Atopic

Trend

Dermati

tis: A Ri

sing Tr end

Dr. Dipa

k

Patel M.D., D.V. & D. Aesthetic Dermatolog Consultant ist Dermatolog and Cosmetolog ist, ist in Surat , Gujarat

12 Atopic Dermatitis: A Rising Trend

Abstra

ct

Atopic dermat age groups itis (AD) atopic which is also known eczema, varies presen in a clinical tation as it is chronic a pruritic at differen places. relapsin , inflamm t ages It is g, atory dermat condition skin disorde a relapsing eczem and usually ologica starts in l r charac intense atous early life.The degree pruritic s of pruritus terized by varying rash can and signific be debilita , and inflamm of the antly decrea ting skin quality ation se individu accom cutane of life. panied ous physiol al’s It is one commo by of the ogical n inflamm most and dysreg dysfunction atory skin affectin ulated It is the g children inflamm disease most ation. 1,2,3 s prevale and adults. skin disorde common inflamm nce of The atopic r affectin increas atory dermat as ed 2- to g children adults itis has 3-fold in and a as well nations industr negativ , it affects ialized their quality e impact approx to 20% of life. on imately AD is one of children 15% most commo of the adults worldw and 1% n skin is cumula to 3% disease ide. of s which tive prevale and is nce in This article estimat children ed up summa 1%–3% unders to 8-20% rizes the of tanding adults current the and in most of the of AD, world, countri pathog while in es of diagno India it stic criteria enesis 2.4% and treatme is betwee 6%. 2,4,5, 6, 7 nts. , and n Etiolog Keywo y rds: Atopic Dermatitis, of Life, Multifac Quality The causes torial. in nature, of AD is multifac Introduction torial and trigger they can aggrav Atopic atopic ate include dermat dermat s genetic itis that itis is chronic , immun a commo environ , ologic, mental intense n, inflamm and impact 8 ly atory s. skin conditi pruritic, Recent appear investig s to be on that ations increas atopic over the ing in prevale have shown dermat past few itis is results nce comple frequen x interpla from the tly it occurs decades. Most y of multiple such as can be in children epiderm started factors and it immun al barrier in infancy life, also dysfunction, e dysreg or early it affects ulation, in triggers many adults environ , food, mental drugs in all all are and microb playing a key es role in disease

Dr. Dipak Patel M.D., D.V. & D. 12

12

August

2021

Rational

Treatmen

t of Dermatop

hytic Infection

Rationa Dermato l Treatment of phytic Infectio n

18 Rational Treatment of Dermatophytic Infection

Dr. Ajoy

Kumar Sah

a

Associate Professor, Department HOD of GMC Bettia Skin and VD, h (West Champaran)

Dr. Vika

sh

Anand Assistant Professor Department of Skin JLNMCH, and Bhagalpur VD,

Dr. Ajoy Kumar Saha, MBBS, MD

BACKG

ROUND

In India superfic examin ial dermat ation and running ophytic chronic KOH confirm are and history endemi to 1. Ineffect c course ation of drugs due were taken used previou ive and treatme 2. Inadequ into accoun sly nt which ate t. is leading resistan RESUL ce but to drug T we can effective still treat ly by using it There were our intellige 217 patients AIM nce. male: female in study ratio of in most commo around To cure 2:1 and nly affected superfic age of group ial dermat 30 to infestat were 40 and ion ophytic corpora by (~30%) judiciou intellige and tinea tinea nce use s cruris formed percent and of oral drugs of the case. in our 60 armame present ntarium terbinaf LIMITA (flucona ine, griseofu TION zole, lvin, itracona and comple mentary zole In medica measur l college es). METHO usually treated previou D cases arrive sly so corticos creams were used Patient teroids with dermat in 40 % of cases. ophytic attendin CONCL g OPD infectio USION n of Jawaha medica rlal l college and hospita Nehru We can still adequa rainy season l during treat tely and (July to effective august dermat first half ly 2018) were ophtic of with flucona infectio enrolled zole and n in clinical griseofu terbinaf lvin and ine, itracona effective zole, if go for not multi drug therapy

Dr. Vikash Anand, MBBS, MD 18 18

August

22 Utility of Autologous Platelet Rich Fibrin (PRF) Therapy in the Treatment of Chronic Non-healing Trophic Ulcers Secondary to Hansen’s Disease

2021

Utility of

Autologo

us Platelet

Rich Fibrin

Utility Rich Fi of Autologou br Treatm in (PRF) Th s Platelet ent erap Trophic of Chronic No y in the n-heali Ulcers Hansen Secondary to ng ’s Disea se Dr. (PRF) Therapy

in the Treatmen

t of Chronic

Non-heal

ing Trophic

Ulcers

Secondar

y to Hansen’s

Amina Asfi

ya MI

MD

Assistant Professor Department of Derm Yenepoya atology, Medical College, Mang

alore, Karna

Dr. Man

juna

taka

th Shenoy MD, DNB M Professor and Department HOD of Derm Yenepoya atology, Medical College, Mangalore

Dr. Dr. Amina Asfiya MI, MD

Disease

Introdu

ction

Dr. Manjunath Shenoy M, MD, DNB

22 22

August

2021

28 COVID-19 and Issues Related To Dermatological Care: A Case Report

As dermat ologists applica encoun tion, we frequen ter cases collage healing tly dressings, n or leg ulcers of chronic applica saline due to non growth tion of which venous topical may be modalit factors, and insuffici trauma other ies. But, ency, leprosy , diabete these treatmesurgical s mellitus ulcers , not evidence cause nts are the patients significant etc. These a case on based. 1 Here we report morbid the utility Platelet ity and discharin terms of of autolog Rich pain, disabilitto ous these woundsge. The y healing of chronicFibrin (PRF) treatme nt of ulcers. non healing in the pose a only to challen us but trophic ge not also general vascula A 55-year r surgeon The healingsurgeons s, our old and Out Patient male present others. of these depend compla ent wounds Departm ed to ints of and environ on several ent is over the with non healing physiolo mental gical left foot factors. ulcers There was The healing since 8 months no history to the of neurop in leprosy . of trauma athic ulcers non-diaonset of the prior is slow chronic ulcers. betic due to He was inflamm ageing a atory the was a case and non-sm of the oker. nature of local reparat Various and had comple Hansen’s disease He ted Multiba modalit ive cells. Drug and have ies of Therap been y (MB-MD cillary - Multi tried like treatment year ago. topical T) treatme The metron off-load nt a idazole ing, treated with ulcers were or phenyto multiple previously in like topical modalit and oral ies antibiot ics and

COVID-19

and Issues

Related

To Dermatol

COVID-

ogical

Care: A

Case Report

19 an To Dermd Issues Relat ed Care: A atological Case Re port Dr. K. Laks

hmi

MBBS, prasad DDVL Consultant Dermatolog Aditya ist Polly Clinic Attapur, Hyder

abad

Introdu

ction

Dr. K. Lakshmiprasad, MBBS, DDVL 28 28

August

2021

32 Pincer Nail Deformity Treated with Haneke’s Procedure

COVID19, has spread the world through at a out showed stagger becom ing a ing speed itchy pandem and erethem lesions The most ic emerge on her atous commo ncy. 1 skin. COVIDn sympto 19 are ms in Case Report fever, sympto ms, fatigue, respirat ory nausea dry cough, 80 years old , vomitin g, diarrhea pain, itchy lesions female present , abdom anosmi ed some on her inal very a, succee back and and erythem ded by it was atous, other sympto ageusia, some as headac she was antifung ms, such he, nasal given al topical throat, and anti conges applica myalgia tion, sore fungal oral tions skin manifes , and arthralg medica 2 days tions. After again ia. 2 Many tations been reporte of COVIDwith extensi she visited the doctor 19 have ve lesions d from These ooze across with watery from include the world. maculo urticaria high degree the lesions, papular , pseudo and with rash, recomm of suspicio -chilbla livedo n the Doctor in, reticula ended ris, petechi vesicles, tests. her to erythem do the After doing a multifor ae, and Covid me-like the Covid manifes reports lesions. tation may showed tests, her Skin 19 her CT occur early during detecte was 33, the course or later d, and Covid Initially, very next PCR was of the no skin disease 3 day RT done and . involvem COVID for covid. it was ent during infectio negativ She was e more recently n was observe of oral put on steroids mild dose d, , some her oozing reporte cases have but dried up, d, as well lesions lesions been was got as the reduced related happy. and patient to persona skin problem s equipm l protect ent. Second ive to the differen ary skin reaction t treatme are also nts sugges s possibl 2 ted e. We report a case covid of probab sequen ly post ces, a patient who

Pincer

Nail Deformit

y Treated

with Haneke’s

Pincer Nail with Ha Deformity Tr neke’s Proced eated ure Procedur

e

Dr. Sunil

D. Patw

MBBS, ardhan DVD (BJ Medical Fellow, College, Natio Pune) WHO Train nal Skin Centr e, Singa ed pore. Patwardhan HIV Clinician Skin Clinic , Satara , Maharashtr a

Dr. Sunil D. Patwardhan, MBBS, DVD

Introdu

ction

Pincer nail deform toes are usually ity is also incurve affecte known d nail, d. as Smaller unguis transve constri toes may rse over ngens, also be curvatu The great nail, convolu involve re, trumpe toe commo d. ted nail t lateral nly shows and omega deviatio a n nail. distal phalanx of the long axis nail of the is a , but the dystrop terized over curved hy nails are deviate by transve d even rse over When re that more laterally the lesser increas . es along toes are inal axis the they exhibit involve of the a medial d nail and s its deviatio n. greates There at the t propor are several distal part. tion of differen At this pincer lateral borders t variants point, the nails, both tighten acquire heredit tissues around ary and d. , which the soft are pinched necess arily breakin without The heredit ary pincer g through epiderm always nail is. is almost the symme trical. probab This form In extrem ly a comple is e cases, x domina trait with they may togethe nt genetic the phalang r, forming join at eal bones a tunnel, fault for may roll being or they the develop about themse over curvatu ment of form of lves taking the re. Similar a cone. the may In certain nail change the nails be seen varietie in other s are shaped s, This family membe sometim anoma like claws, ly is seen rs. es resemb adolesc ling pachyo as early congen ence and ita. After as nychia young a while, adultho tissue od. the soft Acquired may actually pincer disapp this may nails ear, and symmetrical are not be accom resorpt panied and ion of by a involvement fingern the underly ail may be (shell nail ing bone appear extensi syndro ve and to be me). fairly symme Acquire The conditio d pincer trical. n is quite nails may to several toes and frequen be due differen rare on t on t causes dermat fingers. includin oses The great g and drugs. Myxoid [Exosto pseudo sis cyst, Epiderm al cyst, Pincer

charac

curvatu

longitud

reache

32

32

August

August - September 2021

2021

5


Editorial Board

Editorial Board Dr. Niti Khunger

MD, DDV, DNB Head, Professor and Consultant Dermatologist, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Dr. Khushpreet Kaur Mann

MBBS, MD, DNB Senior Resident Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Dr. Dipak Patel

M.D., D.V. & D. Aesthetic Dermatologist and Cosmetologist, Consultant Dermatologist in Surat, Gujarat

Dr. Ajoy Kumar Saha

MBBS, MD Associate Professor, HOD Department of Skin and VD, GMC Bettiah (West Champaran)

Dr. Vikash Anand

MBBS, MD Assistant Professor Department of Skin and VD, JLNMCH, Bhagalpur

Dr. Amina Asfiya MI

MD Assistant Professor Department of Dermatology, Yenepoya Medical College, Mangalore, Karnataka

Dr. Manjunath Shenoy M MD, DNB Professor and HOD Department of Dermatology, Yenepoya Medical College, Mangalore, Karnataka

Dr. K. Lakshmiprasad

MBBS, DDVL Consultant Dermatologist Aditya Polly Clinic Attapur, Hyderabad

Dr. Sunil D. Patwardhan

MBBS, DVD (BJ Medical College, Pune) Fellow, National Skin Centre, Singapore. WHO Trained HIV Clinician Patwardhan Skin Clinic, Satara, Maharashtra

6

August - September 2021



Platelet Concentrates In Aesthetic Dermatology

Platelet Concentrates In Aesthetic Dermatology Dr. Niti Khunger

MD, DDV, DNB Head, Professor and Consultant Dermatologist, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Dr. Khushpreet Kaur Mann

MBBS, MD, DNB Senior Resident Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Platelet concentrates, initially described for hemostasis, have multitude of applications in aesthetic dermatology. They function as bioactive regenerative therapies. Autologous platelet concentrates are retrieved from patient’s whole blood via centrifugation. Activated platelets release key growth factors that can affect healing, matrix deposition, inflammation, angiogenesis, stem cell migration, and cell proliferation. Hence they help in tissue repair and rejuvenation. There are various types of platelet concentrates, depending on the mode of preparation. Their utilization in aesthetic dermatology depends on the indications. Platelet rich plasma is the most well known and studied, but other types are increasingly becoming popular. This article aims to give an overview of the various types of platelet concentrates and their role in aesthetic dermatology. 8

August - September 2021

Types of Platelet concentrates There are various types of platelet concentrates, based on the platelet content, leukocyte content and fibrin. Platelet-rich plasma (PRP) It is autologous blood plasma with a concentration of platelets well above baseline (4 to 7 times). Working definition of PRP was given by Marx as 1,000,000 platelets /μL in 5 mL of plasma.i It can be leukocyte rich (L-PRP) or leukocyte poor or pure PRP (P-PRP). Platelet poor plasma Platelet-poor Plasma (PPP) is the residual plasma once the PRP is extracted. Platelet gel If a platelet activator such as thrombin or calcium chloride is added to the


Platelet Concentrates In Aesthetic Dermatology

PRP, platelet aggregation occurs and it is transformed into gel form known as platelet gel (PG). Plasma gel Platelet poor plasma is filled in glass vial of a dental syringe which is kept in a water bath at 1000C and transparent plasma turns opaque. This is called as plasma gel, which can be injected to lift up the scar. Platelet rich fibrin Platelet-Rich Fibrin (PRF) is an autologous fibrin based biomaterial, also called as optimized blood clot, which contains fibrin, platelets and key growth factors. Blood is collected without anticoagulant and centrifuged immediately, leading to the formation of a strong PRF clot in the tube. It causes a slow release of many growth factors during long periods and remains solid and intact after 7 days.ii PRF can also be pure PRF (P-PRF) or leukocyte rich PRF (L-PRF). Preparation of Platelet concentrates The preparation of Platelet concentrates is based on the principle of differential centrifugation. Based on different specific gravity, acceleration force is used to sediment cellular components. It can be single or double spin and can be manual (open technique) or automated using kits (closed technique). A single spin cannot adequately concentrate platelets (regardless of the rate or time of centrifugation) as the RBCs will interfere with the fine separation of the platelets. The double spin method is preferred over the single spin method as it achieves therapeutic concentration of platelets. Steps of preparation of various platelet concentrates: 1. Collect whole blood in anticoagulant containing tubes. 2. Centrifuge the blood using a ‘soft’

spin (200 g to 600 g). 3. Transfer the supernatant plasma into another tube without the anticoagulant. 4. Centrifuge tube using hard spin (700 g to 2,300 g). 5. The lower 1/3rd is PRP and upper 2/3rd is platelet-poor plasma (PPP). 6. To prepare platelet gel, platelet activator such as thrombin or calcium chloride is added to the PRP. 7. To prepare plasma gel, PPP is kept in water bath at 1000C for 1 minute followed by cold water bath at 0-80C for 1 minute. 8. To prepare PRF, whole blood is collect in plain vial instead of anticoagulant containing vial and then centrifuged to collect upper yellow clotted portion called PRF.iii, iv, v Indications Platelet concentrates have been used over a wide variety of indication including skin rejuvenation, hair disorders and tissue repair. Skin rejuvenation In skin rejuvenation, PRP improves, texture, fine lines and facial volume. A study has shown significant improvement in general appearance, skin firmness, reduced sagging, and wrinkles after PRP therapy.vi Three PRP sessions done 1 month apart showed significant improvements of skin elasticity.vii Combining PRP with microneedling has an additive effect.viii It can also lead to faster healing following laser treatment.ix Pigmentary disorders Melasma has also been reported to improve with PRP. A significant decrease in the Melasma Area Severity Index (MASI) score on each side of the face was reported following PRP treatment.x In vitiligo, a

study reported that when combined with narrow band ultraviolet B therapy in patients of stable vitiligo, addition of PRP injections led to faster repigmentation.xi Striae distensae PRP is reported to be more effective and it gives better therapeutic response than tretinoin in treatment of striae.xii Scar revision Platelet gel can increase the survival rate of the skin flap and reduce the inflammatory response in skin flaps and has better effects in terms of generating new soft tissue.xiii Acne scarring PRP serves as an assisted regenerative therapy for atrophic acne scars, along with the primary therapy. It has been used synergistically with microneedling, fractional carbon dioxide laser, and subcision. Following 3 monthly sessions, improvement in acne scars was noted in 62.2% of PRP treatment group compared with 45.84% of control group.xiv The combination treatment of dermaroller with topical plasma gel resulted in better improvement than injectable plasma gel alone, however the plasma gel injection showed a visible difference for most patients after one session.xv Periocular rejuvenation Injecting PRF alone as a natural, autologous dermal filler resulted in volume restoration of hollowing tear troughs, improved fine lines, and homogenization of pigmentation irregularities with repeat treatments.xvi Fat grafting PRP has been used to improve fat survival due to release of growth factors. Combining PRP with fat grafting prolonged fat survival.xvii

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9


Platelet Concentrates In Aesthetic Dermatology

Androgenic alopecia In patients with androgenic alopecia, PRP injections lead to increase in hair count, hair density, terminal density, and anagen or telogen hairs.xviii, xix, xx

• Pain

Alopecia areata When compared with topical minoxidil 5% in patients with alopecia areata, the PRP-treated patients showed earlier new hair regrowth and better new hair quality.xxi Hair transplant surgery The use of PRP in hair transplant can increase graft survival and possibly allow closer packing of grafts.xxii Contraindications Absolute: • Critical thrombocytopenia • Platelet dysfunction • Hemodynamic instability • Local infection • Sepsis Relative: • Non steroidal anti inflammatory drug within 48 hours • Steroid injection at treatment site in past 1 month • Recent illness

• Tenderness • Bleeding at injection site. • Type I hypersensitivity reaction to calcium citrate • Infection xxv Conclusion Platelet concentrates are attractive and evolving newer modalities with wide variety of indications in aesthetic dermatology such as hair restoration, skin rejuvenation, scar improvement and pigmentary disorders. They can be easily harvested from patients’own whole blood, making it a safe, in-office procedure. Moreover, combining them with other treatment modalities, such as lasers, microneedling, and fat injections has demonstrated synergistic effects, thus improving cosmetic outcomes. But more studies are needed to further standardize and define protocols for methods of preparation and use of various platelet concentrates. References Marx RE. Platelet- Rich Plasma (PRP): what is PRP and what is not PRP: Implant Dent 2001; 10: 255-8. i

• Tobacco use • Hematological malignancy or bone cancer • History of tobacco use • Anemia (Hb <10gm/dl) • Thrombocytopenia (<1.05 lakh/ cubic mm) xxiii Complications and Side effects Though generally safe, bruising can occur at the injection site, particularly in areas of loose skin and the under eye area. A single report of skin 10

necrosis and blindness in one eye has been reported following PRP for bilateral cosmetic platelet-rich plasma injections to rhytids in the glabellar region.xxiv

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Dohan Ehrenfest DM, Rasmusson L, Albrektsson T: Classification of platelet concentrates: from pure platelet-rich plasma (PPRP) to leucocyte- and platelet-rich fibrin (LPRF). Trends Biotechnol 2009; 2: 158–167. ii

Dhurat R, Sukesh MS. Principles and methods of preparation of platelet-rich plasma: A review and author’s perspective. J Cutan Aesthet Surg 2014;7:189-97. iii

iv

Elfar NN, Hasby EA. Efficacy and

safety of plasma gel as a new modality in treatment of atrophic acne scars. Int J Dermatol. 2020 ;59:620-626. Piccin A, Pierro A, Canzian L, Primerano M, Corvetta D, Negri G et al. Platelet gel: a new therapeutic tool with great potential. Blood Transfus 2017;15:333-40. v

Yuksel E, Sahin G, Aydin F, et al. Evaluation of effects of platelet rich plasma on human facial skin. J Cosmet Laser Ther. 2014;16:206208. vi

Cameli N, Mariano M, Cordone I, et al. Autologous pure platelet-rich plasma dermal injections for facial skin rejuvenation: clinical, Instrumental, and flow cytometry assessment. Dermatol Surg. 2017;43:826-835. vii

Asif M, Kanodia S, 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;15:434–43. viii

Shin MK, Lee JH, Lee SJ, Kim NI. Platelet-rich plasma combined with fractional laser therapy for skin rejuvenation. Dermatol Surg 2012;38:623–630. ix

Hofny ERM, Abdel-Motaleb AA, Ghazally A, Ahmed AM, Hussein MRA. Platelet-rich plasma is a useful therapeutic option in melasma. J Dermatolog Treat. 2019;30:396-401. x

Ibrahim ZA, El-Ashmawy AA, ElTatawy RA, et al. The effect of platelet- rich plasma on the outcome of short-term narrowband-ultraviolet B phototherapy in the treatment of vitiligo: a pilot study. J Cosmet Dermatol. 2016;15:108-116. xi

Gamil HD, Ibrahim SA, Ebrahim HM, Albalat W. Platelet-Rich Plasma Versus Tretinoin in Treatment of Striae Distensae: A Comparative Study. Dermatol Surg. 2018;44:697-704. xii


Platelet Concentrates In Aesthetic Dermatology

Chai J, Ge J, Zou J. Effect of Autologous Platelet-Rich Plasma Gel on Skin Flap Survival. Med Sci Monit. 2019;25:1611-1620. xiii

Asif M, Kanodia S, 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. xiv

Kalyam K, Kavoussi SC, Ehrlich M, et al. Irreversible Blindness Following Periocular Autologous Platelet-Rich Plasma Skin Rejuvenation Treatment. Ophthalmic Plast Reconstr Surg 2017;33(3S Suppl 1):S12–S16. xxiv

Marwah M, Godse K, Patil S, et al. Is there sufficient research data to use platelet-rich plasma in dermatology? Int J Trichol 2014;6(1):35–6. xxv

Elfar NN, Hasby EA. Efficacy and safety of plasma gel as a new modality in treatment of atrophic acne scars. Int J Dermatol. 2020 ;59:620-626. xv

Karimi K, Rockwell H. The Benefits of Platelet-Rich Fibrin. Facial Plast Surg Clin N Am 2019;27 :331–340. xvi

Azzena B, Mazzoleni F, Abatangelo G et al. Autologous platelet-rich plasma as an adipocyte in vivo delivery system:case report. Aesthetic Plast Surg 2008; 32: 155–8; discussion 9–61. xvii

Gentile P, Garcovich S, Bielli A, et al. The effect of platelet-rich plasma in hair regrowth: a randomized placebocontrolled trial. StemCells Transl Med. 2015;4:1317-1323. xviii

James R, Chetry R, Subramanian V, et al. Platelet-rich plasma growth factor concentrated spray (Keratogrow(R)) as a potential treatment for androgenic alopecia. J Stem Cells. 2016;11:183-189. xix

Alves R, Grimalt R. Randomized placebo-controlled, double-blind, half-head study to assess the efficacy of platelet-rich plasma on the treatment of androgenetic alopecia. Dermatol Surg. 2016;42:491-7. xx

El Taieb MA, Ibrahim H, Nada EA, et al. Platelets rich plasma versus minoxidil 5% in treatment of alopecia areata: a trichoscopic evaluation. Dermatol Ther. 2017;30:1-6. xxi

Rose PT. Advances in Hair Restoration. Dermatol Clin. 2018;36:57-62. xxii

Hesseler MJ, Shyam N. Plateletrich plasma and its utility in medical dermatology: A systematic review. J Am Acad Dermatol 2019;81:834-46. xxiii

August - September 2021

11


Atopic Dermatitis: A Rising Trend

Atopic Dermatitis: A Rising Trend Dr. Dipak Patel

M.D., D.V. & D. Aesthetic Dermatologist and Cosmetologist, Consultant Dermatologist in Surat, Gujarat

Abstract Atopic dermatitis (AD) is also known as atopic eczema, it is chronic relapsing, a pruritic, inflammatory dermatological condition usually starts in early life.The intense pruritic rash can be debilitating and significantly decrease individual’s quality of life. It is one of the most common inflammatory skin diseases affecting children and adults. The prevalence of atopic dermatitis has increased 2- to 3-fold in industrialized nations, it affects approximately 15% to 20% of children and 1% to 3% of adults worldwide. This article summarizes the current understanding of the pathogenesis of AD, diagnostic criteria, and treatments. Keywords: Atopic Dermatitis, Quality of Life, Multifactorial. Introduction Atopic dermatitis is a common, chronic, intensely pruritic, inflammatory skin condition that appears to be increasing in prevalence over the past few decades. Most frequently it occurs in children and it can be started in infancy or early in life, also it affects many adults in all 12

August - September 2021

age groups which varies in a clinical presentation at different ages and places. It is a relapsing eczematous skin disorder characterized by varying degrees of pruritus, and inflammation of the skin accompanied by cutaneous physiological dysfunction and dysregulated inflammation.1,2,3 It is the most common inflammatory skin disorder affecting children as well as adults and a negative impact on their quality of life. AD is one of the most common skin diseases which is cumulative prevalence in children and is estimated up to 8‑20% and 1%–3% of adults in most countries of the world, while in India it is between 2.4% and 6%.2,4,5, 6, 7 Etiology The causes of AD is multifactorial in nature, they can aggravate and trigger atopic dermatitis that includes genetic, immunologic, and environmental impacts.8 Recent investigations have shown atopic dermatitis is results from the complex interplay of multiple factors such as epidermal barrier dysfunction, immune dysregulation, environmental triggers, food, drugs and microbes all are playing a key role in disease


Atopic Dermatitis: A Rising Trend

progression. Immune dysregulation is characterized by Th2 responses in acute AD and Th1 responses in chronic AD.2 In India, especially in the last four decades, a rising trend

has been observed. The recent trend shows the increasing prevalence of atopic dermatitis is attributed to the changing gene-environment interactions.9,10

Figure 1: Etiological factors in atopic dermatitis

Figure 2: Multifactorial pathogenesis of Atopic Dermatitis August - September 2021

13


Atopic Dermatitis: A Rising Trend

Clinical Presentation The typical clinical appearence of AD shows multiple lesions with erythema, excoriation, erosions accompanied by a serous exudate, accentuated skin markings (lichenification), fibrotic papules, severely dry skin, and susceptibility to cutaneous infections. The major symptom is intense itching and excessive scratching; due to this it can cause further damage like

excoriation,

erosions,

and

infections. The skin lesions have a typical

age‑dependent

distribution

pattern. In infants it shows nummular

Figure 3: Erythematous and maculopapular rash on elbow

or seborrheic type eczema on the cheeks, chin, and trunk. Children with

1‑4-year-old

affected

areas

showing

include

most

extensor

and sometimes flexural sides of the extremities, the hands, face, neck, and perioral area. Among 4-16-yearold children the lesions are present on flexural eczema predominates, with face, hands, feet and the gluteal area. 5,11 It is also shows racial and ethnic groups as chronic or relapsing pruritic eczematous skin lesions; however, some features may be more or less prominent in patients with darker

Figure 4: Erythematous, eczematous plaques with excoriations on stomach

skin. Generally the erythema is less visible in patients with darker skin and it may appear reddish-blue or purple (violaceous) rather than red.

Perifollicular

papulation,

scaling,

accentuation, lichenification,

and pigmentary changes may also be more prominent in patients with darker skin.12

Figure 5: Pruritic rash with erosions and scratching in front of elbow 14

August - September 2021


Atopic Dermatitis: A Rising Trend

Figure 6: Erythematous, lichenification lesions with excoriations on ear Diagnosis The diagnosis of AD is based on signs and symptoms. There is no laboratory “gold standard” diagnostic methods.1There are variable clinical findings of atopic dermatitis and it is categorized into three groups of diagnostic features viz. essential, important, and associated.13 For diagnosis the most frequently used diagnostic criteria were developed by Hanifin and Rajka in 1980 and it was later revised by the American Academy of Dermatology.14.

Table 1: Diagnostic criteria proposed by the American Academy of Dermatology.15

August - September 2021

15


Atopic Dermatitis: A Rising Trend

Treatment

naturally produced by Streptomyces

as emollients and corticosteroids

dermatitis, topical therapy is the first-

bacteria

and

line therapy for mild to moderate

dependent T-cell activation, blocking

methotrexate.

cases.

corticosteroids

the production of proinflammatory

source has been shown to achieve

treatment

cytokines and mediators of the AD

better results than natural sunlight.18,15

In

still

the

management

Topical

remain

the

of

atopic

of

choice for treating the majority of the cases because of its broad immunomodulatory effects.11, 14,16 It is always the mainstay of treatment for flare-ups and the standard treatment as compared to other treatments. It is always first-line treatment for atopic dermatitis approved only for shortterm use because their use is limited by the wide distribution of steroidresponsive elements in various cells and tissues. Prolonged use can be lead to signs of skin atrophy, such as striae, and telangiectasias, and even to systemic side-effects, including growth-restriction in children, and glaucoma.17

inhibit

calcineurin-

inflammatory reaction.1

safely

administered The

with

artificial

light

Rarely, systemic agents such as

Phototherapy is the other treatment

cyclosporine,

option considered as second-line

1b, oral corticosteroids may be

therapy in AD that has failed to

considered

respond adequately to emollients,

adults.

topical topical

corticosteroid calcineurin

inhibitors

(TCS), and

interferonin

the

gamma-

treatment

for

1

Conclusion

environmental modifications.18 In the

Atopic dermatitis is a chronically

phototherapy, various sources of light

relapsing hypersensitive manifestation

have been utilized including natural

of

sunlight, NB‑UVB, broadband UVB, ultraviolet A (UVA), UVA1, cold light UVA1, full-spectrum light (including UVA, infrared, and visible light), and psoralen plus UVA. However, narrow band ultraviolet B (UVB) (NB‑UVB) and UVA1 is a safe and effective therapy

the

skin

with

itching

predominant feature.

10

as

a

It shows the

signs of decreased T-helper type

1

(Th1) and increased T-helper type 2 (Th2) immune reactivity.17 The prevalence of AD has been increasing over the past few decades in the developed countries including India.6

for moderate to severe AD in children.

It

are second line therapy for AD.

UVA phototherapy penetrates to the

individuals during their lifetime, in

It is a new class of drugs used in

deep dermis and works better for

which 70% of individuals outgrow AD

dermatology

and it is a second

acute AD, NB‑UVB is more effective

before adolescence, 30% of cases

class of anti-inflammatory therapy

for chronic cases, it can be used

persist into adulthood.2,17

introduced

combined with topical therapies such

In the etiopathogenesis shows the

Topical calcineurin inhibitors (TCIs)

16

and

11

in

2000.

They

are

August - September 2021

affects

about

one-fifth

of

all


Atopic Dermatitis: A Rising Trend

major role of heredity, environment,

tacrolimus: Current perspectives. Indian J

and an expert consensus. Indian J Dermatol

diet, infection, immunity, and IgE. It

PaediatrDermatol 2013;14:54-61.

2019;64:166-81.

6. Dhar S, Parikh D, Rammoorthy R, Srinivas

16. Ring J, Darsow U, Behrendt H (eds):

S, Sarkar R, Inamadar A, et al. Treatment

New Trends in Allergy and Atopic Eczema.

guidelines for atopic dermatitis by ISPD

ChemImmunol

Task Force 2016. Indian J PaediatrDermatol

2012,

2017;18:174-82.

org/10.1159/000331916

different scales were identified, the

7. Dhar S, Srinivas SM, Bajaj AK. Allergic

17. Mandelin J, Remitz A, Virtanen H, Reitamo

most commonly used severity criteria

contact dermatitis in atopic dermatitis. Indian

S. One-year treatment with 0.1% tacrolimus

for AD are the SCORAD ("SCORing

J PaediatrDermatol 2018;19:304-7.

ointment versus a corticosteroid regimen

1

affects infants, children, and adults with a wide degree of severity, hence there is different scoring systems have been developed to determine the severity.10 For the measurement of disease severity more than 28

Atopic Dermatitis") index, the Eczema Area and Severity Index (EASI), Patient Oriented Eczema Measure, and the Six Area, Six Sign Atopic Dermatitis severity score.

AD is typically managed with topical corticosteroids and it is the mainstay line

of

dermatitis. The American Journal of Managed Care. 2017 Jun;23(8 Suppl):S115-S123. 9.

15

first

8. Avena-Woods C. Overview of atopic

treatment.

Topical

Criton

vol

Allergy.

96,

pp

Basel,

Karger,

132–140https://doi.

in adults with moderate to severe atopic dermatitis:

A

randomized,

double-blind,

comparative trial. ActaDermVenereol. 2010 Mar;90(2):170-4. doi: 10.2340/00015555-

S,

Gangadharan

G.

Nonpharmacological

management

of

atopic dermatitis. Indian J PaediatrDermatol 2017;18:166-73.

0803. PMID: 20169301. 18.

Parikh

D,

Dhar

S,

Srinivas

S,

Rammoorthy R, Sarkar R, Inamadar A, et al. Treatment guidelines for atopic dermatitis

treatment along with emollient is

10. Thakur A, Malhotra SK, Malhotra S.

by Indian Society for Pediatric Dermatology

effective to control the condition in

Scoring atopic dermatitis and six sign atopic

task force 2016 ‑.Part‑2: Topical therapies in

more than 80% of the cases.1 For

dermatitis: Comparison of prognostic and

atopic dermatitis. Indian J PaediatrDermatol

more severe cases there is require

predictive value in atopic dermatitis. Indian J

2017;18:274-80.

additional oral immunosuppression

PaediatrDermatol 2013;14:13-8.

with

cyclosporine,

azathioprine, or

methotrexate,

and

mycophenolate

immunotherapy.

Sometimes

targeted biologic agents are needed

11. Dhar S. Topical therapy of atopic dermatitis.

Indian

J

PaediatrDermatol

2013;14:4-8.

for the cases of resistant to systemic

12. Lopez Carrera YI, Al Hammadi A, Huang

immunosuppression

YH, Llamado LJ, Mahgoub E, Tallman AM.

treatment

Epidemiology, Diagnosis, and Treatment of

of AD.

2

Atopic Dermatitis in the Developing Countries

References

of Asia, Africa, Latin America, and the Middle

1. Dhar S, Banerjee R. Atopic dermatitis

East: A Review. DermatolTher (Heidelb).

in infants and children in India. Indian J

2019

DermatolVenereolLeprol2010;76:504-13.

s13555-019-00332-3. Epub 2019 Oct 24.

2. Nguyen M, Pona A, Kolli SS, Feldman

Dec;9(4):685-705.

doi:

10.1007/

PMID: 31650504; PMCID: PMC6828917.

SR, Strowd LC. Recent insights in atopic

13. Buys LM. Treatment options for atopic

dermatitis pathogenesis, treatment, and

dermatitis. Am Fam Physician. 2007 Feb

disease impact. J DermatolDermatolSurg

15;75(4):523-8. PMID: 17323714.

2019;23:66-72.

14.

Thomsen,

Simon

Francis.

“Atopic

clinical

dermatitis: natural history, diagnosis, and

features of atopic dermatitis. Indian J

treatment.” ISRN allergy vol. 2014 354250. 2

DermatolVenereolLeprol 2001;67:25-7.

Apr. 2014, doi:10.1155/2014/354250

3.Sharma

4.

L.

Vaidyanathan

Dhar

S.

Atopy

Diagnostic

V,

Sarda

patch

test.

A,

De Indian

A,

15. Rajagopalan M, De A, Godse K,

J

Krupa Shankar DS, Zawar V, Sharma N,

DermatolVenereolLeprol 2019;85:338-41. 5.

Goyal

T.

Atopic

dermatitis

and

et al. Guidelines on management of atopic dermatitis in India: An evidence‑based review August - September 2021

17


Rational Treatment of Dermatophytic Infection

Rational Treatment of Dermatophytic Infection Dr. Ajoy Kumar Saha

MBBS, MD Associate Professor, HOD Department of Skin and VD, GMC Bettiah (West Champaran)

Dr. Vikash Anand

MBBS, MD Assistant Professor Department of Skin and VD, JLNMCH, Bhagalpur

BACKGROUND

examination and KOH confirmation

In India superficial dermatophytic are running chronic endemic course due to 1. Ineffective and 2. Inadequate treatment which is leading to drug resistance but we can still treat it effectively by using our intelligence. AIM

by

judicious

and

intelligence use of oral drugs present in our armamentarium (fluconazole, terbinafine, griseofulvin, itraconazole and complementary measures). METHOD Patient with dermatophytic infection attending OPD of Jawaharlal Nehru medical college and hospital during rainy season (July to first half of august 2018) were enrolled in clinical 18

August - September 2021

were taken into account. RESULT There were 217 patients in study in male: female ratio of around 2:1 and most commonly affected group were age of 30 to 40 and (~30%) tinea

To cure superficial dermatophytic infestation

and history of drugs used previously

corpora and tinea cruris formed 60 percent of the case. LIMITATION In medical college usually previously treated cases arrive so corticosteroids creams were used in 40 % of cases. CONCLUSION We can still adequately and effectively treat with

dermatophtic fluconazole

and

infection terbinafine,

griseofulvin and itraconazole, if not effective go for multi drug therapy


Rational Treatment of Dermatophytic Infection

with terbinafine with griseofulvin.

Systemic drug is never used as topical

5. 8 cases were given terbinafine

drug except terbinafine. Soap of

and griseofulvin orally as multi drug

ketoconazole is given. Ketoconazole

therapy with ketoconazole soap only.

Dermatophyte has created a havoc

lotion and amorolfine cream is used

All 8 cases responded.

due to wide spread occurrence and

as topical agent.

INTRODUCTION

resistance to treatment prescribed by clinician therefore there is a need to create newer and effective drugs in our armamentarium. METHOD

All cases of first group took full

Patient also develop sensitization due

treatment,

to topical agents application so anti

was 100 % due to the drugs being

histaminic coverage is given during

available in the hospital.

full course of the drug (i. e 30 days). Patient

with

long

standing

dermatophyte

season from July to first half of august

had previously used wide variety of

2018 in dermatology department of

topical cream were given multi drug

Jawaharlal Nehru medical college and

oral therapy only. Griseofulvin FP 250

hospital and were followed for upto 2

mg and terbinafine 250 mg daily for

month for effectiveness of treatment

30 days.

provided by us.

and

who

Griseofulvin

secreted

in

sweat

and

excluded from sample.

penetration in epidermis, nail and

was given for continuous 30 days based on shedding of epidermis in 28

Griseofulvin group 82.35% Terbinafine group 70% Itraconazole group was small and 3 patient fallout of group due to nonavailability of drug in hospital and high cost of treatment.

Tinea unguim, Tenia capatis were

Epidermis is infected so treatment

complicance

Fluconazole group responded 96 %

Study was conducted during rainy

infection

patient

terbinafine

has

excellent

hair. Antihistamines 2.5 LC daily for 30 days. Patient were made to report monthly for 2 months.

Multi drug therapy worked wonders for hopeless patient (100 %). DISCUSSSION Relapse treatment

is

due

and

to

use

inadequate of

cortisone

days. Psoriastic patient usually never

Confirmed cases after KOH positivity

and last one is resistance to drug

develop dermatophytic infection due

were selected for this study; diabetic

terbinafine and griseofulvin.

to rapid turnover of epidermis.

and HIV positive cases are excluded.

Simple efficient way to treatment is

Result: Out of 217

based on previous history of drug used.

But these drugs used as multi drug treatment still gives result as they are

1. 160 cases were given fluconazole

complementary.

weekly orally for 4 week ketoconazole

Itraconazole has to be supplied in

Fluconazole due to its long half life is

lotion topically for 15 days and

medical college so that fair trial can

mainstay of treatment inspite of its

amorolfine cream use on face since

be conducted.

reported resistance.

beginning. Surprisingly only 5 cases

Single missed dose will cause non healing and drug is reported as

(3.12%)

not

responded

to

this

regimen.

resistant. So Hindus are advised to

2. 27 cases were given terbinafine

take on Tuesday or Saturday after

orally and topically. Seven cases not

worship of lord hanuman and Muslims

responded to treatment.

on Friday after offering prayers and Christian on Sunday after visiting church. Patient are advised to wash his/her clothes daily, jeans are not suited for Indian climate so they are strictly forbidden to wear them. If their houses are moist/ damp or mouldy, whitewashing of walls was advised.

3. 17 cases were given Griseofulvin FP 250 with fatty meal and ketoconazole lotion locally 3 cases (17.64%) not

4. 5 Cases were given itraconazole and

group of drug. For resistant case there is need to develop new drug acting on different pathways. Sensitivity testing for sensitivity to drug to be provided in microbiology department. Treatment to be given based on

responded.

orally

Fluconazole and itraconazole is same

ketoconazole

lotion

report, treatment must be adequate full course for a month.

topically, 2 cases responded 3 fall out

Future hold for multi drug regimen for

of the group.

treatment of dermatophyte infection. August - September 2021

19


Rational Treatment of Dermatophytic Infection

REFERENCES

10. De Doncker P. Pharmacokinetics of oral

1. Goldsmith, Lowell A., Fitzpatrick, Thomas B. (2012) Fitzpatrick's dermatology in general medicine (8th ed.) 2. Jameson, J. Larry: Kasper, Dennis L., Fauci, Anthony S. Hauser Stephen L. Longo, Dan L., Loscalzo, Joseph Harrison's principles of internal medicine (Twentieth ed.). 3. Soutor, Carol Hordinsky, Maria K. (2013). Clinical Dermatology. 4. Maria K: Soutor, Carol (2013). Clinical dermatology (fst ed.). Tosti, A.; Piraccini, B. M. (2003), "Dermatophyte infections" European

Handbook

of

Dermatological

Treatments, Springer Berlin Heidelberg. pp. 131-134. 5. Degreef, H. J. DeDoncker, P. R. (September 1994). "Current therapy of dermatophytosis". Journal of the American Academy of Dermatology. 6.

Eur

J

Dermatol.

2000

Mar;

10(2):107-9."Comparative study between terbinafine

1%

emulsion-gel

versus

ketoconazole 2% cream in tinea cruris and tinea corporis" by Bonifaz A, Saúl A 7. Indian J Dermatol VenereolLeprol. 2018 Sep-Oct:84(5):554-557.

Doi

ijdv1.IJDVL_526_17."End

of

10.4103/ the

road

for terbinafine? Results of a pragmatic prospective cohort study of 500 patients by Singh S, Shukla P. 8. Hautarzt. 2016 Sep,67(9):689-99. doi: 10.1007/s00105-016-3848-5 Tinea in the genital area: A diagnostic and therapeutic challenge' by Ginter-Hanselmayer G Nenolf P. Kurrat W. Propst E, Durrant-Finn U, Uhrlaß S. Weger W. 9. IJDVL year 2017 volume : 83 issue:6 page 730-732 "Intracutaneous pharmacokinetics of oral antifungals and their relevance in recalcitrant

cutaneous

dermatophytosis:

Time to revisit basics by Kabir Sardana, Pooja Arora, Khushbu Mahajan.

20

August - September 2021

antifungal agents. Dermatol Ther1997; 3:465.


August - September 2021

21


Utility of Autologous Platelet Rich Fibrin (PRF) Therapy in the Treatment of Chronic Non-healing Trophic Ulcers Secondary to Hansen’s Disease

Utility of Autologous Platelet Rich Fibrin (PRF) Therapy in the Treatment of Chronic Non-healing Trophic Ulcers Secondary to Hansen’s Disease Dr. Amina Asfiya MI

MD Assistant Professor Department of Dermatology, Yenepoya Medical College, Mangalore, Karnataka

Dr. Manjunath Shenoy M

MD, DNB Professor and HOD Department of Dermatology, Yenepoya Medical College, Mangalore, Karnataka

Introduction As dermatologists we frequently encounter cases of chronic non healing leg ulcers which may be due to venous insufficiency, leprosy, trauma, diabetes mellitus etc. These ulcers cause significant morbidity to the patients in terms of pain, disability and discharge. The treatment of these wounds pose a challenge not only to us but also general surgeons, vascular surgeons and others. The healing of these wounds is dependent on several physiological and environmental factors. The healing of neuropathic ulcers in leprosy is slow due to the chronic inflammatory nature and ageing of the local reparative cells. Various modalities of treatment have been tried like off-loading, topical metronidazole or phenytoin 22

August - September 2021

application, collagen or saline dressings, application of topical growth factors, and other surgical modalities. But, these treatments are not evidence based.1 Here we report a case on the utility of autologous Platelet Rich Fibrin (PRF) in the healing of chronic non healing trophic ulcers. A 55-year old male presented to our Out Patient Department with complaints of non healing ulcers over the left foot since 8 months. There was no history of trauma prior to the onset of the ulcers. He was a non-diabetic and non-smoker. He was a case of Hansen’s disease and had completed Multibacillary - Multi Drug Therapy (MB-MDT) treatment a year ago. The ulcers were previously treated with multiple modalities like topical and oral antibiotics and


Utility of Autologous Platelet Rich Fibrin (PRF) Therapy in the Treatment of Chronic Non-healing Trophic Ulcers Secondary to Hansen’s Disease

dressings with no significant result. On examination, there were two trophic ulcers on the plantar aspect of the left foot. The ulcer over ball of the great toe was irregularly shaped with pale slough and measured 6 cm x 4 cm x 3 cm. The second ulcer which was lateral to the above one, measured 3 cm x 2 cm x 2 cm and was similar to the above ulcer. The edges of the ulcers were surrounded by hyperkeratotic skin. Pus culture and sensitivity from the ulcer revealed no growth. In view of the refractory nature of the ulcer, we advocated treatment with autologous platelet rich fibrin (PRF). Following proper aseptic precautions, 5 ml of blood from the patient was taken in anticoagulant tubes and immediately centrifuged at 3000 rpm for 10 minutes. At the end of the spin, three parts were seen in the tube: at the bottom there were the red blood corpuscles (RBC’s), PRF matrix consisting of the fibrin clot in the middle and the top showed acellular plasma. The PRF matrix was then extracted with the help of forceps and separated from the RBC’s with sterile scissors. The clot was then squeezed between two sterile gauze pads and then applied over the wound. This was followed by the application of a sterile dressing over the wound. The dressing was then changed after 3 days. The patient was also advised complete limb rest. The procedure was repeated similarly every week for 4 weeks. Photographs were taken at weekly sittings. The initial area of the ulcer was 18.8 cm2 (ulcer 1) and 4.71 cm2 (ulcer 2). At the end of 4 weeks both the ulcers closed completely. (Figure 1 and 2).

Figure 1: Ulcers at the first sitting

Figure 2: Ulcers healed completely at the end of 4 weeks Discussion Treatment of leprosy includes not only the treatment of the infection but also the complications which arise from the disease process. One such complication is the development of trophic ulcers which may persist even beyond the successful treatment of the disease. The various available treatment modalities for trophic ulcers are not effective satisfactorily. Platelet Rich Fibrin is a recently described second generation platelet concentrate which is easier to process than Platelet Rich Plasma. It helps in wound healing by promoting hemostasis and thus wound closure. The presence of the fibrin matrix helps in stem cell migration and faster wound healing.2 After it was first introduced in 2001 in France by Choukroun and his colleagues, it has since been used in vascular surgery, plastic surgery, cardiothoracic and general surgery, in sinus lift procedures and implantation and also to reduce the postoperative hematoma.3 The occurrence of trophic ulcers in leprosy is attributed to the nerve damage and local anesthesia and not due to the infection itself. The platelets help in healing by releasing growth factors and other proteins. Thus, the presence of a large number of platelets at the local site will help in faster wound healing.4 Regrowth of vascular source that supports cellular function and subsequent tissue formation is a key mechanism involving wound healing due to various causes. Typically wound healing involves the 4 steps namely haemostasis, inflammation, proliferation, and remodelling.5 Platelets play their early role during the haemostasis that involves vascular obliteration and fibrin clot formation. Then they secrete or activate a number of biomolecules involved in inflammation

and proliferation phases. They include platelet-derived growth factor (PDGF), coagulation factors, adhesion molecules, cytokines/chemokines, and angiogenic factors.5 Cells that are activated by platelet derived growth factors are fibroblasts, neutrophils, macrophages, and mesenchymal stem cells which are integral part of wound healing mechanism. White Blood Cells are also one of the first cell types found in wound site which are involved in phagocytizing the microbes and necrotic tissue, and thus preventing infection. Macrophages secrete growth factors that include transforming growth factor beta (TGF beta), PDGF (Platelet derived Growth Factor), and vascular endothelial growth factor (VEGF). PRF thus is capable of initiating and maintaining the process of wound healing by involving the various growth factors and cells involved in wound healing. PRF produces a more sustained wound response which mimics the body’s natural healing process. It delivers platelets to the tissue along with a 3-dimensional fibrin mesh which binds to the platelets and growth factors and hence localizes the tissue activity. Also, the platelets in PRF synthesize and release GFs over the first one week.6 In a study done by Nagaraju, he found that the mean percentage of improvement in the area of the nonhealing trophic ulcers at the end of second sitting was 93.52% which was significant. They also concluded that all the trophic ulcers closed completely by the end of five sittings which was in concordance with our case report wherein the ulcers closed with four sittings.7 In a similar study conducted by Sarvajnamurthy et al. by using Platelet Rich Plasma in chronic venous ulcers, they found that the mean duration of healing of ulcers was 5.1 weeks.8 There are very few studies which have utilized PRF in the treatment of trophic ulcers in Hansen’s disease. The ease of application, patient compliance and lack of complications provide a promising outlook to the future of utilizing PRF in trophic ulcers. Conclusion Plantar ulcers are conventionally treated with rest, dressing, Plaster Of Paris cast and surgeries that

August - September 2021

23


Utility of Autologous Platelet Rich Fibrin (PRF) Therapy in the Treatment of Chronic Non-healing Trophic Ulcers Secondary to Hansen’s Disease

including split-skin or full-thickness skin from pinch or mesh grafts. Recent advances include grafting of bio-engineered or artificial skin. In India, leprosy is one of the common cause of plantar ulcers which is often neglected and complicated due to various reasons including the socio-economic burden. Most patients are poor and unaffordable for advanced treatment options. Often those services are available in tertiary care centres which are not easily accessible to most leprosy patients of rural origin. PRF is a simple, outpatient procedure for accelerating wound healing and does not involve huge cost. It can be done in any centres with minimal training and expertise. Currently, it is being utilized in a variety of settings such as healing of skin wounds to tissue regeneration. Although the clinical experience and available literature support the use of PRF in wound healing, additional randomized control clinical trials are needed to test the long-term benefits and side effects. Apart from wound healing, scope of PRF can be extended to various domains of medicine including tissue engineering. References 1. Saha S, Patra AC, Gowda SP, Mondal N, Rahaman S, Ahmed SK, et al. Effectiveness and safety of autologous platelet-rich plasma therapy with total contact casting versus total contact casting alone in treatment of trophic ulcer in leprosy: An observerblind, randomized controlled trial. Indian J DermatolVenereolLeprol 2020;86:262-71. 2. Rajan M B, Singh S. Utility of platelet rich fibrin gel therapy in nonhealing ulcer secondary to ecthyma gangrenosum. Dermatologic Therapy. 2019;32: e12887. 3. Eshghpour M, Majidi MR, Nejat AH. Platelet-rich fibrin: an autologous fibrin matrix in surgical procedures: a case report and review of literature. Iran J Otorhinolaryngol. 2012;24(69):197-202. 4. Eppley BL, Pietrzak WS, Blanton M. Platelet-rich plasma: A review of biology and applications in plastic surgery. PlastReconstr Surg 2006;118:147e-59e. 5. Miron RJ, Fujioka-Kobayashi M, Bishara M, Zhang Y, Hernandez M, Choukroun J. Platelet-Rich Fibrin and Soft Tissue Wound Healing: A Systematic Review. Tissue Eng Part B Rev. 2017;23(1):83-99. 6. Sclafani AP. Safety, efficacy, and utility of platelet-rich fibrin matrix in facial

24

August - September 2021

plastic surgery. Arch Facial Plast Surg. 2011;13(4):247-251. 7. Nagaraju U, Sundar PK, Agarwal P, Raju BP, Kumar M. Autologous platelet-rich fibrin matrix in non-healing trophic ulcers in patients with Hansen's disease. J CutanAesthet Surg 2017;10:3-7. 8. Sarvajnamurthy S, Suryanarayan S, Budamakuntala L, Suresh DH. Autologous platelet rich plasma in chronic venous ulcers: Study of 17 cases. J CutanAesthet Surg 2013;6:97-9.


NEWS

New study shows cryptic transcription is a novel phenomenon in mammalian stem cells, linked to aging Ageing processes is defined as those that increase the susceptibility of individuals, as they grow older, to the factors that eventually lead to death. It is a complex multi-factorial process, where several factors may interact simultaneously and may operate at many levels of functional organization. Several thoughts and mechanisms of ageing such as pathways involved in oxidative stress, lipid and glucose metabolism, inflammation, DNA damage and repair, growth hormone axis and insulin-like growth factor (GH/IGF), and environmental exposure have been proposed. According to recent study researchers have discovered that a cellular phenomenon called cryptic transcription, which had been previously described and linked to aging in yeasts and worms, is elevated in aging mammalian stem cells. They also discovered a mechanism that triggers the phenomenon in mammals. Cryptic transcription is a phenomenon that interferes with normal cellular processes. Normal gene transcription is a first step in the production of proteins. It begins in a specific location on the DNA called the promoter. This is where the protein coding gene begins to be transcribed into RNA, which is eventually translated into protein. Gene transcription is a well-regulated cellular process, but as cells age, they lose their ability to control it. The researcher reports that cryptic transcription occurs because a cellular mechanism that keeps it in check falls apart as cells get old. The findings suggest that strategies that control cryptic transcription could have pro-longevity effects. The team worked with mammalian stem cells, which have shown to play a significant role in aging. They adapted a method to detect cryptic transcription to determine the level of this transcription in mice and human stem cells and cultured cells. When compared to young stem cells, older ones had increased cryptic transcription. They also looked into other aging cells and found that, in the majority of cells spanning a range of tissues, cryptic transcription was also elevated with age. The findings indicate that elevated cryptic transcription is a hallmark of mammalian aging. Young cells have mechanisms in place to prevent cryptic transcription. In aged mammalian cells, the researchers found that one such mechanisms, which involves limiting the access to chromatin, the material that makes up the chromosomes, is failing, facilitating the production of cryptic transcripts. It is still not clear how elevated cryptic transcription contributes to aging, but the evidence is accumulating that it is detrimental to mammals as it is for yeast and worms, Future studies may result in ways of reduce the pro-aging effects of cryptic transcription.

A simple electromechanical device detecting skin disorders non-invasively and in real-time very soon The Global Burden of Disease project has shown that skin diseases continue to be the 4th leading cause of nonfatal disease burden world-wide. Understanding the impact of dermatological diseases in resource-poor areas of the world is critical in developing a concerted and sustained global response towards reducing this burden. Recent innovations such as teledermatology, point-of-care diagnostic tools, and task-shifting help to provide dermatological care to underserved regions in a cost-effective manner. A researcher has also designed a simple electromechanical device that can be used for deep tissue pathology diagnosis, such as psoriasis, in an automated and non-invasive fashion. The findings will lay a foundation for future applications in the clinical evaluation of skin cancers and other dermatology diseases. By putting a piece of soft, strain-sensing sheet on the skin may be able to detect skin disorders non-invasively and in real-time very soon. Electromechanical systems that enable precise, rapid measurements of the stiffness of soft tissues of the human body can provide useful clinical information for monitoring, diagnosing and treating various pathologies, particularly those of the skin. The latest tissue stiffness-measuring technology based on sensing can only measure to superficial depths of upper skin, up to micrometre scale. To address the issue, the research team designed a simple, miniature electromechanical device for high-precision, real-time evaluations of deep tissue stiffness. The team used a miniature electromagnetic system that integrates a vibratory actuator and a soft strain-sensing sheet to monitor in real-time the Young's modulus, i.e the tensile stiffness, of skin and other soft biological tissues at depths of approximately 1 to 8 mm, depending on the sensor designs.

August - September 2021

25


NEWS

Newly identified bacteria-killing protein needs vitamin A to work Vitamin A is the first vitamin approved by the Food and Drug Administration as an anti-wrinkle agent that changes appearance of the skin surface and has anti-aging effects. Vitamin A is in a group of fat-soluble substances and belongs to the category of retinoids. Vitamin A and its derivatives are among the most effective substances slowing the aging process. People who have inadequate vitamin A in their diets are more susceptible to skin infection, yet how that vitamin affects skin immunity has been unclear. In a new study researchers shed some light on that mystery by identifying a previously unknown bacteria-killing protein on the epidermis that requires the vitamin to work. The researchers found that one protein in the resistin-like molecule (RELM) family. RELM acts as an antibiotic to rapidly kill bacteria. Both RELM, which is made by mice, and the corresponding human RELM family protein, called resistin, are stimulated by dietary vitamin A. RELM is the first example of an antimicrobial protein that requires dietary vitamin A for its bacterial killing activity. This finding gives us an important clue about how the skin defends itself against infection, and how skin defense is regulated by the diet. Dermatologists use synthetic vitamin A, called retinoid, to treat acne, psoriasis, and other skin conditions, although how those drugs work has long been a mystery. The skin is the largest organ of the human body and is tasked with defending us against infection. If the skin immune system breaks down, infection results. Skin infections, from bacteria such as Streptococcus, are among the most common reasons people come to the emergency room. The skin is an important interface between us and the environment and must defend us against infection and inflammation. We are just beginning to understand how bacteria and the microbiome impact skin diseases such as psoriasis and acne. Our work helps to define the molecules that the skin uses to create a healthy relationship between the microbiome and us, the hosts. When the skin encounters bacteria, cells respond by making molecules that help defend the skin against infection.

Preclinical discovery triggers wound healing, skin regeneration Scars arise after almost every dermal injury; rare exceptions include tattoos, superficial scratches, and hopefully venepunctures. Scars are the end point of the normal continuum of mammalian tissue repair. The ideal end point would be total regeneration, with the new tissue having the same structural, aesthetic, and functional attributes as the original uninjured skin. Scars are often considered trivial, but they can be disfiguring and aesthetically unpleasant and cause severe itching, tenderness, pain, sleep disturbance, anxiety, depression, and disruption of daily activities. Chronic ischemic wounds are common in people with conditions such as diabetes, pressure ulcers, hardening of arteries, traumatic injury or side effects of radiation therapy. Standard treatments for these wounds include wound dressing, topical gels and surgery. Although these measures offer some relief, they often cannot fully close the wound. Ischemic wounds occur when arteries are clogged or blocked, preventing important nutrients and oxygen from reaching the skin to drive repair. Difficult-to-treat, chronic wounds in preclinical models healed with normal scar-free skin after treatment with an acellular product. Derived from platelets, the purified exosomal product, known as PEP, was used to deliver healing messages into cells of preclinical animal models of ischemic wounds. The research team documented restoration of skin integrity, hair follicles, sweat glands, skin oils and normal hydration. The study documents that PEP, an off-the-shelf, room-temperature-stable exosome, is capable of healing wounds that are depleted of adequate blood supply. Wounds healed with only a single application of exosome. What they see with this technology is not just that the wound is closed, but also that the blood supply to the tissue is restored. Their effort culminating in the development of this exosomal technology was to create a therapy that can be offered to all patients in need through elimination of logistical limitations often seen with more traditional regenerative therapy. The research team replicated wounds with low blood supply in large animal models. They treated some of the wounds with the purified exosomal product and compared them to wounds that were treated with the hydrogel alone. They found wounds treated with the purified exosomal product were able to heal with skin restored to its normal architecture. They found that this exosome therapy has the ability to enhance regeneration of blood vessels in damaged tissues. Without treatment, chronic ischemic wounds grow larger and more problematic.

26

August - September 2021


NEWS

Dermatological Disorders Rise during COVID-19 Pandemic Due To Infection and PPE Use The skin is the largest multifunctional organ on the surface of the human body. Skin changes are related to environmental factors, genetic makeup, nutrition, and other factors. Many skin diseases have emerged during this pandemic caused by various factors such as viral infection, consequences of PPE use, extra hygiene measures, and exacerbation of pre-existing skin disorders. An increase in personal protective equipment (PPE) use and hygiene measures such as the use of hand sanitizers, hand washing, and mask usage during this pandemic have increased the frequency of dermatological diseases. Moreover, adverse dermatological reactions to prescription or over-the-counter drugs have also been reported. The findings showed many dermatological issues ranging from those related to the infection and other dermatitides linked to PPE use by healthcare workers. An array of skin manifestations, including hives, vesicular, and erythematous eruptions have been reported to be related to SARS-Cov-2 infection, some of which are seen in other viral infections. However, there were some skin findings, such as the chilblains that were specific to COVID-19 and not commonly seen in relation to other viral infections. Multisystem inflammatory syndrome primarily seen in children is another important finding causing mucocutaneous symptoms. Despite the association of multiple pandemic-related factors such as dermatoses, psychological stress, and the use of harsh chemicals and irritants to itch and its considerable effect on the patients' quality of life, there is minimal data available about itching. Skin disorders in healthcare workers are said to be a result of increased use of PPE and enhanced hygiene measures such as gloves, goggles, and gowns as per COVID protocols. Skin disorders caused by these protective measures have been attributed to multiple factors such as the hyperhydration effect seen with prolonged use of the occlusive gear trapping moisture and coupled with friction leads to skin barrier defects and increased risk of contact dermatitis. Excessive handwashing also causes irritant contact dermatitis. Folliculitis is most likely a result of occlusion caused by PPE use. Multiple studies have noted an increase in the risk of skin damage with the increase in the duration of PPE use. An exacerbation of pre-existing skin diseases has also been noted such as increase in acne flares, seborrheic dermatitis, and rosacea.

Imbalance in gut microbiota could play a key role in progression of inflammatory skin disorder Outstanding progresses have been done in the last few decades in dermatology, especially regarding chronic inflammatory skin diseases. The major advances in understanding the pathogenesis of the most common inflammatory skin diseases such as psoriasis, atopic dermatitis and hidradenitissuppurativa have led to the development of selective and targeted innovative therapies. Findings presented that an imbalance in gut microbiota (dysbiosis), could play a significant role in the progression of inflammatory skin disease. Hidradenitis Suppurativa (HS) is a painful, long-term skin condition, with a chronic and relapsing nature that significantly impacts patients’ quality of life.The human gastrointestinal tract is inhabited with a wide variety of bacterial organisms, known collectively as the gut microbiome. Studies have increasingly demonstrated that the gut microbiome and skin are intrinsically connected, offering defence against pathogens in the environment. This relationship is known as the ‘gut-skin axis’ and has been linked to many inflammatory and autoimmune skin disorders, such as acne and psoriasis. This connection inspired the researchers to characterize the composition of HS patients’ intestinal microbiome, hypothesizing that imbalance may play a role in the high inflammatory burden of this condition. HS is a multifactorial disease caused by both genetic and environmental factors. Obesity and smoking can significantly exacerbate symptoms, and both of these have an impact on the gut microbiome. Researchers collected faucal samples from 15 patients with HS and 15 age and sex matched healthy individuals and analyzed regions of the bacterial 16S rRNA gene to investigate differences in their gut microbiota. Researchers found that the relative abundance of three genera of bacteria (known collectively as Firmicutes), unclassified Clostridiales, unclassified Firmicutes and Fusicatenibacter in HS patients were significantly lower than that in controls (p = 0.005, p = 0.029, and p = 0.046, respectively). Reduced amounts of these bacteria are known to disrupt the regulatory balance within the gut and stimulate an inflammatory response. Gut microbiota plays a critical role in human health through development of the immune response, controlled by specific pathways and the products of metabolism, known as short-chain fatty acids (SCFA). Bacteria in the gut (such as Firmicutes) produce these SCFAs that ensure a balance between immune cells that stimulate or suppress an inflammatory response is maintained. Any disruption to this balance, as demonstrated by the reduced abundance of these organisms in the gut microbiome of HS patients, may induce an unwanted inflammatory response. August - September 2021

27


COVID-19 and Issues Related To Dermatological Care: A Case Report

COVID-19 and Issues Related To Dermatological Care: A Case Report Dr. K. Lakshmiprasad

MBBS, DDVL Consultant Dermatologist Aditya Polly Clinic Attapur, Hyderabad

Introduction COVID-19, has spread throughout the world at a staggering speed becoming a pandemic emergency.1 The most common symptoms in COVID-19 are fever, respiratory symptoms, fatigue, dry cough, nausea, vomiting, diarrhea, abdominal pain, anosmia, and ageusia, succeeded by other symptoms, such as headache, nasal congestion, sore throat, myalgia, and arthralgia.2 Many skin manifestations of COVID-19 have been reported from across the world. These include maculopapular rash, urticaria, pseudo-chilblain, vesicles, livedo reticularis, petechiae, and erythema multiforme-like lesions. Skin manifestation may occur early or later during the course of the disease.3 Initially, no skin involvement during COVID infection was observed, but more recently, some cases have been reported, as well as the skin problems related to personal protective equipment. Secondary skin reactions to the different treatments suggested are also possible.2 We report a case of probably post covid sequences, a patient who 28

August - September 2021

showed itchy and lesions on her skin.

erethematous

Case Report 80 years old female presented some itchy lesions on her back and it was very erythematous, she was given some antifungal topical applications and anti fungal oral medications. After 2 days again she visited the doctor with extensive lesions with watery ooze from the lesions, and with high degree of suspicion the Doctor recommended her to do the Covid tests. After doing the Covid tests, her reports showed her CT was 33, Covid 19 detected, and very next day RT PCR was done and it was negative for covid. She was put on mild dose of oral steroids her oozing lesions got dried up, lesions reduced and patient was happy.


COVID-19 and Issues Related To Dermatological Care: A Case Report

After

Before Figure 1: Itchy lesions on face

Before After

After

Before Figure 2: Itchy and erythematous lesions on back

After Before Before

Before

After

Figure 3: Itchy lesions on elbow with watery ooze from the lesions

August - September 2021

29


COVID-19 and Issues Related To Dermatological Care: A Case Report

After After

Before

Figure 4: Itchy, erythematous extensive lesions on right thigh with watery ooze from the lesions

After

Before

Figure 5: Itchy, erythematous extensive lesions on left thigh with watery ooze from the lesions

Before

After

Figure 6: Itchy lesions on forearm

30

August - September 2021


COVID-19 and Issues Related To Dermatological Care: A Case Report

CONCLUSION In the current situation in which COVID-19 manifests in various forms, dermatologists, as the first line of dealing with patients who come with skin rashes, should always be aware of the early diagnosis of this disease.4 The dermatologist should have a thorough knowledge about the atypical presentations of skin lesions in COVID-19 so that they can lend a helping hand in the early diagnosis of the disease, which is of utmost importance in preventing the disease spread, morbidity, and mortality.3 Due to the fact that there are dermatologic manifestations in patients with COVID-19, it is very important to consider the skin examination for patients referring to medical centers.4 References 1. Genovese G, Moltrasio C, Berti E, Marzano AV. Skin Manifestations Associated with COVID-19: Current Knowledge and Future Perspectives. Dermatology. 2021;237(1):112. doi: 10.1159/000512932. Epub 2020 Nov 24. PMID: 33232965; PMCID: PMC7801998. 2. Marraha F, Al Faker I, Gallouj S. A Review of the Dermatological Manifestations of Coronavirus Disease 2019 (COVID-19). Dermatol Res Pract. 2020 Aug 11;2020:9360476. doi: 10.1155/2020/9360476. PMID: 32849867; PMCID: PMC7422480. 3. Mariyath OK, Samad KA, Devi K, Surya VS, Effeena MD, Ajina M. Atypical maculopapular rash as the initial sign of COVID-19: A case report from a COVID hospital. J Skin Sex Transm Dis 2021;3(1):87-90. 4. Shahidi Dadras, M., Dadkhahfar, S., Bahmanjahromi, A., Seifian, H., Abdollahimajd, F. Skin manifestations in three cases of COVID-19 infection from Iran and a narrative literature review. Iranian Journal of Dermatology, 2020; 23(Suppl.1(COVID-19)): 60-66. doi: 10.22034/ijd.2020.114852

August - September 2021

31


Pincer Nail Deformity Treated with Haneke’s Procedure

Pincer Nail Deformity Treated with Haneke’s Procedure Dr. Sunil D. Patwardhan

MBBS, DVD (BJ Medical College, Pune) Fellow, National Skin Centre, Singapore. WHO Trained HIV Clinician Patwardhan Skin Clinic, Satara, Maharashtra

Introduction

toes are usually affected.

Pincer nail deformity is also known as

Smaller toes may also be involved.

incurved nail, unguis constringens,

The great toe commonly shows a

transverse over curvature, trumpet

lateral deviation of the long axis of the

nail, convoluted nail and omega nail.

distal phalanx, but the over curved

Pincer

nail

is

a

dystrophy

characterized by transverse over curvature that increases along the longitudinal axis of the reaches at

its

greatest

proportion

of pincer nails, both hereditary and

tissues, which are pinched without through

the

epidermis.

The hereditary pincer nail is almost always symmetrical. This form is probably a complex dominant genetic

In extreme cases, they may join

at fault for the development of the

together, forming a tunnel, or they

over curvature. Similar nail changes

may roll about themselves taking the

may be seen in other family members.

form of a cone. In certain varieties,

This anomaly is seen as early as

the nails are shaped

adolescence and young adulthood.

like claws,

congenita. After a while, the soft tissue may actually disappear, and this may be accompanied by a resorption of

the underlying bone

(shell nail syndrome).

August - September 2021

acquired.

trait with the phalangeal bones being

sometimes resembling pachyonychia

32

they exhibit a medial deviation. There are several different variants

lateral borders tighten around the soft breaking

When the lesser toes are involved

nail and

the distal part. At this point, the

necessarily

nails are deviated even more laterally.

Acquired

pincer

symmetrical

nails and

are

not

fingernail

involvement may be extensive and appear to be fairly symmetrical. Acquired pincer nails may be due to several different causes including

The condition is quite frequent on

dermatoses

and drugs. [Exostosis

toes and rare on fingers. The great

Myxoid pseudocyst, Epidermal cyst,


Pincer Nail Deformity Treated with Haneke’s Procedure

Tinea unguium, Arteriovenous fistula,

the use of special reversed tie-over sutures to keep the nail

Kawasaki

bed stretched over the bone.

disease,

SCC,

BCC,

Psoriasis, Lupus] Pathology Osteophytes are bigger on the medial than on the lateral aspect, explaining why the nail’s longitudinal axis is deviated more laterally than that of the distal phalanx. The nail matrix is intimately attached to the base of the terminal phalanx, and with its widening it becomes uncurved proximally which automatically causes overcurving distally.

Figure.1: Before Surgery

The heaped-up distal portion of the nail bed pulls the soft tissue up, resulting in a traction osteophyte.

Step 1- Avulsion of two lateral strips of plate.

Case report A 40 year old otherwise healthy lady presented with a left greater toenail deformity that was painful on pressure. She started noticing the changes in the shape of the nail over last two years. The nail became painful only over last two months. On examination she had transverse over curvature which appeared to pinch the nail bed and the nail bed had a heaped up appearance in the distal part. The

Figure.2: Avulsion of lateral strips of nail plate

right greater toe nail had a similar but less severe and asymptomatic deformity. Her brother also had similar deformity Routine

although

asymptomatic.

laboratory

investigations

revealed no abnormality and the X ray did not show any abnormality. Haneke’s procedure was performed. Procedure The aim of the technique is to narrow slightly the nail plate with chemical cautery, remove the bony dorsal distal tuft, and expand the nail laterally, by

Figure.3: Avulsion of lateral strips of nail plate August - September 2021

33


Pincer Nail Deformity Treated with Haneke’s Procedure

Steps 3- Median incision of the nail bed from the lunula border to 2 mm beyond the hyponychium is carried down to the bone.

Figure.4: Avulsion of the lateral strips of nail plate Steps 2- Avulsion of the distal two thirds of the plate. Figure.7: Median incision of nail bed Steps 4-The distal dorsal tuft with the osteophyte is cut.

Figure.5: Avulsion of distal two thirds of nail plate Figure.8: Removal of osteophyte Step 5 - Phenolization of the lateral horn of the matrix.

Figure.6: Avulsion of the distal two thirds of nail plate

Figure.9: Lateral horn phenolization 34

August - September 2021


Pincer Nail Deformity Treated with Haneke’s Procedure

Step 6 - Nail bed is reapproximated with absorbable 5/0 or 6/0 sutures.

Figure 13: Haneke’s Procedure Figure.10: Reapproximation absorbable sutures

of

nail

bed

with

Step 7 - Reverse tie-over sutures are placed in the lateral nail folds to keep the nail bed stretched over the bone and are removed after about 3 weeks.

Conclusion Haneke’s procedure is useful in treating pincer nail deformity. Other surgical modalities to treat pincer nail are described by Suzuki, Fanti, Kosava, Zook. They are also reported to be effective. References 1. Rook’s textbook of dermatology. 2. Bolognea’s textbook of dermatology. 3. Diseases of the nails and their management [Baran and Dawber]. 4. Nail disorders [Bianca Maria Piraccini].

Figure.11: Reverse tie over sutures Result

Figure.12: Result two months after surgery August - September 2021

35


NEWS

Hair aging differs by race, ethnicity Hair color changeis one of the clearest signs of aging. Hair color is due to a pigment called melanin, which hair follicles produce. Hair follicles are structures in the skin that make and grow hair. With aging, the follicles make less melanin, and this causes gray hair. Graying often begins in the 30s. While aging is an unavoidable biological process with many influencing factors that results in visible changes to the hair, there is limited literature examining the characteristics of hair aging across the races. Now a new study describes the unique characteristics of hair aging among different ethnicities that the authors hope will aid in a culturally sensitive approach when making recommendations to prevent hair damage during one's life-time.Among the findings hair-graying onset varies with race, with the average age for Caucasians being mid-30s, that for Asians being late 30s, and that for Africans being mid-40s. Caucasians and Asians typically experience damage to the distal hair shaft, while African-Americans see damage occurring closer to the hair root. Postmenopausal changes include decreased anagen (active or growing) hairs in the frontal scalp, lower growth rates and smaller hair diameters.Similar to skin, hair aging comprises both intrinsic aging, which includes the natural physiological changes that occur with time, and extrinsic aging, or changes associated with environmental exposures and physical stress caused by daily grooming.Despite a similar chemical composition, the structural properties of hair vary between different ethnicities and, consequently, the aging of hair differs as well. As the population ages and becomes more diverse, it is of greater necessity to understand the hair aging process in different types of hair. The researchers performed a literature search among 69 publications to review what is known about changes in hair structure over time, focusing on the differences in hair aging according to ethnic background. Information regarding hair structure, aging characteristics and responses to extrinsic damage together with differences between races and ethnicities was collected. According to the researchers, the role of hair for both protection and cosmetic improvement makes it incredibly important to ones' physical and mental well-being. A thorough understanding of the unique characteristics of hair aging among different races and ethnicities is essential for the appropriate management of mature patients.

Skin-Related Complications Have Been Reported In Some People After Covid Vaccination According to recent research, dermatologists said post-Covid dermatological complications have been reported in many cases, but post-vaccination skin issues are being seen too.When a vaccine shot is administered, the immune system activates, preparing the body to recognise and combat the virus in the future. This immune response and the inflammation that goes with it can sometimes result in a rash.For people with a prior history of skin allergy and complications, in some cases, those could be getting triggered again, so a dermatologist should be consulted after vaccination if any dermatological issues crop up. Dermatologist and hair transplant surgeon said they have come across a couple of cases of dermatological complications, including hair loss, but that generally happens two-three weeks after vaccination.From inflammatory rashes to scaly patches, skin-related complications have been reported in some people after Covid vaccination. Some cases have no known history of dermatological issues and they developed skin reactions after a few days of vaccination. In some cases, these could lead to an exaggerated immune response and depending on the body condition of the persons, may exhibit skin complications like rashes.

36

August - September 2021


Certificate Courses Aesthetic DermAtoloGy COURSE CONTENT • Module 1 : Introduction to Facial Aesthetic Medicine

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Includes: Study Material Test Hands on Sessions WHA Certificate 10

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August - September 2021

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