The Aetheticians Journal February-2024 issue

Total Pages : 32 February 2024 Vol 17* Issue - 2 100

Acne Vulgaris with Post-Inflammatory Hyperpigmentation: A Case Report

Q-switched Nd:YAG Laser for Congenital Melanocytic Naevus: A Clinical Cases

Clinical Cases in Leprosy

Management of Skin Conditions: Dermatological Challenges

EXECUTIVE EDITOR & PUBLISHER Dom Daniel

CORPORATE OFFICE 22, Shreeji Bhavan, 275-279, Samuel Street, Masjid Bunder (W), Mumbai-4000 03, INDIA. EMAIL: theaestheticiansjournalindia@gmail.com Website: theaestheticiansjournal.com TEL: +91 22 2345 1404 +91 22 2345 5844

Printed, Published, Edited and Owned by Dom Daniel Printed at Swastik Printer, Gala No.9 & 10, Vishal Industrial Estate, Bhandup (West), Mumbai- 400078.

Published at 22 Shreeji Bhavan, 275/279, Samuel Street, Masjid Bunder (West), Mumbai - 400003. India.

“The Aestheticians Journal” takes no responsibility for unsolicited photographs or material ALL PHOTOGRAPHS, UNLESS OTHERWISE INDICATED, ARE USED FOR ILLUSTRATIVE PURPOSE ONLY.

Views expressed in this Journal are those of the contributors and not of the publisher. Reproduction in whole or in parts of texts or photography is prohibited.

Manuscripts, Photographs and art are selected at the discretion of the publisher free of charge (advertising excluded). Whether published or not, no material will be returned and remains the property of the publishing house, which may make use of it as seen fit. This may include the withdrawal of publication rights to other publishing houses.

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

Published for the period of February - 2024

Skin conditions represent a diverse array of dermatological challenges that significantly impact individuals' well-being. The effective management of these conditions are dynamic and evolving field, encompassing various diagnoses and treatment modalities. It is imperative to recognize the complexity of clinical skin conditions and the need for a nuanced, patient-centered approach. Dermatological concerns, ranging from common conditions like acne and eczema to more complex issues such as skin cancers and autoimmune disorders, necessitate tailored management strategies. This editorial emphasizes the importance of a comprehensive understanding of each condition and the individualized care required for optimal outcomes. Dermatologists and healthcare professionals play a pivotal role in accurate diagnosis and formulating appropriate treatment plans. The multifaceted nature of skin conditions demands a holistic approach that considers not only the dermatological manifestations but also the potential impact on patients' mental and emotional well-being.

The management of clinical skin conditions often involves a combination of therapeutic interventions.

Topical treatments, systemic medications, lifestyle modifications and in some cases, surgical procedures may be recommended. It is crucial to acknowledge that responses to treatment can vary among individuals, underscoring the need for ongoing patient monitoring and adjustments to the management plan as needed.

Furthermore, this editorial highlights the significance of patient education in the management of skin conditions. Empowering individuals with information about their condition, treatment options and preventive measures fosters active participation in their care and enhances overall outcomes. In conclusion, the management of clinical skin conditions is a dynamic and collaborative process that requires expertise, empathy and ongoing research. By acknowledging the intricacies of each condition and embracing a patient-centered approach, healthcare professionals can contribute to improving the quality of life for individuals affected by dermatological concerns. This editorial encourages continued dialogue, research and advancements in dermatological care to address the evolving challenges in the field of clinical skin conditions.

In this issue we have A clinical case in Leprosy, Ear Lobe Repair with Punch Excision Technique, Laser for Congenital Melanocytic Naevus and Acne Vulgaris with Post-Inflammatory Hyperpigmentation etc.

HOPE YOU HAVE A GREAT READ Thanks & Cheers

- Dom Daniel Executive Editor & Publisher

Acne Vulgaris

with Post-Inf

lammato

ry Hyperpig

Ac Inflam ne Vulgaris wi matory th PostHy A Case perpigmentatio Report n: mentatio

n: A Case

08

Acne Vulgaris with Post-Inflammatory Hyperpigmentation: A Case Report

Report

Dr. Priyank

a Red

MBBS, dy M.D; D.V.L Founder, Medical Director DNA Skin and Chief Clinic and Dermatolo Bangalore Wellness gist Center

Dr. Priyanka Reddy, MBBS, M.D; D.V.L 08 8 Februa

ry 2024

Abstract PIH Hyperpigm (Post-Inflamma tory with condition entation) a high is by darke characteriz a recommend SPF should be ed and ed gene that occu ning of the rously applied to all inflammatiors as a resultskin areas. exposed Topical of play as acne n or injury treatm a , such treating significant role ents concern . It is a comm PIH. Retin in with skin among patie on as tretin oin, andoids, such nts perox of colou When addressing r (SOC). Howe ide are comm benzoyl skin of only ver, acne in start these it is impo used. is essen colour patie rtant to nts, it tial to concentra treatments at simultaneo consider lower tions us mana the incre of PIH ase them and gradually gement in the treatment skin For the to efficient plan. patie irritation and minimize should result patie nt tolera enhance be nce. skincare advised to follownts peels can be used Chemical gentle routine that includ a the PIH to treat as well clean es The comedoge sers and as non- specuse of lasers can scarring. nic mois Harsh ifically of be turize or 1,064-nm done can exace abrasive clean rs. laser in treati sers PIH, rbate ng acne QSNY and -induced potentiallyinflammation with particularly PIH. in patie Fitzpatrick Additionall worsen nts VI which skin haircare y, avoid revealed types IVing result comedogeproducts that impro s both statistically ved help preve nic properties have clinically. and and PIH. nt further irritatcan provided The advantage by this ion are s Daily use is minimal treatment sunsc down colour crucial for skinreen typically patie adverse time and no exposure nts with PIH. of as bleed effects ing such pigmentat can darke Sun The longe or crust forma n the 1,064 tion. ion and r wave the healin lengt nm prolong penetratio allows for h of broad-spec g proce deep ss. n, reduc trum ing the er sunscreenA of paradoxica the treatm l PIH caus risk ent itself. ed by Hence

Q-switc

hed Nd:YAG

Laser for

Congen

Q-switc Congen hed Nd:YAG Laser fo ital Mela r A Clinicanocytic Naevus : l Cases Dr. ital Melanoc

ytic Naevus:

18

Q-switched Nd:YAG Laser for Congenital Melanocytic Naevus: A Clinical Cases

A Clinical

Cases

Vivek

MBBS, M.Ch. (Plas Plastic tic Surge and Associate Cosmetic Surge ry) on Professor Departmen t of Gene Netaji ral Surge Subhas ry/ Unit Medical Chief (Plas College tic

Dr. Vivek, MBBS, M.Ch. (Plastic Surgery) Plastic and Cosmetic Surgeon

18 18 Februa

ry 2024

and Hosp Surgery) Introduct ital, Patna ion Congenita nevi (CMNl melanocy ) are tic of lesions melanocy that are pigmented birth and tic nevi. soma present The at occu tic mutations collections are composed r during that of of mela While nocytes. development early embryonic benign, most give rise presence CMN a small are with of mela to the particularly percentage nocytes , the the mutated the poten larger ones affec genes , in into maligtial to trans have The size ted areas of the skin.

The patho nant mela form can vary, and extent of CMN noma. genesis ranging involves lesions from of CMN mutations in-utero soma nevi that to giant cong small enital cove the mitog in genes relate tic portio n of the r a significant en-activate d to kinase These body surfa d prote ce. primarily (MAPK) pathw in NRAS somatic muta tions in NRAS ay, from and BRAF These and BRAF muta the germ are different . developm tions lead line muta to the associated ent of tions where with genetic inherited the mutamosaicism, are prese neurocutan syndromes ted like eous mela mosaic nt in a patch cells famili al nosis or affected pattern within y or CMN melanoma henc muta individual' e the the to sometimes s skin the affec tions are confi and ned ted (extracutan in other tissues not present in tissues and are eous The MAP the indivi mosaicism germ K pathw dual's s). they cells, simp crucial ay plays ly role in a future are not pass meaning growth, regulating generation ed on to cell differentia proliferation, s. 1 in gene tion hence muta and The clinical featu s tions vary depe res particularlywithin this pathw nding on of CMN ay, and NRAS their size can and BRAF implic can have result prognostic , ations. activation in of the abnormal nevi are rare Giant cong leading enital pathway, risk but of comp have a highe growth to uncontroll ed cell cruci r licatio and the formation cong al to differentia ns. It is te betw enital een melanocy tic

Clinical

Cases

in Leprosy

Clinica

l Cases

Dr. Vinod

24

Clinical Cases in Leprosy Dr. Vinod Chavan, MBBS, DDV, DVD 24 24 Februa

ry 2024

4

February 2024

Cha

in Lepr osy

MBBS, van DDV Consultan , DVD t Dermatolo Shree Tuka gist mayee Skin Nanded, Clinic Maharasht ra

Introduct ion Leprosy is disease, a chronic infect ious the World bacterium caused by Health Mycobacte the (WHO leprae Organizati ), over that rium on 200,000 cases of peripheral affects the skin, new leprosy each transmitte nerves. Prima are rily highe year globally, reported throu droplets d with the st incide of nose gh the nce in lesions, can cause such as countries musc Indonesia. India, Brazi nerve dama le weakness and ge However, l and if left untre incidence leading ated, the to disfig of lepro and sy urement decreased disability. significantl has recen leprosy However, t years y in is due to diagnosis multi-drug now curable with and treatmimproved WHO's diagnosis therapy and ent. The goal is early lepro prevent and treatment to the can probl sy as a publiceliminate complicatio developme em, define health nt of ns. d as reduc of lepro Elimination the globa sy the disea l prevalence ing problem as a public health se to has been of case in many per 10,00less than 1 countries, achieved persists 0 peop but it still Many coun in some achieved tries have alreadle. world, particularly parts of the this goal, y persis stricken in pove areas rty- limite ts in some but it still access with limite areas d acces to health with d It factors is impo s to healthcare. like weak care. Other that lepro rtant to ment ened system, poor living immune ion sy is conta and a lack not conditions gious and highly healthcare of access to prope of the the majo rity may increa r immu population is risk of naturally ne to the contracting se the exact disea In its early stage leprosy. pathophysi se. The leprosy may be s, lepro is not fully ology of have only asymptomatic sy but it is understoo believed or mech Therefore, mild symp that varioud, anisms toms. s are involv it. M. and treatm early diagn leprae osis ent are invasion ed in skin prevent crucial the to wher and peripheral in the complicatio developme e it nerve nt s, of ns. Acco multiplies rding to spreads to and body, causi other parts of the ng nerve damage

February 2024

5

Editorial Board Dr. Priyanka Reddy

MBBS, M.D; D.V.L Founder, Medical Director and Chief Dermatologist DNA Skin Clinic and Wellness Center Bangalor

Advisory Board Dr. Rasya K. Dixit Dr. Sayed Quadri Dr. Sohandas Shetty Dr. Shashidhar Talwar Dr. Archana Gulur Dr. Ramesh A . C .

Dr. Haritha R.

Dr. Vivek

MBBS, M.Ch. (Plastic Surgery) Plastic and Cosmetic Surgeon Associate Professor Department of General Surgery/ Unit Chief (Plastic Surgery) Netaji Subhas Medical College and Hospital, Patna

Dr. Karthik R. Dr. Chaitra Dr. Vinayak Venktesh Dr. Satish K. M. Dr. Pavan Kumar Dr. Ashish B. Shetty

Dr. Vinod Chavan

MBBS, DDV, DVD Consultant Dermatologist Shree Tukamayee Skin Clinic Nanded, Maharashtra

6

February 2024

February 2024

7

Acne Vulgaris with Post-Inflammatory Hyperpigmentation: A Case Report

Acne Vulgaris with PostInflammatory Hyperpigmentation: A Case Report Dr. Priyanka Reddy

MBBS, M.D; D.V.L Founder, Medical Director and Chief Dermatologist DNA Skin Clinic and Wellness Center Bangalore

Abstract PIH (Post-Inflammatory Hyperpigmentation) is a condition characterized by darkening of the skin that occurs as a result of inflammation or injury, such as acne. It is a common concern among patients with skin of colour (SOC).

When addressing acne in skin of colour patients, it is essential to consider the simultaneous management of PIH in the treatment plan.

For the efficient result patients should be advised to follow a skincare routine that includes gentle cleansers and noncomedogenic moisturizers.

Harsh or abrasive cleansers can exacerbate inflammation and potentially worsen PIH. Additionally, avoiding haircare products that have comedogenic properties can help prevent further irritation and PIH. Daily sunscreen use is crucial for skin of colour patients with PIH. Sun exposure can darken the pigmentation and prolong the healing process. A broad-spectrum sunscreen 8

February 2024

with a high SPF should be recommended and applied generously to all exposed areas. Topical treatments play a significant role in treating PIH. Retinoids, such as tretinoin, and benzoyl peroxide are commonly used.

However, it is important to start these treatments at lower concentrations and gradually increase them to minimize skin irritation and enhance patient tolerance. Chemical peels can be used to treat the PIH as well as scarring.

The use of lasers can be done specifically of 1,064-nm QSNY laser in treating acne-induced PIH, particularly in patients with Fitzpatrick skin types IVVI which revealed improved results both statistically and clinically. The advantages provided by this treatment are minimal downtime and no typically adverse effects such as bleeding or crust formation.

The longer wavelength of 1,064 nm allows for deeper penetration, reducing the risk of paradoxical PIH caused by the treatment itself. Hence

Acne Vulgaris with Post-Inflammatory Hyperpigmentation: A Case Report

as these lasers reach deeper layers of skin than the topical agents, laser is used in this study.

Introduction Acne is a prevalent dermatological problem affecting people of all age groups.

Scarring and post-inflammatory hyperpigmentation are the two primary complications associated with acne. Acne vulgaris is a common skin condition characterized by the formation of comedones (blackheads and whiteheads), papules, pustules, nodules or cysts on the skin. Post-inflammatory hyperpigmentation refers to the darkening of the skin, occurs as a result of acne lesions which is a concern for individuals dealing with acne vulgaris. It commonly occurs in skin areas which has experienced inflammatory skin disorders or skin injuries that results in overproduction of melanin (pigment responsible for skin colour), produced by active melanocytes in response to inflammation or injury. PIH tends to affect darker-skinned patients or the people with skin of colour more frequently and with greater severity as these individuals have more active melanocytes. Epidemiological studies reveal that people with dyschromia, PIH are among the primary reasons for individuals of darker racial/ethnic groups seeking the care of a dermatologist.

This is due to the noticeable and persistent nature of PIH that significantly impacts a person's appearance

and quality of life. Various treatment options available include topical creams, chemical peels, laser therapy and microdermabrasion.1,2 PIH occurs more frequently in individuals with Fitzpatrick skin types III-VI, which includes people with darker skin tones.

It becomes clinically apparent a few weeks after the erythema (redness) from acne subsides. The duration for PIH to fade can vary depending on the type and severity of the hyperpigmentation. Dermal hyperpigmentation, which occurs in the deeper layers of the skin, may take years to fade, while the epidermal variant, which affects the outermost layer of the skin, can take several months (typically 6-9 months) to resolve. It is not a life-threatening condition but leads to significant distress to the individuals. In severe cases, PIH can have a substantial impact on an individual's self-esteem and quality of life.3 Acne vulgaris is a skin condition that begins with the formation of microscopic lesions called microcomedones that progress to visible comedones, which can be either open (blackheads) or closed (whiteheads). Over time, these comedones can become inflamed, leading to the development of red papules and pustules. Once the inflammation subsides, two common sequelae of acne, post-inflammatory erythema (PIE) and post-inflammatory hyperpigmentation (PIH) can occur.

Post-inflammatory erythema refers to persistent redness or discoloration of the

skin following inflammatory acne lesions, while PIH refers to the darkening of the skin in the affected area. In severe cases of acne, the follicular walls in the comedo can become dilated, leading to the formation of cysts or nodules.

These are often associated with deeper inflammation and can be more painful and persistent. Additionally formation of atrophic (depressed) scar, commonly occur in inflammatory acne or hypertrophic (raised) scars characterized by excessive collagen formation, leading to raised, thickened areas of scar tissue, in sever form, its referred to as acne conglobata.

PIP i.e. "Post-inflammatory papule" is a new specific manifestation of acne vulgaris that refers to brown and darkbrown papules that develop from the initial red papules and pustules of acne which are characterized by PIH and leads to scarring. It is a transitional stage between the red papules and pustules of active inflammation and the subsequent development of PIH. As the inflammation subsides, the brown and dark-brown papules persist as PIP. It is important to note that PIP is not a macule like PIH, but rather a papule, which is a small solid elevation of the skin. The introduction of PIP provide more specific and descriptive designation for this particular manifestation of acne which can be used in clinical discussions, classification and understanding of the various stages and sequelae of acne vulgaris.4 February 2024

9

Acne Vulgaris with Post-Inflammatory Hyperpigmentation: A Case Report

Histopathology can be helpful in confirming the presence of inflammation, non-inflammatory infiltration and scar tissue in PIP (Post-inflammatory papule).

Importantly PIP should not be treated with antimicrobial therapy alone as they are not primarily by an active infection.

Hence topical treatment with benzoyl peroxide (BPO) and adapalene is recommended to prevent the formation of atrophic scars whereas combination is known to have anti-inflammatory and skin-lightening effects and is commonly used to reduce the risk of acne scarring. In some cases, PIP has been effectively treated with a smooth beam laser, with a 1450-nm diode laser that incorporates cryogen spray cooling to improve the appearance of PIP and address the associated hyperpigmentation and scarring. It has to be noted that a comprehensive approach to acne treatment is necessary as antimicrobial therapy alone may not be sufficient. Combining topical medications with appropriate skincare, lifestyle modifications and in some cases, dermatological procedures can yield better outcomes in managing acne and its sequelae, including PIP.4 Intense pulsed light (IPL) therapy has been utilized for various dermatological conditions, including postburn hyperpigmentation, but its efficacy and safety for acne-related PIH have not been extensively studied.

10

February 2024

By utilizing different cutoff filters, IPL with noninvasive nature can target both erythema (redness) and hyperpigmentation (dark spots) associated with these conditions. Further research and clinical studies are needed to establish the optimal parameters, treatment protocols and longterm outcomes of IPL therapy for acne-related pigmentation issues. Additionally, individual patient factors such as skin type, severity of the condition and response to previous treatments should be taken into consideration when determining the most appropriate treatment approach.5 Case Report A 23 year old patient who came with complaints of active acne and post acne marks was having active acne ever since she was 16 to 17 years old. She had visited many doctors, taken multiple treatments which included oral isotretinoin and several other topical medications but none of the treatments worked. The record of the treatments taken in the past were not available at the time of consultation.

She was in distress due to uncontrollable acne which was leading to severe post acne pigmentation. Further examination revealed no evidence of PCOS, any other medical conditions that could trigger it. After thorough examination of medical history the presence of acne in family history was revealed.

The clinical diagnosis of acne vulgaris with PIH. The overall treatment included chemical

peels, laser treatments and topical applications with a personalized skin care protocol. Initially her active acne were controlled with two sessions of chemical peels. The chemical peel containing ingredients like black acetic acid, salicylic acid, mandelic acid, retinol in various percentages and combinations helped with exfoliation and reducing the inflammation. She was kept on her anti-acne skin routine where the protocol followed was the morning routine which included; gentle face wash in the morning, a serum that containing niacinamide with zinc and a water based light weight sunscreen. The evening routine included washing face with salicylic acid based face wash, chemical exfoliation with BHA 2-3 times a week, azelaic acid serum at night, alternating it with a tretinoin. 2-3 days each in a week and a moisturiser. Spot treatments with ointment containing adapalene, clindamycin, BPO was advised to be used as SOS as and when needed. A dietary modification was also advised like to cut off excess consumption of sugary foods, highly processed foods and heavy fat dairy products were completely taken off her routine. Further treatment for PIH was done with help of combination of lasers and chemical peels.

3 sessions of Q switch laser were done with a gap of one week. It was followed up with a chemical peel considering depigmenting and exfoliating ingredients. After 20 days another session of Q switch

Acne Vulgaris with Post-Inflammatory Hyperpigmentation: A Case Report

laser was done, followed by another session of chemical peel after 10 days. The results of treatment was achieved after 4 months. Active acne came under control in about 1 - 1 1/2 months time, post which we had done laser treatments for PIH. The first three sessions of laser treatment were done with a gap of one week and the duration was increased to 15 days between the sessions for the next two sessions. Follow ups were advised for personalized skin care routine and the patient was counselled about the nature of acne and why following a good routine and diet is very important. It has been over a year now after treatments and the patient is doing very well. She is happy and confident in her own skin. Images clicked before and after 4 months treatment are depicted below.

Before treatment

After 4 months of treatment Figure 1: Acne vulgaris with post-inflammatory hyperpigmentation Diagnosis The diagnosis of acne vulgaris with post-inflammatory hyperpigmentation is typically based on the clinical presentation and history of the patient. The dermatologist or healthcare provider will evaluate the skin for the presence of acne lesions such as comedones (blackheads and whiteheads), papules, pustules, nodules or cysts. They will also assess

for signs of inflammation and post-inflammatory changes, including hyperpigmentation.

Proper diagnostic approach has to be considered which includes; thorough medical history including any previous or current acne symptoms, treatment history and the development of hyperpigmentation following acne lesions, comprehensive physical examination of the patient's skin, for characteristic acne lesions and signs of inflammation and will also assess the presence and extent of post-inflammatory hyperpigmentation.

Other conditions that cause similar manifestations like melasma, post-inflammatory erythema or other form of hyperpigmentation may also be considered to ensure accurate diagnosis and appropriate treatment plan.

Additional tests or procedures may be performed to assess the severity of the condition which includes wood's lamp examination; were lamp emits ultraviolet light and helps to identify certain types of pigmentation or determine if the hyperpigmentation is due to melanin or other factors, biopsy; skin examine a small tissue sample under a microscope to confirm the diagnosis and rule out other skin conditions.6,7 Treatment Acne vulgaris with post-inflammatory hyperpigmentation is a common condition that can be frustrating to deal with. PIH occurs when dark patches develop after a blemish has healed. The treatment of February 2024

11

Acne Vulgaris with Post-Inflammatory Hyperpigmentation: A Case Report

PIH tends to be a difficult and prolonged process that often takes 6-12 months to achieve the desired results of depigmentation.

To effectively manage acne vulgaris with associated PIH, a comprehensive treatment approach is necessary.

Addressing the underlying acne is crucial to prevent further inflammation and subsequent PIH formation.

Hence treatment options for acne vulgaris may include topical medications (e.g. retinoids, benzoyl peroxide or topical antibiotics), oral antibiotics, hormonal therapy (e.g. oral contraceptives or anti-androgens) or isotretinoin for severe cases.

First-line therapy for PIH typically includes topical de-pigmenting agents and photoprotection.

Some depigmenting agents include hydroquinone, azelaic acid, kojic acid, arbutin, certain licorice extracts that inhibits the activity of tyrosinase, an enzyme involved in melanin production.

Retinoids, mequinol, ascorbic acid, niacinamide, N-acetyl glucosamine and soy are other depigmenting agents that may be used. Simultaneous management of PIH alongside acne treatment is essential like protecting the skin from sun exposure is crucial, as UV radiation can worsen PIH. The use of a broad-spectrum sunscreen with SPF 30 or higher daily, even on cloudy days or indoors, the use of gentle cleansers and noncomedogenic moisturizers to maintain a healthy skin barrier and prevent further irritation, harsh or abrasive 12

February 2024

products that can exacerbate inflammation and prolong PIH can be beneficial. Certain topical corticosteroids may be prescribed for certain types of hyperpigmentation, especially when inflammation is present. Keratolytic agents, such as alpha-hydroxy acids (e.g., glycolic acid) and betahydroxy acids (e.g., salicylic acid), help exfoliate the skin and promote cell turnover, which can improve PIH. Patients have to be instructed to avoid picking, popping or squeezing acne lesions which can cause additional inflammation and increase risk of PIH. Chemical peels like glycolic acid, salicylic acid and trichloroacetic acid can help exfoliate the skin and promote the fading of hyperpigmentation and laser modalities like Q-switched (QS) ruby laser, Q-switched alexandrite laser and Q-switched neodymiumdoped yttrium aluminum garnet (QSNY) laser are used for treating PIH. Treatments can be considered for more severe or stubborn cases of PIH which help exfoliate the skin and promote a more even skin tone.8 Several specific treatments have shown efficacy in managing PIH. Here retinoids, azelaic acid and hydroquinone are indeed common prescription treatments for PIH. Retinoids such as tretinoin and other retinoids promote proliferation, differentiation, cohesiveness, showing antiinflammatory effect and help fade hyperpigmentation over time. It can also induce apoptosis. They are available

in various formulations, such as creams, gels or serums.

Azelaic Acid (AZA) is a naturally occurring dicarboxylic acid which is a topical medication having both anti-inflammatory and depigmenting properties is beneficial for PIH treatment in skin of colour patients. It directly inhibits tyrosinase activity, which is involved in melanin production. A study shows twice-daily use of azelaic acid gel 15% over 16 weeks resulted in significant improvement of PIH, with more than 50% of participants having no PIH by the end of the study. Hydroquinone (HQ) is considered the gold standard for PIH treatment. It acts as a depigmenting agent by inhibiting melanin synthesis.

HQ 4% is commonly used once or twice daily for 3 to 6 months to treat PIH. It is important to educate patients on proper HQ use to minimize the risk of adverse effects, such as ochronosis, which is a rare side effect characterized by blue-black or gray-blue discoloration.

Long-term use should be monitored carefully. Triple combination cream: this cream consists of hydroquinone 4%, fluocinolone acetonide 0.1% and tretinoin 0.05% showed marked efficacy and tolerability after eight weeks of treatment in patients with moderate-to-severe melasma and Fitzpatrick Skin Types I to IV.1,2,3,7,9,10 The use of specific ingredients such as black acetic acid, salicylic acid, mandelic acid, and retinol can be beneficial in the management of acne vulgaris with PIH. Black acetic

Acne Vulgaris with Post-Inflammatory Hyperpigmentation: A Case Report

acid, also known as black vinegar or black rice vinegar, is a fermented product that contains acetic acid has antimicrobial properties, which can help in reducing acne-causing bacteria on the skin. Salicylic acid is a betahydroxy acid (BHA) exfoliates the outer layers of the skin, unclogs pores and helps in the removal of dead skin cells and excess oil as well as have anti-inflammatory effects.

Mandelic acid is an alphahydroxy acid (AHA) derived from almonds exfoliates and helps in the removal of dead skin cells, unclogging pores and promoting skin cell turnover. It also has antibacterial properties that help in reducing acne-causing bacteria. Retinol is a form of vitamin A that is commonly used helps in regulating skin cell turnover, promoting the exfoliation of dead skin cells and preventing the clogging of pores. It also has antiinflammatory properties that can help in reducing acne inflammation and minimizing the risk of PIH formation.

Furthermore, retinol promotes collagen production and can improve the appearance of acne scars and PIH over time.1,11 Laser modalities like Q-switched lasers emit highenergy, short-duration pulses of light that target specific pigments in the skin, including melanin. The laser energy is absorbed by the melanin, leading to its fragmentation and subsequent clearance by the body's natural processes which can help to lighten the hyperpigmentation and even

out the skin tone. This lasers come in different wavelengths and the choice of laser wavelength will depend on the specific condition being treated. For PIH, lasers with wavelengths such as 532 nm (green) or 1064 nm (near-infrared) may be used, as they are absorbed by melanin. The individual results can vary while using this laser treatment. Hence a comprehensive treatment plan that include a combination of topical medications, lifestyle modifications and other procedures to achieve optimal results for acne and PIH management is needed.3,12,13 A skin care routine suggested include morning and evening routine were the morning routine starts with a gentle face wash to cleanse the skin without stripping it of natural oils followed by application of serum containing niacinamide (anti-inflammatory) and zinc ( regulate oil production) and lastly applying a waterbased lightweight sunscreen to protect the skin from UV damage. Whereas the evening routine includes application of salicylic acid face wash, various topical agents (BHA, AZA serum, Tretinoin) and moisturizer as well. For spot treatment of active acne lesions, we can use an ointment containing a combination of adapalene (a retinoid), clindamycin (an antibiotic) and benzoyl peroxide (BPO).

This combination helps to reduce inflammation, kill acne-causing bacteria and promote healing.

Hence regular monitoring and proper skincare routine to be

followed to get an effective treatment plan.1,7,14,15 Discussion In the management of PIH, the primary focus is on treating the underlying inflammatory condition, such as acne, to prevent further hyperpigmentation.

Photo-protection through the use of sunscreens, sunprotective clothing and sun avoidance is also important in preventing an increase in melanin production. Topical depigmenting agents, such as hydroquinone, kojic acid, azelaic acid, arbutin, licorice extracts, retinoids, ascorbic acid, niacinamide and soy are commonly used as first-line treatments for PIH. However, in cases where topical therapy alone is not sufficient, various laser modalities can be employed. The treatment of post-inflammatory hyperpigmentation and the use of lasers, specifically the 1,064-nm Q-switched neodymium-doped yttrium aluminum garnet (QSNY) laser, is a longer wavelength pigment-specific laser that can target dermal pigment that may be too deep for topical agents to reach. Different approaches can be used with the QSNY laser, including traditional laser toning and low-fluence settings with large spot sizes and multiple passes. The mechanisms involved in PIH include pigment incontinence, where melanophages containing melanin accumulate in the upper dermis after the basal cell layer is destroyed and an epidermal inflammatory response that stimulates February 2024

13

Acne Vulgaris with Post-Inflammatory Hyperpigmentation: A Case Report

melanin synthesis and transfer to surrounding keratinocytes.

Studies have demonstrated the efficacy of the 1,064-nm QSNY laser in treating acneinduced PIH, particularly in patients with Fitzpatrick skin types IV-VI which revealed significant improvement in PIH both statistically and clinically, with a majority of patients reporting good to excellent improvement.

However, it's important to note that confetti-like or spotty hypopigmented macules, punctate leukoderma, and rebound hyperpigmentation are potential side effects associated with the use of low-fluence QSNY laser.

Managing longlasting post-inflammatory hyperpigmentation caused by acne can be challenging in individuals with darker skin. Despite the availability of various treatment options, it often takes months for PIH to resolve even with adequate therapy. The use of Q-switched neodymiumdoped yttrium aluminum garnet (QSNY) laser for PIH offers several advantages. It has minimal downtime and does not typically cause adverse effects such as bleeding or crust formation.

The longer wavelength of 1,064 nm allows for deeper penetration, reducing the risk of paradoxical PIH caused by the treatment itself. While there is limited data on the use of QSNY laser specifically for acne-induced PIH in the Indian literature, the authors of the mentioned study found it to be a feasible and costeffective treatment modality.

They believe that QSNY 14

February 2024

laser can be a viable option for addressing persistent PIH due to acne, particularly in individuals with darker skin types. However, more randomized controlled clinical studies involving larger numbers of PIH patients are needed to establish standardized and measurable outcomes for this indication.3 Conclusion Post-inflammatory....... hyperpigmentation is a complex condition associated with changes in melanin pigment due to inflammation or injury to the skin. In India, acne-induced PIH is a common concern, particularly among young females seeking dermatological care. There is a wide range of topical depigmenting agents available for effectively treating hyperpigmentation in acne patients. Additionally, procedures such as chemical peels, laser and light therapies are commonly used.

However, the management of acne-induced PIH presents challenges in Indian clinical settings due to factors such as frequent relapses, longlasting nature of the condition, the potential for treatmentinduced pigmentation, limited clinical data on natural ingredients and the lack of specific guidelines for Indian patients. The use of lasers, including the 1,064-nm QSNY laser, can be a valuable adjunctive treatment option for PIH, particularly when topical therapy alone is not sufficient or when dermal pigmentation is present. However, it's essential to consult with a qualified dermatologist who

can assess specific condition and recommend the most appropriate treatment approach for individual needs. Hence for individuals with acne-induced PIH it is essential to consult with a dermatologist who can provide personalized advice and treatment based on an individual's specific skin type and condition.

References 1.

Sangha, Archana M. “Managing Post-inflammatory Hyperpigmentation in Patients with Acne.” The Journal of clinical and aesthetic dermatology vol. 14,6 Suppl 1 (2021): S24-S26.

2. Davis, Erica C, and Valerie D Callender.

“Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color.”

The Journal of clinical and aesthetic dermatology vol. 3,7 (2010): 20-31.

3. Zawar, Vijay P.; Agarwal, Madhuri; Vasudevan, Biju.

Treatment of Postinflammatory Pigmentation Due to Acne with Q-Switched Neodymium-Doped Yttrium Aluminum Garnet In 78 Indian Cases. Journal of Cutaneous and Aesthetic Surgery 8(4):p 222-226, Oct–Dec 2015. | DOI: 10.4103/0974-2077.172196.

4. Nogita, T., Nomura, Y. & Kurokawa, I. Postinflammatory Papule: A Tentative New Designation for Acne Vulgaris. Dermatol Ther (Heidelb) 11, 1867–1869 (2021). https://doi.org/10.1007/s13555021-00629-2.

5. Wu, X., Wang, X., Wu, X. et al. Intense Pulsed Light Therapy Improves Acne-Induced Postinflammatory Erythema and Hyperpigmentation: A Retrospective Study in Chinese Patients. Dermatol

Acne Vulgaris with Post-Inflammatory Hyperpigmentation: A Case Report

Ther (Heidelb) 12, 1147–1156 (2022). https://doi.org/10.1007/ s13555-022-00719-9 6. Lawrence E, Al Aboud KM. Postinflammatory Hyperpigmentation. [Updated 2022 Oct 3]. In: StatPearls [Internet].

Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih. gov/books/NBK559150/ 7. Ichiro Kurokawa ,"Comprehensive Sequential Successful Therapy Comprising Chemical Peeling, Iontophoresis and Topical Vitamin C for Postinflammatory Hyperpigmentation in Acne Vulgaris",Journal of Cosmetics, Dermatological Sciences and Applications, Vol.10 No.3, 2020 ISSN:2161-4105 DOI: 10.4236/ jcdsa.2020.103010

12. Arora, Pooja et al. “Lasers for treatment of melasma and postinflammatory hyperpigmentation.”

Journal of cutaneous and aesthetic surgery vol. 5,2 (2012): 93-103. doi:10.4103/0974-2077.99436 13. E.F. Battle and C.E. Soden. The Use of Lasers in Darker Skin Types.

Semin Cutan Med Surg 28:130-140. doi:10.1016/j.sder.2009.04.003 14. De Felice E. Shedding light: laser physics and mechanism of action.

Phlebology.

2010;25(1):11-28. doi:10.1258/phleb.2009.009036 15. BLAIR ALLAIS, Acne Vulgaris: Nuances in the Approach to Treatment in Patients with Darker Skin Tones, february 2022.

8. Susan Taylor, et al , Treatment recommendations for acneassociated hyperpigmentation: Results of the Delphi consensus process and a literature review March 14, 2023DOI:https://doi. org/10.1016/j.jaad.2023.02.053 9. Castillo, David E, and Jonette E Keri. “Chemical peels in the treatment of acne: patient selection and perspectives.” Clinical, cosmetic and investigational dermatology vol. 11 365-372. 16 Jul. 2018, doi:10.2147/CCID.S137788 10. Rendon, Marta I et al. “Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing.” The Journal of clinical and aesthetic dermatology vol. 3,7 (2010): 32-43.

11. Trivedi, M K et al. “A review of laser and light therapy in melasma.” International journal of women's dermatology vol. 3,1 1120. 21 Mar. 2017, doi:10.1016/j. ijwd.2017.01.004 February 2024

15

16

February 2024

February 2024

17

Q-switched Nd:YAG Laser for Congenital Melanocytic Naevus: A Clinical Cases

Q-switched Nd:YAG Laser for Congenital Melanocytic Naevus: A Clinical Cases Dr. Vivek

MBBS, M.Ch. (Plastic Surgery) Plastic and Cosmetic Surgeon Associate Professor Department of General Surgery/ Unit Chief (Plastic Surgery) Netaji Subhas Medical College and Hospital, Patna Introduction Congenital melanocytic nevi (CMN) are pigmented lesions that are present at birth and are composed of collections of melanocytes.

While most CMN are benign, a small percentage, particularly larger ones, have the potential to transform into malignant melanoma.

The pathogenesis of CMN involves in-utero somatic mutations in genes related to the mitogen-activated protein kinase (MAPK) pathway, primarily NRAS and BRAF. These mutations lead to the development of mosaicism, where the mutated cells are present in a patchy or mosaic pattern within the affected individual's skin and sometimes in other tissues (extracutaneous mosaicisms).

The MAPK pathway plays a crucial role in regulating cell growth, proliferation, and differentiation hence mutations in genes within this pathway, particularly NRAS and BRAF, can result in abnormal activation of the pathway, leading to uncontrolled cell growth and the formation 18

February 2024

of melanocytic nevi. The somatic mutations that occur during early embryonic development give rise to the presence of melanocytes with the mutated genes in the affected areas of the skin.

The size and extent of CMN can vary, ranging from small lesions to giant congenital nevi that cover a significant portion of the body surface.

These somatic mutations in NRAS and BRAF are different from the germline mutations associated with inherited genetic syndromes like neurocutaneous melanosis or familial melanoma hence the CMN mutations are confined to the affected tissues and are not present in the individual's germ cells, simply meaning they are not passed on to future generations.1 The clinical features of CMN vary depending on their size and can have prognostic implications. Giant congenital nevi are rare but have a higher risk of complications. It is crucial to differentiate between congenital melanocytic

Q-switched Nd:YAG Laser for Congenital Melanocytic Naevus: A Clinical Cases

nevi (CMN) and acquired melanocytic nevi based solely on histologic examination can be challenging in some cases.

Hence the diagnosis of CMN is based on clinical examination and may be confirmed with histopathological evaluation.

Histopathologically, CMN are characterized by nests of melanocytes located in the dermo-epidermal junction, dermis or compound locations which may sometimes extend to the subcutaneous fat or fascia, in a V-shaped configuration on lower magnification and often extend deep into the dermis, surrounding appendageal structures such as sweat glands, follicles, nerves and blood vessels. Cytological atypia, which refers to abnormal cell features, is generally minimal or absent wherein the size of melanocyte within lesions can vary, with larger melanocytes in the superficial area and smaller ones deeper in the lesion.

Such variation in melanocyte size is known as "maturation gradient."

Proliferative nodules (PN) characterized by nodular lesions composed of polymorphic cells can occasionally develop within CMN, but can be differentiated from melanoma based on specific histological features. The nodules often have a pushing border, which can cause deformation of surrounding structures. Unlike melanoma, PN typically do not exhibit cytological atypia or increased proliferative rate and necrosis is usually absent.

These features can be helpful in differentiating PN from melanoma. In some cases,

CMN may show "neuroid differentiation," which manifests as areas of spindle cells with myxoid stroma.1 These areas may resemble neurofibromas, a type of nerve sheath tumor. CMN are categorized into small, medium and large or giant nevi based on their projected adult size, determined by the maximal diameter of the lesion. Small CMNs are projected to be less than 1.5 cm in diameter, mediumsized CMNs range from 1.5 to 19.9 cm and large or giant CMNs are larger than 20 cm. The projected adult size is estimated using a scaling factor that takes into account the anatomical location of the nevus. For example, CMNs on the head are predicted to grow by a factor of 1.7, while those on the lower limb have a growth factor of 3.3 and those on the upper limb and torso have a growth factor of 2.8. This classification based on size is important because larger CMNs are associated with a higher risk of melanoma development, have greater cosmetic implications, pose challenges in surgical excision and are more likely to be associated with symptoms.

Understanding the underlying genetic mechanisms of CMN helps in identifying potential therapeutic targets and provides insights into the pathogenesis of melanocytic nevi and their association with melanoma development.

That the diagnosis and differentiation of melanocytic nevi should be made by a qualified dermatopathologist or healthcare professional who can evaluate the clinical

and histological features in the context of the individual patient. The management of CMN involves surveillance for malignant transformation and potential complications, such as neurocutaneous melanosis (CNS involvement). Treatment options depend on the size and location of the nevi and may include surgical excision, laser therapy and other modalities. Care coordination and an interprofessional team approach are crucial for the comprehensive management of patients with giant congenital nevi, particularly when neurological involvement is present. For small and medium-sized CMN, the risk of melanoma development is extremely low hence routine monitoring may not be necessary in this group of patients. In cases of giant or multiple CMN, regular follow-up is recommended.

Mole mapping with highquality photography and dermoscopy can be beneficial for monitoring changes over time. Excision surgery may be warranted if malignancy is suspected or to improve cosmetic outcomes.

Cosmetic procedures such as dermabrasion, laser modalities, or curettage are not effective in completely removing CMN thus should not be performed for medical reasons, as they do not reduce the risk of melanoma development.

Additionally, there is a possibility of lesion recurrence. In patients with neurocutaneous melanosis, involving central nervous system (CNS) manifestations, consultation with a pediatric neurologist is essential.

February 2024

19

Q-switched Nd:YAG Laser for Congenital Melanocytic Naevus: A Clinical Cases

Surgical interventions or chemotherapy may be considered in certain cases. Symptomatic medical treatment, such as anticonvulsants and dexamethasone, can be used as needed.1 Case Reports In series of cases, substantial improvement is seen in 60% cases were significant no. (15-20%) showed little or no improvement.

Case 1: A patient of age 23 years old was presented to our clinic. Through clinical examination she was diagnosed with congenital benign naevus. No evidence of any other disease condition or medications was found after going through medical history. Considering all the factors and information Before treatment obtained she was treated with Q-switched Nd:YAG laser. Total 10 sessions were conducted in the intervals of 3 weeks. Initially progress was not seen, but after 10 sessions improvement was seen. Both before and after procedural pictures are as follows:

After treatment Figure 2: Congenital melanocytic nevus on right cheek Before treatment

After treatment

Figure 1: Congenital melanocytic nevus involving the right lower eyelid and cheek Case 2: A patient of age 27 years old was presented to our clinic. Clinical examination revealed that she was diagnosed with congenital benign naevus. No evidence of any other disease condition or medications was found in medical history.

Considering all the factors and information obtained she was treated with Q-switched Nd:YAG laser. Total 7 sessions were conducted were initially progress was not seen, but after 7 sessions improvement was seen. Both before and after procedural pictures are as follows:

20

February 2024

Diagnosis The diagnosis of a congenital benign nevus, such as a congenital melanocytic nevus, is typically made based on its clinical appearance and characteristics. A thorough physical examination is conducted by a healthcare professional to assess the characteristics of the nevus including evaluating its size, shape, color, texture and any associated features such as hair growth or satellite lesions. The patient's medical history, including any previous changes or growth of the nevus, has to be taken into account. Information about

Q-switched Nd:YAG Laser for Congenital Melanocytic Naevus: A Clinical Cases

the duration of the nevus since birth or early childhood is important in distinguishing it from acquired nevi.

Further dermoscopy, also known as dermatoscopy or epiluminescence microscopy, may be performed to examine the nevus in more detail. It involves using a handheld device with magnification and light to visualize the surface and subsurface structures of the nevus. Dermoscopy can provide additional information about the pigment network, globules and other dermoscopic patterns characteristic of CMN. In some situations where there is uncertainty or suspicion of atypical features, a biopsy may be performed to confirm the diagnosis. A skin biopsy involves taking a small sample of the nevus tissue for microscopic examination by a pathologist.1,2,3

of sunscreen, protective clothing, and avoiding excessive sun exposure, are important to minimize the risk of UV-induced damage to the nevus and potential complications. In cases where cosmetic appearance is a concern, various procedures may be considered to improve the aesthetics of the nevus. These can include surgical techniques such as excision, shave excision, dermabrasion, laser therapy or camouflage techniques using makeup or tattooing.

The choice of procedure depends on the size, location and individual circumstances and should be discussed with a dermatologist or plastic surgeon. Living with a congenital nevus, especially larger or more visible ones, can have psychological and social implications.

Psychosocial support, including counselling or support groups, can be Treatment beneficial for patients and Some of the primary goals their families to address of treatment are to monitor any emotional or social the nevus for any changes, concerns.1,2,3 manage associated symptoms excision/surgical and address cosmetic Surgical concerns. The treatment removal of the nevus is recommended for options for congenital benign often nevi, such as congenital giant congenital nevi or nevi melanocytic nevi, depend on with suspected malignant various factors including the transformation which can size, location and associated be performed using various risks. Small to medium- techniques, such as traditional sized congenital benign nevi excision, shave excision or without concerning features staged excision. The goal may simply require regular is to remove the nevus and an aesthetically observation, check-ups achieve pleasing result.

Dermabrasion and monitoring to assess the nevus for any changes involves the removal of the or signs of malignancy by a superficial layers of the skin dermatologist or healthcare using a rotating instrument professional. Sun protection which is typically reserved for measures, including the use smaller nevi. It can be used

to improve the appearance of congenital nevi by reducing their prominence and blending them with the surrounding skin. Certain topical treatments, such as bleaching creams or retinoids, may be used to lighten the color of congenital nevi.

However, their effectiveness may be limited, especially for larger nevi. Laser therapy involving Q-switched lasers, such as the Q-switched Nd:YAG laser, can be used to lighten or remove congenital nevi. Multiple laser sessions may be needed for optimal results. The exact number of sessions will depend on the size, location and characteristics of the nevus, as well as the individual's response to the treatment. It is important to consult with a qualified dermatologist or laser specialist who can assess the nevus and determine the appropriate treatment plan using the Q-switched Nd:YAG laser. There are 3 types of laser commonly includes: Ruby Laser that emits red light at a wavelength of 694 nm and is effective in targeting melanin and can be used for the treatment of congenital nevi, particularly in individuals with lighter skin types. The Alexandrite laser emits near-infrared light at a wavelength of 755 nm, also effective in targeting melanin and can be used for the treatment of congenital nevi suitable for individuals with a range of skin types whereas the Nd:YAG laser emits infrared light at a wavelength of 1064 nm and is suitable for individuals with darker skin types (skin types 3-6). It February 2024

21

Q-switched Nd:YAG Laser for Congenital Melanocytic Naevus: A Clinical Cases

has a deeper penetration into the dermis and is less likely to cause epidermal injury or pigmentary alterations.1,4,5 Q-switched lasers have been used in the treatment of congenital benign nevi with favorable results. Q-switched lasers emit ultra-short bursts of laser light that specifically target the melanin pigment in the melanocytes of the nevus.

The laser's high energy and short pulse duration generate a photoacoustic effect, causing rapid thermal expansion and destruction of the target melanin-containing cells.

The Q-switched Nd:YAG laser (neodymiumdoped yttrium aluminum garnet laser) emits a specific wavelength of light (1064 nm) that is well-absorbed by melanin in the skin, has been used for the treatment of congenital benign nevi. It works by producing ultrashort bursts of high-energy laser light. These bursts of light target the melanin pigment in the melanocytes of the nevus, leading to its fragmentation and subsequent clearance by the body's natural processes.

The Q-switched Nd:YAG laser is particularly suitable for the treatment of darker skin types (skin types 3-6) because it has a deeper penetration into the dermis and minimizes the risk of epidermal injury and pigmentary alteration. The longer wavelength of 1064 nm is weakly absorbed by epidermal melanin, allowing it to target the deeper layers where the melanocytes are located. The Q-switched Nd:YAG laser has been widely used for the treatment of 22

February 2024

congenital benign nevi, and it has demonstrated both safety and efficacy in various studies but individual results may vary.

It has been shown to have a good safety profile when used by experienced practitioners.

However, as with any medical procedure, there are potential risks and side effects, including temporary redness, swelling, bruising and changes in pigmentation.

In rare cases, scarring or infection may occur, but these risks are generally low when the procedure is performed by a skilled professional. The mechanism of action may vary slightly depending on the specific laser parameters used, such as pulse duration, fluence and spot size which can be adjusted by the treating physician to optimize the treatment outcomes based on the characteristics of the nevus and the patient's individual needs.4,5,6,7,8 Discussion The choice of the specific Q-switched laser depends on various factors, including the characteristics of the nevus, the individual's skin type and the expertise of the treating physician hence consultancy with a qualified dermatologist or laser specialist who can assess the nevus and recommend the most appropriate laser treatment approach for optimal results and safety to be taken.

Q-switched laser irradiation for the treatment of congenital benign nevi offers significant cosmetic benefits compared to traditional treatments like excision. One advantage of laser treatment is the

avoidance or minimization of scarring, which can be a concern with surgical excision.

In a comparative study evaluating the effectiveness of Q-switched Alexandrite and Q-switched Nd:YAG lasers in the treatment of benign nevomelanocytic nevi, both lasers demonstrated positive results. After three treatment sessions, there was a dramatic lightening of the nevi observed with both lasers.

However, the study reported that the global assessment scores were better with the Q-switched Alexandrite laser compared to the Q-switched Nd:YAG laser. Q-switched Nd:YAG laser treatment for CBN has several advantages.

Firstly, it can achieve significant lightening or complete removal of the nevus, improving its cosmetic appearance. The laser selectively targets the pigmented cells, sparing the surrounding normal skin.

This selective targeting helps minimize the risk of scarring and pigmentary alterations.

Another advantage is the ability of the Q-switched Nd:YAG lasers to penetrate deeper into the dermis, reaching the deeper layers of the nevus. This is particularly beneficial for larger or deeper congenital nevi. The laser can effectively target the melanin in the deeper nevus cells, resulting in more satisfactory outcomes. Studies have reported positive outcomes with Q-switched Nd:YAG laser treatment for CBN. Multiple treatment sessions are usually required to achieve optimal results. The exact number of sessions depends on various factors as well as

Q-switched Nd:YAG Laser for Congenital Melanocytic Naevus: A Clinical Cases

individual patient response.

Close follow-up and monitoring by a dermatologist are important to assess the treatment progress and make any necessary adjustments.

It is worth noting that while Q-switched Nd:YAG laser treatment can provide cosmetic improvement, it does not eliminate the risk of melanoma development in congenital nevi. Regular surveillance for any changes in the nevus and periodic skin examinations are still recommended, particularly for larger or atypical nevi.

Q-switched Nd:YAG laser treatment is considered a safe and effective option for the management of congenital benign nevi. However, it is important to consult with a qualified dermatologist or laser specialist who can evaluate the specific characteristics of the nevus and determine the suitability of Q-switched Nd:YAG laser treatment in each individual case. They can provide a comprehensive assessment and develop a personalized treatment plan to achieve the best possible outcomes while prioritizing patient safety. 4,6,8 Conclusion Congenital benign nevi are pigmented skin lesions that are typically present at birth.

While they are generally benign, their presence can cause cosmetic concerns for individuals, particularly when the nevi are large or located in visible areas. Q-switched Nd:YAG laser works by delivering short bursts of high-intensity laser light that specifically target the melanin

pigment in the nevus cells.

This targeted approach helps lighten or completely remove the nevus while minimizing damage to the surrounding skin. The treatment is considered safe and has a low risk of scarring or pigmentary changes when performed by a skilled dermatologist or laser specialist. There are three types of lasers used commonly are the ruby the alexandrite and Nd:YAG laser.

Q-switched Nd:YAG laser (QSNY) has shown promising results in the treatment of congenital benign nevi.

Q-switched Nd:YAG laser treatment can provide cosmetic improvement, but it does not eliminate the risk of melanoma development in congenital benign nevi hence ongoing surveillance and skin examinations are essential to monitor for any changes or concerning features. The advantages of Q-switched Nd:YAG laser treatment for CBN include its ability to penetrate deep into the dermis, making it suitable for larger or deeper nevi.

Additionally, the laser's ultrashort pulses minimize the risk of scarring and pigmentary alterations, enhancing its safety profile. Multiple treatment sessions are typically required to achieve optimal results, and close follow-up and monitoring by a dermatologist are important. Multiple treatment sessions are often required to achieve desired results and the treatment progress should be closely monitored by a healthcare professional.

Regular surveillance and follow-up visits are important

to monitor any changes in the nevi and detect any signs of malignant transformation.

References 1. Navarro-Fernandez IN, Mahabal GD. Congenital Nevus. [Updated 2022 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi. nlm.nih.gov/books/NBK559270/ 2. Neil F. Gibbs, Hanspaul S. Makkar, Chapter 22 - Disorders of Hyperpigmentation and Melanocytes, Neonatal Dermatology (Second Edition), W.B. Saunders, 2008, Pages 397421, ISBN 9781416034322, https:// doi.org/10.1016/B978-1-4160-34322.50025-X. 3. Neha Shree, Arpan Gandhi, Sima Das, Giant facial congenital melanocytic nevus associated with conjunctival melanoma, journal: Orbit, pages 1-4, year-2023, publisher ;Taylor & Francis, PMID: 37058098, https://doi.org/10.10 80/01676830.2023.2198002 4. Parasramani, etal Q-switched Nd:YAG Laser to Treat Nevomelanocytic Nevi, Journal of Cutaneous and Aesthetic Surgery - Jul-Dec 2009, Volume 2, Issue 2, source-PubMed DOI:10.4103/09742077.58521 5. Duke D, Byers HR, Sober AJ, Anderson RR, Grevelink JM. Treatment of Benign and Atypical Nevi With the Normal-Mode Ruby Laser and the Q-Switched Ruby Laser: Clinical Improvement but Failure to Completely Eliminate Nevomelanocytes.

Arch Dermatol.

1999;135(3):290–296. doi:10.1001/archderm.135.3.290 6. R. Kaufmann, The Role of Lasers in the Treatment of Nevocellular Nevi,LaserMedizin: eine interdisziplinäre Zeitschrift ; Praxis, Klinik, Forschung, Volume 15, Issue 4, 2000, Pages 168-173,ISSN 0938-765X,https://doi.org/10.1016/ S0938-765X(00)80018-8, 7. Nelson JS, Kelly KM. Q-switched ruby laser treatment of a congenital melanocytic nevus. Dermatol Surg.

1999;25(4):274-276. doi:10.1046/ j.1524-4725.1999.08270.x 8. Kim S, Kang WH. Treatment of congenital nevi with the Q-switched Alexandrite laser. Eur J Dermatol.

2005;15(2):92-96.

February 2024

23

Clinical Cases in Leprosy

Clinical Cases in Leprosy Dr. Vinod Chavan

MBBS, DDV, DVD Consultant Dermatologist Shree Tukamayee Skin Clinic Nanded, Maharashtra

Introduction Leprosy is a chronic infectious disease, caused by the bacterium Mycobacterium leprae that affects the skin, peripheral nerves. Primarily transmitted through the droplets of nose can cause lesions, muscle weakness and nerve damage if left untreated, leading to disfigurement and disability.

However, leprosy is now curable with multi-drug therapy and early diagnosis and treatment can prevent the development of complications.

Elimination of leprosy as a public health problem has been achieved in many countries, but it still persists in some parts of the world, particularly in povertystricken areas with limited access to healthcare. Other factors like weakened immune system, poor living conditions and a lack of access to proper healthcare may increase the risk of contracting leprosy.

In its early stages, leprosy may be asymptomatic or have only mild symptoms.

Therefore, early diagnosis and treatment are crucial to prevent the development of complications. According to 24

February 2024

the World Health Organization (WHO), over 200,000 new cases of leprosy are reported each year globally, with the highest incidence in countries such as India, Brazil and Indonesia. However, the incidence of leprosy has decreased significantly in recent years due to improved diagnosis and treatment. The WHO's goal is to eliminate leprosy as a public health problem, defined as reducing the global prevalence of the disease to less than 1 case per 10,000 people.

Many countries have already achieved this goal, but it still persists in some areas with limited access to healthcare.

It is important to mention that leprosy is not highly contagious and the majority of the population is naturally immune to the disease. The exact pathophysiology of leprosy is not fully understood, but it is believed that various mechanisms are involved in it. M. leprae invasion in the skin and peripheral nerves, where it multiplies and spreads to other parts of the body, causing nerve damage

Clinical Cases in Leprosy

to peripheral nerves leading to muscle weakness and loss of sensation in affected areas can further lead to the development of skin lesions that are characteristic of leprosy. These lesions can become disfiguring if left untreated. The body's immune system reacts to the presence of the bacteria by producing inflammation and immune cells that attempt to destroy the bacteria. In some cases, this immune response can lead to nerve damage and skin lesions, thus describing the pathophysiology of 1,2,3,4 leprosy.

involvement which is considered to be less severe and is often associated with a strong immune response. Whereas lepromatous leprosy is characterized by numerous and widely dispersed skin lesions, as well as severe nerve involvement.

This form is considered to be more severe and is often associated with a weak immune response. Additionally, there are several intermediate forms of leprosy that may have characteristics of both tuberculoid and lepromatous leprosy.

These forms are often referred to as borderline tuberculoid, borderline lepromatous and indeterminate leprosy. Importantly there is a spectrum of disease presentations between these two forms and many patients may have a mixture of both.

Hence accurate classification is important for determining the most appropriate treatment and for predicting the prognosis of the disease.5,6,7 Case 1 A 45 years old patient was presented to our clinic. He was having leprosy patches over body specifically over the back region. After clinical and histopathological examination no evidence of genetic factors were involved. The patient was not on any other medication and did not had any medical history.

The patient has just started with multidrug therapy (MDT). This MDT of leprosy generally involves dose of dapsone, rifampicin and clofazimine. The clinical photos before and after treatment is presented below.

The symptoms of leprosy can vary depending on the type of leprosy a person has and the severity of the disease.

Some common symptoms include Inflammation skin lesions which may be numb, nerve damage that cause muscle weakness, especially in the hands and feet and loss of sensation in the affected areas. Such nerve damage can also occur around eyes which can cause loss of eyebrows and eyelashes.

Skin thickening/ lepromatous nodules can occur in the later stages of leprosy. Overall, the Before treatment pathophysiology of leprosy involves the interaction between the bacterium M. leprae and the host's immune system. It is classified into two main forms, depending on the number and distribution of skin lesions, as well as the severity of nerve involvement which are tuberculoid leprosy and lepromatous leprosy. Tuberculoid leprosy After Treatment is characterized by a small number of well-defined skin Figure 1: Leporsy patches over the back region lesions and minimal nerve February 2024

25

Clinical Cases in Leprosy

Case – 2 In this case report we present a case of a 25-year-old male with a clinical presentation of multiple discolored patches of skin, usually flat, that may be numb and look faded (lighter than the skin around). Skin manifestation of the patient multiple, discrete, poorly-defined borders, irregular and hyperpigmented patches were seen on the back and hand of the patient. No other family members or relatives showed symptom. Skin examination revealed asymmetrical, multiple, discrete, poorly defined borders and hyperpigmented plaques with decreased sensation on his back and hands. Other physical examinations and peripheral nerve findings were unremarkable. At this stage, the provisional diagnosis of the patient's illness was leprosy. The patient was treated with multidrug therapy (MDT) of dapsone, rifampicin and clofazimine. The clinical photos before and after treatment was compared.

Before treatment

After Treatment Figure 2: leporsy patches on hands and the back region Diagnosis Leprosy, also known as Hansen's disease, is a chronic bacterial infection caused by Mycobacterium leprae. Research in molecular biology has helped us understand the genetic basis of leprosy, including the genetics of susceptibility and resistance to infection. Studies on the immune response to M. leprae have helped us understand how the host defense mechanisms are involved in the pathogenesis of leprosy 26

February 2024

and why some individuals are more susceptible to infection.

Research on leprosy has helped improve diagnostic methods, including the development of new diagnostic tools such as serological tests and molecular assays. Studies for development of new and more effective treatment regimens for leprosy, including multi-drug therapy (MDT), identifying effective measures for preventing the spread of leprosy, including vaccination and community education programs has made important contributions to our understanding of this disease and has led to significant advances in the control and elimination of leprosy worldwide. However, ongoing research is needed to better understand the epidemiology, pathogenesis and optimal management of leprosy, as well as to develop new and more effective treatments for this disease. During early stages or presents with atypical symptoms leprosy can be mistaken for other conditions like psoriasis, tinea, vitiligo, tuberculosis, syphilis and lupus erythematosus.

Hence differential diagnosis of leprosy is required, done by a thorough medical history and physical examination, as well as laboratory tests and biopsy of skin lesions. A definitive diagnosis of leprosy can only be made by an experienced physician and a laboratory confirmation. There are two main clinical forms

Clinical Cases in Leprosy

of leprosy: paucibacillary (PB) and multibacillary (MB). Paucibacillary (PB) leprosy is characterized by fewer than five skin lesions and a low bacillary load typically associated with milder symptoms, including hypopigmented patches on the skin and minimal nerve damage. Whereas multibacillary (MB) leprosy is characterized by more than five skin lesions and a high bacillary load typically associated with more severe symptoms, including skin nodules, thickened nerves and muscle weakness. The histopathological and physical examination are important components in the evaluation and diagnosis of leprosy. In the physical examination, assess to the person's skin for lesions and perform a thorough neurological examination to check for nerve damage, muscle weakness, loss of sensation and reflexes in the affected areas.

Histopathologic examination involves a detailed examination of the tissue sample under a microscope to identify the characteristic features of leprosy. This may include the detection of the bacterium (Mycobacterium leprae), the presence of immune cells (macrophages and T-lymphocytes) and the extent of nerve damage.

Additionally, tests such as a skin biopsy or a nerve conduction study, to confirm the diagnosis and determine the type and severity of

leprosy. The biopsy is usually taken from one of the skin lesions and can provide important information about the type of leprosy (tuberculoid or lepromatous) and the stage of the disease. In tuberculoid leprosy, the biopsy may show well-defined, thin skin lesions with a limited number of bacteria. In lepromatous leprosy, the biopsy may show widespread skin involvement and an increased number of bacteria.8,9,10 Treatment The treatment of leprosy is an outpatient treatment, which is basically three first-line drugs: dapsone, rifampicin and clofazimine with a recommended regimen of 6 to 12 months depending on the type and severity of the disease along with combination of two or more antibiotics. It is highly effective and more than 11.2 million patients have received it. Sulfone (diaminodiphenyl sulfone - DDS), also known as dapsone, has mainly a bacteriostatic action, with low bactericidal activity.

It probably acts as an antagonist of the paraaminobenzoic acid (PABA), preventing its utilization in the synthesis of folic acid by M. leprae. It is well-tolerated, with many side effects that, in the majority of cases, do not lead to discontinuation of treatment.

Rifampicin (RMP), a semi synthetic derivative of rifamycin B, has mainly bactericidal action that inhibits the RNA-polymerase

enzyme in the multiplying bacillus. It's believed that the combination of DDS and RMP would prevent the appearance of resistance to both drugs. Clofazimine (CLF) is an iminophenazine dye, with a mild bactericidal and anti-inflammatory action, acting slowly and destroying 99% of the bacteria in approximately five months. Its efficacy is similar to DDS. This association of DDS, RMP and CLF is also known as MDT or polychemotherapy (PCT).

Patients receive rifampicin 600 mg monthly, dapsone 100 mg daily, with clofazimine 300 mg monthly and 50 mg daily added in for patients with multibacillary leprosy. It is essential to complete the full course of antibiotics to ensure that the bacteria are completely eradicated and to prevent the development of antibiotic-resistant strains.

In some cases, other medications and treatments may also be necessary to manage symptoms and prevent complications, such as corticosteroids to reduce inflammation, physiotherapy to maintain joint mobility and reconstructive surgery for severe disfigurement. Patients should continue treatment for the recommended duration, even if symptoms have resolved, to ensure full cure and prevent relapse.11,12 Studies from India show that patients with a very high initial bacterial load have higher relapse rates (four to seven per 100 person years) and February 2024

27

Clinical Cases in Leprosy

these relapses may occur late (averaging five years after treatment). The Indian study compared relapse rates in patients with a very high initial bacterial load either given 24 months' treatment or until slit skin smears were negative; the relapse rate was much higher in the group treated for 24 months and this only emerged after four years of follow up after treatment.

One option is to give such patients the choice of being treated until their skin smears are negative or being kept under regular review. The place of the drug combination rifampicin, ofloxacin and minocycline is also unclear. It was used as a single dose for single skin lesions but in a large study from India was found to be less efficacious than the standard paucibacillarymultiple drug therapy (PBMDT) regimen, given for six months. Monthly rifampicin, ofloxacin and minocycline in combination has been used in both multibacillary and paucibacillary disease, with good clinical responses.

Although the initial response to this new regimen may be good, the critical question is the relapse rate over the following 10 years and this requires careful long term studies before the regimen can be recommended generally.13 Discussion Leprosy can cause a number of complications, depending on the severity of the disease and the extent of nerve involvement. Some common 28

February 2024

complications include nerve damage, skin lesions which can be painful, dry eye, inflammation, blindness, breathing difficulties, complications such as pleural effusions, lung collapse, weakness, numbness and a loss of reflexes. In severe cases, nerve damage can lead to deformities and disabilities, such as clawed hands, drooping eyelids and footdrop whereas skin lesions can cause a scarring. Leprosy can cause social isolation, stigma and depression, which can have a significant impact on mental health. Prevention of leprosy involves reducing the risk of exposure to the bacterium (Mycobacterium leprae) and ensuring prompt treatment of those who develop the disease. Early detection and treatment can reduce the risk of serious complications and long-term disability.

Good hygiene practices community education and creating awareness, regular screening programs in highrisk populations, such as those living in close proximity to leprosy patients, can help identify and treat new cases of leprosy. The Bacillus Calmette-Guérin (BCG) vaccine, which is commonly used to prevent tuberculosis, may also provide some protection against leprosy. All these prevention measures can help reduce the burden of leprosy and improve outcomes for those affected by the disease. Regular follow-up and monitoring with a healthcare provider

are also important to assess the response to treatment and monitor for any adverse effects or complications.14,15 The World Health Organization (WHO) has set a target to eliminate leprosy as a public health problem by 2020, which means reducing the global prevalence rate of leprosy to less than one case per 10,000 people.

However, the target has not yet been met and more efforts are needed to achieve it. New drugs and treatment strategies are needed to improve the management of leprosy, reduce the risk of relapse and minimize adverse effects. Research into the pathogenesis and immunology of leprosy will also help in the development of new therapeutic interventions.

Leprosy remains a highly stigmatized disease and affected individuals often face discrimination and isolation. Addressing this issue requires a multifaceted approach, including education, public awareness campaigns and support for affected communities. Many individuals with leprosy do not have access to health care services, which can lead to late diagnosis and a higher risk of complications.

Improving access to health care, particularly in remote and underdeveloped areas, is essential for the effective management of leprosy.

Leprosy being a major public health concern in many parts of the world the future of leprosy management and control will require a

Clinical Cases in Leprosy

concerted global effort, provide knowledge that can including research, advocacy contribute to the worldwide and effective implementation elimination of leprosy. of existing interventions. 14,15 References Conclusion 1. Lastória, Joel Carlos, and Marilda In conclusion, leprosy is a Aparecida Milanez Morgado de Abreu.

“Leprosy: review of the epidemiological, chronic bacterial infectious clinical, and etiopathogenic aspects disease primarily spread - part 1.” Anais brasileiros de through close and prolonged dermatologia vol. 89,2 (2014): 205-18. contact with an infected doi:10.1590/abd1806-4841.20142450 person. The symptoms can 2. Centers for Disease Control and range from mild skin lesions Prevention , National Center for to severe nerve damage and Emerging and Zoonotic Infectious disability. Early diagnosis and Diseases (NCEZID) , Division of High-Consequence Pathogens and prompt treatment are crucial Pathology (DHCPP) in the management of leprosy.

The recommended treatment 3. Bhandari J, Awais M, Robbins BA, et al. Leprosy. [Updated 2023 Sep 15]. is a combination of antibiotics, In: StatPearls [Internet]. Treasure Island which can be effective in (FL): StatPearls Publishing; 2023 Jan-. eradicating the bacteria and Available from: https://www.ncbi.nlm. preventing the development of nih.gov/books/NBK559307/ complications. However, it is 4.Bonamonte, D., Filoni, A., Verni, P., important to complete the full Romita, P., Angelini, G. (2017). Leprosy. course of antibiotics to ensure In: Bonamonte, D., Angelini, G. (eds) Mycobacterial Skin Infections. Springer, a successful outcome. Other Cham. https://doi.org/10.1007/978-3treatments may be necessary 319-48538-6_5 to manage the complications 5. Franco-Paredes, Carlos et al. “Two of leprosy, such as nerve patients with leprosy and the sudden damage, skin lesions and appearance of inflammation in the skin eye problems that includes and new sensory loss.” PLoS neglected physical therapy, surgery and tropical diseases vol. 3,9 e425. 29 reconstructive procedures. Sep. 2009, doi:10.1371/journal. pntd.0000425 It is a complex disease that requires prompt and effective 6. K. Eichelmann, S.E. González management to prevent the González, J.C. Salas-Alanis, J. Ocampo-Candiani, Leprosy. An Update: development of complications Definition, Pathogenesis, Classification, and achieve the best Diagnosis, and Treatment, Actas outcome. The importance of Dermo-Sifiliográficas (English Edition), healthcare workers having Volume 104, Issue 7, 2013,Pages 554563, ISSN 1578-2190, https://doi. a basic understanding of org/10.1016/j.adengl.2012.03.028. leprosy in order to diagnose, treat and prevent its spread. 7. Lastória JC, Abreu MA. Leprosy: review of the epidemiological, clinical, It highlights the ongoing and etiopathogenic aspects - part challenges in diagnosing and 1. An Bras Dermatol. 2014 Martreating leprosy, including the Apr;89(2):205-18. doi: 10.1590/ PMID: need for further studies on the abd1806-4841.20142450.

24770495; PMCID: PMC4008049. impact of leprosy on mental health and discrimination. 8. Chen KH, Lin CY, Su SB, Chen KT. The goal of this review is to Leprosy: A Review of Epidemiology,

Med. 2022 Jul 4;2022:8652062. doi: 10.1155/2022/8652062. PMID: 35832335; PMCID: PMC9273393.

9. Kumar, B., Narang, T. (2017).

Leprosy. In: Singh, S. (eds) Neglected Tropical Diseases - South Asia.

Neglected Tropical Diseases. Springer, Cham. https://doi.org/10.1007/978-3319-68493-2_6 10. J Gordon Burrow, Keith Rome, Nat Padhiar, chapter 14 - Leprosy and Tropical Diseases, Neale's Disorders of the Foot and Ankle (Ninth Edition), Elsevier, 2020, Pages 384-405, ISBN 9780702062230, https://doi. org/10.1016/B978-0-7020-62230.00014-5.

11. Cruz, Rossilene Conceição da Silva et al. “Leprosy: current situation, clinical and laboratory aspects, treatment history and perspective of the uniform multidrug therapy for all patients.”

Anais brasileiros de dermatologia vol.

92,6 (2017): 761-773. doi:10.1590/ abd1806-4841.20176724 12. Lockwood, Diana N J, and Bhushan Kumar. “Treatment of leprosy.” BMJ (Clinical research ed.) vol. 328,7454 (2004): 1447-8. doi:10.1136/ bmj.328.7454.1447 13. Saunderson, Paul R. “Uniform multidrug therapy for leprosy - time for a rethink?.” The Indian journal of medical research vol. 144,4 (2016): 499-501. doi:10.4103/0971-5916.200884 14. Reinar, Liv Merete et al.

“WITHDRAWN: Interventions for skin changes caused by nerve damage in leprosy.” The Cochrane database of systematic reviews vol. 8,8 CD004833.

1 Aug. 2019, doi:10.1002/14651858.

CD004833.pub4 15. Conlon, Christopher P., and Diana N.J. Lockwood, 'Leprosy (Hansen’s disease)', in John Firth, Christopher Conlon, and Timothy Cox (eds), Oxford Textbook of Medicine, 6 edn (Oxford, 2020; online edn, Oxford Academic, 1 Jan. 2020), https://doi.org/10.1093/ med/9780198746690.003.0132, accessed 6 Dec. 2023.

Clinical Diagnosis, and ManagementTrop

February 2024

29

30

February 2024

RNI No. MAHENG/2010/44622