The Aestheticians Journal March'2024 issue

Platelet-Rich Plasma in Alopecia Areata: A Case Report

Effectiveness of Various Organic Peels – In Skin Rejuvenation and Sensitive Skin Part-I

Treating Acne: A Comprehensive Approach to Preventing Scars

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Published for the period of March - 2024

Achieving Radiant and Rejuvenated Skin

In the pursuit of radiant and rejuvenated skin, skincare professionals recognize the unique challenges faced by individuals with sensitive skin. This feature explores the delicate balance between achieving skin rejuvenation goals and nurturing skin that requires extra care and attention. In our exploration, we delve into the symbiotic relationship between sensitivity, strength and beauty. Expert insights from dermatologists and skincare professionals provide a roadmap for navigating the rejuvenation journey with a focus on preserving and enhancing the natural beauty of sensitive skin.

Our feature champions a gentle approach to skin rejuvenation. We highlight non-invasive procedures, gentle skincare routines, and the use of dermatologist-approved products. This balanced strategy aims to rejuvenate without compromising the delicate nature of sensitive skin. Embark on a journey with real-life case studies and personal stories, showcasing the transformative power of adopting a tailored skincare regimen. These narratives not only resonate but also inspire readers to embrace their unique skin journey, fostering a sense of community and understanding. We emphasize the importance of safety in every rejuvenation endeavor.

Skin rejuvenation for sensitive skin is not just a journey; it's a celebration of diversity and resilience. Dermatologists are the one who providing a comprehensive understanding of rejuvenation practices tailored for sensitive skin. We trust that this feature will be a valuable guide on the path to skin rejuvenation, empowering us to make choices that enhance the beauty while cherishing the delicate nature of the skin.

In this issue we have a articles on Effectiveness of Various Organic Peels –In Skin Rejuvenation and Sensitive Skin, Platelet-Rich Plasma in Alopecia Areata and Treating Acne: A Comprehensive Approach to Preventing Scars.

HOPE YOU HAVE A GREAT READ

Thanks & Cheers

- Dom Daniel Executive Editor & Publisher

Effectiveness of Various Organic Peels – In Skin Rejuvenation and Sensitive Skin Part - I

Dr. Sowmya N Dogiparthi, MD, DVL, FAM

Platelet-Rich Plasma in Alopecia Areata: A Case Report

Dr. Nandita Rai, MBBS, MD

Treating Acne: A Comprehensive Approach to Preventing Scars

Dr. Pramila Kanchan Aswani, MBBS, DVD, FAGE

Venue: Mumbai

Venue: Hotel Ginger, Near Domestic Airport, Vile Parle (East)

Editorial Board

Dr. Sowmya N Dogiparthi

MD DVL, FAM Professor Department of Dermatology

Shri Sathya Sai Medical College and Research Institute (SSSMC & RI), Chennai Consultant - Apollo Hospitals, Chennai Dermipure Dermaclinic, Chennai.

Dr. Nandita Rai

MBBS, MD

Dermatology and Clinical Cosmetology

Cosmetic Dermatologist

West Bengal

Dr. Pramila Kanchan Aswani

MBBS, DVD, FAGE

Consultant Dermatologist & Cosmetologist Santacruz, Mumbai

Advisory Board

Dr. Vinayak Venktesh

Dr. Satish K.M.

Dr. Manjunath Hulmani

Dr. Syed Salahuddin

Dr. Abdul Samad

Dr. Somashekar

Dr. H.B. Ravi

Dr. Rasya K. Dixit

Dr. Sayed Quadri

Dr. Sohandas Shetty

Dr. Shashidhar Talwar

Dr. Archana Gulur

Dr. Ramesh A . C .

Dr. Haritha R.

Dr. Karthik R.

Dr. Chaitra

Dr. Vinayak Venktesh

Dr. Satish K. M.

Dr. Pavan Kumar

Dr. Ashish B. Shetty

Effectiveness of Various Organic Peels –In Skin Rejuvenation and Sensitive Skin Part-I

Dr. Sowmya N Dogiparthi MD, DVL, FAM

Professor

Department of Dermatology

Shri Sathya Sai Medical College and Research Institute (SSSMC & RI), Chennai Consultant - Apollo Hospitals, Chennai Dermipure Dermaclinic, Chennai.

Abstract

Background: The peeling procedure, also known as chemical peeling, is indeed a valuable method for treating aged skin, photoaging, wrinkle skin, acne scars and melasma. Preparing the skin before undergoing a peeling procedure helps to optimize the skin's condition and improve its tolerance to the procedure to ensure the best possible results. A common approach is to apply a mask containing acids to the skin twice a week leading up to the treatment. These acids help exfoliate the skin, remove dead cells, and promote cellular turnover, allowing for better penetration of the peeling agents. After the peeling procedure, proper post-procedure care is essential for the success of the treatment. The skin may be temporarily sensitive, red or irritated and it requires gentle handling and adequate protection. Dermatologists often provide specific instructions for post-peeling care, which may include

avoiding excessive sun exposure, using moisturizers, avoiding harsh skincare products and following a gentle skincare routine. While chemical peeling can yield excellent results, it's important to note that complications can arise, particularly in cases where the procedure is not performed correctly or suitable precautions are not taken. Common complications may include excessive redness, irritation, hyperpigmentation or in rare cases, infection. Hence the use of organic peels is way now beneficial that chemical peels. Dermatologists are trained to recognize and manage these complications and their expertise plays a crucial role in ensuring the best possible outcomes for patients.

Objective: To study the effectiveness of various organic peels in the management of acne vulgaris, seborrhoea and skin rejuvenation for brightness enhancement as basic low

strength peels.

Materials and Method:

Patients above the age of 18 years, who presented with acne vulgaris, seborrhoea and tanned skin were included in the study from March 2022 to December 2022. Total of 60 patients were included in the study with obtaining consent.

Results: Patients were followed up weekly for signs of improvement of texture, hydration, reduction of active skin lesions and even coloration of skin. Majority of the patients in each category showed improvement without adverse effects or aggravation of existing skin condition.

Conclusions: Medi-Facial, as the name suggests, is the new age treatment that combines medicine and facial. They contain Vitamins, Minerals and Antioxidants. It not only imparts an instant glow to the skin but also nourishes it, thereby reducing the effects of ageing without any harmful long-term side effects. They provide longterm nourishment and rejuvenation to your skin.

Introduction

Skin rejuvenation is a popular goal in dermatology, aiming to improve the appearance and texture of the skin while addressing various concerns such as aging, sun damage, acne scars and hyperpigmentation. Organic peels have gained attention as potential treatments for skin rejuvenation due to their perceived natural and potentially milder properties compared to conventional chemical peels. They play an important role in skin rejuvenation and their

suitability for sensitive skin. This article aims to explore the effectiveness of various organic peels for the same. There are different types of peels used for skin rejuvenation e.g. Organic peels which utilizes natural ingredients, such as plant extracts, fruit enzymes and acids, to exfoliate the skin and promote cell turnover, leading to a smoother, brighter complexion. Some commonly used organic peels are derived from fruits like pineapple, papaya and pumpkin, as well as botanical extracts such as licorice, green tea and chamomile. Fruit enzyme peels; some fruits like pineapple or papaya have enzymes, such as bromelain or papain respectively, known for their exfoliating properties. These enzymes help to remove dead skin cells and stimulate cell renewal, resulting in a fresher and more youthful appearance. Such peels are often gentle and well-tolerated, making them suitable for individuals with sensitive skin. Botanical peels; botanical extracts, such as licorice, green tea and chamomile, possess antioxidant, anti-inflammatory properties with a wide range of benefits including reducing redness and irritation, evening out skin tone and improving overall skin texture. These are often considered gentle and safe for sensitive skin. Pumpkin enzyme peels; pumpkin contains natural enzymes and a variety of beneficial vitamins and antioxidants. These peels can help to exfoliate the skin, promote cell turnover, and stimulate collagen production and are often used for skin rejuvenation, targeting

concerns such as fine lines, dullness and uneven skin tone. Another advantage of organic peels often considered is the suitability for sensitive skin individuals which are prone to adverse reactions from stronger chemical peels. Since traditional chemical peels cause skin irritation and require careful assessment and monitoring, organic peels are perceived as mild and less likely to cause adverse reactions. Care has to be taken as even organic peels can vary in strength and individual sensitivities can still occur. Conventional treatments showing adverse effects, after exploration by scientist, can be now replaced with alternative compounds having therapeutic value. Natural products offer potential effective treatment with fewer side effects thus have gained attention of population. Several natural products have been evaluated for their dermatological benefits e.g. manuka honey; has antimicrobial properties is used clinically as a part of medifacials or in low-strength peels for skin rejuvenation. Similarly black olives and citrus extracts are potential antioxidants which are rich in bioactive compounds that provide antioxidant protection, hydration and skin brightening. Pumpkin enzyme extracts contain enzymes, vitamins and antioxidants that can exfoliate dead skin cells, stimulate cell turnover and promote a more radiant complexion which can be used in skinrejuvenation. Even though natural products can offer promising benefits, individual results may vary and as not all

Effectiveness

natural products are suitable for everyone. Hence patch testing or consulting with a dermatologist or skincare professional is recommended before undergoing any peel, especially for those with sensitive skin.1,2,3,4

Some of the common natural peels include:

Manuka honey peel:

Manuka honey derived from the nectar of the Manuka tree in New Zealand and Australian Kaolin Clay, is known for its unique antibacterial, antiinflammatory, detoxifying and wound-healing properties which benefits in skincare, including skin rejuvenation and its suitability for sensitive skin. In skin rejuvenation it works by gently exfoliating the skin, removing dead cells and promoting cell turnover. The enzymes present in Manuka honey help to break down the bonds between dead skin cells, resulting in a smoother and brighter complexion.

Manuka honey also has antioxidants that help to protect the skin against free radicals, reducing oxidative stress and promoting a more youthful appearance. Its antiinflammatory property and soothing effect make it less likely to cause irritation or adverse reactions compared to stronger chemical peels. Usage include application of thin layer of honey to clean face and left on specifically for 20-30 minutes. Afterwards, the honey can be rinsed off with warm water. Regular use of Manuka honey peels can help improve skin texture, tone and overall appearance, giving a rejuvenated and refreshed look. It has to be ensured that the Manuka

honey used for peeling is of high quality and has a sufficient concentration of active compounds. Products that have to be looked on should have a certified UMF (Unique Manuka Factor) rating, which indicates the honey's antibacterial potency.5,6,7,8

Mandelic peel: Mandelic acid is an alpha-hydroxy acid (AHA) derived from bitter almonds and are known for their gentler nature compared to other chemical peels. The cream formulated has silky texture with niacinamide, vitamin E and mandelic acid as ingredients. It has a larger molecular size compared to other AHAs, such as glycolic acid, which allows for slower and more controlled penetration into the skin thus reduces irritation or side effects of skin, making them suitable for sensitive skin types. When used as a peel for skin rejuvenation, mandelic acid exfoliates the skin's surface, promoting the removal of dead skin cells and stimulating cell turnover that helps to improve skin texture, reduce the appearance of fine lines and wrinkles and enhance overall skin tone. It also has antibacterial properties, making it beneficial for individuals with acne-prone skin thus offering a gentle yet effective option for skin rejuvenation, particularly for individuals with sensitive skin. A notable advantage is their ability to target hyperpigmentation and melasma, common concerns in skin with increased sensitivity. Mandelic acid inhibits the production of melanin, the pigment responsible for skin

coloration, helping to reduce the appearance of dark spots and uneven skin tone. These peels are typically available in varying concentrations, allowing for customization based on individual needs and skin tolerances. Lower concentrations are often recommended for sensitive skin, gradually increasing the strength over time as the skin becomes more accustomed to the treatment.9,10,11,12

Citrus peel: Citrus peels contain natural acids, such as citric acid, that have exfoliating properties which are particularly derived from fruits like oranges, lemons and grapefruits, have been used in skincare potentially in skin rejuvenation. These peels are rich in antioxidants, such as vitamin C, that protects the skin from damage caused by free radicals. These acids can remove dead skin cells, promote cell turnover and improve skin texture and tone as well. A caution needed to be considered while using these peels, is to avoid prolonged or excessive contact with skin as high acidity of citrus fruits can potentially cause irritation or sensitization, especially in sensitive skin types. A way to incorporate citrus peels into skincare is by creating a homemade citrus peelinfused toner or mask. Soak citrus peels in water or a mild toner for a certain period and then apply the infused liquid to the skin using a cotton pad. This allows for a milder form of exfoliation and can provide a refreshing and brightening effect. There are also many skincare products available in market that contain citrus peel extracts or derivatives. These

products have undergone specific formulation processes to ensure safety and efficacy. Additionally citrus peels can be quite potent but may not be suitable for individuals with sensitive skin hence patch testing or consulting with a dermatologist or skincare professional has to be done.13,14,15,16,17,18

Black olive peel: Chemical peels or exfoliating treatments involve the use of specific compounds or ingredients with known exfoliating properties, such as alpha-hydroxy acids (AHAs) or beta-hydroxy acids (BHAs). Black olives contain certain beneficial compounds like antioxidants and healthy fats there is no significant scientific evidence to suggest that they are used as a primary component in professional-grade chemical peels for skin rejuvenation. Black olives are commonly used in culinary applications and as a food ingredient, but their use as a primary component in skincare peels is not widely recognized. Natural ingredients like olive oil having moisturizing properties or olive leaf extract having antioxidant and antiinflammatory effects can be used in skincare. However, individual sensitivities can vary hence precautions have to be taken before using them.19,20,21

Materials and Method

Patients above the age of 18 years, who presented with acne vulgaris, seborrhoea and tanned skin were included in the study from March 2022 to December 2022. Total of 60 patients were included in the study with obtaining consent.

Patients above 18 years of age are divided in to the following skin types and type of peel used for each category.

• Combination Skin – Peel of patient’s choice was done

• Dry Skin – Manuka Honey peel, Citrus peel

• Oily Skin- Pumpkin peel, Black olive peel, Mandelic peel

Objective criteria: Include the following skin characteristics: smoothness, firmness, even coloration, normal texture and absence of any clinically evident disease. Grading of each element in the scoring system [minimal (1), average (2), maximal (3)] and subsequently the final score [excellent (12 to 15), average (7 to 11), poor (<7)] are done with reference to the healthy skin model defined.

The above grading is done after the application of various organic peels depending on the skin types. The scoring system is novel and easy to use and can be implemented to help improve communication between physicians and patients as well as during the dissemination of knowledge during medical conferences. Organic peels such as manuka honey peel, black olive peel, pumpkin peel, citrus peel and mandelic peel were used based on skin type of the patient at the interval of 2 weeks once sitting over a period of 2 months.

Results: Before full face peel application; the initial irritation patch test results carried out on the skin of volunteers obtained that: there were no visible side effects in the form

of redness, itching on the skin caused by the preparation of the peels. Patients were followed up weekly for signs of improvement of texture, hydration, for reduction of active skin lesions and even coloration of skin for 3 weeks. The study consisted of 25 male and 35 female volunteers.

The volunteers were subdivided into 20 volunteers for each skin type, i. e 20 for combination skin type, 20 for dry skin, 20 for oily skin.

In the oily skin category; out of 20, 6 patients had black olive peel and 7 each had pumpkin peel and mandelic peel each. Firmness, even coloration and normal texture were comparable among the study groups. Smoothness was comparatively significant among patients with mandelic peel (P value 0.041). There was no clinical evidence of skin disease.

In patients with combination skin type, 4 patients each underwent black olive peel, pumpkin peel, mandelic peel, manuka honey peel and citrus peel. Smoothness, firmness, even coloration and texture was comparable among all the groups with no statistical difference (P value >0.05). One patient with citrus peel had acne after the procedure.

Lastly, among 20 patients with dry skin type, 10 patients had manuka honey peel and 10 patients had citrus peel. Smoothness, firmness, even coloration and texture was comparable among all the groups with no statistical difference (P value >0.05).

40% of dry skin patients

underwent citrus peel had acne which may be due to vitamin C sensitivity of the skin which was statistically significant (P value 0.025). The overall score in current study was showed that the effectiveness of mandelic peel was more when compared with other organic peels which showed significant difference (P value 0.033).

References

1. Farber SE, Epps MT, Brown E, Krochonis J, McConville R, Codner MA. A review of nonsurgical facial rejuvenation. Plastic and Aesthetic Research. 2020; 7: 72. http://dx.doi.org/10.20517/23479264.2020.152

2. Ganceviciene, Ruta et al. “Skin anti-aging strategies.” Dermatoendocrinology vol. 4,3 (2012): 30819. doi:10.4161/derm.22804

3. Rostkowska E, Poleszak E, Wojciechowska K, Dos Santos Szewczyk K. Dermatological Management of Aged Skin. Cosmetics. 2023; 10(2):55. https://doi.org/10.3390/ cosmetics10020055

4. Guthrie et al. Modern Approaches to Skin Care. Facial Plast Surg 2017;33:653–660.DOI https://doi. org/ 10.1055/s-0037-1607448. ISSN 0736-6825.

5. Johnston, Matthew et al. “Antibacterial activity of Manuka honey and its components: An overview.” AIMS microbiology vol. 4,4 655-664. 27 Nov. 2018, doi:10.3934/microbiol.2018.4.655

6. Patel, S., Cichello, S. Manuka honey: an emerging natural food with medicinal use. Nat. Prod. Bioprospect. 3, 121–128 (2013). https://doi.org/10.1007/s13659013-0018-

7. Lu, Jing et al. “The effect of New Zealand kanuka, manuka and clover honeys on bacterial growth dynamics and cellular morphology varies according to the species.” PloS one vol. 8,2 (2013): e55898.

doi:10.1371/journal.pone.0055898

8. Clearwater, M.J., Noe, S.T., Manley-Harris, M., Truman, G.-L., Gardyne, S., Murray, J., ObengDarko, S.A. and Richardson, S.J. (2021), Nectary photosynthesis contributes to the production of mnuka (Leptospermum scoparium) floral nectar. New Phytol, 232: 17031717. https://doi.org/10.1111/ nph.17632

9. Karwal, K.; Mukovozov, I. Topical AHA in Dermatology: Formulations, Mechanisms of Action, Efficacy, and Future Perspectives. Cosmetics 2023, 10, 131. https://doi. org/10.3390/ cosmetics10050131

10. Binu Sowmya Mandelic Acid: Benefits, Uses, Side Effects Of This Wonder Ingredient In Your Skincare Routine. Last updated on:01 Jun 2022.

11. Palmer Angela. Mandelic Acid Skincare Treatments. Updated on August 14, 2022

12. Shivaram S. Mandelic Acid: Learn about the benefits of this gentle chemical exfoliant. November 11.

13. Goyal, N., Jerold, F. Biocosmetics: technological advances and future outlook. Environ Sci Pollut Res 30, 25148–25169 (2023). https://doi. org/10.1007/s11356-021-17567-3

14. Nishala Erandi Wedamulla, Meiqi Fan, Young-Jin Choi, Eun-Kyung Kim.Citrus peel as a renewable bioresource: Transforming waste to food additives,Journal of Functional Foods. Volume 95, 2022, 105163, ISSN 1756-4646, https://doi. org/10.1016/j.jff.2022.105163.

15. Rishi Richa, Deepika Kohli, Dinesh Vishwakarma, Ananya Mishra, Bhumika Kabdal, Anjineyulu Kothakota, Shruti Richa, Ranjna Sirohi, Rohitashw Kumar, Bindu Naik. Citrus fruit: Classification, value addition, nutritional and medicinal values, and relation with pandemic and hidden hunger, Journal of Agriculture and Food Research,Volume 14, 2023, 100718, ISSN 26661543, https://doi.org/10.1016/j.

jafr.2023.100718.

16. Saini, Ramesh Kumar et al. “Bioactive Compounds of Citrus Fruits: A Review of Composition and Health Benefits of Carotenoids, Flavonoids, Limonoids, and Terpenes.” Antioxidants (Basel, Switzerland) vol. 11,2 239. 26 Jan. 2022, doi:10.3390/antiox11020239

17. Hannah Sakile, Medapati Hema Sundar Satish, Chetan Kandapal, Pooja Sanasam and Ishika Bajaj. Citrus peel: An essential source of bioactive compounds and nutraceutical constituents. The Pharma Innovation Journal 2023; 12(6): 01-16

18. Mahato N, Sinha M, Sharma K, Koteswararao R, Cho MH. Modern Extraction and Purification Techniques for Obtaining High Purity Food-Grade Bioactive Compounds and Value-Added Co-Products from Citrus Wastes. Foods. 2019; 8(11):523. https://doi.org/10.3390/ foods8110523

19. Soleymani, Teo et al. “A Practical Approach to Chemical Peels: A Review of Fundamentals and Stepby-step Algorithmic Protocol for Treatment.” The Journal of clinical and aesthetic dermatology vol. 11,8 (2018): 21-28.

20. Kornhauser A, Coelho SG, Hearing VJ. Applications of hydroxy acids: classification, mechanisms, and photoactivity. Clin Cosmet Investig Dermatol. 2010;3:135-142https://doi. org/10.2147/CCID.S9042

21. Singhal Mukul, Khanna Surabhi, Nasa Atul. Cosmeceuticals for The Skin: An Overview. Asian J Pharm Clin Res, Vol 4, Issue 2, 2011, 16.

Note- Part-II will come in April'2024 issue

Effectiveness

Platelet-Rich Plasma in Alopecia Areata: A Case Report

Dr. Nandita Rai

MBBS, MD

Dermatology and Clinical Cosmetology

Cosmetic Dermatologist

West Bengal

Abstract

Hairs has significant role in an individual's self-image and is often related to socialization and cultural norms. Male androgenetic alopecia, commonly known as male pattern baldness, can have psychological consequences for those experiencing it. Numerous studies have indicated that balding individuals, both in Western and Asian cultures, tend to have negative selfperceptions regarding their hair loss which suggests that the psychological impact of MAA is consistent across different cultural backgrounds which can lead to distress and anxiety in the individuals experiencing it. This has resulted an increase in number of men approaching treatment to prevent further hair loss. This has spurred advancement in many context of hair treatment technologies which provides various options such as medications like minoxidil and finasteride, 5-alpha reductase inhibitors stem cell-based therapies, genetic interventions and immunomodulation, PRP

etc. Other current treatment options include laser therapy, scalp microneedling, hair mesotherapy and hair transplantation. The development of new pharmacologic therapies has been slow; however, research is currently being conducted using Janus kinase inhibitors and autologous platelet-rich plasma injections in men with AGA.

Introduction

Androgenetic alopecia is a genetically predetermined disorder characterized by loss of hair on scalp and can effect upto 50 percent of males and females. Male androgenetic alopecia (MAA) most commonly occurs in men, is a progressive loss of terminal hair on the scalp and typically follows a predictable pattern, with the temples, vertex, mid-frontal and frontotemporal regions of scalp being the most affected. This often results in a receding hairline and thinning or balding at the top of the head. In females, the frontal hairline is usually spared, but

there is diffuse hair loss at the vertex and top of the head which may be noticed as wider center with parting of the hair. The evaluation can involve a thorough medical history, physical examination and sometimes additional diagnostic tests such as a pull test or scalp biopsy to confirm the diagnosis and rule out other causes of hair loss. Being considered a minor dermatological condition it can impact on self-image which can be so significant that it can lead to anxiety and depression in some men. There are emerging evidences linking MAA to arterial stiffness and cardiovascular disease, suggesting potential systemic implications beyond its cosmetic aspects. The hereditary nature of MAA is well recognized, with genetic factors accounting for around 80% of the predisposition. In such cases, were individuals are susceptible to MAA, even normal levels of androgens (male hormones) can trigger hair loss in individuals. The key pathophysiological features of MAA involve alterations in the hair cycle, follicular miniaturization and inflammation were the growth phase of the hair follicles (anagen phase) becomes progressively shorter with each cycle, while the resting phase (telogen) remains constant or is prolonged. This eventually leads to the hair follicles producing shorter, thinner hairs that fail to reach the skin's surface, resulting in empty follicular pores. Hair follicle miniaturization, characterized by shrinking follicles, is a histological

hallmark of androgenetic alopecia. Some approved treatment options available are topical minoxidil and oral finasteride (both approved by the U.S. Food and Drug Administration (FDA)) helps to prevent further hair loss, but restricts their ability to reverse baldness, hence continuous use is required to maintain their effects. Topical minoxidil is available as a solution or foam, generally is well-tolerated but initially can accelerate hair loss with minor adverse effects like scalp itching, dandruff, redness etc. Finasteride, an oral medication, works by blocking the enzyme that converts testosterone into dihydrotestosterone (DHT), which is implicated in MAA. It has a good safety profile, with uncommon sexual side effects that usually resolve upon discontinuation. However, reports of permanent sexual adverse effects found on social media and internet forums have not been conclusively established in scientific studies. Other emerging medical treatments include topical antiandrogens, prostaglandin analogues, topical antifungals, growth factors and laser treatments. However, more research is needed to establish their efficacy and safety. Hair transplantation being another option, involves taking hair from the back of the scalp (occipital region) and transplanting it into the balding areas of the vertex and frontal scalp. Modern techniques have greatly improved graft survival rates, with success rates exceeding 90% in

skilled hands. Combination treatment can be preferred to enhance it’s effectiveness. It's important for individuals experiencing MAA to consult with dermatologists or hair restoration specialists or collaboratively work with the interprofessional team who can provide guidance on the available therapeutic options addressing both the medical and psychological aspects of the condition to improve favourable cosmetic outcomes.1,2

Case Report

A 27 years old male was presented to the clinic with the complaint of hairfall since 3 years. He had visited 2-3 dermatologists and was undergoing the treatment of minoxidil and fenestride daily along with a antidandruff shampoo. The medical history revealed both father and mother had dandruff and showed the history of hairfall problems as well. The patient didn't have any habits of smoking or drinking. He has a good balanced diet but has less sleep and excercise. No significant history of allergy is present. Various test were carried out including blood test report of CBC (complete blood count), lipid profile, LFT (Liver function tests), urea, creatinine, FBS (Fasting blood sugar), PPBS (Post Prandial Blood Sugar Test ), hepatitis b and c, HIV which showed clear results with no abnormalities. Platelet-Rich Plasma (PRP) treatment was started in February and was repeated in april with total 2 sessions associated with capixyl rednsyl serum, organic

anti-hair fall shampoo and multivitamin capsules. The improvements were achieved in 3 months of treatment and was having more than 50% of along with lifestyle management.

Before treatment

After 1 session of PRP

After 2 session of PRP

Diagnosis

Androgenetic alopecia commonly affecting male population leads to progressive loss of terminal hairs. It affects up to 50 percent of males and females and hits at any time after puberty. This hair loss shows a predictable pattern, with the front, crown and frontotemporal regions of scalp being the most affected. Since genetic predisposition being major factor for androgenetic alopecia a thorough physical examination and comprehensive medical history and are the most important aspects of diagnosis in patients. The usual diagnosis include examination of the scalp clinically with a wider part or a visible scalp. In some cases, blood tests or a biopsy of the scalp may be needed to look for other causes of hair loss. In both males and females, it is not known how far pattern baldness will progress. Sometimes genetic testing like gene polymorphism based diagnostic test can be done to predict the future chances of development of androgenetic alopecia. This can be useful for young patients who are concerned about hair loss which can help to define the value of early treatment initiation. Hormones also play an important role in AA. A study was assessed of different hormonal levels in MAA and age matched controls measured elevated levels of cortisol and androstenedione in those experiencing MAA. This study further suggests

a broad range of hormones may influence androgenetic alopecia. Even though scalp hair loss and hirsutism are essential features of hyperandrogenism in women, several investigations failed to demonstrate raised androgen levels in women therefore, it is suggested that normal levels of androgens are sufficient to cause hair loss in genetically susceptible individuals.1,2,3,4,5

Treatment

Male androgenetic alopecia or male pattern baldness is a common condition that causes many men to seek medical attention. It is characterized by hair follicles that gradually decrease in size and lead to baldness over time. There are several therapies available for the treatment of this condition, with 5-alpha reductase inhibitors and minoxidil most commonly used. Topical minoxidil and oral finasteride are the only two treatments currently approved by the Food and Drug Administration (USA) for androgenetic alopecia in men. Both of these medications prevent further hair loss and promote hair growth. Dutasteride is another possible treatment for androgenetic alopecia. This drug inhibits type I and type II 5-a reductase isoenzymes and is felt to be more effective than finasteride in inhibiting type II 5-a reductase. Nutraceuticals such as vitamins, omega fatty acids and antioxidants have also been shown to promote hair growth, suggesting a role of these supplements in the management of

Figure 1: PRP for hairloss

MAA. Surgical treatment of androgenetic alopecia has been successfully performed for the past 4 decades, although the cosmetic results are variable. It's recommended to consult with a healthcare professional or a dermatologist before starting any new treatment regimen.1,6,7,8

Other options like plateletrich plasma (PRP) therapy, capixyl, redensyl serum, organic anti-hair fall shampoo and multivitamin capsules are also available that have gained attention for male androgenetic alopecia (MAA). Platelet-rich plasma (PRP) is an autologous preparation of platelets in concentrated plasma that has gained attention for its potential therapeutic benefits. PRP is prepared by centrifuging the patient's blood to separate the platelet-rich plasma from other blood components. The resulting PRP has a higher concentration of platelets compared to whole blood, typically reporting 300700% enrichment. Platelets are rich in various growth factors, such as plateletderived growth factor (PDGF), transforming growth factor (TGF), vascular endothelial growth factor (VEGF), insulinlike growth factor (IGF), epidermal growth factor (EGF) and interleukin (IL)-1. These growth factors play a role in wound healing and tissue regeneration processes. Whereas hypothesis is made that when PRP is injected in scalp the released growth factors from platelets may act on stem cells in the bulge area

of hair follicles. This activation of stem cells could potentially stimulate the development of new hair follicles and promote neovascularization, which may contribute to hair growth. The optimal concentration and preparation methods of PRP for hair loss treatment are not yet well-established.1,9,10,11

Capixyl and Redensyl are two active ingredients commonly found in hair care products that are marketed for the treatment of male androgenetic alopecia (AGA) or male pattern baldness. Capixyl and Redensyl are patented ingredients commonly found in topical hair products like serums, shampoos or hair tonics, which are typically applied directly to the scalp and massaged in to allow absorption into the hair follicles. They are designed to target hair loss and promote hair growth. Capixyl is a combination of two peptides: acetyl tetrapeptide-3 and biomimetic peptide which increases hair density and reduce hair loss by strengthening the hair follicles thus stimulating hair growth and improving hair anchoring. It is believed to work by boosting the extracellular matrix proteins in the scalp and improving cell adhesion. While redensyl is said to activate hair stem cells and improve hair density. It contains a combination of four molecules: dihydroquercetin-glucoside (DHQG), epigallocatechin gallate-glucoside (EGCG2), glycine and zinc. While these ingredients are often marketed as effective solutions for hair loss, the

scientific evidence supporting their efficacy in treating AGA is limited. Organic anti-hair fall shampoos may contain botanical ingredients, vitamins and minerals that are claimed to nourish the scalp and hair follicles, strengthen the hair strands and reduce hair fall thus promoting healthier hair.1,4,7,10,12,13

Using an organic anti-hair fall shampoo can be a part of a comprehensive hair care routine for individuals with male androgenetic alopecia (AGA) or male pattern baldness. While specific shampoos may claim to prevent hair fall or promote hair growth, it's not that a shampoo alone can completely reverse or treat AGA. When selecting an organic anti-hair fall shampoo, it can be helpful to look for ingredients such as: Biotin (vitamin B7) support hair health and promote stronger and thicker hair, Niacin (vitamin B3), help improve blood circulation in the scalp, which may promote healthier hair growth, Saw palmetto extract which is a natural ingredient that is believed to inhibit the production of dihydrotestosterone (DHT), a hormone linked to AGA, aloe vera has soothing and hydrating properties that can help maintain a healthy scalp environment and essential oils such as rosemary, peppermint or lavender, have scalp-stimulating and hairnourishing effects. These shampoos primarily focus on improving the overall health of the hair and scalp, reducing breakage and providing a

nurturing environment for the hair follicles.7,11

Multivitamin capsules are the supplements containing key vitamins and minerals may be recommended to support overall hair health. Adequate intake of nutrients like biotin, vitamin C, vitamin D, vitamin E, Omega-3 fatty acids, zinc and iron is important for healthy hair growth. However, nutrient deficiencies are not always the primary cause of MAA and individual needs should be assessed by a healthcare professional before starting any supplements.1,4,10

Proper consultancy to be taken by doctors as they can evaluate specific nutritional needs, conduct any necessary tests and provide personalized recommendations based on health status and AGA severity. Addressing underlying hormonal factors and genetic predisposition associated with AGA may require additional medical treatments and interventions beyond multivitamins alone.3,7,8,14,15

The effectiveness of these treatments like organic antihair fall shampoo, multi-vitamin capsules, can vary among individuals and results may not be as significant as those achieved through medical treatments like minoxidil or finasteride. It's always advisable to consult with a dermatologist or healthcare professional specializing in hair loss to determine the most suitable treatment plan for specific situation. They can provide personalized

recommendations based on medical history, the severity of hair loss, and other relevant factors.1,10,11

Discussion

Male androgenetic alopecia, also known as male pattern baldness is a progressive condition characterized by the gradual conversion of terminal hairs (thick, pigmented hairs) into vellus hairs (thin, unpigmented hairs), leading to pattern baldness and typically affects the scalp. While some degree of androgendependent hair loss is common in men after puberty, the prevalence of significant balding increases with age. Twin studies have confirmed that genetic factors play a major role in the development of MAA. Observational studies in eunuchs, who lack male sex hormones, have further established the androgen-dependent nature of this condition. The morbidity of MAA is primarily psychological, as the impact on self-image and self-esteem can be significant. It's worth noting that MAA is associated with a slightly increased risk of melanoma and nonmelanoma skin cancer on the scalp. Additionally, some studies have reported associations between MAA and cardiovascular conditions such as myocardial infarction, hypertension and hypercholesterolemia, although more research is needed to establish the nature of these associations. Currently, only the FDAapproved treatments for MAA are topical minoxidil and finasteride, which is a 5 alpha

reductase type II inhibitor. Both medications can slow down the progression of hair loss and stimulate partial regrowth of hair. Dutasteride, a dual 5 alpha reductase type I and II inhibitor, has shown promising results in phase II trials, but limited phase III trial data are available. Hair transplantation is also a widely practiced option for treating MAA, as it takes advantage of the fact that hair follicles from the back of the scalp (donor area) are relatively resistant to the effects of androgens. Hair loss can have a significant impact on an individual's psychological well-being, leading to distress, low self-esteem, and even depression. The available treatment options for androgenic alopecia, such as topical minoxidil and oral finasteride, have limitations and potential side effects. Topical medication minoxidil has side effects such as headaches and increased hair growth in other areas of the body whereas oral finasteride inhibits the enzyme responsible for converting testosterone to its active form, may have side effects like loss of libido. Hence it is also contraindicated in pregnant women due to the potential risk of fetal genital development abnormalities. Platelet-rich plasma (PRP) has gained attention in various medical fields, including plastic surgery, orthopedic surgery and cardiac surgery, for its potential regenerative effects. The growth factors present in PRP can activate the proliferative phase and transdifferentiation of hair and

stem cells, potentially leading to the development of new follicular units. Basic fibroblast growth factor (bFGF) is one of the growth factors found in PRP and has been reported to promote the proliferation of papilla cells, which play a role in elongating the hair shaft. There is a ongoing research of pathophysiology and genetic basis of MAA as well as the role of androgens, may lead to the discovery of additional treatments for androgenetic alopecia in the future. Such insights can potentially offer new avenues for managing this common condition and improving outcomes for individuals experiencing hair loss.1,9

Conclusion

Male androgenetic alopecia is a condition that causes distress and is undesirable for many men, particularly as they age. This has resulted, an increase in number of men approaching treatments to prevent further hair loss and potentially reverse the process thus has spurred research and advancements in the field of hair biology. The hair follicle itself is a complex biological organ and the understanding of the changes that occur in hair follicles leading to baldness has attracted the attention of various scientific disciplines, including stem cell scientists, geneticists, developmental biologists, and immunologists. From FDA-approved medications like minoxidil and finasteride to emerging treatments such as stem cell-based therapies, genetic interventions and immunomodulation, there is a growing array of possibilities

to address hair loss. The increased understanding of the biology of hair follicles and the development of innovative treatment leads the new insights into the underlying mechanisms of hair loss and potential therapeutic approaches to prevent and potentially reverse hair loss. PRP injection for androgenic alopecia is gaining attention as a potential treatment option for hair loss as it is simple, cost-effective and feasible even though supporting clinical evidence is limited. PRP has a good safety profile, as it utilizes the patient's own blood components, reducing the risk of adverse reactions. Although the scientific basis for using PRP in hair restoration is promising, further research is needed to establish its efficacy and optimal protocols. It is important to manage expectations and understand that individual results may vary. However, due to its safety profile and relatively low cost compared to other hair restoration treatments, PRP can be considered a valuable adjuvant treatment modality for androgenic alopecia.

References

1. Asfour L, Cranwell W, Sinclair R. Male Androgenetic Alopecia. [Updated 2023 Jan 25]. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000. Available from: https://www.ncbi.nlm.nih. gov/books/NBK278957/

2. Ho CH, Sood T, Zito PM. Androgenetic Alopecia. [Updated 2022 Oct 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK430924/

3. Schmidt JB. Hormonal basis of male and female androgenic alopecia: clinical relevance. Skin Pharmacol. 1994;7(1-2):6166. doi:10.1159/000211275

4. Narad, Smita et al. “Hormonal profile in Indian men with premature androgenetic

alopecia.” International journal of trichology vol. 5,2 (2013): 69-72. doi:10.4103/09747753.122961

5. Stevens, J, and S Khetarpal. “Platelet-rich plasma for androgenetic alopecia: A review of the literature and proposed treatment protocol.” International journal of women's dermatology vol. 5,1 46-51. 21 Sep. 2018, doi:10.1016/j.ijwd.2018.08.004

6. Ring, Christina et al. “Nutraceuticals for Androgenetic Alopecia.” The Journal of clinical and aesthetic dermatology vol. 15,3 (2022): 26-29.

7. Deepani Rathnayake & Rodney Sinclair (2010) Male androgenetic alopecia, Expert Opinion on Pharmacotherapy, 11:8, 12951304, DOI: 10.1517/14656561003752730

8. Almohanna, Hind M et al. “The Role of Vitamins and Minerals in Hair Loss: A Review.” Dermatology and therapy vol. 9,1 (2019): 51-70. doi:10.1007/s13555-0180278-6

9. Khatu, Swapna S et al. “Platelet-rich plasma in androgenic alopecia: myth or an effective tool.” Journal of cutaneous and aesthetic surgery vol. 7,2 (2014): 107-10. doi:10.4103/0974-2077.138352

10. Nestor, Mark S et al. “Treatment options for androgenetic alopecia: Efficacy, side effects, compliance, financial considerations, and ethics.” Journal of cosmetic dermatology vol. 20,12 (2021): 3759-3781. doi:10.1111/ jocd.14537

11. Lalwala B, Das S, Murthy S, Saraswat A, Dhanalakshmi UR, Girdhar M et al. Expert opinion on current and emerging treatment options in androgenetic alopecia and telogen effluvium: an Indian perspective Int J Res Dermatol. 2022;8:152-60.

12. Karaca, Nezih and Nebahat Demet Akpolat. “A Comparative Study between Topical 5 % Minoxidil and Topical “ Redensyl , Capixyl , and Procapil ” Combination in Men with Androgenetic Alopecia.” (2019).

13. Katoulis AC, Liakou AI, Koumaki D, et al. A randomized, single-blinded, vehiclecontrolled study of a topical active blend in the treatment of androgenetic alopecia. Dermatol Ther. 2020;33(4):e13734. doi:10.1111/dth.13734

14. Kondrakhina, I.N., Verbenko, D.A., Zatevalov, A.M. et al. A Cross-sectional Study of Plasma Trace Elements and Vitamins Content in Androgenetic Alopecia in Men. Biol Trace Elem Res 199, 3232–3241 (2021). https://doi.org/10.1007/s12011020-02468-2

15. Sarita Sanke etal, Study of serum vitamin D levels in men with premature androgenetic alopecia, Volume59, Issue9 Pages 11131116 September 2020 , https://doi. org/10.1111/ijd.14982

Treating Acne: A Comprehensive Approach to Preventing Scars

Dr. Pramila Kanchan Aswani

MBBS, DVD, FAGE

Consultant Dermatologist & Cosmetologist

Santacruz, Mumbai

Introduction

Acne is a common skin condition now a days, as a dermatologist, our role is crucial in providing effective treatment options to patients and preventing the development of acne scars. This article will outline a comprehensive approach to treating acne, including proper assessment, counselling, topical creams, oral medications and other preventive measures. Acne is a condition that affects individuals of all ages and can lead to complications such as scarring and pigmentary issues, which can affect a significant number of patients. Acne scars often manifest as depressed or indented scars and are more commonly associated with severe grades of acne. Pigmentary complications resulting from acne are most common concerns for all patients, regardless of their skin color. Generally people with dark skin tone have a higher risk

of developing pigmentary complications, such as postacne hyperpigmentation (PIH) where inflammation plays a crucial role. When evaluating patients with acne, it is crucial to consider this higher risk of pigmentary complications in individuals with darker skin colors. Such complications can be more distressing for patients than the acne itself. Hyperpigmentation can occur even in cases of mild to moderate acne, where inflammation may be less severe. This suggests that other factors might also be involved however the exact etiology including their specific roles and mechanisms are not known yet.1 There are 4 grades of acne, Grade 1 being mild shows presence of whiteheads and blackheads, with a few papules and pustules. Grade 2 is a moderate or pustular acne with multiple papules and pustules, mostly on your face. Grade 3 with pigmentation

represents a moderately severe or nodulocystic acne characterized by the presence of inflammatory lesions, such as papules, pustules and nodules, along with the additional complication of post-acne hyperpigmentation. The number of such acne lesions is increased compared to milder forms of acne whereas they can be painful, red and often result in scarring or PIH. Post-acne hyperpigmentation (PAH) results to the darkening or discoloration of the skin that occurs after the inflammation and leaves behind pigmented marks or spots which fade on it’s own within weeks or even months, while can also persist for a prolonged period of time.1,2,3,4,5

PIH is more commonly observed in individuals with Fitzpatrick skin types III-VI, which include people with darker skin tones. Dermal hyperpigmentation, which occurs deeper in the skin, can take several years to fully fade back to normal. Clinically few weeks after erythema (redness) from the acne subsides, PIH becomes apparent and manifests as dark spots or patches on the skin in the areas where acne lesions previously occurred. On the other hand, the epidermal variant, which affects the upper layers of the skin, may resolve within 6-9 months. Treatment for

PIH can be challenging as not all therapeutic options yield satisfactory results. However, there are several approaches that may help improve the appearance of PIH but the effectiveness of these modalities can vary depending on the individual and the specific characteristics of their PIH. Managing it requires a combination of treatment approaches and patience, as the process of fading pigmentation can take time.3 The diagnosis of acne involves a thorough evaluation of the patient's skin condition, including the type and severity of the acne lesions. Initially a detailed medical history, including information about the onset of acne, previous treatments, family history and any factors that may aggravate or improve the acne condition should be obtained. Further physical examination of skin to be conducted to assess the type, severity of acne lesions and will examine the distribution of lesions, their size and the presence of any scarring or PIH. The lesions then has to be categorized as different types, such as comedones (open or closed), papules, pustules and nodules which will nextly be graded by using the grading system, such as the Global Acne Grading System (GAGS) or the Pillsbury scale, to assess the severity of acne. By differential diagnosis the

dermatologist can rule out other skin conditions that may resemble acne, such as folliculitis, rosacea or druginduced eruptions which ensures accurate diagnosis and appropriate treatment plan. The treatment may include topical medications, oral medications or combination therapies to address the inflammatory lesions, prevent scarring and manage associated complications of PIH.6,7,8,9,10

Case Report

A patient, 13 years old was presented to our clinic with acne problems. After thorough examination the diagnosis concluded having grade 3 of acne with pigmentation. When gone through medical history, it suggested that the cause was due to age related and exam stress problems. No other medications or medical conditions were present. The treatment given was of oral and topical medications with included Nadifloxacin gel at daytime, oral Doxycycline short course for 20 days initially for acute phase along with Isotretinoin 20 mg daily, tapped to 5 mg daily then pluse therapy twice a week - treatment over 3-4 months. After 4 months of treatment the result were seen and the patient was satisfied by the treatment. The clinical pictures before and after treatment seen are as follows:

Before treatment

After treatment

Diagnosis

Thorough Assessment:

The first step in treating acne is to conduct a thorough assessment of the patient's skin. This involves evaluating the type and severity of acne lesions, identifying any underlying causes or contributing factors and assessing the patient's medical history. A detailed assessment allows you to tailor the treatment plan to the individual patient's needs.1,11

Treatment

The treatment approach for grade 3 acne with pigmentation aims to address both the inflammatory acne lesions and the associated post-inflammatory hyper pigmentation.

Topical Treatments:

Topical treatments play a crucial role in acne management. Depending on the patient's specific needs, you may prescribe creams or gels containing ingredients such as benzoyl peroxide, retinoids, salicylic acid or antibiotics. These medications target different aspects of acne, including bacteria, inflammation and clogged pores and prevent the formation of new acne lesions. Nadifloxacin is an antibiotic primarily indicated for the treatment of bacterial infections is commonly used as a topical treatment for acne. It belongs to the fluoroq uinolone class of antibiotics and has both antibacterial and anti-inflammatory properties. Antibacterial activity helps

to reduce the population of Propioni bacterium acnes that prevent new acne lesions from forming and control the inflammatory response. Whereas antiinflammatory properties reduce the redness, swelling and discomfort associated with inflamed acne lesions. It also shows adjunctive effect by resolving the acne lesions, indirectly contributing to the improvement of pigmentation over time. The use of nadifloxacin for acne treatment, including grade 3 acne with pigmentation, should be done under the guidance of a healthcare professional, typically a dermatologist to assess the specific condition, evaluate the severity of the acne and consider the presence of

Figure 1: Acne with pigmentation

pigmentation to determine the most appropriate treatment approach. Sometimes it can also be used in combination with other topical medications, such as retinoids or benzoyl peroxide, to enhance the overall effectiveness of the treatment. Additionally complementary therapies such as chemical peels or laser treatments are also recommended to address the pigmentation aspect of the condition. The study having a randomized controlled trial, aimed to evaluate the clinical effectiveness and safety of topical nadifloxacin in comparison to clindamycin (commonly used antibiotic for acne treatment) both in combination with benzoyl peroxide was done to provide comparable results in terms of acne improvement while ensuring safety and tolerability so as it can be a potential alternative to the standard regimen of clindamycin and benzoyl peroxide. The results of this trial could provide valuable insights into the efficacy and safety profile of nadifloxacin and benzoyl peroxide combination therapy, helping clinicians make informed decisions when choosing treatment options for patients with acne. The effectiveness, safety, and tolerability of nadifloxacin 1% cream for the treatment of mild to moderate acne vulgaris in Korean patients have been demonstrated in studies were positive clinical outcomes in improving acne symptoms and has been welltolerated by patients. Even histo pathological changes observed after nadifloxacin

treatment have been found to correlate well with the clinical improvement seen in patients that suggests clinical outcomes are supported by favourable changes in the underlying skin pathology.12,13,14

Oral Medications:

In moderate to severe cases of acne, oral medications may be necessary. Oral medications like a Antibiotics eg. doxycycline or minocycline can help control bacterial overgrowth and inflammation. For hormonal acne in females, oral contraceptives, spiron olactone or antiandrogen medications can be prescribed. Isotretinoin, a potent oral retinoid, is reserved for severe, treatment-resistant acne.

Oral doxycycline (tetracycline class of antibiotic) is a commonly prescribed antibiotic for the treatment of acne, including grade 3 acne with pigmentation and is known for its anti-inflammatory and antibacterial activity same as that of nadifloxacin thus preventing the formation of new acne lesions and control inflammation, improving the overall appearance of the skin and reducing pigmentation. Doxycycline also regulates sebum production which can be elevated in acne-prone skin thus can help prevent clogged pores and the formation of new acne lesions. Doxycycline is usually prescribed as a short-term treatment, typically for a few months and may be combined with topical medications or also with adjunctive treatments for pigmentation, such as

topical retinoids, chemical peels or laser therapies for enhanced efficacy to address the pigmentation aspect of the condition. The safety parameter explains that usually it is well-tolerated by most patients, however it may cause side effects in some individuals, such as gastrointestinal symptoms (nausea, diarrheoa), photosensitivity (increased sensitivity to sunlight) and rarely, allergic reactions. Whereas precautions has to be taken for pregnant women, children under the age of 8, individuals with certain liver or kidney conditions, and those with a history of hypersensitivity to tetracycline antibiotics as it can interact with these medications. The mechanism of action works by inhibiting bacterial protein synthesis, specifically targeting the 30S ribosomal subunit of bacteria thus which prevents the growth and replication of Propioni bacterium acnes, leading to a reduction in acne-causing bacteria.14,15,16

Isotretinoin, is a systemic medication that is commonly used for the treatment of severe acne, including grade 3 acne with pigmentation and is a potent oral retinoid derived from vitamin A highly effective in managing severe acne that has not responded to other treatments. It has the potential to induce longlasting remission or even cure acne in many cases.

Isotretinoin is taken orally in the form of capsules were the dosage regime is determined by the healthcare

professional based on various factors, including the severity of acne, individual response and potential side effects. It is particularly effective in managing severe nodular or cystic acne, including grade 3 acne and is often reserved for cases where other treatments have been unsuccessful or insufficient. Isotroin positively work on post- inflammatory hyper pigmentation (PIH) thus reducing inflammation and improving overall skin health fading pigmentation over time. Certain precautions has to be taken as it is highly teratogenic i.e if taken during pregnancy can cause severe birth defects hence use of reliable contraception, are necessary to prevent pregnancy while taking Isotretinoin. Isotretinoin can have various side effects, including dryness of the skin, lips and eyes, increased sensitivity to sunlight, muscle and joint discomfort, elevated liver enzymes and in rare cases, mood changes or depression. Hence regular monitoring and follow-up visits with the prescribing healthcare professional are crucial to monitor treatment progress, assess side effects and ensure patient safety. Thus isotretinoin treatment requires careful consideration of the individual's medical history, potential risks and benefits. 17,18,19,20,21,22,23,24

Mechanism of action includes decrease in sebum production by reducing the size and activity of the sebaceous glands in the skin thus helps to prevent the clogging of hair follicles and the formation of comedones (blackheads

and whiteheads). It also decreases the production of pro-inflammatory substances and inhibits the migration of inflammatory cells to the skin thus giving anti-inflammatory effect. Additionally it normalizes the process of keratinization, which is the natural shedding of dead skin cells and reduces the formation of abnormal keratinocytes within the hair follicles, which can contribute to the development of acne lesions. The exact mechanism still being unknown, it is predicted that it directly affects the metabolic activity of keratinocytes, which are the cells responsible for producing keratin. It also exhibit antimicrobial activity by indirectly affecting the colonization of Propioni bacterium acnes, dramatically reducing sebum excretion rate (SER) and decreasing the size of the pilosebaceous duct, however it is considered to have a secondary role in acne treatment. The significant reduction in the population of P. acnes, with a reported logarithmic reduction of approximately 3 (log3). This level of suppression is greater than that typically observed with oral and topical antibiotics, which are commonly used to target P. acnes.25,26

Isotretinoin shares similarities with tretinoin (all-trans retinoic acid), it differs in its ability to bind to cellular retinol-binding proteins or retinoic acid nuclear receptors (RARs and RXRs). Instead, isotretinoin is thought to act as a prodrug, undergoing intracellular

conversion to metabolites that serve as agonists for RAR and RXR nuclear receptors. These receptors play a role in regulating gene expression and cellular differentiation. It may have effects on host defense mechanisms and modify monocyte chemotaxis, which can contribute to its anti-inflammatory effects, enhancing the body's ability to fight against inflammation. The significant reduction in the population of P. acnes also plays a role in reducing acnerelated inflammation.17,27

In-office Procedures:

Certain in-office procedures can complement the treatment plan and help prevent scarring. These procedures may include chemical peels, microdermabrasion, corticosteroid injections for cystic acne, or lightbased therapies like photodynamic therapy (PDT) or laser treatments. These interventions can help improve acne, reduce inflammation, and minimize the risk of scarring.

Chemical peels, especially those containing alphahydroxy acids (AHAs) or betahydroxy acids (BHAs), can help exfoliate the skin, reduce pigmentation, and improve the overall appearance of the skin. Certain laser treatments, such as fractional laser resurfacing or intense pulsed light (IPL), can target both the acne lesions and the post-inflammatory hyper pigmentation which can stimulate collagen production, reduce inflammation and lighten pigmented areas.

Treating

Micro needling, also known as collagen induction therapy, involves creating controlled micro-injuries in the skin to stimulate collagen production and promote skin rejuvenation. It can improve acne scars and help in reducing pigmentation. In some cases, dermal fillers may be used to fill in depressed acne scars, helping to even out the skin's texture and improve its appearance. Combination therapies to address both the acne and the associated pigmentation can include a combination of topical medications, procedural interventions (e.g., chemical peels, lasers) and possibly oral medications, tailored to the individual's needs.2,4,28

Lifestyle Modifications:

Encourage patients to adopt healthy lifestyle habits that can support acne treatment. Emphasize the importance of a balanced diet, regular exercise, stress management, and adequate sleep. Although lifestyle changes alone may not cure acne, they can contribute to overall skin health and treatment effectiveness.

Follow-up and Maintenance:

Regular follow -up appointments are crucial for monitoring the patient's progress, adjusting treatment if necessary, and addressing any concerns. Once the acne is under control, a maintenance plan should be established to prevent future flare-ups. Maintenance may involve continued use of topical treatments or a personalized skincare routine.

The treatment plans may vary depending on the patient's specific condition and response to treatment. Good skincare habits such as gentle cleansing, avoiding picking or squeezing acne lesions, and using sunscreen can help optimize treatment outcomes and prevent further pigmentation issues. Regular follow-up visits with a dermatologist are crucial to monitor progress and make any necessary adjustments to the treatment plan.29,30

Discussion

The pathogenesis of acne is multi factorial, involving various factors. Sebum secretion from sebaceous glands being the centre player, cause sebum secretion, attributing the abundance of acne lesions in such areas. Additionally inflammation in acne pathogenesis is crucial as it is always present at the microscopic level even if clinically it is not seen. Propioni bacterium acnes contributes to inflammation within the pilose baceous unit (PSU), which consists of the hair follicle and the sebaceous gland. The activation of the inflame masome leads to the release of inflammatory mediators, such as IL-1 beta. This, in turn, activates TH17 cells, which are a type of T-helper cell involved in the inflammatory response. The interplay between sebum production, the presence of Propioni bacterium acnes and inflammation sets the stage for acne development. These factors contribute to the formation of comedones, the development of inflammatory papules, pustules, nodules and ultimately the pathogenesis

of acne. Topical medications containing retinoids, benzoyl peroxide or azelaic acid, oral medications such as antibiotics or hormonal agents can be effective in reducing inflammation and promoting the resolution of acne. Various treatment modalities like chemical peels, which involve the application of specific acids to exfoliate the skin, can help to lighten pigmented areas and promote a more even skin tone. Laser and light-based therapies, such as fractional laser resurfacing or intense pulsed light (IPL), can target the pigmentation and stimulate skin rejuvenation. Microneedling, with or without the addition of topical serums, can also improve the appearance of pigmented areas and acne scars. Dermatologists may recommend a combination of topical medications, procedural interventions, and possibly oral medications, depending on the individual's specific needs which can yield better results. Moreover patient education in the management of grade 3 acne with pigmentation also plays a crucial role as they should be educated about the importance of adhering to the prescribed treatment regimen, avoiding picking or squeezing acne lesions and using sunscreen to prevent further pigmentation issues and protect the skin from sun damage. The treatment options for acne should be tailored to the individual patient, taking into account their preferences, tolerability and any specific considerations such as pregnancy or lactation as limited data is available on the safety of various therapies. During pregnancy, certain

medications commonly used for acne treatment, such as oral retinoids (isotretinoin) and tetracycline antibiotics, are contraindicated due to potential risks to the fetus.

Topical treatments containing ingredients like benzoyl peroxide or azelaic acid may be considered as safer alternatives, but it is essential to consult with a healthcare provider for appropriate recommendations based on individual circumstances. Similarly, during lactation, it is important to consider the safety of medications that could potentially be transferred to the infant through breast milk. Some topical treatments, such as benzoyl peroxide and certain antibiotics (e.g., erythromycin), may be considered safe to use during this period. However, it is advised to consult with a healthcare provider to determine the most appropriate options and ensure the well-being of both the mother and the baby. Research and development of novel agents for acne treatment are ongoing, which can offer additional therapeutic options in the future. It is essential for clinicians to stay updated on the latest advancements in acne management to provide the best care possible for their patients. 25,31,32,33,

Conclusion

As a dermatologist, my role in treating acne extends beyond simply prescribing medications. By implementing a comprehensive approach that includes proper assessment, patient counselling, topical and oral treatments, inoffice procedures, lifestyle modifications and long-

term maintenance, we can effectively manage acne and minimize the risk of scarring. I do my best to tailor the treatment plan for each of my patient's unique needs and provide ongoing support throughout their acne journey. There are several risk factors that contribute to the development of PAH that includes inflammation, dark skin color (particularly in females), severe facial acne, excessive sunlight exposure and lesion trauma. The first step in treating acne is to conduct a thorough assessment of the patient's skin. This involves evaluating the type and severity of acne lesions, identifying any underlying causes or contributing factors and assessing the patient's medical history. A detailed assessment allows you to tailor the treatment plan to the individual patient's needs. Proper counselling and patient education like explaining them the nature of acne, its causes and dispel any misconceptions providing them a proper skincare routines, including gentle cleansing, avoiding harsh products, and the importance of not picking or squeezing acne lesions, the need for patience etc as acne treatments often take time to show results has to be done. Furthermore, the use of an artificial neural network (ANN) as a predictive tool for PAH is indeed valuable in dermatology practice. ANN can assist in predicting the likelihood of developing PAH based on the identified risk factors. The incorporation of ANN in dermatology practice can enhance diagnostic capabilities and improve patient care by providing

additional insights into the prognosis and potential outcomes of PAH. This predictive tool can aid in early intervention and appropriate management strategies, leading to more effective treatment and improved patient outcomes. Considering the treatment, individual patient factors, including preferences, tolerability and any specific circumstances such as pregnancy or lactation should be understood and then appropriate treatment option to be selected. People with allergies or sensitivities should share such things with healthcare provider before starting treatment as drugdrug interactions can be resulted.

References

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2. Tan, A U et al. “A review of diagnosis and treatment of acne in adult female patients.” International journal of women's dermatology vol. 4,2 56-71. 23 Dec. 2017, doi:10.1016/j. ijwd.2017.10.006

3. Fox, L.; Csongradi, C.; Aucamp, M.; Du Plessis, J.; Gerber, M. Treatment Modalities for Acne. Molecules 2016, 21, 1063. https:// doi.org/10.3390/molecules21081063

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