The Aestheticians journal January'24 issue

Total Pages : 36 January 2024 Vol 17* Issue - 1 100

Q-switched Lasers Treatment for Unilateral Freckles: A Case Presentation Dermatofibrosarcoma Protruberans (DFSP): A Rare Fibrous Tumor –Where Recurrence is a Rule than Exception Oral Isotretinoin for Acne Grade 4: A Case Presentation

Androgenetic Alopecia Role of Early Interventions

Dry Skin and Moisturizer 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

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Dry skin is a common condition that is attributed to a lack of water in the stratum corneum. Dry skin and moisturization are important topics because they impact the lives of many individuals. For most individuals, dry skin is not a notable concern and can be adequately managed with current moisturizing products. However, dry skin can affect the quality of life of some individuals because of the challenges of either harsh environmental conditions or impaired stratum corneum dry skin protection processes resulting from various common skin diseases.

Dry skin during winter is a common issue for many people due to the cold and dry air. The combination of low temperatures outside and heated indoor environments can strip our skin of its natural moisture, leading to dryness, flakiness and discomfort. Dry skin protection processes of the stratum corneum, such as the development of natural moisturizing factor (NMF), are complex, carefully balanced and easily perturbed.

Dry and damaged skin needs moisture replenishment. It is best to keep a skin care regimen as simple as possible when treating dry skin. A simple regimen avoids overloading the skin with unnecessary products, such as toners, serums and heavy makeup. Using a moisturizer is the best way to rehydrate the epidermis and prevent water loss from the skin. Thick, greasy moisturizers without perfumes are generally the best option.

Thinner gels, lotions and creams can cause stinging when a person uses them on irritated skin. Moisturizers containing emollients, which include linoleic and lauric acids, can help smooth the surface of the skin. They fill the spaces between skin cells where there has been a loss of moisture.

In this issue we have clinical articles on Dermatofibrosarcoma Protruberans, Oral Isotretinoin for Acne Grade 4, Ear Lobe Repair with Punch Excision Technique and Androgenetic Alopecia.

HOPE YOU HAVE A GREAT READ

Published for the period of January - 2024

Thanks & Cheers

- Dom Daniel Executive Editor & Publisher

Q-switc

hed Lasers

Treatme

Q-switc hed La Unilater sers Treatm A Case al Freckles: ent for Presenta tion Dr. nt for Unilater

al Freckles

: A Case

08

Presenta

tion

Deepti Sax

MBBS,

Q-switched Lasers Treatment for Unilateral Freckles: A Case Presentation Dr. Deepti Saxena, MBBS, DNB, (Dermatology & Venereology), M. Derm, PGDHA

DNB (Derm ena

Consultan atology & Vene t Dermatolo Director gist & Aesth reology), M. of Skin Derm, PGD etician and Ches Ghaziabad HA t Clinic, Laser & Aesthetic Centre

08 8 January

2024

Introduct ion Unilateral unilateral freckles, know n as specific lentiginosis, freckles are type of or dark disorder pigmentat the exact etiolo spots. ion The gy being presence characterized unknown, by the some possible spots localiof freckles factors or dark genetic zed to area or predispos like post -infla a partic ular ition, mma common side of body , unlike hyperpigmentat tory. ....... .... freckles evenly distributed which are neurocutaneousion (PIH) and appear can predi and disorders on most commboth sides can and effec ct the diagnosis . tive sun-expos only appe They Unila teral frecktreatment for ar on ed it. areas face, neck like the genetic comp les may have a body and , arms and legs of can run in onent, as they families. as small are usually genetic prese , that vary dark spots or patch nt in gene mutations or Certain variations of colou in size and inten es produ s involved in ction r. mela and regul nin harmless They are gene sity may contr rally any medi and do not developm ibute to ation caus the but can cal complicatio e In PIH ent of these the inflam freckles. appearancimpact on perso ns, injury mation to the e and n’s or The pigmentat self-esteem. from burns skin, such as , infect results trauma, ion due ions or production to increase often as mela can develop of mela in the overp nin in such freckles pigment roduc areas is responsible nin (the colour skin’s healined as a for of our g proce part of skin, hair the neuro eyes), ss. Some cutan which and radiation abso as neuro eous disor from the rbs UV helps 1 (NF1) fibromatosis ders, sun prote or McC type its harm ct the skin and synd une-Albrigh rome from by certa ful effects. t can unilateral , Trigg develop in facto overproduc rs result er characteris freckles as tion in tic a and leads feature involves of mela to the as it formation nin that affecgenetic muta tions of and t both nervous the skin system.

A rare

Dermato

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Dermat of (DFSP) ibrosarcoma :A Pr Where Rare Fibrou otruberans s Tum Recurr than Ex ence is a Ruleor – ception rans (DFSP):

16

Fibrous

Tumor

–Where

Recurre

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Dermatofibrosarcoma Protruberans (DFSP): A Rare Fibrous Tumor –Where Recurrence is a Rule than Exception

Dr. Rupa

Mavani MBBS, Adatia DVD Dermatolo gist Skin Welln ess Clini c, Nagp ur, Maha rasht

ra

Dr. Rupa Mavani Adatia, MBBS, DVD

16 16 January

22

A Rare

2024

Introduct ion Dermatofib protuberan rosarcoma ..........

Later soft tissue s (DFSP) is a rare enlar in the cours tumour affecting e it may ge and primarily and ulcer become subcutane the dermis nodu cases muscous fat and in and seen due ate. Ignorance lar It typica le and fascia some the tumo to indolent natur is r, slowly lly manifests also. presentatio leading to delaye of growing, as a can n. ed on the be perfo A skin biops trunk of firm plaque rmed to y DFSP. DFSP diagn It was first young adults. spread has the poten ose Darier desc ribed and Ferra by rarely to nearby tissue tial to and later nd in metastasiz s in 1925 named by Hoffm1924 it does es. Howe but have a . The ver, ann local recur exact not being high etiology rence. 1,2,3,4 rate of some resea fully unde rch has rstood, Case report a chrom ident osomal A that incre 54 years translocatified old fema of plate ases the produ ion presented le asym ction let-de with ptomatic rived factor an growth lump y grow skin color prevalence(PDGF). ed It th on per millio of 0.8 to 4.5 has shoulder since right cases months almost incidence n persons per which 8-10 rate. The year size gradu increased at risk range popu ally. s between lation there was On examinatioin 50 age n 20 and hype group rpigmented erythematous more and is common slight plaqu indurated than in in wom ly multipes studded en le nodu can occu men These with tumo les the body r in various parts rs size with a large of variable , pedu includ exteriorize of nculated, neck, head ing the trunk, nodule non-tended It is most , breast and of size r vulva 8cu.c appro ly asym ptomatic.. occa m in centr ximately siona e with telangiect l discharge, asia visible.

No

Oral Isotretin

oin for

Acne Grade

Oral Iso

Oral Isotretinoin for Acne Grade 4: A Case Presentation

4: A Case

Presenta

tion

tretinoin A Case for Acne Gr Presenta ade 4: tion Dr. Diwaka

MBBS.,D.

N.B.

r Sharma

Consultan t Dermatolo BVP Hosp gist ital, Kota Rajasthan ,

Dr. Diwakar Sharma, MBBS, DNB 22 22 January

2024

Introduct ion Acne is common a highly preva lent, skin cond affects ition that to use non-a all medication ntibiotic which is the age group people caused s in comb topical reduce in the seba by block inatio the risk the colon ceous gland ages Severe of resist n to s ance. leading ization of bacteand cystic acneacne, including to ria, may (Grade the forma inflammatio 3 and requi n 4), blackhead tion of pimp and isotretinoin re treatment with s and , a powe les, medi It is whitehead cation rful not s. to that can oral typically threatening lead life- Howepermanent cond have a ver, isotre remission. significantition but can poten a perso n's emot impact on dry tial side effecttinoin has psychologic s, includ ional and skin, can also lips, and eyes ing to anxie al state leadin cause ty or and like birth defec depressiong if used cond during ts the sever itions. pregnancy.

Grading Exact unknown etiology important ity of acne is an devel being it is the approstep in deter opment considered that minin of acne approach. priate treatm g genetic, environmeninvolves ent well Mild 1) is as tal as typically acne (Grade Furthermo hormonal topical treated factors. benzoyl agents such with sweating, re stress, perox as can androgensexcess acid or topic ide, salicylic also contribute etc developme These al retino medi to unclo cations can ids. of acne nt and sever to . Acne help affect ity inflammatiog pores, gene s reduce units in the pilosebace rally formation n and preve nt Moderate of new pimp the the kerat the skin, chan ous may requi acne (Grad les. the hair inisation patte ges rn of oral antibre treatment e 2) blockage follicle that lead tetracycline iotics, such with Hyperrespof sebum secre to tion. onsiveness as andro However, s or macr gen to long-term olides. to hype stimulation of antib can lead rplasia resistanceiotics can lead use glands of and sebo sebaceous , so it's to important are characteris rrhea, which of acne tic featu . Propi onobacter res ium

Androge

netic Alopecia

Role of

Early Interven

Androg eneti Early Inc Alopecia Ro le of tervent ions Dr. tions

28

V. Sitalak

Androgenetic Alopecia Role of Early Interventions

shmi MBBS, Diploma in Derm Aesthetic atology Dermatolo , Fellowship Consultan gy in t Aesthetic and Cosm Physician etic Surge , Ojas Aesth ry Cente etic Skin r, Hyde rabad

Dr. V. K.

Dr. V. Sitalakshmi, MBBS, Diploma in Dermatology Fellowship in Aesthetic Dermatology

ry Cente

Dr. V. K. Srinagesh, MBBS, MS, MCh

28 28 January

4

January 2024

Srin

agesh MBBS, MS, Consultan MCh t Cosmetic Ojas Aesth Surgeon etic Skin Hyderabad and Cosm etic Surge

2024

r,

Introduct ion Androgene miniaturiza also know tic alopecia (AGA) of tion baldness n as male anagen/te and rever pattern or fema sal logen Some is the le hair ratio etc. treatm most comm loss, includ of hair e topic ent optio on loss age group occurring form finasteride al minoxidil, ns oral influenced s, it is geneat all therapy, , low-level scalp micro light rally hair by gene well as mesothera needling, tic as transplant particularly hormonal py, ation hair androgens factors rich and as such trans plasma (PRP platelet dihydrotes (DHT). ). Hair Early interv tosterone and plant in early AGA can AGA cases repeated entio PRP the progr help slow ns in are painfu down treatm l. Early treatments and potenession of hair interventio ent n regrowth. tially promote loss years ago introduced a few are usefu hair cases diagnosed Since it is l in such often cell ; called as after trails with micrograph medi repeated t a FDA- ated treatm proprietary home reme ent approved dies of as nutrit it is often brush or A single treatment.is effectiveneional deficiency. ed to prolo sitting of suffic ng the The and can vary ss of interv hair grow e alter the entio th ns disea 1,2,3 depending stage individual se. of the facto on stage and severrs including AGA is genetic a dyna ity of chron mic response predisposition AGA, affect ic hair loss disorder and diagnosis to treatment. and and s 80% of that white The 40% of being involves men very easy age 70. Micro women befor trichoscop typical ic chan history, is a poten graft techniquee tial treatm ges like AGA that ent micrografts involves inject for ing containing

Editorial Board Dr. Deepti Saxena

MBBS, DNB (Dermatology and Venereology), M. Derm, PGDHA Consultant Dermatologist and Aesthetician Director of Skin and Chest Clinic, Laser and Aesthetic Centre, Ghaziabad

Advisory Board Dr. K.T. Upadhya Dr. Poornima Mahadeva Dr. Arun Kumar Dr. Sohandas Shetty Dr. Shashidhar Talwar Dr. P.R. Beliappa

Dr. Rupa Mavani Adatia MBBS, DVD Dermatologist Skin Wellness Clinic, Nagpur, Maharashtra

Dr. Shamanth Murthy Dr. Pawan Kumar Dr. Savitha T. G. Dr. Dinesh Kamath

Dr. Diwakar Sharma MBBS.,D.N.B. Consultant Dermatologist BVP Hospital, Kota, Rajasthan

Dr. Mansore Ahmed Dr. Chaitanya Divi Dr. Himabindu Burli Dr. B.R.Harish Prasad Dr. Abdul Samad

Dr. V. Sitalakshmi

MBBS, Diploma in Dermatology , Fellowship in Aesthetic Dermatology Consultant Aesthetic Physician, Ojas Aesthetic Skin and Cosmetic Surgery Center, Hyderabad

Dr. Harish Nooka Dr. Mohamed Gulam Darzi Dr. Girish Hanumatiha Dr. Neelima Ravipathi Dr. Haritha Ravipathi

Dr. V. K. Srinagesh

MBBS, MS, MCh Consultant Cosmetic Surgeon Ojas Aesthetic Skin and Cosmetic Surgery Center, Hyderabad

Dr. Karthik R. Dr. Roopa Shree Dr. Deepthi Balusu Dr. Sudhir Dr. Ashwini Ravisha Dr. Archana Gulur Dr. Ankita Ramesh

January 2024

5

Hands on Workshop on Aesthetic Dermatology

Setting the Standard for Training Aesthetic Excellence!

AESTHETICCON the "One Day Hands-on Workshop on Aesthetic Dermatology" held in Mumbai on December 17th, 2023 has left an indelible mark on participants, redefining the landscape of training in aesthetic dermatology.

Overall Rating: Over 92% rated this event as Excellent the remaining 8% rated it as good thus setting a new standard for excellence in training in Aesthetic Dermatology.

Practical Hands on Workshop

Meeting Expectations: A unanimous 100% of participants agreed that AESTHETICCON Mumbai exceeded their expectations attesting to the high caliber and impactful nature of the program.

Practical Learning Impact: A remarkable 100% of attendees expressed confidence in incorporating injectables into their practice post this workshop. This speaks volumes about the practical and applicable nature of the hands-on learning experience obtained at AESTHETICCON. Faculty Performance: All the participants found the expertise and guidance provided by the faculty members viz Dr.Farida Modi (M.D) and Dr.Satish Bhatia (M.D) to be nothing short of extraordinary The faculties have always been the true architects of the success of AESTHETICCON .

Faculty Guiding at the Hands on Workshop

Recommending to their Colleagues: Every single participant expressed a wholehearted willingness to recommend AESTHETICCON workshops to their Dermatology colleagues.

What Participants Liked Most: • Faculty Excellence : The faculties viz Dr.Farida Modi (M.D) and Dr.Satish Bhatia (M.D) emerged as shining stars, leaving an indelible mark on the participants with their expertise and engaging teaching style.

• Genuine Hands-On Experience : The opportunity for genuine hands-on practice was a major highlight, bridging the gap between theory and application.

Attentive Audience during the Lecture

• Event Arrangements : Meticulous arrangements, involving logistics to venue setup and execution, garnered appreciation from the attendess, ensuring a seamless experience for all.

Feedback of some of the Participants • Dr. Farhat Khan (Bhopal) – The workshop was well organised and the faculty was excellent..

• Dr. Reena Parveen (Hyderabad) – The detailed explanation by the faculty and the way they patiently responded to our doubts… lovely faculty.

• Dr. Sujata Garje (Mumbai) - I really liked hands on given for each delegate and also the faculty guiding us at each stage.

Certificate Distribution

• Dr. Sushma G Rajgopal (Bangalore) – The hands on workshop of botulinum Toxin injectable was explained very well covering facial anatomy and vascularity for dermal fillers was executed well.

• Dr. Tejaswitha Gudivada (Hyderabad) – The sessions were very much informative and has provided confidence in me to start botulinum toxin, fillers, threads in my clinic.

Stay Tuned: The pursuit of excellence in aesthetic dermatology January 2024 6 education continues! Stay tuned for future AESTHETICCON events, where innovation and knowledge converge with AESTHETICCON HAIR 2024

End of The Workshop

ththDecember'2023 January'2024 1728

Vennue: HotelHotel Ginger, Near Airport, Vile Parle, Mumbai Venue: Ginger, NearDomestic Domestic Airport, Vile Parle (East)(East) Mumbai 1 Day Hands on Workshop Training by Masters in Aesthetic Dermatology

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with procedures 1. PRP 2. GFC 3. Threads 4. Microneedling FACULTY

with International Certficate by

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MD Dermatologist and Cosmetologist Dermacare Skin Clinic & Cosmetic Center, Mumbai

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Email : aestheticconindia@gmail.com January 2024

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For further details and to register for the conference and hands on workshop call us at+91 98205 07771

Terms & Conditions: 1. Only for Dermatologist.Please share your PG in Dermatology Credentials while registering.

7

Q-switched Lasers Treatment for Unilateral Freckles: A Case Presentation

Q-switched Lasers Treatment for Unilateral Freckles: A Case Presentation Dr. Deepti Saxena

MBBS, DNB (Dermatology & Venereology), M. Derm, PGDHA Consultant Dermatologist and Aesthetician Director of Skin and Chest Clinic, Laser and Aesthetic Centre Ghaziabad

Introduction Unilateral freckles, known as unilateral lentiginosis, are the specific type of pigmentation disorder characterized by the presence of freckles or dark spots localized to a particular area or side of body, unlike common freckles which are evenly distributed and can appear on both sides. They most commonly appear on sun-exposed areas like the face, neck, arms and legs of body and are usually present as small, dark spots or patches that vary in size and intensity of colour. They are generally harmless and do not cause any medical complications, but can impact on person’s appearance and self-esteem.

The pigmentation often results due to increase in the production of melanin (the pigment responsible for the colour of our skin, hair and eyes), which absorbs UV radiation from the sun and helps protect the skin from its harmful effects. Trigger by certain factors result in overproduction of melanin and leads to the formation of 8

January 2024

freckles or dark spots. The exact etiology being unknown, some possible factors like genetic predisposition, post-inflammatory............ hyperpigmentation (PIH) and neurocutaneous disorders can predict the diagnosis and effective treatment for it. Unilateral freckles may have a genetic component, as they can run in families.

Certain genetic mutations or variations in genes involved in melanin production and regulation may contribute to the development of these freckles. In PIH the inflammation or injury to the skin, such as from burns, infections or trauma, can develop freckles as melanin in such areas is overproduced as a part of skin’s healing process. Some neurocutaneous disorders, as neurofibromatosis type 1 (NF1) or McCune-Albright syndrome, can develop unilateral freckles as a characteristic feature as it involves genetic mutations that affect both the skin

Q-switched Lasers Treatment for Unilateral Freckles: A Case Presentation

and nervous system. A rare pigmentary disorder called partial unilateral lentiginosis (PUL) or segmental lentiginosis is a presence of multiple lentigines (dark spots) grouped within an area of normal skin, typically in a segmental pattern. It usually appears during early childhood, with the lesions commonly developing before the age of 15 and can occur on various parts of body including face, neck, trunk and extremities. Histologically, PUL shows features of lentiginous epidermal melanocyte proliferation and elongation of rete ridges, similar to simple lentigines.

Being typically an isolated condition it can be associated with other abnormalities such as lisch nodules (benign hamartomas of the iris), neurofibromatosis, café-aulait spots (light brown patches on the skin) or ocular nevus.

Partial unilateral lentiginosis itself is not medically concerning, but many individuals with facial PUL may experience emotional distress due to the cosmetic impact of the condition, particularly in social interactions. Hence many of them seek treatment to address their concerns.

The treatment options for unilateral freckles are similar to those for common freckles and involve approaches aimed at lightening or reducing the pigmentation.

These can include sun protection, topical creams or ointments, chemical peels, laser therapy, cryotherapy or surgical excision, depending on the individual case and the preferences of the affected

person. Conventional laser methods for PUL treatment may have limitations and side effects such as PIH, scarring and the potential for recurrence. Given that many patients with facial PUL are young, factors like long downtime and pain can also be significant considerations.

Since skin lesions can highly influence a person's appearance and quality of life, such conditions should be diagnosed and treated properly. Specialty-specific quality of life questionnaires, such as the Skindex-29 or the Skindex-17, can be used to Before treatment evaluate differences among conditions and help health policy makers understand the impact of skin diseases on patients' quality of life.1,2,3,4,5,6,7,8,9,10 Case report A 28 years old female patient was presented to our clinic with freckles on her face. Past history revealed that she had this pigmentation since 5 to 6 years; this pigmentation was present on the face region only. No evidence of any other medical condition or intake of any medications was present.

After examination and medical history she was diagnosed with unilateral freckles like pigmentation. The treatment provided was Q switch laser therapy which was done in 3 sittings. Effects were seen after 1st sitting onwards. The images of pre and post cleanup taken are as follows.

After treatment Figure 1: Unilateral freckles like pigmentation on face Diagnosis The diagnosis of PUL or freckles is typically based on the clinical presentation and characteristic features of the skin lesions. Some considerations are taken for diagnosing PUL like clinical representation include spotting of numerous lentigines grouped together January 2024

9

Q-switched Lasers Treatment for Unilateral Freckles: A Case Presentation

on normal skin often following a unilateral (one-sided) and segmental pattern, stopping at the midline of the body, unilateral distribution; limiting to one side of the body and do not cross the midline and it’s benign nature (condition without malignant transformation or significant health risks).

Similarly ephelides (freckles can be identidied as small, flat, tan to light-brown spots that appear on sun-exposed areas of the skin, such as the face, arms and shoulders commonly found on sun-exposed areas and are mostly benig.1,2,11,12 Treatment There are several treatment options available for managing freckles or nevi. It includes protection of skin from harmful UV rays of sun as freckles are often caused or exacerbated by sun exposure hence use of broad-spectrum sunscreen with a high SPF, wearing protective clothing’s like hats, long sleeves etc to be used. Certain topical creams or ointments which contains ingredients like hydroquinone, kojic acid or retinoids can help lighten the appearance of freckles or reduce pigmentation. Chemical peels involve application of solution to skin that exfoliates the top layer and promotes the growth of new, healthier skin, superficial chemical peels can help lighten freckles or reduce the appearance of certain nevi. Such procedures are typically performed by a dermatologist. Cryotherapy involves freezing the targeted area with liquid nitrogen to destroy the excess pigment 10

January 2024

cells and is commonly used for certain types of nevi or other benign skin lesions. Multiple sessions may be required as temporary skin discoloration or blistering may occur. In some cases, surgical excision may be necessary to remove larger or suspicious nevi which involves cutting out the lesion and closing the wound with stitches. The excised tissue may be sent for further analysis to determine if there are any concerning features.

Thus the selection of most appropriate treatment option for an individual depends on various factors, including the type and location of the lesions, skin type and personal preferences. For freckles, light-based treatments such as laser or BBL intense pulsed light are considered effective.

Topical treatments like the Cosmelan Skin Lightening System can also be used.

Laser therapy can help lighten or remove freckles. It involves different types of lasers, such as Q-switched lasers or fractional lasers, may be used depending on the specific condition being treated. It can require multiple sessions and may have some associated risks, so consultance with a dermatologist is necessary.7, 9, 13, 14, 15

The commonly used treatment for pigmented lesions, including freckles are Q-switched lasers technology were lasers emit short, high-energy pulses in the nanosecond range and selectively target and fragment the melanocytes in the skin without causing significant damage to the

surrounding tissues. The specific wavelength of the laser depends on the type and depth of pigmentation.

In unilateral freckles-like pigmentation most commonly used Q-switched lasers to effectively lighten or remove the pigmented lesions are Q-switched Nd:YAG laser 1064 nm (Q-switched neodymium-doped yttrium aluminum garnet ) used to treat deeper pigmentation, such as epidermal melanin and dermal melanin. It is commonly used for the treatment of freckles, lentigines and melasma, Q-switched Ruby laser (694 nm) is often used for superficial pigmentation, such as freckles and lentigines and is effective for targeting melanin in the epidermis and Q-switched Alexandrite laser (755 nm) is also suitable for treating various pigmented lesions, including freckles and lentigines and targets melanin in the skin. These lasers emits short pulses of high-energy light, which are absorbed by the pigmented cells leading to the fragmentation of the pigment, thus gets removed by the body over a period of time. Multiple treatment sessions may be required to achieve the desired results and the specific treatment plan will depend on the individual's skin type, pigmentation severity and response to the laser treatment.16,17,18 Low-fluence Q-switched Nd:YAG 1,064-nm laser is a promising treatment that shows effective results when used in facial PUL. However the exact mechanism through

Q-switched Lasers Treatment for Unilateral Freckles: A Case Presentation

which it improves pigmentary lesions is not completely known, assumptions have been made based on concepts like "subcellular selective photothermolysis" and "melanocyte apoptosis and replacement".

The concept of subcellular selective photothermolysis suggests that repetitive laser energy delivered at a subphotothermolytic fluence (less than 5 J/cm2) with a large spot size can fragment and disperse melanin granules within the cytoplasm of melanocytes without causing cellular destruction. This effect is particularly focused on the dendrites of melanocytes since mature melanosomes tend to accumulate in these dendritic extensions.

By targeting the dendrites selectively, the laser can induce a subcellular selective photothermolytic effect on mature melanosomes, resulting in their reduction and dispersal. This mechanism has been proposed to explain the improvement of melasma and other pigmentary lesions with low-fluence 1,064-nm QS Nd:YAG laser treatment.

Another proposed explanation is melanocyte apoptosis and replacement tells that weekly laser treatments with complete destruction of melanocytes may accelerate apoptotic cell death of abnormal melanocytes, leading to their removal. The absence of abnormal melanocytes then allows for the migration and replacement of normal melanocytes from the outer root sheath of hair follicles.

These proposed mechanisms suggest that effects occur

on the subcellular level, targeting melanin and melanocytes specifically.

However, further research is needed to fully elucidate the underlying mechanisms and confirm these proposed explanations.

Furthermore appropriate measures has to be taken to monitor patient response during and after the procedure. These explanations being specific to the use of low-fluence 1,064-nm QS Nd:YAG laser in treating pigmentary lesions should not directly apply to other laser treatments or conditions. The mechanism of low-fluence 1,064-nm QS Nd:YAG laser treatment aims to minimize epidermal damage while targeting and destroying melanosomes in the epidermal melanocytes. In contrast, conventional highfluence laser techniques, such as 532 nm QS Nd:YAG laser, 694 nm ruby laser, 755 nm alexandrite laser, and 515755 nm intense pulsed light (IPL), absorb more melanin than 1,064 nm QS Nd:YAG laser. When the fluence is high enough to destroy epidermal melanocytes, it can also cause injury to the surrounding keratinocytes.

The damaged keratinocytes then secrete various cytokines such as endothelin-1, ɑ-MSH, ACTH, prostaglandins (PGE2, PGF2ɑ) and nitric oxide.

These cytokines activate melanocytes and stimulate increased melanin synthesis in the melanosomes, leading to postinflammatory hyperpigmentation (PIH).

Furthermore, free radical oxygen and peroxide released from the injured keratinocytes

can activate melanocytes and promote melanin synthesis, further contributing to the development of PIH. Conventional high-fluence laser treatments can also result in petechiae (small red or purple spots) and crusts, which may cause damage to various skin cells, including fibroblasts, mast cells, lymphocytes, macrophages and vascular endothelium.

Human fibroblasts, in particular, can secrete melanogenic cytokines like bFGF, HGF and SCF during periods of rapid growth or inflammation.

The overexpression of these cytokines by dermal fibroblasts may activate melanocytes in the overlying epidermis, potentially leading to increased melanogenesis and PIH. Metabolites from the arachidonic acid pathway and histamine released by mast cells may also influence melanogenesis, contributing to the development of PIH. Thus the use of low-fluence 1,064-nm QS Nd:YAG laser aims to minimize damage to the epidermis and avoid triggering the release of cytokines and free radicals that can activate melanocytes and increase melanin synthesis.1 Discussion Partial unilateral lentiginosis (PUL) is a pigmentary disorder that has been reported under various names, including unilateral lentigines, lentiginous mosaicism, segmental lentiginosis, zosteriform lentiginous naevus and agminated lentiginosis characterized by the presence January 2024

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Q-switched Lasers Treatment for Unilateral Freckles: A Case Presentation

of numerous lentigines grouped within an area of normal skin in a segmental pattern. Sometimes PUL has been observed in patients with either contralateral or bilateral segmental neurofibromatosis type 1 (NF1) and they may exhibit café-au-lait macules (light brown patches) and neurofibromas (benign tumors of nerve tissue). The coexistence of PUL with ipsilateral Lisch nodules (benign nodules on the iris), axillary freckling or skeletal alterations suggests that PUL may represent a variant of segmental NF1, lacking neurofibromas. This provides a possible connection between PUL and NF1 and it is advisable to rule out NF1 in patients with PUL. Further PUL cases associated with abnormalities of the central nervous system, including mental retardation and ipsilateral cerebrovascular abnormalities with focal epilepsy have been reported and suggests a potential common developmental problem involving the neural crest, which is the precursor to melanocytes and various other cell types.

Certain observations shows chromosomal mosaicism confined to neural crest melanoblasts which can play role in development of PUL.1 PUL, with histological features resembling those of lentigo when treated with 532-nm QS Nd:YAG laser, similar to the treatment for lentigo, the rate of recurrence appears to be high based on the author's experience. It is a benign condition, unassociated with 12

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other genetic disorders such as Peutz-Jeghers syndrome or Leopard syndrome, can be differentiated due to its typical unilateral and segmental distribution and the absence of other clinical signs and symptoms present in those syndromes. It has been reported to be associated with various cutaneous and systemic disorders like mental retardation, seizures, sickle cell anemia and celiac disease. However, the presence of these associated skin lesions does not necessarily indicate the presence of other concurrent anomalies. The treatments usually used like several non-invasive agents such as hydroquinone, tretinoin and glycolic acid targets the epidermis and potentially improve the pigmentation.

Laser modalities, including the 755-nm QS alexandrite laser and 532-nm and 1,064nm QS Nd:YAG lasers, based on histological findings, reported positive outcomes especially using a Q-switched alexandrite laser for PUL treatment. However it was seen that the patients did not respond to QS alexandrite laser treatment even after multiple sessions.

This highlights the challenges in finding an effective treatment for PUL. Hence a combination treatment using both 532-nm and 1,064-nm QS Nd:YAG lasers employed where initial use of lower fluences of the 532-nm laser did not respond but showed a favorable outcome with a higher fluence. This higher fluence can serve as a reference for both safety and efficacy in

treating refractory epidermal pigmentation lesions like PUL. Subsequent treatment with low-fluence 1,064-nm QS Nd:YAG laser was used to address the remaining PUL lesions. This combination approach aims to achieve a more comprehensive and effective response, targeting both the epidermal and deeper dermal pigment clusters. While 532-nm laser treatment alone can lead to crust formation, recurrence rates can be high after the crust resolves. On the other hand, low-fluence 1,064-nm laser treatment alone may require multiple sessions and show gradual responses. By combining the two lasers, a prompt initial response and better control of recurrence can be achieved, potentially reducing the number of treatment sessions needed.1 Conclusion Ephelides, commonly known as freckles, are small, flat, light to dark brown spots that appear on sun-exposed areas of the skin. They are typically more prominent during sun exposure and tend to fade or lighten during the winter months when there is less sun exposure. On the other hand, lentigines are also small, flat, brown spots, but they persist even in the absence of UV stimulation commonly referred to as age spots or liver spots, although they are not directly related to liver function or age.

Partial Unilateral Lentiginosis (PUL) is indeed a pigmentary disorder characterized by multiple lentigines that appear on normal skin in a unilateral and segmental pattern, often

Q-switched Lasers Treatment for Unilateral Freckles: A Case Presentation

stopping at the midline.

These lentigines are typically present from birth or become noticeable during childhood.

Regarding the long-term prognosis of PUL, malignant transformation within the lentigines of PUL is extremely rare and there are very few reported cases of melanoma arising within PUL lesions.

Regular monitoring of the lentigines and any changes in their appearance is advisable and individuals with PUL should follow routine skin cancer prevention measures, such as sun protection and periodic skin examinations by a dermatologist.

Various treatment options available such as topical medications, incisions, surgery, cyrotherapy, laser modilities can be effective.

Cryotherapy, although effective, can lead to scarring and hypopigmentation.

Laser treatments based on the concept of selective photothermolysis have also yielded varying outcomes and high recurrence rates.

In recent years, the QS Nd:YAG laser has gained popularity for various dermatological procedures, including "laser toning" or "laser facial," as well as nonablative skin rejuvenation and the treatment of melasma, particularly in Asian countries.

Laser toning involves multiple passes of a low-fluence laser with subthreshold fluences to achieve clinical effects while minimizing downtime.

It is worth mentioning that there have been isolated reports of individuals with extensive bilateral lentiginosis who developed malignant

melanomas. These cases are exceptional and do not represent the typical course of PUL. Hence proper diagnosis, evaluation and management of PUL or any pigmentary disorders, as they can provide personalized guidance based on the individual's specific condition and medical history is necessary.

Refrences 1. Kim, En Hyung. “A Case of Facial Partial Unilateral Lentiginosis Treated with Low-Fluence 1,064 nm Q-Switched NeodymiumDoped Yttrium Aluminum Garnet Laser.” Case reports in dermatology vol. 9,2 30-34. 1 Jun. 2017, doi:10.1159/000477376 2. Kim J, Kim DH, Chun SH, Ryu HJ. Partial Unilateral Lentiginosis Treated with 532-nm and Subsequent Low-Fluence 1,064nm Q-Switched NeodymiumDoped Yttrium Aluminum Garnet Lasers. Medical Lasers 2016;5:4246. https://doi.org/10.25289/ ML.2016.5.1.42 3. Erdem Y, Altunay IK, Ozkur E, Duzgun E. Partial unilateral lentiginosis with ipsilateral lisch nodules and pilocytic astrocytoma: Is this a type of segmental neurofibromatosis?

Indian J Dermatol Venereol Leprol 2021;87:109-111.

4. Kowalewska, Beata et al. “Quality of life in skin diseases as perceived by patients and nurses.” Postepy dermatologii i alergologii vol. 37,6 (2020): 956-961. doi:10.5114/ ada.2019.86182 5. Sampogna F, Tabolli S, Abeni D. Impact of different skin conditions on quality of life. G Ital Dermatol Venereol. 2013 Jun;148(3):255-61.

PMID: 23670062.

6. N. Germain etal, Stigma in visible skin diseases – a literature review and development of a conceptual model, Volume35, Issue7 , Pages 1493-1504, July 2021 https://doi. org/10.1111/jdv.1711 7. Lodish, Maya B, and Constantine A Stratakis. “The differential diagnosis of familial lentiginosis syndromes.” Familial cancer vol.

10,3 (2011): 481-90. doi:10.1007/ s10689-011-9446-x 8. Wang, Rebecca F. et al.Disorders of hyperpigmentation. Part I. Pathogenesis and clinical features of common pigmentary disorders.

Journal of the American Academy of Dermatology, Volume 88, Issue 2, 271 - 288 9. Passeron T, Mantoux F et al.

Genetic disorders of pigmentation.

Clinics in Dermatology (2005) 23, 56 – 67 10. Sardana K, Goel K, Chugh S. Reticulate pigmentary disorders.

Indian J Dermatol Venereol Leprol 2013;79:17-29 11. P. Beattie , K. Kenicer, Partial unilateral lentiginosis (poster), Clinical and Experimental Dermatology, Volume 27, Issue 3, 1 May 2002, Pages 255–256, https://doi.org/10.1046/j.13652230.2002.1041810.x 12. Shirbeigi, Leila et al. “Evaluating the Causes of Freckle and Nevus from the Viewpoint of Iranian Traditional Medicine.” Iranian journal of medical sciences vol. 41,3 Suppl (2016): S67.

13. D'Orazio, John et al. “UV radiation and the skin.” International journal of molecular sciences vol.

14,6 12222-48. 7 Jun. 2013, doi:10.3390/ijms140612222 14. Christoph Schwab, Christoph Mayer, Iris Zalaudek, Regina January 2024

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Q-switched Lasers Treatment for Unilateral Freckles: A Case Presentation

Riedl, Markus Richtig, Werner Wackernagel, Rainer HofmannWellenhof, Georg Richtig, Gerald Langmann, Lisa Tarmann, Andreas Wedrich, Erika Richtig; Iris Freckles a Potential Biomarker for Chronic Sun Damage. Invest. Ophthalmol.

Vis. Sci. 2017;58(6):BIO174BIO179. https://doi.org/10.1167/ iovs.17-21751.

15. Taylor et al. Photoaging/ photodamage and photoprotection.

(J AM ACAD DERMATOL 1990;22:1 - 15.)

16. Gaffey MM, Johnson AB. Laser Treatment of Pigmented Lesions. [Updated 2023 Jul 24].

In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https:// www.ncbi.nlm.nih.gov/books/ NBK560613/ 17. Cannarozzo G, Del Re C, Negosanti F, Bennardo S, Amoruso GF, Nisticò SP, Bennardo L. Q-Switched Nd:YAG Laser to Manage Hyperpigmentation in Asians: A Multicenter Study.

Cosmetics.

2023; 10(2):44. https://doi.org/10.3390/ cosmetics10020044 18. Han Zheng, Gang Qiao, Yong Zhang, "Treatment of Combined Freckles with Chloasma Using Q-Switched 1064 nm Laser", International Journal of Clinical Practice, vol. 2023, Article ID 4081427, 6 pages, 2023. https:// doi.org/10.1155/2023/4081427

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Dermatofibrosarcoma Protruberans (DFSP): A Rare Fibrous Tumor –Where Recurrence is a Rule than Exception

Dermatofibrosarcoma Protruberans (DFSP): A Rare Fibrous Tumor – Where Recurrence is a Rule than Exception Dr. Rupa Mavani Adatia

MBBS, DVD Dermatologist Skin Wellness Clinic, Nagpur, Maharashtra

Introduction Dermatofibrosarcoma....... protuberans (DFSP) is a rare soft tissue tumour primarily affecting the dermis and subcutaneous fat and in some cases muscle and fascia also.

It typically manifests as a slowly growing, firm plaque on the trunk of young adults.

DFSP was first described

by Darier and Ferrand in 1924 and later named by Hoffmann in 1925. The exact etiology not being fully understood, some research has identified a chromosomal translocation that increases the production of plateletderived growth factor (PDGF).

It has prevalence of 0.8 to 4.5 cases per million persons per year incidence rate.

The population at risk ranges between 20 and 50 age group and is slightly more common in women than in men. These tumors can occur in various parts of the body, including the trunk, neck, head, breast and vulva. It is 16

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mostly asymptomatic later in the course it may enlarge and become nodular and ulcerate. Ignorance is seen due to indolent nature of the tumor, leading to delayed presentation. A skin biopsy can be performed to diagnose DFSP. It has the potential to spread to nearby tissues but rarely metastasizes. However, it does have a high rate of local recurrence.1,2,3,4 Case report A 54 years old female presented with an asymptomatic skin colored lumpy growth on right shoulder since almost 8-10 months which increased in size gradually. On examination there was erythematous hyperpigmented indurated plaques studded with multiple nodules of variable size with a large exteriorized pedunculated, non-tender nodule of size approximately 8cu.cm in centre with occasional discharge,

Dermatofibrosarcoma Protruberans (DFSP): A Rare Fibrous Tumor –Where Recurrence is a Rule than Exception

telangiectasia visible. No enlargement was seen on lymph node examination (LNE). The biopsy was taken with differential diagnosis- keloid and large dermatofibroma.

We inferred it as local recurrence, investigated for distant spread which was not the case, advised the patient for follow up with the plastic surgeon but she was not very keen. Patient is stable healthy otherwise with normal blood parameters.

Diagnosis

Figure 2 : Histopathology report showed non-epidermal neoplasm with fibrocystic Figure 1: Asymptomatic skin differentiation colored lumpy growth on right shoulder (developed in 2015) It was operated by a plastic

surgeon with a complete excision with a margin of 2cm. The patient was referred for surgery and was lost to follow up after that. After approximately 4 years, the same patient presented again with tiny growths over the scar of the previous surgery.

They were 3-4 asymptomatic sessile, flesh colored growths, soft to firm in consistency.

Histopathology report showed non-epidermal neoplasm with fibrocystic differentiation from dermis to subcutis at places storiform. Fibrocytes were monomorphous elongated and at places spindle shaped, at places with storiform appearance. There were many mast cells, moderate mucin and a few lymphocytes in the fibrocystic proliferation.

In the reticular dermis, cells were spindle shaped.

In subcutis, proliferation extended in a honey-combed pattern with pseudoseptae.

The neoplastic cells were closely crowded and showed moderate atypia. Epidermis was hyperplastic and hyperpigmented. All these suggested the diagnosis Figure 3 : Dermato of Dermatofibrosarcoma fibrosarcoma recurrence after protruberans.

4 years of complete excision treatment

Skin biopsy which involves a sample of the lesion obtained examined under a microscope to confirm the presence of characteristic features such as spindleshaped cells arranged in a storiform pattern, is the primary diagnostic tool for DFSP. The tumor involves dermis and subcutis. The cell gets arranged in a storiform or intersecting pattern parallel to the epidermal surface.

These are spindle-shaped with little pleomorphism and scant cytoplasm.

Immunohistochemical......... staining can aid in diagnosing DFSP. But as the patient couldn’t afford we did not order them. The use of differential diagnoses for DFSP highlights the importance of considering various tumor types that may have overlapping clinical and histological features with DFSP which includes cellular fibrous histiocytoma/ dermatofibroma, spindle cell lipomas, angiomyxomas, myxoid sarcomas characterized by a myxoid stroma are a distinct type of tumor that can be considered in the differential diagnosis.1, 2 Treatment in our case we had referred the patient for surgery which was done with 2cm wide margin of excision but January 2024

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Dermatofibrosarcoma Protruberans (DFSP): A Rare Fibrous Tumor –Where Recurrence is a Rule than Exception

with the recurrence patient tumour, is less common denied surgery or for that and represents fewer than matter any form of therapy.1, 2 5 percent of all DFSP cases. Another variant is the Discussion fibrosarcomatous variant DFSP is an uncommon soft (DFSP-FS), which accounts tissue neoplasm that grows for approximately 5 to 15 slowly but is locally aggressive, percent of DFSP cases.5,6,7,8,9 though rarely spreads.

DFSP is a heterogeneous Investigations condition and its incidence The radiological appearance and variants may vary among of DFSP typically shows different populations and a non-calcified superficial geographical regions. It is an nodular mass that is often uncommon locally aggressive associated with the skin. sarcoma of the skin and On computed tomography soft tissues. The majority of (CT), the tumour is usually DFSP cases are classified as isodense to muscles. On lowgrade, while the remaining magnetic resonance imaging cases exhibit a high-grade (MRI), it appears as lesion sarcomatous component with high signal intensity on known as DFSP-FS, making T2-weighted images and them intermediate-grade low signal intensity on T1sarcomas. Although DFSPs weighted images. These rarely metastasize, with less characteristic imaging features than 5 percent of cases can aid in the diagnosis and exhibiting metastasis, they differentiation. Histologically, have a high potential for it’s characterized by neoplastic local recurrence. The risk of cells throughout the dermis, recurrence is associated with lacking a clear boundary the extent of the initial surgical (grenz zone) between the resection.4 tumour and the epidermis. The tumour exhibits a storiform Epidemiology-While DFSP pattern, with short spindle most commonly occurs in cells arranged in a pinwheel adults in their thirties, it can fashion throughout the mass. be diagnosed in individuals The nuclei of these cells show of all age groups, including modest pleomorphism and children and older adults. It dispersed chromatin and starts as a small, firm patch of mitotic figures are generally skin, ranging in size from 1 to rare. Unlike benign cutaneous 5 cm in diameter and affects fibrohistiocytic neoplasm, the skin. The typical clinical giant cells are not typically presentation involves slowly present in DFSP. This absence growing; firm plaque on the can help differentiate it from trunk with the lesion can vary other similar neoplasms. in size at presentation having A thorough evaluation of a reddish-brown or purplish the histological features color and may appear slightly is crucial for an accurate raised or protuberant. Bednar diagnosis. The information variant, characterized by emphasizes the importance the presence of melanin of early diagnosis, appropriate containing cells within the 18

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surgical intervention and close monitoring to achieve complete local control of DFSP and minimize the risk of recurrence and associated complications.

Close collaboration between surgical teams, dermatologists and radiation oncologists can optimize the management of DFSP and improve patient outcomes.5,6,7,8,9 TreatmentSurgery The standard treatment for DFSP is surgical excision, which applies to all stages of the disease, including stage I, II, III and IV whenever feasible. The goal of surgery is to achieve wide clear margins. Surgical techniques for DFSP include wide local excision (WLE) with tumourfree margins and Mohs micrographic surgery (MMS) that are used in clinical practice have their own advantages and drawbacks.

Wide local excision involves removing the tumour with a margin of healthy tissue, while Moh’s micrographic surgery involves serial excision and microscopic examination of the tumour margins to ensure complete removal while preserving healthy tissue. The goal is to achieve complete tumour removal with negative margins while minimizing functional and cosmetic 1,2 impact.

Depending on the size and location of the tumour, reconstructive surgery may be necessary to restore the appearance and function of the affected area after tumour removal. In some cases, adjuvant radiation

Dermatofibrosarcoma Protruberans (DFSP): A Rare Fibrous Tumor –Where Recurrence is a Rule than Exception

therapy may be considered following surgical resection to further reduce the risk of recurrence, especially when there are factors indicating a higher risk, such as positive margins or large tumours. A close followup after treatment is essential to monitor for any signs of recurrence and ensure longterm management of DFSP.

increases its aggressiveness.

Therefore, complete resection of the tumour from the outset is crucial, especially in cases of multiple recurrences.

Imaging plays a limited but valuable role in the evaluation of DFSP. Local recurrence of DFSP typically occurs within the first 3 years after initial surgery, although cases have been reported even after a longer period, emphasizing the importance of long-term follow-up.

Conventional surgery with wide margins, while effective, has drawbacks such as the associated morbidity of removing large areas of healthy tissue and the risk of missing eccentric subcutaneous tumour extension. Mohs micrographic surgery is considered the preferred surgical technique for DFS, with a recurrence rate of less than 5%. This case study aims to enhance the understanding and recognition of DFSP, contributing to improved diagnosis and management of this rare tumour.

Chemotherapy Chemotherapy with imatinib has shown promise in the management of DFSP. Imatinib is a tyrosine kinase inhibitor that specifically targets the platelet-derived growth factor receptor tyrosine kinase, which is involved in the pathogenesis of DFSP. It has been used in cases of inoperable, recurrent or metastatic DFSP and has shown efficacy in controlling the disease. Neoadjuvant imatinib has also been explored as a treatment option for locally advanced primary tumours, while adjuvant imatinib has been used in cases where surgical resection resulted in positive References 1.

Brooks J, margins.1,2 Conclusion DFSP is a locally aggressive tumour that primarily requires surgical treatment.

The majority of DFSP cases exhibit low malignancy, characterized by slow invasive growth and a low likelihood of distant metastasis. However, they have a high rate of local destruction and recurrence following surgery. In about 10-15% of cases, DFSP can undergo fibrosarcomatous transformation, which

a male patient’s breast: a case report and review of the literature. World J SurgOnc 13, 158 (2015). https://doi. org/10.1186/s12957- 015-0562-1 4. Mendenhall W M, Scarborough M T, Flowers F P. Dermatofibrosarcoma protuberans: pathogenesis,

Epidemiology, clinical

presentation,

diagnosis, and staging. Aug 2023.

5. Hao, X.; Billings, S.D.; Wu, F.; Stultz, T.W.; Procop, G.W.; Mirkin, G.; Vidimos,

A.T.

Dermatofibrosarcoma

Protuberans: Update on the Diagnosis and Treatment. J. Clin. Med. 2020, 9,

1752.

https://doi.

org/10.3390/

jcm9061752 6.

Stephen

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Dermatofibrosarcoma protuberans: A report on 29 patients treated by Mohs micrographic surgery with long-term follow-up and review of the literature, Volume 101, Issue1, 1 July 2004, Pages 28-38, https://doi.org/10.1002/ cncr.20316

https://acsjournals.

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wiley.com/doi/10.1002/

cncr.20316 7. Bichakjian CK, Alam M, Andersen J et al. “Dermatofibrosarcoma protuberans: Clinical practice guidelines in oncology.”

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Wiesmueller,

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9. Kim, Grace K. “Status report on the

Ramsey

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nih.gov/books/ NBK513305/

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2. Al Barwani, Aliya Sarhan et al.

protuberans: is there a viable role for

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Protuberans:

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Oral Isotretinoin for Acne Grade 4: A Case Presentation

Oral Isotretinoin for Acne Grade 4: A Case Presentation Dr. Diwakar Sharma MBBS.,D.N.B. Consultant Dermatologist BVP Hospital, Kota, Rajasthan

Introduction Acne is a highly prevalent, common skin condition that affects all the age group people which is caused by blockages in the sebaceous glands and the colonization of bacteria, leading to inflammation and the formation of pimples, blackheads and whiteheads.

It is not typically lifethreatening condition but can have a significant impact on a person's emotional and psychological state leading to anxiety or depression like conditions.

Grading the severity of acne is an important step in determining the appropriate treatment approach. Mild acne (Grade 1) is typically treated with topical agents such as benzoyl peroxide, salicylic acid or topical retinoids.

These medications can help to unclog pores, reduce inflammation and prevent the formation of new pimples.

Moderate acne (Grade 2) may require treatment with oral antibiotics, such as tetracyclines or macrolides.

However, long-term use of antibiotics can lead to 22

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resistance, so it's important to use non-antibiotic topical medications in combination to reduce the risk of resistance.

Severe acne, including cystic acne (Grade 3 and 4), may require treatment with isotretinoin, a powerful oral medication that can lead to permanent remission.

However, isotretinoin has potential side effects, including dry skin, lips and eyes and can also cause birth defects if used during pregnancy. Exact etiology being unknown it is considered that development of acne involves genetic, environmental as well as hormonal factors.

Furthermore stress, excess sweating, androgens etc can also contribute to development and severity of acne. Acne generally affects the pilosebaceous units in the skin, changes the keratinisation pattern of the hair follicle that lead to blockage of sebum secretion.

Hyperresponsiveness to androgen stimulation can lead to hyperplasia of sebaceous glands and seborrhea, which

Oral Isotretinoin for Acne Grade 4: A Case Presentation

are characteristic features of acne. Propionobacterium acnes is a bacterial acne were the bacterium colonizes the follicular duct and contributes to the development of acne.

It breaks down sebum into triglycerides, which can be irritating to the skin and contribute to inflammation.

When the follicular epithelium is invaded by lymphocytes, it can rupture and release sebum, microorganisms and keratin into the dermis, leading to the development of erythematous papules, pustules and nodular swelling characteristic of inflammatory acne.

Other potential environmental triggers for acne include exposure to certain cosmetics, oils, certain medications and other substances that come into contact with the skin.

Additionally to external environmental factors, evidence also suggest that internal environmental factors for example, diet and lifestyle factors such as stress, sleep and exercise may play a role in the development and severity of acne. In addition to these physical symptoms, acne can also have psychological and emotional effects, as mentioned above.

It is important for healthcare professionals to recognize the impact that acne can have on patients' quality of life and mental health and to provide appropriate support and treatment. Treatment should also take into account the type and severity of acne, as well as any underlying conditions or medications that may be contributing to the development of acne.

Early intervention can help to prevent scarring and minimize the risk of adverse psychological effects.1,2 Case report A 22 year old male was presented to our clinic with the presentation of inflammatory lesions with erythematous papules, pustules and nodular swelling. When physically examined he was suffering from severe acne i.e. grade 4 acne. No evidence on genetic predisposition was obtained after going through the medical history. The patient had no family history, he was not on any medication or diagnosed with any diseases, presented in good health. He was treated with isotrerinoin for 4 months. Dose regimen decided was 20mg dose twice a day. Significant results were seen within 4 months.

Regular monitoring and consistent follow ups were set for effective treatment result.

The clinical pictures of before and after treatment taken is as follows.

Before treatment

After 4 months of treatment Figure 1: Inflammatory acne with erythematous papules, pustules and nodular swelling Diagnosis 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. The diagnosis of acne grade 4 is typically made by a dermatologist or healthcare professional who evaluates the severity of the acne lesions based on the specific grading system used.

The grading system may vary, but generally, grade 4 acne is characterized by the presence of pustules, nodules, deep cysts with numerous blackheads and whiteheads. There is pronounced inflammation and breakouts likely extend to areas other than the face, such as the neck, upper chest and back. The diagnosis is January 2024

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Oral Isotretinoin for Acne Grade 4: A Case Presentation

made through a physical examination of the affected areas, which may include the face, neck, chest and back which include assessing the size, number and distribution of the acne lesions, as well as the presence of scarring or pigmentation changes. In some cases, additional diagnostic tests or assessments may be performed to rule out underlying hormonal imbalances or other contributing factors. These may include blood tests to evaluate hormone levels, cultures to check for bacterial infection or other specialized tests as deemed necessary.

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.1,2 Treatment Isotretinoin is a prescription medication used to treat severe nodular acne, with grade 4 acne, that has not responded to other treatments, including antibiotics. It is a powerful medication commonly used at a dosage of 20mg.

The safety and efficacy of isotretinoin have been well established through numerous studies and clinical experience. It efficaciously works by reducing the size of the sebaceous glands, which decreases sebum production and the risk of blockages in the pores by effectively regulating the 24

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keratinization process, inhibit bacterial growth and regulate skin cell turnover. Clinical studies have consistently shown that isotretinoin leads to significant improvement in acne symptoms, including a reduction in the number and severity of nodules, pimples, cysts, blackheads, whiteheads and inflammatory lesions. Depending on the severity of acne and patients response to medication the duration of isotretinoin treatment typically ranges from several months to a year. Oral isotretinoin is recommended for the treatment of severe nodular acne and low-dose isotretinoin can be used to effectively treat acne and reduce the frequency and severity of medication-related side effects. The duration of therapy can be up to 20 weeks and patients should take some formulations of this drug with food. Systemic isotretinoin is widely regarded as the most effective treatment for severe acne and remains a cornerstone therapy in dermatology. On completion of treatment, patients can experience longterm remission from acne or a significant reduction in the frequency and severity of breakouts. Some side effects like dry skin, chapped lips, increased sensitivity to sunlight associated with rare but serious side effects like depression and suicidal thoughts are oftenly seen so it should be taken under close medical supervision.

Additionally it also causes liver toxicity, increase in blood lipid levels, also leads to birth

defects, so it is crucial for women of childbearing age to use effective contraception while taking this medication.

These side effects can usually be manageable and improve with time or dosage adjustments, however regular monitoring of liver function, lipid profiles and followup visits are crucial during treatment. The standard dosage range is typically from 0.5 to 1 mg/kg of body weight per day but the actual dosage prescribed may vary depending on factors such as the severity of the acne, the patient's response to treatment and individual considerations.

In some cases, a lower initial dose may be prescribed, with the dosage gradually increased over time.3,4,5,6,7 Furthermore isotretinoin influences cellular processes of progression, differentiation, survival and causes apoptosis thus normalizing the function of sebaceous glands and reduce acne symptoms leading to significant improvements. It induces apoptosis in sebocytes, leading to sebaceous gland involution and reduced sebum production. This effect appears to be independent of retinoic acid receptor (RAR) activation, suggesting that sebaceous gland involution contributes to the decrease in sebum production. It affects comedogenesis process by decreasing hyperkeratinization, which helps prevent the formation of comedones. It indirectly reduces the population of Propionibacterium acnes

Oral Isotretinoin for Acne Grade 4: A Case Presentation

(P. acnes) bacteria, altering microenvironment within the pilosebaceous duct such as it becomes unsuitable for P. acnes colonization thus preventing acne. The suppression of P. acnes is more substantial compared to oral and topical antibiotics commonly used to treat acne.

It may show anti-inflammatory effect by modifying monocyte chemotaxis and increase host defense mechanisms.

Several biologically important metabolites, including 13-cis4-oxo-retinoic acid, all-transretinoic acid (tretinoin), alltrans-4-oxo-retinoic acid, 9-cis-retinoic acid and 9-cis4-oxo-retinoic acid may play a role in isotretinoin's therapeutic effects and receptor activation. Tretinoin and all-trans-4-oxo-retinoic acid bind to the RAR-γ receptor, which is important in retinoid treatment of acne.3,4,5,6,7

number of acne-causing bacteria on the skin and normalizes the shedding of skin cells. In many cases, it can lead to long-term remission of acne symptoms. Isotretinoin is typically used as a last resort for severe cases of acne that have not responded to other treatments. This is due to its potential side effects and the need for close monitoring during treatment with regular follow-up so as to monitor the patient's progress, address any side effects and ensure the medication is working effectively. Some of the potential side effects of isotretinoin include dryness of the skin, lips and eyes, increased sensitivity to sunlight, muscle and joint pain and changes in mood which are temporary and resolve after the completion of treatment. In rare cases, more serious side effects such as liver toxicity, increase in blood lipid levels, birth defects Discussion during pregnancy can be Grade 4 type of acne seen hence strict precautions is characterized by the are needed to be taken.3,4,5,6 presence of severe nodules, cysts, pimples, blackheads Isotretinoin is considering valuable therapeutic and whiteheads associated a option for the treatment of with inflammation. It is often lead to significant acne, particularly severe acne, the physical and psychological nodulocystic distress for the affected recommended dosage for individuals.

Isotretinoin, isotretinoin in these cases a retinoid medication, is is usually 1-2 mg per day. this treatment considered one of the most However, effective treatments for protocol is associated with this severe form of acne. It a relatively high incidence of works by targeting multiple side effects, necessitating factors involved in acne regular monitoring, including development. It reduces monitoring of the serum sebum (oil) production, which lipid profile. There has been helps prevent clogged pores. ongoing debate regarding It also has anti-inflammatory whether isotretinoin should properties, reduces the be reserved exclusively for

severe nodulocystic acne or if it can also be used for milder and moderate forms of acne.

To reduce the occurrence of side effects and simplify the therapy, researchers have explored lower-dose regimens of isotretinoin.

Several studies have been conducted on the use of low-dose and intermittent regimens of isotretinoin, that can be effective for managing moderate to severe acne with a lower incidence and severity of side effects compared to higher-dose regimens.7,8,9,10,11,12 Conclusion Acne can have a significant psychological impact, often leading to depressive symptoms.

Effective treatment not only helps minimize the risk of permanent physical scarring but also helps with psychological aspects, improving the quality of life of patients.

Appropriate cosmetic advice and treatments should be considered alongside pharmacological treatment to diminish the adverse effects and encourage adherence to treatment, thus improving outcomes. Oral isotretinoin is a milestone in the treatment of acne, particularly severe or recalcitrant disease. It is recommended for the treatment of severe nodular acne and moderate acne that is treatment-resistant or producing physical scarring and psychosocial distress.

Low-dose isotretinoin can be used to effectively treat acne and reduce the frequency and severity of medicationrelated side effects. However, January 2024

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Oral Isotretinoin for Acne Grade 4: A Case Presentation

isotretinoin is teratogenic and associated with a number of other adverse effects that can limit its use. The most serious side effect is teratogenicity, so adherence to existing pregnancy prevention programs is paramount, regardless of the isotretinoin dose. Other side effects, in the vast majority of the cases, can be easily prevented and treated. Oral isotretinoin, appropriately managed, may be considered a reasonable alternative in cases of acne that fails to respond to therapies such as antibiotics.

6. Pile HD, Sadiq NM. Isotretinoin.

References

treatment protocols for moderate acne

1. Ayer J, Burrows N. Acne: more

using isotretinoin based on the global

than skin deep. Postgrad Med J. 2006

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[Internet].

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Available from: https://www.ncbi.nlm. nih.gov/books/NBK525949/ 7. Cunliffe WJ, Stables G. Optimum use of isotretinoin in acne. J Cutan Med Surg. 1996;1:S2-14–S2-25.

8. Agarwal US, Besarwal RK, Bhola K.

Oral

isotretinoin

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dose regimens for acne vulgaris: A randomized comparative trial. Indian J Dermatol Venereol Leprol 2011;77:688694 9. Kassem, Bushra et al. “Evaluation of the efficacy and relapse rates of

comparative

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10. Agarwal, Uma Shankar et al. “Oral isotretinoin in different dose regimens

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dermatology,

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doi:10.4103/0378-6323.86482 11. Leyden, James J et al. “The use of isotretinoin in the treatment of acne vulgaris: clinical considerations and

3. Strauss, J S et al. “Isotretinoin

future directions.” The Journal of clinical

therapy for acne: results of a multicenter

and aesthetic dermatology vol. 7,2

dose-response study.” Journal of the

Suppl (2014): S3-S21.

American Academy of Dermatology vol. 10,3 (1984): 490-6. doi:10.1016/ s0190-9622(84)80100-0

12. Skroza, Nevena et al. “Advantages of Tailored Isotretinoin Treatment in Moderate to Severe Acne: Real-Life

4. Strauss, John S et al. “Guidelines of

Data.” Frontiers in pharmacology vol.

care for acne vulgaris management.”

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Dermatology vol. 56,4 (2007): 651-63. doi:10.1016/j.jaad.2006.08.048 5. Layton, Alison. “The use of isotretinoin in

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Androgenetic Alopecia Role of Early Interventions

Androgenetic Alopecia Role of Early Interventions Dr. V. Sitalakshmi

MBBS, Diploma in Dermatology , Fellowship in Aesthetic Dermatology Consultant Aesthetic Physician, Ojas Aesthetic Skin and Cosmetic Surgery Center, Hyderabad

Dr. V. K. Srinagesh

MBBS, MS, MCh Consultant Cosmetic Surgeon Ojas Aesthetic Skin and Cosmetic Surgery Center, Hyderabad Introduction Androgenetic alopecia (AGA) also known as male pattern baldness or female hair loss, is the most common form of hair loss occurring at all age groups, it is generally influenced by genetic as well as hormonal factors particularly androgens such as dihydrotestosterone (DHT). Early interventions in AGA can help slow down the progression of hair loss and potentially promote hair regrowth. Since it is often diagnosed after repeated trails with home remedies or proprietary it is often brushed of as nutritional deficiency. The effectiveness of interventions can vary depending on individual factors including stage and severity of AGA, genetic predisposition and response to treatment. The diagnosis being very easy involves typical history, trichoscopic changes like 28

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miniaturization and reversal of anagen/telogen ratio etc.

Some treatment options include topical minoxidil, oral finasteride, low-level light therapy, scalp microneedling, hair mesotherapy, hair transplantation and platelet rich plasma (PRP). Hair transplant in early AGA cases and repeated PRP treatments are painful. Early intervention treatment introduced a few years ago are useful in such cases; called as micrographt cell mediated treatment is a FDA-approved treatment.

A single sitting of suffice to prolong the hair growth and alter the stage of the disease.1,2,3 AGA is a dynamic and chronic hair loss disorder that affects 80% of white men and 40% of women before age 70. Micrograft technique is a potential treatment for AGA that involves injecting micrografts containing

Androgenetic Alopecia Role of Early Interventions

human follicle mesenchymal stem cells (HF-MSCs) into the scalp of AGA patients.

Injections of micrografts containing HF-MSCs in the scalps of AGA patients have shown improvements in hair density and diameter.

Autologous cellular method using micrografts of human adipose tissue-derived hair follicle stem cells (HD-AFSCs) is another treatment option that has shown promise in improving hair growth in AGA patients.4,5,6,7,8,9

area, preliminary studies have shown promising results, whereas further research is needed to understand the optimal methods of harvesting and culturing HF-MSCs, as well as their long-term efficacy and safety. It is worth noting that the field of regenerative medicine and stem cell therapy is continuously evolving and future advancements may provide additional insights into the potential use of HFMSCs for AGA treatment.10,11 Principle of Micrograft Technique Micrograft technique is a potential treatment for androgenetic alopecia that involves injecting micrografts containing human follicle mesenchymal stem cells (HFMSCs) into the scalp of AGA patients. The micrografts are obtained by a process that involves selecting cells with a size of 50 μm, collecting the micrograft's suspension from the system and mechanically infiltrating it into the selected area of the patient's scalp affected by AGA. Injections of micrografts containing HF-MSCs in the scalps of AGA patients have shown improvements in hair density and diameter. Activation of bulb stems cells, to prolong the anagen phase of hair growth. The micrograft derived cell suspension is injected into the scalp as meso injections.

The cell suspension contains peptides, vaso active proteins and growth factors a few stem cell. Which increased cell growth and vascularization.

Antinflamatory effect in an additional advantage.12

Treatment The use of micrografts containing autologous human hair follicle mesenchymal stem cells (HF-MSCs) for therapeutic hair regrowth has not been extensively explored or considered. The current treatments approved for AGA include minoxidil, finasteride and hair transplantation.

These treatments aim to slow down hair loss and promote hair regrowth. Additionally, the use of autologous platelet-rich plasma (A-PRP) has shown some promising results in AGA treatment. In AGA, the miniaturization of hair follicles is observed, with a reduction in the anagen (growth) phase and an increase in the telogen (resting) phase of the hair follicles. This results in the presence of microscopic hairs in a hairless scalp. Micrografts containing autologous HFMSCs for hair regrowth is an interesting approach that has gained attention in recent years. HF-MSCs have the potential to differentiate into various cell types, including hair follicle cells and may have a role in stimulating hair growth.

Micrograft Procedure Research being limited in this

"Gentile protocol" represents an innovative clinical approach to obtain micrografts through a mechanical fragmentation process that involve various tissues from the scalp, is generally followed for micrografting in AGA. Initially a punch biopsy tool with a 2mm diameter is used to harvest scalp tissues. The number of fragments harvested depends on the size of the area to be treated. These harvested tissue fragments are stored in a saline solution which are then cut into strips measuring 2.0 x 2.0 mm. These strips are then manually splitted in a sterile environment with each group containing three fragments in it performed by doing multiple incisions using a scalpel. The aim is to obtain a cell group with a diameter of 80-120 μm.

These disaggregated and fragmented suspension obtained from above step is collected and an average of 20 ml of suspension from 50 fragments is collected and divided into two 10 ml LuerLock syringes. The syringes are then centrifuged for 3 minutes at 3000 RPM, resulting in the removal of 1.5 ml of the supernatant from each syringe. After centrifugation, 9 ml of the micrograft's suspension is obtained from the two syringes. The suspension is then loaded into a mesotherapy gun, a medical device equipped with software that allows for controlled depth of injection and the amount of infiltration per cm2. Finally the last step involves the controlled infiltration of the micrograft's suspension into the selected January 2024

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Androgenetic Alopecia Role of Early Interventions

area of the scalp. This is performed using the mesotherapy gun, with the depth of injection and the amount of infiltration per cm2 scheduled using the device's software. It has to be noted that this protocol describes a specific method for obtaining autologous micrografts of HFSCs and may require further validation and assessment of its efficacy and safety through clinical studies.

Figure 1: Micrograft’s preparation with the “Gentile protocol” (first and second steps). (a) Harvesting of the scalp tissues with punch biopsy (2 mm diameter). (b) Storing scalp tissues in saline solution. (c) Cutting and splitting of the fragments into strips of 2.0 × 2.0 mm (group of 3 fragments each time) sterilely through a manual splitting performed by multiple incisions with scalpel number 11 in 1.2 mL of saline for each 3 fragments. (d) Splitted strips and obtained suspension; an average 20 ml for 50 fragments was disaggregated and fragmented.

30

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Figure-2

Figure 2: Micrograft’s preparation with the “Gentile protocol” (third step). (a) 20 ml of suspension containing strips splitted. (b) Collection of the suspension obtained, in two 10 mL Luer-Lock syringes, and centrifugation for 3 minutes at 3000 RPM. (c) Two syringes containing 4.5 ml of the micrograft’s suspension were positioned in a mesotherapy gun. (d) Mechanical and controlled infiltration, using 10 ml syringes in the selected area of the scalp through a mesotherapy gun.10 Protocol and Injection of the Micrograft’s Suspension The protocol involved in administration of micrograft's suspension in specific anatomical areas of the scalp for the treatment of hair thinning or alopecia involves various conisderations.

The scalp is divided into six different anatomical areas: left frontal area, right frontal area, left parietal area, right parietal area, left vertex area and right vertex area. Further anesthesia, either local or potentially fundamental (general anesthesia), to be given depends on the individual and the medical practice.

The micrograft's suspension is then administered through interfollicular infusions in the targeted area (TA).

The infusion is performed at a depth of 5 mm using a mesotherapy medical device equipped with a 10 mL LuerLock syringe and a 30-gauge needle. The volume of infusion is specified as 0.2 mL/cm2.

Infusion of this micrograft

Androgenetic Alopecia Role of Early Interventions

cell suspension is done in a single sitting. In cases where hair thinning is confined to specific areas (e.g., frontal and parietal areas or parietal and vertex regions), placebo infusions (saline solution NaCl 0.9%) are administered in the respective areas which are done to provide a comparison for evaluating the clinical impacts of the micrograft's suspension. To demonstrate the clinical impacts, each area is further divided into two sides (left or right), and the infusions are performed on the chosen side. This approach allows for a comparative assessment of the treatment results. The efficacy and safety of this approach should be evaluated through scientific research and clinical trials.10 Results The results are monitored every 4 weeks through photographs and trichoscopic evaluation good results are seen at the end of 6 to 8 weeks.

Before treatment

After 8 weeks of treatment

After 12 weeks of treatment

Figure 3: Micrograft's suspension Discussion The micrograft technique, also known as micrografting or microhair transplantation, is a hair restoration procedure that involves the transplantation of tiny hair grafts to treat hair loss or baldness. It is a minimally invasive technique that has gained popularity due to its natural-looking results and relatively quick recovery time. Consultancy with a hair transplant specialist to assess the extent of hair loss, examine the donor area (usually the back or sides of the head where hair follicles are genetically resistant to balding) and discuss the patient's goals and expectations is done initially. The individual hair follicles or sometimes small clusters of two to four hairs called follicular units are harvested from the donor area, typically done using a specialized instrument, such as a microneedle or a punch tool, to extract the follicles without causing significant damage to the surrounding tissue. Once the donor hairs are extracted, they are carefully dissected, prepared under a microscope were the individual follicles or follicular units are separated and trimmed to ensure they are of an appropriate size for transplantation.

The recipient site, where the hair grafts will be transplanted, is created using small incisions or punctures in the bald or thinning areas of the scalp. The size, angle and density of these recipient sites are crucial to achieving a natural-looking result.

The prepared hair grafts are then placed into the recipient sites, following the natural hair growth pattern and taking into

account the desired density and distribution. The surgeon or technician performing the procedure uses specialized instruments, such as forceps, to carefully insert the grafts into the scalp. After the micro graft procedure, patients are provided with specific instructions on how to care for their newly transplanted hair. This may include guidelines on washing, avoiding strenuous activities, and protecting the scalp from direct sunlight. Over time, the transplanted hair follicles will typically shed their hairs, but the roots remain intact leading to new hair growth within a few months and the results continue to improve over the course of several months as the transplanted follicles enter the normal hair growth cycle. There are several hair restoration options available for micro graft technique, such as follicular unit transplantation (FUT) and follicular unit extraction (FUE), which has their own advantages and considerations. It's essential to consult with a qualified hair transplant specialist to determine the most suitable technique for individual needs and expectations.12,13,14 There are potential tissue engineering and stem cellbased therapies for hair regrowth. In this particular study, a placebo-controlled, randomized, evaluatorblinded, half-head group design was employed to compare the efficacy of micrografts containing human hair follicle mesenchymal stem cells (HF-MSCS) versus placebo. The results of the January 2024

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Androgenetic Alopecia Role of Early Interventions

study indicated that after 58 weeks, patients who received micrografts containing HFMSCs displayed a significant increase in hair count and hair density in the targeted area compared to baseline measurements. Specifically, the increase was reported as 18.0 hairs per 0.65 cm2 and 23.3 hairs per cm2, respectively. In contrast, the control area (treated with a placebo) exhibited a slight decrease in hair count. Furthermore, after 26 months, six patients experienced dynamic hair loss and were subsequently retreated, suggesting the need for further evaluation and longer-term monitoring of the treatment's effectiveness.

These findings suggest that HF-MSCs contained in micrografts have the potential to be a safe and viable alternative for hair loss treatment. However, more extensive controlled examinations are necessary to establish the efficacy, safety and long-term effects of this approach. Tissue engineering and stem cell-based therapies hold promise in the field of hair regrowth, as they offer the potential to regenerate and restore hair follicles.

Continued research and clinical trials will be crucial in furthering our understanding of these techniques and their applications in treating hair loss.10

4 vertex. It is a minimally invasive hair restoration procedure that involves the transplantation of tiny hair grafts to address hair loss or baldness which has gained popularity due to its naturallooking results and relatively quick recovery time. The key steps of the procedure include consultation, donor hair extraction, graft preparation, recipient site creation and graft placement. The micrograft technique, along with other hair transplantation techniques such as follicular unit transplantation (FUT) and follicular unit extraction (FUE), offers a viable solution for individuals seeking to restore their hair. The procedure relies on the careful extraction and transplantation of individual hair follicles or follicular units from the donor area to the recipient site. The transplanted hair follicles enter the normal hair growth cycle, resulting in new hair growth over time.

The choice of technique depends on individual factors, such as the extent of hair loss, the quality of the donor area and the patient's goals and expectations. Consulting with a qualified hair transplant specialist is crucial to determine the most suitable technique and to understand the potential outcomes and risks associated with the procedure.

Additionally, ongoing advancements in the field, such as tissue engineering and stem cellConclusion based therapies, may offer Micrograft technique of further opportunities for hair hair treatment is a valuable regrowth treatments. treatment for early stages of androgenetic alopecia stage 1 and stage 2 and for stage 32

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References 1. THIEDKE C.C., Alopecia in Women, AMERICAN FAMILY PHYSICIAN, VOLUME 67, NUMBER 5, MARCH 1, 2003, 2003;67(5):1007-1014 2. Jones M.C., Treatment Options for Androgenetic Alopecia, US Pharm. 2018;43(8):12-16.

3. 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 4. Rafael G. Ruiz etal , Progenitorcell-enriched micrografts as a novel option for the management of androgenetic alopecia, Journal of cellular physiology, Volume235, Issue5, Pages 4587-4593 , https:// doi.org/10.1002/jcp.29335 5. Gentile, Pietro. “Autologous Cellular Method Using Micrografts of Human Adipose Tissue Derived Follicle Stem Cells in Androgenic Alopecia.” International journal of molecular sciences vol. 20,14 3446. 13 Jul. 2019, doi:10.3390/ ijms20143446 6. Pietro Gentile, The new regenerative and innovative strategies in hair loss, volume 37,100995,July 2021, June 28, 2021DOI:https://doi.org/10.1016/j. eclinm.2021.100995 7. Zari S. Short-Term Efficacy of Autologous Cellular Micrografts in Male and Female Androgenetic Alopecia: A Retrospective Cohort Study. Clin Cosmet Investig Dermatol.

2021;14:1725-1736 https://doi.org/10.2147/CCID. S334807 8. Jong-Hyuk Sung, Effective and economical cell therapy for hair regeneration, Biomedicine &

Androgenetic Alopecia Role of Early Interventions

Pharmacotherapy, Volume 157, 2023,113988, ISSN 0753-3322, https://doi.org/10.1016/j. biopha.2022.113988.

3, May 1997, Pages 165–169, https://doi.org/10.1016/S1090820X(97)80037-4

9. Nepal, Suman; Venkataram, Aniketh; Mysore, Venkataram.

The Role of Adipose Tissue in Hair Regeneration: A Potential Tool for Management?. Journal of Cutaneous and Aesthetic Surgery 14(3):p 295-304, Jul–Sep 2021. | DOI: 10.4103/JCAS.JCAS_47_19 10. Gentile, Pietro et al "Autologous Micrografts from Scalp Tissue: Trichoscopic and Long-Term Clinical Evaluation in Male and Female Androgenetic Alopecia", BioMed Research International, vol. 2020, Article ID 7397162, 10 pages, 2020. https://doi. org/10.1155/2020/7397162 11. Gentile, Pietro et al. “PlateletRich Plasma and Micrografts Enriched with Autologous Human Follicle Mesenchymal Stem Cells Improve Hair ReGrowth in Androgenetic Alopecia.

Biomolecular Pathway Analysis and Clinical Evaluation.” Biomedicines vol. 7,2 27. 8 Apr. 2019, doi:10.3390/biomedicines7020027 12. Barrera A. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp. Plast Reconstr Surg. 2003;112(3):883890. doi:10.1097/01.

PRS.0000072253.54359.7F 13. Uebel, Carlos Oscar. “The Punctiform Technique in Hair Transplantation.” Seminars in Plastic Surgery vol. 19,2 (2005): 109–127. doi:10.1055/s-2005-871727 14. Alfonso Barrera, Micrograft and Minigraft Megasession Hair Transplantation: Review of 100 Consecutive Cases, Aesthetic Surgery Journal, Volume 17, Issue January 2024

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RNI No. MAHENG/2010/44622