RESIDERM DIGITAL March'2024 issue

YOUNG SUCCESSFUL DERMATOLOGISTS OF TOMORROW

Dermatologist is one the specialist which responsible for helping patients with medical conditions of the body's largest and fastest growing organ –i.e. skin. They also specialize in skin appendages, such as hair and nails. These physicians are also be responsible for helping patients with the improvement to their physical appearance as it relates to the skin, hair and nails; for example, lessening the appearance or wrinkles or scars. And for those that have a desire to learn how to become a dermatologist, the career and educational path is a challengingyet; highly rewarding one indeed. The purpose of “RESIDERM”is to provide a forum for discussion of cutting-edge topics in Post graduate medical education in Dermatology from a resident Doctors perspective." It aims at providing high quality research, Personality improvement, tips on study life balance so as to better prepare them to be Dermatologists of tomorrow. The RESIDERM is a neutral platform in which enjoys tremendous good will with the Dermatologists community.Focus to success with young, successful Dermatologist, learning first hand of their journey to success.

Acne Scars - Overview With Various Recent Treatment Modalities

Dr. Kira A Pariath

Junior Resident

Department of Dermatology, Shree Krishna Hospital, Karamsad, Anand, Gujarat,

Dr. Trusha Patel

Junior Resident

Department of Dermatology, Shree Krishna Hospital, Karamsad, Anand, Gujarat,

Dr. RahulKrishna S Kota

Senior Resident

Department of Dermatologist

DU 40

Shree Krishna Hospital, Karamsad, Anand, Gujarat,

Dr. Rita V Vora

M.D.

Department of Dermatology, Shree Krishna Hospital, Karamsad, Anand, Gujarat,

- Dom Daniel Executive Editor & Publisher

10

Microneedling – A Form Of Collagen Induction

Dr. Nilofar Diwan

Senior Resident

Department of Dermatology & Venereology, Pramukhswami

medical college, Shree Krishna hospital, Karamsad, Gujarat, r

Dr. Pragya Nair Professor

Department of Dermatology & Venereology, Pramukhswami

medical college, Shree Krishna hospital, Karamsad, Gujarat, up Clinic

Acne Scars - Overview With Various Recent Treatment Modalities

Dr. Kira A Pariath

Junior Resident

Department of Dermatology, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India.

Dr. Trusha Patel

Junior Resident

Department of Dermatology, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India.

Dr. RahulKrishna S Kota

Senior Resident

Department of Dermatology, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India.

Dr. Rita V Vora

M.D.

Department of Dermatology, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India.

Acne is a chronic, self limiting, wnflammatory disease of pilosebaceous unit, manifesting generally in adolescence with pleomorphic lesions like comedones, papules, nodules, cysts and scar can occur. [1] Based on clinical appearance and relationship to surrounding skin, the acne scars are divided into elevated, dystrophic and depressed. A scar is defined as “the fibrous tissue that replaces normal tissue destroyed

by injury or disease’’.[2] There are two main types of acne scars which are atrophic scars and hypertrophic scars. Our article will be pertaining to atrophic scars with its various treatment modalities. There are basic three types of atrophic scars depending upon width, depth and three dimensional structure[3] which are-Icepack scars - Narrow (diameter is less than 2 mm), deep, sharply marginated, and depressed tracks

that extend vertically to the deep dermis or the subcutaneous tissue.

Boxcar scars - round to oval depression with sharply demarcated vertical edges that are wider at the surface than the icepack scars and do not taper to a point at the base. These scars may be shallow (0.1 to 0.5 mm) or deep (>0.5mm) and the diameter may vary from 1.5mm to 4mm.

Rolling scars - occur from dermal tethering of otherwise relatively normal-appearing skin and are usually wider than 4-5 mm diameter. An abnormal fibrous anchoring from dermis to the subcutis leads to superficial shadowing and to a rolling or undulating appearance of the overlying skin. Hypertrophic scars and keloids are both scars of tissue excess.

Physiological wound healing and scar development - Physiological wound healing progresses through three overlapping phases.

1.Inflammation

2.Proliferation phase

3.Maturation

The balance of synthesis and degradation of scar components shifts into a down regulation of healing to allow the final scar to reach maximum organization and strength.

Acne scar development

There is a complex multistep process involved in physiological wound healing and scar development regulated by several molecules. In such a system, vulnerabilities are common which explains the relative facility of abnormal scar development in an inflammatory disease like acne. [4-5] Acne scar begins when non inflammatory comedones evolve into an inflammatory lesion that ruptures through the weaken infrainfundibular section of the follicle. Perifollicular abcess is the result of such a rupture. This will be repaired without scarring within 7-10 days. Cells grow from the epidermis and appendageal structures to circumscribe the inflammatory reaction. If this is complete there is resolution of the lesion with no sequelae. If however the encapsulation is incomplete and further rupture occurs then the result may be the development of

the fistulous track. If deep dermis is affected sharp-walled or icepacks scars are produced and if more extensive dermal damage occurs broad scars can develop like rolling and boxcar scars.

Therapeutic approach to a patient of acne scar

Different treatment modalities includeTopical therapy for acne

Topical retinoids- include tretinoin, adapelene and tazarotene. Topical retinoids have been shown to exhibit anti inflammatory and antiproliferative activities which should result in a diminished potential for acne scarring in acne vulgaris. They may possibly produce some smoothing of skin around areas of acne scarring through treatment of underlying acne and reduction in inflammation. However, evidence is lacking regarding their effectiveness in treating scars that are already fully formed in the dermis.[6-9] Topical antimicrobial agentsapplication of topical antimicrobial agents such as benzoyl peroxide, clindamycin significantly reduce inflammation and acne lesions therefore the potential to develop acne scars is diminished.

Chemical Peeling- A chemical peeling is the application of a chemical agent to the skin which causes controlled destruction of a part or the entire epidermis with or without the dermis leading to exfoliation and removal of superficial lesions followed by regeneration of new epidermis and dermis tissue.

Superficial peeling- This peeling causes necrosis through the entire epidermis upto the basal layer.[10] Salicylic acid 20-30% followed by Trichloroacetic acid 30% in patients with active acne and box scars. It is most effective for patients with comedonic acne and deeper scars. Tricholoracetic acid (TCA) 25-30% is used in patients with boxcar scars without active lesions in 25% and 30%

concentration and can be used in the same patient to treat scar of different depth. Salicylic acid 25% is used in patients with active acne and macular scars. It has very rapid effect and is safe in dark skin. Glycolic acid 70% is used in macular scars in patients without active acne lesions. Pyruvic acid 40-60% is used in patients with active acne, macular scars and very superficial boxcar scars.

Medium depth- It causes necrosis upto upper reticular dermis. TCA is the most common chemical used in medium peeling. Its destructive activity is related to the activity of the solution. Deep peeling- It causes necrosis upto mid reticular dermis. The solutions for deep peelings are based on a combination of phenol and croton oil. These solutions penetrate to the mid-reticular region and maximize the production of collagen. Dermaroller The mechanism hypothesised for action of percutaneous collagen induction using dermaroller is that it creates thousands of microclefts through the epidermis into the papillary dermis. These wounds create a confluent zone of superficial injury which initiates the normal process of wound healing[11] with release of several growth factors. This stimulates the migration and proliferation of fibroblasts resulting in collagen deposition[12] which continues for months after the injury. Another hypotheses states that on penetration of skin with the microneedles, the cells react with a demarcation current which in addition to the needles own electrical potential results in release of various growth factors. This cuts short the healing process and stimulates the healing phase. Dermaroller also opens pores in upper layers of epidermis and allows creams to be absorbed more effectively by the skin. Down time, significant clinical benefits and lesser side effects compared to selective photothermolysis. Photothermolysis for Fractional treatment of acne scars.In fractional photothermolysis microscopic beams of pixilated light induced small, deep, focal zones which represent a fraction of a treated area where as the surrounding tissue is uninjured. Fractional lasers may be ablative or non ablative. Non ablative fractional photothermolysis has emerged as one of the preferred treatment options in acne scarring,

but the ideal patient for fractional laser skin resurfacing undeniably belongs to skin prototypes I, II, or III, hence its use in Indian skin tones (IV,VI) must be dealt with caution keeping the risk of post inflammatory hyperpigmentation in mind.[13]

Non-ablative and ablative devices for treatment of acne scars

Ablative lasers such as CO2 and Er:YAG laser have efficacy of 2590% for treatment of acne scars but is associated with excessive tissue reaction as erythema and edema, and complications such as pigmentation and scarring. It is less suited for skin types 5–6. As Indians are more commonly having skin types 5 and 6, ablative lasers are not so useful in our case. The 1450nm diode laser is an infrared laser and has now become a common modality for laser treatment of acne in view of its ability to heat the sebaceous glands, thereby reducing seborrhea and improving inflammatory acne. It has been assessed in a randomized, split face, blinded trial and found to improve acne on the non treated side as well, thus suggesting a possibility of a systemic effect of the laser.[14] Recent innovation in non ablative resurfacing is combined fractional laser with bipolar radiofrequency (RF) in a single hand piece followed by fractional RF. It causes reductions in perifollicular inflammation and sebaceous gland areas. This novel device has been shown to be safe and effective for both superficial and deep acne scars with modest improvement and lower post inflammatory hyperpigmentation risk comparable to other resurfacing techniques.[15]

Surgical techniques :

Derma-abrasion for acne scars

Derma-abrasion is one of the most effective therapy for acne scars. Derma-abrasion involves mechanically removing the epidermis and papillary dermis, creating a newly countered open wound to heal by secondary intention. Re-epithelization of derma-abraded skin occurs by upward migration of cells from the adenexal structures including hair follicle, sebaceous gland and sweatducts.[16]

Fillers and fat transfer for treatment of acne scarring

tThe aim is to lift the depression caused by scars, by injecting a filler underneath.

There are several options. Resorbable filler such as hyaluronic acid is a good option. It lasts for 6–12 months. It is expensive but safe. It is indicated for scars with gentle slopes and no sclerosis. Non resorbable fillers carry the risk of granuloma formation. Autologous fat transfer is another option. Scars which are due to tissue loss (atrophic scars) are amenable to fillers and fat transfer.[17] Replacing the volume of the subcutaneous tissue through deeper fillers or autologous fat transplantation can stretch back out the skin and bring the skin to a more even tension and elevation. Most commonly used filler substances are collagens, hyaluronic acids, poly L lactic acid, calcium hydroxyapatite.

Excision

Excision should be used when ones aesthetic goal is to replace a prominent scar with a less conspicuous linear superficial scar excision is often the best option for the treatment of acne scars with cutaneous bridges for persistant cysts and tunnels. It may also be option for certain hypertrophic and keloidal scars.[18] Punch excision is indicated for the treatment of icepack and deep boxcar scars that are less than 3 mm in diameter and scars larger than 3.5 mm are repaired with elliptical excision.

Punch elevation

It has a very narrow indication for deep boxcar scars with basis that are smoothly textured, normal in pigmentation, with vertical walls and not fibrotic.

Dermal grafting

Dermal grafting is indicated for the correction of broad (3mm-2cm) in diameter and linear scars that are soft and distensible.[19] It augments depressed scars while leaving overlying epidermis intact so it is best suited to treat scars with normal overlying skin and a lack of sharp walls.

Subcision

Subcision is designed to address the underlying patho-physiology of rolling acne scars. These scars appear as

broad, undulating depressions on the surface of the skin and lack the sharply delineated edges seen in box scar and icepack scars. Despite their superficial appearance, rolling scars develop from deep fibrous attachments tethering the epidermis to the subcutis. Subcision is designed to severe these fibrous bands,resulting in elevation of the depressed scar to the level of the surrounding skin. Other cutaneous depressions, such as rhytids, depressed skin grafts, surgical wounds, and cellulite dimples are also considered as valid indications for subcision.[20] Author has experience in using ophthalmic keratotome (2.8mm in size) as subcision needle for acne scars with very good results.

Conclusion

Hence, according to our view there is no single modality which will be completely effective in the treatment of acne scars. Combination of treatment options from the above given ones may have to be used in order to benefit the patient completely depending on the acne scar type and patient compliance. Patient compliance is directly related to a cost effective treatment, minimally invasive therapy and least downtime leading to maximum patient satisfaction.

References

1. Simpson NB, Cunliffe WJ. Disorders of sebaceous glands. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook’s Textbook of Dermatology,7th ed., Oxford ; Blackwell publishing; 2004.P.43.143.75

2. “Scar.” The American Heritage Stedman’s Medical Dictionary. Houghton Mifflin Company. 10 Feb. 2009. Available from: http://dictionary. reference.com/browse/scar

3. Su CW, Alizadeh K, Boddie A, Lee RC. The problem scar. Clin Plast Surg 1998; 25: 451-65

4. Fujiwara M, Murugaki Y, Ooshima A. Keloid-derived fibroblasts show increased secretion of factors involved in collagen turnover and depend on matrix metalloproteinase for migration. Br J Dermatol 2005; 153: 295-300.

5. Tsujita-Kyutoku M, Uehara N,

Matsuoka Y et al. Comparison of transforming growth factor-beta/ Smad signalling between normal dermal fibroblasts and fibroblasts derived from central and peripheral areas of keloid lesions. In Vivo 2005; 19: 959-63

6. Rivera A. Acne scarring: a review and current treatment modalities. J Am Acad Dermatol 2008; 59: 659-76

7. Jemec G, Jemec B. Acne: treatment of scars. Clinics in Dermatol 2004; 22:434-8.

8. Frith M, Harmon C. Acne scarring: current treatment options. Dermatol Nursing 2006; 18: 139-42.

9. Kim G, Del Rosso J. Acne scarring: treatment and management. Cosmet Dermatol 2009 (accepted for publication).

10. Chemical peels. In: Rubin MG, editor. Procedures in cosmetic dermatology. Elsevier Inc :2006 p. 1-12.

11. Flabella AF, Falanga V. Wound healing. In: Feinkel RK, Woodley DT editors. The Biology of the Skin. New York: Parethenon; 2001. p. 281-97.

12. Fabbrocini G, Farella N, Monfrecola A, Proietti I, Innocenzi D. Acne scarring treatment using skin needling. Clin Exp Dermatol 2009;34:874-9

13. Lee HS, Lee JH, Ahn GY et al. Fractional photothermolysis for the treatment of acne scars: a report of 27 Korean Patients. J Dermatolog Treat 2008; 19(1): 45-9.

14. Darne S, Hiscutt EL, Seukeran

DC. Evaluation of the clinical efficacy of the 1,450 nm laser in acne vulgaris: A randomised split-face, investigatorblinded clinical trial. Br J Dermatol 2011;165:1256-62

15. Yeunf CK, Chan NP, Shek SY, Chan HH. Evaluation of combined fractional radiofrequency and fractional laser treatment fpr acne scars in Asians. Lasers Surg Med 2012;44:622-30.

16. Campbell RM, Harmon CB. Dermabrassion in our practice. J Drugs Dermatol 2008;7:124-8

17. Jacobs I, Dover JS Kamien MS. Acne scarring: a classification system and review of treatment options. J Am Acad Dermatol 2004; 22: 434-8.

18. Choi JM, Rohrer TE, Kaminer MS, Batra RS. Surgical Approaches to Patients with Scarring. In: Scar Revision. Arndt KA, ed. Elsevier Saunders, 2006: 45-66

19. Swinehart JM. Dermal grafting. Dermatol Clin 2001; 19: 509-22

20. Hexsel DM, Mazzuco R. Subcision: a treatment for cellulite. Int J Dermatol 2000; 39: 539-44.

Quiz 3. What is the ideal ratio of cholesterol, ceramide to essential and non essential fatty acids in an ideal moisturizers for SS patients

A. 3:1:1:1

Quiz 4. Ideal cosmetics for patients with SS would be

A. Mineral based B. Liquid based C. Cream based D. None of the above

17th December'2023

28th April'2024

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

Venue: Hotel Orchid, Nr.Domestic Airport, Vile Parle (E) Mumbai

1 Day Hands on Workshop Training by Masters in Aesthetic Dermatology

Microneedling – A Form Of Collagen Induction Therapy For Acne Scars

Dr. Nilofar Diwan

Senior Resident

Department of Dermatology & Venereology, Pramukhswami medical college, Shree Krishna hospital, Karamsad, Gujarat, India .

Dr. Pragya Nair Professor

Department of Dermatology & Venereology, Pramukhswami medical college, Shree Krishna hospital, Karamsad, Gujarat, India .

Acne vulgaris(AV) is the most common skin disease affecting adolescents and young adults with reported prevalence of nearly 80%. [1] It is characterized by comedones, papules, pustules, nodules and scars involving face, upper back, chest and upper arms. It is due to an interplay of four factors :

(1) Follicular epidermal hyperproliferation with subsequent plugging,

(2) Excess sebum production,

(3) Activity of the commensal bacteria Propionibacterium acnes,

(4) Inflammation. AV has a psychological impact on patient, regardless of the severity or grade of the disease.[2] It cause long-lasting and detrimental psychosocial effects and is associated with depression and anxiety. Furthermore, it causes permanent scarring which is difficult to treat. Acne scars are graded broadly, as atrophic and hypertrophic. Atrophic acne scars have been further classified as ice-pick, rolling, and boxcar.[3] The European acne group

(ECCA) has renamed the atrophic acne scars as V-shaped (ice-pick), U-shaped (boxcar), and W-shaped (rolling).[4] Microneedling, a form of collagen induction therapy introduced in 1997 as a new treatment modality using a device called dermaroller was used as an indication for scars. [5] Important milestones in its development are 1995-Orentreich and Oretreich described subcision or dermal needling for scars.

1997 - Camirand and Doucet described needle dermabrasion using tattoo pistol to treat scars.[6]

2006 - Fernandes developed percutaneous collagen induction (PCI) therapy with dermaroller to initiate the natural post traumatic inflammatory cascade by rolling needles vertically, horizontally, and diagonally with pressure over the treated area. Many therapies like CO2 laser resurfacing, dermabrasion and deep chemical peeling used for the treatment for scars ablate the epidermis with subsequent reepitheliazation, which may render the skin more sensitive to photodamage and dyschromia.

Dermaroller or microneedling in contrary do not damage the skin or remove the epidermal layer. One single microneedling causes tiny wound in skin, as a result of post traumatic response platelets are released, which produce a series of growth factors that promotes the bodies own production of collagen and elastin. It is a safe alternative not only for acne scar, but also for the treatment of post-burn injury, wrinkles, stretch marks and smoothing of skin without the risk of dyspigmentation.[5]

Contraindication

1. Active acne, herpes labialis.

2. Patients with dermatosis like vitiligo, lichen planus and psoriasis as trauma leading to koebnerization can aggravate the dermatosis.

3. Blood clotting disorders and patients on any anticoagulant therapy like warfarin, heparin, as it can cause uncontrolled bleeding.

4. Rosacea.

5. Skin malignancy, moles, warts and solar keratosis: as the needles may disseminate abnormal cells by implantation.

6. Patients who have history of taken isotretinoin with in 6 months. Microneedling is effective in Grade 2 and 3 rolling/box car scars. Good to excellent response is achieved in 88.7% patients studied by Majid,[7] in rolling or boxcar scars and moderate response in pitted scars. Grade 4 scar, linear and deep pitted scars do not respond well which are difficult to treat by laser as well and requires surgical corrections. I have an experience of treating patients of acne scar. Grade 2& 3 scars with response after 2 to 3 sittings [Figure].

Figure 1.

Figure 2.

Figure 3.

Pathophysiology of collagen induction therapy

Needles pierce the stratum corneum,create holes without damaging epidermis. Each pass of rolling produce 16 micro punctures/ cm2. Rolling with dermaroller over an area for 15 times results in approximately 250 holes/cm2. Microneedling aims to stimulate collagen production by producing microwounds and initiating the normal post-inflammatory chemical cascade.

There are 3 phases in the woundhealing process which follow each other in predictable fashion as described by Falabella and Falanga.[8]

Before Treatment (RIGHT SIDE)

Preoperative care

Patients skin should be prepared preoperatively for atleast 1 month with vitamin A and vitamin C cream twice a day to maximize dermal collagen formation as described by Aust.[5] Vitamin A, a retinoic acid is an essential vitamin for skin. It expresses its influence on 400-1000 genes that control proliferation and differentiation of all major cells in epidermis and dermis. Vitamin A may control the release of TGFβ3 in preference to TGFβ1 and TGFβ2. Vitamin C, is essential for production of normal collagen. Percutaneous collagen induction and vitamin A switch on the fibroblast to produce collagen and therefore increases the need for vitamin C.

Procedure

Area to be treated is anesthetised with topical anaesthesia i.e EMLA and covered with cellophane tape for 45 minutes to 1 hour. EMLA removed using normal saline. The skin of face is stretched by one hand while the other hand is used to roll the instrument over in a direction perpendicular to that of stretching force. Roller is rolled 15-20 times in horizontal, vertical and both oblique directions. Base of the scar is to be treated. Pin point bleeding should occur from the base of scar. Saline pads are kept over treated area. Topical antibiotic cream is applied. Whole procedure takes 15-20 minutes. Treatment is to be repeated after 4-6 weeks.

1. Platelets and neutrophils release growth factors such as, TGF, platelet derived growth factor, connective tissue activating protein, connective tissue growth factor which all increase the production of intercellular matrix.

2. Monocytes then release growth factor to increase the production of collagen, elastin, glycosaminoglycans. After 5 days of injury – a fibronectin matrix forms with an alignment of fibroblast that determines the deposition of collagen, which remains for 5 – 7 years and tightens naturally.

3. It also increases gene and protein expression of collagen, glycosamino glycans and growth factors, vascular endothelial growth factor, epidermal growth factor, fibroblast growth factor which are relevant for skin regeneration. Collagen fibre bundles qualitatively increases, thickens and more loosely woven in both papillary and reticular dermis. It appears to have laid down in normal lattice pattern than in parallel bundles as in scar tissue.[9] Neovascularization and neocollagenesis following treatment leads to reduction of scars.

Postoperative care

Treated area is swollen and superficially bruised. To absorb the bleeding and serous discharge, it should be covered with cool, damp swabs that are replaced for 2 hours. Topical antibiotic cream (mupirocin) is applied for few days to minimize the chance of bacterial infection. Avoid sun exposure & harsh chemicals or any cosmetic procedure over the face for atleast for one week.

Figure 3.

After Three Sittings(LEFT SIDE)

After Three Sittings(RIGHT SIDE)

Before Treatment (LEFT SIDE)

Side effects

They are almost neglible

1. Pain.

2. Reactivation of herpes simplex.

3. Impetigo.

4. Allergic contact dermatitis to the material used in needles.

5. Exposure to blood.

6. Poor quality needles of the roller device often result in bending at needle tips after repeated treatments, which results in more tissue damages and haemorrhage with linear hypertrophic scars or post inflammatory hyperpigmentation. Over aggressive needling may also cause scarring using a tattoo gun but not with special barrel of needles.

Advantages

1. It has a short healing time.

2. It can be used in any type of skin where lasers and deep peels cannot be performed.

3. It is a convenient office procedure and cost effective than other alternative therapy like laser.

4. Well tolerated by patients.

5. No risk of post –inflammatory hyperpigmentation. Interleukin10 was increased after PCI therapy while expression of MCIR (Melanocortin l receptor) gene coding for a melanocyte stimulating hormones indicates a faint down regulation upto 2 weeks post operatively, therefore in opposite to dermabrasion, PCI therapy appear to have lower risk of dyspigmentation.[5]

6. Microneedling can be combined with other acne scar treatment like subcision, chemical peeling, microdermabrasion and fractional

resurfacing giving maximum benefits.

7. Technique is easy to master.

8. It can be done on people who have had laser resurfacing or have very thin skin.

References

1. Cunliffe WJ, Gould DJ. Prevalence of facial acne vulgaris in late adolescence and in adults. Br Med J 1979;1:1109-

2. Kellett SC, Gawkrodger DJ. The psychological and emotional impact of acne and the effect of treatment with isotretinoin. Br J Dermatol. 1999 Feb.

3. Jacob CI, Dover JS, Kaminer MS. Acne scarring: A classification system and review of treatm options. J Am Acad Dermatol 2001;45:109-17.

4. Dreno B, Khammari A, Orain N,Noray C, Mirial-Kieny C, Miry S, et al . ECCA grading scale: An original validated acne scar grading scale for clinical practice in dermatology. Dermatology 2007;214:46-51.

5. Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy: An alternative treatment for scars, Wrinkles and skin laxity. Plast Reconstr Surg 2008;121:1421-9.

6. Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast Surg 1997;21:48-51.

7. Imran Majid. Microneedling Therapy in Atrophic Facial Scars: An ObjectiveAssessment. J CutanAesthet Surg 2009;2:26–30.— 15

8. Fernandes D. Minimally invasive percutaneous collagen Induction. Oral Maxillofac Surg Clin North Am 2005;17:51-63.

9. Bandyopadhyay B, Fan J, Guan

Quiz 5.What is the dosage of Polypodium leucotomos

S, Li Y, Chen M, Woodley DT, Li W. A “traffic control” role for TGFbeta3: Orchestrating dermal and epidermal cell motility during wound healing. J Cell Biol 2006;172:1093-105.

A. 200 mg/day B.480-1200mg/day C. 2000mg/day D. 4800 mg/day

Quiz 6.what is the role of 595 nm QS Nd:YAG laser in SS

A. reduces erythema B. Reduces acne C. reduces symptoms D. All of the above

Start Up Clinic Dr. PQR

How to Open a Private Medical Practice, Step by Step

Opening your own medical practice is an exciting way to take the practice of medicine into your own hands. Unfortunately, it is also complicated and challenging. To ensure success, it's critical to have a clear and detailed plan at the outset that can help keep things moving on schedule. Between putting together a team, finding financing and choosing equipment, opening your own medical practice is already a big undertaking. Add in moving parts that depend on other organizations, such as completing insurance credentialing and securing a tax ID, and you've got a herculean effort on your hands.

Why open your own practice?

The inherent risk, upfront expenses and difficulty of opening your own practice may explain the breakneck pace of consolidation within the healthcare industry. According to Becker's Hospital Review, forprofit insurers control 43 percent of the market, while 60 percent of community hospitals are part of an enterprise health system. That trend is likely to continue through 2025, when the healthcare industry is projected to reach $5.5 billion in value. The influence of large enterprise systems and big-name hospitals over healthcare providers has grown as control of the industry has become concentrated in fewer hands. For many providers, joining these conglomerates seems to be the only realistic choice. Indeed, after spending so much money and time attending medical school, why go through the risk and trouble of starting your own practice when you could simply step into a well-paying job, where business operations are already established and there are no overhead costs to you? For starters, when smaller, private practices open, it means more competition and more widespread distribution of profits

throughout the industry. It also means that more healthcare providers are granted more autonomy, becoming free to determine their own workflows. Another major by product of proliferating smaller practices is that they help expand healthcare access to local areas that might currently be underserved. Also, the ability to "be your own boss" is a large draw for entrepreneurial providers who choose to enter private practice. The sense of ownership and agency that comes with running your own practice is unmatched in a larger hospital system. The good news is that as difficult as it can be to get your practice started, it's well within reach if you have the right information.

Step 1: Creating a pro forma and obtaining financing

A pro forma is essentially the lighter version of a full-blown business plan, with revenue and debt projections grounded in reality. In your pro forma, account for all your expenses, debt and anticipated revenues. Bankers can tell what projections are realistic and which aren't; it's their job to make wise investments, so you'll want to back up any numbers you use. A strong pro forma will project at least three years into the future, sometimes as far as five years out.

"The first thing you need to do is build a pro forma, which basically tells the story of what your revenue will be from the first until at least the third year, because you need to go out and get financing,You're not going to get capital to start your business without a solid business plan," Reiboldt said.

"We show cash flow needs and debt

projections by month, or at least by quarter. Furthermore, in healthcare you don't get paid very much when you perform the services. You're really at the mercy of the insurance companies and the government. So, there is a tremendous lag … on cash flow on top of this tremendous capital investment you're making."

Some financing tips

1. Find the specialists. Submit your pro forma and loan request to the medical/dental division of the bank, if it has one. These people specialize in the healthcare industry and understand the risks, expenses and revenue models of that sector.

2. Shop around. Submit your pro forma and loan request at five to 10 banks. That way, you'll receive several offers, each with slightly different terms. Prioritize what terms are most important to you – interest rate, amortization schedule, etc. – and then make your selection based on which offer you deem most attractive.

3. Stay conservative. When creating your pro forma, maintain a conservative approach to purchasing equipment and furniture – and stick to it. You don't need leather chairs and cutting-edge machinery just yet.

4. Use the waiting period wisely. While the banks are reviewing your pro forma and considering whether to approve your loan request, you can prepare to tackle some of the next crucial steps, like signing a lease, determining whether you'll need to hire a contractor to modify your space, incorporating as a legal entity, obtaining a tax ID, buying liability and malpractice insurance, and credentialing with your payers.

Step 2: Purchasing equipment and staffing your practice

Once you've obtained a loan and opened a line of credit, you're ready to start putting together the meat and potatoes of your practice – hiring your team and purchasing the equipment you'll need. This task is easier said than done, and ample research is necessary for each decision.

1. Electronic health record system

Electronic health record (EHR) systems are increasingly universal tools of the trade for medical providers. Digitizing records and streamlining communication is a high priority for the modern healthcare provider.

2. Practice management system

Your practice management system is the lifeblood of your practice. Integrated with your EHR system, a practice management system keeps track of all your front-office information and facilitates operations. Chief among its uses is conducting and monitoring your billing and revenue cycle. Not only will your staff use the practice management system to bill patients and send claims to payers, but any relevant information will be shared between the EHR system and the practice management software, eliminating the need to duplicate records.

3. Medical billing service

Of course, you can always outsource your billing to a third-party company. You'll still need a practice management system, but then your staff won't be responsible for overseeing the billing process. Not only is submitting claims time-consuming and difficult, but your staff would also be responsible for responding to rejected or denied claims to get the money due to

your practice. When you opt for a third-party billing service, that burden shifts to the company you've contracted with. Still, there are a lot of potential problems with a thirdparty biller. You'll want to consider how medical transcription fits into your practice. There are typically three ways a medical practice performs transcription: in-house with a staff member, via voice recognition software, or outsourced to a medical transcription service. The key aspects are timeliness and accuracy.

4. Background check services

Medical practices are founded on trust. Not only do they handle a lot of sensitive patient information every day, but people are literally trusting the practice with their lives. That extends beyond exams, diagnoses and treatments. You'll want to know and be able to trust your staff, which means employing a background check system. Of course, you'll be interested in criminal and employment histories, but healthcare providers have more to consider beyond what the average background check provides. There are also required certifications and licenses to consider. Failing to ensure your staff isn't properly credentialed could result in big problems for your practice.

5. Credit card processor

Although you'll be making most of your money through payers like insurance companies or Medicare, your practice is going to need a credit card processor for when patients have to pay at the point of care. Not only has the world of credit card processing changed lately, with the addition of EMV chips and other security measures, but some systems are more suited to the medical field than others. Our best pick offers additional security and is a participant in the American Medical Association's Member Value Program, which partners with vendors to provide discounts and perks to medical practitioners.

6. Office manager

As you assemble your front-office team, you'll need a reliable office manager to run the day-to-day operations of your practice. Of course, this person must be responsible and dedicated, but those qualities are not

enough. You'll also need someone with the necessary experience. "You need to decide how you're going to staff your practice. Who's going to help you run your practice? A friend? A nurse? Your spouse?" said Zetter. "If you get an accountant to do it, get one that knows how to run a medical practice.

Step 3: Preparing to open

You must complete several logistical steps before you can open your doors. These things should really be done in conjunction with steps 1 and 2. Credentialing, for example, can take quite a while and depends on the pace at which other organizations operate.

1. Incorporating as a legal entity and obtaining a tax ID

This one is self-explanatory but extraordinarily important. The main reason for incorporation is limited liability, which means if you're sued, only the assets held by the company are subject to any risk. Without incorporating, you've opened up your personal assets to the threat of a lawsuit. Moreover, as Medical Economics notes, certain tax benefits are associated with each type of entity. Whether you incorporate as an S-corp or LLC, a C-corp or a general partnership, it's important to do your research on each type of entity and the potential benefits it offers your practice.

2. Credentialing physicians with payers

You will also need to get your healthcare providers credentialed to submit claims to the payers you'll be working with. The credentialing process can take up to three months, but Physicians Practice suggests giving yourself as long as 150 days, in case something goes awry. You'll need to navigate the process for each payer you plan on submitting claims to, which includes offering up information on each physician's work history, proof of malpractice insurance, hospital privileges, attestations and more.

3. Establishing policies, procedures and compliance documentation

A set of responsible, current, and verifiable policies and procedures, in

addition to compliance with all legal regulations, is a vital component of your practice's success. These standards should cover all your daily operations, including data entry, billing and interactions with patients. Since the healthcare environment is always changing, you'll want to periodically update your policies and procedures as well, lest they become antiquated and ineffective.

4. Purchasing insurance

Every business owner understands the importance of insurance, but for medical professionals, it's even more crucial. First and foremost, you'll want to be covered by malpractice insurance. Beyond that, it's likely that the bank issuing your loan will require you to adopt additional coverage, though the exact kind might vary from bank to bank. At the very least, Zetter said, be prepared to purchase malpractice, liability and life insurance policies when planning to open your medical practice. "You have to start thinking about insurance," Zetter said. "[You'll need] malpractice and general liability. You will probably at least need life and liability insurance, just because bankers will require it."

Step 4: Opening your doors and evaluating practice performance

Congratulations! If you've reached this point, you've already put in plenty of blood, sweat and tears, and haven't seen a dime in compensation for it. But it surely will all be worth it when you get the chance to cut that ribbon and welcome your first patients to your very own practice. It's an accomplishment plenty of healthcare providers don't get to enjoy in the modern medical industry, so pat yourself on the back. "Once you've got all of this designed and planned, you roll up your sleeves and get ready for opening day.

1. Construction needs: If you need to perform any kind of construction on your office space, make sure you start as early as possible. Otherwise, you might find yourself well past your target opening date without a workable space. It's always best to find a turnkey location where you can immediately set up shop, but, realistically, such space is not always available. Make sure you evaluate your location early on and determine exactly what work needs to be done, then get to hiring the contractors who will do it. With luck and planning, construction will be complete by the time you're ready to start purchasing equipment.

2. Changing regulations and payer rules: The healthcare industry is a highly regulated one, with complex rules surrounding virtually everything a provider does. For a small practice, which doesn't have legions of attorneys on retainer like a large hospital system does, it can be difficult to navigate the web of legal requirements and payer rules. However, it is extremely important that your practice understands what it takes to be in compliance. In fact, the rules governing the healthcare industry are constantly being changed and updated, so even if you comply today, you'll have to keep an eye on the future.

3. Marketing: With all the necessary preparation prior to opening combined with the hustle and bustle of treating patients once you do open, it can be easy to forget about marketing. Marketing and advertising are as fundamental to a private medical practice as it is to a Dunkin' Donuts franchise, particularly for those general practitioners who won't be able to rely on a referral network for their patients. "One thing you would plan for prior to opening and then continuously do after opening is marketing," Reiboldt said. "This is a patient-caring, disease-treating business, but with that said, it is a business.

4. Advisors: This guide, however informative, is certainly not exhaustive, and no amount of research can possibly prepare you for everything that might happen as you get started. For that, you need real experience, and there are plenty of professionals who have experience in spades.

5. Meaningful Use standards: The healthcare industry is currently going through a period of digitization, largely focused on the adoption of electronic medical records (EMR) software and practice management software. Now known as Promoting Interoperability (PI), the meaningful use standards prescribed by the Center for Medicare and Medicaid Services lay out exactly

"Opening a new medical practice will be the most exhilarating and scary thing that you will ever do in your career," Inselman said. "When we coach our clients on opening up a medical, dental, chiropractic or any other healthcare practice, the first thing we advise is to assemble your team.

5. Meaningful Use standards: The healthcare industry is currently going through a period of digitization, largely focused on the adoption of electronic medical records (EMR) software and practice management software. Now known as Promoting Interoperability (PI), the meaningful use standards prescribed by the Center for Medicare and Medicaid Services lay out exactly

Quiz 11.With respect to chemical peel formulation for SS

a. Gels are better than alchol based

b. Alchol based are better than gel based

c. Not to be used in patients of SS d. Formulation does not matter

Quiz 12.Newer peels that can be used in SS include

a. Polyhydroxy acids &Lactolionic acid

b. A-hydroxy acids &Lactolionic acid

c. B-Hydroxy acid&Lactolionic acid d. None of the above

May 2019 26

Quiz 11.With respect to chemical peel formulation for SS

a. Gels are better than alchol based

b. Alchol based are better than gel based

c. Not to be used in patients of SS d. Formulation does not matter

Quiz 12.Newer peels that can be used in SS include

a. Polyhydroxy acids &Lactolionic acid

b. A-hydroxy acids &Lactolionic acid

c. B-Hydroxy acid&Lactolionic acid d. None of the above