RESIDERM January'2024 Digital issue

R.N.I No. MAHENG/2017/ 71390 Total Pages : 24 January 2024 Vol 4* Issue 1 100

Epidermodysplasia Verruciformis, Squamous Cell Carcinoma,

BASAL CELL CARCINOMA, HERPES PAPILLOMA VIRUS,

Vigtiligo, Cutaneous Depigmentation, Melanogenesis,

YOUNG DERMATOLOGIST, LEADERSHIP, POLITENESS, MANAGERIAL Skills, Domestic Life, Work life, Start up Clinic,

PRACTICE MANAGEMENT, CLIMB UP, BE HONEST, Confidence, Indulge, Pilot, Quick buck

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TODAY A RESIDERM – TOMORROW A

Role Of Diet In Vitiligo Dr. Varsha K L, 2nd Year Resident Dr. Sudha Vani, MD, Associate Professor

Epidermodysplasia Verruciformis Masquerading As Non-Melanoma

CONGRATS!!!!

YOU are amongst the privileged few to be a ResiDerm The joys of Residency are accompanied by challenges and struggles including burnout as you develop your professional identity.

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“RESIDERM ” is your Platform to connect with your colleagues who are Resident Dermatologists across India” It aims at providing high quality medical research work and papers from residents in Dermatology, tips on personality improvement, study life balance, practice management , start up guidance , training etc so as to better prepare you to be Dermatologists of tomorrow.

Dr. Reema Joshi, Assistant Professor

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Connecting Young Dermatologist

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Editorial Board Dr. Varsha K L. Dr. Sudha Vani, Dr. Palvi Singla, Dr. Reema Joshi, Dr. Bela K Shah, Dr. Ishad Aggarwal, Dr. Satish Bhatia, Dr. Ganesh Pai.

Start up India Start up clinic Dr. Satish Bhatia

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19 Dr. Ganesh Pai M. D. January 2024

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Role Of Diet In Vitiligo

Role Of Diet In Vitiligo Dr. Varsha K L

2nd Year Resident Department of DVL, Gandhi Medical College, Telangana, Hyderabad.

Dr. Sudha Vani

MD Associate Professor Department of DVL, Osmania Medical college, Hyderabad.

Ex Assistant Professor, Department of DVL, Gandhi Medical College, Telangana, Hyderabad.

Introduction

these factors into account .²

Vitiligo is a common form of localised depigmentation. It is an acquired condition resulting from the progressive loss of melanocytes, clinically characterised by milky white sharply demarcated macules.¹

Treating the cases of cutaneous depigmentation though challenging, is evolving due to recent advances made in understanding pathogenesis and availability of newer modalities of treatment like excimer laser, phototherapy, epidermal grafts and life style modification. These treatments have improved the results of treatment and quality of lives of patients with vitiligo. Nevertheless, many patients seek alternative medical options including Ayurveda, Homeopathy for treatment of their Vitiligo. Dermatologist should have an objective point of view on how to use and combine complementary and alternative medicine with modern medicine .³

Though considered an autoimmune disorder, controversy still exists regarding its true etiopathogenesis.

Oxidative stress theory, neurogenic theory, immune dysregulation, T cell mediated destruction are among the various other hypothesis. The most accepted and evidence claimed one is 'integrated theory', wherein loss of melanocytes may be the result of different pathogenetic mechanisms working together.² Certain factors like trauma, eczema, chemical agents play a role in development of vitiligo, so treatment decisions should be made taking

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Role of diet in Vitiligo One of the issue which has created lot of chaos among the Dermatologist

Role Of Diet In Vitiligo and the patients is the role of diet in vitiligo. Due to popular belief of alternative medicine in diet as either beneficial or harmful, many patients are advised on unnecessary dietary restriction or supplementation. A thorough scientific knowledge on role of diet in vitiligo is essential to address these patients.

Table 1: List of micro nutrients / antioxidant, probable mechanism of action and dietary sources found beneficial in vitiligo.3,4,5,6,7 Micronutrients

Probable mechanism of action

Dietary sources

Phenylalanine

1. Essential amino acid, precursor of tyrosine in melanin biosynthesis.

Protein rich foods – milk, meat, fish, chicken, eggs, beans and nuts.

(Hypothetised that metabolism and uptake is defective in vitiligo patients )

According to Vitiligo Support International group, there is no 'Vitiligo Diet’. A healthy diet with balanced nutrition from variety of sources is a good way to support the immune system.

2. Phenylalanine may interfere with antibody production.

Diet is often recommended as beneficial based on amount of antioxidants, vitamins and minerals and is said detrimental based on food additives which could cause allergic / irritant reaction or by causing oxidative stress on melanocytes leading to exacerbation of vitiligo.

Zinc

1. Regulation of gene expression - Meat, shellfish, legumes, For apoptosis. nuts, whole grains, eggs, dairy products, potatoes, green beans, 2. Cofactor of super oxide dark chocolate. dismutase.

A. What foods are recommended?

Copper

1. Cofactor enzyme.

As mentioned above a balanced healthy diet is what is advised along with usual therapies like topical immunomodulators or phototherapy.

As evidence suggests food sources rich in proteins, antioxidants and minerals are crucial, as they are involved either in melanin synthesis or preventing melanocytic destruction.

For example a phenylalanine rich protein food, supplements the body with non essential amino acid tyrosine which is the key ingredient for melanin synthesis.

Microelements like copper, zinc serves as cofactors for tyrosinase enzyme during melanogenesis.

Antioxidants rich food reduces the reactive oxygen species involved in destruction of melanocytes in Vitiligo.

Antioxidant rich food containing carotenoids, quercetin, vitamin C, vitamin E, vitamin B12, folic acid, vitamin D, alpha lipoic acid, coenzyme Q10, omega 3 fatty acids and gamma linolenic acid etc. protects

for

tyrosinase

2. Antioxidant

Vitamin C

1. Antioxidant Reduction of malonaldehyde content, a biomarker of lipid oxidation.

Liver, oysters, nuts, seeds, dark chocolate, leafy vegetables, mushrooms.

Citrus fruits, sour food items, tamarind, tomatoes, chocolate, coffee, berries.

- Advantages outweigh the risk of hypopigmentation.

Vitamin B12 and folic acid

1. Association Anemia.

with

pernicious

2. Elevated homocysteine may cause direct damage to melanocytes by oxidative stress.

Quercetin

1. Potent antioxidant

B12 – Animal source – liver, kidney, beef, shellfish, fortified foods.

Folic acid – plant sources – legumes, asparagus, eggs, beets, citrus fruits, broccoli, kiwi greens.

Onion, mushrooms, broccoli.

apples, grapes,

2. Anti inflammatory

3. Immunomodulatory

January 2024

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Role Of Diet In Vitiligo Vitamin D

1. Associated with autoimmunity

Fatty fish, fortified food.

Carotenoids

1. Antioxidant

Carrots, sweet potatoes, green leafy vegetables, apricots, red and yellow peppers.

2. Carotenoid coloration

Omega 3 fatty 1. Anti inflammatory acids and PUFA (Polyunsaturated Fatty Acids) 2. Antioxidant

eggs,

Fish oil, vegetable oil, evening primrose oil, granola, chia seeds, flax seed.

3. Anti depressant

Co Q10

1. Antioxidant

Liver and heart of beef, pork, chicken, fatty fish, oils of soyabean, corn and olive, peanuts, pistachio.

melanocytes from stress reactions.

B. What food needs to be avoided?

Processed foods such as those found in cans or bottles, and preserved or tinned meats, sausages contain Various food additives including dyes, color retention agents, defoaming agents, emulsifiers, flavours, fungicides, preservatives, sweetners, thickeners and chemicals introduced at the agricultural or animal husbandry phases.

While these additives are generally considered harmful in vitiligo, the medical evidence for these harmful effects is weak. Consuming food additives in large amounts can also increase the risk of stress reaction.

These can have harmful effects on vitiligo.

Dermatologists ought to consider the harmful effects of food additives,

Alpha lipoic acid

1. Antioxidant

Spinach, broccoli, potatoes, yeast, sprouts, beets, rice bran, red meat.

Gingko biloba

1. Anti inflammatory (reduced COX- Cyclooxygenase activity, reduces response to TNF alpha).

Chinese herb Gingko biloba / supplements.

2. Immunomodulatory

3. Antioxidant Polypodium leucotomos (Polyphenol compound)

1. Antioxidant

2. Photosensitizing

3. Immunomodulatory action

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Fern plant / supplements.

Role Of Diet In Vitiligo Table 2: List of agents, probable mechanism of action and dietary sources found harmful in vitiligo.3,4,5,6,7 Vitamin C

1. Alternative medicine like Ayurveda and homeopathy claims it as aggravating factors.

2. No evidence Plant phenol and polyphenolic compounds , tannins

1. Anti tyrosinase activity

Tamarind, tomatoes, citrus fruits, grapes, papaya, sour food.

Mangoes, cashews, pista, areca nuts, cassava, berries, tea.

particularly in unstable and progressive vitiligo, although these are not so much of concern in stable vitiligo.

Conclusion Though current research doesn’t fully substantiate the role of diet in vitiligo, most Dermatologists recommend a healthy diet to slow down the progression of vitiligo. A healthy skin is prerequisite for a healthy body and skin being the largest organ, certainly requires a healthy diet to stay healthy.

References Nickel

Barbecued food

1. Associated nickel allergy cause cutaneous reaction.

1. Increased production of oxygen free radicals and carcinogens in body .

Instant tea, chocolate, wheat flour, roasted cashews.

Barbecued meat, fish, vegetable, fruits.

2. Lower antioxidant levels

1. Bologna

J,

Pawelek

JM.

Biology

of

hypopigmentation. J Am Academy Dermatol 1988; 19:217-55.

2. Rooks textbook of dermatology, 9th edition, 2016, Vol3, vitiligo:88.35.

3.

Akyol M et al . The effects of vitamin E

on the skin lipid peroxidation and the clinical improvement in vitiligo patients treated with PUVA . EUR J Dermatol . 2002; 12:24-6.

4. Middelkamp-hup MA et al. Treatment of vitiligo vulagris with narrow band UVB and oral polypodium leucotomos extract: a randomised

Preserved food (sodium benzoate, potassium sorbate.

Sodium propionate )

1. Intolerance reaction

2. Increased oxidative stress

All preserved and processed food.

double blind placebo controlled study. J Eye Acad Dermatol Venereology.2007; 21:942-50.

5. Szczurko O

et al. Effectiveness of oral

Gingko biloba for treatment of Vitiligo vulgaris: an open label pilot clinical trial. BMC complement altern med. 2011;11:21.

6. Evangeline B. Handing et al . Melasma and vitiligo in brown skin, 1st edition. 2017;327-37 .

7.

Coloring agent (sodium nitrate and others)

1. Intolerance reaction

Mono sodium glutamate

1. Intolerance reaction

All artificially coloured food.

Kelly KyungHwa Park et al. Vitiligo –

management and therapy.2011; 143-152.

2. Increased oxidative stress Food with added taste maker.

2. Increased oxidative stress

January 2024

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EPIDERMODYSPLASIA VERRUCIFORMIS MASQUERADING AS NON-MELANOMA SKIN CANCER

Epidermodysplasia Verruciformis Masquerading As Non-Melanoma Skin Cancer Dr. Palvi Singla

3rd Year Resident Department of Dermatology, B.J. Medical College and Civil Hospital, Ahmedabad - 380016

Dr. Reema Joshi

Assistant Professor Department of Dermatology, B.J. Medical College and Civil Hospital, Ahmedabad - 380016

Dr. Bela K Shah

Head and Professor Department of Dermatology, B.J. Medical College and Civil Hospital, Ahmedabad - 380016

Abstract Epidermodysplasia verruciformis, an autosomal recessive inherited disorder caused by HPV in patients with impaired cell mediated immunity.

The disseminated wart-like or pityriasis versicolor-like lesions persist from early childhood.¹ Cutaneous carcinoma can develop in one-third of these patients in adult life. We are reporting 3 adult patients who came to us with carcinoma being their primary concern who were diagnosed as epidermodysplasia verruciformis on further investigations.

A 42 year old male, presented with

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multiple hypopigmented macules over trunk and extremities since early childhood with hyperkeratotic verrucous growths over scalp, face and trunk since 5 years.

Hyperkeratotic lesion over right cheek progressed to ulcer formation over last 2 years. Another 49 year old male came with reddish brown plaques on the trunk, extremities and the face and verrucous lesions over face and arms since 10 years of age. There was asymptomatic nonhealing ulcer over nose since last 3 years. A 58 year old male came with multiple asymptomatic warty lesions on face and extremities and

EPIDERMODYSPLASIA VERRUCIFORMIS MASQUERADING AS NON-MELANOMA SKIN CANCER multiple light colored flat lesions on the trunk and extremities since 15 years of age. Ulceration developed in one of lesions over face since 4 years. Histopathology of first two patients’ ulcerated lesions suggested squamous cell carcinoma and in third patient changes of basal cell carcinoma were seen. In case of first two patients were referred to cancer institute where surgical excision was performed while third patient was started on topical imiquimod thrice/ week.

Key words: Epidermodysplasia Verruciformis (EDV), Squamous cell carcinoma, Basal cell carcinoma, Herpes papilloma virus.

Figure 1

Figure 4 : Multiple verrucous and ulcerated lesions over scalp

Key message: Epidermodysplasia Verruciformis is an AR (autosomal recessive) condition, none of the available therapies are curative.

Lifetime and Regular follow up is necessary to see for any malignancy developing on the lesions of EDV so that early intervention can help patient to lead a normal life.

Introduction Epidermodysplasia verruciformis also known as Lewandowski and Lutz dysplasia is a rare disorder caused

by HPV in patients. It is a complex interplay of 3 factors: genetic factors, immunological factors and HPV infection.The disseminated wart-like or pityriasis versicolor-like lesions persist from early childhood and in about one-third of patients, cutaneous carcinoma develops in adult life.

Figure 2 Figure 1 & 2 : Non-scaly hypopigmented pityriasis versicolorlike lesions on trunk.

Case Report 1. A 42 year old male, presented with multiple white flat lesions over trunk and extremities since early childhood with brownish- black growths over scalp, face and trunk since last 5 years. He developed ulceration over one of those lesions on right cheek since last 2 years.Family history was negative.

On Examination, he had multiple non-scaly hypopigmented pityriasis

Figure 5 : Ulcerated hyperkeratotic growths over right cheek. versicolor like macules over trunk and extremities (Figure - 1,2) and hyperkeratotic growths over scalp, face and trunk (Figure - 3,4). On right cheek there was an ulcer of approximately 3 x 4cm with hyperkeratotic border.(Figure-5).

Provisional diagnosis of Epidermodysplasia Verruciformis was made.

Routine Laboratory investigations i.e.Complete blood count, Urinalysis, Serum glucose level, Renal and Hepatic biochemical parameters were normal.

Figure 3 : Multiple verrucous and ulcerated lesions over face.

Systemic tumor markers were negative and Chest X-ray was normal.

Biopsy was taken from two sites: 1) Verrucous lesion over right forearm showed Keratinocyte with

January 2024

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EPIDERMODYSPLASIA VERRUCIFORMIS MASQUERADING AS NON-MELANOMA SKIN CANCER

Figure 6: On 40 x, H&E stain: Multiple atypical cells and irregular masses of epidermal cells invading epidermis and sebaceous glands.

Figure 9 Figure 8&9 : The flesh-colored, flat-topped papules and plaques on dorsa of both forearms.

bluish cytoplasm and vacuolization suggestive of HPV infection confirming diagnosis of Epidermodysplasia Verruciformis.

suggestive of HPV infection.

2) From border of ulcer over nose showed nests of squamous epithelial cells arising from the epidermis and extending into the dermis and tumor cells with hyperchromatic and hyperplastic nuclei suggestive of squamous cell carcinoma (Figure-11).

2) Ulcerated lesion over right cheek showed multiple atypical cells and irregular masses of epidermal cells that proliferate downward into the dermis suggestive of squamous cell carcinoma (Figure-6).

2. A 49 year old male came with asymptomatic brownish raised lesions on the face, neck, trunk and extremities and flat reddish elevated

Figure 11: On 40 x, H&E stain: Tumor cells with hyperchromatic and hyperplastic nuclei.

So diagnosis of Epidermodysplasia Verruciformis with Squamous cell carcinoma was made.

Figure 10 : Single Nodulo-ulcerative lesion over nose. lesions over face and arms since 10 years of age. He also had non-healing ulcer over nose since last 3 years.

3. A 58 year old male came with multiple asymptomatic black colored flat lesions on face and extremities and multiple light colored flat lesions on the trunk and extremities, since 15 years of age. These lesions had appeared over a period of time and were progressively increasing in number, size and area of involvement.

On examination, there were reddish brown pigmented plaques over face, neck, trunk and extremities (Figure-7) and flesh-colored, flat-topped papules and plaques on dorsa of both forearms (Figure-8,9). Single approximately 2 x 3cm ulcer was present over nose (Figure-10).

Figure 7 : Multiple erythematous to brown colored patches over neck.

All routine blood investigations were normal.

On taking skin biopsy from 1) From flat raised lesion over left forearm showed hyperkeratosis and acanthosis along with vacuolation or ballooning in the perinuclear area of keratinocytes i.e.koilocytes

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Figure 12: Multiple hyperpigmented hyperkeratotic lesions over face.

EPIDERMODYSPLASIA VERRUCIFORMIS MASQUERADING AS NON-MELANOMA SKIN CANCER to a locus on chromosome 17q 25 that encodes zinc-containing transmembrane proteins (TMC6 and TMC8, respectively).4 Patients usually presents with plane warts, pityriasis versicolor-like lesions and reddish verrucous plaques over sun exposed areas like face, neck, trunk and extremities.5

Figure 14: Multiple hypopigmented macules over trunk.

Figure 16: On 40 x, H&E stain: Islands of basaloid cells suggestive of 1) From hyperkeratoticlesion over left forearm- hyperkeratosis and koilocytes were seen suggesting verrucous lesions of Epidermodysplasia Verruciformis.

2) From hyperpigmented plaque over face- Keratinocyte atypia diagnosing it as actinic keratosis.

3) From ulcerated lesion over forehead-showed nodular masses of basaloid cells are extending into the dermis cells suggestive of basal cell carcinoma (Figure-16).

Figure 15: The actinic keratosis and tumoral lesion on the forehead.

Ulceration developed in one of lesions over forehead since last 4 years. No family member has positive history of similar lesions.

On examination, there were multiple hyperpigmented hyperkeratotic lesions over face and bilateral upper limbs (Figure-12, 13) and multiple hypopigmented pityriasis versicolor like lesions over trunk (Figure-14). He also had single ulcer approximately 1 x 2cm over right temporal aspect of scalp (Figure-15).

On histopathology

So diagnosis of Epidermodysplasia Verruciformis with Basal cell carcinoma was made.

First two patients were referred to cancer institute where surgical excision was performed and they are on regular follow up of 3 months.

Third patient was given Imiquimod 3/ week and cryotherapy to which he responded beautifully.

Discussion Epidermodysplasia verruciformis (EV) is an autosomal recessive, characterized by susceptibility to cutaneous infection by a group of 20 HPV most commonly by types 5, 8, 9, 12, 14, 15, 17 and 19–25.2 Among them HPV-5 and - 8 are the main types associated with malignancy.³ The pathogenic mutations have been detected in EVER1/TMC6 and EVER2/TMC8 genes mapped

Malignant changes in the form of actinic keratoses, Bowen's disease, squamous cell carcinoma (SCC) (in 30-70% cases) and basal cell carcinoma over 20 years usually in third and fourth decades of life.

All of our patients had typical lesions i.e. pityriasis versicolor like lesions and verrucous lesions and reddish plaques over face, trunk and extremities, with some of them already showing malignant changes of actinic keratosis, squamous cell carcinoma and basal cell carcinoma.

Histopathology too correlated with the clinical diagnosis of different lesions. Two of our cases developed SCC and one developed BCC. So, histopathology should be performed in all EV patients for early detection of any malignant change and appropriate treatment.

Strict sun protection and lifelong observation of these patients for early diagnosis of malignant lesions, which then can be treated timely leading to better survival of EV patients.

EDV is an asymptomatic condition in initial stages, so patients tend to ignore it; like in our cases where all 3 came to us directly with Non-melanoma skin cancers and were diagnosed to have EDV as their primary disease.

This also emphasizes the importance of keeping all EDV patients under life long surveillance for they have high risk of development of NMSCs as compared to normal Indian population.

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CONNECTING YOUNG DERMATOLOGIST

Dr. Ishad Aggarwal M.D. Dermatology

DU 40

CONNECTING YOUNG DERMATOLOGIST

"Patience, skills, politeness, ability to handle difficult people, ability to handle complications and managerial skills. My practice completes me because it gives me freedom to do things my way."

Dr. Ishad Aggarwal is a young Dermatologist who started independent practice and shares his experience.

1. Tipping point in your dream to start your own private practice.

After having worked at few cosmetic clinics, I felt I needed more freedom in making decisions and not be guided by any one‘s policies. So I decided to take the plunge into private practice.

2. Share your professional experience as a doctor.

After finishing my M.D from IPGMER Kolkata I started working as a Senior Resident there itself. In the evenings I would attend cosmetic clinics like Kaya and VLCC to get a grip of aesthetics. I attended the cadaver dissection program in Singapore and got certifications as an injector for Facial Aesthetics.

3. Which problems have you faced while starting up your private practice? I don’t have my own clinic but I have my own practice at

a high end set up viz Wizderm which is equipped with lasers and machines and we have a profit sharing arrangement. But yes I had a lot of challenges starting private practice because I am not originally from Kolkata. So I started sitting at these clinics and I think what really helped me was word of mouth.

That’s not something for me to answer. I think the first chance at leadership was the Residream program and Residream magazine under the Auspices of IADVL and Dr. Rashmi Sarkar mam and I was founder editor of the magazine. Also I think I had fairly early on decided to be a Facial Aesthetics guy and there are not many people of my age doing it. I started getting a lot queries about fillers, how to go about them, so I started this telegram group on Cosmetic Dermatology and we are doing excellent discussions there.

7. What are the facilities you provide to your patients?

I think the biggest facility I give my patients is Time and a very patient hearing. My consultations last as much as 30 minutes sometime.

8. When you started your clinic what was your clinics mission statement "I want my private practice to be............

I want my

Practice to be niche.

9. What strengths are required to be a good start up Dermatologist? Patience, skills, politeness, ability to handle

difficult people and complications and managerial skills.

4. What are the unique and different skills you should have, as a start up doctor? I think you should have experience and clarity

10. Any challenges faced and how you dealt with them (medical and personal) ? Challenges are always there. The balance

of thought. There should be no rush to set up your practice. First it’s important to understand what kind of practice do you want, then get the skills in place. For example if you want to do hair transplants, then give few years to learn it before starting your practice.

between domestic life and work life is a big challenge.

11. How did you fund your start up clinic? Debt from banks, loans from family or personal savings? Your Advise to Residents.

5. Have you always been successful or faced failure at some time in your career. We all face success and failure all the time. If

12.

In your words "My clinic completes because ............ It gives me freedom to do things my way.

am not able to retain all my patients, then that’s a failure too. But it’s important not be bogged down by it.

13. Anything you would have done differently today?

6. Any instances where have you shown leadership and management skills not expected from a Dr. in your career?

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January 2024

Like I said, I opted for revenue sharing with established brands. me

Nothing.

14. Would you start up your clinic TODAY ? After a few years.

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Dr. Satish Bhatia M.D. Dermatology

S ART UP INDIA S ART UP CLINIC "Improving patient satisfaction is a very important step to increase the practice. Understand the patient needs, take sufficient medical history and BE HONEST to them."

Dr. Satish Bhatia Well known for his expertise in Facial Aesthetics with a clientele which comprises of the who’s who in Mumbai. Highly proficient in PRP for hair restoration and the latest techniques in deep skin peels. Proud recipient of the Fellowship for Dermatology in Israel from the Israel Agency for International Development Cooperation (MASHAV) in association with Sackler University, USA. Conversation with Dr. Satish Bhatia

1.

When did you started practice?

complaints?

I started practice in 1997. I started off as a lecturer and part at CMC, Colaba from 7-9pm.

I have got my staff since 2001, there will always be issues. But it speak volumes since they are with me since 2001.

2. Reflect on your thoughts and experience.

At that time Cosmetic Dermatology was in its egg / cocoon form in India.

3. Did you have financial, personal and emotional support while starting ?

Got my emotional and financial support from my Dad as I was not even able to pay my monthly rentals.

4. I will never forget the first step to start my practice......

8. My way to handle patients.......

Don’t try and CON your patients into procedures.

Pharma / Cosmetic Companies will train you and psych you to sell, more and more use your best judgement.

9. Improving patient satisfaction is a very important step to increase the practice.

Explain to the patient. Understand the patient needs, take sufficient medical history and BE

Got my break in 1998 when I went to France, for training and got introduced to microabrasion through Dr. Francis Mahuzia.

5. What are the challenges in developing the right practice management strategy?

You Gradually climb up, be honest, no short cuts.

6. Ways to handling your professional responsibility and discipline...

Train as much as possible, workshops, events, etc. You never stop learning.

7. How do you manage staff issues and

January 2024

17

HONEST to them.

16. What are the unique and different skills one should have to start an individual practice.

10.

Personal touch with patients, be compassionate, understand their economic status.

17. What particular strengths are required to be a good Dermatologist.

Constantly update yourself. Be humble.

18. Was there any specific guidance on good practice management given to you by your seniors?

My mentors are Dr.Oberoi and Dr.Rui. They always say that patient needs and expectations are always different than the reality of your treatment.

19. Are you satisfied with your practice income?

I am thankful and blessed with my moderate income.

20. Anything you would have done differently today.

Would have been pilot- alternate career.

21. Today I am a successful Dermat having a good practice...

Because of my honesty.

22. Any advice for todays' Residerm , tomorrows Dermatologist.........

DO NOT RUSH IN TO make a QUICK BUCK. Patients counseling is the first part of practice management- My opinion.

If took me years to be a master injector and it’s still a learning curve. You are always a learner.

11. I take care of my patients to the best of my capability.

And their utmost confidence and respecting their privacy.

12. As a Dermat what is your duty towards your patients in clinical practice management.

Complete history before sending them for tests like bioposy.

13. What problems did you face while setting up your practice ?

I did not indulge in Cut practice and hence took longer till word mouth tookover. This is my own special way to set up a practice.

14. How do manage patient’s satisfaction on a day to day basis in clinical practice.

Constant touch with the patients.

15. The one experience which increased your confidence to start your practice.

While working at JJ hospital (Mumbai) a bomb blast patient who was extremely pleased with my work motivated me to start my individual practice.

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23. Nothing is impossible, everything is possible –

Be true and honest to yourself.

24. Word of mouth publicity v/s Social Media engagement.

A Judicious mix of both.

25. Tips on engaging with Pharma and Device Companies.

Trade very carefully.

26. Give a few tips on innovation in practice management and how did you innovate?

Attend more workshops, be well read.

LAST WORD

Dr. Ganesh S. Pai M.D., D.V.D., FAAD Medical Director

LAST WORD "Today I am a successful Dermatologist because I have found the right balance in teaching, practice, family life and hobbies. If I could rewind to 42 years ago I would have still chosen Dermatology as I have got all that I want from my long career."

Dr. Ganesh Pai is an expert and pioneer in the use of lasers for pigments, skin rejuvenation, moles, tattoos, freckles, wrinkles, acne, acne scars and hair removal.

He is the Recipient of the IADVL Lifetime Achievement Award in 2013 and the Prof. K.C KANDHARI Life Time Achievement Award in 2016. He is currently the Director, Professor and Head of Department of Dermatology at K.S. Hegde Medical College, Mangalore.

In a Tete-a-tete with Dr. Ganesh Pai, shares his journey from Resident to highly respected, well regarded Senior Dermatologist.

A

brief introduction of your PG days i.e from where etc?

In 1977 I joined post-graduation in Dermatology at Kasturba Medical College, Mangalore. Those were the days when people wondered why anybody would join Dermatology ? The only implement that we had was a magnifying glass. The speciality had no skills, no glamour, no surgeries and no night duties. It was a safe harbor for the less motivated, comfort loving, and happy go lucky doctor.

When I first started practice in 1979 it was a lucky beginning. It was a small clinic in a decrepit building and the first patient I got after a whole day’s wait came not with skin problem but with hiccups. I could have turned him away as hiccups had nothing to do with Dermatology but then I would draw a blank on day one. So I treated him and since that day there have been no hiccups in my practice.

Did you have any Friend, Guide who mentored you?

Patients were commonly suffering from scabies, eczema, psoriasis, vitiligo and sexually transmitted diseases. Even Hansen's disease was quite frequent in those days. Around mid-Nineties I realised that the nature of practice was changing.

When I was an intern in the Department of Dermatology I had two teachers, Dr. J N Shetty and Dr. Sudharshan Hegde who were full of humor and wit. My interest in skin diseases and my desire to find friendly teachers led me into the Department of Dermatology. Post - graduation was fairly hectic as I was the only student and thus had to handle all admissions, discharges, basic investigations and ward dressing of all patients including the leprosy ward.

The dawn of the Cosmetology era had just broken out and there were great opportunities to upgrade my practice.There was no road to follow and I had to make my own road. It took a large investment to setup a new clinic with 3000 sq.ft of space and all my savings of two decades were used up in this venture in 1997. One by one lasers were added, starting with the erbium laser and then followed by hair removal laser, Carbon Dioxide and Q-sw laser.

Unlike my friends in other specialties we had no night duties. Since the day I joined post-graduation till now I have had wonderful eight hours sleep every night which is a luxury for consultants in other specialties today. There was no structured teaching program since I was the only postgraduate! And I was asked to read any topic and talk about it next day.

Describe your day to day activities, priorities and tasks when you started your practice and today.

Describe your most successful accomplishments.

The first 10 years till 2008 were used to buy this bunch of devices. After that life has been truly satisfying in every possible way with over a dozen devices, both ablative and non-ablative. Virtually every cosmetic need of the patient is fulfilled.

There is a stream of trainees and good teams of aestheticians and nurses who cater to a large influx of patients with a variety of cosmetic problems.

Share your experience and skills – I am what I January 2024

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LAST WORD am A Senior Dermatologist.

I have trained many doctors as post graduates in the Department of Dermatology. Many others have obtained training in my Derma-Care Centre over the last two decades. Some of them are professors and heads of Departments themselves. There are two thoughts that I would like to share with you today. One is to take a speciality that you are keenly interested in. Several of my bright classmates took to medicine, surgery, gynecology, and pediatrics not because they were keen, but they had the marks and the subjects were status symbols. Yet two decades later the most sought after lines were radiology, orthopedics, and Dermatology which were the specialities selected by average students in our time. It is difficult to predict how a speciality will develop in the years to come.So one must only take a career close to his heart.

For a quarter century of my career I have been a professor in Dermatology and it has given me great satisfaction to mould many bright young minds to launch a successful carrier themselves.

true of our speciality. I have been fully involved in charity work and run a large animal care centre looking after stray animals, sterilizing stray dogs and cats and treating animals injured in road accidents. It has given me a lot of satisfaction running this NGO. Along the way there have always being donations to various charities, particularly for the special child and blind, though I have not found time to involve myself in their administration.

The one regret I have is in not having left teaching till I was 54 years old. Half a day of teaching and half a day of laser practice meant that I could not do justice to both. I should have perhaps quit teaching at the age of 46 (1997) when I started my laser center. With enormous investments in machines and manpower, time required for teaching cripples return on investments.

So you have to invest in lasers and devices to set up a proper centre with substantial investment. Therefore the choice today is between full time teaching or full time practice.

The skills developed with the use of ablative lasers has led to many invitations to address Dermatology and Cosmetology conferences in various countries.Today’s generation of Dermatologists have easy access to training at various centres, workshops and conferences, so the trial and error process is eliminated.

What are the key challenges a Dermatologists faces today compared to when you started.

A difficult situation you handled in your practice OR personally which had an influence on you.

The loans can be crippling especially if the demand for cosmetic services does not rise exponentially. Financial planning is thus very important. For example hair removal lasers today are no longer in the growth phase as beauty parlors and several Dermatology centres possess this equipment. Therefore return on investment is much less than what it was ten years ago. On the other hand, Q-sw lasers are a more practical investment and the returns are higher because of issues of hyper pigmentation which affects a large section of the population. When we started practice Dermatologists struggled for a good living as a purely consultation based practice did not fetch high returns.

I have always being frank and forthright in my views. Integrity is a key factor in establishing a successful career. On rare occasions a lack of diplomacy helps guide a patient to proper therapy. I remember a lady who had developed toxicity with oral etretinate consumed for long period of time for psoriasis. When I tried to convince her to start cyclosporine, she lectured me on therapy and I had to tell her firmly that she was wrong and destined to suffer. She went back upset and angry but came back the very next day with chocolates and a bouquet of the flowers. I was surprised but she told me that her husband and her father told her that ‘it is sincerity of the doctor which made him correct you, otherwise he could have very well agreed with you, smiled, collected his fees and sent you on your way’.

Patients are always looking for doctors who will guide them to the best possible therapy.

There has also been the odd angry patient not satisfied with the level of improvement after laser therapy. This we have to take in our stride and do some hand holding to see them through the difficult period.

Is there more to life than Dermatology.

There is much more to life than Dermatology. The free evenings without emergencies gives us the opportunity of engage in sports, games, music, reading and travel.

Work life Balance - Joys, Regrets

Dermatology affords a good work life balance. The joy of good social life after a day of practice is particularly 20

January 2024

The key challenges a Dermatologist faces is investment in equipment and investment in premises. A reasonably large area of practice of at least 1200sq.ft has to be acquired at an early stage in their career.

to

What were the challenges you faced get to where you are now ?

The challenges I faced twenty years into my practice was whether to take a

How would your family describe you?

My family would describe me as a pragmatic person who is conservations in his approach to all aspects of life. I had the choice to start multiples centres in different cities but chose not to do because such a scattering of resources with large loans was a big risk to me. Several centres often lose control over efficient running and proper therapy of patients, as they cannot supervise their therapists and doctors in far flung clinics.

How would you like your patients to describe you. Dr.Pai is.....

Patients will describe me in many ways.

There will always be the unhappy patients, but the vast majority have stuck to me since four decades.The best testimonial to this is the patient loyality which extends to seeing their children and grandchildren in the clinic.

Any Hobbies you have cultivated and pursued?

One of the perks of being a Dermatologist is that we get a lot of spare time to pursue hobbies. I have enjoyed traveling, reading, music and long jogs. For a decade between 1990 and 2000 I wrote a lot of humorous middles for English dailies such as Time of India and

Today I am successful Dermatologist because I Love Dermatology

Today I am a successful Dermatologist because I have found the right balance in teaching, practice, family life and hobbies.

If I could rewind to 42 years ago I would have still chosen Dermatology as I have got all that I want in my long career.

Any message to Residents - As a Senior Dermatologist

Finally a message to residents in Dermatology. There is no better time than now in this speciality. Live life to its fullest and even while you earn a good living and achieve fame think of the poor patients on whom you are presently learning Dermatology and pay back with acts of charity and compassion when you are a senior doctor.Never go for an exclusive cosmetic practice. You will end up a glorified beautician without respect from peers of other specialities. Dermatology should be the bedrock of your career.

From these patients, you will develop a good cosmetology clientele. By constantly keeping abreast of recent advances, you will be intellectually stimulated and have a well moulded practice. Above all keep your reputation intact, as integrity is the single most important aspect of our career to gain respect and recognition in society.

The world is at your feet and there are peaks to scale, all of course with the grace of god.

Derma-Care Skin and Cosmetology Centre The Trade Centre, Near Woodlands, Bunts Hostel Road, MANGALORE - 575 003, INDIA. Landline: 0824-2440923 Email : gspai@derma-care.in Website: www.derma-care.in

January 2020

WORD

It is easy to lose reputation and invite medicolegal problems when inexperienced assistants in secondary centres perform poor procedures. I was also careful to invest in stocks, provident fund and bank deposits so that a possible failure in my career did not lower standard of life for my family.

Deccan Herald then I wrote and published a novel called “No Moorings” which was about the life of an Indian Dermatologist who loses his identity in a foreign land. This is so true of many of our doctors who have settled abroad, earned a lot of wealth, but lost their identity in their motherland.

LAST

Dermatology affords a good work life balance.

The joy of good social life after a day of practice is particularly true of our speciality.

I have been fully involved in charity work and run a large animal care centre looking after stray animals, sterilizing stray dogs and cats and treating animals injured in road accidents. It has given me a lot of satisfaction running this NGO.

plunge into Cosmetology and ramp up practice in a field which was uncharted territory. I could not afford failure as I had put in all my savings into a large Cosmetology Centre with laser devices humming in many rooms. I was careful to invest in new equipment only every two years. I started with erbium laser and phototherapy and then moved on to hair removal laser, later Q-sw laser, then fractional CO2 and finally radio frequency devices.

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