Transcript cosmoderm
Cosmetic dermatology Cosmetic problems Acne Pigmentation Ageing Benign tumor / nevi / birthmarks Hair – Alopecia, hirsutism Nails Acne Surgery in acne is indicated for active lesions management of scars Management of active acne Microdermabrasion (Gr I) Evacuation surgery (Gr II and III) Draining of cysts (Gr IV) Intralesional steroids : large cysts (Gr IV) Cryoslush – cystic and nodular (Gr IV) Chemical peels : GA 20-35%, SA 20-30% , TCA 10-25% (Gr II and III) IPL and blue light lasers (400-420nm): (Grade I, II, III, IV ) Acne scars Acne scars can be classified as : Depressed Hypertrophic Keloids Management of acne scars Non-surgical Laser Chemical peel Ablative Cryo peel Non-ablative Microdermabrasion Surgical Subcision Dermabrasion Punch elevation Punch graft Punch excision Pigmentation May be epidermal (brown), dermal (bluishblack) or mixed Wood’s lamp examination determines the level of pigmentation Pigmentary disorders Melasma Post inflammatory hyperpigmentation secondary to acne, lichen planus, fixed drug eruption Macular amyloidosis Lichen planus pigmentosus Toxic melanoderma Addisonian pigmentation Drug induced pigmentation Management of Epidermal pigmentation Use of a broad-spectrum sunscreen Topical lightening agents Various combinations of hydroquinone (210%), arbutin(5%), kojic acid (2 - 4%), azelaic acid (10-20%) Kligman’s formula: Tretinoin 0.05% + Hydroquinone 4% + dexamethasone 0.5% Modified Kligman: the steroid component is substituted with fluocinolone, mometasone or hydrocortisone Chemical peels Management of dermal and mixed pigmentation Sunscreen Chemical peels: Glycolic, lactic, salicylic, koj ic, retinol etc. peels at repeated intervals Topical retinoids to hasten the cell turnover and the expulsion of pigment granules IPL (Intense Pulse Light), Erbium and Qswitched Nd-YAG lasers Possibility of an increase in pigmentation or hypopigmentation in darker skin types Ageing Ageing process results in: Wrinkles Rough dry skin with a yellow hue Loss of tone and elasticity Loss of subcutaneous tissue Development of freckles, and lentigenes (sun spots), senile comedones, sebaceous hyperplasia, seborrhoeic warts, rosacea, telangiectases. Management Sunscreens Retinoids Chemical peels Microdermabrasion Lasers - ablative and non-ablative Botox and Fillers Fat lysis and transfer Surgery-thread lifts, face lifts Implants Benign tumors/nevi/birthmarks Facial angiofibromas, syringomas, Becker’s nevus, nevus of Ota, café au lait macules, hemangiomas . May be congenital/acquired. Following treatment modalities can be used: Surgical excision, electrocautery, radiofrequency Lasers- CO2, vascular, pigmented Camouflague Hair-Alopecia Treatment depends on scarring/non-scarring Scarring: surgical excision, scalp reduction, hair transplants Non-scarring: topical minoxidil, topical steroids, oral vitamins and finasteride, hair transplant Hair Transplantation Re-distribution/re-arrangement of existing hair follicles in a particular pattern to cover the bald areas Types: Punch grafting - Standard, Mini and Micro grafting Follicular unit grafting (most recent) Synthetic hair grafting Indications and contraindications Indications: Male pattern alopecia Female pattern alopecia Cicatricial alopecia Contraindications: Large bald area, small donor area Low hair density Age-group between 15-25 years Unrealistic expectation Procedure Occipital area commonest donor site, others are temporal and parietal area After anaesthetising the area, single elliptical donor strip is harvested from the donor site Follicular unit grafts are dissected from the strip Grafts then inserted at recipient site into tunnels made with needles Grafts taken up by tenth day Minoxidil application advised to promote hair growth Post operative course Interval of three months required for transplanted hair to enter anagen phase Hair growth continues for 6-8 months Hirsutism Distribution of thick dark terminal hair in the male distribution pattern in females Hair removal: Temporary measures: plucking, threading, waxing, bleaching, shaving Permanent measures: electrolysis Permanent reduction : Laser hair removal Topical eflornithine 12.5% as an adjuvant Nails Treatment of primary condition causing dystrophy eg: treat infections or skin disease Surgical avulsion Artificial nails Nail extensions Nail paint Cosmetic dermatology Topical agents: Cosmetics, cosmeceutical Procedures : Chemical peels Dermabrasion Botox Electrosurgery Dermal fillers Radiosurgery Camouflage creams Cryosurgery Tattooing Lasers Microdermabrasion Cosmetics A cosmetic is any article intended to be rubbed, poured, sprinkled, or sprayed on, introduced into, or otherwise applied to the human body for cleansing, beautifying, or altering the appearance Commonly used cosmetics: Soaps, shampoos, moisturizers, anti aging products, eye and lip cosmetics, bleaching and highlighting hair products Adverse reactions to cosmetics have been recorded Moisturizers Moisturizers are agents which hydrate the stratum corneum by either providing water or helping to draw water from the deeper layers of the skin Oil-in water or water in oil preparations Sunscreens , anti-ageing products like retinols, alpha or beta hydroxy acids and skin-lightening agents may be added Moisturizers - types Oil- in- water: More cosmetically acceptable by patients Not very effective for very dry skin conditions Exists as a cream or lotion Water-in-oil: Create an occlusive film on the skin surface; reduce water loss and traps moisture in the skin Stickier, less cosmetically acceptable More effective for dry skin and ichthyotic conditions Sunscreens Sunscreens protect from the harmful rays mainly UVA and UVB Reflects, absorbs or scatters harmful rays Most sunscreens have a SPF label. SPF: ability of a sunscreen to delay sun-induced skin erythema Types of sunscreens Physical: Form an opaque layer which totally blocks out the sunrays e.g zinc oxide, titanium dioxide and calamine Chemical: Absorb the rays and convert the energy to heat which is diffused. These may selectively protect against UVA or UVB UVA blockers: Benzophenones, dibenzoylmethanes, Mexoryl UVB blockers: P-aminobenzoic acid (PABA) derivatives, salicylates, cinnamates Proper sunscreen rules 2mg/cm2 of sunscreen needs to be applied Use half hour before exposure Repeat every 2 hours if sweating or swimming Adverse reactions to cosmetics Soaps: Repeated use may strip the skin of its protective lipid layer Shampoos: Daily washing with harsh shampoos can dry the shaft and make it brittle Moisturizers: Comedogenic ingredients like isopropyl myristate irritate the pilosebaceous follicles Fragrances: May cause photocontact dermatitis Hair colors: Frequent hair lightening or coloring can cause irreversible damage to the hair shaft. Cosmetic alopecia may follow. Contd… Adverse reactions to cosmetics Sunscreens: Vehicle may exacerbate or induce acne; contact folliculitis may occur Skin lightening agents: Excessive and prolonged use may cause exogenous ochronosis Cosmeceuticals Pharmacological agents which have an effect intermediate between cosmetics and drugs ◦ Cosmeceutical botanicals ◦ Retinoids, bleaching agents, sunscreens, chemical peels, minoxidil Cosmeceutical botanicals Cosmeceutical botanicals are obtained from plant sources Aloe vera, soya, ginko biloba, tea tree oil, mulberry etc Aloe vera: increases blood flow, reduces inflammation, enhances wound healing and decreases bacterial colonization Cosmeceutical botanicals Green tea: Contains flavanoids : anti-inflammatory against UVB-induced erythema Soy: A rich source of flavanoids (genestein and daidzein) Genestein: potent topical radical scavenger and promotes collagen synthesis Topical retinoids Tretinoin: comedolytic Adapalene: anti-inflammatory, comedolytic Tazarotene: comedolytic, anti-inflammatory Isotretinoin: comedolytic Used in: Acne Photoaging Pigmentation Combined with minoxidil in alopecia Topical retinoids Adverse effects: Redness, burning, Dryness Post inflammatory pigmentation Acne flare up Chemical peels Controlled application of one or more exfoliating agents to improve photoaging, pigmentation or scarring Single peel - skin smoothening Repeated peels - collagen and elastic remodelling Performed every 2 to 3 weeks Agents used: glycolic acid, trichloroacetic acid, salicylic acid, mandelic acid, phenol Indications of Chemical Peels Acne Ageing skin Photodamage Freckles Melasma Scars Fine lines and wrinkles Xanthelasma Dilated pores Improving complexion Botulinum toxin (BTX) Produced by the bacterium Clostridium botulinum ( Serotype A ) Inhibits release of acetylcholine at the neuromuscular junction Temporary flaccid paralysis of muscle Re-innervation and recovery in 3 to 4 months Aesthetic use of BTX For dynamic wrinkles: Upper face: frown lines, forehead lines, crows feet Lower face: Perioral, smile and frown lines, neck lines and folds Advanced use: Post-herpetic neuralgia, migraine Dermal fillers Specialized materials injected into the dermis and subcutaneous tissue to replace the lost tissue during aging or injury Types of filers : Temporary- gets absorbed in 3 to 6 months Semi-permanent: absorbed within 2 years Permanent: lasts longer than 2 years Sources of fillers Heterograft/Xenograft: Bovine collagen, porcine collagen, hyaluronic acid Allografts: Human-derived collagen Autografts: Autologous fat, collagen,fibroblasts Synthetic: Silicone, polytetrafluoroethylene Indication for fillers Wrinkles Scars Augmentation Lipoatrophy Enhancement of facial contour Cosmetic camouflage Concealing of unsightly marks on the skin with specially matched opaque creams and powders Contents: ◦ Calamine, zinc oxide, bentonite ◦ Colour pigments ◦ Setting powder Indications for cosmetic camouflage Vitiligo Freckles Melasma, post inflammatory pigmentation Hemangiomas Nevi Scars Tattooing To mask the vitiligo macules especially over the lips, areola Localized small macules of vitiligo resistant to conventional treatment Vitiligo lesions should be stable for at least two years Material Electrical tattooing gun or manually operated punch holding multiple needles (optimal depth 1.5 mm) Pigment paste: mixture of various ferric oxides (yellow, brown, red and black in colour) in normal saline and glycerine Advantages Immediate results Inexpensive, safe and simple office procedure Useful in sites difficult for grafting Can be repeated if required Electrosurgery The frequency of electric current used in hyfrecator is 50kHz (50000 cycles/sec), whereas in the operating room devices, it is between 500 and 2000 kHz. In these devices, the electrode becomes hot and acts more like true cautery. Mode of action The heat generated by the electrical current at the tip of an electrode, destroys the tissue. (Thermal damage) Moderate heat causes evaporation of the water content of the tissue (Dessication) Radiofrequency When the frequency is raised to 3000kHz (3.0MHz), the electrode itself does not get heated. The instrument, which operates at a frequency of 3.8 Mhz is also known as Radio-frequency (RF) or Radio-surgical unit Mode of action As the current passes through the tissues impedance to the passage of current generates heat → boils the tissue-water creating steam → cutting or coagulation of tissue Indications Skin tags Verrucae Molluscum contagiosum Seborrheic Keratosis Epilation Moles Complications and disadvantages Complications Sepsis Scar Disadvantages Uncontrolled thermal damage Painful Contraindications and precautions Contraindications: Patients with pacemaker implants Keloidal tendency History of seizures Precautions: Avoid spirit for local disinfection; if used wait for complete evaporation Face mask when treating warts to prevent HPV transmission Cryosurgery Use of local freezing for the controlled destruction of living tissues by intracellular ice formation, osmolality and vascular changes, thermal shock - cryonecrosis Cryogens: Freezing agents Ice Carbon dioxide slush Carbon dioxide snow Nitrous oxide Liquid nitrogen Boiling temperature 0 -200 C -790 C -890 C -1960 C Cryosurgery indications Indicated for warts, molluscum, keloid, acne, skin tag, leukoplakia, basal and squamous carcinoma Methods: ◦ Cryospray ◦ Cryoprobe ◦ Dipstick Microdermabrasion Microdermabrasion is a minimally - invasive, office-based mechanical resurfacing technique Forcibly propels sterile micronized aluminium oxide crystals at the skin Vacuum suction sucks back the crystals and the desquamated skin Indications Acne scars Fine lines Pigmentary disorders Striae Skin rejuvenation Skin polishing Open pores Dermabrasion Abrading the epidermis and part of papillary dermis mechanically, leaving the wound to heal by secondary intention. Re-epithelialization Formation of new collagen fibres in an organized fashion Indications Acne scars Preparation of recipient site in vitiligo Rhinophyma Traumatic or surgical scars Milia, trichoepitheliomas Verrucous epidermal nevi Lichen amyloidosis Actinic damage Superficial basal cell carcinoma Contraindications Keloidal tendency Bleeding disorders Immunocompromised person Theoretically dermabrasion or laser resurfacing not be performed at least 6 months following isotretinoin Recent episode of herpes simplex or bacterial infection; prophylactic valacyclovir Instruments Manual or Electric dermabrader Handpiece Wire brush or Diamond fraises: More coarse or rough the cutting surface and faster the rotation speed, greater the penetration into the tissues and deeper the damage Procedure Local / General anaesthesia/ Cryoanaesthesia with liquid nitrogen Hold the hand-piece parallel to the surface Linear and rotating movements Never go beyond mid reticular dermis Lasers Light Amplification by Stimulated Emission of Radiation (LASER) The light energy in the LASER beam is converted into heat, which destroys the targeted tissue A laser beam of particular wavelength destroys a specific target (Chromophore) Chromophores and Wavelengths Melanin - UV, infra red Oxyhaemoglobin - 488, 512, 585 nm Water - above visible spectrum Lasers for Epilation (Chromophore: Melanin) 1. Alexandrite 755 nm 2. Diode 800 nm 3. Ruby 694 nm 4. Nd-Yag 1064 nm Lasers for vascular lesions (Chromophore: Haemoglobin) 1. Pulsed Dye 585 nm 2. Nd-Yag 1064 nm 3. Nd-Yag 532 nm 4. Diode 800nm Lasers for pigmented Lesions and tattoo removal Dermal 1. Q-switched Ruby 694 nm 2. Q-Switched Alexandrite 755 nm 3. Q-Switched Nd-Yag 1064 nm Epidermal 1. Pulsed Dye 510 nm 2. Q-Switched Nd-Yag 532 nm Lasers for resurfacing (Chromophore: Water) CO2 , Erbium YAG Indications Acne scars Wrinkles Rhinophyma, xanthelesma Verrucous epidermal nevi Seborrhoeic keratosis Lichen amyloidosis Non ablative Lasers Induces collagen remodeling by creation of a dermal wound without disruption of the epidermis Nd:Yag 1064 nm Diode 1450 nm Erbium glass 1540 nm Indications Wrinkles Superficial atrophic scars Excimer Laser Monochromatic light of wavelength 308 nm Targeted treatment of : Vitiligo Psoriasis Complications of LASER Persistent erythema Vesiculation and crusting Hyperpigmentation Hypopigmentation Scarring Good expertise → minimal complications Thank you