Balakrishnan Nirmal

Efficacy and safety of Erbium-doped Yttrium Aluminium Garnet fractional resurfacing laser for treatment of facial acne scars

BACKGROUND Treatment of acne scars with ablative fractional laser resurfacing has given good improvement. But, data on Indian skin are limited. A study comparing qualitative, quantitative, and subjective assessments is also lacking. AIM Our aim was to assess the improvement of facial acne scars with Erbium-doped Yttrium Aluminium Garnet (Er:YAG) 2940 nm fractional laser resurfacing and its adverse effects in 25 patients at a tertiary care teaching hospital. METHODS All 25 patients received four treatment sessions with Er:YAG fractional laser at 1-month interval. The laser parameters were kept constant for each of the four sittings in all patients. Qualitative and quantitative assessments were done using Goodman and Barron grading. Subjective assessment in percentage of improvement was also documented 1 month after each session. Photographs were taken before each treatment session and 1 month after the final session. Two unbiased dermatologists performed independent clinical assessments by comparing the photographs. The kappa statistics was used to monitor the agreement between the dermatologists and patients. RESULTS Most patients (96%) showed atleast fair improvement. Rolling and superficial box scars showed higher significant improvement when compared with ice pick and deep box scars. Patients satisfaction of improvement was higher when compared to physicians observations. No serious adverse effects were noted with exacerbation of acne lesions forming the majority. CONCLUSION Ablative fractional photothermolysis is both effective and safe treatment for atrophic acne scars in Indian skin.Precise evaluation of acne scar treatment can be done by taking consistent digital photographs.

'Look Beyond Skin': Psychogenic Excoriation - A Series of Five Cases

Psychogenic excoriation is a condition where the patient picks the skin repetitively to produce excoriations. Treating this clinical entity is challenging as these patients often have an associated psychological abnormality. The five cases in this case series include two children and three adults. They presented with skin lesions ranging from excoriations and ulcers to scars and pigmentation. Detailed evaluation was done by clinical psychologist. Two cases had anxiety traits, one had alcohol dependence, one had difficult temperament and one had depressive symptoms. Habit reversal was introduced. Psychiatry referral was given for three cases and started on selective serotonin reuptake inhibitors. On follow-up, the urge to scratch reduced substantially and skin lesions were also improving. It is important to identify the underlying psychological disorder accounting for skin picking behavior. Incorporating psychotherapeutic techniques into clinical practice will improve the quality of life of many of these patients.

Our Experience in a Psychodermatology Liaison Clinic at Manipal, India

Psychodermatology is an emerging specialty in dermatology which deals with the interactions between mind and skin. Psychocutaneous diseases can be either primary psychiatric or primary cutaneous, with various degrees of associations between psyche and skin. Unless the dermatologist cultivates a special interest in this field, many an invisible mental disorder may be missed leading to sub optimal treatment of the visible skin condition. Though Dermatology Psychiatry liaison clinics are common in Europe and other western countries, it is just an emerging concept in India. Here we describe the working pattern of psychodermatology liaison clinic established in Manipal in August 2010 and describe briefly the type of cases attended to.

A simple instrument designed to provide consistent digital facial images in dermatology

Photography has proven to be a valuable tool in the field of dermatology. The major reason for poor photographs is the inability to produce comparable images in the subsequent follow ups. Combining digital photography with image processing software analysis brings consistency in tracking serial images. Digital photographs were taken with the aid of an instrument which we designed in our workshop to ensure that photographs were taken with identical patient positioning, camera angles and distance. It is of paramount importance in aesthetic dermatology to appreciate even subtle changes after each treatment session which can be achieved by taking consistent digital images.

Hansen's disease associated with erythromelalgia mimicking Lupus erythematosus

Hansens disease, though considered to be at the verge of elimination in many countries including India, still continues to surprise patients and dermatologists alike. This is mainly due to its varying and unconventional presentations which may lead to initial misdiagnosis and prolongation of treatment. Here we describe an unusual case presenting with erythematous photosensitive facial lesions associated with erythromelalgia of the finger tips, provisionally diagnosed as SLE. A subsequent histopathology examination proved it to be Hansens’ disease Borderline Tuberculoid variety. Hansens disease can be termed as the modern great imitator, displacing the traditional great imitator, syphilis.

Poorly differentiated cutaneous adenocarcinoma masquerading as scrofuloderma

We report the case of a 60-year-old male presented with axillary swelling of 18 months duration with ulceration and cervical lymphadenopathy of 3 months duration with a clinical diagnosis of scrofuloderma. Histopathology showed dermis infiltrated by sheets, nests, and clusters of polygonal cells with markedly pleomorphic mitotically active nuclei suggestive of a more sinister condition, poorly differentiated cutaneous adenocarcinoma either primary or metastasis from breast. The condition is reported for its rarity from male breast and the need to consider it as a differential diagnosis in similar clinical presentation.

Evidence-based review, grade of recommendation, and suggested treatment recommendations for melasma

Treatment of melasma is known to be less satisfactory, often incomplete, and relapse is frequent. Although many treatment options are available, they are either known to be unsafe on long-term use or their long-term safety profile is unknown. Patients often use various drugs, even topical steroid-based preparation without any medical supervision for long period of time, making the skin unsuitable for many of the drugs available. Thus, there has been gross disparity among the treating physician about what drugs and what regimen are best suitable for various categories of melasma patients and in different situations. With this background, numerous newer drugs, mostly combinations of some proprietary molecules or even unknown plant extracts, have flooded the market for the management of melasma. Information on efficacy or safety of these products are almost unknown. Studies on Asian people, especially Indian population, are far less commonly available. Therapeutic guideline for use on Indian patients with melasma is almost missing. Extrapolation of data from Caucasian people for use on Asian people may not be scientifically justifiable because Caucasian and Asian people are known to have inherent difference in their response as well as tolerance to the drugs used for melasma. With this background, we have extensively evaluated, following a strict, scientifically designed protocol, all the available studies on melasma management till May 2016 and prepared this document on level of evidence, grade of recommendation and suggested therapeutic guideline for melasma as per the method proposed by Oxford Centre of Evidence-Based Medicine. Various ethical, social, logical, regional, and economic issues in the context of Indian and similar populations were given due importance while preparing the suggested therapeutic recommendation.