Dermatology – IADVL Manipur Branch

Pimples

Dr Zamzachin Guite — Sat, 13 Apr 2024 05:20:28 +0000

Pimple (acne) is so common that it is considered to be a normal physiological reaction unless and until it develops into a boil. Over 80% of teenagers and 1 in 5 newborns have pimples of various forms with varying degrees of severity. Severe pimples can leave behind a trail of blemishes and in some labile persons can affect the self-image. A ‘simple pimple’ therefore can be ignored only at one’s peril.
Diet and dirt as believed by some to be the cause of pimples is not simply true. The skin oil wells (sebaceous glands) start producing lubricating oil (sebum lipid) from teenage years onward. These oil wells are plenty, about 700/cm2 in the face and upper body. It keeps the skin soft and supple and also inhibits some skin germs. When oil glands are overactive as happens in some people, the excess oil (seborrhoea) blocks the pores and ducts of the skin. Moreover, the pore lining cells become sticky in the presence of oil, and they get stuck up further plugging the pores. Thus, the oil products start to swell up in the form of white head (closed comedone) and black head (open comedone).
Another cause of pimples is the skin germ, Propionibacterium acnes which can transform oil into oil acid (free fatty acid). This acid damages the wall of pores allowing it to escape into surrounding deeper tissue causing untold damage in its wake. The resultant painful soft swelling pimple (cystic acne) often ends up in a pit, scar and blemish.
Some cosmetic agents notably old cream, soap and drugs give rise to pimple-like eruptions (acneiforms). Fat, grease, lubricating machine oil, tar, pomade and hair oil also can aggravate pimples by irritating and preventing the escape of sweat and body fluid onto the surface. This type is usually seen in individuals with oily skin.
The oil gland is also vulnerable to the effects of heat and humidity, a life-stress situation, lack of sleep, tension and a sumptuous lifestyle. For this reason, we see pimples flaring up during examination, menstruation, public festivity and upheaval.
Last but not least, it has been found that 50% of the pimple cases gave history of first-degree relative pimple affection. This family propensity is usually observed in severe types of pimples.
The approach to pimple management has to be multi-pronged. Great care a to be taken in choosing the type of medication as its effect on pimples can be damning. One approach is to explain and educate the person about his condition. This will give confidence, motivation and rapport to both the care receiver and provider. General measures as under will benefit the person. Rinse the face morning and evening with water using mild soap and dab the face gently after each rinse to retain moisture. Do not scrub your face as it removes the oil that the skin needs to be healthy and supple. Do not pick pimples. This may damage the skin and leave scars. Avoid facials since they sometimes aggravate the pimple. Carry out moderate exercise every day. Sleep 6-7 hours per day as lack of sleep may open up sleeping pimples. Avoid in-between meals and heavy snacks. Avoid hair oil and pomade. Use shampoo regularly. Drinking not less than 2 litres of water will help open up pores to clear pimples.
It is to be stressed that self-medication and manipulative measures will do more harm than good. Indeed, the affected person overestimates the severity of his pimple, while the physician underestimates its impact on the client.

-Dr. Zamzachin Guite

Sunscreens

Dr Thokchom Nandakishore — Sat, 13 Apr 2024 05:00:24 +0000

Ultraviolet radiation is that portion of the electromagnetic spectrum with a narrow band of radiation from 200-400 nm. Spectrum – UVC (200-290 nm), UVB (290- 320 nm) and UV A (320-400nm –UV A 2 =320-340; UVA 1 = 340-400). UVA rays constitute 90-95% of the ultraviolet light reaching the earth and it is not absorbed by the ozone layer. UV A light penetrates deep into the skin and is involved in sun tanning, UV A tends to suppress the immune function and is implicated in photoaging of the skin by inducing changes in the extracellular matrix decreased collagen synthesis, increased degradation of collagen, infiltration of inflammatory cells and release of ROS from neutrophils etc. UVB rays – partially absorbed by the ozone layer, are the primary cause of sunburn and reach upto papillary dermis only. It is also responsible for photoaging, photo carcinogenesis and are implicated in cataract formation. UVC rays are almost totally absorbed by the ozone layer. However with the depletion of the ozone layer because of environmental pollution UVC rays are beginning to contribute to sunburn and premature ageing of the skin.

Sunscreens- divided into chemical absorbers and physical blockers. Chemical sunscreens absorb high-energy ultraviolet rays and release the energy later as heat. No significant photo degradation occurs except avobenzones.

Physical blockers or non chemical sunscreens reflect or scatter UVR. They contain inert minerals such as titanium dioxide or zinc oxide. (new nanosized particles may help by absorption also)

1. Ultraviolet B Blockers –

Para-aminobenzoic acid- one of the first chemical sunscreens, padimate 0 or octyl dimethyl PABA is associated with greater compatibility, Padimate 0 is the most potent UV-B absorber.

Cinnamates- Octyl methoxy cinnamate ( OCTINOXATE) is the most frequently used sunscreen ingredient.

Octyl salicylate – Octisalate or octyl salicylate is used to augment the UV-B protection in a sunscreen.

Octocrylene – Octocrylene used in combination with other sunscreen ingredients, such as avobenzone, add to the overall stability.

Phenyl benzimidazole sulfonic acid – (Ensulizole) is water soluble ,used in products formulated to feel lighter and less oily.

2. Ultraviolet A Blockers – Benzophenone

Although benzophenones are primarily UV-B absorbers, oxybenzone absorbs well through UV-A2. Oxybenzone is considered a broad-spectrum absorber.

Anthranilate – absorb mainly in the UV-A2 portion, less widely used.

Avobenzone – (ParsoI1789) a large portion of the UV-A range, including UVAl

Mexoryl SX- ( L’oreal) – (ecamsule) photo stable, block UV -A range (320- to 340-nm); it is water soluble and less water resistant.

Helioplex (Neutrgena)- Oxybenzone + abobenzone stabilised with 2, 6, diethylexylnaphalate

Bisethylhexyloxyphenol methoxy phenyl triazene – This broadband sunscreen filter lends photostability to avobenzone containing sunscreens.

Physical blockers – inert minerals such as titanium dioxide or zinc oxide; particles scatter and reflect the solar radiation. Ultrafine titanium dioxide, provides broad-spectrum protection against UV, it is invisible when applied in cosmetic formulations. Chemically stable and do not cause photo-allergic or contact dermatitis and do not break down over time and are far less liable to cause skin irritation. However protection against UVA 1 is superior for zinc oxide (340- 380nm), more broad spectrum. (Good for porphyrias)

Sunscreen vehicles: Most effective UV absorbers are oils – heavy, greasy feel, polymeric film formers and silicone oils – less greasy; ‘ultrasheer’ products utilise silica; gels- rely on phenyl benzimidazole sulfonic acid or trolamine salicylate

Systemic photo protection – Systemic agents, eliminate substantivity , include PABA, indomethacin, retinol, steroids, psoralen, antimalarials and antioxidants like vitamin A, vitamin C, vitamin E and beta-carotene. Antioxidants are less potent than sunscreens in preventing sunburn.

Indications & Contraindications of Sunscreens –

Indications:

Protection from UVR to prevent the following-

– Sunburn

– Skin or lip damage, freckling, skin discoloration

– Skin aging

– Skin cancer

– Phototoxic or photo allergic drug reactions

– Photosensitivity diseases

– Photo aggravated dermatoses.

Contraindications

– Known sensitivity to any sunscreen ingredient or vehicle ingredient

– Infants < 6 months

– As sole component of an overall program of photoprotection

Side effects of sunscreens –

– Upto 19% of users can develop adverse reaction, to both active and vehicle ingredient equally.

– Majority are irritant in nature, < 10 % allergic, and most patch test negative.

– Subjective irritation- immediate stinging or burning , without visible erythema, most frequently in the eye area, even if applied away from, by migration through sweating; even several hrs after application, falsely implicated as allergy.

– contact urticaria

– allergic contact dermatitis – PABA earlier, benzophenones increasingly nowadays, fragrances, preservatives and other excipients

– photosensitivity reactions- sunscreen active ingredients have become the leading cause of photo contact allergic reactions, mainly to avobenzone. Photosensitive eczematous pts particularly predisposed (suspect in clinical exacerbation).

– acne induction and exacerbation vehicles may induce ; mainly aggravation of pre-existing acne; contact folliculitis (shortly after application) a form of irritation.

Effectiveness and efficacy of Sunscreens

1. UV B
a) Sun protection factor (SPF) – Amount of ultraviolet energy (UVB) required to produce minimal erythema on sunscreen protected skin-(2 mg/cm 2 layer) to the amount of energy required on unprotected skin.

b) Substantivity – the ability of a sunscreen to remain effective under the stress of prolonged exercise, sweating and swimming.

Sweat-resistant: protects up to 30 minutes of continuous heavy perspiration.

Water-resistant: protects up to 40 minutes of continuous water immersion and

Waterproof (very water resistant) : protects for up to 80 minutes of continuous water immersion

PABA and its esters demonstrate more resistance to sweating and/ or water immersion than do other chemical sunscreens.

2. UV A

Protection of Sunscreen- no uniformly accepted standard method for measuring UV A protection of sunscreen. PPD (persistent pigment darkening) is most commonly used because pigmentation remains stable between 2 and 24 hours.

Broad-spectrum label should have a critical wavelength of more than 370 nm and a PPD or protection factor in UV A greater than 4.

Some more facts –

– Even on cloudy days up to 80% of UVR is transmitted to the Earth’s surface.

– Sun exposure during childhood (upto 18 yrs is about 80% of an average person’s lifetime exposure ton the sun)

– Sun protection should begin at young age and may start as early as 6 months of age

– Surfaces such as sand, snow, concrete and water can reflect up to 85% of the UV radiation

– UV A penetrate window glass, UVB do not; indoor light sources have been shown to emit UV A, UVB & sometimes UVC rays.(i.e. indoor exposure possible)

– UV A varies much less in intensity throughout the day than UVB.

Instruction to patients:

1. Depending on latitude and climate, sunscreens may be needed yearround.

2. Sunscreens most important from lOAM to 4 PM. To protect from harmful radiation during this period, stay in shade or indoors .

3. For intermittent casual daily use, an SPF 15 is sufficient. For prolonged recreational exposures, an SPF30 is desirable.

4. Sunscreens should be applied 15-30 minutes before exposure, reapply after activities such as swimming, sweating and rubbing. Common advice earlier was to apply sunscreen every 2-3 hours, (however new research shows that reapplication 15- 30 minutes after the sun exposure begins may be the best way)

5. Apply liberally. Most do not. An adequate amount of sunscreen (2 mg/ ern 2) provides greater sun protection than using an inadequate amount of a sunscreen with a higher SPF rating. The teaspoon rule: (~3ml) to each arm, to the face and the neck. On each leg, the chest and back, (~6ml); about 30 ml to cover entire body.

6. Patients should select broad-spectrum sunscreens that contain agents that effectively block both UVB and UV A preferably above SPF 30. The SPF applies for UVB rays and near UVB- i.e. UV A-2 only. A sunscreen with a SPF of 15 filters out approximately 94%, with a SPF of 30 filters out 97 % of UVB (difference in penetration of about 3 % not significant in most clinical situations).

Patients requiring UV A protection should apply sunscreens longer particularly with drug photosensitivity or various photoaggravated dermatoses.

Natural pigments such as titanium dioxide and zinc oxide are good UVB and UVA blockers. Today, certain chemicals can be added to sunscreen products to give them good UVA ray blocking abilities. Such chemicals include avobenzone and Mexoryl SX.

However, most of cosmetic products that contain sunscreen chemicals offer various SPF levels up to 15-30.

Future trends in photoprotection – in stages of investigation- The antioxidants are caffeic acid, poly podium leukotomes, zinc, polyphenolic compounds, isoflavone, N-acetylcysteine and butyrated hydroxy toluene (synthetic antioxidant). Calcitriol and citrus which are free radical scavengers. Plant oligosaccharides and genistein help in prevention of UV ind uced immunosuppression.

Sunscreens alone are insufficient for protection from UVR as they prevent sunburn from UV -B radiation and provide more limited protection from UV-A radiation. Protective clothing and sun avoidance particularly at times of peak intensity is warranted.

-Dr. Th. Nandakishore

This article is reproduced from the edition of “Souvenir” VII CUTICON Manipur 2010.

Facial Rejuvination

admin — Sat, 13 Apr 2024 04:54:42 +0000

Rejuvenation is the noun of the verb word ‘rejuvenate’ which means” make young or as if young again” as per the 9th edition of Concise Oxford Dictionary. It comes from Latin – “juvenis” – young.

The Process of rejuvenation is as old as history itself. Cleopatra used Ass’s milk to keep herself young & beautiful. Balms have been used since the time of the Pharaohs of Egypt. India was never far behind. It is said the sages lived for centuries.

We have lost the formulas with time, yet the undaunted search was always there.

The first person who rejuvenated himself was he who washed himself with water. Yes, water is a good rejuvenator, though it is very evanescent. In fact all modalities are transient, some less than the other.

We cannot stop ageing, we can only postpone it. The urge to look better and remain young as long as possible has initiated people to delve into the mysteries of the body and to search for that ” Amrit” or the “Elixir” of life, to defy death & ageing. The search is still on.

Now let us understand what is rejuvenation. It is an improvement of skin texture, closure of big pores, reduction of scars, marks & blemishes, reduction of facial hairs, lightening of the skin to look fairer, tightening and toning of the skin, reduction of blemishes & wrinkles, and reduction of excessive fat.

Recent advances in Cosmetic Dermatology have come up with many options which, though costly, give us a rather satisfactory result. The modalities can be surgical or non-surgical, ablative or non-ablative.

With Micro Dermabrasion we remove the dead cells and stimulate fresh growth of Epidermis. With aloe vera & other moisturizers we make the skin more turgid & it gives a polished look.

To decrease dark-pigmented lesions & tattoo marks we use Q-switched ND Yag Lasers.

To decrease vascular leacons we use IPL Lasers & Pulse Dye Lasers. To decrease hairs we can use IPL or High frequency Ruby Laser pulse

To remove Seborrhoic Keratosis or Acanthosis Nigricans can use Alexandrite Lasers.

To increase the collagen bulk and initiate fibroblast formation, which is the main anchor of rejuvenation we can use non-ablative low-energy photothermal treatment, Radiofrequency instrument, IPL Laser etc.

To remove pockmarks & depressed scars we can use radio frequency instruments, RF cutting of the margins of the scars, derma roller, dermal fillers, laser resurfacing etc & also with medicines.

To improve wrinkles, along with creams, we can use derma roller, dermal fillers, and laser resurfacing. :

We also use Botox to relax taut muscles & relax the muscular tension which also gives the face a youthful look.

With the increasing popularity of “Beauty Competitions” and the instinctive urge to look good and more confident, young as well as older people are seeking professional help. The emerging super speciality called “Cosmetic Dermatology” has come to stay. The domain of Dermatologists is touching newer horizons and expanding rapidly for the service of mankind.

Prof R. N. Dutta
Professor & Head
Department of Dermatology
IPGMER & SSKM Hospital

*This article is reproduced from the edition of “Souvenir” IV CUTICON Manipur 2007

Senescence and ageing skin

Dr Karam Lokendro — Sat, 13 Apr 2024 04:46:40 +0000

After a period of perfect renewal, in humans between 20-35 years of age, there is a gradual declining ability to respond to stress, increased homeostatic imbalance and increased risk of disease. This irreversible series of changes is inevitable for life. Death is the ultimate consequence. “Old age” is not scientifically recognized as a cause of death because there is always a specific proximal cause, such as cancer, heart disease or liver failure. This is what we call senescence.

Life is about such changes and skin is the proof of aging and is at the mercy of many forces as we age. Intrinsic ageing is due to various factors like genetics, apoptosis, wear and tear, free radicals, hormonal decline, accumulation of waste products etc. Many of the conditions cannot be intervened, though some may be modifiable. But could we expand the lifespan? Maybe or maybe not! But each species has its own prescribed life period too. With modified healthy lifestyle and measures, like modified food habits, carbohydrate restriction, exercise, stress reduction, good sleep, bio-identical hormone corrective measures, antioxidant supplements etc., quality of life can certainly be improved with a low probability of diseases and disability with high cognitive and physical functional capacity.

The ageing of the skin (external) is seen vividly. 80% of the cause is contributed by photodamage. Other important causes are smoking, stress, poor nutrition, environmental pollution etc. Dry skin, fine lines and wrinkles, freckles, skin tags, red spots, pigmentations, telangiectasia, atrophy, laxity, and premalignant cutaneous conditions are the signs of ageing skin. Many of these conditions can be prevented. Many are treatable or at least modifiable.

Management of ageing skin includes measures to prevent UV damage and medications and procedures to reverse existing damages. Sunscreens, topical retinoids, peptides, and vitamin C are used with good results. Systemic and topical antioxidants have variable results. Various rejuvenation procedures like chemical peels, botox, facial fillers, radio frequency, lasers and other light systems are giving excellent results. Perhaps these may be a booming medical industry.

Dr. Karam Lokendro