Prescribing practices of tranexamic acid for melasma: Delphi consensus from the Pigmentary Disorders Society.

Introduction There is ambiguity regarding usage of tranexamic acid for melasma in India, be it in its pre-administration evaluation, administration route, dosing or monitoring. Hence, we conducted this study to understand various tranexamic-acid prescribing patterns and provide practical guidelines. Materials and methods A Google-form-based questionnaire (25-questions) was prepared based on the key areas identified by experts from the Pigmentary Disorders Society, India and circulated to practicing dermatologists across the country. In rounds 2 and 3, the questionnaire was re-presented to the same group of experts and their opinions were sought. The results of the practitioners' survey were denoted graphically alongside, to guide them. Consensus was deemed when at least 80% of respondents chose an option. Results The members agreed that history pertaining to risk factors for thromboembolism, cardiovascular and menstrual disorders should be sought in patients being started on oral tranexamic-acid. Baseline coagulation profile should be ordered in all patients prior to tranexamic-acid and more exhaustive investigations such as complete blood count, liver function test, protein C and S in patients with high risk of thromboembolism. The preferred oral dose was 250 mg orally twice daily, which can be used alone or in combination with topical hydroquinone, kojic acid and sunscreen. Repeated dosing of tranexamic-acid may be required for those relapsing with melasma following initial tranexamic-acid discontinuation. Coagulation profile should ideally be repeated at three monthly intervals during follow-up, especially in patients with clinically higher risk of thromboembolism. Treatment can be stopped abruptly post improvement and no tapering is required. Limitation This study is limited by the fact that open-ended questions were limited to the first general survey round. Conclusion Oral tranexamic-acid provides a valuable treatment option for melasma. Frequent courses of therapy may be required to sustain results and a vigilant watch is recommended for hypercoagulable states during the course of therapy.

Isotretinoin and dermatosurgical procedures.

Several early reports suggested that performance of dermatosurgical procedures in patients on oral isotretinoin is associated with abnormal skin healing, keloid or hypertrophic scar formation. However, this association has been recently questioned in some studies. This review examines this issue, analyzes the studies published and concludes that the recommendation made earlier about the need to avoid dermatosurgical procedures in patients on isotretinoin is based on inadequate and insufficient evidence and hence needs revision. The review also suggests that recent studies on the subject establish that performing such procedures is safe.

Guidelines on the use of finasteride in androgenetic alopecia.

BACKGROUND: Finasteride is a widely used drug in dermatology for the treatment of androgenetic alopecia. There are many reports of associated sexual side effects. This article reviews the use of once-daily 1 mg finasteride in androgenetic alopecia and its associated sexual adverse effects. METHODS: A literature search was performed to collect data on the use of finasteride in male pattern baldness. Relevant literature published till March 2014 was obtained from MEDLINE, EMBASE, CINAHL, Cochrane registers and LILACS. The keywords "finasteride", "male pattern baldness" and "androgenetic alopecia" were used for literature search. Similarly, a search was done for finasteride in female pattern hair loss with keywords "female pattern baldness", "finasteride" and "female pattern alopecia". All systematic reviews, meta-analyses, national guidelines, randomized controlled trials, prospective open label studies and retrospective case series in the English literature were reviewed. RESULTS: Two hundred sixty two studies were evaluated, twelve of which fulfilled the inclusion criteria. CONCLUSIONS AND RECOMMENDATIONS: Current evidence on the safety of finasteride indicates that it is safe but there is growing concern about its sexual side effects. In view of this, proper information should be provided to patients prior to starting treatment (Level of recommendation 1+, Grade of recommendation B). The reported sexual side effects are few and reverse with stoppage of the drug (Grade of recommendation B) but further studies are required.

Targeted phototherapy.

BACKGROUND: Targeted phototherapy is a new form of phototherapy which has many advantages and disadvantages over conventional phototherapy. This article reviews the different technologies and outlines recommendations based on current evidence. METHODS: A literature search was performed on targeted phototherapy to collect data. Relevant literature published till March 2014 was obtained from PubMed, EMBASE, and the Cochrane Library. Keywords like "targeted phototherapy", "excimer laser", "excimer lamp", "Nonchromatic ultraviolet light", "vitiligo", and "psoriasis", were used for literature search. All systematic reviews, meta-analysis, national guidelines, randomized controlled trials (RCT), prospective open label studies and retrospective case series in English were reviewed. RESULTS: Three hundred and forty studies were evaluated, 24 of which fulfilled the criteria for inclusion in the guidelines. CONCLUSIONS AND RECOMMENDATIONS: All forms of targeted phototherapy are useful in vitiligo. Good responses were seen in localized involvement, resistant lesions and in children in whom their use is more accepted and convenient (Level of evidence 2+, Grade of recommendation B). Similarly it is useful in psoriasis, either alone or in combination with drugs, even in resistant forms such as palmoplantar psoriasis. In view of expense and practical application, their use is limited to resistant lesions and localized disease. (Level of evidence 2+, Grade of recommendation B). But in other conditions there is no convincing evidence for its use. (Level of evidence 3+, Grade of recommendation C).

Fractional lasers in dermatology--current status and recommendations.

INTRODUCTION: Fractional laser technology is a new emerging technology to improve scars, fine lines, dyspigmentation, striae and wrinkles. The technique is easy, safe to use and has been used effectively for several clinical and cosmetic indications in Indian skin. DEVICES: Different fractional laser machines, with different wavelengths, both ablative and non-ablative, are now available in India. A detailed understanding of the device being used is recommended. INDICATIONS: Common indications include resurfacing for acne, chickenpox and surgical scars, periorbital and perioral wrinkles, photoageing changes, facial dyschromias. The use of fractional lasers in stretch marks, melasma and other pigmentary conditions, dermatological conditions such as granuloma annulare has been reported. But further data are needed before adopting them for routine use in such conditions. PHYSICIAN QUALIFICATION: Any qualified dermatologist may administer fractional laser treatment. He/ she should possess a Master's degree or diploma in dermatology and should have had specific hands-on training in lasers, either during postgraduation or later at a facility which routinely performs laser procedures under a competent dermatologist or plastic surgeon with experience and training in using lasers. Since parameters may vary with different systems, specific training tailored towards the concerned device at either the manufacturer's facility or at another center using the machine is recommended. FACILITY: Fractional lasers can be used in the dermatologist's minor procedure room for the above indications. PREOPERATIVE COUNSELING AND INFORMED CONSENT: Detailed counseling with respect to the treatment, desired effects and possible postoperative complications should be provided to the patient. The patient should be provided brochures to study and also adequate opportunity to seek information. A detailed consent form needs to be completed by the patient. Consent form should include information on the machine, possible postoperative course expected and postoperative complications. Preoperative photography should be carried out in all cases of resurfacing. A close-up front and 45-degree lateral photographs of both sides must be taken. LASER PARAMETERS: There are different machines based on different technologies available. Choice parameters depend on the type of machine, location and type of lesion, and skin color. Physician needs to be familiar with these requirements before using the machine. ANESTHESIA: Fractional laser treatment can be carried out under topical anesthesia with eutectic mixture of lidocaine and prilocaine. Some machines can be used without any anesthesia or only with topical cooling or cryospray. But for maximal patient comfort, a topical anesthetic prior to the procedure is recommended. POSTOPERATIVE CARE: Proper postoperative care is important in avoiding complications. Post-treatment edema and redness settle in a few hours to a few days. A sunscreen is mandatory, and emollients may be prescribed for the dryness and peeling that could occur.

Nonablative lasers and nonlaser systems in dermatology: current status.

Nonablative lasers and nonlaser systems are newer systems used for skin rejuvenation, tightening, body sculpting, and scar remodeling. DEVICES: Different technologies such as lasers, Intense Pulsed Light (IPL), and radiofrequency have been introduced. Most nonablative laser systems emit light within the infrared portion of the electromagnetic spectrum (1000-1500 nm). At these wavelengths, absorption by superficial water containing tissue is relatively weak, thereby effecting deeper tissue penetration. A detailed understanding of the device being used is recommended. INDICATIONS: Nonablative technology have been used for several indications such as skin tightening, periorbital tissue tightening, treatment of nasolabial lines and jowl, body sculpting/remodeling, cellulite reduction, scar revision and remodeling and for the treatment of photodamaged skin. FACILITY: Nonablative laser and light modalities can be carried out in a physician treatment room or hospital setting or a nursing home with a small operation theater. PREOPERATIVE COUNSELING AND INFORMED CONSENT: The dermatologic consultation should include detailed assessment of the patient's skin condition and skin type. An informed consent is mandatory to protect the rights of the patient as well as the practitioner. All patients must have carefully taken preoperative and postoperative pictures. CHOICE OF THE DEVICE AND PARAMETERS: Depends on the indication, the area to be treated, the acceptable downtime for the desired correction, and to an extent the skin color. ANESTHESIA: These lasers are mostly pain-free and tolerated well by patients but may require topical anesthesia. In most cases, topical cooling and numbing using icepacks is sufficient, even in an apprehensive patient. POSTOPERATIVE CARE: The nonablative lasers, light sources and radiofrequency systems are safe, even in darker skin types, and postoperative care is minimal. Proper postoperative care is important in avoiding complications. Post-treatment edema and redness settle in a few hours to a few days. Postoperative sun avoidance and use of sunscreen is mandatory.

Position paper on mesotherapy.

Mesotherapy is a controversial cosmetic procedure which has received publicity among the lay people, in the internet and in the media. It refers to minimally invasive techniques which consist of the use of intra- or subcutaneous injections containing liquid mixture of compounds (pharmaceutical and homeopathic medications, plant extracts, vitamins and other ingredients) to treat local medical and cosmetic conditions. This position paper has examined the available evidence and finds that acceptable scientific evidence for its effectiveness and safety is lacking. IADVL taskforce, therefore would like to state that the use of this technique remains controversial at present. Further research and well-designed controlled scientific studies are required to substantiate the claims of benefit of this mode of therapy.

Invisible dermatoses.

'Invisible dermatoses' is a concept which has not received wide recognition, but is nevertheless very important both clinically and histologically. The term invisible dermatoses has been used in two contexts: a) Diseases, with out definite clinical features, and are therefore "invisible" to the clinician, but yet can be diagnosed by special investigations. b) Dermatoses which present with definite and obvious clinical features, but subtle or hidden histological features and are therefore "invisible" histologically. Diagnosis of such diseases represents a great challenge to both the dermatologist and dermatopathologist. This article discusses such diseases and offers clues and tools for their diagnosis. Diagnosis of such 'Invisible dermatoses' needs proper awareness, recognition of subtle features, special stains, special investigations such as immunofluorescence and histochemistry and proper clinicopathological correlation.

Targeted phototherapy.

Phototherapy is one of the most important therapeutic modalities in dermatology. This field has seen several major advances in the recent years, the most recent being targeted phototherapy. Targeted phototherapy, which includes laser and nonlaser technologies, delivers light/laser in the ultraviolet spectrum, of specific wavelength, specifically targeted at the affected skin and thereby avoids many of the side effects of conventional phototherapy. The treatment has been claimed to be effective, quick, and needing fewer treatment sessions. The article reviews this new mode of phototherapy.

Hair transplantation: standard guidelines of care.

Hair transplantation is a surgical method of hair restoration. PHYSICIAN QUALIFICATION: The physician performing hair transplantation should have completed post graduation training in dermatology; he should have adequate background training in dermatosurgery at a centre that provides education training in cutaneous surgery. In addition, he should obtain specific hair transplantation training or experience at the surgical table(hands on) under the supervision of an appropriately trained and experienced hair transplant surgeon. In addition to the surgical technique, training should include instruction in local anesthesia and emergency resuscitation and care. FACILITY: Hair transplantation can be performed safely in an outpatient day case dermatosurgical facility. The day case theatre should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place and all nursing staff should be familiar with the emergency plan. It is preferable, but not mandatory to have a standby anesthetist. Indication for hair transplantation is pattern hair loss in males and also in females. In female pattern hair loss, investigations to rule out any underlying cause for hair loss such as anemia and thyroid deficiency should be carried out. Hair transplantation can also be performed in selected cases of scarring alopecia, eyebrows and eye lashes, by experienced surgeons. PREOPERATIVE COUNSELING AND INFORMED CONSENT: Detailed consent form listing details about the procedure and possible complications should be signed by the patient. The consent form should specifically state the limitations of the procedure and if more procedures are needed for proper results, it should be clearly mentioned. Patient should be provided with adequate opportunity to seek information through brochures, computer presentations, and personal discussions. Need for concomitant medical therapy should be emphasized. Patients should understand that proper hair growth can be expected after about 9 months after transplantation. Preoperative laboratory studies to be performed include Hb%, blood counts including platelet count, bleeding and clotting time (or prothrombin time and activated partial thromboplastin time), blood chemistry profile including sugar. METHODS: Follicular unit hair transplantation is the gold standard method of hair transplantation; it preserves the natural architecture of the hair units and gives natural results. Mini-micro-grafting is a method hair transplantation involving randomly assorted groups of hairs, with out consideration of their natural configuration of follicular units, under loupe or naked eye examination. Mini-grafts consist of 4-5-6 hairs while micro-grafts consist of 1-3 hairs. Punch gives ugly cosmetically unacceptable results and should no longer be used. PATIENT SELECTION: Hair transplantation can be performed in any person with pattern hair loss, with good donor area, in good general health and reasonable expectations. Caution should be exercised in, very young patients whose early alopecia is still evolving, patients with Norwood grade VI or VII with poor density, patients with unrealistic expectations, and patients with significant systemic health problems. MEDICAL THERAPY: Most patients will need concurrent medical treatment since the process of pattern hair loss is progressive and may affect the remaining hairs. MANPOWER: Hair transplantation is a team effort. Particularly, performing large sessions, needs a well trained team of trained assistants. ANESTHESIA: 2% lignocaine with adrenaline is generally used for anesthesia; tumescent technique is preferred. Bupivacaine has been used by some authors in view of its prolonged duration of action. DONOR DISSECTION: Strip dissection by single blade is recommended for donor area. Steromicroscopic dissection is recommended for dissection of hair units in follicular unit transplantation; mini-micro-grafting does not need microscopic dissection. RECIPIENT INSERTION: Different techniques and different instruments have been used for recipient site creation ;these depend on the choice of the operating surgeon and have been described in the guidelines. Graft preservation is important to ensure survival. DENSITY: Minimum density of 35-45 units per sq cm is recommended. Results depend on donor characteristics, technique used and individual skills of the surgeon.

Tumescent liposuction: standard guidelines of care.

DEFINITION: Tumescent liposuction is a technique for the removal of subcutaneous fat under a special form of local anesthesia called tumescent anesthesia. PHYSICIAN'S QUALIFICATIONS: The physician performing liposuction should have completed postgraduate training in dermatology or a surgical specialty and should have had adequate training in dermatosurgery at a center that provides training in cutaneous surgery. In addition, the physician should obtain specific liposuction training or experience at the surgical table ("hands on") under the supervision of an appropriately trained and experienced liposuction surgeon. In addition to the surgical technique, training should include instruction in fluid and electrolyte balance, potential complications of liposuction, tumescent and other forms of anesthesia as well as emergency resuscitation and care. FACILITY: Liposuction can be performed safely in an outpatient day care surgical facility, or a hospital operating room. The day care theater should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place with which all nursing staff should be familiar. A physician trained in emergency medical care and acute cardiac emergencies should be available in the premises. It is recommended but not mandatory, that an anesthetist be asked to stand by. INDICATIONS: Liposuction is recommended for all localized deposits of fat. Novices should restrict themselves to the abdomen, thighs, buttocks and male breasts. Arms, the medial side of the thigh and the female breast need more experience and are recommended for experienced surgeons. Liposuction may be performed for non-cosmetic indications such as hyperhidrosis of axillae after adequate experience has been acquired, but is not recommended for the treatment of obesity. PREOPERATIVE EVALUATION: Detailed history is to be taken with respect to any previous disease, drug intake and prior surgical procedures. Liposuction is contraindicated in patients with severe cardiovascular disease, severe coagulation disorders including thrombophilia, and during pregnancy. Physical evaluation should be detailed and should include assessment of general physical health to determine the fitness of the patient for surgery, as well as the examination of specific sites that need liposuction to check for potential problems. PREOPERATIVE INFORMED CONSENT: The patient should sign a detailed consent form listing details about the procedure and possible complications. The consent form should specifically state the limitations of the procedure and should mention whether more procedures are needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures, computer presentations, and personal discussions. Preoperative laboratory studies to be performed include Hb%, blood counts including platelet counts, bleeding and clotting time (or prothrombin and activated partial thromboplastin time) and blood chemistry profile; ECG is advisable. Liver function tests, and pregnancy test for women of childbearing age are performed as mandated by the individual patient's requirements. Ultrasound examination is recommended in cases of gynecomastia. PREOPERATIVE MEDICATION: Preoperative antibiotics and non-sedative analgesics such as paracetamol are recommended. The choice of antibiotic and analgesic agents depends on the individual physician's preference and the prevailing local conditions. TYPE OF ANESTHETIC EMPLOYED: Lidocaine is the preferred local anesthetic; its recommended dose is 35-45 mg/kg and doses should not exceed 55 mg/kg wt. The recommended concentration of epinephrine in tumescent solutions is 0.25-1.5 mg/L. The total dosage of epinephrine should be minimized and should not exceed 50 microg/kg. SURGICAL TECHNIQUE/PROCEDURE: t is always advisable not to combine liposuction with other procedures to avoid exceeding the recommended dosage of lignocaine. However, such combinations may be attempted if the total required dose of lignocaine does not exceed the maximum dose indicated above. The recommended cannula size for liposuction is not to be larger than 3.5 mm in diameter. The recommended volume of fat removed is in proportion to the fat content and/or size and/or weight of the patient being treated. It is recommended that the volume of fat removed not exceed 5000 mL in a single operative session. arge volume liposuctions or mega-liposuctions are not recommended. INTRAOPERATIVE AND POSTOPERATIVE MONITORING: Baseline vital signs including blood pressure and heart rate, are recorded pre- and postoperatively. Pulse oximeter monitoring is essential in all cases. POSTOPERATIVE CARE: Postoperative antibiotics should be selected by the physician and taken for five days. Postoperative antiinflammatory drugs such as Cox 2 Inhibiters may be given for 5-7 days; specialized compression garments, binders, and tape help to reduce bruising, hematomas, seromas, and pain. Generally, compression is recommended for two weeks although this is variable according to the needs of the individual patient.

Microcannular tumescent liposuction.

Liposuction is a commonly performed procedure to remove localized deposits of fat. Liposuction under general anesthesia is associated with significant morbidity and risk of mortality. Dermatologic surgeons have made significant contributions in this field. Tumescent liposuction using microcannuale under local anesthesia, as practised by dermatologic surgeons is safe and effective. This article describes the procedure of microcannular tumescent liposuction.

Synthetic hairs: should they be used?

Artificial hair fibers have recently been marketed in India as an alternative method of hair restoration. However, the subject of artificial hairs is controversial, as FDA in the United States has banned them. Several side effects have been reported after their use and it is therefore important that dermatologists are aware of all aspects about these devices. This article presents the author's viewpoint on the subject and suggests guidelines for using them.