Fractional CO2 laser with topical 1% terbinafine cream versus oral itraconazole in the management of onychomycosis: A randomized controlled trial.

Background Onychomycosis accounts for 20-40% of all nail disorders. It is difficult to cure with resistance to anti-fungal drugs, their side effects and drug interactions limiting treatment options. Itraconazole is a widely accepted oral medication used for onychomycosis while fractional CO2 laser along with a topical anti-fungal has shown promising results for nail plate clearance in onychomycosis. Aim To compare the efficacy of fractional CO2 laser with 1% terbinafine cream versus itraconazole in the management of onychomycosis. Methods A prospective, randomised, single-centre, two-arm, parallel-group interventional study was conducted at Command Hospital Air Force, Bangalore. Onychomycosis cases confirmed by KOH mount/culture-positive were included. Patients were randomly divided into two groups. Group A received 4 sessions of fractional CO2 laser every fourth week with twice-daily application of 1% terbinafine cream; Group B received one-week pulse therapy with capsule itraconazole once every four-week for three pulses. The response was assessed by Onychomycosis Severity Index, a validated onychomycosis assessment scale, at baseline and at six months. Results Group A had 50 patients with a total of 98 nails. Clinical improvement was seen in 83/98 (84.7%) nails. The average reduction in Onychomycosis Severity Index was 8.65 (P < 0.05). Group B had 50 patients with a total of 136 nails. Clinical improvement was seen in 104/136 (76.5%) nails. The average reduction in Onychomycosis Severity Index was 7.37 (P < 0.05). Both groups showed statistically significant improvement measured by 'Reduction in Onychomycosis Severity Index' at six months; however, there was no significant difference between the two arms. Limitations The main limitations of the study are the small sample size and lack of long-term follow-up to assess recurrence of infection. Conclusion Fractional CO2 laser with 1% terbinafine cream is an effective and safe method for inducing nail clearance in onychomycosis and has efficacy similar to itraconazole pulse therapy.

Efficacy of autologous platelet-rich plasma combined with fractional ablative carbon dioxide resurfacing laser in treatment of facial atrophic acne scars: A split-face randomized clinical trial.

BACKGROUND: Autologous platelet-rich plasma has recently attracted significant attention throughout the medical field for its wound-healing ability. AIMS: This study was conducted to investigate the potential of platelet-rich plasma combined with fractional laser therapy in the treatment of acne scarring. METHODS: Sixteen patients (12 women and 4 men) who underwent split-face therapy were analyzed in this study. They received ablative fractional carbon dioxide laser combined with intradermal platelet-rich plasma treatment on one half of their face and ablative fractional carbon dioxide laser with intradermal normal saline on the other half. The injections were administered immediately after laser therapy. The treatment sessions were repeated after an interval of one month. The clinical response was assessed based on patient satisfaction and the objective evaluation of serial photographs by two blinded dermatologists at baseline, 1 month after the first treatment session and 4 months after the second. The adverse effects including erythema and edema were scored by participants on days 0, 2, 4, 6, 8, 15 and 30 after each session. RESULTS: Overall clinical improvement of acne scars was higher on the platelet-rich plasma-fractional carbon dioxide laser treated side but the difference was not statistically significant either 1 month after the first treatment session (P = 0.15) or 4 months after the second (P = 0.23). In addition, adverse effects (erythema and edema) on the platelet-rich plasma-fractional carbon dioxide laser-treated side were more severe and of longer duration. LIMITATIONS: Small sample size, absence of all skin phototypes within the study group and lack of objective methods for the evaluation of response to treatment and adverse effects were the limitations. CONCLUSION: This study demonstrated that adding platelet-rich plasma to fractional carbon dioxide laser treatment did not produce any statistically significant synergistic effects and also resulted in more severe side effects and longer downtime.

Newer and upcoming therapies for melasma.

Melasma is one of the most common and distressing pigmentary disorders presenting to dermatology clinics. The precise cause of melasma remains unknown; however, there are many possible contributing factors. It is notably difficult to treat and has a tendency to relapse. The existing and most tried topical therapy is hydroquinone and the triple combination with tretinoin and corticosteroids, which is considered the gold standard for melasma. Besides that, azelaic acid, kojic acid, arbutin, ascorbic acid, glycolic acid and salicylic peels have also been tried with limited success. However, multiple novel topical agents are being investigated for their potential as hypopigmenting agents with unique mode of action. But, further trials are required to study their efficacy and safety before they can be further recommended. The article highlights these newer formulations and also briefly mentions about the newer chemical peels and the much hyped lasers in treating this difficult and frustrating condition.

Standard guidelines of care: CO2 laser for removal of benign skin lesions and resurfacing.

UNLABELLED: Resurfacing is a treatment to remove acne and chicken pox scars, and changes in the skin due to ageing. MACHINES: Both ablative and nonablative lasers are available for use. CO 2 laser is the gold standard in ablative lasers. Detailed knowledge of the machines is essential. INDICATIONS FOR CO 2 LASER: Therapeutic indications: Actinic and seborrheic keratosis, warts, moles, skin tags, epidermal and dermal nevi, vitiligo blister and punch grafting, rhinophyma, sebaceous hyperplasia, xanthelasma, syringomas, actinic cheilitis angiofibroma, scar treatment, keloid, skin cancer, neurofibroma and diffuse actinic keratoses. CO 2 laser is not recommended for the removal of tattoos. AESTHETIC INDICATIONS: Resurfacing for acne, chicken pox and surgical scars, periorbital and perioral wrinkles, photo ageing changes, facial resurfacing. PHYSICIANS' QUALIFICATIONS: Any qualified dermatologist (DVD or MD) may practice CO 2 laser. The dermatologist should possess postgraduate qualification 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/plastic surgeon, who has experience and training in using lasers. For the use of CO 2 lasers for benign growths, a full day workshop is adequate. As parameters may vary in different machines, specific training with the available machine at either the manufacturer's facility or at another centre using the machine is recommended. FACILITY: CO 2 lasers can be used in the dermatologist's minor procedure room for the above indications. However, when used for full-face resurfacing, the hospital operation theatre or day care facility with immediate access to emergency medical care is essential. Smoke evacuator is mandatory. PREOPERATIVE COUNSELING AND INFORMED CONSENT: Detailed counseling with respect to the treatment, desired effects, possible postoperative complications, should be discussed with the patient. The patient should be provided brochures to study and also given adequate opportunity to seek information. Detailed consent forms need to be completed by the patients. Consent forms should include information on the machine used; possible postoperative course expected and postoperative complications. Preoperative photography should be carried out in all cases of resurfacing. Choice of the machine and the parameters depends on the site, type of lesion, result needed, and the physician's experience. ANESTHESIA: Localized lesions can be treated under eutectic mixture of local anesthesia (EMLA) cream anesthesia or local infiltration anesthesia. Full-face resurfacing can be performed under general anesthesia. Proper postoperative care is important to avoid complications.