An observational study on glabellar wrinkle patterns in Indians.

BACKGROUND: Botulinum A exotoxin is an established treatment for glabellar frown lines, crow's feet, and horizontal furrows of the forehead. The glabella is probably the most common site for botulinum toxin treatment in Asians. Five glabellar contraction patterns have been classified in earlier studies based on eyebrow approximation, depression, and elevation. Unfortunately, this was found to be confusing by many practitioners. Indians, as all Asians, have smaller muscles compared to the European population, and there is no consensus on the optimal dosage per injection site or concentration of toxin to be used. AIMS: (a) Identification and classification of glabellar wrinkle patterns in Indians. (b) Optimization of the minimal effective dose of toxin per site. MATERIALS AND METHODS: Retrospective photographic analysis of 200 patients who received botulinum toxin for the first time to treat glabellar wrinkles was conducted. The wrinkle patterns were identified and classified by the authors based on the prevalence of perpendicular and transverse glabellar lines, nasal, and forehead wrinkles. RESULTS: Six patterns were identified: (1) 11 (2) U (3) Pi (4) X (5) W (6) I. The relevant muscles were identified and doses optimized for those sites. LIMITATIONS: The doses mentioned in this study are not universal for all patients and toxin units would have to be altered and individualized according to the bulk of the facial muscles and individual needs. CONCLUSION: The investigators classification, injection patterns, and dosage may provide valuable guidance to facial esthetic treatment.

Efficacy and safety of 0.1% kinetin cream in the treatment of photoaging skin.

BACKGROUND: Kinetin is a plant-derived compound, which is reported to possess antiaging properties. It has been used in a topical cream to manage facial photo-damage and aging. Although studies elsewhere have shown its benefits, not many studies of the effects of kinetin in Asian skin are available. OBJECTIVES: To assess the efficacy and tolerability of 0.1% kinetin cream in the treatment of facial photo-aging. METHODS: The study was designed to be open-label and single-blinded, without a control group. One hundred Thai female and male subjects with mild, moderate or severe facial photo-damage were enrolled. They were asked to apply 0.1% kinetin cream twice daily for 12 weeks and follow up at 4, 8, and 12 weeks. Subjective patient self-assessment and physician assessment of facial skin photo-damage were accompanied by digital photographic analysis using the VISIA® (Canfield Scientific Inc, Fairfield, NJ) imaging system. RESULTS: At baseline, most patients reported moderate skin changes related to photo-damage, skin texture, skin color and wrinkles. After 12 weeks, physician and patient assessments showed slight but statistically significant improvements in overall skin condition, skin texture, color, and wrinkles. Findings were similar with the digital photographic system analysis, especially in relation to skin color. Facial ultraviolet spots and redness also showed statistically significant improvements after 12 weeks. The treatment was generally well tolerated. LIMITATIONS: The study was designed to be pragmatic and hence no randomization was carried out; there were also no intrapatient or interpatient control observations, and no comparison arm. CONCLUSION: Kinetin (0.1%) cream was found to slightly improve cutaneous facial photo-damage after 12 weeks of use in a group of Thai patients.

Topical photodynamic therapy with methylaminolevulinate for the treatment of actinic keratosis and reduction of photodamage in organ transplant recipients: a case-series of 16 patients.

BACKGROUND: Organ transplant recipients (OTR) are at high risk of developing cutaneous neoplasms. Topical photodynamic therapy (PDT) has been used for the treatment of actinic keratosis (AK) in OTR. AIMS: The objective was to evaluate the efficacy of PDT with methylaminolevulinate (MAL) in the treatment of facial AK in OTR. As a secondary objective, we wanted to evaluate the usefulness of topical PDT in the reduction of photodamage in OTR. METHODS: A prospective, single center, single arm study was made. 16 OTR were included. Topical PDT was applied for 1 or 2 cycles depending on the patient's characteristics. An evaluation of AK was made at visits pre-treatment, at 12 weeks and at 24 weeks. Photodamage was measured with multispectral image technique (SkinCare). RESULTS: A complete response rate of 100% was achieved for AK in all patients; it persisted without change at 12 and 24 weeks of follow-up. 62.5% of patients improved their photodamage as measured by SkinCare®, but this result was not statistically significant (P = 0.12). All patients had high level of satisfaction at the end of the therapy. CONCLUSIONS: MAL-PDT is an effective therapy for the treatment of AK in OTRs. It can reduce photodamage in this group of patients, but these results were not statistically significant.

The effects of a daily facial lotion containing vitamins B3 and E and provitamin B5 on the facial skin of Indian women: a randomized, double-blind trial.

BACKGROUND: The B vitamins niacinamide and panthenol have been shown to reduce many signs of skin aging, including hyperpigmentation and redness. AIMS: To measure the facial skin effects in Indian women of the daily use of a lotion containing niacinamide, panthenol, and tocopherol acetate using quantitative image analysis. METHODS: Adult women 30-60 years of age with epidermal hyperpigmentation were recruited in Mumbai and randomly assigned to apply a test or control lotion to the face daily for 10 weeks. Effects on skin tone were measured using an image capturing system and associated software. Skin texture was assessed by expert graders. Barrier function was evaluated by transepithelial water loss measurements. Subjects and evaluators were blinded to the product assignment. RESULTS: Of 246 women randomized to treatment, 207 (84%) completed the study. Women who used the test lotion experienced significantly reduced appearance of hyperpigmentation, improved skin tone evenness, appearance of lightening of skin, and positive effects on skin texture. Improvements versus control were seen as early as 6 weeks. The test lotion was well tolerated. The most common adverse event was a transient, mild burning sensation. CONCLUSIONS: Daily use of a facial lotion containing niacinamide, panthenol, and tocopheryl acetate improved skin tone and texture and was well tolerated in Indian women with facial signs of aging.

Modeling signaling pathways leading to wrinkle formation: identification of the skin aging target.

BACKGROUND: In the present scenario, wrinkle formation, prominent sign of skin ageing, is one of the most demanding areas of research. This burgeoning research demand to reduce, delay and restore the effects of skin ageing has led to the study of various signaling pathways leading to wrinkle formation. Wrinkles appear on skin due to influence of intrinsic and extrinsic factors on mitogenic reactions and signal transduction pathways. AIM: The aim of the present study is to analyze each protein involved in the signaling pathway leading to dilapidation of collagen and an attempt has been made to compare different signal transduction pathways to identify a common target for skin ageing. METHODS: In the present work, bioinformatics tools have been used to extract information from already existing experimental data. The statistical techniques are used for further analysis and make useful predictions for skin ageing. RESULTS: Stressors like UV irradiation, osmotic stress and heat shock have been reported to activate epidermal growth factor receptor, interleukin 1 receptor, tumor necrosis factor receptor, platelet-derived growth factor receptor and platelet activation factor receptor signaling pathways, which lead to the production of matrix metalloproteinases, collagen degradation and, consequently, wrinkle formation. When all the five signaling pathways were modeled, the c-jun part of the AP-1 transcription factor was found to be a common intermediate protein involved in all the signaling cascades. Moreover, it shows differential expression in the skin on response to stressors. CONCLUSION: We proposed c-jun to be the most potent target for drug designing against wrinkle formation.

Guidelines on the use of botulinum toxin type A.

UNLABELLED: Botulinum toxin is available as types A and B. These two different forms need different dosages and hence, the physician needs to be familiar with the formulations. A thorough knowledge of the anatomy and physiology of the muscles in the area to be injected is essential. INDICATIONS FOR BOTULINUM TOXIN: Dynamic wrinkles caused by persistent muscular contractions are the main aesthetic indications for the use of Botulinum toxin. These include forehead lines, glabellar lines, crow's feet, bunny lines, perioral wrinkles, and platysmal bands. Non-aesthetic indications include hyperhidrosis of the palms, soles and axillae. PHYSICIANS' QUALIFICATIONS: Any qualified dermatologist may practice the technique after receiving adequate training in the field. This may be obtained either during post-graduation or at any workshops dedicated to this subject. FACILITY: Botulinum toxin can be administered in the dermatologist's minor procedure room. PREOPERATIVE COUNSELING AND INFORMED CONSENT: Detailed counseling with respect to the treatment, desired effects, and longevity of the results should be discussed with the patient. The patient should be given brochures to study and adequate opportunity to seek information. A detailed consent form needs to be completed by the patient. The consent form should include the type of botulinum toxin, longevity expected and possible postoperative complications. Pre- and postoperative photography is recommended. Dosage depends on the area, muscle mass, gender and other factors outlined in these guidelines. It is recommended that beginners should focus on the basic indications in the upper third of the face and that they treat the middle and lower parts of the face only after garnering adequate experience.

Standard guidelines for the use of dermal fillers.

UNLABELLED: Currently used fillers vary greatly in their sources, efficacy duration and site of deposition; detailed knowledge of these properties is essential for administering them. Indications for fillers include facial lines (wrinkles, folds), lip enhancement, facial deformities, depressed scars, periocular melanoses, sunken eyes, dermatological diseases-angular cheilitis, scleroderma, AIDS lipoatrophy, earlobe plumping, earring ptosis, hand, neck, décolleté rejuvenation. PHYSICIANS' QUALIFICATIONS: Any qualified dermatologist may use fillers after receiving adequate training in the field. This may be obtained either during postgraduation or at any workshop dedicated to the subject of fillers. The physicians should have a thorough knowledge of the anatomy of the area designated to receive an injection of fillers and the aesthetic principles involved. They should also have a thorough knowledge of the chemical nature of the material of the filler, its longevity, injection techniques, and any possible side effects. FACILITY: Fillers can be administered in the dermatologist's minor procedure room. PREOPERATIVE COUNSELING AND INFORMED CONSENT: Detailed counseling with respect to the treatment, desired effects, and longevity of the filler should be discussed with the patient. Patients should be given brochures to study and adequate opportunity to seek information. Detailed consent forms need to be completed by the patients. A consent form should include the type of filler, longevity expected and possible postoperative complications. Preoperative photography should be carried out. Choice of the filler depends on the site, type of defect, results needed, and the physician's experience. Injection technique and volume depend on the filler and the physician's preference, as outlined in these guidelines.

Standard guidelines of care for chemical peels.

UNLABELLED: Chemical peeling is the application of a chemical agent to the skin, which causes controlled destruction of a part of or the entire epidermis, with or without the dermis, leading to exfoliation and removal of superficial lesions, followed by regeneration of new epidermal and dermal tissues. Indications for chemical peeling include pigmentary disorders, superficial acne scars, ageing skin changes, and benign epidermal growths. Contraindications include patients with active bacterial, viral or fungal infection, tendency to keloid formation, facial dermatitis, taking photosensitizing medications and unrealistic expectations. PHYSICIANS' QUALIFICATIONS: The physician performing chemical peeling should have completed postgraduate training in dermatology. The training for chemical peeling may be acquired during post graduation or later at a center that provides education and training in cutaneous surgery or in focused workshops providing such training. The physician should have adequate knowledge of the different peeling agents used, the process of wound healing, the technique as well as the identification and management of complications. FACILITY: Chemical peeling can be performed safely in any clinic/outpatient day care dermatosurgical facility. PREOPERATIVE COUNSELING AND INFORMED CONSENT: A 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 should clearly mention if more procedures are needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures, presentations, and personal discussions. The need for postoperative medical therapy should be emphasized. Superficial peels are considered safe in Indian patients. Medium depth peels should be performed with great caution, especially in dark skinned patients. Deep peels are not recommended for Indian skin. It is essential to do prepeel priming of the patient's skin with sunscreens, hydroquinone and tretinoin for 2-4 weeks. ENDPOINTS IN PEELS: For glycolic acid peels: The peel is neutralized after a predetermined duration of time (usually three minutes). However, if erythema or epidermolysis occurs, seen as grayish white appearance of the epidermis or as small blisters, the peel must be immediately neutralized with 10-15% sodium bicarbonate solution, regardless of the duration of application of the peel. The end-point is frosting for TCA peels, which are neutralized either with a neutralizing agent or cold water, starting from the eyelids and then the entire face. For salicylic acid peels, the end point is the pseudofrost formed when the salicylic acid crystallizes. Generally, 1-3 coats are applied to get an even frost; it is then washed with water after 3-5 minutes, after the burning has subsided. Jessner's solution is applied in 1-3 coats until even frosting is achieved or erythema is seen. Postoperative care includes sunscreens and moisturizers Peels may be repeated weekly, fortnightly or monthly, depending on the type and depth of the peel.