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.

Proposed global drooping and wrinkles classification and scoring system for aging face with validation and experience on 54 Indian subjects.

BACKGROUND: Aging is an inevitable biological change, but understanding the process of aging of face is important to customize the treatment options for facial rejuvenation. Evidence-based estimation of global facial aging is necessary for the validation of various treatment modalities. AIMS: Classification and implementation of a scoring system for aging face based upon volume loss and surface changes as evident by drooping of different areas of the face and appearance of fine and deep wrinkles, respectively, and to apply this drooping-wrinkles classification on 54 participants to evaluate and understand the validity of scoring. METHODS: An observational study was conducted, and scores were calculated based on 13 parameters (7 areas of drooping and 6 areas of wrinkles on the face) at Aura Skin Institute, Chandigarh, India. Accordingly, age was divided in different age groups followed by clinical estimation of facial age and calculation of scores. RESULTS: According to our classification and scoring system, 61% (33 out of 54) of the participants were correlated with their chronological age group. Out of the remaining 21 (39%) participants who were aging faster, 13 (24%) were in the age group of 25-35 years. Approximately one-fourth of the patients in the age groups 36-45 and 46-55 years were aging faster. Only 1 patient had scores showing younger age in comparison to chronological age. Overall, there was a good correlation between the calculated score and the chronological age of patients. Moreover, a gradual increase in scores was noticed with increasing age groups. CONCLUSIONS: This is a new clinical classification and scoring system for facial age which is much easier to apply in daily clinical practice for easy calculation of baseline scores and customizing their antiaging treatment options. Moreover, it will also make it easier to compare the efficacy of treatment in their future follow-ups. The limitation of this study is that it has been proposed for all skin types but validation has been done only for Indian participants.

Effects of air pollution on the skin: A review.

The increase in air pollution over the years has had major effects on the human skin. Various air pollutants such as ultraviolet radiation, polycyclic aromatic hydrocarbons, volatile organic compounds, oxides, particulate matter, ozone and cigarette smoke affect the skin as it is the outermost barrier. Air pollutants damage the skin by inducing oxidative stress. Although human skin acts as a biological shield against pro-oxidative chemicals and physical air pollutants, prolonged or repetitive exposure to high levels of these pollutants may have profound negative effects on the skin. Exposure to ultraviolet radiation has been associated with extrinsic skin aging and skin cancers. Cigarette smoke contributes to premature aging and an increase in the incidence of psoriasis, acne and skin cancers. It is also implicated in allergic skin conditions such as atopic dermatitis and eczema. Polyaromatic hydrocarbons are associated with extrinsic skin aging, pigmentation, cancers and acneiform eruptions. Volatile organic compounds have been associated with atopic dermatitis. Given the increasing levels of air pollution and its detrimental effects on the skin, it is advisable to use strategies to decrease air pollution.

A clinical rating scale for the assessment of facial aging in Indian population.

BACKGROUND: Estimation of facial aging has assumed growing importance due to the advent of several antiaging therapies. Evidence-based estimation of global facial aging is often necessary, especially for validation of these treatment modalities. Most available methods are expensive and have been used in fair skinned individuals. AIM: We attempted to develop a clinical rating scale for the estimation of global facial aging applied on an Indian population which has brown to black skin. We have also measured the association of this rating scale score with the chronological age. METHODS: Initially, a 14- item summated rating scale was developed with inputs from five dermatologists and a clinical pharmacologist. The rating scale was applied to 105 consenting subjects with healthy facial skin between 30 to 90 years of age. Intra- and inter-rater reliability was assessed. RESULTS: The summated rating score showed a significant positive correlation with the chronological age (Pearson's correlation coefficient 0.834, P < 0.001). We omitted one item from the scale due to a low inter-rater agreement. The resulting 13-item rating scale was internally consistent (Cronbach's alpha: 0.905), with substantial inter- and intra-rater reliability (intraclass correlation coefficient: 0.973 and 0.788, respectively). Principal components and predictive equation for perceptible age were identified on further computation. LIMITATIONS: Participants of this study were limited to a particular ethnic group from West Bengal and other neighboring states of Eastern India. CONCLUSIONS: We have developed and validated a 13-item rating scale for the quantification of global facial aging suitable for Indian (brown to black) skin type. This scale can be utilized effectively for clinical estimation of global facial aging.

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.

Mechanobiological dysregulation of the epidermis and dermis in skin disorders and in degeneration.

During growth and development, the skin expands to cover the growing skeleton and soft tissues by constantly responding to the intrinsic forces of underlying skeletal growth as well as to the extrinsic mechanical forces from body movements and external supports. Mechanical forces can be perceived by two types of skin receptors: (1) cellular mechanoreceptors/mechanosensors, such as the cytoskeleton, cell adhesion molecules and mechanosensitive (MS) ion channels, and (2) sensory nerve fibres that produce the somatic sensation of mechanical force. Skin disorders in which there is an abnormality of collagen [e.g. Ehlers-Danlos syndrome (EDS)] or elastic (e.g. cutis laxa) fibres or a malfunction of cutaneous nerve fibres (e.g. neurofibroma, leprosy and diabetes mellitus) are also characterized to some extent by deficiencies in mechanobiological processes. Recent studies have shown that mechanotransduction is crucial for skin development, especially hemidesmosome maturation, which implies that the pathogenesis of skin disorders such as bullous pemphigoid is related to skin mechanobiology. Similarly, autoimmune diseases, including scleroderma and mixed connective tissue disease, and pathological scarring in the form of keloids and hypertrophic scars would seem to be clearly associated with the mechanobiological dysfunction of the skin. Finally, skin ageing can also be considered as a degenerative process associated with mechanobiological dysfunction. Clinically, a therapeutic strategy involving mechanoreceptors or MS nociceptor inhibition or acceleration together with a reduction or augmentation in the relevant mechanical forces is likely to be successful. The development of novel approaches such as these will allow the treatment of a broad range of cutaneous diseases.

Upper face rejuvenation using botulinum toxin and hyaluronic acid fillers.

The demand for facial rejuvenation is increasing, with each passing day, in all age groups. A number of procedures like chemical peels, microdermabrasion, laser and light therapies, and minimally invasive procedures like botulinum toxin injections (BTX A) and hyaluronic acid (HA) fillers are being extensively used by the dermatologist and plastic surgeons to meet this growing demand. A good knowledge of use of these techniques is becoming imperative for the dermatologist. In the present article, we discuss in detail the use of botulinum toxin injections and hyaluronic acid fillers for rejuvenation of upper face. Special emphasis has been placed on the complications associated with treatment of each area and on how to manage the same.

Blepharoplasty and periorbital surgical rejuvenation.

The periorbital region forms the epicenter of facial aging changes and receives highest attention from physicians and patients. The concern about visual function, clubbed with the need for hidden incisions, makes the periocular region a highly specialized surgical area, most appropriately handled by an ophthalmic plastic surgeon. The article provides an overview of cosmetic eyelid and facial surgery in the periocular region. Common aesthetic surgical procedures as well as ocular side-effects of commonly performed periocular injections are discussed from the dermatologist's point of view.

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.

Ultrasonographic assessment of skin structure according to age.

BACKGROUND: High-frequency ultrasound is a noninvasive tool that offers characteristic markers, quantifying the cutaneous changes of the physiological senescence process. AIMS: The aim was to assess the changes in skin thickness, dermal density and echogenicity, as part of the ageing process, with different age intervals. METHODS: The study was performed on 160 patients, aged 40.4 ± 21.2, divided into four age categories: <20, 21-40, 41-60, 61-80. Ultrasonographic images (Dermascan device) were taken from three sites: dorsal forearm (DF), medial arm (MA), zygomatic area (ZA). We assessed the thickness of epidermis and dermis (mm), number of low, medium, high echogenicity pixels, the ratio between the echogenicity of the upper and lower dermis (LEPs/LEPi), and SLEB (subepidermal low echogenicity band). The statistical analysis was performed using SPSS 15.00. A P value <0.05 was considered significant. RESULTS: On all examined sites, it was found that the dermal thickness increases in the 21 to 40 year interval (P<0.0001). After the 21 to 40 year interval, the number of low echogenic pixels increases significantly, especially on photoexposed sites. High-echogenic pixels follow the same pattern on all examined sites: they increase in the 21 to 40 year interval and decrease in the 3rd and 4th age category. The LEPs/LEPi ratio increases significantly with age, at all sites (P<0.05), due to an increase of hypoechogenic pixels in the upper dermis. CONCLUSIONS: High-frequency ultrasound is a noninvasive "histological" tool that can assess the cutaneous structure and age-related changes. It offers imagistic markers, comparable to the histological parameters and also characteristic ultrasonographic markers. Histology remains the gold standard for the investigation of the integumentary system.

Cutaneous solar ultraviolet exposure and clinical aspects of photodamage.

Solar ultraviolet (UV) radiation reaching the earth is a combination of UVB (290-320 nm) and UVA (320-400 nm) wavelengths. Since UVA is less energetic than UVB, UVB has long been thought to be the factor responsible for the damaging effects of solar radiation. But with modern tools such as in vitro models, it has been proven that UVA plays a major role. The objective of this review is to show how skin may be exposed to UV light and to highlight the clinical aspects of UV-induced skin damages with the respective contribution of UVB or UVA. Even if UVA is less energetic than UVB, it is more abundant and penetrates deeper into the skin, reaching as far as the dermis. Various factors also influence skin exposure to UV light: the latitude, season, and time of the day. Acute as well as chronic sun exposure induces short- and long-term clinical damages. Erythema and pigmentation are immediate responses of normal human skin exposed to UV radiation. The long-term effects are photoaging and photocarcinogenesis. In particular, UVA appears to play a major role in the deterioration of dermal structure leading to the photoaged appearance of the skin.

The safety and efficacy of a combined diode laser and bipolar radiofrequency compared with combined infrared light and bipolar radiofrequency for skin rejuvenation.

BACKGROUND: As the demand for noninvasive procedures for skin rejuvenation is increasing, combined diode laser and radiofrequency and combined infrared and radiofrequency devices have recently emerged. AIM: To compare Polaris WRA(TM), a combination device of diode light and RF, and ReFirme ST(TM), a combination device of infrared and bipolar RF, in terms of safety and efficacy on skin rejuvenation. METHODS: Fourteen Korean volunteers of skin type II-IV, with facial laxity and periorbital rhytids, received three treatments at 3-week intervals with combined diode laser and bipolar radiofrequency (laser fluence 30 J/cm2, RF fluence 90 J/cm3) on the right half of their faces and combined infrared light and bipolar radiofrequency (RF fluence 120 J/cm3) on the left half of their faces. Clinical photos of front and bilateral sides of the subjects' faces were taken at baseline and at 6, 9, 12 weeks after the treatment initiation. The investigators' and the subjects' global assessments were performed. RESULTS: There is no statistically significant difference in the overall outcome between Polaris WRA(TM) and Refirme ST(TM) based on pre- and post-treatment objective measurements. Polaris WRA(TM) was more effective than Refirme ST(TM) at reducing wrinkles when therapeutic results of the two appliances were compared based on the patient satisfaction measurements. After the treatment with both instruments, histological increase in the production and rearrangement of collagen fibers at the dermal layer was observed. The density of the collagen fibers was more increased with the Polaris WRA(TM)-treated facial area than that of Refirme ST(TM). Treatment was generally well tolerated, and there was no serious complication. CONCLUSION: In this study, both the lasers appeared to be safe, and effective methods for treating skin laxity and facial wrinkles. Combined diode laser and radiofrequency was more effective than combined infrared and radiofrequency at reducing wrinkles and pores when the therapeutic results of both the appliances were compared.

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.

Pigmentary demarcation lines on the face in Saudi women.

BACKGROUND: Pigmentary demarcation lines (PDL) are physiological abrupt transition lines between hyperpigmented skin and lighter areas. Recent evidence suggests that they involve the face. AIMS: To survey facial PDL in Saudi females referred to general dermatology clinics for various complaints and determine any associated risks. METHODS: Screening for facial lines was done in general dermatology clinics over a year. Whenever a patient was found to have facial PDL, a detailed questionnaire and examination were undertaken. RESULTS: Out of 1033 patients screened, 144 patients (14%) were found to have at least one of the facial PDLs. The median age of onset was 16 years. The most common line was F with 76 patients (53%). Family history was positive in 51 patients (35%). CONCLUSION: Facial PDL is a common and chronic pigmentary problem in Saudi women. It should be recognized and differentiated from other similar diseases like melasma. A significant proportion of patients have a milder presentation.

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.