Comparative Clinical Study Evaluating the Efficacy and Safety of Topical 5% Cetosomal Minoxidil and Topical 5% Alcohol-Based Minoxidil Solutions for the Treatment of Androgenetic Alopecia in Indian Men.

Introduction Patients with androgenetic alopecia (AGA), who use alcohol-based topical minoxidil solutions, frequently experience localized irritation, dryness, and scalp redness. In this study, we compared the safety and effectiveness of topical 5% cetosomal minoxidil solution to those of topical 5% alcohol-based minoxidil solution in Indian men with AGA. Methods In this randomized, open-label study, male patients with AGA were randomized 1:1 to receive either solutions twice daily for 16 weeks. Efficacy endpoints included changes in basic and specific (BASP) grading, improvement in the trichoscopy score, and global photography at week 16 from baseline, whereas safety was evaluated by adverse events reported by patients and hair-related quality of life (QoL) using the Hairdex-29 questionnaire. Results Of the 80 patients, only 40 completed the study and were considered for complete analysis. Twelve out of 23 patients (52%) in the cetosomal minoxidil group and four out of 17 patients (24%) in the alcohol-based minoxidil group showed a positive increase in hair growth according to the trichoscopy score (p=0.1). According to the BASP grading system, nine patients (39%) and five patients (29%) in the cetosomal and alcohol-based minoxidil groups, respectively, showed improvement (p=0.73). Similarly, 19 (83%) and 10 (59%) patients in the cetosomal and alcohol-based minoxidil groups, respectively, reported positive hair growth on the global photography assessment (p=0.15). All the patients tolerated the treatment well, with no discontinuation in either group. There were four adverse events in the cetosomal minoxidil group, reported by two (9%) patients, whereas in the alcohol-based minoxidil group, 10 adverse events were reported by seven (41%) patients (p=0.02). In addition, the mean Hairdex-29 score of 40.26±4.71 at baseline improved to 32.32±3.35 in the cetosomal group, whereas it improved to 34.64±3.41 from 39.64±4.98 in the other group (p=0.03). Conclusions The 5% cetosomal minoxidil group showed improved safety but similar efficacy when administered twice daily. Therefore, cetosomal minoxidil may be a better option for treating AGA in males who are sensitive or nontolerant to alcoholic formulations.

Role of Dermoscopy in Laser Therapy.

Lasers have revolutionized the interventional dermatology field over the last two decades. Dermatologic conditions previously untreatable are now treated with lasers and lights. A large number of laser systems with advances in technologies have expanded applications of lasers for conditions like birth marks, acne scars, wrinkles, pigmentation, etc. Newer avenues and protocols are now set to treat skin conditions with lasers. The applicability of laser for any indication is dependent on laser tissue interaction which is well documented. For a successful outcome with laser therapy, a right end point of treatment should be achieved. The laser physician often adjusts parameters for laser therapy depending on tissue response, the ultimate aim being achieving optimum outcome with minimum side effects. Gadget based skin evaluation techniques are now an integral part of dermatology and are extending to interventional dermatology too. Application of dermoscopy before, during, and after lasers in various indications has been documented and reviewed. The representative cases highlighted in article emphasize the added dimension to non-invasive diagnostic capabilities of a dermatologist by enabling subsurface microscopy and enhancing therapy outcomes, and incorporation of these into daily practice offers value addition to not only evaluation but also gauging response to therapies. Use of dermoscopy before, during, and after laser therapies is an invaluable non-invasive tool to assess the right indication, initiate appropriate priming, achieve good end point, gauge untoward side effects, achieve good results, and engage patient confidentiality. Comparison of high magnification digital images is also enabled by digital videodermoscopy. Structured studies and protocols are needed to standardize the use of dermoscopy integrated with laser procedures.

Recommendations for Cutaneous and Aesthetic Surgeries during COVID-19 Pandemic.

BACKGROUND: Amid the coronavirus disease 2019 (COVID-19) pandemic, dermatologists must be prepared to restructure their practice of procedural dermatology and cutaneous aesthetic surgeries. The COVID-19 pandemic has presented several challenges and has ushered in several changes in practice such as teledermatology, with many physicians adopting virtual consultations and treatments. Performing procedures in the times of COVID-19 pandemic presents challenges such as risk of transmission to doctors and staff due to potential aerosolization, release of virus droplets during the procedures, and risk of virus transfer through the instruments both in the peri- and postoperative period. This can have several medical, administrative, and legal implications. OBJECTIVES: This document aimed to outline best practices that can be followed in this scenario to perform cutaneous surgeries and procedures to ensure safer skin surgery. RECOMMENDATIONS: Standard precautions include social distancing of at least 1 m, hand hygiene, appropriate use of personal protective equipment (PPE), safe injection practices, sterilization and disinfection of medical devices, environmental cleaning, and respiratory hygiene. It is generally advisable to see patients only by appointments. Each clinic should have a special area at entry for screening patients and providing sanitizers and masks. Procedures, which are of short duration, performed on nonfacial areas are considered as low risk and require donning surgical mask. Procedures involved with minimal invasiveness and bleeding, short duration procedures on the face such as injectables, chemical peels, and aerosol-generating procedures on nonfacial areas are considered moderate risk. These procedures need apron with head cover, N95 mask, face shield, double gloves, and smoke evacuator with high-efficiency particulate air (HEPA) or ultralow particulate air (ULPA) filter. Aerosol and plume-regenerating procedures (such as ablative lasers on the face), prolonged surgeries on head (such as hair transplantation), intraoral, and intranasal procedures are considered high risk. These procedures must be carried out with full body cover with surgical gown, head cover, N95 mask, face shield, double gloves, and smoke evacuator. Physicians should be aware of local epidemiological situation and adhere to the relevant guidelines issued by the relevant governmental agencies.

Fractional Carbon Dioxide Laser: Optimizing Treatment Outcomes for Pigmented Atrophic Acne Scars in Skin of Color.

Dark skin type has high propensity to acne scarring and is often complicated by persistent erythema or pigmentation at the base. Fractional lasers are available for the longest period and are able to improve most atrophic acne scars. Often pigmented scar bases and dark skin types limit the use of aggressive laser parameters. Long pulse mode is preferred over short pulse to prevent epidermal damage; low fluence is chosen versus high fluence and low density versus high density. Repeated treatments are needed to minimize complications and optimize results; all these must be achieved through a controlled stage of inflammation. Interventional priming with chemical peels and laser toning before ablative fractional carbon dioxide laser helps to reduce photodamage, recent tan, and pigment at scar base, thus minimizing the risk of post-inflammatory hyperpigmentation. Multiple recent literature evidence validates the combinations to optimize outcomes in atrophic acne scars as discussed in this review article.

Methods to overcome poor responses and challenges of laser hair removal in dark skin.

Conventional and advance technologies are available for laser hair removal. Complete and permanent hair reduction is not yet possible by treatment with lasers. Ideal patient for any conventional laser hair removal treatment is one who has thick, dark terminal hair, light skin and normal hormonal status. Factors that contribute to variable outcomes in laser hair removal can be broadly divided into patient related ones and the technology related ones. Skin type, hair color, thickness and density, degree of tan, hormonal dysfunction etc., constitute the patient related factors. The wavelength, fluence, spot size and pulse duration of the laser system are the technology related factors. There are some patients who respond variably, unpredictably or poorly to laser hair removal despite ensuring that indication for treatment is appropriate with adequate parameters of the laser system. This article reviews various patient related and technology related factors which lead to variable-to-poor outcomes in laser hair removal; and various challenges and limitations of laser hair removal technology in patients with dark skin types.

Simplifying Injectables for Volumetric Rejuvenation of Face.

Volumetric rejuvenation with fillers is a minimally invasive technique used for facial volume restoration. Volume restoration demands adequate knowledge of fat pads and vascularity of the face and the understanding of the depletion patterns. Volumetric restoration with injectable has witnessed a paradigm shift in the last decade with a global rejuvenation, acquiring a predominant emphasis over focal wrinkle filling to restore the depletion pattern of facial fat layers. The techniques used to achieve optimal restoration of facial volume revolve around zonal lifting and tenting, and the impact of treatment on one zone of the surrounding zones is crucial. A face mapping performed for filler technique has thus evolved, with many experts advocating varied techniques from global restoration to point lifts at key areas, to improve the outcome of filler injections, albeit safely, thus simplifying the process. A systematic approach to various techniques and the point lifts in various zones pertaining to the face structure in the Indian skin are highlighted in this article.

Medical Management of Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group.

Melasma is one of the most common hyperpigmentary disorders found mainly in women and dark-skinned patients. Sunlight, hormones, pregnancy, and genetics remain the most implicated in the causation of melasma. Although rather recalcitrant to treatment, topical agents such as hydroquinone, modified Kligman's Regime, azelaic acid, kojic acid, Vitamin C, and arbutin still remain the mainstay of therapy with sun protection being a cornerstone of therapy. There are several new botanical and non botanical agents and upcoming oral therapies for the future. There is a lack of therapeutic guidelines, more so in the Indian setup. The article discusses available evidence and brings forward a suggested treatment algorithm by experts from Pigmentary Disorders Society (PDS) in a collaborative discussion called South Asian Pigmentary Forum (SPF).

Chemical Peels in Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group.

Melasma is a notorious dermatosis, often resistant to treatment. Chemical peeling constitutes an acceptable option of management of melasma (of any type and duration). In this article, as a group of experts from Pigmentary Disorders Society (PDS) in collaboration with South Asian Pigmentary Forum (SPF), we have tried to elaborate the various chemical peeling agents for the treatment of melasma. Besides, we have reviewed the indications, mechanism of action, rationality and the detailed procedure of peeling. The evidence in favor of various peeling agents have been summarized as well.

Lasers in Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group.

Lasers have come up as the newest therapeutic modality in dermatological conditions including melasma. In this article, as a group of experts from Pigmentary Disorders Society in collaboration with South Asian Pigmentary Disorders Forum (SPF), we have tried to discuss the lasers which have been used in melasma and formulate simple consensus guidelines. Following thorough literature search, we have summarised the rationale of using the lasers and the supporting evidences have also been provided. It is clear that laser cannot be the first line treatment for melasma. However, it can be used as an adjuvant therapy in resistant cases, provided the selection of patient and counselling has been done properly.

Infliximab: efficacy in psoriasis.

Moderate to severe psoriasis often needs to be addressed with standard disease modifying therapies such as methotrexate, cyclosporine, acitretin or ultraviolet radiation, which have their potential benefits and limitations. The tumor necrosis factor-alpha (TNF-α) is elevated in psoriatic plaques compared to non lesional skin as well as in the plasma of patients with moderate to severe psoriasis. Infliximab, a TNF-α blocker, has been recommended for the treatment of moderate to severe plaque psoriasis in adults who have failed to respond to these therapies or who cannot tolerate them. Its specific action on the bound and membrane forms of the pro-inflammatory cytokine TNF-α has made it the molecule of choice for obtaining quicker and longer remission in recalcitrant cases. However, the widespread use of infliximab in the Indian subcontinent is limited by its cost. This article reviews the international guidelines for use of infliximab, its dosage patterns, and efficacy in chronic plaque psoriasis, nail psoriasis, erythrodermic psoriasis, and pustular psoriasis as well as Indian experience.

Safety and persistence of non-animal stabilized hyaluronic Acid fillers for nasolabial folds correction in 30 Indian patients.

BACKGROUND: Correction of nasolabial creases through minimally invasive procedures is increasingly being sought by patients. Injecting non-animal stabilized hyaluronic acid filler is a highly effective method to achieve an optimal and persistent cosmetic result AIMS: To evaluate the efficacy, persistence and safety of Restylane and Perlane (Q-Med, Sweden) for correction of nasolabial folds in Indian patients MATERIALS AND METHODS: Thirty Indian patients with mild, moderate and severe nasolabial folds (based on Wrinkle Assessment Scale) were recruited in the study after informed consent for correction of their folds with Restylane or Perlane or both. Injections were administered in a single sitting after global assessment of the patient's face using Wrinkle assessment scale (WAS).Optimal filling was performed by using appropriate techniques and its safety and efficacy assessed independently by the investigator as well as by patients at immediately, 3, 6 and 9 months post-procedure. Any adverse reactions were noted. RESULTS: Twenty two females and 8 males (age range 45-55 years, mean age 52 years) were recruited in the study. An optimum cosmetic correction was obtained in all patients. The efficacy increased with time and was greatest at 3 months after the treatment. Grade 2 improvement was maintained at 9 months in mild and moderate folds, and grade 3 improvement for severe folds. Minor post injection side effects like erythema at puncture site, needle marks and bruising were seen. CONCLUSION: Restylane and Perlane are safe and effective dermal fillers for correction of nasolabial creases and offer immediate effect.