Non-Ablative super-pulsed Radiofrequency for face lift

(International Cosmoderm Congress, 8-10 February 2005, Mumbai. Annual conference of The Cosmetology Society, India in association with ESCAD.)

Title : Non-Ablative super-pulsed Radiofrequency for face lift.

Author and speaker : Dr.Jaishree Sharad
Affiliation : Consultant dermatologist, Navi Mumbai.

Aim: To study the effect of super-pulsed radiofrequency for skin tightening & face lift.
Material & methods: 20 females, 35-50 yrs with laxity of skin over face & neck. Exclusion criteria: active skin problems, on going treatment with retinoids or chemical peels, pregnancy, pace makers, ablative or non ablative laser resurfacing within last 6 months.
Instrument & settings: RF300 super pulsed radiofrequency
Procedure: Consent, photographs. The area to be treated was pre-cooled with ice packs. Electrode gel was applied. RF 300 connected & 5mm ball electrode moved back & forth with moderated pressure to cover entire face & neck. End point: erythema, mild oedema & improvement of skin folds. Post cooling done with ice packs. Patient resumed normal activities immediately. Repeat sitting every month for 4 months.
Result: Marked improvement in naso-labial ,meso-labial, glabellar folds, cheek laxity, neck laxity, peri-orbital laxity in age group 30 - 40 yrs. Moderate to marked improvement in age group 40 -60 yrs.
Complication: None if power setting appropriate. Skin burn if power too high.
Conclusion: Safe, simple, effective office procedure with excellent cosmetic results. It can be combined with other modalities like botox, IPL, Non ablative ND-Yag rejuvenation.

SURGICAL PEARLS IN TREATMENT OF DERMATOSIS PAPULOSA NIGRA

(Annual conference of Maharashtra branch of IADVL, Mumbai, 5th March 2001)

Title : Surgical pearls in the treatment of dermatosis papulosa nigra.

Author and speaker : Dr.Jaishree Sharad

Affiliation : Consultant dermatologist, Navi Mumbai.

Introduction : Flat and pedunculated DPN are usually either electrodessicated or snipped off and then electrodessicated. Both these techniques lead to scarring and/or pigmentation. A simpler technique to treat the same has been described here.

Method :

• For pedunculated DPN : The lesion is crushed at its base with an artery forceps and then snipped off. There is no intra-operative bleeding & thus no scarring.
• For flat DPN : The lesion is electro-fulgurated with a fine electro-epilation needle or a spade shaped electrode. It is then curetted or scraped off with the spade electrode itself. By adjusting the distance between the electrode tip and the lesion, it is possible to save the adjacent uninvolved skin from damage.
  
  

CRYO - CHEMO SURGICAL TREATMENT FOR GIANT CONDYLOMA ACUMINATA (genital warts).

(30th Annual Conference of Indian Association of dermatologists Venerologists and leprologists, Cochin, Kerela, 24th - 27th January, 2002)

Speaker: Dr Jaishree Sharad.

Author: Dr Jaishree Sharad.

Title : Cryo - Chemo surgical treatment for giant condyloma acuminata.


Aim: To assess the effect of liquid nitrogen cryo-therapy and podophyllin for the treatment of giant (more than 5 centimeters in diameter) condyloma acuminata (GCA).

Summary: 15 cases (9 males and 6 females) were taken 3 out of 15 were HIV positive no other immuno-compromised condition was detected.
   After local anesthesia the lesions were sprayed with Liquid Nitrogen and 2 rapid freeze - slow thaw cycles were given. Lesions were covered sequentially in overlapping manner. After complete thawing 25% podophyllin in Tincture Bezoin solution was generously applied. Initial oedema was followed by local necrosis and crusting (7 days). All lesions healed by secondary intention.
   10 cases (66%) cases had complete remission in one sitting and 2 cases (13.3%) required a second sitting.
    Complications: De-pigmentation in 8 (53%), scarring in 2 (13.3%), recurrence in 2 (13.3%) was seen.

Conclusion: Combination of liquid nitrogen cryotherapy and podophyllin was found to be safe and effective in GCA. It was found to be effective in resistant and HIV positive cases.

DERMATO-SURGERY - A BRIEF OVERVIEW

(Indian Medical Association, Navi Mumbai, Bulletin millennium issue, January 2001)

Author: Dr Jaishree Sharad

Dermato-surgery has evolved as that branch of dermatology where conditions refractory to medical treatment are dealt with and cosmetic improvement of skin is thus brought about. Skin biopsies, excision of cysts and corns, earlobe repairs, mole removal, nail avulsion in cases of onychomycosis, are now being done by dermato-surgeons.

The other common office procedures are as follows:

1. Electro-surgery : This involves procedures employing electrically generated heat. a) Electro-fulguration : small epidermal lesions such as verruca plana, milia, dermatitis papulosa nigrosa skin tags can be removed by electro-fulguration with "fine epilation needle" electrode wherein the superficial tissue is charred by sparks from the electrode, without actually touching the tissue. b) Electrodessication: This involves touching the lesion with the electrode with a marginally higher current. Conditions like seborrhoeic keratoses, verruca vulgaris, granuloma pyogenicum, cherry angiomas, senile lentigenes etc. are removed by electro-dessication followed by curettage. c) Electro-epilation : This is a permanent hair removing technique useful in hirsutism, cosmetic awareness for facial hair etc. where the hair bulb is destroyed by various electrical techniques such as thermolysis, electrolysis or blend.
   The "Dermablend" which is a combination of both direct and alternating current with bi-terminal application is the most effective method for permanent hair removal.
   
2. Chemosurgery ( superficial and medium depth chemical peeling ) : chemical agents such trichloro-acetic acid, glycolic acid, phenol etc. are applied locally to skin so as to produce controlled epidermal burns. The living tissue is destroyed deep enough to cause exfoliation while being superficial enough to allow regeneration from appendageal structures & dermis. TCA is used in the concentration of 10 - 35 %, glycolic acid : 20 - 70 % and phenol : 88%.
   Common indications are, post acne hyper-pigmentation, post-acne superficial scaring, freckles, lentigenes, xanthelasma, melasma, photomelanosis, post- inflammatory hyper-pigmentation, fixed drug eruptions, dilated pores etc.
   
3. Cryosurgery : Among various cryogens such as Co2 snow(-79oC), Nitrous oxide(-89oC) and Liquid nitrogen(-196oC), liquid nitrogen (LN2) is commonly used .The two LN2 cryosurgical units are : a) Table top unit manufactured by Frigitronics Inc. USA. b) Hand held cryo-jet LN2 is either sprayed onto the target area or applied with a probe for a specific no. of seconds & the lesion is allowed to freeze & thaw .The cycle is repeated if required. This localized freezing leads to controlled destruction or removal of the required living tissue. Postoperative pigmentation can occur in some cases; hyper-pigmentation fades over weeks but hypo-pigmentation remains for a long time. Common indications are: a) Benign: Warts, Molluscum contagiosum, Cystic acne, Acne scars, Keloids, Granuloma pyogenicum, Prurigo nodularis and Mucoid cyst.
   Seborrhoeic warts, Epidermal naevi, mucosal lichen planus. b) Pre-malignant conditions: Leukoplakia, Bowen's disease, actinic keratoses. c) Malignant: Basal cell carcinoma, lentigo maligna, squamous cell carcinoma less than 3cm in size.
   
4. Vitiligo surgery : Stable vitiligo (Vitiligo which has not responded to medical treatment but is non-spreading for two years ) and secondary leucoderma ( due to chemicals or burns) can be treated by the following methods - 1) Miniature punch grafting followed by PUVA. 2) Suction blister grafting. 3) Thin Thiersch's graft. 4) Spot dermabrasion. 5) Melanocyte culture and transplant. 6) Cosmetic tattooing.
   
5. Spot Dermabrasion : It involves sequential planing of the skin to the desired depth with electrical or manual dermabraders. Hyper-keratotic lesions such as lichen simplex chronicus, papular lichen amyloidosis, hypertrophic lichen planus, prurigo nodularis etc; Pigmentary conditions such as tattoo removal , stable vitiligo and atrophic lesions such as scars, actinic cheilitis, striae distensae can be dermabraded & allowed to heal by secondary intention so as to make the lesions less conspicuous & cosmetically acceptable.
   
6. Surgical treatment for active acne : Surgery can be used as an "adjunct" to medical line of treatment. Types of surgical procedures are :-
   Comedone extraction : Comedones ( blackheads ) are expressed out with the help of a comedone extractor. Papules, pustules and cysts are ruptured with a 24no. needle and drained out. Cryoslush : Co2 snow ( - 79°C ) causes superficial desquamation of comedones and rapid resolution of inflammatory and cystic acne. Cryopeel : LN2 is sprayed over nodulo-cystic acne, resistant acne and acne keloidalis lesions to cause desquamation and faster resolution.
   
7. Surgical treatment for post acne scars : 1) Local undermining combined with cryoslush. 2) LN2 spray for superficial scars. 3) Punch excision and closure. 4) Punch incision and elevation. 5) Punch excision and graft replacement. 6) Full face dermabrasion. 7) Laser surgery.
   
8. Laser surgery : The word laser is an acronym for "Light Amplification by Stimulated Emission of Radiation". Laser surgery provides good cosmetic results and multiple lesions can be treated in one sitting. Scarring, pigmentation, local infection & texture damage are the known complications if not used by an experienced hand. Some of the commonly used lasers are: 1) Co2 laser in cases of warts, xanthelasma, syringomas, epidermal nevi, seborrhoeic keratosis, periorbital / perioral rhytides, actinic chelitis etc. 2) Pulsed dye laser in cases of all vascular lesions. 3)Argon laser in cases of pigmented & vascular lesions. 4) Ruby laser for epilation.
   
   To conclude, the horizons of dermatology will always continue to fulfill the growing expectations of the patients.
   
   

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   ACNE

   (Indian Medical Association, Navi Mumbai, Bulletin, Vol. 1 No. 2, April 2001)
   
   Author: Dr Jaishree Sharad
   
   Synonymous with 'Pimples', it is one of the most common of all skin problems. Acne is a chronic inflammatory disorder of the pilo-sebaceous unit commonly affecting the age group of 12 - 25yrs. It occurs more frequently in males owing to the androgen activity. In females a premenstrual exacerbation occurs probably due to rise in progesterone levels in the luteal phase. Predisposition to acne may be genetically determined. The sites involved are face, chest, back, upper arms, shoulders, ears and nuchal area. Usually the disease runs a self-limiting course. Etio-pathogenesis: 1) Alteration in the level of circulatory sex hormones, particularly an increase in the androgen-oestrogen ratio. 2) Increased production of keratinocytes & their increased adherence leading to formation of comedones. 3) increased sebum secretion. 4) Bacteria present in the sebaceous follicles, mainly propionibacterium acne, metabolises sebum to produce free fatty acids, thus causing follicular hyperkeratosis. 5) External factors such as hot and humid climate, application of comedogenic cosmetics etc. Clinical Classification: Grade I (mild) - comedones or blackheads, occasional papules. Grade 2 (moderate) - comedones, papules and few pustules. Grade 3 (severe) - predominant pustules, nodules, abscesses. Grade 4 (cystic) - cysts, abscesses, scarring. Variants of acne: 1) Infantile acne : seen in infants 3mths & above due to increased plasma adrenal androgens, maternal In origin. 2) Senile acne: seen in age group of more than 50 years. 3) Drug Induced acne: Certain drugs may cause acne-form eruptions. 4) Occupational acne: Acne due to contact with hydrocarbons, heavy oils, cutting oils. Grease, waxes, coal tar derivatives, industrial oil. 5) Tropical acne : occurs in people working in hot, humid climate. cosmetics on face & brillantines on hair. 7) Acne excoriae: Exacerbation, pigmentation & scarring of preexisting acne lesions occur when squeezed or picked at by the patient. 8) Severe variants: Acne conglobata, acne keloidalis, acne fulminans, pyoderma faciale.
   Treatment of Acne : Acne if not treated on cause pigmentation and / or scarring, thus leading to tremendous psychological trauma. Hence, it must be treated promptly. Medical line of treatment comprises of topical and systemic therapy. Surgery used as an adjunct gives better results. Persistent acne associated with hirsutism or alopecia calls for hormonal evaluation to rule out endocrine disorders. Grade 1 acne: can be treated with topical creams such as tretinoin, benzoyl peroxide, erythromycin or clindamycin. Peeling agents like alpha hydroxy acids, salicylic acid, resorcinol may also be used. Comedone extraction done at weekly Intervals leads to faster resolution of lesions. Grade 2: Apart from the above, one needs to give systemic antibiotics such as tetracycline, doxycycline or minocycllne for 6-5 weeks. Grade 3 and 4: Systemic antibiotics like azithromycin and 2nd generation cephalosporins are seen to act better in nodular or cystic acne when given for at least 8-12 weeks, in addition, surgical modalities should be sought for better cosmetic results. They may be in the form of comedone extraction, evacuation surgery, cryoslush with Carbon dioxide ice, cryo-spray with liquid nitrogen or superficial chemical peeling with trichloro-acetic acid. Intra-lesional steroid injection may be given into large cysts for regression. Last but not the least, personal care by the patient is most important and so is the need to allay anxiety and stress.