Cosmetic dermatology
Cosmetic problems

Acne

Pigmentation

Ageing

Benign tumor / nevi / birthmarks

Hair – Alopecia, hirsutism

Nails
Acne
Surgery in acne is indicated for

active lesions

management of scars
Management of active acne

Microdermabrasion (Gr I)

Evacuation surgery (Gr II and III)

Draining of cysts (Gr IV)

Intralesional steroids : large cysts (Gr IV)

Cryoslush – cystic and nodular (Gr IV)

Chemical peels : GA 20-35%, SA 20-30% ,
TCA 10-25% (Gr II and III)

IPL and blue light lasers (400-420nm): (Grade
I, II, III, IV )
Acne scars
Acne scars can be classified as :

Depressed

Hypertrophic

Keloids
Management of acne scars
Non-surgical
Laser

Chemical peel

Ablative

Cryo peel

Non-ablative

Microdermabrasion
Surgical

Subcision

Dermabrasion

Punch elevation

Punch graft

Punch excision
Pigmentation

May be epidermal (brown), dermal (bluishblack) or mixed

Wood’s lamp examination determines the level
of pigmentation
Pigmentary disorders

Melasma

Post inflammatory hyperpigmentation
secondary to acne, lichen planus, fixed drug
eruption

Macular amyloidosis

Lichen planus pigmentosus

Toxic melanoderma

Addisonian pigmentation

Drug induced pigmentation
Management of Epidermal pigmentation

Use of a broad-spectrum sunscreen

Topical lightening agents
Various combinations of hydroquinone (210%), arbutin(5%), kojic acid (2 - 4%), azelaic
acid (10-20%)

Kligman’s formula: Tretinoin 0.05% +
Hydroquinone 4% + dexamethasone 0.5%

Modified Kligman: the steroid component is
substituted with fluocinolone, mometasone or
hydrocortisone

Chemical peels
Management of dermal and
mixed pigmentation

Sunscreen

Chemical peels: Glycolic, lactic, salicylic, koj

ic, retinol etc. peels at repeated intervals

Topical retinoids to hasten the cell turnover and
the expulsion of pigment granules

IPL (Intense Pulse Light), Erbium and Qswitched Nd-YAG lasers

Possibility of an increase in pigmentation or
hypopigmentation in darker skin types
Ageing
Ageing process results in:

Wrinkles

Rough dry skin with a yellow hue

Loss of tone and elasticity

Loss of subcutaneous tissue

Development of freckles, and lentigenes (sun
spots), senile comedones, sebaceous
hyperplasia, seborrhoeic warts, rosacea,
telangiectases.
Management

Sunscreens

Retinoids

Chemical peels

Microdermabrasion

Lasers - ablative and non-ablative

Botox and Fillers

Fat lysis and transfer

Surgery-thread lifts, face lifts

Implants
Benign tumors/nevi/birthmarks

Facial angiofibromas, syringomas, Becker’s
nevus, nevus of Ota, café au lait macules,
hemangiomas .
May be congenital/acquired.
Following treatment modalities can be used:

Surgical excision, electrocautery,
radiofrequency

Lasers- CO2, vascular, pigmented

Camouflague
Hair-Alopecia
Treatment depends on scarring/non-scarring

Scarring: surgical excision, scalp reduction, hair
transplants

Non-scarring: topical minoxidil, topical steroids,
oral vitamins and finasteride, hair transplant
Hair Transplantation

Re-distribution/re-arrangement of existing hair
follicles in a particular pattern to cover the bald
areas
Types:

Punch grafting - Standard, Mini and Micro
grafting

Follicular unit grafting (most recent)

Synthetic hair grafting
Indications and contraindications
Indications:

Male pattern alopecia

Female pattern alopecia

Cicatricial alopecia
Contraindications:

Large bald area, small donor area

Low hair density

Age-group between 15-25 years

Unrealistic expectation
Procedure

Occipital area commonest donor site, others are
temporal and parietal area

After anaesthetising the area, single elliptical
donor strip is harvested from the donor site

Follicular unit grafts are dissected from the strip

Grafts then inserted at recipient site into tunnels
made with needles

Grafts taken up by tenth day

Minoxidil application advised to promote hair
growth
Post operative course

Interval of three months required for transplanted
hair to enter anagen phase

Hair growth continues for 6-8 months
Hirsutism

Distribution of thick dark terminal hair in the male
distribution pattern in females
Hair removal:

Temporary measures: plucking, threading,
waxing, bleaching, shaving

Permanent measures: electrolysis

Permanent reduction : Laser hair removal

Topical eflornithine 12.5% as an adjuvant
Nails

Treatment of primary condition causing dystrophy
eg: treat infections or skin disease

Surgical avulsion

Artificial nails

Nail extensions

Nail paint
Cosmetic dermatology
Topical agents: Cosmetics, cosmeceutical
Procedures :

Chemical peels

Dermabrasion

Botox

Electrosurgery

Dermal fillers

Radiosurgery

Camouflage creams

Cryosurgery

Tattooing

Lasers

Microdermabrasion
Cosmetics

A cosmetic is any article intended to be rubbed,
poured, sprinkled, or sprayed on, introduced into,
or otherwise applied to the human body for
cleansing, beautifying, or altering the appearance

Commonly used cosmetics: Soaps, shampoos,
moisturizers, anti aging products, eye and lip
cosmetics, bleaching and highlighting hair
products

Adverse reactions to cosmetics have been
recorded
Moisturizers

Moisturizers are agents which hydrate the
stratum corneum by either providing water or
helping to draw water from the deeper layers of
the skin

Oil-in water or water in oil preparations

Sunscreens , anti-ageing products like retinols,
alpha or beta hydroxy acids and skin-lightening
agents may be added
Moisturizers - types
Oil- in- water:

More cosmetically acceptable by patients

Not very effective for very dry skin conditions

Exists as a cream or lotion
Water-in-oil:

Create an occlusive film on the skin surface;
reduce water loss and traps moisture in the skin

Stickier, less cosmetically acceptable

More effective for dry skin and ichthyotic
conditions
Sunscreens

Sunscreens protect from the harmful rays mainly
UVA and UVB

Reflects, absorbs or scatters harmful rays

Most sunscreens have a SPF label.

SPF: ability of a sunscreen to delay sun-induced
skin erythema
Types of sunscreens

Physical: Form an opaque layer which totally
blocks out the sunrays e.g zinc oxide, titanium
dioxide and calamine

Chemical: Absorb the rays and convert the
energy to heat which is diffused. These may
selectively protect against UVA or UVB
UVA blockers: Benzophenones,
dibenzoylmethanes, Mexoryl
UVB blockers: P-aminobenzoic acid (PABA)
derivatives, salicylates, cinnamates
Proper sunscreen rules

2mg/cm2 of sunscreen needs to be applied

Use half hour before exposure

Repeat every 2 hours if sweating or swimming
Adverse reactions to cosmetics

Soaps: Repeated use may strip the skin of its
protective lipid layer

Shampoos: Daily washing with harsh shampoos
can dry the shaft and make it brittle

Moisturizers: Comedogenic ingredients like
isopropyl myristate irritate the pilosebaceous
follicles

Fragrances: May cause photocontact dermatitis

Hair colors: Frequent hair lightening or coloring
can cause irreversible damage to the hair shaft.
Cosmetic alopecia may follow.
Contd…
Adverse reactions to cosmetics

Sunscreens: Vehicle may exacerbate or induce
acne; contact folliculitis may occur

Skin lightening agents: Excessive and prolonged
use may cause exogenous ochronosis
Cosmeceuticals

Pharmacological agents which have an effect
intermediate between cosmetics and drugs
◦ Cosmeceutical botanicals
◦ Retinoids, bleaching agents, sunscreens,
chemical peels, minoxidil
Cosmeceutical botanicals

Cosmeceutical botanicals are obtained from
plant sources

Aloe vera, soya, ginko biloba, tea tree oil,
mulberry etc

Aloe vera: increases blood flow, reduces
inflammation, enhances wound healing and
decreases bacterial colonization
Cosmeceutical botanicals
Green tea:

Contains flavanoids : anti-inflammatory against

UVB-induced erythema
Soy:

A rich source of flavanoids (genestein and
daidzein)

Genestein: potent topical radical scavenger and
promotes collagen synthesis
Topical retinoids

Tretinoin: comedolytic

Adapalene: anti-inflammatory, comedolytic

Tazarotene: comedolytic, anti-inflammatory

Isotretinoin: comedolytic
Used in:

Acne

Photoaging

Pigmentation

Combined with minoxidil in alopecia
Topical retinoids
Adverse effects:

Redness, burning,

Dryness

Post inflammatory pigmentation

Acne flare up
Chemical peels

Controlled application of one or more exfoliating
agents to improve photoaging, pigmentation or
scarring

Single peel - skin smoothening

Repeated peels - collagen and elastic
remodelling

Performed every 2 to 3 weeks

Agents used: glycolic acid, trichloroacetic acid,
salicylic acid, mandelic acid, phenol
Indications of Chemical Peels

Acne

Ageing skin

Photodamage

Freckles

Melasma

Scars

Fine lines and wrinkles

Xanthelasma

Dilated pores

Improving complexion
Botulinum toxin (BTX)

Produced by the bacterium Clostridium botulinum
( Serotype A )

Inhibits release of acetylcholine at the
neuromuscular junction

Temporary flaccid paralysis of muscle

Re-innervation and recovery in 3 to 4 months
Aesthetic use of BTX
For dynamic wrinkles:

Upper face: frown lines, forehead lines, crows
feet

Lower face: Perioral, smile and frown lines, neck
lines and folds
Advanced use:

Post-herpetic neuralgia, migraine
Dermal fillers

Specialized materials injected into the dermis and
subcutaneous tissue to replace the lost tissue
during aging or injury
Types of filers :

Temporary- gets absorbed in 3 to 6 months

Semi-permanent: absorbed within 2 years

Permanent: lasts longer than 2 years
Sources of fillers

Heterograft/Xenograft: Bovine collagen, porcine
collagen, hyaluronic acid

Allografts: Human-derived collagen

Autografts: Autologous fat, collagen,fibroblasts

Synthetic: Silicone, polytetrafluoroethylene
Indication for fillers

Wrinkles

Scars

Augmentation

Lipoatrophy

Enhancement of facial contour
Cosmetic camouflage

Concealing of unsightly marks on the skin with
specially matched opaque creams and powders

Contents:
◦ Calamine, zinc oxide, bentonite
◦ Colour pigments
◦ Setting powder
Indications for cosmetic camouflage

Vitiligo

Freckles

Melasma, post inflammatory pigmentation

Hemangiomas

Nevi

Scars
Tattooing

To mask the vitiligo macules especially over the
lips, areola

Localized small macules of vitiligo resistant to
conventional treatment

Vitiligo lesions should be stable for at least two
years
Material

Electrical tattooing gun or manually operated
punch holding multiple needles (optimal depth 1.5
mm)

Pigment paste: mixture of various ferric oxides
(yellow, brown, red and black in colour) in normal
saline and glycerine
Advantages

Immediate results

Inexpensive, safe and simple office procedure

Useful in sites difficult for grafting

Can be repeated if required
Electrosurgery
The frequency of electric current used in
hyfrecator is 50kHz (50000 cycles/sec), whereas
in the operating room devices, it is between 500
and 2000 kHz.
In these devices, the electrode becomes hot and
acts more like true cautery.
Mode of action

The heat generated by the electrical current at
the tip of an electrode, destroys the tissue.
(Thermal damage)

Moderate heat causes evaporation of the water
content of the tissue (Dessication)
Radiofrequency
When the frequency is raised to 3000kHz
(3.0MHz), the electrode itself does not get heated.
The instrument, which operates at a frequency of
3.8 Mhz is also known as Radio-frequency (RF) or
Radio-surgical unit
Mode of action
As the current passes through the tissues
impedance to the passage of current generates
heat → boils the tissue-water creating steam →
cutting or coagulation of tissue
Indications

Skin tags

Verrucae

Molluscum contagiosum

Seborrheic Keratosis

Epilation

Moles
Complications and disadvantages
Complications

Sepsis

Scar
Disadvantages

Uncontrolled thermal damage

Painful
Contraindications and precautions
Contraindications:

Patients with pacemaker implants

Keloidal tendency

History of seizures
Precautions:

Avoid spirit for local disinfection; if used wait for
complete evaporation

Face mask when treating warts to prevent HPV
transmission
Cryosurgery

Use of local freezing for the controlled destruction
of living tissues by intracellular ice formation,
osmolality and vascular changes, thermal shock
- cryonecrosis

Cryogens:
Freezing agents
Ice
Carbon dioxide slush
Carbon dioxide snow
Nitrous oxide
Liquid nitrogen
Boiling temperature
0
-200 C
-790 C
-890 C
-1960 C
Cryosurgery indications

Indicated for warts, molluscum, keloid, acne, skin
tag, leukoplakia, basal and squamous carcinoma

Methods:
◦ Cryospray
◦ Cryoprobe
◦ Dipstick
Microdermabrasion

Microdermabrasion is a minimally - invasive,
office-based mechanical resurfacing technique

Forcibly propels sterile micronized aluminium
oxide crystals at the skin

Vacuum suction sucks back the crystals and the
desquamated skin
Indications

Acne scars

Fine lines

Pigmentary disorders

Striae

Skin rejuvenation

Skin polishing

Open pores
Dermabrasion

Abrading the epidermis and part of papillary
dermis mechanically, leaving the wound to heal
by secondary intention.

Re-epithelialization

Formation of new collagen fibres in an organized
fashion
Indications

Acne scars

Preparation of recipient site in vitiligo

Rhinophyma

Traumatic or surgical scars

Milia, trichoepitheliomas

Verrucous epidermal nevi

Lichen amyloidosis

Actinic damage

Superficial basal cell carcinoma
Contraindications

Keloidal tendency

Bleeding disorders

Immunocompromised person

Theoretically dermabrasion or laser resurfacing
not be performed at least 6 months following
isotretinoin

Recent episode of herpes simplex or bacterial
infection; prophylactic valacyclovir
Instruments

Manual or Electric dermabrader

Handpiece

Wire brush or Diamond fraises: More coarse or
rough the cutting surface and faster the rotation
speed, greater the penetration into the tissues
and deeper the damage
Procedure

Local / General anaesthesia/ Cryoanaesthesia
with liquid nitrogen

Hold the hand-piece parallel to the surface

Linear and rotating movements

Never go beyond mid reticular dermis
Lasers
Light Amplification by Stimulated Emission of
Radiation (LASER)

The light energy in the LASER beam is converted
into heat, which destroys the targeted tissue

A laser beam of particular wavelength destroys a
specific target (Chromophore)
Chromophores and Wavelengths

Melanin - UV, infra red

Oxyhaemoglobin - 488, 512, 585 nm

Water - above visible spectrum
Lasers for Epilation
(Chromophore: Melanin)
1. Alexandrite
755 nm
2. Diode
800 nm
3. Ruby
694 nm
4. Nd-Yag
1064 nm
Lasers for vascular lesions
(Chromophore: Haemoglobin)
1. Pulsed Dye
585 nm
2. Nd-Yag
1064 nm
3. Nd-Yag
532 nm
4. Diode
800nm
Lasers for pigmented Lesions and
tattoo removal
Dermal
1. Q-switched Ruby
694 nm
2. Q-Switched Alexandrite
755 nm
3. Q-Switched Nd-Yag
1064 nm
Epidermal
1. Pulsed Dye
510 nm
2. Q-Switched Nd-Yag
532 nm
Lasers for resurfacing

(Chromophore: Water)

CO2 , Erbium YAG
Indications

Acne scars

Wrinkles

Rhinophyma, xanthelesma

Verrucous epidermal nevi

Seborrhoeic keratosis

Lichen amyloidosis
Non ablative Lasers

Induces collagen remodeling by creation of a
dermal wound without disruption of the epidermis
Nd:Yag
1064 nm
Diode
1450 nm
Erbium glass 1540 nm
Indications

Wrinkles

Superficial atrophic scars
Excimer Laser
Monochromatic light of wavelength 308 nm
Targeted treatment of :

Vitiligo

Psoriasis
Complications of LASER

Persistent erythema

Vesiculation and crusting

Hyperpigmentation

Hypopigmentation

Scarring
Good expertise → minimal complications
Thank you