Botulinum toxin (BTX) has gained a great interest in cosmetic dermatology for its effects on hyperkinetic facial lines. Understanding the basic research and analysis of effects of this potent drug can lead to other possible indications of interest for dermatologists. The use of BTX in focal hyperhidrosis is well established, but BTX has also effects on pain perception, itch and inflammation as discussed in this review.

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Giant lipomas are benign soft tissue tumours. They are found relatively rarely on the posterior part of the neck. Bleeding pressure ulcer in this giant tumour is a rare presentation. Surgical interventions in these tumours are very challenging because, sometimes, extension to the spinal cord and malignant change may occur, especially in old age. Knowledge of the anatomy and meticulous surgical techniques are needed for such giant lipomas.

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The field of hair restoration has had a chequered history. From the days of punch grafting to the present day techniques of follicular unit hair transplantation, the field has seen a number of new advances. This article reviews these developments.

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Background : Chemical reconstruction of skin scars (CROSS) is a technique using high concentrations of trichloroacetic acid (TCA) focally on atrophic acne scars to induce inflammation followed by collagenisation. This can lead to reduction in the appearance of scars and cosmetic improvement. Aims : The aim of this pilot study is to investigate the safety of the CROSS technique, using 100% TCA, for atrophic ice pick acne scars. Settings and Design : Open prospective study. Materials and Methods : Twelve patients with predominant atrophic ice pick post acne scars were treated with the CROSS technique, using 100% TCA, applied with a wooden toothpick, at two weekly intervals for four sittings. Efficacy was assessed on the basis of the physician's clinical assessment, photographic evaluation at each sitting and patient's feedback after the fourth treatment, and at the three-month and six-month follow-up period, after the last treatment. Results : More than 70% improvement was seen in eight out of ten patients evaluated and good results (50 - 70% improvement) were observed in the remaining two patients. No significant side effects were noted. Transient hypopigmentation and hyperpigmentation was observed in one patient each. Physician's findings were in conformity with the patient's assessment. Three months after the last treatment, one patient noted a decrease in improvement with no further improvement even at the six-month follow-up period. Conclusion : The CROSS technique with 100% TCA is a safe, efficacious, cost-effective and minimally invasive technique for the management of ice pick acne scars that are otherwise generally difficult to treat. In few patients the improvement may not be sustained, probably due to inadequate or delayed collagenisation.

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Cystic hygromas are the cystic variety of lymphangioma, common locations being cervico-facial regions and axilla. Respiratory distress, recurrent infections or cosmetic reasons are the main indications of the treatment. The ideal treatment is complete surgical excision; however, there is a gradual conversion towards sclerosant therapy. This article reviews the current literature and discusses the various problems encountered during the management of these lesions.

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Chronic anal fissure is a common proctologic disease. Botulinum toxin (BTX) can be used for temporary chemical denervation to treat this painful disorder. Its application is by intramuscular injections into either the external or internal anal sphincter muscle. The mode of action, application techniques, and possible complications or adverse effects of BTX therapy are discussed in this report. The healing rate is dependent on the BTX dosage. The short-term healing rate (≤ 6 months) is 60-90%, whereas about 50% of the patients show a complete response in long-term follow-up studies (> 1 year). Adverse effects are generally mild, but relapses occur more often than with surgery. Conservative therapy is currently considered as a first-line treatment. With increasing evidence for its efficacy, BTX can now be considered among the first-line nonsurgical treatements. Although, surgical management by lateral sphincterotomy is the most effective treatment, it shows a higher incidence of incontinence and greater general morbidity rate than BTX. BTX is a useful alternative to surgery and in many cases, surgery can be avoided with the use of BTX.

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Venous ulcers cause considerable morbidity. A 45-year-old man reported with non healing ulcer since 15 years. Patch tests revealed multiple sensitivity. Infection was first controlled with antibiotics and antiseptics. Dressing with modified Unna's boot made with zinc oxide 40% and glycerine paste 60% resulted in formation of healthy granulation tissue. Pinch grafting was subsequently done to promote epithelization. We recommend the use of Unna's paste instead of more expensive synthetic and occlusive and semi occlusive dressing to promote granulation tissue and pinch grafting after bed is ready to hasten epithelization.

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Fillers are generally considered safe. However side effects may happen and hence a practicing dermatologist need to be aware of such side effects, contraindicatons and precaution to be adopted while using fillers.

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Face lift hitherto had been a complicated and elaborate procedure. The introduction of threads to lift skin has been a major advance in lifting sagging skin. These threads which have barbs on their surface have simplified the procedure and have the possibilities of combination with other rejuvenation procedures. The article traces the evolution of threadlift.

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Background : Despite the many advances, scarring, particularly acne or pimple scarring, does not have a satisfactory treatment. A new armamentarium in this field is this recently devised matrix-tunable radiofrequency technology, which utilizes radiofrequency emission in the treatment of acne scars. Aims : To evaluate the efficiency of the new matrix-tunable radiofrequency technology in patients with acne scars of varying sizes. Settings and Design : A prospective study of 30 randomly selected patients with acne scars was carried out. Materials and Methods : Thirty healthy patients with different types of acne scars - ice pick, box and rolling type - were randomly selected. The scars were either shallow or deep, varied in size from 2 to 20 mm and ranged in number from 10 to 50. These patients were first treated with broad-spectrum antibiotics and local exfoliating agents (topical tretinoin 0.025%) and then subjected to matrix-tunable radiofrequency technology. Each scar was treated at intervals of 1 month. A maximum of four such sittings were carried out. Patients were followed-up every 15 days. Results were noted at the end of 2 months and 6 months. Improvement was assessed by using the visual analog scale (VAS) at 2 months and 6 months, and results were noted in terms of percentage improvement of the whole face by calculating an average of percentage improvement on the basis of interviews of the patient and his/her accompanying relatives. The visual analog scaling was performed by means of high-resolution digital photographs taken at the baseline and at each subsequent visit. Results : The VAS improvement in scars ranged from 10 to 50% at the end of 2 months to 20 to 70% at the end of 6 months. Of the 30 patients of acne scars, the cosmetic result was excellent (>60% improvement) in four, good (35-60% improvement) in 18 and moderate to poor (<35% improvement) in eight. A few patients reported burning sensation and a mild sunburn-like sensation for about 1 h after treatment. The patients reported a pinkish tone for 2-3 days. Importantly, with the help of some slight make up, all the 30 patients could return to work the following day. Conclusion : Matrix-tunable radiofrequency technology is a safe and economically viable option for the dermatologists for the treatment of acne scars, because of the effective results coupled with a low downtime.

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Informed consent is a vital document while performing all surgical and aesthetic procedures, particularly in the current day practice. Proper documentation and counseling of patients is important in any informed consent.

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Background: Longer wavelength lasers such as Nd: Yag0 are considered to be the best for darker skin phototypes. Objectives : The aim of this study was to investigate the safety and efficacy of long-pulsed, 1064 nm Nd:YAG laser-assisted hair removal in relation to multiple treatment sessions and different hair types in Indian patients. Method: Fifty-nine adult women with skin phototypes IV and V were treated with a long-pulsed Nd: Yag0 laser (1064 nm, 10 mm spot size, fluence of 30-50 J/cm ² , pulse duration 15-30 ms). Six consecutive treatment sessions were given at 4-6 week intervals. The modified Ferriman Gallway system of scoring was used to grade the hairs before each treatment session and six weeks after the last therapy. Based on this grading, three main hair types were recognised: thin vellus (Grade 1), intermediate (Grade 2), and terminal hair (Grades 3 and 4). Patients were divided into three groups: achievers who converted to thin vellus hair (Grade I), responders who shifted to a lower grade but were short of reaching grade 1, and failures who did not show any change throughout the six laser sessions. Results: Six weeks after six laser treatment sessions, the achievers totaled 56%, responders 23%, and failures 20% of the patient population. At the end of the 3 ^rd , 4 ^th , 5 ^th , and 6 ^th sessions, achievers were 5, 15, 25, and 56% respectively of all the patients ( P < 0.001, which was statistically significant). Achievers for terminal hair were 57.5% while it was 53.8% for intermediate hair ( P = 0.9, nonsignificant). There were no permanent side effects. There were no failures in the terminal group while nearly 50% of the patients were failures in the intermediate group. Conclusion: Six multiple laser treatment sessions with a long-pulsed, 1064 nm Nd: Yag0 laser with contact cooling were found to be safe and effective for hair reduction in Indian patients with both terminal and intermediate hair. The success rate was found to improve with successive sessions. However, terminal hairs responded better than intermediate hairs.

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Fillers have become a common aesthetic treatment for several cosmetic problems. Several types of fillers are available from different sources and of different longevities. It is important that the treating physician be aware of the different techniques of administration and their possible side effects. This article reviews the available literature on the subject.

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Finasteride, a specific and competitive inhibitor of 5a-reductase enzyme Type 2, inhibits the conversion of testosterone to dihydrotestosterone (DHT). In adults, DHT acts as primary androgen in prostate and hair follicles. The only FDA-approved dermatological indication of finasteride is androgenetic alopecia. But, apprehension regarding sexual dysfunction associated with finasteride deters dermatologists from prescribing the drug and patients from taking the drug for androgenetic alopecia. Testosterone, through its humoral endocrine and local paracrine effects is relevant in central and peripheral modulation of sexual function than locally acting DHT. Several large population-based long-term placebo-controlled studies, using International Index of Erectile Function-5 questionnaire and objective method (Nocturnal Penile Tumescence) to assess the erectile function have demonstrated no clear evidence of the negative effect of finasteride on erectile function. Reduction in ejaculatory volume is the only established causal relationship between finasteride and sexual dysfunction. Though finasteride causes significant reduction in all the semen parameters except sperm morphology, they did not fall below the threshold levels to interfere with fertility. Therefore, the sexual adverse effects associated with finasteride should be viewed in relation to normal prevalence and natural history of erectile dysfunction in the population, age of the patient, other confounding factors and also nocebo effect. The impact of finasteride on the prevention of prostate cancer has been discussed extensively. Finasteride is found to be effective in significantly reducing the incidence of low-grade prostate cancer. But the paradoxical increase in high-grade cancer in the finasteride group has been attributed to increased sensitivity and improved performance of prostate specific antigen levels to detect all grades of prostate cancer.

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Background: Atrophic facial scars are always a challenge to treat, especially the ones that are deep-seated and/or involve much of the face. Microneedling or dermaroller therapy is a new addition to the treatment armamentarium for such scars that offers a simple and reportedly effective management of these scars. Aims: The aim of the present study was to perform an objective evaluation of the efficacy of dermaroller treatment in atrophic facial scars of varying etiology. Materials and Methods: Thirty-seven patients of atrophic facial scarring were offered multiple sittings of microneedling (dermaroller) treatment and their scars were evaluated and graded clinically and by serial photography at the start as well as at two months after the conclusion of the treatment protocol. Any change in the grading of scars after the end of treatment and follow-up period was noted down. The patients were also asked to evaluate the effectiveness of the treatment received on a 1-10 point scale. The efficacy of dermaroller treatment was thus assessed both subjectively by the patients as well as objectively by a single observer. Results: Overall 36 out of the total of 37 patients completed the treatment schedule and were evaluated for its efficacy. Out of these 36 patients, 34 achieved a reduction in the severity of their scarring by one or two grades. More than 80% of patients assessed their treatment as 'excellent' on a 10-point scale. No significant adverse effects were noted in any patient. Conclusions: Microneedling therapy seems to be a simple and effective treatment option for the management of atrophic facial scars.

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Most cutaneous surgeries are performed under local anaesthesia. It is important the process of administration of local anaesthetics is pain free. This article suggests simple tips to make local anaestesia less painful.

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Congenital melanocytic nevus needs to be excised for aesthetic reasons and concerns regarding its malignant potential. Many methods like surgical resection, dermabrasion, curettage, chemical peeling, laser resurfacing, etc., are available for treatment. We hereby report the efficacy of excision of nevi by serial excision.

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Periungual wart presents challenge for management in view of their frequent recurrence. The case report demonstrates the efficacy of a combination treatment of electrodessication and trichloroacetic acid application.

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Six techniques not yet widely known or used in the dermatologic surgery of the nails are briefly described. Small-to-medium-sized tumours of the proximal nail fold (PNF) can be excised and the defect repaired with advancement or rotation flaps. A superficial biopsy technique of the matrix for the diagnosis of longitudinal brown streaks in the nail, which allows rapid histological diagnosis of the melanocyte focus to be performed, is described here. Because the excision is very shallow and leaves the morphogenetic connective tissue of the matrix intact, the defect heals without scarring. Laterally positioned nail tumours can be excised in the manner of a wide lateral longitudinal nail biopsy. The defect repair is performed with a bipedicled flap from the lateral aspect of the distal phalanx. Malignant tumours of the nail organ often require its complete ablation. These defects can be covered by a full-thickness skin graft, reversed dermal graft, or cross-finger flap. The surgical correction of a split nail is often difficult. The cicatricial tissue of the matrix and PNF have to be excised and the re-attachment of these wounds prevented. The matrix defect has to be excised and sutured or covered with a free matrix graft taken either from the neighbouring area or from the big toe nail.

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Background: Nevus of Ota is very common in Asian patients. The condition is more common in females, with a male-female ratio of 1:4.8. Most patients seek treatment early in life due to the psychological trauma and cosmetic disfigurement. The Q-switched lasers have changed the way we approach the condition and have become the mainstay of therapy. Aims and Objectives: To evaluate long-term safety and efficacy of pigmented lesion laser Palomar QYAG5 Q-switched Nd:YAG in 50 Indian patients. Materials and Methods: Fifty patients of nevus of Ota underwent multiple treatments (average 6 sessions) carried out over a period of 1year with a Q-switched Nd:YAG laser (QYAG5, Palomar, USA). Of the 50 patients, 2 were males; and the rest, females. Five patients had a bilateral involvement. Skin types treated included phototypes 4 and 5. The response after subsequent treatments was documented through serial photographs that were taken before and after the completion of treatments. Patients were followed up for a period of 1 year after the last session. Response to treatment was graded based on physician's global assessment. Results: Excellent improvement was noted in a majority of the patients at the end of the treatments. Greater-than-60% improvement was seen in 66% of the patients. The remaining patients had moderate clearing of pigmentation (30%-60% improvement). No significant adverse effects were seen immediately after the treatments and on long-term follow-up. Transient post-inflammatory hyperpigmentation was observed in 5 (10%) patients, which cleared with use of sunscreens and bleaching agents within 2 months. No textural change or scarring was seen. Hypopigmentation (guttate type) was observed in 1 (2%) patient, which resolved within 3 months. No recurrence was observed after 1 year of follow-up. Conclusion: This study validates the superior efficacy of Q-switched Nd:YAG laser when compared to conventional methods for treatment of nevus of Ota.

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Hair transplantation has come a long way from the days of Punch Hair Transplant by Dr. Orentreich in 1950s to Follicular Unit Hair Transplant (FUT) of 1990s and the very recent Follicular Unit Extraction (FUE) technique. With the advent of FUE, the dream of 'no visible scarring' in the donor area is now looking like a possibility. In FUE, the grafts are extracted as individual follicular units in a two-step or three-step technique whereas the method of implantation remains the same as in the traditional FUT. The addition of latest automated FUE technique seeks to overcome some of the limitations in this relatively new technique and it is now possible to achieve more than a thousand grafts in one day in trained hands. This article reviews the methodology, limitations and advantages of FUE hair transplant.

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Blepharoplasty plays a vital role in facial rejuvenation, with direct aesthetic relation to the brow and the cheek. Upper and lower eyelid blepharoplasty are indicated for the treatment of excess skin and/or orbital fat. Preoperative evaluation should include a thorough medical and ophthalmic history, along with a detailed cutaneous and eye examination. Symptoms of preexisting dry eye should be elicited preoperatively, as they directly correlate with postoperative complications. Physical examination should take into account brow position, eyelid ptosis, lower eyelid position, and cheek projection. Blepharoplasty can be performed by many operative approaches. This review highlights the standard skin-only upper blepharoplasty and lower eyelid conservative fat excision or repositioning.

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Leg ulcers as a complication of rheumatoid arthritis are difficult to heal. We present a case responding to treatment with cyclophosphamide and split skin grafting

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