Must-Dos By A Doctor
Acne falls under two categories -Adolescent Acne and Adult Acne. Childhood acne may occur at the age of 7 or 10 and it may also be steroid induced, which is very common in our country. Seborrhic Dermatitis, commonly known as dandruff is caused by the sebaceous glands. It is not necessary that the same person gets both but may get either one of the two. The diet plays a very important role and so do the cleansing agents used by the individual.
One important point to note is, that under no instance should a cream be used on the skin of a person who is suffering from acne. This is because all creams are emulsions, which contain a component of oil, the extent to which may vary from one cream to another. This oil in the cream tends to block the pores of the skin, which results in the increase in acne, although the medicament present in the cream may tend to reduce its occurrence.
This results in the nullification of the cream treatment as a whole. The next group of diseases is Papilosquamus Dermatosis, which includes the likes of Psoriasis. Pitryasis rosea, Tinea versicular and Lichen planus. Under each of these diseases there are many sub categories. Psoriasis: Today there are 16 or more types of the psoriasis starting with the raindrop or the guttate variety leading to exfoliative psoriasis. There are cases where individuals have been treated who could not even close his or her eyelids once they are open, when they suffered from the disease.
This shows that a doctor must constantly update his knowledge. Pitryasis rosea: This disease is purely seasonal in nature. Certain foodstuff may also trigger it and it could appear again in the following year provided you are living under the same habitat or environment. In fact, it has been proven and stated that if this condition if left untreated. it may disappear in a matter of 10 to 12 weeks by itself.
But if treated wrongly, the condition may prolong for years in the person’s life. Tinea versicolor: This is nothing but a hyper-pigmented patch. In the earlier days such conditions were treated with Pottasium Hydroxide. But today, much better and more efficient modes of treatment are available, with certain medicines taken internally combined with a specialised medicated shampoo. The individual is also requested to have a bath a number of times.
The pH of the skin of individuals with this disease differs by about 0.015 to 0.016 from other normal individuals. Lichen planus: All the above mentioned diseases (except the Tinea versicular) have something in common – Koobner phenomenon. The phenomenon named after its discoverer explains the fact that whenever trauma is applied on the skin, which may be a prick or a dot or a scratch.
If this person has any of the above mentioned diseases, then the individual gets a string in the form of a straight line appearing on the skin in line with the applied trauma and the person is likely to get a number of new lesions in all these places. A common factor in all of these is that they are psyco somatic in origin and this factor should not be disregarded or left untreated.
The youngest patient treated by Dr. Krishnan was a boy who was 10-year-old who had got it when he was 5-year-old and on diagnosis, Dr. Krishnan just put him on mild Fluoxetine syrup one teaspoon a day with an anti histamine and an ordinary cream which is readily available as an OTC product. The child got rid of the problem in just a month because there was no lasting tension or stress involved here. In bacterial infections of the skin, bacteria exist on the skin as common non-pathogenic resident flora or pathogenic organisms.
These pathogenic bacteria cause primary, secondary and systemic infections. The primary is Impetigo ectima folliculate which is basically superficial folliculitis of the scalp and then folliculitis of the face, which is of the beard called psychosis barbae and a sty of the eye. Folliculitis barbae, which is of the beard, is commonly referred to as the waterloo of the dermatologists, because there are very few dermatologists around who can successfully treat the above mentioned condition.
This is of course possible only with the full co-operation of the patient and the dermatologist knows what the cause is. Erysepalis falls under this. In fact, Dr. Krishna had the privilege of being in the Department of Dermatology in Vienna, Austria and assisting in the treatment of a British fisherman, who happened to reside in Vienna and had the same condition of Erysepalis. Something very strange about it was the fisherman only had it on one entire leg, from the thigh onwards to the foot and he used to get it just once a year.
The patient claimed that it had started after the scales of a particular fish that they had caught entered his skin 10 years before and after which he has been having this recurrent condition once a year. The scales of the fish must have had some bacteria, but Dr. Krishna cannot explain why the problem occurred only once a year. But on this particular occasion the man’s skin responded very well to Augmentin, which was just introduced in Europe at that time. Augmentin basically comprises Amoxycillin and Clavudinic acid, which extends the half-life of amoxycillin thereby lending it a knock out punch.
The secondary bacterial infections are like Bacterial Intertrigo of Infants, Atopic Eczema, Infectious Eczematoid Dermatitis secondary to Empyema Sinus. The third group of systemic bacterial infections include Scarlet fever, Granuloma engruanale, Chankroid, myco bacterial infections which include tuberculosis of the skin along with leprosy and sarcoidosis. Most of these diseases can be cured successfully today. Dr. Krishna was unfortunate once to have a patient in Vienna, who was a 25-year-old successful skier suffering from Pyoderma gangrenosum.
This young man seemed to recover from the lesions with the medication but again got new lesions appearing on the skin. It was quite painful for Dr. Krishna to see him die of this disease within a month. Its not easy for a man to see his own skin being eaten away by the bacteria and yet being able to put up with it. It is a slow and painful death, but there are cases, which come around too and get cured and as doctors one should always hope for the best.
Dermatologists with the multi-drug therapy treat leprosy though not suggested by the WHO. In this, the patient can afford the medicine prescribed by the doctor that is to be taken for a period of six months. This is contrary to what is practiced by the WHO for reasons best known to them. Going by the cost and efficacy ratio, there are patients who cannot afford more than Rs 15 per month, as stated by a doctor who has now retired from the WHO and has put in 30 years in the Dharavi slums, Mumbai.
This gentleman used to be quoted saying that for us, by putting in one million dollars, even if we get a success rate of 60 per cent is much more efficient than if we get a success rate of 100 per cent but by putting in 100 million dollars, which is not available from the WHO. But in private practice one should forget using drugs like Dapsone, which are bacteriostatic and move on to prescribing ofloxacin combined with a good diet and not to forget the Clofazimine. It must be made sure that the drug is taken on a daily basis continuously, with drugs to take care of the liver if required, to improve upon the appetite of the individual so that the disease is thrown off by the individual himself or herself.
Improvements will be seen usually within the first month of the therapy, but the time taken for the disease to completely get cured depends on the extent to which the disease has already progressed before the commencement of the treatment. It also depends on the use of any immuno-suppressive drugs, which were taken prior to the treatment and also on the financial affordability of the patient and the co-operation of the patient during the course of the treatment.
Syphilology is basically to do with the disease Syphilis, a skin condition that is completely curable. Most people usually get cured by themselves, without any realisation because of the action of some other antibiotic, which they may have taken for some other ailment if taken in the early stage itself. The next category is Herpes Simplex and Herpes Zoster or Shingles. It must be kept in mind that Herpes Simplex is a sexually transmitted disease that can also be obtained by touching a wet spot or area, which was previously touched by another individual who has the same disease.
The drug Acyclovir was earlier used to totally control the disease or keep it at bay. Now we have the Pencyclovir followed by the Valcivir or Valcyclovir, which are more effective than its predecessors. One must always remember that once the individual is infected, the virus remains in the blood for life with an occurrence of the disease externally, at unspecified intervals. Dr. Krishna’s worst patient of this condition used to get it intermittently by being normal for three days then having an attack for five days.
This gentleman is now hail and hearty. It was thought that the same Simplex virus caused Herpes Zoster or Shingles, which is not the case. The virus called varicella causes zoster and Chicken pox. Invariably a person who gets Zoster must have had a childhood occurrence of chicken pox wherein at that point of time a couple of cells get lodged in the posterior horn cell of one of the spinal nerves. It could be just one or more nerves. Normally an individual gets only one attack, 20 or 30 years down the line, but there are cases where individuals get more attacks when the body resistance is low. Suffering for the older patients is due to the post-herpetic neuralgia with myalgia.
Here again the drug choice is Acyclovir and it still is in most countries, unless the patient can afford the new third generation anti-viral drugs like Valcivir and its types. Almost 20 years ago it was thought that smallpox has been totally eradicated from India. Recent newspaper reports mention topical occurrences of the disease. The source or origin of the disease could even be from an infected foreign national who would have visited an epidemic country.
But this information remains to be seen about how far it is true and if so to what extent. The common warts or Veruca vulgaris or Veruca as they are known are very common and can occur anywhere and in any part of the body. It can be removed by an ordinary cotry machine to a laser machine with practically no scarring of the tissue. Children are more prone to Molluscum Contagiosum, which has an appearance of pearls with molluscum bodies that break out to form the condition.
The best thing is that this molluscan body is very unstable. So this pearl like lesions on the skin will be killed by simple using a sterilised needle on it, the only hazard being that the child must co-operate with the doctor. Hence local anesthesia is advised to reduce or nullify the pain. Fungal infections occur to people who are not too clean or don’t have a bath too often. They basically are of two varieties – the dermatophytes and the ones caused by Candida Albicans, which are also known as the Filamentous Fungus.
The dermatophytes respond very well to Itraconozole, Terbinofin, whereas, candida responds very well to Flucanozole. One must keep in mind that both these fungi love damp surroundings. So, one should see to it that the area is kept clean and dry. Dr. Krishna has successfully used the Botox treatment on at least 25 individuals; the oldest was a white Caucasian lady who was approximately 58 years old. The interesting point was that the effect of each sitting of botox lasted for almost 8 months contrary to the company’s claim of 3-6 months.
The Botox was used for the crow’s feet as well as for the wrinkles of the forehead and the lines on the glabellar region of the nose. Dr. Krishna is yet to try out the Chinese equivalent of the Botox serum or the French equivalent. Botulinum Toxin Type A (Botox Cosmetic) is a protein complex produced by the bacterium Clostridium botulinum, which contains the same toxin that causes food poisoning. When used in a medical setting as an injectable form of sterile, purified botulinum toxin, small doses block the release of a chemical called acetylcholine by nerve cells that signal muscle contraction.
By selectively interfering with the underlying muscles’ ability to contract, existing frown lines are smoothed out and in most cases, are nearly invisible in a week. Botox injections are the fast-growing cosmetic procedures in the industry and are even more popular than breast enhancement surgery and a potential blockbuster; some as the ultimate fountain of youth regards Botox. The FDA approved such usage in the late 1980s upon the discovery that Botox could stop ailments like blepharospasm (uncontrolled blinking) and strabismus (lazy eye).
Cosmetic physicians have been using Botox for years to successfully treat wrinkles and facial creases. In April 2002, Botox gained FDA approval for treatment of moderate-to-severe frown lines between the eyebrows – called glabellar lines. However, Botox is often used for other areas of the face as well. Botox blocks signals from the nerves to the muscles. The injected muscle can no longer contract, which causes the wrinkles to relax and soften. It is most often used on forehead lines, crow’s feet (lines around the eye) and frown lines. Wrinkles caused by sun damage and gravity will not respond to Botox.
The procedure takes only a few minutes and no anesthesia is required. Botox is injected with a fine needle into specific muscles with only minor discomfort. It generally takes three to seven days to take full effect and it is best to avoid alcohol at least one week prior to treatment. Aspirin and anti-inflammatory medications should be stopped two weeks before treatment as well in order to reduce bruising.
The effects from Botox will last four to six months. As muscle action gradually returns, the lines and wrinkles begin to re-appear and wrinkles need to be re-treated. The lines and wrinkles often appear less severe with time because the muscles are being trained to relax. Temporary bruising is the most common side effect. Headaches, which resolve in 24-48 hours can occur, but this is rare. A small percentage of patients may develop eyelid drooping, which usually resolves in three weeks. This development is usually caused by migration of the Botox and for this reason one should not rub the treated area for 12 hours after injection or lay down for three to four hours.
There have been no allergies associated with Botox to date. Patients who are pregnant, breastfeeding or have a neurological disease should not use Botox. Since Botox doesn’t work for all wrinkles, a consultation with a doctor is recommended. Laser Therapy in dermatology has a very wide range of applications for various skin conditions. The term LASER denotes Light Amplification by Stimulated Emission of Radiation.
One basic fact, which most people are not aware of, is that there are different types of lasers, which emit light of different wavelengths and each type can be used only for a particular set of skin ailments. The wavelengths of laser in medicine range from 400 nm to 10600 nm. But there are doctors who misguide their patients into thinking that one particular laser can be used for all skin ailments, which is absolutely false. This may be a tactic of the concerned doctor too because of the high cost involved in the cost of the machine so that the doctor gets back the money invested in the unit as soon as possible.
Most people are under the false notion that the same laser can be used for any problem, be it hair removal or skin resurfacing or any other treatment, which is not possible, because certain lasers emit only certain specified wavelengths and these are used only for certain categories of skin conditions. The wavelength is defined as the distance between crests of each wave and that determines the functional properties of the LASER energy. Wavelengths in the 0.4-0.7 urn range form the visible light of the spectrum. Ultraviolet rays, X-rays and gamma rays are forms of electromagnetic radiation with the wavelengths shorter than the visible light.
Frequency is the number of waves passing at a given point per second and is expressed in cycles per second. The shorter the wavelength, the higher is the frequency and thus higher the energy. Laser light beams have a constant velocity, which is equal to 186000 miles per second. Surgical lasers fall between the longest and the shortest wavelengths, in the infrared and visible as well as the ultraviolet portions of the electromagnetic spectrum. CO2 Laser is the most widely and precise tool used in dermatology, cosmetology and general surgery. The laser medium is mixture of carbon dioxide, nitrogen and helium gases, usually excited by direct current electricity.
The CO2 laser emits a continuous beam having a wavelength of 10600 nm, in the mid-infrared portion of the electromagnetic spectrum. The beam of CO2 laser is invisible. Laser energy passes through an articulated arm and focussing lens or through a hollow wave-guide. The tissue target for this type of laser is water, where light is absorbed by biologic tissues causing destruction by rapidly heating and vaporisation of the intercellular water. The strong absorption of the laser light by water causes tissue destruction. ‘What you see during operation is what you get of the effect on human tissue’. The output power may exceed 100 watts in the continuous operation and 50 watts when using the pulsed operation.
The factors affecting tissue destruction by laser is the power reaching the tissue, spot size and the thermal relaxation time, which is the time between heating of tissues by the laser beam and the time of cooling of tissues. The 0-switched Ruby Laser (694 nm) was first used in 1965 for treatment of pigmented skin lesions and tattoos. 0-switched type can remove blue and black tattoo pigment with minimal scarring and without anesthesia. Several sessions may be needed to remove pigmented lesions by the Q-switched Ruby laser. The Nd:YAG Laser is another type of Q-switched laser with longer wavelength (1064 nm) and can be used to remove tattoos and pigmented skin lesions. The laser medium is neodymium-doped yttrium aluminum garnet crystal.
Several metal lasers like copper vapour lasers have been introduced recently, which depend on a metal lazing medium heated above the boiling point to the gaseous state. Two different lights with two different wavelengths are emitted from this type of laser. The Green light at 511 nm is used for treatment of benign pigment lesions such as Cafe au lait spots, lentigo and benign dermal tumors.
The Yellow light with a wavelength of 578 nm is used for treatment of vascular lesions such as telengectasia. Cryo Surgery is one aspect of dermatology, which uses hyper cooled medium to cure lesions ranging from cancer or melanoma, warts, ordinary viral warts to a number of other multiple uses. Internationally, the medium is cryogenic when the temperature is below -100 degree Centigrade. The basic requirements to perform dermatological cryo surgery are a highly pressurised gas chamber and a canister along with a cryo gun totally, which may cost a doctor around a lakh for a 50 kg flask. The hyper cooled substance used is usually Liquid Nitrogen -the coldest substance known to man, which is 196 degrees centigrade.
These are specialised dermatological surgery tools, which should be used with utmost care and precision. So the main factor is to make sure that the treatment is not overdone or underdone. Dermatology in India was not in demand till a couple of years ago. It has now started to begin to manifest its true potential and is now one of the most sought after subject for remedies for the common man and is here to stay in India as well as worldwide.
– Dr. Anand Krishna
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