Diagnosis And Treatment Of Erythema

Diagnosis And Treatment Of Erythema

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Diagnosis And Treatment Of Erythema

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Diagnosis And Treatment Of Erythema

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Question:
Discuss about the Diagnosis And Treatment Of Erythema And Dyspigmentation.
 
 
Answer:

Aetiology and Pathogenesis
The patient came to the clinic with erythema and dyspigmentation. The patient history showed that the patient spend substantial time in the sun. The Anglo-Saxon background of besides the difficulty in tanning classifies the patient as Fitzpatrick skin Phototype II. This is as the skin burns easily, tans with difficulty, and has white constitutive colour. The Fitzpatrick skin photypes are base on the skin color of an individual, and the responses of the skin to sun exposure with respect to the measures of burning and tanning form the basis of classification (Sachdeva, 2009). Furthermore, the characteristic irregular alterations in pigmentation, reticulate pattern, reddish coloration, irregular but symmetrical distribution of pigmentation, and hyperpigmentation associated with superficial atrophy, is indicative of Cervical Poikiloderma. The condition was first described by Achilles Civatte, a French dermatologist, a common benign form of dermatosis (Civatte, 1923). It mostly affects fair skinned people, in the fourth to seventh decade of their life. With respect to the case study patient, the cumulative exposure to sun due to spending lot of time in garden could have resulted in respective pathophysiology. This could also have been aggravated by the direct application of fragrance on skin. It is also important to notice that the area of skin shaded by skin has not developed the respective dermatologic condition.
Cervical Poikiloderma, has a debated aetiological and pathogenesis, however cumulative sun exposure has been dictated to play a central role in disease causation and development. The age and sex influencing the hormonal factors have also been attributed to contribute to disease development. The low level of oestrogen during menopause is one of the prominent factors. In context of the present patient, the fragrance acts an exacerbating factor, as it contains photodynamic substances which can induce photoallergic or phototoxic reactions (Placzek, Frömel, Eberlein, Gilbertz, & Przybilla, 2007). As the patient presents all these causal factors, therefore the genetic factors cannot necessarily be implicated for disease causation. Similar conclusions were also drawn by Katoulis et al. (2002) in their study which evaluated the role of contact sensitization and photosensitivity in Cervical Poikiloderma 32 patients. The exposure to ultra violet radiations have been regarded as the reason for changes induced in connective tissue, which ultimately results in development of the respective histological characteristics. The reticulate pigmentation develops die to delayed hypersensitivity reaction to fragrance. Hence, contact sensitization due to cosmetic ingredients contained in fragrance and perfumes contributes to development of Cervical Poikiloderma (Khunkhet & Wattanakrai, 2014). To treat the condition photoprotective measures are a pre-requisite, facilitated with advanced laser treatments such as selective photothermolysis or intense pulsed light treatment. Therefore, for the given patient a suitable treatment methodology, as mentioned below has been planned.
 
Treatment plan
The treatment of diagnosed condition is possible through lasers such as potassium titanyl phosphate, argon, pulsed dye laser, and light treatments using intense pulsed light. However, the use of lasers at times proves to be ineffective, inefficient, or inconvenient in treating the condition. Also, adverse side effects of these treatments might involve hypopigmentation, hyperpigmentation, and scarring, post treatment (Goldman & Weiss, 2001). Furthermore, the treatment of Cervical Poikiloderma demands the addressal of both pigmented and vascular lesions simultaneously. The laser treatments thus failed to reach the optimal level of treatment effect, and present variable levels of lesion clearance. Therefore, Intense Pulsed Light (IPL) treatment proves to be an effective modality. The IPL treatment includes a laser like device using a flash lamp which produces polychromatic light in the broad spectrum of 515-1200 nm. This treatment also allows for the adjustment of duration, and number of pulses, besides exercising control over pulse delay, and fluency as per requirements. Owing to this flexibility the treatment finds application for a wide range of dermatological conditions such as vascular lesions, photoepilation, and removal of pigmented lesions. With respect to Cervical Poikiloderma the technique is used to target the lesions, by utilizing selective photothermolysis, targeting the melanin, oxyhaemoglobin, and chromophores.
The pigmentary and vascular components of the conditions determine the cur off filters to be used (Elsaie, Vejjabhinanta, Martins, & Nouri, 2010). With respect to vascular lesions, the one limitation associated with laser treatment is the lack of achievement of acceptable results. IPL poses the advantage of minimal postprocedure downtime due to lack of development of postoperative purpura. Also, as it is characterized with polychromaticity IPL is used to target oxyhaemoglobin found in red lesions (418 nm), deoxygenated haemoglobin found in blue lesions (542 nm), and methemoglobin (577 nm). The facial telangiectasis could be treated effectively with IPL using cut off filter of 590 nm, pulse time 2.4, 3.0 and 3.5 milliseconds, with a pulse delay 30 – 25 milliseconds. The red telangiectasis show improvement over 570 nm cut off, 2.8 and 4.5 millisecond pulse time, with a delay of 30 milliseconds. The other component of pigmented lesions could be treated using a wavelength range of 630 to 1100 nm (Goldberg, 2012). However, prior treatment it is preferable for the patient to undergo treatment procedure for a test spot so as to check for the ability to tolerate the treatment plan. The multiple treatment sessions spaced 3-4 weeks apart would prove to be favourable, with number of sessions dependable on the improvement of appearance. The postoperative care procedures may involve the regular use of sunscreen, and hydroquinone.
 
Wound healing process
As mentioned above, the treatment of Cervical Poikiloderma demands the treatment of vascular lesions and pigmented lesions. The IPL technique generates polychromatic incoherent light of high intensity in the broad spectrum of 550 – 1200 nm, and targets the chromophores haemoglobin and its variants, namely oxyhaemoglobin, deoxyhaemoglobin, and methemoglobin. The telangiectasias, or the vascular lesions, are characterized with permanent dilation of superficial capillaries and venues which are proximal to the surface of skin or mucosa. IPL treats these vascular lesions by raising the temperature of effected blood vessels high enough so as to cause coagulation. The coagulated blood vessels are then destructed, and are biologically replace with fibrous granulation tissues, through normal body functioning. While treating vascular lesions it is important to keep into account the type and size of the vessels being targeted. The broader wavelength of IPL allows the pulse to reach the deep seated vessels, and thus the cavernous vascular lesions could also be targeted. The advantage of using IPL device is that it allows uniform heating of the vessel over longer periods of time, so as to reducing the risk of vessel rupture, associated purpura and hyperpigmentation. Henceforth, the larger vessels (300 microns) the thermal relaxation time is 100 milliseconds, whereas that for small sized vessels (100 microns) the relaxation time is 10 milliseconds (Goldberg, 2012; Wat, Wu, Rao, & Goldman, 2014).
On the other hand for the treatment of pigmented skin lesions the key determinant for selecting the most appropriate therapeutic wavelength is the localization of pigment target. The selected IPL wavelength in the range of 630 – 1100 nm is applicable for targeting the pigmented lesions. The mode of action involves rapid differentiation of the keratinocytes as induced by thermal heating. The differentiation process results in the transfer of melanosomes in upward direction, along with the necrotic keratinocytes. This ultimately results in the elimination of keratinocytes as microcrusts, which are removed from the surface of the skin.  Therefore, IPL successfully removes the dense melanosomes from the basal layer of epidermis. Hydroquinone helps in suppressing the activity of the remaining active melanocytes (Yamashita et al., 2006). The lower cut off filters is used for treating the superficial pigmentation, whereas the higher cut off filters are used for treating deeper lesions. This is because the longer pulse durations help in effective heating of the deeper vessels. IPL devices are regarded with high level of efficacy for the treatment of Cervical Poikiloderma. It also minimizes the risk of any possible side effects, scarring, purpura, hyperpigmentation and downtime (Husain & Alster, 2016).
 
Risks and potential complications
Although IPL is associated with less risks and complications, still it is imperative to discuss some of the probable risks and potential complications associated with the chosen procedure. The foremost disadvantage associated with the technique is the lack of selectivity due to its versatility which includes the activation of all the three different chromophores in human blood. Although, the wide range of parameters such as pulse duration, frequency, fluency, and delay, makeup for this shortcoming, however this makes the technique safe in hands of a highly skilled and experienced dermatologist only. Hence, an inexperienced physician, or non medical staff pose the risk of invoking thermal damage to the skin, if the parameters are not set properly. This demands great adherence to standard guidelines for the purpose of using IPLs in treating vascular malformation especially. As the purpura development does not occur, the region of delivery of last pulse cannot be detected, which could prove to be problematic. This could be overcome by including skip area, so as to avoid overlap between puleses. This skip area leaves footprint of dyspigmentation with respect to the neighbouring areas which have been subjected to treatment (AlNomair, Nazarian, & Marmur, 2012).
Another potential complication of the technique is the inconsistency of emitted spectrum and fluence, which could vary from pulse to pulse (Katoulis et al., 2002). Also, the IPL treatment for the pigmented lesions could result in formation of darkened and sloughed treated spot. The minimal side effects of the treatment involve transient post-inflammatory hyperpigmentation, moderate erythema, ecchymosis and edema, and linear hypopigmentation (Feng, Zhao, & Gold, 2008; Katoulis et al., 2002). Pang & Wells (2008) reported the dyschromasia of both the upper eyelids as a side effect of IPL treatment. Also, absorption of light by iris during treatment could lead to bilateral ocular iritis, which might lead to irreversible ocular damage. On the contrary, even though the given patient has Type II skin, and not highly susceptible to development of dyspigmentation and scarring, still it is important to emphasize upon the necessity to use the present technique cautiously while treating patients with Type III to IV skin, and tanned skin. This emphasizes on the importance of assessing each patient’s skin type carefully before giving the treatment. Additionally, the African-American and Hispanics having Type IV-VI skin are also at higher of developing hyperpigmentation and scarring. This is due to the fact that pigmented skin tends to absorb 40% more energy than the non-pigmented skin. To counter this the pigmented skin tyoe individuals are recommended a topical solution of 4% hydroquinone and 0.1% tretinoin for 8 weeks post treatment (Aston, Steinbrech, & Walden, 2012).
Also, it is important to emphasize the patients upon the importance of avoiding sun post treatment, and using sunscreen to avoid post inflammatory hyperpigmentation. The patients also need to be informed about all the potential complication before they undergo anaesthesia for treatment.
 
Topical care
The treatment with IPL could lead to after sensations of mild sunburn, which can last up to 2 to 72 hours. The region might also be accompanied with mild swelling and redness, which takes up to 2-3 days to resolve. In order to relieve swelling or discomfort the application of cold compress is recommended. Also certain skin products such as Vaseline may also be applied on the broken skin to prevent infection. Further, additional topical treatment could help augment the impact of the procedural treatment. The retinoids such as Retin-A, could prove to be vital adjunctive treatment. There is a wide variety of cosmeceutical topical agents which contain glycolic acid, filagrin based anti-oxidants, azealic acid could also prove to be useful adjunctive treatments. As IPL is less aggressive, and presents very minimal side effects, one need not resort to the use of topical preparations, except for serious side effects. The patients can also use moisturizer twice a day to accelerate the process of peeling off of the crust. They can also perform microdermabrasion of the treated area after 1-2 days of treatment. Currently, researchers are also exploring the action of brinomidine cream in reducing the inflammation, redness, pain and swelling induced post IPL treatment. The research investigates the application of brimonidine cream as it has previously shown efficacy in reducing symptomatic erythema in patients suffering from rosacea. As the reduction of erythema is brought about due to vasoconstriction, thus brimonidine can further reduce odema and pain induced by IPL (U.S. National Library of Medicine, 2018).
 
References
AlNomair, N., Nazarian, R., & Marmur, E. (2012). Complications in lasers, lights, and radiofrequency devices. Facial Plastic Surgery, 28(3), 340–346.
Aston, S. J., Steinbrech, D. S., & Walden, J. L. (2012). Aesthetic plastic surgery. Elsevier Health Sciences.
Civatte, A. (1923). Poikilodermie reticulee pigmentaire du visage et du cou. Ann Dermatol Syphilol, 6, 605–620.
Elsaie, M. L., Vejjabhinanta, V., Martins, A. C., & Nouri, K. (2010). Treatment of poikiloderma by pigment and vascular lasers. In M. Alam & M. Pongprutthipan (Eds.), Body Rejuvenation (pp. 47–51). Springer New York.
Feng, Y., Zhao, J., & Gold, M. H. (2008). Skin rejuvenation in Asian skin: The analysis of clinical effects and basic mechanisms of intense pulsed light. J Drugs Dermatol2, 7(3), 273–279.
Goldberg, D. J. (2012). Current trends in intense pulsed light. J Clin Aesthet Dermatol., 5(6), 45–53.
Goldman, M. P., & Weiss, R. A. (2001). Treatment of poikiloderma of civatte onthe neck with an intense pused light source. Plastic and Reconstructive Surgery, 107(6), 1376–1381.
Husain, Z., & Alster, T. S. (2016). The role of lasers and intense pulsed light technology in dermatology. Clin Cosmet Investig Dermatol., 9, 29–40.
Katoulis, A. C., Stavrianeas, N. G., Katsarou, A., Antoniou, C., Georgala, S., Rigopoulos, D., … Katsambas, A. D. (2002). Evaluation of the role of contact sensitization and photosensitivity in the pathogenesis of poikiloderma of Civatte. British Journal of Dermatology, 147, 493–497.
Khunkhet, S., & Wattanakrai, P. (2014). The possible role of contact sensitization to fragrances and preservatives in Poikiloderma of Civatte. Case Reports in Dermatology, 6(3), 258–263.
Pang, A. L., & Wells, K. (2008). Bilateral anterior uveitis after intense pulsed light therapy for pigmented eyelid lesions. Dermatol Surg., 34(9), 1276–1279.
Placzek, M., Frömel, W., Eberlein, B., Gilbertz, K. P., & Przybilla, B. (2007). Evaluation of phototoxic properties of fragrances. Acta Derm Venereol., 87(4), 312–316.
Sachdeva, S. (2009). Fitzpatrick skin typing: applications in dermatology. Indian Journal of Dermatology, Venereology, and Leprology, 75(1), 93.
U.S. National Library of Medicine. (2018). Topical brimonidine to reduce inflammation after IPL-treatment in patients With facial telangiectasias.
Wat, H., Wu, D. C., Rao, J., & Goldman, M. P. (2014). Application of intense pulsed light in the treatment of dermatologic disease: a systematic review. Dermatol Surg., 40(4), 359–377.
Yamashita, T., Negishi, K., Hariya, T., Kunizawa, N., Ikuta, K., Yanai, M., & Wakamatsu, S. (2006). Intense pulsed light therapy for superficial pigmented lesions evaluated by reflectance-mode confocal microscopy and optical coherence tomography. Journal of Investigative Dermatology, 126(10), 2281–2286.

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