Journal of Cutaneous and Aesthetic Surgery
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   Table of Contents - Current issue
Coverpage
January-March 2022
Volume 15 | Issue 1
Page Nos. 1-100

Online since Tuesday, May 17, 2022

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REVIEW ARTICLE  

Acute and chronic paronychia revisited: A narrative review p. 1
Vineet Relhan, Anuva Bansal
DOI:10.4103/JCAS.JCAS_30_21  
Paronychia refers to the inflammation of the tissue which immediately surrounds the nail and it can be acute (<6 weeks duration) or chronic (>6 weeks duration). Disruption of the protective barrier between the nail plate and the adjacent nail fold preceded by infectious or noninfectious etiologies results in the development of paronychia. A combination of general protective measures, and medical and/or surgical interventions are required for management. This review explores the pathogenesis, clinical features, differential diagnosis, medical, and surgical management of paronychia. For the purpose of this review, we searched the PubMed, Cochrane, and Scopus databases using the following keywords, titles, and medical subject headings (MeSH): acute paronychia, chronic paronychia, and paronychial surgeries. Relevant review articles, original articles, and case reports/series published till February 2020 were included in this study.
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ORIGINAL ARTICLES Top

To compare the efficacy and safety of autologous non-cultured non-trypsinized keratinocyte and melanocyte grafting (Jodhpur technique) with autologous platelet-rich fibrin matrix (PRFM) in the treatment of chronic non-healing ulcer p. 17
Shreyansh Bhansali, Dilip Kachhawa, Pankaj Rao
DOI:10.4103/JCAS.JCAS_196_20  
Background: Chronic non-healing ulcers (NHUs) are often associated with some underlying pathology which prevents timely healing thus increasing the patients morbidity and healthcare expenses. Autologous non-cultured non-trypsinized keratinocyte and melanocyte grafting also known as Jodhpur technique (JT), an epidermal graft and autologous platelet-rich fibrin matrix (PRFM) are newer modalities with promising results. Aims: To compare the efficacy and safety of JT and autologous PRFM in the treatment of chronic NHU. Design: A prospective hospital based interventional study conducted on 50 patients of chronic NHU attending the dermatology outdoor of a tertiary level government hospital. Materials and Methods: After taking clearance from the institutional ethical committee, the patients were enrolled into 2 groups of 25 each. JT was done on group A and autologous PRFM on group B and their efficacy and safety compared. Statistical Analysis: Chi square test was used to analyze categorical variables summarized as number and percentage while continuous variables were analyzed using student t-test for intergroup comparison. Results: In Group A, the mean time to ulcer healing was 6.17 ± 2.17 weeks while 6.43 ± 2.33 weeks in Group B. No side effects were found in either group. Conclusion: Both the techniques fair equally in terms of wound healing time and safety but required multiple sittings in group B and a single session in group A.
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Operative treatment of severe allergic reactions to red tattoo dye: Presentation and comparison of possible surgical procedures in seven patients p. 24
Joerg Laske, Jan Maschke, Andrea Bauer, Stefan Beissert, Roland Aschoff
DOI:10.4103/JCAS.JCAS_202_20  
Context: The treatment of allergic reactions to red tattoo dye is challenging in most cases, as local therapy often does not offer long-term improvement and laser therapy is considered relatively contraindicated by many authors owing to the risk of generalized side effects. Therefore, surgical removal of these tattoos is favored; shave excision is the method of choice, particularly for the removal of the entire dye. Aims: The aim of this article was to retrospectively analyze the best post-operative outcome after surgical removal of allergic tattoo reactions using different excision techniques. Materials and Methods: We compared the different surgical procedures performed on seven patients with single and multiple allergic tattoo reactions treated between 2013 and 2018. Results: The best aesthetic results were achieved by superficial ablation of the inflammatory reaction, partially leaving tattoo remains in the skin. Conclusion: Based on our experience with this small number of patients, a superficial removal of the tattoo without complete removal of the dye is, in most cases, sufficient to achieve healing. The remaining dye residues seem to be better tolerated by the immune system afterwards. Furthermore, the tattoo is often preserved in large parts.
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Tertiary health care-based randomized controlled study to compare autologous, non-cultured, non-trypsinized epidermal cell transplant (Jodhpur technique) with split-thickness skin grafting (STSG) in stable vitiligo p. 33
Manjulata Verma, Shivani Saini, Pankaj Rao, Chandraprakash Chouhan, Dilip Kachhawa
DOI:10.4103/JCAS.JCAS_205_20  
Background: Surgical treatment of vitiligo is reserved for stable recalcitrant vitiligo patches. Split-thickness skin grafting (STSG) is an important established modality for the surgical treatment of vitiligo, whereas autologous, non-cultured, non-trypsinized epidermal cell transplant, also known as Jodhpur technique (JT), is an unconventional innovative surgical modality for the treatment of stable vitiligo. Aims: To compare the two techniques, JT and STSG, with regards to the extent and pattern of repigmentation achieved, color matching of the repigmented area, patient satisfaction (Dermatology Life Quality Index [DLQI] questionnaire and patient global assessment), and adverse events (if any) in patients with stable vitiligo. Materials and Methods: It was a randomized comparative study. We randomized 32 patients with 180 stable vitiligo lesions into two groups. Patients in group 1 were treated with JT, and those in group 2 with STSG. They were subjectively evaluated 20 weeks post-surgery for the extent of repigmentation, color match, change in DLQI score, and patient satisfaction. The categorical data were presented as number (percent) and were compared among groups using Chi-square test. Mean and standard deviation were calculated for demographic data, and they were also compared by using student t-test. Probability P value < 0.001 was considered statistically significant. Results: The extent of repigmentation was excellent (90%–100% repigmentation) in 72.5% of lesions in the JT group and in 40% of lesions in the STSG group (P < 0.001). Seventy-five percent repigmentation (good repigmentation) was observed in 95% of lesions in the JT group and in 83.75% of lesions in the STSG group (P = 0.040). There was a highly significant decline in DLQI score. Post-procedure DLQI (0.79 ± 1.13) and pre-procedure DLQI (15.39 ± 4.76) in the JT group were compared with post-procedure DLQI (3.85 ± 2.89) and pre-procedure DLQI (16.19 ± 4.56) in the STSG group. The mean decline among groups differed significantly (P < 0.001). Adverse events were significantly higher in the STSG group at the recipient site. Conclusions: JT is found to be significantly better than STSG with regard to the degree of repigmentation.
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Evaluation of healing effects of poultice containing 0.5% fulvic acid on male white-male rats with skin ulcer p. 40
Fatemeh Samiee-Rad, Seyede F Hosseini Sedighi, Armane Taherkhani, Nematollah Gheibi
DOI:10.4103/JCAS.JCAS_215_20  
Background: Chronic and acute skin wounds are an important health concern because they are very frequent during human life and affect millions of people worldwide. Shortening the wound healing process reduces treatment costs and hospitalization. Therefore, researchers have been looking for new treatment approaches to shorten the wound healing process. Aims and Objectives: The aim of this study was to evaluate the wound healing properties of poultice containing 0.5% fulvic acid. Materials and Methods: In this experimental study, a full-thickness skin wound was created on the dorsal side of 24 male rats. The animals were then randomly assigned to control, sham, and experiment groups. The skin defects were daily bandaged by using sterile gauze dipped in normal saline, carboxymethylcellulose, and 0.5% fulvic acid for 21 days, respectively. The wound healing rate was evaluated grossly and histologically at various time intervals post injury. Both descriptive and statistical analysis methods were applied (P < 0.05). Results: The wound healing percentage was significantly higher in the poultice treatment group at all time intervals (P < 0.001). The wound was completely closed in this group compared with other groups at the end of week 4 post treatment. The mean numbers of inflammatory cells were statistically lower, and fibroblasts and vessels were higher in the poultice group than in the other groups at various time intervals post injury (P < 0.001). Conclusion: Fulvic acid (0.5%) could be used as an effective therapeutic approach to improve the wound healing process because of its unique anti-inflammatory and neovascularization properties at the skin wound site.
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Periorbital rejuvenation: A study on the use of dermal threads as monotherapy, with a review of literature p. 48
Gulhima Arora, Sandeep Arora
DOI:10.4103/JCAS.JCAS_221_20  
The periorbital region, a major impressionable area holds a special place in aging of the face. It reflects chronological aging which are reflected not only as structural changes but also emotive expressions of sadness and tiredness. Dermal threads have been used in combination with other aesthetic procedures, however their use as monotherapy especially in periorbital region needs evaluation. Aim: To evaluate the improvement in wrinkling and skin texture in the infero-lateral periorbital region with monofilament dermal threads. Settings and Design: A prospective observational study in a tertiary hospital was conducted between January 2019 and February 2020 after institutional ethical clearance and patient consent. Materials and Methods: 25 adults between 40 and 65 years of age reporting for infero-lateral periorbital rejuvenation and opting for dermal threads, with no history of aesthetic treatment in this region for the past three months were included after their informed consent. 10 monofilament dermal threads (5 each in lateral and infraorbital) in either periorbital region were inserted. Cases were assessed with Lemperle’s wrinkle scale and visual analog scale (VAS) and photographic record maintained before procedure and after 16 weeks of procedure. Change in wrinkle grade was analysed using paired t-test and VAS was used to assess patient’s perception of the result. Results: 25 cases were included in the study, 21 completed the follow-up and 4 were lost to follow up. The mean preprocedure wrinkle score was 2.29 and postprocedure mean scores were 1. This finding was statistically significant. 16 cases were satisfied with their textural improvement (VAS >+2) while 4 reported mild improvement (VAS 2+) and 1 reported no improvement. Side effects observed were bruising in two cases and thread displacement in one case within 24 hours. Conclusions: Polydioxanone monothreads offer an alternative aesthetic procedure for periorbital rejuvenation.
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Clinical uses of NPWT with irrigation of normal saline in diabetic foot ulcer: Outcome assessed by DEPA score p. 58
Vikas Kumar Malviya, Sakshi Goyal, Vishal Bansal, Kritik Jaiswal
DOI:10.4103/JCAS.JCAS_227_20  
Introduction: Diabetic foot ulcer (DFU) is a common complication of uncontrolled diabetes. Negative pressure wound therapy (NPWT) with irrigation of normal saline is one of the methods for wound care and dressing techniques in DFU. Wound assessment is another aspect of DFU management for deciding whether the wound is prepared or not for coverage. The present study uses DEPA score as a wound assessment tool in DFU. Materials and Methods: This case series include 11 patients with DFU who were treated using NPWT with simultaneous irrigation of normal saline. Results: All 11 patients were male and age more than 60. Most patients have duration of diabetes for less than 10 years. Staphylococcus aureus (n = 5, 45.4%) was most common bacterial flora. Most patients in series presented with DEPA score more than 7 and after application of NPWT instillation therapy significant improvement seen with score in most of the patient with DEPA score below 6. Mean time for NPWT (irrigation) application was 15 days. Mean time of wound preparation was 18.7 days. Final surgical procedures executed in all patients, split skin grafting performed in 7 patients. 4 patients had wound coverage by reverse sural flap (2), medial plantar flap (1) and local flap coverage (1). Conclusion: NPWT with normal saline irrigation is an effective method of wound preparation in DFU. DEPA score is an important tool for assessment of wound preparation which gives exact information for timing of wound coverage once diabetic foot wound is prepared.
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A therapeutic trial comparing modified autoinoculation, a novel approach with topical potassium hydroxide application in the treatment of molluscum contagiosum p. 65
Akshay Samagani, Leena Raveendra, Belliappa P Raju
DOI:10.4103/JCAS.JCAS_228_20  
Context: Molluscum contagiosum (MC) is a common viral cutaneous infection. Despite multiple treatment options, there is no definitive treatment. In some cases, the lesions are severe, recurrent, and cosmetically odd. Modified autoinoculation (MAI) is a novel technique that induces cell-mediated immunity resulting in clearance of local as well as distant lesions. Potassium hydroxide (KOH) acts by dissolving the keratin and penetrating deeply destroys the hyperproliferative tissue. We would here like to compare MAI with topical KOH in the treatment of MC. Aims and Objective: The aim of this study was to assess the effectiveness of MAI in treatment of MC and to compare its response with topical KOH application. Settings and Design: This was an open-labeled longitudinal therapeutic outcome study carried out at a tertiary care center over a period of 1 year. Materials and Methods: Hundred consenting MC patients attending the department of dermatology were randomized into Group A and Group B. Group A patients were subjected to MAI and Group B to topical application of 10% KOH. Statistical Analysis Used: The continuous variables are presented as mean ± standard deviation (SD). The difference between the mean score was analyzed using Student’s t test for independent variable and paired t test for paired results. Results: At the end of 16 weeks, 91.48% showed complete clearance by MAI compared to 81.64% with topical 10% KOH solution. There was a significant reduction of mean score of lesions in patients treated by MAI compared to patients treated with KOH. Conclusion: MAI therapy provides a promising, easy, cost-effective, daycare option for MC infections.
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A comparative study of efficacy of 5% minoxidil and 5% minoxidil plus platelet-rich plasma in same patient for treatment of androgenetic alopecia p. 71
Sandeep Pachar, Chandraprakash Chouhan, Pankaj Rao, Dilip Kachhawa, Harshvardhan Singh, Chimai Yadav
DOI:10.4103/JCAS.JCAS_232_20  
Background: Androgenetic alopecia (AGA) is characterized by androgen-related progressive thinning of the scalp hair in a defined pattern. It has an effect on social and psychological well-being of the patient. It is often recalcitrant to medical treatment alone. Aim: The aim of the study was to compare the efficacy of 5% minoxidil and 5% minoxidil plus platelet-rich plasma (PRP) in same patient for the treatment of AGA. Materials and Methods: A prospective randomized study was conducted on 50 patients of AGA attending the outdoor department. Scalp of each patient was divided into right side and left side, to compare the effectiveness of 5% minoxidil on the right side with combination of 5% minoxidil and intradermal PRP on the left side at an interval of 1 month for a period of 6 months. Clinical improvement was assessed monthly till 6 months by the serial hair pull test, global photography, patient satisfaction score, trichoscopic evaluation, and hair density. Results: For post-procedure subjective perception at the end of 6 months, the minoxidil 5% side showed good response in 41% (n = 18), moderate in 20% (n = 9), and poor in 39% (n = 17), whereas the PRP + minoxidil 5% side showed good response in 59% (n = 26), moderate in 16% (n = 7), and poor in 25% (n = 11) of the patients. Conclusion: The combination consists of 5% minoxidil and intradermal PRP, which appears to be simple, safe, and effective treatment in AGA. It can be used in poor responders in conventional medical therapy.
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Dermatological research in India: A brief bibliometric analysis of publications during 1999–2019 p. 77
Manjula Nayak, Dharmagadda Sreedhar, S Smitha Prabhu, Virendra S Ligade
DOI:10.4103/JCAS.JCAS_243_20  
Background: Dermatology is the science of the skin. In India, dermatology came into picture in the twentieth century. Today’s dermatology practiced in India is the modern approach developed and established in western countries based on western medical theory, knowledge, experience, and results from study. Growth of dermatology field in India has progressed since two to three decades. This paper assesses the contributions made by India in the dermatology field by analyzing the total number of publications in top dermatological journals. Materials and Methods: SCImago Journal Rank indicator (2019) was used to search for top dermatology journals and publication metrics was recorded from respective journal websites. Simple statistics tools were used to determine the number of publications during this 20-year period. Results: From 1999 to 2019, there were 547 publications from India, in the top dermatologic journals. It was noted that, original research article contributes maximum number of documents (136). Journal of Dermatology had a maximum number of publications with 174 when compared to other journals. Postgraduate Institute of Medical Education and Research, Chandigarh’ had a maximum number of publication (150). Conclusion: The last 20 years have seen a massive increase in the field of dermatology. Today, dermatology is a well-developed field in India. From 1999 to 2019, there is an increase in the trend of publications along with the collaborative publications in the top dermatologic journals. This show the encouraging trend in terms of publications from India in past 20 years.
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PRACTICE POINTS Top

Hybrid conferences in the post-COVID-19 era: Time yet for a paradigm shift for medical associations p. 82
Dinesh Kumar Devaraj, Shyamanta Barua, Neeta karal Nair, Raghunatha R Reddy, Namitha Chathra, Aruna Devi, Dipak Kumar Agarwal, Savitha Somaiah, Jagadish P
DOI:10.4103/JCAS.JCAS_207_21  
Materials and Methods: The physical attendees were surveyed post-ACSICON 2021 conference online, using a mixed-methods technique. Attendees were given a 16-point questionnaire using Google Forms that covered subjects including the COVID-19 preventive procedure, immunization status, infection rates during and after the conference, and overall satisfaction with the hybrid conference. A total of 231 people were sent the survey questionnaire. Results: Only 0.4% (n = 1) of the participants reported being infected by COVID-19 virus after the conference. 86% (n = 198) of the respondents also felt that all the necessary precautions were taken during the ACSICON 2021conference. Most of the respondents (82%, n = 189) rated the hybrid conference interaction to be more satisfying than an online conference. An overwhelming majority of the respondents (92%, n = 209) found hybrid conferences to be a safer option than regular conference. Conclusion: The COVID-19 pandemic’s scope has forced a paradigm change in medical practice and research (1). ACSICON 2021 is an example of how, with careful organization, strict implementation of meticulous preventive procedures, and strict adherence to the COVID-19 protocol, medical conferences may be held without danger of infection and its transmission. Given the pace with which vaccinations are being administered, a new reality in which technology and live networking intersect via hybrid conferences will result in a more engaging and adaptable medical conference experience. In the long run, this can bring about a significant shift in the conduct of scientific meetings to best suit delegates’ needs and conveniences.
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INNOVATIONS Top

Surgical pearl: Chemical ball pen for cautery p. 86
Muhammed Mukhtar
DOI:10.4103/JCAS.JCAS_254_20  
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Window approach in conventional phototherapy to protect non-lesional skin Highly accessed article p. 89
Feroze Kaliyadan, Puravoor Jayasree, Karalikkattil T Ashique
DOI:10.4103/JCAS.JCAS_257_20  
We propose the use of protective coverings—gloves, socks, or clothing, with windows cut out into them, to ensure that the phototherapy targets only the affected areas.
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CASE REPORTS Top

Delayed onset nodules after hyaluronic acid fillers: A case series p. 91
Aman Dua, Bhawna Bhardwaj
DOI:10.4103/JCAS.JCAS_200_20  
Non-surgical techniques with hyaluronic acid fillers to rejuvenate face are very popular treatment due to ease of administration and achievement of faster improvement. Although they are considered to be safe procedures, few rare adverse effects have been reported in literatures. The number of these cosmetic procedures being performed is increasing every year. Simultaneously, the rate of filler complications has also increased. This case series presents three clinical cases of delayed onset nodules after hyaluronic acid fillers after 1–5 months post-procedure. Juvederm Volift was used in all the mentioned patients. Granulomatous reactions can occur with any of the hyaluronic acid fillers. These are generally localized immunological reactions. An awareness about these rare side effects helps us in the assessment and ensurance of accurate diagnosis and treatment.
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Botulinum toxin for scalp dysesthesia p. 95
Kevin Phan, Matthew James Lin
DOI:10.4103/JCAS.JCAS_197_20  
Scalp dysesthesia is characterized by abnormal cutaneous sensations such as burning, stinging, or itching of the scalp. This condition is particularly challenging to manage as there is a lack of well-established treatments. By limiting release of neurotransmitters such as substance P, glutamate, and calcitonin gene-related peptide, botulinum toxin may have a role in ameliorating neuropathic pain. We report a unique case in which botulinum toxin was used in the management of scalp dysesthesia.
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Autologous fat grafting for plantar fasciitis p. 97
Kevin Phan, Matthew J Lin
DOI:10.4103/JCAS.JCAS_206_20  
Plantar fasciitis is the most common cause of heel pain, accounting for up to 15% of medical foot inquiries. Autologous fat grafting (AFG) is a promising new treatment for plantar fasciitis, whereby the injection of fat may promote a cushioning effect on the heel and reduce plantar pressure, thereby reducing heel pain. We present the case of a patient with chronic plantar fasciitis treated with AFG with significant improvement in foot pain and functional scores.
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LETTER TO THE EDITOR Top

Truncal anesthesia for hair mesotherapy p. 99
Pablo Martín-Carrasco, Jose Bernabeu-Wittel, Mercedes Sendín-Martín, JJ Domínguez-Cruz
DOI:10.4103/JCAS.JCAS_225_20  
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