Cutaneous Larva Migrans

Cutaneous larva migrans (CLM) is skin infection caused by hookwork. This is most commonly transmitted by animal feces depositing eggs in the soil, with larvae entering humans through direct contact with skin. However larvae can't penetrate the basal membrane of the skin to enter lymphatic system. Therefore, hookworms can't complete their life cycle (CLM is self-limited).

CLM is a clinical manifestation demonstrated by creeping migration of larva through the skin (creeping eruption). The most common initial finding is a small reddish papule that progresses to a serpiginous pruritic rash with a slow rate of progression from less than 1 to 2 cm per day.

                                   

The disease is self-limited. However, for local infection use topical thiabendazole 15% ointment (as first line) applied 2 to 3 times daily for 5 to 10 days. Small studies have shown improvement of pruritus may occur as early as 48 hours after beginning treatment, and cure rates as high as 98% within ten days have been achieved. The largest advantage of topical therapy is a lack of systemic absorption and side effects.

For multiple lesions or severe infestation, albendazole and ivermectin are first-line systemic therapies. Oral albendazole, 400 mg daily for 3 to 5 days, is very effective with cure rates nearing 100%. Some studies show that a 7-day course of albendazole may decrease the rates of recurrent disease. Oral ivermectin is also effective, and its advantage is a patient only has to take a one-time dose of 12 mg by mouth. Cure rates near 100% with ivermectin administration.

Reference 

Maxfield, L. & Crane, J. S., 2020, StatPearls : Cutaneous larva migrans, Treasure Island.

Beauty Corner : Tips to Minimize Large Pore ?

Skin contains millions of pores. All of these pores are open, allowing the skin to “breathe.” Each pore contains a hair follicle, sebaceous (oil) glands that make an oil called sebum and also eccrine glands that excrete sweat. Any skin type, whether it’s oily, normal, or dry, can take on the appearance of having large pores. 

This is important thing to know. Pores cannot be opened or closed and the cannot be made smaller. Often, when people say they wish to open their pores, what they’re referring to is a deep cleaning to remove excess oil and debris. This may make open pores look as if they’ve shrunk or closed. 

What causes enlarged pores?

• Increased sebum production
• Hair follicle size
• Use of comedogenic products
• Loss of skin elasticity with age
• Sun damage.

Acne is associated with enlarged pores for example open comedones (blackheads) can be seen within a pore. Inflammatory acne may cause enlarged pores through weakening sebaceous gland and hair follicle openings, making them more prone to blockage.

What Should I Do to Make My Pores "Shrink"?

Use only non-comedogenic skin care products and makeup

It means the product won’t clog your pores and oil free. When pores clog, they expand, which can make your pores look more noticeable.

Cleanse your face twice a day

Cleansing twice daily can unclog pores, prevent clogged pores, and reduce oiliness. When cleansing your face, you’ll want to:

• Use warm water. 

• Gently wash your face. 

• Find a gentle, non-comedogenic cleanser. 

Use retinol

Using a skin care product with retinol or retinyl palmitate may help. For best results, apply the product before going to bed.

Some people find that this type of skin care product irritates their skin. You can prevent this by washing your face and then waiting 30 minutes to apply the product.

If you’re pregnant or breastfeeding, you shouldn’t use a product containing retinol or retinyl palmitate.

Treat acne

Acne clogs your pores, which can make your pores more noticeable.

Using a cleanser with salicylic acid may help. Studies show salicylic acid can unclog pores. Some cleansers containing salicylic acid are gentle enough to use every day.

If the salicylic acid dries or irritates your skin, try alternating cleansers. Use a mild, non-comedogenic cleanser when you wake up and the salicylic acid cleanser before bed.

Do you want to know how to treat acne? Read more : Treat Acne

Protect your face with sunscreen every day

The more sun damaged your skin, the less firmness it has. When skin starts to lose its firmness, pores look more noticeable.

Applying a broad-spectrum, water resistant sunscreen with an SPF 30 or higher helps prevent sun-damaged skin. To protect your skin, apply sunscreen every day, even when it’s raining or cold outside. Every time the sun’s rays hit our skin, they can damage our skin. This damage builds up over time.

Exfoliate

Exfoliating may make pores less noticeable. 

If exfoliating your skin makes you uncomfortable or you aren’t sure this is right for you, You can consult your dematologist. 

Be gentle with your skin

Scrubbing your face won’t make it any cleaner, but scrubbing can irritate your skin, which can make your pores look larger.

Picking at, squeezing, or digging into your pores can also irritate your skin, making pores look more noticeable.

Treat sagging skin

As we age, our skin loses its firmness and starts to sag. Pores look larger when skin sags.

Reference :

https://www.healthline.com/health/open-pores

https://www.aad.org/public/everyday-care/skin-care-secrets/face/treat-large-pores

Hair Loss : Types, Cause, Prevention, Treatment

Hair loss is not life threatening, but it is distressing and significantly affects the patient’s quality of life. Hair loss can range from mild hair thinning to total baldness. Hair can fall out for many different reasons.

Types of Hair Loss

There are several categories of hair loss, including:

• Telogen effluvium — This common form of hair loss happens two to three months after a major body stress, such as a prolonged illness, major surgery or serious infection. It also can happen after a sudden change in hormone levels, especially in women after childbirth. Moderate amounts of hair fall out from all parts of the scalp, and may be noticed on a pillow, in the tub or on a hairbrush. While hair on some parts of the scalp may appear thinner, it is rare to see large bald spots.
• Drug side effects — Hair loss can be a side effect of certain medications, including lithium, beta-blockers, warfarin, heparin, amphetamines and levodopa.  In addition, many medications used in cancer chemotherapy — such as doxorubicin (Adriamycin) — commonly cause sudden hair loss affecting the entire head.
• Symptom of a medical illness — Hair loss can be one of the symptoms of a medical illness, such as systemic lupus erythematosus (lupus), syphilis, a thyroid disorder (e.g. hypothyroidism or hyperthyroidism), a sex-hormone imbalance or a serious nutritional problem, especially a deficiency of protein, iron, zinc or biotin. T
• Tinea capitis (fungal infection of the scalp) — This form of patchy hair loss happens when certain types of fungi infect the scalp. This causes the hair to break off at the scalp surface and the scalp to flake or become scaly. 
• Alopecia areata — This is an autoimmune disease that causes hair to fall out in one or more small patches. The cause of this condition is unknown, although it is more common in people who have other autoimmune diseases. Total loss of hair from the scalp with the same process, it is known as alopecia totalis.
• Traumatic alopecia — This form of hair loss is caused by hairdressing techniques that pull the hair (tight braiding or cornrowing), expose hair to extreme heat and twisting (curling iron or hot rollers) or damage the hair with strong chemicals (bleaching, hair coloring, permanent waves). It can also happen in some people  who have an uncommon psychiatric disorder (trichotillomania) in which compulsive hair pulling and twisting can cause bald spots.
• Hereditary pattern baldness, or androgenetic alopecia — In men, hair loss may follow the typical male pattern (receding front hairline and/or thinning hair at the top of the head). This is the most common type of hair loss, and it can begin at any time in a man's life, even during his teen years. It usually is caused by the interaction of three factors: an inherited tendency toward baldness, male hormones and increasing age. Many women will develop some degree of female-pattern baldness. In women, thinning occurs over the entire top or crown of the scalp, sparing the front of the scalp.

Difference male vs female pattern hair loss

Male Pattern Baldness

Female Pattern Baldness

Duration of hair loss lasts depends on the cause. 

• In telogen effluvium, hair usually is lost over several weeks to months, but then grows back over the next several months. 
• If hair loss caused by side effect of a medication, hair growth usually returns to normal once the drug is stopped. 
• When the cause is abusive hairdressing, the hair loss usually stops after you change to more natural styling, except in traction alopecia, which results from years of pulling the hair back in tight braids. 
• In tinea scalp infection, the fungus must be treated for at least 6 to 12 weeks and hair regrowth may be slow.

Early treatment is very important in preventing possible permanent hair loss. Both male- and female-pattern baldness tend to get worse over time but can be treated.

Can we prevent hair loss ?

Some forms of hair loss can be prevented by 

• minimizing stress
• eating a healthy diet
• using sensible hairdressing techniques,
• if possible, switching to medications that do not cause hair loss. 
• keeping hair clean and by never sharing hats, combs or brushes with other people ( fungal infection)
• For hereditary-pattern baldness can sometimes be prevented by medication.

Treatment

Call your doctor whenever you are concerned about hair loss, especially if you are having other unexplained symptoms. Your doctor will identify the cause and give the spesific treatment to treat hair loss. 

Hair loss resulting from telogen effluvium or drug side effects usually requires no treatment other than discontinuing the medication that is causing the problem. 

Limiting trauma or chemical exposure (such as use of a blow dryer, hair straightener, coloring or perms) may limit or stop hair loss. 

Hair loss from poor nutrition or medical illness usually stops with the adoption of a healthy diet and treatment of the underlying medical condition. 

Treatment of fungal scalp infection requires 6 to 12 weeks of oral medication, such as terbinafine or itraconazole, with or without shampoos containing selenium sulfide or ketoconazole. 

Alopecia areata can be treated with a corticosteroid that is injected or applied to the skin. Other treatments for this condition include anthralin cream, minoxidil  or a combination of these therapies.

Many men and women with hereditary-pattern baldness do not seek treatment for hair loss. For those who do seek medical treatment, initial therapy is usually topical minoxidil . Men can also be treated with oral finasteride  or dutasteride  or they can choose hair transplants or scalp-reduction surgery. 

Premenopausal women may be treated with estrogen or spironolactone while finasteride may be recommended for postmenopausal women.

Reference :

www.health.harvard.edu/a_to_z/hair-loss-a-to-z

www.aafp.org/afp/2017/0915/p371.html

 

Why I can Have Migraine ?

A migraine can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It is a common health condition, affecting around 1 in every 5 women and around 1 in every 15 men. They usually begin in early adulthood.

Type of Aura

• migraine with aura – where there are specific warning signs just before the migraine begins, such as seeing flashing lights
• migraine without aura – the most common type, where the migraine happens without the specific warning signs
• migraine aura without headache, also known as silent migraine – where an aura or other migraine symptoms are experienced, but a headache does not develop

Examples of migraine aura include:

• Visual phenomena, such as seeing various shapes, bright spots or flashes of light
• Vision loss
• Pins and needles sensations in an arm or leg
• Weakness or numbness in the face or one side of the body
• Difficulty speaking
• Hearing noises or music
• Uncontrollable jerking or other movements

A migraine usually lasts from four to 72 hours if untreated. How often migraines occur varies from person to person. Migraines might occur rarely or strike several times a month.

During a migraine, you might have:

• Pain usually on one side of your head, but often on both sides
• Pain that throbs or pulses
• Sensitivity to light, sound, and sometimes smell and touch
• Nausea and vomiting

After a migraine attack, you might feel drained, confused and washed out for up to a day. Sudden head movement might bring on the pain again briefly.

Causes of Migrain

The causes aren't fully understood, genetics and environmental factors appear to play a role. But there are some factors that might trigger migrain, including:

• Hormonal changes in women. Fluctuations in estrogen, such as before or during menstrual periods, pregnancy and menopause and hormonal medications, such as oral contraceptives and hormone replacement therapy, also can trigger and worsen migraines. Some women, however, find their migraines occurring less often when taking these medications.

• Drinks include alcohol, especially wine, and too much caffeine, such as coffee.
• Stress. 
• Sensory stimuli. Bright lights and sun glare can induce migraines, as can loud sounds. Strong smells — including perfume, paint thinner, secondhand smoke and others — trigger migraines in some people.
• Sleep changes. Missing sleep, getting too much sleep or jet lag can trigger migraines in some people.
• Physical factors. Intense physical exertion, including sexual activity, might provoke migraines.
• Weather changes. A change of weather or barometric pressure can prompt a migraine.
• Medications. Oral contraceptives and vasodilators, such as nitroglycerin, can aggravate migraines.
• Foods. Aged cheeses and salty and processed foods might trigger migraines. So might skipping meals or fasting.
• Food additives. These include the sweetener aspartame and the preservative monosodium glutamate (MSG), found in many foods.

Preventing migraines

First of all, avoid specific factors that may trigger your migraine. So, it's important to identify the trigger by yourself. Then, maintain healthy lifestyle, including regular exercise, sleep and meals, as well as ensuring you stay well hydrated and limiting your intake of caffeine and alcohol.

If your migraines are severe or you have tried avoiding possible triggers and are still experiencing symptoms, a GP may prescribe medicines to help prevent further attacks.

Reference :

https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-20360201

https://www.nhs.uk/conditions/migraine/

https://www.webmd.com/migraines-headaches/migraines-headaches-migraines

Treatment of Acna Vulgaris Part I

High rates of treatment failure often happens in women over 25 years old. Approximately 80% of women fail multiple courses of systemic antibiotic medications and approximately 30% to 40% fail after a course of isotretinoin (endocrinology disorder should be considered). 

Topical treatments for patients with acne include benzoyl peroxide (BP), salicylic acid (SA), antibiotic medications, combination antibiotic medications with BP, retinoid medications, retinoid with BP, retinoid with antibiotic medication, azelaic acid, and sulfone agents. Topical agents are safer than oral medications for pregnant or lactating women.

Benzoyl Peroxide

BP is available in a variety of strengths (2.5-10%) and formulations (cream, gel, wash, foam, aqueous gel, leave-on, and wash-off). BP is a comedolytic, keratolytic, anti-inflammatory agent with antimicrobial properties. BP is bactericidal mainly against P. acnes. The combination of BP and antibiotic therapy enhances results and may reduce antibiotic resistance development. Topical BP in varying formulations may be used 1 to 3 times daily as tolerated. Lower concentrations (2.5-5%), water-based, and wash-off agents may be better tolerated in patients with more sensitive skin.

Salicylic Acid

SA (0.5 to 2%) is a comedolytic agent in both wash-off and leave-on preparations. BP and SA are the most widely used over-the-counter topical acne treatments and are often used in combination. SA may be applied 1 to 3 times daily as tolerated. SA has an FDA pregnancy rating of C.

Topical Antibiotic 

Topical antibiotic alone is not recommended because high rates of resistent. It is best used in combination with BP. The main topical antibiotic medications are clindamycin and erythromycin.

1. Topical clindamycin 1% solution or gel is preferred and recommended dosing is an application of a thin layer once daily.

2. Topical erythromycin is less efficacious in patients with acne than clindamycin because of P. acnes resistance. It is usually administered 1 to 2 times daily.

3. Fixed-combination agents are available with erythromycin 3% plus BP 5%, clindamycin 1% plus BP 5%, and clindamycin 1% plus BP 3.75%. It is usually administered 1 to 2 times daily.

Topical Retinoid 

It's vitamin A–derivative prescription agents. It's often used as first-line treatment for  mild-to-moderate acne, especially comedonal. Retinoid therapy is comedolytic and resolves the precursor microcomedone lesion. Topical retinoid treatments are the mainstay in the maintenance of clearance after discontinuation of oral therapy. 

Tretinoin (0.025-0.1% in cream, gel, or microsphere gel vehicles), adapalene (0.1% cream, gel, or lotion and 0.3% gel), and tazarotene (0.05%, 0.1% cream, gel, or foam) are usually used. The recommended dosing is application of a thin layer once daily in the evening and avoid sensitive areas (e.g., eyelids, perioral area, nasal creases, and mucous membranes). Sunscreen lotion should be used to prevent photosensitivity.

Available combination agents that contain retinoid include adapalene 0.1% plus BP 2.5% and adapalene 0.3% plus BP 2.5% gels, which are approved for use in patients older than 9 years. In addition, clindamycin phosphate 1.2% plus tretinoin 0.025% gel is approved for patients older than 12 years of age. 

Tretinoin and adapalene are classified as FDA pregnancy category C but tazarotene is category X. Patients should be counseled on these pregnancy risks when initiating retinoid treatment if they desire pregnancy.

TO BE CONTINUED

Reference 

Tan, A. U. et al., 2018,'A review of diagnosis and treatment of acne in adult female patients', Int J Womens Dermatol, vol. 4, no. 2, pp. 56-71

Acne Vulgaris

Acne vulgaris (AV) is a disease of the pilosebaceous unit that causes noninflammatory lesions (open and closed comedones), inflammatory lesions (papules, pustules, and nodules), and varying degrees of scarring. 

The formation of acne lesions: 

• Alteration of follicular keratinization that leads to comedones 
• Increased and altered sebum production under androgen control (androgens stimulate sebum production via androgen receptors on the sebaceous glands).
• Follicular colonization by Propionibacterium acnes 
• Complex inflammatory responses

Risk factor

• Family history of severe acne 
• Diet (chocolate and dairy consumption) 
• Environmental factors (smoking, occlusive cosmetics, occupational exposures) 
• Hormone-based therapies such as oral contraceptive and anti-androgen medications in women with normal androgen levels

Comedones

Papules and pustules

Cysts and/or Nodules

Reference 

Tan, A. U. et al., 2018,'A review of diagnosis and treatment of acne in adult female patients', Int J Womens Dermatol, vol. 4, no. 2, pp. 56-71.

Beauty Corner : The Truth about Vitamin C

Vitamin C is a diva in natural skincare product. They have amazing benefits for our health especially for our skin. Uneven skin tone, rough texture, fine lines, acne scars, general dullness, any common complexion concern and there's a good chance that vitamin C is a recommended treatment. But, how actually vitamin C works? Do all product that contain vitamin C have the same potential effect ?  Does vitamin C have any adverse effect if we use for long time ? Okay before we discuss about that, let's find out about what is vitamin C.

What is Vitamin C?

Officially known as ascorbic acid, vitamin C is a water-soluble vitamin. Your body doesn’t produce it, so you must obtain it through your diet (from natural sources such as citrus fruits, green leafy vegetables, strawberries, papaya and broccoli). 

In nature, Vit. C is found in equal parts as LAA and D-ascorbic acid. However, only LAA is biologically active and thus useful in medical practice. 

How actually Vitamin C Works ?

• Vit C as Antioxidant

Vit C is very potent antioxidant. It protects the skin from oxidative stress by neutralized them. 

• Vit C as Photoprotector

Vit. C is equally effective against both UVB (290-320 nm) and UVA (320-400 nm). How about if we only use sunscreen ? Sunscreen is also photoprotector, right ? Sunscreens when properly applied prevent UV-induced erythema and cell mutations that contribute to skin cancer. However, sunscreens block only 55% of the free radicals produced by UV exposure. To optimize UV protection, it is important to use sunscreens combined with a topical antioxidant.

Although Vit. C alone can provide photoprotection, it works best in conjunction with Vitamin E (Vit. E), which potentiates the action of Vit. C four-fold.

• Vitamin C and Synthesis Collagen

Vit. C is essential for collagen biosynthesis. Clinical studies have shown that the topical use of Vit. C increases collagen production in young as well as aged human skin. Because of that, Vitamin C is known as anti-aging agent

• Vitamin C as a Depigmenting Agent

The action of vitamin C as a depigemented agent is interrupting the key steps of melanogenesis. However, Vit. C is an unstable compound. It is therefore often combined with other depigmenting agents such as soy and liquorice for better depigmenting effect.

• Anti-Inflammatory Action of Vitamin C

Vit. C has a potential anti-inflammatory activity and can be used in conditions like acne vulgaris and rosacea. It can promote wound healing and prevent post-inflammatory hyperpigmentation

Which form of Vitamin C skincare product that best to use ?

Vit. C is available in the market as a variety of creams, serum and transdermal patches. Of these, only the serum contains active Vit. C in an almost colorless form.The other form of vitamin C that you can find in skincare product is Magnesium ascorbyl phosphate (MAP). It is lipid-soluble form. It is stable and has hydrating effect. 

What is the adverse effect of vitamin C?

Topical Vit. C is largely safe to use on a daily basis for long durations. It can safely be used in conjunction with other common topical anti-ageing agents such as sunscreens, tretinoin, other antioxidants and alfa hydroxy acids such as glycolic acid. Stinging, erythema and dryness are very rare. But if this is happened, you can use moisturizer as the treatment. Care must be taken while applying Vit. C around the eyes.

Reference :

Telang, P.S, 2013, Vitamin C in Dermatology, Indian Dermatol Online J. 4(2): 143–146

www.healthline.com/nutrition/vitamin-c-for-acne#vitamin-c-skincare