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DAFTAR PUSTAKA

1. Fitzpatrick TB, et al. Fitzpatricks Dermatology In General Medicine, 7th edition. NewYork : McGraw-Hill Companies; 2008. P:401-16.

2. Vachiramon V, Thadanipon K. Postinflammatory hypopigmentation. Clinical andExperimental Dermatology 2011.

3. Larregue M, Martin J, Bressieux JM et al. Vitiligoid achromias and severe atopicdermatitis. Apropos of 4 cases. Ann Dermatol Venereol 1985; 112: 589 600.

4. Ruiz-Maldonado R, Orozco-Covarrubias ML. Postinflammatory hypopigmentation andhyperpigmentation. Semin Cutan Med Surg 1997; 16: 36 43.

5. Savant SS. Facial dermabrasion in acne scars and genodermatoses a study of 65 patients. Indian J Dermatol Venereol Leprol 2000; 66: 79 84.

6. Grimes PE, Bhawan J, Kim J et al. Laser resurfacinginduced hypopigmentation:histologic alterations and repigmentation with topical photochemotherapy. Dermatol

Surg 2001; 27: 515 20.7. Verma S, Patterson JW, Derdeyn AS et al. Hypopigmented macules in an Indian man.Arch Dermatol 2006; 142:1643 8.

8. Rowley MJ, Nesbitt LT Jr, Carrington PR, Espinoza CG. Hypopigmented macules inacantholytic disorders. Int J Dermatol 1995; 34: 390 2.

9. Xiang W, Xu A, Xu J et al. In vivo confocal laser scanning microscopy ofhypopigmented macules: a preliminary comparison of confocal images in vitiligo, nevusdepigmentosus and postinflammatory hypopigmentation. Lasers Med Sci 2010; 25: 551 8.

10. High WA, Pandya AG. Pilot trial of 1% pimecrolimus cream in the treatment ofseborrheic dermatitis in African American adults with associated hypopigmentation. J

Am Acad Dermatol 2006; 54: 1083 8.11. Tierney EP, Hanke CW. Treatment of CO2 laser induced hypopigmentation with

ablative fractionated laser resurfacing: case report and review of the literature. J DrugsDermatol 2010; 9: 1420 6.

Hypopigmented macules in an Indian man.Verma S , Patterson JW , Derdeyn AS , Pasale R , Patel D , Ganju A .

Author information

University of Virginia, Charlottesville, USA.

PMID:17178995[PubMed - indexed for MEDLINE]

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3Ann Dermatol Venereol. 1985;112(8):589-600.

[Vitiligoid achromias and severe atopicdermatitis. Apropos of 4 cases].[Article in French]Larrgue M , Martin J , Bressieux JM , Canuel C , De Giacomoni P , Ramdene P , Babin P .

Abstract

Four patients with important and disabling atopic dermatitis persisting during adulthood have presented leucodermia in certain areas of eczema. As melanosomes and melanocytes have

totally disappeared in these regions, this depigmentation corresponds thus to an achromia.Clinically, we noted macular achromia with hyperpigmented border of special topographysince touching pleat regions initially present eczema lesions: anterior face of wrists andfootnecks. Slight lichenification is noted in achromic regions. In spite of many analogies withvitiligo, we differentiate this achromia from vitiligo on the basis of absence of familial post-history and absence of new localisations after 5 to 6 years cause. A review ofdepigmentations described during atopic dermatitis does not show similar facts.Depigmentation induced by local steroid therapy does not give such clinical andultrastructural aspects. In 3 patients, there was no local application of depigmenting agent. Inone case, 8-oxyquinoleine was applied transiently. Vitiliginous achromias of pleat regionsinitially presenting important atopic dermatitis are probably due to multifactorial factors:

possible factors are inflammation and secondary epidermal modification due to local steroidtherapy and may be some excipients. Being a rare situation in atopy, we have registered itonly 14 times in 860 followed atopic dermatitis. The study of series of atopic dermatitisfollowed on a long-term basis should allow to evaluate the frequency of such incidents andthe respective role of aetiological factors with we suspect.

PMID:4096464[PubMed - indexed for MEDLINE]

5Facial dermabrasion in acne scars andgenodermatoses-A study of 65 patients

SS Savant

Abstract

bermabrasion is sequential planing of the raised skin/lesions to the desired depth. Facialdermabrasion was carried out in 65 patients (acne scars -48, adenoma sebaceum 12, multiple

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trichoepitheliomas 4, barier's diease-1). Preancillary acne scar revision in 34/48 patients andexcision of larger papules and electrodesiccation was performed in 10/12 adenoma sebaceum.In acne scars, 35/48 showed good to excellent and 13/48 poor results. In adenoma sebaceum,9/12 had excellent and 3 satisfactory results. Preancillary procedures enhanced results in bothconditions. Excellent results were obtained in 3/4 multiple trichoepitheliomas and in barier's

disease. Repeat dermabrasion was helpful in 7/65 patients. Side effects seen were persistenthypopigmentation 41, persistent erythema 30, milia 20, hyperpigmentation 15 andexacerbation of acne 3. Complications encountered were small deep scars 8, recurrence ofadenoma sebaceum 3, gouging 2, secondary infection 2, oval large atrophic hypo-depigmented scar I and hypertrophic linear scar 1. Facial dermabrasion is a usefuldermatosurgical modality to treat various skin disorders.

Keywords: Dermabrasion, Acne scars, Trichoepitheliomas, Adenoma sebaceum, Dariersdisease

How to cite this article: Savant S S. Facial dermabrasion in acne scars and genodermatoses-A study of 65 patients.Indian J Dermatol Venereol Leprol 2000;66:79-84

How to cite this URL: Savant S S. Facial dermabrasion in acne scars and genodermatoses-A study of 65 patients.Indian J Dermatol Venereol Leprol [serial online] 2000 [cited 2014 Jan 28];66:79-84.Available from: http://www.ijdvl.com/text.asp?2000/66/2/79/4875

Introduction

Dermabrasion (DA) consists of sequential planing of the raised skin/lesions with electricaland/ or manual abraders and allowing the wound to heal by secondary intention, so as toachieve a levelling effect to make the lesions less conspicuous. [1] ,[2] Facial DA carried out onentire face is primarily utilised for its cosmetic as well as therapeutic value in treatingexophytic genodermatoses or various facial skin tumours such as adenoma sebaceum,multiple trichoepitheliomas, Darier's disease, multiple neurofibromatosis, syringomas etc. [1] ,[2],[3] ,[4] ,[5] In this study, facial DA performed in 65 patients for various conditions such asacne scars, adenoma sebaceum, multiple trichoepitheliomas and Darier's disease is reportedherewith.

Materials and Methods

Sixty-five patients (45 females and 20 males, age range 16-54) participated in this study.Facial DA was carried out in -acne scars 48, adenoma sebaceum 12, multipletrichoepitheliomas 4, and Darier's disease 1. The acne scars varied in shape from circular,oval, linear to irregular and had depressed bases. They were either shallow or deep, varied in

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size from 2 to 50mm and ranged in number from 30 to 70. Nineteen patients gave a history ofsporadic activity. These were first treated with broad spectrum antibiotic and local exfoliatingagents and then subjected to DA. Prior acne scar revision (ASR) was carried out in 34/48

patients in one or more sittings, 6-8 weeks prior to DA. These were subcision followed bycryoslush punch excision and suturing, punch incision and elevation, punch excision and

graft replacement and elliptical excision and suturing. The other 14 patients were taken updirectly for DA because they had scars covering more than 70% of the face. Small to mediumsized papular lesions in 10/12 cases of adenoma sebaceum were electrodesiccated and largelesions were excised 6-8 weeks prior to DA. Four cases of multiple trichoepitheliomas, twocases of adenoma sebaceum and single case of Darier's disease were taken up directly forDA.

Haemogram, blood sugar, BT, CT, PT, routine urinalysis, X-ray chest, ECG and screeningfor syphilis (VDRL), HIV and hepatitis B were done for all patients. Biopsy was performedto confirm all genetic disorders. BCG scars or old scars were examined for keloidal tendencyand written consent was obtained along with fitness for general anaesthesia (GA).

Main instruments used were manual metallic dermabraders, motor driven wire brushes ordiamond fraises mounted on electric hand machine and number 80 and 110 sand (water)

papers. After surgical preparation and isolation, 60 patients were given GA of IV ketaminehydrochloride combined with local tumescent anaesthesia consisting of 1 litre of normalsaline, 50 ml of 1% xylocaine, 1 ml of 1: 1000 adrenaline and 12.5 ml of sodabicarbonate 1m eq. The other 5 patients were given GA of halothane after napentothal induction andintubation combined with local tumescent anaesthesia. In acne scar cases, first the markedscars were individually smoothened out by abrading their bases and edges.Submandibularmargin was established in all cases by dermabrading along the marked line from ear to thechin on both sides. The infraorbital margin was then established by dermabrading downwardson to the cheeks and sideways on to the temporal regions leaving 2-3 cm of the skin aroundthe eyes unabraded. Initially the face was abraded superficially to get rid of epidermis andreach the superficial papillary dermis. Further deep DA was carried out in the following orderof cosmetic units-right cheek, chin, left cheek, forehead, glabella, nose and upper lip till the

junction of deep papillary and upper reticular dermis. In patients of adenoma sebaceum,multiple trichoepitheliomas and Darier's disease, all the raised lesions were flattened with

proper contouring. DA was then continued with manual metallic dermabraders, till the junction of upper and mid reticular dermis. Important landmarks corresponding to the level ofdepth in the skin were standardised while dermabrading and were as follows:

1. Loss of skin pigment-epidermis

2. Multiple tiny punctate bleeding points-Superficial papillary dermis.

3. Change in bleeding pattern with appearance of larger rapidly bleeding points with low fielddensityJunction of mid to deep papillary dermis.

4. Whitish pink parallel ridges - Junction of upper and mid reticular dermis.

5. Break in these ridges with fraying - Junction of upper and mid reticular dermis. (Optimumdepth and termination point).

Finally two rubs were given with no. 80 followed by no. 110 water papers to smoothen out

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the surface. Haemostasis was achieved by pressure and the wounds were covered with doublelayer of framycetin tulle. All patients were given broad specrum antibiotic, anti-inflammatorydrugs and analgesics for the first few days. Tapering doses of steroids were used IV or orally(1-4mg of dexamethasone) for first 3-4 days. There was considerable oedema, pain andserous discharge in the first 48-72 hours. Gradually the discharge reduced and the tulle

adhered to the underlying wound surface. It came off completely by 10th - 15th day. Patientsremained hospitalised for first 10-15 days and were further sun protected by avoiding directsunlight or by using umbrella, sun screening agents with SPF of 15 and above and emollientsfor next 23 months. All 65 patients were followed up for 6 months, 52 for one year, and16 for3 years.

Results

In all patients abraded area healed with erythema, hypopigmentation and demarcation at thesubmandibular margin which reduced over next 312 months. Out of the 48 patients of acnescars the cosmetic result was excellent (>60% improvement) in 15, good (35-60%improvement) in 20, and poor (

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flattening effect, thus improving the overall appearance of the acne scars. [1] ,[2] DA carried tooptimum depth appears to be the key solution for the improvement of acne scars. It does notsignificantly improve scars with wide atrophic base, punched out deep scars and ice pickscars. [1] ,[2],[3] ,[4] ,[5] ,[6] ,[7] Aronsonn et all in their study of 25 cases observed that 50% improvedwith DA and concluded that those with small and superficial scars showed better results than

those with deep scars. In the present study also it was noted that the superficial scarsdisappeared completely whereas deep pitted ice pick or irregular scars did not improve unlessthey had been revised before DA. Various ASR procedures tailored to improve individualscars have been described in literature. [2],[3] ,[4] ,[5] ,[6] ,[7] They were carried out in 31/34 patientswith good to excellent results 6-8 weeks before DA.

In acne scars, 37.5% had 60% or more improvement; 41.7% had 35-60% and 20.8% had lessthan 35% improvement. The improvement obtained in this series is less than those attained

by Alt et al. [2] They have achieved overall improvement of 60% to 70% in more than 75% ofthe patients. The higher improvement obtained could be due to difference in the techniquesfollowed. In this study, patients were dermabraded using combination of general and localtumescent anaesthesia whereas Alt et al, [2] Roenigk [3] and Yarborough et al have all usedcryoanaesthesia (freon + ethyl chloride mixture - fluro ethyl). Alt et al have pointed out thatwhen the skin is frozen during cryoanaesthesia it is firm, nonpliable, nonmobile and hencecan be abraded easily. Cryoanaesthesia also causes haemostasis and the landmarks likecapillary loops, yellow sebaceous glands etc can be easily visualised, and thus DA can beeffectively carried out to the optimal desired depth. Despite all these advantages,cryoanaesthesia was not used in this study as it is not available in India. Alt et al have statedthat manual stretching of the skin during DA should be avoided as stretching will flatten outthe scars. Marking of the acne scars prior to anaesthesia helped in better visualisation andeasy abrasion. The advantage of tumification and manual stretching was that the skin surfaceremained firm and the dermabraders could be moved freely. Tumescence also safeguards theunderlying important tissues from injury [1] ,[2] and has haemostatic effect due to its physical

pressure and the adrenaline added to it. Maneksha has achieved excellent results in small poxand acne scars with manual metallic dermabraders and sandpapers. [10] In this study initial DAwas carried out electrically with hand motor till the junction of deep papillary and upperreticular dermis and further deep DA was done manually with metallic dermabraders andsandpapers. This way the procedure was faster and provided safety to deeper and surroundingstructures. Many workers advocate repeat DA rather than a single aggressive DA to achieve

better cosmetic result and avoid complications. [1] ,[2] The same was confirmed in 3 patientswith severe acne scarring in this study. It has been observed that DA is effective in improvingchronic active acne, [1] ,[2],[3] which was confirmed in this study as 12/19 sporadically active

patients of acne showed reduction in their activity. Exact mechanism of this therapeutic benefit of DA is not known but may be due to drainage and deroofing of comedones andcysts or its direct effect on the pilosebaceous apparatus. [1],[2]

Facial lesions of adenoma sebaceum pose a problem of cosmesis and consist of multipleangiofibromas of various sizes. Treatment has included excision, DA, cryosurgery, lasers etc. [1] ,[2],[3] ,[4] Alt et all have recommended DA alone. Verheyden [4] found excellent resultscombining shave excision with DA in 3 patients. Kaufman et al [11] who have treated 9

patients with copper vapour laser, found that 50% of them had recurrence needing furthertreatment. In this study combining electrodesiccation for small lesions and surgical excisionfor large lesions with DA after a gap of 6-8 weeks was found to give good cosmetic results in

9 patients. Remaining 3 patients had to be dermabraded again for recurrence, thus confirmingthat combining two methods can be advantageous in providing excellent cosmetic result and

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avoiding or reducing recurrence.

Multiple trichoepitheliomas are benign neoplasms of the hair follicles and present as flesh-coloured round papules and nodules with centrofacial distribution. [12] Multiple methods oftreatment including surgical excision, DA, cryosurgery and laser surgery have been reported

in literature to treat this cosmetic problem. [3] ,[4] ,[5] ,[6] ,[7] ,[8] ,[9] ,[10] ,[11] ,[12]

In this study DA wascarried out on 4 cases with excellent results. Roenigk [3] has reported impressive results in 3

patients by using wire brush. He has further reported regrowth of tumours on follow up in 1 patient but with less severity. In this study too, wire brush followed by manual DA was usedto plane away hundreds of lesions and the wounds healed with smooth flattened skin surfacewithout scarring thus providing a very high cosmetic relief with safety to the patients.

In Darier's disease medical modalities of treatment have only temporary success. [13] Hyperkeratotic localised lesions have been treated by surgical excision and grafting,cryosurgery, laser abrasion or DA. [14] Surgical modality of full face DA has been indicatedfor facial lesions, [1] ,[2] ,[3] and this was confirmed in this study.

Most common side effect seen was persistent hypopigmentation which although graduallyreduced in 3-9 months, persisted permanently in 41 patients. During DA, facial skin alongwith its melanocytes is lost suddently. This couples with sun restriction measures contributetowards early and prolonged hypopigmentation. [1] ,[2] ,[3] ,[4] ,[5] ,[6] ,[7] ,[8] ,[9],[10] ,[11] ,[12],[13] ,[14] ,[15] Erythema was another side effect which persisted and then improved completely over a

period of 3-6 months in 30 patients. Post operative erythema represents angiogenesis andoccurs during wond healing in all the patients. It persists for longer time where DA has beencarried to greater depth. [2] ,[3] ,[4] ,[5] ,[6] ,[7] ,[8] ,[9] ,[10] ,[11] ,[12],[13] ,[14] ,[15] as was seen in this study.Hyperpigmentation was observed in 15 patients which reverted completely to normal ontreatment with hydroquinone creams and sunscreens in 3-6 months. It is a known

phenomenon that skin trauma or many inflammatory skin diseases induce post-inflammatoryhyperpigmentation [16] in Fitzpatrick skin type IV,V and VI and hence it is recommended thatresurfacing should be done with caution. [1] ,[2] ,[3] ,[4],[5],[6] ,[7] ,[8] ,[9],[10] ,[11] ,[12] ,[13] ,[14] ,[15] Miliaformation (20) and flare up of acne (3) occurred 1-4 months after the surgery. These have

been described as postoperative sequelae due to the occlusion effect to the petrolatum basedointments and sunscreen agents used postoperatively. [1] ,[2] ,[3] ,[4] ,[5] ,[6] ,[7] ,[8] ,[9] ,[10] ,[11 ],[12] ,[13] ,[14],[15]

DA when carried into deep reticular dermis can lead to scarring. [1] ,[2] This was seen in 8 patients of acne scars and can be avoided by accurate planing. Recurrence of adenomasebaceum was noted in 3/12 patients. The lesions of any exophytic condition such as multiple

trichoepitheliomas, multiple neurofibromatosis, adenoma sebaceum etc. are situated deep indermis and hence liable for regrowth if partially removed. [3] ,[4] Also being genetic disordersnew lesions can always crop up at a later date. [11] However, pre-ancillary procedures can helpminimise recurrence as was seen in this study. In 2 patients of acne scars gouging occurred

because the lax skin got caught in the wire brush as it was not properly stretched, thus bringing out the importance of stretching during DA. [1] Secondary bacterial infection as aresult of improper compliance on part of patients was seen in 2 patients (3 sites) and led toscarring at 2 sites in one patient. Of these one remained permanent (oval atrophic) and theother (linear hypertrophic) showed considerable improvement on treatment with intralesionalsteroid injection and silastic gel sheet dressing.

Facial DA, in this study, was found to be very useful for acne scars and exophyticgenodermatoses such as adenoma sebaceum, multiple trechoepitheliomas and Darier's

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disease, thus bringing out the importance of it being an excellent modality for both cosmeticand therapeutic application. This study also brings out the usefulness of preancillarytreatment before final resurfacing in acne scars and adenoma sebaceum and the importance ofrepeat DA to further improve cosmesis, treat recurrences and avoid complications of singleaggressive DA. various technical adaptations adjustable to the Indian scenario were followed

in this study. [1]

Combination anaesthesia (IV ketamine and local tumescent) used to non-availability of surface cryoanaesthetic agents in India, was found to be safe, was easilyavailable, economical and achieved desired optimal anaesthetic effects. The local tumescentwas useful in making the skin taut and for achieving better haemostasis. This helped in propervisualization of various landmarks and DA could be carried out to the desired optimumdepth. Various landmarks were standardised in this study, corresponding to the related levelof depth in the skin. This is the most important finding of this study. Another usefuladaptation followed in this study was the combined technique of using electrical and manualDA. This cuts down the total time required for the procedure and makes it safe. All theseadaptations, help in minimising side effects, complications and achieve good therapeutic andcosmetic results.

Other modalities useful for facial skin resurfacing apart from DA are chemical peeling [17] andlasers. [18] ,[19] However DA is found to be superior to peeling in removing acne scars. [17] Alsoexophytic growths cannot be treated by peeling. [17] Lasers are easy to operate and achieve

precise desired depth through micrometer accuracy. [18] Carbon-dioxide laser causeshaemostasis and immediate skin tightening through collagen contraction. [18] However it cancause pigmentary problems in skin type V [18] ,[19] ,[20] Erbium Yag laser is suitable for darkerskin type but it cannot reach the optimum depth to correct acne scars. [19] Also the cost oflasers is as yet prohibitive and no long term studies have standardised the technique on Indianskin types. Dermabrasion thus still remains the only major effective, inexpensive cosmetic aswell as therapeutic skin resurfacing modality available in India for successfully treating a vastvariety of skin conditions. Although the procedure is complex, once mastered, the results aregratifying for both the patient and surgeon. However proper patient selection, technical

perfection and good postoperative management are the keys to its success.

References

1. Savant SS. Dermabrasion. In: Savant SS, Shah RA, Gore D eds. Textbook and Atlas ofDermatosurgery and Cosmetology. 1st edn. Mumbai: ASCAD, 1998; 162-168.

2. Alt TH, Goodman GJ, Coleman WP, et al. Dermabrasion. In: Coleman WP, Hanke CW,Alt TH, et al. eds. Cosmetic Surgery of the Skin. 2nd edn. St. Louis: Mosby Year BookInc., 1997; 112-151.

3. Roenigk HH Jr. Dermabrasion for miscellaneous cutaneous lesions exclusive of scarringof acne. 3 Derm Surg Oncol 1977; 3: 322-328.

4. Verheyden CN. Treatment of facial angiofibromas of tuberous sclerosis. Plast Reconst

Surg 1996; 98: 777-783. [PUBMED ] [FULLTEXT ] 5. Rossiter JL. Dermabrasion : clinical uses in otolaryngology. 3 Oto Rhino Laryngo 1994;

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23; 347-353.6. Savant SS, Mehta N. Acne and its scars. In: Savant SS, Shah RA, Gore D eds. Textbook

and Atlas of Dermatosurgery and Cosmetology. 1 edn. Mumbai: ASCAD, 1998; 338-341.

7. Savant SS. Pitted facial scar revision. In: Savant SS, Shah RA, Gore D eds. Textbook

and Atlas of Dermatosurgery and Cosmetology. 1st edn. Mumbai: ASCAD, 1998; 156-161.

8. Aronsson A, Erikssen T, Jacobsson S, et al. Effect of dermabrasion on acne scars- areview and study of 25 cases. Acta Derm Venereol 1997; 77: 39-42.

9. Yarborough IM Jr, Bessan WH. Dermabrasion. In: Bessan WH, Mc Collaugh EH eds.Aesthetic Surgery of the aging face. V edn. Toronto: CV Mosby, 1986; 142-81.

10. Maneksha RJ. Scars. In: Maneksha R) ed. Plastic Surgery in the Tropics. 1st edn.Mumbai: Bombay Popular Prakashan 1965; 20: 31.

11. Kaufman Al, Grekin RC, Giesse JK et al. Treatment of adenoma sebaceum with coppervapour laser. J Am Acad Dermatol 1995; 33: 1770-1774.

12. Fitzpatrick JE, Golitz LE. Unusual Tumours. In: Ronigk RK, Roenigk HH Jr. eds.Dermatologic Surgery Principles and Practice 2nd edn., New York Marcel Dekker Inc.,1996 : 585 - 601.

13. Pavithran K. Disorders of keratinization. In: Valia RG, Valia AR eds. IADVL Textbookand Atlas of Dermatology. 1st edn. Mumbai: Bhalani Publishing House 1994; Vol 2:697-739.

14. Miller PK, Azhary RA, Roenigk RK. Newer uses for the CO 2 laser. In: Roenigk HH Jr.eds. Surgical Dermatology. Advances in Current Practice. 1st edn. London : MartinDunitz Ltd. 293-305.

15. Goldman MP, Fitzpatrick RE, Smith SR. Resurfacing complications and theirmanagement. In: Coleman WP, Lawrence N eds. Skin Resurfacing. 1st edn. Baltimore :Williams and Wilkins Co. 1998; 295-301.

16. Epstein JH. Postinflammatory hyperpigmentation. Clinic Dermatol 1989; 7: 55-65.17. Brody HJ. Current advances and trends in chemical peeling. J Dermatol Surg Oncol

1995; 21: 385-387.18. Cox SE, Cockerell CJ. Skin response to laser resurfacing. In: Coleman WP, Lawrence N

eds. Skin resurfacing. 1st edn. Baltimore: Williams and Wilkins Co. 1998; 143-153.

19. Kaufman R. Hibst R. Pulsed Erbium YAG Laser ablation. In: Cutaneous Surgery. LaserSurg Med 1996; 19: 324-330.

20. Betnstein U, Kanvar AN, Grossman MC, et al. The short and long term side effects ofcarbon dioxide laser resurfacing. 3 Dermatol Surg Oncol 1997; 23: 519-525.