Author Archives: Dr Naphisabet

About Dr Naphisabet

Hi, I’m Dr Naphisabet Wanniang (it's a mouthful :P ). I am from a beautiful small hill station in India called Shillong and I am a dermatologist. I completed my MD from Goa Medical College and I am now pursuing a PhD in Food Allergies in Luxembourg, Europe. I love to share educational content on everything related to dermatology hoping that it will help you make more educated choices when it comes to your skin, hair or nails. I will try to share more on Food allergies as well as I leant more about it during my PhD. Thank you for being here and how you enjoy my blog:)

Chemical peels: the modern day equivalent to Cleopatra’s beauty regimen

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The quest for youth and beauty dates back to centuries ago when Cleopatra allegedly bathed in donkey milk (contains high amount of lactic acid which is an alpha hydroxy acid -AHA) to maintain a youthful clear skin. Cleopatra was not alone in this, the Greeks and French were also using sour milk (lactic acid) and fermented grapes (tartaric acid) for their skin.

Elisabeth Taylor as the beautiful Cleopatra

These ladies were not wrong in doing so! These centuries old beauty regimes have paved the way for modern anti ageing, and anti pigmentation beauty treatments.

So what does the 21st century beauty treatment look like?

The same concept of using sour milk etc to chemically exfoliate the upper dead layers of your skin is now being performed by dermatologists all over the world as an office based treatment called “chemical peel”.

There are various beauty treatment options available now, from creams, to LASER’s, to botox, fillers and chemical peels being one of them.

What is chemical peel?

Chemical peels are well controlled cosmetic procedures where a chemical with keratolytic property (able to exfoliate the skin cells -keratinocytes) is applied to the face with the aim of accelerating the natural exfoliation process wherein the superficial dead damaged skin is removed thereby improving the texture of skin, the appearance of fine wrinkles and decreases pigmentation.

In layman terms, chemical peels are cosmetic procedures that uses chemicals to peel off the dead layer of the skin.

The depth of such an effect will depend on the type of chemical used and the concentration of the substance ( eg. Glycolic acid- GA 10-30% is a very superficial peel i.e works in the upper epidermis while GA > 30-70% is a superficial peel effecting the lower epidermis and >70% is a medium peel reaching the dermis).

How does chemical peel work?

The skin has 3 layers : epidermis (uppermost) , dermis (middle) & sunbcutaneous fat (lowermost). The epidermis itself is divided into 4 layers (basal layer, stratum spinosum, stratum granulosum and the statum corneum.

The cells in our skin undergoes a process of multiplication and differentiation (change in shape, structure and biochemical composition) in which cells in the lowermost epidermis change their shape and composition as they move up to the uppermost layer and are eventually shed off.

This is called “skin cell turnover” which normally takes 28-40 days. This turnover is faster in babies and children and slows down with age.

As the cell turnover slows down, the dead skin cells in the uppermost layer of the skin do not get renewed but accumulates and gives the skin a dull, dry and aged appearance.

Ingredients such as alpha hydroxy acids (glycolic acid, lactic acid, mandelic acid etc) disrupts enzymes in the skin that hold the cells together. They can therefore cause the superficial layer of the skin to exfoliate and induce new cell replacement.

At higher concentration, these acids can penetrate deeper into the dermis and stimulate the fibroblast (cells that make collagen) to produce more collagen, elastin and substance that add structure to the skin (GAG’s) thus improves skin thickness and hydration.

Tricholoroacetic acid (TCA) works by causing destruction of the cells by protein denaturation. This then stimulates new wound healing.

Overall benefits that can be achieved with chemical peels

Improves skin texture
Can even out skin tone
Spot peels can be used to treated selected hyper-pigmented areas
Salicyclic peels are used as an adjunctive treatment for acne
Improves the appearance of aged skin.

Melasma after medium depth peel (Jessner’s solution) Image : Rooks textbook of dermatology

Acne scars after medium depth chemical peel. Image : Rooks textbook of dermatology

Procedure of a chemical peel

Chemical peels are not meant to work just on their own. One has to be motivated to follow a strict skin care plan for the maximum benefits from such a procedure.

A dermatologist will take a detailed history and clinical examination to assess if a patient is a good candidate for chemical peels.

A patient will be counselled on the skin care measures that needs to followed prior and after the procedure as well as about the expectations from this cosmetic procedure.

A process called “priming” which is done to thin out the epidermis so as the acids used in the chemical peel can penetrate the layers of the skin evenly. This step involves daily application of creams containing either retinoids/ azaelic acid/ kojic acid etc for at least 2-4 weeks prior the chemical peel procedure.

Sunscreens is an absolute must before and after the procedure.

A dermatologist may do a test peel behind the ear or other areas just to check if a patient is allergic to any of the ingredient or to assess for potential side effects.

Chemical peels are done in an office based setting once in a 3-4 weeks for 6-7 sessions depending on a patient’s response. The chosen acid is applied to the entire face or target area using a brush after degreasing the face. The peels are left for a certain contact time which is increased every session ( for eg, for the first session the contact time maybe 2 min which is then increased by a minute or two every successive session).

Post peel care

This step is just as important as the actual peel procedure.

Cold compression using ice packs if there is any redness after the prcedure.

Strict sun protection using broad spectrum sunscreens.

Use mild cleansers or soap free cleansers for washing the face.

Use a moisturiser at least twice daily to help reduce the peeling of the skin.

Avoid facial waxing, threading, facials and skin bleaching procedures for at least 1 week after the procedure.

Avoid scratching, picking or peeling of the skin.

Complications

Chemical peels are not free form side effects, that’s why pre procedure counselling and right patient selection is very important.

The possible side effects are :

Persistent redness of skin
Post inflammatory hyper or hypo-pigmentation (i.e dark or light spots)
Scarring
Excessive peeling of skin
Scabbing
Allergic reactions.
Scabbing.

Chemical burns (left) and post inflammatory hyperpigmentation (right) as complications of chemical peel. Image : Rooks textbook of dermatology

Chemical peels are add on cosmetic procedures that can be used for various indications. The effects can be impressive when done by an experienced dermatologist and when a patient is compliant with the pre and post peel skin care.

Never try to attempt a self chemical peel at home with products that can be bought online because the side effects could be permanent if sub optimal products are used and with inexperienced hands.

Freckles or Sun spots?

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The beauty standards of this world fuelled by unrealistic expectations through social media has made the slightest blemishes on the skin an un-welcomed sight.

The world is more forgiving towards skin blemishes now, luxury brands are embracing models with vitiligo, freckles have made their way into instagram filters and I personally love seeing this change.

I’m hoping this post will help individuals understand why freckles occur and hopefully help one embrace them.

What are freckles?

Ephelides the medical term for freckles are small unform light brown pigmented areas (maucles) usually occurring on sun exposed skin such as the cheeks, bridge of nose or over the hands.

They are commonly seen in fair skinned individuals with red hair and blue eyes. Freckles can also occur in Asian and Indian skin type though with lesser prevalence.

In an Indian study of pigmentation disorders in Indian skin type, melasma was the commonest cause and freckles only contributed to ~7% of the study population.

Freckles usually start appearing in childhood & adolescence period.

What causes freckles?

Genetics plays a huge role, mutation of a gene encoding for melanocortin receptors have been found especially in red haired individuals. A positive family history of freckles is usually present.

UV radiation stimulates the melanocytes to produce more melanin (the pigment of our skin) and it also increases the transfer of the melanin to the keratinocytes (cells of the upper layers of our skin) and is responsible for the pigmenation.

Image source: http://droualb.faculty.mjc.edu/Lecture%20Notes/Unit%201/FG04_06.jpg

The number of melanocytes (specialised cells in the skin that makes the pigment melanin) are not increased but there is an increase activity of these melanocytes.

For an individual who is genetically predisposed, UVR (sun exposure) can cause the development of freckles

How to differentiate freckles from sun spots?

Freckles/ Ephelids

Freckles appear at early childhood (2-3 years) over the cheeks, nose or the hands.

They are light brown, 1-5 mm in size, round to oval, regular & well defined patches. Freckles are mostly uniform in size, colour and distribution.

They become darker on sun exposure and fade with strict sun protection. Hence they tend to be more prominent in summer and lighter in winter.

They may even fade with age.

Solar lentigens / Sun spots

Starts appearing in adulthood 20-30 years.

Light -dark brown patches on the sun exposed areas such as face, upper neck, hands. They are larger & more irregular than freckles.

Can occur both in light and dark coloured skin.

Caused by prolonged sun exposure over time.

They become darker with more sun exposure and do not fade in winter. They are persistent throughout life and no not fade with time. They may even increase in number with age.

When to worry about freckles?

A child with multiple freckles and a severe intolerance to sunlight

If the child develops severe sun burns even with minimal sun exposure, a detailed medical examination may be required to rule out genetic disorders such as xeroderma pigmentosa where the cells fail to repair the DNA damaged by UV radiation.

Are freckles harmful?

Freckles are completely harmless unless if its associated with the above mentioned condition.

How to fade freckles?

Freckles respond well to strict sun protection either in the form of sunscreens or physical protection.

I’ve mentioned in my previous blog posts on how to achieve a good level of sun protection.

Other form of treatments are topical creams such as hydroquinone or retinoids. However these tend to give an uneven result.

Chemical peels have shown good results, such as spot TCA or Phenol peels. In these procedures, a high strength alpha hydroxy acid (glycolic acid, mandelic acid etc) or caustic acid (TCA)are applied by a dermatologist using a toothpick or cotton buds to the freckles. These areas then forms a scab with falls off in 7-10 days and heals with a normal pigmented skin.

LASERS have been widely used successfully for fading the freckles as well.

All the above procedures do come with certain side effects such as irritation, redness, pigmentation (especially in dark skinned individuals). Therefore always find a dermatologist experienced in this field to perform such procedures.

Recurrence of the freckles or sun spots can occur hence strict sun protection must be maintained even when the freckles have faded.

My advised is, start loving your sunscreen, use it judiciously for best results.
Try the other treatment options if you are very concerned about the freckles but in my opinion, every blemish, or scar or mole adds character to your face, learn to embrace it.

Melasma: the number one facial pigmentation

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As I was growing up I’ve seen my mum and most of my aunts trying in vain every remedy available for the pigmentation on their face

What is melasma?

Melasma also called cloasma is a common acquired hyperpigmentation disorder affecting mostly women in their reproductive age groups (~15-45 years) . It is the most common pigmentation disorder & is seen more commonly especially in individuals with darker skin type (FST IV-VI) affecting 9 -50% of the such high risk population . (Find out your skin type here)

What causes melasma?

Cause of melasma is multifactorial and factors such as UV radiation, elevated estrogen (female hormones) level work together to result in melasma in genetically predisposed individuals

Genetics: Certain genes are responsible for up regulating enzymes in the melanogenesis pathway (process of melanin production) which results in more melanin production.
UV Rays: Increase production of reactive oxygen species, which can then increase tyrosinase activity.
Hormones: Estrogen can up regulate enzymes (tyrosinase) and genes in the melanogenesis pathway, resulting in increase pigment production in genetically predisposed individulas.

How does it present?

Melasma presents with tan brown reticulate (lacy) pigmentation described in three distinct pattern on the face.

Centro facial pattern: Most common pattern affecting the forehead, nose, upper lip, chin and cheeks
Malar pattern : As seen in the below images affects the malar area (cheeks) of face
Mandibular pattern: Affects the jawline and chin, mostly seen in late onset melasma

Melasma in women can present for the first time in pregnancy and its referred to as “Mask of Pregnancy“. Treatment of which is more difficult because of the increase estrogen level in the body and as most medications used for pigmentation may not be safe during pregnancy.

The good news is that in some women, this mask of pregnancy is transient and will fade with time and proper management.

Can melasma occur in males?

Yes, melasma can occur in males as well. The male to female is ratio 1:9 i.e for every 9 females with melasma, 1 male individual also suffers from melasma. It has also been reported to have a higher prevalence in Indian males compared to Caucasian males.

Does melasma occur elsewhere besides the face?

Yes, rarely it can involve the neck, chest, the upper arms or forearms and it’s called “Extra facial melasma”

How is it diagnosed?

Most of the time a dermatologist can diagnose melasma by just examining it.

A wood’s lamp examination may be used to assess the dept of the pigmentation i.e if it is epidermal (superficial) or dermal (deep) pigmentation. Epidermal pigmentation respond to treatment better.

Occasionally a skin biopsy (examining of a skin sample under a microscope) may be required for a definitive diagnosis as all facial pigmentation is not melasma.

Treatment options

The hunt for the cure for melasma is still ongoing.

Though numerous treatment options are available now, there is still no “one product” that does it all.

The mainstay of treatment is avoiding the factors responsible for it as much as possible. Since one cannot change one’s genetic makeup, taking measures to avoid the modifiable factors (such strict sun protection) will help prevent its occurrence and reduce the appearance of an already developing melasma.

Its always good to know your personal risk of developing melasma so as you can actively prevent it from occurring in the future.

If melasma is highly prevalent in your ethnic group (for eg: melasma is highly prevalent in my hometown i.e Shillong, Northeast India) start taking preventive measures at the earliest. Its best to consult a dermatologist as early as possible at the start of the pigmentation rather than after a trail and error of using multiple self prescribed creams and remedies.

Shillong, though blessed with its hills, rivers, waterfalls and clouds, being at a higher altitude (1525 m above sea level) means it gets more UV rays than lower altitude areas and the cloud cover aids in scattering these UV rays. Understanding these facts will help individuals be more aware of the need of sun protection even in cloudy, pleasant days without the sun shining bright.

The first step to the treatment or prevention of melasma is strict sun protection. No creams, chemical peels or LASERS will effectively work if one is not complaint with this step

Ideal choice and method of a sunscreen application:

SPF of at least 30 (measure of UVB protection)
PA factor +++ (measure of UVA protection)
Gel formulation or matte finish for those with oily skin
Apply to both face and neck at least 20 mins prior to sun exposure and reapply every 2 hours especially when outdoors
Sunscreen application should be on all days even when the sky is cloudy or rainy
Use a sunscreen even when indoors (as glass cannot filter UVA light)

Other measures of sun protection include using a wide brim hat during your outing tot he beach or during any outdoor activity.

Avoid the peak hours of the day such as between 12 noon -2 pm when the sun is directly above the earth.

Seek shade whenever possible

Treatment to reduce pigmentation

Now that we’ve had sun protection covered, you will need to seek expert opinion (dermatologist) for further management as there are many active ingredients available for treating pigmentation and not everything is suitable for everyone.

If you are on medications such as oral contraceptive pills containing estrogen or drugs for seizures such as phenytoin which could be the potential cause of the melasma, then its best to speak to your treating physician for a possible changeover of the medications.

What are the treatment options available?

To understand how the treatments work, we first need to have an overview of how melanin (pigment responsible for our skin, hair, eyes colour) is formed.

Melanogenesis i.e process of melanin formation in melanocytes (cells for melanin production). The 3 main types of melanin are eumelanin brown, eumelanin black & phaeomelanin (yellow red). Humans have all 3 types but the ratio of each type of melanin is different in different ethnic group. For eg more pheomelanin is present in red heads with pale fair skin, more of brown eumelanin is seen in blondes and more of eumelanin black is seen in brown-black skin type with black hair.

Topical medications for melasma

Various options are availabe in the form or creams, ointments or serums and the choice will differ from patient to patient.

Topicals required long term and consistent use for the best results.

Not every option will work for everyone

Some of the active ingredients that are use to reduce pigmentation are enumerated in the tables below:

There are numerous options for the treatment of melasma, and the choice will depend with every patient.
For best results, sun protection, strict compliance and abundance of patience is required as improvement can only be appreciated after months of consistent skin care routine.

Oral medications for melasma

Trenexamic acid – An anti fibrinolytic drug that prevents the breakdown of protein (fibrin) present in blood clots. Therefore it is traditionally used to treat bleeding disorders.

It has been shown to be effective for the treatment of melasma in low doses. It has been show to produce results in 3 months but relapse rates are high and melasma recurs within 3 months of discontinuation of the drug.

Side effects are nausea, vomiting & serious side effects such as heart attacks, blood clots in veins of legs, renal injury (kidney problems) could potentially occur in individuals at risk.

Chemical peels

Dermatological procedure where acids of higher strength is used such as glycolic acid, salicylic acid, trichloroacetic acid etc are applied to the face or pigmented area by a dermatologist for a short contact time.

The procedure is done every 3-4 weeks for 5-6 sessions depending on the patient’s response.

Second line treatment for those not responding to topicals alone.

Expensive and requires an experienced hand.

LASER for melasma

Various types of LASER are available for the treatment of melasma.

LASER treatment can be tricky especially in individual’s with darker skin type as the risk of pigmentation is higher. LASER are usually reserved for resistant cases not responding to the above mentioned treatment options.

LASER are not one time treatment. Creams and sunscreens will still be required to maintain the result and prevent recurrence.

LASER treatment are expensive but may be worth it when done by experienced hand.

There is still no cure for melasma.
Seek guidance from a dermatologist as the appearance of the pigmentation can be improved with either depigmenting creams & sunscreens or a combination of treatment especially when the treatment is started early.

Fungal Acne: A misnomer. Medically it’s called Pityrosporum folliculitis

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Acne is such a common condition that to an untrained eye, all red bumps (papules/pustules) must be acne.

There are other dermatological disorders that present like acne but are not acne.

Pityrosporum folliculitis or Malassezia folliculitis (Fungal acne in layman terms, but fungal acne is not a medical diagnosis since it’s not acne or form of acne) is one of the most common skin condition mistaken for acne. It is caused by increase colonisation (multiplication) of a yeast called Malassezia species which is normally present as part of the normal flora in our skin. (yes! our skin has a world of micro organisms living in it 😉 )

It is the inflammation caused by such an increase colonisation that causes the symptoms.

So what causes this increase colonisation by this yeast?

Malassezia thrives in the oily environment produced by the sebaceous glands. Adolescents (10-19 years) have an increase sebaceous glands activity due to the hormonal fluctuations. Therefore this condition is commonly seen in adolescents.
Excessive sweating is also a risk factor, and people living in hot humid areas are more predisposed.
Individuals on topical or oral antibiotic, as this can suppress the growth of the normal bacteria in the skin giving way for this yeast to multiply unchecked.
Use of steroids or other immunosuppressant agents.
Diabetic patients may also experience such eruptions.
Genetic predisposition also plays a role. As mentioned earlier everyone has this yeast in their skin, but only some people are able to mount an inflammatory response to it causing the symptoms while others do not.

How can you differentiate it from acne ?

Firstly by the looks of the lesion, fungal acne presents with monomorphic (uniform looking) papules (red raised bumps) or pustules (pus filled bumps). There will not be any comedones (such as white heads or black heads) unless a patient also has concurrent acne.

Secondly by examining the site of involvement, face (forhead), back, upper arms, chest and back are involved in fungal acne. One wouldn’t normally see acne vulgaris involving the upper arms, neck.

Thirdly, fungal acne tends to be itchy while acne is not. Do you ever remember your pimple itching unless you’ve picked on it and a scab has formed?

Fourthly, history of acne not responding to anti acne treatment despite strict compliance or acne which had responded to treatment and suddenly flares up even while on the same treatment.

Fifthy, individuals with fungal acne may also have dandruff or tinea versicolor.

Do you need to see a dermatologist for such a condition?

Its always better to get an expert opinion before you self treat any skin condition.

Though the above points can help distinguish between acne and fungal acne, it may not be as clear cut in most cases, especially when one also has co existing acne. A variant of acne called truncal acne vulgaris can also present with similar eruptions on the back and chest.

Another dermatological condition called acneiform eruption which presents as eruption of skin lesions similar to acne caused by certain medications, mechanical friction, certain compounds used in textile dyes, insecticides, pesticides, detergents or soaps (halogenated aromatic hydrocarbon) presents similar to acne, and is sometimes difficult to differentiate it from fungal acne.

This is where a dermatologist’s opinion is important, so that certain questions can be asked, and if necessary certain tests performed (such as Wood lamp examination or KOH mount which can help in the diagnosis of fungal acne) for the correct diagnosis and management of the condition.

How to treat it?

As it is seen that the organism causing fungal acne (i.e Malassezia sp) can multiply more in hot and humid areas and summers are the season for most flare ups due to the increase ambient temperature and sweating, measures to reduce these factors can help reduce the symptoms

Have frequent cold showers in the summers
Change clothing such as gym wear, uniforms as soon as possible
Opt for loose fitting clothing
Avoid tight fitting attire
Seek the comfort of an air conditioned room

Products to use :

Use an anti-fungal shampoo (such as 2% ketoconazole or selenium sulfide or zinc pyrithione), look out for these ingredients in your anti dandruff shampoos. (List of few of such shampoos on previous post)

Massage the shampoos to the affected areas and leave it for 5-10 mins and wash off. This can be done twice weekly for at least 2-4 weeks depending on your response.

If the above fails, your dermatologists may add topical anti-fungal creams which are to be applied once-twice daily over the lesions.

Topical creams that helps to unclog the blocked sebaceous glands such as salicycic acid is another adjunctive treatment option in addition to the above.

Systemic anti-fungals (oral tablets/capsules) may be required in some cases.

Remember that the condition may recur, especially in summers.
Applying the anti-fungal shampoos during the summer months once weekly even if you don’t have the flares may help reduce chances of recurrence

Understanding hair fall

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We have all, at one point in time, dealt with excessive hair fall that alarmed us enough to either self treat with DIY/home remedies or to seek a dermatologist’s opinion.

Let us understand the normal physiological process that our hair goes through which is called “Hair cycle”.

Hair cycle is divided into 3 main phases :

Anagen (90% of the hair are in this active growing phase ) which proceeds to:
Catagen (resting phase), which then progress to :
Telogen (regressing phase)–> the hair then eventually falls out (exogen) as the hair follicle enters a new anagen phase.

As you can see that as new hair grows, the existing hair in that particular hair follicle has to fall out. So hair fall should not necessarily alarming, and this normal hair shedding is seen to be 50-100/day and in some individuals it could be upto 150/day as well.

When to seek a dermatologist’s opinion?

When the hair fall exceeds what was mentioned above, or you start noticing recession of the hair line or thinning of hair in crown (in men), thinning of the hair and a more visible scalp along the part line (in females), or patches of hair loss.

Common causes of hair loss:

1. Telogen effluvium: Presents with a more diffuse hair loss of >150/day. Occurs 2-4 months after any systemic illness such as infections (malaria, typhoid etc), childbirth, surgeries, crash diet, thyroid disorders, psychological stress etc.

The condition is completely reversible and the hair loss starts improving in 4-6 months once the underlying factor is corrected.

2. Androgenetic alopecia ( also called male pattern baldness or female pattern baldness in men & women respectively due to the characteristic pattern of hair loss). It is genetic disorder, in which susceptible hair follicles either have a higher response to the hormone testosterone, or have a higher amount/activity of the enzyme ( 5 alpha reductase) which converts testosterone into a more active form.

This result is the normal terminal hair (thick , black scalp hair) is transformed into vellus hair (thin, fine, light coloured hair mostly found in other parts of our body).

The overall effect is gradual thinning of hair. The disorder can be inherited from either maternal or paternal side

3. Traction alopecia:

Caused by the excessive constant stretching of the hair shaft from hair styling such as tight braids/ ponytails

4. Alopecia areata: Considered an autoimmne disease normally seen in children and presenting with localised patches of hair loss, rarely it can affect adults and be of a more diffuse nature.

Usually self limiting i.e hair regrows back even without treatment.

There are more causes of hair loss, but the ones mentioned above are the commonest ones experienced by individuals.
Treatment for the different types of hair loss may vary with some requiring no specific treatment at all such a telogen effluvium whereas others have specific therapy such as alopecia areata and androgenetic alopecia.

Biotin: the lack of science behind its use as a hair supplement

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Continuing my hair care series, I thought this topic is definitely worth writing about. Biotin (vitamin B7) supplements has been widely popularised for the treatment of hair fall and thinning hair. It’s promised to help grow long, thick, luscious hair and for healthy nails as well.

But is there a rational scientific evidence behind this popular trend?

I’m here to discuss the science (or more like the lack of it) behind the use of biotin supplements for hair loss.

What is biotin?

Biotin is a water soluble vitamin, and functions as a co-factor for various enzymes responsible for energy production in our body. Being water soluble means it does not get stored in the body and is excreted in the urine via the kidneys. So chances of toxicity from over consumption of biotin is minimal and so far there has not been any adverse effects from biotin supplementation. This being said, biotin supplementations for general well being or for healthy nails and hair is still not justified!!

The recommended daily allowance of biotin is 30 µg per day.

And we meet this requirement adequately from our diet.

If less is good, is more better?
from my dermatology text book

My answer to this question when it comes to nutrients for our body, is NO!! More is definitely not better and more is actually un necessary.

So why is biotin heavily popularised?

Few reported cases of biotinase (an enzyme required for recycling biotin in our body) deficiency was reported in infants and children who inherited the disease due to genetic mutations. It was noted that few of these cases had alopecia (hair loss) with or without brittle nails. Biotin helped improve the hair and nail changes in these cases.

Thus stemmed the popular trend of biotin supplements for hair fall or nail disorders.There is no regulation on vitamin supplementation production, hence pharmaceutical companies take advantage of this and advertise and market biotin supplements as a saviour for hair loss.

Note: in these cases describes above, biotin was a treatment of choice because they lacked biotin in their body.

Biotin deficiency in general population is very rare as we get adequate amounts from our diet. Supplementation of high doses (500-1000 µg/ day when the required amount is only ~ 30 µg/ day) is highly unjustified.

The few rare instances when a person can develop biotin deficiency are:

So does biotin also improve hair loss in healthy individuals without its deficiency?

There has never been any scientific study on the effectiveness of biotin for the treatment of hair loss in healthy individuals.

A study on 541 women with hair loss, showed that only 38% of these individuals had biotin deficiency of which 11% had histories on being on long term medications that can cause biotin deficiency and 35% of these women also had co-existing skin condition called seborrheic dermatitis, which shows that in individuals with hair loss, majority had normal levels of biotin and supplementation was un-necessary.

Even lab studies found that the differentiation and proliferation (growth) of the follicular keratinocytes (cells in the hair follicle) was unaffected by the level of biotin.

Biotin supplementation is not the treatment for hair loss/ hair thinning nor does its intake help aid other scientifically proven treatments for hair loss

Can biotin supplements do any harm?

Like I’ve mentioned earlier, there are no known toxicities reported so far as a result of biotin supplementation.

However, excessive amount of biotin in the blood can interfere with many of the laboratory investigations such as thyroid function tests, other hormonal profiles as well as levels of troponin in the blood (which is an indicator of a heart attack).

Many lab tests rely on a biotin-streptavidin reaction as part of the test procedure. The low amount of biotin we obtain from our diet does not affect these tests however biotin level > 1 mg/ day (Biotin supplements available in the market contains around 10mg of biotin) can result in false positive or false negative test results.

FDA issued a warning to help educate about the possible interaction between high biotin levels in the blood and troponin level ( a biomarker which helps physicians diagnose a heart attack for patients presenting with chest pain). This could be dangerous as a heart attack requires immediate treatment and an early diagnosis could potentially be missed.

My take on this topic

Biotin supplements are not required for the treatment of hair loss.
If you are on long term supplements, remember to mention it to your treating physician especially if you are getting evaluated for hormonal issues, thyroid function or for a chest pain.
Follow the general hair grooming measures available on a post on my instagram feed.
Get the hair loss evaluated by a dermatologist to get to the cause of it as different types of hair loss requires different form of treatment.
Instead of wasting your money on buying these vitamin supplements, spend it on products that have actually proven to work such as minoxidil, or well formulated shampoos and conditioners instead.

Prickly heat : Another nuisance of the summers

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Summer is here is various parts of India!!! Its hot, its humid, we’re sweating and for the unlucky few, the skin is actually itching and pricking.

Stay ahead of the summer…

Miliaria also called “prickly heat”, “sweat rash”, “heat rash” “ñiang shit” (in my mother tongue) is a common dermatological condition occurring mostly in hot, humid summers. Infants ( <1 year) are more susceptible as their sweat glands have not well developed.

But this does not mean adults are spared, it can occur in adults as well, both males and females

So how and why does it occur?

Miliaria is caused due to blockage of the sweat glands ( eccrine glands) which may be due to excessive colonisation of a bacteria in our skin ( don’t worry its mostly the bacteria which normally resides in our skin. Yes! we have bacteria and yeast, a small little world living in out skin :p).

Sometimes these sweat glands can be occluded by debris (i.e dirt)

Sweating is therefore a risk factor, and activities or febrile illness (infection/medical conditions that causes fever) that could increase sweating are high risk factors for developing miliaria.

Source : https://www.ncbi.nlm.nih.gov/books/NBK537176/

Levels of occlusion of the sweat duct and its resulting clinical presentation

Sometimes the duct ruptures causing inflammation around the area, seen clinically as red bumps, itching, pricking sensation.

How does it present?

Occlusion of these sweat glands result in sweat not being able to leave the surface of the skin, & instead gets pushed back into the different layers of the skin forming small sweat filled lesions.

Depending on where the blockage occurs, the presentation can be different clinically.

Miliaria crystallina

Miliaria crystallina : Sweat filled blisters with “Dew drops” appearance
See the resemblance?

Blockage occurs at the superficial part of the skin (epidermis). Presents with these asymptomatic (no itching /pain/burning sensation) clear fluid filled lesions (vesicles) over normal looking skin.They are referred to as “dew drops” .
The fluid collected is actually sweat!!

2. Miliaria rubra

Most common form, presents with multiple red raised lesions (papules). (“Rubra”= Red in Latin). Individuals also experience an uncomfortable pricking/itching sensation in their skin. Pustules (pus filled lesion) may also be present and its referred to “miliaria pustulosa”.

3. Miliaria profunda

Least common form. Mostly seen in individuals who suffer from repeated episodes of miliaria rubra. Seen as large deeper lesions either skin colored or red. May be itchy.

Is this condition dangerous?

Apart from being a nuisance, miliaria normally resolves once the factors causing the sweating is removed.

In very rare occasions when the involvement is extensive or in infants with poorly developed sweat glands, it can be threatening.

Normally, sweating is a defence mechanism to increasing body temperatures, which cools the body down as the sweat evaporates from our skin. As the sweat glands are blocked this process is not able to take place and individuals may then be at risk of hyperthermia.

Signs to look out for:

Fever, muscle cramps, headache, fainting, increase heart rate, dizziness.

How to prevent and treat it?

As the condition is cause by heat and sweating, the main measures are to reduce exposure to such environmental conditions as much as possible.

General measures

Staying indoors in air conditioned , well aerated rooms/offices.
Avoid strenuous exercise which is a potential risk factor.
Wear loose fitting, cotton clothing
Avoid tight fitting clothing ( jeans, jeggings, treggings and all the likes) , un-necessary bandaging as friction can lead of excess distension of the sweat duct causing its rupture.
Avoid wrapping your baby in layers of clothing.
Take frequent showers with cool water and mild pH balanced soaps (such as dove, or other syndet soaps) to help remove debris from the skin. You do not need to use a soap for every bath you take in a day, using a soap once a day is adequate.
Cool compressed with a damp towel helps calms the skin
If you don’t have the luxury of travelling in air conditioned cars/buses, try carrying a face towel with you which you can damp with cold water for regular compressions on your face, chest, neck etc.
Change clothes such as gym wear, uniforms and hop into a cold shower immediately once the activity is over.
Avoid use of occlusive moisturisers/ointments.

Specific treatment options

Powders/Sprays formulated with menthol (for cooling and anti-itch action), anti-bacterial (boric acid), anti-septic (zinc oxide) are easily available in the market. Note that, without the general cooling measures mentioned above, this form of treatment would not be effective on its own.
Seek a dermatologist opinion if the rash gets too uncomfortable, as a course of mild steroid to help reduce the inflammation my be required. ( I stress on the term “mild steroid” as there are various classes of steroids with various potency and we do not want you to be given the wrong form of such creams/ointments as they do come with their own set of complications)
A course of antibiotic cream may be needed if pustules are present and extensive.

Heat rash usually subsides spontaneously even without treatment if the above general cooling measures are followed and treatment is usually un necessary.

Miliaria crystallina, usually subsides within 24 hours of removal of the predisposing factors. And the good news is that miliaria heal without scarring.

featured image: Photo by Hans Reniers on Unsplash

A dermatologist’s take on DIY skincare

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As a dermatologist, I’m a firm believer in evidence based medicine. We study dermatological issues and their treatment options throughout our training. We study molecules used in skin or hair care products religiously, reading the research available on them, which active ingredient works, how they work, the dosage, their benefits and side effects and how effective they can be for a particular condition.

Therefore, I personally do not advised nor can I validate the popular culture of “DIY” (do it yourself) or home remedies for skin or hair care.

Yes, dermatologist keep saying that the basics to skin care are ABC (Vitamin A, Vitamin B, Vitamin C), and many of the active ingredients used in skincare are plant derived, this can be confusing to many of us. One can find the “ABC’s” easily in one’s kitchen, pantry, or garden so why shed your money buying expensive products containing the same?

Let me break it down for you in simple terms:

The skin has three layer, the epidermis (uppermost), the dermis (middle) and the subcutaneous tissue (fat and lowermost). the diagram on the right is the epidermis, which is composed of several layers.

The upper layer of the skin (epidermis) is described as resembling a ***“brick and mortar”*** structure.

The main function of the skin is acting as a barrier, protecting our body from various environmental substances and it does a pretty good job at it too.

This means many of the DIY’s of tomato paste, lemon juice, etc may not even be able to reach the inside of your skin through that “brick wall” to perform the functions you are expecting them to do.

This is why we have well formulated creams, ointments, serums etc because they contain other agents that help deliver the desired active ingredient (be it vitamin A, B or C etc) to cells in the skin.

Secondly, vitamins are present in various forms, for example for vitamin A we have beta carotene, retinol, retinal, and the most active form retinoic acid. Retinoic acid is the one that binds to receptors present in the cells of our skin to bring about beneficial changes such as anti ageing, anti acne etc.

Simply applying a paste of vitamin A rich fruits such as papaya does not achieve the same result, because vitamin A in fruits & vegetables are in the form of beta carotene.

Thirdly, DIY,s could potentially be doing more harm than good. A common example is a condition called “PHYTOPHOTODERMATITIS” where patients develop an irritant dermatitis when the skin is exposed to certain plants/citrus fruits and sunlight.

Patients develop a red rash on areas of exposure, burning sensation and may develop fluid filled lesions as well. The rash would then heal with pigmentation.

Left image is also called “Margarita burn” -phytophotodermatitis due to the limes present in a margarita cocktail followed by sun exposure. Right image– pigmentation left behind when the irritation subsides.

Just because DIY/Home remedies are all natural does not necessarily mean they are completely harmless and safe

Lastly, even though some skin care products use active ingredients such as various forms of vitamin A, B or C, they have been extensively researched in the labs, animal and human studies. Scientists study the active form of these vitamins, the strength at which these ingredients that have been proven to be effective to produce a desired effect (eg: niacinamide- vit B3, strength of at least 4 % works to reduce pigmentation, repair skin barrier, vitamin C of 20% works as an anti-oxidant, anti ageing, salicylic acid of at least 2% helps unclog pores and so on and so forth).

Simply grinding vegetables, or whisking eggs making a paste for your skin, is not going to achieve the same result
How does one know the strength of the vitamin present in that paste?

Yes, Cleopatra may have bathed in milk to maintain a beautiful youthful skin. We now know that milk has lactic acid which helps in exfoliation of the skin, and we have products designed particularly for that now with or without lactic acid, so people wont have to be bathing in milk for a glowing youthful skin.

Photo by ian dooley on Unsplash

The only time dermatologist advised on using ingredients available at home is for coconut oil. We advised coconut oil application for patients with conditions causing dryness of their skin, who are not able to afford regular moisturisers.

Consuming fruits and vegetables provides you with more nutrients that can be beneficial for skin & hair rather than external application of various DIY concoctions of eggs/lemons/mango etc

Hair oils: Science behind its use in hair care

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Hair oil application has been the basic hair care remedy for beautiful, black, luscious hair especially in Indian females (and for some males who groom their beard religiously :P). We’ve been taught at a very early age about hair grooming, mothers would be seen applying and massaging layers of oil into their daughters scalp while enjoying the afternoon sun.

I remember during my time living in Kerala (southern tropical state in India, where the inhabitants use coconut il for everything, from cooking to hair grooming). Girls there has long thick hair touching their knees, but it was always covered in coconut oil so I could never appreciate the overall health status of their hair. I couldn’t tell if the shine was natural or because of the layer of oil, the split ends were beautifully hidden as well. But this was the norm there, they love having oil on their hair day and night and it seems to work for them.

Personally for me, as someone with fine hair, which can get oily pretty quick even just after a day post hair wash, hair oiling never played an important part in my hair grooming process.

Individuals with thin fine hair do experience oiliness of the hair quicker than those with thicker hair, as the sebum produced in our scalp can be transmitted to the hair shaft easily.

As a dermatologist, I often get question on which oil is best to use, how frequently is it to be used, is pre or post shower hair oiling better and so on and so forth.

Honestly, there is no right answer to these questions, as there are very few scientific studies done to compare between the various hair oils or their methods of application.

Lets see which hair oil actually have science backing up its claim

Coconut oil

Studies have found that coconut oil is able to penetrate the hair shaft and this can be enhanced by application of warm oil. The oil coats the hair, prevents absorption of moisture into the hair and thus prevent the recurrent swelling and shrinking up of hair cortex which is responsible for hair fragility and breakage.

Coconut oil has been found to be the only oil to prevent protein loss from the hair shaft, thus providing more stability to the hair.

Photo credit: Photo by Marvin Meyer on Unsplash

Sunflower oil

Though this oil also provides hydration to the hair similar to coconut oil by forming a film coat on the hair . It however cannot prevent protein loss from the hair shaft due to its bulky nature and presence of double bonds that prevent penetration into the hair fibre.

Articles that claims its beneficial effect on hair are based on the study of the effect of Vitamin E on hair growth. A study of 39 patients (note- small sample size) showed that oral vitamin E supplementation for a period of 8 months had positive outcome on patients suffering from hair loss. Sunflower oil is also rich in Vitamin E, but it doesn’t necessarily mean that topical application of a vitamin E rich oil will also achieve the same result as daily oral supplementation.

Moroccon argan oil

Another oil rich in vitamin E, the argan tree is endemic to Morocco, has emerged as the most expensive essential oil and as a popular hair cosmetic from shampoos, to conditioners to hair oils.

Is it worth the hype?

There are no scientific evidence for its use in hair care so far, the only reason for its popularity is that its rich in Vitamin E (a potent anti-oxidant) and the study mentioned above, of Vitamin E positive effect on hair growth.

Almond oil

Again rich in Vitamin E, though it has lots of health benefits when consumed. The effects of almond oil in hair, except for its emollient action i.e coats an oily film on the hair and prevents breakage, no other scientific data available for stimulating hair growth.

Olive oil

Compound found in olive oil such as oleuropein (promotes anagen hair growth -active growing phase of hair, in mouse skin. No human studies yet.

Oleocanthal an anti-inflammatory phenolic compound found in olive oil, when consumed orally is known to help reduce inflammation. Again no data on its effect when applied topically.

image credit:Photo by Roberta Sorge on Unsplash

Rosemary oil

Unlike other oils which lacks strong scientific evidence backing up their claims in promoting hair growth, rosemary oil actually helps improve microcirculation ( improves blood flow to skin). It has been compared to be equally effective to 2% minoxidil in the treatment of androgenetic alopecia (male pattern hair loss). Increase in hair count were seen only after 6 months of daily application.

Whether minoxidil can be completely replaced by rosemary oil, the answer is still “NO”. Because though it was seen to be as effective as 2% minoxidil, we normally prescribe a 5%-10% strength of minoxidil in dermatology.

Hibiscus oil

An animal study concluded that extracts from the leaves of hibiscus plant does promote terminal hair growth. No new hair follicles were formed.

Image credit:Photo by Georgia de Lotz on Unsplash

Onion Juice extract

Crude onion juice extract was used in a study of patients with alopecia areata (auto-immune condition causing patchy hair loss) which is different from diffuse hair loss from other causes. Daily topical application of onion juice to the area of hair loss showed significant improvement in the form of new terminal hair (dark, thick hair) at the end of 6 weeks.

How it works is thought to be by “antigenic competition” ( my fellow dermatologist will understand this term.:P

To summarise

Hair oils (all types; from coconut, almond, olive, vegetable oil etc) are beneficial in a way that they form an oily film on the hair shaft and prevents excess moisture absorption from the environment and prevents water loss from the hair cortex. This is important because the recurrent swelling (from absorbing water) & shrinking (from losing water) of the hair cortex is responsible for the fragility, split ends and eventually breaking off of the hair from its weakest point (which can be seen as hair fall).

Oiling hair can prevent split ends, strengthen the hair (coconut oil) and reduces the friction that arises when combing the hair. Thus, helps manage frizzy hair, gives the hair shine and tames the fly aways.

With regards to stimulating hair growth, only rosemary oil has scientific data backing up its claim.

Olive oil could have potential based on the studies available. Still no conclusive data yet as a topical application.

Heat i.e warm oil application helps the oil to penetrate into the hair fibre and leaving just a thin film on the hair shaft, giving a less oily appearance.

Regarding how to use hair oils, frequency, duration, sadly I do not have the right foolproof answer for this. My personal advice based on my understanding of the research on this topic is :

Coconut oil is definitely the hero here, its the best, safest & cheapest option, especially if you have dry, frizzy, splits ends, apply it on you hair from root to tip. It has the additional advantage of preventing protein loss from the hair. There is actually no need to apply to the scalp, as your skin produces sebum naturally. But go ahead if you have dry scalp or if you enjoy the head massages.

Since we all do not like walking around with oily hair, and since we have products like conditioners & hair serums to use post showers, to make our hair more soft, shiny and manageable, reserve hair oil application for pre-showers. Applying too much & leaving the hair oil for too long will only attract more dirt to your hair which will make it difficult washing the oil out from the hair. Extra manual effort of massaging the shampoo will only cause more friction which can lead to increase falling of hair in the shower.

You can use hair oils as frequent as you like, all the studies reporting positive effects is based on daily hair oil application. I know its impossible to keep up with this in real life, so be flexible, go with your flow. ( I know, not a very scientific advise, but there is no clear cut science behind it yet!! )

Do not depend on hair oils to fix all your hair issues. It should only be a complimentary step to your already existing hair care (shampooing, conditioning, serums, or hair treatment such as minoxidil).

And lastly, if you have straight, non frizzy hair and you’re not in the habit to apply hair oil, then thats also okay. You do not need to follow the crowd.

Dandruff : What you need to know.

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Dandruff is part of a common dermatological condition called “Seborrhoeic dermatitis” with dandruff being the most common & mildest form of the disease. It is said that 50% of the adult population worldwide are affected by it.

The title of an article published in the Indian journal of dermatology read: “Dandruff: The most commercially exploited skin diseases” which is aptly put. We’ve all seen the amount of commercially available anti-dandruff shampoos out there in the market. Their marketing strategies, using celebrities to endorse products with the labels such as “get rid of dandruff”, “100% dandruff free forever” etc. What they fail to mention is that, one will only be dandruff free, if one uses the product forever as well.

That being said there is still no clear explanation of why it occurs nor is there is cure for it yet. ( Yes, its frustrating that most dermatological conditions still don’t have any cure, but science is evolving, and so far dandruff is completely manageable)

So what causes dandruff?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4852869/

How does it present?

Seborrhoeic dermatitis can present in infancy, and is thought to be due to the maternal androgens (male hormones) that stimulate the sebaceous glands (oil producing glands) to produce more sebum. This commonly presents as “cradle cap” in infants. The condition is self limiting, which usually resolves with just regular bathing and with application of moisturisers. Medicated shampoos containing 2% ketoconazole may be required for persistent cases.

Yellowish greasy scales can be seen adherent to the scalp

Dandruff

In adults, it usually starts at puberty. In it mildest form i.e dandruff one may experience itchy oily scalp, with easily removable dry white flakes. These flakes are the upper layers of the skin (stratum corneum) that are being shed off and not dirt. It has been observed that patients with dandruff do experience an increase amount of hair loss as well.

Seborrheic dermatitis

Coming to the more serious form called seborrheic dermatitis, here,inflammation (red inflamed skin) is marked and the condition is not limited to the scalp. Areas with high amount of sebaceous glands may be involved as well such as behind the ears, around the nose and mouth, forehead, chest. Patient will present with recurrent flares of such red itchy skin with greasy yellow scales. These flares are usually precipitated by emotional stress.

Source: Bolognia: textbook of dermatology

Now lets see how it can be managed.

Firstly its important to remember that there is no one time cure for dandruff or seborrheic dermatitis.

Dandruff may occur in individuals who have never experienced it before, if the conditions mentioned as the causes find a favourable environment and it may also resolve once such conditions are removed.

Avoid hair oil application, this can favour the over growth of the yeast Malassezia (or if that’s something you’re used to doing and do not want to give that up, then strictly avoid applying to the scalp & apply the oil only to the hair)

Use shampoos specially labelled “anti-dandruff”, but remember not to blindly trust labels, and look for ingredients such as anti-fungals (active against the yeast) like 2% ketoconazole, selenium sulfide, ciclopirox olamine, and 1% zinc pyrithione (helps regulate sebum production). Salicylic acid helps remove the excess sebum and helps exfoliate the flakes better.

Use 2-3 times per week for at least a month.
Massage gently into the scalp, leave for ~ 2-3 mins and rinse it off. Continue using such shampoos once a week for maintenance even when the dandruff has cleared. This will help prevent recurrence.

Conditioners can be used as usual, which is to be applied only to the hair shaft avoiding the scalp.

Bioderma Nodé DS antidandruff shampoo contains Zinc pyrithione, & salicylic acid as active ingredients. It also contains sodium shale oil sulfonate (extract from fine grained sedimentary rocks), which is approved in Europe for its anti inflammatory properties. This shampoo helps remove the flakes from the scalp, helps those with the oily sclap and also acts on the yeast. Advantage: Effectively controls dandruff, does not dry the hair out and has a neutral smell. Disadvantage– Expensive ~ Rs 1400, some people may actually prefer some scent to their shampoo.

Neutrogena T/Sal shampoo : Also conatins salicyclic acid as active ingredient. Ideal for oily scalp. Price – ~1300

Over the counter affordable anti dandruff shampoos containing zinc pyrithione.

Loreal professional anti dandruff shampoo contains zinc pyrithione with salicyclic acid. MRP – Rs 590

Scalpe + shampoo contains both ketoconazole and zinc pyrithione. Also does not dry out the hair.

Dove anti-dandruff shampoo contains zinc pyrithione but also ingredients that helps with hydrating the hair.

When to see a dermatologist?

When the skin on your scalp, face etc is red, itchy with yellowish greasy scales which in this case the seborrheic dermatitis may require a course of topical steroids to bring the inflammation down.

When the redness extends beyond the hairline and the scales are firmly adherent to your scalp,this could be a form of psoriasis instead.

Picture source:https://www.webmd.com/skin-problems-and-treatments/psoriasis/ss/slideshow-scalp-psoriasis-tips

When you notice your child having patches of hair loss, with either pustules (boils) or scaling, in this case, examination by a dermatologist is necessary to rule out fungal infection.

Pic source:https://www.webmd.com/skin-problems-and-treatments/picture-of-ringworm-of-the-scalp-tinea-capitis

Here are some questions I’ve received on this topic.

1. Could you suggest shampoos for dandruff that does not cause hairfall?

The shampoos are not the cause of the hair loss but its rather the dandruff that causes it. And list of shampoos are given above.

2. Does dandruff cause hair fall? And how to promote thick hair growth?

Yes, individuals with dandruff do experience from more hair fall. Its been noticed that they have 100-200 hair fall per day compared to the normal 50-100 per day

Hair thickness is determined by your genetics, there is nothing that can change that. However for a person with male or female pattern hair loss, the terminal hair (the thick black hair on the scalp) is turned to vellus hair (thin, fine hair normally seen in other other parts) which gives the impression of thinning of hair. Its always best to get this examined by a dermatologists, since the treatment for this is completely different.

3. Does dandruff worsen in pregnancy?

Yes, it can. As you can see from the explanation on the causes of dandruff, increase activity of the sebaceous glands (which in turn produce more oil, and facilitates overgrowth of the yeast) is one of the main factors in causing dandruff. Sebaceous glands activity also increases during pregnancy especially during the 3rd trimester due to increase level of the hormones -progesterone and androgens. But fear not!! This is completely reversible post delivery. And the anti-dandruff shampoos are completely safe to be used during pregnancy.

4. Solution for oily scalp and dandruff that is not getting controlled?

Check out the shampoos I mentioned earlier containing salicyclic acid (available ay nykaa, amazon) . This should help control the excess sebum production in your scalp. Use a combination of shampoo, for example, one containing salicylic acid on one day and one containing anti-fungals on the other hair wash day. You could also increase the frequency of shampooing, like 3 times times a week with these medicated shampoos and 2 times a week for maintainence.

5. I also have a very oily scalp, and I get too many DIY suggestions from people and I don’t know which one to believe.

Management of oily scalp, check answer on question no 4. As for the DIY lemon juice, onion juice, daily hair washes etc, its all time consuming, messy, requires a lot of effort and all un-necessary for something that is not even scientifically proven. Just stick to the advises that is known to work, follow the instructions as mentioned above and you’ll be able to manage your condition in no time.

Featured picture source: Unsplash