Botulinum Toxin for Axillary Hyperhidrosis
Botulinum Toxin is a safe and highly effective treatment of axillary hyperhidrosis (excessive armpit sweating). Treatment involves several injections of botulinum toxin into each armpit. It is generally well-tolerated and has very few side effects. Needles used to inject botulinum toxin are very fine which minimizes discomfort. It works very quickly within 2-4 days and beneficial effects can last for up to 6 months.
Isotretinoin (Roaccutane) for Acne, Folliculitis, Rosacea, Seborrheic Dermatitis
Isotretinoin is the most effective prescription treatment available for severe acne. It prevents scarring in patients with severe acne. Isotretinoin starts working within 7-10 days. 4 out of 5 people have clear skin after 4 months. This is this only medication known to address all major acne causing factors. It reduces skin oil production, improves cell turnover inside pores, decreases the activity of P. acnes bacteria on the skin, and reduces inflammation. Isotretinoin unblocks pores and prevents further blockages, minimizes pigmented blemishes and evens out skin complexion. This is the best long-term treatment for acne. Over 50% of treated patients have long-standing acne free skin after one treatment course. In others, acne may recur a few months to a few years after the treatment. Recurrences are generally less aggressive than before. In low doses, it is highly effective in the treatment of resistant rosacea, folliculitis and seborrheic dermatitis.
Hydroquinone is a highly-effective skin-bleaching agent used to lighten areas of darkened skin in melasma. It improves pigmentation by inhibiting the activity of the enzyme needed to make melanin. It is available in concentrations of 2% and 4%. It is generally well tolerated. It is used twice daily and visible improvement can be seen within 8-12 weeks.
Pigmanorm is widely used and highly-effective. It contains Hydroquinone, Tretinoin and Hydrocortisone. Hydroquinone stop melanocytes (pigmenting cells) in your skin from making melanin. Melanin is the substance that causes pigmentation (natural colouring) of your skin. Tretinoin increase the turnover of new skin cells and help the hydroquinone to penetrate the skin. Hydrocortisone prevents and reduces inflammation of the skin. It is used once a day for 7-8 weeks. Results vary but 60-80% of those treated show improvement and about 30% achieve complete clearance.
3. Tranexamic Acid
By a chance discovery in dermatology it was discovered that tranexamic acid (commonly used to treat heavy menstrual bleeding) also has a skin-lightening effect. The first report of a significant improvement in melasma dates back to 1979. A patient was given tranexamic acid orally and coincidentally it was found that during the treatment period of only 2-3 weeks, her melasma improved significantly. It is not licensed (off-label) for treatment of melasma but appears to be effective. Exactly how it improves melasma remains unknown but hypothesized mode of action include shrinkage of skin blood vessels (which reduces redness by its effect on the superficial blood vessels) and decreased melanin synthesis (which improves pigmented patches). Tranexamic Acid is a prescription tablet which can be taken in addition to other treatments for melasma.
Hair Loss Treatments
1. Finasteride for Androgenic Alopecia
Finasteride is highly effective treatment of mild to moderate male pattern hair loss (androgenic alopecia) licensed for use in men aged 18 to 41. Studies have shown that finasteride stops hair loss or regrows hair in 9 out of 10 men taking it long term every day. Finasteride at a higher dose also helps hair regrowth and slows hair loss in postmenopausal women with female pattern hair loss. Finasteride can make hair thicker, stronger and healthier. It is particularly effective on the thinning temples and receding hairline. Finasteride is best started early to encourage hair regrowth and won’t have much impact if you have already lost all or most of the hair. Long-term treatment is recommended as hair loss will return when medication is stopped.
Spironolactone reduces the production of male hormone levels which can slow down the progression of hair loss caused by female pattern hair loss (androgenic alopecia). It can also encourage hair to regrow but long-term treatment is generally required and beneficial effects are seen after 6-12 months. It is often combined with low dose oral minoxidil for best results. This combination has shown reduced shedding, increased hair growth, and thicker hair.
Hydroxychloroquine is an anti-malarial drug commonly used to treat scarring hair loss conditions like lichen planopilaris, frontal fibrosing alopecia and cutaneous lupus. The aim of treatment is to slow the progression of the disease and relieve symptoms. Baseline blood tests and an eye check by an optician is required before the medication can be initiated.
Intralesional Steroid Injections
1. Keloid and Hypertrophic Scars
Steroid injection into the keloid/hypertrophic scar aims to soften and flatten the scar thereby reducing symptoms of pain and itching. Sometimes it is combined with cryotherapy for better response rates. Initial success rates range from 80-90% but recurrences are also high. Repeated treatment every 4-6 weeks is required.
2. Alopecia Areata
Steroid Injection into the bald patches of Alopecia Areata is one of the most commonly used treatments. It is highly effective and hair growth is usually visible within 4 weeks. Repeated injections every 4-6 weeks are required.
Cryotherapy is a safe and highly effective procedure that is used to freeze and destroy benign skin lesions like viral warts, seborrheic keratosis, skin tags amongst others. It is also commonly used to treat pre-cancerous skin conditions like actinic keratosis. Treatment involves an ultra-cold jet of high pressure nitrous oxide directly on the skin lesion. Treatment duration depends upon the location and size/thickness/surface area of the lesion being treated. Repeat treatment every 2-4 weeks is usually required.
Treatment of Viral Warts
Treatment of viral warts depends upon the age of the patient, location and thickness of warts. Other factors to consider include general health and immunosuppression. In children, two thirds have warts clear spontaneously in 2 years. Warts tend to persist for several years in adults. I use combination treatments for plantar warts and thick warts on hands. This involves daily chemical treatment and fortnightly cryotherapy for 3-4 months. Combination treatments have better response rates. For plain warts on the face and hands, I use either a low-concentration chemical treatment or mild freeze with cryotherapy. Cryotherapy success is around 70% after 3–4 months of regular freezing. However, cryotherapy is not suitable for everyone, especially children, as it is painful. There are a number of chemical treatments which are commonly utilized to help remove warts/verrucas. Commonly used chemical treatments include salicylic acid, glutaraldehyde, formaldehyde, retinoids, efudix, imiquimod and many more. All of these (except salicylic acid) are off-label but appear to be safe treatments for viral warts. Warts can also be removed surgically by curettage and cautery under local anaesthesia especially if other treatments have failed. As with other treatments warts can still recur.