How to have youthful skin in forties
Dr Gurinderjit Singh

Some features of our body are age-determined —— they are inevitable. Others are age-related and result from a combination of factors such as lack of exercise, poor diet, cigarette smoking, heavy alcohol consumption or exposure to sunlight. Age-related changes can, therefore, be slowed or prevented by a healthy lifestyle and this remains worth encouraging even in old age.

Common complaints related to aging skin are wrinkles, dryness of the skin, skin tags, warts, moles, cellulite accumulation, dark circles around the eyes and abnormal facial hairs in females.

MANAGEMENT OF AGING SKIN

A. SUN PROTECTION
Perhaps the single most cost effective therapy that can be offered to patients is sun protection in the form of sun avoidance, sun-protective clothing and sunscreens. Peak time for sun exposure is between 10 a.m. and 4 p.m. and sun avoidance should be encouraged during this time.

B. MEDICAL INTERVENTION  
Medical intervention in the form of cosmeceuticals (cosmetics with active ingredients) when applied locally and certain supplements when taken orally help in delaying or preventing extrinsic aging. The agents that can be used locally are tretinoin, retinols, tazarotene, vitamin-C serum and alpha hydroxy acids. Orally effective agents are vitamin-C, antioxidant supplements, alpha lipoic acid, estrogens (when taken under medical supervision by women), growth factors and cytokines.

C. COSMETIC DERMATOLOGIC REJUVENATION PROCEDURES

1 Chemical peels
Various medium-depth and deep chemical peels are used to improve the sun-damaged textural changes and also to help promote new collagen. These are simple cost- effective and office procedures, which are widely used as anti-aging rejuvenating procedures.

2. Resurfacing techniques
Microdermabrasion uses aluminium oxide crystals to abrade the old superficial layers of the skin, thus leading to fresh glowing skin, whereas diamond peeling uses the precious metal to remove the blemished skin to produce the same effect.

3. Laser systems
The carbon dioxide laser has been the gold standard for ablative re-surfacing. The results are dramatic when treating severely photo-damaged skin but the down-time required for recovery is long and there is always the risk of hyperpigmentation in Indian skin.

Newer techniques, including the erbium yag systems, fractional lasers and plasma skin regeneration devices are used to treat a variety of skin disorders while offering shorter recovery time and improved safety.

4. Radio frequency technology
The best candidates for radio-frequency skin tightening include patients of a younger age group with mild laxity. The deeper layers of skin are given controlled heat but at the same time fully protecting the superficial layers from burns. This leads to collagen shrinkage upon healing, thus leading to ironing out of wrinkles.

5. Bothlinum toxin (BTX)
It weakens the overactive muscle contraction causing flattening of the facial skin, thus leading to improved cosmetic appearance. The BTX injection is a very well tolerated, low invasive and non-surgical method to treat hyperkinetic wrinkles. The effect, though temporary, is extremely popular with the people mainly because of no side-effects.

6. Soft tissue augmentation (fillers)
When combined with the increasing popularity of injectable botox and other office-based procedures, the role of injectable fillers continues to expand in the management of aging skin. These are effective in erasing static wrinkles and lines.

In an attempt to delay facial skin damage, the responsible causes for aging — mainly elastic and collagen fibre degradation and mimetic muscles of facial expressions — have to be targeted. It is important to have an excellent concept of the three dimensional aspect of the face and the neck. Only then the various above-mentioned treatment modalities could be used as a monotherapy or combination treatment to achieve a desirable overall effect.

The patients must know that they will continue to age because of collagen breakdown as well as being subjected to the forces of gravity. It is also important to make sure that the patients take responsibility for skin care, including high-grade cosmecutical or pharmaceutical preparations known to stimulate collagen synthesis, as well as practising excellent sun protection to save the investment they have made in their skin.

The writer is Chief Dermatologist and Laser Surgeon, Mohan Dai Oswal Multispeciality & Cancer Hospital, Ludhiana.

Scientists identify new cases of rare genetic disorder

Liverpool: Scientists at the UK-based University of Liverpool, working with international partners, have shown a rare genetic disease that causes crippling osteoarthritis in the spine and major joints, is far more prevalent worldwide than previously thought.

Researchers have identified more than 100 new cases of the disease called alkaptonuria (AKU) in a small community in Vellore, India, bringing the total number of patients there to 130. Approximately 40 patients have been found in a village in Southern Jordan, but previously the disease had been unknown to healthcare workers in the region. There were only four known cases in the UK in 2003, but this has since risen to more than 80 patients across the country.

Research findings suggest that more work is needed to raise the profile of the disease in countries around the world so that it can be correctly identified by medics. It is thought to affect one in 250,000 people worldwide, but many remain undiagnosed or mis-diagnosed as osteoarthritis.

Scientists at Liverpool are bringing international researchers together as part of the AKU Society to establish a global network that will help further understanding of the condition within communities and healthcare practices. The AKU Society was established in Liverpool in 2003 and supports patients diagnosed with the disease.

Patients being treated for AKU do not have enough of the enzyme, homogentisic acid oxidase, which causes acid to build up in the body. Some of this acid is eliminated in the urine, but the remainder is deposited in body tissue where it is toxic. As a result, a black pigment, called ochronosis, forms and binds to bone, cartilage and skin. This can cause erosion of the cartilage and patients often have to undergo joint replacement surgery.

Dr Lakshminarayan Ranganath, researcher at the University’s Institute of Ageing and Chronic Disease and clinician at the Royal Liverpool University Hospital, said: “AKU was the first genetic disease to be identified by scientists. It was described in 1902 by an English physician, but more than 100 years later there is still no cure for the disease. A drug candidate has recently been identified and is awaiting clinical trials to see if it could be used to treat AKU patients. We want to identify as many people with the condition as possible to ensure these important trials go ahead.

“Recent findings in India and Jordan show us that this disease is more prevalent than current statistics suggest and we urgently need to get research out into healthcare practices around the world so that cases can be identified and diagnosed correctly. We want to expand our international links as well as promote PhD opportunities to young researchers looking to progress our knowledge of the disease.” — ANI

Anal fissures: Beware of constipation
Dr Pankaj Garg

Anal fissure is a tear in the anus causing a painful ulcer at the lower  margin of the anus. The major cause for a fissure is constipation which results from the passage of hard dry stool. This type of stool tears the lower anal lining during defecation. Occasionally, diarrhoea can also cause fissures due to the over-use and over-wiping of an inflamed anal canal. Water jet usage in the toilet seat can easily cause anal fissures.

In some patients, the anal fissure doesn’t heal and becomes a painful sore that is constantly re-injured or torn with each bowel movement. This is called a chronic fissure (old fissure). The chronic fissure usually has an external anal skin tag called a sentinel pile (It is not a pile or haemorrhoids but is erroneously called a sentinel pile).

Human body has a spontaneous reflex in which any kind of pain in the sensitive lower part of the anus causes reflex contraction (spasm) of the sphincter muscle (muscle around the rectum which helps control bowel movements).  So, the tear caused in the lower anal canal leads to  sphincter muscle spasm. The resultant sphincter muscle spasm makes the passage of even normal stools difficult and painful which further increases the spasm of sphincter muscle thereby starting a vicious cycle in which pain and sphincter muscle spasm increase each other constantly.

Symptoms
Severe pain is the main symptom of an acute (fresh) anal fissure. Fissure-produced pain at defecation may persist for several hours. A small amount of bright red blood, which may or may not be mixed with stool, is common. A fissure produces pain disproportionate to its size. An inadequately treated fissure may lead to a chronic fissure which leads to less pain but more burning and itching, and these symptoms persist intermittently for weeks and months. Diagnosis can be made by inspection and a gentle examination by your surgeon. No additional test is required for diagnosis.  Fissures are mostly on the posterior (back side of the anus), but nowadays anterior fissures (towards the front of the anus) are also commonly seen primarily due to the use of the water jet in the toilet seats.

Treatment

Medical management
Most of the acute fissures heal by medical management without the need for an operation. The longer the fissure persists, the less likely chances of its getting heeled by itself are.

The use of sitz bath (soaking the anal area in plain warm water for 5-10 minutes) helps relieve fissure symptoms, but may not actually aid in the healing process. Stopping the use of water jet in toilet seats is very important. Water shower (health faucet) should be used instead. A high-fibre well-balanced diet along with optimal laxatives and use of sphincter-relaxing creams, especially diltiazem or nitroglycerin, help cure acute fissures (fissures of recent origin) in most cases. The principal side-effect of these creams is headache in 10-20 % of the patients.

Chemical sphincterotomy with injections of botulinum toxin has also been used when creams are ineffective to relieve the sphincter tightness. The main side-effect is temporary incontinence of flatus and/or feces in 2-15 % of the patients

Surgical treatment
When an acute fissure doesn’t get alright with medication, surgery is required. Lateral partial internal sphincterotomy is recommended for uncomplicated acute fissures. This surgery consists of a small operation to cut a portion of the anal sphincter muscle (the muscle around the rectum which helps control bowel movement). This helps the fissure to heal by preventing pain and spasm, which interferes with healing. Cutting this muscle generally does not interfere with the ability to control bowel movement, but recent studies have indicated that this operation leads to the weakening of control over bowel motions in the old age (due to sphincter cutting). Anal dilatation is strongly discouraged as it leads to flatus and/or liquid incontinence in many patients.

Chronic fissures (older fissures) generally require surgical excision (Fissurectomy) in which case the chronic fissure along with the sentinel pile, papilla and the adjacent infected crypts are removed.  The advantages of this procedure are that the risk of incontinence (weakening of control over bowel movements) is negligible and the diseased tissue is also removed. Anal advancement flap (skin from outside the anus is used to cover the wound) is used to minimise the pain after operation and for rapid healing of the wound.

The writer is a senior colo-rectal surgeon at Fortis Hospital, Mohali. Email: drgargpankaj@yahoo.com