Simple, effective and inexpensive skin treatments
Dr Christopher Rowland-Payne discusses alternatives to expensive devices for the treatment of moles, brown spots, unwanted thread veins and scars
Good communication is the basis of mutual trust and confidence. Eye contact is critical. You get many clues from watching people’s eyes and their faces when talking to them. All this plays an important part in patient selection.
Demonstrate any asymmetries or abnormalities to the patient before starting treatment. As a rule, what is explained to patients beforehand is knowledge and what is explained afterwards is excuses. Informed consent is advisable.
Do we actually need the most expensive and up-to-date devices? There are some inexpensive and simple things we can do that work just as well.
The domed intradermal naevus—the ordinary mole—can be taken off by tangential excision. Driclor is a very efficient haemostatic. The tangentially excised base may then be touched with dermabrasion to soften the edges. This is a very simple treatment—very swift and with virtually no scars.
Dermabrasion can be used for other things too. If a rhinophymatous nose has some pits and bumps, spot dermabrasion can reduce the bumps. The patient will have eschars for perhaps six days. Then there will be a pink mark for a couple of weeks, which can be hidden with make up.
Keeping a wound greasy allows it to heal best. Cloramphenicol ointment, which is an antibiotic in Vaseline, is suitable.
Taking the top off a mole is rather like taking the top off an iceberg, a little bit may rise up from the base, “the iceberg effect”. If this happens, at three months we just take a little bit more off the tip of the iceberg. Avoid doing this before three months have elapsed as the healing process is still active until then.
Sometimes, when the top is taken off a pigmented mole, a little bit of pigment may appear in the base of the healed wound. It may look a little alarming and it is best to take that off. A good rule is to send that bit for histology and explain to the histologist what you have done, otherwise they will not be able to diagnose a pseudomelanoma, which is a benign phenomenon.
Brown spots or macular seborrhoeic warts are very simple to treat using a liquid nitrogen spray gun. With a spray gun, you can go very quickly and spray a very light spray. It is a cryo-peel. When the patient leaves the room they will be a little bit reddened.
Over the next couple of days the treated brown may temporarily darken slightly. These dark marks last 4-8 days on the face. On the hands they will be black for three weeks. As long as we warn the patients, they do not mind. The treatment is repeated twice more at six weekly intervals.
If you do this over three sessions, you can get a perfect result. If you try and do it in one go the patient may end up with a white scar or some of the original brown spot may persist. Thus it is advised to do this treatment over three sessions, each separated by four to six weeks. If you treat someone who has a slightly darker skin or who is very tanned then post-inflammatory pigmentation is a risk and it is well worth warning patients of this possibility.
Thread veins of face
Thread veins of the face, including rosaceous telangiectasia and spider naevi, are another very common problem. There are very expensive lasers available to treat these. However there are easier ways to treat them. A very simple, radiosurgical treatment administered over three sessions, separated each by four weeks, can achieve the same result as an expensive device. An excellent and inexpensive such device is the Conmed hyfrecator. The tip used is a fine epilation needle. It is a very simple and quick treatment. Sometimes, if there is a dermatographic urticarial tendency, there may be an immediate dermatographic response and we need to explain this to the patient. Once treated the patient washes briskly, applies make up and is then on their way. Although it is a little uncomfortable, it is swift and very effective and it can also be used for post-radiotherapy telangiectasia.
Sclerotherapy for leg veins
Thread veins of the legs are a very common problem and very easy to treat. Sclerotherapy is the easiest way to do this. First of all examine the patient standing, observe for slow filling veins, perforator veins and superficial veins, palpate for palpable veins—everything needs to be treated. If you don’t treat the bigger veins first, then all the little ones will reform very quickly.
The agent I use is polidocanol, which is very non-irritant, even if it is accidentally injected extravascularly. With sclerotherapy, a large area can be treated with a simple injection whereas a laser would have to shoot each of the little tiny veins.
To treat a starburst mark, don’t start with the starburst venules, you must try and inject the feeder vein. Clearance is achieved over three or four visits, each separated by eight weeks.
In the first 48 hours, we cover all the treated areas with cotton wool balls and tape them in place. Then for three days we use compression support stockings. Thereafter we advise them not to go in the sun for six weeks.You have to remember to ask the patient whether they are going to be in the sun, because that would raise the likelihood of post-inflammatory hyperpigmentation.
There is blushing in some patients afterwards, if you use quite a lot of the material. This can be rather alarming for the patient but it is only likely to last up to 20 minutes. Patients who are susceptible to migraine may develop one after treatment. Complications include post-inflammatory hyperpigmentation and very occasionally after unintended extravascular injection a tiny bit of ulceration, which may be followed by atrophie blanche.
Compression is useful and reduces the likelihood of bruising or the development of sclerotherapy-induced mat telangeictasia. Sometimes you get intravascular entrapment of blood and sometimes the inflammation can lead to post-inflammatory pigmentation. These are things we try to avoid. If there is intravascular entrapment, we simply puncture with a needle and express it.
Post-entrapment pigmentation is more of a nuisance because it may persist on lower limbs for many months so prevention by post-sclerotherapy compression bandaging is better.
We can treat hypertrophic scars, white scars or depressed scars. For hypertrophic scars, the standard treatment is intralesional triamcinolone. With white scars, manual needling is very good. For a small scar we would do this twice, each visit separated by eight weeks. If there are larger areas we might use a dermaroller or needle pen or something similar.
The problem with the dermaroller is that as the spikes pass through, they cause slits, so there is a bigger epidermal than dermal injury. The epidermal injury is uncomfortable and leaves marks for a couple of days. It is to be avoided if possible, so perpendicular needling is better. Needle pens deliver up to 1300 punctures per minute. There are up to 13 needles in the tip and it goes very fast. It produces an equal epidermal and dermal injury. With the pen you don’t need any anaesthetic on the lateral face. It can be more uncomfortable around the central face but it is tolerable with topical anaesthetic. Combined with platelet rich plasma (PRP) it works particularly well.
Depressed scars, such as chicken pox scars, are also a very simple thing to treat and are very common. You can do this by subcision, which is effectively horizontal or tangential needling using an 18-30 gauge needle. It is a two stage procedure and the stages are separated by six weeks. Immediately after treatment the scar will be lifted slightly. The only small inconvenience might be an intradermal bruise, which may last for about four days.
The next thing you can do is inject into a depressed scar serial microdroplet silicone. This is a controversial treatment but there is no other filler which can do what silicone does. You can precisely put the silicone exactly where you want it but you would need to have the technique taught to you personally. You cannot put hyaluronic acid into a tight fibrotic scar but silicone you can. It is particularly suitable for depressed scars.
A patient who had elsewhere had a percutaneous rhinoplasty was left with disfiguring scarring across the dorsum of his nose. Hyaluronic acid into the larger depressions and serial microdroplet silicone into other scars, together with spot dermabrasion to elevated papules and needling to white scars, produced useful improvement over four to six treatment sessions. This could be termed a complex medical repair rhinoplasty (Fig 3).
These are very simple, everyday treatments that can be applied in most people’s practice. They are easy to carry out and most are best done over three visits.
Dr Christopher Rowland Payne is a Consultant Dermatologist at the London Clinic.