Ask the Dermatologist

Got a question for a Dermatologist? This issue your questions are answered by Consultant Dermatologist Dr Nazirin Ariffin

March 12, 02:42 PM

CLEAN SLATE
I’m a young professional with a full-sleeve tattoo. Since starting my new job, I’ve been desiring to laser off all the tattoos below my elbow. In your opinion, will it be possible to remove tattoos on my lower arm without distorting or damaging the tattoos on the upper half? Any advice would be appreciated!
Raff, Gombak
Tattoo
Removal of tattoos on the lower arm can be done without damaging the tattoos on the upper arm. However, if the pattern or the image of the tattoo on the lower arm is a continuation of the pattern on the upper arm, you may want to make a slight revision to the lower edges of the tattoos on the upper arm so that what is left of the tattoo on the upper arm will not look odd. 
The standard modality of tattoo removal uses Q-switched lasers. Different wavelengths of Q-switched lasers are used to target different colours of tattoo ink depending on the specific light absorption spectra of the tattoo pigments. When the tattoo ink particles absorb this laser light energy, they instantly shatter into tiny fragments. Once the laser has broken the ink into smaller pieces, your body's immune system works to remove the ink over the following weeks, flushing it away from the tattooed area, resulting in lightening of the appearance of the tattoo.
Typically, black and other darker-coloured inks can be removed completely or almost completely, while lighter colours such as yellow and fluorescent are still very difficult to remove. Pastel coloured inks contain high concentrations of highly reflective titanium dioxide, which are difficult to remove since they reflect a significant amount of light energy. 
Success, the number of sessions and spacing between treatments depend on a wide variety of factors including skin colour, ink colour, the depth and layering at which the ink was applied, the area of the body treated, and effectiveness of the immune system. Although it is possible to see immediate results, in most cases the fading occurs gradually over seven to eight weeks. Each additional laser treatment breaks down more and more ink.  Therefore, it is recommended to space treatments at six-weeks to three-month intervals. 
 
BUMPS IN THE ROAD
I often experience pimples along my groin. This has made moving around with tight underwear and jeans quite painful. I’m not sure why pimples keep popping up in this region, since I keep the area clean and dry at all times. Why do you think this is happening, and what can I do?
Taj, Kuching
From your description, you may have a condition called Hidradenitis Suppurativa.  It is an inflammatory skin disease that affects apocrine gland-bearing skin in the axillae, groin, anogenital area and under the breasts. It is characterised by recurrent acne, pus discharging boils and abscesses with difficult-to-heal open wounds, sinuses and scarring.
Hidradenitis often starts at puberty and is most active between the ages of 20 and 40 years. Risk factors include other family members with hidradenitis suppurativa, obesity and insulin resistance or metabolic syndrome, cigarette smoking, acne conglobata and pilonidal sinus.
Hidradenitis suppurativa is an autoinflammatory disorder. Although the exact cause is not yet understood, contributing factors include friction from clothing and body folds, abnormal immune response to commensal bacteria, follicular occlusion, secondary bacterial infection and certain medications.
Hidradenitis suppurativa is difficult to treat and requires long-term management. This may include topical or oral antibiotics, oral antiandrogens, immunomodulatory treatments, metformin in patients with insulin resistance, colchicine and surgical treatment. However, there are also general measures that can be taken which may help with the management of hidradenitis suppurativa like weight loss and low-sugar diets, low-dairy diet, smoking cessation, wearing loose fitting clothing, use of daily non-fragranced antiperspirants, washing with antiseptics, applying hydrogen peroxide solution or medical grade honey to reduce malodour, and applying simple dressings to draining sinuses.
 
NOT SWELL
I’m a 30-year old who’s undergone a series of filler injections. Whenever I get sick, the areas which have been injected will sometimes become swollen and sensitive to the touch. Once I start feeling better however, the tenderness and swelling dissipates. Is this normal and is there anything I should be worried about?
Loni, Kayu Ara
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The phenomenon you described may be caused by the enlargement or swelling of the lymph nodes which lies underneath specific areas of the skin. Your filler may have been injected around a collection of lymph nodes. Lymph nodes usually enlarge when there is infection nearby. For instance, if you are having a throat infection, your neck lymph nodes will get enlarged and sometimes feel tender as the lymph nodes need to produce extra white cells as part of your immune system to fight the infection. When you feel better, the swelling of the lymph nodes will subside.
Swelling and tenderness can also be early side effects after injections with fillers and can present as redness, oedema (swelling), and bruising as a normal physiological reaction to the injection of a foreign substance, and can often be mitigated by cooling the injected areas. Bruises can be reduced by using arnica, aloe vera, or vitamin K creams. Allergies may occur within hours in cases where the patient has been sensitized before. Lumps and bumps occur when an unsuitable filler is injected superficially or in the wrong location. These may occur immediately or develop from clumping of the substance due to muscle activity. 
Late complications defined as those appearing after about two to six weeks can produce swelling too. They comprise of late allergic reactions, chronic inflammation and infection, granulomas, filler migration, and hypertrophic scars. A detailed history may disclose a potential allergy. To avoid infection, the injection site has to be thoroughly disinfected. Infection should be immediately treated with antibiotics. Granuloma formation is unpredictable but depends on the material used. They are caused mainly due to bacterial biofilms, which may induce granulomas as well as cold abscesses. The treatment for granulomas will depend on the type of filler used, which may include injection of hyaluronidase, steroid with anaesthetic, oral antibiotics in addition to allopurinol or surgery.
 
WEIGHING OPTIONS
I’m a 40-year-old who’s ready for rejuvenative injectable treatments. While I’ve read up on the many available treatments, I want to find out the difference between muscle relaxants like Botox and autologous procedures like PRP. How do both these treatments work and in your opinion, which of the two offers the best and most enduring rejuvenative outcomes?
Sue, Penang
 
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Botulinum toxin (eg Botox) is a purified protein made from bacteria which acts as a muscle relaxant. Botulinum toxin has been used for many years to treat some neurological disorders that cause muscle spasm, over sweating and migraine. For wrinkle treatment, it is primarily used to treat dynamic wrinkles (wrinkles produced during facial muscle movement). These wrinkles occur naturally around the eyes, mouth, between the eyebrows and forehead.  When botulinum toxin is injected, it blocks certain nerve signals that make muscles contract. The muscles relax, and by doing this it reduces the appearance of unwanted dynamic wrinkles. This effect lasts about three to six months. After that, the muscles move again and wrinkles come back. The procedure only takes a few minutes, and you will be able to continue your daily activities right afterwards.
Botulinum toxin injection is an effective rejuvenative treatment, but unfortunately, not long lasting. After about three days post injection, you will notice some muscles starting to relax and after two weeks, you likely will see the maximum result with fewer facial wrinkles and lines. This effect wears off in about three to six months.    
Platelet rich plasma (PRP) is derived from autologous (your own) blood, centrifuged to remove red blood cells. PRP contains several different growth factors and cytokines. PRP has been used to treat tendinitis and muscle injuries, for bone healing, hair growth and skin rejuvenation and scars whereby the substance is injected into the area of treatment. 
The skin rejuvenating effect is slower compared to botulinum toxin (three months compared to two weeks for botulinum toxin injection). However, the level of evidence is limited to the quality and heterogeneity of the studies. PRP treatment regimens for skin rejuvenation remain non-standardised with variable dosing and number of treatment sessions needed.   
Inter-individual variability in the quality of the PRP, which can be effected by age and Treatments using controlled multiple tiny traumas on the skin with fractional Erb YAG laser, CO2 laser, dermaroller or micro-needling are likely to induce more of new collagen and elastin synthesis than the PRP alone. 
Before undergoing either procedure, you also need to discuss with your doctor possible side effects, and let your doctor know about your pre-existing medical conditions and medications taken.