1. ww
Volume 15, Number 4 October 2024
ISSN: 2956-7904
p. 332-434
DOI: 10.7241/ourd
Issue online since Tuesday October 01 2024
Dermatology Online
www.odermatol.cowm
Our
Issue 4.2024
- Comparative study assessing the effica-
cy of topical lignocaine prilocaine cream
vs. lignocaine infiltration for dermato-
surgical procedures;
- Fact-checking cosmetic trends: Syste-
matic review of the use of topical astra-
galus derivatives to treat dermatologic
conditions;
- Redefining skin health: The potential
of plant-based bakuchiol as a sustainable
substitute for retinoids;
- Quality of life in patients with chronic
dermatophytosis: A cross-sectional stu-
dy;
- Prevalence of skin diseases in Camero-
onian children and adolescents: Insights
into outpatient units at Laquintinie, Ca-
meroon;
- Dermoscopic features of vulvar lichen
sclerosus and their correlation with di-
sease duration;
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© Our Dermatol Online 4.2024
Contents
Original articles
Comparative study assessing the efcacy of topical lignocaine prilocaine cream vs. lignocaine
infltration for dermatosurgical procedures ........................................................................................................332
Kathirvel Ganesasooria, Pottipati Preetham, Selvasudha, Dhanalakhmi
Fact-checking cosmetic trends: Systematic review of the use of topical astragalus derivatives to treat
dermatologic conditions ....................................................................................................................................337
Shangi Fu, Swathi Holla, Harrison Zhu, Sophia Fu, Kate Liu, Annie Vu, Zachrieh Alhaj, Danny Huynh,
Ola Khaled Soliman, Ida Orengo
Redefning skin health: Te potential of plant-based bakuchiol as a sustainable substitute for retinoids .............345
Martyna Kuśmierska, Jakub Kuśmierski, Anna Martyka, Przemysław Ujma
Quality of life in patients with chronic dermatophytosis: A cross-sectional study ...............................................349
Namitha Prabhu, Kokkarne Anandarama Rajeshwari, Prabhakar M Sangolli
Prevalence of skin diseases in Cameroonian children and adolescents: Insights into outpatient units
at Laquintinie, Cameroon .................................................................................................................................353
Edgar Mandeng Ma Linwa, Charlotte Eposse Ekoube, Odette Berline Sigha, Sajida Misse Dicka,
Angelique Jacquie Djeumen Touka, Esther Eleonore Ngo Linwa, Michael Ngenge Budzi, Martin Geh Meh,
Hélene Kamo, Nelson Sontsa Venceslas Njedock, Anne Cécile Zoung Kanyi Bissek
Dermoscopic features of vulvar lichen sclerosus and their correlation with disease duration ...............................361
Noura Kalmi, Hanane Baybay, Souad Choukri, Zakia Douhi, Sara Elloudi, Meryem Soughi,
Fatima-Zahra Mernissi, Hajar Mahfoudi, Samira El Fakir
Brief repOrts
Environmental factors associated with the severity of atopic dermatitis in Cotonou and Parakou,
Benin, in 2020 ..................................................................................................................................................365
Felix Atadokpede, Bérénice Dégboé, Nadège Elégbédé Adégbitè, Fabrice Akpadjan,
Marcelline Hounnou d’Almeida², Jules Alao, Francis Lalya², Hugues Adégbidi
Evaluation of the knowledge of general practitioners in the region of Fez (Morocco) regarding the
management of sexually transmitted infections ..................................................................................................370
Kaoutar Mejjati, Meryem Soughi, Zakia Douhi, Sara Elloudi, Hanane Baybay, Fatima Zahra Mernissi,
Jaafar Marrakchi Benjaafar, Rhyan Alami Ouaddane, Mustapha Ahsaini, Soufiane Mellas,
Jalal Eddine El Ammari, Moahammed Fadl Tazi, Mohammed Jamal El Fassi, Moulay Hassan Farih
case repOrts
Histoplasmosis in an immunocompetent adult ..................................................................................................373
Adama Aguissa Dicko, Lamissa Cissé, Aboubacrine Traore, Koreissi Tall, Binta Guindo, Ousmane Faye
Trilateral Blaschkoid linear lichen planus associated with COVID-19 vaccination .............................................376
Theodora Douvali, Eleni Zachariadou, Leftheria Tampouratzi, Maria Gerochristou,
Maria Gerodimou, Christina Vourlakou, Vasiliki Chasapi
Acquired facial Blaschkoid melanocytic nevus in a young adult: An extreme rarity ............................................379
Shrikant Kumavat, Vijay Zawar
Progressive nodular histiocytosis: An exceptional case in dermatology ...............................................................382
Alberto Gómez Trigos, Luis Miguel Alfonso Fernandez Gutierrez, Edgardo Gomez Torres,
Cynthia Lizbeth Reyez Martinez, Yukari Alejandra Katsuda Montaño
Diagnostic challenges in identifying Kaposi’s sarcoma: A case report .................................................................385
Jakub Kruszewski, Konrad Sułkowski, Daniel Worobiej
Severe chemical burns secondary to unregulated online peeling treatment .........................................................388
Casper Bo Poulsen, Luit Penninga, Peter Bjerring, Carsten Sauer Mikkelsen
© Our Dermatol Online 4.2024
ii
Contents
Chronic vegetative eruption in a child ...............................................................................................................391
Imane Kacimi Alaoui, Hanane Baybay, Sara El-Ammari, Zakia Douhi, Meryem Soughi, Sara Elloudi,
Fatima-Zahra Mernissi
Cellular dermatofbroma: A case report and review of the literature ...................................................................395
Amal Abduladheem Jaafar
review articles
Mitochondrial dysfunction in metabolic syndrome and infammatory skin disease ............................................398
Victoria Palmer, Tyler Beck, Sarah Shareef, John Helmy, Manuel Valdebran
Systemic complications and skin cancers due to voluntary cosmetic depigmentation in sub-Saharan Africa .......409
Abla Sefako Akakpo, Julienne Noude Téclessou, Ablavi Ahoefa Oyenitiwa Adani-Ife, Panawe Kassang,
Abas Mouhari-Touré, Koussake Kombaté, Palokinam Pitché, Bayaki Saka
clinical image
Congenital pedunculated dermal nevus and nodular malignant melanoma .......................................................412
Eleni Klimi
case letters
Symmetrical drug-related intertriginous and fexural exanthema (SDRIFE) associated with
oral metronidazole .............................................................................................................................................413
Chaimaa Fikri, Layla Bendaoud, Maryem Aboudourib, Ouafa Hocar, Said Amal
Acral herpetic infection after COVID-19 vaccination ........................................................................................415
Sara Oulad Ali, Jihane Belcadi, Kawtar Znati, Karima Senouci, Marieme Meziane
Necrotizing fasciitis with histoplasma duboisii ...................................................................................................417
Ida Aurélie Lenga Loumingou, Irène Ondima², Rufin Claude Soussa, Ornella Djouboué,
Fabien Gael Mouamba, Jean Félix Peko
Rainbow pattern: A rare dermoscopic feature of palmoplantar lichen planus .....................................................419
Souad Choukri, Hanane Baybay, Sara Elloudi, Zakia Douhi, Meryem Soughi, Fatima Zahra Mernissi
Hyperkeratotic scabies in an immunocompetent infant: An unusual case ..........................................................421
Zineb Mouhsine, Fatima-Ezzahra El Fatoiki, Fouzia Hali, Soumiya Chiheb
A case of hypocomplementemic urticarial vasculitis in a patient with possible IgG4-related disease ...................423
Muneyuki Kumekawa, Toshiyuki Yamamoto
Association of Shulman fasciitis, generalized morphea, and thyroid cancer ........................................................425
Siham Boularbah, Sara Elloudi, Sabrina Oujdi, Zakia Douhi, Meryem Soughi, Hanane Baybay,
Fatima Zahra Mernissi
Pitted keratolysis ...............................................................................................................................................427
Shirley Sical, Patricia Chang
Pemphigus or pemphigoid dilemma: A case letter on this persisting confusion ..................................................429
Hariharasubramony Ambika
Papillon–Lefèvre syndrome................................................................................................................................431
Asmaa El Kissouni, Fatima Ezzahra El Fatoiki, Hayat Skali Dahbi, Fouzia Hali, Soumiya Chiheb
Pseudopelade of Brocq: Clinical presentation and trichoscopy ...........................................................................433
Soukaina Karimi, Layla Bendaoud, Maryem Aboudourib, Ouafa Hocar, Said Amal
����������������������
© Our Dermatol Online 4.2024
332
Comparative study assessing the efcacy of topical
lignocaine prilocaine cream vs. lignocaine infltration
for dermatosurgical procedures
Kathirvel Ganesasooria, Pottipati Preetham, M Selvasudha, K Dhanalakhmi
Karpaga Vinayaga Institute of Medical sciences and Research Center, GST road, Chinnakolambakkam, Chengalpattu (Dt), India
Corresponding author: Pottipati Preetham, MD, E-mail: drpreethamdvl@gmail.com
INTRODUCTION
Dermatosurgery is one of the swiftly expanding
subspecialty of dermatology of the past decade with
infinite and complex procedures being performed for
various conditions [1]. Local anesthetics are defined
as drugs applied topically or used as infiltration
locally to produce a focal reversible loss of sensation
such as pain and touch. A local anesthetic may be
administered via scores of techniques. Traditionally,
anesthetics were injected at the site, which by itself,
may cause severe pain in some patients and may
change the normal anatomy while performing some
aesthetic and dermatosurgcal procedures [2]. Local
anesthetic agents, which were the basis of use of the
modern local anesthetic agents in the field of dentistry
and medicine, have evolved [3]. The skin is one of
the major avenues by which humans perceive the
world and, in turn, are perceived by it. When these
perceptions go awry, great distress may result. When
the skin is markedly affected by a primary dermatologic
condition, psychological sequelae in the form of
comorbidity often follow, greatly impacting patient
quality of life [4]. Some of the topical anesthetic
creams such as lignocaine, prilocaine tetracaine, etc.,
are developed over a period to overcome the infiltration
pain, following the administration of intralesional
anesthetic agents. To escalate the potency of local
anesthetic agents, to augment the depth of anesthesia
and to extend the duration of topical anesthetic agents,
varied combinations have been tried recently. When
approaching these issues, it is important to explore
ABSTRACT
Background: Dermatosurgery is one of the fastest expanding subspecialty of dermatology. Local anesthetic agents
play an important role in these procedures. Materials and Methods: This was a prospective, interventional study that
included eighty patients with forty patients in each group (groups A and B). Group A: Topical 2.5% lignocaine and
2.5% prilocaine cream. Group B: Infiltration of 2% lignocaine Injection. Patients satisfying the inclusion criteria were
recruited for the study. The patients were asked to rate pain perception at the time of drug administration and, then,
during and after the surgical procedure using a visual, analogue scale separately. Results: In our study, the most common
age group at presentation was 21–40 years. Males constituted 57.8%, whereas females constituted 42.2%. The common
procedures performed in our study were electrocautery 33.3%, intralesional steroid 18.9%, and intralesional PRP 15.7%.
In the topical EMLA cream group, the VAS score during drug administration was 0. In the lignocaine infiltration
group, 70% were found to have VAS a score of 4–6, and 30% had a VAS score of 1–3, preprocedurally. The mean VAS
score during the procedure was 3.36 for the topical EMLA cream group and 1.33 for the lignocaine infiltration group.
The post-procedural VAS score showed similar results as the procedural VAS score. Conclusion: The results of our
study showed that topical EMLA cream is a better choice of anesthesia in superficial aesthetic and dermatosurgical
procedures in providing adequate analgesia.
Key words: Topical anesthesia, EMLA, Lignocaine, Dermatosurgery
Original Article
How to cite this article: Ganesasooria K, Preetham P, Selvasudha, Dhanalakhmi. Comparative study assessing the efÏcacy of topical lignocaine prilocaine cream
vs. lignocaine infiltration for dermatosurgical procedures. Our Dermatol Online. 2024;15(4):332-336.
Submission: 15.02.2024; Acceptance: 21.05.2024
DOI: 10.7241/ourd.20244.1
www.odermatol.com
© Our Dermatol Online 4.2024
333
psychiatric, and particularly psychotic, symptoms as
well as compliance with medications [5]. A handful
of studies were conducted to collate the efficacy of
different amalgams of topical anesthetics in different
dermatological and aesthetic procedures.
MATERIALS AND METHODS
The study was conducted at the department of
dermatology, venereology, and leprosy at a tertiary-care
center. This was a prospective, interventional study that
included two groups with a total of eighty patients with
forty patients each (groups A and B). The patients were
allocated to groups in an alternating fashion (patient 1
to group A, patient 2 to group B, and so on).
Group A: The local anesthetic used was a eutectic
combination of 2.5% lignocaine and 2.5% prilocaine
cream (EMLA) [6]. Under aseptic precautions, the
cream was applied as a thick film (1–2 mm thick) over
the area to perform the procedure and covered with
a thin occlusive and adhesive sheet, which was given
inside the anesthetic package. After forty minutes of
application, the EMLA cream was removed with the
help of a wet saline gauze.
Group B: Infiltration with 2% lignocaine injection was
used as local or regional infiltration anesthesia. The
test dose was given on the left forearm 5 cm below the
cubital fossa and waited for the allergic effect to take
place. The procedure was done after a period of five
minutes if no allergy was encountered to the infiltration
agent [7].
The patients were thoroughly screened. A detailed
history was taken, and clinical examination was done.
Those patients satisfying the inclusion criteria were
included in the study after obtaining informed and
written consent. All patients were asked to rate pain
perception at the time of drug administration and,
then, during the surgical procedure using a visual
analogue scale separately, along with the immediate
post-procedure pain score also recorded using VAS.
Ethics Statement
This study was done after obtaining approval from
Institutional Ethics Committee. The information of
the subjects is kept confidential and all the ethical
guidelines were followed during the process of this
study. No humans or animals are harmed during the
study.
RESULTS
A total of eighty patients attending the DVL op for
dermatosurgical procedures department were examined
and included in the study.
In our study, the most common age group at
presentation was 21–40 years (50%), followed by
< 20 years (25.6%) (Fig. 1). Males constituted 57.8%,
whereas females constituted 42.2%. All three groups
were found to be similar with respect to age and sex
(p = 0.143; p > 0.05).
In our study, we included various dermatosurgical
procedures where the local anesthetics were used.
Among them, a majority of the patients had alopecia
areata (27.5%), and the least had striae distensiae
(1.25%), for which they underwent carbon laser therapy
(Table 1).
We used local anesthetics in a variety of procedures,
among them the biggest number constituted
intralesional steroid injection (13.5%) (Table 2).
Table 1: Dermatoses for which local anesthesia was
administered.
Dermatoses
Topical
EMLA
cream
Lignocaine
infiltration
TOTAL
n=80
Acne scar
7.5
3.75
Alopecia (areata, androgenic)
12
30
10
2.5
22
27.5
Seborrheic keratosis & its variants
10
14
35
18
22.5
Colloid milium/milia
12.5
6.25
Chronic eczema (LSC)
7.5
10
Infections (MC, Verruca)
20
17.5
15
18.75
Naevus (compound/LEN)
2.5
3.75
Pyogenic granuloma
12.5
6.25
Striae distensae
2.5
1.25
Trachyonychia
2.5
3.75
TOTAL
40
100
40
100
80
100
X2 – 47.518 p value – 0.138
Figure 1: Age and sex distribution among the subjects.
www.odermatol.com
© Our Dermatol Online 4.2024
334
The mean procedure duration for the topical EMLA
cream group and lignocaine infiltration group was
7.60 ± 3.20 minutes and 8.77 ± 4.04 minutes, respectively.
The mean procedural time was found to be similar in both
groups, with a p value of more than 0.05 (Table 3).
In the topical EMLA cream group, the VAS score during
drug administration was 0. In the lignocaine infiltration
group, 70% were found to have a VAS score of 4–6,
and 30% had a VAS score of 1–3, pre-procedurally. The
mean VAS score during the procedure was 3.36 for the
topical EMLA cream group and 1.33 for the lignocaine
infiltration group.
The mean VAS score during drug administration was
zero in the topical EMLA and 3.83 in the lignocaine
infiltration group. During the procedure, the VAS
score for topical EMLA cream was 4.46 and 1.43 for
lignocaine infiltration. The post-procedure VAS score
was 2.8 for topical EMLA cream, 1.0 for lignocaine
infiltration (Table 4). The mean VAS score during
the procedure for the topical EMLA cream group was
higher when compared to the other group. The above
pattern was found to be statistically significant, with a
p value of 0.001 (< 0.05) (Table 5).
The post-procedural VAS score was comparable to
the procedural VAS score, with a VAS score higher
in the topical EMLA cream group when compared with
the other group (Table 6).
In our study, the mean VAS score according to site was
lower in the face (1.32) and neck (1.78) when compared
to other sites. In the topical EMLA cream group, the
VAS score was lower in the neck (2) and face (2.14).
In the lignocaine infiltration group, the VAS score was
lower in the face (1) and lower limb (0.67) (Table 7).
The mean duration of pain relief for the topical
EMLA cream group was 127.66 ± 8.14 minutes
(minimum: 20 minutes; maximum: 300 minutes),
and for the lignocaine infiltration group, it was
72.16 ± 6.15 minutes (minimum: 20 minutes;
maximum: 240 minutes). The mean duration for pain
relief was greater in the topical EMLA cream group than
the lignocaine infiltration group. The above difference
in the mean duration of pain relief was found to be
statistically significant, with a p value of 0.001 (< 0.05).
In our study, around 84.5% did not show any adverse
events. Among those who received topical EMLA
cream, 6.7% had mild edema and 6.7% had mild itching
at the site of application, which was short lived. In the
lignocaine infiltration group, 6.7% had edema and
Table 4: Distribution of the Visual Analog Scale (VAS) score
during drug administration among the groups.
VAS
score
Topical EMLA
cream
Lignocaine
infiltration
40
100
1‑3
12
30
4‑6
28
70
> 6
Table 2: Distribution of planned procedures among the groups.
Planned procedure
Topical EMLA
cream
Lignocaine
infiltration
TOTAL
n=80
Electrocautery
20.0
20
50
28
35
Extirpation
2.5
Intralesional bleomycin
Intralesional PRP
10
25
12
15
Microneedling & PRP
15
10
Intralesional steroid
20
7.5
11
13.5
Intralesional steroid with
cryotherapy
2.5
2.5
2.5
Nail avulsion
15
7.5
Radiofrequency ablation
Shave excision
2.5
3.75
TOTAL
40
100
40
100
80
100
X2 – 32.625 p value – 0.059
Table 3: Comparison of mean procedure duration between the
groups.
Group
Mean
(minutes)
Std.
Deviation
f Value
p Value
Topical EMLA cream
40
7.60
3.20
0.141
0.869
Lignocaine infiltration
40
8.77
4.04
Table 5: Comparison of the mean VAS score during the
procedure between the groups.
Groups
Mean Std. Deviation
f Value
p Value
Topical EMLA cream
40
4.46
2.31
43.74
0.001
Lignocaine infiltration
40
1.43
0.84
Table 6: Post‑procedural VAS score.
GROUP
Mean VAS Score
Topical EMLA cream
40
2.8
Lignocaine infiltration
40
1.0
Table 7: Comparison of VAS scores according to site between
the groups.
Site
Topical EMLA
Cream (mean
VAS score)
Lignocaine Infiltration
(mean VAS score)
Mean VAS
Score
Face
2.14
1.32
Neck
1.33
1.78
Trunk
3.33
1.67
2.05
Upper Limb
4.17
1.25
2.01
Lower Limb
0.67
2.22
Scalp
3.42
2.25
2.33
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335
3.3% had very mild itching. All groups were found to
be similar with respect to adverse events with a p value
of 0.314 (> 0.05).
The VAS scores during drug administration or the
pre-procedural, procedural, and post-procedural scores
were also recorded in the patients. As these values were
subjective, there was a chance of individual variations
(Fig. 2).
DISCUSSION
In our study, a majority of the patients were in the
age group of 20 to 40 years, accounting for 50% of
the total study subjects. The mean age group of our
study population was 30.9. This was similar to the age
distribution of 35.4 years seen in a study by Fredman
et al. [8]. This shows that the adolescent age group
was more cosmetically concerned when compared with
other age groups.
Our study showed a modest increase in the number
of male subjects (57%) when compared to females
(43%). This finding did not correlate with most of the
other studies in which the female sex was more often
involved.
In our study, waiting time for an infiltration anesthetic
was five minutes when compared to forty minutes
for topical creams. An infiltration anesthetic acts
more quickly than topical creams, which take time
to penetrate the skin layers. Various studies have
a different cut-off for the waiting time. The study
conducted by Carter et al. [9] suggested a waiting time
of thirty minutes for superficial procedures.
The mean duration of procedure timing in our study for
the various groups was around 7.27 +/- 1.99 minutes.
This was similar to the study by Pratik et al. [2], in
which the duration of procedures was 5–7 minutes on
average.
In the topical EMLA cream group, the pre-procedural
VAS score for pain (during drug administration) was
zero. In the lignocaine infiltration group, the mean VAS
score for pain was 3.83, among which 70% were found
to have a VAS score of 4–6, and 30% had a VAS score
of 1–3 pre-procedurally.
The mean VAS score for pain during the procedure was
3.36 for the topical EMLA cream group and 1.33 for the
lignocaine infiltration group. The mean VAS score for
pain during the procedure for the topical EMLA cream
group was higher when compared to the other group. This
was similar to the study conducted by Alster et al. [10].
The significant higher VAS pain severity scores with
EMLA cream in our study might have been due to
the shorter application time. EMLA does not provide
adequate anesthesia at peripheral skin margins. The
depth of analgesia achieved after 60 minutes is 3 mm
and 5 mm after 120 minutes of application. The time
of application to achieve adequate anesthesia typically
exceeds 60 minutes, limiting the practical use of the
combination in a hectic clinical setting.
Regarding the need for additional requirement of
anesthetic modality, we found that 93.3% in the topical
EMLA group and 100% in the lignocaine infiltration
group tolerated the procedure well and did not
require any intervention. This was similar to the study
conducted by Suzzane et al. [11], in which 95% of the
patients tolerated the procedure without any additional
anesthetic requirements.
The mean duration of pain relief for the topical EMLA
cream group was 127.66 minutes (40–210 minutes)
and for the lignocaine infiltration group, it was
72.16 minutes (12–130 minutes). The mean duration
of pain relief was greater in the topical EMLA cream
group than the lignocaine infiltration group. This was
similar to study findings by Lischeng Kang et al. [12].
Regarding the need for additional requirement of
anesthetic modality, we found that 93.3% in the topical
EMLA group and 100% in the lignocaine infiltration
group tolerated the procedure well and did not
require any intervention. This was similar to the study
conducted by Suzzane et al. [11], in which 95% of the
patients tolerated the procedure without any additional
anesthetic requirements. This shows that most of the
Figure 2: Preprocedural, procedural, and post‑procedural VAS score.