Embedded Files
Below are case studies showcasing the treatment and management of various skin conditions I encountered during clinical practice.
Below are case studies showcasing the treatment and management of various skin conditions I encountered during clinical practice.
Scar Management after Burn Injury
Scar Management after Burn Injury
1-2hrs post injury
2 days post injury
Before pico laser treatment
Immediately after pico laser treatment
After last treatment
Treatment Plan
Treatment Plan
For this client, our primary goal is to support epidermal barrier repair, reduce inflammation, and minimise post-inflammatory hyperpigmentation (PIH) resulting from a superficial first-degree burn sustained from a heater. The client’s long-term goal is full resolution of erythema and pigmentation, restoration of skin function, and prevention of long-term textural or pigmentary changes.
An evidence-based treatment plan can be implemented using the following modalities:
Immediate post-burn care consisting of BurnAid gel and a cooling dressing applied
NIR LED Therapy (830nm)
Red LED Therapy (633nm)
Skin Needling (Dermal Needling with 1.0–1.5 mm depth)
Picosecond Laser (for residual pigmentation)
Supportive home care focusing on barrier repair and UV protection
NIR LED Therapy (830nm)
NIR LED Therapy (830nm)
Near-infrared light at 830nm enhances wound healing by stimulating ATP production, modulating inflammatory cytokines, and improving microcirculation (Barolet & Boucher, 2010). NIR LED is particularly effective in the acute phase of burn injury to reduce inflammation and promote tissue regeneration.
Treatment frequency: 2–3 times per week for 2–3 weeks, depending on inflammatory symptoms and tissue recovery.
Red LED Therapy (633nm)
Red LED Therapy (633nm)
Red light at 633nm supports re-epithelialisation, enhances keratinocyte activity, and reduces residual inflammation. It is especially useful in the subacute phase to transition from wound healing to skin normalisation and barrier restoration (Avci et al., 2013).
Treatment frequency: Combined with NIR LED therapy, 2–3 times per week for 2–3 weeks.
Picosecond Laser
Picosecond Laser
In the earlier stages of healing, picosecond laser was utilised for focal pigmentation. The ultra-short pulse duration targets melanin with high precision and minimal thermal damage, making it ideal for treating PIH in delicate areas (Brauer et al., 2015).
Wavelength: 532 nm or 755 nm depending on pigment depth
Sessions: 1–3, spaced 6–8 weeks apart
Objective: Break up dermal and epidermal pigment deposits while minimising inflammation and downtime
Skin Needling
Skin Needling
After initial wound healing and once the epidermis has fully re-epithelialised, skin needling was introduced to address residual post-inflammatory pigmentation. Skin needling creates controlled micro-injuries that stimulate fibroblast activity and increase epidermal turnover, promoting the dispersal of melanin and enhancing transdermal delivery of pigment-lightening serums (Fabbrocini et al., 2014). It also triggers the release of growth factors that aid in pigment regulation and collagen remodelling.
This treatment was suitable for this case due to the non-ablative, low-risk approach it offers for treating PIH, particularly in skin of colour or sensitive areas.
Needling depth: 1.0–1.5 mm in affected areas
Frequency: 2–3 sessions spaced 4–6 weeks apart, depending on pigment depth and skin response
Post-treatment care: Barrier-repair moisturisers, SPF, and avoidance of irritants for 5–7 days post-needling
Tattoo Removal
Tattoo Removal
Treatment Plan
Treatment Plan
History & Relevant Patient Information
History & Relevant Patient Information
Client presented with a professionally done multicoloured butterfly tattoo located on the right dorsal foot. The tattoo is approximately five years old and comprises red, blue, and black ink. The client is seeking significant fading/removal of the tattoo for aesthetic purposes. No allergic or adverse reactions to the tattoo ink were reported after the initial tattooing.
Current skincare routine (overall):
AM: Gentle soap-free cleanser, ceramide-rich moisturiser, SPF50 sunscreen (broad spectrum), with reapplication during the day.
PM: Mild cleanser, fragrance-free moisturiser, occlusive cream if required for dry areas.
Medications: Nil photosensitising medications. Nil anticoagulants. Client is generally fit and well. No contraindicated topical or systemic therapies.
Assessment
Assessment
The client is a Fitzpatrick Skin Type III. Tattoo assessment using the Kirby-Desai scale was performed to determine estimated treatment sessions.
The butterfly tattoo on the dorsal foot is around five years old, with medium-density pigment distribution and multiple colours including red, blue, and black. There is no evidence of fibrosis or scar tissue under clinical and dermatoscopic assessment. The area presents anatomical challenges due to reduced circulation, minimal cushioning, and slower healing times.
0A42D56C-4694-4DD1-92AF-0F06707FB242.movTattoo Removal Treatment with the Cutera Enlighten Pico Laser
Kirby-Desai Scale Evaluation:
Location (foot): 2
Skin type (III): 2
Colour (red, blue, black): 3
Ink density: 2
Layering: 0
Scarring/fibrosis: 0
Total Score: 9
Estimated sessions required: 9–10
Risk Assessment
Risk Assessment
Nil photosensitising medications
Nil blood thinning medications (e.g., aspirin, warfarin)
Nil pregnancy or breastfeeding
No history of adverse reactions to laser or other dermal therapies
Low skin cancer risk
Expected side effects: Erythema, oedema, blistering, frosting, pinpoint bleeding, crusting. Red ink removal poses a small risk of allergic contact dermatitis or lichenoid reaction (Hernandez et al., 2022).
Treatment
Treatment
The client was educated on risks, side effects, and the clinical endpoints of laser tattoo removal. The following priming advice was given:
Avoid sun exposure or tanning for four weeks prior
Shave the treatment area 24 hours before
Apply numbing cream independently, if desired, before arrival
Ensure the area is clean and product-free at the time of treatment
Lumenis Ultrapulse CO2 Fractional Ablative Laser
Lumenis Ultrapulse CO2 Fractional Ablative Laser
Used to prime the skin by creating microthermal channels, releasing steam to reduce blistering and inflammation. This also improves laser light penetration and provides a route for pigment to exit through the skin surface. It is also beneficial in treating pigment trapped in minor scar tissue (Sardana et al., 2013).
Settings: 12.5 mJ, 5% density, rectangular shape adjusted to tattoo
Cutera Enlighten Pico Laser
Cutera Enlighten Pico Laser
Used immediately after CO2 laser. Targets pigment through selective photothermolysis. Each colour absorbs different wavelengths:
532 nm: Red ink
785 nm: Blue ink
1064 nm: Black ink
This laser has a pulse duration shorter than the thermal relaxation time of the tattoo particles (<10 ns), fragmenting pigment while minimising thermal damage to surrounding skin (Hernandez et al., 2022).
Clinical endpoint: Frosting, mild oedema, pinpoint bleeding
Based on Kirby-Desai scale and pigment colours, 8–10 sessions are recommended, spaced at 6–8 weeks apart to allow the lymphatic system to remove fragmented pigment and permit complete skin healing.
Immediately post-treatment:
TRPro+ 0.1% Glucoprime gel
Sterile gauze and Fix-A-Clear dressing
References
References
Cannarozzo, G., Negosanti, F., Sannino, M., et al. (2019). Q-switched Nd:YAG laser for cosmetic tattoo removal. Dermatologic Therapy, 32(3), e13042. https://doi.org/10.1111/dth.13042
Hernandez, L., Mohsin, N., Frech, F. S., Dreyfuss, I., Vander Does, A., & Nouri, K. (2022). Laser tattoo removal: laser principles and an updated guide for clinicians. Lasers in Medical Science, 37(6), 2581–2587. https://doi.org/10.1007/s10103-022-03576-2
Kirby, W., Desai, A., Desai, T., Kartono, F., & Geeta, P. (2009). The Kirby-Desai Scale: A Proposed Scale to Assess Tattoo-removal Treatments. The Journal of Clinical and Aesthetic Dermatology, 2(3), 32–37.
Sardana, K., Garg, V. K., Bansal, S., & Goel, K. (2013). A promising split-lesion technique for rapid tattoo removal using a novel sequential approach of a single sitting of pulsed CO2 followed by Q-switched Nd: YAG laser (1064 nm). Journal of Cosmetic Dermatology, 12(4), 296–305. https://doi.org/10.1111/jocd.12060
Melasma
Melasma
History & Relevant Patient Information
The client, a 35-year-old female with FST IV, presented with concerns of skin dehydration and hyperpigmented patches (melasma). Client has a fairly active occupation & works as a dietician, and leads a healthy lifestyle. The client has a history of prolonged UV exposure in her teenage years without correct SPF usage whilst residing in South America. Client has seen the same centrofacial melasma pattern on her mother and grandmother. To address her concerns, the client has previously received a Q-switched 532nm laser test patch for pigmented lesions on her nose & upper cheek at the VU Dermal Clinic and had changed her skincare routine.
Currently, she follows a good skincare regimen consisting of a Vitamin C & niacinamide in the AM and a SPF50+. She is also using a 0.3% OTC retinol once a week, in the PM. The SPF50+ has been used since Nov 2022.
Assessment
Fitzpatrick Skin Type IV. Glogau scale 3. Visual assessment revealed medium-thick, overall healthy skin with slight dehydration. There is a semi-centrofacial pattern of melasma, with the absence of a pigmented patch on the forehead. Woodslamp assessment reveals little sebaceous activity around the nose and T-zone; spots of symmetrical hyperpigmentation across the upper lip & upper cheeks as hazy corresponding to junctional-dermal pigmentation; and more defined pigmentation is seen across the nose corresponding to more epidermal pigmentation. Dermatoscope assessment of mole shows some irregularity; Skin check clearance given by GP. No signs of barrier impairment after clinical cleanse
Risk Assessment
In terms of risk assessment, the client's Fitzpatrick Skin Type and the difficulty of treating melasma were taken into account. The irregularity of the facial mole was also noted, however the client has obtained a GP clearance for laser & light based treatments. These factors indicated a potential risk of post-inflammatory hyperpigmentation (PIHP) and exacerbation of melasma lesions. The objective is to ensure the safe implementation of therapies and mitigate any associated risks. The client has been on a skincare regime with actives & SPF50+ for several weeks and is primed for skin treatments. The parameters chosen for light based devices are within cautious standards for darker FST & refractory dermal pigment conditions like melasma, and used after GP clearance was obtained. The chemical peel strength used for this client is low & appropriate as an initial preparatory peel.
The common patterns that melasma presents in. Extrafacial patterns are present however are predominantly located on the upper extremities, often on sun-exposed sites.
MedLite C6 Q-switched Nd:YAG with 532nm LITE used for treatment of epidermal pigmented lesions for this client.
Lutronic Spectra XT Q-switched Nd:YAG laser used for this client's laser toning treatment.
Treatment Plan
Treatment Plan
For this client, our goal is to improve the appearance of hyperpigmented patches on upper lip, nose & cheeks & also improve the dehydration the client has been experiencing. We also wish to reduce the chance of further pigmentation. The client's overall goal is skin rejuvenation and evening skin tone.
An evidence-based treatment plan can be implemented using the following treatments:
Q-Switched Laser for Epidermal Pigment Lesions (nose, upper cheeks)
Laser Toning
Lactic Acid Chemical Peel
A strong home care routine, with an emphasis on UV protection
Q-Switched Laser for Pigment
Q-switched 532nm/1064nm laser is considered the gold standard for treatment of epidermal pigmented lesions (Nisticò et al., 2021; Silvestri et al., 2021). The nanosecond pulse duration allows for subcellular photothermolysis of melanocytes and acts specifically on the melanin chromophore while preserving surrounding skin (Nisticò et al., 2021; Silvestri et al., 2021). This is an appropriate treatment for our client as we are targeting the more epidermal pigmentation present on the nose & upper cheek area.
1-3 sessions of this treatment may be required with minimum intervals of 4-6 weeks between treatments or until satisfactory clearance of treated lesions.
Laser Toning
Laser toning with a 1064nm short pulsed Nd:YAG laser is suitable to address the client’s junctional-dermal pigmentation (Jung et al., 2012; Yoo, 2022). Laser toning is commonly used for treatment of melasma due to its reduced affinity to melanin compared to other laser & light based wavelengths (Jung et al., 2012; Yoo, 2022). Laser toning employs the mechanism of subcellular selective photothermolysis to target melanosomes within melanocytes & keratinocytes. Targeting melanophages within the dermis with a longer wavelength and larger spot size can help the dermal component of the pigment. The low fluence, ultrashort pulse duration and lack of cell death helps to reduce the degree of inflammation within the tissue, thus mediating the risk of PIH and exacerbating the melasma (Shah & Aurangabadkar, 2019).
Each session of this treatment can be done 1-2 weeks apart. A total of 8-10 sessions are recommended as per operator guidelines, however this should be evaluated at the 3rd & 6th session to determine improvement of pigment.
Lactic Acid Chemical Peel
This intervention acts as an adjunctive therapy alongside Laser Toning to address pigmentation and dehydration concerns. Superficial peels such as Lactic Acid peels act on the epidermis without penetrating the basement membrane to stimulate keratinocyte proliferation from the basal layers of the epidermis and produce a reactive inflammation in the upper dermis that stimulates neocollagenesis by activating fibroblasts (Truchuelo et al., 2017). AHA peels such as Lactic Acid cause a breakdown of desmosomes between corneocytes to induce desquamation and melanin dispersion (Truchuelo et al., 2017). Lactic Acid peels are able to lessen pigmentation by dissolving bonds between skin cells and lifting dead, hyperpigmented skin cells. Lactic Acid peels are also humectant, which means they draw moisture and water into the skin to restore hydration. Lactic acid has a larger molecular weight than other AHA’s which makes it less aggressive & suitable for all skin types.
Approximately 4-6 treatments at 2-4 weeks apart were suggested for optimal results.
In summary, the recommended treatment plan for the client is aimed at improving the pigmentation & dehydration present to provide overall skin rejuvenation. The evaluation of the treatment plan includes skin assessments to monitor the improvement in skin tone, hydration and pigmentation. Each treatment modality would be evaluated after completion to assess the achievement of treatment goals. With this treatment plan, I intend to demonstrate the professional competency that I can develop evidence based and patient centered care plans & execute them in a clinical setting.
Grade 2 Acne
Grade 2 Acne
History & Relevant Patient Information
19 year old FST IV male. Student, casual barista. Dancer as a hobby. Balanced diet.
Hay Fever (experiences runny nose, sneezing, itchy eyes, watery eyes). Takes tablets during this season.
Acne flares up with sleep deprivation & in times of stress. Experiencing acne & acne scarring since puberty (5-6 years ago). Recent acne flare up on the right side of face on cheeks. Client also has concerns of back acne. Post-Inflammatory Erythema that gets worse with flare-ups & causes scars to appear more noticeable.
Current Skincare & Medications
Melatonin, not daily, only when stressed or not sleeping. Currently using melatonin due to exam stress.
Tried Retin-A, but no targeted treatments. Ceased use of retinol.
Roaccutane tried and discontinued 3-4 years ago.
Current Skincare Routine
Recommended products by dermal student & friend. Sometimes exfoliates, hasn’t for a while.
Uses a Salicylic Acid cleanser 1x weekly. No adverse reactions.
Daily double cleanse with oil cleanser that emulsifies & then a foaming cleanser.
Korean Skincare Toner with ceramides.
Vitamin C serum daily in the morning.
Soothing moisturiser at night.
TheOrdinary 10% Niacinamide + Zinc following by soothing moisturiser some nights. Causes some irritation.
Daily use of SPF50+. Only on the face. Gets minimal-moderate sun exposure.
Client Goals for Treatment
The client's primary concerns are their facial acne and redness. The main client goal is to reduce the appearance of acne scarring/PAE and prevent further acne flare-ups.
Assessment
To assess the client's condition comprehensively, a series of skin analysis methods are employed. These include Wood's Lamp Analysis, Dermatoscope assessment, and visual examination. The skin analysis reveals generalised dehydration across the face. Post inflammatory erythema/post acne erythema & post inflammatory hyperpigmentation are present around sites of inflammation/acne lesions. Active acne lesions are seen predominantly across the cheeks area. Inflammatory acne papules are present all over with forehead involvement. Couple of active acne lesions/ pustules across the right side of face. The right side of the skin is more flared up than the left. Ice pick scarring is present across the face as well. More pronounced & localised erythema is noted in areas with more inflammatory skin. The acid mantle, responsible for maintaining the skin's natural barrier, appears impaired. There is inflammation and barrier impairment present across the face. The client is categorised as Fitzpatrick Skin Type IV, which helps in understanding their risk of post-inflammatory hyperpigmentation (PIH) and further inflammation with treatment. FST also assists in assessing the level of chromophore and competing chromophore in the client's skin, thus determining the potential risk of PIH or scarring.
Global Acne Grading System (GAGS): Score 22; Moderate
Differential Diagnosis & Working Diagnosis
As per the skin assessment and grading scales, the working diagnosis for this client’s condition is Grade II (Moderate) Acne. Grade 2 acne is classified as “inflammatory lesions present as a small papule with erythema”.
Differential diagnoses include:
Demodex folliculitis presents as inflammatory papules and pustules with erythema. It is suspected when patients fail to respond to acne treatments
Rosacea (Absence of telangiectasia & presence of comedones rule out rosacea)
Risk Assessment
Nil photosensitizing medications.
Nil previous adverse reactions or outcomes to laser or chemical peel test patch.
Low risk on the skin cancer risk matrix.
The client has been experiencing some irritation & inflammation that may be attributed to their current state of stress and also their use of a high percentage niacinamide. The treatment plan should be altered to reflect the client's current state of their skin. A chemical peel or laser genesis treatment may not be suitable upon assessment of the client's barrier health & inflammation.
Complex Acne Client Verbal Handover.m4aThis is a verbal handover of the client case outlining the client's history, concerns, risks etc.
Aesthetic Bureau XEN LED machine with 415nm, 633nm and 830nm LED available.
Mesoestetic Mesopeel Mandelic 30% peel.
Cryomed Aesthetics V-Laser long-pulsed KTP 532nm and Nd:YAG 1064nm used in this treatment plan
Genesis Mode/V-toning mode: 1064nm micropulse with 0.3ms.
Contact Dermatitis
Contact Dermatitis
History & Relevant Patient Information
History & Relevant Patient Information
The client, a 21-year-old male, works as a cleaner and is frequently exposed to harsh chemicals in his line of work. He has a medical history of hay fever and asthma, conditions that tend to flare up during specific seasons. Interestingly, the client's father also experienced similar skin conditions, particularly during hay fever seasons, although his symptoms were not as severe. Dermatitis has an "atopic tendency", which is characterized by a strong association between dermatitis, asthma, and allergic rhinitis (hay fever) (Levin et al., 2013). Upon assessment, it is observed that the client's acne is predominantly comedonal, with no active acne lesions or pustules/papules present.
Medications: The client is currently using topical Advantan (Methylprednisolone) steroid cream twice a week and topical Tacrolimus ointment/compound cream five times a week. Tacrolimus, in combination with a ceramide-dominant emollient, has been found to influence both transepidermal water loss and antimicrobial peptide expression in patients with dermatitis, thereby aiding in the management of the condition (Hon et al., 2013). Additionally, the client has been taking Oratane/Accutane since March 2023, four times a week for four weeks, to address his skin concerns.
Client Goals for Treatment: The client's primary goals for treatment are to reduce inflammation in the skin, restore the skin's barrier function, and improve the overall appearance of his skin while addressing dryness and flakiness.
Assessment
Assessment
To assess the client's condition comprehensively, a series of skin analysis methods are employed. These include Wood's Lamp Analysis, Dermatoscope assessment, and visual examination. The skin analysis reveals hyperkeratosis on the forehead, indicative of thickened skin in this region. Erythema is noted in areas with flakier and more inflammatory skin, while the acid mantle, responsible for maintaining the skin's natural barrier, appears impaired. The overall assessment indicates dehydration and oil buildup around the nose and forehead. Pigmentation is observed in the center of the forehead. The client is categorized as Fitzpatrick Skin Type V, which helps in understanding his risk of post-inflammatory hyperpigmentation (PIH) and pigmentation with treatment. FST also assists in assessing the level of chromophore and competing chromophore in the client's skin, thus determining the potential risk of PIH or scarring. The client's skin has been cleared by a dermatologist for LED treatments, which are considered as adjunctive therapy with prescription topicals.
Based on the assessment findings and the client's medical history, the client is diagnosed with severe eczema/contact dermatitis with bacterial infection likely due to exposure to chemicals from his cleaner job.
One of the associated risks in treating this condition is the possibility of exacerbating the skin condition with LED treatments. To manage this risk, the practitioner will ensure appropriate treatment parameters and intervals and closely monitor the client's response during the course of treatment. A risk to be addressed is the client's use of topical steroids and systemic medications. To mitigate any chance of adverse events, I researched some evidence behind the combined use of topical steroids & LED in management of dermatitis. I found that the combined therapy is not only safe, but is advantageous.
Treatment Plan
Treatment Plan
The treatment plan for the client includes LED therapy with both blue LED (415nm) and near-infrared LED (830nm). The blue LED treatment at 415nm involves LV2, with an energy density of 30J/cm2 and a treatment duration of 16 minutes and 27 seconds. Blue LED at this wavelength targets endogenous bacterial coprophyrin III, leading to singlet oxygen production and subsequent bacterial destruction (Gold et al., 2011). On the other hand, near-infrared LED therapy at 830nm involves LV4, with an energy density of 60J/cm2 and a treatment duration of 11 minutes and 27 seconds. Near-infrared LED penetrates the dermis, exerting significant anti-inflammatory therapeutic effects (Liao et al., 2021). It induces mitochondrial changes, generates reactive oxygen species (ROS), and stimulates cell activity, contributing to toning, firming, and oxygenation of the skin.
The combination of Tacrolimus (prescribed to the client) and LED therapy has been researched with success, showing decreased levels of IgE and NO (Kim et al., 2013).
To complement the clinical treatments and achieve the client's treatment goals, home-care measures are recommended. The client should use a moisturizer with SPF50+ sunblock to protect the skin from harmful UV rays and prevent further sun damage, which can exacerbate the condition. The use of Propaira Biotic Cream for Eczema, enriched with Niacinamide and Ceramides, is suggested to restore and repair the skin barrier effectively. Proper moisturization can also reduce the need for topical corticosteroids and promote optimal skin health (Hon et al., 2013).
The client will have 8 alternating treatments of NIR LED and blue LED over a four-week period, with at least 48 hours between each treatment.
Post-treatment care is crucial to maintaining the benefits of the LED therapy and supporting the skin's healing process. The client should diligently use a moisturizer with SPF50+ sunblock and avoid sun exposure during peak hours of dangerous UV rays. Additionally, avoiding triggers, where possible, is essential to reduce the severity and frequency of flare-ups associated with his condition.
Dermatitis is a multifaceted condition, and successful management should be personalized and comprehensive, taking into account the severity of symptoms and their impact on the client's quality of life. This entails addressing the inflammation in the skin barrier, treating any infections present, and evaluating and managing environmental and allergic triggers to achieve optimal outcomes. The approach should consider the individual's unique needs and circumstances to provide effective and holistic care
Google Sites
Report abuse