Skin Deep - Clinical & Cosmetic Dermatology Blog

Skin Deep is a blog for dermatologists and skin care professionals with focus on theoretical, cosmetic and aesthetic dermatology. This blog is associated with ‘Dermatologists Sans Borders’ one of the largest curated groups of skin care professionals on facebook. If you are looking for non-technical information, please visit


Listen2Me (Photo credit: beapen)
During my early days in dermatology, I used to notice a rare condition being written as diagnosis by a senior colleague for few patients on their file. The condition was called GOK. I had absolutely no idea what this elusive condition GOK was, and I asked her one day to learn more about the condition. She explained to me that GOK stands for ‘God Only Knows’ and we had a hearty laugh.

With every passing year, my GOK moments started to become more frequent and after my transition to Cosmetic Dermatology, everything other than acne and melasma became GOK. I consoled myself that, I was probably undergoing a Benjamin Button retrogression towards the neo Google generation, who never had to remember anything, as everything is ‘searchable’. But Google was not the panacea for GOK as it was designed for more mundane tasks.

After several months of (GOK how many!) sleepless nights, I think I have succeeded in brewing the right elixir for GOK. Please try this elixir for yourself! Enter a short history of your GOK moments below and click 'process' to see what happens! The actual homepage is here.

Disclaimer: This is an experimental application for medical professionals and is provided for informational purposes only. This information is not intended to be medical advice or a substitute for professional medical advice, diagnosis, or treatment. Read the full disclaimer before you proceed.

You may cut and paste your clinical findings in the box below using medical terms. Please note that any numbers in the text will be ignored. Please avoid adding any confidential patient data.
Example: Multiple, itchy, tender, subcutaneous nodules on abdomen with septal panniculitis.

Your Primary Diagnosis:(Ignore if GOK)

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Digital Imaging and COmmunications in Dermatology: A prelude

I recently read a 2 decade old editorial on digital imaging in dermatology. The editorial started off with a question:

"Why do dermatologists need any imaging techniques for skin, an entirely visible organ?" 

This image shows a Canon EOS 350D digital sing...
(Photo credit: Wikipedia)

Every time I open my facebook, I see clinical dermatology images posted for opinion, with a good number of comments and likes. Though crowdsourcing dermatological diagnosis in this manner is a grave violation of privacy to me, digital imaging has become an integral part of dermatology practice.

For some dermatologists (like me), the digital photographs are the only contact with the world of lesions. With the growing popularity of teledermatology and (ethical and non-ethical) crowdsourcing, your exposure to digital photographs as a window to your patient is going to increase. This post is actually a prelude to (an attempt at) defining that future of digital dermatology.

The future has many challenges: Standardization, Sensitivity, Privacy and Ethics are just few of them. In this series, I will discuss these challenges from a technical perspective. I dream of a future when ‘diagnosing from digital photograph’ will be an important part of dermatology training curriculum.

English: National Naval Medical Center, Bethes...
(Photo credit: Wikipedia)

So I have defined the beginning of this journey. I have an endpoint in mind too: A dermatology specific IOD recommendation for WG-19 DICOM. Don’t worry if you don’t understand the endpoint now. Suffice to say that we will partly follow the specialty with a well defined imaging standard; Radiology, and modify their tools for our domain. At this juncture, the path to that endpoint is less clear to me too! Technical parts of this series will be on my informatics blog.

Here is the link to the wiki page, where I shall collect all the resources, and this is where we shall reach our destiny with your comments and contributions! I have given the name DICODerm (Digital Imaging and COmmunications in Dermatology) for this project. So if you tweet or discuss in #DsB (Dermatologists Sans Borders), please use the hashtag #DICODerm and feel free to follow me @beapen

Here is a useful preliminary solution to your image organization problems! Dermatology Image Tagger.

Disclaimer: I am not a member of NEMA, Medical Imaging and Technology Alliance or WG-19. The opinions mentioned here and internally hyperlinked pages are my own. External sites are hyperlinked in good faith, but does not mean endorsement.

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Peptide design for skin rejuvenation

Helium Ion Microscopy of collagen
Helium Ion Microscopy of collagen (Photo credit: ZEISS Microscopy)
Skin rejuvenation peptides are cosmetic dermatology’s answer to retinoids. Retinoids stimulate collagen production at the transcriptional level by directly interacting with nuclear receptors. The skin rejuvenation peptides trick the body into synthesizing more collagen.

Collagen production and its ultimate destruction by a group of enzymes called MMPs are controlled by a complicated system of signal molecules. The skin rejuvenation peptides supposedly resemble collagen degradation particles and trigger the synthetic pathway to compensate for the perceived degradation.
The short peptide KTTKS from alpha­-procollagen-­I is the most successful peptide within this category that is being extensively used. However three factors limit the efficacy of peptides.

  • Stability in the base formulation
  • Penetration across the cell membrane
  • The predilection for enzymatic destruction inside the cell.

The last and the often ignored limitation is its propensity to catalytically increase hyaluronic acid degradation along with UVB.(1) Though peptides may have a positive effect on chronological ageing, its overall effect on photo ageing needs to be studied.

Several modifications have been suggested and tried for KTTKS to circumvent the above limitations. The addition of a palmitoyl group to increase penetration was the most successful modification and palmitoyl­-KTTKS was the industry standard anti-­ageing peptide for a long time.

L'Oreal Collagen Filler
L'Oreal Collagen Filler (Photo credit: ATIS547)
Recently a new tetrapeptide called tetrapeptide­-21 has emerged as a collagen enhancer more effective than palmitoyl­KTTKS.(2) The inventors have demonstrated the superiority by several ex-­vivo studies. They claim to have arrived at this molecule by using bioinformatics methods. They collected the sequence of all collagen and elastin. They extracted the most commonly occurring tetrapeptide sequence among these molecules. From 30 or so commonly occurring tetrapeptides with the general formula GxxG and PxxP, they tested by ex­-vivo methods and found the most effective one, GEKG. GEKG is claimed to have a beneficial effect on hyaluronic acid as well.(3)

But there are several limitations with their bioinformatics methodology:

  • Type I and III collagen are the most common types in skin. Why did they include all?
  • How can they claim that the most commonly occurring tetrapeptide is the most potent signal peptide for collagen synthesis.

Studies have shown other limitations of their methodology.(4) I recently came across a new algorithm to predict the potential short peptide signal molecules within proteins based on conserved domains. I used the new algorithm to analyze collagen III. I found that the common tetrapeptide repeats are those proposed by tetrapeptide­21 inventors. However the highest scoring short peptide based on the above algorithm was different.

I believe, I have discovered a short peptide out of millions of probable short peptides within collagen that is most likely to mimic the signal molecule for collagen production. Cosmetic companies may find this short peptide interesting. However further refinement may be needed to improve penetration and stability. Besides my theoretical prediction needs experimental proof.


  1. Röck, Katharina et al. "Collagen Fragments Inhibit Hyaluronan Synthesis in Skin Fibroblasts in Response to Ultraviolet B (UVB) NEW INSIGHTS INTO MECHANISMS OF MATRIX REMODELING." Journal of Biological Chemistry 286.20 (2011): 18268­18276.
  2. Mentel, M et al. "Innovative Peptide Technologies for Even, Young and Healthy Looking Skin." SOFW Journal­Seifen Ole Fette Wachse 138.3 (2012): 22.
  3. "TEGO® Pep 4­17." 2009. 28 Mar. 2013  
  4. Neduva, Victor et al. "Systematic discovery of new recognition peptides mediating protein interaction networks." PLoS biology 3.12 (2005): e405.
Read the full series on peptides here.

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Post-acne hyperpigmentation index (PAHPI)

Acne vulgaris
Acne vulgaris (Photo credit: Adams999)
Post Inflammatory Hyperpigmentation (PIH) after successful acne treatment used to get ignored as a first world cosmetic concern till recently. But with the burgeoning cosmetic dermatology industry, acne treatment remains incomplete till PIH is taken care of. Though many effective and not so effective treatments arrive every now and then on the scene, with enticing theories about slaying melanocytes, there is no validated scale for quantitative research on PIH.

Researchers from University of Texas Southwestern Medical Center have validated a post-acne hyperpigmentation index (PAHPI)(1), (much to the chagrin of fairness cream tycoons). The paper (soon to appear in JAAD) is an excellent example of effectively combining qualitative and quantitative methods. The index was developed after focus group interviews and was rigorously tested for inter and intra rater reliability. The validity was tested for 3 independent outcome measures:  global severity ratings, pigmentation, and quality of life.

The simple index that takes into account size, intensity, and number of lesions showed substantial reliability and validity. This may be an excellent tool for PG thesis research on acne and PIH management.

The authors were able to recruit 21 patient from the community with fliers and radio advertisement. Wonder how many PIH patients visit a dermatologist daily in the Indian subcontinent!

1. "Reliability assessment and validation of the postacne ..." 2013. 4 Nov. 2013

Read more »

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Know your skin: Melanoma infographic from Myriad Genetics

Know Your Skin


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About Me

As a Dermatologist and Informatician my research mainly involves application of bioinformatics techniques and tools in dermatological conditions. However my research interests are varied and I have publications in areas ranging from artificial intelligence, sequence analysis, systems biology, ontology development, microarray analysis, immunology, computational biology and clinical dermatology. I am also interested in eHealth, Health Informatics and Health Policy.


Bell Raj Eapen
Hamilton, ON