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

Time to respect your patient privacy

In a small town called payyanur in Kerala, INDIA, three doctors were suspended for allegedly sharing a labour room video of triplets being delivered by C-section on social media. The powerful local media rebuked the medical community for their irresponsible behaviour.

Is taking clinical photos on your mobile second nature for you?   Do you share them on Facebook? 

Photo credit: Jay Wennington @
Think again. In this fast growing digital world, it is time to consider the repercussions. This is not a review of the privacy concerns. Please refer to Kunde (below) for a short and sweet review on ethical and medico-legal considerations of digital photography in dermatology. This is about a solution, though little cumbersome and incomplete.

Dermatology is a speciality that depends on visual cues. Photography can even be considered therapeutic in dermatology, since it is an important part of disease monitoring. Social media like facebook is an important and popular platform for crowdsourcing diagnosis. This is especially important for those practicing in resource deprived areas. How can this be achieved without compromising patient privacy?

I have developed a tool for visual diagnostic information encoding. The tool called LesionMapper(TM) captures information such as location, distribution, progression and severity using pre-defined representative lesion images and icons. It also provides the capability to create lesion icons from existing clinical images. Without further ado here is the link to LesionMapper(TM):

Lesion Canvas for LesionMapper(TM)

The instructions tab has details on how to use it. Below I have added basic steps to add a lesion from your photograph. Please note that using LesionMapper(TM) does not guarantee anonymity. It is your responsibility to ensure that you have obtained the necessary consent. If the preset images and icons are insufficient, you can crop the lesion from the clinical image  itself as below.

  1. Go to
  2. Click on Upload Image 1 (Blue Button)
  3. Upload your image. Select only the lesion and follow instructions. (In the new window)
  4. Click on Upload 1 (White button). Image will be added to canvas. If not press the button again.
  5. Drag the image to the area of involvement. You can resize the image if needed.
  6. Click on the Download button (A small button right below the image). You can also save it on the site. You will be provided with an ID that can be used to render the image by clicking on Load.
Please share below to see the reference to medico-legal considerations in dermatology photography.

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Oral tranexamic acid for the treatment of melasma

My Friend Mr +Devdas Pai  asked for a review of this article [1] (Link to full text below) and our experience on oral tranexamic acid for the treatment of Melasma.

English: Melasma on the face
Melasma on the face (Photo credit: Wikipedia)
I don’t have personal experience using oral tranexamic acid, an antifibrinolytic hemostatic agent with alleged activity as a melanin synthesis inhibitor. Do I think whether this study provides a proof for this activity that was suggested way back in 1979? Not really!

We discussed the methodological challenges in cosmetic dermatology research before and I don’t believe that an RCT should be the gold standard in cosmetic dermatology. But unfortunately, if you set out to prove something in cosmetic dermatology, you invariably can if you use subjective assessments without blinding! When your eyes are not blinded, the random number generator does not do justice in allocation either with a substantial difference in epidermal type of melasma in both groups, enough in my opinion for the demonstrated effect size.

Digital photographs are your best weapon to prove your point. The photograph in the article will probably give you hopes of the miraculous melasma eraser. But you can easily see the difference in white balance between the before and after pictures by looking at the shadow below the nose.

Recurrence is the biggest limitation in melasma management. A statistical quirk has been inappropriately exploited to allude to a sustainable solution without real evidence. The study provides ample proof for the authors conviction in the agent, but not for its actual effect on melasma. Go ahead and try it if you are adventurous. I shall stick to my trusted treatment; PhotoShop :)

Please support below to see the full text of the article.

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Allured to Lignin Peroxidase

In this article I have reviewed lignin peroxidase (LIP) as a skin tone enhancing cosmetic. This is not a paid review.

Various types of cosmetic concealer.
Various types of cosmetic concealer. (Photo credit: Wikipedia)
Is it fair enough to say that 1.3 billion people in Indian sub-continent and many more in the far east have found the panacea for FAIR beautiful skin. Though only few of them will be able to afford LIP and the company aptly follows my time machine rules, I must say that I find the theory behind  LIP (distributed under a popular trade mark name) enticing.

The theory sans all the hype is simple: An isoenzyme of LIP (H1 or modified H2 to be exact) can oxidize melanin in the presence of an electron acceptor in acidic pH. So it is not, 'yet another tyrosinase inhibitor' and theoretically aid removal of already formed melanin. European CRO that reported their "Asian" trials  on company inscribed reports was hardly convincing  with their hanging "significant" improvement in 8 days.

The preparation transiently brings the cutaneous pH to acidic levels for LIP to have its effect. Once the pH returns to normal, LIP disintegrates and vanishes ensuring high safety profile. Since hypopigmenting properties of LIP secreting fungi are long known, this melanin zapper could be a reasonably good addition to any pigmentation treatment (if it were cheaper). It must be noted though that the patent application was filed in 2003 and the idea of a fungal derived fairness agent is not exactly theirs.

I have added LIP to the 'elimination' arm of Pigment Map Project. Do you agree with this placement?

I give 3 peels to the concept (The highest I have ever given to a cosmetic, despite 'sold only to aesthetic physician or spa' marketing gimmick ). Do give your rating using the widget below. peel rating
What is peel score?

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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