This document provides a classification and overview of the differential diagnosis of papular lesions that can occur on the face. It categorizes potential causes into infections, inflammatory disorders, tumors, and others. Key points include descriptions of common infections like molluscum contagiosum and lupus vulgaris. Inflammatory conditions discussed are acne, rosacea, perioral dermatitis, and sarcoidosis. Benign and malignant tumors of the skin and adnexal structures are also reviewed. Differential diagnoses and treatment approaches are mentioned for many of the conditions.

1. DIFFERENTIAL DIAGNOSIS OF
PAPULAR LESIONS ON FACE
DR.MIKHIN GEORGE THOMAS

2. CLASSIFICATION
INFECTIONS
INFLAMMATORY DISORDERS
TUMOURS
OTHERS

3. INFECTIONS
• Molluscum contagiosum
• Tinea faciei
• Lupus vulgaris
• Demodicidosis

4. INFLAMMATORY DISORDERS
• Acne
• Rosacea
• Perioral dermatitis
• Lupus miliaris disseminatus faciei
• FACE
• Sarcoidosis
• Follicular mucinosis
• Pseudofolliculitis barbae

5. TUMOURS
BENIGN EPIDERMAL TUMORS
AND CYSTS:
DPN
Seborrhoeic keratosis
Keratoacanthoma
Milia

6. Tumors cont…
PREMALIGNANT
EPITHELIAL LESIONS
 Actinic keratosis
 Cutaneous horn
MALIGNANT
 Basal cell carcinoma

7. Tumors of skin appendages
• Eccrine gland tumors : syringoma, eccrine hidrocystoma
• Apocrine gland tumors : syringocystadenoma papilliferum
• Sebaceous gland tumors : sebaceoma, sebaceous adenoma,
sebaceous hyperplasia
• Tumor of hair follicle mesenchyme : trichodiscoma
• Hair follicle tumors : dilated pore, trichoadenoma
• External root sheath tumors : trichilemmoma
• Hamartomas : trichoepithelioma, trichofolliculoma

8. Soft tissue tumors
• Fibrous tumor : fibrous papule of face
• Fibrohistiocytic tumors : atypical fibroxanthoma

9. OTHERS
• Colloid milia
• Angiofibroma

10. INFECTIONS

11. MOLLUSCUM
CONTAGIOSUM
• Pox virus family
• MCV 1-4; majority : type 1
• Contact with infected persons or contaminated
objects, sexual abuse
• Peak incidence : 2-5 yrs
• IP: 14 days to 6 mths
• C/F : shiny, pearly white, hemispherical, umbilicated
papule, 5-10 mm
• Agminate form or giant molluscum
• Distribution depends on the mode of infection

12. • Widespread and refractory
mollusca on the face- HIV
infection and iatrogenic
immunosuppression.
• Viral entry into the basal layer
where an early increase in cell
division extends into the
supra basal layer.
• Molluscum bodies

13. Course & treatment :
Spontaneous clearance
• Curettage
• Cryotherapy
• Electrosurgery
• Phenol
• cantharidin
• tricholoroacetic acid
• pot.hydroxide solution
• topical salicylic acid preparations
tretinoin
• imiquimod cream
• cidofovir

14. LUPUS VULGARIS
• Chronic progressive post primary,
paucibacillary form of cutaneous tuberculosis
• Moderate or high degree of immunity
• Underlying focus- bone, joint or lymph node
• Haematogenous or lymphatic spread
• C/F: 80%- head and neck
India- buttocks and trunk
Initial lesion : small reddish brown plaque,
soft, with peripheral extension.
5 types: plaque, ulcerative, vegetating,
tumour like, papular and nodular forms.
• Diascopy : apple jelly nodules

15. • Diagnosis
• Treatment : standard ATT
• Differential diagnosis :
 Rosacea
 leprosy nodules: firmer
 Nodules of sarcoidosis :
resemble grains of sand

16. DEMODICIDOSIS
• Demodex folliculorum - follicle mite
• Areas of high sebum production
• Head down position in the follicle, 2-6 mites, motile
• Can produce papular and papulopustular lesions in
immunosuppressed individuals
• Pathogenic role: pityriasis folliculorum, rosacea, perioral
dermatitis, blepharitis
• Treatment : topical acaricides

17. TINEA FACIEI
• Ringworm of glabrous skin of face
• Trichophyton mentagrophytes, T.rubrum
• Direct inoculation or secondary spread from
other sites
• Itching, burning & exacerbation with sun
exposure
• Erythema +, Scaling less prominent
• Simple papular lesions or flat patches of
erythema
• D/D : PMLE and DLE
• Treatment : antifungals

18. TINEA BARBAE
• A disease of adult male
• Ringworm of beard and moustache areas of
face
• Invasion of coarse hairs
• Commonly farm workers
• Trichophyton verrucosum,
T.mentagrophytes
• C/F: highly inflammatory pustular
folliculitis
Hairs surrounded by red inflammatory
papules or pustules
Loose hairs in affected areas
• Treatment : antifungals

19. ACNE
• A chronic inflammatory disease of pilosebaceous units
• Usually starts in adolescence
• Seborrhoea , open & closed comedones, erythematous
papules & pustules, nodules, pseudocysts, scarring
• Pathogenesis : 4 factors
• 99% - lesions on face
• Early lesions – comedones
• Grading of acne
• Acne variants – infantile, occupational, mechanical,
tropical, acne excoriee, acne conglobata, acne fulminans
fulminans.

21. Treatment :
 Topicals – retinoids, benzoyl
peroxide, topical antibiotics,
nicotinamide, azelaic acid
 Physical modalities
 Systemic therapy : antibiotics,
oral retinoids, hormonal
therapy, zinc
 Acne surgery
Differential diagnosis :
rosacea, perioral dermatitis,
gram negative folliculitis

22. ROSACEA
• A vascular disorder affecting central face
• Presence of one or more of the following:
flushing, non transient erythema, papules and
pustules, telangiectasia
• Not a disorder of sebaceous glands, absence of
comedones
• Pathogenesis :
o Damage to dermal connective tissue
o Abnormal vascular reactivity
o Sensitivity to noxious stimuli
o High levels of cathelicidin
o H.pylori, Demodex folliculorum

23. Cont…
• Early : episodic flushing, mild telangiectasia, transient
edema
• Progressive : papules, pustules, sustained edema, extensive
telangiectasia
• Late : induration, rhinophyma
• Lymphoedema, eye involvement, salivary gland involvement
• Histopathology :
– Dilated capillaries & lymphatic channels in mid dermis
– Perivascular lymphohistiocytic infiltrates
– Solar elastosis
– Sometimes granulomas
– Pustules – neutrophilic infiltration

24. • Treatment
• Topical : metronidazole, tretinoin,
clindamycin, tacrolimus, azelaic acid
• Systemic : tetracyclines, metronodazole, isotretinoin
• Rhinophyma : surgical excision, intense pulsed light lasers,
dermabrasion

25. PERIORAL DERMATITIS
• Persistent erythematous eruption
of tiny papules and papulopustules
– perioral
• Periocular dermatitis
• Pathogenesis :
 Demodex, candida , fusiform
bacteria
 Irritant and allergic contact factors
 Atopy
 Topical steroids, cosmetic products
 Hormonal factors, sensititvity to
sunlight

26. Cont..• Begins in nasolabial areas  perioral areas; sparing lip
margins
• Monomorphic papules & pustules
• Histopathology – eczematous changes, mononuclear
infiltrate; rarely granulomatous inflammation
• Treatment
– Discontinue topical steroids
– Avoid potential contact allergens
– Oral tetracyclines for 4 weeks
– Topical tetracycline, metronidazole, erythromycin
– Pimecrolimus 1% cream

27. ACNE AGMINATA
• Lupus miliaris disseminatus faciei – historical
• Acnitis or FIGURE
• A self limiting variant of granulomatous form of rosacea
• C/F : Multiple, monomorphic, symmetrical, reddish-brown
papules on the chin, forehead, cheeks and eyelids
• Clustering around mouth or eyelids or eyebrows - ‘agminata’
• Diascopy – apple jelly nodules
• Granulomatous histology with large area of caseation
• D/D : micropapular sarcoidosis
• Treatment : tetracyclines, dapsone, low dose prednisolone

29. Facial Afro-Caribbean childhood
eruption
• FACE or granulomatous periorificial dermatitis
• A juvenile form of perioral dermatitis or acne agminata
• Papular eruption confined to the face – clustering around
mouth, eyes and ears
• Pustules absent, vermilion border involved
• Histology – nonspecific inflammation with hyperkeratosis
or granulomatous mainly perifollicular
• Complete resolution
• Treatment – systemic erythromycin or minocycline or
topical metronidazole or tacrolimus

31. SARCOIDOSIS
• A disease characterised by formation in all or
several affected organs or tissues of epithelioid cell
tubercles, without caseation, proceeding either to
resolution or to conversion into hyaline fibrous
tissue.
• Etiology : genetic factors, infectious agents,
immunological response

32. • Acute and subacute : erythematopapular lesions, scar
sarcoidosis , papular and lichenoid variety
• Sub acute and chronic : erythrodermic, nodular, annular,
angiolupoid, subcutaneous
• Chronic : plaque ( lupus pernio)
• Others : ulcerative, psoriasiform, palmoplantar, ungual,
mucosal
• Systemic features : cardiac, respiratory, muscle, CNS,
ocular, renal, liver, spleen, lymphnodes
• Raised ACE levels , hypercalcemia

34. Cont…Histopathology
– Well defined aggregates of epithelioid cells
– Few Langhan’s type giant cells
– Naked tubercle – paucity of lymphocytes
– MNG cells with asteroid bodies and Schaumann bodies

35. Treatment :
– Corticosteroids
– Immunosuppressants
– Biologics
– Other drugs – allopurinol,
doxycycline, chloroquine,
minocycline, levamisole,
isotretinoin, fumaric acid
esters, thalidomide
– Topical therapy – high potent
topical steroids, ILS,
tacrolimus
– PUVA, cryotherapy,
radiotherapy

36. FOLLICULAR MUCINOSIS
• Alopecia mucinosa
• 2 distinct forms: associated with MF and benign inflammatory form
• C/F are identical : follicular papules and boggy cutaneous plaques
• Severe pruritus and prediliction for face and scalp
• Prominent giant comedones and alopecia
• Pathology : degeneration of involved hair follicles with a prominent
pilotropic atypical T cell infiltrate, inter follicular epidermotropism
• CD3+ve, CD4+ve and CD8 –ve
• Treatment : dapsone for inflammatory forms
Associated with MF: bexarotene, radiotherapy, total skin electron
beam therapy

38. PSEUDOFOLLICULITIS BARBAE
•Inflammation due to penetration into the skin of sharp tips
of shaved hairs
•If shaven too long – the hair may curve backwards after
emerging from the follicle to penetrate the adjacent skin
•If cut very short – it retracts into the follicle; may directly
penetrate the follicle wall
•Curly hair – more prone
•Male beard – commonest area
•Complications – keloid, hyperpigmentation

39. Treatment
• Stop shaving for 4-6 weeks
• Lifting out of reentrant hairs
• Hair maintained at 1 mm length
• Steroid-antibiotic combination
creams and emollients
• Hair removal with chemical
depilatories or topical
eflornithine hydrochloride cream
• Laser

40. TUMOURS

41. Benign epidermal tumors and
cysts
• DPN
• Seborrhoeic keratosis
• Milia

42. • Dermatosis papulosa nigra
• Pigmented papular eruption of face and neck
• Nevoid developmental defects of pilosebaceous
follicles
• Histology resembling seborrhoeic keratoses
• C/F: black or dark brown, flattened or
cupuliform papules 1-5 mm
• Malar regions and forehead
• Also on neck, chest and back
• Treatment : electrosurgery

43. SEBORRHOEIC
KERATOSIS
• Benign tumor of epidermal keratinocytes
• Increasing age ; 5th decade ; M=F
• Most frequent on face and upper trunk
• Classical, DPN, stucco keratosis
• Hyperpigmented papules or plaques
• Sign of Leser-Trelat
• Histopathological types : clonal, hyperkeratotic,
acanthotic, irritated, reticulate, melanoacanthoma
• Treatment : curettage, electrosurgery, cryotherapy

45. KERATOACANTHOMA
• Molluscum sebaceum
• Rapidly evolving tumor of the skin composed of
keratinizing squamous cells originating in pilosebaceous
follicles
• M>F; middle aged ; white races
• Etiology : sunexposure, tar and mineral oil, sorafenib
• C/F: firm, rounded, flesh colored or reddish papule
rapid growth phase- 10- 20mm
Telangiectasias, central horny plug or crust concealing a
keratin filled crater

46. • Central part of face – nose,
cheeks, eyelids and lips
• Usually solitary
• Histopathology : epidermis
normal or acanthotic, composed
of mass of rapidly multiplying
squamous cells,
hyperchromaticity, atypical
mitotic figures, dyskeratosis and
loss of polarity
• D/D : SCC
• Treatment : curettage and
coagulation of base, excision
and suture, radiotherapy, 5-FU.

47. MILIA
• Small subepidermal keratin cyst
• All ages ; from infancy onwards
• Due to pilosebaceous or eccrine sweat duct plugging
• Primary or secondary
• Subepidermal blistering diseases(BP , EB, PCT), burns,
dermabrasion, radiotherapy
• Firm white or yellowish 1-2mm dome
shaped papules, on cheeks and eyelids
of adults
• Eruptive milia- rare
• Milia en plaque

48. • Histopathology : small
cysts lined by stratified
epithelium few cell layers
thick and contain
concentric lamellae of
keratin
• D/D : milia are whiter and
more translucent than
syringomas
• Spontaneous clearance
• Treatment : incision and
squeezing of contents,
chemical cautery,
electrosurgery.

49. Tumors cont…
PREMALIGNANT
EPITHELIAL LESIONS
 Actinic keratosis
 Cutaneous horn
MALIGNANT
 Basal cell carcinoma

50. ACTINIC KERATOSIS
• Or solar keratosis
• Premalignant epithelial lesion
• Hyperkeratotic lesions on chronically light exposed
skin
• Low risk of progression to invasive SCC
• Middle aged or elderly; fair skinned
• Relapsing or remitting lesions
• Face, scalp and dorsa of hands
• C/F : multiple macules or papules with a rough scaly
surface, 1mm to 2 cms, aymptomatic
• Hyperemic base with punctate bleeding points

51. • Histopathology :
• Treatment : curettage and cautery, cryotherapy, topical
5-FU, imiquimod, photodynamic therapy, dermabrasion
and chemical peels

52. CUTANEOUS HORN
• Horny plugs or outgrowths due to various epidermal
changes
• Infection : molluscum, viral wart
• Benign: keratoacanthoma, seborrhoeic keratosis,
trichilemmal and epidermoid cyst
• Malignant : BCC, SCC
• C/F : hard yellowish brown horn, curved,
circumferential ridges, surrounded by normal
epidermis or acanthotic collarette
• Upper face and ears
• Inflammation and induration beneath : malignant
transformation
• Histology : absent granular layer, no atypicality
• Treatment : excision

53. BASAL CELL
CARCINOMA
• Basalioma or rodent ulcer
• Most common malignant tumour of skin ; rarely metastasizes
• Composed of cells similar to basal cells an appendages
• M>F
• Etiology: UV exposure, arsenic, ionizing radiations and burns,
mutations in PTCH1 gene, immunosuppression
• C/F : small, translucent or pearly papule, raised and rounded
areas covered by thin epidermis, dilated superficial vessels,
nodule or plaque
• Erosions & crusting common, sometimes ulcerate
• Types

54. Pathology
-Tumor cells resemble
basal cells of epidermis
-Peripheral palisading of
nuclei
-Stroma
-Clefting artefact
-Atypia

55. Treatment
– Surgical excision
– Non-surgical approaches:
curettage and cautery,
cryotherapy,
laser, topical imiquimod,
topical 5FU, PDT,
systemic retinoids

56. Tumors of skin appendages
 Eccrine gland tumors : syringoma, eccrine hidrocystoma
 Apocrine gland tumors : syringocystadenoma papilliferum
 Sebaceous gland tumors : sebaceoma, sebaceous adenoma,
sebaceous hyperplasia
 Tumor of hair follicle mesenchyme: trichodiscoma
 Hair follicle tumors : dilated pore, trichoadenoma
 External root sheath tumors : trichilemmoma
 Hamartomas : trichoepithelioma, trichofolliculoma

57. SYRINGOMA
• Benign tumor with differentiation
towards eccrine acrosyringium
• F>M
• C/F : numerous small, firm, smooth
skin colored or yellowish papules,
<3 mm
• Outline – angular or crenated
• Face esp lower eyelids
• Other sites: neck, chest, trunk,
axillae, vulva,ventral trunk.
• Eruptive syringomas : familial in
adolescent girls

58. • Histopathology :
 collections of convoluted and cystic
duct spaces in upper dermis
 Lined by double layer of cells
 Tail like strand of cells into the stroma-
‘tadpole or comma appearance’
• Treatment :
electrosurgery, cryotherapy, dermabrasion,
laser resurfacing

59. ECCRINE HIDROCYSTOMA
• Tumour by mature deformed eccrine sweat units; secretions dilate
the ducts
• Rare; middle aged women; exposure to heat
• Confined to cheeks and eyelids
• Cystic, blue, increase in size on exposure to heat and flattens with
exposure to cold
• Multiple, pigmented lesions on face
• Pathology : uni or multilocular dermal cystic lesion lined by 2 layers
of cells
• Inner layer- columnar , outer layer- myoepithelial cells
• Treatment : electrodessication, CO2 laser, pulse dye laser, excision

61. SYRINGOCYSTADENOMA
PAPILLIFERUM
• Exuberant proliferating lesion with apocrine differentiation
• Birth or childhood
• C/F : Multiple warty papules, translucent and pigmented
• Majority on face and scalp
• Pathology
– Papillomatosis with invaginations
– Cystic structures –
apocrine pattern
– Dermis – plasma cells
– Sometimes sebaceous, eccrine,
follicular differentiation
• Treatment – surgical excision

62. SEBACEOUS TUMOURS
• Sebaceous adenomas and
sebaceomas
• Benign tumors composed of
incompletely differentiated
sebaceous cells
• Rare; elderly
• C/F : rounded, raised, sessile or
pedunculated, <10 mm,waxy or
yellowish, plaques or ulceration
• Face and scalp
• Multiple - Muir Torre syndrome

63. • Pathology
– Sebaceoma – irregular cell masses of mostly undifferentiated
basaloid cells
– Sebaceous adenoma – sharply demarcated lesion with peripheral
basaloid cells and central mature sebaceous cells
• Treatment – surgical excision

64. SEBACEOUS HYPERPLASIA
• Benign proliferation in middle aged
and elderly
• Yellowish-pink papules 1-3 mm
• Forehead and temples
• Renal transplant patients on CsA
• Treatment – cautery, cryotherapy,
TCA, laser

65. TRICHODISCOMA
• Hamartomatous proliferation of
mesodermal component of the
Haarscheibe
• Haarscheibe – a slowly reacting
mechanoceptor associated with
hair follicle
• C/F : multiple, discrete, flat
topped papules 2-3 mm
• Central face
• Birt – Hogg- Dube syndrome
• Pathology : non encapsulated area
of myxoid, poorly cellular stroma
wirh focal collagen deposition in
dermis, proliferation of vessels

66. DILATED PORE
• Wiener’s pore or infundibuloma
• Area of expanded follicular infundibulum
• Dilated poral opening into subcutaneous
tissue
• C/F : comedo like lesion on head and neck
in elderly
• Pathology : wide crater like cavity, from
which acanthotic areas of follicular
epithelium radiate; follicle lined by outer
root sheath epithelium

67. TRICHOADENOMA
• Rare benign tumor, with multiple cystic
structures closely resembling
infundibular portion of hair follicle
• Differentiates towards follicular
infundibulum
• C/F : Papule or nodule on the face
• Pathology : lesions in upper dermis,
cluster of cysts

68. TRICHILEMMOMA
• Proliferation of external root sheath of hair
follicle
• Infundibular keratinisation
• C/F : small non specific papules on facial
skin in young adults
• Multiple : Cowden’s syndrome
• Pathology
– Lobular tumors extending from epidermis
– Clear cytoplasm – glycogen
– Peripheral palisading
– Sometimes prominent epidermal changes
– Variant – desmoplastic trichilemmoma

69. TRICHOEPITHELIOMA
• Hamartoma of the hair germ
composed of immature islands
of basaloid cells
• Focal primitive follicular
differentiation and induction of
a cellular stroma
• 3 forms : solitary, multiple and
desmoplastic
• Solitary- skin colored papules,
5-8 mm, on face esp around
nose, upper lips, cheeks
• Brooke spiegler syndrome –
trichoepitheliomas,
cylindromas and spiradenomas

70. • Pathology
– Well circumscribed lesion in
superficial dermis
– Horn cysts and basaloid cells
– Tumor islands show
peripheral palisading
• Treatment – surgical excision,
curettage, electrosurgery,
cryotherapy ,dermabrasion

71. TRICHOFOLLICULOMA
• Hamartoma of pilosebaceous follicle
• Several hairs form within the follicular
opening , protruding onto the epidermal
surface
• Young adults
• Prediliction for face
• C/F : small raised nodules, 2-3 hairs
protruding in a small tuft
• Pathology
– Cystic cavity lined by squamous
epithelium
– Keratinised material & fragments of hair
shafts
– Several pilosebaceous structures opening
into the canal
Treatment : excision

72. Soft tissue tumors
• Fibrous tumor : fibrous papule of face
• Fibrohistiocytic tumors : atypical fibroxanthoma

73. FIBROUS PAPULE OF FACE
• Benign tumor
• Small facial papule with distinctive
fibrovascular component
• C/F: slowly developing dome shaped skin
colored or red or pigmented papule, sessile,
• Nose, forehead, cheeks, chin or neck
• Pathology: normal epidermis, clear cells
overlying the lesion, increased collagen in
the dermis, dilated vascular channels,
increased cellularity
• Treatment : excision or surgical paring

74. ATYPICAL FIBROXANTHOMA
• Fibrohistiocytic tumor
• Sun damaged skin of elderly ; M>F
• UV induced p53 mutations
• C/F : papules or nodules with ulceration
, red fleshy appearance
• On ears, cheeks, bald scalp of elderly
males
• Local recurrence, metastasis to
lymphnodes and internal organs
• Pathology: large spindle shaped and
histiocytic cells, multinucleated in
dermis, mitotic figures, atypical forms
• Resembles a highly malignant soft
tissue sarcoma histologically
• Treatment : mohs micrographic surgery

75. COLLOID MILIA
• Degenerative change on light exposed skin
• Nonfamilial occurring in later life
• UV, trauma, hydroquinone
• C/F : small dermal papules, 1-2 mm, yellowish
brown , irregular groups
• Face esp around orbits, sides of neck, ears, dorsa of
hands and back.
• Rare juvenile and nodular form
• Histopathology : colloid globules at tips of dermal
papillae
• Treatment : electrosurgery, dermabrasion, Er:YAG
laser, topical retinoids

77. • Small flesh colored to brownish
red papules – usually on central
face
• Multiple lesions – Tuberous
Sclerosis Complex
• Composed of hyperplastic blood
vessels, sebaceous glands,
immature hair follicles
• Treatment – electrosurgery, laser
ANGIOFIBROMA

78. HOW TO
APPROACH??

79. Onset
Duration
Evolution
Mucosal lesions
Systemic Complaints
Treatment history
? Symptomatic
Triggering factors
Photosensitivity
Past history
HISTORY

80. Morphology of predominant lesion
Number of lesions, symmetry
Size, colour and surface
? Flat topped ? Translucent
Umbilication? Erythema ? Telangiectasia
Annular lesions
Diascopy
Other types of lesions
? Scarring ? Ulceration
Distribution over face
Nasolabial fold, perioral & periocular regions
Involvement of other areas
Other systems
Investigations
EXAMINATION…

82. GOECKERMAN REGIMEN
2-5% CRUDE
COAL TAR
• Applied over the lesions for period of 24hrs
• Excess wiped off with mineral oil
UV- B
• Sub erythmogenic dose for 2-5 mins
COAL TAR
BATH
• 90mL of coal tar in 120L water

83. INGRAM REGIMEN
COAL TAR BATH
• 15-30 mins
UV-B
• Exposed to suberythmogenic
dose(1/3 to ½ of MED)
ANTHRALIN(0.1%)
• Apply with spatula over lesions
• Paste is powdered with talc

84. BATH PUVA
SPECIFICATIONS
• A special room with non skid bath tiles with bath
tub containing markings for 50,65,80,100L.
• Geyser for warm water
Principle
• Final concentration- 3.75mg/L
• 3.75mL of 1% psoralen in 100L of water
Procedure
• 10mins in supine and prone, maximum coverage
• Avoid splashing of face and eyes

85. BATH PUVA
Procedure
• Gently pat dry, and exposed to UV-
A with special precautions
• 3 times a week
Follow up
• 12-15 sessions for improvement
• Maintenance for 3-4 months