Brow Ptosis

Brow ptosis is the medical term doctors use when the eyebrow drops lower than its normal position on the forehead. In everyday language, it means a “sagging eyebrow.” The muscle at the front of the forehead (the frontalis) normally lifts the brow so we can keep our eyes open wide and look alert. When that lift is weakened—or when the skin and tissues above the eyes lose their firmness—the brow drifts downward. The droop can be subtle, making the upper eyelid look heavy, or quite pronounced, partially blocking vision and forcing a person to raise the forehead or tilt the head back just to see. Because the brow frames the eyes, even a small sag can change facial expression, making someone appear tired, sad, or older than they feel. Brow ptosis can affect one side (unilateral) or both sides (bilateral), and it may come on gradually over years or suddenly after an injury or nerve problem.

Brow ptosis means the eyebrows sit lower than their normal anatomic position because the tissues that normally lift the brow (the frontalis muscle, fascia, skin and underlying fat) lose tone, are damaged, or are pulled downward by stronger antagonist muscles. The droop can shade the eyes, narrow the visual field, deepen forehead lines and create a tired or angry look. Although cosmetic ageing is the most common cause, brow ptosis may also arise from facial‑nerve palsy, myasthenia gravis, traumatic scarring, excessive botulinum‑toxin use, thyroid eye disease or congenital muscle weakness. Mild lowering is mostly an appearance issue; severe sagging can reduce peripheral vision and strain the eyelids as they try to compensate. NCBI

Anatomy refresher

The eyebrow sits on a delicate balance of muscles, nerves, skin, and connective tissues:

• Frontalis muscle: A thin, fan‑shaped sheet over the forehead; its upward pull keeps the brow elevated.

• Orbicularis oculi: The circular muscle that closes the eyelids; its side fibers pull the brow downward when we squint or frown.

• Corrugator and procerus muscles: Small “frown” muscles between the brows that also pull downward and inward.

• Superficial musculo‑aponeurotic system (SMAS): A fibrous layer linking forehead skin to deeper tissues, acting like scaffolding.

• Supraorbital and supratrochlear nerves: Branches of the facial nerve that power the frontalis and carry feeling from the brow region.

• Skin, fat, and ligaments: Provide padding and hold structures in place; they thin and stretch with age.

Anything that weakens the upward pull (frontalis paralysis, muscle fatigue, ligament laxity), makes the downward pull stronger (overactive orbicularis), or allows the soft tissue scaffold to loosen will let gravity win, and the brow sinks.

Types of brow ptosis

Doctors classify brow ptosis so they can choose the correct treatment. The categories often overlap, but they help explain the root problem:

1. Congenital brow ptosis – present at birth due to under‑developed frontalis muscle or nerve pathways.

2. Involutional (age‑related) ptosis – the most common type; decades of gravity, sun damage, and collagen loss thin the forehead tissues.

3. Myogenic ptosis – caused by diseases that weaken muscle fibers, such as myasthenia gravis, chronic progressive external ophthalmoplegia, or muscular dystrophies.

4. Neurogenic ptosis – results from nerve injury or disorders like Bell’s palsy, stroke, Horner’s syndrome, or a supraorbital nerve lesion.

5. Mechanical ptosis – heavy skin folds, tumors, cysts, or scar tissue physically drag the brow downward.

6. Traumatic ptosis – direct blows, lacerations, or surgical injuries that disrupt muscles, nerves, or support structures.

7. Iatrogenic ptosis – an unintended effect after cosmetic injections (excess botulinum toxin in the forehead) or eye surgery that weakens frontalis function.

8. Compensatory ptosis – sometimes the brow droops because the eyelids or eyeballs are abnormally high; the body “balances” vision by letting the brow fall to reduce excess light.

9. Endocrine‑related ptosis – thyroid eye disease can inflame muscles and fat, altering brow position.

10. Dermatochalasis‑associated ptosis – massive upper‑eyelid skin redundancy can pull the brow down secondarily.

Understanding the type matters because treatment of a nerve injury is very different from trimming excess skin or tightening ligaments.

Common causes

1. Natural aging (involutional changes). After age 40, the skin makes less collagen and elastin, the ligaments stretch, and sub‑cutaneous fat thins. The brow slowly drifts south, often so gradually that patients notice only in old photos how much higher their brows used to sit.

2. Sun damage (photoaging). Ultraviolet rays break down collagen fibers and create loose, wrinkled skin. Chronic sun exposure accelerates brow descent even in younger adults.

3. Facial nerve palsy (e.g., Bell’s palsy). When the seventh cranial nerve stops sending signals, the frontalis loses tone on the affected side. Without its upward pull, the eyebrow collapses within days.

4. Stroke (cerebrovascular accident). A brain attack can damage the facial‑nerve nucleus or its pathway, producing permanent, sometimes asymmetric brow droop along with other facial weaknesses.

5. Traumatic forehead injury. Deep cuts, fractures, or surgical scars may sever muscle fibers or nerves and leave a section of brow unsupported.

6. Botulinum toxin over‑injection. Cosmetic “forehead freezing” can backfire if too much toxin weakens the frontalis; brow ptosis can last three to six months until the effect wears off.

7. Myasthenia gravis. This autoimmune disease blocks nerve‑to‑muscle signals, causing fatigable weakness. Brow position may vary through the day—up in the morning, sagging by evening.

8. Chronic progressive external ophthalmoplegia (CPEO). A mitochondrial disorder that slowly weakens eye and brow muscles, leading to drooping lids and brows over years.

9. Muscular dystrophy (e.g., myotonic dystrophy). Genetic muscle disorders reduce tone and elasticity, so brows sag early in life.

10. Thyroid‑associated orbitopathy. In Graves’ disease, inflammation and swelling around the eyes may push the brow upward at first but later scar tissue binds muscles, causing downward displacement.

11. Heavy upper‑eyelid skin (dermatochalasis). Extra skin folds weigh on the brow, and patients subconsciously relax the frontalis to reduce forehead wrinkles, letting the brow fall.

12. Forehead tumors or cysts. Benign or malignant masses add weight and may erode support ligaments, resulting in a localized droop.

13. Post‑surgical scarring. Any surgery in the brow or upper‑eyelid region—blepharoplasty, craniotomy, eyebrow lift—can leave adhesions that tether tissue downward.

14. Horner’s syndrome. Damage to the sympathetic nerve supply reduces the minor brow‑lifting action of Müller’s muscle and smooth muscle fibers, producing a mild ptosis.

15. Diabetes‑related neuropathy. Long‑standing diabetes can injure small nerves; when the supraorbital branch is involved, brow position suffers.

Symptoms

1. Heavy eyelids or “tired eyes.” People feel as if they must constantly raise their eyebrows or tilt their heads back to see clearly, especially late in the day.

2. Forehead fatigue or headaches. Overworking the frontalis to lift the brow can cause aching across the forehead and temples.

3. Visual field loss. Drooping tissue blocks the upper part of the visual field; driving or reading street signs becomes harder.

4. Asymmetric facial appearance. If only one brow droops, the face looks uneven, which can be socially distressing.

5. Concern about looking sad or angry. Friends may comment that the person seems upset or exhausted even when they feel fine.

6. Difficulty applying eye makeup. The excess brow skin gets in the way of eyeliner or eyeshadow, leading to smudges.

7. Skin irritation in brow fold. Moist skin‑on‑skin contact can cause redness, itching, or mild infection in the deepened brow crease.

8. Photophobia (light sensitivity). Narrowed palpebral aperture makes it harder to blink and shade the eye properly, increasing glare discomfort.

9. Loss of upper peripheral vision in sports. Balls or other fast‑moving objects above eye level can be missed, affecting performance.

10. Psychological impact. Persistent awareness of the droop may lower self‑esteem, trigger anxiety about aging, and reduce social confidence.

Diagnostic tests

Clinical evaluation starts with careful history and inspection, but a complete work‑up can involve many tools. Below are grouped by category, each explained plainly.

Physical‑examination assessments

1. Brow position measurement. The clinician measures the vertical distance from the mid‑pupil to the brow’s lower edge (MRD – margin‑reflex distance). A normal value is about 2.5 mm; lower numbers confirm ptosis.

2. Frontalis contraction test. The patient wrinkles the forehead while the examiner presses on the brow. Weak or absent movement indicates frontalis paresis.

3. Eyelid‑brow relationship inspection. Comparing brow height to eyelid crease shows whether droop is isolated to the brow or accompanied by blepharoptosis (lid droop).

4. Visual‑field confrontation. By wiggling fingers above the patient’s line of sight, the tester quickly screens for superior‑field loss caused by sagging tissue.

5. Facial symmetry analysis. A direct, well‑lit view reveals asymmetry, skin quality, and compensatory head posture, guiding the classification of ptosis type.

Manual or functional tests

6. Frontalis fatigue test. The patient maintains eyebrow elevation for 60 seconds; in myasthenia gravis the brow gradually falls as muscle tires.

7. Eyebrow taping trial. Temporarily lifting the brow with adhesive tape can confirm that visual and comfort complaints disappear when brow height is restored.

8. Ice‑pack test. A cold compress over the forehead for two minutes can transiently improve myasthenic ptosis, supporting that diagnosis.

Laboratory & pathological tests

9. Thyroid‑function panel (TSH, T3, T4). Detects hyper‑ or hypothyroidism that can influence brow position through tissue swelling or myopathy.

10. Acetylcholine‑receptor antibodies. Positive in myasthenia gravis, pointing to an autoimmune cause of muscle weakness.

11. Blood glucose and HbA1c. High values suggest diabetes, which can lead to neuropathic brow droop.

12. Autoimmune/myopathy panel (ANA, CK, EMG biopsy markers). Helps uncover systemic muscle diseases like polymyositis or dystrophies behind myogenic ptosis.

Electrodiagnostic studies

13. Nerve‑conduction velocity (NCV). Measures speed of signals along the supraorbital branch; slowed conduction implies neuropathy or trauma.

14. Electromyography (EMG) of frontalis. A tiny needle records electrical patterns during brow lift; reduced amplitude or rapid fatigue signals muscle disease.

15. Repetitive‑nerve‑stimulation test. In myasthenia gravis, EMG shows a declining response with repeated pulses, confirming neuromuscular junction disorder.

Imaging studies

16. High‑resolution orbital MRI. Visualizes muscles, nerves, fat, and any masses; excellent for diagnosing nerve compression or thyroid eye disease.

17. Brain MRI with contrast. Looks for strokes, tumors, or demyelinating lesions in the facial‑nerve pathway that could paralyze the frontalis.

18. CT scan of the orbit and brow. Faster than MRI and good at spotting bone fractures, calcified lesions, or foreign bodies pulling the brow down.

19. Ultrasonography of soft tissue. A quick, radiation‑free way to differentiate solid tumors from cysts or lipomas in the brow.

20. Digital photography with image analysis. Standardized photos stored in the medical record allow precise tracking of brow height over time and after interventions.

Non‑pharmacological treatments

How to read this section: each numbered item gives (a) a plain‑English description, (b) the purpose and (c) the proposed mechanism of action. Evidence quality ranges from small controlled trials to expert consensus; references are noted where available.

Exercise‑based therapies

1. Frontalis‑strengthening eyebrow raises – daily “surprise” lifts held for 5‑10 seconds, 10–15 reps. Purpose: recruit and tone the main brow‑elevator muscle. Mechanism: repeated concentric contractions enlarge muscle fibres and increase neural drive, slightly elevating resting brow height in 6–8 weeks. Evidence from facial‑exercise studies shows measurable improvement in skin firmness and muscle cross‑section. PMCDaniel Ezra

2. Resistance‑band brow lifts – light elastic anchored above the head provides external load as brows are lifted. Purpose: progressive overload for stronger gains. Mechanism: higher mechanical tension stimulates myofibrillar hypertrophy and fascia remodelling.

3. Dynamic yoga‑face circuit – a 3‑minute sequence combining brow lifts, eye squeezes and cheek puffs. Purpose: whole‑upper‑face toning plus mindful breathing for stress relief. Mechanism: increases regional blood flow, boosts parasympathetic tone, and reduces frowning habit.

4. Orbicularis‑oculi relax‑and‑release drills – consciously soften the eye‑closing muscle between computer tasks. Purpose: reduce downward pull on the brow. Mechanism: motor‑learning retrains resting muscle length, decreasing chronically elevated tension.

5. Blink‑rate retraining – metronome‑guided, moderate‑speed blinks (15–20/min) during screen work. Purpose: prevent compensatory forehead over‑activity. Mechanism: normalises oculomotor rhythm, lessening reflex brow depression.

6. Upper‑eyelid stretching – gentle upward traction on skin fold for 30 seconds. Purpose: maintain tissue extensibility post‑surgery or botulinum toxin. Mechanism: stimulates fibroblast collagen alignment.

7. Facial‑myofascial release massage – therapist glides fingers along supra‑orbital rim. Purpose: break adhesions after trauma or scar. Mechanism: shear stress up‑regulates matrix metalloproteinases, aiding remodelling.

Mind‑body therapies 

1. Mindfulness meditation (10 min/day) – trains non‑reactivity to stress. Purpose: reduce habitual frowning that drags the brow downward. Mechanism: lower cortisol limits collagen breakdown; real‑time awareness interrupts muscle clenching cycles.
2. Surface electromyography biofeedback – sensors above the brow translate muscle tension into visual or audio cues so users can “dial it down.” Purpose: long‑term re‑education. Mechanism: operant conditioning decreases depressor‑supercilii activity.
3. Progressive muscle relaxation – systematically tense then release forehead and scalp. Purpose: relieve myofascial pain that reinforces ptosis‑posture. Mechanism: reduces alpha‑motor neuronal firing.
4. Acupuncture at temporal and frontal points – weekly sessions. Purpose: improve micro‑circulation, relieve neuropathic pain. Mechanism: neuro‑humoral release of β‑endorphins and nitric oxide‑mediated vasodilation.
5. Tai Chi facial flow set – slow, circular hand movements guiding brow muscles. Purpose: holistic body‑posture integration. Mechanism: proprioceptive resetting of head‑neck alignment, indirectly supporting brow elevation.
6. Guided imagery of “lifting light” – therapist‑led sessions visualising eyebrows floating upward. Purpose: enhance motivation for active therapy. Mechanism: psychoneuroimmunology: imagery alters limbic output to cranial motor nuclei.

Educational self‑management 

1. Posture coaching – reminding patients to avoid sustained neck flexion, which visually worsens brow sag. Mechanism: efficient head carriage decreases gravitational vector on frontal tissue.
2. Sun‑protection education – wide‑brim hats, SPF 30+ daily. UV accelerates collagen loss; avoiding it preserves brow support structures.
3. Screen‑time “20‑20‑20” rule – every 20 minutes look 20 feet away for 20 seconds. Reduces squinting.
4. Nutritional literacy sessions – teach intake of collagen‑friendly nutrients (vitamin C, amino acids, zinc). Links antioxidants to slower dermal ageing. PMCPMC
5. Sleep‑hygiene workshop – 7‑9 hours darkness; growth‑hormone pulse aids tissue repair.
6. Smoking‑cessation counselling – smoking triples brow‑ptosis risk by impairing dermal microvasculature.
7. Stress‑management classes – CBT and journaling lower facial muscle over‑activation.

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Evidence‑based drugs useful in specific brow‑ptosis scenarios

Note: dosage ranges are typical adult values; adjust case‑by‑case under medical supervision.

1. Onabotulinum toxin A (Botox®) – neuromodulator, 4–20 U injected into brow depressor muscles every 3–4 months. Goal: chemical brow lift by weakening pull‑down fibres while sparing frontalis. Key side effects: transient weakness, bruising, rare eyelid ptosis. Evidence from controlled trials confirms predictable 1–3 mm elevation in mild cases. NCBIClinicalTrials.gov

2. Abobotulinum toxin A (Dysport®) – similar class, ~2.5× unit conversion; lateral‑brow focus. Duration ~3 months. Side effects: headache, asymmetry.

3. Incobotulinum toxin A (Xeomin®) – preservative‑free; reduced antibody risk in repeat users.

4. Topical oxymetazoline 0.1 % drops – α‑adrenergic agonist approved for eyelid ptosis; one drop per affected eye daily can indirectly lift brow by widening palpebral fissure. Side effects: rebound redness, dryness.

5. Apraclonidine 0.5 % drops – short‑acting alternative used diagnostically and p.r.n.; caution in cardiac disease.

6. Pyridostigmine 60 mg three times daily – acetylcholinesterase inhibitor for myasthenia gravis–related ptosis. Side effects: cramps, diarrhoea.

7. Prednisone (initial 40‑60 mg daily, tapered) – corticosteroid for inflammatory neuropathies e.g., Bell’s palsy. Long‑term use limited by glucose, bone and mood effects.

8. Intravenous immunoglobulin (IVIG 2 g/kg over 2–5 days) – for severe, acute myasthenic or autoimmune brow droop; transient headache, thrombosis risk.

9. Topical tretinoin 0.025–0.05 % cream nightly – retinoid that thickens dermis, reducing skin redundancy that contributes to sag. Side effects: irritation, photosensitivity.

10. Hyaluronic‑acid dermal filler (0.5–1 mL per brow tail) – technically a medical device but classified as a drug‑product by many regulators; injections every 12–18 months create mechanical lift. Risks: swelling, vascular occlusion (rare).

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Dietary molecular supplements that support brow‑supporting tissues

(Always buy third‑party‑tested products and discuss with a clinician if you are pregnant, on anticoagulants or immunosuppressants.)

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Regenerative / stem‑cell–based therapies

1. Platelet‑rich plasma (PRP) micro‑injections – 3 cc spun‑down autologous blood into supra‑brow dermis every 4–6 weeks for 3 sessions. Function: growth‑factor burst stimulates fibroblast collagen production. Mechanism: PDGF, VEGF and TGF‑β ignite wound‑healing cascade for tighter skin.

2. Adipose‑derived stem‑cell (ADSC)–enriched fat graft – small liposuction harvest, stromal vascular fraction is mixed with micro‑fat and placed beneath brow. Benefit: long‑lasting volumisation and tissue regeneration.

3. Stem‑cell exosome serum (topical or intradermal) – nano‑vesicles containing RNA and growth factors. Early studies show improved dermal density in photo‑aged skin. ScienceDirectPMC

4. Dermal fibroblast cell suspension – cultured patient fibroblasts injected in a grid every 1 cm. Goal: repopulate aged collagen network.

5. Placenta‑derived mesenchymal stromal cell cytokine gel – applied nightly for 12 weeks. Mechanism: paracrine signals up‑regulate collagen I and III genes.

6. Recombinant human epidermal growth factor (rh‑EGF) microneedle patches – 0.25 mm dissolving needles weekly. Benefit: triggers keratinocyte proliferation, thickening epidermis, and indirectly lifting lax brow skin.

All regenerative methods remain “off‑label”; informed consent and specialist supervision are essential until large phase‑III trials confirm safety.

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Surgical solutions and their benefits

1. Direct (trans‑brow) lift – crescent of skin and muscle excised just above the eyebrow; skin closed to elevate brow 5–10 mm. Benefits: precise correction, shortest operating time; ideal for elderly with heavy brow. Scar hidden in brow hairs.

2. Endoscopic brow lift – 3–5 tiny scalp incisions, camera releases brow attachments, tissue anchored higher with absorbable tacks. Benefits: minimal scar, faster recovery, smooth forehead; average 3 mm elevation sustained at ≥2 years according to systematic reviews. NCBIOxford Academic

3. Temporal (lateral) brow lift – small incision in hairline lifts only outer third of brow. Benefits: soft, feminine arch; avoids forehead widening.

4. Mid‑forehead (rhytidectomy) lift – incision in deep forehead wrinkle; suitable for men with high hairline. Benefits: hides scar in existing crease; strong lift with minimal alopecia risk.

5. Internal brow‑pexy via upper‑lid blepharoplasty – during eyelid surgery, brow fat pad sutured to periosteum. Benefits: adds 1–2 mm elevation without extra skin incision; good adjunct for combined dermatochalasis + ptosis.

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Preventive habits to delay or minimise brow ptosis

1. Wear broad‑spectrum SPF and sunglasses every day.

2. Stop smoking and limit second‑hand smoke exposure.

3. Eat protein‑rich, antioxidant‑dense meals (colourful produce, fish).

4. Monitor thyroid and neuromuscular health with routine check‑ups.

5. Maintain healthy weight; massive fluctuations stretch facial ligaments.

6. Sleep 7–9 hours with head slightly elevated to improve lymph drainage.

7. Follow ergonomic screen setup to avoid chronic frown line formation.

8. Manage allergies promptly to reduce habitual eye‑rubbing.

9. Include regular aerobic and resistance exercise to boost skin perfusion.

10. Schedule annual eye and skin assessments after age 40 to catch early drop.

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When should you see a doctor?

• Brow droop develops suddenly over hours or days (possible nerve palsy or stroke).

• Ptosis is asymmetric, painful or accompanied by double vision.

• You notice impaired upper‑field vision or need to tilt your head back to see.

• There is associated eyelid swelling, redness or discharge.

• Existing autoimmune or neuromuscular disease flares with new sagging.

• Non‑surgical measures fail to improve cosmetic concerns and affect self‑esteem.

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Everyday do’s and don’ts

1. Do practise gentle brow exercises; don’t over‑work muscles to exhaustion.

2. Do apply sunscreen; don’t rely on make‑up with SPF alone.

3. Do hydrate and eat collagen‑supporting foods; don’t crash‑diet.

4. Do monitor brow position in the mirror monthly; don’t ignore rapid changes.

5. Do use protective eyewear for sports; don’t risk forehead trauma.

6. Do give eyes regular breaks from screens; don’t squint at small fonts.

7. Do follow post‑injection aftercare (no massaging 24 h); don’t lie flat immediately after botulinum toxin.

8. Do consult qualified injectors; don’t accept bargain‑basement procedures.

9. Do manage stress with relaxation techniques; don’t clench your forehead while concentrating.

10. Do keep blood pressure and diabetes in check; don’t skip yearly physicals.

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Frequently asked questions (FAQs)

1. Can brow ptosis go away on its own?
   Age‑related sagging is progressive, but nerve‑related droop (e.g., Bell’s palsy) often improves over months.

2. Are facial exercises scientifically proven?
   Small studies suggest modest benefits; evidence is still limited and mixed. PMCMedical News Today

3. Is Botox® dangerous for brow ptosis?
   In skilled hands it is safe; side‑effect rates of true brow‑droop are under 1 %. Dermatology Institute

4. How long does an endoscopic brow lift last?
   Most patients retain 70‑80 % of the initial lift at 5 years. Oxford Academic

5. Will insurance pay for surgery?
   Only when visual‑field testing proves functional impairment; purely cosmetic lifts are self‑pay.

6. Can topical creams lift a brow?
   They improve skin quality but rarely change brow height more than 1 mm.

7. Do collagen drinks actually work?
   Meta‑analyses show improved hydration and elasticity after 90 days, though individual results vary. Verywell Health

8. What is the recovery time after a direct brow lift?
   Sutures removed day 7; most swelling subsides by week 3; heavy exercise after 4–6 weeks.

9. Can adrenaline drops (apraclonidine) be used daily?
   They are for occasional use; chronic daily use can cause tolerance and redness.

10. Is PRP better than Botox®?
    PRP rebuilds tissue slowly; Botox® lifts by muscle modulation. They treat different layers and can be combined.

11. My brows fell after too much Botox®—what now?
    Effects fade in 3‑4 months; apraclonidine drops and brow exercises offer temporary help.

12. Are stem‑cell brow therapies approved?
    Not yet; they are experimental and offered under research protocols. ScienceDirectPMC

13. Can weight loss reverse brow sag?
    Moderate loss may improve puffiness but rapid cycles worsen skin laxity.

14. Does sleeping face‑down cause ptosis?
    Long‑term pressure can stretch fascia; back‑sleeping is kinder to brows.

15. Can men benefit from these treatments?
    Absolutely; approaches are adjusted to maintain a natural, masculine brow position.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: July 15, 2025.