Skin Growths

Common tumors/growths that are come across on the face and trunk are:

  • Benign:
    • Seborrhoeic keratosis
    • Dermatosis papillosa nigra
    • Skin tags (acrochordon)
    • Warts
    • Melanocytic naevi (moles)
    • Cherry angioma
    • Syringoma (Sweat gland tumor)
  • Malignant:
    • Basal cell carcinoma
    • Squamous cell carcinoma
    • Malignant melanoma

sebker1Seborrhoic Keratosis: It is a common, benign tumor of the top layer (epidermis) of the skin, seen after the age of 30 years. Tendency to develop seborrhoic keratosis can be familial. Sudden appearance of a large number of seborrhoic keratosis should arouse the suspicion of underlying systemic diseases like cancers.

Pic: Seborrhoic Keratosis Before Excision

They are commonly seen as brown to black raised lesions on the face, scalp and back with a stuck-on appearance. The surface of the lesion is uneven. It can produce symptoms like itching and pain when irritated.

It has to be differentiated from melanocytic nevi (mole) and wart (viral infection).

Treatment is for cosmetic reasons or when it becomes symptomatic. Treatment includes excision or curettage, cryo and cautery.

dpn1Dermatosis papillosa nigra: These are common, benign, epidermal tumors that may be a variant of seborrhoic keratosis, unique to black race. It is associated with a familial predisposition. They appear as brown to black, comedone like globoid lesions on the face and neck.

They usually begin at puberty or adolescence and slowly increase in size and number until the third to fifth decades.

Treatment is for cosmetic reasons and includes curettage and electrocautery.

acroch1Skin tags: These are common epidermal outgrowths seen as minute flakes or balls of skin. These appear after the age of 30 at the sites of wear and tear (axillae, groin, neck, eye lids)  and are especially associated with obesity. These lesions can get irritated by clothing or chains on the neck. These should not be mistaken with warts that have finger like projections and look fleshy, which are caused by viruses and hence contagious.

Pic: Skin Tag (Acrochordon) on the neck

Treatment is mainly for cosmetic reasons or when it gets strangulated or irritated.

In the presence of large number of skin tags, investigations for endocrinal disorders may be needed.

Syringoma:

syringpre3syringpre2

They are benign tumors of sweat glands and seen as skin coloured or pinkish, shiny, raised, flat lesions on the face (eyelids and centre of the cheeks), chest and neck. They appear in large numbers in patients with a familial tendency.

They first appear during adolescence and further increase during adult life. They become more prominent under humid conditions and are mistaken for acne vulgaris (pimples).

Treatment includes electrocautery, cryo and excision.[See Syringoma After Electrocautery]

melnevipre1Melanocytic nevi (Mole): It is a benign tumor of melanocytes (pigment producing cells of the skin). There are two types: those present at the time of birth (congenital) and those appearing later (acquired). Presence of a large number of nevi may be a familial trait. They appear at childhood, increase sharply at adolescence and then grow slowly during early adult life to reach a plateau by middle age.

Based on the site at which the proliferation of the cells occur, they are seen clinically as black spots or black, raised, dome shaped lesions.

Moles are most commonly seen on the face and the trunk and rarely on the palms and soles.
By their smooth and shiny surface, moles have to be differentiated from seborroic keratosis and warts. Whenever moles suddenly increase in size, ulcerate, bleed or become itchy, malignant transformation should be suspected and should be subjected for biopsy.

Treatment: Very early lesions can be treated by cryo. Treatment of choice is complete excision (punch or elliptical) and subjecting to histopathological examination.

Basal Cell Carcinoma:

bcc1

Nail Disorders

Common problems affecting the nail unit (nail and the skin around and under the nail) are:

Paronychia: It is the painful swelling of the nail fold; it can be acute or chronic.

  • Acute paronychia: Usually caused by bacterial infection following trauma to the nail folds
  • Chronic paronychia: Caused by fungal infection; secondary to the destruction of the cuticle due to detergents and water. It is common in individuals who do wet jobs – house wives, hotel workers, maids, gardeners etc. It is also common in diabetics.

Paronychia can lead to nail changes in the form of ridging, scaling and discoloration.

Treatment:

Acute paronychia – if pus is present, incision and drainage should be done. Antibiotics should be directed against the most common pathogenStaphylococcus aureus and the drug of choice is cloxacillin.

Prevention is by avoiding trauma to the nail unit during manicure.

Chronic paronychia – It can sometimes present with acute exacerbation due to secondary bacterial infection and a course of antibiotics as mentioned above would be needed. In addition, systemic antifungals like fluconazole or itraconazole (for moulds) or terbinafine (for dermatophytes) should be taken for 3-4 months for finger nails and 4-6 months for toe nails.

Preventive measures:

  • Do not use harsh detergents
  • Wipe the hands dry every time the hands are washed
  • Do not destroy the cuticle during manicure and pedicure
  • Use moisturizers regularly to prevent chapping and cracking of nail folds

Other common problems involving the nails are:

  • Brittleness of the nail
  • Discoloration
  • Pitting an ridging of the nail
  • Separation of the nail from the nail plate
  • In-growing nail

Sweat Disorders

Excessive sweating (Hyperhydrosis), bad body odour (Bromhydrosis) and colouring of sweat (chromhydrosis) are common sweat gland related problems. Hyperhydrosis can be generalized or localized to palms, soles and axillae.

Generalised Hyperhydrosis: There is a marked physiologic variation in the amount of sweating from person to person. Commonly, generalised hyperhydrosis is seen during attacks of fever; this can persist for a few days to months and subsides as the fever subsides. Other causes for generalised hyperhydrosis are:

  • Emotional
  • Obesity
  • Menopause
  • Diabetic autonomic neuropathy
  • Hypoglycemia
  • Hyperthyroidism
  • Hyperpituitarism
  • Phaeochromocytoma
  • Lymphoma
  • Idiopathic

Localised Hyperhydrosis: It occurs especially on the palms, soles and the axillae and to a lesser extent over the groins and face. It is usually related to emotional factors. The sweating of palms and soles could be continuous or phasic. When continuous, it is worse in the summer and not so clearly precipitated by emotional factors. The phasic type is usually precipitated by minor emotional or mental activity and is not markedly different in summer and winter. Excessive sweating of palms and soles predisposes to a type of eczema called as pompholyx, contact dermatitis and infections.

Treatment:
Generalised hyperhydrosis:

  • Treatment of the underlying disease
  • Systemic anticholinergic agents
  • Reassurance

Localised hyperhydrosis:

  • Reassurance and relaxation
  • 1% formaldehyde soaks
  • 10% glutaraldehyde solution
  • 20% aluminium chloride in absolute ethanol
  • 1-4% poldine methosulfate in alcohol
  • 5-10% methanone
  • Iontophoresis using tap water or anticholinergic agents
  • Oral medications: Propantheline 15mg three times daily, diltiazem
  • Surgical correction: Sympathectomy
  • Injection of Botulinum toxin (Botox)

Bromhydrosis: Secretions are odourless by themselves, but bacterial action on the secretions results in formation of bad odour (commonly in the axilla, groins, feet). Treatment includes topical antibiotic creams, deodorant antiperspirant preparations containing acidic aluminium or zinc salts, 10-20% aluminium chloride (Drysol) for nights.

Xerosis

Water is essential to maintain skin plasticity and barrier integrity. Xerosis or dryness of the skin is the result of decreased water content in the stratum corneum which leads to abnormal desquamation of the corneocytes (top-most layer of the skin). For the skin to appear and feel normal, the water content of this layer should be more than 10%.

Hydration of the skin is achieved by three sources: diffusion from underlying dermis, from sweating and from surrounding atmosphere. The hydration is maintained by a barrier in the top most layer of the skin that guards against trans-epidermal water loss (TEWL) and this barrier is made up of fats released by the sebaceous glands (oil glands) and layers of the skin. Any factor that leads to either excessive loss of water through defective barrier or decreased hydration from the different sources can result in a dry skin (xerosis). Xerosis is seen clinically as flaky or ash-like skin. Dry skin is not only aesthetically unappealing but also itchy.

Defective barrier can be due to:

  • Atopics (those with family history of asthma, allergic rhinitis or dermatitis)
  • Skin diseases like psoriasis
  • Use of harsh detergents
  • Nutritional deficiency (essential fatty acids, vitamins)
  • Drugs (lipid lowering agents)
  • Aged skin

Decreased diffusion can occur in:

  • Elderly
  • Dehydration
  • Chronic photo damage
  • Decreased sweating (hypothyroidism, decreased exercise)
  • Other factors: Low humidity in the atmosphere
    • Winter
    • Central heating
    • Air-conditioning etc.

Dry skin is the most important cause of eczema that starts as itching followed by rash. Itching in individuals with dry skin may be precipitated by the following:

  • Woolen clothing
  • Detergents
  • Water (bathing for long hours)
  • Environmental changes (winter, areas with low humidity)
  • Friction (use of scrub, rough clothing)
  • Stress
  • Excessive use of talcum powders

Preventive Measures:

  • Use a mild soap and as little soap as possible
  • Bathe with warm rather than hot water
  • Avoid long bathing; use bath oils during bathing.
  • Apply moisturizers immediately after bathing, this helps retain the moisture in the skin.
  • Avoid mechanical trauma from rough clothing.
  • Use moisturizers with sun-screens on the exposed parts

Moisturization can be achieved by using the products containing the following:

  1. Occlusives: Occlusives prevent trans-epidermal water loss. Many chemicals act as occlusives; the most occlusive is petrolatum, others are vegetable and animal fats, silicon oils, vegetable waxes and phospholipids
  2. Humectents: Humectents draw water from environment and deeper tissues to rehydrate the horny layer. They may also allow the skin to feel smooth by filling the holes. Glycerin, honey, urea, propylene glycol are examples of humectents
  3. Emolients: Emolients function by filling the spaces between the desquamating skin scales and provide a smooth feel to the skin.
  4. Hydrophilic matrices: Hydrophilic matrices provide blanket against water evaporation. Hyaluronic acid is an example.
  5. Sunscreens: Sun screens prevent cellular damage and prevent dehydration. Many of the repair and replenishing moisturizing formulations contain sunscreens.

Selection of moisturizers based on body sites and skin type:

Ideal moisturizer is a combination of an occlusive, a humectent and an emolient. Selection of moisturizer should be done on the basis of the site of application, type of the skin and acceptance.

Facial moisturizers should be chosen correctly depending on the skin type. With proper use of facial moisturizers, fine wrinkling due to skin dehydration and roughness due to skin scales can be improved.

  • Oily skin moisturizers contain water and silicon derivatives such as cyclomethicone or dimethicone
  • ‘Oil control’ moisturizers contain oil absorbing substances such as talc, clay or starch and methacrylate.
  • Normal or combination skin moisturizers contain predominantly water, mineral oil and propylene glycol with very small amounts of petrolatum or lanolin.
  • Anti-wrinkle moisturizers contain sun-screen agents and alpha hydroxy acids in addition.
  • Dry skin moisturizers contain water, mineral oil, propylene glycol and larger amounts of petrolatum and lanolin.

Body moisturizers should be non-greasy and easily spreadable. Lotions are preferable. Creams and ointments are preferred in extreme cases of dryness.

Hand moisturizers – simplest is petrolatum jelly. Those with silicon derivatives can render the hand-cream water resistant.

Proper moisturizer selection can aid in the treatment of disease, whereas poorly formulated, poorly selected products can initiate the disease process.

Ageing Skin

Aging is a dynamic process; as we age several changes occur in our skin. These changes are induced by either intrinsic or extrinsic factors. Intrinsic aging is a natural process of everyone’s skin and the severity of some elements of intrinsic aging have genetic basis allowing some people’s skin age more than others.

However the most dramatic changes seen are due to extrinsic causes, the most important being sunlight (particularly the invisible UV light), smoking and pollution. UV rays in sunlight are responsible for sun burns, premature wrinkles, dark spots (lentigines and freckles), unsightly growths, rough skin texture with yellow hue and even skin cancer. The fairer the skin, the most susceptible it is. The harmful effects of UV rays are cumulative and generally not visible until middle age, even though the damage would have occurred in teenage years. Hence avoidance of sun-exposure should begin in early life.

Sun Protection: This can be achieved by use of protective clothing and sun-screens. Most clothing absorb or reflect UV rays, but white fabric like loose knit cotton and wet clothes (due to sweating) do not offer much protection. The tighter the weave, greater the protection.

Sun-screens should be used regularly and every day, whether the person is indoors or outdoors. Sun-screens are of two types – physical blocks and chemical sun-screens.

Physical sun-screens (zinc oxide and titanium dioxide) create a physical barrier for the penetration of UV light (UV-A and UV-B). These are quite effective, but cosmetically unacceptable. Now micronised titanium dioxide is available for better acceptance.

Chemical sun-screens (PABA and its derivatives, parsol etc.) absorb UV rays; some absorb only UV-A (parsol) and some only UV-B (PABA and its derivatives).

SPF (Sun Protection Factor) of a sunscreen indicates protection against burning that is caused by UVB. UVA penetrates deeper and plays a significant role in wrinkling, loss of elasticity and pigment changes. Our skin rarely burns. What we need is a protection against UV-A in addition to UV-B. Therefore daily use of broad spectrum sun-screen is a must.

Treatment of aging: Choice of treatment depends on severity and type of wrinkles along with the aesthetic needs of the patient.

Cosmetic camouflage is an effective, temporary means of concealing aging skin problems like wrinkles, mottled pigmentation and xerosis.

Treatment of aging skin includes surgical and non-surgical methods. Non-surgical treatment include use of retinoic acid (RA) and alpha hydroxy acids (AHAs). AHAs are derived from fruits and referred as fruit acids – glycolic acid from sugarcane, citric acid from citrus fruits and mallic acid from apple. But glycolic acid available in the market is synthesized in the lab and not extracted from fruits. These acids reverse the changes caused by photo-damage by increasing the epidermal thickness, dermal collagen and ground substance. AHAs take minimum of 6-8 weeks to show improvement. Results will be better if RA and AHA are used together.

Surgical methods include

  • Chemical peeling
  • Liquid nitrogen peel
  • Dermabrasion
  • Laser resurfacing
  • Injection of fats, collagen
  • Injection of botulinus toxin (for wrinkles caused by muscle contraction)
  • Face lifts and blepharoplasty

Sunscreens are the best agents anyone can use to maintain a youthful skin

Points to remember while using a sun screen:

  • Use a broad spectrum sun screen (that protects against both UVA and UVB)
  • Should be used at the right time (between 8am and 5pm)
  • Should be used in sufficient quantities (2mg/cm2 area)
  • Should be used regularly, whether indoors or outdoors
  • In countries like India, it should be used through out the year

Sun screens used in right time prevents/improves:

  • Sunlight induced skin disease
  • Pigmentation changes on the face
  • Growths on the face
  • Wrinkling of face
  • Acne scars and comedones

Pigmentation

Pigmentation disorders are disfiguring and disturbing. Hyperpigmented patches in the form of lentigines, melasma, post-acne pigmentation and peri-orbital hypermelanosis are the ones that are commonly come across.

Lentigines: These are small, 2-5mm size, dark brown to tan coloured lesions seen on the skin. They can occur both on the sun-exposed and sun-protected skin. In the elderly they are called as senile lentigines or ‘age-spots’. Sometimes they appear after acute or chronic sun exposure, hence they are called as ‘solar lentigines.’ Lentiginosis can be a feature of certain hereditary syndromes as well. Lentigines appear in childhood and increase in number up to adult life.
Treatment includes use of sun screens, hydroquinone, retinoic acid, cryotherapy etc.

lentcasitu1Freckles: These are brown coloured small lesions that are present only on sun-exposed areas in fair-skinned individuals. They appear darker in summer than in winter. They are markers for individuals at risk for sun damage and sunlight induced tumors.
Treatment includes use of sun screens, hydroquinone, retinoic acid, liquid nitrogen cryotherapy etc.

Pic: Freckles with carcinoma-in-situ on the lower lip

 

 

melasmaMelasma is an acquired, light or dark brown pigementation seen on the face, particularly on the cheeks, central forehead, nose and the upper lip. Causes could be familial, pregnancy, use of oral contraceptives, certain medicines like phenytoin, menopause, idiopathic etc. The lesions progress after exposure to sunlight.

Treatment: The response to treatment depends upon the level of the pigment and the duration of the pigmentation. Those developing during pregnancy may disappear spontaneously. Treatment includes sun screens, hydroquinone, retinoic acid, azelaic acid, kogic acid, topical vitamin C, chemical peeling etc.

Post-inflammatory hyperpigmentation: It is a common problem in dark skinned individuals. This can develop following acne, dermatitis, any type of trauma etc. The response to treatment is good when the pigmentation is in the superficial layers of the skin.
OLYMPUS DIGITAL CAMERATreatment includes mild topical steroids in early stages followed by hydroquinone and chemical peeling with trichloroacetic acid or glycolic acid. Sun screens containing titanium dioxide should be used daily.

Other than the above mentioned modalities, pigmentation can also be treated with – Nd-YAG and Q switched ruby lasers also.

Periorbital pigmentation (Dark circles around the eyes): It is very common and often causes concern in patients. Transient pigmentation under the eyes occurs following lack of sleep, physical strain, mental stress etc., which most often clears once the precipitating cause is corrected. Persistent pigmentation around the eyes could be due to the following:

  • Familial
  • Atopy
  • Eye strain
  • Acanthosis nigricans
  • Post inflammatory (following dermatitis around the eyes)
  • Aging

Treatment of periorbital hyperpigmentation is less satisfactory.

Diffuse hyperpigmentation: Pigmentation of the face can be sometimes a part of diffuse hyperpigmentation due to various causes. A thorough, systemic examination should be undertaken to look for such conditions:

  • Mechanical – Friction induced (macular amyloidosis)
  • Drug induced – Minocycline, phenytoin, chlorpromazine, antimalarials, oral contraceptives, heavy metals like arsenic, antitumor agents like busulfan, bleomycin, cyclophosphamide etc.
  • Endocrinal – Pregnancy, Addison’s disease, thyrotoxicosis
  • Nutritional causes – Vitamin B12 and folate deficiency, anemia, vitamin C deficiency
  • Chronic illnesses – renal failure, cirrhosis of liver, malabsorption syndromes
  • Collagen vascular diseases – scleroderma [See], SLE [See], dermatomyositis
  • Neoplasms – Tumors of pituitary origin, lymphomas, pheochromocytoma
  • Photosensitizing dermatoses – Pellagra, drugs, porphyria

Treatment of diffuse hyperpigmentation includes treatment of underlying causes along with use of sunscreens and depigmenting agents like hydroquinone, azelaic acid, kogic acid, retinoic acid, glycolic acid and chemical peeling. Response to treatment may be partial.

Properly chosen sun screens are the mainstay of treatment of pigmentation.

Hair Loss

Hair loss is a very common problem and the concern a patient shows for hair fall is usually out of proportion to the magnitude of hair loss. When the patient is convinced of hair loss, even normal loss of 50 to 100 per day causes anxiety. Therefore reassurance forms the mainstay of management of hair fall, after evaluating the patient to rule out the possible disease states.
Causes of hair loss can be broadly classified into:

  • Non-cicatricial (without change in the scalp skin)
  • Cicatricial (hair loss due to underlying skin disease)

See Normal Hair

Most commonly encountered hair loss is non-cicatricial and is further classified into those due to internal causes and external causes.

External causes include such common practices that damage the hair shaft – chemical treatment of hair (dying, perming, waving etc.), grooming (back combing, combing wet hair, use of dryers) etc.

Internal causes are the ones that affect the hair cycle (anagen, catagen, telogen).

  • Seasonal: Hair fall is maximum in the months of August-September and minimum in March
  • Nutritional: Iron deficiency anemia, Zinc deficiency, protein deficiency, essential fatty acid deficiency, biotin deficiency
  • Physical stress: Surgery, accidents, unusually hectic work, medical illness (chronic renal failure, liver disease etc.)
  • Emotional stress: Depression, anxiety
  • Endocrinal: Hypothyroidism, hyperthyroidism, hypoparathyroidism, hyperparathyroidism, hyperandrogenism
  • Post partum (after delivery), menopause, oral contraceptives
  • Medications: High doses of vitamin A, retinoids (used in the treatment of acne); propranolol, captopril (used for high blood pressure); lithium carbonate; thiouracil; blood thinning agents like heparins and coumarins; cancer chemotherapeutic agents
  • Chronic dandruff (See Dandruff)

Physical, emotional stress and post partum state: Hair fall following physical, emotional stress and post partum is called telogen effluvium. The hair follicles prematurely exit the anagen phase (growing phase) to enter the telogen phase (shedding phase) and are thus shed prematurely. There is a delay of about 3 months between the actual event and the onset of hair loss. Furthermore, there may be another 3-6 months delay prior to the return of noticeable hair growth. Therefore a patient should wait for about 6-9 months following such incidents to naturally gain back the lost hair.

Nutritional Deficiency: Iron deficiency (due to nutritional deficiency or blood loss) results in thinning of the hair rather than shedding and the hairs fail to enter the anagen (growing) phase. Protein calorie malnutrition, zinc deficiency, biotin deficiency and essential fatty acid deficiency result from inadequate intake (food fadism, crash dieting) or inadequate supplementation following major illnesses and lead to diffuse hair loss. Such hair loss improves on correction of nutritional deficiency.

Hypothyroidism has been found to be the cause in 10% of patients with diffuse hair loss. It is reversible on administration of Thyroxine, but if the hypothyroidism has been present over a long period, it can result in permanent miniaturization of the hair follicle.

Assessment: Assessment of a patient with hair loss should include

  • Detailed medical history and physical examination
  • Full blood count
  • Serum iron and ferritin measurement
  • Thyroid function tests
  • Liver and renal function tests
  • Microscopy of the hair

Treatment of diffuse hair loss involves correction of the underlying problem. When no cause is present, reassurance helps.

Tips for hair care:

  • Regular hair cleansing to remove the excess sebum and dirt (2-3 washes per week)
  • Use of shampoo appropriate for the type of the hair (normal, oily, dry, damaged or chemically treated) as mentioned on the shampoo containers
  • Not to comb the hair when it is wet
  • Combing and brushing should be minimised
  • Back combing should be avoided
  • As far as possible, hair should be dried naturally, without using hair dryers. If the dryer has to be used, hold the nozzle at least 6 inches away from the scalp with the lowest heat setting
  • Hair conditioners are like ‘skin moisturizers’; those with dry, damaged and chemically treated hair should use conditioners. The best conditioners anybody can use are simple oils (non-fragrant, non-medicated); the oil should be applied to the hair shaft and not to the scalp skin. In the presence of oily hair, conditioners are not required.
  • Chemical treatment of the hair (permanent dying, waving, hair colouring) should be less frequent or even avoided.
  • Consult a dermatologist in the event of any infection of the scalp like dandruff, head lice, boils etc., without resorting to unscientific home remedies.

Dandruff

Flaking of the skin on the scalp is called dandruff. It is a papulosquamous disorder with distinctive distribution and characteristic morphology. Severe variety of dandruff, characterised by redness, scaling and itching, is called seborrhoic dermatitis [SD]. It affects about 3-5% of general population, but the life time incidence may be much higher. Men are more commonly affected and tend to have more severe disease. It commonly occurs in infants and in the 18-40 years age group. There is no evidence of genetic predisposition and no evidence of horizontal transmission. Severe SD is a manifestation of HIV/AIDS.

Factors causing dandruff are:

  • Maturation of sebaceous glands: Influence of puberty and androgens
  • Malassezia yeast: Malassezia globosa, Malassezia restricta and Malassezia furfur
  • Host factors:
    • Altered immunity
    • Altered composition of sebum such as increased triglycerides and cholesterol, decreased squalene and free fatty acids (FFA)
    • Type of skin (abnormal multiplication & keratinization)

Pathogenesis:

SD is characterised by increased desquamation evidenced by increased mitotic index and parakeratotic cells. The inflammation can be immunogenic, resulting in an altered immune response to Malassezia or non immunogenic, initiated by the Malassezia yeast itself. Decreased levels of Interleukin 2 (IL2) and Interferon γ (IFNγ) result in decreased cell mediated immunity and promote fungal growth. Increased IL10 and IgE result in increased humoral response, promoting inflammation. Non immunogenic mechanisms include the Lipid like leukocyte activator (LILA) released by the Malassezia that induce neutrophil chemotaxis, Malassezia lipase that acts on triglycerides to release free fatty acids that act as irritants, stimulating Neurokinin-1, CD16+ and compliments and the action of Malassezia on human keratinocytes, resulting in the production of IL-1b, IL-6, IL-8, and TNF-α, leading to neutrophil infiltration and inflammation.

Precipitating/exacerbating factors include:

  • Nutritional factors such as pyridoxine deficiency, biotin deficiency, EFA deficiency
  • Dietary factors such as high glycemic diet that can result in increased triglycerides
  • Atopy predisposes to SD and SD in turn may worsen atopic dermatitis. Whereas infantile SD is commonly associated with atopic manifestations, adult SD is seen with asthma, Hay fever, childhood dermatitis etc.
  • Minerals – Copper and magnesium excess
  • Humidity and temperature – Increased in winter, lesser in summer
  • Stress – Increased MSH, melatonin and sebaceous secretion

SD may be associated with:

  • Parkinson’s disease
  • Mood disorders
  • Diabetes mellitus
  • Myocardial ischemia
  • Dyslipidemias
  • Obesity
  • Epilepsy
  • Malabsorption
  • Alcoholism
  • Alcoholic pancreatitis
  • Psoriasis – sebopsoriasis
  • Atopic dermatitis
  • Acne
  • Rosacea

Drugs causing SD like eruption include Methyl dopa, cimetidine and chlorpromazine. Antiepileptics may lead to SD secondary to biotin deficiency.

Clinically, dandruff manifests as greasy flaking of the scalp, sometimes associated with redness and itching and acne-like rash (Pityrosporum folliculitis) on the face, back and chest. On the face, seborrhoic dermatitis is manifested as redness and scaling on the inner side of the eye brows, glabella, sides of the nose, beard region and around the ears. Sometimes this can lead to scaling, swelling and itching of the eyelid margins.

Course: Severity of dandruff keeps varying, often aggravated by stress, tiredness and exposure to sunlight. In chronic cases, there is some degree of hair loss which is reversible. SD may be complicated by secondary bacterial infections and hair fall. Dandruff may accelerate the onset of male pattern baldness. It can also sometimes cause pigmentation on the face. Medications used for SD may result in dermatitis.

Control measures: Regular hair wash (2-3 per week), avoidance of diet rich in sugar and processed and refined food, avoidance of too much of hair oil and avoidance of stress. A diet rich in vitamins (biotin) and essential fatty acids is useful.

Treatment should be done in consultation with a dermatologist and includes antifungal shampoo and shampoos containing coal tar, selenium sulfide or zinc pyrethione. In the presence of severe scaling, salicylic acid preparations are used and in the presence of redness, mild anti-inflammatory preparations are prescribed. Oral antifungals are given in case of extensive, severe disease and associated with acne-like rash. Regular treatment is needed for many years.

Acne Vulgaris

Acne (Pimples) is a common problem seen after puberty, leading to distress, discomfort and disfigurement.

It is caused by many factors:

  • Sebacious glands (oil glands of the skin) activity under the influence of androgen hormones
  • Defective keratinisation (cell shedding) leading to partial or complete blockage of the glands
  • Propionibacteria (normal commensals of the skin) acting on the fats of the glands, releasing chemicals that cause inflammation (redness)

Eight out of ten adolescents suffer from acne. Those with a family history tend to suffer from severe acne that last longer. Patients with recalcitrant and severe acne and those who develop acne at middle age should be evaluated for underlying endocrinal disorders. Acne can be precipitated by drugs like Lithium, hydantoin, topical and systemic steroids, OCPs, androgens etc.

acnevulgaris1Clinically acne occur over the face, back and the chest and is characterised by comedones (black heads and white heads), red, raised lesions (Papules and Nodules), pus filled lesions (Pustules) and sometimes cysts.

Certain factors can increase the severity of acne like emotional stress, oily cosmetics, tight clothing, working in humid environment etc. Recent studies suggest that high carbohydrate diet may promote acne through changes in the hormonal milieu, particularly increased levels of insulin which in turn causes an increase in androgen levels. In addition, a diet rich in Omega 6 fatty acids (refined vegetable oils) and poor in Omega 3 fatty acids (fish oils) leads to pro-inflammatory cytokine profile which in turn can increase the development of acne. Omega 3 fatty acids also prevent hyperkeratinisation that leads to comedogenesis.

Preventive measures include cleansing with soaps or cleansers that are mild and gentle. Too frequent washing so as to render the face non-greasy may also precipitate acne. Use of abrasive cleansers can precipitate comedones. Picking of the comedones can lead to pigmentation. Cosmetic agents should be used carefully. Diet rich in vitamin A and omega 3 fatty acids (fish and fish oils) is useful in prevention of acne.

Treatment of acne: Acne should be treated properly and on time so as to avoid the sequelae such as scarring and pigmentation. Treatment should be done in consultation with a dermatologist who may use the following depending on the type, extent and severity of acne:

Do Don’t
Cleanse with mild and gentle soaps or cleansers Use abrasive cleansers
Use cosmetic agents carefully Indulge in too frequent washing
Use diet rich in vitamin A and EFA Pick comedones

Topical Agents:

  • Erythromycin (1-4%)
  • Clindamycin (1%)
  • Benzyl peroxide (2.5, 5, 10%)
  • Tretinoin (0.025, 0.05, 0.1%)
  • Adapeline (0.1%)
  • Azelaic acid (10-20%)
  • Keratolytic agents like salicylic acid, glycolic acid (BHA and AHA)
  • Anti-inflammatory agents

Systemic Antibiotics (for SIX months):

  • Tetracycline: 1000mg/day
  • Minocycline: 100mg/day
  • Doxycycline: 100mg/day
  • Erythromycin: 1000mg/day
  • Azithrmycin: 1000mg/day

Isotretinoin (Synthetic Vitamin A) influences all the major pathogenetic factors:

  • Reduces sebum production
  • Reduces the population of P. acnes
  • Reduces ductal cornification
  • Anti inflammatory action

Dose: 0.5-1mg/kg body weight

Adverse effects: Cheilitis, Conjunctivitis, Head ache

Hormones may be useful in cases of hormonal abnormalities

  • Oral contraceptive pills containing estrogen and cyproterone acetate
  • Glucocorticoids (only in case of congenital adrenal hyperplasia)
  • Anti-androgens (for those with features of hyperandrogenism)
    • Cyproterone acetate
    • Spironolactone
    • Ketoconazole
    • Flutamide
    • Cimetidine

Surgical procedures:

  • Comedone extraction – helps in faster resolution of acne
  • Cryo therapy (CO2 snow or liquid nitrogen spray) – improves cornification and prevents comedones (See Cryo Therapy)
  • Chemical peeling – helps in improving the cornification and also remodelling of the scars. (See Peels)
Acne Before and After Treatment
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Acne Before Treatment Acne After Chemical Peeling
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Acne Before Treatment Acne After CO2 Slush and Chemical Peeling
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Acne Before Treatment Acne After CO2 Slush and Chemical Peeling
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Acne Before Treatment Acne After CO2 Slush and Chemical Peeling
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Acne Before Treatment Acne After CO2 Slush and Chemical Peeling
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Acne Before Treatment Acne After CO2 Slush & TCA Peels
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Acne Before Treatment Acne After CO2 Slush & TCA Peels
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Acne Before Treatment Acne After Salicylic Acid Peel
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Acne Before Treatment Acne After Salicylic Acid Peel
More Acne Treatment Results