Psoriasis is a chronic inflammatory conditions that affects the skin, nails, and joints. It impacts more than 7-million Americans and can affect both children and adults. It is characterized by well-defined pink scaly plaques that commonly affect the scalp, elbows and knees, but it can affect any part of the body. The amount of skin involvement can range from mild/localized to severe/extensive. Treatment should be tailored to the individual and often consists of topical therapies (topical steroids & Vitamin D analogues). For more extensive disease or those who also have psoriatic arthritis, there are oral treatments (methotrexate, cyclosporine, and acitretin) and various injectable biologic medications (Enbrel®, Humira®, Remicade® and Stelara®) that can help control the symptoms and skin disease. Ultraviolet lights (narrowband-UVB and UVA) have been shown to be quite effective in controlling the skin disease. Importantly, patients with psoriasis appear to be at risk for developing hypertension, diabetes, and dyslipidemia, and they are ultimately at higher risk for vascular disease. Patients benefit most by screening for these modifiable risk factors and providing a multidisciplinary comprehensive approach.
Acne is a multifactorial disorder of the pilosebaceous unit that is characterized by comedones, papules, pustules, nodules, and by cystic lesions and scarring in more severe cases. It most commonly begins in early adolescence and affects most individuals between 12 and 24, but it affects a wide range of patients and may even first develop in adulthood. The earliest lesion are microcomedones, which may develop into closed comedones (“whiteheads”) and open comedones (“blackheads”). These lesions can become larger and rupture into the surrounding skin, which causes redness and lots of inflammation. Treatment for acne is directed by the severity and by the other contributing factors. First-line therapy for mild disease often includes topical antimicrobial solutions/washes (Clindamycin, benzoyl peroxide and salicylic acid) and topical retinoids. For moderate to severe disease, many patients require treatment with oral antibiotics (doxycycline, minocycline, tetracycline, and trimethoprim-sulfamethoxazole), oral contraceptives, oral antiadrogens (spironolactone), and even oral retinoids (isotretinoin/Accutane®/Claravis®). For inflammatory or cystic lesions, they can be extracted or drained and may be injected with intralesional steroids to reduce inflammation.
Eczema is a generic term used to describe inflammation of the skin. In the acute stages, it begins with red edematous plaques that may have small microvesicles. Subacute lesions present as erythematous plaques with some scale or crusting. Over time, these lesions may be covered with thick dry scale and can become lichenified. In most types of eczema, pruritus is a prominent symptom and may be severe at times. It may affect particular areas of the skin, including the hands, eyelids, or ears.
Atopic dermatitis is one of the most common types of eczema and most frequently begins in early childhood. It presents with mild irritation of the extensor surfaces of knees/elbows and the face in early infancy, which often progresses to involve the skin folds of the arms and legs later in childhood and in adults. Patients often have other signs/symptoms of an allergic or atopic background, including asthma, allergic rhinitis, and seasonal skin sensitivity. While many cases appear to improve during childhood, many patients experience a more chronic course with relapses and remissions. Treatment for this dermatitis aims at reducing inflammation in the skin with the use of topical steroids and other topical immunomodulators (Protopic® and Elidel®). Antihistamines can be used when pruritus is a prominent symptom. Topical antiseptics including antibacterial ointments and antiseptic washes are aimed at reducing the incidence of secondary bacterial infections in the skin. Beyond prescription topical therapies, patients must adhere to a good regimen with moisturizers and emollients.
Rosacea is a chronic skin condition that is characterized by acne-like pimples and pustules, facial redness, inflammation, broken red vessels, and frequently irritation of the eyes and eyelids. This inflammation most frequently involves the central face, particularly the forehead, nose, cheeks, and chin. It often begins after age 30 and goes through periods with flares and remissions. Beyond the skin, it often produces various symptoms, such as flushing, burning, itching and sometimes swelling. Patients often find that there are certain triggers which may cause acute flares or worsening of inflammation. These triggers are often individual and include sun exposure, heat, alcohol, spicy foods, or even emotional stress. Patients are encouraged to identify their triggers and try to avoid them to reduce the severity of disease. For patients with acne-like lesions, inflammation or involvement of the eyes/eyelids, treatment may include an oral antibiotic (such as doxycycline), which are used for their anti-inflammatory properties. Gentle skin cleansing along with various topical therapies may help to improve the condition of the skin. For patients with predominantly redness and broken blood vessels, treatment with vascular lasers can help to improve the background color, reduce inflammation, and help to eliminate the more prominent dilated vessels.
Contact dermatitis refers to irritation/inflammation of the skin that falls into two main categories: irritant and allergic. Irritant contact dermatitis, as the name implies, produces a non-specific irritation of the skin from a particular chemical without previous exposure. These chemicals can produce an eruption in most people who come in contact with them. Many cases of irritant dermatitis come from excessive hand washing, often with alcohol-based rubs, or from occupational exposures. The mainstay of treatment in these cases are protection of the skin from these chemicals, avoidance of excessive moisture, and appropriate use of emollients. Allergic contact dermatitis, on the other hand, is an acquired sensitivity to various substances that produce inflammatory reactions in those previously sensitized to the allergen. The most common contact allergens include poison ivy, nickel, fragrance, formaldehyde and formaldehyde-releasing preservatives, neomycin, bacitracin, and rubber compounds. Patch testing is commonly used to detect sensitivity to a panel of the most commonly encountered contact allergens in the skin. A positive reaction can identify the causative allergen and will allow for appropriate avoidance of this agent to improve presenting skin dermatitis. Treatment of the acute dermatitis often consists of medium- to high-potency topical steroids and may even require short courses of oral steroids in more severe cases. Ultimately, careful allergen avoidance and product selection helps to maintain the skin in its best possible condition.
Vitiligo is an autoimmune disorder of the skin where the immune system targets and destroys the pigment-producing cells (melanocytes). This results in pink to white patches of the skin with hypopigmentation and ultimately depigmentation in some cases. It commonly occurs in the perioral and periocular areas, as well as the hands, feet and areas of trauma or friction. There is believed to be some genetic component to this condition, and there may even be other associated autoimmune thyroid conditions. These light patches on the skin can be difficult to treat and may present a significant cosmetic concern to patients with prominent facial involvement or conspicuous involvement on the torso or extremities. Treatment often consists of topical steroids and topical immunomodulators (Protopic® and Elidel®). Ultraviolet therapy with narrowband-UVB can be effective for extensive generalized involvement, whereas the Excimer laser with a wavelength of 308-nm can provide phototherapy exclusively to the affected areas of the skin. Beyond treatments directed at improving skin pigmentation, patients may benefit from various camouflaging make-ups or cover-ups, such as Dermablend™.
Shingles, otherwise known as herpes zoster, is caused by a reactivation of the chickenpox virus (varicella-zoster virus) in a particular area of the skin. It usually presents with an erythematous, pink, red crusted vesicular eruption, which may be preceded by or accompanied by a significant burning, itching or tingling sensation. In the skin, it is typically limited to a single side of the body along the distribution of a single nerve, the so-called dermatomal distribution. Many believe that shingles develops because a person’s immunity to the chickenpox virus can decrease over time or with high levels of stress on the body. Patients must recognize the symptoms and characteristic pattern to this rash to make sure to visit their doctor and institute early treatment with oral antiviral medications (Acyclovir or Valacyclovir). This early treatment may help to improve the rash and symptoms faster, but it may also help to reduce the severity of post-herpetic neuralgia (persistent burning/tingling sensation in the skin after the episode of shingles has resolved). Additionally, patients over the age of 50 may consider the shingles vaccine (Zostavax) for the prevention of shingles. The vaccine contains a weakened varicella-zoster virus, which can boost your immunity to this virus and reduce the chances of developing shingles by nearly 50%. Additionally, the vaccine has been shown to shorten the course of pain episodes associated with a shingles outbreak. It is important to know that this virus is still contagious in its earliest stages with oozing/open/vesicular lesions, and it can be transmitted to other patients and may cause chickenpox in a patient who has never had the disease. Also, patients should not be around pregnant women, as this virus can pose significant risks to a developing fetus and can cause damage or even fetal demise.
Seborrheic dermatitis is a very common, inflammatory skin condition that’s characterized by greasy/oily areas with flaky, yellow-white scales. It most commonly affects the scalp, ears, eyebrows, nose, nasolabial folds, and beard area, thought it can also affect the chest, back and even groin area. It is believed to be due to a combination of overgrowth of yeast on the skin and overproduction of skin oil. Individual patients may have a particular sensitivity to this yeast and develop more prominent inflammation, which is seen in pink-red color of the skin. It does appear to run in families and can be worsened by stress, fatigue, weather extremes, or other skin disorders. This type of eruption in children is referred to as cradle cap and typically is self-limited and often does not require any treatment. In children and adults with more prominent scalp dandruff/scaling or facial involvement, there are a number of topical therapies which appear to provide some relief. Topical antifungal agents, such as ketoconazole in its cream, gel or shampoo formulations, can be used to cut down the amount of yeast on the skin and thereby reduce inflammation. Topical steroid creams and lotions, along with non-steroidal topical antiinflammatory (Protopic® and Elidel®), can also help to calm down the inflammation and reduce the appearance of redness and irritation. Patients may be given prescription-strength shampoos and are often encouraged to incorporate various anti-dandruff shampoos, such as Head-&-Shoulders (pyrithione zinc) or Selsun Blue (selenium sulfide).
Most fungal infections in the skin are caused by very superficial infection with dermatophytes, which are referred to as tinea. The various skin infections get there name for the body locations that are affected: tinea capitis (scalp), tinea corporis (body), tinea versicolor (trunk), tinea cruris (groin/folds), tinea manuum (hands), and tinea pedis (feet). This type of superficial fungal infection often presents with prominent pink-to-red scaly plaques, which tend to be annular or ring-shaped when they affect most areas of the scalp, face or body. They frequently cause discoloration and lightening of the skin in the affected areas. When the skin over a light area is stretched, there will often be more noticeable scaling. The diagnosis can often be made by good clinical examination and relatively easily confirmed with a skin scraping and examination using potassium hydroxide (KOH) under a microscope. In some cases, nail clippings, hair cultures or even skin biopsies can be sent out to confirm the diagnosis. Oftentimes, this superficial fungal infection will respond well to antifungal shampoos which can be used for the scalp or as a body wash for other areas along with antifungal creams. More extensive cases in the skin or involvement of the scalp or nails may require a more extended period with oral antifungal treatments, such as terbinafine (Lamisil®) or griseofulvin. It is important to have your treatment monitored by your doctor to ensure complete resolution of your symptoms and to limit the possibility of side effects.
Warts are a very common skin condition in younger children and are frequently seen in adolescents and even adults. It is caused by a particular strain of a virus (human papilloma virus, or HPV) and presents with overgrowth or hyperproliferation of the skin. These typically present as small, hard, rough verrucous or warty-looking growths. Since this is caused by a virus, they can be contagious and spread from person to person. Most people will develop immunity to this virus and will ultimately clear their warts and never develop them again. Other people may have a greater sensitivity to these viruses and can have more difficulty treating them and clearing up the skin. Most treatments are focused on destruction of the affected skin, which can be done using cyrotherapy (cold spray) with liquid nitrogen. Various topical solutions contain salicylic acid and aim to more gently exfoliate and remove the top layers of the skin. Most cases will respond to a combination of these therapies. For more extensive cases, patients may receive topical medications or intralesional injections that are designed to enhance the individual’s immune response to the virus or even to cause greater damage to the affected tissue to enhance the inflammatory response to the warts.
Molluscum contagiosum is another common skin condition that is caused by a virus. In this case, a pox virus is responsible for the superficial infection of the skin and development of the characteristic umbilicated pink-white papules. These lesions may also be contagious and can be transmitted from person to person, though most individuals develop an immunity to this virus early on in life. Treatment of these lesions is primarily directed at destruction and removal. This can be achieved using cryotherapy with liquid nitrogen, cantharidin (blister beetle juice, which causes blisters to develop to remove the lesions), or even light curettage (scraping the skin). As this condition is frequently encountered in younger children with sensitive skin, parents must find a balance between treating the individual lesions and watchful waiting to see if they will resolve without any treatment. It is important to realize that these spots can be alarming or frightening to patients and to parents, but they are not dangerous and must be treated in a way that will leave the least amount of permanent changes or scarring in the skin.
Many patients come to the dermatology office for evaluation of new or concerning skin growths. It is important for a trained professional to examine these lesions and to provide a comprehensive skin examination. It is important to understand that these types of skin lesions may benign skin growths or may be early pre-cancerous lesions or even skin cancers.
There are many different benign skin growths, ranging from seborrheic keratoses (“barnacle”-looking rough spots) and warts to angiomas (soft purple-to-red papules), skin tags, and many others. Most concerning spots that bring patients into the office fall into this category. It is important to know that some of these growths can become irritated, enlarge, and bleed, making them difficult to distinguish from certain skin cancers. With this understanding, it’s important for a trained professional to examine these lesions and determine the need for skin biopsy and/or additional treatment.
Non-melanoma skin cancers, which include both basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs), are the most commonly diagnosed new cancers in all patients. While these lesions tend to be superficial and confined to the skin, there are certain subtypes of SCCs or high-risk locations that can be a greater risk for spread to local lymph nodes or other parts of the body. Melanoma is one of the most dangerous skin cancers and has a much greater risk of spread than BCCs or SCCs. However, early diagnosis and treatment of superficial or “in-situ” melanomas has nearly a 100% cure rate, so it is important to be have a skin cancer screening by your dermatologist on at least an annual basis (or more frequently if you’re at higher risk because of a personal and/or family history of melanoma).
For a review of actinic keratoses, BCCs, SCCs, and Melanoma, please see “Surgical” section.
Amongst all visits to doctors, skin rashes are one of the most common complaints for patients. “Rash” is a generic term for a wide variety of skin conditions. Most of these rashes are not dangerous and can be fairly easily treated with over-the-counter topical therapies and oral antihistamines. As you probably read above, there are a number of skin rashes which have a characteristic presentation that makes their diagnosis and treatment more straightforward. These most common skin rashes include atopic dermatitis (eczema), contact dermatitis, psoriasis, seborrheic dermatitis, acne, and various skin infections (bacterial, fungal, and viral). While these are the most common, it’s important to realize that there may be a lot of contributing factors to a particular skin rash, and there may be an overlap of two or more different components (such as an eczema with superimposed contact dermatitis or a foot fungus with secondary bacterial infection). In certain cases, skin biopsy may be useful to aid in the diagnosis. Nonetheless, most cases can be treated using a combination approach with topical and/or oral therapies with great response in the hands of an experience dermatologist. If you have a rash that’s not getting better or causing persistent symptoms, please make an appointment to be evaluated by your doctor.
More information coming soon.