ACNE
Acne is a skin condition which has plugged pores (blackheads and whiteheads), inflamed pimples (pustules), and deeper lumps (nodules). Acne occurs on the face, as well as the neck, chest, back, shoulders, and upper arms. Although most teenagers get some form of acne, adults in their 20’s, 30’s, 40’s, or even older, can develop acne. Often, acne clears up after several years, even without treatment. Acne can be disfiguring and upsetting to the patient. Untreated acne can leave permanent scars; these may be treated by your dermatologist in the future. To avoid acne scarring, treating acne is important.
Types of Acne and How Acne Forms
Acne is not caused by dirt. Testosterone, a hormone which is present in both males and females, increases during adolescence (puberty). It stimulates the sebaceous glands of the skin to enlarge, produce oil, and plug the pores. Whiteheads (closed comedones), blackheads (open comedones), and pimples (pustules) are present in teenage acne.
Early acne occurs before the first period and is called prepubertal acne. When acne is severe and forms deep "pus-filled" lumps, it is called cystic acne. This may be more common in males. Adult acne develops later in life and may be related to hormones, childbirth, menopause, or stopping the pill. Adult women may be treated at the period and at ovulation when acne is especially severe, or throughout the entire cycle. Adult acne is not rosacea, a disease in which blackheads and whiteheads do not occur.
Cleansing
Acne has nothing to do with not washing your face. However, it is best to wash your face with a mild cleanser and warm water daily. Washing too often or too vigorously may actually make your acne worse.
Diet
Acne is not caused by foods. However, if certain foods seem to make your acne worse, try to avoid them.
Cosmetics
Wear as little cosmetics as possible. Oil-free, water-based moisturizers and make-up should be used. Choose products that are “non-comedogenic” (should not cause whiteheads or blackheads) or “non-acnegenic” (should not cause acne). Remove your cosmetics every night with mild soap or gentle cleanser and water.
A flesh-tinted acne lotion containing acne medications can safely hide blemishes. Loose powder in combination with an oil-free foundation is also good for cover-up.
Shield your face when applying sprays and gels on your hair.
Treatment
Control of acne is an ongoing process. All acne treatments work by preventing new acne breakouts. Existing blemishes must heal on their own, and therefore, improvement takes time. If your acne has not improved within two to three months, your treatment may need to be changed. The treatment your dermatologist recommends will vary according to the type of acne.
Occasionally, an acne-like rash can be due to another cause such as make-up or lotions, or from oral medication. It is important to help your dermatologist by providing an updated history of what you are using on your skin or taking internally.
Many non-prescription acne lotions and creams help mild cases of acne. However, many will also make your skin dry. Follow instructions carefully. |
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Topicals
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Your dermatologist may prescribe topical creams, gels, or lotions with vitamin A acid-like drugs, benzoyl peroxide, or antibiotics to help unblock the pores and reduce bacteria. These products may cause some drying and peeling. Your dermatologist will advise you about correct usage and how to handle side effects.
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Before starting any medication, even topical medications, inform your doctor if you are pregnant or nursing, or if you are trying to get pregnant.
Special Treatments
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Acne surgery may be used by your dermatologist to remove blackheads and whiteheads. Do not pick, scratch, pop, or squeeze pimples yourself. When the pimples are squeezed, more redness, swelling, inflammation, and scarring may result.
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Microdermabrasion may be used to remove the upper layers of the skin improving irregularities in the surface, contour, and generating new skin.
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Light chemical peels with salicylic acid or glycolic acid help to unblock the pores, open the blackheads and whiteheads, and stimulate new skin growth.
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Injections of corticosteroids may be used for treating large red bumps (nodules). This may help them go away quickly.
Oral
Antibiotics taken by mouth such as tetracycline, doxycycline, minocycline, or erythromycin are often prescribed.
Birth Control Pills
Birth control pills may significantly improve acne, and may be used specifically for the treatment of acne. It is also important to know that oral antibiotics may decrease the effectiveness of birth control pills. This is uncommon, but possible, especially if you notice break-through bleeding. As a precautionary measure use a second form of birth control. |
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Other Treatments
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In cases of unresponsive or severe acne, isotretinoin may be used. Patients using isotretinoin must understand the side effects of this drug. Monitoring with frequent follow-up visits is necessary. Pregnancy must be prevented while taking the medication, since the drug causes birth defects.
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Women may also use female hormones or medications that decrease the effects of male hormones to help their acne.
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Photodynamic therapy using the blue wavelength of light can be helpful in treating acne as well.
Your dermatologist will evaluate you and suggest the appropriate treatment regimes considering your age, sex, and the type of acne you have.
Treatment of Acne Scarring
The dermatologist can treat acne scars by a variety of methods. Skin resurfacing with laser, dermabrasion, chemical peels, or electrosurgery can flatten depressed scars. Soft tissue elevation with collagen or fat-filling products can elevate scars. Scar revision with a microexcision and the punch grafting technique can correct pitted scars, and combinations of these dermatologic surgical treatments can make noticeable differences in appearance.
Alopecia areata
Alopecia areata (AA) causes hair loss in small, round patches that may go away on their own, or may last for many years. Nearly 2% of the U.S. population (about four million people) will develop AA in their lifetime. Some people with AA (about 5%) may lose all scalp hair (alopecia totalis) or all scalp and body hair (alopecia universalis). The immune system, for unknown reasons, attacks the hair root and causes hair loss.
Who gets AA?
AA occurs world-wide in both genders and in every ethnic group. Children and young adults are most frequently affected, but persons of all ages are susceptible. One in five persons with AA has a family member who also has the disease.
What are the signs and symptoms of AA?
AA usually begins with one or more small, round, coin-size, bare patches. It is most common on the scalp, but can involve any hair-bearing site including eyebrows, eyelashes, and beards. Hair may fall out and regrow with the possibility of full hair regrowth always present. AA usually has no associated symptoms, but there may be minor discomfort or itching prior to developing a new patch. Nails may have tiny pinpoint dents and may rarely become distorted.
| What causes AA?
AA is not contagious. It is an autoimmune disease in which the body’s immune system attacks itself, in this case, the hair follicles. The cause is not known. A person’s particular genetic makeup combined with other factors triggers AA. |
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What tests are done to confirm AA?
Although your dermatologist may know by examining your scalp that you have AA, occasionally, a scalp biopsy is helpful in confirming the diagnosis.
Is this a symptom of a serious disease?
AA is not a symptom of a serious disease and usually occurs in otherwise healthy individuals. Persons with AA may have a higher risk of atopic eczema, asthma, and nasal allergies, as well as other autoimmune diseases such as thyroid disease (Hashimoto’s thyroiditis), and vitiligo. Family members may also have atopic eczema, asthma, nasal allergies, or autoimmune diseases (i.e. insulin-dependent diabetes, rheumatoid arthritis, thyroid disease, or systemic lupus erythematosus).
| Will the hair grow back?
Yes, it is likely that the hair may regrow, but it may fall out again. The course of the disease varies from person to person, and no one can predict when the hair might regrow or fall out again. This unpredictability of AA, and the lack of control over it, makes this condition frustrating. Some people lose a few patches of hair, the hair regrows, and the condition never returns. Other people continue to lose and regrow hair for many years. The potential for full regrowth is always there, even in people who lose all the hair on their scalp and body (alopecia totalis/universalis). Hair could regrow white or fine, but the original hair color and texture may return later. |
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What treatments are available?
There is no cure for AA. While treatments may promote hair growth, new patches of hair loss may continue to appear. The treatments are not a cure. Only the body, itself, can eventually turn off the condition.
Corticosteroids — are anti-inflammatory drugs that suppress the immune system. They can be given as injections into the areas of hair loss, taken as pills, or rubbed into affected areas. Steroid injections every 3-6 weeks are given directly into hairless patches on the scalp, eyebrow, and beard areas. Hair growth usually begins approximately 4 weeks after the injection. Steroids that are rubbed directly into affected areas are less effective than injections. Corticosteroids taken by mouth have potential side effects. They are not used routinely, but may be used in certain circumstances.
| Topical minoxidil 5% solution — may promote hair growth in alopecia areata. Minoxidil 5% solution applied twice daily to the scalp, brow, and beard areas may promote hair growth in both adults and children with AA. New hair growth may appear in about 12 weeks. |
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Anthralin — is a synthetic tar-like substance that alters immune function in the affected skin. It is applied for 20 to 60 minutes (“short contact therapy”) and then washed off to avoid skin irritation. Irritation is not needed in order to stimulate hair regrowth in AA.
Combinations of these treatments may add to the effectiveness. Hopefully, new hair growth will appear in 8 to 12 weeks.
Other Alternatives
Wigs, caps, hats, or scarves are important options. Wearing a head covering does not interfere with hair regrowth. This may be a good choice for people with extensive scalp hair loss who do not have enough hair to cover it. |
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Will alopecia areata affect life?
The emotional aspects of living with hair loss can be challenging, especially in a society that regards hair as a sign of youth and good health. It is reassuring that alopecia areata does not affect general health, and should not interfere with your ability to achieve all of your life goals at school, in sports, in your career, and in raising a family.
Athlete’s foot
Athlete’s foot is a very common skin condition — many people will develop it at least once in their lives. It is more frequent among teenage and adult males, but may occur in women and in children under the age of 12. Athlete’s foot can be easily treated, but may recur in susceptible individuals.
Athlete’s foot, or tinea pedis, is a fungal infection, tiny plant-like “germs," that can grow and multiply on human skin, especially the feet. It grows best in a dark, moist, and warm environment. A foot inside a shoe is the perfect place for the fungus. The same fungus may also cause “jock itch” in the groin.
Why does athlete’s foot develop?
Athlete’s foot is contagious and may be caught by walking barefoot in the locker room. However, it is not known exactly who is at risk for getting athlete’s foot. Sweaty feet, tight shoes/socks, not drying one’s feet well after swimming, bathing, or exercising all contribute to the development of athlete’s foot.
What does athlete’s foot look like?
Athlete’s foot may not always have the same appearance. In some people, the skin between the toes (especially the last two toes) peels, cracks, and scales. There may be redness, scaling, and even dryness on the soles and along the sides of the feet. Athletes foot may also produce itching and burning of the feet. A few individuals may develop a single small patch of intensely itchy blisters. These skin changes can also be caused by other medical conditions like contact dermatitis and psoriasis.
Athlete's foot
(tinea pedis)
Fungal infections of the toenails can also occur and be difficult to treat. Toenail infections cause scaling, crumbling, thickening, and even partial loss of the nails. These changes can also result from other conditions such as psoriasis, injury, and aging.
Because all rashes on the feet are not athlete’s foot, using over-the-counter antifungal preparations on a rash that is not athlete’s foot may make your condition worse. You should see a dermatologist if over-the-counter medications do not clear the condition or if it becomes worse. Your dermatologist can correctly diagnose the condition and prescribe an effective medication. Untreated, athlete’s foot can result in blisters and cracks that may lead to secondary bacterial infections.
How is athlete’s foot diagnosed?
Your dermatologist will examine your feet thoroughly. This examination may include a scraping of the scaly area from the skin on your feet. The skin scales are then examined under a microscope to look for the tiny fungi or placed in a test tube to look for growth of the fungus.
How is athlete’s foot treated?
Once the fungus is diagnosed, treatment can begin immediately. For simple cases, anti-fungal creams are effective and can relieve symptoms such as burning and itching fairly quickly. In more severe cases, or if your infection is resistant to usual treatment, antifungal pills may be prescribed. Toenail infections may be difficult to treat and require several months of an oral antifungal medicine. It’s important to continue the use of your prescribed antifungal creams and to take all the oral medications properly. While your skin may look better, the infection can remain active for some time and could get worse again if you stop your treatment before completion.
Athlete's foot (tinea pedis)
What is the best way to prevent athlete’s foot?
You can help prevent athlete’s foot by following some simple rules:
- Wash your feet daily.
- Dry your feet thoroughly, especially between your toes, after bathing.
- Avoid tight footwear, especially in the summer. Sandals and “flip-flops” are the best warm weather footwear.
- Wear cotton or synthetic running socks which absorb sweat and change the socks daily or more frequently if they become damp.
- Dust an antifungal powder on your feet and into your shoes.
Athlete's foot (tinea pedis)
Cutaneous T-Cell lymphoma
What is cutaneous T-Cell lymphoma?
Cutaneous T-Cell lymphoma (CTCL) is a type of cancer of the T-lymphocytes (white blood cells) that affects the skin and the blood. Occasionally, it also involves the lymph nodes and internal organs.
The malignant T-Cells are attracted to the skin and can appear anywhere on the body surface. If it is mild, there will only be a rash, but if it is more severe, thick lesions called tumors can form. In some instances the skin becomes red all over.
What is the progression of CTCL?
The course of CTCL is unpredictable. Some patients progress slowly, rapidly, or not at all. Most patients will only experience skin symptoms without serious complications. About 10% of people diagnosed with CTCL will experience a progression with lymph node, internal involvement, or serious complications. Most patients live normal lives while they treat their disease, and some are able to remain in remission for long periods of time.
A 70-year-old man presented with a
strikingly digitate pattern of non-atrophic
patch stage lesions on his flank.
A 24-year-old presented with marked hyper
keratosis of the palms. Despite the thickened skin,
the histology was non-atrophic patch stage.
Is there a cure?
While there is no cure, research is ongoing. Patients diagnosed early (disease involving less than 10% of the body) will live a normal life expectancy. If you have symptoms, it is best to see your dermatologist.
Causes of CTCL
CTCL is a rare disease - five to ten persons per million are affected. The cause of CTCL remains unknown, but research continues. CTCL is not contagious and is not inherited. Men are affected more than women, and it is more common after the age of 50.
Types of CTCL
There are many types of CTCL which differ in appearance, progression, and treatment. The two main types are mycosis fungoides and Sézary syndrome.
Mycosis Fungoides - is the most common type of CTCL that primarily affects the skin. Generally it has a slow course and often remains confined to the skin. Mycosis fungoides has three phases: patch, plaque, and tumor. The patient may have one or all of these phases which can appear anywhere on the skin. Patches are usually flat, red, and scaly. They are often mistaken for eczema or dermatitis because often patients will complain of itching. Plaques are thicker raised lesions. Tumors are larger lesions that can ulcerate and can become huge and mushroom shaped (fungoides). The disease is NOT a fungal infection.
A 73-year-old man presented with
extensive atrophic patch stage lesions.
A 61-year-old woman presented with this
plaque stage lesions on her face.
Tumor on scalp of 43-year-old man.
Sézary Syndrome - is the advanced form of mycosis fungoides and affects the blood. It consists of red skin, a large number of tumor cells found in the blood (leukemia), and larger than normal lymph nodes. Often referred to as the "red-man disease," patients with Sézary syndrome often are red from head to toe and complain that their skin is hot, sore, and itchy. There may be intense skin flaking; itching and burning of the skin; loss of hair; thickening of the palms, fingernails, and soles; drooping eyelids; loss of eyelashes; and difficulty closing the eyes.
Diagnosis
CTCL is not an easy disease to diagnose. It may take years to make a diagnosis. Dermatologists diagnose CTCL from the patient's medical history, performing a physical examination, and obtaining blood tests and skin biopsies. Many skin biopsies may be needed in order to make the correct diagnosis.
This 66-year-old woman presented with a total body
erythrodermy. She was classified as having Sézary
syndrome because of the atypical lymphocytes.
Treatment
The goal of treatment is to control symptoms such as itching and burning, and to make the patches and skin tumors go away. In Sézary syndrome, treatment reduces skin redness and reduces the number of abnormal lymphocytes in the blood.
Treatment is based on the type of CTCL, patient's health, extent of disease, age, and lifestyle. Different treatments include: application of creams and ointments to the skin, oral medication, light therapies (phototherapy), interferon injections, and radiation. Different types of biological therapies which use the body's own immune system to fight the cancer are being tested in clinical trials.
Topicals
Cortisone (Corticosteroid) Cream - Cortisone is a drug that reduces inflammation. Cortisone creams, ointments, gels, and lotions temporarily control skin inflammation in many patients with CTCL. Generally, lower strength cortisone preparations are used on sensitive areas of the body such as the groin, armpits, and face. Stronger preparations are usually needed to control affected skin elsewhere on the body.
Side effects of the stronger cortisone preparations include: thinning of the skin, dilated blood vessels, bruising, and skin color changes. If creams are stopped too quickly the disease may get worse. CTCL may become resistant to cortisone creams with time.
Nitrogen Mustard Ointment and Liquid - Nitrogen mustard ointment and liquid is a type of topical chemotherapy that may clear the skin temporarily and control CTCL. Patients use gloves to apply nitrogen mustard once daily. The face, groin, and armpits are sensitive; patients should ask their dermatologist whether these areas should be avoided.
A possible side effect may be an allergic reaction to nitrogen mustard, which involves skin irritation.
Retinoids (Gel) - Also known as bexarotene, retinoids are derivatives of vitamin-A. Bexarotene, can be used as a gel or taken orally. Bexarotene gel was approved by the FDA in 2000 for patients with early-stage CTCL. When applied to the skin, it acts by interfering with the growth of cells of the tumor.
Side effects of taking bexarotene gel may be skin rash, redness, and itching.
Oral
Corticosteroids - This is a group of drugs that have powerful anti-inflammatory properties. Corticosteroids (prednisone) is common, and is usually used only in severe cases of CTCL. It can be used alone or in combination with other treatments to control CTCL.
Side effects from taking corticosteroids over a long period of time include weight gain, development of round face, increased blood sugar levels (diabetes), and thinning of the bones. A dermatologist will watch for side effects.
Retinoids (Capsule) - The oral form of bexarotene gained FDA approval in 1999 for patients with advanced-stage CTCL, or for patients who have not responded well to other therapies. The capsule acts on selecting cancerous T-Cells and causing apoptosis (cell death). The capsules are taken every day and are easily tolerated.
Side effects may include an allergic reaction, headaches, fatigue, weakness, swelling, rash, dry skin, nausea, elevation of the blood fat called triglycerides and cholesterol, decreased thyroid function, and changes in liver function. The dermatologist will monitor you with regular blood tests for side effects. Medication may be needed to control high fat levels in the blood.
Methotrexate - This is an oral anticancer drug that is used to control CTCL. Side effects include upset stomach, nausea, mouth ulcers, and dizziness. Liver function is monitored as well.
Systemic Chemotherapy
These medications kill cancer cells intravenously. Chemotherapy given in this way is called systemic treatment because the drug enters the bloodstream and travels through the body killing cancer cells. Many different types of drugs are used for systemic chemotherapy.
Fusion Protein - Is an immune system called interleukin-2 that is fused with a toxin (diphtheria). Fusion protein works by seeking and attaching to receptors for IL-2 found on malignant T-Cells. This allows the toxin to be taken inside and kills the malignant T-Cells. Fusion protein has been approved for recurrent CTCL patients in all stages of the disease.
Side effects of chemotherapy depend on the type of drug being used.
Light Therapies
Ultraviolet Light B (UVB) or Narrow-Band UVB Ultraviolet Light - slows the rapid growth of skin cells and is safe and effective under a doctor's care. Light boxes with full-body exposure are used to deliver ultraviolet rays that can treat CTCL.
PUVA - The name "PUVA" stands for "psoralen," (the drug), and the term "UVA," the specific type of ultraviolet light. After psoralen pills are taken, a carefully measured amount of UVA light is delivered to the patient in a light box. Treatments are usually three times a week and it may take several months of treatment until there is improvement. The frequency of PUVA treatments may be decreased and a maintenance regime will start when the patient is clear. Psoralen temporarily remains in the lens of the eye, therefore, patients must wear UVA blocking sunglasses on the days of treatment.
Extracorporeal Photopheresis (ECP) - The term "extracorporeal" means "outside the body" and "photopheresis" comes from the Greek words "photo" meaning "light" and "aphairesis" meaning "removal." During treatment, blood is taken from a vein and circulated through a machine where it is sensitized with psoralen, then exposed to ultraviolet light and returned to the body. This process causes selective destruction of the cancerous cells in the blood. To receive treatment, patients usually visit a medical center for two days once a month.
Side effects of all light therapies include burning of the skin (like a sunburn), premature aging, freckling, and skin cancer.
Radiation Therapy
X-ray Therapy - Spot radiation is sometimes used to focus on the affected area in the skin in an effort to kill cancerous cells. Another type of radiation is directed at the whole body called total body irradiation or TSEB (total skin electron beam).
Side effects of radiation therapy include inflammation of the skin, hair and nail loss, and lack of energy.
Interferon - This medication is used to control tumor growth. It is given by injection under the skin three to five times a week. Injections can be given by the patients themselves, a person at home, or by a dermatologist.
Side effects include: flu-like symptoms and fatigue or lack of energy. Side effects usually disappear when the drug is discontinued.
Ongoing FDA Clinical Trials
Biological Therapy - Tries to get the body to fight the cancer. It uses materials made by the body to restore the body's natural defenses against the disease. Although various new biological drug modifiers are being tested, they are not yet approved by the FDA.
Also in research is a type of bone marrow transplant called autologous bone marrow transplant, in which bone marrow is taken from the patient and treated with drugs to kill any cancer. The marrow is then frozen while the patient undergoes chemotherapy, and is given back to the patient to replace what was destroyed once the patient is finished with the chemotherapy treatment.
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