SKIN CARE

ACNE

Acne is an inflammatory skin condition, commonly affecting the face, chest and back. It is one of the most common skin conditions, affecting up to 80-90% of adolescents. Acne may also occur during infancy due to the activation of sebaceous glands by maternal hormones in-utero. It can be a persistent problem, although it spontaneously resolves after a period of 4-5 years in about 70% of people. Approximately 30% of people continue with their acne into adult life. The incidence of acne at the age of 40 is reported to be 1% in men and 5% in women.

Causes
Acne is caused by the overactivity of the sebaceous (oil) glands. Sebaceous glands are active due to the hormone testosterone. Testosterone is produced in men from the testes and in women from the ovaries and the adrenal gland. Although testosterone levels are usually normal in people who develop acne, the sebaceous glands are overly sensitive to the hormone. Over production of oil leads to a greasy feel to the skin. In addition, there is a change in the growth of the cells lining the follicular canal (pore). Instead of dislodging normally and being carried away by the oil (sebum) when they die, these cells become sticky and stick to the inner surface of the gland and gradually build up a partial blockage.

Symptoms
The partial blockage of the pore is called a microcomedone and is the starting point of all inflammatory and non-inflammatory spots in acne. Bacteria start to multiply within the blockage, which leads to inflammatory lesions or red papules. As part of the healing process, the body recruits white blood cells which destroy the bacteria but lead to the formation of pus. In some cases the blocked pores remain full of this solidified pus and may never become inflamed, these are known as the blackheads and whiteheads. Some people may go on to develop painful swollen cysts which need urgent treatment as they are more likely to lead to scarring. There are many myths surrounding the causes of acne, which include:

only teenage spots - you'll grow out of it.
eating too much chocolate and too many chips.
not keeping your skin clean enough.

Acne can be a devastating psychological disease commonly affecting the face, neck, chest, shoulders and back. The latest survey by the Acne Support Group shows that 12% of people with acne feel suicidal as a result of having the condition. Whilst it is a very common skin condition, it need not be left untreated and leave a person feeling so desperate that they want to take their own life.

Treatments
There are many treatments available, which need to be given at an early stage to prevent scarring. Treatments are generally longterm, however with encouragement and support a person can improve their skin substantially.

First line treatment for acne includes creams or gels containing the active ingredients benzoyl peroxide, nicotinamide or salicylic acid, all of which are available from chemists. Topical retinoid treatments can be particularly effective at reducing comedonal (blackhead) type acne. Antibiotics are a very popular treatment for acne as they target the inflammation associated with acne. They can be taken in tablet form, or used topically. Some topical antibiotic treatments are combined with other anti-acne ingredients such as zinc, benzoyl peroxide or retinoids. Other treatments include preparations containing the hormone therapy cyproterone acetate (females only).

For those who have not responded to systemic and topical therapies, isotretinoin, which is a synthetic vitamin A, can be very useful. This is a hospital-only drug and can achieve up to 95% positive results in patients. There are many potential side effects from this drug and hence the patient will need monitoring by their dermatologist.

Generally, treatments need to be taken for two months before any improvement is noticed and used ongoing if necessary. The aim of treating acne successfully is to stop new spots forming and avoid scarring which can be difficult to treat.


ECZEMA
The word eczema comes from the Greek and means ‘to boil over’. The main features of eczema are dry, itching, red and inflamed skin. The words eczema and dermatitis mean the same thing. Eczema affects about one in every ten people in the United Kingdom and can be mild, moderate or severe. Eczema can be a disruptive and distressing condition and can affect all areas of personal and family life.

Types, Symptoms and Causes
Atopic eczema. This is the most common type of eczema. It usually starts in babies and young children and is thought to affect up to one in every five children. The main features are itching, redness, and inflammation. Dry, scaling skin is often seen in the creases of legs, wrists and neck as well as on the face and forehead. If the skin is weeping and crusting the skin may be infected.
Atopic eczema is an inherited condition, linked to asthma and hayfever. It is thought that people with atopic conditions are sensitive to things found in their environment (allergens) which people that are not atopic find harmless. Allergens may affect the skin by direct contact, or by being breathed in or swallowed. Eczema is not contagious – it cannot be caught from someone else.

Many people have mild to moderate eczema, which can be successfully managed. However, some people do have severe eczema, which may sometimes need hospital treatment. Three quarters of children with atopic eczema grow out of it by the time they reach their teenage years.

Contact dermatitis. There are two types of contact dermatitis: allergic and irritant. Both types have similar symptoms, though the hands are most often affected. It is sometimes referred to as occupational dermatitis due to the impact it can have on a person’s occupation.

Allergic contact dermatitis. This tends to appear where the skin is in direct contact with something, for example, the earlobes in nickel allergy (if wearing earrings). It is caused when the immune system overreacts to a substance that would normally be considered harmless, and creates an allergic response. Common allergens include nickel, chromates, and fragrances. It can be a painful and disabling condition with skin which is often dry, red, split, cracked, weeping, fluid-filled and intensely itchy, sore and stinging. If the condition is related to the person’s work, a change of career is sometimes necessary. Jobs that are at high risk include hairdressing, catering, cleaning, construction, engineering, printing, health care, agriculture and horticulture.

Irritant contact dermatitis. This has virtually the same signs and symptoms as allergic contact dermatitis but is caused by repeated contact with an irritant substance such as diluted acids, diluted alkalis, solvents, soaps, detergents, metallic salts, cement, resins and cutting fluids. The most common occupations at risk of irritant contact dermatitis are those that involve wet work, for example, chefs, bakers, bartenders, caterers, cleaners, hairdressers, metal workers, surgical nurses, printers, solderers, fishermen and construction workers.

Seborrhoeic eczema. This can occur in adults, children and babies. In babies it is often associated with ‘cradle cap’. It usually starts on the scalp as dandruff that can progress to redness, irritation and scaling which can spread to the face and skin creases. It is a reaction to the increased production of pityrosporum ovale, a yeast that occurs normally on the skin in those areas which generally produce a lot of oil such as scalp, face and chest and back in men. Candida (which causes thrush) can also be found on the skin of people with seborrhoeic eczema and can make the condition worse.

Gravitational eczema. Also known as varicose or stasis eczema, this type appears on the lower legs and generally affects people in later life, particularly women. It is related to poor blood circulation and high blood pressure. Special care needs to be taken to make sure that legs are not knocked as the skin can become thin, fragile, shiny and flaky which can lead to leg ulcers.

Treatments
The main treatment for eczema is emollients (moisturisers) and an explanation of the condition and its treatments. Other treatments for mild to moderate eczema might include topical corticosteroids (applied to the skin), antibiotics, and bandaging. People with eczema might also be given advice on how to avoid allergens, the ‘triggers’ that make their eczema worse. Some people also find complementary medicines useful to treat their eczema.

Severe eczema might be treated with stronger topical corticosteroids, ultra-violet light therapy, drugs which suppress the immune system, such as ciclosporin, and oral steroids taken by mouth. New treatments, known as topical immunomodulators, such as tacrolimus and pimecrolimus, are now available for people with atopic eczema.

The term immunomodulator refers to a drug that is able to modulate or alter the immune system. In the short term topical immunomodulators appear safe but their long term safety is not yet known.


PSORIASIS

There are several forms of psoriasis, which usually appear as patches of silvery scales on top of areas of crimson skin. The scales are easily shed or scratched off. It is a distressing condition, which can lead to a reduced self-esteem. Over a million people in the United Kingdom and Ireland express the condition, equating to 2% of the population; with men and women being equally affected. Psoriasis usually occurs between the ages of 10 and 45 years, although there are exceptions. It is an inherited condition, which does not necessarily recur in successive generations.

Causes
Psoriasis is caused by the over production of skin cells. The development of skin cells to replace those naturally sloughed off occurs at up to seven times the normal replacement rate. Hence, raised red patches are produced. These can be covered with scaly, dead skin. Trigger factors for a psoriasis flare-up include: infection; damage to the skin (burns, sunburn and scratching for example) and, certain medications (eg. anti-malarial, anti-depressant and beta receptor blocking drugs). Very commonly, stressful events such as death, divorce, examinations and work pressures may precipitate a flare-up or may exacerbate a mild flare-up. In women, hormonal changes can affect the condition. The basic cause of the condition remains unknown and is subject to ongoing research.

Types and Symptoms
Chronic plaque psoriasis (psoriasis vulgaris) - This is the most common type, appearing on elbows and knees, or sometimes more extensively over the trunk and limbs.

Pustular psoriasis (palmar plantar) - Pustules on the soles of the feet and palms of the hand, which go brown and develop scales. The skin often cracks. More often seen in middle age.

Flexural psoriasis - This type appears in the armpits, groin and under the breasts. It is fiery, shiny red, with little or no scaling.

Guttate psoriasis - This is quite common in children and teenagers, often occurring after a streptococcal throat infection. Lesions appear as small ‘raindrop’ patches.

Psoriasis of the scalp and nails -Scalp psoriasis affects the majority of people who develop the condition. Scaling occurs, especially around the hairline. It is often itchy and can sometimes lead to a temporary loss of hair. Nail involvement is less common. Nails may show pitting, flaking and ridges. This can be an early indication of psoriatic arthritis (see section on Psoriatic Arthritis).

The lowering of self-esteem is one of the most profound aspects of psoriasis. With such an emphasis on appearance in society, the incidence of psoriasis can cause a great deal of distress. One of the most difficult aspects is its effects on everyday life. A reduced self-esteem can affect the freedom to sunbathe or swim, visit the hairdresser or try on new clothes in a store and sometimes the choice of career. Having to cover up in warm weather and feeling unable to pursue the activities of people who are unaffected by the condition, add to the debilitating features of living with psoriasis.

Temperature regulation is affected and people with the condition can feel hot when others feel cold, and vice versa. Sleep can be difficult. Itching and soreness can exacerbate the condition, leading to a general feeling of being unwell.

It is important to recognise that psoriasis is a non-contagious condition and cannot be spread by touch to unaffected areas of skin or to other people.

Treatments Mild to moderate psoriasis is treated with topical applications containing coal tar, dithranol, or the novel Vitamin A and D derivatives. Ultra violet light therapy and immunosuppressants are used in more resistant cases.