Tuesday, 24 May 2011 14:39

Skin Conditions and Disorders - Part One

Written by   Carl Thornfeldt, M.D.

In my article “Guidelines for Recognizing Common Skin Disorders," we looked at the most prominent skin diseases including acne, rosacea, atopic dermatitis, hyperpigmentation, and actinic keratoses. In this article, we will cover the next level of common skin conditions skin care professionals will face, which can be improved with or without the use of prescription topical therapies for which a physician, nurse practitioner, or physician’s assistant is needed. It is also important to know that several conditions, when severe, will have increased size or number of lesions that indicate there is a significant risk of an underlying potentially serious disease. These will also be addressed.

Although there is not an official definition which differentiates skin conditions and skin diseases, both skin conditions and skin diseases are characterized by abnormal appearance, feel or sensation of the skin. In this case, we will define diseases as requiring diagnosis by a medical practitioner and may need treatment either by prescription medicines or procedures performed by a medical professional, while conditions generally do not require medical attention.

Many of these conditions can look similar, and often people will attempt self-diagnosis. For instance, actinic comedones, perioral dermatitis, and sebaceous hyperplasia can resemble acne. However, traditional acne treatments for these conditions are less effective. Noting these similarities and differences you can assist your client/patient by being able to provide therapeutic options and/or refer to a specialist physician when necessary.

How to Recognize – This is an increasing problem now being claimed by 30 to 50 percent of women depending on the race. Northern Europeans and Asians seem to have a greater incidence. There are two types: 1) occult induced by increased nerve activity manifesting as burning or itching but no visible change upon exposure to topical agents; 2) visible with redness, scaling, and/or hives with burning and itching upon exposure to sunlight, water, change in humidity, in addition to exposure to topical agents.
The first type is due to abnormal skin barrier function and/or nerve enlargement and/or hyperactivity. Exposure to low concentrations of irritants applied to the skin will activate the sensitivity. Prolonged use of low fat diets and using lipid lowering medications also predispose clients to these symptoms. The second is due primarily to exposure to high concentrations of contact irritants, allergic contact reactions, and/or excessively active skin mast cells as in those with allergies, hayfever, asthma, and dermatitis personally or in the family. Nearly 30 percent of these secondary sensitive skin types react to topical retinoids, 15 percent become allergic to tea tree oil, and 10 percent react to ultraviolet light.
How to Treat – Recommend fragrance-free, as opposed to unscented or hypoallergenic products. Fragrances including some essential oils can activate sensitive skin. Products containing formaldehyde and quaternium 15 should be avoided. Avoid extreme heat such as steam, hot masks, saunas, and paraffin treatments. Avoid scrubbing products, microdermabrasion, and exfoliants. Avoid any products that contain enzymes and treatments such as chemical peels or scrubs. Any products with SD or isopropyl alcohol should be avoided as well. Topical therapies with barrier optimization properties containing petrolatum, ceramides, cholesterol, and free fatty acids are vital. Select sunscreens with only zinc oxide as the active agent.
When to Refer – Refer to a physician when symptoms are intolerable and need prescription topical and/or oral therapies.

How to Recognize – These bright red macules or papules are due to dilated small veins, arteries or capillaries.
The vessels are not “broken,” rather very dilated.
How to Treat – Long wave length (greater than 790nm) lasers and eletrocautery for localized lesions are effective. Reversing cutaneous atrophy and extrinsic aging with non retinoid cosmeceuticals is helpful. Ingested foods that increase cutaneous blood flow like chocolate, alcohol, caffeine, spicy foods, and hot beverages as well as niacin supplementation aggravate these conditions. Oral supplements consisting of glucosamine, MSM, polyphenols of green tea extract, flavonoids quercetin, and rutin shrink the vessels with six to 12 months of use. One can decrease sensitivity to ultraviolet light with oral vitamin C 500 mg, vitamin E 200 mg, and melatonin at two to six mg daily. Sunscreen with SPF 30 or higher used daily is necessary.
When to Refer – Telangiectasias may occur as the primary skin abnormality or as a result of another disease, induced by medications or from UV and X radiation. Secondary telangiectasias occur with auto immune collagen vascular diseases such as scleroderma and lupus, as well as liver disease. Estrogen supplementation or pregnancy also drive telangiectasias. Primary telangiectasias occur in two genetic syndromes and are a characteristic of rosacea.

How to Recognize – Sebaceous hyperplasia is a hypertrophy of the entire sebaceous gland. These are yellow to orangish color with a central depression like a “donut hole,” sometimes with telangiectasias. Elevations above the skin (papules) rarely occur before age 30. Actinic damage and genetics contribute to their formation as does androgen/estrogen imbalance. Wide pores are also often present. The lesions are usually located on the face and forehead of middle-aged persons and up to 80 percent of elderly people.
How to Treat – Topical therapy consists of oral prescription isotretinoin and/or anti-androgens, topical retiniods/retinol, azelaic acid, or topical salicylate. Destructive treatments consist of CO2 laser, salicylate, Jessner or TCA chemical peels, electrodessication with or without curettage as effective.
When to Refer – Refer when there is not improvement by more than 50 percent with at least six months of treatments.

How to Recognize – Actinic comedomes are due to extrinsic aging. These open and closed comedomes may progress to follicular cysts and yellowish nodules. It is reported to afflict six percent of people 50 years of age and older, predominantly Caucasians with outdoor lifestyles and/or occupations. The lesions are located on the superior cheeks, eyelids, and temples.
How to Treat – Destruction with expression then chemical peels (Salicylate, TCA, Jessner, but not glycolic) or topical retinoids, salicylates, or azelaic acid are effective treatment options. Encouraging sunscreen use will assist in preventing new ones
from appearing.
When to Refer – Refer if your patient/client has failed at least 12 months of treatment, options as more aggressive surgical procedures would be necessary.

How to Recognize – These brown, flat spots found on the face, neck, upper trunk, dorsal arms, and hands are commonly called “liver spots” along with seborrheic keratoses. The solar induced lentigines afflict 75 percent of Caucasians 60 years and older. They result from damage to the melanocytes in the skin, but are not potentially malignant unless they do NOT have sharply defined borders or even color throughout. Lentigos may increase in size and number with age.
How to Treat – Many lightening creams claim to be able to treat lentigos, but the most effective treatments are liquid nitrogen, one or more IPL treatments or a series of TCA or other chemical peels. Prescription mequinol and melasma therapy are successful options as well. Sunscreens are essential for both treatments and prevention.
When to Refer – If your patient/client is not satisfied with results from your treatments, a referral to a dermatologist is needed. When more than 30 lesions occur on a pre-puberal child this is associated with a rare serious syndrome which needs physician evaluation.

How to Recognize – These scaly white to black colored thick lesions are rare before the age of 30. These keratoses commonly exceed one half inch and tend to run in families. Multiple small white lesions on the feet are known as stucco keratoses. Small dark brown to black lesions occur around the eyes in one third of black Americans. Seborrheic keratoses are tender and crumble when picked at because the dark appearance is due to massive epidermal thickening not melanocyte abnormalities.
How to Treat – Treatments consist of spot application of chemical peel solution, cryotherapy, electrotherapy, and wart treatments. Superficial lesions over widespread areas may experience some relief and prevention of new lesions with topical salicylates and hydroxy acids.
When to Refer – When many lesions develop over a short period, an internal cancer must be suspected. When the lesions have symptoms such as itching and/or erythema lasting more than two weeks, especially if there is a color change, a referral should be made. The black ones do not predispose to melanoma, but can be confused with pigmented basal cell cancers. Melanoma, pigmented basal cell cancer, and squamous cell cancers have been diagnosed upon the removal of symptomatic atypical or inflamed seborrheic keratoses.

How to Recognize – Acrochordans, also called a “skin tag,” are small non-cancerous tumors less than four millimeters in size that are usually located on the neck, underarms, upper trunk, buttocks, behind knees, eyelids, or groin area. Nearly 50 percent of the population over the age of 30 has acrochordans. They are more common on people with weight gain, family history, aging, and on females.
How to Treat – The only treatment option is a small procedure by a dermatologist to remove the growth.
When to Refer –Acrochordans are harmless unless they become twisted resulting in red or black crusted papules. If irregular erythema or hyperpigmentation especially with symptoms, a biopsy is needed. Since such a procedure is required, refer to
a dermatologist.

How to Recognize – Poikilderma of civatte appears as hyperpigmentation on the sides of the neck and face with sparing under the chin in a horse-shoe like pattern. It results from prolonged or severe actinic damage. It less frequently results from inflammatory processes. Examination also reveals cutaneous atrophy and usually small telangiectasias.
How to Treat – Current non-prescription topical therapies are somewhat effective, but adding procedures such as a series of low potency chemical peels and/or IPL really improves results. Prescription therapies contain several active ingredients, which are effective in removing the pigmentation, but tend to induce significant cutaneous atrophy, contact irritation reactions, and rapid recurrence with minimal light exposure. As a skin care professional, it is important to be aware of these side effects. Encouraging your patient/client to avoid sun exposure and use a broad-spectrum sunscreen with an SPF of at least 45 is necessary. Using epidermal thickening cosmeceuticals such as AHAs and retinoids at low concentrations two to three times a week alternating with a depigmenter two to three times per week is helpful. Optimizing the skin barrier function improves clinical response as well as prevents recurrence. Use of gentle chemical peels, microdermabrasion, low dose IPL, and monochromatic wavelengths above 530nm are beneficial.
When to Refer – Poikiloderma seen on any body site that is not sun exposed may be associated with white blood cell malignancy (lymphoma) or premalignant parapsoriasis and should be referred to a dermatologist immediately.

How to Recognize – Solar Elastosis are yellowish papules forming plaques especially on the periphery of the face and neck. Infrequently telangiectasias are present. There are no symptoms but clients have suffered severe or prolonged actinic damage.
How to Treat – Treatment is with medium depth chemical peels (TCA and Jessner’s), IPL, CO2, or fractionated laser.
When to Refer – If the patient/client is not having success with one year of therapy, a referral to a dermatologist may be necessary to determine secondary disease.

How to Recognize – Wide, or enlarged, pores result from acne or problem skin damaging the sebaceous gland pore. It is then aggravated or may result from significant actinic damage, especially tanning booths. Sebaceous hyperplasia often accompanies the wide pores.
How to Treat – Treatments include topical retinoids, salicylates and azelaic acid, chemical peels, and microdermabrasion.

Through the course of your career, there is a good chance that you will see clients/patients who are afflicted by one or more of these skin conditions. Many of the treatment options require prolonged periods of time or multiple treatments to be effective – there are not quick fixes for these chronic conditions. However, your client/patient will be able to have long term success with proper treatment series that are coupled with proper at-home care. It is important to remind your patient/client that they play an equally important part in the long term success of treating their condition with at-home care. Recommending the usage of sunscreen and cosmeceutical products which focus on optimizing the function of the skin barrier while relieving and preventing chronic inflammation will enhance your current treatment procedures for these patients/clients and maintain remissions.

Dr. Carl R. Thornfeldt is President, CEO, and Chief Scientific Officer of Episciences, Inc. He is a practicing dermatologist with 24 years of skin research experience, 21 U.S. patents granted, and over 19 scientific publications in the area of treatment of skin diseases and conditions, including chapters in five dermatological textbooks. Along with these accomplishments, he has also spent nearly two decades focusing on researching the skin barrier and cutaneous inflammatory conditions. Dr. Thornfeldt received his M.D. from the Oregon Health Sciences University, and completed his dermatology residency at University Hospital, San Diego, Calif


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