Who Has Acne & Where?

Acne is a very common skin problem in adolescents. You and your friends probably have had this trouble in the past or even now. Girls reach their puberty earlier and have the peak around age 14 - 17, while boys around age 16 - 19. Actually, lots of adults are troubled by acne too, and believe it or not, even people around the age of 40 still come to the doctors seeking treatments for acne. Their acne is also more difficult to treat than those in youngsters.

Acne distributes mainly in areas where there are lots of oily secreting glands called sebaceous glands. Apart from the face, it is frequently seen on the chest, back and shoulders. Among the sufferers, 99% have it on their face, 90% on their back, 78% on their chest, and 75% in all 3 areas.

Not uncommonly acne happens only on the shoulder or the chest, and patients are puzzled to learn that it is acne rather than some skin allergy they have in mind.

Acne on Chest	Acne on Back

What Causes Acne?

• The sebaceous glands secret oil into the follicles, and the oil then flow onto the skin surface. During puberty, the sebaceous glands are stimulated by the surge of male hormones that escalate the oil production. Sometimes it may be over sensitivity to a normal amount of male hormone.

• The cells in the follicles grow abnormally, and cause thickening. Together with excess oil, this blocks the pores and leads to whiteheads and blackheads, referred to as pimples, or medically non-inflammatory acne.

• The thickened and enlarged follicles encourage growth of bacteria, which break down the oily content into some harmful chemicals. These chemicals cause inflammation, with redness, swelling, and pus formation, the inflammatory acne.

Mild Acne
There are mainly features of blockage, with few whiteheads and blackheads. There may be some small inflammed acne.

Moderate Acne
The number of inflamed acne and the degree of inflammation increase, but mostly in the superficial level. There may some deep pustules.

Severe AcneThere are lots of large inflamed acne and deep pustules. The chest and back may be affected too. This can lead to scarring easily.

Mild	Moderate

Moderate to Severe	Severe

Treatments For Acne

Some people may think that acne is only a mild skin problem that would burn itself out after a while, and ignore proper treatments. This could lead to long-term deep-seated inflammation and leave permanent scars. This is totally preventable these days with very effective medications, and so early treatment is warranted.

Cleansers

There are numerous of them around, and you can find from very cheap one to very expensive cosmetic brands in the chemists. Even the expensive ones are not necessarily good. All of them are helpful only to the mild acne.

They contain too many different ingredients that cannot be all listed out here. The more effective ones are glycolic acid, salicylic acid, and benzoyl peroxide.

Glycolic and salicylic acid can improve the dead skin layer and reduce blockage. Benzoyl peroxide can inhibit the growth of bacteria and prevent the pimples from becoming inflamed acne.

External Preparations

1. Benzoyl Peroxide
Concentration from 2.5% to 10%. There are solution, gel, and cream available. It can inhibit bacterial growth and has inflammatory property. It has the advantage of not causing bacterial resistance. The side effects include irritation with red, dry and itchy skin.

2. Antibiotics
There are Erythromycin and Clindamycin, again with solution, gel and cream. They are anti-bacterial, but the incidence of resistance is mounting. To avoid this and to increase the anti-inflammatory effect, it is commonly used together with benzoyl peroxide.

3. Retinoids
They are vitamin A derivatives. There are Tretinoin 0.025%, 0.05% and 0.1%; Isotretinoin 0.05% and 0.1%; Adapalene 0.1%. They work by reducing the oily secretion and normalise the cell growth inside the follicles. They are particularly effective for non-inflammatory acne, but the effect is slow and usually takes several months. Sometimes they can make the acne slightly worse.

To the first-users, there may be irritation in the initial period, with dryness and flaky skin. This usually subsides after getting adapted to it. This is best avoided during pregnancy because there is uncertainty regarding their absorption into the system and safety to the babies.

4. Azelaic Acid
This is a natural chemical acid, which is present on our body. It has many different functions:

• Inhibit the bacteria inside the follicles

• Inhibit the free radicals causing the inflammation

• Normalise the cell growth inside the follicles

• Inhibit abnormal growth of melanocytes

• Inhibit the enzyme tyrosinase, which is essential in making melanin

Therefore azelaic acid is very effective against both non-inflammatory and inflammatory acne. It can soften the deep pustules and make them smaller. Like others, significant improvement takes 3 - 4 months.

The main side effect is irritation and dryness. Because of its effect on melanin, it can also be used in lightening melasma.

5. Fruit Acid
There is glycolic acid, which is an Alpha Hydroxyl Acid, and salicylic acid, which is a Beta Hydroxyl Acid. They can clear the blockage by loosening the dead skin cells. They are prepared as cleansers as well as lotions, but the concentrations over the counters are usually quite low.

Doctors will, according to individual cases, prescribe higher concentrations like 10 - 15%. Some will also use 20 - 70% solution to perform chemical peeling, which is useful in treating acne as well as the acne scars.

Oral Preparation

1. Antibiotics
This is necessary when you have moderate to severe acne. They can directly reduce the bacteria inside the follicles and have anti-inflammatory property.

You need to take them for a course of 3 - 6 months. Sometimes people stop taking them after only a short period when they see some improvement. This can cause the bacteria becoming resistant and make future treatments more difficult.

The usual antibiotics prescribed are Tetracycline and Oxytetracycline. They cannot be taken together with milk because of poor absorption. The new generations like Doxycycline and Minocycline do not have this limitation and also have less bacterial resistance. Another choice is Erythromycin.

The problem with antibiotics is the ease of bacteria becoming resistant. Also the treatment effect is short lasting, with high chance of early recurrence. Therefore you may be taking course after course of antibiotics over the years, and each time of recurrence may give you new marks and scars on the face.

Antibiotics may cause gut upset or skin allergy. Tetracycline can stain the developing teeth black, and may make the skin more sensitive to the sun with easier burn. Minocycline can rarely cause some bluish grey discolouration of the skin, and allergedly some skin features similar to those in systemic lupus.

Females can be troubled by the overgrowth of candida in the vagina, because the antibiotics disturb the balance of micro-organisms. The effectiveness of the contraceptive pills may be reduced too.

2. Hormones
Anti-male hormone treatments can shrink the sebaceous glands and reduce oily secretion. The usual preparation is Cyproterone Acetate, together with female hormone Ethinyl Estradiol in contraceptive pills. If you are a female who requires contraception, with acne flaring up during menstruation, and other external preparations fail to work, then this is suitable for you.

Like antibiotics, recurrences are common. The main side effects are gut upset and liver damage. If you cannot take the contraceptive pills for some reasons, for example migraine, then you cannot take this too.

3. Vitamin A Derivatives
The only one available on the market is Isotretinoin, which is a very effective medicine. More than 10 years ago, it was prescribed only for the most severe cases of acne, but it is now becoming more widely used. Apart for some other skin diseases, it is also used in the milder cases of acne, in order to prevent the ultimate scars.

The usual course of Isotretinoin is 4 - 6 months. On average, the dosage is 0.5mg for every kg of body weight per day. So most people would be taking 20mg - 30mg daily, although sometimes more may be needed.

It has many functions. It can shrink the sebaceous glands and reduce their oily secretion; normalise the cell growth inside the follicles, reduce the blockage and pimples; and also has anti-bacterial and anti-inflammatory effects.

Although it has to be taken for a few months as for antibiotics, it has a major significant difference. Recurrence after antibiotics is quick and common, while the improvement from Isotretinoin can last for a long time, on average 2 - 5 years, although some may be shorter or longer. Even though when the acne does recur, the degree is usually much less, with less inflammation and smaller pimples. Therefore, despite the higher initial cost, it is more economical in the long term when compared to antibiotics.

If you decide to take Isotretinoin, pay attention to the following:

• The initial improvement is slow to come, usually takes about 4 weeks to become apparent, so be patient
• The improvement occurs faster on the face than the chest and back.
• In the first few weeks, there may be a temporary mild flare up in some cases, but it will stop and improve as you continue the treatment.

The main side effect is dryness, of the skin, lips, and even insides of your eyes. This usually slowly disappears in weeks. You need to apply plenty of moisturiser.

Other side effects include mild muscle ache, and headache. Sometimes the liver enzymes and triglycerides levels may rise, so may the sugar level in diabetics. If they are too high you need to stop the medication and they will return to normal with no permanent damages.

The most important thing is that female patients should not become pregnant while they are on this medication, otherwise the baby will be abnormal. Therefore during and 4 weeks after the treatment, an effective contraception must be used.

On the whole, Isotretinoin is a very effective treatment. It should be considered before the permanent acne scars are formed, and not after everything else has failed, because it would not be useful for scars.

Severe Acne Scars

Common Mis-understanding About Acne

• Acne is not contagious!
• Acne is not going to heal automatically. Treatment can prevent the scars from forming.
• Acne is not just due to poor hygiene and cleaning. To wash your face more frequently with different cleansers will not cure acne, although this may help to reduce the oiliness.
• Acne is not going to get better in days after treatment. You need to be persistent and continue most forms of treatment for 3 months or more.
• You may think sunlight may kill the bacteria. In fact sun exposure helps only 60% of acne sufferers, while 20% has no effects, and 20% will get worse. Some sunscreens will block the follicles and cause more acne. UV lamps are definitely useless, and will cause you skin aging.
• You may think some foodstuffs will stimulate acne, and avoiding them will make acne better. Actually there is no scientific proof of this. No matter how you try, it will not help.

There is still no answer as what causes rosacea. There have been many theories, including the helicobacter pylori in stomach ulcer, and hormonal imbalance, but none of them is confirmed to play a part.

Since the main symptom in rosacea is the flushing, one reasonable suggestion is that the blood vessels in the face are over-sensitive to some normal stimulating signals, with resulting inflammation in the follicles and oily glands.

This is a very common problem and affects our appearance. Generally it is more common in females in the age group of 20 - 40, but is more severe when it happens in the males. Because of its red-faced, acne-like effects, it can cause significant psychological, social and occupational problems if left untreated.

Signs

Typical signs and symptoms include facial flushing, redness, burning, red bumps, and cysts. Initially, the face turns red under a hot stuffy environment, or after exercise. This is intermittent and the redness tends to come and go, lasting for only minutes.

The symptoms will gradually happen more often and last for longer, and eventually turning into a semi-permanent and then permanent flushing.

Later on the blood vessels on the cheeks and nose will become dilated and obvious. First they are thin, but then will get larger and appear purplish red.

Typical Distribution	Dilated Blood Vessels

In the next stage, there will be acne-like little papules, which can be itchy and contain pus.

The flushing, dilated blood vessels, and papules can appear either independently, or altogether. They go away when the skin is cooled down. The sequence may be different. Some sufferers may only have the papules, while some may have all three of them.

If left untreated for a long time, because of the inflammation, the skin on the face is hardened and swollen. The nose will appear lumpy and swollen like a strawberry. This disfiguring nose condition is called rhinophyma, which occurs mainly in the males, and may require surgical repair.

Some people will have complications affecting the eyes, such as dry eyes, conjunctivitis and even keratitis (inflammation of the cornea).

Management & Treatments

Rosacea cannot be cured; but it can usually be controlled with proper, regular treatments. Mild rosacea may not necessarily require treatment if the individual is not bothered by the condition. More resistant cases may require a combination approach, using several of the treatments at the same time.

A combination approach may include antibiotic cream morning and night, and taking an oral antibiotic for flares. A series of in-office laser, intense pulsed light, or photodynamic therapies may also be used in combination with the home regimen.

Since there is some overlap between acne and rosacea, some of the medications may be similar. Acne and rosacea have in common several possible treatments including oral antibiotics, topical antibiotics, and isotretinoin.

General Measures

Hot stuffy environment will aggravate the symptoms and should be avoided. Sunscreen should be used when going under the sun. Too hot or too cold weather will affect the contraction and dilation of blood vessels. Hot and spicy food, coffee, tea, and alcohol all make rosacea worse and should be avoided or kept to a minimum.

Topical & Oral Antibiotics

They are used for their anti-inflammatory effect, not to kill bacteria. Mils cases can use topical metronidazole, clindamycin, or erythromycin. When more severe, oral erythromycin, doxycycline, minocycline, or tetracycline can be used. Some doctors also find oral metronidazole helpful.

Isotretinoin

Isotretinoin has been prescribed to patients with severe rosacea. However, close physician monitoring and blood testing are necessary while on isotretinoin.

Topical Steroid

Short-term topical steroid preparations of minimal strength may in occasional cases be used to reduce local inflammation. It should not be used often or for a long period because it may actually cause a flare up.

Laser and Intense Pulsed Light

Many patients are now turning to laser and intense-light treatments to treat the continual redness and noticeable blood vessels on the face, neck, and chest. Often considered a safe alternative, laser and intense pulse-light therapy may help to visibly improve the skin and complexion.

Treatments are recommended every 3 - 6 weeks; during this time, sun avoidance is necessary. Risk, benefits, and alternatives should be reviewed with your physician prior to treatment. Laser treatments may be combined with photodynamic therapy for more noticeable results.

Sweating is a normal physiological phenomenon. It is required to regulate the body temperature during times of exercises and in hot environment. Excessive inappropriate sweating is referred to as hyperhidrosis, although this can also include facial blushing.

Hyperhidrosis causes a great deal of inconvenience. A cold sweaty hand makes hand shaking embarrassing; or the handling of delicate materials impossible, and the unpleasant odour from the underarm drives everybody away from you. The sweaty feet can also lead to other problems like fungal infections and warts.

It is divided into primary and secondary hyperhidrosis.

Primary Hyperhidrosis

Means it has no known cause. It is far more common than secondary hyperhidrosis. It usually starts during childhood or adolescence and persists all life. It mainly involves a localised part. Nervousness and anxiety can elicit or aggravate the sweating.

Excessive Sweating

No one knows what the mechanism is but the endocrine system may be related. The endocrine system regulates chemicals such as epinephrine (adrenaline), nor-epinephrine (nor-adrenaline) and serotonin, which control anxiety levels, mood and appetite.

This can occur in :
1. hands (palmar hypherhidrosis)
2. feet (plantar hyperhidrosis)
3. armpits (axillary hyperhidrosis)
4. face

Facial Blushing

The mechanism is similar with chemicals above stimulate the blood vessels in the face and make them dilate. As a result more blood go through them, causing a red or flushed face. Facial blushing too can be devastating socially. People often develop vast avoidance behavior to deal with the blushing episodes.

Medications that can be helpful for facial blushing include:

• Beta blockers, such as atenolol, help to slow down the heart rate and reduce anxiety associated with public speaking.
• Alpha blockers help blood vessel to maintain constriction.
• SSRI's (selective serotonin re-uptake inhibitors) can be helpful to reduce anxiety that causes the flushing.
• Diazepam, Lorazepam and other benzodiazapines can also be very effective for controlling the anxiety that results in facial blushing.

Secondary Hyperhidrosis

As a rule it involves the whole body. It is usually caused by another disease, such as hyperthyroidism, diabetes mellitus, hyperpituitarism or similar endocrine diseases. Menopause commonly has hyperhidrosis as one of the features. Occasionally severe psychiatric disorders and obesity is the cause.

Treatment of the underlying cause is first attempted to relieve the symptoms.

Non-Surgical Treatments (Primary Hyperhidrosis)

Anti-perspirants

The simplest method and is usually recommended as the first therapeutic measure. They are effective in mild to moderate hyperhidrosis but have to be repeated regularly. The commonest agent is aluminum chloride or chlorhydrate. Sometime in the presence of sufficient moisture and heat, aluminum chlorhydrate can be converted into hydrochloric acid and causes irritation and clothes staining

Oral Medications

Oral prescription medications commonly used include:

• anti-cholinergics
• beta-blockers (e.g., atenolol, propanolol)
• benzodiazapines (e.g., diazepam , lorazepam)

Tap Water Iontophoresis

This is a very popular method being used more frequently nowadays.

What Is Iontophoresis?

Iontophoresis is defined as the topical introduction of ionized substance into the skin using direct current. The positive current will drive positively charged drug molecules away from the electrodes and into the tissues, similarly, a negative current will drive negatively charged ions into the tissues.

Simple tap water contains different minerals that can act as the substance, is successful in a vast majority of patients.

How Does Iontophoresis Work?

The exact mechanism for the effects of tap water iontophoresis on hyperhidrosis remains uncertain. However, the electrical charges may cause a plug forming in the first layer of skin (stratum corneum), blocking the sweat duct without damaging the sweat gland.

Where Do We Perform The Treatment?

Until recently, iontophoresis can be performed only in the clinic or a hospital, and require the use of expensive equipment. It is costly and involves multiple visits in a week. Now, a relatively inexpensive, portable, battery-powered iontophoresis device is available for home use.

How Is It Done?

During iontophoresis, you immerse the hands or feet (one at a time) in a shallow tray of water with a wool pad at the bottom. The electrodes in the tray emit an electrical current through the water. The electrical charges are delivered to the affected area through the saturated wool pads.

You can rotate the hand or foot to expose all affected areas to the current. There is usually little or no discomfort during the procedure. Treatments are usually given for about 20 minutes per hand or foot, every 2 to 3 days, for 6 to 10 sessions and then it can last up to 6 weeks. After that another course is initiated but some patients only need one treatment every 2 weeks.

Are There Any Side Effects?

This conservative therapy has few side effects. Mild irritation may occur immediately after therapy, and can be resolved with an application of hydrocortisone cream. Over-dryness of the skin may occur and can be dealt with by moisturisers and increasing the interval between treatments. Patients who are pregnant or who have pacemakers should not be treated with iontophoresis.

There are plenty of clinical evidences to support the effectiveness of this method. It is widely mentioned in dermatological textbook and published in dermatology journals. Different models are available from Europe and the USA. One model called Dr-ionic from the USA provide 2 forms of pads, one that only works on hands or feet, and the other is designed to work on the underarms.

Botox / Dysport

This is mentioned in the section Aesthetic Medicine > Aesthetic Treatments > Botox / Dysport.

Others

Various methods including psychotherapy, hypnosis, aromatherapy, have been tried but these are not proven to work.

Surgical Treatments

Excision of the Axillary Sweat Glands

Patients with axillary hyperhidrosis who are unresponsive to medical therapy can be effectively treated by excision of the axillary sweat glands. If sweating extends beyond the hairy portion of the axilla, several skin incisions may be needed, sometimes resulting in formation of hypertrophic and/or constrictive scars

Sympathectomy

It is a surgical procedure during which segments of the sympathetic nerve pathways that lead to excessive sweating are cut.

Traditional Open Sympathectomy

They are effective at treating palmar hyperhidrosis, but virtually all patients find that they have increased sweating in other parts of their bodies, called compensatory hyperhidrosis. Compensatory hyperhidrosis can be severe and even more disruptive than palmar hyperhidrosis. Hyperhidrosis in the original location can also recur. In addition, complications such as Horner's syndrome, injuries to arteries, veins and nearby tissues, pneumothorax, and painful scars may occur.

Open sympathectomy at the lower back area for plantar hyperhidrosis (excessive sweating of the feet) is similarly very effective, but sexual dysfunction and other complications may arise, and thus this procedure is infrequently performed at this time.

Endoscopic Thoracic Sympathectomy

This is a minimally invasive procedure, now available for palmar hyperhidrosis and hyperhidrosis of the face and head.

Under general anesthesia, a small incision, approximately one centimeter in length is made under both armpits. Endoscopic equipment is then inserted to cut a precise nerve. The process is then repeated on the other side of the chest.

Scarring is minimal, as the skin cuts made are small and well hidden in the folds of skin in the armpit. Compensatory hyperhidrosis occurs in a large percentage.

Bromhidrosis is a condition of abnormal or offensive body odour from the sweat. Sweat glands are divided into eccrine and apocrine sweat glands.

Eccrine Sweat Glands & Bromhidrosis

Eccrine glands are located at the dermis, and found over the entire body, but are richest on the palms and soles. They produce a dilute salt solution in response to increased body temperature, and serve primarily to regulate body temperature and excrete waste products.

Eccrine bromhidrosis occurs in all races, sex and age groups. Eccrine sweat is normally odourless but can start to smell if bacteria get a chance to break down the stale sweat.

Excessive eccrine sweating (hyperhidrosis) leads to a sweaty wet environment that encourages the growth of some organisms, for example fungi, which will break down the skin protein and cause some smelly skin conditions. Various substances, including foods (e.g. garlic, curry), alcohol, or certain medications, find their ways into the sweat after ingestion and can lead to an offensive odour.

Apocrine Sweat Glands & Bromhidrosis

Most cases of bromhidrosis are due to apocrine gland secretion.

Apocrine glands are much bigger, and found only in the underarms, breasts and groin regions. They produce a thick secretion rich in fatty acid. Apocrine sweat is odourless when it first appears, but within an hour the fatty acid is broken down by bacteria on the skin, and produces a strong offensive odour like rotten meat

Apocrine bromhidrosis is more common in men than women, and in dark-skinned ethnic groups who have larger and more active apocrine glands. There may be a positive family history. It only occurs after puberty when the apocrine glands become active.

Management & Treatments

Use of topical deodorants may help to cover the offensive odour. Simply maintaining personal hygiene is a good way to improve bromhidrosis. The main issues are dryness and reduction of bacteria.

The skin, particularly the armpits, should be kept as dry as possible. Hair removal can be considered, as it will prevent accumulation of bacteria and sweat on hair shafts. Laser hair removal is better as it will remove the hair shafts in the follicles too.

A dry skin condition will reduce the growth of bacteria. Washing the underarm at least twice daily with germicidal soap will keep the number of naturally occurring skin bacteria to a minimum.

In more severe cases, when it is suspected to have heavy growth of bacteria, or when there are coexisting skin conditions, such as intertrigo or erythrasma, antibiotics cream or even a short course of oral antibiotics (for example Erythromycin) is a good regime.

If hyperhidrosis is a contributing factor, this needs to be treated. It is described in details in the previous section. In brief, the treatments include:

• anti-perspirants
• anti-cholinergic or beta-blocking drugs
• tap water iontophoresis
• botulinum toxin injection
• surgical sympathectomy
• surgical excision of apocrine sweat glands

Eczema is not a single disease. It is a term frequently used to describe a group of skin problems, and sometimes used interchangeably with dermatitis. Each has different causative factors, is characterised by different signs of inflammation, and almost invariably causes itchiness. Its features depend on the cause, the area affected, and whether it is acute or chronic in time.

Possible Signs of Eczema

• Redness
• Blisters
• Weeping
• Dry scabs
• Scratch marks
• Dry and broken skin
• Thickened skin

Features of Eczema	Blisters in Acute Eczema

Acute eczema is red, may weep and has blisters. When the inflammation subsides, the redness decreases and dry scabs begin to form.

If the inflammation is allowed to continue, the eczema will become chronic. The skin is thickened and hardened because of the continual scratching. The skin lines are deepened, the skin colour is darkened, and the surface is broken.

The causes of eczema may simply be divided into internal and external factors, but in practice, most cases have many different causing factors, both internally and externally. Because of this, there are many types of eczema, the prevalence of each is different in different age groups. This is a rough distribution below:

Psoriasis is a common skin disorder affecting 1 - 2% of the population. It ranges from very mild, almost unnoticeable, to very severe disabling conditions. It occurs equally in men and women, at any age, and tends to come and go unpredictably. It is not infectious, and does not scar the skin.

The usual age of onset is after 20 years old, but for those with a positive family history, it can be as early as below 10 years old.

Although there is no cure for psoriasis, but with the appropriate treatments, it is very possible to control the disease to the minimum, with the least adverse effect on the patient’s life.

The underlying problem in the cellular level is a disordered cell division and migration process. The skin cells in the basal layer change gradually as they move towards the surface where they are continually shed. This process normally takes between 3 and 4 weeks. In psoriasis, the rate of turnover is dramatically increased to as little as 3 or 4 days. The reasons for this are still not fully understood, but there is certainly a genetic component, which is expressed by some unknown environmental factors.

Clinical Types & Signs

Chronic Plaques Psoriasis

It accounts for over 90% of psoriasis. It is red, thick and covered with silvery white scales. They can take up a variety of shapes and sizes, and have well defined edges from the surrounding skin.

These plaques are distributed mainly on the trunk, scalp, and the outside of the limbs, particularly the knees and elbows. Those on the limbs are usually symmetrical. In the scalp, the scales heap up so that the underlying redness is hard to see.

In the beginning it is mild with only one or two plaques, and becomes more obvious and numerous after a number of years. Only 20% may experience some degree of itch, others do not have any feeling. The severity may vary from time to time, while in the summer it usually improves somewhat because of the ultraviolet light exposure.

Some come up where the skin has been damaged and this is known as the Köbner phenomenon.

Acute Guttate Psoriasis

It is seen most often in children and is sometimes triggered by a sore throat 1 – 2 weeks prior to the onset of psoriasis. The patches are usually small, often less than 1 cm across, but numerous. Again there are some fine white scales on the surface, and it is not difficult to diagnose, although it can be confused with Pityriasis Vesicolor or Pityriasis Rosea. The patches are sometimes itchy.

Acute guttate psoriasis usually disappears after a few months, but may recur when the throat is again infected with streptococci. It is not uncommon to turn to chronic plaques psoriasis some years later.

Flexural Psoriasis

In contrast to chronic plaques psoriasis in other areas, when in body folds such as the armpits or under the breasts, the red well-defined areas are easy to see but are seldom scaly because of the trapped moisture.

Localized Psoriasis

It affects local areas on the scalp, the palms, the soles, or the nails.

Scalp: lots of large and thick scales. Initially they are smaller and may be confused with seborrhoeic dermatitis.

Palms and soles: the skin is very thick and rough, the dryness causes cracks and can be very painful.

Nails: irregular pitting of the surface of the nail, the colour may turn yellow and the nail is very thickened, the nail may separate from the nail bed, and the surface may peel in flakes. These may be confused with fungal infection of the nails.

Erythrodermic Psoriasis

The skin of the whole body is red, dry and inflamed. This is unstable psoriasis and can be dangerous and the patient needs to be admitted to hospital for systemic therapy.

Local Pustular Psoriasis

It involves only the palms and soles, where the red areas are studded with a mixture of new yellow pus spots and older brown dried up pus spots. This is slow to clear and often responds poorly to treatment.

Generalized Pustular Psoriasis

This is usually due to the sudden withdrawal of oral steroid in someone who needs to take it for another reason. Sometimes pregnancy may be a precipitating factor too. There are wide spread pustules, causing pain, and burning sensation. This is a serious complication and is dangerous; again the patient needs to be admitted to hospital for systemic therapy.

Joint Psoriasis

Very few psoriasis cases affect the joints alone, but it can happen without any signs on the skin itself. This usually affects the large joints such as the knees, elbows, or shoulders.

Diagnosis

Psoriasis is usually easy to recognise by the features on the skin, scalp, and nails. If a definitive diagnosis is required, a biopsy can be done by cutting off a very small piece of skin for laboratory analysis.

X rays examinations may find out some typical changes, and would help in arriving the diagnosis when only the joints are affected.

Management & Treatments

Psoriasis cannot be cured. However, treatment to control the signs and symptoms is usually effective. The skin becomes less scaly and may then look completely normal.

There are many different treatment methods available; each has its good and bad points. This will depend on the type of psoriasis and on its severity. Also, when deciding on the treatments, the doctor and the patient need to discuss them in details so as to arrive at a regime that will take into account the patient’s life style, occupation and family circumstances.

Attention is required in some factors outside the usual treatment regime:

• Ultra violet light usually makes psoriasis better, but rarely can make it worse. Over exposure may cause sunburn, which is an injury that can lead to new areas of psoriasis when it heals.
• Some medicines may make psoriasis worse, and the doctor’s advice is required when taking new medicines. These include Lithium, Aspirin, Iodides, and Beta-blockers.
• Alcohol is best avoided, because it can stimulate the onset of psoriasis. Alcohol also causes liver damages, which may prevent the patient from receiving some treatments when necessary.

Topical Therapies

1. Topical Steroid

It is widely used because of its simplicity and efficacy. Weaker steroids often do not work very well on thick patches of psoriasis, but may do better on the face or in the skin folds. The stronger ones have side effects, one of which is to make the skin thinner. Psoriasis sometimes comes back quickly when topical steroid treatment stops.
Therefore the strong preparations are usually avoided by the doctors.

There is also steroid solution available for application on the scalp. The penetration is better if mixed together with salicylic acid.

2. Vitamin D analogues

Recently, two new vitamin D3 preparations, calcipotriol and tacalcitol, have been introduced. They are safe and cosmetically acceptable. They are mainly used in chronic plaques psoriasis.

Treatment is applied either once (tacalcitol) or twice a day (calcipotriol) and can go on for as long as required. Irritation may occur, especially on the face, bottom and genitals. Treatment should be applied to those areas only on the specific instructions of the doctor.

3. Emollient

The purpose is to keep the skin softer and improve the external appearance by removing the flaky scales. 10% urea has a good effect and can be purchased easily from the chemist.

4. Tar preparations

This is a very traditional treatment and is divided into pine tar and coal tar. Coal tar is better for stable chronic plaques psoriasis, but the effect is slower than steroid or calcipotriol.

It used to be done as a tar bath in the hospital out-patient clinic, followed by wrapping the skin with gauze, or photo-therapy. This method is messy, can stain clothing, and requires a lot of medical labour, and is no longer a popular treatment.

Coal tar paste can be applied to the plaques but again is smelly and messy. Now the tar preparations have been improved in the texture and smell, with cream and gel form. Shampoo is also available for washing the hair in scalp psoriasis.

5. Dithranol

This can be used for minor or moderate chronic plaques psoriasis. The strength of the dithranol is gradually increased every 3-5 days, from 0.01% to a maximum of 1%.

Dithranol is often used as short contact therapy, being applied only to areas of psoriasis, and washed off after 30 to 60 minutes. If the areas being treated become inflamed, treatment should stop until this settles, but may then be resumed at a lower concentration. As your psoriasis clears, the treated areas will gradually stain brown. The staining goes away over the next couple of weeks. Many patients can clear their psoriasis in 6 weeks.

Occasionally dithranol irritates the skin, making it inflamed and sore. The face should not be treated, as contact with the eyes must be avoided and staining may be unsightly. Dithranol stains not only the skin and clothing, but baths and showers as well. The latter should be cleaned immediately to avoid permanent staining.

6. Vitamin A analogues

Tazarotene is a vitamin A gel that is applied once daily to patches of psoriasis. Irritation may occur if it is applied to the face or skin folds. It must not be used during pregnancy.

Oral Therapies

1. Vitamin A analogues

Acitretin can be used for moderately severe psoriasis not responding to topical treatments. It is particularly useful for generalised pustular psoriasis. It has a synergistic effect if used together with phototherapy.

It can cause severe birth defects; women must avoid pregnancy for at least six months after taking the medication.

It may cause an increase an increase in the liver enzymes and triglycerides levels, and blood tests are required for this every month. If taking it for longer than a few years, the bone may be abnormally thickened. Other side effects include dryness of the skin, lips, eyes, and even the inside of vagina.

2. Methotrexate

This is taken only once a week, with good effect on different types of psoriasis including the joint psoriasis.

The main side effect is liver damage, and regular blood tests are required to check the liver enzymes levels. When an accumulative dose of 1.5g is reached, a liver biopsy is needed to check for early cirrhosis. The treatment needs to be stopped when this happens.

Those with kidneys problems may excrete the drug more slowly and accordingly a lower dosage should be taken. Other side effects include anaemia, reduction of white blood cells, hair loss and rash. Again, methrotrexate may cause birth defects, and women should discontinue it for at least 3 months before getting pregnant

3. 5-Hydroxyurea

This medication is not as effective as cyclosporine or methotrexate, but unlike the stronger drugs it can be used with phototherapy treatments. Another advantage is that it can be used in patients with some liver damage. Possible side effects include anemia and a decrease in white blood cells and platelets. It should not be taken by women who are pregnant or planning to become pregnant.

4. Cyclosporin A

Cyclosporine works by suppressing the immune system and is similar to methotrexate in effectiveness. Like other immunosuppressant drugs, cyclosporine increases the risk of infection. Other side effects include overgrowth of gum, kidney problems and high blood pressure, the risk increases with higher dosages and long-term therapy.

Phototherapy

This term refers to treatment with various forms of ultraviolet light, sometimes assisted by taking particular tablets. It is helpful if the psoriasis is extensive, or fails to clear with topical treatment or comes back quickly after seeming to clear. Topical therapy will usually continue during the phototherapy.

1. UVB Phototherapy

Artificial sources of UVB light are similar to sunlight. Some physicians will start with UVB treatments instead of topical agents. UVB phototherapy also is used to treat widespread psoriasis and lesions that resist topical treatment. UVB phototherapy also may be combined with other treatments. One combined therapy program, referred to as the Ingram regime, involves a coal tar bath, UVB phototherapy, and application of an anthralin-salicylic acid paste, which is left on the skin for 6 to 24 hours. A similar regime, the Goeckerman treatment, involves application of coal tar ointment and UVB phototherapy.

Because UV exposure may increase the risk of skin cancer, it needs to be followed up carefully and the total accumulative doses of UVB should be recorded.

2. PUVA

This treatment combines oral or topical administration of a medicine called psoralen a couple of hours before exposure to ultraviolet A light (P + UVA). Psoralen makes the body more sensitive to UVA light. PUVA is normally used when more than 10 percent of the body's skin is affected or when rapid clearing is required.

Compared with daily UVB treatment, PUVA treatment two to three times per week clears psoriasis more consistently but less quickly. After 15 – 25 treatments, it can be reduced to maintenance of one treatment every 1 to 2 weeks. When the psoriasis recurs again, a new cycle of treatment can be started again.

It is associated with more side effects, including nausea, headache, fatigue, burning, and itching. Long-term treatment is associated with irregular skin pigmentation. Researchers have found that PUVA is effective and relatively safe when combined with some oral medications (retinoids and hydroxyurea), but appears to be associated with skin cancer when combined with other oral medications (methotrexate or cyclosporine). The patient needs to wear protective goggles during treatment to prevent the happening of eye damages and cataracts

Immunomodulator drugs (biologics)

Biologics work by blocking interactions between certain immune system cells. They have strong effects on the immune system and may pose many of the same risks as other immunosuppressant drugs. They are approved for the treatment of moderate to severe cases of psoriasis, which has failed to respond to traditional therapy, or for people with associated psoriatic arthritis.

They include alefacept, efalizumab, etanercept and infliximab. These drugs are given by intravenous infusion, intramuscular or subcutaneous injection.

Urticaria is a raised itchy skin rash due to exposure to an allergen, sometimes called a “nettle rash” or hives. Acute urticaria is a fast reaction, often caused by food, insect sting, or medications, and can last between several hours and several days.

Common causes of acute urticaria:

• Food : shellfish, nuts, egg and dairy products
• Medication : antibiotics (penicillin, tetracycline, sulphonamides and cephalosporins), blood pressure pills (ACE inhibitors and diuretics), codeine and aspirin containing pain killers
• Bee and wasp stings

The underlying physiology of urticaria is stimulation of the mast cells in the subcutaneous tissue. They secret chemicals called histamines when stimulated, which will cause the blood vessels to dilate, and fluid is expelled from the blood vessels to the surrounding tissue with the swellings seen. Other chemicals will stimulate the nerves with an intense itchy feeling.

Signs

Most people know what hives look like. When it is due to insect bites, there are some isolated discrete “itchy bumps”. Medication and food taken internally will have a much wider distribution on different parts of the body, and may have different shapes. Some people will have swellings in the lips, eye areas, or the whole face. When it is so severe to involve the tongue or the pharynx, suffocation may occur and results in death.

Typical Urticaria

Treatments

Mild cases such as insect bites require only some anti-itch cream such as menthol, with or without oral anti-histamines. They will resolve after a while if scratching is avoided. Slightly worse cases may need to apply steroid cream.

Those caused by food and medication internally usually are more severe, and will need oral anti-histamines or steroid to control the symptoms. The most severe cases require injections of anti-histamines or steroid for a fast result.

The older generation of anti-histamines include Chlorpheniramine、Diphenhydramine and Hydroxyzine. They all cause some drowsiness and affect driving and work. It is best to take them before bed. The usually anti-histamine injected by the doctor is Chlorpheniramine.

The newer generation is more effective, and has the advantage of not causing drowsiness. There are Loratidine, Cetirizine and Fexofenadine. They only have oral preparation.

The response to different anti-histamine is different. If it is not too satisfactory with one of them, then it is reasonably to try another one, sometimes with dramatically improvement. It is also not uncommon to use more than one anti-histamine to achieve a better control.

However, all these only control the symptoms. It is only when our body system gets rid of all the allergen inside, then the urticaria will stop.

The underlying mechanism is essentially the same as acute urticaria, but we do not know what trigger the mast cells to release those chemicals, including histamines, in chronic urticaria. Hence the diagnosis is often called Chronic Idiopathic Urticaria.

What we do know now is that, it is a disorder of the immune system, which somehow produces “auto-antibodies” which in turn attack specific mast cells in our skin and tissues causing an enormous release of histamines. Why we suddenly switch-on production of these aggressive antibodies to attack our own skin cells is still not understood.

Over 50% of chronic urticaria cases are due to production of these “auto-antibodies”, some of them have co-existing auto-immune problems such as thyroid and joint diseases. Most sufferers are younger females, who have twice as much chance of having this as the male counterparts.

Other factors may play a role but are never really confirmed. Food additives, such as salicylate, sodium benzoate, sulphites, colourings and nitrites; chronic undetected dental, urinary or parasitic infections are thought about. Stress is known to aggravate urticaria and stress reduction measures may help.

Definition Of Chronic Urticaria

In general, almost every day in a six week period, there are wide spread urticarial lesions, each of them will not last for more than 24 hours and leaves no trace after disappearing.

Signs

There are itchy lumps of different sizes, at different places, come and go at different time, and last for a different period of time. Many people have very sensitive skin and any friction or rubbing will cause raised red lines to develop. This is called dermatographism and indicates just how easily they can release histamine in their own skin.

Dermatographism

Some physical factors can trigger chronic urticaria, such as exposure to environmental heat (prickly heat), intense cold, sunlight, vibration or pressure on the skin (from tight clothing). Very rarely some people react to bath water, this is called “aquagenic” urticaria. Exercising and sweating provoke cholinergic urticaria with tiny swellings around the follicles.

Management & Treatments

Although they are not the actual cause, it is still important to avoid any obvious triggers or exacerbating factors.

• Keep the skin cool, avoid getting hot from exercise and take lukewarm baths.
• Resist the temptation to rub the itchy skin
• Avoid alcoholic drinks
• Avoid foods containing additives
• Avoid medication containing aspirin and codeine
• Avoid too tight clothings

Although it does not make the urticaria go away, 1% menthol in aqueous cream help to soothe the affected skin and reduce scratching, which will make the urticaria worse.

The mainstay of treatment is anti-histamines, which may be necessary for prolonged periods, sometimes many months. Usually the second generation is more effective and they do not cause drowsiness. Cetirizine, loratadine, acrivastine, fexofenadine, desloratadine and levocetirizine are all very useful.

The first generation anti-histamines such as chlorpheniramine, diphenhydramine and hydroxyzine cause drowsiness and it is better to take them before bedtime. Chlorphenamine and loratadine are safe to use in pregnancy, while cetirizine and loratadine are safe to take whilst breastfeeding.

The response to different anti-histamine is different. If it is not too satisfactory with one of them, then it is reasonably to try another one, sometimes with dramatically improvement. It is also not uncommon to use more than one anti-histamine to achieve a better control.

Newer leukotriene receptor antagonists currently used for asthma such as montelukast and zafirlukast have provided some symptom relief in chronic urticaria, when used in combination with antihistamines.

Short courses of oral steroids may be necessary for short periods to settle more severe symptoms. It should not be used for prolonged periods of time as this may lead to stunted growth in children and osteoporosis in adults.

Although as mentioned, some people may have co-existing auto-immune problems, but the vast majority of cases do not have any hidden diseases, and blood tests in general are all un-productive.

Chronic urticaria will resolve on their own in about half of the cases, but many of them will have this troublesome problem lasting for many years.

Steroid creams and ointments are an effective method of treating many different inflammatory skin conditions. However they are not suitable to treat inflammation due to infection caused by bacteria and fungi, otherwise the condition may get even worse and more difficult to control.

The function of steroid cream is to suppress the immune system from reacting, whether appropriately or not, but it cannot cure the source leading to the inflammation. When it is stopped, the inflammation will get worse again, unless the source has been removed, for example the metal earring containing nickel.

They are extremely helpful medicine if used properly. Unfortunately, many of the stronger steroid creams were abused and resulted in side effects such as thinning of the skin and prominent stretch marks. This abuse has given topical steroid creams a bad name.

Steroid cream cannot resolve acute or chronic urticaria. It should not be used for the ordinary acne. It should be kept to a minimum when treating rosacea, because of the short lasting effect, with a possible rebound, which is more severe than before. It should not be used on a large area of skin unlimitedly just to reduce itchiness.

In psoriasis, mild to moderate strength steroid cream can be used with good result. However, it is best to avoid using the strongest preparation, because of the possible rebound after a quick short-lived improvement, which can result in the life threatening pustular psoriasis.

Side Effects

If it is used for a prolonged period, particularly the strong preparations on a large area of skin, ultimately it can be absorbed enough into the body system and cause suppression of the body’s own secretion of steroid from the supra-adrenal glands. Due to the feedback mechanism, the pituitary gland in the brain will shrink as well. The absorption is highest in thinnest skin, the skin folds and occluded areas.

Over absorption in the local area may:

• Thin the dermis, and it may not return to normal even after stopping its use
• Produce irreversible white thin atrophic lines
• Stimulate the blood vessels to expand, causing facial flushing, similar to the rosacea symptoms
• Possibly make the skin even more sensitive to irritation
• Cause contact dermatitis, acne, or peri-oral dermatitis
• Lead to loss of melanin and hypo-pigmentation

Method Of Application

They vary in strength from very mild, mild, moderate to strong. Because of the possible side effects, the strong preparation should only be reserved for the most resistant dermatitis not responding to the milder preparations. When treating the face, unless in special circumstances, only the mildest preparation should be used, usually 0.5% - 1% Hydrocortisone. The frequency of applying it should be one to two times a day, more frequent application is usually not necessary.

Extra caution should be exercised when using it on babies and infants, because they are more susceptible to side effects. Having said that, when it is necessary to use it in, for example atopic eczema, over restriction is not warranted, as long as the strong preparations are avoided and is used for only a short time, otherwise the side effects from the disease itself may be even more damaging.

Very often steroid cream can be mixed with other ingredients, such as urea or salicylic acid, which will enhance the absorption and is particularly useful in thickened skin such as the palms, or after chronic inflammation. Antibiotic is useful in cases with coexisting bacterial infection, while it can reduce the itch from fungal infection when used together with anti-fungal cream. Mixed preparations with both antibiotic and anti-fungal are very often used to cover a broader range of skin problems, but this use tends to be abused.

Attention should be paid to the name of the steroid, and also the suffix, as well as other ingredients. The following are some commonly encountered steroids, antibiotic and anti-fungal preparations:

Very Mild to Mild

• Hydrocortisone 0.5% - 1%
• Methylprednisolone acetate 0.25%

Moderate

• Clobetasone butyrate 0.05%
• Mometasone furoate 0.1%

Strong

• Hydrocortisone butyrate 0.1%
• Fluocinolone acetonide 0.025%
• Fluticasone propionate 0.05%
• Beclomethasone dipropionate 0.025%
• Betamethasone valerate 0.1%
• Betamethasone dipropionate 0.1%
• Triamcinolone acetonide 0.1%

Very Strong

• Clobetasol propionate 0.05%
• Halcinonide 0.1%

Antibiotics:

• Clioquinol
• Fusidic acid
• Gentamycin
• Neomycin
• Oxytetracycline

Anti-fungals:

• Clotrimazole
• Econazole
• Miconazole
• Nystatin