Acne

What is acne?

Acne is a very common skin condition characterised by comedones (blackheads and whiteheads) and pus-filled spots (pustules). It usually starts at puberty and varies in severity from a few spots on the face, neck, back and chest, which most adolescents will have at some time, to a more significant problem that may cause scarring and impact on self-confidence. For the majority it tends to resolve by the late teens or early twenties, but it can persist for longer in some people.
Acne can develop for the first time in people in their late twenties or even the thirties. It occasionally occurs in young children as blackheads and/or pustules on the cheeks or nose.

What causes acne?

The sebaceous (oil-producing) glands of people who get acne are particularly sensitive to normal blood levels of a hormone called testosterone, which is present in both men and women. This causes the glands to produce an excess of oil. At the same time, the dead skin cells lining the pores are not shed properly and clog up the follicles. These two effects result in a build up of oil, producing blackheads (where a darkened plug of oil is visible) and whiteheads.
The acne bacterium (known as Propionibacterium acnes) lives on everyone’s skin, usually causing no problems, but in those prone to acne, the build-up of oil creates an ideal environment in which these bacteria can multiply. This triggers inflammation and the formation of red or pus-filled spots.

Is acne hereditary?

Acne can run in families, but most cases are sporadic and occur for unknown reasons.

What does acne look like and what does it feel like?

The typical appearance of acne is a mixture of the following: oily skin, blackheads and whiteheads, red spots, yellow pus-filled pimples, and scars. Occasionally, large tender spots or cysts may develop that can eventually burst and discharge their contents or may heal up without bursting. The affected skin may feel hot, painful and be tender to touch.  Not all spots are acne, so if there is something unusual about the rash it may be advisable to consult your doctor.

How is acne diagnosed?

Acne is easily recognised by the appearance of the spots and by their distribution on the face, neck, chest or back. However, there are several varieties of acne and your doctor will be able to tell you which type you have after examining your skin. The most common type is ‘acne vulgaris’.

Can acne be cured?

At present there is no ‘cure’ for acne, although the available treatments can be very effective in preventing the formation of new spots and scarring.

How can acne be treated?

If you have acne but have had no success with over-the-counter products then it is probably time for you to visit your doctor. In general, most treatments take two to four months to produce their maximum effect.

Acne treatments fall into the following categories:

• Those that are applied directly to the skin (topical treatments)
• Oral antibiotics (tablets taken by mouth)
• Oral contraceptive pills
• Isotretinoin capsules
• Other treatments

Topical treatments

These are usually the first choice for those with mild to moderate acne. They should be applied to the entire affected area of the skin (for example all of the face) and not just to individual spots, usually every night or twice daily. Consult your doctor if they cause irritation of the skin; reducing the frequency of application may be required, at least temporarily, to help overcome this problem. There are a variety of active anti-acne agents, such as benzoyl peroxide, antibiotics (erythromycin, tetracycline and clindamycin), retinoids (such as tretinoin, isotretinoin and adapalene), azelaic acid.

Oral Antibiotic Treatment

Your doctor may recommend a course of antibiotic tablets, usually erythromycin or a type of tetracycline, which should be taken in combination with suitable topical treatment.

Antibiotics need to be taken for a minimum of two months, and are usually continued until there is no further improvement, for at least 6 months. Some should not be taken at the same time as food, so read the instructions carefully.

Oral Contraceptive Treatments

Some types of oral contraceptive pills help females who have acne. The most effective contain a hormone blocker (for example, cyproterone) which reduces the amount of oil the skin produces. It usually takes at least three to four months for the benefits to show. Although they may not be taken for this reason, the pills also help to prevent conception. As they prevent ovulation, they may be less suitable in young teenage girls where ovulation is not well established.

Isotretinoin (Roaccutane)

This powerful and effective treatment has the potential to cause a number of serious side effects and is prescribed in the main only by a dermatologist. Isotretinoin can harm an unborn child. Women will be asked to enrol in a pregnancy prevention programme and need to have a negative pregnancy test prior to starting treatment. Pregnancy tests will be repeated every month during treatment and five weeks after completing the course of treatment.

Effective contraception must be used whilst on treatment, and for four weeks afterwards.

There are concerns that isotretinoin may cause depression and suicidal feelings. Details about any personal and family history of mental illness should be discussed with your own doctor and dermatologist prior to considering treatment with isotretinoin.

Most courses of isotretinoin last for four months during which time the skin may become red and dry. Often, acne becomes a little worse before improvement occurs.

It should be emphasised that many thousands of people have benefited from treatment with isotretinoin without serious side effects.

An information leaflet provided by Dr O Connor and Dr Gibson to their patients on Roaccutane can be downloaded by clicking on this link

Other treatments

There have been developments in the use of light and laser therapy for inflammatory acne but these forms of treatment have yet to be fully evaluated and are generally ineffective in the treatment of severe inflammatory acne. Laser resurfacing of facial skin to reduce post-acne scarring is an established technique requiring the skills of an experienced laser surgeon.

What can I do?

• Try not to pick or squeeze your spots as this usually aggravates them and may cause scarring.
• However your acne affects you, it is important to take action to control it as soon as it appears. This helps to avoid permanent scarring and reduces embarrassment. If your acne is mild it is worth trying over-the- counter preparations in the first instance. Your pharmacist will advise you.
• Expect to use your treatments for at least two months before you see much improvement. Make sure that you understand how to use them correctly so you get the maximum benefit.
• Some topical treatments may dry or irritate the skin when you start using them. An oil-free moisturiser should help, but you may also have to cut down on the frequency with which you apply the treatments, for example to using them on alternate nights.
• If you wear make-up, wear products that are oil-free or water-based. Choose products that are labelled as being ‘non-comedogenic’ (should not cause blackheads or whiteheads) or non-acnegenic (should not cause acne).
• Cleanse your skin and remove make-up with a mild soap or a gentle cleanser and water, or an oil-free soap substitute. Scrubbing too hard can irritate the skin and make your acne worse.
• The jury is still out on the link between foods and acne. There are some studies showing a link between acne and a high dairy or high glycaemic diet but these findings have not been proven. However, your health will benefit overall from a balanced diet including fresh fruit and vegetables

Actinic Keratoses

What are actinic keratoses?

Actinic keratoses are areas of sun-damaged skin found predominantly on sun- exposed parts of the body, particularly the backs of the hands and forearms, the face and ears, the scalp in balding men and the lower legs in women. The terms actinic and solar are from Greek and Latin, respectively, for ‘sunlight- induced’, and the term keratosis refers to thickened skin. They are usually harmless but there is a very small risk of some actinic keratoses progressing to a form of skin cancer called squamous cell carcinoma (see Patient Information Leaflet on Squamous Cell Carcinoma). Actinic keratoses are not contagious.

What causes actinic keratoses?

They are caused by excessive sun exposure over many years (from sunbathing, sunbed use, outdoor work or recreational activities) and are therefore more common in older people. Fair-skinned, blue-eyed, red- or blonde-haired individuals, who burn easily in the sun but tan poorly, are at particular risk.

Are actinic keratoses hereditary?

No, but some of the factors that increase the risk of getting actinic keratoses such as a tendency to burn rather than tan, and freckling, do run in families.

What are the symptoms of actinic keratoses?

They often cause little trouble. Many affected individuals are not aware of them at all. The affected skin feels rough and dry. However, if an actinic keratosis starts to grow into a lump, becomes itchy, tender or starts to bleed, medical advice should be sought as these changes could indicate the development of skin cancer (a squamous cell carcinoma).

What do actinic keratoses look like?

Actinic keratoses can be variable in appearance, even differing from one another within a single individual. At first they can be hard to see, and are more easily felt, being rough, like sandpaper. They may grow up to a centimetre or two in diameter. Some are skin coloured, others are pink, red or brown. They can become raised, hard and warty, and may even develop a small horny outgrowth. The surrounding skin often looks sun-damaged - blotchy, freckled and wrinkled.

How are actinic keratoses diagnosed?

Usually the appearance of an actinic keratosis is sufficient to enable the diagnosis to be made, but in cases of doubt, for example if an early skin cancer is suspected, a sample (or the whole lesion) may be removed under a local anaesthetic for microscopic examination in the laboratory.

Can actinic keratoses be cured?

Yes, but others may develop in the future from the surrounding sun-damaged skin.

How can actinic keratoses be treated?

It is advisable to protect the skin from further sun damage (for example, by wearing a hat, long sleeves and a sunscreen with a high sun protection factor).

Occasionally, small actinic keratoses may go away spontaneously, but generally it is advisable to treat them as there is a small risk that some might transform into a skin cancer.

Treatments used for actinic keratoses include the following:

• Freezing with liquid nitrogen (Cryotherapy). This is an effective treatment which does not normally leave a scar, but it can be painful.
• Surgical removal. This requires local anaesthetic, after which the actinic keratosis can be scraped off with a sharp spoon-like instrument (a curette), or it can be cut out and the wound closed with stitches. Surgical removal leaves a scar but provides a specimen that can be analysed in the laboratory to confirm the diagnosis.
• Creams. Courses of creams containing drugs called 5-fluorouracil, imiquimod and imgenol mebutate are useful treatments for actinic keratoses, especially if there are a lot of them. These preparations appear to selectively destroy the abnormal cells in sun-damaged skin. However, they often cause a good deal of temporary inflammation of the treated areas. Diclofenac and retinoic acid are other drugs in cream or ointment form that may be helpful when applied to actinic keratoses.
• Photodynamic therapy. A chemical is applied to the affected area, which is then treated with the correct wavelength of visible light. This treatment is only available in certain centres.

Self care (What can I do?)

Protecting your skin from the sun will reduce the number of new actinic keratoses you get, and also reduce the risk of getting a sun-induced skin cancer. You should be extra cautious in the sun by following these recommendations:

• Protect yourself from the sun, from 10am to 3pm, especially in sunny weather.
• Wear protective clothing - hats, long sleeves, long skirts or trousers.
• Apply a sunscreen regularly, of sun protection factor 30 or above (and able to block both UVA and UVB light), to exposed skin before going into the sun, and re-apply according to the manufacturer’s recommendations, especially after swimming, when you are out in the sun.
• Protecting your children from the sun in the same way may reduce their risk of developing actinic keratoses.
• Avoid sunbeds. Examine your own skin every few months and see your doctor if an actinic keratosis starts to itch, bleed, or thicken, in case it has changed into a skin cancer (a squamous cell carcinoma).

Vitamin D advice The evidence relating to the health effects of serum Vitamin D levels, sunlight exposure and Vitamin D intake remains inconclusive. Avoiding all sunlight exposure if you suffer from light sensitivity, or to reduce the risk of melanoma and other skin cancers, may be associated with Vitamin D deficiency.

Individuals avoiding all sun exposure should consider having their serum Vitamin D measured. If levels are reduced or deficient they may wish to consider taking supplementary vitamin D3, 10-25 micrograms per day, and increasing their intake of foods high in Vitamin D such as oily fish, eggs, meat, fortified margarines and cereals. Vitamin D3 supplements are widely available from health food shops.

Alopecia Areata

What is alopecia areata?

Alopecia is a general term for hair loss. Alopecia areata is a specific, common cause of hair loss that can occur at any age. It usually causes small, coin- sized, round patches of baldness on the scalp, although hair elsewhere such as the beard, eyebrows, eyelashes, body and limbs can be affected. Occasionally it can involve the whole scalp (alopecia totalis) or even the entire body and scalp (alopecia universalis). It is not possible to predict how much hair will be lost. Regrowth of hair in typical alopecia areata is usual over a period of months or sometimes years, but cannot be guaranteed. The hair sometimes regrows white, at least in the first instance. Further hair loss is not uncommon. In alopecia totalis and alopecia universalis, the likelihood of total regrowth is less.

What causes alopecia areata?

Hair is lost because it is rejected by the affected person’s immune system, which does not recognise the hair roots (follicles) as "self", but regards them as "foreign" (autoimmunity). Why this happens is not fully understood, nor is it known why only localised areas are affected and why the hair regrows again.
Someone with alopecia areata is more likely than a person without it to develop other autoimmune conditions such as thyroid disease, diabetes and vitiligo (white patches on the skin), although the risk of getting these disorders is still low. Your doctor may suggest a blood test looking for antibodies that may predict whether you are likely to develop thyroid problems or pernicious anaemia.

Alopecia areata is not catching nor is it related to diet or vitamin deficiencies. Stress, particularly events such as bereavement, separation and accidents, occasionally appears to be a trigger for alopecia areata.

Is alopecia areata hereditary?

There is a genetic predisposition to alopecia areata and close family members may be affected. Thyroid problems or diabetes are also more common.

What are the symptoms?

There may be a tingling sensation in the scalp. It can be a very upsetting condition to the sufferer, especially if the bald area cannot be disguised by hairstyle.

What does alopecia areata look like?

Typically, it starts as one or more bald, smooth patches on the scalp, which are not inflamed or scaly. It tends to affect the pigmented hair so there may be some white hairs left within the bald area in older people. Sometimes the hair loss is diffuse rather than well-circumscribed patches. Short, tapered hairs, known as exclamation mark hairs that are characteristic of alopecia areata, may be seen at the edge of the bald patch. Regrowth usually starts at the centre of the bald patch with fine white hair that thickens with time and usually regains its colour. Some people with alopecia areata develop small pits on their nails, similar to the dimples seen on a thimble.

Can it be cured?

No, alopecia areata cannot be cured. If the hair loss is patchy, there is a good chance (about 60 to 80%) that there will be complete regrowth within 1 year without treatment. There may, however, be further episodes of hair loss in the future. If there is very extensive hair loss from the start, the chances of it regrowing may not be as good. In people with Down's syndrome, or those who have severe eczema, the chances of regrowth are not so good either.

How can alopecia areata be treated?

People with mild early alopecia areata may need no treatment, as their hair is likely to come back anyway without it. Some treatments can induce hair growth, though none is able to alter the overall course of the disease. Any treatments that carry serious risks should be avoided, as alopecia areata itself has no adverse affect on physical health.

The treatments that are available include:

• Steroid creams and scalp applications. These are applied to the bald patches, usually twice a day, for a limited time.
• Local steroid injections. These can be used on the scalp and brows, and are the most effective approach for small patches of hair loss. Injections can be repeated every few months. A small dimple may develop at the injection sites, but this usually recovers after a few months. Special care is taken around the eyes, when injecting the brows, as injecting too much may cause glaucoma (raised pressure inside the eyeball).
• Steroid tablets. Large doses of steroid tablets may result in regrowth of the hair, but when the treatment stops the alopecia often recurs. Taking steroids by mouth over a period of time can cause many side effects including raised blood pressure, diabetes, stomach ulcers, cataracts and osteoporosis as well as weight gain.
• Dithranol cream. This cream, which is usually used to treat another skin condition called psoriasis, causes irritation of the skin, and occasionally this stimulates the hair to regrow when applied to the bald areas. It is safe to use, but stains the skin and hair a purple-brown colour, which is particularly prominent in blond and fair-headed people.
• Contact sensitisation treatment. This involves making the patient allergic to a substance (usually a chemical called diphencyprone) and then applying very weak strengths of this chemical to the bald patches, usually once a week to maintain a mild inflammation. Side effects of possible itching, blistering and enlarged glands in the neck can be troublesome. Loss of skin colour (depigmentation) may develop, so it is used with caution in those with dark skin. This treatment is only available in specialized centres
• Ultraviolet light treatment. This involves taking a tablet or applying a cream that makes the skin sensitive to light, and then exposing the bald patches to ultraviolet light, two or three times a week for a number of months. Relapse of the alopecia is common when the treatment is stopped. There is also a possible long-term risk of skin cancers.
• Minoxidil lotion. This is available over the counter. Applied to the bald patches it may help some sufferers although it seldom produces cosmetically useful regrowth of hair.

Androgenetic Alopecia

What is androgenetic alopecia?

Androgenetic alopecia is the most common type of progressive hair loss. It is also known as malepattern baldness, female-pattern baldness, or just common baldness. It affects about 50% of men over the age of 50, and about 50% of women over the age of 65. In women the severity varies, it may present as widespread hair thinning but in some cases it can lead to complete baldness.

What causes androgenetic alopecia?

Androgenetic alopecia is caused by a combination of genetic and hormonal factors. Dihydrotestosterone (DHT) is the main hormone responsible for androgenetic alopecia in genetically susceptible individuals. DHT causes scalp hair loss by inducing a change in the hair follicles on the scalp. The hairs produced by the affected follicles become progressively smaller in diameter, shorter in length and lighter in colour until eventually the follicles shrink completely and stop producing hair.

Is androgenetic alopecia hereditary?

Yes. It is believed that genetic susceptibility to this condition can be inherited from either or both parents.

What are the symptoms of androgenetic alopecia?

Androgenetic alopecia affects men earlier, and more commonly, than women. Males typically become aware of scalp hair loss or a receding hairline, beginning at any time after puberty. In women, the age of onset is later compared to men, usually occurring in the 50s or 60s. Occasionally, androgenetic alopecia in women may start earlier than this, in the 30s or 40s. In some women, this condition can be associated with an excess of male hormones such as in polycystic ovary syndrome (PCOS). Acne, increased facial hair, irregular periods and infertility are all signs of PCOS.

What does androgenetic alopecia look like?

Androgenetic alopecia looks different in males and females. Hairs in the affected areas are initially smaller in diameter, and shorter compared to hairs in unaffected areas, before they become absent.

In men, the usual pattern of hair loss is a receding hairline, and loss of hair from the top and the front of the head.

In women, hair loss or thinning typically occurs at the crown of the scalp, with complete or nearly complete preservation of the frontal hairline.

How is androgenetic alopecia diagnosed?

The diagnosis is usually based on the history, pattern of hair loss and family history of a similar pattern of hair loss. The skin on the scalp looks normal on examination. Occasionally blood tests may be carried out.

Can androgenetic alopecia be cured?

No, there is no cure for androgenetic alopecia. However, the progression of this condition in both men and women tends to be very slow, spanning several years to decades. An earlier age of onset may predict a quicker rate of progression.

How can androgenetic alopecia be treated?

Licensed topical and oral treatments:

Applying 2% or 5% minoxidil solution to the scalp may help to slow down the progression and partially restore hair in a small proportion of males and females. In those who respond, the benefit is only maintained for as long as the treatment is used. Minoxidil has been known to cause irritant or allergic reactions at the site of application.

For men, finasteride tablets reduce levels of dihydrotestosterone which may slow hair loss and possibly help regrowth of hair. Continuous use for 3 to 6 months is required before a benefit is usually seen. Decreased libido and erectile dysfunction are recognised side-effects of this treatment. Any beneficial effects on hair growth will be lost within 6 to 12 months of discontinuing treatment.

Unlicensed treatments:

For women, medications such as spironolactone, ciproterone acetate, flutamide and cimetidine can block the action of dihydrotestosterone on the scalp which may result in some improvement in hair loss. Spironolactone and ciproterone acetate however should be avoided in pregnancy since they can cause feminisation of a male fetus; both should be avoided during breast feeding. Flutamide carries a risk of damaging the liver.

It is important to note that all of the topical and oral treatments only work for as long as the treatment is continued.

Wigs and hair pieces:

Some affected individuals find wigs, toupees and even hair extensions very helpful in disguising androgenetic alopecia. There are two types of postiche (false hairpiece) available to individuals; these can be either synthetic or made from real hair. Synthetic wigs, and hairpieces, such as a toupee, usually last about 6 to 9 months, are easy to wash and maintain but can be susceptible to heat damage and may be hot to wear. Real hair wigs or hairpieces can look more natural and can be styled with low heat.

Cosmetic camouflage:

Spray preparations containing small pigmented fibres are available from the internet and may help to disguise the condition in some individuals. These preparations however may wash away if the hair gets wet (.e. rain, swimming, perspiration), and they only tend to last between brushing/shampooing.

Surgical treatments:

Surgical treatment includes (i) hair transplantation, which is a procedure whereby hair follicles are taken from the back and sides of the scalp and transplanted onto the bald areas, and (ii) scalp reduction which involves the removal of an ellipse from the bald area with closure by stretching of the hair baring scalp. Tissue expanders may be used to stretch the skin in some cases, and in addition the scars from a scalp reduction may be too evident.

Self care (What can I do?)

An important function of hair is to protect the scalp from sunlight; it is therefore important to protect any bald areas of your scalp from the sun to prevent sunburn and to reduce the chances of developing long-term sun damage.

You should cover any bald patches with sun block, your wig or a hat if you are going to be exposed to sunlight.

Atypical Mole Syndrome

What is atypical mole syndrome?

Atypical mole syndrome is a disorder of the skin which is seen in approximately 2% of the population. It is defined as where an individual has a collection of more than 50 moles composed of melanocytes (cells able to produce pigment) present on their bodies, whereby three or more are atypical (unusual) in their appearance, e.g. size and structure. An atypical mole is one greater than 5mm in diameter, often with flat and raised areas, often oval rather than round, and often with some colour variation.

Solitary atypical moles are individually benign moles with a low risk of progression to melanoma (which is a type of skin cancer). However, people with multiple atypical moles (atypical mole syndrome) are considered to have a higher risk (increased 7 to 10 fold) of developing melanoma and skin cancer compared to the general population, due to the presence of atypical moles especially if some of these moles are on the scalp, buttocks, or the back of the feet. The risk is increased further if one or more first or second degree relatives (i.e. a close blood relative including parents, full siblings or children, or a blood relative including grandparents, grandchildren, aunts, uncles, nephews, nieces or half-siblings, respectively) have been diagnosed with malignant melanoma; this combination is known as familial atypical mole syndrome.

What causes atypical mole syndrome?

It is likely that both genetics and UV radiation have a role to play in development of atypical moles. The Caucasian population, especially Celtic (fair-skinned) people, are much more prone to developing multiple atypical naevi, whereas the condition is rare in other ethnic groups.

Is atypical mole syndrome hereditary?

Yes, it is a hereditary condition; however, it may also occur sporadically with no family history.

What are the symptoms of atypical mole syndrome?

There may be no adverse symptoms at all with atypical mole syndrome, other than the appearance of the moles themselves. It is also possible for new moles to appear over time, for existing moles to itch, become crusted or inflamed, or for a mole to change in size, shape or colour.

What does atypical mole syndrome look like?

As mentioned above atypical mole syndrome is where an individual has a collection of melanocytic naevi, whereby three or more are atypical (unusual) in their appearance.

Atypical moles are generally larger than normal moles (greater than 5mm in diameter), and have irregular borders and some asymmetry meaning that they are often oval rather than round. Their colour varies from pink to dark brown and they are usually flat or slightly raised from the surface of the skin. They can be positioned on any part of the body, but are most commonly found on sunexposed areas such as the scalp, upper limbs and trunk. Atypical moles may resemble a melanoma in appearance; however, they do not have other features of melanoma such as persistent and ongoing change.

How is atypical mole syndrome diagnosed?

Atypical mole syndrome can often be recognised by its appearance, if examined by a dermatologist. If there are any concerns over the diagnosis your doctor can arrange for the mole to be removed and examined. A set of baseline photographs of the entire skin surface may be requested to facilitate monitoring of the moles.

People who have atypical mole syndrome, or familial atypical mole syndrome, are at an increased risk of developing melanoma and therefore it is recommended that the skin is checked, on a regular basis, for any changes (as mentioned under the Self care (What can I do?) section).

Can atypical mole syndrome be cured?

No.

How can atypical mole syndrome be treated?

An individual atypical mole can be removed surgically if the dermatologist is concerned about it. However, most moles will not require removal, and any surgical procedure carried out will, inevitably, leave a scar.

Self care (What can I do?)

Second only to dermatologists, many patients identify skin cancers, including melanoma, themselves.

Check your skin for changes once a month. A friend or family member can help you, particularly with checking areas that you cannot easily inspect such as your back.

Top sun safety tips:

• Protect your skin with clothing, and don’t forget to wear a hat that protects your face, neck and ears, and a pair of UV protective sunglasses.
• Spend time in the shade between 10am and 3pm when it’s sunny. Step out of the sun before your skin has a chance to redden or burn. Keep babies and young children out of direct sunlight.
• When choosing a sunscreen look for a high protection SPF (SPF 30 or more) to protect against UVB, and UVA . Apply plenty of sunscreen 15 to 30 minutes before going out in the sun, and reapply every two hours and straight after swimming and towel-drying.
• Keep babies and young children out of direct sunlight.
• Tell your doctor about any changes to a mole. If your GP is concerned about your skin, he or she can refer you to a Consultant Dermatologist
• Sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection.
• It may be worth taking Vitamin D supplement tablets (available from health food stores) as strictly avoiding sunlight can reduce Vitamin D levels.

Vitamin D advice: The evidence relating to the health effects of serum Vitamin D levels, sunlight exposure and Vitamin D intake remains inconclusive. Avoiding all sunlight exposure if you suffer from light sensitivity, or to reduce the risk of melanoma and other skin cancers, may be associated with Vitamin D deficiency.

Individuals avoiding all sun exposure should consider having their serum Vitamin D measured. If levels are reduced or deficient they may wish to consider taking supplementary vitamin D3, 10-25 micrograms per day, and increasing their intake of foods high in Vitamin D such as oily fish, eggs, meat, fortified margarines and cereals. Vitamin D3 supplements are widely available from health food shops.

Basal Cell Carcinoma (BCC)

What is a basal cell carcinoma?

A basal cell carcinoma (BCC) is a type of skin cancer. There are two main types of skin cancer: melanoma and non-melanoma skin cancer. BCC is a non-melanoma skin cancer, and is the most common type (greater than 80%) of all skin cancer. BCC are sometimes referred to as ‘rodent ulcers’.

What causes basal cell carcinoma?

The commonest cause is too much exposure to ultraviolet (UV) light from the sun or from sunbeds. BCC can occur anywhere on your body, but is most common on areas that are often exposed to the sun, i.e. your face, head, neck and ears. It is also possible for a BCC to develop where burns, scars or ulcers have damaged the skin. BCC is not infectious.

BCC mainly affects fair skinned adults, but other skin types are also at risk.

Those with the highest risk of developing a basal cell carcinoma are:

• People with pale skin who burn easily and rarely tan (generally with light coloured or red hair, although some may have dark hair but still have fair skin).
• Those who have had a lot of exposure to the sun, such as people with outdoor hobbies or outdoor workers, and people who have lived in sunny climates.
• People who use sun beds or sunbathe.
• People who have previously had a basal cell carcinoma.

Are basal cell carcinomas hereditary?

Apart from a rare familial condition called Gorlin’s syndrome, BCCs are not hereditary. However some of the things that increase the risk of getting one (e.g. a fair skin, a tendency to burn rather than tan, and freckling) do run in families.

What does a basal cell carcinoma look like?

BCC can vary greatly in their appearance, but people often first become aware of them as a scab that bleeds occasionally and does not heal completely. Some BCC are very superficial and look like a scaly red flat mark; others have a pearl-like rim surrounding a central crater. If left for years the latter type can eventually erode the skin causing an ulcer; hence the name “rodent ulcer”. Other BCC are quite lumpy, with one or more shiny nodules crossed by small but easily seen blood vessels. Most BCC are painless, although sometimes can be itchy or bleed if caught on clothes or picked up.

How will my basal cell carcinoma be diagnosed?

Sometimes the diagnosis is clear from its appearance. If further investigation is necessary to confirm the diagnosis then a small area of the abnormal skin (a biopsy) or the entire lesion (an excision biopsy) may be cut out and examined under the microscope. You will be given a local anaesthetic beforehand to numb the skin.

Can basal cell carcinomas be cured?

Yes, BCCs can be cured in almost every case, although treatment becomes complicated if they have been neglected for a very long time, or if they are in an awkward place, such as near the eye, nose or ear.

BCCs never spread to other parts of the body except very rarely (fewer than 1 in 20) if neglected for years, when it may spread to draining lymph nodes. Hence, although it is a type of skin cancer it rarely endangers life.

How can a basal cell carcinoma be treated?

The commonest treatment for BCC is surgery. Usually, this means cutting away the BCC, along with some clear skin around it, using local anaesthetic to numb the skin. The skin can usually be closed with a few stitches, but sometimes a small skin flap or graft is needed.

Other types of treatment include:

• Difficult or neglected BCC - Mohs micrographic surgery. This involves the excision of the affected skin that is then examined under the microscope straight away to see if all the BCC has been removed. If any residual BCC is left at the edge of the excision further skin is excised from that area and examined under the microscope and this process is continued until all the BCC is removed.

To download an information leafet on Mohs micrographic surgery, click here

• Radiotherapy - shining X-rays onto the area containing the BCC.
• Very superficial BCC: - Curettage and cautery - the skin is numbed with local anaesthetic and the BCC is scraped away (curettage) and then the skin surface is sealed by heat (cautery).
• Cryotherapy - freezing the BCC with liquid nitrogen (not used often due to difficulty determining temperature at base of lesion)
• Creams - these can be applied to the skin. The two most commonly used are 5-fluorouracil (5-FU) and imiquimod.
• Photodynamic therapy - a special cream is applied to the BCC which is taken up by the cells that are then destroyed by exposure to a specific wavelength of light. This treatment is only available in certain dermatology departments

Surgical excision is the preferred treatment, but the choice of other treatments depends on the site and size of the BCC, the condition of the surrounding skin and number of BCC to be treated (some people have multiple ) as well as the overall state of health of each person to be treated.

Self care (What can I do?)

Treatment will be much easier if your BCC is detected early. BCC can vary in their appearance, but it is advisable to see your doctor if you have any marks or scabs on your skin which are:

• growing
• bleeding and never completely healing
• changing appearance in any way

Check your skin for changes once a month. A friend or family member can help you particularly with checking areas that you cannot easily inspect, such as your back.

You can also take some simple precautions to help prevent a BCC appearing:

Top sun safety tips:

• Protect your skin with clothing, and don’t forget to wear a hat that protects your face, neck and ears, and a pair of UV protective sunglasses.
• Spend time in the shade between 10am and 3pm when it’s sunny. Step out of the sun before your skin has a chance to redden or burn.
• When choosing a sunscreen look for a high protection SPF (SPF 30 or more) to protect against UVB and UVA . Apply plenty of sunscreen 15 to 30 minutes before going out in the sun, and reapply every two hours and straight after swimming and towel-drying.
• Keep babies and young children out of direct sunlight.
• Tell your doctor about any changes to a mole or patch of skin. If your GP is concerned about your skin, he or she may refer you to a Consultant Dermatologist.
• Sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection.
• It may be worth taking Vitamin D supplement tablets (available from health food stores) as strictly avoiding sunlight can reduce Vitamin D levels.

Vitamin D advice:

The evidence relating to the health effects of serum Vitamin D levels, sunlight exposure and Vitamin D intake remains inconclusive. Avoiding all sunlight exposure if you suffer from light sensitivity, or to reduce the risk of melanoma and other skin cancers, may be associated with Vitamin D deficiency.

Individuals avoiding all sun exposure should consider having their serum Vitamin D measured. If levels are reduced or deficient they may wish to consider taking supplementary vitamin D3, 10-25 micrograms per day, and increasing their intake of foods high in Vitamin D such as oily fish, eggs, meat, fortified margarines and cereals. Vitamin D3 supplements are widely available from health food shops.

Bowens Disease

What is Bowen’s disease?

Bowen’s disease is also known as squamous cell carcinoma in situ, and is a growth of cancerous cells that is confined to the outer layer of the skin. Its importance rests on the fact that it can progress into an invasive skin cancer (squamous cell carcinoma). For this reason, dermatologists usually treat Bowen's disease.

What causes Bowen’s disease?

Most cases of Bowen’s disease develop as a result of long-term sun exposure. Very occasionally, Bowen’s disease may be seen in the context of previous radiotherapy, following chronic arsenic ingestion (very rare nowadays) or on the genitalia in association with the virus that causes warts (the human papillomavirus). Bowen's disease is neither infectious, nor due to an allergy.

Is it hereditary?

No, but some of the factors that increase the risk of getting it, such as a fair skin and a tendency to burn in the sun, do run in families.

What are its symptoms?

Often there are no symptoms, although the surface crusting may catch on clothing.

What does it look like?

A patch of Bowen’s disease starts as a small red scaly area, which grows very slowly. It may reach a diameter of a few centimetres across. It commonly occurs on sun-exposed skin, especially the head, hands and lower legs. More than one lesion may be present. The development of an ulcer or lump on a patch of Bowen’s disease may indicate the formation of invasive squamous cell carcinoma.

How will it be diagnosed?

A patch of Bowen’s disease can look rather like other skin conditions, such as psoriasis. For this reason a biopsy may be needed to make the diagnosis.

Can it be cured?

Yes. As Bowen’s disease is confined to the surface of the skin, there are a variety of ways in which this can be achieved (see below).

How can it be treated?

A number of treatments are available for Bowen’s disease:

• Freezing with liquid nitrogen. This is done in the clinic. It causes redness, puffiness, blistering or crusting, and may be slow to heal. It can be done in stages for large areas of Bowen's disease.
• Curettage. This involves scraping off the abnormal skin under a local anaesthetic. The area then heals with a scab, like a graze.
• Excision. The abnormal skin can be cut out, under local anaesthetic.
• 5-fluorouracil (Efudix) cream. This is a cream that may control or eradicate the disorder. There are various different ways of using it, and, if it is felt to be the best treatment, the doctor who sees you will explain these to you. Efudix works by killing the abnormal skin cells. This means that the skin will become red and look worse during treatment, and will then heal after the end of the course of treatment, once the abnormal cells have gone
• Imiquimod (Aldara) cream. This was originally developed for the treatment of genital warts, but imiquimod cream has been found useful in treating Bowen’s disease. It also causes inflammation of the skin during treatment.
• Photodynamic therapy. A chemical is applied to the skin that makes the cells in the patch of Bowen’s disease sensitive to particular wavelengths of light. Light from a special lamp is then shone onto the lesion. This treatment can be painful and cause inflammation; however any inflammation should disappear within a few days.
• A particular problem with Bowen’s disease is that it is frequently found on the lower leg - where the skin is often tight and sometimes quite fragile, especially in older patients. Healing there is slow. Many factors, therefore, play a part in selecting the right treatment:
• The size and thickness of the patch
• The number of patches
• The presence of swelling of the legs
• The general state of the skin on the legs

If the affected area is judged to be thin and not likely to cause problems soon, your dermatologist may simply suggest that it is kept under observation in a clinic, or in some cases by yourself or by your GP.

Self care (What can I do?)

• From now on, you should take sensible precautions to prevent additional patches of Bowen’s disease developing. This means wearing clothing that protects you against the sun, avoiding strong sunlight, and using a sun block with a sun protection factor (SPF) of at least 30.
• Check your skin regularly for new patches.
• The smaller your patch of Bowen’s disease is, the better the results of treatment are likely to be. If you think another one is developing, see your doctor about it promptly.
• If your patch changes in any way (e.g. bleeds, ulcerates or develops a lump) contact your doctor as soon as possible as this could be the start of an invasive skin cancer.

Vitamin D advice:

The evidence relating to the health effects of serum Vitamin D levels, sunlight exposure and Vitamin D intake remains inconclusive. Avoiding all sunlight exposure if you suffer from light sensitivity, or to reduce the risk of melanoma and other skin cancers, may be associated with Vitamin D deficiency.

Individuals avoiding all sun exposure should consider having their serum Vitamin D measured. If levels are reduced or deficient they may wish to consider taking supplementary vitamin D3, 10-25 micrograms per day, and increasing their intake of foods high in Vitamin D such as oily fish, eggs, meat, fortified margarines and cereals. Vitamin D3 supplements are widely available from health food shops.

Contact Dermatitis

What is contact dermatitis?

Dermatitis means an inflammation of the skin. Contact dermatitis is a term used when this inflammation is caused by contact with something in the environment. The changes of dermatitis seen in the skin take the form of eczema; hence it may sometimes be referred to as contact eczema but may have nothing to do with atopic tendencies and atopic eczema.

What causes contact dermatitis?

Two main groups of things in the environment cause contact dermatitis, irritants and allergens.

• Irritants are substances like detergents and solvents that strip the skin of its natural oils, and cause dermatitis to develop if contacted frequently and without skin protection. When this happens, the skin changes are known as an irritant contact dermatitis. The most important factor in causing this type of contact dermatitis is the amount of irritants to which you are exposed. It is particularly common in people who do a lot of wet work (especially in hand dermatitis), e.g. nurses, hairdressers, those who work in bars, and those in the catering trade.
• Allergens are things to which your immune system can develop a specific reaction after you have come into contact with them. Examples include substances such as nickel, rubber, and perfumes or preservatives used in some creams and cosmetics. This type of dermatitis is called an allergic contact dermatitis. It is not known why some people who are exposed to these allergens develop it while others do not.

Sometimes substances such as proteins in fruit and vegetables, when touched, can cause an immediate allergic reaction leading to itchy skin swellings known as contact urticaria (hives), which in turn can aggravate your dermatitis.

Contact dermatitis cannot be caught from nor spread to other people.

Is contact dermatitis hereditary?

People with a tendency to asthma, eczema and hay fever develop irritant contact dermatitis more easily than others, and this tendency does run in families.

What are the symptoms of contact dermatitis?

Itching of the skin is the commonest symptom, and this can be intense. Sometimes the skin becomes sore, and painful cracks can develop on the fingers when dermatitis affects the hands. Other areas that can be affected, and become red and raised, include the arms, face, legs and feet.

What does contact dermatitis look like?

The commonest areas on which contact dermatitis occurs are the hands, neck, arms, face and legs. During a flare, contact dermatitis inflames the skin surface making it look red and scaly. Sometimes, tiny water blisters develop and these leak fluid when scratched. When the contact dermatitis is less active, the skin looks thick and dry, and painful little cracks can form over joints.

How will it be diagnosed?

• Irritant contact dermatitis is diagnosed simply by knowing which irritant substances your skin is exposed to, and how often this occurs.
• Allergic contact dermatitis is diagnosed by patch testing. This involves putting sticky patches containing different substances on your back. The patches are taken off 2 days later, and the doctor will then look at your back to see which ones have reacted. They will need to look again after a further 24 to 48 hours to see if there are further reactions.

Can contact dermatitis be cured?

If you can greatly reduce your contact with irritants then your irritant contact dermatitis will improve or clear.

If patch testing shows that you are allergic to a specific allergen, then avoiding that allergen will usually lead to a big improvement or even complete clearance of your allergic contact dermatitis.

How can contact dermatitis be treated?

The main way of treating contact dermatitis is to identify its cause (irritant or allergen) and then to remove it or reduce contact with it. Complete avoidance may be easy for some types of allergic contact dermatitis, for example to a substance such as rubber. However complete avoidance is impossible for some people whose irritant contact dermatitis is due to prolonged contact with water and soap. In cases such as these measures to protect the skin, such as wearing gloves and using emollient creams, may help. If the problem is severe enough, some people may have to change their job, if they cannot otherwise avoid coming into contact with irritants.

It may take several months for contact dermatitis to settle, so topical steroid creams and moisturisers are used to help the skin heal and to reduce the itching and redness. Topical steroid creams come in different strengths and it is important that you use the right strength for the right length of time; your doctor will advise you on this. It is also very important to protect your skin and to keep it supple by using a suitable emollient several times a day. Thick emollients are best for the hands, and it is important that you find one that you like to use.
People with very severe contact dermatitis may need other treatments such as steroid tablets, or medicines such as ciclosporin or azathioprine, to settle things down.

What can I do?

• If you think you might have contact dermatitis, you should see your doctor who may then refer you to a dermatologist for further assessment and patch tests.
• If you have contact dermatitis, you can look after your skin by avoiding the allergic reaction causing substances (though this is easier said than done).
• Use moisturisers several times a day.
• Take time to look after your skin and follow your doctor’s advice on using the various creams and treatments. If they are not working, go back and see your doctor.
   

Atopic Eczema (Atopic Dermatitis)

What is atopic eczema?

Atopic eczema is an inflammatory condition of the skin. Atopic is the term used to describe conditions such as eczema, asthma, seasonal rhinitis and hay fever, which often have a genetic basis. Eczema is the term used to describe changes in the upper layer of the skin that include redness, blistering, oozing, crusting, scaling, thickening and sometimes pigmentation (although not all of these changes will necessarily occur together). The words eczema and dermatitis are interchangeable and mean the same thing: thus atopic eczema is the same as atopic dermatitis. For simplicity we shall use atopic eczema in this leaflet.

Atopic eczema affects both sexes equally and usually starts in the first weeks or months of life. It is most common in children, affecting at least 10% of infants at some stage. It usually disappears during childhood, although it can carry on into adult life or come back in the teenage or early adult years. It may occasionally develop for the first time in adulthood.

What causes atopic eczema?

This is still not fully understood. A tendency to atopic conditions often runs in families (see below) and is part of your genetic make-up. In people with atopic eczema, the function of their skin as a barrier to the outside world does not work well, so that irritant and allergy-inducing substances enter their skin, and may cause dryness and inflammation. Atopic eczema is not catching.

Is atopic eczema hereditary?

Yes. Atopic eczema (as well as asthma and hay fever) tends to run in families. If one or both parents suffer from eczema, asthma or hay fever, it is more likely that their children will suffer from them too. In addition, there is a tendency for these conditions to run true to type within each family: in other words, in some families most of the affected members will have eczema, and, in others, asthma or hay fever will predominate.

What are the symptoms of atopic eczema?

The main symptom is itch. Scratching in response to itch may be the cause for many of the changes seen on the skin. Itching can be bad enough to interfere with sleep, causing tiredness and irritability.

What does atopic eczema look like?

Atopic eczema can affect any part of the skin, including the face, but the areas most commonly affected are the bends of the elbows and knees, and around the wrists and neck (a flexural pattern). Other common appearances of atopic eczema include discrete coin-sized areas of inflammation (a discoid pattern), and numerous small bumps that coincide with the hair follicles (a follicular pattern).

If you have eczema, it is likely your skin will be red and dry, and scratch marks (and bleeding) are common. When the eczema is very active (during a ‘flare-up’) you may develop small water blisters on the hands and feet, or the affected areas of your skin may become moist and weepy. In areas that are repeatedly scratched, the skin may thicken up (a process known as lichenification), and become even more itchy.

What makes atopic eczema flare up?

• Many factors in a person’s environment can make eczema worse. These include heat, dust and contact with irritants such as soap or detergents
• Being unwell: for example having a common cold can make eczema flare
• Infections with bacteria or viruses can make eczema worse. Bacterial infection (usually with a bug called Staphylococcus) makes the affected skin yellow, crusty and inflamed, and may need treatment with antibiotics. An infection with the virus that causes cold sores (herpes simplex virus) can cause a painful widespread (and occasionally dangerous) flare of eczema, and may need treatment with antiviral tablets
• Dryness of the skin
• Perhaps stress

How is atopic eczema diagnosed?

It is usually easy for health care professionals, such as health visitors, practice nurses and general practitioners, to diagnose eczema when they look at the skin. However, sometimes the pattern of eczema in older children and adults is different, and the help of a dermatologist may be needed. Blood tests and skin tests are usually not necessary. Occasionally the skin may need to be swabbed (by rubbing a sterile cotton bud on it) to check for bacterial or viral infections.

Can atopic eczema be cured?

No, it cannot be cured, but there are many ways of controlling it. Most children with atopic eczema improve as they get older (75% clear by their teens). However, many of those who have had eczema continue to have dry skin and need to avoid irritants such as soaps or bubble baths. Eczema may persist in adults, but it should be controllable with the right treatment. Atopic eczema may be troublesome for people in certain jobs that bring them into contact with irritant materials, such as catering, hairdressing or nursing.

How can atopic eczema be treated?

You will need the advice of a health care professional on the best treatment for your eczema and on how long this should continue. The regime used most often in the treatment of atopic eczema consists of moisturisers and topical steroids.

Moisturisers (emollients): These should be applied every day to help the outer layer of your skin function as a barrier to your environment. The dryer your skin, the more frequently should you apply a moisturiser. Many different ones are available, varying in their degree of greasiness, and it is important that you choose one you like to use. A moisturiser in your bath or shower is a good idea.

Topical steroid creams or ointments: These will usually settle the redness and itching of your eczema when it is active. They come in different strengths (mild, moderately-potent, potent and very potent), and your doctor will advise you on which type needs to be used where, and for how long. Used inappropriately (too strong or for too long), topical steroids may cause side effects, including thinning of the skin, but they are very safe as long as they are used correctly - using the right strength to settle a flare up and stopping them or reducing their strength once things have improved. Doctors vary in their preference for how to stop topical steroids: some may suggest they are stopped abruptly, others may prefer to gradually decrease the potency of the steroid preparation, and yet others will advise a “maintenance regime” of using them intermittently for a few weeks after a flare of eczema has settled.

By and large, weaker topical steroids should be used where the skin is particularly thin, such as on the face, eyelids and armpits: stronger steroids can be used at other sites.

Antibiotics and antiseptics: If your eczema becomes wet, weepy and crusted, it may mean that it is infected and that a course of antibiotic is needed. Antiseptics, when applied to the skin alone or as part of a moisturising preparation, can be very helpful in stopping the growth of bugs, although a possible side effect is that they may irritate the skin.

Topical immunosuppressants (calcineurin inhibitors): Some people with atopic eczema find the relatively new calcineurin inhibitor, tacrolimus ointment effective in reducing the inflammation of their skin. They are not steroids and thus do not thin the skin, nor cause the other side effects associated with topical steroids. Their commonest side effect is stinging on application, which quickly disappears. They may increase risk of skin infections and, thus, should not be applied to obviously infected skin. Theoretically at least, they might increase the risk of skin cancer, and therefore should not be applied to sun-exposed sites in the long term, nor used at the same time as ultraviolet light treatment.

Antihistamines: Your doctor may recommend antihistamine tablets, which in certain patients can be helpful. Those antihistamines that make people sleepy (such as chlorphenamine and hydroxyzine) may help the itch of atopic eczema, although they are less effective if used in the long term.

Bandaging (dressings): The use of medicated paste bandages can sometimes be very helpful, as they are soothing and provide a physical barrier to scratching. ‘Wet wraps’ are cooling bandages that are sometimes helpful for short periods. If the skin is infected, appropriate treatment is necessary if dressings are being considered. Your doctor or nurse will advise you regarding the suitability of dressings.

Ultraviolet light: Some people with chronic eczema benefit from ultraviolet light treatment, which is usually given in a specialist hospital department and supervised by a dermatologist.

Stronger treatments: People with severe or widespread atopic eczema sometimes need stronger treatments, which dampen down the immune system, and these will usually be given under the close supervision of a dermatologist. These include:

• Oral steroids (usually prednisolone): sometimes used for a short time if the eczema has flared badly: they work well but should not be used in the long term because of the risk of side effects
• Azathioprine
• Ciclosporin

Treatments that are not recommended:

• ‘Natural’ herbal creams, as they can cause irritation and allergic reactions. Their use on broken and inflamed skin is therefore not recommended.
• Evening primrose oil tablets are no longer recommended, as they have shown no proven benefit.

Allergy and atopic dermatitis:Atopic people often have allergies, for example to cats, dogs, pollen, grass or the house dust mite. Contact with these normally causes hay fever or asthma rather than eczema. However, a nettle type rash (urticaria) can occur after contact, and this may then cause eczema to flare.

• The house dust mite. The most common allergy in people with atopic eczema is to the house dust mite. Reducing the amount of house dust, especially in living rooms and bedrooms, may help to control eczema.
• Food allergies. Atopic people are more prone to food allergy. If such an allergy is present, the symptoms are usually obvious to the patient. The lips and eyelids may swell, there may be a rash, or there may be an irritation inside the mouth immediately on eating the culprit food (usually eggs, milk and other dairy products, wheat, nuts and fish). However, it is rare for these allergies to cause eczema, and thus tests for food allergy are not performed routinely in atopic eczema. In a small proportion of children with atopic eczema, the avoidance of certain foods, after appropriate investigation, may help to control their eczema. A healthy, well-balanced diet is important, especially for children, and foods should not be excluded without advice from your doctor or a dietician.
• Latex (rubber) allergy is more common in people who are atopic. The symptoms may be minor, consisting only of itching of the skin after contact with rubber products, or they may be more severe, requiring hospital treatment. If you are allergic to latex, you may also be allergic to certain foods such as kiwi fruit, bananas, potatoes or tomatoes. Latex allergy is very important – mention it to your doctor if you think you have it.
• 'Contact’ allergy to creams and ointments used to treat atopic eczema can occur. Let your doctor know if your treatments seem to be making your skin worse.

What can I do?

• Moisturise your skin as often as possible – maybe as often as 6 times each day. A bland, nonperfumed moisturiser is best. This is the most important part of your skin care.
• Wash with a soap substitute. Try to avoid using soap, bubble baths, shower gels and detergents.
• Wear gloves to protect your hands if they are likely to come into contact with irritants.
• Shower well after swimming, and apply plenty of your moisturiser after drying.
• Wear comfortable clothes made of materials such as cotton, and avoid wearing wool next to your skin.
• Try to resist the temptation to scratch. It may relieve your itch briefly, but it will make your skin itchier in the long term. Massage a moisturiser onto itchy skin.
• Avoid close contact with anyone who has an active cold sore.
• Do not keep pets to which there is an obvious allergy.

Fungal Infection of the Nail

What is a fungal infection of the nail?

Fungal infections of the nails are also known as onychomycosis and tinea unguium. The fungi in question are usually those that cause athlete’s foot – a common infection of the skin of the feet. In athlete’s foot the fungi live in the keratin that makes up the outer layer of the skin, but they can also invade the hard keratin of which nails are made. When this happens, the result is a fungal infection of a nail.

What causes onychomycosis?

Fungi spreading from athlete’s foot (known as ‘dermatophyte fungi’) cause most fungal nail infections. Far less often a nail infection is due to other types of fungi, usually yeasts (eg. Candida) and moulds (e.g. Scopulariopsis), which do not cause athlete’s foot. These like to attack nails that are already weak, perhaps after an old injury. Fungal infections of toenails are common, those of fingernails far less so. Both are seen most often in the elderly.

Are they hereditary?

No, but several family members may have them at the same time because they can catch them from each other.

What are the symptoms of fungal infections of the nails?

At the start, there are usually no symptoms. Later the nails may become so thick that they hurt when they press on the inside of a shoe. They are then hard to trim. The look of an infected nail, particularly a fingernail, can be embarrassing.

What do fungal infections of the nails look like?

When fungi invade a nail, they usually start at its free edge, and then spread down the side of the nail towards its base. Eventually the whole nail may be involved. The infected areas turn white or yellowish, and become thickened and crumbly. Less common patterns of infection include white patches or streaks on the nail surface. The nails most commonly affected by fungal infections are those on the big and little toes. When several fingernails are infected, they are usually on the same hand.

How are fungal infections of the nail diagnosed?

Many nail problems can look like a fungal infection – for example the changes seen in psoriasis, or after a bacterial infection or an old injury – however, long courses of antifungal tablets will not help them. This is why the diagnosis of a fungal infection may confirmed before treatment starts. Your doctor will take a piece from a crumbly area of your nail and send it to the laboratory to check if a fungus can be seen under the microscope or grown in culture. The right treatment may depend on knowing which fungus is causing the trouble but it can take several weeks for the final culture results to come through.

Can fungal infections of the nails be cured?

Yes – usually they can.

How can fungal infections of the nails be treated?

Fungal infections of the nail do not clear up by themselves, but not all of them need treatment. Many people with infected toenails are not bothered by them at all. In that case they can be left alone. On the other hand, if infected nails are embarrassing or uncomfortable then they are usually worth treating.

The aim of the treatment is to get rid of the fungus: the nail will then usually return to normal. However, if the nail was abnormal before it picked up the fungal infection, it will be hard to clear and may just go back to its former state. Nail infections caused by moulds and yeasts can be very resistant to treatment.

Treatments applied to the nail

Treatments put on the nail do much less well than those taken by mouth. They work best if the infection is at an early stage, just on the free edge of one or two nails, or lying close to the surface of the nail. The preparations used most often are amorolfine nail lacquer and tioconazole nail solution. Alone, they may not be able to clear the deeper parts of an infected nail, though regular removal of abnormal nail material with clippers or filing can help with this. Used in combination with an antifungal remedy taken by mouth, they increase the chance of a cure. They may have to be used for a period of 4 to 12 months before a response is noted.

Treatment by mouth

Three medicines are available for use in fungal nail infections:

• Griseofulvin has been used for many years and is the only one of the three medicines licensed for use in children. It is only absorbed fully if taken with fatty foods, and long courses of treatment are usually needed (6 to 9 months for fingernails, and up to 18 months for toenails). Even so, only about three quarters of infected fingernails and one third of infected toenails will clear up. Relapses are common.
• Terbinafine and itraconazole have largely taken over from griseofulvin now. They work better and much more quickly. Cure rates are 80 to 90% for fingernails, and about 70% for toenails.
• Terbinafine works best against dermatophyte fungi (the ones that cause athlete’s foot). It is taken daily for 6 weeks for fingernail infections and for 12 weeks for toenail infections.
• Itraconazole acts against dermatophytes too, although usually it is not quite as effective as terbinafine; but it is also active against other fungi such as yeasts. It is often given in bursts – for one week in every month. Two of these weekly courses, taken 21 days apart, are usually enough for fingernail infections and three for toenail infections.

Remember that the new normal nail will grow slowly outward from its base, and it may be 6 months to a year after the treatment has finished before the nails look normal again. Fingernail infections clear up more quickly and completely than toenail ones.

Surgical removal of nails

Sometimes very thick nails that are not likely to respond to tablets alone may have to be removed under a local anaesthetic.

Self care (What can I do?)

• Keep your nails short, dry, and clean. Stick to one nail clipper for the infected nails and another for the normal ones.
• Don’t just treat your nails; use an antifungal cream to treat the skin that has athlete’s foot as well.
• Keep your feet dry, wear cotton socks, changed daily, and use ‘breathable’ shoes.
• Your activities need not be limited during treatment but, to avoid a recurrence, don’t walk barefoot around public pools, showers, and locker rooms.

Hand Dermatitis – Care for the Hands

Why do I need to care for my hands?

The hands are the point of contact for many irritants such as soap, detergent, shampoo, water, fibreglass, plasterboard, cutting fluids etc. Frequent contact with irritants, including excessive use of water, reduces skin barrier function and can promote the development of hand eczema or cause the recurrence of pre-existing hand eczema. The hands become red, scaly, cracked, itchy and sore.

Who is most likely to get hand dermatitis?

This is most likely to occur in those who have had eczema in the past (including childhood eczema) and those who are working in certain occupations where a lot of wet work is carried out.

Which occupations are most at risk?

Cleaners, housewives, care workers, chefs, hairdressers, mechanics, surgeons, dentists, nurses, florists, machine operators, aromatherapists, beauticians, and construction workers are some of those with an occupational risk of hand dermatitis due to frequent wet work, contact with irritants and minor trauma.

Will taking good care of my hands cure my skin condition?

No, but taking good care of your hands will help to repair the skin barrier and reduce inflammation. It will not usually cure the condition completely and if these measures are discontinued, the condition will frequently recur. The resistance of the skin is lowered for several months after the dermatitis has apparently healed.

What are emollients (moisturisers) and how do they work?

Emollients are mixtures of oil (creams), or paraffin (ointments), and water in different formulations. They are designed to smooth and hydrate the skin. Their effects are short-lived and they need to be applied very frequently. There are many different types of emollients, and it will be important to find one or two types that suit you and are practical for your daily routine. You need to use emollients several times a day as directed by your doctor or nurse.

How should I apply emollients (moisturisers)?

You should use emollients as frequently as you can manage, ideally after every hand wash and during every break from work. It is important to remember to bring the emollient to work with you, and you may need to purchase a small tub to take to work as well as a larger tub to use at home. In the evenings, emollients are often most conveniently applied whilst watching television or before bed.

If the hands are severely affected apply the emollient under cotton gloves. Apply generously all over the hands and smooth in.

If you have been prescribed a steroid cream, to use on the worst affected areas of your hands, then you will need to apply this once or twice daily until the flare of dermatitis comes under control, under the emollient (you should not be using a steroid cream as your only treatment without an emollient). You should continue to apply the emollient regularly even after things have improved, to try to reduce the chance of the condition worsening again.

What are the side effects of emollients?

Emollients rarely cause significant side effects. However, if the hands are very cracked or sore, they can occasionally cause some stinging during the first few days of application. Occasionally, an allergy to the emollient may develop, and cause more inflammation. It is well worth trying a different emollient if you are having problems with the one recommended.

Is there anything I should do or avoid whilst applying emollients?

If you are carrying out fine paperwork or similar activities, you may find that your hands are too greasy to handle the work for a few minutes after applying the emollient. In such a case, you may wish to choose a less greasy cream prior to such work, and use the greasier preparations at other times as these are more effective and long-lasting. Do not share your or other people’s emollients, as this can introduce infection into the container.

How should I wash my hands?

Use lukewarm water with a soap substitute (e.g. soapless wash, emollient shower gel, emulsifying ointment or paraffin-based ointment). If your hands are dirty, use a non-perfumed soap without tar or sulphur, applied sparingly and rinse the hands thoroughly. Never wash your hands with soap while wearing a ring.

After washing, dry your hands carefully with a clean towel, especially between the fingers and under rings. After drying, apply the recommended emollient. You may be able to avoid some hand washing by using gloves for dirty tasks.

Is there anything I can do to avoid or reduce the frequency of flares?

Avoid contact with detergents and other strong cleansing agents. Use a measure when handling detergent powder, and avoid contact with grease which will necessitate using a detergent to remove it from the hands.

Using washing machines and dishwashers can help to reduce manual labour, and in turn may help to reduce the chance of further attacks of hand dermatitis. Try and rest your hands when at home and ask someone else to do the housework. Ask a family member to do jobs like gardening which cause trauma to the hands.

Always avoid contact with car oil and grease. Do not use heavy duty hand cleaners or wire wool on the hands; these are highly irritant. Fibreglass and plasterboard are also highly irritant. Avoid contact with paint and cement.

Avoid direct contact with shampoo. Use plastic/PVC gloves, or let someone else shampoo your hair or your children’s hair.

Avoid contact with polish: metal, wax, shoe, floor, car, furniture and window polishes.

Avoid contact with solvents: white spirit, petrol, paraffin, turpentine, thinners and trichloroethylene. Do not peel or squeeze citrus fruits with bare hands.

Do not apply hair lotion, hair cream or hair dye with bare hands.

Rings should not be worn for work or housework until the skin has been clear for three months. Keep the inside of rings clean (brush under running water).

When washing-up, use running water if possible, keeping the temperature of the water low. Use long handled brushes rather than cloths. Always wear gloves when in contact with washing-up liquid or detergent.

If working in healthcare, use alcohol hand rubs instead of full hand washing for infection control purposes as much as possible. If hands are not visibly dirty or visibly soiled with blood or other body fluids, alcohol rubs can be used for decontamination. Always follow the infection control and hand hygiene guidelines in your own workplace. Some people can be sensitive to alcohol hand rubs in which case they should seek help from occupational health nurses to confirm their sensitivity and for supplying alternative disinfectants.

When should I wear gloves?

Use protective gloves when necessary for wet work or when handling chemicals or potentially infectious material. Use gloves for as short a time as possible, ideally not for more than 20 minutes at a time, to reduce sweating (which can make dermatitis worse). When using gloves make sure they are clean, dry and intact (no holes). Use PVC if possible rather than rubber, preferably with cotton gloves inside, to reduce sweating and friction.

Gloves should be turned inside out and rinsed under warm water several times a week. The outside gloves should be replaced every few weeks for home use and more frequently for industrial use. If water happens to enter a glove, it should be immediately removed.

Wear warm gloves in cold weather.

Melanoma

What is a melanoma?

Cutaneous malignant melanoma is a cancer of the pigment cells of the skin. If it is treated early, the outlook is usually good. It is not contagious.

The word ‘melanoma’ comes from the Greek word ‘melas’, meaning black. Melanin is the dark pigment that gives the skin its natural colour. Melanin is made in the skin by pigment cells called melanocytes. After our skin is exposed to sunlight, the melanocytes make more melanin, and so the skin becomes darker.

Melanocytes sometimes grow together in harmless groups or clusters, which are known as moles. Most people have between 10 and 50 moles and often they are darker than the surrounding skin.

Melanomas can come up in or near to a mole, but can also appear on skin that looks quite normal. They develop when the skin pigment cells (melanocytes) become cancerous and multiply in an uncontrolled way. They can then invade the skin around them and may also spread to other areas such as the lymph nodes, liver and lungs.

What causes melanoma?

The most important preventable cause is exposure to too much ultraviolet light in sunlight, especially during the first 20 years of life. There is lots of evidence linking melanoma to this, and melanomas are especially common in white-skinned people who live in sunny countries. The use of artificial sources of ultraviolet light, such as sun beds, also raises the risk of getting a melanoma.

Some people are more likely to get a melanoma than others:

• People who burn easily in the sun are particularly at risk. Melanoma occurs most often in fairskinned people who tan poorly. Often they have blond or red hair, blue or green eyes, and freckle easily. Melanomas are less common in dark-skinned people.
• Past episodes of severe sunburn, often with blisters, and particularly in childhood, increase the risk of developing a melanoma. However, not all melanomas are due to sun exposure, and some appear in areas that are normally kept covered.
• People with many (more than 50) ordinary moles, or with a very large dark hairy birthmark, have a higher than average chance of getting a melanoma.
• Some people have many unusual (atypical) moles (known as ‘dysplastic naevi’). They tend to be larger than ordinary moles, to be present in large numbers, and to have irregular edges or colour patterns. The tendency to have these ‘dysplastic naevi’ can run in families and carries an increased risk of getting a melanoma.
• The risk is raised if another family member has had a melanoma.
• People who have already had one melanoma are at an increased risk of getting another one.
• People with a damaged immune system (e.g. as a result of an HIV infection or taking immunosuppressive drugs, perhaps after an organ transplant) have an increased chance of getting a melanoma.

Are melanomas hereditary?

About 1 in 10 of people with a melanoma have family members who have also had one. There are several reasons for this. Fair skin is inherited; dysplastic naevi can run in families, as can a tendency to have large numbers of ordinary moles.

What are the symptoms of melanoma?

Melanomas may not cause any symptoms at all, but tingling or itching may occur at an early stage. Some melanomas start as minor changes in the size, shape or colour of an existing mole (see below): others begin as a dark area that can look like a new mole. Later on a melanoma may feel hard and lumpy, and bleed, ooze or crust up.

What does a melanoma look like?

All melanomas do not look the same, and there are several different types. The ABCD system (below) tells you some of the things to look out for.

A melanoma may show one or more of the following features:

Asymmetry – the two halves of the area differ in their shape.

Border – the edges of the area may be irregular or blurred, and sometimes show notches.

Colour – this may be uneven. Different shades of black, brown and pink may be seen.

Diameter - most melanomas are at least 6 mm. in diameter.

Melanomas can appear on any part of the skin but they are most common in men on the body, and in women on the legs.

How is a melanoma diagnosed?

If you are at all worried about changes in a mole, or about a new area of pigmentation appearing on your skin, you should see your family doctor. The ABCD changes listed above can sometimes be found in completely harmless conditions, and your doctor will often be able to put your mind at rest quickly. However, if there is still any doubt, your doctor will usually refer you to a specialist (a dermatologist or a surgeon with a special interest in pigmented lesions) who will examine the area and decide whether it needs to be removed. The only way in which the diagnosis of a melanoma can be made firmly is by looking at the suspected area under microscope in the laboratory.

If the mole needs to be examined further, the whole of the suspicious area will then be removed under a local anaesthetic (an excision biopsy) and sent to the laboratory to be examined. If the area is too large to remove easily, a sample of it (a biopsy) will be taken. If a melanoma is found, the biopsy specimen will provide valuable information about its type and depth that will help to plan the next step in treatment.

Can a melanoma be cured?

Yes: three quarters of the people who have a melanoma removed will have no further problems. However it is crucial for a melanoma to be removed as early as possible - before it has had time to spread deep into the skin or to other parts of the body. The thinner the melanoma is when it is removed; the better is the survival rate. This is why a doctor should examine anyone with a suspicious mole or blemish as soon as possible. In a small minority of people the melanoma may have spread but further surgery or chemotherapy can often help to control this.

How can a melanoma be treated?

At present, the treatment for melanoma is surgical. For melanoma which has spread beyond the original site on the skin there are some new drugs which may be recommended.

Most people who have had a melanoma removed will need another operation to try to prevent the melanoma from coming back at the original site. During the operation, some healthy skin will be removed from around the original scar to make absolutely sure that all of the melanoma has been taken away, and this makes the scar larger than before. Occasionally a skin graft will be needed.

“Sentinel node biopsy” may be discussed with some people. In this, a small sample of the nearest lymph node is taken as an additional procedure when the melanoma is being removed.

After your operation you will be followed up regularly in the outpatient clinic. There are three main reasons for this:

1. To make sure the tumour has not come back or spread. 2. To detect any other skin cancers. 3. To provide you with support and information.

At the clinic your scar will be checked, and your neck, groin and armpits will also be examined for lumps to detect any spread to the lymph nodes there. Any other moles that you are concerned about will be examined and, if you have large numbers of moles, an eye will be kept on these too.

What can I do?

Once your melanoma has been treated, you should be able to get back to a normal lifestyle quite quickly. You should also take a few sensible precautions to stop yourself getting another one.

You should look at all areas of your skin monthly for moles that are growing, or changing in the ways listed in the ABCD rules (see above). There is no way that you can memorise all your existing moles, but you will notice subconsciously if any mole begins to change or if a new mole develops. It is as if someone has moved something in one of your rooms at home – it looks wrong. If you find any worrying changes, contact your doctor immediately.

You must also protect yourself from too much sun. This does not mean that you can’t ever go on a sunny holiday again; it just means that you need to be careful to avoid sunbathing and burning. You can do this by covering yourself up and using sun protection creams.

Covering up is better than using a sunscreen. Wear long sleeves, use a hat when out in the sun, and wear long trousers rather than shorts. Use clothing with a tight weave that will block ultraviolet light. Avoid the sun particularly from 11 am until 3 pm when its rays are strongest. Seek shade whenever possible. Use a high factor sunscreen (factor 30 or above) on areas you can’t cover. A broad spectrum one is best, as it will block both types of ultraviolet radiation (UVA and UVB). Put it on half an hour before going out and reapply it at least every 2 hours, but don’t use these sunscreens as an excuse to stay out in the sun or not to bother with protective clothing. Avoid sun beds and tanning lamps. Share sun advice and other information with blood relatives as they also may be at increased risk of getting a melanoma. In particular, protect your children from the sun, as exposure during childhood seems to be particularly damaging.

Top sun safety tips

• Protect the skin with clothing, including a hat, T shirt and UV protective sunglasses
• Spend time in the shade between 11am and 3pm when it’s sunny
• Use a 'high protection' sunscreen of at least SPF 30 which also has high UVA protection, and make sure you apply it generously and frequently when in the sun.
• Keep babies and young children out of direct sunlight Sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection.

Psoriasis

What is psoriasis?

Psoriasis is a common skin problem affecting about 2% of the population. 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.

What causes psoriasis?

The skin is a complex organ made up of several different layers. The outer layer of skin (the epidermis) contains cells which are formed at the bottom and then move up towards the surface, gradually changing as they go, finally dying before they are shed from the surface. This process normally takes between 3 and 4 weeks. In psoriasis, the rate of turnover is dramatically increased within the affected skin, so that cells are formed and shed in as little as 3 or 4 days. There is also inflammation and blood vessel proliferation on the affected skin; the reasons for these are still not fully understood. There is activation of the immune cells in the skin causing inflammation.

Some people are more likely to develop psoriasis than others, particularly if there is someone else in their family who has psoriasis: in other words, it is a genetic or hereditary disease (see below). However, the trigger for psoriasis to appear is often an outside event, such as a throat infection, stress or an injury to the skin.

In practice, for most patients who develop psoriasis, or for whom it clears and then comes back, no obvious cause can be detected. Usually, sunlight improves psoriasis, though occasionally it makes it worse (especially if the skin gets burned). A high alcohol intake and smoking can worsen psoriasis too, as can medicines used for other conditions - such as lithium, some tablets used to treat malaria (e.g. hydroxychloroquine), and other drugs such as beta blockers (medicines commonly used to treat angina and high blood pressure). There is no apparent relationship between diet and psoriasis.

Is psoriasis hereditary?

Yes, but the way it is inherited is complex and not yet fully understood. Many genes are involved, and even if the right combination of genes has been inherited psoriasis may not appear.

Other features of the inheritance of psoriasis are:

• There is more likely to be a family history of psoriasis in people who get it when they are young than in those who develop it when they are older.
• A child with one parent with psoriasis has roughly a 1 in 4 chance of developing psoriasis.
• If one of a pair of twins has psoriasis, the other twin has a 70% chance of having it too if the twins are identical, but only a 20% chance if not identical.

What are the symptoms of psoriasis?

• The main problem with psoriasis for many people lies in the way it looks, and the way it attracts comments from others. This can affect their quality of life.
• Psoriasis can itch and the affected skin can split, which may be painful.
• Some people with psoriasis may develop stiff and painful joints, which can be due to a form of arthritis associated with psoriasis called psoriatic arthritis. The joints most commonly affected are the fingers, toes, wrists, knees and ankles.

What does psoriasis look like?

Lesions of psoriasis (often known as plaques) are pink or red, and covered with silvery-white scales. They can form a variety of shapes and sizes, and have well-defined boundaries with the surrounding skin. Some arise where the skin has been damaged, for instance by a cut or a scratch, and this is known as the Köbner phenomenon. On the scalp, the scales heap up so that the underlying redness is hard to see. In contrast, in body folds such as the armpits and groin, the red well-defined areas are easy to see but are seldom scaly.

The severity of psoriasis varies with time, and from person to person. When it is mild, there may be only one or two plaques, whilst when it is more severe there may be large numbers.

The plaques can take up a variety of patterns on the skin:

• The most common pattern is chronic stable plaque psoriasis. The persistent plaques tend to appear symmetrically, most often on the knees, elbows, trunk and scalp, though any area can be involved.
• Guttate psoriasis is another variant. It is seen most often in children and is sometimes triggered by a sore throat. The patches of guttate psoriasis are usually small (often less than 1 cm in diameter), but numerous.
• In unstable psoriasis, the plaques of psoriasis lose their clear-cut sharp edges, enlarge, and sometimes join up. New ones may appear too. Occasionally the skin becomes red all over; this condition is known as erythrodermic psoriasis. Unstable psoriasis must be treated with bland preparations as stronger ones can make it worse.
• There are two main types of pustular psoriasis. The first, and most common, involves only the palms and soles (palmo-plantar pustulosis), where the red areas contain a mixture of new yellow pustules (containing pus) and older brown dried-up pustules. This type is slow to clear and often responds poorly to treatment. A different, unrelated, and more widespread (generalised) type of pustular psoriasis can affect any part of the skin, and is more severe.

Changes in the nails can often be seen too, if looked for carefully. They appear in up to 50% of people with psoriasis. The most striking ones are:

• Irregular pitting (indentations) of the surface of the nail
• Circular areas of discolouration under the nail
• Separation of the nail from the underlying nail bed
• Thickening of the nails

How will psoriasis be diagnosed?

• Psoriasis is usually easy to recognise and a skin biopsy is seldom needed.
• If a sore throat has triggered an attack of psoriasis, your doctor may take a swab from your throat to see if bacteria known as beta-haemolytic streptococci are present. If they are, a course of an antibiotic may help.
• If you are suffering from painful joints, your doctor may want to take a blood test to rule out rheumatoid arthritis. If you have several inflamed or tender joints you may need to be assessed by a rheumatologist, a specialist in joint diseases.

Can psoriasis be cured?

No. However, treatment to control the signs and symptoms is usually effective. The skin becomes less scaly and may then look completely normal. However, even if your psoriasis disappears after treatment, there is a tendency for it to return. This may not happen for many years, but can do so within a few weeks.

How can psoriasis be treated?

This will depend on the type of psoriasis that you have, and on its severity.

1. Topical therapies:

Treatments that are applied directly to the skin are known as topical therapies. They include creams, ointments, pastes and lotions. If your psoriasis is mild, topical therapies will be the mainstay of your treatment. Topical treatments include the following:

• Emollients (moisturisers). Emollients reduce scaling and can be used as often as needed.
• Salicylic acid. Preparations containing salicylic acid can help heavily scaled plaques.
• Topical steroids. 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 possible side effects, one of which is to make your skin thinner. Your doctor will monitor their use closely. Psoriasis sometimes comes back quickly when topical steroid treatment stops.
• Tar preparations. Tar creams or ointments help most patients but may be messy and can stain clothing. They can be very helpful for short periods in scalp psoriasis.
• Dithranol. This can be used at home for minor or moderate psoriasis. Patients may be also treated in specialized units in hospitals. Dithranol may be effective on patients with thick plaque psoriasis, however, it is rarely used nowadays, since it may irritate the skin and also it stains not only the skin and clothing, but baths and showers.
• Vitamin D analogues. Vitamin D preparations used to treat psoriasis (e.g. calcipotriol) are safe, clean to use and do not stain the skin. They may be prescribed as a compounded preparation in combination with a topical steroid. Irritation may occur, especially on the face, buttocks and genitals, and these treatments should be applied to those areas only on the specific instructions of your doctor.
• 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 is important to tell your doctor if you are pregnant or breast-feeding. You should avoid becoming pregnant during your treatment.
• Topical immunosuppressant medications, also called calcineurin inhibitors, Tacrolimus is an ointment that is used mainly for eczema but can be effective and safe on treating psoriasis on special areas like face, folds or genitals.

Topical treatments for special sites:

• Skin folds and the face. A weak steroid, a vitamin D derivative or topical immunosuppressant creams or ointments, or a tar preparation, may be prescribed for use once or twice a day. These can also be combined to increase efficacy. Regular review by your doctor will ensure that the quantities used stay within safe limits.
• The scalp. A medicated tar or coconut oil shampoo may be used in addition to a steroid or calcipotriol scalp lotion. Tar or coconut oil preparations should be rubbed thoroughly into the scalp at night and washed out next morning with a tar shampoo. Wearing a shower cap overnight helps the treatment to penetrate and protects your pillowcase from stains.
• The nails. There is no reliably effective treatment. Nails should be trimmed to prevent them catching.

2. Phototherapy

This term refers to treatment with various forms of ultraviolet light, sometimes assisted by taking particular tablets or soaking the skin in a medicated solution beforehand. 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.

Two types of ultraviolet (UV) light may be given, using special machines: UVA and UVB. These are different parts of normal sunlight. Treatment with UVA is helped by taking a medication known as a psoralen – a combination known as PUVA therapy. Treatment with UVB does not need tablets.

Both UVB and PUVA treatments have to be given with great care, and you will come to the physiotherapy department at the hospital 2 or 3 times a week for a number of weeks.

Dr O’Connor and Dr Gibson provide an information sheet and consent form for patients undergoing phototherapy. This can be downloaded by clicking here

3. Internal treatments

In cases, where the disease is very extensive or severe, patients may need oral treatment; however all of the different tablets have potential risks. In addition, you will usually have to continue with some topical therapy even though you are taking the tablets.

Your dermatologist will discuss the risks with you if you start on this kind of treatment. All of the tablets will require blood tests, and many interfere with other medicines. Female patients should not become pregnant whilst on any tablets for psoriasis, and with some of them it is important that male patients should not father a child.

The oral treatments include acitretin (related to vitamin A), ciclosporin (suppresses the immune system), methotrexate (slows down the rate at which the skin cells are dividing in psoriasis There are also several injectable forms of treatment available for severe forms of psoriasis. The biologic medications, that target more specific components of the defence system, include adalimumab, ustekinumab, etanercept and infliximab.

Self care (What can I do?)

• It helps to educate those around you about psoriasis. A simple explanation will often turn their misconceptions into support. Make sure they know that it is not infectious.
• If possible, cut down your smoking and consumption of alcohol.
• Consider contacting others who have psoriasis through a support group.
• Stress management may be helpful.
• Always use the treatments prescribed for you.

In the last few years, there are a number of research papers that point to the fact that there is a higher risk of heart disease, diabetes and obesity in people with psoriasis therefore it is advisable to take regular exercise, have a healthy diet and keep an eye on your blood pressure

Rosacea

What is rosacea?

Rosacea is a common rash, usually occurring on the face, which predominantly affects both middleaged and fair-skinned people. It is more common in women, but tends to be more severe in men. It is a chronic condition and, in any individual, the severity tends to come and go. Rosacea tends to affect the cheeks, forehead, chin and nose, and is characterised by redness, dilated blood vessels, small red bumps and pus-filled spots (sometimes these may only be visible with a magnifying glass), often with a tendency to blush easily. There may also be uncomfortable inflammation of the eyes and eyelid.

What causes rosacea?

The cause of rosacea is unknown, but underlying trigger factors cause both inflammation and an undue readiness of the blood vessels in the skin of the face to dilate. The theory that rosacea is due to bacteria in the skin or gut has not been proven, however antibiotics have proven efficacious. It is not contagious. Antibiotics are prescribed for their antinflammatory effect.

There are a variety of trigger factors which may make rosacea worse, but which probably do not cause it in the first place; these include alcohol, exercise, high and low temperatures, hot drinks, spicy foods and stress. Rosacea can be worsened by natural sunlight.

Is rosacea hereditary?

Rosacea does seem to run in some families, but there is no clear genetic link.

What are the symptoms of rosacea?

The rash and the flushing associated with rosacea are cosmetic issues and can lead to embarrassment, lowered self-esteem and self-confidence, anxiety and even depression. Furthermore, the skin of the face is often sensitive, and the affected area can feel very hot or sting.

Some people with rosacea have eye symptoms (which include red, itchy, sore eyes and eyelids, a gritty feeling and sensitivity to light). A few patients with rosacea may develop more serious eye problems, such as painful inflammation involving the clear front part of the eye (rosacea keratitis), which may interfere and cause blurred vision. Be sure to consult your doctor if you have problems with your eyes.

What does rosacea look like?

Rosacea usually starts with a tendency to blush and flush easily. After a while, the central areas of the face become a permanent deeper shade of red, with small dilated blood vessels studded with small red bumps and pus-filled spots, which come and go in crops. Scarring is seldom a problem.

Occasionally, there may be some swelling of the face (lymphoedema), especially around the eyes. Very occasionally, an overgrowth of the oil- secreting glands may cause the nose to become enlarged, bulbous and red (rhinophyma), which is more common in men than women.

How will rosacea be diagnosed?

Rosacea can be diagnosed by its appearance; there are no diagnostic laboratory tests.

Can rosacea be cured?

No, but long-term treatments can be very effective.

How can rosacea be treated?

The inflammation that accompanies rosacea can be treated with preparations applied to the skin or taken by mouth; however, these will not help the redness or blushing that may be associated with rosacea.

Local applications:

• The inflammatory element of mild to moderate rosacea may be controlled with just a topical preparation (one that is applied to the skin).
• Useful preparations include metronidazole and azelaic acid. They take time, at least 8 weeks, for their effect to become evident.

Oral antibiotics:

These are helpful for the inflammatory element of moderate or severe rosacea. The most commonly used antibiotics belong to the tetracycline group and include tetracycline, oxytetracycline, doxycycline, lymecycline and minocycline. Erythromycin is another commonly used antibiotic. The duration of an antibiotic course depends on your response. Your doctor may suggest that you use a topical and oral treatment together.

Other treatments:

• An eye specialist should manage the more severe types of eye involvement.
• A bulbous nose affected by rhinophyma can be reduced surgically.
• Unsightly redness and dilated blood vessels can be treated with lasers and other light treatments.
• A beta-blocker tablet or clonidine may help if blushing is a big problem.
• Isotretinoin tablets are occasionally given for very severe rosacea.

Self-Care (What can I do?)

• Protect your skin from the sun by using a sun block (with a sun protection factor of at least 30) on your face every day.
• Do not rub or scrub your face as this can make rosacea worse.
• Do not use perfumed soap as this can make rosacea worse.
• Use a soap substitute (emollient) to cleanse your face.
• Use an unperfumed moisturiser on a regular basis if your skin is dry or sensitive.
• Consider the lifestyle factors that can worsen rosacea (listed above). Learn which upset your rosacea and avoid them; a written record of your flare-ups may help.
• Cosmetics can often cover up rosacea effectively, and some rosacea patients may benefit from the use of skin camouflage. This may help hide excessive redness. A health care professional will be able to make a referral for you if necessary.
• Unless they are specifically recommended to you by your doctor it may be best to avoid some treatments for acne, as they can irritate skin that is prone to rosacea.
• Do not use topical preparations containing corticosteroids, unless specifically recommended by your doctor, as these may make rosacea worse in the long run.
• If your eyes are giving problems, do not ignore them - consult your doctor.
• Some drugs can aggravate blushing, and your doctor may make appropriate changes to your medication.

Squamous Cell Carcinoma (SCC)

What is a squamous cell carcinoma?

A squamous cell carcinoma is a type of skin cancer. There are two main types of skin cancer: melanoma and non-melanoma skin cancer. Squamous cell carcinoma (SCC) is a non-melanoma skin cancer and the second most common type of skin cancer.

What causes a squamous cell carcinoma?

The most common cause is too much exposure to ultraviolet (UV) light from the sun or from sunbeds. This causes certain cells (keratinocytes) in one the outer layer of the skin (the epidermis) to grow out of control into a tumour.

SCC can occur on any part of your body, but is most common on areas that are exposed to the sun, i.e. your head and neck (including the lips and ears) and the backs of your hands. SCC can also develop where the skin has been damaged by X-rays, ulcers, burns and on persistent chronic wounds and old scars. SCC is not contagious.

Who is most likely to have a squamous cell carcinoma?

SCC mainly affects the following groups:

• Older people - even those who tend to avoid the sun
• Builders, farmers, surfers, sailors and people who often are out in the sun, can develop a SCC when they are quite young.
• Those with a fair skin are more at risk of developing SCC than people with a darker skin.
• Anyone who has had a lot of ultraviolet (UV) light treatment for skin conditions such as psoriasis will also be at increased risk of getting an SCC.
• Those whose immune system has been suppressed by medication taken after an organ transplant, or by treatment for leukaemia or a lymphoma.

Are squamous cell carcinomas hereditary?

No, they are not; however, some of the things that increase the risk of getting one, such as fair skin, a tendency to burn rather than tan, and freckling, do run in families.

What does a squamous cell carcinoma look like?

SCC can vary greatly in their appearance, but most SCC usually appears as a scaly or crusty area of skin or lump, with a red, inflamed base. SCC are often tender, but some small SCC are not painful.

How will my squamous cell carcinoma be diagnosed?

If your doctor thinks that the mark on your skin needs further investigation, you will be referred to a skin specialist who will decide whether or not it is an SCC. To confirm the diagnosis, a small piece of the abnormal skin (a biopsy), or the whole area (an excision biopsy), will be cut out and examined under the microscope. You will be given a local anaesthetic beforehand to numb the skin.

Can a squamous cell carcinoma be cured?

Yes, SCC can be cured if they are detected early. If an SCC is left untreated for too long there is a small risk (2-10 %) that it may spread to other parts of the body, and this can be serious.

How can a squamous cell carcinoma be treated?

Surgery is the first choice of treatment and several different methods are available. To select the right one, your surgeon will take into account the size of the SCC, where it is, what type it is, and how long you have had it. The most common surgical technique is simply to cut the SCC away, along with some clear skin around it, using local anaesthetic to numb the skin. The skin can usually be closed with a few stitches, but sometimes a small skin graft is needed.

Other types of treatment include:

Curettage and cautery - first the SCC is scraped away (curettage) then the skin surface is sealed (cautery). This is a reaasonable treatment for small SCC

Cryotherapy - freezing the SCC off, as you would a wart, usually with liquid nitrogen. This is used only occasionally for superficial SCC

Advanced surgery, using the Mohs’ technique - undertaken only in specialist centres, and then only for difficult or recurring SCC. This involves the excision of the affected skin that is then examined under the microscope straight away to see if all the SCC has been removed. If any residual SCC is left at the edge of the excision further skin is excised from that area and examined under the microscope and this process is continued until all the SCC is removed. The site may then be covered with a skin flap or graft (should a skin graft be necessary skin camouflage can assist greatly in colour toning the skin graft to match your natural skin tone, making the skin graft less obvious).

Removal of lymph nodes - this is unusual but may be needed if there are concerns that the SCC has spread.

Radiotherapy (treatment with X-rays) may be used if the SCC is large or in an awkward place. You may be offered this on its own or alongside surgery. Radiotherapy may also be used to relieve symptoms when SCC has spread to other parts of the body.

Chemotherapy (treatment with drugs) is only used when a SCC has spread to other parts of the body.

Self care (What can I do?)

Treatment will be much easier if your SCC is detected early. SCC can vary in their appearance, but it is advisable that you should see your doctor if you have any marks on your skin which are:

• growing
• bleeding and never completely healing
• changing appearance in any way

You can also take some simple precautions to help prevent a SCC appearing:

Top sun safety tips:

• Protect your skin with clothing, and don’t forget to wear a hat that protects your face, neck and ears, and a pair of UV protective sunglasses.
• Spend time in the shade between 10am and 3pm when it’s sunny. Step out of the sun before your skin has a chance to redden or burn.
• When choosing a sunscreen look for a high protection SPF (SPF 30 or more) to protect against UVB, and UVA. Apply plenty of sunscreen 15 to 30 minutes before going out in the sun, and reapply every two hours and straight after swimming and towel-drying.
• Keep babies and young children out of direct sunlight.
• Tell your doctor about any changes to a mole or patch of skin.
• Sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection.
• It may be worth taking Vitamin D supplement tablets (available from health food stores) as strictly avoiding sunlight can reduce Vitamin D levels.

Vitamin D advice The evidence relating to the health effects of serum Vitamin D levels, sunlight exposure and Vitamin D intake remains inconclusive. Avoiding all sunlight exposure if you suffer from light sensitivity, or to reduce the risk of melanoma and other skin cancers, may be associated with Vitamin D deficiency.

Individuals avoiding all sun exposure should consider having their serum Vitamin D measured. If levels are reduced or deficient they may wish to consider taking supplementary vitamin D3, 10-25 micrograms per day, and increasing their intake of foods high in Vitamin D such as oily fish, eggs, meat, fortified margarines and cereals. Vitamin D3 supplements are widely available from health food shops.

Urticaria & Angioedema

What is urticaria and angioedema?

• Urticaria is common, and affects about 20% of people at some point in their lives. It is also known as hives or nettle rash. The short-lived swellings of urticaria are known as weals (see below) and typically any individual spot will clear within 24 hours although the overall rash may last for longer.
• Angioedema is a form of urticaria in which there is deeper swelling in the skin, and the swelling may take longer than 24 hours to clear.

An affected individual may have urticaria alone, angioedema alone, or both together. Both are caused by the release of histamine from cells in the skin called mast cells. When angioedema occurs in association with urticaria, the two conditions can be considered part of the same process. When angioedema occurs on its own, different causes need to be considered.

,p>There are different types of urticaria of which the most common form is called ‘ordinary or idiopathic urticaria’. In this type no cause is usually identified and often patients have hives and angioedema occurring together. Ordinary urticaria with or without angioedema is usually divided into ‘acute’ and ‘chronic’ forms. In ‘acute’ urticaria/angioedema, the episode lasts from a few days up to six weeks. Chronic urticaria, by definition, lasts for more than six weeks. Ongoing ordinary urticaria should be differentiated from an isolated individual episode of acute urticaria which occurs for example with ingestion of or contact with an allergen.

Other less common types of urticaria are described later in this leaflet. Also included is urticarial vasculitis (in which inflammation of the blood vessels causes an urticarial-like rash, and is therefore different from normal urticaria).

What causes urticaria and angioedema?

In the common ‘ordinary’ form of urticaria and angioedema, it is unusual for an external cause to be identified. Intercurrent infections such as a cold, influenza or a sore throat may act as a trigger.

Almost any medicine can cause ‘acute’ urticaria, but painkillers (especially aspirin and medicines like ibuprofen), antibiotics (especially penicillins) and vaccinations are most likely to be responsible. Angioedema, in particular, can be caused by a type of drug (ACE inhibitors) used to treat high blood pressure.

In some patients with ordinary chronic urticaria, the release of histamine from skin mast cells is triggered by factors circulating in the blood, such as antibodies directed against their own mast cells, a process known as autoimmunity. Tests for this are not routinely available, and generally do not alter the treatments used.

What are the symptoms of urticaria and angioedema?

The main symptom of urticaria is itch but angioedema is not usually itchy. Although urticaria can be distressing, because of the itching and its appearance, it has no direct effect on general health. Rarely, the swelling of angioedema may affect the tongue or throat, causing difficulty with breathing or swallowing. This can be alarming but is rarely life-threatening.

Are urticaria and angioedema hereditary?

The ‘ordinary’ common type of urticaria and angioedema is not hereditary.

What do ordinary urticaria and angioedema look like?

The weals of urticaria may be flesh-coloured, pink or red. They can be of different shapes and sizes, but usually look like nettle stings. An important feature of urticaria is that although the rash may persist for weeks, individual lesions usually disappear within a day, and often last only a matter of hours. However, they sometimes leave bruising especially in children. New weals may then appear in other areas. In ordinary urticaria, the weals can occur anywhere on the body, at any time.

The deeper swellings of angioedema occur most frequently on the eyelids, lips and sometimes in the mouth, but they may occur anywhere. They are not usually itchy, and tend to settle within a few days. If the hands and feet are affected, they may feel tight and painful.

How will ordinary urticaria be diagnosed?

Usually its appearance, or a description of it, will be enough for your doctor to make the diagnosis. In the vast majority of people no cause can be found, though your doctor will ask you questions to try to identify one. There is no special test that can reliably identify the cause of ordinary (idiopathic) urticaria, but some tests may be done if your answers suggest an underlying cause, which may be suspected from a detailed history.

Occasionally, if a trigger is suspected, blood tests or a skin prick test may be performed by a specialist in skin or allergic disease. In chronic urticaria, no specific trigger is usually identified so routine allergy tests are not necessary. In a small percentage of people, foods, colouring agents and preservatives appear to worsen urticaria, and it might be helpful to identify these by keeping a food diary. These substances can be left out of the diet to see if the condition improves, and later reintroduced to confirm whether they are the cause of the urticaria. However, as urticaria is such a fluctuating disease, this is not always accurate and will not always show you definitely what is causing the problem.

Can ordinary urticaria and angioedema be cured?

The treatments outlined below suppress the condition rather than cure it. In about half of the people affected by chronic ordinary urticaria, the rash lasts for 6-12 months, and then gradually disappears. It can however last considerably longer. In any one individual the course of urticaria is unpredictable.

What is the treatment for ordinary urticaria?

• Antihistamines block the effect of histamine, and reduce itching and the rash in most people, but may not relieve urticaria completely. If urticaria occurs frequently, it is best to take antihistamines regularly every day. There are many different types including non sedating and sedating antihistamines, in addition to short acting and long acting types Your doctor may need to try different ones to find a regime that suits you best. The antihistamine tablets can to be taken for as long as the urticaria persists.
• A related type of antihistamine (e.g. cimetidine and ranitidine), which is usually used to treat stomach ulcers, can be added to the standard antihistamines used to treat the skin.
• If antihistamine tablets are not helpful, your doctor may recommend other medicines. These may include other types of histamine blockers, or drugs such as montelukast, which is a treatment for asthma and although they may not be licensed for urticaria, they can be useful treatments
• Oral steroids can occasionally be given briefly for severe flares of acute and chronic urticaria, but generally are not necessary.
• Treatments that act by suppressing the immune system (e.g. ciclosporin) may be beneficial for the most severely affected people not responding to the treatments outlined previously.
• Very rarely injections of adrenaline (epinephrine) may be required if there are breathing problems.

Self care (What can I do?)

• It is important to avoid anything that may worsen urticaria, such as heat, tight clothes, and alcohol.
• Avoidance of foods, colouring agents and preservatives may be helpful in the rare instances where these have proved to be a problem.
• Seek medical advice urgently if you are having problems with breathing or swallowing.

Other urticarias In some patients, when a detailed history is taken, clear trigger factors for urticaria/angioedema can be identified. These may include physical factors (called physical urticaria) or foods, drugs and infections.

The physical urticarias - Urticaria may be triggered by physical factors such as heat, cold, friction, pressure on the skin and even by water. The weals usually occur within minutes, and last for less than one hour (except delayed pressure urticaria). Physical urticarias usually occur in healthy young adults, and are not uncommon. Some patients suffer from more than one type of urticaria; they include the following types:

Dermographism (“skin writing”). In this type, itchy weals occur after friction such as rubbing or stroking the skin. Itch may be aggravated by heat. Weals and red marks often appear as lines at the sites of scratching, and generally last for less than one hour.

Cold urticaria. This type is precipitated by exposure to cold, including rain, wind and cold water, causes itching and wealing in chilled areas. Swimming in cold water may cause severe wealing and fainting, and should be avoided. Patients should report their cold urticaria to medical personnel before operations so that, if weals appear during the procedure, cold urticaria can be considered.

Solar urticaria. This is rare. Redness, itching and weals occur on the skin immediately after exposure to sunlight, and last for less than one hour.

Aquagenic urticaria. This is extremely rare. Small weals occur on the skin at the site of contact with water of any temperature, usually on the upper part of the body.

Delayed pressure urticaria. Urticaria develops where pressure has been applied to the skin, for example from tight clothes or from gripping tools. Usually the swelling develops several hours later. It can be painful and last longer than a day. People with pressure urticaria nearly always have ordinary urticaria as well.

Many of the physical urticarias are improved by avoiding their trigger, and by taking regular treatment with antihistamines. Delayed pressure urticaria can be more difficult to treat.

Cholinergic urticarial. This occurs under conditions that cause sweating, such as exertion, heat, emotional stress and eating spicy food. Within minutes, small itchy bumps with variable redness appear, usually on the upper part of the body but they may be widespread. The weals last for less than one hour, but in severe cases may join together to form larger swellings. Antihistamines usually help, and are sometimes best taken before a triggering event (e.g. exercise).

Contact urticarial. Various chemicals, foods, plants, animals, and animal products, can cause weals within minutes at the site of contact. These weals do not last long. Some of the commoner causes are eggs, nuts (e.g. peanuts), citrus fruits, rubber (latex) and contact with cats and dogs. Although often the reactions are mild, occasionally they can be severe, for example after contact with rubber and peanuts in very sensitive individuals.

Angioedema without weals - Angioedema occurring without urticaria can be due to a variety of causes such as medicines (e.g. aspirin, ACE inhibitors) or food allergies. When angioedema occurs without associated urticaria, a hereditary form of angioedema should be considered.

Hereditary angioedema - This is a very rare form of angioedema which tends to run in families. Patients get swelling of the face, mouth, throat, and sometimes of the gut, leading to colic. The condition is due to an inherited deficiency of a blood protein and can be identified by a blood test. It can be treated by medicines to prevent attacks and sometimes by replacing the deficient protein in the blood in an acute attack. A severe attack of hereditary angioedema can be life threatening if left untreated; therefore patients may be advised to wear a Medic Alert bracelet to alert physicians in an emergency.

Urticarial vasculitis - A small percentage of people with urticaria develop weals that last longer than one day. These may be tender and occasionally bruise. People affected with this condition may feel unwell and have joint and stomach pains. This is because their blood vessels become inflamed (a process known as vasculitis). The diagnosis is confirmed by examining a skin biopsy from one of the weals under the microscope. The cause is rarely found, though blood tests are usually undertaken. Antihistamines are not very helpful but other medicines that help inflammation can be used.