October 3rd, 2011
A common plantar (foot) wart
Warts are among the most common, persistent, and frustrating conditions that we see on a daily basis in our dermatology office. Described throughout recorded human history, they affect both children and adults alike. Without treatment (sometimes even with treatment) they can persist for months, even years.
Warts, or verrucae, are a viral infection of the skin, caused by the human papilloma virus (HPV). There are over 100 known HPV types, and the virus can infect almost any area of the skin. Probably the most common areas are the feet (known as ‘plantar warts”) and hands, but in our office we certainly see them on many other areas such as elbows and knees, the face, or the genital area (where they are known as ‘condyloma’).
Infection occurs when the skin comes into contact with the virus, whether from a surface (like a health club shower floor) or from another person; the virus infects the skin cells, which then form a visible skin lesion. From an original site on the skin, the virus can spread locally to adjacent areas, or be transferred to distant sites, such as when someone scratches or picks at a wart and then touches another part of the skin. Since the virus must live inside the cells on the surface of the skin, they cannot travel internally to the rest of the body.
A very difficult to treat wart around a nail
Who gets warts? They are extremely common in children, but can also be seen in adults of any age. Certain individuals seem to pick them up much more easily (and develop a greater number of warts) than others, leading to the thought that some people have less of a natural immunity to the human papilloma virus specifically (not to all infections). Modern medicine has also led to a category of people who regularly take medications that suppress the immune system, and these patients are also more likely to develop warts, possibly many of them.
Treatment of warts comes in many forms, and here is where the frustration begins! There are no medications that directly kill HPV, and the virus is very good at resisting our efforts to eradicate it. Frequently a person’s natural immune system at some point kicks in and takes care of them on its own, but there is no way to predict in any one person how long this will take. There is a vaccination currently available (Gardasil®) for young women to protect them against the dangerous sexually transmitted form of human papilloma virus that causes some forms of genital warts (condyloma) and cervical cancer. There is currently no vaccination against common warts. In centuries past there have been some rather bizarre approaches to treating warts, such as applying spider webs or pork fat to the affected skin, or using magic words.
Over-the-counter salicylic acid liquid
Currently there are a few over the counter remedies: salicylic acid application, freezing equipment, and duct tape. Salicylic acid works by exfoliating the infected skin cells, but can take a lot of time to see improvement. Over-the-counter freezing products, which contain dimethyl ether and propane (a common refrigerant) cool the affected skin to negative 57 degrees and cause the wart area to slough away. While this treatment can be helpful, it may be painful to use and difficult to self administer. The mechanism of duct tape is unkown, though it may help by irritating or warming the area, and its benefit is limited (about 1 in 5 people improve).
Liquid nitrogen, an in-office treatment
In our office we have a number of approaches to treating warts. The ideal treatment would be very effective, with minimal discomfort and minimal risk of scarring. While this ideal may be difficult to obtain, we use our best efforts to tailor our treatment to what is best for each patient. Most commonly, we use liquid nitrogen; with a temperature of negative 200 degrees, it essentially destroys the wart infected skin. Unfortunately, it causes some discomfort and often requires multiple treatments. An alternative choice is called Cantharidin, a topical medication derived from the so-called “blister beetle”. Some time after application it causes blistering in the skin, hopefully destroying the wart infected skin away as it heals. It also usually requires multiple treatments. We occasionally use one of our vascular lasers to target the blood supply in the wart, which some patients find effective. There is some discomfort involved in laser treatment, multiple treatments are needed, and the laser itself is very expensive. Finally, we can treat resistant warts with an injection of Candida proteins. A series of 3 (unfortunately painful) treatments can stimulate an immune reaction at the site of the wart to destroy it. There are also a number of prescription creams that have been used to treat warts including Fluorouracil and Imiquimod. They generally cause less discomfort than many in-office treatments, but their use often requires weeks or months and may not work for everyone.
Many of our patients ask us (often in frustration) if warts can be surgically removed. The answer is yes, and there are times when this is a reasonable option. The procedure can be performed under a local anesthetic, and may result in the eradication of the wart. However, with this treatment comes discomfort, the risk of permanent scarring, as well as the possibility that the wart may still recur.
So what to do if you see a wart on your skin?
1. If the wart is rapidly growing, painful, or bleeding make sure you seek a physician’s opinion as it may be something else entirely.
2. Try over-the-counter salicylic acid wart remover. Particularly helpful is the liquid, though patches and bandaids containing salicylic acid are available.
3. Use duct tape. This works very well applied on top of the liquid wart remover every night. If you are pregnant, or if the wart is on a young child, try the duct tape alone and replace it daily.
4. Don’t pick or touch your warts, as this can spread them.
5. If the warts are winning the battle after 6 weeks of diligent home treatment, see your local dermatologist for other options.
Warts have been with humans for thousands of years, and their treatment is a daily challenge for those of us in dermatology, as well as our patients who suffer with them. Someday, we hope to have a “magic bullet” for these stubborn lesions. Until then, we will continue to work with our patients to determine which treatment or combination of treatments will work best for them.
Ellen Lacomis, M.D., Krauss Dermatology
Tags: liquid nitrogen, salicylic acid, verruca, wart, wart treatment
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July 25th, 2011
It was Tuesday morning, July 5th, and I was on call the day after the holiday weekend. In only the first 30 minutes of the day, we received 5 emergency calls for rashes from the weekend. Summer had officially arrived and with it came picnics, barbecues, hiking, gardening and of course, poison ivy.
These blisters form a line in the same pattern as the poison ivy leaf rubbing against the skin
The typical poison ivy rash is caused by urushiol, the same oil found in poison oak and sumac. The oil is found in every part of the plant, including the leaves, stems and roots. It is absorbed into the skin within minutes of exposure. The first time you touch urushiol, you might not develop a rash. With repeated exposures, however, your immune cells recognize the oil as foreign and launch an immune attack that causes the itching, redness and blistering of the skin that make you regret your outdoor adventures in the woods. Many people develop a more intense reaction with each exposure that occurs. Although some people claim that they are “not allergic to poison ivy,” there is no way to be sure. After many rash-free exposures year after year, your immune system may kick in and make you wish you hadn’t been so confident!
Most rashes from poison ivy go away on their own within a few weeks. For a mild rash, discomfort can be treated with over-the-counter hydrocortisone cream or calamine lotion applied topically. Creams containing menthol or camphor may help soothe the skin but won’t speed the resolution of the rash. Cool cloths, showers, oatmeal baths and compresses with astringents such as Domeboro may also help alleviate the itch. Oral antihistamines like Benadryl work beautifully at relieving the itch but might make you drowsy. Newer antihistamines such as Zyrtec and Allegra also help with symptom relief and usually cause much less sleepiness. Many patients find it useful to take Zyrtec or Allegra in the daytime while they work or take care of the kids. They then use Benadryl at night when the itching is often worse and fatigue is not a problematic side effect.
Serious reactions, however, require treatment. You need to see a physician if the itch is severe, continues for more than a few weeks, spreads over most of the body, or is associated with swelling of the eyes or face. An uncommon complication of poison ivy is infection, which is usually accompanied by fever and pus, pain, or warmth of the affected skin. If any of these develop, you should definitely schedule an appointment to see your doctor. I often prescribe patients topical steroids stronger than the ones available over-the-counter to make them more comfortable and help speed healing. If the rash is extensive or unusually severe, systemic steroids like prednisone may be needed, however there are potential side effects to these oral medications.
One thing that you do not need to worry about is passing the rash on. The rash is not contagious and does not spread from one area to another. While it might seem like the rash is spreading, this is a delayed response to the initial poison ivy exposure. Unfortunately, by the time the rash appears, the damage has already been done! Scratching does not make the rash spread, but it may irritate the skin and increase the chances of infection or other complications.
Patients (and parents of patients!) often ask me how to prevent the rash associated with poison ivy. Obviously, the most effective preventive measure is to stay away from the plant that causes it. These plants are found all over the United States. Typical locations include the woods surrounding your house, in the garden, and along the side of the road. Both poison ivy and poison oak grow in clusters of three leaves. Poison sumac, however, has long oval leaves in clusters of 7-13 leaves angled upward on a stem. The saying “Leaves of three, let them be” should help remind you how to identify the plant, but unfortunately unless you moonlight as a botanist, it isn’t always easy to tell.
"Leaves of Three" configuration associated with poison ivy
When you anticipate spending time in area where poison ivy grows, you should wear protective clothing that covers your arms and legs. Heavy duty vinyl gloves are recommended when you have to touch the plant, as rubber is not protective. Better yet, if you can, hire a professional to help. Remember that even dead poison ivy plants often contain the nasty urushiol that you need to avoid. If you believe that your skin has contacted the plant, wash immediately and thoroughly with soap and water. Immediate washing can prevent the rash, but waiting even 10 minutes to wash will decrease the amount of oil that can be removed by 50%. Oil residue may linger on clothing, pets, sports equipment or toys, and these should be washed as well to prevent further exposure. In fact, exposure to contaminated equipment, tools, and clothing is the primary cause of poison ivy rashes, rather than direct contact with poison ivy itself.
Since poison ivy typically grows in locations where you will be unable to wash immediately, there is great interest in finding compounds that can be applied hours after exposure to remove the oil from the skin. Products such as Tecnu, Zanfel and Ivarest claim to bond to urushiol and eliminate it, but these products have not been scientifically proven to help.
Poison ivy is one of those summertime pests that can affect any of us. Thankfully it’s unusual for poison ivy to cause serious complications, but it is a notorious cause of some unpleasant summer days or weeks. If you pay attention to your surroundings and follow the tips presented above, chances are that you will have a relatively itch-free summer.
Pamela Norden, M.D.
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May 4th, 2011
A tick feeding on a patient's neck.
In early April, I was performing a routine skin exam on a patient. I asked her if she had noticed anything unusual on her neck. She answered that she hadn’t, as the dark spot on her neck began to move. The first tick of the season had arrived. Upon further discussion, the patient had carried her little dog against her chest the night before, and the tick must have crawled from the dog to the patient’s neck. However, the dog also sleeps in her bed, so it could have transferred via the bedding.
Why all the worry about tick bites when we get bitten by other bugs (such as mosquitos) all the time? The concern is that many of the common tiny deer ticks (20%-60%) carry a type of bacteria called Borrelia burgdorferi. This little spirochete can be transferred during a feeding frenzy into our bloodstream from the tick. Deer and mice are also reservoirs of this bacteria, and the ticks pass the organism between them, and us. Lovely.
Borrelia burgdorferi was discovered (by Dr. Burgdorfer) to be the culprit of an illness causing inflamed joints in a cluster of children in Lyme, Connecticut in the 1970s. It soon became evident that males and females of any age could have the disorder. Lyme disease is most common in the Northeast U.S. from Maryland to Maine, but can also be seen more rarely in the Midwest, California, Oregon and Europe. Approximately 25,000 cases per year are reported, primarily between May 1 and November 30, but the number is increasing every year. Many of our favorite summer spots such as Cape Cod and Nantucket have a high incidence of Lyme disease.
The erythema migrans (EM) rash of Lyme Disease.
Most tick bites do not cause Lyme disease, either because the tick was not on long enough (it generally takes 48 hours to transfer the bacteria), because the tick was the larger “dog tick” which does not harbor the bacteria, or because there were no bacteria in the particular tick that fed. If, however, the B. burgdorferi bacteria does get into the bitten person’s bloodstream, a series of events occurs. Between 3 days to a few weeks after the bite, a spreading rash called “erythema migrans” occurs on the skin in about 50% of adults and 90% of children with Lyme. As you can see from the photo, this painless rash is generally not subtle. The lesion or lesions can be large (15 cm.), and are sometimes mistaken by a patient as a “spider bite” (real spider bites are extremely uncommon). The rash usually occurs in the location of the bite, though the bug is long gone. It can last anywhere from a day to a year, though a few weeks is most common. Unfortunately, many people with Lyme disease do not get this bullseye rash, and so are less likely to know they have Lyme disease.
With or without a rash, patients experience some flu-like symptoms, including muscle soreness and aches, fatigue, enlarged lymph nodes, headache, neck pain, fever and chills, and joint pain. These symptoms can last a few hours to months, and be constant or intermittent, and change over time. Fatigue is generally longer lasting than the other symptoms. A cluster of these signs during the summer in an area with a lot of Lyme disease and ticks, even without a rash, should be treated for Lyme disease.
About 15% of untreated patients develop problems with their nervous system within weeks to months of the flu-like illness. These can include symptoms of meningitis (head and neck pain, light sensitivity, headache), and Bell’s palsy (loss of movement on one side of the face) or nerve pain. This can last months but generally resolves completely. In addition, 8% of patients can develop problems with the heart, including electrical problems called arrythmias which can be dangerous. Finally, 60% of untreated patients will get arthritis , often of the knee, in one or more joints with swelling and fatigue.
Now that I have scared you all, why don’t we just perform a blood test when someone is bitten by a tick? Unfortunately, the available tests are not extremely reliable, particularly in the early stage of the disease. It takes weeks for the tests to become positive, and even then not everyone who has Lyme disease, even with the classic enlarging bullseye rash of erythema migrans, has a positive result.
Be sure to check yourself and your children for ticks after being in the woods.
So what to do? First of all, try to make sure you find ticks before they have been feasting on you for 2 days. Sounds easy, but it’s not. These ticks are very small at first, and enlarge only when filled with your own blood. First instinct is to smash them or pull them out with anything you’ve got. But you need to take your time. Clean the area with the tick with alcohol or hand sanitizer. Take a pair of tweezers and get down to the very base of the bug almost below the surface of your skin, grab and pull it straight out. If you squeeze on the wider part of the bug, you may force more of its salivary juices into you, together with the Borrelia bacteria living in there.
Second, if you are able to take a single 200 mg dose of the antibiotic Doxycycline (if you are not allergic to it) within 3 days of finding a tick on yourself, this will reduce your chance of contracting Lyme disease from that bite by 50%. Some physicians don’t advocate this, as the risk of contracting Lyme from any single tick bite is low to begin with, but I think it is a helpful measure. Children under 8 years old cannot take Doxycycline as it can permanently stain their teeth. You do not need to be treated with a full course of antibiotics for each tick bite, but if you discover a tick, then days to weeks later get the symptoms discussed above, then you must get the full course of antibiotics to protect yourself from the more serious manifestations of Lyme disease. This full course is generally Doxycycline 100 mg twice per day for 2-3 weeks. Side effects include possible nausea, heartburn, allergic reaction and sun sensitivity. For children under 8 years old, pregnant women and patients that are allergic to Doxy or cannot tolerate its side effects, Amoxicillin can be used instead.
If you have the erythema migrans (EM) rash, see your primary care doctor or dermatologist right away to confirm and to start medication. If you get a cluster of flu-like symptoms including joint or muscle pains with the EM rash or a tick bite, and you live in the Northeast, discuss with your doctor to see if your illness fits Lyme disease, or another problem (such as Mono) and whether you should be tested for Lyme disease, or treated with antibiotics without the test.
Get the dog out of the bed to prevent tick bites!
To help prevent Lyme in the first place, use a DEET containing insect repellent when spending time in the woods or other outdoor areas. Check yourself and your kids from head (and scalp) to toe for ticks after spending time outside, gardening, running in the woods, etc.. Keep your dogs and outdoor cats out of your bed! See your doctor if you have unusual joint pains, or a large reddish skin lesion or lesions, or other symptoms mentioned during the late spring, summer or early fall. There is no vaccine commercially available to prevent Lyme disease. Ah, the joys of the outdoors. And don’t forget your sunscreen too!
Madeline Krauss, M.D.
Tags: dermatology, Lyme Disease, medical dermatology, tick removal, ticks
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March 21st, 2011
Summer is coming sooner than you think!
Here in Massachusetts, we are in a great mood. The temperature is rising. The mounds of gray ice and snow have melted, and the days are longer. Daylight savings time has caused a rush of after work joggers to compete with traffic outside our office window, directly on the route of the Boston Marathon. This is the time of year I start to obsess about one thing: sun protection.
April and May are surprisingly huge months for sunburns. There is still a slight chill in the air, so most people don’t bother with sunscreens. Teens on doxycycline and minocycline antibiotics for acne have forgotten the warnings that they are extremely sensitive to the sun on these medications. The follicularly challenged men (also known as balding) neglect to wear their baseball caps. They have already forgotten the discomfort of my liquid nitrogen treatment of their precancerous scalp spots last year. The runners forget they need a waterproof sunscreen that resists sweating. And the walk-a-thons! So many painful, red, swollen noses and forearms.
There is no question that ultraviolet light contributes to the development of skin cancer, just as cigarettes contribute to lung cancer. It has also been proven that protecting from the sun reduces the incidence of skin cancer. Furthermore, and many of my patients will heed this warning more, ultraviolet light makes you look old before your time. Wrinkles, brown spots, big pores, yellowish bumps, a sallow tone, these are the harvest of the sun worshiper. By protecting, you will look younger, period. One recent article tells the story best. A study showed facial photos (sun exposed area) of people in their 20s, 30s, 40s, 50s. 60s and 70s to a group of observers, and asked them to rate the age of the people in the photos. The same photo subjects also had their sun protected buttock skin photographed and the same observers rated the age of the buttocks. You would think that observers could correctly identify a 20 year old buttock from a 70 year old one. The ages of the facial photo subjects were correctly determined 90-100% of the time, whereas the ages of the buttock photo subjects were correctly identified about 20% of the time. Sun exposure is much more aging than time and gravity! This is supported by earlier data that sun exposed skin of the forearm produces 50% less Collagen type I than does sun protected (buttock) skin. Want collagen? Protect your skin from the sun.
This hat from Wallaroo has a wide brim to protect your face.
We dermatologists do not expect you to hide in a cave all summer. There are great ways to protect from the damaging UVA and UVB waves. Common sense is the rule. Wear a hat. When I am asked what is the most cost effective cosmetic treatment, I instantly respond, “A hat.” A hat prevents skin cancer, wrinkles, brown spots, broken capillaries, fine lines, crinkly skin texture. The trick is to find one that you will actually put on your head and wear. Even in front of other people. Do not spend $100 on a tube of cream and only $10 on a hat. Buy a beauty. And wear it. Adding sun glasses will make you more chic, and protected.
Quicksilver rash guard protects from UV rays and looks great
Other forms of non-sunscreen sun protection are also extraordinarily helpful in preventing sunburn, chronic sun damage and eventually skin cancer. The swim shirt or rashguard is a close fitting shirt that goes over your bathing suit and protects from the sun as well as from abrasions (from surfing, windsurfing etc.). Getting your kids used to wearing these is a great way to limit their lifetime exposure. Some of the most attractive swim shirts are available through surfer brands such as
Quicksilver, and high quality versions for kids area available from many catalogs including
Coolibar’s. And don’t forget the umbrella. Whether using a portable one for your day excursion, or taking advantage of a resort’s cabanas, staying in the shade can keep you from getting fried during a long day at the beach. In addition, a long lunch break in the shade, removing you from the sun’s rays during the peak hours (about 11:30 a.m. to 1:30 p.m. in the northeast) will save your skin from damage, and your kids from painful sunburns.
Use sunscreen. SPF or sun protection factor rates how well a sunscreen shields you from UVB rays. Find an SPF 30 or above product that also states “broad spectrum” or UVA/UVB protection, as protection from UVA rays is not part of the SPF rating. Ratings of higher than 30 do not mean that the product works much better than one that states 30. Because of the way the ratings are calculated, there is a much greater difference between SPF 15 and 30 than there is between 30 and 45 or 45 and 60. The higher numbers give you a false sense of security. In fact, Australian sunscreens can only be labelled up to 30+ to avoid this misconception in the skin cancer capital of the world down under.
Elta UV Pure is a safe and effective sun block.
Many patients ask how safe the chemicals in sunscreen really are. All sunscreen chemicals have been approved by the FDA, but there are some limits to how high a percentage may be used
Top Rated Sunscreen by the EWG/Skin Deep Cosmetic Safety Database! Received a #1 Rating for “Best Moisturizer with SPF”
in sunscreens. The safest and least likely to cause an allergic reaction on your skin are the “physical” sun blocks, Zinc and Titanium. An additional advantage is that Zinc and Titanium work immediately to protect you. Suntegrity is a line of sunscreens without chemical sunblocks, and no artificial preservatives (like parabens or formaldehyde releasing chemicals). Another great physical sunblock without chemical sunscreen ingredients is very water resistant Elta UV Pure . This product does not have any parabens or formaldehyde releasing preservatives. Elta and Suntegrity rate among the most safe sunscreens by the Environmental Working Group. Both Suntegrity and Elta UV Pure are available in our office or over the internet. The physical sunblock Aveeno Mineral Block, available in your local pharmacy, also contains Zinc and Titanium, but its variety of chemical preservatives make Suntegrity and Elta UV Pure better choices for those wishing to use less allergenic and artificial products. However, among the choices at your neighborhood drug store, Aveeno Mineral Block is a good option.
Most chemical sunscreens require at least 30 minutes on your skin to become active, so you are relatively unprotected when you first apply. For chemical sunscreens, it is important to apply early, and not to wait until you are about to go out in the sun. Combinations of physical and chemical sun blocks work very well and are easy to apply. We love
Elta UV Shield SPF 45 particularly for acne or rosacea prone skin.
Coppertone Kids Sunscreen Lotion combines physical and chemical sunblocks in a waterproof formula. If you are using a traditional sunscreen off the shelf that does not contain zinc or titanium, just make sure it is SPF 30 or above, broad spectrum, apply an adequate amount, and leave 30 minutes between application and sun exposure.
Enjoy your summer and beach vacations! Improving your sun protection habits is easy. Your good behavior will inspire your family to do the same. Feel free to cheat using
bronzers and self tanners (these are not harmful) or treat yourself to a professional spray tan (try the fabulous
Blush in Wellesley). Never, never using a tanning booth. Look good, stay beautiful, and decrease your chance of skin cancer. Finally, and I apologize for repeating myself, get a hat!
Madeline Krauss, M.D.
Tags: dermatology, hats, photodamage, prevention, skin cancer, sun protection, sunblock, sunscreen
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March 15th, 2011
Barnacles on a ship.
The most common lesions dermatologists see are not pimples, moles (also called nevi), or freckles. They are seborrheic keratoses. What? You have never heard of them? In the confusing and archaic world of dermatology terms, seborrheic keratosis ranks high in difficult spelling and pronunciation. An easier synonym is “age spot” or “barnacle”. It is pretty tough on a younger patient to hear they have an “age spot” the first time. Many dermatologists use pleasant euphemisms, “knowledge spot”, “wisdom mark”. Older patients may use the term “liver spots.” You don’t have to be ancient to have them, but their prevalence increases dramatically with the years.
A classic seborrheic keratosis
“Seb Kers” as we fondly call them, are raised velvety or warty looking spots that can be a variety of colors from white to black with yellows and many shades of brown in between. Often they appear “stuck on” or “pasted on” to the skin. They can occur almost anywhere on the body. They have absolutely nothing to do with sun exposure, and almost everything to do with genetics. You are somehow programmed that at a certain age, you will begin to get them. Some people will get a few, some literally hundreds. Unfortunately there is no cream or medication that can prevent or eradicate these growths. The good news is they are completely benign and don’t evolve into anything cancerous.
In the doctor’s office there are some procedures that can remove seborrheic keratoses. The most common methods of removal are liquid nitrogen treatment (cryotherapy) or surgical removal with a scalpel or a sharp circular blade called a curette. Cryotherapy does not require an injection of local anesthetic, so is easier to perform and more popular with doctors and patients. The risk of both of these procedures is a discoloration or lightening of the treated area, or an area of texture change or scar. This occurs more often when seborrheic keratoses on the legs or back are treated.
Seborrheic keratoses can get red, swollen and crusty. These inflamed lesions can be itchy or tender. Many insurances cover removal of inflamed lesions. Treatment of asymptomatic, noninflamed age spots is considered to be cosmetic. Most practices will perform removal of multiple seb kers for a reasonable fee. Post freezing of the lesions, application of petroleum jelly, or of the ointment Aquaphor to the treated area 2 to 3 times per day will speed up the healing process. Earlier, smaller, flatter lesions are a lot easier to remove than large, thick ones. For a better cosmetic outcome, have them treated with liquid nitrogen periodically at the dermatologists office.
Seborrheic keratosis (left lower corner) resembling an abnormal mole
One big problem with seb kers is they make self skin exam difficult. We have been instructing our patients for years to monitor their skin for changing moles, and the “A, B, C, D, E”s of melanoma. When you have many brown spots, and all appear irregular, different colors, and changing, identification of worrisome moles and melanomas becomes difficult. Moles (nevi) tend to be smoother in texture than a seb ker, but that is sometimes difficult to judge. In fact, every dermatologist has sent in biopsies over the years to the lab asking them to identify whether the growth in question was an innocent seborrheic keratosis or a dangerous mole or melanoma. For that reason, it is important for patients with many spots and changing lesions to be monitored by their dermatologist or primary care doctor.
Most of us would like to grow old. We can’t always do that without a few barnacles to show for it. No need to panic if an evenly tan or brown, velvety spot appears on the face, back of the hands, or other location on the trunk or extremities. If the presence of an age spot is getting you down and you want to eradicate it, see a dermatologist. If it is irregular and you are not sure what it is, see a dermatologist. He or she will be very impressed when you say that 8 syllable tongue twister “seborrheic keratosis“.
Madeline Krauss, M.D.
Tags: brown spots, dermatology, seborrheic keratoses, self skin exam, skin cancer
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February 25th, 2011
Often at the completion of a skin check or other dermatologic visit, a patient will say, “Before you leave, I just want to ask you one thing about my 12 (13,14…) year old.” Parents are naturally concerned about the adolescent transformation of their young teen. Part of this transformation for most children, is that disturbing rite of passage, acne. Blackheads, whiteheads and pimples begin to erupt.
Blackheads are commonly seen in adolescent acne.
For some there are subtle breakouts over the T-zone (chin, nose and forehead) only. For others the changes are more dramatic, and can lead to scarring of the face, chest and back. If the acne lesions are painful, large, or resolve leaving behind a pitted or discolored area, or if there is extensive involvement of the face, chest or back, it is time to see the doctor. Some pediatricians are adept at treating acne, particularly of the mild to moderate variety. A dermatologist, however, can provide a full array of treatment for mild acne all the way to severe scarring acne. If acne is mild, as it is for most teens, a trial of over-the counter acne medication is in order.
The least irritating treatment is a wash that contains salicylic acid (such as Olay Total Effects Cream Cleanser with Blemish Control or Neutrogenal Oil-Free Acne Wash). This helps unclog pores which prevents the formation of pimples and comedones (black heads and white heads). Start the wash and wait at least 1 week before adding a second treatment to assess if your child is allergic to the active ingredient, salicylic acid.
Week 2 add a cream containing benzoyl peroxide (BP). BP kills bacteria and decreases inflammation in the follicle where acne pimples form. Creams that contain 10% BP are very harsh and irritating and work no better than creams containing a lower percentage. Try to find a product containing 2.5% to 5% benzoyl peroxide. Apply a small amount of BP product to the entire acne prone area, not just active pimples, once per day (try Neutrogena On-the-Spot Acne Treatment or Proactiv Repairing Treatment lotion). Keep in mind that BP can bleach clothing and bedding, so white pillow cases and towels are recommended. About 5% of people are allergic to or irritated by benzoyl peroxide, so if the skin becomes red, itchy or swollen, stop the cream immediately. Pregnant women should not use any over-the-counter or prescription acne medication without first consulting their doctor.
Combination of pimples and whiteheads in moderate acne.
It takes a full 2 months to see the improvement from any acne treatment, even the strongest oral therapy. So patience is the key here. At the 2 month point, if the skin still has multiple pimples, blackheads or whiteheads, prescription medication is the next step. Topical medications include creams that are made of Vitamin A derivatives to unclog the follicles. These include the topical medications adapalene (Differin), tretinoin (Retin-A) and tazarotene (Tazorac). Prescription washes that contain a blend of sulfacetamide and sulfer can also be helpful in killing bacteria and decreasing inflammation, as can gels containing antibiotics such as clindamycin or erythromycin. Again, 8 weeks are necessary to see results.
Once the topical treatments have been exhausted, oral medications may be necessary for persistent acne. Oral options include antibiotics, hormonal medications for women (such as birth control pills) and finally the oral Vitamin A derivative isotretinoin (Accutane). The risks and benefits of all of these options should be reviewed with a knowledgeable dermatologist.
Acne is largely genetic, and is also affected by hormones, hence its appearance and persistence throughout puberty, and sadly reappearance during early menopause. It is important to understand that foods do not cause acne. Though it may be tempting to tell your teen that french fries and donuts cause their acne, that isn’t the case. Some moisturizing creams and sunscreens can, however, make acne worse. Make sure all products used on the skin have the words “non-comedogenic” or “oil free” on their label. Moisturizers are often necessary to counteract the dryness from the acne treatment medications. Good non-comedogenic choices are Neutrogena and Cerave moisturizers.
Although facials and glycolic peels may be helpful in some patients, they do not replace the need for evaluation and the prescription of appropriate medications. Likewise the Smoothbeam Laser is used in our office for acne resistant to medications, or patients that are unable to tolerate oral medications, as well as for acne scarring. However, we recommend this laser only after optimal treatment with prescription medication is instituted.
Don’t wait until scarring sets in to have your child’s acne treated. Acne treatment is a process. It may take months to come up with the best treatment while minimizing the potential side effects of acne medication.
Madeline Krauss, M.D.
Tags: acne, benzoyl peroxide, blemish, Krauss Dermatology, teenage acne, treatment
Posted in Medical Dermatology | 1 Comment »
February 25th, 2011
Welcome to our new blog! We hope to answer the commonly asked questions by our patients. Hopefully with these tips and advice, we can make your skin healthier and perhaps even save you a trip to the dermatologist!
The skin of the shin is often the driest on the body.
For our first blog entry we will try to help you solve one of New England’s most difficult problems. How to help the dry, itchy skin of winter. Dry skin is not only uncomfortable, unsightly and extremely common, it can also become inflamed leading to dermatitis (eczema) and can even become infected. But have no fear, there are simple and inexpensive ways of improving your scaly epidermis.
The skin resembles the "craquelae" finish used in porcelain.
First, identify the problem. Dry skin begins to resemble the craquelae finish of a porcelain vase.Often this is accompanied by itch in the area. The first step is to use a fragrance free moisturizer every day immediately after you get out of the shower and bath. Good choices are Cerave lotion , or Cetaphil Restoraderm . In addition, the use of a moisturizing body wash (also made by Cerave or Cetaphil Restoraderm) in the bath or shower can prevent the irritation and dryness caused by many soaps. Very dry skin is more prone to allergic reactions to products, so avoid fragranced lotions and cleansers. Do not scratch, as the injury to the skin and the bacteria on your hands and under your nails can encourage infection.
If you still have dry itchy areas despite the above regimen, apply 1% hydrocortisone ointment (not cream!) to the area twice a day. Although ointment is greasy, the petrolatum in the ointment will help heal and treat the skin and allow better penetration of the hydrocortisone which will stop the inflammation which is causing the itch. If itch continues to be an issue, an oral antihistamine such as Benadryl can help stop itch and help sleep when taken before bed. If itch is an issue during the day, try Zyrtec in the morning. This over the counter antihistamine does not cause the drowsiness that Benadryl does.
Dry skin resistant to basic moisturizers can resemble the shell of an armadillo.
So now you are better, but somehow that scale on the legs is still visible no matter how much moisturizer you use, resembling the plates of an armadillo.Ask for Amlactin Lotion at the pharmacy desk. This over-the-counter lotion contains lactic acid. It dissolves the dead skin accumulating on the surface and makes the skin a better barrier to moisture loss. Be careful not to get Amlactin in open, scratched skin as it will cause a really uncomfortable burning sensation.
If all of this has failed to improve your skin, a visit to the dermatologist in order. You may have a different cause for your itching such as a fungal infection (ringworm), bacterial infection (impetigo) or other condition. Other clues that you should see your doctor right away are pain, swelling, or fever.
Madeline Krauss, M.D.
Tags: dry skin, itchy skin, Krauss Dermatology, winter itch
Posted in Medical Dermatology | No Comments »
