The Center for Disease Control and Prevention (CDC) performed a national survey in 2008 which gives us some insight as to why this incidence may be increasing.  Causative factors are thought to include limited or no use of sun-protective behaviors by adults and adolescents, increased adolescent use of tanning facilities, and a large incidence of more than one sunburn within the past year among adolescents and young adults.

Regardless of reason, skin cancer is becoming more and more common and thus new technologies and devices are being developed to help identify these cancers earlier, educate and increase awareness among the public, and prevent adolescents and adults from excessive sun exposure that increases their skin cancer risk dramatically. This is extremely important because research has shown that a single diagnosis of skin cancer increases one’s risk for a second skin cancer and other, non-skin related, types of cancer.

The American Academy of Dermatology has a “Suntelligence Quiz”  for you to test your knowledge on sun protective behaviors and determine your risk for developing a skin cancer, with advice on how to alter your behavior to prevent it. Hopefully, by the end of this article you will agree that dermatologic technology is definitely your friend and can be invaluable resources.

Smart phone apps are becoming increasingly useful resources for both patients and healthcare providers in dermatology.

Smart Phone Apps

“There’s an app for that,” a saying we have all reiterated or heard dozens of times. However, 9 times out of 10, it’s likely true. It is no different when it comes to apps for medicine and specifically, dermatology.  There has recently been a lot of controversy over the accuracy of medical apps utilized by patients to aide in identification and diagnosis of skin lesions. Whether some apps pose more risks than they do benefits and prevent patients from seeking proper medical assessment and treatment is a true concern among healthcare providers.  These worrisome and irresponsible apps claim to analyze a lesion through comparison to other malignant lesions in a computer software system or by sending the photograph (taken on your smartphone) to a dermatologist, who then diagnoses it. These apps often charge per lesion analyzed and cannot assess other characteristics of a lesion that are important in determining it’s diagnosis, such as texture not visible on a smart phone photo, and don’t take into account factors such as personal or family history, exposure risks, and if a lesion is changing or symptomatic. While no diagnostic test or procedure is 100% accurate, studies have shown that misdiagnosis of a melanoma or other malignant skin lesions occurs more frequently in these apps than it should.

UM Skin Check is an excellent tool to assist patients in monitoring their moles.

Recommended Apps

• “UMSkinCheck” is an excellent free app, developed by the University of Michigan that we often recommend to our patients at Krauss Dermatology.   It helps patients to monitor their moles and other skin lesions, set reminders for monthly self-skin exams, and take photographs of  lesions to track any possible changes.  It helps educate people on the most effective sunscreen use and sun-protective behaviors, instructs patients in specific lesion characteristics when looking at moles during a self-skin exam.
• “Epi-Tracker”: an app for those afflicted with acne that will help to monitor the progression of treatment through the use of a photo journal, set medication reminders, provide tips on how to prevent scarring, and information on Epiduo (a common acne medication).
• “The Eczema App”: can help patients track their flares and identify potential triggers while providing an on-the-go resource dedicated solely to eczema.
• “Sun Effects Booth”: developed by the Queensland Government, Australia to help users predict their skin’s future. It asks a series of questions about your sun-protective behaviors (or lack of them!) and analyzes your answers and the average UV index of your location to predict what your face will look like in the future. The results may be shocking, but the app also provides information on how to save your skin and prevent the results that you see.
• “The Rosacea App”: endorsed by the National Rosacea Society, this app can help patients afflicted with rosacea identify and track triggers, learn about the variety of treatment options, and how to alter one’s lifestyle to help reduce flare-ups. This app also provides information on a common rosacea medication, called Finacea.
• “CARD-Contact Allergen Replacement Database”: an app to help those with persistent contact allergies and have had patch testing keep track of their identified allergens and identify both safe products and products to avoid. This app also has a diary to help identify products that may cause flaring of allergies.
• “Psoriasis Symptom Monitor”: helps patients set appointment and medication reminders, track the progress of their treatment, label body areas affected by psoriasis, take photos of flare-ups and/or improvement to help you and your dermatologist follow your treatment and insure it is working well. It is password protected to insure your photos are secure and private.

While this is not an all-encompassing dermatology “app-list” and none of these apps are the sole solution to one’s ailment, they can help those afflicted better manage their condition while providing education and helpful tips. If you are more of a game-oriented individual, check out these fun dermatology game apps:

• “Smack A Mole”: A dermatology spin on the old-time arcade favorite “smack a mole.” However, instead of a pesky rodent, these moles are abnormal skin moles that have border irregularities, uneven pigmentation, grow (or evolve), and have a larger than 6mm diameter. These are all lesion characteristics to assess when performing your monthly self-skin exam and thus, this game may help you better identify abnormalities within your moles.“Safe Sun Game”:  This game emphasizes the importance of proper sunscreen application and mirrors the popular game angry birds, as it has the gamer strategically shoot sunscreen onto beachgoers.

A lesion is seen with visual inspection (top left corner) and then viewed with dermoscopy with greater detail appreciated.

Dermoscopy

A dermatoscope is a non-invasive diagnostic instrument utilized by dermatologists, with special training in its use, to magnify a skin lesion and assess its potential for malignancy. Skin surface microscopy dates back to 1663 but dermoscopy started in the early 1900s and only gained wide acceptance in the late 1900’s with the first dermoscopy international conference in 2001. Dermoscopy, also known as epiluminescent microscopy, magnifies a skin lesion in such a manner that its structure and color become visible in a way that it isn’t to the naked eye or regular magnification. Dermatologists utilize dermoscopy to improve identification of lesions prior to biopsy or excision, which is still the gold standard for diagnosis of a skin lesion.  Through utilization of a dermatoscope, earlier identification of malignant skin lesions is possible, as well as more accurate diagnosis of benign skin lesions without biopsy.

Mole-Mapping

If you see your dermatologist utilize a device that looks like this, they are performing dermoscopy. This will provide your doctor with more information about the lesion.

Mole-mapping or digital total body imaging, utilizes a single-lens camera and imaging software that compares lesion changes over time and identifies new lesions. In a patient with many moles, a personal or family history of melanoma, or rare genetic disorders that increase one’s risk for melanoma, this type of imaging and mole-tracking can be beneficial in identifying early melanomas and may improve patient outcomes. However, for most individuals extensive full body imaging is time consuming, costly, and generally not covered by insurance. Your dermatologist may perform a simpler type of mole mapping when photographing some of your moles for comparison at future skin exams.

MelaFind®

MelaFind® has been developed by MELA Sciences as a new diagnostic tool to aide in earlier diagnosis and detection of melanoma and decrease the number of unnecessary biopsies, while improving accuracy of lesion categorization. MelaFind is one of the newest technological devices in dermatology. However, a recent study found that if physicians rely too heavily on the findings of MelaFind®, some melanomas may be missed. MelaFind is specifically used to assess pigmented skin lesions with one or more atypical characteristics, in deciding whether or not to perform a biopsy.  MelaFind® differs from dermoscopy in that it utilizes 10 different wavelengths of light to examine lesions up to a depth of 2.5mm beneath the skin’s surface and then compares that lesion to a database of malignant lesion photographs. While this tool has been shown to aide in identifying atypical lesions, it is not a replacement for a thorough skin examination by a dermatologist, is time consuming, costly, and not covered by insurance companies.

There are also limitations to the use of MelaFind® as it does not aide in identifying non-melanoma malignancies (such as basal cell and squamous cell carcinoma) and the lesion must meet specific criteria to be analyzable by the device. It is also important to note that out of the 1831 lesions analyzed in the clinical study performed by MELA Sciences, 1702 of the lesions were identified as “cannot be excluded as melanoma,” a majority of the cases. While MelaFind® should not be discounted completely and may be appropriate for a certain patient, the evidence-base for this tool is from a study funded solely by the manufacturer of the product and thus presents a potential conflict and bias. There is currently insufficient evidence to support that its use improves patient outcomes, decreases the amount of inappropriate biopsies, or that it should be used by dermatologists or non-dermatologist physicians in the routine skin examination of patients.

Conclusion

Technology is important in dermatology and is changing rapidly.  We hope you find this review helpful in caring for your skin.  Do not use any app that promises to tell you from a photo whether your mole is a melanoma.  But do use digital photography, whether using UMSkinCheck or your digital camera, to help you monitor your moles and identify changing skin lesions.  When in doubt, see your dermatologist!

Kalei Ensminger, RN, Krauss Dermatology

Family Nurse Practitioner Student, Regis College

Madeline Krauss, MD

Dermatologist Krauss Dermatology

Once one BCC is diagnosed, the risk of developing a second BCC within 5 years is 50%. While BCC is enough of a concern on its own, the Journal of the National Cancer Institute also found that those diagnosed with any skin cancer are slightly more likely to have another type of cancer, unrelated to the skin. This risk increases even more in those diagnosed with BCC at a younger age. This information makes it clear that preventing BCC, as well as early diagnosis and treatment of BCC is becoming increasingly important.

There are many factors that can increase a person’s risk for BCC, including:

• chronic sun exposure
• fair skin type, with red or blonde hair and/or green or blue eyes, or tendency to burn easily and rarely tan (Skin Type l or ll)
• family or personal history of basal cell or other skin cancers

Less common risk factors are arsenic exposure, therapeutic radiation, chronic immunosuppression – such as transplant recipients or those with HIV – and some rare genetic conditions. The strongest cause of BCC is excessive or chronic sun exposure. UV radiation causes a genetic mutation to several tumor suppressing genes, which are part of the “hedgehog” molecular pathway (important in early fetal development). The malfunction of those genetic “brakes” allows uncontrolled growth, resulting in basal cell cancer.

The warning signs of BCC include:

• A persistent sore that remains open and does not heal for several weeks
• A red patch, that may or may not be irritated, and that does not go away
• A new, shiny bump. May be red, translucent, white or pigmented
• A pink, growth with rolled borders and sometimes a central crust. There may also be small blood vessels visible in the growth.
• A white, yellow, waxy area with undefined borders that may lo0k like a scar

The diagnosis of BCC is made after a small skin biopsy has been performed by your dermatologist, which is sent to a dermatopathologist, who then views the tissue specimen underneath the microscope, and analyzes the histology of the cells. At Krauss Dermatology, we use Miraca Life Sciences’ expert dermatopathologists. http://www.miracalifesciences.com/dermatology

A nodular basal cell cancer

Different types of BCC exist and are important to understand when making a clinical decision about the best treatment option. A nodular BCC is the most common type of BCC and is the case in about 60% of confirmed BCC diagnoses. Nodular BCC appears as a pink, pearly bump that usually has a defined border and may have areas of pigmentation or ulceration. Another common BCC is the superficial BCC. These occur in 30% of the cases and are light red and scaly, resembling eczema. An ulcerating BCC is usually firm, translucent, often with a depressed area or crust, and may bleed. A pigmented BCC may be partially or completely brown or blue, and has a  firm surface that may be depressed. These types of BCC are easy to mistake as a melanoma, and are found more commonly in people with darker complexions, who naturally have more melanin (the molecule that gives skin its color) in their skin.

Treatment options for BCC are varied and depend on the type of BCC, it location and the patient’s overall health, but are all typically done on an outpatient basis. Higher risk locations for BCC include the areas around the eyes, mouth, ears and scalp, where there is risk of cosmetic and functional impairment, and increased risk of recurrence. Foregoing or delaying treatment usually results in extensive damage to the local surrounding tissues, but in extremely rare instances, the cancer can metastasize to other organs and tissues.

Electrodessication and curettage is an option if the BCC is nodular or superficial, smaller than 1cm, in a low risk area(such as the trunk, arms and legs), and is now an aggressive subtype. This procedure requires local

2 Superficial Basal Cell Cancers on the chest, marked with green surgical marker prior to electrodessication and curettage treatment.

anesthetic and then the malignant tissue is scraped away and electrically cauterized a total of three times. This process destroys the malignant tissue, leaving surrounding normal skin intact, with a saucer shaped wound that can take up to 4-6 weeks to heal.

Another option to removed BCCs is with surgical excision. A local anesthetic is used, and the malignant tissue is surgically excised. A local anesthetic is used, and the malignant tissue is surgically excised with a margin of normal skin tissue around the edges minimize risk that there will be any remaining malignant cells from that lesion. This specimen is then sent for pathology to validate these margins are negative. This procedure is best for BCCs that are in a high risk area, for small and large lesions, and if definitive pathology is wanted for more aggressive type BCCs.

Mohs surgery, named after the physician who created it, is a surgical procedure performed by a specially trained dermatologic surgeon. This treatment option is best for BCCs with an aggressive growth pattern (determined by pathology) and for those in high risk areas and where removing the least amount of tissue is important, such as the face.  A Mohs surgeon will remove the visible malignant tissue and look at it underneath the microscope while the patient waits. If there are still malignant cells at the border of the specimen – indication it is not completely removed -  the surgeon will go back and remove more and again look at it underneath the microscope. This will be done until there are no remaining, microscopically visible malignant cells. Mohs surgery has the highest cure rate of any procedure for both BCC and for the more worrisome Squamous Cell Carcinoma of the skin, but is covered by insurance for specific types and locations of BCC only.

The smooth shiny bump is a basal cell cancer in the corner of the nose area.

The cancer is removed and the margins checked under the microscope.

After the cancer is removed, the surgeon stitches the skin in a way that will lead to the best cosmetic outcome.

After the area heals, an excellent cosmetic result is obtained and the skin cancer is gone. Surgical procedure performed by Mohs surgeon Dr. Helen Raynham, Wellesley, MA.

Other, less invasive, treatment options include treatment with a topical agent, called Imiquimod (Aldara).  This is only indicated for low risk, superficial BCC not on the face and is used once daily for 6-12 weeks. Less commonly used treatments with a lower cure rate than surgery are photodynamic light therapy (PDT) and cryotherapy (freezing). In the rare instances of metastasis or advanced local spread of the basal cell cancer, a new medication, Vismodegib can be used. Vismodegib was approved by the FDA in January 2012 and is 90% effective at inhibiting a molecular process in the “hedgehog pathway” involved in tumor gene activation. This medication is currently in clinical trials to treat other types of cancers such as colon, lung, and pancreatic tumors, and has shown some success in managing patients with rare genetic disorders causing multiple BCCs.

Prevention of sun damage is crucial to thwarting a diagnosis of BCC. This means using moisturizers with SPF 30 or higher on a daily basis, applying sunscreens correctly when in direct sunlight (reapplication every 2 hours is important), using appropriate types of sunscreens (UVA/UVB or broad spectrum), avoiding excessive sun exposure whenever possible between 11am and 3pm, seeking shade, wearing long sleeve shirts and wide-brimmed hats, avoiding tanning and burning, and taking vitamin D supplements. Of course, avoiding the use of UV tanning booths is imperative to decrease your risk of BCC, Squamous Cell Carcinoma and Melanoma.

Early detection of BCC will help you avoid more extensive and invasive treatments. Monthly self-skin exams, visting your dermatologist for your regular skin exam, and notifying your doctor of any new or changing lesions are important. The free iPhone/iPad application “UMSkin check” can help you identify new or changing skin lesions quickly. Visit http://www.aad.org/spot-skin-cancer for skin cancer information and tips on performing your monthly self-skin exam.

Kalei Ensminger, RN, Krauss Dermatology

Family Nurse Practitioner Student, Regis College

Madeline Krauss, MD

Dermatologist Krauss Dermatology

Do you have flushing or chronic facial redness? Do your cheeks sting? Are there small visible blood vessels on your cheeks, nose or forehead? Do you get pimples or white heads on your cheeks or nose?  Are your eyes dry, red and irritated?  Are you noticing thickening of the skin on your nose?

These are common symptoms of rosacea, a problem affecting more than 15 million Americans. If you’ve been diagnosed with rosacea, or suffer from some of the symptoms described above, this blog post is for you.

Bill Clinton's red nose and cheeks are classic signs of rosacea.

A rosacea flare can be annoying and uncomfortable.   While there is no cure, rosacea can be successfully managed with help from a dermatologist. Famous faces, such as Bill Clinton, Cameron Diaz and Mariah Carey battle their rosacea and control their rosy, red cheeks; so can you!  Sex and the City star, Cynthia Nixon, talks about her rosacea in a series of videos at http://www.rosaceafacts.com.

The exact cause of rosacea is unknown. The condition is found equally among men and women, and more frequently in those with a fair complexion, over the age of 30, or with a family history of rosacea.  Symptoms can wax and wane, but without treatment the condition can worsen, leading to irreversible changes in the skin.  The bulbous nose of W.C. Fields is the most famous example of unchecked rosacea.

W.C. Fields' nose shows the changes of untreated rosacea, called rhinophyma.

Spicy foods can cause flushing and a flare of rosacea.

The first step in managing your rosacea is to identify things that trigger your rosacea to flare. A flare is a period of time when your symptoms of facial redness, swelling, andstinging are worse. These triggers are different for everyone, so learning which cause your rosacea to flare is a key first step in managing your symptoms. Common triggers include alcohol, warm and humid weather, exercising, spicy foods, hot beverages, stress, some medications, heat and sun exposure. Avoidance of these triggers will help to decrease the frequency of flares, the redness of your face and other symptoms.  Strategies for avoiding and managing your unique triggers include:

• Wear a hat to protect your face from the sun, and keep it cool
• Avoid outdoor work and exercise in hot and humid weather
• Ventilate the kitchen when you cook
  

  Alcoholic beverages may cause a flare of rosacea.

• Exercise when and where it is cool (early morning, evening, or in an air-conditioned gym)
• Avoid alcoholic beverages and hot beverages (or know that these may cause some redness)
• Be cautious with eating heavily-spiced dishes
• Avoid saunas, very hot showers, hot baths
• Refrigerate your moisturizers
• Manage stress with relaxation techniques that work for you (visualization, yoga, meditation, listening to calming music)
• Get enough sleep

It is also important for you to protect your face from sun exposure and irritating cosmetic products to prevent further irritation and redness. Tactics to accomplish this include utilization of the following:

• Soapless cleansers (e.g., Cetaphil or Cerave)
• Avoidance of facial exfoliants/scrubs and harsh toners
• Hypoallergenic and oil-free make-up products
• Daily moisturizer with SPF 30, broad-spectrum sunscreen (UVA/UVB) preferably with titanium dioxide or zinc oxide, as well as a hat
• Sunglasses
• Avoidance of extended sun exposure between 10am-2pm

A patient before Vbeam laser for rosacea above, and after below.

Avoiding triggers will improve your rosacea, but other treatments are often needed to help manage your symptoms. These treatment options are varied and depend upon several factors, including what type of rosacea you have, whether there is eye involvement, your lifestyle and your medical history. A combination of an oral antibiotic (such as doxycycline) and topical prescription medications (sulfur based, metronidazole, azeleic acid) are frequently used to control the redness and inflammation with great success. In addition, laser treatment for rosacea and superficial blood vessels on the face can be very helpful.  The Vbeam pulsed dye laser usually requires only two or three treatments, with minimal recuperation time.

So what does all this information mean for you? Can your rosacea be remedied? With the appropriate skin care regimen, avoidance of triggers and a tailored treatment plan developed by you and your dermatologist, your rosacea can be successfully controlled. With appropriate care you can face the world with your eyes a little brighter – and cheeks a little less rosy!

Visit the National Society of Rosacea for additional information and support at http://www.rosacea.org.

Kalei Ensminger, RN. Family Nurse Practitioner Student, Regis College.  Nurse, Krauss Dermatology

Madeline Krauss, MD. Dermatologist, Krauss Dermatology

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

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.

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.

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.

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.

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.