The relationship between stress and disease has been well described with many conditions proven to be triggered or exacerbated by stress. Well known examples are hypertension, migraines and epileptic seizures. However, does stress worsen skin conditions? The answer is a resounding ‘Yes’. In fact, this has been clearly demonstrated during the pandemic over the last 18 months, when mounting emotional stress has triggered some skin diseases and caused other stable skin conditions to flare up.
While from clinical experience we are certain that a relationship does exist, are there any clear underlying mechanisms to support this?
Indeed, there is…. in embryology the skin and brain are derived from the ectoderm layer. As a result, it doesn’t seem a stretch to believe that the same cells and pathways found in the central nervous system (CNS) are also found in the skin.
What is Stress?
Stress is the body’s natural response to physical, mental, or emotional pressure from events in our life. When the amount of stress we perceive overwhelms our coping mechanisms, hormones are produced to adapt our body to cope with the stress. In the short term these can cause changes to blood pressure, heart rate, blood sugar levels and mood. In the long term, with prolonged stress there may be more lasting changes impacting our overall health as well as skin health. These hormones are sometimes called ‘stress hormones’ and there are various pathways between the brain and the endocrine system releasing these hormones.
The main pathway is the HPA axis (hypothalamic- pituitary-adrenal axis). Stress causes the hypothalamus in the brain to produce CRH (corticotrophin releasing hormone) which in turn causes the pituitary gland in the brain to release ACTH (adrenocorticotrophic hormone). ACTH enters the blood and cause the adrenal gland to secrete cortisol and glucocorticoids. Cortisol is considered our main ‘stress hormone’ and remains elevated in those with chronic stress. Interestingly the skin also has a peripheral HPA axis and CRH, ACTH and cortisol are released by various cells in the skin.
Other important stress hormones, adrenalin and noradrenalin, neurotrophins, substance P and prolactin are released by cells of the brain and endocrine system as well as the skin. The result is that the skin is both a producer and a target of these hormones that mediate a range of effects impacting the course of many skin conditions.
Skin and Stress
What are the effects of these stress hormones and which skin conditions do they impact?
In a nutshell ‘Stress hormones’ impair the skin barrier function, immune function, wound healing and fibroblast function. These hormones also increase inflammation, sebum production, melanogenesis (pigment production) and angiogenesis (blood vessel production). Most of these hormone mediators have more than one effect.
Inflammation in particular seems to feature as the major contributing factor in the exacerbation of disease in general in the body as well as the skin. Stress seems to worsen inflammation by various mechanisms.
As a result of these hormonal effects stress can aggravate conditions like psoriasis, eczema, acne, urticaria and rosacea or trigger new onset of a skin condition. Chronic stress can even accelerate the ageing process!
Atopic eczema/ Atopic dermatitis
Atopic dermatitis (AD) is a chronic inflammatory skin disease characterised by a defect in skin barrier function and a faulty inflammatory response. Stress exacerbates AD by impairing the integrity of the skin barrier leading to trans epidermal water loss (TEWL). Stress causes release of hormones in the skin that increase inflammation and worsen eczema. Impaired barrier function also means that more irritants can penetrate the skin and further worsen inflammation. Common scenarios demonstrating the effect of stress on eczema include worsening of eczema during exams, pregnancy and conditions affecting general health and wellbeing
Psoriasis
Psoriasis is a chronic skin condition in which there is overproduction of keratinocytes and inflammation which leads to itchy, red, thickened psoriatic plaques.
It is well known that psoriasis is worsened by stress, though the exact mechanism is still not quite certain. One theory is that activation of the HPA axis by stress causes increased ACTH and cortisol promoting proliferation and inflammation. Another is that increased substance P released by nerve fibres in the skin of patients with psoriasis triggers an inflammatory response. High levels of cortisol have also been found in the blood and in psoriatic plaques of patients with psoriasis.
Rosacea
Rosacea is a skin condition characterised by vascular hyperreactivity and resultant dilated blood vessels and inflammation. Rosacea sufferers flush in response to various stimuli like hot drinks, spicy food and emotional stress. Stress hormones increase inflammation, and skin sensitivity. Histamine released from mast cells in stressful situations also causes flushing.
Urticaria
In more than 50 % of cases the cause of urticaria or hives can’t be identified, but psychological factors have consistently shown to trigger episodes of urticaria. The most likely mechanism is anxiety causing the release of cortisol and adrenalin leading to inflammation as well as release of histamine from unstable mast cells.
Over production of sebum and/ or Acne
Stress does not directly cause acne but can worsen it. Stress causes the adrenal glands to produce more adrenalin, cortisol and androgens that in turn stimulate the sebaceous glands to produce more sebum. The follicles become blocked with sebum and dead surface keratin. This blocked follicle is the perfect environment for acne bacteria in the follicle to proliferate and trigger inflammation around the follicle resulting in acne or breakouts on the skin. CRH receptors on sebocytes promote sebum production. In addition ‘picking of acne spots” during times of stress also worsens acne.
Skin barrier function
The stratum corneum which is the uppermost layer of the skin has a combination of proteins and lipids that create a ‘seal’ on the skin. The skin barrier functions to prevents bacteria and irritants from entering the skin and maintains hydration by preventing water loss (TEWL) from the skin.
Though the exact mechanism in unknown, studies have shown that stress, including reduced sleep can alter the protein and lipid content of the stratum corneum. This leads to impaired barrier function with consequent dehydration and a dry flaky skin. Untreated, this can trigger an inflammatory response and dermatitis.
Impaired wound healing
Fibroblasts and keratinocytes (skin cells) are key players in the process of wound healing which is regulated by various chemical mediators. There is evidence to demonstrate that elevated levels of cortisol and epinephrine which occur during periods of stress impair wound healing by affecting the functions of these cells. Psychiatric conditions like anxiety, depression and dementia have been associated with delayed wound healing, presumably due to psychological stress in these patients. The risk of skin infection during wound healing is also increased during periods of stress due to impaired immune function in the skin. An infected wound is slower to heal.
Wrinkles and fine lines and hyperpigmentation(chronic stress)
We know that genetics, lifestyle and environmental factors affect the ageing process, but emotional and psychological stress can be a big contributor towards ageing. While short periods of stress can sometimes benefit us chronic stress leads to suppressed immune function with increased susceptibility to infections, inflammation and skin cancers.
The skin immune function protects against both ultraviolet (UV) damage and infection and consequently protects from skin cancers. With suppressed skin immune function there is a greater chance for skin cancers to occur.
As we age our DNA shortens with each cell division. This process is called telomere shortening. Chronic stress has been shown to further reduce the length of our telomeres, accelerating ageing.
Stress reduces the production of healthy fibroblasts which synthesize collagen and elastin and the extracellular matrix. This results in thinning of the dermis, loss of elasticity and resultant fine lines and wrinkles.
CRH causes increase in Alpha MSH which promotes pigment production in melanocytes which explains why skin hyperpigmentation can increase during periods of chronic stress, severe illness and even lack of sleep.
What is the way forward?
There is more than enough circumstantial evidence to support the connection between the skin and brain. It seems that stress management should be an integral part of management of most skin conditions
The first step is to be able to identify our triggers of stress, then to start managing them as best we can. This is a difficult task as stress shows up in many ways and does affect the body as a whole. Most people may not even perceive that they are experiencing emotional stress and find it difficult to accept as a reason for their worsening skin condition. Doctors and dermatologists take care to first exclude all possible explanations for exacerbation of disease before considering stress as a cause.
Make an appointment with Dermatologist Dr Kesiree Naidoo to assist you with any stress related skincare conditions or contact one of our medical skincare specialist to help you with a customized skincare routine. For a complimentary Skin Assessment, click here.
Inflammation & Allerfy – Drug Targets, 2014, 13, 177-190
Brain-skin Connection: Stress, Inflammation and Skin Ageing
Ying Chen* and John Lyga – Global R&D, avon products, 1 avon place, Sufferen, NY 10901, USA
2014 Bentham Science Publishers
Experts explore the underlying mechanisms of the link between the brain and the skin, feature: By Allison Evans, assistant managing editor, December 1, 2020
Adult acne also known as late onset or post adolescent acne has been the anguished subject of many dermatology room consults worldwide. Its diagnosis is almost always followed by questions like ‘Why do I still have acne now? ‘or ‘Aren’t I too old to get Acne’ or sometimes statements like ‘I’ve never had acne before’ or ‘I’ve always had a perfect skin till now’.
Sadly, adult acne is a continuous challenge, especially as it is difficult to treat with an often prolonged and recurrent course. It has become increasingly more common in recent years for leading dermatologists to question whether there are different factors playing a role as opposed to those causing adolescent acne.
Adult acne is defined as acne that affects men and women over the age of 25. It is by far more common in women than men. Adult acne may persist continuously from adolescence, recur after age 25 or in fact occur for the first time after the age of 25 years old. So, to answer those questions ‘Yes, you can still have acne beyond adolescence’ and ‘yes it can be for the first time’. Most cases of adult acne persist from adolescence and only around 20 % occurs for the first time after the age of 25. Hence the term adult acne seems more appropriate than late onset acne.
Traditionally it is believed that the main factors causing adult acne are genetic and hormonal, with predominant involvement of the lower third of the face. Flare-ups are typically premenstrual supporting the role of hormones. Most patients complain of deep seated and painful nodules with very few comedones (blackheads and whiteheads). The acne nodules are usually sparse, but can lead to significant scarring.
There are now considered to be 2 predominant forms of adult acne, inflammatory and retentional:
Inflammatory acne is the most common type accounting for 50-60% of cases. The skin is not always oily, and in fact may be normal to dry making it sensitive to topical treatments generally prescribed in adolescent acne. The acne spots can be on multiple areas and not just the lower third of the face. Retentional acne is the other predominant subtype and is characterised by increased sebum or oily skin and multiple comedones (blackheads and whiteheads).
What causes adult acne?
The fundamental factors causing acne whether adolescent or adult are:
Genetic predisposition. As many as 40% of acne sufferers have a family history of acne. This may be related to the size, number and activity of sebaceous glands which are genetically determined.
Increased androgenic hormone (testosterone, dehydroepiandrosterone sulphate and dihydrotestosterone) stimulation of the sebaceous glands leading to an oily skin. The levels of the androgen need not be higher than normal. It is the sebaceous glands that are more responsive to normal levels of circulating androgens. Oestrogen inhibits the secretion of androgenic hormones and inhibits sebaceous gland activity. An age related decline in oestrogen tips the balance towards androgenic stimulation.
Excessive sebum production by sebaceous glands. While this is largely driven by androgenic hormones, there are other factors that also stimulate the sebaceous glands.
Abnormal follicular keratinisation leading to blocked pilosebaceous unit (hair follicle unit) and the formation of a comedones. The skin cells in the hair follicle do not shed easily. They accumulate and together with the increased sebum from the sebaceous glands block the opening of the follicle. This in turn contributes to the inflammatory response.
Propionibacterium acnes or cutibacterium acnes which live normally in the sebaceous glands proliferate with increased sebum production worsening the inflammatory response and acne
an inflammatory response primarily to Propionibacterium or cutibacterium acnes which release enzymes that trigger the inflammatory cascade. These cause papules and pustules in acne that we commonly refer to as ‘pimples’.
There are however other factors or triggers that may be more significant in causing adult acne and these need to be further evaluated:
Ultraviolet light exposure- excessive sun exposure causes thickening of the stratum corneum and accumulation of dead surface skin cells. There is stimulation of the sebaceous glands producing more sebum. Both these processes lead to comedones and acne
Stress- a stressful lifestyle with poor sleep patterns can cause acne by its effects on the pituitary adrenal axis and resultant release of corticotrophin releasing hormone, neuropeptides and proinflammatory cytokines which stimulate the sebaceous glands and worsen the inflammatory response.
Obesity and insulin resistance is associated with hormonal imbalance and acne.
Endocrine disorders – There are numerous endocrine diseases that cause acne by increasing the activity of androgens, stimulating the sebaceous glands or inducing abnormal keratinization. The most common cause is polycystic ovarian syndrome aka PCOS. Other conditions include congenital adrenal hyperplasia, hypothyroidism, Cushings syndrome and various other adrenal and ovarian tumours. Acne also occurs in menopause due to the decline in oestrogen and resultant increasing effects of male hormones.
Smoking – causes acne by stimulating the sebaceous glands and inducing abnormal keratinization. The acne associated with smoking is typically a non-inflammatory, comedomal acne. There are mainly blackheads and whiteheads without significant papules and pustules.
Diet -does diet worsen acne? There is not much scientific evidence, but studies have shown that high glycaemic index foods increase insulin and insulin like growth factor 1(IGF1) which stimulate the production of androgens and sebum.
In addition, diets rich in dairy products and muscle building supplements with whey protein have also been found to worsen acne. Anabolic steroids used by weight lifters and body builders can cause a severe scarring acne affecting the face and body.
Damage to the skin barrier – Over washing of the skin leading to a damaged epidermal skin barrier which in turn causes water loss through the skin and worsens the inflammatory cascade.
Greasy cosmetics – Occlusive makeup, Vaseline and other thick greasy creams block the follicles and cause acne in those that are susceptible. This problem is sometimes seen in actors and models or those requiring heavy make up as part of their job. Hair products that spreads onto the hairline can cause acne in the affected areas.
Medication- Some drugs can cause acne as a side effect. Examples of these drugs are progesterone only contraception (includes commonly used injectable contraception) benzodiazepines, mood stabilisers like lithium and blood pressure medication like ramipril. There is also some speculation as to whether hormone releasing intrauterine contraceptive devices and contraceptive implants possibly trigger acne in some women who are predisposed. Anabolic steroids used by weight lifters and body builders can cause a severe scarring acne affecting the face and body.
Are there any tests needed to diagnose adult acne?
Acne is a clinical diagnosis and lab tests are not needed to make the diagnosis. Even though androgenic (male) hormones are one of the main pathogenetic factors causing acne there is usually no increase in hormone levels. It is rather the balance between androgenic hormones and oestrogen that causes acne. Investigations may be required if endocrine disorders associated with acne are suspected, though these conditions will usually have other signs and symptoms to warrant further investigation. Polycystic ovarian syndrome (PCOS) commonly presents with acne as well as other signs of hyperandrogenism (increased male hormones). It is the most commonly suspected cause of adult female acne. PCOS will need laboratory investigations and abdominal imaging and a visit to the gynaecologist or endocrinologist.
How is acne treated?
This is the most difficult part.
Adult acne is challenging as it typically responds to treatment, but frequently recurs once treatment is stopped. Acne is also of varying severity and is sometimes not even present at the time of the dermatology consult. This is frustrating for both the patient and the dermatologist. Prolonged courses of treatment are often needed as well as rotating different treatment options, and off course maintenance treatment is essential, which often involves a good skincare regimen. We also have to take into account the possibility of pregnancy and breastfeeding which decreases treatment options. Adult patients tend to have a drier skin compared to adolescents which does not always tolerate topical prescription acne medication. There is really no one size fits all approach and each person needs to be evaluated individually and treated accordingly. I am often asked for ‘the best treatment ‘or the ‘strongest treatment’. Patients are sometimes under the impression that it is possible to ‘treat acne and get it right the first time’. Sadly, the truth is there is no quick fix for adult acne. If there were.
You would probably know about it
Doctors would give it to you and there would not be more than that 1 treatment option
You would not see so many people walking around with adult acne
Treatment options can be broadly divided into topical, systemic treatments, skincare and procedures.
Topical Acne Treatments
Topical treatments are best suited to mild to moderate acne and sporadic lesions. In this case they can be used as a spot treatment as needed. Topical treatments are also an important part of maintenance treatment.
Retinoids
Retinoids used for topical treatment include 0.1% adapalene gel( Differin, Dapta), and tretinoin( Retin -A, Ilotycin -A,Retacnyl) 0.05% cream and 0.025% gel.
These treatments are also fundamental to adolescent acne. Gradual introduction is recommended. Interestingly retinoids are also anti-ageing and prevent skin cancer. As mentioned, these topical treatments cause dryness and irritation of the skin in the first few weeks of use. They also cause photosensitivity. They must be used with a good moisturiser for skin hydration and comfort and with sunscreen over moisturiser in the daytime. Retinoids are not suitable during pregnancy and breastfeeding.
Topical antibiotics
Topical antibiotic treatments include clindamycin and erythromycin which are both safe to use in pregnancy. These work by reducing Propionibacterium/cutibacterium acnes as well as having a direct anti-inflammatory effect. Antibiotics used alone whether topical or oral can create resistant strains of Propionibacterium/cutibacterium. For this reason, it is important to use antibiotics with either topical retinoids or benzyl peroxide to prevent antibiotic resistance.
Benzoyl peroxide
Benzoyl peroxide has been used for decades and is especially beneficial to an oily skin type as it causes further dryness and irritation with normal to dry skin. It also makes skin sun sensitive and bleaches clothing and towels. Benzoyl peroxide (5%) is recommended as first line therapy in mild adolescent acne and is safe to use in pregnancy.
Azelaic acid
20% Azeleic ( Skinoren) twice daily is effective in mild to moderate acne and especially suited to a dry skin as it is not irritating. Azeleic acid is also effective in reducing post inflammatory hyperpigmentation caused by acne lesions. It is safe to use during pregnancy and breastfeeding.
Topical combination treatments
Adapalene0.1% combined with 2.5% benzoyl peroxide (Epiduo) is an effective treatment for mild to moderate acne. It needs gradual introduction to minimise skin irritation. I recommend initiation of treatment twice a week for the first week, 3 times per week for second week and then every day once tolerated. It should be used at night with a good moisturiser to relieve dryness and sunscreen in the day.
This combination is also good for oily skin and excellent at reducing post inflammatory hyper-pigmentation.
Benzoyl peroxide 5% and clindamycin1% (Clindoxyl) is a topical treatment combining an antibiotic with benzoyl peroxide. This gel can therefore be used alone without resistance developing. It is suitable to treat both inflammatory lesion (papules and pustules) and non-inflammatory lesions (blackheads and whiteheads)
Systemic treatments
Systemic or oral medication is best for moderate to severe acne and widespread acne where it is difficult to treat all affected skin with topical medication.
Antibiotics
Adult facial acne responds very well to oral antibiotic treatments, but the problem is recurrence once the course is completed. Antibiotics should always be used in combination with a topical retinoid or benzoyl peroxide as the combined treatment prevents resistance, and has a synergistic effect which speeds up the response to treatment.
First line antibiotics for adolescent or adult acne are the tetracyclines. Commonly used in this class are lymecycline (Tetralysal ) and doxycycline. The once daily acne dosage greatly improves compliance. Other antibiotics that can be used are erythromycin and sulfamethoxazole/trimethoprim combination (Purbac)
Hormones
Hormonal treatments are highly effective in treating adult female acne (they cannot be used in men).
As mentioned earlier they work even when there is no measured androgen excess and have the added benefit of being suitable for long periods of use. For this reason, they are also a very good maintenance treatment.
When would I choose to prescribe a hormonal treatment?
First of all, the patient must not be pregnant, attempting to fall pregnant or breastfeeding and must be willing to take hormonal treatments. They work best when there is skin oiliness and premenstrual flare ups of acne and should ideally be combined with a topical retinoid, benzoyl peroxide, azelaic acid or antibiotic.
Cyproterone acetate
Cyproterone acetate is an anti-androgenic progesterone found either combined with oestrogen in the oral contraceptive pill (Diane -35, Minerva, Ginette) or alone at varying doses (Androcur). It works by blocking the androgen receptor on the sebaceous glands preventing excessive sebum production. Side effects include mood swings, breast tenderness, fluid retention, nausea and vomiting.
Spironolactone
This potassium sparing diuretic also works by blocking the androgen receptors on sebaceous glands. It may cause increased potassium levels in those susceptible eg renal failure. It is however safe to use in young healthy women. It may be combined with the oral contraceptive pill, with the intrauterine contraceptive device or topical retinoids for added benefit.
Other combined oral contraceptive pills with antiandrogenic progesterone(drospirenone) eg Yaz, Yasmin. It is important to exclude risk of thromboembolism ie heart attacks and strokes when prescribing the oral contraceptive pill
Isotretinoin
Isotretinoin (roaccutane, oratane, acnetane, acnetret) is usually reserved for severe or resistant acne where other treatments have failed. It is also used in acne with significant scarring which deserves a more aggressive treatment approach. Isotretinoin works by reducing the size and activity of the sebaceous glands, improving keratinocyte shedding and reducing inflammation. Even though the results are undeniable, isotretinoin has many side effects which make many patients reluctant to take it unless absolutely necessary. The biggest problem with prescribing it in females is the risk of teratogenicity, which makes contraception essential in females at least while on the medication and 2-3 months after stopping treatment. Isotretinoin does not affect fertility. Other side effects include dryness of the lips, eyes, nose and other mucous membranes, dermatitis, joint and muscle pains. Isotretinoin can cause raised liver enzymes and raised cholesterol and triglycerides so baseline blood tests are needed before treatment and during the treatment period. Isotretinoin may also be associated with depressed moods. Despite all this it is still used frequently in adult acne especially after repeated courses of antibiotics and topical treatments prove to be unsuccessful. As with all other treatments of adult acne there is frequent relapse once treatment is discontinued. There are therefore many off label low doses used which are effective in treating acne while the patient is on the medication.
Acne treatments frequently cause dryness and skin irritation and may damage the epidermal skin barrier. This leads to increased transepidermal water loss (TEWL) and worsening of inflammation through triggering of the skin’s innate immunity. It is important to moisturise the skin and maintain the integrity of the epidermal barrier so that the treatment can be continued and the skin is comfortable without burning and peeling.
In addition to this cosmeceutical skincare has many ingredients that can help in the treatment of the acne. Ingredients like salicylic acid, lactic acid and glycolic acid help shed dead surface skin cells unblocking the opening of the hair follicle unit. This reduces the earliest lesion of acne, the microcomedone. Acne facewashes and toners can help reduce oiliness of the skin. Ingredients in skincare will also assist with reducing and treating post inflammatory hyperpigmentation and scarring which often remains long after the acne has been treated. Sunscreens protect against post inflammatory hyperpigmentation and counteract the sun sensitivity caused by many acne treatments.
It is important to note that skincare is ideally used together with prescription treatment in the case of active acne or plays a role in maintenance once the course of treatment is complete. A supportive skincare regimen is especially important in adult acne as the skin is not generally oily and thus more in need of hydration. Visit a dermatologist early for skin assessment and advice as delay in starting treatment can cause scarring to develop.
Steroid injection of acne nodules is used for resistant painful inflammatory nodules or scarring nodules that fail to subside despite treatment. Injections can be carried out even during the course of treatment.
Comedone (blackhead and whiteheads) extraction may be necessary to speed up response to treatment. Open comedones(blackheads) are easier to remove, while closed comedones (whiteheads) may sometimes need very careful light cautery to open up the lesions. This will reduce the amount of inflammatory acne lesions forming and prevent trauma to the skin caused by picking if the patient is impatient and wants quicker results.
Superficial chemical peels aid in superficial exfoliation and removal of dead surface skin cells which contribute to forming acne lesions. They are useful for acne with multiple comedones ( blackheads and whiteheads), to reduce inflammation in mild inflammatory acne and to improve post inflammatory hyperpigmentation and scarring. Glycolic, lactic, salicylic and pyruvic acid peels have been used.
PDT has been used as an alternative treatment for acne. Amino levulanic acid (ALA) in a 10- 20% concentration is applied to the skin and red or blue light is shone on the skin to activate it. This treatment works as it’s anti-inflammatory. ALA penetrates into the follicular unit and on activation destroys Propionibacterium / cutibacterium acnes.
This treatment is effective at remodelling the dermis and treating acne scarring and post inflammatory pigmentation effectively. It is best to start after active treatment is complete with a course of 6-8 sessions.
Conclusion
Adult acne is a challenge because its chronicity and significant impact on the quality of life of those that suffer from it. It perhaps becoming more and more prevalent. We don’t fully understand what causes it, though it seems the same pathogenetic mechanisms causing adolescent acne are at the root of it, with a whole range of contributing factors. It is critical to consult with your dermatologist sooner than later to discuss what treatment course is best suited to you. The management of adult acne is complex and there is no one size fits all perfect treatment, but acne can be controlled and managed with the correct guidance and tools.
You can have a look at our FREE online skin assessment that will help you get started , if you however would like to rather book a consultation to see Dr Kesiree Naidoo or the Skinsmart medical therapist, please do not hesitate to contact us on 021 531 1107 or email us on i[email protected] or alternatively at [email protected]
Hyperpigmentation is the darkening of areas of skin compared to the surrounding skin colour leading to uneven skin tone or large darker patches. It occurs when melanocytes are stimulated to produce increased pigment called melanin. Melanocytes can be stimulated by sunlight, hormones, trauma, inflammation, medication and a constantly growing list of other factors. It was recently discovered that vascularisation (increase in blood vessels) also has a role to play in melanocyte stimulation and hyperpigmentation.
Hyperpigmentation is a common and intensely distressing condition. The commonest forms seen are melasma, solar lentigenes (sun spots) and post inflammatory hyperpigmentation (PIH).
What causes hyperpigmentation? – new evidence!
Melasma and sunspots mostly occur on sun exposed areas, particularly the face, while PIH can occur in any area of skin trauma or skin conditions like acne, eczema or insect bites.
All forms of hyperpigmentation worsen with sun exposure. It is well established as the greatest contributor, with the condition worsening during summer and improving in winter when ultraviolet exposure is less intense.
Melasma is also strongly influenced by genetic and hormonal factors and is often precipitated by pregnancy or the use of the contraceptive pill.
The influence of other environmental factors is only recently being examined, and other causative factors have now come to our attention as contributing to skin ageing and hyperpigmentation.
The solar energy spectrum is composed of ultraviolet radiation (A, B and C), visible light and infrared. The visible light spectrum is the light that we see. It has longer wavelengths than ultraviolet A and B and therefore actually have a deeper penetration into the skin, though they have never been regarded as potentially harmful.
Recent studies have found that visible light stimulates melanocytes to produce pigment. This is especially significant in darker skinned individuals and it seems that repeated long term exposure to visible light may cause hyperpigmentation. In addition, visible light may also cause inflammation and induce reactive oxygen species causing DNA damage, though it has not yet been established as a cause of skin cancer.
Important to note that most traditional sunscreens do not adequately protect against visible light. Fe oxide in sunscreens and antioxidants offer protection from visible light.
Infrared or heat represents the longest wavelength of solar energy and hence penetrates even further than visible light. IR activates matrix metalloproteinase and causes the breakdown of collagen causing skin ageing. Infrared also causes hyperpigmentation by inducing inflammation and vascularization (production of blood vessels). There is currently no effective way of protecting against infrared and only topical antioxidants have shown to offer some protection.
Traffic related air pollutants including a harmful form of ozone called tropospheric ozone and polycyclic aromatic hydrocarbons cause the formation of free radicals which depletes our skins antioxidant reserve. This leaves the skin vulnerable to further insult including DNA mutations and melanocyte stimulation.
Treatment for hyperpigmentation
Hyperpigmentation is treated with a combination of topically applied creams, and skincare procedures like chemical peels and dermal needling.
A complete treatment regimen should:
Protect against factors that cause melanocyte stimulation
Inhibit the production of melanin by inhibiting the enzyme tyrosinase
Improve the turnover of cells that have accumulated pigment
Maintenance treatment is critical to ensure that results are lasting as hyperpigmentation should be seen as a chronic condition that requires constant management.
The gold standard skin lightening agent is hydroquinone which has come under scrutiny as it was used to lighten skin generally, not just for treating hyperpigmentation.
Hydroquinone works by inhibiting the enzyme tyrosinase. This medication can be prescribed where appropriate by a dermatologist in various combinations and works well when used responsibly.
Kojic acid is an effective and well studied skin lightening agent. It is an ingredient in numerous creams and generally well tolerated
Neoretin Booster Serum is a lightweight serum containing Kojic Acid and other active ingredients which inhibit melanin synthesis.
SkinCeuticals Metacell Renewal contains Kojic Acid and other active ingredients to target the early signs of ageing and hyperpigmentation.
NeoStrata Enlighten Pigment Gel contains Kojic Acid, Liquorice extract, citric acid and multiple other active ingredients to target hyperpigmentation.
Arbutin is a glycosylated hydroquinone extract and has been considered one of the safest and most effective skin lightening agents. Its effects may also be optimised when combined with other substances like vitamin c, liquorice, glycolic acid and kojic acid.
Arbutin inhibits the enzyme tyrosinase decreasing the production of melanin pigment.
The active ingredient is slowly released making it suitable for those with sensitive skin.
The Nuderm system combines Arbutin and exfoliating ingredients to inhibit melanin production and remove cells containing pigment. Arbutin is a smaller molecule that penetrates deeper into the skin reaching the basal layer of the epidermis and inhibiting the enzyme tyrosinase.
Obagi C Clarifying Serumcombines 10% Vitamin C and Arbutin to protect against sunlight and environmental aggressors and inhibit production of melanin. This product targets early ageing and hyperpigmentation.
Vitamin C is a potent antioxidant which indirectly inhibits the enzyme tyrosinase leading to decreased melanin production
The anti inflammatory effect reduces cell injury and pigment production.
SkinCeuticals CE Ferulic and SkinCeuticals Phloretin CF are patented combination antioxidant formulations. Vitamin C is combined with other antioxidants for a potent synergistic effect that protects against ultraviolet light and visible light and offers some protection against infrared (IR) and air pollutants.
The Obagi Professional C range contains different concentrations of Vitamin C to suit different skin sensitivities.
Ellagic acid
Is a natural phenol antioxidant that inhibits the transfer of melanin to skin cells.
SkinCeuticals Advanced Pigment Corrector contains ellagic acid, niacinamide , vitamin and salacylic acid. It lightens dark spots by gentle exfoliation and prevents the formation of new pigment spots.
Tranexamic acid reduces pigmentation by its effect on the plasminogen activator pathway.
Combines tranexamic acid (inhibits the UV induced production of melanin by melanocytes), Kojic acid , niacinamide and HEPES which work synergistically to inhibit melanin production and remove epidermal cells containing pigment.
———————————————-
Note from Dr. Kesiree
HYPERPIGMENTATION should be regarded as a chronic condition that needs to be constantly managed. Be consistent with your treatment regimen. Treatment protocols generally combine intense phases of prescription treatment and procedures with maintenance regimens.
No treatment regimen for hyperpigmentation would be complete without strict daily sunscreen use.
Book an appointment with your dermatologist or skincare professional for advice on how best to treat your hyperpigmentation
Rosacea is a skin condition characterised by redness and flushing of the skin of the face, affecting mainly the cheeks and nose.
People who have Rosacea complain of a red complexion with dilated, broken blood vessels (telangiectasias), but sometimes have papules and pustules that can be mistaken for acne.
One less common form leads to an enlarged, red nose with thickened skin, large sebaceous glands and large pores. This form is called Phymatous Rosacea and occurs mainly in men, who are often wrongly thought to be alcoholics.
Ocular Rosacea presents with redness and irritation of the eyes.
Rosacea is common in fair skinned individuals but can occur in skin of any colour. Patients with Roscaea also complain that their skin is dry and ‘sensitive’, and ‘stings’ on application of skincare products.
For this reason there are numerous ranges of skincare that cater for those with Rosacea.
What causes Rosacea?
The cause of Rosacea is mainly unknown, there are however genetic and environmental influences and people with Rosacea have a 20% chance of having a family history of the condition.
Rosacea may start from an early age with frequent flushing and redness of the face. This is due to abnormal reactivity of blood vessels caused by dysregulation of the nervous system. This vascular hyper-reactivity worsens into adulthood. At first it is reversible, but in time there is persistent dilatation of the blood vessels and leaking of fluid into the tissue. The face may become tense with fluid (oedematous), leading to the formation of papules and pustules similar to acne.
In addition the skin is dry and sensitive due to a damaged skin barrier and there is a defective immune response further contributing to the inflammation seen in Rosacea.
Rosacea may also be caused by sun damage to the skin with damage to the dermal connective tissue and blood vessels and resultant leakage of fluid from blood vessels into the surrounding tissue.
Demodex mites, which seem to contribute to the development of Rosacea, are part of the normal skin flora and are found in large numbers in the skin of Rosacea sufferers
A secondary form of Rosacea can be caused by using steroids on the skin, often seen with inappropriate use of steroid creams on the face when treating conditions like eczema.
What triggers Rosacea?
A trigger is anything that causes Rosacea to flare up.
These may be anything from food and drinks, medication, medical conditions, physical activity, emotional factors, to weather and temperature changes and personal care products.
Identifying and avoiding trigger factors is an important part of the management of Rosacea but may not always be possible.
Most patients have multiple triggers and the list of reported triggers is exhaustive.
The most common trigger for Rosacea is heat and temperature changes, while other common triggers are alcohol, hot or spicy foods, emotional stress, wind and cold exposure, smoking and menopause.
Can Rosacea be cured?
Rosacea cannot be cured.
It is important for patients to understand what their possible triggers are and to try to avoid them.
Medical treatments are aimed at controlling signs and symptoms and the condition may then go into remission for some time.
What are my treatment options?
Treatment options are medical and surgical and an individual will probably go through a variety of different treatment options in their lifetime.
Rosacea requires continuous management and the foundation for this is a good skincare regimen including a gentle cleanser, moisturiser and suitable sun protection. There are also various ingredients in skincare that successfully reduce redness and calm inflammation.
In addition, this is combined with a prescription treatment depending on the type of Rosacea.
Erythematotelangiectatic Rosacea is characteristised by redness and broken veins.
This type is best treated with topical metronidazole or topical azeleic acid. Laser may be helpful to improve redness.
Topical oxymetazoline is used in the United States, but is not available in South Africa
Papulopustular Rosacea is treated with a combination of topical antibiotics eg metronidazole, erythromycin, or clindamycin and oral antibiotics eg tetracyclines and erythromycin.
Other treatments including benzoyl peroxide, tretinoin, pimecrolimus and permethrin are also sometimes prescribed.
Isotretinoin may be prescribed for Rosacea that is severe and unresponsive to other treatment.
It is also used for a type of Rosacea called solid facial oedema in which the skin is tense with inflammation.
Are there any procedures to treat Rosacea?
Laser or light treatment can reduce redness, shrink blood vessels and remove thickening of the skin.
Laser is particularly useful for Erythematotelangiectatic Rosacea or Phymatous Rosacea.
Some chemical peels may also be suitable to calm skin and reduce redness and inflammation. An example of this is SkinTech Easy Phytic peel.
This chemical peel is specifically designed for sensitive skin like Rosacea. It is useful for those that have an acute flare-up of their Rosacea.
General measures
Identify and avoid your triggers.
Sun protection is essential, as sun damage may precipitate or worsen Rosacea.
Use a sunscreen for sensitive skin. These are usually mineral sunscreens contains zinc oxide or titanium dioxide.
Wash the face twice daily with a gentle soap-free cleanser suitable for sensitive skin.
Avoid products with alcohol, menthols, camphor, witch hazel and fragrances.
Avoid toners and facial scrubs.
Use your prescription topical treatment after washing the face.
Use a moisturiser with ingredients that reduce redness and calm the skin.
Avoid heavy occlusive makeup or greasy cosmetics as these are difficult to remove without scrubbing the skin.
Patients with Rosacea often complain that products ‘sting’ their skin. This is because of a damaged skin barrier.
It is sometimes necessary to try a few skincare products before finding a suitable one.
Rosacea is a condition that develops over time and patients are initially unaware of their symptoms. If you are experiencing some of these symptoms and believe you may have Rosacea, visit your dermatologist to confirm your diagnosis and receive prescription treatment suitable for your skin.
To book an appointment with our skin specialist email [email protected]
Acne is a common disorder of the pilosebaceous unit (hair follicle). There are two main types of acne lesions:
Inflammatory lesions consists of papules and pustules, more commonly referred to as ‘pimples’, as well as nodules and cysts which can be found in severe acne.
Non-inflammatory lesions called open and closed comedones are better known as ‘blackheads’ and ‘whiteheads’.
Acne mainly affects the face, neck, back and chest and can affect a localized area or all these areas extensively, acne can therefore vary greatly in appearance and severity.
Mild acne is characterised by comedones, while severe acne can be disfiguring with large nodules and cysts.
Rarely patients may have a systemic form of acne called Acne fulminans which can leave them feeling very unwell.
Whether mild or severe, acne can still have a huge psychological impact and lead to significant permanent scarring.
Who gets acne?
Acne is primarily a disease of adolescence and affects about 85% of the young between 12 and 24 years. However it can also affect any other age group from infants to adults. It is not uncommon for acne to develop in the 30’s and 40’s and 50’s without any prior teenage acne. We call this type of acne ‘late onset acne’ and it is particularly challenging to manage.
What causes acne ?
While there are many factors that play a role, the four main pathogenetic mechanisms are:
– A defect in keratinisation at the hair follicle opening which causes keratinocytes (skin cells) to block the opening of the hair follicle
– Androgens (male hormones) which cause the sebaceous glands to produce more sebum. Androgen production increases around puberty as the adrenal glands mature which results in oiliness of the skin, causing the higher incidence of acne at this age.
– Propionibacterium acnes proliferate in the hair follicle and contribute to triggering an inflammatory response and worsening acne.
– An inflammatory response that leads to the formation of papules and pustules in response to the blocked follicle.
Other possible contributing factors:
The use of oral or topical steroids on the face for prolonged periods can lead to steroid induced acne. Many prescription drugs can cause acne as a potential side effect. Examples are epileptic medication and injectable progesterone containing contraceptives.
Greasy face creams or hair products may further block follicles and worsen acne. We call this type of acne Pomade acne.
High humidity contributes to a kind of acne found in the tropics known as Tropical acne.
Pinching and scratching acne lesions can worsen acne, particularly acne scarring. This type of acne is called Acne excorie.
Is acne genetic?
Acne may be considered genetic as one is more likely to get acne if either parent has had severe acne. The incidence of both identical twins having acne is high, supporting a genetic link. The size, number and activity of sebaceous glands which is directly related to acne is genetically determined and can’t be altered.
What is hormonal acne?
All acne can be considered ‘hormonal’ as the major contributing factor to developing acne is androgen (male hormone) induced stimulation of sebum production from the sebaceous glands. In most case the hormone levels are normal. There are however some conditions in which there is an increase in androgen production. An example of this is Polycystic ovarian syndrome.
Late onset acne is thought to be partly because of an increased effect of androgens on the sebaceous glands even at normal blood levels.
Late onset acne is usually distributed on the lower face of women. We often refer to this as ‘hormonal acne’.
How do I treat my acne?
The acne guidelines have been developed to provide a guide to treating acne.
The guidelines divide acne into mild, moderate and severe and treatment is based on the grading of acne.
Mild acne with open and closed comedones (‘blackheads’ and ‘whiteheads’) is treated with topical benzoyl peroxide and topical retinoids.
Moderate acne is treated with antibiotics (either topical or oral) in combination with topical benzoyl peroxide or topical retinoid. It is very important to combine antibiotics with topical treatments as it prevents resistance to the antibiotic.
Severe acne usually warrants prescription of isotretinoin (Roaccuatane, Oratane, Acnetane) which is the most effective treatment for this type of acne.
In addition to this oral contraceptives can be used by women as this counteracts the effects of androgens.
In all forms of acne the first lesion is the microcomedone. For this reason no treatment regimen is complete without a topical treatment to prevent the formation of new comedones.
Some other treatments that have some success are usually recommended in combination with prescription treatment.
These include:
Chemical peels
Peels help to decrease the amount of dead keratin blocking the follicular unit, reducing the amount of blackheads and whiteheads and calming down inflammation.
Chemical peels assist with mild acne scarring and post Inflammatory hyperpigmentation which is often more emotionally disturbing than the acne.
Photodynamic therapy
Red and blue light with or without topical aminolevulinic acid can decrease the amount of propionibacterium acnes in the follicle and in this way improve acne.
Home-care
A carefully tailored home-care regimen can help reduce oiliness and moisturise skin that has been left dry and sensitive from prescription medication. Ingredients like salacylic acid, lactic acid and glycolic acid can also help shed dead surface skin cells and reduce the amount of blackheads.
Does diet affect acne?
This is still a controversial topic as there is still not much evidence available. In general dairy and high glycaemic index foods may worsen acne. This does not mean that they are causing acne, nor does it mean that you don’t need acne treatment if you control your diet.
My acne has cleared, how do I treat the scars?
In most cases untreated acne will eventually resolve. The problem with this is the resultant scarring and post inflammatory hyperpigmentation which is often permanent. It is therefore important to start treating soon and to continue treatment.
Management of the acne will prevent scarring.
Treatment of scars starts with topical retinoids in the treatment phase.
After acne has cleared options for scarring include chemical peels, dermal needling and laser therapy.
Dermal filler may also be injected to fill up pits caused by acne scarring.
General measures
Keep the skin clean by washing twice daily with a gentle cleanser suitable for your skin type.
Avoid harsh soaps or scrubs which traumatize the skin and worsen inflammation.
Very oily skins may benefit from a cleanser with added salacylic or glycolic acid.
Toners may be used to reduce oiliness after cleansing.
Use a suitable moisturiser.
Use your prescription topical treatment regularly. The results will not be quick but regular treatment helps prevent new acne and assists with maintenance of a skin condition that often fluctuates in severity for many years.
Wear sunscreen in the day as most acne treatments make the skin sun sensitive.
Sunscreen will also help reduce post inflammatory hyperpigmentation.
Avoid heavy occlusive makeup or greasy cosmetics which block the follicles and worsen acne.
Seek treatment early to avoid scarring.
Visit your doctor or dermatologist for prescription treatment, and a home care regimen that can be tailored to suit your skin.
What is eczema or dermatitis?
The terms Eczema or dermatitis can be used interchangeably and are used to describe an inflammation of the skin – the suffix “-itis” means inflammation.
Another example is “arthritis” which means inflammation of a joint.
Atopic eczema is the most common type of eczema that affects up to 30% of children and 10% of adults. Rarely, one can develop eczema for the first time even after the age of 60. Atopy means a genetic predisposition to develop eczema, asthma and hayfever and we find that these conditions run in families, children also have a greater risk of developing eczema if one of their parents have had it.
A few other common types of eczema are:
Seborrhoeic eczema – a mild form of eczema occurring most commonly on the scalp, ears, face and mid chest and ‘Cradle cap’ is a variant of seborrhoeic eczema which affects babies. Malassezia yeasts are thought to contribute to the cause of seborrhoeic eczema.
Allergic contact eczema is a variant of eczema that occurs from contact with chemical substances that the skin is allergic to.
A common example is contact allergy to nickel in earrings and clothing studs leading to an eczema around the area of contact.
People may also develop allergies to various other allergens including plant materials (eg poison ivy), hair dyes and ingredients in personal care products.
Asteatotic eczema occurs mostly in elderly patients and starts with a very dry skin that cracks and becomes red and inflamed. This kind of eczema occurs mostly on the lower limbs and flanks.
Stasis dermatitis occurs particularly on the lower limbs in patients with varicose veins and is due to the pooling of the circulation beneath the skin.
What does eczema look like?
The inflamed skin of eczema can look red, wet and weeping if the eczema is acute and severe.
The skin is leathery with varying redness, scaling and crusting if the eczema is subacute, or thickened and nodular if the eczema is chronic.
The distribution of eczema may vary with age.
Babies generally have eczema on the face, neck and scalp, outer arms and front of the legs.
Childhood eczema is typically in the folds of the elbows and knees, the wrists, ankles hands and feet, we call this flexural eczema.
The distribution may alter yet again in adults who have a higher incidence of hand eczema. It is important to exclude allergic contact eczema in adults with hand eczema.
What causes Eczema?
As with most disease there is a genetic predisposition and contributing environmental factors. These vary with different types of eczema.
The skin in Atopic eczema has an impaired skin barrier function and a defective immune response.
Mutations in a gene called fillagrin is a strong predisposing factor which weakens the skin barrier and allows allergens to penetrate and trigger the immune response.
There are multiple potential environmental triggers; irritants like detergents, soaps and fragrances contribute to weaken the skin barrier, as well as synthetic fabrics and wool which irritate the skin and worsen itching and scratching.
Allergens like house dust mite, pollen and animal hair have also been shown to trigger atopic eczema.
Is eczema contagious?
No. You will not get eczema from touching an area of eczema on another person. Similarly you can’t make your eczema ‘spread’ over your own skin by touching it.
Can you outgrow eczema?
Yes. As many as 50-60% of sufferers can outgrow their eczema around puberty.
Regular moisturizing of the skin can control asteatotic eczema. Avoidance of the offending substance in allergic contact allergy may resolve this condition.
What are the treatment options?
Treatment consists of maintenance treatment and treatment of the acute flare up.
Maintenance is exceptionally important as it can help keep the eczema in remission for prolonged periods of time and reduce the need for topical steroids .
Avoid soap on the skin as it has an ingredient called sodium laurel sulphate which weakens the skin barrier, also avoid perfumed products, bubble baths and other environmental triggers.
Use soap free products to wash with and a suitable emollient to moisturise the entire skin at least twice a day.
Topical treatments
The first line treatment for the ‘acute flare-up’ of eczema are topical corticosteroids which range in strength or potency. There is much controversy regarding the use of ‘steroids’ leading to ‘steroid phobia’ in patients with eczema. Topical corticosteroids remain the most potent anti-inflammatory agent for a condition that is characterized by varying levels of inflammation.
As a dermatologist I am constantly educating my patients on the correct and responsible use of steroids to prevent occurrence of known steroid side effects.
Topical calcineurin inhibitors pimecrolimus and tacrolimus are used in ongoing maintenance of atopic eczema. They may sometimes be used as first line treatment in suitable patients.
A new topical therapy for atopic eczema, crisaborole has recently been approved by the United States food and drug administration.
Systemic treatments
These include oral steroids, steroid injections, and oral immuno-suppressive drugs which include include azathioprine, cyclosporine and methotrexate. These treatments are indicated for severe flare-ups of eczema, or eczema that cannot be managed with topical treatment.
A new biologic injectable drug called dipilumab was recently approved by the United States Food and Drug Administration and has shown promising results in clinical trials.
Phototherapy (light therapy)
Light therapy with narrow band UVB light has been shown to improve inflammation in eczema and the associated itch. Light therapy is generally combined with other treatment options.
Are there certain foods I need to avoid if I have eczema?
Food avoidance is only recommended if there is a proven food allergy.
Atopic eczema, food allergy, asthma and hay fever are genetically linked. If you have one of these conditions, then you may be predisposed to develop any of the others. However it does not necessarily mean that avoiding certain foods will have any effect on the eczema. If you believe that a certain food is worsening your eczema, keep a food diary to establish whether this is consistent. Food allergies can be investigated and tested by an allergologist. This will prevent you avoiding food that you are not actually allergic to.
Does stress worsen eczema?
Yes. Psychological factors including emotional stress can certainly trigger worsening of eczema. Flare ups of eczema are commonly seen in students around exam time.
Another reported example of stress triggering eczema, is the occurrence of first onset of atopic eczema in pregnant women.
Can I use sunscreen if I have eczema?
There are sunscreens suitable for sensitive eczema-prone skin. These are usually the physical or mineral sunscreens and those that are free of perfumes and fragrance.
Dermatitis or eczema can be a frustrating condition to live with particularly if it is chronic.
It’s also difficult to accept the first onset of a chronic skin condition later in life and with such a wide variety of washes and emollients available, patients are often overwhelmed for choice. It’s always best to contact your dermatologist if you are suffering with eczema or feel you may be developing a similar skin condition.
What is Melanoma?
Melanoma is a malignant tumour of pigment producing cells called melanocytes. These cells are found in the skin, but also in the meninges which cover the brain and spinal cord, and in the eye. Melanoma most commonly occurs on the skin. Most melanomas are brown-black in colour, but some may be red or skin-coloured. We call these amelanotic melanomas and they are difficult to spot. The incidence of melanoma has risen in the past few decades, which is alarming as it is a tumour that leads to death in young adults. It occurs mainly in white populations , but can occur in other race groups. Melanoma is always malignant and a deadly cancer
What causes Melanoma?
Melanoma develops when melanocytes are damaged in some way and become cancerous. This can occur to melanocytes in a pre existing melanocytic naevus (‘mole’) or to a random melanocyte usually in the skin.
What makes these cells turn cancerous?
The most important contributing factors are sun exposure and sunburns, especially since these are the factors that can be controlled.
Genetic factors that contribute to melanoma risk include skin type, hair and eye colour, the presence of lots of moles and certain gene mutations. Researchers are discovering more and more gene mutations that contribute to causing melanoma. This helps with developing novel treatments for melanoma.
Is there a difference between Melanoma and Skin Cancer?
Melanoma is a one type of skin cancer. It makes up a small percentage of skin cancers but is the most deadly.
Can Melanoma spread?
Yes, melanoma is an aggressive skin cancer and can spread rapidly even though it remains a small spot or nodule in the skin.
In fact sometimes a melanoma can completely disappear on the skin without ever being noticed and first present with metastasis in the body.
Can Melanoma be life threatening?
Yes. Melanoma is one of the most dangerous cancers worldwide and causes death in young people.
But early detection can lead to successful treatment!
Is Melanoma hereditary?
Melanoma can be considered hereditary in some cases as certain gene mutations occur in families. The risk factors like skin colour, eye colour, hair colour and the presence of multiple moles also runs in families.
You have a greater risk of getting a melanoma if you’ve had a close family member who has had a melanoma.
When should I worry about a mole or skin spot?
You should worry about a new ‘spot’ on the skin or an existing melanocytic naevus (‘mole’) that is changing. Most melanomas occur as a new lesion. Only around one third of melanomas develop in pre-existing moles.
Can I reduce my risk of getting Melanoma?
Yes you can with safe sun practice. Do not allow your skin to burn. Do not allow your child’s skin to burn. Stay away from tanning booths.
If you have risk factors for melanoma as discussed above make sure you examine your skin and visit your dermatologist regularly.
How do I examine myself for skin Cancer?
Be aware of changes in your existing moles or new spots that appear on your skin. Sometimes these will be noticed by friends or family who draw your attention to it.
Take a look at your back and the backs of your arms and legs in the mirror, as most people do not look here.
What are my treatment options?
The treatment options for melanoma depends on the depth of the melanoma in the skin. We call this the Breslow depth and it is the most important prognostic indicator.
The best scenario is early detection of a melanoma. Melanomas that are early or ‘thin’ can be cut out completely giving you a normal life expectancy. Beyond a certain depth treatment options are limited with limited survival. These options include surgery, chemotherapy and newer classes of drugs called immunotherapy and targeted therapy. But even though there is lots of ongoing research we still do not have drugs to guarantee long term survival.
The bottom line is, be aware of your body, look after your body and if you have a mole that has changed, or a spot on your skin that is concerning you, contact your Dermatologist immediately.
Pseudofolliculitis is a common chronic skin condition which typically affects the beard area of men who shave.
It is then referred to as pseudofolliculitis barbae or more commonly called ‘shavers rash’.
It typically occurs in men with tightly curled hair and of African descent. ‘Barbae’ refers to the beard area though pseudofolliculitis can occur in any shaved area and could even affect women and other race groups. It occurs where hair is coarse and abundant and subject to shaving, waxing or plucking
In all cases it is a cosmetically disfiguring condition which is difficult to treat and often recurrent.
How does it occur?
Paeudofolliculitis is caused when hair grows parallel to the skin surface rather than perpendicular to it such that the sharp tip of the newly cut hair curls back and pierces the skin causing trauma, inflammation and ultimately an ingrown hair.
A newly cut or plucked hair shaft may pierce the follicular wall to enter the dermis without ever leaving epidermis (upper layer of the skin) once again resulting in an ingrown hair and inflammation
While this process occurs mainly in curly hair, skin folds or scarred skin may cause the condition in straight hair.
Pseudofolliculitis barbae is essentially a chronic foreign body reaction to an ingrown hair shaft.
What does it look like?
Pseudofolliculitis barbae typically presents with firm papules and pustules in the beard area. For some reason it does not occur on the moustache area. The appearance of the disorder can be cosmetically distressing for affected patients. Postinflammatory hyperpigmentation, secondary bacterial infection, scarring, and keloid formation are potential complications.
How can you prevent it?
Use good shaving techniques.
Cleanse the skin thoroughly and wet the skin and hair before shaving. Wetting the hair softens the keratin making it easier to cut. Applying a warm wet towel for a few minutes before shaving may also be helpful.
Shaving preparations provide additional hydration and cushion the blade against the skin to minimise trauma.
Use a clean,sharp blade and shave in the direction of hair growth where possible.
This may be difficult as the hair in the beard area tends to grow in different directions.
Cleanse the skin thoroughly after shaving, as residual shaving preparation left on the skin surface may cause irritation.
How do you treat Pseudofolliculitis?
Stop shaving
The first step is to stop shaving in the area till all inflammatory lesions and ingrown hairs have cleared.
You may trim the hair to a minimum length of 0.5 cm with a scissors or electric clippers
Release ingrown hairs on a daily basis
Apply a warm water compress to the affected area for 10 min to soften the epidermis ( upper layer of the skin). Then release the ingrown hairs with a sterile needle or toothpick.
Topical corticosteroid
Apply a mild topical steroid to the area to decrease the inflammation and reduce burning and itching.
Systemic antibiotics
Some patients may need an oral antibiotic for secondary infection or for anti inflammatory effect.
Other treatments
Other treatment options include topical retinoids, alphahyroxyacids and benzoyl peroxide.
Chemical depilatory creams may be used for hair removal.
Laser hair removal is sometimes recommended for those with resistant and recurrent pseudofolliculitis.
Once the condition has resolved, adopt good shaving techniques as described above, and invest in a suitable skincare regimen as recurrence is common.
Skincare recommendations for Pseudofolliculitis.
Neostrata Foaming Glycolic wash
– This is a potent, foaming facial cleanser with glycolic acid and lactobionic acid to resurface and hydrate the skin with minimal irritation. The special formulation exfoliates and unclogs congested pores.
Obagi Clenziderm pore therapy
This liquid treatment contains salicylic acid which helps unclog pores and remove dead surface skin cells.
NeoStrata Ultra Smoothing Lotion 10 AHA
– Ultra Smoothing Lotion is an antioxidant-rich, exfoliating moisturiser. This is a lightweight formulation which is suitable for use on the face and body and may be preferred by men. The exfoliating action of alphahydroxyacids removes the surface dead skin cells and helps unclog pores.
One of the most important steps in treating male skin is to select a good eye cream, as ageing is first noticed in the eye area with the appearance of ‘ crows feet’.
Here are a few eye creams preferred by men which will assist with fine lines and wrinkles in the eye area (crows feet), which is a common skin concern in men.
• Obagi ELASTIderm Eye Serum
Elastiderm eye serum refreshes the appearance of the delicate skin around the eye area. It reduce the appearance of periorbital fine lines and wrinkles and improves the appearance of dark under-eye circles.
It is a lightweight serum in a rollerball dispenser
• Neostrata Skin Active Intensive Eye Therapy
Skin Active Intensive Eye Therapy is an advanced SynerG formulation aimed at building and plumping the delicate skin in the eye area. Apple Stem Cell Extract protects the longevity of the skin cells, while Peptides stimulate collagen production.
It is a lightweight cream in a pump dispenser.
• SkinCeuticals A.G.E. Eye Complex A.G.E. Eye Complex is a specially formulated eye cream that improves the appearance of puffiness, dark circles and crow’s feet, associated with the formation of advanced glycation end products during the ageing process. There is immediate enhanced radiance of tired, dull eyes.
It is a cream which is rapidly absorbed into the eyelid skin and comes in a jar.
• Neostrata Bionic eye cream plus
Bionic Eye Cream Plus is a multi-functional eye cream that targets dark under-eye circles and reduces fine lines, wrinkles and puffiness. Vitamin K diminishes the appearance of dark circles, while the Lactobionic Acid prevents collagen breakdown, making the skin look and feel firmer.
It is a lightweight cream in a tube.
If you are still not sure about which eye cream to select or need advice on your skincare regimen, email Annika on [email protected].
This type of hyperpigmentation occurs in all skin types but is most common in those with darker skin.
It occurs after a skin condition or skin injury that causes the skin to become inflamed with resultant damage to the melanocytes, which are the cells that produce melanin pigment. Sometimes the preceding condition is barely noticeable.
Damage to the melanocytes causes melanin to be deposited in the dermis or epidermis (upper layer of the skin). This is important as epidermal hyperpigmentation fades faster than dermal hyperpigmentation, and in fact the dermal type may be permanent.
This type of hyperpigmentation can occur at any age, and on any part of the body.
It may appear tan, various shades of brown or blue gray. A blue gray appearance points to dermal melanin and a more prolonged and difficult treatment. Sometimes a dermatologist may be able to see lesions of the preexisting condition making it easier to make a diagnosis.
Common causes of post inflammatory hyperpigmentation that I see in my practice every day are acne, eczema, insect bites and skin infections. We need to treat the underlying disorder if it is still present to prevent more PIH from developing. If left untreated PIH may take years to resolve.
Melasma
Melasma or chloasma is a common disorder of hyperpigmentation that mainly involves the face. It usually affects both sides almost symmetrically and occurs in both males and females, though commoner in females. At least 90% of patients with melasma are women.
It can affect all races but is most common in darker skins where it is also the most difficult to treat.
Nevertheless melasma is a very distressing condition as it occurs somewhat out of the blue, sometimes seemingly without any precipitating factors.
Common precipitants are sunlight and hormonal influences (OCP and pregnancy). There is a genetic predisposition as in most diseases.
It may not seem fair that some of us will never get melasma even with reckless sun behavior and others will get it even with strict sun avoidance. The hyperpigmentation of melasma is due to increased melanin production by melanocytes i.e. increased activity of the melanocytes and not an increased number in the cells.
These melanocytes are called ‘reactive’ melanocytes. They produce an excess of melanin pigment, which is transferred to the skin cells called keratinocytes. Some of this pigment also ‘falls’ into the dermis where it gives a blue gray appearance to the skin. The key enzyme in the process of melanin pigment production is called tyrosinase.
Melasma is a clinical diagnosis based on a typical presentation. We do not do any tests to confirm the diagnosis. The hyperpigmentation of melasma can be described as flat coalescing brown, gray or bluish patches with irregular edges.
There are three typical patterns of distribution.
Centrofacial involves the forehead, nose, chin and cheeks. Malar pattern involves the cheeks and nose and mandibular pattern involves the area over the jawline.
Melasma may also occur on the neck and forearms i.e. extrafacial melasma.
Melasma is a common condition, but the treatment remains difficult particularly in darker skinned individuals where the condition may often either persist or recur.
Apart from classification according to distribution on the face, melasma is also classified according to where in the skin the pigment sits. As with PIH, epidermal melasma is more likely to respond to treatment than dermal melasma.
Melasma is managed with a combination of treatment modalities. Treatment needs to target various stages in the production and clearance of the excess melanin pigment.
Treatment of hyperpigmentation
Three pronged approach.
1. Avoid factors that stimulate melanocytes and cause them to produce more melanin ie avoidance of sun exposure, meticulous use of sunscreen and protective clothing. I must stress that protecting your skin from the sun is critical to the treatment and ongoing maintenance for patients with melasma. If you are on an oral contraceptive pill, consider an alternative form of contraception.
2 . Inhibit the production of melanin by melanocytes by targeting the enzyme tyrosinase.
The gold standand treatment to inhibit tyrosinase is hydroquinone. This treatment is only available by prescription. Other options are Arbutin, Kojic Acid and ellagic acid which are gentler and less likely to cause a worsening of the hyperpigmentation when discontinued.
3. Increasing the epidermal turnover will help to shed those keratinocytes which have been loaded with melanin pigment.
Topical creams and chemical peels help to remove the pigmented epidermal skin layers. Good options for accelerating epidermal turnover include glycolic acid and lactic acid
Proceed cautiously especially with darker skin types as there is no quick fix and epidermal injury from aggressive treatments could worsen hyperpigmentation
Remember that to maintain results as long as possible you will need to continue with your maintenance products.
