Complexion complexities

Although therapists are not doctors and therefore cannot prescribe medications, they should be able to recognise commonly found skin conditions, such as eczema, psoriasis and rosacea. Leading dermatologist, Dr Lushen Pillay, unpacks each of these

Dermatitis refers to a group of itchy inflammatory conditions characterised by epidermal changes and affects about one in every five people at some time in their lives. It results from a variety of different causes and has various patterns. The terms dermatitis and eczema are often used interchangeably. In some cases, the term eczematous dermatitis is used. Dermatitis can be acute, or chronic, or both. Acute eczema refers to a rapidly evolving red rash, which may be blistered and swollen. Chronic eczema refers to a longstanding, irritable area. It is often darker than the surrounding skin, thickened (lichenified) and much scratched. An in-between state is known as subacute eczema. Psychological stresses can provoke or aggravate eczema, presumably by suppressing normal immune mechanisms.

Atopic eczema is particularly prevalent in children; inherited factors seem important, as there is nearly always a family history of dermatitis or asthma. Irritant contact dermatitis is provoked by body fluids, handling water, detergents, solvents or harsh chemicals, and by friction. Irritants cause more trouble in those who have a tendency to atopic dermatitis.

Allergic contact dermatitis is due to skin contact with substances that most people don’t react to, most commonly nickel, perfume, rubber, hair dye or preservatives.

A dermatologist may identify the responsible agent by patch testing. Dry skin, especially on the lower legs, may cause asteatotic dermatitis, also called eczema craquele. Nummular dermatitis (also called ‘discoid eczema’) may be set off initially by an injury to the skin: scattered coin-shaped irritable patches persist for a few months.

Seborrhoeic dermatitis and dandruff are due to irritation from toxic substances produced by Malassezia yeasts that live on the scalp, face and sometimes elsewhere. Infective dermatitis seems to be provoked by bacterial infection or fungal infection. Stasis dermatitis arises on the lower legs of older people, due to swelling and poorly functioning leg veins. Meyerson naevus is dermatitis that affects moles.

An important aspect of treatment is to identify and tackle any contributing factors. Bathing: reduce how often you bathe or shower and use lukewarm water (showers are better). Replace standard soap with a mild detergent, soap-free cleanser. Clothing: wear soft smooth cool clothes; coarse fibres (wool or synthetic) are best avoided (microfine merino wool may be suitable). Irritants: protect your skin from incontinence, dust, water, solvents, detergents and injury. Emollients: Apply an emollient liberally and often, particularly after bathing. When itchy, avoid perfumed products. Topical steroids: apply a topical steroid cream or ointment (prescribed by a doctor or dermatologist) to the itchy patches for a five to 15-day course. Steroids should usually be applied once or twice daily to the red and itchy areas only. Calcineurin inhibitors: they are part of an anti-inflammatory cream shown to be very effective for atopic dermatitis mantenance, with fewer side effects than topical steroids. Antibiotics: can be used if infection is complicating or causing dermatitis. The infection is most often with Staphylococcus aureus or Streptococcus pyogenes. Eczema is often a long-term problem. When you notice your skin getting dry, moisturise your skin again and carefully avoid the use of soap. If the itchy rash returns, use both the moisturiser and the steroid cream or ointment. If it fails to improve within two weeks, see your doctor for further advice.

Psoriasis is a chronic inflammatory skin condition characterised by clearly defined, red and scaly plaques (thickened skin). It is classified as an immunemediated inflammatory disease (IMID). This condition affects 2–4% of males and females. It can start at any age including childhood, with peaks of onset at 15–25 years and 50–60 years. Psoriasis tends to persist lifelong, fluctuating in extent and severity. It is particularly common in Caucasians but may affect people of any race. About one-third of patients with psoriasis have family members with psoriasis. Genetic factors are important. An individual’s genetic profile influences their type of psoriasis and its response to treatment. Psoriasis usually presents with symmetrically distributed, red, scaly plaques with well-defined edges. The scale is typically silvery white, except in skin folds where the plaques often appear shiny and they may have a moist peeling surface. The most common sites are scalp, elbows and knees, but any part of the skin can be involved. The plaques are usually very persistent without treatment. Itch is mostly mild but may be severe in some patients, leading to scratching and lichenification (thickened leathery skin with increased skin markings). Painful skin cracks or fissures may occur.

The following factors can aggravate psoriasis: Streptococcal tonsillitis and other infections, cuts, abrasions, sunburn, obesity, smoking, excessive alcohol, stress, and medications (such as lithium, beta-blockers, anti-malarials and nonsteroidal anti-inflammatories).

Patients with psoriasis should ensure they are well informed about their skin condition and how

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to treat it. There are benefits from not smoking, avoiding excessive alcohol and maintaining optimal weight. Mild psoriasis is generally treated with topical agents alone. Which treatment is selected may depend on body site, extent and severity of psoriasis. Topical solutions include emollients, coal tar preparations, dithranol, salicylic acid, vitamin D analogue, topical corticosteroids, a combination calcipotriol/ betamethasone dipropionate ointment/ gel or foam and phototherapy. Moderate to severe psoriasis warrants treatment with a systemic agent and/ or phototherapy.

Rosacea is a chronic rash involving the central face that most often starts between the ages of 30 and 60. It is common in those with fair skin, blue eyes and Celtic origins. It may be transient, recurrent or persistent and is characterised by its red colour. Although once known as acne rosacea, this is incorrect, as it is unrelated to acne. There are several theories regarding the causes of rosacea, including genetic, environmental, vascular and inflammatory factors. Skin damage due to chronic exposure to ultraviolet radiation plays a part. The skin’s innate immune response appears to be important, as high concentrations of anti-microbial peptides such as cathelicidins have been observed in rosacea. The condition may be aggravated by facial creams or oils. Rosacea results in red spots (papules) and sometimes pustules. They are dome-shaped rather than pointed and unlike acne, there are no blackheads, whiteheads or nodules. Rosacea may also result in red areas, scaling and swelling. Characteristics of rosacea include frequent blushing or flushing; a red face due to persistent redness and/

or prominent blood vessels (telangiectasia); red papules and pustules on the nose, forehead, cheeks and chin often follow (inflammatory or papulopustular rosacea); and in rare cases, the trunk and upper limbs may also be affected. Other characteristics are dry and flaky facial skin; aggravation by sun exposure and hot and spicy food or drink; burning and stinging on sensitive skin; red, sore or gritty eyelid margins including papules and styes; sore or tired eyes; and enlarged unshapely nose with prominent pores.

Where possible, reduce factors causing facial flushing and avoid oil-based facial creams. Never apply a topical steroid to the rosacea as although short-term improvement may be observed (vasoconstriction and anti-inflammatory effect), it makes the rosacea more severe over the next weeks. Protect yourself from the sun. Use light oil-free facial sunscreens. Keep your face cool to reduce flushing. Minimise your exposure to hot or spicy foods, alcohol, hot showers and baths, and warm rooms. Oral antibiotics for rosacea may be prescribed by your doctor or dermatologist. In terms of topical treatments, metronidazole cream or gel can be used intermittently or long-term on its own for mild inflammatory rosacea and in combination with oral antibiotics for more severe cases. Azelaic acid cream or lotion is also effective for mild inflammatory rosacea, applied twice daily to affected areas. Persistent telangiectasia can be successfully improved with vascular laser or intense pulsed light treatment.

Dr Lushen Pillay is a specialist dermatologist and dermatologic surgeon at Helen Joseph Hospital, where he is also the head of the Dermatology department. He lectures at Wits University and completed his undergraduate degree at the University of Pretoria, and then completed the fellowship in Dermatology, FC Derm (SA), as well as a Masters (MMed) in Dermatology through Wits University. Pillay has won various research awards and has a special interest in facial aesthetics.