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Sensitive skin

Sensitive skin is not an uncommon problem. It is almost always a problem of facial skin, but can occur anywhere or everywhere on the body. The most common complaint is that facial products start to burn, tingle or sting when applied. The product often needs to be washed off quickly to relieve the sensation.

Sensitive skin is a symptom. It is not a specific disease, like asthma. Therefore, the question to ask when you have sensitive skin is: “What is the underlying condition that is causing the sensitive skin?”

From a purely anatomical or physiological perspective any condition that can disturb the epidermis, which is the top layer of the skin, can lead to a sensitive skin. Nerve fibres terminate in the epidermis, so any condition that disturbs the area around a nerve fibre can result in that nerve fibre becoming too easily stimulated. This over sensitivity of nerve fibres is experienced by the patient as sensitive skin.

The two most common causes of a sensitive skin are Atopic Dermatitis and Irritant Dermatitis.

Atopic Dermatitis is a genetic condition that results in many different signs and symptoms, but a tendency to dryness is perhaps the most common symptom. Dryness leads to an abnormal epidermis, disturbs the environment of the epidermal nerve endings and opens the door for sensitive skin to develop. Because dryness is the primary problem, the cornerstone of the treatment of Atopic Dermatitis is moisturisers and the avoidance of products that can dry the skin even more, like regular soaps and cleansers. Over time, this will improve the epidermis, normalize the area around the nerve fibre and result in less sensitivity. In many patients Atopic Dermatitis only manifests later in life.

Irritant dermatitis is caused by exposure to irritants. These irritants are most often soaps, cleansers, toners and other cosmetic preparations. Very often these products are advertised as mild, natural and non-irritant. The cornerstone of the treatment if Irritant Dermatitis is to avoid the irritant. With complete avoidance of the irritant and other supplementary measures, the skin sensitivity will gradually subside over a period of weeks to months.

Irritant dermatitis can often be superimposed on Atopic dermatitis. The patient with Atopic dermatitis already has an abnormal epidermis and is therefore already much more sensitive to the potential irritant effects of soaps and other cosmetic products. Patients often find it difficult to believe that their facial products or facial cosmetic routine can play a role in their sensitive skin. “Doctor, but I have used those products for years”, is a common explanation for why the facial products cannot possibly play a role. But, it can.

There are two possible explanations why an existing product can suddenly start stinging. Either the person himself/herself has changed or the product ingredients or way of use have changed.

Here are some examples of the “person has changed” scenario:

  • Perhaps an oral medication was started that makes the skin drier. Statins, used to treat elevated cholesterol levels, often leads to dry skin and then increased skin sensitivity.
  • Perhaps the work or home environment changed. Air conditioners can sometimes tip the scale towards dryness.
  • Perhaps a Contact dermatitis has developed. Contact dermatitis is a type of skin allergy that can be investigated by doing an allergy tests, called patch tests.
  • Stress has been showed to influence the epidermis in dramatic ways.
  • The thyroid gland might have become under active, leading to a disturbed epidermis and increased skin sensitivity.
  • The normal ageing process and sun damage leads to increased skin dryness that can then lead to sensitive skin.
  • After the menopause the skin becomes significantly drier and prone to sensitivity

To figure out what exactly tipped the scale towards a sensitive skin and to treat sensitive skin will often require the help of a dermatologist.

What is Keratosis Pilaris?

Keratosis pilaris arm

Keratosis Pilaris is a hair follicle condition. It can be thought of as hair follicle eczema. It most commonly affects the hair follicles of the upper arms, but can also affect hair follicles on the upper legs and occasionally on the face and other areas.

Keratosis Pilaris affects the hair follicle in 2 ways. It causes the mouth of the hair follicle to become slightly elevated due to overproduction (hyperkeratosis) of skin in the area. That is why the condition feels rough to the touch. Secondly, it causes inflammation of the hair follicle, which results in the spotty reddish appearance of the affected area.

The roughness combined with the redness can be unsightly and a source of embarrassment to patients.

Like asthma and hay fever, the condition can not be cured, but it can be improved.

The roughness can be treated with a moisturiser that contains Urea or Salicylic acid. It takes a few weeks to see good results. Sometimes retinoid containing creams, like Differin cream, needs to be used in addition to the moisturiser. An achievable goal is to improve the roughness by 80%.

The redness is more difficult to treat. It improves slightly when the roughness improves, but in most cases additional anti-inflammatory preparations like mild topical corticosteroids, Protopic or Elidel must be used for short periods. An achievable goal is to improve the redness by 50%.

The keep the Keratosis Pilaris under control daily use of moisturisers, with or without a retinoid cream and intermittent use of anti-inflammatory preparations are required.

Remember, the goal of treatment is improvement and not cure.

How to eliminate House Dust Mite

House_Dust_MiteThere are many triggers that can cause a flare-up of Atopic eczema. The House Dust Mite is one such trigger.  House Dust Mite lives in the dust found in human and animal habitation.  Not everybody with Atopic eczema will be sensitive to the House Dust Mite, but more than 35% of Atopic eczema patients are sensitive to House Dust Mite. The Atopy Patch test can be used to test for House Dust Mite Allergy.

House Dust Mites feed on pollen, fungi, bacteria and most importantly on the skin flakes shed from humans and animals. These skin flakes concentrate in the creases of bedding and furniture. The number of skin flakes and House Dust Mites found in an area is proportional to the time humans and animals spend in that area. Bedding will therefore contain large numbers of House Dust Mites.

If you want to start a House Dust Mite elimination campaign the places to concentrate your efforts should therefore be those areas where the family spend most of their time.

Before describing the steps needed to contain the House Dust Mite population, please note that the elimination of House Dust Mite is still vastly less important than the regular application of moisturisers.

PREPARATION

  • Completely empty the room, just as if you were moving.
  • Empty and clean all cupboards. If possible, store contents elsewhere and seal the cupboards.
  • Remove carpeting.
  • Replace curtains with metal of wooden blinds that are easy to clean
  • Clean and scrub the woodwork and floors thoroughly to remove all traces of dust.
  • Wipe wood, tile, or linoleum floors with water, wax, or oil.
  • Cement any linoleum to the floor.
  • Keep the doors and windows closed.

MAINTENANCE

  • Clean the room thoroughly and completely once a week.
  • Clean floors, furniture, tops of doors, window frames and sills, etc., with a damp cloth.
  • Carefully vacuum upholstery regularly. Use a special filter in the vacuum.
  • Air the room thoroughly after cleaning

BEDS AND BEDDING

  • Keep only one bed in the bedroom. Most importantly, wrap mattress in a zippered dust-proof or allergen-proof cover. Scrub beds outside the room. If you must have a second bed in the room, prepare it in the same manner.
  • Use only washable materials on the bed. Sheets, blankets, and other bedclothes should be washed frequently in water that is at least 50 degrees Celsius. Lower temperatures will not kill dust mites. If you set your hot water temperature lower, wash items at a laundromat which uses high wash temperatures.
  • Use a synthetic material for bedding. Avoid fuzzy wool blankets or feather- or wool-stuffed pillows.

FURNITURE AND FURNISHINGS

  • Go for the minimalist look on the room.
  • Avoid upholstered furniture.
  • Use only a wooden or metal chair that you can easily clean.

AIR CONTROL

  • Modern air conditioners can reduce the levels of house dust mite in the air.

CHILDREN

  • Keep toys that will accumulate dust out of the child’s bedroom.
  • Avoid stuffed toys
  • Use only washable toys of wood, rubber, metal, or plastic
  • Store toys in a closed toy box or chest

PETS

  • Keep all animals with fur or feathers out of the bedroom. If you are allergic to dust mites, you could also be allergic or develop an allergy to cats, dogs, or other animals.

These steps are extreme, but it is only by eliminating >90% of house dust mites in an area, that you obtain any benefit. If these measures does not help to reduce the severity of your Atopic Eczema, you are most likely not sensitive to House Dust Mite allergens.

What is Perioral dermatitis?

Perioral dermatitis is a type of dermatitis that occurs only around the mouth, nose and eyes. It does not have to be present in all of the areas at the same time.

Some dermatologists believe that Perioral dermatitis does really exist and that patients that fit the clinical picture of Perioral dermatitis has Rosacea. Rosacea and Perioral dermatitis can sometimes be present in the same patient. Because it is always more likely that a patient has 1 condition rather than two, the finding of both Rosacea and Perioral dermatitis in the same patient support to the thesis that the 2 conditions are in fact the same. Furthermore, when looking at a sample of skin under the microscope, both Rosacea and Perioral dermatitis displays the same type of inflammation, knows as a granulomatous peri-folliculitis. The word granulomatous refers to a collection of macrophages (a type of white blood cell). Peri-folliculitis means that the “collection of macrophages” is lying in close proximity to a hair follicle.

Whether or not Rosacea and Perioral dermatitis are the same disease or two separate diseases is an academic question and not very important from a treatment perspective. The fact is that the clinical picture known as Perioral dermatitis is quite classic and most often easily recognizable and treatable.

Classically young female patients are affected. The rash consists of small red bumps (knows as papules) and occasionally small pimples (knows a pustules) occurring around the mouth, nose and eyes. Interestingly, a small margin of skin around the edge of the lips are always unaffected. As mentioned before not all 3 of these areas has to be affected at the same time.

More than 80% of patients with Perioral dermatitis have been applying corticosteroid-containing creams to the face, before the rash started to appear. In the remaining cases the cause is unclear, but the excessive use of facial products seem to be another common factor.

The treatment of this condition involves the elimination of all (if possible) facial products. If topical corticosteroid-containing creams have been used they should be tapered off slowly and not stopped suddenly, because this will lead to a flare-up of the condition.

The treatment of Perioral dermatitis involves the use of oral tetracycline antibiotics for a few months. Sometimes this is combined with antibiotic creams, but in general it is better to avoid as many creams as possible. Most often this approach results in complete clearance of the skin condition in a few weeks.

Perioral dermatitis treatment

Perioral dermatitis is sometimes also called Perioral-nasal-ocular dermatitis (PONOD) or periorificial dermatitis, because the rash can also appear around the nose and eyes.

Perioral dermatitis is associated with the use of facial products. Most patients with Perioral dermatitis are using multiple different types of facial products. The use of corticosteroid containing creams over extended periods are strongly linked to the development of Perioral dermatitis. One of the most important aspects of the treatment of Perioral dermatitis is therefore the gradual elimination of all non-essential facial products.

Depending on the severity of the Perioral dermatitis the above process is started while taking an oral Tetracycline antibiotic, like Minocycline, Doxycycline or Lymecycline. Normally this antibiotic must be continued for at least 3 months (or until the rash has disappeared) and is then tapered off over a 2 month period.

Paradoxically, the early phases of the treatment of Perioral dermatitis might involve using a mild topical corticosteroid cream on the face to calm down the active redness and inflammation. The most commonly used corticosteroid cream contains Mometasone furoate. This is initially applied daily until the redness subsides and then tapered off as soon as possible.

The tapering off process of the corticosteroid cream normally occurs over a few weeks. The average patient will use the corticosteroid cream daily for about 5 days, on alternate days for about 4 days, twice a week for about 2 weeks and after that maybe once or twice a month. There is however considerable variation.

While the corticosteroid cream is tapered off the oral antibiotic is continued until the rash has been absent for at least a month. Only then is the oral antibiotic also tapered off. It is extremely important that during this treatment period all non essential facial products (yes all!) must be gradually eliminated. If this is not entirely possible then try to eliminate as many facial products as you can. Only after all facial products have been stopped and the Perioral dermatitis has been clear for at least one month, can facial products be gradually reintroduced one by one.

Perioral dermatitis is normally quite responsive to the above treatment regime and most patients will experience a marked improvement in only a few days to weeks.

What is Cradle Cap?

Baby With Cradle CapCradle cap is a term used to refer to any red scaly rash on the scalp of babies. Cradle cap is not a medical diagnosis, but simply a descriptive term, like the term diaper dermatitis.

There are a few causes of Cradle cap, including Seborrheic dermatitis, Atopic Dermatitis and Plaque Psoriasis. Seborrheic dermatitis is the most common cause of cradle cap. Before Cradle Cap can be treated, the specific cause of the Cradle cap must first be diagnosed. To diagnose the cause of the Cradle cap your doctor will have to examine the baby from head to toe.

A concomitant rash in the skin-folds and the nappy area might indicate Seborrheic dermatitis, whereas a generally dry skin might indicate Atopic Dermatitis as the cause of the Cradle cap. Nobody knows exactly why babies develop Seborrheic dermatitis or Atopic Dermatitis. The theory is that Seborrheic dermatitis is related to the overgrowth of the yeast Pityrosporum ovale which was recently renamed Malassezia furfur. The yeast overgrows because of overactive oil glands on the scalp. The oil glands become overactive because of genetic influences or perhaps because of hormones passed to the baby from the mother.  Seborrheic dermatitis is not due to bad hygiene or a bad diet! Perhaps as many as 50% of babies born in the developed world have some degree of cradle cap.

Once the diagnosis is made, treatment can be started. The following treatment options will apply especially to Cradle cap caused by Seborrheic dermatitis.

The are really 2 aspects of Cradle cap to treat; scaling and redness. The scaling develops from the areas of redness. Once the redness is resolved the scaling will cease. Initially however, treatment is targeted at both scaling and redness.

Redness can be treated with mild topical corticosteroids. Corticosteroids is not dangerous if used correctly and sparingly. Do not let anybody tell you different, because mild topical corticosteroids can rapidly improve the condition and make your baby feel better. Mild topical corticosteroids should be applied once of twice per day while there is redness. If there is no redness do not apply any corticosteroids.

Ketoconazole containing shampoos can also help. Ketoconazole is an anti-fungal that will help to eradicate yeasts. It is a good idea to dilute the Ketoconazole shampoo perhaps 50:50 or greater initially, to make sure the shampoo does not irritate the babies skin. Use the shampoo every second day initially. Ketoconazole creams can also be applied once or twice per day to the red areas.

Scaling is treated by moisturising the skin. Many different oil and creams can be used for this. Examples include Vaseline, over-the-counter moisturizers, olive oil, borage oil, tea-tree oil, aloe gel etc.

Cradle cap due to Seborrheic dermatitis will resolve spontaneously within a few months in the vast majority of babies.

Elidel

ElidelThe active ingredient is Elide, Pimecrolimus, is an immunosuppressant derived from Ascomycin. Ascomycin is produced by the fungus Streptomyces hygroscopicus.

Topical Pimecrolimus become available for prescription around 2001. Pimecrolimus cream comes in one strength (1%) and is available in 30g, 60g and 100g tubes.

The most important use for Pimecrolimus (Elidel) cream is to treat Atopic Dermatitis. The manufacturer recommends that Pimecrolimus (Elidel) should only be used for age 2yr and older, but is has been used successfully in younger children. Pimecrolimus (Elidel) works by inhibiting the molecule Calcineurin that is essential for activating T-lymphocytes. T-lymphocytes, which are white blood cells, play an active role in Atopic Dermatitis. When T-lymphocytes become activated they help to induce a flare-up of Atopic Eczema.

Pimecrolimus (Elidel) is most often used as a third line treatment for Atopic Dermatitis. First line treatment is emollients and second line treatment is topical corticosteroids. Pimecrolimus (Elidel) is often prescribed when it is difficult or impossible for eczema-sufferers to wean themselves of topical corticosteroids. The extra immunosuppressive effect of the Pimecrolimus (Elidel) should allow most patients to reduce the topical corticosteroids needed to control the dermatitis.

A comparison of Pimecrolimus (Elidel) with Tacrolimus 0.03% showed no significant differences in efficacy at 6 weeks after treatment started. Tacrolimus 0.1% is more potent that Pimecrolimus (Elidel) and 0.03% Tacrolimus.

Side effects from using Pimecrolimus (Elidel) cream are mild. About 4% of people using Pimecrolimus (Elidel) will experience a burning or stinging sensation where they apply the Pimecrolimus (Elidel). The burning sensation disappears in about 15 minutes. It only occurs in the first week or two and in active patches of dermatitis.

The long-term risks (years) of using Pimecrolimus (Elidel) is unclear. The biggest concern about Pimecrolimus (Elidel) cream is that it might raise the risk of developing skin cancers. People using Pimecrolimus (Elidel) cream should limit their exposure to sunlight. In animal studies Pimecrolimus (Elidel) speeded up the cancer-forming effects of sunlight. There have been a few people that have developed a skin cancer while using Pimecrolimus (Elidel). Four of these were skin lymphomas.

The skin cancers occurred on average 90 days after the start of therapy. It is unclear if Pimecrolimus (Elidel) caused the skin cancers or whether the skin cancers would have developed anyway. Until long-term data becomes available Pimecrolimus (Elidel) will probably remain an important third line treatment for eczema-sufferers finding it difficult or impossible to wean themselves of topical corticosteroids.

Protopic

Protopic ointmentProtopic contains the active ingredient, Tacrolimus. Tacrolimus is an immunosuppressant produced by the fungus Streptomyces tsukubaensis.

Fujisawa laboratories discovered Tacrolimus in 1984. The first publications of experimental data appeared in 1987 and clinical trials started in 1989. Topical Tacrolimus become available for prescription around 1999. Tacrolimus is available as an ointment, an intravenous infusion and in 1mg and 5mg capsules.

The main users of Tacrolimus infusions and capsules are organ transplant patients to prevent organ rejection and people with conditions needing potent immunosuppresion. The ointment comes in two strengths (0.1% & 0.03%) and is available in 30g and 60g tubes. The most important use for Tacrolimus ointment is to treat Atopic Dermatitis, but it has been used for many other skin ailments as well. The 0.1% formulation is better than the 0.03% formulation. The manufacturer recommends the 0.1% ointment for people older than 16 years and the 0.03% ointment for children older than 2 years. Both strengths have however been used successfully in both age groups.

Tacrolimus works by inhibiting the molecule Calcineurin that is essential for activating T-lymphocytes. T- lymphocytes, which are white blood cells, play an active role in Atopic Dermatitis. When T-lymphocytes become activated they help to induce a flare-up of Atopic Eczema. Tacrolimus is most often used as a third line treatment for Atopic Dermatitis.

First line treatment is emollients and second line treatment is topical corticosteroids. Tacrolimus is often prescribed when it is difficult or impossible for eczema-sufferers to wean themselves of topical corticosteroids. The extra immunosuppressive effect of the Tacrolimus should allow most patients to reduce the topical corticosteroids needed to control the dermatitis.

Side effects from using Tacrolimus ointment are mild. About 40% of people using Tacrolimus will experience a burning or stinging sensation where they apply the Tacrolimus. The burning sensation disappears in about 15 minutes. It only occurs in the first week or two and in active patches of dermatitis.

The long-term risks (years) of using Tacrolimus is unclear. The biggest concern about Tacrolimus ointment is that it might raise the risk of developing skin cancers. People using Tacrolimus ointment should limit their exposure to sunlight. In animal studies Tacrolimus accelerated the cancer-forming effects of sunlight. There have a few people that have developed a skin cancer while using Tacrolimus. Nine of these were skin lymphomas. The skin cancers occurred on average 150 days after the start of therapy.

It is unclear if Tacrolimus caused the skin cancers or whether the skin cancers would have developed anyway. Until long-term data becomes available Tacrolimus will probably remain an important third line treatment for eczema-sufferers finding it difficult or impossible to wean themselves of topical corticosteroids.