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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.

Seborrheic dermatitis

Seborrhoeic_eczemaSeborrheic dermatitis/eczema is a form of eczema that can appear only on certain parts of the body. The appearance of the rash varies depending on the area of the body that is involved. On the scalp the rash typically appears red and scaly, whereas in the skin folds the rash is typically devoid of scale and therefore appears red and moist.

The typical areas of the body that can be involved by Seborrheic dermatitis are as follows:

  • Scalp
  • The skin fold behind the ears
  • The skin fold between the nose and cheeks
  • The ear canals
  • The eyebrows
  • The mid chest
  • The mid back
  • The groin area, including the skin folds between the upper legs and abdomen

Not all of these areas have to be involved and most often it is just the scalp areas.

The rash is generally not very itchy, but some people describe a burning sensation on the involved areas, especially the scalp. People that suffer from so-called “Dandruff” is frequently in fact suffering from Seborrheic dermatitis. Dandruff is not a medical diagnosis and refers to the small white skin flakes occurring on the scalp. There can be many reason for excessive flaking of the scalp, of which Seborrheic dermatitis is one.

Seborrheic dermatitis occurs in two separate age groups, before 1 year of age and after puberty. After puberty men tends to be affected more often than women.

Nobody really knows the cause of Seborrheic dermatitis, but the overgrowth of a certain organism called Pityrosporum ovale has been implicated. However, not all people with Seborrheic dermatitis have Pityrosporum ovale overgrowth. The finding of huge numbers of Pityrosporum ovale in areas of Seborrheic dermatitis might therefore be just the result of the Seborrheic dermatitis and not the cause of the Seborrheic dermatitis. Another theory about the cause of Seborrheic dermatitis is that Seborrheic dermatitis is a disease of skin overgrowth just like Psoriasis.

Another important association with Seborrheic dermatitis is infection with HIV. People with HIV tend to develop Seborrheic dermatitis when the suppression of their immune systems reaches a certain level.

The treatment of Seborrheic dermatitis involves the use of various shampoos containing one or more of the following ingredients: Zinc, Selenium, tar and anti-fungals. A corticosteroid containing lotion, cream or mouse can be used during a flare up. Recently Tacrolimus and Pimecrolimus has also been used successfully for the treatment of Seborrheic dermatitis.

Dyshidrotic eczema

DyshidroticDermatitisOnHandsDyshidrotic eczema (otherwise known as pompholyx or vesicular eczema of the hands and/or feet.) is viewed by some dermatologists as a specific disease, while others use the term to describe a clinical picture that can have more than one cause. In the rest of this article I will take the view that Dyshidrotic eczema is a clinical reaction pattern caused by more than one condition.

The typical areas affected by Dyshidrotic eczema are the sides of the fingers and toes. On occasion any palmar area of the hand (palm-side) or plantar area of the feet (sole-side) can be affected. The hands are affected in isolation in 80% of cases, the feet  in 10% of cases and both the hands and feet in the remaining 10% of cases. Dyshidrotic eczema can be extremely itchy.

The eruption consists of multiple small (<5mm) vesicles (small blisters) that are closely packed together. The vesicles are situated in the upper layer of the skin called the epidermis and are filled with a watery fluid. In severe cases these small vesicles coalesce with the resulting formation of large tense bullae (large blisters).

The causes of “Dyshidrotic eczema”:

  • Dyshidrotic eczema (as a specific disease entity with an unknown cause)
  • Atopic dermatitis
  • Allergic contact dermatitis to many substances, including nickel
  • Irritant dermatitis
  • Id reaction (eczema due to an infection at a distant site e.g. the feet or scalp)
  • Stress, although stress might just be contributing to one of the above factors

So, as you can see, there are quite a few potential causes of Dyshidrotic eczema. The first step is to identify which one of these diseases are the cause of the Dyshidrotic eczema. The diagnosis of Dyshidrotic eczema (as a specific disease entity with an unknown cause) is only made once other possible causes have been excluded.

You can be tested for Allergic contact dermatitis by patch testing. Patch testing involves placing many different substances on the back for 2 DyshidroticDermatitisOnPalmsdays and then after 2 days the substances are removed and your skin is inspected. If you have an allergy to any of the substances that was patched on your back the area will be inflamed.

Id reactions are eczematous reactions occurring as a result of a fungal or bacterial infection elsewhere on your skin. It is important to remember that the infection does not have to be near the eczema. Infection of the feet or scalp can give rise to an Id reaction of the hands! Fungal infections of the feet has been reported in up to 30% of cases of Dyshidrotic eczema. In these case the treatment of the Dyshidrotic eczema will therefore be the treatment of the fungal infection of the feet. Be warned however, that even if you have a fungal infection of your feet, it is not necessarily the cause of your Dyshidrotic eczema!

When irritant dermatitis is the causative factor of your Dyshidrotic eczema it implies that your hands or feet are excessively exposed to a skin irritant such as soap or washing powder.

The primary treatment of Dyshidrotic eczema is therefore the “removal” of the cause. If the cause can not be identified the treatment is symptomatic.

Dyshidrotic eczema is mostly treated with potent topical corticosteroids combined with the frequent application of moisturizers. Other treatment options include light therapy (PUVA). In severe cases oral prednisolone can be used in short courses. In the most severe and resistant cases other immunosuppressants like Azathioprine, Methotrexate and even Cyclosporine have been used.

How to treat nappy rash

The term nappy rash simply refers to a rash in the nappy area. Many conditions can cause a rash in the nappy area. The first step is to determine what the cause of the nappy rash is.

Conditions that can cause a rash in the nappy area:

  • Primary irritant dermatitis
  • Candida infection
  • Atopic dermatitis
  • Allergic Contact Dermatitis
  • Seborrheic dermatitis
  • Psoriasis
  • Acrodermatitis Enteropathica
  • Langerhans Cell Histiocytosis
  • Bullous Mastocytosis
  • Incontinentia pigmenti
  • Bullous Pemfigoid
  • Dermatitis Herpetiformis
  • Linear IgA disease
  • Epidermolysis Bullosa
  • Herpes Simplex virus infection
  • Bullous Impetigo
  • Tinea cruris
  • Scabies
  • Papular urticaria

See why is it essential to determine the cause first?!

The most common cause of nappy dermatitis is Primary irritant dermatitis. Primary irritant dermatitis is a result of urine and faeces irritating the skin. The irritation of the skin is due to wetness, the alkalinity of urine and faeces, irritating enzymes in urine and faeces and secondary infection with Candida and bacteria.

The initiating irritating factor is wetness. The most important part of the treatment of Primary irritant dermatitis is to keep the baby’s bottom DRY. Regular nappy changes, frequently enough to prevent too much wetness, is the most important part of the treatment. Nappy changes can be reduced by using more absorbent nappies. After every nappy change apply a nourishing moisturiser to help repair the skin.

Inflammation (redness) can be treated with mild corticosteroid ointments.

Small sores and ulcers can be covered with Vaseline / White soft paraffin or Zinc oxide ointment.

Infections can be treated with antifungal creams and antibacterial creams.

How to treat dandruff

Dandruff is a non-medical term for a scaly scalp. Many different conditions can cause a scaly scalp. The most common skin condition that causes dandruff is Seborrheic Dermatitis, followed closely by Atopic Dermatitis. Seborrheic Dermatitis tends to flare during  stressful periods.

The first step in treating dandruff is to decide which condition is causing the dandruff.

If the cause is Seborrheic Dermatitis the treatment is as follows:

Step 1:

Shampoos containing ketoconazole, e.g. Nizshampoo.
The shampoo is used 3-4 x per week and left on for a few minutes before rinsing off. Some people need to continue this process for years. If ketoconazole shampoo is not sufficient to control the dandruff the treatment in Step 2 is added.

Step 2:

Scalp lotions containing corticosteroids, e.g. Advantan scalp lotion, Synalar gel and Dermovate scalp lotion.
These lotions are best applied after washing the hair, while the scalp is still moist.

Step 3:

Shampoos containing corticosteroids, e.g. Clobex shampoo. Clobex shampoo is applied on dry hair. The Clobex shampoo can be washed off with the Ketoconazole containing shampoo.

Step 4:

Oral medications containing antifungals, e.g. Nizoral tablets or Sporonox tablets.
Most often, step 1, the ketoconazole containing shampoo, is all that is required

Treatment of psoriasis

Psoriasis-on-backThe treatment of psoriasis depends on the severity of the psoriasis. Think of the treatment of psoriasis as a flight of stairs. Each step represents a treatment of greater potency, but with more potential side effects. The treatment of psoriasis always starts at the bottom step, i.e. the least potent treatment with the least potential side effects. If the treatment at this level does not work, the treatment can progress to the next level. This stepwise approach allows for control of the psoriasis with the least potent and safest medication possible.

The treatment levels for psoriasis are as follows:

LEVEL 1:

  • Moisturisers containing Urea or Salicylic Acid.  Moisturisers help to remove the white scaling of psoriasis lesions.
  • Sun exposure. Sun exposure should not be overdone, because a sun burn can also worsen psoriasis. The time spent in the sun should be just enough to feel you have been in the sun the day before.
  • Rest and relaxation

LEVEL 2:

  • Diluted corticosteroid creams.  Corticosteroid creams suppress the redness and inflammation of psoriasis lesions.

LEVEL 3:

  • Undiluted corticosteroid creams, corticosteroid ointments, corticosteroid lotions and corticosteroid shampoos. The most reliably effective ointment is Dovobet™ ointment. Dovobet™ is actually a combination of a topical corticosteroid and a Vitamin D derived ingredient.

LEVEL 4:Alternate Text

  • Vitamin D derived creams like Calcipotriol (Dovonex™)
  • Vitamin A derived creams like Tazarotene (Zorac™)
  • Anthralin or Dithranol containing ointments Level one to four treatments are often used in combination and additively. So, if you progress to a level 4 treatment it is very likely that you will be using all the treatments from level one to four.

LEVEL 5:

  • Ultraviolet light therapy. Narrow band Ultraviolet B treatment is the most effective of the ultraviolet treatment options. Ultraviolet treatments can be combined with level 1-4 treatments, but corticosteroid medications should be gradually stopped during Ultraviolet treatment.

LEVEL 6:

  • Methotrexate tablets
  • Acitretin containing tablets, like Neotigason™. Acitretin is derived from Vitamin A and is especially useful in Pustular Psoriasis

LEVEL 7:

  • Cyclosporin tablets (Sandimmun Neoral™)

LEVEL 8:

  • Various injections. These medications are also known as the Biologic Response Modifiers

The safe way to use corticosteroid creams

This article is especially applicable to Atopic Dermatitis, but you can follow these general rules for any form of dermatitis.

Always use the lowest potency corticosteroid creams at the lowest frequency of application that will just control your eczema.

So how do I find the correct potency of corticosteroid and correct frequency of application?

Generally speaking when you initially start treating your eczema start with one of the higher potency corticosteroids. Once you have achieved control start reducing the number of applications. If you can reduce the number of applications to once or twice weekly, while still retaining control over your eczema, then you can try a lower potency corticosteroid application.
Use the weakest corticosteroid cream/ointment just frequent enough to control your eczema.

Once you have this “new” lower potency corticosteroid application, again start with daily applications and if the eczema is still controlled after about a week you can start reducing the frequency of application again.

If you repeat this process you will eventually end up using the lowest potency corticosteroid application at the lowest frequency of application that will just control your eczema.

When the dermatitis flares up, as it will, then go back to daily application of your current potency corticosteroid. If the flare-up is severe your doctor might start you on the higher potency daily application again.

Once the eczema is controlled again you can again start the above “reducing” regime so that you will again end up on the lowest potency corticosteroid application at the lowest frequency of application that will just control your eczema!

And remember, never let up on the moisturizers!!