Special Feature: Recognising Common Skin Conditions

By Shannon Kilgariff / 02 Feb 2018

Four practitioners share their preferred treatment methods for common dermatological conditions presenting in clinic

It is well-known that the patients who are commonly presenting to aesthetic clinics have skin concerns associated with ‘ageing’. However, other skin concerns are not beyond the remit for many practitioners working in private aesthetic practices. Around 25% of the UK population will consult a GP each year because of a skin complaint. With only around 650 consultant dermatologists currently practising in the UK, it is likely that some of these patients will turn to private medical aesthetic practitioners for guidance on their dermatology issues too.1,2 As aesthetic professionals regularly perform all kinds of skin treatments, they are in a prime position to ensure their patients are getting the best skin advice possible. In this article, Aesthetics asks four practitioners who specialise, or have experience, in dermatology to discuss a skin condition that they believe is important for medical aesthetic practitioners to be able to diagnose and treat. The practitioners also recommend when the time is right for a referral.

Keratosis pilaris with dermatology and cosmetic nurse practitioner Anna Baker

Characteristics: redness, bumps, rough skin 

Can be confused with: folliculitis, ichthyosis vulgaris, atopic eczema

Keratosis pilaris (KP) is a common skin condition presenting in at least half the UK population.3 

Known as ‘chicken skin’, it is completely benign and non-contagious. It can manifest early on in childhood, going through into adulthood.

KP may uncommonly present on other areas of the body, but is most common on the back of the arms or the sides of the thighs, and appears as very red, rough, bumpy skin. Interestingly, KP is usually symmetrical, affecting both sides of the body. KP can be more common in women than in men and has quite a strong genetic component.3 There is no ‘quick fix’ and people often get it more in the winter months, possibly because the skin is dryer and produces less sebum.3

‘Keratosis’ refers to a build-up of keratin, the most abundant protein in the epidermis, and ‘pilaris’ comes from the Latin word for ‘hair’. Therefore, it refers to an excessive build-up of keratin, resulting in an over-keratinisation in the skin’s hair ducts.4

There are two factors in dermatology that are really important for diagnosis: pattern recognition and good history taking. With KP, I believe it’s all about taking a thorough history as other conditions may occur at the same time, such as ichthyosis vulgaris – accumulation of dead skin – and atopic eczema, so it’s imperative that practitioners are 100% sure it’s only KP before administering treatment.

There are other types of KP that aren’t as common, such as on the face and neck, but the most common types that we see tend to be on the body, so I will be focusing on that. KP on the body is usually something that can be managed by a patient at home. Universal recommendation for treatment involves an exfoliating topical ingredient. So, that could be something such as salicylic acid, which is a very effective keratolytic agent, urea or alpha hydroxy acids such as glycolics or citric acid.4

Personally, I find that a very cost-effective option for patients is to give them a multi-purpose glycolic and citric acid body lotion to use twice a day. In my experience, these ingredients are very good at de-plugging and reducing the amount of keratin production of the skin, while still giving some hydration. I use NeoStrata Ultra Smoothing Lotion, which is an 8% glycolic and 2% citric acid homecare product. I would say that in 90% of my cases, just using the lotion at home will produce an improvement within three to four weeks. However, if the case is quite stubborn, or if a patient wants a quicker result, I would look to combine a 20% glycolic peel with the body lotion. It’s important that the patient has been using the body lotion for a few weeks first so that their skin acclimatises to the pH of the peel. The course of peels would range from four to six, every two to three weeks, or thereabouts. I would recommend reassessing the area after each peel to determine whether you need to treat again. If, for whatever reason, the KP wasn’t responding, I wouldn’t hesitate to tell patients to stop treatment and refer them to a dermatologist.

In terms of other measures, I’d tell patients to avoid taking very hot showers, which can irritate skin, or over-manually exfoliating, because that can make the area tender, sore and uncomfortable. KP treatment is generally not a ‘quick fix’. The overarching aim is to try and give a nice superficial exfoliation without irritating and drying the skin out. As a nurse, I recommend that others get involved with the British Dermatological Nursing Group (BDNG), which runs great CPD courses in all aspects in dermatology, if they would like more information on this and other conditions.4-6

Atypical naevus syndrome with Dr Christopher Rowland
Payne, consultant dermatologist to The London Clinic

Characteristics: many and various moles of different sizes, shapes, colours 

Can be confused with: ordinary moles, seborrhoeic warts

Atypical naevus syndrome (ANS) is common in young adults and is a major risk factor for the development of melanoma, which affects one in 50 of the British population.7

ANS is characterised by many and various naevi (also known as moles) and is usually easy to distinguish. There are variations in shape, size, colour and pattern of pigmentation but the moles are flat to the touch, unlike ordinary moles which are usually slightly raised. It is defined when an individual has more than 50 moles in total and, typically, these are scattered over the trunk and limbs, especially at the edge of clothing sites, where people have had sunburn in the past.8

ANS will present in patients, years after they have been sunburnt earlier in their life, usually during childhood or as a teenager, and the diagnosis will typically be made in their 20s or early 30s.

The number and variety of the moles indicate how susceptible the patient is to changes in their ANS – they can also become very unstable if they are burnt again, which increases the risk of irritation and the likelihood of it becoming a melanoma.

However, the people who are most at risk of melanoma are people who have what’s called a ‘triple inheritance’.8 This is the ability to tan from one ancestor, ability to burn from another ancestor and the ability to produce moles from a third. So, the types of people who get ANS are people who go out in the sun and go brown, but they also burn, and if people have the third inheritance, a large number of moles, then when they burn the moles will rise a few years later. Typically, the skin types that present with ANS are usually Fitzpatrick II-III rather than I, as they only burn; the individual must also have the mole inheritance.7,8,9

Due to its association with melanoma, it is very important that every medical aesthetic practitioner knows how to recognise ANS. If you see it in a patient, which you will often because it’s very common, then you have a responsibility to mention it to the patient, advise them about sun avoidance and always ask the question, ‘Have any changed?’ If there are reported changes in shape, size, number or especially if one becomes blacker in colour, it is vital that they are referred to a dermatologist for mole removal.

Removal is traditionally achieved through cutting it out in an elipse excision, which leaves unattractive scars. The other way is to do a superficial excision, which produces a better cosmetic outcome, where you split the skin by holding the scalpel in almost a parallel way and leaving the deeper part of the skin in place. The mole will then be sent for microscopic examination and, if it is found to be a melanoma, then the doctor may need to do another larger excision of the area. So, ANS itself is not dangerous – it’s the potential for the moles to change which is dangerous. Practitioners should never attempt to remove these moles using lasers or chemical peels as they absolutely must be studied microscopically to determine whether it is benign atypical naevus, or one that has evolved into a melanoma due to sun exposure. Encourage patients to seek expert advice, check their moles and body regularly and, if there is any change whatsoever, then this needs to be reported to a dermatologist.7-9

Rosacea with consultant dermatologist Dr Daron Seukeran

Characteristics: facial redness, flushing, spots, pustules

Can be confused with: acne, seborrheic dermatitis, facial weathering

Rosacea is a relatively common, chronic inflammatory condition that usually occurs in patients in their middle ages between 30-50. 

It’s found in both men and women, although men are considered to get it more severely.10

Rosacea is a condition that is localised on the face and its characteristic features are often associated with a flushing or a burning sensation, sometimes with spots or pustules.

Practitioners must first identify if patients are experiencing redness and if it is triggered by any environmental factors. These factors can be different among individuals but can include sunlight, hot drinks, spicy food, alcohol, going from a cold to a hot room, or other lifestyle factors. In men, sometimes there is a thickening of skin on the nose that makes it look quite deformed – called rhinophyma.11

Once someone has rosacea, it tends to be a chronic condition that works in waves and relapses with time. Although there is much research, the cause is still unknown. Theories have suggested it may be due to an overgrowth of the demodex mite that lives in the pilosebaceous follicles.12 We also know that it runs in families and those with very fair skin seem to have a higher instance of rosacea.10

Treatment depends on the type of rosacea the patient has. If the patient has active lesions with spots and pustules, they will need to be treated medically. This involves using a combination of topical treatments and creams – such as metronidazole gel, 1% ivermectin cream or azelaic acid – and often combining these with oral antibiotics, such as oral tetracycline.10,12

However, if the patient has rosacea which is just associated with a bit of redness and flushing without the spots and pustules, they can respond very well to three to six light-based treatments such as pulsed dye laser (PDL) or intense pulsed light (IPL) in my experience. By removing the superficial blood vessels, light technologies do two things, they reduce the redness and the symptoms of flushing or burning. I personally prefer the PDL as I find it is quite precise in removing the vessels, but IPL can also be useful. At sk:n clinics, we either use the VBeam pulsed dye 595 nm laser.

It’s vital that aesthetic practitioners are careful when giving aesthetic treatments to patients with rosacea, you don’t want to use anything that’s going to irritate the surface of the skin because the skin is so sensitive and you can make it worse if you treat it inappropriately.

Practitioners also need to be wary of giving the patient inappropriate advice and should refer to a consultant dermatologist if they don’t have specific knowledge in this area.10,11,12

Acne vulgaris with aesthetic practitioner Dr Dev Patel, who has completed the Postgraduate Diploma in Practical Dermatology

Characteristics: comedones, papules, pustules, nodules, cysts

Can be confused with: rosacea, seborrheic dermatitis, steroid related dermatitis, tinea barbae, perioral dermatitis, keratosis pilaris, adenoma sebaceum, pityrosporum folliculitis

Acne vulgaris is a very common, long-term inflammatory skin condition that involves the pilosebaceous unit, which consists of the hair follicle, the cells lining the hair follicle and the associated sebaceous gland.

The general pathophysiology components to acne include: increased sebum production, follicular hypercornification and proliferation of propionibacterium (p.) acnes bacteria, resulting in a T-cell mediated anti-inflammatory response. It’s these collectively, which are hormonally driven, that give the various clinical manifestations of acne as we know it.13

There are many potential consequences of acne, such as scarring and post-inflammatory hyperpigmentation, which may be secondary to the inflammatory lesions or due to increased photosensitivity from retinoid therapy. Another consequence that is rarely discussed is acne’s impact on ageing of the skin. Inflammation leads to the presence of free radicals such as reactive oxygen species (ROS), which can have a deleterious effect on vital components such as telomerase, mitochondrial DNA and cell walls.14,15 The relationship between inflammation and ageing give us even more reason to successfully treat inflammatory acne in an individual.

Acne is almost always clinically diagnosed through history and medical examination. Practitioners must look for the presence of comedones, which may be open (black heads), or closed (white heads). There will usually be some papules – red spots – and pustules, which are spots containing puss; and in more severe cases, nodules, which are papules that are bigger than 1cm in diameter; and cysts, which affect the deeper layers of the skin.

There are more than 25 different grading systems for acne; I use the EU Acne Classification Scale, which grades from 1-4. Grade 1 involves comedonal acne, Grade 2 presents papules and pastules, Grade 3 is severe papulo-pustular that may or may not be combined with moderate nodular acne, and patients with Grade 4 will usually present with nodulo-cystic acne.13 It’s very important that the practitioner also completes a psychological assessment questionnaire to understand how the acne is impacting the patient, as it may have very strong psychological implications.

As acne is a huge topic, I will be focusing on my treatment methods for mild Grade 1-2 acne, which are the grades that medical aesthetic practitioners are likely to be treating. I have not covered topical therapy that a GP may prescribe.

When a patient presents to me in clinic, the first thing I do is ensure they are on a good skincare regime and introduce ingredients that will help with their overall skin health, as well as their acne. I am looking for ingredients such as java tea, which we know reduces 5-alpha reductase and sebum production16 and linseed extract, which is anti-inflammatory.17 Other ingredients that are good to help inhibit some of the enzymes or pathways that lead to the worsening of the acne include: oligopeptide 10, vitamin B3, B5 and salicylic acid. Hydration is a key aspect for acne, so I will always give them a good moisturiser and/or serum, as well as a cleanser – I use the AlumierMD Acne Clarifying Cleanser and Acne Balancing Serum. I will get patients to use skincare for at least six weeks, before considering in-clinic treatments. I would also ensure they do not overuse exfoliates and retinol or over-wash their skin.

In my clinic, the mainstay treatment for Grade 1-2 acne is four to six sessions of a salicylic acid, which is a beta hydroxy acid (BHA) skin peel. In moderate to severe cases I use a 30% salicylic acid peel by Enerpeel or Radiant 20/10 or Glow Peel by AlumierMD. Salicylic acid is fantastic because it’s a lipophilic acid, which is a small molecule that will drive down into the follicles and go into the sebum. It’s a comedolytic and it loosens the keratinocytes and unclogs the pores – I call it my ‘gutter cleaner’.

Of course, you can also use lasers; we have the Harmony XL Pro system (ClearSkin) that can give quite good results, however I usually prefer peels because they offer a more cost-effective treatment.

Every aesthetic practitioner needs to be confident in their acne diagnosis before treatment, and they must work like a detective to make an accurate diagnosis. Be honest with the patient and make it clear where the limits of your knowledge lie; if someone has mild acne, you can give them some good skincare that you know will help. If they require further treatment that is beyond your remit, or if you suspect a different condition, give them the details of a colleague you know can help.18

Summary

According to the practitioners interviewed for this article, the conditions discussed are common among patients who may present in aesthetic clinics, so clinicians should investigate such skin concerns thoroughly to ensure a correct diagnosis is made. The treatment approaches discussed are not the only possible methods, and each patient should be consulted and given treatment on an individual basis. Whether practitioners have the knowledge and experience to treat themselves or not, they should be true to their limitations and know when is best to refer if necessary.


References
  1. Health Committee, ‘Written evidence from the British Association of Dermatologists (LTC 89)’, 2014. <https://publications.parliament.uk/pa/ cm201415/cmselect/cmhealth/401/401vw78.htm>
  2. Julia Schofield, Douglas Grindlay, Hywel Williams, ‘SKIN CONDITIONS IN THE UK: a Health Care Needs Assessment’, Centre of Evidence Based Dermatology, University of Nottingham, 2009. <https://www.nottingham.ac.uk/research/groups/cebd/documents/ hcnaskinconditionsuk2009.pdf>
  3. Ann L. Marqueling, Amy E. Gilliam, Julie Prendiville, et al. ‘Keratosis Pilaris Rubra’, Arch Dermatol. 2006;142(12):1611-1616.
  4. <https://jamanetwork.com/journals/jamadermatology/fullarticle/410006>
  5. British Association of Dermatology, KERATOSIS PILARIS. <http://www.bad.org.uk/shared/get-file.ashx?id=217&itemtype=document>
  6. Amanda Oakley, ‘Keratosis Pilaris’, Derm Net New Zealand, 2015 <https://www.dermnetnz.org/topics/keratosis-pilaris/>
  7. NHS, Keratosis pilaris (‘chicken skin’), 2015. <https://www.nhs.uk/conditions/keratosis-pilaris/>
  8. British Association of Dermatology, ATYPICAL MOLE SYNDROME <http://www.bad.org.uk/shared/get-file. ashx?id=152&itemtype=document>
  9. Christopher Rowland Payne, Royal Society of Medicine, ‘2017 Stevens Lecture: Sun addiction and skin cancer’, 2017. <https://videos.rsm. ac.uk/video/2017-stevens-lecture-sun-addiction-and-skin-cancer>
  10. D. A. Burns, et al., Rook’s Textbook of Dermatology, 2010.
  11. British Association of Dermatology, ROSACEA. <https://www.bad.org.uk/shared/get-file.ashx?id=229&itemtype=document>
  12. Dr Amanda Oakley, Rosacea, DermNet New Zealand, <https://www.dermnetnz.org/topics/rosacea/>
  13. Rios-Yuil JM, Mercadillo-Perez P. Evaluation of Demodex folliculorum as a risk factor for the diagnosis of rosacea in skin biopsies. Mexico’s General Hospital (1975-2010). Indian J Dermatol2013;58:157.
  14. A. Nast , B Dréno , V Bettoli, Z. Bukvic Mokos et al., ‘European Evidence-based (S3) Guideline for the Treatment of Acne’, 2016. <http:// www.euroderm.org/edf/index.php/edf-guidelines/category/4-guidelines-acne>
  15. S Briganti, M Picardo, ‘Antioxidant activity, lipid peroxidation and skin diseases’, What’s new, 2003. <http://onlinelibrary.wiley.com/ doi/10.1046/j.1468-3083.2003.00751.x/full>
  16. Thornfeldt CR, ‘Chronic inflammation is etiology of extrinsic aging’, J Cosmet Dermatol, 2008.
  17. <https://www.ncbi.nlm.nih.gov/m/pubmed/18254816/>
  18. B. Vogelgesang & N. Abdul-Malak et al., ‘On the effects of a plant extract of Orthosiphon stamineus on sebum-related skin imperfections’, International Journal of Cosmetic Science, 2010. <http://onlinelibrary.wiley.com/doi/10.1111/j.1468-2494.2010.00581.x/full>
  19. Renata Dawid-Pać, Medicinal plants used in treatment of inflammatory skin diseases, Postepy Dermatol Alergol. 2013 Jun; 30(3): 170–177. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3834722/>
  20. British Association of Dermatology, ACNE, <http://www.bad.org.uk/shared/get-file.ashx?id=65&itemtype=document>

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