Understanding Dermatology Conditions

01 Feb 2020

Journalist Allie Anderson speaks to dermatologists about the procedures and methods they have successfully used to treat dermatology cases

The skin is the largest organ of the body, so treatment of dermatological conditions is a vast area. Moreover, when the skin is not at its best it can significantly impact the quality of life of patients. Many minor, everyday skin complaints can be successfully addressed in a conventional aesthetic clinic, while others – like many discussed in this article – are referred to a consultant dermatologist.

This article delves into some interesting dermatology cases that have been successfully treated, educating practitioners about the skin condition and how patients are managed. Note that when it comes to dermatology, practitioners need to recognise when the case is outside their remit and refer to an appropriate consultant

Folliculitis

Consultant dermatologist Dr Daron Seukeran specialises in laser surgery. He has successfully used lasers to treat folliculitis in amputees. Folliculitis is a condition in which the hair follicles become inflamed, resulting in clusters of small, red bumps or white pimples around hair follicles. These can develop into pus-filled blisters and can be itchy and painful.1 It is frequently caused by bacterial or fungal infection or physical irritation, for example in patients who shave their beards, with skin occlusion being a risk factor.2 According to Dr Seukeran, this makes it a common complaint among amputees – particularly lower-limb amputees – who wear a prosthesis. It is estimated that around 70-75% of lower-limb amputees experience skin problems related to using a prosthesis.3,4 

“Patients often still get hair growth around their stump, particularly on the leg,” explains Dr Seukeran. However, he says, “The occlusive effect of the prosthesis, where it comes into contact with the skin of the stump, can cause irritation, which leads to inflammation of the hair follicles. The problem can be exacerbated with constant use of the prosthesis, with the stump subject to pressure and rubbing against the weight-bearing prosthesis, resulting in discomfort that can be severe. Therefore, patients can’t wear their prosthesis for the length of time they might want to, and, for these people, it can have a major impact on their day-to-day life.” Laser hair removal therapy has been demonstrated to yield a marked improvement in folliculitis,5 with a significant decrease in hair density (and thus, gravity of symptoms). Exacerbations of the disease at follow-up are also reduced after treatment with an alexandrite laser6 – Dr Seukeran’s tool of choice in this patient cohort. During the initial consultation, he establishes the severity, frequency and factors that worsen the patient’s symptoms, and what treatments they have tried. “Often, they’ll have used remedies like shaving and depilatory creams, which can themselves cause irritation and the hair grows back quickly,” Dr Seukeran comments. “The advantage of lasers is that, even though sometimes the hair may come back, you get long periods with no hair growth and if the hair returns, it’s thinner and less prone to folliculitis,” he explains. In this case study (Figure 1), Dr Seukeran used an alexandrite laser with a wavelength of 755 nanometres (nm) and fluence of 16-22 joules per square centimetre (J/cm2). An 18mm spot size enabled each pulse to target a relatively large area, with fewer pulses needed to treat the whole area of affected skin, meaning each session was just 15 minutes long. Performed at four-to-six-week intervals, the treatment was completed over a four-month period.

Dr Seukeran adds, “In general, it’s fast, comfortable and well-tolerated; and, because there is no breaking of the skin, there’s no wound care. Although, we do recommend patients use a little moisturiser or aloe vera gel immediately after the treatment.”

Some patients, Dr Seukeran says, experience slight redness, but it’s typically asymptomatic and transient at the time of the treatment, so patients can wear their prosthesis straight away. Longer-term risks include pain, tenderness, crusting, blistering, swelling, scarring and infection, although all are rare.7

Figure 1: Patient presenting with folliculitis before and four months after four laser hair removal treatments using Candela Gentlelase alexandrite laser.

Pilonidal sinus

Dr Seukeran also treats patients with the very rare and complex skin condition, pilonidal sinus. Again, laser hair removal has yielded positive results. Pilonidal describes a chronic skin disease of the natal cleft; the deep crease between the buttocks that runs between just below the sacrum to the perineum. Dr Seukeran explains it is thought to be caused by inflammation and infection of the hair follicles in the cleft, where skin debris can accumulate and worsen the problem. Men are more commonly affected than women.8 

Dr Seukeran says most patients will develop a pilonidal sinus where a narrow cavity (known as a sinus tract) extends from beneath the skin where there is inflammation and infection, through the soft tissue to the skin’s surface around the coccyx. A painful abscess with foul-smelling discharge can form, he explains.9 “Patients will often have had multiple courses of antibiotics to treat a pilonidal sinus and that may lead to partial improvement, but the tissue quickly breaks down again,” notes Dr Seukeran. He adds that some patients have surgery to remove the abscess and cut out the sinus tract, with the area being allowed to heal by secondary intention – where the wound is left open. However, he highlights that surgical intervention is associated with a 40-60% recurrence rate, and secondary intention carries a risk of post-operative infection and healing time of up to 10 weeks.10 Where hair continues to grow in the natal cleft, it can trap faeces and other debris and proliferate bacteria spread. Thus, he says, “The need to eliminate a nidus of inflammation/infection and provide hair-free wound and peri-wound skin cannot be overstated.”10 Dr Seukeran explains that, “Because persistent hair growth in this area contributes to the development of the problem, permanent hair removal with lasers, often in addition to surgery, can be helpful.”5 

The initial consultation would comprise a full medical history, examination of the area and discussion of the symptoms and their impact on the patient’s life in terms of pain and discomfort. “I would also ask whether they’ve had previous treatments and how effective they were,” Dr Seukeran says. To treat the patient in Figure 2, Dr Seukeran used the same parameters as with the folliculitis patient: an alexandrite laser at 16-20 J/cm2 fluence with an 18mm spot size, in order to cover the affected area quickly. “If the hairs are stubborn and a patient doesn’t respond to the standard laser, or if we don’t achieve the results we want, then we can use a different type of laser, such as a long-pulsed Nd:YAG laser, which gives a deeper penetration to impact the hair more effectively,” Dr Seukeran comments. 

Figure 2: Patient presenting with pilonidal sinus before and approximately seven months after seven laser hair removal treatments using the Candela Gentlelase alexandrite laser.

According to Dr Seukeran, this laser type is also considered the most effective for patients with darker or tanned skin, owing to its longer wavelength (1064 nm).11,12 While no specific pre- or post-procedural care is required, the pilonidal sinus must be free from infection for laser treatment to take place Dr Seukeran states. “If there was any concern about infection, we would take wound swabs beforehand and treat accordingly,” he says, adding, “The most important thing is to reassure the patient that it can be treated successfully, but it’s going to take multiple treatments to heal.” For this case study, seven treatments over several months were necessary. He says, “The patient is still undergoing treatment, but they are now asymptomatic with no discharge of pain. It should be noted that there is always risk of recurrence.” Post-procedural effects can include blistering, crusting and localised pain, which can be minimised with topical or local anaesthetic. Generally, lasers are an effective and well-tolerated treatment for pilonidal sinus, according to Dr Seukeran, resulting in healing of problematic and treatment-resistant cases, and improved quality of life for patients.5

Acne

Among other specialties, consultant dermatologist Dr Nicole Chiang offers comprehensive and personalised treatment plans for patients with acne. For those with persistent and scarring acne, her approach is to use oral isotretinoin. Dr Chiang says acne is a skin condition driven by three main factors:13

  1. Overactive sebaceous glands, which are usually triggered by hormones – hence acne usually begins at puberty.
  2. Follicular hyperkeratosis, whereby the pores become clogged by a build-up of dead skin cells that aren’t shed properly.
  3. Overgrowth of Propionibacterium acne (P-acne) bacteria on the skin, which multiply due to excess oil production caused by over activity of the sebaceous glands.
Figure 3: Patient presenting with acne before and 10 months after treatment using oral isotretinoin.

“Acne can present as blackheads and whiteheads, red spots known as papules, and yellow spots known as pustules, or large, painful nodules or cysts,” Dr Chiang explains. “When patients have severe acne, they often have scarring too. But before carrying out any aesthetic treatments for the scarring, we need to address the acne itself,” she states. 

The patient in Figure 3 had experienced severe acne for 10 years, and in that time, he had tried numerous topical treatments and several courses of oral antibiotics that had limited long-term success. As a result, the patient had also begun to develop scarring. As well as a full clinical assessment, Dr Chiang’s consultation entails establishing the impact the patient’s acne has on their quality of life, which – as is common with severe dermatological conditions – was significant. “In this patient, I recommended a course of oral isotretinoin. This is the most effective treatment for severe acne accompanied by scarring and in many cases, it’s the only treatment option unless there are contraindications,” Dr Chiang says. A 2019 literature review suggested that the use of isotretinoin in patients with acne might increase the risk of depression,14 so Dr Chiang advises clinicians to exercise caution in patients with active or historical depression. Dr Chiang explains that isotretinoin works by targeting the pilosebaceous unit, a structure of the skin comprising hair; the hair follicle, small muscles attached to the hair follicles; and the sebaceous gland. It shrinks the sebaceous glands, reduces sebum production, limits follicular occlusion and inhibits the growth of bacteria, as well as having anti-inflammatory properties.15 “This leads to a reduction in blackheads, whiteheads and clogged pores,” adds Dr Chiang.

The treatment course length and doses are determined by the severity of the patient’s condition at baseline and how they respond over time. This patient took one isotretinoin tablet each day for 10 months, beginning with a low dose of 20mg and gradually increasing to 60mg a day. “His acne cleared to a level he was happy with in around eight months, but because it was so severe to begin with, we continued with the treatment for two more months to reduce the risk of relapse,” Dr Chiang comments. Most cases of acne clear in a single course or treatment, and long-term remission can be achieved in 70-80% of cases,16 Dr Chiang says. Blood tests are taken before starting treatment and at regular intervals throughout to check kidney and liver function, to ensure the patient can metabolise and excrete the isotretinoin, says Dr Chiang. Because the medication is teratogenic, she highlights that treatment must be stopped if a female patient falls pregnant. “This is a very effective treatment for acne, but it’s important to manage a patient’s expectations from the beginning,” Dr Chiang concludes, adding, “We must establish the end point the patient hopes to reach in terms of skin clearance, and make sure they understand how long the treatment is likely to last.”

Acne scarring

Dr Firas Al-Niaimi is a consultant dermatologist who regularly treats patients with scarring caused by acne. He offers a number of different treatments for this condition and his approach is determined on a case-by-case basis. Acne scarring is a relatively common problem that often results from very aggressive acne, or less severe acne that isn’t properly treated. “It mostly presents on the face and it can have a huge impact on the psychological wellbeing of patients, who tend to be very self-conscious of their scars,” explains Dr Al-Niaimi. “Successful treatment is dependent on accurately describing the type and the severity of the scarring – that will dictate the type of treatment and the prognosis,” he adds.

Dr Al-Niaimi explains that acne scarring can be classed as either atrophic, where there is loss of tissue or damage to the collagen; or hypertrophic, in which there is thickening of the tissue. Acne scarring on the face normally has an indented appearance, and is thus atrophic in nature. He says that this type of scarring can be subcategorised as:17

  • Boxcar scars – broad indentations with sharply defined edges
  • Ice-pick scars – deep, narrow, pitted scars
  • Rolling scars – broad indentations with sloping edges

Dr Al-Niaimi points out that grading the severity of acne scarring is subjective, with different clinicians using different scales. “In general, the more extensive the scars are, the deeper and more visible they are from a social distance and the more shadows you see, the higher the severity grading,” he comments, emphasising, “The less visible the scars, and the closer you have to come for the scarring to be visible, the milder the severity.” This particular case study in question (Figure 4) had severe, atrophic rolling scars, and on that basis and following a full medical consultation, Dr Al-Niaimi recommended surgical subcision in the first instance, followed by volume replacement with injectable fillers to correct the collagen loss. 

Figure 4: Patient presenting with acne scarring before and four months after treatment using subcutaneous surgical subcision and Sculptra poly-L-lactic acid filler.

With this type of scarring, Dr Al-Niaimi explains that the scars are tethered to the underlying subcutaneous layer by strands of tissue, which pull on the dermis and give each scar its dipped, hollow appearance. Surgical subcision entails inserting a needle through a puncture in the skin and cutting the fibrous strands underneath the skin’s surface. In doing so, the tether is released, and the indentation is lifted.18 

“I use an advanced technique, where through a single needle entry point, I inject tumescent anaesthesia to expand the subcutaneous layer between the dermis and the fascia. This creates an inflated area that allows for enhanced safety and erects the strands of the scars to keep them under tension,” says Dr Al-Niaimi. At this point, Dr Al-Niaimi makes a 4-5mm incision in the side of the cheek and inserts a long surgical cutting instrument underneath the skin, to subcise the strands of the scars in the entire affected area. He highlights, “It’s a complex procedure that requires skill and thorough understanding of the anatomy to ensure you don’t go too deep or too superficial, but rather along the right plane.” The technique usually takes around an hour and is performed under light sedation. Some transient post-procedure swelling, bruising and pain can be expected, and most patients report significant improvement of the appearance of scarring.19 However, it’s not uncommon for a degree of dipping to remain, Dr Al-Niaimi states. For this reason, Dr Al-Niaimi explains surgical subcision is often combined with other treatments for maximum efficacy.18,20 

In this patient, Dr Al-Niaimi recommended an injectable poly-L-lactic acid filler (Sculptra) to stimulate collagen production and restore volume. “I know from experience that subcision alone is not sufficient for severe rolling acne scars, but together with this filler, it can give very good results,” he says. The patient underwent both treatments on the same day, requiring a single anaesthetic and just one trip to the clinic. Alternatively, Dr Al-Niaimi explains that the filler treatment can be performed six-to-eight weeks after the subcision, and follow-up treatments at six-to-eight-week intervals as required; although, this particular patient did not need any subsequent injectables. Dr Al-Niaimi highlights that swelling, bruising, redness, pain and tenderness can occur,21 following surgical subcision, and a small minority of patients can develop nodules after the filler,22 which can be prevented or managed with gentle massage of the area.

Psoriasis

Dr Sandeep Cliff is a consultant dermatologist and dermatological surgeon. Among the various treatments he prescribes for patients with psoriasis is a topical agent that combines corticosteroids and vitamin D analogue, called Enstilar. The inflammatory skin condition psoriasis often presents from young adulthood and affects around 2.2% of the UK population.23 “It’s a symmetrical rash that presents equally on both sides of the body, typically on the elbows and knees,” 

Dr Cliff explains, adding, “It can also affect individual parts of the skin like the scalp, nails, face and chest, and it can be extremely itchy and sore because the skin cracks. It can sometimes bleed, and it can be very embarrassing and affect a patient’s personal life.” Dr Cliff says that typically, psoriasis is marked by patches of red, thick scaly skin that has a silvery appearance. If it’s correctly diagnosed and appropriately treated, patients very often respond well. In order to confirm psoriasis, Dr Cliff explains that it’s important to examine all of the skin – not just the affected areas – to identify the pattern and distribution of the rash and rule out other conditions. “Quite often, patients will have tried other treatments that haven’t worked, so it’s important to ask them to score the severity of the condition, with zero being very clear and 10 being awful,” Dr Cliff says. “While I may score it a one or two, they might score it an eight or nine because, although it may not be very severe or affect a large area, it might stop them from doing certain things and affect them quite badly,” he adds.

So, the consultation should ascertain the patient’s hopes for treatment and what they would like to be able to do – for example, go swimming or wear dark clothes without the skin flaking. He describes a case which demonstrates that not only is it essential to find the right treatment, but the regime must be followed to the letter in order for it to be effective, highlights Dr Cliff. The patient had previously been prescribed Enstilar, a topical foam that combines the active ingredients calcipotriene (a vitamin D analogue) and the corticosteroid betamethasone dipropionate.24

“This is very effective if it’s used properly, but this patient had used it very sparingly and not regularly enough,” Dr Cliff recalls. So, he explains, the medication was restarted. The patient was instructed to apply the foam liberally to the affected areas of skin before going to bed, and to leave it to absorb overnight. After a four-week course, the psoriasis had cleared considerably; the thick, scaly patches had flattened and smoothed and the redness had subsided. In cases where the first-line treatments don’t yield satisfactory results, Dr Cliff says the next steps might be a course of medical sunbeds, whereby the skin is exposed to controlled doses of ultraviolet light for 10-minute sessions a few times a week. Other options are methotrexate, a medication that binds to and inhibits an enzyme involved in the rapid growth of skin cells, and cyclosporine, which stops the growth of immune cells.25 

According to Dr Cliff, it’s essential to address lifestyle and (where applicable) to advise patients to avoid excessive alcohol consumption, give up smoking, maintain a healthy weight, take part in physical activity and have their cardiovascular risk assessed.22 “Managing expectations is important,” says Dr Cliff, adding, “We can’t cure psoriasis, but for most patients it’s a question of management and achieving clearance to the point they are happy with. As clinicians, our job is to try and match those aspirations realistically and pragmatically.”

Summary

People with skin conditions will often present in the first instance to an aesthetic clinic, sometimes seeking help for complaints that have resisted treatment. It’s essential to acknowledge the limitations of aesthetic treatments, and to refer on to a consultant dermatologist for medical care where required. Interviewees highlight that the success of any dermatological treatment should be measured according to the hoped-for end goal – and that must be determined by the patient, with guidance from their clinician.

Board-certified dermatologist and Aesthetics journal Clinical Advisory Board member Dr Stefanie Williams highlights, “Dermatology patients may present to aesthetic clinics. However, it is essential to acknowledge that these skin conditions are in fact medical issues that should be referred for prescription treatment. The acne patient mentioned in this article who was successfully treated with oral isotretinoin and the psoriasis patient treated with a prescription combination of a topical vitamin D analogue and corticosteroid are perfect examples of this. My recommendation is to refer patients with dermatological conditions to a dermatologist, rather than delaying their treatment by attempting aesthetic procedures.”

References
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  2. Knott, L. Folliculitis. December 2017. Accessed at www.patient.info/doctor/folliculitis-pro 17 January 2020
  3. Baars, EC et al. Skin problems of the stump and hand function in lower limb amputees: A historic cohort study. Prosthet Orthot Int. 2008 Jun;32(2):179-85.
  4. Highsmith, MJ et al. Identifying and Managing Skin Issues With Lower-Limb Prosthetic Use. In Motion, Volume 21, Issue 1 January/February 2011.
  5. Aleem S, Majid I. Unconventional Uses of Laser Hair Removal: A Review. J Cutan Aesthet Surg. 2019;12(1):8–16.
  6. Koch D, Pratsou P, Szczecinska W, Lanigan S, Abdullah A. The diverse application of laser hair removal therapy: a tertiary laser unit’s experience with less common indications and a literature overview. Lasers Med Sci. 2015;30:453–67.
  7. NHS.uk, Laser hair removal, September 2019. <https://www.nhs.uk/conditions/cosmetic-procedures/laserhair-removal/>
  8. Webdale M et al, Department of Colorectal Surgery Pilonidal Sinus Operation, Norfolk and Norwich University Hospitals NHS Trust, August 2017.
  9. ASCRS, Pilonidal Disease, American Society of Colon and Rectal Surgeons. <www.fascrs.org/patients/disease-condition/pilonidal-disease>
  10. Harris CL et al, Twelve Common Mistakes in Pilonidal Sinus Care, Advances in Skin & Wound Care: July 2012 - Volume 25 - Issue 7 - p 324–332.
  11. Lorenz S et al, Hair removal with the long pulsed Nd:YAG laser: a prospective study with one year follow-up. Lasers Surg Med. 2002;30(2):127-34.
  12. Mittal R et al, Evaluation of Long-pulsed 1064 nm Nd:YAG Laser-assisted Hair Removal vs Multiple Treatment Sessions and Different Hair Types in Indian Patients. J Cutan Aesthet Surg. 2008;1(2):75–79.
  13. Oakley A, What causes acne? June 2014, DermNET NZ. <www.dermnetnz.org/topics/what-causes-acne/>
  14. Li C et al, Use of isotretinoin and risk of depression in patients with acne: a systematic review and meta-analysis. BMJ Open 2019;9:e021549.
  15. Oakley A et al, Isotretinoin, February 2016, DermNET NZ. <www.dermnetnz.org/topics/isotretinoin/>
  16. Rademaker M, Isotretinoin: dose, duration and relapse. What does 30 years of usage tell us? Australas J Dermatol. 2013 Aug;54(3):157-62.
  17. Oakley A, Acne scarring, June 2014, DermNET NZ, <www.dermnetnz.org/topics/acne-scarring/>
  18. Chandrashekar B et al. Acne scar subcision. J Cutan Aesthet Surg. 2010;3(2):125–126.
  19. Alam M et al, Subcision for Acne Scarring: Technique and Outcomes in 40 Patients. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 31. 310-7; discussion 317.
  20. Bayat A et al. Skin scarring. BMJ. 2003;326(7380):88–92.
  21. Santos-Longhurst A, Will Sculptra Effectively Rejuvenate My Skin? Healthline, June 2018. <www.healthline.com/health/sculptra#risks-and-side-effects>
  22. Chen H et al. Quantitative Assessment of the Longevity of Poly-L-Lactic Acid as a Volumizing Filler Using 3-Dimensional Photography. JAMA Facial Plast Surg. 2015;17(1):39–43. Accessed at www.jamanetwork.com/journals/jamafacialplasticsurgery/fullarticle/1917535 17 January 2020
  23. National Institute of Health and Care Excellence, Psoriasis: assessment and management, Clinical guideline [CG153], September 2017. <www.nice.org.uk/guidance/cg153/chapter/Introduction>
  24.  Leavitt M, New topical foam reduces itch, improves skin, National Psoriasis Foundation, December 2015. <www.psoriasis.org/advance/topical-foam-improves-itch-clears-skin>
  25. National Psoriasis Foundation, Systemic Medications: Methotrexate. <www.psoriasis.org/aboutpsoriasis/treatments/systemics/methotrexate>

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