Medical Dermatology

General Skin Checks and Self-Monitoring

Self-Monitoring

• any crusty, non-healing sores/ulcers
• small lumps that are red, pale or pearly in colour
• new spots, freckles or any moles changing in colour, thickness or shape over a period of weeks to months (especially those dark brown to black, red or blue-black in colour).

• Asymmetry
• Irregular Border
• Uneven Colour
• Diameter (usually over 6 mm)
• Evolving (ie. changing and growing).

Pre-Cancerous Sun Spots (Solar Keratoses)

Sun spots or Solar keratoses are pre-cancerous lesions usually found on sun-exposed skin. They most commonly appear as single, scattered or clustered rough, scaly patches. Sun spots are warning signs: they indicate that your skin has been damaged by ultraviolet (UV) radiation from sun exposure, and that you may be at risk of developing skin cancers.

These spots can sometimes disappear with strict sun avoidance and regular sunscreen use, but most persist and can become uncomfortable and unsightly. Solar keratoses of the lower lip is known as Actinic Cheilitis.

A proportion of sun spots can develop into an invasive form of skin cancer called Squamous Cell Carcinoma (SCC). Progression to SCC may be indicated by growth, discomfort/tenderness, persistent ulceration or bleeding.

The appearance of sun spots can vary, even on the same person. Early sun spots can often be more easily felt than seen, as rough sandpaper-like patches on the skin. They can also be sensitive, with a burning or stinging feeling especially in hot weather. Sun spots may appear as:

• a flat or slightly raised, scaly, skin coloured, red or brown patch
• a thickened or warty area
• a small horny outgrowth

Treatment of sun spots

Cryotherapy: Liquid nitrogen is used to freeze and destroy the damaged skin cells. This is usually used for small numbers of sun spots. The procedure stings, and the treated area forms a welt or blister, which crusts and usually heals over a couple of weeks. There is a small risk of leaving (permanent) white scars.

Curettage and Cautery: This is performed after the injection of local anaesthetic, and involves scraping away the abnormal tissue and sealing the wound using an electric current. This may be used for thicker sun spots or when early skin cancer is suspected. The treated area looks a little like a graze, takes a few weeks to heal (longer on the legs), and can leave an obvious scar.

‘Field Treatments’: If you have lots of sun spots it may not be practical to treat each spot individually, so a range of treatments are used that are applied to the whole affected area. These types of treatments have the advantage of treating not only visible sun spots, but also early microscopic ones which are not yet visible to the naked eye.

• Topical chemotherapy. This utilises a chemotherapy drug used to treat a number of different cancers. When used as a cream, it is absorbed by pre-cancerous skin cells and leads to their destruction. The cream is usually applied twice a day for about 2–4 weeks. The treated areas slowly become red, swollen, crusted and uncomfortable before settling down after treatment is stopped. Some people can develop more prolonged redness after use. As the cream can make you more sun sensitive, treatment is often recommended in the cooler months of the year.
• Topical immunotherapy. This works by stimulating the skin’s own immune system to attack and selectively destroy sun-damaged cells as well as reducing the occurrence of new sun spots. A cream is applied to affected skin according to your doctor’s instructions, usually 3 times a week for a period of 4 weeks. Your doctor then assesses the results and decides if another cycle of treatment is necessary. The reaction to this treatment varies from person to person, and most people experience some degree of inflammation of the skin with redness, scaling and crusting.
• Anti-inflammatory gel. This is a non-steroidal anti-inflammatory drug (NSAID) that interferes with the development of sun spots. The gel is usually applied to the skin twice daily for 3 months. Most people develop few side effects, apart from some scaling and flaking. While this form of therapy has the advantage of minimal ‘down time’, the long treatment period can be a problem, and longer term cure rates are not yet known.
• Photodynamic therapy (PDT). A cream containing a light-sensitising chemical is applied to the affected area and accumulates in sun damaged cells. These cells are then destroyed when the chemical is ‘activated’ after exposing the skin to a bright light source several hours later. The treatment can be quite painful. The treated area develops an uncomfortable ‘burn’: the area reddens, can blister, peel and become crusted while healing over about 2 weeks. Daylight PDT is a variation of this which utilises natural daylight rather than a light source to activate the chemical, and is particularly useful for treating facial sun spots.
• Laser and chemical peels can occasionally be used. There have been some recent studies using the Fraxel™ re:store laser for treatment of sun spots. Laser treatment is generally the treatment of choice for actinic cheilitis of the lower lip.

How can I help prevent sun spots developing?

Skin Cancers

They can offer you an extensive range of treatments varying from conventional surgical therapies to newer topical treatment modalities where appropriate.

The best option will vary from person to person and will be individually tailored depending on the size, site and type of skin cancer.

Skin Cancer

Skin cancers can be broadly divided into non-melanoma skin cancers (NMSC) and malignant melanoma (MM). The commonest forms of NMSC are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

Fair-skinned Australians are at highest risk of developing both NMSC and MM, with exposure to sunlight in childhood and adolescence being a major risk factor. The risk of MM increases greatly with repeated episodes of sunburn, particularly if they occur before adulthood. Also at risk are people who have fair skin, increased numbers of unusual moles (dysplastic naevi), depressed immune systems, and a family or past history of MM. However, persistent moderate sun exposure over time increases the risks of both NMSC and MM.

Types of Skin Cancer

1. Basal Cell Carcinoma (BCC): BCCs are the most common and least worrying type of skin cancer. They arise from cells in the lower part (basal layer) of the upper layer of the skin (epidermis) and tend to grow slowly. BCCs are most common on the face, head, neck and trunk regions. Nodular BCCs usually appear as a non-healing pimple-like lump, which may intermittently bleed, form an ulcer or scab. Superficial BCCs can appear as a red, scaly patch. The less common morphoeic or infiltrating BCCs can be subtle, appearing as a scar-like or shiny plaque on the skin. BCCs are locally destructive but are generally easily treated in their early stages. If left untreated they can grow and destroy adjoining structures, although they rarely spread throughout the body (metastasize).

2. Squamous Cell Carcinoma (SCC) SCCs are the second most common form of skin cancer. They tend to grow much faster than BCCs and most commonly occur on sun-exposed areas such as the face, ears, scalp, lips and backs of the hands. They can occasionally metastasize. SCCs often appear as a fast-growing pink lump, or wart-like growth, which may have a central crater. They may also break down, crust, bleed and ulcerate. Occasionally they may be tender, or cause a burning or stinging sensation. People who have had organ transplants, or are immunosuppressed for other reasons, are at higher risk of developing SCCs. Regular skin checks are particularly important in these groups because if an SCC does occur it can behave more aggressively, making treatment more difficult. Bowen's Disease (SCC in situ) is an SCC which has not spread beyond the epidermis (the first layer of skin). They have no risk of spreading to other sites but can develop into an invasive SCC if left untreated. They are usually red, scaly patches and are quite common on lower legs and feet.

3. Malignant Melanoma (MM)

MMs are less common than BCCs and SCCs, but are much more dangerous. Australia has the world's highest incidence of melanoma and more than 1200 people die from melanoma each year. Like SCCs and BCCs, melanomas can occur on sun-exposed skin, but they also occur on skin that is usually covered, but has been sunburnt in the past. Malignant melanomas may metastasize and cause death. Most MM start as a new, often dark spot that continues to change. They may also occur in moles which may have been present for years but then change their appearance. Most melanomas are usually asymptomatic, though uncommonly present with itch, or bleeding in the absence of trauma.

Skin Cancer Treatment

Several types of skin cancer treatment are now available, ranging from surgical options to creams and light treatments. Your Dermatologist will advise you on the different types of treatments that may be suitable for you depending on the type, site, size and depth of your skin cancer.

Dermatologic Surgery

Mohs’ Surgery

Topical Immunotherapy

Curettage and Cautery

Topical chemotherapy

Photodynamic therapy (PDT). A cream containing a light-sensitising chemical is applied to the affected area and accumulates in cancerous cells. These cells are then destroyed when the chemical is ‘activated’ after exposing the skin to a bright light source several hours later. The treatment can be quite painful and the area develops an uncomfortable ‘burn’: the area reddens, can blister, peel and become crusted while healing over about 2 weeks. 2 treatments are generally required. It is only suitable for some superficial skin cancers and cure rates are much lower than other modalities. There have been some concerning reports of more aggressive skin cancers developing in treated areas.

Excessive Sweating (Hyperhidrosis)

A Medicare rebate may be available for patients who have failed treatment with Driclor deodorant if treated by a Medicare-approved specialist. Dr Michelle Hunt and Dr Andrew Ming are approved to treat patients with severe underarm sweating under this scheme. This dramatically reduces out-of-pocket costs for patients, who can have up to 3 treatments a year.

Acne and Acne Scarring

Acne is a common disorder of the oil or sebaceous glands, which causes pimples. It occurs when the openings to the oil glands (pores) become blocked, allowing a build up of oil and bacteria, and subsequent inflammation. The clinical features vary from person to person and can include blackheads, whiteheads, pustules and/or nodules or cysts. Acne generally occurs in areas where there is a high concentration of oil glands ie. the face, chest, upper back, shoulders, neck. Although acne is most commonly seen in teenagers, it can affect people of all ages.

Acne can be triggered by hormonal changes during puberty, pregnancy or the menstrual cycle. However, acne an also be aggravated by stress, some medications, make-ups or face creams, and other external or environmental factors. Genetics also plays a role, as acne often runs in families. The role of diet has always been controversial but some studies have shown a reduction in acne in patients consuming a low GI (glycaemic index) diet.

Treatment

Anti acne cleansers

Topical treatments

• Benzoyl peroxide
• Topical antibiotics
• Vitamin A analogue creams
• Azelaic acid

Oral medications

• Oral antibiotics. These are used for their anti-bacterial and anti-inflammatory effects. It generally takes up to 2 months to see a result and most patients need to stay on these medications for at least 6 months.
• Hormonal treatment. In some women certain oral contraceptive pills and other anti-androgen hormones can be useful in controlling acne.
• Oral retinoids (vitamin A analogues)
. These are generally reserved for patients with severe acne, or those who have failed other oral therapies. They work by shrinking the oil glands, thus reducing the production of oil and pore blockage, and the development of new acne lesions. They can only be prescribed by Dermatologists and some specialist GPs, and require regular monitoring.

Acne scarring

Treatment

Your Dermatologist will recommend a treatment plan that is tailored to your particular skin type and scarring.

Treatments include:

Cortisone injections

Subcision

Fractional Laser

Fractional Radiofrequency

Punch excisions

Fillers

Rosacea

Rosacea is a chronic condition that primarily affects the central face. It is characterized by

• a tendency to flush and blush
• facial redness
• broken capillaries
• episodes of inflammation (resulting in pimple-like spots)
• swelling, which can be intermittent or persistent

The cause of rosacea is unknown. Although various theories have implicated bacteria, mites, a fungus, a disturbance of connective tissue under the skin, or psychological factors, none have been proven. It seems likely that there is no single cause of rosacea and that it develops in individuals who are susceptible due to a variety of factors such as heredity, skin colour, skin structure, and immune response.

Factors that can aggravate rosacea include:

• hot liquids
• alcoholic beverages
• spicy foods
• sun exposure
• extremes of temperature
• exercise
• emotional influences
• certain medications

Treatment

Generally, only gentle cleansers and moisturisers should be used on the face, in combination with a low irritant sunscreen. Agents containing alcohol or other irritating ingredients should be avoided.

Topical Agents: The most commonly used topical preparations are antibacterial agents, azelaiec acid or botanical extracts, which are generally applied twice daily to to a clean, dry face. Topical medications usually produce some improvement within three to four weeks, but may take up to two months to show maximum improvement. Vasoconstricting agents: When applied to the skin, these cause surface blood vessels to constrict, resulting in a reduction in facial redness which generally lasts 12 hours.

Oral Agents: The tetracycline group of antibiotics is most commonly used. Oral medications are usually taken once or twice daily and tend to produce results more quickly than topical medications, but usually need to be taken for several weeks to months. Some patients require low-dose maintenance therapy.

Laser and Light: Vascular lasers (such as Vbeam® Perfecta Pulsed Dye Laser) and BroadBand Light (BBL) can be used to eliminate redness and broken capillaries, reduce pore size and improve skin texture. However, these changes can recur over time (generally years), particularly if flushing triggers are not avoided.

Resurfacing or Fractional lasers or surgery can also be used to correct the nose enlargement in people with rhinophyma.

Eczema

Different forms of eczema exist including atopic eczema, discoid eczema, eczema craquele, venous eczema and irritant or allergic contact dermatitis. They are usually distinguished based on the history, clinical appearance, age of onset and the areas affected. Atopic eczema often begins in childhood, and may improve or even disappear as children get older. It classically affects the face, neck and creases of the elbows and knees. In younger children though, the location of eczema can be quite different.

The exact cause of eczema is unknown, however genetic factors play a role as it often runs in families. Patients with eczema have a problem with their skin barrier function. Not only is water lost from the skin leaving it dry and scaly, but the skin is vulnerable to irritants, allergens and infections. The use of regular moisturizers is therefore crucial in the management of eczema.

In addition to problems with the skin barrier function, there is an imbalance of the skin’s immune system. Often there is a history of atopy i.e. eczema, asthma or hayfever, as well as other allergies in the patient or family members.

There are a number of recognized factors that can trigger or exacerbate eczema and these include house dust mite, moulds, pet fur, changes in weather or humidity, soaps and shampoos, other irritants (including cosmetics chemicals, perfumes, grasses, pollens, sand, harsh clothing such as wool), and sometimes certain foods or stress.

Treatment

• Avoid Irritants: protect the skin from exposure to water and detergents, chemicals, dust etc
• Bathing: avoid long hot showers (use lukewarm water) or prolonged baths. Uses a soap-free wash instead of soap, or bath oil
• Clothing: wear soft, breathable fabrics. Avoid rough fabrics such as wool and some synthetics
• Moisturisers: apply perfume-free creams or ointments liberally and often, especially after showering or swimming
• Steroid creams and ointments: these may be prescribed by your Dermatologist and applied to the affected patches of skin to reduce inflammation and itching. Providing they are used as instructed they are perfectly safe, even for baby’s skin
• Other prescription anti-inflammatory creams: can sometimes be used instead of topical steroids
• Antibiotics: these may be prescribed by your Dermatologist if your eczema is infected (most commonly due to Staphylococcus Aureus)
• Anti-Histamines: these may be used to help reduce itching
• Wet dressings: wet bandages are often used in combination with moisturisers and steroid creams to help soothe the skin
• Other: more severe cases of eczema may require light treatment (phototherapy) or stronger oral medications

Psoriasis

Psoriasis can start at any age including childhood, but is most common in adulthood. It affects males and females equally and about one third of patients have a family history of the condition. Although genetic factors are important, the disease is thought to be an inflammatory disorder related to 'over-activation' of the immune system.

Psoriasis most commonly presents as symmetrical red, scaly patches and plaques on the elbows, knees, lower back and scalp, although any part of the skin can be involved including the palms and soles, skin creases and genital area. It can also affect the nails, and occasionally the joints (psoriatic arthritis).

There are several different types of psoriasis, which vary in their appearance. These include:

• Scalp psoriasis: often the first or only affected area
• Chronic plaque psoriasis: red patches and plaques of varying sizes appear and usually have a silvery white scale. This type can occur anywhere on the skin but commonly affects the elbows, knees, scalp and lower back
• Acute guttate psoriasis: widespread, small plaques appear on the trunk and limbs, often following a Strep throat infection
• Flexural or inverse psoriasis: shiny, red and sometimes fissured and painful patches affect the skin folds (armpits, groin creases, under the breasts, genitals and buttocks). Sometimes the areas become secondarily infected with Candida
• Pustular psoriasis: multiple small red pustules appear on the skin, often associated with other symptoms such as fevers and pain
• Palmoplantar psoriasis: affects the palms and or soles, and is often associated with thickening of the skin and painful fissures
• Nail psoriasis: pitting, ridging, discolouration and lifting of the nails can occur

Treatment

• Mositurisers: to reduce skin dryness and scaling
• Tar based or other medicated shampoos
• Creams, ointments or lotions prescribed by your Dermatologist: these may include tar based preparations, Vitamin D analogues, topical steroids and other anti-inflammatory creams
• Phototherapy (light therapy) such as Narrow Band UVB
• Oral medicines for more severe psoriasis
• Biologics: a relatively new type of treatment generally given my injection and reserved for patients with conventional treatment-resistant psoriasis

Paediatric Dermatology