SkinFoto BETTER SKIN THROUGH TECHNOLOGY

What is this section about?

This section provides a wealth of information about each of the conditions skinfoto can analyze, so that you can learn about your condition and perhaps get a better understanding about how to treat it.

SCARS: What is it?

A scar is a permanent patch of skin that grows over a wound. It forms when the body heals itself after a cut, scrape, burn or sore. Scars also appear after surgery that cuts through the skin, infections like chickenpox, or skin conditions like acne. Scars may be depressed (atrophic) or raised (hypertrophic and keloids).

A total of 100 million patients develop scars in the developed world alone each year as a result of 55 million elective operations and 25 million operations after trauma.

SCARS: Causes

Scars form when the dermis (deep, thick layer of skin) is damaged. The body forms new collagen fibers (a naturally occurring protein in the body) to mend the damage, resulting in a scar. The new scar tissue will have a different texture and quality than the surrounding tissue. Scars form after a wound is completely healed.

There are different kinds of scars:

Atrophic: This kind of scarring occurs when underlying structures supporting the skin (for example, fat or muscle) are lost. Some surgical scars have this appearance, as do some scars from acne. Some atrophic scar may appear when the skin stretches rapidly (for example, as in growth spurts or during pregnancy). In addition, this type of scar can occur when the skin is under tension (near a joint, for example) during the healing process.

Hypertrophic or Keloids: The body produces too much collagen resulting in raised scars called hypertrophic scars or keloid scars. Keloid scars result from an overproduction of collagen that grows beyond the margins of the original wound. Both types of scars are more common in younger and dark-skinned people.

SCARS: Signs and Symptoms

Atrophic: Atrophic scars may be flat and pale. Some atrophic scars can have a sunken or pitted appearance. This kind of scarring occurs when underlying structures supporting the skin (for example, fat or muscle) are lost. Some surgical scars have this appearance, as do some scars from acne. Some atrophic scars also can appear as stretched skin. Such scars result when the skin stretches rapidly (for example, as in growth spurts or during pregnancy). In addition, this type of scar can occur when the skin is under tension (near a joint, for example) during the healing process.

Hypertrophic Scars. Hypertrophic scars are thick, red, and raised, however, unlike keloids the scar remains within the boundaries of the original incision or wound.

Keloid. Keloids are thick, protrusive mounds of scar tissue and are often red or darker in color than the surrounding skin. See table 1 for differences between hypertrophic scars and keloids.

Contractures. Burns or other major injuries may form a scar that pulls the edges of the skin together, a process called contraction. The resulting contracture may affect the adjacent muscles and tendons, restricting normal movement.

Fig 1. Atrophic Scars (Left: pitted - Center: stretched - Right: atrophic, post acne)

Fig. 2 Hypertrophic scar after abdominal surgery Fig.3 Keloid scar after vaccine on shoulder

Table 1. Differences between hypertrophic scars and keloids

SCARS: Treatment

Topical treatment:

Atrophic Scars: There is no topical treatment that can prevent or remove atrophic scars. Retinoic acid

Hypertrophic scars and Keloids: The best treatment to prevent the formation and to reduce some signs and symptoms associates to this type of scars is 100% topical silicone. It comes in gel or spray. The most effective is the one that dries itself in seconds, allowing the use of other cosmetics like sunscreens, moisturizers and make-up, on top of it.

Procedures:

Atrophic scars: These lesions can be treated with a procedure called microneedling and some types of laser to stimulate collagen. A procedure called subcision is used to remove the fibrous tissue of scars attached to deeper tissues. Sometimes derma fillers can be used to fill in depressed scars. The best results are obtained with the combination of procedures.

Hypertrophic scars and Keloids: Intralesional corticosteroids and cryotherapy with liquid nitrogen are the most common for the treatment of this type of scars. Some other procedures including scar revision, radiotherapy, intralesional 5-fluoruracilo, lasers have been used with variable results.

SCARS: References

1. http://www.webmd.com/skin-problems-and-treatments/guide/scars. Consulted 02.12.12
2. http://www.aafprs.org/patient/fps_today/vol18_1/vol18_1pg4.html. Consulted 02.12.12
3. http://www.skincarephysicians.com/acnenet/depressed_acne_scars.html Consulted 02.12.12
4. Gupta S, Sharma VK. Standard guidelines of care: Keloids and hypertrophic scars. Indian J Dermatol Venereol Leprol 2011;77:94-100
5. Gauglitz GG, Korting HC, Pavicic T, Ruzick T, Jeschke MC Hypertrophic Scarring and Keloids: Pathomechanisms and Current and Emerging Treatment Strategies Mol Med 2011;17: 113-125
6. Wolfram D, Tzankov A, Pulzi P Piza-Katzer H. Hypertrophic Scars and Keloids: A Review of Their Pathophysiology, Risk Factors, and Therapeutic Management Dermatol Surg 2009;35:171-181
7. http://www.nlm.nih.gov/medlineplus/scars.html#cat3 Consulted 02.12.12
8. http://www.webmd.com/skin-problems-and-treatments/guide/scars Consulted 02.12.12
9. De Giorgi V, Sestini S, Mannone F, et al. The use of silicone gel in the treatment of fresh surgical scars: a randomized study. Clin Exp Dermatol. 2009;34:688-93.
10. Sebastian G [Therapy for pathologic scars (hypertrophic scars and keloids)] JDDG [J Dtsch Dermatol Ges], 2004; 2: 308-12

Wrinkles: What are They?

Wrinkles are a natural part of aging, but they're most prominent on sun-exposed skin, such as the face, neck, hands and forearms.

Wrinkles come in two categories: fine surface lines and deep furrows. Wrinkle treatments are in general much more effective for fine lines. Deeper creases may require more aggressive techniques, such injection of fillers or plastic surgery.¹

Wrinkles: Causes?

Wrinkles are caused by a combination of factors, resulting in the reduction of the protein that helps support the skin (collagen) and subsequent loss of elasticity in the skin. Although genetics are the most important determinant of skin structure and texture, sun exposure is the major contributor to wrinkles. Environmental exposure, such as to heat, wind and dust, as well as smoking, also may contribute to wrinkling.

• Age. As you get older, your skin naturally becomes less elastic and more fragile. Decreased production of natural oils makes your skin drier and appears more wrinkled. Fat in the deeper layers of your skin, which gives the skin a plump appearance, starts to diminish. This causes loose, saggy skin and more-pronounced lines and crevices.
• Exposure to ultraviolet (UV) light. Ultraviolet radiation markedly speeds up the natural aging process and is the primary cause of early wrinkling. Exposure to UV light breaks down your skin's connective tissue - collagen and elastin fibers, which lie in the deeper layer of skin (dermis). Without the supportive connective tissue, your skin loses its strength and flexibility. As a result, skin begins to sag and wrinkle prematurely.
• Smoking. Smoking can accelerate the normal aging process of your skin, contributing to wrinkles. This may be due to changes in the blood supply to your skin.
• Repeated facial expressions. Facial movements and expressions, such as squinting or smiling, lead to fine lines and wrinkles. They are called dynamic wrinkles. Each time you use a facial muscle, a groove forms beneath the surface of the skin. And as skin ages, it loses its flexibility and is no longer able to spring back in place. These grooves then become permanent features on your face.
• Gender. Women tend to develop more wrinkles around their mouths (perioral) than men do. That may be because women have fewer sweat glands and glands that secrete an oily matter known as sebum (sebaceous glands) to lubricate the skin and fewer blood vessels in this area.
• Poor nutrition. Nutritional deficiencies are believed to contribute to skin aging.

WRINKLES: Signs and Symptoms ^1,2

The classification of wrinkles, also known as rhytids, is based on how deep into the skin the wrinkles extend. They could be fine surface lines and deep furrows.

Fine wrinkles or fine lines: Are the result of changes in the upper dermis and may appear "etched" in the skin. They are superficial and are often located around the eyes, secondary to the contraction of facial muscles during smiling. Are also called "expression lines". (Fig. 1)

Deep wrinkles: Some wrinkles can become deep crevices or furrows and may be especially noticeable around the eyes, mouth and neck. (Fig. 2)

Fig. 1 Fine lines/wrinkles (Superficial) around the eyes Fig. 2 Deep wrinkles on the entire face

WRINKLES: Treatment ^1-4

Today we have more options than ever to help eliminate or at least diminish the appearance of wrinkles. Medications, skin-resurfacing techniques, fillers, injectables and surgery top the list of effective wrinkle treatments.

Non-prescription topical products: The effectiveness of anti-wrinkle products depends in part on the active ingredient or ingredients. Retinol, alpha hydroxy acids, poly-hydroxy acids, copper peptides and antioxidants may improve the appearance of fine lines, wrinkles and the overall tone and texture of skin. Newer products containing active ingredients such as adult stem cells have also been shown to be effective at stimulating collagen and enhancing skin tone.

Topical Retinoids: Prescription retinoids, derived from vitamin A (e.g. tretinoin, tazarotene) may be able to reduce fine wrinkles, splotchy pigmentation and skin roughness and must be used with a skin care program that includes daily broad-spectrum sunscreen application and protective clothing because the medication can make your skin burn more easily. It may also cause redness, dryness, itching, and a burning or tingling sensation.

Cosmetic procedures:

Chemical Peels: Can be performed with different type of acid and can be superficial, medium or deep. With superficial peels, only a portion of the epidermis (outer layer of the skin) is removed. After a series of peels less fine wrinkling and a fading of brown spots may be noticed. With medium-depth peels, the entire epidermis and a small portion of the dermis are removed. New skin forms to take its place. The new skin is usually smoother and less wrinkled than the old skin. Redness lasts up to several weeks. Deep peels are rarely performed due to the long recovery time.

Microdermabrasion: This refers to "sanding the skin" with a machine containing silica, aluminum crystals or diamond tips. Microdermabrasion does not change skin anatomy, though it may make the face feel smoother.

Laser, light source and radiofrequency treatments. In ablative (wounding) laser resurfacing, a laser beam destroys the epidermis and heats the underlying skin (dermis), which stimulates the growth of new collagen fibers. As the wound heals, new skin forms that's smoother and tighter. It can take up to several months to fully heal from ablative laser resurfacing. Newer developments in laser technology, such as non-ablative fractional resurfacing, in which the laser divides the light up into many smaller pulses, have decreased the healing time. Non-ablative lasers are less intense, so they don't injure the epidermis. These treatments heat the dermis and cause new collagen and elastin formation. After several treatments, skin feels firmer and appears refreshed. Non-ablative laser treatment typically needs to be repeated more often and results are subtle. There's also a device that uses radiofrequency instead of light to heat the dermis and underlying tissue to achieve mildly to moderately tighter skin.

Botulinum toxin type A. When injected in small doses into specific muscles, botulinum toxin blocks the chemical signals that cause muscles to contract. When the muscles can't tighten, the skin flattens and appears smoother and less wrinkled. Botox works well on frown lines between the eyebrows and across the forehead, and crow's-feet at the corners of the eyes. Results typically last about four to five months. Repeat injections are needed to maintain results.

Soft tissue fillers. Soft tissue fillers, which include fat, collagen, hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid can be injected into mid and deep dermis or below to improve deep wrinkles. They plump and smooth out wrinkles and furrows and give more volume to the skin. Temporary swelling, redness and bruising in the treated area may be present. The procedure may need to be repeated every few months.

Combination of treatments: Best results are achieved with the combination of treatments to improve skin texture, restore volume and produce a scaffold to the skin. These include a good home skin care regimen, resurfacing with chemical peels or laser treatments, botulinum toxin and medium to deep fillers.

Face-lift. The face-lift procedure involves removing excess skin and fat in the lower face and neck and tightening the underlying muscle and connective tissue. The results typically last five to 10 years. Healing times can be lengthy after a face-lift. Bruising and swelling are usually evident for several weeks after surgery.

WRINKLES: References

1. http://www.mayoclinic.com/health/wrinkles/DS00890 Consulted 01.12.12
2. Yaar M, Eller MS, Gilchrest BA. Fifty Years of Skin Aging. JID Symposium Proceedings, 2002; 7:51 58
3. Antoniou C, Kosmadaki MG, Straigos AJ, Katsambas AD Photoaging, Prevention and Topical Treatments Am J Clin Dermatol 2010; 11: 95-102
4. http://www.medicinenet.com/wrinkles/page2.htm

ACNE: What is it?

Acne is a very common, chronic, skin disease that affects 60-70% of Americans at some time during their lives.

It is more frequent in adolescence and young adulthood, thought it may present at any age. Acne begins as a noninflammatory comedonal condition and then evolves to the mildly inflammatory papular pustular acne before proceeding to the more inflammatory nodulocystic lesions. Each stage seems to be separated by 2-3 years. It becomes more common and severe, reaching its peak between 14-17 years in females and 16-19 years in males. For most people, acne diminishes over time and tends to disappear, but at 40 years of age 1% of men and 5% of women exhibit acne lesions.

Acne by definition is a multifactorial, chronic disease of the pilosebaceous units. The hair follicles become plugged with oil and dead skin cells. Acne most commonly appears on face, neck, chest, back and shoulders, where there are more sebaceous glands. Acne can be distressing and annoyingly persistent. Acne lesions heal slowly, and when one begins to resolve, others seem to crop up.

Depending on its severity, acne can cause emotional distress and lead to scarring of the skin. The good news is that effective treatments are available - and the earlier treatment is started, the lower your risk of lasting physical and emotional damage.³

The treatment should be directed to prevent physical and emotional scarring.

ACNE: Causes

Acne develops as a result of blockages in follicles. Follicular hyperkeratinization

and formation of a plug of keratin (a protein from the skin) and sebum (a mix of naturally occurring oil, and dead skin cells) is the earliest change (a microcomedo). Enlargement of sebaceous glands and an increase in sebum production occur with increased male sex hormones production (androgens). The microcomedo may enlarge to form an open comedo (blackhead) or closed comedo (whitehead or milia). Comedones are the direct result of sebaceous glands' becoming clogged with sebum. In these conditions, the bacteria called Propionibacterium acnes, which lives in the sebaceous glands, can cause inflammation, leading to inflammatory lesions. ^4-6

Main factors involved in the production or exacerbation of acne are:^4-8

1. Genetics: Acne is more frequent in adolescents which both parents had acne. A family history of acne is associated with early acne appearance.
2. Hormonal activity: Increase of androgens (testosterone, dihidrotestosterone and dehydroepiandrosterone sulfate) during puberty, menstrual cycle, pregnancy, post menopause, etc. Insulin growth factor has also been associated with certain type of acne and polycystic ovary syndrome.
3. Psychological factors: Most of the recent studies indicate that increase in the level of emotional stress increases the severity of acne flares, probably due to the increase in the production of neuropeptides around the sebaceous glands that also increase sebum production and inflammation.
4. Diet: No direct link has been found between acne and diet. In particular, no effect has been established between chocolate, shellfish, or fatty foods. However, the influence of dietary factors on the initiation and course of acne has recently received increased recognition. A connection has been postulated between acne and nutrients with high glycemic index, as well as with milk and dairy products.

Tobacco: Clinical evidence and experimental data showed a straight correlation between smoking habit and post-pubertal acne in which the clinically non-inflammatory type is the most frequent.⁸

ACNE: Signs and Symptoms ^9,10

Acne is a polymorphic disease, in other words it is characterized by the presence of different types of lesions simultaneously.In almost all patients comedones(white and black heads), papules and pustules (pinheads and pimples) can be found at the same time. Two main patterns of disease have been described. The first pattern is that of essentially noninflammatory disease, which tends to be an early phase often seen in the peri-pubertal age group. There is increased oil production on the face, chest, back and shoulders. This may be accompanied by an increase in pores' size, blackheads or open comedones. Occasionally noninflammatory whiteheads or closed comedones will also be seen, premonitory of other more significant inflammatory disease. This presentation of the disease is alsoknown as comedonal acne (see fig. 2 - 3)The second clinical pattern is that of inflammatory disease, that tends to lead to more scarring. This may span the full gamut from papules (pinheads), pustules (pimples), nodules and cysts and any combination of these. Postinflammatory macular disease may follow resolution and these may be red or hyperpigmented, representing a component of postinflammatory change. Severe forms of inflammatory acne such as nodular cystic disease, with all its potentially destructive sequelae, often occur later in predisposed individuals. (Fig 4 and 5)

If acne is not adequately treated, physical atrophic (depressed) or hypertrophic/keloid (elevated) scars may occur. (Fig.6)

Fig 2. Comedonal acne Fig 3.medonal acne (open comedones) Fig 4. Papular-pustular acne

Fig. 5 Nodulocystic acne Fig 6. Atrophic acne scars (back)

(Pictures courtesy of Dr. Mercedes Florez and Ana Kaminsky)

ACNE: Myths ^11-14

1. Acne is a disease that will improve by itself and has to run its course: Dermatologists know that letting acne runs its course is not always the best advice because without treatment dark spots and permanent scars can appear on the skin as acne clears. Acne treatment helps also increasing the self-esteem of the person.
2. Acne is a contagious infectious disease: Patients believe that acne is an infection and that they are infectious to others. Although Propionobacterium acnes is important in the extension of the disease from simple comedones to full blown inflammatory lesions, it is a secondary phenomenon once the disease has been initiated. Thus, acne is not an infectious or contagious disease.
3. Sexual activity is related with acne: There are misconceptions regarding variably too little or too much sexual activity and acne. First that too much sex or masturbation may worsen acne. Second that somehow when females begin having a regular sex life their acne will be improved. Although acne is tied up with androgen metabolism at the level of the sebaceous glands, there appears no basis to either of these rather strange extrapolations. Acne is occurring at a similar stage as sexual adventure and this may be a plausible reason for the uninformed to associate the two. One may also possibly look at the beneficial effect of oral contraceptives on acne as a possible explanation for improvement associated with the beginning of sexual activity in females.
4. Acne is curable: There is a widespread belief that acne is curable and that a course of antibiotics is all that is required. Patients will often make statements such as: 'the treatment didn't work because when I stopped the tablets the acne came back again' or, 'the acne only improved but didn't completely disappear'. It must be made clear that continued treatment is required and that there is no cure (although isotretinoin may cause long term remission of the disease).
5. Frequent skin hygiene and intense face cleansing improve acne: Not only are the facial cleansing regimens of patients with acne often burdensome, they can be expensive. The evidence for the role of a lack of facial hygiene in acne pathogenesis and for face cleansing in its management is mostly of poor quality. Furthermore, face-washing has been proposed as being traumatizing, and so exacerbating acne and as increasing the skin irritation adverse effects of topical tretinoin and isotretinoin (though not other topical therapies) in acne treatment. Additionally, commonly used soaps and shampoos have been found to be comedogenic when applied to the rabbit ear.

ACNE: Treatment ^15-18

Today, there are many effective acne treatments. This does not mean that every acne treatment works for everyone who has acne. But it does mean that virtually every case of acne can be controlled.

People who have mild acne have a few blemishes. They may have whiteheads, blackheads, papules, and/or pustules. Many people can treat mild acne with products that can be bought without a prescription. A product containing benzoyl peroxide or salicylic acid often help to clear the skin. This does not mean that the acne will clear overnight. At-home treatment requires 4-8 weeks to see improvement. Once acne clears, a maintenance treatment must continue to prevent breakouts.

If acne is moderate to severe, in other words there are many pustules, papules, cysts, or nodules, it is important to see a dermatologist. Dermatologists offer the following types of treatment:

Topical treatment: This is a treatment that is applied to the skin. There are many topical acne treatments,

and there is no magic product or regimen that is right for every person and situation. Topical treatment is usually broken down into two categories:

• Cleansers: A good part of any topical regimen can include both mild cleansers that keep the skin clean and minimize sensitivity and irritation and exfoliating cleansers that remove the outer layer of the skin and loosen pore-clogging dirt.
• Topical leave on products: Topical products can help kill the bacteria that cause acne and others work on reducing the oil. The topical medicine may contain a retinoid, benzoyl peroxide, antibiotic, or even salicylic acid.

Systemic treatment: This is a treatment that works throughout the body and may be necessary for inflammatory (red, swollen) types of acne, including the papular-pustular and nodulocystic forms. Your dermatologist may prescribe one or more of these:

• Antibiotics (helps to kill bacteria and reduce inflammation).
• Birth control pills and other medicine that works on hormones (can be helpful for women).
• Isotretinoin (the only treatment that works on all that causes acne).

Procedures that treat acne: Your dermatologist may treat your acne with a procedure that can be performed during an office visit. These treatments include:

• Lasers and other light therapies: These devices reduce the p. acnes bacteria. Your dermatologist can determine whether this type of treatment can be helpful.
• Chemical peels: You cannot buy the chemical peels that dermatologists use. Dermatologists use chemical peels to treat 2 types of acne - blackheads and papules.
• Acne removal: Your dermatologist may perform a procedure called "drainage and extraction" to remove a large acne cyst. This procedure helps when the cyst does not respond to medicine. It also helps ease the pain and the chance that the cyst will leave a scar. If you absolutely have to get rid of a cyst quickly, your dermatologist may inject the cyst with medicine.

Outcome

Waiting for acne to clear on its own can be frustrating. Without treatment, acne can cause permanent scars, low self-esteem, depression, and anxiety.

To avoid these possible outcomes, dermatologists recommend that people treat acne. When the skin clears, treatment should continue. Treatment prevents new breakouts. Your dermatologist can tell you when you no longer need to treat acne to prevent breakouts.

ACNE: Quality of Life

The presence of acne can negatively affect quality of life, self-esteem, and mood in adolescents. Acne is associated with an increased incidence of anxiety, depression, and suicidal ideation. The occurrence of these and other co-morbid psychological disorders should be considered in the treatment of acne patients when appropriate. A strong physician-patient relationship and thorough history taking may help to identify patients at risk for the adverse psychological effects of acne. Successful treatment of acne with isotretinoin qualitatively decreases depressive symptoms and improves quality of life. The effect of other topical and systemic therapies for acne on psychological symptoms has not been assessed.

In addition to the effect of acne on the patient, family and social relationships may also be strained. Parents may worry about the short- and long-term repercussions of their child's appearance, such as being bullied at school or having permanent scarring from acne lesions. As teens gain independence during adolescence, their attitudes toward treatment and adherence to the prescribed regimen may be adversely affected. Parents and patients may not always be adequately educated about the causes and treatment of acne, which may further delay or affect successful treatment. Poor adherence to therapy is a barrier to successful acne treatment. There is a positive correlation between treatment adherence and improved quality of life for other cutaneous diseases such as psoriasis and is an important area of future research in the clinical setting of acne treatment.¹⁹

ACNE: References

1. Fulton J, Elston DM Acne Vulgaris http://emedicine.medscape.com/article/1069804-overview- Consulted Jan.16, 2012
2. Yentzer BA, Hick J, Reese EL, Uhas A, Feldman SR, Balkrishnan R. Acne vulgaris in the United States: a descriptive epidemiology. Cutis. 2010; 86:94-9.
3. Mayo Clinic Staff. Acne Definition http://www.mayoclinic.com/health/acne/DS00169 - Consulted Jan.16, 2012
4. Kurokawa I, Danby FW, Ju Q, Wang X, Xiang LF, Xia L, Chen W, Nagy I, Picardo M, Suh DH, Ganceviciene R, Schagen S, Tsatsou F, Zouboulis CC. New developments in our understanding of acne pathogenesis and treatment. Exp Dermatol. 2009;18:821-32
5. Makrantonaki E, Ganceviciene R, Zouboulis C. An update on the role of the sebaceous gland in the pathogenesis of acne. Dermatoendocrinol. 2011; 3:41-9.
6. Bhambri S, Del Rosso JQ, Bhambri A. Pathogenesis of Acne: Recent Advances J Drugs Dermatol 2009;8:615-618
7. Veith WB, Silverberg NB. The association of acne vulgaris with diet. Cutis. 2011;88:84-91
8. Capitanio B, Sinagra JL, Ottaviani M, Bordignon V, Amantea A, Picardo M. Acne and smoking. Dermatoendocrinol. 2009;1:129-35
9. Thiboutot DM, et al New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group J Am Acad Dermatol 2009;60:S1-50.
10. Strauss JS, Krowchuk DP, Leyden JJ, Lucky AW, Shalita AR, et al Guidelines of care for acne vulgaris management J Am Acad Dermatol 2007;56:651-663
11. Poli F, Auffret N, Beylot C, Chivot M, Faure M, Moyse D, Pawin H, Revuz J, Dréno B. Acne as seen by adolescents: results of questionnaire study in 852 French individuals. Acta Derm Venereol. 2011;91:531-6.
12. Goodman G. Acne--natural history, facts and myths. Aust Fam Physician. 2006 ;35:613-6.
13. Rasmussen JE, Smith SB. Patient concepts and misconceptions about acne. Arch Dermatol 1983;119:570-2.
14. Magin P, Pond D, Smith W, Watson A. A systematic review of the evidence for 'myths and misconceptions' in acne management: diet, face-washing and sunlight. Fam Pract. 2005;22:62-70.
15. AAD Acne: Diagnosis, treatment, and outcome http://www.aad.org/skin-conditions/dermatology-a-to-z/acne/diagnosis-treatment/acne-diagnosis-treatment-and-outcome-consulted Jan. 16,2012
16. Rathi SK. Acne vulgaris treatment: the current scenario. Indian J Dermatol. 2011;56:7-13
17. Kim RH, Armstrong AW. Current state of acne treatment: highlighting lasers, photodynamic therapy, and chemical peels. Dermatol Online J. 2011;17(3):2
18. Kanlayavattanakul M, Lourith N. Therapeutic agents and herbs in topical application for acne treatment. Int J Cosmet Sci. 2011;33:289-97
19. Dunn LK, O'Neill JL, Feldman SR. Acne in adolescents: quality of life, self-esteem, mood, and psychological disorders. Dermatol Online J. 2011;17:1.

SKIN HYPERPIGMENTATION: What is it? ¹

Hyperpigmentation is the change of skin color because the body produces too much of a pigment called melanin, which is responsible for the brown color of the skin, causing it to become darker than usual. Hyperpigmentation could be diffuse or circumscribed. Diffuse hyperpigmentation could be secondary to certain medications, metabolic and nutritional diseases and autoimmune disorders. Circumscribed hyperpigmentation may occur in a variety of conditions.

The most common disorders associated with this type of skin hyperpigmentation are:

• Postinflammatory hyperpigmentation, secondary to trauma or inflammatory lesions
• Melasma, a dark mask-like discoloration most often located on the face

POSTINFLAMMATORY HYPERPIGMENTATION: ^1-4

Postinflammatory hyperpigmentation (PIH) is an acquired increase of pigmentation occurring after cutaneous inflammation, such as infections, trauma and inflammatory skin diseases. This is because cells that normally produce melanin (melanocytes) evenly across your skin go into overdrive and produce too much melanin. If the excess melanin is produced in the upper layer of skin (epidermis), the pigmentation color is a darker shade of brown. If the excess melanin is produced in the lower layer of skin (the dermis), a gray or blue discoloration becomes visible. This condition can occur in all skin types, but most often affects people with darker skin as black, olive skin, yellow skin, or mixture thereof and is particularly common in African-American, Latin American indigenous, Asian, native American, Pacific Islander and Middle Eastern descent.

Causes: Many types of inflammatory skin conditions or cutaneous injuries can cause pigmentary changes; however, there are some diseases that show a proclivity to develop PIH rather than hypopigmentation. (Table 1)

Table 1. More common causes of postinflammatory hyperpigmentation

POSTINFLAMMATORY HYPERPIGMENTATION: Signs and Symptoms

POSTINFLAMMATORY HYPERPIGMENTATION: Signs and Symptoms. PIH typically manifests as spots or patches in the same distribution as the initial inflammatory process. The location of the excess pigment within the layers of the skin will determine its coloration. Epidermal, (superficial) increase of melanin will appear tan, brown, or dark brown and may take months to years to resolve without treatment. Hyperpigmentation within the dermis (deep) has a blue-gray appearance and may either be permanent or resolve over a prolonged period of time if left untreated. The intensity of PIH may also correlate with darker skin types. In addition, PIH can worsen with ultraviolet (UV) irradiation or with persistent or recurrent inflammation.²

Fig. 1 Postinflammatory hyperpigmentation after acne Fig. 2 Postinflammatory hyperpigmentation after TCA Peel

Fig. 1 Picture Courtesy of Heather Woolery-Lloyd, MD Fig. 2 Picture courtesy of Mercedes Florez-White, MD

POSTINFLAMMATORY HYPERPIGMENTATION: Treatment

The treatment of PIH should begin first with addressing the underlying inflammatory skin condition. Initiating treatment early for PIH may help speed its resolution and prevent further darkening Photoprotection: Photoprotection is one of the most important measures to prevent the worsening of PIH and to improve it. A daily broad spectrum sunscreen with a sun protection factor (SPF) of 30 or more should be used, along with other sun-protective measures, such as sun avoidance and the use of protective clothing (Wide brimmed hat, long sleeves and long pants)

Topical treatment: Hydroquinone alone or in combination with other agents, helps in the reduction of pigmentation and must be prescribed by a physician. Other topical agents include: Tretinoin, tazarotene, Kojic acid, azelaic acid, arbutin, N-acetylglucosamine, among others.

Cosmetic procedures: Chemical peels with glycolic acid and salicylic acid may help, but should be performed by specifically trained professionals. Special attention should be taken in selecting and using the specific chemical peel to avoid irritation, which can worsen PIH and lead to other complications, such as new areas of discoloration, keloid formation, and hypertrophic scarring.^2-4

HYPERPIGMENTATION: References

1. Chang MW. Disorders of hyperpigmentation. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. 2nd ed. Elsevier Mosby; 2009:333-389
2. Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010 Jul;3(7):20-31.
3. Lacz NL, Vafaie J, Kihiczac NI, et al. Postinflammatory hyperpigmentation: a common but troubling condition. Int J Dermatol. 2004;4:362-365.
4. Ruiz-Maldonado R, Orozco-Covarrubias ML. Postinflammatory hypopigmentation and hyperpigmentation. Semin Cutan Med Surg. 1997;16:36-43.

MELASMA: What is it? ^5,6

Melasma is a common acquired, symmetric skin problem characterized by light to dark brown macules and patches occurring in the sun-exposed areas of the face, particularly on cheeks, bridge of the nose, forehead, chin, and above the upper lip. It also can appear on other sun-exposed parts of the body, such as the forearms and neck.

One of the most important risk factors is sun exposure. Excessive solar radiation without protection triggers melasma.

Women are far more likely than men to get melasma (9:1 ratio). It is seen more often in women between 20 to 50 years old. It is so common during pregnancy that some people call it the "mask of pregnancy". Hormones seem to trigger melasma.

People with darker skin, such as those with black skin, olive skin, yellow skin, or mixture thereof of African-American, Latin American indigenous, Asian, native American, Pacific Islander and Middle Eastern descent, are more likely to get melasma.

MELASMA: Causes ^5-7

What causes melasma is not yet clear. It likely occurs when the brown color-making cells in the skin (melanocytes) produce too much melanin. People with darker skin are more prone to melasma because they have more active melanocytes than those with light skin. Factors related with the presence of melasma include:

• Genetic Influence: As mentioned above, people with darker skin of African-American, Latin American indigenous, Asian, Native American, Pacific Islander and Middle Eastern descent, are more likely to get melasma.
• Sun exposure: Ultraviolet (UV) light from the sun stimulates the melanocytes. In fact, just a small amount of sun exposure can make melasma return after fading. Sun exposure is why melasma often is worse in summer. It also is the main reason why many people with melasma get it again and again.

• A change in hormones: Pregnant women often get melasma. Birth control pills and hormone replacement medicine also can trigger melasma.

• Cosmetics: Skin care products that irritate the skin may worsen melasma.

MELASMA: Signs and Symptoms ⁵

Common signs of melasma are light to dark brown or gray-brown patches on the face. These patches most commonly appear on the cheeks, forehead, bridge of the nose, above the upper lip and chin. Rarely, brown patches appear on forearms or neck. (Figs. 3 to 6)

Melasma does not cause any symptoms (what people feel). But many people dislike the way melasma makes their skin looks.

Fig. 3 Diffuse melasma Fig. 5 Blotchy patches of darker color on forehead

Fig. 4 Melasma. Blotchy patches of darker color Fig. 5 Blotchy patches of darker color on upper lip
on cheeks and maxillary area

Figures 3, 4, 5 and 6 courtesy of Mercedes Florez-White, M.D.

MELASMA: Treatment ^5,6,8

Melasma can fade on its own. This often happens when a trigger is causing the melasma, such as a pregnancy or birth control pills. When the woman delivers the baby or stops taking the birth control pills, melsama can fade. Some people, however, have melasma for years - or even a lifetime.

If the melasma continues a variety of treatments is available, most of them should be prescribed by a physician.

Photoprotection: A daily broad spectrum sunscreen with a sun protection factor (SPF) of 30 or more should be used, along with other sun-protective measures, such as sun avoidance and the use of protective clothing (Wide brimmed hat, long sleeves and long pants)

Topical treatment:

• Non-prescription "bleaching" or brightening agents: There are a lot of products on the market that contain bleaching agents derived from plants such as arbutin, licorice extract, emblica, etc., claiming to be depigmenting agents. Before using them a doctor should be consulted.
• Hydroquinone: This medicine is a common first treatment for melasma. It is applied to the skin and works by lightening the skin. It could be used alone or in combination with other agents than enhance its effect.

• Tretinoin and corticosteroids: To enhance skin lightening, a dermatologist may prescribe a second medicine. This medicine may be tretinoin or a corticosteroid. Sometimes a medicine contains 2 or 3 ingredients in 1 cream.

• Other topical (applied to the skin) medicines: Your dermatologist may prescribe azelaic acid or kojic acid to help lighten melasma.

Procedures: If a topical medicine does not get rid of melasma, a procedure may succeed. Procedures for melasma include chemical peels (such as glycolic acid), microdermabrasion, and certain type of lasers and lights. A dermatologist should perform these procedures. New skin problems can occur when the person who gives the treatment does not tailor it to the patient's skin type.

MELASMA: Quality of Life

Melasma have a significant emotional and psychological distress on affected patients. The discoloration affects their self-esteem. It is also considered in some Asian cultures a sign of "bad luck".

Physicians must consider the devastating psychosocial impact of pigmentary imperfections in addition to pharmacological and physical treatment.⁹

MELASMA: References

5. http://www.aad.org/skin-conditions/dermatology-a-to-z/melasma/melasma - Consulted February 2, 2012

6. Kang HY, Ortonne JP. What should be considered in treatment of melasma. Ann Dermatol. 2010;22,373-8.

7. Bandyopadhyay D. Topical treatment of melasma. Indian J Dermatol. 2009;54,303-9.

8. Safizade H. Quality of Life in Patients with Melasma. Dermatol and Cosm. 2010;1:179-186

STRETCH MARKS: What are they?

Stretch marks or striae distansae (SMs) are a well-recognized, common skin condition that rarely causes some significant medical problems but is often a significant source of distress for those affected. The characteristic lesions are pink, reddish or purplish indented streaks that often appear on the abdomen, breasts, upper arms, buttocks and thighs. Stretch marks are particularly common in pregnant women, especially during the latter half of pregnancy. They also appear in the outer thighs or lower back in in adolescent boys and the buttocks, thighs, upper arms, and breasts in adolescent girls.

STRETCH MARKS: Causes

Stretch marks occur in the dermis, the elastic middle layer of the skin that allows it to retain its shape. However, when constantly stretched, the dermis can break down leaving behind stretch marks. They are a type of scar caused by hormones impacting the elastin proteins in the skin.

Causes of SMs are not clear, and a number of theories have been proposed, including

• Mechanical effect of stretching leading to the rupture of the skin fibers (e.g., pregnancy, obesity, weight lifting).
• Normal growth, with these marks commonly developing during adolescence and associated with the rapid increase in size of particular regions of the body.
• Obesity and rapid changes in weight have been shown to be associated with the development of SMs.

Steroid hormones either induced from local or systemic steroid therapy or associated to Cushing's disease. Steroids decrease the fibers of the skin (collagen and elastic fibers). SMs are very common in athletes taking steroids.

STRETCH MARKS: Signs and Symptoms

SMs progress through three different stages of maturation:

Acute Stage: The acute stage is characterized by red, slightly raised streaks. At this stage the lesions may be itchy. (Fig.1)

Sub-acute stage: Red streaks acquire a darker purple color. (Fig 2)

Chronic stage: Characterized by bright, flat streaks that fade to light pink, white or grayish color. (Fig 3)

Fig.1 Acute stage, red slightly raised streaks Fig. 2 Sub-acute stage, purple larger streaks

Fig. 3 Chronic stage, white grayish flat streaks

STRETCH MARKS: Treatments

There are several treatment options for stretch marks. If you are serious about dealing with unwanted stretch marks, it's best to be in the care of a surgeon or dermatologist who can recommend your best options. Your doctor will take a detailed medical history, including medications you are taking. Some medications can cause stretch marks, and it is very important to be open and honest with your doctor. Those medications include hormones and steroids.

The following treatments are among those available to help improve the appearance of stretch marks. None has been proved to be more consistently successful than the others.

Topical treatment:

Over-the-counter treatments: Over the counter stretch mark treatments are available, some of which are effective. They may contain active ingredients such as darutoside and peptides that stimulate collagen production or collagen infused microspheres that encourage the underlying skin cells to absorb moisture and swell. Moisturizers can help with appearance and itchiness. Ingredients such as registril can also work to improve skin tone and appearance. Sunless tanning products can also help mask stretch marks.

Topical retinoids. Some research has shown that topical tretinoin may improve the appearance of recent stretch marks - those that are less than six weeks old and still pink or red in color. When it works, helps to rebuild collagen, making the stretch mark look more like normal skin, but can irritate the skin. Tretinoin should never be used during pregnancy. This treatment is not effective on older stretch marks.

Cosmetic Procedures:

Pulsed dye laser therapy: Used at wavelengths of light that are non-wounding (non-ablative), this type of laser therapy remodels underlying skin (dermis) by stimulating the growth of collagen and elastin. Pulsed dye laser therapy is most effective when stretch marks are new, but it may still be effective on older stretch marks. This type of treatment may alter skin color on darker skin tones.

Fractional photothermolysis: Like pulsed dye laser therapy, this non-ablative laser treatment uses wavelengths of light to stimulate new growth of collagen and elastin. The difference is that it causes partial (fractional) damage to small dot-like areas within a targeted zone. Because most of the treated area remains undamaged, the skin heals quickly.

Excimer laser: The excimer laser does nothing for collagen or elastin growth. Instead, its aim is re-pigmentation by stimulating melanin production. If it works, the old and lighter streaks become similar in color to the surrounding skin, and therefore less visible. This is often used for older stretch marks.

STRETCH MARKS: References

1. http://www.mayoclinic.com/health/wrinkles/DS00890 Consulted 01.12.2012
2. Atwal GSS, Manku LK, Griffiths CEF, Polson DW. Striae gravidarum in primiparae, Br J Dermatol 2006;155: 965-969, 2006.
3. García Hidalgo L, Dermatological complications of obesity. Am J Clin Dermatol. 2002; 3:497-506
4. http://www.stretchmarks.org/laserremoval.aspx - Consulted 02.12.2012
5. Bleve M, Capra P, Pavanetto F, Perugini P. Ultrasound and 3D Skin Imaging: Methods to Evaluate Efficacy of Striae Distensae Treatment. Dermatol Res Pract. 2012;2012:673-706.
6. Yang YJ, Lee GY. Treatment of Striae Distensae with Nonablative Fractional Laser versus Ablative CO(2) Fractional Laser: A Randomized Controlled Trial. Ann Dermatol. 2011;23:481-9.

Red Face: What is it?

A red face is a condition characterized by redness, blushing or flushing of the face. It can be temporary and last just a few moments, or it can be present for days, weeks or months at a time. It is most noticeable in fair-skinned individuals and occurs as a result of cutaneous blood vessel dilation and increased blood flow to the skin. Although transient facial erythema is often observed as a normal, neurologically-mediated response to strong emotion, exercise, or heat exposure, a variety of medical conditions can lead to longer-lasting and symptomatic or cosmetically distressing facial erythema.

Red Face: What are the causes?

A red face can be caused by strong emotions, such as anger, anxiety or embarrassment. It is called blushing. Some people tend to blush more easily than others.

A red face can also be caused by a variety of diseases, disorders and conditions that include skin conditions, allergies, inflammation, infections, and dietary habits.

Skin conditions that can cause a red face:

A red face may be caused by skin conditions including:

• Rosacea, chronic inflammatory skin disorder with pimples and broken capillaries. It is the most frequent skin disease associated to redness of face skin. (Fig. 1)
• Acne, bumps formed by clogged oil glands (white and blackheads) and pimples.
• Eczema
  • Atopic dermatitis, a common, chronic skin condition marked by itching, inflammation, redness and swelling of the skin, especially on cheeks. (Fig. 2)
  • Seborrheic dermatitis, a common, chronic condition that is often accompanied by scaling of the eyebrows and
  • the creases of the nose, as well as dandruff.

Allergic and inflammatory causes of a red face

A red face may be caused by allergic reactions and inflammatory conditions including:

• Allergic contact dermatitis, such as an allergy to a face cream or face wash
• Allergy to an oral medication, food, or insect bite
• Burns
• Hypersensitivity vasculitis or allergic vasculitis (inflammation of blood vessels often caused by an allergy to a medication)
• Irritant contact dermatitis, which can be caused by poison ivy, poison oak, or poison sumac
• Respiratory allergies
• Sunburn
• Dermatomyositis
• Systemic lupus erythematosus (disorder in which the body attacks its own healthy cells and tissues, causing inflammation)
• Toxic epidermal necrolysis (skin and mucosal loss due to a severe medication reaction)

Infectious causes of a red face

A red face may be caused by infections including:

• Cellulitis (invasive bacterial infection of the skin and surrounding tissues)
• Fifth disease (viral disease that causes a slapped cheek appearance)
• Impetigo (bacterial skin infection)
• Scarlet fever (infection caused by group A Streptococcus bacteria causing a red rash on the body and face)

Other causes of a red face

A red face may be caused by other diseases, disorders and conditions that include:

• Alcohol consumption or alcoholism
• Carcinoid tumor
• Chapping from wind, cold or heat
• Consumption of spicy or hot foods
• Coughing or choking
• Emotions, such as embarrassment, anxiety and anger
• Hypertension (high blood pressure)
• Menopause and hot flashes
• Stress
• Use of certain medications, such as vitamin B₃ and certain drugs used to treat cardiovascular disease and diabetes

Red Face: What are the stymptoms?

To diagnose the underlying cause of a red face, your doctor or licensed health care provider will ask you questions about your symptoms. You can best help your health care provider in diagnosing the underlying cause of a red face by providing complete answers to these questions:

• How long have you had a red face?
• Do you have other symptoms, such as fever or pain?
• Before or while you experienced a red face, was the temperature hot?
• Have you recently begun eating a new type of food or using a new type of cosmetic item on your skin?
• How much alcohol do you drink? What medications are you taking and how long have you been taking them?
• What other symptoms do you have?

A red face can be caused by a serious underlying disease, disorder or condition, such as anaphylactic shock, alcoholism, and infection. Complications of untreated or poorly managed diseases, disorders or conditions can be serious and life threatening. In addition, appearance has significant importance in our society; a red face can greatly impact self-image and self-esteem. Follow the treatment plan you and your health care professional design specifically for you to reduce your risk of complications

Red Face: Treatment & Prevention?

Prevention:

Avoid triggers or aggravating factors is the first step to prevent red face. A dermatologist can help you identify and treat the sources of your red skin.

Treatment:

General measures: Make sure to use products designed for sensitive skin. Eliminating harsh, drying, or strongly scented products can help reduce redness in any skin type. Use mild cleansers and moisturizers that help repair the damaged skin and always a broadband (UVA, UVB) sunscreen with antioxidants and SPF 30 or more.

Treatment of underlying disorders: Consult a physician if you have a persistent redness of the skin to identify possible causes of the condition and possible treatments available.

The treatment of Rosacea includes a medicine that is applied to the compromised skin (e.g. metronidazole, azelaic acid, etc.), the use of sunscreen, (wearing it every day can help prevent flare-ups.) an emollient to help repair the skin, topical or oral antibiotics, oral isotretinoin and lasers or other light treatments.

Red Face: References

1. Dahl MV http://www.uptodate.com/contents/approach-to-the-patient-with-facial-erythema (Consulted 03.26.12)
2. Izikson L, English JC, Zirwas MJ The Flushing patient: differential diagnosis, workup and treatment J Am Acad Dermatol 2006;55:193-208
3. http://www.aad.org/skin-conditions/dermatology-a-to-z/rosacea/diagnosis-treatment/rosacea-diagnosis-treatment-and-outcome
4. http://www.mayoclinic.com/health/rosacea/DS00308