Acne is a chronic inflammatory disease of the hair follicle and sebaceous gland unit, and is the most common skin condition in the United States. The primary presentation of acne is that of open comedones (blackheads), closed comedones, inflammatory papules, pustules, cysts, and occasionally scarring. Patients often have a combination of these types, affecting most commonly the face, neck, and upper torso. While most associate acne with the teenage years surrounding puberty, acne can persist into the 30s and 40s. The formation of acne lesions is an interplay between hormones, blocked pores, inflammation, and bacteria. Depending on the clinical presentation, therapies addressing some or all of these aspect can be used to control acne. Treatments for acne include topical and oral antibiotics, topical and oral retinoids, azaleic acid, salicyclic acid, and others. In women, treatments targeted at preventing hormonal effects on acne include oral contraceptive pills and spironolactone.
Alopecia (Hair Loss)
Alopecia, or hair loss, is a multifaceted and complex issue that encompasses many different conditions of varying severity. Some types of hair loss are permanent and can cause scarring, while others are temporary or may wax and wane. Hair loss can be a result of emotional stress, physical stress, autoimmune disease, medications, infections, inflammatory diseases, hormones, certain types of hairstyling, and other causes. The most common cause of hair loss is hereditary alopecia, also known as androgenetic alopecia, effecting an estimated 80 million men and women. Other types of non-scarring hair loss include alopecia areata, telogen effluvium, and trichotillomania, among others. Scarring, or cicatricial, alopecia can include discoid lupus, lichen planopilaris, central centrifugal cicatricial alopecia, folliculitis decalvans, and others. The clinical examination of the scalp and hair, and often times a skin biopsy are necessary to get an accurate diagnosis. Naturally, given the many different types and causes of alopecia, there are a multitude of different treatments for hair loss. Treatments can include local and systemic steroids, minoxidil, immune modulators, hormonal treatments, antimicrobials, and more.
Psoriasis is a common, chronic, inflammatory disorder that can affect the skin, scalp, joints, and nails. It occurs equally between males and females and it is estimated that between 2-8% of the world population is affected. In the United States, an estimated 7.5 million people have psoriasis. The inheritance of the disease is multifactorial and multiple genetic loci have been associated. While psoriasis is a genetically associated disease, the manifestations of psoriasis usually present after an environmental exposure such as medications, infections, medical diseases, or other physiologic stressors. The condition can affect people of all ages, but it is most common in adults. Plaque psoriasis is by far the most common type of psoriasis, but there are other variants including pustular, nail, guttate, inverse, and erythrodermic. The prototypical presentation of psoriasis is that of raised, well defined, salmon colored plaques with adherent silvery scale. This clinical picture is actually driven by a complex interplay of inflammatory cells, and their secreted products known as cytokines, that lead to a hyperproliferation of skin keratinocytes. It is these signals for hyperproliferation and inflammation that we see clinically as thickening, scaling, and redness. Similarly, these types of cellular responses are responsible for each of the other types of psoriasis mentioned above. Psoriasis can frequently be diagnosed based on clinical exam; often times with the addition of a skin biopsy which will show the classic features associated with psoriatic skin. The treatment of psoriasis is varied and is dependent on the clinical subtype and severity of the disease. For limited involvement of the skin the typical first line treatments are potent topical steroids, topical calcineurin inhibitors, vitamin D analogues, or topical retinoids. For more widespread disease narrow band ultraviolet light therapy is often employed. In moderate to severe psoriasis or psoriatic arthritis a systemic medication is needed. Traditionally this has included systemic retinoids or classic DMARDs such as methotrexate, cyclosporine, mycophenolate mofitil, and azathioprine. These medications have been used for decades and are effective, but require expertise and regular blood monitoring. Newer immune modulating drugs have become available over these last two decades, beginning with TNF-alpha inhibitors such as adalimumab, infliximab, and etanercept. These medications are very effective, although their relative non-specificity means there are potential side effects that dermatologists will monitor. Subsequently, a more specific and effective medication named ustekinumab became available, and over the last several years there has been an explosion of highly efficacious treatments for psoriasis. Some of these include apremilast, secukinumab, guselkumab, ixekizumab, and others. To determine the right treatment for a patient with psoriasis requires a dermatologist who can accurately assess the type and severity of psoriasis, can understand the patient's coexisting conditions, and has a strong grasp on the use and side effects of the many medication options.
Rosacea, a common skin condition affecting 16 million Americans, is a constellation of skin findings that produces dramatic redness and sensitivity in the skin along with acne-like lesions, facial flushing, and dilated blood vessels. Rosacea is a chronic condition that often waxes and wanes in intensity. There are several known triggers in rosacea including sunlight, emotional stress, heat, alcohol, and spicy foods. Treatment usually requires a multimodal approach, with topical creams and oral anti-inflammatories being the mainstays of treatment. It is also crucial to limit flares by avoiding potential triggers and avoiding UV exposure.
Vitiligo is an autoimmune skin condition caused by inappropriate immune response to melanocytes, which are the cells that provide color to our skin. The immune attack of the melanocyte leads to well-defined depigmented, or white, patches of skin. While more striking in people with a darker natural skin color, the condition actually equally effects people of all skin types. Vitiligo can be categorized into focal (localized), segmental, or generalized disease; with generalized being the most common subtype The condition often starts insidiously and follows an unpredictable course. In fact, while one patient may have just a few patches or non-progressive disease, the next may have widespread or rapidly changing disease. Vitiligo is generally asymptomatic, but the psychological impact on patients is typically quite significant. This is especially true because the most commonly affected areas include the face, hands, chest, armpits, and groin. Depending on the type and severity of the disease, treatment options for vitiligo include topical or systemic steroids, topical calcineurin inhibitors, light therapy such as narrow band ultraviolet light, or immune suppressing medications. While there is no cure for vitiligo, with these treatments patients are often able to regain some of the lost pigment. Occasionally there can be other associated autoimmune or endocrine diseases in association with vitiligo, so evaluation and discussion of your vitiligo with a board-certified dermatologist will lead to the best outcomes.
Warts and Molluscum
There are many different types of viral infections of the skin that lead to different clinical presentations, but among the most common are warts and molluscum contagiosum.
Warts, or verruca, can present in a multitude of different ways, but all types of warts are caused by the various subtypes of the human papilloma virus. The most common types of warts include common warts, genital warts, plantar warts, and flat warts. Most people will experience some form of warts during their lifetime, and this pervasiveness is due to the virus’ ability to evade destruction by the host immune system. Warts can be transmitted via direct contact, indirect contact, or via autoinoculation. Once the virus is in place the virus promotes keratinocyte proliferation that leads to the ‘warty’ appearance clinically. Warts can be painful, interfere with activities, and cause social distress. Some types of warts, specifically genital warts and the strains of HPV that cause cervical cancer, can be prevented with the HPV vaccine. Treatment of warts depends on their location, appearance, and immune status of the patient. Typically the treatment is broken into two different categories: destructive and immunologic. Destructive methods can include cryotherapy, salicylic acid, cantharidin, 5-fluorouricil, and laser. Immunologic therapies can include imiquimod, candida antigen injection, or contact sensitization. Because some strains of the HPV virus can cause cancer, and because the clinical appearance of some warts can mimic squamous cell carcinoma, it is important to see a board certified dermatologist if you have concerns about warts.
Molluscum contagiosum is a common skin condition most often seen in school aged children, but which can also be found in sexually active adults, and in immunosuppressed individuals. It is caused by a type of poxvirus that infects the skin. As the name implies, the virus is very easily spread from person to person, usually by skin to skin contact but also by indirect contact with shared items such as towels. Autoinoculation is also common and scratching an affected area can lead to more of the lesions in other areas of the body. In adults the virus is usually sexually transmitted. Clinically, the lesions of molluscum appear as small, smooth, dome shaped pink bumps, typically with a dimple in the center. At times the lesions can get crusted, pustular, or have surrounding dermatitis, which can herald the resolution of that lesion. Children that have eczema, or people with altered immune systems, often have more extensive cases of molluscum. While they are often bothersome, the virus is otherwise relatively harmless. The natural course of molluscum is self-resolution over 1-2 years. Because they self-resolve, it is reasonable to leave them alone. However, for those wanting treatment there are several modalities that can be tried including cryotherapy, canthardin, topical tretinoin, curettage, extraction and others.