Keratosis Pilaris (Chicken Skin)

 

 

 

Keratosis pilaris is a very common inherited condition where small keratotic papules in hair follicles appear as patches of bumps on the skin.  The bumps can be red, white, or darker than the skin.

 

Keratosis pilaris is stealthy in that patients who develop this condition are asymptomatic and it goes unnoticed. The disorder usually affects upper arms, upper legs, and buttocks. Certain age groups have a higher prevalence of this disorder, adolescents to be exact.

 

It is caused by excess keratin in the hair follicles, and although the causes have not been understood, a hormonal influence may be involved considering the high prevalence in adolescents.

 

No cure is available for keratosis pilaris, preventive measures like avoiding excessive skin dryness by moisturizing, staying away from long hot baths, and using mild soaps decrease the symptoms. In severe cases, keratolytic agents such as lactic acid, salicylic acid and urea cream are effective at reducing the appearance.

 

 

 

Written by: Naif Alshaikh, Medical Student 

 

References:

Pediatric dermatology

DermNet NZ

Werewolf syndrome: A brief touch on the different causes of excessive body hair.

 

 

 

 

Hypertrichosis (also known as Werewolf syndrome) is the presence of abnormal amounts of hair on the body in non-androgenic sensitive areas. This needs to be differentiated from hirsutism, which is a condition associated with male-like pattern growth of hair in females, mostly due to endocrine causes.

 

Excess hair growth associated with hypertrichosis may include any hair type (terminal, vellus, and lanugo), this hair growth particularly involves non-androgenic sensitive areas. Congenital form of hypertrichosis is believed to be due to inheritance or a spontaneous mutation. In addition, this form of hypertrichosis is extremely rare, and only a few cases have ever been reported. Furthermore, hypertrichosis could also be acquired and presents in late stages of cancer by an unknown mechanism, this hair growth is termed “malignant down”. However, cancer is not the only cause of the acquired form, it can also be caused by certain medications, such as minoxidil, phenytoin, and cyclosporine. There is not a known cure for the congenital form of hypertrichosis, however, the mainstay of treatment for the acquired form is addressing the culprit and using cosmetic hair removal methods (shaving, waxing, eflornithine cream, etc.).

 

Hypertrichosis is a rare disorder that presents with excessive unwanted hair growth. It could be congenital or acquired, however, the congenital is very rare. Treatment involves treating the underlying cause and using hair removal techniques.

 

 

 

Written by: Khalid Al Dakheel, Medical Student 

 

Resources:

Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, Seventh Edition

https://www.mayoclinic.org/

www.DermNetNZ.org

Keloid scarring

 

 

Keloids form following dermal scarring of tissue with abnormal wound healing. The scarring’s origin can be multifaceted, developing from any level of skin trauma or inflammation including surgery, burns, acne, insect bites and a multitude of other reasons.

 

How do keloids develop?

 

The etiology is not fully understood yet. Genetic and environmental factors are strongly implicated in its development in that incidents are higher in darker-skinned individuals of African, Asian, or Hispanic descent. Subsequent to an injury, fibroblasts produce exuberant and indefinite collagen and growth factors that cause aberrant wound healing.

 

How do keloids appear?

 

Keloids manifest as sturdy, enlarged raised scar that is pink or darker in color than the surrounding tissue. They appear hairless and shiny in relation to the tissue within proximity.  Keloids can arise anywhere on the body; however the upper chest, ears, and shoulders are more prone to them. Sometimes keloids can be misconstrued with hypertrophic scar, both have separate clinical and histochemical entities; hypertrophic scar is confined to the area of damaged skin, whereas keloids extend to nearby cells in the dermis.

 

Treatments for keloid scarring:

Various treatment modalities are available, but there aren’t any gold standard treatments that supersedes the others.

Options include:

  • Steroid injection- considered as a first line of treatment, it may be used alone or in conjunction with other treatments.
  • Cryotherapy- freezing early keloids to stunt their growth. This method is less recommended for darker people as it can lead to pigmentation.
  • Surgical removal- often accompanied by another modality to remove the scar (high reoccurrence rate)

Keloids are generally harmless and painless and do not change into cancer; they are benign. Dark-skinned individuals and familial tendencies play an important role in the development and formation of keloids. The treatments address symptom alleviation, and since keloids have significant cosmetic repercussions, many of the treatments are directed towards cosmetic concerns.

 

 

Written by: Naif Alshaikh, Medical Student 

 

Resources:
dermnetnz.org
www.nhs.uk
Plast. Reconstr. Surg. 117: 286, 2006
https://www.ncbi.nlm.nih.gov/books/NBK507899

 

Herpes zoster

 

 

 

Herpes zoster (also known as shingles) is a localized, blistering, and painful rash caused by reactivation of varicella-zoster virus (VZV) (as known as herpesvirus 3 member of the Herpesviruses). Herpes zoster is characterized by blisters that are confined to the cutaneous distribution of one or two adjacent sensory nerves, which are usually unilateral with a sharp cut-off at the anterior and posterior midlines.

 

 

the clinical presentation includes pain, which may be severe, relating to one or more sensory nerves. The patients usually feel quite unwell with fever and headache with the lymph nodes draining the affected area being enlarged and tender. The chest (thoracic), neck (cervical), forehead (ophthalmic), and lumbar/sacral sensory nerve supply regions are most commonly affected at all ages, with the frequency of ophthalmic herpes zoster increases with age. Anyone with previous varicella (chickenpox) may subsequently develop zoster. they may occur in childhood but are more common in adults, especially the elderly. After primary infection, VZV remains dormant in dorsal root ganglia nerve cells in the spine for many years before reactivating and migrating down sensory nerves to the skin causing herpes zoster. it’s still unknown why certain nerves are at higher risk, but the currently acknowledged trigger factors are: Pressure on the nerve roots, radiotherapy at the level of the affected nerve root and Spinal surgery.  Common complications are: Involvement of several dermatomes or bilateral eruptions in unique dermatomes. Eye complications when the ophthalmic division of the fifth cranial nerve is involved. Deep blisters that destroy the skin. Muscle weakness in about one in 20 patients, with Facial nerve palsy being the most common result (Ramsey Hunt syndrome). Post-herpetic neuralgia is the persistence or recurrence of pain in the same area, more than a month after the onset of herpes zoster and It becomes increasingly common with age.

 

 

Antiviral treatment can reduce pain and the duration of symptoms if started within one to three days after the onset of herpes zoster. Because the risk of severe complications from herpes zoster is higher in older people, those aged over 60 years might consider the zoster vaccine, which can reduce the incidence of herpes zoster by half, and if they get herpes zoster despite being vaccinated, the symptoms are usually less severe and post-herpetic neuralgia is less likely to develop.

 

 

 

Written by: Bayan Alhazmi, Medical Student 

 

Resources:

https://www.dermnetnz.org/

Infantile Hemangiomas

 

 

 

Infantile hemangiomas are the most common vascular tumor in infants and children. The majority of hemangiomas are not evident at birth but most become apparent in the first few months of life. Infantile hemangiomas may occur anywhere in the skin, mucous membranes and even internal organs. However, they are usually seen in the head and neck area.

 

Hemangiomas may range in size from a few millimeters to huge sizes covering a large area of the skin. Hemangiomas may be categorized as focal, segmental, or multiple, depending on the pattern of skin or organ involvement. Most hemangiomas undergo a proliferative phase of accelerated growth, usually during the first few months after diagnosis. Depending on the type of hemangioma, the proliferative phase may or may not be followed by a phase of involution, in which the tumor regresses in size and may even disappear completely.

 

The diagnosis of hemangiomas is clinical and requires no investigations. Most cutaneous hemangiomas are asymptomatic and require no treatment. However, hemangiomas may lead to ulceration, bleeding, functional impairment, and disfigurement.

 

Management of hemangiomas differs by case and should be individualized. Options for management may include active observation, medical therapy such as propranolol and corticosteroids, surgery especially if the hemangioma is causing functional impairment and laser therapy.

 

 

Written by: Turki Alsehli, Medical Student 

 

Resources:

www.UpToDate.com

www.DermNetNZ.org

A brief touch on some of the skin manifestations associated with diabetes mellitus

 

 

 

Diabetes mellitus is a disorder occurring when the body is unable to process glucose resulting in high blood glucose. It is a very common disease; it has been estimated that around 18% of the adult population in Saudi Arabia suffer from diabetes mellitus. There are 3 types of diabetes mellitus, type 1, type 2, and gestational. Type 1 occurs due to autoimmune destruction of insulin-producing pancreatic beta cells causing little to no insulin to be released. On the other hand, type 2 is due to insulin resistance rather than destruction of insulin-producing cells.

 

 

There are a couple of skin manifestations occurring in diabetics, and they are usually more common in type 2 than type 1. Furthermore, poorly controlled diabetes mellitus is associated with an increased incidence of skin infections and “diabetic foot”. Acanthosis nigricans (AN) associated with diabetes mellitus (benign AN) has an insidious onset and often described as velvety thickening and hyperpigmentation of the skin. Another disorder often associated with diabetes mellitus is Necrobiosis lipoidica (NL). NL lesions start as a papule that slowly develops into a well-demarcated plaque. A combination of peripheral arterial disease and peripheral neuropathy causes something known as “diabetic foot”. Patients suffering from diabetic foot have reduced sensation in their extremities, thus making them more prone to acquire undiscovered minor injuries that may later progress to full-thickness ulcers.

 

 

Diabetes mellitus is linked with some skin manifestations, we have briefly touched on a few of them such as acanthosis nigricans, necrobiosis lipoidica, and diabetic foot. Maintaining proper blood glucose and frequent foot care is important in the prevention of ulcers in the foot and infections.

 

 

 

Written by: Khalid Al Dakheel, Medical Student 

 

Resources:

Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, Seventh Edition

https://www.mayoclinic.org/

www.DermNetNZ.org

Viral warts

 

 

 

Viral warts are ubiquitous and harmless skin growths caused by human papillomavirus (HPV). It infects epidermal or mucosal cells creating a warty knoll lesion called verruca.

 

Diagnosis is clear-cut and based on clinical grounds, but in some cases uncertainty emerges. Facial warts can be mistaken for lichen nitidus, in such instances, histological differences confirm the diagnosis.

 

Common locations for warts include the hands and feet, but they manifest differently depending on the location. Palmar or hand warts appear as hyperkeratotic papules, whereas plantar or feet warts are exhibited as thick plaques. Both arise under pressure points and may cause pain.

 

Treatments are discounted due to the nature of warts; they resolve spontaneously and appear to be for the most part asymptomatic. If treatment is pursued, different modalities can be used to tackle it. The use of topical salicylic acid treatment, which is typically tolerated, works gently at exfoliating the skin from the epidermal layer, softening the skin, and encouraging cell turnover. Another modality, which the commonest, utilizes liquid nitrogen, formerly called “cryotherapy”, to directly destroy and induce secondary inflammation.

 

In general, cutaneous viral warts are uncommon, nonetheless, they do appear often in children, particularly schoolchildren and immunocompromised. Patients choose to excise warts for cosmetic reasons, pain, or discomfort, but they do not pose a health threat as they are benign, however, they are mischievously contagious and can be spread through contact.

 

 

 

Written by: Naif Alshaikh, Medical Student 

 

Resources:

https://dermnetnz.org/topics/viral-wart/

https://www.huidhuis.nl/sites/huidhuis.nl/files/inline-images/PDF/BMJ_cutaneous_viral_warts.pdf

https://www.yalemedicine.org/conditions/viral-warts/

Cutaneous Melanoma

 

 

Cutaneous melanoma is a malignant neoplasm of the melanocytes. Melanocytes are cells found in the basal layer of the epidermis which its main function is to produce the pigment melanin that is responsible for skin color. As one of the three major types of skin cancer (basal cell carcinoma and squamous cell carcinoma being the other two) melanoma remains the deadliest, causing the vast majority of the skin cancer-related deaths although it only accounts for approximately 5% of the skin cancer cases.

 

There are four major forms of melanoma being: superficial spreading, nodular, lentigo maligna, and acral lentiginous melanomas. superficial spreading form remains the most common and accounts for about 70% of melanomas. Studies have shown that the major risk factor for melanoma development is exposure to Ultraviolet (UV) radiation as UV radiation frequently leads to DNA mutations. Another risk factor is the melanocytic nevus (colloquially known as mole or birthmark) nevi are benign lesions composed of clusters of melanocytes. This leads to a dark pigmented spot on the skin due to the large amount of melanin production.

 

Clinicians assess lesions based on the “ABCDE rule” that is meant to indicate A: asymmetry, B: irregular border, C: color variations, D: diameter >6 mm, and E: elevated surface in order to diagnose malignant melanoma.

 

 

Written by: Bayan Alhazmi, Medical Student 

 

Resources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346328/

https://www.nhs.uk/conditions/melanoma-skin-cancer/

Hidradenitis Suppurativa: Causes, clinical features, and management

 

 

Hidradenitis Suppurativa (HS) is a chronic inflammatory skin disease affecting the apocrine gland causing suppurative lumps in areas of skin folds, such as the axilla and groin. HS tends to appear around puberty and is three times more common in females. The exact cause is unknown; however, some predisposing factors include obesity, smoking, and genetic predisposition to acne.

 

 

Severity and progression of HS differs, some patients may only experience mild symptoms and thus do not seek treatment. On the other hand, they may undergo severe progression with chronic pain, draining sinuses, scarring and significant psychological impact. Treatment includes glucocorticoids, antibiotics, and surgery. In addition, isotretinoin could be used in early presentations to prevent follicular plugging.

 

 

HS is a chronic skin disease causing recurrent, deep, and painful abscesses. In severe cases it has a substantial psychological effect, thus every effort should be made to improve the patient’s quality of life.

 

 

 

 

Written by: Khalid Al Dakheel, Medical Student 

 

Resources:

Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, Seventh Edition

https://www.mayoclinic.org/

www.DermNetNZ.org

Lichen Planus: a brief summary.

 

 

 

Lichen Planus is a chronic disorder that can present with a variety of dermatological manifestations. There are many clinical types of Lichen Planus which are based on the extent of involvement of different body parts, examples include Cutaneous, Mucosal and Nail Lichen Planus.

 

It is thought to be of an autoimmune etiology where the immune system attacks a protein within the skin and mucosal surfaces. Risk factors that may be involved include genetic predisposition, injury to the skin (Koebner’s Phenomenon) and skin diseases such as Herpes Zoster. Some drugs can induce a Lichenoid rash, examples include Quinine and Captopril.

 

Skin manifestations of Lichen Planus usually are in the form of papules and plaques. The plaques are crossed by fine white lines called Wickham’s striae. Lichen planus can occur anywhere on the skin but common sites include the wrists, ankles and the lower back. The plaques usually resolve after many months.

 

The diagnosis of Lichen Planus is usually clinical. In cases of diagnostic uncertainty, a skin biopsy may be needed to rule out competing diagnoses.

 

Mild Lichen Planus is usually treated with topical medications like steroids, calcineurin inhibitors and retinoids. More severe local disease, or in widely distributed disease, oral steroids are needed. Other immuno-modulators may be combined with oral steroids to reduce the dose, examples include Methotrexate and Azathioprine.

 

 

Written by: Turki Alsehli, Medical Student 

 

Resources:

www.UpToDate.com

www.DermNetNZ.org

Microneedling: a new approach in dermatology

 

 

Microneedling (percutaneous collagen induction therapy) is a new promising mini-invasive therapeutic procedure where small holes are created across the stratum corneum while keeping the epidermis partially intact.

 

The method is called microtraumatization which leads to an activation of the healing cascade and growth factors, which in turn activate cell proliferation in the wound and increase the synthesis/deposition of collagen (elastin complex with successive transformation of collagen III to collagen I) and neoangiogenesis which ultimately accelerates scar remodeling with minimal damage to the epidermis. This produces microchannels that increase skin permeability which greatly increases the efficacy of topical treatments applied after the procedure. Microneedling has been widely used for the treatment of skin alterations of different etiologies, like burns, acne scars, and other textural skin anomalies.

 

Numerous studies are currently examining its potential in focal diseases of inflammation, dyschromia, and photodamage. In the meantime, many clinical experiences show that microneedling appears to be a suitable micro-invasive treatment for the improvement of scar quality which has less risk of infection, post-inflammatory hyperpigmentation, and scarring compared to other resurfacing modalities.

 

 

 

Written by: Bayan Alhazmi, Medical Student 

 

 

Resources:

https://pubmed.ncbi.nlm.nih.gov/28869385/

https://pubmed.ncbi.nlm.nih.gov/29224032/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556180/

https://www.pinebeltderm.com/blog/strata-pen-microneedling-at-pine-belt-dermatology

What is Rosacea? Causes, clinical features and treatment

 

 

Rosacea is a common condition and one that dermatologists come across all the time. It is characterized by either transient or persistent facial erythema involving a chronic rash, sometimes accompanied with conspicuous blood vessels and protruding lesions.

 

Although the cause is still unclear, several hypotheses have suggested a multifactorial etiology, whether it be genetic, environmental or chronic prolonged exposure to ultraviolet radiation.

 

Rosacea is subdivided into four stages: First stage consists of episodes of flushing often frequent, followed by the second stage which comprise persistent erythema and dilated vessels (telangiectases). A minority develop the third stage, mainly manifested as papules and pustules. The fourth and last stage is Rhinophyma, a skin deformity appearing as large, bumpy red nose. It is seen more in men than in women.

 

Diagnosis is based on diagnostic phenotype, and it usually does not require an invasive investigation. Sometimes skin biopsies are performed to confirm diagnosis.

 

There is no available treatment that provides desirable results for the redness. Precautionary and preventive measures, prescribing sunscreen and avoiding exposure to heat. Oral antibiotic treatment is available, but its side-effect in the long run outweigh the calming effect. Topical treatment are as effective as oral, azelaic acid cream is efficacious at treating mild forms of rosacea.

 

Addressing Rosacea is a tricky task; the pathophysiology is still not fully understood and more research is needed to be able to target rosacea at the root cause. For the time being, lifestyle changes such as wearing sunscreen and avoiding excessive cold or heat have profound impact on the severity of the disease.

 

Written by: Naif Alshaikh, Medical Student 

 

Resources:

DermaNet NZ
The Journal of Investigative Dermatology

Rebora, Alfredo. “Rosacea.” Journal of investigative dermatology 88.s 3 (1987): 56-60