Rosacea differs from teenage acne. Rosacea is a name that means "rosy" or "red". It is a form of adult acne and frequently presents with rosiness or redness of the face. Adult acne is a different condition than teenage acne; it also behaves differently. It can effect adults at any age, but is seen more frequently in the 30's and 40's. It also tends to be more inflammatory than teenage acne. Rosacea typically has more red inflamed areas, papules and cysts (larger acne lesions), while teenage acne tends to have more "whiteheads" and "blackheads" and a greater tendency for oily skin.

The exact cause of rosacea is unknown. There are many factors which can aggravate it. Stress is a major aggravating factor, just as it is in teenage acne. Also, many women find a link with their menstrual cycle. Finally, diet can aggravate rosacea. Although we no longer believe that diet plays a major role in teenage acne, the role of diet in adult acne has been proven. Caffeine in coffee, tea, cola, iced tea and chocolate is known to flare rosacea. Alcohol, especially wine and beer, is also known to flare this condition. Spicy foods can make some patients worse, as can exercise or any activity which may cause flushing or overheating.

Rosacea may respond to different treatments than does teenage acne. Depending on the severity, treatments may range from a combination of topical antibiotics and topical cortisone lotions to oral antibiotics.

Since this condition is inflammatory, anti-inflammatory therapies, such as topical cortisone preparations are frequently beneficial and help to control redness. Strong topical cortisones or steroids, however, as well as internal steroid medications, can aggravate and cause a condition called "steroid rosacea".

Keratolytics or acids that peel the skin and clear the pores are also used. Newer acids include glycolic acid, a naturally occurring fruit acid in a family called "alpha hydroxy acids". Cleansers, astringents and lotions containing glycolic acid , such as Glytone Cream Wash 5, are often effective in treating acne and acne scarring. Also, a treatment performed in the office using stronger glycolic acid, chemical exfoliation for acne, not only smoothes and freshens the skin, but loosens blackheads and promotes acne healing.

As is true for teenage ace, adult acne is slow to respond to treatment. It may take a month or more to evaluate the effectiveness of any treatment program started. It is important to keep follow-up appointments to assess the effectiveness of any particular treatment and make changes as needed. Also, any side effects experienced, especially any rash which develops while taking oral antibiotics, should be reported to me immediately. I may need to see you back in the office to determine if this represents an allergic reaction.

General precautions

Moisturizers should be used only if necessary to treat dryness of the skin of the face. Many moisturizers are "comedogenic", meaning that they aggravate acne. It is important to use a moisturizer that is oil-free and "non-comedogenic".

The skin should be cleansed in a gentle manner, avoiding vigorous scrubbing which may traumatize the skin. "Acne mechanica" results when mild acne is converted to more severe acne due to mechanical trauma from over-washing the skin.

The exact cause of acne is unknown. Acne vulgaris is a complex condition involving many factors. The changes that occur in the body around the time of puberty are part of the story. Increased "sebum" or oil made by the oil glands in the skin on the face, chest and back also play a role. Stress is an aggravating factor. So is caffeine, found in coffee, tea, cokes, iced tea and chocolate.

The key problem in acne vulgaris is an abnormal accumulation of keratin, the protein that makes up the dead layer of the skin. This keratin is retained within the hair follicle, resulting in a "plugging up" of the follicle. These keratin plugs become the "whiteheads" and "blackheads" known as "comedones."

Bacteria called Propiobacterium acnes digests the oil inside these comedones ("whiteheads" and "blackheads") and releases highly inflammatory waste products into the surrounding skin. This inflammation gives rise to inflammatory papules ("pimples") , pustules, and cysts (larger "pimples").

Grading Acne

Acne is often graded. Grade 1 acne consists of comedones, ("whiteheads" and "blackheads") only. Grade 2 acne also has inflammatory papules ("pimples") along with comedones. Grade 3 acne has papules, pustules, and comedones. Grade 4 acne has all of the above, along with acne cysts.

Grade 4 acne is the most severe and causes the most scarring. Simple Grade 1 or Grade 2 acne usually does not cause scarring, unless a patient scratches, picks or traumatizes the acne.

Treatment of Acne

Acne treatment differs for different people and different types of acne. External or topical treatment alone is often effective for Grade 1 or early Grade2 acne. Severe Grade 2, Grade 3 or 4 acne often requires internal medication. These medications may include antibiotics aimed at the acne-producing bacteria, as well as other medications aimed at the keratin plugs.

An external method of treatment, "chemical exfoliation for acne", is usually added to medication. This therapy consists of the use of a mild acid ("glycolic acid" from fruit) to promote light peeling of whiteheads and blackheads and remove keratin plugs.

The use of an alpha-hydroxy acid cleanser, such as Glytone Cream Wash 5 or Glytone Gel Wash 9 (containing 5-9% glycolic acid) is usually started two weeks prior to the chemical exfoliation in the office.

Acne is often slow to respond to any treatment. It may take four weeks or more to evaluate the success of any new treatment program. More frequent follow-up evaluation may be necessary in the beginning so that changes in the therapy can be made as needed. It is important to keep these follow-up appointments, so that valuable time, energy and money are not wasted on treatments which are not working!

It is also important to report any side effects you may have from a treatment, particularly if you develop a rash while taking an antibiotic. It may be necessary to see you again to evaluate such a rash and determine if it is an allergic reaction. Also, be aware of precautions. Many medications, such as tetracycline, may make you more sensitive to sunburn.

Any moisturizers, foundations or sunscreens used should be oil-free.

Above all, try to be patient. Not everyone responds to the same medications, and some patients need to try several treatments before one is found that works well.

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Atopic eczema tends to be worse in infancy. Most children outgrow eczema as they get older. A few unfortunate individuals will carry this form of eczema into adulthood. Other individuals may go into remission in adulthood, with only occasional flare-ups often limited only to the hands, or the hands and feet.

The areas of skin involved most often in childhood eczema are the face, the neck, the inside of the elbows and the backs of the knees. Any surface of the skin, however, may be involved. The diaper area is commonly involved in small children. The hands may be the only manifestation in many adults.

Although atopic eczema is not itself a true allergic reaction in most patients, atopic individuals do have a high incidence of allergies. In addition to hay fever or sinus allergies, the atopic person may also be particularly sensitive to nickel, such as is present in most costume jewelry. Also, certain additives and ingredients in topical creams and moisturizers, such as "lanolin", a frequently used moisturizer, and "paraben", a preservative found in many lotions.

Atopic eczema is frequently aggravated by stress. It also is known to have "ups and downs" of its own. Many patients are worse in the winter when their skin is dry, and improve in the summer due to ultraviolet exposure. Others worsen in the summer due to aggravation of the eczema from increased sweating.

Atopic eczema must be distinguished from other types of dermatitis, including contact dermatitis (a rash resulting from coming into contact with a substance to which the patient is allergic). Also, a scraping of a scaly patch of skin in order to perform a microscopic examination for fungus helps to rule out the possibility of ringworm or fungal infection. Psoriasis may also be confused for this condition, but is usually a thicker and more scaly eruption.

Treatment of atopic eczema can sometimes be challenging. There is no cure for this skin disease, but many treatments exist which can cause a remission. Reduction of stress is frequently helpful. Other treatments include the use of topical and/or internal cortisone medications and moisturizers. Proper treatment of dry skin is crucial, as it can easily flare eczema. Newer topical and internal antihistamines are often helpful.

Periodic examinations may be needed to gauge the effectiveness of treatment and make changes or try new treatments as they become available.

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Dysplastic Nevus ("Abnormal Moles")

Some forms of melanoma, a deadly form of skin cancer, may arise from a pre-existing mole or "nevus". Other melanomas can arise with no pre-existing growth.

The melanomas that do come from a pre-existing mole often do not suddenly arise from a completely benign normal appearing mole. A mole can go through a changing process from being completely benign to being abnormal, but not yet cancerous, and then finally becoming a melanoma.

These early pre-cancerous abnormal moles are now called "dysplastic nevi". A dysplastic nevus is one that looks abnormal clinically, that is, to look at on the skin, and it also looks abnormal under the microscope when it is removed and tested.

Dysplastic moles can run in families. It is thought that people who have an inherited form of dysplastic moles have approximately six times greater risk of developing a melanoma, the deadliest form of skin cancer. People who have these abnormal moles should be watched carefully for the possibility of development of melanoma.

It is advisable to remove worrisome looking moles early in their development. Melanoma may be prevented in this manner. Dysplastic moles can be mildly, moderately, or severely dysplastic. If a mole is dysplastic, particularly if it is moderately or severely dysplastic, it is important to be sure that the mole has been completely excised. If the margins of the original specimen excised show any residual mole a wider excision is required to ensure that the growth has been removed completely with "clear margins."

If we find that you have any dysplastic moles, it is advisable that you return for periodic skin examinations. You may have an increased risk for developing other pre-cancerous moles in the future.

How to tell if a mole has become dysplastic - what to look for? The warning signs are known as the A, B, C, D's of moles:

A: ASYMMETRY: A mole should be round and symmetrical. If asymmetrical in its shape, a mole is considered worrisome.

B: BORDER: A border should be smooth, round and well demarcated. If the border is jaggedy, notched, scalloped, or trails off and is indistinct such that it is difficult to tell where it starts and stops, this can be a worrisome sign.

C: COLOR: A mole can be anything from flesh color to dark brown, but it should be evenly all one color. If a mole has several different colors, has irregular color, or particularly if it is blue, black or red, or if it loses color and becomes white, this can be worrisome.

D: DIAMETER: Basically, most normal moles are less than 6 millimeters (smaller than a pencil eraser tip). If a mole becomes larger than 6 millimeters, this also can alert us to the possibility of dysplastic change.

"Congenital nevi", moles arising at birth or shortly thereafter, may also have an increased risk of turning into melanomas and may be excised preventively.

Dysplastic moles, whether congenital or acquired later in life are frequently excised in order to prevent the development of a melanoma. If you have many abnormal looking moles, we will most likely treat you with a combination of surgery and surveillance. Periodic examinations will be done and the most abnormal moles removed. Others will be watched for change or worsening in above characteristics.

Other characteristics which may indicate that a mole should be removed include:

*any recent or sudden change in size or shape of a mole

*symptoms such as pain, bleeding, itching, infection or inflammation in a mole

Dry skin is a common affliction. Environmental changes along with bathing habits may contribute to aggravate dry skin. Individuals with dry skin often experience an unusual amount of itching and can be more prone to the development of certain conditions such as eczema and psoriasis.

Causes

Dry skin is often aggravated during the winter due to cold dry weather aggravating the dryness of the skin. Also, the heat being on in the house will tend to dry the air and cause the skin to be drier.

Dry skin also becomes worse with age particularly in the lower extremities where fewer oil glands exist to begin with. As one ages, the skin has less and less actively functioning oil glands and nature's own moisturizer to the skin begins to be depleted.

Prevention

In order to treat dry skin it is important to use a soap that contains a moisturizing cream. Deodorant soaps although helpful in controlling bacteria especially when used in bacteria prone areas, often are harsh and drying to the skin and may aggravate dry skin especially on the arms and legs.

It is also important to avoid the use of very hot water in the bath or shower. Hot water tends to leach out the skin's natural oils just as hot water is helpful in washing a greasy pan in the sink. Also, it is important to avoid staying in the bath or shower for a long time. Prolonged exposure to water such as during bathing or soaking in hot tubs or swimming in a swimming pool tends to leach out the natural oils from your skin.

Treatment

Treatment of dry skin consists of not only following the above recommendations, but applying a good moisturizer immediately following the bath or shower. One should pat dry immediately following bathing and then apply moisturizer to all areas of the body surface while the skin is still slightly damp.

Moisturizers often come in both creams and lotions. Creams, although slightly more greasy, are usually heavier and provide more moisturizing during the winter. Lotions are lighter and sometimes more cosmetically acceptable especially during the summer.

There are basically two classes of moisturizers. One class is those containing oils or other moisturizing ingredients that help to add back oil or seal in moisture to the skin.

A second class of moisturizers are those containing active ingredients that actually hold additional water in the skin. These active ingredients are known as alpha-hydroxyacids (AHA's).

Several alpha-hydroxyacids such as "glycolic acid" are used in moisturizing creams and lotions and are very effective in holding moisture in the skin. These active ingredients actually are able to hydrate the skin more than just a plain oil or lotion or cream.

A strong glycolic acid moisturizer, Glytone Body Lotion 20, is available at my check-out desk.

In this century there has been an alarming rise in the attack rate of skin cancer! Back in the 1930's, only one out of every 1500 hundred people developed malignant melanoma, the deadliest form of skin cancer. That rate has doubled each decade so that by 1995 the attack rate has reached one out of every 75 persons!

Skin cancers when detected early are often very easy to treat, but when detected late, especially in the case of melanoma, can be devastating.

Office Skin Examinations

Our philosophy in the practice of dermatology is that an ounce of prevention is worth a pound of cure. We strongly believe in regular skin exams to detect and prevent early skin cancer and pre-cancerous growths.

Therefore, we recommend fair-skinned patients, or other patients who may have an increased risk for skin cancer due to personal or family history, return for a general skin examination every six months.

New patients, regardless of the purpose of their visit, are encouraged to seek a skin examination to evaluate moles, growths and possible early skin cancers or pre-cancerous growths.

Personal skin self-examination is also encouraged once a month to notice new skin growths or changes in existing growths or moles.

The best way to prevent skin cancer is to protect your skin from the harmful effects of the sun's rays. We now know that both UVA and UVB ultraviolet light is damaging to the skin and can cause skin cancer.

Patients with fair skin or other risk for skin cancer should wear a high level of sunscreen, with an SPF of at least 15, starting in the spring from early April until late September each year.

A broad spectrum sunscreen (such as our Maximum Protection Sunscreen 25 available at the check out desk) which contains UVA coverage along with UVB protection is preferable.

We believe that only through aggressive and careful follow-up can the skin cancer epidemic be stopped. Remember, if you can spot it, you can stop it!

Seborrheic dermatitis is a form of dermatitis or eczema, the cause of which is unknown. We do know several things about it. Firstly, it has a tendency to break out in certain areas such as the scalp, the ears and the face. On the face it particularly tends to be in the eyebrows, the areas beside the nose, and also the areas around the mouth and eyelids. Particularly in men, it may also break out on the middle of the chest. It may also less commonly break out under the arms and in the genital area.

Seborrheic dermatitis is known to be aggravated by stress. This does not mean that stress is the cause of the condition, but that stress can cause flare ups or worsen it. It is also known to be helped by exposure to ultraviolet radiation or sunlight. Therefore, frequently people will flare with this in the winter when they are getting less ultraviolet light. There is also some evidence that a hyper-sensitivity reaction to a yeast present on the skin known as "pityrosporum" may also play a role in this disease.

There is no cure for seborrheic dermatitis. It is characterized by having "ups and downs". However, there is treatment that can put it into remission, but it may need to be treated intermittently whenever it flares up again.

Treatment of seborrheic dermatitis of the scalp includes the use of different medicated shampoos. Tar is beneficial but can stain light hair. Glycolic acid-containing shampoos have recently been shown to be helpful. Topical prescription cortisone lotions may also be of benefit.

Seborrheic dermatitis of the face may be treated by different topical prescriptions including cortisone cream and anti-yeast agents. A facial cleanser with glycolic acid such as Glytone Cream Wash 5 (available at the check-out desk) is also helpful for facial involvement. Seborrheic dermatitis can sometimes be confused with another condition known as psoriasis or may also mimic a fungal infection on the face. A scraping for examination under the microscope may be done.

There are several forms of skin cancers that dermatologists see and treat in their practice. Three of the most important and commonly seen forms of skin cancers are the deadly "melanoma", the much more innocuous "basal cell carcinoma" and the "squamous cell carcinoma".

All three of these important forms of skin cancer are seen more commonly in fair skinned individuals and are directly related to the cumulative amount of sun exposure that one has over the course of a lifetime. Persons with red hair are particularly at risk for melanoma, as are fair skinned people of Irish or Northern European descent. Also, a history of living in areas with more sun exposure such as Florida puts one at greater risk. Finally, certain occupations which involve over the course of a lifetime much outdoor exposure such as farming or construction work, may also increase the likelihood of developing skin cancer.

It is alarming that the incidence of skin cancer, and particularly melanoma, is very much on the rise. The incidence of melanoma in the United States has doubled every decade since 1930. It is currently estimated that 1 in 100 children in the United States will develop melanoma in the course of their lifetime.

Melanomas are the most serious form of skin cancer commonly seen. Melanomas may arise from a pre-existing mole or may arise on their own without any pre-existing growth. They are generally black, dark blue or brown-black in color. However, there is a form of melanoma called "a-melanotic melanoma" in which there is no color associated. Melanomas on the skin can be easily detected by an experienced observer before they have had a chance to spread internally.

Predisposing factors to melanoma in addition to those mentioned above, i.e., red hair, fair skin, and prolonged exposure to the sun, also include a positive family history of melanoma, as well as a personal history or a family history of abnormal moles. These abnormal moles are called "dysplastic nevi". For a more in-depth discussion of these, see my handout on Dysplastic Nevus. These unusual moles are larger than normal and irregular in shape and color and can progress to melanoma. There is thought to be approximately a six-time greater risk of melanoma in patients who have dysplastic nevi than in patients who do not.

The most common form of skin cancer and the most harmless is called the "basal cell carcinoma". These sun-induced skin cancers grow most commonly in sun exposed areas such as the face, the arms, the upper back and chest. They are generally flesh-colored, dome-shaped elevated growths on the skin, often with a smooth or pearly surface. Sometimes dilated blood vessels can be seen in these. Also, if they have been present long enough, small ulcerations may begin to appear in the center. Another clinical version of this skin cancer is the superficial basal cell. In this form, rather than a dome-shaped bump on the skin, one may only have a flat red scaly patch on the skin resembling a patch of eczema or psoriasis. This form of skin cancer is slow growing most commonly. It very rarely ever spreads internally. Basal cells, however, if neglected and left to grow, can grow deeper than the skin surface. They have been known to grow into muscle and bone. People have died from these lesions when neglected especially when present on the face and head.

The third most frequently encountered form of skin cancer is known as the "squamous cell carcinoma". This form of skin cancer is intermediate between the basal cell and melanoma in its tendency to spread internally. They do not spread internally as readily as do melanomas, and yet they do have the capacity to do so unlike the basal cell which almost never spreads internally. Squamous cells are often hard elevated growths in the skin sometimes having a bumpy surface and resembling warts. There is also a superficial form of squamous cell carcinoma known as Bowen's disease. A Bowen's disease may look somewhat similar to a superficial basal cell in that it may resemble a red scaly patch of dry skin. Squamous cells near the lip or mouth are more dangerous and more likely to spread internally. It is important to be sure that squamous cells have been adequately treated as they do have the capacity to spread internally to other organs if left neglected.

Treatment for Skin Cancer

Treatment of each of these forms of skin cancer will vary according to the type, as well as the depth and extent of the lesion. The location will also play a role. Melanomas generally require larger excision if more involved than just the top layer of skin.

Squamous cell carcinomas and basal cell carcinomas are generally treated by the dermatologist in the office. Different treatment modalities include "elliptical excision" of the skin cancer and closure with sutures and "cryosurgery" in which liquid nitrogen is applied to the malignant growth.

Pre-cancerous growths known as "actinic keratoses" may also be seen in patients at risk for the above types of skin cancer. These are generally treated either by cryosurgery with liquid nitrogen or may be removed and tested in the laboratory if there is a possibility that these lesions may have gone from the pre-cancerous into the early cancerous phase.