Dermatology

What is Dermatology?

Dermatology focuses on the diagnosis, treatment and management of skin disease in children and adults.

The three most common dermatology conditions are:

  • Skin Itching and Rash
  • Psoriasis,
  • Eczema


Descriptions and management of these conditions are detailed below.


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Skin Itching and Rash

Itchy skin can be a symptom of an underlying illness or it can be due to eczema or dermatitis, rash or skin inflammation, dry skin, scabies, psoriasis, burns and scars or nerve disorders, etc.


Treatment involves finding the cause of itching and then removing it.


Your doctor may recommend prescription medications or other treatments if home remedies do not work.


Psoriasis

What is Psoriasis

Psoriatic lesions develop on the skin due to the abnormal functioning of the lymphocytes present in the blood resulting in a more rapid turnover of skin cells.

It is a non-communicable disease and is considered mild or severe depending upon the area of involvement of the disease and the time for its recovery.


Psoriasis is a chronic, incurable skin condition with periods of clear skin followed by episodes of relapse. Some patients notice more lesions in winter, with emotional stress, injury to the skin, skin infections and use of certain medications.


Psoriasis is a global condition affecting people of all age groups with a higher incidence in younger adults.


Symptoms of Psoriasis

Symptoms of psoriasis depend on the type of psoriasis.


The most common symptoms include dry, red patches which can be itchy and irritating; often develop on the elbows and knees but can spread to the other parts of the body. It may also affect the joints, nails and present as severe dandruff.


Based on the characteristics of plaques and the body part affected, psoriasis is categorised into five types, namely:

  • Erythrodermic psoriasis – Spreads all over the body with characteristic red skin and shed the scales in sheets
  • Guttate psoriasis – Small pink spots develop on the trunk and limbs
  • Inverse psoriasis – Smooth, shiny bright-red lesions develop in the regions of skin folds such as armpits, groin, under breasts and around the groin
  • Plaque psoriasis – Most common form of psoriasis and is characterised by red raised plaques with silvery-white scales that develop on elbows, knees, scalp and lower back
  • Pustular psoriasis – Psoriasis subtype with blisters of non-infectious pus surrounded by inflamed skin


Diagnosis of Psoriasis

The diagnosis of psoriasis involves the physical examination of the patient’s skin and rarely a skin biopsy. X-rays may be requested if joint pains are present.


Treatment of Psoriasis

There are a number of treatment options to treat psoriasis and including:

  • creams,
  • injections,
  • tablets and
  • light therapy.


At your consultation, your skin will be assessed and a treatment plan will be discussed.


Eczema

What is Eczema?

Eczema is also referred to as Atopic Dermatitis (AD). Eczema is not a minor skin disorder, Eczema is a chronic inflammatory skin disease. It is a term used to describe red, inflamed or irritated skin.


While a cure does not exist, certain precautions, self-care regimes and treatment can greatly reduce Eczema and prevent new episodes of Eczema recurrence. Eczema is not contagious.


What Does Eczema Look Like??

Eczema can present with many symptoms. Typically it is characterised by red, dry, scaly, thickened skin.


Eczema can appear very differently due to many reasons, but commonly has varying signs including:

  • Location - even in the same patient, Eczema on the scalp, lips, eyes, hands, genital areas etc. can look nothing like each other.
  • Severity: Depending on how serious the condition is, it can look like “just a dry skin patch” or inflamed, crusty blood over the eczema wounds or lesions and broken skin or weeping (oozing) with yellow fluid and pus due to a secondary infection - impetigo.
  • Chronicity: newly developed eczema lesion looks very different from the one that has been there a long time which can look like elephant skin without much inflammation or oozing.
  • Colour: Due to chronic inflammation, the skin lesion can become lighter than normal skin colour – hypopigmentation; or darker colour – hyperpigmentation. Hypo and hyperpigmentation can occur concurrently in the same patient and even in the same lesion.


How is Eczema Characterised

Eczema skin is characterised by:

  • Skin Dryness - Dry skin is the key feature of eczema. Skin can be dry, very dry or extremely dry. This is due to the lack of natural oil (NMF – natural moisturising factor) production of eczema skin.
  • Skin Infection - Lack of “natural antibiotic” or AMP – antimicrobial peptide,
  • Skin Repair - Poor skin reparation and regeneration ability.
  • Skin Immunity - Compromised local immune system as a result of a combination of above.


Who is affected by eczema?

It is very common in children. In Australia, 38.5% of infants suffer eczema, and while most children with atopic dermatitis grow out of the disease when their skin matures, about 15 % will continue to suffer from eczema into adulthood.


Eczema in children usually begins before the age of 5. In 60% of the cases, the symptoms will develop by the age of 1 and in nearly 30% of cases, the symptoms are visible by the age of 5.


Children that carry a genetic variation that affects the functionality of the skin as a barrier and the immune system is more vulnerable, hence more likely to develop Eczema.


What are the causes of eczema in Children?

Historically, eczema has been believed to be caused by allergies and that psoriasis is an autoimmune disease.


These views have been constantly challenged by evidence of modern research which links these inflammatory diseases to compromised skin barriers due to a genetic mutation. Skins of these patients are also proven to lack adequate antimicrobial peptides, which is our first line of defence against microorganisms, and natural moisturisers. This, in turn, weakens the ability of the skin to repair and fight infections. The absence of this optimal ability of the skin to repair and fight microorganisms leads to a hyperactive and dysfunctional immune system.


Abnormal immune system functioning is the clinical manifestation of eczema (and psoriasis) but not the cause. These deregulated immune system activities are the desperate attempts of the skin to repair and rid invasive microorganisms. Treatments that aim to restore/enhance skin barriers and to kill microbes have been proven to improve eczema (and psoriasis).


How does eczema occur in children?

Eczema occurs when the skin is unable to perform its function as a barrier normally and the body reacts in an overdrive heightened fashion.


Normally. The skin acts as a barrier that locks in moisture and prevents environmental agents, bacteria, viruses, irritant substances and allergens from entering the body.


If this ability is affected, the skin reacts to exposure by these irritants and bacteria by turning red and becoming itchy.


Eczema occurs only when we have the combination of the 2 factors:

  1. Internal factor from a genetic predisposition.
  2. Environmental or external factors from any skin unfriendly or unfavourable environment.


Either of them can be the predominant factor or both can be equally blamed for causing the disease. Patients with strong genetic predisposition can develop eczema with minimum help from the environmental factor. On the other hand, patients with a weak genetic predisposition still can have severe eczema if the environmental insult is overwhelming.


Genetic predisposition can be inherited or “self-manufactured” – meaning the genetic anomaly happened within you. In the latter, environmental insults e.g. frequent contact with toxic chemicals, repeated trauma etc. can be a trigger of the genetic mutation.


Skin DNA change due to genetic mutation - either from inheritance or self-manufacturing – makes the skin of these patients “sensitive”, prone to develop eczema when given the right setting.


Environmental factors such as harsh climate – too cold, too dry – or chemicals, pollutants, microorganisms i.e. germs, allergens etc. will unfriendly react to an already sensitive [weak] skin [due to genetic mutation] and starts eczema.


Normal skin under these circumstances can easily overcome these conditions warding off the attacks and recovering. This is not the case for eczema skin, it will struggle and keep on fighting the unwinnable battle. This is the reason for ongoing inflammation with symptoms and signs of eczematous skin.


Other environmental factors that can trigger an episode of Eczema include:

  • Dry skin left untreated,
  • Using harsh soaps and skin products that result in dry skin,
  • Dry weather such as cold winters and low humidity, and
  • Certain food allergies can also trigger eczema. However, food allergies and eczema are totally different disease entities. As a matter of fact, most allergy sufferers don’t have eczema and the majority of eczema patients have no allergy at all! The way food allergies trigger eczema is not much different from insect bites and chemicals. Ingested allergic food in a certain individual can cause allergic skin reaction within turn will cause inflammation and itchy skin which will lead to scratching, traumatising of the skin barrier and at the same time introducing microorganisms into the skin - The eczema process is set in motion.


What are the symptoms of eczema?

The main symptom of Eczema is mild to severe itching, which gets noticeably worse at night.


Some of the common presenting signs include:

  • Dry skin with or without visible cracks,
  • Cracked thickened skin,
  • Tiny bumps, which are raised and may ooze liquid on pressing and become crusty on scratching,
  • Patches on the skin are red to brown in colour, the size of which varies.


These visible signs of Eczema may present anywhere on the body such as

  • the upper chest,
  • neck and
  • eyelids,
  • hands and wrists,
  • ankles and feet and
  • even the knee and elbow pits.


In small children, the most affected areas also include the scalp and the face.


What are the types of eczema?

Eczema has several different types, which include:

  • Atopic dermatitis
  • Contact dermatitis
  • Nummular Eczema
  • Stasis dermatitis
  • Dyshidrotic dermatitis
  • Seborrheic dermatitis


These types differ in their initial causative triggers, target population and appearance of symptoms.


What are the stages of eczema?

There are no stages, but the severity of the symptoms is gradient and depends on the:

  • Size of the affected area, and
  • Duration of the inflammation.


How is eczema diagnosed?

The standard diagnosis of eczema is made most of the time from

  • a clinical examination, and
  • patient history.


However, if in doubt, the doctor will do a biopsy to get a histological diagnosis. This is considered the gold standard of many skin condition diagnoses. 


How is eczema in children treated?

The conventional treatment of eczema is using mild potency topical corticosteroid. In severe cases, doctors even prescribe oral steroids or immunosuppressant medications.


These treatments aim to reduce inflammation to give the benefit of symptom relief. It requires ongoing treatment to keep eczema symptoms at the base. There are problems with the long term use of steroids and immunosuppressants which are well documented.


Our doctors, however, treat eczema based on a different approach.


To treat eczema effectively, we need to address not one but all of the four issues associated with eczema:

  1. Stop the dryness: optimal skin hydration is the key to eczema management. It does not matter how many times moisturiser is applied to the skin, if skin hydration is not 100%, eczema cannot get better. Using moisturiser from 2-3 times a day to 6-8 times a day is quite common among eczema patients.
  2. Kill the germs, remove all irritants: these are the reason for the ongoing inflammatory reaction inside your skin.
  3. Repair broke and damaged skin, regenerate healthy skin: This will help to restore the healthy skin barrier and close up all the entry points of germs and irritants.
  4. Reducing inflammation: Reducing inflammation means reducing itchiness. Every time patients scratch [mostly due to intense itch], they will damage the healing skin and simultaneously introduce additional germs into their broken skin and at the same time, they will damage the healing skin.


Even though steroids are the most widely used form of treatment for eczema, they only help in reducing inflammation [hence reducing symptoms of eczema]. On the other hand, the steroid will weaken the skin immune system and make it harder for the body to kill germs. Furthermore, steroids also impair the skin ability to repair and regenerate.


What If eczema is left untreated?

If eczema is left untreated, it can cause a number of complications which can include:

  • Skin Infections. Secondary skin infection with oozing fluid and pus is a common complication of untreated eczema. Occasionally, the infection can turn to cellulitis which requires hospitalisation.
  • Poor Sleep. Poor and broken sleep in children will result in failure to thrive and growth retardation.
  • Anxiety, depression, poor self-esteem.
  • Lichenification. Skin becomes leather-like due to chronic scratching and inflammation.
  • Hypo or hyperpigmentation. Skin whiter or darker.
  • Permanent scarring.