Medical and Surgical Dermatology

Acne • Psoriasis • Rosacea • Warts

Atopic Dermatitis/Eczema • Seborrheic Dermatitis (Dandruff) • Tinea Versicolor • Spider Veins

Melasma: The Mask of Pregnancy • Hives/Urticaria • Atypical or Dysplastic Moles • Actinic Keratosis

Basal Cell Carcinoma (BCC) • Squamous Cell Carcinoma (SCC) • Malignant Melanoma

 

Acne

Acne is a common skin condition that affects not only teenagers, but can extend well into the adult years. A wide variety of variables contribute to the development of acne, including skin irritants and genetic factors, as well as stress and hormonal changes. Bacteria may play a role by feeding on the sebum produced in the sweat glands, which can then grow to high numbers and cause inflammation. Certain medications, such as anabolic steroids, testosterone, prednisone and other medications may increase the incidence of acne. In general, foods such as chocolate and sweets have little effect on the development of acne.

Treatment of acne: In the early stages, treatment may be as simple as over-the-counter preparations containing benzoyl peroxides, or salicylic acid preparations may be sufficient. However, for patients with persistent acne, ongoing treatment and topical prescription medications, such as retinoids like Retin-A and Differin, may be prescribed. Various antibiotics may be prescribed, but there is no guarantee that they will be effective. In cases of severe, persistent acne, Accutane has proven to be the most effective therapy. Although there are many well-documented severe side effects, under close medical supervision Accutane is a safe therapy for the treatment of recalcitrant acne. Clearing can last for a few months for some patients, but in most cases positive results can last for many years. In any treatment of acne, it is important to follow the prescribed dosage and procedure, heed the cautions and remember that not every patient will respond in the same way. There is no "cookbook" treatment for acne.

 

Psoriasis

Psoriasis often presents as raised, thickened skin that may be covered by adherent silvery/white scale. It commonly appears on the scalp, elbows, knees, trunk, hands and feet, but it can occur anywhere on the body. Psoriasis can range from mild and localized disease to extensive, severe pustular psoriasis. Between 10 and 30 percent of patients may develop psoriatic arthritis. While the cause is still unknown, the disease probably arises from genetic predisposition triggered by external factors such as infections or emotional and physical stress. In many cases, however, the disease appears to develop spontaneously. Typically, the disease remains long after the initiating factor is removed.

Treatment: Dramatic strides have been made in the treatment of psoriasis. While topical steroids and ultraviolet light therapy have been the mainstay for many years and are still in use today, new topical agents and biologic drugs such as Humira, Enbrel and Remicade have dramatically changed the treatment paradigm. Patients no longer need to suffer the "heartbreak of psoriasis." These agents do have risks, but for most patients the results have been revolutionary.

 

Rosacea

Rosacea is a very common, and often undiagnosed, skin disease occurring in adults, though it may appear in teenagers as an inflammatory form. The disease presents as prominent facial redness or flushing. The redness may be either intermittent or persistent and include pustules and nodules on the face. Over time, enlarged, distinctly visible blood vessels may develop. In some patients, though not all, this can lead to prominent enlargement of the nose, a condition often mistakenly associated with heavy drinking or alcoholism. Although there are many dietary triggers that can cause facial flushing, such as spicy food and alcohol consumption, altering dietary stimuli will not make the rosacea go away.

Treatment is generally twofold. One prong treats the ongoing problem through a combination of topical anti-inflammatories, such as MetroGel and Finacea, as well as oral antibiotics, such as doxycycline or Minocin, which also reduce inflammation. A second prong includes treatment with topical cortisone creams and sulfur washes, which further reduce inflammation. Avoiding oil-based makeup and year-round protection from sun exposure through the use of sunscreens is strongly recommended. In some patients, these treatments do not reduce the lingering appearance of redness and enlarged capillaries. In these cases, Dr. Humeniuk recommends laser treatments. For optimum results, he offers the state-of-the-art Candela Vbeam pulsed dye laser, which can remove and eliminate most of the vessels and dramatically decrease facial redness in as few as two treatments. Intense pulsed light (IPL) can be used, but generally this requires many more treatments.

 

Warts

Warts are dry, thick growths protruding from healthy skin, often appearing on the hands, elbows and knees. They are usually caused by the human papilloma virus (HPV). They may also appear on the soles of the feet as plantar warts and around the nail folds on the fingers. These can be the most difficult to treat. Warts are transmitted when an infected patient sheds skin contaminated with the virus. It then penetrates, or seeds, through breaks and openings in the skin of another person. While warts commonly appear in children, no one is immune.

Treatment: 90 percent of warts will respond to multiple applications of liquid nitrogen with total clearing after several visits. Warts may also be removed surgically by scraping or electrocautery. Laser treatments and injecting chemotherapy drugs may also be utilized. For difficult cases of persistent warts, the patient may have an innate weakness in the immune system specific to the wart virus. In such cases, combinations of treatments listed above may be combined to further stimulate the skin's immune system to fight off the virus. For most patients, multiple treatments are required, and persistence yields the best results.

 

Atopic Dermatitis/Eczema

Atopic dermatitis (AD), or eczema, is a very common skin condition that is worldwide and can occur at any age, but it typically appears before age five and may persist into the adult years. The disease presents as dry, chapped, flaky skin appearing in the skin folds, such as the inside of the elbow creases and behind the knees and ears, though it may appear anywhere on the body. Some forms, such as dyshidrotic eczema, may cause painful and severe breaks in the skin or small, itchy blisters on the hands and feet. The condition may be associated with allergic rhinitis or asthma. Eczema can have profound spells of itching and severe skin inflammation complicated by infection caused by scratching the skin, thus producing persistent, non-healing wounds.

Treatment: Avoiding irritants to the skin, such as harsh soaps or deodorant soaps, and using moisturizers make up the front line of treatment. Mild soaps, such as Dove, Tone and Oil of Olay, as well as non-soap cleansers like Cetaphil or CeraVe, are recommended. Over-bathing or taking long, hot and/or frequent showers can also contribute to or exacerbate eczema. In persistent and severe cases, topical cortisone cream, oral antihistamines and occasionally even oral or systemic cortisone, such as prednisone, may be prescribed. In some cases, antibiotics may also be prescribed. Extreme cases may be treated with light therapy, such as PUVA, or an immune modifier such as methotrexate.

 

Seborrheic Dermatitis (Dandruff)

Seborrheic dermatitis is a very common skin disorder that is often dismissed as dry skin on scalp. Seborrheic dermatitis presents as persistent itchy, flaky skin in the eyebrows, sides of the nose, and ear canals. The diffuse redness, scaling and itching can also appear in the scalp, beard and chest hair in some men. Patients typically use moisturizers to treat the problems, only to make it worse. Rather than resulting from a lack of moisture, seborrhea is believed to be an "allergic phenomenon," a reaction to an overgrowth of yeast-like organisms and bacteria. It often appears in the elderly and also in infants, in which case it is called "cradle cap."

Treatment of seborrheic dermatitis is generally controlled by the combination of medicated shampoos containing zinc, selenium and ketoconazole compounds. Topical corticosteroid creams, lotions or antifungal preparations may also be prescribed. Unfortunately, the condition is often persistent and requires daily or intermittent therapy to control it.

 

Tinea Versicolor

Tinea versicolor is a fungal infection that earns its name due to the multiple colors that may appear in the circular or oval patches of mildly scaly skin often seen during the summer months on the upper chest and back, though the face and other parts of the body may be involved. White is the most common color seen in the patches, though the lesions may also appear medium brown and quite red. Various factors secreted by the fungus inhibit tanning, causing the skin to burn readily. Typically the patches appear during the teenage years and then spontaneously resolve in the 40s and 50s. Some patients may experience only one or two "attacks," but others may be plagued by frequent recurrences. The fungus grows in warm climates, becoming prominent during the summer. The organism that causes tinea versicolor is a normal resident of the skin. Most people are able to inhibit its growth. Thus, patients who present with the disease lack the ability to prevent it from growing on the skin.

Treatment: TV usually responds well to topical therapy with antifungal shampoos or creams and rarely needs oral antifungal medication.

 

Spider Veins

Spider veins, known as telangiectasias, are small capillaries commonly seen on the legs of women and occasionally on men. They may also appear on the face. In time, they may become quite prominent and cosmetically disfiguring.

Treatment: Sclerotherapy, in which 20 percent saline is injected into the capillaries, remains the gold-standard treatment for spider veins on the legs. The saline destroys the veins, leaving a small bruise, which lasts usually three to four weeks. Most patients achieve 85 to 90 percent clearing after several sessions. Lasers, although widely promoted as a treatment, have produced disappointing results with fewer veins responding to the treatment. Also, complications such as an increased possibility of permanent scarring and discoloration have occurred. Conversely, for spider veins on the face, pulse dye laser therapy is a safe and highly effective treatment, creating dramatic clearing in two to three sessions with minimal side effects.

 

Melasma: The Mask of Pregnancy

Though melasma, commonly called the "mask of pregnancy," is typically seen in women, it may appear in men. Lesions are characterized by persistent grayish/brown pigmentation of the face, including the cheeks, chin and forehead. The skin appears "tan," but the tan does not fade when sun exposure is reduced. Though a strong association exists between the appearance of melasma due to pregnancy and the use of birth control pills, it may also appear spontaneously in other patients, especially those in their 30s and 40s.

Treatment that includes four percent hydroquinone skin bleaches, matched with high-block sunscreens, can yield good results in some patients. Others may require multiple modalities including topical Retin-A and glycolic acid peels. The Fraxel laser, which is available at Dr. Humeniuk's main office, has demonstrated improvement even in the most resistant cases.

 

Hives/Urticaria

Hives, or urticaria, present as pink/red, well-defined, itchy swellings on the skin. In many cases, though not all, a definitive cause such as a reaction to foods, drugs or medications may trigger the response. Spontaneous cases may arise from viruses and environmental factors, such as pollen and mold. Individual lesions may resolve within 24 hours, but others can persist for days or even weeks. Most cases resolve within six weeks.

Treatment includes a combination of antihistamines and occasionally oral steroids. In cases lasting more than six weeks, medical investigation is warranted to look for other underlying causes or medical conditions. Access to a good patient history, including timing of onset and activities within 24-48 hours of onset, is helpful. Elimination of certain foods in the diet may be necessary to determine the cause.

 

Atypical or Dysplastic Moles

Dysplastic moles are notable for having somewhat irregular borders and an uneven internal pattern that may include bright red and brown spots or patches. These moles may appear to mimic, or in some cases may actually be, precursors to melanoma. While many atypical moles are benign or safe, it is important to have any moles evaluated that fit such a description. Several tools are available to the physician for use, such as a dermatoscope, which uses high-power magnification and polarized light to penetrate the mole, thus getting a thorough picture. If the mole appears questionable, it may be removed and sent to a pathologist to examine the cellular patterns.

Treatment: Dysplastic moles that do not exhibit an abnormality are often left alone, but continued self-examination by the patient is recommended. Moles that indicate signs of early progression toward melanoma after being examined by a pathologist will require a wider excision of the skin surrounding the initial site. Even if that particular mole is determined to be benign, monthly self-examination by the patient or a family member is important.

 

Actinic Keratosis

Actinic keratoses appear as persistent, rough, sometimes red and tender dry patches on the skin on the face, head, hands, arms or other body parts that typically have experienced long-term and frequent exposure to the sun. Up to 10 percent of actinic keratoses may progress to skin cancers, such as squamous cell or basal cell carcinoma. Many lesions are benign and remain unchanged for many years. Some may appear and progress rapidly. Also, old stable lesions can suddenly change and begin to grow. Unfortunately, it is impossible to predict which lesions will remain stable and which will grow.

Treatment: Cryotherapy, or liquid nitrogen freezing, is the most effective treatment for individual lesions. Extensive areas may be treated with topical creams, such as 5-fluorouracil, Efudex, Carac and Solaraze. Aldara is a new treatment that stimulates the immune system to fight pre-cancers in the skin. Some resistant actinic keratoses may need to be surgically removed.

 

Basal Cell Carcinoma (BCC)

Basal cell carcinoma is the most common form of skin cancer, appearing primarily on sun-exposed skin, though it may appear on covered skin. The risk of BCC increases with age and is most likely to appear as a non-healing, pearly nodule that occasionally bleeds, though it may also mimic scar tissue or eczema. While it rarely spreads to the bloodstream, if left unattended it can be very destructive, as it appears most often on the cheeks, nose, eyelids and ears.

Treatment includes simple surgical removal using electrodessication and curettage (scraping and cautery the area) or elliptical excision. Repair of large lesions may require skin grafts or skin flaps, which can be performed in the office. Difficult cases may require Mohs chemosurgery.

 

Squamous Cell Carcinoma (SCC)

Squamous cell carcinoma represents 30 percent of all skin cancers and presents as firm, pink/red nodular growths typically on sun-exposed skin. They are frequently seen in patients whose immune systems are suppressed, such as patients who have had heart or kidney transplants, and those with severe chronic illness, such as patients on renal dialysis. Left untreated, SCC may metastasize, or spread, to other parts of the body, including major organs, and possibly cause death.

Treatment: In the early stages, SCC is easily treated by simple in-office surgical removal of the lesion before it is able to spread.

 

Malignant Melanoma

Malignant melanoma arises from the pigment cells in the skin called melanocytes. It may occur in pre-existing moles or spontaneously arise from normal-appearing skin. Unlike basal cell and squamous cell carcinomas, it may appear in young patients who are still in their late teens. Early detection is vital since the risks and morbidity are directly related to the progression of the cancer through the layers of the skin at the time of diagnosis. 50 percent of diagnosed melanomas are in "in situ," which means they have not penetrated beyond the epidermis or outer layer of the skin. Thus, it is important for patients to recognize the characteristics associated with melanoma. Is the mole new or has an old mole begun to change within the previous one to six months? Are the margins smooth or irregular? Is the surface even in color? Is the mole smaller than the eraser on a pencil? Asymmetry, border irregularities, color variations, diameter and evolving appearance are all important factors and should lead the patient to make an appointment. However, the final diagnosis can only be made by looking at the cellular morphology, or structure.

Treatment: If a mole appears suspicious on visual exam, it will be removed in the office and sent for examination by a pathologist who specializes in dermatology. If nothing is found, the patient will simply be encouraged to continue monitoring the skin. If a diagnosis of melanoma is made, and the depth of invasion is less than one millimeter, a wider excision will be performed. This is typically done in the office by Dr. Humeniuk. Patients with melanomas having invasion depths greater than one millimeter are sent to a general surgeon for wide excision and sentinel lymph node mapping. In any case, self-examination by the patient is extremely important.