VITILIGO

How to Recognize – This chronic skin disease afflicts one percent of the population. It is most notably recognized by irregular shaped porcelain white patches of skin and mucosa as well as hairy areas. It is most often seen on hands and commonly around the eyes, nostrils, mouth, nipples, umbilical, body folds, and axilla. Vitiligo occurs when pigment cells (melanocytes) are damaged or destroyed. The pigment loss is variable progressing at different rates. The depigmented areas have an increased risk of sunburn and skin cancer. There is an increased incidence of thyroid disease associated with vitiligo as well.
How to Treat – Treatment requires two parts working in tandem: at-home care and medical treatment. At-home care includes increased protection with UVA/UVB sunscreen of at least SPF 30 and protective clothing, and oral supplements. Vitamins C, E, and B, melatonin, ferulic acid, green tea, and golden fern extracts (Heliocare), are all documented to provide photoprotection. Sunless tanning products do help the cosmesis and safely add protection comparable to SPF2. Camouflaging agents are effective, especially for Fitzpatrick III to V. Medical treatment consists of topically applied high potency prescription corticosteroids, calcipitriol, and tacrolimus. Phototherapy with psoralens and UVA are most effective but need 50 to 100 treatments. When to Refer – Effective therapy requires a dermatologist’s care.

SEBORRHEIC DERMATITIS
How to Recognize – The most common and mildest form of this disease is dandruff, and as such is probably the most common of all skin diseases when all the variants and associated conditions are included. For example, rosaceic dermatitis includes characteristics of both seborrheic dermatitis and rosacea. Seborrheic dermatitis is usually found on areas of the body with more sebaceous glands, such as the forehead, eyebrows, around the nose and ears, scalp, midchest, and central trunk. Changes in weather conditions, physical and emotional stress, or trauma to the skin can activate and/or amplify the symptoms. Although all ages are affected, it is more common in elderly and infants, which is called cradle cap. Seborrheic dermatitis is characterized by greasy yellow scaling on erythematous patches of various thicknesses. It often has no itching. Neurologic problems such as Parkinson’s, stroke, spinal cord injury, and human immunodeficiency viral infections are afflicted with a high rate of seborrheic dermatitis. It appears pitysporum yeast is the major cause although secondary bacterial infections may produce weeping and fissuring.
How to Treat – Again, treatment of seborrheic dermatitis will be most effective with a dual approach. A diet high in anti-inflammatory foods such as salmon, cabbage, avocado, and antioxidant rich foods such as spinach are helpful. Avoiding foods that increase peripheral blood flow such as alcohol, hot spicy foods, sugar, and caffeine can help improve control.
Topical therapies are effective in most patients. Oral antibiotics may be needed to achieve control. However, oral corticosteroids are rarely used.
When to Refer – When topical non-prescription anti-inflammatory agents such as salicylic acid, hydrocortisone, tar, selenium sulfide, micronazole, or zinc pyrithione products do not control the disease along with the above mentioned dietary adjustments, refer to a physician.

PERIORAL DERMATITIS
How to Recognize – This disease is characterized by pinpoint erythematous papules and pustules, similar to small acne lesions around the mouth, nose, chin, and eyelids on top of a scaly, red base. Typically found in young women and children, perioral dermatitis is usually not found close to the edge of the mouth. Usually it has no symptoms but may itch. It is thought that use of higher potency corticosteroids than hydrocortisone for other skin diseases can actually induce perioral dermatitis outbreaks as can frequent prolonged use of heavy moisturizers. The presence of Fusobacterium and the response to oral anti-inflammatory antibiotics such as doxycycline, azithromicin, and clindamycin indicates that a bacterial infection is a causative factor.
How to Treat – Traditional topical acne treatments are not effective for perioral dermatitis as it has a different mechanism of action. This disease is often initially mis-diagnosed. Non-prescription treatments used for seborrheic dermatitis are often effective in treating perioral dermatitis. Effective topical therapy includes prescription metronidizole, sulfacetamide, and clindamycin, which are anti-inflammatory antibiotics. Topical anti-inflammatory medications such as pimecrolimus and tacrolimus effectively treat this disease. Corticosteroid creams other than hydrocortisone should not be used as worsening can be expected when their use is stopped.
When to Refer – When non-prescription therapies fail to control the visible lesions, including avoiding a diet high in pro-inflammatory items mentioned above for seborrheic dermatitis treatment, a physician will need to prescribe appropriate prescription therapy.

WARTS
How to Recognize – Warts are caused by the human papilloma virus (HPV). HPV has 150 subtypes, but four account for 75 percent of genital cancers. About three percent of warts present more than 10 years on palms and soles progress to squamous cell carcinoma. Warts of varying types afflict 10 percent of children and young adults. They are transmitted from touch, so it is important to be careful when working with a patient/client with warts. HPV is the second most common sexually transmitted disease.
The classic verrucae vulgaris is brownish or flesh colored with a rough, scaly surface or multiple rounded papules. Some look like thick calluses with depressions in the center while others are pink, scaly papules. Any part of the body can be involved, but the trunk is usually spared. The characteristic change of black dots is due to thrombosed vessels.
How to Treat – Combining multiple treatments is the most effective strategy. There is a vaccination on the market for HPV (Gardasil) for young women to prevent cervical cancer. Effective topical treatment options include liquid nitrogen, trichloroacetic acid, ablative laser, topical cantharidin, azelaic acid, salicylic acid, imiquimod, and tretinoin. Oral cimetidine increased the body’s immunity against HPV. Intralesional bleomycin, intralesional candidin, and topical squaric acid administered by dermatologists all modulate immunity as well. Rarely, shave removal with curettage is needed. Electrocuentery should be avoided as it always scars. Other treatments may produce abnormal pigmentation.
When to Refer – Often times people will go for long periods of time before having a physician check their wart(s). If you notice that a patient or client has a wart(s), refer them to a physician. Due to the potential for causing cancer and afflicting babies, wart therapy is not considered cosmetic.

PSORIASIS
How to Recognize – One of the most widely known skin diseases afflicting one to three percent of the population, this chronic autoimmune disease afflicts joints in eight percent and nails in 33 percent. The abnormal nails range from pitting to yellow spots (oil spots) and yellow thickened brittle nails. Psoriasis classically looks like raised, red, thickened patches covered with a silvery white scale of dead skin cells. Psoriasis is not limited to any particular part of the body, but commonly involves scalp, knees, elbows, hands, and feet. Genital involvement is especially troublesome for the patient. According to quality of life measures, this is one of the most debilitating of skin diseases.
How to Treat – There are a variety of topical and oral prescription and over-the-counter therapeutic options, including light therapy. Phototherapy with sunlight, tanning booths with or without tar can be helpful, but in-office narrow band UVB (NBB) or psoralen with UVA (PUVA) are more effective. Especially when more than 10 percent of the body surface area is involved or severe involvement of key functioning anatomic sites such as hands, feet, scalp, and genitalia aggressive therapy is needed. Over-the-counter products that have been found to be effective include a combination of skin barrier repair technology and anti-inflammatory ingredients such as tar, sulfur, salicylic acid, urea, peanut oil, phenol and sodium chloride, and aloe vera. Diet therapy such as the South Beach diet, high anti-inflammatory/antioxidant diets such as Mediterranean and Asian diets are helpful as does avoiding caffeine, theobromine (chocolate), and alcohol. High protein diet and often iron supplementation is needed to counteract the loss of scaly skin. It is the combination of different types of therapeutic options which will produce the best, longest lasting clearing of the disease. The root cause of psoriasis is autoimmune inflammation coupled with a skin barrier abnormality, and the most effective therapy is rotating multiple therapies every three months.
When to Refer – Moderate to severe cases require a physician for prescription oral retinoids, immunosuppressive and/or chemotherapeutic agents, topical calcipitriol and high potency corticosteroids and phototherapy with NBB or PUVA.

FOLLICULITIS
How to Recognize – This disease is caused by inflammation of the hair follicle. The most common types are mechanical due to tight abrasive clothing or persistent rubbing, and bacterial due to staphylococcuss aureas. Pitysosporum yeast folliculitis can mimic acne, although it usually itches. Pseudomonas type occurs with hot tubs, but is distributed in bathing trunks. The others tend to involve scalp, face, upper back, arms, and legs. A hair is usually visible in the pustule. The infectious types may be associated with the crusted lesions of impetigo. Folliculities can also be confused with heat rash.
How to Treat – Culturing of the pustules is critical since antibacterial medicines will make pitysosporum folliculitis worse. For individuals who suffer chronic folliculitis, laser hair removal is helpful, but usually three to four months of suppressive antibiotics may be required. Since up to 25 percent of Americans carry staphylococcus, topical therapy with Altabax or Mupirocin is necessary for all members of the patient’s household for complete control in recurrent folliculitis.
When to Refer – A physician will need to make an official diagnosis as to ensure the correct disease is being treated.

HERPES SIMPLEX
How to Recognize – This virus is the most common cause of oral and genital mucosal ulcerations in the developed world, afflicting 20 percent of adults. This highly contagious infection can be transmitted without active ulcers or blisters. The classic genital infection (Type 2) has an 85 percent recurrence rate averaging four times a year, while the oral (Type 1) has a 55 percent rate of recurrence averaging once a year. The primary infection is invariably severe with blisters becoming pustules, pain, swollen nodes, and crusted ulcerated lesions lasting up to four weeks. The recurrent lesions have two to 24 hours of preceding itching or tenderness, and then a cluster of blisters appears for two to four days followed by crusts for four more days. Herpes simplex infections are usually described as fever blisters or cold sores. A highly infectious virus, herpes simplex is usually transmitted by sharing utensils, cups, razors, glasses, towels, oral/genital sexual contact, or kissing.
How to Treat – The best treatment is prevention. However, prescription oral anti-viral medications are the best treatment option. Non-prescription topical medications include docosanol and tetracaine. Photoprotection is critical to prevent reactivation on
the lips.
When to Refer – If you suspect that a client or patient has herpes simplex, refer to a physician immediately and be careful with physical contact with that individual until they have begun receiving treatment. The highest “cure” rates occur with the primary severe initial episode. Once it becomes recurrent, treatments only give symptomatic relief.

KERATOSIS PILARIS
How to Recognize – This common follicular disease is characterized by rough, tiny papules with variable amounts of scale or pustules usually located on the posterior lateral upper arms and less commonly afflicting thighs, buttocks, and lateral face. Lesions may be erythematous when perifollicular inflammation occurs. They occur from follicular plugging and viscous sebum forming keratotic scaly plugs in the pores, and may itch. It is very common in atopic children, and peaks in incidence as a teen. Many women are very self-conscious of keratosis pilaris particularly during the summer, although the disease usually flares in the winter and in dry climate.
How to Treat – There are a number of treatment options which can lessen the appearance of keratosis pilaris but rarely cure the visible the disease. Topical options include hydrating keratolytic products such as ammoniated lactic acid and salicylic acid, sulfur, hydrocortisone, and retinols. Prescription topicals with high concentrations of salicylic or azelaic acid, tretinoin, and potent corticosteroids are also helpful. Treatment is slow requiring two to four months to achieve control. Dietary supplementation with flax and borage oils is helpful as is vitamin A in rare cases.
When to Refer – Keratosis pilaris is a persistent disease which will not easily go away. Your patient/client will
need to see a physician for the prescription products.

Skin care professionals with significant experience and a trained eye will be more easily able to decipher the differences between some of these diseases in order to determine when to refer to a physician. As noted throughout this article, many of the diseases are most effectively treated with a combination of different therapeutic options. You can provide your patients/clients some therapeutic value with the appropriate treatments in tandem with physician-focused treatments.

Refrences:
1) Habif TP et al SKIN DISEASE 2nd ed. ElsevierMosby Philadelphia 2005:20-51,96,97,106-115,148,149,186-194,198-203.
2) Paller AS, Mancini AJ CLINICAL PEDIATRIC DERMATOLOGY 3rd ed. ElsevierSaunders Philadelphia 2006:49-83, 85-106, 365-396.
3) Bolognia JL, Jorizzo JL, Rapini RP eds. DERMATOLOGY Mosby London 2003:125-150, 199-227, 553-566, 1217-1254

Dr. Carl R. Thornfeldt is President, CEO, and Chief Scientific Officer of Episciences, Inc. He is a practicing dermatologist with 24 years of skin research experience, 21 U.S. patents granted, and over 19 scientific publications in the area of treatment of skin diseases and conditions, including chapters in five dermatological textbooks. Along with these accomplishments, he has also spent nearly two decades focusing on researching the skin barrier and cutaneous inflammatory conditions. Dr. Thornfeldt received his M.D. from the Oregon Health Sciences University, and completed his dermatology residency at University Hospital, San Diego, Calif