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Acne
Acne is a common condition which affects most people going through puberty. It is caused by a combination of factors: Excess production of sebum (oil), the pores becoming clogged up by dead skin cells and the proliferation of a bacterium, called Propionibacterium acnes, which causes inflammation and the formation of spots (comedones and pustules). Mild to moderate acne can be treated topically (with benzoyl peroxide, retinoids, antibiotics and azelaic acid). Chemical peelings or light treatment may also be effective in some cases. More severe forms, where marks have been left behind or scarring has occurred, require oral treatment (antibiotics or contraceptives; the latter helping to reduce the amount of oil produced). The most effective treatment is Isotretinoin/Roaccutane?ƒ©â?‚¬?…¸ but due to its numerous potential side effects (including, the potential for causing deformity in the unborn child) it must be taken under the careful supervision of a specialist. Dermatology Consultant London Specialists have extensive experience of working with this medication which, in the majority of cases, has positive and permanent results.
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Allergies (allergic contact dermatitis + patch testing)
An allergy can be defined as a reaction to contact with a substance(s) present in the environment. This may be something you touch (contact dermatitis), eat or inhale (urticaria-angioedema). Based on the clinical presentation, diagnosis can be helped by RAST (blood) tests and/or Patch Tests (the application of various substances to the skin with checks made, at regular intervals, to see if they have caused any reactions). Due to modern lifestyles and exposure to an increasing number of chemicals and pollutants, the incidence of allergies is on the increase.
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Skin Cancer
Skin Cancer: a term which encompasses a number of different lesions: the most common of which are listed below:
Actinic (or solar) keratoses: These are pre-cancerous conditions, typical of chronically sun exposed areas, such as the dorsum of the hands, forehead, and top of the ears. In appearance they look like pink or red spots, with a scaly surface. Sometimes they may just feel like rough spots to the touch, with very little to see. If left untreated they can change to invasive squamous cell carcinoma. Treatments include Cryotherapy, Creams (Fluoruracile-Efudix, or Imiquimod), and surgery under local anaesthetic.
Basal Cell Carcinoma (rodent ulcer): These lesions can have different appearances to the naked eye; from a pink/red flat patch, to a grey translucent nodule. They are not painful, but if left for long enough can invade deep into structures, and become increasingly difficult to operate on.
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| Squamous cell carcinomas: These look like scaly patches or nodules, lying over a red, inflamed base. They are not painful and are common on sun-exposed areas, such as the face, dorsum of the hands and ears. They are the most common forms of cancer in patients who have undergone transplants. Left untreated, they can spread initially to local lymph nodes, and possibly to other organs. If caught in time, however, excision is usually curative. |
Squamous cell carcinomas
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Melanomas are one of the most serious forms of skin cancer and, unfortunately, their incidence is on the increase. They manifest themselves as dark spots, although sometimes they can be pink and pale. Any pre-existing mole which changes, or a mole that appears "de novo" from previously normal skin, should be checked by a specialist, as it could be a melanoma.
Diagnosis can be enhanced by the use of special magnifiers (Dermatoscopes), and when diagnosis remains unclear on visual inspection, a biopsy taken under local anaesthetic usually clears any doubts over diagnosis. |
Melanoma
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All skin cancers have sun exposure in common, as a possible causative agent, and sun protection is, therefore, the first measure to adopt in order to prevent skin cancers. Sun protection measures should be consistent, and one should never forget that there is no difference in terms of sun exposure, whether lying sunbathing in a chair, or simply working in a car-park for the same amount of time!
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Drug reactions
Any drug can be responsible for an undesirable response, although antibiotics, painkillers, antidepressants or other psychotropic drugs and Beta blockers tend more often to be the cause of unwanted reactions than other medications.
Time of onset of a negative reaction varies from almost immediately, to days or weeks, and the effects can persist for a long time after the offending agent has been discontinued. In some cases allergic reactions may suddenly occur even when the offending drug has been taken for many years previously, without any problems.
The spectrum of manifestation of a drug reaction can be broad: From a rash similar to measles, to urticaria, blisters, acne, to the most severe erythrodermic reaction requiring hospitalisation.
Given the fact that sometimes the suspected offending agent may be essential for the long term treatment of a patient (for instance a drug given for a heart condition), a proper diagnosis and treatment plan is crucial.
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Eczema
Eczema is a term used to describe a broad spectrum of inflammatory skin conditions. The most common, however, is Atopic Eczema, which most likely has a hereditary component and causes the skin's natural properties as a barrier to the external world to malfunction. It is characterised by dry, itchy skin. A number of factors can contribute to an eczema flare up such as contact with irritants, dust or heat, and/or a patient suffering from either a systemic infection (e.g. common cold or chest) or a skin bacterial or viral infection. The first line of treatment is to try and re-establish the skin's barrier properties via the use of moisturisers and soap substitutes. Other treatments include the use of immunosuppresants (both topically and orally), ultraviolet light, antihistamines to suppress itchiness, antibiotics and antiseptics.
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Hair Loss (alopecias)
There are multiple causes of Hair loss and a correct diagnosis is crucial to achieving a successful outcome. Androgenic alopecia, which is the most common balding process is caused by minuturisation (shrinking) of the hair follicles. Treatments are available to stop or reverse this process. Other common scalp conditions resulting in hair loss are Telogen effluvium, Alopecia Areata and diffused Alopecia Areata. Telogen effluvium is characterised by sometimes dramatic shedding of hair which causes the loss of a significant volume of hair, at times over a very short timeframe. Treatment is available but because Chronic telogen effluvium sometimes may mimic androgenic alopecia, correct diagnosis is crucial before any steps are taken.
Alopecia areata, a form of "patchy" hair loss, is caused by the body's immune system attacking the hair follicles. Effective treatments are available for all these conditions. At Dermatology Consultants London, our Specialists take all necessary steps (including biopsies, blood tests etc) to ensure that there is no medical treatment which will successfully restore lost hair, before going down the route of hair transplantation, as a last resort. Some systemic disorders (e.g. Lupus or thyroid conditions) can manifest themselves with hair loss. We have long term experience of and expertise in treating such conditions.
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Hidradenitis suppurativa
Hidradenitis suppurativa is the inflammation of the sweat glands, occurring principally in the armpits and groin. It is very stubborn to treat and can evolve into deep seated abscesses and fistulae, leading to scar formation. This condition can have a far reaching impact on the lives of sufferers. New treatments include the use of biologic agents which have been found to grant good results in a number of cases.
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Hirsutism
Hirsutism is the term used to describe excessive hair growth in female patients, in a pattern normally seen in men; it can cause embarrassment and distress. Sometimes the reason for the condition is excess androgens (male hormones), which can be triggered by an underlying condition. Scans, in conjunction with specific blood tests, may be required as part of the diagnostic process. In most cases, however, hormone levels are perfectly normal and blood tests reveal no abnormalities.
Treatment is available either medically (with the use of anti-androgenic medications taken orally) or by hair removal with Laser or Intense Pulsed Light (IPL).
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Hyperhidrosis (excessive sweating)
In the most severe cases, hyperhidrosis can cause hands to be constantly wet with sweat, the armpits to drip perspiration, and be a cause of extreme social embarrassment. The cause is sometimes secondary to thyroid problems or diabetes and treating the root cause of the problem may correct the hyperhidrosis. More frequently, however, the problem is primary, in which case the problem area needs to be specifically treated. Where antiperspirants have failed, Botulin toxin (Botox) or Iontophoresis (a technique which involves the application of an electric current to the affected areas, and which is most successful when used on the palms of the hands and soles of the feet) can offer relief. Surgical solutions may also be considered.
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Infections
Infections can be caused by bacteria, fungi and viruses.
Bacterial infection can be superficial (such as a common folliculitis, boils or impetigo) or deep (cellulitis). Bacteria belonging to the tuberculosis family can also colonise the skin.
As international travel becomes more common, it is important that the specialist is also familiar with symptoms caused by tropical infective agents.
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Fungal infections (e.g. ringworm) are quite a common occurrence in dermatological practice. Manifestation of fungal infections ranges from a ring like pink/red patch, to multiple coalescent patches of discoloration. Treatment is different, depending on the fungal agent causing the problem. A possible target for fungal infection can be the nails, where single or multiple nails can be involved. In the case of the latter problem, treatment, usually oral, can be protracted for many months.
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Fungal infection viewed under the microscope
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Viral infections: Common viral infections are molluscum contagiousum, herpes (cold sores) and HPV (the agent responsible for warts). Shingles is also a condition caused by reactivation of the latent Herpes zoster virus (the same agent in chicken pox). Treatments available include topical antivirus agents, medications that prompt the immune system to clear the infected cells, oral antiviral agents and sometimes surgery is also required in, for instance, cases of condylomas (HPV infection) of the genital areas.
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Lichen Planus
Lichen Planus is a condition characterised by small, itchy red bumps usually scattered over the sides of the trunk, lower legs and forearms and at times it may affect the inside of the mouth and the genitalia. The nails can also sometimes be affected, at times resulting in permanent damage. The immune system is known to play a role in causing this rash. It usually spontaneously resolves itself, but for persistent or particularly severe cases, effective treatment is available.
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Lichen Sclerosus et Atrophicus
This condition is characterised by white patches on the skin and although the patches can be located anywhere, they are most commonly located on the genital area. It is usually extremely itchy (above all when localised in the genitalia) and the scarring process can tighten the skin, shrinking the vulva and urethra (in women) and the foreskin (in men) and interfering with normal urinary function. Diagnosis may sometimes require a biopsy to be taken. Treatment aims to control the symptoms with ointments or, at times, surgical intervention is required.
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Lupus
Lupus is a condition wherein the immune system attacks areas of the body itself. When the attack is against multiple organs (e.g. kidneys, skin, joints) it is known as "systemic lupus". At the other end of the spectrum (which is far more common) attack by the immune system is limited to the skin, above all against sun-exposed areas. It manifests itself in the form of red scaly patches which, when resolved, leave an indented, discoloured mark. Effective treatments are available both in the form of ointments and tablets.
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Immunoflourescence test
for Lupus
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Melanoma
Melanoma is one of the most serious forms of skin cancer and, unfortunately, its incidence is on the increase.
Melanomas manifest themselves as dark spots, although sometimes they can be pink and pale. They can arise from a pre-existing mole, or as a completely new lesion, appearing on previously normal skin. Any pre-existing mole which changes or a mole that appears "de novo" from normal skin should be checked by a specialist, as they could be a melanoma. Changes in size, colour and shape are all factors which should suggest a quick visit to the Doctor.
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Melanoma
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When a diagnosis of melanoma is suspected or ascertained, management of the condition should be discussed and agreed within a specialist set up involving a team of experts including Dermatologists, Pathologists, Plastic Surgeons and Clinical Oncologists. MDT (Multidisciplinary Team) meetings are now commonly used to ensure the best outcome for patients.
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Mycosis (ringworm)
Fungal infections such as ringworm are quite a common occurrence in dermatological practice. Manifestation of fungal infection ranges from a ring like, pink/red patch to multiple coalescent patches of discoloration. Treatment varies, depending on the causative fungal agent involved. A possible target for fungal infection is the nails, with single or multiple nails involved. In this case the treatment, usually oral, can be protracted over many months.
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Fungal infection viewed under the microscope
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Naevi (moles)
These are composed of clusters of melanocytic cells i.e. the cells in the skin that form melanin, the pigment which gives the skin its colour.
Melanocytic naevi can be congenital (present from birth), or acquired (the majority forming during adolescence/juvenile years, and pregnancy). It is perfectly normal to have naevi, although sometimes they can be a nuisance if located in areas where they catch on garments, or become inflamed in cases where they lie over hair follicles. The main problem with naevi is that they can mask a melanoma. Sometimes it is necessary to perform an excision and to send the specimen off to the laboratory for examination to ensure that the lesion is, in fact, a naevus and not a dangerous melanoma.
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Nail Surgery
Nail surgery is a highly specialised type of surgery, which requires particular training and dedication. Surgery on the nail is usually performed to obtain samples from the nail bed (the portion of skin which lies under the nail) in case a mole or a suspected melanoma is growing below the nail. An excision or a diagnostic biopsy may be necessary to clarify the diagnosis. Other reasons for partially removing nails are, again, to take significant samples of tissue below them to clarify the presence (or not) of fungal infection, or to determine whether a process involving the nail is infective in nature or may be a form of psoriasis or eczema. Sometimes it becomes necessary to rectify the nail matrix (the special tissue from which the nail originates), in order to modify the shape of the nail itself.
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Corrective procedures (following previous surgery)
A considerable source of requests made to our Consultants, given their surgical experience, centres around improving the appearance of scars, originating for example from the removal of a skin cancer of the face. Correction is sometimes inevitable, and does not mean that the original procedure was performed badly. Sometimes treatment of pre-existing scars can be carried out by another operation, at other times by injecting medications into the scar itself if it raised (in, for example, Keloids), by laser, or by injecting fillers (if the scar is depressed).
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Peelings
Certain skin conditions such as hyperpigmented marks, depressed or hypertrophic scars and wrinkles can sometimes benefit from a program of skin peelings, where some layers of skin are removed to allow new skin to generate possibly without, or having minimised the original defect. A number of types of peeling are available, the most common being salicylic acid, glycolic acid, and trichloroacetic acid (and a number of combinations of the three substances listed above are also possible). All can be used at different concentrations, achieving different levels of penetration into the epidermis and dermis, and therefore different results, either from simple deep cleansing of the skin, to complete skin removal with action on the dermal collagen which can have an effect on wrinkles and scars.
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Photodermatitis
Photodermatitis is one of the possible reactions to light exposure. Some conditions, such as Lupus, are aggravated by light; whereas photodermatitis is actually induced by light exposure. In photodermatites, the common causative mechanism is the activation of a substance by light, with production of energy and free radicals inside the skin resulting in damage to the skin which appears red and blistered. Another possibility is the alteration of a substance of common use, such as a perfume or a medication, by ultraviolet light. The interaction of the substance with light alters the inner molecular structure of the substance which is then recognised by the immune system as a target and becomes a trigger for an allergic reaction (photoallergic dermatitis). The usual appearance of this condition is an eczematous, florid rash which is more severe in sun exposed areas. Special tests are required to obtain a firm diagnosis.
Apart from discontinuing use of the substance that has acted as a trigger, treatment is available, usually by down-regulating the immune-system and protecting, a skin prone to infection, from possible secondary infection.
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Psoriasis
Psoriasis affects 3% of the population and is characterised by pink/red patches, covered by silvery scales, usually with symmetric distribution. It can be very itchy, and a source of significant social embarrassment. It is a genetic condition, although a pattern of transmission is unclear. Stress, injuries, infections are the recognised triggers. Nails or joints can be involved, also with debilitating consequences. Unfortunately no cure is yet available but a multitude of treatments to control this condition are well known.
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Scars
When a wound heals, it leaves a scar. Sometimes scars can protrude, being wider than the original wound and be itchy. Although a genetic predisposition is not recognised, certain families seem to show a tendency towards developing keloid scars. Treatments are available, although none grant certain and complete success and a combination of medications and physical treatments (UV Light) may be required. Breakthroughs in the molecular pathway leading to the formation of psoriasis lesions, though, has led to the recent development of a number of new medications which, in recent years, have significantly broadened the spectrum of treatments available to control this disorder.
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Cysts
Cysts (including those of the scalp) are usually benign growths, composed of a walled sack with semi-fluid content. They can be multiple, above all if localised on the scalp. If small they can simply be left alone, but voluminous cysts, especially on the face, can be troublesome or embarrassing, and excision may have to be performed. Sometimes, unfortunately, if only partially removed they have a tendency to reoccur. For this reason, although they are completely benign growths, they need to be properly removed. Moreover the diagnosis needs to be correct, as sometimes other more severe conditions may mimic innocent cysts.
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Sarcomas
These are tumours arising from underlying tissues such as the nerves, blood vessels, connective tissue or muscles cells. They can be very difficult to treat, and their management should be discussed and agreed in conjunction with a team of experts, including Dermatologists, Pathologists, Plastic Surgeons and Clinical Oncologists. Anybody diagnosed with this sort of lesion should be referred to a specialist centre, specifically set up for the treatment and management of this particular form of tumour.
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Urticaria
Urticaria manifests itself with itchy wheals. There are no preferred sites and any area can be affected. A deep form of urticaria is angioedema, the oedema of subcutaneous tissue causing swelling of the throat, tongue, eyelids and lips. The two types may coexist. Urticaria is common, and up to 20% of the population will be affected at least once in their lifetime.
Acute forms of urticaria are usually triggered by medications, or febrile illnesses.
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An example of chronic urticaria
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Chronic forms of urticaria (chronic is when it persists for more than 6 weeks) are idiopathic (cause unidentified) in more than 75% of the cases. Although it is a well recognised fact that aspirin and painkillers in general (but not paracetamol) can aggravate chronic urticaria, most cases of chronic urticaria are not allergic, but caused by an antibody in the blood stream able to release the histamine stored inside particular cells in the skin, called mast cells. If untreated, many cases can persist for months or years. The condition can be controlled with the appropriate use of antihistamine preparations or immunosuppressants.
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Vesiculobullous diseases
Vesiculobullous diseases: result from the discohesion, genetic or acquired, of the cells of the epidermis.
Based on the level of the problem within the skin, a number of different diseases have been recognised: The most common are bullous pemphigoid and pemphigus vulgaris.
Both conditions are caused by the presence in the bloodstream of antibodies targeted against certain components of the skin itself, leading to a weakening of the skin and the creation of fluid-filled blisters. Diagnosis, above all at an early stage, can be rather difficult and biopsies taken to perform special studies with special techniques (immunofluorescence) may be required. Treatment aims to control the autoimmune reaction and can be based on a combination of a variety of drugs.
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Vitiligo
Vitiligo: A disorder characterised by depigmented macules which tend to grow in size and coalesce, resulting sometimes in extensive depigmented areas of the skin. The cause of Vitiligo seems to be an autoimmune reaction against the melanocytes.
It can be a profoundly embarrassing disorder, above all in individuals with dark skin.
Treatment is performed in steps, initially trying to control the autoimmune process which has led to the loss of melanocytes. Once the vitiligo is stable, pigmentation can be brought back with various techniques, from the administering of Ultraviolet light using a particular wavelength to laser (eccimer Laser), or melanocyte transplantation (the latter used if the patches are not particularly extensive). It must be said, however, that success is not guaranteed and sometimes, after an initial success the patches may reoccur, either in the same places or in other areas.
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Vitiligo before treatment
Vitiligo after treatment
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