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Skin problems - symptoms, diagnosis & treatment

Following is the list and detailed description (most of it quoted from the NHS Direct website “NHS Direct Online Health Encyclopaedia” (www.nhsdirect.nhs.uk/articles) of the most common skin problems.




Cold sores/ Herpes Simplex virus


General information


Cold sores are caused by the herpes simplex virus, which also causes genital herpes. The strain that causes cold sores around the mouth is called Type 1 (HSV-1).

Herpes simplex viruses are highly contagious. Around 80% of the UK population carry the herpes simplex viruses, but for the majority of the time they lie dormant (inactive) in the nerves at the junction of skin and mucous membranes. Every now and then in some people, dormant viruses become active and cause cold sores.

Around 1 in 5 people in the UK have frequently recurring cold sores. Others will have one but then never have another. Some people never get them, either because they do not have the virus or because it never becomes active”.

Symptoms

An outbreak of cold sores usually starts with tingling around the mouth, chin, nose, or other areas of the face. Small fluid-filled blisters then appear, which grow in size and cause irritation and pain. They may weep, and eventually grow a crust or scab.

Most cold sores disappear within a week or so, and they generally heal without scarring.

When you are infected with the virus for the first time, it is called the primary infection. This may have different symptoms:

  • There may be no symptoms at all;

  • There may be only trivial symptoms such as a small spot, which you may not realise is caused by the cold sore virus; or

  • You may have a more severe infection in or around the mouth, with painful ulcers or blisters, as well as fever, swollen glands and pain when eating and swallowing”.

Causes

Cold sores are usually passed on early in childhood when someone is kissed by a person such as a family member, with an active cold sore. The virus goes through the skin and travels up the nerve, where it lies dormant until triggered.

Attacks appear to be triggered by:

  • emotional upset;

  • fatigue and tiredness;

  • colds or other viruses that weaken the body’s defences;

  • menstrual periods; and

  • strong sunlight and cold winds.

Triggers are different for each person.

Cold sores do not usually appear until after puberty, although children may experience the primary infection with a fever and sore throat.

You are not usually infectious unless you have an active cold sore.

Treatment

The most common treatment for cold sores is the drug aciclovir. It stops the virus from reproducing by interfering with its DNA.

Aciclovir is available as a cream for the treatment of cold sores on the lips. The cream should be applied 5 times a day for 5 days. Aciclovir can also be taken by mouth in tablet form (for recurrent, severe attacks). Another drug called valacyclovir is also sometimes prescribed as tablets.

Balm mint extract and tea tree oil may also help with pain and itching.

Treat any pain by taking paracetamol or applying witch hazel to the sore. A topical (applied to the skin) anaesthetic may be prescribed by your doctor. See your pharmacist for advice on pain relief.

Don’t pick cold sores because this may spread the virus to other parts of the body, or allow the sore to become infected.

Drink plenty of fluids to keep hydrated, and avoid salty, spicy or acidic foods and drinks, which may irritate the sore. Eating soft foods such as soup may be less painful, as there is less need to chew and move the mouth”.

Prevention

If you know what triggers your cold sores, the best way to prevent them is to avoid the triggers. For example, if sunlight causes them, use a lip balm that has a UV sun block

When you feel the first tingle use a medicine containing aciclovir, which seems to lessen the duration and severity of attacks.

Wash your hands after touching the sore (or your lips) and don’t put your fingers near your eyes.

Avoid direct contact with anyone who has an active sore. People with cold sores should be particularly careful around newborn babies, or people with a low immune system such as those with AIDS or who have been undergoing chemotherapy.

Avoid sharing cups, towels, lipsticks or other objects with people who have an active cold sore. (www.nhsdirect.nhs.uk/articles)

Warts/ Verrukas


General information


Warts are small, skin-coloured, roughish lumps on the skin. They often appear on the hands and feet and look different depending on where they are on the body and how thick the skin is.

Warts are caused by an infection with a virus called human papilloma virus (HPV). There are many different types of this virus. It causes a reaction with the skin that makes part of the top layer of skin (the epidermis) grow too much. Keratin is the hard protein in the skin that grows too much, causing the rough, hard texture of warts.

Warts are usually harmless, but they can look unsightly. They often clear up by themselves, but treatment can help to get rid of them more quickly. Warts aren’t normally painful, although verrucas (warts on the feet) can sometimes hurt.

Warts are very contagious. The skin cells in the warts releases thousands of viruses, so close skin-to-skin contact can pass on the infection. However, it can take several months for warts and verrucas to appear after you’ve caught the infection.

People with weak immune systems, are more likely to get warts. This is because the body is less able to fight off the HPV virus.

Most people develop warts at some point in their life, usually before the age of 20. About 1 in 10 people in the UK have warts at any one time.


Symptoms


Warts can be different sizes, ranging from 1mm to over 1cm. You may only have only one or two warts, or lots can develop on the same area of skin.

The size and shape of warts varies:

  • Common wart (verucca vulgaris) – is a firm, raised wart with a rough surface that can look a bit like a cauliflower. They can occur anywhere, but are most common on the knuckles, knees and nail folds.

  • Plane wart (verruca plana) - is a round, flat topped, yellowish type of wart. It mainly occurs on the back of the hands, especially around the nails and fingers.

  • Filiform wart (verruca filiformis) is a long, slender wart that is common on the thin skin of the eyelids, armpits or neck.

  • Genital warts (condylomata acuminata) - are small, pink, cauliflower-shaped growths on the penis, vulva (the female external sex organs), or around the rectum. Warts on the vulva are usually soft because the skin here is moist and hairless. Warts that develop on skin that is dry and hairy (such as the shaft of the penis) tend to be firm. The number of warts that develop varies. Some people have a few that are not very noticeable, while others have a lot. Genital warts do not usually cause any symptoms, although they may be itchy if they are around the anus. However, the warts may a sign of a sexually transmitted infection (STI), or in rare cases, cancer.

  • Verrucas (planter warts) are warts on the soles of the feet. They don’t stick up from the surface of the skin; the pressure of your body weight on the feet instead pushes them backwards. This causes verrucas to grow back into the skin, which can be painful. Verrucas often have a black dot in the centre, surrounded by a hard, white area. The dot is the blood supply to the wart, and the white area is the skin of the wart that is closely packed together. Plantar warts that grow in clusters they are sometimes called mosaic warts.

Causes

Warts are caused by different strains of the human papilloma virus (HPV). The infection is present in the skin cells of the wart, and can be passed on through close skin-to-skin contact.

You are more likely to catch the infection if your skin is damaged, or if it is wet or in contact with rough surfaces. For example, public swimming pools are a common place to catch verrucas. People with scratches or cuts on the soles of their feet are especially vulnerable.

You can also spread the warts to other areas of your body, for example, if you scratch or bite them. This can cause the wart to break up and bleed, making it easier to spread the infection.

People with a weak immune system (as a result of immune system diseases, such as AIDS, or as a result of certain treatments such as chemotherapy) are more likely to catch warts. They may develop lots of warts that are difficult to get rid of.

Genital warts are caused by a strain of the HPV virus that is passed on during sex, or very close sexual contact. However, most people infected with HPV don’t develop visible warts. You can carry the virus without realising, and pass it onto other people who then go on to develop genital warts.

Diagnosis

Warts on the hands and feet are easy to recognise.(Usually raised growths with a hard uneven surface. On your feet, they may have been pushed in by the weight of your body.)

See your GP if they are painful, if they are spreading, or if they don’t seem to be clearing up of their own accord (this can take several months). If you are worried that the warts are unsightly, see your GP about treatment options to help them to clear up more quickly.

Although genital warts can be embarrassing, it is important to have them checked out at your GP surgery or local sexual health (GUM) clinic. This is because genital warts can be caused by a sexually transmitted infection, and in rare cases, can be a sign of cervical cancer. The doctor or nurse that you see will probably take a swab (sample of cells)from the area to check for the infection that’s causing the warts.

If there are no obvious warts, but infection is suspected (because a partner has warts, for example), the doctor or nurse may apply a solution that turns warts white, making very small or flat warts more visible.

Treatment

Most warts clear up without treatment, but this can take a long time (up to a year). There are treatment options available to clear up warts faster, particularly if they are painful, multiplying or making you feel unhappy. However, some types of treatment can be painful, and there is no guarantee that warts won’t come back again.

Treatment depends on where the warts are and how many there are. Options include:

  • Over-the-counter treatments: A variety of creams, gels, paints and medicated plasters are available from pharmacies. Most of these contain salicylic acid as their active ingredient. Salicylic acid and other wart treatments also destroy healthy skin so it is important to protect the skin around the wart - use petroleum jelly or a corn plaster to cover it. Apply the medication following the packet instructions, but stop the treatment if your skin becomes sore. Rub dead skin off once a week with a pumice stone or emery board.

  • Chemical treatments: Treatments containing chemicals such as formaldehyde, glutaraldehyde, and podophyllin can be used to remove warts. These chemicals are poisonous to skin cells – they are dabbed onto warts to kill the skin cells there. You can get these treatments on prescription.

  • Cryotherapy: Very cold liquid nitrogen is sprayed onto the wart to freeze and destroy the cells. A sore blister develops, followed by a scab, which falls off a week to ten days later. Treatment takes about 5-15 minutes, and can be painful, so you might need a local anaesthetic beforehand. It’s usually carried out at hospital skin clinics or at your GP surgery. Large warts sometimes need to be frozen a few times before they go.

  • Surgery: The aim of surgical treatment is to completely get rid of warts. Surgery is carried out under general or local anaesthetic. Warts can be cut out of the skin (useful for a few, large warts), or the skin of the wart can be scraped off with a spoon-like instrument called a curette.Other surgical options are laser treatment, in which the wart is destroyed using a very precise laser beam, and electrocautery, in which the wart is burnt off using an electric current.

If you have genital warts, don’t try to treat them yourself with over-the-counter medicines. Instead see your GP or GUM clinic for treatment. Genital warts can usually be removed using similar techniques to those described above. However, the method depends on how big they are and whether they are inside the body or on the skin surface.

Complications

A sudden outbreak of a lot of genital warts suggests there could be a problem with your immune system, possibly caused by HIV. It’s important to see your GP immediately if this happens.

Some types of genital warts may be connected cell changes in the cervix (neck of the womb), as well as some types of cancer in the sexual organs. This is rare, but women with genital warts may be advised to have a smear test to check for unusual cell change.

Prevention

To reduce your risk of getting a wart or verruca:

  • don’t touch other people’s warts;

  • don't share towels with a person who has warts;

  • don't share shoes or socks with someone who has a verucca;

  • don't scratch or pick at a wart as this may encourage it to spread; and

  • wear flip-flops in communal showers and in swimming pool changing areas.

If you have a verruca, cover it with a plaster when you go swimming. People with hand warts should wear gloves if they are using communal equipment (for example, in a gym).

To avoid catching genital warts, you should practice safe sex. The best way to do this is to use condoms. However, condoms don’t cover the entire genital area, and are usually put on after sexual contact has begun, so the virus can still be passed on.

Use a condom (as well as your normal form of protection) for 3-6 months following treatment for warts. This helps to stop you and your partner getting re-infected.

Remember, the more sexual partners you have, the higher your chance of getting genital warts and other STIs”. (www.nhsdirect.nhs.uk/articles)

Acne Vulgaris


General information


Acne is a skin condition that affects the hair follicles and the sebaceous glands in the skin, which secrete an oily substance called sebum. Acne is most common on the face, arms, back and chest.

The onset of acne is usually around puberty, but in a minority of cases it may also start in adulthood. About 80% of people will have some degree of acne between the ages of 11 and 30.

In puberty, acne occurs because of changes to hormone levels, which cause the sebaceous glands to produce increased amounts of sebum. Together with dead skin cells, the sebum blocks the hair follicles, which enables the formation of ‘spots’ ranging from blackheads to painful red nodules.

As with the other physical changes that happen during puberty, acne usually corrects itself over time. It most cases it should get better without treatment. However, in some people this may take many years and can potentially cause permanent scarring, so a variety of treatments are available.

Symptoms

Acne spots appear in areas of skin that have a large number of sebaceous glands. They appear most often on the face, but can also form in other places such as the neck, shoulders, behind the ears, on the chest, on the buttocks and on the upper back.

Acne consists of several different types of ‘spot’, which can be roughly divided as follows:

  • Blackheads – tiny dark coloured blocked pores. The black of the blackheads is due to skin pigment, not dirt.

  • Whiteheads - small, firm bumps with a white centre.

  • Pustules - pus-filled spots with an obvious balloon of white pus, which may turn yellow as the spot begins to heal.

  • Nodules - hard lumps under the skin that can be very painful, go deep into the skin and often cause scars. These are the most common type of spot found in very severe acne, and they often run together in groups. When they heal, they may leave scars.

Causes

Acne that begins at puberty is the result of increased sensitivity to the hormone testosterone, which is present in both boys and girls. Testosterone causes excessive sebum to be secreted from the skin’s sebaceous glands. Skin cells rapidly divide and sometimes block the opening of hair follicles. The resulting build up of sebum behind the blockage helps produce blackheads and whiteheads.

At puberty changes in skin acid levels also encourage the growth of bacterium, which can become trapped in the hair follicles. This produces a deeper infection, in the form of pustules and nodules.

Other causes:

  • Acne sometimes seems to run in families, so there may be a genetic factor that makes certain people more likely to have it.

  • Acne may become worse in times of stress, although it is not clear why. It may be because stressed people touch their faces more, spreading the bacteria, or because they are sweating more.

  • In girls, outbreaks may be affected by the hormonal changes that occur during the menstrual cycle.

  • Another cause may be excessive production of androgens (hormones like testosterone), resulting not from puberty but from conditions such as polycystic ovary syndrome (PCOS).

  • Certain drugs such as corticosteroids, anti-epileptic medicines like phenytoin, and oral contraceptives containing levonorgestrel or norethisterone, may aggravate acne.

  • Anabolic steroids, sometimes used by body-builders, can cause acne as a side-effect.

  • Exposure to dangerous chemicals called dioxins can cause a rare form of acne called chloracne.

Eating greasy foods or chocolate does not cause acne. Having poor hygiene is also not a direct cause, although if you do not wash your face or remove make-up, bacteria will be able to multiply on your skin.

Treatment

The type of treatment depends on how severe the acne is, and whether it is inflammatory (whether the spots are red swollen bumps).

Mild non-inflammatory acne (whiteheads and blackheads) may be treated with gels, creams or lotions that are applied directly to the skin (topical). These include:

  • Retinoids, which contain vitamin A and loosen skin cells that are sealing the hair follicles;

  • Adapalene, which affects the growth of skin cells; or

  • Benzoyl peroxide, which has anti-bacterial properties.

Mild to moderate inflammatory acne (with some pustules and nodules) is often treated with gels, creams or lotions containing:

  • Benzoyl peroxide;

  • Azelaic acid, which stops the growth of skin bacteria keeping skin pores clear; or

  • Topical antibiotics such as clindamycin, which fight bacteria and reduce inflammation.

Moderate acne is often successfully treated with a low-dose oral antibiotic, such as tetracycline or erythromycin. These reduce the number of bacteria, inflammation and sebum production. It sometimes takes up to 8 weeks for any noticeable improvement and the treatment is usually needed for at least six months.

For women, taking a high oestrogen contraceptive pill may also help acne, by regulating the hormones that cause excess sebum production.

If the acne is severe, a dermatologist (skin specialist) may prescribe isotretinoin, a retinoid taken by mouth that acts to loosen excess skin cells and reduce sebum secretion.

If acne has already left noticeable scars, a cosmetic surgeon may discuss techniques such as dermabrasion or laser treatment. In these procedures, the top layer of skin is removed under a general anaesthetic, leaving a more even layer of skin. There is limited clinical evidence about the effectiveness of these treatments.

Treatment should also help address some of the psychological issues associated with acne, for example by reassuring the person that some of the myths are not true. Acne is not caused by poor hygiene, poor diet or lack of exercise, and is not infectious.

Complications

Permanent scarring may occur, although this will usually be prevented if treatment is started at an early stage, and by not picking or squeezing spots.

Acne can also contribute to psychological problems such as anxiety and depression.

Prevention

Acne is not infectious and it is not caused by poor hygiene. However, a build-up of sebum and dead cells on the skin surface may increase the risk of blocked follicles and allow bacteria to multiply. You can help prevent this by washing your face with a gentle cleansing product, and making sure that if you wear make-up, you wash it off before you go to bed.

There is no evidence that wearing make-up causes spots, but the less you touch your skin the fewer bacteria will be spread on your skin. To prevent the spread of bacteria, wash your hands before touching your face (for example to apply make-up).

There is also no evidence that certain foods, such as fried foods or chocolate, cause or aggravate acne. A good balanced diet is, however, important to help your body work properly and keep you healthy”.

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Dandruff

General information


Dandruff is the most common condition affecting the scalp.

The skin cells on the scalp are constantly renewing and the old cells get pushed to the surface by the new ones. If you have dandruff, the process of skin renewal (or skin turnover) speeds up to twice the normal rate, so a greater number of dead cells are shed.The scalp becomes scaly and the skin cells shed and collect in clumps. They are noticeable when brushing the hair and can gather on the shoulders. The condition mostly occurs after puberty, usually between the ages of 20 and 30 (1), and affects males more than females.Dandruff responds very well to treatment, but will commonly recur if treatment is stopped.

Symptoms

The flakes of skin are greyish white and are often very visible on the hair and shoulders. There is sometimes itching or soreness and the scalp can feel tight.Seborrhoeic eczema (or seborrhoeic dermatitis) is a more severe form of dandruff that also affects the skin around the eyebrows, nose, ears, face and forehead. The scales are yellow and greasy looking and the skin is inflamed, red and crusty. Psoriasis also affects the scalp, and the skin around the ears, knees and elbows. The scales are silvery-white with red, inflamed patches.

Causes

Not brushing the hair regularly to allow for normal shedding of dead skin cells can result in dandruff. The rate of shedding is increased if the scalp is already inflamed or itchy.An overgrowth of yeast fungus (pityrosporum ovale) can lead to dandruff. The condition may improve in the summer and get worse in winter, because UVA light from the sun counteracts pityrosporum ovale. Dandruff can also be due to nutritional deficiencies, for example, a lack of vitamin B or essential fatty acids, or a diet high in sugar and refined carbohydrates.Seborrhoeic dermatitis is more common in people with HIV, and those with an underlying neurological illness such as Parkinson’s disease.

Diagnosis

If only the scalp is affected, it is likely to be dandruff. If the scaling is very severe and affects other areas, it may be seborrhoeic eczema (or seborrhoeic dermatitis), which is a more severe form of dandruff. If the scales are silvery-white with red, inflamed patches, this may be psoriasis.

Treatment

The aim of treatment is to reduce the level of the yeast pityrosporum ovale on the scalp. Dandruff responds well to the use of medicated, anti-fungal shampoos, especially those containing, in order of effectiveness:

  • Selenium sulphide

  • Zinc pyrithione

  • Coal tar

  • Ketoconazole

The shampoo should be massaged into the scalp and left on for 3-5 minutes before being thoroughly rinsed. The hair and scalp should be shampooed with this type of shampoo 1-2 times a week. Dandruff should improve within 1-2 weeks of starting treatment, but will commonly recur if treatment is stopped.Additional treatment for seborrhoeic dermatitis can help control symptoms but cannot cure the condition. Treatments include topical corticosteroids (applied to the scalp) to reduce inflammation, keratolytics to remove thick scaly patches, oral antifungals if a fungal infection is widespread, and oral antibiotics if the scalp becomes infected.

Complications

In some cases, there may be an irritation or allergic reaction to shampoos containing coal tar or ketoconazole. If you experience irritation, itching or a burning sensation you should stop using the shampoo immediately, and ask your pharmacist to recommend an alternative.Itching of the scalp can break the skin and lead to infection with bacteria such as staphylococcus aureus. If this occurs you should see your GP for advice.

Prevention

You can prevent dandruff by:

  • regular daily brushing;

  • washing your hair at least three times a week;

  • using a specially medicated shampoo every 1-2 weeks to prevent recurrence;

  • rinsing your hair thoroughly after shampooing;

  • avoiding the use of chemicals on the scalp such as those used in hair colouring; and

  • making sure that you have enough vitamins such as zinc,beta-carotene, B6, B12and selenium your diet.

You can reduce the frequency of bouts of seborrhoeic dermatitis by washing hair regularly (every week or every other week) with medicated antifungal shampoo”.(www.nhsdirect.nhs.uk/articles)

Athlete's foot

General information

Athletes foot is a common, persistent infection of the foot, usually caused by a fungus called a dermatophyte. The fungus lives on dead skin, hair and toenails and thrives in warm, moist environments.

Symptoms

The symptoms of Athlete’s foot are a flaky, itchy, red rash between the toes. This can crack or become white and peal off, may blister and become very sore. The space between the 4th and 5th toes is the most commonly affected. Your feet may also smell unpleasant.

If untreated it can spread to other areas, like the toe nails and adjacent areas of the foot, causing it to be red, dry and itchy. A more serious secondary bacterial infection may also develop.

Causes

There are several dermatophytes that can cause athletes foot. The most common is trichophyton rubrum. These fungi live on human skin and may be present without you being aware of it. However, under certain conditions the fungi are able to multiply and cause infection, in warm enclosed environments e.g. between your toes.

Athlete’s foot is contagious and can be spread through direct contact through a cut or abrasion of the foot or indirectly through towels, the floor, shoes etc. They thrive in warm, moist conditions and are spread in public showers, swimming pools etc.

Cracks in the skin sometimes leads to a secondary bacterial infection.

Diagnosis


Diagnosis is usually made from the visual appearance of the symptoms. Skin scrapings, can be used to determine the type of fungus.


Treatment



There are various creams, powders, and sprays available, which can mostly be bought over the counter (OTC) at the pharmacist.

  •  There are two Imidazole creams (miconazole and clotrimazole) available OTC- These will kill the fungus and need to be applied for two weeks after symptoms appear to have cleared up to get rid of all the remaining fungal spores.

  •   Topical terbinafine cream is available OTC, and requires only 1 to 2 weeks of treatment, but is more expensive than Imidazole creams.

  •  Tolnaftates act by reducing the growth of fungus, and can be in conjunction with Imidazole creams. They are available as: A cream- for use directly on to the feet: A powder - for use in shoes and socks: A spray - for use directly on the feet and sprayed in shoes

  •  Salicylic and Benzoic Acid- Together these have anti- fungal properties and are able penetrate the skin by removing surface hard skin.

If symptoms do not improve, see your doctor, who will make sure the diagnosis is correct and may be able to prescribe alternative treatment.

An antifungal tablet may be prescribed if the infection does not clear up with a cream.

Complications

The fungus can spread to the nails, which makes it very much more difficult to treat and takes much longer to cure.

Prevention

  • Wash your feet and toes daily and dry thoroughly between your toes.

  • Do not wear shoes without socks or tights

  • Change your socks or tights daily Wear socks and shoes made from natural materials

  • Do not share towels

  • Wear plastic shoes or flip- flops in communal showers, changing rooms and around pools

Ideally, spend time in bare feet, leaving your shoes and socks off as much as possible”. (www.nhsdirect.nhs.uk/articles)

Skin cancer


General information


Skin cancer is common. There are three main kinds:

  • basal cell carcinoma, often known as a rodent ulcer;

  • squamous cell carcinoma; and;

  • malignant melanoma.

Fortunately, the commonest kind is the least dangerous, and the most dangerous kind, malignant melanoma, is the least common.

Skin cancer is very rare in children but is more common as people get older. The numbers of skin cancers rise with age because the main cause of all types of skin cancers is sunlight exposure. Sunlight contains ultraviolet light (UV), and this is what does the harm, particularly to the skin of babies and young children. The numbers of skin cancers vary from country to country. In tropical countries with large white populations, the numbers are proportional to the amount of sunlight. Australia, South Africa and the Southern American states all have a very high incidence of skin cancer in their white populations. People with black skin (for example, people of African or Caribbean descent) are better protected by their skin colouring.

Symptoms

Rodent ulcer (basal cell carcinoma) is one of the commonest of all cancers and one of the least dangerous. It affects the skin, mainly in areas exposed to the sun, and especially on the nose and around the eyes.

It is a slowly growing, raised-edged swelling with a dimple in the centre. Small blood vessels are often visible just below the surface. It hardly ever spreads to other parts of the body, although it can do so if neglected. It can then cause a lot of tissue damage, especially by burrowing deep into the tissues (hence the name rodent ulcer).

Squamous cell carcinoma is a skin cancer also related to sunlight exposure. It starts as a small, firm, painless lump occurring most often on the lip, ear or back of the hand. It enlarges fairly rapidly and then will often break down in the centre to form a crater. This is called ulceration. It can spread to the lymph nodes and from there to various parts of the body. Be very suspicious of anything like this on your lip.

Diagnosis

The diagnosis of both rodent ulcer and squamous cell carcinoma is usually made by examination under the microscope of the tumour (lump) after it has been fully removed.

Treatment

Rodent ulcer can be treated by direct surgical removal, by radiation or by freezing. The method advised is likely to depend on whether you are seen by a surgeon or by a dermatologist. All methods are equally effective.

Squamous cell carcinoma must be removed surgically as early as possible. Unlike the rodent ulcer, this tumour may spread to other parts of the body and this can lead to death.

Prevention

The best way to protect yourself from skin cancer is to take care in the sun:

  • Don't wait till your skin feels uncomfortable before taking preventative action. The best form of protection is defence.Once your skin is burned the damage has already been done so cover-up up with loose-fitting clothes.

  • Make sure that your legs and arms are covered. Tightly woven fabrics will provide the best protection from the sun.

  • Avoid direct exposure to sunlight between the hours of 11am and 3pm when the sun is at it’s strongest. If you do go outside between these times cover-up with clothes, hat and sunglasses and apply plenty of sun protection lotion.

  • Always use a sun protection lotion with an SPF (sun protection factor) of at least 15. Very fair-skinned people and children need to use lotions with an SPF of up to 40.

  • The skin is damaged most by the sun before the age of 18.

  • Make sure that your entire body is covered by sun protection lotion.This includes your face, hands, feet and neck. The most vulnerable parts of your body are the places that are not usually exposed to sunlight.

  • Apply sun lotion at least 30 minutes before going out in the sun. Reapply it every couple of hours, as sweat and friction against towels for example will cause it to wear off. Reapply immediately after swimming, even if your lotion is a waterproof variety.

  • Wear waterproof sun protection when swimming. UVA and UVB rays can penetrate through a metre or so of water.

  • Cloud and fog do not protect skin from ultraviolet rays. Cover up with clothing and use SPF 15 sun lotion even on cloudy days.

  • Always wear a hat and sunglasses that have UVA and UVB filters when in the sun. Ultraviolet rays can damage the retinas in your eyes causing cataracts.

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Eczema (atopic)



General information


Eczema is a skin condition, which can result in dry, red and flaky skin. The skin may feel hot and very itchy and scratching can lead to the skin becoming damaged and infected. Eczema is not contagious. Eczema is also known as dermatitis, a term used to describe inflammation of the skin.

Atopic eczema is the most common type of eczema and is linked with hay fever and asthma. The tendency to develop atopic eczema is inherited but is strongly influenced by environmental factors.

Atopic means an extra sensitivity to substances (allergens). The most common allergens are house dust mites, feathers, pollen, cat or dog fur and sometimes foodstuffs e.g. cows milk, eggs or nuts.

Atopic eczema may start in babies from 3 months, often on the face, then to the outside limbs and the body. In older children it can occur on almost any part of the skin but most commonly involves the creases of the limbs, especially in front of the elbows and behind the knees and the wrists, ankle and neck.

Atopic eczema affects approximately 15-20% of young children in the UK. Atopic eczema clears up in approximately 70% of children by the time they reach their teens and in many it largely clears up by 4-5 years of age. If it persists into adult life, it usually affects the body creases, the face and hands. The incidence of atopic eczema has increased in recent years.

Symptoms

In the acute form (flare- ups):

  •  The skin will be extremely itchy, red, hot, dry and scaly

  •  The skin may also be wet and weeping and swollen

  •  There may be infection with bacteria (usually staphylococcus)

  •  The most common areas affected are the skin creases such as the front of the elbows and wrists, backs of knees and around the neck. However, any areas of skin may be affected. The common area for babies to be affected is the face and scalp, while the hands are a common site in adult.

In the chronic form (persistent):

  • The skin will be dry and thickened and may be scaly or cracked, as a result of continual scratching.

Your skin is vulnerable to further damage and infection when you have atopic ezcema, it is more likely to be sensitive to and react more easily to certain substances. These trigger factors will make you particularly vulnerable to a flare ups.

Itchiness and heat cause a strong urge to scratch, which further damages the skin. The scratching can disrupt sleep and may be so severe as to make the area bleed. Scratching can make an itch worse and an itch-scratch cycle may develop with regular scratching. In children this can lead to sleepless nights and difficulty concentrating at school.

Causes

Atopic eczema is a condition where inherited factors are important . These inherited factors make you more sensitive to allergens in the environment and increase the risk of developing eczema, asthma or hay fever.

Atopic eczema has become more common in recent years, the cause of this is uncertain.

There are also a number of factors may trigger an eczema flare-up, these include specific allergies to foods, overheating, secondary infection, wool next to the skin, cat and dog fur, soaps, detergents, house dust mites and pollen. Extreme hot and cold, humidity (moisture in the area), and hormonal changes in women (caused by the menstrual cycle and pregnancy) can also cause a flare-up.

Diagnosis

Your doctor can usually diagnose atopic eczema by skin examination. You will be asked if there is a family history of eczema, asthma and hay fever. Sometimes a blood allergy test will be suggested to help identify any eczema triggers, this however will not usually alter your treatment unless the trigger is easily avoided.

Treatment

There is no simple cure for atopic eczema but you can do a lot to prevent and treat it. The three main goals of treatment of atopic eczema are healing the skin and keeping it healthy, preventing flare-ups, and treating symptoms as they occur.

Treatment is based on the use of, emollients (moisturisers) including soap substitutes, bath oils and general moisturizers, and topical corticosteroids (steroids) for flare-ups.

There may also be a need for antimicrobial treatment (to treat skin infection), and antihistamine tablets (to help sleep disturbance caused by itching).

In more severe cases which are difficult to treat there may be a need for, oral corticosteroids, other immunosuppressant medicines such as ciclosporin and azathioprine, and phototherapy and photochemotherapy. (light treatment, or light treatment plus medication).

The way you use and apply the treatments is a key factor in how successful control. Failure of treatment can often be due to incorrect use. There are many preparations of each type of treatment.It may take time to find the best one(s). Do not try several new treatments at once - for example, a mixture of creams, new diet and herbal medicine, because if things improve, you will not know which treatment has worked.

Emollients (moisturisers) reduce water loss from the outer layer of your skin by covering it with a protective film. This keeps the water in the skin where it is needed and also helps to keep infections and other harsh substances out. Emollient creams and ointments are essential in the prevention and treatment of eczema. Emollients are very safe and you cannot overuse them. They are not active drugs and do not get absorbed through the skin into the body.

Topical corticosteroid (steroid) preparations, including creams or ointments can quickly bring the eczema under control and is the main treatment even in small children. It is not a cure but is effective in reducing the inflammation associated with a flare up of eczema.

For most people with mild to moderate eczema, treatment with a mild steroid (hydrocortisone 1% cream or ointment) for one to two weeks is enough to treat a flare up. You may need to step up to a stronger steroid if there is no response, but in general, you should use the lowest strength that works. Your doctor or pharmacist can explain the differences between the preparations available.

Topical steroids must only be used to treat eczema when the eczema has flared. Start treatment at the first sign of a flare up. You should already be using emollients regularly. Used correctly, topical steroids are safe and effective whereas untreated eczema can have serious consequences. You could be sensitive to one of the ingredients in the cream or ointment, apart from the steroid. If you notice that the eczema gets worse, it is important that you talk to your pharmacist or doctor to discuss alternatives. See general section on topical steroids for more information.

Anti-infective agents

You can help to prevent eczema becoming infected by, keeping hands clean and nails clean and short, and avoiding scratching.

If there is any suspicion that the eczema has become infected (redness, weeping or blisters) see your doctor because the infection can spread quickly and the use of steroid creams can mask or further spread the infection. Your GP will give you a course of oral antibiotics and/or an antibiotic cream or ointment.

The oral antibiotic is usually a penicillin such as flucloxacillin (or erythromycin if the patient is allergic to penicillin). Antibiotic creams or ointments used are fusidic acid or mupiricin or a combined steroid and antibiotic cream or ointment Rarely, the infection may have been caused by the cold sore virus (herpes simplex). This is treated with an anti-viral medicine such as aciclovir and hospital admission may be necessary if severe.

Antihistamines Sedative antihistamines, such as alimemazine (previously known as trimeprazine) and hydroxyzine may sometimes help to reduce the itch of eczema at night and give a good night’s sleep. They are only suitable for short periods of treatment (e.g. to break a pattern of sleepless nights). They can make you feel drowsy the next day so may not be suitable if you drive or, if you are treating a child going to school. Give the dose about one hour before bedtime so that it has time to take effect. A bath about an hour before bed followed by plenty of moisturisers can help cool the skin and may be more effective than the antihistamine. Give the antihistamine after bathing not before.

Antihistamine creams are not effective in eczema treatment and should be avoided as sometimes the ingredients in them can make the eczema worse.

Topical immunomodulators

Tacrolimus ointment and pimecrolimus cream have recently been introduced. They are not recommended for the treatment of mild atopic eczema or as first-line treatments for atopic eczema of any severity.


Topical tacrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate to severe atopic eczema in adults and children aged 2 years and older that has not been controlled by topical
corticosteroids where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.


Pimecrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate atopic eczema on the face and neck in children aged 2 to 16 years that has not been controlled by topical
corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.

Over-the-counter medicines for eczema

A range of shampoos, emollient products and some topical steroid preparations can be bought from pharmacies. Some of them are cheaper to buy this way, than on a prescription. Ask your pharmacist for advice on the different products and how to use them. After asking you a few questions to find out about you, your condition and any medicines you may take or use (including any treatments applied directly to the skin), they may decide it would be better for you to see your GP to review your condition and its treatment.

Tell your pharmacist if you, or the person who needs the treatment, is allergic to peanuts because some products contain peanut (arachis) oil. If your eczema does not improve after one week of using an over-the-counter preparation, particularly a moderately potent corticosteroid e.g. clobetasone butyrate, you should see your GP.

Hospital treatments

People with severe eczema or eczema resistant to treatment may require referral to a skin specialist (dermatologist). Treatments used may include: 'wet wraps', tar and/or steroid occlusion bandages, light therapy, and medicines which suppress the immune system such as ciclosporin.

Complementary treatments

Evening primrose oil supplements, borage oil, homeopathy (graphites, nat.mur) and Chinese herbal medicine (Chinese gentian, Chinese wormwood, peony root, rehmannia) have all been used to treat atopic eczema. There is little evidence to prove how these alternative medicines work or how safe or effective many of them are. Certain herbs and preparations contain ingredients that can be harmful if not used with care or if not obtained from reputable sources.

Before using any complementary medicine for eczema, you should talk to your GP or pharmacist (chemist). You can also phone NHS Direct on 0845 4647.

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Eczema (contact dermatitis)


Contact eczema is often referred to as dermatitis. It is an acute (short- term flare-up) or chronic (long term) skin reaction where there is sensitivity to materials or substances that come in contact with your skin. It may involve allergic or non-allergic reactions.

Irritant contact dermatitis is a skin reaction caused by the direct effect of an irritant substance on the skin. Contact dermatitis typically causes inflammation on areas of skin which have come into contact with the substance. No prior exposure to the substance is necessary. An irritant dermatitis is most likely to occur on the hands. If you have atopic eczema (the most common type of eczema, which is linked with hay fever and asthma) you may be more prone to irritant dermatitis. These irritants are commonly found in various occupations e.g. cleaning, hairdressing, horticulture and building work.

Allergic contact dermatitis is a skin reaction that occurs when your immune system reacts against a specific substance (called an allergen). Your immune system becomes sensitised to the allergen over time. Previous exposure to the substance is needed to produce an allergy. Therefore you can suddenly react to a substance you may have come in contact with many times before. A small amount of the allergen can then cause a skin reaction. Once your skin has become sensitised it can persist for life and there is no cure. Common substances include: nickel (jewellery, bra straps, belt buckles etc.), perfumes, rubber, some plants, some ingredients in cosmetics, skin medications, hairdressing chemicals etc.

Symptoms

Irritant dermatitis may appear as a slight redness, with mild inflammation to a severe inflammation with redness, itching and skin blistering or cracking and bleeding at the site of contact with the irritant. If the condition becomes chronic (long-term), the skin will be dry, inflamed, scaly and thickened.

Allergic contact dermatitis may initially appear as an itchy red rash at the site of contact with the skin. There may be some swelling and blistering. The skin may become thicker and dry and scaly if the allergen persists. The reaction is generally confined to the site of contact with the allergen, although occasionally it may extend outside the contact area or it may spread all over your body. The rash usually clears if the allergen is no longer in contact with the skin, but recurs with any slight contact with it again.

Causes

Substances penetrate the skin and the outer layer of the skin (epidermis) becomes damaged. This damage can be due to an irritant effect, which can cause a reaction in anyone or an allergic reaction, which will only cause a reaction in some people. It is unclear why some people become allergic to some substances, while most people do not.

Common irritants include detergents and cleaning products, solvents, oils and chemicals.

Common substances that cause allergies include: nickel, jewellery, wristwatches, belt buckles, cement, leather, tights, rubber, creams and ointments, cosmetics and perfumes, hair dyes, some plants and preservatives.

Diagnosis

Your GP will normally refer you to a skin specialist (dermatologist) for patch testing to find out what is causing your allergic contact dermatitis. The test patches are left in place for two days then removed and any reaction is noted. A further examination is carried out after a further two days to detect any further reactions.

Your GP may refer you to a dermatologist for a full assessment and investigation as to the cause of irritant dermatitis, although this is sometimes clear. If the reaction is due to substances you are working with, they can be avoided as far as possible.

Treatment

The three main goals of controlling and treating contact eczema are, the identification and avoidance of the cause, and healing the skin and keeping it healthy.

Whether your eczema is due to an irritant, such as detergent, or due to an allergen, such as nickel, care and treatment of your skin is the same. Treatment is based on the use of, emollients (moisturisers) including soap substitutes, bath oils, and topical corticosteroids (steroids) for flare-ups.

There may also be a need for antimicrobial treatment (to treat skin infection), and antihistamine tablets (to help sleep disturbance caused by itching).

In more severe cases which are difficult to treat there may be a need for, other immunosuppressant medicines such as ciclosporin and azathioprine, and phototherapy and photochemotherapy. (light treatment, or light treatment plus medication).

The way you use and apply the treatments is a key factor in how successful you will be in keeping the eczema under control. Failure of treatment can often be due to incorrect use. There are many preparations of each type of treatment. It is often a matter of practicality and personal preference that determines which preparation is best. It may take time to find the best one(s).

Emollients (moisturisers)

Emollients reduce water loss from the outer layer of your skin by covering it with a protective film. This keeps the water in the skin where it is needed and also helps to keep infections and other harsh substances out. Emollient creams and ointments are essential in the prevention and treatment of eczema. Emollients are very safe and you cannot overuse them. They are not active drugs and do not get absorbed through the skin into the body.

Topical corticosteroid (steroid) preparations

A topical corticosteroid cream or ointment can quickly bring the eczema under control. It is not a cure but is effective in reducing the inflammation associated with a flare up of eczema.

For most people with mild to moderate eczema, treatment with a mild steroid (hydrocortisone 1% cream or ointment) for one to two weeks is enough to treat a flare up. You may need to step up to a stronger steroid if there is no response, but in general, you should use the lowest strength that works. Your doctor or pharmacist can explain the differences between the preparations available. Topical steroids must only be used to treat eczema when the eczema has flared. Start treatment at the first sign of a flare up. You should already be using emollients regularly throughout the day .

Used correctly, topical steroids are safe and effective whereas untreated eczema can have serious consequences.

You could be sensitive to one of the ingredients in the cream or ointment, apart from the steroid. If you notice that the eczema gets worse, it is important that you talk to your pharmacist or doctor to discuss alternatives.

Anti-infective agents

You can help to prevent eczema becoming infected by, keeping hands clean and nails clean and short, and avoiding scratching.

If there is any suspicion that the eczema has become infected (such as redness, weeping or blisters) see your doctor as soon as possible because the infection can spread quickly and the use of steroid creams can mask or further spread the infection.

Your GP will give you a course of oral antibiotics and/or an antibiotic cream or ointment. The oral antibiotic is usually a penicillin such as flucloxacillin (or erythromycin if the patient is allergic to penicillin). Antibiotic creams or ointments used are fusidic acid or mupiricin or a combined steroid and antibiotic cream or ointment

Antihistamines

Sedative antihistamines, such as alimemazine (previously known as trimeprazine) and hydroxyzine may sometimes help to reduce the itch of eczema at night and give a good night’s sleep. They are only suitable for short periods of treatment (e.g. to break a pattern of sleepless nights). They can make you feel drowsy the next day so may not be suitable if you drive.

Give the dose about one hour before bedtime so that it has time to take effect. A bath about an hour before bed followed by plenty of moisturisers can help cool the skin and may be more effective than the antihistamine. Give the antihistamine after bathing not before. Antihistamine creams are not effective in eczema treatment and should be avoided as sometimes the ingredients in them can make the eczema worse.

Over-the-counter medicines for eczema

A range of shampoos, emollient products and some topical steroid preparations can be bought from pharmacies. Some of them are cheaper to buy this way, than on a prescription.
Ask your pharmacist for advice on the different products and how to use them.

After asking you a few questions to find out about you, your condition and any medicines you may take or use (including any treatments applied directly to the skin), they may decide it would be better for you to see your GP to review your condition and its treatment.

Tell your pharmacist if you, or the person who needs the treatment, is allergic to peanuts because some products contain peanut (arachis) oil.

If your eczema does not improve after one week of using an over-the-counter preparation, particularly a moderately potent corticosteroid e.g. clobetasone butyrate, you should see your GP.

Hospital treatments

People with severe eczema or eczema resistant to treatment may require referral to a skin specialist (dermatologist).

Treatments used may include: 'wet wraps', tar and/or steroid occlusion bandages, light therapy, and medicines which suppress the immune system such as ciclosporin.

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Allergies

General information

Allergy is the term used to describe an adverse (bad) reaction by the body to a particular substance. Most things that cause allergies are not obviously harmful, and have no affect on people who are not allergic.

Any substance that triggers an allergic reaction is called an allergen. There are many different types of allergens; three of the most common are pollen, dust mites and nuts. Allergens contain protein, which is found in all living organisms, and it is the protein that causes the reaction. Some drugs such as penicillin can also cause allergic reactions. They do not contain protein, but they can cause a reaction if they bind to proteins in the body.

An allergic reaction to the allergen happens when you come into contact with it. Contact may be with your skin, or with the lining of your lungs, mouth, gullet, stomach or intestine. If your body reacts badly to a particular substance, you are said to be allergic to it.

Allergic reactions can cause a range of symptoms. Some can be quite mild, and some are serious, very occasionally resulting in death.

Allergies are very common and affect around one in four people in the UK at some time in their lives. Each year the numbers increase by 5%, with many more children being affected.

Symptoms

Allergic reactions do not happen the first time you come into contact with the allergen, but at a later point of contact. This is because the body has to develop sensitivity to something before it can become allergic to it.

Allergic reactions produce many different symptoms and affect people in different ways. Some of the most common symptoms include the following:

  • Sneezing,

  • Wheezing,

  • Sinus pain (feelings of pressure or pain high up in the nose, around the eyes, and at the front of the skull),

  • Runny nose,

  • Coughing,

  • Nettle rash / hives,

  • Swelling,

  • Itchy eyes, ears, lips throat & palate (roof of mouth),

  • Shortness of breath, and

  • Sickness, vomiting, & diarrhoea.

It is important to remember that these symptoms can also be caused by conditions other than allergies, and some may be illnesses themselves. See your GP or ask your pharmacist for advice if you are not sure what is wrong.

Causes

Allergies are caused by the body’s immune system reacting to allergens as if they were harmful. The immune system does this by making antibodies to fight off the allergen. Antibodies are  special proteins made in the immune system to fight off viruses and infections that could harm us.

When the body comes into contact with an allergen, the antibody released is called Immunoglobulin E (IgE) This antibody causes other blood cells to release more chemicals (including histamine), which together cause the symptoms of an allergic reaction. Histamine causes most of the typical symptoms that happen in allergic reaction:

  • It makes muscles contract, including those in the walls of the air tubes of your lungs.

  • It increases the amount of fluid that is released from small veins, so that membranes swell.

  • It increases the amount of mucus produced in your nose lining and causes local itching and burning.

Atopy:

Some people are predisposed to allergy. This means they are more likely to develop an allergy because it runs in their family. If you are predisposed to an allergy, the condition is called atopy. People who are atopic are more likely to develop allergies because their body produces more IgE antibody than normal.

Although atopy is inherited, environmental factors also play a part in the development of allergic disorders. This is why not all members of a family are affected to the same extent. The amount of contact you have with allergens in your first years of life is particularly important. For example, constant exposure to cigarette smoke, house dust mites, pollens, pets and certain foods makes you more likely to become allergic to them. Air pollution, processed foods and frequent use of antibiotics all seem to make us more likely to develop allergies as well.

There are thousands of allergens. Some of the most common include:

  • House and dust mites,

  • Grass and tree pollens,

  • Pet skin flakes or hair,

  • Fungal or mould spores,

  • Food (milk, egg, wheat, soya, seafood, fruit and nuts)

  • Wasp and bee stings,

  • Certain medication,

  • Latex , and

  • Nickel, rubber, preservatives and chemical resins.

Diagnosis

If you think you have an allergy, you should see your GP.

You will need to tell your GP about the symptoms you are having, when they happen and how often they occur.

Your GP will want to know if any family members have similar symptoms, or if there is a family history of allergy. You should also think about any triggers that seem to cause a reaction, and whether it happens at a particular place or time.

Your GP will probably carry out tests to identify the allergen that is causing your symptoms. Alternatively, you may be referred to an NHS or independent allergy clinic. There are about 90 NHS allergy clinics in the UK, some of which specialise in certain conditions such as asthma.

Even if you think you know what is causing the allergic reaction, you may need to be tested to find out the exact allergen. There are several different tests that can be carried out:

  • Skin prick test: this is usually the first test to be carried when looking for an allergen. The skin is pricked with a tiny amount of the suspected allergen to see if there is a positive reaction (the skin becomes itchy, red and swollen).

  • Blood test: this is used to measure the amount of IgE antibody in the blood, which has been produced by the immune system in response to a suspected allergen.

  • Patch test: this test is used to find the allergen causing eczema or contact dermatitis. Special metal discs are spread with a small amount of the suspected allergen and taped to the skin, usually for 48 hours, to see how the skin reacts. This test is usually carried out in dermatology (skin) departments in hospital.

  • Home allergy test: these kits can be used at home to find out if you are allergic to three of the most common allergens – house dust mites, pollen and cats. The test contains a sterile finger pricker for you to take a small blood sample with. This is collected in a tube and posted to a laboratory that tests the sample and lets you know the results. Home allergy test kits can be bought from most chemists.

Treatment

Wherever possible, the most effective way of treating allergies is to avoid all contact with the allergen causing the reaction.

There are many drugs available to treat the common symptoms of allergies, such as runny nose, itchy mouth and sneezing. Many of these treatments are available over the counter; ask your pharmacist or GP for advice.

  • Antihistamines treat allergies by blocking the action of the chemical, histamine, which the body releases when it thinks it is under attack from an allergen. Antihistamines can be taken in tablet, cream and liquid form. They can also be taken in eye drops and nasal drops.

  • Decongestants help to relieve symptoms such as a blocked nose, which is often caused by hay fever, and dust and pet allergies. Decongestants can be taken as tablets, capsules, nasal sprays or in liquid form.

  • Nasal sprays and eye drops: nasal sprays reduce swelling and irritation in the nose; eye drops relieve sore, itchy eyes. Some sprays and drops are only suitable for adults; ask your GP or pharmacist for advice before buying treatments for children.

  • Drugs such as sodium cromoglicate and corticosteroids can be used regularly to stop symptoms developing. These are commonly available as nasal sprays and eye drops.

Another form of treatment is hyposensitisation. This can help people who have a specific allergy to something like bee stings. The person is gradually introduced to more and more of the allergen to encourage the body to make antibodies that will stop future reactions. This type of treatment must only be carried out under close supervision from a doctor because of the risk that it may cause a serious allergic reaction called anaphylactic shock.

For further information about treatment of specific conditions, including asthma, hay fever, and eczema, please see separate encyclopaedia entries.

Complications

In rare cases, allergic reactions can be very serious. This is called anaphylactic shock. It is a sudden, severe allergic reaction that involves the whole body and it usually happens within minutes of coming into contact with a particular allergen.

The symptoms of anaphylactic shock affect the respiratory and circulatory system, and include raised blood pressure, swelling, and breathing difficulties. Emergency treatment is needed, usually with an injection of a drug called adrenaline.

For more information about anaphylaxis, please see separate encyclopaedia entry.

Prevention

Repeatedly coming into contact with allergens tends to make allergies worse. You can help to prevent this by taking the following steps:

  • Keep your home dry and well ventilated by opening windows, not drying clothes indoors and turning down central heating. Dehumidifiers are also helpful.

  • Cut down on dust mites by dusting and vacuuming regularly. Remove cushions and soft toys, and buy bedding made from synthetic fabric rather than using feather pillows and woollen blankets.

  • If you are allergic to house dust mites, it is especially important wash your sheets and pillows once a week on a hot wash, and buy barrier covers for your bedding.

  • Avoid eating allergens you know can affect you.

  • If you suffer from hay fever, wear sunglasses to stop pollen getting in your eyes, avoid going outdoors when the pollen count is high (often included in TV and radio weather reports), and don’t mow the grass or lie on freshly cut grass.

  • If you are allergic to pets, keep them outdoors, or make sure they only go into one room, preferably without carpet. Do not allow pets in bedrooms.

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Psoriasis

Psoriasis is a dry, scaly skin condition in which skin cells are reproduced too quickly. It affects approximately 2% of people in the UK. It can start at any age, but most often develops between 11 and 45 years old, often at puberty. It is much less common in childhood than other skin conditions such as eczema but rarely, it does develop before the age of ten years.

Normally skin cells take about 21-28 days to replace themselves, in psoriasis they take around 2-6 days. Normally there is a constant shedding of dead cells; however in psoriasis because of the acceleration of the replacement process, both dead and live cells accumulate on the skin surface. Often this causes red, flaky, crusty patches covered with silvery scales, which are shed easily. It can occur on any part of the body although it is most commonly found on the elbows, knees, lower back and the scalp. It can also cause intense itching and burning.

The condition is not contagious and most people have only small patches of their body affected. The severity varies greatly. Symptoms often come and go without treatment. However a few people with psoriasis have a more severe form that requires intensive medical and nursing care.

Symptoms

Plaque psoriasis- Approximately 80% of people with psoriasis have plaque psoriasis. Typically, it is characterised by plaques on the elbows, knees, scalp and lower back, but it can be found on any area of the skin. Each plaque usually looks like a red raised patch with overlying flaky white scaly surface that feels rough. The plaques are well defined, single or multiple, and vary in size (a few mm's to several cm's)

Nail psoriasis -This occurs in many people with plaque psoriasis. However it may also occur alone without the plaques. Tiny pits occur in the nails, sometimes causing the nail to separate from the nail bed.

Guttate psoriasis – This is characterized by small (less than 1 cm) droplet- shaped scaly patches occurring in many areas of the body. It typically occurs following a throat infection (streptococci); children and teenagers are particularly prone. The rash usually disappears (in several weeks or months), but some children go on to develop plaque psoriasis, which may remain indefinitely. Others will go on to develop plaque psoriasis later on in life. Some children, who are prone to tonsillitis, may develop Guttate psoriasis with each attack.

Inverse psoriasis: This is characterised by areas of skin in folds or creases (flexures), becoming dry with large smooth red patches. It is most commonly found in the armpits, groin, between the buttocks and under the breasts. Because these are sites of friction and sweating the areas can become itchy and very uncomfortable, especially in hot weather.

Erythrodermic psoriasis: This is characterised by the entire body periodically becoming red, inflamed and scaly. This is a very rare condition, which seriously compromises the body's temperature and fluid balance.

Pustular psoriasis is rare: There are several different types of pustular psoriasis. It is characterised by either widespread areas of red skin with pus filled blisters (pustules) (Von zumbusch pustular psoriasis), or localized areas, particularly the palms of the hands and soles of the feet (palmaplanter pustular psoriasis) or the fingers or toes ( Acropustulosis)

Von zumbusch pustular psoriasis develops very quickly, firstly the skin reddens and it feels tender, then pustules develop. The pus is not infected but consists of white blood cells. It is not contagious. It can also cause fever, chills, muscle weakness and malaise. The pustules, then dry and peel off within a couple of days, leaving the skin, shiny and smooth. Pustules may then reappear every few days or weeks.

In palmaplanter pustular psoriasis, the fleshy areas of the palms of the hands or the soles of the feet develop reddened plaques of skin and large pustules develop in a studded pattern. The pustules gradually develop into circular, brown, scaly spots, which then peel off. The pustules erupt repeatedly over months or years.

 In acropustulosis pustules develop then burst, leaving bright red areas that may ooze and become scaly on the fingers and/or toes. These may lead to painful nail deformities.

Typically, people have only one form of psoriasis at a time, although sometimes two different types can occur together. One type may change to another type, or one type may become more severe

Causes

The cause of psoriasis is unknown. There is a genetic link and it tends to run in families. About 30% of people with one first degree relative with psoriasis develop the condition. The genetic tendency however appears to need to be triggered by such things as: -

  • Infection- Streptococcal throat infections appear to trigger guttate psoriasis, usually in children and young adults, HIV infection can cause psoriasis to flare up or to appear for the first time.

  • Certain medicines may trigger or worsen symptoms in some people, including alcohol: smoking: lithium: beta blockers, for example atenolol: non-steroidal anti-inflammatory drugs, for example, ibuprofen, antimalarial drugs, for example chloroquine and ACE inhibitors, for example, ramipril

  • Psychological factors: Stress appears to trigger psoriasis flare-ups in some people.

  • Skin trauma: Psoriasis may develop if the skin is injured. This is known as the Koebner phenomenon. It may appear in an operation scar or in a scratch. It may also appear in the spots of chickenpox. Sunburn may also trigger a flare- up.

Diagnosis

There is no blood test for psoriasis. Usually the doctor will make the diagnosis from the appearance of the affected skin. Rarely, a sample of skin scrapings or a small sample of skin will be sent to the laboratory for examination under a microscope.

 If your doctor suspects you have psoriatic arthritis (see complications), you should be referred to a rheumatologist, who specializes in arthritis. Blood tests may be taken to rule out other conditions and x rays of the affected joints may be taken.

 Inverse psoriasis may be confused with the presence of the yeast, candida, scalp psoriasis for seborrhoeic dermatitis and nail involvement for a fungal infection. Treatment may also be more complex as these conditions can co-exist.

Treatment

There is no known cure for psoriasis. However, treatment is usually effective and will control the condition by clearing or reducing the patches of psoriasis. Most patients with psoriasis can be treated by their GP. Your GP may refer you to a dermatologist (skin specialist) and their team based in a hospital if symptoms are particularly severe or have not responded well to treatments already tried.

Psoriasis tends to come and go so relapses are difficult to predict and cannot be prevented with topical treatment There are many preparations and treatment combinations and your treatment will depend on the severity and the type of psoriasis you have, whether it is on the scalp or other areas of the body. It usually takes several weeks of treatment to clear plaques and some treatments take longer than others to work.

Self care

There are several tar based shampoos and emollient preparations that you can buy over- the- counter . Tell your pharmacist if you are allergic to peanuts because some preparations contain peanut (arachis) oil.

Emollients hydrate and sooth the skin and soften the plaques of psoriasis. For mild psoriasis, treatment with an emollient may be all that is needed. You can also use emollients in addition to any other treatment, to keep the skin moist and supple. Use them regularly to care for all of your skin. See general section on emollients for more information.

Topical steroids may be used in on their own or in rotation with other treatments to achieve a more effective result. Face and flexures (under breasts, behind knees/elbows) are treated with a mild steroid (e.g. hydrocortisone 1%). Thicker patches on the scalp, hands and feet are treated with a potent (e.g. betamethasone valerate) or very potent (e.g. clobetasol propionate) steroid as these areas can be more difficult to treat. Sometimes, in cases of more severe psoriasis of flexures, a moderately potent steroid steroid used in combination with an antibiotic and anti-fungal medicine may be used. This is because the psoriasis and surrounding skin may be broken and more susceptible to infection. Various preparations such as lotions, gels, creams and ointments are available to suit the different areas to be treated. See general section on topical steroids for more information.

Calcipotriol and tacalcitol belong to a group of medicines known as Vitamin D analogues (which are chemically related to vitamin A). Calcipotriol is available as a cream or ointment to treat plaque psoriasis and as a lotion for scalp psoriasis. It is also available in combination with betamethasone, a potent topical steroid. Tacalcitol is available as an ointment to treat plaque psoriasis. Calcitriol is a form of Vitamin D and is available as an ointment for the treatment of mild to moderate plaque psoriasis. These are effective treatments and usually well tolerated but sometimes cause irritation. These preparations do not smell or stain. Some people find that after several weeks, the treatment is not as effective. It may be helpful to alternate with another treatment every few weeks.

Dithranol is an effective treatment. It is sometimes used in combination with salicylic acid, coal tar or with hospital based treatments such as UV irradiation (particularly UVB). Dithranol is only used on areas affected by psoriasis because it is an irritant. You can protect the surrounding normal skin with yellow or white soft paraffin. To avoid irritation, dithranol treatment normally begins with the lowest strength, which is gradually increased if necessary. Do not try to persevere with treatment if it causes irritation, it might make the psoriasis worse. Depending on the type and strength of preparation being used, dithranol may be left on overnight or washed off after ten minutes. Dithranol stains skin, hair, material, plastics and enamel. Stains on skin and hair disappear when you finish the course of treatment but it may take several weeks or months.

Coal tar helps to reduce inflammation and also helps to remove loose scales from the patches of psoriasis. Coal tar can be applied to or allowed to come into contact with normal skin. Some tar products can be used on the face and in the flexures (behind elbows/knees and on the shins). Tar baths and shampoos can also be helpful. Higher strengths of coal tar may be needed to treat the thicker patches of psoriasis. The disadvantages of coal tar preparations are that they can cause skin irritation, they can also stain clothing and sheets or pillowcases. If you are using a coal tar preparation for your scalp, which needs overnight application, wear a shower cap to help the treatment penetrate and also protect your pillowcase from stains.

Tazarotene is a retinoid (a substance chemically similar to vitamin A). It is available as an ointment and is an effective treatment. It does not smell or stain. It is only used on areas affected by psoriasis and not on normal skin and it can cause irritation. You can protect the surrounding normal skin with yellow or white soft paraffin.

Other topical treatments

Salicylic acid is known as a keratolytic agent. This means that it softens the scaly layers of the psoriasis plaques and eases their removal. It is often combined with other treatments such as coal tar and/or dithranol in ointments and scalp applications. Coconut oil helps to soften the psoriasis plaques. It is used in combination with salicylic acid and coal tar for treatment of scalp psoriasis

Hospital based treatments

You may need to be referred to a dermatologist if your psoriasis is severe or resistant to treatment. Preparations you have used previously may be applied at different strengths, with various dressings or alternative methods of application and combinations. These treatments may also be used in combination with systemic treatments (treatments taken by mouth), with phototherapy (light treatment) or with photochemotherapy (light treatment plus a medicine called psoralen). You may be treated as an outpatient or admitted to hospital depending on the severity of your condition or the treatment to be used.

Complementary treatments

Aromatherapy (such as angelica, bergamot and true lavender), acupuncture, fish oils, zinc and aloe vera have all been used to treat psoriasis. There is little evidence to prove how these treatments work or how safe or effective many of them are. Certain herbs and preparations contain ingredients that can be harmful if not used with care or if not obtained from reputable sources.

Sun

You may find that exposure to sun improves your condition. Even if the sun does help, you should always use a high factor sunscreen.

 Before using any of these treatments for psoriasis, you should talk to your GP or pharmacist (chemist). You can also phone NHS Direct on 0845 4647.

Complications

Between 10% and 20% of people with psoriasis develop psoriatic arthritis, which causes tenderness, pain and swelling in the joints and connective tissue with associated stiffness. It commonly affects the ends of the fingers and toes. In some people it affects the lower back, neck and knees. About 80% of those affected develop psoriatic arthritis after the onset of psoriasis, but in about 20% the arthritis occurs before the onset of psoriasis.

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Hair loss/ Alopecia

General information

Alopecia is baldness or loss of hair. The commonest form is male-pattern baldness (also known as androgenic alopecia), but both women and men can get hair loss.

Alopecia areata is another type of hair loss, involving patches of baldness that may come and go. It affects about 1 in 100 people, mostly teenagers and young adults.

In some cases, hair loss is a side effect of having cancer treatment drugs, but in many cases the hair grows back.

Hair loss can lead to problems with confidence and self-esteem.

Symptoms

Male-pattern baldness is hereditary which means it runs in families. It usually starts to happen around the late twenties and thirties although this can vary. By the age of 60, most men have some degree of hair loss.

Male-pattern baldness is so called because it tends to follow a set pattern. The first stage is usually a receding hairline, followed by thinning of the hair on the crown and temples. When these two areas meet in the middle, you have a horseshoe shape of hair around the back and sides of your head. Eventually you may be completely bald.

Women’s hair gradually thins with age but they only tend to lose hair from the top of the head. This usually gets more noticeable after the menopause. It is called androgenetic alopecia, or female-pattern hair loss, and also tends to run in families.

Alopecia areata causes patches of baldness that are about the size of a large coin. They usually appear on the scalp but can occur anywhere on the body, including the beard, eyebrows and eyelashes. There are usually no other symptoms.

Causes

The average human head has 100,000 hairs. Hair is made in hair follicles (the root of the hair). Each hair grows for about 3 years then it drops out and a new one grows - we lose 40-120 hairs a day (1).

Male-pattern and female-pattern baldness is caused by over-sensitive hair follicles. This is linked to dihydrotestosterone (DHT) that is produced by the male hormone testosterone. If there is too much DHT, the follicles shrink, so the hair becomes thinner and grows for less time than normal. The balding process is gradual because different follicles are affected at different times.

Alopecia areata is linked to a problem with the immune system.  The hair follicles are not permanently damaged and in many of these cases the hair grows back in a few months. In 1 in 5 cases it runs in the family (2).

Some conditions such as anaemia (disorder of the blood), illness, stress (including bereavement), fungal infections and thyroid problems can make you lose some of your hair, as well as drug treatment for cancer. Women who are pregnant or have recently given birth may also experience some hair loss. Hair loss is not caused by a lack of any vitamins in the diet.

Diagnosis

Male-pattern baldness is usually easy to identify because of the pattern it follows. It usually begins with a receding hairline in the late twenties or thirties, but can start earlier. At first, you may notice that your hair is starting to get thinner.

Female-pattern baldness usually becomes noticeable after the menopause; the hair on top tends to thin first.

If your hair loss does not follow the typical pattern as above you should see your GP to find out what is causing it. It could be linked to an illness such as anaemia or a fungal scalp infection. Your GP may refer you for more tests or suggest that you see a dermatologist.

With alopecia areata, there are no obvious symptoms other than patches of baldness, so your partner or hairdresser may notice it before you do.

Treatment

If the hair loss is caused by an infection, or other condition such as anaemia, this can be treated to prevent further hair loss. In some cases, including after cancer treatment, your hair may start to grow again.

There are drugs available to treat male-pattern and female-pattern baldness but they do not work for everyone and the effects are not long lasting. You have to take the drugs for 4–24 months before you notice any improvement (3) and the effects will not usually last long after you stop taking them (4). These drugs are not available on the NHS so you have to pay for them. See your GP for advice.

You can also get lotions that you rub on your scalp, although these do not work for everyone, or have long-lasting effects. There are shampoos and formulas available for improving circulation to the scalp, and some people try herbal treatments.

Other treatments include wigs, hair transplants (taking hair from the sides and back of the head) and plastic surgery (such as scalp reduction where the bald area is removed and the bit with hair on is stretched forward).

There is no real effective treatment for alopecia areata. Some treatments can encourage hair to grow, such as steroid injections or creams – see your GP for more information. In 60-80% of cases the hair grows back after about a year (5) without any treatment.

A person with alopecia areata is more likely to have or to develop other autoimmune conditions such as thyroid disease, diabetes and vitiligo (a condition that produces white patches on the skin). These are all linked to problems with the immune system.

Prevention

If you have inherited the genes responsible for male-pattern or female-pattern baldness there is not a lot you can do to prevent it happening. The treatment suggestions may slow down the loss but are not an actual cure.

It is important to remember that hair loss happens to a lot of people as they get older and there is no need to be embarrassed or depressed about it. If hair loss is making you worried or unhappy you can see your GP or ask to see a dermatologist. Your local pharmacist may have some useful advice for you as well. Your hairdresser may be able to suggest a flattering haircut for you.

References

1) British Association of Dermatologists

2) British Association of Dermatologists

3) British Association of Dermatologists

4) ATTRACT (Wales)

  1. Prodigy guidance”

(www.nhsdirect.nhs.uk/articles )