Nail conditions we treat

Apart from consulting in our wonderful clinic in South Melbourne, I also am a staff specialist at The Alfred Hospital in the general dermatology clinic and have held that position for about 6 years. But another position I also hold is at the Nail Clinic in the Skin and Cancer Foundation Inc in Carlton. Here at this monthly clinic, our team consisting of dermatology specialists, podiatrist, nurses and clinical photography assess all manner of nail conditions and concerns. Dr Anne Howard leads our team and she has contributed to a recent article in Prevention Magazine about Nail Conditions in Salons. A lot of patients may not even know that nail conditions are managed by dermatologists! Nail conditions are a sub-specialty interest of mine and I see a lot of patients with nail issues in my private clinic in South Melbourne too. Recently I have seen a whole load of nail cases and below are some of my recommendations about nail issues arising from common cases or questions that my patients ask me.

Shellac/SNS/gel nails 

  • Be careful to only use LED light and not UV light in the curing phase for these types of nail treatments. There have been studies to suggest that using UV lamps to harden gel nail polish may be harmful and lead to skin cancers. One observational study from Ireland has recently published about this risk in the Australasian Journal of Dermatology and has suggested the use of a high SPF, broad spectrum sunscreen before lamp exposure or the use of fingerless gloves to minimise risk.
  • Try to avoid pushing back or cutting the nail cuticles with your nail treatment as the cuticle is important for healthy nail growth.
  • Some chemicals used in the nail manicure process can cause allergic contact dermatitis which can show up first as an eyelid/facial eczema. The only way to confirm such an allergy is to perform patch testing. Common allergens include –
    • methylisothiazolinone (or MI for short) – used in some wet wipes in the prep phase of a nail treatment
    • toluene sulfonamide formaldehyde resin (or TSFR for short) – a chemical in many nail polishes and nail hardeners
    • acrylates – a chemical used in the binding process and seen in nail polishes and artificial nails

Nail infections

  • Tinea (fungal infection) of the nail plate typically leads to a thick, crumbling and discoloured nail plate. It’s always best to prove there is a fungal infection present by taking a good quality nail clipping of the affected area and send for fungal culture. If fungal infection is proven, then a course of oral anti-fungal tablets is required (can be a 3-6 month treatment). Typically, topical anti-fungal paints/tinctures are not effective when the nail plate is heavily infected. If you are going to salons for your mani/pedi, be careful to ensure instruments are sterilised properly; or better yet, bring your own set of instruments.
  • Thrush infection of the nail plate can cause discoloured nails and lifting of the nail plate and may need treatment with oral anti-yeast tablets.
  • Pseudomonas (bacterial infection) of the nail plate can cause the nail to have a black/green discolouration. Dilute white vinegar soaks can help to improve the appearance of the nail.

Onycholysis (lifting) of the nail plate

  • Too much manipulation of the nail can lead to lifting of the nail plate – manicures/pedicures with soaking of the nails, inserting instruments to clean under the nail, trauma (from footwear and running for example)…all these factors influence the “adhesiveness” of the nail plate to the underlying nail bed.
  • Another cause of nail plate lifting can be psoriasis of the nail; with other features seen including pitting of the nail, discoloured red/yellow nails and thick crumbling nails. Nail psoriasis can sometimes be mistaken for tinea (fungal infection).

Onychogryphosis 

  • This refers to very thick nails that can resemble a scallop shell with layers upon layers of keratin deposited over many years. Often patients are concerned about tinea infection of the nail but nail clippings do not grow any tinea. Management of this condition is cutting back and filing down the nail (with podiatry help if needed) and getting good supportive footwear to prevent the condition worsening.

Longitudinal melanonychia (pigmentation) of the nail 

  • These present as long brown/black streaks on the nail plate and in most cases, is benign. Longitudinal melanonychia is seen often in patients with darker skin (Asians, Africans, Indians, Mediterranean backgrounds). It is thought to be due to a mole or a freckle residing around the area of the nail matrix and hence, as the nail grows, pigment is deposited along the nail plate.
  • We always need to be on the lookout for melanoma of the nail unit. Features which are suspicious for melanoma include asymmetry of the pigment band, asymmetrically placed globules and dots, pigment bands of uneven thickness and uneven colour, and pigmentation on the skin at the base of nail (periungual fold).

Brittle nails/splitting of the nails 

  • can be dietary related and hence bloods to check on general health could be helpful
  • General weathering of the nails from ageing, wet work, trauma etc can lead to brittle nails. We would recommend using a good quality hand cream and ensure the cuticles are not damaged.
  • Nail supplements containing biotin (vitamin B) may be helpful.

Nail tumours/cysts

  • These are rare but can present as a split in the nail, a sore lump under the nail, or a lump that discharges fluid under the nail or around the nail fold. Treatment for these types of lumps is usually surgical excision via dermatologist or plastic surgeon.

Great outcomes for urticaria (“hives”) patients with new injectable medication!

 

Spontaneous urticaria (hives) is such a common condition but can be difficult to manage. Patients describe itchy welts, swollen and red skin, and sometimes swollen eyes and lips too. The rash typically resolves within 24 hours but then the cycle repeats itself and new rash appears on other areas of the body. It can be incredibly itchy or even painful and can be frustrating to treat.

I myself suffer from urticaria too but mine is set off by temperature changes (“cold-induced urticaria”) and friction (“delayed-pressure urticaria”).  Any of my urticaria patients will attest to my empathy with their skin rash; as I have first hand knowledge of how frustrating it can be to manage! When patients present with urticaria, it is important to find out the triggers (heat, sweat, friction, stress, medication etc) and also exclude any other underlying medical conditions that can contribute to their urticaria flaring. This means taking a detailed history for other symptoms and blood tests may be needed. Typically urticaria treatments might involve creams, UV therapy and tablets.

Now a new injectable biologic medication, Omalizumab, is available under the PBS for our patients with chronic spontaneous urticaria since late 2017. Only some dermatologists are able to prescribe this medication (Dr Georgina Lyons and myself satisfy PBS criteria to prescribe this medication). Omalizumab works by binding to circulating IgE; a molecule responsible for setting off an inflammatory cascade, leading to the symptoms of itch and rash. Omalizumab has been on the PBS for a while for the indication of asthma but has been a recent addition to the PBS under dermatology for the indication of Chronic Spontaneous Urticaria (or CSU for short). In the past, patients with CSU have used various combinations of H1 (histamine 1) blockers and H2 blockers, UV therapy, Plaquenil (an anti-malarial tablet that acts to reduce inflammation), mast-cell stabiliser medications and then immunosuppression – all in a bid to control their rash and itching. Now we are finding that patients are able to transition straight from the H1 and H2 blocker combination, to Omalizumab straight away and these patients are reporting great outcomes.

Omalizumab is given as a monthly injection and PBS gives patients 3 months worth of medication at a time. After the 3-month period of medication is up, patients then make an assessment as to whether they need another round of injections or they can take a trial period off the injections and monitor their symptoms to see if there is a flare. If they need another period of treatment, then their dermatologist can apply for another 3 months.

It is a well tolerated medication and some patients with a history of very difficult to control urticaria have had a great response to this medication. We would be happy to offer you an appointment with our team to fully assess and manage your urticaria.

Acne and early treatment

In this blog we would like to discuss one of our lovely patient’s journey with acne and share with you some very impressive before and after photo’s.

Our patient is a 25yo gentleman who has been struggling with cystic acne since the age of 14. Over the course of 11 years he experienced large cystic lesions to his chest, back, face and neck that are typically associated with significant atrophic (pitted) scarring. He found his acne would increase with consumption of certain foods and had tried many different types of skincare with little change to his skin.

The lesions were painful, red and visible.

He came to us with a pre-conceived notion of treatment options and their side effects and efficacy and had avoided medical treatment for many years because of this.  After a thorough consultation, with skin education and encouragement he was happy to try treatment and commenced on oral isotretinoin, oral antibiotic cover and anti-inflammatories to reduce flare-up which can occur with this type of acne. He received a detailed consultation regarding appropriate skincare and acne aetiology (causal factors).

The images pictured are only 4 weeks post commencement of treatment and this gentleman is so thrilled with his results he has provided his very own ‘before and after’ images that he has previously shared on social media personally and was more than happy for us to share on this platform for the benefit of others. We are thrilled to join him on his journey to great skin!

He told us he wanted to share his images as (in his own words) “I put up with my acne for so long and if my “before and after” pictures can help patients make the decision to see a dermatologist and get treatment early, then I’m happy to help.”

 

For more images please follow the links to Instagram and Facebook from our home page!

Eczema in babies

 

 

And just like that in the blink of an eye my youngest is nearly 8 months. Trawling through old videos and photos, I came across this video that was shot when I was pregnant with him. I am talking about eczema in the video and little did I know that he would also have infantile eczema, like his older sister (eczema tends to run in families). And little did I know I would have many a sleepless night with him scratching and irritable!

Today I was asked about suggestions for eczema management for a medical colleague’s baby. She was having trouble managing her 4 month old’s eczema. Here is the conversation, almost verbatim….

{Sleepless mum of 4-monther}  Eczema runs in my family. Bub has eczema and dribble rash and also heat rash on the trunk. He is scratching at night and I really want to help him. I have been putting on greasy moisturiser on the dribble rash and barrier cream containing zinc but I think this has made it worse. I have been applying bath oils in the bath, moisturising creams and 1% hydrocortisone cream for the body rash but am getting no where and no one in my house in getting sleep. HELP!

{Me} Don’t bother with 1% hydrocortisone on the body. This over-the-counter cream is really only for the mildest of eczema rashes. It does have its place but when the eczema is severe enough that no one in the family is getting any sleep, you need to bring in the medium/strong potency topical steroids for the body eczema. I would suggest topical steroids such as methylprednisolone aceponate 0.1% daily for about 2-3 weeks until the rash settles considerably and then downgrade to the 1% hydrocortisone for maintenance.

{Sleepless mum of 4-monther} But the 0.1% cream you’ve suggested must be weaker than the 1% hydrocortisone that I have been using.

{Me} This is a common misconception. The percentage that is displayed on the topical steroid cream does not in any way correlate with potency strength. It is a bit confusing but as dermatologists we are used to figuring out which potency strength patients are going to need to sort out their rashes. A lot of people ask me about steroid atrophy (thinning of the skin)  but if you apply the steroid cream only to the rash areas and not on normal skin, and apply for short periods of time to control the rash, you would rarely get skin thinning. You should go with your gut and if bub is unhappy and itching away, then he needs active cream treatments.

{Sleepless mum of 4-monther} What about his heat rash? I’m doing all the right things; avoiding overheating; using lukewarm baths…

{Me} Here are some additional things that you might want to make sure you are doing for the heat rash/eczema….If you have a mattress protector, consider ditching it for the short while until the rash resolves. Most mattress protectors will be quite “plasticky” and trap heat. As you have a young 4 monther that is not yet able to roll over, he might get too hot in the cot but he won’t be able to roll over or get himself in a more comfortable position. I have found with my 8 monther, once he was rolling and sitting up by himself, a lot of his eczema settled down as he is able to “air himself” out more. If bub co-sleeps in bed with you, he may also be overheated. Also if he uses a sleeping bag, try and opt for a light cotton one rather than a heavy duty style. Try and use 100% cotton sheets in bedding rather than poly/cotton blend to keep him cool, avoid any clothes that might irritate his skin – wool, clothes with irritating zips and tags (consider cutting off tags even!), ribbed singlets..

{Sleepless mum of 4-monther} **SMS’ me a picture of the heat rash**

{Me} ….bub’s skin does look irritated in the pic. I would also steer clear of occlusive ointments. So if you are using topical steroids, go for the cream preparation rather than the greasy ointment as ointments can be too “sticky” and make the heat rash worse. Get bub reviewed if the above don’t help. Sometimes eczema can become secondarily infected and then there might be a need for topical or oral antibiotics or anti-septic washes. Good luck! Most kids will grow out of eczema but hopefully by doing all of the above, you can make the transition easier….and hopefully get some more zzzzzz in the meantime.

 

Get the glow; just not the red glow…..

We often hear from our patients that they want their skin to glow! But not the RED kind of glow!

If you’re plagued with skin that glows red for hours after any physical exertion, at the thought of public speaking or you just wake up red and rosy you could probably benefit from our vascular laser!  There are a number of skin conditions that can cause excessive redness in the skin. Rosacea is a common one that we see as dermatologists and laser bridges the gap between a medical approach (prescription creams, medicine) and a cosmetic approach to shut down the telangiectasia (blood vessels) caused by flare-ups. Many of our patients present with generalised sun damage caused by accumulated UV exposure, causing dilation of the superficial vessels and making them visible or obvious. Surprisingly, many people are not aware that WE CAN TREAT THIS…. With laser.

Laser has been available in Australia since the early 80’s and these days the technology has been refined to give us great results, safely, with as little downtime as possible.  In saying this… laser is NOT a walk-in, walk-out treatment in most cases! Expect some downtime in most instances. HINT: swelling++.

So if redness, red spots or large vessels are getting you down, pick up your biggest pair of Hollywood sunglasses to hide behind and book yourself in for some laser at our clinic!