When a skin boil is more serious….could this be hidradenitis?

Hidradenitis Suppurativa (HS) – the latest information from the recent Melbourne Dermatology Conference May 2019.

Every year the Australasian College of Dermatologists holds an annual scientific meeting to update us all on the latest advancements in the diagnosis and management of dermatologic diseases. This year it was held in Melbourne (YES – my home town!). After 4 days of absorbing all this amazing information, my head is bursting with ideas for managing our existing patients. One session that really got my attention was the hidradenitis suppurativa lecture. Mainly under-diagnosed and sub-optimally managed, the prevalence of this condition is 0.67% (so, it’s more common than you think!). It was pleasing to hear that dermatologists lead the list of the medical specialists diagnosing this condition but there is STILL a LONG delay of MANY YEARS to patients being formally diagnosed with this condition.

WHY?

There can be many factors leading to diagnosis delay including embarrassment from the patient about the condition and so they never speak up about it, sub-optimal education of other medical specialties about the condition, patients thinking it is just a “simple boil” in the groin etc  ……in order to diagnose HS earlier, the public needs to be more aware that a condition like HS even EXISTS…..

We really should be asking our patients –Do you suffer from sore painful lumps or boils under your armpits or groin area?? Do you mind if I have a look? As it could be hidradenitis suppurativa.”

“SEEK and YOU WILL FIND”

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Hidradenitis suppurativa is an inflammatory skin disease that affects gland-bearing skin in the underarms, in the groin, and under the breasts. It is characterised by recurrent boil-like nodules and abscesses that culminate in pus-like discharge, difficult-to-heal open wounds (sinuses) and scarring. Hidradenitis suppurativa also has significant psychological impact and many patients suffer from impairment of body image, depression and anxiety.

Hidradenitis often starts at puberty, it is most active between the ages of 20 and 40 years, and in women, can resolve at menopause. It is three times more common in females than in males. Risk factors include:

  • Other family members with hidradenitis suppurativa
  • Obesity and insulin resistance/metabolic syndrome
  • Cigarette smoking
  • Acne
  • Inflammatory bowel disease
  • Rare autoinflammatory syndromes

Signs and Symptoms

HS can affect single or multiple areas in the armpits, neck, sub mammary area, groin and inner thighs. Anogenital involvement most commonly affects the groin and vulva (in females), sides of the scrotum (in males), buttocks and perianal folds.

  • Open and closed comedones (white heads and blackheads)
  • Painful firm papules, larger nodules and pleated ridges
  • Pustules, fluctuant pseudocysts and abscesses
  • Draining sinuses (like “tunnels” under the skin) linking inflammatory lesions
  • Thick (hypertrophic) scarring

Hidradenitis can be associated with inflammatory bowel disease and so it is important for your dermatologist to also consider screening for your risk of this condition too. HS can also be associated with acne, psoriasis and hirsutism.

General measures you can do at home

  • Loose fitting clothing
  • Avoiding too much friction in affected areas (being careful with the types of exercise pursued). It may be worth considering the High Intensity Workout regimes which get your blood pumping quickly but minimise too much frictional irritation.
  • Reduction in weight (to lead to decreased friction in the skin fold areas); dietician advice may be helpful
  • Daily un-fragranced antiperspirants
  • If prone to secondary infection, wash with antiseptics or use dilute bleach baths
  • Apply simple dressings to draining sinuses
  • Analgesics, such as paracetamol (acetaminophen), for pain control
  • Seek help to manage co-existing mood issues such as anxiety and depression
  • Seek GP advice about weight loss, mood issues, quitting smoking etc. Also GPs can act and possibly come up with Team Care Arrangements which then allow patients to access some allied health services for FREE (like dietician consults and psychological support).
  • Join a support group so you can receive tips and support from people who going through the EXACT same issues as you!

We are here to help you manage your disease!

The dermatologist may prescribe local therapies such as –

  • anti-septic washes (such as Phisohex or Chlorhexidine),
  • antibiotic cream (such as Clindamycin 1% cream),
  • injections of steroid solution into the inflamed lumps.
  • Topical vitamin A creams (retinoids) to help unblock the blackheads and whiteheads

Oral medications include –

  • Oral contraceptive pill or hormonal treatments such as spironolactone (for females).
  • Oral antibiotics to clear any infection and reduce inflammation (must be taken for a few months to see the outcome).
  • Vitamin A tablets such as isotretinoin or acitretin
  • Metformin (a diabetic medication) which can help with the insulin resistance pathway which can drive HS
  • Oral immunosuppression tablets

Injectables

  • There are the new injectable “biologic” medications which have recently been approved under the PBS for eligible patients with hidradenitis.

Surgery

  • Simple surgery that can be done at the dermatologist without general anaesthetic. This is the technique of de-roofing the very inflamed lesions to allow for healing.
  • More complex surgery can be done in hospital via Plastics and usually done with consultation with the Dermatology Team.

Key points to remember

– Get the correct diagnosis from a professional such as a dermatologist EARLY, don’t mistake it just as a pimple

– Early treatment can mean less chance of scarring

– There are simple home measures you can do to prevent them from flaring

– With appropriate treatment you can stop this disease from returning

Want to know more? Here are some online resources

https://www.hs-online.com.au

https://www.dermnetnz.org/topics/hidradenitis-suppurativa/

http://anzvs.org/patient-information/hidradenitis-suppurativa/

http://hidradenitissuppurativasupportgroup.org/

Treatment options for viral warts

Warts are growths on the surface of the skin caused by human papillomavirus (HPV). While usually benign, these pesky bumps are in fact contagious.

Warts can be stubborn things to get rid of and can sometimes take months to resolve. You may have visited your GP for a wart where just freezing the wart can be an effective treatment. If however it doesn’t go away with a couple of freezing treatments, you may need to see a dermatologist to receive different treatment. The quicker you get on to the wart the easiest it will be to remove it.

Warts are contagious and you are more likely to pick them up in warm moist areas such as swimming pools or public showers. People who sweat more may be more prone and it is very common to see in children as they may pick them up at school from others.

Treatment in our clinic can involve different strength topicals that illicit the immune system to, in a sense, ‘’wake up’’ and shock the immune system to expel the viral skin lesion. The immune system will then start to fight the virus from the inside; the treatments can also attack the wart from the outside.

The topical solutions we use on the wart may provoke a blister to develop and this will typically begin to heal within a week. Once the blister resolves, so does that wart!

Sometimes, with in-clinic medication, only one or two treatments are necessary. We will also give you home treatment to do in the weeks after, to make sure the wart doesn’t have a chance to grow back! As we know, warts are stubborn little things and need to be attacked quite regularly to stop spreading and remove them for good!

Helpful hints to avoid getting warts!

As warts thrive in hot/sweaty conditions, if you sweat a lot, wear cool clothing/change socks frequently etc. Baby powder can be an option to put on the feet before socks, to soak up any excess sweat.

Wear thongs in public showers to avoid picking up viral warts

If you do have some warts, avoid picking/scratching them as they can directly spread via this method! Call us on 03 9039 5644 for an appointment to clear those warts for good!

Professional Help to Combat Hair Loss

Hope Dermatology welcomes our first guest blog contributor, Dr Elaine Sung (General Practitioner) from Doctors of South Melbourne, giving us her insights on hair loss from the GP perspective – 

 “Finding an increasing number of hair strands on the shower floor, in your brush or on your pillow can strike instant fear. The thought of premature baldness is something we would all rather not contemplate.

If this is something you have recently experienced, first and foremost don’t panic. There is every chance it’s a passing issue and absolutely nothing to worry about.

However, you should get the problem checked out if it persists or is severe.

As a GP, I’m usually the first medical professional patients visit to complain about their hair loss. We usually do a pretty good job at finding a cause. I always make a point to reassure patients that while not all hair loss is curable, it can be managed in the majority of cases.

GPs are well placed to discuss simple treatment options depending on the cause, of which there are many possibilities. Any good doctor will thoroughly go through a patient’s medical history, conduct an examination and order blood tests.

Importantly, I tell patients to steer clear of fads that promise quick results and deliver nothing but a lighter wallet. Herbal supplements and most lotions are as effective as placing a cut onion on your scalp (as someone had suggested to a recent patient).

I’ll usually write a referral to see a dermatologist if a patient’s diagnosis isn’t clear or more intensive treatment is needed.

Follicle Experts

Being leaders in the field of hair loss, dermatologists have access to an extensive range of treatment options. What’s more, they have the experience and tools to conduct more in-depth diagnosis, including scalp biopsies to determine the rarer causes of hair loss.

Depending on the circumstances, dermatologists can be better equipped to get patients on the right path to slow, stop or even reverse their hair loss.

Impact of Stress

Premature hair loss can cause enormous stress and anxiety. Sometimes it’s helped with education on the subject, other times this isn’t nearly enough.

Adding insult to injury, a poor mental state can itself contribute to further hair loss; quite a cruel double-edged sword.

Stress can be a factor in a hair loss condition called telogen effluvium. This is generally a condition that resolves on its own.

Stress and anxiety are also related to certain conditions that can trigger hair loss, such as trichotillomania: an anxiety disorder that results in people consciously or sub-consciously pulling their hair out.

GPs will talk with patients about options for managing anxiety issues stemming from hair loss. They can also arrange for specialists to assist in treatment, and coordinate care with a psychologist if required.”

Dr Elaine Sung is a local GP and owner of Doctors of South Melbourne. Her areas of special interest include women’s health, mental health and complex health needs.

Wet dressings provide soothing relief from itchy skin conditions

There are numerous skin conditions such as psoriasis, eczema or even urticaria (hives) that can be horrible and debilitating conditions that affect many people at some point in their life.

The itch can sometimes be unbearable to the point people can’t sleep and the rash itself is just a pain! Wet dressings come as a life saver to soothe and help cool the symptoms while moisturising the area to help heal the rash. Our dermatologists may prescribe you a certain medicated cream, ointment or just some moisturiser depending on the condition of concern. Either way wet dressings can help you! We have made this informative video on wet dressings to help our patients with the technique.

Method:

(1) Wet a crepe bandage with lukewarm water (you can add some bath oil into the water before-hand) and wring out excess water. You want it damp not dripping wet as you have to normally have the dressing on for a few hours! If suffering large areas on your body you can also use an old long sleeve cotton top or leggings and use these these as your “wet dressing.”(Much easier pulling on a stocking than wrapping a crepe bandage around)

(2) Apply medicated cream/ointment

(3) Apply Moisturiser over the top

(4) Apply wet dressing (either the crepe bandage or clothing)

You can put a pair of dry pyjamas/clothes over the top and sleep with it on for the night and by the morning you should be feeling better and had hopefully had a good night sleep! If you can only tolerate the wet dressings on your skin for a few hours at a time, that is fine too. It may take a few treatments to notice significant change however most of our patients notice a change in 24-48 hrs.

So next time you’re in to see one of our dermatologists for a skin concern, feel free to ask them if our nurses can show you how a wet dressing works and we would be happy to demonstrate for you!

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.