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!

How to choose a sunscreen – SPF myths and misconceptions

 

 

UV radiation from sun exposure is the greatest risk factor for developing skin cancer.  Here in Australia dangerous melanomas are the third most common types of cancer diagnosed. 
Simple sun protection measures including daily use of a broad-spectrum sunscreen can reduce you and your family’s risk of developing skin cancers later in life.  If this is not compelling enough to encourage you to protect yourself, see our earlier post on UV photo ageing.  Wrinkles! Argghhhh

 

 
Our Cosmetic Nurse Kristie breaks down the jargon and myths surrounding sunscreen use.
 
“What does SPF even mean?”

SPF is an acronym for Sun Protection Factor and is a measurement of how effectively a sunscreen will protect the skin from UVB rays (it does not measure UVA, this is important! More on this later).

Confusingly, it talks about time e.g. if it takes 10 minutes to burn without cream, applying an SPF 15 means it will take approximately 150 minutes to burn (a factor of 15 times longer).  THIS DOES NOT MEAN YOU CAN STAY IN THE SUN LONGER OR THAT YOU CAN GO LONGER WITHOUT REAPPLYING.  Sunscreen should always be reapplied after 2 hours to ensure continuous protection.

Misleading I know.

“So, what SPF should I be using?”

The SPF (Sun Protection Factor) scale is not linear, in that an SPF 30 is not “twice” as protecting as an SPF 15.  In fact, SPF 15 blocks 93% of UVB rays, SPF 30 blocks 97% of UVB rays and SPF 50 blocks 98% of UVB. The difference from an SPF 15 to SPF 30 is only 4%.

“So why do I need a higher SPF?”

Flip it around and think about what you are letting through.

SPF 15 (93% protection) allows 7 out of 100 photons through. SPF 30 (97% protection) allows 3 out of 100 photons through. That’s twice as many skin damaging photons!

“I don’t need sunscreen because I’m not outdoors?”

Not true.  UVA, which is responsible for ageing of the skin and contributes to skin cancer formation can pass through glass.  And incidental sun adds up.  Walking to the train, sitting in the window, driving.  So you don’t need to be “outside” to be exposed.

I always tell people to invest in a broad-spectrum product containing SPF 30-50 that they like enough to wear every single day.

Why?

The Anti-Cancer council recommends that sunscreen is required on days when the UV index is 3 or greater (typically in the warmer months between 11-3 pm), which is the threshold at which the UV is strong enough to damage the skin.  HOWEVER, we are creatures of habit and I find in myself and many of my patients that if your skincare routine is not just that, a ROUTINE, then things go to the wayside and before you know it, it’s mid-September, 12 noon and you find yourself in a café without sun protection!

A broad-spectrum sunscreen is important as SPF measures only UVB and we know UVA is a big culprit in causing skin damage.  A broad-spectrum sunscreen will protect against both UVA and UVB.

“What is the UV index?”

It’s “sciency”.  There are a LOT of variables that can influence the amount of UV reaching us.  But scientists are all over this and we highly recommend everyone download the Sun Smart App which will tell you what the maximum UV index for the day is forecast to be and when it is at its highest.

Thank you science!

“Do I need to reapply?”

Yes. All sunscreens need to be reapplied after two hours to maintain their SPF role. Are you going to reapply your sunscreen over your makeup at lunchtime in the middle of winter when you’re in the office? Probably not. And that’s ok.

1/ Because the UV index is low then

2/ Most of the damage from UV comes from accumulated exposure. Our skin is like a data bank for sun damage! So having your base SPF on for incidental sun when you leave the house helps reduce your lifetime UV exposure and associated damage. Unless your office desk is next to a window. Then see my earlier point about UVA passing through glass.

The reason to reapply is often unclear?  Is it wiping off? Does it have a time-limit of efficacy? Does it breakdown?

The answer is all of those things.  You will touch, rub, wipe, smear, and remove some of your SPF protection without noticing.  If you are sweating, exercising, swimming, etc we are pretty clear on the fact that your sunscreen will not withstand that.  Reapply.

Some chemical sunscreens do break down when exposed to sunlight. This is less of a concern with mineral (zinc or titanium oxide) sunscreens but this does mean that if you are outdoors, in the sun, your sunscreen DOES have a lifespan and it DOES breakdown.  It lends merit the argument that if you are in an office, away from all windows and will have minimal incidental sun (and don’t touch your face AT ALL) then your sunscreen MAY last longer.  I would definitely encourage you to reapply if you are planning on spending significant time (>1 hour) outdoors.

“I heard Nanoparticles were dangerous?”

They’re not.  The worry here was that the smaller nanoparticles which allow higher concentrations of our physical blocks containing zinc and titanium dioxide to be used in creams and still feel lovely and light on the skin were able to be absorbed though the skin and enter our bodies and cause harm.

This is not proven. The current evidence is that these particles do not penetrate the skin and remain on the surface as intended so the risk is negligible.  If applied to damaged or compromised skin there can be some penetration of the outermost layer of skin but they are not absorbed systemically (i.e. they don’t circulate throughout the body).   Be more concerned about inhaling spray sunscreens! Stay away from light sprays that flow with the wind and avoid these on the face.

“But what about Vitamin D?”

According to the Cancer Council sensible sun protection does not put people at risk of vitamin D deficiency and several studies have shown that sunscreen use has minimal impact on Vitamin D levels over time.  Incidental exposure, a few minutes most days is all most people require for adequate Vitamin D production.  If you are deficient in Vitamin D increasing UV exposure is not recommended and you should speak with your GP regarding supplementation.

We hope this clears up some common excuses people use for NOT applying sunscreen every day.  There are no excuses!  We KNOW skin cancer is directly related to UV exposure and we KNOW sunscreen protects us from this.  

 

There are so many nice, easy-to-use sunscreens available these days for every budget.  If you need a hand choosing one, call us today on 9039 5644 and book a consultation with our Cosmetic Nurse Kristie and we will get you on the right track.

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!