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.

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.

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!

Autumn is officially here! And with the cooler weather, lots of our patients are wanting laser and treatment for their pigmented and blotchy skin. Our laser nurse Kristie gives us an overview of pigmentation…Freckles, pigment, sunspots…

What’s the difference!?

“In my 18 years of lasering I have often been asked this very question, and frequently in general conversation the terms “freckle”, “pigment” and “age spot” get bandied around interchangeably.

Whilst as a consumer, you probably don’t need to know the ins and out of what constitutes a freckle versus a sun spot, or whether you have sun damage or melasma it is important to understand there IS a difference and this can be VERY important when it comes to treatment”.

 

PIGMENT essentially refers to the colour of the skin and is determined by the level of melanin, produced by melanocytes. Melanin production is determined by racial origin and sun exposure. People with dark skin produce more melanin than those who are fair skinned, and exposure to sun and UV stimulates our melanocytes to produce more melanin, resulting in a tan. Generally when people are seeking treatment for their pigmentation, we are referring to excess and uneven pigment.

MELASMA is a chronic skin disorder that results in a symmetrical, blotchy, darkening of the skin that can be both difficult to treat and distressing for sufferers. It commonly affects women more so than men, manifesting around the ages of 20-40. It results from the production of melanin by melanocytes, as with a tan, but is an overstimulation of melanin that persists long term (often despite our best efforts!) The cause of melasma can be complex and can have a genetic predisposition. Common triggers can include sun exposure, pregnancy, hormone therapy such as the oral contraceptive pill, other medications and inflammation from cosmetics such as perfumes or soaps and so strict avoidance of these is vital in treatment.

FRECKLES (medically we call them ephelides just to add another term into the mix) present as small, flat brown lesions on sun exposed areas of the body such as the face, shoulders, arms etc and are common in people with fair skin and red heads. Freckles are the result of sun exposure which again is stimulating our melanocytes to produce melanin, which then accumulates locally in the superficial skin cells (keratinocytes). They typically darken in summer (with sun exposure) and fade in winter (due the natural exfoliation and replacement of the keratinocytes).

SUN SPOTS / AGE SPOTS / LIVER SPOTS etc etc are all terms used to describe SOLAR LENTIGINES. Like freckles, solar lentigines are benign dark patches in the skin, as a result of sun induced melanin production and localised proliferation within the keratinocytes.   Unlike freckles, they do not fade in winter and tend to present in people over the age of 40 and accumulate with continued sun exposure, hence the terms “sun damage” and “aged spots”. They have NOTHING to do with your liver.

So how do we treat them? Well first I would always suggest a skin check with the dermatologist to diagnose your skin condition and rule out the myriad of OTHER brown spots and skin lesions and potential skin cancers.

Beyond that…

Prevention – with daily (rain, hail or shine) use of an SPF 50+.

Repair  – with good quality, cosmeceutical skincare (think AHA, Vit A, Vit B, Vit C etc etc).

Remove – generally with laser. There are a variety of lasers available to treat various types of pigment irregularities and a consultation is a must.

Kristie Phillips, RN