skin disease

Atopic dermatitis
Atopic dermatitis is a chronic (long-lasting) disease that affects the skin. It cannot be passed from one person to another. The word "dermatitis" means inflammation of the skin. "Atopic" refers to a group of diseases where there is often an inherited tendency to develop other allergic conditions, such as asthma and hay fever. Atopic dermatitis is often referred to as "eczema," which is a general term for the several types of inflammation of the skin. Atopic dermatitis is the most common of the many types of eczema. It affects males and females and accounts for 10 to 20 percent of all visits to dermatologists. More than 15 million people in the United States have symptoms of the disease. Symptoms Symptoms vary from person to person. The most common symptoms are dry, itchy skin and rashes on the face, inside the elbows and behind the knees, and on the hands and feet. Itching is the most important symptom of atopic dermatitis. Scratching and rubbing in response to itching irritates the skin, increases inflammation, and actually increases itchiness. Itching is a particular problem during sleep when conscious control of scratching is lost. The appearance of the skin that is affected by atopic dermatitis depends on the amount of scratching and the presence of secondary skin infections. The skin may be red and scaly, be thick and leathery, contain small raised bumps, or leak fluid and become crusty and infected. Atopic dermatitis may also affect the skin around the eyes, the eyelids, and the eyebrows and lashes. Scratching and rubbing the eye area can cause the skin to redden and swell. Some people with atopic dermatitis develop an extra fold of skin under their eyes. Patchy loss of eyebrows and eyelashes may also result from scratching or rubbing. Researchers have noted differences in the skin of people with atopic dermatitis that may contribute to the symptoms of the disease. The outer layer of skin, called the epidermis, is divided into two parts: an inner part containing moist, living cells, and an outer part, known as the horny layer or stratum corneum, containing dry, flattened, dead cells. Under normal conditions the stratum corneum acts as a barrier, keeping the rest of the skin from drying out and protecting other layers of skin from damage caused by irritants and infections. When this barrier is damaged, irritants act more intensely on the skin. The skin of a person with atopic dermatitis loses moisture from the epidermal layer, allowing the skin to become very dry and reducing its protective abilities. Thus, when combined with the abnormal skin immune system, the person's skin is more likely to become infected by bacteria (for example, Staphylo-coccus and Streptococcus) or viruses, such as those that cause warts and cold sores. Atopic dermatitis usually begins in childhood. As some children with atopic dermatitis grow older, their skin disease improves or disappears altogether, although their skin often remains dry and easily irritated. In others, atopic dermatitis continues to be a significant problem in adulthood. Causes The cause of atopic dermatitis is not known, but the disease seems to result from a combination of genetic (hereditary) and environmental factors. Children are more likely to develop this disorder if one or both parents have had it or have had allergic conditions like asthma or hay fever. While some people outgrow skin symptoms,

approximately three-fourths of children with atopic dermatitis go on to develop hay fever or asthma. Environmental factors can bring on symptoms of atopic dermatitis at any time in individuals who have inherited the atopic disease trait. Atopic dermatitis is also associated with malfunction of the body's immune system. Scientists have found that people with atopic dermatitis have a low level of a cytokine (a protein) that is essential to the healthy function of the body's immune system and a high level of other cytokines that lead to allergic reactions. The immune system can become misguided and create inflammation in the skin even in the absence of a major infection. This can be viewed as a form of autoimmunity, where a body reacts against its own tissues. Things That Make Atopic Dermatitis Worse Irritants and allergens can make atopic dermatitis worse. Irritants are things that may cause the skin to be red and itchy or to burn. They include: Wool or man-made fibers Soaps and cleaners Some perfumes and makeup Substances such as chlorine, mineral oil, or solvents Dust or sand Cigarette smoke. Allergens are allergy-causing substances from foods, plants, animals, or the air. Common allergens are: Eggs, peanuts, milk, fish, soy products, and wheat Dust mites Mold Pollen Dog or cat dander. Stress, anger, and frustration can make atopic dermatitis worse, but they havent been shown to cause it. Skin infections, temperature, and climate can also lead to skin flares. Other things that can lead to flares are: Not using enough moisturizer after a bath Low humidity in winter Dry year-round climate Long or hot baths and showers Going from sweating to being chilled Bacterial infections. Several types of medications are available for the treatment of eczema (atopic dermatitis). Immuno-modulators New medications known as immuno-modulators have been developed that help control inflammation and reduce immune system reactions when applied to the skin. Examples of these medications are tacrolimus ointment (Protopic) and pimecrolimus cream (Elidel). They can be used in patients older than 2 years of age and have few side effects (burning or itching the first few days of application). They not only reduce flares, but also maintain skin texture and reduce the need for long-term use of corticosteroids. Topical Corticosteroids Corticosteroid creams and ointments have been used for many years to treat atopic dermatitis

and other autoimmune diseases affecting the skin. Sometimes over-the-counter preparations are used, but in many cases the doctor will prescribe a stronger corticosteroid cream or ointment. When prescribing a medication, the doctor will take into account the patient's age, location of the skin to be treated, severity of the symptoms, and type of preparation (cream or ointment) that will be most effective. Sometimes the base used in certain brands of corticosteroid creams and ointments irritates the skin of a particular patient. Side effects of repeated or long-term use of topical corticosteroids can include thinning of the skin, infections, growth suppression (in children), and stretch marks on the skin. Click here for a list of topical corticosteroids with various strengths. Systemic Corticosteroids When topical corticosteroids are not effective, the doctor may prescribe a systemic corticosteroid, which is taken by mouth or injected instead of being applied directly to the skin. An example of a commonly prescribed corticosteroid is prednisone. Typically, these medications are used only in resistant cases and only given for short periods of time. The side effects of systemic corticosteroids can include skin damage, thinned or weakened bones, high blood pressure, high blood sugar, infections, and cataracts. It can be dangerous to suddenly stop taking corticosteroids, so it is very important that the doctor and patient work together in changing the corticosteroid dose. Antihistamines Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching makes the disease worse. Antibiotics Antibiotics are used to treat skin infections. They may be applied directly to the skin in an ointment, but are usually more effective when taken by mouth. If viral or fungal infections are present, the doctor may also prescribe specific medications to treat those infections.

Immunosuppressive Drugs In adults, drugs that suppress the immune system, such as cyclosporine, methotrexate, or azathioprine, may be prescribed to treat severe cases of atopic dermatitis that have failed to respond to other forms of therapy. These drugs block the production of some immune cells and curb the action of others. The side effects of drugs like cyclosporine can include high blood pressure, nausea, vomiting, kidney problems, headaches, tingling or numbness, and a possible increased risk of cancer and infections. There is also a risk of relapse after the drug is stopped. Because of their toxic side effects, systemic corticosteroids and immunosuppressive drugs are used only in severe cases and then for as short a period of time as possible. Patients requiring systemic corticosteroids should be referred to dermatologists or allergists specializing in the care of atopic dermatitis to help identify trigger factors and alternative therapies.

Psoriasis
Psoriasis is a chronic (long-lasting) skin disease of scaling and inflammation that affects 2 to 2.6

percent of the United States population, or between 5.8 and 7.5 million people. Although the disease occurs in all age groups, it primarily affects adults. It appears about equally in males and females. Symptoms and Diagnosis Psoriasis occurs when skin cells quickly rise from their origin below the surface of the skin and pile up on the surface before they have a chance to mature. Usually this movement (also called turnover) takes about a month, but in psoriasis it may occur in only a few days. In its typical form, psoriasis results in patches of thick, red (inflamed) skin covered with silvery scales. These patches, which are sometimes referred to as plaques, usually itch or feel sore. They most often occur on the elbows, knees, other parts of the legs, scalp, lower back, face, palms, and soles of the feet, but they can occur on skin anywhere on the body. The disease may also affect the fingernails, the toenails, and the soft tissues of the genitals and inside the mouth. While it is not unusual for the skin around affected joints to crack, approximately 1 million people with psoriasis experience joint inflammation that produces symptoms of arthritis. This condition is called psoriatic arthritis. There are several forms of psoriasis. Some of these include: Plaque psoriasis--Skin lesions are red at the base and covered by silvery scales. Guttate psoriasis--Small, drop-shaped lesions appear on the trunk, limbs, and scalp. Guttate psoriasis is most often triggered by upper respiratory infections (for example, a sore throat caused by streptococcal bacteria). Pustular psoriasis--Blisters of noninfectious pus appear on the skin. Attacks of pustular psoriasis may be triggered by medications, infections, stress, or exposure to certain chemicals. Inverse psoriasis--Smooth, red patches occur in the folds of the skin near the genitals, under the breasts, or in the armpits. The symptoms may be worsened by friction and sweating. Erythrodermic psoriasis--Widespread reddening and scaling of the skin may be a reaction to severe sunburn or to taking corticosteroids (cortisone) or other medications. It can also be caused by a prolonged period of increased activity of psoriasis that is poorly controlled. Psoriatic arthritis--Joint inflammation that produces symptoms of arthritis in patients who have or will develop psoriasis. Occasionally, doctors may find it difficult to diagnose psoriasis, because it often looks like other skin diseases. It may be necessary to confirm a diagnosis by examining a small skin sample under a microscope. Causes Psoriasis is a skin disorder driven by the immune system, especially involving a type of white blood cell called a T cell. Normally, T cells help protect the body against infection and disease. In the case of psoriasis, T cells are put into action by mistake and become so active that they trigger other immune responses, which lead to inflammation and to rapid turnover of skin cells. In about one-third of the cases, there is a family history of psoriasis. Researchers have studied a large number of families affected by psoriasis and identified genes linked to the disease (more info). People with psoriasis may notice that there are times when their skin worsens, then improves. Conditions that may cause flareups include infections, stress, and changes in climate that dry the skin. Also, certain medicines, including lithium and betablockers, which are prescribed for high

blood pressure, may trigger an outbreak or worsen the disease. Psoriasis is a chronic (long-lasting) skin disease of scaling and inflammation that affects 2 to 2.6 percent of the United States population, or between 5.8 and 7.5 million people. Although the disease occurs in all age groups, it primarily affects adults. It appears about equally in males and females. Symptoms and Diagnosis Psoriasis occurs when skin cells quickly rise from their origin below the surface of the skin and pile up on the surface before they have a chance to mature. Usually this movement (also called turnover) takes about a month, but in psoriasis it may occur in only a few days. In its typical form, psoriasis results in patches of thick, red (inflamed) skin covered with silvery scales. These patches, which are sometimes referred to as plaques, usually itch or feel sore. They most often occur on the elbows, knees, other parts of the legs, scalp, lower back, face, palms, and soles of the feet, but they can occur on skin anywhere on the body. The disease may also affect the fingernails, the toenails, and the soft tissues of the genitals and inside the mouth. While it is not unusual for the skin around affected joints to crack, approximately 1 million people with psoriasis experience joint inflammation that produces symptoms of arthritis. This condition is called psoriatic arthritis. There are several forms of psoriasis. Some of these include: Plaque psoriasis--Skin lesions are red at the base and covered by silvery scales. Guttate psoriasis--Small, drop-shaped lesions appear on the trunk, limbs, and scalp. Guttate psoriasis is most often triggered by upper respiratory infections (for example, a sore throat caused by streptococcal bacteria). Pustular psoriasis--Blisters of noninfectious pus appear on the skin. Attacks of pustular psoriasis may be triggered by medications, infections, stress, or exposure to certain chemicals. Inverse psoriasis--Smooth, red patches occur in the folds of the skin near the genitals, under the breasts, or in the armpits. The symptoms may be worsened by friction and sweating. Erythrodermic psoriasis--Widespread reddening and scaling of the skin may be a reaction to severe sunburn or to taking corticosteroids (cortisone) or other medications. It can also be caused by a prolonged period of increased activity of psoriasis that is poorly controlled. Psoriatic arthritis--Joint inflammation that produces symptoms of arthritis in patients who have or will develop psoriasis. Occasionally, doctors may find it difficult to diagnose psoriasis, because it often looks like other skin diseases. It may be necessary to confirm a diagnosis by examining a small skin sample under a microscope.

Causes Psoriasis is a skin disorder driven by the immune system, especially involving a type of white blood cell called a T cell. Normally, T cells help protect the body against infection and disease. In the case of psoriasis, T cells are put into action by mistake and become so active that they trigger other immune responses, which lead to inflammation and to rapid turnover of skin cells. In about one-third of the cases, there is a family history of psoriasis. Researchers have studied a large number of families affected by psoriasis and identified genes linked to the disease (more info).

People with psoriasis may notice that there are times when their skin worsens, then improves. Conditions that may cause flareups include infections, stress, and changes in climate that dry the skin. Also, certain medicines, including lithium and betablockers, which are prescribed for high blood pressure, may trigger an outbreak or worsen the disease. Several types of medications are available for the treatment of eczema (atopic dermatitis). Immuno-modulators New medications known as immuno-modulators have been developed that help control inflammation and reduce immune system reactions when applied to the skin. Examples of these medications are tacrolimus ointment (Protopic) and pimecrolimus cream (Elidel). They can be used in patients older than 2 years of age and have few side effects (burning or itching the first few days of application). They not only reduce flares, but also maintain skin texture and reduce the need for long-term use of corticosteroids.

Topical Corticosteroids Corticosteroid creams and ointments have been used for many years to treat atopic dermatitis and other autoimmune diseases affecting the skin. Sometimes over-the-counter preparations are used, but in many cases the doctor will prescribe a stronger corticosteroid cream or ointment. When prescribing a medication, the doctor will take into account the patient's age, location of the skin to be treated, severity of the symptoms, and type of preparation (cream or ointment) that will be most effective. Sometimes the base used in certain brands of corticosteroid creams and ointments irritates the skin of a particular patient. Side effects of repeated or long-term use of topical corticosteroids can include thinning of the skin, infections, growth suppression (in children), and stretch marks on the skin. Click here for a list of topical corticosteroids with various strengths.

Systemic Corticosteroids When topical corticosteroids are not effective, the doctor may prescribe a systemic corticosteroid, which is taken by mouth or injected instead of being applied directly to the skin. An example of a commonly prescribed corticosteroid is prednisone. Typically, these medications are used only in resistant cases and only given for short periods of time. The side effects of systemic corticosteroids can include skin damage, thinned or weakened bones, high blood pressure, high blood sugar, infections, and cataracts. It can be dangerous to suddenly stop taking corticosteroids, so it is very important that the doctor and patient work together in changing the corticosteroid dose.

Antihistamines Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching makes the disease worse.

Antibiotics Antibiotics are used to treat skin infections. They may be applied directly to the skin in an ointment, but are usually more effective when taken by mouth. If viral or fungal infections are present, the doctor may also prescribe specific medications to treat those infections.

Immunosuppressive Drugs In adults, drugs that suppress the immune system, such as cyclosporine, methotrexate, or azathioprine, may be prescribed to treat severe cases of atopic dermatitis that have failed to respond to other forms of therapy. These drugs block the production of some immune cells and curb the action of others. The side effects of drugs like cyclosporine can include high blood pressure, nausea, vomiting, kidney problems, headaches, tingling or numbness, and a possible increased risk of cancer and infections. There is also a risk of relapse after the drug is stopped. Because of their toxic side effects, systemic corticosteroids and immunosuppressive drugs are used only in severe cases and then for as short a period of time as possible. Patients requiring systemic corticosteroids should be referred to dermatologists or allergists specializing in the care of atopic dermatitis to help identify trigger factors and alternative therapies.

Doctors generally treat psoriasis in steps based on the severity of the disease, size of the areas involved, type of psoriasis, and the patient's response to initial treatments. This is sometimes called the "1-2-3" approach. In step 1, medicines are applied to the skin (topical treatment). Step 2 uses light treatments (phototherapy). Step 3 involves taking medicines by mouth or injection that treat the whole immune system (called systemic therapy). Over time, affected skin can become resistant to treatment, especially when topical corticosteroids are used. Also, a treatment that works very well in one person may have little effect in another. Thus, doctors often use a trial-and-error approach to find a treatment that works, and they may switch treatments periodically (for example, every 12 to 24 months) if a treatment does not work or if adverse reactions occur.

Topical Treatment Treatments applied directly to the skin may improve its condition. Doctors find that some patients respond well to ointment or cream forms of corticosteroids, vitamin D3, retinoids, coal tar, or anthralin. Bath solutions and moisturizers may be soothing, but they are seldom strong enough to improve the condition of the skin. Therefore, they usually are combined with stronger remedies. Corticosteroids--These drugs reduce inflammation and the turnover of skin cells, and they suppress the immune system. Available in different strengths, topical corticosteroids (cortisone) are usually applied to the skin twice a day. Short-term treatment is often effective in improving, but not completely eliminating, psoriasis. Long-term use or overuse of highly potent (strong) corticosteroids can cause thinning of the skin, internal side effects, and resistance to the treatment's benefits. If less than 10 percent of the skin is involved, some doctors will prescribe a high-potency corticosteroid ointment. High-potency corticosteroids may also be prescribed for plaques that don't improve with other treatment, particularly those on the hands or feet. In situations where the objective of treatment is comfort, medium-potency corticosteroids may be

prescribed for the broader skin areas of the torso or limbs. Low-potency preparations are used on delicate skin areas. Calcipotriene--This drug is a synthetic form of vitamin D3 that can be applied to the skin. Applying calcipotriene ointment (for example, Dovonex) twice a day controls the speed of turnover of skin cells. Because calcipotriene can irritate the skin, however, it is not recommended for use on the face or genitals. It is sometimes combined with topical corticosteroids to reduce irritation. Use of more than 100 grams of calcipotriene per week may raise the amount of calcium in the body to unhealthy levels. Retinoid--Topical retinoids are synthetic forms of vitamin A. The retinoid tazarotene (Tazorac) is available as a gel or cream that is applied to the skin. If used alone, this preparation does not act as quickly as topical corticosteroids, but it does not cause thinning of the skin or other side effects associated with steroids. However, it can irritate the skin, particularly in skin folds and the normal skin surrounding a patch of psoriasis. It is less irritating and sometimes more effective when combined with a corticosteroid. Because of the risk of birth defects, women of childbearing age must take measures to prevent pregnancy when using tazarotene. Coal tar--Preparations containing coal tar (gels and ointments) may be applied directly to the skin, added (as a liquid) to the bath, or used on the scalp as a shampoo. Coal tar products are available in different strengths, and many are sold over the counter (not requiring a prescription). Coal tar is less effective than corticosteroids and many other treatments and, therefore, is sometimes combined with ultraviolet B (UVB) phototherapy for a better result. The most potent form of coal tar may irritate the skin, is messy, has a strong odor, and may stain the skin or clothing. Thus, it is not popular with many patients. Anthralin--Anthralin reduces the increase in skin cells and inflammation. Doctors sometimes prescribe a 15- to 30-minute application of anthralin ointment, cream, or paste once each day to treat chronic psoriasis lesions. Afterward, anthralin must be washed off the skin to prevent irritation. This treatment often fails to adequately improve the skin, and it stains skin, bathtub, sink, and clothing brown or purple. In addition, the risk of skin irritation makes anthralin unsuitable for acute or actively inflamed eruptions. Salicylic acid--This peeling agent, which is available in many forms such as ointments, creams, gels, and shampoos, can be applied to reduce scaling of the skin or scalp. Often, it is more effective when combined with topical corticosteroids, anthralin, or coal tar. Clobetasol propionate--This is a foam topical medication (Olux), which has been approved for the treatment of scalp and body psoriasis. The foam penetrates the skin very well, is easy to use, and is not as messy as many other topical medications. Bath solutions--People with psoriasis may find that adding oil when bathing, then applying a moisturizer, soothes their skin. Also, individuals can remove scales and reduce itching by soaking for 15 minutes in water containing a coal tar solution, oiled oatmeal, Epsom salts, or Dead Sea salts. Moisturizers--When applied regularly over a long period, moisturizers have a soothing effect. Preparations that are thick and greasy usually work best because they seal water in the skin, reducing scaling and itching.

Light Therapy Natural ultraviolet light from the sun and controlled delivery of artificial ultraviolet light are used in treating psoriasis.

Sunlight--Much of sunlight is composed of bands of different wavelengths of ultraviolet (UV) light. When absorbed into the skin, UV light suppresses the process leading to disease, causing activated T cells in the skin to die. This process reduces inflammation and slows the turnover of skin cells that causes scaling. Daily, short, nonburning exposure to sunlight clears or improves psoriasis in many people. Therefore, exposing affected skin to sunlight is one initial treatment for the disease. Ultraviolet B (UVB) phototherapy--UVB is light with a short wavelength that is absorbed in the skin's epidermis. An artificial source can be used to treat mild and moderate psoriasis. Some physicians will start treating patients with UVB instead of topical agents. A UVB phototherapy, called broadband UVB, can be used for a few small lesions, to treat widespread psoriasis, or for lesions that resist topical treatment. This type of phototherapy is normally given in a doctor's office by using a light panel or light box. Some patients use UVB light boxes at home under a doctor's guidance. A newer type of UVB, called narrowband UVB, emits the part of the ultraviolet light spectrum band that is most helpful for psoriasis. Narrowband UVB treatment is superior to broadband UVB, but it is less effective than PUVA treatment (see next paragraph). It is gaining in popularity because it does help and is more convenient than PUVA. At first, patients may require several treatments of narrowband UVB spaced close together to improve their skin. Once the skin has shown improvement, a maintenance treatment once each week may be all that is necessary. However, narrowband UVB treatment is not without risk. It can cause more severe and longer lasting burns than broadband treatment. Psoralen and ultraviolet A phototherapy (PUVA)--This treatment combines oral or topical administration of a medicine called psoralen with exposure to ultraviolet A (UVA) light. UVA has a long wavelength that penetrates deeper into the skin than UVB. Psoralen makes the skin more sensitive to this light. PUVA is normally used when more than 10 percent of the skin is affected or when the disease interferes with a person's occupation (for example, when a teacher's face or a salesperson's hands are involved). Compared with broadband UVB treatment, PUVA treatment taken two to three times a week clears psoriasis more consistently and in fewer treatments. However, it is associated with more shortterm side effects, including nausea, headache, fatigue, burning, and itching. Care must be taken to avoid sunlight after ingesting psoralen to avoid severe sunburns, and the eyes must be protected for one to two days with UVA-absorbing glasses. Long-term treatment is associated with an increased risk of squamous-cell and, possibly, melanoma skin cancers. Simultaneous use of drugs that suppress the immune system, such as cyclosporine, have little beneficial effect and increase the risk of cancer. Light therapy combined with other therapies--Studies have shown that combining ultraviolet light treatment and a retinoid, like acitretin, adds to the effectiveness of UV light for psoriasis. For this reason, if patients are not responding to light therapy, retinoids may be added. UVB phototherapy, for example, may be combined with retinoids and other treatments. One combined therapy program, referred to as the Ingram regime, involves a coal tar bath, UVB phototherapy, and application of an anthralin-salicylic acid paste that is left on the skin for 6 to 24 hours. A similar regime, the Goeckerman treatment, combines coal tar ointment with UVB phototherapy. Also, PUVA can be combined with some oral medications (such as retinoids) to increase its effectiveness.

Systemic Treatment For more severe forms of psoriasis, doctors sometimes prescribe medicines that are taken internally by pill or injection. This is called systemic treatment. MethotrexateLike cyclosporine, methotrexate slows cell turnover by suppressing the immune system. It can be taken by pill or injection. Patients taking methotrexate must be closely

monitored because it can cause liver damage and/or decrease the production of oxygen-carrying red blood cells, infection-fighting white blood cells, and clotenhancing platelets. As a precaution, doctors do not prescribe the drug for people who have had liver disease or anemia (an illness characterized by weakness or tiredness due to a reduction in the number or volume of red blood cells that carry oxygen to the tissues). It is sometimes combined with PUVA or UVB treatments. Methotrexate should not be used by pregnant women, or by women who are planning to get pregnant, because it may cause birth defects. RetinoidsA retinoid, such as acitretin (Soriatane), is a compound with vitamin A-like properties that may be prescribed for severe cases of psoriasis that do not respond to other therapies. Because this treatment also may cause birth defects, women must protect themselves from pregnancy beginning 1 month before through 3 years after treatment with acitretin. Most patients experience a recurrence of psoriasis after these products are discontinued. CyclosporineTaken orally, cyclosporine acts by suppressing the immune system to slow the rapid turnover of skin cells. It may provide quick relief of symptoms, but the improvement stops when treatment is discontinued. The best candidates for this therapy are those with severe psoriasis who have not responded to, or cannot tolerate, other systemic therapies. Its rapid onset of action is helpful in avoiding hospitalization of patients whose psoriasis is rapidly progressing. Cyclosporine may impair kidney function or cause high blood pressure (hypertension). Therefore, patients must be carefully monitored by a doctor. Also, cyclosporine is not recommended for patients who have a weak immune system or those who have had skin cancers as a result of PUVA treatments in the past. It should not be given with phototherapy. 6-ThioguanineThis drug is nearly as effective as methotrexate and cyclosporine. It has fewer side effects, but there is a greater likelihood of anemia. This drug must also be avoided by pregnant women and by women who are planning to become pregnant, because it may cause birth defects. Hydroxyurea (Hydrea)Compared with methotrexate and cyclosporine, hydroxyurea is somewhat less effective. It is sometimes combined with PUVA or UVB treatments. Possible side effects include anemia and a decrease in white blood cells and platelets. Like methotrexate and retinoids, hydroxyurea must be avoided by pregnant women or those who are planning to become pregnant, because it may cause birth defects. Biologic Response ModifiersRecently, attention has been given to a group of drugs called biologics, which are made from proteins produced by living cells instead of chemicals. They interfere with specific immune system processes which cause the overproduction of skin cells and inflammation. Some examples are alefacept (Amevive), etanercept (Enbrel), and efalizumab (Raptiva). These drugs are injected (sometimes by the patient). Patients taking these treatments need to be monitored carefully by a doctor. Since these drugs suppress the immune system response, patients taking these drugs have an increased risk of infection, and the drugs may also interfere with patients' taking vaccines. Also, some of these drugs have been associated with other diseases (like central nervous system disorders, blood diseases, cancer, and lymphoma) although their role in the development of or contribution to these diseases is not yet understood. Some are approved for adults only, and their effects on pregnant or nursing women are not known. AntibioticsThese medications are not indicated in routine treatment of psoriasis. However, antibiotics may be employed when an infection, such as that caused by the bacteria Streptococcus, triggers an outbreak of psoriasis, as in certain cases of guttate psoriasis.

Combination Therapy There are many approaches for treating psoriasis. Combining various topical, light, and systemic

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treatments often permits lower doses of each and can result in increased effectiveness. Therefore, doctors are paying more attention to combination therapy.

Epidermolysis Bullosa
Epidermolysis Bullosa (EB) is an illness that causes the skin to be fragile. Because the skin is so fragile, it can be easily injured, causing painful blisters to form. These blisters can cause serious problems if they become infected. Some people with EB have a mild form of the disease with few blisters. For others, there may be many blisters on the skin. Some people develop blisters inside the body - in places such as the mouth, stomach, esophagus, bladder, and elsewhere. It is estimated that 2 to 4 out of every 100,000 people, or up to 12,000 people in the United States, have some form of EB.

Symptoms The major sign of all forms of EB is fragile skin that blisters, which can lead to serious complications. For example, blistering areas may become infected, and blisters in the mouth or parts of the gastrointestinal tract may interfere with proper nutrition. Following is a summary of some of the characteristic signs of various forms of EB. EB Simplex (EBS)--A generalized form of EBS usually begins with blistering that is evident at birth or shortly afterward. In a localized, mild form called Weber-Cockayne, blisters rarely extend beyond the feet and hands. In some subtypes of EBS, the blisters occur over widespread areas of the body. Other signs may include thickened skin on the palms of the hands and soles of the feet; rough, thickened, or absent fingernails or toenails; and blistering of the soft tissues inside the mouth. Less common signs include growth retardation; blisters in the esophagus; anemia (a reduction in the red blood cells that carry oxygen to all parts of the body); scarring of the skin; and milia, which are small white skin cysts. Junctional EB (JEB)--This disease is usually severe. In the most serious forms, large, ulcerated blisters on the face, trunk, and legs can be life-threatening due to complicated infections and loss of body fluid that leads to severe dehydration. Survival is also threatened by blisters that affect the esophagus, upper airway, stomach, intestines, and the urogenital system. Other signs found in both severe and mild forms of JEB include rough and thickened or absent fingernails and toenails; a thin appearance to the skin (called atrophic scarring); blisters on the scalp or loss of hair with scarring (scarring alopecia); malnutrition and anemia; growth retardation; involvement of soft tissue inside the mouth and nose; and poorly formed tooth enamel. Dystrophic EB (DEB)--The dominant and recessive inherited forms of DEB have slightly different symptoms. In some dominant and mild recessive forms, blisters may appear only on the hands, feet, elbows, and knees; nails usually are shaped differently; milia may appear on the skin of the trunk and limbs; and there may be involvement of the soft tissues, especially the esophagus. The more severe recessive form is characterized by blisters over large body surfaces, loss of nails or rough or thick nails, atrophic scarring, milia, itching, anemia, and growth retardation. Severe forms of recessive DEB also may lead to severe eye inflammation with erosion of the cornea (clear covering over the front of the eye), early loss of teeth due to tooth decay, and blistering and scarring inside the mouth and gastrointestinal tract. In most people with this form of EB, some or all the fingers or toes may fuse (pseudosyndactyly). Also, individuals with recessive DEB have a high risk of developing a form of skin cancer called squamous cell carcinoma. It

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primarily occurs on the hands and feet. The cancer may begin as early as the teenage years. It tends to grow and spread faster in people with EB than in those without the disease. Diagnosis Dermatologists can identify where the skin is separating to form blisters and what kind of EB a person has by doing a skin biopsy (taking a small sample of skin that is examined under a microscope). One diagnostic test involves use of a microscope and reflected light to see if proteins needed for forming connecting fibrils, filaments, or hemidesmosomes are missing or reduced in number. Another test involves use of a high-power electron microscope, which can greatly magnify tissue images, to identify structural defects in the skin. Recent techniques make it possible to identify defective genes in EB patients and their family members. Prenatal diagnosis can now be accomplished by amniocentesis (removing and examining a small amount of amniotic fluid surrounding the fetus in the womb of a pregnant woman) or sampling the chorionic villus (part of the outer membrane surrounding the fetus) as early as the tenth week of pregnancy.

Causes Most people with EB have inherited the condition through faulty genes they receive from one or both parents. More than 10 genes are known to underlie the different forms of EB. Although EB Simplex can occur when there is no evidence of the disease in the parents, it is usually inherited as an autosomal dominant disease. In EB Simplex, the faulty genes are those that provide instructions for producing keratin, a fibrous protein in the top layer of skin. As a result, the skin splits in the epidermis, producing a blister. In Junctional EB, there is a defect in the genes inherited from both parents (autosomal recessive) that normally promote the formation of anchoring filaments (thread-like fibers) or hemidesmosomes (complex structures composed of many proteins). These structures anchor the epidermis to the underlying basement membrane. The defect leads to tissue separation and blistering in the upper part of the basement membrane. There are both dominant and recessive forms of Dystrophic EB. In this condition, the filaments that anchor the epidermis to the underlying dermis are either absent or do not function. This is due to defects in the gene for type VII collagen, a fibrous protein that is the main component of the anchoring filaments. Epidermolysis bullosa acquisita (EBA) is a rare autoimmune disorder where the body attacks its own anchoring fibrils with antibodies, the special proteins that help fight and destroy foreign substances that invade the body. In a few cases, it has occurred following drug therapy for another condition; in most cases, the cause is unknown. Persons with mild forms of Epidermolysis Bullosa (EB) may not require extensive treatment. However, they should attempt to keep blisters from forming and prevent infection when blisters occur. Individuals with moderate and severe forms may have many complications and require psychological support along with attention to the care and protection of the skin and soft tissues. Preventing Blisters To protect the skin from forming blisters, you can: Avoid getting too hot by keeping rooms at an even temperature Apply lotion to the skin to reduce friction and keep the skin moist Wear soft clothing

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Use sheepskin on car seats and other hard surfaces Wear mittens at bedtime to help prevent scratching. Treating Blisters When blisters appear, the goal of care is to: Reduce pain or discomfort Prevent loss of body fluid Promote healing Prevent infection. Doctors may treat the blisters by: Explaining how to safely break a blister in its early stages Prescribing a mild painkiller so that changing bandages won't hurt as much Recommending special bandages that will help the blisters to heal, lessen the pain, and prevent infection. Treating Infection The chances of skin infection can be reduced by good nutrition, which builds the body's defenses and promotes healing, and by careful skin care with clean hands and use of sterile materials. For added protection, the doctor may recommend antibiotic ointments and soaks. Even in the presence of good care, it is possible for infection to develop. Signs of infection are redness and heat around an open area of skin, pus or a yellow drainage, excessive crusting on the wound surface, a red line or streak under the skin that spreads away from the blistered area, a wound that does not heal, and/or fever or chills. The doctor may prescribe a specific soaking solution, an antibiotic ointment, or an oral antibiotic to reduce the growth of bacteria. Wounds that are not healing may be treated by a special wound covering or biologically developed skin.

Treating Nutritional Problems Blisters that form in the mouth and esophagus in some people with EB are likely to cause difficulty in chewing and swallowing food and drinks. If breast or bottle feeding results in blisters, infants may be fed using a preemie nipple (a soft nipple with large holes), a cleft palate nipple, an eyedropper, or a syringe. When the baby is old enough to take in food, adding extra liquid to pureed (finely mashed) food makes it easier to swallow. Soups, milk drinks, mashed potatoes, custards, and puddings can be given to young children. However, food should never be served too hot. Dietitians are important members of the health care team that assists people with EB. They can work with family members and older patients to find recipes and prepare food that is nutritious and easy to consume. For example, they can identify high-caloric and protein-fortified foods and beverages that help replace protein lost in the fluid from draining blisters. They can suggest vitamin and mineral nutritional supplements that may be needed, and show how to mix these into the food and drinks of young children. Dietitians can also recommend adjustments in the diet to prevent gastrointestinal problems, such as constipation, diarrhea, or painful elimination.

Surgery

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Surgical treatment may be necessary in some forms of EB. Individuals with the severe forms of autosomal recessive Dystrophic EB whose esophagus has been narrowed by scarring may require dilation of their esophagus for food to travel from the mouth to the stomach. Other individuals who are not getting proper nutrition may need a feeding tube that permits delivery of food directly to the stomach. Also, patients whose fingers or toes are fused together may require surgery to release them.

hair loss
There are two types of hair loss: Alopecia areata - It is considered an autoimmune disease, affecting about 4 million Americans. Androgenetic alopecia - It is also known as pattern baldness, affecting about 35 million Americans. This page is focused on androgenetic alopecia (pattern baldness).

Symptoms In men, hair is lost in a well-defined pattern, beginning above both temples. Over time, the hairline recedes to form a characteristic "M" shape. Hair also thins at the crown (near the top of the head), often progressing to partial or complete baldness. The pattern of hair loss in women differs from male-pattern baldness. In women, the hair becomes thinner all over the head, and the hairline does not recede. Androgenetic alopecia in women rarely leads to total baldness.

Causes A variety of genetic and environmental factors likely play a role in causing androgenetic alopecia. Although researchers are studying risk factors that may contribute to this condition, most of these factors remain unknown. Researchers have determined that this form of hair loss is related to hormones called androgens, particularly an androgen called dihydrotestosterone. Androgens are important for normal male sexual development before birth and during puberty. Androgens also have other important functions in both males and females, such as regulating hair growth and sex drive. Hair growth begins under the skin in structures called hair follicles. Each strand of hair normally grows for 2 to 6 years, goes into a resting phase for several months, and then falls out. The cycle starts over when the follicle begins growing a new hair. Increased levels of androgens in hair follicles can lead to a shorter cycle of hair growth and the growth of shorter and thinner strands of hair. Additionally, there is a delay in the growth of new hair to replace strands that are shed. Although researchers suspect that several genes play a role in androgenetic alopecia, variations in only one gene, AR, have been identified in people with this condition. The AR gene provides instructions for making a protein called an androgen receptor. Androgen receptors allow the body to respond appropriately to dihydrotestosterone and other androgens. Studies suggest that variations in the AR gene lead to increased activity of androgen receptors in hair follicles. It remains unclear, however, how these genetic changes increase the risk of patterned hair loss in men and women with androgenetic alopecia. Androgenetic alopecia in men has been associated with several other medical conditions

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including coronary heart disease, enlargement of the prostate, diabetes, and high blood pressure. In women, androgenetic alopecia is associated with an increased risk of polycystic ovary syndrome (PCOS). Researchers believe that some of these disorders may be associated with elevated androgen levels, which may help explain why they tend to occur with androgenrelated hair loss. Medications and hair transplantation are available for the treatment of hair loss. In the near future, hairs may grow on a large bald area by using a new method called "hair multiplication" or "hair cloning". Medications Two types of drugs are approved by Food and Drug Administration (FDA). Minoxidil (Rogaine) Rogaine is a topical solution that does not need a prescription. It may be used by both men and women. Rogaine works best at the early stage of baldness. However, after using for 2 years, Rogaine may slowly lose its effectiveness. Finasteride (Propecia) Finasteride inhibits the formation of dihydrotestosterone which is the main cause of pattern baldness (androgenetic alopecia). It is an oral medication that requires prescription. A study showed that, after 5 years of treatment, 48% of men exhibited hair increase and 42% maintained the original hair. Finasteride may cause some side effects such as sexual dysfunction, but they usually disappeared after the drug was discontinued. Finasteride does not work for women, and it may cause birth defects if taken during pregnancy.

Hair Transplantation Hair transplantation is a procedure in which hair follicles are removed from bald-resistant regions (the 'donor' area) and implanted in bald or balding areas of the scalp (the 'recipient' area). The donor area is usually at the back or sides of the head. The transplanted follicles will grow hair in the new area for as long as it would have grown in the donor area. The techniques of hair transplantation have evolved from transplanting a large strip of skin to a large number of tiny "Follicular Units". A Follicular Unit contains a naturally occurring group of 14 hairs. Because each time the transplantation involves only a tiny area of the scalp, the damage is minimal and the healing is rapid.

Hair Multiplication The hair transplantation described above has a limitation. It can only redistribute the healthy follicles that are still capable of growing new hairs. It does not create new follicles. A person has a finite number of hair follicles, approximately 100,000. If a person is almost totally bald, most of his or her follicles have lost the ability to grow hairs. The remaining healthy follicles will not be sufficient to cover the whole scalp. Although a person may receive follicles from another person, the donated follicles will be rejected by the person's immune system. Hair multiplication, also called hair cloning, can create as many hairs as you want. In this method, a small number (~ 100) of follicles are taken from the patient. The follicles cannot be multiplied. However, the lower part of the follicle contains hair-inductive dermal papilla cells,

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which can be isolated and multiplied by a special process. In this way, a large number of hairinductive cells can be created. These cells are then injected into the patient's scalp to stimulate hair growth. Hair multiplication is currently in Phase II clinical trial, conducted by Intercytex.

Vitiligo
Vitiligo is a pigmentation disorder in which melanocytes (the cells that make pigment) in the skin are destroyed. As a result, white patches appear on the skin in different parts of the body. Similar patches also appear on both the mucous membranes (tissues that line the inside of the mouth and nose), and the retina (inner layer of the eyeball). The hair that grows on areas affected by vitiligo sometimes turns white. About 0.5 to 1 percent of the worlds population, or as many as 65 million people, have vitiligo. In the United States, 1 to 2 million people have the disorder. Half the people who have vitiligo develop it before age 20; most develop it before their 40th birthday. The disorder affects both sexes and all races equally; however, it is more noticeable in people with dark skin.

Symptoms People who develop vitiligo usually first notice white patches (depigmentation) on their skin. These patches are more commonly found on sun-exposed areas of the body, including the hands, feet, arms, face, and lips. Other common areas for white patches to appear are the armpits and groin, and around the mouth, eyes, nostrils, navel, genitals, and rectal areas. Vitiligo generally appears in one of three patterns: focal patternthe depigmentation is limited to one or only a few areas segmental patterndepigmented patches develop on only one side of the body generalized patternthe most common pattern. Depigmentation occurs symmetrically on both sides of the body. In addition to white patches on the skin, people with vitiligo may have premature graying of the scalp hair, eyelashes, eyebrows, and beard. People with dark skin may notice a loss of color inside their mouths. Diagnosis The diagnosis of vitiligo is made based on a physical examination, medical history, and laboratory tests. A doctor will likely suspect vitiligo if you report (or the physical examination reveals) white patches of skin on the bodyparticularly on sun-exposed areas, including the hands, feet, arms, face, and lips. If vitiligo is suspected, the doctor will ask about your medical history. Important factors in the diagnosis include a family history of vitiligo; a rash, sunburn, or other skin trauma at the site of vitiligo 2 to 3 months before depigmentation started; stress or physical illness; and premature (before age 35) graying of the hair. In addition, the doctor will ask whether you or anyone in your family has had any autoimmune diseases, and whether you are very sensitive to the sun. To help confirm the diagnosis, the doctor may take a small sample (biopsy) of the affected skin

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to examine under a microscope. In vitiligo, the skin sample will usually show a complete absence of pigment-producing melanocytes. On the other hand, the presence of inflamed cells in the sample may suggest that another condition is responsible for the loss of pigmentation. Because vitiligo may be associated with pernicious anemia (a condition in which an insufficient amount of vitamin B12 is absorbed from the gastrointestinal tract) or hyperthyroidism (an overactive thyroid gland), the doctor may also take a blood sample to check the blood-cell count and thyroid function. For some patients, the doctor may recommend an eye examination to check for uveitis (inflammation of part of the eye), which sometimes occurs with vitiligo. A blood test to look for the presence of antinuclear antibodies (a type of autoantibody) may also be done. This test helps determine if the patient has another autoimmune disease.

Causes The cause of vitiligo is not known, but doctors and researchers have several different theories. There is strong evidence that people with vitiligo inherit a group of three genes that make them susceptible to depigmentation. The most widely accepted view is that the depigmentation occurs because vitiligo is an autoimmune diseasea disease in which a persons immune system reacts against the bodys own organs or tissues. As such, peoples bodies produce proteins called cytokines that alter their pigment-producing cells and cause these cells to die. Another theory is that melanocytes destroy themselves. Finally, some people have reported that a single event such as sunburn or emotional distress triggered vitiligo; however, these events have not been scientifically proven as causes of vitiligo. The main goal of treating vitiligo is to improve appearance. Therapy for vitiligo takes a long time it usually must be continued for 6 to 18 months. The choice of therapy depends on the number of white patches; their location, sizes, and how widespread they are; and what you prefer in terms of treatment. Each patient responds differently to therapy, and a particular treatment may not work for everyone. Current treatment options for vitiligo include medical, surgical, and adjunctive therapies (therapies that can be used along with surgical or medical treatments). Medical Therapies A number of medical therapies, most of which are applied topically, can reduce the appearance of white patches with vitiligo. These are some of the most commonly used ones: Topical steroid therapysteroid creams may be helpful in repigmenting (returning the color to) white patches, particularly if they are applied in the initial stages of the disease. Corticosteroids are a group of drugs similar to hormones such as cortisone, which are produced by the adrenal glands. Doctors often prescribe a mild topical corticosteroid cream for children under 10 years old and a stronger one for adults. You must apply the cream to the white patches on the skin for at least 3 months before seeing any results. Corticosteriod creams are the simplest and safest treatment for vitiligo, but are not as effective as psoralen photochemotherapy (see below). Yet, like any medication, these creams can cause side effects. For this reason, the doctor will monitor you closely for skin shrinkage and skin striae (streaks or lines on the skin). These side effects are more likely to occur in areas where the skin is thin, such as on the face and armpits, or in the genital region. They can be minimized by using weaker formulations of steroid creams in these areas. Psoralen photochemotherapyalso known as psoralen and ultraviolet A therapy, or PUVA therapy, this is probably the most effective treatment for vitiligo available in the United States. The goal of PUVA therapy is to repigment the white patches. However, it is time-consuming, and care must be taken to avoid side effects, which can sometimes be severe. Psoralen is a drug that contains chemicals that react with ultraviolet light to cause darkening of the skin. The treatment involves taking psoralen by mouth (orally) or applying it to the skin (topically). This is

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followed by carefully timed exposure to sunlight or to ultraviolet A (UVA) light that comes from a special lamp. Typically, you will receive treatments in your doctors office so you can be carefully watched for any side effects. You must minimize exposure to sunlight at other times. Both oral and topical psoralen photochemotherapy are described below. Topical psoralen photochemotherapyoften used for people with a small number of depigmented patches affecting a limited part of the body, it is also used for children 2 years old and older who have localized patches of vitiligo. Treatments are done in a doctors office under artificial UVA light once or twice a week. The doctor or nurse applies a thin coat of psoralen to your depigmented patches about 30 minutes before exposing you to enough UVA light to turn the affected area pink. The doctor usually increases the dose of UVA light slowly over many weeks. Eventually, the pink areas fade and a more normal skin color appears. After each treatment, you wash your skin with soap and water and apply a sunscreen before leaving the doctors office. There are two major potential side effects of topical PUVA therapy: (1) severe sunburn and blistering and (2) too much repigmentation or darkening (hyperpigmentation) of the treated patches or the normal skin surrounding the vitiligo. You can minimize your chances of sunburn if you avoid exposure to direct sunlight after each treatment. Usually, hyperpigmentation is a temporary problem that eventually disappears when treatment is stopped. Oral psoralen photochemotherapyused for people with extensive vitiligo (affecting more than 20 percent of the body) or for people who do not respond to topical PUVA therapy, oral psoralen is not recommended for children under 10 years of age because it increases the risk of damage to the eyes caused by conditions such as cataracts. For oral PUVA therapy, you take a prescribed dose of psoralen by mouth about 2 hours before exposure to artificial UVA light or sunlight. If artificial light is used, the doctor adjusts the dose of light until the skin in the areas being treated becomes pink. Treatments are usually given 2 or 3 times a week, but never 2 days in a row. For patients who cannot go to a facility to receive PUVA therapy, the doctor may prescribe psoralen that can be used with natural sunlight exposure. The doctor will give you careful instructions on carrying out treatment at home and monitor you during scheduled checkups. Known side effects of oral psoralen include sunburn, nausea and vomiting, itching, abnormal hair growth, and hyperpigmentation. Oral psoralen photochemotherapy may also increase the risk of skin cancer, although the risk is minimal at doses used for vitiligo. If you are undergoing oral PUVA therapy, you should apply sunscreen and avoid direct sunlight for 24 to 48 hours after each treatment to avoid sunburn and reduce the risk of skin cancer. To avoid eye damage, particularly cataracts, you should also wear protective UVA sunglasses for 18 to 24 hours after each treatment. Depigmentationthis treatment involves fading the rest of the skin on the body to match the areas that are already white. For people who have vitiligo on more than 50 percent of their bodies, depigmentation may be the best treatment option. Patients apply the drug monobenzylether of hydroquinone (monobenzone or Benoquin) twice a day to pigmented areas until they match the already-depigmented areas. You must avoid direct skin-to-skin contact with other people for at least 2 hours after applying the drug, as transfer of the drug may cause depigmentation of the other persons skin. The major side effect of depigmentation therapy is inflammation (redness and swelling) of the skin. You may experience itching or dry skin. Depigmentation tends to be permanent and is not easily reversed. In addition, a person who undergoes depigmentation will always be unusually sensitive to sunlight.

Surgical Therapies All surgical therapies must be considered only after proper medical therapy is provided. Surgical

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techniques are time-consuming and expensive and usually not paid for by insurance carriers. They are appropriate only for carefully selected patients who have vitiligo that has been stable for at least 3 years: Autologous skin graftsthe doctor removes skin from one area of your body and attaches it to another area. This type of skin grafting is sometimes used for patients with small patches of vitiligo. The doctor removes sections of the normal, pigmented skin (donor sites) and places them on the depigmented areas (recipient sites). There are several possible complications of autologous skin grafting. Infections may occur at the donor or recipient sites. The recipient and donor sites may develop scarring, a cobblestone appearance, or a spotty pigmentation, or may fail to repigment at all. Treatment with grafting takes time and is costly, and many people find it neither acceptable nor affordable. Skin grafts using blistersin this procedure, the doctor creates blisters on your pigmented skin by using heat, suction, or freezing cold. The tops of the blisters are then cut out and transplanted to a depigmented skin area. The risks of blister grafting include scarring and lack of repigmentation. However, there is less risk of scarring with this procedure than with other types of grafting. Micropigmentation (tattooing)this procedure involves implanting pigment into the skin with a special surgical instrument. This procedure works best for the lip area, particularly in people with dark skin. However, it is difficult for the doctor to match perfectly the color of the skin of the surrounding area. The tattooed area will not change in color when exposed to sun, while the surrounding normal skin will. So even if the tattooed area matches the surrounding skin perfectly at first, it may not later on. Tattooing tends to fade over time. In addition, tattooing of the lips may lead to episodes of blister outbreaks caused by the herpes simplex virus. Autologous melanocyte transplantsin this procedure, the doctor takes a sample of your normal pigmented skin and places it in a laboratory dish containing a special cell-culture solution to grow melanocytes. When the melanocytes in the culture solution have multiplied, the doctor transplants them to your depigmented skin patches. This procedure is currently experimental and is impractical for the routine care of people with vitiligo. It is also very expensive, and its side effects are not known. Additional Therapies In addition to medical and surgical therapies, there are many things you can do on your own to protect your skin, minimize the appearance of white patches, and cope with the emotional aspects of vitiligo: Sunscreenspeople who have vitiligo, particularly those with fair skin, should minimize sun exposure and use a sunscreen that provides protection from both the UVA and UVB forms of ultraviolet light. Sunscreen helps protect the skin from sunburn and long-term damage. Sunscreen also minimizes tanning, which makes the contrast between normal and depigmented skin less noticeable. Cosmeticssome patients with vitiligo cover depigmented patches with stains, makeup, or selftanning lotions. These cosmetic products can be particularly effective for people whose vitiligo is limited to exposed areas of the body. Dermablend, Lydia OLeary, Clinique, Fashion Flair, Vitadye, and Chromelin offer makeup or dyes that you may find helpful for covering up depigmented patches. Selftanning lotions have an advantage over makeup in that the color will last for several days and will not come off with washing. Counseling and support groupsmany people with vitiligo find it helpful to get counseling from a mental health professional. People often find they can talk to their counselor about issues that

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are difficult to discuss with anyone else. A mental health counselor can also offer support and help in coping with vitiligo. In addition, it may be helpful to attend a vitiligo support group. Every woman, and most men, want to have a smooth skin. Americans spent billions of dollars each year trying to erase wrinkles caused by aging processes. They bought products that claim to "revitalize aging skin." However, according to the American Academy of Dermatology, overthe-counter "wrinkle" creams and lotions may soothe dry skin, but they do little or nothing to reverse wrinkles. Causes There are three layers in the skin: epidermis (outermost layer), dermis (middle layer), and subcutis (innermost layer). The dermis is the thickest of the three layers (1.5 to 4 mm thick), making up approximately 90 percent of the thickness of the skin. The dermis is held together by collagen, a tough, insoluble protein. The dermis also contains elastin, which is the protein that allows the skin to spring back into place when stretched and keeps the skin flexible. The two proteins are important in preventing wrinkles. Over time, the sun's ultraviolet (UV) light damages elastin and collagen, resulting in wrinkles. Cigarette smoking also contributes to wrinkles. People who smoke tend to have more wrinkles than nonsmokers of the same age, complexion, and history of sun exposure. The reason for this difference is not clear. Prevention Although wrinkles cannot be completely prevented, the following can slow the skin aging. Minimize exposure to sunlight. Use cream or lotion to moisturize skin. Do not smoke. Treatment At this time, the only products that have been studied for safety and effectiveness and approved by the Food and Drug Administration (FDA) to treat signs of sun-damaged or aging skin are tretinoin cream and carbon dioxide (CO2) and erbium (Er:YAG) lasers. Tretinoin cream (Renova), a vitamin A derivative available by prescription only, is approved for reducing the appearance of fine wrinkles, mottled darkened spots, and roughness in people whose skin doesnt improve with regular skin care and use of sun protection. However, it doesnt eliminate wrinkles, repair sun-damaged skin, or restore skin to its healthier, younger structure. It hasnt been studied in people 50 and older or in people with moderately or darkly pigmented skin. The CO2 and Er:YAG lasers are approved to treat wrinkles. The doctor uses the laser to remove skin one layer at a time. Laser therapy is performed under anesthesia in an outpatient surgical setting. The FDA currently is studying the safety of alpha hydroxy acids (AHAs), which are widely promoted to reduce wrinkles, spots, and other signs of aging, sun-damaged skin. Some studies suggest that they may work, but there is concern about adverse reactions and long-term effects of their use. Because people who use AHA products have greater sensitivity to the sun, the FDA advises consumers to protect themselves from sun exposure by using sunscreen, wearing a hat, or avoiding mid-day sun.

sklerosis,"
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Derived from the Greek words "sklerosis," meaning hardness, and "derma," meaning skin, scleroderma literally means hard skin. Though it is often referred to as if it were a single disease, scleroderma is really a symptom of a group of diseases that involve the abnormal growth of connective tissue, which supports the skin and internal organs. It is sometimes used, therefore, as an umbrella term for these disorders. In some forms of scleroderma, hard, tight skin is the extent of this abnormal process. In other forms, however, the problem goes much deeper, affecting blood vessels and internal organs, such as the heart, lungs, and kidneys. Scleroderma is called both a rheumatic disease and a connective tissue disease. The term rheumatic disease refers to a group of conditions characterized by inflammation and/or pain in the muscles, joints, or fibrous tissue. A connective tissue disease is one that affects tissues such as skin, tendons, and cartilage. Estimates for the number of people in the United States with systemic sclerosis range from 40,000 to 165,000. By contrast, a survey that included all scleroderma-related disorders, including Raynauds phenomenon, suggested a number between 250,000 and 992,500.

Symptoms of Different Types

The group of diseases we call scleroderma falls into two main classes: localized scleroderma and systemic sclerosis. Localized diseases affect only certain parts of the body; systemic diseases can affect the whole body. Both groups include subgroups. Although there are different ways these groups and subgroups may be broken down or referred to, the following is a common way of classifying these diseases: Localized Scleroderma Localized types of scleroderma are those limited to the skin and related tissues and, in some cases, the muscle below. Internal organs are not affected by localized scleroderma, and localized scleroderma can never progress to the systemic form of the disease. Often, localized conditions improve or go away on their own over time, but the skin changes and damage that occur when the disease is active can be permanent. For some people, localized scleroderma is serious and disabling. There are two generally recognized types of localized scleroderma: Morphea: Morphea comes from a Greek word that means "form" or "structure." The word refers to local patches of scleroderma. The first signs of the disease are reddish patches of skin that thicken into firm, oval-shaped areas. The center of each patch becomes ivory colored with violet borders. These patches sweat very little and have little hair growth. Patches appear most often on the chest, stomach, and back. Sometimes they appear on the face, arms, and legs. Morphea can be either localized or generalized. Localized morphea limits itself to one or several patches, ranging in size from a half-inch to 12 inches in diameter. The condition sometimes appears on areas treated by radiation therapy. Some people have both morphea and linear scleroderma (described below). The disease is referred to as 21

generalized morphea when the skin patches become very hard and dark and spread over larger areas of the body. Regardless of the type, morphea generally fades out in 3 to 5 years; however, people are often left with darkened skin patches and, in rare cases, muscle weakness. Linear scleroderma: As suggested by its name, the disease is characterized by a single line or band of thickened and/or abnormally colored skin. Usually, the line runs down an arm or leg, but in some people it runs down the forehead. People sometimes use the French term en coup de sabre, or "sword stroke," to describe this highly visible line. Systemic Scleroderma (also known as Systemic Sclerosis) This is the term for the form of the disease that not only includes the skin, but also involves the tissues beneath, the blood vessels, and the major organs. Systemic sclerosis is typically broken down into limited cutaneous scleroderma and diffuse cutaneous scleroderma. Some doctors break systemic sclerosis down into a third subset called systemic sclerosis sine (Latin for "without" scleroderma. This means that patients have other manifestations of scleroderma but they do not have any overt skin thickening. Limited cutaneous scleroderma Limited cutaneous scleroderma typically comes on gradually and affects the skin only in certain areas: the fingers, hands, face, lower arms, and legs. Most people with limited disease have Raynauds phenomenon for years before skin thickening starts. Telangiectasias and calcinosis often follow. (See definitions below.) Gastrointestinal involvement occurs commonly and some patients have severe lung problems, even though the skin thickening remains limited. People with limited disease often have all or some of the symptoms that some doctors call CREST, which stands for the following: Calcinosis: the formation of calcium deposits in the connective tissues, which can be detected by x ray. They are typically found on the fingers, hands, face, and trunk and on the skin above elbows and knees. When the deposits break through the skin, painful ulcers can result. Raynauds phenomenon: a condition in which the small blood vessels of the hands and/or feet contract in response to cold or anxiety. As the vessels contract, the hands or feet turn white and cold, then blue. As blood flow returns, they become red. Fingertip tissues may suffer damage, leading to ulcers, scars, or gangrene. Esophageal dysfunction: impaired function of the esophagus (the tube connecting the throat and the stomach) that occurs when smooth muscles in the esophagus lose normal movement. In the upper and lower esophagus, the result can be swallowing difficulties. In the lower esophagus, the result can be chronic heartburn or inflammation. Sclerodactyly: thick and tight skin on the fingers, resulting from deposits of excess collagen within skin layers. The condition makes it harder to bend or straighten the fingers. The skin may also appear shiny and darkened, with hair loss.

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Telangiectasia: a condition caused by the swelling of tiny blood vessels, in which small red spots appear on the hands and face. While not painful, these red spots can create cosmetic problems. Diffuse cutaneous scleroderma This condition typically comes on suddenly. Skin thickening begins in the hands and spreads quickly and over much of the body, affecting the hands, face, upper arms, upper legs, chest, and stomach in a symmetrical fashion (for example, if one arm or one side of the trunk is affected, the other is also affected). Some people may have more area of their skin affected than others. Internally, it can damage key organs such as the intestines, lungs, heart, and kidneys. People with diffuse disease often are tired, lose appetite and weight, and have joint swelling and/or pain. Skin changes can cause the skin to swell, appear shiny, and feel tight and itchy. The damage of diffuse scleroderma typically occurs over a few years. After the first 3 to 5 years, people with diffuse disease often enter a stable phase lasting for varying lengths of time. During this phase, symptoms subside: joint pain eases, fatigue lessens, and appetite returns. Progressive skin thickening and organ damage decrease. Gradually, however, the skin may begin to soften, which tends to occur in reverse order of the thickening process: the last areas thickened are the first to begin softening. Some patients" skin returns to a somewhat normal state, while other patients are left with thin, fragile skin without hair or sweat glands. Serious new damage to the heart, lungs, or kidneys is unlikely to occur, although patients are left with whatever damage they have in specific organs. People with diffuse scleroderma face the most serious long-term outlook if they develop severe kidney, lung, digestive, or heart problems. Fortunately, less than onethird of patients with diffuse disease develop these severe problems. Early diagnosis and continual and careful monitoring are important.

Diagnosis
A diagnosis of scleroderma is based largely on the medical history and findings from the physical exam. Finding one or more of the following factors can help the doctor diagnose a certain form of scleroderma: changed skin appearance and texture, including swollen fingers and hands and tight skin around the hands, face, mouth, or elsewhere calcium deposits developing under the skin changes in the tiny blood vessels (capillaries) at the base of the fingernails thickened skin patches.

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The doctor may order lab tests to help confirm a suspected diagnosis. At least two proteins, called antibodies, are commonly found in the blood of people with scleroderma: Antitopoisomerase-1 or Anti-Scl-70 antibodies appear in the blood of up to 30 percent of people with diffuse systemic sclerosis. Anticentromere antibodies are found in the blood of as many as 50 percent of people with limited systemic sclerosis. A number of other scleroderma-specific antibodies can occur in people with scleroderma, although less frequently. When present, however, they are helpful in clinical diagnosis and may give additional information as to the risks for specific organ problems. Because not all people with scleroderma have these antibodies and because not all people with the antibodies have scleroderma, lab test results alone cannot confirm the diagnosis. In some cases, the doctor may order a skin biopsy (the surgical removal of a small sample of skin for microscopic examination) to aid in or help confirm a diagnosis. However, skin biopsies, too, have their limitations: biopsy results cannot distinguish between localized and systemic disease, for example. Diagnosing scleroderma is easiest when a person has typical symptoms and rapid skin thickening. In other cases, a diagnosis may take months, or even years, as the disease unfolds and reveals itself and as the doctor is able to rule out some other potential causes of the symptoms. In some cases, a diagnosis is never made, because the symptoms that prompted the visit to the doctor go away on their own.

Causes
Although scientists dont know exactly what causes scleroderma, they are certain that people cannot catch it from or transmit it to others. Studies of twins suggest it is also not inherited. Scientists suspect that scleroderma comes from several factors that may include: Abnormal immune or inflammatory activity: Like many other rheumatic disorders, scleroderma is believed to be an autoimmune disease. An autoimmune disease is one in which the immune system, for unknown reasons, turns against ones own body. In scleroderma, the immune system is thought to stimulate cells called fibroblasts so they produce too much collagen. The collagen forms thick connective tissue that builds up within the skin and internal organs and can interfere with their functioning. Blood vessels and joints can also be affected. Genetic makeup: While genes seem to put certain people at risk for scleroderma and play a role in its course, the disease is not passed from parent to child like some genetic diseases. Environmental triggers: Research suggests that exposure to some environmental factors may trigger sclerodermalike disease (which is not actually scleroderma) in people who

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are genetically predisposed to it. Suspected triggers include viral infections, certain adhesive and coating materials, and organic solvents such as vinyl chloride or trichloroethylene. But no environmental agent has been shown to cause scleroderma. In the past, some people believed that silicone breast implants might have been a factor in developing connective tissue diseases such as scleroderma. But several studies have not shown evidence of a connection. Hormones: By the middle to late childbearing years (ages 30 to 55) women develop scleroderma 7 to 12 times more often than men. Because of female predominance at this and all ages, scientists suspect that hormonal differences between women and men play a part in the disease. However, the role of estrogen or other female hormones has not been proven. Currently, there is no treatment that controls or stops the underlying problem - the overproduction of collagen - in all forms of scleroderma. Thus, treatment and management focus on relieving symptoms and limiting damage. Here is a listing of the potential problems that can occur in systemic scleroderma and the medical and nonmedical treatments for them. These problems do not occur as a result or complication of localized scleroderma. This listing is not complete because different people experience different problems with scleroderma and not all treatments work equally well for all people. Work with your doctor to find the best treatment for your specific symptoms. Raynauds Phenomenon More than 90 percent of people with scleroderma have this condition, in which the fingers and sometimes other extremities change color in response to cold temperature or anxiety. For many, Raynauds phenomenon precedes other manifestations of the disease. In other people, however, Raynauds phenomenon is unrelated to scleroderma, but may signal damage to the blood vessels supplying the hands arising from occupational injuries (from using jackhammers, for example), trauma, excessive smoking, circulatory problems, and drug use or exposure to toxic substances. For some people, cold fingers and toes are the extent of the problem and are little more than a nuisance. For others, the condition can worsen and lead to puffy fingers, finger ulcers, and other complications that require aggressive treatment. If you have Raynauds phenomenon, the following measures may make you more comfortable and help prevent problems: Dont smoke! Smoking narrows the blood vessels even more and makes Raynauds phenomenon worse. Dress warmly, with special attention to hands and feet. Dress in layers and try to stay indoors during cold weather. Use biofeedback, which governs various body processes that are not normally thought of as being under conscious control, and relaxation exercises.

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For severe cases, speak to your doctor about prescribing drugs called calcium channel blockers, such as nifedipine, which can open up small blood vessels and improve circulation. Other drugs are in development and may become available. If Raynauds leads to skin sores or ulcers, increasing your dose of calcium channel blockers (under the direction of your doctor ONLY) may help. You can also protect skin ulcers from further injury or infection by applying nitroglycerine paste or antibiotic cream. Severe ulcerations on the fingertips can be treated with bioengineered skin. Stiff, painful joints In diffuse systemic sclerosis, hand joints can stiffen due to hardened skin around the joints or inflammation within them. Other joints can also become stiff and swollen. Stretching exercises under the direction of a physical and/or occupational therapist are extremely important to prevent loss of joint motion. These should be started as soon as the diagnosis of scleroderma is made. Exercise regularly. Ask your doctor or physical therapist about an exercise plan that will help you increase and maintain range of motion in affected joints. Swimming can help maintain muscle strength, flexibility, and joint mobility. Use acetaminophen or an over-the-counter or prescription nonsteroidal antiinflammatory drug, as recommended by your doctor, to help relieve joint or muscle pain. If pain is severe, speak to a rheumatologist about the possibility of prescription-strength drugs to ease pain and inflammation. Learn to do things in a new way. A physical or occupational therapist can help you learn to perform daily tasks, such as lifting and carrying objects or opening doors, in ways that will put less stress on tender joints. Skin problems When too much collagen builds up in the skin, it crowds out sweat and oil glands, causing the skin to become dry and stiff. If your skin is affected, you may need to see a dermatologist. To ease dry skin, try the following: Apply oil-based creams and lotions frequently, and always right after bathing. Apply sunscreen before you venture outdoors, to protect against further damage from the suns rays. Use humidifiers to moisten the air in your home in colder winter climates. Clean humidifiers often to stop bacteria from growing in the water. Avoid very hot baths and showers, as hot water dries the skin. Avoid harsh soaps, household cleaners, and caustic chemicals, if at all possible.

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Otherwise, be sure to wear rubber gloves when you use such products. Exercise regularly. Exercise, especially swimming, stimulates blood circulation to affected areas. Dry mouth and dental problems Dental problems are common in people with scleroderma for a number of reasons. Tightening facial skin can make the mouth opening smaller and narrower, which makes it hard to care for teeth; dry mouth due to salivary gland damage speeds up tooth decay; and damage to connective tissues in the mouth can lead to loose teeth. You can avoid tooth and gum problems in several ways: Brush and floss your teeth regularly. If hand pain and stiffness make this difficult, consult your doctor or an occupational therapist about specially made toothbrush handles and devices to make flossing easier. Have regular dental checkups. Contact your dentist immediately if you experience mouth sores, mouth pain, or loose teeth. If decay is a problem, ask your dentist about fluoride rinses or prescription toothpastes that remineralize and harden tooth enamel. Consult a physical therapist about facial exercises to help keep your mouth and face more flexible. Keep your mouth moist by drinking plenty of water, sucking ice chips, using sugarless gum and hard candy, and avoiding mouthwashes with alcohol. If dry mouth still bothers you, ask your doctor about a saliva substitute, or prescription medications such as Salagen or Evoxac, that can stimulate the flow of saliva. Gastrointestinal (GI) problems Systemic sclerosis can affect any part of the digestive system. As a result, you may experience problems such as heartburn, difficulty swallowing, early satiety (the feeling of being full after youve barely started eating), or intestinal complaints such as diarrhea, constipation, and gas. In cases where the intestines are damaged, your body may have difficulty absorbing nutrients from food. Although GI problems are diverse, here are some things that might help at least some of the problems you have: Eat small, frequent meals. To keep stomach contents from backing up into the esophagus, stand or sit for at least an hour (preferably two or three) after eating. When it is time to sleep, keep the head of your bed raised using blocks. Avoid late-night meals, spicy or fatty foods, alcohol, and caffeine, which can aggravate GI distress.

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Eat moist, soft foods, and chew them well. If you have difficulty swallowing, or if your body doesnt absorb nutrients properly, your doctor may prescribe a special diet. Ask your doctor about prescription medications for problems such as diarrhea, constipation, and heartburn. Some drugs called proton pump inhibitors are highly effective against heartburn. Oral antibiotics may stop bacterial overgrowth in the bowel that can be a cause of diarrhea in some people with systemic sclerosis. Lung damage Virtually all people with systemic sclerosis have some loss of lung function. Some develop severe lung disease, which comes in two forms: pulmonary fibrosis (hardening or scarring of lung tissue because of excess collagen) and pulmonary hypertension (high blood pressure in the artery that carries blood from the heart to the lungs). Treatment for the two conditions is different: Pulmonary fibrosis may be treated with drugs that suppress the immune system such as cyclophosphamide (Cytoxan) or azathioprine (Imuran), along with low doses of corticosteroids. Pulmonary hypertension may be treated with drugs that dilate the blood vessels such as prostacyclin (Iloprost), or with newer medications that are prescribed specifically for treating pulmonary hypertension. Regardless of your particular lung problem or its medical treatment, your role in the treatment process is essentially the same. To minimize lung complications, work closely with your medical team. Do the following: Watch for signs of lung disease, including fatigue, shortness of breath or difficulty breathing, and swollen feet. Report these symptoms to your doctor. Have your lungs closely checked, using standard lung-function tests, during the early stages of skin thickening. These tests, which can find problems at the earliest and most treatable stages, are needed because lung damage can occur even before you notice any symptoms. Get regular flu and pneumonia vaccines as recommended by your doctor. Contracting either illness could be dangerous for a person with lung disease. Heart problems Common among people with scleroderma, heart problems include scarring and weakening of the heart (cardiomyopathy), inflamed heart muscle (myocarditis), and abnormal heart beat (arrhythmia). All of these problems can be treated. Treatment ranges from drugs to surgery, and varies depending on the nature of the condition. Kidney problems

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Renal crisis occurs in about 10 percent of all patients with scleroderma, primarily those with early diffuse scleroderma. Renal crisis results in severe uncontrolled high blood pressure, which can quickly lead to kidney failure. Its very important that you take measures to identify and treat the hypertension as soon as it occurs. These are things you can do: Check your blood pressure regularly. You should also check it if you have any new or different symptoms such as a headache or shortness of breath. If the blood pressure is higher than usual, call your doctor right away. If you have kidney problems, take your prescribed medications faithfully. In the past two decades, drugs known as ACE (angiotensin-converting enzyme) inhibitors, including captopril (Capoten), enalapril (Vasotec), or lisinopril, have made scleroderma-related kidney failure a less threatening problem than it used to be. But for these drugs to work, you must take them as soon as the hypertension is present. Cosmetic problems Even if scleroderma doesnt cause any lasting physical disability, its effects on the skins appearance - particularly on the face - can take their toll on your self-esteem. Fortunately, there are procedures to correct some of the cosmetic problems scleroderma causes: The appearance of telangiectasias - small red spots on the hands and face caused by swelling of tiny blood vessels beneath the skin - may be reduced or even eliminated with the use of guided lasers. Facial changes of localized scleroderma - such as the en coup de sabre that may run down the forehead in people with linear scleroderma - may be corrected through cosmetic surgery. (However, such surgery is not appropriate for areas of the skin where the disease is active.)

Rosacea
Rosacea is a chronic (long-term) disease that affects the skin and sometimes the eyes. The disorder is characterized by redness, pimples, and, in advanced stages, thickened skin. Rosacea usually affects the face; other parts of the upper body are only rarely involved. Approximately 14 million people in the United States have rosacea. It most often affects adults between the ages of 30 and 60. Rosacea is more common in women (particularly during menopause) than men. Although rosacea can develop in people of any skin color, it tends to occur most frequently and is most apparent in people with fair skin.

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Symptoms
Rosacea has many symptoms, including the following: Frequent redness (flushing) of the face. Most redness is at the center of the face (forehead, nose, cheeks, and chin). There may also be a burning feeling and slight swelling. Small red lines under the skin. These lines show up when blood vessels under the skin get larger. This area of the skin may be somewhat swollen, warm, and red. Constant redness along with bumps on the skin. Sometimes the bumps have pus inside (pimples), but not always. Solid bumps on the skin may later become painful. Inflamed eyes/eyelids. A swollen nose. In some people (mostly men), the nose becomes red, larger, and bumpy. Thicker skin. The skin on the forehead, chin, cheeks, or other areas can become thicker because of rosacea. How Are the Eyes Affected? Up to 50 percent of people who have rosacea get eye problems. Eyes can have redness, dryness, itching, burning, excess tears, and the feeling of having sand in the eye. The eyelids may become inflamed and swollen. The eyes may become sensitive to light, and the person may have blurred vision or some other kind of vision problem.

Causes
Doctors don't know the exact cause of rosacea. Some doctors think rosacea happens when blood vessels expand too easily, causing flushing. People who blush a lot may be more likely to get rosacea. It is also thought that people inherit the likelihood of getting the disease. Though not well-researched, some people say that one or more of these factors make their rosacea worse: Heat (including hot baths) Heavy exercise Sunlight Winds Very cold temperatures

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Hot or spicy foods and drinks Drinking alcohol Menopause Emotional stress Long-term use of steroids on the face. People with rosacea and pimples may think the pimples are caused by bacteria. But no one has found a clear link between rosacea and bacteria. There is no cure for rosacea, but it can be treated and controlled. In time the skin may look better. For skin: Sometimes antibiotics can be put right on the skin. Other times, oral antibiotics can be used. The skin bumps may get better quickly, but redness and flushing are less likely to improve. Small red lines can be treated with electrosurgery and laser surgery. For some people, laser surgery improves the skin without much scarring or damage. Patients with a swollen, bumpy nose can have extra skin tissue taken off to make it smaller. Usually patients feel this process helps their appearance. Some people find that green-tinted makeup is good for hiding the skin's redness. For the eyes: Most eye problems are treated with oral antibiotics. People who get infections of the eyelids must clean them a lot. The doctor may say to scrub the eyelids gently with watered-down baby shampoo or an over-thecounter eyelid cleaner. After scrubbing, you should apply a warm (but not hot) compress a few times a day. If needed, the doctor may prescribe steroid eye drops. There is no cure for rosacea, but it can be treated and controlled. In time the skin may look better.

Acne
Acne is a disorder resulting from the action of hormones and other substances on the skin's oil glands (sebaceous glands) and hair follicles. These factors lead to plugged pores and outbreaks of lesions commonly called pimples or zits. Acne lesions usually occur on the face, neck, back, chest, and shoulders. Although acne is usually not a serious health 31

threat, it can be a source of significant emotional distress. Severe acne can lead to permanent scarring. Doctors describe acne as a disease of the pilosebaceous units (PSUs). Found over most of the body, PSUs consist of a sebaceous gland connected to a canal, called a follicle, that contains a fine hair (left figure). These units are most numerous on the face, upper back, and chest. The sebaceous glands make an oily substance called sebum that normally empties onto the skin surface through the opening of the follicle, commonly called a pore. Cells called keratinocytes line the follicle. The hair, sebum, and keratinocytes that fill the narrow follicle may produce a plug, which is an early sign of acne. The plug prevents sebum from reaching the surface of the skin through a pore. The mixture of oil and cells allows bacteria Propionibacterium acnes (P. acnes) that normally live on the skin to grow in the plugged follicles. These bacteria produce chemicals and enzymes and attract white blood cells that cause inflammation. When the wall of the plugged follicle breaks down, it spills everything into the nearby skin - sebum, shed skin cells, and bacteria - leading to lesions or pimples.

Symptoms
People with acne frequently have a variety of lesions. The basic acne lesion, called the comedo, is simply an enlarged and plugged hair follicle. If the plugged follicle, or comedo, stays beneath the skin, it is called a closed comedo and produces a white bump called a whitehead. A comedo that reaches the surface of the skin and opens up is called an open comedo or blackhead because it looks black on the skin's surface. This black discoloration is due to changes in sebum as it is exposed to air. It is not due to dirt. Both whiteheads and blackheads may stay in the skin for a long time. Other troublesome acne lesions can develop, including the following: Papules - inflamed lesions that usually appear as small, pink bumps on the skin and can be tender to the touch. Pustules (pimples) - papules topped by white or yellow pus-filled lesions that may be red at the base. Nodules - large, painful, solid lesions that are lodged deep within the skin. Cysts - deep, painful, pus-filled lesions that can cause scarring.

Causes
The exact cause of acne is unknown, but doctors believe it results from several related factors. One important factor is an increase in hormones called androgens (male sex hormones). These increase in both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormonal changes related to pregnancy or starting or stopping birth control pills can also cause acne. Another factor is heredity or genetics. Researchers believe that the tendency to develop

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acne can be inherited from parents. For example, studies have shown that many schoolage boys with acne have a family history of the disorder. Certain drugs, including androgens and lithium, are known to cause acne. Greasy cosmetics may alter the cells of the follicles and make them stick together, producing a plug. Factors that can make acne worse include: Changing hormone levels in adolescent girls and adult women 2 to 7 days before their menstrual period starts. Oil from skin products (moisturizers or cosmetics) or grease encountered in the work environment (for example, a kitchen with fry vats). Pressure from sports helmets or equipment, backpacks, tight collars, or tight sports uniforms. Environmental irritants, such as pollution and high humidity. Squeezing or picking at blemishes. Hard scrubbing of the skin. Stress. Chocolate and greasy foods are often blamed for acne development, but there is little evidence that foods have much effect on the development and course of acne in most people. Depending on the extent of the acne problem, the doctor may recommend one of several over-the-counter (OTC) medicines and/or prescription medicines. Some of these medicines may be topical (applied to the skin), and others may be oral (taken by mouth). The doctor may suggest using more than one topical medicine or combining oral and topical medicines. Treatment for Blackheads, Whiteheads, and Mild Inflammatory Acne There are several OTC topical medicines used for mild acne. Each works a little differently. Following are the most common ones: Benzoyl peroxide - destroys P. acnes, and may also reduce oil production. Resorcinol - can help break down blackheads and whiteheads. Salicylic acid - helps break down blackheads and whiteheads. Also helps cut down the shedding of cells lining the hair follicles. Sulfur - helps break down blackheads and whiteheads. Treatment for Moderate to Severe Inflammatory Acne

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Several types of prescription medicines are used to treat acne. They include: Antibiotics - help stop or slow the growth of bacteria and reduce inflammation. They include tetracycline, minocycline, doxycycline, clindamycin, erythromycin, and sulfonamides. Vitamin A derivatives (retinoids) - unplug existing comedones (plural of comedo), allowing other topical medicines, such as antibiotics, to enter the follicles. Some may also help decrease the formation of comedones. These drugs contain an altered form of vitamin A. Some examples are tretinoin, adapalene, and tazarotene. Others - may destroy P. acnes and reduce oil production or help stop or slow the growth of bacteria and reduce inflammation. Some examples are prescription strength Benzoyl peroxide, sodium sulfacetamide/sulfur-containing products, or Azelaic acid. Treatment for Severe Nodular or Cystic Acne For patients with severe inflammatory acne that does not improve with medicines such as those described above, a doctor may prescribe isotretinoin (Accutane), a retinoid (vitamin A derivative). Isotretinoin is an oral drug that is usually taken once or twice a day with food for 15 to 20 weeks. It markedly reduces the size of the oil glands so that much less oil is produced. As a result, the growth of bacteria is decreased. Advantages of Isotretinoin (Accutane) Isotretinoin is a very effective medicine that can help prevent scarring. After 15 to 20 weeks of treatment with isotretinoin, acne completely or almost completely goes away in most patients. In those patients where acne recurs after a course of isotretinoin, the doctor may institute another course of the same treatment or prescribe other medicines. Disadvantages of Isotretinoin (Accutane) Isotretinoin may cause the following side effects: birth defects in the developing fetus of a pregnant woman dry eyes, mouth, lips, nose, or skin (very common) itching nosebleeds muscle aches sensitivity to the sun poor night vision

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changes in the blood, such as an increase in triglycerides and cholesterol change in liver function. There have been a number of reported suicides and suicide attempts in people taking isotretinoin; however, the connection between isotretinoin and suicide or depression is not known.

Lichen sclerosus
Lichen sclerosus is a chronic inflammatory skin disorder that can affect men, women, or children, but is most common in women. It usually affects the vulva (the outer genitalia or sex organ) and the anal area. While lichen sclerosus appears predominantly in postmenopausal women, this skin condition is also known to develop on the head of the penis in men. Occasionally, lichen sclerosus is seen on other parts of the body, especially the upper body, breasts, and upper arms. Lichen sclerosus is considered a rare disorder, although definitive data are not available.

Symptoms and Diagnosis

Early in the disease, small white spots appear on the skin. The spots are usually shiny and smooth. Later, the spots grow into bigger patches. The skin on the patches becomes thin and crinkled. Then the skin tears easily, and bright red or purple bruises are common. Sometimes, the skin becomes scarred. If the disease is a mild case, there may be no symptoms. Other symptoms are: Itching (very common) Discomfort or pain Bleeding Blisters. Doctors can diagnose an advanced case by looking at the skin. However, early or mild disease often requires a biopsy (removal and examination of a small sample of affected skin). Because other diseases of the genitalia can look like lichen sclerosus, a biopsy is advised whenever the appearance of the skin is not typical of lichen sclerosus.

Causes
The cause is unknown, although an overactive immune system may play a role. Some people may have a genetic tendency toward the disease, and studies suggest that abnormal hormone levels may also play a role. Lichen sclerosus has also been shown to appear at sites of previous injury or trauma where the skin has already experienced

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scarring or damage. Patients with lichen sclerosus of nongenital skin often do not need treatment because the symptoms are very mild and usually go away over time. The amount of time involved varies from patient to patient. However, lichen sclerosus of the genital skin should be treated, even when it is not causing itching or pain, because it can lead to scarring that may narrow openings in the genital area and interfere with either urination or sexual intercourse or both. There is also a very small chance that skin cancer may develop within the affected areas. In uncircumcised men, circumcision is the most widely used therapy for lichen sclerosus. This procedure removes the affected skin, and the disease usually does not recur. Prescription medications are required to treat vulvar lichen sclerosus, nongenital lichen sclerosus that is causing symptoms, and lichen sclerosus of the penis that is not cured by circumcision. The treatment of choice is an ultrapotent topical corticosteroid (a very strong cortisone cream or ointment). These creams or ointments may be applied daily for several weeks, which will be sufficient to stop the itching. However, long-term but less frequent applications (sometimes as infrequently as twice a week) will be needed to keep the lesions from reactivating and to help restore the skin's normal texture and strength. Treatment does not reverse the scarring that may have already occurred. Because prolonged use of ultrapotent corticosteroid creams and ointments can cause thinning and redness of the skin, give rise to "stretch marks" around the area of application, and predispose individuals to vulvar yeast infections, periodic followup by a doctor is necessary. Young girls may not require lifelong treatment, since lichen sclerosus can sometimes, but not always, disappear permanently at puberty. Scarring and changes in skin color, however, may remain even after the symptoms have disappeared. Ultrapotent topical corticosteroids are so effective that other therapies are rarely prescribed. The previous standard therapy was testosterone cream or ointment, but this has been proven to produce no more benefit than a placebo (inactive) cream. Prolonged use of the testosterone cream or ointment can cause masculinization (low-pitched voice, increased coarse facial hairs). Another hormone cream, progesterone, was previously used to treat the disease, but has also been shown to be ineffective. Retinoids, or vitamin A-like medications, may be helpful for patients who cannot tolerate or are not helped by ultrapotent topical corticosteroids. Tacrolimus (Protopic) ointment has been reported to benefit some patients, but more research is needed to confirm this. Tacrolimus is a steroid-free ointment; it is not a corticosteroid. Tacrolimus has no apparent side effects other than local irritation in some patients. There are some early indications that different forms of ultraviolet light treatments, with or without psoralens (pills that intensify the effect of ultraviolet A light), may be effective and well-tolerated treatments for some patients with lichen sclerosus on nongenital skin. 36

Patients who need medication should ask their doctor how the medication works, what its side effects might be, and why it is the best treatment for their lichen sclerosus. For women and girls, surgery to remove the affected skin is not an acceptable option because lichen sclerosus comes back after removal. Surgery may be useful for scarring, but only after lichen sclerosus is controlled with medication. Sometimes, people do not respond to the ultrapotent topical corticosteroid. Other factors, such as low estrogen levels, an infection, irritation, or allergy to the medication, can keep symptoms from clearing up. Your doctor may need to treat these as well. If you feel that you are not improving as you would expect, talk to your doctor.

Alopecia areata
Alopecia areata is considered an autoimmune disease, in which the immune system mistakenly attacks the hair follicles, the tiny cup-shaped structures from which hairs grow. This can lead to hair loss on the scalp and elsewhere. Alopecia areata affects an estimated four million Americans of both sexes and of all ages and ethnic backgrounds. It often begins in childhood.

Symptoms
In most cases, hair falls out in small, round patches about the size of a quarter. In many cases, the disease does not extend beyond a few bare patches. In some people, hair loss is more extensive. Although uncommon, the disease can progress to cause total loss of hair on the head (referred to as alopecia areata totalis) or complete loss of hair on the head, face, and body (alopecia areata universalis).

Causes
In alopecia areata, immune system cells called white blood cells attack the rapidly growing cells in the hair follicles that make the hair. The affected hair follicles become small and drastically slow down hair production. Fortunately, the stem cells that continually supply the follicle with new cells do not seem to be targeted. So the follicle always has the potential to regrow hair. Scientists do not know exactly why the hair follicles undergo these changes, but they suspect that a combination of genes may predispose some people to the disease. In those who are genetically predisposed, some type of trigger--perhaps a virus or something in the person's environment--brings on the attack against the hair follicles. There is no cure for alopecia areata. There are no drugs approved to treat it. Doctors may use medicines approved for other diseases to help hair grow back. The following are some treatments for alopecia areata. Corticosteroids

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Corticosteroids are drugs that reduce swelling and pain. They also affect the immune system. Corticosteroids may be given in three ways for alopecia areata: Injected in the skin Swallowed as pills Rubbed on the skin as a cream or ointment. Drugs that are rubbed on the skin as a cream or lotion Minoxidil (5%) Anthralin Squaric acid dibutyl ester (SADBE) and diphenylcyclopropenone (DPCP). Drugs that affect the immune system Sulfasalazine Cyclosporine. Photochemotherapy In photochemotherapy, a person is given a drug called a psoralen, which is affected by light. The drug can be swallowed or rubbed on the skin. Once the drug is taken or applied, the area with hair loss is exposed to an ultraviolet light source. This combined treatment is called PUVA. Alternative therapies Some people with alopecia areata try other treatments. These alternatives include acupuncture, aroma therapy, evening primrose oil, zinc and vitamin supplements, and Chinese herbs. Because many alternative therapies have not been studied in clinical trials, they may or may not help hair grow back. In fact, some may cause more hair loss. Talk with your doctor before you try alternative therapies.

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