Surface tension: a guide to skin conditions

It is the largest human organ, but possibly the one we take most for granted. We shave it, wax it, spray perfume and deodorant on it and often carelessly expose it to the wind, rain and sun. Is it any wonder our skin sometimes objects, or that we realise how precious it is only when something goes wrong?

“The Irish population is fair-skinned and, as such, are really prone to the daily effects of the sun, wind and cold. All these can have an effect on our skin; from blotchy discolourations, broken blood vessels, blotchy brown marks, rosacea and, of course, the risk of skin cancer,” says Prof Frank Powell, associate professor of dermatology at University College Dublin (UCD) and consultant dermatologist at the Mater hospital in Dublin.

Rosacea

Known as the “curse of the Celts”, rosacea is the most common skin condition in Ireland, with a higher incidence than other European countries. It causes facial redness and flushing, and is characterised by dry, sensitive skin.

“It is very common; about 15 per cent have the most common kind of facial redness. Some have the form that has bumps or pimples. There is a social stigma associated with rosacea; people often associate it with alcohol intake. That is not true, although alcohol intake can exacerbate it,” says Powell.

Many rosacea sufferers have watery, red-rimmed, sensitive eyes that are prone to eye infections. “Rosacea can cause a burning, stinging sensation in the eyes, due to the tear glands not producing enough of the oil that lubricates the eye. There is also a rare version that causes the nose to distort and enlarge. It is called rhinophyma, and occurs mostly in men.”

Previously classed as incurable, there have been significant treatment advances in rosacea in recent years, including creams, laser and antibiotics, as well as avoiding triggers such as alcohol, the sun, stress, certain foods and using appropriate skincare products.

“There is very good treatment for rosacea now. Most patients can have their skin cleared. You can often get it under very good control but that doesn’t mean it has gone away. The problem is it tends to remit and relapse, maybe after months or a year. It might come back if you are stressed, run down or for other reasons we don’t understand,” says Powell.

While a variety of potential factors, such as a family history, are involved in the development of rosacea, studies have shown that microscopic mites known as demodex are much more common in individuals with rosacea than in those without the condition.

“Antibiotics work by reducing the inflammation more than killing bacteria. A new cream has now been developed that actually kills the mite rather than bacteria, so hopefully we won’t have to continue using antibiotics to treat this condition,” Powell says. The cream, Soolantra, has just become licensed in Ireland and is available on prescription.

Psoriasis

Psoriasis is a chronic, debilitating inflammatory skin disease, characterised by red, scaly skin, caused by an accelerated rate of turnover of the top layer of the skin. Although it is a chronic condition, its course may be variable, with flare-ups and remissions. The cause of psoriasis is not fully understood, but evidence suggests that there is a strong genetic component and that environmental factors, such as emotional stress or infection, also play a role: they may trigger the first episode of psoriasis, or exacerbate it.

More than 73,000 people are affected by psoriasis in Ireland, and 9,000 of those have a severe form of the disease, a new Irish report, Burden of Psoriasis, states.

A survey, conducted in conjunction with the report, found an overwhelming 93 per cent of those affected by psoriasis had felt embarrassed by it, with 77 per cent indicating their skin had made them “hide themselves away”.

In addition, 73 per cent agreed their psoriasis had had a negative impact on their social life. One in five (21 per cent) admitted their psoriasis had stopped them applying for a job.

Treatment for psoriasis, which includes creams, UV light and medications such as methotrexate for the more severe forms, has advanced significantly over the past decade with the introduction of biologic drugs.

“Biologics, however, are very strong medications and work by causing a depression of the immune system and are extremely expensive, so they are restricted for those patients who have psoriasis that can’t be controlled by other means. So the biologics are an exciting new advance, but we are a bit cautions about the long-term side effects,” says Powell.

Eczema

The Irish Skin Foundation describes eczema as a common, recurring, non-infectious, inflammatory skin disease in which the skin becomes red, dry, itchy or scaly and may even weep, bleed or crust over.

In 80 per cent of cases, eczema develops in children under the age of two and affects an estimated one in five children under the age of six, and one in 12 adults. While most children grow out of it, it may recur in later life.

One of Ireland’s leading researchers on eczema, Prof Alan Irvine, consultant paediatric dermatologist at Our Lady’s Children’s Hospital, Crumlin, explains that if both parents have eczema, there is an 80 per cent chance their children will too. There is also often a family history of atopic conditions such as asthma and hay fever.

Children who attend creches or who have older siblings are more likely to develop eczema, says Irvine, adding there has been a huge increase in eczema worldwide. He attributes this to environmental factors such as urban living.

Filaggrin mutations in the skin increase the risk of developing eczema significantly and lead to more serious disease, which is harder to treat, as well as increasing the risk of other allergies and asthma.

In a small number of cases, eczema continues into adulthood. “[These patients] need ongoing treatment and their skin is very sensitive and reactive; men, for example, can’t use aftershaves on their faces and women’s sprays and perfume tend to irritate their skin. So it is a difficult ongoing problem but a good skincare routine helps,” says Powell.

Acne

Most of us will suffer from acne at some stage of our life. While for most it is an embarrassing phase during teenage years, it can be a longer-term, more disfiguring condition for some adults and can reoccur during times of hormonal changes such as pregnancy.

“Acne generally develops at a sensitive time in a young person’s development during teenage years, when they are self-conscious about their appearance and interacting socially. It can have a very big impact on some, and others can just shrug it off; so it is not just about the severity, it is about the individual impact,” says Powell.

There are plenty of effective treatments for acne now, including cleansing products, creams and medications with derivatives of vitamin A, “so it can generally be [brought] under control, and there is usually a natural end to it”.

Itching

Everyone at some stage suffers from the most frequent symptom in dermatology: itchy skin. While for most of us it is a temporary annoyance associated with a skin reaction, for some it is an ongoing problem that can have a severe impact on their lives.

Therapy-resistant skin itch in renal and liver diseases and leukaemia, as well as in elderly people, is a major medical burden. Prof Martin Steinhoff of UCD is leading a team to examine the causes of itch.

A lack of understanding of the molecular mechanisms of itch in humans has represented a significant barrier for therapeutic progress. To develop new treatments against therapy-resistant itch, Steinhoff and his team will first identify in a translational setting key cytokines and chemokines in different human itch subtypes.

Together with pharmaceutical companies, they will then test in human studies the beneficial effects of treating skin itch by blocking cytokine/chemokine pathways.

Skin cancer

There are more than 10,000 cases of skin cancer annually in Ireland, up more than 80 per cent since records began in 1994. While much rarer than non-melanoma skin cancer, the incidence of more deadly melanoma here has risen faster than most other types of cancer from 1994 to 2010: by 138 per cent. There are now about 889 cases of melanoma annually. The majority of skin cancers are caused by exposure to ultraviolet (UV) rays from the sun or from sunbeds, and can be prevented.

“Irish people living in Australia have a very high incidence of skin cancer because their sensitive skin is exposed to the extremes of the weather there. One thing I emphasise to people, particularly women who are more skin-conscious, is to wear a high sun factor [all year round] in their make-up and moisturiser,” says Powell.

Skin threats
Autoimmune diseases Autoimmune diseases such as lupus, vasculitis, and sarcoidosis can have a significant impact on the skin, says Prof Frank Powell of UCD and the Mater hospital.

Lupus, or systemic lupus erythematosus, can affect almost any part of the body, but especially skin, blood, joints, kidneys, heart, lungs and brain. A hallmark sign of lupus is a butterfly-shaped rash that often appears over the bridge of the nose and extends to the cheeks. Rashes may also occur on the neck or chest and the skin may appear scaly. People with lupus tend to be sensitive to sunlight and prone to sunburn.

Some people with lupus develop Reynaud’s syndrome, a condition where the sufferer has poor circulation and the skin of the ears, nose, fingers and toes goes numb and pale or purple when exposed to cold. These skin manifestations of lupus are underappreciated and undertreated, according to Prof Michelle Petri of the Johns Hopkins University School of Medicine in the US, one of the world’s foremost experts on the autoimmune disease.

Speaking at a recent Irish meeting of dermatologists, she stressed the key role dermatologists have with quality of life in the treatment of lupus patients, who suffer from rashes, hair loss and scaly skin lesions.

Sarcoidosis is a relatively rare inflammatory disease that normally involves the lungs but can affect any organ. The skin is the second most commonly affected, with rashes, redness, small tender lumps and lesions, and patchy hair loss common in sufferers. There is no cure, but a healthy lifestyle and medications are used to relieve symptoms and reduce the inflammation of the affected tissues.

Vasculitis is a rare disease with a number of subtypes, characterised by inflammation of the blood vessels, arteries, veins or capillaries. Urticarial vasculitis affects the skin, causing weals or itchy, painful hives and/or red patches.

Skin patches are often red-rimmed, with white centres and, unlike common hives, they may bleed. The patches can be present for days or weeks and result in skin discolouration as they heal.

“The skin can be the mirror of internal problems in the body and that is something we should all be aware of,” Powell concludes.

skinfoundation.ie; isarc.ie; lupus.ie