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In July, our guest expert in Le Club's Ask the Expert segment was Sandra Walsh, RN, who works in the Phototherapy Education and Research Centre (PERC) at Women's College Hospital.

The centre is a light-treatment facility specializing in educating patients about photosensitive diseases - diseases of the skin that are sensitive to and affected by light - and helping patients manage such diseases.

Sandra graduated with a Bachelor's Degree in Nursing in 1989 from Memorial University of Newfoundland. She received the Dermatology Nurse Certified recognition in 1999.

Sandra has worked in the dermatology field since 1991, specializing in the treatment of psoriasis and cutaneous T-cell lymphoma. She is also an executive member of the Central Canadian Chapter of the Dermatology Nurses' Association.

Here are Sandra's answers to your questions about Skin Care:

(*Please note, due to the similarity of content, some of the questions are grouped together under a main heading, with one answer following the group of questions.)

Rash on Arms

Q: I have a bumpy rash on my upper arms. I have had it for years. It does not hurt or itch but looks unpleasant. What can I do for it?

A: A rash on the upper arms could be keratosis pilaris. It is a common inherited condition in which there is a thickening of the skin and plugging of the hair follicle. The rash is most commonly seen on the outer upper arms, upper back and front of the thighs.

Sometimes the bumps are red in colour. It is usually apparent during childhood and becomes less obvious with age. This condition is usually asymptomatic and does not require treatment. If a person wants to treat the condition they should take steps to avoid dry skin. This can be achieved by avoiding harsh soaps and applying moisturizer to damp skin after bathing.

An exfoliating sponge as well as creams containing lactic acid, salicylic acid, urea or ammonium lactate will help to loosen the thickened skin and plugs. Once the condition is under control, a once or twice weekly application of a 20 percent urea cream is recommended. These products can be found over the counter, ask your pharmacist for help.


Itchy Skin

Q: i) What would cause a painful, prickly itch with no visible rash? It is mostly on my back and buttocks?

ii) I have dry skin and use moisture cream daily all over my body - usually Jergens or Vaseline extra strength dry skin moisturizer.

I am 48 years old and have used moisture cream for 30 years without any reactions. Since the spring of 2005 I have been getting very itchy skin sporadically. When I scratch I get very red and sometimes welts form for several minutes. I also find if I scratch in one area, another area will be come itchy.

I live and work in Toronto where the air quality is not great. I also have had slight allergies (runny nose/itchy eyes/sneezing) for the past two years. Could the skin itchiness be allergies also? Thank you.

A: There are many causes of itch. Itch may be related to a subtle skin condition that is not very obvious, allergies, a systemic disease, certain medications or psychological causes. I recommend that you see your family doctor or dermatologist for a skin examination and the appropriate diagnostic tests.


Darkening of skin and age spots

Q:i) I have two areas on either side of my neck that are discoloured. Sometimes they look brownish and other times more reddish. What could cause this? Thank you for your reply.

ii) I have noticed pigment changes to the area above my upper lips and wonder if there is a way to get rid of this discolouration. I realize this is more of an esthetics issue, but I am feeling self-conscious about it due to its location.

iii) My skin has been darkening over the years (I'm now 63) and people often ask me in the winter if I have a tan. I take a number of drugs for high blood pressure (Atenolol, Hydrochlorothiazide, Ibersartan, Amlodipine), as well as HRT - but this darkening started before I took these drugs, except perhaps the Hydrochlorothiazide. My doctor has tested me for hemachromatosis. The results were negative. He says not to worry, but I do. What do you think?

iv) I have a young friend whose skin is darkening above her upper lip and now over her eyebrows. To me it almost looks grey. She takes Plaquenil. I've looked the side effects up on the Internet and changes in skin pigmentation appear to be a possible side effect of the drug, but her dermatologist says it's not a side effect. What do you think?

v) My face is starting to show the effects of many hours spent in the sun as a teenager and young adult - in particular I have a number of brown spots. What treatment would you recommend to remove these spots?

vi) Just in the last year, the skin on my left cheek has become rough with a bit of reddish small blotches. I also have a lot more age or sun spots in the area. Any idea what this may be?

A: There are many different causes of hyperpigmentation or darkening of the skin.

Generally speaking, you should consult your doctor about any changes in the colour of your skin; your doctor may refer you to a dermatologist. Proper diagnosis should be made prior to treatment as treatment varies depending on the diagnosis.

The most common causes of darkened skin on the face are melasma, postinflammatory hyperpigmentation and solar lentigines. Many people don't realize that changes in skin colour may be caused by the exposure of the sun to perfumes. Perfumes may be applied to the shoulders or scalp to avoid this problem. Sun avoidance and the use of sunscreen/sunblock may prevent further darkening of skin.

Melasma is a condition in which brown to grayish brown patches appear on the face especially on cheeks, upper lip, nose, forehead or chin. The patches are usually symmetrical with an irregular (moth-eaten) border. It most commonly occurs during pregnancy or when taking birth control pills or hormone replacement. The condition mostly affects women especially those with light brown skin of Latin American and Far East Asian descent. Exposure to sun makes melasma worse. Therefore sun avoidance and the use of sunblock is recommended.

Postinflammatory hyperpigmentation is the excess of pigment in the skin following inflammation or injury. It is more obvious in persons with brown or black skin. It will fade over time. Complete fading may not occur for months to years, especially for dark skinned persons. Most cases improve with time; however, some topical medications may be prescribed.

Solar lentigines usually appear as brown 2-4 mm patches of the skin on areas that are exposed to the sun or artificial ultraviolet light. They gradually increase in size and number and may combine to form larger patches. Solar lentigines are seen in 90% of Caucasians over the age of 60. They are more common in persons who burn easily and tan poorly. Treatment is for cosmetic purposes and includes various modalities such as cryotherapy, laser, topical tretinoin and bleaching agents. Sun exposure should be limited and sunblock used for prevention of new lesions.

Sun Protection

Here are some tips to follow to reduce your sun exposure and prevent the damaging effects of the sun:
1. Minimize sun exposure from 10:00 am to 4:00 pm
2. Avoid sunlamps and tanning beds
3. Use a broad spectrum sunscreen/sunblock with SPF 30 or higher and reapply every 2 hours
4. Wear protective, tightly woven clothing, a broad brimmed hat and sunglasses.



Q: i) What is the best skin care for back acne? I have really bad acne on my back and some on my chest. I tried numerous prescription drugs but they don't work. I don't have acne on my face, but I wonder why I have it on my back. How can I get rid of them?

ii) My daughter who is 17 suffers from severe acne, was taking Diane 35 which helped tremendously but her doctor took her off it because of the risk. She has tried different soaps, lotions, antibiotics and nothing seems to work. She is very self conscious about it so she uses lots of cover-up. Is there anything else she can try?

iii) I have suffered from moderate acne since puberty (I am 28 now). No matter what I do or don't do as far as cleansers and diet, nothing helps out. I've been on Tricyclen and Diane 35 and they didn't help. It doesn't change with my cycles or with pregnancy. I am trying to get pregnant, so I can't use any of the strong meds. What else can I do to clear this up for good?

iv) I have been experiencing adult acne, and found Diane 35 very effective in treating it. However, I'd rather not be on birth control for long periods - are there any natural alternatives?

A: Acne is a common inflammatory condition of the hair follicle and its sebaceous gland. It can affect the face, chest and/or back and vary in severity. It is composed of non-inflamed lesions (blackheads and whiteheads), inflamed lesions (papules, pustules, nodules and cysts) and the consequences of acne (darkened skin and scarring). Treatment depends on the severity which is determined by the physical appearance, psychological effects, duration of disease, failure of previous treatment and scarring.

Topical treatments (creams and gels) are usually prescribed for mild acne. Some are more useful for blackheads while others are more effective for the inflamed lesions.

Moderate acne is commonly treated with oral antibiotics and often combined with topical therapies. Oral contraceptives may be combined with topical medications for females.

Severe acne may be treated with higher doses of antibiotics and Accutane® may be considered.

Topical therapies may be required for many years as acne may persist into a person's forties. Oral antibiotics and Accutane® are prescribed for courses of many months and repeat courses may be prescribed as required.

Commitment to treatment may be an issue as acne is a slow responding condition. There is usually little improvement in the first four weeks of treatment and often acne may flare when medication is started. A 40 percent improvement is expected at four months. An 80 percent improvement is expected at eight months. About 20 percent of people may not get the expected response.



Q: What can be done about rosacea? Are there ways to prevent a flare up? Why is it bad sometimes and not others? Should I always be using cream?

A: Rosacea is a common chronic facial skin disorder which usually gets worse over time and requires continuous treatment.

It often first appears as flushing with a burning sensation, a ruddy complexion or an extreme sensitivity to makeup. The basis of rosacea is believed to be vascular instability. Eventually it may involve the cheeks, nose, chin and forehead with persistent redness, swelling, pimples and pustules. It may be mistaken for acne but does not involve blackheads.

The eyes may be affected in about 50 percent of people and should be treated to avoid more serious complications. There may be periods in which the skin improves and periods when it worsens. When the skin does not return to its normal colour or other symptoms such as pimples and enlarged blood vessels are evident, a dermatologist should be consulted. Rosacea affects about 10 percent of the Canadian population. It is more common in women especially fair skinned persons of British, Irish and Northern and Eastern European decent.

Treatments for rosacea are prescribed by the doctor based on his/her assessment of your skin, the symptoms present and your feelings about treatment. Topical creams and gels are often prescribed and usually take about two months to make a significant improvement.

Oral antibiotics tend to have a faster effect and may be used in addition to the topical medications. Rosacea may flare anytime within one week to six months if the medication is stopped. Therefore, the topical medication should be used even when the condition is under control.

Things to avoid if you have rosacea:
1. Hot drinks, spicy foods, caffeine, and alcohol
2. Rubbing, scrubbing and massaging
3. Overheating - exercise in a cool environment
4. Extreme hot and cold temperatures and wind
5. Irritating cosmetics and facial products
6. Sun exposure
7. Stress

Rosacea skin care: twice daily
1. Cleanse - use a gentle, soap-free, fragrance free cleanser. Rinse well and pat dry with a soft towel.
2. Medicate - Apply a thin layer of your topical medication on affected areas and allow to dry. Apply a sunscreen/sunblock of SPF 30 or higher.
3. Moisturize - Apply a long-lasting, water-based moisturizer. Don't use products with fragrances or lanolin.


Wrinkle Prevention and Aging Skin

Q: i) I am wondering what type of face skin care regime I should be following as a 21 year old with healthy skin. I currently use a sensitive skin foaming facial cleanser by Clean and Clear and a two-in-one moisturizer afterwards, but I am wondering if I should be spending the extra money on more expensive products in order to maintain my skin's vitality.

Are other products necessary (toner, under-eye cream, astringent, etc.) for a person of my age? I am wondering if I should be taking steps in prevent wrinkles now, both on my face and elsewhere. In the summertime, I use Neutrogena Healthy Defense with SPF 30 on my face, and sunscreen everywhere else. Any insight, product recommendations and advice would be appreciated. Thanks very much.

ii) What is the best method of preventing or slowing age-related loss of elasticity of the skin and slowing the onset of "sagging" skin related to aging? This question applies to the body and the face. Thank you.

A: Cumulative sun exposure is the largest contributing factor in aging skin and is responsible for the unwanted aesthetic effects such as wrinkles and loss of elasticity. Therefore, the best advice to prevent wrinkles is to use a sunscreen/sunblock everyday of the year. The sun's UVA rays (tanning rays) go through clouds and windows.

There are other reasons that the skin begins to sag with age such as the loss or redistribution of the fat under the skin and the supporting structures may lose their ability to resist the effects of gravity. Improvement in the appearance of aging skin can be achieved through a variety of modalities ranging from antiaging topical products to surgical procedures.


Sensitive Skin

Q: i) I am 21 years old. My skin is very sensitive to cosmetics. If I do not use anything after a bath or washing my face, the skin is very dry and I get rashes. If I use Vaseline my face becomes too oily which does not look good and also I get pimples. I do not know what to use. Please advise.

ii) Please help...I am now 46 years of age. From the age of 12 I developed acne. It continued through my teen years, 20s and 30s. Now here I am 46 with a combinational skin. My cheeks are so dry and yet the T-zone of my face continues to be quite oily. I have tried various recommended skin care programs and nothing seems to work.

My skin is so sensitive and I can't seem to put anything on my skin without it burning or breaking out. On top of this I now have wrinkles. My ego, not to mention my self confidence, has dwindled away to nothing. Looking forward to your recommendations.

A: Steps to taking care of sensitive skin include:
1. Cleanse with a gentle, soap-free, fragrance free cleanser. Rinse well and pat dry with a soft towel.
2. Astringents or toners may be used but are not necessary. They were originally created to remove soap scum left behind after washing. If you want to use these products, choose one that is right for your skin type. Astringents for dry skin have moisturizers added while those made for oily skin may contain ingredients that will remove excess oil or deliver ingredients used for acne.
3. Apply a long-lasting, non-comedogenic, hypoallergenic, water-based moisturizer. Don't use Vaseline on your face as it will block the pores and cause pimples. Apply moisturizer twice a day. If you have pimples, don't use oily products.
4. Apply a sunscreen/sunblock of SPF 30 or higher.

If you continue to experience pimples, burning or sensitivity with a proper skin care routine, see your doctor as it's possible that you may need treatment for acne or rosacea.


Pimples on Buttocks

Q: i) I have pimples on my rear that I cannot seem to get rid of. I know they get worse when I exercise or when I sweat a lot. I have a desk job so I know sitting a whole day makes it worse, along with the fact that I wear pantyhose and a girdle most of the time. My doctor suggested fucidin which mildly helps. Is there anything better that I can be using?

ii) I break-out on my butt. They are just red bumps that hang around for quite awhile. There is no itch or whitehead. I've tried different soaps/body washes and switched to cotton underwear. Nothing seems to work. What could be the problem?

A: Folliculitis is a common disorder characterized by inflammation of the hair follicle. The lesions may be tender or itchy. It occurs on areas of the body that are occluded or have longer thicker hairs as with the buttocks, scalp, beard area, upper torso, arm pits, and groin. Your doctor may take a culture (swab) from the pimple itself or from your nose. Treatment will depend on the results of the culture. Topical or oral antibiotics may be required. Also, attempts to reduce occlusion such as wearing cotton underwear may help.


Foot Eczema

Q: I have been bothered with eczema on both feet for around 10 years. Sometimes it has been so bad that they crack and bleed. I have tried numerous different cortisone creams and so far without much luck. The only one that appears to help a bit is Dermovate but I do not like to use this on a regular basis, however, as soon as I stop it flares again. I have heard from some people they have had luck with going to tanning beds. Does this help for eczema? Would going regularly for pedicures help?

A: Foot eczema is a common condition. With proper treatment and compliance, the condition can be controlled in the majority of people. However, eczema on the feet can be troublesome. Eczematous skin does not have the same water retaining capacity as normal skin resulting in moisture loss producing dry itchy skin. It is very important to hydrate the affected area and continue to do so even when the eczema is under control.

This can be achieved by soaking your feet in a bath with an emulsifying oil daily for 5-15 minutes, do not use hot water. Pat skin dry and apply a moisturizer while skin is still damp within two minutes of removing feet from water (the two minute rule). Moisturize as often as needed throughout the day and Humidifying the air in your home during the winter may.

Potent topical corticosteroids that are applied to the skin (Dermovate® [clobetasol propionate]) may be used during a flare of eczema. As the skin improves you should decrease the use of the steroid by gradually weaning off of the medication. Weaning is important to prevent a rebound of the eczema. There is an alternative prescription nonsteroidal ointment available that your doctor may recommend.

Artificial ultraviolet light (phototherapy) may be used in conjunction with your topical medications. It is best to treat your feet at a phototherapy centre under the care of your dermatologist and a dermatology nurse rather than a tanning bed. Overheating and sunburn can result from tanning bed use and may aggravate your eczema. Tanning beds are not usually recommended by dermatologists or dermatology nurses as they may increase your risk of developing skin cancer.

Tips for persons with eczema:
2. Don't rub or scratch (don't have your feet rubbed or scrubbed during a pedicure)
3. Pat skin dry, don't rub
4. Be consistent and persistent with your treatment
5. Avoid irritants and allergens
6. Avoid overheating
7. Use clothing and shoes made with natural fibers
8. Avoid perfumed products
9. Avoid stress when possible or change the way you react to stress


In general, skin conditions must be examined by a family doctor or dermatologist. Many different skin conditions look and behave the same and may require a skin biopsy for diagnosis.


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