Dermatology Tips 2003:
- Seborrheic Dermatitis. A speeding up of the production of keratin causes excess scale production (dandruff), and there may also be redness and itching.
- Occurs only with functioning oil glands – after puberty, or in infancy (from maternal hormones).
- May be an immune response to a normal skin yeast-like organism (Malazzeia ovalis) but can occur in the absence of the organism.
- More common and more severe in the fair-skinned
- Often worse in the winter, better in the summer (ultraviolet light helps)
Aside from the scalp is very common in facial hair, brows, lashes, and behind and in the ears. Occasionally on the chest in men, especially if there is much chest hair.
For scalp dandruff most cases controlled by dandruff shampoos. All varieties of dandruff shampoos are about equally effective, but they must be used properly:
If severe, or for psoriasis (which is little benefited by shampoos), use topical corticosteroid overnight, under a shower cap, for several days, then as needed.
For white patients, order a thin liquid preparation (betamethasone lotion) which evaporates and leaves little residue on the hair. Black patients often prefer an ointment, since they often use oils or ointments for grooming.
Other options are tars or salicylic acid (scale-removing) products left on overnight, especially if scaling is severe, but corticosteroids better control redness and itching, and ultimately reduce scale formation.
"Beard bumps" or ingrowing of beard hairs, particularly on the sides of the neck. Is the result of shaving, and some of the hair tips retract slightly and then puncture the side of the hair follicle and grow into the skin. Is very uncomfortable, feels like splinters in the skin, and inflammation is made worse by the presence of normal bacteria on the skin and hair shafts.
Occurs on the sides of the neck because the hair grows out of the skin at a sharp angle, making it easy for the ingrowing to start. Rare on the chin, where hair grows straight out and not at an angle. Extremely common in Blacks because the tightly curly hair grows out at a sharp angle and wants to curl back into the skin. Does not occur if no shaving.
Best treatment is to grow a beard! Failing that, most Blacks "shave" with a clipper set at 1 mm, leaving the hair long enough to not grow back in. If clean shaving is required or desired, shave only with the grain and do not stretch the skin when shaving. Use of an electric razor with only a few light passes also leaves a little stubble. Another excellent technique is to "shave" with chemical depilatories. This gives a smooth shave but leaves blunt tips on the hairs, so they don’t puncture the follicular walls. Unfortunately, many men cannot tolerate the skin irritation, and it is time-consuming, messy and smelly.
Anti-acne oral antibiotics (tetracyclines) significantly reduce the inflammatory response and make the patient more comfortable, but do not prevent or correct the ingrowing of hairs.
In the US is a new product for facial hair in women, eflornithine cream (Vaniqa). It is applied BID and slowly causes the hairs to grow slower and become finer. Women then need to shave or use depilatories much less often than without treatment. Patient satisfaction is pretty high. A very recent report shows that this is also helpful in pseudofolliculitis barbae in men, reducing lesions and making them milder.
Oral finasteride 1 mg per day (Propecia) is fairly effective at stopping the progression of balding and causing modest thickening of thinned areas, and it has become fairly popular in the US. It is significantly more effective than topical minoxidil (Rogaine).
Just reported in a new side effect, not previously reported even with the 5 mg per day doses of the same drug for prostatic hypertrophy (Proscar). The side effect is depression, which occurred in 19 of 23 patients, after 9 to 25 weeks of therapy. In 14 of the 19 cases, the depression was fairly severe, and there were also significant cases of anxiety and anorexia. All symptoms resolved 2-3 weeks after stopping the medication, and in 2 willing volunteers the depression returned within a few days of resuming finasteride. Most of the patients were pleased with the effects on balding, so that was not the cause of their depression!
If you have patients on this drug, start inquiring about these symptoms. In men with depression, ask if they are taking the medication. Balding in women is not helped by finasteride.
New Treatment for VitiligoHandouts
All treatments for this disease are discouraging. Success rates are only about 30%, and that is mostly for vitiligo on the face or genital area. Spots on the extremities have a much lower response rate. It is an autoimmune disease and traditional treatments are the topical immunosuppressive strategies of topical steroids, or PUVA (oral psoralen followed by ultraviolet A light).
A new treatment with about the same success rate is topical tacrolimus (Protopic), a topical immunosuppressive developed for atopic dermatitis. It has the benefit over topical steroids that it can be used long-term on the face and fold areas without inducing atrophy or rosacea . The drawbacks are that it often causes significant burning for several minutes after application, and it costs about £55 per ounce in the US – several times the cost of generic corticosteroids.
Protopic is not the magic bullet for this frustrating disease but it gives us another safe option to offer desperate patients
John R. T. Reeves, MD