Category Archives: Dermatology

How to Manage Hair Loss in Females

 

In males, usually generalized hair loss is due to male pattern common baldness. In females, though, the hair loss could be due to many causes.

The main causes of male type baldness in females is due to excessive production of circulating androgens, resulting from diseases of various endocrine glands, like polycystic ovarian disease, adrenal hyperplasia, cushing’s syndrome and adrenal and ovarian tumors.

As we have already discussed, hair fall can also have many other causes, usually due to abnormalities in hair cycling. (hair has got growth, resting and falling cycles, any abnormality of these will cause hair to fall)

Normal causes for hair loss or alopecia in females are:

  1. Following delivery: hormonal changes.
  2. Stress
  3. Prolonged illness
  4. Nutritional deficiencies.
  5. Anemia: an important cause
  6. Local causes in the scalp: dandruff, too much chlorine in water and contact allergy.

Tests for Hair Loss in Women

  • Hormone levels (DHEA, testosterone, androstenedione, prolactin, follicular stimulating hormone, and leutinizing hormone)
  • Serum iron, serum ferritin, and total iron binding capacity (TIBC)
  • Thyroid levels (T3, T4, TSH)
  • VDRL (a screening test for syphilis)
  • Complete blood count (CBC)
  • Vitamin D3 levels
  • Scalp biopsy — A small section of scalp, usually 4 mm in diameter, is removed and examined under a microscope to help determine the cause of hair loss.
  • Hair pull – Your dermatologist lightly pulls a small amount of hair (about 50-60 strands) to determine if there is excessive loss. If more that 5-6 hairs come out, then the patient is likely suffering from excess hair loss. Normal range is one to three hairs per pull.
  • Densitometry — The densitometer is a handheld magnification device used to check for miniaturization of the hair shaft.
  • Trichoscopy

Here is what to do if you are a female suffering from hair loss:

  1. If you have any of the above triggers, try to correct them
  2. Check your Hemoglobin level. If it is lower than 11 gms/dl, you should take an iron-folic acid supplement.
  3. Do not use hot water to wash your hair. Do not put on tight clips.
  4. Take a balanced diet
  5. Practice relaxation techniques.

Specific treatments, along with the above:

  1. Topical hair tonics, with or without 2% minoxidil
  2. Multivitamin for hair
  3. Treatment for specific causes as determined through the lab investigations.

Also read:

Published by Dr Hanish Babu, MD on 9th June, 2018

Click here to book an appointment with Dermatologist Dr Hanish Babu, MD



Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

 

How to Treat Hair Loss?

Hair Loss Causes

Treatment of hair loss depends upon finding the cause and treating it. It is not as simple as it sounds, though!

Proper diagnosis, as was discussed earlier depends upon detailed history, clinical examination including hair pull test and trichoscopy and relevant lab investigations.

Once these are done, we are ready to deal with the enigma of hair loss or alopecia!

The first step would be to differentiate scarring from non-scarring alopecia.

How to Differentiate Scarring from Non-Scarring Hair Loss?

Close examination of the skin is enough to differentiate the scarring from non scarring alopecia. In scarring alopecia, there is absence of hair follicle opening and increased wrinkling of the involved skin. The skin surface is thin, shiny and dry. Underlying small blood vessels may be visible through the atrophic skin. Towards the periphery of the bald patch, hairs will be twisted because of the pull of the scar tissue.

Treatment of Common Baldness

Treatment of common baldness could be medical or surgical.

Medical Treatment of common  baldness: Topical Minoxidil is THE treatment for baldness. Most so called herbal and other miraculous cures are ineffective, or a concoction containing minoxidil itself.

Finasteride is an oral medication used for extensive male pattern baldness. It works by binding the enzyme which converts free testosterone to Dehydrotestosterone (DHT). This is a prescription medication and should only be used under the supervision of a dermatologist.

Salient features of Minoxidil therapy:

  • Life long treatment
  • Limited improvement
  • Arrest progress of hair loss
  • Expensive
  • Response is seen typically after 3-4 months
  • Hair fall restarts after stopping medication
  • Should be used carefully in those with fluctuant blood pressure and heart diseases
  • Irritation and allergic contact dermatitis may occur to the application.
  • Application 1 ml twice daily after wash with minimal rubbing

PRP Treatment and Mesotherapy for Common Baldness and Hair Loss 

Platelet Rich Plasma injections and Mesotherapy with hairtonics and vitamins are becoming increasingly popular in treatment of hairloss including common baldness.

Surgical Treatment of Common Baldness: 

Before contemplating surgery like hair transplantation, the subsequent risks and cost of such surgeries should be considered. In milder cases, a change of hair style or later, a wig would suffice. Flap and strip grafts, scalp reduction operations are also available as alternatives to hair transplantation . Hair weaving is a new technique that is gaining popularity.

When to Consult a Dermatologist

  1. Sudden , generalized hair fall should be reported at once
  2. If associated with other systemic symptoms like generalized weakness, palor, in females, menstrual iirregularities et

Generalized Hair Loss Treatment Tips

  1. Do not pour hot water on the scalp
  2. Do not use harsh shampoos
  3. Hair fall is common after delivery or after a prolonged illness, take nutritious food and use mild shampoos.
  4. Vitamin supplements are beneficial, especially biotin and zinc containing vitamins help hair growth.
  5. Check haemoglobin level for anaemia, and, if present, correct it.
  6. Rule out thyroid and other endocrinological causes.
  7. Learn to manage stress properly, here is an appropriate program which gives a practical program to manage your stress for life.

Localized Non Scarring Hair Loss:

Recurrent Patchy Hair Loss (Alopecia Areata) is the commonest type of localized hair loss : Learn more about alopecia areata.

Also Read:

 

Published by Dr Hanish Babu, MD on 9th June, 2018

Click here to book an appointment with Dermatologist Dr Hanish Babu, MD

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

How to Diagnose the Exact Cause of Alopecia or Hair Loss?

Diagnosis of Hair Loss includes extensive history taking and investigations
Diagnosis of Hair Loss includes extensive history taking and investigations.

Treatment of hair loss depends upon finding and treating the cause of alopecia. Hence diagnosing the cause of alopecia is the first step in the effective management of hair loss. This involves extensive history taking, thorough examination of the hear bearing areas and doing relevant lab tests. What makes the alopecia an enigma is that even after such thorough clinical approach, the cause of hair loss may still remain a mystery,

As we have already seen in the previous article on different types of hair loss, alopecia can either be scarring or non-scarring. Androgenic alopecia  or male pattern baldness, alopecia areata, and telogen effluvium are examples for  non-scarring alopecia.

Taking extensive history about the hair loss is of utmost importance in making a diagnosis as to the cause of the hair loss. Your dermatologist may ask the following questions:

  1. How long have you been experiencing hair loss?
  2. Is the hair loss gradual or sudden?
  3. Whether extensive or localized and patchy?
  4. Any associated symptoms like itching, scaling, burning sensations etc?
  5. Has the patient noticed hair thinning also, in addition to hair loss? Gradual hair thinning and hair loss may be due to male and female pattern baldness.
  6. Do you feel tired all the time(anemia)?
  7. Any history of hormonal imbalances (Thyroid disease or hyperandrogenism)
  8. Is hair pulling test positive? In hair shedding due to telogen effluvium and alopecia areata, hair pulling test will be positive.
  9. Any history of recent illnesses, trauma, stress, medications?
  10. While doing hair pulling test, is the hair coming out along with the root or is it breaking on traction?
    • Hair pull test (coming out as a whole with root) is positive in:
      • Telogen effluvium
      • Alopecia areata
      • Androgenic alopecia
      • Drug induced hair loss
    • When hair breaks on pulling, showing hair shaft weakness, the causes may be:
      • Tinea capitis (fungal infection)
      • Use of hair straighteners and other abrasive hair cosmetic treatments
      • Hair shaft abnormalities
      • Hair growth retardation
  11. In females, a detailed menstrual history is important to rule out hormonal causes
  12. Is there hair loss in other body parts as well??
  13. Is there a family history of hair loss? A genetic predisposition has to be ruled out.
  14. What are your food habits? Balanced nutrition is essential for normal hair growth.
  15. How often do you expose your skin to sun? Vitamin D deficiency is an important cause for chronic hair loss and hair thinning.

What is hair pulling test?

This is a simple and easy test to assess the status and degree of hair loss.

  • Hold around 50- 60 hairs firmly between the thumb, index, and middle fingers , near the base of hair shaft. Pull firmly along the direction of hair follicle.
  • If more than 10% (5-6) whole hairs (with roots) come out from the scalp, the hair pull test is considered as positive. Shampooing should be avoided at least 1 day before.

Trichoscopy for Hair Loss

      Trichoscopy (dermoscopy of hair) is very useful in outpatient diagnosis of hair loss causes. Being non-invasive it carries better patient acceptance as well.

Laboratory investigations in alopecia:

Essential tests in case of chronic hair loss:

  1. Serum ferritin
  2. Hemoglobin
  3. Vitamin D3, Serum Zinc and Calcium levels should be routinely tested
  4. Thyroid Function tests
  5. in women with androgenic alopecia, an endocrinologic profile including serum testosterone, androstenedione and dehydro-epiandrosterone (DHEA) are done to rule out hyperandrogenism.
  6. if discoid lupus erythematosus is suspected, antinuclear antibody tests are indicated.

Once the diagnosis is made, a comprehensive treatment plan can be charted out.

Read also:

Published by Dr Hanish Babu, MD on 9th June, 2018

Click here to book an appointment with Dermatologist Dr Hanish Babu, MD

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Hair Loss: Causes & Types

Hair Loss Causes
Hair Loss Causes are Many
Proper diagnosis is essential for effective Hair Loss Treatment

Hair loss is a universal occurrence and has a high cosmetic impact on the affected individuals. It is depressing for the sufferer and a headache for the physician, because, except in a few instances, finding the exact cause of the hair loss remains a mirage.

Shedding of hair is known as effluvium or defluvium and the resulting condition is known as alopecia (Greek alopekia for baldness) or hair loss.

Hair Loss Causes

Causes for hair loss  or alopecia may be classified into two major types: scarring and non-scarring alopecia.

In scarring or cicatricial alopecia, there is sign of tissue damage like inflammation, atrophy and scarring in the hair loss area. The hair loss is permanent.

Noncicatricial or nonscarring alopecia is the commonest type, shows a normal skin structure with loss of hair and usually is amenable to treatment. Nonscarring hair loss can either be diffuse or localized depending upon the extend of involvement.

Diffuse Non-scarring Hair Loss Causes

In diffuse non-scarring alopecia, hair loss is  disseminated throughout the scalp, and, at times, on the body as well. These are caused by

  1. Failure of hair follicle production due to hormonal and genetic reasons, as in male pattern baldness (the common baldness),
  2. Hair shaft abnormalities, as in chemical damage due to hair straighteners.
  3. Abnormalities in hair cycling, as seen in telogen effluvium, anagen effluvium, loose anagen syndrome or generalized alopecia areata. Abnormalities of hair cycling occur usually following a prolonged illness, pregnancy, stress and nutritional deficiencies including anemia and vitamin deficiencies.

Focal or Localized Non-scarring Hair Loss Causes

Focal, patchy or localized non-scarring alopecia may be caused by

  1. Hair follicle production decline as in focal male pattern hair loss.
  2. Hair breakage: Trichotillomania, traction alopecia, tinea capitis, hair straighteners etc.
  3. Abnormal hair cycling: Alopecia areata, secondary syphilis.

Scarring Alopecia Causes

Cicatricial or scarring alopecia may cause hair loss in many hereditary and acquired disorders of the hair and hair follicle.

  1. Hereditary diseases: Defective development of hair follicles and skin, as in aplasia cutis, darier’s disease.
  2. Traumatic: Chemical and mechanical, as in burns
  3. Neoplastic: Basal cell carcinoma
  4. Follicular inflammation: Discoid lupus erythematosus, tinea capitis
  5. Dermal Inflammation leading to secondary damage to hair follicle, as in morphea, skin tuberculosis, lichen planopilaris etc

From the above short review of causes of hair loss, it is evident that a correct diagnosis is essential for effective treatment of alopecia.

Read also:


Published by Dr Hanish Babu, MD on 5th June, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Acanthosis Nigricans: How to Manage

 

Treatment of acanthosis nigricans involves topical treatment and removal of the offending cause of the skin thickening and pigmentation.

Treatment of Acanthosis Nigricans: Treating the Cause
Treatment of Acanthosis nigricans involves treating the Cause

Tips on Dealing with Acanthosis Nigricans

There are certain do’s and don’ts in dealing with acanthosis nigricans. These are important in limiting the spread of the disease and finding the underlying causes.

Do’s in dealing with acanthosis nigricans:

  • The first course open to a patient is of course differentiating the benign and malignant varieties of acanthosis nigricans, preferably with the help of a dermatologist.
  • Diet control and regular exercise to reduce weight is essential in controlling acanthosis nigricans
  • Diabetes, if present, should be brought under strict control through dietary restriction, exercises and effective medications
  • In case of suspected malignant acanthosis nigricans, full panel of laboratory investigations should be carried out without much delay. Tumor markers, hormonal assays, endoscopy, Ultrasound and CT scans and whole body MRI are mandatory in such cases. The appearance of acanthosis nigricans can precede the full expression of cancer even by 5 years.
  • Consultations with a general physician and a gastro-enterologist once in six months is advisable in suspected acanthosis nigricans where no primary focus could be found in previous check ups. The frequency should be increased in cases where the skin changes are rapidly progressing.
  • Any sudden progression of the skin condition, appearance of skin tags or seborrheic keratosis (Leser Trelat sign) calls for urgent medical consultation.

 

Acanthosis nigricans treatments depends upon finding and treating the basic cause

Don’ts in Dealing with Acanthosis Nigricans

There are certain things to be avoided in the presence of acanthosis nigricans:

Most people think that the dirty appearance of the skin in acanthosis nigricans is due to dirt deposition on the skin. This results in constant vigorous scrubbing of the involved skin. This should be avoided at all cost.

So, Don’t

  • Scrub too much, as frequent rubbing will only increase skin thickening and pigmentation
  • Use strong abrasives: tend to irritate the skin more.

Treatment Guidelines for  Acanthosis Nigricans

  1. Correction of underlying cause
  • Removal of tumor
  • Correction of endocrine disorder: In case of Insulin Resistance, Metformin could be useful in treating Acanthosis Nigricans, alone or in combination with Rosiglitazone.
  • Reduction of weight: Low carb diets and exercise will help.
  • Removal of causative drug
  • Dietary supplimentation with fish oil containing omega 3 fatty acids have been reported to be beneficial
  • Cyproheptadine has been found useful in some cases

 2. Management of Skin Lesions:

  • Topical Retin A
  • Salicylic acid application alone or in combination with steroids, alternating with emollient applications to minimize irritation.
  • Calcipotriol
  • In severe unresponsive cases, systemic retinoids are useful.
  • TCA Peels, laser ablation all have been tried with varying results

Read also:


Published by Dr Hanish Babu, MD on 29th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

 

Acanthosis Nigricans: How to Differentiate Malignant from Benign

 

We have already seen the main causes and different types of Acanthosis Nigricans.

As acanthosis nigricans is, at times, a fore-runner of internal cancer, it is important to differentiate between the harmless benign acanthosis nigricans from the malignant variety of acanthosis nigricans, as early diagnosis of cancer could be life saving. It is reported that the appearance of acanthosis nigricans precedes the appearance of internal cancer even before a couple of years!

Malignant Acanthosis Nigricans has to be Differentiated from Benign

Even after treatment of the causative cancer, acanthosis nigricans plays an important role as a followup indicator as well. Usually when the cancer is surgically excised and treated with radiation or chemotherapy, acanthosis nigricans disappears. Any recurrence of acanthosis nigricans later may thus point to recurrence of the cancer.

Curth HO (Archives of Dermatology, Vol 102, 1970) reports a remarkable case of acanthosis nigricans persisting for years even after excising  a leiomyoma of stomach, squamous cell carcinoma of bladder and nephrectomy of one kidney for transitional cell carcinoma in a 84 year old man.Then one lesion of adenocarcinoma was found in his colon and removed. Surprise! His long standing acanthosis nigricans disappeared within a few days without any treatment!

Moral: To achieve cure you must excise the responsible hormone secreting tumor, not just any tumor!

How to Differentiate Benign from Malignant Acanthosis Nigricans?

If any of the following features are present in a patient with acanthosis nigricans, presence of internal cancer may be suspected:

  1. Age of onset: Benign acanthosis nigricans appear soon after birth, childhood or in puberty. Early age of onset should arouse suspicion.
  2. Speed of Progression: If the typical features of acanthosis nigricans appear and progress rapidly, it is indicative of a malignant origin.
  3. Severity of Skin Changes: In malignant acanthosis nigricans, the skin changes are more pronounced compared to the benign types of acanthosis nigricans. The dark color (pigmentation) is present beyond the area of thickening in the malignant acanthosis nigricans.
  4. Distribution of Skin Lesions: In malignant acanthosis nigricans, there is extensive involvement of the skin, almost all folds and palms and soles and face are involved.
  5. Mucous membrane involvement: In contrast to the benign acanthosis nigricans, mucous membrane involvement is prominent in about 50% of malignant type of acanthosis nigricans.
  6. Skin Tags: Sudden appearance of skin tags in a case of acanthosis nigricans is indicative of serious underlying illness.
  7. Symptoms: Most benign acanthosis nigricans are asymptomatic. Usually there is irritation and itching in the skin lesions of malignant acanthosis. 

Also Read:


Published by Dr Hanish Babu, MD on 29th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Acanthosis Nigricans, a Marker of Cancer: Types, Causes and Diagnosis

 

Acanthosis Nigricans
Acanthosis Nigricans can be a marker of Internal Cancer

Acanthosis nigricans is a dark and velvety thickening of the skin in the armpits, neck and other body folds. It is considered as a marker for certain internal malignancies and endocrinal disturbances.

Acanthosis nigricans may occur due to a hereditary predisposition or associated with many diseases and medications.  People with acanthosis nigricans are known for their resistance to insulin in diabetics. The importance of acanthosis nigricans lies in the fact that at times it could be associated with certain cancers. Infact, sudden appearance of  acanthosis nigricans at any age calls for a thorough investigation of body systems to rule out any underlying cancers.

What is the Cause for Acanthosis Nigricans?

As mentioned above, there are many causes for acanthosis nigricans. According to the underlying cause, acanthosis nigricans is divided into 5 different types.

  1. Hereditary Benign Acanthosis Nigricans. This type runs in families and there is usually no associated endocrine disorders. This type of acanthosis nigricans appears in childhood and increases at puberty though many regress with age.
  2. Benign Syndromic Acanthosis Nigricans. This is associated with certain endocrine diseases. Insulin resistance is an underlying pathology in benign acanthosis nigricans. Most patients will have any of the following hormonal problems: diabetes, increased androgen secreting tumors, acromegaly or gigantism, Cushing’s syndrome, Addison’s disease , hypothyroidism etc. Course depends upon the management of underlying disturbance.
  3. Pseudo Acanthosis Nigricans  associated with Obesity. Starts at puberty. Common among dark skinned. Obesity—insulin resistance. Regression seen with significant weight loss.
  4. Drug induced Acanthosis Nigricans. High dose nicotinic acid, stilbesterol in young males, systemic steroid therapy, certain OCPs, growth hormone therapy, insulin, pituitary extract, protease inhibitors are some of the medications that can cause acanthosis nigricans
  5. Malignant Acanthosis Nigricans. Associated with adenocarcinoma of GIT and GUT tracts, less commonly with lymphomas. Even as early as 5 years of onset of other signs and symptoms of certain malignancies. Usually regress after successful treatment.

The typical skin features of thickening and dark pigmentations in acanthosis nigricans are caused by  certain chemicals secreted by the tumors or the effect of hormones, including insulin on the skin fibroblasts and melanocytes.

How Can Acanthosis Nigricans be Diagnosed?

Acanthosis nigricans has to be differentiated from diseases like Confluent and Reticulated papillomatosis, pigmented pityriasis versicolor, X-linked Icthyosis, retention hyperkeratosis and excessive nicotinic acid ingestion. Diagnosis of acanthosis nigricans is mainly from the history and clinical presentations. A complete workout including a hormonal profile, blood sugar,  biopsy of the skin and histopathological study, and, in case of suspected malignant acanthosis nigricans, a full body imaging and endoscopy is called for.

Clinical Features

Irrespective of the cause, all varieties of acanthosis nigricans show a  dark pigmentation and thickening of the skin, usually in a symmetrical manner, on the neck, axillae, groins, elbows, behind the knees, around umbilicus and in the perianal region. Skin looks dirty and the surface is wavy and rugose with a velvety appearance. Skin lines show up prominently. In acanthosis associated with obesity, the dark, thickened and velvety patches are more pronounced on the apposed surfaces of the folds, especially the thighs. Skin tags appear in large numbers in these patients.

In the severe malignant variety, all features of acanthosis nigricans are accentuated: the skin is  more thickened, dark and velvety and there is often involvement of the palms, soles, oral cavity and the edges of the lips.

Also Read:

Book an Appointment with Dermatologist Dr Hanish Babu, MD


Published by Dr Hanish Babu, MD on 29th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

The Best Treatment for Very Severe Nodulocystic Acne

 

Very Severe Nodulocystic Acne
Very Severe Nodulocystic Acne should be treated on an emergency footing

How to Manage Very Severe Acne

The best treatment options for very severe nodulocystic type of acne include systemic medications, surgical interventions and combined topical therapies.

Very severe acne comprises of numerous pustules, deep fluctuant nodules and cysts on the face, chest, back, and at times, on the buttocks, groin and armpits. The main concern of treating this grade 4 nodulocystic acne is prevention of scarring, which is present in more than 90% of affected individuals.

The Best Treatment for Very Severe Nodulocystic Acne

 The best medication available for very severe nodulocystic acne is oral isotretinoin. The dosage is 0.5 to 1 mg per kg body weight per day as a single dose.

As isotretinoin is teratogenic (causes birth deformities), women of child bearing age group should avoid this medication unless absolutely necessary. Pregnancy should be avoided during and two months after treatment with isotretinoin. All patients should be aware of side effects of isotretinoin and how to avoid them.

For those who would like to avoid isotretinoin, the following are the alternative choices to treat their very severe pimples:

  1. Initiate therapy with Minocycline 100 mg twice a day with topical application of either Benzoyl peroxide 5% or topical tretinoin 0.05% at night.
  2. Deep seated nodules and cysts should be drained to enhance the therapeutic effects of the antibiotics and aid the healing.
  3. Intralesional triamcinolone injection at a strength of 5mg/ml into the nodules hastens the healing process.
  4. In explosive cases of nodulocystic acne (known as pyoderma faciale), which is more common in females, a combination of oral steroids and isotretinoin works wonders in clearing the eruptive bumps at a faster rate.
  5. After 4-6 weeks, the response to treatment is reassessed. If the nodules and cysts have healed, minocycline is continued at a dose of 100 mg per day for another 4-6 weeks.
  6. If there is no recurrence and the acne bumps have healed well, minocycline may be replaced with doxycycline 100 mg daily for another one month and then tapered over a period of 2-4 months.
  7. While the oral medications are tapered, add topical clindamycin as morning applications with topical tretinoin replacing benzoyl peroxide as a maintenance therapy.
  8. If any recurrence is there, a short course of oral minocycline is repeated.
  9. If, after 4-6 weeks of minocycline, the response to treatment is not satisfactory, then the option of oral isotretinoin is explored for the patient.
Acne Conglobata
Very Severe Acne: Acne Conglobata

Females with explosive nodulocystic acne, with or without associated increased hair growth (hirsutism), should be investigated for diseases like polycystic ovarian disease.

Patients who have been treated satisfactorily should modify their life style and follow the specific tips to prevent recurrence of acne in the future.


Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

 

Very Severe Nodulocystic Acne: FAQ

 

Frequently Asked Questions about Very Severe Acne

Sudden, very severe eruptions of nodules and cysts on the face, chest and back have to be dealt with on an emergency basis as these are potentially deep scar forming conditions.

Very Severe Nodulocystic Acne FAQ
Very Severe Nodulocystic Acne

What is Nodulocystic Acne?

Nodulocystic acne is the very severe grade 4 acne consisting of deep seated fluctuant nodules and cysts and numerous pus filled bumps. Most of the face, front of chest and back is commonly involved in nodulocystic acne.

How is Nodulocystic Acne Formed?

The basic pathogenesis of nodulocystic acne is similar to formation of other types of acne. Increased sebum secretion and inflammation caused by the bacteria P.acnes causes stretching and weakening of the wall of the sebaceous gland and hair follicle. This leads to rupture of the contents in to the dermis. A severe foreign body reaction takes place and the whole inflammatory debris and cells are segregated into fluctuant nodules and cysts deep within the dermis. Thus is formed the nodulocystic acne.

What is the Best Treatment for the Very Severe Nodulocystic Acne?

The best treatment for the very severe type of nodulocystic acne includes drainage of the pus, intralesional steroids, and oral isotretinoin. Isotretinoin gives very good results in this type of very severe acne, but its toxicity reduces its appeal to many patients. It is absolutely contraindicated in pregnancy. The second line of treatment involves use of minocycline in place of isotretinoin.

Other principles of treatment of acne also have to be observed in the case of nodulocystic acne. Avoiding acne triggers is also an important part of the management of nodulocystic acne.

What are the Complications of Very Severe Pimples?

Acne Conglobata
Very Severe Acne: Acne Conglobata result in deep scars

The nodules and cysts in the very severe type of pimples are situated deep within the dermis and when they heal, leave depressed, deep scars. Chances of hypertrophic scars are also high and in those with keloidal tendency, these will form disfiguring keloidal scars. Immediate institution of isotretinoin and other measures help reduce the severity of scarring in nodulocystic acne.

 

What are the Side Effects of Isotretinoin?

The main side effect of isotretinoin is the teratogenic effect on the fetus. Because of the risk of deformities, women should take care that they do not become pregnant during and two months after the course of isotretinoin. Most other side effects of isotretinoin in acne are related to the extreme dryness caused by the medication.

What are the Other Different Types of Very Severe Acne?

In addition to the nodulocystic acne, acne conglobata, pyoderma faciale and acne fulminans are the most severe types of pimples that are seen in patients.

What is Acne Conglobata?

Acne conglobata runs a chronic course with involved areas of the face and trunk filled with communicating cysts, abscesses and draining sinuses. The healing is with hypertrophic and atrophic scars. Recurrent episodes of joint inflammation may also be present in some patients. Treatment is similar to nodulocystic acne.

What is Pyoderma Faciale?

Pyoderma faciale commonly affects females and presents with an explosive eruption of large, tender, red cysts, mainly in the central part of the face. Spontaneous purulent discharge is present from the cysts. Comedones are conspicuous by their absence in this type of acne. Treatment is with drainage, oral isotretinoin and systemic steroids. In fact this is one of the rarer forms of acne where a short course of systemic steroids can bring fast relief to the patient.

What is Acne Fulminans?

Acne fulminans is a rare, ulcerative type of acne that mainly affects young adolescent males. There is an abrupt eruption of inflamed, necrotic acne leaving superficial and deep ulcers on the skin surface. Associated systemic symptoms of fever, weight loss, muscle and joint pains give the patient a toxic and weak appearance. Treatment is similar to pyoderma faciale.

Nodulocystic acne and other types of very severe types of acne are dermatological emergencies which need to be treated aggressively in early stages to avoid permanent deep scars.

Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

How to Treat Severe Acne

The Best Treatment for Severe Acne: Treat Early to Prevent Acne Scars

The best treatment for severe acne is a combination of oral retinoids or antibiotics and topical anti-acne medications.

Severe acne, with high number of inflammatory pustules and nodules, should be treated promptly to prevent deep ice pick and hypertrophic acne scars.

Severe Acne
Severe Acne: Early Treatment Prevent Scar

In severe acne, there are pus filled lesions, formed fresh or from already existing papules, and a few nodules. Numerous red, painful, pus filled bumps and humps are seen on the face, chest and back.

 How is Severe Acne Treated?

 As with other types of acne, there are specific and general measures to deal with the severe type of acne. In general, the specific treatment of inflammatory acne consists of oral retinoids, oral antibiotics, topical antibiotics, benzoyl peroxide and topical retinoids.

What is the Best Treatment for Severe Acne?

 Oral isotretinoin is the single best treatment for acne. But it is a medication to be used with care and only under the supervision of a dermatologist. It is absolutely contraindicated in pregnancy .

Following is the treatment protocol for severe acne followed by most dermatologists:

  1. Treatment is started with oral isotretinoin at a dose of 1-2 mg per kg body weight per day in males and non pregnant females who are on double contraception during and two months after the medication.
  2. From family history, depth and severity of the inflamed acne bumps, if there is less chance for scar formation, and in those where oral retinoids are not advisable the treatment is initiated with oral antibiotics (minocycline, tetracycline or doxycycline), with a gradual tapering of dosage over a period of 6-8 weeks. In pregnancy, only if severe pustular or nodular bumps are there is systemic treatment advised. The drug of choice for inflammatory acne in pregnancy is erythromycin. All medications are best avoided in the first trimester of pregnancy.
  3. Topical therapy of severe acne is same as in the moderate type of acne. Morning topical clindamycin/erythromycin and evening benzoyl peroxide 5% gel is the preferred combination used in severe acne.
  4. Once the pustules regress, topical benzoyl peroxide is replaced with topical isotretinoin.
  5. Benzoyl peroxide and Topical Tretinoin cause irritation in some patients because of their peeling effect on the epidermis. The following steps will help reduce the irritation in sensitive individuals:
    • Tretinoin and benzoyl peroxide should be applied at night only.
    • A non-comedogenic water based sun screen is used during daytime to avoid sun-sensitization.
    • If redness and scaling occur and skin becomes dried up, wash off the benzoyl peroxide or tretinoin cream/gel after 2 hours in the first week of application. Once the skin starts tolerating the medication, overnight application can be restarted.
    • In these patients, lower strengths of benzoyl peroxide and tretinoin is used in the first two weeks, later shifting to higher strengths, if necessary.
    • At times, after 2-3 weeks of treatment, topical retinoids can cause a flare up. This indicates an inflammatory blowup of the acne bumps and is a good sign. There is no need to discontinue the application.
    • A post inflammatory reddish brown pigmentation is seen after treatment with benzoyl peroxide. This will gradually disappear on continued treatment. A sun protection cream should be used during daytime till the pigmentation subsides.

What are the General Measures in the Treatment of Severe Acne?

 General measures include advices on skin care, washing, diet and life style management. These and the tips on preventing new acne eruptions are the same for all types of acne.

 What are the Complications of Untreated Severe Acne?

Untreated severe acne causes deep ice pick scars and hypertrophic scars in most patients. Post inflammatory pigmentation is common, especially in the dark skinned individuals.

The best treatment for severe acne is a combination of oral retinoids or antibiotics and topical anti-acne medications. The treatment is individualized according to the extent, type of acne and sex and age of the patient.



Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD