Melasma is an acquired skin problem of hyperpigmentation, frequently faced by women in their reproductive years. The condition is characterized by hyperpigmentation primarily on the face, so we may observe irregular brown or blue-grey macules on the face. Common areas where the brown patches appear are cheeks, nose, forehead, jaw and the chin.
How prevalent is the disorder?
While melasma occurs in all ethnic and population groups, studies have shown that there is a higher prevalence among more pigmented phenotypes. These include Asians, Indian, Pakistani and Middle Eastern. In the Americas, those who suffer from melasma mostly live in intertropical areas where exposure to UV rays are greater.
What are the different types of hyperpigmentation?
You may be doing your research diligently to find out more about melasma, but there are different types of pigmentation, and they are not all the same. Apart from melasma, your face could be suffering from freckles, sun spots or age spots. Freckles, or ephelides, are small, flat and brown marks that are prevalent in childhood. Sunspots, or solar lentigo, only surfaces in our late twenties and can increase in size and number with increasing sun exposure. Age spots, or seborrheic keratosis, is actually not a form of pigmentation, but a non-cancerous skin growth that kicks in with age.
Melasma, on the other hand, can be identified with a greyish-brown discolouration, at times in the shape of a butterfly.
What causes melasma?
While the cause of the disorder remains unknown, current research point towards sex hormones and sun exposure as the greatest culprits.
These brown patches appear on our face as when there is an excessive production of a pigment called melanin. UV radiation induces the increase in melanin production to protect the skin from sun damage. This causes the development of pigmentation to take place on the skin. A leading cause of melasma is excessive sunlight exposure.
Hormones can also be another cause of melasma. You may develop this condition at the start of your pregnancy or if you are on birth control pills. Pregnant women experience higher levels of increased progesterone, estrogen and melanocyte-stimulating hormones. Melanocytes are cells that produce melanin in your skin.
Other causes can be due to certain medications, scented or deodorant soaps, or your toiletries. These products may contain an ingredient that causes a phototoxic reaction that can trigger melasma.
What are the types of melasma?
There are three types of melasma: epidermal, dermal and mixed.
The epidermal layer affects the outermost surface of the skin, and the easiest type to treat. It can be identified by the presence of excessive levels of melanin in that layer. Patches will be a darker brown colour, with a defined outline.
The dermal layer will affect a deeper layer of the skin beneath the superficial layer, and we can recognise it by the occurrence of melanophages throughout the dermis. Melanophages are cells that ingest melanin. The dermal layer can be more deep-rooted, and may not respond well to treatment. For this layer, patches have a less defined outline, with light brown or bluish colour.
A mixed condition of melasma would be having both the epidermal and dermal types, and improvements on the condition can be expected with treatment.
How to treat melasma?
The response of melasma to treatment can be slower if the condition has been present for a longer time.
Excessive sun exposure leads to the deposition of melanin cells within the dermis and can persist long term. Coming into contact with UV radiation will deepen the pigmentation as it will activate the production of more melanin, causing your brown patches to turn darker and harder to remove.
Generally, by including sun protection into your skin routine, hyperpigmentation can be resisted. With Singapore’s tropical weather, it is recommended to reapply sun protection every 2 hours with a broad-spectrum sunscreen having at least SPF 30. Consider bringing along sunglasses or a hat when you are outdoors.
For clinical treatments, consultation with a trained dermatologist is recommended. A proper diagnosis of melasma should be conducted, and screened if there are any underlying conditions that may require treatment.
Prescriptions may be given to inhibit the formation of melanin. Hydroquinone is a controlled ingredient that is frequently included in medications to treat melasma, as it allows lightening of the skin. A precise concentration of hydroquinone should be administered for treatment, and may be professionally managed so by your dermatologist.
Procedural treatments for melasma can also be considered, such as chemical peels and lasers. Expected efficacy of each treatment can vary depending on the severity of melasma, with topical combination therapies being one of the most effective treatments for hyperpigmentation.
Speak to your dermatologist for a tailored recovery experience.
The word anti-aging alone turns many heads. Living in a beauty-centric society, we are pressurised to maintain our youth. Although it’s a natural process to age, once we hit the big 3-0, we are told to maintain our youth with an onslaught of anti-aging products that promotes and stimulates collagen production. You can’t really blame yourself for getting sucked into this black hole and there’s nothing really wrong about wanting to look young.
Are you looking for the fountain of youth? Look no further. Fillers are actually becoming a popular option for those wanting a youthful look. In comparison to anti-aging skincare, injectables such as fillers offer an almost instant youthful look and are fairly safe and natural looking when done right at the right place.
Although our skin is remarkable in protecting our bodies from the outside world and repairing itself every day, with age, lifestyle and environmental factors such as sun damage, smoking and poor diet, the condition of our skin deteriorates. This is inevitable. When it comes to giving your skin a refreshing and youthful appearance by giving it definition, firmness and a deep hydration, fillers are an effective method. Done by injecting a gel-like substance into lines and wrinkles, these injectables either fill or add volume to the sunken areas.
Hyaluronic acid is a common component that is used in fillers. Before you shrug at the term acids, know that hyaluronic acid is a component naturally found in the human body. Its sole function is to provide hydration and structure. Since skin hydration and structure depletes as we age, it is quickly removed from the body. By injecting these fillers, we are essentially introducing hydration and structure in the skin. Lasting up to six to twelve months, these temporary fillers plumps up the eyebrow and temporal region, defines and contours the cupid’s bow, cheeks and jawline, smoothens out the under-eye hollows, facial creases and can even minimise the appearance of scars and other depressed creases.
Restylane is one of the many available injectables out there. Using a patented Non-Animal Stabilised Hyaluronic Acid (NASHA) technology, Restylane injectables are generally firmer for a more pronounced lifting capacity and targeted product integration. This delivers a longer lasting skin hydration. Its Optimal Balance Technology (OBT), ensures that the injectable is more evenly diffused in the injected area, creating a softer and more natural look.
Next question in mind would be what to expect before, during and after a filer procedure. First things first, always consult an accredited dermatologist or surgeon when getting a filler or any cosmetic surgery. Avoid going to any aesthetic spas or worse neighbourhood malls to get your fillers done. Hygiene and sanitary is pertinent when it comes to any corrective treatments, to avoid infections and side effects. Make sure you understand the procedure and don’t be afraid to ask any questions. Always remember to inform the dermatologist or surgeon about your present medical condition and allergies. Avoid taking any medications such as panadol that may hasten bruising, or intoxicants such as alcohol, and stay hydrated. Always ask your dermatologist, or trained practitioner what type of filler you are getting injected with. Do some background research of it and make sure you are comfortable with being injected with that particular type of filler chosen for you. Instead of going for a cheaper alternative, choose the type of filler that is recommended by your dermatologist or surgeon, to avoid a botched procedure.
If you feel uncomfortable or uneasy during your filler procedure, voice out your concerns. As for post-procedure, expect minor bruisings. Hydration is key when it comes to healing. So drink up. Avoid using controlled substances such as cigarettes and alcohol immediately after the procedure. To avoid irritating the injected area, minimise makeup or external touch such as facials, pinching or scratching of the skin, high-intensity workouts and even sauna sessions. It is pertinent to abide by the post-procedure instructions given by your dermatologist or surgeon. Although minor bruisings can be expected, always report any signs of abnormality such as bumps, unevenness or unforeseen side effect to your dermatologist or surgeon immediately.
The word anti-aging alone turns many heads. Living in a beauty-centric society, we are pressurised to maintain our youth. Although ageing is considered a natural process, once we hit the big 3-0, we are told to maintain our youth with an onslaught of anti-aging products purportedly promoting rejuvenation and stimulating collagen production.Is the aesthetic and beauty industry just a vicious black hole sucking in the vulnerable and playing on our insecurities? Hey, if you are reading this, there’s nothing wrong about wanting to look good, or a youthful, energised version of yourself.
A myriad of cosmetic procedures are being offered by every aesthetic set up, beauty parlor and medi-spa. If you are looking to look your best this festive season and have decided to get some pampering, do read this article beforehand to educate yourself on what’s out there.
First things first, it’s important to understand, that according to the latest Singapore Medical Council guidelines has clarified its stand on who should and should not perform aesthetic procedures such as lasers, botox, fillers or other cosmetic procedures. Read all about it here. What does this mean? Well,
It’s best to visit an accredited dermatologist or a plastic surgeon who will ensure the safety and efficacy of the treatment, depending on what you are looking for. Non dermatologists who practise “aesthetic medicine” require additional certification of competency conducted by the Dermatological Society of Singapore. Not sure about the qualifications of your doctor? Check your doctor’s accreditation here.
Once you’ve decided on who to see, make a note of the research you’ve done and how you actually feel about yourself. Our take on this? Filler injections are one of the fastest, most dramatic yet natural-looking ( if well done) aesthetic procedures that can instantly rejuvenate a tired face. One of the reasons fillers have sometimes gained a bad- reputation amongst the beauty fans and watchers is that the early nineties were filled with images of Hollywood stars suffering less than ideal( sometimes botched) jobs with unnatural lumps of flesh on their faces or oddly elongated chins. Fast-forward to today, we asked Dr. Teo Wan Lin, a Consultant Dermatologist what her thoughts are on those in their thirties considering facial fillers. “ The benefits to having fillers in the younger age group, say those in their thirties to early forties, as compared to those in their midforties and beyond, is that hyaluronic acid -based facial fillers can provide natural-looking volume to restore areas of the face where fat has been lost or where gravity has taken its toll. Not a lot of product is required to be injected in these women to achieve the desired outcome, but at the same time thit;s a very quick pick-me up to a tired face, when injected at the correct areas, in addition to giving a smooth, radiant look to one’s complexion almost instantly, because hyaluronic acid itself is a water molecule that naturally exists in one’s skin and is depleted as one ages. The pores also end up looking more refined and one also has a smooth youthful contour of the face”.
So it seems indeed, that facial fillers rightfully remain a popular option for those wanting to achieve a youthful look. “Relying on a rigid regimen of filler injections alone is bound to disappoint,” says Dr. Teo, “as the skin itself, like the face structure, is dynamic, different for each individual and requires expert assesment to tailor treatments, all this in order to achieve the desired outcome. For an individual who needs a quick freshening up before the festive period, I start with facial fillers and combine with High Intensity Focussed Ultrasound to target the SMAS layer( Superficial Musculoaponeurotic System), together with cosmeceutical skincare for maintenance of clear radiant and hydrated skin.”
While we don’t need any further reminders that with each passing day, genetics, lifestyle and environmental factors i.e. sun damage, smoking, poor diet, the condition of our skin deteriorates. Before you despair at mankind’s seemingly inevitable fate, here’s some good news. Milennial skincare has extended its technological advances to the field of aesthetic dermatology, and take it from the dermatologists–when it comes to giving your skin a refreshing and youthful appearance, fillers work by giving your ageing face definition, firmness and deep hydration, talk about multi-tasking. No amount of skincare can do that overnight. What to expect?A gel like substance containing a natural water molecule in your skin, known as hyaluronic acid, is injected into parts of your face that has lost volume or sagging, erasing lines and wrinkles at the same time. Talk about getting rid of the tired and pissed look off your face, erase the years away!
Hyaluronic acid is a common component that is used in fillers. With many people reacting to “acid”, probably the last time they have heard of that term was in their chemistry class, where the corrosive substance was definitely not something one would put on their face. Here’s where it’s a fallacy. Hyaluronic acid is a component naturally found in the human body and it is no mean chemical acid! It’s actually really good for your skin, with almost every beauty product these days touting it as its superstar ingredient. According to dermatologist Dr. Teo Wan Lin, “Most commercial brands of hyaluronic acid products contain a concentration ranging between 0.01- 0.1%, simply because of the cost of the molecule. Injecting hyaluronic acid is a totally different story, purity and concentration is important, as it serves to hold up the structure of the face.” Seems like when the creator made hyaluronic acid for the human skin, He also found its sole function to provide hydration and structure, both of which get depleted as we age. So here’s the science of filler injections: one is essentially introducing hydration and structure in the the skin. The next time you see a young girl, notice the fullness of her facial contours. That, is the key to a youthful face. Besides, many who are risk-adverse and into an au-naturale look (who isn’t?) will be pleased to know that hyaluronic acid facial fillers are considered temporary. Lasting up to six to twelve months, these fillers have the ability to plump up the eyebrow and temporal region, define and contours the cupid’s bow, cheeks and jawline, smoothen out the under-eye hollows, facial creases and can even minimise the appearance of scars and other depressed creases.
Restylane is used exclusively at our clinic, for the following reasons. Using a patented Non-Animal Stabilised Hyaluronic Acid (NASHA) technology, Restylane injectables are generally firmer for a pronounced lifting capacity and for targeted product integration. What this means is, it’s now possible to deliver skin hydration that’s longer lasting, giving the dewy, glowy skin look. Its Optimal Balance Technology (OBT), ensures that the injectable is more evenly diffused in the injected area, creating a softer and more natural look.
Finally, know what to expect before, during and after a filler procedure. First things first, always consult an accredited practtioner, such as a dermatologist or plastic surgeon prior to getting a filler. This should be taken seriously, and performed in a accredited medical clinic rather than in a spa or a beauty parlor. He or she will run through which areas are suitable for filler treatment, and what to expect. Hygiene and sterility is pertinent when it comes to any cosmetic treatments, to avoid infections and side effects, and a licensed practitioner will take steps to make sure that all risks of infection are minimised. Next up, during your consultation, make sure that you understand the procedure and don’t be afraid to ask questions. Always remember to inform the dermatologist or surgeon about your present medical condition and allergies. Avoid taking any medications such as panadol that may hasten bruising, or intoxicants such as alcohol, and stay hydrated. Here are more tips: always ask your dermatologist, or trained practitioner what type of filler you are getting injected with. Do some background research and make sure you are comfortable with being injected with that particular type of filler chosen for you. The important thing to know here is, Instead of going for the cheapest deal available, choose the type of filler that is recommended by your dermatologist or plastic surgeon, to minimise risks of any botched procedures. Remember, there is a cost to quality fillers, in addition to the skill of the practitioner injecting it. So if the price or the deal seems too good to be true, it probably is!
Some final words. If you feel uncomfortable or uneasy during your filler procedure, voice out your concerns. Your doctor will reassure you or make adjustments to ensure that the procedure carries on to your comfort level. Post-procedure, minor bruising is expected. Tips for recovery would be staying well hydrated with fluids, avoiding smoking and alcohol as these delay wound healing. Recovery is typically quick and uneventful and one could return to work or activities the same day except for maybe high intensity workouts which are best avoided for a couple of days.
With the term “organic skincare” gaining popularity among the masses, I was recently asked, more than once by different people, what I felt were the benefits relating to organic skincare and why people should be using that. Perhaps my answers would surprise people but I feel that it is time the public gets a honest take on this topic by a dermatologist.
Let me first clarify my position, I am an accredited dermatologist and practice evidence-based medicine, whereby specialist recommendations are always made based on peer-reviewed journal publications or at least on an international consensus of the medical community. The terms “organic skincare”, “all-natural”, “chemical-free”, “pregnancy-safe” skincare are rampant in mass media these days, so I certainly don’t fault the lay person or even beauty writers who get the impression that this is the real thing.
In light of these, I seek to discuss “organic skincare” in this article. You will discover my choice of putting the term in parentheses and hopefully this will open your eyes to what the term really means, and does not, information only your dermatologist would tell you about . Without bias, I personally formulate a cosmeceutical skincare line myself as an adjunct to my cosmetic dermatology practice, with natural ingredients which are also evidence-based for anti-ageing and skin rejuvenation, but by the end of the article you will discover for yourself why I do not label any of the skincare as “organic”, and why “organic” is not exactly my key priority when it comes to skincare.
1.To a dermatologist, organic skincare does not exist
First and foremost, the term “organic skincare’’ itself is not regulated and from a dermatologist perspective, organic skincare does not exist as anything more than a marketing fad. Organic is a term relating to food or farming practices, and is applied correctly to vegetables or other crops which are grown without the use of chemical pesticides. If organic skincare manufacturers are keeping to the above definition at all, what this should mean is that were plant derived ingredients are used in skincare, these are grown in a chemical pesticide-free environment. What would be surprising to the lay person is that neither the FDA or HSA (in Singapore) makes any provision in their regulation of cosmetics for labelling “organic skincare”. As such, any skincare label touting this would be responsible for their own definitions of such and the consumer should be wary of such claims and what it implies.
2.There are no specific benefits to skin of using an organically-derived skincare brand
Contrary to popular belief, there are no specific dermatological advantages of using such a brand over any ordinary skincare. In fact, most of these eco-skincare brands often go untested and unquestioned as well. Often, these organic skincare brands boast plant or nature derived ingredients, without “preservatives” and parabens, also being touted as “home-made”. Despite the seemingly positive branding surrounding these skincare, the associated pitfalls are not different from any other cosmetic skincare — they all have the ability to cause irritation, or allergic reactions in individuals who are susceptible, such as those with sensitive skin i.e. atopic dermatitis.
3. An important factor to consider in anti aging skincare is the effectiveness measured by bioactivity of the active ingredients,as well as the scientific literature surrounding it
Plant-derived ingredients, depending on the source and type, may have anti-oxidant or moisturising properties, but simply including it in the skincare does not guarantee that it is effective. Bioactivity has to be measured by a trained chemist or scientist, which is when the extract is carefully distilled or harvested from the plant in such a way that the effectiveness is proven in the laboratory and can be measured.
4. The safety of organic skincare is not guaranteed, and could be even riskier than normal skincare with chemical preservatives
Brands touting “organic skincare”, especially when home-made, lack the stringent quality controls present in a laboratory setting, which is required for the formulation of dermatologist-grade cosmeceutical skincare. One real danger of certain types of “organic skincare”’ is that they are not regulated for safety, in terms of bacterial contamination. Preservatives such as parabens have gotten some bad press in recent years but the overall consensus in the dermatological community and by the FDA is that they are still regarded as safe and necessary to reduce bacterial growth in applied creams. The lack of “preservatives” is again a questionable label because this means that something else should be added to the product to increase the shelf-life of such a product which is meant for public sale. If not, this product should state the expiry of within 2 weeks to a month maximum of opening, because bacterial contamination will set in and this will cause problems when applied to skin.
Furthermore, the current Singapore Health Sciences Authority — HSA requirements for cosmetic skincare distributed via public sale, requires that the production facility acquires a basic certificate of Good Manufacturing Practices (GMP) before it is allowed approval. Home-made formulas that are sold online or by individual proprietors are hence on a “at your own risk basis”, and as a dermatologist, I do not recommend using any home-made or naturally derived products (from plants etc.) on a DIY basis because the irritation and allergy risk, i.e. phototoxic or photoallergic risks are high. Besides, the benefits of plant ingredients can only be harvested and extracted under a controlled laboratory setting with proper testing, as in the case with cosmeceutical skincare. Anything else, the public would be better off with a simple dermatologist-recommended pharmacy-brand moisturiser that is free from fragrances.
5. Problem-skin can’t be treated with ANY type of skincare but can be worsened with certain products
If you have problem skin, no amount of good skincare can treat medical skin conditions such as acne, eczema (dry sensitive skin) or rosacea (a condition that results in red flushed face with pimples). Such conditions require treatment with prescription medications and can be well controlled. These also do not disappear on their own so waiting to “outgrow” the condition, no matter what age you are at, is not a wise idea. Also, avoid consulting the internet, or beauty forums as suggestions there are not based on medical evidence and could even result in worsening of the condition or create a new problem, such as skin irritation or allergies from these DIY remedies.
I have encountered patients who developed phototoxic or photoallergic reactions from citrus (lemon/ orange juices) applied to their skin. A common misconception is that these DIY home remedies are ‘’natural and organic” but from a dermatologist perspective, this is not true. There are no skin benefits to applying lemon or orange juice such as vitamin C, which is only beneficial when one ingests it as a fruit or a juice. Topically applied vitamin C needs to be in a certain formulation, either ascorbic acid or Sodium Ascorbyl Phosphate — I incorporate a nano-formulated form of SAP in the cosmeceutical Vita C Gold which I prescribe in my practice for it to have brightening and anti-oxidant properties for skin.
Applying orange or lemon juice directly will simply result in skin irritation due to the acidic nature of these juices, worse still, some individuals may react to sunlight (UVA component) with the citrus component and develop a severe skin allergy that can result in scarring or pigmentation.
6. Facials, organic or not, makes no difference to your acne-prone skin
The above also applies to skincare services (e.g. facials) similarly labeled with the “organic” term, that organic skincare does not offer any true differentiation from any ordinary cosmetic skincare. Similar to any individually-applied skincare products, it is pertinent to know what is in the products applied during facials and skincare services. As your skin absorbs whatever you apply on them, it is important to always read through the labels and ingredient list, conduct prior research and then a patch test on the inner part of your arm. This helps to prevent any form of skin allergy and sensitivity you might get from trying such new products.
Besides, most aestheticians and facialists use instruments such as extractors and needles which are not medically sterilised (i.e. autoclaved, there is a difference between a new clean needle vs a sterilised instrument). This may lead to infections and scarring, besides having absolutely no benefit in the treatment of acne. Acne is primarily a inflammatory process, worsened by hormones, genetics and oil production. Treatment of acne by dermatologists involves addressing inflammation using oral or topical medications, as well controlling hormonal and oil production factors, via medications or certain cosmeceuticals. Comedonal extraction is only sometimes performed by dermatologists, as the preferred method of eliminating comedones is by the use of retinoids, which modulate the way skin turnovers, as well as with chemical peels whereby the top layer of skin dissolves with glycolic, lactic and salicylic acids, preventing the accumulation of keratin (read: dead skin cells) which can worsen comedonal acne.
7. Environmentally friendly? Perhaps. Skin-friendly, not necessarily
Most people think organic skincare are either eco-friendly, natural or vegan. Here’s the catch, they can and cannot be. Organic skincare products can have components which are organically farmed and also approved by the FDA (which simply means it does not contain toxic or banned ingredients), but having the HSA or FDA approval does not necessarily mean that these are effective or deliver significant benefits. Organically farmed produce can be friendlier on the environment in general, as less pesticide use means less harmful release of chemicals to the environment which accumulates as waste and potentially harms wildlife. However, these can also come at a greater cost, and by no means does that translate into any real benefits when incorporated into skincare which is not consumed but applied.
In fact, organic skincare often boasts essential oils which can cause both allergic( in susceptible individuals) and irritant contact dermatitis( due to the concentration of most essential oils, it is not medically advisable to apply any type of essential oil directly to skin as it can result in a chemical burning type of reaction).
For patients with otherwise healthy skin, whether they are in their twenties, thirties or beyond and who are interested in maintaining youthful skin in a cost-effective manner, I would suggest getting started on cosmeceuticals, and regular medical grade chemical peels supervised by a dermatologist, who would determine the concentration and type of acid suitable for your skin. A chemical peel treatment is designed to improve the appearance of the skin by gently stimulating the top layer of skin cells (epidermis) by applying a solution composed of fruit derived acids such as alpha-hydroxy acids, glycolic acids, lactic and salicylic acids. This stimulates the skin to regenerate, smoothening out wrinkles.
Rounding up the discussion here, I hope readers have gained some insight on the labelling of skincare as “organic” and what that doesn’t mean. It is not a defined or regulated term in dermatology and can lead to great misconceptions by the public, in addition to brands riding on a fad which delivers no real benefits skin-wise. As a dermatologist, I am all for public education for skin health. Skin health is not about “aesthetics”, the skin is an organ of the body just like the heart, lungs and the liver, and these tend to degenerate due to genetics, age as well as poor lifestyle habits. Healthy skin certainly looks good, but in the pursuit of beauty, one should always be wise, consult a dermatologist if you have a skin issue such as acne or skin sensitivity, rather than trying all sorts of products. While there is no miracle product that exists that can cure your skin woes, non-dermatologist-tested cosmetic skincare can worsen problem skin. If you have healthy skin and desire some radiance and want to preserve your youth, then go for cosmeceuticals, instead of ‘‘organic skincare” or any other type of skincare fad.
Mainly affects the sebaceous, gland-rich regions of the scalp, face, and trunk, seborrhoeic or seborrheic dermatitis is a common, chronic or relapsing form of eczema/dermatitis. There are infantile and adult forms of seborrhoeic dermatitis. It is sometimes associated with psoriasis (sebopsoriasis). Seborrhoeic dermatitis is also known as seborrhoeic eczema.
Dandruffalso known as pityriasis capitis is considered to be an uninflamed form of seborrhoeic dermatitis. Scattering within hair-bearing areas of the scalp, dandruff of such presents as itself as bran-like scaly patches.
Although the cause of seborrhoeic dermatitis is not completely understood, it is associated with proliferation of various species of the skin commensal Malassezia, in its yeast, non-pathogenic form. Its metabolites (such as the fatty acids oleic acid, malssezin, and indole-3-carbaldehyde) may cause an inflammatory reaction. Differences in skin barrier lipid fuction and content may account for individual presentations.
Adult seborrhoeic dermatitis tends to begin in late adolescence. It is less common in females than in males and most common amongst young adults and in the elderly.
The following factors are sometimes associated with severe adult seborrhoeic dermatitis:
– A family history of psoriasis or familial tendency to seborrhoeic dermatitis
– Oily skin (seborrhoea)
– Lack of sleep, and stressful events.
– Immunosuppression: organ transplant recipient, human immunodeficiency virus (HIV) infection and patients with lymphoma
– Neurological and psychiatric diseases: congenital disorders such as Down syndrome, depression, epilepsy, facial nerve palsy, tardive dyskinesia, parkinson disease, spinal cord injury
– Psoralen and ultraviolet A (PUVA) therapy used in treatments for psoriasis
Infantile seborrhoeic dermatitis is the type of seborrhoeic dermatitis that affects babies under the age of 3 months and usually resolves by 6–12 months of age. Its causes cradle cap, the diffuse greasy scaling on scalp. The rash may spread to affect armpit and groin folds resulting in a type of napkin dermatitis. They are characterised by their flaky or peeling salmon-pink patches. Since it is not itchy, babies often appear undisturbed by the rash, even when generalised.
As seborrhoeic dermatitis often affects the upper trunk, facial areas such as within eyebrows, around the nose and behind ears and scalp, typical features of this condition include:
– Winter flares, improving in summer following sun exposure
– Minimal itch most of the time
– Combination oily and dry mid-facial skin
– Ill-defined localised scaly patches or diffuse scale in the scalp
– Blepharitis: scaly red eyelid margins
– Ill-defined, thin, scaly and salmon-pink plaques in skin folds on both sides of the face
– Ring-shaped or petal-shaped flaky patches on anterior chest or hair-line
– Rash in armpits, under the breasts, in the groin folds and genital creases
– Superficial folliculitis (inflamed hair follicles) on cheeks and upper trunk
Pityriasiform seborrhoeide is a form of extensive seborrhoeic dermatitis that affects the scalp, neck and trunk
Seborrhoeic dermatitis is often diagnosed by its clinical appearance and behaviour. This is because Malassezia is a normal component of skin flora. Due to this, their presence on microscopy of skin scrapings is often not diagnostic.
Although skin biopsy may be helpful but is rarely indicative. Histological findings specific to seborrhoeic dermatitis are as following:
– superficial perivascular and perifollicular inflammatory infiltrates
– psoriasiform hyperplasia
– parakeratosis around follicular openings.
Treatment of seborrhoeic dermatitis often involves several of the following options:
– Keratolytics can be used to remove scale when necessary, eg salicylic acid, lactic acid, urea, propylene glycol
– To reduce Malassezia, topical antifungal agents such as ketoconazole, or ciclopirox shampoo or and/or cream are applied. It is important to note that some strains of Malassezia are resistant to azole antifungals. In such cases, it is advised to try zinc pyrithione or selenium sulphide, under a dermatologist supervision.
– Mild topical corticosteroids are prescribed for 1–3 weeks to reduce the inflammation of an acute flare
– Topical calcineurin inhibitors (pimecrolimus cream, tacrolimus ointment) are indicated if topical corticosteroids are often needed, as they have fewer adverse effects on facial skin
– In resistant cases in adults, oral itraconazole, tetracycline antibiotics or phototherapy may be recommended. Low dose oral isotretinoin has also been shown to be effective for severe or moderate seborrhoeic dermatitis.
Scalp treatments include the following:
– Medicated shampoos containing zinc pyrithione, selenium sulfide, coal tar, ciclopirox, ketoconazole and salicylic acid should be used twice weekly for at least a month
– Steroid scalp applications are seen to reduce itching. These should be applied daily for a few days every so often.
– Calcineurin inhibitors such as tacrolimus can be used as steroid alternatives.
– Coal tar cream can be applied to scaling areas and removed several hours later by shampooing.
– Combination therapy is often advisable.
Treatment for face, ears, chest and back affected by seborrhoeic dermatitis include:
– Using a non-soap cleanser, cleanse the affected skin thoroughly once or twice each day.
– Apply ciclopirox cream or ketoconazole once daily for 2 to 4 weeks, repeated as necessary.
– Hydrocortisone cream can also be used, applied up to twice daily for 1 or 2 weeks. Occasionally a more potent topical steroid may be prescribed.
– Topical calcineurin inhibitors such as pimecrolimus cream or tacrolimus ointment may be used instead of topical steroids.
– A variety of herbal remedies are commonly used, but their efficacy is uncertain.
– Regular washing of the scalp with baby shampoo or aqueous cream is followed by gentle brushing to clear the scales.
– White petrolatum may be useful.
– Depending on the extent of the rash, topical antifungals are often prescribed.
Formerly known as Besnier prurigo, Eczema — also known as atopic dermatitis — is the most common form of dermatitis. It is categorised as a chronic, itchy skin condition. Eczema is less common in adults and more commonly affects 15–20% of children. It is almost impossible to predict whether the condition of one’s eczema will improve by itself or not in an individual. Sensitive skin is a condition that persists life-long. In a meta-analysis of over 110,000 subjects, it was found that children who developed eczema before the age of 2 had a much lower risk of persistent disease than those who developed eczema later in childhood or during adolescence. 20% of children with eczema still had persistent disease 8 years later. Fewer than 5% had persistent disease 20 years later.
Since ‘atopic tendency’ such as eczema, asthma and hay fever can be passed down through the family, knowing one’s own family history of asthma, eczema or hay fever is very useful in diagnosing atopic dermatitis in infants. The complex interaction between genetic and environmental factors causes and triggers Eczema. Defects in skin barrier function make the skin more susceptible to irritation by contact irritants such as soap, the weather, temperature and non-specific triggers. The appearance of eczema varies from person to person. In acute eczema flares, inflamed, red, sometimes blistered and weepy patches are common. In between such eczema flares, the skin may appear normal or suffer from chronic eczema with dry, thickened and itchy areas. The appearance and feel if eczema varies from one’s ethnic origin, age, types of creams applies, the presence of infection or an additional skin condition. However, there are some general patterns to where the eczema is found on the body according to the age of the affected person.
Although eczema can manifest itself in older people for the first time, the onset of eczema is usually seen before a child turns two. It is widely distributed amongst infants less than one-year-old. It is unusual for an infant to be affected with eczema before the age of four months. However, they may suffer from infantile seborrhoeic dermatitis or other rashes prior to this. As infant’s tend to scratch at their itchy skin with their sharp baby nails, the appearance of eczema in infants tend to be usually scaly, dry, and red. The signs of eczema are physically first apparent on cheeks of infants. Due to the moisture retention of nappies, the appearance of eczema in the napkin area is frequently spared. However, just like other babies, if wet or soiled nappies are left on too long, they can develop irritant napkin dermatitis. Although, eczema is often worst between the ages of two and four it usually improves after four and it may clear altogether by the time one enters into teenhood.
As toddlers tend to scratch vigorously at their itchy skins, the appearance of their eczema may look very raw and uncomfortable. As they start to move around, eczema tends to become more thickened and localised. Body parts and areas such as the extensor aspects of joints, specifically the elbows, wrists, knees and ankles and even genitals are most commonly affected in this age group. This changes as the child grow older. The pattern frequently shifts from extensor aspects of the joints to the flexor surfaces of the same joints, such as creases. This is when the affected skin often becomes lichenified; thickened and dry from constant rubbing and scratching. However, the extensor pattern of eczema persists into later childhood in some children. Older school-age children tend to develop a flexural pattern of eczema which commonly affects the elbow and knee creases and other susceptible areas such as the scalp, eyelids, earlobes, and neck. It is possible for school-age children to develop recurrent acute itchy blisters on their palms, fingers and sometimes on the feet, medically known as pompholyx or vesicular hand/foot dermatitis. Many children in this age group tend to develop a ‘nummular’ pattern of atopic dermatitis. This refers to the appearance of small coin-like areas of eczema scattered over the body. Commonly mistaken for a fungal infection such as a ringworm, the appearance of these round patches of eczema are usually red, dry and itchy. Most of the eczema tends to improve during school years and it may completely clear up by the time they reach their teenage years. However it is important to note that the barrier function of the skin is never entirely normal.
The presence of eczema in adults are varied in many ways. Despite having a possibility to have a diffused pattern of eczema, eczema in adults is usually more dry and lichenified compared to eczema in children. Eczema is adults are commonly persistent, localised, and possibly confined to the eyelids, nipples, flexure, and hands or all of these areas. Hand dermatitis in adult atopic tends to appear thickened, dry but may also be blistered at the same time. Infections such as staphylococcal infections are both recurrent and a prominent possibility. Occupational irritant contact dermatitis can trigger eczema. This most often affects hands that are regularly exposed to water, detergents and /or solvents. As eczema can be triggered by physical, environmental and cosmetic factors, particular occupations such as hairdressing, farming, domestic duties, domestic and industrial cleaning and caregiving tend to expose the skin to various irritants and, sometimes, allergens, aggravating eczema. As it is easier to choose a more suitable occupation from the outset than to change it later, tt is wise to bear this in mind when considering career options. Having atopic dermatitis does not exclude contact allergic dermatitis (confirmed by patch tests in children and adults).
It could take many months to years to treat eczema and treatments plans often includes:
– Intermittent topical steroids
– Reduction of exposure to trigger factors
– Regular moisturisers, medically known as emollients
– In some cases, management may also include one of more of the following:
– Crisabarole ointment
– Topical calcineurin inhibitors, such as pimecrolimus cream or tacrolimus ointment
– Oral corticosteroids
– Longstanding and severe eczema may be treated with an immunosuppressive agent.
Clinical trials of biologics such as Dupilumab are promising cures for eczema.
Also known as the “mask of pregnancy”, Melasma is the presence of either brown or grayish brown patches, that typically appears on both sides of the face, especially on cheeks, upper lip, nose, forehead or chin area. The excessive production of melanin from melasma causes the pigment in the affected skin area to tan, resulting in a brownish or grayish brown discolouration.
Who does Melasma affect?
Although anyone can have melasma, it is more common amongst pregnant women, women who consume oral contraceptives and people with darker skin types. Even though sun exposure is seen to be a triggering factor, experts believe that the pigmentation is caused by hormonal changes that occur when a woman begins to consume birth control pills or is on hormone replacement therapy or during her second or third trimester of pregnancy.
What should I know about Melasma?
The duration in which the pigmentation fades, varies from individual to individual depending on the intensity and cause of Melasma. For some individuals, pigmentation caused by Melasma may worsen over time. For individuals who have been affected by Melasma during pregnancy or through the consumption of birth control pills or undergoing hormonal therapy, it may fade without treatment after childbirth or the discontinuation of such hormonal treatments. However, it is important to note that, Melasma can return with each future pregnancy, even if it fades after a prior child delivery.
What are the treatment plans available for Melasma?
Before starting any treatment against melasma it is important to consult a trained and accredited dermatologist. This is important to confirm the diagnosis of Melasma and to check that there is no underlying or associated skin disease that would require immediate treatment. Secondly, as Melasma can worsen over time and even become permanent, by having a consultation with a dermatologist this can be prevented. Thirdly, as effective medical melasma treatments require a prescription — as these treatments may sometimes produce mild side effects — these medications need to be consumed under medical supervision.
There are 3 ways that are used to treat Melasma:
Cosmetic: The use of cosmetics such as colour correctors, concealers and foundations to cover the dark areas. However, in the long haul, this method does not help melasma to fade.
Medical: Prescription medications such as those containing hydroquinone. These medications are aimed at inhibiting melanin production selectively, therefore causing a depigmenting effect, allowing Melasma to fade over time.
Physical: The use of topical agents such as chemical peels and lasers.
Dermatologists may recommend undergoing ‘combination therapies’ such as creams that combines a few active ingredients, in conjunction with laser treatments and chemical peels. This prescription treatment is able to lighten moderate to severe melasma quickly and effectively.
How to prevent Melasma from getting worse?
As tanning of the skin occurs when the pigment in the skin — melanin — absorbs the ultraviolet rays produced by the sun, with constant exposure to the sun, Melasma has a tendency to get darker. It is recommended that one avoids exposure from the sun to prevent further darkening of existing melasma as well as the formation of new patches. By protecting your face from harmful UV rays of the sun by either wearing a hat or a sunscreen with SPF30 or higher, the possibilities of Melasma darkening could be reduced.
Dermoscopy is a skin examination technique used to evaluate skin growths as well as pigmented skin lesions, without the need for surgery. The accuracy of the technique is dependent on the operator’s experience, and can help facilitate the diagnosis of potentially fatal skin cancers such as melanoma.
The use of dermoscopy involves advanced lens magnification together with an intense lighting structure incorporated in a portable handheld instrument known as a dermatoscope. This instrument reveals skin structures and patterns and can be attached to computers or smartphones for transmitting images.
Some techniques used in dermoscopic interpretation would include pigmentation colour and structure. In terms of colours, a trained dermatologist will pick up hues in pigmented lesions ranging from black, brown, red, blue, grey, yellow and white. Some tips on patterns and structures that dermatologists specialising in skin cancers would involve determining if a growth has the following features of asymmetry, heterogeny, uniformity. Dermoscopic examination also gives clues to keratin on the skin surface,blood vessels, borders, ulceration which can be signs of skin cancers.
What are cosmeceuticals? Cosmeceuticals refer to skincare that has been developed from the combination of cosmetics and pharmaceuticals. They have medical or drug-like benefits, such as improving appearance through its ability to affect the structure and function of the skin and are recognised by dermatologists.
As these types of skincare contain bioactive ingredients, which means it has been laboratory tested and formulated, they ensure effective and proper penetration of skincare onto the skin. Cosmeceuticals differ from normal moisturisers or typical cosmetic formula as they contain anti-ageing, anti-wrinkle, sun-protective, anti-acne and anti-oxidant ingredients that have indeed been backed by dermatological research.
Who are cosmeceuticals for? Cosmeceuticals are for everyone. They are commonly recommended by dermatologists as a complementary treatment for those who are undergoing cosmetic dermatology treatments such as lasers, fillers and botox for anti-ageing. It is also recommended as a form of skincare when treating skin conditions like acne. In addition, they serve as a cost effective option for patients to maintain the beneficial effects of such cosmetic treatments at the comfort of their homes and regular users of cosmeceuticals to maintain their youth and improve the appearance of their skin.
How to find the right type cosmeceuticals for you? As cosmeceuticals are not regulated by the FDA or Health Sciences Authority in Singapore, as a quick rule of thumb, a product recommended by a dermatologist (check your doctor’s accreditation) would be safe bet. The skincare and aesthetics market today is flooded with cosmetic companies and even ‘doctor-designed’ skincare products by aesthetic doctors (who are not dermatologists) to add on to the public’s confusion of who’s the real skin expert.
One would be wise to do thorough brand research, look for the labels ‘dermatologist-tested’, ‘dermatologist formulated/recommended’ or just consult a dermatologist before you buy. As a cosmeceutical product, it should also ideally be formulated in a laboratory rather than in a cosmetic factory. It should also have the approval of a dermatologist. The reason these factors are important are because, one has to bear in mind that even when a correct active ingredient is present, it may lack effectiveness because of an inappropriate drug delivery system, compound instability, poor penetration, inadequate dosing or the ingredient itself may lack good clinical studies to back it up.
If you’ve ever been struck with a pesky wart over your palms or soles at least once in your life, you’ve probably been left wondering what caused it. Nope, it is no longer just a childhood infection, adults are increasingly attending my clinic with concerns about stubborn warts that don’t go away and are plain annoying. In this article, I share my experience with the common concerns of those of you who are troubled by viral warts.
1. What exactly are warts?
Warts, also known as verruca, are growths of the skin due to human papillomavirus (HPV) infection. Several subtypes are known, and they all look different. The initial infection occurs in the top layers of the skin, it reprogrammes the skin to cause excessive growth of the keratinocytes (skin cells), leading to thickening of the skin where the viral wart has started. The most common subtypes of HPV are types 2, 3, 4, 27, 29, and 57. Warts appear first like an area of hardened skin, and when one looks carefully, one may find tiny black dots centrally, which is due to thrombosed(or clotted) tiny blood vessels.
2. Who gets viral warts?
Warts are traditionally more commonly found in school-going children and teenagers but can affect people of any age group. People suffering from eczema, whereby their skin barrier is genetically defective, are also prone to getting viral wart infections from areas of broken skin. Those who are immune suppressed are at high risk of getting larger, persistent and multiple warts. These include patients who are pregnant, on medications such as azathioprine or ciclosporin, or with human immunodeficiency virus (HIV) infection. Nevertheless, it’s perfectly normal to have a healthy young adult to suffer from viral warts as well, especially in areas of friction and contact, such as the palms and soles. The palms and soles of feet are subject to small cuts and wounds due to contact on a day to day basis. HPV virus, which is present on surfaces, then has the potential to infect the skin.
3. Is your gym giving you warts?
Moving on to the causes of viral warts. HPV is contagious and is most commonly spread by direct skin-to-skin contact. Another way it occurs is via scratching or picking warts, whereby the virus may be spread to other areas of uninfected skin. Common places where people pick up the wart virus are at public areas such as pools, bathrooms and gyms. Sharing footwear, slippers and shoes, walking barefoot and handling shared gym equipment that has not been properly disinfected. So yes, a good proportion of adults who visit dermatologists for treatment of their viral warts actually get it from shared gym equipment, especially when small cuts are present.
4. Do I need to see a dermatologist to diagnose viral warts?
Warts are common and have a typical appearance, with painful areas of hard skin, almost like a callus, and black dots centrally. While tests are usually not required to diagnosis viral warts, there are some cases whereby the appearance or the location of the wart is unusual, leading to a missed diagnosis of a potential skin cancer. In such cases, dermatologists usually would perform either a dermatoscopic examination or may recommend a skin biopsy to distinguish viral warts from other growths such as seborrhoeic keratosis and skin cancer. It may be necessary sometimes to perform a skin biopsy for diagnosis, especially to rule out rare infections( in people who are immunosuppressed) and also skin cancers.
5. When to get your wart treated by a dermatologist
Small warts which otherwise don’t hurt or bother in any way can sometimes be left alone. However, once you suspect you may have a wart, do get it checked out by a dermatologist rather than using DIY methods. I have seen several patients who have used corn plasters or DIY freeze kits bought online over their wart, which all became worse after their self-treatment. I do not recommend corn plasters as these typically contain salicylic acid which is a keratolytic, essentially dissolving the thicker layers of skin overlying the wart, often causing irritation and blistering, but does not actually treat the underlying viral wart. Many end up with complications of skin infection. DIY freeze kits or not permitted legally in Singapore, however, I have had patients who purchased such kits online or overseas and ended up having severe blistering and infections, some even requiring drainage after that. The reason is that these freeze kits contain liquid nitrogen, which is meant to kill off the virus-infected skin cells and should be applied by a trained healthcare professional upon the direction and assessment of a dermatologist. Importantly, there are variations of the appearance of viral warts as well, which may lead to misdiagnosis or delayed diagnosis. I have seen cases of squamous cell carcinoma, a potentially lethal form of skin cancer, for example, which had been undiagnosed because of an assumption that it was just a stubborn wart that would not go away.
6. How does wart treatment work?
The truth is, once you get a viral wart infection, the virus affects your skin’s DNA where it has infected, causing all new skin cells to be produced with the HPV virus. What that means is the treatment of viral warts is not like that of a skin growth or cyst, whereby cutting it out fully results in removal and a cure. Viral warts are persistent because they are alive, and in order to eliminate the wart virus one has to rely on stimulating the body’s own immune system to overcome the wart virus. Hence, surgeries whereby the wart is excised does not work because the HPV virus replicates and would grow the wart again.
The location of the wart, the morphology as well as the underlying health status of the patient affects the type of treatment chosen as well. There are subcategories of warts as follows which your dermatologist will diagnose you with:
Common warts and plantar warts are those commonly appearing over the palms and soles, with characteristic pinpoint black dots centrally due to clotted blood vessels, a result of the HPV virus infection. Plane warts as the name suggests, have a plane or a flat surface and are found over areas of the knuckles, the knees and the elbows. Another type known as filiform warts are protuberant with a thread-like elongated stalk and are common in areas such as the face. Mucosal warts affect areas such as the lips, inside the mouth and also the anal/genital region.
7. What treatments are available for viral warts?
First of all, make sure the growth you are dealing with is indeed a viral wart. From there, depending on the type of viral wart, your dermatologist will suggest one or a combination of the following.
Use of topical treatment alone in the treatment of viral warts is uncommon and is usually used in combination with topical treatment i.e. creams, ointments and lotions formulated for wart treatment usually contain active ingredients such as salicylic acid. Salicylic acid is a keratolytic, which means it works by dissolving dead skin cells. Another anti-viral ingredient used is podophyllin, which destroys skin cells i.e. cytotoxic, but is prohibited in pregnancy.
Cryotherapy is the use of liquid nitrogen to freeze areas of infected skin. It is performed every one to two weeks. It is a safe and effective treatment except that it requires multiple sessions, with a success rate of about 60–70% for 3 months of regular treatments. It causes blistering and may subsequently leave a scar after treatment.
Electrosurgery and Laser Vaporisation
Electrosurgery and laser vaporisation would be used for larger or stubborn warts. Surgical paring is performed under local anaesthesia and the base of the wart is burned, destroying both healthy tissues together with the bulk of virus infected tissue. Wound healing is expected within two weeks generally. However, about 20%- 30% of warts do recur within a few months, although the rate of recurrence decreases with proper monitoring by a dermatologist.
Meet with Dr. Teo Wan Lin, founder and Specialist Consultant Dermatologist of TWL Specialist Skin & Laser Centre, an accredited dermatologist specialising in medical and aesthetic dermatology. She integrates her artistic sensibility with her research background and specialist dermatologist training, by means of customised, evidence-based aesthetic treatments using state-of the-art machines, injectables (fillers and toxins) which work synergistically with her proprietary line of specialist dermatologist grade cosmeceuticals Dr.TWL Dermaceuticals.
To book an appointment with Dr. Teo, call us at +65 6355 0522, or email firstname.lastname@example.org. Alternatively, you may fill up our contact form here.