Dr Frances Pitsilis - Common skin problems and their solutions

Although everyone is an individual and has unique needs, there are a number of common problems that affect many people – the red stuff, the brown stuff, bumps and hair.


Skin problems that make you see red
Red discolouration of the skin generally comes from sun damage and prolonged periods of time in the sun and can take different forms.

Many people have a red discolouration can look like blusher across the cheek, around the chin and over the nose and the frown area. Some can present with “red veins” or telangiectasiae (which in medical terms refers to broken capillaries). Often a combination of these two types of red skin problems occurs together.

It is also fairly common to have deep red skin across the cheeks and nose that gets worse in the sun, after coffee, alcohol and hot or spicy foods. This is acne rosacea, or rosacea for short.


Treatments for sun-related discolouration
To deal with sun-related red discolouration, some vitamins and botanicals can stabilise and improve the appearance of redness. They do this by either acting as anti-inflammatories or as barrier enhancers.

Aloe vera and prickly pear can act as a mucilage (moist, viscous substance) to place a protective coating over the skin. In addition, aloe vera is rich in choline salicylate, an anti-inflammatory.

Other plant based anti-inflammatories include bisabol and allantoin.

A third category is those that reduce redness by improving the skin barrier. For instance, pantothenic acid (Vitamin B5) is a humectant which hydrates and improves barrier function.

Finally, there are the anti-inflammatory polyphenols. The best studied is green tea, which is also the most potent.


Skin care ingredients to seek out

• When choosing skin care treatments, follow these guidelines:
• Avoid toner or astringents, as these products evaporate quickly from the skin and give the type of stimulation that could cause flushing and redness.
• Use a cream-based moisturizer with minimal water rather than a lotion, so it doesn’t evaporate. Avoid ingredients that contain propylene glycol, glycolic acid, salicylic acid, strong perfumes and extensive botanical cocktails, as they can all irritate. Many sensitive skin moisturizers contain allantoin, bisabol and pantothenic acid.
• Sunscreen should be a thicker cream labelled for sensitive skin and contain zinc oxide (a barrier sunscreen). Avoid chemical sunscreens such as oxybenzone, because they work by absorbing UV radiation and converting it to heat. This may worsen facial flushing and redness.
• The treatment moisturizer should contain green tea, as it is the most potent botanical anti-inflammatory available. Also, consider good levels of petrolatum, dimethicone and low levels of glycerin. This prevents water loss from the skin and enhances skin hydration, thus improving the barrier function of the skin.

Intense pulse light treatment - IPL
Apart from a good skin regime to minimize the problem, the only treatment that does a good job of wiping it out is intense pulse light (IPL) treatment.

IPL is a broad band of light with technology similar to that of laser. Instead of one single wavelength, IPL employs a broad band of light, often somewhere from about 600nm to 1200nm. This light selectively is attracted to the red discolouration, heats that area, effectively “cooking” the tiny vessels involved and eradicating them. It feels like a hot rubber band flicking the skin. Typically, after a facial treatment, the skin is somewhat blotchy for around seven days, but afterwards the results are very good.

IPL treatment will get all of the flush-type redness and many of the very fine broken capillaries, but will not treat bigger vessels. These vessels need to be treated with a dedicated vascular laser if that is available. If it is not available, depending on the size of the vein, it may be possible for the therapist to treat this with electrical cautery or using an epilation machine.


The signs of rosacea
Rosacea is a red facial rash that commonly occurs in people aged 30-60 years who typically have fair skin, blue eyes and are of Celtic origin. This red rash can be quite deep and sometimes have lumps in it. It can affect the nose and therefore cause a thick “drinker’s nose”. It can even affect the eyes and create a blepharitis with flaking, scaling and inflammation of the eyelids.

We don’t know the cause of rosacea, but we do know that it is an inflammation within the skin that causes these dilated blood vessels, general redness and red bumps.

Rosacea is an important condition to get under control, because if left unchecked it can, in extreme cases, cause scarring. If you are having difficulty getting control of the redness over the malar or cheek area, and across the nose, then you should suspect rosacea.


How to treat rosacea
The treatment of rosacea runs from foundation concepts like diet and fish oil to avoiding the triggers that cause the problem to flare up. Rosacea triggers commonly include alcohol, spicy food, hot foods, strong emotion and sunshine. The doctor will give sufferers oral antibiotics or, when severe, even strong medication like isotretinoin.

Rosacea patients need to avoid oily creams because they will irritate the skin further. Water-based creams are a good idea. Some botanicals may help this condition, but beware that this skin can be extremely sensitive.

IPL can help somewhat, with some of the more difficult cases needing a combined approach. In my clinic, I use a dedicated 1064nm laser (which selectively treats the deep redness), a vascular laser, and sometimes an IPL for this condition – the first two treatments are virtually painless, which is good for older clients.

IPL on its own will still be able to significantly help rosacea. It is important to remember that you must avoid light or laser treatments is you have been on oral tretinoin (Roaccutane) in the last six months.

However, the most important thing about rosacea is to suspect it early when the redness does not respond to therapy. You should then consult your family doctor, a dermatologist, or a medical clinic with the appropriate expertise.

Another unusual cause of redness across the cheeks that may not respond to therapy and that is also sun sensitive is the rash associated with an autoimmune disease called systemic lupus erythematosis. This is one of the conditions where the skin becomes sensitive to sun and causes redness across the cheeks and nose. Once again, consulting your family doctor will help sort this out.


Getting rid of brown blotches
In most cases, brown blotches on the skin are directly related to sun exposure. Completely flat ones may require no more than a therapist’s treatment. However, the bumpy ones might be seborrhoeic keratoses (also known as senile warts) which can be treated by your family doctor with liquid nitrogen. Seborrhoeic keratoses are lumpy, greasy looking areas that can be on the face or body.

People can prevent wrinkles and brown discolouration from a lifetime of sun exposure by following an ideal skincare regimen in the first place. But once the brown blotches are there, a therapist can help you treat them by enhancing your skincare regime and, in addition, using suitable products.


Products that can help
A retinoid will not only reduce wrinkles, protect the skin from further ageing and ultraviolet light, but will also help reduce brown discolouration. Available retinoids include Vitamin A, retinol and retiniol parmitate. Add hydroquinone to this, and you have the foundation of good depigmentation skincare.

There are concerns about hydroquinone, however, because it can be cytotoxic (poisonous) to melanocytes, and can cause irritation. There is a risk, especially in darker skins, of inflammatory hypo-pigmentation. This has led to the development of a variety of botanical and vitamin pigment lightening agents. Of these, kogic acid, glabridin and azaelic acid show the best promise by all acting as tyrosinase inhibitors.

Combining skin lightening agents with penetration enhancers like glycolic acid helps. You can also use pigment lightening vitamins such as niacinamide (Vitamin B3) or retinol.

Vitamin C is also a tried and true product ingredient that is known to protect the skin and reduce brown blotches. Research has shown that it will work in more than 10% of cases.


Salon procedures increase effectiveness
With all skincare for pigmentation, undergoing simple salon procedures can enhance its effectiveness. Microdermabrasion (or peels) helps with epithelial pigmentation. Needling helps the skincare ingredients to penetrate better.

Intense pulse light (IPL) can be as useful for brown blotches as it is for red discolouration, especially if it is epithelial.

In dark-skinned people, IPL may not be advisable because of the risk of hypo-pigmentation. These people would particularly benefit with an ideal skincare regime with the addition of microdermabrasion and even needling to help reduce the brown blotches. Peels are not advised in darker skins, because of the risk of post-inflammatory hyperpigmentation.


Dark circles under the eyes
Dark circles under the eyes are related to several factors, including lack of sleep and chronic stress. Apart from these causes, it is most likely to be due to the thinning of the skin with age, as well as the effects of smoking.

Lifestyle changes and stopping smoking are obviously a priority. Skincare that helps in this area includes anything that will build collagen under the eyes. This can include copper peptides, antioxidants, etc.

Other substances known to reduce discoloration under the eyes include azaleic acid and kogic acid.

I have experience with a non-ablative laser that is used to build collagen under the eyes. However, I do not know of any other lasers that can do this with no pain or downtime. When it comes to laser and light therapies, types of semi-ablative treatments such as fractionated laser could also be useful for you.


Smoothing out bumps on your skin
Milia are seen all the time on many people. They are common benign keratin filled cysts under the skin and contain sebaceous material. There is no skin care that will make milia go away.

Milia can often occur after blistering or trauma to the skin or disruption of the sweat ducts. It can also be part of some skin conditions including bullous pemphigoid, inherited and acquired epidermolysis bullosa, bullous lichen planus, porphyria cutanea tarda. It can also occur from skin trauma after radiotherapy, ablative laser treatment or even after use of a potent steroid cream on the skin.

They will not respond to squeezing and this is discouraged. Milia can be safely left alone. However, if you want treatment there are various methods you can use. The commonest method is a sharp superficial incision with the cutting edge of a needle or blade and then gentle expression with the fingers or an implement. Another method is freezing them with liquid nitrogen or even light cautery.

If the milia looks unusual or seems to be in unusual places or part of other rashes, then a visit to a dermatologist may be necessary.


Treating acne
Acne causes bumps and this occurs in teenagers and adults. I have written about adult acne recently. Teenage acne fundamentals need to involve eradication of sugar and starch from the diet, because acne is caused by inflammation in skin from these substances. Adding in a multivitamin and fish oil will help the teenager.

In an adult woman who has had acne all her life or whose acne has started later on in life, hormones need to be suspected. You need to consult your doctor for help with this.

Aside from this, skin care that helps acne includes a retinoid to normalise the skin and the pyelo-sebaceous unit. Using glycolic acid away from the retinoid (because they do not go well together) is a good idea. This could possibly be in the form of a morning scrub. Glycolic acid acts to exfoliate the surface of the skin and unblock the pores as well as balancing the oil.

Botanicals that can be useful with acne include anything that is anti-inflammatory or helps with excess oil.

• Niacinamide reduces oil when used on the skin.
• Salicylic acid unblocks pores and removes oily residue, in addition to being an anti-inflammatory.
• Witch hazel removes excess sebum from the skin.
• Papaya acts as an enzyme to remove oil and desquamate corneocytes from the skin surface.
• Retinol normalizes the pilosebaceous unit.

Useful clinic treatments for acne can include anything that will help exfoliate the skin like microdermabrasion or a facial peel.


Getting rid of old acne scars
Skin scarring from trauma or old acne scars is also commonly seen. I believe the best tool to help people with scarring is the microdermabrasion machine and a good home programme of skin care, together with a needle roller. In the salon, the suction aspect of the microdermabrasion stimulates the mid-dermis to activate fibroblasts which create collagen. At the same time, the physical side of the treatment is softening and moving the skin.

Adopting a good skin care programme along with a needle roller will further stimulate the mid-dermis layer with the roller at home. The added bonus will be that the skin care ingredients will get into the skin better because of the use of the needle roller.
There are different types of needle rollers available. The type that you need for this work is the facial roller. The use of a roller may enable you to get even better results on top of just using the microdermabrasion with our without peel treatment.


Too much hair, or not enough?
When it comes to hair, women either have too much or not enough. When it comes to too much, this is where waxing, electrolysis and intense pulse light (IPL) and laser treatments come into play.

It is when the pattern of the hair starts to become unusual or excessive that you may wish to consult your doctor.


PCOS and insulin resistance
Women with polycystic ovarian syndrome (PCOS) often have excessive hair as well as facial acne. This requires medical help for the underlying cause, which usually involves hormonal imbalance and insulin resistance.

Hormonal imbalance in PCOS usually involves inadequate progesterone in the second half of the cycle. This is preferably dealt with via bio-identical hormones which are safer than synthetic hormones. Synthetic progesterone, called progestins, increases the risk of breast cancer by increasing dangerous oestrogen metabolites.

Insulin resistance is where your insulin levels start to increase in response to poor glucose handling of the body. These people often have more abdominal fat and can’t lose weight. A low starch and sugar diet, along with fish oil, magnesium and other useful vitamins for insulin resistance will help.


Losing hair
Alopecia is when hair falls out of places it should remain, e.g. the scalp or the beard in men. Alopecia totalis is a condition where all of the body hair falls out at once.

The cause of alopecia is often unknown. However, in men and pre-menopausal women it usually is due to stress, drugs or a vitamin deficiency. In the case of the scalp, dermatitis or a fungal infection may be at the root of the problem.

In postmenopausal women with hair loss, it is usually in relation to the change in their hormones. This can be remedied by helping improve the balance of their hormones.

In all cases of alopecia, a visit to your family doctor or a dermatologist is useful.

Whatever your skin problem, it is important to accept when your condition is not responding to treatment or when it seems unusual. Seeking a medical opinion is crucial in these cases.