The Dermatology Clinic - Dr Daniela Vanousova

New Zealand has a very high rate of skin cancer, when compared to other countries. The most common forms of skin cancer usually appear on areas of skin that have been over-exposed to the sun. Risk factors for developing skin cancer are:  prolonged exposure to the sun; people with fair skin; and possibly over-exposure to UV light from sun beds.   There are three main types of skin cancers: basal cell carcinoma, squamous cell carcinoma and malignant melanoma.   Basal Cell Carcinoma (BCC) This is the most common type and is found on skin surfaces that are exposed to sun. A BCC remains localised and does not usually spread to other areas of the body.  Sometimes BCCs can ulcerate and scab so it is important not to mistake it for a sore. BCCs occur more commonly on the face, back of hands and back.  They appear usually as small, red lumps that don’t heal and sometimes bleed or become itchy. They have the tendency to change in size and sometimes in colour.   Treatment Often a BCC can be diagnosed just by its appearance.  In other cases it will be removed totally and sent for examination and diagnosis, or a biopsy may be taken and just a sample sent for diagnosis. Removal of a BCC will require an appointment with a doctor or surgeon.  It will be termed minor surgery and will require a local anaesthetic (numbing of the area) and possibly some stitches. A very small number of BCCs will require a general anaesthetic (you will sleep through the operation) for removal.   Squamous Cell Carcinoma (SCC) This type of skin cancer also affects areas of the skin that have exposure to the sun.  The most common area is the face, but an SCC can also affect other parts of the body and can spread to other parts of the body.  The spreading (metastasising) can potentially be fatal if not successfully treated.   A SCC usually begins as a keratosis that looks like an area of thickened scaly skin, it may then develop into a raised, hard lump which enlarges.  SCCs can sometimes be painful. Often the edges are irregular and it can appear wart like, the colour can be reddish brown.  Sometimes it can appear like a recurring ulcer that does not heal. All SCCs will need to be removed, because of their potential for spread.  The removal and diagnosis is the same as for a BCC.   Malignant Melanoma This is the most serious form of skin cancer. It can spread to other parts of the body and people can die from this disease. A melanoma usually starts as a pigmented growth on normal skin.  They often, but not always, occur on areas that have high sun exposure.  In some cases, a melanoma may develop from existing pigmented moles.   What to look for: an existing mole that changes colour  (it may be black, dark blue or even red and white) the colour pigment may be uneven the edges of the mole/freckle may be irregular and have a spreading edge the surface of the mole/freckle may be flaky/crusted and raised sudden growth of an existing or new mole/freckle inflammation and or itchiness surrounding an existing or new mole/freckle.   Treatment It is important that any suspect moles or freckles are checked by a GP or a dermatologist. The sooner a melanoma is treated, there is less chance of it spreading. A biopsy or removal will be carried out depending on the size of the cancer.  Tissue samples will be sent for examination, as this will aid in diagnosis and help determine the type of treatment required.  If the melanoma has spread more surgery may be required to take more of the affected skin.  Samples from lymph nodes that are near to the cancer may be tested for spread, then chemotherapy or radiotherapy may be required to treat this spread.  Once a melanoma has been diagnosed, a patient may be referred to an oncologist (a doctor who specialises in cancer).   A melanoma that is in the early stages can be treated more successfully and cure rates are much higher than one that has spread.

Acne is a skin disorder that is characterised by pimples, blackheads, whiteheads, and, in bad cases, cysts (deeper lumps).  Acne usually starts at puberty and is in response to our body’s production of hormones, called androgens. These hormones cause the sebaceous glands (oil-producing glands in the skin) to get bigger and produce more oil. The extra oil (sebum) mixes with dead skin cells and naturally occurring bacteria on the surface of the skin and blocks pores.  Once a pore is blocked the bacteria multiply and cause inflammation, which produces the characteristic signs of acne. Acne commonly occurs on the face, neck, back and chest.  Acne can lead to permanent scarring. Other causes of acne may include: genetics heavy makeup harsh and repetitive cleansing picking and squeezing certain medications diet.

Acne Vulgaris is the most common form of acne. Adult Acne occurs in about 30% of people at some stage in their adult life.  It is thought that adult acne also has some hormonal influences. Acne Rosacea is similar to acne vulgaris, with oily skin and spots, but also has flushing or redness of the skin in the affected area.  The flush may be set off by certain spicy food or alcohol.   Treatment Usually acne can be treated successfully, but results do not happen overnight and what can work for one person may not work for another.  It may take several months to see initial results, and once it significantly clears treatment is still required to keep it from coming back. Some medications for acne can only be prescribed by a dermatologist.  When acne is treated early the results are very good and it also helps to reduce scarring. Over-the-counter products are available to treat mild-to-moderate acne, but check with a pharmacist which product is the best for your type of acne.  In moderate-to-severe acne, treatment usually requires the help of a dermatologist and often more than one type of treatment.  Treatments may include: antibiotic creams topical (apply to your skin) retinoids oral (take by mouth) antibiotics: these reduce the number of bacteria present on the skin which leads to a decrease in inflammation oral contraceptives: these reduce the amount of oil produced by the sebaceous glands.  However, possible side effects must be taken into consideration before starting treatment over-the-counter acne products.   Severe acne, with deep cysts, inflammation and scarring, should be treated by a dermatologist and in most cases can be successfully treated. Treatment may include: surgery: the deep cysts are removed and drained corticosteroid injection: used to treat the inflammation, promote healing of an acne cyst and help prevent scarring isotretinoin: an oral medication prescribed by a dermatologist that effectively works on all factors that cause acne. It can also have some side effects so you will need to be continually monitored whilst on this medication oral antibiotics oral contraceptives.

There are several different types of eczema but all have a number of common symptoms, the main feature being red, inflamed, itchy skin.  The skin can be covered with small, fluid-filled blisters that might ooze and form a scale or crust. Constant scratching can eventually lead to thickening and hardening of the skin. The several types of eczema are caused by a number of different things, such as irritant contact and allergies, or from unknown causes.  Determining the cause can be very difficult.   Atopic eczema This is the most common form of eczema.  It often occurs in the first few months after birth and is a chronic condition (may last for many years). Atopic eczema is often associated with hay fever and asthma, and has a tendency to run in families.  It is also known to disappear with age. Emotional stress, changes in climate or diet or certain fibres in clothing (especially wool) can be triggers for atopic eczema or can worsen the existing condition. Generally the eczema occurs in areas where the skin folds in upon itself, such as behind the knees, inside the elbows, the neck and eyelids.  It is more likely to occur in winter. With uncontrolled itching the skin can become grazed and weepy and is a potential area for a secondary bacterial infection.  As this is more common in young children, it is important to control scratching. There are no specific tests to diagnose atopic eczema, but a visit to the doctor is an important step. The diagnosis can be made once the rash has been viewed, based on its typical pattern and also whether an atopic tendency (i.e. eczema, hay fever or asthma) runs in the family. Symptoms are: redness and inflammation of the skin small fluid-filled blisters intense itching, especially at night dry scaly/cracked skin thickened skin as a result of continuous scratching.   Treatment There is no cure, but the following actions can help control the symptoms: moisturising creams help soothe and heal dry skin soap substitutes prevent drying of the skin when washing corticosteroid cream/ointment relieves inflammation and controls itching.  These should be used as directed by your doctor, nurse or pharmacist. non-steroidal creams that alter your body’s immune system response antibiotic creams can be used if a secondary infection is present avoidance of any known irritants oral antihistamines can also be prescribed for itchiness keep fingernails short to prevent damage to the skin from scratching.   Seborrhoeic dermatitis This is an inflammation of the upper layers of the skin, which gradually results in dry or greasy scaling of the affected area. This type of dermatitis tends to be chronic and recurrent.  It occurs in both infants and adults and tends to run in families. In infants, this condition is known as ‘cradle cap’ when it occurs on the scalp, but can also affect the nappy area to cause ‘nappy eczema’. In adults, the rash tends to occur around the nose, eyebrows and scalp. Treatment Infants: wash the scalp with mild shampoo. Oil can be applied to help comb scale out. Adults: regular use of an anti-dandruff shampoo is often all that is needed. Corticosteroids can also be applied, only 1% strength to the face.  Ketoconazole 1% shampoo and cream are very effective.   Contact dermatitis Contact dermatitis is inflammation of the skin caused by contact with a specific substance.  This happens because of irritation or by an allergic reaction. Substances that can trigger this inflammation can include cosmetics, soaps, detergents, rubber, nickel (in jewellery) or specific chemicals used in skin creams or from plants. With an allergic reaction, it is not the first exposure that causes a reaction but may be the next exposure or, in some cases, it is possible to have contact with a substance for a number of years without any skin inflammation occurring.  But once the skin has become sensitive, even a tiny amount of that substance can cause a reaction. Usually contact dermatitis affects only the area that has been in contact with the trigger or irritant (item that has caused the reaction). Symptoms can vary from a mild rash to a severe rash and blisters, with subsequent scaling and itching. The severity depends on the concentration of the irritant and how long the skin was exposed to it.  Once the irritant is taken away, the redness and rash usually disappear over a few days. Treatment A dermatologist can perform patch testing to find out which substances are causing the allergic reaction.  This is done by placing small discs (with possible allergen-causing substance on them) on the skin and removing them after 48 hours for examination.  The patches are then examined again 2 days later, to check for delayed reactions. Once the trigger has been identified, it is important to avoid it as continued exposure may cause a persistent rash, which will be difficult to treat. Treatment involves the use of steroid creams to decrease the symptoms of the reaction. With severe contact dermatitis, oral steroids or a steroid injection may be given.    Nummular Eczema This is also known as discoid eczema.  This form of eczema is more common in older males, is associated with existing dry skin and is most common in the winter season. The cause is unknown. It is characterised by an itchy rash that forms in coin-shaped spots, sometimes with associated small blisters, scabs, scales and thickened skin on the forearms and elbows, the backs of hands, tops of legs and the feet. Nummular eczema can be confused with a fungal infection but diagnosis can be made from a skin biopsy (removing a small piece of skin for examination under a microscope). Treatment is usually with moisturisers, steroid creams and sometimes antihistamines, if required.   Asteatotic eczema This is generally common in the elderly and is mainly caused by the dryness of the skin that accompanies older age.  It is characterised by a scaly itching rash that can often be cracked and have a pattern to it.   Dyshidrotic eczema This type of eczema is characterised by thickening of the skin accompanied by large numbers of blisters that tend to ooze. It usually affects the fingers, palms and soles of the feet. The cause is unknown.

Psoriasis is a common, recurring (keeps coming back) skin condition that is hard to treat. It is characterised by raised patches of skin (known as plaques) that are red, thickened and scaly that commonly occur on the elbows, knees and scalp, but can affect any parts of the body. Psoriasis usually starts out as a small spot that is excessively flaky and that gradually enlarges, then other plaques start to appear.  Sometimes the flaking can be mistaken for dandruff.  These areas are not always itchy. It is unusual in children and more common in adults. Psoriasis happens when new skin cells are produced at a faster rate than the dead skin cells are removed, thus excess skin cells form in thick scaly patches on top of the skin. The reason this happens is unknown, but it is known that: it may run in families; it may be triggered by infection, injury or stress; it is associated with the use of certain medications; and it is associated with psoriatic arthritis.   There are different types of psoriasis and a person can have more than one type at a time.   Plaque psoriasis – the most common type, which keeps recurring, or coming back, over a lifetime.  It can develop at any age. Symptoms are: plaques on the elbows, knees, nails, scalp, and behind the ears. This condition can be itchy at times.  When it occurs on the nails, it is associated with discolouration and pitting of the nail.

Guttate psoriasis – this type is more common in children and young adults and often follows a bacterial throat infection. It appears as many coin-shaped pink scaly plaques usually covering the back and chest. It can be itchy. Guttate psoriasis usually disappears over time and does not recur, although if someone has guttate psoriasis they are more likely to go on to get other types of psoriasis at a later stage.

Pustular psoriasis – a rare and potentially fatal condition that generally affects adults.  Symptoms are: small pus-filled blisters on palms of hands and soles of feet, with areas of skin that are painful, red and inflamed. Some scaling and thickening may be seen.

Inverse psoriasis – this commonly affects the elderly.  It is characterised by large moist reddened areas of skin occurring in skin folds such as the groin area, armpits and under the breasts. This type of psoriasis is easily treated, but is also recurring.   Psoriasis can be hard to diagnose as other conditions have similar symptoms.  To confirm a diagnosis a skin biopsy (small sample of skin is removed for examination) can be taken.   Treatment Treatment can begin once a diagnosis is made and usually involves both topical (applied to the skin) and generalised treatments. There is no cure for psoriasis but treatment can control symptoms.   Topical treatments: skin creams and ointments to lubricate and soften the skin corticosteroids vitamin D cream coal tar preparations salicylic acid preparations.   Oral medications such as etretinate, retinoids, methotrexate or cyclosporin can be prescribed, under the guidance of a dermatologist.   A generalised treatment such as ultraviolet light therapy may be effective and can be combined with an oral medication, which makes the skin more sensitive to the effects of light. This treatment is called PUVA or UVB and is given under the direction of a dermatologist.

Bacteria and a number of types of fungi live on the surface of the skin. Fungi generally live in moist areas of the body, thus these are the areas where fungus tends to overgrow and create a fungal infection.  A type of fungi that occur naturally in the gastrointestinal tract (mouth, oesophagus, stomach, intestines) and moist skin areas are yeasts. Fungal infections are named according to the type of fungi and area of infection.   Common fungal infections: Athletes Foot (Tinea pedis) – a tinea fungal infection of the foot and between the toes that is more common in males. Ringworm (Tinea corporis) – the same type of infection as athletes foot. Ringworm of the Scalp (Tinea capitis) – a  tinea fungal infection characterised by raised bumps that form in a circular pattern on the scalp. This may result in bald patches. Jock Itch (Tinea cruris) – a tinea infection that affects the inner thighs, bottom and genital area. Pityriasis Versicolor – a yeast infection of the skin resulting in lighter patches in areas of skin. Candida Infection – a yeast infection that occurs on the skin’s surface or within mucous membranes especially when they are damaged.  Yeast infections require a humid, moist environment and grow rapidly when your immune system is not working properly.  Antibiotics can also cause yeast infections by killing off the normal flora (bacteria) and allowing growth of the yeast.  Yeast infections occur in: skin folds tummy button vagina (thrush) penis (thrush) mouth (inside and outer) skin surrounding and under nails.
Symptoms of Candida infections depend upon the area involved and can include: itchiness/burning redness general irritation and tenderness skin splits dry scaly skin discharge (thrush).   Treatments Generally over-the-counter products are enough to treat mild-to-moderate fungal skin infections.  If symptoms persist, it is important to see a doctor.

Our skin is our body’s first defence mechanism and even though many types of bacteria live on its surface, we still need a healthy, intact skin surface to maintain its defence. Any break in this defence, whether it is from a cut or a pimple, is a possible risk for a bacterial infection. Some diseases such as diabetes and HIV increase the risk of major infection when this barrier is broken, as these patients already have a faulty immune system.   Impetigo This is a bacterial infection of the outer layers of the skin. It is infectious and is spread to others by direct contact, but can also spread to other areas on the body. It shows up as a crusty, weepy area and most often begins on the face or exposed areas of the arms and legs.  The bacteria that cause it are commonly found around children and schools.  Thus, impetigo is more common among children than adults and often occurs in spring and autumn. Impetigo is easily treated with oral or topical antibiotics. In some cases a child may require time off from school to prevent spread to others.   Cellulitis This is a bacterial infection of the skin and underlying tissues that can happen in normal skin but often occurs in an area of skin damaged by a wound, insect bite, eczema, chicken pox etc. It usually involves the skin of the face, arms and legs.  Bacteria spread and cause the following symptoms: swelling, pain and inflammation of tissue warmth and redness of skin fever aches and general unwellness red streaks from original cellulitis site.   In someone with diabetes or someone who is taking medications to suppress the immune system, cellulitis can start in areas of intact skin. The bacteria that cause cellulitis are usually Streptococcus or Staphylococcus. Cellulitis responds rapidly to antibiotic treatment, either orally or through injections.   Boil This is a tender, red, inflamed raised lump that has a pus-filled centre.  A boil develops when a hair follicle becomes infected with bacteria.  The usual bacteria that causes a boil is Staphylococcus.  Common areas of infection are the neck and face, breast and buttocks. Boils are more prevalent in people who have a low immunity.   Carbuncles This is the term for a cluster of boils.   Folliculitis This is inflammation of the hair follicle, caused by the Staphylococcus bacteria. The inflammation produces pus-filled pimples around the follicle.  It can occur on any area of the body but is more common in areas that are shaved or plucked.   Treatment Often boils, carbuncles and folliculitis clear without any specific treatment. They may burst and release the pus. Keeping the skin clean with antibacterial wash can prevent infections and prevent the spread. Do not squeeze as this can spread and worsen the infection. Application of warm heat can help to relieve symptoms. Antibiotics can be prescribed in some cases.

Shingles is caused by a virus called herpes zoster, this is the same virus that causes chickenpox.  After the virus has caused chicken pox it remains dormant (inactive) in the nerve cells, but can then be reactivated in later life to cause shingles.  It is not known why the virus is reactivated, but it often occurs in times of stress and illness.  Shingles is more common in the older age group or among people with decreased immunity.  Shingles is characterised by clusters of small fluid-filled blisters that erupt along a nerve path in a belt-like line, often on the stomach, chest or face.  This is a very painful condition and  tender to touch.  The rash dries out and slowly disappears over several weeks, occasionally leaving scars.  The pain from the area is slower to disappear and can last for months. The symptoms are: fever, chills, nausea, diarrhoea, and the appearance of tiny red spots that form into blisters then dry out over 3-5 days to form scabs.   Shingles itself cannot be caught from someone with shingles but chickenpox can be caught from someone with active shingles (active meaning before the rash has formed scabs).   As shingles can often be hard to diagnose it is important to visit your doctor early. A description of a band of pain will help the doctor to diagnose the condition. Once the rash appears, it is much easier to diagnose.   Treatment Starting treatment early is important as this can reduce the severity of the illness and how long it lasts. Anti-viral drugs will be prescribed if the shingles is in its early stages but these are not useful if the rash has been present for a number of days.  At this stage treating the symptoms is all that can be done e.g.  medication for pain and applying cooling antiseptic gels/lotions. Avoid secondary bacterial infections by keeping the rash clean and dry and get lots of rest. Avoid children/adults who have not had chickenpox.

Scabies is a very common skin infection that is caused by a mite that burrows under the top layer of skin and lays its eggs.  The eggs hatch in a few days.  The skin then becomes very itchy and a red, raised rash may appear.  Itching is worse at night and can occur before the rash appears and can continue after the rash disappears.  Sometimes the burrows can be seen; they appear as wavy brownish lines. The areas most affected are: between the fingers; between the toes; palms; heels; wrists and groin. Scabies is more common in children and young adults.Scabies is highly contagious (easy to catch) and is spread via physical contact (person to person).  It is more common in overcrowding situations.  The sooner it is treated, the sooner the spread is stopped. TreatmentThe presence of mites can be confirmed by taking a scraping from the burrows and examining it under a microscope. However, a negative scraping does not rule out the possibility of scabies.An antiparasitic lotion is used to kill the mites and this should be applied over the whole body (excluding the face).  A hydrocortisone cream can also be used to reduce the itching. It is important that all family members and close contacts also be treated at the same time as the initial patient.  This helps prevent the spread.