Hidradenitis suppurativa

 Understanding Hidradenitis Suppurativa: Causes, Symptoms, and Treatment Options

Introduction:

Hidradenitis Suppurativa (HS) is a chronic skin condition that can significantly impact the quality of life for those affected. Characterized by painful, recurrent nodules and abscesses, HS often manifests in areas where skin rubs together, such as the armpits, groin, buttocks, and under the breasts. At our dermatology clinic, we strive to provide comprehensive information about HS, from its causes to available treatment options.

Causes and Risk Factors:

The exact cause of Hidradenitis Suppurativa remains unclear, but it is believed to involve a combination of genetic, environmental, and lifestyle factors. Individuals with a family history of HS may have a higher predisposition. Other risk factors include obesity, smoking, metabolic syndrome, and a history of inflammatory skin conditions.

Symptoms:

Hidradenitis Suppurativa typically begins with the formation of painful, pea-sized bumps under the skin, which may progress to larger nodules and abscesses. These lesions can rupture, leading to the development of tunnels or tracts beneath the skin, causing further inflammation and scarring. The condition often presents with recurrent flare-ups, interspersed with periods of remission.

Diagnosis:

Diagnosing HS requires a thorough examination by a dermatologist. Medical history, clinical presentation, and physical examination are crucial components of the diagnostic process. In some cases, additional tests such as skin biopsies may be performed to rule out other skin conditions with similar symptoms.

Treatment Options:

While there is no cure for Hidradenitis Suppurativa, various treatment modalities aim to manage symptoms, reduce inflammation, and improve patients' quality of life. Treatment plans are often tailored to the severity of the condition and may include:

    Topical and Oral Medications:
        Antibiotics to control bacterial overgrowth and infection.
        Anti-inflammatory medications to reduce swelling and pain.
        Corticosteroids to alleviate inflammation.

    Lifestyle Modifications:
        Weight management to reduce friction and pressure on affected areas.
        Smoking cessation, as smoking is a known risk factor for HS.

    Intralesional Injections:
        Injections of corticosteroids directly into nodules to reduce inflammation.

    Biologics:
        Advanced treatments, such as biologics, that target specific pathways involved in the inflammatory process.

    Surgical Interventions:
        Drainage of abscesses and removal of damaged tissue.
        Surgical excision for severe cases, although this is typically reserved for advanced stages of the disease.

Patient Support and Management:

Living with Hidradenitis Suppurativa can be challenging, both physically and emotionally. Our dermatology clinic emphasizes the importance of a multidisciplinary approach, including ongoing patient education, psychological support, and regular follow-ups to monitor and adjust treatment plans as needed.

Conclusion:

At our dermatology clinic, we are committed to providing compassionate care and effective management strategies for individuals dealing with Hidradenitis Suppurativa. If you or a loved one is experiencing symptoms of HS, we encourage you to schedule a consultation with our experienced dermatologists. Together, we can work towards improving your skin health and overall well-being.

Vitiligo

 Vitiligo is a disease in which there is milky white discoloration of the skin in some areas due to autoimmunity. Though it goes unnoticed in white skin of western population, it is easily noticeable in colored skin like Indian skin. 

There is a lot of stigma associated with the disease. People even call it with wrong names like leukoderma or leprosy.

 For the people uninitiated, leprosy is a bacterial infection causing slightly whitish discolored patches with loss of sensation over the patches, thickened nerves, tingling numbness of peripheries. 

Leukoderma is white discoloration of skin due to known or evident causes like physical or chemical injury to the skin.

Vitiligo, in contrast, is a disease whose cause is not known. It can affect any age group from congenital vitiligo, childhood vitiligo to vitiligo among elderly. There is no cause known, dietary, environmental or occupational though there is mild genetic predisposition.

The melanocytes are destroyed slowly and the area develops white patches of different morphology. There are many types of vitiligo like generalised vitiligo, lip-finger tip vitiligo, segental vitiligo etc.

The diagnosis is done clinically, by dermoscopy and through skin biopsy.

The treatment is easier in hair-bearing areas as there are some melanocytes still persisting among hair follicles within vitiligo patches. 

The treatment includes oral agents , topical agents , phtotherapy , surgical management, micropigmentation where skin colored pigments are tattooed into skin, cosmetic camouflage like makeup etc.

Oral medicines are of generally 3 types.

1. Nutritional supplements like antioxidants, vit D3 etc.

2. Photosensitizing agents like psoralens which make skin absorb more UV Rays and thereby aid melanin synthesis.

3. Immunosuppressants to reduce autoimmunity; like steroids and steroid sparing agents like azathioprine, methotrexate etc. There is a new molecule tofacitinib which seems to promising too.

Topical agents are very important agents in vitiligo as they can be used without oral medicines in limited area involvent of vitiligo. They include topical psoralens, steroids, fluorouracil, calcipotriol, tacrolimus, pimecrolimus, tofacitinib etc.

Phototherapy using UVA, narrowband UVB, Excimer laser also are very important tools.

Surgeries are only done in stable vitiligo patches which means the patch is not showing any change, neither increase nor decrease in pigmentation for the past 6 months to 2 years.The surgeries include skin grafting, punch grafting, blister grafting, non cultured melanocyte suspension transfer etc.

This is all about the medical aspect of vitiligo.

My information about the disease is certainly not complete as this blog post is meant for general population and the intention of posting it is not just to impart knowledge regarding the disease, but also to drive home completely different aspect of the problem.

 The reality is that the medical or the surgical treatment in vitiligo is "frying pan into fire" like scenario for both doctors and the patients alike.

Vitiligo is completely an  unpredictable disease. Still the prediction which is more appropriate is that the disease is going to recur. The disease activity  usually occurs in bouts and stopping the activity means using steroids or immunosuppressants. These are certainly not good for our body. 

Topical treatment is a big story in itself and a disappointing one. Some agents maynot work in some people, they are expensive, require time for application, can irritate skin. 

In spite of all the efforts the results are not perfect and patches generally recur.

The patients are so ashamed of the disease that they spend huge amount of money, time and their mindspace on treatment and eventually get disillusioned.

Many go into depression. The quality of life of the patient and his/her family members gets extremely poor. Children lag behind in their studies. Marriages get cancelled. There are just too many sad stories.

And surprisingly all of this is just because we have a patchy skin due to auto immunity. 

I am sure each one of us carries some kind of auto immune process in the body at any given point of time. But most are small, hidden or unknown. 

But the skin is the biggest visible organ and our society puts too much emphasis on skin color and we as a society have lost immensely due to our lack of insight into the problem.

Ironically the same society considers the fair skin to be the best one and when this small white patch appears on skin it becomes the black dot on that person's life.

Many a time I try to convince my patients to abandon the treatment and live life happily because they are fighting a losing battle. Unfortunately none accepts this option.

I hope that in the coming years we see more acceptance of vitiligo in the society and every vitiligo patient gets to live life proudly and happily.

Take your lifestyle seriously, not life!

 As doctors, we  go through gamut of emotions on daily basis. In addition to our personal lives and the challenges of running our clinics or hospitals, there are a few things that bother us constantly which are unfortunately beyond our control. Naturally we cannot control everything, but the ones that bother me are genuinely controllable problems if we become more aware and decide to change our thought processes. 

 The issues like sedentary lifestyle, malnutrition, social stigma against vitiligo, reluctance to educate themselves on chronic conditions like psoriasis, atopic dermatitis, self medication, social media influence and misinformation, lack of sex education thereby people risking their lives, rampant usages of steroids- the list goes on. In this piece of writing I will briefly touch upon  lifestyle.

Lifestyle disorders are already the leading cause of morbidity at present if not mortality. The modern inventions have taken us as much backward physically as they have taken us forward technologically. People do not realize the simple fact that human body has evolved over millions of years when it was crucial for human to be physically agile for his survival. Moreover food has always been scarce and they had to hunt, gather or cultivate food which required physically intense activities. Mere 50 years are not enough for us to change the way our body functions. It needs constant movement and calorie restricted organic diet.

As science aspired to make our lives comfortable, we have crossed that line which separated essential inventions that increased our efficiency and inventions that are potentially disastrous for human race.

Agricultural revolution ensuring food safety, advances in medical sciences, quick communication technologies, easy transportation etc have greatly improved our quality of life. But processed food, presence of unending entertainment at the fingertips rendering people immobile for hours, societal norms which pressurize people to assume that a person is successful if he has money; have played complete havoc with human body and minds. 

Most of the children coming to my clinic, whether they are from urban or rural backgrounds eat the most unhealthy diet. Processed food like chips, biscuits, chocolates, pizzas etc form the major part of the children's diet. The majority do not eat green vegetables or fruits. Many are completely sedentary and are obese. 

The people have lost the sense of ideal body weight and the appearance of an overweight person is called 'healthy'. Some parents of completely normal children approach doctors to increase their children's weight because the majority of peer group looks different from their children. 

The society is blissfully unaware of coming catastrophe. Most of the children are obese. Most of the girls have poly cystic ovarian disease, many young people in early twenties have abnormal sugar and lipid profiles, many have early onset of hypertension. The collateral issues which associate with these are infertility, abnormal susceptibility to infections, poor wound healing, knee joint damage, atherosclerosis, metabolic syndrome etc. Many are unaware that these unhealthy lifestyle patterns cause or accelerate a lot of common skin problems like acne, hairfall, melasma, psoriasis, fungal infections etc.

It just takes a little bit of effort and willpower to overcome lifestyle problems. 

Hope you all try.

Diet in dermatology

 Generally, we, the doctors practicing  modern biomedicine or evidence based medicine, do not ask for too many dietary restrictions unlike other complementary medical practitioners, except in a few specific cases.

Dietary restrictions Generally make people restricted in their lives because they are unable to eat certain fruits or commonly used food items like curd, and the dietary restrictions remind them of the diseases that they are suffering from each moment.  This can cause a huge psychological impact on them in addition to depriving them of some most important nutrients.

In dermatology where I find the most common myth being carried forward is avoidance of milk, curd or anything that's looking white among vitiligo patients. This deprives them of very important source of proteins from milk as well as probiotic action of curds. Moreover they are asked to avoid all citrus fruits which are rich on vit C.
I would like to stress on all vitiligo patients that they are free to eat whatever they want in moderation.
There is another common disease called psoriasis where we generally do ask our patients to restrict their salt , sugar and oil intake to prevent metabolic syndrome.  As there is sufficient evidence that psoriasis being an inflammatory disease, the patients are prone to develop metabolic syndrome that comprises of hypertension, diabetes, lipid profile abnormalities, cardiac diseases and their complications.

The young patients with acne are required to have a high fibre, low sugar, low dairy diet with a lot of exercise.

In rosacea, where the central part of the face becomes reddish and shows some acne like lesions we ask patients to avoid hot, spicy food and beverages in addition to avoidance of sun exposure.

In dermatology There are certain dos and don't for a few specific disorders. But overall speaking,  patients must realise that they should eat a low calorie balanced diet rich in fresh fruits and vegetables and they must exercise regularly.

For more queries regarding I request you all to visit your nearest dermatologist rather than following fad diets and self medication.

Hope what I said helped you to some extent.  You take care and stay safe.

Acne vulgaris

                               

Though the acne or pimples are very common among adolescence or young adults, it is better classified as a disease rather than a physiological phenomenon due to inflammatory component and scarring it can cause.

It is a common disease with more than 90% of the people experiencing it sometime or other in their lifetime. Age of onset is between 14-17 years among girls and 16-19 among boys.

Severity of acne is usuallny more among males due to androgen activity. Genetic factors influence the susceptibility to acne.

Causes

1.     Alteration in the pattern of keratinization within the sebaceous follicle

2.     Level of circulating sex hormones, especially androgens

3.     Quantity and quality of sebum production

4.     Colonization by follicular microbial flora

5.     Immunological factors

6.     Environmental factors

Alteration in the pattern of keratinization

The comedones which are the primary lesions of acne are formed by increased production as well as accumulation of keratin in the sebaceous follicles. The stimulus for this may be androgens or the irritating effect of sebum. It is found that the prepubertal girls with inflammatory and comedonal acne have significantly higher levels of androgens. The acceleration in the sebum secretion or its composition may irritate keratinocytes of infundibulum leading to release of inflammatory substances.

The hyperkeratinization leads to decreased barrier function which in turn makes it susceptible to inflammatory agents. Horny plug debris become inflammatory and trigger acne. Increased hydration of comedones causes obstruction of sebum outflow. This mechanism is the cause of tropical acne and premenstrual flare of acne.

Circulating sex hormones

Androgens increase sebum secretion and cause sebaceous gland hyperplasia while estrogens suppress sebaceous gland activity. When there is increased androgen-estrogen ratio there is increase in acne.

Quality and quantity of sebum

Excess sebum secretion and sebaceous gland hypertrophy is seen in acne patients. At the same time there is difference in the composition of sebum too is responsible for inflammation. High levels of wax esters and squalene are found in sebum of acne patients.

Follicular microbial flora

The resident bacterial flora like P.acnes, P.granulosum, p.ovale and Staphylococcus epidermidis play important role in the production of acne. Lipases released by these bacteria cause follicular hyperkeratosis and even rupture of follicles. The materials thus released attract neutrophils and inflammation sets in.

Immunological factors

Various immunological phenomena take place in acne prone skin the details of which are beyond the scope of this article.

Environmental factors

A hot and humid environment aggravates acne due to ductal hydration. The occupations involving exposure to such environments make the persons with pre existing acne more susceptible to acne flares. Emotional stress and strains of various types are known to worsen the condition while natural light often improves acne. External applications of oils, pomades and other comedogenic chemicals cause acneiform eruptions.

Diet plays a role in pathogenesis of acne. Sugar rich diet causes hyperinsulinemia which results in androgen synthesis leading to comedone formation. Diet induced hyperinsulinemia increases insulin like growth factor (IGF-1) causing unregulated growth of follicular epithelium, sebum production and synthesis of androgens from gonads.

Similarly, this insulin like growth factor (IGF-1) is increased on intake of milk and diary products. Milk contains IGF-1 and induces endogenous production as well. Milk also contains androgens. Iodine and low omega fatty acids content of milk also seems to be responsible for acne formation in high glycemic load diet.

Sequence of events

Microcomedo is the first lesion formed due to increased keratinization leading to blockage of sebaceous canal resulting in retension of sebum and initiation of inflammatory reaction. Increase in bacterial flora increases inflammation. Further retention of sebum and release of enzymes causes rupture of the gland. The spread of sebum in dermis adds to the inflammation causing areas of accumulation of fluid, pus and glandular debris. Scar forms on healing the pattern of which is determined by the size and pattern of lesion and individual susceptibility.

Clinical features

The lesions of acne are seen on face, chest, back, shoulders and upper arms. Comedones or the early lesions of acne are chiefly of two types-open and closed. Open comedones represent follicles with dilated follicle.the black dot is caused by oxidization of melanin, transmission of light through compacted epithelium and presence of certain lipids. Closed comedones are small papules without surrounding erythema. There are several subtypes like macrocomedones, sandpaper comedones and submarine comedones all of which do not easily respond to topical therapies.

Grading of acne

Grade 1(mild): comedones, occasional papules

Grade 2(moderate): comedones, many papules, a few pustules

Grade 3(severe): predominantly pustules, nodules and abscesses

Grade 4(cystic): mainly cysts and abscesses ,widespread scarring

Oily skin is always associated feature and seborrhoeic dermatitis also may coexist. Premenstrual flare and postmenstrual improvement is common. Sequelae include hyperpigmentation and various types of scars.

Psychological impact of acne

Patients with severe acne and scarring have shown wide range of psychological abnormalities like depression, suicidal ideation, anxiety, embarrassment, body dysmorphic disorder and social inhibition.

Treatment

Aims of treatment

1.     To reduce follicular bacterial population , reduce lipases

2.     To remove follicular obstruction

3.     To reduce inflammation

4.     To reduce sebaceous gland activity by blocking androgen stimulation.

General measures

1.     Avoid usage of acnegenic drugs, oils, cosmetics.

2.     Stress control.

3.     Rule out hormonal abnormalities.

4.     Regular face wash with proper cleansing agents.

5.     Dietary restrictions as per the personal observation, balanced diet.

Treatment modalities

1.     Mild involvement: Benzoyl peroxide/salicylic acid/azelaic acid topically.

2.     Mild to moderate involvement: Benzoyl peroxide/ tretinoin/adapalene/tazarotene/clindamycin  topically.

3.     Moderate to severe involvement:

a.     Oral antibiotics like doxycycline, minocycline, lymecycline, azithromycin etc.

b.     Isotretinoin

4.     Cystic acne:

a.     Aspiration of cyst or intralesional injection of steroid.

b.     Systemic antibiotics.

c.      Dapsone.

d.     Isotretinoin

5.     Adjunctive therapies like comedo extraction, chemical peels, microdermabrasion, laser and light therapies.

6.     Acne surgeries like draining cysts, punch grafts, resurfacing with laser, cryosurgery, dermarollers, fillers.

[ Reference: IADVL textbook of dermatology]