What are the different types of skin concerns and their treatments?

Common Skin Concerns and Their Treatments

The most common skin concerns include acne vulgaris, psoriasis, atopic dermatitis, vitiligo, basal cell carcinoma, and squamous cell carcinoma in situ, each requiring specific treatment approaches based on severity, type, and patient factors.

Acne Vulgaris

Acne is one of the most prevalent skin conditions with significant impact on emotional functioning, social relationships, and quality of life. Its health-related impact is comparable to chronic conditions like asthma, psoriasis, and arthritis 1.

Classification and Assessment

• Acne severity should be consistently assessed using standardized scales like the Physician Global Assessment (PGA) to guide treatment selection 2
• Evaluation should include impact on quality of life, satisfaction with appearance, and presence of scarring, as these factors may warrant more aggressive treatment 2

Treatment Algorithm by Severity

• Mild Acne:

  • First-line: Topical retinoids (tretinoin, adapalene, tazarotene) + benzoyl peroxide 2
  • Alternative: Azelaic acid for patients with post-inflammatory dyspigmentation 2

• Moderate Acne:

  • First-line: Fixed-dose combination of topical retinoid + benzoyl peroxide 2
  • Add topical antibiotics (clindamycin or erythromycin) for inflammatory lesions, always in combination with benzoyl peroxide to prevent bacterial resistance 2

• Moderate-to-Severe Acne:

  • First-line: Oral antibiotics + topical retinoid + benzoyl peroxide 2
  • Recommended oral antibiotics: doxycycline (strongly recommended) and minocycline (conditionally recommended) 2

• Hormonal Therapy Options:

  • For female patients with hormonal acne: Combined oral contraceptives and spironolactone 2

Key Medications

• Topical Retinoids: Cornerstone of treatment due to comedolytic and anti-inflammatory properties 2

  • Options include tretinoin (0.025-0.1%), adapalene (0.1%, 0.3%), tazarotene (0.05%, 0.1%), and trifarotene 2

• Benzoyl Peroxide: Effective antimicrobial agent (2.5-5% concentrations) with no reported bacterial resistance 2

• Topical Antibiotics: Include clindamycin and erythromycin, always used with benzoyl peroxide 2

• Newer Options:

  • Topical dapsone 5% gel: Particularly effective for inflammatory acne in adult females 2
  • Clascoterone: Topical antiandrogen that inhibits androgen-mediated lipid and inflammatory cytokine synthesis 2

Psoriasis

Psoriasis is a chronic inflammatory condition characterized by scaling patches and plaques 3.

Treatment Approach

• Topical Therapy:

  • First-line: Topical emollients and corticosteroids 3
  • Phototherapy for refractory cases 3

• Systemic Therapy:

  • For moderate-to-severe cases: Biologics and oral medications 1

Atopic Dermatitis

Atopic dermatitis presents with scaling patches and plaques, and may include bullous and vesicular changes 3.

Treatment Options

• First-line: Topical emollients and corticosteroids 3
• Second-line: Phototherapy for refractory cases 3
• Newer Treatments: Topical calcineurin inhibitors and PDE4 inhibitors 4

Vitiligo

Vitiligo is a pigmentation disorder characterized by depigmented patches 3.

Treatment Options

• Topical Therapy:

  • Potent or very potent topical steroids for a trial period of no more than 2 months (risk of skin atrophy) 1
  • Topical pimecrolimus as an alternative to topical steroids (better side-effect profile) 1

• Phototherapy:

  • NB-UVB should be used in preference to PUVA due to greater efficacy and safety 1
  • Safety limits for NB-UVB: 200 treatments for skin types I-III 1

• Surgical Options:

  • Reserved for cosmetically sensitive sites in patients with stable disease (no new lesions, no Koebner phenomenon for 12 months) 1
  • Split-skin grafting provides better cosmetic results than minigraft procedures 1

Basal Cell Carcinoma (BCC)

Treatment Options

• Topical Photodynamic Therapy (PDT):

  • Recommended for superficial BCC, particularly for poorly healing or cosmetically sensitive skin sites, multiple lesions, and large-area lesions 1
  • Consider for thin (<2 mm) nodular BCC when other treatments aren't practical or are contraindicated 1
  • Use red light (not blue or green light, or daylight) for enhanced penetration 1
  • Offer a further cycle of PDT for residual lesions that showed good response to initial treatment 1

• Important Caution:

  • Do not offer topical PDT as a standard treatment for nodular BCC at high-risk sites 1

Squamous Cell Carcinoma in situ (Bowen Disease)

Treatment Options

• PDT is recommended:
  • Particularly for poorly healing or cosmetically sensitive skin sites, multiple lesions, and large-area lesions 1
  • PDT should not be offered for invasive SCC 1

Actinic Keratosis

Treatment Options

• Topical PDT:
  • Recommended particularly for cosmetically sensitive skin sites, multiple lesions, and large-area lesions 1
  • Consider daylight PDT for mild to moderate lesions where pain is likely to be an issue, especially for confluent areas on face or scalp 1
  • Consider combining PDT with other treatment modalities (e.g., imiquimod or pretreatment with ablative fractional laser) for thick lesions 1

Common Pitfalls to Avoid

• For Acne:

  • Using topical antibiotics as monotherapy increases bacterial resistance risk 2
  • Underestimating severity when scarring is present 2
  • Extended use of systemic antibiotics beyond 3-4 months 2
  • Not considering psychological impact, especially with scarring 2

• For Vitiligo:

  • Treating children with phototherapy when they can be managed with more conservative treatments 1
  • Exceeding recommended treatment limits for phototherapy 1

• For Skin Cancers:

  • Using PDT for invasive SCC 1
  • Using PDT for nodular BCC at high-risk sites 1

Diagnostic Considerations

• Dermoscopy is a valuable non-invasive diagnostic tool for various dermatological disorders, helping differentiate between conditions with similar clinical presentations 5
• For complex or atypical presentations, referral to a dermatologist is recommended, as diagnostic accuracy is higher with specialist evaluation 6