Do You Have A Burning Question To Ask?

Our resident Doctor is here to answer all questions that you may have, so why not email your thoughts to Emma O'Callaghan at Emma.O'Callaghan@hsdcomm.com who will forward your query and come back to you with a response.

Q.
I have just been informed by my GP that I have a Solar Keratosis on the bridge of my nose.
He is sending me to see a dermatologist locally and advised that the treatment they use is cryotherapy or dermabrasion.  However, I am afraid of these treatments because the SK is in such a prominent position on my face and it is about a half an inch in length.

 I have read about a topical treatment called diclofenac gel on the internet and would be far happier with this treatment or perhaps Imiquimod cream (but I have read that this results in a lot of irritation). Do you think I would have more options if I went for private treatment? I would be very grateful for your opinion or thoughts as which treatment would be best.

A.
Solar Keratosis may be treated using surgical or non surgical methods such as currettage (scraping out), Cryotherapy (freezing), photodynamic therapy (PDT) or topical drug treatment.  The choice of which method is best suited depends largely on the size, depth, location and number of lesions.  Discuss your concerns with your dermatologist and they will go through all of your treatment options with you.  Treatment of a solar keratosis requires removal of the defective skin cells and can usually be easily and successfully treated if they are detected at an early stage, however, if left untreated, the lesion may progress and develop into a more serious form of non-melanoma skin cancer called squamous cell carcinoma (SCC).

Cryotherapy with liquid nitrogen is very effective, especially if lesions are few. In white skin it leaves little scaring or colour change. Dermabrasion and chemical peels are another option for facial and scalp lesions, however, there is a risk of recurrence six months after chemical peel treatment has been undertaken.  Solaraze (Diclofenac gel) is a nonsteroidal anti-inflammatory drug (NSAID) which is used for the treatment of Actinic Keratosis and is usually well tolerated, treatment is usually twice a day for 60-90 days.  Other topical treatments such as Efudix (5-florouracial -5-FU) or Aldara (immiquimod cream 5%) are both particularly effective treatments, but are stronger and so inevitably cause more inflammation. The advantage of topical treatments if effective is the minimal scarring and repeatability as SK not only return but are multiple increasing with age.

I would also ask your dermatologist to check other areas of your skin, as SK is a sign of sun damage and it is likely that you may also have other sundamaged skin, on other parts of your body such as your back that have also been previously exposed to the sun. Also remember to always use a sunblock of at least factor 30 (even during winter) daily to protect your skin from any further sun damage and wear protective clothing (long sleeved shirts and hats).  Try to limit all sun exposure whether recreational or work related and try to avoid sun in tropical areas and remember to seek shade particularly when the sun is high between 11am and 3pm.

Q.
I have Bowens Disease mainly on my legs and arms.  I have tried many creams, PTD therapy and other treatments but to no avail and I feel that my body is now not coping with any of these creams anymore.  The Aldara cream which I used last affected all of my nerve endings and was very painful.

 My specialist has now recommended that I try Solaraze gel.  She said if it does not do any good it won’t do any harm.  Please can you advise me of your opinion of this treatment.  She has told me to use it twice a day for 60 to 70 days which seems very severe to me. 
 Please could I have your comments and do you know anybody who I could contact to speak to about my bowen's disease as nobody seems to be able to do anymore for me and I am very frustrated and uncomfortable with this.

A.
Bowen’s Disease is the name for a pre-invasive form of non-melanoma skin cancer which is in situ, Squamous Cell Carcinoma (SCC) and can also be known as squamous cell carcinoma-in-situ.  Pre-invasive means that cancer cells are present, but are only in the outermost layer of skin, the epidermis.  This means that while non progressive the cancer cells will not spread to the lymph nodes via vessels in the skin, but it does often spread along the skin surface.  If exposed to more sunburn and left untreated, Bowen's disease could spread deeper into the deeper layers of the skin (invasive SCC cancer) and may spread into the lymphatic system, however, it takes a long time for Bowen's disease to develop into an invasive cancer.  But although low, the risk of developing into a cancer remains as long as the Bowen's is present especially on the lip, genitals and fingers.

Like squamous cell carcinoma of the skin, Bowen's disease can grow anywhere and is most common on the trunk, arms or legs.  There are many effective treatments such as, chemotherapy creams which are applied onto affected skin, freezing with liquid nitrogen and various types of surgery.

Solaraze (Diclofenac gel) is a nonsteroidal anti-inflammatory drug (NSAID) which is used for the treatment of Actinic Keratosis (AK) and is usually well tolerated.  AK unlike Bowens does not usually involve the full thickness of the epidermis. It is not a severe treatment and may take more than 90 days, but these treatments are reliant on accurate pathological sampling pre and post treatment to ensure successful cure.

Q.
I am 33 years old and have had a fair bit of sun exposure in the past, I have worked in Saudi Arabia for several years and have on occasion used sunbeds.  I have noticed a small red lesion on my chest/neck which i am concerned could be a BCC.  I have seen my GP who thinks the same and has referred me to a dermatologist.  The skin on my chest area has been sunburnt in the past and now appears quite sun damaged.  I wondered if there is anything that could be prescribed to improve the appearance of the skin in this area?

A.
This could be a BCC but to be sure your dermatologist should do a biopsy to get confirmation as it may also be a SCC or even an amelanotic (without pigment) malignant melanoma.  I would suggest that it is imperative that you use emollients on a daily basis that contain an SPF of at least factor 15 and when on holiday, to reduce further photodamage, use suncreams of no less than factor 30 repeatedly.

Whilst the lesion in question is visible, with any sun damage on the skin there is a risk that the damaged area may show signs of further damage in the future so once treatment has been received for this lesion please be vigilant in checking your skin on a regular basis for any further new marks or lesions and consult your GP immediately if you notice anything suspicious. I would also advise that your dermatologist checks all of your skin and shows you how to identify anything sinister while you are there.

Q.
I have quite a lot of small red pinhead sized spots on my face and have been asked to use the efudix cream.. It is a very severe cream and my dose is once a day for 2 weeks. I am wondering if there is any scarring also if i can use a moisturiser whilst treatment is in progress as I have very dry skin at the best of times...perhaps something like sorbolene or similar ? Also what would your recommendation be for a suitable produce for a mature skin ? There is a lot of products available but also a lot of hype. I am 66 years old and slim 52 kgs fit and very few wrinkles (so far) !! and am wondering which to select. I live on the Gold Coast Qld. Aust. but by no means am I a sun person.

A.
It sounds to me like the small ‘pinhead sized spots’ are a skin condition, resulting from culmative over exposure to the sun, called solar keratoses (SKs).   SKs are not life threatening and appear in the form of small raised rough patches on the skin and are often pink, red or brown in colour, however if left untreated they can sometimes lead to a form of skin cancer known as squamaous cell carcinoma (SCC) so it important to at least monitor and if necessary keep up with the treatment prescribed by your GP.  However, there are a few treatment options available, Efudix is an effective treatment, but does have the inevitable side effects of skin inflammation including blistering; this is how it works to clear the SKs. Therefore if you are finding it too severe there is a ‘gentler’ gel called Solaraze (3% diclofenac sodium) which is a topical gel also available on prescription.  Other treatments currently available and commonly used to treat and manage SK include surgery such as scraping (curretage), freezing (cryosurgery) and other licensed topical treatments such as Aldara.

I would recommend not using moisturiser in the therapy phase as this will dilute any benefit.  After therapy is complete using a moisturiser is fine and I would recommend wearing a high SpF sunscreen on a daily basis.  Moreover an anti ageing cream containing vitamin A and/or vitamin C may also be helpful.

Q.
Due to over exposure on sun beds for many years my skin is now looking older than persons 20 years my senior. I know it can age skin, but is there anything I can now do to regenerate my skin or is it too late?

A.
Sun damage can cause many changes in our skin, including aging, roughness of texture, discoloration (sun spots/freckles), wrinkles, loss of elasticity, and of course, skin cancer.

Unfortunately, we can’t turn back time to alter what we did (or didn’t do) to our skin as teenagers and young adults. However, it is not too late to start protecting it now to stop any further damage.  Going forward, stop using sun beds and make sure you always apply a high protection sun cream (SPF 25 plus) every day when going outside (even in the winter!).  Reduce sun exposure as much as possible and try to stay in the shade during the hottest part of the day (12-3pm).... and wear a hat!

To keep your skin in good condition, I recommend a daily routine of using moisturisers, avoiding smoking, eating healthily and drinking plenty of water. Temporary improvement can be gained with vitamin A/C anti aging creams which are widely available (however, some are better than others). To cosmetically improve the appearance of sun-damaged and aging skin you could also consider the following physical treatments, but always do your homework on the potential risks!:

Microdermabrasion is an abrasive action of tiny crystals delivered under pressure to remove the superficial layer of the epidermis way, to remove the superficial, dead and damaged cells from the surface of the skin.  The most effective microdermabrasion machines are used by cosmetic doctors, but “salon-grade” treatments are available at some spas.

Chemical Peels involve the application of chemicals to the skin to perform a ‘chemical peel’, which results in exfoliation and skin regeneration.  Older, rough, and damaged skin cells are exfoliated, allowing regeneration of new, healthier cells from the layers underneath. Superficial chemical peels are not painful and do not cause significant “down time”. They can be used in conjunction with microdermabrasion for an enhanced effect. As with superficial laser therapy all physical therapy may alter final skin pigmentation and infection must be avoided post operatively. Make sure you choice a competent practitioner.

It is also vital to keep a close eye on your skin and look out for any unusual marks or changes which may result from your sun overexposure.  One common condition which is a result of over exposure to the sun is solar keratosis.  This may appear in the form of small raised rough patches on the skin and are often pink, red or brown in colour.  Whilst not life threatening these can sometimes lead to skin cancer so it is best to get any new or unusual mark checked out by your doctor who can treat them easily with a prescription cream or gel.  

But remember.... the only “healthy tan is a fake tan. Protection of your skin from UV light exposure is the most important commitment you can make keep your skin healthy and younger looking!

Q.
I was wondering if you could tell me a little bit more on why the sun bed is more harmful then being outside.  I have always tanned indoors thinking it was safer because when I lay out side I always burn my face, chest and back.  When I tan indoors the salon staff always put me in the tanning bed for 5 to 7 min the 1st few times so i will not get burned and I never have gotten a sun burn from a tanning bed.  I fell as if tanning indoors I can control the amount of sun exposure I get and when I tan outdoors I cannot.    Is this a wrong attitude to have.  I love to have a little bit of colour and I feel so much better after getting out of a tanning bed so I don't want to give it up, I am very concerned about my skin though!

A.
I am afraid that there is no such thing as a safe tan! Moreover, you will wrinkle before your time! And if you are concerned about your skin my advice would be to stop using sunbeds and switch to fake tans instead!

The tan produced by a sun bed in a tanning salon is not as deep as a tan produced in the sun as tanning beds have higher overall levels of UV than the sun on a typical day, so the exposure times are shorter than the average session spent in the sun to achieve the same amount of tan. Overexposure to UV rays actually destroys melanin (the skin’s natural defense from the sun) and greatly increases your chances of skin cancer later in life.

If you do not want to give up the bronzed glow, there are many ways of safely achieving this look without damaging your skin.  Chose from salon professional spray tans, which can last up to a week, to fake tans that you apply at home and simply wash off.  Alternatively for that every day glow why not use a daily moisturiser that contains a small amount of fake tan in it, such as Johnson’s Holiday skin, touch of Sunshine, by Olay or Dove, Summer Glow.

Q.
My GP has treated three lesions on my back by freezing. This resulted in big blisters and then scabs, very unsightly! As I have two areas on my face I want treated how else can they be treated as I don’t fancy that treatment there?

A.
Cryotherapy , cryosurgery (or freezing) is a very common procedure used to treat skin lesions both in primary (General Practice) and Secondary (Hospital) care.  It is the application of extreme cold usually by liquid nitrogen spray, to destroy abnormal or diseased tissue, by freezing the lesion. The procedure is used often because of its efficacy and low rates of side effects.  However, it can result in temporary unsightly blisters as you have experienced!  Cryotherapy can be used to treat lesions on the face, however, you may consider alternative options if you have a dark complexion due to potential risks of post-inflammatory pigmentary problems (although scaring is rare!)

As an alternative, you could ask for a topical treatment, such as Solaraze (Diclofenac 3% gel) which is usually well tolerated but may take some weeks, or either Efudix (5-Fluorouracial - 5-FU) or Aldara (Imiquimod 5% cream) both of which are stronger but inevitably cause inflammation to be effective.  Alternatively a procedure called currettage (surgical scraping) which is carried out after numbing the skin with local anaesthetic would be effective. The lesion is removed with a ‘curette’ which is a spoon-shaped instrument with a sharp edge. The advantage of such a procedure would be the benefit of historical assessment but scaring is more likely.

Q.
Is going into the real sun as bad for you as using sun beds? Is it ok to use sun beds wisely as long as you use protective cream for sun beds?

A.
Whether you get your tan naturally from the sun or from using a sun bed, it is a sign that the skin has been damaged, particularly in vulnerable fair skinned individuals, as a tan is your body's attempt to protect itself from the damaging effect of UV rays.  Sun beds are adapted to mimic the natural sun's UV rays and often to intensify it, so in half an hour on a sun bed you'll get far more exposure than spending the same amount of time in the outdoor sun. Tans from sun beds are considered more dangerous than tanning naturally in the sun, as the UV radiation penetrates deeper into the skin. Sun beds emit predominantly UVA and some UVB rays, both of which damage the DNA in cells of the skin, however in recent years lamps of sun beds have been manufactured to produce higher levels of UVB which speed up the tanning process but also lead to premature ageing and possible development of skin cancers!

In contrast, some time in the outdoor sun is in fact healthy for us as it enables our body to produce its own Vitamin D as well as Melatonin which helps us to sleep at night but obviously this has to be used in moderation!  However in the same way as sun beds, overexposure to UV rays from the outdoor sun is just as likely to result in the development of both melanoma and non-melanoma skin cancers, even with the use of sunscreen! 

Just remember, there is no way of sunbathing without damaging your skin and definitely no such thing as a safe suntan!

Q.
Hello, I was told by a dermatologist that I have had a keratosis - that it was linked to skin damage and that I would not need to see him again. Apart from high protection factor sun cream is there anything else I need to know about it please?
Mary Simpson

A.
A ‘Solar Keratosis’, or ‘sun wart’ is damage to the skin caused by the sun.  They are a common indicator of sun damage, resulting from cumulative sun exposure and burning over the years.  They appear in the form of small raised rough patches on the skin and are often pink, red or brown in colour.  Whilst not ‘life threatening’, in vulnerable individuals with many, SKs can sometimes lead to non-melanoma skin cancer. 

Fortunately, if diagnosed early, SK is one of the most treatable forms of skin damage. There are different treatment options that are available depending on the size, the number of lesions that you have; and your personal treatment preference, these include:
Freezing (often referred to as cryotherapy) where the lesion is sprayed with liquid nitrogen which destroys the tissue which then falls off a few days later, leaving a small scab until the fresh healthy skin has grown through.
Curettage (scraping) is a procedure that is carried out after numbing the skin with local anaesthetic. The lesion is removed with a ‘curette’ which is a spoon-shaped instrument with a sharp edge.
Or you may prefer a medicated cream or gel available on prescription such as Solaraze Diclofenac 3% gel, Efudix 5-fluorouracil (5-FU) cream or Aldara, Imiquimod 5% cream.

Q.
Having had an outdoor hobby (horse riding) for 18 yrs and a job for the last 3 yrs involving a lot of outdoor work I am concerned about a red mark on my forearm. I first noticed this mark at the end of last year (2006) it does itch occasionally and the skin becomes flaky. I saw my own GP who checked it under a hand held magnifying glass and said it was nothing to worry about. This mark does become more prominent when exposed to the sun’s rays even if sun screen is used. The mark at present is smooth and shinny and is not causing any problems, do you think I need a second opinion or leave it and see if anything else develops.
Your thoughts would be very much appreciated.
regards
Liz Smith

A.
This sounds like it may be an inflamed or irritated seborhoeic keratosis which is a benign and non infective dry lesion, that may varying in colour from light to dark brown when not inflamed. These marks are very common, harmless skin lesions that may appear in middle aged adult life and never become malignant.  Treatment is rarely necessary and if required, would usually consist of emollients, exfoliation or sometimes cryotherapy (freezing).
However, it may also be Bowen’s disease , which is a very early type of non-melanoma skin cancer, which usually appears as reddened patches on the skin. If left untreated, it can develop into a more aggressive form of squamous cell carcinoma.   My advice is to seek a second opinion for peace of mind. A definitive diagnosis can be made by taking a pathological skin sample. Often examination by dermoscopy can differentiate both.