Call Us

(718) 253-2053

Our Location
Eliot Y Ghatan,MD, PC Dermatology, Cosmetic & Laser Surgery

1226 Ocean Parkway
Brooklyn, NY 11230

1226 Ocean Parkway
Brooklyn, New York 11230

(718) 253-2053


Learn more about how our Dermatology services can help you and your family to have healthy skin.

Can I Prevent Acne?

Contrary to what you may have heard, acne is not caused by dirty skin, eating chocolate, or drinking lots of soda. Acne is caused by overactive oil glands in the skin. These glands become stimulated with the hormones that come with puberty. Some people have more of a reaction to their hormone levels than others.

Although there is no surefire way to prevent acne, there are several ways to help reduce the number and severity of your breakouts.

Although washing your skin is essential (it helps remove excess surface oils and dead skin cells that can clog your pores), washing too much can actually cause damage by overdrying your skin or irritating existing acne.

As a general rule, wash your skin twice a day with a mild soap and water. Avoid harsh alcohol-based cleansers and cleansers that contain oil and use your hands instead of a washcloth. Never scrub your skin and always gently pat it dry with a clean towel.

Remember to wash after exercising because sweat can clog your pores and make your acne worse. If you work around greasy food or oil or if you've been sweating from heat or because you've been working hard, wash your face and other acne-prone areas as soon as possible.

If you use skin products, such as lotions or makeup, look for ones that are noncomedogenic or nonacnegenic, which means that they don't clog pores.

If you can't live without your hair spray or styling gel, be sure to keep them away from your face as much as possible. Many hair products contain oils that can make acne worse. Wash your sheets and pillowcases frequently to avoid sleeping on built-up dirt, oil, or dead skin cells.

If you get acne on areas such as your chest or back, avoid wearing tight clothes, which can rub and cause irritation.

Some teens find that over-the-counter products available that can help clear up prevent acne. It may take some time to find the one that works best for you - some may not do the trick and others may cause irritation.

What about pimples you already have? It's a tempting thought, but popping or squeezing a pimple usually won't get rid of the problem. Squeezing can actually push infected material and pus further into the skin, which can lead to more swelling, redness, and even scarring.

In general, acne decreases through time, though some adults continue to get pimples. Many teens choose to see a doctor to get professional treatment. This might involve prescription gels or creams, pills, or a combination of both. It may feel pretty awkward or embarrassing to talk about your acne with someone, especially a stranger, but your doctor is trained to help get your skin looking its best.

Even if your skin clears up, you should finish your entire prescription unless your dermatologist says you can stop. If you stop too early, there's a chance your skin could break out all over again.

Reviewed by: Neil Izenberg, MD
Date reviewed: June 2002
Originally reviewed by: Patrice Hyde, MD

Acne FAQ

What Is Acne?

Acne is a disorder resulting from the action of hormones on the skin's oil glands (sebaceous glands), which leads to plugged pores and outbreaks of lesions commonly called pimples or zits. Acne lesions usually occur on the face, neck, back, chest, and shoulders. Nearly 17 million people in the United States have acne, making it the most common skin disease. Although acne is not a serious health threat, severe acne can lead to disfiguring, permanent scarring, which can be upsetting to people who are affected by the disorder.

How Does Acne Develop?

Doctors describe acne as a disease of the pilosebaceous units (PSUs). Found over most of the body, PSUs consist of a sebaceous gland connected to a canal, called a follicle, that contains a fine hair (see "Normal Pilosebaceous Unit" diagram, below). These units are most numerous on the face, upper back, and chest. The sebaceous glands make an oily substance called sebum that normally empties onto the skin surface through the opening of the follicle, commonly called a pore. Cells called keratinocytes line the follicle.

The hair, sebum, and keratinocytes that fill the narrow follicle may produce a plug, which is an early sign of acne. The plug prevents sebum from reaching the surface of the skin through a pore. The mixture of oil and cells allows bacteria Propionibacterium acnes (P. acnes) that normally live on the skin to grow in the plugged follicles. These bacteria produce chemicals and enzymes and attract white blood cells that cause inflammation. (Inflammation is a characteristic reaction of tissues to disease or injury and is marked by four signs: swelling, redness, heat, and pain.) When the wall of the plugged follicle breaks down, it spills everything into the nearby skin--sebum, shed skin cells, and bacteria--leading to lesions or pimples.

People with acne frequently have a variety of lesions, some of which are shown in the diagrams below. The basic acne lesion, called the comedo (KOM-e-do), is simply an enlarged and plugged hair follicle. If the plugged follicle, or comedo, stays beneath the skin, it is called a closed comedo and produces a white bump called a whitehead. A comedo that reaches the surface of the skin and opens up is called a blackhead because it looks black on the skin's surface. This black discoloration is not due to dirt. Both whiteheads and blackheads may stay in the skin for a long time.

What Causes Acne?

The exact cause of acne is unknown, but doctors believe it results from several related factors. One important factor is an increase in hormones called androgens (male sex hormones). These increase in both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormonal changes related to pregnancy or starting or stopping birth control pills can also cause acne.

Another factor is heredity or genetics. Researchers believe that the tendency to develop acne can be inherited from parents. For example, studies have shown that many school-age boys with acne have a family history of the disorder. Certain drugs, including androgens and lithium, are known to cause acne. Greasy cosmetics may alter the cells of the follicles and make them stick together, producing a plug.

Factors That Can Make Acne Worse

Factors that can cause an acne flare include:

• Changing hormone levels in adolescent girls and adult women 2 to 7 days before their menstrual period starts
• Friction caused by leaning on or rubbing the skin
• Pressure from bike helmets, backpacks, or tight collars
• Environmental irritants, such as pollution and high humidity
• Squeezing or picking at blemishes
• Hard scrubbing of the skin.

Myths About the Causes of Acne

There are many myths about what causes acne. Chocolate and greasy foods are often blamed, but foods seem to have little effect on the development and course of acne in most people. Another common myth is that dirty skin causes acne; however, blackheads and other acne lesions are not caused by dirt. Finally, stress does not cause acne.

Who Gets Acne?

People of all races and ages get acne. It is most common in adolescents and young adults. Nearly 85 percent of people between the ages of 12 and 24 develop the disorder. For most people, acne tends to go away by the time they reach their thirties; however, some people in their forties and fifties continue to have this skin problem.

How Is Acne Treated?

Acne is often treated by dermatologists (doctors who specialize in skin problems). These doctors treat all kinds of acne, particularly severe cases. Doctors who are general or family practitioners, pediatricians, or internists may treat patients with milder cases of acne.

The goals of treatment are to heal existing lesions, stop new lesions from forming, prevent scarring, and minimize the psychological stress and embarrassment caused by this disease. Drug treatment is aimed at reducing several problems that play a part in causing acne: abnormal clumping of cells in the follicles, increased oil production, bacteria, and inflammation. Depending on the extent of the person's acne, the doctor will recommend one of several over-the-counter (OTC) medicines or prescription medicines that are topical (applied to the skin) or systemic (taken by mouth). The doctor may suggest using more than one topical medicine or combining oral and topical medicines.

Treatment for Blackheads, Whiteheads, and Mild Inflammatory Acne

Doctors usually recommend an OTC or prescription topical medication for people with mild signs of acne. Topical medicine is applied directly to the acne lesions or to the entire area of affected skin.

Benzoyl peroxide, resorcinol, salicylic acid, and sulfur are the most common topical OTC medicines used to treat acne. Each works a little differently. Benzoyl peroxide is best at killing P. acnes and may reduce oil production. Resorcinol, salicylic acid, and sulfur help break down blackheads and whiteheads. Salicylic acid also helps cut down the shedding of cells lining the follicles of the oil glands. Topical OTC medications are available in many forms, such as gel, lotion, cream, soap, or pad.

In some patients, OTC acne medicines may cause side effects such as skin irritation, burning, or redness. Some people find that the side effects lessen or go away with continued use of the medicine. Severe or prolonged side effects should be reported to the doctor.

OTC topical medicines are somewhat effective in treating acne when used regularly. Patients must keep in mind that it can take 8 weeks or more before they notice their skin looks and feels better.

Treatment for Moderate to Severe Inflammatory Acne

Patients with moderate to severe inflammatory acne may be treated with prescription topical or oral medicines, alone or in combination.

Prescription Topical Medicines

Several types of prescription topical medicines are used to treat acne, including antibiotics, benzoyl peroxide, tretinoin, adapalene, and azelaic acid. Antibiotics and azelaic acid help stop or slow the growth of bacteria and reduce inflammation. Tretinoin, a type of drug called a retinoid that contains an altered form of vitamin A, is an effective topical medicine for stopping the development of new comedones. It works by unplugging existing comedones, thereby allowing other topical medicines, such as antibiotics, to enter the follicles. The doctor may also prescribe newer retinoids or retinoid-like drugs, such as tazarotene or adapalene, that help decrease comedo formation.

Like OTC topical medicines, prescription topical medicines come as creams, lotions, solutions, or gels. The doctor will consider the patient's skin type when prescribing a product. Creams and lotions provide moisture and tend to be good for people with sensitive skin. Gels and solutions are generally alcohol based and tend to dry the skin. Therefore, patients with very oily skin or those who live in hot, humid climates may prefer them. The doctor will tell the patient how to apply the medicine and how often to use it.

Some people develop side effects from using prescription topical medicines. Initially, the skin may look worse before improving. Common side effects include stinging, burning, redness, peeling, scaling, or discoloration of the skin. With some medicines, like retinoids, these side effects usually decrease or go away after the medicine is used for a period of time. Patients should report prolonged or severe side effects to their doctor. Between 4 and 8 weeks will most likely pass before patients see their skin improve.

Prescription Oral Medicines

For patients with moderate to severe acne, the doctor often prescribes oral antibiotics (taken by mouth). Oral antibiotics are thought to help control acne by curbing the growth of bacteria and reducing inflammation. Prescription oral and topical medicines may be combined. For example, benzoyl peroxide may be combined with clindamycin, erythromycin, or sulfur. Other common antibiotics used to treat acne are tetracycline, minocycline, and doxycycline. Some people have side effects when taking these antibiotics, such as an increased tendency to sunburn, upset stomach, dizziness or lightheadedness, and changes in skin color. Tetracycline is not given to pregnant women, nor is it given to children under 8 years of age because it might discolor developing teeth. Tetracycline and minocycline may also decrease the effectiveness of birth control pills. Therefore, a backup or another form of birth control may be needed. Prolonged treatment with oral antibiotics may be necessary to achieve the desired results.

Treatment for Severe Nodular or Cystic Acne

People with nodules or cysts should be treated by a dermatologist. For patients with severe inflammatory acne that does not improve with medicines such as those described above, a doctor may prescribe isotretinoin (Accutane*), a retinoid. Isotretinoin is an oral drug that is usually taken once or twice a day with food for 15 to 20 weeks. It markedly reduces the size of the oil glands so that much less oil is produced. As a result, the growth of bacteria is decreased.

* Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

Advantages of Isotretinoin (Accutane)

Isotretinoin is a very effective medicine that can help prevent scarring. After 15 to 20 weeks of treatment with isotretinoin, acne completely or almost completely goes away in up to 90 percent of patients. In those patients where acne recurs after a course of isotretinoin, the doctor may institute another course of the same treatment or prescribe other medicines.

Disadvantages of Isotretinoin (Accutane)

Isotretinoin can cause birth defects in the developing fetus of a pregnant woman. It is important that women of childbearing age are not pregnant and do not get pregnant while taking this medicine. Women must use two separate effective forms of birth control at the same time for 1 month before treatment begins, during the entire course of treatment, and for 1 full month after stopping the drug. They should ask their doctor when it is safe to get pregnant after they have stopped taking Accutane.

Some people with acne become depressed by the changes in the appearance of their skin. Changes in mental health may be intensified during treatment or soon after completing a course of medicines like Accutane. A doctor should be consulted if a person feels unusually sad or has other symptoms of depression, such as loss of appetite or trouble concentrating.

Other possible side effects include dry eyes, mouth, lips, nose, or skin; itching; nosebleeds; muscle aches; sensitivity to the sun; and, sometimes, poor night vision. More serious side effects include changes in the blood, such as an increase in triglycerides and cholesterol, or a change in liver function. To make sure Accutane is stopped if side effects occur, the doctor monitors blood studies that are done before treatment is started and periodically during treatment. Side effects usually go away after the medicine is stopped.

Treatments for Hormonally Influenced Acne in Women

Clues that help the doctor determine whether acne in an adult woman is due to an excess of androgen hormones are hirsutism (excessive growth of hair in unusual places), premenstrual acne flares, irregular menstrual cycles, and elevated blood levels of certain androgens. The doctor may prescribe one of several drugs to treat women with this type of acne. Low-dose estrogen birth control pills help suppress the androgen produced by the ovaries. Low-dose corticosteroid drugs, such as prednisone or dexamethasone, may suppress the androgen produced by the adrenal glands. Finally, the doctor may prescribe an antiandrogen drug, such as spironolactone (Aldactone). This medicine reduces excessive oil production. Side effects of antiandrogen drugs may include irregular menstruation, tender breasts, headache, and fatigue.

Other Treatments for Acne

Doctors may use other types of procedures in addition to drug therapy to treat patients with acne. For example, the doctor may remove the patient's comedones during office visits. Sometimes the doctor will inject cortisone directly into lesions to help reduce the size and pain of inflamed cysts and nodules.

Early treatment is the best way to prevent acne scars. Once scarring has occurred, the doctor may suggest a medical or surgical procedure to help reduce the scars. A superficial laser may be used to treat irregular scars. Another kind of laser allows energy to go deeper into the skin and tighten the underlying tissue and plump out depressed scars. Dermabrasion (or microdermabrasion), which is a form of "sanding down" scars, is sometimes combined with the subsurface laser treatment. Another treatment option for deep scars caused by cystic acne is the transfer of fat from one part of the body to the face.

How Should People With Acne Care for Their Skin?

Clean Skin Gently

Most doctors recommend that people with acne gently wash their skin with a mild cleanser, once in the morning and once in the evening and after heavy exercise. Some people with acne may try to stop outbreaks and oil production by scrubbing their skin and using strong detergent soaps and rough scrub pads. However, scrubbing will not improve acne; in fact, it can make the problem worse. Patients should ask their doctor or another health professional for advice on the best type of cleanser to use. Patients should wash their face from under the jaw to the hairline. It is important that patients thoroughly rinse their skin after washing it. Astringents are not recommended unless the skin is very oily, and then they should be used only on oily spots. Doctors also recommend that patients regularly shampoo their hair. Those with oily hair may want to shampoo it every day.

Avoid Frequent Handling of the Skin

People who squeeze, pinch, or pick their blemishes risk developing scars or dark blotches. People should avoid rubbing and touching their skin lesions.

Shave Carefully

Men who shave and who have acne can test both electric and safety razors to see which is more comfortable. Men who use a safety razor should use a sharp blade and soften their beard thoroughly with soap and water before applying shaving cream. Nicking blemishes can be avoided by shaving lightly and only when necessary.

Avoid a Sunburn or Suntan

Many of the medicines used to treat acne can make a person more prone to sunburn. A sunburn that reddens the skin or suntan that darkens the skin may make blemishes less visible and make the skin feel drier. However, these benefits are only temporary, and there are known risks of excessive sun exposure, such as more rapid skin aging and a risk of developing skin cancer.

Choose Cosmetics Carefully

People being treated for acne often need to change some of the cosmetics they use. All cosmetics, such as foundation, blush, eye shadow, and moisturizers, should be oil free. Patients may find it difficult to apply foundation evenly during the first few weeks of treatment because the skin may be red or scaly, particularly with the use of topical tretinoin or benzoyl peroxide. Oily hair products may eventually spread over the forehead, causing closed comedones. Products that are labeled as noncomedogenic (do not promote the formation of closed pores) should be used; in some people, however, even these products may cause acne.

What Research Is Being Done on Acne?

Medical researchers are working on new drugs to treat acne, particularly topical antibiotics to replace some of those in current use. As with many other types of bacterial infections, doctors are finding that, over time, the bacteria that are associated with acne are becoming resistant to treatment with certain antibiotics. Research is also being conducted by industry on the potential side effects of isotretinoin and the long-term use of medicines used for treating acne.

Scientists are working on other means of treating acne. For example, researchers are studying the biology of sebaceous cells and testing a laser in laboratory animals to treat acne by disrupting sebaceous glands. Scientists are also studying the treatment of androgenic disorders, including acne, in men by inhibiting an enzyme that changes testosterone to a more potent androgen.

Where Can People Find More Information on Acne?

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484 or 877-22-NIAMS (226-4267) (free of charge)
TTY: 301-565-2966
Fax: 301-718-6366

NIAMS provides information about various forms of arthritis and rheumatic disease and bone, muscle, joint, and skin diseases. It distributes patient and professional education materials and refers people to other sources of information. Additional information and updates can also be found on the NIAMS Web site.

American Academy of Dermatology
P.O. Box 4014
Schaumburg, IL 60168-4014
Phone: 847-330-0230 or 888-462-3376 (free of charge)
Fax: 847-330-0050

This national organization can provide referrals to dermatologists. It also publishes a brochure on acne for adults and a fact sheet for young people. These are available on the organization's Web site or can be obtained by calling or writing to the academy.


The NIAMS gratefully acknowledges the assistance of Robert Katz, M.D., Rockville, MD; Larry Miller, M.D., Chevy Chase, MD; Alan Moshell, M.D., NIAMS, NIH; Gary Peck, M.D., Washington Hospital Center, Washington, DC; and Maria Turner, M.D., National Cancer Institute, NIH, in the preparation and review of this booklet.

The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH), is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases, the training of basic and clinical scientists to carry out this research, and the dissemination of information on research progress in these diseases. The National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse is a public service sponsored by the NIAMS that provides health information and information sources. Additional information can be found on the NIAMS Web site at

This booklet is not copyrighted. Readers are encouraged to duplicate and distribute as many copies as needed.

Additional copies of this booklet are available from

National Institute of Arthritis and Musculoskeletal
and Skin Diseases (NIAMS) Information Clearinghouse
National Institutes of Health (NIH)
1 AMS Circle
Bethesda, MD 20892-3675

NIH Publication No. 01-4998

Actinic Keratoses

Actinic keratoses (AKs) are known as the early beginnings of skin cancer. This most common lesion of the outermost layer of the skin (epidermis) is caused by long-term exposure to sunlight (specifically to ultraviolet wavelengths). AKs are most likely to appear after age 40-50, and years of chronic exposure to the sun. However, in geographic areas with year-round high-intensity sunlight (e.g., Florida, southern California) AKs are now found in persons as young as the teens and twenties. The incidence of AKs is over 50 percent in older, fair-skinned persons in hot, sunny geographic areas.

AKs are defined as a cutaneous dysplasia of the epidermis (the outermost layer of skin). In everyday terms, AKs are an alteration in size, shape and organization of skin cells. The cells most affected in AKs are the keratinocytes, the tough-walled cells that make up more than 90 percent of the epidermis and give the skin its texture. Cellular alterations in AKs may extend into the dermis, the layer of skin under the epidermis. The most significant cause of actinic keratoses is long-term exposure to sunlight, and specifically to the ultraviolet wavelengths of solar radiation. The most significant predisposing factor to AKs is fair skin.

The alteration in growth and differentiation of keratinocytes is manifested in the clinical features of AKs—rough, scaly skin, "bumps" on the skin, mottled skin, and cutaneous horn. Alterations in cell growth and differentiation also set the stage for transformation of AKs into invasive squamous cell carcinoma.

Allergic Skin Conditions

Red, bumpy, scaly, itchy, swollen skin-any of these symptoms can signify an allergic skin condition. These kin problems are often caused by an immune system reaction, signifying an allergy. Allergic skin conditions can take several forms and are due to various causes.

Hives and Angioedema

Hives or urticaria are red, itchy, swollen areas of the skin that can range in size and appear anywhere on the body. Approximately 25% of the U.S. population will experience an episode of hives at least once in their lives. Most common are acute cases of hives, where the cause is identifiable-often a viral infection, drug, food or latex. These hives usually go away spontaneously. Some people have chronic hives that occur almost daily for months to years. For these individuals, various circumstances or events, such as scratching, pressure or "nerves," may aggravate their hives. However, eliminating these triggers has little effect on this condition.

Angioedema, a swelling of the deeper layers of the skin, sometimes occurs with hives. Angioedema is not red or itchy, and most often occurs in soft tissue such as the eyelids, mouth or genitals. Hives and angioedema may appear together or separately on the body. Hives are the result of a chemical called histamine-responsible for many of the symptoms of allergic reactions-in the upper layers of the skin. Angioedema results from the actions of these chemicals in the deeper layers of the skin. These chemicals are usually stored in our bodies' mast cells, which are cells heavily involved in allergic reactions. There are several identifiable triggers that release histamine and other chemicals from the mast cells, causing hives.

In adults, reactions to medicines are a common cause of acute hives. Medications known to cause hives or angioedema include aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, high blood pressure medicines known as ACE-inhibitors, or pain-killers containing codeine or codeine-like drugs. Like all drug-induced hives, these reactions occur within only minutes to an hour of taking the drug. Adults can also develop hives after eating certain foods, including nuts, eggs, shellfish, soy, wheat or milk-the culprits in more than 90% of proven food-induced hives. In children, foods or viral infections such as a cold can trigger acute hives. Physical urticaria are hives resulting from an outside source: rubbing of the skin, cold, heat, physical exertion or exercise, pressure or direct exposure to sunlight. Patients with chronic urticaria often report that at least one of these triggers induces their hives.

Whenever there is an identifiable trigger of hives, it should be eliminated. In patients with acute hives, some drugs or foods may take days to be eliminated from the body. For these individuals, an allergist may prescribe antihistamines to relieve symptoms until the culprit is eliminated. For patients with chronic hives, treatment cannot control the eruptions; these hives will eventually disappear on their own, with or without treatment. For 50% of these patients, the hives will clear in three to 12 months; 40% will clear in one to five years. Up to 1.5% of these patients may experience these hives for more than 20 years. Forty percent of patients with chronic hives will have at least one more episode of chronic hives in their lifetime. For these patients, the treatment objective is to provide comfort. If you experience chronic hives, your allergist will prescribe antihistamines, and will combine medications and adjust your dosages as needed for your individual symptoms. In rare cases, if antihistamines do not provide appropriate comfort, the allergist will prescribe an oral corticosteroid.

Contact Dermatitis

When some substances come into contact with skin, they may cause a rash called contact dermatitis. Some of these reactions are the result of an allergic reaction that involves the immune system, but many are the result of a non-allergic, or irritant, reaction. Often, it is difficult to tell the difference between these two types of reactions. The hallmark of allergic contact dermatitis is that it occurs almost exclusively where the offending agent-such as a plant or chemical-comes in contact with the skin. Irritant contact dermatitis is often more painful than itchy, and is the result of an offending agent that actually damages the skin with which it comes into contact. The longer the skin is in contact-or the more concentrated the agent-the more severe the reaction. Water with added soaps and detergents is the most common cause. Thus, it is not surprising that these reactions appear most often on the hands, and are frequently work-related. Individuals with other skin diseases, especially eczema (ex-zeh-ma), are most susceptible.

Allergic contact dermatitis is best exemplified by the itchy, red, blistered reaction that almost everyone experiences after touching a plant in the "rhus" family-poison ivy, poison oak or poison sumac. This allergic reaction is caused by a chemical in the plant called urushiol. You can have a reaction from touching other items with which the plant has come into contact, including yard tools or the family dog. However, once your skin has been washed, you cannot get another reaction from touching the rash or blisters. Unlike irritant contact dermatitis, which occurs within minutes of coming into contact with an offending agent, allergic contact dermatitis reactions can occur 24-48 hours after contact. Once a reaction starts, it takes 14-28 days to resolve, even with treatment.

Other agents that frequently cause allergic contact dermatitis include nickel, perfumes and fragrances, dyes, rubber (latex) products and cosmetics. Some ingredients in medications applied to the skin also can cause an allergic reaction, most commonly neomycin, an ingredient in antibiotic creams. To avoid reactions, any cream that ends in "caine" should never be applied to damaged skin.

Treatment of irritant contact dermatitis requires that the skin be kept from contact with the agent that is causing the reaction, and that every precaution is taken to avoid spilling caustic chemicals on the skin. Gloves can sometimes be helpful. Since these reactions are non-allergic in nature, treatment is directed toward relieving symptoms and preventing any permanent damage to the affected skin.

Treatment for allergic contact dermatitis depends on the severity of the symptoms. Cold soaks and compresses can offer relief for the acute, early, itchy blistered stage of the rash. When the rash is limited to small areas of the skin, topical corticosteroid creams may be prescribed to offer relief. When large areas of the body are involved, oral corticosteroids may be prescribed. If prescribed, it is important to continue to take oral medications for the entire duration of the reaction (14-28 days). To prevent the reaction from recurring, make sure to avoid contact with the offending substance. If the patient and allergist cannot determine the substance that caused the reaction based on the patient's history, the allergist may conduct a series of patch tests to help identify it.

Atopic Dermatitis/Eczema

A common allergic reaction often affecting the face, elbows and knees is atopic dermatitis, also known as eczema. This red, scaly, itchy rash is usually seen in young infants, but can occur later in life in individuals with personal or family histories of atopy, meaning asthma or allergic rhinitis ("hay fever"). Eczema may at times ooze, or at times may look very dry. A physician will rarely have difficulty diagnosing atopic dermatitis, based on three factors: an 1) itchy, 2) "eczematous" or bubbly rash in an 3) atopic individual. If one of these three features is missing, your physician should consider other causes. Identifying the cause of the itch is essential in managing symptoms. Common triggers include overheating or sweating, and contact with irritants such as wool, pets or soaps. In older individuals, emotional stress can cause a flare-up. For some patients, usually children, food can also trigger eczema. Secondary staph infections also can cause a flare-up in children. These patients usually have very dry skin and "allergic shiners"-an extra crease, called a Dennie's line, across their lower eyelids. They are also more susceptible to other skin infections.

Preventing the eczema itch is the primary goal of treatment. The patient must stop scratching and rubbing the rash. Applying cold compresses is helpful, and lubricating the dry skin with cream or ointment, especially during dry seasons, is essential. Patients should remove all "irritants" that aggravate the condition from their environments. If a food is identified as the culprit, it must be eliminated from the diet.

Topical corticosteroid cream medications are most effective in treating the rash once all preventative measures are taken. Rarely, antihistamines or oral corticosteroids are also prescribed, and if a secondary infection has been introduced by scratching, antibiotics are required.

See your Allergist/Immunologist

Whenever you have an unusual rash, make sure to contact your allergist, who will work with you to determine its cause-whether allergies, irritants, or another trigger. Most importantly, your physician and other health care providers can offer a support system and assist you in managing your skin condition.

Your allergist/immunologist can provide you with more information on allergic skin conditions.


Atopic Dermatitis (Eczema)

This booklet is for people who have atopic dermatitis (often called "eczema"), parents and caregivers of children with atopic dermatitis, and others interested in learning more about the disease. The booklet describes the disease and its symptoms and contains information about diagnosis and treatment as well as current research efforts supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and other components of the Department of Health and Human Services' National Institutes of Health (NIH). It also discusses issues such as skin care and quality of life for people with atopic dermatitis. If you have further questions after reading this booklet, you may wish to discuss them with your doctor or your child's pediatrician.


Defining Atopic Dermatitis

Atopic dermatitis is a chronic (long-lasting) disease that affects the skin. It is not contagious; it cannot be passed from one person to another. The word "dermatitis" means inflammation of the skin. "Atopic" refers to a group of diseases where there is often an inherited tendency to develop other allergic conditions, such as asthma and hay fever. In atopic dermatitis, the skin becomes extremely itchy. Scratching leads to redness, swelling, cracking, "weeping" clear fluid, and finally, crusting and scaling. In most cases, there are periods of time when the disease is worse (called exacerbations or flares) followed by periods when the skin improves or clears up entirely (called remissions). As some children with atopic dermatitis grow older, their skin disease improves or disappears altogether, although their skin often remains dry and easily irritated. In others, atopic dermatitis continues to be a significant problem in adulthood.

Although atopic dermatitis may occur at any age, it most often begins in infancy and childhood.

Atopic dermatitis is often referred to as "eczema," which is a general term for the several types of inflammation of the skin. Atopic dermatitis is the most common of the many types of eczema. Several have very similar symptoms.


Incidence and Prevalence of Atopic Dermatitis

Atopic dermatitis is very common. It affects males and females and accounts for 10 to 20 percent of all visits to dermatologists (doctors who specialize in the care and treatment of skin diseases). Although atopic dermatitis may occur at any age, it most often begins in infancy and childhood. Scientists estimate that 65 percent of patients develop symptoms in the first year of life, and 90 percent develop symptoms before the age of 5. Onset after age 30 is less common and is often due to exposure of the skin to harsh or wet conditions. Atopic dermatitis is a common cause of workplace disability. People who live in cities and in dry climates appear more likely to develop this condition.

Although it is difficult to identify exactly how many people are affected by atopic dermatitis, an estimated 20 percent of infants and young children experience symptoms of the disease. Roughly 60 percent of these infants continue to have one or more symptoms of atopic dermatitis in adulthood. This means that more than 15 million people in the United States have symptoms of the disease.

Types of Eczema (Dermatitis)

• Allergic contact eczema (dermatitis): a red, itchy, weepy reaction where the skin has come into contact with a substance that the immune system recognizes as foreign, such as poison ivy or certain preservatives in creams and lotions
• Atopic dermatitis: a chronic skin disease characterized by itchy, inflamed skin
• Contact eczema: a localized reaction that includes redness, itching, and burning where the skin has come into contact with an allergen (an allergy-causing substance) or with an irritant such as an acid, a cleaning agent, or other chemical
• Dyshidrotic eczema: irritation of the skin on the palms of hands and soles of the feet characterized by clear, deep blisters that itch and burn
• Neurodermatitis: scaly patches of the skin on the head, lower legs, wrists, or forearms caused by a localized itch (such as an insect bite) that become intensely irritated when scratched
• Nummular eczema: coin-shaped patches of irritated skin-most common on the arms, back, buttocks, and lower legs-that may be crusted, scaling, and extremely itchy
• Seborrheic eczema: yellowish, oily, scaly patches of skin on the scalp, face, and occasionally other parts of the body

• Stasis dermatitis: a skin irritation on the lower legs, generally related to circulatory problems


Cost of Atopic Dermatitis

In a recent analysis of the health insurance records of 5 million Americans under age 65, medical researchers found that approximately 2.5 percent had atopic dermatitis. Annual insurance payments for medical care of atopic dermatitis ranged from $580 to $1,250 per patient. More than one-quarter of each patient's total health care costs were for atopic dermatitis and related conditions. The researchers project that U.S. health insurance companies spend more than $1 billion per year on atopic dermatitis.

Causes of Atopic Dermatitis

The cause of atopic dermatitis is not known, but the disease seems to result from a combination of genetic (hereditary) and environmental factors.

Atopic dermatitis is also associated with malfunction of the body’s immune system.

Children are more likely to develop this disorder if one or both parents have had it or have had allergic conditions like asthma or hay fever. While some people outgrow skin symptoms, approximately three-fourths of children with atopic dermatitis go on to develop hay fever or asthma. Environmental factors can bring on symptoms of atopic dermatitis at any time in individuals who have inherited the atopic disease trait.

Atopic dermatitis is also associated with malfunction of the body's immune system: the system that recognizes and helps fight bacteria and viruses that invade the body. Scientists have found that people with atopic dermatitis have a low level of a cytokine (a protein) that is essential to the healthy function of the body's immune system and a high level of other cytokines that lead to allergic reactions. The immune system can become misguided and create inflammation in the skin even in the absence of a major infection. This can be viewed as a form of autoimmunity, where a body reacts against its own tissues.

In the past, doctors thought that atopic dermatitis was caused by an emotional disorder. We now know that emotional factors, such as stress, can make the condition worse, but they do not cause the disease.

Skin Features of Atopic Dermatitis

• Atopic pleat (Dennie-Morgan fold): an extra fold of skin that develops under the eye

• Cheilitis: inflammation of the skin on and around the lips

• Hyperlinear palms: increased number of skin creases on the palms

• Hyperpigmented eyelids: eyelids that have become darker in color from inflammation or hay fever
• Ichthyosis: dry, rectangular scales on the skin

• Keratosis pilaris: small, rough bumps, generally on the face, upper arms, and thighs
• Lichenification: thick, leathery skin resulting from constant scratching and rubbing
• Papules: small raised bumps that may open when scratched and become crusty and infected
• Urticaria: hives (red, raised bumps) that may occur after exposure to an allergen, at the beginning of flares, or after exercise or a hot bath

Symptoms of Atopic Dermatitis

Symptoms (signs) vary from person to person. The most common symptoms are dry, itchy skin and rashes on the face, inside the elbows and behind the knees, and on the hands and feet. Itching is the most important symptom of atopic dermatitis. Scratching and rubbing in response to itching irritates the skin, increases inflammation, and actually increases itchiness. Itching is a particular problem during sleep when conscious control of scratching is lost.

The appearance of the skin that is affected by atopic dermatitis depends on the amount of scratching and the presence of secondary skin infections. The skin may be red and scaly, be thick and leathery, contain small raised bumps, or leak fluid and become crusty and infected. The box on page 8 lists common skin features of the disease. These features can also be found in people who do not have atopic dermatitis or who have other types of skin disorders.

Atopic dermatitis may also affect the skin around the eyes, the eyelids, and the eyebrows and lashes. Scratching and rubbing the eye area can cause the skin to redden and swell. Some people with atopic dermatitis develop an extra fold of skin under their eyes. Patchy loss of eyebrows and eyelashes may also result from scratching or rubbing.

Researchers have noted differences in the skin of people with atopic dermatitis that may contribute to the symptoms of the disease. The outer layer of skin, called the epidermis, is divided into two parts: an inner part containing moist, living cells, and an outer part, known as the horny layer or stratum corneum, containing dry, flattened, dead cells. Under normal conditions the stratum corneum acts as a barrier, keeping the rest of the skin from drying out and protecting other layers of skin from damage caused by irritants and infections. When this barrier is damaged, irritants act more intensely on the skin.

The skin of a person with atopic dermatitis loses moisture from the epidermal layer, allowing the skin to become very dry and reducing its protective abilities. Thus, when combined with the abnormal skin immune system, the person's skin is more likely to become infected by bacteria (for example, Staphylo-coccus and Streptococcus) or viruses, such as those that cause warts and cold sores.

Stages of Atopic Dermatitis

When atopic dermatitis occurs during infancy and childhood, it affects each child differently in terms of both onset and severity of symptoms. In infants, atopic dermatitis typically begins around 6 to 12 weeks of age. It may first appear around the cheeks and chin as a patchy facial rash, which can progress to red, scaling, oozing skin. The skin may become infected. Once the infant becomes more mobile and begins crawling, exposed areas, such as the inner and outer parts of the arms and legs, may also be affected. An infant with atopic dermatitis may be restless and irritable because of the itching and discomfort of the disease. The skin may improve by 18 months of age, although the infant has a greater than normal risk of developing dry skin or hand eczema later in life.

In childhood, the rash tends to occur behind the knees and inside the elbows; on the sides of the neck; around the mouth; and on the wrists, ankles, and hands. Often, the rash begins with papules that become hard and scaly when scratched. The skin around the lips may be inflamed, and constant licking of the area may lead to small, painful cracks in the skin around the mouth.

In some children, the disease goes into remission for a long time, only to come back at the onset of puberty when hormones, stress, and the use of irritating skin care products or cosmetics may cause the disease to flare.

Although a number of people who developed atopic dermatitis as children also experience symptoms as adults, it is also possible for the disease to show up first in adulthood. The pattern in adults is similar to that seen in children; that is, the disease may be widespread or limited to only a few parts of the body. For example, only the hands or feet may be affected and become dry, itchy, red, and cracked. Sleep patterns and work performance may be affected, and long-term use of medications to treat the atopic dermatitis may cause complications. Adults with atopic dermatitis also have a predisposition toward irritant contact dermatitis, where the skin becomes red and inflamed from contact with detergents, wool, friction from clothing, or other potential irritants. It is more likely to occur in occupations involving frequent hand washing or exposure to chemicals. Some people develop a rash around their nipples. These localized symptoms are difficult to treat. Because adults may also develop cataracts, the doctor may recommend regular eye exams.

Diagnosing Atopic Dermatitis

Each person experiences a unique combination of symptoms, which may vary in severity over time. The doctor will base a diagnosis on the symptoms the patient experiences and may need to see the patient several times to make an accurate diagnosis and to rule out other diseases and conditions that might cause skin irritation. In some cases, the family doctor or pediatrician may refer the patient to a dermatologist (doctor specializing in skin disorders) or allergist (allergy specialist) for further evaluation.

A medical history may help the doctor better understand the nature of a patient's symptoms, when they occur, and their possible causes. The doctor may ask about family history of allergic disease; whether the patient also has diseases such as hay fever or asthma; and about exposure to irritants, sleep disturbances, any foods that seem to be related to skin flares, previous treatments for skin-related symptoms, and use of steroids or other medications. A preliminary diagnosis of atopic dermatitis can be made if the patient has three or more features from each of two categories: major features and minor features.

Currently, there is no single test to diagnose atopic dermatitis. However, there are some tests that can give the doctor an indication of allergic sensitivity.

Pricking the skin with a needle that contains a small amount of a suspected allergen may be helpful in identifying factors that trigger flares of atopic dermatitis. Negative results on skin tests may help rule out the possibility that certain substances cause skin inflammation. Positive skin prick test results are difficult to interpret in people with atopic dermatitis because the skin is very sensitive to many substances, and there can be many positive test sites that are not meaningful to a person's disease at the time. Positive results simply indicate that the individual has IgE (allergic) antibodies to the substance tested. IgE (immunoglobulin E) controls the immune system's allergic response and is often high in atopic dermatitis.

Recently, it was shown that if the quantity of IgE antibodies to a food in the blood is above a certain level, it is diagnostic of a food allergy. If the level of IgE to a specific food does not exceed the level needed for diagnosis but a food allergy is suspected, a person might be asked to record everything eaten and note any reactions. Physician-supervised food challenges (that is, the introduction of a food) following a period of food elimination may be necessary to determine if symptomatic food allergy is present. Identifying the food allergen may be difficult when a person is also being exposed to other possible allergens at the same time or symptoms may be triggered by other factors, such as infection, heat, and humidity.

Major and Minor Features of Atopic Dermatitis

Major Features

• Intense itching
• Characteristic rash in locations typical of the disease
• Chronic or repeatedly occurring symptoms
• Personal or family history of atopic disorders (eczema, hay fever, asthma)

Minor Features

• Early age of onset
• Dry skin that may also have patchy scales or rough bumps
• High levels of immunoglobulin E (IgE), an antibody, in the blood
• Numerous skin creases on the palms
• Hand or foot involvement
• Inflammation around the lips

• Nipple eczema
• Susceptibility to skin infection
• Positive allergy skin tests

Factors That Make Atopic Dermatitis Worse

Many factors or conditions can make symptoms of atopic dermatitis worse, further triggering the already overactive immune system, aggravating the itch-scratch cycle, and increasing damage to the skin. These factors can be broken down into two main categories: irritants and allergens. Emotional factors and some infections and illnesses can also influence atopic dermatitis.

Irritants are substances that directly affect the skin and, when present in high enough concentrations with long enough contact, cause the skin to become red and itchy or to burn. Specific irritants affect people with atopic dermatitis to different degrees. Over time, many patients and their family members learn to identify the irritants causing the most trouble. For example, frequent wetting and drying of the skin may affect the skin barrier function. Also, wool or synthetic fibers and rough or poorly fitting clothing can rub the skin, trigger inflammation, and cause the itch-scratch cycle to begin. Soaps and detergents may have a drying effect and worsen itching, and some perfumes and cosmetics may irritate the skin. Exposure to certain substances, such as solvents, dust, or sand, may also make the condition worse. Cigarette smoke may irritate the eyelids. Because the effects of irritants vary from one person to another, each person can best determine what substances or circumstances cause the disease to flare.

Allergens are substances from foods, plants, animals, or the air that inflame the skin because the immune system overreacts to the substance. Inflammation occurs even when the person is exposed to small amounts of the substance for a limited time. Although it is known that allergens in the air, such as dust mites, pollens, molds, and dander from animal hair or skin, may worsen the symptoms of atopic dermatitis in some people, scientists aren't certain whether inhaling these allergens or their actual penetration of the skin causes the problems. When people with atopic dermatitis come into contact with an irritant or allergen they are sensitive to, inflammation-producing cells become active. These cells release chemicals that cause itching and redness. As the person responds by scratching and rubbing the skin, further damage occurs.

Common Irritants

• Wool or synthetic fibers
• Soaps and detergents
• Some perfumes and cosmetics
• Substances such as chlorine, mineral oil, or solvents
• Dust or sand
• Cigarette smoke

A number of studies have shown that foods may trigger or worsen atopic dermatitis in some people, particularly infants and children. In general, the worse the atopic dermatitis and the younger the child, the more likely food allergy is present. An allergic reaction to food can cause skin inflammation (generally an itchy red rash), gastrointestinal symptoms (abdominal pain, vomiting, diarrhea), and/or upper respiratory tract symptoms (congestion, sneezing, and wheezing). The most common allergenic (allergy-causing) foods are eggs, milk, peanuts, wheat, soy, and fish. A recent analysis of a large number of studies on allergies and breastfeeding indicated that breastfeeding an infant for at least 4 months may protect the child from developing allergies. However, some studies suggest that mothers with a family history of atopic diseases should avoid eating common allergenic foods during late pregnancy and breastfeeding.

In addition to irritants and allergens, emotional factors, skin infections, and temperature and climate play a role in atopic dermatitis. Although the disease itself is not caused by emotional factors, it can be made worse by stress, anger, and frustration. Interpersonal problems or major life changes, such as divorce, job changes, or the death of a loved one, can also make the disease worse.

Bathing without proper moisturizing afterward is a common factor that triggers a flare of atopic dermatitis. The low humidity of winter or the dry year-round climate of some geographic areas can make the disease worse, as can overheated indoor areas and long or hot baths and showers. Alternately sweating and chilling can trigger a flare in some people. Bacterial infections can also trigger or increase the severity of atopic dermatitis. If a patient experiences a sudden flare of illness, the doctor may check for infection.


Treatment of Atopic Dermatitis

Treatment is more effective when a partnership develops that includes the patient, family members, and doctor. The doctor will suggest a treatment plan based on the patient's age, symptoms, and general health. The patient or family member providing care plays a large role in the success of the treatment plan by carefully following the doctor's instructions and paying attention to what is or is not helpful. Most patients will notice improvement with proper skin care and lifestyle changes.

The doctor has two main goals in treating atopic dermatitis: healing the skin and preventing flares. These may be assisted by developing skin care routines and avoiding substances that lead to skin irritation and trigger the immune system and the itch-scratch cycle. It is important for the patient and family members to note any changes in the skin's condition in response to treatment, and to be persistent in identifying the treatment that seems to work best.

Medications: New medications known as immuno-modulators have been developed that help control inflammation and reduce immune system reactions when applied to the skin. Examples of these medications are tacrolimus ointment (Protopic*) and pimecrolimus cream (Elidel). They can be used in patients older than 2 years of age and have few side effects (burning or itching the first few days of application). They not only reduce flares, but also maintain skin texture and reduce the need for long-term use of corticosteroids.

Corticosteroid creams and ointments have been used for many years to treat atopic dermatitis and other autoimmune diseases affecting the skin. Sometimes over-the-counter preparations are used, but in many cases the doctor will prescribe a stronger corticosteroid cream or ointment. When prescribing a medication, the doctor will take into account the patient's age, location of the skin to be treated, severity of the symptoms, and type of preparation (cream or ointment) that will be most effective. Sometimes the base used in certain brands of corticosteroid creams and ointments irritates the skin of a particular patient. Side effects of repeated or long-term use of topical corticosteroids can include thinning of the skin, infections, growth suppression (in children), and stretch marks on the skin.

When topical corticosteroids are not effective, the doctor may prescribe a systemic corticosteroid, which is taken by mouth or injected instead of being applied directly to the skin. An example of a commonly prescribed corticosteroid is prednisone. Typically, these medications are used only in resistant cases and only given for short periods of time. The side effects of systemic corticosteroids can include skin damage, thinned or weakened bones, high blood pressure, high blood sugar, infections, and cataracts. It can be dangerous to suddenly stop taking corticosteroids, so it is very important that the doctor and patient work together in changing the corticosteroid dose.

Antibiotics to treat skin infections may be applied directly to the skin in an ointment, but are usually more effective when taken by mouth. If viral or fungal infections are present, the doctor may also prescribe specific medications to treat those infections.

Certain antihistamines that cause drowsiness can reduce nighttime scratching and allow more restful sleep when taken at bedtime. This effect can be particularly helpful for patients whose nighttime scratching makes the disease worse.

In adults, drugs that suppress the immune system, such as cyclosporine, methotrexate, or azathioprine, may be prescribed to treat severe cases of atopic dermatitis that have failed to respond to other forms of therapy. These drugs block the production of some immune cells and curb the action of others. The side effects of drugs like cyclosporine can include high blood pressure, nausea, vomiting, kidney problems, headaches, tingling or numbness, and a possible increased risk of cancer and infections. There is also a risk of relapse after the drug is stopped. Because of their toxic side effects, systemic corticosteroids and immunosuppressive drugs are used only in severe cases and then for as short a period of time as possible. Patients requiring systemic corticosteroids should be referred to dermatologists or allergists specializing in the care of atopic dermatitis to help identify trigger factors and alternative therapies.

In rare cases, when home-based treatments have been unsuccessful, a patient may need a few days in the hospital for intense treatment.

Phototherapy: Use of ultraviolet A or B light waves, alone or combined, can be an effective treatment for mild to moderate dermatitis in older children (over 12 years old) and adults. A combination of ultraviolet light therapy and a drug called psoralen can also be used in cases that are resistant to ultraviolet light alone. Possible long-term side effects of this treatment include premature skin aging and skin cancer. If the doctor thinks that phototherapy may be useful to treat the symptoms of atopic dermatitis, he or she will use the minimum exposure necessary and monitor the skin carefully.

Treating Atopic Dermatitis in Infants and Children

• Give lukewarm baths.
• Apply lubricant immediately following the bath.
• Keep child's fingernails filed short.
• Select soft cotton fabrics when choosing clothing.
• Consider using sedating antihistamines to promote sleep and reduce scratching at night.
• Keep the child cool; avoid situations where overheating occurs.
• Learn to recognize skin infections and seek treatment promptly.
• Attempt to distract the child with activities to keep him or her from scratching.
• Identify and remove irritants and allergens.

Skin Care: Healing the skin and keeping it healthy are important to prevent further damage and enhance quality of life. Developing and sticking with a daily skin care routine is critical to preventing flares.

A lukewarm bath helps to cleanse and moisturize the skin without drying it excessively. Because soaps can be drying to the skin, the doctor may recommend use of a mild bar soap or nonsoap cleanser. Bath oils are not usually helpful.

After bathing, a person should air-dry the skin, or pat it dry gently (avoiding rubbing or brisk drying), and then apply a lubricant to seal in the water that has been absorbed into the skin during bathing. In addition to restoring the skin's moisture, lubrication increases the rate of healing and establishes a barrier against further drying and irritation. Lotions that have a high water or alcohol content evaporate more quickly, and alcohol may cause stinging. Therefore, they generally are not the best choice. Creams and ointments work better at healing the skin.

Another key to protecting and restoring the skin is taking steps to avoid repeated skin infections. Signs of skin infection include tiny pustules (pus-filled bumps), oozing cracks or sores, or crusty yellow blisters. If symptoms of a skin infection develop, the doctor should be consulted and treatment should begin as soon as possible.

Protection from Allergen Exposure: The doctor may suggest reducing exposure to a suspected allergen. For example, the presence of the house dust mite can be limited by encasing mattresses and pillows in special dust-proof covers, frequently washing bedding in hot water, and removing carpeting. However, there is no way to completely rid the environment of airborne allergens.

Changing the diet may not always relieve symptoms of atopic dermatitis. A change may be helpful, however, when the medical history, laboratory studies, and specific symptoms strongly suggest a food allergy. It is up to the patient and his or her family and physician to decide whether the dietary restrictions are appropriate. Unless properly monitored by a physician or dietitian, diets with many restrictions can contribute to serious nutritional problems, especially in children.

Atopic Dermatitis and Quality of Life

Despite the symptoms caused by atopic dermatitis, it is possible for people with the disorder to maintain a good quality of life. The keys to quality of life lie in being well-informed; awareness of symptoms and their possible cause; and developing a partnership involving the patient or caregiving family member, medical doctor, and other health professionals. Good communication is essential.

When a child has atopic dermatitis, the entire family may be affected. It is helpful if families have additional support to help them cope with the stress and frustration associated with the disease. A child may be fussy and difficult and unable to keep from scratching and rubbing the skin. Distracting the child and providing activities that keep the hands busy are helpful but require much effort on the part of the parents or caregivers. Another issue families face is the social and emotional stress associated with changes in appearance caused by atopic dermatitis. The child may face difficulty in school or with social relationships and may need additional support and encouragement from family members.

Adults with atopic dermatitis can enhance their quality of life by caring regularly for their skin and being mindful of the effects of the disease and how to treat them. Adults should develop a skin care regimen as part of their daily routine, which can be adapted as circumstances and skin conditions change. Stress management and relaxation techniques may help decrease the likelihood of flares. Developing a network of support that includes family, friends, health professionals, and support groups or organizations can be beneficial. Chronic anxiety and depression may be relieved by short-term psychological therapy.

Recognizing the situations when scratching is most likely to occur may also help. For example, many patients find that they scratch more when they are idle, and they do better when engaged in activities that keep the hands occupied. Counseling also may be helpful to identify or change career goals if a job involves contact with irritants or involves frequent hand washing, such as kitchen work or auto mechanics.

Atopic Dermatitis and Vaccination Against Smallpox

Although scientists are working to develop safer vaccines, persons diagnosed with atopic dermatitis (or eczema) should not receive the current smallpox vaccine. According to the Centers for Disease Control and Prevention (CDC), a U.S. Government organization, persons who have ever been diagnosed with atopic dermatitis, even if the condition is mild or not presently active, are more likely to develop a serious complication if they are exposed to the virus from the smallpox vaccine.

People with atopic dermatitis should exercise caution when coming into close physical contact with a person who has been recently vaccinated, and make certain the vaccinated person has covered the vaccination site or taken other precautions until the scab falls off (about 3 weeks). Those who have had physical contact with a vaccinated person's unhealed vaccination site or to their bedding or other items that might have touched that site should notify their doctor, particularly if they develop a new or unusual rash.

During a smallpox outbreak, these vaccination recommendations may change. Persons with atopic dermatitis who have been exposed to smallpox should consult their doctor about vaccination.

Tips for Working With Your Doctor

• Provide complete, accurate medical information.
• Make a list of your questions and concerns in advance.
• Be honest and share your point of view with the doctor.
• Ask for clarification or further explanation if you need it.

• Talk to other members of the health care team, such as nurses, therapists, or pharmacists.

• Don't hesitate to discuss sensitive subjects with your doctor.
• Discuss changes to any medical treatment or medications with your doctor.

Additional information about atopic dermatitis and smallpox vaccination is available from CDC.

Current Research

Researchers supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and other institutes of the National Institutes of Health are gaining a better understanding of what causes atopic dermatitis and how it can be managed, treated, and, ultimately, prevented. Some promising avenues of research are described below.

Genetics: Although atopic dermatitis runs in families, the role of genetics (inheritance) remains unclear. It does appear that more than one gene is involved in the disease.

Research has helped shed light on the way atopic dermatitis is inherited. Studies show that children are at increased risk for developing the disorder if there is a family history of other atopic disease, such as hay fever or asthma. The risk is significantly higher if both parents have an atopic disease. In addition, studies of identical twins, who have the same genes, show that in an estimated 80 to 90 percent of cases, atopic disease appears in both twins. Fraternal (nonidentical) twins, who have only some genes in common, are no more likely than two other people in the general population to both have an atopic disease. These findings suggest that genes play an important role in determining who gets the disease.

Biochemical Abnormalities: Scientists suspect that changes in the skin's protective barrier make people with atopic dermatitis more sensitive to irritants. Such people have lower levels of fatty acids (substances that provide moisture and elasticity) in their skin, which causes dryness and reduces the skin's ability to control inflammation.

Other research points to a possible defect in a type of white blood cell called a monocyte. In people with atopic dermatitis, monocytes appear to play a role in the decreased production of an immune system hormone called interferon gamma (IFN-?), which helps regulate allergic reactions. This defect may cause exaggerated immune and inflammatory responses in the blood and tissues of people with atopic dermatitis.

Faulty Regulation of Immunoglobulin E (IgE): As already described in the section on diagnosis, IgE is a type of antibody that controls the immune system's allergic response. An antibody is a special protein produced by the immune system that recognizes and helps fight and destroy viruses, bacteria, and other foreign substances that invade the body. Normally, IgE is present in very small amounts, but levels are high in 80 to 90 percent of people with atopic dermatitis.

Controlling Atopic Dermatitis

• Prevent scratching or rubbing whenever possible.
• Protect skin from excessive moisture, irritants, and rough clothing.
• Maintain a cool, stable temperature and consistent humidity levels.
• Limit exposure to dust, cigarette smoke, pollens, and animal dander.
• Recognize and limit emotional stress.

In allergic diseases, IgE antibodies are produced in response to different allergens. When an allergen comes into contact with IgE on specialized immune cells, the cells release various chemicals, including histamine. These chemicals cause the symptoms of an allergic reaction, such as wheezing, sneezing, runny eyes, and itching. The release of histamine and other chemicals alone cannot explain the typical long-term symptoms of the disease. Research is underway to identify factors that may explain why too much IgE is produced and how it plays a role in the disease.

Immune System Imbalance: Researchers also think that an imbalance in the immune system may contribute to the development of atopic dermatitis. It appears that the part of the immune system responsible for stimulating IgE is overactive, and the part that handles skin viral and fungal infections is underactive. Indeed, the skin of people with atopic dermatitis shows increased susceptibility to skin infections. This imbalance appears to result in the skin's inability to prevent inflammation, even in areas of skin that appear normal. In one project, scientists are studying the role of the infectious bacterium Staphylococcus aureus (S. aureus) in atopic dermatitis.
Researchers also think that an imbalance in the immune system may contribute to the development of atopic dermatitis.

Researchers believe that one type of immune cell in the skin, called a Langerhans cell, may be involved in atopic dermatitis. Langerhans cells pick up viruses, bacteria, allergens, and other foreign substances that invade the body and deliver them to other cells in the immune defense system. Langerhans cells appear to be hyper-active in the skin of people with atopic diseases. Certain Langerhans cells are particularly potent at activating white blood cells called T cells in atopic skin, which produce proteins that promote allergic response. This function results in an exaggerated response of the skin to tiny amounts of allergens.

Scientists have also developed mouse models to study step-by-step changes in the immune system in atopic dermatitis, which may eventually lead to a treatment that effectively targets the immune system.

Drug Research: Some researchers are focusing on new treatments for atopic dermatitis, including biologic agents, fatty acid supplements, and new forms of phototherapy. For example, they are studying how ultraviolet light affects the skin's immune system in healthy and diseased skin. They are also investigating biologic agents, including several aimed at modifying the response of the immune system. A biologic agent is a new type of drug based on molecules that occur naturally in the body. One promising treatment is the use of thymopentin to reestablish balance in the immune system.

Researchers also continue to look for drugs that suppress the immune system. In this regard, they are studying the effectiveness of cyclosporine A. Clinical trials are underway with another drug called FK506, which is applied to the skin rather than taken orally. Also, anti-inflammatory drugs have been developed that affect multiple cells and cell functions, and may prove to be an effective alternative to corticosteroids in the treatment of atopic dermatitis.

Several experimental treatments are being evaluated that attempt to replace substances that are deficient in people with atopic dermatitis. Evening primrose oil is a substance rich in gamma-linolenic acid, one of the fatty acids that is decreased in the skin of people with atopic dermatitis. Studies to date using evening primrose oil have yielded contradictory results. In addition, dietary fatty acid supplements have not proven highly effective. There is also a great deal of interest in the use of Chinese herbs and herbal teas to treat the disease. Studies to date show some benefit, but not without concerns about toxicity and the risks involved in suppressing the immune system without close medical supervision.

Hope for the Future

Although the symptoms of atopic dermatitis can be difficult and uncomfortable, the disease can be successfully managed. People with atopic dermatitis can lead healthy, productive lives. As scientists learn more about atopic dermatitis and what causes it, they continue to move closer to effective treatments, and perhaps, ultimately, a cure.

Additional Resources

National Institute of Arthritis and Musculoskeletal and Skin Diseases
NIAMS/National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
(301) 495-4484 or (877) 22-NIAMS (226-4267) (free of charge)
TTY: (301) 565-2966
Fax: (301) 718-6366

NIAMS provides information about various forms of skin diseases; arthritis and rheumatic diseases; and bone, muscle, and joint diseases. It distributes patient and professional education materials and refers people to other sources of information. Additional information and updates can be found on the NIAMS Web site. Listings of clinical trials recruiting patients who have or are at risk of developing a skin disease can be found at

Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
(888) 246-2675 (free of charge)
TTY: (866) 874-2646

This government organization is a focus for disease prevention and control, environmental health, and health promotion. It provides detailed information about smallpox and vaccination against smallpox, including those who should not receive the vaccine, precautions vaccinated persons should take to prevent harm to those with atopic dermatitis and certain other conditions, and answers to frequently asked questions.

American Academy of Dermatology
P.O. Box 4014
Schaumburg, IL 60168
(847) 330-0230 or (888) 462-DERM (3376) (free of charge)
Fax: (847) 330-0050

This national professional association can provide referrals to dermatologists. It has published a pamphlet on atopic eczema/dermatitis, which is available on the organization's Web site or can be obtained by calling or writing to the academy. Single copies are free.

American Academy of Allergy, Asthma, and Immunology
611 East Wells Street
Milwaukee, WI 53202
(414) 272-6071 or (800) 822-2762 (free of charge)

This national professional association representing allergists and clinical immunologists publishes pamphlets about allergies and atopic dermatitis. The academy can also provide physician referrals for evaluation of allergies.

National Eczema Association for Science and Education
4460 Redwood Highway, Suite 16-D
San Rafael, CA 94903-1953
(415) 499-3474 or (800) 818-7546 (free of charge)
Fax: (415) 472-5345

This is a national patient-oriented association devoted to eczema. It publishes a quarterly newsletter, provides patient brochures and provider educational materials, offers resource services to patients, and provides referrals to atopic dermatitis/eczema research centers.

Inflammatory Skin Disease Institute
P.O. Box 1074
Newport News, VA 23601
(757) 223-0795 or (800) 484-6800, Ext. 6321 (free of charge)
Fax: (757) 595-1842

This national organization provides educational information and support and engages in advocacy. It is dedicated to improving the lives of people with inflammatory skin disease.

Food Allergy and Anaphylaxis Network (FAAN)
10400 Eaton Place
Fairfax, VA 22030
(703) 691-3179 or (800) 929-4040 (free of charge)
Fax: (703) 691-2713

The organization provides education, emotional support, and coping strategies to individuals with food allergies. It publishes a bimonthly newsletter and has books, videos, and other educational materials pertaining to food allergy diets and to food-related issues in schools, daycare centers, and camps. FAAN also makes physician referrals.


The NIAMS gratefully acknowledges the assistance of the following people in the preparation and review of this publication: Joanne Cono, M.D., Sc.M., Centers for Disease Control and Prevention, Atlanta, Georgia; Kevin Cooper, M.D., Case Western Reserve University, University Hospitals of Cleveland, Cleveland, Ohio; Jon Hanifin, M.D., Oregon Health & Science University, Portland, Oregon; Donald Leung, M.D., Ph.D., National Jewish Medical and Research Center, Denver, Colorado; Alan Moshell, M.D., NIAMS, NIH; Amy Paller, M.D., Children's Hospital of Chicago, Chicago, Illinois; Hugh Sampson, M.D., Mount Sinai School of Medicine, New York, New York; Maria Turner, M.D., National Cancer Institute, NIH; and LaDonna Williams, Inflammatory Skin Disease Institute, Newport News, Virginia.

About NIAMS and Its Clearinghouse:

The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH), is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases, the training of basic and clinical scientists to carry out this research, and the dissemination of information on research progress in these diseases. The National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse is a public service sponsored by the NIAMS that provides health information and information sources. Additional information can be found on the NIAMS Web site at

Contact Dermatitis

What Is It?

Contact dermatitis is a form of skin inflammation that occurs because the skin has been exposed to a substance that irritates it or that causes an allergic reaction. A long list of natural and synthetic chemicals can trigger contact dermatitis, including those found in soaps, household cleaners, laundry detergents, metal jewelry, perfumes, industrial solvents, cosmetics, fabric finishes, shampoos and even antibiotic ointments. As a result, the problem can develop in an almost endless variety of ways. Common types of skin exposures (or "contacts") that can lead to contact dermatitis include hand washing; housecleaning; wearing a diaper; hiking near poison ivy, oak or sumac; spraying or dabbing on perfume; wearing a metal necklace or bracelet that contains nickel; wearing clothes with metal snaps or zippers; shampooing hair; applying makeup or hair dye; working with industrial solvents; and sitting near a campfire where poison ivy is being burned.

For purposes of diagnosis and treatment, doctors classify contact dermatitis into two types, depending on the cause of the skin inflammation:

• Irritant contact dermatitis (ICD) — ICD is triggered by exposure to a chemical that is naturally toxic (poisonous) or irritating to human skin. It is not an allergic reaction. In children, the most common form of ICD is "diaper dermatitis," a skin reaction in the diaper area that is caused by prolonged contact with the natural chemicals found in urine and stool. Childhood ICD also can develop around the mouth because of skin contact with dribbles of baby food or drools of saliva. In adults, ICD is often an occupational illness that can be triggered by exposure to, strong soaps, solvents or cutting agents. It is especially common among health-care workers, homemakers, janitors, mechanics, machinists and hairdressers, but it can occur in anyone whose household chores or hobbies involve exposure to irritating chemicals.
• Allergic contact dermatitis (ACD) — This form of contact dermatitis is an immune reaction that occurs only in people who are naturally hypersensitive to certain chemicals. Unlike the inflammation of ICD, which usually happens rather quickly after the skin is exposed to a harmful chemical, the inflammation of ACD may not develop until 24 to 36 hours after skin contact with the substance (allergen). This is because ACD is a delayed form of hypersensitivity that involves recruiting the body's immune defenses, a process that takes some time. Specific skin allergies vary from person to person. However, among the most common types of allergens responsible for ACD are a chemical found in poison ivy, oak and sumac; nickel and cobalt in metal jewelry, clothing snaps, zippers and metal-plated objects; neomycin, in antibiotic skin ointments; potassium dichromate, a tanning agent found in leather shoes and clothing; latex in gloves and rubberized clothing; and certain preservatives, such as formaldehyde. Overall, an estimated 20 percent of the U.S. population is probably at risk of ACD because of skin sensitivity to at least one common chemical allergen.


Symptoms of contact dermatitis may vary slightly, depending on the cause:

• ICD — In mild cases, there may be only mild redness of the skin. However, more severe cases may cause skin swelling, blistering or even ulceration. Symptoms usually begin immediately after exposure to the harmful substance, and they are limited to areas of the skin that have been touched, splashed, covered by or immersed in the irritant. For example, a janitor may develop symptoms on his hands after washing the floor with a strong detergent, while a factory worker may develop ICD on her face after an industrial solvent splashes upward.
• ACD — When contact dermatitis is caused by an allergic reaction, it usually produces localized skin redness, blistering and severe itching. Because ACD is a form of delayed hypersensitivity, these skin symptoms may not appear for several hours after exposure to the allergen. As in ICD, the specific distribution and pattern of the skin reaction may provide clues to the cause of the skin problem. For example, poison ivy usually appears as a pattern of tiny lines or streaks in places where plant leaves have brushed against the skin, while allergies to metal jewelry often produce rings of skin inflammation around the neck and wrist. An allergy to laundry detergent may cause symptoms that are limited to the torso and other clothed areas of the body, while an allergy to tanning chemicals in leather will affect parts of the feet that are covered by shoes.

If symptoms of ICD or ACD are not treated, and the skin continues to be exposed to the substance that is triggering the skin reaction, contact dermatitis may become a chronic condition. In chronic contact dermatitis, the affected skin eventually becomes thick, scaly and dry, with pigment changes and areas of hair loss.


Depending on your specific pattern of skin symptoms, the doctor will ask about your personal and family allergy history, your history of exposure to irritating chemicals at work or at home, or your contact with poisonous plants. In some cases, your doctor also may need to know the names of specific ingredients found in products that you routinely apply to your skin or hair, especially cosmetics, shampoos, hair dyes, skin lotions, nail polish or antibiotic skin ointments.

After reviewing your history of allergies and chemical exposures, your doctor usually can confirm the diagnosis of contact dermatitis by examining your skin.

In cases of possible ACD, your doctor may refer you to a dermatologist (skin specialist) for a more detailed workup using patch testing. Patch testing is a type of allergy test in which small amounts of specific allergens are applied to the skin of your back, and then covered with tape. After 48 hours, the doctor removes the tape and examines the underlying skin for signs of an allergic reaction. A second reading is done after three to seven days.


In general, you can prevent contact dermatitis by avoiding exposure to irritating chemicals, plants, jewelry and other substances that trigger ICD or ACD.

To help prevent diaper dermatitis, you should change your baby's diaper frequently, cleanse the soiled area with warm water and a soft cloth, and apply a protective coat of zinc oxide ointment. Also, avoid using store-bought wipes and cleansers on your child's skin, since these products may trigger skin reactions.

To help prevent work-related ICD and ACD, the U.S. National Institute of Occupational Safety and Health (NIOSH) has established the Allergic and Irritant Dermatitis Team to research contact dermatitis in the workplace. The team's goal is to be able to provide workers with reliable information about specific types of protective equipment, protective clothing and "barrier creams" that can be used to prevent contact dermatitis on the job.


Your doctor usually will treat contact dermatitis with the following:

• An antihistamine to control the itch — Common antihistamines used to treat contact dermatitis include diphenhydramine (Benadryl), hydroxyzine (Atarax), cetirizine (Zyrtec), loratadine (Claritin) and fexofenadine (Allegra). Of these five medications, the last three are less likely to cause drowsiness than the first two.
• A corticosteroid to relieve skin inflammation — In most cases, the corticosteroid can be applied as a cream or ointment containing one of the following: hydrocortisone (Hytone), hydrocortisone valerate (Westcort), desonide (Tridesilon or DesOwen), hydrocortisone butyrate (Locoid), desoximetasone (Topicort), fluocinonide (Lidex) or amcinonide (Cyclocort). If symptoms are especially severe, corticosteroids can be given by mouth or by injection.
• A moisturizer to help restore the normal texture of the skin — Your doctor probably will suggest a nonirritating ointment or cream that contains few potential allergens. Examples include petroleum jelly, Vanicream, Cetaphil and Eucerin. For many people, oatmeal baths (Aveeno) are also helpful.

When To Call A Professional

Call your doctor whenever you are troubled by an area of skin that is red and very itchy, or skin that is cracked, blistered or painfully dry. Even if you are certain that your skin problem is "just a case of poison ivy," your doctor may be able recommend a prescription medication that will relieve your symptoms more effectively than over-the-counter remedies.


For most cases of ICD or ACD, the prognosis is excellent, as long as you can identify the substance that triggered your contact dermatitis and avoid future exposure to it.

Additional Information

National Institute of Arthritis and Musculoskeletal and Skin Diseases
Information Clearinghouse
1 AMS Circle
Bethesda, MD 20892-3675
Phone: (301) 495-4484
Toll-Free: (877) 226-4267
Fax: (301) 718-6366
TTY: (301) 565-2966

American Academy of Dermatology
930 E. Woodfield Rd.
Schaumburg, IL 60173-4927
Phone: (847) 330-0230
Toll-Free: (888) 462-3376
Fax: (847) 330-0050

National Institute for Occupational Safety and Health
4676 Columbia Parkway
Mail Stop C-18
Cincinnati, OH 45226
Toll-Free: (800) 356-4674
Fax: (513) 533-8573

Collagen Vascular Disease


This booklet is for people who have scleroderma, as well as for their family members, friends, and others who want to find out more about the disease. This booklet describes the different forms of scleroderma and provides information on their symptoms, diagnosis, and treatment, including what patients can do to help manage their disease and the problems associated with it. It also highlights current research efforts into the understanding and treatment of scleroderma, many of which are supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and other components of the National Institutes of Health (NIH). If you have further questions after reading this booklet, you may wish to discuss them with your doctor.

What Is Scleroderma?

Derived from the Greek words "sklerosis," meaning hardness, and "derma," meaning skin, scleroderma literally means hard skin. Though it is often referred to as if it were a single disease, scleroderma is really a symptom of a group of diseases that involve the abnormal growth of connective tissue, which supports the skin and internal organs. It is sometimes used, therefore, as an umbrella term for these disorders. In some forms of scleroderma, hard, tight skin is the extent of this abnormal process. In other forms, however, the problem goes much deeper, affecting blood vessels and internal organs, such as the heart, lungs, and kidneys.

Scleroderma is called both a rheumatic (roo-MA-tik) disease and a connective tissue disease. The term rheumatic disease refers to a group of conditions characterized by inflammation and/or pain in the muscles, joints, or fibrous tissue. A connective tissue disease is one that affects the major substances in the skin, tendons, and bones.

In this booklet we'll discuss the forms of scleroderma and the problems with each of them as well as diagnosis and disease management. We'll also take a look at what research is telling us about their possible causes and most effective treatments, and ways to help people with scleroderma live longer, healthier, and more productive lives.

What Are the Different Types of Scleroderma?

The group of diseases we call scleroderma falls into two main classes: localized scleroderma and systemic sclerosis. (Localized diseases affect only certain parts of the body; systemic diseases can affect the whole body.) Both groups include subgroups. Although there are different ways these groups and subgroups may be broken down or referred to (and your doctor may use different terms from what you see here), the following is a common way of classifying these diseases:

Localized Scleroderma

Localized types of scleroderma are those limited to the skin and related tissues and, in some cases, the muscle below. Internal organs are not affected by localized scleroderma, and localized scleroderma can never progress to the systemic form of the disease. Often, localized conditions improve or go away on their own over time, but the skin changes and damage that occur when the disease is active can be permanent. For some people, localized scleroderma is serious and disabling.

There are two generally recognized types of localized scleroderma:

Morphea: Morphea (mor-FEE-ah) comes from a Greek word that means "form" or "structure." The word refers to local patches of scleroderma. The first signs of the disease are reddish patches of skin that thicken into firm, oval-shaped areas. The center of each patch becomes ivory colored with violet borders. These patches sweat very little and have little hair growth. Patches appear most often on the chest, stomach, and back. Sometimes they appear on the face, arms, and legs.

Morphea can be either localized or generalized. Localized morphea limits itself to one or several patches, ranging in size from a half-inch to 12 inches in diameter. The condition sometimes appears on areas treated by radiation therapy. Some people have both morphea and linear scleroderma (described below). The disease is referred to as generalized morphea when the skin patches become very hard and dark and spread over larger areas of the body.

Regardless of the type, morphea generally fades out in 3 to 5 years; however, people are often left with darkened skin patches and, in rare cases, muscle weakness.

Linear scleroderma: As suggested by its name, the disease has a single line or band of thickened and/or abnormally colored skin. Usually, the line runs down an arm or leg, but in some people it runs down the forehead. People sometimes use the French term en coup de sabre, or "sword stroke," to describe this highly visible line.

Systemic Scleroderma (also known as Systemic Sclerosis)

Systemic scleroderma, or systemic sclerosis, is the term for the disease that not only includes the skin, but also involves the tissues beneath to the blood vessels and major organs. Systemic sclerosis is typically broken down into diffuse and limited disease. People with systemic sclerosis often have all or some of the symptoms that some doctors call CREST, which stands for the following:

• Calcinosis (KAL-sin-OH-sis): the formation of calcium deposits in the connective tissues, which can be detected by x ray. They are typically found on the fingers, hands, face, and trunk and on the skin above elbows and knees. When the deposits break through the skin, painful ulcers can result.
• Raynaud's (ray-NOHZ) phenomenon: a condition in which the small blood vessels of the hands and/or feet contract in response to cold or anxiety. As the vessels contract, the hands or feet turn white and cold, then blue. As blood flow returns, they become red. Fingertip tissues may suffer damage, leading to ulcers, scars, or gangrene.
• Esophageal (eh-SOFF-uh-GEE-ul) dysfunction: impaired function of the esophagus (the tube connecting the throat and the stomach) that occurs when smooth muscles in the esophagus lose normal movement. In the upper esophagus, the result can be swallowing difficulties; in the lower esophagus, the problem can cause chronic heartburn or inflammation.
• Sclerodactyly (SKLER-oh-DAK-till-ee): thick and tight skin on the fingers, resulting from deposits of excess collagen within skin layers. The condition makes it harder to bend or straighten the fingers. The skin may also appear shiny and darkened, with hair loss.
• Telangiectasias (tel-AN-jee-ek-TAY-zee-uhs): small red spots on the hands and face that are caused by the swelling of tiny blood vessels. While not painful, these red spots can create cosmetic problems.

Limited scleroderma: Limited scleroderma typically comes on gradually and affects the skin only in certain areas: the fingers, hands, face, lower arms, and legs. Many people with limited disease have Raynaud's phenomenon for years before skin thickening starts. Others start out with skin problems over much of the body, which improves over time, leaving only the face and hands with tight, thickened skin. Telangiectasias and calcinosis often follow. Because of the predominance of CREST in people with limited disease, some doctors refer to limited disease as the CREST syndrome.

Diffuse scleroderma: Diffuse scleroderma typically comes on suddenly. Skin thickening occurs quickly and over much of the body, affecting the hands, face, upper arms, upper legs, chest, and stomach in a symmetrical fashion (for example, if one arm or one side of the trunk is affected, the other is also affected). Some people may have more area of their skin affected than others. Internally, it can damage key organs such as the heart, lungs, and kidneys.

People with diffuse disease are often tired, lose appetite and weight, and have joint swelling and/or pain. Skin changes can cause the skin to swell, appear shiny, and feel tight and itchy.

The damage of diffuse scleroderma typically occurs over a few years. After the first 3 to 5 years, people with diffuse disease often enter a stable phase lasting for varying lengths of time. During this phase, skin thickness and appearance stay about the same. Damage to internal organs progresses little, if at all. Symptoms also subside: joint pain eases, fatigue lessens, and appetite returns.

Gradually, however, the skin starts to change again. Less collagen is made and the body seems to get rid of the excess collagen. This process, called "softening," tends to occur in reverse order of the thickening process: the last areas thickened are the first to begin softening. Some patients' skin returns to a somewhat normal state, while other patients are left with thin, fragile skin without hair or sweat glands. More serious damage to heart, lungs, or kidneys is unlikely to occur unless previous damage leads to more advanced deterioration.

People with diffuse scleroderma face the most serious long-term outlook if they develop severe kidney, lung, digestive, or heart problems. Fortunately, less than one-third of patients with diffuse disease develop these problems. Early diagnosis and continual and careful monitoring are important.

Sine scleroderma: Some doctors break systemic sclerosis down into a third subset called systemic sclerosis sine (SEEN-ay, Latin for "without") scleroderma. Sine may resemble either limited or diffuse systemic sclerosis, causing changes in the lungs, kidneys, and blood vessels. However, there is one key difference between sine and other forms of systemic sclerosis: it does not affect the skin.

What Causes Scleroderma?

Although scientists don't know exactly what causes scleroderma, they are certain that people cannot catch it from or transmit it to others. Studies of twins suggest it is also not inherited. Scientists suspect that scleroderma comes from several factors that may include:

Abnormal immune or inflammatory activity: Like many other rheumatic disorders, scleroderma is believed to be an autoimmune disease. An autoimmune disease is one in which the immune system, for unknown reasons, turns against one's own body.

In scleroderma, the immune system is thought to stimulate cells called fibroblasts to produce too much collagen. In scleroderma, collagen forms thick connective tissue that builds up around the cells of the skin and internal organs. In milder forms, the effects of this buildup are limited to the skin and blood vessels. In more serious forms, it also can interfere with normal functioning of skin, blood vessels, joints, and internal organs.

Genetic makeup: While genes seem to put certain people at risk for scleroderma and play a role in its course, the disease is not passed from parent to child like some genetic diseases.

However, some research suggests that having children may increase a woman's risk of scleroderma. Scientists have learned that when a woman is pregnant, cells from her baby can pass through the placenta, enter her blood stream, and linger in her body--in some cases, for many years after the child's birth. Recently, scientists have found fetal cells from pregnancies of years past in the skin lesions of some women with scleroderma. They think that these cells, which are different from the woman's own cells, may either begin an immune reaction to the woman's own tissues or trigger a response by the woman's immune system to rid her body of those cells. Either way, the woman's healthy tissues may be damaged in the process. Further studies are needed to find out if fetal cells play a role in the disease.

Environmental triggers: Research suggests that exposure to some environmental factors may trigger the disease in people who are genetically predisposed to it. Suspected triggers include viral infections, certain adhesive and coating materials, and organic solvents such as vinyl chloride or trichloroethylene. In the past, some people believed that silicone breast implants might have been a factor in developing connective tissue diseases such as scleroderma. But several studies have not shown evidence of a connection.

Hormones: By the middle to late childbearing years (ages 30 to 55), women develop scleroderma at a rate 7 to 12 times higher than men. Because of female predominance at this and all ages, scientists suspect that something distinctly feminine, such as the hormone estrogen, plays a role in the disease. So far, the role of estrogen or other female hormones has not been proven.


Who Gets Scleroderma?

Although scleroderma is more common in women, the disease also occurs in men and children. It affects people of all races and ethnic groups. However, there are some patterns by disease type. For example:

• Localized forms of scleroderma are more common in people of European descent than in African Americans.
• Morphea usually appears between the ages of 20 and 40.
• Linear scleroderma usually occurs in children or teenagers.
• Systemic scleroderma, whether limited or diffuse, typically occurs in people from 30 to 50 years old. It affects more women of African American than European descent.

Because scleroderma can be hard to diagnose and it overlaps with or resembles other diseases, scientists can only estimate how many cases there actually are. Estimates for the number of people in the United States with systemic sclerosis range from 40,000 to 165,000. By contrast, a survey that included all scleroderma-related disorders, including Raynaud's phenomenon, suggested a number between 250,000 and 992,500.

For some people, scleroderma (particularly the localized forms) is fairly mild and resolves with time. But for others, living with the disease and its effects day to day has a significant impact on their quality of life.

How Can Scleroderma Affect My Life?

Having a chronic disease can affect almost every aspect of your life, from family relationships to holding a job. For people with scleroderma, there may be other concerns about appearance or even the ability to dress, bathe, or handle the most basic daily tasks. Here are some areas in which scleroderma could intrude.

Appearance and self-esteem: Aside from the initial concerns about health and longevity, one of the first fears people with scleroderma have is how the disease will affect their appearance. Thick, hardened skin can be difficult to accept, particularly on the face. Systemic scleroderma may result in facial changes that eventually cause the opening to the mouth to become smaller and the upper lip to virtually disappear. Linear scleroderma may leave its mark on the forehead. Although these problems can't always be prevented, their effects may be minimized with proper treatment and skin care. Special cosmetics--and in some cases, plastic surgery--can help conceal scleroderma's damage.

Caring for yourself: Tight, hard connective tissue in the hands can make it difficult to do what were once simple tasks, such as brushing your teeth and hair, pouring a cup of coffee, using a knife and fork, unlocking a door, or buttoning a jacket. If you have trouble using your hands, consult an occupational therapist, who can recommend new ways of doing things or devices to make tasks easier. Devices as simple as Velcro* fasteners and built-up brush handles can help you be more independent.

* Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

Family relationships: Spouses, children, parents, and siblings may have trouble understanding why you don't have the energy to keep house, drive to soccer practice, prepare meals, and hold a job the way you used to. If your condition isn't that visible, they may even suggest you are just being lazy. On the other hand, they may be overly concerned and eager to help you, not allowing you to do the things you are able to do or giving up their own interests and activities to be with you. It's important to learn as much about your form of the disease as you can and share any information you have with your family. Involving them in counseling or a support group may also help them better understand the disease and how they can help you.

Sexual relations: Sexual relationships can be affected when systemic scleroderma enters the picture. For men, the disease's effects on the blood vessels can lead to problems achieving an erection. In women, damage to the moisture-producing glands can cause vaginal dryness that makes intercourse painful. People of either sex may find they have difficulty moving the way they once did. They may be self-conscious about their appearance or afraid that their sexual partner will no longer find them attractive. With communication between partners, good medical care, and perhaps counseling, many of these changes can be overcome or at least worked around.

Pregnancy and childbearing: In the past, women with systemic scleroderma were often advised not to have children. But thanks to better medical treatments and a better understanding of the disease itself, that advice is changing. (Pregnancy, for example, is not likely to be a problem for women with localized scleroderma.) Although blood vessel involvement in the placenta may cause babies of women with systemic scleroderma to be born early, many women with the disease can have safe pregnancies and healthy babies if they follow some precautions.

One of the most important pieces of advice is to wait a few years after the disease starts before attempting a pregnancy. During the first 3 years you are at the highest risk of developing severe problems of the heart, lungs, or kidneys that could be harmful to you and your unborn baby.

If you haven't developed organ problems within 3 years of the disease's onset, chances are you won't, and pregnancy should be safe. But it is important to have both your disease and your pregnancy monitored regularly. You'll probably need to stay in close touch with the doctor you typically see for your scleroderma as well as an obstetrician experienced in guiding high-risk pregnancies.


How Is Scleroderma Diagnosed?

Depending on your particular symptoms, a diagnosis of scleroderma may be made by a general internist, a dermatologist (a doctor who specializes in treating diseases of the skin, hair, and nails), an orthopaedist (a doctor who treats bone and joint disorders), a pulmonologist (lung specialist), or a rheumatologist (a doctor specializing in treatment of rheumatic diseases). A diagnosis of scleroderma is based largely on the medical history and findings from the physical exam. To make a diagnosis, your doctor will ask you a lot of questions about what has happened to you over time and about any symptoms you may be experiencing. Are you having a problem with heartburn or swallowing? Are you often tired or achy? Do your hands turn white in response to anxiety or cold temperatures?

Once your doctor has taken a thorough medical history, he or she will perform a physical exam. Finding one or more of the following factors can help the doctor diagnose a certain form of scleroderma:

• Changed skin appearance and texture, including swollen fingers and hands and tight skin around the hands, face, mouth, or elsewhere.
• Calcium deposits developing under the skin.
• Changes in the tiny blood vessels (capillaries) at the base of the fingernails.
• Thickened skin patches.

Finally, your doctor may order lab tests to help confirm a suspected diagnosis. At least two proteins, called antibodies, are commonly found in the blood of people with scleroderma:

• Antitopoisomerase-1 or Anti-Scl-70 antibodies appear in the blood of up to 40 percent of people with diffuse systemic sclerosis.
• Anticentromere antibodies are found in the blood of as many as 90 percent of people with limited systemic sclerosis.

A number of other scleroderma-specific antibodies can occur in people with scleroderma, although less frequently. When present, however, they are helpful in clinical diagnosis.

Because not all people with scleroderma have these antibodies and because not all people with the antibodies have scleroderma, lab test results alone cannot confirm the diagnosis.

In some cases, your doctor may order a skin biopsy (the surgical removal of a small sample of skin for microscopic examination) to aid in or help confirm a diagnosis. However, skin biopsies, too, have their limitations: biopsy results cannot distinguish between localized and systemic disease, for example.

Diagnosing scleroderma is easiest when a person has typical symptoms and rapid skin thickening. In other cases, a diagnosis may take months, or even years, as the disease unfolds and reveals itself and as the doctor is able to rule out some other potential causes of the symptoms. In some cases, a diagnosis is never made, because the symptoms that prompted the visit to the doctor go away on their own.


What Other Conditions Can Look Like Scleroderma?

Symptoms similar to those seen in scleroderma can occur with a number of other diseases. Here are some of the most common scleroderma lookalikes:

• Eosinophilic fasciitis (EF) (EE-oh-SIN-oh-FIL-ik fa-shi-EYE-tis): a disease that involves the fascia (FA-shuh), the thin connective tissue around the muscles, particularly those of the forearms, arms, legs, and trunk. EF causes the muscles to become encased in collagen, the fibrous protein that makes up tissue such as the skin and tendons. Permanent shortening of the muscles and tendons, called contractures, may develop, sometimes causing disfigurement and problems with joint motion and function. EF may begin after hard physical exertion. The disease usually fades away after several years, but people sometimes have relapses. Although the upper layers of the skin are not thickened in EF, the thickened fascia may cause the skin to look somewhat like the tight, hard skin of scleroderma. A skin biopsy easily distinguishes between the two.
• Undifferentiated connective tissue disease (UCTD): a diagnosis for patients who have some signs and symptoms of various related diseases, but not enough symptoms of any one disease to make a definite diagnosis. In other words, their condition hasn't "differentiated" into a particular connective tissue disease. In time, UCTD can go in one of three directions: it can change into a systemic disease such as systemic sclerosis, systemic lupus erythematosus, or rheumatoid arthritis; it can remain undifferentiated; or it can improve spontaneously.
• Overlap syndromes: a disease combination in which patients have symptoms and lab findings characteristic of two or more conditions.

At other times, symptoms resembling those of scleroderma can be the result of an unrelated disease or condition. For example:

• Skin thickening on the fingers and hands also appears with diabetes, mycosis fungoides, amyloidosis, and adult celiac disease. It can also result from hand trauma.
• Generalized skin thickening may occur with scleromyxedema, graft-versus-host disease, porphyria cutanea tarda, and human adjuvant disease.
• Internal organ damage, similar to that seen in systemic sclerosis, may instead be related to primary pulmonary hypertension, idiopathic pulmonary fibrosis, or collagenous colitis.
• Raynaud's phenomenon also appears with atherosclerosis or systemic lupus erythematosus or in the absence of underlying disease.

What's important to understand, however, is that scleroderma isn't always easy to diagnose; it may take time for you and your doctor to establish a diagnosis. And while having a definite diagnosis may be helpful, knowing the precise form of your disease is not needed to receive proper treatment.


How Is Scleroderma Treated?

Because scleroderma can affect many different organs and organ systems, you may have several different doctors involved in your care. Typically, care will be managed by a rheumatologist, a specialist who treats people with diseases of the joints, bones, muscles, and immune system. Your rheumatologist may refer you to other specialists, depending on the specific problems you are having: for example, a dermatologist for the treatment of skin symptoms, a nephrologist for kidney complications, a cardiologist for heart complications, a gastroenterologist for problems of the digestive tract, and a pulmonary specialist for lung involvement.

In addition to doctors, professionals like nurse practitioners, physician assistants, physical or occupational therapists, psychologists, and social workers may play a role in your care. Dentists, orthodontists, and even speech therapists can treat oral complications that arise from thickening of tissues in and around the mouth and on the face.

Currently, there is no treatment that controls or stops the underlying problem--the overproduction of collagen--in all forms of scleroderma. Thus, treatment and management focus on relieving symptoms and limiting damage. Your treatment will depend on the particular problems you are having. Some treatments will be prescribed or given by your physician. Others are things you can do on your own.

Here are some of the potential problems that can occur in systemic scleroderma and the medical and nonmedical treatments for them. (These problems do not occur as a result or complication of localized scleroderma.)

[Note: This is not a complete listing of problems or their treatments. Different people experience different problems with scleroderma and not all treatments work equally well for all people. Work with your doctor to find the best treatment for your specific symptoms.]

Raynaud's phenomenon: One of the most common problems associated with scleroderma, Raynaud's phenomenon can be uncomfortable and can lead to painful skin ulcers on the fingertips. Smoking makes the condition worse. The following measures may make you more comfortable and help prevent problems:

• Don't smoke! Smoking narrows the blood vessels even more and makes Raynaud's phenomenon worse.
• Dress warmly, with special attention to hands and feet. Dress in layers and try to stay indoors during cold weather.
• Use biofeedback (to control various body processes that are not normally thought of as being under conscious control) and relaxation exercises.
• For severe cases, speak to your doctor about prescribing drugs called calcium channel blockers, such as nifedipine (Procardia), which can open up small blood vessels and improve circulation. Other drugs are in development and may become available in the future.
• If Raynaud's leads to skin sores or ulcers, increasing your dose of calcium channel blockers (under the direction of your doctor ONLY) may help. You can also protect skin ulcers from further injury or infection by applying nitroglycerine paste or antibiotic cream. Severe ulcerations on the fingertips can be treated with bioengineered skin.


Stiff, painful joints: In diffuse systemic sclerosis, hand joints can stiffen because of hardened skin around the joints or inflammation of the joints themselves. Other joints can also become stiff and swollen. The following may help:

• Exercise regularly. Ask your doctor or physical therapist about an exercise plan that will help you increase and maintain range of motion in affected joints. Swimming can help maintain muscle strength, flexibility, and joint mobility.
• Use acetaminophen or an over-the-counter or prescription nonsteroidal anti-inflammatory drug, as recommended by your doctor, to help relieve joint or muscle pain. If pain is severe, speak to a rheumatologist about the possibility of prescription-strength drugs to ease pain and inflammation.
• Learn to do things in a new way. A physical or occupational therapist can help you learn to perform daily tasks, such as lifting and carrying objects or opening doors, in ways that will put less stress on tender joints.

Skin problems: When too much collagen builds up in the skin, it crowds out sweat and oil glands, causing the skin to become dry and stiff. If your skin is affected, you may need to see a dermatologist. To ease dry skin, try the following:

• Apply oil-based creams and lotions frequently, and always right after bathing.
• Apply sunscreen before you venture outdoors, to protect against further damage by the sun's rays.
• Use humidifiers to moisten the air in your home in colder winter climates. (Clean humidifiers often to stop bacteria from growing in the water.)
• Avoid very hot baths and showers, as hot water dries the skin.
• Avoid harsh soaps, household cleaners, and caustic chemicals, if at all possible. If that's not possible, be sure to wear rubber gloves when you use such products.
• Exercise regularly. Exercise, especially swimming, stimulates blood circulation to affected areas.

Dry mouth and dental problems: Dental problems are common in people with scleroderma for a number of reasons: tightening facial skin can make the mouth opening smaller and narrower, which makes it hard to care for teeth; dry mouth due to salivary gland damage speeds up tooth decay; and damage to connective tissues in the mouth can lead to loose teeth. You can avoid tooth and gum problems in several ways:

• Brush and floss your teeth regularly. (If hand pain and stiffness make this difficult, consult your doctor or an occupational therapist about specially made toothbrush handles and devices to make flossing easier.)
• Have regular dental checkups. Contact your dentist immediately if you experience mouth sores, mouth pain, or loose teeth.
• If decay is a problem, ask your dentist about fluoride rinses or prescription toothpastes that remineralize and harden tooth enamel.
• Consult a physical therapist about facial exercises to help keep your mouth and face more flexible.
• Keep your mouth moist by drinking plenty of water, sucking ice chips, using sugarless gum and hard candy, and avoiding mouthwashes with alcohol. If dry mouth still bothers you, ask your doctor about a saliva substitute or a prescription medication called pilocarpine hydrochloride (Salagen) that can stimulate the flow of saliva.

Gastrointestinal (GI) problems: Systemic sclerosis can affect any part of the digestive system. As a result, you may experience problems such as heartburn, difficulty swallowing, early satiety (the feeling of being full after you've barely started eating), or intestinal complaints such as diarrhea, constipation, and gas. In cases where the intestines are damaged, your body may have difficulty absorbing nutrients from food. Although GI problems are diverse, here are some things that might help at least some of the problems you have:

• Eat small, frequent meals.
• Raise the head of your bed with blocks, and stand or sit for at least an hour (preferably two or three) after eating to keep stomach contents from backing up into the esophagus.
• Avoid late-night meals, spicy or fatty foods, and alcohol and caffeine, which can aggravate GI distress.
• Chew foods well and eat moist, soft foods. If you have difficulty swallowing or if your body doesn't absorb nutrients properly, your doctor may prescribe a special diet.
• Ask your doctor about prescription medications for problems such as diarrhea, constipation, and heartburn. Some drugs called proton pump inhibitors are highly effective against heartburn. Oral antibiotics may stop bacterial overgrowth in the bowel that can be a cause of diarrhea in some people with systemic sclerosis.

Lung damage: About 10 to 15 percent of people with systemic sclerosis develop severe lung disease, which comes in two forms: pulmonary fibrosis (hardening or scarring of lung tissue because of excess collagen) and pulmonary hypertension (high blood pressure in the artery that carries blood from the heart to the lungs). Treatment for the two conditions is different.

• Pulmonary fibrosis may be treated with drugs that suppress the immune system such as cyclophosphamide (Cytoxan) or azathioprine (Imuran), along with low doses of corticosteroids.
• Pulmonary hypertension may be treated with drugs that dilate the blood vessels such as prostacyclin (Iloprost).

Regardless of the problem or its treatment, your role in the treatment process is essentially the same. To minimize lung complications, work closely with your medical team. Do the following:

• Watch for signs of lung disease, including fatigue, shortness of breath or difficulty breathing, and swollen feet. Report these symptoms to your doctor.
• Have your lungs closely checked, using standard lung-function tests, during the early stages of skin thickening. These tests, which can find problems at the earliest and most treatable stages, are needed because lung damage can occur even before you notice any symptoms.
• Get regular flu and pneumonia vaccines as recommended by your doctor. Contracting either illness could be dangerous for a person with lung disease.

Heart problems: About 15 to 20 percent of people with systemic sclerosis develop heart problems, including scarring and weakening of the heart (cardiomyopathy), inflamed heart muscle (myocarditis), and abnormal heart beat (arrhythmia). All of these problems can be treated. Treatment ranges from drugs to surgery, and varies depending on the nature of the condition.

Kidney problems: About 15 to 20 percent of people with diffuse systemic sclerosis develop severe kidney problems, including loss of kidney function. Because uncontrolled high blood pressure can quickly lead to kidney failure, it's important that you take measures to minimize the problem. Things you can do:

• Check your blood pressure regularly and, if you find it to be high, call your doctor right away.
• If you have kidney problems, take your prescribed medications faithfully. In the past two decades, drugs known as ACE (angiotensin-converting enzyme) inhibitors, including captopril (Capoten), enalapril (Vasotec), and quinapril (Accupril), have made scleroderma-related kidney failure a less-threatening problem than it was in the past. But for these drugs to work, you must take them.

Cosmetic problems: Even if scleroderma doesn't cause any lasting physical disability, its effects on the skin's appearance--particularly on the face--can take their toll on your self-esteem. Fortunately, there are procedures to correct some of the cosmetic problems scleroderma causes.

• The appearance of telangiectasias, small red spots on the hands and face caused by swelling of tiny blood vessels beneath the skin, may be lessened or even eliminated with the use of guided lasers.
• Facial changes of localized scleroderma, such as the en coup de sabre that may run down the forehead in people with linear scleroderma, may be corrected through cosmetic surgery. (However, such surgery is not appropriate for areas of the skin where the disease is active.)


How Can I Play a Role in My Health Care?

Although your doctors direct your treatment, you are the one who must take your medicine regularly, follow your doctor's advice, and report any problems promptly. In other words, the relationship between you and your doctors is a partnership, and you are the most important partner. Here's what you can do to make the most of this important role:

• Get educated: Knowledge is your best defense against this disease. Learn as much as you can about scleroderma, both for your own benefit and to educate the people in your support network (see below).
• Seek support: Recruit family members, friends, and coworkers to build a support network. This network will help you get through difficult times: when you are in pain; when you feel angry, sad, or afraid; when you're depressed. Also, look for a scleroderma support group in your community by calling a national scleroderma organization. (See national resources for scleroderma.) If you can't find a support group, you might want to consider organizing one.
• Assemble a health care team: You and your doctors will lead the team. Other members may include physical and occupational therapists, a psychologist or social worker, a dentist, and a pharmacist.
• Be patient: Understand that a final diagnosis can be difficult and may take a long time. Find a doctor with experience treating people with systemic and localized scleroderma. Then, even if you don't yet have a diagnosis, you will get understanding and the right treatment for your symptoms.
• Speak up: When you have problems or notice changes in your condition, don't feel too self-conscious to speak up during your appointment or even call your doctor or another member of your health care team. No problem is too small to inquire about, and early treatment for any problem can make the disease more manageable for you and your health care team.
• Don't accept depression: While it's understandable that a person with a chronic illness like scleroderma would become depressed, don't accept depression as a normal consequence of your condition. If depression makes it hard for you to function well, don't hesitate to ask your health care team for help. You may benefit from speaking with a psychologist or social worker or from using one of the effective medications on the market.
• Learn coping skills: Skills like meditation, calming exercises, and relaxation techniques may help you cope with emotional difficulties as well as help relieve pain and fatigue. Ask a member of your health care team to teach you these skills or to refer you to someone who can.
• Ask the experts: If you have problems doing daily activities, from brushing your hair and teeth to driving your car, consult an occupational or physical therapist. They have more helpful hints and devices than you can probably imagine. Social workers can often help resolve financial and insurance matters.


Is Research Close to Finding a Cure?

No one can say for sure when--or if--a cure will be found. But research is providing the next best thing: better ways to treat symptoms, prevent organ damage, and improve the quality of life for people with scleroderma. In the past two decades, multidisciplinary research has also provided new clues to understanding the disease, which is an important step toward prevention or cure.

Leading the way in funding for this research is the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH). Other sources of funding for scleroderma research include pharmaceutical companies and organizations such as the Scleroderma Foundation, the Scleroderma Research Foundation, and the Arthritis Foundation. Scientists at universities and medical centers throughout the United States conduct much of this research.

Studies of the immune system, genetics, cell biology, and molecular biology have helped reveal the causes of scleroderma, improve existing treatment, and create entirely new treatment approaches.

Research advances in recent years that have led to a better understanding of and/or treatment for the diseases include:

• The use of a hormone produced in pregnancy to soften skin lesions. Early studies suggest relaxin, a hormone that helps a woman's body to stretch to meet the demands of a growing pregnancy and delivery, may soften the connective tissues of women with scleroderma. The hormone is believed to work by blocking fibrosis, or the development of fibrous tissue between the body's cells.
• Finding a gene associated with scleroderma in Oklahoma Choctaw Native Americans. Scientists believe the gene, which codes for a protein called fibrillin-1, may put people at risk for the disease.
• The use of the drug Iloprost for pulmonary hypertension. This drug has increased the quality of life and life expectancy for people with this dangerous form of lung damage.
• The use of the drug cyclophosphamide (Cytoxan) for lung fibrosis. One recent study suggested that treating lung problems early with this immunosuppressive drug may help prevent further damage and increase chances of survival.
• The increased use of ACE inhibitors for scleroderma-related kidney problems. For the past two decades, ACE inhibitors have greatly reduced the risk of kidney failure in people with scleroderma. Now there is evidence that use of ACE inhibitors can actually heal the kidneys of people on dialysis for scleroderma-related kidney failure. As many as half of people who continue ACE inhibitors while on dialysis may be able to go off dialysis in 12 to 18 months.

Other studies are examining the following:

• Changes in the tiny blood vessels of people with scleroderma. By studying these changes, scientists hope to find the cause of cold sensitivity in Raynaud's phenomenon and how to control the problem.
• Immune system changes (and particularly how those changes affect the lungs) in people with early diffuse systemic sclerosis.
• The role of blood vessel malfunction, cell death, and autoimmunity in scleroderma.
• Skin changes in laboratory mice in which a genetic defect prevents the breakdown of collagen, leading to thick skin and patchy hair loss. Scientists hope that by studying these mice, they can answer many questions about skin changes in scleroderma.
• The effectiveness of various treatments, including (1) methotrexate, a drug commonly used for rheumatoid arthritis and some other inflammatory forms of arthritis; (2) collagen peptides administered orally; (3) halofugione, a drug that inhibits the synthesis of type I collagen, which is the primary component of connective tissue; (4) ultraviolet light therapy for localized forms of scleroderma; and (5) stem cell transfusions, a form of bone marrow transplant that uses a patient's own cells, for early diffuse systemic sclerosis.

Scleroderma research continues to advance as scientists and doctors learn more about how the disease develops and its underlying mechanisms.

Recently, the NIAMS funded a Specialized Center of Research (SCOR) in scleroderma at the University of Texas-Houston. SCOR scientists are conducting laboratory and clinical research on the disease. The SCOR approach allows researchers to translate basic science findings quickly into improved treatment and patient care.


More Questions? Count on More Answers

Scleroderma poses a series of challenges for both patients and their health care teams. The good news is that scientists, doctors, and other health care professionals continue to find new answers--ways to make earlier diagnoses and manage disease better. In addition, active patient support groups share with, care for, and educate each other. The impact of all of this activity is that people with scleroderma do much better and remain active far longer than they did 20 or 30 years ago. As for tomorrow, patients and the medical community will continue to push for longer, healthier, and more active lives for people with the diseases collectively known as scleroderma.

National Resources for Scleroderma

National Institute of Arthritis and Musculoskeletal
and Skin Diseases Information Clearinghouse
NIAMS/National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
(301) 495-4484 or (877) 22-NIAMS (226-4267) (free of charge)
TTY: (301) 565-2966
Fax: (301) 718-6366

This clearinghouse, a public service sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), provides information about various forms of arthritis and rheumatic diseases. The clearinghouse distributes patient and professional education materials and also refers people to other sources of information.

American Academy of Dermatology
P.O. Box 4014
Schaumburg, IL 60168-4014
(847) 330-0230

This national professional association for dermatologists publishes a pamphlet on skin conditions and can also provide physician referrals.

American College of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345
(404) 633-3777
Fax: (404) 633-1870

This association provides referrals to doctors and health professionals who work on arthritis, rheumatic diseases, and related conditions. The association also provides educational materials and guidelines.

Scleroderma Foundation
12 Kent Way, #101
Byfield, MA 01922
(800) 722-HOPE (free of charge) or (978) 463-5843
Fax: (978) 463-5809

This voluntary organization publishes information on scleroderma and funds research. It also offers patient education seminars, support groups, physician referrals, and information hotlines.

Scleroderma Research Foundation
2320 Bath Street, Suite 315
Santa Barbara, CA 93105
(800) 441-CURE (2873) (free of charge) or (805) 563-9133

The foundation's goal is to find a cure for scleroderma by funding and facilitating the most promising, highest quality research and by placing the disease and its need for a cure in the public eye. The foundation distributes patient handbooks and a twice yearly, research-related newsletter.

Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
Call your local chapter (listed in the telephone directory), or (404) 872-7100 or (800) 283-7800 (free of charge)

The foundation is a major voluntary organization devoted to supporting research on arthritis and other rheumatic diseases, such as scleroderma. It also provides up-to-date information on treatments, nutrition, alternative therapies, and self-management strategies. Chapters nationwide offer exercise programs, classes, support groups, physician referral services, and free literature.

Fungal Skin Infections

Athlete's Foot (Tinea Pedis)

Athlete's foot, also known as tinea pedis, is a common foot infection caused by fungi called dermatophytes. Found in many different places indoors and outdoors, dermatophytes are especially common in the warm, moist environments of pools, showers, locker rooms and other sports facilities, where people walk with bare feet. Once dermatophytes contaminate the skin of someone's foot, the warm, moist environment of sweaty socks and shoes encourage them to grow.


Symptoms of athlete's foot include:
• Intense itching of the feet
• Cracked, blistered or peeling areas of skin, especially between the toes
• Redness and scaling on the soles

In most people, signs of infection are seen on the webbed skin between the toes. In some people, the infection spreads to one or more toenails, causing the nail to appear unusually thick and cloudy yellow.


Your health-care provider will ask you about your symptoms and about factors that make you more likely to develop athlete's foot, such as your use of public sports facilities, clubs or showers. He or she also will ask about your foot-care habits, including the type of shoes and socks you wear, what kind of work you do and what you wear on your feet to work.

Your health-care provider usually can diagnose athlete's foot simply by looking at your feet. He or she can confirm the diagnosis by gently scraping some flakes of skin from a scaly portion of your foot onto a slide. The dermatophytes that cause the infection often show up under a microscope.

Expected Duration

Response to treatment usually takes several weeks to months. Even after proper medical treatment, the infection can recur easily if your feet are exposed again to fungi and sweaty, warm conditions. For this reason, many people have persisting and recurring athlete's foot infection for many years. Successfully curing the infection often requires changes in how you care for your feet and what you wear on your feet.
Prevention is as important as medications in treating athlete's foot because of frequent recurrences. In general, you can help to prevent athlete's foot by keeping your feet clean and dry. More specifically, you can try the following:

• Wash your feet thoroughly every day and wear a clean pair of socks after your bath or shower.
• Take time to dry your feet, including each toe, thoroughly (especially the webbed area between the toes) after you bathe, shower or swim.
• If you use public pools or showers, wear thongs or sandals to prevent your feet from being exposed to floors contaminated with fungi.
• Choose leather shoes rather than vinyl, since leather lets feet "breathe" so they are more likely to stay dry.
• Wear cotton socks to absorb sweat.
• If possible, don't wear the same pair of shoes for two days in a row. Give shoes a 24-hour break between wearing to air out and dry out.
• Don't share shoes.


Doctors usually begin treating athlete's foot with an antifungal medication applied to the feet. Theses medications include ciclopirox (Loprox), clotrimazole (Lotrimin, Mycelex), econazole (Spectazole), ketoconazole (Nizoral), miconazole (Micatin), naftifine (Naftin), oxiconazole (Oxistat), sulconazole (Exelderm), terbinafine (Lamisil), terconazole (Terazol), and tolnaftate (Desenex, Tinactin and others). Some are available without a prescription. Many weeks of treatment may be necessary. For people with long-standing or recurring athlete's foot infections, topical antifungal drugs may relieve symptoms without actually curing the infection.

Medications by mouth can be more successful at curing an infection. However, you still can be susceptible to recurrences, and oral medications may be more likely to cause side effects. These require a prescription and include griseofulvin (Fulvicin, Grifulvin, Grisactin), itraconazole (Sporanox) and terbinafine (Lamisil).

When To Call A Professional

If you think you have athlete's foot, try a nonprescription antifungal ointment, cream or powder. Keep your feet as dry and clean as possible. If these measures do not help, make an appointment to see your doctor. Call your doctor for a more urgent evaluation and treatment if you see spreading redness or have fevers.

If you have diabetes and any foot problems, see your doctor promptly. People with diabetes easily get skin infections, so they should see a doctor as soon as an abnormality appears.


People with new or short-term symptoms of athlete's foot usually can be cured after several weeks of treatment with a medication applied to the feet. Chronic or recurring athlete's foot infections also can be cured, but may require significant changes in foot care as well as several weeks of treatment. In more severe cases, an oral medication may be used. Even after successful treatment, you remain at risk of re-infection if you do not follow prevention guidelines. Relapses are common.

Jock Itch (Tinea Cruris)

The term "jock itch" is used to describe an itchy rash in the groin of a man. Although there are other causes of jock itch, this term has become synonymous with the medical diagnosis of tinea cruris in both men and women. Tinea cruris is a common fungal infection that affects the groin and inner thighs and often is experienced by athletes. Tinea is the name of the fungus; cruris comes from the Latin word for leg.

Jock itch can develop when tight garments trap moisture and heat, which creates an environment in which fungi multiply and flourish. It occurs more commonly in men, but can affect women as well. The jock-itch fungus also may cause a rash on the upper and inner thighs, the armpits, the area just underneath the breasts, and the feet (athlete's foot). Many people with tinea cruris also have athlete's foot. Athlete's foot is called tinea pedis.


Symptoms of athlete's foot include:

A flat, red, itchy rash first appears high on the inner side of one or both thighs. It spreads outward in a ringlike circular pattern while the center partially clears. The border is sharply demarcated, slightly raised and often beefy red in color. Jock itch can spread to the pubic and genital regions and sometimes to the buttocks.


Your doctor often can make the diagnosis just by looking at the rash. He or she confirms the diagnosis by scraping a small amount of irritated skin onto a slide. Usually, fungi can be seen under a microscope. Occasionally, your doctor may send the sample to a laboratory to pinpoint the trouble-causing fungus. Other causes of a rash in the groin include yeast infection of the skin, seborrheic dermatitis and psoriasis.

Expected Duration
Jock itch can be treated in a matter of weeks, although it commonly recurs. Treatment for chronic infections may last one or two months.


Your general state of health helps determine your susceptibility to fungal infections. Remaining healthy through diet, rest and exercise is the first step in avoiding fungal infection.

Here are other steps you can take to remain fungus free:

• Keep your body clean.
• Dry yourself well after showers and baths.
• Shower immediately after athletic activities.
• Wear loose clothing whenever possible.
• Do not share clothing or towels with others, and wash towels frequently.
• Clean exercise equipment before use.
• Wear sandals in the shower area at the gym and swimming pool.


Most likely, your doctor will prescribe a topical antifungal treatment for you to apply once or twice a day for at least two weeks. If you have athlete's foot, your doctor should address that as well. Untreated athlete's foot may cause jock itch to recur.

Because jock itch commonly recurs, you need to be extra cautious. Daily application of a powder such as talc helps keep the area dry. The itching can be alleviated with an over-the-counter treatment such as Sarna lotion. You also should avoid hot baths and tight-fitting clothing. Men should wear boxer shorts rather than briefs.
When To Call A Professional
Call your doctor whenever you develop a skin rash.


Treatment for jock itch is quick and usually effective, but the condition often recurs. The following people should be especially vigilant to prevent recurrence:

• Athletes
• People with fungal infections that affect other parts of the body (such as athlete's foot)
• People who wear tight clothing
• People with damaged or altered immune systems

Ringworm (Tinea)

Ringworm, also called tinea, is a skin infection caused by fungi, microscopic organisms that are similar to yeast and molds. It does not have any relation to worms, but is called "ringworm" because the infection can produce ring-shaped patches on the skin that have red, wavy, wormlike borders.

Although ringworm can affect almost any portion of the body from head to toe, it favors places that are dark and moist, such as skin in the groin area, the spaces between the toes and the deep skin folds of obese people. People can catch ringworm in several different ways, including:
• Direct skin-to-skin contact with an infected person
• Playing with, or caring for, an infected pet or farm animal
• Using an infected person's clothing, shoes or personal grooming items such as combs, brushes or towels
• Sharing an infected child's toys, especially stuffed toys
• Touching a contaminated surface — Some common high-risk surfaces include floors in bathrooms, showers and locker rooms; shower stalls; gym mats; and pool decks, especially at school or community pools. In general, any surface that is used by many different people can carry ringworm, especially if the surface is also wet or damp. Even contaminated carpets and couches can spread the infection.

Depending on its specific location, tinea may be known by a more common name, such as athlete's foot or jock itch. The various types of ringworm include:
• Ringworm of the scalp — This infection, also known as tinea capitis, causes patches of hair loss on the scalp. It is especially common among children aged 3 to 9, particularly children who live in crowded conditions in urban areas. Scalp ringworm spreads on contaminated combs, brushes, hats and pillows, and it may occur in epidemics in schools and day-care centers.
• Barber's itch (ringworm of the beard) — This fungal infection affects bearded areas of the face and neck in adult men.
• Ringworm of the body — Ringworm of the body, also known as tinea corporis, involves the non-hairy skin of the face, trunk, arms or legs. Of all types of ringworm, tinea corporis is the one that most often produces the classic, ring-shaped patches with wormlike borders. Ringworm of the body occurs in people of all ages and races, with women affected as often as men.
• Jock itch (ringworm of the groin) — This infection, also known as tinea cruris, typically causes itchy, scaly, red patches of skin on the groin area. It most often affects teen-age and adult men, especially those who are obese, or who wear tight-fitting underwear. It is the most common type of tinea.
• Athlete's foot (ringworm of the foot) — Athlete's foot, also known as tinea pedis, is the second most common form of tinea. In some individuals, the fungus attacks not only the skin of the foot but also the toenails. Athlete's foot is often acquired by walking barefoot on contaminated floors, especially in gyms and locker rooms.

Doctors estimate that at least 20 percent of all people will develop tinea at some time during life. People with a higher-than-average risk of fungal skin infection include people who live in hot, humid climates; athletes, especially swimmers; children in day care; people who work with animals; obese people with deep, moist skin folds; and anyone whose immune defenses are weakened by illness (HIV, organ transplant, some cancers) or by medications.


Symptoms of ringworm vary, depending on the site of the infection:

• Ringworm of the scalp — Symptoms can include a diffuse, itchy, scaling of the scalp that resembles dandruff; itchy, scaly, round patches of hair loss on the scalp; black-dot ringworm in which stubs of broken hairs form a dotted pattern on the scalp; or kerion, a thick, nodular, patch of inflamed skin that may ooze pus
• Barber's itch — Symptoms often include kerion and crusted skin. Bearded areas of the face and neck are affected.
• Ringworm of the body — This infection produces itchy, red, scaly, round patches with a raised border. Individual patches are usually less than 5 centimeters (2 inches) in diameter, and may occur singly or in groups of three to four
• Jock itch — Jock itch causes red, scaly patches that may itch or burn. These patches usually occur on the groin area and upper thigh, but not on the penis or scrotum.
• Athlete's foot — Athlete's foot produces areas of redness, scaling or cracked skin on the feet, especially between the toes. The affected skin may itch or burn, and the feet may have a strong odor.


If you have symptoms of athlete's foot, ringworm of the body or jock itch, you often can make the diagnosis yourself. Begin by asking yourself whether you are at risk of these infections. For example, do you have an athletic lifestyle that routinely exposes you to pools, gyms, locker rooms and other places where fungi thrive? Do you live or work in crowded conditions? Have you shared clothing, shoes, towels or personal-grooming items with other people? Have you recently been exposed to a person or animal that has patchy hair loss or areas of scaly, red skin? If you answered yes to any of these questions, then you probably have tinea.

On the other hand, if your symptoms involve the scalp or beard, you should not attempt to diagnose and treat the problem yourself. You should be checked by a health-care professional. Your doctor will review your symptoms and risk factors, and then examine your skin. In many cases, the ringworm can be diagnosed based on your history, symptoms and skin findings. Sometimes, however, your doctor may need to scrape gently an area of skin to check for ringworm fungi under the microscope. A few affected hairs may be examined as well. If necessary, a tiny sample of skin or hair may be sent for laboratory culture to isolate and identify the particular type of fungus causing the infection.

Expected Duration

With proper treatment, both jock itch and ringworm of the body usually improve within one to two weeks. Ringworm of the scalp or beard may take a few weeks longer. However, athlete's foot can be a chronic problem that comes and goes over many years. This can be caused in part by an active lifestyle that keeps the feet moist and sweaty.


To help prevent tinea, try the following suggestions:

• Avoid sharing anyone else's clothing, shoes, towels or personal-grooming items (hairbrushes, combs, makeup brushes).

• If your child goes to sleepover parties, provide a sleeping bag, pillow and blanket from home.

• Bathe regularly and dry your skin thoroughly afterwards. Be especially careful to dry the area between your toes and under your breasts.
• Wear clean socks and underwear every day. When possible, choose absorbent cotton socks and underwear rather than synthetic fabrics. At the gym, keep an extra pair of socks in your locker to replace sweaty socks after a workout.
• Wear sandals, flip-flops, shower shoes or other protective footwear when you walk through locker rooms or shower rooms or near pools.
• If you care for a pet or farm animal that develops areas of hair loss or scaly patches, take the animal to a veterinarian for a checkup.


If you have jock itch, athlete's foot or ringworm of the body, you usually can begin treatment yourself with a nonprescription antifungal cream, lotion or powder. Check the medication's label for the type of skin symptom it treats, the list of active ingredients and the way it should be applied. Some of the nonprescription medications available include terbinafine (Lamisil), tolnaftate (Tinactin), miconazole (Micatin and other brand names), clotrimazole (Lotrimin, Mycelex) and undecylenic acid (Desenex and other brand names). Be sure to follow the directions carefully when you apply the medication. If your symptoms do not improve significantly after you have used a nonprescription medicine for approximately two weeks, call your doctor. Your doctor may suggest a prescription antifungal medication that will cure the problem. For extremely stubborn infections, the antifungal medication may be taken by mouth rather than being applied to the skin.

If you have ringworm of the scalp or beard your doctor may treat you with an oral antifungal medication, such as itraconazole (Sporanox) or griseofulvin (Grisactin and other brand names). In addition, you will have to apply antifungal creams to your hair and scalp. Complete treatment can take up to two months.

When To Call A Professional

Make an appointment to see your doctor if you have symptoms of ringworm that involve the scalp or beard. For other forms of ringworm, call your doctor if nonprescription medicine does not improve your skin problem after two weeks of treatment.

If your immune system is weakened by illness or medication, contact your doctor promptly whenever you develop any unusual skin symptoms. In particular, people with diabetes should have skin symptoms, especially on the feet, checked as soon as possible.


Although treatment may take several weeks, antifungal medication almost always cures ringworm infections. Hair eventually regrows, and scarring is rare.

However, people do not develop immunity to tinea. Because it is possible to catch the fungus again, follow the suggestions outlined in the Prevention section above to avoid recurrence.

Tinea Versicolor

Many microorganisms are normally live on our skin, including a yeast called Pityrosporum orbiculare. The yeast lives in our pores. Under certain conditions, it can grow out of control and produce a rash called tinea versicolor, also called pityriasis versicolor.

Tinea versicolor is common year-round in the tropics and subtropics, and is seen in the summer months in more temperate climates, because the yeast grows best in hot and humid conditions. The rash occurs more often in teen-agers and young adults, and appears on the back, neck, upper chest, shoulders, armpits and upper arms. It is more likely to occur on oily skin.

It is not clear why some people get tinea versicolor, while others do not. The yeast grows slowly and normally is washed off the skin during normal cleansing.


Your doctor can shine an ultraviolet light on the rash. If your skin is infected with P. orbiculare, the rash will glow under the light. Your doctor also can take skin scrapings from the lesions and examine them under the microscope to see if the yeast is present.


The yeast responds well to treatment, but the changes in skin color may remain for several months, especially if you have spent time in the sun. Wearing a strong sunscreen and taking other precautions against sun exposure can minimize the difference in skin color between normal skin and skin affected by tinea versicolor.

Expected Duration

With proper treatment, both jock itch and ringworm of the body usually improve within one to two weeks. Ringworm of the scalp or beard may take a few weeks longer. However, athlete's foot can be a chronic problem that comes and goes over many years. This can be caused in part by an active lifestyle that keeps the feet moist and sweaty.


Because the yeast grows more readily in hot, humid conditions, keep your skin as dry and cool as possible. Tinea versicolor can be spread through skin-to-skin contact or by coming in contact with contaminated articles such as unwashed towels or bedding. Tinea versicolor is more common in people who have a suppressed immune system (for instance, people who are taking a corticosteroid medication such as prednisone for another health problem). It is also more common in women who are taking birth-control pills and pregnant women.


Topical treatments (shampoos, sprays) and oral medications are available to treat tinea versicolor. Topical treatments usually are used one or two times each day. Oral antifungal agents, such as itraconazole (Sporanox), may be prescribed by your doctor if you have a more severe case. For six months after your original treatment, you may be advised to apply topical treatments occasionally or take one or more doses per month of oral antifungal medicine to help prevent a recurrence of the rash.

During treatment, bed linens and pajamas should be washed daily to avoid reinfection.
When To Call A Professional
If you have a skin rash that you think might be tinea versicolor, you should make an appointment with your doctor to have the rash evaluated.


There are no serious complications from tinea versicolor. In most people, the rash goes away with treatment. However, it takes several months for the skin to return to its normal appearance. The rash returns after treatment within six months in nearly 40 percent of people who are not using intermittent antifungal treatments to suppress the rash.

Toenail Fungus (Onychomycosis)

Toenail fungus, also called onychomycosis, is a relatively common condition that disfigures and sometimes destroys the nail. Onychomycosis can be caused by several different types of fungi (microscopic organisms related to mold and mildew). These fungi thrive in the dark, moist and stuffy environment inside shoes. As they grow, they feed on keratin, the tough protein that makes up the hard surface of the toenails. In most cases, the fungus belongs to a group of fungi called dermatophytes, which include Trichophyton rubrum and Trichophyton interdigitale. Other, less common causes of onychomycosis include yeasts and molds.

Toenail fungus affects 2 percent to 18 percent of all people worldwide and 3 percent to 5 percent of people in the United States. It is relatively rare in children, affecting only about one out of every 200 people younger than 18. However, the likelihood of getting toenail fungus increases with age, so that up to 48 percent of people have at least one affected toe by the time they reach age 70. Although 2.5 million Americans see a podiatrist annually for treatment of toenail fungus, many more are infected but never seek help. Some people consider toenail fungus just a cosmetic problem, and don't bother seeking treatment.

Almost anyone who wears tight-fitting shoes or tight hosiery has an increased risk of developing toenail fungus, especially if they also practice poor foot hygiene. Wearing layers of toenail polish, which doesn't allow the nail to breathe, is another risk factor. Also, because toenail fungi may spread from foot to foot on the floors of showers and locker rooms, fungal infections of the toenails are especially common among military personnel, athletes and miners. The condition also tends to affect people with chronic illnesses, such as diabetes or HIV, as well as people with circulatory problems that decrease blood flow to the toes. However, many people have no clear risk factors.

Of all the toenails, those on the big toe and little toe are the most likely to develop a toenail fungus. This may be partly because the big toe and little toe are constantly exposed to the mild trauma of friction from the sides of shoes.


When a toenail develops a fungal infection, it typically turns yellow or brown and becomes thick and overgrown. Foul-smelling debris also may accumulate under the nail, especially at the sides and tip. As the infection continues, the nail either may crumble gradually and fall off or become so thick that the affected toe feels uncomfortable or painful inside shoes.

In a less common variety of toenail fungus, called white superficial onychomycosis, the nail turns white rather than yellow or brown, and the surface becomes soft, dry and powdery.


After you describe your foot symptoms, your doctor will ask you about any factors that might increase your risk of toenail fungus. These include a high-risk occupation, sports participation, tight-fitting shoes or hosiery, poor foot hygiene or use of heavy toenail polish. Your doctor will also ask whether you have a history of poor circulation, diabetes, HIV or any other illness that might decrease your resistance to infection or interfere with blood flow to your toes.

Because psoriasis sometimes can cause nail problems that look similar to a fungal infection, your doctor may ask whether you or anyone in your family has psoriasis. In some people with psoriasis, the nails are the only part of the body affected; the skin is largely spared. Also, it is possible for psoriasis and a fungal infection to affect the same toenail.

If you and your doctor decide that this nail problem is important, he or she will examine your affected toenail or toenails. To confirm that you have a fungal infection, your doctor will take small samples of the affected nails and send them to a laboratory. The nail samples will be examined under a microscope and will be checked for fungi and other microorganisms.

Expected Duration

Toenail fungus rarely heals on its own. It is usually a chronic condition that gradually progresses to involve more and more of the nail. Even if the affected nail falls off or is knocked off, the new nail that grows usually is infected with fungus.


You can help to prevent toenail fungus by:
• Wearing comfortable shoes and hosiery that allow your feet some "breathing space"
• Wearing shoes, sandals or flip-flops in community showers or locker rooms
• Washing your feet every day, drying them thoroughly and using a good-quality foot powder
• Wearing clean socks or stocKings, Queens, Richmond every day
• Keeping toenails trimmed
• Disinfecting pedicure tools before you use them


There are several approaches to therapy. Treatment may begin with your doctor removing as much of the infected nail as possible. This can be done by trimming the nail with clippers, filing it down or dissolving it away with a paste that contains urea and bifonazole.

Next, if the infection is mild and very localized, your doctor may prescribe a medicated nail polish containing either amorolfine (Loceryl) or ciclopirox (Loprox). You should apply the nail polish twice a week until your nail is cured.

If the infection involves a wider area of your nail, or several nails, your doctor will prescribe an oral antifungal medication, such as itraconazole (Sporanox) or terbinafine (Lamisil). Either itraconazole or terbinafine can be taken daily for 12 weeks, or a higher dose of itraconazole can be taken for one week per month for three months. Both itraconazole and terbinafine occasionally cause troublesome side effects, and itraconazole has the potential to produce serious drug interactions in people taking terfenadine (Seldane), astemizole (Hismanal), cisapride (Propulsid), midazolam (Versed), triazolam (Halcion) or lovastatin (Mevacor).

In very severe cases of toenail fungus resistant to therapy, it may be necessary to remove the nail surgically.
When To Call A Professional
You may wish to make an appointment to see your family doctor or podiatrist if you notice that a portion of your toenail has become abnormally thick or discolored. Call your doctor promptly if any problem involving your feet or toes makes walking painful or difficult.


According to one study involving 195 patients with toenail fungus, 81 percent of those treated with terbinafine and 63 percent of those treated with itraconazole were cured fungus after 12 weeks of therapy. However, even after the fungus was dead in these patients, only 36 percent to 50 percent had completely clear, normal-looking nails.

After treatment with itraconazole, the fungus returns after nine to 12 months in 9 percent to 11 percent of patients. After treatment with terbinafine, the fungus returns within 12 months in about 12 percent of patients.

Hair Loss (Alopecia)

Alopecia Areata

Alopecia areata is a skin disorder that typically produces one or more patches of hair loss, most often on the scalp. Usually the bald patches appear suddenly, affect only a limited area, and regrow hair within 12 months or less. For some people, however, the problem can be more chronic and more severe, producing either total baldness (alopecia totalis) or total loss of all body hair (alopecia universalis).

The underlying problem in alopecia areata is probably an autoimmune reaction, in which the body's immune defenses incorrectly target and attack the body's own cells. In this case, the targeted cells are those of the skin's hair follicles (structures that grow hair), especially follicles within the scalp. In addition, genetic (inherited) factors may play a role, particularly when the disorder strikes those under the age of 30. In this age group, almost 40 percent of people with alopecia areata have at least one additional family member who has been diagnosed with the same disorder. The risk of developing alopecia areata is also unusually high in people who suffer from asthma, hay fever, thyroid disease, vitiligo (a condition in which patches of skin lose their color), pernicious anemia and Down syndrome. Although experts once believed that episodes of alopecia areata could be triggered by stress, newer research studies have failed to prove that stress is a risk factor for this disorder.

Approximately 1 percent to 2 percent of people in the United States develop alopecia areata at some time during their lives. In about 60 percent of cases, the first episode of hair loss occurs before age 20 and is followed by hair regrowth. Unfortunately, recurrences are common, and new bald patches can develop at the same time as the older ones are regrowing hair.


In its most common form, alopecia areata produces small round or oval patches of baldness on the scalp. The area of bald skin looks smooth and normal, with no unusual redness, scaling or pimples. In most cases, there are no other scalp symptoms. Occasionally, there is mild itching, tingling, tenderness or a burning sensation in the affected area. Some people with alopecia areata also suffer from abnormalities in the surface of their fingernails, such as tiny pits or dents, grooves, superficial splitting or an abnormal area of redness.

In rarer, more severe forms of the disorder, hair loss can involve the entire scalp or the entire body, including the eyebrows, eyelashes, beard, underarm hair and pubic hair (hair around the genitals).


Your doctor may suspect that you have alopecia areata based on your symptoms and, in some cases, your family history of the disorder. To look for further evidence, your doctor will examine your scalp and pull gently on the hairs near the margin of the bald area. If these hairs come out very easily, the doctor will inspect them for any obvious structural abnormalities of the root or shaft. In some cases, a small skin biopsy of your scalp may be done to confirm the diagnosis.

Expected Duration

In most small patches of alopecia areata, the hair regrows spontaneously within six to 12 months. However, recurrences are common.


Alopecia areata cannot be prevented.


Although there is no permanent cure for alopecia areata, there are ways to short-circuit the body's autoimmune reaction in the scalp and encourage hair regrowth. Options include:

• No immediate treatment — Since hair usually regrows inside the bald areas within a few months, if you have mild hair loss you may choose to simply modify your hairstyle or wear a hairpiece until the bald area fills in.
• Cortisone injected directly into the bald patches to suppress the immune reaction locally
• Topical (applied to the surface) medications such as minoxidil (Rogaine), anthralin (Drithocreme, Dritho-Scalp, Micanol) or corticosteroid creams
• Topical immunotherapy
• Psoralen and ultraviolet A phototherapy (careful, controlled exposure of the affected skin to ultraviolet light)
• A short course of corticosteroids (such as prednisone) by mouth, or rarely, intravenously (through a vein) for adult patients with extensive hair loss

Your treatment plan will depend on several factors, including your age (some treatments are used only in adults), the extent of your hair loss and your willingness to deal with any treatment-related discomfort or side effects. If you have lost a large amount of hair on your scalp, you may be more comfortable wearing a wig or hairpiece until your treatment starts to work. If you have a very obvious loss of eyebrow hair, you also may choose to have careful injection of tiny dots of colored pigments into the eyebrow area (a procedure called dermatography). If coping with the change in your appearance is hard to deal with, mention it to your physician or seek advice from a mental-health professional.

When To Call A Professional

Make an appointment to see your doctor if:

• You suddenly develop a bald spot on your scalp
• Your hair stylist tells you that your hair is thinning, or that you have small bald areas
• You have lost your eyebrows or eyelashes, your beard is thinning, or you have noticeably less hair on your underarms or pubic area


In more than 90 percent of cases, the hair regrows and fills the bald spot within one year, even without treatment. However, recurrences are common, and most patients have several episodes of the disorder during a lifetime. Only about 7 percent of patients go on to develop severe, chronic forms of the illness that produce large areas of hair loss with little hair regrowth.

Hereditary-Patterned Baldness

Hereditary-patterned baldness — or androgenetic alopecia — is the most common cause of hair loss, affecting 30 percent to 40 percent of both men and women. Hereditary-patterned baldness is not really a disease. It is a natural condition caused by some combination of genetics, hormone levels and the aging process. Hair loss typically begins in the 20s and 30s, although in women the changes are most noticeable after menopause.

In recent years researchers have begun to understand more about the cause of this type of hair loss. Under the influence of a form of the male hormone testosterone, there is a change in the normal cycle of hair growth, resulting in shorter, thinner or "miniaturized" hair. Eventually, hair growth in certain parts of the scalp stops entirely, which produces the typical pattern of hair loss. Contrary to the folk wisdom that baldness is inherited from one's mother's family, genes contributed by both parents appear to affect hormone levels as well as the general susceptibility to this process.


Hereditary-patterned baldness starts with thinning of the hair and progresses to complete hair loss in parts of the scalp. Hairs on the pillow, in the tub or on the comb are unreliable symptoms of hair loss. The average non-balding person loses 100 hairs per day, and more hair may fall out under certain circumstances, such as after childbirth or a serious illness.

In men, the hair loss typically begins at the temples and crown and proceeds in an M-shaped pattern. In the most advanced stage, only a rim of hair along the side and back of the scalp remains.

In women, hair loss tends to be more widespread but better camouflaged. The top of the head down the middle is most commonly affected, often in a "Christmas-tree" pattern. In contrast to men, the hairline along the forehead and temples usually remains normal in women. Complete loss of hair in any one place on the scalp is unusual and may suggest that a different process is at work, such as alopecia areata (an immune system disorder that causes bald patches), a fungus infection or one of a number of skin conditions.


Hereditary-patterned baldness usually is diagnosed by both its pattern and a history of a similar type of hair loss affecting family members. In most people, no further tests are required.

Expected Duration

Hair loss should be expected to be permanent.


If you begin to lose hair in a hereditary pattern you may be able to prevent further hair loss by using minoxidil (Rogaine) or finasteride (Proscar). Minoxidil can be used by both men and women, while finasteride usually is used just for men.

Minoxidil is a lotion, now available over the counter, that is applied to the scalp twice daily. It prevents further hair loss in most people within two months of starting treatment. Within four to eight months, about 30 percent of people will grow new hair that is long enough to be cut or combed. Success is greatest in younger people who have just begun to lose hair. Women appear to respond to minoxidil just as well as men do. Better success generally is seen with a higher-strength (5-percent) solution. One caution: If you stop using minoxidil, you probably will lose all the hair that was retained or restored by the medication.

Finasteride is a prescription-only, once-daily pill that blocks the formation of the type of testosterone that affects hair growth. Higher strengths of the same medication are used in men to stop benign growth of the prostate gland. Studies suggest that finasteride helps to prevent hair loss in up to 99 percent of men with hereditary-patterned baldness, and that two-thirds experience some new hair growth. As with minoxidil, any benefits from the medication are quickly lost once it is discontinued. In addition, a small number of men develop difficulty with sexual function.

Finasteride does not appear to prevent hair loss in women. It also may cause birth defects, and should not be used by any woman who could possibly get pregnant. However, other types of hormonal treatment (for example, certain types of birth-control pills) may help the minority of women with hair loss who have elevated levels of male hormones.

In some people, hair loss may be caused by certain hair treatments (straightening, coloring), hairstyles (tight braids) or hair-pulling. Although these are not factors in most cases of hereditary-patterned baldness, they may contribute to hair loss and should certainly be discontinued.

A variety of other creams, oils, lotions and herbal remedies for hair loss are regularly advertised. However, only minoxidil and finasteride have been proven effective.


As noted above, minoxidil and finasteride can promote new hair growth in addition to preventing hair loss. This effect is quite unpredictable from one person to the next.

Hair weaves, wigs and toupees can be used. In addition, a variety of surgical techniques also can be used, including:
• Scalp reduction — Strips of bald skin are removed surgically to decrease the size of a bald spot.
• Hair flaps — A strip of skin with good hair growth can be moved from a less cosmetically important area to a more important one.
• Hair transplants — Tiny plugs of skin containing from one to 15 hairs are moved from the back or side of the scalp to a bald area. The newer "micrografts," which contain very few hairs, yield the best results, but are more expensive and time-consuming than older types of transplants. Up to 700 individual grafts may be necessary to complete a treatment. It may take up to two years to see the full benefit of hair-replacement surgery.

Some over-the-counter scalp treatments can cause irritation or harm and worsen hair loss.

When To Call A Professional

You should call a health-care professional if you have any of the following symptoms because they can suggest a problem other than hereditary-patterned baldness:

• Hair that falls out suddenly or in clumps

Patchy hair loss ("flea-bitten" appearance)
• Redness, flaking or scarring of the scalp in the area of hair loss
• Hair loss in women under age 30
• Signs of abnormally high testosterone levels in women, including abnormal menstrual periods, deepening of the voice, acne, hair loss in a male pattern or hair growth in unusual places (face, chest)

Most primary-care physicians or dermatologists will prescribe finasteride to men who would like to use it. If you are interested in cosmetic surgery, you should consult a cosmetic surgeon or dermatologist who specializes in hair restoration.


Unless a preventive treatment is started, hereditary hair loss becomes more pronounced over time. Generally, the earlier hair loss begins, the more severe it will become. As noted above, preventive treatment with minoxidil or finasteride must be continued indefinitely to maintain results.

Insect Bites and Stings

Facts on stinging insects

1. The majority of insect stings in the U.S. come from yellow jackets, hornets, wasps, bees, and fire ants. These insects occur throughout the U.S. except for fire ants which are found only in the Southeastern states.
2. Over 2 million Americans are allergic to stinging insects.
3. More than 500,000 people enter hospital emergency rooms every year suffering from insect stings and 40-150 people die as a result of an allergic reaction to these stings.
4. An allergic reaction to an insect sting can occur immediately, within minutes, or even hours after the sting (although never more than 24 hrs.). Such a reaction is characterized by hives, itchiness, and swelling in areas other than the sting site, difficulty in breathing, dizziness or a sharp drop in blood pressure, nausea, cramps or diarrhea, unconsciousness and cardiac arrest.
5. Patients who have experienced a systemic allergic reaction to an insect sting have a 60% chance of a similar (or worse) reaction if stung again.
6. An allergic reaction in progress can be stopped with epinephrine, either self-injected or administered by a doctor. People who carry these sting kits must keep them close at hand wherever they go and remember that one dose is not always enough to stop a reaction. If you are stung, seek medical attention immediately.
7. A person suffering from insect sting allergy can have this condition treated with venom immunotherapy (VIT), a 97% effective desensitization therapy administered by an allergist.
8. Stinging insects are most active during the summer and early fall when nest populations can exceed 60,000 insects.
9. These insects are most dangerous in the vicinity of their nests. A passer-by is viewed as a threat to the safety of their home and is often chased out of the area by a sting(s).
10. Yellow jackets, hornets, and wasps can sting repeatedly. Honeybees have barbed stingers which are left behind in their victims' skin. These stingers are best removed by a scraping action rather than a pulling motion which actually squeezes more venom into the skin.
11. Stinging insects are especially attracted to sweet fragrances (perfumes, colognes, and hair sprays), picnic food, open soda and beer containers, and garbage areas. Avoiding these attractants will lessen a person's chance of being stung.

Tips to Remember: Stinging Insect Allergy

Each year, many Americans are stung by insects. For most, these stings mean pain and discomfort generally lasting only a few hours. Symptoms may include redness, swelling and itching at the site of the sting.

However, some people are allergic to insect stings. This means that their immune systems overreact to the venom injected by a stinging insect. After the first sting, the allergic person's body produces an allergic substance called Immunoglobulin E (IgE) antibody, which reacts with the insect venom. If he or she is stung again by an insect of the same or similar species, the insect venom interacts with the IgE antibody produced in response to the earlier sting. This triggers the release of histamine and other chemicals that cause allergic symptoms.

Symptoms of severe reactions

For a small number of people with severe venom allergy, stings may be life-threatening. Severe allergic reactions to insect stings can involve many body organs and may develop rapidly. This reaction is called anaphylaxis. Symptoms of anaphylaxis may include itching and hives over large areas of the body, swelling in the throat or tongue, difficulty breathing, dizziness, stomach cramps, nausea or diarrhea. In severe cases, a rapid fall in blood pressure may result in shock and loss of consciousness. Anaphylaxis is a medical emergency, and may be fatal. If you or anyone else experiences any of these symptoms after an insect sting, obtain emergency medical treatment immediately. After your symptoms are treated in the emergency room, you should also obtain referral to an allergist/immunologist to learn about treatment options.

Identifying stinging insects

To avoid stinging insects, it is important to learn what they look like and where they live. Most sting reactions are caused by five types of insects: yellow jackets, honeybees, paper wasps, hornets and fire ants.

Yellow jackets are black with yellow marKings, Queens, Richmond, and are found in various climates. Their nests, which are made of a papier-maché material, are usually located underground, but can sometimes be found in the walls of frame buildings, cracks in masonry or woodpiles.

Honeybees have a rounded, "fuzzy" body with dark brown coloring and yellow marKings, Queens, Richmond. Upon stinging, the honeybee usually leaves its barbed stinger in its victim; the bee dies as a result. Honeybees are nonaggressive and will only sting when provoked. However, Africanized honeybees, or so-called "killer bees" found in the southwestern United States and South and Central America, are more aggressive and may sting in swarms. Domesticated honeybees live in man-made hives, while wild honeybees live in colonies or "honeycombs" in hollow trees or cavities of buildings. Africanized honeybees may nest in holes in house frames, between fence posts, in old tires or holes in the ground, or other partially protected sites.

Paper wasps' slender, elongated bodies are black, brown, or red with yellow marKings, Queens, Richmond. Their nests are also made of a paper-like material that forms a circular comb of cells which opens downward. The nests are often located under eaves, behind shutters, or in shrubs or woodpiles.

Hornets are black or brown with white, orange or yellow marKings, Queens, Richmond and are usually larger than yellow jackets. Their nests are gray or brown, football-shaped, and made of a paper material similar to that of yellow jackets' nests. Hornets' nests are usually found high above ground on branches of trees, in shrubbery, on gables or in tree hollows.

Fire ants are reddish brown to black stinging insects related to bees and wasps. They build nests of dirt in the ground that may be quite tall (18 inches) in the right kinds of soil. Fire ants may attack with little warning: after firmly grasping the victim's skin with its jaws, the fire ant arches its back as it inserts its rear stinger into the skin. It then pivots at the head and may inflict multiple stings in a circular pattern. Fire ant venom often causes an immediate burning sensation.

Preventing stings

Stay out of the "territory" of the stinging insects' nests. These insects are most likely to sting if their homes are disturbed, so it is important to have hives and nests around your home destroyed. Since this activity can be dangerous, a trained exterminator should be hired.

If you encounter any flying stinging insects, remain calm and quiet, and move slowly away from them. Many stinging insects are foraging for food, so don't look or smell like a flower - avoid brightly colored clothing and perfume when outdoors. Because the smell of food attracts insects, be careful when cooking, eating, or drinking sweet drinks like soda or juice outdoors. Keep food covered until eaten. Wear closed-toe shoes outdoors and avoid going barefoot. Also, avoid loose-fitting garments that can trap insects between material and skin.

Treating stings

If you are stung by a honeybee that has left its stinger (and attached venom sac) in your skin, remove the stinger within 30 seconds to avoid receiving more venom. A quick scrape of a fingernail removes the stinger and sac. Avoid squeezing the sac - this forces more venom through the stinger and into the skin. Hornets, wasps, and yellow jackets do not usually leave their stingers. Try to remain calm, and brush these insects from the skin promptly with deliberate movements to prevent additional stings. Then, quietly and immediately leave the area.

If you are stung by fire ants, carefully brush them off to prevent repeated stings, and leave the area. Fire ant stings usually result in the development of a blister about 24 hours after the sting. The material in this will become cloudy and appear to be pustular. IT IS NOT! Fire ant venom kills bacteria, this is just dead tissue and should be left alone. It will dry and heal within the next 7 - 10 days. If the blister is opened it must be monitored for secondary bacterial infection. Diabetics and others with circulatory disorders, including varicose veins and phlebitis, can be particularly at risk for complications, and should see a physician to monitor their condition after being stung. Up to 50% of patients develop large local reactions at the site of fire ant stings - swelling may last for several days and may be accompanied by itching, redness and pain.

Taking the following steps can help in treating local reactions to insect stings:
• Elevate the affected arm or leg and apply ice or a cold compress to reduce swelling and pain.
• Gently clean blisters with soap and water to prevent secondary infections; do not break blisters.
• Use topical steroid ointments or oral antihistamines to relieve itching.
• See your doctor if swelling progresses or if the sting site seems infected.

If you are severely insect-allergic and have had prior reactions, try to avoid being outdoors in case you require prompt emergency treatment. Carry an auto-injectable epinephrine (adrenalin) device, a short-term treatment for severe allergic reactions. Learn how to self-administer the epinephrine according to your allergist/immunologist's instructions, and replace the device before the labeled expiration date.

Remember that injectable epinephrine is rescue medication only, and you must still have someone take you to an emergency room immediately if you are stung. Additional medical treatment may be necessary. Those with severe allergies may want to consider wearing a special bracelet or necklace that identifies the wearer as having severe allergies and supplies other important medical information.

Consulting your allergist

Anyone who has had a serious adverse reaction to an insect sting should be evaluated by an allergist/immunologist, who will take a thorough history, perform an examination and recommend testing to determine whether you have an allergy, and which type of stinging insect caused the reaction. Skin or blood (RAST) testing for insect allergy is used to detect the presence of significant amounts of IgE antibody.

Your allergist/immunologist will help you determine the best form of treatment. People who have severe allergies to insect venom should consider receiving insect venom immunotherapy, a highly effective vaccination program that actually prevents future allergic sting reactions in 97% of treated patients. During immunotherapy, the allergist/immunologist administers gradually stronger doses of venom extract initially every week, but as maintenance doses are reached the interval may sometimes be expanded to one month or more.

If you have questions about venom immunotherapy or other treatments for stinging insect allergy, be sure to ask your allergist/immunologist. Patients who receive appropriate treatment such as immunotherapy and who practice careful avoidance measures can participate in regular outdoor activities.

Your allergist/immunologist can provide you with more information on stinging insect allergy.

Tips on Avoiding Insect Stings

Knowing how to avoid stings from bees, wasps, hornets, and yellow jackets leads to a more enjoyable summer for everyone. The following precautions are suggested:
1. Avoid walking barefoot in the grass (honeybees and bumblebees forage on white clover, a weed that grows in lawns throughout the U.S.).
2. Insect repellents DO NOT work against stinging insects.
3. Never swat or flail at a flying insect. If need be, gently brush it aside or patiently wait for it to leave.
4. DO NOT drink from open beverage cans. Stinging insects will crawl inside a can attracted by the sweet beverage.
5. When eating outdoors, try to keep food covered at all times. Stinging insects are fond of the same foods you are.
6. Garbage cans stored outside should be covered with tight- fitting lids.
7. Avoid wearing sweet-smelling perfumes, hairsprays, colognes, and deodorants.
8. Avoid wearing bright colored clothing with flowery patterns. Bees may mistake you for a flower.
9. If you have had an allergic reaction to an insect sting, it is important that you see an allergist. You have a 60% chance of having a similar, or worse reaction if stung again. There is a treatment, venom immunotherapy, which is 97% effective in preventing future allergic reactions to insect stings.

Herpes & Herpes Zoster

Genital Herpes

Genital herpes is a sexually transmitted disease (STD) that produces blisters and skin ulcers in the genital area. It can be caused by either one of two types of herpes simplex virus, HSV-1 or HSV-2. HSV-2 is the more common culprit. HSV spreads from person to person through kissing and skin-to-skin contact, as well as through vaginal, oral or anal intercourse. An infected person can transmit the virus during times when skin blisters or ulcers are visible, but he or she also can spread the virus when there are no symptoms at all. The virus also can be transmitted by people who are unaware that they are infected.

In a pregnant woman with HSV infection (usually HSV-2), the virus can pass to the baby during delivery, causing infections of the newborn's skin, mouth, lungs or eyes. If the herpes virus spreads through the baby's bloodstream, serious infections of the brain and other vital organs also can occur.

According to government health experts, approximately 45 million people in the United States older than age 12 are infected with HSV-2. Genital herpes, with or without symptoms, currently affects approximately one in every four females and one in every five males in the total population of U.S. adults and adolescents between ages 15 and 45. Within the past two decades, the number of genital herpes infections has increased significantly among Americans, with the most dramatic increases seen in adolescents and young adults.


Most people with an HSV-2 infection have no symptoms. When symptoms appear, they are usually mild and can include itching, burning, soreness and small blisters in the genital area; small ulcers (skin sores) when the blisters break; local pain if urine contacts the genital ulcers; enlarged and/or painful lymph nodes (swollen glands) in the groin; headache, fever and a generally sick feeling. In some people with genital herpes, cold sores or fever blisters also can erupt around the mouth. In general, symptoms of genital herpes appear approximately one week after being exposed to someone with herpes infection.

The first episode of herpes symptoms is usually the worst. About 40 percent of infected people never have a second attack. Others, however, have four to five recurrences per year. In people who have recurrent herpes episodes, symptoms generally are most common after sexual intercourse, after sunbathing, and during times of physical or emotional stress.

In newborns who are infected with herpes during delivery, symptoms usually appear nine to 11 days after birth and can include skin blisters, red eyes and an abnormal eye discharge. If the virus spreads through the baby's bloodstream to the brain, there can be lethargy, irritability and seizures. If the virus spreads to the baby's lungs, the baby may have difficulty breathing and may need to be placed on a ventilator for breathing assistance.


Your doctor can diagnose genital herpes based on your sexual history, your symptoms and the results of your physical examination. Your doctor may want to confirm the diagnosis by scraping the affected skin area for laboratory testing. Because people who have one type of STD are at risk for others, your doctor may wish to perform tests for other STDs, such as syphilis, gonorrhea, chlamydia, chancroid and human immunodeficiency virus (HIV).

Expected Duration

The HSV infection that causes genital herpes is a lifelong illness whose symptoms tend to recur. The pattern of recurrence is different for every person.


To help prevent the spread of genital herpes, people who have the illness should abstain from sexual activity when they have symptoms of a herpes recurrence. They also should tell all sex partners about their herpes infection and use condoms during sexual activity. Even without symptoms, the virus still can be shed and transmitted.

Pregnant women who have visible ulcers from genital herpes at the time of delivery usually are encouraged to undergo Caesarean section to prevent HSV from spreading to her newborn. Because the decision for Caesarean section is based on many factors, a pregnant woman with HSV infection should discuss the subject with her physician as early as possible in her pregnancy. If a pregnant woman in her third trimester feels a recurrence of herpes coming on, she should call her doctor right away.

People with genital herpes are more likely to contract HIV infection if they are exposed through sexual intercourse. If you already have HIV, a simultaneous HSV-2 infection may make you more likely to spread HIV to others in high-risk situations.


Episodes of genital herpes can be treated with oral anti-viral medications, including acyclovir (Zovirax), famciclovir (Famvir) and valacyclovir (Valtrex). These medications do not cure the herpes infection. They can shorten the duration of skin symptoms but most often are used to prevent symptoms from recurring or make recurrences less severe. When herpes infection spreads through the bloodstream and causes widespread infection, it can be treated with antiviral medication given intravenously (directly into the veins).

When To Call A Professional

Call your doctor if you have blisters or sores in your genital area, especially if you are pregnant or have frequent bouts of symptoms.


Although there currently is no cure for genital herpes, the frequency of recurrences often decreases with time. Daily oral antiviral medication also can decrease the number of recurrences by at least 75 percent in people with frequent herpes episodes (six or more recurrences per year).

Herpes Zoster (Shingles)

What is Shingles?

Shingles is an infection caused by the varicella-zoster virus, which is the virus that causes chickenpox. Shingles occurs in people who have had chickenpox and represents a reactivation of the dormant varicella-zoster virus. The disease generally affects the elderly, although it occasionally occurs in younger and/or immunodeficient individuals. The first sign is usually a tingling feeling, itchiness, or stabbing pain on the skin. After a few days, a rash appears as a band or patch of raised dots on the side of the trunk or face. The rash develops into small, fluid-filled blisters which begin to dry out and crust over within several days. When the rash is at its peak, symptoms can range from mild itching to extreme and intense pain. Contact with a person with shingles may cause chickenpox (but not shingles) in someone who has never had chickenpox before.

Is there any treatment?

Treatment for shingles includes antiviral drugs, steroids, antidepressants, anticonvulsants, and topical agents. The severity and duration of an attack of shingles can be significantly reduced by immediate treatment with the antiviral drugs acyclovir, valacyclovir or famcyclovir. These drugs may also help stave off the painful aftereffects of shingles known as postherpetic neuralgia.

What is the prognosis?

Although shingles can be very painful and itchy, it is not generally dangerous to healthy individuals and it usually resolves without complications. The rash and pain usually go away within 3 to 5 weeks. Sometimes serious effects including partial facial paralysis (usually temporary), ear damage, or encephalitis (inflammation of the brain) may occur. Persons with shingles on the upper half of the face should seek medical attention immediately as the virus may cause serious damage to the eyes. Most people who have shingles have only one bout with the disease in their lifetime. However, individuals with impaired immune systems, i.e., people with AIDS or cancer, may suffer repeated episodes.

What research is being done?

The NINDS conducts and supports a program of research aimed at developing new treatments for and preventing the painful conditions of shingles.


What Is Psoriasis?

Psoriasis is a chronic (long-lasting) skin disease of scaling and inflammation that affects 2 to 2.6 percent of the United States population, or between 5.8 and 7.5 million people. Although the disease occurs in all age groups, it primarily affects adults. It appears about equally in males and females. Psoriasis occurs when skin cells quickly rise from their origin below the surface of the skin and pile up on the surface before they have a chance to mature. Usually this movement (also called turnover) takes about a month, but in psoriasis it may occur in only a few days. In its typical form, psoriasis results in patches of thick, red (inflamed) skin covered with silvery scales. These patches, which are sometimes referred to as plaques, usually itch or feel sore. They most often occur on the elbows, knees, other parts of the legs, scalp, lower back, face, palms, and soles of the feet, but they can occur on skin anywhere on the body.

The disease may also affect the fingernails, the toenails, and the soft tissues of the genitals and inside the mouth. While it is not unusual for the skin around affected joints to crack, approximately 1 million people with psoriasis experience joint inflammation that produces symptoms of arthritis. This condition is called psoriatic arthritis.

How Does Psoriasis Affect Quality of Life?

Individuals with psoriasis may experience significant physical discomfort and some disability. Itching and pain can interfere with basic functions, such as self-care, walking, and sleep. Plaques on hands and feet can prevent individuals from working at certain occupations, playing some sports, and caring for family members or a home. The frequency of medical care is costly and can interfere with an employment or school schedule. People with moderate to severe psoriasis may feel self-conscious about their appearance and have a poor self-image that stems from fear of public rejection and psychosexual concerns. Psychological distress can lead to significant depression and social isolation.

What Causes Psoriasis?

Psoriasis is a skin disorder driven by the immune system, especially involving a type of white blood cell called a T cell. Normally, T cells help protect the body against infection and disease. In the case of psoriasis, T cells are put into action by mistake and become so active that they trigger other immune responses, which lead to inflammation and to rapid turnover of skin cells. In about one-third of the cases, there is a family history of psoriasis. Researchers have studied a large number of families affected by psoriasis and identified genes linked to the disease. (Genes govern every bodily function and determine the inherited traits passed from parent to child.) People with psoriasis may notice that there are times when their skin worsens, then improves. Conditions that may cause flareups include infections, stress, and changes in climate that dry the skin. Also, certain medicines, including lithium and betablockers, which are prescribed for high blood pressure, may trigger an outbreak or worsen the disease.

How Is Psoriasis Diagnosed?

Occasionally, doctors may find it difficult to diagnose psoriasis, because it often looks like other skin diseases. It may be necessary to confirm a diagnosis by examining a small skin sample under a microscope. There are several forms of psoriasis. Some of these include:
• Plaque psoriasis--Skin lesions are red at the base and covered by silvery scales.
• Guttate psoriasis--Small, drop-shaped lesions appear on the trunk, limbs, and scalp. Guttate psoriasis is most often triggered by upper respiratory infections (for example, a sore throat caused by streptococcal bacteria).
• Pustular psoriasis--Blisters of noninfectious pus appear on the skin. Attacks of pustular psoriasis may be triggered by medications, infections, stress, or exposure to certain chemicals.
• Inverse psoriasis--Smooth, red patches occur in the folds of the skin near the genitals, under the breasts, or in the armpits. The symptoms may be worsened by friction and sweating.
• Erythrodermic psoriasis--Widespread reddening and scaling of the skin may be a reaction to severe sunburn or to taking corticosteroids (cortisone) or other medications. It can also be caused by a prolonged period of increased activity of psoriasis that is poorly controlled.
• Psoriatic arthritis--Joint inflammation that produces symptoms of arthritis in patients who have or will develop psoriasis.


How is Psoriasis Treated?

Doctors generally treat psoriasis in steps based on the severity of the disease, size of the areas involved, type of psoriasis, and the patient's response to initial treatments. This is sometimes called the "1-2-3" approach. In step 1, medicines are applied to the skin (topical treatment). Step 2 uses light treatments (phototherapy). Step 3 involves taking medicines by mouth or injection that treat the whole immune system (called systemic therapy).

Over time, affected skin can become resistant to treatment, especially when topical corticosteroids are used. Also, a treatment that works very well in one person may have little effect in another. Thus, doctors often use a trial-and-error approach to find a treatment that works, and they may switch treatments periodically (for example, every 12 to 24 months) if a treatment does not work or if adverse reactions occur.

Topical Treatment

Treatments applied directly to the skin may improve its condition. Doctors find that some patients respond well to ointment or cream forms of corticosteroids, vitamin D3, retinoids, coal tar, or anthralin. Bath solutions and moisturizers may be soothing, but they are seldom strong enough to improve the condition of the skin. Therefore, they usually are combined with stronger remedies.
• Corticosteroids--These drugs reduce inflammation and the turnover of skin cells, and they suppress the immune system. Available in different strengths, topical corticosteroids (cortisone) are usually applied to the skin twice a day. Short-term treatment is often effective in improving, but not completely eliminating, psoriasis. Long-term use or overuse of highly potent (strong) corticosteroids can cause thinning of the skin, internal side effects, and resistance to the treatment's benefits. If less than 10 percent of the skin is involved, some doctors will prescribe a high-potency corticosteroid ointment. High-potency corticosteroids may also be prescribed for plaques that don't improve with other treatment, particularly those on the hands or feet. In situations where the objective of treatment is comfort, medium-potency corticosteroids may be prescribed for the broader skin areas of the torso or limbs. Low-potency preparations are used on delicate skin areas.
• Calcipotriene--This drug is a synthetic form of vitamin D3 that can be applied to the skin. Applying calcipotriene ointment (for example, Dovonex*) twice a day controls the speed of turnover of skin cells. Because calcipotriene can irritate the skin, however, it is not recommended for use on the face or genitals. It is sometimes combined with topical corticosteroids to reduce irritation. Use of more than 100 grams of calcipotriene per week may raise the amount of calcium in the body to unhealthy levels.

* Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.
• Retinoid--Topical retinoids are synthetic forms of vitamin A. The retinoid tazarotene (Tazorac) is available as a gel or cream that is applied to the skin. If used alone, this preparation does not act as quickly as topical corticosteroids, but it does not cause thinning of the skin or other side effects associated with steroids. However, it can irritate the skin, particularly in skin folds and the normal skin surrounding a patch of psoriasis. It is less irritating and sometimes more effective when combined with a corticosteroid. Because of the risk of birth defects, women of childbearing age must take measures to prevent pregnancy when using tazarotene.
• Coal tar--Preparations containing coal tar (gels and ointments) may be applied directly to the skin, added (as a liquid) to the bath, or used on the scalp as a shampoo. Coal tar products are available in different strengths, and many are sold over the counter (not requiring a prescription). Coal tar is less effective than corticosteroids and many other treatments and, therefore, is sometimes combined with ultraviolet B (UVB) phototherapy for a better result. The most potent form of coal tar may irritate the skin, is messy, has a strong odor, and may stain the skin or clothing. Thus, it is not popular with many patients.
• Anthralin--Anthralin reduces the increase in skin cells and inflammation. Doctors sometimes prescribe a 15- to 30-minute application of anthralin ointment, cream, or paste once each day to treat chronic psoriasis lesions. Afterward, anthralin must be washed off the skin to prevent irritation. This treatment often fails to adequately improve the skin, and it stains skin, bathtub, sink, and clothing brown or purple. In addition, the risk of skin irritation makes anthralin unsuitable for acute or actively inflamed eruptions.
• Salicylic acid--This peeling agent, which is available in many forms such as ointments, creams, gels, and shampoos, can be applied to reduce scaling of the skin or scalp. Often, it is more effective when combined with topical corticosteroids, anthralin, or coal tar.
• Clobetasol propionate--This is a foam topical medication (Olux), which has been approved for the treatment of scalp and body psoriasis. The foam penetrates the skin very well, is easy to use, and is not as messy as many other topical medications.
• Bath solutions--People with psoriasis may find that adding oil when bathing, then applying a moisturizer, soothes their skin. Also, individuals can remove scales and reduce itching by soaking for 15 minutes in water containing a coal tar solution, oiled oatmeal, Epsom salts, or Dead Sea salts.
• Moisturizers--When applied regularly over a long period, moisturizers have a soothing effect. Preparations that are thick and greasy usually work best because they seal water in the skin, reducing scaling and itching.

Light Therapy

Natural ultraviolet light from the sun and controlled delivery of artificial ultraviolet light are used in treating psoriasis.
• Sunlight--Much of sunlight is composed of bands of different wavelengths of ultraviolet (UV) light. When absorbed into the skin, UV light suppresses the process leading to disease, causing activated T cells in the skin to die. This process reduces inflammation and slows the turnover of skin cells that causes scaling. Daily, short, nonburning exposure to sunlight clears or improves psoriasis in many people. Therefore, exposing affected skin to sunlight is one initial treatment for the disease.
• Ultraviolet B (UVB) phototherapy--UVB is light with a short wavelength that is absorbed in the skin's epidermis. An artificial source can be used to treat mild and moderate psoriasis. Some physicians will start treating patients with UVB instead of topical agents. A UVB phototherapy, called broadband UVB, can be used for a few small lesions, to treat widespread psoriasis, or for lesions that resist topical treatment. This type of phototherapy is normally given in a doctor's office by using a light panel or light box. Some patients use UVB light boxes at home under a doctor's guidance.

A newer type of UVB, called narrowband UVB, emits the part of the ultraviolet light spectrum band that is most helpful for psoriasis. Narrowband UVB treatment is superior to broadband UVB, but it is less effective than PUVA treatment (see next paragraph). It is gaining in popularity because it does help and is more convenient than PUVA. At first, patients may require several treatments of narrowband UVB spaced close together to improve their skin. Once the skin has shown improvement, a maintenance treatment once each week may be all that is necessary. However, narrowband UVB treatment is not without risk. It can cause more severe and longer lasting burns than broadband treatment.
• Psoralen and ultraviolet A phototherapy (PUVA)--This treatment combines oral or topical administration of a medicine called psoralen with exposure to ultraviolet A (UVA) light. UVA has a long wavelength that penetrates deeper into the skin than UVB. Psoralen makes the skin more sensitive to this light. PUVA is normally used when more than 10 percent of the skin is affected or when the disease interferes with a person's occupation (for example, when a teacher's face or a salesperson's hands are involved). Compared with broadband UVB treatment, PUVA treatment taken two to three times a week clears psoriasis more consistently and in fewer treatments. However, it is associated with more shortterm side effects, including nausea, headache, fatigue, burning, and itching. Care must be taken to avoid sunlight after ingesting psoralen to avoid severe sunburns, and the eyes must be protected for one to two days with UVA-absorbing glasses. Long-term treatment is associated with an increased risk of squamous-cell and, possibly, melanoma skin cancers. Simultaneous use of drugs that suppress the immune system, such as cyclosporine, have little beneficial effect and increase the risk of cancer.
• Light therapy combined with other therapies--Studies have shown that combining ultraviolet light treatment and a retinoid, like acitretin, adds to the effectiveness of UV light for psoriasis. For this reason, if patients are not responding to light therapy, retinoids may be added. UVB phototherapy, for example, may be combined with retinoids and other treatments. One combined therapy program, referred to as the Ingram regime, involves a coal tar bath, UVB phototherapy, and application of an anthralin-salicylic acid paste that is left on the skin for 6 to 24 hours. A similar regime, the Goeckerman treatment, combines coal tar ointment with UVB phototherapy. Also, PUVA can be combined with some oral medications (such as retinoids) to increase its effectiveness.

Systemic Treatment

For more severe forms of psoriasis, doctors sometimes prescribe medicines that are taken internally by pill or injection. This is called systemic treatment. Recently, attention has been given to a group of drugs called biologics (for example, alefacept and etanercept), which are made from proteins produced by living cells instead of chemicals. They interfere with specific immune system processes.
• Methotrexate--Like cyclosporine, methotrexate slows cell turnover by suppressing the immune system. It can be taken by pill or injection. Patients taking methotrexate must be closely monitored because it can cause liver damage and/or decrease the production of oxygen-carrying red blood cells, infection-fighting white blood cells, and clotenhancing platelets. As a precaution, doctors do not prescribe the drug for people who have had liver disease or anemia (an illness characterized by weakness or tiredness due to a reduction in the number or volume of red blood cells that carry oxygen to the tissues). It is sometimes combined with PUVA or UVB treatments. Methotrexate should not be used by pregnant women, or by women who are planning to get pregnant, because it may cause birth defects.
• Retinoids--A retinoid, such as acitretin (Soriatane), is a compound with vitamin A-like properties that may be prescribed for severe cases of psoriasis that do not respond to other therapies. Because this treatment also may cause birth defects, women must protect themselves from pregnancy beginning 1 month before through 3 years after treatment with acitretin. Most patients experience a recurrence of psoriasis after these products are discontinued.
• Cyclosporine--Taken orally, cyclosporine acts by suppressing the immune system to slow the rapid turnover of skin cells. It may provide quick relief of symptoms, but the improvement stops when treatment is discontinued. The best candidates for this therapy are those with severe psoriasis who have not responded to, or cannot tolerate, other systemic therapies. Its rapid onset of action is helpful in avoiding hospitalization of patients whose psoriasis is rapidly progressing. Cyclosporine may impair kidney function or cause high blood pressure (hypertension). Therefore, patients must be carefully monitored by a doctor. Also, cyclosporine is not recommended for patients who have a weak immune system or those who have had skin cancers as a result of PUVA treatments in the past. It should not be given with phototherapy.
• 6-Thioguanine--This drug is nearly as effective as methotrexate and cyclosporine. It has fewer side effects, but there is a greater likelihood of anemia. This drug must also be avoided by pregnant women and by women who are planning to become pregnant, because it may cause birth defects.
• Hydroxyurea (Hydrea)--Compared with methotrexate and cyclosporine, hydroxyurea is somewhat less effective. It is sometimes combined with PUVA or UVB treatments. Possible side effects include anemia and a decrease in white blood cells and platelets. Like methotrexate and retinoids, hydroxyurea must be avoided by pregnant women or those who are planning to become pregnant, because it may cause birth defects.
• Alefacept (Amevive)--This is the first biologic drug approved specifically to treat moderate to severe plaque psoriasis. It is administered by a doctor, who injects the drug once a week for 12 weeks. The drug is then stopped for a period of time while changes in the skin are observed and a decision is made regarding the need or further treatment. Because alefacept suppresses the immune system, the skin often improves, but there is also an increased risk of infection or other problems, possibly including cancer. Monitoring by a doctor is required, and a patient's blood must be tested weekly around the time of each injection to make certain that T cells and other immune system cells are not overly depressed.
• Etanercept (Enbrel)--This drug is an approved treatment for psoriatic arthritis where the joints swell and become inflamed. Like alefacept, it is a biologic response modifier, which after injection blocks interactions between certain cells in the immune system. Etanercept limits the action of a specific protein that is overproduced in the lubricating fluid of the joints and surrounding tissues, causing inflammation. Because this same protein is overproduced in the skin of people with psoriatic arthritis, patients receiving etanercept also may notice an improvement in their skin. Individuals should not receive etanercept treatment if they have an active infection, a history of recurring infections, or an underlying condition, such as diabetes, that increases their risk of infection. Those who have psoriasis and certain neurological conditions, such as multiple sclerosis, cannot be treated with this drug. Added caution is needed for psoriasis patients who have rheumatoid arthritis; these patients should follow the advice of a rheumatologist regarding this treatment.
• Antibiotics--These medications are not indicated in routine treatment of psoriasis. However, antibiotics may be employed when an infection, such as that caused by the bacteria Streptococcus, triggers an outbreak of psoriasis, as in certain cases of guttate psoriasis.

Combination Therapy

There are many approaches for treating psoriasis. Combining various topical, light, and systemic treatments often permits lower doses of each and can result in increased effectiveness. Therefore, doctors are paying more attention to combination therapy.

Psychological Support

Some individuals with moderate to severe psoriasis may benefit from counseling or participation in a support group to reduce self-consciousness about their appearance or relieve psychological distress resulting from fear of social rejection.

What Are Some Promising Areas of Psoriasis Research?

Significant progress has been made in understanding the inheritance of psoriasis. A number of genes involved in psoriasis are already known or suspected. In a multifactor disease (involving genes, environment, and other factors), variations in one or more genes may produce a greater likelihood of getting the disease. Researchers are continuing to study the genetic aspects of psoriasis. Since discovering that inflammation in psoriasis is triggered by T cells, researchers have been studying new treatments that quiet immune system reactions in the skin. Among these are treatments that block the activity of T cells or block cytokines (proteins that promote inflammation). Several of these drugs are awaiting approval by the U.S. Food and Drug Administration (FDA).

Advances in laser technology are making it possible for doctors to experiment with laser light treatment of localized plaques. A UVB laser was recently tested in a study that was conducted at several medical centers. Although improvements in the skin were noted, this treatment is not without possible side effects. In some patients, the skin became inflamed, blistered, or discolored following treatment.


What Is It?

Rosacea [rose-AY-shah] is a common, long-lasting skin condition that causes inflammation and redness of the face. It usually starts with redness on the cheeks and nose, and also can affect the forehead and chin. The late comedian W.C. Fields, who was known for his wicked wit and red, bulbous nose, had an advanced case of rosacea.

Rosacea currently affects about 13 million people in the United States, usually fair-skinned adults between ages 30 and 50 who have "peaches and cream" complexions and a history of blushing easily. Women develop rosacea more often than men, but men are more apt to develop lumpy enlarged noses, a condition called rhinophyma. Rosacea often is mistaken for sunburn, and often goes undiagnosed. It is a very treatable condition.


There are four progressive stages of rosacea.
• First stage — Slight redness on the cheeks, nose, chin or forehead
• Second stage — Persistent redness on the cheeks, nose, chin or forehead
• Third stage — Small, pus-colored or red bumps, along with tiny blood vessels that appear as red, thin lines called telangiectasias
• Fourth stage — Bumps and skin thickening of the nose

Here's a detailed look at the most common symptoms of rosacea:
• Redness — Facial skin redness looks like a sunburn or blush. This is caused by flushing, which occurs when excess blood rapidly flows through the skin's blood vessels and the vessels enlarge to handle this flow. Gradually, this redness becomes more noticeable and does not go away. Facial skin also may become very dry.
• Pimples — Small, red and solid or pus-filled pimples may appear on the face. Because these pimples look like teen-age acne, rosacea has often been nicknamed adult acne or acne rosacea. However, rosacea has different causes than acne, and adults with rosacea do not have the whiteheads or blackheads (called comedones) commonly seen in acne.
• Red lines (telangiectasias) — Facial blushing or flushing causes small blood vessels to expand and eventually to show through the skin. These enlarged blood vessels appear as thin red lines (telangiectasias) on the face, especially on the cheeks. At first, telangiectasias may be hidden by the redness of flushing or blushing, but they usually reappear after this redness fades.
• Nasal bumps — Left untreated, rosacea eventually can create small, knobby bumps on the nose, which make the nose appear swollen. This condition is more common among men and is called rhinophyma.
• Eye irritation — Red, dry eyes develop in about half of patients with rosacea. Eye involvement is usually relatively mild. Rarely, severe involvement of the eyes develops. If untreated, it can affect vision.


A doctor usually can diagnose rosacea based on the history of flushing and the appearance of your skin. In the early stages of rosacea, the rash sometimes can be mistaken for sunburn, acne, hot flashes of menopause or allergy to cosmetics.

Expected Duration

Rosacea is a lifelong condition that has no cure. Symptoms commonly come and go in cycles. By seeking medical help early and adhering to medical treatments, you can improve your skin condition and perhaps stop, or reverse, the progress of this disease.


There is no way to prevent rosacea, but the symptoms can be reduced by recognizing these common triggers: hot drinks, alcohol, spicy foods, stress, sunlight, extreme heat or cold. These conditions increase blood flow and cause the small blood vessels in the face to widen (dilate). If you have rosacea, try to identify your particular triggers and either modify them or avoid them entirely.

To cleanse and moisturize your face, you should select facial products that do not burn, sting, irritate or cause redness when they are applied. You should wash your face with lukewarm water and a mild soap, using your fingertips to apply the soap gently. You should avoid toners, astringents, scrubs, exfoliating agents and products that contain alcohol or acetone. Hydroxy acids and tretinoin (for example, Retin A) may sensitize the skin to sun and can worsen rosacea.

Sunscreens and sun blockers should be used regularly and liberally to protect the face. Use sunscreens with SPF factor of 15 or higher. If chemical sunscreens cause stinging, switch to physical sun blocks, which contain titanium or zinc oxide.


Depending on your symptoms, your doctor may prescribe the following:
• Antibiotics — Topical metronidazole cream or gel (MetroCream, MetroGel) is the most frequently prescribed first-line therapy. Other topical antibiotics also may be effective. Tetracycline and tetracycline derivatives, such as doxycycline, are drugs taken by mouth once or twice per day. They are sold under several brand names. Improvement is usually noticeable within the first two months after beginning treatment.
• Azelaic acid (Finacea) — The U.S. Food and Drug Administration approved this drug in January, 2003, for topical (applied to the skin) use. It is a gel containing dicarboxylic acid, and is used for the inflammatory pimples of mild to moderate rosacea.
• Beta-blockers and alpha antagonists — These medications may reduce flushing through their effect on blood vessels. Propranolol (Inderal) and nadolol (Corgard) are beta-blockers and clonidine (Catapres) is an alpha antagonist. The use of these drugs for rosacea is off-label, meaning that the FDA has not approved their use for rosacea. Beta-blockers usually are used to treat high blood pressure and heart disease. Clonidine was developed to treat high blood pressure, but also is used to decrease hot flashes in menopause.
• Estrogen — This female hormone is used when rosacea is aggravated by the hot flashes of menopause. The smallest dose of estrogen that controls menopausal symptoms should be used, then the hormone should be stopped when hot flashes no longer occur.
• Laser treatment — This is used to get rid of dilated blood vessels or to remove excess nose tissue.

When To Call A Professional

Contact your doctor if you notice a persistent facial blush, or if your complexion shows persistent pimples and red, dry, scaly blotches. Also call your doctor if you suspect that constant redness on your cheeks is not caused by sunburn or to your tendency to blush easily. Remember, it's easy to misdiagnose rosacea as acne, and using nonprescription acne medications may worsen your rosacea by irritating skin that is already dry and sensitive.


The progression of rosacea varies from patient to patient, depending on factors such as genetics, skin sensitivity, skin complexion, length of time spent in sunlight without sunscreen, consumption of alcohol and spicy foods, and exposure to extreme hot and cold temperatures. With appropriate treatment and avoidance of triggers, rosacea generally can be well controlled.

Rosacea FAQ

What Is Rosacea?

Rosacea is a chronic (long-term) disease that affects the skin and sometimes the eyes. The disorder is characterized by redness, pimples, and, in advanced stages, thickened skin. Rosacea usually affects the face; other parts of the upper body are only rarely involved.

Who Gets Rosacea?

Approximately 14 million people in the United States have rosacea. It most often affects adults between the ages of 30 and 60. Rosacea is more common in women (particularly during menopause) than men. Although rosacea can develop in people of any skin color, it tends to occur most frequently and is most apparent in people with fair skin.

What Does Rosacea Look Like?

There are several symptoms and conditions associated with rosacea. These include frequent flushing, vascular rosacea, inflammatory rosacea, and several other conditions involving the skin, eyes, and nose.

Frequent flushing of the center of the face--which may include the forehead, nose, cheeks, and chin--occurs in the earliest stage of rosacea. The flushing often is accompanied by a burning sensation, particularly when creams or cosmetics are applied to the face. Sometimes the face is swollen slightly.

A condition called vascular rosacea causes persistent flushing and redness. Blood vessels under the skin of the face may dilate (enlarge), showing through the skin as small red lines. This is called telangiectasia (tel-AN-je-ek-tay-ze-ah). The affected skin may be swollen slightly and feel warm.

A condition called inflammatory rosacea causes persistent redness and papules (pink bumps) and pustules (bumps containing pus) on the skin. Eye inflammation and sensitivity as well as telangiectasia also may occur.

In the most advanced stage of rosacea, the skin becomes a deep shade of red and inflammation of the eye is more apparent. Numerous telangiectases are often present, and nodules in the skin may become painful. A condition called rhinophyma also may develop in some men; it is rare in women. Rhinophyma is characterized by an enlarged, bulbous, and red nose resulting from enlargement of the sebaceous (oil-producing) glands beneath the surface of the skin on the nose. People who have rosacea also may develop a thickening of the skin on the forehead, chin, cheeks, or other areas.

How Is the Eye Affected?

In addition to skin problems, up to 50 percent of people who have rosacea have eye problems caused by the condition. Typical symptoms include redness, dryness, itching, burning, tearing, and the sensation of having sand in the eye. The eyelids may become inflamed and swollen. Some people say their eyes are sensitive to light and their vision is blurred or otherwise impaired.

What Causes Rosacea?

Doctors do not know the exact cause of rosacea but believe that some people may inherit a tendency to develop the disorder. People who blush frequently may be more likely to develop rosacea. Some researchers believe that rosacea is a disorder where blood vessels dilate too easily, resulting in flushing and redness.

Factors that cause rosacea to flare up in one person may have no effect on another person. Although the following factors have not been well-researched, some people claim that one or more of them have aggravated their rosacea: heat (including hot baths), strenuous exercise, sunlight, wind, very cold temperatures, hot or spicy foods and drinks, alcohol consumption, menopause, emotional stress, and long-term use of topical steroids on the face. Patients affected by pustules may assume they are caused by bacteria, but researchers have not established a link between rosacea and bacteria or other organisms on the skin, in the hair follicles, or elsewhere in the body.


Can Rosacea Be Cured?

Although there is no cure for rosacea, it can be treated and controlled. A dermatologist (a medical doctor who specializes in diseases of the skin) usually treats rosacea. The goals of treatment are to control the condition and improve the appearance of the patient's skin. It may take several weeks or months of treatment before a person notices an improvement of the skin.

Some doctors will prescribe a topical antibiotic, such as metronidazole, which is applied directly to the affected skin. For people with more severe cases, doctors often prescribe an oral (taken by mouth) antibiotic. Tetracycline, minocycline, erythromycin, and doxycycline are the most common antibiotics used to treat rosacea. The papules and pustules symptomatic of rosacea may respond quickly to treatment, but the redness and flushing are less likely to improve.

Some people who have rosacea become depressed by the changes in the appearance of their skin. Information provided by the National Rosacea Society indicates that people who have rosacea often experience low self-esteem, feel embarrassed by their appearance, and claim their social and professional interactions with others are adversely affected. (See "Where Can People Get More Information About Rosacea?" below.) A doctor should be consulted if a person feels unusually sad or has other symptoms of depression, such as loss of appetite or trouble concentrating.

Doctors usually treat the eye problems of rosacea with oral antibiotics, particularly tetracycline or doxycycline. People who develop infections of the eyelids must practice frequent eyelid hygiene. The doctor may recommend scrubbing the eyelids gently with diluted baby shampoo or an over-the-counter eyelid cleaner and applying warm (but not hot) compresses several times a day. When eyes are severely affected, doctors may prescribe steroid eye drops.

Electrosurgery and laser surgery are treatment options if red lines caused by dilated blood vessels appear in the skin or if rhinophyma develops. For some patients, laser surgery may improve the skin's appearance with little scarring or damage. For patients with rhinophyma, surgical removal of the excess tissue to reduce the size of the nose usually will improve the patient's appearance.

Working With Your Doctor To Manage Rosacea

The role you play in managing your rosacea is important. You can take several steps to keep rosacea under control:
• Keeping a written record of when flareups occur may provide clues regarding what is irritating the skin.
• Most people should use a sunscreen every day that protects against UVA and UVB rays (ultraviolet rays) and has a sun-protecting factor (SPF) of 15 or higher, but sunscreen is particularly important for people whose skin is irritated by exposure to the sun.
• Using a mild moisturizer may be helpful, but avoid applying any irritating products to the face. Some people find that a green-tinted makeup effectively conceals skin redness.
• If your eyes are affected, faithfully follow your doctor's treatment plan and clean your eyelids as instructed.

What Research Is Being Conducted To Help People with Rosacea?

Researchers are studying the eyes of people who have rosacea to find ways to prevent dry eyes and other eye problems related to rosacea. Scientists also are evaluating the most effective ways to use medications to treat rosacea and the best methods to minimize scarring of the sebaceous glands when removing excess nasal tissue in rhinophyma.

Sun Exposure

When do I need to protect myself from sun exposure?

Protection from sun exposure is important all year round, not just during the summer or at the beach. Any time the sun's ultraviolet (UV) rays are able to reach the earth, you need to protect yourself from excessive sun exposure. UV rays can cause skin damage during any season or temperature.

Relatively speaking, the hours between 10 a.m. and 4 p.m. during daylight savings time (9 a.m. - 3 p.m. during standard time) are the most hazardous for UV exposure in the continental United States. UV radiation is the greatest during the late spring and early summer in North America.

Remember: UV rays reach you on cloudy and hazy days, as well as on bright and sunny days. UV rays will also reflect off any surface like water, cement, sand, and snow.

Skin Conditions

Lichen Sclerosus

Lichen sclerosus (LIKE-in skler-O-sus) is a skin disorder that can affect men, women, or children, but is most common in women. It usually occurs on the vulva (the outer genitalia or sex organ) in women, but sometimes develops on the head of the penis in men. Occasionally, lichen sclerosus is seen on other parts of the body, especially the upper body, breasts, and upper arms.
The symptoms are the same in children and adults. Early in the disease, small, subtle white spots appear. These areas are usually slightly shiny and smooth. As time goes on, the spots develop into bigger patches, and the skin surface becomes thinned and crinkled. As a result, the skin tears easily, and bright red or purple discoloration from bleeding inside the skin is common. More severe cases of lichen sclerosus produce scarring that may cause the inner lips of the vulva to shrink and disappear, the clitoris to become covered with scar tissue, and the opening of the vagina to narrow.
Lichen sclerosus of the penis occurs almost exclusively in uncircumcised men (those who have not had the foreskin removed). The foreskin can scar, tighten, and shrink over the head of the penis. Skin on other areas of the body affected by lichen sclerosus usually does not experience scarring.

How Common Is It?

Although definitive data are not available, lichen sclerosus is considered a rare disorder that can develop in people of all ages. It primarily affects the vulva. Fewer than 1 in 20 women who have vulvar lichen sclerosus have the disease on other skin surfaces. The disease is much less common in childhood. In boys, it is a major cause of tightening of the foreskin, which requires circumcision. Otherwise, it is very uncommon in men.

What Are the Symptoms?

Symptoms vary depending on the area affected. Patients experience very different degrees of discomfort. When lichen sclerosus occurs on parts of the body other than the genital area, most often there are no symptoms, other than itching. If the disease is severe, bleeding, tearing, and blistering caused by rubbing or bumping the skin can cause pain.

Very mild lichen sclerosus of the genital area may cause itching, but often causes no symptoms at all. If the disease worsens, itching is the most common symptom. Rarely, lichen sclerosus of the vulva may cause extreme itching that interferes with sleep and daily activities. Rubbing or scratching to relieve the itching can create painful sores and bruising, so that many women must avoid sexual intercourse, tight clothing, tampons, riding bicycles, and other common activities that involve pressure or friction. Urination can be accompanied by burning or pain, and bleeding can occur, especially during intercourse. When lichen sclerosus develops around the anus, the discomfort can lead to constipation. This is particularly common in children.

Most men with genital lichen sclerosus have not been circumcised. They sometimes experience difficulty pulling back the foreskin and have decreased sensation in the tip of the penis. Occasionally, erections are painful, and the urethra (the tube through which urine flows) can become narrow or obstructed.

What Causes Lichen Sclerosus?

The cause is unknown, although an overactive immune system may play a role. Some people may have a genetic tendency toward the disease, and studies suggest that abnormal hormone levels may also play a role. Some scientists believe that an infectious bacterium, called a spirochete, may cause the changes in the immune system that lead to lichen sclerosus.

Is It Contagious?

No, lichen sclerosus is not contagious.

How Is It Diagnosed?

Doctors can diagnose an advanced case by looking at the skin. However, early or mild disease often requires a biopsy (removal and examination of a small sample of affected skin). Because other diseases of the genitalia can look like lichen sclerosus, a biopsy is advised whenever the appearance of the skin is not typical of lichen sclerosus.

How Is It Treated?

Patients with lichen sclerosus of nongenital skin often do not need treatment because the symptoms are very mild and usually go away over time. (The amount of time involved varies from patient to patient.)

However, lichen sclerosus of the genital skin should be treated, even when it is not causing itching or pain, because it can lead to scarring that may narrow openings in the genital area and interfere with either urination or sexual intercourse or both. There is also a very small chance that cancer may develop.

In uncircumcised men, circumcision is the most widely used therapy for lichen sclerosus. This procedure removes the affected skin, and the disease usually does not recur.

Prescription medications are required to treat vulvar lichen sclerosus, nongenital lichen sclerosus that is causing symptoms, and lichen sclerosus of the penis that is not cured by circumcision. The treatment of choice is an ultrapotent topical corticosteroid. Daily use of these creams or ointments can stop itching within a few days and restore the skin's normal texture and strength after several months. However, treatment does not reverse the scarring that may have already occurred.
Because ultrapotent corticosteroid creams and ointments are very strong, frequent evaluation by a doctor is necessary to check the skin for side effects when the medication is used every day. Once the symptoms are gone and the skin has regained its strength, medication can be used less frequently, although use must continue indefinitely, several times a week, to keep vulvar lichen sclerosus in remission.

Ultrapotent Corticosteroids
Available by Prescription in the United States
• betamethasone dipropionate
• clobetasol propionate
• diflorasone diacetate
• halobetasol propionate

Young girls may not require lifelong treatment, since lichen sclerosus can sometimes, but not always, disappear permanently at puberty. Scarring and changes in skin color, however, may remain even after the symptoms have disappeared.

Because ultrapotent topical corticosteroids are so effective, other therapies are rarely prescribed. The previous standard therapy was testosterone ointment or cream, but this has recently been proven to produce no more benefit than a placebo (inactive) cream. Another hormone cream, progesterone, was previously used to treat the disease, but also has little beneficial effect. Retinoids, or vitamin A-like medications, may be helpful for patients who cannot tolerate or are not helped by ultrapotent topical corticosteroids.

Patients who need medication should ask their doctor how it works, what side effects it might have, and why it is the best treatment for lichen sclerosus.

For women and girls, surgery to remove the affected skin is not an acceptable option. Surgery may be useful for scarring, but only after lichen sclerosus is controlled with medication.

Sometimes, people do not respond to the ultrapotent topical corticosteroid. Other factors, such as low estrogen levels that cause vaginal dryness and soreness, a skin infection, or irritation or allergy to the medication, can keep symptoms from clearing up. Your doctor may need to treat these factors as well. If you feel that you are not improving as you would expect, talk to your doctor.

Can People With Lichen Sclerosus Have Sexual Intercourse?

Women with severe lichen sclerosus may not be able to have sexual intercourse because of pain or scarring that narrows the entrance to the vagina. However, proper treatment with an ultrapotent topical corticosteroid should restore normal sexual ability, unless severe scarring has already narrowed the vaginal opening. In this case, surgery may be needed to correct the problem, but only after the disease has been controlled.

Is Lichen Sclerosus Related to Cancer?

Lichen sclerosus does not cause skin cancer. However, skin that is scarred by lichen sclerosus is more likely to develop skin cancer. About 1 in 20 women with untreated vulvar lichen sclerosus develops skin cancer. The frequency of skin cancer in men with lichen sclerosus is not known. It is important for people who have the disease to receive proper treatment and to see their doctor every 6 to 12 months, so that he or she can monitor and treat any changes that might signal skin cancer.

What Kind of Doctor Treats Lichen Sclerosus?

Lichen sclerosus is treated by dermatologists (skin doctors) and by gynecologists if the female genitalia are involved. Urologists and primary care health providers with a special interest in genital diseases also treat this disease. To find a doctor who treats lichen sclerosus, ask your family doctor for a referral, call a local or State department of health, look in the local telephone directory, or contact a local medical center. The American Academy of Dermatology also provides referrals to dermatologists in your area, and the American College of Obstetricians and Gynecologists can refer you to a gynecologist. The Directory of Medical Specialists, available at most public libraries, lists dermatologists, gynecologists, and urologists in your area.


Vitiligo (vit-ill-EYE-go) is a pigmentation disorder in which melanocytes (the cells that make pigment) in the skin, the mucous membranes (tissues that line the inside of the mouth and nose and genital and rectal areas), and the retina (inner layer of the eyeball) are destroyed. As a result, white patches of skin appear on different parts of the body. The hair that grows in areas affected by vitiligo usually turns white.

The cause of vitiligo is not known, but doctors and researchers have several different theories. One theory is that people develop antibodies that destroy the melanocytes in their own bodies. Another theory is that melanocytes destroy themselves. Finally, some people have reported that a single event such as sunburn or emotional distress triggered vitiligo; however, these events have not been scientifically proven to cause vitiligo.

Who Is Affected by Vitiligo?

About 1 to 2 percent of the world's population, or 40 to 50 million people, have vitiligo. In the United States, 2 to 5 million people have the disorder. Ninety-five percent of people who have vitiligo develop it before their 40th birthday. The disorder affects all races and both sexes equally.

Key Words

• Antibodies--protective proteins produced by the body's immune system to fight infectious agents (such as bacteria or viruses) or other "foreign" substances. Occasionally, antibodies develop that can attack a part of the body and cause an "autoimmune" disease. These antibodies are called autoantibodies.
• Pigment--a coloring matter in the cells and tissues of the body.
• Pigmentation--coloring of the skin, hair, mucous membranes, and retina of the eye.
• Depigmentation--loss of color in the skin, hair, mucous membranes, or retina of the eye.
• Melanin--a yellow, brown, or black pigment that determines skin color. Melanin also acts as a sunscreen and protects the skin from ultraviolet light.
• Melanocytes--special skin cells that produce melanin.
• Ultraviolet light A (UVA)--one type of radiation that is part of sunlight and reaches the earth's surface. Exposure to UVA can cause the skin to tan. Ultraviolet light is also used in a treatment called phototherapy for certain skin conditions, including vitiligo.

Vitiligo seems to be more common in people with certain autoimmune diseases (diseases in which a person's immune system reacts against the body's own organs or tissues). These autoimmune diseases include hyperthyroidism (an overactive thyroid gland), adrenocortical insufficiency (the adrenal gland does not produce enough of the hormone called corticosteroid), alopecia areata (patches of baldness), and pernicious anemia (a low level of red blood cells caused by failure of the body to absorb vitamin B-12). Scientists do not know the reason for the association between vitiligo and these autoimmune diseases. However, most people with vitiligo have no other autoimmune disease.

Vitiligo may also be hereditary, that is, it can run in families. Children whose parents have the disorder are more likely to develop vitiligo. However, most children will not get vitiligo even if a parent has it, and most people with vitiligo do not have a family history of the disorder.

What Are the Symptoms of Vitiligo?

People who develop vitiligo usually first notice white patches (depigmentation) on their skin. These patches are more common in sun-exposed areas, including the hands, feet, arms, face, and lips. Other common areas for white patches to appear are the armpits and groin and around the mouth, eyes, nostrils, navel, and genitals.

Vitiligo generally appears in one of three patterns. In one pattern (focal pattern), the depigmentation is limited to one or only a few areas. Some people develop depigmented patches on only one side of their bodies (segmental pattern). But for most people who have vitiligo, depigmentation occurs on different parts of the body (generalized pattern). In addition to white patches on the skin, people with vitiligo may have premature graying of the scalp hair, eyelashes, eyebrows, and beard. People with dark skin may notice a loss of color inside their mouths.

Will the Depigmented Patches Spread?

There is no way to predict if vitiligo will spread. For some people, the depigmented patches do not spread. The disorder is usually progressive, however, and over time the white patches will spread to other areas of the body. For some people, vitiligo spreads slowly, over many years. For other people, spreading occurs rapidly. Some people have reported additional depigmentation following periods of physical or emotional stress.

How Is Vitiligo Diagnosed?

If a doctor suspects that a person has vitiligo, he or she usually begins by asking the person about his or her medical history. Important factors in a person's medical history are a family history of vitiligo; a rash, sunburn, or other skin trauma at the site of vitiligo 2 to 3 months before depigmentation started; stress or physical illness; and premature (before age 35) graying of the hair. In addition, the doctor will need to know whether the patient or anyone in the patient's family has had any autoimmune diseases and whether the patient is very sensitive to the sun. The doctor will then examine the patient to rule out other medical problems. The doctor may take a small sample (biopsy) of the affected skin. He or she may also take a blood sample to check the blood-cell count and thyroid function. For some patients, the doctor may recommend an eye examination to check for uveitis (inflammation of part of the eye). A blood test to look for the presence of antinuclear antibodies (a type of autoantibody) may also be done. This test helps determine if the patient has another autoimmune disease.

How Can People Cope With the Emotional and Psychological Aspects of Vitiligo?

The change in appearance caused by vitiligo can affect a person's emotional and psychological well-being and may create difficulty in getting or keeping a job. People with this disorder can experience emotional stress, particularly if vitiligo develops on visible areas of the body, such as the face, hands, arms, feet, or on the genitals. Adolescents, who are often particularly concerned about their appearance, can be devastated by widespread vitiligo. Some people who have vitiligo feel embarrassed, ashamed, depressed, or worried about how others will react.

Several strategies can help a person cope with vitiligo. First, it is important to find a doctor who is knowledgeable about vitiligo and takes the disorder seriously. The doctor should also be a good listener and be able to provide emotional support. Patients need to let their doctors know if they are feeling depressed because doctors and other mental health professionals can help people deal with depression. Patients should also learn as much as possible about the disorder and treatment choices so that they can participate in making important decisions about medical care.

Talking with other people who have vitiligo may also help a person cope. The National Vitiligo Foundation can provide information about vitiligo and refer people to local chapters that have support groups of patients, families, and physicians. Family and friends are another source of support.

Some people with vitiligo have found that cosmetics that cover the white patches improve their appearance and help them feel better about themselves. A person may need to experiment with several brands of concealing cosmetics before finding the product that works best.

What Treatment Options Are Available?

The goal of treating vitiligo is to restore the function of the skin and to improve the patient's appearance. Therapy for vitiligo takes a long time--it usually must be continued for 6 to 18 months. The choice of therapy depends on the number of white patches and how widespread they are and on the patient's preference for treatment. Each patient responds differently to therapy, and a particular treatment may not work for everyone. Current treatment options for vitiligo include medical, surgical, and adjunctive therapies (therapies that can be used along with surgical or medical treatments).

Treatment Options for Vitiligo

Medical Therapies
• Topical steroid therapy
• Topical psoralen photochemotherapy
• Oral psoralen photochemotherapy
• Depigmentation

Surgical Therapies
• Skin grafts from a person's own tissues (autologous)
• Skin grafts using blisters
• Micropigmentation (tattooing)
• Autologous melanocyte transplants

Adjunctive Therapies
• Sunscreens
• Cosmetics
• Counseling and support

Medical Therapies

Topical Steroid Therapy

Steroids may be helpful in repigmenting the skin (returning the color to white patches), particularly if started early in the disease. Corticosteroids are a group of drugs similar to the hormones produced by the adrenal glands (such as cortisone). Doctors often prescribe a mild topical corticosteroid cream for children under 10 years old and a stronger one for adults. Patients must apply the cream to the white patches on their skin for at least 3 months before seeing any results. It is the simplest and safest treatment but not as effective as psoralen photochemotherapy (see below). The doctor will closely monitor the patient for side effects such as skin shrinkage and skin striae (streaks or lines on the skin).

Psoralen Photochemotherapy

Psoralen photochemotherapy (psoralen and ultraviolet A therapy, or PUVA) is probably the most beneficial treatment for vitiligo available in the United States. The goal of PUVA therapy is to repigment the white patches. However, it is time-consuming and care must be taken to avoid side effects, which can sometimes be severe. Psoralens are drugs that contain chemicals that react with ultraviolet light to cause darkening of the skin. The treatment involves taking psoralen by mouth (orally) or applying it to the skin (topically). This is followed by carefully timed exposure to ultraviolet A (UVA) light from a special lamp or to sunlight. Patients usually receive treatments in their doctors' offices so they can be carefully watched for any side effects. Patients must minimize exposure to sunlight at other times.

Topical Psoralen Photochemotherapy

Topical psoralen photochemotherapy often is used for people with a small number of depigmented patches (affecting less than 20 percent of the body). It is also used for children 2 years old and older who have localized patches of vitiligo. Treatments are done in a doctor's office under artificial UVA light once or twice a week. The doctor or nurse applies a thin coat of psoralen to the patient's depigmented patches about 30 minutes before UVA light exposure. The patient is then exposed to an amount of UVA light that turns the affected area pink. The doctor usually increases the dose of UVA light slowly over many weeks. Eventually, the pink areas fade and a more normal skin color appears. After each treatment, the patient washes his or her skin with soap and water and applies a sunscreen before leaving the doctor's office.

There are two major potential side effects of topical PUVA therapy: severe sunburn and blistering and too much repigmentation or darkening of the treated patches or the normal skin surrounding the vitiligo (hyperpigmentation). Patients can minimize their chances of sunburn if they avoid exposure to direct sunlight after each treatment. Hyperpigmentation is usually a temporary problem and eventually disappears when treatment is stopped.

Oral Psoralen Photochemotherapy

Oral PUVA therapy is used for people with more extensive vitiligo (affecting greater than 20 percent of the body) or for people who do not respond to topical PUVA therapy. Oral psoralen is not recommended for children under 10 years of age because of an increased risk of damage to the eyes, such as cataracts. For oral PUVA therapy, the patient takes a prescribed dose of psoralen by mouth about 2 hours before exposure to artificial UVA light or sunlight. The doctor adjusts the dose of light until the skin areas being treated become pink. Treatments are usually given two or three times a week, but never 2 days in a row.

For patients who cannot go to a PUVA facility, the doctor may prescribe psoralen to be used with natural sunlight exposure. The doctor will give the patient careful instructions on carrying out treatment at home and monitor the patient during scheduled checkups.

Known side effects of oral psoralen include sunburn, nausea and vomiting, itching, abnormal hair growth, and hyperpigmentation. Oral psoralen photochemotherapy may increase the risk of skin cancer. To avoid sunburn and reduce the risk of skin cancer, patients undergoing oral PUVA therapy should apply sunscreen and avoid direct sunlight for 24 to 48 hours after each treatment. Patients should also wear protective UVA sunglasses for 18 to 24 hours after each treatment to avoid eye damage, particularly cataracts.


Depigmentation involves fading the rest of the skin on the body to match the already white areas. For people who have vitiligo on more than 50 percent of their bodies, depigmentation may be the best treatment option. Patients apply the drug monobenzylether of hydroquinone (monobenzone or Benoquin*) twice a day to pigmented areas until they match the already depigmented areas. Patients must avoid direct skin-to-skin contact with other people for at least 2 hours after applying the drug.
The major side effect of depigmentation therapy is inflammation (redness and swelling) of the skin. Patients may experience itching, dry skin, or abnormal darkening of the membrane that covers the white of the eye. Depigmentation is permanent and cannot be reversed. In addition, a person who undergoes depigmentation will always be abnormally sensitive to sunlight.

* Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

Surgical Therapies
All surgical therapies must be viewed as experimental because their effectiveness and side effects remain to be fully defined.

Autologous Skin Grafts
In an autologous (use of a person's own tissues) skin graft, the doctor removes skin from one area of a patient's body and attaches it to another area. This type of skin grafting is sometimes used for patients with small patches of vitiligo. The doctor removes sections of the normal, pigmented skin (donor sites) and places them on the depigmented areas (recipient sites). There are several possible complications of autologous skin grafting. Infections may occur at the donor or recipient sites. The recipient and donor sites may develop scarring, a cobblestone appearance, or a spotty pigmentation, or may fail to repigment at all. Treatment with grafting takes time and is costly, and most people find it neither acceptable nor affordable.

Skin Grafts Using Blisters

In this procedure, the doctor creates blisters on the patient's pigmented skin by using heat, suction, or freezing cold. The tops of the blisters are then cut out and transplanted to a depigmented skin area. The risks of blister grafting include the development of a cobblestone appearance, scarring, and lack of repigmentation. However, there is less risk of scarring with this procedure than with other types of grafting.

Micropigmentation (Tattooing)

Tattooing implants pigment into the skin with a special surgical instrument. This procedure works best for the lip area, particularly in people with dark skin; however, it is difficult for the doctor to match perfectly the color of the skin of the surrounding area. Tattooing tends to fade over time. In addition, tattooing of the lips may lead to episodes of blister outbreaks caused by the herpes simplex virus.

Autologous Melanocyte Transplants

In this procedure, the doctor takes a sample of the patient's normal pigmented skin and places it in a laboratory dish containing a special cell culture solution to grow melanocytes. When the melanocytes in the culture solution have multiplied, the doctor transplants them to the patient's depigmented skin patches. This procedure is currently experimental and is impractical for the routine care of people with vitiligo.

Additional Therapies


People who have vitiligo, particularly those with fair skin, should use a sunscreen that provides protection from both the UVA and UVB forms of ultraviolet light. Sunscreen helps protect the skin from sunburn and long-term damage. Sunscreen also minimizes tanning, which makes the contrast between normal and depigmented skin less noticeable.


Some patients with vitiligo cover depigmented patches with stains, makeup, or self-tanning lotions. These cosmetic products can be particularly effective for people whose vitiligo is limited to exposed areas of the body. Dermablend, Lydia O'Leary, Clinique, Fashion Flair, Vitadye, and Chromelin offer makeup or dyes that patients may find helpful for covering up depigmented patches.

Counseling and Support Groups

Many people with vitiligo find it helpful to get counseling from a mental health professional. People often find they can talk to their counselor about issues that are difficult to discuss with anyone else. A mental health counselor can also offer patients support and help in coping with vitiligo. In addition, it may be helpful to attend a vitiligo support group.

What Research Is Being Done on Vitiligo?

For more than a decade, research on how melanocytes play a role in vitiligo has greatly increased. This includes research on autologous melanocyte transplants. At the University of Colorado, NIAMS supports a large collaborative project involving families with vitiligo in the United States and the United Kingdom. To date, over 2,400 patients are involved. It is hoped that genetic analysis of these families will uncover the location--and possibly the specific gene or genes--conferring susceptibility to the disease. Doctors and researchers continue to look for the causes of and new treatments for vitiligo.

Skin Infections



What causes warts?

Warts are a type of infection caused by viruses in the human papillomavirus (HPV) family. There are at least 60 types of HPV viruses. Warts can grow on all parts of your body. They can grow on your skin, on the inside of your mouth, on your genitals and on your rectal area. Some types of HPV tend to cause warts on the skin, while other HPV types tend to cause warts on the genitals and rectal area. Some people are more naturally resistant to the HPV viruses and don't seem to get warts as easily as other people.

Can warts be passed from one person to another person?
Yes. Warts on the skin may be passed to another person when that person touches the warts. It is also possible to get warts from using towels or other objects that were used by a person who has warts.

Warts on the genitals can be passed to another person during sexual intercourse. It is important not to have unprotected sex if you or your partner has warts on the genital area. In women, warts can grow on the cervix (inside the vagina), and a woman may not know she has them. She may pass the infection to her sexual partner without even knowing it.

Will warts go away on their own?
Sometimes yes and sometimes no. Often warts disappear on their own, although it may take many months, or even years, for the warts to go away. Some warts won't go away on their own. It is not known why some warts disappear and others don't.

Do warts need to be treated?
Generally, yes. Warts are often bothersome. They can bleed and cause pain when they're bumped. They also can cause embarrassment, for example, if they grow on your face. Treatment may also decrease the chance that the warts will be spread to other areas of your body or to other people.

How are warts on the skin removed?
First of all, it's important to know that warts on the skin (such as on the fingers, feet and knees) and warts on the genitals are removed in different ways. Don't try any home remedies or over-the-counter drugs to remove warts on the genital area. You could damage your genital area by putting certain chemicals on it. You also shouldn't treat warts on your face without talking to your doctor first. The following are some ways to remove warts from the skin:

• Applying salicylic acid--For warts on places such as the hands, feet or knees, one treatment method is to put salicylic acid (one brand name: Compound W) on the warts. To get good results, you must apply the acid every day for many weeks. After you take a bath or shower, pat your skin dry lightly with a towel. Then put salicylic acid on your warts. The acid sinks in deeper and works better when it is applied to damp skin. Before you take a shower or a bath the next day, use an emery board or pumice stone to file away the dead surface of the warts.
• Applying cantharidin--Your doctor may use cantharidin on your warts. With this treatment, the doctor "paints" the chemical onto the wart. Most people don't feel any pain when the chemical is applied to the wart. You'll experience some pain and blistering of the wart in about 3 to 8 hours. After treatment with cantharidin, a bandage is put over the wart. The bandage can be removed after 24 hours. When mixtures of cantharidin and other chemicals are used, the bandage is removed after 2 hours. When you see your doctor again, he or she will remove the dead skin of the wart. If the wart isn't gone after one treatment, your doctor may give you another treatment.
• Applying liquid nitrogen--Your doctor may use liquid nitrogen to freeze the wart. This treatment is called cryotherapy. Applying liquid nitrogen to the wart causes a little discomfort. To completely remove a wart, liquid nitrogen treatments may be needed every 1 to 3 weeks for a total of 2 to 4 times. If no improvement is noted, your doctor may recommend another type of treatment.
• Other treatments for warts on the skin--Other ways that your doctor can remove warts on the skin include burning the wart, cutting out the wart and removing the wart with a laser. These treatments are stronger, but they may leave a scar. Ask your doctor about the risks and benefits of these treatments before you decide what kind of treatment to have for your warts.

How are warts in the genital area treated?

As mentioned previously, warts on the genital area aren't treated exactly like warts on other parts of the skin. The following are some ways to treat warts on the genitals:

• Applying liquid nitrogen--Warts on the genitals may be frozen with liquid nitrogen (cryotherapy). With liquid nitrogen treatment, the doctor applies the liquid nitrogen at a number of different office visits until the warts are completely gone.
• Applying podophyllin--Warts on the genitals may be treated weekly with podophyllin by your doctor. You may also put a medicine called podofilox (brand name: Condylox) on the warts at home twice a day for 3 days, and then rest for 4 days. This process is repeated weekly until the warts are gone.
• Loop electrosurgical excision procedure (LEEP)--With this method for removing genital warts, the doctor passes a sharp instrument shaped like a loop underneath the wart, cutting the wart out of the skin.
• CO2 laser surgery--For large warts in the genital area, laser surgery may be needed for complete removal.
• Interferon injections--If genital warts don't go away after they've been treated with different methods, your doctor may try an interferon injection into the warts. Interferon is a chemical that our bodies make. It helps our immune system fight infection. An injection of interferon into the wart may help your body's immune system fight the virus that is causing the wart. Generally, interferon is injected into warts twice a week for up to 8 weeks, or until the warts are gone.

Do warts ever come back?

Most of the time, treatment of warts is successful and the warts are gone for good. Your body's immune system can usually get rid of any tiny bits of wart that may be left after a wart has been treated. If warts come back, though, see your doctor to talk about other ways to treat them.

Surgical and Other Procedures

Warts: Removal by Freezing

How can my wart be removed?

Warts can be removed in a number of ways. One way is called cryosurgery(freezing the wart). This 2-step process removes the wart without hurting the skin around it.

The first step is getting your wart ready to be removed. You can help with this step. The second step is freezing the wart, which will be done by your doctor in his or her office. You may need to have several freezing treatments before the wart is completely removed.

What do I need to do?

You must do some things on your own at home to get the wart ready for removal. Doing these things before you come to your doctor's office can reduce the number of freezing treatments you need. You should do the following:

1. Every night for 2 weeks, clean the wart with soap and water and put 17% salicylic acid gel (one brand name: Compound W) on it.
2. After putting on the gel, cover the wart with a piece of 40% salicylic acid pad (one brand name: Mediplast). Cut the pad so that it is a little bit bigger than the wart. The pad has a sticky backing that will help it stay on the wart.
3. Leave the pad on the wart for 24 hours. If the area becomes very sore or red, stop using the gel and pad and call your doctor's office.
4. After you take the pad off, clean the area with soap and water, put more gel on the wart and put on another pad. If you are very active during the day and the pad moves off the wart, you can leave the area uncovered during the day and only wear the pad at night.

What happens next?

After 2 weeks of this treatment, your wart will have turned white and will look fluffy. Your doctor will then be able to remove the white skin layer covering the wart and use cryosurgery to freeze the base (root) of the wart. If your skin reacts strongly to cold, tell your doctor before cryosurgery.

Cryosurgery can be uncomfortable, but it usually isn't too painful. The freezing is somewhat numbing. When your doctor places the instrument on your skin to freeze the wart, it will feel like an ice cube is stuck to your skin. Afterward, you may feel a burning sensation as your skin thaws out.

Healing after cryosurgery usually doesn't take long. You will probably be able to enjoy all your usual activities while you heal, including bathing or showering. Cryosurgery leaves little or no scar. After the area has healed, the treated skin may be a bit lighter in color than the skin around it.