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For more information about skin conditions and treatment, contact:


Elizabeth H. Hamilton, MD, PhD
Amy Stein, MD
Julie Dodge, PA-C
4321 Medical Park Dr., #102
Durham, NC 27704
Telephone: (919) 220-7546 (SKIN)

Balancing Art & Science
When Caring for Your Skin

Deciding which course of treatment to give a patient is often an art form, weighed heavily with science and laced with a bit of detective work, says Dr. Amy Stein of Regional Dermatology of Durham. “One of the beautiful aspects of dermatology is that the skin frequently reflects a great variety of health conditions, when you learn to read the many clues it offers.

Dr. Stein: “The skin is a remarkable source of information when you learn to read the many clues it offers.”

“There’s more to dermatology than looking at a chief complaint,” she points out. “We often need to step back and make sure we’re not missing a deeper imbalance. Often a collaborative approach is required with the primary care physician and even a nutritionist, because people today don’t seem to know what healthy eating is. There are so many things that we see that are a function of internal manifestations.”

For example, says Dr. Stein, “when a young woman comes in with a lower face distribution of acne lesions, and they’re overweight, and they have some hair thinning, these are clues. When we take her medical history, we’ll want to know if she’s having abnormal menstrual cycles and/or difficulty getting pregnant. These are findings suggestive of a hormonal imbalance, rather than just a typical, ‘teenager with acne.’ In such a case, we’ll often recommend that a workup be done to check for a polycystic ovarian syndrome. Obviously, we still need to treat the acne, but the broader underlying problem will also be addressed.”

Dermatological Problems:
Often More Than Skin Deep

“We see cases,” notes Dr. Stein, “where dermatological problems reflect serious underlying conditions. If someone relatively young has numerous skin tags, for example, but also has hyperpigmentation, thickening of the neck, and is obese, we want to elicit a history as well, and not simply remove the skin tags. Quite often, these people can actually be insulin resistant, have diabetes, or pre-diabetes.”

Another example of surface indications of deeper problems, says Dr. Stein, “are the patients who come in bothered by bumps on or around their eyelids, and want to have them treated. Sometimes these fatty deposits can be a signal of high lipids and high triglycerides. Obviously, there is the cosmetic and aesthetic issue, but there is a far greater problem if they also have either really high triglycerides or cholesterol. That can lead them to a stroke or heart attack. In these instances, I want to make sure that they’re up-to-date with their primary care visits.”

Other potential indicators of deeper issues, Dr. Stein notes, “are the conditions of vitiligo or alopecia areata. These are local patches of depigmentation and hair loss, respectively, that can be associated with other autoimmune issues—imbalances in the thyroid, diabetes, things of that nature. It’s important to get a thorough history and, if appropriate, screening for those conditions as well. I believe that I’ve only caught one example of something abnormal in such cases, but the one you catch makes you keep on asking and checking.”

Understanding the Connections
Between Inner and Surface Health Issues

Not only do skin conditions reveal other, deeper health problems, notes Dr. Stein, “but when certain kinds of skin conditions are left untreated or the treatment isn’t working, it can cause other imbalances. Psoriasis is a good example. Not that many years ago, people would be given a topical steroid or a topical vitamin D medication, and—with rare exception—an oral medication. This approach had significant potential side effects and required a lot of monitoring.

“Happily, we’ve come a long way since then. The new psoriasis medicines reflect tremendous progress in our understanding of the disease. Today we know that it’s not just what’s on the outside that needs to be addressed, but that our skin is essentially a marker of inflammation. It’s well established that there are a lot of other co-morbidities (the presence of two chronic conditions simultaneously) that occur when there’s internal inflammation, such as cardiovascular risk and joint disease. Obviously, you don’t always see the degree of destruction in the joints on the outside—unless you look for these things. Today we diagnose psoriasis with a much more holistic, systemic approach. And, as a result, for many patients, their psoriasis clears up, or mostly clears up, over time while on treatment.”

Eczema, or atopic dermatitis, is another condition that can be a marker for other problems,” says Dr. Stein. “Many children with eczema have been found to have other comorbidities, such as ADHD. And, when you’re constantly itching, moving around a whole lot, that can lead to social problems, weak performance in school, or even depression.”

Treatment: A Balancing Act

Treatment of skin conditions can pose problems as well, notes the doctor. “For our eczema or psoriasis patients using a topical steroid, we’re careful to educate them on its appropriate use and make sure they follow up. Topical steroids also have risks and can wind up thinning the skin and can cause acne or acne-like breakouts. If used around the eyes, they can increase risk for cataracts.

“Monitoring is so important. Sometimes people don’t want to come back into the office because their medication is working and they just want a refill. But steroid use is also a matter of balancing, particularly with regard to how often you use it. Without that careful monitoring, long-term steroid use can cause significant problems. We’ve seen patients coming back—often after years of the initial treatment—with severe atrophy and thinning of the skin, where you see all of the blood vessels. And it’s because they have been using their steroid medications for years without supervision—refilling their prescription with another provider.

“We do understand how that can happen; it’s not always convenient to schedule follow-up appointments. But there’s a method to our madness. For instance, something may start out as eczema, and it’s cleared up with a topical steroid. But then another rash comes along; you have the prescription refilled without coming in—assuming it’s eczema. But this time the medication’s not working, so you come in and we find that it’s not eczema at all, but tinea—ringworm—and it’s getting worse because the topical steroid is food for the ringworm. Another example are the biologic medicines for psoriasis, which can alter the immune system, making you prone to getting an infection.

“Basically, treating skin conditions with medication is all about balance—risk versus benefit must always be considered.”