pdf of this article

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)

Chronic Skin Problems:
Individual and Treatable

Treating a chronic skin disease, observes Dr. Elizabeth Hamilton of Regional Dermatology of Durham, “is such an individualized, personalized process. First of all, having a ‘chronic’ skin disease simply means that someone has a problem or tendency. The manifestations may be continual or episodic.

Dr. Hamilton emphasizes that getting regular, thorough skin exams is an important part of self-care

“A good example of this is sebor-rheic dermatitis. It’s one of the most common conditions we treat. And, with rare exception, almost every-one will have a flare of seborrheic dermatitis at some point in their life, perhaps beginning as cradle cap in babies, and later flaring as a teenager and/or adult. Its symptoms include itchy, scaly scalps and dryness in the central face.

“As you get older, dry skin tends to be more likely to flare if you don’t regularly moisturize. Some people will feel the effects of dry skin with a certain frequency, such as when the weather changes or when they’re stressed. If you want an example of how common it is, look at how many shampoos there are at the store for seborrheic dermatitis—there are shelves of them!”

Chronic Skin Problems: Highly Individual

This pattern of symptoms that flare periodically, notes Dr. Hamilton, is true for many skin conditions, including rosacea. “Some people battle rosacea every day,” she notes, “while others experience only infrequent episodes. The point is that any chronic skin condition—including rosacea, acne, psoriasis, and seborrheic dermatitis—is sensitive to many factors and is very much an individual experience.

“The products we use on our skin, what we eat, what toxins we’re exposed to, the medications we take, even climate—all affect the way these illnesses manifest. And a trigger for one person may not affect another. Rosacea offers a good example of this. For some people red wine and spicy foods can cause a flare; others are particularly sensitive to extremes in temperature and sun exposure. Stress could be called the ‘universal trigger’—it aggravates all these conditions.”  

Dermatological Detective Work

Knowing what will trigger a flare is a key to managing a chronic skin problem, notes Dr. Hamilton, “and it’s a critical part of designing an effective treatment plan.

“A lot of what we do in dermatology is detective work,” she points out. “There is no one-size-fits-all medicine for rosacea or seborrheic dermatitis. There can be a ‘right’ medicine or treatment protocol for an individual patient, however—we just need to determine what that is, which is what the detective work is all about.

“But we can’t do it alone! Patients need to understand that doctors only know for certain what our patients tell us. Many people come in who haven’t really thought about their disease beforehand. People honestly expect us to be able to tell them what causes their symptoms without revealing what they do in their lives, such as the foods they eat, the medicines they take, their skin care routine, or what allergens they may have come in contact with. That’s a challenge.”

Treating for Chronic Conditions

“Treating these conditions,” explains Dr. Hamilton, is necessarily a process—not a single event. We do have standard medications and treatment options, but we are continually testing and evaluating our choices, always looking for the approach that works best for a particular patient, ideally with the least medication.

“There are four parts to treating rosacea, for example, and only one involves medication. The first is skin care—products need to be gentle because the skin tends to be more reactive, and is more likely to be set off by irritants. The second component is the faithful use of sunscreen protection, because rosacea is a sun-sensitive condition. Third, we advise patients to identify and avoid personal triggers, such as stress, alcohol, coffee, spicy food.

“The fourth option,” says Dr. Hamilton, “is medication. Typically, we’ll use a topical treatment with or without antibiotics—perhaps low-dose tetracycline as an anti-inflammatory. There are a number of possibilities—old and new—the key is to find the right medicine for a particular patient. I tend to be very pragmatic about this: I like to start with free office samples, and if one treatment doesn’t work, then try another.”

Dr. Hamilton uses a similar approach in treating seborrheic dermatitis, with a real emphasis on trial-and-error monitoring. “For this condition, I tell my patients to use medications only if they have a flare, otherwise put them away. At some point you don’t know whether the disease is just dormant, or whether the medicine’s working. The only way to find out is to stop the medication and observes the results.

“With seborrheic dermatitis, some patients do fine with an over-the-counter dandruff shampoo. Depending on how bad it is, we may combine medicated shampoo with a maintenance medicine—such as ketoconazole— with proven anti-inflammatory properties. And then, for flares, we prescribe a form of topical mild steroid and an anti-inflammatory. Those with mild disease have a tube of medicine and every now and again treat the condition when it flares.

“This approach is more effective for light-skinned Caucasians. If you’re dark skinned, however, seborrheic dermatitis will alter the pigment in your skin, and often the pigmentary changes bother people more than the active disease. These patients should probably be on a maintenance routine to minimize flaring.”

The Power of Patient Choice

“It’s probably obvious,” says Dr. Hamilton, “but I’ll underscore an important point: patient choices are key to managing a chronic skin condition successfully. Let’s say you have allergic contact dermatitis— where you break out when you contact the allergen. If you’re allergic to poison ivy and you rub it on your skin every day, you’ll be broken out every day of your life—bad choice! No amount of medicine can alter that.

“So, if you have dry, sensitive skin, and you don’t take care of it every day, you’ll suffer from irritant dermatitis for the rest of your life. A case in point: I once saw a man who had the driest skin; he was constantly itching and miserable. When I asked about what he bathed with and if he moisturized, he said he used a horribly drying soap and no moisturizer—and then he asked me why that mattered. I said: ‘Because you’re itching. That’s how your skin talks to you.” He looked at me and said, ‘Well, that’s what the other seven dermatologists told me.’ Perhaps he should have listened?

“The bottom line is you have to know what your skin needs and wants. I can’t tell you what you must use. I can give you samples, recommendations, and prescribe medicines. If you choose to rely just on meds, you may feel better, but you’re not going to do as well as you would if you had a good, daily skin routine. Listen to your skin; you’ll know when your skin is happy.”