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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)

Many Approaches to Healing:
One Patient at a Time

Skin issues require individualized treatment—for good reason. Stress, allergies, response to medications, and even nutrition play significant roles in skin problems, and must be taken into account in their treatment, note the practitioners at Regional Dermatology of Durham: Dr. Elizabeth Hamilton, Dr. Amy Stein, and Physician Assistant Julie Dodge.

The practitioners of Regional Dermatology of Durham, from left: Julie Dodge, PA-C, Amy Stein, MD, Elizabeth Hamilton, MD, PhD.

“It’s seems counter-intuitive,” says Ms. Dodge, “but at times it’s what patients aren’t doing that can help them improve. A great example of this is a patient who came in recently for a skin exam. She had redness on her cheeks with broken blood vessels, clearly indicating rosacea. Rosacea can be a long conversation requiring therapy in prescribed steps, so I spent a good deal of time with this patient, explaining all the details and treatment options. She came back a month later and told me that she never used any of the medications I prescribed, and the rosacea became better right away. She had recalled that I had mentioned charcoal soap, so she stopped her usual cleanser, and began using it, along with the same moisturizer she had always used. She hasn’t had an issue with rosacea since. While we have not cured her of her tendency to develop rosacea, it is clear that her cleanser was causing worsening disease—perhaps through dryness—and, in this case, not using it helped her condition.”

“I agree,” adds Dr. Stein. “At times outcomes are not necessarily the consequence of what we’re doing, but more of what they are not doing. There are people who come to us with very stubborn rashes, for example, who have randomly tried everything, but their condition keeps getting worse and worse. The tendency is to keep adding products in hopes of improving the rash, which can be counterproductive in that it increases the potential for an irritant or an allergic reaction. It’s not uncommon that, after taking away everything that they think is helping, simplifying the skin care, and targeting the treatment the condition gets better.

“That’s because,” she explains, “once the skin is red and irritated it is much more susceptible to further contact dermatitis. In other words: the patient’s treatments are producing problems—which is an example of  a need for a different approach, that being ‘less is more’.”

“An example of that,” adds Dr. Hamilton, “is sometimes people start with a small, dry patch of skin that looks like eczema. Either over-the-counter or prescription strength steroids have been used or prescribed and now the problem is significantly more widespread. Scraping the scale from the rash reveals yeast and hyphae indicating that it’s clearly a fungal infection such as ringworm, athlete’s foot, or jock itch. Treatment is relatively easy—just take away the steroid that’s feeding that infection and treat the fungal infection. Occasionally, taking away is better than adding.

“The simple truth is,” she continues, “many conditions can be prevented from flaring or worsening by eating better, taking care of your skin, wearing sunscreen, not drinking heavily, and not smoking. That can make a world of difference to the condition and appearance of the skin.”

The Role of Stress

“There are endless examples of linking skin conditions to stress,” says Dr. Stein. “For example, one of my patients was struggling for a long time with a persistent condition. When she came in, she had inflammatory lesions all over her face, and we tried many different treatment approaches. Months went by; she came back in—dramatically improved. I asked what she had done—what was different in her life—and she replied: ‘I retired, started exercising, and focusing on me!’

“And that happens so often. We see conditions like hives and inflammatory skin disorders that are caused by stress. Later, the patient returns and their symptoms are gone and they explain that they have changed something in their lives for the better.”

“I remember a patient who had plaque psoriasis that covered more than half his body,” Ms. Dodge adds. “For whatever reason, he refused systemic medications, and it was clear he was experiencing high levels of stress. He told me his business was failing and he was overwhelmed. And then, during another visit, he said to me, ‘I’m going to sell my business and work for somebody else.’

“And he did that. When he came back, only weeks later, his skin was virtually clear. The rapid change was amazing. While this is an extreme example, most individuals with skin problems will improve with reduced stress.”

“You’d be amazed at how many times we hear, ‘Well doc, I went to the beach and everything cleared up,’” chuckles Dr. Hamilton. “Everyone seems to think that everything gets better at the beach. It does. Why do you think that is? Is it the ocean water? No! You’ve gotten rid of your stress!”

The Importance of Diet

“Another major contributor to skin problems is poor diet,” notes Dr. Hamilton. “When people make a major change in their diet, like going gluten free, it impacts their skin. They get rid of packaged, processed food and their skin problems clear up.”

And diet and stress are connected, notes Dr. Stein. “I have several acne patients where stress exacerbates their acne. Everyone is so busy rushing from one activity to another. In their rush, they have no time to make home cooked meals so they grab something processed and unhealthy on the fly. Patients will ask me about what supplements to take, and often it has nothing to do with additional supplements, but rather taking the time to eat whole foods: more fruits and vegetables and staying away from all the processed whites—flour, sugar, and rice. The supplement isn’t going to help you; it’s the natural vitamins and minerals in real, whole foods that will.”

And there’s a clear link, she points out, between our fast-paced stressed lives, poor nutrition, and skin problems. “Drive-through window foods have a tremendous amount of trans-fats, which can lead to more inflammation and exacerbate skin conditions that are already inflamed, like acne. It’s all connected; we need to find a balance to reduce the stress and to eat better.”

Skin Issues Reflect Underlying Illnesses

“People used to look at psoriasis as primarily a skin problem,” notes Dr. Hamilton. “But there are joint aches and associated arthritis that go along with it that need to be addressed. More recently, there’s been a lot more of an emphasis on minimizing systemic inflammation, because there’s a much higher risk of cardiovascular events if that’s left unchecked. It’s not simply slapping a cream on people who have really bad psoriasis; it’s about minimizing systemic inflammation so risk of cardiac events—which has been shown to be associated with psoriasis—is not increased long-term.

“Now there are more systemic, biologic medications available than there ever used to be. We’re practicing in a very exciting and amazing time, because the expectation of treatment for psoriasis is so much higher than I would have ever thought possible when I started out in practice. People truly can be clear, or close to clear, on these medications.”

The Challenge of Compliance

“At times we have to get really creative with our teens who have acne,” adds Dr. Stein, “especially the boys. We constantly hear that they’ve forgotten to take their medicine. You have to start removing their excuses: ‘I forgot to wash my face, so I didn’t apply my medicine.’ ‘Use your medicine anyway. You don’t have to put it on a clean face, just use it!’ I give them a medicated cleanser because they have to take a shower at some point. Half the battle with teens is compliance.”