Illustration by Gianpaolo Pagni
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Skin So Sad
By Karen Cheney, September & October 2007
Millions with chronic skin conditions are finding hope thanks to new technologies and medicines
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You may remember the commercial from the ’60s on “the heartbreak of psoriasis.” Not having the illness, you would be forgiven for thinking this depiction was a tad overboard. But ask Barbara Brennan, now 62, who first experienced this persistent skin condition in her 20s, while traveling in Europe. “I woke up one morning and was covered in what I thought were bedbug bites,” the Missouri woman recalls. Instead, she learned she had psoriasis, which causes painful scaling and itching. She began a series of therapies—from tar treatments to basking under light boxes—that lasted more than two decades. Her doctors at one point even prescribed Valium because they thought the problem was caused by stress.
Her condition was so debilitating that she became a recluse. “We’re a very visual society,” she says. “If you have something wrong with you, people either look away or look aghast.”
Many years later Barbara became part of a drug trial for a medicine called Remicade, which was approved by the FDA for psoriasis in 2006. “I’m literally free and clear now,” says Barbara, who works for a managed care organization in St. Louis. “It’s wonderful.”
In the past few years thousands of patients like Barbara, who have suffered for years with chronic skin diseases, are finding new hope through technology and sophisticated medications. High-tech lasers are smoothing the faces and eliminating the redness of rosacea sufferers. Immuno-modulator drugs—which increase or decrease your immune response—are tackling continual outbreaks of eczema. And new biologics—medicines like vaccines that are made from living organisms—are working wonders on the toughest cases of psoriasis.
Here are five common skin conditions—and the best treatments available for them.
 Psoriasis
“In the 1970s we suspected that psoriasis was a disease of the immune system,” says Liz Horn, Ph.D., director of research for the National Psoriasis Foundation, “so our biggest treatment advances are in drugs that target the immune system.” In people with psoriasis, T cells in the skin release chemical messengers that speed up the life cycle of cells, causing them to die and slough off in a matter of days rather than weeks. As dead cells pile up, patients develop patches of thick, red skin covered with silvery scales, typically on the scalp, knees, elbows, legs, and back. In about 20 percent of patients, the condition may lead to psoriatic arthritis—a painful inflammation of the joints.
Fight back: In 2003 a new class of drugs called biologics began to receive FDA approval for treating psoriasis. Biologics work by blocking interactions between immune system cells. For instance, Amevive and Raptiva, approved in 2003, limit the number of T cells in the skin. And Enbrel, which was approved in 2004, and Remicade, the drug that finally brought relief to Barbara, work by blocking a signal in the immune system that causes inflammation.
Many dermatologists also prescribe topical medicine, including corticosteroid ointments, creams, and foams. If the patient has psoriasis on less than 10 percent of the body, doctors may prescribe only a topical cream and no oral medicine. For such patients, Neil Korman, M.D., Ph.D., a member of the National Psoriasis Foundation Medical Board, likes a new topical prescription drug called Taclonex, which combines a steroid and a synthetic vitamin D cream to reduce inflammation and scaling and to slow the rate of skin-cell growth.
 Eczema
“It essentially means there is a demon in the epidermis,” says Mark V. Dahl, M.D., a dermatology professor at the Mayo Clinic College of Medicine in Scottsdale, Arizona. That’s an apt description for a condition characterized by patches of red, swollen skin and relentless itching. “In older people the root of eczema is often dry skin,” adds Dahl.
Shingles Shot
In 2006 the FDA approved a vaccine against herpes zoster, the virus that causes the painful, blistering rash known as shingles. For some people, shingles is accompanied by persistent pain that lasts for months or even years after the initial rash heals—a condition known as postherpetic neuralgia (PHN). The vaccine, known as Zostavax, has been shown to reduce the occurrence of shingles (and PHN) by 64 percent in people ages 60 through 69.
As we age, the epidermis—the top layer of skin—becomes thinner and doesn’t hold as much water. Eczema can also be caused by allergens—including rubber, cosmetics, and metals such as nickel. “As you go through life, you accumulate allergies,” says Dahl. If you have persistent eczema that isn’t clearing up, it’s a good idea to undergo a patch test.
Fight back: “As soon as you itch, you have to start using a moisturizing cream. Don’t wait for a rash,” urges Barbara Reed, M.D., a dermatologist in Denver and spokesperson for the American Academy of Dermatology. “The drier your skin, the thicker the cream should be—something out of a jar, not a bottle.” Turning down the heat in your house, taking lukewarm showers or baths, and using a humidifier can also help dry, itchy skin.
If the rash and itching persist, use an over-the-counter hydrocortisone cream or, if that doesn’t work, a stronger prescription one, to suppress the inflammation. If itching is severe, your doctor may suggest topical antihistamines, as well. Two fairly new prescription topical immunomodulators—Elidel and Protopic—are popular, too, though they should be used only on limited areas of the body. “The advantage to them is that you can use them on the face, where prolonged use of a steroid would cause skin thinning and side effects,” says Norman Levine, M.D., a dermatologist in Tucson, Arizona, and author of Skin Healthy: Everyone’s Guide to Great Skin (Taylor Publishing).
 Seborrheic dermatitis
This chronic, inflammatory disorder is actually a form of eczema, but it occurs most typically on the face and scalp and in the ears—and causes a red rash with yellowish and somewhat greasy scales. The disorder is more common in older people and in patients with neurological disorders such as Parkinson’s disease, says Arthur Balin, M.D., Ph.D., a dermatologist in Media, Pennsylvania.
Fight back: For outbreaks on the scalp, dermatologists recommend using over-the-counter dandruff shampoos that contain salicylic acid, pyrithione zinc, or selenium sulfide. Brand names include Scalpicin, Head & Shoulders, Selsun, and Exsel. “I tell people to start with a nontar dandruff shampoo, because tar—a common ingredient in dandruff shampoos—can turn white hair yellow,” says Reed. She likes Nizoral, which contains the antifungal ingredient ketoconazole.
Joseph Fowler, M.D., a clinical professor of dermatology at the University of Louisville, recommends loosening dry scales by applying nonprescription P&S Liquid, which contains salicylic acid, to the scalp and wearing a shower cap overnight, then using a dandruff shampoo in the morning. Another new product that reduces inflammation and itching is Olux, which is a prescription corticosteroid delivered in a foam form. “This foam rubs in and evaporates in three or four minutes, so it doesn’t get your hair greasy and messy,” says Fowler. For the face and chest, dermatologists recommend hydrocortisone, Elidel, and Protopic. Fowler’s patients also like the nongreasy Xolegel, a nonsteroid, antifungal gel approved by the FDA last year.
 Rosacea
This condition typically starts as a tendency to flush easily and may progress to small broken blood vessels or spider veins (called telangiectasia). In its most advanced form—known as inflammatory rosacea—small pus-filled bumps, or pustules, begin to form, giving rosacea its nickname: adult acne. Left untreated, some rosacea sufferers also develop rhinophyma—a red, thickened nose like that of W.C. Fields.
While the exact cause of rosacea is unknown, dermatologists have identified several triggers, including spicy foods, alcohol, exercise, and the sun. Other medical conditions and drugs, such as topical steroids and medicine to treat acne or high blood pressure, may aggravate it. “For some women rosacea first becomes apparent during hot flashes caused by menopause,” says Jonathan Wilkin, M.D., chairman of the medical advisory committee for the National Rosacea Society.
Fight back: For a mild case of inflammatory rosacea, doctors prescribe topical antibiotics such as MetroGel and Noritate. Azelaic acid, which reduces redness and inflammation, is another popular treatment. Wilkin expects dermatologists will soon begin trying a new topical dapsone product called Aczone, FDA-approved for acne.
More severe cases of rosacea require both topical and oral antibiotics, such as tetracycline, minocycline, doxycycline, and erythromycin. There’s also a new pill called Oracea, which works to reduce inflammation and eliminate pustules.
For redness, you need to see a laser physician, says Wilkin. “Four to six weeks after treatment, the injured vessels go through a process of closing down and disappearing, and the redness goes away,” says Philip Bailin, M.D., head of dermatological surgery and cutaneous oncology at the Cleveland Clinic Foundation.
The biggest downside to laser treatments is that they are expensive and rarely covered by insurance. Costs run $250 to $500 per treatment, and most people require two to three procedures. Rhinophyma treatment runs $2,500 to $3,500 or more.
 Nail fungus
Some studies say that as many as one in two people get nail fungus after age 50. Even so, if you have a thickened, yellow toenail or fingernail, get it cultured. “Half the time it’s nail fungus, and half the time it’s psoriasis or some other trauma and inflammation,” says Robert T. Brodell, M.D., a professor of internal medicine at Northeastern Ohio Universities College of Medicine.
Why does nail fungus become so common as we age? “The sequence of events is that people get athlete’s foot and then they traumatize the nail. That opens a space between the nail plate and the nail bed and allows the fungus in,” says Ralph Daniel, M.D., a clinical professor of dermatology at the University of Mississippi Medical Center.
Fight back: The first line of defense is an oral antifungal called Lamisil. Unlike topical treatments, which have a hard time penetrating the nail, this medicine goes into the bloodstream and targets the fungus in your nail bed. “The biggest downside is, it’s expensive,” says Daniel, “but it recently went off-patent, so there should be cheaper generics in the not-too-distant future.”
After patients complete the oral treatment, Brodell recommends using Naftin, a prescription antifungal gel, on the nail at night. Other dermatologists suggest using a fairly new product called Penlac Nail Lacquer, an antifungal medication you brush on the nail once a day.
Karen Cheney’s last piece for AARP The Magazine, about the effect of stress on longevity, appeared in the September & October 2006 issue.
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