Skin

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chapter 42 Skin

The skin, the skin

’Tis a wonderful thing.

Keeps the outside out

And the inside in.

INTRODUCTION AND OVERVIEW

The skin is the most obvious organ in the body and every practitioner sees lots of it—about two square metres of it walks through the door with each adult patient. Skin is our interface with the environment and it always tells us things about the patient.

Every primary practitioner sees a wide variety of skin diseases in patients of all age groups, including eczema, psoriasis, infections, acne, urticaria, various pigmented lesions and solar damage including skin cancer. Up to 15% of general practice presentations are for skin conditions.

The skin can itch, burn, swell and appear unsightly, and this can frequently lead to anxiety or psychological reactions. The skin presents to the world and even an apparently trivial skin blemish may be considered a major problem by the patient. Many skin conditions can also cause such persistent discomfort and inconvenience in day-to-day living that patients feel restricted, even in the most basic of activities, resulting in loss of confidence, low self-esteem and diminished quality of life.

The more skin conditions can be understood and managed in relation to the patient’s general health, the more likely there is to be a cure, sustained relief or benefit to the patient as a whole.

This chapter is too brief to give a comprehensive coverage of skin disease. Instead, it provides a framework to enable a clinician to approach skin conditions from an integrative perspective, using some common conditions as examples. Some skin conditions are covered at greater length, with integrative approaches, while others have been included only briefly, to represent what is common in primary care practice.

As in other areas of medicine it is important to ensure that both diagnosis and treatment of skin conditions address causes, rather than suppressing symptoms alone. Skin conditions often have multiple contributing causes, including topical influences, autoimmune or genetic susceptibility, food factors and numerous ancillary triggers.

AETIOLOGY

Many people have a predisposition to skin disease before triggers or precipitating events cause the condition to appear. Allergic or autoimmune predisposition, dry skin, excessive sun exposure, stress or nutritional deficiencies can all set the scene. The triggers may include infection (bacteria, fungi, yeasts, viruses, parasites) or trauma, leading to inflammation or neoplastic change. There are also systemic diseases that have skin manifestations, such as diabetes, thyroid disease, high lipids, and deficiencies including fatty acids, zinc, iron and B vitamins.

DIAGNOSIS

While diagnosis of many skin conditions relies on pattern recognition, sometimes it is elusive. A well-honed systematic approach is essential for diagnosis.

Systematic steps:

3. Accurate description of lesions or skin

4. Differential diagnosis

5. Special tests

7. Treatment plan.

• History—in addition to the history of the condition, questions relating to general health are also needed. Past medical history, family history, allergic history, a nutritional assessment, including supplements, and medications are all important. Listen to patients, as they often have perceptions about their skin and ideas that provide clues to the causes or triggers for the condition.

• Examination

• Dermatology is a visual branch of medicine, and in order to ensure accurate diagnosis, examination requires a bright light and good magnification.

• Dermoscopy is a valuable examination tool for pigmented lesions. An ultraviolet Wood’s lamp can cause fungal infections and erythrasma to fluoresce.

• Examine the whole skin in addition to the specific lesion. Have a good look—touch, stretch and feel the texture and thickness.

• Accurate description of lesions or skin—an accurate description (Table 42.1) requires careful observation and often leads directly to the diagnosis. A dermatology atlas and comprehensive text are helpful.

• Special tests—take the time and make the effort to do the tests. Investigations are:

• swabs, skin scrapings or nail clippings

• punch, shave or incisional biopsy. These are simple procedures that take little extra time and often make or confirm a diagnosis. It is important to provide a brief clinical outline, a description of the lesion and, if possible, a differential diagnosis for the histopathologist, as microscopic appearances can be equivocal.

• Diagnosis will arise from the above systematic approach. Remember that the skin is a reflector of systemic conditions.

TABLE 42.1 Terminology of lesions

TREATMENT PLAN

Each skin condition requires specific treatment measures. In general, however, integrated management could include the following:

• Prevention—where triggers are identifiable; for example, avoidance of arginine-rich foods (peanuts, almonds and chocolate) with herpetic infections; management of sun exposure to minimise solar sun damage while ensuring adequate sun exposure to manufacture vitamin D in the skin.

• Surveillance—Hippocrates said to ‘Make a habit of two things—to help or at least to do no harm’. The positive diagnosis of benign or self-limiting conditions such as pityriasis rosea, keratosis pilaris, granuloma annulare or toxic viral rashes is important, as they often require no intervention.

• Self-help and general remedies that aim to improve the patient’s general health and benefit the condition. For example:

• Reduce exposure to heat, spices or alcohol with rosacea.

• Reducing immune stressors can reduce the threshold to autoimmune disease that affects or reflects in the skin. These diseases include vitiligo, melanoma, halo naevus, idiopathic thrombocytopenic purpura, Hashimoto’s thyroiditis, systemic lupus erythematosus, scleroderma and diabetic skin disease. Stressors that reduce a patient’s adaptive capacity include emotional stress (including anxiety and depression), chemical load, allergic load, hormonal imbalance, fatigue, endocrine disease, chronic viral infections and nutritional deficiencies (zinc, iron, vitamin D, vitamin B₁₂ or folic acid). These stressors are common and need to be addressed.

• Pharmacological relief is important—a teenager with severe acne can try multiple nutritional and topical measures but needs treatment with a high probability of a rapid response. This will often include topical as well as oral treatments.

• Surgical excision is still the treatment of choice for the majority of skin cancers. Excision provides a specimen, which is always sent to pathology. The dermatopathologist will confirm or make the diagnosis and establish the presence of a margin of safety around the malignant lesion.

IMPORTANT PITFALLS IN SKIN MANAGEMENT

• Remember to take skin conditions seriously. Most are not fatal but many cause angst and suffering, or low mortality with high morbidity. Take the trouble to assess the impact of the condition on the patient. For example, most young people with moderate acne experience significant loss of confidence, depression or even difficulty gaining employment.

• Work for a positive diagnosis before committing to long-term treatment. For example, is it psoriasis, eczema or fungal?

• Do not use fluorinated steroids on the face, especially around the mouth.

• Do not use steroids on rashes where there could be fungal infections as this can lead to extension of the infection, known as tinea incognito.

SPECIFIC SKIN CONDITIONS

In order to see how a well-honed systematic approach can be applied in practice, we will look at the management of some specific skin conditions. Some of these conditions are well managed using an integrative approach and are discussed more fully. Others require standard medical treatment alone, and many of these are covered only briefly, in order to provide a more representative picture of skin presentations.

ECZEMA

Eczema is the most common skin reaction. It is an inflammatory disorder and the term is interchangeable with dermatitis, although sometimes ‘dermatitis’ is used when the cause is external or exogenous (Box 42.1).

Contact or exogenous eczema

• Irritant contact—occurs whenever irritant materials are in prolonged contact with the skin. This is not an allergy and does not reflect individual sensitivity. It is a direct irritant effect of substances such as detergent, petrol or solvents. Irritant contact dermatitis of the hands is the most common occupational disease.

• Allergic contact—occurs when there is an allergic reaction to an agent in contact with the skin (Box 42.2). There are many causes. These may be suspected from the history and confirmed by patch testing if necessary.

• Photosensitive dermatitis is eczema in light-exposed areas, often as a side effect of a drug.

• Napkin dermatitis is a specific form of irritant contact dermatitis following prolonged contact with urine and faeces.

• Plant contact dermatitis.

Constitutional or endogenous eczema

• Atopic eczema (see next section)

• Pompholyx or dyshidrotic eczema—this is a common hand or foot eczema characterised by small blisters on the palms or soles, especially at the margins, that burst and heal with peeling. Because the skin is thick, inflammatory fluid is trapped in the skin, leading to this characteristic appearance. A potent topical steroid ointment is required.

• Hyperkeratotic eczema

• Discoid or nummular eczema—the pattern of one or more oval or coin-shaped plaques of eczema is characteristic. The cause is unknown but lesions may occur on any part of the body, particularly on the legs.

• Asteatotic eczema or eczema craquelé—a dry and itchy form of eczema on the legs that produces a ‘crazy paving’ type of appearance. It is related to dry skin (xerosis) and is common later in life.

• Seborrhoeic eczema—a red, itchy, scaling rash that commonly affects the scalp and midline areas of the face, including around the nose and between the eyebrows. The ears may also be involved, and occasionally areas on the central chest and axillae are affected. It is thought to be caused by sensitivity to a yeast, Malassezia. The eyelids often have scales and redness (blepharitis).

Patients often notice that seborrhoeic eczema is worse when they are tired, run-down or eating excessive sugar or refined carbohydrates. Yeasts feed on sugar.

Management is most effective when anti-yeast shampoos or creams are combined with a diet that avoids sugar and refined or high-GI carbohydrates.

• Infantile seborrhoeic eczema—affects newborns up to 6 months of age, manifesting as cradle cap, napkin dermatitis or sometimes spreading over the whole trunk.

Atopic eczema

Atopic eczema is dealt with in detail here, as it is a good example of how a practitioner can make a great contribution to the wellbeing of the patient and their family, by employing integrative principles. This discussion emphasises management in children, where atopic eczema is most common, but the principles can be adapted to all age groups.

Atopic eczema is common, often very itchy and usually begins in young children from allergic families. Atopic patients have an allergic predisposition to asthma, eczema, hay fever, urticaria and other allergies. It is important to spend time with the patient, collecting information and piecing together the puzzle. Patients or parents will tell you the answers if you ask and listen. Avoid reflex prescriptions for medications, including nutritional supplements.

Atopic eczema can be likened to a slow-burning scrub fire. It is much more than a steroid-responsive dermatosis. Each patient needs to be managed with an appreciation of the causes, triggers and individual patterns of their disease.

The prevalence of atopic eczema and allergic disease has increased dramatically over the past three decades. One theory put forward to explain this is the ‘hygiene hypothesis’, which argues that early childhood exposure to infections inhibits the tendency to develop allergic disease. The idea behind this hypothesis is that bacterial and viral infections during childhood somehow ‘tone up’ the immune system and thereby reduce the tendency to develop allergic disease. Children in Western societies have a more hygienic and ‘sanitised’ lifestyle and a greater risk of developing allergic illness. The increasing prevalence of autoimmune disease may be related.

The cause of atopic eczema is probably multifactorial: genetic, immunological and environmental.

Other predisposing factors to be considered may include a family history of allergies, early introduction of cow’s milk or wheat, and of antibiotics (beta-lactam), vaccinations (pertussis, influenza), dust mite or cockroach exposure, a smoking parent and stress.

Atopic eczema will resolve in at least half of children by the age of five, but a significant number will go on to develop asthma. Atopic eczema is a T helper 2 (Th2) dominant disease.

Clinical presentation

Commencing around 3 months of age, atopic eczema is characterised by dryness, itching and scaling. The rash is usually symmetrical and commences on the cheeks and flexures. There is often subsequent excoriation and lichenification from scratching.

Assessment

A detailed history should be taken, including suspected allergies, details of the diet and preparations used to treat the skin. The family will usually have suspicions about factors thaat may be contributing, and clues will emerge about foods or general triggers. These families have a child with a chronic disease that requires ongoing monitoring, considerable thought and a lot of care each day. The impact on the family as a whole needs to be appreciated.

Food sensitivity is more likely to be a factor in childhood eczema than in adults, and parents will often ask about this. Features in the history that suggest food intolerance as more probable than inhalant allergy include: early age of onset; past history of atopic disease; infective pattern to asthma; sinusitis, otitis media, glue ear or grommets; associated symptoms relating to other systems, such as irritable bowel syndrome, migraine, fatigue, behaviour problems in children; recurrent croup; positive family history of food problems; negative skin tests for inhalants; and a poor response to drug therapy.

Children tend to react to foods that they eat frequently or crave. Wheat, potato, tomato, cows’ milk and citrus are common food sensitivities that may contribute to eczema.

Sometimes skin testing for inhalant allergens, and particularly for those that can be avoided, such as house dust mite, cat or dog, can be useful. Radioallergosorbent test (RAST) is an alternative technique with blood testing to test for IgE-mediated allergies.

Most food sensitivity is not IgE mediated, and skin or blood testing (IgE or IgG) is not reliable in excluding food problems. The most accurate way of diagnosing food sensitivities is through food elimination and challenge dietary testing.

Prevention

(See also Ch 55, Child health and development.)

• Pregnant mothers with a family history of atopy or allergies should have their diet discussed. Avoidance of specific foods such as egg white or shellfish in pregnancy may reduce the risk of atopic disease in the baby, but there should also be discussion of the patient’s food intake to ensure that there is a good variety of foods and moderation of intake of foods where there has been a family problem.

• A good level of antioxidant intake during pregnancy reduces allergic disease in the first 2 years of life.

• Breastfeeding should be encouraged, as this is protective of the infant’s immunological health.

And for all age groups:

• Avoid known or suspected allergens, to reduce the allergic load on the individual.

• Minimise exposure to potentially toxic or sensitising chemicals in the environment. These include petrochemicals, pesticides, deodorisers, aldehydes, solvents and other volatile organic chemicals.

Treatment

These approaches are directed towards young children, but are adaptable to all age groups.

• Once a young child has atopic eczema, reducing dust in the bedroom and removing pets and feathers are precautionary measures.

• Reduce trigger factors, including woollen clothes in contact with the skin.

• Avoiding contact with skin infections, especially cold sores or herpetic infections, helps to prevent infections that cause more severe eruptions in eczematous skin.

• Treat dry skin—like dry leather, dry skin does not respond well to soaps or detergents, and needs oil or moisturising preparations to keep it soft and healthy. How well would leather shoes respond to regular washing with soap and hot water? Similarly, eczematous skin is best cleansed with cooler water and minimal use of a soap substitute or cream.

• Emollients or moisturisers are useful for greasing dry skin (xerosis). Although many commercial brands have petrochemical bases, they usually work well in practice. Often these base preparations have added ingredients such as oils or colloidal oatmeal. Plant oils can also be useful topically, and include evening primrose, vitamin E, rosehip and coconut oils. Emollients soak into the skin within 2 hours and need to be used frequently to moisturise the skin effectively. These oils can also be applied as ointments or creams. Creams contain water and therefore also preservatives, which have the potential for sensitisation. The more greasy the emollient the more effective, but often also the less cosmetically acceptable.

• Ensure there are adequate oils in the diet. Fish oil (adult dose 1000 mg caps, four daily) or flaxseed oil (especially for vegetarians), which is a comparable omega-3 fatty acid. Omega-6 fatty acids such as evening primrose oil can be used in smaller doses and also applied topically as an emollient. Dietary olive oil can be used for dressings, salads and cooking.

• Infection is important in atopic eczema. Up to 80% of eczema is colonised by pathogenic bacteria, especially Staphylococcus aureus. The more severe the dermatitis, the denser the infection. S. aureus causes direct irritation or exotoxin immunological sensitisation. Bacteria belong on the outside of the skin but in eczema they readily penetrate the skin, causing inflammation and itching. Scratching then ploughs in more bacteria. Antiseptic measures or topical antibiotics can help eradicate infection and aid repair of the barrier function of the skin.

Infection control measures in atopic eczema:

• Condy’s crystals (KMnO₄)—1:8000 solution gives a light-pink solution in the bath and is a safe and effective antiseptic

• other antiseptics in the bath water—these include triclosan and benzalkonium chloride in oil

• calendula cream ³—has antiseptic properties for topical use

• topical antibiotic—(e.g. mupirocin ointment) for established localised bacterial infection

• oral antibiotics—for more widespread or severe local infection.

• Anti-inflammatory agents such as topical corticosteroid ointments or pimecrolimus cream (for the face) reduce inflammation and restore the barrier function of the skin, moisture and normal texture.

• Know the forms and doses of topical medications. Common forms: ointments are oil in oil, creams are oil in water, and lotions contain still more water.

• Different potencies of topical corticosteroids are used for different areas and age groups. Use only hydrocortisone on the face, and only the more potent fluorinated topical corticosteroids on the hands and feet where the skin is thick. Hydrocortisone can be effective on the trunk and limbs in children.

• Non-steroidal pimecrolimus cream can be useful, especially on the face.

• How much ointment will be needed? To work out the dose needed, use the ‘rule of hand’ (Fig 42.1).⁴ Four hand areas (using the area under the flat of the hand) requires one gram of ointment per treatment. For example, if ointment is being used daily over eight hand areas, this is 2 grams daily, and a 15-gram tube will last 1 week. It is important to prescribe an adequate quantity to last until the next review.

• Put out the fire. Cool down the inflammation of eczema. Eat, drink, dress, sleep, bathe, shower and think cool. Inflammatory conditions are like a grass fire—easier to prevent than to put out. Turning down the central heating, avoiding heating foods such as spices, sleeping and dressing cool, bathing or showering cool and keeping a cool head, all help. Traditional Chinese medicine incorporates concepts of heat in diagnosis and treatment.

• Nutritional supplements:

• omega-3 fatty acids—replace arachidonic acid and lead to reduced levels of inflammatory mediators and IgE. Sources are:

deep-sea cold water fish such as salmon, sardines, herrings, mackerel or fish oil capsules 1000 mg (adult dose: four daily)

flaxseed (linseed) oil, LSA (linseed, sunflower, almond mix). Fish oil may have more anti-inflammatory action than flaxseed oil.

• evening primrose oil—can be used and absorbed as a topical emollient in children

• olive oil—can be used in dressings, salads and cooking

• probiotics—helpful to ensure normal bowel flora, which has a role in immune system regulation. With the number of antibiotics and antiseptics in foods and the environment, probiotics should probably be used intermittently by most people. Probiotics benefit atopic eczema in both children and adults. Children have different bacterial populations in the gut and need preparations containing bifidobacteria; acidophilus in yoghurt provides fewer beneficial bacteria

• adequate glutathionone peroxidase—provided by selenium supplementation (50–200 μg daily adult dose) if necessary

• antioxidants—vitamin C, vitamin E, beta-carotene, selenium

• increase fresh vegetables, fruits and foods rich in naturally occurring dietary antioxidants

• thiamin B₆ and folate

• zinc—adequate levels enhance immunity

• traditional Chinese medicine—especially Chinese herbs, including Panax ginseng⁵ (Korean ginseng), which increases Th1 cells.

FIGURE 42.1 Rule of hand for estimating dosage of topical therapy ³

Eczema causes significant morbidity for the patient and their family.⁶ Treat the patient and the family as a whole. Remember the total load on the system.

Remember that the body as a whole (including the nervous system and the mind) is always trying to heal itself, always trying to maintain balance in a life of constant ‘wear and tear’. Many factors contribute to this wearing down of the system, and the total load on the individual is always important. When the stressors on the body are too much for it to manage, the ‘barrel’ overflows and symptoms result (Fig 42.2). Stress or anxiety, therefore, having a pro-inflammatory effect, is commonly associated with exacerbations of eczema, whereas stress reduction techniques are associated with improved control and reduced exacerbations.⁷

FIGURE 42.2 The barrel effect

PSORIASIS

Psoriasis is a chronic condition commonly characterised by symmetrical, well-defined red plaques with silvery white scale. Psoriasis can affect many parts of the body, with varying appearances. The nails, joints and eyes may also be affected.

Pathophysiology

Psoriasis is characterised by epidermal hyperproliferation, with epidermal cells dividing and moving to the surface of the skin. This normally takes 28 days but in psoriasis it is accelerated to 4 days. Psoriasis is a T helper 1 (Th1) dominant disease.

Treatment

Aims of therapy:

• reduce inflammation

• promote growth of healthy skin

• reduce stress and the stress resulting from the condition.

Medical treatment depends on the location:

• extensor surfaces

• calcipitriol

• topical corticosteroids

• tar preparations

• steroid lotion or cream

• topical corticosteroid creams rather than ointments.

Lifestyle factors including exercise, nutrition and stress management can all influence psoriasis.

Dietary guidelines

Many patients report improvement with diets that include large quantities of fresh fruits and vegetables, small amounts of protein from fish and fowl, fibre supplements, olive oil and minimisation of red meat, processed foods and highly refined carbohydrates.

• a diet rich in fresh fruits and vegetables, especially carrots, garlic, turmeric/curcumin, nuts and seeds

• fish, especially oily fish, flaxseed oil and olive oil for cooking.

Foods to avoid or restrict:

• foods to which sensitivity has been demonstrated; gluten sensitivity needs to be excluded ⁸

• chemical additives, colourings, flavourings and preservatives, including processed meats such as bacon, ham, corned beef and sausages

• ‘spicy’ foods, including spices, chillies, peppers and the deadly nightshade family (potato, tomato, capsicum, chilli)

• alcohol, sugar, sweets, coffee, soft drinks and fruit juices—minimise intake.

Nutritional supplements

• Fish oil—4000 mg daily or vitamin A 10,000 IU; other omega-3 oils including flaxseed oil also reduce Th1

• Vitamin D (sunlight or vitamin D₃, 2000 IU orally daily)—down-regulates Th1, which may explain summer improvement

• Omega-6 oils—modulate Th1/Th2 balance

• Folic acid 1–5 mg (especially for patients requiring methotrexate)

• B vitamins (especially B₆, B₁₂ and folic acid)—reduce homocysteine and may improve psoriasis; betaine also decreases homocysteine and dampens down the Th1 immune response. Dose of vitamin B₁₂ varies according to level of deficiency. Current recommendation is 2000 μg of oral B₁₂ daily, followed by 1000 μg daily and then 1000 μg weekly and, finally, monthly

• Zinc 30 mg daily (depending on testing) with copper 2 mg

• Vitamin C

• Probiotics such as Lactobacillus acidophilus, L. plantarum, L. rhamnosus, L. fermentans or bifidobacteria

• Beta-sitosterol, found in the cells and membranes of all oil-producing plants, fruit, vegetables, grains, seeds and trees, ideally in a balanced diet or supplemented

• Selenium 50–200 μg daily

• Multivitamin B and multimineral supplement.

Lifestyle

• Exercise decreases Th1 and helps psoriasis.

• Cigarette (or marijuana) smoking should be avoided.

• Minimise chemical exposure—chlorine, hairsprays, perfumes, household cleaning agents, insecticides, aerosol sprays, paints and thinners, plasticisers and printing chemicals.

• Because psoriasis can affect the patient’s self-image and confidence, psychological management may be beneficial. Anxiety and stress often contribute to flares in psoriasis. Mind–body therapies such as mindfulness-based interventions have been found to improve the clearing rate for patients with severe psoriasis when used as an adjunct with other medical therapies.

Herbal treatments

Phytomedicines can assist in the management of symptoms of chronic autoimmune, inflammatory skin conditions such as psoriasis. Topical (and internal) use of plant oils high in omega-3 and -6 fatty acids are also of benefit. Saponin-rich herbs have a beneficial effect on the symptoms of persistent psoriasis. They must be used under expert professional supervision.

Common herbs used are:

• evening primrose oil ⁹ (Oenothera biennis)—anti-inflammatory

• sarsaparilla ¹⁰ (Smilax officinalis)—anti-inflammatory, antipruritic, alterative (saponin rich)

• turmeric ¹¹ (Curcuma longa)—anti-inflammatory, antioxidant, hepatoprotective.

• celandine (Cheladonium majus)—inhibits keratinocyte proliferation

• aloe vera 0.5% cream ¹²—may be effective.

Other herbal treatments for psoriasis include:

• Western herbs—yellow saffron,¹³ ginseng¹⁴ and polypodium¹⁵

• ayurvedic herb Coleus forskohlii¹⁶ (traditional use but no evidence of efficacy)

• traditional Chinese herbs—including Rehmania glutinosa, Angelica sinesis, Salvia miltorrhiza, Dictamnus dasycarpus, Smilax glabra, Oldenlandia diffusa, Lithospermum erythrorhizon, Paeonia lactiflora.¹⁷

INFECTIONS

Host factors are important and infection is more common with impaired immunity. When infections thrive, spread more rapidly than usual or recur despite appropriate therapy, it is important to ask why this may be happening. Causes of impaired host immunity or reduced threshold to infection can include:

• nutritional deficiencies such as iron, vitamin B₁₂, vitamin C, vitamin D, zinc or low protein intake

• diabetes or hyperglycaemia

• physical or emotional stress

• food sensitivity.

Therefore, in the prevention or management of infectious diseases, particularly those that have a chronic and relapsing course, attention should be given to lifestyle and psychological factors.

Viral infections

Warts

Warts are a very common infection of the skin and mucous membranes caused by papillomavirus. As with other infections, the viability of a wart depends on the immunity of the host. Warts are very susceptible to lifestyle and psychological influences that increase immunity.

Other treatments include:

• salicylic acid preparations, sometimes in combination with lactic acid

• liquid nitrogen cryotherapy, repeated if necessary every 2–3 weeks

• salicylic acid 70% in linseed oil plasters (pare down after 5 days)

• curettage and cautery under local anaesthetic—rarely used now

• immunotherapy with DCP (diphencyprone), which is a potent topical sensitiser.

General measures to enhance immunity and general wellbeing can be important, and include: nutrition, antioxidants and immunostimulant herbs.

Check for zinc deficiency. Recalcitrant warts may respond to zinc supplementation.¹⁸

Because warts can be painful and potentially infectious, some treatment should be offered. First-line physical treatments such as curettage with diathermy or excision are rarely indicated and can lead to scarring. It should be remembered that in the presence of normal immunity, warts will nearly always resolve over time without active therapy.

Herpes simplex

Herpes simplex virus 1 and 2 infections cause primary and recurrent oral and genital infections. Genital herpes and oral cold sores are frequently painful and emotionally distressing. It is important to recognise the emotional stigma that patients with herpes often feel. Treatment measures can include:

• avoidance (by all patients with herpetic infections) of arginine-rich foods (chocolate, peanuts, almonds)

• antioxidants, including vitamins C, A, D and selenium

• echinacea and immunostimulant herbs ¹⁹

• avoidance of trigger foods or physical factors such as excessive sunlight or wind

• probiotics supplementation.

Herpes zoster

Patients with shingles will feel unwell for days or weeks, but the greatest morbidity is from post-herpetic neuralgia. Early intervention with antiviral agents, antioxidants and especially vitamin C (oral or intravenous), immunostimulant herbs, optimal nutrition and topical vitamin E oil will reduce the morbidity. It should be remembered that, with a debilitating systemic condition like shingles, there is no substitute for rest.

Molluscum contagiosum

Molluscum contagiosum is a common benign skin infection, with dome-shaped papules that have central umbilication. Lesions eventually resolve spontaneously. Most children will only tolerate treatment of a limited number of lesions at a time.

Treatment options:

• 5% benzoyl peroxide

• tape stripping (duct/Leukosilk®/Micropore® tape)—change daily after bath or shower for 4–8 weeks

• Duofilm® lotion (17% salicylic acid, 17% lactic acid) or gel (27% salicylic acid) used twice weekly

• Imiquimod cream thrice weekly for 3 weeks.

Fungal and yeast infections

Tinea of the body, feet, hands, scalp, flexures or incognito are common. The characteristic appearance of tinea on the body is an asymmetrical annular erythematous rash with a slightly raised margin and peripheral scale. Ringworm or tinea spreads outwards.

• Confirm the diagnosis when treating tinea. Take scrapings, nail clippings or plucked hairs rather than guess. Confident treatment based on a positive diagnosis will provide a better outcome.

• Beware of tinea incognito or fungal infection treated and modified with topical corticosteroids.

• Check the toenails, as recurrent fungal infections in the skin can come from unrecognised toenail tinea (onychomycosis).

Thrush or Candida albicans is a common commensal infection in warm, moist environments. Yeast and fungal infections thrive in ‘tropical’ (warm and moist) environments such as on the feet or in the groin or flexures.

Pityriasis versicolor is a benign skin reaction to Malassezia furfur yeast infection. It causes small patches of altered skin colour, especially on the trunk. It is more common in people who sweat heavily and in hot, humid climates.

Bacterial infections

Bacterial infections include impetigo, folliculitis, boils, cellulitis and erysipelas. Remember that appropriate antibiotics will treat bacterial infection but pus needs to drain. When bacterial infections persist, remember host factors including diabetes or deficiencies of iron, zinc or vitamin D.

INSECT BITES

Insect bites are common and often present with a secondary allergy rash. This may take the form of papular urticaria, where there may be a small number of primary bites with numerous itchy papules spread over many parts of the body.

Scabies

A common example of insect bites is scabies. Scabies is an intensely itchy mite infestation usually affecting the forearms and web spaces of the fingers, together with the cooler areas of the areolae in women and the scrotum in men (papulonodules). It has an incubation period of 3–4 weeks with 10–15 mites. Itch is increased by warmth.

Diagnosis

Diagnosis is made on the clinical picture and confirmed with skin scrapes or shave of the entire burrow to enable microscopic visualisation of the mite.

Treatment

• Topical permethrin cream 5%, from the neck down. This should be left on overnight and washed off in the morning. Clothes should be tumble dried after a hot wash. Re-treat symptomatic cases after 1 week.

• Treat eczema after scabies with a fluorinated topical corticosteroid ointment and emollients.

• Scabetic nodules may need intralesional steroid injection.

• Pregnancy alternative—10% sulfur in soft white paraffin daily for 3 days.

• Infants under 6 months—as for pregnancy (need the scalp to be treated as well), or daily crotamiton cream for 3 days.

• Resistant cases—oral ivermectin 12 mg stat and repeat after 10 days.

ACNE

Most people have at least some acne during their teenage years. Acne is redness, swelling and inflammation of the hair and oil gland unit (pilosebaceous follicle) of the skin. In acne there are blackheads and whiteheads (comedones) or pimples, abscesses and inflammation (redness and soreness), and eventually there may be scars. Changing levels of androgen and heredity set the stage, but all the causes are not known.

Most young people with acne (as with eczema and psoriasis) experience degrees of shame, embarrassment, anxiety, depression, loss of self-confidence or significant difficulty with employment. It is important that practitioners take acne seriously, treat it enthusiastically and encourage regular review.²⁰ Patients need to be reassured that acne is not infectious, is not caused by poor hygiene, and can be controlled.

What produces acne?

Acne is produced by pores blocked with plugs of oily secretions and skin material, increased sebum (oil) from the sebaceous glands, bacteria thriving in the oily secretions, and inflammation from oil and bacteria bursting out of the comedones (Fig 42.3).

FIGURE 42.3 Causes and treatment of acne

Treatment

The aim of treatment is to control these steps and prevent or minimise the development of scars that may be permanent.

• Retinoids (adapalene or retinoic acid) unblock pores.

• Benzoyl peroxide reduces bacteria and unblocks pores.

• Azelaic acid reduces bacteria and unblocks pores.

• Antibiotics (topical such as erythromycin or clindamycin, or oral such as minocycline) reduce bacteria and inflammation.

• Isotretinoin can be curative for severe acne.

Patients need to be reminded to:

• use water-based rather than oil-based make-up

• use oil-free sunscreens

• eat good food, including plenty of fruit, vegetables and fish

• avoid squeezing pimples, as this causes the infection and inflammation to spread

• avoid thick, oily moisturisers that block the pores of the skin

• wash the skin gently without excessive scrubbing

• follow through the treatment and discuss problems with their practitioner.

• Most treatments take at least 4 weeks to work, and longer to achieve full effect. Reassurance is needed that all acne can be controlled.

• It is normal for lotions or gels to irritate or burn at the start of treatment.

• Acne often has to get worse before it gets better!

• Antibiotics by mouth can potentially interfere with the efficacy of the oral contraceptive pill.

• 10% picolinic acid gel can be used.²¹

General management

• Wash once or twice a day only, with low-residue soap or soap substitute in lukewarm water.

• Topical therapy

• Dietary measures:

• Minimise sugar intake—sugar ingestion causes increased insulin levels, which may trigger the release of androgens and activate pro-inflammatory cytokines, including leptin.

• Restrict refined carbohydrates, especially wheat.

• Avoid caffeine-containing foods or drinks.

• While it is unwise to generalise about the effect on acne of foods such as chocolate and fats, individual patients may notice specific triggers.

• Supplements:

• zinc 30 mg daily

• vitamins A, C and E

• vitamin A or beta-carotene 10 mg daily

• fish oil capsules 4000 IU daily

• vitamin D—ensure adequate sun exposure in winter, or check blood levels and supplement

• Herbal treatment:

• Vitex²² (chaste tree) tablets—2 tablets on rising

• Arctium²³ (burdock root)

ROSACEA

Rosacea is a chronic inflammatory disorder of the skin of the face characterised by persistent redness and dilated blood vessels of the cheeks, nose, chin and forehead. It is more common with fair skin. It is a blushing disorder. Acute episodes occur with papules, swelling and pustules (Ace of clubs distribution, the curse of the Celts). The cause is unknown but exposure to sunlight and UV light damage play a role. Demodex mites have been found in the skin of affected individuals.

The following can be aggravants:

• alcohol, hot drinks or hot spicy foods, which cause facial vessels to dilate

• temperature fluctuations and hot weather—there may be impairment in the vasomotor tone of facial blood vessels

• topical corticosteroids—these have a profoundly deleterious effect and should always be avoided.

Treatment

Rosacea usually responds within a few days to oral antibiotic therapy and although treatment may need to be maintained for about 10 weeks, often only low doses are required. The initial course can be repeated if or when there is a flare. If oral maintenance therapy is required, low doses on alternate days may be sufficient. Oral antibiotic therapy should be followed by probiotic supplementation to replace gut flora. Topical therapy will usually be adequate for milder cases and for longer-term maintenance.

Acute rosacea (with erythema and papules):

• topical metronidazole 0.75% (up to 1.5%) gel applied sparingly twice daily, with second-line topical treatment of clindamycin 1% lotion

• oral minocycline 50 mg b.i.d. or doxycycline 100 mg daily, reducing after several weeks and continuing for 6–12 weeks

• erythromycin 250 mg q.i.d. as second-line oral therapy

Chronic rosacea with erythema and telangiectasia—treatment is more difficult.

• Avoid factors that cause flushing.

• Avoid UV exposure and use sunscreens.

• Apply soothing emollients.

• Zinc supplementation may be beneficial for rosacea.

Complications

• Conjunctivitis, blepharitis, styes and rosacea keratitis (rare)

• Rhinophyma (sebaceous gland hyperplasia)—surgery, dermabrasion or isotretinoin

• Lymphoedema around eyes or forehead.

URTICARIA, ANGIO-OEDEMA AND ALLERGIC RASHES

Urticaria (hives, wheals) is a common eruption characterised by transient dermal oedema. Angio-oedema is the same reaction as urticaria, but in the deep dermis and subcutaneous tissues, with oedema spreading more diffusely. Angio-oedema often affects the face and neck.

There are many manifestations of allergic rashes in response to antigenic exposure through contact, ingestion or exposure to infections such as viruses.

Urticaria is an example of a skin condition that is easy to recognise but for which a cause is often difficult to discover.

Questions to ask:

• Is it urticaria? Could it be scabies, tinea, contact dermatitis, dermatitis herpetiformis or pruritus related to lymphoma, biliary obstruction or cancer?

• Is it simple urticaria? A residual bruise or stain points to vasculitis. Systemic upset points to systemic disease.

• Is the eruption acute or chronic? Acute is often allergic, but chronic is less likely to be allergic.

• Can trigger factors be identified?

Management

• Emergency treatment for severe urticaria is adrenaline with the possible addition of steroids. Urticaria becomes a medical emergency when it is widespread or affecting the airway or breathing.

• An antihistamine such as cetirizine is first-line treatment for the majority of urticarial eruptions.

General measures include the following:

• Avoid non-specific precipitants, including unnecessary allergenic foods, food additives, temperature stress, exertion and alcohol.

• Eat, drink, dress, bathe, sleep and think cool. All these measures cool the fire.

• Vitamin C (sodium ascorbate) 1000 mg × 2–5 doses daily (for food reactions, take enough ascorbate until the stools become loose. This will ‘flush’ the food through the digestive tract).

• For food allergies, take an alkalinising agent such as sodium bicarbonate, one teaspoon in water followed by another glass of water up to three times daily, or ‘Tri-Salts’ (3 parts NaHCO₃, 2 parts KHCO₃ and 1 part CaCO₃).

• Drink copious water.

• See Table 42.2.

TABLE 42.2 Management of urticaria

Type	Causes & diagnosis	Treatment
Acute (week): likely to be allergic	Drugs: aspirin, antibiotics (beef, chicken), NSAIDs, quinine, morphine, codeine	AH
	Insect stings: bee, wasp
	Foods: salicylates, amines, benzoates, preservatives, colourings, peanut, shellfish, egg white	Avoidance
	Infection: focal sepsis, viral, worms, parasites, e.g. Candida, protozoa	Empirical metronidazole
	Idiopathic
Physical	Cold: icy water	Self-limiting, AH
	Pressure (delayed): weights for 8 hours	Self-limiting, AH
	Solar: sunlight or solar stimulation
	Aquagenic: water	Bicarbonate in water
	Cholinergic/heat: heat, exercise or stress. Five minutes of exercise will evoke < 2 mm diameter wheals	± AH
	Dermographism: 2% population, most common
Chronic (years): non-allergic	History of implants, silicon, rubber, prosthesis, nickel, iodine Diagnosis: FBE, ESR, LFTs, stool & urine micro & culture, X-ray chest & sinus, complement, auto antibodies, HepBsAg

AH, e.g. cetirizine (empirical metronidazole)

AH: antihistamines; FBE: full blood examination; HepBsAg: hepatitis B virus surface antigen; LFT: liver function test.

ENVIRONMENTAL INJURY AND SKIN CANCER

Skin cancer is the most common cancer in the body, and Australia has the highest incidence in the world. Currently 280,000 skin cancers are diagnosed each year, including 8000 melanomas. Around 1200 Australians die each year of skin cancer and the incidence continues to rise. The highest incidence of melanoma in Australia extends from Sydney up the coast to Far North Queensland. Melanomas are more likely to occur with intermittent sun exposure, such as in weekend beachgoers. Non-melanoma skin cancer is more common inland and appears to be more closely related to total sun exposure.

What causes skin cancer?

Exposure to excessive ultraviolet (UV) rays from the sun is the major cause. UVA rays penetrate more deeply than UVB and are the most carcinogenic wave band. Other traumatic or damaging agents include:

• petrochemicals—e.g. a ship’s engineer exposed to heat and petrochemical vapours

• chemicals, such as chlorinated pools in combination with sunshine

• trauma or heat damage to the skin, including dryness

• poor general health, especially problems of the immune system

• immunosuppressive drug therapy

• clear, hot, sunny days in summer—risk is greatest on these days, as they have the highest UV index

• geography—areas where the risk is greater include at altitude in mountains or with aviation and where there is increased reflection of UV rays from reflective surfaces such as snow, water, sand or granite

• pale skin—more vulnerable to solar damage and skin cancer.

Classification

Non-melanoma skin cancer

Basal cell carcinoma (BCC) is the most common skin cancer and can be superficial, nodular or tough (pigmented, recurrent, infiltrating, morphoeic, desmoplastic).²⁴ Spread is local. BCC appears as a red papule or plaque, which may have a pearly edge. The pearly edge becomes more obvious when the skin is stretched under good light.

Squamous cell carcinoma (SCC)—there can be a continuum from solar or actinic keratosis to intraepidermal cancer (IEC or Bowen’s disease) to SCC. SCC grows locally but can later spread to regional nodes and beyond. High-risk locations include the lip, ear and scalp. Recurrent tumours also carry a higher risk.

Melanoma

Melanoma is the most malignant of common skin cancers. Melanomas are usually pigmented and many arise from normal skin. Melanomas tend to be irregular, and initially grow laterally before later deep spread with increase in thickness and increased risk of metastatic spread.

Other

Other forms of skin cancer include Merkel cell carcinoma and other less common skin tumours.

Prevention

• Avoiding, and protecting the skin from, excessive UV exposure is the main preventative approach. This has been reinforced through the national ‘Slip Slop Slap’ campaign in Australia, which encourages people to ‘slip on a shirt, slop on sunscreen, slap on a hat and sunglasses’.

• Correcting predisposing factors in general health includes moisturising dry skin, and improving general nutrition where there may be low levels of iron or antioxidants, vitamin D, vitamin C, zinc, vitamin B₆ or low protein intake.

• Keep the skin healthy—skin cancers generally become more common as people age. With age and time there is a progressive loss of functions in the skin. Dry skin or xerosis needs to be managed as it leaves the skin more vulnerable to disease, including infections and malignant change.

• Use external moisturisers or emollients—these oils, ointments or creams soften the skin, rather like polishing and preserving leather in shoes.

• Avoid hot water, detergents and soap, which wash out natural oils.

• A diet rich in healthy oils will also prevent dryness—these dietary oils include fish oil or flaxseed oil (omega-3 fatty acids), some omega-6 fatty acids from vegetable sources and olive oil.

• Drink plenty of fresh water.

• Avoid excessive heat—‘Dress, bathe, sleep and think cool’.

• Many people are vitamin D deficient, especially at the end of winter. This can be checked with a simple blood test, 25-OH vitamin D. Vitamin D has a role in preventing cancer and it acts to tan and possibly repair solar skin damage. Ironically, many Australians need less sun exposure in summer than they currently get, but many in the southern states need more sun exposure in winter than they currently receive. Outdoor exercise could help give multiple benefits compared with being indoors or exercising only in gyms during winter. Vitamin D₃ (cholecalciferol) can be taken as a supplement where blood levels are inadequate.

Checking the skin:

• Examination includes checking the skin all over to identify general abnormalities, and specific examination of pigmented lesions and moles. Dermoscopy is a useful skill to improve the diagnosis of pigmented lesions.

• Most patients with melanoma have noticed a change in the skin in the previous few months. There are two systems for assessing features suspicious of melanoma in pigmented lesions (Box 42.3).

Treatment of premalignant lesions

• Observation of solar or actinic keratoses (SK) is often appropriate, especially in low-risk areas of the body or in the frail or elderly patient. SKs may resolve spontaneously.

• Liquid nitrogen cryotherapy destroys abnormal cells by freezing and thawing abnormal tissue. Using a spray gun or cotton wool stick dipped in nitrogen, the SK and a surrounding millimetre of normal skin is frozen for a predetermined ‘freeze time’ of around 10 seconds.

• Immunostimulant therapy with imiquimod cream stimulates the body’s immune system to heal SKs.

• Diclofenac sodium 3% gel can likewise be used over weeks to eradicate SKs.

• Therapy with imiquimod cream, diclofenac gel or 5-fluorouracil cream is particularly useful where there is a more extensive area of solar damage, such as the face and scalp.

• Shave, punch or excision biopsy for lesions that do not resolve or that appear more substantial, or where the diagnosis is in doubt. Be prepared to biopsy lesions that are atypical in any way, or that persist after ablative therapy, especially in high-risk parts of the body.

• Send all excised or biopsy specimens to pathology.

Treatment of malignant skin cancer

• Surgical excision of non-melanoma skin cancer is sometimes preceded by biopsy: punch, shave, incisional or excisional. Surgical excision has the advantage of providing a specimen for histopathological confirmation of the diagnosis, as well as establishing that there is a margin of safety around the excised tumour. Surgical excision remains the gold standard for treating skin cancer.

• Other treatments for superficial BCCs are curettage, imiquimod cream, diathermy or photodynamic therapy. These are not suitable for tough BCCs, which require surgical excision.

• Mohs surgery is a specialised surgical technique for excising high-risk BCCs, especially on the face near vital structures.

• SCCs require surgical excision, especially from high-risk areas of the lip, ear or scalp, or recurrent tumours.

• Surgical excision with an adequate margin is the only curative treatment for melanoma. The width of the surgical margin depends on the thickness of the melanoma measured by the histopathologist at the initial excision. Melanomas are usually re-excised with a margin of safety, which increases with the increasing tumour depth.

• Non-surgical treatments such as liquid nitrogen cryotherapy, laser or imiquimod cream do not provide confirmation of histology or evidence of adequate clearance. These should only be used for superficial, straightforward, non-melanoma tumours in low-risk areas where the diagnosis is clear.

Examine the rest of the skin after a malignant skin cancer has been diagnosed.

AGEING SKIN, DRY SKIN AND WOUND HEALING

With many chronic skin diseases and in the elderly, the skin tends to be dry. The functions of the skin deteriorate with age. Oil glands don’t work as well and, like old leather, the skin dries out and cracks. Oils can be used externally and internally. Essential fatty acids and oils in the diet make a difference to the health of the skin. Some oils such as fish oil also have anti-inflammatory functions. Topical evening primrose oil may benefit eczema and there are many oils that can be used topically, including vitamin E, rosemary, coconut or evening primrose oil.

It should be remembered that keeping the skin healthy with moisturisers and oils is more than a cosmetic exercise. Healthy skin is less likely to break down or undergo malignant change.

Wound healing depends on multiple general and local factors. Healing is aided by:

• good circulation

• adequate exercise levels

• avoidance of smoking

• normal weight

• normal blood sugar levels

• local factors including good circulation and tissue vitality

• adequate levels of vitamin B₆, vitamin C, iron, zinc and protein.

SYSTEMIC DISEASES AND THE SKIN

The skin frequently reflects underlying health or disease and can provide vital windows or clues to assist the practitioner in identifying systemic conditions.

• Autoimmune conditions of the skin—halo naevus, vitiligo, alopecia areata, Addison’s disease and melanoma—should alert the practitioner to the possibility of coexisting systemic autoimmune conditions.

• Skin can be an early reflector of systemic illness in diabetes, Graves’ disease, Hashimoto’s thyroiditis, pernicious anaemia, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), morphea and lichen sclerosis.

• Skin infections that persist may be associated with low levels of ferritin, vitamin B₁₂ or vitamin D, or with early diabetes.

• Dermatitis herpetiformis is linked with coeliac disease.

• Acquired ichthyosis can be associated with Hodgkin’s disease.

• Erythema gyratum repens may reflect underlying malignancy.

• Nail fold abnormalities occur in Raynaud’s phenomenon, SLE, RA, dermatomyositis, systemic sclerosis and CREST syndrome.

• Cutaneous xanthomas may be associated with hyperlipidaemia.

Although skin presentations are often simple and can be summarily treated, almost all skin diseases can be considered from an integrative perspective. A comprehensive integrative approach to the management of skin conditions will usually have a positive, and sometimes dramatic, impact on a patient’s general health. It is important to have well-informed patients by being a caring practitioner who educates and who constantly learns.

1 Hunter JC, Savin J, Dahl M. Clinical dermatology. 2nd edn. Oxford: Blackwell Science, 1995;36.

2 Gawkrodger DJ. Dermatology: an illustrated colour text. Edinburgh: Churchill Livingstone, 1992;13.

3 Pommier P, Gomez F, Sunyach MP, et al. Phase III randomized trial of Calendula officinalis compared with trolamine for the prevention of acute dermatitis during irradiation for breast cancer. J Clin Oncol. 2004;22(8):1447-1453.

4 Long CC, Findlay AY. The rule of hand. Arch Dermatol. 1992;128:1129-1130.

5 Surh Y, Lee J, Choi K, et al. Effects of selected ginsenosides on phorbol ester-induced expression of cyclooxygenase-2 and activation of NF-kappaB and ERK1/2 in mouse skin. Ann NY Acad Sci. 2002;973:396-401.

6 Holm EA, Wulf HC, Stegmann H, et al. Life quality assessment among patients with atopic eczema. Br J Dermatol. 2006;154(4):719-725.

7 Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health Technol Assess. 2000;4(37):1-191.

8 Michaelsson G, Kristjansson G, Pihl Lundin I, et al. Palmoplantar pustulosis and gluten sensitivity. Br J Dermatol. 2007;156(4):659-666.

9 Berbis P, Hesse S, Privat Y. Essential fatty acids and the skin. Allerg Immunol (Paris). 1990;22(6):225-231.

10 Weiss R, Fintelmann V. Herbal medicine. 2nd edn. Stuttgart: Thieme, 2000.

11 Strimpakos A, Sharma R. Curcumin: preventive and therapeutic properties in laboratory studies and clinical trials. Antiox Redox Signal. 2008;10(3):511-545.

12 Choonhakarn C, Busaracome P, Sripanidkulchai, et al. A prospective, randomized clinical trial comparing topical aloe vera with 0.1% triamcinolone acetonide in mild to moderate plaque psoriasis. J Eur Acad Dermatol Venereol. 2010;24(2):168-172.

13 Brown AC, Hairfield M, Richards D, et al. Medical nutrition therapy as a potential complementary treatment for psoriasis—five case reports. Altern Med Rev. 2004;9(3):297-307.

14 Shin Y-W, Bae E-A, Kim D-H. Inhibitory effect of ginsenoside Rg5 and its metabolite ginsenoside Rh3 in an oxazolone-induced mouse chronic dermatitis model. Arch Pharm Res. 2006;29(8):685-690.

15 Vasange-Tuominen M, Perera-Ivarsson P, Shen J, et al. The fern Polypodium decumanum, used in the treatment of psoriasis, and its fatty acid constituents as inhibitors of leukotriene B4 formation. Prostaglandins Leukot Essent Fatty Acids. 1994;50(5):279-284.

16 Anon. Coleus forskohlii. A monograph. Altern Med Rev. 2006;11(1):47-51.

17 Tse W. Use of common Chinese herbs in the treatment of psoriasis. Clin Exp Dermatol. 2003;28(5):469-475.

18 Al-Gurairi FT, Al-Waiz M, Sharquie KE. Oral zinc sulphate in the treatment of recalcitrant viral warts: randomized placebo-controlled clinical trial. Br J Dermatol. 2002;146(3):423-431.

19 Schneider S, Reichling J, Stintzing F, et al. Anti-herpetic properties of hydroalcoholic extracts and pressed juice from Echinacea pallida. Plant Med. 2010;76(3):265-272.

20 Basra MKA, Sue-Ho R, Finlay AY. The Family Dermatology Life Quality Index: measuring the secondary impact of skin disease. Br J Dermatol. 2007;156(3):528-538.

21 Heffernan MP, Nelson MM, Anadkat MJ. A pilot study of the safety and efficacy of picolinic acid gel in the treatment of acne vulgaris. Br J Dermatol. 2007;156(3):548-552.

22 Amman W. Acne vulgaris and Agnus castus (Agnolyt). Z Allgemeinmed. 1975;51(35):1645-1648.

23 Mills S, Bone K. Principles and practice of phytotherapy. Modern Herbal Medicine. London: Churchill Livingstone, 2000.

24 Dixon AJ, Hall SH. Managing skin cancer. Aust Fam Physician. 2005;34(8):669-671.

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