Guest blog entry: Dermatology consults

This week's guest blog is a first. It is the first time that a guest blog entry has been written by one of you -- a reader. That reader is Bruce Kalin, PA-C, a Dermatology Physician Assistant with Kuflik Dermatology, in Ocean County New Jersey. He is a graduate of the Medical College of Pennsylvania & Hahnemann University Physician Assistant Program, and has been in practice dermatology practice for 11 years. Prior to that he was in Family Practice. He is the current President of
the New Jersey Dermatology Physician Assistants, a past Vice President of the New Jersey State Society of Physician Assistants, a frequent presenter and consultant on "The Proper Utilization of Physician Assistants in a Dermatology Practice," and, lectures on the topic of skin cancer. Bruce Kalin is married for 30 years, has raised three adult sons, two of whom are employed by a Derm-Path Lab, and the third
planning to enter a Physician Assistant Program.

Here is the entry, written exlusively for MedFriendly.com. Please keep in mind that the comments of guest bloggers do not constitute medical advice by MedFriendly.com and you should always check with your health care provider for medical advice for your speciic situation.

A Free Dermatology Consult

Everyone knows there is really nothing in this life that is free, especially a visit to a medical specialist. But, this advise is truly free, as it cost you nothing but the time it takes you to read this from beginning to end, to benefit from what I am about to tell you.

It is now the beginning of the fall and, soon to be winter season in the Mid Atlantic Region of the US. This means, "the itchy season" is here. The percentage of patients coming in for a consult because of itching all over, or on their scalp, arms, legs, etc. will go up significantly for every dermatologist in the area. Primarily, the patients that will be seen in the office fit into a few distinct categories, but at this time I am only going to discuss the itchy patients who are of the self inflicted variety. What I mean by self inflicted itching is, that they are using products, and/or living in an environment that promotes dry, itchy skin. Some of the most common things that people do to create drying of their skin is, bathing with very drying products, using very drying shampoo, bathing in very hot water, keeping the temperature in their house excessively warm, and wearing too much warm clothing for extended periods.

Years ago, it was common for a physician to tell a patient to bath infrequently in the winter to avoid drying out the skin, which would cause itching. With the advent of newer bathing products, and the knowledge that water alone does not help remove the dead skin layer, most dermatologists will recommend bathing and moisturizing the skin on a fairly regular basis, using the correct products. When bathing or showering, it is best to use a gentle cleanser, such as Dove Soap or Cetaphil Cleanser. There are other products on the market that will perform as well, you just need to search for the product that works best for your skin. It should be noted that most anti-bacterial cleansers are very drying. Because of the prevalence of MRSA in our communities, anti-bacterial cleansers are no longer recommended for general cleansing, due to their promotion of resistant bacteria, so avoid them if at all possible. Rubbing and scrubbing with a wash cloth is also not recommended, as it promotes irritation, rather than a cleaner skin layer. Simply using your hands to apply the cleanser is more than adequate to clean your skin.

An application of a moisturizing lotion after every bath/shower is also strongly recommended. A lotion is easy to apply, and goes on more quickly than a cream. A moisturizing cream, on the other hand is better than a lotion if you begin to develop dry areas of skin, but you can go back to using your preferred lotion once the dry area resolves. Also keep in mind that thicker applications of cream or lotion on your skin are NOT better. The products will not soak into your skin hours later because you put on a thick layer. In fact, most of the cream that was not massaged into the skin will have already rubbed off on your clothing, your bed linens or, someone else long before it had a chance to soak in. You just wasted most of the product. A thin film, applied more frequently is always better. If you have a tendency toward dry skin, apply the lotion two times a day, or more if needed. Shampoos fall into the same category as soaps. A medicated shampoo obtained over the counter without a prescription, applied several times weekly, according to the manufactures recommendations is your best first line of treatment for an itchy scalp.

Using hot water in the shower or bath has an anesthetic effect on the skin, so most people that tend to itch like to take very hot showers. The problem is that the hot water is actually causing a low grade burning of the skin, which in itself is creating more of an itch. If you want to test this, just go into your hot shower, enjoy it for the moment, and then come out. Your itch will return with a vengeance. While I'm on the subject of showers, let me recommend that you towel dry while still in the shower, with the curtain or shower door closed. This will help to prevent the cooler air of the room to cause excessive evaporation of the water from the surface of your skin. Evaporation is a drying process, so if you step out of the shower while still soaking wet, you will be right back to where you started from before your shower - maybe even worse. So, as far as showers go, you want to take a warm shower, use a gentle cleanser, dry off in the shower with the curtain closed, and apply moisturizing lotion before you exit the shower. Enough for showers, so let's move out side of the bathroom.

As we age, we lose much of the fat layer under our skin. The fat is our natural insulator, and without this insulation we tend to have less ability to retain our own body heat. So, in cold weather we try to compensate for heat loss by turning up the thermostat in the house, or try to save on the heating bill by wearing warmer clothing indoors, or both. Since the clothing has no natural thermostat, which could release the heat at the proper temperature if it did have one, we overheat, the body compensates with sweat (a cooling and drying process), in an effort to cool off. Unfortunately, that sweat will evaporate, and the dry, itchy skin process will be well under way. People that work outdoors in the winter, and those who participate in exercise and outdoor sports in the winter, and who don't wear special clothing to help wick the sweat away from their bodies, will also tend to develop itchy skin. A good example of this are Police Officers that wear armored vests, but don't wear the recommended moisture wicking underwear. They tend to develop irritant, itchy rashes on their upper body. Another example are construction workers who wear the same pair of heavy socks inside their work boots all day, also will sweat and develop an itch on their feet. Most of the red itchy feet that dermatologists see in the winter are due to sweating and dryness, not fungus. The same goes for heavy underwear, which accounts for most of the rashes in the groin and in the arm pits, also known as intertrigo.

It is best to try to avoid dry skin, but if it develops, treat the condition as quickly as possible so that it doesn't get out of hand. Remember, when you itch you scratch, and scratching makes you itch more so, you scratch more, which makes you itch more .................. and on, and on and on. Dry skin, plain and simple is itchy skin, and once you begin to scratch, it is very difficult to stop. Left untreated for extended periods of time, chronic scratching can create lichenification, which is a thickening of the skin. More severe scratching can open the skin to infection, as well as leaving life long scarring. As a last ditch effort, prior to seeking medical help you can try this remedy. Take the thickest moisturizing cream that you can find without a prescription (usually Aquaphor)and an over the counter cortisone cream. Mix the both of them together in equal parts in a jar. Use this mixture in the morning, in the evening, and every time you itch. DO NOT SCRATCH - apply the mixture instead. As soon as the itch resolves, go back to your normal moisturizing routine. DO NOT continue the steroid mixture for any time greater than a week. DO NOT use it on your face, arm pits or groin for more than a few days.

When all else fails, and if the itch has not resolved by one week, you'll need to follow up with your medical professional. You should not expect that to be a free consult.

Bruce Kalin, PA-C
NJDPA President
http://www.njdpa.org
AAPA, SDPA, NJSSPA, NJDPA