Which sunscreen? A brief guide.

Why should I use a sunscreen?

• UVB damages your skin cell and melanocytes (the cells that give you skin colour and protect against the sun). Damage to these cells causes skin cancer.
• UVA penetrates deeper into the skin and damages collagen. Collagen serves as scaffolding and shock absorber to protect deeper structures of the skin. It also gives volume to the skin. UV damage to collagen results in wrinkles, sagging skin and easy bruising.
  
  
  

• Broad spectrum sunscreens offer protection against skin cancer and premature aging of the skin.

Wrinkling on the sun-exposed side after 28 years of working as a truck driver.

What is SPF?

• SPF stands for sun protection factor. It is a measure of the fraction harmful UVB rays that reach the skin. For example, "SPF 20" means that 1/20 of harmful UV rays reach the skin when the sunscreen is applied appropriately. In other words, if takes you 10 minutes to get sunburnt without sunscreen, it will take you 20 times longer (200 minutes) to get sunburnt with SPF 20 sunscreen adequately applied.

What is the difference between chemical and physical sunscreens?

• Chemical sunscreens absorb the energy from the UV rays and convert it to other forms of energy that do not damage the skin. Their advantage is that formulations they are easier apply and rub into the skin without leaving a white residue. This makes them cosmetically more acceptable. Their disadvantage is that they are slightly less effective than physical sunscreens and can cause irritation.
• Physical sunscreens form a shield on the surface of your skin that reflects or deflects UV rays before they reach your skin. They are cosmetically less acceptable but they are less likely to cause skin irritation.

What is non‐comedogenic sunscreen?

• This is a sunscreen that does not contain oily substances that predispose to formation of blackheads, whiteheads and acne. 

What is a “sensitive skin” sunscreen?

• These generally are physical sunscreens and do not contain irritants and allergens such as fragrances, preservatives, and synthetic dyes. 

What are baby sunscreens? 

• These are typically physical sunscreens without fragrances or other irritants. 
• They are similar to  “sensitive skin” sunscreens.

Which sunscreen should I choose?

• Broad-spectrum sunscreen which protects against UVA and UVB rays.
• SPF 30 or higher. Higher SPF sunscreens are more likely to have good UVA protection and give some margin for error if under applied.
• Use water-resistant sunscreen when sweating, exercising or swimming.
• Physical sunscreens if you have a sensitive skin or react to sunscreens
• Rather buy enough of the sunscreen that you can afford to use continuously rather than buying an expensive which you have to use sparingly or intermittently.

When should I apply sunscreen?

• Apply sunscreen every time you are outside, even on a cloudy day up to 80 percent of UV rays still reach the exposed skin. 
• Apply sunscreen to dry skin at least 15 minutes before going outdoors.
• The need for sunscreen is even more in water, snow or sand because they reflect harmful UV rays back to the skin.
• Reapply every two hours when you are outdoors or immediately after swimming or sweating regardless of the SPF you use.

How much sunscreen should I apply?

• Most people only apply 25-50 % of the recommended amount of sunscreen.
• You need enough sunscreen to fill a shot glass (25ml in South Africa) to cover an average adult body not covered by clothing. With increasing clothes cover, proportionately less is required.

What is the difference between regular, water-resistant and waterproof sunscreens?

• Currently there is a global drive to remove the label waterproof from sunscreens because no sunscreen is waterproof.
• A water-resistant sunscreen retains its SPF activity after immersion in water for at least 40 minutes.

Do people with dark skin need to use sunscreen?

• Darker skin is much less susceptible to sunburn and UV damage than lighter skin.
• White residue from physical sunscreens is more visible on darker skin making it undesirable cosmetically and limiting options.
• Darker skin is more susceptible to hyperpigmentation that is aggravated by UV rays. In this group of patients there is good evidence supporting use of sunscreen.
• In general, there is no good evidence to support or refute the benefit of sunscreen to prevent skin and premature skin aging in darker skinned individuals.

Are sunscreens safe? 

• There is a general consensus that the benefits of sunscreens outweigh potential risks.

I hope this helps in your choice of sunscreen.

Prof Rannakoe Lehloenya

Atopic Eczema – a brief overview

What is Eczema?

Eczema or dermatitis refers to a non-infectious disorder that is characterised by water between the skin cells if examined under the microscope. The term eczema encompasses a group of heterogeneous conditions that have many different and overlapping clinical features and many of these features may be found in one individual.  It is possibly for this reason members of the public and non-dermatologists sometimes find it difficult to diagnose eczema. Sometimes even the most experienced dermatologists need a skin biopsy to make the diagnosis of eczema. The skin in eczema is more susceptible to irritation by soaps, contact irritants, coarse fibers in clothes, high ambient temperature and weather changes.  In this article we will use pictures to briefly describe the different conditions that are referred to as eczema and their associated or differentiating features.

What is Atopy?

Atopy is a general term used to describe an inherited susceptibility to allergies on the skin, lungs and mucosal surfaces. The conditions that make up atopy are eczema, hay fever (or sinuses as sometimes incorrectly referred) and asthma. If one of the parents has personal or family history of these conditions their children a predisposed to develop eczema. If this applies to both parents, the life-time risk for their children is even higher. “Atopic march” or “allergic march” refers to the natural history or typical progression from one to the other of the three allergic diseases during a life-time.

Atopic eczema is common and, in some countries, affects up to 20% of children.

What are the features of Atopic Eczema?

The character of the lesions and their distribution in atopic eczema, varies markedly between individuals, age groups and affected parts of the body.  In infancy, the cheeks are usually the first to be affected becoming red, sometimes weepy, dry and scaly. The nose is usually spared. Overtime the rash spreads to other parts of the body. 

As the child mobilizes and up to starting school, the rash tends to mainly affect extensor surfaces of arms and legs as well as the groin. In later preschool years and school-going age, the body folds tend to be the most affected. The most notable folds are the elbows and knees. Other body folds that may be affected include eyelids, earlobes, angle of the mouth, the neck and greases of the buttocks. 

In adulthood, the rash is more variable. The childhood patterns may be maintained with additional involvement of the nipples, lips and hands.  With time and scratching, the skin in the affected areas changes colour and become thickened, a feature called lichenification. 

Both children and adults with atopic eczema may develop recurring intensely itchy ‘coin-like’ or ‘ring-like’ lesions called nummular eczema, most often on the arms and legs. Depending on the age of the lesions these can be weepy or dry and scaly. With time and scratching, the lesions of nummular eczema can become darker and thickened.

Is Atopic Eczema curable?

Although most atopics outgrow their eczema, it persists in about 5% of patients who had the disease as children. However, the predisposition of atopics to skin sensitivity and susceptibility to allergic reaction persists for life.

Comment

The diagnosis and management of atopic eczema can be difficult and an initial consultation with your dermatologist to get a definitive diagnosis and a management plan may save your family large amounts of money and years of discomfort.  

Professor Rannakoe J Lehloenya

Alopecia series - Traction

Traction alopecia

The word alopecia refers to loss of hair regardless of cause.

What is Traction Alopecia?

Traction alopecia is just one type of alopecia caused by repeated or prolonged pulling of the hair. Traction most often affects the hairline, the front and the sides being the most common. 

What causes Traction Alopecia?

The pulling of hair creates tension that extends deep to the roots of the hair. Traction creates inflammation around the root of the hair (also called hair follicle). The hair follicle is effectively the factory that produces hair. If the factory, in this case the hair follicle, is damaged, it will either produced abnormal or reduced quantities hair. In extreme cases, the damage is permanent, and that area will never grow hair again.

In the case of traction alopecia, the persistent traction results in inflammation of the hair follicle and over time the cells that invade the hair follicle to repair the damage end up causing permanent damage to the hair follicle (the hair factory), resulting in permanent hair loss. 

Who gets Traction Alopecia?

Traction alopecia is related to hair grooming practices or hairstyles as they are more commonly known. Females of African descent tend to be the most affected because of the type of hairstyles they prefer. These include braids, weaves, twisted dreadlocks, tight ponytails and hair extensions. Other less recognized causes of traction alopecia include hair pins, tight fitting headwear and heavy ornaments attached to hair. A study conducted in Langa, Cape Town by my colleagues Professor Nonhlanhla Khumalo and Doctor Sue Jessop showed that people who pulled their hair while it was relaxed, tended to have more severe traction alopecia over time. People who give a history of relaxing their hair, pain, itch, pimples and burning after one of the above-mentioned hairstyles are at a higher risk of developing traction alopecia.

How does Traction Alopecia look like?

This depends on the stage of the disease. In early stages, the hair loss may not be visible to a naked eye, only a slight reduction in hair density. What may be visible is inflammation of the hair follicle, called folliculitis, seen as redness, pimples, pustules and scale in the affected area.  Often this is associated with pain or itch. The typical picture is repeated patting of the scalp in the affected area or using cold compresses after the hairstyle to relieve the symptoms. At this stage, the alopecia is usually reversible.

With progression, the hair in the affected area progressively thins until there is complete loss. On close inspection, early on the hair follicles are still visible but with time only a shiny smooth surface results. The smooth surfaces indicates irreversible damage of the hair follicles and scarring of these follicles and surrounding tissues. There is often a fringe of fine hair that is preserved at the edge. This hair was too small to be incorporated into the hairstyle, thus it was spared the traction.  

What can you do to prevent Traction Alopecia

Change hair grooming practices to safer ones

If you still wish to have any of these hairstyles:

§  Tell your hairdresser in advance and clearly what you want

§  Make sure the pulled hair is comfortably loose enough and not too tight

§  Listen to your scalp or your child’s complaints – if it is uncomfortable, it is not good for your scalp

§  If it is uncomfortable, undo it as soon as possible regardless of cost

How do we manage Traction Alopecia

Correct diagnosis by a doctor and staging of the disease are essential before embarking on any treatment.

Available treatments include topical steroids, topical minoxidil, oral antibiotics and hair transplantation. All these become increasingly less effective with advancing Traction Alopecia. Even hair transplantation is not effective in advanced disease because of the scarring that affects the surrounding tissues. It is equivalent to planting a seed on barren rock.

Last word

The best treatment for Traction Alopecia is prevention by using correct hair grooming practices from childhood. As I often say to my patients with early disease – Listen to me now or you will forever have a bigger face to wash and a smaller head to comb.

Professor Rannakoe Lehloenya

An appeal: Do not stock and deprive chloroquine those who need it

Managing hand dermatitis while maintaining adequate hand hygiene during the COVID-19 pandemic.

The current COVID-19 pandemic has considerably increased the frequency of handwashing as well as the use of gloves and hand sanitizers. One of the unintended consequences of these good practices is an upsurge in the incidence of hand dermatitis we are seeing as dermatologists.

Hand dermatitis or hand eczema is a non-communicable inflammation of the hands characterized by itch, redness, scale, weeping, blisters and/or fissuring. Hand dermatitis can be due to an allergy to one of the constituents of a product (allergic contact dermatitis) or prolonged exposure to chemical or physical irritants we are exposed to (irritant contact dermatitis). With prolonged exposure, substances that would not otherwise cause any damage to the skin, impair the skin’s integrity resulting in dermatitis.  Irritant contact dermatitis that develops in children whose nappies are left on for prolonged time is a good example.

Frequent washing of hands with soaps and detergents, use of alcohol-based sanitizers and prolonged wearing of plastic or rubber gloves predisposes to hand dermatitis. The trapping of moisture on the surface of the skin increases permeability, chemical exposure and the risk of irritation.

Hand dermatitis has been shown to significantly reduce hand hygiene compliance amongst workers who are compelled to use hand hygiene products. The most common reason for the lack of compliance is the repeated and deleterious effects of using these products. Non-compliance with hand hygiene protocols by workers who provide essential services during this concerted effort to control the pandemic would be undesirable. It is important to disseminate information on the current best practices to manage hand dermatitis in those who are affected or susceptible to maintain high levels of hand hygiene compliance during this time and in the future.

Alcohol-based hand sanitizers recommended by the World Health Organization (WHO) contain glycerin as a moisturizer to protect the skin against dryness and irritant dermatitis. In a small proportion of people who regularly use hand sanitizers, the concentrations of glycerin as recommended by WHO, are insufficient to prevent irritant hand dermatitis. Supplementary moisturizing of the skin is required after use of sanitizers in those who are susceptible or develop hand dermatitis. This is to prevent worsening of the condition and resultant non-compliance with recommended hand hygiene protocols.

Recommendations for those who are susceptible or develop hand dermatitis are summarized below:

·      Most importantly, do not reduce the frequency and duration of hand hygiene protocols that are currently recommended by the Department of Health.

·      Maintain the integrity of skin by applying a moisturizer after sanitizing while ensuring that the surface of moisturizer container is clean by only touching it after sanitizing every time.

·      Do not use unsanitized hands to collect the moisturizer from the container.

·      Apply protective barrier cream before wearing gloves if you fall into the category of people that has to wear gloves as per the current recommendations by the Department of Health. Amongst others, these barrier creams typically contain zinc oxide, talc, silicones, aluminum chlorohydrate or kaolin.

·      Allow your hands to dry and apply a moisturizer between changes of gloves.

·      Apply alcohol-based sanitizer to gloves between changes if you fall in the category people that has to wear gloves as per current recommendations by the Department of Health. Remember, alcohol-based sanitizers may degrade some types of gloves.

·      In severe cases, contact your doctor for advice on appropriate corticosteroid cream

In intractable and severe cases, alcohol free sanitizers are an alternative.

Despite these minor problems that may be associated with the upsurge in hand hygiene, do not lose sight of the bigger picture – good hand hygiene will save lives even if it irritates.

Prof Rannakoe J Lehloenya

Tattoos - an overview

Tattoos are becoming increasingly common. Did you know that:

•       Tattoos can be accidental or deliberate, permanent or temporary,

•       professional or amateur, cosmetic, decorative or medical, or invisible.

•       Amateur tattoos are more superficial and easier to remove.

•       Cosmetic tattoos are used to enhance the appearance of body parts, resemble make-up or mask deformities e.g. permanent make-up, tattoos over surgical scars and nipple tattoos after a mastectomy.

•       Invisible tattoos are only visible when they glow under UV light.

•       The following world leaders are or were tattooed: Winston Churchill and his mother, Tsar Nicholas II, King George V, Thomas Edison, Theodore Roosevelt, and current Canadian Prime Minister Justin Trudeau.

•       More than 100 million Europeans have tattoos.

•       More recent data shows that tattoos are obtained by individuals with higher levels of education to remember a loved one or purely for enjoyment.

•       In Germany a tattooed individual has the mean age of 35 years, most are females, employed and with no history of drug or alcohol abuse.

•       Motivation for tattooing include religion, personal symbolism, expression of shared values within a subculture, quest for individuality, enhancing attractiveness, rebellion, fashion, using the body as a canvas for art, peer pressure and impulsive tattooing under the influence of alcohol and drugs.

•       Complications of tattoos include infections, allergic reactions (mainly to red dye), psychological and social complications and tattoo regret.

•       Tattoo regret is estimated to be between 14 and 17% in the general population.

•       Main reasons for wanting removal of tattoos are: complications as well as personal reasons like change in relationship status, religious reasons, past drug addiction or gang membership, dissatisfaction and boredom with the tattoo and desire for re-integration into society, particularly by rehabilitated prisoners and gang members. Professional reasons are becoming less common.

•       Tattoo removal is generally difficult and unsatisfactory depending on the size, location and depth. Methods of removal include abrasion with coarse salt, dermabrasion, surgery, laser and chemicals. See your dermatologist for the best method for each tattoo.

     Here is a link to an article we published on tattoos mainly directed at doctors but can be of interest to anyone who wants to know a bit more detail about tattoos. 

http://www.samj.org.za/index.php/samj/article/view/12420

La Roche-Posay Atopy School

As Dermatolology Treatment and Phototherapy Clinic (http://www.capedermatologyclinic.com/) we hosted a successful Atopy School with our partners, La Roche-Posay this past weekend at the clubhouse in Century City Cape Town. It was a chance for myself and Dr Nomphelo Gantsho to interact with children with atopic eczema and their parents, improve their insight into the disease and management strategies to prevent and control flares.

Courtesy of L'Oreal and La Roche-Posay the kids had fun, loads to eat and La Roche-Posay Baume hamper worth almost R1000.00 to take home.

We thank all the parents and children who came and from their feedback, it was a very enlightening experience for them.