Dr Paul Charlson, FRCGP DRCOG DPD DOccMed MBCAM is President of the British College of Aesthetic Medicine. He has worked as a GP for 30 years and a GPwER (GP with an extended role in dermatology and skin surgery) for 15 years. In the latest blog, he shares the most challenging skincare questions he sees from his patients.
With the prevalence of health-based forums on the internet, patients are increasingly researching information, self-diagnosing and challenging our advice. Below are five of the most challenging questions I experience and the advice I offer:
1.) Can I still wear makeup when I have acne?
Maturity onset acne, which is often androgen driven, is quite common in women in their twenties and thirties. Acne can be disfiguring so patients tend to want to cover the skin with thick make-up. The problem is that many foundation products clog the pilo-sebaceous glands and this is going to aggravate their acne. They compound this by using dirty brushes that contain bacteria and infect the clogged pilo-sebaceous glands creating further issues.
It is fine to use make-up if the patient has acne but first you must ensure the patient uses a mild non-comedogenic cleanser after they wake up, before they go to bed and after exercise. Make-up wipes, many of which are not environmentally friendly, are not going to clean off all the make-up. A more clinical approach using clean gauze and cleanser is more effective.
Secondly, it is useful, particularly if the patient’s skin is dry and dehydrated, to use a non-comedogenic emollient as a primer. This needs to be applied reasonably, thickly and allowed to settle into the skin for 15 minutes. Make-up should be applied with clean brushes – washed and dried at least weekly. The make-up should be mineral or non-comedogenic.
2.) My eczema seems to be getting worse. I have tried the moisturisers and steroids from the GP.
When I see patients with eczema, there are a number of things I ask. Firstly, what do you wash with? The usual answer is either soap or shower gel. Any soapy substance will denude the lipid barrier on the skin and make eczema worse. You have to persuade patients not to use soap and substitute for emollients.
Secondly, I ask them to show me how they apply emollients. They usually explain they use a small amount, which they rub in. What I would actually recommend is a thick layer of emollient that is allowed to soak in. Patients rarely use more than 25% of the required emollient.
Lastly, I show them how much steroid cream to apply. I recommend using fingertip measures and to smear it, not rub it. These measures usually resolve eczema quickly.
3.) I keep getting a small blotchy itchy rash that lasts only a few hours when I work out or get sweaty
This is likely to be a cholinergic urticarial when the body releases histamine in response to the skin getting warm1. Quite often, the patient takes anti-histamines, which are sometimes helpful however frequently a standard dose of anti-histamine fails to control the problem. Off license, many physicians prescribe larger doses, which are safe and effective and they may add other drugs to the regime. Whilst there are treatments available, it is worth having a conversation about the potential triggers and how the patient can avoid them, if possible.
If the urticaria has lasted less than six weeks, further investigations are usually not required. For longer-term problems, we usually perform a blood screen to exclude other issues but quite often, these are normal. Usually the problem rights itself in one to two years.
4.) I have rosacea and I don’t know what to do. My skin has a few pimples and many red veins
No-one knows what causes rosacea but the redness is usually caused by a proliferation of blood vessels in the skin. There are several prescription creams that are helpful and oral antibiotics to be taken over a course of 8 to 12 weeks that can resolve the problem for a time.
It is again worth having a conversation with your patient about triggers. I would suggest patients should wear sun protection 365 days a year as this is a major trigger of rosacea. Alcohol may also be a trigger, if this is the case, I would suggest patients reduce the amounts the drink.
I suggest patients use a mild cleanser applied gently with their fingertips and then rinse with luke-warm water. They should avoid scrubbing and the use of flannels or towels as this can exacerbate the problem. Green tinted make up helps to hide the reddening. Some people advocate Brimonidine cream which lasts up to 12 hours and has minimal side effects. It is worth knowing that sometimes when patients stop using the cream, the symptoms can rebound. Finally, lasers can effectively treat the small blood vessels.
5.) I have terrible dandruff and I am looking for solutions
Many people think this is due to bad hygiene, which it is not. Dandruff is best controlled with anti-dandruff shampoos and other medication. I recommend that patients start with a shampoo and follow the specific instructions on the bottle but they should usually use this daily but slightly less often if they have thicker hair. Sometimes an anti-fungal shampoo can be helpful. Tar based shampoos are useful but they can discolour blond, grey or white hair and can sensitise the scalp to sun light and, of course, they have an odour. If the shampoo fails to help, it’s worth considering that the patient may have seborrhoic dermatitis, psoriasis, eczema or sometimes a fungal infection which may require different treatment.
Resource to support healthcare professionals:
Bio-Oil Professional has several free resources for healthcare professionals on the topic of skincare, free to download:
Resources for healthcare professionals:
Resources for your patients:
1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3840548/ https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails/urticaria-hives