QuestionI have keratosis pilaris on my upper arms. Is there anything I can do to ease it? Sometimes when I get up in the mornings, my arms are silky smooth! but only for about an hour or so, then it is right back to being bumpy and reddish. Why is that, and is there anything I can do about it? Thank you for your time.
AnswerHere is a good summary of what we know about this condition. OK?
Background: Keratosis pilaris (KP) is a disorder of hyperkeratosis. It is a very common benign condition that manifests as folliculocentric keratotic papules. Although no etiology has been defined, KP is often described in association with ichthyosis vulgaris and less commonly with atopic dermatitis.
It affects 50-80% of all adolescents and approximately 40% of adults. Approximately 30-50% of patients have a positive family history. Autosomal dominant inheritance with variable penetrance has been described.
Seasonal variation is described, with improvement of symptoms in summer months. Overall, KP is self-limited and tends to improve with age in many patients. More widespread atypical cases may be cosmetically disfiguring and psychologically distressing.
Pathophysiology: KP is a hyperkeratotic disorder of the skin and a very common benign condition that manifests as discrete 1-mm folliculocentric papules. Often, a small, coiled hair can be seen beneath the papule. Papules are thought to arise from excessive accumulation of keratin at the follicular orifice.
Frequency:
Internationally: KP affects 50-80% of adolescents and approximately 40% of adults worldwide.
Mortality/Morbidity: This condition is not associated with increased mortality or morbidity. Often, patients are bothered by the cosmetic appearance of their skin and its rough, gooseflesh texture.
Race: KP has no racial predilection.
Sex: Females may be affected more frequently than males.
Age: Age of onset is often within the first decade of life; symptoms particularly intensify during puberty. However, KP may manifest in persons of any age and is common in young children.
History:
Patients often report a rough texture (gooseflesh appearance) and overall poor cosmetic appearance of their skin.
Eruption is usually asymptomatic, except for occasional pruritus.
Physical:
Physical findings are limited to the skin.
Small (1-2 mm) folliculocentric keratotic papules are noted (see Image 1).
Some associated inflammation (erythema) may be present, and lesions may be the color of the skin. Often, a small, coiled hair can be seen beneath the papule.
Commonly involved areas include posterolateral upper arms (see Image 2), anterior thighs, and facial cheeks.
Causes:
Dry skin conditions seem to exacerbate the disease.
Symptoms generally tend to worsen in winter and improve in summer.
Common associations include a family history of KP, ichthyosis, or atopic dermatitis.
DIFFERENTIALS
Acne Vulgaris
Atopic Dermatitis
Folliculitis
Keratosis Follicularis (Darier Disease)
Kyrle Disease
Lichen Spinulosus
Milia
Pityriasis Rubra Pilaris
Other Problems to be Considered:
Phrynoderma (vitamin A deficiency)
Lab Studies:
No specific laboratory tests aid in diagnosis.
Imaging Studies:
Imaging studies are not indicated.
Procedures:
Skin biopsy with histopathological examination may be useful in atypical cases.
Histologic Findings: Papules are thought to arise from excessive accumulation of keratin at the follicular orifice. The epidermis shows mild hyperkeratosis, hypergranulosis, and follicular plugging. The upper dermis may have some mild superficial perivascular lymphocytic inflammatory changes.
Medical Care: No cure or universally effective treatment is available. Symptoms usually remit with increasing age.
General measures to prevent excessive skin dryness (eg, use of mild soaps) are recommended.
Some available therapeutic options include emollients, lactic acid, tretinoin cream, alpha-hydroxy acid lotions, urea cream, salicylic acid, and topical steroids. Mild cases may improve with emollients.
More prominent inflammatory eruptions may benefit from a limited 7-day course of a medium-potency, emollient-based topical steroid applied once or twice a day followed by a routine of twice-daily applications of a compound preparation of 2-3% salicylic acid in 20% urea cream. Advise the patient to gently massage lotions into the affected area. After attaining initial control, patients can then be placed on a maintenance regimen.
Although calcipotriol ointment has been used effectively for various forms of ichthyosis, it has not demonstrated a therapeutic effect for KP in clinical trials.
Surgical Care: Surgery is not indicated.
Consultations: Consultation with a dermatologist is appropriate for refractory or widespread cases.
Diet: KP has no dietary associations.
Activity: KP does not limit any patient activities
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Drug Category: Retinoids -- Retinoic acid decreases cohesiveness of follicular epithelial cells, stimulates mitotic activity, and increases turnover of follicular epithelial cells.Drug Name
Tretinoin (Retin-A, Avita) -- Inhibits microcomedo formation and eliminates lesions present. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. Available as 0.025%, 0.05%, and 0.1% creams. Available also as 0.01% and 0.025% gels.
Adult Dose Begin with lowest tretinoin formulation and increase as tolerated; apply hs or qod; decrease frequency of application if irritation develops
Pediatric Dose <12 years: Not established
>12 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Toxicity increases with coadministration of benzoyl peroxide, salicylic acid, and resorcinol; avoid topical sulfur, resorcinol, salicylic acid, other keratolytics, abrasives, astringents, spices, and lime
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Photosensitivity may occur with excessive sunlight exposure; caution in eczema; do not apply to mucous membranes, mouth, and angles of nose
Drug Category: Alpha-hydroxy acids -- Normal constituent of tissues and blood. Act as humectants when applied topically and may decrease corneocyte cohesion.Drug Name
Ammonium lactate lotion (AmLactin, Lac Hydrin) -- Indicated for treatment of ichthyosis vulgaris and xerosis. Contains lactic acid, an alpha-hydroxy acid that has keratolytic action, thus facilitating release of comedones. Causes disadhesion of corneocytes. Use 12% cream or lotion.
Adult Dose Apply bid to affected skin
Pediatric Dose <12 years: Not established
>12 years: Apply as in adults
Contraindications Documented hypersensitivity
Interactions None reported
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions May sting or cause pain if applied to broken skin; may cause irritation with erythema, burning, and peeling if applied to face at 12% concentration; avoid contact with eyes, mucous membranes, and lips; minimize sun exposure because of possibility of heightened photosensitivity
Deterrence/Prevention:
Measures should be taken to prevent excessive skin dryness.
Mild soaps and cleansers should be used.
Frequent application of emollients is very beneficial.
Complications:
Complications are infrequent. However, postinflammatory hypopigmentation or hyperpigmentation and scarring may occur.
Prognosis:
Overall prognosis is good. Many cases resolve with increasing age. However, others may persist into late adulthood with intermittent exacerbations and remissions.
Patient Education:
Patient education should focus on the tendency for chronicity of the condition and the need for ongoing maintenance therapy.
Patients should be advised that the condition is not contagious and is not a threat to their overall health.
eMedicine has excellent skin, hair, and nail patient education resources available at http://www.emedicinehealth.com/collections/1596.asp These resources may be printed free of charge.
