YOUNG ADULTS YOUNG ADULTS (20 - 35 YEARS) A large number of skin diseases reach their peak of expression during the young adult years, and these individuals also represent a large and growing proportion of the South African population, in common with other developing countries. Young adults are especially distressed by skin conditions that are uncomfortable, disfiguring or contagious. This group has also been severely affected by HIV/AIDS, with a consequent increase in the frequency and severity of the HIV- associated dermatoses. Some of these conditions have been discussed in other sections of this review. ACNE KELOIDALIS Inflammatory papules and pustules located mainly on the nape of the neck and occiput characterise this acne-like condition. It primarily affects black males. The lesions heal with scarring, creating huge keloids if this tendency exists. The cause is unknown, and unlikely to result from repeated shaving or short hair cutting. It DENGA A MAKHADO may be caused by unusually thick collagen, which traps and disrupts terminal MB ChB, FCDerm (SA) hair follicles. Treatment is not very successful, and large keloids are best excised Consultant Dermatologist by a surgeon. Mild cases can be helped by intralesional injection of steroids like Division of Dermatology Celestone Soluspan into individual papules and scars. Long-term oral tetracy- clines, as for acne, can also be beneficial, as can topical antibiotics like erythro- University of the Witwatersrand and mycin and clindamycin. Chris Hani Baragwanath Hospital Johannesburg ACNE VULGARIS Denga Anna Makhado is a consultant der- There has been a recent tendency for acne to persist beyond the teens, or even matologist at Chris Hani Baragwanath occur for the first time in adulthood, called persistent adult acne. Adult acne has the same pathogenesis as ordinary acne, but is often more resistant to treatment; Hospital and the University of the individuals are also less likely to leave the condition untreated. The principles of Witwatersrand. She is also in private prac- treatment are as for teenage acne. It is important to exclude drug causes such as tice in Johannesburg. She was a general lithium, phenytoin and other anticonvulsants, steroids and cyclosporin. practitioner for 5 years prior to specialis- Widespread misuse of potent topical steroid creams for acne and other facial ing. conditions will aggravate acne in the long term, and cause other side-effects like atrophy and telangiectasia. CHLOASMA This is an acquired tan-brown symmet- rical discolouration of facial skin on the forehead, nose, cheeks, upper lip and chin (Fig. 1). It is much more com- mon in women, and is thought to be due to a combination of sun exposure and hormonal changes such as preg- nancy and hormonal contraceptives. It is darker and more disfiguring on dark- er skins. Chloasma is very difficult to treat: sun avoidance and strong sun- screens are important to prevent wors- ening of the condition. Bleaching agents like 2 - 4% hydroquinone are widely used. There are many propri- etary compounds that contain mild bleaches: kojic acid, vitamin C and Fig. 1. Chloasma. 512 CME September 2004 Vol.22 No.9 YOUNG ADULTS liquorice extract. Retinoid creams like to allergic contact dermatitis, con- tretinoin (Renova, Retin-A), azelaic firmed on patch tests. The condition acid (Skinoren) and glycolic acid can also be triggered by psychogenic products can also be tried. In fair- factors like stress, but this is difficult to skinned people, certain light therapy prove. Finally dyshidrotic eczema can devices can alleviate chloasma. be an allergic reaction to a distant focus of fungal infection, especially CONDYLOMATA ACUMINATA tinea pedis, giving rise to the id reac- tion. All types tend to be resistant to These are genital warts caused partic- therapy, and a treatable cause gives ularly by human papillomavirus (HPV), the best results. Failing this, milder types 6 and 11. They appear initially cases should be treated with a potent as small, raised, flesh-coloured or pale topical steroid cream like clobetasol papules with an irregular surface, on propionate or mometasone, together the skin or mucous membranes of the with a course of oral antibiotics. More penis, vulva, vagina, anus and sur- severe cases are better treated with a rounding areas (Fig. 2). Infection can Fig. 3. Discoid lupus erythematosus. short course of oral steroids, such as be latent or subclinical, enhancing the prednisone 20 - 60 mg daily for 5 - risk of unexpected spread. Without trally leaving depigmentation (Fig. 3). 10 days. prompt treatment, or in the presence Plaques on the scalp are associated of immunosuppression, the lesions can with scarring alopecia, which is per- grow to a huge size, obscuring the manent. The diagnosis is normally con- normal anatomy. There is also firmed on skin biopsy, and SLE is increased risk of malignancy, especial- excluded through history and examina- ly carcinoma of the cervix, and squa- tion and testing for antinuclear anti- mous carcinoma of the genital skin. body (ANA), although this may be Treatment is generally difficult and the positive in low titre with DLE. The con- principles are the same as in infants dition is more common with HIV. DLE (see article on infants, pp.). is resistant to therapy, and the result- ant scarring is permanent. Mild cases are treated with sun avoidance, sun- screens and potent topical steroids: clobetasol (Dermovate, Dovate) or betamethasone dipropionate (Diprosone, Diprolene). More exten- sive cases are treated with low to medium doses of systemic steroids: prednisone, together with chloroquine (remember retinal toxicity). Fig. 4. Dyshidrotic eczema. DYSHIDROTIC ECZEMA Fig. 2. Condylomata acuminata — perianal. This common and potentially severe DYSPLASTIC NAEVI form of dermatitis affects the hands and feet, but can spread. It starts with These are acquired melanocytic naevi DISCOID LUPUS intensely itchy small vesicles on the (moles) that are larger than usual and ERYTHEMATOSUS (DLE) palms and/or soles, and the sides of slightly irregular in shape, border and the fingers or toes (Fig. 4). These colour, with features suggestive of This form of lupus erythematosus is not enlarge, coalesce and rupture to leave melanomas (Fig. 5). They increasingly uncommon, mainly affecting women. red, fissured, scaly and painful areas. appear from the late teens into the In most cases the condition occurs The condition usually occurs intermit- twenties, often with a family history of independently of systemic lupus erythe- tently, but can persist. Dyshidrotic similar moles. Sun exposure probably matosus (SLE), but can occur as part eczema can represent hand and foot plays a major role in converting a of, or progress to, SLE. Typical lesions involvement in atopic dermatitis, when benign melanocytic naevus into a dys- start as itchy, painful, reddish, scaly the usual trigger is a contact irritant plastic naevus. Their natural history is swellings or plaques on sun-exposed such as frequent hand washing, not clear, but some may become areas: the face, lips, chest, upper soaps, detergents and solvents. It can melanomas, hence the importance back and hands. The lesions heal cen- also occur independently and be due attached to these lesions. Some recom- September 2004 Vol.22 No.9 CME 513 YOUNG ADULTS mend elective removal of all suspected lococcal antibiotics like cloxacillin can 250 mg bd. HIV or another cause of dysplastic naevi, but this is seldom also be used. Another type is caused immune suppression results in progres- practical. Regular examination is pru- by a commensal fungus, Malassezia, sion to painful, chronic ulcers. dent, often by means of epilumines- and presents as itchy follicular papules cence microscopy (Molemax machine), and pustules on the upper chest, back to highlight more suspicious lesions, or and arms (Fig. 6). This is best diag- those which are changing: these are nosed on biopsy, and is treated with then excised surgically. antifungal shampoos like ketoconazole (Nizshampoo) or econazole (Pevaryl foaming solution), or with oral antifun- gals like itraconazole (Sporanox). This fungal folliculitis, also known as pity- rosporum folliculitis, can closely resem- Fig. 7. Herpes labialis. ble acne. Another type of folliculitis occurs exclusively in HIV infection, HYPERHIDROSIS and is due to eosinophil infiltration of the vellus hair follicle. This so-called Hyperhidrosis is excessive sweating, eosinophilic folliculitis is exceptionally objectively apparent and which inter- itchy, and untreatable. Fortunately the feres with daily activities, usually on condition usually remits spontaneously. the palms, soles and axillae and trig- Potent topical steroids, antihistamines, gered by heat, stress or anxiety, antifungals and ultraviolet B photother- although there may be no obvious apy may help. All types of folliculitis stimulation. Hyperhidrosis can cause are more common in HIV, and follow- loss of confidence, and depression, ing cancer chemotherapy. and should not be trivialised. A simple but effective treatment of axillary HERPES SIMPLEX hyperhidrosis is aluminium chloride hexahydrate antiperspirant roll-on Fig. 5. Dysplastic naevi. Human herpesviruses 1 and 2 cause (Driclor). Irritation and contact der- the common cold sore (recurrent labial matitis are possible side-effects. An FOLLICULITIS herpes) and genital herpes. Frequent effective and long-lasting alternative is recurrences are a hallmark of the con- Botox injection. Palmoplantar hyper- Folliculitis occurs when small pustules