Your Guide to Common Skin Conditions

Paul Hackbarth, senior content marketing specialist at Phelps Health, talks with Cory Offutt, MD, a Phelps Health family medicine doctor, about common skin conditions on The Scope at Night podcast.

Paul Hackbarth: Welcome to The Scope at Night podcast. I am your host Paul Hackbarth with the Phelps Health Marketing and Public Relations Department. Before we begin tonight, I'd like to introduce tonight's expert, Dr. Cory Offutt. Dr. Offutt is a family medicine physician here at Phelps Health. Welcome to the show.

Dr. Cory Offutt: Thanks for having me.

Paul: Today, we're going to be talking with Dr. Offutt about some common skin conditions, skin lesions and more. Let's go ahead and jump right in. Question number one: what is the purpose of our skin, and why is our skin so important?

Dr. Offutt: The skin is the body’s largest organ. It's our primary first-line defense against pretty much everything. It's the primary insulating aspect of the body, as well. The skin maintains body temperature and protects against other infections and physical barriers of harm. It really has a multifunction approach.

Paul: Moving on to our next question, I've always heard there are different layers of skin. Can you break down these different layers?

Dr. Offutt: So there's the epidermis, which is the top layer, and the initial protective barrier. That's where most of the new skin cells are being made. It [the epidermis] also provides all of your pigment cells. Then there's the dermis, which is the middle layer, where all of your hair follicles are located that grow up through the top of the skin. There's also a lot of connective tissue and collagen in this layer, which predominantly provides all of the structure to your skin. Finally, there's the hypodermis, the fatty layer that's underneath. That [layer] is right before you get to your muscles, bones and other connective tissues: nerves, blood vessels and more. That's [the hypodermis is] predominantly the layer that regulates your body temperature.

Paul: That's very interesting. We only think about the part we see, the epidermis, but there are layers underneath that as well.

Dr. Offutt: Yes, definitely.

Paul: Dr. Offutt, can you tell us how skin conditions are typically diagnosed?

Dr. Offutt: There are so many different types of skin conditions, and it depends if you're talking about individual lesions versus rashes versus any number of things. Usually those [skin conditions] are diagnosed in a clinical setting at a primary care provider's office. Sometimes we can even diagnose them via telemedicine and video visits. This depends on the size of the area we're looking at. Poison ivy [and] hives, [for example,] are pretty easily diagnosed. And then [there are] different rashes. Sometimes we actually have to feel the rash, because it'll have a different texture, or if it's a very fine rash that doesn't really show up well on video, we would have to see it in person. Sometimes you can make a diagnosis off of looking at something and the history alone. But other times, we have to do skin scrapings, biopsies, shave biopsies and more to determine what's going on exactly.

Paul: Understood. So you mentioned being able to diagnose a skin condition over video. I know Phelps Health does offer telehealth visits. Assuming I had a skin condition, could I do a video visit for that, with my provider?

Dr. Offutt: It is possible. It varies by provider and the condition that's going on. Some things are very straightforward and to the point like poison ivy, for instance. Most people that get poison ivy know they can get poison ivy. And so they'll know whenever they have it. Most providers would do a video visit on that [poison ivy]. That way, you don't have to necessarily come into the office in person.

Paul: Great information. Onto question four, what are the different types of skin lesions?

Dr. Offutt: So that's a very open-ended question. There are so many different types, that I couldn't begin to name them all. There are benign lesions, which are non-cancerous; and then also malignant lesions, which are cancerous; and then there's a wide spectrum within each of those. There are benign moles, freckles, you name it. There are solar lentigines, regular lentigines, warts, hives and all sorts of other lesions. And then there are pre-malignant lesions, which are pre-cancerous and likely to turn into cancer, that you want to get addressed before they turn into cancer. Ideally, those things [lesions] are often actinic keratosis, which is super common. [Actinic keratosis is] most common on sun-exposed areas, particularly on the face and the tops of the ears and scalp, if there's not much hair coverage. Also of interest, the left arm is actually more susceptible [to actinic keratosis] than the right arm, due to it being out the car window when driving. There are also cancerous lesions; and basal cell cancers, squamous cell cancers and melanoma, the three most common types of skin cancer. [Of course, there also are] rarer [cancers] that fall in between those.

Paul: That's really interesting. I didn't think about the left arm getting more sun exposure.

Dr. Offutt: [From there,] all of those lesions can be described individually based on what they look like, and if they're raised or not, among other factors.

Paul: You mentioned that some of these skin lesions can be cancerous. That's a great segue into our next question here. What is skin cancer, what causes this disease, and finally, what is melanoma? Sometimes I hear the term melanoma as being synonymous with skin cancer, but is that really the case?

Dr. Offutt: Melanoma is a specific type of skin cancer, and it's probably one of the most aggressive forms of skin cancer. I'll get to that part in a second, but like cancer in general, and this goes for any cancer, not just skin cancer, it is a dysfunction in the body’s ability to take care of abnormal cells. Something most likely went wrong in the hardwiring of those particular cells, and they were able to thrive. Typically, our bodies will basically attack and destroy anything that's abnormal, that's not dividing normally. But those particular cells have developed a mutation of some kind that prevents your body from destroying it. It’s then able to divide over and over and over again, and continue to thrive without your body actually being able to take care of it on its own. It then turns into a larger cancer, [which is] predominantly how all cancers form. Some can be genetic, and some are just spontaneous mutations in the cell machinery that doesn't allow your body to take care of what it's supposed to do. Melanoma is a very specific type of skin cancer. I wouldn't say it's the most common, but it's one of the most aggressive and probably most recognized. [You would notice] very dark black, irregular skin lesions. We'll go over how to tell the difference between the concerning and not-concerning lesions here in just a minute. But melanoma is probably the more invasive form that everybody worries about. [However,] there are other forms [of skin cancer] that are actually even more common.

Paul: Yes, I was going to ask if melanoma was the most common type of skin cancer. Great answers to those questions. Along these lines, with it now being summer, we’re outside more, possibly going to rivers, creeks or beaches. We may start to notice a little discoloration on our skin, be it moles, freckles, sun spots or age spots. Can you tell us the difference between these particular types of skin lesions?

Dr. Offutt: So sun spots and age spots are essentially synonymous. These discolorations are solar lentigines, and they tend to come with age and exposure to sun. [Naturally,] the older you get, the more sun you will have been exposed to. Freckles are something you're born with and are often genetic. Freckles generally will not turn into cancers, but people with more freckles may be at higher risk of developing skin cancers because they tend to be fairer skinned. Moles are usually raised, [whereas] freckles are not. Sun spots and age spots are also generally not raised, and there's an additional lesion I’ll address in a second. But moles are typically raised and can potentially turn into some skin cancers as well. So you do have to keep an eye on them; any moles that are actively changing are ones to be concerned about.

Paul: Okay, that’s good information for sure. We now have a question from Facebook, asking if actinic keratosis can become cancer.

Dr. Offutt: Actinic keratosis are pre-cancerous lesions, so yes. [These lesions] are more common, [and typically found on] the left arm, the tops of the ears, the scalp and areas that have more direct sunlight exposure. The tops of the ears are especially susceptible, as that's [often] the one spot people forget to put sunblock on.

Paul: Thanks, Dr. Offutt. So, how can I tell if a mole is cancerous? What are the signs I should look for? You mentioned a change in its appearance. What else is concerning?

Dr. Offutt: So, we use the A-B-C-D-E acronym when evaluating skin lesions. [To start,] we look for asymmetry in the skin lesion. If you draw a line right in the middle of it, does one side look like the other? You then look at the borders: is there a nice smooth border all the way around, or is it a very irregular, jagged border, or even a very hazy border. You then examine the color. If it’s uniform in color versus variations in color, that matters. Variations in color are usually more concerning. The diameter is also important, and anything greater than six millimeters is usually more of a concern, unless a smaller lesion is actively changing and growing. [Finally, is the lesion evolving?] Furthermore, if the lesion is raised or not plays into what type of lesion it could be.

Paul: So, it’s important to remember your ABCs when it comes to moles. Now that we've discussed skin cancer causes and types, what are ways to prevent skin cancer?

Dr. Offutt: The number one way is just to avoid and reduce sun exposure, and to avoid tanning beds and wear sunscreen. It all comes down to the amount of UV exposure. [Of course,] there are some extenuating circumstances, like genetics, that play a factor as well. [Factors somewhat under our control include] the amount of sunscreen used, the level of sunscreen, the particular [sun protection factor or] SPF, the overall time in the sun and how much damage is acquired from the sun. The more times you are sunburned, the more at risk you are.

Paul: You mentioned SPF. When looking to buy sunscreen, there are several different kinds of SPF and numbers. What numbers should we be looking for?

Dr. Offutt: The higher the SPF, the more protection you will get. If you're a fairer-skinned person with a tendency to sunburn easily, the more sun-exposed areas should get a higher SPF. The areas that don't burn as easily can get a lower SPF. [I suggest] anywhere from 50 to 100 SPF for the more direct areas, and 25 to 50 SPF for areas that don’t get as much sun. [To be safe, a good rule of thumb is to purchase] 50 or higher SPF for everything.

Paul: Okay, that's great information.

Dr. Offutt: You also want to look for a specific ingredient in the sunscreen. Avobenzone, [for example,] will provide even more protection within the sunscreen.

Paul: Let’s say you forget to put on sunscreen, or maybe you didn't put on enough, and you end up with a sunburn…what are some treatment options for people who get a sunburn?

Dr. Offutt: Really, it's just symptomatic treatment, depending on the severity of the sunburn. [It’s very important to] prevent complications from the sunburn. If you're blistering, you can actually become very dehydrated very quickly. Because you have disrupted the skin barrier, you can lose quite a bit of fluid through the skin. [In this case, it’s important to] make sure you stay very well hydrated. Anti-inflammatories, ibuprofen, Aleve and other similar over-the-counter medicines can help alleviate some of the pain, swelling and redness. Make sure you're using moisturizers that contain aloe and are preferably unscented, [so as to] not further irritate the skin. [I also suggest] cool baths and showers, and cold compresses for symptomatic relief. That's really all you can do. If [you are] unable to take oral anti-inflammatories, are on blood thinners or have a history of ulcers, you can also use topical anti-inflammatories, [such as] topical diclofenac. I believe the brand name is Voltaren, and you can purchase it over the counter now as well. This can supplement the more conservative treatments.

Paul: Great information. Now that summer has arrived, we may be having campfires, barbecuing and enjoying fireworks, especially with the Fourth of July around the corner. These activities increase the chances that you may get first-, second- and even third-degree burns. Can you walk us through the different types?

Dr. Offutt: Yes, you can actually get first-, second- and third-degree sunburns as well, along with just regular thermal burns. So first-degree burns are fairly superficial. They may have a little bit of swelling and redness, but no blisters are present. With second-degree burns, blisters may be present with some thickening of the skin and redness. [These burns are] pretty painful. Third-degree burns will generally turn more waxy and white in color, with the skin significantly raised and leathery in texture. Third-degree burns generally don't hurt because you actually damage the nerves, and they don't hurt nearly as much. The surrounding areas, however, may also have second-degree burns that can pose quite a bit of discomfort. [So while third-degree burns] won't be as painful, they do carry a significant risk of infection and dehydration.

Paul: Let’s transition to a different type of common skin condition. I think most people have experienced this, so can you talk about acne, and what causes acne or pimples? I know it goes by several different names.

Dr. Offutt: [Under the umbrella of acne, there are several] different types, and I won't get into all of the kinds, but there are varying treatments for them. [As far as what causes acne,] basically oil glands and hair follicles become clogged, due to buildup of the sebaceous material the skin normally produces and dead skin cells. These glands and follicles then become acutely inflamed, leading to more painful pimples, or comedones, and blackheads. [Unfortunately,] some people are more genetically disposed to acne. Others seem to get it simply by rotten luck; it just varies from person to person.

Paul: Interesting. So, as far as treating acne, what are your recommendations, and how can acne be prevented in the first place?

Dr. Offutt: The number one thing is not to over-treat. If you over-treat, you can actually make your acne worse. So, if you are one of those people who can't stand the acne and are washing your face say, three to four times a day, that's way too much. You will actually end up making the glands in your skin overactive, as they [compensate for] the over-drying of the skin. [That in turn] leads to worsening acne. Another thing that people need to remember is that the skin is multiple layers thick, and everything goes from the bottom up. So any treatment that you do to prevent acne is going to take several weeks before you will notice any difference. This is because lesions that are already there, but not yet visible, still have to make their way to the surface. And so it will seem like the treatment is not working for at a minimum of four weeks, before noticing any improvement. I always make sure and tell my patients, "Don't get discouraged if it's not working; give it time." And most patients have been extremely happy with our management options, because we keep everything fairly conservative with minimal side effects.

Dr. Offutt: But a large variety of over-the-counter treatments and medications [do exist]. Most patients have already tried the over-the-counter stuff by the time they get to me to discuss different medical options. Benzoyl peroxide is usually the most common starting point. You can get those [products] over the counter. [This topical antiseptic] comes in foams, lotions, you name it – all different types of formulations. Usually, that's going to be [applied] one to two times per day. You have to be careful with it, [however,] because it can bleach pillowcases and clothing. Retinoids are also used in topical [treatments], and can be used for mild-to-moderate acne. [It’s also important to] make sure to moisturize if you have dry skin, as too much dryness can cause more lesions from inflammation. [On the other hand, if] you've got really oily skin, you’ll want to make sure you use something drier.

Paul: That makes a lot of sense.

Dr. Offutt: Makeup will also increase your risk of acne. Be sure to remove makeup every day and don't sleep in it.

Paul: Now onto another type of skin condition, eczema. Can you define what eczema is, and what causes it?

Dr. Offutt: So eczema is a specific type of what's called atopic dermatitis. It is essentially an autoimmune, or intrinsic, response, as if your body is attacking the skin. It causes an inflammation of the skin. Usually this is brought on by a scratch that itches. A rash can actually develop from scratching the skin, and become progressively itchier. [If a person] continues to scratch, the rash will continue to get worse. Usually, [we see eczema] on the extensor surfaces. It will be on the flexor surfaces of the arms and legs… so, inside the elbow, on the back side of the knees and also on the hands.

Paul: Good information. How then can eczema be treated?

Dr. Offutt: It depends on the severity and the location [of the eczema]. [For example,] you can't use high-potency steroid creams on the face, as this skin is thinner, and repetitive steroid use can actually thin the skin. There’s only a handful of options that are actually safe for the face, as well as the genitals and the ears, etc. But when you get to the arms, legs and hands, there's a whole slew of options that you can use both topically and orally. There are even biologic medications for eczema. If your eczema is bad enough, you may have to have injections every couple of weeks, every month or every couple of months…it varies by patient.

Paul: That’s interesting, Dr. Offutt. Now, let’s switch gears to psoriasis. Can you explain what psoriasis is, what causes this skin condition and how it can be treated?

Dr. Offutt: Psoriasis is another autoimmune skin condition. You actually develop large plaques that have an-almost silvery texture to the top of them. [These plaques] will be almost white with very red surrounding areas, and will be significantly raised from the skin. Usually, these occur on the extensor surfaces, [which include the] backs of the elbows and the fronts of the knees, but it can be head to toe as well. There are multiple types of psoriasis. Some types only occur on the palms and soles of the feet. Small lesions, no larger than a quarter, are classified as guttate psoriasis. There is also regular plaque psoriasis, where the plaques can be as large as the entire back. And so it just varies from person to person. You actually treat psoriasis similarly to eczema. Topical steroids [are indicated] depending on the person, the body surface area where the plaques are located and the percentage of body coverage. We will [also have to determine if we want to] use systemic or topical medications.

Paul: Another skin condition that people may be interested to hear about is chronic dry skin. What are your recommendations for that?

Dr. Offutt: So chronic dry skin, technically called xerosis, can be caused by any number of things, or it can simply be what it is called, or idiopathic, meaning, we don't have an underlying cause. Being dehydrated in and of itself is probably one of the most common causes of xerosis. We often get so busy in our lives, that we tend to go without drinking like we should. Or most people around here anyway, are more interested in drinking sodas, sweet teas and [other sugary beverages], which are actually dehydrating. There are also underlying health conditions like hypothyroidism and diabetes, [for example,] that can actually make you more dehydrated, as well as medications that dry out your skin and make it very itchy. [When it comes to treatment of dry skin, it’s most important to] treat the underlying conditions, use good moisturizers, make sure you're staying hydrated and utilize symptomatic control for the itching. Ideally, we wouldn't want to use topical steroids for dry skin, because of the side effects [we mentioned earlier], but they can also be combined with topical emollients to hold in moisture, like Aquaphor and Vaseline. [These emollients are important to use] right after bathing.

Paul: That makes sense. Another skin condition we want to cover during this Zoom meeting is rosacea. What is it, what causes it and how is it treated?

Dr. Offutt: So rosacea is very common. It predominantly occurs on the cheeks, but can also extend up to the forehead and onto the nose. You can actually get a sub-component of rosacea called rhinophyma, where the nose actually starts getting bigger and more inflamed. [Thankfully, it is] treatable with topical medications. Other times, it may be necessary to see a facial specialist to have debridement [performed] on the thickened skin. While rosacea flare-ups can last weeks to months at a time, it is very treatable with both topical antibiotics, topical anti-inflammatories and oral medications.

Paul: Good to know. This next question hits closer to home. I was out weeding the other day at our house, when I ran across some poison ivy. I feel like I’m pretty good at identifying it, so I tried to stay away from it, because I do get a bad reaction from it. For those of us allergic to poison ivy, poison oak or poison sumac, who might accidentally come into contact with those plants, what can we do?

Dr. Offutt: You want to thoroughly rinse it off as quickly as you can, ideally within 30 minutes before you start to have a reaction to it. Ideally, you should use cold water to do that, because warm water will actually just increase the histamine response, which then worsens itching and makes things exponentially worse. Once you actually have the lesions, if you've already washed off the oils, and you still develop the rash, that rash isn't going to spread if you scratch it. What’s already there is there. It’s still not good to scratch, [however,] because you can actually cause infection as well. And that's super easy to do whenever you've already developed blisters from the rash itself.

Paul: Advice noted! Under what conditions would you recommend going to see a healthcare provider for poison ivy?

Dr. Offutt: So if you present with [poison ivy on] a large enough surface area on your body, are unable to manage it and it's making you miserable, then definitely see your provider. You can use over-the-counter calamine for symptomatic relief. You can also use hydrocortisone three-to-four times a day, except on the genitals and face. Hydrocortisone can be used in a limited amount on the face and genitals but should be at the recommendation of your medical provider. Topical Benadryl cream will also work, or at least help [alleviate] some of the symptoms. But if you have any poison ivy around your eyes or mouth, you need to see a provider immediately. [Same goes for] any trouble breathing, trouble swallowing and/or eyes swelling shut. I've seen people who were burning brush and [unknowingly] burned poison ivy. It can bind with them, and they don’t even realize it. So, they’ve actually inhaled it. It goes down into their airways, and they were excessively allergic to it. [In this instance,] the patient actually ended up in the hospital with a breathing tube. It can be pretty bad in those kind of situations. Be sure to avoid exposure, [if at all possible,] if you have a history of an allergic poison ivy reaction. And if you should accidently come in contact with it, [be diligent] about rinsing it off as soon as possible.

Paul: That's great advice. Now that we’ve addressed some of the things that can go wrong with our skin, what are some general health tips to keep our skin healthy?

Dr. Offutt: [For starters,] I recommend getting a yearly skin check. Whether you are pale or dark-skinned, having a skin check at your yearly wellness exam is super important. [Unfortunately,] this check is often forgotten at yearly exams. I make it a priority during all of my patients’ visits, [especially] if they have any skin lesions or concerning spots. [It’s crucial to] be more proactive than reactive and [to be diligent] in finding abnormal skin lesions before they become too abnormal. Make sure you're staying well hydrated. And if you get any cuts in your skin, make sure you know about them so you can keep them clean and free from infection. [Finally,] wear sunscreen and do your best to limit UV exposure: these are probably the most important [action items] to [protect] your skin.

Paul: As you said in the beginning, it's our largest organ, so we really do need to take care of it.

Dr. Offutt: Yes, and I also [recommend] taking a multivitamin once a day. It [certainly] doesn't hurt anything and can only help.

Paul: All great advice. Now for our last question. If someone has a skin condition that concerns them, would you recommend they visit their primary healthcare provider? Or do they need to see a dermatologist?

Dr. Offutt: It depends on the provider. Some primary care providers, like myself, are extremely comfortable with dermatology. I have extra training in dermatology through my residency program. We had a dermatology clinic right next to our primary care clinics, so I took [advantage of] training in all dermatology procedures, excluding a few specific to dermatology residencies. Some primary care providers will do minor dermatologic procedures, like biopsies and shave biopsies, whereas others aren't as comfortable with that. They may not have had that specific training while in residency. [In that case,] you may need to see a dermatologist for those minor procedures. In my office, I can even address lipomas and cysts. Every provider is different, so it’s best to first [present] your concerns to your primary care provider. You can send pictures on MyChart of various skin lesions and see if it's something that they would be willing to look at. Or they may refer you to a dermatologist, to a different clinic or be able to address it [right] here at Phelps Health. I have a number of colleagues who send me patients for dermatologic conditions; it just varies by provider.

Paul: Great information, Dr. Offutt. Thanks so much to everyone for tuning into The Scope at Night, and a huge thank you to Dr. Offutt for joining us this evening. We appreciate all of the insight you've been able to share with our community.

Dr. Offutt: Thanks for having me.

Paul: This show can also be re-watched on our Facebook page and shared with any family and friends who may have missed the show. If you enjoyed this show and would like to know more, check out our other episodes of The Scope on YouTube or visit phelpshealth.org.