Epidermal Inclusion Cysts


Photo credit: http://en.wikipedia.org/wiki/Sebaceous_cyst

Patients will often come into the urgent care with a small skin lump that has become red and/or painful.  Often if they think back, they might recall feeling a small nodule under the skin in that same area perhaps months or years before it became swollen and red.  The epidermal inclusion cyst is one of the most common skin cysts and can occur anywhere on the body but they are more common on the face or upper body. Most of the time, these cysts do not cause any problems, but can sometimes be cosmetically unpleasing.

Other names for epidermal cysts:

1)   Epidermoid cyst

2)   Sebaceous cyst

3)   Keratin cyst

4)   Epidermal inclusion cyst

5)   Infundibular cyst

Appearance:  Epidermal cysts have a cyst wall that is make of skin cells of the outside layer of the skin called the epidermis.  The cyst wall is like a balloon that goes down into the second layer of skin called the dermis.  The cyst wall/balloon makes a protein found in the skin/nails called keratin that is usually white, cheesy or firm in consistency.   It is often foul smelling as well.

Cyst Rupture:  If the cyst wall ruptures underneath the skin (usually due to trauma or bumping the area unintentionally), the keratin (cheesy white material) comes out and is exposed to the surrounding tissues and is very irritating.  It can make the skin become red, swollen and painful.  It’s best to see your doctor instead of trying to “pop” or drain the cyst yourself.  Sometimes your doctor may recommend treating you with an oral antibiotic before opening the cyst if he/she thinks that the cyst has become infected.

How epidermal cysts are removed:  If the cyst needs to be removed, your doctor will try to remove the entire cyst including the cyst wall.  Remember, the cyst wall is what makes the keratin (that cheesy white material inside the cyst).   If the cyst wall is allowed to remain underneath the surface of your skin, it may start making more keratin which can cause the cyst to come back.

Usually we make an incision over the cyst and separate the underlying skin from the cyst wall and try to remove it in one piece.  If the cyst has ruptured (which is most likely brought the patient in), the cyst is removed in a piecemeal fashion with an attempt to get all of the keratin, and cyst wall out.  The doctor may irrigate the  wound with sterile solution after the procedure.  The skin is usually left open and not stitched.  The doctor may place a small piece of packing gauze under the skin where the cyst was and then put a bandage over it.  This will allow the wound to drain while it’s healing.  The wound is usually examined by a medical provider every 2-3 days to check on the healing process and part or all of the packing gauze will usually be removed.

The reason that your medical provider may put some sterile gauze inside the wound and ask you to come back to be reexamined instead of just putting some stitches over the wound is because sometimes these areas can be infected with bacteria and if the skin is closed right away with sutures, the bacteria will have a small pocket under the skin to grow and form an abscess.  If the wound is allowed to heal from the inside out, there is less chance of an abscess forming and wound healing can happen more quickly.

When to have a cyst removed:  If it’s small and doesn’t hurt and isn’t painful/red/swollen, it probably doesn’t need to be removed.  I might recommend removing a cyst if:

1)   It keeps getting red and irritated or infected

2)   It’s getting larger quickly

3)   It’s in a place that rubs against your clothes or jewelry and gets irritated

4)   If it becomes red, inflamed or painful

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com


Seborrheic Dermatitis – Dandruff, Cradle Cap and Adult Seborrhea










Photo credit: http://hardinmd.lib.uiowa.edu/dermnet/seborrheicdermatitis22.html

Photo credit:  http://siklusair.com/seborrheic-dermatitis-eyes

Photo credit:  http://medicalcontent.hubpages.com/hub/Seborrheic-Dermatitis-Pictures-on-Face-Scalp-Hair-loss-Causes-Treatment


Seborrheic dermatitis is a common skin condition that occurs in infants and adults and can cause redness, greasy scales, skin flaking along the eyebrows and itching.  It is one of the most common skin conditions that I see as an urgent care physician.

Seborrheic dermatitis (also called seborrhea) is an inflammation of the skin that usually occurs in areas that have an abundance of oil glands such as on the scalp, face, around the eyes, ears, neck, and even the diaper area.  In men, it’s more common in areas where there is hair on the face.  Infants often have seborrhea on their scalp that is known as cradle cap.  A mild form of seborrhea is known as dandruff and that is when it is confined to the scalp in children or adults.  Some symptoms may be:

1)   Skin scales – white or yellow and usually oily/greasy

2)   Itching

3)   Mild redness

4)   Skin lesions or plaques

The exact cause of seborrheic dermatitis is unknown but there is some evidence that it seems to flair up in times of stress, hormonal changes or during particular seasons (ie. During extreme cold or warm weather).  It is more common in those people with weakened immune systems, in people who have oily skin, or certain neurological conditions such as Parkinson’s Disease.

Diagnosis:  Your healthcare provider is usually able to diagnose seborrheic dermatitis by examining you and taking a history.  A biopsy (sample of skin that is surgically removed and sent to a doctor to examine under a microscope) is rarely needed.

Treatment:  Usually tailored toward the individual patient and what part of the body is affected.  Some possible treatments include:

1)   Medicated shampoos such as Neutrogena T-Gel or T-Sal, Head and Shoulders or Nizoral are commonly prescribed.   These shampoos usually contain Salicylic acid, Coal Tar, Zinc, Selenium Sulfide, Ketoconazole, or Resorcin.  Even if you do not have dandruff, these shampoos may be used on the face and/or other body areas and usually work best if they are left in place for 5-10 minutes before rinsing.

2)   Topical Steroid creams, lotions, foams or shampoos:  Low, medium or even high potency steroid creams are sometimes prescribed to help decrease the inflammation depending on the severity and where the rash is. Usually the lower potency creams are used on the face (such as Desonide 0.05% lotion).

3)   Antibacterial creams:  Sometimes topical antibacterials such as Sodium Sulfacetamide with sulfur are prescribed.

4)   Antifungal creams:  Ketoconazle 2% cream, and Ciclopirox 1% creams are commonly used.

5)   Other anti-inflammatory medications such as pimecrolimus cream or tacrolimus ointment are sometimes prescribed for use on facial seborrhea.

6)   Dermatologists sometimes recommend a compound or mixture of a combination of a steroid cream along with an anti-fungal or antibacterial agent.

Cure:  Unfortunately there is no cure for seborrheic dermatitis. It is a chronic life-long condition. It may go away for months or years and then return (relapse).  We usually focus on controlling seborrhea often by using a combination of the strategies for treatment listed above along with decreasing known triggers such as emotional stress, extreme cold temperatures and decreasing body weight.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

What is a Pressure Ulcer (AKA Pressure sore)?

shutterstock_89421025bed-soresPhoto credit:  http://diseasespictures.com/bedsores/

A patient came in to see me today with a sore on his heel that’s been bothering him for the past few months.  He’s diabetic and has lost feeling in the bottom of his feet.  He’s had these pressure sores in the past but has trouble getting them to heal up.

Pressure sore:  Areas of skin that have been damaged by pressure such as sitting or lying in one position for a very long period of time.  They can also be called “bedsores.”  The are more commonly found in areas of the body where the bone is near the surface of the skin such as on the hips, elbows, ankles and back/buttocks. The skin and soft tissues become damaged because not enough oxygenated blood can get to the area to promote healing usually due to the compression of the damaged skin and soft against hard bone tissue.

Appearance:  The sores change in the way they look depending on how long they’ve been present and how much damage has been done.  In the beginning, the sore appears as a small red patch of skin, and if not treated, the skin will break down and cause a hole or crater to form (we call this an ulcer).

Stage 1:  The skin is intact without ulcers but when you push on the skin it does not change colors to indicate good blood flow.  Usually, healthy tissue will be pink and when you push on the area with your finger you can notice it will become less pink and in a couple seconds the pinkness will return.  This does not happen in the damaged skin at this stage – it may have a darkly pigmented color.

Stage 2:  There is an open, shallow ulcer with a red-pink color at the base of the wound.  Sometimes there may be blisters present which are either intact or ruptured.

Stage 3:  Structures beneath the skin such as fat may be exposed but at this stage, you should not see bone, tendons or muscle tissue.

Stage 4:  Structures beneath this skin including bone, tendon and muscle may be seen in the bottom part of the ulcer

People at Risk:  Some patients are more at risk than others of getting pressure sores.

1)   Patients who cannot move very well because they have a medical problem.  These people may sit or lay in one position for a long time.  They need help to move to a different position so that the skin doesn’t form sores.

2)   Older people are more prone to pressure sores because they often don’t move around as much and their skin is more fragile and thinner than a younger person.

3)   Patients who have diabetes or nerve problems in their feet may not feel when a small pebble or area gets into their shoe or pressure pushes on the foot causing injury.

4)   Patients in the hospital or nursing home are at especially high risk for many of the factors noted above – increased age, decreased mobility, and other complicated medical problems.

Prevention:  Some things can be done to lower the chances of getting pressure sores

1)   Repositioning the patient’s body every two hours so that they are not lying on one area where the skin is being crushed, pinched or pressure is building

2)   Putting pillows between the ankles and knees to decrease the pressure on the skin over these boney areas

3)   Raising the head of the bed when the patient is lying on their side to decrease the pressure on the hip bone

4)   Getting special foam or soft mattresses that decrease the pressure on the areas of the body that have the most pressure on them

For patients in wheelchairs:

1)   Use a special cushioned seat if possible to prevent pressure on the sacrum

2)   Every hour tilt forward or to the side to release pressure on the seat

3)   If ankles or heels press on the chair, use foam padding to protect against sores

4)   Check skin regularly for signs of pressure or ulcers

Treatment:  Pressure sores are treated differently depending on the stage of ulceration and how severe the damage to the skin is.

1)   If there is mild erythema, the treatment is generally off-loading the area but decreasing the amount of time that this area is compressed by body re-positioning, and/or using pillows to cushion the area.  We also use transparent films over the ulcers to protect the areas.

2)   In patients who have diabetes, adequately managing blood sugars to keep them under good control is very important.  Elevated blood sugars impede wound healing.

3)   If there is dead or dying skin or soft tissues, this often needs to be removed to help prevent infection.

4)   Special bandages may be needed to keep the healing tissue moist but prevent tissue maceration (from being too moist). Sometimes the dressings that we use to treat wounds can be very expensive.

5)   Antibiotics may be prescribed if there is a wound infection

6)   Medication for pain may also be prescribed

There are some tools to score the pressure and grade the healing process.  These are helpful for patients who come back for repeat visits to wound care clinic or their primary care provider and there is a need to grade the healing by giving them a score.  Some clinical features that are examined include:

1)   Amount of Exudate

2)   Skin color surrounding the wound

3)   Peripheral tissue swelling

4)   Peripheral tissue firmness around the wound

5)   Amount of granulation (healing) tissue

6)   How much epithilization is present

It’s important to optimize the nutritional status of patients with wounds.  Particularly for patients who have Stage 3 and 4 ulcers, they need enough protein and calories to help heal these wounds.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

What do I do about my acne?

shutterstock_124292974shutterstock_153263516During the first week of my third year medical school dermatology rotation I thought I’d definitely decided that I wanted to become a dermatologist.  I’d been present in the room with my dermatology preceptor and patients who asked about what to do for their acne at least a hundred times, and I knew I could give the same speech as my dermatology teacher.  I later changed my mind about becoming a dermatologist but I still have a great interest in dermatology.  Most people who come into the medical clinic due to problems with acne have tried various over the counter treatments to help with common black heads, white heads or deep cysts from acne.  It’s a common problem for adolescents (85% are effected) and teenagers but also effects many adults as well.  Untreated acne can lead to embarrassment, loneliness and even permanent facial scarring.

So what is acne?  Acne is a skin problem where the openings in the skin where hairs come out (pores) become blocked by skin cells and oil and this creates a plug.  During adolescence the glands that produce oil in the skin enlarge and produce increased amounts of the oily substance we call sebum.  These oil glands are most often found on the face (most commonly an area called the T-Zone of the face – around the eyebrows and nose), neck, chest, upper back and arms.  Even normally, there are bacteria which are present on the surface of the skin and normally they don’t cause any problems in small numbers.  With an increased production of oil on the surface of the skin that occurs during adolescence however, these bacteria reproduce and become present on the surface of the skin in much higher numbers than normal.  The bacteria then combine with the oil and skin cells and become trapped in the pores (hair follicles) and lead to the formation of tender “pimples” that we call acne.

A special type of acne that affects newborn babies is called neonatal acne and usually goes away within a few weeks after birth.  It is related to the hormones from pregnancy and causes small pimples often noticeable on a newborn babies face

There are multiple types or ways we describe acne and grade the severity

1)      Non-inflammatory acne is acne without redness or skin swelling and usually is described as just being whiteheads or blackheads.

2)     Inflammatory acne has redness and swelling and is more severe.  There can be papules, pustules, nodules or cysts present.

Causes of acne:

1)      Sebaceous (oil) glands become more sensitive to hormones during adolescence and become enlarged and produce more oil than normal which increased the likelihood of acne.

2)     Cosmetics that contain oil may clog pores in a similar way to the oil secreted by the sebaceous glands in the skin and can lead to acne.

3)     Frequent or aggressive rubbing with soaps or cleansers can actually increase the production of oil from the skin.  Wash your skin gently.

4)     Some people believe that diet can affect acne.  If you find that you develop worsening oily skin or acne after eating certain foods, avoid these foods if possible.

5)     Psychological stress can increase or worsen acne.

Acne Treatment:  Since there are multiple causes of acne, there is not once simple treatment that works for everyone.  Skin doctors (dermatologists) usually recommend a combination of treatments to reduce acne formation in multiple ways.  Some simple suggestions are outlined below but keep in mind that they may not work for everyone.

1)      Wash your face with a gentle non-soap skin cleanser.  Most of the dermatologists that I’ve trained with have recommended a fragrance free cleanser such as Cetaphil or Dove.  They usually recommend using warm water and washing gently with your hands rather than using a washcloth, skin brush or skin scrubber.  Some of the prescription skin cleansers contain an antibiotic or sulfa base that helps soak up the oil and decrease the bacterial count on the surface of the skin.  In general we don’t recommend washing your face more than twice a day unless you have been sweating excessively or you need to wash off sunscreen.

2)     Most dermatologists don’t recommend picking or squeezing pimples yourself because you might risk causing scars or worsening the infection.  Hearing this however always makes me laugh (usually not out loud in front of the dermatologist though) because they often help patients to pick and squeeze their pimples in a fashion similar to what I think most people would probably do themselves at home.  The difference however is that in the office, they have access to special instruments and tools to help reduce the risk of scarring.

3)     Cautious use of skin moisturizers is recommended.  Remember, your skin is producing oil in abundance and that is a natural skin moisturizer.  If you use too much moisturizer you could worsen the acne by causing plugging of the pores/hair follicles.  If you use a skin moisturizer to help minimize dryness or peeling in certain areas, be sure it’s hypoallergenic or “non-comedogenic” formula to decrease the chance of blocking the skin pores.

4)     Sun screen:  Many of the antibiotics and even topical medications prescribed by medical professionals can increase your chances of getting a sun burn.  Use a sunscreen with at least an SPF of 15 and make sure the sunscreen blocks both UVA and UVB.

5)     Over the counter products:  There is a huge market for acne medications.  Television ads, various articles on the internet and in magazines tout the latest non-prescription skin formula.  Most of these “formulas” that I’ve encountered contain benzoyl peroxide, salicylic acid or a combination of these two ingredients and put their own brand names on them.  I recommend reading the ingredients to determine if the formula you are about to purchase is similar to one you might have already tried.  Benzyl peroxide is an agent that dries the skin and helps decrease the amount of oil.  It is usually applied twice a day.  You should be aware that it can irritate the skin and possibly cause skin redness or flaking.  It can also bleach your pillow case or clothes so be careful not to get it on your favorite items.   If you find that the over the counter product that you try is not working, contact a healthcare provider.  Untreated or inadequately treated acne can lead to permanent scarring of your skin.

Prescription treatments:  Prescriptions for acne can be divided into topical (applied directly to the skin) and non-topical treatments.

A)     Topicals: 

  1. Prescription skin cleansers are topical washes that often contain an antibiotic or drying agent.  They are made to be hypoallergenic and usually do not have a fragrant odor to them.  Examples of a topic skin cleaner include a sulfacetamide/sulfur topical wash.  Multiple companies produce their own brands such as Klaron,  Plexion, Rosanil or Rosula.  These are usually expensive and insurance companies often do not cover them.
  2. Benzoyl peroxide mixed with topical antibiotics: Various pharmaceutical companies make combined products that include benzoyl peroxide with various topical antibiotics such as clindamycin, erythromycin or metronidazole.  Examples are Acanya, BenzaClin, Benzamycin, or Duac.  These topical can be solutions, gels or creams.
  3. Topical antibiotic only:  Many topical antibiotics are produced to help reduce the bacterial count on the skin.  Most of them contain Erythromycin, Clindamycin, Sulfacetamide,  Metronidazole or Dapsone.  Examples are Aczone, Clenia, Cleocin T, Clindagel, Klaron, Metrocream, and Sulfacet-R.
  4. Retinoids:  These medications often produce skin drying and can cause irritation.  Examples are Retin-A, Differin and Tazorac.  Differin tends be less potent and Tazorac is the strongest of the three.  The first time I tried using Retin-A, I woke up with red, irritated, scaly skin that looked worse than the acne.   I recommend starting with a small amount and trying on a small patch of skin first to see how your skin reacts to it.

B)     Oral antibiotics:  The reasons for using an oral antibiotic to treat acne are actually two-fold.  The first reason is that some oral antibiotics have been found to have anti-inflammatory properties in the skin and decrease the inflammatory response leading to the pimples.  The other reason is more straight-forward – to reduce the bacterial count on the skin and thereby decrease the acne.  The most commonly prescribed oral antibiotics for acne at this time are Minocycline or Doxycycline but they should not be used during pregnancy or in young children.

C)     Oral Isotretinoin (previously called Accutane):  It’s also called Amnesteem, Claravis and Sotret.  This medication is most often limited to be prescribed only by dermatologists are physicians who have had special training about this medication.  This is one of the most successful medications that we have for the treatment of severe acne and is usually taken as a pill once or twice a day for 20 weeks.   The reason it is not the first line of treatment for acne and mostly prescribed by dermatologists is because there are some possible serious side effects that can occur when using this medication.  Isotretinoin can cause miscarriage or life-threatening malformations to babies so it cannot be taken by women who are pregnant or at risk of becoming pregnant.  Most dermatologists require women of child bearing age to use  birth control before they will prescribe this medication.  There are strict rules for using the medication regulated by the iPLEDGE program:

1)      Women have to have two documented negative pregnancy tests before starting the medication and continue to take monthly pregnancy tests throughout their treatment.

2)     Any women who might become sexually active (or is already sexually active) with a male partner must use two forms of birth control for at least one month before starting therapy and continue until one month after stopping the medication.

3)     Women of child bearing age who could become pregnant must get their prescription filled at the pharmacy within 7 days of receiving it from their doctor.  Each month a new prescription must be written by their doctor.

4)     Women who cannot become pregnant or men must participate in iPLEGE but do not have to do the pregnancy testing or use birth control.

Side effects of oral Isotretinoin:  I’ve seen many patients who are treated with this medication and I’ve noticed that it works very well for their acne in most cases.  Some of the common side effects that I’ve observed are:

1)      Cracking or sore lips and dry or peeling skin.  Patients may get nosebleeds very easily and have a tough time wearing contact lenses because their eyes dry out.  They may have itchy skin (because of the dryness).  Skin sensitivity to the sun is increased and risk of sunburn is severe.

2)     There can be an increased level of triglycerides (fat) in the blood, it can cause liver damage and cause changes in blood counts when taking this medication so monitoring the blood cholesterol and triglyceride level as well as liver function and blood count is important.

3)     There has been some talk about an increased risk for depression or suicidal behavior when taking this medication but there is not enough evidence to conclude that this is a risk.

Hormone treatment options:  Women with acne are sometimes prescribed a birth control pill to help control acne.  Some hormones and IUDs and injectable hormones however can actually worsen acne, so make sure to talk to your doctor about which birth control might be better for acne if you are considering this form of treatment.

A blood pressure medication called spironolactone has also been used to help with acne because it can effect  hormone levels in women (and thereby decrease acne) but it can also cause an increase in the blood potassium and birth defects so it is usually cautiously.

Where to get more information:

1)      American Academy of Dermatology:  http://www.aad.org/skin-conditions/dermatology-a-to-z/acne

2)     National Library of Medicine:  www.nlm.nih.gov/medlineplus/acne.html


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com


1)      Haider A, Shaw JC. Treatment of acne vulgaris. JAMA 2004; 292:726

2)     Ozolins M, Eady EA, Avery AJ, et al. Comparison of five antimicrobial regimens for treatment of mild to moderate inflammatory facial acne vulgaris in the community: randomized controlled trial. Lancet 2004; 364:2188

All about Psoriasis

shutterstock_45868720shutterstock_45922807A few times each week a patient will come in to see me due to a rash of unknown cause.  The rash is usually an inflamed, red skin and sometimes it’s a bit thickened and/or covered with a silvery scale.  Since psoriasis often develops in adults, many people are puzzled when they come in and learn they have psoriasis and have lots of questions about the condition.  I’d try to answer some of the most common questions that patients ask me about psoriasis.

What causes psoriasis?  We’re not exactly sure about the cause, but we do know that it seems to have a genetic link (it often runs in families), it involves the immune system and environmental conditions seem to trigger it.  The skin actually is made up of several layers and the top layer of your skin is in a state of shedding old skin cells as new skins cells are produced.  This process keeps the top layer of skin relatively smooth.  Psoriasis is a process in which the outter layer of skin cells grow too quickly and they stop shedding properly.  This leads to a scaly build-up of skin cells that we see on the skin in affected patients.  We believe that the immune system causes certain cells to enter the skin and cause the disorder.

About 40% of patients with psoriasis have family members who also have the condition.

We know that smoking appears to increase the risk of psoriasis.  Certain medications can worsen psoriasis symptoms including beta blockers (used for blood pressure), lithium, and medications that we commonly use to treat malaria.  Stress and anxiety may trigger psoriasis to become noticeable in people who have the genetic risk.  It has also been linked with obesity and increased risk for heart disease.

What are the symptoms of psoriasis?  How do I know if I have it?  A medical provider may determine if you have psoriasis usually by examining your skin.  There is not a blood test that can tell you if you have psoriasis but a doctor may due a biopsy of your skin if it is not clear what is causing your rash.  There are several symptoms of psoriasis including:

1)      Patches of skin more common on certain areas of the body such as the elbows, knees, scalp, genitals, and belly button that may be dry or red and have a white or silver scale.  If you peel the scale off, the skin will likely bleed.

2)     Sometimes people with psoriasis develop a form of arthritis that causes joint pain or aching

3)     At times patients with psoriasis can develop finger or toenail pitting, or crumbling

What can I do about my psoriasis?  Is there a cure?  Unfortunately there is not a complete cure for psoriasis but there are treatment options that can substantially improve the symptoms.  Patients who have severe psoriasis that is highly noticeable to other people may feel embarrassed or feel low self-esteem or anxiety due to the disorder.  The treatment offered to a patient will depend on the severity of the symptoms, the area of the body affected as well as the cost and convenience of treatment and other medical conditions that the patient may have.  Severe psoriasis is usually always treated by a dermatologist (skin specialist) and patients with psoriatic arthritis may be treated by a rheumatologist (joint specialist).  Treatments are organized by whether they are topically applied to the skin or are taken orally or given in an injectable form.

Topical medications:

1)      Moisturizers:  It is very important to keep the skin moist so that the itching and irritation caused by the psoriasis is minimized.  Decreasing the itching and irritation helps to decrease the risk of scarring.  Patients who are constantly scratching their skin may cause increased inflammation and risk damaging their skin and cause thickening and increase the risk for infection.  Greasy ointments or thick creams work better than lotions.

2)     Steroid creams or ointments:  work to decrease the inflammation and redness of the skin.  The most potent creams or ointments work the best for psoriasis but require a prescription.  Sometimes solutions are easier to apply when patients has psoriasis of the scalp.

3)     Tar:  Comes from coal and has been used to treat psoriasis for years.  It is commonly found in shampoos such as Neutrogena T-Gel.  It seems to help decrease the amount of cells produced in the epidermis that actually causes the psoriasis.  Preparations containing tar are non-prescription and over the counter and may be in the form of lotions, creams, oils or shampoos.  They can stain the skin, hair and clothing but are not thought to have any serious side effects.

4)     Ultraviolet Light:  Patients often find that their psoriasis is better in the summer time with exposure to the sun’s ultraviolet light.  Other people actually treat their psoriasis in sun tanning beds if their condition is severe.  The risk of causing skin cancer must be weighed against the effects of psoriasis.

5)     Calcipotriene (Dovonex):  This is a cream that is applied twice a day and slows the growth of the epidermal skin cells.  Another medication called calcitriol (Vectical) is similar to Dovonex and Taclonex is a medication that has calcipotriene and betamethasone (a steroid cream) combined together.

6)     Tazarotene (Tazorac):  This is a vitamin A derivative that is a cream or gel and is applied once a day.  It can cause skin irritation so sometimes it is washed off after 20 minutes.  This medication is similar to Retin-A and Differin.

7)     Calcineurin inhibitors (Protopic and Elidel): are creams that are often used on the face or in skin fold areas where scarring or disfigurement may occur if high potency steroids are used.

Medications that suppress the immune system:  Several medications target the immune system such as Enbrel, Amevive, Remicade, Humira and Stelara.  These are usually reserved for severe forms of psoriasis because they are very expensive and are injections that are either given into the skin or muscle or into a vein over hours in the doctor’s office.  Methotrexate and cyclosporine also suppress the immune system and can increase the risk of the patient developing an infection.

Soriatane is an oral medication that is derived from vitamin A and is called a retinoid.  It may help reduce the symptoms of psoriasis in 3-6 months but should generally not be used in women of child-bearing age as it can cause severe birth defects.

For additional information, feel free to check out the following sites:

1)      Psoriaisis.net:  http://www.skincarephysicians.com/psoriasisnet/whatis.html

2)     National Psoriasis Foundation:  www.psoriasis.org/home/

3)     American Academy of Dermatology:  www.aad.org/skin-conditions/dermatology-a-to-z/psoriasis

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com


1)      Schon, M, Boehncke, W-H Psoriasis. New England Journal of Medicine 2005; 352:1899

2)     Lebwohl M. Psoriasis. Lancet 2003; 361:1197

3)     Strober BE, Siu K, Menon K. Conventional systemic agents for psoriasis. A systematic review. J Rheumatol 2006; 33:1442.

What to do about the common skin wart


shutterstock_115521190shutterstock_148362410I often have people come into the clinic and ask me to treat warts, mostly on their hands or their feet.  Some people aren’t aware of what these are so I thought a brief discussion might help people identify warts and also mention some common treatments.

Common skin warts are generally non-dangerous raised and round or oval shaped skin growths that often stick up compared to the surrounding skin.  If they’ve been present for months or years, they can sometimes become rather large or form patches that appear like a cauliflower shaped lesion.  Sometimes they are identified by tiny black spots or dots that are small, clotted blood vessels but some people call them “seeds.”

What causes a wart?  Warts are actually the result of a virus (human papillomavirus) and is spread by touching someone else’s skin who has a wart.  They’re also often spread by picking at existing warts and touching other areas on your own body.  The virus lives in skin surrounding the wart and can be spread easily by scratching are removing some of the virus under your finger nails.  Warts can also be spread by coming into contact with skin cells that have fallen off an infected persons foot.  It can actually take up to six months after exposure to the virus for a wart to appear.

What are the most common areas where warts occur on the body?  The most common areas of the body for warts are:

1)     Fingers

2)     Hands

3)     Knees

4)     Elbows

5)     Around the fingernails (periungual warts)

6)     Feet (plantar warts)

7)     Face

8)     Lower legs

How do I know if I have a wart or if the skin lesion is due to something else?  Usually a medical provider can diagnose a wart based on how it looks.  A biopsy is not usually required.

Once I know that I have a wart, how do I get rid of it?  Warts can be very difficult to treat and there are many different options for treating warts.  The treatment of choice often depends on where there wart is located and how sensitive the skin is.  Some possible treatment options are:

1)      Leave it alone – about 67% of all warts will go away within two years even if not treated.  Most people treat then however because they can spread or become larger over time.

2)     Liquid nitrogen:  In the doctor’s office, we usually use this very cold liquid to freeze the skin around the wart.  It can be painful so it can be a difficult treatment for young children to tolerate.  We often need to treat a wart several times using liquid nitrogen and if the wart is large, we may need to trim the top part of the wart off to make the treatment more effective.

3)     Salicylic acid:  Over the counter patches employ this kind of treatment.  Usually a liquid or patch is applied to wart and left in place for several days.  It is often helpful to soak the skin in warm water for 10-20 minutes before applying the acid to soften the skin.  Treatment with salicylic acid can be painful and cause redness to the skin and even bleeding.  Many people find that using a nail file or pumice stone is helpful to gently remove the dead skin from the surface of the wart every few days during the treatment.  You should be cautious when doing this however because there is a high risk of spreading the virus/warts to other areas on the body when using a file or stone.  I usually recommend using a new file or stone each time to help prevent spreading the wart virus.  Most people don’t realize that you need to keep applying the acid each day for 1-2 weeks even after the wart is gone because the virus can be present on the skin even if no wart is visible.  This helps ensure that the wart does not return weeks or months later.

4)     Duct tape:  The sticky tape easily found in most home improvement stores has been helpful to some people with warts.  They apply it directly to the skin over the wart and leave it in place for about a week.  It’s not entirely clear how the treatment works, but my thought is that the tap sticks to the surface of the skin where the wart is present and the tape on the skin causes moisture to build up and this makes it easier to remove the dead skin cells (containing the wart virus) when the tape is removed.  Many people use an emery board or pumice stone to remove the excess skin after removing the tape and then reapply the tape for another week.  It may take up to 4 weeks for the wart to go away using this treatment.  We usually don’t recommend using duct tape if you have diabetes because if you cover your skin and a bacterial infection begins, you might not be able to see it starting and an infection may get very large before it is noticed.

5)     Cantharidin:  This is a liquid that is prescribed by healthcare providers such as a dermatologist and applied directly to the wart on the skin.  It may cause a blister to appear over the wart after 2-24 hours of treatment.  It is usually just placed on the skin once and often dermatologists will recommend using salicylic acid for a week after the skin heals to decrease the chances of the wart coming back.

6)     Imiquimod:  Aldera is the other name for this prescription cream that is applied at bed time several times per week.  It works by stimulating the immune system to fight off the wart virus.  It is rather expensive and is usually prescribed for genital warts or another type of virus called condyloma acuminate.  It can also be used to treat small skin basal cell skin cancers or pre-cancers.

7)     5-Fluorouracil:  This cream which also goes by the name Carac, Efudex or Fluroplex is applied to flat warts twice a day for 3-5 weeks.  We also use this cream to treat small skin pre-cancers and superficial basal cell cancers.  It can cause skin irritation especially for those people who get lots of sun exposure.

8)     Shave excision:  This is a procedure where the skin is cut away or removed where the wart is present on the body.  This procedure is not very common for treating warts because it can cause permanent skin scarring or keloid formation and may also require stiches after the procedure.

9)     Immunotherapy:  A dermatologist (skin doctor) may inject a medication directly into the wart that triggers the body’s natural immune system to attack the virus.  These medications called contact sensitizers are not widely used because they are highly potent, expensive and require careful handling to avoid causing unintentional allergic reactions.

Should I see a doctor to treat my wart?  I’d recommend seeking the help of a medical provider if you are not sure that the skin growth is a wart, if it’s not improving with home treatment, if you have questions about what treatment is best for you or if you have been treated for warts before and have developed a complication such as a skin infection or scar.

Where can I get more information?  The following sources may be helpful:

1)      American Academy of Dermatology:  www.aad.org/skin-conditions/dermatology-a-to-z/warts

2)     Medline Plus:  www.nlm.nih.gov/medlineplus/ency/article/000885.htm


1)     Gibbs S, Harvey I. Topical treatments for cutaneous warts.  Cochrane Database Syst Rev 2006

2)     Moed L, Shwayder TA, Chang MW. Cantharidin revisted: a blistering defense of an ancient medicine. Arch Dermatol 2001; 137:1357

3)     Muzio G, Massone C, Rebora A. Treatment of non-genital warts with topical imiquimod 5% cream. Eur J Dermatol 2002; 12:347

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

A comparison of topical steroid medications

shutterstock_47533036Many patients come into the clinic and are confused about steroid creams, ointments, lotions, sprays, foams, and gels.  They come in many different forms and vary in their degree of potency.  They are generally grouped into classes according to their strength.  The medical provider’s choice in prescribing  a particular topical steroid medication depends on many factors including the medical condition (ie. eczema, psoriasis, bee sting, allergic reaction, etc.) the location of the body that is being treated and of course the patient’s ability to afford the prescription.

There are some potentially harmful consequences that can occur if a steroid cream is used inappropriately.  For example, applying a high potency steroid cream to an area of the body such as the face or groin can cause permanent thinning of the skin.

Here is a list of the different classes or categories that topical steroids are grouped into:

Class 1:  Superpotent

Class 2:  Potent

Class 3:  Upper Mid-Strength

Class 4:  Mid-Strength

Class 5:  Lower Mid-Strength

Class 6:  Mild

Class 7:  Least Potent

Over the counter topical steroids are generally in the class 7 or least potent category.

Some examples of topical steroids and their respective classes include:

CLASS 1—Superpotent
Clobex Lotion/Spray/Shampoo, 0.05% Clobetasol propionate
Cormax Cream/Solution, 0.05% Clobetasol propionate
Diprolene Ointment, 0.05% Betamethasone dipropionate
Olux E Foam, 0.05% Clobetasol propionate
Olux Foam, 0.05% Clobetasol propionate
Temovate Cream/Ointment/Solution, 0.05% Clobetasol propionate
Ultravate Cream/Ointment, 0.05% Halobetasol propionate
Vanos Cream, 0.1% Fluocinonide
Psorcon Ointment, 0.05% Diflorasone diacetate
Psorcon E Ointment, 0.05% Diflorasone diacetate
CLASS 2—Potent
Diprolene Cream AF, 0.05% Betamethasone dipropionate
Elocon Ointment, 0.1% Mometasone furoate
Florone Ointment, 0.05% Diflorasone diacetate
Halog Ointment/Cream, 0.1% Halcinonide
Lidex Cream/Gel/Ointment, 0.05% Fluocinonide
Psorcon Cream, 0.05% Diflorasone diacetate
Topicort Cream/Ointment, 0.25% Desoximetasone
Topicort Gel, 0.05% Desoximetasone
CLASS 3—Upper Mid-Strength
Cutivate Ointment, 0.005% Fluticasone propionate
Lidex-E Cream, 0.05% Fluocinonide
Luxiq Foam, 0.12% Betamethasone valerate
Topicort LP Cream, 0.05% Desoximetasone
CLASS 4—Mid-Strength
Cordran Ointment, 0.05% Flurandrenolide
Elocon Cream, 0.1% Mometasone furoate
Kenalog Cream/Spray, 0.1% Triamcinolone acetonide
Synalar Ointment, 0.03% Fluocinolone acetonide
Westcort Ointment, 0.2% Hydrocortisone valerate
CLASS 5—Lower Mid-Strength
Capex Shampoo, 0.01% Fluocinolone acetonide
Cordran Cream/Lotion/Tape, 0.05% Flurandrenolide
Cutivate Cream/Lotion, 0.05% Fluticasone propionate
DermAtop Cream, 0.1% Prednicarbate
DesOwen Lotion, 0.05% Desonide
Locoid Cream/Lotion/Ointment/Solution, 0.1% Hydrocortisone
Pandel Cream, 0.1% Hydrocortisone
Synalar Cream, 0.03%/0.01% Fluocinolone acetonide
Westcort Cream, 0.2% Hydrocortisone valerate
CLASS 6—Mild
Aclovate Cream/Ointment, 0.05% Alclometasone dipropionate
Derma-Smoothe/FS Oil, 0.01% Fluocinolone acetonide
Desonate Gel, 0.05% Desonide
Synalar Cream/Solution, 0.01% Fluocinolone acetonide
Verdeso Foam, 0.05% Desonide
CLASS 7—Least Potent
Cetacort Lotion, 0.5%/1% Hydrocortisone
Cortaid Cream/Spray/Ointment Hydrocortisone
Hytone Cream/Lotion, 1%/2.5% Hydrocortisone
Micort-HC Cream, 2%/2.5% Hydrocortisone
Nutracort Lotion, 1%/2.5% Hydrocortisone
Synacort Cream, 1%/2.5% Hydrocortisone

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com