Common Skin Conditions

Acne is a condition which develops in and around the hair follicles and their oil-producing glands called the sebaceous glands. Although we have these glands all over the surface of our body, it is only on the face, chest and back that acne develops. The oil produced by sebaceous glands is called sebum and it begins to appear soon after puberty. Acne usually starts during the teenage years but it may also begin in the twenties or thirties.

There are several causes of acne. During puberty, the male hormone level increases and this causes increased sebum production in the skin. The oil glands also become blocked and this leads to the formation of comedones also known as blackheads and whiteheads.

Bacteria in the deeper part of the hair follicles act on the sebum, resulting in chemicals released which lead to the development of inflamed papules, nodules and cysts. Large, painful swellings called nodules and cysts may result in scarring.

Acne should be treated as early treatment can prevent scarring. Furthermore, treated acne improves one’s image and self-confidence.

1. Mild acne usually responds well to topical treatment. This includes sulphur and resorcinol preparations (e.g. acne clear cream and lotion), benzoyl peroxide containing preparations, topical antibiotics (erythromycin and clindamycin gel and lotions), and vitamin A creams or gels (adapalene and tretinoin).

2. Moderate acne. If you have a lot of inflamed spots, topical treatment alone may not adequate to control your acne. Oral antibiotics such as doxycycline, erythromycin, minocycline and cotrimoxazole may be prescribed and this is usually taken for several months.

3. Severe acne. In very severe nodulocystic acne or in cases who do not respond to oral antibiotics, oral isotretinoin may be prescribed. This medication has a number of side effects, including tetratogenicity. Your doctor will discuss with you further if you require this medication.

There is some evidence that a high glycaemic index diet (containing foods that are rich in carbohydrates which cause a rapid sugar release) and excessive consumption of dairy products may be related to acne. For most other foods, there is no restriction.

You should remove the oil from your face with a mild soap or cleanser. Avoid excessive squeezing of the acne bumps as this can lead to more persistent marks left on the face and can lead to scarring.

Alopecia areata is a common cause of hair loss. It presents with coin-shaped patches of hair loss. It can affect men and women of all ages, and is common in children and young adults. While the scalp is the most commonly affected area, it can also affect any hair bearing areas including the beard area and eyebrow. Sometimes, the entire scalp can be affected and this is termed alopecia totalis. If the hairs from the entire body is affected, this is termed alopecia universalis.

The hair may take some months, or even years to regrow. The prognosis is generally good.  However, the regrowth may not always occur. In more extensive cases like alopecia totalis, complete regrowth may be less likely to occur. The new hair that regrows may be white in colour but unlike aging white hair, it may darken with time.

Alopecia areata is an autoimmune disease and the body’s own immune cells attack hair follicles, causing the hair loss. There may be a genetic predisposition. Stress may be a trigger but diet and nutritional deficiencies are not known to be a cause.

Alopecia areata may be associated with other autoimmune conditions like thyroid disease, and vitiligo and these may be screened for in some cases.

The available treatments are:

1) Topical applications

Topical steroids and minoxidil may be used.

2) Steroid injections

This is the most commonly employed and effective treatment for small patches of hair loss. Multiple injections are given at the patches and this needs to be treated monthly. There may be some pain during the injection. There is a risk of causing a depression of the scalp at the sites of the injection.

3) Steroid tablets

Steroid tablets may be used when there is rapidly progressive hair loss. The dose of steroids is gradually tapered over a couple of months.

4) Other treatment modalities include immunotherapy and topical PUVA. These treatments are useful in cases which fail to respond to the topical of intra-lesional injections and in very extensive cases of hair loss.

Wigs can be helpful during the treatment or if the hair fails to regrow.

While complete regrowth of hair is likely to occur in cases of small areas of hair loss, there is a risk that the hair loss can recur. In more severe cases, the chances of full recovery are smaller. It is difficult to predict the natural course of alopecia areata. There is no effective treatment to prevent relapse of alopecia areata.

It is an inflammation of the skin on the hands. It is often a reaction to several factors, including irritating or allergic substances.

Hand eczema may be caused by:

1. Constitutional factors – genetic predisposition

2. Irritation from contact with excessive detergents, solvents, acids, etc. and wet work.

3. Allergy to certain substances (e.g. cement, perfume, etc).

4. A combination the above factors.

You should also protect yourself from irritants. When doing wet work like washing clothes and dishes, you should wear impervious gloves like rubber or vinyl gloves. The interior of the gloves should be dry and the gloves should not be worn for more than 30 minutes at one time.

Use gloves when preparing these foods, and avoid handling fruits, vegetables, shellfish and raw meat with bare hands. Avoid handling dirty diapers with bare hands and avoid contact with soap when doing housework. The gloves should be changed if the interior is gets damp and wet.

Protect your hands with gloves when contacting grease, chemicals and solvents. Cotton gloves are not recommended as they soak up the irritants and worsen the problem.

Avoid frequent washing of your hands and moisturise your hands regularly and frequently.

Atopic dermatitis is a very common skin condition that often occurs childhood. In atopic eczema, the skin may be dry, itchy and red.   This commonly occurs over the flexural areas such as the neck, elbow and the back of the knees. Other areas that may be commonly involved include the areas around the eyes (peri-orbital), but just about any part of the body may be affected. Atopic eczema can sometimes begin in adulthood, although this is far less common.  The term ‘dermatitis’ refers to inflammation of the skin.  The term ‘dermatitis’ and ‘eczema’ are often used inter-changeably.

Genes do play an important role in atopic eczema, and we often see this run in families. An impaired skin barrier also plays an important part and the skin is often cracked and dry and is usually more susceptible to bacterial and viral infections. The immune system is altered in atopic eczema and this leads to the development of eczema. However, the exact cause of eczema is still unknown.

At present, there is no known cure for eczema. However, there are many treatments that can control the eczema.  The eczema in most cases will improve with age and about half the cases will improved in the teenage years. Good skin care is important to maintain and keep the eczema under control.

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1. It is important to avoid scratching and rubbing the skin as this will aggravate the eczema and make the skin redder and more inflamed. This can also lead to breaks and cracks in the skin which can then predispose to bacterial infection.

2. Use gentle soap or soap substitutes. Regular soaps may can be too drying and harsh for the skin and disrupt the skin barrier.

3. Moisturize, moisturize and moisturize. It is safe to apply moisturizers regularly to the skin and this helps to maintain the skin hydration and improve the skin barrier. This is best applied straight after a bath, after you have pat dry, as this will help to trap a layer of moisture on the skin.

4. It is also important to moisturize more often when in a cold and dry climate as the low humidity can aggravate the skin dryness and eczema.

5. Wear clothes such as cotton and silk as this is comfortable for the skin. Materials like wool and linen and some other materials can irritate the skin and aggravate the itch and are best avoided.

In the majority of cases, food is not the main cause or trigger for the eczema.  Food allergies are most common in children below the age of 3 with severe eczema. Some common allergens include cow’s milk, peanuts, shellfish, wheat, soy and eggs.  In adults, food allergies are fair less common. Skin prick test and blood test (RAST test) can be done to test for food allergies. The results should be interpreted together with the clinical symptoms and your dermatologist will advise you accordingly.

The above mentioned skin care regime is very important and this should be carried out all the time.

In addition, you may be prescribed with other steroid and non-steroid medications for the eczema.

1. Topical steroids. These are most commonly prescribed for eczema and they are effective in bringing down the redness and itch in eczema.  Topical steroids are safe when they are used in the appropriate strength, at the appropriate site and for the right duration.  Long term inappropriate use of topical steroids can lead to skin thinning and atrophy. Your dermatologist will prescribe the most appropriate steroid cream for you.

2. Calcineurin inhibitors (TCI) creams. These are newer creams that can be used to treat the eczema. They are non-steroids and do not have side effect of skin thinning and atrophy even with prolonged use. They are costlier than steroids creams and you may experience some transient burning sensation when applied to the skin.

3. Topical and oral antibiotics may be prescribed when there is evidence of skin infection. Bacterial infections can trigger and worsen the eczema and the eczema improves when the infection is treated.

In cases where the eczema is extensive or poorly controlled with topical creams, you may need to move on to phototherapy, systemic or oral treatments. These oral treatments do have their own set of side effects and your dermatologist will assess the need and prescribe the most appropriate treatment for you.

What Is Freckles?

These appear as small, flat brownish spots on the face, often on the cheeks, nose and on the sun exposed areas.  They can start from a young age and can worsen with increasing sun exposure and improve with sun avoidance and protection. Topical creams can be applied to lighten the pigmentation. This type of pigmentation can be treated with intense pulse light and the pigment laser with a favourable outcome.

What Is Solar Lengtigines?

These appear as well defined brownish pigmentation on the sun exposed sites such as on the cheeks and forearms. This is due to cumulative sun exposure and usually appears in the 30’s to 40’s age group. They are usually flat, but may gradually thicken with time. They are harmless lesions but can be removed or treated for cosmetics concerns.  Sun avoidance and protection is very important to prevent worsening of the lesions.  Topical lightening creams may also be prescribed. These lesions can also be treated with cryotherapy (liquid nitrogen), pigment laser or intense pulse light therapy.

What Is Melasama?

Melasma is a common facial pigmentary disorder. It causes a diffuse patchy brownish pigmentation on the cheeks, temples, forehead, nasal bridge and can also appear on the upper lip. Hormonal factors, genetic and environmental factors like sun exposure are thought to play an important role in the development of melasma. Women are more prone to melasma and the use of oral contraceptives can worsen the melasma. This can also follow childbirth and is also known as ‘the mask of pregnancy’.

Treatment of melasma can be difficult. Sun protection and avoidance is extremely important. Topical lightening creams can help the melasma in some cases especially when the pigmentation is more superficial. The use of intense pulse light and laser have less predictable results and the use of these treatments have to be discussed with your dermatologist.

What Is Hori’s Naevus?

This is a type of pigmentation that is more often seen in Asian patients. It presents with brown to greyish spotty pigmentation on the cheeks and often starts to appear in the 20s to 30s age group. This can sometime run in families. The exact cause is unknown.  The pigmentation in Hori’s naevus is deeper in the skin and the response to topical lightening creams is less favourable.  This can be effectively treated with the pigment laser treatment but multiple sessions (about 7 to 10 treatments) are required.

Fungal Infection also known as white spots or tinea versicolor commonly presents as scaly white patches on neck and trunk, although it can appear on other parts of the body It can also appear as brownish or reddish patches with overlying powdery scales. It is caused by a fungus called malassaesia furfur. It tends to occur in hot humid tropical climates and in individuals who perspire a lot.

This can be treated with topical antifungal creams or lotion. Often a selenium sulphide lotion is prescribed. This should be applied to the body for 10 to 15 minutes prior to bathing and rinsed off. This should be done for 1 to 2 weeks. Leaving the lotion on for longer periods of time can lead to irritation of the skin.

In cases not responding to topical treatment or in severe cases, oral antifungal medication may be prescribed.

Tinea infection is caused commonly by the trichophyton fungus.

It can present as

1. Tinea corporis – infection on the trunk

2. Tinea cruris – infection on the groin

3. Tinea pedis – infection of the feet

4. Tinea manus – infection on the hands

5. Tinea capitis- infection of the scalp

The fungal infection often presents itself with a ring-shaped scaly rash on the affected site. The fungus thrives in a hot, humid and sweaty environment. It can be very itchy.

Topical antifungal creams are often prescribed to treat the infection. Oral antifungal medications may also be prescribed when the infection is more extensive or for more infection on more stubborn sites like the feet.

Every day, we are losing some hair. This is normal. However, if we lose more than a 100 strands of hair in a day, that would be significant hair fall. The hair loss can be diffuse or patchy.

Our hairs cycle through 3 phases:

1. A growing phase (Anagen)

2. A resting phase (Catagen)

3. A falling phase (Telogen)

1. Androgenetic alopecia

This is also known as male or female pattern baldness and is the commonest cause of hair loss and can occur both in men and women.  This is a hereditary condition and often runs in families. It is due to the action of the hormone dihydrotestosterone acting on the hair follicles, causing it miniaturize or shrink progressively.  This often started after the pubertal years (age over 20 years old).

2. Telogen effluvium

This is a diffuse hair loss that occurs about 2 to 4 months after a peroid of stressful insult on the body. This can occur after high fever, viral infections, a crash diet, physical or emotional stress and childbirth. The hair loss is due an increase shift of hairs to the telogen phase or falling phase. This hair fall will usually improve over a few months.

3. Chronic illness

Certain illnesses like thyroid disease, autoimmune disease (eg. Systemic lupus erythematosus), iron deficiency and syphilis can also lead to hair fall. These should be screened for with blood tests if suspected.

4. Alopecia areata

This a form of hair loss which appears as distinct coin-shaped bald patches on the scalp. This can also occur on beard area, eyebrow area and any hair-bearing areas of the body can also be affected.  This is due to the body’s immune system attacking the hair follicles.

5. Trichotillomania

This is a self-inflicted hair loss and is due to the individual pulling out their own hairs. This may be triggered by stress.

6. Traction alopecia

This occurs at the hairlines and is due to pulling the hair too tightly when it is tied up into a pony tail or braiding the hair. The traction on the hair cause the hair loss.

7. Drug-induced hair loss

Some drugs are known to cause hair loss. These include chemotherapy drug and other systemic oral medications.

8. Scarring alopecia

This is an irreversible hair loss when there is hair loss with destruction of the hair follicle. This leads to a permanent patch of hair loss. This can be due to infections from bacterial and fungus and other inflammatory skin diseases.

If you have excessive hair loss or progressive thinning of the hair, you should consult your dermatologist who will assess you and determine the most likely cause and prescribe the appropriate treatment for you.

You should avoid perming the hair or excessive pulling or force on the hair.  It is preferable to comb the hair with a wide tooth comb than with a brush.

Keloids are due to an overgrowth of scar tissue at the site of skin injury. They occur following trauma, surgery, blisters, vaccinations, acne or body piercing. Less commonly, keloids may form in places where the there is no obvious injury. Keloids, unlike normal scars, grow beyond the site of injury. They can be very large at times.

The cause of keloids is still unknown. Some people are much more prone to keloids.

Keloids may form on any part of the body, but the keloid prone areas of the body include the ears, upper chest, upper back, and shoulders. Persons with darker skin types tend to develop keloids more easily than those with lighter skin. Untreated, keloids gradually enlarge and some keloids can become very large.

Keloids can be difficult to treat.

The goal in treating keloids is to reduce any pain and itch and to flatten the lesion so that it is less protruding and flush with the surrounding skin.

The most common types of treatments include:

1.  The injection of steroid into the keloid – Steroids have anti-inflammatory and antipruritic (anti-itch) effects. The injection is given directly into the keloids.

The number of treatments required depends on the size of the keloids and the injections are usually given at monthly intervals.

2. Cryotherapy – Cryotherapy consists of applying liquid nitrogen to the keloid.

If you experience discomfort, itching and pain after the treatment is given, you can take some oral analgesic like Panadol and relieve the pain with a cold compress. Sometimes, a numbing cream is applied to the keloids prior to the injection to reduce the pain of injection.

What Are Melanocytic Naevi (Moles)?

Moles commonly present as darkly pigmented bumps on the skin. However, in some cases they may be lighter or even skin coloured. They occur in childhood, adolescence and early adulthood. They are due to abnormal collection of melanocytes, a pigment producing cell in the skin.

Moles may gradually increase in size over the years and may be raised and dome-shaped and may even appear lighter. They are non-cancerous and can be removed if there are cosmetic concerns.

However, if there is a sudden increase in size of the moles, or if it has irregular border and starts to bleed, these are signs for concern and you should consult your dermatologist.

The best treatment for removal of moles is surgical excision. The mole can be sent for histological examination to rule out cancer.  There will be stitches in place after the excision and this may take 7 to 14 days before removal. There will be a line scar left in place of the mole.

What Are Skin Tags?

Skin tags are harmless brownish or skin-coloured growths, commonly affecting the neck, armpit area, eyelids and groin. They vary in size from less than 1mm to as large as 10mm. In some individuals, there may be numerous lesions.

Skin tags can be easily removed. Electrosurgical ablation is commonly used to treat the skin tags. This is done under topical anaesthesia.  After the surgery, there will be scabbing and superficial wounds. These may take up to a week or so to heal. There is often some darkening as the wound heals. This will gradually fade over a few weeks to 1-3 months.

What is Seborrhoeic Keratosis (Seborrheic Warts)?

Seborrhoiec warts are harmless growths that appear as brown or pigmented superficial growths on the skin. They often occur on the face but can also affect the trunk, neck and groin. Some may be flat or slightly raised, but they can enlarge and become fairly large in size. They can be numerous in some individuals. They can be easily removed if there are cosmetic concerns. Some seborrhoeic keratosis can be treated with liquid nitrogen. When multiple, seborrheic warts are best treated with electrosurgery.

What is Sebaceous Hyperplasia?

Sebaceous hyperplasias appear as yellowish growths and are often seen on the cheeks. They have a characteristic central dimpling. This is due to the proliferation of oil glands in the skin and is benign condition. Sebaceous hyperplasia may be treated with electrosurgery or laser. These treatments will help to flatten the lesions. There is a risk of scarring and hyperpigmentation post treatment. There is a high risk of recurrence of the lesions after the treatment.

Psoriasis is a chronic immune-mediated inflammatory skin disease.  It is NOT contagious. The rate of multiplication of the skin cells in markedly increased, leading to the appearance of thick, red and scaly patches on the skin. Psoriasis often affects the scalp (appearing like dandruff), hairline, extensors of the elbow and knees and umbilical area, but just about any part of the body can be affected. Most people have mild psoriasis affecting only small regions of the body, but in about a quarter of the cases, the psoriasis is moderate to severe. Psoriasis can also affect the nails, presenting with pitting, thickening and/or separation of the nail from the nailbed. About a third of patients may have psoriatic arthritis, which is swelling and inflammation of the joints.

Psoriasis is caused by an inter-play of genetic and environmental factors.   Individuals with psoriasis have a greater likelihood of family members afflicted with the disease. While the exact cause of psoriasis is unknown, common triggers of psoriasis include infection (eg throat infection), stress and trauma to the skin. Certain medications like anti-hypertensive medication and oral steroid withdrawal can also aggravate psoriasis.

Psoriasis is a condition that tends to be persistent. While there is currently no known cause for psoriasis, there are many treatments available that can treat psoriasis effectively and control the disease, leading to a marked improvement in the quality of life.

Psoriasis Is now known to be associated with metabolic syndrome and its components. This includes obesity, hypertension, diabetes and raised lipid levels. It is advisable to screen for these conditions and keep them under control. The risk of fatty liver disease is also increased in psoriasis.

1. Topical treatment.

The first line treatment for psoriasis is topical treatment. This is prescribed in cases where the psoriasis is mild. There are a number of different topical preparations including topical steroids, coal tar and vitamin D3 derivative like calcipotriol ointment.

2. Phototherapy.

This is used to treat psoriasis especially when it is moderately severe. NBUVB or PUVA  may be employed.  It requires regular attendance 2 to 3 times a week for several months for the treatment.

3. Oral medication.

This is used when topical treatment has failed or in moderate to severe cases of psoriasis. There are a number of oral medications including methotrexate, acitretin and cyclosporine. These medications have their own set of side effects and regular blood test monitoring is necessary while on these medications to ensure the safe use of the drugs.

4. Biologics.

These are the latest treatments available for the treatment of psoriasis. They are usually given by injections and are highly effective for the treatment of psoriasis. These medications are safe but do cause immune suppression and you will require regular blood test and monitoring while on the treatment.  Examples of currently available biologics include etanercept, adalimumab, infliximab, ustekinumab and secukinumab.

Scabies is a very itchy skin condition and this is due to an infestation of the skin by the microscopic scabies mite. It presents with itchy red papules that often affect the finger web spaces, armpits, groin, buttocks and genitalia.  The itch is often worse at nights.

Scabies is very contagious and often other family members will also be affected. It is spread by close contact with an affected individual. Sharing of clothes and bedding and poor hygiene are factors that can lead to spread of scabies.

Topical lotions containing benzyl benzoate, malathion, crotamiton and permethrin can be used to treat scabies. Usually 1 to 3 days of application is required. Your dermatologist will advise you accordingly.

On the 1st day, you should first take a shower. This is followed by the application of the lotion all over the body from neck down, including the unaffected areas. This should also be applied on the armpit, groins, genital and soles. This is left on till the next evening when is showered off.

If necessary, the above process may be repeated on the 2nd or 3rd day.

If there are any affected family members, or family members in close contact, they should similarly be treated. Your dermatologist should supply you with enough lotions to treat them.

Bed linen, pillow cases and blankets should be washed in hot water and left to dry in the sun.

Urticaria, often known as ‘hives’, is a common skin condition. It appears as redness and whealing of the skin and can range from small mosquito-like bumps, to large patches resembling the shape of a map.  It is often very itchy and can last from minutes to several hours. Just about any part of the body can be affected. It may settle in one area, only to pop up in another site. This usually resolves with no scars or marks.

The swelling can also sometimes involve the lips and peri-orbital area and when this happens, it is termed as angioedema.

Urticaria can be arbitrarily classified as being acute or chronic.

1. Acute urticaria – lasts for less than 6 weeks

This is the commonest form and the urticaria usually settles within days to weeks.

2. Chronic urticaria – lasts beyond 6 weeks

This may usually last for several months, and in a minority of cases, can persist for years.

The redness and swelling of the skin is due to the release of histamine by the mast cells in the skin. The mast cells are a type of immune cell in the skin. The histamine released causes the blood vessels to dilate and there is increased blood flow to the skin. Some excessive fluid leaks into the surrounding tissue, leading the wheal. When the effect of the histamine wears off, the fluids gets reabsorbed and the wheal starts to settle.

While the exact trigger is often unknown, some of the known triggers of urticaria include:

1. Viral infections

2. Allergies – Certain foods such as shellfish, food additives, nuts and strawberries and citrus foods can trigger the urticaria

3. Insect bites and insect stings

4. Medications- Certain medications like pain-killers, NSAIDS (eg. Aspirin), penicillin

5. Contact with certain substances like chemicals, plant sap, latex and cosmetics

Physical factors: Pressure on the skin, scratching, cold temperature, heat, exercise and sun exposure can also be a trigger for urticaria in some individuals.  Avoidance of these triggers can prevent the appearance of the urticaria.

Autoimmune: In some individuals, the immune cells of the skin target the mast cells in the skin, leading to the release of histamine and development of hives.

In general, avoid medications like pain-killer that can trigger the urticaria. Avoid alcohol and excessive hot and cold environments. Also avoid scratching at the rashes.

Acute urticarias will usually settled within a few weeks. No further investigations are usually required. Oral antihistamines are the mainstay of treatment to block the effects of the histamine.

Chronic urticarias can persist for weeks to months. Further investigations may be necessary to rule out an underlying cause or associated medical conditions.

Oral antihistamines are the mainstay of treatment. They help to settled the wheals faster, control the itch and prevent the hives from appearing. These may be taken continuously or intermittently and your dermatologist will advise you accordingly.  Anti-histamines are safe, with drowsiness being the main side effect of the treatment. The newer generation anti-histamines are non-sedating.

In severe cases, other oral medications like leukotriene inhibitors may be added on to control the hives. There is now a new biologic treatment that has been approved for use in individuals with severe recalcitrant hives. Your dermatologist will advise you on the most appropriate treatment for your condition.

Vitiligo is a skin condition that presents with white patches on the skin. This can affect any part of the body.

Vitiligo can be broadly divided in to 3 groups.:

1. Focal vitiligo – affecting a small area of the body

2. Segmental vitiligo – affecting a segment of the body and this does not usually cross the midline.

3. Generalized vitiligo – this a more diffuse form which can affect the skin all over the body, often in a symmetrical fashion.

Common sites of vitiligo include the back of the hands, elbows and knees. It can also affect the flexural areas like the armpit and groin and also around the eyes and mouth.

Vitiligo can also affect the overlying hairs, which may turn white.

Vitiligo is noncontagious and will not spread to others through contact.

The cause of vitiligo is unknown.  There is loss of a pigment cell called melanocyte in the skin. This cell is responsible for the brown or black colour of the skin and when this is lost, the skin appears white.

Some may be due to an autoimmune cause, where the melanocytes are targeted by the immune system.  Other autoimmune disorders like thyroid disease, diabetes mellitus and pernicious anaemia may be associated.

Vitiligo can be aggravated by trauma to the skin and can appear over sites of injury on the skin.

General measures:

Apply sunscreen on the vitiligo areas as they are more susceptible to sunburn. You can also use camouflage cosmetic to cover the up white spots and this can markedly improve the appearance of the vitiligo.

There are a number of treatments for vitiligo. However, the response to the treatment varies according to each individual and the extent of improvement is difficult to predict.

1. Topical steroids creams. This can be used to treat vitiligo. Topical steroids can cause skin atrophy with prolonged use and your dermatologist will advise you on the appropriate use of topical steroids.

2. Topical Calcineurin inhibitors

These are non-steroid creams, which are immunomodulators. They can be used for vitiligo without the risk of skin atrophy.

3. Phototherapy

Ultraviolet light can help to stimulate re-pigmentation.  Commonly used light treatments include NBUVB phototherapy and PUVA treatment.

There are now machines that can deliver the light to a local area of skin such as the excimer light. Phototherapy is generally safe but there is an increased risk of sunburn and skin cancer with the treatment. It also requires attendance for the treatment 1 to 3 times a week for several months.

4. Surgical options

Surgical options such as punch grafting and cellular grafting can be used in cases which fail to respond to treatment. They are indicated for cases of stable vitiligo which have not progressed over 12 to 24 months. They are best for segmental or focal vitiligo.