Your Skin as a Diagnostic Tool | A Woman’s Journey

Your Skin as a Diagnostic Tool | A Woman’s Journey


>>Some ways in which the
skin can give us clues to our overall health. So most of us have experienced
the ways the impact of our health can have on our skin. So personally I can tell when
I’ve had not enough sleep, I’m stressed, I’ve had too
much wine or coffee or sugar, salt, carbs, and you wake
up and you can see it on your face and your skin, versus when you’ve had
a great night’s sleep, you’ve been eating well,
exercising, maybe you just came off vacation, and you just have that glow. You just look different. So recent research has
shown what we have observed ourselves to know to be
true that this is the case. So our skin can be not only
a barometer of our lifestyles and our habits, but it can
provide us information about actual medical health problems. So this is a topic that is vast. It’s had multiple large
textbooks, some of which we had to get through in dermatology residency, have been written on this topic. And so I’ll try and hit some highlights. We also have a printout of
more conditions that can be associated with internal
health, and they’ll be available on the way out at one
of the tables outside. So before I launch into some of these skin health conditions, I’ll
give you just a brief synopsis of skin function. So we all know that the skin
is involved in temperature regulation and serves a barrier function. So we know we’re 70% water,
and we need to hold onto that water so that we
don’t become dehydrated. But beyond those temperature
regulation and barrier functions, it also has a
whole host of many, many other functions, including
vitamin D production and immuno surveillance. The skin also has photo
receptors, and although we don’t know exactly their function,
there are some theories that maybe it helps us to regulate
our circadian rhythms. But I wanted to focus on
the immune surveillance part of it for just a second. So our skin has an immune system. There are immune cells that
are circulating through, and they help us to fight off infections, so bacterial, viral and fungal infections. But they also help to seek
and destroy potentially tumorous cells. And this is so important
because as we learn more about skin cancer and UV exposure,
it’s becoming really clear that UVA, which used to be
thought as a pretty benign thing, that’s the basis of tanning
booths is UVA, because that range of wavelength of light
is what gives us the tan, suppresses our immune response. And so it used to be that
a lot of sunscreens would cover UVB but not cover UVA,
and so we were out putting UVB sunscreens on, able
to stay out in the sun so much longer, gaining
lots of DNA mutations. So within a 10- to 15-minute
span we have billions of DNA mutations in our skin cells. Fortunately most of those are eradicated. Those cells are taken out
by our immune systems, but with the UVA suppressing
that immune response, then it allows the skin
cancer cells to divide and become skin cancers. And so that’s why tanning is
so harmful is that tanning, whether it’s in a tanning
salon or on the beach. So the only reason we
get a tan is because the DNA mutations signal to our
cells to open up the umbrella, which is melanin, that’s
what gives us a tan, to prevent further DNA
mutations, and then the UVA suppresses our repair
mechanisms to get rid of those tumor cells. So unfortunately because
of that we’re seeing a rise in melanoma among especially
young women who are getting lots of tans. So with that quick overview,
we see that our skin is really complex, it’s really dynamic, and it’s in constant
communication with our bodies. So with our internal
organs, with our brains, and they signal each other
via hormones, nerves, these immune cells that can
circulate, as well as chemical signals that are providing
communication from our organs to our skin and then the reverse as well, from our skin to our organs. So we can see our skin as a
window into what’s going on, or a check engine light like on your car. Sometimes these associations
are really classic, such as the target lesion of Lyme Disease. You see that bull’s eye
rash, you think Lyme Disease. But sometimes the
findings are more subtle, and it requires a expert,
such as with hypothyroidism. You might just develop some
dry skin and slight loss of the outer third of your
eyebrows, which could happen to any of us just with age as well. And so I’ll kind of go
into some areas in which, why would you see a dermatologist? Well, I’ll give you three reasons. When something is new to you,
so a new growth or something that is just not normal
for you, such as hair loss. If you develop something
that should go away, but doesn’t go away, so a
pimple that just doesn’t heal. And if you have skin findings
that are associated with some systemic problems,
like a fever and a rash, or joint pains. So those are all reason why
you should seek expert advice. So we’ll start with the first
one, when you find something new on your skin or something
that is not normal for you. So if you develop a new bump
or a new lump or a new mole, definitely get it checked
out sooner than later. Fortunately the vast majority
of these are going to be benign, but we do need
to rule out skin cancer, especially melanoma, as well
as rule out the possibility that it could be a metastasis
from an internal cancer. Even sometimes a benign
growth can be associated with something internally. For example, I recently had
a patient who had a really benign looking growth. It just looked like an
overgrowth of oil glands, but it was just a little
bit bigger than what I would typically see. So we did a biopsy, and
it came back as a type of non-cancerous tumor called
a sebaceous adenoma, which of itself is not going
to turn into skin cancer, so there’s no worry about
that particular thing on his face turning into a skin cancer. However, there is an
association with a genetic cancer syndrome called Muir-Torre,
which can predispose to a whole host of internal
issues, including colon cancer. And so we tested him, and
indeed he does have Muir-Torre. And so we tested his family
as well, and so one of his two children has the gene
associated with Muir-Torre. And so she’s in her 30’s,
so she’ll be getting colonoscopies regularly. So even the benign growths
can have certain associations, and that’s why that expert’s
opinion is really important to get the testing that’s required. Another condition that we
see oftentimes which can be associated with some
internal issues is hair loss. So a lot of us in this
room will experience some hair loss in our lifetimes,
and that is really normal. So female pattern hair loss
is something that we don’t talk about a lot because
most of us don’t lose our hair completely. We all know about male pattern hair loss, but female pattern hair loss occurs also, and that’s very common. But if you’re experiencing
rapid shedding that is unusual for you, then that
might be a signal that there could be something else happening. So shedding can be
associated with a recent medical illness, like a
flu or a recent surgery. Delivering a baby and having
that post-partum shedding is really normal. But it can also be associated
with weight loss or dieting, thyroid conditions, some
autoimmune conditions, such as lupus, vitamin D
deficiency, iron deficiency and anemia. We had a patient a few years
back who had a really nice full head of hair I thought,
but she said that she thought she had loss half her hair. And to an outside observer
you couldn’t see it, but she really felt that
her ponytail bundle was much smaller. So we ran a whole series
of tests that we normally would check, and they were all normal. But she was just so worried,
and so we brought her to grand rounds, and on
further questioning she told us that she had been eating
a can of tuna fish every day for lunch. And so she was getting
mercury poisoning from her can of tuna. Here she thought she was
being really healthy and having fish every day, but
so the testing confirmed it. And she went on to have
decreased shedding. And so in that case it was not
necessarily our observation that her hair was thinning,
but her own sort of observation that it was not normal for her. I had another patient who
had a lifetime history of psoriasis and some
growths that are called seborrheic keratoses. They’re often called
barnacles is the colloquial term for them, or wisdom spots. They’re really common. But all of a sudden one day
he noticed that they were all becoming really inflamed. So he had dozens and dozens
of these inflamed seborrheic keratoses on his skin, and
that was unusual for him even though he had a
history of psoriasis and had some skin inflammation
and has always had these seborrheic keratoses, that was unusual. And so I followed him over time. We froze some of them so
that they wouldn’t itch. But then one day as he was
undressing I noticed that his left nipple was inverted. And you don’t typically
think of men as having breast cancer, but sure
enough, when it palpitated, it was rock hard, and he
did have a breast cancer. And he subsequently
went on to have surgery, and was tested, had the BRCA gene, and so then his children were also tested. And so it is important to
get things checked out, even if it seems like
these are common things that anyone could deal with. If it is a change for you,
and it’s not normal for you, have a doctor check it out. So the second reason
to see a dermatologist, if you have something that
should normally resolve, should go away, but doesn’t. So I mentioned if you have a
pimple that doesn’t resolve. Most pimples should go
away in a couple weeks. Sometimes we get those
underground ones that are on our chin, and those can
take about a month to go away. But if you have a pimple
that’s not going away, get it checked out. It could be a basal cell
skin cancer or another type of skin cancer. Likewise, if you have a
little sore, a little bleeding spot that normally those
would heal up within a few days or a week. If it doesn’t, again that
could be a presenting sign of a skin cancer. Or a little rash that isn’t
resolving could be a sign of skin cancer or breast cancer. So anything that you think
intuitively really should resolve and isn’t, make sure
you have it checked out. Also itching is another really
common dermatologic symptom that most of us have
experienced at some point in our lives, but it
shouldn’t be persisting. So if your itch is not
resolving with moisturizers and a little cortisone, then
definitely see a doctor because itching, although most of
the time is just associated with dryness or excema,
sometimes bug bites, it can also be associated
with other internal conditions such as kidney, gall bladder,
liver, thyroid conditions. Sometimes it could be a pinched nerve. Degenerative spine disease
can cause this really classic type of itching that
is over the shoulder blade, and it can be really, really aggravating, but that’s due to that pinched nerve. Sometimes itching can
be the presenting sign of an internal cancer,
either an organ cancer or lymphoma or leukemia. And so if you have persistent
itching, make sure your doctor knows about it and
so that you get worked up. Sometimes pigmentary issues
can also be associated with some internal conditions. So normally you get a tan
and the tan then goes away with cooler weather, and
you’re not in the sun. There are some internal
conditions that manifest as a perpetual tan though. So hemochromatosis, which
is a condition of excessive iron accumulation, and it
can result in some cardiac and liver complications
that can present as just a perpetual tan that never goes away. Likewise Addison Disease. So this is a condition that
the late JFK had actually. So this is a adrenal gland problem, and it affects our ability to
react to stressful situations. So blood pressure can drop,
we can have difficulty regulating our glucose levels. And so a tan that doesn’t
go away can be a indication of an internal issue. Likewise hypopigmentation,
so lack of or decreased pigmentation of the skin
can be due to either chronic sun exposure or excema, but
also it can be associated with an autoimmune condition
called vitiligo where your immune cells attack your
pigment producing cells, and that results in some
very pale patches of skin. And there’s a type of skin
lymphoma called cutaneous T-cell lymphoma, which in
darker skinned individuals can present with perpetually
pale areas of skin, especially in areas that are
normally covered by clothing and some suits. So the third reason to
seek expert advice would be if you have skin findings
that are accompanied by systemic symptoms, so fever
and joint pain and a rash, or two out of the three,
or flushing and some gastrointestinal issues. The CDC just issued some
statistics, I think it was yesterday, that the number
of vector borne, so tick and mosquito borne illnesses, tripled. I see some heads nodding. You probably saw this on CNN
yesterday, but it tripled from 2004 to 2016. So it went from about 27,000
cases in the U.S. to just under 100,000 cases of
vector borne illnesses, so make sure you’re
wearing your bug repellent. But those can often present
with fever as well as a rash. And sometimes the rash is
classic, like I mentioned with Lyme Disease it’s
that bull’s eye rash, but sometimes it can be
really subtle, just a fine sort of red speckling over the skin. But if you’re not feeling
well, and you have a rash, make sure you get that checked out. Certain medication
hypersensitivities can also present with fever and a rash, and
if it’s allowed to progress, it can affect internal
organs such as the liver. And so it’s important not
to ignore those signs. A skin change with some
joint symptoms could herald the start of an autoimmune
condition such as lupus or dermatomyositis. And most of these conditions
are best if you can catch them early before
they are allowed to progress and affect more organs
in a more severe way. Flushing can occur sometimes
with gastrointestinal symptoms, and rarely sometimes tumors
can cause these two symptoms. So carcinoid and
pheochromocytoma can results in these symptoms. So with all of this it’s
really important to trust your intuition and not
to be afraid to speak up. Years ago I had a patient
who came in for a skin check, and she said you know, I’ve
had this mole on my back for forever, and I don’t think
it’s changed in appearance, but there is something
about it that I don’t like, and it’s worrying me. And when I looked at it, you
know, it looked really benign. It wasn’t bigger than an eraser. It didn’t have irregular borders. It wasn’t even very
dark, just a pinkish tan, but when we biopsied
it, it was a melanoma. And so I really, and that has
happened time and time again where a patient just has
a certain intuition about one of their moles, and sometimes
it comes back as cancer. So definitely trust your
intuition, and don’t be afraid to speak up about these skin findings. Before we end I just wanted
to go over a couple of newer more recent associations
of internal conditions and skin findings. So the first one is psoriasis. So psoriasis is a pretty common condition. It affects about two percent
of the U.S. population. Many of us in this room
probably know someone or have psoriasis or a
loved one with psoriasis. And it used to be thought
that psoriasis really was a skin and joint condition. So a certain percentage
of people with psoriasis would also have psoriatic arthritis. But more recently we’re
finding out that psoriasis is really a systemic
inflammatory condition. So the inflammation affects
not only the skin and joints, but also our blood vessels. So it affects our cardiovascular health. And people with psoriasis
have three times the risk of cardiovascular disease,
heart attacks and strokes because of this systemic inflammation. It lodges in the blood vessels. Patients with psoriasis we
also see an increased risk of metabolic syndrome and
insulin resistance and diabetes. So now whenever we have a
new patient with psoriasis we make sure that they are
well connected with their primary care doctor and are
being screened for these serious conditions to prevent
the long term sequella. Rosacea is another condition
that we’re just learning has systemic associations. So these associations haven’t
been worked out quite as well as it has been for psoriasis,
but we’re learning that individuals with psoriasis,
especially, or with rosacea, especially severe rosacea
have an increased risk of gastrointestinal conditions,
so reflux, inflammatory bowel and irritable bowel
syndrome, as well as hypertension, hyperlipidemia, diabetes,
other metabolic conditions. And some may have a slightly
increased risk of certain types of cancers, such as thyroid cancer. And there is a theory that
perhaps there is a role for the micro flora of the
gastrointestinal system in mediating this inflammation. There’s more research that
needs to be done in that area. So to summarize, the skin
really is a window into our overall health. When we see something
happening in our skin, it’s oftentimes your body
signaling to you that there is something that needs attention. And so really if you see
something new or something that’s not normal for you, or if you
have something on your skin that you would expect to
go away but isn’t resolving on its own, or if you have
skin findings with systemic systems, definitely seek
some dermatologic care. And then some parting advice. Wear your sunscreen. Don’t get a tan. Wear your bug spray. And to really trust your intuition. I’m amazed that in this
room full of mainly women we chose to hear about the prostate. (laughing) So we are advocates for health
for our entire families. And really I think we’re so
intuitive, and so if you are worried about something,
let your doctor know.

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