THE AUSTRALIAN SOCIETY OF DERMAL CLINICIANS

Early detection and identifying people at risk of developing lymphedema is very important in preventing late onset symptoms and morbidity associated with the condition. The development of secondary lymphoedema can be multifactorial, however there is developing theories that there is an underlying predisposition to lymphatic dysfunction. Secondary lymphoedema aetiology is diverse and multifactorial. For this reason patients at risk of developing lymphedema will be encountered in a wide variety of clinical settings (primary, secondary and tertiary health care providers). These include dermatology, vascular surgery, oncology, plastic surgery, and wound care. The dermal clinician will be found in all of these settings and therefore should have a thorough understanding of risk assessment, early identification of lymphatic dysfunction and referral pathways (Lymphoedema framework, 2006). The Burden Management of oedema is a heavy burden on the sufferer including financial cost, time and emotional investment. As such all of these considerations can affect “compliance” with therapy (Dart, 2012). To achieve optimal and maintainable outcomes for our patients we must ensure that we keep the patient at the centre of their care planning. This revolves around accurate assessment and classification to determine the most efficient and effective therapies. 50% of chronic oedema sufferers report long-term pain in oedematous limbs, which can restrict movement and cause distress. Patients with chronic oedema are at high risk of skin breakdown and infections such as cellulitis as repeated trauma and loss of skin integrity allow opportunistic pathogens to enter. 33% of chronic oedema sufferers will develop cellulitis, 27% of these cases will require hospitalisation for IV antibiotics The condition can be so debilitating impact sufferers psychologically that 80% of of those with lymphoedema report taking time off work, and 2% giving up employment entirely (Todd, 2013). Risk Factors and Early Identification Below are Box 4, Table 1 and Figure 1 from the international consenus document on the best practice management of lymphoedema (International Lymphoedema Framework,2006). These figures summarise the most common causes or risk factors for development of chronic oedema and lymphoedema. Figure 1 presents a flow chart that is useful for the Dermal Clinician in understanding their role in identification of chronic oedema and lymphoedema. This includes the referral of those identified with chronic oedema and lymphoedma to a specialised service for diagnosis. It also outlines the importance of education that can be provided by the Dermal Clinician to those at risk in order to prevent or identify early signs of oedema so that it can be managed quickly to reduce morbidity. Assessment: What are the early signs? The first signs of lymphatic dysfunction and chronic oedema (subclinical signs) are usually perceivable by the patient themselves. For this reason it is important to educate clients at greater risk of what the early signs can be. Clients at greater risk include those with chronic inflammatory disorders, post surgical patients and those on medications that induce oedema. Clothing or jewellery that is becoming tighter Aching, pain Feeling of heaviness, fullness, tightness or woodeness Problems with range of movement Obvious swelling Those identified with chronic oedema and suspected Lymphoedema may be referred to a GP with knowledge of lymphatic dysfunction, or a specialised Lymphoedema service. At the present time there is reported to be a shortage of medical professionals and services for those with lymphatic issues. Currently patient support groups and advocacy organisations are campaigning for funding to increase hospital and outpatient services as well as cover the cost of management with a medical (medicare) rebate. At the present time there is great inconsistency in these services and funding offered nationally. The tests below may be carried out by medical professionals or specialists. They provide information on the underlying aetiology of the oedema and provide insight into best management strategies. Blood tests Urine testing Bioimpedence X-rays Ultrasound imaging CT/MRI Scans Lymphoscintography/ indocyanine green & near infrared imaging Genetic testing Clinical Assessment Clinical assessment, grading and classification of Chronic Oedema and Lymphoedema allows for these conditions to be managed more effectively. Various tools are used from the clinically useful but more subjective assessment techniques including: circumference measurements, goblet (pitting) sign and stemmer test to more objective research tools including water displacement, perometry and tonometry. Detailed skin assessment is also vital as well as assessment of nutritional status, pain, vascular function (heart, arterial and venous), mobility and psychosocial support or needs. Watch below as to how to perform a pitting test and observe for Stemmer Sign. Resources for Dermal Clinicians For more information stay up and become an ASDC Member. Other Resources can be found at: International Lymphoedema framework Australasian Lymphology Association References Dart. L. (2012). Non-compliance? It's easy for you to say. Journal of Lymphoedema. 7(1), 8-10 Haesler. E. (2015). Evidence summary: Lymphoedema: Objective assessment using circumference measurement. Wound Practice and Research. 23(1), 36-38 Haesler. E. (2015). Evidence summary: Lymphoedema: Objective assessment using tonometry. Wound Practice and Research. 23(3), 150-151 Jones. J. (2014). Lymphoedema and chronic oedema: What’s the difference? Nursing and residential care. 16(2), 684-886 Kamble. R., Shetty. R., Diwakar. N. & Madhusudan. G. (2011). Technical note: MRI lymphangiography of the lower limb in secondary lymphedema. Indian Journal of Radiology and Imaging. 21(1),15-17 Lymphoedema Framework. (2006). Best Practice for the Management of lymphedema. International consensus. London. MEP Ltd. Mellor. R., Bush. N., Stanton. A., Bamber. J., Levick. R., & Mortimer. P. (2004). Dual- frequency ultrasound examination of skin and subcutis thickness in breast cancer related lymphedema. The Breast Journal. 10(6), 496-503 Mendoza. E. (2013). Differential diagnosis of leg oedemas of venous and lymphatic origin. Phlebologie. 42, 153-157 Mihara. M., Hara. H., Narushima. M., Todokoro. T., Iida. T., Ohtsu. H., Murai. N., Koshima. I. (2013). Indocyanine green is superior to lymphoscintigraphy in imaging diagnosis of secondary lymphedema of the lower limbs. Journal of Vascular Surgery. 1, 194-201 Naouri. M., Samimi. M., Atlan. M., Perrodeau. E., Vallin. C., Zakine. G., Vaillant. L. & Machet. L. (2010). High resolution cutaneous ultrasonography to differentiate lipoedema from lymphedema. British Journal of Dermatology. 163, 296-301 Nikitenko. L., Shimosawa. T., Henderson. S., Makinen. T., Shimosawa. H., Qureshi. U. Pedley. B., Rees. M., Fujita. T. & Boshoff. C. (2013). Adrenomedullin Haploinsufficiency predisposes to secondary lymphedema. Journal of Investigative Dermatology. 133, 1768-1776 Piller. N. (2007). To measure or not to measure? What and when is the question. Journal of Lymphoedema. 2(2), 39-45 Todd. M. (2013). Chronic oedema: impact and management. British Journal of Nursing. 22(11). 623-627 Tomczak. H., Nyka. W. & Lass. P. (2005). Lymphoedema: Lymphoscintigrapy versus other diagnositic techniques: a clinician’s point of view. Nuclear Medicine Review. 8(1), 37-43 Trayes. K., Studdiford. J., Pickle. S., & Tully. A. (2013). Edema: Diagnosis and management. American Academy of Family Physicians. 88(2). 102-110 Varricchi. G., Yamamoto. T., Matsuda. N., Doi. K., Oshima. A., Yoshimatsu. H., Todokoro. T. Ogata. F., Mihara. M., Narushima. M., Iida. T., & Koshima. I. (2011). The earliest finding of Indocyanine Green Lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: The modified dermal backflow stage and concept of subclinical lymphedema. Plastic and Reconstructive Surgery. 127(5), 1979-1986

Acne vulgaris is the most common inflammatory dermatological disease which disturbs the pilosebaceous unit. Acne is distinguished by non-inflammatory lesions in the form of comedones; or inflammatory lesions in the manifestation of papules, pustules, nodules and cysts. However widespread acne may be globally, the comprehensive pathogenesis of acne is complex, multifactorial and still unidentified. Formerly, it has been proposed the progression of acne is due to four factors; the production of additional sebum, the interference of keratinisation within the infundibulum of the hair follicle, the colonisation of the pilosebaceous duct by Propionibacterium acnes and the discharge of inflammatory mediators into the skin. Yet, emerging and continuing research encompassing the pathogenesis of the chronic inflammatory disorder is still advancing. Propionibacterium acnes (P. acnes) For an extended time, it has been thought P. acnes, fostered on the skin of most humans, donates considerably to the pathogenesis of acne, though, it has been conjectured that not all who harbour P. acnes suffer from acne, as P. acnes, located within the pilosebaceous unit bestows in both acne sufferers and healthy individuals. Henceforth, evidence and research is continuously emergent surrounding the role of P. acnes in acne advancement, with one study implicating that certain P. acnes strains may be linked to healthy individuals, whilst other P. acnes strains may be closely related to acne sufferers. Studies have also inferred that P. acnes may be significant in the adaptive immune response of acne. In biopsy tests of inflammatory acne lesions Interleukin 17 (IL-17) cells were discovered in perifollicular infiltrates and resultant of P. acnes being an inducer of IL-17 and IFN-y from CD4 T-cells a consensus was drawn that acne may possibly be a T-helper type 17 (Th17) mediated condition, where Th17 cells could possibly contribute to either the homeostasis or the pathogenesis of acne vulgaris. Considering these findings, it is imperative to note that the P. acnes strain and its correlation to the development of acne is controversial and not yet wholly understood or recognised. Inflammation A noteworthy expanse of histological, immunological and clinical research indicates inflammation is significant in all stages of the acne lesion, including the instigation, propagation and resolution. Recent findings indicate inflammation and follicular epithelial hyperproliferation are present in the microcomedo, prior to the the comedo formation, which tests the categorisation of non-inflammatory and inflammatory acne lesions and the consensus that inflammation is only extant in the delayed phases of acne vulgaris lesions. Research has also demonstrated that uninvolved skin from acne patients contains raised levels of CD3+ and CD4+ T-cells in the perifollicular and the papillary dermis in accumulation with amplified macrophage activity, similarly to that of papular lesions. Additionally, in the regression period of acne lesions an excessive level of T-cells, macrophages and leukocyte antigens are found to be existing, suggesting that delayed hypersensitivity reactions are significant in the inflammation of acne. Hormones An upsurge in androgen levels inspires sebum production via the binding of receptors on sebaceous glands and pilosebaceous ducts, and research has exhibited that acne prone skins have higher levels of androgen receptors and increased testosterone and 5a-dihydrotestosterone activity. This discovery further supports the proposed correlation between acne development and those possessing high levels of androgens, which is seen in puberty, Polycystic Ovarian Syndrome and Congenital Adrenal Hyperplasia, whilst conversely, those with deficient androgens are said to not develop acne. Interestingly, endocrine interrupting chemicals which are widely used in industrial, pharmaceutical and personal care products, have the potential to inhibit synthesis of natural hormones, and studies suggest contact with these chemicals can result in raised androgen levels and henceforth are also capable of promoting the progression of acne. Sebum composition Emerging evidence also indicates that it is not the amount of sebum secreted rather the alterations in the components and composition of sebum lipids which correlates with the occurrence and the development of inflammation and acne. Sebum is composed of a mixture of non-polar and polar lipids consisting of triglycerides and free fatty acids (57.5%), wax esters (26%), squalene (12%) and cholesterol and cholesterol esters (4.5%) and research has indicated that certain molecules found within the composition of sebum are cytotoxic and irritant and therefore provoke reactive follicular hyperkeratosis and the formation of comedones. This concept is further supported by the mechanism of antiacne compounds which have the ability to reduce acne lesions through inhibition of proinflammatory lipids. Diet and Environmental Factors Exposome factors involving nutrition, medication, occupational aspects, pollutants, climatic, psychosocial and lifestyle influences are also said to contribute to the development of acne due to their capabilities to interact and generate a chronic inflammatory response within the pilosebaceous unit and therefore affect the skins natural barrier and microorganisms. In conjunction with the Exposome factors, examinations have also hypothesised that the Western Diet of hyperglycaemic carbohydrates and dairy proteins are fundamental contributors in the progression of acne due to their ability to upregulate the insulin-like growth factor (IGF-1) and alter the composition of sebum. It is also interestingly noteworthy that acne is absent in populations which consume less insulinotropic Palaeolithic diets which could be due to the lower insulin-like growth factor (IGF-1). Interprofessional practice and the role of Dermal Clinician’s in the management of Acne Research affirms that acne necessitates systemic treatments in the form of Oral Antibiotics (Benzoyl Peroxide Antibiotics, Clindamycin and Crythromycin), Oral Hormone Antiandrogens and Oral Retinoids (Isotretinoin). Though, due to the collective cases of antibiotic resistance and the major adverse effects of these medications, such as Xerosis and skin irritations, an increased demand for alternative therapies in the management of acne has become apparent. As Dermal Clinicians there are a number of ways we can work interprofessionally to aid in the support, treatment and management of acne sufferers, some of these involve; Photodynamic Therapy, which can destruct sebocytes and reduce inflammation via the application of 5-aminolevulinic acid and the use of Red Light. Non-Ablative Radiofrequency which can be used to denature bacteria and diminish sebaceous glands through heating of the dermis and subcutaneous tissue via the use of radio waves. Fractional Radiofrequency, which entails the use of microneedles to target the mid dermis and reduce inflammation of acne lesions. Laser, which can reduce sebaceous gland activity and inflammation through Thermal coagulation of the sebaceous glands and the associated hair follicles. IPL, which can treat inflammatory lesions and cause destruction of the sebaceous glands by targeting the blood cells using heat and energy generation. In addition, through selectively targeting the chromophores melanin and water, IPL devices can also be used to treat post inflammatory pigmentation and atrophic scarring linked with acne. LED can photoactivate endogenous porphyrins in P. acnes. Chemical Peeling Preparations can be used for antibacterial, anti-inflammatory, keratolytic and comedolytic effects, these are achieved through the manipulation and creation of a controlled and managed injury to the skin, which promotes regeneration of the epidermal layer of the dermal tissues. It is vital to note, depending on the severity of the acne, these modalities and alternative treatments alone may not achieve complete resolution of the condition. Therefore, it is recommended for best clinical outcomes that Dermal Clinicians work interprofessionally alongside other medical specialists and in some cases, treatment and management can be undertaken in conjunction with the administration of topical or systemic medications. References Agak, G. W., Kao, S., Ouyang, K., Qin, M., Moon, D., Butt, A., & Kim, J. (2018). Original Article: Phenotype and Antimicrobial Activity of Th17 Cells Induced by Propionibacterium acnes Strains Associated with Healthy and Acne Skin. Journal of Investigative Dermatology, 138, 316–324. doi: 10.1016/j.jid.2017.07.842 Bergler-Czop, B. (2014). The aetiopathogenesis of acne vulgaris - what’s new? International Journal Of Cosmetic Science, 36(3), 187–194. doi:10.1111/ics.12122 Beylot, C., Auffret, N., Poli, F., Claudel, J.-P., Leccia, M.-T., Del Giudice, P., & Dreno, B. (2014). Propionibacterium acnes: an update on its role in the pathogenesis of acne. Journal Of The European Academy Of Dermatology And Venereology: JEADV, 28(3), 271–278. doi:10.1111/jdv.12224 Chen, X., Wang, S., Yang, M., & Li, L. (2018). Chemical peels for acne vulgaris: a systematic review of randomised controlled trials. BMJ Open, 8(4), e019607. doi:10.1136/bmjopen-2017-019607 Cong, T.-X., Hao, D., Wen, X., Li, X.-H., He, G., & Jiang, X. (2019). From pathogenesis of acne vulgaris to anti-acne agents. Archives Of Dermatological Research. doi:10.1007/s00403-019-01908-x Contassot, E., & French, L. E. (2014). New insights into acne pathogenesis: propionibacterium acnes activates the inflammasome. The Journal Of Investigative Dermatology, 134(2), 310–313. doi:10.1038/jid.2013.505 Das, S., & Reynolds, R. V. (2014). Recent advances in acne pathogenesis: implications for therapy. American Journal Of Clinical Dermatology, 15(6), 479–488. dDoi:10.1007/s40257-014-0099-z Gollnick, H. P., Bettoli, V., Lambert, J., Araviiskaia, E., Binic, I., Dessinioti, C., … Dréno, B. (n.d.). A consensus-based practical and daily guide for the treatment of acne patients. Journal of the European Academy of Dermatology and Venereology. doi: 10.1111/jdv.13675 Gollnick, H. P. M. (2015). From new findings in acne pathogenesis to new approaches in treatment. Journal Of The European Academy Of Dermatology And Venereology: JEADV, 29 Suppl 5, 1–7. doi:10.1111/jdv.13186 Kurokawa, I., & Ohyama, M. (2015). Revisiting the dogma of acne pathogenesis. The British Journal Of Dermatology, 172(4), 851. doi:10.1111/bjd.13654 Li, X., He, C., Chen, Z., Zhou, C., Gan, Y., & Jia, Y. (2017). A review of the role of sebum in the mechanism of acne pathogenesis. Journal Of Cosmetic Dermatology, 16(2), 168–173. doi:10.1111/jocd.12345 Mazioti, M. (2017). Chemical environmental factors: Can they affect acne? Indian Journal Of Dermatology, Venereology And Leprology, 83(5), 522–524. doi:10.4103/ijdvl.IJDVL_736_16 Melnik, B. C., & Zouboulis, C. C. (2013). Potential role of FoxO1 and mTORC1 in the pathogenesis of Western diet-induced acne. Experimental Dermatology, 22(5), 311–315. doi: 10.1111/exd.12142 Momen, S., & Al-Niaimi, F. (2015). Acne vulgaris and light-based therapies. Journal Of Cosmetic And Laser Therapy: Official Publication Of The European Society For Laser Dermatology, 17(3), 122–128. doi: 10.3109/14764172.2014.988727 Paithankar, D. Y., Sakamoto, F. H., Farinelli, W. A., Kositratna, G., Blomgren, R. D., Meyer, T. J., … Anderson, R. R. (2015). Original Article: Acne Treatment Based on Selective Photothermolysis of Sebaceous Follicles with Topically Delivered Light-Absorbing Gold Microparticles. Journal of Investigative Dermatology, 135, 1727–1734. doi: 10.1038/jid.2015.89 Reena Rai, & Karthika Natarajan. (2013). Laser and light based treatments of acne. Indian Journal of Dermatology, Venereology and Leprology, (3), 300. doi:10.4103/0378-6323.110755 Suh, D. H., & Kwon, H. H. (2015). What’s new in the physiopathology of acne? The British Journal Of Dermatology, 172 Suppl 1, 13–19. doi:10.1111/bjd.13634 Tanghetti, E. A. (2013). The role of inflammation in the pathology of acne. The Journal Of Clinical And Aesthetic Dermatology, 6(9), 27–35. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=mnh&AN=24062871&site=eds-live Wang, B., Wu, Y., Luo, Y.-J., Xu, X.-G., Xu, T.-H., Chen, J. Z. S., … Li, Y.-H. (2013). Combination of intense pulsed light and fractional CO(2) laser treatments for patients with acne with inflammatory and scarring lesions. Clinical And Experimental Dermatology, 38(4), 344–351. doi: 10.1111/ced.12010 Wiznia, L. E., Stevenson, M. L., & Nagler, A. R. (2017). Laser treatments of active acne. Lasers In Medical Science, 32(7), 1647–1658. doi:10.1007/s10103-017-2294-7 Zouboulis, C. C., Jourdan, E., & Picardo, M. (2014). Acne is an inflammatory disease and alterations of sebum composition initiate acne lesions. Journal Of The European Academy Of Dermatology And Venereology: JEADV, 28(5), 527–532. doi:10.1111/jdv.12298

What is Polycystic Ovarian Syndrome (PCOS)? Polycystic Ovarian Syndrome (PCOS) is the most common endocrinological disorder within the female population and is characterised by clinical hyperandrogenism, ovulatory dysfunction and polycystic ovarian morphologic features. According to present statistics PCOS approximately affects between 10-15% of reproductive aged women. Although, these prevalence rates do vary amongst ethnic origin, race and other environmental factors. Currently the exact pathogenesis of PCOS is unclear and not yet completely understood. It has been postulated through evidence that PCOS is a genetic disorder resultant of high androgen levels which result in hyperandrogenemia. PCOS is associated with an increased risk of cardiovascular disease, hypertension, dyslipidaemia and impaired glucose tolerance or type 2 Diabetes. Additionally, PCOS also brings many reproductive and health implications such as, higher rates of obstructive sleep apnoea, non-alcoholic steatohepatitis, menstrual cycle disturbances, fertility problems, obesity and psychiatric disorders including anxiety, depression, eating disorders and an overall decreased quality of life. Common skin conditions linked with PCOS Due to the elevation in circulating androgen levels, approximately 40 per-cent of PCOS patients present with various cutaneous manifestations comprising hirsutism, acne, acanthosis nigricans and psoriasis. Hirsutism: Hirsutism is an indicator of elevated serum androgen levels and is characterised by the conversion of fine, non-pigmented, short vellus hairs into coarse, stiff, dark terminal hairs. These terminal hairs present in a male pattern distribution in the chin, upper-lip, chest, upper and lower back, upper and lower abdomen, upper arm, thighs and buttocks areas. It is estimated up to 60% of women with PCOS will extant with hirsutism, although the commonness does vary significantly amongst ethnicities. Acne: Acne is a multifactorial skin disorder of the pilosebaceous unit, and it has been affirmed that over 90% of PCOS sufferers have been diagnosed with acne. In PCOS patients ovarian and adrenal androgens stimulate the production of acne by binding to androgen receptors on the pilosebaceous unit. This action increases the sebaceous gland size, activates sebum production and causes abnormal follicular epithelial cell keratinisation. The sebum production leads to Propionibacterium acnes (P.acnes) overgrowth and then triggers the pathways that result in the formation of inflammatory acne lesions. Women with PCOS present with predominantly inflammatory lesions on the lower face, neck and chest and upper aspect of the back. Acanthosis Nigricans: Acanthosis Nigricans is a marker of insulin resistance and is caused by hyperinsulinemia and increased binding of excessive serum insulin to insulin-like growth factor 1 (IGF-1). Acanthosis Nigricans presents with velvety, thickened, hyperpigmented patches on the nape, axilla, groin and antecubital fossa, and affects 50 per-cent of obese women with PCOS, and 5-10 per-cent of non-obese women with PCOS. Psoriasis: Psoriasis is a chronic inflammatory, immune mediated skin disease characterised by marked proliferation of keratinocytes leading to pronounced epidermal hyperplasia elongation of rete ridges and hyperkeratosis, and recently research has demonstrated that in psoriatic populations the prevalence of PCOS is remarkably greater, although the mechanism of this correlation is currently unknown. Treatment options and the Dermal Clinician Laser hair removal or Intense Pulsed light (IPL): Laser hair removal and IPL are effective treatment for the management of hirsutism and if successful can positively impact the patient’s emotional burden and quality of life. These modalities target melanin (pigment) within the hair bulb with the aim to destruct the hair follicles that are within the anagen phase. This treatment requires multiple sessions, and it is recommended that hormonal agents are administered and used concurrently to maximise the treatment results. Intense Pulsed Light (IPL): IPL relies on a combination of photochemical and photothermal mechanisms of action. Owing to IPL’s wide range of visible and near-infra red light spectrum it has been used for some time in the treatment and management of acne. The theory behind the success of IPL in the treatment of acne is based upon the photochemical and photothermal effects on the bacteria- derived porphyrins, as well as the inflammatory cells which mediate the inflammatory cascade and heating of the sebaceous glands. Near-infrared laser: Near-infrared lasers have been used in the treatment of acne lesions owing to its potential to target the depth in the skin where sebaceous glands are located. The near-IR pulse heats the dermal volume encompassing the sebaceous glands, whilst the epidermal cooling method preserves the epidermis from thermal damage. Monopolar Radiofrequency (RF): RF has been employed for the successful treatment of acne owing to its abilities in reducing perifollicular inflammation and sebaceous glands, however it is highly endorsed when treating inflammatory acne lesions that RF should be combined with IPL for greatest outcomes. Retinoids: Dependant on the severity of the acne, topical retinoids can be used independently or alongside other agents. Topical retinoids possess anti-inflammatory properties and have a comedolytic action, therefore they are able to normalise desquamation of keratinocytes. Low-Level Laser Therapy (LLLT) and Light Emitting Diodes (LED): LLLT and LED devices have been recognised in the treatment of acne due to their photochemical effects. Blue light, at a wavelength of 407-420nm exhibits the strongest porphyrin photoexcitation coefficient and therefore is the most effective wavelength in photo activating the endogenous porphyrins contained in P. acnes. Whilst red light, through its ability to penetrate the skin deeper than blue light and reach the sebaceous glands it is capable of inducing an anti-inflammatory effect. Isotretinoin: Isotretinoin is the only acne medication that targets all of the pathophysiological factors of acne, and is only administered in severe acne cases, where first line treatments have elicited no successful response. This is administered by Dermatologists only however the Dermal Clinician may support this intervention through skin health management. Owing to the nature of these conditions and due to their ability to greatly affect ones self-image and psychological state, PCOS patients will commonly seek assistance from a Dermatologist, Endocrinologist, General Practitioner and Dermal Clinician. Therefore it is important for clinicians to gain a greater understanding and awareness of these conditions and the presently available treatment options in order to manage these patients collaboratively and inter-professionally with fellow health care professionals. References Acmaz, G., Cınar, L., Acmaz, B., Aksoy, H., Kafadar, Y. T., Madendag, Y., … Muderris, I. (2019). The Effects of Oral Isotretinoin in Women with Acne and Polycystic Ovary Syndrome. BioMed Research International, 2019, 1-5. doi:10.1155/2019/2513067 Balen, A. H. (2017). Polycystic ovary syndrome ( PCOS). Obstetrician & Gynaecologist, 19(2), 119–129. https://doi-org.wallaby.vu.edu.au:4433/10.1111/tog.12345 Buzney, E., Sheu, J., Buzney, C., & Reynolds, R. V. (2014). Polycystic ovary syndrome: A review for dermatologists: Part II. Treatment. Journal of the American Academy of Dermatology, 71(5), 859. https://doiorg.wallaby.vu.edu.au:4433/10.1016/j.jaad.2014.05.009 Dierickx, C. C. (2004). Lasers, Light and Radiofrequency for Treatment of Acne. Medical Laser Application, 19(4), 196-204. doi:10.1078/1615-1615- 00143 Feng, J., Guo, Y., Ma, L., Xing, J., Sun, R., & Zhu, W. (2017). Prevalence of dermatologic manifestations and metabolic biomarkers in women with polycystic ovary syndrome in north China. Journal of Cosmetic Dermatology, 17(3), 511-517. doi:10.1111/jocd.12387 Housman, E., & Reynolds, R. V. (2014). Polycystic ovary syndrome: A review for dermatologists. Journal of the American Academy of Dermatology, 71(5), 847.e1-847.e10. doi:10.1016/j.jaad.2014.05.007 Kini, S., & Ramalingam, M. (2018). Hirsutism. Obstetrics, Gynaecology & Reproductive Medicine, 28(5), 129–135. https://doiorg.wallaby.vu.edu.au:4433/10.1016/j.ogrm.2018.03.004 Momen, S., & Al-Niaimi, F. (2014). Acne vulgaris and light-based therapies. Journal of Cosmetic and Laser Therapy, 17(3), 122-128. Doi:10.3109/14764172.2014.988727 Moro, F., Tropea, A., Scarinci, E., Federico, A., De Simone, C., Caldarola, G., … Apa, R. (2015). Psoriasis and polycystic ovary syndrome: a new link in different phenotypes. European Journal of Obstetrics & Gynecology and Reproductive Biology, 191, 101-105. Doi:10.1016/j.ejogrb.2015.06.002 Pace, J. L. (2015). Acne - a potential skin marker of internal disease. Clinics in Dermatology, 33(5), 572-578. Doi:10.1016/j.clindermatol.2015.05.010 Pace, J. L. (2015). Acne - a potential skin marker of internal disease. Clinics in Dermatology, 33(5), 572-578. Doi:10.1016/j.clindermatol.2015.05.010 Rai, R., & Natarajan, K. (2013). Laser and light based treatments of acne. Indian Journal of Dermatology, Venereology, and Leprology, 79(3), 300. Doi:10.4103/0378-6323.110755 Wiznia, L. E., Stevenson, M. L., & Nagler, A. R. (2017). Laser treatments of active acne. Lasers in Medical Science, 32(7), 1647-1658. doi:10.1007/s10103-017- 2294-7 Yasa, C., Dural, Ö., Bastu, E., & Uğurlucan, F. G. (2016). Hirsutism, Acne, and Hair Loss: Management of Hyperandrogenic Cutaneous Manifestations of Polycystic Ovary Syndrome. Gynecology Obstetrics & Reproductive Medicine, 1. Doi:10.21613/gorm.2016.613

Mini Series Part 2 Rosacea prone skins may react to extrinsic or intrinsic stimuli that would not usually trigger an immune response in healthy skins, and these stimuli that worsen the condition can vary between individuals. Treatment must start with identifying and avoiding individual triggers, the most important being avoidance of ultraviolet radiation from environmental exposure, as it is considered a common trigger which causes inflammation in all rosacea subtypes. UVR exposure contributes to vascular changes and a dysregulation of the innate immune response, with studies suggesting that UVR may initiate the condition in genetically-prone people, as well as contributing to flare-ups. UVR exposure damages keratinocytes leading to an increase in reactive oxidative species (ROS), an increased degradation of collagen by MMP’s and an upregulation of the antimicrobial protein cathelicidin as part of the innate immune response. UV damage also contributes to an impaired barrier function through an increased alkaline pH, increased trans-epidermal water loss and reduced stratum corneum hydration levels, intensifying the immune response and exacerbating the typical presentation of erythema and telangiectasia. Physical and environmental factors such as heat, humidity, hot weather, wind, intense cold, strenuous exercise, use of saunas and hot baths, consumption of spicy foods, hot beverages and alcohol which raise body temperature may trigger a flare up. In particular, red wine has a vasodilatory effect, contributing to the typical presentation of phymatous rosacea: enlarged sebaceous glands, thickened skin, inflammatory lesions and telangiectasia on the nose. Further evidence suggests a dysregulated microbiome comprising bacteria or Demodex mites may trigger an innate immune response, so the promotion of a healthy varied diet is important. Some cosmetic and skincare products may be comedogenic and therefore worsen the condition, such as those containing alcohol, witch hazel or fragrances. Intrinsic factors such as emotional stress and anxiety, or physiological actions of hormones may also contribute to rosacea severity. It is suggested that a high Glycemic Index diet, from foods high in histamine, citrus foods or dairy products may exacerbate the presentation of rosacea. Smokers have an increased risk of developing the erythematotelangiectatic (ETR) rosacea subtype. Chemical triggers including nicotine, acetones and other toxic components often found in tobacco smoke contribute to the visible effects of an erythematous skin. Nicotine causes vasoconstriction of the skin’s microcirculation, one of the detrimental effects of smoking on the skin in particular, making it a risk factor for the development of rosacea. Of course, the negative effect of smoking on all other body systems is well documented, and should then be avoided. Medications such as topical steroids, niacin and beta blockers may act as trigger factors. To assist in identifying potential triggers, individuals could keep a journal of lifestyle and activities, diet and medications, for example, so they know what to avoid. TREATMENTS The condition of Rosacea often presents as a combination of the various features of the subtypes; therefore, a combination of therapies may be used to optimise treatment results. Treatment should be personalised to take into account patient preference, symptoms and presentation, severity of the condition and individual trigger factors. Inflammatory targets in rosacea skins can be repressed by more than one treatment or intervention, another benefit of combination therapy. Darker Fitzpatrick skin types must also consider longer wavelengths and lower fluence when treating with laser to avoid post inflammatory hyperpigmentation. Dermal Clinicians will assess the current manifestations their client presents with, devise treatment plans through a thorough consultation including medical history, advise on appropriate skin care and will reassess regularly with their clients throughout the course of treatment. Treatment options include topical preparations, oral or systemic medications and laser or light-based modalities, with systemic medication and physical modalities often combined to produce best results. Although it is beyond the scope of a Dermal Clinician to prescribe medication, they can inform clients of the drugs available to treat rosacea, and play a vital role in supporting clients during treatment and afterward with maintenance of results. The clinician’s role includes managing the client’s expectations for the timeline of long-term improvement, based on the client’s own goals. Steps in treatment include controlling and clearing inflammatory lesions such as papules and pustules through medications such as tetracycline and isotretinoin, and long-term suppression of erythema, inflammation and visible vessels using laser/IPL modalities. Laser/light-based treatments will produce the best results for treating the vascular abnormalities (telangiectasia) of Rosacea, and the patient may need 1-4 sessions. Energy from the laser wavelength is absorbed by the chromophore haemoglobin, enabling the treatment of vascular lesions in the skin, as topical and systemic medications will not be effective in treating telangiectasia. Patient education regarding the relapsing nature of rosacea, gentle skincare, topical and systemic medications and physical modalities make up an effective and comprehensive management program for the treatment of cutaneous rosacea. Subtypes including phymatous and ocular rosacea require medical interventions, however a Dermal Clinician can possibly assist with laser treatments in conjunction with medical specialists, in the maintenance phase of treatment. The Global Rosacea Consensus panel (ROSCO) recommends treatment options for inflamed phymatous rosacea including surgical excision (electrocoagulation), dermabrasion, Pulsed Dye laser, IPL and Carbon dioxide laser ablation. Treatment for ocular rosacea requires referral to an Ophthalmologist. Skincare A clinician-designed skincare routine is a vital component of rosacea management to improve and maintain barrier function, and optimize results from other treatments. Skincare is important both in skin priming prior to treatments, and is also restorative post treatment. Skincare ingredients which assist in the management of rosacea include peptides, vitamin A (retinoids), vitamin C (L-ascorbic acid), Vitamin E (tocopherol), vitamin B3 (niacinamide) vitamin B5 (panthenol), and allantoin. Dermal Clinicians are invaluable in providing clients with the most effective skincare products and education as to their best use, in order to improve skin integrity and alleviate rosacea symptoms. Retinoids (vitamin A derivatives) assist in desquamation, encourage cellular turnover, upregulate the synthesis of collagen, enhance angiogenesis providing greater tissue oxygenation, and regulate immune responses. Through these and many other long-term beneficial clinical effects, retinoids are advisable in daily skincare routines and are also able to accelerate post procedural wound healing in rosacea treatment. While retinoids will produce desirable clinical results, it is important to consider the most appropriate formulation that will not irritate or cause further sensitivity. Niacinamide improves epidermal strength and barrier function, important in barrier-impaired rosacea skins, and L-Ascorbic Acid and tocopherol work synergistically as powerful antioxidants to improve skin defence and aid wound healing. Morning skincare routine: Basic skin cleanser (pH balanced, non-foaming, non-alkaline, fragrance free e.g. Cetaphil) Emollient moisturiser (silicone based) SPF 50+ broad spectrum UVA/UVB Physical Sunblock (zinc oxide) Antioxidant serum (Vitamins C and E) Evening skincare routine: Basic skin cleanser Retinoid Antioxidant serum (used only at night at retinols are photosensitizing) Emollient moisturizer (restorative and occlusive) Topical Agents (prescribed by a Doctor) Ivermectin – anti-parasitic drug which reduces inflammatory lesions and is useful in maintenance Brimonidine – vasoconstrictor topical gel to treat persistent erythema Oxymetazoline - topical alpha-adrenergic agonist and vasoconstrictor Intradermal botulinum toxin A injections - for flushing and erythema Azelaic acid - anti-inflammatory, reduces papular and pustular lesions Benzoyl peroxide Dapsone Permethrin Clindamycin Erythromycin Beta blockers – Carvedilol (reduces redness) Antihypertensive drugs Retinoids – anti-inflammatory Metronidazole – scavenges free radicals and inhibits ROS production Oral Medications (Doctor prescribed) Tetracycline - inhibits inflammatory mediators Doxycycline – downregulates many inflammatory mediators in the inflammatory rosacea cascade Minocycline Low dose Isotretinoin (retinoids) however there are common side effects of dry skin and eyes due to the drug’s effects on the pilosebaceous unit. It is contraindicated in pregnancy. Zinc sulphate – reduces inflammatory lesions Azithromycin Clarithromycin Modalities available to Dermal Clinicians Dual frequency ultrasound – reduces erythema and trans-epidermal water loss and improves barrier function Fractional microneedling Radiofrequency Pulsed dye laser (595nm) treats diffuse redness IPL (560nm) is safe and effective to target haemoglobin Dual wavelength 775nm alexandrite/ 1064nm neodymium: yttrium-aluminum (Nd: YAG) 1064nm Nd: YAG laser is the best choice for Fitzpatrick skin types IV-VI to minimize the risk of post inflammatory hyperpigmentation.) Frequency-doubled potassium titanyl phosphate (KTP) laser 532nm Non ablative fractional resurfacing laser Gel based AHA peel BHA peels for acne rosacea Ongoing Management Sun protection (broad spectrum) at all times, or avoidance of exposure where possible. Use of physical zinc oxide sunscreen is preferable. Avoid stimulants, and patient-specific triggers (keep face cool) Use water based make up (avoid oil based) Use concealers to cover redness (low allergenic, mineral make up) Avoid skincare products containing alcohol and astringents, or abrasive exfoliants Avoid chemical sunscreens if sensitivity occur Avoid corticosteroids Use basic daily skin care to improve barrier function Seek advice from a Dermatologist if necessary Seek Counselling if necessary, taking into account the debilitating nature of the condition Avoid aggressive exfoliation or abrasive skin lightening ingredients Mineral makeup is well tolerated and will help to conceal redness References Alexis, A. F., Callender, V. D., Baldwin, H. E., Desai, S. R., Rendon, M. I., & Taylor, S. C. (2019). Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: Review and clinical practice experience. Journal of the American Academy of Dermatology, 80(6), 1722-1729.e7. https://doi.org/10.1016/j.jaad.2018.08.049 Alinia, H., Tuchayi, S. M., Patel, N. U., Patel, N., Awosika, O., Bahrami, N., Cardwell, L. E., Richardson, I., Huang, K. E., & Feldman, S. R. (2018). Rosacea Triggers: Alcohol and Smoking. Dermatol Clin, 36, 123-126. https://doi.org/10.1016/j.det.2017.11.007 Baumann, L. (2016). Validation of a Questionnaire to Diagnose the Baumann Skin Type in All Ethnicities and in Various Geographic Locations. Journal of Cosmetics, Dermatological Sciences and Applications, 06(01), 34-40. https://doi.org/10.4236/jcdsa.2016.61005 Cices, A., & Alexis, A. F. (2019). Patient-focused Solutions in Rosacea Management: Treatment Challenges in Special Patient Groups. Journal of Drugs in Dermatology, 18(7), 608-612. Del Rosso, J. Q. (2016). Cutaneous rosacea: a thorough overview of pathogenesis, clinical presentations, and current recommendations on management. Vestnik Dermatologii i Venerologii, 0(2), 32-40. https://doi.org/10.25208/0042-4609-2016-0-2-32-40 Del Rosso, J. Q., Tanghetti, E., Webster, G., Gold, L. S., Thiboutot, D., & Gallo, R. L. (2019). Update on the Management of Rosacea from the American Acne & Rosacea Society (AARS). Journal of Clinical and Aesthetic Dermatology, 12(6), 17-24. (n.d.). DermNet NZ – All about the skin | DermNet NZ. https://dermnetnz.org Dual-frequency ultrasound as a new treatment modality for refractory rosacea: A retrospective study of 42 cases. (2018). Journal of the American Academy of Dermatology, 79(3), AB113. https://doi.org/10.1016/j.jaad.2018.05.482 Dursun, R., Daye, M., & Durmaz, K. (2019). Acne and rosacea: What's new for treatment? Dermatologic Therapy, 32, 1-4. Doi: 10.1111/dth.13020 Elewski, B., Draelos, Z., Dréno, B., Jansen, T., Layton, A., & Picardo, M. (2010). Rosacea -global diversity and optimized outcome: proposed international consensus from the Rosacea International Expert Group. Journal of the European Academy of Dermatology and Venereology, 25(2), 188-200. https://doi.org/10.1111/j.1468-3083.2010.03751.x Emer, J., Weinkle, A., & Doktor, V. (2015). Update on the management of rosacea. Clinical, Cosmetic and Investigational Dermatology, 159. https://doi.org/10.2147/ccid.s58940 Engin, B., Özkoca, D., Kutlubay, Z., & Serdaroğlu, S. (2020). <p>Conventional and Novel Treatment Modalities in Rosacea. Clinical, Cosmetic and Investigational Dermatology, Volume 13, 179-186. https://doi.org/10.2147/ccid.s194074 Evaluation of the safety and effectiveness of microfocused ultrasound with visualization (MFU-V) for the treatment of erythematotelangiectatic rosacea. (2014). Journal of the American Academy of Dermatology, 70(5), AB43. https://doi.org/10.1016/j.jaad.2014.01.178 Feaster, B., Cline, A., Feldman, S. R., & Taylor, S. (2019). Clinical effectiveness of novel rosacea therapies. Current Opinion in Pharmacology, 46, 14-18. https://doi.org/10.1016/j.coph.2018.12.001 Gallo, R. L., Granstein, R. D., Kang, S., Mannis, M., Steinhoff, M., Tan, J., & Thiboutot, D. (2018). Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. Journal of the American Academy of Dermatology, 78(1), 148-155. https://doi.org/10.1016/j.jaad.2017.08.037 Hofmann, M. A., & Lehmann, P. (2016). Physical modalities for the treatment of rosacea. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 14, 38- 43. https://doi.org/10.1111/ddg.13144 Holmes, A. D., & Steinhoff, M. (2016). Integrative concepts of rosacea pathophysiology, clinical presentation and new therapeutics. Experimental Dermatology, 26(8), 659- 667. https://doi.org/10.1111/exd.13143 Juliandri, J., Wang, X., Liu, Z., Zhang, J., Xu, Y., & Yuan, C. (2019). Global rosacea treatment guidelines and expert consensus points: The differences. Journal of Cosmetic Dermatology, 18(4), 960-965. https://doi.org/10.1111/jocd.12903 Kucukunal, A., Altunay, I., Arici, J. E., & Cerman, A. A. (2015). Is the effect of smoking on rosacea still somewhat of a mystery? Cutaneous and Ocular Toxicology, 1- 5. https://doi.org/10.3109/15569527.2015.1046184 Levin, M. K., Juhasz, M. L., & Marmur, E. S. (2016). An Update on Combination Treatments with Fractional Resurfacing Lasers. Current Dermatology Reports, 5(3), 191- 199. https://doi.org/10.1007/s13671-016-0145-6 McCoy, W. H. (2020). “Shedding Light” on How Ultraviolet Radiation Triggers Rosacea. Journal of Investigative Dermatology, 140(3), 521-523. https://doi.org/10.1016/j.jid.2019.09.008 Oge, L. K., Muncie, H. L., & Phillips-Savoy, A. R. (2015). Rosacea: Diagnosis and Treatment. American Family Physician, 92(3), 188-197. Oltz, M., & Check, J. (2011). Rosacea and its ocular manifestations. Optometry - Journal of the American Optometric Association, 82(2), 92-103. https://doi.org/10.1016/j.optm.2010.01.015 Rosacea.org - National Rosacea Society. https://rosacea.org Salleras, M., Alegre, M., Alonso-Usero, V., Boixeda, P., Domínguez-Silva, J., Fernández- Herrera, J., García-Navarro, X., Jiménez, N., Llamas, M., Nadal, C., Del Pozo- Losada, J., Querol, I., Salgüero, I., Schaller, M., & Soto de Delás, J. (2019). Spanish Consensus Document on the Treatment Algorithm for Rosacea. Actas Dermo- Sifiliográficas (English Edition), 110(7), 533-545. https://doi.org/10.1016/j.adengl.2019.01.018 Select treatments for rosacea based on signs, symptoms and severity. (2015). Drugs & Therapy Perspectives, 31(3), 93-96. https://doi.org/10.1007/s40267-015-0187-z Steinhoff, M., Schmelz, M., & Schauber, J. (2016). Facial Erythema of Rosacea – Aetiology, Different Pathophysiologies and Treatment Options. Acta Dermato Venereologica, 96(5), 579-586. https://doi.org/10.2340/00015555-2335 Thiboutot, D., Anderson, R., Cook-Bolden, F., Draelos, Z., Gallo, R., Granstein, R., Kang, S., Macsai, M., Gold, L. S., & Tan, J. (2020). Standard Management Options for Rosacea: the 2019 Update by the National Rosacea Society Expert Committee. Journal of the American Academy of Dermatology. https://doi.org/10.1016/j.jaad.2020.01.077 Two, A. M., Wu, W., Gallo, R. L., & Hata, T. R. (2015). RosaceaPart II. Topical and systemic therapies in the treatment of rosacea. J Am Acad Dermatol, 72(5), 761- 770. http://dx.doi.org/10.1016/j.jaad.2014.08.027 Van Zuuren, E., & Fedorowicz, Z. (2015). Interventions for rosacea: abridged updated Cochrane systematic review including GRADE assessments. British Journal of Dermatology, 173(3), 651-662. https://doi.org/10.1111/bjd.13956 Van Zuuren, E. J., & Fedorowicz, Z. (2016). Low-Dose Isotretinoin: An Option for Difficult-to-Treat Papulopustular Rosacea. Journal of Investigative Dermatology, 136(6), 1081-1083. https://doi.org/10.1016/j.jid.2016.03.003 Wollina, U. (2019). Is rosacea a systemic disease? Clinics in Dermatology, 37(6), 629- 635. https://doi.org/10.1016/j.clindermatol.2019.07.032

By Pia Kynoch, Naturopath. The ASDC asked Pia, a well respected Naturopath and Clinic Owner about her thoughts on Female Hormones and Acne. Women and their hormones are incredibly individual which is why unravelling the specifics behind why acne vulgaris is presenting for your client can be very challenging. Besides from overall skin health, hormones play a vital role towards one’s well being, such as their emotional and mental health. This adds another dimension to the sensitivities of skin issues, treatment protocols, expectations, satisfaction and progress, for both the skin practitioner and client. It is important to keep in mind that with over 50 different hormones functioning with such complex interlinking pathways (many of which science still doesn’t have a great grasp on), the term “hormonal imbalance” is solely descriptive and no diagnosis can be made until thorough testing has taken place. Before and during adolescence, we can expect changes in our hormones (especially testosterone) to create the development and subsequent secretions of the sebaceous glands. However, when it comes to what exactly is happening in a acneic skin it is very multifactorial. Acne is a result of a combination of factors that are increased and up regulated in the body such as; hormonal activity, inflammation, our adaptive immunity, sebaceous gland activity, keratinisation, microbial hyper-colonisation and abnormal follicular differentiation. Although most people generally consider acne being prevalent among adolescence, skin practitioners are well aware that adult acne is a common problem that many women face. Current research indicates the prevalence is increasing, particularly in women aged between 25 and 44, with persistent acne as the most common (noted in 75% to 85% of cases), and although late-onset acne is far less common (reported only in 20% to 40% of women in this age group) the statistics are still high. Another important factor to consider is stress. Unfortunately, stress in which is so ubiquitous and chronic in our modern life, is a well known and inevitable factor affecting the health and quality of women’s lives. Stress is suggested as a precipitating and exacerbating factor towards the development of acne through multiple pathways. The hypothalamic–pituitary–adrenal (HPA) axis is the primary mediator of our central stress response system, and its activity mediates functions of both the hypothalamic–adrenal–gonadal (HPG) and hypothalamic–adrenal–thyroid (HPT) axis. The HPA, HPG and HPT axis do not act independently of each other, rather they are intrinsically and powerfully linked. Environmental hormone-like substances (endocrine-disrupting chemicals or EDCs), other environmental toxins, medications, recreational drugs, diet, poor sleep, gut health, and poor elimination of excess hormones will also participate in modifying hormonal responses within these axes. The diverse functioning of the three axes (HPA, HGP and HPT) are strongly interconnected that any changes in one will manipulate or modify changes in the other, with repercussions that can be local and/or systemic as well as acute or long term. There is a big assumption that acne breakouts only occur with imbalances of our hormones such as testosterone, oestrogen, and progesterone. Yet, stress through the production of cortisol and variations with our thyroid hormones can also play a huge role in the development of acne. The steroid biosynthesis pathway that makes our steroid sex hormones and the glucocorticoid “stress” hormone known as cortisol come from the same precursor molecule, which becomes an issue when stress is chronic. The function of our liver is also a very important piece of the acne puzzle! The liver significantly contributes to overall homeostasis and responses during stress in combination with our steroid sex hormones. They are all interconnected. Initially, our body will follow the command of the HPA axis stress signalling pathway leading to the production of cortisol which is required to keep the body in ‘fight or flight’ mode. This leaves less precursors available for the production of sex hormones, particularly progesterone which upregulates ovarian and adrenal androgen production. These androgens are testosterone (T), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), androstenedione, and androstenediol. Although most of our oestrogen is produced in the ovaries small amounts are also produced in our adrenal glands and fat cells. For instance, progesterone is produced in the ovaries, adrenal glands and placenta. There are specific progesterone and oestrogen ratios which allows for a balanced, functioning system. Besides from inhibiting optimal HPG axis activity, excess cortisol also has a systemic catabolic effect on the body that promotes insulin resistance (IR), abdominal fat storage and inflammation. The more fat we store and the longer our stress continues, the greater the insulin resistance which can then lead to hyperinsulinemia. Furthermore, continued aggravation of the HPA axis means additional upregulation of ovarian androgen production and adrenal androgen secretion. At the same time, androgen production increases, which puts stress on the liver, which will produce less sex hormone binding globulin (SHBG). This SHBG is a very specialised protein that binds hormones in the blood until signalled to release them at specific target sites. Without SHBG, free androgen concentration plays havoc, and a vicious cycle is created. Androgen excess means that androgen production is dysfunctional and inadequate conversion of oestrogens occurring. (Our most common oestrogens are oestradiol- the most potent, oestrone, and oestriol. The aromatisation of androstenedione and testosterone creates oestrone and estradiol, respectively). Hyperandrogenic states induce IR and hyperinsulinemia, thus promoting abdominal fat deposition. With increasing fat deposition, secretion of inflammatory cytokines, triggering HPA hyperreactivity leads to signalling of extra androgen by both the ovaries and adrenal glands. Androgens attach easily to receptors found in the skin and increase activity of 5a-reductase enzyme, which converts Testosterone into a form 10x more powerful called dihydrotestosterone (DHT). It is DHT that promotes acne via growth of the sebaceous gland, increased sebum production and hyperkeratinization. The increased inflammation and hyperinsulinemia will interfere with immune function, slowing healing. So how does oestrogen and progesterone fit into all of this? Oestrogen dominance, due to either excess being endogenously produced (especially from fat stores), unmetabolized oestrogen being reabsorbed, recirculated, exogenously introduced (xeno-oestrogens and/or synthetic oestrogens), or a lack of progesterone is now considered by many naturopaths and allied health professionals to be the most common endocrine disorder in adult women. Premenstrual and ovulation breakouts are related to our oestrogen to progesterone ratios. Each month a woman at reproductive age will move through each of the 4 very unique phases of a menstrual cycle, with each phase having very unique emotional and physical needs. Our cycle contains powerful information, and how we are travelling through each of these 4 cycles can be a window into how the rest of our body systems are functioning. Acne is a frustrating condition, especially along with the anxiety it creates. Acne often creates distress. Without properly diagnosing the cause will mean it will be much more challenging to resolve it. It is always a multi-dimensional journey into wellness! Below are some tips on what you can do to help: Track your menstrual cycles and secretions, and learn to listen to the language of your body Maintain a normal weight, with a good muscle to fat ratio. Eat a diet rich in a wide variety of vegetables and some fruits. At least five to nine servings of organic produce favouring vegetables over fruits is ideal Ensure there is a wide range of fibres, phytonutrients, minerals and vitamins in your diet Increase good fats, especially mono, polyunsaturated and omega 3’s. Also ensure you have an above adequate Vitamin D3 Support liver detoxification processes, and improve the process of oestrogen elimination Identify, acknowledge and find ways to start decreasing the lifestyle or dietary choices that contribute to unrelenting chronic stress. Find extra support through rest, restorative activities such as yoga and mindfulness or other mind-body stress-relief techniques. Seek any emotional processing support and social connection Rest is truly transformative Support your adrenal and thyroid function with specific supplementation (under the care of a practitioner) Restore optimal digestive function - this is another hugely complex topic, so there are a myriad of ways in which you may need to support digestive processes that are very individual. Practitioner support may be required to achieve this Decrease exposure to xenoestrogens. Decrease alcohol and coffee consumption. Stop smoking Increase water consumption Search for a practitioner that knows how to support you, or knows someone to refer you onto References Joseph, D., & Whirledge, S. (2017). Stress and the hpa axis: Balancing homeostasis and fertility. International journal of molecular sciences, 18(10), 2224. Brüggemann, M., Licht, O., Fetter, É., Teigeler, M., Schäfers, C., & Eilebrecht, E. (2018). Knotting nets: molecular junctions of interconnecting endocrine axes identified by application of the adverse outcome pathway concept. Environmental toxicology and chemistry, 37(2), 318-328. Charni-Natan, M., Aloni-Grinstein, R., Osher, E., & Rotter, V. (2019). Liver and Steroid Hormones—Can a Touch of p53 Make a Difference?. Frontiers in Endocrinology, 10. Wolkenstein, P., Machovcova, A., Szepietowski, J. C., Tennstedt, D., Veraldi, S., & Delarue, A. (2018). Acne prevalence and associations with lifestyle: a cross‐sectional online survey of adolescents/young adults in 7 European countries. Journal of the European Academy of Dermatology and Venereology, 32(2), 298-306. Rocha, M. A., & Bagatin, E. (2018). Adult-onset acne: prevalence, impact, and management challenges. Clinical, cosmetic and investigational dermatology, 11, 59. Sievert, L. L., Jaff, N., & Woods, N. F. (2018). Stress and midlife women’s health. Women's midlife health, 4(1), 4.

What is a Dermal Clinician? Dermal Clinicians are specialists in skin management and non-surgical treatments and are committed to ethical and evidence-based practice. Dermal health professionals assist in the facilitation and management of both acute and chronic skin conditions, disorders and diseases. They also attentively focus on public health, skin conditions and education and prevention programs. Dermal Clinicians also assess, evaluate and manage risks linked with tissue interactions and advanced therapies in order to guarantee procedures are effective and safe for consumers and patients. What does a Dermal Clinician’s education involve? Dermal Clinicians are those who have undertaken an Australian Society of Dermal Clinicians (ASDC) endorsed bachelor’s degree level of qualification of approximately 3-4 years in length, full time. Many bodily system have the ability to impact the health of the skin therefore, throughout their education, Dermal health professionals cover an extensive array of subjects including; skin and wound biology, nutrition, dermatological conditions and their management and treatment, studies in sciences, such as; laser physics, chemistry, psychology and biology- particularly anatomy and physiology. What is a Dermal Clinician’s scope of practice and what can they treat? Dermal Clinicians promote optimal skin function and integrity through delivering management and treatments in skin health, disease or damage. Dermal health professionals use a holistic approach whereby patient education, topical therapies, therapeutic interventions and clinical procedures may be provided. Dermal Clinicians undertake comprehensive skin health assessments and detailed patient consultations that incorporate medical conditions, medications and lifestyle factors to ensure the provision of effective and safe treatments. Dermal Clinicians commonly treat the following; Acne Rosacea Psoriasis Eczema and dermatitis Xerosis (excessively dry skin) Hyperkeratosis (thickened skin) Photo damage (sun damage) Pigmentary disorders and dyschromia (e.g. uneven pigment, brown spots) Intrinsic and extrinsic ageing (normal and premature ageing) Vascular disorders and conditions (e.g. birthmarks, telangiectasia/dilated capillaries, superficial spider veins on the face and body) Assisting with optimal wound repair for acute and chronic wounds Scar management and minimisation Skin management associated with diabetes, arterial or venous insufficiency and disease Excessive or unwanted pilosity (hair growth) Hyperhidrosis (excessive sweating) Oedema management Lymphoedema Localised adiposity (localised fat deposits) Micro-pigmentation Tattoo removal Career outcomes for Dermal Clinicians and where can they be found working? A referral is not necessary to see a Dermal Clinician, though many patients will have been referred by other health and medical professionals, such as Cosmetic and Plastic Surgeons, Dermatologists, Endocrinologists, General Practitioners and Nurses. Dermal health professionals are independent health practitioners, yet often work inter-professionally and collaboratively with other specialists and health professionals to ensure patients receive specialist advice, assistance and treatments that will result in optimal clinical patient outcomes. Dermal Clinician’s career prospects include: Working collaboratively alongside; Plastic Surgeons (surgical, non-surgical, reconstructive and cosmetic) Dermatologists: Aiding in diagnosing, treating and delivering services and procedures pertaining to skin diseases and conditions Endocrinologists General Practitioner’s Or, independently; as clinical practitioners and allied health professionals in skin cancer clinics: Offering skin checks and early skin cancer detection, in education, training and academia and in research. References The Australasian College Of Dermatologists. (2014). Understanding Dermatology. Retrieved from   https://www.dermcoll.edu.au/ The Australian Society of Dermal Clinicians. (2001). Industry Information. Retrieved from https://www.dermalclinicians.com.au/ Australian Society of Plastic Surgeons. (n.d.). Information For Patients. Retrieved from https://plasticsurgery.org.au/ Skin Smart Australia. (2015). Skin Checks. Retrieved from https://skinsmartaustralia.com.au/

Published and accurate as of 15/3/2020 The WHO announced Covid-19 as a pandemic which has caused a great deal of anxiety and panic as our supermarket shelves can attest to. For Australia these are unprecedented times. The unfamiliar can bring to the fore, subconscious fears and concerns and make everyone feel a little unsure and insecure. As allied health professionals you can and will be the voice of compassion and reason. Ensuring you are well educated and prepared for the coming months is going to be vital. Whilst cases of transmission in Australia are still low (197 as of 6.30am on Saturday 14, 2020) to protect the most vulnerable among our population precautions are needed to slow the progression of this virus. As allied health practitioners our duty of care is to our clients and the public we serve as well as our colleagues, family and friends. With regard to infection control, Dermal Clinicians are well trained in preventing the transmission of any contagious pathogens, whether they be the common cold to blood borne viruses. However, the coming months will require a change in our practices. Therefore it is going to be important to consider ways to protect your businesses and possible economic or operational implications. This blog post will be dedicated to reminding Dermal Clinicians and the broader industry of our obligations for infection control and providing links to some important resources for your businesses. The ASDC are also providing some areas to consider in protecting industry practitioners and their businesses as well as the public. This information is based on advice and information provided with collaboration between AHPA partner professional bodies and recommendations from the Australian federal and state health departments. This is however, information as of this minute. It will be important to stay up to date with alerts and information as it evolves. You can find current information at Coronavirus (COVID-19) health alert and About coronavirus (COVID-19) Covid-19 (Coronavirus) Resources Whilst infection control and prevention of transmission of disease is something we all do as individual practitioners and as clinical practices it is prudent to provide some links and resources to brief your staff and clients. These resources reinforce the steps and roles we can play to prevent transmission of Covid-19 as well as any other seasonal viruses and flus. These events are a timely reminder that clinical governance processes including annual training in these practices is important. It would be a good time to refresh your staff and remind them to ensure they are utilising and adhering to environmental cleaning and equipment processing protocols, as well as the 5-moments of hand hygiene, standard and where necessary additional precautions in client management. It is also important to ensure that the business has considered and is implementing your infection control policies around illness in your workforce and clientele. Reducing risk of contracting coronavirus 1. Ensure that you, your staff and your clientele are looking after themselves, the best defence is a good attack. 2. Educate staff and clients to not come into the clinic if they are unwell with fever, sore throats, coughing and sneezing. 3. Ensure that your bathrooms, reception and public spaces have access to hand sanitiser and tissues as well as how to dispose of them safely. 4. Implement higher level and more frequent environmental cleaning protocols in high traffic areas and on high contact surfaces. Resources 1.Environmental cleaning and disinfection principles for COVID-19 2. Ten ways to reduce your risk of coronavirus 3. Wash your hands regularly - poster 4. Cover your cough and sneeze - poster 5. Coronavirus (COVID-19) resources 6. Coronavirus (COVID-19) resources for health professionals, including aged care providers, pathology providers and healthcare managers 7. Coronavirus (COVID-19) information on the use of surgical masks Wider Implications for your business to consider There are wider implications to consider and prepare for as the situation evolves and more stringent social isolation controls may come into effect over the coming months. The government has announced packages to assist small businesses with the economic impact that changing your business operations and practices may have. You can find more information on the government economic stimulus package and how this may relate to you. Some small businesses may be eligible for financial assistance and rebates. If you are business owner it's also important to seek independent advice. Social distancing: risks and opportunities to business operations and being a socially responsible clinic Many health and allied health professions are beginning to implement the use of tele health as a strategy to both align with possible pending social distancing recommendations and also as a means of maintaining some continuity of business operations and client care. As primary contact practitioners, that don't require a referral for the public to access our services, we will come into contact with clients that may potentially be unwell before they are aware and have symptoms. As resources such as PPE are also diverted to health professions that need these more desperately than we do, there may be implications for the services we offer. Finally there may be times when you, your staff or clients may have to stay home because they themselves are unwell or they are required to care for family. As a business you may want to consider the following: 1. Utilising online tele-conferencing tools such as Skype or Zoom for new client consultations and client education sessions as well as follow up, post procedural checks rather than face to face in the clinic. Skin health evaluations and assessments obviously require in clinic visits however, offering a solution whereby people can still contact you for advice and check in particularly if they are unwell on the day of their appointment will be a method to avoid loosing revenue but also a demonstration of commitment to their physical and emotional well-being. 2. Re-evaluate your online store. Now is the time to look at your online store. You can look at offering online services such as the above consultation, product assessment and advice, or follow up video conference. You may also want to look at your offering of online products or renew how this is offered to ensure that you have another revenue stream if there is a down turn with in-clinic clients. 3. There may be some impact on the services we can perform or ethically should avoid performing given the pressures or precious resources such as PPE. Whilst healthy people and the general public don't require wearing a face mask, those that are unwell and also health care providers are needing access to face masks, particularly N95 respirators to prevent transmission of the virus. It is important for Dermal Clinicians to continue to wear masks when performing face to face assessments where you are coming in contact with clients faces as well as non-intact skin and mucous membranes. In alignment with other health professions that are primary care providers and also come into close contact with client respiration and potential droplet transmission. Dermal Clinicians also wear masks for OHS reasons performing microdermabrasion treatments, skin penetration or laser procedures where particulate or vapourised tissue and bodily fluids or plume may be inhaled. In the coming months we may need to evaluate whether these services are ethically necessary to perform at this point in time. Particularly if pressure on these resources leads to shortages. You may want to consider educating clients that these types of services can wait a few months and offer clinically effective alternatives that don't require these precious resources. This is to ensure that a) health professionals and those that need these masks will be able to access them and b) you don't have to compromise your own best practice infection control and OHS procedures. 4. Developing a working from home policy, contracts and negotiating tasks. If a staff member does require to self isolate at some stage due to their own or their families health, but they can contribute to the business in another way it will be important to have work from home arrangements. Staff may be able to still work by updating policies and procedures, developing client education resources, working on your media and marketing for example or conducting online consultations and follow up. These changes in work arrangements may require considering business operational strategies to support this. Including digital security and access to information or communication strategies. How are the ASDC responding to the Covid-19 and Australian Government response? On Friday 13th, 2020 the government announced that un-necessary large scale events of 500 people or more should be postponed or cancelled for the coming months. This has had implications already with the Grand Prix cancellation as well as potentially other sporting events such as the AFL. Professional bodies are also looking at their own events in the coming months. Jennifer Byrne as the Chairperson and ASDC representative in forums and discussions for AHPA (Allied Health Professions Australia) will be participating in an emergency forum on Friday 20 March. This forum is discussing Covid-19 and its implications to allied health. We will keep you updated on any news that comes out of these meetings that will benefit members. The ASDC have been planning our annual education event that was planned in July in Melbourne this year as well as smaller education days in Brisbane (October) and Sydney (November). However, in light of these recent events and due to the Melbourne event being a large scale event, the ASDC General Committee has decided to cancel our Melbourne event in July. We understand that this may cause some disappointment. We will keep an eye on the situation and evaluate planning for an event later in the year in its place. There are currently discussions around offering in its place an interactive virtual conference and our AGM on our electronic platforms, as well more webinars and smaller scale workshops in the coming months. We have already organised a dermoscopy workshop in April and will work with our industry partners and our members for other exciting opportunities for continuing education. The ASDC are already planning our big 20th birthday next year with a bigger and better conference and gala event, so keep an eye out for more news on this in the coming months and this will be something to put in the calendar and look forward to. Members can also capitalise on other great benefits of membership including the Ausmed learning platform that has some great e-learning modules, including those to brush up on infection control and patient management. All of our ASDC webinars are also now posted to our Ausmed learning platform. Members can read up on the latest evidence with our EbscoHost journal database and blogs straight from the website or our WIX app on their smart devices. To stay up to date with vital information follow us on facebook, instagram and LinkedIn. Members that have concerns or queries on how to handle coming events are encouraged to discuss with their industry colleagues in our facebook members only group or they can also contact the ASDC directly through our website, facebook or email info@dermalclincians.com.au As a parting message from the ASDC General Committee, we will get through these times together as a community working for the common good. We all need to play our part in our small corner of the world and together we can make a difference.

The skin, comprising of three strata’s, encases most of the human body, rendering it the greatest bodily organ. The stratum corneum is the exterior layer of the epidermis, engendering it the initial interaction for the external environment. The stratum corneum operates as a penetrable yet defensive layer against external compounds, and also inhibits the loss of bodily fluids and electrolytes in order to ultimately guarantee the retainment of vital moisture and hydration within the epidermis. Though, the effective performance of the stratum corneum relies wholly on the integrity of its physiological constituents, and the colder months can have immense damaging impacts on these physiological components and hence the skin’s complete functionality and integrity can be destructively influenced, which highlights the gravity of prevention, protection and management of skin barrier elements in the colder seasons. The bearing effects of winter on the skin The winter season entertains an unforgiving impact on the skin’s typical integrity and health, irrespective of age or genetic predisposition. While research states the impediments may not be serious, a sizable emphasis has been placed on winter’s undesirable capabilities to diminish water retentive competencies and hydration levels within the skin, which conclusively pilot a reduced functioning stratum corneum. Consequently, the skin can befit as dry, irritated, erythematous, inflamed, cracked, blistered and pruritic, and what is more, in further unyielding cases where the skin has fissured, secondary bacterial infections may extant. Namely, research has offered numerous considerable causative factors donating to the skins compromised integrity when colder temperatures present, these involve; -Central heating, such as wood burning stoves, fireplaces and heating units which power hot, dry air into the environment and then ensue lowered humidity levels -Tight and restrictive clothing which may foster abrasive friction on the skin’s exteriors - And finally, bathing and showering, as extreme hot water contact with the skin for extended periods of time can disrupt lipid barriers and instigate moisture loss within the skin. Indications of winter’s influence on the skin’s integrity While undoubtedly the exhibition and anatomical locality of Xerosis may diverge among age groups and individual health status’s, the central indicators encompass; - Sensations of pruritis, tautness, stinging, tingling, burning and discomfort, and excoriations may also extant resultant of the sufferer scratching and rubbing with the purpose of easing the related itching and irritation - The sufferer’s skin may lack lustre and bestow as thinner with associated erythema, inflammation, blisters, cracks, scaling, peeling and fine lines - The subject's skin may also be rough, uneven, withered, and dry to palpate - And lastly, it is noteworthy to also declare in more ruthless circumstances accompanying bleeding and secondary infections may display consequential of deep fissures that have reached the dermal capillaries. Winter’s impact on already existing skin conditions Studies propose winter, owing to its aptitude to impair the skin’s barrier, can either exacerbate already existing skin conditions or stimulate their onset. Research states both Eczema and Atopic Dermatitis, chronic inflammatory skin disorders, have the potential to intensify in winter. Both skin aberrations are depicted by dry, pruritic and inflamed skin, and fascinatingly both occupy an advancing incidence in countries distant from the equator, and what’s more, studies have also proposed a notable increase in their prevalence’s among children born during the colder seasons. Further to this, skin conditions exclusive to winter can also develop, for instance Chilblains, which foster on the skin subsequent to exposure of cold climates. Chilblains universally emerge on extremities such as the nose, ears, fingers and toes, and are distinguished by minor, erythematous, pruritic and painful swellings which may blister or ulcerate. Chilblains consequentially appear due to small blood vessel restriction, once the skin reheats again the fluid from the blood vessels escapes into the tissues, ensuing both swelling and inflammation on the skins surface. Prevention, protection and management for patients It is essential to acknowledge that the damaging effects of winter on one’s skin can momentously influence the sufferer’s quality of life and pose limitations on their mundane affairs. Though fortunately, as Dermal Clinicians there are various ways to work collaboratively with patients to assist in the management, prevention and protection of their skin’s integrity during the colder seasons. The recommended preventative and management methods that patients can employ are outlined below; - Avoidance of excessive bed clothes and electric blankets - Avoidance of wearing wool and other irritating and abrasive fabrics, alternatively loose cotton and linens should be introduced - The installation of a humidifier set at sixty degrees Celsius - Avoidance of extended, hot showers, rather showers should be two-three minutes long and it is suggested the water temperature is to be tepid - Avoidance of extended hot bath soaks - Avoidance of rough bathing sponges, scrub brushes and washcloths that may trigger friction and irritation - Avoidance of vigorous rubbing post shower or bathing, preferably the skin should be softly patted dry - Avoidance of soaps, rather a pH balancing wash should be introduced - Application of a moisturiser containing both humectants (ceramides, glycerine, sorbitol, hyaluronic acid and lecithin) and emollients (linoleic and lauric acids) to attract and enclose moisture within the skin - Moisturiser should be applied generously and immediately after bathing or showering - Application of a lip balm throughout the day and before bed to repair and hydrate - Application of keratolytic’s such as salicylic acid, lactic acid or glycolic acid if there is extreme flaking - Administration of oral antihistamines to control and lessen accompanying pruritis - Avoidance of scratching and rubbing affected areas - Avoidance of sweat inducing activities To finish, it is profound to express that research affirms the devising of a prevention and management plan must convene to the individual needs of each sufferer and their distinctive offerings. References Andriessen, A. (2013). Prevention, recognition and treatment of dry skin conditions. British Journal of Nursing, 22(1), 26–30. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=c8h&AN=104409642&site=eds-live Camargo, J. C. A., Ganmaa, D., Sidbury, R., Erdenedelger, K., Radnaakhand, N., & Khandsuren, B. (2014). Randomized trial of vitamin D supplementation for winter-related atopic dermatitis in children. The Journal of Allergy and Clinical Immunology, 134(4), 831–835. https://doi-org.wallaby.vu.edu.au:4433/10.1016/j.jaci.2014.08.002 Dyble, T., & Ashton, J. (2011). Use of emollients in the treatment of dry skin conditions. British Journal of Community Nursing, 16(5), 214–220. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=c8h&AN=104663894&site=eds-live Guenther, L., Lynde, C. W., Andriessen, A., Barankin, B., Goldstein, E., Skotnicki, S. P., … Sloan, K. (2012). Pathway to dry skin prevention and treatment. Journal Of Cutaneous Medicine And Surgery, 16(1), 23–31. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=mnh&AN=22417992&site=eds-live Hashiguchi, N., Hirakawa, M., Tochihara, Y., Kaji, Y., & Karaki, C. (2008). Effects of setting up of humidifiers on thermal conditions and subjective responses of patients and staff in a hospital during winter. Applied Ergonomics, 39(2), 158–165. https://doi-org.wallaby.vu.edu.au:4433/10.1016/j.apergo.2007.05.009 How to prevent and treat dry skin. Be proactive this winter by moisturizing often and avoiding hot water. (2015). Harvard Health Letter / from Harvard Medical School, 40(3), 7. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=edselc&AN=edselc.2-52.0-84941770431&site=eds-live Lodén, M. (2003). Role of Topical Emollients and Moisturizers in the Treatment of Dry Skin Barrier Disorders. American Journal of Clinical Dermatology, 4(11), 771–788. https://doi-org.wallaby.vu.edu.au:4433/10.2165/00128071-200304110-00005 Philpott, W. L. (2018). Chilling out Winter skin woes. Australian Journal of Pharmacy, 99(1173), 41–44. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=edselc&AN=edselc.2-52.0-85047980363&site=eds-live Sasaki, M., Yoshida, K., Adachi, Y., Furukawa, M., Itazawa, T., Odajima, H., … Akasawa, A. (2016). Environmental factors associated with childhood eczema: Findings from a national web-based survey. Allergology International, 65(4), 420–424. https://doi-org.wallaby.vu.edu.au:4433/10.1016/j.alit.2016.03.007 What to do about dry skin in winter. At this time of year, hands may be red, rough, and raw, and skin may feel itchy and uncomfortable. (2011). Harvard Women’s Health Watch, 18(6), 6–7. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=edselc&AN=edselc.2-52.0-84989767485&site=eds-live Zuccaroli, J. (2011). Dry skin, chilblains and other winter skin scourges. Professional Nursing Today, 15(4), 28–30. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=c8h&AN=104143204&site=eds-live

Disorders of pigmentation are significantly increasing worldwide and currently are the most frequently presented skin condition in clinical practice. The most commonly exhibited pigmentary disorders are ephelides, solar lentigos, post- inflammatory hyperpigmentation (PIHP), melasma, poikiloderma of civatte and nevus of ota. Types of Pigmentary Disorders and their Treatment Ephelides Ephelides, universally known as ‘freckles’ are flat, sharply demarcated, light brown lesions generally detected in fair skinned and red-haired individuals. Ephelides are mostly small in diameter and develop early in childhood. Though, it is not unusual for them to escalate in size, number and colour after substantial sun exposure or during adolescence, they somewhat fade throughout young adulthood. Ephelides are not concomitant with an increase in the number of melanocytes, but rather there is a surge in melanin of the basal layer within the epidermis, and while these hyperpigmented lesions may be triggered by significant sun exposure, they are genetically determined. Solar Lentigo Solar Lentigo, also dubbed ‘age spots,’ ‘senile lentigo,’ or ‘liver spots,’ are described as irregularly outlined, light or dark brown macules which range from 1mm-1cm in diameter. Solar Lentigo frequently arise after middle age and are commonly located on the backs of hands and the face. Contrastingly to ephelides, these lesions are associated with an increased number of melanocytes. Sun avoidance and the use of broad spectrum sunscreen are the suggested preventative measures, though pertaining to the treatment of existing macules, studies endorse the application of topical products such as tretinoin cream, hydroquinone, retinoids, alpha hydroxy acids (AHA’s) or a topical corticosteroids, as well as cryotherapy and melanin specific high energy lasers and light therapies, such as Q-switched ruby and alexandrite lasers, or Nd: YAG lasers. Post-Inflammatory Hyperpigmentation (PIHP) Post-inflammatory hyperpigmentation (PIHP) is an acquired and reactive pigmentary disorder of the skin that ensues as a result of inflammation and trauma. There are various causative factors associated with PIHP, such as acne, folliculitis, lichen planus, herpes zoster and eczema, as well as medications and procedural complications. All of these factors instigate damage to the basal layer which then moderates the collection of melanophages within the superficial dermis. PIHP lesions are irregularly shaped and vary in colour, from light brown to bluish grey. Studies have suggested there to be an equal incidence between males and females, however there is a commonality among darker skin phototypes. Currently, treatment options include hydroquinone, kojic acid, retinoids, corticosteroids, ascorbic acid (Vitamin C), chemical peeling preparations, dermabrasion and various laser modalities. Though, treatment for PIHP remains challenging and research reveals variable success rates. Melasma Melasma (from the Greek word, meaning “black”) is the most common pigmentary disorder largely affecting women. Melasma is a chronic, acquired, circumscribed, symmetrical hypermelanosis located on sun exposed regions. The hyperpigmented areas are characterised by irregular brown macules that are well defined with scalloped edges. Melasma most commonly presents on the cheeks, upper lips, the chin and the forehead on darker skinned phenotypes, although the condition does affect all races. Several risk factors portray major roles in the accumulation of melasma, such as; genetics, sun exposure, age, gender, hormones, pregnancy (‘Mask of Pregnancy’), thyroid dysfunction, cosmetics and medications. Present treatment and management approaches include; hydroquinone preparations, topical steroids, retinoids, tyrosinase inhibitors (kojic acid and azelaic acid), ascorbic acid (Vitamin C), superficial chemical peels (glycolic peeling solutions being the most effective), and laser and light interventions, such as Intense Pulsed Light (IPL), Q- Switched Nd: YAG, Q-Switched alexandrite and pulsed dye lasers as well as various other fractional lasers. Melasma is renowned for its challenges when treating, owing to the residing melanin in varying depths of the epidermis and the dermis, and even minor sun exposure can reactivate the condition, therefore it is crucial to ensure strict sun avoidance in accordance with the application of broad spectrum sunscreen throughout treatment and management programs. Poikiloderma of Civatte Poikiloderma of civatte is a collective benign skin manifestation bestowing a triad of signs, including; telangiectasia, atrophy and macular or reticulated hypo- hyperpigmentation. It is not a disease, but a response to many causes including irradiation, photo-contact reactions and connective tissue and lymphoreticular disorders. The condition most commonly assumes lighter phototypes and is generally observed on the lateral cheeks and the sides of the neck, with the submental area generally spared. This anomaly can consequently result in cosmetic disfigurement and social impairment for the sufferer, and while there is no consensus regarding the treatment of choice, Intense Pulsed Light (IPL) is said to be the most clinically successful. Naevus of Ota Naevus of ota, also called oculodermal melanocytosis, is a form of dermal melanosis and usually arises at birth, although in some cases it may emerge later. This condition presents as a slate grey, blue or brownish unilateral macule along the dissemination of the ophthalmic or maxillary branches of the trigeminal nerve. Naevus of ota is concurrent with melasma and various other pigmentary disorders, with 80 per-cent of cases occurring in females. Former treatments for this irregularity have included; hydroquinone, cryotherapy, dermabrasion and skin grafting, though presently these approaches have been substituted with the implementation of laser and light therapies, with the Q-switched Nd: YAG being the most widely used. The patient and the Dermal Clinician Pigmentary disorders can be exasperating for the sufferer, and though there are various management and treatment options available as previously outlined, they do come with their perils and risks, one of the most common being recurrent relapse. Owing to the Dermal Clinician’s central and in-depth knowledge concerning the dangers, challenges and benefits associated with these present treatment approaches, they hold significant roles in the treatment, management, monitoring, collaboration and appropriate referral of patients with pigmentary disorders. References Dabas, G., Vinay, K., Parsad, D., Kumar, A., & Kumaran, M. (2019). Psychological disturbances in patients with pigmentary disorders: a cross‐sectional study. Journal of the European Academy of Dermatology and Venereology. doi:10.1111/jdv.15987 Dlova, N. C., Akintilo, L. O., & Taylor, S. C. (2019). Prevalence of pigmentary disorders: A cross-sectional study in public hospitals in Durban, South Africa. International Journal of Women's Dermatology. doi:10.1016/j.ijwd.2019.07.002 Handel, A. C., Miot, L. D., & Miot, H. A. (2014). Melasma: a clinical and epidemiological review. Anais Brasileiros de Dermatologia, 89(5), 771-782. doi:10.1590/abd1806-4841.20143063 Hernando, B., Ibañez, M. V., Deserio-Cuesta, J. A., Soria-Navarro, R., Vilar- Sastre, I., & Martinez-Cadenas, C. (2018). Genetic determinants of freckle occurrence in the Spanish population: Towards ephelides prediction from human DNA samples. Forensic Science International: Genetics, 33, 38-47. doi:10.1016/j.fsigen.2017.11.013 Kaufman, B. P., Aman, T., & Alexis, A. F. (2017). Postinflammatory Hyperpigmentation: Epidemiology, Clinical Presentation, Pathogenesis and Treatment. American Journal of Clinical Dermatology, 19(4), 489-503. doi:10.1007/s40257-017-0333-6 Sarkar, R., Garg, V., Arya, L., & Arora, P. (2012). Lasers for treatment of melasma and post-inflammatory hyperpigmentation. Journal of Cutaneous and Aesthetic Surgery, 5(2), 93. doi:10.4103/0974-2077.99436 Sarma, N., Chakraborty, S., Poojary, S., Rathi, S., Kumaran, S., Nirmal, B., … Joseph, B. (2017). Evidence-based review, grade of recommendation, and suggested treatment recommendations for melasma. Indian Dermatology Online Journal, 8(6), 406. doi:10.4103/idoj.idoj_187_17 Scattone, L., De Avelar Alchorne, M. M., Michalany, N., Miot, H. A., & Higashi, V. S. (2012). Histopathologic Changes Induced by Intense Pulsed Light in the Treatment of Poikiloderma of Civatte. Dermatologic Surgery, 38(7pt1), 1010- 1016. doi:10.1111/j.1524-4725.2012.02393.x Shankar, K., Godse, K., Aurangabadkar, S., Lahiri, K., Mysore, V., Ganjoo, A., … Motlekar, S. A. (2014). Evidence-Based Treatment for Melasma: Expert Opinion and a Review. Dermatology and Therapy, 4(2), 165-186. doi:10.1007/s13555-014-0064-z Sheth, V. M., & Pandya, A. G. (2011). Melasma: A comprehensive update. Journal of the American Academy of Dermatology, 65(4), 699-714. doi:10.1016/j.jaad.2011.06.001 Weller, R. B., Hunter, H. J., & Mann, M. W. (2015). Clinical Dermatology. Hoboken, NJ: John Wiley & Sons. Yan, L., Di, L., Weihua, W., Feng, L., Ruilian, L., Jun, Z., … Weihui, Z. (2017). A study on the clinical characteristics of treating nevus of Ota by Q-switched Nd:YAG laser. Lasers in Medical Science, 33(1), 89-93. doi:10.1007/s10103- 017-2342-3

October 14, 2020 is a day worth celebrating for Dermal Skin Health Professionals, with two equally important coinciding events. INTERNATIONAL SKIN HEALTH DAY The Australasian College of Dermatologists (ASD) is celebrating International Skin Health Day. Skin Health Day is a joint project of the International League of Dermatological Societies and the International Society of Dermatology. Many organisations, including the ASDC are expressing support for the importance of Skin Health in Australia and around the world. This year the ASD are focusing on the importance of accessing expert advice and care for skin problems during this time and into the future with Tele-health. Chronic skin conditions and chronic wounds are a significant burden in both cost and psychosocial impact to those with these health issues. The ASD have released a new report ‘More than skin deep: Skin diseases in Australia- navigating the health care system and challenges with access‘ ALLIED HEALTH PROFESSIONS DAY AHPA is also celebrating Allied Health Professionals Day today. This event is also an international event bringing together and celebrating all Allied Health Professions. The Commonwealth Chief Allied Health Officer, Dr Anne-Marie Boxall has recorded a message for AHPs Day in acknowledgement of the important and valued contribution made by all Allied Health Professions in Health and other sectors to ensure the health and wellbeing of Australians. Victorian Chief Allied Health Officer, Donna Markham, will be hosting a webinar by safer Victoria today, celebrating the important work of those in allied health and continuing to looking beyond COVID-19 with a strong future for all AHPs. CELEBRATE AS DERMAL SKIN HEALTH PROFESSIONALS As affiliate members of AHPA and with a strong connection to Skin Health working in interprofessional teams with both allied health and health professionals, including Dermatologists, we encourage ASDC members to join us in celebrating International Skin Health & AHPs Day 2020. You can contribute to raising awareness of the allied health sector and those with skin conditions by sharing social media posts such as photos of staff events marking the occasion, profiles of allied health teams and practitioners, and videos highlighting the work of different professions. Don’t forget to include event hashtags such as #AHPsDay #AHPsDay2020 #strongertogether #alliedhealth #DermalClinians #ASDC #SkinHealth2020

Jennifer Byrne (ASDC Chairperson) 12th September, 2020 The ASDC know that this is, and continues to be a really difficult time for our members, the dermal therapy profession and the wider beauty and cosmetic medical industry. In fact for many in business this may be the biggest challenge we have ever faced collectively. Our profession and the beauty industry overall has been exceptional in its commitment to follow all directions to prevent transmission of coronavirus (COVID-19) and has implemented many strategies to ensure that when businesses can open, they do so as safely as possible. The reality that professional practice and life in general is not going to be the same for some time has well and truly sunk in. However, as a profession we have soldiered on and got on with the task at hand. When the roadmap to re-open Victoria was announced many sectors including personal services (beauty), allied and community health and retail were all concerned. Particularly at the lack of transparency around decision making regarding opening dates for those working in these sectors. This initiated collective and collaborative efforts from professional bodies, organisations and independent business owners to lobby for further consideration by the government. This lobbying has advocated for decision making further evaluating the financial and psychological impacts of current restrictions. As well as being based on infection control focusing on actual transmission risk and minimisation strategies. With previous decisions around "essential" health services becoming less viable when considering a longer term view of not only the economy but also health care and prevention of health problems for the public. The announcement on Saturday 12 September, 2020 allowing the beauty therapy industry to open a month earlier than initially announced is a testament to the efforts of all involved. The details are still not clear for all of us. There are still grey areas around the differences between regional and metro Victoria, as well as particular services in a variety of settings that our members work in. We are working on gaining further clarity and hopefully these details will emerge over the next weeks before Stage 4 ends. We also wanted to re-assure you that we continue to work on your behalf lobbying to health ministers at state and federal levels as well as collaborating with allied health and beauty professional bodies to raise concerns regarding the impact that this is having on business owners, employees as well as the public. What is the current status for all 'beauty' services The most recent announcement on the government restriction tracker is as follows: From Monday 26 October 2020 (subject to public health advice), if you live in metro Melbourne: you can visit a hairdressing salon or barber you can visit beauty and personal care services if you wear a mask for the entire time, practise physical distancing and follow other safety measures. However, services where you can’t wear a mask for the entire time — such as facials, face tattoos and face piercings — are not allowed. From Monday 23 November 2020 (subject to public health advice), in metro Melbourne: all other beauty and personal care businesses can resume operating, but with physical distancing and other safety measures in place It is noted that changes have not flowed through as yet for regional Victoria, however the press conference indicated that regional Victoria may be able to open earlier if community transmission rates remain low. The government have asked for patience while they collate data in order to make further announcements. For more information you can check details over the subsequent weeks HERE. For the full announcement please see the press conference below. The ASDC will also review these and further announcements this week to provide members with further guidance as we aim to engage in discussions with the health department and ministers in order to provide a recommendation for how this impacts on some of the services provided by members. What is the current status providing 'Health Services in Health Care Settings' The following advice only applies to our full members that meet the criteria of performing in the capacity as an allied health professional in a permitted workplace. At this stage if you don't meet the criteria outlined below, advice is to look at opening at the same time and with the same conditions as beauty therapy. AHPA are currently working to set up a Webinar with Victorian Health officials. Members will be able to attend and ask questions. We will keep you posted when this is decided and announced. At the current point in time, we have been provided the following message from AHPA to pass onto our members: Allied Health Professions Australia today met with the Victorian Chief Allied Health Officer and representatives from the Department of Health and Human Services to seek further clarification in relation to the Coronavirus (COVID-19) reopening roadmap for Metropolitan Melbourne (https://www.vic.gov.au/coronavirus-covid-19-restrictions-roadmap-metro-melbourne). Unfortunately, at this time there is no further official guidance and we are continuing to wait for details, which we understand will be available next week. However, based on our discussions to date it is our understanding that restrictions remain at their current levels for an additional 14 days from the 14th of September to the 27th of September. We encourage providers to contact clients with bookings over the next 14 days that do not meet the current definitions outlined in the permitted workplaces guidance (https://www.dhhs.vic.gov.au/health-care-and-social-assistance-restrictions-covid-19) to reschedule appointments appropriately. We are cautiously optimistic that restrictions will be eased slightly from the 28th of September, however we will provide further updates early next week or whenever further information is available. We thank and acknowledge allied health professionals for their ongoing support for the community and their diligence in managing the tough balance between maintaining client health of their clients and reducing potential exposure to Covid-19 Further announcements business support The Victorian government has also announced further grants for businesses and more information to follow on support offered to sole traders. Other assistance includes deferring payroll tax for 2020/2021. For more information on eligibility and details of grants click HERE What are the ASDC doing? The ASDC are currently working collaboratively with other professional bodies such as APAN and AHPA in proposals for government to further protect the industry for the future. We will be also advocating on behalf of our profession in the attempt to have explicit advice regarding procedures and patient groups that may meet the criteria for health services in various practice settings. In making this case, we are asking for members to assist us with collecting data on the demographic of our profession as well as the impact to the services you are offering and the financial burden you are suffering. We participated in a workforce impact survey in March-June this year. However we would ask that you participate in this survey again so that we can gather data on how the last 6 months have impacted on your businesses, employees and clients. Click HERE to participate. COVID-19 Practice Guideline Members are able to download a copy of the ASDC COVID-19 Practice Guideline from the membership portal. Also updated recently are guidelines to assist clinics with ongoing provision of tele-health services. The COVID guidelines may need to be modified slightly with updated information regarding PPE and other information that may come out of further discussions in the next few weeks. Updates to PPE Requirements Currently there has been a recommendation for any in close clinical contact to be using PPE Level 1 recommendations (rather than Level 0) as previously indicated. This includes the use of eye wear or a face shield and face mask in adherence to droplet precautions. PPE according to standard contact precautions as per the risk assessment for that service Is still required. For more information please see the PPE guidance on the government website. At this stage it isn't clear if these levels will remain the same with the reopening in October. However it has been a requirement for those in health settings prior to stage 4 closures. We thank you for your hard work and persistence during this challenging time. Please contact us with any concerns or queries you may have on info@dermalclinicians.com.au The Australian Society of Dermal Clinicians (ASDC)

What is Atopic Dermatitis? Atopic Dermatitis, also frequently termed ‘Atopic Eczema’ or ‘Eczema’, is the most common chronic inflammatory skin disorder seen in patients globally. Atopic Dermatitis is characterised by itchy dry lesions and possesses a multifaceted pathogenesis involving both genetic and environmental underpinnings. Atopic Dermatitis mostly arises in childhood, with research declaring that approximately 60% of childhood cases begin in the first year of life. What are the signs, symptoms and clinical manifestations of Atopic Dermatitis? Atopic Dermatitis frequently bestows in patients who have what is called an ‘Atopic Tendency,’ or the ‘Atopic Triad.’ This means sufferers may acquire all three closely interconnected conditions; Atopic Dermatitis, Asthma and Rhinitis (hay-fever), in a sequential manner. Specific to the cutaneous presentation of Atopic Dermatitis, there is quite a disparity amongst individuals, though the main manifestations involve: Erythema (redness) Oedema (swelling) Crusting Weeping Pruritus (itching) Excoriation from excessive scratching Lichenification / lichenified plaques (thickened skin) Xerosis (dryness) Scaling Cracking Fissuring Vesicles (blisters) Pigmentary alterations Erosions Bleeding The anatomically affected regions of Atopic Dermatitis are dependent upon the age range of the sufferer: 3 months – 2 years: the scalp (also commonly termed ‘cradle cap’), cheeks, neck, extremities and trunk are affected, while the diaper region is usually spared. 2 – 12 years: The outer aspects of joints, as well as the wrists, elbows, ankles and knees are generally disturbed. 12-60 years: The affected regions include the head, neck, hands and flexural regions. 60+ years: The flexural regions are usually spared, and it is important to note that a number of differential diagnoses which may mimic Atopic Dermatitis must be excluded. Atopic Dermatitis and the skin’s barrier One of the exclusive hallmarks of Atopic Dermatitis is a deficiency in the skin’s barrier functionality. The Stratum Corneum is composed of corneocytes which are responsible for secreting intercellular substances (filaggrin). These breakdown into constituents, such as amino acids (Natural Moisturising Factors) and lipids (ceramides) which then operate to arrange a barrier layer which defends the epidermis against environmental insults. But in Atopic Dermatitis patients, there are numerous alterations and deficiencies in the proteins and the lipids of the Stratum Corneum, resulting in bacterial colonisation and hence secondary bacterial, viral and fungal skin infections. Atopic Dermatitis and the environment Atopic Dermatitis sufferers will often discover their condition is exacerbated throughout winter. The water content of the epidermis mirrors the environmental humidity levels and owing to the reduced humidity levels in the cooler months the skin becomes considerably drier, resulting in impairment of the natural barrier function and thence the potential for secondary skin infections. Atopic Dermatitis and COVID-19 COVID-19 has seen numerous alterations in Atopic Dermatitis patients. Alcohol-based sanitisers containing at least 60% ethanol are recommended for hand hygiene, as the alcohol is able to denature proteins and thus inactivate enveloped viruses including coronaviruses. Excess use of sanitisers can lead to skin dryness, itching, burning, erythema, scaling and vesiculation through depletion of skin surface lipids allowing penetration of detergents into the epidermis. Additionally, it is marked in research that other various factors resultant of the coronavirus are responsible for exacerbating this chronic condition, these include: Repeated hand washing and sanitising which causes further disruption to the skin’s barrier Adverse psychological effects which have increased pruritus in Atopic Dermatitis sufferers Reduced UV exposure in aggregation with high temperatures and low humidity have exerted an immunosuppressive effect on the skin Greater exposure to indoor pollutants Reduced routine dermatologic visits References Bieber, T., D'Erme, A. M., Akdis, C. A., Traidl-Hoffmann, C., Lauener, R., Schäppi, G., & Schmid-Grendelmeier, P. (2017). Clinical phenotypes and endophenotypes of atopic dermatitis: Where are we, and where should we go? Journal of Allergy and Clinical Immunology, 139(4), S58- S64. https://doi.org/10.1016/j.jaci.2017.01.008 De la O-Escamilla, N. O., & Sidbury, R. (2020). Atopic dermatitis: Update on pathogenesis and therapy. Pediatric Annals, 49(3), 140-146. https://doi.org/10.3928/19382359-20200217-01 DermNet NZ. (2020). Atopic dermatitis. DermNet NZ – All about the skin | DermNet NZ. https://dermnetnz.org/topics/atopic-dermatitis/ Drucker, A. M., Wang, A. R., & Qureshi, A. A. (2016). Research gaps in quality of life and economic burden of atopic dermatitis. JAMA Dermatology, 152(8), 873. https://doi.org/10.1001/jamadermatol.2016.1978 Hill, M. K., Kheirandish Pishkenari, A., Braunberger, T. L., Armstrong, A. W., & Dunnick, C. A. (2016). Recent trends in disease severity and quality of life instruments for patients with atopic dermatitis: A systematic review. Journal of the American Academy of Dermatology, 75(5), 906-917, https://doi.org/10.1016/j.jaad.2016.07.002 How to prevent and treat dry skin. Be proactive this winter by moisturizing often and avoiding hot water. (2015). Harvard Health Letter / from Harvard Medical School, 40(3), 7. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=edselc&AN=edselc.2 Novak, N., & Bieber, T. (2005). The role of dendritic cell subtypes in the pathophysiology of atopic dermatitis. Journal of the American Academy of Dermatology, 53(2), S171-S176. https://doi.org/10.1016/j.jaad.2005.04.060 Patruno, C., Nisticò, S. P., Fabbrocini, G., & Napolitano, M. (2020). COVID-19, quarantine, and atopic dermatitis. Medical Hypotheses, 143, 109852, https://doi.org/10.1016/j.mehy.2020.109852 Rerknimitr, P., Otsuka, A., Nakashima, C., & Kabashima, K. (2018). Skin Barrier Function and Atopic Dermatitis. Current Dermatology Reports, 7(4), 209. https://doi.org/10.1007/s13671-018-0232-y Sasaki, M., Yoshida, K., Adachi, Y., Furukawa, M., Itazawa, T., Odajima, H., … Akasawa, A. (2016). Environmental factors associated with childhood eczema: Findings from a national web-based survey. Allergology International, 65(4), 420–424, https://doi-org.wallaby.vu.edu.au:4433/10.1016/j.alit.2016.03.007 Schmitt, J., Langan, S., Deckert, S., Svensson, A., Von Kobyletzki, L., Thomas, K., & Spuls, P. (2013). Assessment of clinical signs of atopic dermatitis: A systematic review and recommendation. Journal of Allergy and Clinical Immunology, 132(6), 1337-1347, https://doi.org/10.1016/j.jaci.2013.07.008 Silverberg, J. I., & Hanifin, J. M. (2013). Adult eczema prevalence and associations with asthma and other health and demographic factors: A US population–based study. Journal of Allergy and Clinical Immunology, 132(5), 1132-1138. https://doi.org/10.1016/j.jaci.2013.08.031 Silverberg, J. I., & Silverberg, N. B. (2012). Atopic dermatitis: Update on pathogenesis and comorbidities. Current Dermatology Reports, 1(4), 168- 178, https://doi.org/10.1007/s13671-012-0021-y Sullivan, M., & Silverberg, N. B. (2017). Current and emerging concepts in atopic dermatitis pathogenesis. Clinics in Dermatology, 35(4), 349-353, https://doi.org/10.1016/j.clindermatol.2017.03.006 Terui, T. (2009). Analysis of the mechanism for the development of allergic skin inflammation and the application for its treatment: Overview of the pathophysiology of atopic dermatitis. Journal of Pharmacological Sciences, 110(3), 232-236, https://doi.org/10.1254/jphs.09r02fm Wang, B., Liu, L., Zhao, Z., & Tu, P. (2018). Impaired skin barrier function and Downregulated expression of caspase-14 in moderate to severe chronic hand eczema. Dermatology, 234(5-6), 180- 185, https://doi.org/10.1159/000489701 What to do about dry skin in winter. At this time of year, hands may be red, rough, and raw, and skin may feel itchy and uncomfortable. (2011). Harvard Women’s Health Watch, 18(6), 6–7. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=edselc&AN=edselc.2 Wolf, R., & Wolf, D. (2012). Abnormal epidermal barrier in the pathogenesis of atopic dermatitis. Clinics in Dermatology, 30(3), 329- 334, https://doi.org/10.1016/j.clindermatol.2011.08.023 Zuccaroli, J. (2011). Dry skin, chilblains and other winter skin scourges. Professional Nursing Today, 15(4), 28–30. Retrieved from https://search-ebscohost-com.wallaby.vu.edu.au:4433/login.aspx?direct=true&db=c8h&AN=104143204 &site=eds-live