Canadian Skin - Winter 2024 by Kelman & Associates

COMPLIMENTARY

Winter 2024

VOLUME 14 � ISSUE 3

CANADIAN

Dermatology and rheumatology:

Why, where, and how they connect CSPA’s new Self-Empowerment Toolkit (SET) www.canadianskin.ca The Official Publication of the Canadian Skin Patient Alliance

CLOSE-UP ON LUPUS SKIN PIGMENTATION DISORDERS

SKINfacts New skin of colour dermatology clinic opens at The Ottawa Hospital

One of the first centres of its kind in Canada, the clinic is designed to address critical gaps in patient care for racialized people. The Ottawa Hospital recently opened a skin of colour dermatology clinic to better serve the needs of patients with darker skin types. The hospital’s new specialty clinic features dermatologists trained in diagnosing and treating people with darker skin. It also serves as a research and professional development centre for medical students and residents. Dr. Reetesh Bose, a dermatologist at The Ottawa Hospital, said he founded the clinic in an attempt to address some of the inequities he saw in the field of dermatology, and provide better care for racialized patients. Bose explained that skin conditions can present differently in darker skin types and they can be tougher to diagnose. This may lead to delays in diagnosis and affect the outcomes of treatment.

Scalp psoriasis

Did you know? 45 to 56% of people living with psoriasis have scalp psoriasis. Scalp psoriasis is a common skin condition that may not always look the same on different skin tones. It often shows up as raised, reddish, or salmon-colored patches with white scales on light to medium skin tones. On darker skin, the patches may be purple and the scales grey. It can be a single patch or several, and can even affect the entire scalp.

COMPLIMENTARY

Winter 2024

VOLUME 14 • ISSUE 3

CANADIAN

Winter 2024 • Volume 14 • Issue 3 ISSN 1923-0729 Publisher: Craig Kelman & Associates www.kelman.ca

Dermatology and rheumatology:

Why, where, and how they connect

CSPA’s new Self-Empowerment Toolkit (SET) www.canadianskin.ca The Official Publication of the Canadian Skin Patient Alliance

CLOSE-UP ON LUPUS SKIN PIGMENTATION DISORDERS

2 | www.canadianskin.ca | Winter 2024

SUGGESTIONS AND TIPS FOR SKIN PATIENTS AND THEIR FAMILIES

Scalp psoriasis can also spread to your forehead, the back of your neck, or behind and inside your ears. Doctors believe scalp psoriasis is a result of an immune system problem that causes skin cells to grow too quickly and build up into patches. You may be more likely to get scalp psoriasis if it runs in your family. This skin condition can be mild and almost unnoticeable. But it can also be severe, long lasting, and cause thick, crusted sores. Itchiness can affect your sleep and everyday life, and constant scratching can lead to skin infections and hair loss. Scalp psoriasis itself doesn’t cause hair loss, but picking at the scaly spots, certain harsh treatments, and the stress that goes along with the condition can lead to temporary baldness. Fortunately, hair usually grows back after the skin clears.

Watch out for frostbite!

Frostbite is damage to the skin caused by extreme cold. It happens when the skin, nerves, and blood vessels below the top layer of the skin freeze. Rain, snow, water, and wind can cause the skin to cool faster, which may lead to frostbite. Symptoms include numbness, stinging, throbbing, and skin discoloration. Treatment includes gradually warming the skin and removing restrictive clothing or jewelry. In the earliest stage of frostbite, known as frostnip, there is no permanent damage to skin. Symptoms include cold skin and a prickling feeling, followed by numbness and inflamed or discolored skin. As frostbite worsens, skin may become hard or waxy-looking. Because of skin numbness, you may not realize you have frostbite until someone else points it out. Frostbite is most common on the fingers, toes, nose, ears, cheeks, and chin. To help avoid frostbite, be sure to wear winter clothing that is suitable for the weather conditions and limit your time outside in severe cold and winds.

Canadian Skin Patient Alliance: G303-851 Industrial Avenue, Ottawa, ON K1G 4L3 Toll Free: 1-877-505-CSPA (2772) • Email: info@canadianskin.ca Canadian Publication Mail Sales Product Agreement No 40065546. Printed in Canada.

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ASK THE EXPERT

Learn more, live better.

Foot care, and tips for sleeping better with HS By Dr. Raed Alhusayen and Dr. Dimitra Bednar

I get dry, thick skin on my foot. How can I remove it? Can it be prevented?

Preventing dry, thick (callused) skin is preferred and simpler than removal. To avoid getting calluses, wear proper-fitting shoes that do not cause points of friction or repeated pressure, wear socks, and apply a thick moisturizer to the feet often. Moisturizer is most effective when applied after a shower, and wearing socks overtop will keep the moisturizer from rubbing off and sealed in. Callus removal must be done carefully to avoid creating wounds which may get infected. This is critical for people with poor circulation and diabetes. The simplest and safest method to remove a callus is with a chemical exfoliant such as urea or salicylic acid. These acids are in many overthe-counter creams and ointments and may be used safely multiple times daily. Calluses may also be filed using a pumice stone or emery board, which is more practical on softened skin after bathing. Do not use any sharp objects to remove a callus! This should be done by a professional at a foot care clinic, such as a chiropodist, who may also advise you on footwear. Callused skin may appear similar to medical conditions including but not limited to eczema and psoriasis. If you do not see an improvement with these suggestions, see your primary care provider who may consider an alternative diagnosis or referral to a board-certified dermatologist.

Q A

HS impacts my sleep – any tips for sleeping better with HS?

If your sleep is impacted by hidradenitis suppurativa (HS), consider whether the disease is well controlled. If not, please consult whichever provider manages your HS

to discuss treatments. If your HS is currently well controlled but your sleep is still poor, ensure you have developed a nighttime routine and optimized your sleeping environment. A regular night-time routine signals to your body and mind that it is time to rest, and may include tending to your personal hygiene, reading, meditating, or journaling, then turning off the lights and trying to sleep. Your sleeping environment should limit all natural and artificial sources of light including screens and be cool in temperature. To sleep better with HS, wear comfortable, non-occlusive (breathable) pyjamas and sleep in sheets made of natural, quick-drying materials (linen or cotton). Remember that HS can co-occur with many other conditions including sleep apnea, which can be diagnosed with a sleep study. There are over-the-counter supplements and prescription medications that facilitate better sleep, but these are dangerous for their addictive and sedative properties. Sleep medications and supplements can also interact with other medications you may be taking, altering their effectiveness. The use of any supplement or prescription medication for sleep should be limited to severe cases and regularly reviewed by your prescriber. Speak with your primary care provider before you begin taking any supplements or sleep medications. Dr. Raed Alhusayen is a consultant dermatologist at Sunnybrook Health Sciences Centre in Toronto, Ontario. Dr. Dimitra Bednar is a dermatology resident at the University of Toronto. Have a question? Send it to info@canadianskin.ca. Winter 2024 | www.canadianskin.ca | 3

Dermatology and rheumatology:

Why, where, and how they connect By Katie Yeung

Dermatology is the study of the skin; however, many dermatological conditions can have manifestations that extend far deeper than the skin itself. Dermatologists, therefore, are tasked with not only understanding the skin, also but how it functions as part of a larger network of systems in our bodies. By appreciating the intricacies and overlaps between these systems, we can achieve a more comprehensive understanding and management of the conditions affecting the skin. In particular, many dermatological conditions have important 4 | www.canadianskin.ca | Winter 2024

crossovers with rheumatology, the study of inflammation and connective tissue disorders. SKIN SIGNS OF RHEUMATOLOGICAL CONDITIONS Autoimmune connective tissue disorders are a group of rheumatological conditions that occur when the immune system incorrectly targets and attacks the body’s own cells, causing systemic (multiple organ) inflammation. The skin is commonly involved, either as the only

“As research into the underlying processes driving systemic autoimmune conditions such as SLE, scleroderma, and Sjögren’s continues to grow, the crossovers between dermatology and rheumatology will likely become increasingly clear.” site of inflammation or as part of an inflammatory process that involves many different organs. The autoimmune condition systemic lupus erythematosus (SLE) is an example of a rheumatological condition that often presents with signs and symptoms that impact the skin. People with SLE produce antibodies that travel in the blood and deposit in different organs and tissues causing inflammation. Depending on where they deposit, patients can develop serious conditions affecting those organs (e.g., heart, kidney, eyes). When these antibodies deposit in the skin, the inflammation can cause rashes, scarring, and photosensitivity (sensitivity to sunlight). In these cases, a dermatologist may focus on the management of more skin-specific concerns while a rheumatologist can help in assessing whether other organs are affected and if so, provide guidance on starting immunosuppressive medications (medications that calm the immune system) to control the inflammation. Interdisciplinary care between dermatology and rheumatology can also help make diagnosing and managing these conditions easier. The benefits of this are highlighted in the management of scleroderma, an autoimmune condition that can affect the skin, connective tissues, and internal organs. Scleroderma occurs when the body inappropriately responds to inflammation by replacing normal tissue with excess collagen (a type of protein) leading to thickening and hardening of the affected areas. This condition often presents with tightening skin on

the hands, feet, and/or face. Localized scleroderma that only affects certain areas of the skin is called morphea and is often managed by dermatologists using topical or injection medication at the affected site. However, when other connective tissues (e.g., blood vessels) and internal organs are involved, the overlaps with rheumatology become more evident. Patients may experience symptoms resulting from inflammation and scarring of internal organs/tissues that can be life-threatening without appropriate treatment. As dermatologists may be less comfortable with managing these non-skin-related symptoms of scleroderma, rheumatologists are often added to the care team to help manage the condition. The opposite is also true, where rheumatologists may refer patients with extensive skin changes from scleroderma to a dermatologist to explore options for improving skin appearance and symptoms, such as using ultraviolet therapy or lasers. People who have certain rheumatological conditions that have signs or symptoms affecting the skin may also benefit from involving a dermatologist in symptom management. Sjögren’s syndrome (Sjögren’s) is an autoimmune condition that affects the ability of glands to secrete fluid. As a result, patients often experience dryness of the mouth and eyes. Patients with only gland involvement are diagnosed with primary Sjögren’s. However, patients with Sjögren’s who also have other coexisting rheumatic conditions are diagnosed with secondary Sjögren’s. While Sjögren’s is a systemic condition affecting multiple organs and therefore primarily managed by rheumatologists, dermatologists can help in treating associated skin signs and symptoms. These may include dry skin (xerosis), hives, palpable purpura (raised red or purplish spots from bleeding), and other rashes. In patients with secondary Sjögren’s, dermatologists also play an important role in managing the skin impacts of any coexisting conditions like SLE and scleroderma. RHEUMATOLOGIC SYMPTOMS OF DERMATOLOGICAL CONDITIONS Some skin conditions like psoriasis also impact the joints, muscles, and bones in a person's body. Psoriasis is a chronic inflammatory condition that

causes red, purple, or silvery scaly skin lesions and affects approximately 2–3% of Canadians.1 Around 20% of people with psoriasis also develop inflammation and swelling of the joint in a condition called psoriatic arthritis (PsA).2 PsA is caused by the body’s own immune system attacking cells in the joint, leading to joint pain or stiffness. Although in some cases, PsA can occur before or at the same time skin changes are seen, many people may develop PsA years after the initial diagnosis of psoriasis. Therefore, dermatologists may be the first to diagnose PsA and are in the ideal position to monitor for joint symptoms over time. Earlier diagnosis and treatment improves outcomes, highlighting the importance of recognizing the connections between dermatology and rheumatology.

“Patients with these conditions will benefit from working with a care team that involves both of these specialists, particularly if they have complex and difficult-tomanage conditions.” As research into the underlying processes driving systemic autoimmune conditions such as SLE, scleroderma, and Sjögren’s continues to grow, the crossovers between dermatology and rheumatology will likely become increasingly clear. Patients with these conditions will benefit from working with a care team that involves both of these specialists, particularly if they have complex and difficult-to-manage conditions. REFERENCES:

1. Eder, L., Widdiﬁeld, J., Rosen, C.F., et al. Trends in the Prevalence and Incidence of Psoriasis and Psoriatic Arthritis in Ontario, Canada: A Population-Based Study. Arthritis Care Res (Hoboken). 2019;71(8):1084-1091. doi:10.1002/acr.23743 2. Karmacharya, P., Chakradhar, R., Ogdie, A. The epidemiology of psoriatic arthritis: A literature review. Best Pract Res Clin Rheumatol. 2021;35(2):101692. doi:10.1016/j.berh.2021.101692

Katie Yeung is a fourth-year medical student at Queen's University in Kingston, Ontario. X/Twitter: @KatieYeung_ Winter 2024 | www.canadianskin.ca | 5

Close-up on: Lupus BY SHABNUM TEJA

Do you remember when you had the flu, and your doctor told you to rest so that your body and immune system could “fight it off”? This is similar to what happens in lupus, except with a twist. Your body and its immune system, which usually work night and day to protect you, suddenly starts attacking… itself. This is what makes lupus an autoimmune condition. Lupus is a chronic and potentially life-threatening disease that can cause widespread inflammation and pain in the body. Lupus is an especially tricky condition because it can attack virtually any part of the body. For this reason, lupus has been called the “disease of 1,000 faces” because it presents differently from person to person. One of the more visible symptoms is a red rash called a ‘malar rash’ that appears in the shape of a butterfly over the nose and cheeks of the face. A hallmark feature 6 | www.canadianskin.ca | Winter 2024

of lupus is fatigue that is so severe it interferes with an individual’s daily activities. It also commonly affects the bones, joints and lungs.1 There are four primary types of lupus: systemic lupus erythematous, discoid lupus, drug-induced lupus, and neonatal lupus. Lupus is diagnosed by a doctor when the signs and symptoms of lupus are present. The condition is difficult to detect because its symptoms tend to come and go. However, if the physician or patient is uncertain or wants to confirm the diagnosis, they can do additional tests to see the tell-tale signs that the immune system is attacking its own body and check for the resulting damage (for example, increased inflammation markers in the body or remnants of red blood cells). Because it’s the immune system attacking itself, the path to treatment is turning off that immune system using immunosuppressants and

corticosteroids.1 Behaviour change, such as exercising, not smoking, not spending too much time in the sun, and managing any other health conditions2 can also prevent and reduce symptoms. While there is no present cure for lupus, research is actively being done to find one. There are many national and provincial groups that have come together to support those with lupus. Organizations like Lupus Canada, Lupus Ontario, and the Lupus Society of Alberta offer weekly support groups, educational resoures, and peer contacts. REFERENCES

1. Maidhof, W., & Hilas, O. (2012). Lupus: an overview of the disease and management options. P & T : A peer-reviewed journal for formulary management, 37(4), 240–249. 2. Chowdhary, V. R. (2017). Broad concepts in management of systemic lupus erythematosus. Mayo Clinic Proceedings, 92(5), 744.

Shabnum Teja is a third-year medical student at Western University in London, Ontario.

Self-Empowerment Toolkit: CSPA’s new resource to help you navigate life with a skin condition BY SABRINA RIBAU, R.KIN Living with a skin, hair, or nail condition can be overwhelming, stressful, and ever challenging. From the first moment you notice an unusual change in your skin, to the process of seeking answers and trying to find a treatment that works for you, the journey can be a long and winding rollercoaster. While no two patient experiences are the same, many people often share similar concerns. These may include feelings of shame and stigma around your appearance as you wonder how others perceive you, worry around talking to your friends or family about your condition and trying to decide how you will handle their questions and comments, and learning to navigate your new life with your diagnosis. Psychosocial well-being refers to the mental, emotional, social, economic, physical, cultural, and

spiritual factors that influence your ability to function and thrive in dayto-day life. In speaking with patients and families from across the country with a wide range of dermatological conditions, Canadian Skin Patient Alliance (CSPA) recognized gaps in the existing supports available. We noticed the absence of tools to strengthen psychosocial health and well-being, as well as a lack of resources tailored specifically to supporting the experiences of people in the community. With increasing waitlists for doctor and dermatologist appointments and a growing risk for mental health concerns, the need for assistance has never been greater. To equip our community members and their loved ones with the skills they need to flourish, CSPA developed the Self-Empowerment Toolkit (SET) – a series of resources designed to

help people cope with the complexities of life with a skin, hair, or nail condition. A dermatological condition impacts more than just a person’s skin – it affects how you see yourself, how the world sees you, your employment opportunities, your social life, your romantic relationships, and how you spend your time. Aware of the burden carried by affected individuals and their families, CSPA teamed up with patients, medical students, dermatologists, and mental health professionals to produce the following three resources: Talking to Kids: How to talk to children, youth, and adult children about your skin condition; You and Your Derm: How to get the most out of your dermatology appointment; and Just Diagnosed: How to support your mental and social well-being to navigate life with a skin condition. Winter 2024 | www.canadianskin.ca | 7

TALKING TO KIDS: How to Talk to Children, Youth, and Adult Children About Your Skin Condition

Finding ways to empower yourself with the skills needed to make the most of life is one of the most important things that you can do for your health and well-being.

Talking to Kids explains why it is important to communicate your health condition to children and how to do so in a way that is ageappropriate and relevant to the child. This guide was designed to help parents, teachers, coaches, and other adults with skin, hair or nail conditions engage in open discussions with youth about their health concerns. CSPA understands the impact a diagnosis can have on a family, which is why this booklet was created with a social worker to support you through those sometimes-tough conversations.

You and Your Derm breaks down the before, during, and after of a dermatology appointment so that individuals can feel more confident and better prepared. Equipped with a helpful checklist and designed in collaboration with dermatologists and patients, this guide ensures that you and your loved ones can be ready to advocate for the best care and make the most of your dermatologist appointment.

The newest resource, Just Diagnosed, as the name suggests, was developed to support individuals who are at the beginning of their patient journey as they embark on a new life with a skin condition. There are many feelings and experiences a person can have around a new diagnosis, and understanding how a change like this can influence your health and well-being is a critical part of learning to live and thrive with your condition. From the emotions you may experience as you begin to think about how your life might change moving forward, to figuring out how you will tell people about your condition or how you will answer questions from friends, family, and co-workers, this tool looks to support you through the many steps of your journey. Just Diagnosed also explores different coping strategies to help you lead a more meaningful and fulfilling life with your condition. CSPA recognizes that skin conditions can come in waves, with many people experiencing flare-ups that lead to “good days” and “bad days.” However, finding ways to empower yourself with the skills needed to make the most of life is one of the most important things that you can do for your health and well-being. To learn more about our Self-Empowerment Toolkit, visit https://canadianskin.ca/ education/self-empowerment-toolkit. Sabrina Ribau is a registered kinesiologist and the Programs Manager at CSPA.

8 | www.canadianskin.ca | Winter 2024

What ’s new on the research front?

Top Stories in Research By Dr. Megan Lam

Psoriasis and cancer: Is there a connection? Psoriasis is a chronic skin disease that has been found to have a connection with other diseases, including heart disease and arthritis. Older people are more likely to have multiple medical conditions and are at a greater risk for serious conditions like cancer. A new study published in 2023 in the Journal of the American Academy of Dermatology used large sets of data from the Ontario Cancer Registry to answer the question of whether people with psoriasis are at a higher risk of having cancer. What they found Over 40,000 people with psoriasis and around 430,000 people without psoriasis were included in this analysis. People with psoriasis were found to be 50% more likely to have cancer in their lifetime than people without psoriasis. When the study accounted for people

with a previous history of cancer, people with psoriasis were 80% more likely to have cancer than those without psoriasis. Specifically, pancreatic cancer and liver cancer showed the greatest increase in risk for people with psoriasis, who were over five times more likely to have these types of cancer than people without psoriasis. Why this is important for people with psoriasis It is important for people with psoriasis to know that they could be at a higher risk for having cancer. Making sure that they are staying up to date on their cancer screening could become part of the advice that doctors give their patients with psoriasis, especially for older people who might have other risk factors that increase their chances of having cancer. What’s next in research? Important dermatology research topics for Canadian patients, caregivers, and healthcare providers The Skin Investigation Network of Canada (SkIN Canada) is a national group comprised of researchers, patients, healthcare providers, as well as the Canadian Skin Patient Alliance. It was created to advance skin research. As one of its missions, SkIN Canada developed a series of questions for patients, healthcare providers, and researchers to find out which skin conditions they thought were important topics for future research. As part of this project, the investigators at SkIN Canada also searched through previously published articles on older surveys from the past that looked at what patients and healthcare providers thought were important research topics. Taking both the results from their survey and their search into

account, a list was created of the top 10 most important topics in skin research for nine different skin conditions. What they found Over 500 patients, healthcare professionals, and researchers answered the survey. Top topics of interest ranged from studies on the long-term safety of treatment options for skin conditions like psoriasis, to trying to better understand how a disease like atopic dermatitis progresses over time. Having a better understanding of the molecules and proteins involved in causing a disease was an important topic for many skin conditions. What does this mean for people with skin conditions? There are many ways to get involved with research as a skin patient, caregiver, or healthcare provider. Part of SkIN Canada’s mission is to reach out to people who are impacted by skin disease in order to work together to improve research on skin conditions. Including the voices of patients and caregivers on which research topics are considered most important means that future research can be more relevant to what is most helpful for patients. Reach out to info@skincanada.org for more information about how you can get involved in future initiatives. REFERENCES

1. Finstad, A. et al. (2023). Investigating the risk of malignancy in elderly patients with psoriasis: A population-based retrospective matched cohort study. JAAD 88(5);1129-1131. https://doi. org/10.1016/j.jaad.2022.08.017. 2. Drucker, A.M. et al. (2023). Top Ten Research Priorities for Psoriasis, Atopic Dermatitis, and Hidradenitis Suppurativa: The SkIN Canada Priority Setting Initiative. Journal of Cutaneous Medicine and Surgery 27(2);133-139. https://doi. org/10.1177/12034754231156103.

Dr. Megan Lam is a dermatology resident at the University of Toronto. Winter 2024 | www.canadianskin.ca | 9

Living With…

Vitiligo By Tamara Surujbally

Let’s start from the beginning: About 13 years ago, just after moving cities and starting the second semester of grade nine, I was diagnosed with vitiligo. Fourteen-year-old me was extremely self-conscious about the few spots I had on my elbows and chin, and navigating this new diagnosis while trying to make new friends and get familiar with my new neighbourhood was a lot to digest. I was thankful that I could wear long sleeves and makeup to hide them. I visited many doctors and tried prescribed creams as well as random ones I found online that convinced me they would reverse my white patches or slow down the process. Before being diagnosed, I was worried I had a type of skin cancer, so in a way, getting the vitiligo diagnosis was a bit of a relief. However, my vitiligo did heavily impact my life and well-being for many years. I searched for the best high-coverage foundation and concealer I could use on my face. I felt uncomfortable if strangers, friends, or family looked anywhere but my eyes when talking to me. I often broke out in tears when someone simply asked a question about vitiligo. I am thankful that I never got bullied for having different skin, as I could barely handle someone glancing at my chin during a conversation. Years passed and there would be days where I thought these creams were working and days where I thought

they were a waste of time and money. I couldn’t tell if progress was being made and refused to take photos because I couldn’t stand how “sickening” I thought I looked. Plus, I noticed more patches appearing on my skin after spending time in the sun or during stressful periods of my life. Western medicine didn’t have answers for me, so I reached out to multiple naturopaths to see what they had to offer; however, their approach didn’t address my needs either. I took the time to research vitiligo and learned that it is an autoimmune condition that specifically targets a component in our immune system called T-cells which in turn impact melanocytes (pigment producing cells in our skin), and began looking for ways to take control of my health. After spending too much money on creams or high-coverage makeup and time on how to hide my patches, I got tired. I just wanted to feel cozy in my skin and knew it was not going to happen with these band-aid fixes. I always had a great support system at home including my parents and boyfriend, which was essential for me because they would help me realize how perfectly imperfect I was. I took a step back and knew that I felt the best when I ate whole foods, followed my workout routine, and did well in my studies so I shifted my energy and focused on these things. Before I knew it,

Try not to let vitiligo take experiences from you – because the truth is the people who love you aren’t staring at your patches, they just want to spend time with you. 10 | www.canadianskin.ca | Winter 2024

I was comfortable leaving the house with low-coverage natural makeup that didn’t hide any spots. I wore a sports bra and shorts in public without hesitation, since my vitiligo patches spread to all areas of my body at this point. I managed to prepare for a bodybuilding competition, got on stage in a bikini, specifically asked the tanning company to avoid hiding my patches – I rarely wore bikinis to the beach before this year – and I smashed my goals. All to say, try not to let vitiligo take experiences from you – because the truth is the people who love you aren’t staring at your patches, they just want to spend time with you. Know that some people (especially children and older adults) might stare but take it as an opportunity to educate. It is easier said than done and it does take time. Be kind to yourself, take your time, and know that I will always be in your corner!

FOCUS

The magnificent organ called skin By Jini John and Anie Philip, Division of Plastic Surgery, McGill University

Are you ready to learn about skin? The skin is the largest organ in our body, and it is very important for keeping us healthy! The skin is made up of three layers – the epidermis, the dermis, and the hypodermis – and each layer plays an important role in skin health. The top layer of skin is called the epidermis. This layer is mostly made up of cells called KERATINOCYTES. This layer protects us from the environment and keeps our skin looking and feeling smooth. It also keeps moisture in and germs out.

The middle layer of the skin is called the dermis, and this is the thickest layer of the skin. The dermis is where our hair follicles, blood vessels, nerve endings, and sweat glands are. This layer also contains hardworking cells called FIBROBLASTS. The dermis is important for keeping skin strong, as the cells in this layer, like the fibroblasts, produce proteins like collagen and elastin that makes the skin strong and elastic. The amounts of collagen and elastin in the skin are important to keep our skin looking young. As we age, our bodies produce less of these proteins, resulting in wrinkles and other signs of aging. The third and deepest layer of skin is called the hypodermis. This layer is made up of fat and connective tissue which connect skin to the muscle and bone. This layer, along with the top layers of the skin, helps keep us

3 layers of human skin

Epidermis

Dermis

Hypodermis

warm and provides cushioning for our body. Our skin is an amazing organ that helps us in so many ways! In addition to protecting us from the environment, the skin has special nerve endings in its epidermal and dermal layers which allow us to feel heat, cold, pain, pressure, and itch. The skin also helps regulate our body temperature, helping our bodies to not get too hot or too cold so that we stay healthy. It is our first line of defence against the sun’s harmful UV rays, too. It is so important to take care of our skin. You can care for your skin by wearing sunscreen when outside, keeping it moisturized, drinking plenty of water, and safely treating your wounds. With proper care our skin can stay healthy and help to keep us healthy, too! Winter 2024 | www.canadianskin.ca | 11

SKIN PIGMENTATION DISORDERS BY SIMAL QURESHI

Skin pigmentation, otherwise known as the colour of the skin, depends on several factors, including melanin, hemoglobin, carotene, blood vessels, and skin thickness.1, 4 The main factor behind skin pigment is melanin. Melanin is created by specialized skin cells called melanocytes, and the amount and type of melanin we produce varies according to our race.1, 2 The more melanin we produce, the darker our skin will be.3

WHAT ARE SKIN PIGMENTATION DISORDERS? Pigmentation disorders can be due to changes or differences in melanocytes, such as the number, activity, and functioning of these cells.1, 4 For instance, hyperpigmentation disorders can be due to enhanced activity or the number of melanocytes, leading to an increase in melanin production (more melanin in these areas) and a darker appearance.1 On the other hand, hypopigmentation, where the body doesn’t produce enough melanin, may be due to fewer melanocytes or their inability to produce 12 | www.canadianskin.ca | Winter 2024

melanin leading to a lighter appearance because there’s less melanin there.1

HYPOPIGMENTATION DISORDERS Vitiligo Vitiligo is an autoimmune condition which destroys the melanocytes, thereby inhibiting melanin production. This destruction of the pigmentproducing cells leads to loss of colour, resulting in white patches on the skin.6 Common sites where vitiligo may present include the face, hands, forearms, neck, genitalia, and body folds.1 In addition to where skin is losing its colour, hair may also turn white in areas such as the eyebrows, eyelashes, and scalp6. This condition is especially noticeable in people with darker skin tones. Vitiligo can present in a localized manner, otherwise known as segmental vitiligo, where hypopigmented patches appear on one side of the body.1, 6 However, vitiligo may also present in a more generalized manner, known as nonsegmental vitiligo, where symmetrical patches appear on both sides of the body.6 These patches can

cover more than 10% of the body.1, 6 Treatment for vitiligo is not always necessary as the skin changes are not harmful to the body but can be used if the patient’s physical or emotional well-being is impacted. Treatment can range from medications such as topical corticosteroids or calcineurin inhibitors, or light therapy such as narrowband ultraviolet B (UVB).6

Pityriasis alba Pityriasis alba is a condition that is often associated with atopic dermatitis, also known as eczema. This condition may be exacerbated through sun exposure and can leave skin feeling itchy, with scaly patches.1 These patches can eventually result in hypopigmentation. Pityriasis alba generally resolves on its own, but if patients have symptoms, medical treatment may include topical corticosteroids.

HYPERPIGMENTATION DISORDERS Solar lentignes (sun spots) Also known as sun spots, solar lentignes may occur due to chronic

sun exposure, presenting as flat patches (macules) that are darker than your natural skin tone, ranging from 1–3 cm in size.1 Solar lentignes vary in colour, from light yellow to dark brown, more commonly affecting individuals with a lighter skin tone.1 The most effective treatment for solar lentigines are topical therapies, such as hydroquinone and retinoids.1 However, alternative therapies such as light/lasers, chemical peels, and cryotherapy (freezing the skin) may also be considered.1

Melasma Melasma often manifests as brown to gray-brown patches on the face, specifically on the nose, chin, and cheeks. This condition more commonly impacts women and individuals with darker skin tones.1,7 Melasma can happen for reasons, such as pregnancy, hormonal therapy, sun exposure, or genetics.7 Treatment can consist of triple combination therapy which includes hydroquinone, tretinoin, and fluocinolone. Alternatively, one

may also use chemical peels or laser therapies to treat the appearance of the skin.1,7

HOW CAN I HELP PREVENT HYPER- OR HYPOPIGMENTATION? For many of these conditions, sun exposure is a trigger and can worsen the patient’s symptoms. To prevent this, practicing sun safety is an important step to take. This includes limiting sun exposure, using broadspectrum sunscreen regularly, and wearing sun-protective clothing such as long sleeves, hats, and pants.1

SOCIAL IMPACTS OF SKIN PIGMENTATION DISORDERS It is important to recognize the social ramifications of pigmentation disorders. For instance, conditions such as vitiligo can be deeply stigmatized, leading individuals living with these conditions to be discriminated against and feel marginalized. These feelings of isolation can lead to developing low self-esteem and affect quality of life.1, 5, 6

As such, it is important to foster understanding around these types of skin conditions. Through education, we can deconstruct biases and empower people living with diverse conditions to feel safe, welcomed, and confident in their skin. REFERENCES:

1. Plensdorf, S., & Martinez, J. (2009). Common pigmentation disorders. American family physician, 79(2), 109-116. 2. Cichorek, M., Wachulska, M., Stasiewicz, A., & Tymińska, A. (2013). Skin melanocytes: biology and development. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, 30(1), 30-41. 3. Mount Sinai. Pigmented Conditions. [Internet]. 2023 [cited 2023 August]. Available from: https://www.mountsinai.org/ care/dermatology/services/pigmented 4. Fistarol, S. K., & Itin, P. H. (2010). Disorders of pigmentation. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 8(3), 187-202. 5. Mosca, S., & Morrone, A. (2023, July). Human Skin Pigmentation: From a Biological Feature to a Social Determinant. In Healthcare (Vol. 11, No. 14, p. 2091). MDPI. 6. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Vitiligo. [Internet]. 2022 October [cited 2023 August]. Available from: https://www.niams.nih.gov/healthtopics/vitiligo 7. Basit, H., Godse, K. V., & Al Aboud, A. M. (2023). Melasma [updated 2023 Apr 16]. StatPearls.

Simal Qureshi is a third-year medical student at Memorial University of Newfoundland. Winter 2024 | www.canadianskin.ca | 13

CSPA IN ACTION

The Canadian Skin Patient Alliance (CSPA) has had another eventful season of championing patients’ rights and raising public awareness about life with a skin, hair, or nail condition. Following a productive summer on the advocacy front, we worked hard behind the scenes throughout the fall in preparation for a forum we hosted in October titled Breaking Barriers: A patient roundtable discussion on how to improve equity in dermatological care. Marking CSPA’s first in-person event after four years of virtual gatherings, this forum gave individuals with darker skin types (i.e., Black, Indigenous, or people of colour) the opportunity to share their personal experiences about the obstacles they encounter when seeking diagnosis, care, and treatment. CSPA also held a meeting for our Affiliate Members this past November. Collaboration is key to the work that we do, and CSPA continues to seek 14 | www.canadianskin.ca | Winter 2024

CSPA in action: A spotlight on our latest activities, events and other information of importance to skin patients in Canada

Together, we can drive progress forward and create a brighter future for ALL skin patients. and build vital connections within the community. Among organizations we recently welcomed to our network are MiaThrives (epidermolysis bullosa), Lupus Ontario, and the Canadian Association of Psoriasis Patients. In other news, CSPA has been receiving much positive feedback on our newly revamped website (English and French)! With its fresh look, updated content, and improved navigation, it is the go-to place for information on common and rare dermatological conditions, exciting advocacy initiatives, unique educational resources, clinical trial participation and much more. Whether you are a person living with a skin, hair, or nail condition,

an Affiliate Member, or a member of the public, we invite you to explore our website and let us know what you think. Lastly, we are pleased to share that CSPA is now a registered charity! With millions of people across Canada impacted daily by dermatological conditions, we recognize that it is a burden and a community that too often go unnoticed. We are working to change that, so please donate today to support our mission (https:// canadianskin.ca/en). Together, we can drive progress forward and create a brighter future for ALL skin patients. Rachael Manion, Executive Director, CSPA

SPONSOR OF CANADIAN SKIN MAGAZINE AbbVie is the Founding Sponsor of the Canadian Skin magazine and an ongoing supporter of CSPA’s 2024 publications. AbbVie is not providing editorial support for the magazine. The CSPA is responsible for the final content featured in Canadian Skin.

CSPA CORPORATE SPONSORS

Become a CSPA Volunteer! Are you interested in joining a dedicated patient advocacy organization and contributing to a better world for people living with skin, hair, and nail conditions across Canada? If so, there are many ways you can get involved and help support our community and mission. Let us know by completing this survey – we’d love to hear from you! https://forms.office.com/r/ KdEyvXQH5y

CANADIAN SKIN MEDICAL ADVISORS + BOARD MEMBERS + VOLUNTEERS Thank you to the medical advisors, board members, and volunteers who support the work of the CSPA. For an updated list of names, visit canadianskin.ca/about-us.

CSPA AFFILIATE MEMBERS AboutFace: aboutface.ca Acne and Rosacea Society of Canada: acneaction.ca (acne) rosaceahelp.ca (rosacea)

Canadian Chronic Urticaria Society – Société canadienne d’urticaire chronique: chronicurticaria.ca Canadian Psoriasis Network: cpn-rcp.com

Melanoma Canada: melanomanetwork.ca MiaThrives: miathrives.org Myositis Canada: myositis.ca

Alberta Lymphedema Association: albertalymphedema.com

Canadian Skin Cancer Foundation: canadianskincancerfoundation.com

BC Lymphedema Association: bclymph.org

DEBRA Canada (epidermolysis bullosa): debracanada.org

BC Professional Firefighters’ Burn Fund: burnfund.org

Eczéma Québec: eczemaquebec.com

Camp Liberté Society: campliberte.ca

Eczema Society of Canada: eczemahelp.ca

Canadian Alopecia Areata Foundation (CANAAF): canaaf.org

Firefighters’ Burn Fund: burnfundmb.ca

Canadian Arthritis Patient Alliance: arthritispatient.ca

Hidradenitis & Me Support Group: hidradenitisandme.ca

Scleroderma Canada: scleroderma.ca

Canadian Association for Porphyria: canadianassociationforporphyria.ca

HS Heroes: hsheroes.ca

Scleroderma Manitoba: sclerodermamanitoba.com

Canadian Association of Psoriasis Patients: canadianpsoriasis.ca

Lupus Ontario: lupusontario.org

Scleroderma Society of Ontario: sclerodermaontario.ca

Canadian Autoinflammatory Network: autoinflammatory.ca

Lymphedema Association of Ontario: lymphontario.ca

Stevens–Johnson Syndrome Canada: sjscanada.org

Canadian Burn Survivors Community (CBSC): canadianburnsurvivors.ca

Mamingwey Burn Society: mamingwey.ca

Tumour Foundation of BC: tumourfoundation.ca

Neurofibromatosis Society of Ontario: nfon.ca Save Your Skin Foundation: saveyourskin.ca Scleroderma Association of B.C.: sclerodermabc.ca Scleroderma Atlantic: sclerodermaatlantic.ca

2022 2022 Dermatologist of the Year The Canadian Skin Patient Alliance (CSPA) is thrilled to announce Dr. An-Wen Chan as our 2022 Dermatologist of the Year!

Dr. Chan is recognized for his commitment to advancing life-changing research for the prevention, detection, and treatment of high-risk skin cancers. He is an accomplished dermatologist, clinical epidemiologist, and surgeon who works to improve the efficiency of research while enhancing health outcomes for skin cancer patients and their loved ones. Dr. Chan has served as a managing director with the Skin Investigation Network of Canada. A champion of the skin patient community, he is to be lauded for his extraordinary compassion and dedication.

We gratefully acknowledge Dr. Chan and all the healthcare professionals who continue to support the efforts of CSPA in informing, educating, and advocating on behalf of the skin patient community. Thank you!