Canadian Skin – Summer 2021 by Kelman & Associates

COMPLIMENTARY

Summer 2021

VOLUME 12 • ISSUE 2

CANADIAN

Navigating dermatology for

Muslim patients

sun protection FACTS ABOUT

FOR CHILDREN

www.canadianskin.ca The Official Publication of the Canadian Skin Patient Alliance

CLOSE-UP ON HYPERHIDROSIS TELEDERMATOLOGY SERVICES IN CANADA

SKINfacts Caffeine consumption may be linked to decreased rosacea symptoms

A study of nearly 5,000 patients found that women who consumed four or more cups of coffee per day had a lower incidence of rosacea symptoms. Interestingly, caffeine intake from other foods such as tea, soda, and chocolate did not have the same effect.

• Men start to go grey earlier, at about age 30; women at around 35. • Genetics play a role. If your parents went grey early, you are more likely to see the same pattern. • Grey hairs first appear around the temples and the top of the head. • Grey hair is not truly grey in colour. It is a mixture of the remaining hair pigment and white hairs. White hair is also an optical effect; keratin in hair actually has a yellow colour, however, light reflects back to the eye and creates a white appearance for the hair.

Melanoma is a type of skin cancer that can rarely develop beneath the surface of the nail. Called subungual (under the nail) melanoma, it appears as a brown or black streak. People may delay seeing a doctor because they mistake the discoloration for a bruise, assuming they’ve stubbed their toe or hit a finger. Subungual melanoma more often occurs in patients of colour. Only about 2% of cases are people with lighter skin types, whereas about 30–40% of cases are in people of

Summer 2021

VOLUME 12 • ISSUE 2

CANADIAN

Summer 2021 • Volume 12 • Issue 2

COMPLIMENTARY

ISSN 1923-0729 Navigating dermatology for

Muslim patients

sun protection FACTS ABOUT

FOR CHILDREN

www.canadianskin.ca The Official Publication of the Canadian Skin Patient Alliance

CLOSE-UP ON HYPERHIDROSIS TELEDERMATOLOGY SERVICES IN CANADA

2 | www.canadianskin.ca | Summer 2021

AND TIPS FOR SKIN PATIENTS AND THEIR FAMILIES

colour. However, many people with darker skin types may have streaks in their nails that are not cancer; these do not change or increase in size. Men and women are at equal risk, and the risk increases after age 50. Most subungual melanomas occur in the thumbnail or big toenail, although it can develop in any nail. Repeated injury to finger- or toenails has been identified as a risk factor for developing subungual melanoma. Always see a dermatologist as soon as possible if you notice potential signs of subungual melanoma.

Healthy, happy feet

Facts about greying hair

Notice your nails

SUGGESTIONS

With the warmer summer weather comes sandal season. Here are some tips for taking care of your feet and toes. • Check your toenails for signs of nail fungus. Did you know that men are 2.4 times more likely to have nail fungus than women? The CSPA site (www.canadianskin.ca/nailfungus/361-overview-what-is-nail-fungus) has information on symptoms and other fast facts. • Use petroleum jelly to moisturize your feet and ankles at least once a week. Try applying it before going to bed and sleeping with your socks on after moisturizing. • Patients with type 2 diabetes and arthritis should pay extra attention to their feet. Check them regularly for cuts, sores, swelling, and infected toenails. • Trim your toenails regularly, but don’t cut them too short to help prevent ingrown nails. • Dry your feet off well, including in between the toes. • Wear sunscreen on the tops of your feet. Apply a broadspectrum sunscreen with an SPF of at least 30 to your feet when you’re going barefoot or wearing open sandals.

Canadian Skin Patient Alliance: 111-223 Colonnade Road South, Ottawa, ON K2E 7K3 Toll Free: 1-877-505-CSPA (2772) • E-mail: 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. A Canadian health care professional answers your questions.

Questions about how clothing and diet may affect your skin conditions By Dr. Isabelle Delorme

Q A

Can the clothes I wear affect my HS?

Although it has not been proven scientifically, we believe that friction caused by tight clothing can worsen HS symptoms. Hidradenitis suppurativa (HS) is a chronic condition characterized by recurrent, inflammatory bumps which usually occur in areas where two parts of the body rub against one another. In women, when the region under the breast where the breast meets the chest and the sides of the breast are involved, choosing appropriate bras can have a significant impact on disease severity for female patients. Bra designs that can help offload pressure and prevent excessive friction underneath the breast where the bra band sits include sports bras or camisole tanks with built-in wireless bras. Underwear should be loose-fitting without tight bands or seams in the groin region or across the abdomen. For women, designs that may help to decrease friction in the lower abdomen include “boy shorts,” briefs, and high-cut briefs. For men, most loose boxers or trunks are usually appropriate for HS. Clothing fabric choice may also play an important role in minimizing friction and skin irritation in HS patients. Clothing made from 100% cotton is a great option. These are readily available and affordable. In recent years, “new age fibers” have emerged in the textile industry, and may help to minimize inflammation and irritation from clothing in HS patients. These include cellulose-derived rayon fibers (Tencel, Lyocell) and bamboo fibers. Finally, silver-containing antimicrobial fabrics may also be a consideration in garment selection for HS patients. Silver ions are known to prevent the growth of bacteria and yeast, which are known to colonize HS lesions. However, these fabrics are more expensive and less accessible compared to other clothing types.

I’ve heard that my diet can impact my eczema – is this true? Is there anything I can do to improve my condition?

The role of diet in dermatology is a frequent source of patient questions and physician uncertainty. It’s possible that diet can impact eczema, but we do not yet fully understand the role diet might play in the onset of eczema or eczema symptoms. Some people have found that certain foods, such as dairy, eggs, or nuts, may trigger their eczema and that eliminating them from their diet has improved symptoms. However, there is no clinical evidence to support a connection between diet and eczema getting better or worse. We do not know what exactly causes eczema. However, for most types of eczema, researchers believe a combination of genes and triggers are involved. People with eczema tend to have an over-reactive immune system that, when triggered, responds by producing inflammation. Known triggers include dry skin, emotional stress, cold weather, sweat, harsh soaps and detergents, and certain fabrics like wool and polyester. The following tips may help prevent eczema flares: • Moisturize your skin at least twice a day. • Try to identify and avoid triggers that worsen the condition. • Use only gentle soaps. • Wear loose, breathable cotton and soft fabric clothes. • Avoid rough, scratchy fibers and tight-fitting clothing.

Dr. Isabelle Delorme is a certified dermatologist working in Drummondville, Quebec. Got a question? Send it to info@canadianskin.ca. If your question is published you will receive a $25 gift card. Good luck! Summer 2021

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sun protection FACTS ABOUT

FOR

CHILDREN By Harry Liu, MD

What is UV light? Ultraviolet (UV) light can be classified into UVA and UVB light. UVAs penetrate deeper into the skin and cause skin aging. UVB rays affect the skin on a more superficial level, causing sunburns and increasing the risk of skin cancer. Protection from UV light is particularly important in childhood because, currently, many individuals receive 40–60% of their total lifetime UV exposure before the age of 20. Protection from the

FACT Studies have shown that, for adolescents, the harmful eﬀects of UV on appearance, including wrinkles, motivate them more eﬀectively than fear of developing cancer.

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FACT Sunscreen decreases the production of vitamin D in the skin, but an oral vitamin D supplement is a much safer, inexpensive, and well-tolerated way to achieve suﬃcient vitamin D without UV damage from the sun.

harms of UV light remains the most important strategy to decrease the risk for developing skin cancer. Protective methods for sun protection 1. Understand the risk: seek shade and minimize direct sun exposure from 11 am to 3 pm between April and September in Canada, because the UV Index can be 3 or higher which means moderate risk of sunburn. A quick way is to see if your shadow is shorter than you are. If so, it is particularly important to ask your children to stay in the shade.

2. Wear clothes that cover as much of the body as possible. When picking out clothes, go with the ones made with tightly woven fabrics and dark colours but make sure they are loose and lightweight to avoid excessive heat. 3. Wearing a hat with a brim of 7.5 cm (3 inches) provides additional protection for the head and neck. For infants, sunshades are available for strollers. 4. Special window glass exists to provide both UVB and UVA protection. Common window glass provides a variable degree of UV

protection; however, if the child spends a lot of time in the car, there are window films that can be applied to the side windows of the car for further protection. When to use sunscreen When other protective methods are not available, sunscreen can be used. It is important to know that many studies have shown that people of colour are less likely to practice sun-protective behaviours and they may also be less likely to be prescribed a sunscreen by their physician. However, sun protection is crucial in people of colour to prevent skin cancer and reduce photoaging and UV-induced hyperpigmentation of the skin. Sun protection factor (SPF) is the most important property of sunscreen, which is a number that tells you how long the sun’s UVB rays would take to redden your skin if you apply the sunscreen exactly as directed compared with the amount of time without sunscreen. For example, if using a sunscreen with SPF of 30, it would take you 30 times longer to burn than if you used no sunscreen. Protecting against UVA rays is not currently labelled in Canada. Sunscreen labelled as broad-spectrum should offer protection from both UVA and UVB rays. Sunscreen is recommended for people of all skin types.

FACT Tanning lamps and beds can give oﬀ 2 to 5 times more UVA radiation than natural sunlight, increasing the risk for malignant melanoma. The Canadian Pediatric Society supports laws that prohibit indoor commercial tanning for youth under 18 years old.

FACT Many insect repellents have N,N-diethyl-meta-toluamide (DEET) as their active chemical ingredient, which can make sunscreen less eﬀective; it is important to apply suﬃcient sunscreen about 20 minutes before insect repellent. Avoid products with a combination of repellent and sunscreen because sunscreen may need to be reapplied more often than repellent.

Types • Organic sunscreen (avobenzone, oxybenzone, octocrylene, and ecamsule) • Mineral/inorganic sunscreen (titanium dioxide and zinc oxide) Formulation • Creams are best for dry skin • Gels are good for hairy areas • Stick is safe to use around the eyes • Spray formulas are not routinely recommended for children because they can get in the eyes, may be inhaled by people who have asthma, or result in missed areas • Tinted sunscreen blocks visible light Which sunscreen should I pick? • Water-resistant broad-spectrum sunscreen with a SPF of at least 30 • Pick products with less fragrance, preservatives, and formaldehyde releasers to decrease the chance of irritant or allergic contact dermatitis • Pick sunscreen endorsed by the Canadian Dermatology Association (CDA) • Use something your children like best so that they will use it more routinely How to apply sunscreen • Check expiry dates on sunscreen products before using them • Most sunscreens now work immediately when they are applied to the skin • If sunscreen is applied sufficiently and correctly for the first time, there may be less of a need to reapply as frequently as we expect • Always reapply sunscreen after swimming or with heavy sweating • Teach teens the teaspoon rule: apply 1 teaspoon of sunscreen to the face and neck area, 1 teaspoon to each arm, a total of 2 teaspoons

to the front and back torso, and 2 teaspoons to each leg • Wearing lip balm with sunscreen SPF 30 is equally important • For children younger than 6 months old, sunscreen is not usually recommended • Canadian Pediatric Society (CPS) suggests an inorganic sunscreen SPF 30 to be used when protective clothing or shade is not accessible How to treat sunburn The signs of sunburn, including redness, swelling, burning sensation or even blisters, usually appear 6 to 12 hours after sun exposure and children can be more symptomatic by then; the full effect may take 24 hours to appear. You need to seek medical attention if sunburn happens in a baby younger than one year. Blisters with the risk of infection, significant pain, or fever are the reasons for medical attention for older children. Some basic strategies you can use for milder sunburn: • For rehydration, give the child water • Avoid further sun exposure • Use a cool water compress or a cool bath to help skin feel better • Acetaminophen or ibuprofen for pain management if needed There are many other methods for sun protection besides sunscreen, including seeking shade, wearing protective clothes, and picking window glass with UV protection. These should be the first-line approach to be supplemented with sunscreen to any remaining exposed skin. It is crucial to educate teens to avoid tanning beds and lamps since they significantly increase the risk of developing melanoma. Harry Liu is a dermatology resident at the University of British Columbia. @harryliumd Summer 2021

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Close-up on: Hyperhidrosis BY ZOË PHILLIPS, MPH

Hyperhidrosis is a common condition characterized by excessive and uncontrollable sweating. While it is not dangerous, it can be distressing and seriously impact everyday function and quality of life. There are two main categories of hyperhidrosis: primary and secondary. Primary hyperhidrosis tends to be localized (focal) in nature, whereas secondary hyperhidrosis more often presents as generalized sweating. Primary focal hyperhidrosis commonly affects the underarms, soles of the feet, palms, head, and face, but can also involve other areas of the body. It tends to affect both sides of the body equally, and it is common for combinations of areas to be affected. Symptoms usually begin in childhood or adolescence. It can occur continuously or in phases, and sweating is often better at night and absent during sleep. Sweating attacks can be triggered by things such as heat, physical activity, spicy foods, caffeine, alcohol, or anxiety. It is not caused by any underlying medical disease or drug, but the tendency may be inherited. Secondary hyperhidrosis is less common. It is most commonly generalized, but rarely can be localized. Secondary hyperhidrosis is caused by an underlying condition or medication. How do I know if I have hyperhidrosis? Sweating is an important way for the body to regulate its temperature; however it should not interfere with your ability to interact and function. If excessive sweating is negatively affecting your life, you should see a doctor about this. Diagnosis There is no specific test to diagnose primary focal hyperhidrosis. It is diagnosed by a doctor based on your history and symptoms. If your doctor suspects secondary hyperhidrosis then they may order further investigations, such as laboratory 6 | www.canadianskin.ca | Summer 2021

work, to see if it is caused by an underlying medical condition.

It is generally applied daily as a medicated wipe.

Treatment General measures include: • Avoiding triggers such as heat, physical activity, spicy foods, caffeine, alcohol, or situations that evoke anxiety. • Avoiding medications that may be contributing to hyperhidrosis. • Washing with an antibacterial cleanser to help reduce odour and risk of bacterial infection. • Drying skin thoroughly after bathing and apply corn starch powder. • Choosing clothing made with absorbent material (such as cotton) over synthetic fabric. • Wearing loose-fitting, stain-resistant, sweat-proof clothing: “Moisture-wicking” fabrics like cotton, wool, and other synthetic fabrics for pulling sweat away from the skin. Choose dark coloured clothing or bold patterns to help conceal sweat marks. • Using underarm liners or dress shields to absorb excess sweat. • Using foot powder, absorbent shoe insoles, and change shoes frequently. • Choosing cotton or wool socks to absorb dampness, and change socks frequently. • Wearing socks containing silver or copper to reduce infection and odour.

Iontophoresis: This is used for hyperhidrosis of the palms or soles and involves placing the affected areas in shallow water and applying a lowintensity electrical current. Regular treatments are needed to maintain results, but they can be done at home.

Treatment options differ depending on location and severity of sweating. Speak with your doctor to find a treatment option that works for you. Antiperspirants: These are topical sprays, gels, roll-ons, and lotions that block sweat at the surface of the skin. They are available in commercial and prescription-strength forms and are usually the first line of treatment. Topical glycopyrrolate: This agent blocks receptors that are responsible for activation of the sweat glands.

Botulinum toxin: This medication is injected into affected areas and interrupts the signal from the nerve to the sweat gland. Most people require one to two treatments annually. Oral medication: Oral anticholinergics block receptors in the body to reduce sweating. Other oral medications such as beta-blockers, clonidine, and benzodiazepines may also be helpful. Their use may be limited by side effects. Microwave thermolysis: It involves using a handheld device in the underarms to deliver electromagnetic energy, causing eccrine sweat glands to be destroyed. It typically requires two treatment sessions separated by three months and may provide a lasting reduction in sweat. Surgery: Surgical procedures such as sweat gland removal and sympathectomy are reserved for people with severe symptoms that cannot be managed with other therapies. A potential side effect of surgery is compensatory sweating in non-treated areas. Support Excessive sweating can have a significant impact on quality of life, with serious emotional, physical, and social repercussions. The International Hyperhidrosis Society (www.sweathelp. org) provides education and support for people living with hyperhidrosis. Zoë Phillips is a fourth-year medical student at University of Saskatchewan.

Navigating dermatology for

Muslim patients By Maaz Haq and Shaimaa Helal

In North America, there is currently a difference in care for many Muslim patients within the healthcare system compared to patients of other faiths. Studies done on samples of Muslim women in the United States suggest that up to 53% of Muslim women delay seeking care due to a perceived lack of availability of female physicians.1 Canadian South Asian Muslims with end-stage kidney disease are less likely to receive a kidney transplant compared to their Caucasian non-Muslim counterparts. 2 Muslim women in Ontario have significantly lower rates of breast cancer and cervical cancer screening. 3-4 These health disparities arise when cultural and

religious needs are not expressed and addressed. Dermatology, with its focus on the examination of traditionally covered areas such as the skin and the scalp, may be nerve-racking for a Muslim to navigate. We have created this guide to empower Muslims with the knowledge of what is acceptable to request, which religious practices have medical relevance, and potential treatment considerations. Addressing comfort during the medical encounter The impermissible nature of khalwa (being alone with a member of the opposite gender) may prompt Muslims to request a same-gendered physician

or the presence of a chaperone. Both are reasonable requests. It would be best to ask the referring physician to make this request on your behalf. If that is not feasible, however, then it may help to inform the clinic at the time of booking the appointment that you would be more comfortable with a physician of the same gender, or that you’ll be needing a chaperone. If neither are possible, inform the physician of what they can do to make the experience more comfortable. For instance: • Ask to expose the least amount of skin possible • Ask for time to adjust your clothing/ hijab without the physician present in the room. Summer 2021

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Just remember… Empowering yourself with information about the intersection of your faith and health allows you to come to appointments equipped to ask the right questions. Sharing your religious needs and health preferences helps open up a conversation to allow shared decision making and enhances not only your comfort, but your quality of care.

Medically relevant details There are certain Islamic practices which are relevant to concerns brought up in dermatology. Wudu and xerosis (dry skin) Wudu (ablution) involves repeatedly washing the hands, face, arms, and feet throughout the day. This frequent washing of the skin, particularly in the presence of a pre-existing skin condition, can worsen dryness.5-7 If you are unable to perform wudu safely, tayammum is a water-free alternative.8

Courtesy of Muslim patient with wudu-exacerbated xerosis Hijab and hair care Hijab is the Arabic word for ‘partition’ and refers to the religious attire worn by Muslims. The term is often used colloquially to refer to the headscarf worn by Muslim women. While hijab itself does not cause hair loss or thinning, improper hair care while wearing hijab can lead to hair thinning. This includes wearing synthetic fabrics that create friction leading to hair breakage9, tying up hair tightly under your hijab leading to traction alopecia10, or tying up hair while it is still wet.11 Furthermore, women who observe hijab, particularly those living in northern climates, are at an increased risk of vitamin D deficiency which may impact hair health.12-13 Discussing your hair care practices with your dermatologist may help you recognize some possible reasons for hair thinning. The mark of Sujood/’devotion’ sign A small, darkened bump on the forehead of someone who regularly prostates on hard surfaces is usually benign. If unfamiliar with the practice, a dermatologist may wonder what created this sign. 8 | www.canadianskin.ca | Summer 2021

Courtesy of Muslim patient with the ‘devotion’ sign Tailoring treatment Dietary restrictions Muslims may have preferences for medications due to religious dietary restrictions. There are a variety of ingredients that may be included in medications which a Muslim may choose to avoid. These include: • Porcine-derived ingredients* • Non-halal animal-derived ingredients* • Alcohol when orally administered. It is important to note, in several schools of Islamic Jurisprudence, ingredients that are classically impermissible can become acceptable in extenuating circumstances, such as a lack of availability of an equally effective alternative, or a life-threatening emergency that requires prompt action. *For a full list of animal-derived medications, visit bit.ly/animal-derived-meds.

Treatment regimens in Ramadan If you are fasting during Ramadan, you may want to ask your dermatologist if they can accommodate your treatment regimen around fasting hours. For example, they may recommend that you take your morning medication with iftar (the meal eaten after sunset in Ramadan), and your evening medication with suhoor (the meal eaten before dawn in Ramadan). This may also apply for topical medications, as a study in the UK showed that over a third of Muslim patients do not use topical dermatologic treatments while fasting.14 Your dermatologist can work with you to find a treatment schedule that works. Treatment plans work best when both patients and physicians are involved in the decision-making process. As a patient, this means being proactive by doing your own research and coming prepared to discuss your treatment preferences.

Maaz Haq is a second-year medical student at Queen’s University. Shaimaa Helal is a third-year medical student at Queen’s University. REFERENCES

1. M. Vu, A. Azmat, T. Radejko, and A. I. Padela, “Predictors of Delayed Healthcare Seeking Among American Muslim Women,” J. Women’s Heal., vol. 25, no. 6, pp. 586–593, Jun. 2016, doi: 10.1089/jwh.2015.5517. 2. A. Ali et al., “South Asian and Muslim Canadian Patients are less Likely to Receive Living Donor Kidney Transplant offers Compared to Caucasian, Non-Muslim Patients,” Transplantation, vol. 102, p. S502, Jul. 2018, doi: 10.1097/01. tp.0000543324.75699.94. 3. M. Vahabi et al., “Breast cancer screening utilization among women from Muslim majority countries in Ontario, Canada,” Prev. Med. (Baltim)., vol. 105, pp. 176–183, Dec. 2017, doi: 10.1016/j.ypmed.2017.09.008. 4. A. K. Lofters, M. Vahabi, E. Kim, L. Ellison, E. Graves, and R. H. Glazier, “Cervical Cancer Screening among Women from Muslim-Majority Countries in Ontario, Canada,” 2017, doi: 10.1158/1055-9965.EPI-17-0323. 5. A. P. Lazar and P. Lazar, “Dry skin, water, and lubrication,” Dermatologic Clinics, vol. 9, no. 1. pp. 45–51, Jan. 01, 1991, doi: 10.1016/s0733-8635(18)30432-7. 6. M. Greenberg, H. Galiczynski, and J. Edward M. Galiczynski, “Dry skin: common causes, effective treatments: ruling out systemic causes is the first step to diagnosing xerosis, and patient education is the key to management. The good news is that dry skin can usually be managed effectively and inexpensively,” JAAPA-Journal Am. Acad. Physicians Assist., vol. 17, no. 9, pp. 26–31, Sep. 2004, Accessed: Aug. 06, 2020. [Online]. Available: https://go.gale.com/ps/i.do?p=AONE&sw=w&issn=15471896&v= 2.1&it=r&id=GALE%7CA123079399&sid=googleScholar&linkacce ss=fulltext. 7. E. Proksch and J. M. Lachapelle, “The management of dry skin with topical emollients – Recent perspectives,” JDDG – Journal of the German Society of Dermatology, vol. 3, no. 10. J Dtsch Dermatol Ges, pp. 768–774, Oct. 2005, doi: 10.1111/j.16100387.2005.05068.x. 8. Sahih al-Bukhari 334 9. A. Shafik, “Polyester but not cotton or wool textiles inhibit hair growth,” Dermatology, vol. 187, no. 4, pp. 239–242, 1993, doi: 10.1159/000247256. 10. V. Billero and M. Miteva, “Traction alopecia: The root of the problem,” Clinical, Cosmetic and Investigational Dermatology, vol. 11. Dove Medical Press Ltd., pp. 149–159, Apr. 06, 2018, doi: 10.2147/CCID.S137296. 11. C. R. Robbins, Chemical and Physical Behavior of Human Hair. Springer Berlin Heidelberg, 2012. 12. M. Razzaghy-Azar and M. Shakiba, “Assessment of vitamin D status in healthy children and adolescents living in Tehran and its relation to iPTH, gender, weight and height,” Annals of Human Biology, vol. 37, no. 5. Taylor & Francis, pp. 692–701, Sep. 2010, doi: 10.3109/03014460903527348. 13. S. Hatun et al., “Subclinical vitamin D deficiency is increased in adolescent girls who wear concealing clothing,” in Journal of Nutrition, 2005, vol. 135, no. 2, pp. 218–222, doi: 10.1093/ jn/135.2.218. 14. T. Patel, A. Magdum, and V. Ghura, “Does fasting during Ramadan affect the use of topical dermatological treatment by Muslim patients in the UK?,” Clin. Exp. Dermatol., vol. 37, no. 7, pp. 718–721, Oct. 2012, doi: 10.1111/j.1365-2230.2012.04403.x.

What ’s new on the research front? The articles from which these summaries of the latest in skin research are taken are hot off the press!

Top Stories in Research By Irma Shaboian Filler injections: Use of cannulas associated with lower vascular occlusion risk compared to needles Injectable skin fillers can be delivered with needles or microcannulas. However, unwanted vascular occlusions are possible, which occur when blood is no longer able to pass through a blood vessel. Researchers sought to determine whether fillerassociated vascular occlusions of the face take place more often when injections are performed with needles than with microcannulas, where occlusion events were graded by severity. In total, 370 dermatologists participated in the study and reported 1.7 million syringes injected between August 2018 to August 2019. It was found that the risk of occlusion with any particular filler injection that used a needle or cannula never exceeded 1 per 5,000 syringes injected. Filler injections with either needles or cannulas were associated with a very low risk of vascular occlusion. For injections with needles, there was 1 occlusion event per 6,410 per 1-mL syringe injections observed, whereas there was 1 occlusion event observed per 40,882 syringe injections when cannulas were used. The vast majority of blocked vessels reported were minor and resolved without scar or other injury. Nevertheless, the researchers noted that injections with cannula had 77.1% lower odds of occlusions compared with needle injections. Nasolabial folds and lips were most likely to be occluded. Overall, the researchers found that while filler injections with either needles or cannulas were associated with a very low risk of occlusion events, injections with cannulas were less often associated with occlusion events than injections with needles. Moreover, the researchers note that occlusion risk per syringe seemed to decrease after the first few years of clinical practice and was lower among those who more frequently inject fillers. The study’s findings are helpful to both patients and practitioners when deciding on the method of injection. Study Information: Alam, M., Kakar, R., Dover, J. S., Harikumar, V., Kang, B. Y., Wan, H. T., ... & Jones, D. H. (2021). Rates of Vascular Occlusion Associated With Using Needles vs. Cannulas for Filler Injection. JAMA dermatology, 157(2), 174-180.

High cumulative amounts of potent topical corticosteroids associated with increased risk of osteoporosis Corticosteroids given orally or by injection, also known as systemic corticosteroids, have been linked to causing systemic adverse events, such as negatively affecting bone remodeling or causing osteoporosis when given continuously or in high doses. The risk of osteoporosis and osteoporotic fracture (MOF) is largely unexplored. To determine whether topical corticosteroids (TCSs) cause systemic adverse events such as those linked with systemic corticosteroids, researchers examined the association between cumulative exposure to potent and very potent TCSs and risk of osteoporosis and MOF. The study involved more than 723,000 Danish adults treated with potent or very potent TCSs, such as mometasone, between January 1, 2003 and December 31, 2017. Included in the analysis were adults who were treated with the equivalent of at least 200 mg of mometasone. The findings found that a dose-response relationship existed between increase use of potent or very potent TCSs and the risk of MOF. The researchers note that the meaning of their findings indicate that clinicians may need to consider other corticosteroid-sparing therapeutic options to limit the risk of osteoporosis for people who require potent antiinflammatory treatment on large body surfaces. Study Information: Egeberg, A., Schwarz, P., Harsløf, T., Andersen, Y. M., Pottegård, A., Hallas, J., & Thyssen, J. P. (2021). Association of Potent and Very Potent Topical Corticosteroids and the Risk of Osteoporosis and Major Osteoporotic Fractures. JAMA dermatology, 20.

Association between alopecia areata and dark hair colour Alopecia areata (AA) is an autoimmune disorder that causes nonscarring hair loss, often in patches. Previous studies have found that AA has been observed to selectively involve pigmented hair follicles with sparing of grey, nonpigmented hair follicles in alopecia lesions. In this study, researchers investigated the association of AA with hair colour among Caucasian residents of the UK. It was found that black hair and dark brown hair had significantly increased risk of AA compared with light brown hair, and blond individuals were significantly less likely to receive a diagnosis of AA compared to individuals with light brown hair. Findings involving individuals with red hair colour were not significantly different from those with light brown hair. The findings of the study indicate that AA is modulated by hair colour and preferentially targets darker hair. This study supports and expands previous studies that hypothesized that an association between AA and hair pigmentation exists. The researchers note that further study is needed to more precisely understand the immunopathogenic association between AA and hair colour. Study Information: Yousaf, A., Lee, J., Fang, W., & Kolodney, M. S. (2021). Association Between Alopecia Areata and Natural Hair Color Among White Individuals. JAMA dermatology.

Irma Shaboian holds bachelor of science and law degrees, and is currently articling in Ottawa. Summer 2021

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Living With…

Living with psoriasis By Bobby Huang

My experience with psoriasis has been quite the journey since I was first diagnosed in 2008 at the age of 21 with plaque psoriasis. Psoriasis is an auto-immune skin disease that causes red, itchy, scaly patches on the skin due to the body producing too many skin cells. Even prior to my diagnosis, I was already suffering from psoriasis during high school. Back then, I kept my diagnosis a secret – I went to great lengths to hide my condition from friends and family. I would wear long-sleeved tops and pants to cover my arms and legs, even during the summer. I would make the conscious effort to avoid standing in front of people in lines so that they wouldn’t see the skin flaking on my shoulders. I closed myself off from the world as I began to suffer from increasing anxiety, depression, and shame as my psoriasis became more severe, to the point where over 90% of my body was covered in psoriasis lesions. I was afraid of being made fun of for my condition and constantly worried that others would back away in disgust because they wrongly believed that psoriasis was contagious. By 2013 I was open about the fact that I had this condition. I began taking biologics and felt as though I was getting my life back the more I was able to manage my psoriasis. I was feeling better; I was feeling less self-conscious. After years of hiding away, I was faced with the question: what do I do with my life now? I desperately wanted to make up for time I had lost due to psoriasis. Unfortunately, I took it too far the other way, engaging in reckless behaviour and making dangerous choices that put me and others in harm’s way. I was binge drinking, going out every night, driving drunk, and abusing substances – I quickly spiralled out of control but couldn’t recognize how far I had fallen. 10 | www.canadianskin.ca | Summer 2021

“Rules don’t apply to me” was my mentality during those years; the sense of entitlement that I felt was overpowering. I was going out at all hours and I became an unpleasant person to be around. I was angry and resentful that psoriasis had done so much to me physically, socially, and psychologically that I felt entitled to take back what psoriasis had taken from me. My relationship with my skin led to self-destructive behaviours and beliefs that impacted how I saw myself in relationships with others and how others saw me as well. Even when psoriasis is managed or the symptoms feel more under control, the emotional and social damage caused by psoriasis can persist, as well as the desire to make up for lost time. The lasting impact of the condition, how we see ourselves, and how we see the world even when the condition is managed are all issues that we as skin patients and caregivers need to carefully consider. It’s important to address the emotional, psychological, and social impacts your skin condition has on you. I wish someone living with psoriasis had taken me aside and said, “Okay, I know how it feels and I know how psoriasis has deeply hurt you, but there are more constructive and healthy ways to deal with what you’re going through.” Now, at 34, my condition is fairly stable. My psoriasis affects less than 5% of my skin area and the biologic medication I’m on is working very well. Over the years, I used many topicals, ointments, and corticosteroids and became frustrated that these treatments worked for others but not for me. Acknowledging that there is no cure for psoriasis and that there’s a chance of relapsing at any time is something that I think about often, but I’m grateful that my treatment is working and that I have a job with great

insurance coverage that allows me to access the medications that work for me. I’m now over two years sober and I have found that abstaining from alcohol has really helped improve my condition as well. The journey with a chronic skin condition isn’t over just because the physical symptoms are gone. We’re as sick as our secrets. The longer that we suppress our secrets, the more they fester and worsen. You don’t have to tell everyone, but it’s important to find one person who you can confide in about how having a skin condition affects not only your skin, but emotionally and socially too, and allow that person to be there for you. I kept too many secrets and it led me down a path that I would like to help others avoid so that they don’t have to go through the same harmful experiences that I did. Working on the other parts of my life has been so important for me to understand that yes, while psoriasis has had a severe impact on all aspects of my life, my condition does not define me and I can still lead a healthy, meaningful life. If this story resonates with you and you’re looking for someone to speak with about living in your skin, reach out to us at info@canadianskin.ca and we will be in touch.

FOCUS

What makes you feel good in your skin? Is it playing sports and feeling stronger? Is it playing fetch with your dog? Hanging out with your stuffed animals? How about listening to your favourite song or reading a new book? Draw what makes you feel great and cut it out as a reminder of what helps to bring you joy! To share what makes you happy in your skin, ask a trusted adult in your life to share your drawing on social media and tag CSPA on Instagram – @CanadianSkin – to see what makes others feel great too!

Word Search

O W M

HAT

M N W R

UMBRELLA

Q W U

INDOORS

SUNSCREEN

SPF

COTTON

M Q

SHADE

M N

B W O

SAFE SUMMER FUN!

TREE LONG SLEEVES

SUN REAPPLY

Answers can be found on page 14.

Summer 2021

W N

| www.canadianskin.ca | 11

Teledermatology

services in Canada By Y. Lytvyn, PhD, F. Haxho, PhD, and T. Champagne, MD

Dermatology is a visual field of medicine, with a large part of training spent studying pictures of skin, hair, and nail conditions. As a result, a large number of conditions can be diagnosed and managed remotely using rapidlyevolving platforms, such as high-resolution cameras and video technology. Dermatologists have been working on developing remote healthcare delivery methods, known as teledermatology. 12 | www.canadianskin.ca | Summer 2021

Teledermatology has been around for decades; however, development of available services and technologies was significantly accelerated with the increased demand during the COVID-19 pandemic. There are many advantages to using teledermatology services for patients, physicians, and the healthcare system. Teledermatology allows doctors to see more patients, which means reduced wait-times to see a specialist. Additionally, healthcare professionals separated geographically can have virtual consultations with a dermatology specialist. Overall, this increases access to dermatology services for patients from rural and remote communities that are located many kilometers away from the nearest dermatology clinic. In addition to eliminating geographical distance, telemedicine reduces the burdens of travel-associated costs, taking time off work, availability of physicians, and a patient’s physical ability to come into the clinic. Teledermatology also comes with some challenges. For example, full body exams are difficult to do virtually and some body parts are challenging to examine, such as hair, mucous membranes, and genitals. Additionally, privacy and confidentiality of patient information is held at a high standard in Canada, which means there is an

important need to use secure and user-friendly telecommunication platforms for virtual clinics. Newer services are attempting to more accurately assess lesions so that virtual teledermatology appointments can be used more often across the country, such as MedX's skin screening telemedicine platform. After the initial assessment, if a more detailed examination or a physical procedure is needed, a dermatology specialist guides the patient or the consulting healthcare provider through available options depending on specific circumstances. These options may include finding the nearest healthcare provider for patient referral or guiding the consulting healthcare specialist through a procedure and treatment options. Unfortunately, a large proportion of teledermatology programs were not funded by provincial healthcare systems until the recently increased need for such programs during the pandemic. The ultimate goal is to reduce the need for patients to pay for these services out of pocket. Finally, it is also important to note that not all patients and healthcare providers are aware of teledermatological services available to them, highlighting the need to raise awareness of such useful tools.

Table 1: Canadian teledermatology programs presented in this article. Teledermatology program

Store and forward or real time

Direct to patient or direct to healthcare provider

Funding

Availability in the following provinces

ConsultDERMTM Teledermatology

Store and forward

Direct to healthcare provider

Provincial

AB, BC, NWT, PEI

Ontario Telemedicine Network/eConsult

Combination: store and forward or real time

Direct to healthcare provider

Provincial

University of British Columbia Rural and Remote Dermatology Services

Combination: store and forward or real time

Direct to healthcare provider in rural and remote settings

Provincial

BC, YT

DermaGo

Store and forward

Direct to patient

Patient

AB, BC, NWT, PEI, ON, NL, NS, NB, QC, MB, YT, NU

DermCafe

Combination: store and forward or real time

Direct to patient

Patient and provincial options available

Maple

Combination: store and forward or real time

Direct to patient

Patient and provincial options available

ON, QC, BC, NS, AB, NL

DermSecure (by MedX)

Store and forward

Both

Patient and provincial options available

AB: Alberta; BC: British Columbia; NWT: Northwest Territories; PEI: Prince Edward Island; ON: Ontario; NL: Newfoundland and Labrador; NS: Nova Scotia; NB: New Brunswick; QC: Quebec; MB: Manitoba; YT: Yukon; NU: Nunavut.

Various teledermatology programs are available across Canada, some of which are listed in Table 1. ConsultDERMTM Teledermatology is a store and forward model, which means that images and patient history get sent to a dermatologist by a healthcare provider. Dermatologists can also provide consultations to other physicians via the Ontario Telemedicine Network/ eConsult service, which is a similar store and forward provincial initiative in Ontario. This service is geared towards underserviced hospitals and populations in Ontario and receives consultation requests from urban clinics, such as the Crossroads refugee clinic, critically underserviced rural and remote areas. Similar services are provided by the University of British Columbia rural and remote dermatology services. The idea for this program began with a dermatologist and dermatology residents traveling to provide services to First Nations in British Columbia and Yukon, which has now been transitioned to a partially virtual program. The benefit of direct communication between the dermatologist and the patient’s healthcare practitioner is that the practitioner can provide all the relevant medical information to the dermatologist. At the same time, the patient has the practitioner to obtain

detailed explanation, to answer any questions, and to perform necessary procedures (e.g., skin biopsies). Moreover, patients do not have to worry about using specific technologies to communicate or taking high-quality images. In addition, it provides the opportunity for the dermatologist to train other healthcare providers in common skin, hair and nail diseases, which is especially important in remote areas which do not have access to a dermatology clinic geographically. Direct-to-patient teledermatology services are also becoming available but are not usually covered by Medicare. For example, DermaGo provides services across all provinces in Canada, except for Saskatchewan. Another service called DermCafe operates with both insured and noninsured options in Ontario. Maple (the general telemedicine service which recently partnered with Shoppers Drug Mart) also now offers direct-to-patient teledermatology. These programs allow patients to have quick access to a dermatologist from the comfort of their home without the need for a referral. In these programs, a patient submits their medical history and, ideally, highquality pictures of the concern in an online portal. Unfortunately, such services are not yet fully covered by

provincial healthcare systems and come at typically a $100–300 cost to the patient, depending on the turnaround time. Most companies are working on securing partnerships with insurance companies to help patients pay for these services. Overall, teledermatology is an up-and-coming efficient resource for caregivers and patients, especially in remote areas without access to specialists. Although some logistical challenges remain, rapidly evolving technologies are improving the availability of high-quality services. More advocacy is needed to raise awareness, financing, and support of teledermatology programs across Canada to improve access to medical care across Canada. Conflict of interest declaration: Dr. Champagne is head of the medical advisory board of MedX, Inc. Dr. Lytvyn and Dr. Haxho are both medical students at the Temerty Faculty of Medicine at the University of Toronto. Dr. Champagne is a dermatologist with the Division of Dermatology, Women’s College Hospital, at the University of Toronto. Summer 2021

| www.canadianskin.ca | 13

CSPA IN ACTION

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

The CSPA is a home for all people in Canada impacted by a hair, skin, or nail disorder. We have been proud supporters of the first Indigenous Skin Spectrum Summit, raising awareness and educating healthcare professionals about skin disorders in Indigenous communities. We are also proud to release resources for Muslim skin patients (www. canadianskin.ca/our-resources) that complement the article in this issue about navigating dermatology appointments, which can involve exams of bared skin. We continue to ensure that information added to our website about skin disorders is useful for all skin types, from lighter to darker. Raising awareness This issue of the magazine has a close-up on hyperhidrosis to provide facts about excessive sweating. For more details, check out the new hyperhidrosis section on our website (www.canadianskin.ca/skin-conditions-anddiseases#resources-18). May was Melanoma Awareness Month and the CSPA was proud to support the work of Affiliate Member Save Your Skin Foundation to raise awareness of this important time in recognition of survivors and those we have lost to melanoma. The CSPA is working with HS Heroes and Hidradenitis & Me to celebrate HS Awareness Week 2021 in June. Amplifying the voice of skin patients CSPA has been bringing skin patients’ perspectives to ongoing consultations on drug pricing and rare disease drugs. Through both of these consultations, we have reinforced that these policies must have improving patients’ lives at their heart, even if they are being developed in order

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Through what means would you like your CSPA content? (infographics, podcasts, webinars, etc.) Submit your response to info@canadianskin.ca by July 30, 2021, along with your name and contact information, and you will be entered in a draw to win a $25 gift card. Good luck!

In the Spring 2021 issue, we asked readers if they had any questions about COVID-19 vaccines. Congratulations to our contest winner: Andre B.!

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14 | www.canadianskin.ca | Summer 2021

to save money. All patients want our health systems to be sustainable but they also want them to provide them with the best options for a healthy life. The CSPA has also provided patients’ perspectives on the need for new treatments for atopic dermatitis, basal cell carcinoma, and cutaneous T cell lymphoma to policy makers. Catalyzing skin research important to patients The CSPA is actively supporting the Skin Investigation Network of Canada’s (SkIN Canada’s) Priority Setting Initiative (skincanada.org) to identify unanswered questions of importance to patients. We also welcome fellow organizations into the network as Partners of SkIN Canada to help share these surveys and the results! A warm welcome to: • Canadian Association of Psoriasis Patients • Canadian Burn Survivors Community • Canadian Psoriasis Network • Eczéma Québec • Hidradenitis & Me • HS Heroes • Save Your Skin Foundation Upcoming awareness days Scleroderma Awareness Month (June) Hidradenitis Suppurativa (HS) Awareness Week (June 7–13) World Scleroderma Day (June 29) International Self-Care Day (July 24) International Alopecia Awareness Day (August 7) Acne Awareness Month (September)

Word search answers

H N

M S

U D

O W M

Q A

G O

O U Q G M N W R

N Q N

M E

Q H

Q D Q

N U U N U

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H Q W U

M P

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Diabetic foot care Facebook group study

CSPA AFFILIATE MEMBERS

This study aims to explore the feasibility of a Facebook group-based program to support people with diabetes in their self-management and prevention of foot ulcers. The study is designed by Queen’s University scholars in collaboration with Wounds Canada.

Acne and Rosacea Society of Canada: acneaction.ca (acne) rosaceahelp.ca (rosacea)

Who is it for? You are eligible to participate if you a) are 18 years or older and have a diagnosis of diabetes, b) reside in Canada, c) have or are willing to create a Facebook account, d) have access to the internet, computer/smartphone, and email, and e) speak and write in the English language. Why is it important? Diabetic foot ulcers are severe complications linked to a higher rate of lower limb amputations. While foot ulcers are preventable through regular foot self-care practices, the COVID-19 pandemic has affected access to clinic/community-based education support programs vital to sustaining individual motivation and practice of foot self-care. The study intervention involves using the Facebook group platform to create a virtual private community for people with diabetes to continuously learn foot care strategies and gain motivation to better care for their feet and prevent ulcers. How can I participate? To participate in this study, you will be required to complete a survey to give consent, provide baseline assessment information, and choose the preferred study group – experimental or control. The survey takes about 15 minutes to complete. Based on your responses, the researcher, Helen Obilor, will contact you within a week about your enrollment and with instructions on proceeding to the next study stage. Please visit this link – www.woundscanada.ca/patient-or-caregiver/diabetic-footcarefacebook-group-study – to access the letter of information and complete the survey. For more information about this study, please contact Helen Obilor at 343-333-8226 or email 15hno@queensu.ca; or Dr. Kevin Woo at 613-533-6000 ext. 74747 or email kevin.woo@queensu.ca.

SPONSOR OF CANADIAN SKIN MAGAZINE AbbVie is the Founding Sponsor of the Canadian Skin Magazine and an ongoing supporter of CSPA’s 2021 publications.

CSPA CORPORATE SPONSORS

AboutFace: aboutface.ca

Alberta Lymphedema Association: albertalymphedema.com Alberta Society of Melanoma: abmelanoma.ca BC Lymphedema Association: bclymph.org Camp Liberté Society: campliberte.ca Canadian Alopecia Areata Foundation (CANAAF): canaaf.org Canadian Association for Porphyria: canadianassociationforporphyria.ca Canadian Association of Scarring Alopecias: casafiredup.com Canadian Burn Survivors Community: canadianburnsurvivors.ca Canadian Psoriasis Network: cpn-rcp.com Canadian Skin Cancer Foundation: canadianskincancerfoundation.com DEBRA Canada (epidermolysis bullosa): debracanada.org Eczema Society of Canada: eczemahelp.ca Firefighters’ Burn Fund: burnfundmb.ca Hidradenitis & Me Support Group: hidradenitisandme.ca HS Heroes: hsheroes.ca Melanoma Network of Canada: melanomanetwork.ca Myositis Canada: myositis.ca Neurofibromatosis Society of Ontario: nfon.ca Save Your Skin Foundation: saveyourskin.ca Scleroderma Association of B.C.: sclerodermabc.ca Scleroderma Canada: scleroderma.ca Scleroderma Manitoba: sclerodermamanitoba.com

CSPA MEDICAL ADVISORS + BOARD MEMBERS + CONTRIBUTORS Thank you to the Medical Advisors, Board Members, and Volunteers who support the work of the CSPA. To learn more about how to get involved, visit: www.canadianskin.ca/about-us/volunteers/how-to-volunteer.

Scleroderma Society of Ontario: hardword.ca Stevens–Johnson Syndrome Canada: sjscanada.org Tumour Foundation of BC: tumourfoundation.ca

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SCAN ME