Keratosis pilaris

Keratosis pilaris (KP) is a common skin condition characterized by the appearance of tiny bumps on the skin. These bumps resemble the texture of plucked chicken skin or goosebumps, leading to the terms "plucked chicken skin" and "goosebump skin." The bumps become more prominent during the winter season due to dry skin. They may appear in episodes of flare-ups and can disappear later on. This cycle can continue throughout life, making it a chronic condition.

Characteristics of Bumps

• Feel dry and rough
• Occasionally itch
• Appear in different colors such as the color of the skin, white, red, pinkish-purple (on fair skin), and brownish-black (on dark skin)

Location of the Bumps

Bumps can develop on any part of the body, but the common locations include:

• Upper arms
• Front part of the upper thighs
• Cheeks
• Buttocks (mostly in children)
• Trunk
• Chest

In severe cases, bumps can extend to the skin of the lower legs and forearms. The condition is harmless and non-infectious but can have psychological impacts due to its cosmetically displeasing appearance.

The term keratosis means 'scaly skin', and pilaris means 'hair'. Keratosis pilaris occurs due to the buildup of keratin in hair follicles. Keratin is a protein that protects the skin from environmental damage and is present in the skin, hair, and nails.

The exact cause of this condition is not known. However, it is mostly thought to be caused by mutations (genetic changes) in a protein called filaggrin, which plays a role in skin barrier function.

The exact cause of keratosis pilaris (KP) is unknown, but it may be triggered by several factors. These include:

• Age: Children under 2 years of age are more prone to this condition. It is also commonly seen in adolescents and tends to fade during adulthood.
• Dry Skin: Dry skin is the most prominent risk factor for keratosis pilaris. The consistent dryness exacerbates KP symptoms by causing itching.
• Gender: Women are more prone to this condition due to hormonal fluctuations.
• Medical Conditions: Some medical conditions increase the risk of developing KP, including:
  • Atopic dermatitis
  • Ichthyosis vulgaris
  • Asthma
  • Hay fever
  • Malnutrition
  • Diabetes
  • Obesity
  • Melanoma (skin cancer)
  • Down syndrome
  • Noonan syndrome
• Family History: Individuals with a family history of keratosis pilaris are more prone to this condition. Studies suggest that KP development is more common in siblings and twins.
• Medication: Vemurafenib, a drug used in skin cancer treatment, may increase the likelihood of developing keratosis pilaris.
• Season: The bumps become more prominent during the winter season, likely due to reduced moisture content in the air.

Here are 5 simple skin care tips for dry skin in winter!

Keratosis pilaris can be easily diagnosed because of its specific appearance. The common procedures used in diagnosing KP include:

• Medical History and Physical Examination: Almost all cases of keratosis pilaris can be diagnosed through a physical examination due to its distinct bumpy appearance. The physician will investigate the onset, appearance, location, symptoms, and family history.
• Dermoscopy: This refers to the examination of the skin using a high-quality magnifying lens and a powerful lighting system (a dermatoscope). It reveals abnormalities of the hair follicle. The dermoscopic findings of keratosis pilaris include:
  • Increase in the diameter of follicular orifices
  • Presence of keratin plugs
  • Coiled or twisted hair follicles
  • Thin hair shaft
  Dermoscopy is also used to monitor the progress of treatment.
• Punch biopsy: This involves the examination of a small sample of skin tissue. The sample is collected by cutting the affected area using a circular scalpel. It reveals:
  • Clogged hair follicles
  • Hyperkeratosis (thickening of the skin)
  • Lymphocytic infiltration (build-up of white blood cells in the skin)

Keratosis pilaris is a very common variant of skin with a strong genetic connection. It cannot be prevented; however, certain measures can help minimize the flare-ups associated with the condition. These include:

• Keep the skin moisturized: Most skin conditions, including keratosis pilaris, develop due to dry skin. It is advisable to apply moisturizer within 5 minutes of bathing or whenever the skin feels dry.
• Use a mild cleanser: Wash your face and body with a mild cleanser to minimize the chances of skin dryness.
• Limit shaving or waxing: Excessive shaving or waxing increases the risk of keratosis pilaris. Individuals at high risk for this condition should limit waxing sessions or consider laser hair removal.
• Avoid long showers: Prolonged exposure to water can dry out the skin, increasing the chances of keratosis pilaris. Keep shower time short (20 minutes or less) and avoid excessive hot water for bathing.
• Use a humidifier: Utilize a humidifier in the room whenever the air feels dry.

Keratosis pilaris is generally harmless. Patients may seek treatment if they experience constant itching, dryness, or are concerned about its appearance.

Keratosis pilaris cannot be permanently cured as there is no universally effective treatment available. However, treatment can provide symptomatic relief to some extent. In most cases, the bumpy appearance tends to decline with age.

Continuous treatment is necessary for noticeable improvement. The treatment options include:

• Moisturization: Moisturizers are primarily used in keratosis pilaris to soothe itching and dryness. Most moisturizers for this condition contain one of the following ingredients:
  • Urea
  • Lactic acid
  • Salicylic acid

Everyone has different skin types and medical conditions. Here is a simple way to choose a good moisturizer for your skin.

• Exfoliating Agents: These agents help remove dead skin cells along with small keratin plugs over the follicles, reducing the bumpy appearance and improving skin texture. Common exfoliating agents include:
  • Glycolic acid
  • Lactic acid
  • Retinoids (adapalene, retinol, tazarotene, and tretinoin)
  • Salicylic acid
  • Urea
  These creams should be gently massaged using a polyester sponge for five seconds during the first week of treatment.

• Anti-inflammatory Medications: These are used to reduce redness associated with keratosis pilaris. They are typically prescribed for 7 to 10 days over inflamed areas. Common options include:
  • Hydrocortisone
  • Clobetasol

• Skin Lightening Agents: Long-term keratosis pilaris can lead to skin discoloration in some patients. Skin-lightening agents used include:
  • Hydroquinone
  • Kojic acid
  • Azelaic acid
  Note: Higher concentrations and long-term use of hydroquinone may irritate the skin and increase the risk of adverse effects such as ochronosis (yellow discoloration of the skin). It should only be used under medical supervision.

• Immunomodulators: These drugs target the immune system and are used in resistant cases where the patient has considerable skin redness and inflammation. Common examples include:
  • Pimecrolimus
  • Tacrolimus

• In-office Treatments:
  • Microdermabrasion: A safe in-office procedure that involves minimal invasion by rubbing the skin with abrasive particles, such as fine powdery aluminum particles, using vacuum-assisted pumps. This technique helps remove excess keratin and dead cells from the outer skin layer.
  • Photodynamic Therapy: This involves a topical photosensitizer combined with a light source that kills damaged skin cells previously photosensitized. Common photosensitizers include:
    • Aminolevulinic acid
    • Methyl levulinate
    Light sources include:
    • Sunlight
    • Blue light
    • Red light (630 nm)
    • Multiple laser devices
  • Laser Hair Removal: This procedure involves destroying hair follicles using various types of lasers, which decreases hair growth in affected areas and reduces bumps caused by small, coiled hairs. Common lasers used include carbon dioxide and fractional lasers. Dermatologists often recommend microdermabrasion sessions before laser treatment for optimal results.
  • Other In-office Treatment Options:
    • Chemical peels (using a chemical solution to remove layers of skin)
    • Extraction of keratin plugs or trapped coiled hairs
    • Vacubrasion (using vacuum suction and synthetic diamond abrasion to remove excess keratin)

Here are some practical tips for choosing your skin specialist.

Some home remedies might be used for KP. However, make sure to consult your doctor before starting any of these:

• Coconut oil: The application of coconut oil eases the symptoms of KP by softening the skin. It also has anti-inflammatory properties that help reduce the inflammation seen in some KP patients.
• Lemon oil: It aids in reducing symptoms by soothing the skin.
• Lavender oil: It keeps the skin healthy and infection-free due to its antibacterial properties.
• Cod liver oil: It has anti-inflammatory and healing properties. It keeps the skin healthy and aids in overall recovery. It can be consumed in the form of capsules available in the market.
• Apple cider vinegar: It acts as an exfoliant, helping to remove dead cells and excess keratin present on the skin. It can be applied by mixing with coconut oil and honey in equal proportions.
• Tea tree oil: It purifies the skin through its antimicrobial and anti-inflammatory action. KP individuals have a higher chance of developing secondary infections due to damaged skin, and tea tree oil helps in preventing them.
• Aloe vera: It is well known for its moisturizing effect along with its healing properties. The gel of aloe vera can be applied directly to the affected area and helps relieve itching through its cooling effect.
• Argan oil: This oil contains Vitamin E, which is known to remove scars. The application of argan oil nourishes the skin while providing a blemish-free appearance.
• Baking soda: It helps remove dead skin cells, improves blood circulation, and reduces skin inflammation. It can be applied in the form of a paste by mixing with water.
• Sugar: Massaging granulated sugar with sour cream acts as a natural scrub, helping to remove dead skin cells and diminish the bumpy appearance.

Keratosis is a harmless skin condition and does not lead to any complications in general. In rare cases, it can cause:

• Scarring (mostly due to rupturing the lesions)
• Postinflammatory hypopigmentation (lightening of the skin color)
• Postinflammatory hyperpigmentation (formation of darker patches on the skin)
• Gradual loss of hair in affected facial areas, especially the lateral eyebrows

Along with the medical complications, KP affects the individual psychologically due to the condition’s cosmetic appearance.

• Cosmetic Camouflage: This involves the use of concealers and other pigmented cover-ups to even skin complexion. This approach serves as an adjuvant therapy that has been proven to improve psychosocial effects and quality of life.
• Climatotherapy: Climatotherapy refers to the temporary or permanent relocation of a patient to a region with a climate more favorable to recovery. Since keratosis pilaris tends to improve in summer, this can be a viable alternative option. Exposure to sunlight has been shown to be beneficial for individuals.

The overall outcome of keratosis pilaris (KP) is controllable. Many cases resolve completely with increasing age, but some patients may experience exacerbations and remissions. The following measures can help patients prevent flare-ups and improve their overall quality of life (QoL):

• Keep the skin moisturized: This is the most important aspect for individuals living with keratosis pilaris. Individuals should carry a moisturizer with them, even while traveling.
• Tips for applying moisturizer:
  • Apply at least 2 to 3 times a day, including immediately after bathing and whenever the skin feels dry.
  • Gently massage the moisturizer into the skin instead of applying it superficially.
• Limit bath time: Excessive water exposure can dry the skin and trigger keratosis pilaris symptoms. Limiting shower time to 5 to 10 minutes is advisable.
• Try an oatmeal bath: Oatmeal has soothing properties that help reduce dryness due to the hydration and cleansing effect of saponin present in oatmeal.
• Steps for an oatmeal bath:
  • Fill the bathtub with lukewarm water and add oatmeal.
  • Soak your body in the water for 15 minutes.
  • Take a shower followed by moisturization.
• Use a mild and fragrance-free cleanser: Individuals with KP should wash the affected area once or twice daily with a gentle cleanser. Those with acne-prone skin should use therapeutic cleansers such as salicylic acid or benzoyl peroxide.
• Use topical agents cautiously: It is crucial to follow all guidelines provided by the doctor when applying medications. General rules include:
  • Apply the agent in the prescribed quantity, as over-application can worsen the condition.
  • Avoid excessive massaging or scrubbing while applying medications.
  • Stop using the medicine for a few days if the skin becomes dry or irritated.
• Avoid shaving or waxing: Hair removal can lead to the development of more bumps. If necessary, use a single-blade razor or consider laser therapy.
• Avoid rupturing the lesions: Many individuals rupture lesions manually, which should be avoided as it increases the risk of secondary infections.
• Follow a maintenance plan: Keratosis pilaris cannot be cured permanently, so the skin should be treated well even in the absence of symptoms.
• Dealing with the emotional effects: Keratosis pilaris can affect an individual emotionally due to its disfiguring appearance. Many people lose confidence and self-esteem, feeling they do not look normal, which can impact friendships, family relationships, and career choices.
• How to deal with emotional distress:
  • Understand and accept that the disease is chronic and there is no permanent cure.
  • Engage in progressive muscle relaxation activities to decrease anxiety.
  • Ensure adequate sleep to maintain energy levels.
  • Exercise to improve blood circulation, clear the mind, and reduce stress hormones.
  • Learn to say no, set priorities, and focus on important matters.
  • Take more time for leisure activities.