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Jade and her “very common and completely harmless” problem

When Janet Webb met seven-year-old Jade, who had keratosis pilaris, a common disorder that affects the hair follicles, she realised that "harmless" conditions can seem anything but to the patients affected by them …

Janet Webb
BSc(Hons) RGN DipN(Lond)
Practice Nurse
Lindum Medical Practice
London

According to the British Association of Dermatologists, keratosis pilaris "is such a common condition in childhood and adolescence that it can be regarded as one end of the normal spectrum of skin changes".(1) It is "very common and completely harmless".(2) This is all well and good, but if you're only seven and your classmates tease you for having spiky skin it can seem enormously serious.

Strong familial link
Jade came to the surgery with her mum and was initially very shy and reluctant to talk about her concerns. At home Jade isn't unusual at all, since her father, two brothers and two cousins also have keratosis pilaris. It is a condition affecting the hair follicles, typically of the face, upper arms and thighs, and tiny keratin plugs cause a rough textured, spiky surface to the skin, which is sometimes red but often skin-coloured. There tends to be a strong familial link and it often first presents within the first decade of life.(2,3)
With encouragement Jade showed me the patches on each upper arm. Her mother explained how she had told Jade it was nothing to worry about, but Jade's body language showed acute embarrassment. Jade's mum was trying to reassure her; perhaps she couldn't see what the fuss was about; possibly she felt she was wasting surgery time, a commonly expressed but rarely founded fear; or maybe she was frustrated that she couldn't resolve Jade's anxiety. This had obviously been an ongoing conversation, but because her family was so familiar with the condition it had become normal to them. But Jade's classmates were not familiar with it and it had clearly become something of an issue, and now she only wanted to wear long sleeves and was reluctant to undress for games lessons.  

"Nothing to worry about"
I could imagine some of Jade's concern; at home, because everyone except her mum had similar patches of skin that came and went, no one seemed to pay it much attention. Her brothers were older than her, so no one really made much of an issue when Jade developed the rough patches of skin - she was just one of the clan. She probably thought nothing of it herself until classmates pointed it out, and was unprepared for being made to feel different. She probably felt hurt, upset, alienated and confused by her classmate's actions. Perhaps her mum's attempted reassurance that it was "nothing to worry about" compounded her confusion - conflicting reactions from her two main environments might leave her feeling alone and misunderstood - itself a symptom of growing up. But Jade was just starting to make an identity for herself, expressing herself through her developing fashion-sense, and was becoming confident socially. She needed a bit of help.

Choosing emollient
Keratosis pilaris is not, apparently, the subject of current research, glossy self-help brochures, or advertising campaigns from pharmaceutical companies. I did manage to enthuse Jade with a printout from DermnetNZ complete with colour photographs - at last some acknowledgement that it existed! Rather than playing down her concern I tried to encourage Jade to talk about how it felt for her, as a way of boosting her self-esteem and sense of being taken seriously. I told her that although we couldn't cure her condition we could help her to manage it, but she would need to follow a regime of carefully applied emollient - did she feel she could do that? She did. She was interested and keen to try the samples of cream from my cupboard. The previous vigorously applied yellow soft paraffin had been rubbed in using a circular motion. I explained to her that her skin has fine hairs, and that the hairs usually grow in a downward direction on her arms and legs. On the areas of keratosis pilaris, the hairs needed some help because they had grown curled and the skin was blocked by little plugs. By stroking the skin in a downward direction, along the natural direction of hair growth, the cream she chose would help the tiny hairs to grow flatter and smoother.
Jade was happy to try the various creams on her hands first, comparing the different textures; she quite liked the packaging of Aveeno even before she opened it, so she did not surprise me by deciding she would like to use that at home. Guidelines from the National Prescribing Centre advise: "Patients should use the cheapest emollient that is effective, cosmetically acceptable and which they are prepared to use regularly."(4) Aveeno cream is far from the cheapest,(3) but it was Jade's choice, which probably meant that she would use it. I would give her a prescription and follow up in two weeks. Jade's mum was happy to buy the cream over the counter from the pharmacy after that if it helped.
On prescription, Aveeno is considered a "borderline substance." Because it is made from colloidal oatmeal, a food substance with the characteristic of a drug, there is the requirement to acknowledge this by writing "ACBS" in the prescription margin.
Jade returned two weeks later and I was frankly astounded by the improvement. She wore a strappy top so that she could show me the smooth skin, and positively glowed with pride when praised for doing such a good job of self-management.
It's a shame we refer to some conditions as "trivial" or "minor ailments". To the people affected by them they can seem anything but!

References

  1. Ashton R, Leppard B. Differential diagnosis in dermatology. Oxford: Radcliffe Publishing; 2005.
  2. British Association of Dermatologists. Keratosis pilaris. Available from: http://www.bad.org.uk
  3. British National Formulary for Children. Available from: http://www.emedicine.com
  4. National Prescribing Centre. The use of emollient therapy in dry skin conditions. London: MeReC; 1998.

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"What a simple remedy and well done in how you have helped this child through your approach. Sharing your experience and knowledge would now help so many more" - Anne Majumdar, Wilts