Keratosis pilaris

Symptoms Of Keratosis pilaris

Keratosis pilaris (KP) is a common skin condition that is characterized by the appearance of tiny bumps on the skin. These bumps look similar to that of a plucked chicken or goosebumps, giving it the name “plucked chicken skin” and “goosebump skin”. 

The bumps became more prominent during the winter season due to dry skin. These bumps appear as 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 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 be extended to the skin of lower legs and forearms. 

The condition is harmless and non-infectious but impacts psychologically due to its cosmetically displeasing appearance. 

Causes Of Keratosis pilaris

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. It is present in skin, hairs, and nails.

The exact cause of this formation is not known. Mutations (genetic changes) in a protein called filaggrin which plays a role in skin barrier function is mostly thought to cause this.

Risk Factors For Keratosis pilaris

The exact cause of 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 fades away during adulthood.  

Dry skin

Dry skin is the most prominent risk factor for keratosis pilaris. The consistent dryness also makes the symptoms of KP worse by causing itching. 

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Gender

Women are more prone to this condition due to hormonal fluctuations.

Medical conditions

Some medical conditions increase the risk of developing KP. These include:

• Atopic dermatitis

• Ichthyosis vulgaris

• Asthma

• Hay fever

• Malnutrition

• Diabetes

• Obesity

• Melanoma (skin cancer)

• Down syndrome

• Noonan syndrome

Family history

Individuals having a family history of keratosis pilaris are more prone to this condition. Studies also suggest the development of KP is more common in siblings and twins.

Medication

Vemurafenib, a drug used in skin cancer makes the individual more prone to keratosis pilaris.

Season

The bumps become prominent during the winter season. This is most likely due to the reduced moisture content of the air. 

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Prevention Of Keratosis pilaris

Keratosis pilaris is a very common variant of skin with a very strong genetic connection. It can not be prevented. However, certain measures can help in minimizing the flare ups associated with the condition. These include:

Keep the skin moisturized

Most of the skin conditions including keratosis pilaris are developed due to dry skin. 

It is always advisable to apply the moisturizer within 5 minutes of bathing or whenever skin feels dry.

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Use a mild cleanser

Use a mild cleanser to wash your face/body to minimize the chances of skin dryness. 

Limit shaving or waxing

Excessive shaving or waxing increases the risk of keratosis pilaris.

Individuals with a high risk of this condition should limit their waxing sessions or should undergo laser hair removal. 

Avoid long showers

The exposure of water for a long period of time makes the skin dry which increases the chances of keratosis pilaris. 

• Keep the shower time short (20 minutes or less)

• Avoid excessive hot water for bathing

Use humidifier

Use a humidifier in the room, whenever the air feels dry.

Diagnosis Of Keratosis pilaris

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

Medical History and Physical Examination

Almost all cases of keratosis pilaris can be easily diagnosed with physical examination due to its specific bumpy appearance. 

The physician will investigate the onset, appearance, location, symptoms and family history. 

In case of doubt, following confirmatory tests may be performed:

Dermoscopy

It refers to the examination of 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 

It involves examination of a small sample of tissue of the skin. 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 on the skin)

Specialist To Visit

Most of the cases of keratosis pilaris can be treated with over-the-counter medications and home remedies. The health care provider should be consulted in case:

• Worsening of symptoms with time

• Introduction of new symptoms frequently

The doctors that might help include:

• General physician

• Dermatologist

• Cosmetologist

A general physician will examine your symptoms and initiate treatment.

Dermatologists can also be consulted as they have expertise in diagnosing and treating skin disorders like keratosis pilaris. 

Cosmetologists are trained and licensed to perform cosmetic treatments of the skin, nails, and hair. They help manage the skin's appearance and also perform in-office treatments. 

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Treatment Of Keratosis pilaris

Keratosis pilaris is generally harmless. Patients need treatment if the constant itching, dryness, and appearance is bothering them. 

Keratosis pilaris can not be cured permanently as there is no universally effective treatment available. The treatment can provide symptomatic relief to some extent. In most cases, the bumpy appearance starts declining with age. 

The treatment needs to be continuous for a good visible improvement. The treatment options include:

Moisturization

Moisturizers are the primary thing that are used in KP.  They are applied to soothe itch and dryness. Most of the moisturizers used to treat keratosis pilaris contain any one of the following ingredients:

• Urea

• Lactic acid

• Salicylic acid

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Exfoliating agent

These agents remove the dead skin cells along with small keratin plugs that are present over follicles. Exfoliating agent reduces the bumpy appearance and also gives a good skin texture. The common exfoliating agents used in keratosis pilaris are:

• Glycolic acid

• Lactic acid

• Retinoid (adapalene, retinol, tazarotene, and tretinoin)

• Salicylic acid

• Urea

These creams should be gently massaged using a polyester sponge for five seconds for the first week of treatment. 

Anti-inflammatory

These medications are used to reduce redness associated with keratosis pilaris. In most cases, they are prescribed for 7 to 10 days over the inflamed red rash areas. 

• Hydrocortisone

• Clobetasol

Skin lightening agents

The long-term keratosis pilaris can lead to skin discoloration in some patients. In such patients, skin-lightening agents are used such as:

• Hydroquinone

• Kojic acid

• Azelaic acid

Note: Higher concentrations and long-term use of hydroquinone may be irritating and increase the risk of adverse effects such as ochronosis (yellow discoloration of the skin) amongst others. It should only be used under medical supervision.

Immunomodulators

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

• Pimecrolimus

• Tacrolimus

In-office treatments

Microdermabrasion: It is a safe in-office procedure that involves minimum invasion. This involves rubbing the skin with abrasive particles such as fine powdery aluminum particles using vacuum-assisted pumps. The technique helps in the removal of extra keratin along with the other dead cells present on the outer layer of the skin. 

Photodynamic therapy: It involves a topical photosensitizer along with a light source. The light source kills the damaged cells of the skin that are previously photosensitized using the topical agent. The common examples of photosensitizers used are:

• Aminolevulinic acid

• Methyl levulinate 

 Light sources include 

• Sunlight

• Blue light 

• Red light (630 nm)

• Multiple laser devices

Laser hair removal: This involves killing the hair follicles using different types of lasers. It decreases hair growth in the affected areas. LHR is also known to decrease the portion of bumps that arise as a result of small and coiled hairs. 

The lasers that are commonly used include carbon dioxide and fractional lasers. 

Dermatologists recommend microdermabrasion sessions before undergoing laser treatment. This will bring the best results from the laser treatments.

Other in-office treatment options include:

• Chemical peels (uses a chemical solution to remove layers of skin)

• Extraction of keratin plugs or trapped coiled hairs

• Vacubrasion (uses vacuum suction and synthetic diamond abrasion to remove excess keratin

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Home-care For Keratosis pilaris

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 antiinflammatory properties which helps in reducing the inflammation that can be seen in some KP patients.

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•  Lemon oil: It also aids in reducing the 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 helps in overall recovery. It can be consumed in the form of capsules available in the market. 

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• Apple cider vinegar: It acts as an exfoliant which helps in removing dead cells and excess keratin present on the skin. It can be applied by mixing with coconut oil and honey in equal proportions. 

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• Tea tree oil: It purifies the skin through its antimicrobial and anti-inflammatory action. KP individuals have more chances of developing secondary infections due to damaged skin. 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 on the affected part. It also helps in relieving itching through its cooling effect.

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• Argan oil: This oil contains Vitamin E which is known to remove scars. The application of argan oil nourishes the skin along with providing  blemish-free skin.

• Baking soda: It helps in removing 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: The massaging of granulated sugar with sour cream acts as a natural scrub. It helps in removing dead cells of the skin. This aids in diminishing the bumpy appearance. 

Alternative Therapies Of Keratosis pilaris

Cosmetic camouflage

It includes the use of concealers and other pigmented cover-ups to even skin complexion. 

This approach is used as an adjuvant therapy that has been proven to improve psychosocial effects and quality of life.

Climatotherapy

Climatotherapy refers to temporary or permanent relocation of a patient to a region with a climate more favorable to recovery. 

Since keratosis pilaris is found to be improved in summer, this can be an alternative option for it. The exposure to sunlight to the individuals has been shown to help. 

Complications Of Keratosis pilaris

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. 

Living With Keratosis pilaris

The overall outcome of KP is controllable. Many cases resolve completely with increasing age. But some patients may face exacerbations and remissions. The following measures helps the patients in preventing the flare ups and improves the overall quality of life (QoL):

Keep the skin moisturized

It should be the most important aspect for the individuals living with keratosis pilaris. Individuals should carry a moisturizer with them even while traveling.  

Tips to follow while applying moisturizer

• It should be applied at least 2 to 3 times a day including immediately after bathing and whenever the skin is feeling dry

• It should be gently massaged instead of only applying superficially

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Limit bath time

The exposure of excessive water on the skin can make it dry which can trigger the symptoms of keratosis pilaris. Limiting the shower time to 5 to 10 minutes is advisable for the individuals to reduce the symptoms. 

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Try oatmeal bath

Oatmeal has soothing properties which helps to reduce dryness. The hydration and cleansing effect is provided by the saponin present in oatmeal. 

Steps to take oatmeal bath 

• Fill the bathtub with lukewarm water and add the oatmeal to it

• Soak your body in that water and remain in the bathtub for 15 minutes

• Then, take a shower followed by moisturization

Use a mild and fragrance-free cleanser

Individuals having KP should wash the affected area once or twice daily with a gentle cleanser. 

People having acne-prone skin should use therapeutic cleansers such as salicylic acid, or benzoyl peroxide.

Use topical agents cautiously

It is very important to follow all the guidelines given by the doctor while applying medications. As a general rule, follow measures:

• Apply the agent in the prescribed quantity as over application can worsen the condition

• Avoid too much massaging or scrubbing while applying the medications 

• Stop using the medicine for a few days, if your skin becomes dry or irritated

Avoid shaving or waxing 

The detachment of hair can cause the development of more bumps. Individuals should avoid shaving and waxing. In case it cannot be avoided, use single blade razor or laser therapy. 

Avoid rupturing the lesions 

Many individuals rupture the lesions manually. It should be avoided as it makes the person more prone to 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 effect

Keratosis pilaris affect an individual emotionally due to disfiguring appearance. Many people lose confidence and self esteem thinking that they do not look normal. 

This could affect many areas of their life including friendships, family relationships and even career choices.

How to deal with emotional distress?

• Understand and accept the core facts that the disease is chronic and there is no permanent cure for the condition

• Indulge yourself in progressive muscle relaxation activities to decrease anxiety

• Get enough sleep to keeps your energy levels up

• Exercise as it improves blood circulation, clears your mind and reduces stress hormones

• Learn to say No! Set priorities and focus on the important things

• Take more time for leisure activities