Rough, Spiky Skin

What is rough, spiky skin?

Keratosis pilaris (KP) is a common condition characterised by rough, spiky, gooseflesh-type skin, usually upon the upper arms, cheeks or thighs. Occasionally it is also found on the back or buttocks. It may be seen on the face - particularly on the jawline and the outside of the eyebrows. The numerous bumps may be skin-coloured, red or brown and each one is a plug of dead skin cells that forms at the site of a hair follicle. A particularly troublesome variety produces a lot of redness of the face in particular (keratosis pilaris rubra)

While it is not a medical concern, KP is unsightly, sometimes itchy and can affect self-esteem when widespread, bringing about a degree of emotional distress. KP is a non-contagious condition that is often present in otherwise healthy people. It does not have any long-term medical implications whether treated or not.

There are several less common variants of keratosis pilaris that can include reddened lesions, small scar-like depressions, involvement of the outer eyebrows, a severe worm-eaten appearance of the cheeks, one or more bumpy patches topped with scaly spines on any part of the body, and in rare, familial cases, bald areas on the scalp and eyebrows.

Roughly half of the world's population is affected at some time in their lives by KP. Most prevalent at puberty, it's estimated that 50-80% of children and adolescents are affected. Among adults, about 40% of adults have KP and its incidence generally diminishes with age; it is rare among the elderly. Yet sometimes people acquire it for the first time as adults. Women are slightly more prone to developing KP than men are. It's particularly common in those of Celtic background, those who are overweight, or who have atopic dermatitis (eczema) or ichthyosis. An association also exists between KP and Noonan and Down syndromes.

Few people are aware that KP is a treatable condition. Even though it's not currently curable, it can be easily treated through ongoing topical treatments.

What causes keratosis pilaris?

KP is hereditary, inherited as an autosomal dominant gene, i.e. received if one parent has the condition. Beyond this, its root cause is unknown.

It is widely considered to be a disorder of hyper-keratinisation (keratin: the hard protein in the skin, nails and hair) in the skin whereby the sticky cells that line hair follicles (pilaris) form a spiky plug rather than exfoliating. As a result, the pores become wider and more noticeable. Often a curled hair appears beneath the bump.

Its degree of severity is increased in the winter months when there is decreased humidity and skin becomes dryer. As such, dry skin conditions seem to exacerbate the disease and this must be considered in any treatment program.

What are the available treatments?

Education and reassurance form the basis of therapy for patients with KP. It must be remembered that KP is often chronic and, as such, in attempting to treat it, we are dealing with a process of continuing maintenance rather than cure. Symptoms tend to remit with age but this is not always the case. For this reason, many patients choose to take matters into their own hands rather than taking a wait-and-see approach. However, short-term treatments are not highly successful, so in order to overcome the symptoms of KP, regular topical skin care treatments must be used indefinitely. KP therapy can smooth out the bumps, remove the closed plugs that can lead to acne and improve both the skin's appearance and texture. One common method of treatment is topical exfoliation.

Lifestyle modification

The following measures will ensure that your skin doesn't succumb to dryness - and the associated itchiness - by protecting the natural moisture that keeps the skin healthy:

tepid, shorter showers should replace hot baths
soap-free cleansers should replace regular soap
scrub with a pumice stone or loofah in the shower
use a moisturising cream (particularly urea creams) immediately after bathing to effectively trap water in the skin before it has time to evaporate.
use shaving cream when shaving the face or legs, change blades regularly and always shave in the direction that your hair grows
a home humidifier should be used, particularly during the dry winter months in temperate climates. This will also reduce some of the red colouration that can be found with KP.
drink plenty of water (roughly eight glasses per day)

Avoid abrasive self-therapy, such as picking and squeezing at the bumps. This may heighten the problem through secondary infections of the bumps, potentially requiring topical steroid therapy. Self-mutilation through scarring often results from such attempts at self-therapy for KP.
Avoid scratchy, tight-fitting clothing which may also irritate the KP, resulting in discomfort or even infection of the bumps.

Topical options

KP can be easily controlled by adhering to ongoing topical treatments. As mentioned above, emollients such as a moisturising cream should be applied daily. This is often the most suitable option for mild cases. Over-the-counter lactic acid or urea-based products help the skin's surface to retain moisture and may be more appropriate in cases of more severe dryness. Usually, efforts to moisturise reduce dryness and its asscociated itchiness. If this is not found to be the case, contact your dermatologist.

Despite their benefits, regular moisturisers do not clear away the bumps. For this reason, creams containing mild peeling agents such as alpha-hydroxy acids or salicylic acid are particularly useful for those with KP. Vitamin A treatments such as Retin-A have also been found to be beneficial for smoothing out the skin. These mild peeling agents smooth out the bumps by removing the excess dead skin that is plugging the hair follicles.

Others therapeutic options such as topical steroids and tretinoin cream can each be beneficial. Topical steroids are commonly prescribed - their potency is matched to the severity of the particular condition.

Topical retinoids are available on prescription only and are often used to treat more severe cases. They must not be used by children or by pregnant women due to potentially harmful side effects.

With the exception of the initial few weeks of treatment with retinoids, the process of chemical exfoliation does not involve any redness or discomfort to the skin.

All products should be used only as indicated. Excessive application of products won't hasten results; often, it will actually worsen your skin condition.

Other modes of treatment

As is the case with the topical treatments, microdermabrasion and laser treatments must be repeated periodically to prevent the skin re-forming around the hair follicles. These other modes of treatment tend to be more expensive than topical treatments and may not prove to be any more successful.

Microdermabrasion can effectively smooth out the skin by removing the skin's upper layers and the associated bumps.

Pulse dye laser treatment can reduce the red appearance of KP for some time, but it doesn't smooth out the rough texture. Repeated treatments may be required.

Laser assisted hair removal has been known to improve symptoms in some cases.