Mimi Balch, MD

Acne is the most frequent skin condition in the United States. It is characterized by pimples that appear on the face, back and chest. Every year, about 80% of adolescents have some form of acne and about 5% of adults experience acne. Acne is made up of two types of blemishes: - Whiteheads/Blackheads, also known as comedones, are non-inflammatory and appear more on the face and shoulders. As long as they remain uninfected, they are unlikely to lead to scarring. - Red Pustules or Papules are inflamed pores that fill with pus. These can lead to scarring. CAUSES In normal skin, oil glands under the skin, known as sebaceous glands, produce an oily substance called sebum. The sebum moves from the bottom to the top of each hair follicle and then spills out onto the surface of the skin, taking with it sloughed-off skin cells. With acne, the structure through which the sebum flows gets plugged up. This blockage traps sebum and sloughed-off cells below the skin, preventing them from being released onto the skin’s surface. If the pore’s opening is fully blocked, this produces a whitehead. If the pore’s opening is open, this produces blackheads. When either a whitehead or blackhead becomes inflamed, they can become red pustules or papules. It is important for patients not to pick or scratch at individual lesions because it can make them inflamed and can lead to long-term scarring. TREATMENT Treating acne is a relatively slow process; there is no overnight remedy. Our team will evaluate and treat your acne with the plan of care that best suits your needs.

Diseases of Hair and Nails cover everything from dandruff, hair loss, nail fungus and so much more. Our Dermatology team is here to help you with any issues or conditions you are dealing with not just on your skin but also anything relating to your hair and/or nails. Our skin experts are here to help find an individualized treatment plan that works for you and your specific needs!

Eczema is a form of skin irritation that can cause the skin to become inflamed, itchy, cracked and rough. If left untreated it could cause blisters. The most common form of eczema is Atopic Dermatitis. Some (younger) patients will outgrow the condition while others will continue to have it throughout adulthood. Treatments can include home remedies and medications, including topical creams and ointments. Our Dermatology team will determine what treatment plan is best for you based on your specific needs.

As you age, you may notice the appearance of new spots and bumps on your skin (such as miles, skin tags, lipomas, warts, etc.). While many of these growths; aside from moles that turn into skin cancer, are typically benign and harmless, patients sometimes choose to have them removed for aesthetic purposes or if they are bothersome in any way. The removal method will be decided by our Dermatology team and will be based on the size and location of the growth.

Psoriasis is a skin condition that creates red patches of skin with white, flaky scales. It most commonly occurs on the elbows, knees and trunk, but can appear anywhere on the body. The first episode usually strikes between the ages of 15 and 35. It is a chronic condition that will then cycle through flare-ups and remissions throughout the rest of the patient’s life. Psoriasis affects as many as 7.5 million people in the United States. About 20,000 children under age 10 have been diagnosed with psoriasis. In normal skin, skin cells live for about 28 days and then are shed from the outermost layer of the skin. With psoriasis, the immune system sends a faulty signal which speeds up the growth cycle of skin cells. Skin cells mature in a matter of 3 to 6 days. The pace is so rapid that the body is unable to shed the dead cells, and patches of raised red skin covered by scaly, white flakes form on the skin. Psoriasis is a genetic disease (it runs in families), but is not contagious. There is no known cure or method of prevention. Treatment aims to minimize the symptoms and speed healing. THERE ARE FIVE DISTINCT TYPES OF PSORIASIS: Plaque Psoriasis (Psoriasis Vulgaris) — About 80% of all psoriasis sufferers get this form of the disease. It is typically found on the elbows, knees, scalp and lower back. It classically appears as inflamed, red lesions covered by silvery-white scales. Guttate Psoriasis — This form of psoriasis appears as small red dot-like spots, usually on the trunk or limbs. It occurs most frequently among children and young adults. Guttate psoriasis comes on suddenly, often in response to some other health problem or environmental trigger, such as strep throat, tonsillitis, stress or injury to the skin. Inverse Psoriasis — This type of psoriasis appears as bright red lesions that are smooth and shiny. It is usually found in the armpits, groin, under the breasts and in skin folds around the genitals and buttocks. Pustular Psoriasis — Pustular psoriasis looks like white blisters filled with pus surrounded by red skin. It can appear in a limited area of the skin or all over the body. The pus is made up of white blood cells and is not infectious. Triggers for pustular psoriasis include overexposure to ultraviolet radiation, irritating topical treatments, stress, infections and sudden withdrawal from systemic (treating the whole body) medications. Erythrodermic Psoriasis — One of the most inflamed forms of psoriasis, erythrodermic psoriasis looks like fiery, red skin covering large areas of the body that shed in white sheets instead of flakes. This form of psoriasis is usually very itchy and may cause some pain. Triggers for erythrodermic psoriasis include severe sunburn, infection, pneumonia, medications or abrupt withdrawal of systemic psoriasis treatment. People who have psoriasis are at greater risk for contracting other health problems, such as heart disease, inflammatory bowel disease and diabetes. It has also been linked to a higher incidence of cardiovascular disease, hypertension, cancer, depression, obesity and other immune-related conditions. Psoriasis triggers are specific to each person. Some common triggers include stress, injury to the skin, medication allergies, diet and weather. MILD TO MODERATE PSORIASIS TREATMENT Psoriasis is classified as Mild to Moderate when it covers 3% to 10% of the body and Moderate to Severe when it covers more than 10% of the body. The severity of the disease impacts the choice of treatments. Mild to moderate psoriasis can generally be treated at home using a combination of three key strategies: over-the-counter medications, prescription topical treatments and light therapy/phototherapy. MODERATE TO SEVERE PSORIASIS TREATMENT Treatments for moderate to severe psoriasis include prescription medications, biologics and light therapy/phototherapy.

“Rash” is a general term for a wide variety of skin conditions. A rash refers to a change that affects the skin and usually appears as a red patch or small bumps or blisters on the skin. The majority of rashes are harmless and can be treated effectively with over-the-counter anti-itch creams, antihistamines and moisturizing lotions. Rashes can be a symptom for other skin problems. The most prevalent of these are: - Atopic Dermatitis, the most common form of eczema - Bacterial Infections, such as impetigo - Contact Dermatitis, a type of eczema caused by coming into contact with an allergen - Chronic skin problems, such as acne, psoriasis or seborrheic dermatitis - Fungal Infections, such as ringworm and yeast infection - Viral Infections, such as shingles A rash may be a sign of a more serious illness, such as Lyme Disease, Rocky Mountain Spotted Fever, liver disease, kidney disease or some types of cancers. If you experience a rash that does not go away on its own after a few weeks, make an appointment to have it properly diagnosed and treated.

Rosacea is a chronic skin condition that causes facial redness, acne-like pimples, visible small blood vessels on the face, swelling and/or watery, irritated eyes. This inflammation of the face can affect the cheeks, nose, chin, forehead or eyelids. More than 14 million Americans suffer from rosacea. It is not contagious, but there is some evidence to suggest that it is inherited. There is no known cause or cure for rosacea. There is also no link between rosacea and cancer. Rosacea generally begins after age 30 and goes through cycles of flare-ups and remissions. Over time, it gets ruddier in color and small blood vessels (like spider veins) may appear on the face. If left untreated, bumps and pimples may form, the end of the nose may become swollen, red and bulbous and eyes may water or become irritated. Rosacea occurs most often among people with fair skin who tend to blush or flush easily. It occurs more often among women than men, but men tend to suffer from more severe symptoms. Most patients experience multiple symptoms at varying levels of severity. Common symptoms include: - Flushing - Persistently red skin on the face - Bumps or acne-like pimples - Visible blood vessels on facial skin - Watery or irritated eyes - Burning, itching or stinging of facial skin - Skin roughness and dryness - Raised red patches - Swelling (edema) These symptoms may also appear on the neck, chest, scalp and ears. Research conducted by the National Rosacea Foundation found that the leading triggers for rosacea are: - Sun exposure - Hot or cold weather - Emotional stress - Wind - Alcohol - Heavy exercise - Spicy foods - Hot baths - Some skin care products - Humidity While there is no cure for rosacea and each case is unique, your doctor will probably prescribe oral antibiotics and topical medications to reduce the severity of the symptoms. When the condition goes into remission, only topical treatments may be needed. In more severe cases, a vascular laser, intense pulsed light source or other medical device may be used to remove any visible blood vessels and reduce excess redness and bumpiness on the nose. To help reduce the incidence of flare-ups, a gentle daily skin care routine is recommended that includes the use of mild, non-abrasive cleansers, soft cloths, rinsing in lukewarm water (not hot or cold), and blotting the face dry (not rubbing). Additionally, individuals with rosacea need to protect themselves from sun exposure by using sunscreens with SPF 15 or higher and sunblocks that eliminate UVA and UVB rays. Patients are also encouraged to keep a record of flare-ups to try and determine the lifestyle and environmental triggers that aggravate the condition.

Skin cancer is the most common form of human cancers, affecting more than one million Americans every year. One in five Americans will develop skin cancer at some point in their lives. Skin cancers are generally curable if caught early. However, people who have had skin cancer are at a higher risk of developing a new skin cancer, which is why regular self-examination and doctor visits are imperative. The vast majority of skin cancers are composed of three different types: basal cell carcinoma, squamous cell carcinoma and melanoma. BASAL CELL CARCINOMA This is the most common form of skin cancer. Basal cells reside in the deepest layer of the epidermis, along with hair follicles and sweat ducts. When a person is overexposed to UVB radiation, it damages the body’s natural repair system, which causes basal cell carcinomas to grow. These tend to be slow-growing tumors and rarely metastasize (spread). Basal cell carcinomas can present in a number of different ways: - Raised pink or pearly white bump with a pearly edge and small, visible blood vessels - Pigmented bumps that look like moles with a pearly edge - A sore that continuously heals and re-opens - Flat scaly scar with a waxy appearance and blurred edges Despite the different appearances of the cancer, they all tend to bleed with little or no cause. Eighty-five percent of basal cell carcinomas occur on the face and neck since these are areas that are most exposed to the sun. Risk factors for basal cell carcinoma include having fair skin, sun exposure, age (most skin cancers occur after age 50), exposure to ultraviolet radiation (as in tanning beds) and therapeutic radiation given to treat an unrelated health issue. Diagnosing basal cell carcinoma requires a biopsy — either excisional, where the entire tumor is removed along with some of the surrounding tissue, or incisional, where only a part of the tumor is removed (used primarily for large lesions). TREATMENTS FOR BASAL CELL CARCINOMA INCLUDE: Cryosurgery — Some basal cell carcinomas respond to cryosurgery, where liquid nitrogen is used to freeze off the tumor. Curettage and Desiccation — The preferred method of dermatologists, this treatment involves using a small metal instrument (called a curette) to scrape out the tumor along with an application of an electric current into the tissue to kill off any remaining cancer cells. Mohs Micrographic Surgery — The preferred method for large tumors, Mohs Micrographic Surgery combines removal of cancerous tissue with microscopic review while the surgery takes place. By mapping the diseased tissue layer by layer, less healthy skin is damaged when removing the tumor. Prescription Medicated Creams — These creams can be applied at home. They stimulate the body’s natural immune system over the course of weeks. Radiation Therapy — Radiation therapy is used for difficult-to-treat tumors, either because of their location, severity or persistence. Surgical Excision — In this treatment the tumor is surgically removed and stitched up. SQUAMOUS CELL CARCINOMA Squamous cells are found in the upper layer (the surface) of the epidermis. They look like fish scales under a microscope and present as a crusted or scaly patch of skin with an inflamed, red base. They are often tender to the touch. It is estimated that 250,000 new cases of squamous cell carcinoma are diagnosed annually, and that 2,500 of them result in death. Squamous cell carcinoma can develop anywhere, including inside the mouth and on the genitalia. It most frequently appears on the scalp, face, ears and back of hands. Squamous cell carcinoma tends to develop among fair-skinned, middle-aged and elderly people who have a history of sun exposure. In some cases, it evolves from actinic keratoses, dry scaly lesions that can be flesh-colored, reddish-brown or yellow black, and which appear on skin that is rough or leathery. Actinic keratoses spots are considered to be precancerous. Like basal cell carcinoma, squamous cell carcinoma is diagnosed via a biopsy — either excisional, where the entire tumor is removed along with some of the surrounding tissue, or incisional, where only a part of the tumor is removed (used primarily for large lesions). TREATMENTS FOR SQUAMOUS CELL CARCINOMA INCLUDE: Cryosurgery — Some squamous cell carcinomas respond to cryosurgery, where liquid nitrogen is used to freeze off the tumor. Curettage and Desiccation — This treatment involves using a small metal instrument (called a curette) to scrape out the tumor along with an application of an electric current into the tissue to kill off any remaining cancer cells. Mohs Micrographic Surgery — The preferred method for large tumors, Mohs Micrographic Surgery combines removal of cancerous tissue with microscopic review while the surgery takes place. By mapping the diseased tissue layer by layer, less healthy skin is damaged when removing the tumor. Prescription Medicated Creams — These creams can be applied at home. They stimulate the body’s natural immune system over the course of weeks. Radiation Therapy — Radiation therapy is used for difficult-to-treat tumors, either because of their location, severity or persistence. Surgical Excision — In this treatment the tumor is surgically removed and stitched up. MELANOMA While melanoma is the least common type of skin cancer, it is by far the most virulent. It is the most common form of cancer among young adults age 25 to 29. Melanocytes are cells found in the bottom layer of the epidermis. These cells produce melanin, the substance responsible for skin pigmentation. That’s why melanomas often present as dark brown or black spots on the skin. Melanomas spread rapidly to internal organs and the lymph system, making them quite dangerous. Early detection is critical for curing this skin cancer. Melanomas look like moles and often do grow inside existing moles. That’s why it is important for people to conduct regular self-examinations of their skin in order to detect any potential skin cancer early, when it is treatable. Most melanomas are caused by overexposure to the sun beginning in childhood. This cancer also runs in families. WHAT TO LOOK FOR The key to detecting skin cancers is to notice changes in your skin. Look for: - Large brown spots with darker speckles located anywhere on the body. - Dark lesions on the palms of the hands and soles of the feet, fingertips toes, mouth, nose or genitalia. - Translucent pearly and dome-shaped growths. - Existing moles that begin to grow, itch or bleed. - Brown or black streaks under the nails. - A sore that repeatedly heals and re-opens. - Clusters of slow-growing scaly lesions that are pink or red. The American Academy of Dermatology has developed the following ABCDE guide for assessing whether or not a mole or other lesion may be becoming cancerous. - Asymmetry: Half the mole does not match the other half in size, shape or color. - Border: The edges of moles are irregular, scalloped, or poorly defined. - Color: The mole is not the same color throughout. - Diameter: The mole is usually greater than 6 millimeters when diagnosed, but may also be smaller. - Evolving: A mole or skin lesion that is different from the rest, or changes in size, shape, or color. If any of these conditions occur, please make an appointment to see Dr. Bradley right away. She may do a biopsy of the mole to determine if it is or isn’t cancerous. PREVENTION Roughly 90% of nonmelanoma cancers are attributable to ultraviolet radiation from the sun. That’s why prevention involves: - Staying out of the sun during peak hours (between 10 a.m. and 4 p.m.) - Covering up the arms and legs with protective clothing - Wearing a wide-brimmed hat and sunglasses - Using sunscreens year round with a SPF of 15 or greater and sunblocks that work on both UVA and UVB rays. Look for products that use the term “broad spectrum.” Checking your skin monthly and contacting your dermatologist if you notice any changes. Getting regular skin examinations. It is advised that adults over 40 get an annual exam with a dermatologist.

Hidradenitis suppurativa (HS) is a skin condition that causes painful lumps deep in the skin. These lumps usually develop on parts of the body where skin touches skin such as armpits, inner thighs, and groin area.