Common Skin Conditions and What to Do About Them

This is the chapter where we get specific.

In my office, most people aren't coming in with a general "I want better skin" complaint. They're coming in with something concrete. Acne that won't quit. Redness that flushes at every meal. Brown patches that appeared after pregnancy and never left. Skin that itches and flares for no clear reason. These are the conditions I treat all day, and they're where good information matters most.

I'm going to walk you through the conditions I see most often. For each one, I'll cover what's actually happening, what you can do at home, when to see a professional, and what's worth knowing about the deeper or more aggressive treatments.

A note before we start. If something on your skin is changing rapidly, painful, bleeding, asymmetric, growing, or just feels wrong to you, skip the home treatment and go see someone. A book is not a substitute for an in-person exam, and some of what looks like a "skin condition" is something more serious that needs an expert eye.

Acne

Acne happens when oil, dead skin cells, and bacteria combine inside a pore. The body sees the trapped contents as an invader and inflames the surrounding tissue. That's the pimple.

There are different types, and the type matters because the treatment differs.

Comedonal acne is the non-inflamed kind. Blackheads (open comedones) and whiteheads (closed comedones). Caused mostly by congestion and slow cell turnover. Responds well to retinoids and salicylic acid.

Inflammatory acne is the angry red bumps and pustules. Caused by bacteria triggering an inflammatory response inside a clogged pore. Responds to retinoids, benzoyl peroxide, and sometimes antibiotics.

Cystic or nodular acne is the deep, painful, often scarring kind. Often hormonal in adults. Topicals alone usually aren't enough. This category often needs prescription help.

Hormonal acne isn't a separate type by mechanism, but by trigger. It's typically inflammatory or cystic, located along the jawline, chin, and lower face, and flares cyclically with menstrual cycles. Common in women in their twenties through forties. Often resistant to topical treatments alone.

What to try at home, in order:

Start with a salicylic acid cleanser or treatment. Two percent salicylic acid two or three times a week to start, then daily as tolerated. If you can also tolerate it, add an adapalene gel at night. Adapalene (the over-the-counter retinoid I mentioned earlier) is genuinely transformative for many acne patients and costs about fifteen dollars at any drugstore. Give it three months before judging it.

If you're still breaking out after twelve weeks of consistent use, or if you have cystic or hormonal acne, see a provider. There are several escalations available.

Prescription topicals include stronger retinoids (tretinoin, tazarotene), topical antibiotics (clindamycin), benzoyl peroxide at higher strengths, and combination products.

Oral options include antibiotics like doxycycline (for inflammatory acne, short-term), spironolactone (for hormonal acne in women, often a meaningful shift), oral contraceptives (specific formulations help hormonal acne), and isotretinoin (Accutane, for severe or treatment-resistant acne, a powerful option with real side effects).

A common mistake I see is people fighting acne with harsh products that strip the skin and make everything worse. A wrecked barrier produces more oil, more inflammation, and more breakouts. If your skin is acneic and also tight, flaking, and irritated, the problem isn't that you need to be more aggressive. It's that you've been too aggressive. Back off, repair, and reintroduce slowly.

One more note: please stop picking. I know. I know. But every pimple you pop has a fifty-fifty chance of leaving either a scar or post-inflammatory hyperpigmentation that takes six to twelve months to fade. The picking is making the long-term problem worse than the short-term one.

Rosacea

Rosacea is a chronic inflammatory condition. It typically starts in the thirties or forties, often in people of Celtic or Northern European descent, though it occurs in all ethnicities and is often underdiagnosed in darker skin tones.

The signs include persistent redness across the cheeks and central face, visible small blood vessels, flushing in response to triggers, sometimes acne-like bumps, and in advanced cases, thickening of the skin (most often on the nose).

Common triggers: heat, sun, alcohol (especially red wine), spicy food, stress, hot drinks, intense exercise, harsh skincare products, and for many women, hormone changes around menopause.

What helps:

Identify and avoid your triggers. This is the cheapest and often most effective intervention. Keep a journal for a few weeks and see what correlates with flares.

Use mineral sunscreen daily. Sun is one of the biggest rosacea triggers, and chemical sunscreens can occasionally aggravate. SPF 30 to 50 mineral, every morning, no exceptions.

Use gentle skincare. No harsh exfoliation. No aggressive actives. No fragranced products. Niacinamide, azelaic acid, and centella are your friends.

See a provider for prescription topicals. Metronidazole, azelaic acid 15%, ivermectin, and newer options like minocycline foam are all effective. Some people also benefit from oral antibiotics in low doses for the anti-inflammatory effect.

For the visible blood vessels, lasers (IPL and pulsed-dye laser) can be remarkably effective. This is one of the procedures I do where patients consistently get emotional about the results.

What doesn't help: harsh exfoliants, alcohol-based toners, aggressive scrubs, hot water, anti-aging actives that increase cell turnover. Rosacea-prone skin needs to be calmed, not pushed.

Melasma

Melasma is patches of darker pigmentation, usually on the cheeks, forehead, upper lip, and chin. Often symmetrical. Strongly associated with hormones (pregnancy, birth control, hormone therapy) and sun exposure. Far more common in women than men, and more common in skin tones with more pigment.

Melasma is the most stubborn pigmentation issue I treat. Patients want it gone in a month. The truth is that even excellent management takes six to twelve months to see meaningful results, and once you have it, you'll likely manage it for life.

Treatment is multi-pronged:

Aggressive sun protection. SPF 50 mineral, reapplied. Wide-brimmed hats. UPF clothing. Window film for your car. The sun drives melasma even on cloudy days. If you can't commit to sun protection, melasma treatment is fighting a losing battle.

Topical pigment inhibitors. Hydroquinone 4% (prescription) is the gold standard for short-term use (three to six months, then a break). Tranexamic acid topically or orally. Azelaic acid. Kojic acid. Cysteamine. Many providers use compounded combinations.

Retinoids. They help by speeding up cell turnover and pushing pigmented cells to the surface.

Vitamin C in the morning. For both antioxidant protection and gentle pigment-fading.

Chemical peels. Gentle ones, repeated over months. Not aggressive ones, which can actually worsen melasma by triggering inflammation.

What to avoid: aggressive lasers in many cases, especially ablative or fractional lasers. They can worsen melasma rather than improve it, particularly in darker skin tones. Lasers can play a role, but they need to be chosen carefully and used by someone who treats melasma regularly. If your first provider's plan for your melasma is "let's laser it," get a second opinion.

Also avoid hot environments when possible. Heat itself, not just UV, can worsen melasma. Saunas, steam, intense workouts in the heat, even just hot showers on your face. Be aware.

Hyperpigmentation (Non-Melasma)

This category covers everything else pigmentation-related. Sun spots, age spots, post-inflammatory hyperpigmentation (dark marks left after acne or other inflammation), and freckles.

Treatment is similar in principle to melasma but typically responds faster.

Sun protection first, always. Pigment that's still being driven by daily sun exposure won't fully fade no matter what else you do.

Vitamin C, retinoid, and one or more of: azelaic acid, niacinamide, kojic acid, alpha arbutin, or tranexamic acid.

For stubborn spots, in-office options include chemical peels, IPL (intense pulsed light), and pico lasers. These can dramatically improve sun spots and post-inflammatory marks. They should be used cautiously in darker skin tones because of the risk of paradoxical pigment changes.

Post-inflammatory hyperpigmentation specifically (the dark marks after acne) tends to fade with consistent topical treatment over six to twelve months. The actives I mentioned plus aggressive sun protection will get you there. Patience matters.

Eczema (Atopic Dermatitis)

Eczema is chronic inflammation that leads to dry, itchy, often red or thickened patches of skin. It tends to come in flares, often triggered by stress, irritants, allergens, weather changes, or unknown triggers.

The core issue is a damaged skin barrier that loses moisture and lets in irritants. Treatment focuses on barrier repair, moisture retention, and managing flares.

Daily habits:

Use lukewarm water, not hot. Hot water destroys an already fragile barrier.

Apply moisturizer immediately after bathing, while skin is still damp. Cream-based, fragrance-free. Ceramide-rich formulations are particularly helpful.

Avoid known irritants. Wool, harsh soaps, fragranced products, certain laundry detergents.

Manage stress where possible. Stress is a well-documented eczema trigger.

For flares, topical steroids are often necessary. Low-potency over-the-counter hydrocortisone works for mild flares. Stronger prescription steroids may be needed for worse ones. Non-steroid options (tacrolimus, pimecrolimus, crisaborole) can be used for areas like the face or for longer-term management.

For severe eczema, newer biologic medications (like dupilumab) have changed the game. If you have eczema that's significantly affecting your life and topical treatments aren't enough, see a dermatologist about systemic options.

Sensitive Skin (Versus Sensitized Skin)

I want to draw a distinction I touched on earlier.

True sensitive skin is a lifelong, often genetic pattern. It's commonly associated with rosacea or eczema. The skin's barrier is naturally more reactive and less strong. It needs respectful, minimal, calming care.

Sensitized skin is sensitivity you created. Usually by overusing actives, exfoliating too much, layering products carelessly, or following routines designed for someone else's skin. Sensitized skin can be repaired.

If you suspect you have sensitized skin, here's the protocol:

Stop everything. Cleanser, moisturizer, sunscreen only. Gentle versions of each. No actives. No exfoliants. Nothing fragranced.

Add a barrier repair moisturizer. Ceramides, fatty acids, panthenol. Apply generously, twice a day.

Wait. Two to four weeks of barrier repair before reintroducing anything.

Reintroduce one product at a time. Start with the gentlest active you need. Use it once or twice a week. Watch for reaction. Only add another active after the first has been stable for a few weeks.

This is the path most of my patients with "sensitive skin" actually need. Their barriers have been wrecked by aggressive routines. Once we calm everything down and rebuild slowly, most of them tolerate active ingredients just fine.

Dehydration

I mentioned dehydration earlier as a condition that can layer on any skin type. It looks like dullness, fine lines that appear and disappear, tightness that goes away after moisturizer, skin that drinks up product, sometimes paradoxical oiliness as the skin overcompensates.

Dehydrated skin is missing water. Treatment is straightforward:

Add humectants. Hyaluronic acid, glycerin, polyglutamic acid.

Apply to damp skin and seal with moisturizer.

Avoid overcleansing. Once a day or with water only in the morning may be plenty.

Manage your environment. Humidifiers in dry climates and dry seasons. Less time in dry indoor air when possible.

Drink water, but understand that drinking more water doesn't fix dehydrated skin if your barrier is letting it evaporate. The fix has to happen topically.

Perioral Dermatitis

This one is increasingly common, and it's often misdiagnosed.

Perioral dermatitis shows up as small bumps, sometimes pustules, sometimes scaling, around the mouth, nose, or eyes. It often starts after using a topical steroid on the face, or after switching to a new product, or sometimes for no clear reason at all.

The frustrating thing about perioral dermatitis is that the treatments people instinctively reach for usually make it worse. Hydrocortisone provides initial relief and then causes rebound flares. Aggressive cleansers irritate it. Most actives aggravate it.

The treatment is counterintuitive. Stop almost everything. A "zero therapy" approach: gentle cleanser, simple moisturizer, sunscreen, that's it. Stop the steroid if you've been using one. The condition usually requires prescription help, typically a topical or oral antibiotic for several weeks.

If you've got a rash around your mouth that won't go away, see a provider. Don't keep slathering it with hydrocortisone or trying new products. That makes the problem worse.

Keratosis Pilaris

The little bumps on the backs of your arms, sometimes on the thighs or cheeks. Caused by buildup of keratin around hair follicles. Extremely common. Genetic. Not harmful, just sometimes annoying.

Treatment:

Gentle exfoliation. AHAs (lactic acid is particularly good) or BHA. Body lotions like AmLactin (lactic acid based) or CeraVe SA Lotion.

Moisturization. Dry skin makes KP look worse.

Patience. KP often improves with age, especially after the twenties. It rarely disappears completely, but it can become much less noticeable.

What doesn't help: aggressive scrubs. Picking. Strong steroids. These can irritate the area and create post-inflammatory pigment changes in addition to the original bumps.

Psoriasis

Psoriasis is a chronic autoimmune condition where the immune system signals skin cells to multiply much faster than normal. The result is thick, scaly, often itchy plaques, usually with a silvery scale on top of red or pink skin underneath. Common locations include the elbows, knees, scalp, lower back, and behind the ears, though it can appear anywhere.

A few things to understand:

Psoriasis isn't an isolated skin condition. It's a systemic inflammatory disease. People with psoriasis have higher rates of cardiovascular disease, depression, psoriatic arthritis (which can damage joints permanently if untreated), and other inflammatory conditions. Treating psoriasis isn't just about clearing the skin. It's about addressing systemic inflammation.

Triggers vary by patient but commonly include stress, infections (particularly strep), certain medications (lithium, some blood pressure medications, abrupt steroid withdrawal), alcohol, smoking, weather changes, and skin injury.

There are several forms, with plaque psoriasis being the most common. Guttate psoriasis (small drop-like lesions, often after strep infection), inverse psoriasis (in skin folds), and pustular and erythrodermic forms (more severe) are less common but distinct.

Treatment approach:

Mild cases may respond to topical treatments. Topical steroids of appropriate potency. Vitamin D analogs like calcipotriene. Tar preparations. Salicylic acid to help remove scale. Moisturizers play a supporting role.

Moderate cases often benefit from phototherapy (narrowband UVB), which is genuinely effective and underutilized. Treatments are administered in dermatology offices, typically two to three times per week for several months.

Moderate to severe cases warrant systemic treatment. Methotrexate and cyclosporine are older options. Newer biologics targeting specific inflammatory pathways (TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors) have revolutionized treatment in the last fifteen years. These medications can produce complete or near-complete clearance in many patients, with safety profiles that are well-established at this point.

What I tell patients with psoriasis: if your psoriasis is significantly affecting your quality of life, your sleep, your mental health, or your physical function, you deserve more than topical treatment. The biologic options available now are remarkable. Many of my psoriasis patients have transformed their lives by working with a dermatologist on systemic treatment. If your current provider isn't discussing these options and your psoriasis is significant, get a second opinion.

What to avoid: harsh treatments that injure the skin (which can trigger new psoriasis lesions in the injured area, a phenomenon called the Koebner phenomenon). Aggressive over-the-counter "psoriasis" products that aren't actually addressing what's happening. Stopping topical steroids abruptly after long-term use, which can cause rebound flares.

Seborrheic Dermatitis

Most people know seborrheic dermatitis as dandruff on the scalp, but it can appear on the face (especially the eyebrows, sides of the nose, and behind the ears), the chest, and the back. It shows up as redness, scaling, sometimes greasy-looking patches, and occasional itching.

The cause is multifactorial: a type of yeast (Malassezia) that lives on everyone's skin overgrows or triggers an inflammatory response, combined with sebum production patterns and individual immune factors. Stress, fatigue, certain neurological conditions, and immune compromise can all worsen it.

Treatment:

For the scalp: medicated shampoos containing ketoconazole (Nizoral), selenium sulfide (Selsun Blue), zinc pyrithione (Head and Shoulders), or coal tar. Used regularly, usually two to three times a week, leaving on the scalp for several minutes before rinsing. Different active ingredients work better for different people. Rotating between them sometimes helps.

For the face: antifungal creams like ketoconazole 2% applied to affected areas. Low-strength topical steroids for short-term use during flares. Sulfur-based products. Some patients respond well to azelaic acid, which has antifungal and anti-inflammatory effects.

For severe or treatment-resistant cases: prescription antifungals taken orally, prescription topical antifungal-steroid combinations.

What I tell patients with seborrheic dermatitis: this is typically a chronic condition that comes and goes throughout life. The goal isn't permanent cure but ongoing management with the lightest treatment that controls your symptoms. Many patients do well with intermittent use of medicated shampoo or antifungal cream during flares, then less aggressive maintenance between flares.

What to watch for: severe seborrheic dermatitis that's resistant to treatment can occasionally be a sign of underlying immune issues. If yours is severe and not responding to standard treatment, an evaluation by a dermatologist (and sometimes other specialists) is appropriate.

Hidradenitis Suppurativa

This one is under-recognized and under-treated, and patients with it often suffer for years before getting a real diagnosis.

Hidradenitis suppurativa (HS) is a chronic inflammatory condition affecting hair follicles in areas with apocrine sweat glands. The armpits, groin, under the breasts, the buttocks, and the inner thighs. It produces painful, deep nodules, abscesses, draining tracts, and over time, scarring. It's often misdiagnosed as recurrent boils or acne in unusual locations.

A few things to understand:

HS is significantly more common than people realize, affecting perhaps one to four percent of the population. It's much more common in women, more common in people who smoke, and more common in patients with obesity, though it occurs across all body types and demographics.

It typically starts in late adolescence or early adulthood and progresses if untreated. Early intervention makes a real difference in long-term outcomes.

The disease is staged by severity (Hurley stages I through III). Mild cases may have occasional nodules. Severe cases involve extensive scarring, draining sinuses, and significant impact on daily function.

Treatment approach varies by stage:

Mild cases: topical antibiotics (clindamycin), antiseptic washes (benzoyl peroxide, chlorhexidine), warm compresses for active lesions, lifestyle modifications including smoking cessation and weight management where applicable.

Moderate cases: oral antibiotics (clindamycin and rifampin together is a common combination, used for several months), hormonal treatment in women (spironolactone, oral contraceptives), metformin for some patients.

Severe cases: biologic medications, particularly adalimumab (Humira), which is FDA-approved for moderate to severe HS. Other biologics are being studied and used. Surgical interventions for damaged or scarred areas.

What I tell patients with HS: this is a real disease that deserves real treatment. If you've been told it's just "boils" or "ingrown hairs" and given short courses of antibiotics that don't really help, you deserve better care. Find a dermatologist who treats HS specifically. The HS Foundation maintains resources for finding knowledgeable providers.

The mental health piece of HS is enormous. Patients with HS have very high rates of depression, anxiety, and social isolation because of the pain, the visible flares, the impact on intimate relationships, and the long road to diagnosis. Mental health support is part of comprehensive HS care.

Vitiligo

Vitiligo is loss of pigment in patches of skin, caused by destruction of melanocytes (the pigment-producing cells). It can appear anywhere, often symmetrically. Common locations include the hands, face, around body openings, and in areas of skin trauma.

What's happening biologically:

Vitiligo is now understood to be an autoimmune condition where the immune system mistakenly attacks melanocytes. It often coexists with other autoimmune conditions like thyroid disease, type 1 diabetes, alopecia areata, and others. Patients with vitiligo should have screening for these associated conditions.

It can start at any age but most commonly begins before age thirty. Family history is a risk factor.

The course varies. Some patients have stable patches that don't change much. Others have progressive disease with new patches appearing over time. Stress, illness, and skin trauma can sometimes trigger new patches.

Treatment options have improved significantly in recent years:

Topical treatments: corticosteroids and calcineurin inhibitors (tacrolimus, pimecrolimus) can help repigment affected areas, particularly when used early. JAK inhibitors, both topical (ruxolitinib cream, recently approved) and oral, are a major recent advance.

Phototherapy: narrowband UVB phototherapy is one of the most effective treatments. Used regularly over months to years, it can produce significant repigmentation.

Surgical options: skin grafting techniques for stable, treatment-resistant patches.

Camouflage: cosmetic options like medical-grade camouflage makeup or tattooing can help patients feel more comfortable in their skin while undergoing treatment.

Sun protection: critical for vitiligo. The pigmented and non-pigmented areas respond differently to sun, and burns in depigmented areas are easier and can worsen the condition.

What I tell patients with vitiligo:

Treatment works better when started early. If you have new vitiligo patches, see a dermatologist promptly. Active disease is more treatable than long-standing stable disease.

The emotional impact of vitiligo is real, especially when it affects visible areas like the face or hands. Mental health support is appropriate and helpful.

Newer treatments are changing what's possible. If you have vitiligo and haven't seen a specialist in a few years, an updated consultation is worthwhile.

You're not alone. Vitiligo affects about one percent of the global population. There are growing communities of patients sharing experience and advocacy.

Lichen Planus

A less common but distinct condition worth knowing about. Lichen planus presents as itchy, flat-topped, often purplish bumps, sometimes with a fine white pattern on the surface (Wickham striae). It commonly affects the wrists, ankles, lower back, and inside the mouth. The oral form can be particularly persistent.

The cause is autoimmune in nature, sometimes triggered by medications, viral infections, or unknown factors.

Treatment includes topical and sometimes systemic steroids, calcineurin inhibitors, and addressing any identifiable trigger. The oral form sometimes needs prolonged treatment and can occasionally have an association with hepatitis C, which is worth screening for in affected patients.

If you have an itchy purplish rash that doesn't fit the typical patterns of eczema or psoriasis, lichen planus is worth considering with a dermatology evaluation.

Skin Cancer Awareness

A separate but critical category. I'd be doing you a disservice if a chapter on skin conditions didn't address what to watch for in terms of skin cancer.

The most common skin cancers:

Basal cell carcinoma. The most common skin cancer. Often appears as a pearly bump, sometimes with visible small blood vessels on the surface, sometimes as a non-healing sore. Rarely metastasizes but can cause significant local damage if untreated.

Squamous cell carcinoma. Often appears as a scaly, crusted, sometimes tender area, often on sun-exposed skin. Can spread if untreated, more aggressively than basal cell.

Melanoma. The most dangerous. Typically appears as a pigmented lesion that doesn't match the others on your body. The ABCDE criteria help screen: Asymmetry, Border irregularity, Color variation, Diameter over 6mm, Evolution or change over time. Any of these features in a pigmented lesion warrants evaluation.

A few principles:

Annual skin checks with a dermatologist are reasonable starting in your thirties, more important as you age, and especially important if you have risk factors (fair skin, history of significant sun exposure, family history of skin cancer, prior precancerous lesions, immunosuppression).

Pay attention to changing moles. The "ugly duckling" mole that looks different from your others is the one worth showing a dermatologist.

Skin cancers can occur in unexpected places. The soles of the feet. Under fingernails. The scalp. Behind the ears. Between toes. Skin checks should include these areas.

Skin cancer in darker skin tones is less common but often diagnosed later because of lower awareness in both patients and some providers. Acral lentiginous melanoma, which occurs on the palms, soles, and under nails, disproportionately affects darker skin tones and has worse outcomes when diagnosed late. If you have darker skin, this is worth knowing about and being vigilant for.

This isn't a chapter that can replace a real skin exam. But if anything I've described sounds like something you're noticing, please see a dermatologist promptly. Skin cancers caught early are highly treatable. Skin cancers caught late are sometimes not.

When to See a Professional

A quick checklist for when to stop trying home approaches and get expert eyes on your skin:

Anything that's painful, bleeding, growing, or asymmetric. This could be skin cancer. Don't wait.

Acne that hasn't improved after three months of consistent over-the-counter treatment. There are better options.

Persistent redness or flushing that doesn't fit a clear pattern. Could be rosacea, lupus, or other conditions that need diagnosis.

Pigment changes that appear suddenly, spread, or affect a wide area. Worth ruling out hormonal causes or other underlying issues.

Eczema or other rashes that significantly affect your sleep, work, or daily life. Better treatments exist.

Anything affecting your mental health. If your skin condition is making you anxious, depressed, or avoiding social situations, that's a separate issue worth addressing both for the skin and for you as a whole person.

Skin is one of those areas where the in-person exam matters. A good provider can often diagnose something in thirty seconds that you've been wrestling with for six months. Don't let pride or cost keep you from asking for help when you need it.

The next chapter zooms out. We've been talking about what to put on your skin. The next conversation is about everything else that affects how your skin behaves. Sleep, stress, hormones, gut, what you eat. Some of the most powerful skin interventions don't involve a single bottle.