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Keratosis Pilaris Treatment & Management

  • Author: Ally N Alai, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: May 10, 2016
 

Medical Care

In view of the described genetic predisposition and possible genetic etiology of keratosis pilaris (KP), no cure or universally effective treatment has been available. Inconsistent remissions and variations with seasons and hormonal states (eg, pregnancy[8] ) are described. Although symptoms usually remit with increasing age, this is not always the case. Some cases clear spontaneously without treatment. Keratosis pilaris is generally a controllable but incurable condition.

Many treatment options and skin care recipes are available for treating keratosis pilaris. Many patients have very good temporary improvement following a regular skin care program. As a general rule, treatment needs to be continuous. Because no single therapy is effective, the list of potential lotions and creams is long. Importantly, keep in mind that as with any condition, no therapy is uniformly effective in all people. Complete clearing may not be possible.

General measures to prevent excessive skin dryness, such as using mild soapless cleansers (eg, Dove, Cetaphil), are recommended, and lubrication is the mainstay of treatment for nearly all cases. Exfoliation is helpful in removing the small keratin plugs overlying follicles.

Best results may be achieved with combination therapy.

Mild cases of keratosis pilaris may be improved with basic lubrication using over-the-counter moisturizer lotions such as Cetaphil, Purpose, or Lubriderm.

Additional available therapeutic options for more involved cases of keratosis pilaris include lactic acid lotions (AmLactin, Lac-Hydrin), alpha hydroxy acid lotions (glycolic body lotions, urea cream (Carmol 10, Carmol 20, Carmol 40, Urix 40), salicylic acid (Salex lotion), and topical steroid creams (triamcinolone 0.1%, Locoid Lipocream), retinoic acid products such as tretinoin (Retin-A), tazarotene (Tazorac), and adapalene (Differin). Specially mixed “designer” compound creams with multiple different combined ingredients can also be prescribed by physicians.

The affected area may be washed once or twice a day with a gentle cleanser such as Dove. Acne-prone skin may benefit from more therapeutic cleansers such as salicylic acid, or benzoyl peroxide.

Lotions should be gently massaged into the affected area 2-3 times a day. Irritated or abraded skin should be treated only with bland moisturizers until the inflammation resolves.

Occasionally, physicians may prescribe a 7- to 10-day course of a medium potency, emollient-based topical steroid cream (eg, Locoid Lipocream, Cloderm) to be applied once or twice a day for inflamed, red rash areas. Once the inflammation has remitted, the residual dry rough bumps may be treated with a routine of twice-daily application of a compounded preparation of 2-3% salicylic acid in 20% urea cream.

Intermittent dosing of topical retinoids (eg, weekly or biweekly) seems to be quite effective and well tolerated, but usually the response is only partial. After initial clearing with stronger medications, patients may then be placed on a milder maintenance regimen.

Persistent skin discoloration, termed hyperpigmentation, may be treated with fading creams such as hydroquinone 4%, kojic acid, and azelaic acid 15-20%. Special compounded creams for particularly resistant skin discoloration using higher concentrations of hydroquinone 6%, 8%, and 10% may also be formulated by compounding pharmacists. Higher concentrations of hydroquinone may be irritating and carry an increased risk of adverse effects, including ochronosis.

Keratosis pilaris may be treated with topical immunomodulators such as pimecrolimus (Elidel) or tacrolimus (Protopic). Although these products are approved for atopic dermatitis and eczema, their use would be considered off label for keratosis pilaris. These may be used in more resistant cases or when the patient has considerable skin redness or inflammation.

Photodynamic therapy (PDT) using a 2-step combination of a topical photosensitizer and a light source may be used in off-label fashion for the temporary treatment of keratosis pilaris. Available photosensitizers include aminolevulinic acid (Levulan) or methyl levulinate (Metvixia). Light sources include sunlight, blue light (417 nm), red light (630 nm), and multiple laser devices. PDT has been anecdotally reported as effective, but this successful use of off-label photodynamic therapy requires confirmation.

Laser hair removal (LHR) has been used in keratosis pilaris to decrease hair growth in affected areas. Theoretically, LHR may help decrease the portion of bumps in keratosis pilaris caused by small, coiled, ingrown hairs. There are no studies showing a cure of keratosis pilaris with LHR.

Laser therapies including more aggressive resurfacing lasers, carbon dioxide, fractional lasers, and other aggressive laser therapies have been used in limited cases for keratosis pilaris. There are no studies showing a cure of keratosis pilaris with these types of lasers.

Severe cases of keratosis pilaris have been treated orally with isotretinoin pills for several months. Isotretinoin is generally a very potent oral medication reserved for severe, resistant, or scarring cases of acne. Its use in keratosis pilaris would be considered off label and not routine. There are no studies showing a permanent cure of keratosis pilaris using isotretinoin.

Vitamin D (calcipotriol) is not effective for keratosis pilaris, but clinical trials have found it moderately effective for ichthyosis.[9]

As with most treatments for keratosis pilaris, data exist only in the form of small group observations and anecdotal reports. Because keratosis pilaris is generally a chronic condition that requires long-term maintenance, most therapies would require repeated or long-term use to maintain results.

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Surgical Care

Minor surgical procedures such as gentle acne extractions may be useful in resistant keratosis pilaris (KP). Extractions of keratotic papules and milia are performed using a small 30-gauge needle, larger 18-gauge needle, or a small diabetic lancet to pierce the overlying skin. A comedone extractor or 2 cotton-tipped applicators can be used to extract the keratin plugs or trapped coiled hairs. Best results may be achieved with combination therapy using topical emollients and physical treatments, such as manual extraction of white heads (termed acne surgery), microdermabrasion, and chemical peels.

In-office, physician-performed treatments such as chemical peels; dermabrasion; microdermabrasion; photodynamic therapy; and blue-light, laser, and intense pulsed light devices may be helpful as adjunctive treatment. Because keratosis pilaris has no cure and no universally effective treatment is available, proceed with caution using a combination of in-office treatments and a physician-directed home maintenance skin care routine.

In-office treatments include the following:

  • Chemical peels
  • Extraction of keratin plugs or trapped coiled hairs
  • Vacubrasion (uses vacuum suction and synthetic diamond abrasion)
  • Microdermabrasion
  • Photodynamic therapy
  • Blue-light
  • Laser
  • Intense pulsed light

Case reports in the literature have described effective keratosis pilaris treatment with modalities such as the 595-nm pulsed dye laser, intense pulsed light devices, and various other laser devices, including hair removal lasers.[10, 11] More expansive and larger-scale studies are required to assess the efficacy of potential laser therapies for this chronic, relapsing skin condition.[12]

Microdermabrasion is a safe, minimally invasive, in-office procedure used to gently exfoliate skin. Using vacuum-assisted suction, the skin is rubbed with an abrasive particle such as fine, powdery aluminum crystals or small diamond tips. Microdermabrasion assists in removing the excess keratin and outer layers of the epidermis in a controlled manner. As with other treatments for keratosis pilaris, the reports on this procedure are anecdotal and from small group observations. Instead of in-office microdermabrasion, another option is in-home personal exfoliation with a loofah sponge or a commercially available pad such as Buf-Puff. Newer available home therapies include gentle exfoliation with vacubrasion (fine diamond abrasives) home microdermabrasion systems. Often, vacubrasion and other skin vacuuming procedures combined with retinoid creams over the counter and lactic acid lotions are very effective in controlling keratosis pilaris.

Home therapies may include the following:

  • Exfoliation pads like Buf-Puff
  • Retinol creams
  • Gentle suction exfoliation including Vacubrasion
  • Topical emollients
  • Glycolic acid peels 10-20%
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Consultations

Consultation with a dermatologist is appropriate for refractory or widespread cases.[13]

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Diet

Keratosis pilaris has no dietary associations.

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Activity

Keratosis pilaris does not limit any patient activities.

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Complications

Complications from keratosis pilaris (KP) are infrequent. However, post inflammatory hypopigmentation or hyperpigmentation and scarring may occur.

A gradual loss of hair in affected facial areas, especially the lateral eyebrows, may be seen in ulerythema ophryogenes (keratosis pilaris atrophicans faciei).

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Prevention

In patients with keratosis pilaris (KP), measures should be taken to prevent excessive skin dryness. Mild soaps and cleansers should be used. Frequent application of emollients is very beneficial.

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Contributor Information and Disclosures
Author

Ally N Alai, MD, FAAD Medical Director, The Skin Center at Laguna; Former Professor, Department of Dermatology, Clinical Faculty and Preceptor, Department of Family Practice, University of California, Irvine, School of Medicine; Former Professor and Preceptor, Department of Family Practice Residency Training, Downey Medical Center; Expert Medical Reviewer, Medical Board of California; Expert Consultant, California Department of Consumer Affairs; Expert Reviewer, California Department of Registered Nursing

Ally N Alai, MD, FAAD is a member of the following medical societies: American Academy of Dermatology, American Society for MOHS Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven R Feldman, MD, PhD Professor, Departments of Dermatology, Pathology and Public Health Sciences, and Molecular Medicine and Translational Science, Wake Forest Baptist Health; Director, Center for Dermatology Research, Director of Industry Relations, Department of Dermatology, Wake Forest University School of Medicine

Steven R Feldman, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, North Carolina Medical Society, Society for Investigative Dermatology

Disclosure: Received honoraria from Amgen for consulting; Received honoraria from Abbvie for consulting; Received honoraria from Galderma for speaking and teaching; Received consulting fee from Lilly for consulting; Received ownership interest from www.DrScore.com for management position; Received ownership interest from Causa Reseasrch for management position; Received grant/research funds from Janssen for consulting; Received honoraria from Pfizer for speaking and teaching; Received consulting fee from No.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Arash Taheri, MD Research Fellow, Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

We authors appreciate the clinical photos supplied as a courtesy of The Skin Center at Laguna.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Dena Thompson, MS, and Arash Michael Saemi, MD, to the development and writing of this article.

References
  1. Hwang S, Schwartz RA. Keratosis pilaris: a common follicular hyperkeratosis. Cutis. 2008 Sep. 82(3):177-80. [Medline].

  2. Sardana K, Relhan V, Garg V, Khurana N. An observational analysis of erythromelanosis follicularis faciei et colli. Clin Exp Dermatol. 2008 May. 33(3):333-6. [Medline].

  3. Augustine M, Jayaseelan E. Erythromelanosis follicularis faciei et colli: relationship with keratosis pilaris. Indian J Dermatol Venereol Leprol. 2008 Jan-Feb. 74(1):47-9. [Medline].

  4. Poskitt L, Wilkinson JD. Natural history of keratosis pilaris. Br J Dermatol. 1994 Jun. 130(6):711-3. [Medline].

  5. Yosipovitch G, DeVore A, Dawn A. Obesity and the skin: skin physiology and skin manifestations of obesity. J Am Acad Dermatol. 2007 Jun. 56(6):901-16; quiz 917-20. [Medline].

  6. Arnold AW, Buechner SA. [Keratosis pilaris and keratosis pilaris atrophicans faciei]. J Dtsch Dermatol Ges. 2006 Apr. 4(4):319-23. [Medline].

  7. Mevorah B, Marazzi A, Frenk E. The prevalence of accentuated palmoplantar markings and keratosis pilaris in atopic dermatitis, autosomal dominant ichthyosis and control dermatological patients. Br J Dermatol. 1985 Jun. 112(6):679-85. [Medline].

  8. Jackson JB, Touma SC, Norton AB. Keratosis pilaris in pregnancy: an unrecognized dematosis of pregnancy?. W V Med J. 2004 Jan-Feb. 100(1):26-8. [Medline].

  9. Kragballe K, Steijlen PM, Ibsen HH, et al. Efficacy, tolerability, and safety of calcipotriol ointment in disorders of keratinization. Results of a randomized, double-blind, vehicle-controlled, right/left comparative study. Arch Dermatol. 1995 May. 131(5):556-60. [Medline].

  10. Use of Lasers for Becker's Nevus and Keratosis Pilaris. J Cutan Aesthet Surg. 2008 Jul. 1(2):112. [Medline]. [Full Text].

  11. Kaune KM, Haas E, Emmert S, Schon MP, Zutt M. Successful treatment of severe keratosis pilaris rubra with a 595-nm pulsed dye laser. Dermatol Surg. 2009 Oct. 35(10):1592-5. [Medline].

  12. Clark SM, Mills CM, Lanigan SW. Treatment of keratosis pilaris atrophicans with the pulsed tunable dye laser. J Cutan Laser Ther. 2000 Sep. 2(3):151-6. [Medline].

  13. Novick NL. Practical management of widespread, atypical keratosis pilaris. J Am Acad Dermatol. 1984 Aug. 11(2 Pt 1):305-6. [Medline].

 
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Close-up view of keratosis pilaris. Keratotic follicular-based erythematous papules are noted on upper arm.
Keratosis pilaris in characteristic location on outer upper arm of a 30-year-old woman.
Classic skin-colored bumps on upper arm of young white female twin. Image courtesy of The Skin Center of Laguna.
Keratosis pilaris on the upper arm of a twin female. Image courtesy of The Skin Center of Laguna.
Keratosis pilaris bumps on arm of a white female twin. Image courtesy of The Skin Center of Laguna.
Keratosis pilaris on upper arm. Image courtesy of The Skin Center of Laguna.
Keratosis pilaris on upper arm of twin. Image courtesy of The Skin Center of Laguna.
 
 
 
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