Keratosis Pilaris Treatment & Management

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 ^[13] ) 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), azelaic acid, ^[14] 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. Chlorine dioxide complex cleanser has been reported as effective. ^[15]

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. ^{[16, 17]}

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. ^[18]

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.

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 two 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. ^{[19, 20]} More expansive and larger-scale studies are required to assess the efficacy of potential laser therapies for this chronic, relapsing skin condition. ^[21]

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%

Consultation with a dermatologist is appropriate for refractory or widespread cases. ^[22]

Keratosis pilaris has no dietary associations.

Keratosis pilaris does not limit any patient activities.

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.