Abstract

Background

Waiting times for specialist consultations influence timely diagnosis and appropriate disease management. Given the high prevalence and morbidity associated with skin diseases, prolonged waiting times to access dermatological care have important public health implications. In South Africa, data describing waiting times for dermatology services are lacking.

Methods

This descriptive cross-sectional study assessed waiting times for private-sector dermatology services across South Africa. All dermatology practices listed on Medpages were contacted telephonically on three separate occasions between 01 and 31 August 2023. Using a standardised script, appointment availability was requested for a fictitious patient under three clinical scenarios: a routine skin check, a changing pigmented lesion suggestive of possible melanoma and a cosmetic consultation for neurotoxin injection.

Results

A total of 192 dermatologists were included. The national median waiting time was 15 days (interquartile ranges [IQR] 5–48.3 days) for a routine skin check, 5 days (IQR 1–14 days) for suspected melanoma and 12 days (IQR 4–33.8 days) for cosmetic consultation. Waiting times varied widely across provinces, ranging from same-day access to delays exceeding 1 year. The longest median waiting time for routine consultations was observed in the Northern Cape (227 days), while the shortest was in Limpopo (2 days). Consultation fees also showed substantial interprovincial variation.

Conclusion

While overall waiting times appear acceptable at a national level, marked provincial disparities exist. Urgent cases are generally prioritised, yet prolonged delays in certain regions may compromise timely care, underscoring the need for targeted, context-specific interventions.

Contribution

This study provides the first national overview of private-sector dermatology waiting times in South Africa. It highlights significant geographic disparities in access to care within the private healthcare system and generates evidence to inform health service planning, workforce distribution and strategies to improve equitable access to dermatological services.

Introduction

Skin diseases are often underestimated yet constitute a substantial component of the global burden of disease. They are among the most prevalent medical conditions worldwide and are frequently associated with significant morbidity, either through visible disfigurement or persistent, distressing symptoms such as chronic pruritus.1 Across diverse geographic and socioeconomic settings, multiple authors have highlighted a mismatch between the high burden of skin disease and the limited availability of trained dermatologists.2,3

South Africa, classified as a low- to middle-income country, faces particular challenges in delivering adequate dermatological services. These challenges are compounded by a marked shortage of dermatologists relative to the size and needs of the population.4

Waiting times for specialist care are widely recognised as important indicators of healthcare access, system efficiency and service quality.5 Prolonged waiting times may delay diagnosis and initiation of appropriate treatment, potentially leading to disease progression, avoidable complications and poorer patient outcomes. Extended delays are also associated with increased patient dissatisfaction and reduced confidence in healthcare services.6 While waiting times for dermatology consultations have been investigated in several high-income and selected middle-income countries, there are currently no published data describing dermatology waiting times in South Africa.7

In a resource-constrained healthcare system characterised by high dermatological disease burden and limited specialist capacity, an understanding of waiting times is essential to identify gaps in service delivery and inequities in access to care. This study aims to determine waiting times for dermatology appointments in South Africa. By evaluating waiting times across different clinical indications and geographical regions within the private healthcare sector, this research seeks to generate data that may inform health service planning and contribute to strategies aimed at improving equitable access to dermatological care.

Research methods and design

Study design and setting
This descriptive cross-sectional study was conducted within the private healthcare sector across all nine provinces of South Africa.

Study objectives
The primary objective was to determine the average waiting time to obtain an appointment with a specialist dermatologist under three predefined clinical scenarios: (1) a routine dermatology consultation, (2) an urgent consultation for a changing pigmented lesion suggestive of possible melanoma, and (3) a cosmetic consultation for neurotoxin injection. Secondary objectives included comparison of waiting times across provinces, determination of consultation fees for routine visits nationally and by province and assessment of the proportion of practices willing to submit claims to medical insurers on behalf of patients.

Study population and sampling
All medical practitioners registered with the Health Professions Council of South Africa (HPCSA) as specialist dermatologists and practising in the private sector were eligible for inclusion. Neither the HPCSA nor the Colleges of Medicine of South Africa were able to provide a comprehensive database of private sector dermatologists. Participants were therefore identified using Medpages,8 the largest online directory of private medical practitioners in South Africa, where clinicians are listed by speciality.

General practitioners with a special interest in dermatology (so-called GP dermatologists) were excluded. Dermatologists practising exclusively in the public healthcare sector were also excluded, as they cannot be contacted directly to arrange private consultations. Only in-person consultations were considered; teledermatology services were excluded.

Data collection
Practice telephone numbers listed on Medpages were contacted telephonically by the investigator on three separate occasions to enquire about appointment availability for each of the three predefined scenarios. A standardised script was used for all calls. For each scenario, the earliest available appointment date was recorded; no appointments were confirmed or booked.

Calls were conducted on three separate weekdays between 01 August 2023 and 31 August 2023. Waiting time was calculated as the number of days between the date of the telephone call (day 0) and the proposed appointment date. Where more than one dermatologist practised at the same location, the earliest available appointment at that practice was recorded. Practices that could not be reached telephonically on three separate occasions were excluded.

Statistical analysis
Continuous variables were summarised using means with standard deviations (s.d.) for normally distributed data and medians with interquartile ranges (IQR) for non-normally distributed data. Data analysis was performed using Microsoft® Excel® (Version 2403). Spearman’s rank correlation coefficient was used to assess the strength of association for non-normally distributed variables and was calculated using the RANK.AVG and CORREL functions.9 Correlation coefficients were interpreted as follows: ± 0.90–1.00 very high, ± 0.70–0.89 high, ± 0.50–0.69 moderate, ± 0.30–0.49 low and ± 0.29–0.00 negligible.10

Ethical considerations
Ethical approval for the study was obtained from Stellenbosch University Health Research Ethics Committee (Reference number: S23/05/109). This study did not involve direct interaction with patients, access to patient records or the collection of personal health information. Practice staff were contacted telephonically using publicly available contact details to enquire about appointment availability. As no identifiable personal data were collected and no appointments were confirmed, the study was classified as minimal-risk research. Formal written or oral consent was therefore not required.

To maintain confidentiality, no personal identifiers of healthcare practitioners or practice staff were recorded. Data were anonymised at the point of collection, stored securely and analysed in aggregate form only.

Results

Study participants
A total of 246 dermatologists were identified on Medpages. Of these, 30 practised exclusively in the public sector and were excluded. Thirteen dermatologists could not be contacted on three separate occasions. One dermatologist was on maternity leave, one was on sabbatical and one had recently retired. Two dermatologists accepted referrals exclusively for Mohs micrographic surgery, one offered only cosmetic consultations, one accepted referral solely for laser treatments, and six were not accepting new patients at the time of contact. After exclusions, 192 dermatologists were included in the final analysis.

Geographic distribution of dermatologists
The provincial distribution of included dermatologists is presented in Table 1 and illustrated in Figure 1. Most dermatologists were located in Gauteng (37.5%), followed by the Western Cape (28.1%) and KwaZulu-Natal (17.7%). Smaller proportions were found in the Eastern Cape (5.2%), Free State (5.2%), Mpumalanga (2.6%), Limpopo (2.1%), North West (1.0%), and Northern Cape (0.5%).

Waiting times for dermatology consultations

Median waiting times for dermatology appointments varied widely both nationally and between provinces (Table 2), as illustrated in Figure 2. Nationally, the median waiting time was 15 days (IQR 5–48.3 days) for a routine skin check, 5 days (IQR 1–14 days) for a consultation for a changing pigmented lesion suggestive of possible melanoma and 12 days (IQR 4–33.8 days) for a cosmetic consultation. Provincial variation in waiting times for consultations for suspected melanoma and cosmetic neurotoxin consultations is shown in Figure 3 and Figure 4, respectively.

For routine skin checks, waiting times across individual practices ranged from same-day availability (0 days) to a maximum of 421 days. The provinces with the longest median waiting times for routine consultations were the Northern Cape (227 days), North West (43 days) and Eastern Cape (39 days). The shortest median waiting times were observed in Limpopo (2 days), Gauteng (7.5 days), and KwaZulu-Natal (11.4 days).

In 10 instances where the script for a changing pigmented lesion was used, practices with very long waiting times declined to provide an appointment date and instead advised consultation with a general practitioner, who could refer the patient urgently if deemed necessary. As no appointment dates were provided, these cases were excluded from the waiting-time analysis. These practices were located in the Free State (n = 2), Gauteng (n = 1), Northern Cape (n = 1), Western Cape (n = 3), KwaZulu-Natal (n = 2), and Mpumalanga (n = 1).

A strong negative correlation was observed between provincial contribution to gross domestic product (GDP) and median waiting times for routine skin checks (Spearman’s ρ = −0.78). In contrast, the correlation between the number of dermatologists per million population11 and routine waiting times was negligible (Spearman’s ρ = −0.13).

Consultation fees
The national median consultation fee for a routine dermatology visit in private practice was R1050.00 (IQR R900.00–R1263.00). Median consultation fees were highest in the Western Cape (R1250.00) and lowest in the Northern Cape (R800.00) (Table 3). There was a strong positive correlation between provincial GDP contribution and consultation fees (Spearman’s ρ = 0.82).

Most private dermatology practices required direct payment from patients at the time of consultation. Of the practices contacted, 55.2% (n = 106) did not submit claims to medical insurers on behalf of patients, while 41.7% (n = 80) did submit claims directly. A small proportion (2.6%, n = 5) were willing to submit claims only for selected medical aid schemes. Billing information was not obtained from one practice.

Availability of cosmetic services
Eighty-five practices (44.3%) offered cosmetic consultations for neurotoxin injections, while 107 practices (55.7%) did not. No cosmetic consultation services were offered by dermatology practices in Limpopo, Mpumalanga, Northern Cape, or North West.

Discussion

The most striking finding of this study is that, while overall median waiting times for private dermatology consultations in South Africa appear acceptable, there is marked variation between provinces. Though inequality between the public and private healthcare sectors in South Africa is well recognised, this study highlights substantial inequity within the private sector itself, driven by geographic location. Important secondary findings include significant variation in consultation fees and the observation that only a minority of dermatologists in South Africa offer cosmetic services.

Waiting times in South Africa’s private healthcare sector
The median waiting time to see a dermatologist in South Africa’s private sector was 15 days (IQR 5–48.3 days) for a routine skin check, 5 days (IQR 1–14 days) for a suspected melanoma and 12 days (IQR 4–33.8 days) for a cosmetic consultation. When placed in an international context, these waiting times compare favourably. In the United States, average waiting times for new dermatology appointments are approximately 36 days, with reported ranges from 9 days to 120 days depending on the state.12 In Brazil, private-sector dermatology waiting times range between 2 and 15 working days, with regional variability.13

The relatively short overall waiting times observed in South Africa’s private sector are likely attributable to the higher concentration of dermatologists serving a comparatively small, insured population. According to Tiwari et al., South Africa has approximately 1.2 dermatologists per million population in the public sector compared with 20.1 per million in the private sector.11 Despite this disparity, both sectors remain under-resourced when compared with international benchmarks, with the World Health Organization suggesting an ideal ratio of approximately four dermatologists per 100 000 population.14

Provincial variation in waiting times
Substantial interprovincial differences were observed for routine dermatology consultations. The longest median waiting times were recorded in the Northern Cape (227 days), North West (43 days) and Eastern Cape (39 days), while the shortest were observed in Limpopo (2 days), Gauteng (7.5 days), and KwaZulu-Natal (11.4 days). Notably, a strong negative correlation was identified between provincial contribution to GDP and waiting times, with wealthier provinces experiencing shorter delays.

This association likely reflects the clustering of private dermatology services in economically stronger regions that offer greater professional and personal opportunities. The Northern Cape illustrates this disparity starkly: despite covering a vast geographic area, it contributes only 2.2% to national GDP and is served by a single private-sector dermatologist, resulting in the longest waiting times observed in this study. Similar associations between socioeconomic factors and access to specialist care have been reported internationally.15

In contrast, no meaningful correlation was observed between the number of dermatologists per million population and waiting times. This may reflect the fact that only a minority of South Africans access private healthcare, rendering total provincial population figures a poor proxy for demand. Limpopo, for example, is the fifth most populous province yet has only four private dermatologists and the shortest waiting times, likely due to its low medical aid coverage (9.5%).16 This finding aligns with international literature demonstrating that specialist density alone does not necessarily translate into improved access, though the underlying drivers differ between healthcare systems.13,17

Urgent referrals versus cosmetic consultations
Private dermatology practices appear to prioritise urgent over routine consultations. International melanoma guidelines recommend that patients with suspected melanoma be assessed by an appropriate healthcare professional within 2 weeks of suspicion.18 In this study, patients with a suspected melanoma were generally seen more rapidly than those seeking routine or cosmetic care. However, only Mpumalanga, Limpopo, KwaZulu-Natal, and Gauteng consistently met this 2-week benchmark.

Of concern, 18 practices offered appointment dates exceeding 60 days for suspected melanoma without advising alternative or interim medical assessment. Delays in melanoma diagnosis and definitive treatment are associated with increased morbidity and mortality,19,20 underscoring the clinical implications of these findings. The Northern Cape practice was unable to offer an appointment and appropriately advised urgent assessment by a general practitioner with onward referral if required.

The Free State was the only province where cosmetic consultations were, on average, available sooner than consultations for suspected melanoma. This inversion of clinical priority is concerning and highlights the need for clearer triage pathways within private practices.

In contrast to countries such as Canada, where specialist access requires referral from a primary care provider,3 patients in South Africa’s private sector may self-refer. While this improves access, it may also result in specialist appointments being occupied by conditions manageable at primary care level, potentially contributing to extended waiting times for more urgent cases.

Cost of care and insurance coverage
Most private dermatology practices (58.3%) required direct patient payment and did not submit claims to medical insurers. This may reflect administrative burden, delayed reimbursement or discrepancies between insurer tariffs and actual consultation fees. Medical aid reimbursement rates are often substantially lower than the median consultation fee of R1095.00, potentially creating further barriers to access.

Consultation fees broadly reflected provincial economic status, with the highest median fees observed in the Western Cape, Gauteng, and KwaZulu-Natal, and the lowest in Limpopo, Northern Cape and North West. Mpumalanga was a notable exception, demonstrating relatively high consultation fees despite a lower provincial GDP.21

Cosmetic dermatology services
Only 44.7% of dermatologists in this study offered cosmetic procedures, and no cosmetic services were available in four provinces. This is notable given the global expansion of medical aesthetic procedures, including neurotoxin injections and dermal fillers, over the past two decades.22

Cosmetic dermatology is not formally included in the College of Medicine of South Africa’s dermatology curriculum,23 which may contribute to variable confidence and uptake among specialists. Furthermore, cosmetic procedures in South Africa are frequently provided by general practitioners, dentists and plastic surgeons. In the context of limited specialist capacity and a high burden of medical and surgical dermatological disease, the role of dermatologists in cosmetic medicine remains contested.

Limitations and future directions
This cross-sectional study captured dermatology waiting times during a single time period (August 2023) and therefore does not reflect temporal variation or trends over time. Waiting times may also have been influenced by residual effects of the coronavirus disease 2019 (COVID-19) pandemic on healthcare delivery and workforce availability. Longitudinal studies would be better suited to evaluate changes in waiting times over time and to corroborate the findings of this study.

Identification of dermatology practices relied on Medpages, which lists most private-sector dermatologists in South Africa but includes only those practitioners who have consented to share their contact details. It is therefore possible that some eligible practices were not captured, which may have resulted in under-representation in certain regions.

This study was limited to the private healthcare sector. As the majority of South Africans receive care within the public healthcare system, these findings cannot be generalised to dermatology services nationally. Future research should assess waiting times in the public sector and explore disparities between public and private dermatology services. In addition, qualitative studies examining patient experiences and perceptions of waiting times would provide valuable context to the quantitative findings.

Teledermatology services were not assessed in this study. The inclusion of virtual dermatology consultations may influence access to care and reduce waiting times, particularly in underserved or geographically remote areas. International evidence suggests that teledermatology can reduce unnecessary in-person consultations and improve cost-effectiveness,24 and its role within the South African context warrants further investigation.

Conclusion

This study demonstrates that, while urgent dermatological conditions are generally prioritised over routine and cosmetic consultations in South Africa’s private healthcare sector, access to care varies markedly by geographic location. Across all provinces, waiting times for dermatology consultations showed substantial variability, ranging from same-day access to delays exceeding 1 year. A key finding is the strong association between provincial economic strength and waiting times, with provinces contributing less to national GDP experiencing longer delays.

These disparities highlight inequities within the private healthcare sector itself, beyond the well-recognised divide between public and private care. Though overall median waiting times appear acceptable at a national level, prolonged delays in certain provinces raise concerns regarding timely diagnosis and management, particularly for potentially life-threatening conditions such as melanoma.

The findings underscore the need for targeted, context-specific strategies to improve equitable access to dermatological care, including workforce distribution, service organisation and referral pathways. Future research should incorporate longitudinal designs, public-sector analyses and qualitative assessments of patient experiences to better inform policy development and health system planning aimed at strengthening dermatology services and reducing geographic inequities in South Africa.

Acknowledgements

This article is based on research originally conducted as part of Ruan S. de Jager’s master’s thesis titled ‘Waiting Times to see a private dermatologist in South Africa: A cross-sectional survey’, submitted to the Faculty of Medicine and Health Sciences, Stellenbosch University, in 2024. The thesis is currently unpublished and not publicly available. The thesis was supervised by Dr Willem Izak Visser. The thesis was reworked, revised and adapted into a journal article for publication. The author confirms that the content has not been previously published or disseminated and complies with ethical standards for original publication.

During the preparation of this work, the author used ChatGPT, 5.2 for language editing, improvement of clarity, and refinement of structure in sections. The tool was not used for data collection, data analysis, statistical calculations, or generation of study results. The content was reviewed and edited by the authors, who take full responsibility for its accuracy.

Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

CRediT authorship contribution
Ruan S. de Jager: Conceptualisation, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualisation, Writing – original draft and Writing – review & editing. Nicola A. Gray: Supervision and Writing – review & editing. Willem I. Visser: Conceptualisation, Methodology, Supervision and Writing – review & editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication and take responsibility for the integrity of its findings.

Data availability
The authors declare that all data that support this research article and findings are available in the article and its references.

Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings, and content.

Funding Statement

Funding information This work was self-funded with partial funding from a grant from the Dermatology Society of South Africa (DSSA).

Footnotes

How to cite this article: De Jager RS, Gray NA, Visser WI. Waiting time to see a dermatologist in South Africa: A cross-sectional survey. J Coll Med S Afr. 2026;4(1), a359. https://doi.org/10.4102/jcmsa.v4i1.359

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First published at https://pmc.ncbi.nlm.nih.gov/articles/PMC13058494/

The post Waiting time to see a dermatologist in South Africa appeared first on Dermaporium.

A 45-year-old man born of a non-consanguineous marriage was referred for treatment of “atypical warts” on his hands, elbows, and axillae since childhood. These lesions were asymptomatic with no associated pruritus, pain, or bleeding. The patient had no previous treatment and no other medical comorbidities, and he denied a family history of similar skin lesions.

On clinical examination, the patient had a hoarse voice, skin-colored verrucous papules on the dorsal aspects of his hands, and hyperkeratotic verrucous plaques on elbow extensor surfaces as well as both axillae and his gluteal cleft (Figure 1). There were very subtle papular beads on the eyelid margins, and the oral mucosa was unaffected. Physical examination of other systems was unremarkable, and human immunodeficiency virus (HIV) and syphilis serology were negative.

Figure 1
(a) Verrucous papules on the dorsal aspect of hands bilaterally. (b) Symmetrical verrucous papules and plaques on bilateral elbows and axillae. (c) Subtle papular beading of eyelids

A biopsy specimen obtained from a verrucous plaque on the elbow is shown in Figure 2.

Figure 2
(a) Photomicrograph depicting acanthosis and hyperkeratosis of the epidermis. Vertically orientated deposits of faint eosinophilic, hyaline material fill the papillary and superficial dermis (hematoxylin and eosin, ×40). (b) Hyaline material arranged concentrically around blood vessels and eccrine glands (periodic acid-Schiff, ×100). PAS stain. (c) Close up micrograph of papillary dermis (hematoxylin and eosin, ×100)

A. Cutaneous amyloidosis
B. Lipoid proteinosis
C. Acral persistent papular mucinosis
D. Multicentric reticulohistiocytosis
E. Verruca vulgaris

Diagnosis

B. Lipoid proteinosis

Microscopic findings

The epidermis displays acanthosis and hyperkeratosis. Vertically orientated deposits of faint eosinophilic, hyaline material fill the papillary and superficial dermis. The same material involves the deeper dermis, associated with small blood vessels and the perineurium of nerves and arranged concentrically around eccrine glands. This material is strongly periodic acid–schiff (PAS) positive and diastase resistant, while staining with Congo Red is negative. Immunohistochemistry confirms the presence of Type IV collagen in the material.

Discussion

Lipoid proteinosis (also called “lipoidosis cutis et mucosae” or Urbach-Wiethe disease) is an autosomal recessive genodermatosis.1 Mutations in the extracellular matrix 1 (ECM1) gene on chromosome 1q21 cause this condition. Resultant dysfunction of the ECM1 protein is associated with multisystem disease involving the skin, eye, oropharynx, larynx, and brain.1

A case series of 24 patients from the Namaqualand area in South Africa highlights the clinical variability of lipoid proteinosis.2 The patient described above had a lifelong history of hoarse voice, a consistent feature of the disease. Other typical findings in the above patient include verrucous papules and plaques (Figure 1), subtle beading of the eyelid margins.2 Pustules, vesicles, and bullae are typical childhood features of lipoid proteinosis and are not usually present in adults. Other lipoid proteinosis features absent in this case include cutaneous scarring, alopecia, recurrent salivary gland swelling, a thickened frenulum with decreased tongue movement, stridor, and epilepsy.2 Neuropsychiatric and ophthalmologic manifestations were lacking in this patient but have been described elsewhere.3, 4

Although this patient was initially referred with warts, the symmetry and long duration of the lesions suggested a different diagnosis. Acral persistent papular mucinosis (APPM) is a subtype of localized lichen myxedematous that presents with asymptomatic skin-colored papules confined to the dorsal hands, wrists, and forearms.5 Unlike the above case, other areas such as the axillae and eyelid margins are not involved. Histologically APPM is characterized by well-circumscribed foci of mucin in the papillary and mid-dermis.4

Multicentric reticulohistiocytosis is a rare histiocytosis that mainly affects the skin and joints. Patients can present with skin colored to red-brown papules and nodules on the face, hands, neck, and trunk. Patients may also have nonspecific systemic symptoms, such as fever, malaise, and weight loss, as well as a destructive arthritis. Histologically, multicentric reticulohistiocytosis is characterized by aggregates of foreign body type giant cells, with eosinophilic ground-glass or foamy-vacuolated cytoplasm.5

As clinical manifestations of lipoid proteinosis are present from childhood, it is surprising that this patient presented for the first time at the age of 45 years. Although there is no specific treatment for lipoid proteinosis, the use of oral steroids, intralesional heparin, CO2 laser, and dermabrasion of the skin has been reported.6 This patient indicated satisfaction and relief at finally receiving a diagnosis and declined treatment. He also declined referral to a genetic counselor, as he does not intend to have children. This case of lipoid proteinosis in a skin of color will add to the image repository and aid dermatologists in improving competency.

Acknowledgment

Written consent obtained from the patient as well as ethical approval from Stellenbosch Health Research Ethics Committee (HEA-2022-26871 reference).

References

1. Chan I, Liu L, Hamada T, Sethuraman G, McGrath JA. The molecular basis of lipoid proteinosis: mutations in extracellular matrix protein 1. Exp Dermatol. 2007; 16(11): 881–90. https://doi.org/10.1111/j.1600-0625.2007.00608.x
2. Van Hougenhouck-Tulleken W, Chan I, Hamada T, Thornton H, Jenkins T, WH ML, et al. Clinical and molecular characterization of lipoid proteinosis in Namaqualand, South Africa. Br J Dermatol. 2004; 151(2): 413–23. https://doi.org/10.1111/j.1365-2133.2004.06076.x
3. Koen N, Fourie J, Terburg D, Stoop R, Morgan B, Stein DJ, et al. Translational neuroscience of basolateral amygdala lesions: studies of Urbach-Wiethe disease. J Neurosci Res. 2016; 94(6): 504–12. https://doi.org/10.1002/jnr.23731
4. Harris JE, Purcell SM, Griffin TD. Acral persistent papular mucinosis. J Am Acad Dermatol. 2004; 51(6): 982–8. https://doi.org/10.1016/j.jaad.2004.07.002
5. Tajirian AL, Malik MK, Robinson-Bostom L, Lally EV. Multicentric reticulohistiocytosis. Clin Dermatol. 2006; 24(6): 486–92. https://doi.org/10.1016/j.clindermatol.2006.07.010
6. Rao RS, Betkerur SS, Babu C, Sudha V. Lipoid proteinosis. J Oral Maxillofac Pathol. 2009; 13(2): 81–4. https://doi.org/10.4103/0973-029X.57675

First published at https://onlinelibrary.wiley.com/doi/10.1111/ijd.16679

The post Verrucous papules and plaques in a middle-aged man appeared first on Dermaporium.

Jennifer K. van Heerden, Alistair G.B. Broadhurst, Ruan S. de Jager, Wesley du Plessis, Nabilah Ebrahim, Ayanda T. Mnguni, Denzil Schietekat, Graeme Meintjes
Received: 21 Mar. 2023; Accepted: 08 May 2023; Published: 13 June 2023

Copyright: © 2023. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Cutaneous tuberculosis is an infrequent form of extra-pulmonary tuberculosis, even in high-prevalence settings. We present the case of a patient living with advanced HIV who developed extensive cutaneous tuberculosis. The polymorphic skin lesions were the most striking clinical manifestation of underlying disseminated tuberculosis.

Contribution: This case report highlights an unusual presentation of tuberculosis. Cutaneous tuberculosis has a wide spectrum of clinical presentations and may be under-recognised by clinicians. We recommend early biopsy for microbiological diagnosis.

Background

Tuberculosis (TB) remains a significant contributor to the global burden of disease and an estimated 10.6 million people fell ill with TB in 2021 (95% uncertainty interval: 9.9–11 million).1 Despite the high incidence of TB, often occurring in the setting of human immunodeficiency virus (HIV) co-infection, cutaneous TB is infrequent, comprising less than 2% of all extra-pulmonary forms of TB.2,3,4 As an infrequent and possibly under-recognised presentation of TB, there is a paucity of clinical and microbiological data on cutaneous TB in South Africa.

Cutaneous TB predominantly refers to skin disease caused by Mycobacterium tuberculosis (MTB); although, rarely, it can be caused by Mycobacterium bovis or develop from the attenuated form of M. bovis contained in the bacillus Calmette-Guerin (BCG) vaccine.4 Additionally, cutaneous hypersensitivity reactions to antigen components of MTB are often included as forms of cutaneous TB.5 Cutaneous TB may have a wide variety of clinical presentations each with distinct morphologies. This heterogeneity contributes to diagnostic difficulty, delayed diagnoses and ultimately a delay in initiation of effective treatment.

In light of this, we present a patient with an unusual presentation of cutaneous TB and highlight in the discussion the varied presentation of cutaneous TB, to contribute to the literature on this condition in South Africa. We emphasise the need for prompt recognition with early biopsy for microbiological diagnosis and determination of drug sensitivities to guide therapy.

Case presentation

A 38-year-old woman with advanced HIV disease (antiretroviral treatment experienced with treatment interruption) presented to Khayelitsha District Hospital with multiple cutaneous abscesses and associated constitutional symptoms of loss of appetite, loss of weight and night sweats. She reported a 3-month history of subcutaneous swellings with overlying hyperpigmentation affecting the arms, legs and buttocks, which subsequently formed spontaneous sinuses with drainage of purulent discharge.

The patient had a history of three previous episodes of drug-sensitive TB and had completed anti-TB treatment on all occasions (Table 1). She had recently been admitted to the surgical department where she was diagnosed with lower limb cellulitis complicated by soft tissue collections. During that admission, an incision and drainage procedure was performed, and the patient received an oral course of amoxicillin and clavulanic acid. Routine microscopy, culture and sensitivity of the pus did not identify any bacterial pathogen; however, a specific mycobacterial culture was not requested.

On admission to the internal medicine department, the patient had a tachycardia and a documented fever. She was cachectic with pallor and generalised lymphadenopathy. She had multiple skin lesions with a widespread distribution, affecting predominantly the lower limbs, perianal area, hands and face. The lower limb and perianal lesions involved subcutaneous collections with overlying hyperpigmented patches and central fluctuance. Certain of these collections had ulcerated with draining sinuses (Figure 1). Her facial lesions were hyperpigmented papules and plaques predominantly affecting the nasal area and associated with crusting suggestive of lupus vulgaris (Figure 2). Initial blood results showed acute kidney impairment, normocytic anaemia and an elevated C-reactive protein (Table 2).

Differential diagnosis

The differential diagnosis for this patient’s initial presentation was relatively broad, with infectious causes being the most important considerations.

Firstly, Staphylococcus aureus (including methicillin-resistant S. aureus) and Streptococcus pyogenes are the two most significant bacterial pathogens causing cutaneous abscesses.6 The negative bacterial cultures from the surgical drainage procedure and the chronic course of this presentation made us consider these causes unlikely. Secondly, although far less common, actinomycosis should be considered in this patient with significantly compromised immunity. This sub-acute or chronic suppurative, granulomatous infection caused by Actinomyces spp. may cause purulent, mass-like lesions with draining sinuses, similar to those described here.7

Mycobacterial opportunistic diseases such as MTB and nontuberculous mycobacteria are important aetiologies to consider, as well as other acid-fast bacilli, such as Nocardia spp., that may mimic TB presentations.8 Cutaneous syphilitic gumma, as a manifestation of tertiary syphilis, may also be considered.4

Deep fungal infections may have chronic cutaneous manifestations similar to this case.9,10 The subcutaneous mycoses such as sporotrichosis and mycetoma, as well as the systemic mycoses such as blastomycosis, cryptococcosis and histoplasmosis were all considered in this patient with profound immune compromise.4,9

Case management

Investigations
Laboratory findings are listed in Table 2. Blood cultures showed no growth after 5 days and serum cryptococcal antigen and rapid plasma reagin were non-reactive. The patient developed delirium on day three of admission, necessitating a lumbar puncture for cerebrospinal fluid (CSF) analysis that revealed a lymphocytic pleocytosis and an elevated protein that was suggestive of TB meningitis despite a negative CSF GeneXpert.

A pus aspirate from the largest skin lesion was performed, from which acid-fast bacilli were observed on microscopy and MTB complex was detected by real-time polymerase chain reaction (RT-PCR) testing, with the MTB determined as sensitive to rifampicin (Xpert® MTB/Rif Ultra, Becton Dickinson, United States). Prompt consultation with dermatology was sought for a skin biopsy, where MTB was detected by Xpert® MTB/Rif Ultra on the tissue sample and histopathology showed organising inflammation (Table 3).

Concurrently to the investigation of the skin lesions, laboratory evidence for disseminated TB was sought. A urinary lipoarabinomannan test was positive and a gastric aspirate demonstrated MTB complex, detected by Xpert® MTB/Rif Ultra, with MTB complex isolated by mycobacterial culture. Radiological investigations provided further evidence supporting a diagnosis of disseminated TB with upper lobe cavitation seen on chest radiography and multiple hypoechoic splenic lesions detected by abdominal ultrasound (Table 4).

Outcome and follow-up
The patient was started on anti-TB therapy with rifampicin, isoniazid, ethambutol and pyrazinamide. Corticosteroids were added to the treatment regimen after TB meningitis was diagnosed. The patient was transferred to a designated TB hospital where she continued anti-TB therapy and antiretroviral treatment was subsequently initiated. She had a good clinical response to treatment with marked improvement in all skin lesions and no neurological impairment on discharge from this facility. The discharge plan was to complete a total duration of 9 months of anti-TB therapy on an outpatient basis.

Discussion

This case report demonstrates that multiple cutaneous abscesses in an immunosuppressed individual should alert the treating clinician to consider cutaneous TB. However, this is only one possible form of cutaneous TB as there are many varied presentations of the condition, depending on multiple factors such as the route of transmission, the host’s cellular immunity, the proximity to lymph nodes and the microbial virulence.11

The spectrum of cutaneous TB ranges from inflammatory papules and verrucous plaques to chronic ulcerative lesions and cold abscesses.3,4,11 Cutaneous TB can be broadly categorised according to the mechanism of infection (outlined in Table 5) as this determines the type of lesion.12 For example, spread from an exogenous source (direct inoculation of bacilli) may cause a tuberculous chancre, whereas spread from an endogenous source may cause other manifestations of cutaneous TB, such as lupus vulgaris. Although the mode of infection may not be clear in all cases, in our patient the spread was almost certainly endogenous via haematogenous dissemination.4,11

In another classification analogous to the Ridley and Jopling classification for leprosy, the bacterial load can be used to classify cutaneous TB. Multibacillary forms include scrofuloderma, acute miliary tuberculosis and tuberculous gumma, whereas paucibacillary forms include verrucous tuberculosis and tuberculids.4,5 This classification also provides insight into the immune pathogenesis of cutaneous TB and its relationship to the patient’s cellular immunity to MTB. For example, tuberculids, a paucibacillary form of cutaneous TB, develop as immunological reactions to antigenic components of mycobacteria and usually occur in patients with a good cellular immunity.13 Conversely, in our patient who was severely immunocompromised, the lesions were multibacillary, as evidenced by the positive stain for acid-fast bacilli on the pus aspirated.

The multiple subcutaneous tuberculous abscesses in our patient are analogous to ‘tuberculous gumma’, lesions that characteristically affect individuals during periods of decreased cellular immunity, such as advanced HIV.11 Tuberculous gumma typically affects the trunk and lower extremities and may ulcerate and drain caseous material or pus.11 Another manifestation of cutaneous TB with a similar mechanism of spread and affecting a similar patient population is acute miliary cutaneous TB, where lesions appear as generalised papules, vesicles or pustules.12,14 These two manifestations of cutaneous TB are important to recognise as they may be associated with poor outcomes if therapy is delayed given underlying disseminated TB.

The pattern of cutaneous facial involvement observed in our case was suggestive of lupus vulgaris; however, other forms of cutaneous TB may present similarly and were considered as possible alternative diagnoses. For example, TB cutis orificialis may cause ulcerative cutaneous and mucosal lesions in periorificial areas and usually occurs in individuals with TB at other sites as well as those with impaired immunity.3,4 Additionally, non-mycobacterial cutaneous manifestations of systemic diseases such as syphilis and systemic mycoses formed an important part of the differential diagnosis of the facial lesions in this case.3,4,5

It is imperative to obtain early tissue samples in patients with suspected cutaneous TB. Culture remains the gold standard for making a microbiological diagnosis of TB; however, nucleic acid amplification testing (such as by the Xpert® MTB/Rif Ultra test) has been shown to be a sensitive and specific diagnostic test on pus aspirates as well as tissue homogenate.2,15,16 Xpert® MTB/Rif Ultra performed on both the pus aspirate and tissue were positive for MTB in our patient. This test has the benefit of rapid turnaround time with rifampicin sensitivity testing, allowing for early treatment. Histopathology of cutaneous TB shows inflammation and, classically, caseating granulomas.4 The absence of caseating granulomas in our patient is unusual; however, it is reported in approximately 10% of cases of cutaneous TB and likely related to profound immunosuppression in our patient.17

In our patient, the subcutaneous abscesses present during the previous admission that did not resolve with incision, drainage and antibiotics were almost certainly a missed manifestation of cutaneous TB as no TB tests were requested at the time. This phenomenon is described in other case reports, where patients with cutaneous TB often receive multiple courses of antibiotics prior to diagnosis.2 Although S. aureus was cultured on pus aspirate in our case, it was not considered causative but rather a secondary infection that entered via a draining sinus.

Treatment of cutaneous TB does not differ from other forms of TB and our patient showed a good response to effective combination therapy. Concurrent TB at other sites should be fully investigated as this may guide the duration of treatment and the need for adjuvant glucocorticoids.

Acknowledgements

The authors wish to thank the dedicated staff at Khayelitsha District Hospital, Tygerberg Hospital and D.P Marais Hospital for their role in the care of the patient described in this case report.

Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Authors’ contributions
J.K.v.H. wrote the case report. G.M., A.G.B.B., A.T.M., W.d.P., D.S., N.E. and R.S.d.J. critically reviewed the manuscript. All authors approved the final version.

Ethical considerations
Ethical clearance to conduct this study was obtained from the Stellenbosch University Health Research Ethics Committee (No. C22/10/031).

Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability
The authors confirm that the data supporting the findings of this study are available within the article.

Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

References

1. World Health Organization (WHO). Global Tuberculosis report 2022 [homepage on the Internet]. 2022 [cited 2022 Dec 18]. Available from: https://www.who.int/publications/i/item/9789240061729
2. Tshisevhe V, Mbelle N, Peters RPH. Cutaneous tuberculosis in HIV-infected individuals: Lessons learnt from a case series. South Afr J HIV Med. 2019;20(1):1–3. https://doi.org/10.4102/sajhivmed.v20i1.895
3. Van Zyl L, Du Plessis J, Viljoen J. Cutaneous tuberculosis overview and current treatment regimens. Tuberculosis. 2015;95(6):629–638. https://doi.org/10.1016/j.tube.2014.12.006
4. De Brito AC, Oliveira CM, Unger DAA, Bittencourt M. Cutaneous tuberculosis: Epidemiological, clinical, diagnostic and therapeutic update. An Bras Dermatol. 2022;97(2):129–144. https://doi.org/10.1016/j.abd.2021.07.004
5. Moche M. Clinical and immuno-pathological study of cutaneous tuberculosis in the Johannesburg area. Johannesburg: University of Witwatersrand; 2009.
6. Kobayashi SD, Malachowa N, DeLeo FR. Pathogenesis of staphylococcus aureus abscesses. Am J Pathol. 2015;185(6):1518–1527. https://doi.org/10.1016/j.ajpath.2014.11.030
7. Cunha F, Sousa DL, Trindade L, Duque V. Disseminated cutaneous actinomyces bovis infection in an immunocompromised host: Case report and review of the literature. BMC Infect Dis. 2022;22(1):310. https://doi.org/10.1186/s12879-022-07282-w
8. Jones N, Khoosal M, Louw M, Karstaedt A. Nocardia infectious as a complication of HIV in South Africa. J Infect. 2000;41(3):232–239. https://doi.org/10.1053/jinf.2000.0729
9. Rivitti EA, Criado PR, Hall BJ. Deep fungal infections. In: Hall JC, editor. Skin infections: Diagnosis and treatment. Cambridge: Cambridge University Press; 2009; p. 96–116.
10. Gonzalez Santiago TM, Pritt B, Gibson LE, Comfere NI. Diagnosis of deep cutaneous fungal infections: Correlation between skin tissue culture and histopathology. J Am Acad Dermatol. 2014;71(2):293–301. https://doi.org/10.1016/j.jaad.2014.03.042
11. Dos Santos JB, Figueiredo AR, Ferraz CE, Oliveira MH, Silva PG, Medeiros VL. Cutaneous tuberculosis: Epidemiologic, etiopathogenic and clinical aspects – part I. An Bras Dermatol. 2014;89(2):219–228. https://doi.org/10.1590/abd1806-4841.20142334
12. Macgregor RR. Cutaneous tuberculosis. Clin Dermatol. 1995;13(3):245–255. https://doi.org/10.1016/0738-081X(95)00019-C
13. Dhattarwal N, Ramesh V. Tuberculids: A narrative review. Indian J Dermatol. 2023;14(3):320. https://doi.org/10.4103/idoj.idoj_284_22
14. Viljoen C, Dladla K, Francis I, Wainwright H, Meintjes G. A diffuse fine papular and Pustular Rash in a man with Advanced Human Immunodeficiency Virus and Diabetes. Clin Infect Dis. 2018;66(3):477–447. https://doi.org/10.1093/cid/cix710
15. Scott LE, Beylis N, Nicol M, et al. Diagnostic accuracy of Xpert MTB/Rif for extrapulmonary tuberculosis specimens: Establishing a laboratory testing algorithm for South Africa. J Clin Microbiol. 2014;52(6):1818–1823. https://doi.org/10.1128/JCM.03553-13
16. Antel K, Oosthuizen J, Malherbe F, et al. Diagnostic accuracy of the Xpert MTB/Rif Ultra for tuberculosis adenitis. BMC Infect Dis. 2020;20(1), 33. https://doi.org/10.1186/s12879-019-4749-x
17. Spelta K, Diniz LM. Cutaneous tuberculosis: A 26-year retrospective study in an endemic area of Tuberculosis, Vitória, Espírito Santo, Brazil. Rev Inst Med Trop Sao Paulo. 2016;58:49. https://doi.org/10.1590/S1678-9946201658049

First published at https://sajid.co.za/index.php/sajid/article/view/526/1222

The post Cutaneous tuberculosis appeared first on Dermaporium.

Skin Like Silk

Photographer: August de Richelieu 

Dr Ruan De Jager, a specialist dermatologist at Dermaporium, explains that winter weakens our skin’s barrier, making tightness, flaking, and irritation more noticeable.

“Winter is tough on the skin because almost everything around us becomes drier,” he says. “The air is colder, indoor heating dries the environment even more, and most people take hotter showers. All of that strips water from the outer layer of the skin.”

Thankfully, the answer doesn’t require a bulging bathroom cabinet. For most men, winter upkeep comes down to a few well-chosen habits, such as cleansing gently, replacing lost moisture, and protecting the skin from the sun.

“The goal is not to add 10 new products,” says Dr Ruan. “It is to stop stripping the skin and start replacing moisture properly.”

Begin by easing up on anything aggressive. Traditional bar soaps, strong scrubs, and very hot water can remove the skin’s natural oils. A gentle cleanser should leave the face clean, not feeling as though it has been angrily sandblasted.

Moisturiser is essential. Look for ingredients such as glycerin, ceramides, niacinamide, hyaluronic acid, and dimethicone, all of which help the skin retain water and support its protective barrier.

Tamsyn Van Wyk, a somatologist at Nuskinnovation, also recommends lactobionic acid, a gentle polyhydroxy acid with water-binding and antioxidant benefits.

“When temperatures drop, the skin loses moisture more easily due to cold air, lower humidity, and indoor heating,” she says. “Winter is the time to focus on hydration by using a richer moisturiser, avoiding overly harsh cleansers, and supporting the skin barrier with hydrating products.”

Men with oily skin should still moisturise. Your skin can be shiny and dehydrated at the same time, so opt for a lightweight lotion or gel-cream that restores hydration without venturing into greasy territory.

Anyone using retinoids, acne treatments or exfoliating acids may also need to use them less often if the skin becomes dry or sensitive. Sometimes your most sophisticated move can be knowing when to leave your face alone.

Slather That SPF On

Photographer: Anna Tarazevich

But sunscreen is for summer?

UV rays don’t take holidays.

“If I had to recommend just one habit, it would be wearing SPF every single day,” says Van Wyk. “Many people think sunscreen is only necessary in summer, but UV rays are present year-round and remain one of the biggest causes of premature ageing, pigmentation and skin cancer.”

Apply a broad-spectrum SPF 30 or higher to the face, ears, neck, and hands every day. If you spend long periods outdoors, remember to reapply throughout the day.

Winter Skin Tips and Tricks

• Dry skin? Choose a richer moisturiser containing ceramides, glycerin, hyaluronic acid, dimethicone or niacinamide.
• Oily or acne-prone skin? Look for a lightweight, non-comedogenic lotion or gel-cream. Oily skin can still be dehydrated.
• Sensitive? Avoid fragranced products, harsh scrubs, alcohol-heavy aftershaves, and strong exfoliating acids used too often.
• Rough hands, elbows, knees, and feet? Products containing urea or petrolatum can provide more intensive protection.
• When to see a professional? Redness, itching, burning, cracking, bleeding, or persistent flaking that does not improve after one or two weeks of gentle skincare.

Healthy Hair, Beard, and Scalp Care

Photographer: Mindaugas Lazdauskas

During the colder months, your scalp can become dry or irritated, and regular shaving may trigger redness, sensitivity, and ingrown hairs.

For a more comfortable shave, soften the beard area with warm water first and use a proper shaving cream or gel to reduce friction. Follow up with a moisturiser rather than an aftershave that burns. That bracing sting may feel reassuringly traditional, but it’s more likely a warning sign of irritation than proof that the product is working.

Men with beards should also pay attention to the skin beneath the hair. A beard may look impressive, but it does not grant you diplomatic immunity from dryness. Working a lightweight moisturiser into the skin beneath the beard can help reduce flaking and discomfort.

Maxime Yates, a somatologist at The Lotus Flower, is a strong advocate of microneedling for men concerned about patchy beards, scalp hair loss, and shaving-related skin concerns.

“It can help stimulate hair growth in the beard where there is patchiness, as well as support treatment for hair loss on the scalp,” she says. “It can also help with acne scarring, excessive oiliness, and ingrown hairs caused by shaving.”

However, because hair loss has many possible causes, a professional consultation should always come before beginning treatment.

Beard and Scalp Checklist

• Before shaving? Soften the beard with warm water and use shaving cream or gel.
• After shaving? Apply a soothing moisturiser.
• Beard dryness? Moisturise the skin beneath the hair.
• Patchiness or hair loss? Start with a professional assessment before treatment.

Why Winter Is Ideal for Microneedling

Photographer: Omar Medina

Microneedling creates tiny, controlled punctures in the skin using sterile needles. These micro-injuries encourage the skin’s natural repair response, including collagen and elastin production. For men seeking subtle, natural-looking improvements, it may help with fine lines, acne scarring, uneven texture, enlarged pores, excess oil, and ingrown hairs. It can also be used on certain body scars.

Cooler weather can make the temporary redness and warmth that follow treatment easier to tolerate.

“Winter is a good time for microneedling because the skin can look duller and drier, and there is generally less sun exposure,” Maxime explains. “People also tend to spend more time indoors, so there is less risk of having the treatment and then going to lie in the sun, which can also cause pigmentation.”

Before treatment, a numbing cream is usually applied. Some clients feel very little, while others describe the sensation as similar to sandpaper moving across the skin.

Afterwards, your face may look red and feel warm, rather like a mild sunburn. Over the next two or three days, your skin may feel dry or tight, and some light flaking may occur before your complexion feels refreshed again.

Note that microneedling is not suitable for everyone. Men with active acne, eczema, psoriasis, skin infections, a tendency towards keloid scarring, or compromised immune systems should discuss their suitability with a qualified practitioner.

Microneedling At A Glance

• May help with? Fine lines, acne scarring, texture, enlarged pores, excess oil, ingrown hairs, and selected hair-growth concerns.
• Downtime needed? A few days.
• Aftercare? Keep products gentle and follow professional advice carefully.

Why Winter Is Laser Season

Photographer: Anna Shvets

Winter is also a popular season for laser treatments because treated skin is more sensitive to UV exposure while healing. Spending less time in strong sunlight can make aftercare easier and help reduce the risk of post-inflammatory hyperpigmentation.

Laser therapies are used to treat sun damage, pigmentation, redness, uneven skin tone, enlarged pores, fine lines, acne scarring, and overall skin texture.

There has also been a shift in the way men view aesthetic treatments.

“More men recognise that skincare and aesthetic treatments are part of overall health and self-care rather than vanity,” says Tamsyn. “Many are looking for subtle, natural improvements that help them maintain healthy, youthful-looking skin rather than dramatically changing their appearance.”

Treatments such as Fotona StarWalker and Fotona4Glow may suit gentlemen looking for visible improvement with minimal downtime. The redness often settles by the following day, although the skin can feel slightly rough for a few days.

Retinoids, exfoliating acids, and other potentially irritating products may need to be paused before treatment. Afterwards, a barrier-repair moisturiser and careful sun protection are essential.

A consultation should always come first, as the right treatment depends on the concern, skin type, and medical history.

Before Booking a Laser Treatment

• What is being treated? Pigmentation, redness, enlarged pores, fine lines, acne scarring and uneven texture may require different technologies or settings.
• Is it right for your skin? Treatment choice should take your skin type, medical history, and risk of post-inflammatory pigmentation into account.
• What should you stop using? Retinoids and other active ingredients may need to be paused for several days beforehand and avoided until the skin has recovered.
• What will downtime look like? Most redness may settle by the following day, while mild roughness can last for a few days, often with little or no peeling.

Hibernate into a Handsomer Summer

Winter offers the perfect opportunity to repair and reset, giving you every chance to emerge in the warmer months looking dapper enough to have your friends ask, “What’s your secret?”

First published at https://yourluxury.africa/fashion-beauty/the-gentlemans-winter-glow-up-guide/

The post The Gentleman’s Winter Glow-Up Guide appeared first on Dermaporium.