Overview

Keratosis pilaris is a common skin condition, but many people wonder: Will it ever go away? This article examines the long-term outlook of KP, including its progression with age and potential treatments that may be beneficial.

What is keratosis pilaris?

Keratosis pilaris or “chicken skin” is a common, harmless skin condition characterised by small, rough bumps that typically develop around hair follicles. These bumps are most often found on the upper arms, thighs, or buttocks, but can appear elsewhere on the body.¹ Children can sometimes get these small bumps on their cheeks.

Keratosis pilaris occurs when dead skin cells build up and block hair follicles with keratin, a protein found naturally in the skin, hair, and nails. Since there are thousands of these follicles over the body, multiple blockages can result in the dry, rough patches typical of this condition.² It's important to note that keratosis pilaris is not contagious and cannot be spread from one person to another.

Affected skin usually presents with painless, flesh-colored or slightly red papules, often accompanied by a dry, rough texture that resembles sandpaper. The bumps may appear reddish, flesh-colored, white, pinkish purple on lighter skin or darker (brownish black) on deeper skin tones.² While generally not itchy, some individuals may experience mild irritation. Symptoms often worsen in cold weather or dry climates and improve during warmer months. 

Who is most commonly affected? 

Keratosis pilaris (KP) can occur in people of all ages and ethnicities, but it most commonly appears during early childhood, often before age two, or around puberty.¹ Since it tends to start at a young age, it’s commonly observed in kids and teens. Over time, the condition often gets better on its own and may eventually fade, which is why it’s less frequently seen in adults.

Hormonal changes during puberty can cause flare-ups or worsen existing symptoms. When KP develops during the teenage years, it often improves significantly or resolves by the mid-20s. While many people see gradual improvement with age, the condition can persist into adulthood. The condition tends to occur more often in females than in males.

Although keratosis pilaris tends to improve gradually with age, several treatment options are available to help manage the symptoms and improve the skin’s appearance. These include daily moisturization, the use of exfoliating agents such as salicylic acid, and more advanced options like light-based therapies and laser treatments.³

The risk of developing keratosis pilaris is higher in individuals with certain underlying conditions or characteristics. These include:

• Having relatives with keratosis pilaris suggests a genetic tendency for the condition.
• Chronic dry skin
• A personal history of atopic dermatitis (eczema)
• Coexisting allergic conditions, such as asthma or hay fever
• Overweight or obesity
• Malnutrition
• Ichthyosis vulgaris, a genetic skin disorder characterised by extremely dry, scaly skin
• Treatment with vemurafenib (Zelboraf®), a targeted therapy for metastatic melanoma, has been associated with the onset of keratosis pilaris in some cases¹
• It may also occur alongside conditions like Down syndrome and Noonan syndrome

Etiology

Keratosis pilaris is a common skin condition, though its precise cause remains unclear. It is passed down through families in an autosomal dominant manner. Studies have found associations between keratosis pilaris and changes in the filaggrin gene, along with abnormalities in the Ras signalling pathway.³

 These genetic changes may contribute to the follicular abnormalities characteristic of the condition. Keratosis pilaris is frequently seen in individuals with atopic dermatitis, and this relationship, along with filaggrin mutations, points to a disruption in the normal function of the skin’s epithelial barrier as a key factor in its development.³

Pathophysiology

The exact processes behind keratosis pilaris are still not completely known. However, the most widely accepted explanation involves abnormal keratinisation of the follicular epithelium, which leads to the formation of a plug within the hair follicle opening. These keratin plugs cause redness and scaling around the follicles.³

Additionally, they contribute to the development of inflammatory papules, which are a key feature of the condition. Coiled hairs are often found inside the lesions and may contribute to both the inflammation and the abnormal keratin buildup seen in keratosis pilaris.³

Histopathology

A punch biopsy is generally unnecessary for diagnosing keratosis pilaris. However, if performed, the histological examination would reveal significant plugging of the hair follicle openings with excess keratin. The epidermis would show thickening (acanthosis) and an increased granular layer (hypergranulosis). Additionally, there would be a presence of lymphocytic infiltration in the dermis, reflecting an inflammatory response associated with the condition.³

Diagnosis and clinical features

A comprehensive history and physical examination are essential for diagnosing keratosis pilaris. The healthcare provider should gather information about the onset, appearance, location, and any associated symptoms of the skin lesions. It is also important to ask about any home remedies used and the impact of the condition on the patient’s daily life.³

Keratosis pilaris most commonly appears during adolescence and is often linked with atopic dermatitis.³ Patients typically report the presence of red, bumpy skin that is usually painless and not itchy. This condition frequently affects the outer surfaces of the upper arms and thighs, as well as the buttocks, but it can also involve the face, trunk, and lower legs. 

During the examination, the physician should look for numerous small, inflamed bumps centred around hair follicles in these common areas. Some lesions may show redness and swelling if the patient has squeezed or irritated them. Often, patients seek medical advice more because of concern about the appearance of the bumps rather than any discomfort caused by the lesions themselves.

Long-term outlook and natural course

Survey-based findings provide valuable insights into the natural course of keratosis pilaris (KP), highlighting how it commonly presents, changes with age, and may be influenced by seasonal factors.

A survey was conducted among 83 individuals from South Buckinghamshire who had been diagnosed with keratosis pilaris (KP) within the last 20 years. Of the 50 questionnaires returned, 49 contained valid data and were analysed. Participants’ ages ranged from 18 months to 25 years, with females representing 61% and males 39%.⁴

The majority of cases (51%) reported KP onset during the first decade of life, followed by 35% in the second decade, 12% in the third, and 2% in the fourth decade. The arms were the most commonly affected area (92%), with the legs (59%), face (41%), buttocks (30%), and eyebrows (8%) also involved.⁴

A family history of KP was present in 39% of participants, while 55% had no known family history, and 6% were uncertain. Additionally, 37% reported a personal history of atopic conditions, 16% noted accompanying dry skin, and 47% had neither condition.⁴

Seasonal changes in KP symptoms were reported by 80% of respondents; 49% noticed improvement during summer months, whereas 47% experienced worsening in winter. Regarding the course of the condition over time, 35% observed improvement (with the average age of improvement being 16 years), 43% reported no change, and 22% felt their symptoms had worsened.⁴

Complications and patient considerations

Although keratosis pilaris is not known to cause major medical complications, it can lead to emotional or psychological distress due to its appearance. In some individuals, repeated picking or scratching of the bumps may result in scarring, hyperpigmentation, or persistent redness. These effects underscore the importance of proper skin care and avoiding trauma to the affected areas.

When educating patients, it’s important to highlight that keratosis pilaris is a long-lasting but harmless condition, and there is currently no permanent cure. Many individuals experience gradual improvement with age, but flare-ups can still occur, particularly in dry or cold climates. Treatments are intended to improve the texture and appearance of the skin, not to cure the condition. Setting realistic expectations can help reduce frustration, and patients should be encouraged to be consistent with gentle skincare routines while avoiding harsh treatments or manipulation of the lesions.

Treatment and management

Although keratosis pilaris is a benign and often symptom-free condition that typically improves with age, some individuals may seek treatment for cosmetic reasons. In most cases, active treatment is not medically necessary. However, basic skin care practices, such as maintaining proper hygiene, avoiding aggressive scrubbing or picking at the bumps, and using mild, fragrance-free cleansers, can support the skin’s healing process.

For those who wish to reduce the rough texture and appearance of lesions, topical therapies are commonly used. These include moisturisers and exfoliating agents, also known as keratolytics. Products containing ingredients like urea (20%) or salicylic acid (6%) have been shown to improve skin smoothness over time. Additional treatment options may involve topical retinoids, vitamin D3-based products, or more advanced interventions such as laser therapy. However, it's important to note that while these treatments may offer cosmetic improvement, there’s currently no definitive cure for keratosis pilaris, and clinical trials supporting these therapies are limited.

Some individual reports have described the successful use of topical tazarotene 0.01%, applied nightly, with visible reduction of bumps in two weeks and complete resolution within four to eight weeks. Chemical peels using high-concentration glycolic acid (70%) for short durations have also been reported to improve the skin's appearance in some patients.⁵ Additionally, various types of laser therapy, including pulsed dye, alexandrite, Nd: YAG, and fractional CO₂ lasers, have been explored with promising outcomes in select cases.

Prognosis

Keratosis pilaris usually starts during childhood and gets better slowly over time. In a study assessing the progression of the condition, approximately 35% of individuals experienced noticeable improvement over time. However, for 43%, the symptoms remained unchanged, while around 22% reported worsening of their skin condition as they aged.³

Seasonal variations can also influence the severity of keratosis pilaris. Many individuals notice that their symptoms improve during the warmer summer months and become more pronounced in winter. Specifically, 49% of those surveyed reported improvement in summer, while 47% experienced a flare-up during colder weather. These seasonal fluctuations are likely linked to decreased humidity and moisture levels in the air during winter.³

Summary

While keratosis pilaris tends to improve with age, especially after adolescence, it may persist into adulthood for some. Fortunately, there are several treatments available that can help control the symptoms and gradually enhance the skin’s appearance