Keratosis Pilaris: Causes, Symptoms, and Best Treatment Options

What is Keratosis Pilaris?

Keratosis pilaris is an extremely common and entirely harmless skin condition. It is characterized by the development of small, raised lesions (tiny follicular papules, to be precise) that give the skin a rough, bumpy texture. This texture is often compared to goosebumps or the surface of sandpaper. In fact, it is so prevalent in the general population that many dermatologists consider it more of a natural variation in skin appearance than a true medical disease. Estimates suggest that keratosis pilaris affects approximately 50–80% of adolescents and around 40% of adults at some point in their lives. This makes it one of the most widespread skin conditions in the world.

The condition is most commonly observed on the outer upper arms, thighs, and buttocks, though it can also appear on the face (particularly in younger children), the back, and occasionally other areas of the body. The characteristic rough texture tends to be more pronounced during the winter months, when indoor heating reduces ambient humidity and dries the skin, and often improves during the summer.

The underlying cause of keratosis pilaris is the occlusion of hair follicles by an excess buildup of keratin, a naturally occurring structural protein that makes up the outer layers of skin, hair, and nails. When keratin accumulates and plugs the follicular opening rather than being shed normally, it forms a small, hard bump on the skin’s surface. The precise reasons why this abnormal keratin accumulation occurs in some individuals are not yet fully understood, but current evidence strongly points toward a genetic (hereditary) component.

It is important to emphasize that keratosis pilaris is not contagious. This condition cannot be spread from person to person through touch or any other form of contact.

While the condition is entirely benign and does not pose any health risks, it can be persistent and may last for many years. The good news is that it generally responds reasonably well to dermocosmetic skincare strategies, and many people find that consistent use of appropriate moisturizers and exfoliating products leads to significant improvement in skin texture and appearance.

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Causes

To understand keratosis pilaris at a fundamental level, it helps to consider what happens at the level of an individual hair follicle. Under normal circumstances, dead skin cells are continuously shed from the surface of the skin in an orderly, ongoing process. In keratosis pilaris, this process is disrupted: rather than shedding gradually and naturally, dead skin cells accumulate and clump together, forming a plug of hardened keratin that blocks the opening of the hair follicle (the pore from which a hair grows). The result is a small, raised bump on the skin’s surface. Sometimes, a tiny, coiled hair is trapped beneath it.

Multiplied across hundreds or thousands of follicles over an affected area, these individual plugged follicles collectively produce the characteristic rough, sandpaper-like texture that defines keratosis pilaris.

Despite decades of research, the exact biological mechanisms responsible for this abnormal keratin accumulation have not been fully elucidated. What is generally agreed upon is that:

• The condition is not caused by an autoimmune process. Instead, the immune system does not appear to be attacking the skin in the way seen in conditions like psoriasis or lupus.
• The condition is not caused by an allergic reaction or hypersensitivity. Instead, it does not represent an immune-mediated overreaction to an external trigger.
• The condition is not an infection. It is not caused by bacteria, viruses, or fungi, and it is entirely non-contagious.
• There is compelling evidence of a genetic (hereditary) basis: keratosis pilaris runs strongly in families, and individuals with an affected parent or sibling are significantly more likely to develop the condition themselves. However, the specific genes involved have not yet been definitively identified.

Some researchers have proposed that keratosis pilaris may be linked to an underlying abnormality in how keratinocytes differentiate and mature. These cells are the predominant type in the outer layer of the skin. Others have suggested links to mutations or dysregulation in genes involved in keratin production or desquamation (the natural shedding of skin cells). Research in this area is ongoing.

What is clear, regardless of the precise molecular mechanism, is that the condition reflects an intrinsic tendency of the skin to produce and retain excess keratin in and around hair follicles. This tendency is present from birth in individuals who are predisposed, though it may not become clinically noticeable until childhood or adolescence.

Risk Factors

Understanding who is most likely to develop keratosis pilaris can help individuals at higher risk take proactive steps toward managing the condition and seeking appropriate care when needed.

Age: Keratosis pilaris is considerably more common in children and adolescents than in adults. Many individuals first notice the condition in childhood, and it frequently worsens during puberty. This is likely because hormonal changes associated with adolescence may influence sebum production and skin cell turnover. The condition often improves spontaneously in adulthood, particularly after the age of 30.

Skin type: The condition appears to be more prevalent in individuals with fair or light skin (lower Fitzpatrick skin types), though it can affect people of any skin color. It may simply be more visually noticeable on lighter skin tones.

Associated skin conditions: Keratosis pilaris has a well-established association with certain other skin disorders, most notably:

• Ichthyosis vulgaris: a genetic skin condition characterized by dry, scaly skin. Patients with ichthyosis vulgaris are at significantly elevated risk of also having keratosis pilaris, and the two conditions are thought to share a common genetic basis involving abnormalities in the filaggrin protein, which plays a key role in skin barrier function.
• Atopic dermatitis (eczema): keratosis pilaris is frequently observed in individuals with atopic dermatitis and their family members, again pointing to shared genetic mechanisms involving skin barrier dysfunction.

Atopic tendency: Beyond atopic dermatitis itself, a personal or family history of atopic conditions, such as allergic rhinitis and asthma, is associated with a higher likelihood of developing keratosis pilaris. This cluster of atopic conditions tends to run together in families and shares common immunological and genetic underpinnings.

Body weight: Studies have noted a higher prevalence of keratosis pilaris in individuals with overweight or obesity. The exact mechanism behind this association is not fully understood, but it may relate to altered skin fold anatomy, increased friction, or changes in sebum production associated with excess body weight.

Hormonal factors: As previously noted, keratosis pilaris tends to worsen during puberty, and some women report flare-ups during pregnancy. Hormonal fluctuations may therefore play a modulating role in the severity of the condition, though this area of research is not yet fully developed.

Climate and season: While not a true “risk factor” for developing the condition, cold and dry weather consistently worsens keratosis pilaris in those who have it. The low humidity associated with winter months and indoor heating causes the skin to become drier, which exacerbates follicular plugging and makes the bumps more prominent. Conversely, many individuals notice an improvement in the warmer, more humid months of summer.

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Symptoms

Keratosis pilaris is a benign dermatological condition whose symptoms are primarily aesthetic in nature. It does not cause systemic illness or organ damage, and many individuals with the condition experience minimal or no discomfort beyond its visual appearance.

Location of Lesions

The characteristic lesions of keratosis pilaris appear preferentially on areas of the body with a high density of hair follicles and a tendency toward dryness. The most commonly affected sites are:

• The outer surface of the upper arms (the area between the shoulder and elbow on the lateral side): this is the single most commonly affected area and is present in the vast majority of individuals with the condition.
• The anterior (front) and lateral (side) surfaces of the thighs: another very commonly affected site, often symmetrically on both legs.
• The buttocks: frequently affected, often presenting with a more diffuse roughness than on the arms or thighs.
• The cheeks and face: particularly common in young children, who may present with prominent red or skin-colored bumps on the cheeks, sometimes mistaken for acne or other skin conditions.
• Less commonly: the back, shoulders, forearms, and abdomen.

Appearance and Texture

The individual lesion of keratosis pilaris is a small follicular papule. This is a tiny, raised bump centered on a hair follicle, typically ranging from 1 to 2 millimeters in diameter. When multiple papules appear across an affected area, which is always the case, the skin takes on a characteristic rough, sandpaper-like texture. Patients often describe this as feeling like goosebumps or chicken skin, giving the condition its common colloquial name: “chicken skin”.

The papules themselves can vary in color:

• Skin-colored: blending with the surrounding skin and most noticeable by touch rather than sight.
• Red or pinkish: particularly when there is associated mild inflammation around the follicle.
• White or slightly yellowish: due to the visible keratin plug at the center of the papule.
• Brown: more common in individuals with darker skin tones.

Associated Sensations

In the majority of cases, keratosis pilaris is asymptomatic, meaning the lesions do not cause pain, itching, or burning. However, some individuals do report:

• Mild itching (pruritus), particularly in dry conditions or during winter months,
• Skin tightness or discomfort associated with dryness,
• Redness around affected areas, which may be more pronounced in individuals with sensitive skin or after friction (e.g., from clothing).

The lesions are generally non-inflamed and do not become infected or ulcerated unless significant trauma or aggressive scratching is applied to the affected area.

Seasonal Variation

A hallmark feature of keratosis pilaris is its seasonal variability. The condition characteristically:

• Worsens in winter: when cold temperatures and low ambient humidity (both outdoors and indoors due to heating systems) lead to increased skin dryness, which exacerbates follicular plugging and makes the bumps more prominent and sometimes more inflamed.
• Improves in summer: when higher ambient humidity, perspiration, and increased skin hydration tend to soften the keratin plugs and reduce the roughness of the skin’s texture.

This seasonal pattern can be a helpful diagnostic clue and also underscores the importance of environmental humidity and skin hydration in managing the condition.

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Complications

Keratosis pilaris is fundamentally a benign condition with no known systemic complications or risks of malignant transformation. It does not increase the risk of skin cancer, does not affect internal organs, and does not lead to any form of medical emergency.

However, it would be a disservice to dismiss the condition entirely simply because it is medically benign. The psychological and emotional impact of keratosis pilaris can be significant. This aspect of the condition should not be underestimated, especially in vulnerable populations.

Adolescents and young adults are disproportionately affected by the cosmetic burden of keratosis pilaris. During a life stage when body image, peer acceptance, and self-esteem are already fragile, the visible and tactile abnormality of the skin can contribute to:

• Self-consciousness and embarrassment: many adolescents avoid wearing sleeveless tops, shorts, or swimwear due to concerns about the appearance of their arms, thighs, or buttocks.
• Social withdrawal: in some cases, the desire to conceal affected skin areas leads individuals to avoid social situations, beaches, sports activities, or intimate relationships.
• Anxiety and reduced self-esteem: particularly in young people who may feel that their skin is permanently abnormal or unattractive.

Adults, particularly women, may similarly experience frustration and distress related to the persistent nature of the condition and its resistance to simple remedies. The significant advertising and marketing of skincare products that promise to resolve keratosis pilaris (with varying degrees of evidence to support such claims) can contribute to unrealistic expectations and disappointment.

It is therefore important that healthcare providers acknowledge the psychological dimension of keratosis pilaris when counseling affected patients, and provide realistic, evidence-based guidance on what can and cannot be achieved with current treatments.

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Can Keratosis Pilaris Be Cured?

This is one of the questions patients ask most often. The honest answer, though not the most reassuring, is that there is currently no definitive cure for keratosis pilaris. Available treatments can manage symptoms, improve skin texture and appearance, and provide significant relief, but they do not permanently eliminate the underlying tendency of the skin to produce excess keratin.

The natural history of the condition, however, offers some cause for optimism:

• In many individuals, keratosis pilaris improves spontaneously over time, particularly as they move through their twenties.
• A significant proportion of affected individuals find that the condition resolves on its own by the age of 30, though the precise mechanisms behind this spontaneous improvement are not well understood.
• However, resolution is not guaranteed. Some individuals continue to have keratosis pilaris throughout adulthood, though the severity often fluctuates.

For those in whom the condition persists, consistent and appropriate skincare management can keep symptoms well controlled and the skin’s texture significantly improved. Understanding that management rather than cure is the realistic goal allows patients to approach treatment with appropriate expectations and to find an effective long-term routine that works for their skin.

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Diagnosis

Keratosis pilaris is primarily managed by a dermatologist, though a general practitioner with experience in skin conditions may also be able to make the diagnosis. In the vast majority of cases, the diagnosis relies purely on clinical grounds. This means it is based on a careful physical examination of the skin, with no need for laboratory tests or imaging studies.

Clinical Features That Guide Diagnosis

A dermatologist examining a patient with keratosis pilaris will typically observe:

• Follicular papules concentrated in characteristic anatomical locations (outer arms, thighs, buttocks, and face in children),
• Bilateral and roughly symmetric distribution of lesions,
• Rough, dry skin texture in the affected areas,
• Absence of pain upon palpation of the lesions,
• Color variations ranging from skin-colored to red, white, or brown,
• Mild erythema (redness) around some papules in more inflamed cases,
• Possible mild pruritus reported by the patient.

The combination of these features is highly characteristic and, in most cases, makes the diagnosis straightforward.

When Additional Tests Are Needed

In the overwhelming majority of cases, no additional investigations are required. However, in rare or atypical presentations, a dermatologist may consider:

• Dermoscopy: a non-invasive handheld magnification device that allows detailed visualization of skin structures. In keratosis pilaris, dermoscopy can confirm the follicular nature of the lesions and help exclude other conditions.
• Skin biopsy: extremely rarely indicated, and only when there is genuine diagnostic uncertainty or the need to rule out another skin condition. Histological examination of a biopsy sample would show characteristic features of follicular hyperkeratosis.

Differential Diagnosis

While keratosis pilaris is usually easy to diagnose, it is worth being aware of the conditions that can occasionally be confused with it:

• Folliculitis: inflammation or infection of hair follicles, which can produce similar-looking papules but is typically associated with more pronounced redness, tenderness, and sometimes pustules (pus-filled papules). Folliculitis usually has an infectious (bacterial or fungal) cause and responds to antimicrobial treatment.
• Acne vulgaris: acne on the arms or trunk can resemble keratosis pilaris, though acne typically involves comedones (blackheads and whiteheads), pustules, and nodules, and has a different pathophysiology.
• Milia: tiny white cysts beneath the skin surface, which can resemble keratosis pilaris but are not follicular in origin.
• Lichen spinulosus: a condition characterized by clusters of small, spiny follicular papules, sometimes confused with keratosis pilaris but with a distinct clinical pattern.
• Phrynoderma: a skin condition associated with vitamin A deficiency, presenting with follicular hyperkeratosis. This is now very rare in developed countries but should be considered in individuals with nutritional deficiencies.

An experienced dermatologist can typically distinguish keratosis pilaris from these conditions on clinical grounds alone.

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Remedies and Treatment

It is important to begin this section with an honest and empathetic statement: there is currently no treatment that can permanently cure keratosis pilaris. This is a condition rooted in an individual’s genetic makeup and intrinsic skin biology, and no medication or procedure can permanently alter this underlying predisposition.

That said, there is a wide range of effective strategies for managing the condition, improving skin texture, reducing redness, and minimizing the cosmetic impact of keratosis pilaris. In most cases, the condition responds reasonably well to a consistent and appropriate skincare routine, and many individuals achieve a significant improvement in skin smoothness and appearance with regular use of the right products and habits.

Because the symptoms of keratosis pilaris do not represent a medical emergency or a health risk, treatment is entirely optional and is primarily pursued when the cosmetic appearance of the skin causes personal distress or discomfort. The decision to treat and the choice of treatment should always be individualized based on the patient’s symptoms, preferences, and response to previous interventions.

General Skincare Principles

The cornerstone of keratosis pilaris management is gentle, consistent skincare aimed at reducing keratin buildup, maintaining skin hydration, and avoiding practices that worsen dryness or irritation.

Moisturizing: Daily application of a rich, emollient moisturizer is the single most important step in managing keratosis pilaris. Moisturizers help soften the skin and the keratin plugs, reduce roughness, and improve the overall appearance of affected areas. Products containing ingredients such as urea, lactic acid, glycerin, shea butter, or ceramides are particularly effective because they combine humectant (water-attracting) and occlusive (water-sealing) properties.

Bathing habits:

• Use lukewarm, not hot, water when showering or bathing. Hot water strips the skin of its natural oils and significantly worsens dryness and irritation, which can exacerbate keratosis pilaris.
• Keep showers brief (ideally no longer than 5–10 minutes) to minimize skin dehydration.
• Pat the skin dry gently with a soft towel rather than rubbing vigorously, which can cause friction and irritation to affected areas.

Gentle cleansing:

• Use mild, fragrance-free, dye-free soaps or body washes that are specifically formulated for sensitive skin. Harsh soaps, antibacterial cleansers, and products with strong fragrances can strip the skin’s protective barrier and worsen dryness and irritation.
• Avoid cleansers with alcohol or other drying ingredients.

Gentle exfoliation:

• Periodic, gentle physical exfoliation can help remove dead skin cells and loosen keratin plugs, improving skin texture. A soft exfoliating mitt or gentle washcloth used in circular motions during bathing can be effective.
• Avoid aggressive exfoliation: harsh scrubs, coarse loofahs, or vigorous rubbing can damage the skin’s surface, cause inflammation, and worsen the appearance of keratosis pilaris. Gentle is the key word.

Avoiding triggers:

• Resist the urge to scratch or pick at the papules, as this can cause skin irritation, temporary pigmentation changes, and, in rare cases, introduce infection.
• Minimize friction from tight clothing on affected areas, as this can worsen redness and irritation.
• Consider using a humidifier at home, particularly during the winter months, to add moisture to the air and help prevent the skin from becoming excessively dry.

Topical Pharmacological Treatments

When general skincare measures alone fail to control symptoms, dermatologists may recommend specific topical preparations. These can include either commercially available products or compounded preparations, which are prepared by a pharmacist following a doctor’s prescribed formula. These include:

Keratolytic agents are substances that break down and dissolve excess keratin plugs.

• Urea (10–40%): Urea is one of the most effective and widely used keratolytic and moisturizing agents for keratosis pilaris. At lower concentrations (10–20%), it acts primarily as a humectant and moisturizer; at higher concentrations (25–40%), it has a significant keratolytic effect. It is well-tolerated, available in many commercial creams and lotions, and has a good evidence base for use in keratosis pilaris.
• Lactic acid (5–12%): An alpha-hydroxy acid (AHA) that exfoliates the skin and dissolves the bonds holding dead skin cells together, helping to clear keratin plugs. Buffered lactic acid preparations are generally well-tolerated. Products containing 12% ammonium lactate are particularly effective. Some patients may experience mild initial stinging or irritation.
• Salicylic acid (2–6%): A beta-hydroxy acid with keratolytic properties that helps to loosen and remove the outer layers of skin, clearing follicular plugs. Available in many over-the-counter formulations for keratosis pilaris. Can cause dryness if overused.
• Glycolic acid: Another AHA that promotes skin cell turnover and helps prevent follicular occlusion. Often found in exfoliating creams and toners.

Retinoids:

• Tretinoin (topical retinoic acid): A vitamin A derivative that accelerates skin cell turnover, promoting the shedding of the outer skin layers and preventing the buildup of keratin. It is one of the more effective topical agents for keratosis pilaris, though it can cause significant skin irritation, redness, and peeling. This is especially true when first starting treatment. It is available by prescription only and should be used under dermatological supervision.
• Adapalene: A third-generation synthetic retinoid that is generally better tolerated than tretinoin, with a more favorable irritation profile. Like tretinoin, it promotes cell turnover and can help reduce follicular plugging. Available by prescription (and in some countries in low-concentration over-the-counter formulations).

Anti-inflammatory agents:

• Topical corticosteroid creams: In cases where keratosis pilaris is accompanied by significant redness and inflammation, a mild to moderate-potency topical corticosteroid cream may be prescribed for short-term use to reduce inflammation and erythema. However, long-term use of topical corticosteroids on large skin areas is not recommended due to the risk of skin thinning (atrophy), telangiectasia (visible small blood vessels), and other side effects.
• Tacrolimus ointment (0.03% or 0.1%): A topical calcineurin inhibitor with anti-inflammatory properties, typically used for atopic dermatitis. It may be helpful in cases of keratosis pilaris with significant associated inflammation or erythema, particularly in individuals for whom topical corticosteroids are not appropriate.

Other agents:

• Azelaic acid: Has mild keratolytic and anti-inflammatory properties and may help improve skin texture in keratosis pilaris.
• Hydrophilic petrolatum and water (equal parts): A simple but effective emollient base that can help hydrate the skin and soften keratin plugs. Often used as a base for compounded preparations.

Important notes on topical treatments:

• Many of these agents, particularly retinoids and AHAs, can cause initial irritation when you first start using them. It is advisable to start with lower concentrations and apply less frequently (e.g., every other day) before gradually increasing use as the skin acclimates.
• Combination approaches (e.g., a keratolytic agent used in the morning and a retinoid in the evening) may offer greater efficacy than any single agent alone.
• Consistency is key: topical treatments for keratosis pilaris require weeks to months of regular use before significant improvement is typically observed. Stopping treatment usually leads to the gradual return of symptoms.

Dermatological Procedures

For patients who do not achieve adequate improvement with topical treatments, or for those seeking faster or more dramatic results, dermatologists may offer specific procedural interventions:

Laser therapy: Various laser modalities have been used to treat keratosis pilaris, with the most evidence supporting:

• Pulsed dye laser (PDL): Primarily targets the redness (erythema) associated with keratosis pilaris rather than the bumps themselves. Can significantly reduce the reddish discoloration in affected areas.
• Intense pulsed light (IPL): A broad-spectrum light-based treatment that can similarly reduce redness and improve overall skin tone.
• Non-ablative fractional lasers: These target the follicular keratin plugs and stimulate collagen remodeling, potentially improving skin texture as well as color.

Multiple sessions are typically required, and results are not permanent. Maintenance treatments may be needed over time. Laser therapy for keratosis pilaris is generally considered an elective cosmetic procedure and may not be covered by health insurance.

Microdermabrasion: A mechanical exfoliation technique that removes the outer layer of dead skin cells using fine crystals or a diamond-tipped wand. Can temporarily improve skin texture, though results are modest and must be maintained with regular sessions.

Chemical peels: Application of a chemical exfoliant (such as glycolic acid or salicylic acid at higher concentrations than available in over-the-counter products) by a trained professional. Can provide a deeper exfoliation than at-home products, with temporary improvement in skin texture.

Hair Removal Considerations

Shaving and waxing affected areas can worsen keratosis pilaris by causing additional follicular irritation, ingrown hairs, and inflammation. For individuals who wish to remove hair from affected areas (such as the legs or arms), laser hair removal is generally the preferred option. By permanently reducing hair density in the treated area, laser hair removal minimizes follicular disruption and may actually help improve the appearance of keratosis pilaris over time.

Recommended Skincare Routine

While every individual’s skin responds differently to various products and approaches, and finding the optimal combination may require some experimentation, the following routine represents a reasonable and evidence-based starting point for most individuals with keratosis pilaris:

Morning routine:

1. Shower or bathe with lukewarm water (not hot) for a limited duration (5–10 minutes).
2. Cleanse affected areas with a mild, fragrance-free, non-comedogenic body wash.
3. Gently pat your skin dry with a soft towel, taking care not to rub.
4. While the skin is still slightly damp, apply a rich emollient moisturizer containing urea (10–20%), lactic acid, or ceramides to all affected areas. Applying moisturizer to slightly damp skin helps lock in hydration.
5. Allow the moisturizer to absorb fully before dressing.

Evening routine:

1. Optionally perform gentle physical exfoliation two to three times per week. Use a soft exfoliating mitt or washcloth during the shower, but never on dry skin.
2. If prescribed or recommended by a dermatologist, apply a retinoid (tretinoin or adapalene) or a keratolytic preparation (e.g., higher-concentration urea or lactic acid) to affected areas in the evening.
3. Follow with a generous application of emollient moisturizer if using a potentially drying active ingredient.

Environmental measures:

• Use a humidifier in the bedroom and living areas, particularly during winter months, to maintain a more skin-friendly ambient humidity level (ideally 40–60%).
• Wear soft, non-irritating fabrics (cotton rather than wool or synthetic materials) against affected skin areas to minimize friction.

Hair removal:

• Consider laser hair removal rather than shaving or waxing for affected areas, as this minimizes follicular disruption and may provide additional long-term benefit for the skin’s appearance.

Follow-up and consistency:

• Commit to a consistent daily routine: keratosis pilaris is a chronic condition that requires ongoing management. Skipping skincare steps, especially when symptoms seem to improve, often causes them to return.
• Schedule periodic dermatology appointments to review the effectiveness of your current regimen and adjust as needed.

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Sources and Bibliography

• NHS (National Health Service, UK): Keratosis Pilaris. https://www.nhs.uk/conditions/keratosis-pilaris/
• MSD Manuals (Professional Edition): Keratosis Pilaris. https://www.msdmanuals.com/professional/dermatologic-disorders/cornification-disorders/keratosis-pilaris
• Cleveland Clinic: Keratosis Pilaris. https://my.clevelandclinic.org/health/diseases/17758-keratosis-pilaris
• Ehsani AH et al. “Keratosis pilaris: A common follicular hyperkeratosis”. Clinics in Dermatology. 2020; 38(2):191–196.
• Hwang S, Schwartz RA. “Keratosis pilaris: A common follicular hyperkeratosis”. Cutis. 2008; 82(3):177–180.
• American Academy of Dermatology Association: Keratosis Pilaris Overview. https://www.aad.org/public/diseases/a-z/keratosis-pilaris-overview
• Irvine AD, McLean WH, Leung DY. “Filaggrin Mutations Associated with Skin and Allergic Diseases”. New England Journal of Medicine. 2011; 365(14):1315–1327.
• DermNet NZ: Keratosis Pilaris. https://dermnetnz.org/topics/keratosis-pilaris