dermatology update katie fiala, md department of dermatology scott and white memorial hospital

Dermatology Update

Katie Fiala, MDDepartment of DermatologyScott and White Memorial Hospital

TOPICS

Varicella Zoster Psoriasis Acne Lipodermatosclerosis Hemangiomas Melanoma Miscellaneous Updates

Varicella Zoster

(Shingles)

Reactivation of chickenpox virus along sensory nerve causing a painful blistering skin eruption.

Clinical History

70 year old manRecent Hodgkins Disease dxPainful eruption on facePain is excruciatingBlisters erosions

Varicella zoster

20% of healthy adults 50% adults > 85 Induced by stress, fever, XRT,

trauma, immunosuppression Blacks 75% less likely Transmission via vesicular fluid 4% recurrence rate

Zoster: clinical features Prodrome intense

pain Itch, tingling, or

hyperesthesia Grouped vesicles

on erythematous base

Umbilicated, pustular

Sensory dermatome

Childhood Zoster

Diagnosis Confirmation

Viral Culture swab

Viral PCR swab

Aggressively swab base of lesion

Management / Treatment Early treatment, within first 72

hours Oral anti-virals

– Acyclovir 800mg po 5x/day x 7-10 days– Valacyclovir 1gm po TID x 7 days– Famciclovir 500 mg po TID x 7 days $$

IV acyclovir - immunocompromised and disseminated form– Acyclovir 10mg/kg IV q 8hrs x 7-10 days

Oral prednisone (controversial)

DISSEMINATED ZOSTER >20 lesions outside of affected

dermatome Can cross midline 2 or more non-contiguous

dermatomes May have internal involvement:

hepatitis, encephalitis, pneumonitis

Post-herpetic Neuralgia Post Zoster inflammation/injury to

affected nerves More common >55 years of age Pain may last for months/year Rx: Narcotics, Neurotin

(gabapentin), Nerve Block, topical lidocaine, topical gabapentin 6%

Prevention?

Zostavax

Live attenuated vaccine Reduced incidence by 55% in >60yo in a

real-world practice – (JAMA 2011;305;160-6)

Effective in pts w/ underlying chronic conditions

Reduced in incidence by 70% 50-59 Reduced incidence of PHN by 67% in

>60yo Okay to receive if previous shingles Does prevent ophthalmic zoster

Contraindications

Anaphylaxis to gelatin or neomycin

Immunocompromised: HIV, chemo, chronic steroids, pregnancy, h/o leukemia or lymphoma

Psoriasis

Treatment

Topical steroids Vitamin D analogs – calcipotriene Phototherapy (Narrowband UVB) Methotrexate Cyclosporine Soriatane Biologics **NOT PREDNISONE**

Psoriasis & Biologic Agents

Enbrel, Humira, Remicade (TNF-alpha inhibitors)

Stelara (blocks IL-12 and IL-23) Screening:

– TB/HIV/Hepatitis prior– TB yearly– CBC/CMP prior and q6mo

Contraindications: MS, Solid tumor, severe CHF

Paradoxical Psoriasis (palmo-plantar)

Biologics and Infections 1 in 10 on biologics will have

serious infection/year 10-18 fold increase on biologics Ways to help

– Be aware– Tight control of DM– Education– Vaccines (live given b/f starting tx)

Psoriasis Associations

Obesity Hypercholesterolemia Hypertension Diabetes Mellitus II Depression Alcohol/Smoking Psoriatic Arthritis

Psoriasis & Metabolic Syndrome

Chronic inflammatory skin condition

Pro-inflammatory cytokines Diabetes mellitus type II

(OR=2.48), arterial hypertension (OR = 3.27), hyperlipidemia (OR = 2.09), and coronary heart disease (OR = 1.95).

Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis , Archives of Dermatological Research , Volume 298, Number 7, 321-328, 2006

Psoriasis & Metabolic Syndrome

Metabolic syndrome more common in psoriatic patients than controls OR 1.65, >40 yo.

Psoriatic patients - higher prevalence of hypertriglyceridemia and abdominal obesity

Association independent from smoking. Conclusion: Psoriatic patients have a higher

prevalence of metabolic syndrome, which can favor cardiovascular events. We suggest psoriatic patients should be encouraged to correct aggressively their modifiable cardiovascular risk factors

Prevalence of metabolic syndrome in patients with psoriasis: a hospital-based case–control study, British Journal of Dermatology, Volume 157, Issue 1, pages 68–73, July 2007

Psoriasis and Cardiovascular Risk Risk for MI 3.6 for controls, 4.0 for

mild psoriasis, 5.1 for severe psoriasis

Younger pts with severe psoriasis have the greatest risk of MI

JAMA 2006;296:1735,41

Psoriatic Arthritis

Inverse Psoriasis

Inverse psoriasis

+/- psoriasis elsewhere Treatment

– Low-potency topical steroids– Protopic (tacrolimus) 0.1% ointment

or Elidel cream– Minimize moisture, careful drying,

drying powders (Zeosorb AF)

LIPODERMATOSCLEROSIS

Sclerosing panniculitis Affects lower legs Secondary to chronic venous

insufficiency 2/3 of patients are obese

Presentation

ACUTE– Erythematous, painful, indurated

plaques, swelling– Can be unilateral or bilateral

CHRONIC– Less erythema, significant

induration, hyperpigmentation, may ulcerate

– “inverted champagne bottle”

THERAPY

Leg elevation Compression stockings Potent topical steroids, under occlusion Aspirin NSAIDS Trental 400mg po TID Weight loss ? Vascular surgery

Hemangiomas

Natural course– Proliferate by 9mo– Involute by 10yo

10% rule Complications

– Beard area – Eye– Diaper area

Know when to refer

(

Diffuse Cutaneous Hemangiomatosis

Liver Thyroid High Output

Cardiac Failure

Treatment

Especially if danger zones Prednisone 2-3mg /kg/ day Propanolol 2-3 mg/ kg/day

– Very successful– Risks: Hypotension, hypoglycemia– Pediatric Cardiologist – (Engl J Med 2008;358;2649-51)

ACNE

Topical therapy

Non-comedogenic/ non-acnegenic Topical retinoid – Differin, Retina,

Retina Microgel, Tazorac Topical antibacterial – benzoyl

peroxide, topical clindamycin, Benzaclin or Duac (BPO+ clinda)

Azaelic Acid Topical Dapsone (Aczone)

Oral Therapy Minocycline 100mg bid Doxycycine 100mg bid Clindamycin 150 -300mg bid Bactrim DS bid **Azithromycin 250-500mg TIW Amoxicillin 500mg bid (pregnancy) **Spironolactone 100 - 150 mg daily Oral contraceptives (Yasmin) Isotretinoin 1mg/kg bid x 5 -6 mo

IsotretinoinOther issues

Depression Labs: LFTs, lipids Pseudotumor cerebri: more likely

with tetracyclines Xerosis and cheilitis Flare ? Inflammatory Bowel Disease

Inflammatory Bowel

Crockett SD et al. Isotretinoin use and the risk of inflammatory bowel disease: A case–control study. Am J Gastroenterol 2010 Mar 30

8,189 pts with IBD and 21,832 controls 3664 Crohns & 4428 UC Isotretinoin use strongly associated with UC

(OR 4.36) but not with Crohns Higher dosage and longer duration

increased risk

What does this mean?

Pts must be made aware of risk Stop if bowel symptoms develop

until cleared by GI More studies needed ? Association with Tetracyclines

Melanoma

Barriers to full skin exam– Primary care: time constraints

(54%)– Dermatologists: patient

embarrassment (44%)– Arch Dermatol 2011;147:36-44

Continues to be on the rise One American dies of melanoma

every hour

Melanoma

Asymmetry Borders Color Diameter >6mm Evolution

Lentigo Maligna

SEER Age Adjusted Incidence Rates by Race and SexMelanoma of the Skin, All AgesSEER 9 Registries for 1973-2002

Malignant Melanoma

75% of skin cancer deaths 1 American dies/ hour 25-29 yo Areas of intense, rare sun exposure Scalp = aggressive Also: eyes, mouth, genitalia

Who’s at Risk

Red/blonde hair, blue/green eyes >50 nevi Dysplastic nevi First degree relative H/o melanoma, 9x more likely Tanning bed Summer vacations >5 sunburns doubles risk Higher SES

IPILIMUMAB (Yervoy)

FDA approved for metastatic melanoma

Monoclonal antibody (IV) Median overall survival 10.0

months (both), 10.1 (ipilimumab only) and 6.4 (vaccine only)– N Engl J Med 2010;363;711-23

Vitamin D Debate

Acknowledge benefits Encourage oral supplementation Educate about sun protection

– Avoid peak hours 10am – 4pm– Broad Spectrum (UVA/UVB) SPF 30, year

round– SPF 30 block 97-98% UVB – Adequate amount– Wet white shirt only SPF 4– Special clothing

Miscellaneous

New, COMB-FREE head lice treatment approved by FDA– Natroba Topical Suspension

(spinosad 0.9%)– Approved for children over 4yo– Important not to use <6mo b/c

contains benzoyl alcohol

Miscellaneous

PDT for Actinic Keratoses– Photodynamic Therapy– Metvixia (methyl amiolevulinate

cream) applied to affected area approx 2 hours under occlusion

– Red light for 6-8 minutes– Reaction similar to 5-FU in 1-2 days

Miscellaneous

BRACYTHERAPY– Precise placement of radiation sources – Exposure to radiation of healthy tissues

reduced– Tumor can be treated w/ very high doses – Applicator can conform to contour of face/skin– Cure rates comparable to EBRT– Can be completed in less time

Less visits Less time for cancer cells to divide

Thank you!

Kfiala@swmail.sw.org