Common Dermatologic Conditions

Toby Maurer, MDUniversity of California, San Francisco

Acne

• Papulopustular– Topicals okay

• Cystic, scarring, keloidal– p.o. antibiotics– Accutane

Topicals

• BP 5% gel (10% - more drying)

• Retin A 0.025% - 0.1% ( vehicle determines strength - start with crème)

• Cleocin T or erythromycin topically

– Use 1 qam and 1qhs– If NO success after 8 weeks, go to p.o.’s

P.O. Antibiotics

• TCN - 500 bid x 8 weeks

• Doxycycline - 100 bid x 8 weeks

• Minocycline - 100 bid x 8 weeks

• Taper - Do NOT STOP ABRUPTLY

Alternatives

• Erythromycin - 500 bid

• Septra - check WBC’s

• Keflex-500 tid

Spiranolactone

• Diuretic used in cirrhosis of liver

• Also an anti-androgen

• Useful in females who have cysts around menstruation

• 50-100 mg qday continuously

• Increased urination, don’t use during pregnancy, ?electrolyte imbalance

Accutane

• Document failure of antibiotics

• Baseline CBC, LFT’s ,TG and cholesterol

• Two forms of birth control, negative pregnancy tests

• MD’s will need to be registered as will patients

• Counseling on depression

Acne Rosacea

• Common in women over 40

• Often seen in persons of Irish decent

• Associated with seborrheic dermatitis

• Characterized by papules, erythema, telangiectasia and rhinophyma (M>F)

• Sun exposure, alcohol and spicy foods exacerbate rosacea

Acne Rosacea

• Oral antibiotics for 6-8 weeks clears skin for some amount of time

• Topicals work less frequently

Perioral Dermatitis

TREATMENT

Topicals: Cleocin T Gel bid

Erythromycin bid

p.o. antibiotics –TCN

Doxycycline

Minocycline

- bid x 8 wks

Keeps pts in remission x 2 yrs.

Hair Loss

• Decide if scarring or not:• If scarring-refer• If not scarring and diffuse:• Check recent surgeries/illness, nutrition,

anemia, TSH, estrogen replacement, medication history, VDRL.

• If hirsute with scalp hair loss-DHEAS and free testosterone

• If lactating- check prolactin

If all negative

• Androgenetic Alopecia-Minoxidil 5% bid topically (even in women)Can make hair oily-may want to start with

minoxidil 2% or use 2% by day and 5% at night

Use for at least 6 months for results and what you see after 1 yr. is the effect you can expect.

What about finasteride (propecia)?-equal to minoxidil in men. Does not work in women.

Too Much Hair

• Vaniqa– topical cream that breaks the chemical bond

of hair– apply 2x’s/day forever– 30% effective– $30/month

Hair Removal

– pigment of hair absorbs the light and is destroyed

– dark hair responds– hair is always in different growth phases,

so treatment has to be repeated several times to catch the phase(expensive)

– Side effects: pigment changes of surrounding skin and scarring

Psoriasis-What is it?

• Fast growing skin-takes 3 days to come to surface and desquamate

• Normal rate is 28 days

• Psoriatic skin has a fast mitotic rate

• Triggers an inflammatory response in and around affected skin

• New onset often preceded by strep infection (strep pharyngitis) especially in the younger age group.

• In older age group, drugs often unmask psoriasis

• Drugs: beta-blockers, lithium, NSAIDS, antimalarials, terbinafine, gemfibrozil-pts on these meds for 3-6 months before onset of psoriasis

Psoriasis-Tx:Psoriasis-Tx:

• Decrease the mitotic rate of skin – Tar (LCD 5% in TAC 0.1% oint) ( Tar emulsions),

topical retinoids (Tazarac)• Decrease the inflammatory response of the skin

– Steroid Ointment (mid-potency-1st line)– Calcipotriene (Dovonex Ointment)-not on face or

groin– Clobetasol/Dovonex combination– Ultraviolet light (psoralen+ UVA), UVB– NO PREDNISONE

NEXT STEP• Time for referral• Methotrexate-liver biopsies necessary(don’t

give in HEP C pts)• Oral retinoids (Acetretin)-not in persons of

reproductive potential -? Okay in liver disease; excellent drug in HIV

• Cyclosporine• Biologics (Enbrel, Remicade)-most benefit in

psoriatic arthritis and quick reversal of pustular psoriasis

EczemaEczema

• Dry, inflamed skin that becomes “weepy”• Not bilateral and symmetric• No thick scale• No scalp/nail involvement• Topical steroids first line of treatment• Oral cyclosporine was known to turn off

inflammation• Now: topical formulation of Cyclosporine

EczemaEczema

• Tacrolimus (Protopic) and Pimecrolimus (Elidel), new kids on the block– Great for facial eczema– $120 for 30gm

Topical Immune Modulators and Cancer

• Elidel (pimecrolimus 1%) and Protopic (tacrolimus 0.1% and 0.03%) –heavily marketed

• 29 cases of cancers in children and adults associated with use of these topicals-lymphomas, SCC’s, sarcomas

• Causality not proven

FDA Response

• Black Box Warning

Do not use in children under 2 years of age

Do not us in adults or children with “weakened” immune systems: Transplants, HIV, cancer patients, etc.

• Limit use—no continuous usage; limit area treated

Topical Immunomodulators When to use

• Eyelid dermatitis

• Refractory psoriasis on upper thighs, scrotum, glans penis

• Otherwise use cheaper alternatives first – Protopic=TAC 0.1%– Elidel=HC 2.5%

Buttock Folliculitis

• Mechanical from clothing

• Ban roll-on good

• Topical antibx qd– Cleocin/Erythro

Keratosis Pilaris

• Thickening of hair follicles on the out arms and upper legs

• Associated with dry skin

• Lubrication

• Lachydrin 12% lotion bid

Intertrigo

• Pendulous breasts or pannus

• Always component of candida

• Blow dry area

• Apply topical antifungals

• Tucks pads

Bacterial Skin Infections

• Most common pathogen is staph aureus

• More methicillin resistant staph causing skin and soft tissue infections in the community

• JAMA-Niami et al Dec 2003

Approach to Treatment

• Culture where you can-if you have pus, that is great

• Incise and drain when appropriate (Abcesses)

If no pus:

• Tx with methicillin SENSITIVE drugs-first line but have pt return to evaluate for resolution

• If recurrent infection, tx with methicillin RESISTANT antibiotics right off the bat

Septra, Doxycycline,Cipro/Levofloxacillin), Clindamycin

• Consider adding rifampin 600 qd for 5 days or mupirocin ointment for staph eradication

Was it bacterial in the first place?

• Remember HSV-culture and/or Direct Fleurescent Antibody

• Skin biopsy for histology and tissue culture

• Diseases that Masquerade as Infectious Diseases Ann Int Med 2005 Jan 4; 142:47-55

Hidradenitis Supparativa

• Not an infectious disease• Disease of apocrine glands• Treatment

– IL Kenalog– Minocycline– Surgery– NOT Antibiotics– New Biologics

Inflamed Epidermoid Cysts

• Antibiotics-USELESS

• If just starting to become inflamed and cyst is small( < 1 cm), can try intralesional Kenalog injection but see them back in few days-you can exacerbate the inflammation

• INCISE and DRAIN and PACK

• 6 weeks later, inspect for residual cyst and excise

Recurrent Cellulitis

• Recurrent cellulitis knocks out lymph system causing low grade cellulitis and retention hyperkeratosis

• Tx. Cellulitis-may need 6 months of tx or more

• Tx. Hyperkeratosis-urea crème 40%• Tx. Lymphedema-support stockings with

35mm of pressure or mechanical pumps

Venous Insufficiency Ulcer

• Compression dressing– Unna boot covered by Coban – this requires a good

nursing staff with training and experience

– This both provides graded compression AND creates the correct wound environment

• Semipermeable dressing (Hydrosorb, Duoderm, etc)

• Change dressing weekly• Refer to dermatology if not healing

Venous Insufficiency Ulcer

• Control Edema– Elevation of leg above heart 2 hours twice daily– Walk, don’t sit– Compression

• Diuretics overused and not of benefit unless fluid retention due to central problem is present (CHF, CRF)

• Create an appropriate wound environment for healing– Paradigm shift: Ulcers that don’t heal do not have the

appropriate biochemical environment to promote healing

Complications of Leg Ulcers

• Allergic contact dermatitis to applied antibiotics, topical anesthetics

• Avoid all topical antibiotics to leg ulcers (except topical metronidazole to prevent odor)

• Never apply topical benzocaine, Vitamin E, neomycin, or bacitracin to VI leg ulcer

• 64 year old man with psoriasis, hypertension, hypercholesterolemia

• 3 months of ulceration of medial aspect of left lower leg

• Vascular evaluation confirms venous insufficiency

• 3 months of treatment fails to improve ulceration

• What is your next step?

• Skin Biopsy = Squamous Cell Carcinoma

• Chronic phototherapy and prior immunosuppressive treatments may have led to skin cancer

• If leg ulcer doesn’t heal with appropriate treatment—refer or biopsy