sk“in” too deep? - nevada osteopathic medical...
TRANSCRIPT
Sk“IN” Too Deep?Effective care for commonly
encountered dermatologic complaints
Kara Pretzlaff, MDVivida Dermatology
I have no financial conflicts of interest*
* maybe one day…
Number 1: Acne
Acne
• Contributors• Inflammation• “Sticky” keratinocytes• Hormones
• Ages 12-24 most common• Post pubertal• “Adult” acne is a thing L
• Classifiers• Comedonal• Inflammatory• Nodulocystic
Comedonal versus Inflammatory
Nodulocystic
Treatment Pearls: comedonal acne
Sample regimen:• AM• Gentle cleanser (Cera Ve, Cetaphil)• Moisturizer with SPF (30+)
• PM• Gentle cleanser• Nighttime moisturizer• Adapalene gel 0.1% (OTC)
Treatment Pearls: inflammatory acne
Sample regimen:• AM & PM same plus:
• AM: Anti inflammatory/anti bacterial• Eg Benzoyl peroxude/clindamycin gel
• Doxycycline OR Minocycline 100mg twice daily
• If hormonal: OCPs, spironolactone
• SE• Doxycycline MC: GI upset,
photosensitivity• Minocycline MC: dizziness
• Less common: dyschromia, DRESS
Treatment Pearls: nodulocystic acne
Challenging…• Isotretinoin
• 6+ month course• Goal of 120-150mg/kg• May need to repeat• We can help!
• Watch out for:• DRYNESS• Elevated TGs and LFTs• DRUG INTERACTIONS (eg tetracyclines)• Questions about depression
Not working?
•We can help!• Inflammatory• Nodulocystic• Refractory comedonal• Adult acne• Post inflammatory inflammation• Acne scarring
Number 2: TineaAKA “Ringworm”, “Jock itch”, “Athlete’s Foot”, “Gross toenails”
Tinea: a dermatophyte infection
• Incredibly common superficial fungal infection• Treatment depends on subtype and
location• Inflammatory versus non
inflammatory• Good news: sometimes it’s really
easy to treat• Bad news: sometimes it’s not
Treatment pearls: tinea versicolor
• Ketoconazole 2% shampoo (Rx)• Step 1: Lather on wet skin• Step 2: LEAVE ON 5-10 min• Step 3: Rinse off
• Repeat 3x/week until improved, then once weekly • “Normal” color takes time
• Not working?• There are oral options…we can help!
Treatment pearls: tinea corporis/pedis/cruris
Treatment pearls: tinea corporis/pedis/cruris
• First line: topical cream (OTC)• Eg miconazole, terbinafine,
clotrimazole• Apply twice a day for 2 weeks
beyond clinical improvement
• Second line: oral antifungal agents• Terbinafine preferred• 250mg daily x 2-4 weeks• MC side effect: taste disturbances
• At home tips:• Wash common foot surfaces with
bleach-based wash• Wash socks/towels on hot cycle• Dry feet well• New shoes• Zeasorb powder (OTC)• For thick skin on feet, add urea or
amlactin (OTC)
Treatment pearls: Tinea unguum (aka onychomycosis)
• MAKE SURE IT’S FUNGUS • Who needs treatment?
• Diabetics• Immune suppressed• People who don’t like the way their
nails look/have painful nails• *Personal opinion*:
• Don’t waste time with topicals• First line: Oral antifungals
• Requires longer course• 6 weeks for fingernails• 12 weeks for toenails
Number 3: Seborrheic Dermatitis
Seborrheic dermatitis
• Common inflammatory dermatosis that likes oil-gland bearing skin• MC on scalps, central face, chest,
axillae• Exuberant forms can be seen in
HIV population and Parkinson’s
Treatment pearls: seborrheic dermatitis
• Treatment similar to tinea versicolor• Ketoconazole shampoo 2% (Rx)
• Leave on skin for 5-10 min prior to rinsing
• Start with 3x/week, decrease to weekly as maintenance
• Alternate with OTC anti-dandruff shampoo
• If really inflammatory, can pair with mild corticosteroid during flares (only 1-2 weeks)• Eg desonide 0.5% cream, hydrocortisone
2.5% ointment
Treatment pearls: seborrheic dermatitis
• Not working?• Options for oral therapy and stronger
corticosteroids…We can help!
Number 4: Psoriasis
Psoriasis
• Common, chronic, immune-mediated inflammatory dermatosis• Genetic• Can have mutilating arthritis• Not just “skin deep”
• Cardiovascular risk is equivalent to those with DMII• High risk of depression/suicidality
Treatment Pearls: Psoriasis
• We have SO many options!• If it’s minor (<5% BSA) and patient
doesn’t mind it:• Triamcinolone 0.1% ointment BID PRN
• Counsel on hereditary nature, ask about mood, discuss cardiovascular risk• Send them our way – we can get
them the good stuff J
Treatment Pearls: Psoriasis
• What makes it worse?• IM steroids – watch out!• Infection• Hypocalcemia• Stress• Some drugs
• Beta blockers, anti malarial agents, lithium, IM steroids (see above…)
• Alcohol/smoking/obesity
Number 5: Vitiligo
Vitiligo
• Autoimmune, chronic, inflammatory dermatosis • Defined by striking patches of
depigmented skin• Like psoriasis, HIGH percentage
of patients with depression and suicidality
Treatment Pearls: Vitiligo
• Most important part of treatment:• Letting patients know there ARE
treatments available
• Please don’t treat it like a cosmetic complaint• Class I topical corticosteroids/oral
steroids, JAK kinase inhibitors, NBUVB are the mainstays of therapy• We CAN help!!
Number 6: Sebaceous Hyperplasia and the “aging” face
Sebaceous hyperplasia
• Benign adnexal neoplasms• Often confused for basal cell
carcinoma• If you’re not sure we would love to
see them J
• Men>Women• Tx options: electrodessication
most effective
Sebaceous hyperplasia vs Basal cell carcinoma
*BONUS* “Aging” face
• The absolute basics of “post-poning” photoaging
1. Sunscreen: SPF 30+, re application needed
2. Safe sun practices (can’t get out of a derm talk without this one…)
3. Daily (or twice daily) moisturizer4. Topical anti-oxidant (eg Vitamin C)5. Topical retinoid (rx >> OTC)
• More advanced: botox, filler, laser resurfacing…
Wrinkles
Loss of fat
Dyschromia
Number 7: Seborrheic keratosesAKA “wisdom spots”
Seborrheic keratoses (SKs)
• Benign, incredibly common skin lesions that like hair-bearing areas • Can sometimes look a lot like
melanoma (and vice versa, unfortunately)• Sign of Leser Trelat?
Treatment pearls: Seborrheic keratoses (SKs)
• If not bothersome to patient…leave them alone• If bothersome (eg itch/hurt),
they can be removed or destroyed• Considered a cosmetic
procedure if asymptomatic without any concerning features
SK or Melanoma?
• If you doubt it at all…we’re here to help!!
Number 8: Eczema
Eczema (atopic dermatitis)
• Common inflammatory dermatosis predominantly affecting kids• Up to 85% of kids grow out of
their eczema by age 12• Main problem: faulty epidermal
barrier • Pruritus• Xerosis• Secondary infection
Treatment pearls: Eczema
• If mild-moderate, keep it simple:• Eliminate potential triggers: essential oil
diffusers, “slime”, scented soaps• Gentle skin care
• Short, lukewarm showers• Dove bar soap for sensitive skin• Regular emollient use
• Vaseline or body creams (not lotions)
• Class 3 topical corticosteroid (egtriamcinolone 0.1% ointment)• BID while active, then PRN• DO NOT USE on face, axillae, genitals or
other body folds
Treatment pearls: Eczema
• If moderate-severe:• Need higher potency steoroids• Anti-pruritic• Several options:
• NVUVB• Methotrexate• Cyclosporine• Mycophenalate mofitil• *Dupilumab*
• We’re here to help J
Treatment pearls: Eczema
• Things to watch out for:• Honey colored-crusting• Open erosions• “Punched out” lesions• Intact vesicles
• Decolonization• Mupirocin 2% ointment• Apply to nares BID first week of each
month x 6 months• Bleach baths
• TIW: ¼ cup bleach in ½ bath
*BONUS* Urticaria!• Mast cell-mediated eruption (usually)• Causes: idiopathic (50%) > infection >>
drugs >>> food• Initial treatment• Scheduled antihistamines• Sample regimen:
• AM: 10mg Cetirizine (can increase to 20mg)• PM: 10mg Cetirizine (can increase to 20mg)
• “Cooling” topicals• Avoidance of possible triggers• Oral prednisone generally not indicated
• If not responding…send our way J
Number 9: Poison ivy Or other acute ACD…
Plant-based allergic contact dermatitis
• Type IV (delayed type hypersensitivity) reaction• If sensitized:• Takes ~48 hours to develop rash
• If not sensitized:• Can take up to 3 weeks to develop
rash
Treatment pearls: Plant ACD • Mild
• Topical Class 3 corticosteroid BID until improved
• Oral anti histamines• Moderate to severe
• 3 week oral prednisone taper• 60mg/40mg/20mg x 1 week each*• Watch for REBOUND
• As always, try to avoid triger• Wash off as soon as you come in contact
* Can decrease dose for elderly, those with diabetes or poorly controlled HTN
Number 10: Rosacea
Rosacea
• Chronic inflammatory dermatosis • Affects mostly middle aged
women• LOTS of triggers• Caffeine?• Alcohol• Sun• Spicy foods• Topical steroids (when stopped)
Treatment pearls: Rosacea• Mild• Avoid triggers• Gentle skin care• SPF 30 or higher with re application• Face wash options:
• Sodium sulfacetamide• Avoid exfoliants
• Topicals for BID application• Metronidazole cream• Ivermectin Cream• Azeleic acid Cream
• Moderate to severe• Antibiotics• Isotretinoin
*BONUS* “Red Flags”
WHEN TO BE WORRIED…• If your patient starts a high risk
drug and starts to notice:• Fever, painful skin, sloughing skin,
sores in eyes/mouth/genitals, new LAD, facial/ear swelling
• Timeline: • ~7-21 days for SJS/TEN• ~3-6 weeks for DRESS
“High risk” Drug Examples• Trimethoprim sulfamethoxazole • Aromatic anti-epileptics• Allopurinol• NNRTIs
Questions?