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Notes compiled for Pediatrics Dermatology (Med I, Block 6, DM)

Dermatology - University of Manitoba...Tinea unguium- dermatophyte Risk factors –older age, male, immunosuppressed, DM, PVD, trauma, concomitant nail disease 7/22/2009 12 Onychomycosis

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Notes compiled for Pediatrics

Dermatology (Med I, Block 6, DM)

Contents

Class number Class name Type Department Instructor

DM003 Acne L DM Dr. J Keddy-Grant

DM007 Dermatologic Infection L DM Dr. S Silver

DM008 Dermatitis L DM Dr. M Wiseman

7/22/2009

1

Acne Vulgaris and Related Conditions

By Jill Keddy-Grant M.D., FRCPC

Acne Vulgaris

–Common disease of the pilosebaceous unit

–Usually seen in adolescents

–Can be seen at any age

–Due to the rise in androgens

Sebaceous Glands

–Widespread

–Most numerous on face and scalp

– Largest on forehead, nose and back

–Holocrine glands derived from the sides of hair follicles

– Stimulated by hormones

Pathogenesis

– Increased sebum production

– Hyperkeratosis of follicular epithelium

– Proprionibacterium acnes proliferation

– Sebum hydrolyzed to free fatty acids

– Recruitment of neutrophils

– Release of hydrolytic enzymes

– Rupture of follicular epithelium

– Inflammation and tissue destruction

DM003 - Acne Vulgaris and related conditions

7/22/2009

2

Exacerbating Factors

• Cosmetics

• Increased androgens

• Friction

• Stress

• Drugs

• Oils

Clinical Lesions - Closed Comedone

• Skin colored papule

• Non-inflammatory

• 1-2 mm

Clinical Lesions - Open Comedone

• Papule with central black core

• Non-inflammatory

• 1-2 mm

Clinical Lesions -Inflammatory Papules

• Red

• Follicular

• Papules

• Small or large

7/22/2009

3

Clinical Lesions - Pustules

• Follicular

• Papules

• Red with white center

Clinical Lesions - Inflammatory Nodules

• Deeper lesions

• Red

• 5 mm

Clinical Lesions - Acne Cysts

• Inflammatory nodules

• Central fluctuation

7/22/2009

4

Clinical Lesions - After Acne Heals

• Postinflammatory hyperemia

• Postinflamatory hyperpigmentation

• Scars

7/22/2009

5

Clinical Assessment: History

• Duration

• Severity

• Past treatment

• Cleansing / makeup routine

• Menstrual history

• Past medical history

• Drugs

• Exacerbating factors

Clinical Assessment: Physical

• Lesions– Non inflammatory (closed and open comedones)

– Inflammatory (papules, pustules, cysts)

• Location and extent

• Complications– Excoriations

– Atrophic or hypertrophic scars

– Hyper or hypopigmentation

Clinical Assessment: Tests

• Culture – when gram neg. folliculitis suspected

• Hormone assay (free testosterone, DHEAS, LH, FSH)– Androgen excess

– Prepubertal acne

– Isotretinoin resistant acne

• Skin biopsy– Rarely done to exclude other diseases

7/22/2009

6

Treatment - Comedones

• Topical retinoids

• Salicylic acid

• Sulphur

• Alpha hydroxy acids

• Manual extraction

• Chemical peels

• Oral contraceptives

• Isotretinoin

Topical Retinoids

• Most effective comedolytic agent

• Normalizes follicular hyperkeratosis

• Maximum response in 3-6 months

• Adapalene, tretinoin, tazarotene

• Creams, gels, solutions

• Irritating

Other Comedolytic Agents

• Salicylic acid

– peeling agent

• Sulphur

– peeling agent

– dries papules and pustules

• Alpha hydroxy acids

– glycolic acid, lactic acid

– mild peeling agent

Treatment – Small Inflammatory Papules and Pustules

• Benzoyl peroxide

–2.5, 5 and 10%

• Topical antibiotics

7/22/2009

7

Benzoyl Peroxide

• Inhibits P. acnes proliferation

• Dries acne papules

• Irritating

• Allergenic

• Maximum response 8-12 weeks

Topical Antibiotics

• Clindamycin, erythromycin, sulpha, neomycin

• Inhibits P. acnes proliferation

• Usually well tolerated

• May develop bacterial resistance

• Maximum response 6 weeks

Combined Benzoyl Peroxide and Topical Antibiotics

• 1% Clindamycin or 1% Erythromycin

• 5% Benzoyl peroxide

• Prevents bacterial resistance

Treatment – Large Inflammatory Papules, Pustules, Nodules and Cysts

• Oral antibiotics

• Hormonal therapy

• Oral retinoids

• Blue light laser

• Intralesional steroids

• Cryotherapy

Oral Antibiotics

• Suppress P. acnes and bacterial lipases

• Inhibit neutrophil chemotaxis

• Maximum response in 6-12 weeks

• Standard course – 6 months

7/22/2009

8

Oral Antibiotics - Adverse Effects:General

• Bacterial resistance

• Gram negative folliculitis

• Candidiasis

• Pseudomembranous colitis

Oral Antibiotics – Adverse Effects: Specific

• Tetracycline:• phototoxicity, teeth discoloration, GI upset

• Minocycline:• pigmentation, teeth discoloration, vertigo,

hypersensitivity sydrome

• Erythromycin:• GI upset

• Cotrimoxazole / trimethoprim:• rashes, bone marrow suppression

Oral Antibiotics - Dosage

• Tetracycline 500 mg BID

• Minocycline 100 mg BID

• Erythromycin 500 mg BID

• Septra DS 1 tab BID

Hormone Therapy

• Oral contraceptives– Tricyclen, Cyclen and Marvelon

– response takes 3 months

• Antiandrogens– Spironolactone – only for women

– cyproterone acetate (Diane 35)

– Response takes 6-12 months

Diane 35

• 35 ug of ethinyl estradiol

• 2 mg of cyproterone acetate

• Is a contraceptive but not marketed in Canada for this indication

• Indicated for women with acne

• Indicated for women with symptoms of hyperandrogenization

• Safety profile similar to other OC’s

Diane 35

• Reduces sebum production

–estrogen exerts a negative feedback on production of androgens

– cyproterone acetate has an antiandrogen effect on the sebaceous glands

7/22/2009

9

Oral Retinoids - Isotretinoin

• Decreases sebum production

• Normalizes follicular hyperkeratinization

• Decreases P. acnes

• Anti inflammatory and anti chemotactic effects

Isotretinoin - Benefits

• Most effective agent for treatment of acne

• Long term remissions or cures in the majority of patients

• Side effects are generally temporary and disappear when treatment is stopped

• Most patients improve after 1 or 2 courses

Isotretinoin - Indications

• Scarring acne

• Nodulocystic acne

• Acne unresponsive to conventional therapy

• Adult onset acne (>20 years)

• Persistent acne

• Severe psychological effects of acne

Isotretinoin – Side Effects

• Teratogenicity

• Mucocutaneous drying - 100%

• Arthralgias, myalgias – transient

• Headache – 10%, usually mild

• Eyes – decreased night vision, dry eyes (rarely persistent)

• Mood changes

7/22/2009

10

Isotretinoin – Side Effects

• Temporary elevation of triglycerides and cholesterol - 10 – 20%

– stop or reduce drug if TG > 800 mg/dl

• Transient mild elevation of liver enzymes –10%

Isotretinoin - Contraindications

• Absolute

– pregnancy (pregnancy prevention program)

• Relative

– history of depression

– hypertriglyceridemia / cholesterolemia

– pre – existing liver disease

Isotretinoin – Things to Avoid

• Tetracyclines

• Vitamin A supplements

• Alcohol

• Sun exposure

Isotretinoin - Dosage

• 0.5 mg/kg for the first 2 – 4 weeks

• 1 mg/kg for the next 4 – 5 months

• Total cumulative dose of 120 – 150 mg/kg

Isotretinoin - Monitoring

• Monthly follow up

• Baseline and monthly bloodwork

– pregnancy test

– liver function tests

– complete blood count

– cholesterol and triglyceride levels

7/22/2009

11

Rosacea

• Chronic condition

• Cause is unknown

• Mainly affects face

• Seen from adolescence to old age

• Most common in the third and fourth decade

Rosacea – Clinical Features

• Flushing

• Erythema

• Telangiectasia

7/22/2009

12

Acne Rosacea

• Episodes of inflammation

• Papules

• Pustules

• Edema

Rosacea - Complications

• Ocular rosacea

• Rhinophyma

• Persistent edema

Rosacea –Exacerbating Factors

• Alcohol

• Hot foods and drinks

• Spicy foods

• Hot showers

• Sunshine

• Exercise

• Stress

• Menopause

Rosacea - Treatment

• Remove exacerbating factors

• Avoid irritants

• Sunscreen

• Avoid topical steroids

7/22/2009

13

Mild Acne Rosacea - Treatment

• Topical metronidazole

• Topical antibiotics – erythromycin, clindamycin, sulpha, neomycin

• Topical sulfur

Severe Acne Rosacea - Treatment

• Tetracyclines

• Erythromycin

• Metronidazole

• Sulpha

• Isotretinoin

Erythema of Rosacea -Treatment

• Camouflage

• Topical metronidazole

• Oral antibiotics

• Laser

7/22/2009

14

Telangiectasia - Treatment

• Electrodessication

• Laser

Rhinophyma - Treatment

• Dermabrasion

• Laser resurfacing

Perioral Dermatitis

• Condition of unknown cause

• Affects perioral area

• Occasionally seen in periocular area

• Most common in young women

• Can be seen in men, children and the elderly

Perioral Dermatitis –Clinical Features

• Small papules and pustules

• Erythematous background

• Scaly

7/22/2009

15

Perioral Dermatitis –Contributing Factors

• Fluorinated steroids

• Cosmetics – creamy cleansers and moisturizers

• Fluorinated toothpastes

• Hormones

• Stress

Perioral Dermatitis - Treatment

• Remove contributing factors

• Antibiotics for six weeks

– tetracycline

– minocycline

– erythromycin

7/22/2009

16

7/22/2009

17

7/22/2009

18

7/22/2009

1

Dermatologic Presentations of

Infectious Disease

Shane Silver MD FRCPC

Overview

Bacterial infections

Viral infections

Fungal infections

Infestations

BACTERIAL Impetigo

Staph or Strep

Group II phage Staph – strains 77 and 55

Exfoliative toxin A and B

ECTHYMA

• Neglected impetigo

• Diabetics, homeless

• Crusted erosions with erythema

• Treat as for Staph or strep

DM007 - Dermatologic Presentations of infectious disease

7/22/2009

2

Furuncle and Carbuncle

Furuncle is one abscess and a carbuncle is

many furuncles together

These are follicular based

Paronychia

Staphylococcal scalded skin

syndrome Toxin mediated – exfoliative toxin

Children less than 5 and renal failure patients

Constitutional symptoms, erythema in folded regions, desquamation, bullae and positive Nikolsky sign

Mortality 3% for children and 50% adults

Culture from bullae are negative

Treat with antistaphylococcal Abx and supportive therapy

7/22/2009

3

Staphylococcal infections

Impetigo

Ecthyma

Carbuncle/furuncle

Paronychia

Staphlococcal scalded skin syndrome

Folliculitis / sycocis barbae or lupoides

Staphylococcal infections

Felon

Botryomycosis

Staphylococcal toxic shock syndrome

RED syndrome

Recurrent toxin – mediated perineal

erythema

Streptococcal

Ecthyma

Impetigo

Blistering

Distal

Dactylitis

Scarlet fever

2-10yrs old

Exotoxins B and C

Inc 2-4 days

Pharyngitis and fever, constitutional sx

Enanthen: phaynx red, edema of tonsils, white then red strawberry tongue

Exanthem: H+N, circumoral sparing, sandpaper feel, pastias lines, desquamation when rash begins to fade, exanthem 4-5 days

7/22/2009

4

Associated with Streptococcus

Streptococcal Infections

Impetigo

Ecthyma

Blistering dactylitis

Erysipelas/cellulitis

Scarlet fever

Erythema nodosum

Guttate psoriasis

Vasculitis

Sweets syndrome (acute neutrophilic dermatosis)

endocarditis

Streptococcal Infections

Streptococcal intertrigo

Streptococcal toxic shock syndrome

Perianal streptococcal cellulitis

Necrotizing faciitis

Erythema multiforme

7/22/2009

5

Bacterial infections

Viral infections

Fungal infections

Infestations

Overview

Hand foot and Mouth

Cocksackie A 16 and enterovirus 71

Constitutional symptoms, including

abdominal, sore throat

Extensor surfaces most involved

Rarely encephalitis especially with

enterovirus strain

Erythema infectiosum

30-60% of adults are seropositive

If elderly 90%

Inc 4-14 days

No longer infectious by the time they

manifest symptoms

Aplastic crisis, arthritis, hydrops, chronic

anemia in immunocompromises (lysis)

7/22/2009

6

Herpes viruses

7/22/2009

7

TZANCK SMEAR

Herpes Simplex Virus

HSV1- oral “cold sores”, 10-20% of genital HSV

HSV-2 – Genitals (prevalence is 25%)

Incubation period is 3 – 7 days

Prodrome of lymphadenopathy and Constitutional symptoms, pain tenderness and burning at the site

Grouped vesicles on erythematous base > pustules > crusts

Diagnosis – culture, DFA, Tzanck smear, PCR, serology, western blot

Varicella

7/22/2009

8

Varicella

Chicken pox and shingles (zoster)

90% of children prior to age 10

Zoster is reactivation of varicella after

primary chicken pox

Zoster in 20% of adults and 50% of

immunocompromised

Varicella

Transmission

– Airborne droplets (primary varicella or diss

zoster, not with classic zoster)

– Direct contact of vesicular fluid (primary

varicella or any form of zoster)

Incubation period - 11-20 days

Varicella

Prodrome of fever, malaise, myalgia

Pruritic macules > papules > vesicles >

pustules > crusts

Dew drops on a rose petal

Lesions in all stages of development

Zoster has similar presentation but is

dermatomal

Varicella

Complication

– Bacterial infection, CNS complication, Reyes

syndrome, Pneumonia, keratitis, hepatitis

– Zoster – Ramsay – Hunt syndrome, bacterial

infx, scarring, keratitis, motor neuropathy,

postherpetic neuralgia(incidence inc with age)

7/22/2009

9

Varicella

Prevention

– Varicella zoster immunoglobulin within 96 hrs

of exposure

– Viravax- 96% conversion rate

Molluscum Contagiosum

Molluscum contagiosum

Treatment

– Most resolve on their own

– Liquid nitrogen, cantherone

curettage, aldara, tretinoin, silver nitrate sticks, tape

stripping

Warts

Verrucae vulgaris – common wart , hands

Verrucae plantaris – plantars wart, feet

Verrucae planus – flat wart, dorsal hands

and face

Condyloma acuminata – genital warts,

genitals and perianal

7/22/2009

10

Verrucae vulgaris Verrucae plantaris

Verrucae planus Condyloma acuminata

Treatment - Warts

Cryotherapy

Salicylic acid (over the counter preps)

Glutaraldehyde

Cantherone

Imiquimod

Bleomycin

Podophyllin

Excision

Laser

DPCP

7/22/2009

11

Overview

Bacterial infections

Viral infections

Fungal infections

Infestations

Median rhomboid glossitis

Erosio interdigitalis

blastomycetica Dermatophytes

Onychomycosis

Onychomycosis – dermatophyte, mold or

yeast

Tinea unguium- dermatophyte

Risk factors – older age, male,

immunosuppressed, DM, PVD, trauma,

concomitant nail disease

7/22/2009

12

Onychomycosis

Distal lateral subungual onychomycosis (DLSO)

– T. rubrum, T. mentagrophytes

White superficial onychomycosis (WSO)

– T. mentagrophytes

– Nail plate is with leukonychia

Proximal subungual onychomycosis

– T. rubrum

– Check for HIV

Onychomycosis

Other rare organisms:

– Scopulariopsis, Alternaria, Aspergillus,

Fusarium, Scytalidium, others

Diagnosis

– CULTURE

– Direct microscopy

Onychomycosis Treatment

Establish a diagnosis

Systemic agents

– Terbinafine – 12 wks for toenails, 6 wks for finger nail

(250mg od)

– Itraconazole – 200mg bid 1 week per month for 2

months for fingernails and 3 months for toenails

– Fluconazole – 150 mg per week until nail is clear

– Ciclopirox nail lacquer

Onychomycosis Treatment

Nail is NOT expected to be clear after finishing

the 3 month coarse

Side effects

– Terbinafine –Nausea, GI upset, Taste disturbance,

hepatic toxicity, leukopenia, rash, Drug interactions

CBC, AST, ALT monthly

– Itraconazole – Nausea, GI upset, Rash, Pruritus,

Hepatic toxicity, Drug interactions

Liver test monitoring controversial

Dermatophytes

Caused by 3 genera of species

– Trichophyton

– Microsporum

– Epidermophyton

These fungi attack keratinized tissue

Depending on location is the name given to the

condition

– Tinea pedis, Tinea capitis, Tinea corporis, Tinea

manuum, Tinea cruris, tinea faciei

7/22/2009

13

Dermatophytes

Clinical – annular papulosquamous lesion

with peripheral scale and central clearing

Diagnosis – KOH, Culture

Treatment – topical or systemic antifungals

7/22/2009

14

Tinea Capitis

Ectothrix vs Endothrix

M. canis most common world wide

T. Tonsurans most common in N. America

Inflammatory via Zoophilic organisms

Tinea Capitis

Clinical

– Non- inflammatory- Seborrheic dermatitis like

– Black dot

– Kerion

– Favus

Treatment

– Griseofulvin 20mg/kg x 8 weeks

– Terbinafine 3-6mg/kg/d for 2-4 weeks

– Itraconazole 3-5mg/kg/d for 4-6 weeks

– Fluconazole 6mg/kg/d x 20 days

7/22/2009

15

Overview

Bacterial infections

Viral infections

Fungal infections

Infestations

Scabies

Sarcoptes scabiei var. hominis

Incubation 2-6 weeks

Pruritus more severe at night

Distribution – hands, web spaces, wrists,

axillae, umbilicus, sparing face in adults

Papules with excoriations, characteristic

burrows, scrotal nodules

Scabies

Clothing needs to be washed and stored

All individuals in the house to be treated

whether they are pruritic or not (prevent

ping-ponging between pts)

7/22/2009

16

7/22/2009

1

Dermatitis

Marni C. Wiseman MD FRCPC

Assistant Professor, University of Manitoba

Director, Cutaneous Oncology,

CancerCare Manitoba

What is a dermatitis?

• Difficult to define:

- inflammation involving epidermis and

superficial dermis

- assoc pruritus

- ill-defined and erythematous

- range from:

- acute- vesicles/bullae, oozing

- subacute- crusts

- chronic- lichenification

Types of Dermatitis

• Atopic dermatitis

• Contact dermatitis

• Dyshidrotic eczema

• Nummular dermatitis

• Asteatotic dermatitis

• Lichen simplex chronicus

• Stasis dermatitis

Atopic Dermatitis

Pathophysiology

• Decreased barrier function

–Decreased epidermal lipids

(ceramide)

–Increased transepidermal water

loss

THERAPEUTIC STRATEGIES FOR THE MANAGEMENT OF ATOPIC DERMATITIS (AD):

A Case-Based CHE Program

Barrier function

breakdown in skin

with AD

• Keratinocytes become less tightly held together

• Vulnerable to external factors such as chemical solvents and water, which dissolve the natural protective barrier of the skin

Atopic

Dermatitis

DM008 - Dermatitis

7/22/2009

2

Epidemiology

• 10-20% of children, 17% of

Canadian

• 85% occur before the age of 5

• 30% persist into adulthood

• 50% in children with

asthma/allergic rhinitis

Physical Examination

Distribution

• Infants • face and scalp

• Crawling infant • Extensor surfaces of extremities, trunk, face, and

neck

• Older child• Wrists, ankles, antecubital fossae, popliteal

fossae, and neck

• Adult• May be limited to hands and feet

THERAPEUTIC STRATEGIES FOR THE MANAGEMENT OF ATOPIC DERMATITIS (AD):

A Case-Based CHE Program

Typical presentation in infants, children, adolescents, and adults

Illustration by Carlos Machado, M.D.

7/22/2009

3

Weeping, Oozing, and Fissuring

7/22/2009

4

Hand Dermatitis

Reprinted from J Am Acad Dermatol 2001;44(Suppl1) with permission from Mosby, Inc.

Erythema and Excoriation

Dennie-Morgan Folds

Keratosis Pilaris Hyperlinear Palms

7/22/2009

5

Pityriasis Alba in AD Xerosis

Atopic Dermatitis: Management

• General measures

• Moisturize and hydrate

• Antihistamines prn

• Antibiotics prn

• Anti-inflammatory therapy

• Support for parent

Fitzpatrick’s Dermatology in General Medicine, 1999

Treatment – General Measures

• Avoid irritants

• Loose fitting cotton clothing; avoid wool

• Daily Bath, 10 min.

• Gentle cleansers

• Petroleum jelly around mouth when eating irritating foods (tomatoes, oranges)

Moisturization

• VERY IMPORTANT!

• Aggressive and frequent

• The greasier the better

• 2 minute rule- daily bath- pat dry-apply emmolient within 10 minutes

Fitzpatrick’s Dermatology in General Medicine, 1999

Antihistamines

• Sedating antihistamines at night

• Do not restrain hands of children

7/22/2009

6

Antibiotics

• Systemic or topical- not routine

• Antibiotics should cover staph and strep

• Watch for HSV

• Routine swabs useless

• Topical corticosteroids (“steroids”)

• Topical immunomodulators (TIMS)

– Pimecrolimus (Elidel)

– Tacrolimus (Protopic)

• Systemic

– Methotrexate

– Prednisone

– Azathioprine, MMF

– Light (U VB, narrow band UVB, UVA1, PUVA)

– Cyclosporin

Anti-inflammatories

Treatment –Corticosteroids

• Topical steroids

–Ointment preferred

–Hydrocortisone 1% to face bid/tid

–Betamethasone Valerate .1 % to

body bid/tid

–Increase strength if needed

• Skin Atrophy

• Striae

• Acne

• Tachyphylaxis

• Allergy

• Eyes – Increased Intraocular Pressure

• Systemic Effects

Corticosteroids –

Common Side Effects

Corticosteroids Can Cause

Skin Atrophy & Striae

7/22/2009

7

Impetiginized Eczema

Eczema Herpeticum (HSV)Contact Dermatitis

Two types:

1. Allergic Contact Dermatitis

- Delayed Type Hypersensitivity (type IV)

- common causes- plants, nickel….

2. Irritant Contact Dermatitis

- direct damage to tissue

- causes- strong detergents, chemicals

7/22/2009

8

Contact Dermatitis

• The clue to contact dermatitis is the

distribution!!

• Treatment:

- avoid contact

- compresses

- moderate potent topical steroids (BMV)

- severe- two week course of prednisone

Dyshidrotic Eczema

(pompholyx)

• Pruritic pinpoint vesicles on sides of

fingers, toes, palms, soles

• Idiopathic

• Treatment- topical steroid ointment

7/22/2009

9

Nummular Eczema

• Pruritic ill-defines coin-like plaques

• Trunk and extremities

• Exacerbated in winter

• Treat as atopic dermatitis

Asteatotic Dermatitis

(Eczema craquele)

• Fine fissures with erythema

• Lower extremities- most common site

• Common in elderly

• Exacerbated in winter

• Treatment - ointments- vasaline

- steroid ointments

7/22/2009

10

Lichen Simplex Chronicus

• Chronic dermatitis due to repetitive rubbing

• Lichenified, hyperpigmented, ill-defined

• Ankle – most common site

• Difficult to treat

- superpotent topical steroid +/-occlusion (dermavate)

- educate patient

Stasis Dermatitis

• Dermatitis associated with venous disease and

stasis

• Lower extremity

• Assoc: venous ulcers, hyperpigmentation,

varicosities, pedal edema, lipodermatosclerosis

• Treatment - treat venous disease

- mild steroid ointments

(hydrocortisone)

7/22/2009

11

THE END

QUESTIONS????