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