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Common Dermatologic Conditions

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Common Dermatologic Conditions Common Dermatologic Conditions Presentation Transcript

  • Common Dermatologic Conditions Toby Maurer, MD University of California, San Francisco
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  • Topicals
    • BP 5% gel (10% - more drying)
    • BP 5% wash-great for comedones back/chest
    • Retin A 0.025% - 0.1% ( vehicle determines strength - start with crème)
    • Cleocin T or erythromycin topically
    • Combination topicals good –use qd
      • Use 1 qam and 1qhs
      • ?Not improving after 8 weeks?
  • P.O. Antibiotics
    • TCN - 500 bid x 8 weeks
    • Doxycycline - 100 bid x 8 weeks
    • Minocycline - 100 bid x 8 weeks-too many side effects and high cost
    • 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
  • Laser treatment for acne
    • Placebo effect is strong so controlled studies are essential but lacking
    • INFRARED-1320 and 1450nm wavelength-light absorbed by sebaceous glands-results very poor
    • INTENSE PULSE LASER (585 nm)-decreased comedones but not inflammatory papules
    • BLUE LIGHT (415nm)- decreased inflammatory papules
    • Yeung CK et al Lasers Surg Med 2007 Jan
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  • 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
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  • Acne Rosacea
    • Common in over 40group
    • Often seen in persons of Irish decent
    • Associated with seborrheic dermatitis
  • Acne Rosacea
    • Oral antibiotics for 6-8 weeks clears skin for some amount of time
    • Topicals work less frequently-Metrocreme
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  • 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.
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  • Acne Keloidalis
    • Not acne, not keloid
    • Hard to treat-IL kenalog/surgical excision
    • Don’t crop hair at back of head!!!!
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  • Hair Loss
    • Scarring-refer
    • Non-scarring-work up
  • Non-scarring Hair Loss
    • 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)
    • Minoxidil 5% foam-use once/day
    • 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 best
      • 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
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  • Psoriasis
    • What is it?
    • How did I get it?
    • Can I give it to someone else?
    • Is it associated with anything?
    • How can I get rid of it?
  • Psoriasis-Tx:
    • Decrease the MITOTIC RATE of skin
      • Tar (LCD 5% in TAC 0.1% oint) ( Tar emulsions)
      • topical retinoids (Tazarac)
    • Decrease the INFLAMMATORY RATE of the skin
      • Steroid Ointment (mid-potency-1 st line)
      • Calcipotriene (Dovonex Creme)-not on face or groin
      • Clobetasol/Dovonex combination
      • Ultraviolet light
  • NO PREDNISONE
  • NEXT STEP
    • Time for referral
    • Methotrexate
    • Oral retinoids (Acitretin)
    • Cyclosporine
    • Biologics (Enbrel, Remicade, Humira)-most benefit in psoriatic arthritis and quick reversal of pustular psoriasis
  • Eczema
    • 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
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  • Eczema
    • Tacrolimus (Protopic) and Pimecrolimus (Elidel), newer kids on the block
      • Great for facial eczema/eyelid eczema
      • Expensive
      • Efficacy-???better than steroids
      • Black box warning-do not use in children under 2, in sunexposed areas for long periods of time
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  • Buttock Folliculitis
    • Mechanical from clothing
    • Ban roll-on good
    • Topical antibx qd
      • Cleocin/Erythro
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  • Keratosis Pilaris
    • Thickening of hair follicles on the out arms and upper legs
    • Associated with dry skin
    • Lubrication
    • Lachydrin 12% lotion bid
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  • Intertrigo
    • Pendulous breasts or pannus
    • Always component of candida
    • Blow dry area
    • Apply topical antifungals
    • Tucks pads
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  • Herpes Zoster
    • Zoster vaccine available
    • Study done on 38,000 persons 60 yrs and older (Kimberlin et al NEJM March 2007)
    • INCIDENCE was 51% lower in those that received vaccine vs placebo
    • POST HERPETIC NEURALGIA was 67% lower in vaccinated group
    • Worked best in 60-69 yr olds
    • COST?
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  • Bacterial Skin Infections
    • Most common pathogen is staph aureus
    • More methicillin resistant staph causing skin and soft tissue infections in the community
  • Approach to Treatment
    • If pus-culture it
    • If abcess –drain it-NO ANTIBIOTICS
    • Is this true for abcesses with overlying cellulitis ?-designing that study now
  • 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, Clindamycin, Cipro/Levofloxacillin
    • Consider adding rifampin 600 qd for 5 days or mupirocin ointment for staph eradication
  • Doc-I’ve been on Doxy for 10 days and no change
    • Most likely problem:
    • Could have been strep
    • Wasn’t bacteria
    • It wasn’t infected but INFLAMED
    • Did not treat the underlying dermatologic disease
    • All of the above are equally likely
    • 5) All of the above are equally likely
  • Strep-may need added coverage with Penicillin, cephalosporins
  • Was it bacterial in the first place?
    • HSV, FUNGUS, MYCOBACTERIA
    • Consider it, biopsy it and send tissue culture
    • Diseases that Masquerade as Infectious Diseases Ann Int Med 2005 Jan 4; 142:47-55
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  • INFLAMMATION
  • Hidradenitis Supparativa
    • Not an infectious disease
    • Disease of apocrine glands
    • Treatment
      • IL Kenalog
      • Minocycline
      • Surgery
      • NOT Antibiotics
      • New Biologics
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  • And what about underling derm problem???
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  • Venous Insufficiency Ulcer
    • Control Edema
      • Elevation of leg above heart 2 hours twice daily
      • Walk, don’t sit
      • Compression-UNNA BOOTS
    • Diuretics overused and not of benefit unless fluid retention due to central problem is present (CHF, CRF)
    • Create healing wound environment-DUODERM
  • When is a Leg Ulcer Infected?
    • All leg ulcers are colonized with bacteria. Surface culture of little value
    • Suspect infection if:
      • Increasing pain
      • Surrounding erythema, cellulitis
      • Focal area not healing and undermining present