Post deployment 2013
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Post deployment 2013



Post Deployment presentation

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    Post deployment 2013 Post deployment 2013 Presentation Transcript

    • Dermatology for Post Deployment Jennifer Nevas, CRNP 7/23/13
    • Review: Dermatologic Terminology • Macule – flat (nonpalpable), < 1cm in size • Patch – flat (nonpalpable), > 1cm in size • Papule – raised, < 1cm in size • Plaque – raised (a broad papule), > 1cm in size • Nodule – similar to a papule but > 1cm and located in the dermis or subcutaneous fat • Vesicle – fluid filled, < 1cm in size • Bulla - fluid filled, > 1cm in size • Wheal (hive) – edematous papule or plaque that usually lasts < 24 hours
    • Dermatology Terminology Cont’d • Scale – dry or greasy laminated masses of keratin • Crust – dried serum, pus, or blood • Fissure – a linear cleft through the epidermis or into the dermis • Erosion – loss of all or portions of the epidermis alone, heals without scarring • Ulcer – complete loss of the epidermis and some portion of the dermis, heals with scarring
    • Macule Patch
    • Plaque Papule
    • Nodule
    • Vesicles
    • Bullae
    • Wheals (hives)
    • Crust
    • Fissure
    • Erosion
    • Ulcer
    • Common Benign Skin Lesions • Wart • Molluscum Contagiosum • Seborrheic Keratosis • Skin Tag • Epidermal Inclusion Cyst • Dermatofibroma • Cherry Hemangioma • Nevus
    • Warts • Etiology: Human papilloma virus (HPV) • Common in children, adolescents, & immunosuppressed pts • Presentation: verrucous topped papules • DDx: cutaneous horn, SK, SCC • Lesions may spontaneously resolve • Treatment (nongenital warts): – Cryotherapy (LN2), topical salicylic acid (solution or plaster applied to wart only once daily), surgical removal – Refer if no improvement with topicals • Treatment (genital warts): – Cryotherapy, imiquimod (M,W,F at bedtime), Podofilox (bid for 3 days then take 4 days off) , surgical removal – Refer if no improvement with topicals
    • Molluscum Contagiosum • Etiology: benign viral infection with a DNA poxvirus • Most common in children – infection through direct skin-to- skin contact or indirect skin contact w/ fomites (bath towels) • In adults, molluscum are sexually transmitted • Presentation: ~2-5mm, discrete, nontender, flesh-colored, umbilicated papules - Generally asymptomatic - Most common on the face, trunk, and extremities in children and on the genitalia in adults • DDx: Milia, keratosis pilaris, wart • Treatment: spontaneously resolution can occur or can treat with LN2, curettage, salicylic acid, topical tretinoin, or imiquimod, podofilox - Refer if no improvement with topicals and LN2 needed
    • Umbilicated papules
    • Seborrheic Keratosis (SK) • Etiology: unknown • Most common benign lesion in older individuals (often see these after age 30) • More common in individuals with white skin • Presentation: – Begin as light brown, flat lesions – Become thicker and appear “waxy and stuck-on” – May note pseudohorn cysts • DDx: wart, melanoma, BCC, SCC, lentigo • Note: acute eruption may be an sign of internal malignancy • Treatment: None, LN2, curettage, shave removal, keratolytics (ammonium lactate lotion or urea 20% cream) - Refer for shave removal or LN2 if lesion is irritated
    • Pseudohorn Cysts
    • Dermatosis Papulosa Nigra (DPN) • Variant of seborrheic keratosis found in individuals with darker skin types • Affect the face (cheeks, peri-occular) • Confused with moles • Treatment: – None – Electrodessication – EXTREME caution with LN2 – Refer if treatment desired
    • Stucco Keratosis • Variant of SK • Confused with warts or “dry skin” • Affects the legs and feet • Age > 40, M > F • Treatment: – None – Cyrotherapy – Keratolytics (Ammonium lactate 12% lotion or urea 20% cream)
    • Skin Tags (acrochordon) • Etiology: common, benign lesions thought to be caused by irritation, aging skin, hormone imbalance • Reports of 46% in the general population affected; increase in frequency with age and in obese people • Presentation: small, soft, pedunculated lesion – Usually skin- colored or hyperpigmented – Vary in size from ~2-5 mm in diameter; can grow to 5 cm – Most frequently located on the neck and the axillae, but any skin fold may be affected • DDx: neurofibroma, nevus, SK, wart • Treatment: None, scissor excision, LN2, electrodessication – Refer if patient desires removal (we have a skin tag clinic in the general surgery dept)
    • Epidermal Inclusion Cyst (EIC) • Etiology: result from the proliferation of epidermal cells within a circumscribed space of the dermis • Can occur at any age but most common in 3rd and 4th decades; twice as common in men • Presentation: Appear as flesh–colored-to-yellowish, firm, round, mobile nodules often with central punctum (pore) – Discharge of a foul-smelling “cheese-like” material is common – Occur most frequently on the face, scalp, neck, and trunk – Usually asymptomatic but may become inflamed or infected • DDx: lipoma, milia • Treatment: None required, can refer for tx with ILK or excision but, if pt’s only skin issue is a cyst, please refer to general surgery or ENT based on location of cyst
    • EIC with central punctum
    • Epidermal Inclusion Cyst, inflamed • Cyst rupture due to trauma  inflammation • Can become infected • Treatment: – warm compresses – intra-lesional steroids – +/- oral Abx • Do NOT squeeze or excise at this time!
    • Milium (milia) • Very small epidermal inclusion cysts • Face, eyelids • May be secondary to acne or trauma • Treatment: – Extraction is simple but can refer for this – Topical retinoid • Do NOT confuse with miliaria = heat rash
    • Dermatofibroma (DF) • Etiology: unknown • Can develop at any age, but usually young adulthood; more common in women • Presentation: Usually solitary (0.5 to 1 cm) lesions on extremities – Overlying skin color can range in color – May feel like a small pebble fixed to the skin surface – Tethering of overlying epidermis to the underlying lesion with lateral compression is called the “dimple sign” – Generally asymptomatic, but can be tenderness or itch – Historically attributed to a trauma to the skin (e.g., bug bite) • DDx: Nevus, keloid, melanoma, SCC, prurigo nodule • Treatment: None, can refer for ILK or excision only if the lesion is very symptomatic
    • Dimple sign
    • Cherry Hemangioma • Etiology: benign lesions formed by a proliferation of dilated venules • Frequency increases with age in both sexes and all races • Presentation: • May be found on all body sites though mucous membranes are usually spared • Lesions appearance can range from a small red macule to a larger dome-topped or polypoid papule • The color is described as bright cherry red, but lesions may appear more violaceous at times • DDx: angiokeratoma, bites, Kaposi’s, melanoma • Treatment: None, refer for removal through shave biopsy or electrodessication and curettage only in situations of irritation or hemorrhage
    • Melanocytic Nevus (mole) • Etiology: benign neoplasms composed of melanocytes • Thought to be caused by UV exposure; genetic factors also involved • Commonly form during early childhood • Most persons with light skin have a few nevi (common on trunk) • Lower prevalence in dark-skinned individuals (common on acral sites) • Presentation: • Acquired melanocytic nevi – typically < 1cm and evenly colored • Can be macular or papular • Usually tan to brown, but coloration can range from skin-colored (nonpigmented) to jet black • Not present at birth – incidence increases until ~30 yrs of age • Congenital melanocytic nevi – present at birth or soon after; vary in size • Classified as small (< 2 cm), medium (2-20 cm), or large (>20 cm) • Can commonly see an increase in the number of hair follicles • Treatment: Removal is only needed w/signs of malignant transformation – refer if lesion is suspicious!
    • Dysplastic Nevi • Clinical features: – > 6 mm – Macular component – irregular / indistinct border – Pigment variegation • Marker for increased risk of melanoma • Refer patients for evaluation of these lesions • Histologic grading – Mild  OK – Moderate  +/-excise – Severe  excise (treat as if melanoma in situ)
    • Common Skin Disorders • Tinea • Intertrigo • Herpes • Scabies • MRSA • Folliculitis • Acne • Eczema • Keratosis Pilaris • Contact dermatitis • Urticaria • Seborrheic dermatitis • Psoriasis • Pityriasis Rosea
    • Atopic Dermatitis • Etiology: pruritic disease of unknown origin; evidence indicates that genetic factors are important • Prevalence - 15-30% of children; 2-10% of adults • Male-to-female ratio is 1:1.4; affects persons of all races • 85% of cases occur in 1st year of life; 95% occur before age 5 • Presentation: incessant pruritus – ill-defined, erythematous, scaly, and crusted (eczematous) patches and plaques – Xerosis and lichenification is seen in children and adults • DDx: contact derm, psoriasis, CTCL, scabies, TV, seb derm • Treatment: moisturization, topical steroids, topical calcineurin inhibitors, antihistimines, phototherapy, mild soaps & detergents, cotton clothing; methotrexate, prednisone, or cyclosporine for severe cases; antibiotics or antivirals for secondary infections • Refer if symptoms persistent despite tx or if weird presentation
    • Atopic Dermatitis Major Features  Pruritus  Typical morphology and distribution  Facial and extensor eczema in infants and children (though can have flexural involvement in children)  Flexural eczema in adults  Dermatitis—chronic or chronically relapsing  Personal or family history or atopy—asthma, allergic rhinitis, atopic dermatitis Minor Features  Xerosis  Ichthyosis/keratosis pilaris/hyperlinear palms  IgE reactivity (immediate skin test reactivity; + RAST)  Elevated serum IgE  Early age of onset  Tendency for cutaneous infection (ie. Staph, HSV)  Nonspecific hand/foot dermatitis  Nipple eczema  Cheilitis  Conjunctivitis (recurrent)  Dennie-Morgan infraorbital fold  Keratoconus  Cataracts  Orbital darkening  Facial pallor/facial erythema  Pityriasis alba  Itch when sweating  Wool intolerance  Perifollicular accentuation  Food hypersensitivity  Influenced by environmental & emotional factors  White dermatographism or delayed blanch to cholinergic agents Need: 3 Major + 3 Minor
    • Secondarily infected: Impetiginized
    • Topical Treatment • Topical steroids – may alternate high potency with mid potency to reduce risk or use on weekends only – Risks of overuse of topical steroids include: atrophy, striae, telangiectasias, hypopigmentation (temporary), can have systemic absorption if using long-term on a large body surface area • Topical calcineurin inhibitors (steroid sparing agents) – Tacrolimus (Protopic) ointment – Pimecrolimus (Elidel) cream
    • Steroid Classes • 7 classes based on vasoconstrictive properties • Note: ointment form is stronger than cream form – Class 1 = superpotent • Clobetasol propionate • Betamethasone dipropionate – Class 3 and 4 = mid-strength • Fluocinonide • Betamethasone valerate • Triamcinolone – Class 6 and 7= low potency • Fluocinolone • Desonide • Hydrocortisone Scalp, palms, soles Trunk, extremities Face, genitals, intertriginous areas
    • Hygiene Changes/Lubrication • Avoid barrier disruption – Harsh soaps (note: we recommend using Dove or Aveeno soap and cetaphil for a face wash) – Washcloths – Bathing too frequently • Moisturize, moisturize, moisturize! – The more the better – Soak and smear technique – soak in tub of luke warm water for 20 minutes, pat dry, and liberally apply topical medication or lubricant – The VA carries derma cerin, aquaphor, ammonium lactate lotion, mentholated petrolatum – We have handouts in the derm dept on dry skin care and soak and smear technique
    • Keratosis Pilaris • Etiology: benign, genetic disorder of keratinization of hair follicles • Affects nearly 50-80% of all adolescents and ~40% of adults; often improves with age • Presentation: small folliculocentric keratotic papules (gooseflesh appearance) • Most common on outer-upper arms and thighs • Usually asymptomatic • Worse in wintertime • DDx: acne, folliculitis, atopic dermatitis, milia, lichen nitidus • Treatment: none but ammonium lactate lotion or urea cream may help
    • Allergic Contact Dermatitis • Etiology: delayed type of induced sensitivity resulting from cutaneous contact with a specific allergen to which the patient has developed a specific sensitivity • ~25 chemicals are responsible for as many as one half of all cases • Common culprits: Poison ivy, topical antibiotics (e.g., Neosporin, neomycin, bacitracin), nickel, rubber gloves, hair dye, textiles, preservatives, fragrances, benzocaine • Presentation: pruritic papules and vesicles on an erythematous base – Acute onset – Geometric morphology (circles, lines, etc) – Lichenified pruritic plaques may indicate chronic ACD – Initial site of dermatitis often provides best clue regarding the potential cause • DDx: drug rash, nummular dermatitis, seb derm, tinea, urticaria • Treatment: avoid offending agent, topical steroids or calcineurin inhibitors, antihistimines, cool soaks, emollients, oral prednisone in severe cases, can refer for patch testing to help determine allergen
    • Urticaria (hives) • Etiology: release of histamine and other vasoactive substances from mast cells and basophils • 15-20% of the general population is affected at some point during their lifetime • May be acute (lasting < 6 wk) or chronic (lasting > 6 wk) • Can occur at any age, but chronic urticaria is more common in the 40s and 50s • Acute urticaria – cause unknown in > 60% of cases; known causes include: infections (ask about recent illness and travel); caterpillars/moths; foods (e.g. shellfish, nuts); drugs (e.g. PCN, sulfonamides, salicylates, NSAIDs); environmental factors (e.g. pollens, chemicals, plants, danders, dust, mold); latex; exposure to undue skin pressure, cold, or heat; emotional stress; exercise • Chronic urticaria – cause unknown in 80-90% of patients; known causes include all of the above as well as: autoimmune disorders; chronic medical illness; cold urticaria, cryoglobulinemia, or syphilis; mastocytosis; inherited autoinflammatory syndromes
    • • Presentation: blanching, raised, palpable wheals • Occur on any skin area and are usually transient (last < 24 hrs) and migratory • Dermatographism may occur • Physical exam should focus on conditions that might precipitate urticaria or could be life threatening – refer or send to ED if: • Angioedema of the lips, tongue, or larynx • Urticarial lesions that are painful, long lasting (> 36-48 hrs), ecchymotic, or leave residual hyperpigmentation upon resolution (suggests urticarial vasculitis) • DDx: Contact or atopic dermatitis, pityriasis rosea, drug reaction, mastocytosis, urticarial vasculitis • Treatment: H1 antihistamines (ie Benadryl, hydroxyzine, Zyrtec) • Add H2 antihistamines (ie ranitidine 150mg bid) for severe or persistent urticaria • Glucocorticosteroids for refractory cases • Zyrtec 10mg dosed bid, Doxepin, or TCAs w/ potent antihistamine properties may be useful in chronic urticaria
    • Seborrheic Dermatitis • Etiology: related to a pathologic overproduction of sebum; may involve an inflammatory reaction to the yeast Malassezia • Presentation: – Erythema with greasy yellowish scale on the “T-zone” of the face, scalp, behind the ears, central chest – Dandruff – Can affect intertriginous areas • Usual onset occurs with puberty • Worsens with changes in seasons, trauma, stress, Parkinson disease, AIDS, certain medications • DDx: Atopic or contact dermatitis, rosacea, perioral dermatitis, tinea, impetigo
    • Treatment for Seborrheic Dermatitis • Shampoo at least every other day (shampoos that contain salicylic acid, tar, selenium, sulfur, or zinc are especially helpful) – leave on for 5 minutes before washing off • Synalar solution, Clobetasol 0.05% solution, or Derma- Smoothe/FS (mineral/peanut oil + fluocinolone 0.1%) for severe flaking on the scalp • Ketoconazole 2% cream twice a day (good for face, ears chest) • Hydrocortisone 2.5% cream – for short-term use during flares • Tacrolimus ointment or pimecrolimus cream as steroid sparing agents
    • Psoriasis • Etiology: Multifactorial disease that appears to be influenced by genetic and immune-mediated components • Presentation: Characterized by red papules and plaques with adherent silvery scale • Triggers: Physical trauma, stress, infection (Strep, HIV), pregnancy, medications
    • Drugs that can Trigger Psoriasis • NSAIDs • Antibiotics • Steroids • Antimalarials • Lithium • ACE inhibitors • Beta-blockers • Calcium channel blockers • Interferon • Tetanus • Antihistamines
    • For Each Clinic Visit • Ask about joint pain – 10% of patients have Psoriatic Arthritis (PsA) (Refer to Rheum) • Estimate body surface area (BSA) – An average palm = 1% – Disease Severity: • Mild <5% BSA • Moderate = 5-10% BSA (Refer to Derm) • Severe >=10% BSA (Refer to Derm) • Note – psoriasis is associated with cardiovascular disease, smoking, alcohol, metabolic syndrome, lymphoma, depression, suicide
    • Psoriasis Vulgaris • Chronic and stationary - lesions can persist for years • Distribution: – Elbows – Knees – Scalp – Lumbosacral – Unbilicus
    • Nail pitting and other nail changes are common
    • Koebner’s Phenomenon • Occurs in 20% of patients • Non-specific trauma can lead to formation of psoriasis in the area of irritation
    • Inverse Psoriasis • Involvement limited to skin fold regions • Usually associated with minimal scaling • Distribution: axilla, inframammary region, genitocrural region, neck • Often confused with intertrigo
    • Topical Treatments for Psoriasis • Topical steroids • Hydrocortisone 2.5% ointment (low strength) – good for short term use on face, penis, and intertriginous areas • Triamcinolone 0.1% ointment (medium strength) • Clobetasol 0.05% ointment (high strength) • Synthetic Vitamin D • Dovonex (calcipotriene) cream – helps reduce scale • Topical calcineurin inhibitors – steroid sparing agents (good for face, penis, intertriginous areas • Protopic ointment • Elidel cream • Common treatment regimen • calcipotriene bid Mon-Fri and clobetasol oint bid Sat-Sun for lesions on trunk and extremities; hydrocortisone or calcineurin inhibitor for face, penis, and intertriginous areas
    • Other Treatments for Psoriasis • Ultraviolet light (nbUVB and PUVA) • Systemic therapies – Conventional – methotrexate, Soriatane – Biologics – Enbrel, Humira, Remicade
    • Pityriasis Rosea • Etiology: benign, self-limited disease; considered to be a viral exanthem • More common in women, children, & young adults • Presentation: typically begins with a solitary macule that heralds the eruption (“herald patch”) • This lesion is usually a salmon-colored macule that enlarges over a few days to become a patch with a collarette of fine • Within the next 1-2 weeks, a generalized exanthem usually appears as bilateral and symmetric salmon-colored macules with a collarette scale oriented with their long axes along cleavage lines (creates classic Christmas tree pattern) • Tends to resolve over a 6 week period, but variability is common • DDx: syphilis (so important to check RPR if there are risk factors), nummular dermatitis, psoriasis, lichen planus, tinea corporis • Treatment: None required but can treat pruritus with topical steroids, oral antihistamines, topical menthol-phenol lotions • Refer if skin lesions not resolving in a few months
    • Tinea • Etiology: superficial fungal infection of skin • More common in preadolescents and in hot, humid climates • Presentation: scaly, ring-shaped, erythematous plaque that enlarges and displays central clearing; often mildly itchy • Confirm diagnosis with KOH prep • DDx: nummular dermatitis, granuloma annulare, lupus, psoriasis, pityriasis rosea
    • Tinea Corporis Tinea Pedis
    • Tinea Incognito (Majocchi’s Granuloma) • A deep folliculitis due to a cutaneous dermatophyte infection • Two types: 1) Follicular type - secondary to trauma or topical corticosteroids 2) Subcutaneous nodular type - occurs in immunocompromised pts
    • Treatment of Dermatophytosis • Topicals (localized disease) – Azoles (ketoconazole) – Allylamines (terbinafine) – Applied to the lesion and at least 2 cm beyond this area once or twice/day for at least 2 weeks, depending on which agent is used * No Lotrisone!! (topical steroid is too strong) • Systemic (extensive disease, nail or scalp involvement, Majocchi’s granuloma) – Griseofulvin, itraconazole, terbinafine – May consider referral to dermatology
    • Tinea Versicolor • Etiology: benign superficial cutaneous fungal infection with Malassezia furfur (yeast); not contagious • Most common in persons aged 15-24 years, when the sebaceous glands are more active • Presentation: Fine scaling, salmon-pink, hypo- or hyperpigmented macules and patches – Chronic, recurrent eruption occurring on upper trunk and proximal extremities – Exacerbated by warm, humid conditions • KOH confirms diagnosis • DDx: vitiligo, pityriasis alba, guttate psoriasis, CTCL • Therapy: topical azole antifungals, selenium sulfide (leave on for 5 min before washing off; weekly maintenance can help prevent recurrences)
    • Intertrigo • Etiology: an inflammatory condition of skin folds resulting from heat, moisture, and friction • Often colonized by infection - usually candida but can also be bacterial, fungal, or viral • A common complication of obesity and diabetes • Presentation: Erythema, cracking, and maceration with burning and itching at sites in which skin surfaces are in close proximity (axillae, perineum, inframammary creases, abdominal folds, inguinal creases) • DDx: contact dermatitis, seborrheic dermatitis, cellulitis, inverse psoriasis, acanthosis nigricans • Treatment: Barrier creams such as zinc oxide paste, compresses with Burrow solution 1:40 or dilute vinegar, absorbant powders and moisture-wicking undergarments, exposing the skin folds to air, topical antifungal agents for secondary infections (e.g., clotrimazole, econazole, ciclopirox, miconazole, ketoconazole, nystatin) .
    • Scabies • Etiology: Sarcoptes scabiei • In developed countries, scabies occur primarily in institutional settings and long-term care facilities; also common among children • Presentation: Extremely itchy, especially at night – Often involves armpits, groin, umbilicus, wrists, fingerwebs, nipples – Primary lesions typically include small papules, vesicles, & burrows **Itchy papules on the penis is scabies until proven otherwise! • DDx: atopic dermatitis, bug bites, folliculitis, psoriasis • Treatment: topical antiscabietic agents (e.g., Permethrin 5%) are applied from the neck down with repeat application in 7 days, oral ivermectin is also effective – Pruritus may continue for up to 2 weeks after successful treatment – Antipruritic agents (e.g. sedating antihistamines) and/or antimicrobial agents (for secondary infection) may be needed – All family members and close contacts must be evaluated and treated for scabies, even if they do not have symptoms
    • Scabies mite
    • Tip about HSV2: vesicles occurring in a sacral dermatomal distribution can occur in recurrent genital HSV disease and be confused with herpes zoster – you can do a viral culture to confirm
    • Folliculitis • Etiology: primary inflammation of the hair follicle resulting from infections, follicular trauma or occlusion • Superficial folliculitis is common and often self-limited • Affects all races, ages, and men and women equally • Presentation: acute onset of papules and pustules associated with pruritus or mild discomfort • Treatment: uncomplicated superficial folliculitis can be treated with antibacterial soaps (chlorhexidine wash) and good hand washing technique; refractory or deep lesions that have a suspected infectious etiology may need empiric treatment with topical (clindamycin solution or gel) and/or oral antibiotics that cover gram-positive organisms (choose a drug that covers MRSA in areas of high prevalence or in predisposed patients); mupirocin ointment in the nasal vestibule twice a day for 5 days may eliminate the S aureus carrier state in cases of recurrent folliculitis
    • • Prevalence: Studies have shown ~ 25-30% of the population is colonized with MSSA (usually on skin or in nasal passages) • A study in a California ED found 51% of patients presenting for evaluation of a skin infection had +MRSA cultures • Presentation: infections usually manifest as folliculitis or a similar skin infection (patients often present with a “spider bite” or “infected pimple”) • Transmission of CA-MRSA is though an open wound or from contact with a CA-MRSA carrier • Treatment: I & D of the abscess and tx with appropriate antibiotics when indicated; wound exudates should be cultured to determine the causative organism and appropriate antibiotics Oral antibiotics: Trimethoprim-sulfamethoxazole DS twice daily, w/ or w/o rifampin 600 mg/d; doxycycline 100 mg twice daily; clindamycin 450 mg 3 times a day (96% sensitive) Community Acquired MRSA (CA-MRSA)
    • Acne • Etiology: multifactorial but key factor is genetics (the propensity for follicular epidermal hyperproliferation with subsequent plugging of the follicle is inherited) • Characterized by chronic inflammatory disease of the pilosebaceous follicles (recurrence and relapse is common) • Acne is a common skin disease affecting 60-70% of Americans at some time during their lives • Key elements in the history: • Men vs. women • Menstrual history • PCOS • Previous Hx • Acne as a teenager • Habits • Picking or rubbing • Previous Tx • How long did you use? • How did you use? • Why did you stop? • Medications • Dilantin, lithium, prednisone, etc.
    • The Severity of Acne Varies • Mild – Primarily comedones, pustules and papules (<10) • Moderate – Primarily pustules and papules (10-40), comedones • Moderately severe – Numerous papules and pustules (40-100), comedones, deeper nodular lesions [Refer to derm] • Severe – Nodulocystic acne and acne conglobata [Refer to derm]
    • Mild Acne
    • Moderate Acne
    • Moderately Severe Acne
    • Severe Acne
    • Hormonal Acne • Women • Associated with PCOS, hirsutism, and menstrual irregularity • Treatment: - Multiple estrogen- based OCPs - Spironolactone • Check labs - DHEAS and testosterone
    • Treatment of Acne
    • Mild Acne Primary Treatment • Topical tretinoin (Retin-A) + topical antimicrobial • Tretinoin (Retin-A) at night - 0.025%, 0.05%, and 0.1% cream (gel in pts with very oily skin) • Topical clindamycin 1% gel or lotion in the morning Adjunctive Treatment • Salicylic acid 2% wash to entire face up to twice daily • Benzoyl peroxide (BPO) 2.5-5% gel or lotion in the morning as spot treatment (note that BPO bleaches clothing/bedding) Mild Acne (faux pas) • Topical antimicrobial (e.g., clindamycin) as monotherapy or for >3 months duration encourages antimicrobial resistance
    • Moderate Acne Primary Treatment • Topical retinoid + ORAL antibiotic (esp in acute phase) • Tretinoin (Retin-A) or tazarotene at night • Oral doxycycline or minocycline once daily (often start 100mg bid for a month then drop to once daily and get minocycline to 50mg daily); these should not be taken with dairy but take with food to prevent stomach upset - Amoxicillin and Bactrim (low dose) are also options Adjunctive Treatment • Salicylic acid 2% wash to entire face up to twice daily • Benzoyl peroxide 2.5-5% gel in the morning to entire face • In women, consider oral contraceptive pills and/or spironolactone
    • Moderate-Severe Acne Primary Treatment • Referral to dermatology warranted • Topical retinoid + ORAL antibiotic (high dose) • Tretinoin (Retin-A) or tazarotene at night • Oral doxycycline or minocycline twice daily - Amoxicillin and Bactrim (high dose) are also options Adjunctive Treatment • Benzoyl peroxide 2.5-5% gel in the morning to entire face • Consider Accutane • In women, highly consider spironolactone (alternative) in addition to oral contraceptive pills (OCP)
    • Severe Acne Primary Treatment - Refer to dermatology for tx • Oral isotretinoin (Accutane) as monotherapy OR • Potent topical retinoid (e.g., tazarotene) + ORAL antimicrobial (high dose) + topical benzoyl peroxide Adjunctive Treatment • Women are automatically on OCPs • In women, consider adding spironolactone • OK to add oral or topical antibiotics but be mindful of drug interactions After Accutane • Bridge to topical retinoids and/or oral antibiotics or spironolactone
    • Topical retinoids should be 1st line in maintenance therapy • Target microcomedo formation • Topical retinoid monotherapy is effective • No issue with antimicrobial resistance • Add BPO and not antibiotics for maintenance
    • Therapeutic Considerations • All discussed therapies for acne are pregnancy class C or worse • Spironolactone - Can raise K level so renal function must be normal • Oral antibiotics should be used to shutdown acute inflammatory acne over a few months • If previously on oral antibiotic and patient flares, then restart on the same oral antibiotic (no need to switch) • Start Accutane slowly, especially in those with nodulocystic acne (can paradoxically induce flare)
    • Reducing Antibiotic Resistance • Concurrent use of oral and topical antibiotics should be avoided • Avoid using antibiotics as monotherapy • Antibiotics should be discontinued as soon as inflammatory lesions disappear • Topical antibiotics may be used in mild to moderate acne but should be used in combo with a retinoid or BPO