Common Dermatologic Conditions

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Common Dermatologic Conditions

  1. 1. Common Dermatologic Conditions Toby Maurer, MD University of California, San Francisco
  2. 2. 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?
  3. 3. 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
  4. 4. Alternatives • Erythromycin - 500 bid • Septra - check WBC’s • Keflex-500 tid
  5. 5. Spiranolactone • Diuretic used in cirrhosis of liver • Also an anti-androgen • Useful in females who have cysts around menstruation • 50-100 mg qday continuously
  6. 6. 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
  7. 7. 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
  8. 8. Acne Rosacea • Common in over 40group • Often seen in persons of Irish decent • Associated with seborrheic dermatitis
  9. 9. Acne Rosacea • Oral antibiotics for 6-8 weeks clears skin for some amount of time • Topicals work less frequently- Metrocreme
  10. 10. 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.
  11. 11. Acne Keloidalis • Not acne, not keloid • Hard to treat-IL kenalog/surgical excision • Don’t crop hair at back of head!!!!
  12. 12. Hair Loss • Scarring-refer • Non-scarring-work up
  13. 13. 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
  14. 14. 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.
  15. 15. Too Much Hair • Vaniqa – topical cream that breaks the chemical bond of hair – apply 2x’s/day forever – 30% effective – $30/month
  16. 16. 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
  17. 17. 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?
  18. 18. 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 RATE of the skin – Steroid Ointment (mid-potency-1st line) – Calcipotriene (Dovonex Creme)-not on face or groin – Clobetasol/Dovonex combination – Ultraviolet light
  19. 19. NO PREDNISONE
  20. 20. 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
  21. 21. 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
  22. 22. EczemaEczema • 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
  23. 23. Buttock Folliculitis • Mechanical from clothing • Ban roll-on good • Topical antibx qd – Cleocin/Erythro
  24. 24. Keratosis Pilaris • Thickening of hair follicles on the out arms and upper legs • Associated with dry skin • Lubrication • Lachydrin 12% lotion bid
  25. 25. Intertrigo • Pendulous breasts or pannus • Always component of candida • Blow dry area • Apply topical antifungals • Tucks pads
  26. 26. 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?
  27. 27. Bacterial Skin Infections • Most common pathogen is staph aureus • More methicillin resistant staph causing skin and soft tissue infections in the community
  28. 28. 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
  29. 29. 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
  30. 30. Doc-I’ve been on Doxy for 10 days and no change • Most likely problem: 1) Could have been strep 2) Wasn’t bacteria 3) It wasn’t infected but INFLAMED 4) Did not treat the underlying dermatologic disease 5) All of the above are equally likely
  31. 31. 5) All of the above are equally likely
  32. 32. Strep-may need added coverage with Penicillin, cephalosporins
  33. 33. 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
  34. 34. INFLAMMATION
  35. 35. Hidradenitis Supparativa • Not an infectious disease • Disease of apocrine glands • Treatment – IL Kenalog – Minocycline – Surgery – NOT Antibiotics – New Biologics
  36. 36. And what about underling derm problem???
  37. 37. 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
  38. 38. 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

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