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Post deployment 2013


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Post Deployment presentation

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Post deployment 2013

  1. 1. Dermatology for Post Deployment Jennifer Nevas, CRNP 7/23/13
  2. 2. 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
  3. 3. 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
  4. 4. Macule Patch
  5. 5. Plaque Papule
  6. 6. Nodule
  7. 7. Vesicles
  8. 8. Bullae
  9. 9. Wheals (hives)
  10. 10. Crust
  11. 11. Fissure
  12. 12. Erosion
  13. 13. Ulcer
  14. 14. Common Benign Skin Lesions • Wart • Molluscum Contagiosum • Seborrheic Keratosis • Skin Tag • Epidermal Inclusion Cyst • Dermatofibroma • Cherry Hemangioma • Nevus
  15. 15. 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
  16. 16. 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
  17. 17. Umbilicated papules
  18. 18. 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
  19. 19. Pseudohorn Cysts
  20. 20. 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
  21. 21. 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)
  22. 22. 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)
  23. 23. 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
  24. 24. EIC with central punctum
  25. 25. 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!
  26. 26. 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
  27. 27. 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
  28. 28. Dimple sign
  29. 29. 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
  30. 30. 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!
  31. 31. 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)
  32. 32. Common Skin Disorders • Tinea • Intertrigo • Herpes • Scabies • MRSA • Folliculitis • Acne • Eczema • Keratosis Pilaris • Contact dermatitis • Urticaria • Seborrheic dermatitis • Psoriasis • Pityriasis Rosea
  33. 33. 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
  34. 34. 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
  35. 35. Secondarily infected: Impetiginized
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. • 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. Drugs that can Trigger Psoriasis • NSAIDs • Antibiotics • Steroids • Antimalarials • Lithium • ACE inhibitors • Beta-blockers • Calcium channel blockers • Interferon • Tetanus • Antihistamines
  47. 47. 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
  48. 48. Psoriasis Vulgaris • Chronic and stationary - lesions can persist for years • Distribution: – Elbows – Knees – Scalp – Lumbosacral – Unbilicus
  49. 49. Nail pitting and other nail changes are common
  50. 50. Koebner’s Phenomenon • Occurs in 20% of patients • Non-specific trauma can lead to formation of psoriasis in the area of irritation
  51. 51. Inverse Psoriasis • Involvement limited to skin fold regions • Usually associated with minimal scaling • Distribution: axilla, inframammary region, genitocrural region, neck • Often confused with intertrigo
  52. 52. 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
  53. 53. Other Treatments for Psoriasis • Ultraviolet light (nbUVB and PUVA) • Systemic therapies – Conventional – methotrexate, Soriatane – Biologics – Enbrel, Humira, Remicade
  54. 54. 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
  55. 55. 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
  56. 56. Tinea Corporis Tinea Pedis
  57. 57. 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
  58. 58. 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
  59. 59. 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)
  60. 60. 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) .
  61. 61. 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
  62. 62. Scabies mite
  63. 63. 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
  64. 64. 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
  65. 65. • 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)
  66. 66. 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.
  67. 67. 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]
  68. 68. Mild Acne
  69. 69. Moderate Acne
  70. 70. Moderately Severe Acne
  71. 71. Severe Acne
  72. 72. Hormonal Acne • Women • Associated with PCOS, hirsutism, and menstrual irregularity • Treatment: - Multiple estrogen- based OCPs - Spironolactone • Check labs - DHEAS and testosterone
  73. 73. Treatment of Acne
  74. 74. 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
  75. 75. 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
  76. 76. 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)
  77. 77. 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
  78. 78. 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
  79. 79. 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)
  80. 80. 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