Dermatology for the PCP -...

Winterfield – Dermatology for the PCP March 9, 2018

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Dermatology for the PCP

Laura S. Winterfield, MD MPHAssociate Professor

Medical University of South Carolina

I have no relevant conflicts of interest.


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Learning Objectives

• Identify common skin conditions and potential mimickers

• Describe first‐line therapies for common skin conditions

• Recognize when to refer/collaborate with dermatology

Primary Care Skin Complaints

• Facial breakout

• Rash

• Suspicious Spot(s)


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19yo Male with breakouts

• Several years

• Tried OTC products

• No systemic meds

Acne vulgaris

Pathogenesis therapeutic targets:1. Abnormal desquamation with

obstruction of the pilosebaceouscanal

2. Androgen‐driven excess sebum production

3. Propionobacterium acnes4. Altered immune activity and

inflammation


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Acne vulgaris

Topical retinoid: mainstay of therapy

Benzoyl peroxide

Topical antibiotics

Other topicals

Oral antibiotics

Derm referral

Isotretinoin

Sebum production

AlteredKeratinization

P. acnes Inflammation

Benzoylperoxide ++ ++++Topical retinoid +++ ++Salicylic acid +Azelaic acid ++ ++ +Topical Antibiotic ++ +Oral Antibiotic + +++ ++Oral Retinoid (isotretinoin) ++++ +++ + +++Hormonal tx +++ +

Adapted from Farrah and Tan in Dermatol Ther 2016: 29:377‐84.


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Topical Retinoids

• Options:

– Adapalene

• 0.1% gel: Now OTC

– Tretinoin cream, gel, microsphere gel

• 0.025%, 0.05%, 0.1% and others

• Generics may not be stable in UV (apply at night)

– Tazarotene

• Pregnancy category X

Topical Retinoids

• Once daily application:

– Start every 1‐3 days and increase to QHS

– “Pea” size for entire face

• Thin layer, after gentle washing and drying

• SE: dryness, peeling, redness, irritation, sun sensitivity

• May take 4‐6 weeks to see benefit

• Continue for maintenance


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Antibiotics for Acne

• Topicals:– Clindamycin gel, lotion, solution

– Erythromycin gel, solution (less effective, more resistance)

• Oral:– Tetracycline

– Doxycycline

– Minocycline

• Avoid use as monotherapy– Use with topical retinoid or benzoyl peroxide

Antibiotics for Acne

• Goal: stop systemic antibiotics in <3 months

• No great data for which antibiotic is best

• Avoid use as monotherapy

• Plan for maintenance topical therapy

• Refer for consideration of isotretinoin in refractory patients, cystic lesions or scarring


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38yo Female with acne

• “clear skin as a teenager”

• Flares with menses

• Was on OCP, now has IUD

Female adult acne

• Lower face/jawline• Often resistant to traditional combination therapy

• Treat with topical retinoids• Consider topical dapsone• Target hormonal component

– OCP– Spironolactone

• Consider evaluation for PCOS especially if other signs present (hirsutism, irregular menses, etc)


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Skin Care Products

• Non‐comedogenic, oil‐free, “won’t clog pores”– Moisturizer

– Make‐up

– Sunscreen: helps reduce post‐inflammatory pigmentary alteration

• Gentle cleansers

• Gentle emollients

• Avoid harsh, abrasive, or excessively drying (alcohol)

27yo F with refractory acne

• Acne Excoriee• Predominantly secondary change

• “picker’s acne” or skin‐picking disorder

• More common in females• Consider psychiatric comorbidity– Depression– Anxiety– OCD– ADHD


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Acne treatment in Pregnancy

• Limited options

• Category B

– Topical clindamycin

– Topical azelaic acid

• Retinoids are category C or X

• Occasional intralesional kenalog for inflamed cysts

Diet in Acne

• Low glycemic diet

– Decreased acne severity

– Smaller sebaceous glands

• Low dairy

– Limit skim milk and ice cream

– Whey protein (derived from milk) reported to trigger truncal acne in adolescents


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50yo F with facial breakouts

Rosacea

• More common in fair skin types

• Flushing with fixed facial erythema

• +/‐ Papules and pustules

• No comedones

• Triggers of flushing:

– Dietary

– Environmental

– Menopause


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Treatment of Rosacea

• Trigger avoidance

• Topicals:

– Antibiotics: metronidazole gel or cream

– Anti‐inflammatory: azelaic acid cream or solution

– Anti‐parasitic: ivermectin 1% cream

– Alpha‐2 agonist: brimonidine, oxymetazoline

• May cause rebound flushing in some patients

• Oral antibiotics: tetracyclines, submicrobial dose

• Laser: Best option for persistent redness

Rosacea Mimics

Acute cutaneous lupus:Spares nasolabial folds

Dermatomyositis:mid‐facial erythemaViolaceous color

Rosacea:Crosses NL foldsTelangiectasiasNo scale+/‐ Papules and pustules


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20yo rash around the nose

Perioral dermatitis:Monomorphic papules sparing the vermillion

Treat like rosaceaavoid topical steroids and other triggers

Seborrheic dermatitis:Greasy yellow scale, nasolabial folds, ears, beard and scalp

Treat with topical ketoconazoleTopical steroids for itch

72yo F with itchy rash


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72yo F with itchy rash

• Several weeks

• Started with an abrasion

• Treating with neosporin

• No fever, chills, other sx

• No new medications

Allergic Contact Dermatitis

• Type IV hypersensitivity

• “outside‐in” pattern

• Common allergens:

– Topical antibiotics

– Nickel

– Propylene glycol

– Formaldehyde

– Poison Ivy


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Allergic Contact Dermatitis

Treatment

• Topical steroids

– High potency

• Systemic steroid taper for severe cases

– Poison ivy 3‐4 weeks

• Recurrent cases with unknown trigger?

– Referral for patch testing

Auto‐eczematization

• Severe focal allergic or eczematous dermatitis becomes generalized

• AKA: “id” reaction


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Herpes Zoster

• Respects the midline

• Lesions have scalloped borders

– Vesicles

– Erosions

– Ulcers

Herpes

• Unilateral or bilateral, often recurrent

• Scalloped borders

• Vesicles or erosions

• Often no known history of genital HSV

• Blisters on the buttocks are almost always HSV‐‐No such thing as recurrent spider bites on the buttocks!


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Eczema Herpeticum

• Superinfection of dermatitis with HSV

• Look for scalloped edges, crusting

• Increase in symptoms—pain, severe itch/burning

67yo rash all over torso

Started on back, folds and spread

Medication history:


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Morbilliform Drug Eruption

• Usually starts 7-10 days after initiation of the drug

• May start even after the d/c of a drug• Often starts in intertriginous and dependent

areas• May become erythrodermic• No blisters• No mucous membrane involvement

Morbilliform Drug Eruption

• Treat with topical steroids– Clobetasol for severe symptoms– Triamcinolone 0.1% cream or oint in 1lb jar– May add sauna suit or occlusion

• Antihistamines as needed• OK to treat through the eruption


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Drug Eruption: Red Flags

• Mucous membrane involvement• Skin pain• Blisters• Systemic symptoms / toxic appearance• Facial edema• Lymphadenopathy• Lab abnormalities:

– Liver function tests– CBC with differential: elevated eosinophils– Renal function

68yo with LE discoloration


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Stasis Dermatitis

• Topical steroids: Triamcinolone 0.1% cream

• Domeboro or dilute vinegar soaks• Emollients• Compression, elevation• Avoid topical antibiotics when possible• Bilateral lower extremity cellulitis is RARE

45yo rash on knees


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Psoriasis

• Well‐defined red scaly plaques

• Scalp, elbows, knees, umbilicus, gluteal cleft

• Palmar‐plantar variant

• Pustular variant

• Try to avoid systemic steroids

– may flare with withdrawal

Which topical steroid?

• Clobetasol• Triamcinolone 0.1%• Desoximetasone

• Fluticasone• Desonide• Hydrocortisone 2.5%

STRONGER

STRONGER

Scalp and Body

Face and Folds

Apply BID, 2 weeks on, 1 week off, d/c when flat


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vehicle for topical agents

Type Penetration Use

Ointment Most Dry areas

Cream Moderate Wet areas

Lotion Less intertriginous

Gel

Solution

Least Scalp, intertiginous

Psoriasis & Cardiovascular Risk

• Psoriasis (especially moderate to severe) is an independent risk factor for MI

• Patients should be educated about risk of CAD and counseled to address modifiable risk factors.


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Psoriasis and Psoriatic Arthritis

• May present asynchronously

• Unlike skin, joint damage may be permanent

32yo with itchy ankle


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Tinea

• Always check the feet, too!

• Especially if only 1 scaly hand:

• “1 Hand / 2 Foot tinea”

• KOH shows branching hyphae

Tinea Incognito

• Tinea that has been treated with topical steroids

• May require systemic antifungal therapy

• Terbinafine250mg/d x 2 weeks


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Granuloma Annulare

• Tinea mimicker

• Non‐scaly

• Does NOT improve with antifungals

• Etiology unknown

Sarcoidosis

Non‐scalyAnnular plaques

Predilection for scars


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46yo very itchy all over

Courtesy of Nellie Konnikov


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Crusted Scabies

• Immune compromise

• Huge mite load

Scabies Prep


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Scabies Treatment• Topical permethrin is most effective

– Treat neck down– Treat folds– Treat under nails– Repeat in a week

• Oral Ivermectin 200mcg/kg single dose– Repeat in 1 week

• Treat close contacts• Treat the environment

Concerning Spots

• Evolving Lesion (ABCD‐E)

• Tender, Burns, Itches, Bleeds

• Company It Keeps

• Solitary Lesion, “Ugly Duckling”

• Unresponsive to therapy


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What is the most likely diagnosis?

A. Atypical nevi

B. Basal cell carcinoma

C. Dermatitis

D. Actinic keratoses

E. Squamous cell carinoma

Actinic Keratosis

• Premalignant lesion to SCC

• Who? Fair skin types, > age 40

• Where? Sun‐exposed areas

• Treatment? – Cryotherapy

– Field therapy: • topical 5‐FU

• Topical imiquimod

• photodynamic therapy


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Photo courtesy of S. Desai

Actinic Keratoses

• Poorly defined erythematous macule/papule → gritty thin scale →thicker yellowish scale

• Signs of photodamage

This lesion may be associated with which of these?

A. Verruca

B. Seborrheic keratosis

C. Actinic keratosis

D. Squamous cell carcinoma

E. All of the above


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Cutaneous Horn

• Column of thick keratotic scale

• Differential Diagnosis

– Wart

– Seborrheic keratosis

– Actinic keratosis

– SCC

Most likely diagnosis?

A. Actinic keratosis


C. Cutaneous horn

D. Keratoacanthoma

E. Verruca vulgaris


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Keratoacanthoma

• Low‐grade SCC

• Rapid growth over 4‐6wks

– +/‐ spontaneous regression

• Nodule with keratin filled central crater


A. Pigmented basal cell carcinoma

B. Melanoma

C. Atypical nevus

D. Seborrheic keratosis

E. Actinic keratosis


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Seborrheic Keratosis

‐“stuck‐on”

‐keratotic

‐verrucous

‐+/‐ pigment

‐sharply

‐demarcated


A. Pigmented basal cell carcinoma

B. Melanoma

C. Atypical nevus

D. Seborrheic keratosis


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Melanoma

• Risk factors:– Fair‐skinned

– Red hair

– Atypical nevi

– Multiple nevi (>50)

– Family history

– Blistering sunburns

– Most common malignancy in women age 25‐29


A. Squamous cell carcinoma


C. Keratoacanthoma

D. Amelanoticmelanoma


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Basal Cell Carcinoma

• Who?– Fair skin types

• What?–Pearly, translucent, telangiectatic, rolled border

• Where?– Sun‐exposed areas

• Face, scalp, ears, neck > trunk, extremities

Why do a total body skin exam?

• To look for clues for diagnosis of a rash or other skin problem


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• To look for clues for diagnosis of a rash or other skin problem

• Skin cancer screening


Study by Kantor and Kantor. Arch Dermatol. 2009 Aug;145(8):873‐6

How many melanomas from their practice were the noted by the patient vs how many found on dermatologist‐initiated skin exam?


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Study by Kantor and Kantor. Arch Dermatol. 2009 Aug;145(8):873‐6

How many melanomas from their practice were the noted by the patient vs how many found on dermatologist‐initiated skin exam?

• 56.3% of melanomas were found by the dermatologist and were not part of the presenting complaint.

• Dermatologist detection was significantly associated with thinner melanomas, OR 0.42

• Thinner melanoma = better prognosis

Broad‐spectrum UVA/UVB sunscreen

Physical blockers:

titanium dioxide

zinc oxide

Chemical sunscreens


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Ultraviolet Radiation and Sunscreen

• UVA and UVB contribute to premature skin aging and skin cancer.

• UVA: Tan• UVB: Burn

• SPF = “Sunburn Protection Factor”– Only quantifies UVB protection

• “Broad Spectrum” sunscreen has UVA + UVB protection

• No UVA protection rating in the US

Sunburn protection factor (SPF)

• Measures only UVB protection

• Recommend SPF 30+

• 1 oz (“golf ball size”) each application

• Apply every 1.5‐2h


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Water Resistant = 40 minutesVery Water Resistant = 80 minutes

Questions?

[email protected]

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