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Transcript of Dermatology for the PCP - · PDF fileWinterfield–Dermatology for the PCP March 9, 2018 1...

  • Winterfield DermatologyforthePCP March9,2018

    1

    DermatologyforthePCP

    LauraS.Winterfield,MDMPHAssociateProfessor

    MedicalUniversityofSouthCarolina

    Ihavenorelevantconflictsofinterest.

  • Winterfield DermatologyforthePCP March9,2018

    2

    LearningObjectives

    Identifycommonskinconditionsandpotentialmimickers

    Describefirstlinetherapiesforcommonskinconditions

    Recognizewhentorefer/collaboratewithdermatology

    PrimaryCareSkinComplaints

    Facialbreakout

    Rash

    SuspiciousSpot(s)

  • Winterfield DermatologyforthePCP March9,2018

    3

    19yoMalewithbreakouts

    Severalyears TriedOTCproducts Nosystemicmeds

    Acnevulgaris

    Pathogenesis therapeutictargets:1. Abnormaldesquamationwith

    obstructionofthepilosebaceouscanal

    2. Androgendrivenexcesssebumproduction

    3. Propionobacterium acnes4. Alteredimmuneactivityand

    inflammation

  • Winterfield DermatologyforthePCP March9,2018

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    Acnevulgaris

    Topicalretinoid:mainstayoftherapyBenzoylperoxideTopicalantibioticsOthertopicalsOralantibioticsDerm referralIsotretinoin

    Sebumproduction

    AlteredKeratinization

    P. acnes Inflammation

    Benzoylperoxide ++ ++++Topicalretinoid +++ ++Salicylicacid +Azelaic acid ++ ++ +TopicalAntibiotic ++ +OralAntibiotic + +++ ++OralRetinoid(isotretinoin) ++++ +++ + +++Hormonal tx +++ +

    AdaptedfromFarrah andTaninDermatol Ther 2016:29:37784.

  • Winterfield DermatologyforthePCP March9,2018

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    TopicalRetinoids

    Options: Adapalene

    0.1%gel:NowOTC Tretinoin cream,gel,microspheregel

    0.025%,0.05%,0.1%andothers GenericsmaynotbestableinUV(applyatnight)

    Tazarotene PregnancycategoryX

    TopicalRetinoids

    Oncedailyapplication: Startevery13daysandincreasetoQHS Peasizeforentireface

    Thinlayer,aftergentlewashinganddrying SE:dryness,peeling,redness,irritation,sunsensitivity

    Maytake46weekstoseebenefit Continueformaintenance

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    AntibioticsforAcne

    Topicals: Clindamycingel,lotion,solution Erythromycingel,solution(lesseffective,moreresistance)

    Oral: Tetracycline Doxycycline Minocycline

    Avoiduseasmonotherapy Usewithtopicalretinoidorbenzoylperoxide

    AntibioticsforAcne

    Goal:stopsystemicantibioticsin

  • Winterfield DermatologyforthePCP March9,2018

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    38yoFemalewithacne

    clearskinasateenager Flareswithmenses WasonOCP,nowhasIUD

    Femaleadultacne Lowerface/jawline Oftenresistanttotraditionalcombinationtherapy

    Treatwithtopicalretinoids Considertopicaldapsone Targethormonalcomponent

    OCP Spironolactone

    ConsiderevaluationforPCOSespeciallyifothersignspresent(hirsutism,irregularmenses,etc)

  • Winterfield DermatologyforthePCP March9,2018

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    SkinCareProducts

    Noncomedogenic,oilfree,wontclogpores Moisturizer Makeup Sunscreen:helpsreducepostinflammatorypigmentary alteration

    Gentlecleansers Gentleemollients Avoidharsh,abrasive,orexcessivelydrying(alcohol)

    27yoFwithrefractoryacne AcneExcoriee Predominantlysecondarychange

    pickersacneorskinpickingdisorder

    Morecommoninfemales Considerpsychiatriccomorbidity Depression Anxiety OCD ADHD

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    AcnetreatmentinPregnancy

    Limitedoptions CategoryB

    Topicalclindamycin Topicalazelaic acid

    Retinoids arecategoryCorX Occasionalintralesional kenalog forinflamedcysts

    DietinAcne

    Lowglycemicdiet Decreasedacneseverity Smallersebaceousglands

    Lowdairy Limitskimmilkandicecream Wheyprotein(derivedfrommilk)reportedtotriggertruncal acneinadolescents

  • Winterfield DermatologyforthePCP March9,2018

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    50yoFwithfacialbreakouts

    Rosacea Morecommoninfairskintypes Flushingwithfixedfacialerythema +/ Papulesandpustules Nocomedones Triggersofflushing:

    Dietary Environmental Menopause

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    TreatmentofRosacea

    Triggeravoidance Topicals:

    Antibiotics:metronidazolegelorcream Antiinflammatory:azelaic acidcreamorsolution Antiparasitic:ivermectin 1%cream Alpha2agonist:brimonidine,oxymetazoline

    Maycausereboundflushinginsomepatients

    Oralantibiotics:tetracyclines,submicrobial dose Laser:Bestoptionforpersistentredness

    RosaceaMimics

    Acutecutaneouslupus:Sparesnasolabial folds

    Dermatomyositis:midfacialerythemaViolaceous color

    Rosacea:CrossesNLfoldsTelangiectasiasNoscale+/ Papulesandpustules

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    20yorasharoundthenose

    Perioraldermatitis:Monomorphicpapulessparingthevermillion

    Treatlikerosaceaavoidtopicalsteroidsandothertriggers

    Seborrheic dermatitis:Greasyyellowscale,nasolabial folds,ears,beardandscalp

    TreatwithtopicalketoconazoleTopicalsteroidsforitch

    72yoFwithitchyrash

  • Winterfield DermatologyforthePCP March9,2018

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    72yoFwithitchyrash

    Severalweeks Startedwithanabrasion

    Treatingwithneosporin

    Nofever,chills,othersx

    Nonewmedications

    AllergicContactDermatitis

    TypeIVhypersensitivity outsideinpattern Commonallergens:

    Topicalantibiotics Nickel Propyleneglycol Formaldehyde PoisonIvy

  • Winterfield DermatologyforthePCP March9,2018

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    AllergicContactDermatitis

    Treatment Topicalsteroids

    Highpotency Systemicsteroidtaperforseverecases

    Poisonivy34weeks Recurrentcaseswithunknowntrigger?

    Referralforpatchtesting

    Autoeczematization

    Severefocalallergicoreczematousdermatitisbecomesgeneralized

    AKA:idreaction

  • Winterfield DermatologyforthePCP March9,2018

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    Herpes Zoster

    Respectsthemidline Lesionshavescallopedborders

    Vesicles Erosions Ulcers

    Herpes

    Unilateralorbilateral,oftenrecurrent Scallopedborders Vesiclesorerosions OftennoknownhistoryofgenitalHSV

    BlistersonthebuttocksarealmostalwaysHSVNosuchthingasrecurrentspiderbitesonthebuttocks!

  • Winterfield DermatologyforthePCP March9,2018

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    Eczema Herpeticum

    Superinfection ofdermatitiswithHSV Lookforscallopededges,crusting Increaseinsymptomspain,severeitch/burning

    67yo rash all over torso

    Startedonback,foldsandspread

    Medicationhistory:

  • Winterfield DermatologyforthePCP March9,2018

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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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    DrugEruption:RedFlags Mucousmembraneinvolvement Skinpain Blisters Systemicsymptoms/toxicappearance Facialedema Lymphadenopathy Lababnormalities:

    Liverfunctiontests CBCwithdifferential:elevatedeosinophils Renalfunction

    68yowithLEdiscoloration

  • Winterfield DermatologyforthePCP March9,2018

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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

    45yorashonknees

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    Psoriasis

    Welldefinedredscalyplaques Scalp,elbows,knees,umbilicus,glutealcleft Palmarplantarvariant Pustular variant

    Trytoavoidsystemicsteroids mayflarewithwithdrawal

    Whichtopicalsteroid?

    Clobetasol Triamcinolone0.1% Desoximetasone

    Fluticasone Desonide Hydrocortisone2.5%

    STRO

    NGE

    RSTRO

    NGE

    R

    Scalp and Body

    Face and Folds

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

  • Winterfield DermatologyforthePCP March9,2018

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    vehicle for topical agentsType Penetration Use

    Ointment Most Dry areas

    Cream Moderate Wet areas

    Lotion Less intertriginous

    GelSolution

    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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    PsoriasisandPsoriaticArthritis

    Maypresentasynchronously Unlikeskin,jointdamagemaybepermanent

    32yo with itchy ankle

  • Winterfield DermatologyforthePCP March9,2018

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    Tinea

    Alwayscheckthefeet,too!

    Especiallyifonly1scalyhand: 1Hand/2Foottinea

    KOHshowsbranchinghyphae

    Tinea Incognito

    Tinea thathasbeentreatedwithtopicalsteroids

    Mayrequiresystemicantifungaltherapy

    Terbinafine250mg/dx2weeks

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    GranulomaAnnulare

    Tinea mimicker Nonscaly DoesNOTimprovewithantifungals

    Etiologyunknown

    Sarcoidosis

    NonscalyAnnularplaques

    Predilectionforscars

  • Winterfield DermatologyforthePCP March9,2018

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    46yoveryitchyallover

    Courtesy of Nellie Konnikov

  • Winterfield DermatologyforthePCP March9,2018

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    CrustedScabies

    Immunecompromise

    Hugemiteload

    Scabies Prep

  • Winterfield DermatologyforthePCP March9,2