General DermatologyPearls

Jason M Cheyney, MPAS, PA-CSkin Care Physicians of Georgia

Macon, Ga 31217

Common Inflammatory Diseases of the Skin

Common Infectious Diseases of the Skin

Acne Vulgaris

Atopic dermatitis

Contact Dermatitis

Approximately 45 million Americans have acne

It is often the first assault on teenagers ego

It can become an overly emotional situation

Acne is much worse than a bad hair day

Acne can affect ~ 40% of people over 25 y/o

Over $100 million spent annually to treat acne

Hair follicle plugged by abnormally keratinized cells

Increased oil retention by pilosebaceous unit

Proprionibacterium overgrowth and digestion of oil and production of free fatty acids

Free fatty acids induce inflammation

Androgen induced sebaceous gland hyperactivity

Diet plays a role with increased carbohydrate intake triggers insulin release which causes excess hormone production

Comedonal (Non-inflammatory)Open = blackheads

Closed = whiteheads

Papules: Solid inflamed elevations above the skin

Pustules: pus-filled inflammatory bumps

Nodules: Deeper lesions, often painful and can lead to discoloration and scarring.

TopicalRetinoids

BPO

Antibiotics

Dapsone

SystemicDoxycycline and Minocycline

IsotretinoinDon’t let the rumors scare you

Has been a life-saver for many patients

A Cornerstone of Treatment for All Stages

Maintenance Therapy

MOA: Normalizes Desquamation of Skin Cells

Reduces obstruction in the follicle which reduces P. acnes growth, facilitates the removal of existing comedones, and hinders formation of new lesions and reduces inflammation

Adverse effects: skin irritation, “worse before better”

“Pea-sized” amount to a clean and DRY face

Avoid eyelids – no breakouts there anyway

Wash hands after application

Often a period before skin is “retinized”

May get worse before it gets better

May get dry with use; use moisturizer

If too irritating, use every other day until ready for daily use

Mechanism of Action:- Decreases P. acnes (bactericidal)- Comedolysis

Preparations:- OTC/RX 2.5% - 10%- Wash, creams, gel, foam, combination products

Safety:- Bleaches clothes - Irritation and dryness

Available by prescription only: Lotion, Gel, Cream

Erythromycin, clindamycin, sulfacetamide, metronidazole

MOA: Reduces the bacterial population, also possess anti-inflammatory properties.

Should not be used as monotherapy

Increased incidence of bacterial resistance

Erythromycin is virtually ineffective at this point

Adverse effects: generally mild dermatitis, allergy

Available over the counter and prescription in concentrations ranging from 0.5% to 10% for the treatment of Acne vulgaris (higher concentrations are for the removal of warts).

Most often found in facial cleansers

MOA: Possesses a keratolytic effect and is a mild antiseptic.

Adverse effects: erythema, pruritus, burning/stinging sensation

Generally reserved for moderately severe to severe acne

Inflammatory acne only (not effective for comedonal acne)

Cystic or inflammatory acne resistant to topical treatment

Systemic treatment options:Oral antibioticsIsotretinoinHormonal therapy

Inflammatory or Not?- Determines Need for Antibiotics (topical or oral)

Depth of the Lesions?- Determines Role of Oral Medication

PIH or Scarring Present?- Determines How Aggressive you NEED to Be- Is Patient a Candidate for Isotretinoin?

Psychological Impact?- Will Determine How Aggressive to Get

Unknown etiology, suspect genetics and environmental influencesIncreased permeability of the skin to environmental allergens and immunologic hypersensitivity IL4 and IL13Typically appears in infancy peaks at one year of age and resolves by 6-8 years of ageSome individuals have lifelong issuesSanitary environment may predispose to development. Immune system becomes tolerant of antigens when exposed at a young age

Restoration of skin barrier of paramount importance

Consider infection stimulating superantigen and treat with appropriate antibiotic if flaring

Topical PDE4 or calcineurin inhibitors

Topical corticosteroids

UV light extremely beneficial

Oral steroids as last resort

If no control refer to dermatology for more aggressive therapy.

Caused by contact with an external allergenMost common is plant typeMetals, most common nickel but gold is a rising problem and starting to see platinumTwo most common topical causes are diphenhydramine and triple antibioticDelayed hypersensitivity, rash typically appears 5-7 days after exposureIf concerned about workplace allergen refer to dermatology or allergist for patch testingMost cases resolve spontaneously in several days to weeks

AVOIDANCE

Topical corticosteroids

Oral corticosteroids

Oral antihistamines – NON-SEDATING

If no improvement within 3-4 weeks need biopsy or referral to specialist

Tinea

Folliculitis

Impetigo

Molluscum Contagiosum

Herpes Zoster

Herpes Simplex

Pityriasis Rosea

Intertrigo

Verruca

Tinea (Dermatophyte)

Corporis

Cruris

Pedis

Versicolor (Yeast)

aka “Ringworm”

Dermatophyte Infection of the Trunk, Legs, Arms and/or Neck. (not feet, hands or groin)

Etiology

T. rubrum - most common

T. mentagrophytes

M. canis – from an infected animal

M. gypseum – from infected soil

Transmission:

Direct contact with another person, animal or infected soil.

Auto-innoculation possible (T. pedis, T. cruris)

Treatment:

Topical Antifungal of Choice

Oral Antifungal if Widespread or Recalcitrant

Oral Ketoconazole is Not Indicated for Dermatophyte Infection in the United States

BacterialPityrosporumGram NegativeHot Tub

Infection of Hair

Follicle

? Spider Bite ?

Typically Staph

Culture

Aka Malassezia Folliculitis (Yeast)Most Often Appears on Chest and BackMonomorphicBiopsy Often NecessaryTreatment Options:Topical anti-yeast creamsRecurrence is Common

Common and Contagious

Honey Colored Crusting

EtiologyStaph aureus

Strep pyogenes

Minor Skin TraumaBreak in the skin – Trauma

Atopic Dermatitis

Reactivation of the varicella(chickenpox) virusAfter initial infection disease lies dormant in the dorsal root ganglionProdrome is typically painPost-herpetic neuralgia most common complication which can lasts months to yearsOphthalmic involvement Suppressed immune status leads to greater chance of longterm side effects and complicationsRisk increases with age 4 in 1000 will develop in lifetime, 10 in 1000 after the age of 60Vaccination over 50 yoa ZVR superior to ZVL

Valacyclovir 1 gm tid for 7 days

Acyclovir 800 mg 5x/day for 7 days

Vaccination for pts 60 yo and older even pts who have had a zoster outbreak

HSV IPredominately around the mouth, eyes, face and throat

HSV IIPrimarily anogenital

Individuals with altered immune systems are more susceptible to severe complications

Eczema herpeticum

Approximately 80% of world population is infectedAsymptomatic carriers are common

Condom use to reduce transmission when active lesions present

Valacyclovir1st - 1 gm bid for 7 days

Recurrence - 500 mg bid for 3 days

Suppression - 1 gm qd

Acyclovir1st – 400 mg tid for 7 days

Recurrence – 400 mg tid for 5 days

Suppression – 400 mg bid

Typically preceded by a “Herald Patch”

Commonly mistaken for “ringworm”

Most cases asymptomatic but can be extremely pruritic

Unknown etiology, suspect viral URI as culprit

No evidence of being contagious

Typically lasts 6-8 weeks and resolves spontaneously

None necessary if asymptomatic – self limiting

UV Light can be helpful

Erythromycin, 500 mg bid for 7 days

Topical mid-potency corticosteroid for itching

Oral antihistamines – NON-SEDATING

Inflammation in areas of skin to skin contactAxillaBreastsGroin

Multiple etiologiesBacterialFungalViral

Get comfortable with KOHBe careful not to mistake inverse psoriasis or seborrheic dermatitis for intertrigoRare cases of cancer can mimic always look at the area. Please never take the pts word and treat with out an evaluation, no matter how uncomfortable.

Targeted against cause

Oral or topical antibiotic

Oral or topical antifungal

Topical corticosteroid

Diaper rash cream is a great prevention, reduces skin surface tension

Always see pt back in two weeks or if symptoms worsen.

If no improvement or worsening – BIOPSY or refer!

Multiple types – All in Human Papilloma Virus Family

Common – 2 & 4

Flat – 3, 10 & 28

Genital – 6 & 11 most common, 16 & 18 associated with most cases of cervical and penile cancer

Periungal – 2 & 4

Plantar - 1

Virus that is transmitted from person to person, typically through broken skin

Multiple Therapies – too many to list!!

My ListLeave it alone.

Cryotherapy

Topical keratolytic

Immunotherapy

Vaccine – Giardisil

MMR

Canthardin

Surgery

QUESTIONS?