A1- Contact Dermatitis and Sherlock Holmes · 2020-07-07 · melodie young, msn, agnp a1 52....

Melodie Young, MSN, AGNP

www.mindfuldermdallas.com

Sherlockian Approach to Dermatology Disorders Shared CasesExactly Watson: Dermatology Investigations

Privileged and Confidential; Photographs are not to be used without express written consent

Contact Dermatitis and Sherlock Holmes Melodie Young, MSN, AGNP A1

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Disclosures

• Advisor/Speaker: Abbvie, Amgen, Eli Lilly, Janssen, Leo Pharma, Novartis, Sun Pharma, UCB

• Clinical Research-Sub Investigator: Eli Lilly, Sun Pharma, Menlo Therapeutics, Chemo Centryx, Janssen, Amgen, UCB, Abbvie, Galderma, Bristol Myers Squibb, Leo Pharma


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Objectives•Review a strategic approach to solving simple to complex dermatology cases

•Discuss differentials associated with common presentations in primary care

•Review the most common antigens for all subsets of contact dermatitis, basic treatment paradigms and when to refer.


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Rhu Dermatitis Exposure to Rash…and More Rash

• Exposed to vines on Saturday

• Scattered pruritic vesicles by Tuesday

• Widespread vesicles and bullae throughout by Wednesday

• Generalized erythema by Thursday

• New vesicles and erythematous patches by Friday


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Can you spread allergic contact dermatitis through scratching?

YES OR NO? WHY OR WHY NOT?


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Patient photos

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Allergic Contact Dermatitis Photos

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Rhu Dermatitis: Day 4 and Day 5

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Treatment

• Systemic corticosteroids-oral taper and/or intramuscular

• Topical corticosteroids-class I

• Homeopathic therapy-boro/vinegar solutions

• Antipruritics

• Review expectations and urgencies


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Genital Lesions

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Genital Rash-The Exam and Differentials

-Female in mid 30’s reports chronic rash on labia

-History of moderate atopic dermatitis and psoriatic plaques

-Review signs and symptoms and any precipitating factors and treatments (non-prescribed but many tried)

-Do TBSE-including flexures, scalp/ears and genitalia

Infectious - rule out tinea or candida

Dermatitis– contact (hygiene products) vs irritant (shaving)

Dermatoses-psoriasis vs intertrigo vs atopic


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Genital Psoriasis: Treated with ixekizumab

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©myoung


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Case: Rash on Feet in 65 y/o Healthy Female

• Presents after having seen 2 other dermatologists

• Told it is fungal but not responding to topical ketaconazoleor ciclopirox

• Sudden onset mid-summer and extremely pruritic

• Wears only flip flops

• Differential• Tinea pedis• Allergic Contact Dermatitis• Bullous impentigo


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Assessment: Infectious vs. Contact Dermatitis

• Outdoor activities?• Yard work-chemicals,

footwear?• Animal or insect bite?

• Nail salon visit?

• Affecting anyone else in household?

• Diabetes or vascular disease?

• OTC treatments?

©myoung


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Diagnostic and Treatment Plan

Culture for bacteria and fungal infection

Wash flip flops (she wore the same ones in the yard and garden-even to fertilize and use pesticides) or change gardening footwear

Treat with topical mid-potency corticosteroids


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Next Steps

• Biopsy including investigation of fungal hyphae and spores

• Initiate therapy for pruritis (primary reason she came to clinic) -clotrimazole/betamethasone combination or just class 1 or 2 topical corticosteroid, or anti-fungal

• Culture for bacteria to rule out bullous impentigo

• Change footwear and wash all of her flip flops

• OTC aluminum acetate Burow’s solution compresses


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Case Solved

• Culture negative for bacterial infection

• Fungal exam - + for tinea pedis

• Report of exacerbating rash with prescription corticostseroids

• Initiated naftifine antifungal gel bid x 30 days as well as terbinafine 250mg po x 2 weeks

• Discontinue all topical corticosteroids and OTC diphenhydramine/zinc acetate topical


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Facial Rash

Female in her mid-30s with new onset erythematous pustules and papules in nasolabial folds and chin

Treated with OTC hydrocortisone when it presented several weeks prior as ‘dry patches that burned’


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Perioral Dermatitis

• Nasolabial rash, papules or pustules

• Pruritic or sensitive

• May come and go

• May affect area around the nose, chin or eyes

• Linked to corticosteroid use-topically, nasal spray, and inhalers

• Linked to cinnamon, whitening products, acidic foods, fluorinated dental products and overuse of skincare products

• Most common in young adult females


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Perioral Dermatitis Differentials

• Acne

• Rosacea

• Steroid Induced Perioral Dermatitis (POD)

• Post-dental Procedure (POD)

• Contact Dermatitis


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POD- Mild to moderate: due to 1% hydrocortisone cream bid x 2 weeks

• Wean off hydrocortisone to prevent rebound

• Oral doxycycline til clear

• Sulfacetamide/sulfur cleanser or lotion

• Metronidazole

• Discontinue possible oral hygiene contributors

• Off-label tacrolimus or pimecrolimus

• Gentle care

• Topical erythromycin


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Photos: Recently discharged after IV antibiotics for cellulitis

©myoung


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Cellulitis

47 yo male referred by infectious disease physician post hospitalization for cellulitis

Can you clear him without using any more %$#$& steroids?

History of plaque psoriasis treated with mid to high potency corticosteroids (legs and feet)

History of tinea mid-sole also found in groin folds bilaterally


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Cellulitis continued

• Note erythema throughout-from waist down

• Psoriasis rebound from systemic corticosteroids in hospital

• Note skin atrophy with visible vessles from chronic corticosteroid use over decades

• Started biologic and continued with antifungal creams on feet, genitalia and inguinal folds


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Psoriasis flare after holding his biologic

©myoung


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Nail Disease Psoriasis or Tinea or Something Else?


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Nail Exam and Differentials

• Features-pits, stains, lifting, trauma induced

• Exam all 20 nails

• Rule out psoriasis

• Rule out tinea in other highrisk areas

• Familial

• Presentation and progression history

• Clippings for culture


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Nail Disease

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©myoung


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Nail Treatments

• Psoriasis

• Beware of psoriatic arthritis

• Treatment• Any biologic• Apremilast or methotrexate• Topicals ineffective

• Tinea• 6-12 weeks of terbinafine 250mg po q d• Lab monitoring maybe but not likely• Watch drug interactions• Topical agents-efinaconoazole and

tavaborole most effective (nearing 60%) if used for 9-12 months

• Ciclopirox ( approximately 20% efficacy) over 9-12 months

• If yeast, not fungus, consider fluconazole


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Eyelid Dermatitis: Contact, Atopic, Irritant, Periocular or Psoriasis

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Eyelid Dermatitis

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Eyelid Dermatitis Workup

• Bilateral or unilateral

• New or continuous

• Examine rest of neck, face, ears and hands

• Review all skin and hair care products

• Natural DOES NOT mean it is safe or not an allergen

• Review nail treatments and other common allergens

• OTC treatments as important as PRESCRIPTION therapies

• “Skin Cleanse” of all likely cause/irritants

• Refer for allergy testing to dermatology-not allergist


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Female Pattern Hair Loss

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Hair Loss

• Common complaint among middle-aged females

• Work-up vs. refer to dermatology

• Treatments• Topical Minoxidil 5% only FDA approved therapy• Oral finasteride 1mg (off-label)• Protein Rich Plasma Injections (off-label)• Biotin no sound evidence of efficacy• ‘Laser cap’-FDA cleared as a device 650nm wavelength• Evaluate for weight loss, dietary restrictions, anemia, acute

stressors, hormonal therapy changes, and familial history


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Atopic Dermatitis

• 47 year old female with decades of pruritis and rash

• Intermittent history of asthma

• History of seasonal allergies

• Only relief has been obtained with systemic steroids

• Attempted treatment with cyclosporin A, methotrexate, mycophenolate mofetil and phototherapy

• Dupilumab “life changing”


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Atopic Dermatitis

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Scalp Dermatitis: Flaking or FLAKING


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Recalcitrant Psoriasis

• 10 years of biologic therapies to finally clear scalp/facial psoriasis in young Asian female

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The Work-Up

• Review history, signs and symptoms• Review prior treatments• Review family history • TBSE to rule out psoriasis, seb derm, lupus or psoriasis• Biopsy if uncertain or considering skin cancer or lupus

and with hairloss• Culture if concerned about tinea infection


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Differentials of Scalp Dermatitis

•Seborrheic dermatitis•Psoriasis•Dirty scalp and/or products build up•Lupus lesions•Actinic damage •Skin Cancers


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Common Scalp Dermatitis Therapies

• Prescription products• Corticosteroid lotions, shampoos, solutions or foams• Ciclopirox shampoo• Ketaconazole

• Over-the-counter therapies• Zinc pyrithicone• Tar• Salicylic acid• Tea tree oil• Ketaconazole


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Ear Pain

• Psoriasis patient with complaint of ear pain-diagnosed by PCP as probably TMJ. Dentist disagrees

• History of occupational hearing loss-wearing hearing aids-but unable to tolerate due to pain

• Comes to see me thinking his psoriasis is flaring, wanting to change medications.


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Eye Didn’t Know

• CC: Severe Itch

• HPI: Lifelong history of atopy• Never controlled

• PMH: Decreased vision legally blind, corneal transplant x 3, failure

• Allergies: NKDA

• Medications: Triamcinolone Acetonide Cream 0.1% 464 gm jar x ten years for management of symptoms, PRN triamcinolone acetonide injectable suspension 40 mg, IM

• FMH: unknown adopted

• Social: Disability

• Health Related Behaviors- ETOH daily


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Poison Ivyor

Is It?

• Evaluated for my multiple dermatologists for “poison ivy that will not go away”

• Pruritic rash on arms and trunk that has been getting worse for past two months

• Triamcinolone topical 80 mg IM no relief

• No major medical illnesses or hospitalizations noted

• ROS: Stiffness

• Allergies: NKDA

• Medications: Prednisone 30 mg po qd

• FMH: Paternal BBC

• Social: Enterprise sales x 25 years

• Health Related Behaviors- ETOH 3x per week


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Patient Photos


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Data

Rheumatology work up negative

Second biopsy performed

Spoke to first dermatopathologist for clinical correlation and additional differentials for consideration

Pulled first biopsy and sent to both specimens for second opinion, with copy of chart note and photography and phone consultation


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Prime Suspect


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Prognosis

• Chest X-ray and CT show fibrosing

• Prognosis Poor• Arrest pathogenesis through removal of agent

• This was a concern

• Maintain current function • Hope for reversal of some symptoms, restore ROM• Put on short term disability


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References

• Epocrates app

• Uptodate.com accessed June 24, 2020

• Habif. T. Clinical Dermatology A Color Guide to Diagnosis and Therapy, Mosby, 3rd Edition

• Rook, Wilkinson, Ebling. Textbook of Dermatology, Blackwell Science. Vol 1-4, 6th Edition

• Wolff and Johnson, Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, McGraw Hill. 6th Edition

• The Willis Eye Manual, 5th Edition, Wolters Kluwer Health


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A1- Contact Dermatitis and Sherlock Holmes · 2020-07-07 · melodie young, msn, agnp a1 52....

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Transcript of A1- Contact Dermatitis and Sherlock Holmes · 2020-07-07 · melodie young, msn, agnp a1 52....