Eczema and Atopic Dermatitis

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Dermatology For The Dermatology For The Primary Care Primary Care Practitioner Practitioner Michael G. Bryan, M.D. Michael G. Bryan, M.D. Dermatologist Dermatologist Las Vegas Skin & Cancer Las Vegas Skin & Cancer Clinics Clinics

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Transcript of Eczema and Atopic Dermatitis

  • 1. Dermatology For The Primary Care Practitioner Michael G. Bryan, M.D. Dermatologist Las Vegas Skin & Cancer Clinics

2. Disclosures

  • Novartis Speakers Bureau

3. Overview

  • Acne
  • Eczema
  • Tinea
  • Psoriasis
  • Skin Cancer
  • Biopsies

4. Acne

  • Disease of youth-adult
  • > 85% of individuals affected
  • 4 main pathophysiologic factors:
      • 1follicular plugging
      • 2excess sebum (oil)
      • 3presence/activity ofP. acnes
      • 4 inflammation

5. Acne

  • No set recipe for acne treatment--different patients make different kinds of lesions
  • Comedonesclogged pores (noninflammatory)
      • Openblackheads
      • Closedwhiteheads
      • (not pustules)
  • Inflammatory lesions:
      • Red papules
      • Pustules
      • Nodules/cysts
  • Treatments should target patients type of acne

6. Topical Acne Treatments

  • Comedolytics (topical retinoids)combat clumping of cells and follicular plugging:
      • Retin-A (tretinoin)
      • Differin (adapalene)
      • Tazorac (tazarotene)
  • Benzoyl peroxideanti-inflammatory,
  • antimicrobial toP. acnes(noresistance)
  • Topical antibiotics P. acnes
      • Clindamycin
      • Erythromycin

7. Acne Treatments contin.

  • Oral antibiotics P. acnes(resistance), anti-inflammatory
      • Tetracycline, doxycycline, minocycline
      • Trimethoprim/sulfamethoxazole
      • Erythromycin
  • Hormonal Therapiesreduce circulating androgens
      • Ortho-tri-cylcen (labeled)
      • Yasmin, Yaz (off-label)
      • Spironolactone

8. Acne Treatment contin.

  • Oral retinoids (isotretinoin) decreases sebum, corrects epidermal desquamtion, anti-inflammatory, antimicrobial
  • Usually 16 to 20-week therapy
  • Most insurance plans require at least 90-day trial of more conservative therapy
  • New FDA-mandated, internet-based Ipledge program very restrictive--to reduceaccutane-associated pregnancies (220/yr) from careless prescribing, incorrect usage

9. Isotretinoin contin.

  • Many potential side effectsfew actually seen
  • Very effective and safe if done carefully:
      • Baseline labs (incl. 2 HCGs, if female)
      • 2 forms birth control (abstinence isone )
      • Labs each month: lft, lipids, hcg
      • 30 days of pills, no refills
      • Office visit each month

10. Zit tattoosthe newest craze in the U.K. 11. Left hip

  • Coumadin Necrosis
  • Females > males
  • Usually upon start of coumadin, but reported during chronic therapy
  • Fatty areas: buttocks, breast, thigh, abdomen
  • Common underlying protein C or S deficiency

12. Eczema

  • Umbrella term
  • Definition: Red, dry, itchy skin
  • Location:
      • Lower extremities
      • Upper extremities
      • Hands/feet
      • Trunk

13. Eczema 14. Eczema

  • Family History: allergies,
  • asthma, hayfever, eczema
  • Clinical findings:
      • Erythematous patches, plaques
      • Lichenification (thickened skin/accentuated skin lines)
      • Excoriations (scratches)

15. Eczema Treatment

  • Emollients:ointments > creams > lotions
  • Topical corticosteroids
      • Short-term (2-4 weeks) is OK depending on site
      • Class I-IV intermittent use OK for flares
      • Not on facenothing >class V on face
      • Cannot be used continuously long-term
      • Risks:steroid-induced atrophy, acne, hypopigmentation, striae
  • Topical Immunomodulators (TIMs): safe for short-term or intermittent long-term
      • Pimecrolimus (elidel)
      • Tacrolimus (protopic)

16. Eczema Treatment contin.

  • Systemic corticosteroids
      • Intermittent (1-2x/year) IM can help during flare
      • More commonly used is oral
      • Typical ER dose-pak course (4-6 days) is insufficient, often requires 2-3 weeks
      • Taper 60mg/40mg/20mg over 15-21 days
      • Usually dosed qd in am @ 8:00
      • Side effects/complications inherent to systemic steroidsfor both IM, po
  • Oral Antihistamines
      • Sedating--HS: Benadryl, Atarax, Doxepin
      • Non-sedating--AM: Allegra, Zyrtec, Claritin
  • Oral Leukotriene receptor antagonists
      • Monteleukast (Singulair)

17. Porphyria cutanea tarda

  • Vesicles, bullae ,erosions, scarsandmilia (tiny cysts)in photo-exposed areas
  • Enzyme defect in heme production:
    • 80% sporadic
    • 20% AD
  • Most common porphyria
  • Precipitated by:
    • ETOH-assoc. liver disease
    • Hep C
    • Meds:
      • OCPs
  • Treatment:
    • avoidance of precipitants
    • phlebotomy

18. Tinea 19. Tinea--clues

  • Central clearing
  • Hx of exposure topets or infected humans (school, daycare)
  • 1/10 vs 9/10 rule :* if presented with a red, scaly rash, tinea will likely occur < 1/10 times and eczema will be greater than 9/10 times.
  • Try steroid first, hold off on antifungal

20. Tinea

  • Quick, easy to diagnose in office
  • Do KOH:
      • Scrape scale from leading edge onto glass slide
      • Add 2-3 drops KOH ($12.50/ 1 oz bottle), add cover slip
      • Look under 10x

KOHbranching hyphae 21. Tinea Treatment

  • Topicals:
    • -Azolesfungistatic:
      • Ketoconazole
      • Clotrimazole
      • Miconazole
      • Oxiconazole
      • Sertraconazole
    • Naftifine (naftin)
    • Terbinafine (lamisil) fungicidal
    • Ciclopirox (loprox)

22. Tinea Treatment contin.

  • Systemic for T. capitis or bullous tinea:
      • Griseofulvin ultramicronized15-20 mg/kg/day
          • Safe, effective, cheap
          • Needs fat for absorption
          • Usually treat for 2-4 months
      • Terbinafine (lamisil)
          • > 40 kg250 mg/day
          • 20-40 kg125 mg/day (1/2 tab)
          • < 20 kg62.5 mg/day (1/4 tab)
          • Treat 2-4 weeks

23.

  • Confluent and Reticulated Papillomatosis of Gougerot and Carteaud
  • Young, African-American
  • Midline back or chest
  • Wavy, net-like pattern
  • Clears with one month of minocycline 100 mg bid

24. Psoriasis 25. Psoriasis

  • 2% of population affected
  • Family history in 35-70% of cases
  • Common Distribution
      • Elbows, knees
      • Scalp
      • Hands, feet
      • Extremities, trunk

26. Psoriasis--clues

  • Look elsewherenails
      • Pits
      • Oil spots
      • Onycholysis
  • Look at scale
  • silvery, micaceous

27. Psoriasis Treatment

  • Topical:
      • Calcipotriene (dovonex)corrects abnormal epidermal proliferation, not topical steroid
          • Avoid face, intertriginous areas (irritation)
      • Topical steroidsClass1-2 bid for 2-4 weeks; not good option long-termtolerance, atrophy
      • **Pulse therapy:dovonex bid Mon-Fri, clobetasol (class I) bid Sat/Sun**
      • Taclonexnew topical combination of dovonex + betamethasonedosed qd

28. Psoriasis Treatment contin.

  • ** Systemic:
      • UV lightNBUVB 3x/week
      • Acitretin (soriatane)retinoid, decrease abnormal epidermal proliferation
      • Biologics (enbrel, remicade, raptiva, humira)block cytokines (pro-inflammatory signals)
      • Methotrexateinhibits DNA synth. in rapidly prolif. Cells
      • Others
  • ** Psoriasis requiring systemic therapy should be referred to Derm

29.

  • Erythema Chronicum Migrans
  • (Early localized cutaneous LymeDisease)
  • Red papule @ site of tick bite
  • Expands outward over days-weeksavg. = 16cm.
  • Geographical distrib ofixodestick: 95% of cases from NE U.S.
  • 3 wks of oral antibiotic clears most cases:
  • Adults: Doxy 100 mg bid
  • Peds: Amoxil 250-500 mgtid (20-50 mg/kg/day)

30. Skin Cancer

  • 3 common types:
      • Basal cell carcinoma1million cases/yr in U.S.
          • Most common skin cancer
          • Negligible risk of metastasis
      • Squamous cell carcinoma- - >100 cases/100,000 per year in U.S.
          • Risk of metastasis 2-6%; higher for lip, ear lesions
      • Melanoma least common, most deadly cancer
          • Prognosis depends on depth of tumor at time of biopsy

31. Basal Cell Carcinoma

  • Pearly, translucent papule in sun-exposed area
  • Dilated, superficial vessels--(telangiectasia)
  • Bleeds easily
  • Sore that wont heal
  • Due to cumulative sun damage

32. Basal Cell Carcinoma

  • Treatment options include:
    • Excision
    • Electrodessication and curettage
    • Imiquimod (aldara) cream
    • Mohs micrographic surgery
  • *Most appropriate therapy depends on size, location, histologic subtype of tumor

33. Squamous Cell Carcinoma

  • Keratotic, crusted nodule in sun-exposed area
  • Most frequent risk factor is chronic UV damage
  • Most common skin cancer in immunosuppressed patients
  • Uncommon cases of HPV-related SCC in genital areas and periungual
  • Treatment similar to BCC

34. Mohs Surgery

  • In-office surgery under local anesthesia
  • Thin-margin surgical specimen evaluated by frozen section
  • Highest cure rates of cutaneous cancer surgery
  • Tissue sparing due to micrographic, mapping nature of procedure

35. Melanoma

  • 4% of skin cancer, 77% of skin cancer deaths
  • 1/37 Americans
  • Risk and behavior not fully understood
  • risk appears to be genetic
  • risk appears to be sun-related
  • Growth is initially usually superficial (radial), invades at some pointreasons, signals unknown

36. Melanoma

  • ABCDE Rule
  • A symmetry of lesion is visually different than other
  • B order is irregular, jagged, scalloped
  • C olor is variedblack, tan, brown, pink, white
  • D iameter-- > than 6mm (pencil eraser size)
  • E volvinglesion is changing (possibly most important criteria)

37. Melanoma Treatment

  • Surgery is mainstay of treatment
      • 5 mm margin forin-situlesions
      • 1.0 cm margins for tumors up to 1.0 mm in depth
      • 2.0 cm margin for 1-4 mm tumors
      • Sentinel lymph node biopsy offered for tumors
      • 1.0 mm and greater (no survival benefit yet)
  • Adjuvant medical treatment
      • High-dose Interferon only FDA-approved therapy
      • Some prolongation of relapse-free survival, unclear if overall survival is improved
      • No other treatmentchemotherapy, radiation, vaccinesproven yet to improve survival

38. Red/bluish, tender subcutaneous nodules on lower extremities Erythema Nodosum (erythema contusiformis)

  • Young women 18-34 yrs.
  • Lower extremities
  • Hypersensitivity reaction to:
    • Infections
      • Bacterial *(strep)
      • Fungal (systemic)
    • Drugs
      • OCPs
      • Sulfa
    • Inflam. Bowel Disease
      • UC
      • Crohns
    • Pregnancy
    • Sarcoidosis
  • Key is to find and treat underlying cause
  • NSAIDS for pain/inflammation

39. Skin Biopsies For a pigmented lesion, should I do a punch, a shave, excision, etc?

  • Shave biopsy most commonly done for elevated lesions.
  • Punch biopsy done for flat, depressed or inflammatory lesions.

40. Skin Biopsies

  • Excision is probably best to sample entire lesion
  • Most time-consuming, expensive
  • Punch biopsy, unless entire lesion is removed, will produce sampling error
  • Shave is quick, inexpensive
  • Must be deep enough to remove all pigmenteasily done

41. Summary

  • Acne
  • Eczema
  • Tinea
  • Psoriasis
  • Skin Cancer
  • Biopsies

42. Questions?