Dermatology For The Primary Dermatology For The Primary Care PractitionerCare Practitioner

Michael G. Bryan, M.D.Michael G. Bryan, M.D.

DermatologistDermatologist

Las Vegas Skin & Cancer ClinicsLas Vegas Skin & Cancer Clinics

DisclosuresDisclosures

Novartis Speaker’s BureauNovartis Speaker’s Bureau

OverviewOverview

AcneAcne

EczemaEczema

TineaTinea

PsoriasisPsoriasis

Skin CancerSkin Cancer

BiopsiesBiopsies

AcneAcne

Disease of youth-adultDisease of youth-adult

> 85% of individuals affected> 85% of individuals affected

4 main pathophysiologic factors:4 main pathophysiologic factors:

1—follicular plugging1—follicular plugging

2—excess sebum (oil)2—excess sebum (oil)

3—presence/activity of 3—presence/activity of P. acnes P. acnes

44——inflammationinflammation

AcneAcne

No set recipe for acne treatment--different No set recipe for acne treatment--different patients make different kinds of lesionspatients make different kinds of lesionsComedones—clogged pores (noninflammatory)Comedones—clogged pores (noninflammatory)

Open—”blackheads”Open—”blackheads”Closed—”whiteheads” Closed—”whiteheads”

(not pustules)(not pustules)

Inflammatory lesions:Inflammatory lesions:Red papulesRed papulesPustulesPustulesNodules/cystsNodules/cysts

Treatments should target patient’s type of acneTreatments should target patient’s type of acne

Topical Acne TreatmentsTopical Acne Treatments

Comedolytics (topical retinoids)—combat clumping of Comedolytics (topical retinoids)—combat clumping of cells and follicular plugging:cells and follicular plugging:

Retin-A (tretinoin)Retin-A (tretinoin)Differin (adapalene)Differin (adapalene)Tazorac (tazarotene)Tazorac (tazarotene)

Benzoyl peroxide—anti-inflammatory, Benzoyl peroxide—anti-inflammatory, antimicrobial to antimicrobial to P. acnes P. acnes (no resistance)(no resistance)

Topical antibiotics—Topical antibiotics—P. acnesP. acnesClindamycinClindamycinErythromycinErythromycin

Acne Treatments contin.Acne Treatments contin.

Oral antibiotics—Oral antibiotics—P. acnes P. acnes (resistance),(resistance), anti-inflammatoryanti-inflammatory

Tetracycline, doxycycline, minocyclineTetracycline, doxycycline, minocyclineTrimethoprim/sulfamethoxazoleTrimethoprim/sulfamethoxazoleErythromycinErythromycin

Hormonal Therapies—reduce circulating Hormonal Therapies—reduce circulating androgensandrogens

Ortho-tri-cylcen (labeled)Ortho-tri-cylcen (labeled)Yasmin, Yaz (off-label)Yasmin, Yaz (off-label)SpironolactoneSpironolactone

Acne Treatment contin.Acne Treatment contin.

Oral retinoids (isotretinoin)—Oral retinoids (isotretinoin)—decreases decreases sebum, corrects epidermal desquamtion, anti-sebum, corrects epidermal desquamtion, anti-inflammatory, antimicrobialinflammatory, antimicrobialUsually 16 to 20-week therapyUsually 16 to 20-week therapyMost insurance plans require at least 90-day trial Most insurance plans require at least 90-day trial of more conservative therapyof more conservative therapyNew FDA-mandated, internet-based New FDA-mandated, internet-based ““IpledgeIpledge”” program very restrictive--to reduce accutane-program very restrictive--to reduce accutane-associated pregnancies (220/yr) from careless associated pregnancies (220/yr) from careless prescribing, incorrect usageprescribing, incorrect usage

Isotretinoin contin.Isotretinoin contin.

Many potential side effects—few actually seenMany potential side effects—few actually seen

Very effective and safe if done carefully:Very effective and safe if done carefully:Baseline labs (incl. 2 HCGs, if female)Baseline labs (incl. 2 HCGs, if female)

2 forms birth control (abstinence is 2 forms birth control (abstinence is oneone))

Labs each month: lft, lipids, hcgLabs each month: lft, lipids, hcg

30 days of pills, no refills30 days of pills, no refills

Office visit each monthOffice visit each month

“Zit” tattoos—the newest craze in the U.K.

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

EczemaEczema

Umbrella termUmbrella term

Definition: Red, dry, itchy skinDefinition: Red, dry, itchy skin

Location: Location: Lower extremitiesLower extremities

Upper extremitiesUpper extremities

Hands/feetHands/feet

TrunkTrunk

Eczema

EczemaEczema

Family History: allergies,Family History: allergies,

asthma, hayfever, eczemaasthma, hayfever, eczema

Clinical findings:Clinical findings:Erythematous patches, plaquesErythematous patches, plaques

Lichenification (thickened skin/accentuated skin Lichenification (thickened skin/accentuated skin lines)lines)

Excoriations (scratches)Excoriations (scratches)

Eczema TreatmentEczema Treatment

Emollients: Emollients: ointments > creams > lotionsointments > creams > lotions

Topical corticosteroidsTopical corticosteroidsShort-term (2-4 weeks) is OK depending on siteShort-term (2-4 weeks) is OK depending on siteClass I-IV intermittent use OK for flaresClass I-IV intermittent use OK for flaresNot on face—nothing >class V on faceNot on face—nothing >class V on faceCannot be used continuously long-termCannot be used continuously long-termRisks: steroid-induced atrophy, acne, hypopigmentation, Risks: steroid-induced atrophy, acne, hypopigmentation, striaestriae

Topical Immunomodulators (TIMs): safe for Topical Immunomodulators (TIMs): safe for short-term or intermittent long-termshort-term or intermittent long-term

Pimecrolimus (elidel)Pimecrolimus (elidel)Tacrolimus (protopic)Tacrolimus (protopic)

Eczema Treatment contin.Eczema Treatment contin.

Systemic corticosteroidsSystemic corticosteroidsIntermittent (1-2x/year) IM can help during flareIntermittent (1-2x/year) IM can help during flareMore commonly used is oralMore commonly used is oralTypical ER “dose-pak” course (4-6 days) is insufficient, often Typical ER “dose-pak” course (4-6 days) is insufficient, often requires 2-3 weeksrequires 2-3 weeksTaper 60mg/40mg/20mg over 15-21 daysTaper 60mg/40mg/20mg over 15-21 daysUsually dosed qd in am @ 8:00Usually dosed qd in am @ 8:00Side effects/complications inherent to systemic steroids—for Side effects/complications inherent to systemic steroids—for both IM, poboth IM, po

Oral AntihistaminesOral AntihistaminesSedating--HS: Benadryl, Atarax, DoxepinSedating--HS: Benadryl, Atarax, DoxepinNon-sedating--AM: Allegra, Zyrtec, ClaritinNon-sedating--AM: Allegra, Zyrtec, Claritin

Oral Leukotriene receptor antagonistsOral Leukotriene receptor antagonistsMonteleukast (Singulair)Monteleukast (Singulair)

Porphyria cutanea tarda• Vesicles, bullae, erosions, scars and milia (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

TineaTinea

Tinea--cluesTinea--clues

Central clearingCentral clearing

Hx of exposure to Hx of exposure to pets or infected pets or infected humans (school, daycare)humans (school, daycare)

1/10 vs 9/10 rule : *1/10 vs 9/10 rule : *if presented with a red, if presented with a red, scaly rash, tinea will likely occur < 1/10 times scaly rash, tinea will likely occur < 1/10 times and eczema will be greater than 9/10 times. and eczema will be greater than 9/10 times.

Try steroid first, hold off on antifungalTry steroid first, hold off on antifungal

KOH—branching hyphaeKOH—branching hyphae

TineaTinea

Quick, easy to diagnose in officeQuick, easy to diagnose in office

Do KOH:Do KOH:Scrape scale from leading edge onto glass slideScrape scale from leading edge onto glass slide

Add 2-3 drops KOH ($12.50/ 1 oz bottle), add Add 2-3 drops KOH ($12.50/ 1 oz bottle), add cover slipcover slip

Look under 10x Look under 10x

Tinea TreatmentTinea Treatment

Topicals:Topicals:– -Azoles—fungistatic:-Azoles—fungistatic:

KetoconazoleKetoconazoleClotrimazoleClotrimazoleMiconazoleMiconazoleOxiconazoleOxiconazoleSertraconazoleSertraconazole

– Naftifine (naftin)Naftifine (naftin)– Terbinafine (lamisil)Terbinafine (lamisil) fungicidal fungicidal– Ciclopirox (loprox)Ciclopirox (loprox)

Tinea Treatment contin.Tinea Treatment contin.

Systemic for T. capitis or bullous tinea:Systemic for T. capitis or bullous tinea:Griseofulvin ultramicronized15-20 mg/kg/dayGriseofulvin ultramicronized15-20 mg/kg/day

Safe, effective, cheapSafe, effective, cheap

Needs fat for absorptionNeeds fat for absorption

Usually treat for 2-4 monthsUsually treat for 2-4 months

Terbinafine (lamisil)Terbinafine (lamisil)> 40 kg—250 mg/day> 40 kg—250 mg/day

20-40 kg—125 mg/day (1/2 tab)20-40 kg—125 mg/day (1/2 tab)

< 20 kg—62.5 mg/day (1/4 tab)< 20 kg—62.5 mg/day (1/4 tab)

Treat 2-4 weeksTreat 2-4 weeks

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

PsoriasisPsoriasis

PsoriasisPsoriasis

2% of population affected2% of population affected

Family history in 35-70% of casesFamily history in 35-70% of cases

Common DistributionCommon DistributionElbows, kneesElbows, knees

ScalpScalp

Hands, feetHands, feet

Extremities, trunkExtremities, trunk

Psoriasis--cluesPsoriasis--clues

Look elsewhere—nailsLook elsewhere—nailsPitsPits

Oil spotsOil spots

OnycholysisOnycholysis

Look at scale—Look at scale—

silvery, “micaceous”silvery, “micaceous”

Psoriasis TreatmentPsoriasis Treatment

Topical:Topical:Calcipotriene (dovonex)—corrects abnormal Calcipotriene (dovonex)—corrects abnormal epidermal proliferation, not topical steroidepidermal proliferation, not topical steroid

Avoid face, intertriginous areas (irritation)Avoid face, intertriginous areas (irritation)

Topical steroids—Class1-2 bid for 2-4 weeks; not Topical steroids—Class1-2 bid for 2-4 weeks; not good option long-term—tolerance, atrophygood option long-term—tolerance, atrophy

** ** “Pulse” therapy: dovonex bid Mon-Fri, “Pulse” therapy: dovonex bid Mon-Fri, clobetasol (class I) bid Sat/Sun clobetasol (class I) bid Sat/Sun ****

Taclonex—new topical combination of dovonex + Taclonex—new topical combination of dovonex + betamethasone—dosed qdbetamethasone—dosed qd

Psoriasis Treatment contin.Psoriasis Treatment contin.

****Systemic:Systemic:UV light—NBUVB 3x/weekUV light—NBUVB 3x/weekAcitretin (soriatane)—retinoid, decrease abnormal Acitretin (soriatane)—retinoid, decrease abnormal epidermal proliferationepidermal proliferation““Biologics” (enbrel, remicade, raptiva, humira)—Biologics” (enbrel, remicade, raptiva, humira)—block cytokines (pro-inflammatory signals)block cytokines (pro-inflammatory signals)Methotrexate—inhibits DNA synth. in rapidly prolif. Methotrexate—inhibits DNA synth. in rapidly prolif. CellsCellsOthers…Others…

****Psoriasis requiring systemic therapy should be referred Psoriasis requiring systemic therapy should be referred to Dermto Derm

Erythema Chronicum Migrans

(Early localized cutaneous Lyme Disease)

• Red papule @ site of tick bite

• Expands outward over days-weeks— avg. = 16 cm.

• Geographical distrib of ixodes tick: 95% of cases from NE U.S.

• 3 wks of oral antibiotic clears most cases:

•Adults: Doxy 100 mg bid

•Peds: Amoxil 250-500 mg tid (20-50 mg/kg/day)

Skin CancerSkin Cancer

3 common types:3 common types:Basal cell carcinoma—1Basal cell carcinoma—1 million cases/yr in U.S. million cases/yr in U.S.

Most common skin cancerMost common skin cancer

Negligible risk of metastasisNegligible risk of metastasis

Squamous cell carcinoma-Squamous cell carcinoma-- >100 cases/100,000 - >100 cases/100,000 per year in U.S.per year in U.S.

Risk of metastasis 2-6%; higher for lip, ear lesionsRisk of metastasis 2-6%; higher for lip, ear lesions

MelanomaMelanoma—least common, most deadly cancer—least common, most deadly cancerPrognosis depends on depth of tumor at time of Prognosis depends on depth of tumor at time of biopsybiopsy

Basal Cell CarcinomaBasal Cell Carcinoma

• Pearly, translucent papule in sun-exposed area

• Dilated, superficial vessels--(telangiectasia)

• Bleeds easily

• “Sore that won’t heal”

• Due to cumulative sun damage

Basal Cell CarcinomaBasal 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

Squamous Cell CarcinomaSquamous 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

Mohs SurgeryMohs 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

MelanomaMelanoma• 4% of skin cancer, 77% of skin cancer deaths

• 1/37 Americans

• Risk and behavior not fully understood

• ½ risk appears to be genetic

• ½ risk appears to be sun-related

• Growth is initially usually superficial (radial), invades at some point—reasons, signals unknown

MelanomaMelanomaABCDE Rule

• Asymmetry— ½ of lesion is visually different than other ½

• Border is irregular, jagged, scalloped

• Color is varied—black, tan, brown, pink, white

• Diameter-- > than 6mm (pencil eraser size)

• Evolving—lesion is changing (possibly most important criteria)

Melanoma TreatmentMelanoma Treatment

Surgery is mainstay of treatmentSurgery is mainstay of treatment5 mm margin for 5 mm margin for in-situin-situ lesions lesions1.0 cm margins for tumors up to 1.0 mm in depth1.0 cm margins for tumors up to 1.0 mm in depth2.0 cm margin for 1-4 mm tumors2.0 cm margin for 1-4 mm tumorsSentinel lymph node biopsy offered for tumorsSentinel lymph node biopsy offered for tumors

1.0 mm and greater (no survival benefit yet)1.0 mm and greater (no survival benefit yet)

Adjuvant medical treatmentAdjuvant medical treatmentHigh-dose Interferon only FDA-approved therapyHigh-dose Interferon only FDA-approved therapySome prolongation of relapse-free survival, unclear if overall Some prolongation of relapse-free survival, unclear if overall survival is improvedsurvival is improvedNo other treatment—chemotherapy, radiation, vaccines—No other treatment—chemotherapy, radiation, vaccines—proven yet to improve survivalproven yet to improve survival

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

Skin BiopsiesSkin 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.

Skin BiopsiesSkin 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 pigment—easily done

SummarySummary

AcneAcne

EczemaEczema

TineaTinea

PsoriasisPsoriasis

Skin CancerSkin Cancer

BiopsiesBiopsies

Questions?Questions?