Sk“IN” Too Deep?Effective care for commonly

encountered dermatologic complaints

Kara Pretzlaff, MDVivida Dermatology

I have no financial conflicts of interest*

* maybe one day…

Number 1: Acne

Acne

• Contributors• Inflammation• “Sticky” keratinocytes• Hormones

• Ages 12-24 most common• Post pubertal• “Adult” acne is a thing L

• Classifiers• Comedonal• Inflammatory• Nodulocystic

Comedonal versus Inflammatory

Nodulocystic

Treatment Pearls: comedonal acne

Sample regimen:• AM• Gentle cleanser (Cera Ve, Cetaphil)• Moisturizer with SPF (30+)

• PM• Gentle cleanser• Nighttime moisturizer• Adapalene gel 0.1% (OTC)

Treatment Pearls: inflammatory acne

Sample regimen:• AM & PM same plus:

• AM: Anti inflammatory/anti bacterial• Eg Benzoyl peroxude/clindamycin gel

• Doxycycline OR Minocycline 100mg twice daily

• If hormonal: OCPs, spironolactone

• SE• Doxycycline MC: GI upset,

photosensitivity• Minocycline MC: dizziness

• Less common: dyschromia, DRESS

Treatment Pearls: nodulocystic acne

Challenging…• Isotretinoin

• 6+ month course• Goal of 120-150mg/kg• May need to repeat• We can help!

• Watch out for:• DRYNESS• Elevated TGs and LFTs• DRUG INTERACTIONS (eg tetracyclines)• Questions about depression

Not working?

•We can help!• Inflammatory• Nodulocystic• Refractory comedonal• Adult acne• Post inflammatory inflammation• Acne scarring

Number 2: TineaAKA “Ringworm”, “Jock itch”, “Athlete’s Foot”, “Gross toenails”

Tinea: a dermatophyte infection

• Incredibly common superficial fungal infection• Treatment depends on subtype and

location• Inflammatory versus non

inflammatory• Good news: sometimes it’s really

easy to treat• Bad news: sometimes it’s not

Treatment pearls: tinea versicolor

• Ketoconazole 2% shampoo (Rx)• Step 1: Lather on wet skin• Step 2: LEAVE ON 5-10 min• Step 3: Rinse off

• Repeat 3x/week until improved, then once weekly • “Normal” color takes time

• Not working?• There are oral options…we can help!

Treatment pearls: tinea corporis/pedis/cruris

Treatment pearls: tinea corporis/pedis/cruris

• First line: topical cream (OTC)• Eg miconazole, terbinafine,

clotrimazole• Apply twice a day for 2 weeks

beyond clinical improvement

• Second line: oral antifungal agents• Terbinafine preferred• 250mg daily x 2-4 weeks• MC side effect: taste disturbances

• At home tips:• Wash common foot surfaces with

bleach-based wash• Wash socks/towels on hot cycle• Dry feet well• New shoes• Zeasorb powder (OTC)• For thick skin on feet, add urea or

amlactin (OTC)

Treatment pearls: Tinea unguum (aka onychomycosis)

• MAKE SURE IT’S FUNGUS • Who needs treatment?

• Diabetics• Immune suppressed• People who don’t like the way their

nails look/have painful nails• *Personal opinion*:

• Don’t waste time with topicals• First line: Oral antifungals

• Requires longer course• 6 weeks for fingernails• 12 weeks for toenails

Number 3: Seborrheic Dermatitis

Seborrheic dermatitis

• Common inflammatory dermatosis that likes oil-gland bearing skin• MC on scalps, central face, chest,

axillae• Exuberant forms can be seen in

HIV population and Parkinson’s

Treatment pearls: seborrheic dermatitis

• Treatment similar to tinea versicolor• Ketoconazole shampoo 2% (Rx)

• Leave on skin for 5-10 min prior to rinsing

• Start with 3x/week, decrease to weekly as maintenance

• Alternate with OTC anti-dandruff shampoo

• If really inflammatory, can pair with mild corticosteroid during flares (only 1-2 weeks)• Eg desonide 0.5% cream, hydrocortisone

2.5% ointment

Treatment pearls: seborrheic dermatitis

• Not working?• Options for oral therapy and stronger

corticosteroids…We can help!

Number 4: Psoriasis

Psoriasis

• Common, chronic, immune-mediated inflammatory dermatosis• Genetic• Can have mutilating arthritis• Not just “skin deep”

• Cardiovascular risk is equivalent to those with DMII• High risk of depression/suicidality

Treatment Pearls: Psoriasis

• We have SO many options!• If it’s minor (<5% BSA) and patient

doesn’t mind it:• Triamcinolone 0.1% ointment BID PRN

• Counsel on hereditary nature, ask about mood, discuss cardiovascular risk• Send them our way – we can get

them the good stuff J

Treatment Pearls: Psoriasis

• What makes it worse?• IM steroids – watch out!• Infection• Hypocalcemia• Stress• Some drugs

• Beta blockers, anti malarial agents, lithium, IM steroids (see above…)

• Alcohol/smoking/obesity

Number 5: Vitiligo

Vitiligo

• Autoimmune, chronic, inflammatory dermatosis • Defined by striking patches of

depigmented skin• Like psoriasis, HIGH percentage

of patients with depression and suicidality

Treatment Pearls: Vitiligo

• Most important part of treatment:• Letting patients know there ARE

treatments available

• Please don’t treat it like a cosmetic complaint• Class I topical corticosteroids/oral

steroids, JAK kinase inhibitors, NBUVB are the mainstays of therapy• We CAN help!!

Number 6: Sebaceous Hyperplasia and the “aging” face

Sebaceous hyperplasia

• Benign adnexal neoplasms• Often confused for basal cell

carcinoma• If you’re not sure we would love to

see them J

• Men>Women• Tx options: electrodessication

most effective

Sebaceous hyperplasia vs Basal cell carcinoma

*BONUS* “Aging” face

• The absolute basics of “post-poning” photoaging

1. Sunscreen: SPF 30+, re application needed

2. Safe sun practices (can’t get out of a derm talk without this one…)

3. Daily (or twice daily) moisturizer4. Topical anti-oxidant (eg Vitamin C)5. Topical retinoid (rx >> OTC)

• More advanced: botox, filler, laser resurfacing…

Wrinkles

Loss of fat

Dyschromia

Number 7: Seborrheic keratosesAKA “wisdom spots”

Seborrheic keratoses (SKs)

• Benign, incredibly common skin lesions that like hair-bearing areas • Can sometimes look a lot like

melanoma (and vice versa, unfortunately)• Sign of Leser Trelat?

Treatment pearls: Seborrheic keratoses (SKs)

• If not bothersome to patient…leave them alone• If bothersome (eg itch/hurt),

they can be removed or destroyed• Considered a cosmetic

procedure if asymptomatic without any concerning features

SK or Melanoma?

• If you doubt it at all…we’re here to help!!

Number 8: Eczema

Eczema (atopic dermatitis)

• Common inflammatory dermatosis predominantly affecting kids• Up to 85% of kids grow out of

their eczema by age 12• Main problem: faulty epidermal

barrier • Pruritus• Xerosis• Secondary infection

Treatment pearls: Eczema

• If mild-moderate, keep it simple:• Eliminate potential triggers: essential oil

diffusers, “slime”, scented soaps• Gentle skin care

• Short, lukewarm showers• Dove bar soap for sensitive skin• Regular emollient use

• Vaseline or body creams (not lotions)

• Class 3 topical corticosteroid (egtriamcinolone 0.1% ointment)• BID while active, then PRN• DO NOT USE on face, axillae, genitals or

other body folds

Treatment pearls: Eczema

• If moderate-severe:• Need higher potency steoroids• Anti-pruritic• Several options:

• NVUVB• Methotrexate• Cyclosporine• Mycophenalate mofitil• *Dupilumab*

• We’re here to help J

Treatment pearls: Eczema

• Things to watch out for:• Honey colored-crusting• Open erosions• “Punched out” lesions• Intact vesicles

• Decolonization• Mupirocin 2% ointment• Apply to nares BID first week of each

month x 6 months• Bleach baths

• TIW: ¼ cup bleach in ½ bath

*BONUS* Urticaria!• Mast cell-mediated eruption (usually)• Causes: idiopathic (50%) > infection >>

drugs >>> food• Initial treatment• Scheduled antihistamines• Sample regimen:

• AM: 10mg Cetirizine (can increase to 20mg)• PM: 10mg Cetirizine (can increase to 20mg)

• “Cooling” topicals• Avoidance of possible triggers• Oral prednisone generally not indicated

• If not responding…send our way J

Number 9: Poison ivy Or other acute ACD…

Plant-based allergic contact dermatitis

• Type IV (delayed type hypersensitivity) reaction• If sensitized:• Takes ~48 hours to develop rash

• If not sensitized:• Can take up to 3 weeks to develop

rash

Treatment pearls: Plant ACD • Mild

• Topical Class 3 corticosteroid BID until improved

• Oral anti histamines• Moderate to severe

• 3 week oral prednisone taper• 60mg/40mg/20mg x 1 week each*• Watch for REBOUND

• As always, try to avoid triger• Wash off as soon as you come in contact

* Can decrease dose for elderly, those with diabetes or poorly controlled HTN

Number 10: Rosacea

Rosacea

• Chronic inflammatory dermatosis • Affects mostly middle aged

women• LOTS of triggers• Caffeine?• Alcohol• Sun• Spicy foods• Topical steroids (when stopped)

Treatment pearls: Rosacea• Mild• Avoid triggers• Gentle skin care• SPF 30 or higher with re application• Face wash options:

• Sodium sulfacetamide• Avoid exfoliants

• Topicals for BID application• Metronidazole cream• Ivermectin Cream• Azeleic acid Cream

• Moderate to severe• Antibiotics• Isotretinoin

*BONUS* “Red Flags”

WHEN TO BE WORRIED…• If your patient starts a high risk

drug and starts to notice:• Fever, painful skin, sloughing skin,

sores in eyes/mouth/genitals, new LAD, facial/ear swelling

• Timeline: • ~7-21 days for SJS/TEN• ~3-6 weeks for DRESS

“High risk” Drug Examples• Trimethoprim sulfamethoxazole • Aromatic anti-epileptics• Allopurinol• NNRTIs

Questions?