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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?