DERMATOLOGYFOR THE

NON-DERMATOLOGIST4/30/2021

Megan N. Landis, MD

Clinical Associate Professor of Dermatology

University of Louisville, Division of Dermatology

Dermatology and Skin Cancer Center of Southern Indiana

Corydon, IN

DISCLOSURES

• Investigator and/or Consultant: Abbvie, Celgene, Cutanea, Dermira, Foamix, Galderma, Incyte, Kadmon, Novartis, Novum, Ortho Dermatology, Pfizer, Regeneron, Sanofi Genzyme, Symbio

•

Information presented is based on evidence-based recommendations and well designed published studies

OBJECTIVE

• To Make Your Life Easier!

• Skin issues frequently seen in primary care, common conundrums, pitfalls to avoid

• High yield clinical pearls

ACUTE ALLERGIC CONTACT DERMATITIS

• Linear vesicles in rash (poison ivy)

• Localized: topical corticosteroids

• Diffuse: long, slow prednisone taper over ~21 days (avoid rebound)

RECURRENT OR CHRONIC ALLERGIC CONTACT DERMATITIS

• Patch testing

CASE #2

Which treatment is absolutely contraindicated for this patient?

A. Topical clobetasol 0.05% ointment

B. Oral corticosteroids

C. Phototherapy (nbUVB)

D. Cyclosporine

PSORIASIS:

TOPICAL THERAPIES

• Topical Anti-inflammatories• Topical steroids

• Topical tacrolimus or pimecrolimus (face, underarms, groin)

• Keratinocyte Proliferation Modulators• Vitamin D analogues (calcipotriene)

• Tazarotene (palmar/plantar involvement)

PSORIASIS:

SYSTEMIC THERAPIES

•NO ORAL/SYSTEMIC STEROIDS: severe flare upon withdraw

• Phototherapy

• Cyclosporine

• Methotrexate

• Biologics

• LOOK for joint involvement: permanent destruction (nails = greater risk PsA)AAD.org

PSORIASIS

• Chronic disease, primarily of skin and joints; may wax and wane

• ~2% of US population

• 30% have family history

• Onset most commonly ages 20-30 and 50-60yrs

• 80% of patients have mild to moderate disease (<5% BSA)

• 20% have moderate to severe disease (>5% BSA OR affecting crucial body areas – hands, feet, face, scalp, or genitals)

AAD.org

PSORIASIS: TYPES

• Plaque (most common)

• Inverse/flexural/genital

• Erythrodermic

PSORIASIS: TYPES

• Guttate (often preceded by strep pharyngitis)

• Palmoplantar pustular

• Generalized pustular (von Zumbusch variant) – severe, life-threatening, often due to systemic steroid withdrawal

• Nail psoriasis

PSORIASIS:COMORBIDITIES

Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol2013;79:10-17

IMPORTANT: -Screen psoriasis patients for joint involvement (30%)

-Monitor psoriasis patients for comorbidities routinely

PSORIASIS

• Localized plaque type often managed by PCP

• All other types of psoriasis often referred to derm

MOLLUSCUM

• BOTE sign: Beginning Of The End

• Inflammatory phenomenon, often precedes resolution

• Tender, inflamed, painful

• 8 patients – cultures with only skin flora

• Symptomatic management only

• No antibiotics needed (unless red streaking or abscess formation) Forbat E, et al. Peditr Dermatol 2017;34(5): 504-515.

Image: Butala N, et al. Pediatrics 2013;131:5.

MOLLUSCUM

• Pox virus: skin contact and fomites

• Self-limited, resolves ~6-24mo without treatment

• Watchful waiting

• Cantharidin, podophyllin, cryo, curettage, topical retinoid, hydrogen peroxide, 2.5-15% KOH

• Imiquimod: NOT effective and potential for high systemic absorption and hematologic abnormalities

Forbat E, Al-Niaimi F, Ali FR. Peditr Dermatol 2017;34(5): 504-515. Katz KA. JAMA Dermatol. 2015;151:125-126.Van der Wouden JC et al. Cochrane Database Syst Rev 2017;5:CD004767.Myhre PE, Levy ML, Eichenfield, et al. Pediatr Dermatol. 2008;25:88-95.Romiti, et al. Pediatr Dermatol. 2000;17:495.Romiti, et al. Pediatr Dermatol. 1999;16:228-231.Teixido C, et al. Pediatr Dermatol 2018;35:336-342.

ATOPIC DERMATITIS (AD)

• Chronic, pruritic inflammatory skin disease; wide range of severity

• Up to 20% of children and 4-10% of adults

• Onset ~3-6mo; 90% diagnosed by age 5

• ~30% persist into adulthood

• Eczema: nonspecific reference to group of inflammatory skin diseases with itching, redness, and scale• Atopic dermatitis is a type of eczematous dermatitis

• Also included in eczematous dermatitis: seborrheic dermatitis, allergic contact dermatitis, irritant dermatitis, etc

ATOPIC DERMATITIS (AD)

• “the itch that rashes”: primary symptom is pruritus

• Scratching to relieve AD-associated itch results in “itch-scratch” cycle that exacerbates the disease

• Infants/Toddlers: Scalp, forehead, cheeks, & extensor arms/legs

• Older children: Flexures of neck, arms, legs, cheeks

Eichenfield LF, et al. J Am Acad Dermatol. 2014 Jul;71(1):116-32

ATOPIC DERMATITIS (AD)

• Cause: not completely known, multifactorial with factors including:

• Skin barrier dysfunction

• Immune dysregulation

• Genetics

• Environment

• Usually not food related

ATOPIC DERMATITIS (AD): TREATMENT

• Puts water in the skin

• But, it will evaporate and take more water with it from skin, UNLESS:

SEAL in the moisture

• Water is GOOD as long as you moisturize afterwards

• Gentle, fragrance-free bar soap at end of bath

• Medicine to rash and moisturize everywhere immediatelyEichenfield LF, et al. J Am Acad Dermatol. 2014 Jul;71(1):116-32

ATOPIC DERMATITIS (AD): TREATMENT

• Topical anti-inflammatories: topical corticosteroids, topical calcineurin inhibitors

• Narrow band UVB treatment

• Immunosuppressive meds: cyclosporine, methotrexate, etc

• Dupilumab (DUPIXENT): 1st biologic for AD, approved 2017, monoclonal antibody directed against IL-4 and IL-13

• 6yrs and above

Eichenfield LF, et al. J Am Acad Dermatol. 2014 Jul;71(1):116-32

SEVERE ATOPIC DERM

• NO SYSTEMIC STEROIDS• Makes disease worse in the long run

• Consensus statement from Peds Derms

• Wet wraps

• DIET: VERY RARELY MATTERS. STRICT DIET RESTRICTIONS NOT recommended

Eichenfield LF, et al. J Am Acad Dermatol. 2014 Jul;71(1):116-32

ATOPIC DERMATITIS: WHEN TO REFER

• Severe or extensive disease

• Symptoms poorly controlled with topical therapy

• Recurrent skin infections

CORTICOSTEROID QUANTITIES

• Commonly available in:

• 15g

• 30g

• 45g

• 60g

• 120g

• 240g

• 454g (1LB jar)

Image: Grepmed.comhttps://image.slidesharecdn.com/seminarpresentation0n04-01-2014-140219112401-phpapp01/95/seminar-principles-of-topical-therapy-10-638.jpg?cb=1392809584

Keys:-prescribe enough but not too much to get them in trouble-~30g to cover adult body once-reassess quantity at follow up

TOPICAL MEDICATIONS:VEHICLE/BASE

• What topical medications are prepared in

• Can optimize for various sites on body and to optimize penetration

Solutions

4

Sprays

Gels

FoamsCreams

Oils

Ointments

Vehicles

Lotion(Not Shown)

Image: AAD.org

TOPICAL MEDICATIONS: VEHICLES

• Ointments (Vaseline): lubricating, greasy, semi-occlusive

• BEST for AD, but sometimes not tolerated

• Cream (vanishes when rubbed in): may sting and irritate open skin areas, more preservatives/fragrances

• Useful when can’t tolerate ointment

• Lotion (pourable liquid): may burn or sting

• Helpful for larger and some hair bearing areas

Indian J Dermatol. 2016 May-Jun; 61(3): 279–287.

TOPICAL MEDICATIONS: VEHICLES

• Foam: more elegant, easy to spread, good for scalp/hair bearing areas, $$$

• Gel: may sting, least occlusive, dries quickly

• Good for acne, hair bearing areas

• Oil: less stinging or burning than solution

• Good for scalp

• Solution: water or alcohol-based lotion containing a dissolved powder

• Good for scalp

Indian J Dermatol. 2016 May-Jun; 61(3): 279–287.

TOPICAL MEDICATIONS: VEHICLE RECOMMENDATIONS

• For eczema (AD): for the body ointment if tolerated, cream if not

• For scalp: oil, solution, or foam

• Acne: cream, gel, foam (for large surfacer area, on back)

TOPICAL CORTICOSTEROIDS

• Do NOT look at percentage: strengthdepends on class

• Recommendation: get familiar and comfortable with a few in a few different classes • High: clobetasol 0.05% (body: severe areas only; DO NOT USE

ON FACE OR. FOLDS)

• Medium: triamcinolone 0.1% (body, NO NOT USE ON FACE OR FOLDS)

• Low: hydrocortisone 2.5% (face and folds)

Department of Dermatology

TCS StrengthPotency Class Example Agent

Super high I Clobetasol propionate 0.05%

High II Fluocinonide 0.05%Mometasone furoate ointment 0.1%

Medium III – V Mometasone furoate cream 0.1%Triamcinolone acetonide ointment 0.1%Triamcinolone acetonide cream 0.1%

Low VI – VIIFluocinolone acetonide 0.01%Desonide 0.05%Hydrocortisone 1% 13

RECOMMENDATION

• Use twice daily until itch free and smooth

• If not improved in 2 weeks, patient to call

• Reassess at follow up

• Transition to nonsteroidal (crisaborale, tacrolimus, pimecrolimus) for maintenance

• If not improving as expected: biopsy or refer (other diagnosis? cutaneous T cell lymphoma? Allergic contact dermatitis?)

AMELANOTIC MELANOMA

• Small minority of melanomas do not have clinically apparent pigment

• All subtypes of melanoma can be amelanotic

• Differential diagnosis: • Basal cell carcinoma (#1)

• Squamous cell carcinoma or verruca when on acral surfaces

• Pyogenic granuloma

• Angioma / angiokeratoma

• Prognosis is same whether melanotic or amelanotic

MELANOMA

A = AsymmetricalB = Irregular BordersC = Multiple ColorsD = Diameter > 6 mmE = Evolving (changing)

MELANOMA

• ABCDEs

• “Ugly Duckling” sign

• Early detection: 99% 5-year survival rate for patients whose melanoma is detected early.

• survival rate drops to 66% if the disease reaches the lymph nodes

• 27% if it spreads to distant organs

Skincancer.org

BUT, BEWARE

CANDIDA INTERTRIGO

• Satellite pustules

• Tinea spares scrotum

• Skin cancers occur EVERYWHERE – if doesn’t respond - biopsy

Bowenoid papulosis, aka squamous cell carcinoma-in-situ

CANDIDA INTERTRIGO

• Erythematous and macerated plaques, peripheral scale, often with peripheral satellite lesions

• Skin folds below the breasts, under the abdomen, axilla, and groin

• Tx:

• decrease moisture to area (powder qAM, loose clothing, sweat wicking material),

• topical ketoconazole (+hydrocortisone), iodoquinol

TINEA CRURIS

• Tinea spares scrotum

• KOH

• Localized: topical terbinafine or clotrimazole bid x 2 weeks (check feet and toenail)

• Generalized: terbinafine 250mg daily x 2 weeks

• Skin cancers occur EVERYWHERE – if doesn’t respond - biopsy

PYODERMA GANGRENOSUM

• Painful, sterile pustule >>> rapidly ulcerates with neutrophilic infiltrate

• Punch biopsy from edge of ulcer to aid diagnosis, with tissue culture

• Association with IBD, RA, some leukemias

• Rule out infection (NOT necrotizing fasc – results in erroneous debilitating amputations!!)

• DO NOT DEBRIDE!!!!

• Treatment: Topical and/or intralesional steroids, immunosuppressive meds/TNF-a-Inhibitors

BIOPSY TECHNIQUE

• Pigmented lesions and moles/nevi: NEVER cryo

• Always send for pathology

• Pathologists need to see entire lesion to fully evaluate

• Site documentation – the more detailed, the better

• Photos

• TriangulateMayoClinic.org

BIOPSY TECHNIQUE

• How to biopsy: Punch? Shave? Excision? Incision?

• Where to biopsy? (ex: LCV - newest lesion, pyoderma gangrenosum – edge of ulcer)

PATHOLOGY REQUISITION FORM

• Specimen location

• Biopsy technique: tangential (shave), punch, excision

• Clinical description of lesion or rash (size, appearance)

• Prior and/or current treatments

• Clinical differential diagnosis (what you think it could be)

Image: dermpathdiagnostics.com

SHAVE BIOPSY SUPPLIES

• Persona blade

• Lidocaine with epi

• Alcohol swab

• Cotton tip applicators

• Hyfrecator ands/or aluminum chloride

• Vaseline and bandage

PUNCH BIOPSY SUPPLIES

• Lido w/ epi

• Alcohol swab

• Punch biopsy blade

• Forceps

• Iris Scissors

• Needle driver

• Suture

• Vaseline and bandage

CARE FOR BIOPSY SITE

• Fold 2 x 2 gauze to make mini pressure dressing

• Paper tape or Coban for sensitive skin

• Keep covered and dry for 24hrs, then gently wash with soap and water, pat dry and recover with Vaseline and bandage until healed

• Erythema around shave and punch biopsy sites is expected

Any time something doesn’t respond as expected = BIOPSY

Differential Diagnosis: • Seborrheic dermatitis• Contact dermatitis• Actinic keratosis• Basal cell carcinoma• Squamous cell carcinoma

BASAL CELL CARCINOMA (BCC)

• Most common type of skin cancer

• Most commonly: sun-exposed areas with history excess sun exposure, burns

• 85% occur on head and neck, BUT found EVERYWHERE

• Additional risk factors: male, increased age

Rogers HW, et al. JAMA Dermatol 2015;151: 1081-1086.

BASAL CELL CARCINOMA:TYPES

• Nodular (most common)

• Superficial

• Sclerosing/morpheaform

• Ill-defined border, more aggressive

• Pigmented

AAD.org

BCC TREATMENT:

SURGICAL AND NON-SURGICAL OPTIONS

• Head and neck, sclerosing subtype: Mohs surgery

• Fellowship trained, Board certified dermatologist

• Real time evaluation of margins for tissue conservation to minimize defect

• Other areas: depends on type, size, location

• Mohs surgery

• Excision

• Electrodessication and curettage

• Non-surgical options (superficial and/or poor surgical candidate): Imiquimod 5% cream, 5-Fluorouracil 5% cream, photodynamic therapy (PDT), radiation AAD.org

BASAL CELL CARCINOMA

• History of one skin cancer = likely to get more

• NEEDS ROUTINE full body skin checks

• Sun protection

• Once monthly self skin exams

ACTINIC KERATOSES

• Slow growing rough, scaly macules/papules on sun damaged skin

• From years of sun exposure

• Face, lips, ears, forearms, scalp, neck or back of the hands

• Usually ages 40 and above

• Reduce your risk by minimizing sun exposure and protecting skin from ultraviolet (UV) rays

• Left untreated, the risk of actinic keratoses turning into a squamous cell carcinoma is about 5% to 10%.

MayoClinic.org

ACTINIC KERATOSES

• Many treatment options

• For few focal lesions: cryotherapy (scar)

• Field treatments: 5-fluorouracil, imiquimod, PDT

PITYRIASIS ALBA

• Mild, often asymptomatic type of atopic dermatitis of the face

• Ill-defined, hypopigmented mildly scaly patches on bilateral cheeks

• Often younger children, spring and summer when skin begins to tan with sun

• Skin care: moisturizer twice daily

• +/-low potency topical corticosteroids or topical calcineurin inhibitors

• Sun protection

• Will fade with time once inflammation resolves

CHERRY ANGIOMAS

• Common, acquired vascular proliferation

• Highest concentration on torso

• Increase in number starting at age 40

• May bleed or thrombose and mimic melanoma

• When in doubt – BIOPSY or REFER it out

NEVI (AKA MOLES)

• Often appear sun exposed areas

• Most commonly acquired nevi begin to appear in early childhood• New lesions over age ~50: biopsy or refer

• Appearance changes with time• Brown macule(s)/papule(s) > brown papule(s) > skin-colored soft papule(s)

• Children & adolescents: change in nevi common, doesn’t necessarily indicate malignancy

NEVI (AKA MOLES)

• Increased risk of melanoma: (refer to dermatology)• Personal history melanoma (5-8% chance of 2nd)• Family hx melanoma (first degree family members)

• More than 100 nevi

• <50yo with few melanocytic nevi at low risk for cutaneous melanoma• Counsel on sun protection and skin self-exams

Goodson AG, et al. J Am Acad Dermatol 2009;60(5): 719-35.Cordoro KM, et al. J Am Acad Dermatol 2013;68:913-25.AAD.org

NEVI (AKA MOLES)

• Evaluate nevi in context of individual patient

• Nevi in one patient tend to resemble one another

• Melanoma often has a different pattern: ”ugly duckling” sign

• ABCDE’s of melanoma

• NEVER use cryotherapy on a pigmented lesion

• If uncertain of what lesion is: biopsy or refer to dermatology

• Biopsy goal: get the breadth and depth of entire lesion

STASIS DERMATITISVS

CELLULITIS

• Stasis Dermatitis• Erythema, scale, pruritus, erosions, exudate

• Typically lower third of legs

• Often with pitting edema

• Bilateral or unilateral (previous vascular injury, etc.)

• +/-varicose veins and orange-red-brown discoloration (hemosiderin deposition)

• Cellulitis• Acute, often fever and pain, more erythema, well-demarcated, without pruritus or scale

• 30-75% of pts admitted for cellulitis actually had stasis dermatitis

• Skin cultures, blood cultures, and leukocytosis: NOT reliable indicators of cellulitis

• Antibiotic prescriptions written for cellulitis shown to be unnecessary for 67% of patients

J Am Acad Dermatol 2015; 73: 70-75JAMA Dermatol 2014; 150: 1056-1061.

CELLULITIS VERSUS

STASIS DERMATITIS

VERRUCA VULGARIS (WART)

• Scaly, hyperkeratotic, exophytic (growing upwards and outwards) plaques (also flat variants)

• Small black dots: thrombosed capillaries at base of lesion

• HPV infection of keratinocytes or mucosal epithelial cells

• HPV ubiquitous in environment

• Skin contact and fomites

• COMMON! • At least 20% overall prevalence in US

DIFFERENTIAL DIAGNOSIS

•Epidermal Nevus

DIFFERENTIAL DIAGNOSIS

• Lichen Planus

DIFFERENTIAL DIAGNOSIS

• Squamous cell carcinoma

VERRUCA VULGARIS: TREATMENT

• Necessary?

• Spontaneous resolution in 2 yrs: >75%• Based on placebo groups in trials with cure rate (20-70%)

• Indications for treatment

• No specific anti-HPV therapy

• Prevent self-inoculation:• Discourage picking, biting, touching: risk spreading to lips,

face

VERRUCA VULGARIS: TREATMENTS

• Cryotherapy

• Cure rates rate from 31-52% after 3 treatments. Pain, blistering, scarring

• Tretinoin 0.025-0.05% cream• Facial flat warts

• 5-FU cream (5-fluorouracil)• +/-Irritating to uninvolved skin• +/- salicylic acid

• Imiquimod

• 3 times weekly, cure rate around 44%

• Intralesional Candida AgBologniaSA Ringin. J Cutan Aesthet Surg. 2020 Jan-Mar; 13(1): 24–30.

SALICYLIC ACID 40% PLASTER: WARTS

• 25 pads for ~$20

• Up to 75% cure rate at 12 weeks with daily use

• Clean skin - Gently pare with nail file (don’t use elsewhere) to remove dead skin – apply plaster cut to fit over wart

• May apply tape over

• Repeat daily

• Good adjunctive home treatmentMadan RK and Levitt J. J Am Acad Dermatol 2014;70:788-92.

LIQUID NITROGEN: -196℃

• Pare, then two 10-15 sec freeze-thaw cycles, allowing to thaw between cycles; 1-3 week intervals

• Margin around lesion correlates to depth of freeze

• Spray until “ice-ball” (white freeze color change) formation spreads from center of wart with a 2mm margin

• Produces most damage to koilocytes (keratinocytes infected with HPV)

• CAUTION in periungual area to avoid nail dystrophy Bolognia

CRYOTHERAPY: POST-OP

• Pain

• Post-inflammatory hyper-/hypo-pigmentation

• Blister formation

• Scarring

• Recurrence

• Multiple treatments likely necessary

HPV VACCINE AND WARTS

• Case reports: resolution of refractory skin warts after receiving HPV vaccination

• Vaccine targets:• 6, 11, 16, 18, 31, 33, 45, 52, 58

• Common HPV types for skin warts:• Common: 1, 2, 4, 7• Plantar: 1• Flat: 3, 10,

• Anogenital: 6, 11

IMPACT OF ACNE

• 85% of teens, at least 12% of adult women

• Lower self-confidence and self-esteem

• More likely to employ a teen without acne

• PCPs likely to be the first the patient sees and may open up to. Patients often ashamed to mention

• Successful treatment improves psychological factors

Cotterill J, Cunliffe W. Br. J Dermaotl 1997;137:246-50.

Dreno B et al. Dermatol Ther 2016;6(2):207-218.

ACNE: TREAT AND/OR REFER SOONER RATHER THAN LATER

LESION TYPES

• Comedones: open and closed

• Papules and pustules

• Cysts and nodules

ACNE SEVERITY

• Mild (topical retinoid, +/-topical Abx, BP)• Mostly comedones

• < 10 papules/pustules

• Moderate (topical retinoid, +/-doxycycline, BP, OCPs, spironolactone, topical Abx)• Comedones

• >10 papules/pustules

• Severe (ISOTRETINOIN)• Comedones

• Many papules/pustules

• +/- nodules/cysts (deeper)

• Active scarring

• **recalcitrant to treatment

• Consider: duration, back

TREATMENT

• Combinational almost always

• CHRONIC disease – set patient expectations

• Timing of results

• Inflammatory/non-inflammatory lesions?

• Mild/moderate/severe?

• Scarring? Chronicity? Previous treatments?

TREATMENT: MILD ACNE

• Topical retinoids

• Mainstay of treatment: EVERYONE

• Comedolytic and anti-inflammatory

• Concentration & vehicle impact tolerability

• Adapalene tends to be better tolerated (**OTC**)

• Older formulations inactivated by sunlight and benzoyl peroxide (BP)

• Patient counseling

• +/-BP

• +/-topical antibiotic

• +/-topical dapsone

Eichenfeld LF, et al. Pediatr 2013;131(3): S163-S186.Leyden JJ. J Am Acad Dermatol 2003;49(3): S200-S210.Bolognia 2018

WHO GETS A RETINOID?

TREATMENT: MODERATE ACNE

• “Many” inflammatory papules

• Oral antibiotic (x3mo MAX)• Evidence supports use of doxycycline, minocycline, erythromycin, TMP-SMX,

TMP, and azithromycin

• + BP (ALWAYS)• + topical retinoid• NO NEED for both oral and topical Abx simultaneously

• Female patients: OCPs, spironolactone

Thiboutot D et al. Arch Dermatol 2006;142:597-602Zaenglein et al. J Am Acad Dermatol 2016;74:945-73

BENZOYL PEROXIDE

• Bactericidal: prevents/eliminates C. acnes resistance

• ALWAYS use in patients on oral or topical antibiotics

• Available in strengths of 2.5-10%

• Concentration dependent irritation

• Contact time can affect efficacy: leave-on vs wash-off –location dependent

• Bleaching and staining of fabric

TREATMENT: MODERATE ACNE (CONT’D)

• Follow-up at 3mo, ideally skin cleared and transition to only topical tx

• +/- inc retinoid strength pending tolerability

SEVERE ACNE

• Scarring

• Nodules, cysts

• Unable to maintain clearance on topical regimen

• *the back

• Treatment: ISOTRETINOIN

ISOTRETINOIN

• Reverses retention hyperkeratosis, reducing comedone formation

• Decreases sebum levels

• Reduces C. acnes

• Decreases inflammation

• Remission and “cure” possible

Layton AM. J Dermatol Treat 4: S2-S5,1993

ISOTRETINOIN

• LIFE-CHANGING

• Baseline labs and repeat at 2mo

• Liver, lipid profile, +/-CK

• I-pledge and birth control or abstinence

• Goal dose

• Controversies

Timothy J, et al. J Am Acad Dermatol. 2016;75(2)323—328.

ACNE TOP 5 PEARLS

1. NEVER use antibiotics (topical or oral) as monotherapy. Limit oral antibiotics to 3 months

2. ALWAYS use topical benzoyl peroxide when using an antibiotic3. EVERYONE gets a retinoid4. It takes a good 3 months of consistent use to see the full effects of acne meds5. Isotretinoin is life-changing and typically well tolerated in patients who are good

candidates

CASE: #22

What is this condition?

A. Scarring from overuse of steroids

B. Lichen planus

C. Hidradenitis suppurativa

D. Deep fungal infection

E. Skin cancer

HIDRADENITIS SUPPRATIVA

• Recurrent painful subcutaneous nodules and draining cysts

• Double comedone(s), sinus tracts, and abscesses

• Occurs in axilla*, inguinal, perianal, perineal, mammary, and inframammary regions

HIDRADENITIS SUPPURATIVA

• Begins ages 20s-30s

• Estimated prevalence 1-4% of population

• Women > Men

• Clinical diagnosis

• Time from disease on set to diagnosis: 7-12 years

HIDRADENITIS SUPPRATIVA

• Painful

• Malodorous discharge, soiling of cloths

• Under-diagnosed

• High incidence of depression

• Negative impact on work and social life

HIDRADENITIS SUPPRATIVA: TREATMENT

• Oral and topical antibiotics

• Biologics: TNF-alpha inhibitor, adalimumab, shown to be effective for moderate to severe HS

• Important: Identify disease early and start appropriate treatment

• Underdiagnosed – patients reluctant to mention and/or seek care

Kimball AB, et al. Ann Intern Med. 2012; 157(12):846-855.

SUMMARY: THE IMPORTANT THINGS

• Any skin lesion or condition that doesn’t respond as expected or diagnosis uncertain: biopsy or refer

• When doing a skin biopsy, clarify (and photo ideally) site, use best technique, know which area is best to sample

• Encourage sun protection and monthly self skin checks

• Don’t underestimate acne and its potential long term impacts. No need for scarring

INTERESTED IN LEARNING MORE DERMATOLOGY?

We have a few spots remaining for the CME/CE course: 9/17/21 @ Huber’s in southern IN

Skinternal Medicine: Dermatology for the Non-Dermatologist

www.skinternalmedicineconference.com

THANK YOU!!

meganlandis08@yahoo.com

ADDITIONAL REFERENCES

Zaenglein et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016;74:945-73.

Layton AM, et al. Clin Exp Dermatol 1994; 19: 303-308

GouldenV et al. Prevalence of facial acne in adults. J Am Acad Dermatol.1999; 41: 577-8

Levin J. Dermatol Clin 2016(34): 133-145.

Gastroenterol 93:606

Br J Dermatol 123: 653

Cutis 64: 106

Dupre A, et a;. Vitamin B-12 induced acne. Cutis 1979;24(2):210-11.

Layton AM. J Dermatol Treat 4: S2-S5,1993

Timothy et al. JAAD 2016.

Simonart T. Acne and whey protein supplementation among body builders. Dermatol 2012;225:256-8

Huang et al. Isotretinoin treatment for acne and risk of depression: a systematic review and meta-analysis. J Am Acad Dermatol2017;76:1068-76.

ADDITIONAL REFERENCES

Halioau et al. Feelings of stigmatization in patients with rosacea. J Eur Acad DermatolVenereol. 2017;31:163-8

Bewley et al. Erythema of rosacea impairs quality of life: results of a meta-analysis. Dermatol Ther 2016;6:237-47

Egeberg et al. Patients with rosacea have increased risk of depression and anxiety disorders: a Danish nationwide cohort study. Dermatol 2016;232:208-13

Van Zuuren. Rosacea. New Engl J Med. 2017;377,18:1754-64*

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