principles of dermatologic therapy moisturizers and gentle
TRANSCRIPT
Dermatology Pearls for the Primary Care Practitioner‐ Part 1
Lindy P. Fox, MD
Professor of Clinical DermatologyDirector, Hospital Consultation Service
Department of DermatologyUniversity of California, San Francisco
I have no conflicts of interest to disclose
I may be discussing off-label use of medications
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Outline
• Principles of topical therapy• Nummular Dermatitis• Alopecia• Acne in the adult• Perioral dermatitis
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Principles of Dermatologic TherapyMoisturizers and Gentle Skin Care
• Emolliate skin– All dry skin itches
• Gentle skin care– Soap to armpits, groin, scalp only (no soap on the
rash)
– Short cool showers or tub soak for 15-20 minutes
– Apply medications and moisturizer within 3 minutes of bathing or swimming
Principles of Dermatologic TherapyMoisturizers and Gentle Skin Care
• Moisturizers– Contain oil to seal the surface of the skin and
replace the damaged water barrier– Petrolatum (Vaseline) is the premier and “gold
standard” moisturizer– Additions: water, glycerin, mineral oil, lanolin– Some try to mimic naturally occurring ceramides
(E.g. CeraVe)• Thick creams more moisturizing than pump lotions
Principles of Dermatologic TherapyTopical Medications
• The efficacy of any topical medication is related to: 1. The concentration of the medication
2. The vehicle
3. The active ingredient (inherent strength)
4. Anatomic location
Vehicles
• Ointment (like Vaseline): – Greasy, moisturizing, messy, most effective.
• Creams (vanish when rubbed in): – Less greasy, can sting, more likely to cause
allergy (preservatives/fragrances).
• Lotions (liquid): – Cooling, liquids that pour.
Vehicles
• Solutions (liquids that are greasy or alcoholic): – Can sting, good for hairy areas
• Gels (semi solid alcohol-based): – Can sting, good for hairy areas or wet lesions
• Foams (cosmetically elegant): – For hairy areas
• Sprays: Aerosols (rarely used)
Topical Corticosteroids
• Super-High Potency: Clobetasol
• High Potency: Fluocinonide
• Medium Potency: Triamcinolone (TAC)
• Mid-Low: Aclometasone, Desonide
• Lowest Potency: Hydrocortisone
Topical Therapy
• Choose agent by body site, age, type of lesion (weeping or not), surface area
• For Face: – Hydrocortisone 2.5% ointment BID – If fails, aclometasone (Aclovate), desonide ointment
• For Body: – Triamcinolone acetonide 0.1% ointment BID– If fails, fluocinonide ointment
• For scalp: – Fluocinonide solution– Fluocinolone oil– Clobetasol foam
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Nummular Dermatitis
Nummular Dermatitis
• Affects middle aged men most, but also other age groups and women
• Some patients have atopic dermatitis
• Some patients start with xerotic eczema
• Alcoholics predisposed
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Nummular Dermatitis
• Starts as a single lesion of the lower leg (90%+) or arm (<10%)
• Lesion present for months
• A few new lesions on that leg
• Begins to generalize
• Very, very pruritic
• May become secondarily infected
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13 14
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Nummular Dermatitis
• Disease lasts 18 months, tending to relapse in cleared lesions with minimal irritation or dryness
• Need to be very aggressive in good skin care regimen for 1-2 years after cleared
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Nummular Dermatitis Treatment
• Emolliation, dry skin care• Potent (fluocinonide) or superpotent
(clobetasol) topical steroid BID to red plaques
• Oral antihistamine• Antibiotic if secondarily infected
– bacterial culture
• If fails, send to dermatology
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Alopecia
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Alopecia = hair loss
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Non‐Scarring Scarring
Alopecia areataTelogen EffluviumAndrogenetic alopecia
Traction alopeciaTrichotillomania (end stage)Neutrophil mediated
Folliculitis decalvansDissecting cellulitis of the scalp
Lymphocyte mediatedLichen planopilarisFrontal fibrosing alopeciaCentral centrifugal alopeciaChronic cutaneous lupus
Scalp biopsy:• Area ADJACENT to alopecia, ask for TRANSVERSE sections• ALL scarring alopecias OR nonscarring alopecia where diagnosis uncertain
Alopecia Areata• Affects up to 0.2% US population• Types
– Relapsing remitting– Ophiasis (band like along occipital scalp)– Alopecia totalis (all scalp hair)– Alopecia universalis (all scalp and body hair)
• Associations– Atopic disease– Autoimmune thyroid disease– Vitiligo– Inflammatory bowel disease– APECED syndrome
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Alopecia Areata:Round or oval patches of nonscarring alopecia
22Taken from Dermatology, 2012, Elsevier
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Alopecia Areata:Exclamation point hairs
Taken from Dermatology, 2012, Elsevier
Alopecia Areat: Ophiasis pattern
24Taken from Dermatology, 2012, Elsevier
Alopecia Areata
• IL triamcinolone – 10mg/ml– q month
• Immunosuppression (recurs after stopped)– Pulse steroids – Methotrexate– Cyclosporine
• Contact sensitization• Minoxidil• Antihistamines• Simvastatin/ezetimibe• Tofacitinib
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J Investig Dermatol Symp Proc. 2018 Jan;19(1):S25‐S31J Investig Dermatol Symp Proc. 2018 Jan;19(1):S18‐20JAAD 2018 Jan; 78(1):15‐24
Telogen Effluvium
• Normal hair cycle
– Anagen 90‐95%
– Catagen
– Telogen 5‐10%
– Normal shedding is 50‐100 hairs/day
• Transient shifting of hair cycle
• Shedding
• No scalp itch or rash
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Telogen Effluvium‐ Causes
• Postpartum• Chronic (no cause)• Post febrile• Severe infection• Severe chronic illness (SLE, HIV, etc)• Severe prolonged stress• Post major surgery• Endocrinopathy
– Thyroid, parathyroid
• Crash diets, malnutrition, starvation• Medications
– Stopping OCP, retinoids, heparin, PTU, methimazole, anticonvulsants, β‐ blockers, IFN‐α, heavy metals
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Telogen Effluvium• Examination
– Diffuse thinning– Hair pull
• Diagnostic > 20% hairs are telogen– Look for bulb at end of hair shaft
• Workup– TSH, Vit D, Fe, ferritin, chemistry– Biopsy if > 6 mo (r/o AGA)
• Treatment– Address underlying etiology– Replete ferritin if < 40 ng/dl– Minoxidil– Reassurance (most regrow almost all lost hair)
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Androgenetic Alopecia
• Male or female pattern hair loss• Female
– Complain of widening part– Retain anterior hairline– Early onset/severe: workup for hyperandrogenism
• F/T testosterone, DHEAS, 17‐OH progesterone
• Often “exposed” by telogen effluvium• Treat with
– Minoxidil 5% (F QD, M BID)– Spironolactone (female)– Finasteride‐ up to 5mg/d
• NOT for women of childbearing potential29 30
Taken from Dermatology, 2012, Elsevier
Some scarring alopecias
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Traction Alopecia
32Taken from Dermatology, 2012, Elsevier
Chronic Cutaneous LE
33Taken from Dermatology, 2012, Elsevier
Lichen Planopilaris
34Taken from Dermatology, 2012, Elsevier
Approach to the Adult Acne Patient
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Acne Pathogenesis, Clinical Features, Therapeutics
Oily skin
Non‐inflammatory open and closed comedones(“blackheads and whiteheads”)
Inflammatory papules and pustules
Cystic nodules
Retinoids, spironolactone
Salicylic acid, retinoids
Benzoyl peroxideAntibiotics (topical and oral)SpironolactoneOCPsIsotretinoin
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Excess sebum
Abnormal follicular keratinization
Propionibacteriumacnes
Inflammation
Pathogenesis Clinical features Therapeutics
Acne Treatment• Mild inflammatory acne
– benzoyl peroxide + topical antibiotic (clindamycin, erythromycin)• Moderate inflammatory acne
– oral antibiotic (tetracyclines) (with topicals)• Comedonal acne
– topical retinoid (tretinoin, adapalene, tazarotene)• Acne with hyperpigmentation
– azelaic acid• Acne/rosacea overlap /seborrheic dermatitis-
– sulfur based preparations• Hormonal component
– oral contraceptive, spironolactone• Cystic, scarring- isotretinoin
– Teratogenic, hypertriglyceridemia, transaminitis, cheilitis, xerosis, alopecia (telogen effluvium)
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Acne Therapy Guidelines
• Limit oral antibiotics to 3‐6 mo
• All patients should receive a retinoid for maintenance
– Tretinoin
– Tazarotene
– Adapalene (now OTC)
38JAAD 2016; 75: 1142‐50
Topical Retinoids
• Side effects– Irritating- redness, flaking/dryness
– May flare acne early in course
– Photosensitizing
– Tazarotene is category X in pregnancy !!!
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Acne in Adult Women
• Often related to excess androgen or excess androgen effect on hair follicles
• Other features of PCOS are often not present—irregular menses, etc.
• Serum testosterone can be normal
• Spironolactone 50 mg-200mg daily with or without OCPs
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Acne Pearls• Retinoids are the most comedolytic
• Topical retinoids can be tolerated by most• Start with a low dose: tretinoin 0.025% cream
• Wait 20‐30 minutes after washing face to apply
• Use 1‐2 pea‐sized amount to cover the whole face
• Start BIW or TIW
• Tazarotene is category X in pregnancy
• Back acne often requires systemic therapy
• Acne in adult women‐ use spironolactone– No need to check K+ in healthy adult women
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Perioral dermatitis
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Perioral Dermatitis
• Women aged 20‐45
• Papules and small pustules around the mouth, narrow spared zone around the lips.
• Asymptomatic, burning, itching
• Causes – Steroids (topical, nasal inhalers)
– Fluorinated toothpaste
– Skin care creams with petrolatum or paraffin base or Isopropyl myristate (vehicle)
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Perioral Dermatitis: Treatment
• Stop topical products
• Topical antibiotics
– Clindamycin
• Topical or oral ivermectin
• Oral tetracyclines
• Warn patients of rebound if coming off topical steroids
• Avoid triggers
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