Dermatology & Medications

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Rudolph Owens
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1 Dermatology & Medications If it s dry, then wet it If it s wet, then dry it Three functions of dermatological preparations 1. Provide protective coating for injured skin 2. Lend emollient effect to dry, chapped skin 3. Vehicle for medication 1

2 Ointment and Cream Bases Base White petrolatum, white ointment Aquaphor, Aquabase Eucerin, Nivea, Dermabase, CeraVe, Cetaphil, Velvachol, Lubriderm, Neutrogena, cold cream Skin penetration None or very little Into the dermis Into and through skin Assessments When did it start? Has it changed? Has it spread? What makes it better? What makes it worse? Does it itch? Does it hurt, feel sore, burn? Have you treated it with OTCs? A word about topical antibiotics.. Allergies have increased dramatically Bacitracin: 2003 contact allergen of the year contact anaphylaxis Neomycin 2

3 Assessments Associated symptoms Fever SOB Difficulty swallowing Edema mucous membranes Swollen glands Erythema Weeping lesions Flaking skin Hair loss in area Assessments Other contacts have same rash? Medications Family history Recent immunization Prenatal history Exposures Is it life-threatening? Is it highly contagious? Is it a primary or secondary lesion? Is it acute, recurrent or chronic? Labs?? CBC ESR RPR Lyme serology Rubella titer Varicella titer KOH (fungal) Cultures Patch testing Wound C+S Skin (punch) biopsy 3

4 Wood s Lamp Detection of fluorescence help in dx in some dermatological diseases Low-intensity UV light Tinea capitis: blue-green florescence Tinea corporis: faint green florescence Vitiligo: accentuated milky=white appearance Community Acquired MRSA CDC: 4 Cs Crowding; Contact: skin-to-skin Contaminated items such as towels, surfaces Cleanliness (lack of) Community Acquired MRSA March 13, 2014 New England Journal of Medicine Updated "best practice" guidelines for management skin abscesses Focused on abscesses on trunk of body & extremities Conventional method of packing wound with sterile gauze to help absorb excess fluid may not always be necessary Few changes in antibiotic treatment & who should be treated 4

5 Who to Treat or not to treat NO Healthy patient with no risk factors No signs of systemic illness; isolated cutaneous abscess <5 cm diameter I & D only??? Cellulitis without risk factors & local prevalence < 20% Beta-lactam antibiotic Who To Treat YES Risk Factors Recurrent infection Extensive or systemic disease Rapid disease progression Suppressed immune system Very young or very old Location of abscess in area where complete drainage is difficult Lack of response to initial I&D (also assess for need for additional I&D), extensive abscessassociated cellulitis. Incision and Drainage May need ultrasound for deeper abscesses Debrided material should be sent for culture and susceptibility testing Incision and drainage alone may be sufficient for abscesses smaller than 5 cm Make large enough incision Edges need to stay open for 24 hrs Pack only if needed Special impregnanted packing not necessary 5

6 Larger Abscesses & / or Systemic Infections Incision and drainage plus antimicrobial therapy Important considerations in antibiotic selection Baseline susceptibility testing prior to antibiotic administration Individual patient circumstances Including type of infection Underlying comorbidities Other concurrent medications CA-MRSA: Necrotizing Pneumonia Consider diagnosis Severe pneumonia with evidence cavitation / necrosis Especially after influenza-like illness Treatment of CA MRSA TMP-SMX (Bactrim) < 10% resistance Avoid in 3 rd trimester pregnancy Doxycycline 100mg BID or Minocycline 200mg once then 100mg BID Doxycycline: 10 25% resistance Not recommended for < age 8 Clindamycin Adult dose: mg PO 3-4 X day Pediatric dose: mg/kg/day in 3-4 doses; not to exceed adult dose 3 24% resistance 6

7 Other Therapeutic Considerations Recurrent infection despite therapy Rifampin Combination with TMP-SMX, doxycycline, OR clindamycin Never use rifampin monotherapy, due to rapid emergence of resistance Adult dose: 300 mg PO bid x 5 days Pediatric dose: mg/kg/day in 2 doses not to exceed 600 mg/d x 5 days Other Considerations IV antibiotics generally not needed unless severe infection concomitant bacteremia or systemic toxicity Duration of therapy Depends on extent of disease Usual range 5-10 days Other Therapeutic Considerations Topical mupirocin (Bactroban) TID for 7-10 days with or without systemic antimicrobial therapy IV vancomycin, linezolid, Ceftaroline Severe skin infection Any evidence of invasive disease At risk for serious complications (prosthetic valve or prior endocarditis) 7

8 Use of fluoroquinolones or macrolides is NOT RECOMMENDED for treatment of CA-MRSA Herpes Zoster Frequently occur on face trigeminal nerve & flank / abdominal area Nasociliary branch of trigeminal nerve tip of nose lesions increases risk of eye involvement Can occur outside dermatome in normal, immunocompetent children shingles & cutaneous dissemination Herpes Zoster Lifetime incidence of 10 to 20 % Increases sharply, doubling in each decade past age 50 Increased risk: HIV, certain malignancies, chronic corticosteroid, chemo or radiation therapy Post-herpetic Neuralgia Approximately 20 % develop Risk factor: Age -15 times more often over age 50 8

9 Zoster Transmission Varicella zoster virus Can be spread from person with active shingles to person who has never had chickenpox Person exposed might develop chickenpox, but they would not develop shingles Spread through direct contact with fluid from blisters, not through sneezing, coughing, casual contact or before eruptions of blisters Less contagious than chickenpox and risk of spreading virus is low if rash is covered Treatment Options for Herpes Zoster: Benefit ONLY if started within 72 hrs Medication Dosage Acyclovir (Zovirax) Famciclovir (Famvir) Valacyclovir (Valtrex) Prednisone (Deltasone) 800 mg orally five times daily for 7 to 10 days 10 mg per kg IV every 8 hours for 7 to 10 days 500 mg orally three times daily for 7 days 1,000 mg orally three times daily for 7 days 40mg daily for 5 days longer taper may be needed Zoster Treatment Pediatric Acyclovir 80 mg/kg/day divided into 4 doses Mental status changes = herpes encephalitis CSF and EEG IV acyclovir indicated: 30 mg/kg/day divided into every 8 hr dosing 9

10 Pain & Zoster Treatment Prednisone in conjunction with acyclovir Decreases degree of neuritis & residual damage to affected nerves Analgesics OTC or narcotic medication at regular dosing schedule Calamine or Caladryl Open lesions Crusted lesions: capsaicin cream (Zostrix) Topically administered lidocaine & nerve blocks Pain & Zoster Treatment Tricyclic antidepressants Anticonvulsants Ocular Involvement orally administered antiviral agents and corticosteroids ophthalmologic consultation Qutenza: Capsaicin 8% (179mg) patch <18yrs: not recommended Only administered by healthcare professional Pregnancy Cat.B Nursing: do not breastfeed for remainder of day after treatment Evaluate for recent history of cardio- and cerebrovascular disease Must be monitored periodically during & for at least one hour following patch placement due to risk of significant rise in blood pressure 10

11 Scabies: Sarcoptes scabiei var. hominis Very contagious skin condition caused by a mite mite cannot live more than three days without human host can survive up to a month when living on a human lays eggs in human skin, which hatch, growing into adult mites Scabies Digs a little tunnel (burrow) below the skin Short S-shaped track that indicates mite s movement under skin Causes a type of allergic reaction No previous exposure: no symptoms until four to six weeks after initial infestation Spread: skin-to-skin contact Less common: sharing of clothes & bedding Symptoms Severe, continuous itching, especially at night Skin may show small insect-type bites or lesions may look like pimples may also be red and or have sores due to scratching Burrow may also be visible Average affected person has only five to 10 mites on their body at one time 11

12 Testing Skin scraping Place a drop of oil or saline on top of area Use a scalpel, scrap, place material a slide to examine under a microscope, looking for mite or its eggs Place drop of instant glue on skin & cover with slide Felt-tip-marker test Color with washable felt-tip marker across rash then wipe it off with alcohol, may help identify burrow since ink penetrates deep into skin Treatment All household members, sexual partners, other close contacts should be treated at the same time regardless of whether or not they have symptoms Pt in day care or facility: staff & those in close contact should be treated Wash linens, vacuum Itching & rash may last two weeks after treatment If symptoms last longer, possibility of re-infection or cream was not used appropriately Treatment 5% permethrin cream (Elimite, etc) generally safe > 2 months of age. Lindane (Kwell) rarely used because safety issues in children & may cause neurotoxicity (dizziness, seizures) Apply: head to bottom of feet, paying special attention to skin folds and the webs between fingers and toes Cream should be applied to clean, dry skin; clip & clean all fingernails & toenails Leave on hrs, wash off in shower 12

13 Treatment Ivermectin (Stromectol) Not used small children, pregnancy, breastfeeding 200 mcg / kg (3mg tabs): repeat after 2 wks Crusted scabies Difficult to treat May require several applications of lotions, ivermectin, extensive skin care to treat crusted skin Crusted or Norwegian Scabies Severe form of scabies: crusted scabies Problem with immune response to mites, allows for infestation with hundreds of thousands of mites elderly, mentally or physically disabled, and in patients with AIDS, lymphoma, or other conditions that decrease immune response Eventually take on a wart-like appearance Itching may be minimal or absent in this form Tinea capitis Most common fungal infection of the skin (dermatophytosis) of childhood Marked scaling of scalp and patchy loss of hair Maybe confused with seborrhoeic dermatitis, psoriasis or alopecia areata Diagnosis can be made with potassium hydroxide preparation of hairs and scalp scrapings 13

14 Treatment: Tinea capitis Grifulvin V for 6 weeks Sole agent FDA approved for tinea capitis in children 500mg tabs 1 2 tabs daily Suspension 125mg / 5ml lbs: mg daily >50 lbs: mg daily Plus Selsun Blue shampoo Contraindications: Pregnancy Tinea by any other name Tinea capitis = scalp Tinea corporis = body Tinea cruris = groin Tinea pedis = feet Tinea manuum = hand Tinea faciale = face Tinea unguium = nails Tinea versicolor = trunk Tinea corporis Superficial fungal infection of non-hairy skin. Lesions tend to be annular, with a welldefined border, clear center and spread peripherally. 14

15 Treatment: Tinea Corporis Topical applications of anti-fungal creams Lotrimin AF 1% BID < 4 wks Lotrisone BID Nizoral 2% daily < 6 wks Spectazole once daily for 2 weeks Lamisil 1% BID minimum of 1 week and no longer than 4 weeks OR PO once daily for 7 days Impetigo Contagious, superficial infection of skin Staphylococcus aureus Group A Streptococcus NOT Streptococcus pyogenes: "flesh-eating bacteria" Most common in children: 2 5 year olds Most likely to occur in warm and humid environments Most commonly spread by close contact Impetigo: 2 Types Non-bullous impetigo More common: both staph and strep Initially presents as small red papules similar to insect bites Lesions rapidly evolve to small blisters, then to pustules that finally scab over with a characteristic honey-colored crust Entire process takes about one week 15

16 Impetigo: 2 Types Bullous impetigo This form caused only by staph Bacteria produce toxin that reduces cell-to-cell stickiness (adhesion) causing separation between epidermis and dermis Bullae contain clear yellow-colored fluid Delicate, often break, leaving red, raw skin with ragged edge. A dark crust will commonly develop during the final stages of development. With healing, crust resolves Treatment Mild Gentle cleansing, removing crusts, and applying the mupirocin (Bactroban) BID for 7-10 days Nonprescription topical antibiotic ointments are not effective More severe or wide spread Especially bullous impetigo Penicillin derivatives (PenVK, Augmentin) or cephalosporins (cephalexin) Seborrheic Eczema Also known as Seborrheic dermatitis Cradle cap in infants Chronic inflammatory disorder in areas where sebaceous glands are most prominent?? 2 chief causes Overproduction of oil Lipophilic yeast of Malassezia genus Found naturally in skin s oils. Believed to act as irritant to those with condition 16

17 Seborrheic Eczema Develops in oily areas of body In & around ears Eyebrows Nosearea Back Upper portion of chest Skin develops scaly patches that flake off Patches may be white or yellowish in color Affected areas tend to be greasy and oily Skin may be red, pruritic and hair loss may occur Seborrheic Eczema Risk factors obesity fatigue environmental factors (such as weather) poor skin care stress the presence of other skin issues (such as acne) use of certain skin care products (in particular those with alcohol) ALSO: those who have CVA, HIV or Parkinson s, head injury Seborrheic Eczema: Treatment Shampoo daily or every other day, applied to scalp & beard areas & left in place for five - 10 minutes before rinsing Antidandruff shampoos containing 2.5 % selenium sulfide or 1 2 % pyrithione zinc Ketoconazole shampoo may be used Moisturizing shampoo should be used afterward to prevent dessication of hair 17

18 Seborrheic Eczema: Treatment Ketoconazole cream 2 % QD BID Hydrocortisone cream 1 % QD BID Sodium sulfacetamide 10 % lotion Unresponsive severe seborrhea Isotretinoin (Accutane): 90 percent reduction in sebaceous gland size Daily doses of isotretinoin 0.1 to 0.3 mg / kg Mucocutaneous adverse effects include cheilitis, xerosis, conjunctivitis, urethritis and hair loss Pulse Therapy may be indicated How can I tell the difference between seborrheic dermatitis and psoriasis??? Patchy scales Psoriasis silvery white, thick crust that may bleed when removed. Patches extend beyond hairline or hair area (brows). Pruritis or soreness present Seborrheic dermatitis Greasy white or yellow scales that are easily removed and usually confined by hairline. Pruritis may be severe Treatment is similar. Severe psoriasis may need methotrexate, cyclosporine Measles: Rubeola Highly contagious Nasopharyngeal secretions Koplik spots Blue-white spots on inside of mouth occur hours before rash stage Rash spreads forehead to trunk 1-2 days later Blotchy erythematous morbilliform rash Discrete red-brown macules that blanch with pressure 18

19 Measles Symptom Reminder Cough Conjunctivitis Coryza Fever: onset of rash Light sensitivity Muscle aches Sore throat Measles: Rubeola Complications Pneumonitis/Pneumonia Otitis Media Myocarditis Encephalitis MEASLES All adults born in 1957 or later should have documentation of 1 or more doses of MMR vaccine unless they have a medical contraindication to the vaccine or laboratory evidence of immunity to each of the three diseases. Documentation of provider-diagnosed disease is not considered acceptable evidence of immunity for measles, mumps, or rubella 19

20 Routine second dose of MMR vaccine, administered a minimum of 28 days after the first dose, is recommended for adults who: Students in postsecondary educational institutions Work in a health care facility Plan to travel internationally. Persons who received inactivated (killed) measles vaccine or measles vaccine of unknown type during should be revaccinated with 2 doses of MMR vaccine. Closing thoughts on skin. Try to figure out what you re treating. Testing Referral time Give the medication Adequate doses Adequate time to work 20

The skin is the largest organ of the human body. Functions: protection sensation maintain temperature vitamin synthesis

Dermatology The skin is the largest organ of the human body. Functions: protection sensation maintain temperature vitamin synthesis The image to the left shows an image of skin cells and the proteins which