Office Management of Common Skin Conditions. Goals

Transcription

1 Office Management of Common Skin Conditions Michael J. Blankinship M.D., Ph.D. Essentia Health Spring Conference May 16 th, 2014 Goals I want to discuss conditions that are common enough that you will likely encounter them, but rare enough that I may be able to give you some helpful practical points. The Goldilocks conundrum: 1. Too little information and it may be useless, you take away nothing 2. Too much information and it is like drinking from a fire hose, you take away nothing 3. Just the right balance, in my experience most of us fail, including myself 1

2 Question and Answer Feel free to have me elaborate on anything that I speak about However, also feel free to ask anything you might be curious about, I will attempt to answer Surely, It s All Just Eczema, Right? Here we are in the heart of the Midwest, what kind of crazy things could possibly be hanging around? Histiocytosis X Reticular erythematous mucinosis Cutaneous T cell lymphoma Birt Hogge Dube Sneddon Wilkinson Minute digitate dermatosis Diffuse angiomatosis of the breast Primary cutaneous marginal zone B cell lymphoma 2

3 Scabies Infestation Caused by infestation of obligate human ectoparisite, Sacroptes scabie This creature is a short lived mite that completes its life cycle within the stratum corneum of the skin Much more common than you think, a high index of suspicion is required to detect this condition Mounsey KE and McCarthy JS, Curr Opin Infect Dis, 2013 Scabies Clinical Presentation The hallmark of a scabies infestation is an intense itch associated with a rash that can be relatively minimal The burrows of the animal tend to be concentrated on the interdigital spaces, volar wrist, inframammary creases, waist band line The burrows themselves are small erythematous papules, often in a linear configuration, generally several millimeters in greatest dimension, can be inconspicuous Mounsey KE and McCarthy JS, Curr Opin Infect Dis,

4 Scabies Clinical Presentation The itch can be body wide and is not necessarily limited to areas of the rash The itch is often worse at night, as is most pruritus It is very important to let patients know that the itch will likely last 2 to 6 weeks after successful treatment Occasionally, blisters or pustules can occur Mounsey KE and McCarthy JS, Curr Opin Infect Dis, 2013 Scabies Clinical Presentation It is important to note that many infested individuals may not have visible burrows or symptoms of pruritus However, these individuals can pass on the infestation, leading to treatment failures of symptomatic individuals All household members and close contacts, such as sexual partners, should be presumed to be infested Mounsey KE and McCarthy JS, Curr Opin Infect Dis, 2013 Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition,

5 Scabies VisualDx, 2014 Scabies VisualDx,

6 Scabies VisualDx, 2014 Crusted Scabies Also called Norwegian Scabies A very different, highly transmissible form of the disease Many thousands of mites can be present Treatment and potential complications are different and should be referred for treatment A rare entity Mounsey KE and McCarthy JS, Curr Opin Infect Dis,

7 Crusted Scabies Scabiehelp.com Scabies Diagnosis Requires a high degree of suspicion If there is no other obvious cause of itching, or a common condition, such as presumed eczema, is not responding to treatment, keep this in mind Laboratory studies are non specific, though an eosinophilia may be present A mineral oil preparation can be diagnostic, however, this requires significant experience for good sensitivity Mounsey KE and McCarthy JS, Curr Opin Infect Dis,

8 Scabies Treatment A variety of treatments have been used, including permethrin, lindane, ivermectin, and sulfur have been used Current treatment is mostly based on the use of permethrin cream Treatment of close personal contacts, such as sexual partners, and the household are required for high cure rates Resistance to permethrin treatment is rare, but rising, treatment failures are often postscabetic pruritus or a re infestation Mounsey KE and McCarthy JS, Curr Opin Infect Dis, 2013 Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition, 2013 Scabies Treatment Treatment for all patient s and contacts must be timed at day 0 and then 7 days later The adults are killed but eggs and nymphs have relative resistance, necessitating the second treatment, after maturing but before continuing the life cycle Though the environment and pets are not long term fomites and vectors, they may remain transmissible for 1 3 days Mounsey KE and McCarthy JS, Curr Opin Infect Dis, 2013 Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition,

9 Scabies Treatment A timed treatment of permethrin cream at day zero and seven days later In adults, from the jawline down, paying close attention to skin folds In the very elderly, immune suppressed, infants, and the physically disabled treat from head to toe Vacuuming of the environment, washing and drying of clothes and linens, and washing, but not treating, of pets should accompany the treatments Mounsey KE and McCarthy JS, Curr Opin Infect Dis, 2013 Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition, 2013 Scabies Quiz #1 A) Scabies is a six legged creature that lives in the dermal layer of the skin B) Scabies is an eight legged creature that lives in the upper most layer of the epidermis C) Scabies is a six legged creature that lives in the upper most layer of the epidermis D) Scabies is an eight legged creature that lives in the upper most layer of the epidermis 9

10 Scabies Quiz #1 A) Scabies is a six legged creature that lives in the dermal layer of the skin B) Scabies is an eight legged creature that lives in the upper most layer of the epidermis C) Scabies is a six legged creature that lives in the upper most layer of the epidermis D) Scabies is an eight legged creature (mite) that lives in the upper most layer of the epidermis (stratum corneum) Scabies Quiz #2 Question: The current treatment of choice for scabies in pregnant women is: A) Lindane B) Precipitated sulfur C) Permethrin D) Oral ivermectin 10

11 Scabies Quiz #2 Question: The current treatment of choice for scabies in pregnant women is: A) Lindane (high toxicity) B) Precipitated sulfur (was a prior preferred treatment) C) Permethrin (current preferred treatment) D) Oral ivermectin (not yet directly tested) Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition, 2013 Scabies Quiz #3 Which describes a proper scabies treatment? A) Treatment of the infested patient with permethrin once with cleaning of the environment B) Treatment of the infested patient with permethrin once and seven days later, with cleaning of the environment C) Treatment of the infested patient, his household with permethrin once and seven days later, with cleaning of the environment 11

12 Scabies Quiz #3 Which describes a proper scabies treatment? A) Treatment of the infested patient with permethrin once with cleaning of the environment (ignores presumed carriers, only one treatment) B) Treatment of the infested patient with permethrin once and seven days later, with cleaning of the environment (ignores presumed carriers, only one treatment) C) Treatment of the infested patient, his household with permethrin once and seven days later, with cleaning of the environment Lichen Planus A common rash affecting up to 1% of the population during their lifetime Most common between the fourth and seventh decades of life The lichenoid reaction pattern is one of the major inflammatory reaction patterns Prior to diagnosing someone with the spontaneous, idiopathic version of the disease, at least consider the possibility of a viral, drug, or allergic source of the disease Pickert A, Cutis,

13 Lichen Planus: Clinical Presentation The classic lesion is a small, purple, polygonal, pruritic papule often covered with lacey white Wickham s striae Favors the dorsal hands, pretibial skin, volor wrists, and flexor surfaces The buccal surfaces are also often affected with Wickham s striae This disease demonstrates the isomorphic response (a.k.a. koebnerization), new lesions arising in areas of unrelated trauma/inflammation Pickert A, Cutis, 2012 Lichen Planus: Clinical Presentation The typical symptom is pruritus, which can be intense, though a burning sensation and pain can be common as well The disease can be extensive and ulcerated in the mouth affecting the gingival and buccal mucosa, sometimes limiting PO intake When extensive oral disease is present, especially when it is the sole or major manifestation of the disease, there is an association with hepatitis C Pickert A, Cutis,

14 Lichen Planus VisualDx, 2014 Lichen Planus VisualDx,

15 Lichen Planus VisualDx, 2014 Lichen Planus Medicalook.com 15

16 Lichen Planus: Treatment First line treatment is topical steroids, including for oral disease, I generally use a potent class III I steroid, such as fluocinonide or clobetasol (gel form for mouth) Topical tretinoin has been reported as useful For extensive disease a taper of oral prednisone over 3 6 weeks starting at 1mg/kg For chronic or recalcitrant disease, hydroxychloroquine 200MG PO BID can be attempted For extensive oral disease I obtain hepatitis C serologies as there is an association Pickert A, Cutis, 2012 Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition, 2013 Pityriasis Rosea A very common rash, the etiology is presumed to be a type of viral exanthem though the responsible virus(es) have yet to be identified This is a benign, self limited disease Most frequently seen in young adults and teens between age 10 and 35 years of age There are often peaks of the disease in the Fall and Spring Rarely occurs prior to the age of 2 Pickert A, Cutis, 2012 Stulberg DL and Wolfrey J, Am Fam Physician,

17 Pityriasis Rosea: Clinical Presentation Often starts with a herald patch, often located on the trunk Usually within one week a blooming of the lesions will occur, favoring the trunk and proximal extremities that spreads over the course of the next 1 2 weeks Rarely, there is viral like prodrome seen, though this is identified in less than 5% of patients Though classic, the herald patch is not always present or noted Pickert A, Cutis, 2012 Stulberg DL and Wolfrey J, Am Fam Physician, 2004 Pityriasis Rosea: Clinical Presentation The classic individual lesions are red to salmonpink ovoid papules, patches, and plaques, often slightly raised at the edges These are often associated with small, fine pityriasiform scale which often has a trailing edge The lesions may range in size from several millimeters to over 10 centimeters, the herald patches is often the largest These lesions will often follow a so called Christmas tree distribution following the cleavage lines of Langer Pickert A, Cutis, 2012 Stulberg DL and Wolfrey J, Am Fam Physician,

18 Pityriasis Rosea: Clinical Presentation The face, palms, and soles are generally spared and the distal extremities are usually sparsely affected; and enanathem is rarely noted This conditions is generally asymptomatic, however, approximately 25% of patients will experience pruritus to the point where intervention may be considered The conditions generally resolved in 6 8 weeks without treatment, often with post inflammatory change as the only sequelae, however, it can persist for 6 months or more in atypical cases Pickert A, Cutis, 2012 Stulberg DL and Wolfrey J, Am Fam Physician, 2004 Pityriasis Rosea: Clinical Presentation The nature of the lesion often brings psoriasis, eczema (particularly the numular variant), tinea corporis, or pityriasiform drug eruptions into the differential diagnosis One disease that must be kept in mind is secondary syphilis as this can appear identical to pirytiasis rosea There are more rare variants, such as vesicular, pustular, urticarial, and purpuric Pickert A, Cutis, 2012 Stulberg DL and Wolfrey J, Am Fam Physician,

19 Pityriasis Rosea VisualDx, 2014 Pityriasis Rosea VisualDx,

20 Pityriasis Rosea: Treatment Treatment is usually not required, however, if pruritus is significant or the disease is persistent one can attempt treatment UVA1 phototherapy UVB phototherapy, either broad band or narrow band Topical steroids Oral anti histamines, such as hydroxizine Pickert A, Cutis, 2012 Stulberg DL and Wolfrey J, Am Fam Physician, 2004 Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition, 2013 Pityriais Rosea Quiz What laboratory study should be considered in a patient presenting with possible pityriasis rosea? A) Serologies for human herpes virus 7 and 8 B) None C) Complete blood count with differential D) RPR/VDRL Pickert A, Cutis, 2012 Stulberg DL and Wolfrey J, Am Fam Physician,

21 Pityriais Rosea Quiz What laboratory study should be considered in a patient presenting with possible pityriasis rosea? A) Serologies for human herpes virus 7 and 8 B) None no testing is absolutely required C) Complete blood count with differential D) RPR/VDRL I (almost) always obtain a syphilis screen Pickert A, Cutis, 2012 Stulberg DL and Wolfrey J, Am Fam Physician, 2004 Perioral Facial Dermatitis Facial rash most often seen in young women between the third and fifth decade of life Resembles acne, rosacea, or non specific irritant dermatitis like reactions There is steroid induced variant as well as a spontaneous variant Often considered a rosacea variant though this is of uncertain etiology Weber K and Thurmayr R, Dermatology,

22 Perioral Facial Dermatitis Clinical Presentation Most often composed of 1 2mm erythematous papules Unlike folliculitis or acne, these lesions are not follicularly based These are most often centered around the mouth, but the periorbital skin is also often involved The papules are the most common presentation and are usually present, Areas of poorly defined erythema with minimal scale are commonly seen Weber K and Thurmayr R, Dermatology, 2005 Perioral Facial Dermatitis Dxline.org,

23 Perioral Facial Dermatitis Pcds.org.uk, 2010 Perioral Facial Dermatitis This condition can be steroid induced Often seen after use of a glucocorticoid on the face for several weeks Halogenated glucocorticoids are particularly linked Generally worsens significantly following abrupt withdrawal of the glucocorticoid This frequently necessitates a taper of the glucocorticoid along with treatment of the initial disease, if still active Weber K and Thurmayr R, Dermatology,

24 Perioral Facial Dermatitis Treatment If the patient has a history of topical steroid use, the steroids must be discontinued, often with a taper to prevent Switch to a lower potency steroid and slowly taper the usage, there is no set protocol, I usually will apply BID for one week, QDAY for one week, then once every other day for one week Concomitant treatment with an oral tetracycline is often performed as well Weber K and Thurmayr R, Dermatology, 2005 Perioral Facial Dermatitis Quiz The most common clinical presentation would be: A) An 80 year old man with poorly defined erythema with greasy white scale in the nasolabial folds B) A 16 year old woman with erythematous papules and pustules on the face and upper back centered around hair follicles C) A 35 year old man with erythematous papules on the jawline and upper neck within the distribution of his beard D) A 22 year old woman with erythematous papules and pustules on a background of poorly defined erythema around the mouth and eyes 24

25 Perioral Facial Dermatitis Quiz #1 The most common clinical presentation would be: A) An 80 year old man with poorly defined erythema with greasy white scale in the nasolabial folds Seborrheic dermatitis B) A 16 year old woman with erythematous papules and pustules on the face and upper back centered around hair follicles Acne C) A 35 year old man with erythematous papules on the jawline and upper neck within the distribution of his beard Folliculitis/Pseudofolliculitis barbae D) A 22 year old woman with erythematous papules and pustules on a background of poorly defined erythema around the mouth and eyes Perioral Dermatitis Quiz #2 What is the most effective treatment for perioral Facial Dermatitis? A) Topical metronidazole B) Topical steroids C) Oral minocycline D) Topical tretinoin E) Oral isotretinoin 25

26 Perioral Dermatitis Quiz #2 What is the most effective treatment for perioral Facial Dermatitis? A) Topical metronidazole effective, but not the highest efficacy B) Topical steroids not truly a treatment, can be a cause C) Oral minocycline D) Topical tretinoin effective for acne, a mimic E) Oral isotretinoin occasionally used for recalcitrant cases Weber K and Thurmayr R, Dermatology, 2005 Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition, 2013 Eczema VisualDx,

27 Pearls for Eczema An important component is the use of copious, bland emollients, creams or ointments Short, cool baths Gentle cleansers, such as Dove, Cetaphil, and Vanicream Bleach baths, ¼ cup of household bleach in a bathtub full of water, soak for 5 to 10 minutes, rinse, and bath as normal Pearls For Eczema Class VII thru V topical steroids are useful for thin areas (head, neck, skin folds, and genitalia) and young children occasionally short courses of more potent steroids are required Class IV thru I topical steroids are useful for the body and scalp To prevent resistance and steroid atrophy a burst and taper treatment is often prescribed Topical tacrolimus and pimecrolimus are useful, but less potent, than topical steroids I often use them on non steroid days Torley D, et al., Clin Exp Dermatology, 2013 Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition,

28 Acne VisualDx, 2014 Pearls For Acne Combination antibiotic and retinoid often gain control of disease more quickly, can often back down to just a nightly retinoid when in remission Manage expectations, most patient will require 6 12 weeks to reach maximum effectiveness Topical retinoids are the backbone of therapy and prevent the microcomedo that gives rise to acne As potent a retinoid as is tolerated should be prescribed for use at night at least 3 4 nights a week Titus S and Hodge J, Am Fam Physician, 2012 Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition,

29 Pearls For Acne A combination of topical clindamycin preparations and morning use of a benzoyl peroxide wash is an effective anti bacterial regimen Oral antibiotics, especially of the tetracycline class have anti inflammatory properties independent of their antibiotic activities, they will quickly lead to improvement less appropriate for long term control of the disease as they do not address the microcomedo Titus S and Hodge J, Am Fam Physician, 2012 Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition, 2013 Psoriasis VisualDx,

30 Pearls for Psoriasis Moderate to severe disease or psoriatic arthritis often will require disease modifying medications Topical steroids as discussed previously for eczema are first line therapy Calcipotriene cream BID is a useful adjunct therapy to be used on non steroid days no more than 100g per week For significant scalp involvement, topical steroid solution applied to scalp, covered with mineral oil or Baker s P&S peanut oil under shower cap occlusion over night for 3 nights in a row is very effective Mason A, et al., J Am Acad Dermatolog, 2013 Wolverton, Comprehensive Dermatologic Drug Therapy, 3 rd Edition, 2013 Q&A I would be happy to take any questions. 30

31 References 1. Bolognia JL, Jorizzo JL, Schaffer JV, 2009, Dermatology, 3 rd edition 2. Dxline.org, Mason A, Mason J, Cork M, Hancock H, Dooley G, 2013, Topical treatments for chronic plaque psoriasis: an abridged Cochrane systematic review. J Am Acad Dermatol 69(5): Medicalook.com, Mounsey KE and McCarthy JS, 2013, Treatment and control of scabies, Curr Opin Infect Dis, 26(2): Pcds.org.uk, Pickert A, 2012, Concise review of lichen planus and lichenoid dermatoses, Cutis 90(3)E Scabiehelp.com, Stulberg DL and Wolfrey J, 2004, Pityriasis rosea, Am Fam Physician 69(1): Titus S and Hodge J, 2012, Diagnosis and treatment of acne. Am Fam Physician 86(8): Torley D, Futamura M, Williams HC, Thomas KS, 2013 What s new in atopic eczema? An analysis of systematic reviews published Clin Exp Dermatol. 38(5): Weber K and Thurmayr R, 2005, Critical appraisal of reports on the treatment of perioral dermatitis. Dermatology, 210(4): VisualDx, Wolverton SE, 2013, Comprehensive Dermatologic Drug Therapy, 3 rd edition 31