IT S FUNDAMENTAL MY DEAR WATSON! A SHERLOCKIAN APPROACH TO DERMATOLOGY

Transcription

1 IT S FUNDAMENTAL MY DEAR WATSON! A SHERLOCKIAN APPROACH TO DERMATOLOGY Skin, Bones, and other Private Parts Symposium Dermatology Lectures by Debra Shelby, PhD, DNP, FNP-BC, FADNP, FAANP

2 Debra Shelby, PhD, DNP, FNP-BC, FADNP, FAANP President, National Academy of Dermatology Nurse Practitioners President, American College of Dermatology Nurse Practitioners Owner, Florida Specialty Medical Services, LLC Owner, New Mexico Specialty Medical Services, LLC Owner, National Institute for Dermatology Owner, Dermstaffing No conflicts of interest to report

3 PART FIVE PUNISHMENT THAT FITS THE CRIME: FIRST TIME AND REPEAT OFFENDERS

4 OBJECTIVES Identify one treatment option for Actinic Keratoses Describe two treatment options for BCC, SCC, Discuss one histiologic factor that determines Melanoma treatment Describe three frequently used drug classifications/ therapies used for treatment of dermatoses. Discuss two complications with treatment of common dermatoses.

5 ACTINIC KERATOSES Phototherapy (PDT) Cryo 5FU Imiquimod Topical non-steroidal anti-inflammatory: Diclofenac TCA EDC Shave biopsy hypertrophic and larger AKs Field therapy versus solitary lesions

6 BASAL CELL CARCINOMA Mohs Excision Radiation Cryosurgery Photodynamic therapy Topical chemotherapy: 5FU Biologic therapy: Imiquimod HedgeHog Inhibitors: Sonidegib and Vismodegib Electrodessication and curettage (EDC) Laser

7 SQUAMOUS CELL CARCINOMA Insitu: Saucerize, cryo, 5FU, EDC Invasive: -Mohs -Excisions -Radiation

8 MELANOMA Surgery Radiation Chemotherapy: Dacarbazine Interferon Antiviral therapy Sentinel Lymph node biopsy Limb Perfusions: (ILP) Delivers high dose chemo through a vein and artery circulation throughout the extremity. Limb Infusion: (ILI) Delivers high dose chemo directly to limb through a catheter to the site Liver perfusions/infusion

9 DERMATOSES

10 START WITH THE BASICS: DERMATOLOGIC THERAPIES

11 MOST COMMON DRUG THERAPIES Topical Glucocorticosteriods Antibiotics Antifungals Immunomodulators Biologics Don t forget: With some rashes, effective emollients are as important as drug therapies. DO NOT FORGET COMBINATION THERAPIES!!

12 DERMATOLOGIC THERAPIES Ointments: Consists of mainly water suspended in oil. Generally the most potent vehicle because of their occlusive effect. Creams: Semisolid emulsions of oil in 20% to 50% water. Most cosmetically appealing Lotions: Powder-in-water preparations. Least potent, but are useful in hairy areas and conditions with large surface areas. Solutions: Consist of water mixed with various medications or substances. Used for soaks and open, wet dressings Gels: Oil-in-water emulsions with alcohol in the base. Combines the best therapeutic advantages of ointments with the best cosmetic advantages of creams Foams: Alcohol based, great for large areas and hairy locations

13 TOPICAL GLUCOCORTICOSTEROIDS Class I: Superpotent Examples: Clobetasol proprionate ointment, cream 0.5% Betamethasone diproprionate gel and ointment 0.05% Class II: High Potency Examples: Betamethasone diproprionate AF cream 0.05%, Fluocinonide gel, ointment and cream 0.05% Class III: High Potency Examples: Triamcinolone acetonide cream 0.5% Betamethasone valerate ointment 0.1% (Bolognia,Jorizzo, & Rapini (2003), p. 1882)

14 TOPICAL GLUCOCORTICOSTEROIDS CONT. Class 4: Medium Potency Examples: Fluticasone proprionate cream 0.05%, Triamcinolone acetonide cream 0.1% Class 5: Medium Potency Examples: Hydrocortisone butyrate cream 0.1% Triamcinolone acetonide lotion Class 6: Low Potency Examples: Desonide cream 0.05% Fluocinolone acetonide cream 0.01% (Bolognia, Jorizzo & Rapini (2003), p. 1882)

15 Class 7: Low Potency TOPICAL GLUTICOCORTICOSTEROIDS CONT. Topicals with hydrocortisone, dexamethasone and prednisolone Remember: Brand names may be higher potency than generic Vehicle can affect potency Many topical medications have the same name, but different strength that can change class potency. Make sure you check strength (Bolognia, Jorizzo, & Rapini (2003), pg 1882)

16 FIRST TIME AND REPEAT OFFENDERS

17 Pause for the cause! Don t know what it is? BIOPSY, BIOPSY, BIOPSY CULTURE, CULTURE, CULTURE AVOID PITFALLS Make sure you treat with right antifungal/antibiotic Don t forget labs Past history of steroids? Majocchi s granuloma: Deep follicular fungal infection Remember: Topical only reach so far into the dermis. Deep tissue needs systemic antifungals. Bring the patient back in one to two weeks to reevaluate Document dermatoses correctly and take photos Assess patient education, support, compliance, and financial status Combination therapies

18 ECZEMA Eczema is a broad term to describe an array of inflammatory skin disorders Classified by several classification schemes: Cause, location, degree of involvement, or a generalized condition Acute: severe, with edema, vesicles, and bullae Subacute: Scaling plaques Chronic: Thickened accentuated skin markings called lichenfication

19 ATOPIC DERMATITIS Very pruritic skin disorder involving cutaneous hypersensitivity Usually begins in early infancy after 6 weeks of age Variable symptoms Associated with decreased cellular immunity Often becomes colonized with Staph. aureus Extensor surfaces and face of children Flexural areas in children and adults Plaques, papules, erythema, scale, excoriations, fissures, crust, and lichenfication

20 CONTACT DERMATITIS Pruritic, reactionary skin disorder that results when a particular substance comes in contact with the skin Second most common cause of occupational disability Contact dermatitis occurs when an allergen or related compound causes a delayed type of hypersensitivity reaction on re-exposure (poison ivy) (

21 TREATMENTS Find source of allergy Corticosteroids (careful with vehicle selection) Crisaborole Pimecrolimus Tacrolimus Lactic acid (avoid in inflamed skin) Hydration: Emollients, protective barriers, hyaluronic acid, and petrolatum. (careful with vehicle selection and ingredients) -Vanicream, Vanicream lite lotion, Vanicream bar, Vanicream ointment. Mild cleansers, laundry soap, no fabric softner Narrow band UVB Treat secondary bacterial or fungal infections

22 IRRITANT DERMATITIS Irritant dermatitis occurs secondary to any non-allergic skin irritation resulting from exposure to an offending agent, either with initial or repeated exposures (hand washing, bleach, moisture, friction)

23 IRRITANT DERMATITIS TREATMENT Find source of irritation or friction Intertriginous: Make sure you biopsy to rule out Inverse psoriasis Good hygiene Control moisture: Knitted polyester fabric -With or without silver Control friction Treat fungal and bacterial infections Corticosteroids (careful with vehicle selection and potency) Pimecrolimus Tacrolimus Skin barriers

24 STASIS DERMATITIS Chronic eczematous process resulting from suboptimal lower extremity circulation and chronic venous insufficiency More common in people over 50 Higher incidence in women than men Predisposing conditions: Varicose veins, cardiac failure, surgery, trauma, thrombophlebitis, and hypoalbuminemia. Early signs include hyperpigmentation caused by leakage of blood into the dermis and its subsequent breakdown into hemosiderin.

25 TREATMENTS This is a collaborative team effort! PCP, derm, wound care, and vascular surgeon Compression: support hose, elastic wraps, unna boot (after DVT ruled out!) Diuretics (with the presence of pitting edema) Elevate legs Corticosteroids Emollients: Careful selection Pharmacology: Antibiotics, prednisone, Diosmin and Pentoxifylline Low salt diet Restrict sitting and standing for long periods Vascular Surgeon

26 PSORIASIS Chronic, recurrent, hyperproliferative inflammatory disorder of unknown cause Most prevalent autoimmune disease Affects 7.5 million people in the U.S. 125 million people worldwide Initially appears most commonly in people years old, but can occur at any age Characterized by erythematous plaques with thick, adherent, silvery scales. Up to 30% of people will develop psoriatic arthritis (National Psoriasis Foundation, 2017)

27 PSORIASIS CONT. Auspitz sign: Punctate bleeding points from capillaries close to the top layer of skin after one peels off the scale Distribution: Extensor surfaces, typically sparing the face.

28 INVERSE PSORIASIS Skin folds: Axilla, breasts, genitals, groin and buttocks Biopsy to confirm when other treatments are ineffective. Control moisture: Knitted polyester fabric (InterDry, Maxorb), Castellani s Paint Treatment same as psoriasis. Careful with topical steroids in intertriginous areas.

29 TREATMENTS Topical Corticosteroids NO PREDNISONE: REBOUND Calcipotriene (cream, ointment, scalp solution) Immunomodulators: Tacrolimus, Pimecrolimus Biologics Apremilast Tar PUVA, narrow band UVB Methotrexate Isotretinoin

30 FUNGAL INFECTIONS

31 FUNGAL INFECTIONS Dermatophyte v. yeast Hyphae v. hyphae and spores Look for erythematous plaques with scale, central clearing, and well-demarcated borders. Use topical antifungals: Imidazoles, Polyenes Oral: Griseofulvin, Terbinafine, Itraconazole and Ketoconazole

32 TINEA CRURIS Dermatophyte infection of the groin Scrotum most often spared Characterized by pruritus or burning sensations Erythema, scale, central clearing, and well defined borders KOH Antifungals: Econazole, Terbinafine

33 TINEA MANUS Dermatophyte infection of hand and nails Usually unilateral, but is virtually always associated with bilateral involvement of the hands Plaques, scale, erythema, desquamation KOH Antifungals and oral agents

34 TINEA PEDIS Dermatophyte infection of the feet. Erythema, scale, maceration, and vesicles KOH Antifungals: topical, and oral Treat secondary bacterial infections like pseudomonas!

35 TINEA VERSICOLOR Yeast infection caused by pitysporum orbiculare Hyphae and spores Produces azelaic acid which inhibits pigment transfer to keratinocytes Predisposing factors include hot, humid weather Topical: Selenium sulfide, Ketoconazole Oral: fluconazole, ketoconazole

36 CANDIDIASIS Seen with intertrigo (irritant derm) Caused by candida Skin folds, under breasts, abdominal folds, groin, rectum, axillae, and fingerwebs. Scrotum is involved Beefy red lesions with satellite erythematous papules and/or pustules KOH negative (pseudohyphae and spores) Topical: Selenium sulfide, Ketoconazole, econazole Oral: Ketaconazole, Fluconazole

37 BACTERIAL INFECTIONS

38 ERYTHRASMA Superficial infection of any intertriginous area Caused by Corynebacterium minutissimun Common in hot humid climates Well-defined, brown patches with scale Pruritus Wood s lamp reveals coral-red fluorescence

39 TREATMENTS Topical antibiotics: Benzoyl peroxide, erythromycin, clindamycin, mupirocin ointment or cream Oral antibiotics: Erythromycin, Doxycycline, or Clarithromycin Good hygiene

40 FOLLICULITIS Array of pustular infections that involve the hair follicle Superficial or deep Staph aureus most common, but can be caused by pseudomonas and pitysporum Deep: - Furuncle- deep inflammatory nodule - Carbuncle- aggregation of furuncles

41 OTHER CAUSES Herpes: Herpes Simplex shaving near cold sore Gram negative Lupus Pseudo folliculitis Immune -Eosinophilic Pustular: associated with HIV -Eosinophilic folliculitis: rare autoimmune Oil folliculitis

42 TREATMENT Antibiotics (oral and topical): Doxycycline, minocycline, Clindamycin, erythromycin Benzoyl peroxide Dapsone gel Retinoids Antifungals Isotretinoin

43 A QUICK WORD ON MRSA Drain lesions and irrigate Culture and Sensitivity Treat nares: Mupirocin ointment and gentamicin ointment Systemic and topical Washes: Hibiclens; caution ototoxic Avoid face, head and genitals! Give very clear written instructions to patient. Be aware of allergic reactions and avoid on inflammatory dermatoses.

44 AVOID PITFALLS Pause for the cause! Don t know what it is? BIOPSY, BIOPSY, BIOPSY CULTURE, CULTURE, CULTURE Make sure you treat with right antifungal/antibiotic Don t forget labs Past history of steroids? Majocchi s granuloma: Deep follicular fungal infection Remember: Topical only reach so far into the dermis. Deep tissue needs systemic antifungals. Bring the patient back in one to two weeks to reevaluate Document dermatoses correctly and take photos Assess patient education, support, compliance, and financial status Combination therapies!

45 Questions?