Nkanyezi Ferguson, MD, FAAD University of Iowa Hospital and Clinics Iowa City, IA

Transcription

1 Nkanyezi Ferguson, MD, FAAD University of Iowa Hospital and Clinics Iowa City, IA

2 U030 - Hair Care Practices and Hair Disorders in Skin of Color DISCLOSURES No relevant relationships with industry

3 To discuss practical diagnosis and management of: Acne keloidalis nuchae (AKN) Dissecting cellulitis Folliculitis decalvans

4 Dermatitis papillaris capillitii, folliculitis keloidalis Chronic inflammatory follicular disorder Occipital scalp and posterior neck Etiology is poorly understood Taylor and Kelly. Dermatology for skin of color

5 Clinical manifestations: Inflammatory papules and pustules Dome shaped firm fibrotic papules Coalesce into Keloid-like plaques Alopecia, fringe of tufted hairs or polytrichia Painful, pruritic and of significant cosmetic concern Taylor and Kelly. Dermatology for skin of color

6 Work-up Bacterial cultures from pustules or draining lesions Consider KOH with fungal culture if unresponsive to treatment or cervical lymphadenopathy Dermoscopy Histopathology rarely needed and non-specific Chouk C, et al. BMJ Case Rep Sep 23;2017 Sperling LC, et al. Arch Dermatol Apr; 136(4):479-84

7 Avoidance of risk factors Avoid trauma from razors or clippers Avoid tight fitting shirts, hats or clothing

8 Topical therapy High potency topical steroid (class I or II) vehicle based on efficacy and patient preference (gel, foam) Topical retinoid (gel) Topical antibiotics if pustules are prominent (clindamycin, mupirocin) Imiquimod and picrolimus* Callender VD, et al. Cutis Jun;75(6): Barr J, et al. J Am Acad Dermatol. 2005;52:P64

9 Intralesional therapy (larger lesions) Intralesional corticosteroid (triamcinolone) 10-40mg/mL (27-29-guage needle) Q3-4 weeks, discuss risk of hypopigmentation and atrophy Intralesional 5-fluorouracil Intralesional bleomycin Alexis and Barbosa. Skin of color.

10 Minor surgical intervention Excision of papules Punch excision, heal with primary closure or let heal by secondary intention Punch should be in deep SQ below base of hair follicle De-roofing Shave removal of superficial portion with razor or scalpel blade Cauterize base, higher incidence of recurrence Taylor and Kelly. Dermatology for skin of color

11 Cryotherapy Caution in skin types V-VI patients due to risk of dyspigmentation Sensitivity of cell types to cold-induced injury Melanocytes (-4 to -7 o C) Keratinocytes (-20 to 30 o C) Fibroblasts (-30 to 35 o C) Freeze thaw cycle Layton AM, et al. Br J Dermatol Apr;130(4):

12 Laser therapy: Long pulsed 1064-nm Nd:YAG laser, 810-nm diode laser, pulse dye laser, CO 2 laser Among the light and laser modalities: Nd:YAG laser and 810-nm diode laser appear to be the most effective for treating AKN Destroys the tufted-like hair follicle Decreases overall inflammatory response Decreases further scarring Alexis and Barbosa. Skin of Color Esmat SM. Eur J Dermatol Sep-Oct;22(5):645-50

13 Maranda E, et al. Dermatol Ther 2016;6:

14 Targeted UVB therapy Anti-inflammatory, immunosuppressive and anti-fibrotic effects Randomized, split-scalp trial Eleven patients with AKN One randomly selected side of the scalp was treated with UVB up to three times weekly for eight weeks After week 8, both sides were treated for eight additional weeks Overall improvement noted Okoye GA, et al. Br J Dermatol Nov; 171(5):

15 Surgical management Advanced cases of AKN may require surgical intervention Larger areas of involvement that have failed combination medical therapies Surgical methods Excision with primary closure Excision with closure by secondary healing Excision with skin grafting Larger lesions may require multi- staged excisions or tissue expansion

16 Surgical management Extensive patient counseling is needed to prepare patients for postoperative wound care, realistic expectations of overall cosmesis Anesthesia is achieved with 1% lidocaine with l:loo,ooo epinephrine (max 7 mg/kg) Ring block is performed for very large lesions Excision must be carried down to a depth below bulbs of the hair follicles (muscle fascia or deep subcutaneous tissue) #10 blade, blades need to be changed frequently as they become easily dull Hemostasis is achieved with pressure, electrocoagulation and/or vessel ligation Glenn et al. JAAD1995;33:243-6

17 Excision with primary closure Disadvantages Some keloidal plaques are too large Primary closure scars frequently stretch to a large area Movement may be temporarily restricted Gloster et al. Arch Dermatol. 2000;136(11): Glenn et al. JAAD1995;33:243-6

18 Surgical management Excision with closure by secondary intention healing Excision of the involved area is carried down to muscle fascia or deep subcutaneous tissue Excisions that are too shallow may result in inadequate wound contraction Healing period can take 6-12 weeks Superior cosmetic results are achieved if horizontal elliptic excision includes the posterior hairline Topical therapy and intralesional triamcinolone initiated after complete re-epithelialization Glenn et al. JAAD1995;33:243-6

19 Perifolliculitis capitis abscedens et suffodiens, Hoffmann s disease Chronic progressive inflammatory condition of the scalp Part of the follicular occlusion tetrad Acne conglobata, hidradenitis suppurativa and pilonodal cysts

20 Clinical diagnosis Recurrent eruptions of follicular pustular nodules Crown, vertex and occipital region Evolve to boggy plaques Burrowing interconnecting abscesses with purulent drainage Taylor and Kelly. Dermatology for skin of color Kurtzman DJB, et al. Br J Dermatol Oct;177(4):e160

21 Clinical diagnosis Sinus tract formation Cicatricial alopecia Cerebriform configurations Perifollicular inflammation in the deep follicle Taylor and Kelly. Dermatology for skin of color Kurtzman DJB, et al. Br J Dermatol Oct;177(4):e160

22 Work-up Bacterial cultures and sensitivities Consider KOH and fungal cultures Dissecting cellulitis like presentation of tinea capitis Fluctuant, alopecic surface with intercommunicating sinuses T. tonsurans most common causal dermatophyte Medication review Reports of flares after anabolic steroids Shastry J, et al. Pediatr Dermatol Jan;35(1):e79-e83 Kurtzman DJB, et al. Br J Dermatol Oct;177(4):e160

23 Medical management Topical steroids Topical antibiotics (clindamycin, erythromycin) Oral antibiotics (tetracycline, rifampin*) Isotretinoin TNF alpha inhibitors (adalimumab, infliximab) Dapsone Zinc

24 Antibiotics Used to control the inflammatory process, particularly in cases of suspected secondary bacterial infection Topical clindamycin, topical erythromycin Tetracyclines (doxycycline, minocycline) Rifampin* Remission/relapse is common after discontinuation Marquis K, et al. Pediatr Dermatol Jul;34(4):e210-e211

25 Isotretinoin Normalizes the skin and follicular apparatus to decrease the aberrant immune response Proposed as first-line treatment by some authors 0.5 to 1 mg/kg/day for 3 to 12 months may be effective Marquis K, et al. Pediatr Dermatol Jul;34(4):e210-e211 Koudoukpo C, et al. Ann Dermatol Venereol Aug-Sep;141(8-9):500-6 Badaoui A, et al. Br J Dermatol Feb;174(2):

26 TNF alpha inhibitors Adalimumab 80 mg administered subcutaneously, followed by a dose of 40 mg 1 week later and an additional 40 mg every second week Infliximab 5mg/kg every 8 weeks, only reported in two cases Navarini AA, et al. Arch Dermatol May;146(5): Marquis K, et al. Pediatr Dermatol Jul;34(4):e210-e211.

27 Procedural management Intralesional steroids Incision and drainage Laser-assisted epilation Wide surgical excision Scalpectomy ALA-PDT

28 Nd:YAG laser Decrease in drainage and tenderness of lesions 3 out of 4treated patients either completely stopped or decreased their need for systemic therapy Diode 800nm laser Single case study, dramatic decrease in discomfort and overall quiescent disease Krasner BD, et al. Dermatol Surg 2006 Aug;32(8): Boyd AS, et al. Arch Dermatol. 2002;138(10):1291-3

29 Surgical management Incision and drainage Staged excision Sinus tracts were removed to the level of the periosteum Scalpectomy Powers MC, et al. Dermatol Surg May;43(5): Hintze JM, et al. Case Rep Surg. 2016;2016:

30 Highly inflammatory form of cicatricial alopecia Perifollicular pustules, papules and hemorrhagic crust Follicular hyperkeratosis, tufted hair follicles Chronic and relapsing course Staph aureus commonly isolated Bunagan MJ, et al. J Cutan Med Surg Jan-Feb;19(1):45-9 Collier NJ. Clin Exp Dermatol Jan;43(1):46-49

31 Early Focal areas of perifollicular erythema and pustules Late Process expands centrifugally and leads to cicatricial alopecia Tufted hairs Keith DJ, et al. Clin Exp Dermatol Dec;38(8):924-5

32 Work-up Bacterial cultures and sensitivities Consider KOH and fungal cultures Medication review reports of erlotinib-induced folliculitis decalvans, Methylisothiazolinone Keith DJ, et al. Clin Exp Dermatol Dec;38(8):924-5

33 Treatment Topical antibiotics Topical antiseptics shampoos Oral antibiotics Tetracyclines, rifampicin + clindamycin Decolonization for staph carriers Fusidic acid and zinc* Isotretinoin Taylor and Kelly. Dermatology for skin of color

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