Right type of lesions for topicals. Onychomycosis. Common Diseases and Infections of the SKIN. Toby Maurer, MD University of California, San Francisco

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1 Common Diseases and Infections of the SKIN Toby Maurer, MD University of California, San Francisco Onychomycosis Topical treatment use for the right type of lesions Naftin gel for small superficial lesions Penlac (Ciclopirox 8%) reported to work 35-52% of the time cost: expensive Right type of lesions for topicals Lunula not affected Less than 5 nails affected No thickening of nails No separation of nail plate on sides 1

2 Dermatophytes or Tinea Itraconazole (Sporanox) VERY effective Keeps working even after medication is stopped Pulse therapy - 400mg q day x 7 dys/mo. for 3 mos. Dermatophytes or Tinea Terbinafine (Lamisil) VERY effective Works after medication is stopped 250 qd x 3 months 1 study shows pulse dose (500 mg qd x 1wk/mo for 4 mos) equally effective as continuous dose-for FINGERNAILS only Liver toxicity Transaminase elevation 0.4% to 1% with terbinafine and intraconazole Transaminase elevation does not predict liver failure Liver failure 1/100,000 Terbinafine has gone generic 2

3 Doc-willing to take chance of liver failure with treatment but will I be cured? a) 75% cure after taking terbinafine but 50% recurrence at 5 years. b) 50% cure after taking itraconazole and 90% recurrence at 5 yrs. 60% c) 25% cure after taking terbinafine and 50% recurrence at 5 years. 22% 18% Answer: A Mycologic cure rates for antifungals: Terbinafine: 77% Itraconazole: 70% Griseofulvin: 41% At 12 months: Terbinafine: 75% Itraconazole: 50% At 5 yrs: Terbinafine: 50% Itraconazole: 13% 75% cure after... 50% cure after... 25% cure after... Onychomycosis A New Approach Toenails take months to grow Pulse terbinafine 250 mg per day for 1 week every 2-3 months for one year Booster dose at 9 months (250 mg qd x 1 month) 3

4 Candida of Nails Look for paronychia (erythema and swelling around nailbed) and green nails Green nails represent the co-pathogen which is pseudomonas Fluconazole 150 mg qd x1 month PLUS Ciprofloxacin 500 bid x 2 weeks Or Thymol 2-4% soak 20 mins bid x 3 months and tobramycin or gentamycin solution Pitted Keratolysis May be confused with tinea on foot See pits Bad odor From bacteria-topical erythromycin bid 4

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6 Approach to Treatment Culture where you can-if you have pus Incise and drain when appropriate (Abcesses) If no pus: Tx with methicillin sensitive drugs-first line but have pt return to evaluate for resolution If recurrent infection, tx with methicillin resistant antibiotics right off the bat -Septra, Doxycycline, Clindamycin Consider adding rifampin 600 qd for 5 days or mupirocin ointment for staph eradication If not improving Was patient treated long enough? Once hair structures are involved or deep tissues, treatment time may be longer 6

7 Don t forget strep Strep-may need added coverage with Penicillin, cephalosporins Look for skip lesions, culture when possible Doxycycline and septra resistance possible re: strep Cipro/levo do not cover strep Add antibiotic that covers strep Jacobs et al Diagn Microb Inf Dis 2007, March Was it an inflammatory condition and not an infection Erythema nodosum Pyoderma gangrenosum Hidradenitis suppurativa 7

8 Erythema Nodosum Not an infection Reaction pattern to strep, cocci, oral contraceptives, estrogen replacement, inflammatory bowel disease Painful, red nodules lower legs Pt s feel bad Biopsy diagnosis-inflammation of fat Treatment with bedrest, NSAIDS, prednisone Pyoderma Gangrenosum INFLAMMATION Not an infectious disease A reactive inflammatory disease Biopsy diagnosis Surgical I&D/excision make it worse 8

9 Do Not I&D Treatment Prednisone/cyclosporine Thalidomide Tacrolimus (protopic) Tx underlying disease Hidradenitis Supparativa Not an infectious disease Disease of apocrine glands Treatment IL Kenalog Minocycline Surgery TNF blockers (etanercept/infliximab) NOT Antibiotics Was it a viral infection? Remember HSV-culture Skin biopsy for histology and tissue culture Diseases that Masquerade as Infectious Diseases Ann Int Med 2005 Jan 4; 142:

10 Orolabial Herpes Simplex No prophylaxis Treat when symptomatic Sun exposure can activate HSV-ACV 800 mg 1 hour before sun exposure 10

11 Targetoid Lesions (Erythema Multiforme) Round lesions with dusky blue centers Usually painful Often on palms, soles, knees, elbows +/- blisters Infection, drug Targetoid Lesions: Infection (Reaction pattern to infection) Herpes Simplex Previous history Recent outbreak of orolabial/genital HSV Cx if there is a primary lesion Mycoplasma: dry cough Persons under 21 +/- blisters Titers, chest x-ray, start IV, erythro 11

12 Targetoid Lesions: Drugs Septra most common Pt has erythema multiforme, has history of genital HSV, wants treatment a) Start prednisone at dose of 200 mg /day b) Avoid prednisone c) Start ACV 800 mg three times/day 81% 8% 12% Start predniso... Avoid predniso... Start ACV

13 Targetoid Lesions: Treatment Discontinue offending drug Prednisone controversial Helpful in HSV driven EM Persons with recurrent EM Suppress possible HSV with ACV 400 mg tid Urticaria Wheals that come and go within 24 hr periods Pruritic Infection, drugs, connective tissue disease, unique skin disease with unknown etiology 13

14 Urticaria: Infection Strep-sinusitis, teeth, pharynx Viral Any Aspirin Urticaria: Drugs Others: Food products Nuts, shellfish, citrus fruit Connective Tissue Disease Rare but can see with lupus like diseases and inflammatory diseases Associated with fevers/joint aches Check ANA, ESR, CRP, complement Check U/A Refer to rheum/derm Treatment: Urticaria Anaphylaxis-epinephrine and then prednisone Otherwise: Antihistamines: non-sedating by day and sedating by night. Stay on for 2 months then drug free trial. Urticaria-self-resolves in 2-7 years. AVOID prednisone 14

15 Vasculitis Leaky blood vessels Multiple purple papules/macules Usually legs, arms +/- fever, +/- edema Infection, drugs, connective tissue dz, unique skin disease Vasculitis: Infection Meningococcemia Strep Staph (endocarditis) Hepatitis A, B, C TB 15

16 Vasculitis: Infection Nuchal rigidity/neuro changes Murmur CBC, Pharyngeal cx, ASO titer, Bl cx X 3, Hep screen, Chest X-Ray skin biopsy helpful to confirm Vasculitis: Drugs Any antibiotics Any medications 16

17 Vasculitis: Connective Tissue Disease Lupus/Dermatomyositis Rheumatoid Arthritis/Still s Cryoglobulinemia secondary to Hep C Henoch-Schonlein (+/- GI and renal) Cocaine induced (lavimasole + cocaine in ANCA positive females) Vasculitis: Connective Tissue Disease Joint aches, photosensitivity ANA, ESR, CRP, Ferritin Rheumatoid factor, Hep C and cryoglobulins Tox screen, ANCA (c-anca, p-anca) 17

18 Vasculitis: Unique skin disease Leukocytoclastic vasculitis-idiopathic Biopsy to confirm Labs to rule out underlying etiologies Treat if symptomatic Treatment of Vasculitis Look for and treat underlying disease ALWAYS Check Urinalysis for red cellswill determine if you need to be more aggressive with treatment If asymptomatic-reassure If symptomatic (pain, swelling, joint aches, red cells in urine): bedrest, antihistamines, colchicine (0.6 mg bid), Prednisone 18