Dermatology for the PCP

Transcription

1 Dermatology for the PCP Laura S. Winterfield, MD MPH Associate Professor Medical University of South Carolina I have no relevant conflicts of interest. 1

2 Learning Objectives Identify common skin conditions and potential mimickers Describe first line therapies for common skin conditions Recognize when to refer/collaborate with dermatology Primary Care Skin Complaints Facial breakout Rash Suspicious Spot(s) 2

3 19yo Male with breakouts Several years Tried OTC products No systemic meds Acne vulgaris Pathogenesis therapeutic targets: 1. Abnormal desquamation with obstruction of the pilosebaceous canal 2. Androgen driven excess sebum production 3. Propionobacterium acnes 4. Altered immune activity and inflammation 3

4 Acne vulgaris Topical retinoid: mainstay of therapy Benzoyl peroxide Topical antibiotics Other topicals Oral antibiotics Derm referral Isotretinoin Sebum production Altered Keratinization Benzoyl peroxide Topical retinoid Salicylic acid Azelaic acid P. acnes Inflammation Topical Antibiotic ++ + Oral Antibiotic Oral Retinoid (isotretinoin) Hormonal tx Adapted from Farrah and Tan in Dermatol Ther 2016: 29:

5 Options: Adapalene Topical Retinoids 0.1% gel: Now OTC Tretinoin cream, gel, microsphere gel 0.025%, 0.05%, 0.1% and others Generics may not be stable in UV (apply at night) Tazarotene Pregnancy category X Topical Retinoids Once daily application: Start every 1 3 days and increase to QHS Pea size for entire face Thin layer, after gentle washing and drying SE: dryness, peeling, redness, irritation, sun sensitivity May take 4 6 weeks to see benefit Continue for maintenance 5

6 Antibiotics for Acne Topicals: Clindamycin gel, lotion, solution Erythromycin gel, solution (less effective, more resistance) Oral: Tetracycline Doxycycline Minocycline Avoid use as monotherapy Use with topical retinoid or benzoyl peroxide Antibiotics for Acne Goal: stop systemic antibiotics in <3 months No great data for which antibiotic is best Avoid use as monotherapy Plan for maintenance topical therapy Refer for consideration of isotretinoin in refractory patients, cystic lesions or scarring 6

7 38yo Female with acne clear skin as a teenager Flares with menses Was on OCP, now has IUD Female adult acne Lower face/jawline Often resistant to traditional combination therapy Treat with topical retinoids Consider topical dapsone Target hormonal component OCP Spironolactone Consider evaluation for PCOS especially if other signs present (hirsutism, irregular menses, etc) 7

8 Skin Care Products Non comedogenic, oil free, won t clog pores Moisturizer Make up Sunscreen: helps reduce post inflammatory pigmentary alteration Gentle cleansers Gentle emollients Avoid harsh, abrasive, or excessively drying (alcohol) 27yo F with refractory acne Acne Excoriee Predominantly secondary change picker s acne or skinpicking disorder More common in females Consider psychiatric comorbidity Depression Anxiety OCD ADHD 8

9 Acne treatment in Pregnancy Limited options Category B Topical clindamycin Topical azelaic acid Retinoids are category C or X Occasional intralesional kenalog for inflamed cysts Low glycemic diet Diet in Acne Decreased acne severity Smaller sebaceous glands Low dairy Limit skim milk and ice cream Whey protein (derived from milk) reported to trigger truncal acne in adolescents 9

10 50yo F with facial breakouts Rosacea More common in fair skin types Flushing with fixed facial erythema +/ Papules and pustules No comedones Triggers of flushing: Dietary Environmental Menopause 10

11 Treatment of Rosacea Trigger avoidance Topicals: Antibiotics: metronidazole gel or cream Anti inflammatory: azelaic acid cream or solution Anti parasitic: ivermectin 1% cream Alpha 2 agonist: brimonidine, oxymetazoline May cause rebound flushing in some patients Oral antibiotics: tetracyclines, submicrobial dose Laser: Best option for persistent redness Rosacea Mimics Acute cutaneous lupus: Spares nasolabial folds Rosacea: Crosses NL folds Telangiectasias No scale +/ Papules and pustules Dermatomyositis: mid facial erythema Violaceous color 11

12 20yo rash around the nose Perioral dermatitis: Monomorphic papules sparing the vermillion Treat like rosacea avoid topical steroids and other triggers Seborrheic dermatitis: Greasy yellow scale, nasolabial folds, ears, beard and scalp Treat with topical ketoconazole Topical steroids for itch 72yo F with itchy rash 12

13 72yo F with itchy rash Several weeks Started with an abrasion Treating with neosporin No fever, chills, other sx No new medications Allergic Contact Dermatitis Type IV hypersensitivity outside in pattern Common allergens: Topical antibiotics Nickel Propylene glycol Formaldehyde Poison Ivy 13

14 Allergic Contact Dermatitis Treatment Topical steroids High potency Systemic steroid taper for severe cases Poison ivy 3 4 weeks Recurrent cases with unknown trigger? Referral for patch testing Auto eczematization Severe focal allergic or eczematous dermatitis becomes generalized AKA: id reaction 14

15 Herpes Zoster Respects the midline Lesions have scalloped borders Vesicles Erosions Ulcers Herpes Unilateral or bilateral, often recurrent Scalloped borders Vesicles or erosions Often no known history of genital HSV Blisters on the buttocks are almost always HSV No such thing as recurrent spider bites on the buttocks! 15

16 Eczema Herpeticum Superinfection of dermatitis with HSV Look for scalloped edges, crusting Increase in symptoms pain, severe itch/burning 67yo rash all over torso Started on back, folds and spread Medication history: 16

17 Morbilliform Drug Eruption Usually starts 7-10 days after initiation of the drug May start even after the d/c of a drug Often starts in intertriginous and dependent areas May become erythrodermic No blisters No mucous membrane involvement Morbilliform Drug Eruption Treat with topical steroids Clobetasol for severe symptoms Triamcinolone 0.1% cream or oint in 1lb jar May add sauna suit or occlusion Antihistamines as needed OK to treat through the eruption 17

18 Drug Eruption: Red Flags Mucous membrane involvement Skin pain Blisters Systemic symptoms / toxic appearance Facial edema Lymphadenopathy Lab abnormalities: Liver function tests CBC with differential: elevated eosinophils Renal function 68yo with LE discoloration 18

19 Stasis Dermatitis Topical steroids: Triamcinolone 0.1% cream Domeboro or dilute vinegar soaks Emollients Compression, elevation Avoid topical antibiotics when possible Bilateral lower extremity cellulitis is RARE 45yo rash on knees 19

20 Psoriasis Well defined red scaly plaques Scalp, elbows, knees, umbilicus, gluteal cleft Palmar plantar variant Pustular variant Try to avoid systemic steroids may flare with withdrawal Which topical steroid? Clobetasol Triamcinolone 0.1% Desoximetasone Fluticasone Desonide Hydrocortisone 2.5% Scalp and Body Face and Folds STRONGER Apply BID, 2 weeks on, 1 week off, d/c when flat 20

21 vehicle for topical agents Type Penetration Use Ointment Most Dry areas Cream Moderate Wet areas Lotion Less intertriginous Gel Solution Least Scalp, intertiginous Psoriasis & Cardiovascular Risk Psoriasis (especially moderate to severe) is an independent risk factor for MI Patients should be educated about risk of CAD and counseled to address modifiable risk factors. 21

22 Psoriasis and Psoriatic Arthritis May present asynchronously Unlike skin, joint damage may be permanent 32yo with itchy ankle 22

23 Tinea Always check the feet, too! Especially if only 1 scaly hand: 1 Hand / 2 Foot tinea KOH shows branching hyphae Tinea that has been treated with topical steroids May require systemic antifungal therapy Terbinafine 250mg/d x 2 weeks Tinea Incognito 23

24 Granuloma Annulare Tinea mimicker Non scaly Does NOT improve with antifungals Etiology unknown Sarcoidosis Non scaly Annular plaques Predilection for scars 24

25 46yo very itchy all over Courtesy of Nellie Konnikov 25

26 Immune compromise Huge mite load Crusted Scabies Scabies Prep 26

27 Scabies Treatment Topical permethrin is most effective Treat neck down Treat folds Treat under nails Repeat in a week Oral Ivermectin 200mcg/kg single dose Repeat in 1 week Treat close contacts Treat the environment Concerning Spots Evolving Lesion (ABCD E) Tender, Burns, Itches, Bleeds Company It Keeps Solitary Lesion, Ugly Duckling Unresponsive to therapy 27

28 What is the most likely diagnosis? A. Atypical nevi B. Basal cell carcinoma C. Dermatitis D. Actinic keratoses E. Squamous cell carinoma Actinic Keratosis Premalignant lesion to SCC Who? Fair skin types, > age 40 Where? Sun exposed areas Treatment? Cryotherapy Field therapy: topical 5 FU Topical imiquimod photodynamic therapy 28

29 Actinic Keratoses Poorly defined erythematous macule/papule gritty thin scale thicker yellowish scale Signs of photodamage Photo courtesy of S. Desai This lesion may be associated with which of these? A. Verruca B. Seborrheic keratosis C. Actinic keratosis D. Squamous cell carcinoma E. All of the above 29

30 Cutaneous Horn Column of thick keratotic scale Differential Diagnosis Wart Seborrheic keratosis Actinic keratosis SCC Most likely diagnosis? A. Actinic keratosis B. Basal cell carcinoma C. Cutaneous horn D. Keratoacanthoma E. Verruca vulgaris 30

31 Keratoacanthoma Low grade SCC Rapid growth over 4 6wks +/ spontaneous regression Nodule with keratin filled central crater Most likely diagnosis? A. Pigmented basal cell carcinoma B. Melanoma C. Atypical nevus D. Seborrheic keratosis E. Actinic keratosis 31

32 Seborrheic Keratosis stuck on keratotic verrucous +/ pigment sharply demarcated Most likely diagnosis? A. Pigmented basal cell carcinoma B. Melanoma C. Atypical nevus D. Seborrheic keratosis 32

33 Risk factors: Fair skinned Red hair Atypical nevi Multiple nevi (>50) Family history Blistering sunburns Melanoma Most common malignancy in women age Most likely diagnosis? A. Squamous cell carcinoma B. Basal cell carcinoma C. Keratoacanthoma D. Amelanotic melanoma 33

34 Basal Cell Carcinoma Who? Fair skin types What? Pearly, translucent, telangiectatic, rolled border Where? Sun exposed areas Face, scalp, ears, neck > trunk, extremities Why do a total body skin exam? To look for clues for diagnosis of a rash or other skin problem 34

35 Why do a total body skin exam? To look for clues for diagnosis of a rash or other skin problem Skin cancer screening Why do a total body skin exam? Study by Kantor and Kantor. Arch Dermatol Aug;145(8):873 6 How many melanomas from their practice were the noted by the patient vs how many found on dermatologist initiated skin exam? 35

36 Why do a total body skin exam? Study by Kantor and Kantor. Arch Dermatol Aug;145(8):873 6 How many melanomas from their practice were the noted by the patient vs how many found on dermatologist initiated skin exam? 56.3% of melanomas were found by the dermatologist and were not part of the presenting complaint. Dermatologist detection was significantly associated with thinner melanomas, OR 0.42 Thinner melanoma = better prognosis Broad spectrum UVA/UVB sunscreen Physical blockers: titanium dioxide zinc oxide Chemical sunscreens 36

37 Ultraviolet Radiation and Sunscreen UVA and UVB contribute to premature skin aging and skin cancer. UVA: Tan UVB: Burn SPF = Sunburn Protection Factor Only quantifies UVB protection Broad Spectrum sunscreen has UVA + UVB protection No UVA protection rating in the US Sunburn protection factor (SPF) Measures only UVB protection Recommend SPF oz ( golf ball size ) each application Apply every 1.5 2h 37

38 Water Resistant = 40 minutes Very Water Resistant = 80 minutes Questions? lwinterfield@gmail.com 38