Dermatology for the frontline

Transcription

1 Dermatology for the frontline Kate Foster, D.O. April 28, 2018 Disclaimer: We have consent from patients to use photos for presentation and publication purposes. Please do not take any photos of slides containing images of patients. When asking other derms what should be included in this lecture: Goals for this lecture Seborrheic dermatitis vs. lupus How to treat seb derm Importance of change/ ugling When to refer for urticaria duckling instead of just ABCDE s Do not give PO steroids for urticaria Annular rashes Congenital nevi in infants Impetigo vs cold sore When to refer for hemangiomas Be sure to culture any abscess or boil Intertrigo vs inverse psoriasis Common benign skin growths Perioral dermatitis Treatment of poison ivy- not just a medrol dose pack; lasts for 3 weeks ID of scabies About seborrheic keratoses B/L swelling is not cellulitis Review how to recognize skin cancer with ABCDE s and look for the ugly duckling How to appropriately biopsy skin lesions How to diagnosis and appropriately treat common rashes When to refer your patient to dermatology Review updates in the dermatology world 1

2 Recognizing Skin Cancer 3 main types of skin cancer RECOGNIZING SKIN CANCER To recognize BCC and SCC: Anything that is not healing for >3 months Pimples that don t heal are often BCC Bleeding for no reason Lesions that are not responding to a directed treatment (steroid applications, wart treatment) To recognize melanoma: The ABCDE s and the Ugly Duckling sign RECOGNIZING SKIN CANCER RECOGNIZING SKIN CANCER To recognize BCC and SCC: Anything that is not healing for >3 months Pimples that don t heal are often BCC Bleeding for no reason Lesions that are not responding to a directed treatment (steroid applications, wart treatment) To recognize melanoma: The ABCDE s and the Ugly Duckling sign To recognize the most common skin cancers: Anything that is not healing for >3 months Pimples that don t heal are often BCC Bleeding for no reason Lesions that are not responding to a directed treatment (steroid applications, wart treatment) To recognize melanoma: The ABCDE s and the Ugly Duckling sign 2

3 RECOGNIZING MELANOMA The Ugly Duckling Sign instead of ABCDE s Stems from the notion that each person has a signature nevus Derivations of the themed signature nevus could indicate pathologic change Dysplastic (atypical) nevus Melanoma ABCDE s vs Ugly Duckling 3

4 ABCDE s vs Ugly Duckling RECOGNIZING SKIN CANCER To recognize BCC and SCC: Anything that is not healing for >3 months Pimples that don t heal are often BCC Bleeding for no reason Lesions that are not responding to a directed treatment (steroid applications, wart treatment) To recognize melanoma: The ABCDE s and the Ugly Duckling sign RECOGNIZING SKIN CANCER To recognize the most common skin cancers: Anything that is not healing for >3 months Pimples that don t heal are often BCC Bleeding for no reason Lesions that are not responding to a directed treatment (steroid applications, wart treatment) To recognize melanoma: The ABCDE s and the Ugly Duckling sign How to appropriately biopsy skin lesions PUNCH vs SHAVE bx How to choose punch vs shave Punch Rash of any sort Pigmented lesion that is flat and that you want to get margins on (dark moles that are black or blue) Shave Pigmented lesion that is elevated (papule) Other lesions that are elevated off of surface and easy to get under (BCC, SCC) We do about 80% shave biopsies and 20% punch biopsies. 4

5 Important points Ready to Biopsy? Punch For a rash: always do 4mm; unless on face, then 3mm When cutting off specimen, get the fat For pigmented lesions, always get a margin of normal skin. Shave Use personna blade Be able to get into middermis and it should be about 3-4 mm in diameter for a representative sample Get a photo in clinic! You should also have patient take a photo of the lesion on their cell phone (close up and far away) with relevant landmarks And perhaps most importantly An example of the importance of dermatopathologists: Pigmented lesions Please try to send your skin specimens to a dermatopathologist. ESPECIALLY pigmented lesions and rashes. Pathology results showed: Outside Surg Path Dermpath Let s look at some cases and determine how we should proceed with biopsy. 5

6 Steps to biopsy: How would you bx the lesion? 1) Measure 2) Draw around lesion A) Punch B) Shave 3) Take photo 4) Biopsy 5) Send to dermatopathologist How would you bx the lesion? Lesion present for 1 year, enlarging. Steps to biopsy: A) Punch B) Shave Either answer is okay, but I performed a shave because I knew it was BCC and I wanted a wider sample. 1) Measure 2) Draw around lesion 3) Take photo 4) Biopsy 5) Send to dermatopathologist How would you bx? How would you bx? A) Shave B) Punch with no margins C) Punch with 1 mm margins D) Excise with 5 mm margins A) Shave B) Punch with no margins C) Punch with 1 mm margins D) Excise with 5 mm margins 6

7 Punch biopsy revealed blue nevus = benign. Because we got margins, it should not recur 75 yo WF, rash started 1 year ago and is spreading. Asymptomatic. No new medications. Steps to biopsy: How would you biopsy? 1) Measure 2) Draw around lesion 3) Take photo 4) Biopsy 5) Send to dermatopathologist A) Punch B) Shave How would you biopsy? Cutaneous T-Cell Lymphoma A) Punch B) Shave * Remember that using a 4mm punch on a rash is always a good idea! 7

8 Cutaneous T-cell Lymphoma If this biopsy would have gone to general pathology, it is quite possible that it would have been called an eczematous or spongiotic type reaction and special stains would have not been performed. Diagnosis and Treatment of Common Rashes Case #1 18 yo male with 6 m history of round scaly patches and plaques Psoriasis Frontline treatment Topical corticosteroids FOR THE BODY. No face or folds High potency for body BID for 2 weeks then OQD for 2 weeks repeat if needed Betamethasone diproprionate 0.05% cream or oint Halobetasol proprionate 0.05% cream or ointment Only dispense enough for 2 months (60g) tube with 1 refill should be sufficient until they can be seen by derm; if cannot get into derm, have them f/u with you to get refills Psoriasis Frontline treatment Black Box Warning on Tacrolimus and Pimecrolimus Topical corticosteroids FOR THE FACE and FOLDS: Low potency BID for 2 weeks then OQD for 2 weeks repeat if needed Hydrocortisone 2.5% oint or cream Great summary article reviewing how the black box warning came to be OR Topical calcineurin inhibitors (TCI) such as Tacrolimus 0.03% ages 2-15; 0.1% ages>16 BID 3 months or longer. Must go over black box warning. 8

9 Tacrolimus and pimecrolimus (topical calcineurin inhibitors = TCI) are safe to use: - The risk of lymphoma and other cancers is no higher than that seen in the general population - TCI molecules are about 2x the size of those in topical CS, which makes it more difficult for them to permeate the skin and cause systemic side effects. - The American Academy of Dermatology does not support the black boxed warning - Don t eat the medication and you ll be fine Steroid induced skin atrophy Steroid induced skin atrophy Steroid induced acne And finally, do not ever give a psoriasis patient oral steroids. Horrible psoriasis flare upon discontinuation Risk of erythroderma requiring hospitalization If you have a new psoriasis patient: Start them on topicals with proper dosing and education no oral steroids Refer to dermatology Patients have many questions Need to be evaluated for psoriatic arthritis Provide them with education resources: 9

10 Updates in Psoriasis Management Updates in Psoriasis Management 2017: Tremfya (guselkumab) Siliq (brodalumab) 2016: Taltz (ixekizumab) 2015: Cosentyx (secukinumab) 2014: Otezla (aremilast) only PO psoriasis medication other than the oldies (cyclosporine, mtx) 2010: Stelara (ustekinumab) What do these new psoriasis meds mean to PCP s? Case #2 Expanding ring on arm x 3 years; not itchy; not improving with topical antifungal 2017: Tremfya (guselkumab)? Siliq (brodalumab) monitor for suicidal ideations, mood shifts, IBD; infections 2016: Taltz (ixekizumab) IBD; infections 2015: Cosentyx (secukinumab) IBD; infections 2014: Otezla (aremilast) depression; nausea, GI effects (self limited) 2010: Stelara (ustekinumab) infections Not all rings are tinea What s the clinical difference? Granuloma Annulare Tinea corporis Granuloma Annulare Asymptomatic Tinea corporis Itchy and SCALY 10

11 Tinea corporis Tinea corporis + topical steroids = spreading Scale Central clearing Tinea faceii Tinea differential diagnosis Granuloma annulare (asymptomatic; no scales) Sarcoidosis (the great imitator) Eczema/nummular dermatitis (normally more than one patch without central clearing) Psoriasis (normally >1 patch without central clearing) Pityriasis rosea (multiple patches) Fixed drug eruption (non-scaly) How to approach a red ring Treatment of tinea Is it itchy? If yes, think tinea Is it scaly with central clearing? If yes, think tinea Worse on topical steroids? If yes, think tinea Exposures to family members with ringworm or pets/petting zoo? If yes, think tinea Can you do a KOH? Clotrimazole, econazole, ciclopirox* BID for 4 weeks Head and Shoulders wash on area daily, leave on for 1 minute then rinse for 4 weeks If not improving, it is likely NOT tinea. Either do a punch biopsy Or refer to derm 11

12 Case #3; 55 yo F with 3 wk h/o swelling and pain in BLE Lipodermatosclerosis Lipodermatosclerosis Due to venous insufficiency/ longstanding stasis dermatitis (which we will discuss briefly) Often seen in obese individuals Occurs on lower 1/3 of leg Often occurs above medial malleolus ACUTE Red, painful, swollen sounds like cellulitis, right? CHRONIC Can occur following acute episode or occur gradually Hardening of the skin 12

13 How to distinguish the two Stasis Dermatitis Lipodermatosclerosis Can be unilateral or b/l More chronic progression NO systemic symptoms Evidence of varicose veins/edema Cellulitis RARELY b/l Acute presentation Systemic symptoms Fever WBC Preceding trauma or illness More rashy : Itchy Brown/red d/t poor circulation Stasis Dermatitis Lipodermatosclerosis Frontline Treatment of Stasis Dermatitis and LDS Exercise, weight loss For a rashy presentation (Stasis derm): triamcinolone cream bid for 1 month at a time Pentoxifylline, intralesional kenalog for LDS Frontline Treatment of Stasis Dermatitis and LDS Who needs a vascular consultation before compression therapy? Compression therapy is often necessary to improve vascular flow. Vascular consultation if pt has risk factors for peripheral vascular disease Ultrasound can be performed to determine extent of venous disease w/u for other factors (CHF, arterial dz) If no risk factors for PVD, send to medical supply store for compression hose fitting 13

14 Veins do not get better with age! Therefore, preemptive referrals (vascular) and treatment is necessary. Case #4: Summertime in Michigan brings Rhus dermatitis (Poison Ivy, Sumac and Oak) This is an allergic contact dermatitis This is a delayed hypersensitivity reaction = 2 week long process at least Urushiol is the causative agent Sticky, can be active for years Can continue to get re-exposed to the poison if it is on clothing, pets, garden tools Mythbusters about rhus derm Treatment of rhus derm Scratching the rash will NOT cause it to spread New areas of rash can occur for several days after the initial exposure, even if not getting re-exposed New areas can occur in areas that weren t even exposed! An Id phenomenon It is not contagious You can develop sensitivity to poison ivy at any point in life 10-30% of people do not react this can change at any time Reactions can get worse (or better!) with subsequent exposures Home Treatment for all cases: Wash all areas with good soap and water (urushiol is very sticky!) Wash all clothing Wash pets if they were exposed (it will stick to their fur) 14

15 Treatment of rhus derm Limited rash: Topicals steroids: Body: Betamethasone or clobetasol creams bid for 2 weeks Face: hydrocortisone or desonide Antihistamines Diphenhydramine or hydroxyzine Daily cetirizine Oatmeal bath soaks Calamine lotion Cool compresses When to refer to derm? Refer for skin cancer screenings in: Refer for: Immunosuppressed patients History of radiation exposure History of skin cancer People who have a lot of photodamage Redheads who have had a lot of sun exposure People who have >50 moles Patients who have terrible acne = accutane Blistering disorders Rashes that are not responding to standard tx Babies with hemangiomas ASAP Children with atopic dermatitis Hair loss, nail disorders And anything and everything else skin related Updates in the Derm World New nomenclature Basal cell carcinoma and squamous cell carcinoma Non-melanoma skin cancer Keratinocyte carcinoma 15

16 Lotrisone is still being used in peds despite FDA warnings About Lotrisone Why no Lotrisone? Approved in 1984 for ages >12 2 week use in groin, 4 week use in feet Shortly thereafter, reports of lack of efficacy (bc of betamethasone component) were reported 2 studies then showed pts aged had HPA axis suppression after being prescribed lotrisone Studies have shown dangerous side effects in ages <17: HPA axis suppression Hyperglycemia Hirustism Cushings Delayed Growth Skin atrophy FDA changed label to say: no lotrisone in ages <17 and no use in diaper derm What to use instead of lotrisone? Psoriasis Body Surface Area correlates with risk of DM Athlete s foot, tinea cruris, tinea coporis Clotrimazole cream Ciclopirox cream or gel Candidiasis (under breasts, genital region) Nystatin ointment If there is an inflammatory component, dispense 15 g tube of hydrocortisone 2.5% ointment or cream and use bid for 2 weeks, mixed with the above creams 16

17 Crisaborole for atopic dermatitis In Summary From there were no new drugs for AD This is the first PDE-4 inhibitor for acne Topical ointment, applied bid for 1 month or longer Nearly 50% of patients in 2 phase 3 trials were clear or nearly clear out to 1 year Great safety profile (not a steroid, no black box warning like the TCI s) Keep it simple when teaching patients how to check for skin cancer ( ugly duckling ) Take photos of all biopsy sites Take measurements of all pigmented lesions and lesions that are suspect for cancer Send biopsy to a dermatopathologist if able Not all rings are tinea look for outer ring of scale and itching No oral preds for psoriasis do topicals and refer No medrol dose packs for rhus dermatitis do 2 week course of preds Psoriasis >10% BSA needs to be targeted for diabetes prevention Recommended Resources for Primary Care Resources Andrews Diseases of the Skin textbook CME courses such as Practical Dermatology for the Generalist put on by Mayo Gerhard-Herman M, Gornik H, Barrett C, et al AHA/ACC Guidelines on the management of patient with lower extremity peripheral artery disease: executive summary: A report of the American College of Cardiology/American Heart Association Task force on clinical practice guidelines. J Am Coll Cardiol. 2017; 69(11): Ilyas M, Costello C, Zhang N, Sharma A. The role of the ugly duckling sign in patient education. J Am Acad Dermatol. 2017; 77: Miteva M, Romanelli P, Kirsner R. Lipodermatosclerosis. Dermatol Ther. 2010;23(4): Wan MT, Shin DB, Hubbard RA, Noe MH, Mehta NN, Gelfand JM. Psoriasis and the risk of diabetes: A prospective population based cohort study. J Am Acad Dermatol.2018;78(2): Dermnetnz.org, universityhealthnews.com, for some images Special thanks to Tor Shwyader, MD for use of some pediatric images 17

18 Thank you for having me! Feel free to contact me with any questions: 18