Review patient presentations and pathophysiology. Discuss Treatment options Tried and true New and upcoming. Prevention and Counselling

Transcription

1 Speaker: Janssen Consultant: Valeant, Allergan Drinker: Stone, Pizza Port, Lost Abbey Review patient presentations and pathophysiology Discuss Treatment options Tried and true New and upcoming Prevention and Counselling

2 Inflammatory, involving infundibular portion of hair follicles LL37 multifunction peptide Promotes inflammation and vascular changes Toll-like receptor 2 (TLR2) vascular transmitter Secondary complaints stinging, burning, edema, flake and scale Underlying vasomotor instability worsened by hot beverages Alcohol hot or spicy foods extreme temperatures Sunlight Vasodilator drugs can produce flushing and worsen the condition May develop secondary to topical corticosteroids steroid rosacea Facial erythema, papules, pustules, and telangectasia Excessive facial warmth and redness is the predominant presenting complaint, My face burns Itching not common Women: chin and cheeks Men: nose is common Ocular findings in half of patients NO Comedones (distinguishes from acne) Rosacea occurs in 1 in 20 Americans Onset often between age 30 and 50 yr More common in people of Celtic origin; however, this disease may be overlooked in nonwhites because skin pigmentation results in atypical presentation Female: male ratio of 3:1

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4 Cardiovascular dyslipidemia, HTN, CAD IBS Migraines Parkinson's Diabetes type 1 Celiac GERD Multiple Sclerosis Inflammation Papulopustules Burning Stinging Erythema Redness

5 Metronidazole, 0.75%, 1%, cream, gel, or lotion Apply thin coat to face BID Adverse Effects (AEs) stinging and burning Azelaic acid foam, 15% Apply thin layer to face BID Produced by Malassezia Furfur, Inhibits Toll-like receptor 2 Also has bleaching action Isolated cases of hypopigmentation Ivermectin 1% cream Phase 3 trials proved it to be safe and effective at 12 weeks It is thought to reduce papules by killing Demodex mites, which live in the sebaceous glands The AEs include burning, itching, and dryness at the application site

6 Doxycycline, minocycline, 100mg, 50mg, 40mg SR Daily dosing varies Bacterial resistance issues AEs GI issues, yeast infection Vascular lasers Pulse Dye Laser (PDL) Intense pulsed light (IPL) Treat at least 3 times May retard the advance of rhinophyma AEs - erythema and stinging/burning for hours Brimonidine tartrate gel (Mirvaso), an alpha-2 agonist Reverses vasodilation, reducing redness Patients should apply a pea-size amount to the face once daily The adverse effects (AEs) are mostly mild and often cutaneous, occurring at treatment initiation Several reports of rebound erythema have been reported Can be used in combination with other therapies, including those used to treat papules

7 Oxymetazoline hydrochloride cream 1%, (Rhofade) Alpha1A-adrenoceptor agonist Oxymetazoline acts on alpha1a receptors and brimonidine on alpha2 receptors In a 1-year open label trial of oxymetazoline (440 people), 3% of patients had worsening inflammatory lesions of rosacea Topical minocycline: BioPharmX 1% gel - acne Foamix 4% foam rosacea, acne, impetigo

8 Painful, large pustules and nodules Highly erythematous base Severe inflammation without systemic symptoms Cheeks, chin, nose, forehead Primarily young women Abrupt onset Rarely lasts longer than a year No bacterial cause Oral steroids Start 1mg/kg per day Taper down Up to 3 months Isotretinoin Tetracyclines Doxycycline 100mg PO QD

9 Cluster(s) of small (1-2mm), red papules/papulopustules May itch, sting, burn May occur around mouth (duh), nose, eyes, and genitals Spares lips, nostrils, eyelids Primarily women YO Causes: compromised barrier, immune system reacion, altered skin flora NOT fungal like seborrheic dermatitis (Malessezia)

10 Discontinue ALL topicals Wash face with only warm water Oral tetracyclines Topical pimecrolimus/tacrolimus Topical metronidazole NO TOPICAL STEROIDS! May take 6 months to clear Common for rash to clear first, erythema lags

11 Greasy flake or scale on facial creases, ears, scalp Salmon pink erythematous base Severity from mild to erythrodermic Malassezia metabolites (fatty acids, oleic acid, malssezin), barrier, and lipid content all play a part Keratolytics for scale Salicylic acid, lactic acid, urea, propylene glycol Topical antifungals for Malassezia Ketoconazole, ciclopirox shampoo, OTC zinc-based shampoo Topical mild/mid potency topical steroid for inflammation Hydrocortisone 2%, triamcinalone 0.025% Calcineurin inhibitors pimecrolimus, tacrolimus

12 Eyelids and periocular area Irritant or allergic Swollen, thickened, and scaly skin with itching, stinging and burning Accompanying blepharitis in severe cases Triggered by soaps, lotions, cosmetics, nail polish Drying agents

13 Avoid itching or rubbing Wash with warm water only or gentle, hypoallergenic cleanser Topical low/mid potency steroids Hydrocortisone 2.5% BID no more than 1 week Topical tacrolimus or pimecrolimus Oral steroid burst if severe swelling Prednisone 20-40mg QAM for 3-4 days

14 Erythema with fine flake or scale ITCHING!, stinging, burning Allergens include same as eyelid dermatitis Cosmetics, chemicals Metals and plastics Treat with low/mid potency topical steroids Antihistamine Cetirizine 1 PO QD-BID

15 Malar presenting butterfly rash Much worse with sun exposure Chronic immune disease Common symptoms: Fatigue and fever Joint pain, stiffness and swelling Skin lesions that appear or worsen with sun exposure (photosensitivity) Fingers and toes that turn white or blue when exposed to cold or during stressful periods (Raynaud's phenomenon) Shortness of breath Chest pain Dry eyes Headaches, confusion and memory loss More common in women More common in skin of color African American, Hispanic, Asian Triggered by sun exposure, infections, drugs Multi organ system involvement is common Kidneys, lung, heart, nervous system Consult Rheumatology Topical steroids for skin lesions Oral steroids for more diffuse rashes Antimalarial drugs: Hydroxychloriquine Immune suppressants: azathioprine, cyclophosphamide Biologics: In 2011, the FDA approved a biologic, belimumab (Benlysta) First new drug approved since 1955

16 Rare 400k cases per year in US Serious immune disease Heliotrope rash around eyes, Gotrons papules on hands Erythematous/dusky patches on sun exposed surfaces May be intensely pruritic Proximal muscle weakness Muscle fatigue/weakness when climbing stairs, walking, rising from a seated position, combing hair, or reaching for items above shoulders Confirmed by lab testing and/or skin/muscle biopsy

17 Sun avoidance Sunscreens and photoprotective clothing Topical corticosteroids Oral steroids Antimalarial agents Methotrexate Mycophenolate mofetil Immune globulins Lasts months/years Spontaneous remission 20% Chronic progression 5% Physical therapy is key after remission to regain lost muscle strength Residual muscle loss is 5-20%

18 Needs sunlight exposure to flare-up Plant acids/oils are typical usually seen in spring/summer Pinapple, fig, citrus (lime), St. John s Wort, parsnips, hogweed Peaks hrs post exposure Presents with burning sensation and inflammation Melanin is activated hyperpigmentation common May last for months after inflammation clears

19 Steroids Mid potency topical mometasone 0.1% cream Oral prednisone burst if severe Time will fade hyperpigmentaion HQN 4% cream BID until faded

20 John V. Notabartolo, MPAS, PA-C, DFAAPA Linda Woodson Dermatology Las Vegas, NV (702)