COMMON SKIN CONDITIONS IN PRIMARY CARE Ibrahim M. Zayneh, MD Dermatology Private Practice, Portsmouth, Ohio
DISCLOSURE The Speaker and members of the planning committee do not have a conflict of interest in this topic. There is no commercial support for this program.
Common rash in office setting 1- Atopic dermatitis/eczematous dermatitis. 2- Nummular dermatitis/nummular Eczema. 3- Neurodermatitis & Prurigo nodularis 4- Tineas/Dermatophytes infection. 5- Granuloma annulare. 6- Psoriasis Vulgaris.
Objectives 1- Recognize different types of skin rash. 2- How to differentiate Tinea Corporis from Nummular Eczema and Granuloma Annulare. 3- Recognize different types of Psoriasis and chose the right management plan.
Atopic Dermatitis In pediatric group - Can be at birth - First few months - First few years - If start at birth usually resolve by age 2 - If started later usually resolve by age 7 - Few cases continue to adulthood In adult group - Appear as skin sensitivity -- Associated with atopic condition; asthma, seasonal allergy.. - Very common at later age - Year after year our skin get dryer and dryer, need to restore moister in the skin
Clinical Presentation - Pruritus, proceed the rash. - Erythematous papule and macule. - Excoriation - Lichenification. - Dry skin/xerosis. Chronic and relapsing symptoms
Treatment and prevention general Precautions Restore the skin barrier, use skin moisturizer. Use sensitive skin and Hypo-allergenic skin products and soap. Avoid frequent washing and avoid use of hot water, while washing, shower or bath. Treat secondary infection.
Treatment medications Topical 1- Topical Steroid: depending on the severity, use Mild, Moderate or High Potency, also can use Cream, Ointment or Solution. 2-Topical non Steroidal : Immunomodulators - Topical Tacrolimus ointment. - Topical Pimecrolimus cream. 3- A new topical. A Phosphodiesterase(PDE)-4 Inhibitor; Crisaborole ointment.
Treatment Systemic Medication 1- Systemic Steroid; start tapering dose for acute flair, then maintenance dose for Chronic un controlled case!! Side effects. 2- Other Immunosuppressant's for sever uncontrolled case. 3- New Biologic Agent; Dupilumab, Monoclonal Antibody. Interleukin Inhibitor, IL-4 and IL 13.
Neurodermatitis/LSC Prurigo nodularis Itchy papules and nodules form lichenification and excoriation usually distributed on arms, legs, shoulders and abdomen, areas patient can reach, developed by habitual scratching. Etiology unknown Multiple factors; dermatitis, insect bite, systemic diseases; renal insufficiency, hepatic failure, Pregnancy, anemia, and anxiety and stress very contributing factors.
Early stages
Prurigo Nodularis advanced stage
Neurodermatitis/prurigo nodularis treatment Stop the itch cycle, patient education.. Topical Anti-Itch; OTC: Menthol, Capsaicin.. Antihistamine: H1blocker; 1est generation, 2 nd generation..doxepin!. Steroids: topical high potency ; a short course of systemic; intra-lesional injections. Antianxiety medications..? Usually are on. Oral antibiotics: Tetracycline family, 2 nd infection. Phototherapy; limited effect but can help.
Nummular Dermatitis/Eczema Coin shape macules Can be acute red wet seeping resembling contact dermatitis or chronic dry scaly resembling psoriasis or tinea lesions. Different from tinea; there is No central clearing of the lesion and scaling extend to the edge of the lesion.
Compare eczema & tinea lesions Eczema tinea
Treatment Similar to Atopic Dermatitis/eczema; Topical steroid Topical None steroidal Systemic in sever acute case. Use skin moisturizer and sensitive skin care products
Tinea Corporis Superficial dermatophyte infection of the skin Causative Dermatophytes are: Trichophyton tonsurans Trichophyton mentagrophytes rats Trichophyton verrucosum cattle Microsporum canis cat + dog Microsporum audounii
Tinea Treatment Topical antifungal; safe, cost-effective in limited superficial cases, use for 2-4 wks - Ketoconazole 2 % - Ciclopirox 1 % - Econazole 1% - Clotrimazole OTC - Terbinafine OTC - Miconazol OTC
Tinea Treatment Oral antifungal is used for chronic, large surface area, or involvement of hair follicules and nails; Works by inhibition of Cytochrome P450 Griseofulvin, long safety record, long Tx course. Terbinafine Ketoconazole Itraconazole watch for liver effect and medication interaction
Granuloma Annulare Lesions start as asymptomatic flattopped/pinpoint firm red papules, gradually enlarge to create a coin-like appearance. Usually on the dorsal aspects of hands and feet, wrists and ankles, but could appears any where on the body, at time can be disseminated. Etiology; Idiopathic, Associated with DM, mostly diffuse or generalized case.
Granuloma annulare Diagnosis & Treatment Diagnosis is Clinical, classic appearance, no scaling as in tinea, no central clearing in nummular eczema. Treatment; localized asymptomatic lesions best left untreated. If symptomatic, topical steroid, intralesional Kenalog-10, Cryotherapy also works. Disseminated case can be treated with Dapsone, Isotretinoin, or Hydroxy-Chloroquine.
Psoriasis Vulgaris Common, chronic, and recurrent inflammatory disease of the skin. Circumscribed, erythematous, dry scaling plaques of various sizes. Lesions usually covered by silvery white lamellar scales. Usually on extensor surfaces of limbs, also involve, skin fold, scalp, and nails.
Classification/types Localized plaque psoriasis. Generalized plaque psoriasis. Guttate psoriasis. Scalp psoriasis. Pustular psoriasis. Inverse psoriasis Erythrodermic psoriasis
Treatment Topical treatment; for mild, localized case: Topical steroids, Ointment, Cream or Foam. Calcipotriene, Ointment, cream, or Solution. Combination topical : Oint, solution or Foam. Tazarotene, Cream Macrolactams; Tacrolimus and Pimecrolimus,? Salicylic acid, tar or Steroid shampoos. Ultraviolet light
Treatment continue Systemic treatment; for generalized or more sever cases: Corticosteroids,? Flair up when discontinued. Methotrexate Oral Retinoid; Acitretin Soriatane. Dapsone, cyclosporines Biologic agents; TNF Abs, or IgGAb block IL 12+ 23, IL17, IL 23
Biologic Agents Now Multiple agents, can produce dramatic responses, expensive?. TNF blocker : Etanercept. - Adalimumab. - Infliximab. Monoclonal Abs:-Ustekinumab; IgG1k, IL 12+23. - Secukinumab; IgG1, IL -17A. - Ixekizumab; IgG 4, IL -17A. - Guselkumab; IgG1L, IL-23
Treatment continue PUVA; High-intensity long wave UV radiation given 2 hours after oral ingestion a dose of 8-methoxypsoralen.. Narrowband UVB Phototherapy; most common, more effective, specific wavelength of UV radiation, 311-312.. Combination therapy for more sever case or in case of failed single Tx or to reduce Neutralizing Antibodies or reduce toxicity of an agent.
Thank you QUESTIONS