COST-EFFECTIVE TREATMENT OF ACNE, ATOPIC DERMATITIS AND MOLLUSCUM. Jan Yusk, M.D.

Transcription

1 COST-EFFECTIVE TREATMENT OF ACNE, ATOPIC DERMATITIS AND MOLLUSCUM Jan Yusk, M.D.

2 Conflicts of Interest I have no conflicts of interest to disclose.

3 ACNE

4 Pathogenesis Epidermis Dermis Hair Follicle Hair Oil Gland

5

6 History Sex Age Life style/hobbies Motivation Current and Previous Rx Menstrual History Meds Steroids, OCP Other Illness

7 Physical Skin type (Oily or Dry) Skin color Distribution of acne Morphology of lesions Scarring Postinflammatory pigmentary changes

8 Treatment Overview Topical BPO, Antibiotics, Retinoids, Combination Systemic Antibiotics, Hormones, Isotretinoin

9 Benzoyl Peroxide 2.5%; 5%; 10% gel 5.3%; 9.8% foam (BenzEFoam) Anti-microbial Irritating start thin, increase thickness slowly Bleaches fabric Possible contact allergen; also photosensitizer Micronized forms more efficacious BenzEFoam 5.3% or 9.8%; Persagel 10 (OTC)

10 Topical Antibiotics Clindamycin lotion, wipes, gel anti-microbial Erythromycin solution, gel Sodium sulfacetamide/sulfu lotion, suspension, foam and cleanser

11 Topical Retinoids Tretinoin 0.025%, 0.05%, 0.1% cream Adapalene possibly less irritating; 0.1% cream, gel All are irritating, photosensitizing

12 Combination Topicals ($166-$472)

13 Systemic Antibiotics Oral minocycline can stain teeth, cartilage. Also can cause drug-induced hepatitis or autoimmune process like lupus. Oral doxycycline antimicrobial and antiinflammatory Oral tetracycline no longer manufactured Oral erythromycin or azithromycin nausea often a problem

14 Hormonal Therapies Oral contraceptives Ortho Tri-Cyclen, Estrostep, Yaz Oral spironolactone doses from mg daily. Anti-androgen, diuretic, causes potassium conservation. Check K+ after 1 st 6 wk. May cause breast enlargement or tenderness. Rarely causes decreased BP.

15 Mild Acne Treatment Comedones only topical tretinoin. Use low % if pt. is dry; higher if oily. Use q.1-4 nights. Creams less drying than gels. Papules and Pustules, few comedones topical clindamycin (lotion if dry, wipes if oily); topical benzoyl peroxide low % if dry, higher if oily. Can add topical tretinoin later prn.

16 Moderate Acne Doxycycline 100 mg 1-2 x/day. Take between meals with water; use sunscreen! Wean patient off after clear, can then use for few days prn flares. Clindamycin topical 2x a day (lotion if dry, wipes if oily) Benzoyl peroxide (9.8% or 10%) at night, wash off AM. Thicken prn. Can add topical tretinoin 0.1% after 2-3 months if still lots of comedones.

17 ACNE Handout (1 of 2) 1. No scrubs or abrasives, just gentle skin cleanser (i.e. Cetaphil acne wash, Neutrogena fresh foaming cleanser) 2. Use only oil-free make-up, moisturizer, and sunscreen. 3. Use no over the counter acne meds. 4. Do not pick! It irritates your skin and thus makes you unable to tolerate your acne meds. 5. Apply to all affected acne areas 2x daily after washing the skin first.

18 ACNE Handout (2 of 2) 6. Apply to all affected areas at night. It can go on top of your other acne medicine. Start with thin applications, then use thicker amounts until skin clears. If using a topical benzoyl peroxide, remember that it bleaches fabric. 7. If you receive oral medication, take it exactly as directed. After your acne clears you may often stop the oral medication and then take it for a few days only if your acne flares. 8. It will take 2-3 months for treatment to work so be patient. After your acne is clear continue topical treatment in order to remain clear. 9. Please call if you are unsure how to use your treatment or have other questions about it.

19 Severe Acne? PUNT!

20 ATOPIC DERMATITIS

21 Eczema Variations

22 Associated Findings

23 The Itch that Rashes : Underlying Issues Impaired skin barrier Filaggrin mutations Increased proteases Diminished oil Increased inflammation Epicutaneous sensitization Role of microbial colonization Role of autoimmunity

24 Atopic Dermatitis Treatment Overview Educate, educate, educate Improve barrier function Avoid triggers Treat infection Role of topical Rx s Phototherapy Systemic therapy Test for contact allergies

25 Education Chronic relapsing problem often outgrown Genetics play a role Itch that rashes avoid scratching or rubbing Learn to manage eczema s ups and downs

26 Improve Barrier Function Tepid baths Non-soap cleanser Immediately after bath apply moisturizers (if using Rx, apply it first)

27 Avoid Triggers Stress Foods if known cause of flares Excess fatigue Secondary infection Irritating clothing (no wool)

28 Treat Infection Dilute bleach baths (¼ ½ cup bleach in ½ tub water = swimming pool ) Topical antibiotics mupirocin ointment (inexpensive), retapamulin (altabax expensive) Systemic antibiotics if severe do c & s first

29 Topical Therapy Clobetasol ointment flares, short-term Desoximentasone ointment (if allergy) Fluticasone ointment (lotion for scalp) - for moderate Tacrolimus (Protopic) or pimecrolimus (Elidel) after use above. Then can use on normal skin for maintenance prn

30 Topical Therapy Caveats Start with strong Rx, then decrease Teach how to use sparingly affected areas only, short term Creams sting more than ointments Topical steroids 1 st, then Protopic or Elidel (otherwise more stinging) Use coupons

31 Phototherapy Sun judicious use. Anti-inflammatory. Use sunscreen for sensitive skin Narrow band UVB safer. Expensive

32 Systemic Therapy Prednisone MTX, cyclosporine or azathiaprine I ve never had to use these

33 Patch Testing Some kids develop allergies to skin care, clothing or laundry products or even to topical Rx Patch-testing for contact allergies then necessary

34 Reasons for Failure to Improve Poor compliance with entire Rx regimen Infection overlooked, not Rx ed Contact allergies

35 ECZEMA Handout (1 of 2) 1. Tub bath do for minutes, warm water, not hot No more than once daily. 2. To Cleanse Use gentle cleansing soap (Cetaphil Restoraderm, unscented Dove, etc.) 3. Rinse body, pat dry 4. Immediately apply medications Sparingly to affected areas: Twice a day for no more than 2 weeks to most severe areas sparingly. Do not use on face except for a few days only. Twice a day to other irritated areas. When better, discontinue medication. Then can use Protopic or Elidel twice a day until clear.

36 ECZEMA Handout (2 of 2) 5. Apply moisturizer all over (on top of medications) 2-3 times a day every day, even when not using medications. 6. Try to keep from scratching. Frequently a cool wet cloth held to the itch spot will help decrease the itching. 7. When using any of the above medications to open, oozing, crusted and/or infected areas, also apply mupirocin ointment. 8. Use soft clothing (no wool). Use hypoallergenic laundry products (All Free Clear, Bounce Free, etc.) 9. If dilute bleach baths are recommended, use ¼ - ½ cup bleach in half-full bathtub of water. Soak minutes. Close family members may also need to take a dilute bleach bath.

37 MOLLUSCUM

38

39 Therapy Overview No treatment Physical modalities Cryotherapy (liquid nitrogen) Curettage or manual extraction Scotch tape stripping Topical or Intralesional therapies Cantharidin Imiquimod Potassium hydroxide 10% solution Retinoids Tea tree oil (+/ iodine) Systemic Therapy Cimetidine

40 Canthacur (Cantharidin) Paladin Labs Inc Royalmount Avenue, Suite 102 Montreal, Quebec H4P 2T4, Canada (888) Canthacur 0.7%, 7.5 ml solution lasts about 2 months; Product Code $44.25 a bottle, if spend more than $75 no $5.00 charge per bottle for 5% shipping/handling cost.

41 Topical Cantharidin Apply with wooden end of cotton swab. Let dry 5 minutes Rx only few at first to see how skin reacts Warn about blister size. If Sx, Desitin over areas and/or oral ibuprofen monthly intervals Code as 17110, destruction of benign lesions, 078.0, molluscum.

42 Topical Cantharidin: Adverse Reactions

43 Topical Imiquimod Pierce packet, apply with wooden end of swab Apply nightly until irritates, then DC OK for cost if only have few lesions

44 Topical Potassium Hydroxide (10% Solution) Cost $50 for 210 ml Art Jacob Prescription Shoppe (502) Apply 2x a day until irritates, then DC 32 of 36 kids cleared after 30 days. The rest DC d because of irritation. Ped Derm, May-June, 1999, 16 (3)

45 Topical Tea Tree Oil/Lodine Apply 2x a day until irritates, then DC Can be very irritating 90% reduction in lesion numbers after 30 days of use Available online as Zymaderm ($25) Either agent used alone was not very effective J Drugs Derm, 2012 Mar, 11(3):349-54

46 Oral Cimetidine Dosage - 40mg/kg/day Cost - Generic Adjunct Rx Not very effective as monotherapy

47 Scotch Tape Stripping Good if only have few lesions Do nightly until irritates or lesions are gone

48