Common Dermatologic Problems in Medicine

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1 Common Dermatologic Problems in Medicine Toby Maurer, MD University of California, San Francisco Psoriasis-What is it? Fast growing skin-takes 3 days to come to surface and desquamate Normal rate is 28 days Psoriatic skin has a fast mitotic rate Triggers an inflammatory response in and around affected skin 1

2 New onset often preceded by strep infection (strep pharyngitis) especially in the younger age group. In older age group, drugs often unmask psoriasis Drugs: beta-blockers, lithium, NSAIDS, antimalarials, terbinafine, gemfibrozilpts on these meds for 3-6 months before onset of psoriasis Psoriasis-Tx: NO PREDNISONE Decrease the MITOTIC RATE of skin Tar (LCD 5% in TAC 0.1% oint) ( Tar emulsions), topical retinoids (Tazarac) Decrease the INFLAMMATORY RATE of the skin Steroid Ointment (mid-potency-1 st line) Calcipotriene (Dovonex creme)-not on face or groin Clobetasol/Dovonex combination Ultraviolet light (psoralen+ UVA), UVB 2

3 NEXT STEP Time for referral Methotrexate-liver biopsies necessary(don t give in HEP C pts) Oral retinoids (Acitretin)-not in persons of reproductive potential -? Okay in liver disease; excellent drug in HIV Cyclosporine Biologics (Enbrel, Remicade)-most benefit in psoriatic arthritis and quick reversal of pustular psoriasis 65 yr old male with COPD and few plaques of psoriasis comes in SOBneeds Prednisone a) give it to him-short course (5 days) probably won t hurt him b) give it to him and call dermatology for advice as to how to taper and what to substitute c) Skin vs. lungs-take care of the skin first so no prednisone! b) Can taper slowly and substitute acitretin or methotrexate or etanercept. 3

4 Tinea-nails Terbenifine-best cure rate (75-80%) Terbenifine-now generic and cheap Watch for liver failure-unpredicatble by LFT monitering But recurrence of tinea 65% of the time Remove nail? Qmo dosing of terbenifine until nail grows out? Topicals? 4

5 P.O. Antibiotics Acne TCN bid x 8 weeks Doxycycline bid x 8 weeks Minocycline bid x 8 weeks-too many side effects and high cost Taper - Do NOT STOP ABRUPTLY Alternatives: Septra-watch for neutropenia Azithromycin-dosing? Topicals + po antibiotics? Spiranolactone Diuretic used in cirrhosis of liver Also an anti-androgen Useful in females who have cysts around menstruation mg qday continuously Laser treatment for acne Placebo effect is strong so controlled studies are essential but lacking INFRARED-1320 and 1450nm wavelengthlight absorbed by sebaceous glands-results very poor INTENSE PULSE LASER (585 nm)-decreased comedones but not inflammatory papules BLUE LIGHT (415nm)- decreased inflammatory papules Yeung CK et al Lasers Surg Med 2007 Jan 5

6 Acne Keloidalis Not acne, not keloid Hard to treat-il kenalog (steroid)/surgical excision Don t crop hair at back of head!!!! Herpes Zoster Zoster vaccine available boosts older person s cell-mediated immunity to VZV Study done on 38,000 persons 60 yrs and older (Kimberlin et al NEJM March 2007) Incidence of zoster was 51% lower in those that received vaccine vs placebo Post-herpetic neuralgia was 67% lower in vaccinated group Worked best in yr olds 6

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8 Bacterial Skin Infections Most common pathogen is staph aureus More methicillin resistant staph causing skin and soft tissue infections in the community JAMA-Niami et al Dec 2003 Approach to Treatment Culture whenever you have pus Incise and drain when appropriate (Abcesses)-don t pump up with antibiotics-5 studies reviewed-i & D alone- same as I& D with antibiotics (Hankin et al Annals or Emergency Medicine 2007) Is this true for abcesses with overlying cellulitis or in areas with high MRSA prevalence?-designing that study now If no pus: Tx with methicillin SENSITIVE drugs-first line but have pt return to evaluate for resolution If recurrent infection, tx with methicillin RESISTANT antibiotics right off the bat Septra, Doxycycline,Cipro/Levofloxacillin), Clindamycin Consider adding rifampin 600 qd for 5 days or mupirocin ointment for staph eradication Mupiricin intranasally-first five days of every month for staph eradication 8

9 Was it bacterial in the first place? Remember HSV-culture and/or Direct Fleurescent Antibody Skin biopsy for histology and tissue culture Diseases that Masquerade as Infectious Diseases Ann Int Med 2005 Jan 4; 142:47-55 Hidradenitis Supparativa Not an infectious disease Disease of apocrine glands Treatment IL Kenalog Minocycline Surgery NOT Antibiotics New Biologics 9

10 Inflamed Epidermoid Cysts Antibiotics-USELESS If just starting to become inflamed and cyst is small( < 1 cm), can try intralesional Kenalog injection but see them back in few days-you can exacerbate the inflammation INCISE and DRAIN and PACK 6 weeks later, inspect for residual cyst and excise 10

11 Venous Insufficiency Ulcer Venous Insufficiency Ulcer Control Edema Elevation of leg above heart 2 hours twice daily Walk, don t sit Compression Diuretics overused and not of benefit unless fluid retention due to central problem is present (CHF, CRF) Create healing wound environment Compression dressing Unna boot covered by Coban this requires a good nursing staff with training and experience This both provides graded compression AND creates the correct wound environment Semipermeable dressing (Hydrosorb, Duoderm, etc) Change dressing weekly Refer to dermatology if not healing 11

12 Squamous Cell Carcinoma (SCC) Who is at risk? Age 50+ Chronic sun exposure Head, neck, lower lip, ears, dorsal hands, trunk Special circumstances Immunosuppression (organ transplant) Radiation therapy 12

13 Diagnosis of BCC: Shave or Punch Biopsy Treatment of SCC Recommended treatment Excision Radiation therapy ( > 65 years old & debilitated) Treatments NOT recommended Curettage and desiccation Topical chemotherapy 13

14 When to Refer SCC s may metastasize Low threshold for biopsy and referral Regularly check draining lymph nodes High risk SCC s High-risk SCC s Lip Temple Immunocompromised host (i.e. organ transplant) Area of previous radiation therapy 14

15 Recommended Treatment of BCC Surgical excision (head and neck) Curettage and desiccation (trunk) Radiation therapy (over age 65 & debilitated) Microscopically controlled surgery (Mohs) Recurrent/sclerotic BCC s BCC s on eyelid and nasal tip 15

16 Aldara (Imiquimod) Topical therapy designed for wart treatment Upregulates interferon and down regulates tumor necrosis factor Seems to have efficacy in superficial BCC s Do Not use in BCC s that are nodular or invasive 16

17 How to Diagnose If melanoma is suspected, an excisional biopsy is recommended 17

18 Why Excisional Biopsy? The diagnosis and prognosis of melanoma is dependent on the depth of the lesion Send your pathologist the whole thing If the lesion is too large to excise, an incisional biopsy may be done to include any nodules, dark-black areas and white areas What to do if Melanoma Staging workup for melanomas > 0.7 mm Re-excise all melanomas with wider margins Primary care follow-up For the first two years after diagnosis-see patient back q 6 months for total body exam Looking for local recurrence, in-transit metastases, lymph node involvement and second melanomas. Q yr CBC, LFT s including LDH for lymph node involvement or ulcerative lesion CXray-controversial Life long followup 18

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