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The Red Face and Scalp Misha Miller, MD Assistant Professor, University of Colorado Department of Dermatology Dermatitis 1.1% of All Outpatient Visits Non-dermatologists 4,793,00 The majority of cases are seen by NON-dermatologists! Dermatologists 2,184,000 Types of “Dermatitis” • Allergic contact dermatitis • Irritant contact dermatitis • Atopic dermatitis (“eczema”) • Nummular dermatitis • Dyshidrotic dermatitis (pompholyx) • Seborrheic dermatitis • Exfoliative dermatitis Allergic Contact Dermatitis Pathogenesis • Topical allergens • > 85,000 chemicals in the environment • > 3,700 chemicals are known allergens • Type IV - DTH reaction • Initial exp - 5-21 days, (sensitization) • Subsequent exp - 1-3 days, (elicitation) Most Common Allergens • Nickel 14.3% • Quaternium-15(preservative) • Neomycin 9.6% 9.0% • Formaldehyde (preservative) • Thiuram mix (rubber) 7.8% 7.7% • Balsam of Peru (fragrance mix) 7.5% • p-phenylenediamine (hair products) 6.3% • Carba mix (rubber) 4.8% Allergic Contact Dermatitis Clinical Features • Marked pruritus • Configurations • follows contact initially • may spreads beyond contact site (later) • Erythema, induration, vesicles, bullae • New lesions persist for up to 3 weeks! Allergic Contact Dermatitis Diagnosis • Careful history • Clinical presentation • Biopsy - helpful but not specific • Patch testing Allergic Contact Dermatitis Treatment • Withdrawal of offending agent(s) • Topical corticosteroid (ointment?) • Antihistamines (sedation?) • Hydroxyzine (Atarax®) - moderate sedation • Cetirizine (Zyrtec®) - lesser sedation (? less efficacy) • Fexofenadine (Allegra®) – little sedation (? lesser efficacy) • Oral corticosteroids (poison ivy) Principles of Corticosteroid Therapy • Ointment > cream > gel > solution > spray • Occlusion increases potency • Amount • 15 grams for whole body one time • 1 gram for both hands • Absorption site dependent (scrotum 290x > sole) • Scrotum>cheek>scalp>back>forearm>palm>sole • Avoid fluorinated steroids on face • Superpotent steroids - atrophy in as few as 7 days Topical Corticosteroid Potency • Super potent (~ 1500 times > hydrocortisone) • Clobetasol (Temovate®) • Halobetasol (Ultravate®) • Betamethasone diproprionate (Diprolene®) • High potency (100-500 times > hydrocortisone) • Amcinonide (Cyclocort®) • Fluocinonide (Lidex®) • Mid potency (10-100 times > hydrocortisone) • • • • • Betamethasone valereate (Valisone®) Fluocinolone (Synalar®) Hydrocortisone valereate (Westcort®) Mometasone furoate (Elocon®) Triamcinolone (Kenalog®, Aristocort®) • Low potency (1-10 times > hydrocortisone) • Aclometasone (Aclovate®) • Desonide (DesOwen®, Tridesilon®) Irritant Contact Dermatitis Pathogenesis • Direct toxic injury to the skin • More common than ACD (<75%) • Common causes • • • • • Soaps (bath soap, dishwashing liquids) Cleansers Alcohols Glues/cements Deodorants Irritant Contact Dermatitis Clinical Features • Strong irritants • Immediate burning & stinging • Erythema & edema • Vesiculation • Mild irritants • Hours to days • Mild erythema • Scaling & fissuring Irritant Contact Dermatitis Diagnosis • Clinical history Strong irritants - self-evident Mild irritants - extensive history • Clinical presentation • Biopsies - not particularly helpful • Patch testing - useful to exclude allergic contact dermatitis Irritant Contact Dermatitis Treatment • Withdrawal of offending irritant • Withdrawal of other irritants (soaps) • Moisturizers (Lachydrin®) • Corticosteroids - mild to moderate Atopic Dermatitis Epidemiology • Atopy is inherited (70% pts with + FH) • Atopic diathesis (classic triad) • Allergic rhinitis • Asthma • Atopic dermatitis • Prevalence of atopy in US around 17% (and increasing) Atopic Dermatitis Clinical Features • Dermatitis • erythema, excoriations, lichenification • face/extensors (infants) flexural (children) • hand dermatitis in adults • Xerosis • Keratosis pilaris • Ichthyosis vulgaris • Dennie-Morgan lines • Pityriasis alba Atopic Dermatitis Diagnosis Three of four major criteria: • Presence of pruritus • Morphology & distribution for age group • Chronic or relapsing dermatitis • Personal of family history of atopy Aggravating Factors in 2501 Children Atopic Dermatitis Br J Dermatol 2004; 150: 1154-61. • Sweating • Hot Weather • Fabrics (wool) • Illness • Dust 33% • Sea swimming • Anxiety/stress • Cold weather • Animals • Grass • Soaps/shampoos 26% 42% 40% 39% 36% 30% 28% 28% 28% 27% Atopic Dermatitis Treatment • Removal of irritants/triggers • Food elimination diets - controversial • Lubrication - generous & bland • Topical corticosteroids (mild to potent) • alternatives = tacrolimus or pimecrolimus • Oral antihistamines (hydroxyzine) Excellent Moisturizers • Vaseline® (no irritants) • Cetaphil® • Aquaphor® • Eucerin Plus® • Sodium lactate + urea • AmLactin®/LacHydrin® • 12% ammonium lactate Seborrheic Dermatitis Adult Presentation • Appears after puberty • “Seborrheic” distribution • scalp, eyebrows, eyelashes, nasolabial folds, auditory canal, auricular areas, presternal area, umbilicus, anogenital area • Erythema, white/yellow, greasy scale • Pruritus varies - absent to severe Seborrheic Dermatitis Diagnosis •Clinical presentation •Distribution •Biopsy usually not indicated • can be highly suggestive Seborrheic Dermatitis Treatment • Low potency steroids (HC 1-2.5%, desonide) • Combination agents - (HC + iodoquinol) • Topical imidazole (ketoconazole) • Systemic imidazoles - Sporanox® • 200 mg/day x 7 d then 200 mg/day 2 d/mo • 19/28 with complete clearing at one year • expensive & contraindicated in liver disease Seborrheic Dermatitis Hair Bearing Skin • OTC anti-dandruff shampoos • Keratolytic shampoos (Neutrogena T Sal®) • Ketoconazole shampoo (Nizoral®) • J&J Baby Shampoo® - use near eyes • Steroid solutions (cheap but oily) • Steroid foams - betamethasone & clobetasol, wonderful vehicles but very expensive Exfoliative Dermatitis/Erythroderma Clinical Presentation • Diffuse erythema and scaling 100% • Pruritus 36% • Malaise 34% • Palmar/plantar keratoderma 34% • Lymphadenopathy 26% Exfoliative Dermatitis Pathogenesis in 236 Patients • Idiopathic • Drug-induced dermatitis • Pre-existing skin disease • Lymphoma/leukemia • Atopic dermatitis • Psoriasis • Contact dermatitis 30% 28% 25% 14% 10% 8% 3% Exfoliative Dermatitis/Erythroderma Diagnosis • History - drug use, known skin disorder • Clinical presentation • Biopsy definitive in 43% of cases • CBC - striking eosinophilia favors drug Exfoliative Dermatitis/Erythroderma Treatment • 34% clear spontaneously (~ 7 years) • Diagnosis known - treat specific entity • Idiopathic • • • • • lubrication topical corticosteroids oral antihistamines oral prednisone (rarely) UVB or PUVA therapy Rosacea • Disease of unknown cause that results in: • facial flushing, erythema, and telangiectasias • acneiform papulopustular eruption • Common in certain ethnicities • “Curse of the Celts” • Differs from acne no comedones • Affects only adults Rosacea Four Main Subtypes 1. Erythematotelangiectatic 2. Papulopustular • granulomatous 3. Phymatous 4. Ocular It is certainly possible to have more than one subtype or overlapping types. Rosacea Patient Education • Chronic condition (waxing/waning) • Precise cause unknown • demodex, H. pylori, ROS, UV damage etc. ? • Treatments but no cures • Protect from sun and avoid other triggers • EtOH, caffeine, tomatoes, wind, etc. • Use only gentle cleansers & moisturizers Rosacea Treatment • Topical medications • metronidazole – now qd formulations availablef • azelaic acid 15% – preferred head:head with MTZ • sodium sulfacetamide – lowest irritation, least efficacy • Oral medications • TCN and macrolide families of antibiotics • Other • calcineurin inhibitors (Protopic, Elidel) • green tinted make-up, “redness relief” formulas • Papulopustular responds more than erythematotelangiectatic Azelaic Acid (Finacea™ 15% Gel) • A dicarboxylic acid • Highest concentration in corn flakes Bottom Line: Azelaic acid 15% gel had modest benefits over metronidazole 0.75% gel, but was not as well tolerated. Both medications are reasonable treatment options, and the choice depends upon patient preference/tolerance. Sub-antimicrobial DCN Dosing • Oracea (40 mg immediate, 10 mg delayed release) Brimonidine Topical Gel • Topical gel, alpha agonist • Non transient facial erythema • Vasoconstriction of superficial facial vasculature • Once daily application, peak erythema redution of ~ 6 hrs • Return of facial erythema to less severity than prior to use • Rebound? Brimonidine Topical Gel • Side Effects • Skin irritation, burning sensation • Flushing • Redness • May interact with • Beta blockers • Antihypertensives • MAO inhibitors Topical Ivermectin Targets Demodex mites Anti-inflammatory effects Treats erythematelangiectatic, papulopustular rosacea Once daily application ~40 pts reported clear to almost clear Rosacea Treatment Controversy Retinoids in Roscea • Conventional wisdom - ‘avoid retinoids’ • In practice, certain subsets of patients may benefit from low-strength retinoid: • patients with patulous follicles • ‘oily’ patients • sun-damaged patients whose skin quality will be improved if the retinoid is tolerated Acne • Multi-factorial disease process • genetics, hormones, environmental factors • Most Americans affected • 45 million with acne at any moment • 70% with enough acne to seek medical care • 20% with acne severe enough to scar • direct cost to society exceeds $1 billion USD Acne Subtypes • Comedonal • whiteheads/blackheads • Inflammatory • papules, pustules, nodules, cysts, sinus tracts • Most acne is mixed • Successful treatment interrupts these processes Four Tiered Grading Schema • Grade I – mild acne • • • comedones in any number minor (small) and few papules no inflammation • Grade II –moderate acne • • • comedones generally in greater numbers more papules and formation of pustules slight inflammation of the skin is apparent • Grade III - severe acne • • • • increasing amount of inflammation skin is erythematous and inflamed papules, pustules and nodules will be present, scarring probable usually involves other body areas (neck, chest, shoulders, back) • Grade IV – critically severe nodulocystic • • • • • numerous papules, pustules, nodules, and cysts pronounced inflammation often painful may involve nearly entire back, chest, shoulders, and upper arms scarring inevitable Simplest Grading Scheme for Acne • Mild - comedones and few papulopustules • Moderate - comedones, inflammatory papules, and pustules in greater number • Severe - comedones, inflammatory lesions, and large nodules (>5 mm), often with clearly apparent scarring Acne Treatments Targeting Different Points in Pathophysiology • Comedolytics (salicylic acid, BPO, retinoids) • improve follicular maturation & reduce plugging • Topical anti-inflammatory agents • retinoids comedolytic and block inflammation • Topical antibiotics (BPO, erythro/clindamycin) • reduce counts of P. acnes on skin • Oral antibiotics (mostly TCN & macrolide families) • likely anti-inflammatory and antibacterial roles Acne Treatment Comedolytics • Salicylic acid (0.5 to 2%) • pros: OTC, well tolerated • cons: effective only for mild acne • Benzoyl peroxide (2.5 -10%) • pros: OTC, no significant resistance in P. acnes • cons: bleaches clothing, allergic potential • Tretinoin (0.025 to 0.1%, gels, creams, other) • pros: generics available, also anti-inflammatory • cons: drying, net effect on sun-protection debated • Adapalene (Differin™) (0.1% cream, 0.1% & 0.3% gel) • pros: less irritating than other retinoids • con: underpowered in more advanced acne Acne Treatment Comedolytics • Adapalene 0.1% + BPO 2.5% (Epiduo™ gel) • pros: dual-action, well-tolerated, other advantages of BPO • cons: variable coverage, BPO bleaches fabrics • BPO 5% + 3% erythromycin (Benzamycin™) • pros: generic available • cons: supposed to be refrigerated after use • BPO 2.5% + clindamycin (Acanya™) BPO 5% + clindamycin (Benzaclin™, Duac™) • pros: well-tolerated, elegant, once daily indication • cons: underpowered beyond mild acne, expensive Acne Treatment Retinoids - Anti-Inflammatory • Improve follicular differentiation • Thinned stratum corneum, prevent plugging • Also block inflammation • prevent TLR-2 receptor activation by P. acnes • Many agents/formulations available: tretinoin – first, generic available adapelene – probably least irritating tazarotene – probably most irritating Acne Treatment Antibiotics: Topical & Oral • Inflammatory acne usually needs antibiotic • Topical vs. Oral • Topical abx (erythro/clindamycin) • for mild inflammatory acne • use in combination with BPO (prevents resistance) • Oral antibiotics • TCN family favored for anti-inflammatory properties • relative strength: TCN << DCN < MCN • macrolides useful in preg patients or those unable to take TCNs • TMP/SMX used in treatment resistant cases • oral abx must be removed slowly while maintenance tx con’t Graded Approach (Simplified) • MILD Comedonal: topical retinoid Inflammatory: topical abx/BPO + topical retinoid Alternatives: salicylic acid, azelaic acid, sulfacetamide • MODERATE Papulopustular: oral abx + BPO + topical retinoid Alternatives: OCP + spironolactone (women only) • SEVERE +/- Initial Trial: oral abx + BPO + topical retinoid Mainstay: place on isotretinoin (Accutane™) Acne Treatment Managing Expectations • Realistic goals are important: • inform pts that abx effects not immediate • f/u at 2-3 months, but should call if compliance is not possible for any reason • 50% improvement at 3 months = ‘on track’ • acne “not cured” but “managed” • maintenance Rx needed for years • scarring dealt with separately after new lesions are no longer developing Acne Treatment Resistance to Antibiotics • Resistance to erythro/clinda and TCN/DCN is high in some communities • “Addition of BPO to any regimen decreases the development of resistance” • Monotherapy strongly discouraged • Avoid PRN use of abx where possible • Newer regimens of low-dose DCN or lowdose/extended-release MCN promoted Acne Treatment Isotretinoin • Systemic retinoid • Difficult to use (physically/bureaucratically) • 5 month course • ~ 25% relapse rate • Side effects: • • • • dry lips, eyes, nose teratogen hyperlipidemia ? SI/HI ? (controversial) Acne Treatment Special Considerations - Women • “Beard distribution” • Few comedones • Described as: • ‘deep’, ‘no head’, ‘painful’, ‘long lasting’ • Spironolactone • must follow K+ levels • Oral contraceptives • low estrogen (cyproterone acetate, levonorgestrel) Acne Case #1 • 13 y/o AA girl • blackheads x 6 months • tried OTC BPO and “even Proactiv” • minimal benefit • today is ‘typical’ day What is next for her? Acne Case #1 • Mild acne • mostly comedonal, minimal inflammatory component • ask about “pomade” component • Reasonable starting treatment: • tretinoin cream 0.025 to 0.05% (slow advance to qhs) • BPO + erythro/clinda ($4 drugs) or combination agent • Follow-up in 3 mos, goal of 50% improvement • Poor response increase retinoid strength • Inflammatory component go to oral abx Acne Case #2 • 15 y/o boy • • • • acne x 1 yr no treatment “average day” mom believes acne is related to “lots of burgers and fries” • trunk is not involved What is next for him? Acne Case #2 • Moderate acne • mostly inflammatory component • no evidence that is related to “burgers and fries” • Reasonable starting treatment: • oral DCN/MCN 100 mg BID • topical BPO + retinoid (separately or in combination) • +/- topical BPO/topical abx in combination (if retinoid separate) • Follow-up in 2-3 mos, goal of 50% improvement • Poor response increase retinoid strength • Inflammatory component increases ? isotretinoin Acne Treatment Side-Effects of Medication • Topical comedolytics/retinoids • all are drying and irritating • start retinoids slow (2-3 eve/wk), advance to qhs • watch for bleaching of fabrics with BPO • Oral abx • • • • GI upset (avoid dairy with TCN/DCN > MCN) MCN can cause vertigo (begin qhs only) UV sensitivity: DCN > MCN pigmentation & lupus like syndrome with MCN Acne Treatment TCN-class Side-Effects Perioral/Periocular Dermatitis • Erythematous, monotonous, and slightly exczemaotus papules around mouth/eyes • Most common in women 20-45 y/o • May occur idiopathically or be provoked by use of strong fluorinated steroid on face • Fluorinated toothpaste implicated by some Perioral Dermatitis Treatment • Oral tetracyclines for 2 months • If problem is related to potent steroids • wean with HC 1-2.5% to replace ‘addiction’ • pimecrolimus showed benefit in one study • do not use ointments • “ZERO-THERAPY” likely effective • requires perfect compliance • toleration of initial flare • Oral isotretinoin for rosacea fulminans or treatment resistant cases Lupus Erythematosus Clinical Features • Discoid lupus erythematosus • Fixed plaques with variable scarring, follicular plugs, hyperkeratosis, pigmentary changes • 2-5% may progress into SLE • Subacute cutaneous lupus erythematosus • Nonspecific erythema • Annular erythema • Psoriasiform variant Lupus Erythematosus Diagnosis • Clinical presentation • SCLE - SSA (anti-Ro) antibodies • Skin biopsy - consistent with or diagnostic if classic • Direct immunofluorescence studies Lupus Erythematosus Treatment • Sunscreens- broad spectrum • Parsol 1789 - Presun Ultra® • Pure titanium dioxide - Neutragena Sensitive Skin • Topical corticosteroids - potent • Intralesional corticosteroids for DLE • Oral corticosteroids • Oral antimalarials