Download Common Derm Problems By Theresa M. Vance, PA

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Common Derm Problems
By
Theresa M. Vance, PA-C
WAPA Fall Conference 2010
What We’ll Cover
 How to recognize common derm problems found in primary care
 How to treat them
 Some pearls, too
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Case Study
 56 year old male with rash on the face for many months, won‘t clear no matter what
he uses for it although cortisone cream makes it less red. It is painful at times with
big red bumps, sometimes pustules. No history of acne or other health problems. No
medications.
 What am I?
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Acne Rosacea
 Most common in people age 30-60
 Cause of vascular dilation unknown
 Initial symptom is erythema of the face
 Treat symptoms
– Topical antibiotics and benzyl peroxide
– Retinoids & oral antibiotics for persistent sx
 Do not use topical corticosteroids!!
Closed
Open
Comedo
Comedo
Pathogenesis… 4 factors
 Hyperkeratosis
 Increased sebum production
 Propionibacterium acnes present in the follicle
 Inflammation
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What about adults?
 Acne tends to resolve in the 3rd decade
– Due to DHEA decline
– Premenstrual flares are common in older women
A zit’s a zit…right?
 Open comedo = blackhead
– Follicle is open and distended
– Dark color is due to melanin, lipids, and keratinocytes
 Closed comedo = whitehead
– Progresses from microcomedo due to sebum production
Inflammatory lesions
 Pustules (superficial), papules, nodules
 Develop when follicular contents rupture into surrounding dermis
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What was that about DHEA?
 Androgens in general are the original culprit
– Leads to pubertal production of sebaceous glands and sebum
– Also, some androgens are active on the skin leading to increased metabolic activity
in acne-prone areas of the skin
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in acne-prone areas of the skin
Acne medicamentosa- caused by steroid or medication usage
Acne fulminans
Acne conglobata
External factors
 Acne cosmetica
– Recommend water-based products
 Acne mechanica
– Mechanical trauma may lead to inflammatory lesions
– ―Sports induced‖
External factors
 Clothing can harm
– Pts with acne should avoid occlusive clothing
 Environmental factors
– Humidity & heavy sweating, halogenated hydrocarbons from industrial products
(cutting oils, herbicides, chemical warfare)
 Dietary factors are usually not of concern
– ? milk
Clinical presentation
 Affects face, neck, chest, upper back, upper arms
– Greatest number of sebaceous glands
 Scarring and hyperpigmentation may occur
Diagnostic evaluation
 Check med list
– May be caused by androgens, corticosteroids, lithium, phenytoin, B vitamins, etc.
 Focus on type & location of lesions, scarring, & postinflammatory pigment changes
Diagnosis
 Hirsutism or virilization warrants further lab & imaging studies
 Refer for endocrine evaluation to rule out systemic causes if suspected
– PCOShyperandrogenism

Keys to Clearing Acne
 Treatment is a control not cure
 Patient must want to comply
Takes 8-12 weeks to see effect and may continue to improve for up to six
months
 Long-term, consistent and continuous
When to Refer
 Moderate to severe papular, pustular and nodule acne (10-25 inflammatory lesions)
 Scars
 On chest or back
 Not typical age- greater than 21ish
 Due to medication use
Non-Pharmacological Tx
 Cleanse the skin
– warm water, soap, not vigorous

 Minimizing factors
– avoid friction causing clothes
– no oil based cosmetics
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– no oil based cosmetics
– sun exposure
– don‘t pick or squeeze
OTC products
 Benzyl Peroxide
– 5 or 10%
 Salicylic Acid
– 2-4%
 Sulfur (w/ resorcinol)
Benzyl Peroxide
 Bactericidal against P. acnes
 Increase sloughing of skin cells
 Prevents closure of orifice
 Use 1-2 times daily (4-6 weeks for full effect)
 Excessive dryness, peeling
 May bleach clothes, bedding
Salicylic Acid
 Mild comedolytic agent

 Surface keratolytic
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 Apply 1-3 times daily
Antibiotics
 Erythromycin/Clindamycin/Tetracyclines
– All come in topical or orals (we don‘t use clinda oral for acne- usually)
 Use once or twice daily
 Resistance is an issue!
– TCN doesn‘t really work on teenagers
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A few words about Minocycline
 More photosensitivity than doxycycline
 Can cause bluish-black deposits in the skin which may be permanent
 Can cause lupus-like syndrome, esp. in females
Topical Retinoids
 Azelex
– Cream
Comedogenic and antibacterial
 Retin A
– solution
– Gel
– Lotion
– Cream
 Differin
– Solution
– Gel
– Cream
 Tazorac
– Cream
– Gel
Topical Retinoids
 Cause irritation, drying scale
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 Cause irritation, drying scale
– Usually last 4-6 wks
– Apply moisturizer after the medication dries
 Cornerstone of current acne treatment
 Start slow and work up from there
Isotretinoin
 Used for the worst acne
– Nodulo-cystic or pustulo-cystic
 Basically ‗remodels‘ the oil glands in the entire body, not just the face
 Need to be go through a certification process to be able to prescribe
Isotretinoin
 Patient must be seen monthly and monitored for side effects
– Liver function (ALT), triglycerides, and CBC must be checked once a month,
pregnancy test for females
– Common side effects: dryness, musculoskeletal aches, headaches (increases ICP),
GI symptoms, visual changes
Accutane (isotretinoin)
 Severe side effects
– Teratogenic
Women must be on two forms of birth control and must have two negative
pregnancy tests prior to initiation of med
Pregnancy is treated with abortion due to risk of fetus and mother
– Can cause severe anemia's, liver failure, pancreatitis, metabolic syndrome
associated hypertriglyceridemia, ulcerative colitis
 Very expensive!
 www.ipledgeprogram.com
Case study
 23 year old female presents with rash around the nose, thinks it started with a sinus
infection. It is a little itchy and scaly at times, seems to be spreading. Cortisone
cream and triple antibiotic ointment don‘t help. Menses is normal, just stopped OCP‘s
due to weight gain.
 What am I?
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Perioral dermatitis
 A subset of rosacea, frequently mistaken for impetigo
 Hormonally driven
– Stress can cause it too
 Treatment
– Topical erythromycin or clindamycin
– Oral TCN 500 mg for 30-60 days initially
Flares can later be treated for 14 days
Impetigo
 A common, contagious, superficial skin infection caused by strep, staph or a
combination of both
Bullous and non-bullous represent two clinical forms
– Occurs after a minor skin injury
 Classical presentation: honey crusted exudate/crust with vesicles or pustules
Impetigo
 Treatment:
– Mupirocin 2% ointment or cream (Bactroban TID X 10 days
– Oral Keflex qid X 10 days
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– Oral Keflex qid X 10 days
– If it seems recurrent- CULTURE IT!!!
There‘s lots of MRSA out there!
Case study
 70 year old male, presents with 4 wks of rash and intense itching. His wife died about
a year ago and his 40 year old son moved in with him this summer. No new
medications but did have recent change in laundry detergent. Was thought to be
folliculitis, treated with Keflex and Zyrtec without relief, itches worse at night. His son
has been itchy as well for most of the summer, thought it was allergies.
 What am I?
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Scabies
 An intensely pruritic contagious disease
 Caused by the mite Sarcoptes Scabiei var hominis
– Itching is worse at night- classic!!
– Burrow is a classic lesion: linear, curved or S-shaped, 1-2 mm wide, up to 15 mm
long, pin-white in color and slightly elevated
Scabies
 Typical locations:
– Web spaces of the hands/feet, wrists, genitals, warm intertriginous regions and
abdomen
In infants, the scalp, palms, and soles are affected and there may be pustules
 Lab:
– Skin scraping for mites, eggs or feces using mineral oil applied to a lesion and then
scraped with a #15 scalpel blade and apply to slide with a cover slip
Scabies
 Treatment
– Permethrin (Elimite, Acticin)
Apply to entire body except the eyes, mouth/lips, leave on for 10-12 hours then
wash off completely.
–May need to repeat treatment in 7 days time
Itching may continue for up to one month after tx
– Bedding/pajamas must be washed morning after application- no need to clean the
house
– Kwell/Lindane is an alternative but may be less effective
– Antihistamines and topical cortisone may be helpful
Lice or Pediculosis
 Two types affect humans:
– Pediculus humanus
Capitis- found on the head
Corporis- lives in bed and clothing, bites then leaves
– Phthirus pubis- transmitted by intimate contact
Often associated with other STD‘s
 Sensitization to the louse saliva and antigens result in clinical manifestation (itching)
Lice or Pediculosis
 Tx: Nix (permethrin 1%) cream for head lice or crabs, RID lotion (pyrethrum) for
body lice
– leave on for 10 minutes then rinse, repeat in 7 days
– All sexual partners/bedmates/household member need to be treated at the same
time
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Case study
 46 year old healthy female presents with itching for 3 wks. It comes and goes and as
she scratches the skin gets rashy and red. No new lotions/soaps/creams/medications.
Seems to be worse if she gets in the sun and even sitting leaves makes her itch where
her body hits the furniture.
 What am I?
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Urticaria (Hives)
 Variable pruritic, common, distinctive reaction pattern.
 May be transient, edematous, sometimes reddish plaques that vary in size and shape
 Usually lasts less than 24 hrs.
 Classified as acute (<6 wks duration) or chronic ( >6 wks duration)
Urticaria (Hives)
 May occur at any age
 More common in atopic individuals
 Pruritic, but the itching is milder the deeper the hive (angioedema)
Urticaria (Hives)
 Skin findings
– Erythematous or white non-pitting, edematous plaques, seem to evolve and resolve
 Treatment:
– Suspected triggers should be stopped
– Antihistamines
– Prednisone
– Epinephrine
– Cool soothing baths
Causes of Dry Skin
 Disruption in keratinization
 Impairment of water binding
 Environmental
 Systemic disorders- eg. dehydration or hypothyroidism
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Skin Protectants
 A group of products that serve as a physical barrier between the skin and outside
irritants
– Examples: (white) petrolatum, zinc oxide, dimethicone
 Prevention AND cure
Product Selection/Derm Vehicles
 Creams and lotions restore water and lipids to the epidermis
 Lotions
 Creams
 Ointments
Treatment for Dry Skin
 Hydration
– Drink water
– Take a bath/shower
– Use mild soap
– Apply thick lotion/creams immediately after stepping out of the shower
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– Apply thick lotion/creams immediately after stepping out of the shower
Treatment for Dry Skin Cont…
 Prevent water loss
– Bath oil / colloidal oatmeal
– Moisturizing lotion/cream/ointment
Emollients—petrolatum, mineral oil—prevent water loss
Humectants—glycerin, propylene glycol, phospholipids—hydrating agents
Softener—urea, lactic acid, allantoin—chemically soften keratin layer to help
absorption of water
Treatment of Dry Skin and Atopic Dermatitis
 General principle: if it‘s dry, wet it; if it‘s wet, dry it.
 Hydration!--Same as dry skin.
 Pat dry good/Rub dry bad.
 Rub in lotion while skin is still wet.
 Avoid triggers.
What is the terminology?
 Eczema: an acute or chronic cutaneous inflammation with erythema, papules,
vesicles, pustules, scales, crusts or scabs alone or in combination. May be dry or wet
 Dermatitis: inflammation of skin evident by itching, redness and various skin lesions
– Atopic: may be allergic, hereditary or psychological in a pt. with irritable skin
– Contact: inflammation and irritation of the skin due to contact with an irritating
substance
 Dermatitis is eczema/eczema is dermatitis
Atopic Dermatitis
Signs and Symptoms
 redness and chapping
 pruritic papules and vesicles
 scabbing
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Atopic dermatitis
Complications
 infection
– viral
– bacterial
– refer if pt. presents with pustules, pus filled vesicles, crusting, or signs of herpes
simplex
Atopic Dermatitis
 When to refer…
– < 2years old.
– Severe condition or large area involved.
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– Didn‘t get better after 2~3 days.
Contact Dermatitis
A skin condition characterized by:
 Inflammation
 Redness
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 Redness
 Itching/Burning/Stinging
 Vesicle/pustule formation
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Two types of Contact Dermatitis
 Irritant Contact Dermatitis (ICD)
 Allergic Contact Dermatitis (ACD)
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Irritant Contact Dermatitis (ICD)
 Caused by exposure to irritant
 Onset: Gradual over time
 Appearance: Redness/burning with other symptoms following
 Two different mechanisms of action:
– Direct dermal cell damage
– Immune response
 Removed from the irritant  crusting/resolution of dermatitis
Treatment of contact dermatitis
 Dermatitis will resolve itself!
 Goals of therapy:
– Reduce/Relieve Symptoms
– Prevent Secondary Infection
– Protect Area and Prevent Debris Accumulation
 First identify/avoid the irritant
 Wash the area with soap and water
Continued Exposure to Irritant
Treatment (continued)
 Care for lesions
– Wet compress
– Zinc Oxide
 Stop the Scratching
– Cut nails, wear gloves
– Steroidal cream
– Oral antihistamines
– Oral corticosteroids
Eczema
 Lab:
– Patch testing should be considered if occupational, recurrent or distribution
suggests it!
 Eruptions can be avoided, usually improve over 7-10 days, with clearing in 3 wks
 Excoriation predisposes to infection
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Who To Refer:
 Children under 2 years
 No improvement or worse in 2 or 3 days
 More than 25% of body affected
 Sensitive areas affected
 Large bullae
Non-Pharmacologic Therapy:
Weeping Lesions:
Apply cool compress for 20-30 minutes 4-6x/day
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Apply cool compress for 20-30 minutes 4-6x/day
An astringent can dry the area and remove crusts
- Burrow's solution
- Witch Hazel
Non-Pharmacologic Therapy:
 Sodium Bicarbonate
 Hygiene
– Cold or tepid showers using mild soap for ACD
– Shave and trim fingernails
 Colloidal Oatmeal Baths
 Rehydrate skin after astringent use
Topical corticosteroids
 Potency in groups I to VII
– Cause vasoconstriction of small blood vessels in upper dermis
– Group I is the strongest, VII the weakest
 How do you choose the appropriate strength?
– Go low and slow!
– If patient does not respond in 1-4 wks, reevaluate!
Topical corticosteroids
 The stronger (clobetasol) are used for psoriasis, the weaker (hydrocortisone) for mild
dermatitis or insect bites.
 Lotrisone contains both antifungal clotrimazole and corticosteroid betamethasone--DO
NOT USE THIS MEDICATION!
Do Not Use:
 ―Caine‖ Anesthetics (e.g. Benzocaine)
 Topical Antihistamines
 Neomycin-containing topical antibiotics
 Lotrisone
Warts
 Caused by human papillomaviruses (HPVs)--at least 80 HPVs identified
 Three necessary factors in wart development:
1. HPV must be present
2. Break in the skin for viral entry
3. Immune system must be susceptible to the virus
 Usually not permanent--can spontaneously clear without treatment in 6 months to 5
years
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Why treat warts?
 Relief of pain associated with the wart
 Aesthetics
 Prevent transmission to others
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OTC treatment
 Salicylic acid
– In colloidion vehicle 5%-17%
Apply drop by drop to cover wart, up to 2 times daily
– Plaster/pads 12%-40%
Cut plaster to wart size or choose appropriately-sized pad, apply and cover with
occlusive tape, every 48 hours
– Karaya gum-glycol vehicle 15%
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– Karaya gum-glycol vehicle 15%
Apply plaster at bedtime, remove in am, every 24 hours
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Duct Tape for warts?
 Study published in archives of pediatric and adolescent medicine found duct tape
occlusion therapy more effective than cryotherapy in the treatment of common warts.
 Cut duct tape to size of wart, apply for 6 days, then remove. Soak in water, then
gently debride with emery board or pumice stone. Reapply tape the following
morning.
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Focht III DR, Spicer C, Fairchok M. The efficacy of duct tape vs cryotherapy in the
treatment of verruca vulgaris (the common wart). Arch Pediatr Adolesc med.
2002;156:971-974.
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Case study
 34 year old male with erythema around the ears, nose and eyebrows, itchy at times,
can be very dry and scaly as well. Seemed to start in the scalp but doesn‘t get better.
Has used tea tree, Tgel and Head and Shoulders shampoos but it doesn‘t get better.
His dad has the same problem.
 What am I?
Dandruff
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 Excess scalp scaling
 Epidermal cell turnover rate 2X normal
 Causes: unknown, associated with Pityrosporum ovale
Seborrheic Dermatitis
Seborrheic Dermatitis
 In infants (cradle cap), middle-age, and elderly.
 Cause: unknown, genetic predisposition, environmental factors.
 Easy to confuse with tinea capitis or tinea cruris.
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How to reach me?
 [email protected]
 Rockwood Dermatology
Dr. C. Dan Henderson, Theresa Vance, PA-C and Jeanne Ellern, PA-C
610 S Sherman, Suite 208
Spokane, WA 99202
– 509-342-3946 or 838-2531
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QUESTIONS?
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