Download DERMATOLOGY: HEAD TO TOE - Healthcare Professionals

Dermatology Update
Katie Fiala, MD
Department of Dermatology
Scott and White Memorial Hospital
TOPICS
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Varicella Zoster
Psoriasis
Acne
Lipodermatosclerosis
Hemangiomas
Melanoma
Miscellaneous Updates
Varicella Zoster
(Shingles)
Reactivation of chickenpox virus along
sensory nerve causing a painful
blistering skin eruption.
Clinical History
70 year old man
Recent Hodgkins Disease dx
Painful eruption on face
Pain is excruciating
Blisters
erosions
Varicella zoster
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20% of healthy adults
50% adults > 85
Induced by stress, fever, XRT, trauma,
immunosuppression
Blacks 75% less likely
Transmission via vesicular fluid
4% recurrence rate
Zoster: clinical features
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Prodrome intense
pain
Itch, tingling, or
hyperesthesia
Grouped vesicles on
erythematous base
Umbilicated,
pustular
Sensory dermatome
Childhood Zoster
Diagnosis
Confirmation
Viral Culture
swab
Viral PCR swab
Aggressively
swab base of
lesion
Management / Treatment
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Early treatment, within first 72 hours
Oral anti-virals
– Acyclovir 800mg po 5x/day x 7-10 days
– Valacyclovir 1gm po TID x 7 days
– Famciclovir 500 mg po TID x 7 days $$
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IV acyclovir - immunocompromised
and disseminated form
– Acyclovir 10mg/kg IV q 8hrs x 7-10 days
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Oral prednisone (controversial)
DISSEMINATED ZOSTER
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>20 lesions outside of affected
dermatome
Can cross midline
2 or more non-contiguous
dermatomes
May have internal involvement:
hepatitis, encephalitis, pneumonitis
Post-herpetic Neuralgia
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Post Zoster inflammation/injury to
affected nerves
More common >55 years of age
Pain may last for months/year
Rx: Narcotics, Neurotin (gabapentin),
Nerve Block, topical lidocaine, topical
gabapentin 6%
Prevention?
Zostavax
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Live attenuated vaccine
Reduced incidence by 55% in >60yo in a
real-world practice
– (JAMA 2011;305;160-6)
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Effective in pts w/ underlying chronic
conditions
Reduced in incidence by 70% 50-59
Reduced incidence of PHN by 67% in
>60yo
Okay to receive if previous shingles
Does prevent ophthalmic zoster
Contraindications
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Anaphylaxis to gelatin or neomycin
Immunocompromised: HIV, chemo,
chronic steroids, pregnancy, h/o
leukemia or lymphoma
Psoriasis
Treatment
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Topical steroids
Vitamin D analogs – calcipotriene
Phototherapy (Narrowband UVB)
Methotrexate
Cyclosporine
Soriatane
Biologics
**NOT PREDNISONE**
Psoriasis & Biologic
Agents
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Enbrel, Humira, Remicade (TNF-alpha
inhibitors)
Stelara (blocks IL-12 and IL-23)
Screening:
– TB/HIV/Hepatitis prior
– TB yearly
– CBC/CMP prior and q6mo
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Contraindications: MS, Solid tumor,
severe CHF
Paradoxical Psoriasis (palmo-plantar)
Biologics and Infections
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1 in 10 on biologics will have serious
infection/year
10-18 fold increase on biologics
Ways to help
– Be aware
– Tight control of DM
– Education
– Vaccines (live given b/f starting tx)
Psoriasis Associations
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Obesity
Hypercholesterolemia
Hypertension
Diabetes Mellitus II
Depression
Alcohol/Smoking
Psoriatic Arthritis
Psoriasis & Metabolic
Syndrome
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Chronic inflammatory skin condition
Pro-inflammatory cytokines
Diabetes mellitus type II (OR=2.48),
arterial hypertension (OR = 3.27),
hyperlipidemia (OR = 2.09), and
coronary heart disease (OR = 1.95).
Increased prevalence of the metabolic syndrome in patients
with moderate to severe psoriasis , Archives of Dermatological
Research , Volume 298, Number 7, 321-328, 2006
Psoriasis & Metabolic
Syndrome
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Metabolic syndrome more common in psoriatic
patients than controls OR 1.65, >40 yo.
Psoriatic patients - higher prevalence of
hypertriglyceridemia and abdominal obesity
Association independent from smoking.
Conclusion: Psoriatic patients have a higher prevalence of
metabolic syndrome, which can favor cardiovascular
events. We suggest psoriatic patients should be
encouraged to correct aggressively their modifiable
cardiovascular risk factors
Prevalence of metabolic syndrome in patients with psoriasis: a
hospital-based case–control study, British Journal of Dermatology,
Volume 157, Issue 1, pages 68–73, July 2007
Psoriasis and Cardiovascular
Risk
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Risk for MI 3.6 for controls, 4.0 for
mild psoriasis, 5.1 for severe psoriasis
Younger pts with severe psoriasis have
the greatest risk of MI
JAMA 2006;296:1735,41
Psoriatic Arthritis
Inverse Psoriasis
Inverse psoriasis
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+/- psoriasis elsewhere
Treatment
– Low-potency topical steroids
– Protopic (tacrolimus) 0.1% ointment or
Elidel cream
– Minimize moisture, careful drying, drying
powders (Zeosorb AF)
LIPODERMATOSCLEROSIS
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Sclerosing panniculitis
Affects lower legs
Secondary to chronic venous
insufficiency
2/3 of patients are obese
Presentation
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ACUTE
– Erythematous, painful, indurated plaques,
swelling
– Can be unilateral or bilateral
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CHRONIC
– Less erythema, significant induration,
hyperpigmentation, may ulcerate
– “inverted champagne bottle”
THERAPY
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Leg elevation
Compression stockings
Potent topical steroids, under occlusion
Aspirin
NSAIDS
Trental 400mg po TID
Weight loss
? Vascular surgery
Hemangiomas
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Natural course
– Proliferate by 9mo
– Involute by 10yo
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10% rule
Complications
– Beard area
– Eye
– Diaper area
Know when to refer
(
Diffuse Cutaneous
Hemangiomatosis
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Liver
Thyroid
High Output
Cardiac Failure
Treatment
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Especially if danger zones
Prednisone 2-3mg /kg/ day
Propanolol 2-3 mg/ kg/day
– Very successful
– Risks: Hypotension, hypoglycemia
– Pediatric Cardiologist
– (Engl J Med 2008;358;2649-51)
ACNE
Topical therapy
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Non-comedogenic/ non-acnegenic
Topical retinoid – Differin, Retina,
Retina Microgel, Tazorac
Topical antibacterial – benzoyl
peroxide, topical clindamycin,
Benzaclin or Duac (BPO+ clinda)
Azaelic Acid
Topical Dapsone (Aczone)
Oral Therapy
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Minocycline 100mg bid
Doxycycine 100mg bid
Clindamycin 150 -300mg bid
Bactrim DS bid
**Azithromycin 250-500mg TIW
Amoxicillin 500mg bid (pregnancy)
**Spironolactone 100 - 150 mg daily
Oral contraceptives (Yasmin)
Isotretinoin 1mg/kg bid x 5 -6 mo
Isotretinoin
Other issues
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Depression
Labs: LFTs, lipids
Pseudotumor cerebri: more likely with
tetracyclines
Xerosis and cheilitis
Flare
? Inflammatory Bowel Disease
Inflammatory Bowel
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Crockett SD et al. Isotretinoin use and
the risk of inflammatory bowel disease: A
case–control study. Am J Gastroenterol
2010 Mar 30
8,189 pts with IBD and 21,832 controls
3664 Crohns & 4428 UC
Isotretinoin use strongly associated with
UC (OR 4.36) but not with Crohns
Higher dosage and longer duration
increased risk
What does this mean?
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Pts must be made aware of risk
Stop if bowel symptoms develop until
cleared by GI
More studies needed
? Association with Tetracyclines
Melanoma
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Barriers to full skin exam
– Primary care: time constraints (54%)
– Dermatologists: patient embarrassment
(44%)
– Arch Dermatol 2011;147:36-44
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Continues to be on the rise
One American dies of melanoma every
hour
Melanoma
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Asymmetry
Borders
Color
Diameter >6mm
Evolution
Lentigo Maligna
SEER Age
Adjusted
Incidence Rates
by Race and Sex
Melanoma of the
Skin, All Ages
SEER 9 Registries
for 1973-2002
Malignant Melanoma
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75% of skin cancer deaths
1 American dies/ hour
25-29 yo
Areas of intense, rare sun exposure
Scalp = aggressive
Also: eyes, mouth, genitalia
Who’s at Risk
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Red/blonde hair, blue/green eyes
>50 nevi
Dysplastic nevi
First degree relative
H/o melanoma, 9x more likely
Tanning bed
Summer vacations
>5 sunburns doubles risk
Higher SES
IPILIMUMAB (Yervoy)
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FDA approved for metastatic
melanoma
Monoclonal antibody (IV)
Median overall survival 10.0 months
(both), 10.1 (ipilimumab only) and 6.4
(vaccine only)
– N Engl J Med 2010;363;711-23
Vitamin D Debate
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Acknowledge benefits
Encourage oral supplementation
Educate about sun protection
– Avoid peak hours 10am – 4pm
– Broad Spectrum (UVA/UVB) SPF 30, year
round
– SPF 30 block 97-98% UVB
– Adequate amount
– Wet white shirt only SPF 4
– Special clothing
Miscellaneous
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New, COMB-FREE head lice
treatment approved by FDA
– Natroba Topical Suspension (spinosad
0.9%)
– Approved for children over 4yo
– Important not to use <6mo b/c contains
benzoyl alcohol
Miscellaneous
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PDT for Actinic Keratoses
– Photodynamic Therapy
– Metvixia (methyl amiolevulinate cream)
applied to affected area approx 2 hours
under occlusion
– Red light for 6-8 minutes
– Reaction similar to 5-FU in 1-2 days
Miscellaneous
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BRACYTHERAPY
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Precise placement of radiation sources
Exposure to radiation of healthy tissues reduced
Tumor can be treated w/ very high doses
Applicator can conform to contour of face/skin
Cure rates comparable to EBRT
Can be completed in less time
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Less visits
Less time for cancer cells to divide
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Thank you!
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[email protected]