Download available now - Grand Strand Advanced Practice Nurse Association

Grand Strand Advanced Practice Nurse Association
September 19, 2015
M. Holly B. Glover, M.D.
Grand Strand Dermatology
Myrtle Beach, SC
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I have no financial disclosures nor any conflicts
of interest.
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Introduction to skin anatomy
Introduction to dermatology terminology
Common skin rashes
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Recognition and treatment
Additional pediatric dermatology
Common skin lesions
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Recognition and treatment
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Epidermis: Major
physical barrier
of the skin
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Made up of 4
distinct cell
layers, each with
different cell
structure and
function
1
2
3
4
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Epidermis: Made
up of several
different cell
types
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Keratinocyte:
major cell that
keratinizes to
form hard, outer
layer
Melanocyte:
pigmentproducing cell
Langerhans cell:
immune cell of
skin
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Dermis: tough,
support structure
Hypodermis or
subcutaneous fat:
insulates the body
and cushions deep
tissues
Both contain nerves,
blood vessels, hair
follicles and sweat
glands
Recognition
Diagnosis
Treatment
When to Refer
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Numerous different types:
Atopic dermatitis
 Dyshidrotic eczema
 Xerotic eczema
 Nummular eczema
 Allergic contact dermatitis
 Irritant contact dermatitis
 Stasis dermatitis
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Macrolide immunosuppresants (nonsteroidal
topicals that don’t have the side effects of topical
steroids)
Tacrolimus (Protopic)
 Pimecrolimus (Elidel)

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For itchiness, antihistamines can be recommended
or prescribed
OTC Diphenhydramine (Benadryl) 25-50 mg QID PRN
 Rx Hydroxyzine 10-25 mg QID PRN
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Stasis dermatitis: leg elevation and compression
stockings
Mild soaps and moisturizers
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Incidence rising:
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Around 2% of population
More common in Caucasians
Onset at the average age of 35 but may be any age
Disease usually starts gradually but may have an
explosive onset as in the guttate variety (often
preceded by streptococcal throat infection)
Aggravating factors include trauma, stress,
infections (HIV, strep), obesity, medications,
positive family history
Associations:
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Nail involvement
Psoriatic arthritis
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Topical steroids (medium and high strength)
Triamcinolone 0.1% cream or ointment
 Clobetasol 0.05% cream or ointment
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Topical tars
OTC or compounded Cutar cream
 OTC Tarsum shampoo
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Topical vitamin D derivatives
Calcipotriene cream or ointment
 Calcitriol
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Topical vitamin A derivative
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Tazarotene (Tazorac)
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Phototherapy
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Systemic immunosuppresants
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NBUVB (Narrow band ultraviolet B)
PUVA (Psoralen combined with ultraviolet A)
Methotrexate
Acitretin (Soriatane)
Cyclosporine
Biologics
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Etanercept (Enbrel)
Adalimumab (Humira)
Infliximab (Remicade)
Ustekinumab (Stelara)
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Psoriasis is a chronic condition with
intermittent flares
Above therapies can control disease but not
cure it
A few plaques involving little body surface
area can be controlled with topical medications
However, if more than 5-10% body surface area
is involved, a systemic medication may be
warranted along with a referral to a specialist
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Tinea corporis
Tinea pedis
Tinea manuum
Tinea cruris
Tinea faciale
Tinea barbae
Tinea capitis
Tinea unguium or onychomychosis
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Fungal infections of the skin are caused by
organisms collectively referred to as
dermatophytes
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Feed on the keratin in our epidermis. Prefer warm,
moist environments
“Ringworm” is used by the general population
but is a misnomer
Diagnosis: KOH (potassium hydroxide)
preparation
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Topical antifungals (for limited disease)
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Systemic antifungals (for tinea capitis, tinea
unguium, or extensive involvement)
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OTC clotrimazole 1% cream (Lotrimin)
OTC miconazole 2% cream (Micatin)
OTC miconazole powder (Zeasorb AF)
OTC terbinafine 1% cream (Lamisil)
Rx ketoconazole 2% cream
Griseofulvin (most effective in children with tinea capitis)
Terbinafine 250 mg Qdaily for adults
Ketoconazole
Fluconazole
Itraconazole
Topical efinaconazole 10% solution (Jublia) and
tavaborole 5% solution (Kerydin) now available for
tinea unguium
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Anti-yeast/anti-dandruff shampoos used as a
face/body wash. Leave on for 5 minutes then wash
off. Use daily for a week, then weekly until
resolution, then monthly to prevent recurrence
Zinc pyrinthione 1% (Head and Shoulders)
 Selenium sulfide 1% (Selsun Blue) or 2.5% (Rx only)
 Ketoconazole 1% (Nizoral) or 2% (Rx only)
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If only a few spots, OTC miconazole cream or Rx
ketoconazole cream
Oral: fluconazole (Diflucan) one 200 mg tablet
repeated two weeks apart
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Common:
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Found in around 5% of the healthy population
Treatment:
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Anti-yeast/anti-dandruff shampoos a few times a week,
can use as face or body wash. Leave on for 5 minutes then
wash off
 Zinc pyrinthione 1% (Head and Shoulders)
 Selenium sulfide 1% (Selsun Blue) or 2.5% (Rx only)
 Ketoconazole 1% (Nizoral) or 2% (Rx only)
Ketoconazole 2% cream BID PRN for face
 Hydrocortisone cream 1% or 2.5% BID PRN for face
 Clobetasol solution 0.05% BID PRN for severe
inflammation of scalp
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Grouped vesicles that recur in the same
location
May be preceded by a prodrome of symptoms
including itching, burning, tingling, painful
sensations
Treatment is suppressive, not curative
HSV1 usually causes herpes labialis (cold
sores), and HSV2 usually causes genital herpes
Primary infection ranges from going unnoticed
to being severe with fever, myalgias,
lymphadenopathy, necrotic ulcers, etc.
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Valacyclovir:
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Acyclovir:
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125 mg BID for 5 days
Acyclovir 5% ointment:
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400 mg TID for 5 days
Famciclovir:
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2000 mg BID for 1 day for herpes labialis,
500 mg BID for 3 days for genital herpes
6 times daily for 7 days
Chronic suppressive:
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Valacyclovir 500-1000 mg Qdaily
Acyclovir 400 mg BID
Famcicloir 250 mg BID
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Caused by a reactivation of the latent varicellazoster virus (in the herpes family) in patients
who have had varicella (chicken pox)
May have a prodrome of itching, pain,
headache, myalgias
After the several week disease course,
postherpetic neuralgia may present, which is
characterized by months of skin pain and
burning
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Antivirals
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Valacyclovir 1000 mg TID for 7 days
Acyclovir 800 mg 5 times a day for 7 days
Famciclovir 500 mg TID for 7 days
Pain/nerve medication
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Gabapentin 300 mg BID or TID
Pregabalin 100 mg BID or TID
Amitriptyline 25-100 mg QHS
Analgesics and NSAIDs
OTC capsaicin cream BID or TID
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Antibacterial soaps daily
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Hospital strength antiseptic cleansers 1-2 times per week
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OTC Hibaclens (chlorohexadine)
Bleach baths or bleach spritzers 1-2 times per week
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OTC Dial
OTC Lever 2000
½ cup of bleach in a tub of bath water
1 tablespoon of bleach in spray bottle
Topical antibiotics
Mupirocin 2% ointment (can be used on affected areas and in staph
colonized areas: nose, axilla, umbilicus, groin. Use BID for 5 days
and repeat monthly)
 Clindamycin 1% lotion, solution, or gel
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Oral antibiotics
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Doxycycline 100 mg BID (may require several month course)
Clindamycin 300 mg QID
Bactrim DS BID
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Discontinue suspected drugs
Avoid aspirin and NSAIDs
Antihistamines
OTC diphenhydramine 25 mg QID
 Rx hydroxyzine 10-25 mg QID
 OTC cetirizine (Zyrtec) 10 mg BID
 OTC fexofenadine (Allegra) 180 mg BID
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Tricyclic drugs
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Doxepin 25-75 mg QHS
Immunosuppresants
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Prednisone 0.5 mg/kg daily
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Scabies
Acne vulgaris
Rosacea
Lichen planus
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Hemangioma
Verruca vulgaris
Molluscum contagiosum
Impetigo
Viral exanthems
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Benign proliferation of blood vessels in the dermis
and subcutis
Occur in about 10% of infants, more frequently in
females, premature, and Caucasian infants
Arise in the first few weeks of infancy as a red
macule or patch then rapidly enlarge
Most are asymptomatic and require no treatment,
unless they are large, ulcerate, or cause local
obstruction
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If treatment required, topical or systemic beta blockers
are the mainstay of treatment. Other treatments include
systemic steroids, interferon, laser surgery, or excision
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Most of superficial and have a bright red color,
whereas deeper and mixed varieties may be
skin colored or have a blue or purple hue
Hemangiomas increase in size over the first
year of life then subside spontaneously.
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10% resolve by age 1
50% by age 5
100% by age 10
May resolve with scarring, atrophy, and
telangiectasias
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Wart = verruca vulgaris
Common in healthy children and some adults
Caused by multiple types of human papilloma virus (HPV)
Genital warts = condyloma acuminatum
Treatment:
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Cryosurgery with liquid nitrogen
Acids:
 OTC salicylic
 Trichloroacetic (TCA) in office
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Cantharidin in office
Podophyllin in office
Rx imiquimod 5% cream
Surgical excision
Laser surgery
Candida intralesionally in office
5-fluorouracil intralesionally in office
Bleomycin intralesionally in office
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Becoming more and more common in healthy
children
Caused by a poxvirus
Spontaneous remission usually occurs in 6-18
months
Treatment:
Cryotherapy with liquid nitrogen
 OTC salicyclic acid
 Cantharidin in office
 Curettage
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Superficial skin infection caused by grampositive bacteria, usually Staphylococcus aureus
(including MRSA) or Streptococcus pyogenes
Most common bacterial infection in children,
and tends to affect skin that has been disrupted
with cuts, abrasions, insect bites, etc.
Can occur anywhere but is found most
frequently on the face
Highly contagious and more common in warm,
moist environments
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Even without treatment, impetigo will resolve
within 2-3 weeks. However, treatment is
recommended to prevent the spread of
infection and to speed up recovery
Mupirocin (Bactroban) ointment TID for a
week for isolated lesions
Cephalexin is the treatment of choice in
children with complicated or extensive cases
Erythromycin in penicillin allergic patients
If MRSA suspected, clindamycin and
doxycycline are options (>8 years old)
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Major viruses producing exanthems:
Measles (rubeola)
 German measles (rubella)
 Herpes virus type 6 (roseola)
 Parvovirus B19 (erythema infectiosum)
 Enteroviruses (ECHO and coxsackievirus)
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Most viral exanthems are preceded by a
prodrome of fever and constitutional
symptoms
Recognition
Diagnosis
Treatment
When to Refer
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Extremely common in adults
First begin to appear around the age 30
Everyone will develop this type of lesion;
genetics determine how many we get
Treatment:
None
 Cryosurgery with liquid nitrogen if symptomatic
 Curettage
 Shave biopsy to confirm diagnosis
 Shave removal
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AKA “precancers”
Fair skin, aging skin, and abundant sun
exposure can lead to development of AK’s
Variable course:
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Spontaneous resolution
Remaining unchanged
Intermittent in presentation
Development into squamous cell carcinoma (about
15-20% of the time)
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Sunscreen, broad-brimmed hat, sun protective
clothing, sun avoidance (especially midday sun
from 10:00 AM-4:00 PM)
Cryosurgery with liquid nitrogen
Imiquimod 5% (Aldara) cream
5-Flurouracil 5% (Efudex) cream
Diclofenac 3% (Solaraze) gel
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Malignancy of keratinocytes in the epidermis
Caused by carcinogens: ultraviolent light, Xirradiation, coal tar, arsenic, viruses (HPV)
Second most common skin cancer
Potential to metastasize, especially in
immunosuppressed individuals or transplant
patients
Most common on the head and neck, but can occur
anywhere
Diagnosis: skin biopsy
Chronic ulcers should undergo biopsy to exclude
malignancy
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Excision with 0.5 cm margins
Curettage and electrodessication
Mohs micrographic surgery
Radiation
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Malignancy of the basal keratinocytes of the
epidermis
Caused by ultraviolet radiation; more common in
fair skinned individuals
Most common skin cancer
Very rarely metastasizes. Locally grows
Several different types with different appearances
Most common on the head and neck followed by
the trunk then the extremities
Diagnosis: skin biopsy
Nonhealing scars should undergo biopsy to
exclude carcinoma
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Excision with 0.5 cm margins
Curettage and electrodessication
Mohs’ micrographic surgery
Radiation
Cryosurgery
5-Flurouracil or imiquimod cream for
superficial basal cell carcinomas
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Malignancy of the pigment-forming cells or
melanocytes within the epidermis
Exact cause is unknown but sunlight, heredity, and
a large number of moles are risk factors
Incidence of melanoma is increasing faster than
any other cancer in the USA
Melanomas tend to metastasize to lymph nodes,
lungs, and brain
Several different types depending on location,
growth pattern, metastatic potential, but overall,
most common location is back for men and lower
legs for women
Diagnosis: excisional biopsy
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Thin melanoma is curable with wide excision
Margin recommendations:
0.5 cm for melanoma-in-situ
 1 cm for tumors <2 mm in thickness
 2 cm for tumors >2 mm in thickness
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Prognosis is best predicted by depth of invasion
into the skin
If invades >1 mm, sentinal lymph node biopsy is
recommended
If have a deep tumor, positive lymph nodes, or
metastasis is noted on PET scan, chemotherapy,
immunotherapy, and radiation can be discussed
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Bolognia JL, Jorizzo JL, Schaffer JV. Dermatology.
3rd edition. Saunders Elsevier, PA; 2012.
James WD, Berger TG, Elston DM. Andrews’
Diseases of the Skin: Clinical Dermatology. 11th
edition. Saunders Elsevier, PA; 2011.
Lebwohl MG, Heymann WR, Berth-Jones J.
Treatment of Skin Disease: Comprehensive Therapeutic
Strategies. 4th edition. Saunders Elsevier, PA; 2014.
Marks JG, Miller JJ. Lookingbill and Marks’ Principles
of Dermatology. 4th edition. Saunders Elsevier, PA;
2006.