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Grand Strand Advanced Practice Nurse Association September 19, 2015 M. Holly B. Glover, M.D. Grand Strand Dermatology Myrtle Beach, SC I have no financial disclosures nor any conflicts of interest. Introduction to skin anatomy Introduction to dermatology terminology Common skin rashes Recognition and treatment Additional pediatric dermatology Common skin lesions Recognition and treatment Epidermis: Major physical barrier of the skin Made up of 4 distinct cell layers, each with different cell structure and function 1 2 3 4 Epidermis: Made up of several different cell types Keratinocyte: major cell that keratinizes to form hard, outer layer Melanocyte: pigmentproducing cell Langerhans cell: immune cell of skin 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 Numerous different types: Atopic dermatitis Dyshidrotic eczema Xerotic eczema Nummular eczema Allergic contact dermatitis Irritant contact dermatitis Stasis dermatitis Macrolide immunosuppresants (nonsteroidal topicals that don’t have the side effects of topical steroids) Tacrolimus (Protopic) Pimecrolimus (Elidel) For itchiness, antihistamines can be recommended or prescribed OTC Diphenhydramine (Benadryl) 25-50 mg QID PRN Rx Hydroxyzine 10-25 mg QID PRN Stasis dermatitis: leg elevation and compression stockings Mild soaps and moisturizers Incidence rising: 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: Nail involvement Psoriatic arthritis Topical steroids (medium and high strength) Triamcinolone 0.1% cream or ointment Clobetasol 0.05% cream or ointment Topical tars OTC or compounded Cutar cream OTC Tarsum shampoo Topical vitamin D derivatives Calcipotriene cream or ointment Calcitriol Topical vitamin A derivative Tazarotene (Tazorac) Phototherapy Systemic immunosuppresants NBUVB (Narrow band ultraviolet B) PUVA (Psoralen combined with ultraviolet A) Methotrexate Acitretin (Soriatane) Cyclosporine Biologics Etanercept (Enbrel) Adalimumab (Humira) Infliximab (Remicade) Ustekinumab (Stelara) 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 Tinea corporis Tinea pedis Tinea manuum Tinea cruris Tinea faciale Tinea barbae Tinea capitis Tinea unguium or onychomychosis Fungal infections of the skin are caused by organisms collectively referred to as dermatophytes 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 Topical antifungals (for limited disease) Systemic antifungals (for tinea capitis, tinea unguium, or extensive involvement) 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 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) If only a few spots, OTC miconazole cream or Rx ketoconazole cream Oral: fluconazole (Diflucan) one 200 mg tablet repeated two weeks apart Common: Found in around 5% of the healthy population Treatment: 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 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. Valacyclovir: Acyclovir: 125 mg BID for 5 days Acyclovir 5% ointment: 400 mg TID for 5 days Famciclovir: 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: Valacyclovir 500-1000 mg Qdaily Acyclovir 400 mg BID Famcicloir 250 mg BID 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 Antivirals 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 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 Antibacterial soaps daily Hospital strength antiseptic cleansers 1-2 times per week OTC Hibaclens (chlorohexadine) Bleach baths or bleach spritzers 1-2 times per week 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 Oral antibiotics Doxycycline 100 mg BID (may require several month course) Clindamycin 300 mg QID Bactrim DS BID 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 Tricyclic drugs Doxepin 25-75 mg QHS Immunosuppresants Prednisone 0.5 mg/kg daily Scabies Acne vulgaris Rosacea Lichen planus Hemangioma Verruca vulgaris Molluscum contagiosum Impetigo Viral exanthems 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 If treatment required, topical or systemic beta blockers are the mainstay of treatment. Other treatments include systemic steroids, interferon, laser surgery, or excision 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. 10% resolve by age 1 50% by age 5 100% by age 10 May resolve with scarring, atrophy, and telangiectasias Wart = verruca vulgaris Common in healthy children and some adults Caused by multiple types of human papilloma virus (HPV) Genital warts = condyloma acuminatum Treatment: Cryosurgery with liquid nitrogen Acids: OTC salicylic Trichloroacetic (TCA) in office 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 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 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 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) Major viruses producing exanthems: Measles (rubeola) German measles (rubella) Herpes virus type 6 (roseola) Parvovirus B19 (erythema infectiosum) Enteroviruses (ECHO and coxsackievirus) Most viral exanthems are preceded by a prodrome of fever and constitutional symptoms Recognition Diagnosis Treatment When to Refer 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 AKA “precancers” Fair skin, aging skin, and abundant sun exposure can lead to development of AK’s Variable course: Spontaneous resolution Remaining unchanged Intermittent in presentation Development into squamous cell carcinoma (about 15-20% of the time) 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 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 Excision with 0.5 cm margins Curettage and electrodessication Mohs micrographic surgery Radiation 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 Excision with 0.5 cm margins Curettage and electrodessication Mohs’ micrographic surgery Radiation Cryosurgery 5-Flurouracil or imiquimod cream for superficial basal cell carcinomas 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 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 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 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.