Common Dermatologic Conditions in Women Toby Maurer, MD University of California, San Francisco No Disclosures Acne • Papulopustular – Topicals okay • Cystic, scarring, keloidal – p.o. antibiotics – Accutane
Topicals • BP 5% gel (10% ‐ more drying) • Retin A 0.025% ‐ 0.1% ( vehicle determines strength ‐ start with crème) • Cleocin T or erythromycin topically – Use 1 qam and 1qhs – If NO success after 8 weeks, go to p.o.’s P.O. Antibiotics • TCN ‐ 500 bid x 8 weeks • Doxycycline ‐ 100 bid x 8 weeks • Minocycline ‐ 100 bid x 8 weeks • Taper ‐ Do NOT STOP ABRUPTLY
Alternatives • Erythromycin ‐ 500 bid • Septra ‐ check WBC’s • Keflex ‐ 500 tid Spiranolactone • Diuretic used in cirrhosis of liver • Also an anti ‐ androgen • Useful in females who have cysts around menstruation • 50 ‐ 100 mg qday • Increased urination, don’t use during pregnancy, ?electrolyte imbalance
Post ‐ inflammatory • Hyperpigmentation in the dermis – Time – Hydroquinone does not help Melasma • Hyperpigmentation of cheeks, chin, forehead • Seen in pregnancy and in hormone replacement • Also seen in females and males without hormone treatment • Treatment ‐ Hydroquinone 4%, (Solaquin forte) sunscreen, Trilumma (retinoid, hydroquinone and steroid)
Accutane • Document failure of antibiotics • Baseline CBC, LFT’s TG and cholestrol • Counseling regarding birth control or BCP’s • Perimenopausal women ‐ pregnancy risk • Counseling on depression Acne Rosacea • Common in women over 40 • Often seen in persons of Irish decent • Associated with seborrheic dermatitis • Characterized by papules, erythema, telangiectasia • Sun exposure, alcohol and spicy foods exacerbate rosacea
Acne Rosacea • Oral antibiotics for 6 ‐ 8 weeks clears skin for some amount of time • Add topical flagyl for maintainance • Topicals alone work slowly and less frequently Perioral Dermatitis • Characterized by small papules and pustules • In 30 ‐ 40 year olds, centered around mouth and eyes (perioral/orbital dermatitis) • These patients may never have had history of acne as teens
Seborrheic Dermatitis • Scale ‐ hairline, eyebrows, nasolabial area • Heat and stress exacerbate it • Seen with rosacea in some patients Treatment • Keep scale off scale – Tar shampoo – Selenium sulfide – Nizoral 2% shampoo • HC 1% ointment & Nizoral creme BID • Chronic, no cure • Use when needed
Psoriasis ‐ What is it? • Fast growing skin ‐ takes 3 days to come to surface and desquamate • Normal rate is 28 days • Psoriatic skin has a fast mitotic rate • Triggers an inflammatory response in and around affected skin • New onset often preceded by strep infection (strep pharyngitis) especially in the younger age group. • In older age group, drugs often unmask psoriasis • Drugs: beta ‐ blockers, lithium, NSAIDS, antimalarials, terbinafine, gemfibrozil ‐ pts on these meds for 3 ‐ 6 months before onset of psoriasis
Psoriasis ‐ Tx: • Decrease the MITOTIC • Decrease the INFLAMMATORY Reaction RATE of skin of the skin – Tar (LCD 5% in TAC 0.1% oint) ( Tar emulsions) – topical retinoids (Tazarac) – Steroid Ointment (mid ‐ potency ‐ 1 st line) – Calcipotriene (Dovonex Creme) ‐ not on face or groin – Clobetasol/Dovonex combination – Ultraviolet light NO PREDNISONE
Urticaria • Acute < 6 weeks • Chronic > 6 weeks – 85% of chronic cases, no etiology • Check CBC, LFT’s, PPD, hepatitis A, B and C, tinea and candida • Treatment ‐ treat underlying condition, antihistamines (sedating and non ‐ sedating) • NO PREDNISONE Intertrigo • Pendulous breasts or pannus • Always component of candida • Blow dry area • Apply topical antifungals • Tucks pads
Too Much Hair • Vaniqa – topical cream that breaks the chemical bond of hair – apply 2x’s/day forever – 30% effective – $30/month Hair Removal – pigment of hair absorbs the light and gets destroyed – dark hair responds – hair is always in different growth phases, so treatment has to be repeated several times to catch the phase(expensive) – pigment changes of surrounding skin and scarring – fast and minimal scarring
Hair Loss • If not scarring and diffuse: • Check recent surgeries/illness, nutrition,anemia, TSH, estrogen replacement, medication history, VDRL. • If hirsute with scalp hair loss ‐ DHEAS and free testosterone • If lactating ‐ check prolactin If all negative • Androgenetic Alopecia ‐ Minoxidil 5% bid topically (even in women) Can make hair oily ‐ may want to start with minoxidil 2% or use 2% by day and 5% at night Minoxidil foam –once at night Use for at least 6 months for results and what you see after 1 yr. is the effect you can expect. What about finasteride (propecia)? ‐ Does not work in women.
Cellulitis • Goal in study was to have dermatologists diagnose cellulitis vs other diseases • 635 pts seen ‐ 67% had cellulitis N=425 • 33% had other ‐ eczema, lymphedema, lipodermatosclerosis • Of the 425 with cellulitis, 30% had predisposing dermatologic disease • Hospitalization was averted for 96% of those with cellulitis (p.o antiotics) Levell et al Br J of Dermatol (BJD) 2011 Feb Take Home Points: • Does the patient really have cellulitis? • Is there an underlying dermatologic cause that contributes to condition ‐ if treated could prevent repeated episodes? • Does this patient require hospitalization?
Recurrent Cellulitis • In study of 274 pts who had at least 2 episodes of cellulits in 3 yrs: • Prophylactic penicillin 250 bid decreased rates of recurrence in treatment gp vs placebo group ( tx=22% vs 37% in placebo gp) • BUT off meds and followed ‐ recurrence rate was the same in both groups. • NEJM Thomas etal. May 2013 Venous Insufficiency Ulcer • Control Edema – Elevation of leg above heart 2 hours twice daily – Walk, don’t sit – Compression • Diuretics overused and not of benefit unless fluid retention due to central problem is present (CHF, CRF) • Create healing wound environment
Venous Insufficiency Ulcer • Compression dressing – Unna boot covered by Coban – this requires a good nursing staff with training and experience – This both provides graded compression AND creates the correct wound environment • Semipermeable dressing (Hydrosorb, Duoderm, etc) • Change dressing weekly • Refer to dermatology if not healing When is a Leg Ulcer Infected? • All leg ulcers are colonized with bacteria. Surface culture of little value • Suspect infection if: – Increasing pain – Surrounding erythema, cellulitis – Focal area not healing and undermining present
Hidraadenitis supparativa • Hidradentitis ‐ go back to strong antiinflammatories like rifampin and clindamycin ‐ 12 week course • Moxifloxicin, metranidazole, rifampin ‐ Lambert et al. Dermatology 2011 • Acitretin may have some activity ‐ drug is classically used for psoriasis (original use for TNF blockers Boer et al Br J Dermatol 2011 Jan
Chronic wounds • If not healing and developing thickened or ulcerated skin ‐ biopsy for cancer • Can it be used in pts with previous zoster ‐ yes • How about use in younger age groups? • Needs to be give within ½ hour of reconstitution • $150.00 for injection • Cost ‐ effectiveness of vaccination against herpes zoster and postherpetic neuralgia: a critical review ‐ Kawai K et al, Vaccine March 2014
‐ uptake in most communities is only around 30% ‐ recommended now before giving patients immunosuppressive drugs like MTX or TNF blockers JAMA 2011 • Sunscreens ‐ Australian study randomized residents to daily use vs discretionary us between 1992 and 1996 • Risk for developing any melanoma reduced by 50% and invasive melanoma risk reduced by 73% • Same trial also showed reduction of risk of developing squamous cell cancer Green et al. J Clin Oncol 2011 Jan 20; 29:257
Tanning Beds • International Agency for Research on Cancer • Comprehensive metaanlaysis found that risk of melanoma (skin and eye) increases by 75% when tanning begins before age 30. • Cite this to your young patients El Ghissassi et al. Lancet Oncol 2009 Aug 10:751 The Telederm Experiment • California Health Care Foundation ‐ can we make it happen in San Francisco area • Primary care provider has any derm question or wants to refer to derm • ALL referrals go through telederm ‐ even if it is a pt followed by derm in past
• Obtains verbal consent from pt • Provider or assistant takes picture and uploads picture • Question can be typed in on web based template at the time of pt visit or later that day, etc • Derm group answers question and primary will get notification that derm report is ready • Provider will get first pass advice ‐ what is it, how to treat, when he/she should see pt back or when to refer OR • Provider will be alerted that pt needs derm appointment and pt will be LINKED into CARE within an appropriate time to be seen in LIVE CLINIC (manned by our dermatologists). • Derm report is part of the electronic medical record
• Dermatologists from UCSF read the triage consults and they also staff the live clinics at the primary care providers site Results to date • We have completed around 4000 consults • 75% of consults have been successfully treated by primary provider with derm guidance ‐ the GPS system • 25% seen in live derm clinic • Wait time at San Mateo was 9 months to see DERM. Now we get consults back in 2 days and live clinics booked within 1 month
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