Acne Papulopustular Topicals okay Cystic, scarring, keloidal p.o. - - PDF document

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

RATE of skin

– Tar (LCD 5% in TAC 0.1% oint) ( Tar emulsions) – topical retinoids (Tazarac)

• Decrease the

INFLAMMATORY Reaction

• f the skin

– Steroid Ointment (mid‐ potency‐1st 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
• f 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
• f 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
• r 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

• Primary providers have learned from one on
• ne consults
• Primary providers have had to DO some

dermatology

• Live dermatology clinic –difficult cases but

time has been properly apportioned to see them

• Suspect Hypertrophic lichen planus
• Start pt on clobetasol oint bid
• Order CBC, LFT’s and G6PD
• Look in mouth and genitals‐if lesions‐set up

with GI for endoscopy

• Our scheduler will call pt to come in next 3

wks

PCP’s reply

• Labs obtained, linkage of care to specialists

within 1 month ( bonus for hospital), meds started, I learned what this is, what labs to get and that in some circumstances assoc with cancer‐can I get CME?