Outline Care Practitioner Part 1 Principles of topical therapy - - PDF document

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Outline Care Practitioner Part 1 Principles of topical therapy - - PDF document

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Dermatology Pearls for the Primary Outline Care Practitioner Part 1 Principles of topical therapy Nummular Dermatitis Lindy P. Fox, MD Alopecia Professor of Clinical Dermatology Acne in the adult Director, Hospital

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SLIDE 1

Dermatology Pearls for the Primary Care Practitioner‐ Part 1

Lindy P. Fox, MD

Professor of Clinical Dermatology Director, Hospital Consultation Service Department of Dermatology University of California, San Francisco

lindy.fox@ucsf.edu

I have no conflicts of interest to disclose I may be discussing off-label use of medications

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Outline

  • Principles of topical therapy
  • Nummular Dermatitis
  • Alopecia
  • Acne in the adult
  • Perioral dermatitis

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Principles of Dermatologic Therapy Moisturizers and Gentle Skin Care

  • Emolliate skin

– All dry skin itches

  • Gentle skin care

– Soap to armpits, groin, scalp only (no soap on the rash) – Short cool showers or tub soak for 15-20 minutes – Apply medications and moisturizer within 3 minutes of bathing or swimming

Principles of Dermatologic Therapy Moisturizers and Gentle Skin Care

  • Moisturizers

– Contain oil to seal the surface of the skin and replace the damaged water barrier – Petrolatum (Vaseline) is the premier and “gold standard” moisturizer – Additions: water, glycerin, mineral oil, lanolin – Some try to mimic naturally occurring ceramides (E.g. CeraVe)

  • Thick creams more moisturizing than pump lotions
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SLIDE 2

Principles of Dermatologic Therapy Topical Medications

  • The efficacy of any topical medication is

related to:

  • 1. The concentration of the medication
  • 2. The vehicle
  • 3. The active ingredient (inherent strength)
  • 4. Anatomic location

Vehicles

  • Ointment (like Vaseline):

– Greasy, moisturizing, messy, most effective.

  • Creams (vanish when rubbed in):

– Less greasy, can sting, more likely to cause allergy (preservatives/fragrances).

  • Lotions (liquid):

– Cooling, liquids that pour.

Vehicles

  • Solutions (liquids that are greasy or

alcoholic):

– Can sting, good for hairy areas

  • Gels (semi solid alcohol-based):

– Can sting, good for hairy areas or wet lesions

  • Foams (cosmetically elegant):

– For hairy areas

  • Sprays: Aerosols (rarely used)

Topical Corticosteroids

  • Super-High Potency: Clobetasol
  • High Potency: Fluocinonide
  • Medium Potency: Triamcinolone (TAC)
  • Mid-Low: Aclometasone, Desonide
  • Lowest Potency: Hydrocortisone
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SLIDE 3

Topical Therapy

  • Choose agent by body site, age, type of lesion (weeping
  • r not), surface area
  • For Face:

– Hydrocortisone 2.5% ointment BID – If fails, aclometasone (Aclovate), desonide ointment

  • For Body:

– Triamcinolone acetonide 0.1% ointment BID – If fails, fluocinonide ointment

  • For scalp:

– Fluocinonide solution – Fluocinolone oil – Clobetasol foam

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Nummular Dermatitis Nummular Dermatitis

  • Affects middle aged men most, but also
  • ther age groups and women
  • Some patients have atopic dermatitis
  • Some patients start with xerotic eczema
  • Alcoholics predisposed

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Nummular Dermatitis

  • Starts as a single lesion of

the lower leg (90%+) or arm (<10%)

  • Lesion present for months
  • A few new lesions on that leg
  • Begins to generalize
  • Very, very pruritic
  • May become secondarily

infected

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SLIDE 4

13 14 15 16

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SLIDE 5

Nummular Dermatitis

  • Disease lasts 18 months, tending to

relapse in cleared lesions with minimal irritation or dryness

  • Need to be very aggressive in good skin

care regimen for 1-2 years after cleared

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Nummular Dermatitis Treatment

  • Emolliation, dry skin care
  • Potent (fluocinonide) or superpotent

(clobetasol) topical steroid BID to red plaques

  • Oral antihistamine
  • Antibiotic if secondarily infected

– bacterial culture

  • If fails, send to dermatology

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Alopecia

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Alopecia = hair loss

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Non‐Scarring Scarring

Alopecia areata Telogen Effluvium Androgenetic alopecia

Traction alopecia Trichotillomania (end stage) Neutrophil mediated Folliculitis decalvans Dissecting cellulitis of the scalp Lymphocyte mediated Lichen planopilaris Frontal fibrosing alopecia Central centrifugal alopecia Chronic cutaneous lupus

Scalp biopsy:

  • Area ADJACENT to alopecia, ask for TRANSVERSE sections
  • ALL scarring alopecias OR nonscarring alopecia where diagnosis uncertain
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SLIDE 6

Alopecia Areata

  • Affects up to 0.2% US population
  • Types

– Relapsing remitting – Ophiasis (band like along occipital scalp) – Alopecia totalis (all scalp hair) – Alopecia universalis (all scalp and body hair)

  • Associations

– Atopic disease – Autoimmune thyroid disease – Vitiligo – Inflammatory bowel disease – APECED syndrome

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Alopecia Areata:

Round or oval patches of nonscarring alopecia

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Taken from Dermatology, 2012, Elsevier

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Alopecia Areata:

Exclamation point hairs

Taken from Dermatology, 2012, Elsevier

Alopecia Areat: Ophiasis pattern

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Taken from Dermatology, 2012, Elsevier

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SLIDE 7

Alopecia Areata

  • IL triamcinolone

– 10mg/ml – q month

  • Immunosuppression (recurs after stopped)

– Pulse steroids – Methotrexate – Cyclosporine

  • Contact sensitization
  • Minoxidil
  • Antihistamines
  • Simvastatin/ezetimibe
  • Tofacitinib

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J Investig Dermatol Symp Proc. 2018 Jan;19(1):S25‐S31 J Investig Dermatol Symp Proc. 2018 Jan;19(1):S18‐20 JAAD 2018 Jan; 78(1):15‐24

Telogen Effluvium

  • Normal hair cycle

– Anagen 90‐95% – Catagen – Telogen 5‐10% – Normal shedding is 50‐100 hairs/day

  • Transient shifting of hair cycle
  • Shedding
  • No scalp itch or rash

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Telogen Effluvium‐ Causes

  • Postpartum
  • Chronic (no cause)
  • Post febrile
  • Severe infection
  • Severe chronic illness (SLE, HIV, etc)
  • Severe prolonged stress
  • Post major surgery
  • Endocrinopathy

– Thyroid, parathyroid

  • Crash diets, malnutrition, starvation
  • Medications

– Stopping OCP, retinoids, heparin, PTU, methimazole, anticonvulsants, β‐ blockers, IFN‐α, heavy metals

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Telogen Effluvium

  • Examination

– Diffuse thinning – Hair pull

  • Diagnostic > 20% hairs are telogen

– Look for bulb at end of hair shaft

  • Workup

– TSH, Vit D, Fe, ferritin, chemistry – Biopsy if > 6 mo (r/o AGA)

  • Treatment

– Address underlying etiology – Replete ferritin if < 40 ng/dl – Minoxidil – Reassurance (most regrow almost all lost hair)

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SLIDE 8

Androgenetic Alopecia

  • Male or female pattern hair loss
  • Female

– Complain of widening part – Retain anterior hairline – Early onset/severe: workup for hyperandrogenism

  • F/T testosterone, DHEAS, 17‐OH progesterone
  • Often “exposed” by telogen effluvium
  • Treat with

– Minoxidil 5% (F QD, M BID) – Spironolactone (female) – Finasteride‐ up to 5mg/d

  • NOT for women of childbearing potential

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Taken from Dermatology, 2012, Elsevier

Some scarring alopecias

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Traction Alopecia

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Taken from Dermatology, 2012, Elsevier

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SLIDE 9

Chronic Cutaneous LE

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Taken from Dermatology, 2012, Elsevier

Lichen Planopilaris

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Taken from Dermatology, 2012, Elsevier

Approach to the Adult Acne Patient

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Acne Pathogenesis, Clinical Features, Therapeutics

Oily skin Non‐inflammatory

  • pen and closed

comedones (“blackheads and whiteheads”) Inflammatory papules and pustules Cystic nodules Retinoids, spironolactone Salicylic acid, retinoids Benzoyl peroxide Antibiotics (topical and oral) Spironolactone OCPs Isotretinoin

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Excess sebum Abnormal follicular keratinization Propionibacterium acnes Inflammation

Pathogenesis Clinical features Therapeutics

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SLIDE 10

Acne Treatment

  • Mild inflammatory acne

– benzoyl peroxide + topical antibiotic (clindamycin, erythromycin)

  • Moderate inflammatory acne

– oral antibiotic (tetracyclines) (with topicals)

  • Comedonal acne

– topical retinoid (tretinoin, adapalene, tazarotene)

  • Acne with hyperpigmentation

– azelaic acid

  • Acne/rosacea overlap /seborrheic dermatitis-

– sulfur based preparations

  • Hormonal component

– oral contraceptive, spironolactone

  • Cystic, scarring- isotretinoin

– Teratogenic, hypertriglyceridemia, transaminitis, cheilitis, xerosis, alopecia (telogen effluvium)

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Acne Therapy Guidelines

  • Limit oral antibiotics to 3‐6 mo
  • All patients should receive a retinoid for

maintenance

– Tretinoin – Tazarotene – Adapalene (now OTC)

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JAAD 2016; 75: 1142‐50

Topical Retinoids

  • Side effects

–Irritating- redness, flaking/dryness –May flare acne early in course –Photosensitizing –Tazarotene is category X in pregnancy !!!

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SLIDE 11

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Acne in Adult Women

  • Often related to excess androgen or

excess androgen effect on hair follicles

  • Other features of PCOS are often not

present—irregular menses, etc.

  • Serum testosterone can be normal
  • Spironolactone 50 mg-200mg daily with or

without OCPs

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SLIDE 12

Acne Pearls

  • Retinoids are the most comedolytic
  • Topical retinoids can be tolerated by most
  • Start with a low dose: tretinoin 0.025% cream
  • Wait 20‐30 minutes after washing face to apply
  • Use 1‐2 pea‐sized amount to cover the whole face
  • Start BIW or TIW
  • Tazarotene is category X in pregnancy
  • Back acne often requires systemic therapy
  • Acne in adult women‐ use spironolactone

– No need to check K+ in healthy adult women

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Perioral dermatitis

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Perioral Dermatitis

  • Women aged 20‐45
  • Papules and small pustules

around the mouth, narrow spared zone around the lips.

  • Asymptomatic, burning,

itching

  • Causes

– Steroids (topical, nasal inhalers) – Fluorinated toothpaste – Skin care creams with petrolatum

  • r paraffin base or Isopropyl

myristate (vehicle)

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Perioral Dermatitis: Treatment

  • Stop topical products
  • Topical antibiotics

– Clindamycin

  • Topical or oral ivermectin
  • Oral tetracyclines
  • Warn patients of rebound if coming off

topical steroids

  • Avoid triggers

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