4/5/18 Dermatology Pearls for the Primary Outline Care Practitioner • Urticaria • Alopecia Lindy P. Fox, MD • Acne in the adult • Perioral dermatitis Professor of Clinical Dermatology Director, Hospital Consultation Service • Onychomycosis Department of Dermatology University of California, San Francisco • The red leg lindy.fox@ucsf.edu • Grover’s disease I have no conflicts of interest to disclose I may be discussing off-label use of medications 1 2 • 36 yoF complains of 2 mo of urticaria • Lesions last < 24 hours, itchy • Failed loratadine 10 mg daily Chronic Urticaria 3 1
4/5/18 Chronic Urticaria Chronic Urticaria- Workup • History and physical guides workup • Urticaria, with or without angioedema > 6 • Labs to check weeks – CBC with differential – Lesions last < 24 hours, itch, completely resolve – ESR, CRP • Divided into chronic spontaneous (66-93%) – TSH and thyroid autoantibodies or chronic inducible – Liver function tests • Natural history- 2-5 years – CU Index (Fc-εRIα Ab or Ab to IgE) – Maybe tryptase for severe, chronic recalcitrant disease – > 5 yrs in 20% patients – 13% relapse rate – Maybe look for bullous pemphigoid in an older patient • Etiology • Provocation for inducible urticaria – 30 -50 % - IgG autoAb to IgE or FcεRIα – Remainder, unclear Eur J Dermatol 2016 Clin Transl Allergy 2017. 7(1): 1-10 Allergy Asthma Immunol Res. 2016;8(5):396-403 Eur J Dermatol 2016 Clin Transl Allergy 2017. 7(1): 1-10 J Allergey Clin Immunol Pract. 2017. Sept 6. S2213-2198 Chronic Spontaneous Urticaria- Treatment First line What does my “second line” look like? H1 antihistamines- 2 nd <40% respond to standard dose H1 blockade generation Can increase to up to 4X standard dose Avoid triggers (NSAIDS, ASA) 60% chance of response Second line • Fexofenadine 360 mg am, 180 mg noon, 360 mg pm High dose 2 nd generation AH • Cetirizine 10 mg BID Add another 2 nd generation AH 1 st gen H1 antihistamine QHS • Ranitidine 300 mg QD +/- H2 antagonist • Hydroxyzine 25 mg QHS +/- Leukotriene antagonist Third line • Monteleukast 10 mg QD Omalizumab Cyclosporine Dapsone • When time to taper, get fexofenadine to 180 mg BID Sulfasalazine Hydroxychloroquine J Allergy Clin Immunol 2014. 133(3):914-5 BJD 2016. 175:1134–52 Mycophenolate mofetil Clin Transl Allergy 2017. 7(1): 1-10 TNFα antagonists Allergy Asthma Immunol Res. 2016;8(5):396-403 Anti CD20 Ab (rituximab) Eur J Dermatol 2016 (epub ahead of print) Allergy Asthma Immunol Res. 2017 November;9(6):477-482. Allergy 2018. Jan 15. epub ahead of print 2
4/5/18 CSU- when to refer • Atypical lesion morphology or symptoms – > 24 hours, central duskiness/purpura Alopecia – Asymptomatic or burn >> itch • Minimal response to medications – High dose H1 nonsedating antihistamines – H1 sedating antihistamines • Associated symptoms – Fever, fatigue, mylagias, arthralgias • Elevated ESR/CRP 10 Alopecia = hair loss Alopecia Areata • Affects up to 0.2% US population Non-Scarring Scarring • Types – Relapsing remitting Alopecia areata Traction alopecia – Ophiasis (band like along occipital scalp) Trichotillomania (end stage) Telogen Effluvium Neutrophil mediated – Alopecia totalis (all scalp hair) Androgenetic alopecia Folliculitis decalvans – Alopecia universalis (all scalp and body hair) Dissecting cellulitis of the scalp • Associations Lymphocyte mediated Lichen planopilaris – Atopic disease Frontal fibrosing alopecia – Autoimmune thyroid disease Central centrifugal alopecia – Vitligo Chronic cutaneous lupus – Inflammatory bowel disease Scalp biopsy: – APECED syndrome 11 • Area ADJACENT to alopecia, ask for TRANSVERSE sections • ALL scarring alopecias OR nonscarring alopecia where diagnosis uncertain 12 3
4/5/18 Alopecia Areata: Alopecia Areata: Round or oval patches of nonscarring alopecia Exclamation point hairs 13 14 Taken from Dermatology, 2012, Elsevier Taken from Dermatology, 2012, Elsevier Alopecia Areat: Ophiasis pattern Alopecia Areata • IL triamcinolone – 10mg/ml – q month • Immunosuppression (recurs after stopped) – Pulse steroids – Methotrexate – Cyclosporine • Contact sensitization • Minoxidil • Antihistamines • Simvastatin/ezetimibe • Tofacitinib 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 15 16 Taken from Dermatology, 2012, Elsevier 4
4/5/18 Telogen Effluvium Telogen Effluvium- Causes • Postpartum • Normal hair cycle • Chronic (no cause) – Anagen 90-95% • Post febrile • Severe infection – Catagen • Severe chronic illness (SLE, HIV, etc) – Telogen 5-10% • Severe prolonged stress – Normal shedding is 50-100 hairs/day • Post major surgery • Endocrinopathy • Transient shifting of hair cycle – Thyroid, parathyroid • Shedding • Crash diets, malnutrition, starvation • Medications • No scalp itch or rash – Stopping OCP, retinoids, heparin, PTU, methimazole, anticonvulsants, β- blockers, IFN-α, heavy metals 17 18 Telogen Effluvium Androgenetic Alopecia • Examination • Male or female pattern hair loss – Diffuse thinning • Female – Hair pull – Complain of widening part • Diagnostic > 20% hairs are telogen – Look for bulb at end of hair shaft – Retain anterior hairline • Workup – Early onset/severe: workup for hyperandrogenism – TSH, Vit D, Fe, ferritin, chemistry • F/T testosterone, DHEAS, 17-OH progesterone – Biopsy if > 6 mo (r/o AGA) • Often “exposed” by telogen effluvium • Treatment • Treat with – Address underlying etiology – Minoxidil 5% (F QD, M BID) – Replete ferritin if < 40 ng/dl – Spironolactone (female) – Minoxidil – Finasteride- up to 5mg/d – Reassurance (most regrow almost all lost hair) • NOT for women of childbearing potential 19 20 5
4/5/18 Some scarring alopecias 21 22 Taken from Dermatology, 2012, Elsevier Chronic Cutaneous LE Traction Alopecia 23 24 Taken from Dermatology, 2012, Elsevier Taken from Dermatology, 2012, Elsevier 6
4/5/18 Lichen Planopilaris Approach to the Adult Acne Patient 25 26 Taken from Dermatology, 2012, Elsevier Acne Treatment Acne Pathogenesis, Clinical Features, Therapeutics Pathogenesis Clinical features Therapeutics Retinoids, • Mild inflammatory acne Oily skin Excess sebum spironolactone – benzoyl peroxide + topical antibiotic (clindamycin, erythromycin) • Moderate inflammatory acne – oral antibiotic (tetracyclines) (with topicals) Salicylic acid, Non-inflammatory Abnormal follicular retinoids • Comedonal acne open and closed keratinization – topical retinoid (tretinoin, adapalene, tazarotene) comedones • Acne with hyperpigmentation ( � blackheads and – azelaic acid whiteheads � ) • Acne/rosacea overlap /seborrheic dermatitis- Benzoyl peroxide – sulfur based preparations Propionibacterium Antibiotics • Hormonal component Inflammatory papules (topical and oral) acnes – oral contraceptive, spironolactone and pustules Spironolactone • Cystic, scarring- isotretinoin OCPs Inflammation Isotretinoin – Teratogenic, hypertriglyceridemia, transaminitis, cheilitis, xerosis, Cystic nodules alopecia (telogen effluvium) 28 27 7
4/5/18 Acne Therapy Guidelines Topical Retinoids • Limit oral antibiotics to 3-6 mo • Side effects • All patients should receive a retinoid for –Irritating- redness, flaking/dryness maintenance –May flare acne early in course – Tretinoin –Photosensitizing – Tazarotene –Tazarotene is category X in pregnancy – Adapalene (now OTC) !!! 29 30 JAAD 2016; 75: 1142-50 31 32 8
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4/5/18 Acne Pearls Acne in Adult Women • Retinoids are the most comedolytic • Often related to excess androgen or • Topical retinoids can be tolerated by most excess androgen effect on hair follicles Start with a low dose: tretinoin 0.025% cream • • Wait 20-30 minutes after washing face to apply • Other features of PCOS are often not • Use 1-2 pea-sized amount to cover the whole face present—irregular menses, etc. Start BIW or TIW • • Tazarotene is category X in pregnancy • Serum testosterone can be normal • Back acne often requires systemic therapy • Spironolactone 50 mg-200mg daily with or • Acne in adult women- use spironolactone without OCPs – No need to check K + in healthy adult women 37 38 Perioral Dermatitis • Women aged 20-45 • Papules and small pustules around the mouth, narrow Perioral dermatitis spared zone around the lips. • Asymptomatic, burning, itching • Causes – Steroids (topical, nasal inhalers) – Fluorinated toothpaste – Skin care creams with petrolatum or paraffin base or Isopropyl myristate (vehicle) 39 40 10
4/5/18 Perioral Dermatitis: Treatment • Stop topical products • Topical antibiotics Onychomycosis – Clindamycin • Topical or oral ivermectin • Oral tetracyclines • Warn patients of rebound if coming off topical steroids • Avoid triggers 41 42 Onychomycosis Onychomycosis • Infection of the nail plate by fungus • Vast majority are due to dermatophytes, especially Trichophyton rubrum • Very common • Increases with age • Half of nail dystrophies are onychomycosis • This means 50% of nail dystrophies are NOT fungal 43 44 11
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