Outline Approach to the itchy patient Common Dermatologic Disorders: - PDF document

3/17/2017 Outline • Approach to the itchy patient Common Dermatologic Disorders: • How to really treat eczema • Psoriasis as a systemic disease Tips for Diagnosis and Management • Acne in the adult • Onychomycosis • Grovers disease Lindy P. Fox, MD Associate Professor • The red leg Director, Hospital Consultation Service Department of Dermatology University of California, San Francisco 1 2 Pruritus = the sensation of itch • Itch can be divided into four categories: 1. Pruritoceptive • Generated within the skin Approach to the itchy patient • Itchy rashes: scabies, eczema, bullous pemphigoid 2. Neurogenic • Due to a systemic disease or circulating pruritogens Itch “ without a rash ” • 3. Neuropathic • Due to anatomical lesion in the peripheral or central nervous system • Notalgia paresthetica, brachioradial pruritus 4. Psychogenic itch 3 4 1

3/17/2017 Pruritus- History Pruritus- Physical Exam Are there primary lesions present? • Suggest cutaneous cause of itch: – Acute onset (days) – Related exposure or recent travel no – Household members affected yes – Localized itch • Itch is almost always worse at night – does not help identify cause of pruritus Pruritoceptive Neurogenic, • Aquagenic pruritus suggests polycythemia vera Neuropathic, • Dry skin itches or Psychogenic 5 6 Causes of Neurogenic Pruritus Workup of “ Pruritus Without Rash ” (Pruritus Without Rash) • CBC with differential • 40% will have an underlying cause: Serum iron level, ferritin, total iron binding capacity • • Dry Skin • Thyroid stimulating hormone and free T4 • Liver diseases, especially cholestatic • Renal function (blood urea nitrogen and creatinine) • Renal Failure • Calcium • Iron Deficiency • Liver function tests total and direct bilirubin, AST, ALT, alkaline phosphatase, GGT, • Thyroid Disease – fasting total plasma bile acids • Low or High Calcium • HIV test • HIV • Chest X ‐ ray • Medications • Age ‐ appropriate malignancy screening, with more advanced testing as indicated by symptoms • Cancer, especially lymphoma (Hodgkin ’ s) 7 8 2

3/17/2017 Notalgia Paresthetica Neuropathic Pruritus • Notalgia paresthetica Brachioradial Pruritus • – Localized and persistent area of pruritus, without associated primary skin lesions, usually on the back or forearms • Workup= MRI!! Cervical and/or thoracic spine disease in ~100% of – patients with brachioradial pruritus and 60% of patients with notalgia paresthetica • Treatment ‐ capsaicin cream TID, gabapentin – Surgical intervention when appropriate 9 10 Treatment of Pruritus Antihistamines for Pruritus Treat the underlying cause if there is one • • Work best for histamine ‐ induced pruritus, but may also be effective for other types of pruritus • Dry skin care – Short, lukewarm showers with Dove or soap ‐ free • First generation H1 antihistamines cleanser – hydroxyzine 25 mg QHS, titrate up to QID if – Moisturize with a cream or ointment BID tolerated • Cetaphil, eucerin, vanicream, vaseline, aquaphor • Second generation H1 antihistamines • Sarna lotion (menthol/camphor) – longer duration of action, less somnolence • Topical corticosteroids to inflamed areas – cetirizine, loratidine, desloratidine, fexofenadine – Face ‐ low potency (desonide ointment) – Body ‐ mid to high potency (triamcinolone acetonide 0.1% oint) 11 12 3

3/17/2017 Systemic Treatments for Pruritus • Doxepin - 10mg QHS, titrate up to 50 mg QHS – Tricyclic antidepressant with potent H1 and H2 antihistamine properties Eczemas – Good for pruritus associated with anxiety or depression – Anticholinergic side effects • Paroxetine (SSRI)- 25- 50 mg QD • Mirtazepine- 15-30 mg QHS – H1 antihistamine properties – Good for cholestatic pruritus, pruritus of renal failure • Gabapentin- 300 mg QHS, increase as tolerated – Best for neuropathic pruritus, pruritus of renal failure 13 Eczemas Eczema (=dermatitis) Group of disorders • • Atopic Dermatitis characterized by: • Hand and Foot Eczemas 1. Itching • Asteatotic Dermatitis (Xerotic Eczema) 2. Intraepidermal vesicles (= spongiosis) • Nummular Dermatitis – Macroscopic (you can see) – Microscopic (seen • Contact Dermatitis (allergic or irritant) histologically on biopsy) 3. Perturbations in the skin’s • Stasis Dermatitis water barrier • Lichen Simplex Chronicus 4. Response to steroids 15 16 4

3/17/2017 Eczema Eczema Topical Therapy Good Skin Care Regimen • Soap to armpits, groin, scalp only (no soap on • Choose agent by body site, age, type of lesion (weeping the rash) or not), surface area • For Face: • Short cool showers or tub soak for 15 ‐ 20 – Hydrocortisone 2.5% Ointment BID minutes – If fails, aclometasone (Aclovate), desonide ointment • Apply medications and moisturizer within 3 • For Body: minutes of bathing or swimming – Triamcinolone acetonide 0.1% ointment BID – If fails, fluocinonide ointment • For weepy sites: – soak 15 min BID with dilute Burow’s solution (aluminum acetate) (1:20) for 3 days 17 18 Eczema Eczema Oral Antipruritics Severe Cases • Suppress itching with nightly oral sedating • Refer to dermatologist antihistamine • Do not give systemic steroids • If it is not sedating it doesn’t help • We might use phototherapy, hospitalization, • Diphenhydramine immunotherapy • Hydroxyzine 25 ‐ 50mg • Doxepin 10 ‐ 25mg • Beware of making the diagnosis of atopic dermatitis in an adult ‐ this can be cutaneous T cell lymphoma! 19 20 5

3/17/2017 Psoriasis Aggravators • Trauma • Medications – Systemic steroids • Sunburn (withdrawal) Psoriasis pearls • Severe life stress – Beta blockers – Lithium • HIV – Hydroxychloroquine – 6% of AIDS patients develop psoriasis • Infections – Strep ‐ children and • Alcohol for some young adults • Smoking for some – Candida (balanitis) 22 Psoriasis and Comorbidities • Psoriasis is linked with: • Psoriasis patients more – Arthritis likely to – Cardiovascular disease – Be depressed (including myocardial •Psoriasis - independent risk factor for MI infarction) – Drink alcohol •Risk for MI - – Hypertension – Smoke •Greatest in young patients with – Obesity severe psoriasis – Diabetes •Attenuated with age – Metabolic syndrome •Remains increased after controlling – Malignancies for other CV risk factors • Lymphomas, SCCs, ? Solid •Magnitude of association is equivalent to organ malignancies other established CV risk factors – Higher mortality 23 6

3/17/2017 Psoriasis and Comorbidities Pustular Psoriasis • Pustular and erythrodermic variants of psoriasis • In patients with psoriasis, important to can be life ‐ threatening 1. Recognize these associations • Most common in patients with psoriasis who are given systemic steroids 2. Screen for and treat the comorbidities • High cardiac output state with risk of high output according to American Heart Association, failure American Cancer Society, and other • Electrolyte imbalance (hypo Ca 2+ ), respiratory accepted guidelines distress, temperature dysregulation • Treat with hospitalization and cyclosporine or acitretin or TNF alpha blocker (infliximab) 26 25 Acne Pathogenesis, Clinical Features, Therapeutics Pathogenesis Clinical features Therapeutics Oily skin Retinoids, Excess sebum spironolactone Approach to the Adult Acne Non ‐ inflammatory Abnormal follicular open and closed Salicylic acid, Patient keratinization comedones retinoids ( “ blackheads and whiteheads ” ) Propionibacterium Benzoyl peroxide Inflammatory papules acnes Antibiotics and pustules (topical and oral) Spironolactone Inflammation Cystic nodules OCPs Isotretinoin 27 28 7

3/17/2017 Acne Treatment Topical Retinoids • Mild inflammatory acne • Side effects – benzoyl peroxide + topical antibiotic (clindamycin, erythromycin) • Moderate inflammatory acne –Irritating- redness, flaking/dryness – oral antibiotic (tetracyclines) (with topicals) –May flare acne early in course • Comedonal acne – topical retinoid (tretinoin, adapalene, tazarotene) –Photosensitizing • Acne with hyperpigmentation – azelaic acid –Tazarotene is category X in pregnancy • Acne/rosacea overlap /seborrheic dermatitis- !!! – sulfur based preparations • Hormonal component – oral contraceptive, spironolactone • Cystic, scarring- isotretinoin – Teratogenic, hypertriglyceridemia, transaminitis, cheilitis, xerosis, alopecia (telogen effluvium) 29 30 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 • Other features of PCOD are often not • Wait 20 ‐ 30 minutes after washing face to apply present—irregular menses, etc. • Use 1 ‐ 2 pea ‐ sized amount to cover the whole face • Start BIW or TIW • Serum testosterone can be normal • Tazarotene is category X in pregnancy • Spironolactone 50 mg-100mg daily with or without OCPs • Back acne often requires systemic therapy • Acne in adult women ‐ use spironolactone – No need to check K + 32 31 8