Sk“IN” Too Deep? Effective care for commonly encountered dermatologic complaints Kara Pretzlaff, MD Vivida Dermatology
I have no financial conflicts of interest* * maybe one day…
Number 1: Acne
Acne • Contributors • Inflammation • “Sticky” keratinocytes • Hormones • Ages 12-24 most common • Post pubertal • “Adult” acne is a thing L • Classifiers • Comedonal • Inflammatory • Nodulocystic
Comedonal versus Inflammatory
Nodulocystic
Treatment Pearls: comedonal acne Sample regimen: • AM • Gentle cleanser (Cera Ve, Cetaphil) • Moisturizer with SPF (30+) • PM • Gentle cleanser • Nighttime moisturizer • Adapalene gel 0.1% (OTC)
Treatment Pearls: inflammatory acne Sample regimen: • AM & PM same plus: • AM: Anti inflammatory/anti bacterial • Eg Benzoyl peroxude/clindamycin gel • Doxycycline OR Minocycline 100mg twice daily • If hormonal : OCPs, spironolactone • SE • Doxycycline MC: GI upset, photosensitivity • Minocycline MC: dizziness • Less common: dyschromia, DRESS
Treatment Pearls: nodulocystic acne Challenging… • Isotretinoin • 6+ month course • Goal of 120-150mg/kg • May need to repeat • We can help! • Watch out for: • DRYNESS • Elevated TGs and LFTs • DRUG INTERACTIONS (eg tetracyclines) • Questions about depression
Not working? • We can help! • Inflammatory • Nodulocystic • Refractory comedonal • Adult acne • Post inflammatory inflammation • Acne scarring
Number 2: Tinea AKA “Ringworm”, “Jock itch”, “Athlete’s Foot”, “Gross toenails”
Tinea: a dermatophyte infection • Incredibly common superficial fungal infection • Treatment depends on subtype and location • Inflammatory versus non inflammatory • Good news: sometimes it’s really easy to treat • Bad news: sometimes it’s not
Treatment pearls: tinea versicolor • Ketoconazole 2% shampoo (Rx) • Step 1: Lather on wet skin • Step 2: LEAVE ON 5-10 min • Step 3: Rinse off • Repeat 3x/week until improved, then once weekly • “Normal” color takes time • Not working? • There are oral options…we can help!
Treatment pearls: tinea corporis/pedis/cruris
Treatment pearls: tinea corporis/pedis/cruris • First line: topical cream (OTC) • At home tips: • Eg miconazole, terbinafine, • Wash common foot surfaces with clotrimazole bleach-based wash • Apply twice a day for 2 weeks • Wash socks/towels on hot cycle beyond clinical improvement • Dry feet well • Second line: oral antifungal • New shoes agents • Zeasorb powder (OTC) • For thick skin on feet, add urea or • Terbinafine preferred amlactin (OTC) • 250mg daily x 2-4 weeks • MC side effect: taste disturbances
Treatment pearls: Tinea unguum (aka onychomycosis) • MAKE SURE IT’S FUNGUS • Who needs treatment? • Diabetics • Immune suppressed • People who don’t like the way their nails look/have painful nails • *Personal opinion*: • Don’t waste time with topicals • First line: Oral antifungals • Requires longer course • 6 weeks for fingernails • 12 weeks for toenails
Number 3: Seborrheic Dermatitis
Seborrheic dermatitis • Common inflammatory dermatosis that likes oil-gland bearing skin • MC on scalps, central face, chest, axillae • Exuberant forms can be seen in HIV population and Parkinson’s
Treatment pearls: seborrheic dermatitis • Treatment similar to tinea versicolor • Ketoconazole shampoo 2% (Rx) • Leave on skin for 5-10 min prior to rinsing • Start with 3x/week, decrease to weekly as maintenance • Alternate with OTC anti-dandruff shampoo • If really inflammatory, can pair with mild corticosteroid during flares (only 1-2 weeks) • Eg desonide 0.5% cream, hydrocortisone 2.5% ointment
Treatment pearls: seborrheic dermatitis • Not working? • Options for oral therapy and stronger corticosteroids…We can help!
Number 4: Psoriasis
Psoriasis • Common, chronic, immune- mediated inflammatory dermatosis • Genetic • Can have mutilating arthritis • Not just “skin deep” • Cardiovascular risk is equivalent to those with DMII • High risk of depression/suicidality
Treatment Pearls: Psoriasis • We have SO many options! • If it’s minor (<5% BSA) and patient doesn’t mind it: • Triamcinolone 0.1% ointment BID PRN • Counsel on hereditary nature, ask about mood, discuss cardiovascular risk • Send them our way – we can get them the good stuff J
Treatment Pearls: Psoriasis • What makes it worse? • IM steroids – watch out! • Infection • Hypocalcemia • Stress • Some drugs • Beta blockers, anti malarial agents, lithium, IM steroids (see above…) • Alcohol/smoking/obesity
Number 5: Vitiligo
Vitiligo • Autoimmune, chronic, inflammatory dermatosis • Defined by striking patches of depigmented skin • Like psoriasis, HIGH percentage of patients with depression and suicidality
Treatment Pearls: Vitiligo • Most important part of treatment: • Letting patients know there ARE treatments available • Please don’t treat it like a cosmetic complaint • Class I topical corticosteroids/oral steroids, JAK kinase inhibitors, NBUVB are the mainstays of therapy • We CAN help!!
Number 6: Sebaceous Hyperplasia and the “aging” face
Sebaceous hyperplasia • Benign adnexal neoplasms • Often confused for basal cell carcinoma • If you’re not sure we would love to see them J • Men>Women • Tx options: electrodessication most effective
Sebaceous hyperplasia vs Basal cell carcinoma
*BONUS* “Aging” face • The absolute basics of “post- poning” photoaging 1. Sunscreen: SPF 30+, re application needed 2. Safe sun practices (can’t get out of a derm talk without this one…) Wrinkles 3. Daily (or twice daily) moisturizer 4. Topical anti-oxidant (eg Vitamin C) Loss of fat 5. Topical retinoid (rx >> OTC) • More advanced: botox, filler, laser resurfacing… Dyschromia
Number 7: Seborrheic keratoses AKA “wisdom spots”
Seborrheic keratoses (SKs) • Benign, incredibly common skin lesions that like hair-bearing areas • Can sometimes look a lot like melanoma (and vice versa, unfortunately) • Sign of Leser Trelat?
Treatment pearls: Seborrheic keratoses (SKs) • If not bothersome to patient…leave them alone • If bothersome (eg itch/hurt), they can be removed or destroyed • Considered a cosmetic procedure if asymptomatic without any concerning features
SK or Melanoma? • If you doubt it at all…we’re here to help!!
Number 8: Eczema
Eczema (atopic dermatitis) • Common inflammatory dermatosis predominantly affecting kids • Up to 85% of kids grow out of their eczema by age 12 • Main problem: faulty epidermal barrier • Pruritus • Xerosis • Secondary infection
Treatment pearls: Eczema • If mild-moderate, keep it simple: • Eliminate potential triggers: essential oil diffusers, “slime”, scented soaps • Gentle skin care • Short, lukewarm showers • Dove bar soap for sensitive skin • Regular emollient use • Vaseline or body creams (not lotions) • Class 3 topical corticosteroid (eg triamcinolone 0.1% ointment) • BID while active, then PRN • DO NOT USE on face, axillae, genitals or other body folds
Treatment pearls: Eczema • If moderate-severe: • Need higher potency steoroids • Anti-pruritic • Several options: • NVUVB • Methotrexate • Cyclosporine • Mycophenalate mofitil • *Dupilumab* • We’re here to help J
Treatment pearls: Eczema • Things to watch out for: • Honey colored-crusting • Open erosions • “Punched out” lesions • Intact vesicles • Decolonization • Mupirocin 2% ointment • Apply to nares BID first week of each month x 6 months • Bleach baths • TIW: ¼ cup bleach in ½ bath
*BONUS* Urticaria! • Mast cell-mediated eruption (usually) • Causes: idiopathic (50%) > infection >> drugs >>> food • Initial treatment • Scheduled antihistamines • Sample regimen: • AM: 10mg Cetirizine (can increase to 20mg) • PM: 10mg Cetirizine (can increase to 20mg) • “Cooling” topicals • Avoidance of possible triggers • Oral prednisone generally not indicated • If not responding…send our way J
Number 9: Poison ivy Or other acute ACD…
Plant-based allergic contact dermatitis • Type IV (delayed type hypersensitivity) reaction • If sensitized: • Takes ~48 hours to develop rash • If not sensitized: • Can take up to 3 weeks to develop rash
Treatment pearls: Plant ACD • Mild • Topical Class 3 corticosteroid BID until improved • Oral anti histamines • Moderate to severe • 3 week oral prednisone taper • 60mg/40mg/20mg x 1 week each* • Watch for REBOUND • As always, try to avoid triger • Wash off as soon as you come in contact * Can decrease dose for elderly, those with diabetes or poorly controlled HTN
Number 10: Rosacea
Rosacea • Chronic inflammatory dermatosis • Affects mostly middle aged women • LOTS of triggers • Caffeine? • Alcohol • Sun • Spicy foods • Topical steroids (when stopped)
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