SkIN Too Deep? Effective care for commonly encountered dermatologic - - PowerPoint PPT Presentation

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)
• Eg miconazole, terbinafine,

clotrimazole

• Apply twice a day for 2 weeks

beyond clinical improvement

• Second line: oral antifungal

agents

• Terbinafine preferred
• 250mg daily x 2-4 weeks
• MC side effect: taste disturbances
• At home tips:
• Wash common foot surfaces with

bleach-based wash

• Wash socks/towels on hot cycle
• Dry feet well
• New shoes
• Zeasorb powder (OTC)
• For thick skin on feet, add urea or

amlactin (OTC)

Treatment pearls: Tinea unguum (aka

• nychomycosis)
• 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
• f 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…)

• 3. Daily (or twice daily) moisturizer
• 4. Topical anti-oxidant (eg Vitamin C)
• 5. Topical retinoid (rx >> OTC)
• More advanced: botox, filler, laser

resurfacing…

Wrinkles Loss of fat 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
• ther 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)

Treatment pearls: Rosacea

• Mild
• Avoid triggers
• Gentle skin care
• SPF 30 or higher with re application
• Face wash options:
• Sodium sulfacetamide
• Avoid exfoliants
• Topicals for BID application
• Metronidazole cream
• Ivermectin Cream
• Azeleic acid Cream
• Moderate to severe
• Antibiotics
• Isotretinoin

*BONUS* “Red Flags”

WHEN TO BE WORRIED…

• If your patient starts a high risk

drug and starts to notice:

• Fever, painful skin, sloughing skin,

sores in eyes/mouth/genitals, new LAD, facial/ear swelling

• Timeline:
• ~7-21 days for SJS/TEN
• ~3-6 weeks for DRESS

“High risk” Drug Examples

• Trimethoprim sulfamethoxazole
• Aromatic anti-epileptics
• Allopurinol
• NNRTIs

Questions?