3/26/2014

Disclosures Common Dermatologic Disorders: Tips for Diagnosis and Management • I have no conflicts of interest to disclose Part 1

Lindy P. Fox, MD Associate Professor Director, Hospital Consultation Service Department of University of California, San Francisco [email protected]

1 2

Outline

 Part 1  Approach to the itchy patient  Eczemas and approach to treatment  Fungal infections of the skin Approach to the itchy patient   Grovers disease  Part 2  Acne, Rosacea, Perioral  Drug eruptions  The red leg  Psoriasis as a systemic disease

3 4

1 3/26/2014

Case 1 Question 1: The Best Diagnosis is

• 57M with 3 months of rash 1. Asteatotic dermatitis • started on his lower 2. Pruritus of renal failure extremities • No response to 3. creams and OTC hydrocortisone 4. cream 5. Neuropathic pruritus • He showers 2 x/day with hot water, uses an antibacterial soap, and does not moisturize

5 6

Case 2 Question 2: The Best Diagnosis is 68M with ESRD complains of generalized itch 1. Asteatotic dermatitis 2. Pruritus of renal failure 3. Nummular dermatitis 4. Tinea corporis 5. Neuropathic pruritus

7 8

2 3/26/2014

Pruritus = the sensation of itch Pruritus- History

• Itch can be divided into four categories: Suggest cutaneous cause of itch: 1. Pruritoceptive  Acute onset (days) • Generated within the skin  • Itchy rashes: scabies, eczema, bullous pemphigoid Related exposure or recent travel 2. Neurogenic  Household members affected • Due to a systemic disease or circulating pruritogens  Localized itch • Itch “without a rash” Itch is almost always worse at night 3. Neuropathic • Due to anatomical lesion in the peripheral or central  does not help identify cause of pruritus nervous system  suggests • Notalgia paresthetica, 4. Psychogenic itch Dry skin

9 10

Pruritus- Physical Exam Case 1

Are there primary lesions present?  57M with 3 months of itch rash  started on his lower extremities yes no  No response to antifungal creams and OTC hydrocortisone cream  He showers 2 x/day with Pruritoceptive Neurogenic, hot water, uses an Neuropathic, antibacterial soap, and does not moisturize or Psychogenic

11 Nummular dermatitis 12

3 3/26/2014

Case 2 Causes of Neurogenic Pruritus 68M with ESRD complains of generalized itch (Pruritus Without Rash) • 40% will have an underlying cause: –Dry Skin – diseases, especially cholestatic – Renal Failure – Iron Deficiency – Thyroid Disease – Low or High Calcium –HIV – Medications – Cancer, especially lymphoma (Hodgkin’s)

Linear erosions; “Butterfly” distribution of spared skin Pruritus “without rash” 13 14

Workup of “Pruritus Without Rash” Neuropathic Pruritus Notalgia Paresthetica and Brachioradial Pruritus • CBC with differential • Serum iron level, ferritin, total iron binding capacity • Localized and persistent area of pruritus, without • Thyroid stimulating hormone and free T4 associated primary skin lesions, usually on the back • Renal function (blood urea nitrogen and creatinine) or forearms • Calcium • Workup= MRI • Liver function tests • Cervical spine disease in ~100% brachioradial pruritus • total and direct , AST, ALT, alkaline phosphatase, GGT, fasting total plasma bile acids • Thoracic spine disease in 60% notalgia paresthetica • HIV test • Treatment‐ capsaicin cream TID, neurontin • Chest X‐ray • Surgical intervention when appropriate • Age‐appropriate malignancy screening, with more advanced testing as indicated by symptoms 15 16

4 3/26/2014

Notalgia Paresthetica Treatment of Pruritus

• Treat the underlying cause if there is one • Dry skin care • Short, lukewarm showers with Dove or soap‐free cleanser • Moisturize with a cream or ointment BID • Cetaphil, eucerin, vanicream, vaseline, aquaphor • Sarna lotion (menthol/phenol) • Topical corticosteroids to inflamed areas • Face‐ low potency (desonide ointment) • Body‐ mid to high potency (triamcinolone acetonide 0.1% oint)

17 18

Antihistamines for Pruritus Systemic Treatments for Pruritus

 Work best for ‐induced pruritus, but may • - 10mg QHS, titrate up to 50 mg QHS also be effective for other types of pruritus – Tricyclic antidepressant with potent H1 and H2 antihistamine properties  First generation H1 antihistamines – Good for pruritus associated with anxiety or depression  hydroxyzine 25 mg QHS, titrate up to QID if – Anticholinergic side effects tolerated • Paroxetine (SSRI)- 25- 50 mg QD  Second generation H1 antihistamines • Mirtazepine- 15-30 mg QHS – H1 antihistamine properties  longer duration of action, less somnolence – Good for , pruritus of renal failure  cetirizine, levocetirizine, loratidine, desloratidine, • Gabapentin- 300 mg QHS, increase as tolerated fexofenadine – Best for neuropathic pruritus, pruritus of renal failure

19 20

5 3/26/2014

Eczemas Eczema (=dermatitis)

• Group of disorders characterized by: • Hand and Foot Eczemas 1. Itching • Stasis Dermatitis 2. Intraepidermal vesicles (= spongiosis) • Asteatotic Dermatitis (Xerotic Eczema) – Macroscopic (you can see) – Microscopic (seen • Nummular Dermatitis histologically on biopsy) • 3. Perturbations in the skin’s water barrier • (allergic or irritant) 4. Response to steroids

21 22

Asteatotic Dermatitis (Xerotic Eczema) • Many atopic adults have only hand dermatitis • Caused by loss of the epidermal water • Tinea tends to involve only 1 hand, so if two feet barrier and one hand are involved, think tinea • More common in the elderly • Treatment: • Worsened by hot showers, deodorant – Protect, Moisturize, Medicate soaps • Occupational history – Consider contact dermatitis and patch testing • Worse in the winter (dry, heated air) • Worse after ski trips (altitude, cold)

23 24

6 3/26/2014

Asteatotic Dermatitis (Xerotic Eczema) • Lower legs, flanks, arms • Spares armpits, groin, face • First stage: – flaking of the skin, pruritic • Second stage: – cracking of the skin looking like the bed of a dry lake – itchy and stings • Third stage: Weepy dermatitis, ITCHY

25 26

Asteatotic Dermatitis (Xerotic Eczema) Nummular Dermatitis • Diagnostic clue: • Affects middle aged men most, but also – Itching is relieved by prolonged submersion in other age groups and women bath (20-30 minutes) • Some patients have atopic dermatitis – Then itching starts again 5-30 minutes after • Some patients start with xerotic eczema getting out of the water • Alcoholics predisposed

27 28

7 3/26/2014

Nummular Dermatitis Nummular Dermatitis • Disease lasts 18 months, tending to • Starts as a single lesion of relapse in cleared lesions with minimal the lower leg (90%) or arm irritation or dryness (<10%) • Lesion present for months • Need to be very aggressive in good skin • A few new lesions on that leg care regimen for 1-2 years after cleared • Begins to generalize • Very, very pruritic • May become secondarily infected

29 30

Lichenification Eczema Good Skin Care Regimen Describes lesions that have been rubbed repeatedly • Soap to armpits, groin, scalp only (no soap • Characteristic of any pruritic and chronic dermatosis on the rash) • Short cool showers or tub soak for 15-20 Skin is thickened, with slight scale, minutes excoriations, and ACCENTUATED skin lines • Apply medications and moisturizer within 3 minutes of bathing or swimming Treat with superpotent topical steroids (clobetastol) under occlusion

31 32

8 3/26/2014

Principles of Moisturizers Dermatologic Therapy • Contain oil to seal the surface of the skin and replace the damaged water barrier • Petrolatum (Vaseline) is the premier and “gold • The efficacy of any is standard” moisturizer related to: • Other agents add water to this to make it more 1. The concentration of the medication palatable, OR use glycerin or mineral oil instead or in addition 2. The vehicle – If the first ingredient is “water”, the moisturizer is less 3. The active ingredient (inherent strength) effective than if the first ingredient is an oil 4. Anatomic location (hydrophobic)

Vehicles Vehicles

• Ointment (like Vaseline): • Solutions (liquids that are greasy or – Greasy, moisturizing, messy, most effective. alcoholic): – Can sting, good for hairy areas • Creams (vanish when rubbed in): • Gels (semi solid alcohol-based): – Less greasy, can sting, more likely to cause allergy (preservatives/fragrances). – Can sting, good for hairy areas or wet lesions • Foams (cosmetically elegant): • Lotions (liquid): – For hairy areas – Cooling, liquids that pour. • Sprays: Aerosols (rarely used)

9 3/26/2014

Eczema Topical Corticosteroids Topical Therapy • Choose agent by body site, age, type of lesion • Super-High Potency: Clobetasol (weeping or not), surface area • High Potency: Fluocinonide • Medium Potency: Triamcinolone (TAC) •For Face: – Hydrocortisone 2.5% ointment BID • Mid-Low: Aclometasone, Desonide – If fails, aclometasone (Aclovate), desonide ointment • Lowest Potency: Hydrocortisone • For Body: – Triamcinolone acetonide 0.1% ointment BID – If fails, fluocinonide ointment • For weepy sites: – soak 15 min BID with dilute Burrow’s solution (aluminum acetate) (1:20) for 3 days

38

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 • Avoid making the diagnosis of adult onset • Diphenhydramine atopic dermatitis in a patient without a • Hydroxyzine 25-50mg history of atopy (could be cutaneous T cell • Doxepin 10-25mg lymphoma) • We might use phototherapy, hospitalization, immunotherapy

39 40

10 3/26/2014

Superficial Fungal Infections

• Dermatophytoses: – Infections by fungi that parasitize Superficial Fungal Infections • stratum corneum, nail, or hair • : – Yeast infection of mucosal surfaces and moist skin • : – Yeast infection of skin surface

41 42

Superficial Fungal Infections Diagnosis Superficial Fungal Infections KOH • Clinical examination • Scrape scale, put on – Inaccurate, especially for onychomycosis (nail slide, add KOH, and fungal infection) examine at 10x- 40x •KOH • Rapid, accurate •Culture • Requires training • Biopsy and repetition

43 44

11 3/26/2014

Keys to doing a Good KOH

• Collect from the right area • Get lots of material • Adequately digest the keratin (heat) • Set microscope correctly (condenser down and iris closed partially) • Systematically scan entire slide

45 “Spaghetti and Meatball” KOH smear of Tinea Versicolor 46

Superficial Fungal Infections Diagnosis • Fungal Culture: – Takes up to 4 weeks HYPHAE for results; contaminants • Histology: – or nail for histology

SPORES

KOH for candidiasis 47 48

12 3/26/2014

Dermatophytoses (Tineas) Topical

• Tinea pedis • Polyenes: nystatin • Tinea manuum • Imidazoles (fungistatic; BID) – Miconazole (OTC), Clotrimazole (OTC), Sulconazole, • Oxiconazole, • Tinea corporis • Ciclopirox (QD) • – Loprox • Tinea incognito • Allylamines (fungicidal; QD) – Terbinafine (OTC), Naftifine, Butenafine

49 50

Lotrisone Tinea versicolor

• Combination of betamethasone plus • Etiology: clotrimazole furfur (Pityrosporum – Weak antifungal + superpotent steroid ovale) • Inadequate to kill fungus and may cause • Appearance: well‐ complications (striae, fungal ) defined scaling patches • Dermatologists rarely use it with hypo‐ or hyperpigmentation • Rarely indicated • Diagnosis: clinical morphology, KOH exam

51 52

13 3/26/2014

Tinea Versicolor Treatment

• Selenium sulfide shampoo and lotion • Ketoconazole shampoo • Topical antifungal agents (ketoconazole) • Oral ketoconazole • 400 mg, take with coca‐cola, wait 30 min, exercise, let sweat sit on skin • Repeat in one week • Prophylactic treatment may prevent recurrence

“Spaghetti and Meatball” KOH smear of Tinea Versicolor 53 54

Superficial Cutaneous Candidiasis Candidiasis Treatment • Oral thrush • Etiology: Candida – Nystatin suspension albicans – Clotrimazole troches • Appearance: • Balanitis erythematous – Topical clotrimazole cream plaques, often with “satellite – Oral fluconazole (single dose) pustules” • Candida • Occurs most – Topical imidazole cream commonly in • Paronychia moist, macerated – Avoid wetwork folds of skin – Topical imidazoles – Topical corticosteroid ointment 55 – Systemic therapy in resistant cases 56

14 3/26/2014

Onychomycosis

• Infection of the nail plate by fungus • Vast majority are due to , Onychomycosis especially rubrum • Very common • Increases with age • Half of nail dystrophies are onychomycosis • This means 50% of nail dystrophies are NOT fungal

57 58

Onychomycosis Onychomycosis Diagnosis Interpreting Nail Cultures • KOH is the best test, as it is cheap, accurate if positive, • Any growth of T. rubrum is significant and rapid; Positive 59% • Contaminants • If KOH is negative, perform a fungal culture – Not considered relevant unless grown twice • Frequent contaminant overgrowth from independent samples AND no • 53% positive is cultured • Nail clipping – Relevant contaminants: • Send to lab to be sectioned and stained with special • C. albicans stains for fungus • Scopulariopsis brevicaulis • Accurate (54% positive), rapid (<7d), written report • Fusarium • Downside: Cost (>$100) • Scytalidium (Carribean, Japan, Europe) – Especially in immunosuppressed patients 59 60

15 3/26/2014

Onychomycosis Onychomycosis Treatment Toenail Treatment • Topical Therapy: Limited efficacy • Nail growth • Ciclopirox (Penlac) 8% Lacquer: – At 2 to 3 months nail begins to grow out • Cure rates 30% to 35% for mild to moderate onychomycosis (20% to 65% involvement) – Continues for 12 months • Clinical response about 65% • Repeat KOH/culture at 4-6 months • : 200 mg BID with acid drink and food for one week each month for 3 months – If culture still positive, treatment will likely fail • Terbinafine: 250 mg QD for 12 weeks – KOH may still be positive (dead • Check LFTs at 6 weeks dermatophytes) • Efficacy: 35% complete cures; 60% clinical cures

61 62

Grovers Disease (transient acantholytic dermatosis) • Sudden eruption of , papulovesicles; often crusted • Mid chest and back • Itchy • Middle aged to older men • Etiology unknown‐ heat, sweating • Risk factors: hospitalized, febrile, sun damage • Transient • Treatment: topical steroids (triamcinolone 0.1% cream); get patient to move around

63

16 3/26/2014

Common Dermatologic Disorders: Common Dermatologic Disorders: Tips for Diagnosis and Management Tips for Diagnosis and Management Approach to the itchy patient Eczemas and approach to treatment •Select potency of a topical steroid and it’s Fungal infections of the skin vehicle based on location of treatment site Onychomycosis •Don’t use lotrisone Grovers disease •Onychomycosis requires oral treatment and 12 months to see final results

65 66

17