sign in sign up
<<
Home , Butenafine, Tinea corporis, Tinea cruris, Tinea versicolor

Common • Can be treated by topical agents and 9 best (, ) 9 Ciclopiroxamine 9 • If widespread should be treated systemically Matthew J Zirwas, MD 9 Tebinafine 250 mg QD x 2-4 weeks Assistant Professor of 9 or for 2-4 weeks • Watch Drug Interactions • Consider ketoconazole 2% or Selenium Sulfide 2.5% wash 3x/week to prevent recurrence

Tinea Corporis • Red scaly ring with central clearing 9 Large areas can be involved 9 Central clearing may not be complete 9 Can have pustules or vesicles at periphery 9 Can have multiple lesions • May involve trunk, arms, legs, face • Diagnosis can be confirmed by KOH exam or fungal culture

1 Tinea Pedis • Extremely common fungal of skin of feet, often • Presents as chronic brown to red patches in coexists with groin folds • “Moccasin” type causes redness and scaling of soles • Rare before puberty, more common in men and sides of feet • Often spares , penile shaft, glans penis • Interdigital type produces white macerated fissures between the toes • Should be differentiated from that is • Bullous type produces small on sole of foot typically bright red, often involves scrotum, glans penis, may manifest satellite pustules • Responds well to topical therapy • Usually responds to topical antifungal therapy 9 Most effective are terbinafine, butenafine, ciclopiroxamine 9 Avoid /betamethasone 9 Consider maintenance therapy with weekly combination creams due to high risk of treatment or with foot powders permanent striae 9 Especially important to eradicate in diabetics

2 Onychomycosis

• Fungal infection of toenails , often associated with tinea pedis • May produce yellow or white discoloration of toenails with dystrophy or separation of from nailbed • Nails may become thickened or develop white powder under the nail

3 (TV) • Tinea versicolor (TV) usually presents as hypo or hyperpigmented macules with very fine scale on upper chest, upper back, shoulders • Due to an overgrowth of a (Pityrosporum ovale), which thrives on sebum • Treatment: 9 Single doses or short courses of oral ketoconazole or itraconazole 9 Ketoconazole 2% wash or Selenium Sulfide 2.5% wash • is due to dicarboxylic acid produced by the yeast, which inhibits melanin formation. Persists long after infection resolved.

Treatment of Onychomycosis

• Usually requires systemic antifungal agents with terbenafine being most effective. Itraconazole is less effective. • Close to 100% relapse rate • Topical are less effective • Tinea pedis cannot be effectively treated long term unless onychomycosis is also eliminated.

4 • Due to a large DNA virus classified as a pox virus • Demographics: 9 Most common in children, especially with 9 Sexually transmitted in young adults 9 Immunosuppressed adults, especially with advanced HIV • May have very large lesions or facial lesions • Often presents with a small (1-3mm) shiny, skin colored with a central dimple • Typically resolve spontaneously eventually if not immunosuppressed • Treatment typically with liquid nitrogen or currettage in adults. Many topical options in children.

Warts

• Due to human papilloma virus (HPV), which is a double stranded DNA virus • Can infect epithelial keratinocytes (skin, genital, mucosa) • Well over 70 different HPV viral strains • Can present anywhere in body, including fingers, hands, feet, genitals

5 Genital • Most common sexually transmitted disease • HPV types 6 and 11 are most common • HPV types 16, 18, 31, 33 can induce squamous cell cancer • Can appear as verucous papules in genital surface or genital area • Can be associated with cervical cancer and anal cancer • Individuals with suppressed cell mediated immunity are at particular risk for developing genital and anal cancer, including HIV and organ transplant patients

6 Oral & Genital Virus (HSV)

• Are double-stranded DNA virus and generally spread by direct skin to skin contact • HSV-1 – cause 80% oral-labial, 20% genital herpes cases • HSV-2 – cause 80% genital, 20% oral-labial herpes cases • In the U.S. population, prevalence of HSV-1 antibodies (indicating infection) is 80-90% and prevalence of HSV-2 antibodies is 20%

HSV Cutaneous Treatment Manifestation • Manifest as pain, burning, tingling prior to the • Aggressive debridement of hyperkeratosis appearance of the lesions followed by 2 cycles of liquid nitrogen • Lesions are localized groups of vesicles on an • coupled with topical erythematous base that rupture and form crust. imiquimod (stimulates local interferon • Atypical clinical presentations common. History production – lower recurrence rate, of recurrent eruption in same location preceded especially in genital lesions) by symptoms is highly suggestive. • Laser therapy • Prophylactic therapy – 500 or 1000 mg valacyclovir QD • Many other therapies – none particularly effective. • Episodic therapy – valacyclovir 2000 mg Q12 hrs x 2 doses

7 Varicella Zoster Manifestations • Presents initially as erythematous plaque along a dermatomal distribution with sharp cut off at midline • Pain, burning, tingling often precedes the eruption • Vesicopustules soon develop in the plaque, which rupture and scab

Varicella Zoster Varicella Zoster Complications • Caused by varicella zoster virus • V1 dermatomal involvement can lead to • After an episode of varicella, virus visual impairment remains latent in dorsal root ganglia and trigeminal ganglion • Post herpetic involvement can lead to persistent pain for months after the • Reactivation leads to viral proliferation eruption resolves and retrograde axonal transport to skin • Complications and pain much more • Most common in elderly and common in the elderly. immunosuppressed patients

8 Varicella Zoster Treatment

• Oral antivirals. The earlier initiated, the more effective and the lower the chance of complications. 9 Valacyclovir 1000 mg tid x 7 days is most common • Post-herpetic neuralgia is treated with gabapentin, tricyclic antidepressants, nerve blocks, lidocaine patch, topical capsaicin

Scabies • Caused by mite Sarcoptes scabiei • Common in children, nursing home residents, recently hospitalized individuals • Infestation produces intense pruritus, especially at night • Typical patient has 10-20 mites on their body and is caused by allergic reaction to mites and feces

9 Clinical Manifestations

• Areas commonly involved include finger webs, abdomen, breast, groin, including penis. • Classic lesions are burrows – thin white lines • Crusted scabies – thick crusts on hands, feet, scalp due to thousands or millions of mites – in immunocompromised patients. May not be as itchy.

10 Scabies Treatment

• Consider treating any patient with unexplained pruritus who has recently been institutionalized. • Topical permethrin and/or oral ivermectin 9 Next morning, wash sheets and clothes worn in last 7 days. 9 Repeat in 1 week to kill recently hatched eggs.

Cellulitis

• Common cutaneous infection most often caused by staph aureus & strep pyogenes • Crusting, weeping eruption • Essentially NEVER BILATERAL. ALWAYS SYSTEMICALLY ILL. • Methicillin Sensitive Staph Aureus is most common • Skin demonstrates , edema, warmth, tenderness • Empirically treat with 1st generation • Blood cultures should be obtained and patient cephalosporin until culture results started on a beta-lactamase resistant antibiotic or available other appropriate coverage

11 Spontaneous Abscess • Lance with cruciate incision • Spontaneously appearing are • Antibacterial therapy: specific manifestation of community 9 Empiric therapy with minocycline or tmp/smx acquired MRSA (ca-MRSA) 9 Antibacterial soap in shower 9 Antibiotic resistance genes carried on • Dial bodywash OTC same plasmid as gene for virulence • Chlorhexidine wash factor that promotes abscess formation 9 Consider mupirocin to nares 1 week/month 9 Consider weekly soak in chlorinated water (either swimming pool or bathtub with ¼ cup chlorine added). Address fomites as well.

12 Acne - Inflammatory Non-inflammatory • Comedones • Open and closed comedones • Red Papules, pustules • Treatment: • Face, possibly shoulders, chest, back 9 Salicylic Acid 6% wash • Treatment: 9 Tretinoin 0.025% cream before bed 9 Oral Doxycycline or Minocycline 100 mg bid 2-3 x/week 9 Topical Tretinoin 0.05% cream QHS 9 Benzoyl Peroxide/Clindamycin combo cream 9 Consider OTC benzoyl peroxide gel in AM 9 Benzoyl peroxide or salicylic acid wash

Acne - Inflammatory Acne - Nodular

13 Acne - Nodular • Comedones • Papules, Pustules • Deep nodules • Face, probably chest, shoulders, back • Treatment: 9 Isotretinoin 9 If isotretinoin contraindicated, then treat same as inflammatory, but probability of success is low

Adult Acne Rosacea • Fairly common in women in 20s, 30s, and 40s. +/- teenage acne. • Mild – red cheeks • Usually flares with monthly menstrual • Moderate – red cheeks, red papules cycle due to hormonal variation. • Mostly affects chin and jawline area. • Severe – red cheeks, red papules, pustules • Topical therapy not very effective. • Flushing (hot liquids, spicy food, alcohol) • Best treatment: • Treatment: 9 Oral contraceptives containing 9 Topical Metronidazole drosperinone 9 Oral Doxycycline 9 Oral spironolactone

14 Seborrheic Dermatitis

• Three main types: 9 Plaque 9 Guttate 9 Pustular • Arthritis can be seen with any type • AVOID SYSTEMIC

Seborrheic Dermatitis Plaque Psoriasis • Redness, greasy scale 9 Nasolabial, eyebrows, scalp, chest • Often flares in hospitalized patients • Worse in HIV, Parkinson, other neuro dz • Worse with oily skin/ • Treatment: 9 Ketoconazole cream QD 9 Desonide 0.05% Lotion PRN 9 Wash face with shampoo

15 Plaque Psoriasis Guttate Psoriasis • Most common type • 2nd most common • Elbows, Knees, Scalp, Sacrum, Widespread • More common in children • May itch • Related to strep infections • Trunk most involved • Chronic, persistent • May resolve spontaneously • Treatment: Topical steroids, topical vitamin D, oral immunosuppressants, • Treat with topicals, UV light injectable biologics, UV light

Guttate Psoriasis Pustular Psoriasis

16 Pustular Psoriasis

• CD4 T-cells specifically recognize a substance • Most acute type • When substance contacts the skin, rash • Can be life threatening develops 8-48 hours later • May have fevers, elevated WBC, low • Rash lasts 7-28 days calcium • Very, very itchy • Can be caused by withdrawal of systemic • Treatment: steroids 9 Avoidance of substance • Treat with cyclosporine 9 Oral or topical steroids for flares

Psoriasis Therapy Contact Dermatitis – Nickel • Topical steroids, topical vitamin D • Ultraviolet Light (usually UVB or sunlight) • Consider oral if over 10% of body surface involved 9 Methotrexate, Acitretin, Cyclosporine • Injectable medications 9 Biologics – TNF-alpha inhibitors

17 Contact Dermatitis – Contact Dermatitis - Nickel Fragrance • Very common (up to 10% or more of the • Face, Neck, Hands population) • More common if ears pierced • Common exposures: • Common sources of exposure: 9 Shampoo, soap, conditioner, products, 9 Jewelry (earrings, watches, etc) moisturizer, perfume, deodorant 9 Clothing (belts, snaps, rivets, etc) • Very difficult to avoid fragrances, as even products that say “Fragrance Free” often have 9 Coins, Keys, Eyeglasses fragrances • Coating items with nail polish not much help • Allergic patients only react to some fragrances • Internet for sources of nickel free jewelry

Contact Dermatitis - Contact Dermatitis - Fragrance Preservatives

18 Contact Dermatitis - Contact Dermatitis – Preservatives Poison Ivy • Face, Neck, Hands • Very common, probably 75% of the • Common exposures: population is sensitized 9 Shampoo, soap, conditioner, hair • “Streaky Dermatitis” products, moisturizer, perfume, • New spots can appear for days after rash deodorant starts • Very difficult to avoid preservatives, as • Rash caused by Urushiol almost all products have preservatives • fluid does not spread the rash • Allergic patients only react to some • Treat with 3 weeks of prednisone or with high preservatives potency topical steroids

Contact Dermatitis – Contact Dermatitis - Poison Ivy Neosporin

19 Contact Dermatitis - Neosporin

• Very common, up to 10% of the population is allergic • Both Neomycin (most common cause of allergic contact dermatitis from topical medications) and Bacitracin

Contact Dermatitis - Other • Can be allergic to almost anything: 9 Clothing, Shoes 9 Rubber gloves 9 Leather 9 Fingernail Polish, Acrylic Nails 9 Hair Dye, Perms 9 Tattoos 9 Etc, etc

20