4/5/18 Dermatology Pearls for the Primary Outline Care Practitioner • Urticaria • Alopecia Lindy P. Fox, MD • Acne in the adult Professor of Clinical Dermatology Director, Hospital Consultation Service • Perioral dermatitis Department of Dermatology • University of California, San Francisco Onychomycosis • The red leg [email protected] • Grover’s disease I have no conflicts of interest to disclose I may be discussing off-label use of medications 1 2 • 36 yoF complains of 2 mo of urticaria • Lesions last < 24 hours, itchy • Failed loratadine 10 mg daily Chronic Urticaria 3 1 4/5/18 Chronic Urticaria Chronic Urticaria- Workup • History and physical guides workup • Urticaria, with or without angioedema > 6 • Labs to check weeks – CBC with differential – Lesions last < 24 hours, itch, completely resolve – ESR, CRP • Divided into chronic spontaneous (66-93%) – TSH and thyroid autoantibodies or chronic inducible – Liver function tests • Natural history- 2-5 years – CU Index (Fc-εRIα Ab or Ab to IgE) – > 5 yrs in 20% patients – Maybe tryptase for severe, chronic recalcitrant disease – 13% relapse rate – Maybe look for bullous peMphigoid in an older patient • Etiology • Provocation for inducible urticaria – 30 -50 % - IgG autoAb to IgE or FcεRIα Eur J Dermatol 2016 – Remainder, unclear Clin Transl Allergy 2017. 7(1): 1-10 Eur J Dermatol 2016 Allergy Asthma Immunol Res. 2016;8(5):396-403 J Allergey Clin Immunol Pract. 2017. Sept 6. S2213-2198 Clin Transl Allergy 2017. 7(1): 1-10 First line Chronic Spontaneous Urticaria- Treatment nd H1 antihistamines- 2 <40% respond to standard dose H1 blockade generation Can increase to up to 4X standard dose What does my “second line” look like? Avoid triggers (NSAIDS, ASA) 60% chance of response Second line • Fexofenadine 360 mg am, 180 mg noon, 360 mg pm High dose 2nd generation AH Add another 2nd generation AH • Cetirizine 10 mg BID 1st gen H1 antihistamine QHS +/- H2 antagonist • Ranitidine 300 mg QD +/- Leukotriene antagonist Third line • Hydroxyzine 25 mg QHS • Monteleukast 10 mg QD Omalizumab Cyclosporine Dapsone Sulfasalazine • When time to taper, get fexofenadine to 180 mg BID J Allergy Clin Immunol 2014. 133(3):914-5 Hydroxychloroquine BJD 2016. 175:1134–52 Mycophenolate mofetil Clin Transl Allergy 2017. 7(1): 1-10 Allergy Asthma Immunol Res. 2016;8(5):396-403 TNFα antagonists Eur J Dermatol 2016 (epub ahead of print) Anti CD20 Ab (rituximab) Allergy Asthma Immunol Res. 2017 November;9(6):477-482. Allergy 2018. Jan 15. epub ahead of print 2 4/5/18 CSU- when to refer • Atypical lesion morphology or symptoms – > 24 hours, central duskiness/purpura – Asymptomatic or burn >> itch Alopecia • Minimal response to medications – High dose H1 nonsedating antihistamines – H1 sedating antihistamines • Associated symptoms – Fever, fatigue, mylagias, arthralgias • Elevated ESR/CRP 10 Alopecia = hair loss Alopecia Areata Non-Scarring Scarring • Affects up to 0.2% US population • Types Alopecia areata Traction alopecia – Relapsing remitting Telogen Effluvium Trichotillomania (end stage) – Ophiasis (band like along occipital scalp) Neutrophil mediated – Alopecia totalis (all scalp hair) Androgenetic alopecia Folliculitis decalvans Dissecting cellulitis of the scalp – Alopecia universalis (all scalp and body hair) Lymphocyte mediated • Associations Lichen planopilaris – Frontal fibrosing alopecia Atopic disease Central centrifugal alopecia – Autoimmune thyroid disease Chronic cutaneous lupus – Vitligo – Inflammatory bowel disease Scalp biopsy: 11 – APECED syndrome • Area ADJACENT to alopecia, ask for TRANSVERSE sections • ALL scarring alopecias OR nonscarring alopecia where diagnosis uncertain 12 3 4/5/18 Alopecia Areata: Alopecia Areata: Round or oval patches of nonscarring alopecia Exclamation point hairs 13 14 Taken from Dermatology, 2012, Elsevier Taken from Dermatology, 2012, Elsevier Alopecia Areat: Ophiasis pattern Alopecia Areata • IL triamcinolone – 10mg/ml – q month • Immunosuppression (recurs after stopped) – Pulse steroids – Methotrexate – Cyclosporine • Contact sensitization • Minoxidil • Antihistamines • Simvastatin/ezetimibe • Tofacitinib J Investig Dermatol Symp Proc. 2018 Jan;19(1):S25-S31 J Investig Dermatol Symp Proc. 2018 Jan;19(1):S18-20 15 JAAD 2018 Jan; 78(1):15-24 16 Taken from Dermatology, 2012, Elsevier 4 4/5/18 Telogen Effluvium Telogen Effluvium- Causes • Normal hair cycle • Postpartum • Chronic (no cause) – Anagen 90-95% • Post febrile – Catagen • Severe infection • – Telogen 5-10% Severe chronic illness (SLE, HIV, etc) • Severe prolonged stress – Normal shedding is 50-100 hairs/day • Post major surgery • Transient shifting of hair cycle • Endocrinopathy – Thyroid, parathyroid • Shedding • Crash diets, malnutrition, starvation • • Medications No scalp itch or rash – Stopping OCP, retinoids, heparin, PTU, methimazole, anticonvulsants, β- blockers, IFN-α, heavy metals 17 18 Telogen Effluvium Androgenetic Alopecia • Examination – Diffuse thinning • Male or female pattern hair loss – Hair pull • Female • Diagnostic > 20% hairs are telogen – Complain of widening part – Look for bulb at end of hair shaft – Retain anterior hairline • Workup – Early onset/severe: workup for hyperandrogenism – TSH, Vit D, Fe, ferritin, chemistry • F/T testosterone, DHEAS, 17-OH progesterone – Biopsy if > 6 mo (r/o AGA) • Often “exposed” by telogen effluvium • Treatment • Treat with – Address underlying etiology – Minoxidil 5% (F QD, M BID) – Replete ferritin if < 40 ng/dl – Spironolactone (female) – Minoxidil – Finasteride- up to 5mg/d – Reassurance (most regrow almost all lost hair) • NOT for women of childbearing potential 19 20 5 4/5/18 Some scarring alopecias 21 22 Taken from Dermatology, 2012, Elsevier Traction Alopecia Chronic Cutaneous LE 23 24 Taken from Dermatology, 2012, Elsevier Taken from Dermatology, 2012, Elsevier 6 4/5/18 Lichen Planopilaris Approach to the Adult Acne Patient 25 26 Taken from Dermatology, 2012, Elsevier Acne Pathogenesis, Clinical Features, Therapeutics Acne Treatment Pathogenesis Clinical features Therapeutics Excess sebum Oily skin Retinoids, • Mild inflammatory acne spironolactone – benzoyl peroxide + topical antibiotic (clindamycin, erythromycin) • Moderate inflammatory acne – oral antibiotic (tetracyclines) (with topicals) Non-inflammatory Salicylic acid, Abnormal follicular retinoids open and closed • Comedonal acne keratinization comedones – topical retinoid (tretinoin, adapalene, tazarotene) (blackheads and • Acne with hyperpigmentation whiteheads) – azelaic acid • Acne/rosacea overlap /seborrheic dermatitis- Benzoyl peroxide – sulfur based preparations Propionibacterium Antibiotics • Hormonal component acnes Inflammatory papules (topical and oral) and pustules Spironolactone – oral contraceptive, spironolactone OCPs • Cystic, scarring- isotretinoin Inflammation Isotretinoin – Teratogenic, hypertriglyceridemia, transaminitis, cheilitis, xerosis, Cystic nodules alopecia (telogen effluvium) 27 28 7 4/5/18 Acne Therapy Guidelines Topical Retinoids • Limit oral antibiotics to 3-6 mo • Side effects • All patients should receive a retinoid for – Irritating- redness, flaking/dryness maintenance – May flare acne early in course – Tretinoin – Photosensitizing – Tazarotene – Tazarotene is category X in pregnancy – Adapalene (now OTC) !!! 29 30 JAAD 2016; 75: 1142-50 31 32 8 4/5/18 33 34 35 36 9 4/5/18 Acne in Adult Women Acne Pearls • 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 • Wait 20-30 minutes after washing face to apply • Other features of PCOS are often not • Use 1-2 pea-sized amount to cover the whole face present—irregular menses, etc. • Start BIW or TIW • Serum testosterone can be normal • Tazarotene is category X in pregnancy • • Spironolactone 50 mg-200mg daily with or BacK acne often requires systemic therapy without OCPs • Acne in adult women- use spironolactone – No need to checK K+ in healthy adult women 37 38 Perioral Dermatitis • Women aged 20-45 • Papules and small pustules around the mouth, narrow Perioral dermatitis spared zone around the lips. • Asymptomatic, burning, itching • Causes – Steroids (topical, nasal inhalers) – Fluorinated toothpaste – Skin care creams with petrolatum or paraffin base or Isopropyl myristate (vehicle) 39 40 10 4/5/18 Perioral Dermatitis: Treatment • Stop topical products • Topical antibiotics – Clindamycin Onychomycosis • Topical or oral ivermectin • Oral tetracyclines • Warn patients of rebound if coming off topical steroids • Avoid triggers 41 42 Onychomycosis Onychomycosis • Infection of the nail plate by fungus • Vast majority are due to dermatophytes, especially Trichophyton rubrum • Very common • Increases with age • Half of nail dystrophies are onychomycosis • This means 50% of nail dystrophies are NOT fungal 43 44 11 4/5/18 Onychomycosis Onychomycosis Diagnosis • KOH is the best test, as it is cheap, accurate if positive, and rapid; Positive 59% • If KOH is negative, perform a fungal culture • Frequent contaminant overgrowth • 53% positive • Nail clipping • Send to pathology lab to be sectioned and stained with special stains for fungus • Accurate (54% positive), rapid (<7d), written report • Downside: Cost (>$100) 45 46 Onychomycosis Onychomycosis: Local Treatment Interpreting Nail Cultures • Laser- insufficient data that it works • Any growth of T. rubrum is significant • Topical Therapy: • Contaminants • Ciclopirox (Penlac) 8% Lacquer: – Not considered