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Home , Acne, Onychomycosis, Ophiasis, Pattern hair loss, Perioral dermatitis, Telogen effluvium

4/5/18

Dermatology Pearls for the Primary Outline Care Practitioner • Urticaria • Alopecia Lindy P. Fox, MD • in the adult Professor of Clinical Director, Hospital Consultation Service • Perioral Department of Dermatology • University of California, San Francisco • The red leg [email protected] • Grover’s disease I have no conflicts of interest to disclose

I may be discussing off-label use of

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• 36 yoF complains of 2 mo of urticaria • Lesions last < 24 hours, itchy • Failed loratadine 10 mg daily

Chronic Urticaria

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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 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 2017. 7(1): 1-10 Eur J Dermatol 2016 Allergy 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 - 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 QHS +/- H2 antagonist • Ranitidine 300 mg QD +/- Leukotriene antagonist Third line • Hydroxyzine 25 mg QHS • Monteleukast 10 mg QD Omalizumab Cyclosporine Sulfasalazine • When time to taper, get fexofenadine to 180 mg BID J Allergy Clin Immunol 2014. 133(3):914-5 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

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CSU- when to refer • Atypical lesion morphology or symptoms – > 24 hours, central duskiness/purpura – Asymptomatic or burn >> Alopecia • Minimal response to medications – High dose H1 nonsedating antihistamines – H1 sedating antihistamines • Associated symptoms – Fever, fatigue, mylagias, arthralgias • Elevated ESR/CRP

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Alopecia = loss Non-Scarring Scarring • Affects up to 0.2% US population • Types Alopecia areata – Relapsing remitting (end stage) – (band like along occipital ) mediated – (all scalp hair) Androgenetic alopecia decalvans Dissecting of the scalp – (all scalp and ) Lymphocyte mediated • Associations Lichen planopilaris – Frontal fibrosing alopecia Atopic disease Central centrifugal alopecia – Autoimmune thyroid disease Chronic cutaneous – Vitligo – Inflammatory bowel disease Scalp : 11 – APECED syndrome • Area ADJACENT to alopecia, ask for TRANSVERSE sections • ALL scarring alopecias OR nonscarring alopecia where diagnosis uncertain 12

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Alopecia Areata: Alopecia Areata: Round or oval patches of nonscarring alopecia Exclamation point

13 14 Taken from Dermatology, 2012, Elsevier Taken from Dermatology, 2012, Elsevier

Alopecia Areat: Ophiasis pattern Alopecia Areata

• IL triamcinolone – 10mg/ml – q month • (recurs after stopped) – Pulse steroids – Methotrexate – Cyclosporine • Contact sensitization • • 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

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Telogen Effluvium Telogen Effluvium- Causes

• Normal hair cycle • Postpartum • Chronic (no cause) – Anagen 90-95% • Post febrile – Catagen • Severe • – Telogen 5-10% Severe chronic illness (SLE, HIV, etc) • Severe prolonged stress – Normal shedding is 50-100 hairs/day • Post major • Transient shifting of hair cycle • Endocrinopathy – Thyroid, parathyroid • Shedding • Crash diets, malnutrition, starvation • • Medications No scalp itch or – Stopping OCP, , heparin, PTU, methimazole, anticonvulsants, β- blockers, IFN-α, heavy metals

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Telogen Effluvium Androgenetic Alopecia • Examination – Diffuse thinning • Male or female pattern – 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 – TSH, Vit D, Fe, ferritin, chemistry • F/T , 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 – - up to 5mg/d – Reassurance (most regrow almost all lost hair) • NOT for women of childbearing potential 19 20

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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

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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 – + topical (, ) • Moderate inflammatory acne – oral antibiotic () (with topicals) Non-inflammatory , Abnormal follicular retinoids open and closed • Comedonal acne keratinization comedones – topical (, , ) (blackheads and • Acne with whiteheads) – • Acne/ overlap /seborrheic dermatitis- Benzoyl peroxide – based preparations • Hormonal component acnes Inflammatory (topical and oral) and pustules Spironolactone – oral contraceptive, spironolactone OCPs • Cystic, scarring- Isotretinoin – Teratogenic, hypertriglyceridemia, transaminitis, , xerosis, Cystic nodules alopecia (telogen effluvium)

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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 – Adapalene (now OTC) !!!

29 30 JAAD 2016; 75: 1142-50

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Acne in Adult Women Acne Pearls • Retinoids are the most comedolytic • Often related to excess 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

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Perioral Dermatitis

• Women aged 20-45 • Papules and small pustules around the mouth, narrow spared zone around the lips. • Asymptomatic, burning, itching • Causes – Steroids (topical, nasal inhalers) – Fluorinated toothpaste – creams with petrolatum or paraffin base or Isopropyl myristate (vehicle)

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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

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Onychomycosis Onychomycosis

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

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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)

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Onychomycosis Onychomycosis: Local Treatment Interpreting Nail Cultures • - insufficient data that it works • Any growth of T. rubrum is significant • Topical Therapy: • Contaminants • (Penlac) 8% Lacquer: – Not considered relevant unless grown twice • Cure rates 30% to 35% for mild to moderate onychomycosis from independent samples AND no (20% to 65% involvement) is cultured • Clinical response about 65% – Relevant contaminants: • (Jublia) 10%* • C. albicans • Daily for 48 weeks • Scopulariopsis brevicaulis • Complete or almost complete cure (completely clear nail)- 26% • • Mycologic cure (neg KOH and neg fungal cx)- 55% • Scytalidium (Carribean, Japan, Europe) • (Kerydin) 5%* – Especially in immunosuppressed patients • Daily for 48 weeks • Complete or almost complete cure (completely clear nail)- 15-17% • Mycologic cure (neg KOH and neg fungal cx)- 31-36% 47 48 *Data from pharma website

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Onychomycosis Onychomycosis: Systemic Treatment Assessing Treatment • : • Nail growth – 200 mg/d for 3 months – At 2 to 3 months nail begins to grow out – 400 mg/d for one week per month for 4 months – Continues for 12 months • : 250mg po QD • Repeat KOH/culture at 4-6 months – Fingernails: 6 weeks – If culture still positive, treatment will likely fail – Toenails: 12 weeks – KOH may still be positive (dead dermatophytes) • Check LFTs at 6 weeks • Failures – Pulse dosing – Terbinafine resistance • 500 mg daily for one week monthly for 3 months – Non-dermatophyte – Efficacy: 35% complete cures; 60% clinical cures – Dermatophytoma

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The red leg: Cellulitis and its (common) mimics • Cellulitis/erysipelas • •

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Cellulitis • Infection of the • Gp A beta hemolytic strep and Staph aureus • Rapidly spreading • Erythematous, tender plaque, not fluctuant • Patient often toxic • WBC, LAD, streaking

• Rarely bilateral • Treat tinea pedis

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Stasis Dermatitis Contact Dermatitis

• Often bilateral, L>R • Itch (no pain) • Itchy and/or painful • Patient is non-toxic • Red, hot, swollen leg • and • No fever, elevated WBC, edema can be severe LAD, streaking • Look for: varicosities, • Look for sharp cutoff edema, venous ulceration, • Treat with topical hemosiderin deposition steroids • Superimposed contact dermatitis common

Contact Dermatitis • Common causes – Applied antibiotics (Neomycin, Bacitracin) – Topical anesthetics (benzocaine) Grover’s Disease – Other ( E, topical diphenhydramine) • Avoid topical antibiotics to leg ulcers – OK (prevents odor)

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Grovers Disease (transient acantholytic dermatosis) • Sudden eruption of papules, 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

A few simple rules to live by:

• Chronic urticaria- antihistamines at 4x standard dose • Alopecia- nonscarring (eval, treat) vs scarring (refer) • Spironolactone for acne in adult women • Limit duration of oral antibiotics for acne to < 6mo • Almost all acne patients benefit from topical retinoids • Onychomycosis treatment efficacy: oral > topical • Cellulitis is almost never bilateral • Treat tinea pedis in patients with cellulitis

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