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Common Dermatologic Conditions in Ambulatory Care Dr. Jessica Servey, MD, COL (ret), USAF Associate Dean for Faculty Development Associate Professor of Family Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland Dr. Courtney Halista, MD, Capt, USAF Dr. Glynnis Knobloch, MD, Capt, USAF Family Medicine Chief Resident Family Medicine Chief Resident Travis Air Force Base, California Eglin Air Force Base, Florida

Disclaimer Objectives

Identify the 10 most common conditions encountered in the Family The opinions expressed reflect the personal opinions of the presenters and do not reflect the Medicine clinic opinion of the Uniformed Services University, United States Air Force, or the Department of Understand basic treatment principles Defense. Know when to refer to a Dermatologist We have nothing to disclose. Overview Terminology plaque Top 10 Dermatologic Conditions in Ambulatory Care macule patch Atopic vesicle Seborrheic Dermatitis Dermatology Terminology excoriation scale Condyloma pustule Benign Tumors Skin Tinea bullae

petechiae urticaria

Papules vs Nodules Macule vs Patch Nodules > 1 cm

Only FLAT

Patch > 1 cm < 1cm Both solid raised lesion Flat well circumscribed any color or lack of color

Plaques Vesicles vs Bullae Raised lesion Surface area > height

Often confluence (coalesced) Bulla Vesicle papules Fluid filled structure > 1 cm Fluid filled structure < 1 cm Urticaria Lichenification vs Scale Red, itchy, elevated lesion caused by local

Each lesion lasts < 24 hours Lichenification Scales Thickened Excess dead epidermal cells Accentuates the skin lines Abnormal keratinization and shedding

Petechiae Non-blanchable, punctate foci of hemorrhage Drying plasma or exudate

Ulceration vs Erosion Excoriation Fissure Skin breakdown due to Linear cleavage of skin scratching or rubbing Extends into the

No scarring Scarring

Erosion Ulceration Does NOT cross the Crosses into dermis dermo-epidermal border Permanently dilated vessels

Medication class Diagnosis Side effects Common Other dermatologic features Acne, Psoriasis Skin redness, burning, skin peeling and dryness, sensitivity Steroids , Hypopigmentation, skin thinning, Pattern (oral/topical) Contact dermatitis, , Location Seborrheic dermatitis, Psoriasis, History Atopic dermatitis, Black box warning: Configuration Inihibitors Psoriasis Anti-fungals Seborrheic dermatitis, Oral elevated LFTs, multiple (oral/topical) Tinea, Candida interactions Atopic dermatitis, Drowsiness Contact dermatitis Seborrheic dermatitis, Skin tingling or Psoriasis

Acne ACNE VULGARIS DR. HALISTA ATOPIC DERMATITIS Most common skin disorder CONTACT DERMATITIS affecting adolescents and SEBORRHEIC DERMATITIS PSORIASIS young adults BENIGN TUMORS Prevalence decreases with SKIN TINEA age CANDIDA Males > Females in CONDYLOMA adolescence Females > Males in adulthood Pathophysiology of Acne Role of Androgens

1. Follicular hyperkeratinization Androgen precursors are 2. Increased sebum production converted to active sulfate (DHEA-S) hormones in the 3. Propionibacterium acnes within the sebaceous Dehydroepiandrosterone Testosterone and DHT follicle receptors are present in (DHEA) the sebaceous glands 4. and on the follicular Testosterone

Dihydrotestosterone (DHT)

Types of Acne Vulgaris Types of Acne Vulgaris Open and Closed Comedones Papules and Pustules

Open Comedones

Papule Pustule

Closed Comedones

Types of Acne Vulgaris Nodules and Treatment of Acne Vulgaris 1. Follicular 3. Propionibacterium acnes hyperkeratinization within the follicle Topical retinoids Benzoyl peroxide Oral retinoids Topical and oral Azelaic acid Azelaic acid Hormonal therapies 4. Inflammation Oral 2. Increased sebum Oral production Topical retinoids Nodule Oral isotretinoin Azelaic acid Hormonal therapies Treatment of Acne Vulgaris Treatment Pearls American Academy of Dermatology Benzoyl peroxide bleaches fabric 2016 Guidelines Type of Acne Recommended 1st Line Therapy Benzoyl peroxide and topical retinoids should NOT Comedonal,non-inflammatory acne Topical be applied at the same time Mild papulopustular and Topical (Benzoyl peroxide alone or Benzoyl peroxide oxidizes mixed (comedonal and papulopustular) acne Benzoyl peroxide + Topical ) + Topical Apply benzoyl peroxide in morning and tretinoin retinoid Or in evening Benzoyl peroxide + Topical antibiotic

Moderate papulopustular and mixed acne Topical retinoid + Oral antibiotic + Topical benzoyl Topical antibiotics (e.g. , ) peroxide should not be used as monotherapy Severe (nodular) acne Topical retinoid + Oral antibiotic + Topical benzoyl Use w/ benzoyl peroxide to decrease antibiotic peroxide Or resistance Oral Isotretinoin monotherapy

Hormonal therapies for women

OCPs

OCPs Spironolactone

Estrogen predominant anti-androgenic Androgen blocker and 5-alpha- decreased sebum production reductase inhibitor 3 FDA approved formulations in United States Contraindicated in Estrostep Ideal candidates Ortho Tri Cyclen Women whose flares coincide w/ menses Yaz Women w/ predominant acne on lower face & Many others not FDA approved but can be used jawline Dosing 25 100mg daily divided BID Oral Isotretinoin Oral Isotretinoin

Candidates: patients with severe nodular acne Dosing: that is unresponsive to conventional therapies 0.5 mg/kg/day either daily or divided BID for : decreases size of 1st month sebaceous glands leading to decreased sebum 1 mg/kg/day either daily or divided BID production and decrease P. acnes colonization thereafter

Must be registered in iPledge to prescribe Treatment Goal: 120 150 mg/kg total

Oral Isotretinoin Monitoring on Oral Isotretinoin Highly teratogenic Laboratory Test Prior to Monthly while One month after initiating on therapy completing All females MUST be on 2 forms of birth therapy therapy control Function X X* Tests Fasting Lipids X X* Urine or Serum X X X Potential adverse side effects -hCG Dry skin, including and epistaxis Transaminitis *May discontinue monthly monitoring if stable Hypertriglyceridemia Severe muscle aches, especially after exertion during the first 3 months of therapy Worsening with

When to Discontinue Oral Isotretinoin ACNE VULGARIS Triglycerides > 800 mg/dl due to risk of ATOPIC DERMATITIS DR. KNOBLOCH SEBORRHEIC DERMATITIS pancreatitis CONTACT DERMATITIS PSORIASIS AST or ALT > 3x normal BENIGN TUMORS After reaching treatment goal TINEA CANDIDA CONDYLOMA Atopic Dermatitis Pathophysiology

Affects approximately 11% Genetic defect in and other skin of US population barrier proteins Disrupted epidermis increased contact Most commonly ALLERGIC ATOPIC between environmental antigens and diagnosed <2 years RHINITIS DERMATITIS immune system response to antigens Scratching further disrupts barrier - -

Clinical Presentation

Erythema Papules and plaques Pruritus Xerosis Most commonly on flexural surfaces*

Chronic skin changes Management 1st line

Behavioral and lifestyle changes Warm (not hot) showers, sponge baths Minimize use of Regular emollient use regardless of active lesions immediately after bathing Ointment >> Cream Topical Steroids Management 1st line Superpotent Clobetasol 0.05% Topical Palms, soles, Tailor potency to severity of Occlusive therapy if severe symptoms* ointment 0.01% Apply daily for 2 weeks or until improved Body If not improved, consider step-up in therapy 0.05%, Least potent 2.5% Face, groin, neck

Management 2nd line Management -2nd line

Topical Calcineurin Inhibitors* Second line: Topical phosphodiesterase- Indicated for moderate to severe disease 4 Pimecroliums (Elidel®) (Eucrisa®) (Protopic®) No black box warning Can be used in more sensitive areas Black box warning: lymphoma, skin

Systemic Therapy 3rd liney Complications

Dermatology referral Common secondary bacterial : UV Staphylococcus and Streptococcus Systemic immunomodulatory therapy HSV () Short course of PO or IM Post-inflammatory skin changes, scarring Thinning of skin, hypopigmentation from chronic steroid use Antibiotics Bacterial complications

No indication for MSSA, Strep MRSA routine use Adults Adults: 250-500mg Clindamycin 300-450 QID 2% mupirocin QID for 7 days TMP/SMX DS 1-2 tabs daily ointment as Cephalexin 250-500mg QID 100mg BID Children Children indicated Clindamycin 20mg/kg/day ¼ cup bleach Dicloxacillin 25- in 3 divided doses + 20 gallons water 50mg/kg/day divided in 4 Weekly bleach baths TMP/SMX DS 8-12mg of doses TMP/kg/day in 2 divided for decolonization Cephalexin 25- doses 50mg/kg/day in 3-4 divided Doxycycline (>8 years) 2- doses 4mg/kg/day in 2 divided doses

ACNE VULGARIS ATOPIC DERMATITIS CONTACT DERMATITIS DR. KNOBLOCH SEBORRHEIC DERMATITIS PSORIASIS SKIN CANCER BENIGN TUMORS TINEA CANDIDA CONDYLOMA

Contact Dermatitis Allergic Subtype Inflammatory due to Type IV, T-cell contact with foreign substance mediated Two types Occurs on exposed skin Allergic contact dermatitis (20%) Pruritus is the Irritant contact dermatitis (80%)%) dominant feature Vesicles and bullae Distinct borders Allergic Subtype Allergic Subtype Rhus plant 70% of people become sensitized Other common causes: Initial episode occurs 7-10 days after exposure Topical antibiotic ointments Subsequent exposure 2 days Fragrances/ Streaks of erythematous papules and Latex plaques, may form Children often present with allergy on face

Treatment Treatment

Identify and avoid substance Severe reaction requires 2-3 week PO Referral for patch testing steroid taper Topical steroids 0.5-1mg/kg/day of prednisone Oral anti-histamines may improve DO NOT give steroid burst to these patients pruritus Oatmeal baths, soothing , cool compress Wet dressings if oozing/crusting present

Prevention Irritant Subtype

Consider patch testing to ID substance Symptoms may occur immediately due to direct skin injury coat with iron-on patch, clear polish Usually on Test items with DMG solution Causes burning, pruritus, Use emollients/barrier creams to pain prevent re-exposure Dry and fissured skin with indistinct borders Diagnosis Treatment

Often occupation-related Identify and avoid substance sanitizer in place of Commonly related to soaps Topical steroids Mimicking lesions Emollients, barrier creams If not improving Candida KOH prep Patch testing to rule out allergic subtype microscopy Dermatology referral Bacterial infection

ACNE VULGARIS ATOPIC DERMATITIS CONTACT DERMATITIS SEBORRHEIC DERMATITIS DR. SERVEY PSORIASIS BENIGN TUMORS SKIN CANCER TINEA CANDIDA CONDYLOMA

Seborrheic Dermatitis

Chronic inflammation Common in areas with high density of sebaceous glands scalp, chest, face, and back 1-3% of general population 34-83% of immunocompromised yeast

Men>Women Treatment

Triple pronged management Some have intense pruritus Others have no symptoms Antiproliferative Decrease the organism

Anti- inflammatory

Treatment (OTC) Scalp

Emollients Coal tar : twice weekly , Selenium sulfide shampoo: twice *do not use natural oils such as weekly Soft brush for infants shampoo: daily shampoo: twice weekly Purpose control the scaling! (and helps with pruritus)

Topical Scalp Topical Antifungals Face/Body

Ketoconazole 2% shampoo: daily then 2% cream/shampoo: twice weekly maintenance therapy twice daily for 8 weeks then PRN Creams: BID for 2 weeks for flares followed by twice a week for prevention : leave on for 5-10 minutes. Daily x2 weeks/ twice a week Topical Corticosteroids Scalp Topical Corticosteroids Face/Body

Clobetasol 0.5% solution: alternate with Desonide 0.05% cream, ointment ketoconazole shampoo twice weekly, use for 2 weeks Fluocinolone 0.01% oil Fluocinolone Acetonide 0.01% oil (Derma-Smoothe®): daily for 2 weeks Moderate to severe cases ***KEY** - use a solution!

Calcineurin Inhibitors Face/Body Special consideration - Infants

Pimecrolimus 1% cream: BID Thick white or yellow plaque on scalp Tacrolimus 0.1% ointment: BID Typically self resolves reassure and wait Remove scales with soft brush after shampoo Can still use the treatments for adults starting with antiproliferative

Masqueraders Referral?

Natural disease course can wax and Rosacea wane in severity Rare to need referral If consistently not well controlled on good combination of therapy Always discuss compliance issues Psoriasis ACNE VULGARIS ATOPIC DERMATITIS CONTACT DERMATITIS Complex, immune-mediated SEBORRHEIC DERMATITIS disease w/ genetic component PSORIASIS DR. HALISTA Well-demarcated erythematous BENIGN TUMORS plaques covered with silver scale SKIN CANCER TINEA Typically involves extensor surfaces CANDIDA Elbows CONDYLOMA Knees Gluteal cleft Posterior auricular region Periumbilical Bimodal incidence between ages 30-39 and 50-69

Types of Psoriasis

Chronic Plaque Pustular Guttate Inverse Erythrodermic Psoriatic involvement Diffuse of intertriginous with scaling areas

Nail

Treatment of Psoriasis Auspitz Sign Topical Therapies Punctate Topical corticosteroids following removal of analogues (Calcipotriene) psoriatic scale (retinoid) Named after Austrian Tacrolimus and dermatologist, Emollients Heinrich Auspitz Salicylic acid (1835-1886), who Anthralin discovered Coal Tar phenomenon Topical Corticosteroids Topical Corticosteroids

Superpotent Dosing: 1-2x daily for 2-4 weeks Side effects: Local: skin , telangiectasias, striae, purpura, contact dermatitis, Class 5 (Hydrocortisone Valerate 0.2% rosacea Systemic: HPO suppression, Least potent Class 7 (Hydrocortisone 1% or 2.5%) osteonecrosis of the femoral head, increased intraocular pressure, glaucoma,

Adjunctive Therapies Systemic therapy DMARDs (e.g. , Cyclosporine, , Mycophenolate mofetil, , Tacrolimus) Phototherapy B (UVB) Laser therapy Photochemotherapy plus ultraviolet A (PUVA)

Psoriatic Radiolographic Findings digit

Approximately 10-15% are RF positive Approximately 20-30% of pts w/ psoriasis will develop Clinical manifestations: Peripheral arthritis Axial disease Enthesitis Skin & Sclerosis of the SI joint deformity Treatment of Psoriatic Arthritis ACNE VULGARIS ATOPIC DERMATITIS Mild arthritis (<4 joints, no radiographic changes, CONTACT DERMATITIS minimal functional limitations) SEBORRHEIC DERMATITIS Naproxen 375mg 500mg PO BID PSORIASIS Celecoxib 200mg PO BID BENIGN TUMORS DR. KNOBLOCH Moderate severe arthritis (4 or more joints, SKIN CANCER TINEA radiographic changes, functional limitations) CANDIDA DMARD* CONDYLOMA Methotrexate 15 25mg PO qweekly + Folic Acid 1mg PO daily Effective for both dermatologic and joint manifestations Leflunomide 20mg PO daily Less effective for dermatologic manifestations *Strongly consider referral to guide treatment

Types of benign lesions Seborrheic Most common Acrochordon benign epithelial tumor Epidermal Inclusion Cyst Pts >30, hereditary Yellow to brown, greasy/velvety/war ty Cherry Angioma - Pyogenic appearance

Seborrheic Keratosis Acrochordons

Can mimic Common, pedunculated Treatment: electrodessication, laser skin tags ablation, curettage, Occurs in areas of Shave or punch if is required irritation Can be associated with Increased expression of ILGF-1 Acrochordons Acrochordons

Typically skin colored to brown DDX: , SK, pedunculated Increased incidence with age, nevi, pregnancy Tx: cryosurgery, electrodessication*, Occur in 25-50% of population scissors, shave

Epidermal Inclusion Cyst Epidermal Inclusion Cyst May become inflamed Implantation and or ruptured proliferation of If inflamed, consider epidermal elements in intralesional steroid the dermis Diagnosis based on Do not prescribe physical exam, often antibiotics for have central punctum inflamed EIC

Epidermal Inclusion Cyst Sebaceous Hyperplasia

Treatment not required Common in middle aged and older Accomplished via excisional biopsy to adults include cyst wall Often asymptomatic, soft yellow bumps on , cheeks Most commonly removed for cosmetic purposes Sebaceous Hyperplasia Lipoma

Always keep skin cancer in Most common type of soft differential tissue tumor Tx options: ED&C, Slow-growing, benign phototherapy, shave Often subcutaneous but excision, laser ablation, chemical cautery may occur in any organ Oral isotretinoin if Soft, flesh colored, easily widespread* mobile nodule

Lipoma Lipoma Ddx: v cyst if sub-q, Treatment: Can use US for assistance in diagnosis excision Risk factor for malignancy: >10 cm, old Elective age, rapid growth, location on , invasion into deeper tissue

Dermatofibromas Idiopathic, benign proliferation of Exhibit dimpling/retraction of the lesion with lateral Firm, raised compression papule/nodule No treatment required Darker in the center Punch or excisional and fade to normal biopsy if desired pigmentation Generally lower limb Cherry Angioma Pyogenic Granuloma Rapidly growing Extremely common, increasing nodules that frequency with age easily bleed Bright red to violaceous, soft, Yellow to purple compressible, smooth surface lesions, pulpy and Treated effectively with electrodessication vascular, surrounded by scaly collarette

Pyogenic Granuloma Pyogenic Granuloma

Common in infancy and childhood Treatment: shave ALWAYS send excision, in children electrodessication 2% of women develop a mucosal lesion during pregnancy

ACNE VULGARIS ATOPIC DERMATITIS CONTACT DERMATITIS SEBORRHEIC DERMATITIS PSORIASIS BENIGN TUMORS SKIN CANCERS DR. SERVEY TINEA CANDIDA CONDYLOMA Actinic Keratosis:

- Ablative Treatment Rough, scaly lesions Curettage Sun exposed areas Mechanically scrape away abnormal tissue Thought to be in Requires local anesthesia situ May use electrosurgery for hemostasis Potential to progress to Apply followed by blue light squamous cell Cure rate of 69-93% 26% regress spontaneously Side effects: Burning, erythema, crusting, ulceration

Actinic Keratosis:Topical Types of Skin Cancer Treatment Agent Dosing Notes

Fluorouracil Apply twice daily -Available in 5%, 1%, and 0.5% Basal Cell Carcinoma for 2-4 weeks -Causes local erythema, dryness, scaling, and pain Melanoma Apply once daily -Complete resolution in 45-57% of 2-3x/week for 16 patients weeks - -72% of patients -Local reactions common Apply twice daily -Complete resolution in 50% of in for 90 days patients vs. 20% in placebo group hyaluronan -Local reactions common gel

Squamous Cell Carcinoma Squamous Cell Carcinoma 2nd most common type of skin Risk Factors: cancer in the United States Fair skin Account for approximately 20% Blue eyes Red or light-colored on non-melanoma skin cancers Unprotected sun exposure Incidence highest among non- Exposure to Hispanic whites over age 75 Tanning bed use HPV infection Chronically diseased or injured skin (e.g. ) pigmentosa Squamous Cell Carcinoma

Autosomal recessive disease that affects 1 Characteristic Features Distribution Firm, smooth or Head & neck (55%) in 250,000 Dorsum of hands & (18%) hyperkeratotic papule or Impaired ability to repair UV-damaged DNA Legs (13%) plaque Shoulder or back (4%) Incidence of skin cancer prior to age 20 is Central Chest or (4%) 2000x higher than general population ulceration (3%) Median age of diagnosis of first tumor = 8 Bleeding with minimal trauma

Squamous Cell Carcinoma Basal Cell Carcinoma

: cutaneous SCC in situ Account for 80% of non-melanoma skin : SCC within chronic cancers or Locally invasive Erythroplasia of Queyrat: SCC in situ Rarely metastasize (0.0029 0.55%) involving the penis

Basal Cell Carcinoma Subtypes of Basal Cell Carcinoma

Nodular (60%) Risk Factors Pink or flesh- Predominantly on face Unprotected sun exposure Often with telangiectasias Chronic exposure May have rolled border or central ulceration Radiation therapy Superficial (30%) Slightly scaly, non-firm macules Long-term immunosuppressive Predominantly on trunk therapy Morpheaform (5-10%) Smooth, flesh-colored w/ ill-defined borders Typically atrophic and firm to palpation Non-Melanoma Skin Cancer Non-Melanoma Skin Cancer Excision Treatment Electrodessication & Curettage Shave Biopsy Does not allow for histologic confirmation of tumor removal Epidermis +/- Superficial Dermis Best for low- Punch Biopsy extremities Epidermis + Dermis + Hypodermis Surgical Excision (Subcutaneous Fat) 4mm margin >95% cure rate Surgical Excision Mohs Micrographic Epidermis + Dermis + Hypodermis Histologic evaluation of surgical margins at time of excision (Subcutaneous Fat) face

Melanoma

Increasing incidence A Asymmetry 1990: 2.2/100,000 people 2012: 21.6/100,000 people B (Irregular) Borders Risk Factors C Color Variegation Prior melanoma Numerous nevi or multiple atypical nevi D Dimensions (>6 mm) Strong family hx of melanoma E - Evolution Organ transplant recipients on immunosuppression

How to do a full-body skin exam

Have patient completely undress Underwear and gown only No socks or shoes Be systematic! Head to toe Distal to proximal

Scalp Behind ears Under Within groin folds On buttocks Between fingers and toes Soles of feet Common treatments Treatment Diagnosis Side effects ACNE VULGARIS ATOPIC DERMATITIS Cryotherapy Seborrheic keratosis (SK), Pain, scarring, blistering, CONTACT DERMATITIS Acrochordon, , Actinic SEBORRHEIC DERMATITIS keratosis (AK) PSORIASIS Electrodessication Acrochordon, AK, SCC, BCC, Pain, bleeding, minimal BENIGN TUMORS Pyogenic granuloma scarring, not used with SKIN CANCERS implantable electrical devices TINEA INFECTIONS DR. KNOBLOCH CANDIDA Shave biopsy SK, Acrochordon, Pyogenic Pain, scarring, bleeding CONDYLOMA granuloma Punch biopsy Dermatofibroma, Pyogenic Pain, scarring, bleeding granuloma, AK, SCC, BCC, Melanoma Excision SK, EIC, Lipoma, Pain, scarring, bleeding Dermatofibroma, AK, SCC,BCC, Melanoma

Tinea Infections Tinea Infections

Tinea capitis in the skin Trichophyton Microsporum Epidermophyton Typically limited to hair, nails and

Tinea pedis Tinea unguium

Tinea Capitis Tinea Capitis

Typically affects children between 3-9 Scaly patches years Pruritus More commonly children of African origin Alopecia with hair 3 different types: broken at the base Gray patch Children typically have Black dot T. tonsurans cervical and sub- 95% of US cases occipital LAD* Tinea Capitis Tinea Capitis

Untreated may progress to kerion Diagnosis: KOH prep or culture Boggy, tender plaques Woods lamp not helpful for T. tonsurans Pustules M. canis shows green fluorescence More likely to have permanent scarring under Woods lamp and

Tinea Capitis

MUST use systemic therapy Red superior for T. tonsurans Annular superior for M. canis Scaling Treat PO and topical for the first 2 Central clearing weeks to reduce transmission rate Pruritic 1 or 2.5% selenium sulfide shampoo 2% ketoconazole shampoo

Tinea Corporis Tinea Corporis

Clinical presentation Diagnosis KOH prep Worsening after steroids Cultures not helpful Biopsy with PAS stain Psoriasis Atopic Tinea dermatitis corporis Tinea Corporis Tinea Corporis

Topical antifungals Large burden of disease, , poor response to topical are first line therapy systemic Terbinafine, are therapy second line Obtain fungal culture Apply past the leading Terbinafine 250mg daily for 1-2 weeks edge and use 1 week after resolution

Tinea Corporis

Pearl: Treatment is successful when Red macules/patches no longer scale Annular Patient counseling: Pigment alteration Scaling will take several months to resolve, not Central clearing contagious Pruritic May spread from tinea pedis

Tinea Cruris Tinea Cruris Important to differentiate from: Topical antifungals : involves scrotum tinea spares Clotrimazole, miconazole, terbinafine daily for 1-2 weeks on woods lamp due to Corynebacterium minutissimum Systemic therapy Terbinafine 250mg daily for 1-2 weeks 200mg daily for 1 week 150-200mg daily for 2-4 weeks Tinea Pedis

Typically between toes Treatment: topical but can antifungals, often OTC spread moccasin-type Terbinafine, Acute: erythema, Miconazole: apply daily maceration, blistering foot power Chronic: scaling/peeling in shoes to prevent re- with erythema infection KOH prep can help with diagnosis

Tinea Unguium Tinea Unguium

Thickened, Treatment is a long Terbinafine 250mg PO for course, high failure 6-12 weeks yellow/discolored rate and a high 10% , brittle nails recurrence rate solution topical daily for 48 weeks Subungual debris Assessment for cure should be 8% lacquer Can have done at 9-12 once weekly for 48 weeks months due to separation of nail slow-growing nails plate from bed

ACNE VULGARIS ATOPIC DERMATITIS CONTACT DERMATITIS SEBORRHEIC DERMATITIS PSORIASIS BENIGN TUMORS SKIN CANCERS TINEA CANDIDA DR. HALISTA CONDYLOMA Oropharyngeal Candidiasis Clinical Manifestations

Signs/Symptoms: White patches or plaques on the or mucous membranes Difficulty swallowing Diaper dermatitis Risk Factors: Infants <1-month-old (5-7%) Elderly Immunocompromised individuals, including diabetics Users of inhaled corticosteroids

Treatment of Oropharyngeal Candidiasis Overgrowth of vaginal yeast Swish & Swallow Affects 75% of adult women at least once Occurs in moist areas where friction occurs Adults: 400,000 600,000 units 4 Symptoms: times daily Itching Burning Children: 200,000 units 4 times daily Cottage cheese-like vaginal discharge Risk Factors: Pregnancy *Continue for an additional 3 days Diabetes Long-term use of broad-spectrum antibiotics after all lesions have resolved or systemic corticosteroids

Uncomplicated vs. Complicated Diagnosis of Vulvovaginitis Vulvovaginitis : Uncomplicated Complicated Candidiasis Vaginal itching/soreness, thick, white, curd-like discharge Sporadic, infrequent 4 or more episodes per year Bacterial vaginosis episodes (<4 per year) Thin, gray or yellow, foul-smelling discharge Severe signs/symptoms Trichomoniasis Mild moderate Candida species other than Purulent, malodorous, thin discharge w/ burning, itching, signs/symptoms , and/or dysuria C. albicans (i.e. C. glabrata) Probable infection w/ Pregnancy Diagnostic Tests: Poorly-controlled diabetes Saline wet mount Healthy, non-pregnant Immunosuppression KOH wet mount woman Debilitation Treatment of Vulvovaginitis Recurrent Vulvovaginitis

Uncomplicated Complicated Infectious Disease Society of America Oral Fluconazole 150mg x1 Oral Fluconazole 150mg x2- 3 with each dose 72-hrs (IDSA) recommendation: apart Initiate treatment with 10-14 days of *Side Effects: Topical (e.g. a topical or oral azole - GI upset Clotrimazole) x7-14 days - Treatment of choice for Follow with Fluconazole 150mg PO - pregnant women qweek or Clotrimazole 200mg - Transient LFT elevations vaginally twice weekly for 6-months

Intertrigo Diaper Dermatitis Typically refers to a Candidal infection of two opposing skin surfaces (e.g. Occurs in 4-6% of term infants , groin, breasts) Peak onset between 3-4 months of age Treatment: Typical description: erythematous, Topical antifungal BID x2-4 weeks: Nystatin (polyene) macerated plaques w/ satellite pustules Miconazole, Clotrimazole, Ketoconozole, etc. () Drying agent Candidal infection represents a Talcum powder (concern may increase risk of ovarian cancer) Corn starch Increased exposure to air dermatitis

Treatment of Diaper Dermatitis ACNE VULGARIS ATOPIC DERMATITIS CONTACT DERMATITIS Frequent diaper changes SEBORRHEIC DERMATITIS PSORIASIS Increased air exposure BENIGN TUMORS Barrier preparations SKIN CANCERS TINEA Ointments and pastes are preferable CANDIDA Ex: Vaseline, Desitin, A&D Ointment CONDYLOMA DR. HALISTA Topical corticosteroids (low potency) Topical antifungal Ex: Nystatin or Clotrimazole Condyloma Common Warts (Verruca Vulgaris)

Caused by Human Papillomavirus (HPV) Confirming the diagnosis Double-stranded DNA virus Use 15 blade to scrape off overlying Tissue tropism hyperkeratotic degree Cutaneous epithelium Expose underlying thrombosed 10% of children capillaries (numerous, small, black Anogenital epithelium Cervical cancer dots) Anal cancer

Treatment of Verruca Vulgaris Treatment of Verruca Vulgaris with Cantharidin Goal: Activate a local immune response Apply to lesion an 1-3mm of surrounding Options tissue Once dry, cover w/ non-porous tape Nail file / duct tape Remove tape after 24-hrs OTC products containing salicylic acid +/- curettage Cryotherapy (liquid nitrogen) Repeat weekly, as necessary Cantharidin To be applied by a medical professional only Side Effects: Trichloroacetic acid Blistering Imiquimod Burning Candida injection Hypopigmentation

Genital Warts (Condyloma Treatment for Genital Warts acuminata) Cryotherapy Typically caused by HPV types 6 and 11 Podophyllotoxin >75% of adults in the U.S. are infected Apply BID x3-days Wash the area 1-4 hrs after application to avoid during their lifetime systemic absorption and skin necrosis Almost always acquired through sexual Followed by 4-days of no treatment Repeat up to 4 times contact Imiquimod (e.g. Aldara, Zyclara) - Cannot be used in the or during pregnancy Trichloroacetic acid risk patients Applied by healthcare professional once weekly for 4- Warts do NOT need to be present for the 6 weeks Patient should not sit, stand, or dress until chemical virus to spread has dried Surgical excision Summary

Dermatology Terminology Top

Berke, R, A Singh,References and M Guralnick. 2012. Atopic dermatitis: an overview. Am Fam Physician 86: 35-42. Clark, G, S Pope, and K Jaboori. 2015. Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician 91: 185-190. vulvovaginitis New England Journal of Medicine, vol. 355, no. 12, 2006, pp. 1244- 1252. Ely, JW, S Rosenfeld, and MS Stone. 2014. Diagnosis and management of tinea infections. Am Fam Physician 90:702-710. Firnhaber American Family Physician, vol. 86, no. 2, 2012, pp. 161-168. Hainer American Family Physician, vol. 83, no. 7, 2011, pp. 807-815. Jerant American Family Physician, vol. 62, no. 2, 2000, pp. 357- 368. Luba, MC, SA Bangs, AM Mohler, and DL Stulberg. 2003. Common benign skin tumors. Am Fam Physician 67: 729-738. Menter The Lancet, vol. 370, no. 95683, 2007, pp. 272-284. Clinical Infectious Disease, vol. 62, no. 4, 2016, e1-e50. Q&A Rachakonda Journal of the American Academy of Dermatology, vol. 70, no. 3, 2014, pp. 512-516. Shimizu, Ikue Dermatologic Surgery, vol. 37, no. 10, 2011, pp. 1394-1411. American Family Physician, vol. 86, no. 8, 2012, pp. 734-740. Usatine RP, M Riojas. 2010. Diagnosis and management of contact dermatitis. Am Fam Physician 82:249-255. Yanofsky Journal of Clinical and Aesthetic Dermatology, vol. 5, no. 6, 2012, pp. 25-36. Zaenglein Journal of the American Academy of Dermatology, vol. 74, no. 5, 2015, pp. 945-973.

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@aafp_fmig Use #AAFPNC Treatment of Uncomplicated Bonus: (Herpes zoster) Shingles Reactivation of Varicella-zoster virus Goals of Treatment Treatment Options within sensory dorsal root ganglia Lessen severity and Valacyclovir 1000mg PO TID x7-days duration of pain associated Famciclovir 500mg PO TID x7-days Unilateral, vesicular eruption in a Acyclovir 800mg PO 5 times daily x7- with acute neuritis days dermatomal distribution Promote rapid healing Affects ~30% of people within the Prevent new lesion United States formation Risk factors = age & Decrease viral shedding immunocompromise Prevent post-herpetic neuralgia

Complicated Shingles Herpes Zoster Ophthalmicus Bonus: Infection caused by Poxvirus VZV reactivation within Affects approximately 5% of trigeminal ganglia healthy children May be spread via fomites Frequently involves frontal (e.g. sponges, towels) or branch of V1 contact sports Ophthalmologic emergency! Can be an STI or a sign of immunodeficiency in adults Discrete, smooth, 3-6mm, flesh-colored papules w/ Impetigo superimposed on central umbilication Herpes Zoster Ophthalmicus

Tinea Versicolor (or Versicolor) Pityriasis Versicolor Caused by yeast Ketoconazole 2% shampoo: apply for 5 Malassezia not a mins, repeat for 3 days Terbinafine 1% cream: twice daily for one Well-demarcated scaling week patches Selenium sulfide 2.5% shampoo: ten Typically trunk and arms minute application daily for one week Zinc pyrithione 1% shampoo: 5 minute application daily for 2 weeks Oral -