12/6/19 Dermatology Update Lindy P. Fox, MD Professor of Clinical Dermatology Director, Hospital Consultation Service Department of Dermatology University of California, San Francisco [email protected] I have no conflicts of interest to disclose I may be discussing off-label use of medications 1 1 Outline • Principles of topical therapy • Chronic Urticaria • Alopecia • Acne in the adult • Perioral dermatitis • Sunscreens 2 2 1 12/6/19 Principles of Dermatologic Therapy Moisturizers and Gentle Skin Care • Moisturizers – Contain oil to seal the surface of the skin and replace the damaged water barrier – Petrolatum (Vaseline) is the premier and “gold standard” moisturizer – Additions: water, glycerin, mineral oil, lanolin – Some try to mimic naturally occurring ceramides (E.g. CeraVe) • Thick creams more moisturizing than pump lotions 3 Principles of Dermatologic Therapy Moisturizers and Gentle Skin Care • Emolliate skin – All dry skin itches • Gentle skin care – Soap to armpits, groin, scalp only – Short cool showers or tub soak for 15-20 minutes – Apply medications and moisturizer within 3 minutes of bathing or swimming 4 2 12/6/19 Principles of Dermatologic Therapy Topical Medications • The efficacy of any topical medication is related to: 1. The concentration of the medication 2. The vehicle 3. The active ingredient (inherent strength) 4. Anatomic location 5 Vehicles • Ointment (like Vaseline): – Greasy, moisturizing, messy, most effective. • Creams (vanish when rubbed in): – Less greasy, can sting, more likely to cause allergy (preservatives/fragrances). • Lotions (liquid): – Cooling, liquids that pour. 6 3 12/6/19 Vehicles • Solutions (liquids that are greasy or alcoholic): – Can sting, good for hairy areas • Gels (semi solid alcohol-based): – Can sting, good for hairy areas or wet lesions • Foams (cosmetically elegant): – For hairy areas • Sprays: Aerosols (rarely used) 7 Topical Corticosteroids • Super-High Potency: Clobetasol • High Potency: Fluocinonide • Medium Potency: Triamcinolone (TAC) • Mid-Low: Aclometasone, Desonide • Lowest Potency: Hydrocortisone 8 4 12/6/19 Topical Therapy • Choose agent by body site, age, type of lesion (weeping or not), surface area • For Face: – Hydrocortisone 2.5% ointment BID – If fails, aclometasone (Aclovate), desonide ointment • For Body: – Triamcinolone acetonide 0.1% ointment BID – If fails, fluocinonide ointment • For scalp: – Fluocinonide solution – Fluocinolone oil – Clobetasol foam 9 9 Chronic Urticaria 10 10 5 12/6/19 Question 1 Most patients with chronic urticaria 1. Have an identifiable underlying cause 2. Are undertreated 3. Relapse 4. Have associated constitutional symptoms 5. Require allergy testing 11 Question 1 Most patients with chronic urticaria 1. Have an identifiable underlying cause 2. Are undertreated 3. Relapse 4. Have associated constitutional symptoms 5. Require allergy testing 12 6 12/6/19 • 36 yoF complains of 2 mo of urticaria • Lesions last < 24 hours, itchy • Failed loratadine 10 mg daily 13 Chronic Urticaria • Urticaria, with or without angioedema > 6 weeks – Lesions last < 24 hours, itch, completely resolve • Divided into chronic spontaneous (66-93%) or chronic inducible • Natural history- 2-5 years – > 5 yrs in 20% patients – 13% relapse rate • Etiology – 30 -50 % - IgG autoAb to IgE or FcεRIα – Remainder, unclear Clin Transl Allergy 2017. 7(1): 1-10 Eur J Dermatol 2016 J Allergey Clin Immunol Pract. 2017. Sept 6. S2213-2198 14 7 12/6/19 Chronic Urticaria- Workup • History and physical guides workup • Labs to check – CBC with differential – ESR, CRP – TSH and thyroid autoantibodies – Liver function tests – CU Index (Fc-εRIα Ab or Ab to IgE) – Maybe tryptase for severe, chronic recalcitrant disease – Maybe look for bullous pemphigoid in an older patient • Provocation for inducible urticaria Eur J Dermatol 2016 Allergy Asthma Immunol Res. 2016;8(5):396-403 Clin Transl Allergy 2017. 7(1): 1-10 15 First line Chronic Spontaneous Urticaria- Treatment H1 antihistamines- 2nd generation <40% respond to standard dose H1 blockade Avoid triggers (NSAIDS, ASA) Can increase to up to 4X standard dose 60% chance of response Second line High dose 2nd generation AH Add another 2nd generation AH 1st gen H1 antihistamine QHS Third line +/- H2 antagonist Omalizumab +/- Leukotriene antagonist Cyclosporine Dapsone Sulfasalazine J Allergy Clin Immunol 2014. 133(3):914-5 BJD 2016. 175:1134–52 Hydroxychloroquine Clin Transl Allergy 2017. 7(1): 1-10 Mycophenolate mofetil Allergy Asthma Immunol Res. 2016;8(5):396-403 TNFα antagonists Eur J Dermatol 2016 (epub ahead of print) Allergy Asthma Immunol Res. 2017 November;9(6):477-482. Anti CD20 Ab (rituximab) Allergy 2018. Jan 15. epub ahead of print 16 8 12/6/19 What does my “second line” look like? • Fexofenadine 360 mg am, 180 mg noon, 360 mg pm • Cetirizine 10 mg BID • Hydroxyzine 25 mg QHS • +/- Monteleukast 10 mg QD • +/- Ranitidine 300 mg QD • Give epipens (3) • When time to taper, take off 1 pill per week 17 CSU- when to refer • Atypical lesion morphology or symptoms – > 24 hours, central duskiness/purpura – Asymptomatic or burn >> itch • Minimal response to medications – High dose H1 nonsedating antihistamines – H1 sedating antihistamines • Associated symptoms – Fever, fatigue, mylagias, arthralgias • Elevated ESR/CRP 18 9 12/6/19 More than Just Urticaria Rheumatic Fever Serum sickness-like reaction Adult Onset Stills Disease Rat bite fever Cryopyrin Associated Periodic Leptospirosis Syndrome Brucellosis Schnitzler syndrome Neutrophilic urticaria with systemic inflammation 19 Alopecia 20 20 10 12/6/19 Alopecia = hair loss Non-Scarring Scarring Alopecia areata Traction alopecia Trichotillomania (end stage) Telogen Effluvium Neutrophil mediated Androgenetic alopecia Folliculitis decalvans Dissecting cellulitis of the scalp Lymphocyte mediated Lichen planopilaris Frontal fibrosing alopecia Central centrifugal alopecia Chronic cutaneous lupus Scalp biopsy: 21 • Area ADJACENT to alopecia, ask for TRANSVERSE sections • ALL scarring alopecias OR nonscarring alopecia where diagnosis uncertain 21 Alopecia Areata • Affects up to 0.2% US population • Types – Relapsing remitting – Ophiasis (band like along occipital scalp) – Alopecia totalis (all scalp hair) – Alopecia universalis (all scalp and body hair) • Associations – Atopic disease – Autoimmune thyroid disease – Vitiligo – Inflammatory bowel disease – APECED syndrome 22 22 11 12/6/19 Alopecia Areata: Round or oval patches of nonscarring alopecia 23 Taken from Dermatology, 2012, Elsevier 23 Alopecia Areata: Exclamation point hairs 24 Taken from Dermatology, 2012, Elsevier 24 12 12/6/19 Alopecia Areata: Ophiasis pattern 25 Taken from Dermatology, 2012, Elsevier 25 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 26 JAAD 2018 Jan; 78(1):15-24 26 13 12/6/19 Anagen 90-95% Catagen Normal Hair Cycle Telogen 5-10% Normal shedding is 50-100 hairs/d 27 Telogen Effluvium • Transient shifting of hair cycle • Shedding • No scalp itch or rash 28 28 14 12/6/19 Telogen Effluvium- Causes • Postpartum • Chronic (no cause) • Post febrile • Severe infection • Severe chronic illness (SLE, HIV, etc) • Severe prolonged stress • Post major surgery • Endocrinopathy – Thyroid, parathyroid • Crash diets, malnutrition, starvation • Medications – Stopping OCP, retinoids, heparin, PTU, methimazole, anticonvulsants, β- blockers, IFN-α, heavy metals 29 29 Telogen Effluvium • Examination – Diffuse thinning – Hair pull • Diagnostic • > 20% hairs are telogen – Look for bulb at end of hair shaft Front. Med. 4:112. 2017 30 30 15 12/6/19 Telogen Effluvium • Workup – TSH, Vit D, Fe, ferritin, chemistry – Biopsy if > 6 mo (r/o AGA) • Treatment – Address underlying etiology – Replete ferritin if < 40 ng/dl – Minoxidil 5% (foam) – Reassurance (most regrow almost all lost hair) 31 31 Androgenetic Alopecia • Male or female pattern hair loss • Female – Complain of widening part – Retain anterior hairline – Early onset/severe: workup for hyperandrogenism • F/T testosterone, DHEAS, 17-OH progesterone • Often “exposed” by telogen effluvium • Treat with – Minoxidil 5% (F QD, M BID) – Spironolactone (female) – Finasteride- up to 5mg/d • NOT for women of childbearing potential 32 32 16 12/6/19 33 Taken from Dermatology, 2012, Elsevier 33 Some scarring alopecias 34 34 17 12/6/19 Traction Alopecia 35 Taken from Dermatology, 2012, Elsevier 35 Chronic Cutaneous LE 36 Taken from Dermatology, 2012, Elsevier 36 18 12/6/19 Lichen Planopilaris 37 Taken from Dermatology, 2012, Elsevier 37 Approach to the Adult Acne Patient 38 38 19 12/6/19 Question 2 Which of the following regarding acne in women is TRUE 1. Spironolactone requires K+ monitoring 2. Abnormal follicular keratinization is the first step in the formation of acne 3. Tazarotene is safe in pregnancy 4. Most patients do not require a topical retinoid 39 Question 2 Which of the following regarding acne in women is TRUE 1. Spironolactone requires K+ monitoring 2. Abnormal follicular keratinization is the first step in the formation of acne 3. Tazarotene is safe in pregnancy 4. Most patients do not require a topical retinoid 40 20 12/6/19 Acne Pathogenesis, Clinical Features, Therapeutics Pathogenesis Clinical features Therapeutics Retinoids, Excess sebum Oily skin spironolactone Non-inflammatory