PODIATRIC DERM REVIEW Painting from Philadelphia Art TRACEY C. VLAHOVIC, DPM FFPM RCPS (GLASG) Museum CLINICAL PROFESSOR, TEMPLE UNIV SCHOOL OF PODIATRIC MEDICINE PHILADELPHIA, PA DISCLOSURES

• None for this presentation • Clinical Trials, Speaker: Valeant • Consultant, Speaker: Bako Dx THE ISSUES I GET DAILY CONSULTS ON THE MOST

• Various Inflammatory skin conditions • Verruca • Onychomycosis INFLAMMATORY BASED SKIN CONDITIONS

• Atopic • • • Id Reaction • • • Psoriasis • Tinea pedis • Xerosis HOW WOULD YOU APPROACH THESE?

None of these Are Fungal!!!! THOU SHALL NOT USE CLOTRIMAZOLE-BETAMETHASONE FOR EVERYTHING THAT LOOKS RED AND SCALY

• Antifungal/Class I steroid preparation (fluorinated and high potency) • “the component may interfere with the therapeutic actions of the antifungal agent, or fungal growth may accelerate because of decreased local immunologic host reaction, such that underlying infection may persist, and dermatophytes may even acquire the ability to invade deeper tissues” Am J Clin Dermatol. 2004;5(6):375- 84. • Tinea incognito! J Biomed Res. 2010 Jan; 24(1): 81–83. • AAD guidelines state to use topical antifungal first for superficial fungal infections • Most antifungals have a NATURAL anti-inflammatory property and have a higher cure/lower relapse rate • Don’t take the “easy” way out EVEN METHLYPREDNISOLONE DOSE PACKS CARRY RISK

• I NEVER use for any ---I do prednisone tapers over 4-6 weeks, and I never give to a potential psoriasis patient (controversy) • Recent study showed: over 300,000 patients received a low dose oral steroid (less than 30 day dose), 46.9% received the med dosepack • Within 30 days of drug initiation, there was an increase in rates of sepsis (incidence rate ratio 5.30, 95% confidence interval 3.80 to 7.41), venous thromboembolism (3.33, 2.78 to 3.99), and fracture (1.87, 1.69 to 2.07) BMJ. 2017;357:j1415 ORAL PREDNISONE TAPERING BASICS

• For an acute dermatitis in an adult, you can prescribe: • 10 mg prednisone tablets or 1-2mg/kg/day

• Rx to take 5 days of 60 mg, 5 days of 40 mg, 5 days of 20 mg, 5 days of 10 mg and in some cases 10 mg every other day till they finish. • They must finish all meds and not skip a dose! • HPA axis suppression can occur after just 5 days of taking 40 mg/day WHAT WE TYPICALLY SEE…

• Bilateral and symmetrical presentation on • Scalp/hairline • Elbows • Hands (palmar) • Gluteal cleft • Knees • Feet (plantar) WHAT WALKS INTO THE OFFICE: PHENOTYPIC EXPRESSION OF PALMOPLANTAR PSORIASIS

Retrospective review of 150 patients with palmoplantar psoriasis defined subtypes: 1. Purely hyperkeratotic 2. Purely pustular 3. Mixed hyperkeratotic/pustular 4. With or without psoriasis elsewhere

Farley E, et al. J Am Acad Dermatol 2009; 60(6):1024-31 1ST LINE TO APPROACH PLANTAR PSORIASIS

• Refer patient to National Psoriasis Foundation for support/resources • Topical corticosteroid (clobetasol to hydrocortisone butyrate) • No OTC hydrocortisone • Thou shall not use Lotrisone!!! • NO ORAL STEROIDS---that means no dose pack! • Topical Vitamin D Analog (calcipotriene or calcitriol) • Combo of betamethasone and calcipotriene (foam and ointment) • Rx or OTC moisturizer • Should you Rx Urea? Sal acid 6%? Lactic acid? • Let the medications do their work---no pumice stone or excess soaking!

VITAMIN D ANALOG

• Dovonex (calcipotriene) cream, ointment, scalp solution • Taclonex (calcipotriene/betamethasone) ointment • Vectical (calcitriol) ointment

After 2 months of use A FORGOTTEN TREATMENT FOR INFLAMMATORY BASED CONDITIONS: MOISTURIZERS

• We should have patients using 10x the amount than they already are • Best time to apply: within minutes of getting out of tub/shower • Try to choose fragrance-free preps: Hylatopic Plus, Epiceram, Ceramax, Neosalus, Neocera (all Rx) • Add a keratolytic topical (lactic acid, salicylic acid, urea) • 59% reduction on AD pts when used for two months---J Dermatol Treat 2006 • The vehicle effect? ADDING A KERATOLYTIC…

9/07 1/08 DON’T DEBRIDE PSORIATIC PLAQUES WITH A BLADE PUSTULAR PSORIASIS Medication Use in Psoriasis Side Effects Topical Steroids Plaque Skin atrophy, hypopigmentation, striae

Vitamin D Analog Use in combo with topical Skin irritation, photosensitivity, steroids but can be used with UVB therapy

Topical Retinoid Plaque; Use with topical Skin irritation, photosensitivity steroids

Salicylic or Lactic Acid or Urea Plaque to soften plaques Sal acid can be systemically absorbed if applied to >20% BSA

Coal tar Plaque Skin irritation, odor, stain clothes

Calcineurin inhibitors: Off label use for facial and Skin burning and itching Protopic and Elidel intertriginous HOME NB-UVB PHOTOTHERAPY

https://www.natbiocorp.com/handisol.htm https://www.daavlin.com/patients/uv-phototherapy/home- phototherapy-products/ WHAT IF NOTHING TOPICAL WORKS/PHOTOTHERAPY NOT COVERED? • Our next step is systemic…and the biologics • Systemic Therapies • Cyclosporine, Methotrexate, Acitretin, Dapsone

• Biologic therapy • Plaque affecting >5% of the BSA • Erythrodermic, pustular, or guttate forms/Psoriatic Arthritis • Recalcitrant to topical therapies • <5% BSA, but located on FEET, NAILS, and hands

• My experience has been with cyclosporine, dapsone, infliximab, ustekinumab, apremilast, adalimumab, etanercept, and brodalumab APREMILAST

• Technically not a biologic, but an oral med to treat both plaque psoriasis and arthritis • Phosphodiesterase 4 inhibitor • No requirement for initial or ongoing blood test or PPD test prior • Dosage is (after a titration period), 30 mg bid for plaque psoriasis • For palmoplantar psoriasis: After four months, almost two-thirds of patients achieved clear or almost clear skin, while less than a third of patients on placebo did. J Am Acad Dermatol. 2016 Jul;75(1):99-105. • For Nail psoriasis: After four months, patients experienced an average of 29 percent improvement in their nails J Drugs Dermatol. 2016 Mar;15(3):272-6. • Side effects: diarrhea, nausea, headache 5/25/2017 6/29/2017 Apremilast for ~30 days WHAT’S NEW FOR PSORIATIC NAILS? INDIGO NATURALIS

• Chinese medicine (Qing Dai—from plants indigofera tinctoria, baphieacanthuscusia, isatis tinctoria, polygonum tinctorium, and isatis indigotica) • antipyretic, anti-inflammatory, antiviral, antimicrobial, antitumor and detoxifying properties

J Drugs Dermatol. 2016;15(3):319-323. WEEPY AND ITCHY SKIN ECZEMA OR DERMATITIS

Personal or Family Hx Of “The Triad” + Age Specific Lesions

What do they use daily? As described above: Varicosities: Positive Patch Test: Venous Stasis Atopic Eczema Allergic Contact Dermatitis Dermatitis IRRITANT CD VS ALLERGIC CD= PATCH TEST

Once the allergen is known, remove from the pt’s environment SHOE CONTACT DERMATITIS (FIND THIS LIST ON PODIATRY TODAY ONLINE) 1. Askin Shoes: http://www.askin.it/eng/home.php Shoes that are excluding the following materials such as chromium salts, aluminum, zirconium, titanium, nickel, lead, copper, cadmium, and many others 2. Ausangate Socks: www.ausangatesocks.com/default.asp Offers lanolin-free socks made of breathable alpaca fiber 3.Birkenstock for cork insole replacements n.b. Birkenstock buckles are nickel-free 4. The Cordwainer Shop http://www.cordwainershop.com/: offers Glue-free linings for allergy sensitive customers 5. Loveless Orthopedic Appliance http://www.lovelessboots.com/: Offers hypoallergenic liners for shoes and boots 6. Microair Barrier Socks by Alpretec: http://www.alpretec.com/eng offers barrier socks prevent skin from contacting allergens and irritants. 7. Multnomah Leather Shop: http://www.multnomahleather.com/Allergy Offers clogs made of chromate-free vegetable-tanned cowhide and for those with rubber allergy, they use a wood midsole, isolating the wearer’s feet from the cemented outsole. 8. P.W. Minor and Son http://www.pwminor.com/ offers hypoallergenic footwear, including chrome-free leather and the use of minimal adhesives TREATMENT ALGORITHM Moderate Atopic Dermatitis Severe Atopic Dermatitis Mild Atopic Dermatitis Consider Derm Referral Consider Derm Referral TCS* TCS* TCS* 1st Line BRMD/Emollients BRMD/Emollients BRMD/Emollients (+/-) TCI (+/-) TCI TCI 2nd Line TCI TCI Narrowband UVB Systemic medications BRMD/Emollients BRMD/Emollients BRMD/Emollients Maintenance (+/-) TCS/TCI† (+/-) TCS/TCI† (+/-) TCS/TCI† (+/-) sedating antihistaminea *Potency based on site, *Potency based on site, Special duration and age duration and age Circumstances (+/-) sodium hypochlorite (bleach bath) appropriateness appropriateness or topical hypochlorous †Rotational/intermittent †Rotational/intermittent b acid (+/-) sedating antihistaminea (+/-) sedating antihistaminea c (+/-) oral antimicrobial (+/-) sodium hypochlorite (+/-) sodium hypochlorite (bleach bath) (bleach bath) or topical hypochlorous acidb or topical hypochlorous acidb (+/-) oral antimicrobialc (+/-) oral antimicrobialc Lebwohl MG, et al. JCAD. 2013;6(7 suppl):S1-S18. CLASSES OF TOPICAL STEROIDS • Look at Steroid CLASS not the PERCENTAGE of the drug to determine potency • Pair it with the symptoms! Does this wake them during the night? Is it a mild irritation? • Class I Super Potent • Only use for 2 weeks, NEVER on face, axilla, or groin clobetasol diproprionate betamethasone diproprionate halbetasol proprionate diflorasone diacetate fluocinonide CLASSES OF TOPICAL STEROIDS

• Group II—high potency– use <6-8 wks • Desoximetasone, mometasone • Group III—mid potency—use <6-8 wks • fluticasone • Group IV—low potency—side effects rarer • triamcinolone • Group V—low • Hydrocortisone butyrate • Group VI—low • Alclometasone, desonide • Group VII—weak • Hydrocortisone OTC

• A 30 gram tube should suffice for one week both feet and arms NON STEROIDAL ANTI-INFLAMMATORY TOPICALS • Ultimately steroid sparing and reduce the risk of tachyphylaxis • Pramoxine OTC • Crisaborole Rx • Low molecular weight hyaluronic acid Rx • Hypochlrorous acid Rx • Topical Calcineurin inhibitors Rx • OTC and Rx moisturizers/barrier repair products CRISABOROLE IN ATOPIC ECZEMA Using a non steroidal: Low molecular weight HA (Bionect) HYPOCHORLOUS ACID SOLUTION

• Antipruritic Hydrogel/Spray • Hypochlorous acid plus moisturizer foam or cream = steroid free regimen for pediatric eczema patients

R Smith, Poster at Caribbean Dermatology, Jan 2012 LOGICAL APPROACH TO TREATMENT FOR INFLAMMATORY CONDITIONS • Educate, educate, educate • Reduce signs and symptoms (get acute flare down) • Prevent and decrease frequency of flares

• Skin Hydration! • Avoid triggers! • Frequent moisturizers! • Educate patient and family! • COMBO therapy

• Pediatrics 2008, Br J Derm 2003 HOW I VIEW WART THERAPY WITH A DERMATOSCOPE

Bae, Br J Dermatol 2007 INTRALESIONAL IMMUNOTHERAPY FOR VERRUCA

• Candida • Trichophyton • Mumps

• 70% of the population has immunity • Great for mosaics • Not for immunocompromised, pregnant, etc • Compared to Cryotherapy? Int J Dermatol. 2017 Apr;56(4):474-478 CANDIDA ALBICANS IMMUNOTHERAPY FOR VERRUCA

• Inject 0.1-0.3 cc intralesionally • Candin® by Nielsen BioSciences • One injection per month • Mother wart

• J Am Podiatr Med Assoc. 2015 Sep;105(5):395-400 • Clin Podiatr Med Surg. 2016 Jul;33(3):337-53. INJECT INTRADERMALLY…LIKE GETTING A PPD TEST

• Place needle almost flat against skin, bevel up. Insert needle • Slowly inject agent; watch for wheal to appear. If it does not, withdraw needle slightly and reinject. Do not aspirate before injecting. Do not massage site after injecting. • Withdraw needle quickly at the same angle as it was inserted. Dispose of needle without recapping CANTHARONE PLUS VS YAG LASER FOR VERRUCA

• Cantharidin, salicylic acid, podophylin combo vs long pulsed Nd:YAG laser on plantar warts older than 2 years • Laser group: 1 laser session/month • Cantharone Plus group: 1 application/2 weeks • Bottom line: both work, but cantharone plus seems to work more efficaciously than laser

Soheir Ghonemy (2017): Treatment of recalcitrant plantar warts with longpulsed Nd:YAG laser versus cantharidin–podophylline resin–salicylic acid, Journal of Cosmetic and Laser Therapy HOW DO I PULSE DOSE ORAL TERBINAFINE?

• FDA approved is continuous dosing 250 mg/day for 90 days • One week of 250 mg bid then three weeks off, repeat 4 times total Indian J Dermatol Venereol Leprol. 2015 Jul-Aug;81(4):363-9 • No difference between groups (but continuous dosing higher numbers) and cost effective: J Dermatolog Treat. 2004 Sep;15(5):315-20 • Cost effective? Liver issues? Concomitant meds? Pt wants to drink? • I use only as booster dose… WHAT HAPPENS WHEN ORAL TERBINAFINE DOESN’T WORK?

• 50% of nail disease is NOT onychomycosis!!!!!!! • Controversy of treating empirically without confirmatory test: JAMA 152(3): 276, 2016 • The cost of getting things wrong: J Cutan Med Surg 0(0): 1, 2017 • The cost of an incorrect diagnosis: $375-1175 The cost of a correct diagnosis: $320-930 • Did you lab confirm it was onychomycosis at the start? Did you culture? • Does the patient have an inflammatory based skin condition (alopecia, psoriasis, etc)? • Did you have patient stand or walk? • I examine nails with feet flat on exam table, knees bent • Hydrosoluble nail lacquer, poly-ureaurethane 16%, cosmetic camouflage PT FAILED TWO ROUNDS OF TERBINAFINE USING DERMOSCOPY ON THE HALLUX NAILS

It’s not onyhco!!! A PATIENT PRESENTS WITH COMPLAINT OF…

• Ingrown toenail at the tip of the toe

• Has had multiple nail avulsions to treat nail fungus which has never seemed to solve the problem

• The length of the left hallux nail is not the same as the right, which is bothersome to the patient COMPARISON OF RIGHT VS LEFT PHYSICAL EXAM AND LAB RESULTS

• Pain on palpation at the distal tip of the nail • No pain on palpation of the medial or lateral corners or on the nail plate itself • No drainage, no edema of the lateral nail folds • Distal hypertrophy of the pulp of the hallux

• In office KOH, no hyphae present

• What’s next? DISAPPEARING NAIL BED

• Coined in 2005 by Dr Daniel (Cutis 2005;76:325– 327) • A shortened or narrowed nail bed that is the result of long standing onycholysis • 20% shorter than the bilateral nail • Long standing onycholysis can cause epithelialization to occur and dermatoglyphics to appear • May occur on fingernails (onychophagia) or toenails (hallux most common) WHAT CAN CAUSE IT?

• Onychomycosis • Onychogryphosis • Trauma (blunt force or repetitive) • Nail Surgery (ie iatrogenic) • Biomechanics (ie hallux extensus) • Other disorders that cause nail onycholysis: ie psoriasis, lichen planus, medications

• You do want to rule out subungual exostosis or other boney deformity first

Daniel et al Skin Appendage Disord 2017;3:15–17 WHY?

• Normal nail bed lacks a granular layer of the epithelium and is 2-3 layers thick with a hearty vascular and nerve supply. The nail plate is the “stratum corneum” layer for the nail bed

• As it grows forward, Nail plate slides over the nail bed. There is a thin attachment called the bed epithelium

• Nail bed with no nail plate covering it seems to have digital fingerprint memory—ie the nail bed becomes like the distal tip of your toe. The nail plate can no longer slide across the nail bed. WHY? CONT’D

• The distal pulp of toe deforms, creating a physical barrier for the nail to grow forward

• Unknown how long onycholysis needs to be present for this to occur

• Anecdotally, I have noticed a grossly atrophied nail matrix upon removal of these nails WHAT ARE OUR OPTIONS?

• Doing a total nail avulsion will NOT solve this issue • Once epithelialization has occurred, the nail plate and nail bed will never adhere • If the nail can grow forward, there will be a cavern underneath the nail and discoloration • Must create realistic expectations with patient! HOW DO WE MANAGE?

• Conservative options: • “Tape” the distal skin (Omnifix) • Treat the ingrown nail • Camouflage with Keryflex (ie cosmetic) • Wear shoes that accommodate the deformity • Treat dermatophyte, but set patient expectations HYPERHIDROSIS

• Primary focal hyperhidrosis • age of onset 22, possible family connection • Rule out other causes • Diagnosis is made: • Visible, excessive sweating of at least 6 mo duration • With 2 of the following characteristics: • Bilateral and relatively symmetric • Impairs daily activities • Score of 3 or 4 on Hyperhidrosis Disease Severity Scale (HDSS) • Age of onset less than 25 years • Positive family history • Cessation of focal sweating during sleep WHO IS OUR TARGET PATIENT POPULATION FOR PLANTAR BOTULINUM TOXIN INJECTIONS?

• Patients who have failed topical (OTC and Rx) medications • Patients who have failed iontophoresis • Patients who have failed glycopyrrolate • Patients who have a strong family history

• We should avoid those who: have an allergy to a component in Botox, have had an allergic reaction with any of the injected toxins or have a skin infection at the site of planned injection I now use a BD Ultra Fine insulin syringe 31 gauge

It comes as a 100 unit bottle that has to be reconstituted 4 mL of preserved saline equals 25 U/mL which further translates into 2.5 U/0.1 mL

Injectable Botulinum Toxin as a Treatment for Plantar Hyperhidrosis A Case Study

Vlahovic TC, Dunn SP, Blau JC, Gauthier C. JAPMA. 2008 Mar-Apr;98(2):156-9. Post Minor’s iodine starch test Using a stencil to plan out injection sites No deeper than 2-3 mm!! THANK YOU!!!! [email protected]