Most Common Dermatological Problems in VA Ambulatory Care None

 Intrinsic aging of the skin  Analogous to osteoporosis  Regardless of external physical factors  Regardless of disease states  Ultimately leads to “skin failure”

Dermatology 215:271 and 284, 2007 Int J Cosmet Sci.35:477-83, 2013 What reduces skin’s multipurpose functionality? Intrinsic Aging

EPIDERMIS DERMIS thins Reduced sebaceous gland activity Increased TEWL Reduced sweat gland activity Decreased SC lipids Reduced collagen synthesis Decreased melanocytes Reduced elastin synthesis (10% per decade) Shrinking collagen and elastin Fewer functional dendritic cells (1% per year after age 25) (Reduced immunosurveillance) Increased MMP activity due to decreased MMP inhibitors (destruction dermal fibrils) Reduced hyaluronic acid synthesis

Dermatology 215:271 and 284, 2007 This may be the most obvious extrinsic factor in loss of skin integrity, but not the only one!

Photoaging: UV exposure What reduces skin’s multipurpose functionality? Extrinsic Factors

UV Light Smoking Sedentary life Extreme temps Stress Alcohol abuse Pollutants Drugs What reduces skin’s multipurpose functionality? Extrinsic Factors UV Light Smoking Sedentary life Extreme temps Stress Alcohol abuse Pollutants

EPIDERMIS DERMIS Epidermis thins Collagen degeneration DNA damage: abnormal cells Elastin degeneration Destruction of dendritic cells Increased MMP (due to ROS) (Reduced immunosurveillance) Hyaluronic acid degeneration

Pathol Biol 51:569, 2003 J Cut Med Surg 8:415, 2004 Arch Dermatol 143:397,2007 J Invest Dermatol 130:2719, 2012  Rhytids*  Xerosis  Sagging skin  Skin fragility  Solar elastosis  Senile purpura  Cutis rhomboidalis  Patterned alopecia  Solar lentigines  Poliosis  Actinic comedones  thinning/ridging

Indian J Dermatol 57:343-52, 2012 It doesn’t stop with emphysema and lung cancer! Twin A

52.5 pack-years

Twin B No smoking

Arch Dermatol 143:1543-46, 2007 QUIT SMOKING

Better yet, don’t start!

Int J Dermatol 53:1205, 2014 Plast Reconstr Surg 132:1085, 2013 Exp Dermatol 22:349, 2013 Skin Res Technol 18:511, 2012

Lower skin oxygenation Vasoconstriction Lower telomerase Increased MMP activity Increased cytokines

Skinmed 8:23-9, 2010  Rhytids  Xerosis*  Sagging skin  Skin fragility  Solar elastosis  Senile purpura*  Cutis rhomboidalis  Patterned alopecia  Solar lentigines*  Poliosis  Actinic comedones  Nail thinning/ridging

Indian J Dermatol 57:343-52, 2012

OLD: Bleach with 4% hydroquinone (+ retinoid or AHA) OLD: Liquid nitrogen cryospray NEW: Laser ablation Nd-Yag at wavelength 532nm IPL at wavelength 515nm Alexandrite at wavelength 755nm

Xerosis: Dry Skin Most common skin “disorder” in mature adults May cause inflammation: Xerotic eczema Xerosis may itch…  Cerave: Cream, Lotion, Wash  Curel: “Rough Skin Rescue Lotion”  Curel: “Advanced Ceramide Therapy”  Eucerin: “Professional Repair”  Cetaphil: “Restoradem”  Aveeno: “Eczema Care” OBVIOUS ETIOLOGY ETIOLOGY UNCERTAIN

 Xerosis cutis  incognito  Classic Scabies  Atypical contact  Body lice (homeless) dermatitis  DH, GA,  ID rxn  ,  Unusual  Drug reaction  Prurigo nodularis  Pemphigoid (early, atypical)  “Unclassified  Endogenous Eczema”   Nummular eczema  Tinea pedis/cruris/corporis Atypical in the Elderly  Suspect scabies: mineral oil prep; Likely negative  Suspect scabies but prep negative….  EVERY ELDERLY ADULT PRESENTING WITH NEW ONSET WIDESPREAD ITCH, NON-SPECIFIC SHOULD BE ASSUMED TO HAVE SCABIES  Ivermectin 1 mg/10 lbs + permethrin 5% cr  Repeat in 1-2 week  Treat close contacts with permethrin  Address fabrics contacting skin prior week  FROM: Nurse, Caregiver, Relative….OR… J Gerontol A Biol Sci Med Sci 56:424-7, 2001 Damn Viagra  Given overall: risk of internal malignancy with pruritus is very low, if at all.  Hematologic malignancy OR = 2 Bile duct CA OR = 3.73 Overall OR = 1.14 in itching patients J Am Acad Dermatol 70:651-8, 2014 Semin Cutan Med Surg 30:107-12, 2011 Am J Clin Dermatol 7:71-84, 2006 May be rare, but not impossible! Solar purpura Senile purpura

Skin fragility Solar purpura Senile purpura

NO RELIABLE THERAPY

Skin fragility

 Arnica montana Inhibits hyaluronaidase Decreases capillary permeability  Ascorbic acid Collagen synthesis Capillary strength  Hesperidin Capillary stability  Rutoside Inhibits elastase Decreases capillary permeability  Eriocitrin Antioxidant Many choices; All OTC; All inexpensive…..What’s to lose? J Drugs Dermatol 10:718-22, 2011 Active Active

Placebo Placebo

J Drugs Dermatol 10:718-22, 2011 Superficial fungal infection: foot, groin, trunk

Frequency increases with age Diabetes, Immunosuppression Trichophyton rubrum: 90% All forms itch Tinea pedis probably first, then spreads to groin, trunk ANY topical antifungal works Oral terbinafine 250mg/day

Superficial fungal infection: foot, groin, trunk

Diagnosis: KOH prep KOH the active border Obtain scale for fungal culture  Topical therapy; Many agents to choose from and all work; be aware of dosing, which varies from agent to agent  Vehicle important (cream, gel, lotion, foam)  Azole: clotrimazole, econazole, ketoconazole luliconazole, oxiconazole, sertaconazole  Allylamine: butenafine, naftifine, terbinafine  Olamine: ciclopirox

Br J Dermatol 166:927-33, 2012 Reservoir for fungi that cause other tinea infections

Onychomycosis = 50% abnormal nails DIAGNOSIS: KOH, Culture In most patients, T. Rubrum Rarely Candida, Molds Can cause pain Can cause ulcers on nearby toes Can lead to Rx: Terbinafine 250mg/d x 3-4 months Topical Rx: Efinaconazole, Tavaborole (Daily x 48 weeks!)

What are these bumps?  “Stuck on” appearing, rough and pigmented lesions; Familial  Cherry angiomas Round, bright red to almost black growths; Familial  Sebaceous hyperplasia Small, facial bumps with yellow color, central dip and surface blood vessels; Not familial SK

Cherry Angiomas Sebaceous Hyperplasia

 Seborrheic keratosis, Sebaceous hyperplasia, Cherry Angioma  All Rx with either light liquid nitrogen cryospray or by electrodestruction (“cooked”) or by snip + hemostasis  SK: nitrogen > electrodesiccation >> snip  Seb hyperplasia & cherry angioma Electrodesiccation > nitrogen >> snip  TIP: With multiple lesions, a trial of each modality to see which works best!

Skin Tags (Acrochordons) Skin Tags Snip at base Achieve hemostasis

Pressure Drysol Light ED Immerse hemostat, forceps or needle holder in LN2 Grasp with frozen tip Keep in place ~10-15 seconds  When multiple, associated with increased incidence of diabetes Int J Dermatol 46:1155, 2007 J Dtsch Dermatol Ges 6:852, 2008  When perianal: Sign of Crohn’s Disease J Clin Gastroenterol 44:151, 2010 Inflamm Bowel Dis 14:1236, 2008  When multiple, associated with pre-malignant colonic polyps????? YES! Ann Intrn Med 98:928, 1983 NO! Gastroenterology 95:1127, 1988 Venous Lake Venous Lake Venous Lake  Closely related to senile angioma  COMPRESS with PRESSURE  Slowly refill  May be very dark and resemble Arch Dermatol. 117:250 , 1981  Common sites: ear and lip  Electrodesiccation or laser (YAG at 532; IPL at 560)

All other cancers

Melanoma BCC SCCA

https://www.aad.org/media/stats/conditions/skin-cancer All other cancers 1,689,000 Melanoma 161,800 BCC SCCA 4,000,000 1,400,000

https://www.aad.org/media/stats/conditions/skin-cancer SCCA + BCC 3000 Melanoma 9730

All other cancers 587,490

https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2017.html

AK or SCCA

Complete Rx Clearance Comment References

How long Hautarzt 56:353, 2005 Cryosurgery 68-97% to freeze? Int J Derm 43:687, 2004 BID 4-6 Clin Ther 24:990, 2002 5-FU 0.5-5% 50%-96% Cutis 70:335, 2002 weeks Br J Derm 157(S):34, 2007

Imiquimod 45-85% 2 or 3x/wk JAAD 50:714, 2004 Cont? Cycle? Br J Derm 157(S):41, 2007

BID Int J Derm 40:709, 2001 Diclofenac 33-50% x 90 days Br J Derm 146:94, 2002

JAAD 56:125, 2007 PDT 69-93% ? Protocol Br J Derm 156:793, 2007 Pre-Rx 4 weeks End Rx (16 wk) 4 weeks post  Epidemiology: Least dangerous  Clinical course . Slow growing . Face, scalp, upper back and arms . Increasingly prevalent in elderly . Rarely metastasize….BUT . If neglected, can cause significant functional and cosmetic impairment . Given one BCC, lifetime risk for another >50%; 12-20% in first 12 months

JEADV 20:698, 2006  Nodular  Superficial  (elevated)  Macule (flat)  Translucent,  Red and scaly Pearl-like  Telangiectasia less  Telangiectasia prominent on surface  Painless  Painless  May Itch  May bleed  May bleed  + Pigment  + Pigment

. If untreated may be very destructive!  Second most common NMSC  M:F = 2:1; Face, scalp, hands/arms and lips and ears  More rapid growth; may metastasize  Reddish, scaly, patches to firm plaques, to rock hard and nodules1 . May have ulcerated center . May develop keratin “horn” . May appear “ like”

SCCIS misdiagnosed as eczema or psoriasis

Albino Chronic DLE Transplant Chronic Leg

Sometimes what is seen at the surface is only the tip of the iceberg

 Mohs micrographic surgery  Classic scalpel excision (3-5mm margin)  Curettage with electrodesiccation  Radiotherapy  Cryotherapy (liquid nitrogen)  Topical therapy: 5-FU, Diclofenac  Topical IRM: imiquimod  Photodynamic therapy (ALA, MAL)  (Intralesional interferon)  (Laser ablation, Acid application)  Any pigmented lesion should be viewed with suspicion since this can be fatal (20%)  ABCDE:  Asymmetry, Irregular border, Multiple colors, Large diameter, Evolving (growing)  When in doubt: BIOPSY  Superfical spreading, Nodular, maligna melanoma, Acrolentiginous

 NOT just “adult ”  Inflammatory disorder; unknown precise origin  Classification Erythemato-telangiectatic -Flushing, , telangiectasia Papulopustular -Resembles acne, but no comedones Ocular -Blurred vision, photophobia, blepharitis Phymatous -Soft tissue hypertrophy

J Am Acad Dermatol 46:584, 2002 Cathelicidin Theory of

Cathelicidin Precursor

SCTE LL37 + Other peptides

Chemotactic Angiogenic Anti-bacterial

INFLAMMATION VASODILATION

Nat Med 13:904-06 and 975-80, 2007

Rosen T, Stone MS. Acne rosacea in blacks. J Am Acad Dermatol. 1987 Jul;17(1):70-3

Rosacea in skin of color: uncommon, but not unheard of!  Avoid triggers: sun, wind, humidity  Diet: avoid vasodilatory stimuli . Hot food, spicy food, alcohol (espec wine)  Topical Rx - Metronidazole gel & lotion 1% - Azelaic acid 15% gel - Sulfur & sodium sulfacetamide  Systemic antibiotic (TCN derivatives: espec sub-antimicrobial Br J Dermatol 165:760-81, 2011 dose doxycycline 40mg/d) J Drugs Dermatol 7:573, 2008 J Am Acad Dermatol 51:327, 2004 Baseline

8 weeks Rx SDD Autoimmune blistering disease

Antibodies to BP180 and 230 Initially: red wheals or plaques Then: Small vesicles Then: Tense bullae Total body (20-40g/d) steroids Systemic steroids MTX, AZA, Mycophenolate IVIg, Rituximab

JEADV 28:712, 2014 Autoimmune blistering disease

Biopsy w/ Direct IF Biopsy RED skin NEAR Common dermatological diseases in the VA