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Ted Rosen, MD Professor of Dermatology Baylor College Of

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Ted Rosen, MD Professor of Dermatology Baylor College Of 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 Epidermis 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 Nail 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 Scabies incognito Classic Scabies Atypical contact Body lice (homeless) dermatitis DH, GA, Hives ID rxn Lichen planus, Psoriasis Unusual drug eruption Drug reaction Prurigo nodularis Pemphigoid (early, atypical) “Unclassified Contact dermatitis Endogenous Eczema” Atopic dermatitis 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 RASH 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 cellulitis Rx: Terbinafine 250mg/d x 3-4 months Topical Rx: Efinaconazole, Tavaborole (Daily x 48 weeks!) What are these bumps? Seborrheic keratosis “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 skin tag 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 melanoma 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 Papule (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 papules and nodules1 . May have ulcerated center . May develop keratin “horn” . May appear “wart like” SCCIS misdiagnosed as eczema or psoriasis Albino Chronic DLE Transplant Chronic Leg Ulcer 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
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