3/17/2017 Outline • Approach to the itchy patient Common Dermatologic Disorders: • How to really treat eczema Tips for Diagnosis and Management • Psoriasis as a systemic disease • Acne in the adult • Onychomycosis Lindy P. Fox, MD • Grovers disease Associate Professor • The red leg Director, Hospital Consultation Service Department of Dermatology University of California, San Francisco 1 2 Pruritus = the sensation of itch • Itch can be divided into four categories: 1. Pruritoceptive • Generated within the skin Approach to the itchy patient • Itchy rashes: scabies, eczema, bullous pemphigoid 2. Neurogenic • Due to a systemic disease or circulating pruritogens • Itch “without a rash” 3. Neuropathic • Due to anatomical lesion in the peripheral or central nervous system • Notalgia paresthetica, brachioradial pruritus 4. Psychogenic itch 3 4 1 3/17/2017 Pruritus- History Pruritus- Physical Exam • Suggest cutaneous cause of itch: Are there primary lesions present? – Acute onset (days) – Related exposure or recent travel – Household members affected yes no – Localized itch • Itch is almost always worse at night – does not help identify cause of pruritus • Aquagenic pruritus suggests polycythemia vera Pruritoceptive Neurogenic, Neuropathic, • Dry skin itches or Psychogenic 5 6 Causes of Neurogenic Pruritus Workup of “Pruritus Without Rash” (Pruritus Without Rash) • 40% will have an underlying cause: • CBC with differential • Serum iron level, ferritin, total iron binding capacity •Dry Skin • Thyroid stimulating hormone and free T4 • Liver diseases, especially cholestatic • Renal function (blood urea nitrogen and creatinine) • Renal Failure • Calcium • Iron Deficiency • Liver function tests • Thyroid Disease – total and direct bilirubin, AST, ALT, alkaline phosphatase, GGT, fasting total plasma bile acids • Low or High Calcium • HIV test •HIV • Chest X‐ray • Medications • Age‐appropriate malignancy screening, with more • Cancer, especially lymphoma (Hodgkin’s) advanced testing as indicated by symptoms 7 8 2 3/17/2017 Neuropathic Pruritus Notalgia Paresthetica • Notalgia paresthetica • Brachioradial Pruritus – Localized and persistent area of pruritus, without associated primary skin lesions, usually on the back or forearms • Workup= MRI!! – Cervical and/or thoracic spine disease in ~100% of patients with brachioradial pruritus and 60% of patients with notalgia paresthetica • Treatment‐ capsaicin cream TID, gabapentin – Surgical intervention when appropriate 9 10 Treatment of Pruritus Antihistamines for Pruritus • Treat the underlying cause if there is one • Work best for histamine‐induced pruritus, but may • Dry skin care also be effective for other types of pruritus – Short, lukewarm showers with Dove or soap‐free • First generation H1 antihistamines cleanser – hydroxyzine 25 mg QHS, titrate up to QID if – Moisturize with a cream or ointment BID tolerated • Cetaphil, eucerin, vanicream, vaseline, aquaphor • • Sarna lotion (menthol/camphor) Second generation H1 antihistamines • Topical corticosteroids to inflamed areas – longer duration of action, less somnolence – Face‐ low potency (desonide ointment) – cetirizine, loratidine, desloratidine, fexofenadine – Body‐ mid to high potency (triamcinolone acetonide 0.1% oint) 11 12 3 3/17/2017 Systemic Treatments for Pruritus • Doxepin - 10mg QHS, titrate up to 50 mg QHS – Tricyclic antidepressant with potent H1 and H2 antihistamine properties – Good for pruritus associated with anxiety or depression Eczemas – Anticholinergic side effects • Paroxetine (SSRI)- 25- 50 mg QD • Mirtazepine- 15-30 mg QHS – H1 antihistamine properties – Good for cholestatic pruritus, pruritus of renal failure • Gabapentin- 300 mg QHS, increase as tolerated – Best for neuropathic pruritus, pruritus of renal failure 13 Eczemas Eczema (=dermatitis) • Group of disorders • Atopic Dermatitis characterized by: 1. Itching • Hand and Foot Eczemas 2. Intraepidermal vesicles • Asteatotic Dermatitis (Xerotic Eczema) (= spongiosis) –Macroscopic (you can see) • Nummular Dermatitis – Microscopic (seen histologically on biopsy) • Contact Dermatitis (allergic or irritant) 3. Perturbations in the skin’s • Stasis Dermatitis water barrier 4. Response to steroids • Lichen Simplex Chronicus 15 16 4 3/17/2017 Eczema Eczema Good Skin Care Regimen Topical Therapy • Soap to armpits, groin, scalp only (no soap on • Choose agent by body site, age, type of lesion (weeping the rash) or not), surface area • Short cool showers or tub soak for 15‐20 • For Face: minutes – Hydrocortisone 2.5% Ointment BID – If fails, aclometasone (Aclovate), desonide ointment • Apply medications and moisturizer within 3 • For Body: minutes of bathing or swimming – Triamcinolone acetonide 0.1% ointment BID – If fails, fluocinonide ointment • For weepy sites: – soak 15 min BID with dilute Burow’s solution (aluminum acetate) (1:20) for 3 days 17 18 Eczema Eczema Oral Antipruritics Severe Cases • Suppress itching with nightly oral sedating • Refer to dermatologist antihistamine • Do not give systemic steroids • If it is not sedating it doesn’t help • We might use phototherapy, hospitalization, • Diphenhydramine immunotherapy • Hydroxyzine 25‐50mg • Doxepin 10‐25mg • Beware of making the diagnosis of atopic dermatitis in an adult‐ this can be cutaneous T cell lymphoma! 19 20 5 3/17/2017 Psoriasis Aggravators • Medications • Trauma – Systemic steroids • Sunburn Psoriasis pearls (withdrawal) – Beta blockers • Severe life stress – Lithium • HIV – Hydroxychloroquine – 6% of AIDS patients • Infections develop psoriasis – Strep‐ children and • Alcohol for some young adults – Candida (balanitis) • Smoking for some 22 Psoriasis and Comorbidities • Psoriasis is linked with: • Psoriasis patients more – Arthritis likely to – Cardiovascular disease (including myocardial – Be depressed •Psoriasis - independent risk factor for MI infarction) – Drink alcohol •Risk for MI - – Hypertension – Smoke •Greatest in young patients with – Obesity severe psoriasis – Diabetes •Attenuated with age – Metabolic syndrome •Remains increased after controlling – Malignancies for other CV risk factors • Lymphomas, SCCs, ? Solid •Magnitude of association is equivalent to organ malignancies other established CV risk factors – Higher mortality 23 6 3/17/2017 Psoriasis and Comorbidities Pustular Psoriasis • In patients with psoriasis, important to • Pustular and erythrodermic variants of psoriasis can be life‐threatening 1. Recognize these associations • Most common in patients with psoriasis who are 2. Screen for and treat the comorbidities given systemic steroids according to American Heart Association, • High cardiac output state with risk of high output American Cancer Society, and other failure accepted guidelines • Electrolyte imbalance (hypo Ca2+), respiratory distress, temperature dysregulation • Treat with hospitalization and cyclosporine or acitretin or TNF alpha blocker (infliximab) 25 26 Acne Pathogenesis, Clinical Features, Therapeutics Pathogenesis Clinical features Therapeutics Excess sebum Oily skin Retinoids, spironolactone Approach to the Adult Acne Abnormal follicular Non‐inflammatory open and closed Salicylic acid, Patient keratinization comedones retinoids (“blackheads and whiteheads”) Propionibacterium Benzoyl peroxide acnes Inflammatory papules Antibiotics and pustules (topical and oral) Inflammation Spironolactone Cystic nodules OCPs Isotretinoin 27 28 7 3/17/2017 Acne Treatment Topical Retinoids • Mild inflammatory acne – benzoyl peroxide + topical antibiotic (clindamycin, erythromycin) • Side effects • Moderate inflammatory acne – Irritating- redness, flaking/dryness – oral antibiotic (tetracyclines) (with topicals) • Comedonal acne – May flare acne early in course – topical retinoid (tretinoin, adapalene, tazarotene) • Acne with hyperpigmentation – Photosensitizing – azelaic acid • Acne/rosacea overlap /seborrheic dermatitis- – Tazarotene is category X in pregnancy – sulfur based preparations !!! • Hormonal component – oral contraceptive, spironolactone • Cystic, scarring- isotretinoin – Teratogenic, hypertriglyceridemia, transaminitis, cheilitis, xerosis, alopecia (telogen effluvium) 29 30 Acne in Adult Women Acne Pearls • Retinoids are the most comedolytic • Often related to excess androgen or • Topical retinoids can be tolerated by most excess androgen effect on hair follicles • Start with a low dose: tretinoin 0.025% cream • Other features of PCOD are often not • Wait 20‐30 minutes after washing face to apply present—irregular menses, etc. • Use 1‐2 pea‐sized amount to cover the whole face • Serum testosterone can be normal • Start BIW or TIW • Spironolactone 50 mg-100mg daily with or • Tazarotene is category X in pregnancy without OCPs • Back acne often requires systemic therapy • Acne in adult women‐ use spironolactone – No need to check K+ 31 32 8 3/17/2017 Perioral Dermatitis Perioral Dermatitis: Treatment • Women aged 20‐45 • Papules and small pustules • Stop topical products around the mouth, narrow • Topical Antibiotics spared zone around the – clindamycin lips. • Asymptomatic, burning, • Oral tetracyclines itching • Warn patients of rebound if coming off • Causes topical steroids – Steroids (topical, nasal inhalers) – Fluorinated toothpaste • Avoid triggers – Skin care creams with petrolatum or paraffin base or Isopropyl myristate (vehicle) 33 34 Onychomycosis Onychomycosis Diagnosis • Infection of the nail plate by fungus • KOH is the best test, as it is cheap, accurate if positive, and rapid; Positive 59% • Vast majority are due to dermatophytes, • If KOH is