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Only Skin Deep A Cutaneous Look at Current Events Terri Nagy, MPAS, PA-C [email protected] Credits Dr. Eliot Mostow National Institute of Health Akron Dermatology/Kenyan & Peruvian patients DermnetNZ Emedicine World Health Organization DermAtlas NPR.org Novartis – MSL Kushal Bhatt Galderma – MSL Tom Wiser Cancer.org Skincancer.org CDC New England Journal of Medicine New York Times, Fox News, etc Ohio.com Objectives.. Identify and discuss new and re-emerging diseases, specifically focusing on their cutaneous presentations, using current events as the template Discuss the impact of antibiotic overuse on these particular diseases Heighten knowledge base regarding HIV and how it manifests cutaneously Provide a refresher on melanoma recognition Top Five Emerging Diseases for 2017 Leishmaniasis Rift Valley Fever Mosquito - virus Mayaro Mosquito - virus Oropouche Sandfly - parasite Mosquito - virus Elizabethkingia Mosquito - bacteria CHIKUNGUNYA “To become contorted” Due to severe joint pain which may be chronic High fever Headaches 2-12 days after bite Rash – viral exanthem – 73% of patients Asymptomatic in most; mildly pruritic in others Appears 3-5 days after the onset of fever Diagnosed by ELISA IgG and IgM antibodies Highest 3-5 weeks after onset Other cutaneous findings… Desquamation of the palms Peno-scrotal and perianal ulcerations – 24% Punched out 2-5 weeks after fever Aphthous like ulcers on the tongue, palate, lips, etc Lymphedema 2-3 weeks after onset Vasculitic and EN like lesions Exacerbation of previous cutaneous diagnoses Dengue…. “Notifiable” since 1990 Fever in the presence of one or more of the following Nausea/vomiting Rash Headache/retro-orbital pain/arthralgia/myalgia Leukopenia Persistent abdominal pain Hepatomegaly Pleural/pericardial effusions Increased hematocrit with decreased platelets Dengue… DENV 1, 2, 3 and 4 Estimated: 40% of world’s population at risk Mosquitos with virus are currently found in Florida Louisiana New Mexico Arizona Texas California Utah And…as far north as Illinois and New York Treatment Supportive…. Cautious not to fluid overload in DHF Aedes Aegypti Mosquitoes Microcephaly What about… Reports of Sexual Transmission ZIKA? Guillian Barre Signs and Symptoms… 1 in 5 infected become ill Flu like symptoms: fever, headache, myalgia, macolupapular pruritic rash, nonpurulent conjunctivitis Incubation period is about one week Zika can survive in sperm for up to 6 months Can affect the fetus if exposed anytime during pregnancy – highest risk prior to 18 weeks gestation Labs First week: RT-PCR for Zika Second week: IgM and IgG After two weeks: urine RT-PCR How is it different? Zika vs Chikungunyna No arthritis No facial rash No vesicles/bullae on genitalia Zika vs Dengue No high fever No shock No hemorrhagic manifestations Chagas.. 5% mortality rate Myocarditis Thromboembolism Encephalitis Chronic Cardiac RBBB; cardiomyopathy; third degree atrioventricular block; CHF Chronic GI due to persistent T cruzi infestation Megaesophagus Megacolon Psoriasis Most common autoimmune disorder in US 7.5 million Americans (2% of population) New Treatments Cosentyx (Secukinumab) - Novartis Taltz (Ixekizumab) – EI Lilly Monoclonal antibody SQ Otezla (Apremilast) - Colgene PDE4 inhibitor PO Rash.. Lyme Disease and STARI Erythema Migrans Anaplasmosis – rarely presents Tularemia Ulcer at site and regional lymphadenopathy with a rash Rocky Mountain Spotted Fever Babesiosis 10% do not develop a rash Small, pink macules on arms, legs, trunk; eventually petechial lesions Maculopapular to petechial; splinter hemorrhages; ecchymosis Ehrlichiosis Rarely presents with rash Erythrodermic or similar to RMSF Conjunctivitis is common Treatment?? Viruses… Supportive care Tularemia Streptomycin, Gentamicin, Anaplasmosis Babesiosis Lyme Disease Doxy; Amox; Ceftin Doxy Atovaquone, Azythromycin and Quinine Ehrlichiosis Tick Borne Spotted Fever Doxy Doxy Treatment options with history of attached tick…. All people People with higher risk due to attachment of tick longer than 36 hours All people who develop erythema migrans or other signs and symptoms of tick-borne infection All people who seroconvert from negative to positive for serum antibodies Outcomes… Prevent exposure to vector Routine use of antibiotics and serological testing IS NOT recommended Single dose doxycycline can be used if tick is attached longer than 36 hours and if doxy can be started within 72 hours of tick removal Local infection rates in ticks is >20% Adults: 200 mg dose Children > 8 yo: 4mg/kg but not more than 200 mg Pts should be monitored for 30 days for signs and symptoms of tick-borne infections and treated accordingly E.Coli– susceptible drugs Amikacin Ertapenem Cefotetan Meropenem Cefoxitin Piperacillin/tazobactam Ertapenem All injectable drugs C. Diff 250,000 drug resistant infections/year 14,000 deaths Tetracycline P. acnes resistance - 60% Resistance is being transferred to other organisms Oropharynx – 85% resistance in S. Pyogenes Nares cultures – 77.8% resistance in staph. aureus Gonorrhea 246,000 drug resistant infections 188,600 to TCN 11,480 to Cefixime 3,280 to Ceftriaxone 2,460 to Zithromax MRSA 80,461 severe drug resistant infections/year 11,285 deaths Strep. Pneumonia 1,200,000 severe drug resistant infections/year 7,000 deaths CDC Antibiotic Stewardship Take an “antibiotic time out” – reassessing antibiotics after 48-72 hours All orders should have: Dose, duration and indications Get cultures before starting antibiotics It has been estimated that nearly half all prescriptions written are “unnecessary” Maine Vaccination Rates Measles complications 1:10 children develop perm. hearing loss 1:20 children develop pneumonia ~ the most common cause of death in children with measles 1:1000 develop enchephalitis 2:1000 die Rare~ Subacute Sclerosing Panenchephalitis (SSPE) Develops 7-10 years after the measles infection Involves the CNS Fatal 11:100,000 Supernumerary Nipples 27.2 million americans (10% of population) 1 in 100 men 1 in 50 women Symptoms of breast cancer can be found in extra nipples; but not linked to increased risk Different types Flat Puffy Inverted Average Timeline 1996 AIDS cocktail released Leading cause of death in AA age 25-44 2004 Leading cause of death in AA woman ages 25-34 2007 81% of all new HIV cases in DC are AA Cutaneous manifestations of HIV Lymphadenopathy Maculopapular rash with early disease Deep and superficial fungal infections Syphilis Kaposi sarcoma Impetigo Herpes simplex Drug eruptions Herpes zoster Seborrheic dermatitis Molluscom contagiosum Now….In Kids… Mucocutaneous candidiasis Impetigo Onychomycosis Scabies Herpes simplex Drug eruptions Varicella Warts Molluscum contagiosum Vitiligo Cause ~ not completely understood “Autoimmune disorder” Absence of functional or recognizable melanocytes Destroyed by T cells Presence of circulating antibodies Vitamin deficiency?? Maybe – an over reactive response to protect against MM 0.5-2% of population More females than males? Not statistical – more females present Average age of onset: 20 years old Treatments?? TCS Tacrolimus 0.3-1% ointment Vitamin supplements? (C, Folic Acid, B12) Depigmentation with hydroquinone 20% - Monobenzone – only FDA approved tx Surgical: punch minigrafting Melgain?? New Treatments?? Interferon gamma pathway (IFN-y) Specifically CXCL10 chemokines Biologics in Phase 1 Xeljanz (tofacitinib citrate)– used to treat RA Afamelanotid and Narrowband UVB Melanocyte stimulating hormone Developed by the University of Arizona 1873 Medical records reviewed 20% had at least one comorbid diagnosis Alopecia areata Addison disease Autoimmune gastritis IBD Pernicious anemia Psoriasis RA Systemic lupus 31 fold increase in frequency of alopecia areata than general population Also found association with: Guillain-Barre, myasthenia gravis, linear morphea, discoid lupus and Sjogren syndrome Malignant Melanoma Third most common, but most deadly Estimated 76,380 new cases will be diagnosed in 2016 2017: 87,110 new cases 10,130 people will die/ one person every 57 mins 2017: 9,730 deaths Of the 7 most common cancers in the US, MM is the only one that continues to increase in incidence Cause: sun, tanning bed, genetics (Jimmy Carter) Men Vs Women Men Majority of MM cases are white men over the age of 50 60% of MM deaths 5th most common cancer in men Women 39 and under have a higher chance of developing MM than any other cancer Leading cause of death in women 25-30 yrs old 7th most common cancer in women Ethnicity 60-75% of MM arise on areas of less pigment in people of color: palms; soles; nail beds and mucous membranes MM is uncommon in people of color ~ approximately 1:100,000 Late stage diagnoses are more prevalent among people of color ~ therefore MM is more likely to be fatal Kids and Melanoma MD Anderson 500 children nationwide diagnosed with MM yearly John Hopkins study Children more likely than adults to have metastasis to sentinel lymph node Children with metastasis : 25% Adults with metastasis: 14% New Statistics - Kids 90% of pediatric cases: 10 – 19 years old 6.5% occur in non-Caucasians – higher than adult statistics Diagnosis and treatment is delayed in 40% of pediatric melanoma cases Second most common form of cancer: ages 15-29 Let’s talk tanning beds.. First commercialized in US in 1978 But…Coco Chanel brought the tan into vogue after a trip to the French Riviera in 1929 In 1978– 500,000 cases of skin cancer yearly Now – 3.5 million yearly (melanoma and nonmelanoma) 20 mins of tanning bed = damage of 3-5 hours of natural sun Ohio HB 131 Sec:4713.50 Passed the House summer 2014 Tanning bed regulations Over 18: must obtain consent from individual Between 16- 18 years old: must obtain consent from parent – good for 90 days; parent must remain on premises; no more than 45 sessions in 90 day period Prohibited for children under 16 years of age Jimmy Carter’s treatment.. Keytruda (Pembrolizumab) Side effects - few Monoclonal antibody Rapid FDA approval in 2014 30 min infusion Q 3 weeks Based on weight; cancer, etc Itching; cough; nausea; anemia; rash; fatigue, constipation, arthralgia, diarrhea, etc Effectiveness? Only 1/3 respond Those who do…respond quickly with immediate shrinking of tumors