Transcript Skin Conditions as Women Age: What is Normal, What is Not?

Common Dermatologic
Conditions
Toby Maurer, MD
University of California, San Francisco
Acne
• Papulopustular
– Topicals okay
• Cystic, scarring, keloidal
– p.o. antibiotics
– Accutane
Topicals
• BP 5% gel (10% - more drying)
• Retin A 0.025% - 0.1% ( vehicle
determines strength - start with crème)
• Cleocin T or erythromycin topically
– Use 1 qam and 1qhs
– If NO success after 8 weeks, go to p.o.’s
P.O. Antibiotics
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TCN - 500 bid x 8 weeks
Doxycycline - 100 bid x 8 weeks
Minocycline - 100 bid x 8 weeks
Taper - Do NOT STOP ABRUPTLY
Alternatives
• Erythromycin - 500 bid
• Septra - check WBC’s
• Keflex-500 tid
Spiranolactone
• Diuretic used in cirrhosis of liver
• Also an anti-androgen
• Useful in females who have cysts around
menstruation
• 50-100 mg qday continuously
• Increased urination, don’t use during
pregnancy, ?electrolyte imbalance
Accutane
• Document failure of antibiotics
• Baseline CBC, LFT’s ,TG and cholesterol
• Two forms of birth control, negative
pregnancy tests
• MD’s will need to be registered as will
patients
• Counseling on depression
Acne Rosacea
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Common in women over 40
Often seen in persons of Irish decent
Associated with seborrheic dermatitis
Characterized by papules, erythema,
telangiectasia and rhinophyma (M>F)
• Sun exposure, alcohol and spicy foods
exacerbate rosacea
Acne Rosacea
• Oral antibiotics for 6-8 weeks clears skin
for some amount of time
• Topicals work less frequently
Perioral Dermatitis
TREATMENT
Topicals: Cleocin T Gel bid
Erythromycin bid
p.o. antibiotics –TCN
Doxycycline
Minocycline
- bid x 8 wks
Keeps pts in remission x 2 yrs.
Hair Loss
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Decide if scarring or not:
If scarring-refer
If not scarring and diffuse:
Check recent surgeries/illness, nutrition,
anemia, TSH, estrogen replacement,
medication history, VDRL.
• If hirsute with scalp hair loss-DHEAS and free
testosterone
• If lactating- check prolactin
If all negative
• Androgenetic AlopeciaMinoxidil 5% bid topically (even in women)
Can make hair oily-may want to start with
minoxidil 2% or use 2% by day and 5% at
night
Use for at least 6 months for results and what you
see after 1 yr. is the effect you can expect.
What about finasteride (propecia)?-equal to
minoxidil in men. Does not work in women.
Too Much Hair
• Vaniqa
– topical cream that breaks the chemical bond
of hair
– apply 2x’s/day forever
– 30% effective
– $30/month
Hair Removal
– pigment of hair absorbs the light and is
destroyed
– dark hair responds
– hair is always in different growth phases,
so treatment has to be repeated several
times to catch the phase(expensive)
– Side effects: pigment changes of
surrounding skin and scarring
Psoriasis-What is it?
• Fast growing skin-takes 3 days to come to
surface and desquamate
• Normal rate is 28 days
• Psoriatic skin has a fast mitotic rate
• Triggers an inflammatory response in
and around affected skin
• New onset often preceded by strep
infection (strep pharyngitis) especially in
the younger age group.
• In older age group, drugs often unmask
psoriasis
• Drugs: beta-blockers, lithium, NSAIDS,
antimalarials, terbinafine, gemfibrozilpts on these meds for 3-6 months before
onset of psoriasis
Psoriasis-Tx:
• Decrease the mitotic rate of skin
– Tar (LCD 5% in TAC 0.1% oint) ( Tar emulsions),
topical retinoids (Tazarac)
• Decrease the inflammatory response of the skin
– Steroid Ointment (mid-potency-1st line)
– Calcipotriene (Dovonex Ointment)-not on face or
groin
– Clobetasol/Dovonex combination
– Ultraviolet light (psoralen+ UVA), UVB
– NO PREDNISONE
NEXT STEP
• Time for referral
• Methotrexate-liver biopsies
necessary(don’t give in HEP C pts)
• Oral retinoids (Acetretin)-not in persons
of reproductive potential -? Okay in liver
disease; excellent drug in HIV
• Cyclosporine
• Biologics (Enbrel, Remicade)-most
benefit in psoriatic arthritis and quick
reversal of pustular psoriasis
Eczema
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Dry, inflamed skin that becomes “weepy”
Not bilateral and symmetric
No thick scale
No scalp/nail involvement
Topical steroids first line of treatment
Oral cyclosporine was known to turn off
inflammation
• Now: topical formulation of Cyclosporine
Eczema
• Tacrolimus (Protopic) and
Pimecrolimus (Elidel), new kids on
the block
– Great for facial eczema
– $120 for 30gm
Topical Immune Modulators and
Cancer
• Elidel (pimecrolimus 1%) and Protopic
(tacrolimus 0.1% and 0.03%) –heavily
marketed
• 29 cases of cancers in children and adults
associated with use of these topicalslymphomas, SCC’s, sarcomas
• Causality not proven
FDA Response
• Black Box Warning
Do not use in children under 2 years of age
Do not us in adults or children with
“weakened” immune systems: Transplants,
HIV, cancer patients, etc.
• Limit use—no continuous usage; limit area
treated
Topical Immunomodulators
When to use
• Eyelid dermatitis
• Refractory psoriasis on upper thighs,
scrotum, glans penis
• Otherwise use cheaper alternatives first
– Protopic=TAC 0.1%
– Elidel=HC 2.5%
Buttock Folliculitis
• Mechanical from clothing
• Ban roll-on good
• Topical antibx qd
– Cleocin/Erythro
Keratosis Pilaris
• Thickening of hair follicles on the out
arms and upper legs
• Associated with dry skin
• Lubrication
• Lachydrin 12% lotion bid
Intertrigo
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Pendulous breasts or pannus
Always component of candida
Blow dry area
Apply topical antifungals
Tucks pads
Bacterial Skin Infections
• Most common pathogen is staph aureus
• More methicillin resistant staph causing
skin and soft tissue infections in the
community
• JAMA-Niami et al Dec 2003
Approach to Treatment
• Culture where you can-if you have pus,
that is great
• Incise and drain when appropriate
(Abcesses)
If no pus:
• Tx with methicillin SENSITIVE drugs-first line
but have pt return to evaluate for resolution
• If recurrent infection, tx with methicillin
RESISTANT antibiotics right off the bat
Septra, Doxycycline,Cipro/Levofloxacillin),
Clindamycin
• Consider adding rifampin 600 qd for 5 days or
mupirocin ointment for staph eradication
Was it bacterial in the first place?
• Remember HSV-culture and/or Direct
Fleurescent Antibody
• Skin biopsy for histology and tissue
culture
• Diseases that Masquerade as Infectious
Diseases Ann Int Med 2005 Jan 4;
142:47-55
Hidradenitis Supparativa
• Not an infectious disease
• Disease of apocrine glands
• Treatment
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IL Kenalog
Minocycline
Surgery
NOT Antibiotics
New Biologics
Inflamed Epidermoid Cysts
• Antibiotics-USELESS
• If just starting to become inflamed and cyst is small( <
1 cm), can try intralesional Kenalog injection but see
them back in few days-you can exacerbate the
inflammation
• INCISE and DRAIN and PACK
• 6 weeks later, inspect for residual cyst and excise
Recurrent Cellulitis
• Recurrent cellulitis knocks out lymph
system causing low grade cellulitis and
retention hyperkeratosis
• Tx. Cellulitis-may need 6 months of tx or
more
• Tx. Hyperkeratosis-urea crème 40%
• Tx. Lymphedema-support stockings with
35mm of pressure or mechanical pumps
Venous Insufficiency Ulcer
• Compression dressing
– Unna boot covered by Coban – this requires a good
nursing staff with training and experience
– This both provides graded compression AND creates
the correct wound environment
• Semipermeable dressing (Hydrosorb, Duoderm,
etc)
• Change dressing weekly
• Refer to dermatology if not healing
Venous Insufficiency Ulcer
• Control Edema
– Elevation of leg above heart 2 hours twice daily
– Walk, don’t sit
– Compression
• Diuretics overused and not of benefit unless fluid
retention due to central problem is present (CHF,
CRF)
• Create an appropriate wound environment for
healing
– Paradigm shift: Ulcers that don’t heal do not have the
appropriate biochemical environment to promote
healing
Complications of Leg Ulcers
• Allergic contact dermatitis to applied
antibiotics, topical anesthetics
• Avoid all topical antibiotics to leg ulcers
(except topical metronidazole to prevent
odor)
• Never apply topical benzocaine, Vitamin
E, neomycin, or bacitracin to VI leg ulcer
• 64 year old man with psoriasis,
hypertension, hypercholesterolemia
• 3 months of ulceration of medial aspect of
left lower leg
• Vascular evaluation confirms venous
insufficiency
• 3 months of treatment fails to improve
ulceration
• What is your next step?
• Skin Biopsy = Squamous Cell Carcinoma
• Chronic phototherapy and prior
immunosuppressive treatments may have
led to skin cancer
• If leg ulcer doesn’t heal with appropriate
treatment—refer or biopsy