Winterfield – Dermatology for the PCP March 9, 2018 1 Dermatology for the PCP Laura S. Winterfield, MD MPH Associate Professor Medical University of South Carolina I have no relevant conflicts of interest.
Winterfield – Dermatology for the PCP March 9, 2018
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Dermatology for the PCP
Laura S. Winterfield, MD MPHAssociate Professor
Medical University of South Carolina
I have no relevant conflicts of interest.
Winterfield – Dermatology for the PCP March 9, 2018
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Learning Objectives
• Identify common skin conditions and potential mimickers
• Describe first‐line therapies for common skin conditions
• Recognize when to refer/collaborate with dermatology
Primary Care Skin Complaints
• Facial breakout
• Rash
• Suspicious Spot(s)
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19yo Male with breakouts
• Several years
• Tried OTC products
• No systemic meds
Acne vulgaris
Pathogenesis therapeutic targets:1. Abnormal desquamation with
obstruction of the pilosebaceouscanal
2. Androgen‐driven excess sebum production
3. Propionobacterium acnes4. Altered immune activity and
inflammation
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Acne vulgaris
Topical retinoid: mainstay of therapy
Benzoyl peroxide
Topical antibiotics
Other topicals
Oral antibiotics
Derm referral
Isotretinoin
Sebum production
AlteredKeratinization
P. acnes Inflammation
Benzoylperoxide ++ ++++Topical retinoid +++ ++Salicylic acid +Azelaic acid ++ ++ +Topical Antibiotic ++ +Oral Antibiotic + +++ ++Oral Retinoid (isotretinoin) ++++ +++ + +++Hormonal tx +++ +
Adapted from Farrah and Tan in Dermatol Ther 2016: 29:377‐84.
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Topical Retinoids
• Options:
– Adapalene
• 0.1% gel: Now OTC
– Tretinoin cream, gel, microsphere gel
• 0.025%, 0.05%, 0.1% and others
• Generics may not be stable in UV (apply at night)
– Tazarotene
• Pregnancy category X
Topical Retinoids
• Once daily application:
– Start every 1‐3 days and increase to QHS
– “Pea” size for entire face
• Thin layer, after gentle washing and drying
• SE: dryness, peeling, redness, irritation, sun sensitivity
• May take 4‐6 weeks to see benefit
• Continue for maintenance
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Antibiotics for Acne
• Topicals:– Clindamycin gel, lotion, solution
– Erythromycin gel, solution (less effective, more resistance)
• Oral:– Tetracycline
– Doxycycline
– Minocycline
• Avoid use as monotherapy– Use with topical retinoid or benzoyl peroxide
Antibiotics for Acne
• Goal: stop systemic antibiotics in <3 months
• No great data for which antibiotic is best
• Avoid use as monotherapy
• Plan for maintenance topical therapy
• Refer for consideration of isotretinoin in refractory patients, cystic lesions or scarring
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38yo Female with acne
• “clear skin as a teenager”
• Flares with menses
• Was on OCP, now has IUD
Female adult acne
• Lower face/jawline• Often resistant to traditional combination therapy
• Treat with topical retinoids• Consider topical dapsone• Target hormonal component
– OCP– Spironolactone
• Consider evaluation for PCOS especially if other signs present (hirsutism, irregular menses, etc)
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Skin Care Products
• Non‐comedogenic, oil‐free, “won’t clog pores”– Moisturizer
– Make‐up
– Sunscreen: helps reduce post‐inflammatory pigmentary alteration
• Gentle cleansers
• Gentle emollients
• Avoid harsh, abrasive, or excessively drying (alcohol)
27yo F with refractory acne
• Acne Excoriee• Predominantly secondary change
• “picker’s acne” or skin‐picking disorder
• More common in females• Consider psychiatric comorbidity– Depression– Anxiety– OCD– ADHD
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Acne treatment in Pregnancy
• Limited options
• Category B
– Topical clindamycin
– Topical azelaic acid
• Retinoids are category C or X
• Occasional intralesional kenalog for inflamed cysts
Diet in Acne
• Low glycemic diet
– Decreased acne severity
– Smaller sebaceous glands
• Low dairy
– Limit skim milk and ice cream
– Whey protein (derived from milk) reported to trigger truncal acne in adolescents
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50yo F with facial breakouts
Rosacea
• More common in fair skin types
• Flushing with fixed facial erythema
• +/‐ Papules and pustules
• No comedones
• Triggers of flushing:
– Dietary
– Environmental
– Menopause
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Treatment of Rosacea
• Trigger avoidance
• Topicals:
– Antibiotics: metronidazole gel or cream
– Anti‐inflammatory: azelaic acid cream or solution
– Anti‐parasitic: ivermectin 1% cream
– Alpha‐2 agonist: brimonidine, oxymetazoline
• May cause rebound flushing in some patients
• Oral antibiotics: tetracyclines, submicrobial dose
• Laser: Best option for persistent redness
Rosacea Mimics
Acute cutaneous lupus:Spares nasolabial folds
Dermatomyositis:mid‐facial erythemaViolaceous color
Rosacea:Crosses NL foldsTelangiectasiasNo scale+/‐ Papules and pustules
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20yo rash around the nose
Perioral dermatitis:Monomorphic papules sparing the vermillion
Treat like rosaceaavoid topical steroids and other triggers
Seborrheic dermatitis:Greasy yellow scale, nasolabial folds, ears, beard and scalp
Treat with topical ketoconazoleTopical steroids for itch
72yo F with itchy rash
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72yo F with itchy rash
• Several weeks
• Started with an abrasion
• Treating with neosporin
• No fever, chills, other sx
• No new medications
Allergic Contact Dermatitis
• Type IV hypersensitivity
• “outside‐in” pattern
• Common allergens:
– Topical antibiotics
– Nickel
– Propylene glycol
– Formaldehyde
– Poison Ivy
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Allergic Contact Dermatitis
Treatment
• Topical steroids
– High potency
• Systemic steroid taper for severe cases
– Poison ivy 3‐4 weeks
• Recurrent cases with unknown trigger?
– Referral for patch testing
Auto‐eczematization
• Severe focal allergic or eczematous dermatitis becomes generalized
• AKA: “id” reaction
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Herpes Zoster
• Respects the midline
• Lesions have scalloped borders
– Vesicles
– Erosions
– Ulcers
Herpes
• Unilateral or bilateral, often recurrent
• Scalloped borders
• Vesicles or erosions
• Often no known history of genital HSV
• Blisters on the buttocks are almost always HSV‐‐No such thing as recurrent spider bites on the buttocks!
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Eczema Herpeticum
• Superinfection of dermatitis with HSV
• Look for scalloped edges, crusting
• Increase in symptoms—pain, severe itch/burning
67yo rash all over torso
Started on back, folds and spread
Medication history:
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Morbilliform Drug Eruption
• Usually starts 7-10 days after initiation of the drug
• May start even after the d/c of a drug• Often starts in intertriginous and dependent
areas• May become erythrodermic• No blisters• No mucous membrane involvement
Morbilliform Drug Eruption
• Treat with topical steroids– Clobetasol for severe symptoms– Triamcinolone 0.1% cream or oint in 1lb jar– May add sauna suit or occlusion
• Antihistamines as needed• OK to treat through the eruption
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Drug Eruption: Red Flags
• Mucous membrane involvement• Skin pain• Blisters• Systemic symptoms / toxic appearance• Facial edema• Lymphadenopathy• Lab abnormalities:
– Liver function tests– CBC with differential: elevated eosinophils– Renal function
68yo with LE discoloration
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Stasis Dermatitis
• Topical steroids: Triamcinolone 0.1% cream
• Domeboro or dilute vinegar soaks• Emollients• Compression, elevation• Avoid topical antibiotics when possible• Bilateral lower extremity cellulitis is RARE
45yo rash on knees
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Psoriasis
• Well‐defined red scaly plaques
• Scalp, elbows, knees, umbilicus, gluteal cleft
• Palmar‐plantar variant
• Pustular variant
• Try to avoid systemic steroids
– may flare with withdrawal
Which topical steroid?
• Clobetasol• Triamcinolone 0.1%• Desoximetasone
• Fluticasone• Desonide• Hydrocortisone 2.5%
STRONGER
STRONGER
Scalp and Body
Face and Folds
Apply BID, 2 weeks on, 1 week off, d/c when flat
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vehicle for topical agents
Type Penetration Use
Ointment Most Dry areas
Cream Moderate Wet areas
Lotion Less intertriginous
Gel
Solution
Least Scalp, intertiginous
Psoriasis & Cardiovascular Risk
• Psoriasis (especially moderate to severe) is an independent risk factor for MI
• Patients should be educated about risk of CAD and counseled to address modifiable risk factors.
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Psoriasis and Psoriatic Arthritis
• May present asynchronously
• Unlike skin, joint damage may be permanent
32yo with itchy ankle
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Tinea
• Always check the feet, too!
• Especially if only 1 scaly hand:
• “1 Hand / 2 Foot tinea”
• KOH shows branching hyphae
Tinea Incognito
• Tinea that has been treated with topical steroids
• May require systemic antifungal therapy
• Terbinafine250mg/d x 2 weeks
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Granuloma Annulare
• Tinea mimicker
• Non‐scaly
• Does NOT improve with antifungals
• Etiology unknown
Sarcoidosis
Non‐scalyAnnular plaques
Predilection for scars
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46yo very itchy all over
Courtesy of Nellie Konnikov
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Crusted Scabies
• Immune compromise
• Huge mite load
Scabies Prep
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Scabies Treatment• Topical permethrin is most effective
– Treat neck down– Treat folds– Treat under nails– Repeat in a week
• Oral Ivermectin 200mcg/kg single dose– Repeat in 1 week
• Treat close contacts• Treat the environment
Concerning Spots
• Evolving Lesion (ABCD‐E)
• Tender, Burns, Itches, Bleeds
• Company It Keeps
• Solitary Lesion, “Ugly Duckling”
• Unresponsive to therapy
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What is the most likely diagnosis?
A. Atypical nevi
B. Basal cell carcinoma
C. Dermatitis
D. Actinic keratoses
E. Squamous cell carinoma
Actinic Keratosis
• Premalignant lesion to SCC
• Who? Fair skin types, > age 40
• Where? Sun‐exposed areas
• Treatment? – Cryotherapy
– Field therapy: • topical 5‐FU
• Topical imiquimod
• photodynamic therapy
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Photo courtesy of S. Desai
Actinic Keratoses
• Poorly defined erythematous macule/papule → gritty thin scale →thicker yellowish scale
• Signs of photodamage
This lesion may be associated with which of these?
A. Verruca
B. Seborrheic keratosis
C. Actinic keratosis
D. Squamous cell carcinoma
E. All of the above
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Cutaneous Horn
• Column of thick keratotic scale
• Differential Diagnosis
– Wart
– Seborrheic keratosis
– Actinic keratosis
– SCC
Most likely diagnosis?
A. Actinic keratosis
B. Basal cell carcinoma
C. Cutaneous horn
D. Keratoacanthoma
E. Verruca vulgaris
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Keratoacanthoma
• Low‐grade SCC
• Rapid growth over 4‐6wks
– +/‐ spontaneous regression
• Nodule with keratin filled central crater
Most likely diagnosis?
A. Pigmented basal cell carcinoma
B. Melanoma
C. Atypical nevus
D. Seborrheic keratosis
E. Actinic keratosis
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Seborrheic Keratosis
‐“stuck‐on”
‐keratotic
‐verrucous
‐+/‐ pigment
‐sharply
‐demarcated
Most likely diagnosis?
A. Pigmented basal cell carcinoma
B. Melanoma
C. Atypical nevus
D. Seborrheic keratosis
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Melanoma
• Risk factors:– Fair‐skinned
– Red hair
– Atypical nevi
– Multiple nevi (>50)
– Family history
– Blistering sunburns
– Most common malignancy in women age 25‐29
Most likely diagnosis?
A. Squamous cell carcinoma
B. Basal cell carcinoma
C. Keratoacanthoma
D. Amelanoticmelanoma
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Basal Cell Carcinoma
• Who?– Fair skin types
• What?–Pearly, translucent, telangiectatic, rolled border
• Where?– Sun‐exposed areas
• Face, scalp, ears, neck > trunk, extremities
Why do a total body skin exam?
• To look for clues for diagnosis of a rash or other skin problem
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Why do a total body skin exam?
• To look for clues for diagnosis of a rash or other skin problem
• Skin cancer screening
Why do a total body skin exam?
Study by Kantor and Kantor. Arch Dermatol. 2009 Aug;145(8):873‐6
How many melanomas from their practice were the noted by the patient vs how many found on dermatologist‐initiated skin exam?
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Why do a total body skin exam?
Study by Kantor and Kantor. Arch Dermatol. 2009 Aug;145(8):873‐6
How many melanomas from their practice were the noted by the patient vs how many found on dermatologist‐initiated skin exam?
• 56.3% of melanomas were found by the dermatologist and were not part of the presenting complaint.
• Dermatologist detection was significantly associated with thinner melanomas, OR 0.42
• Thinner melanoma = better prognosis
Broad‐spectrum UVA/UVB sunscreen
Physical blockers:
titanium dioxide
zinc oxide
Chemical sunscreens
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Ultraviolet Radiation and Sunscreen
• UVA and UVB contribute to premature skin aging and skin cancer.
• UVA: Tan• UVB: Burn
• SPF = “Sunburn Protection Factor”– Only quantifies UVB protection
• “Broad Spectrum” sunscreen has UVA + UVB protection
• No UVA protection rating in the US
Sunburn protection factor (SPF)
• Measures only UVB protection
• Recommend SPF 30+
• 1 oz (“golf ball size”) each application
• Apply every 1.5‐2h
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Water Resistant = 40 minutesVery Water Resistant = 80 minutes
Questions?