Controversies in women’s health 2016: Recognition and treatment of common disorders of the skin Kanade Shinkai, MD PhD Associate Professor of Clinical Dermatology University of California, San Francisco Disclosures I have no conflicts of interest to disclose. I may discuss off-label use of treatments for cutaneous disease. A preview • Fictional patient • Series of dermatology visits • Numerous concerns • Acne • Drug eruptions • Skin cancer Acne
16
Embed
Disclosures Controversies in women’s health 2016 ...€¦ · Controversies in women’s health 2016: Recognition and treatment of common disorders of the skin" Kanade Shinkai, MD
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Controversies in women’s health 2016:Recognition and treatment of common disorders
of the skin"
Kanade Shinkai, MD PhDAssociate Professor of Clinical Dermatology
University of California, San Francisco"
Disclosures"
I have no conflicts of interest to disclose.""
I may discuss off-label use of treatments for cutaneous disease."
A preview"
• Fictional patient""
• Series of dermatology visits""• Numerous concerns"
"• Acne""• Drug eruptions""• Skin cancer"
Acne"
Acne “emergency”" Acne pearls for adult female patients"
• Many adult females fail standard acne therapy""- 82% fail multiple systemic antibiotics""- 1/3 fail systemic isotretinoin"""
• Systemic antibiotics (short-term use only)""- indicated for nodulocystic acne, truncal acne""- may require 3 months for truncal lesions""- works faster than hormonal therapy (2-3 weeks)"
Hormonal treatment can be highly-effective foracne in this population"
Hormonal therapy versus antibiotics"
• 226 publications, 32 RCT"• Antibiotics superior @ 3 months"• Equivalent to systemic antibiotics @ 6 months"""
Koo EB et al (2014) JAAD 71:450-459"
How do OCPs work?"• Estrogen provides the most benefit""• Actions:""1. Stimulates SHBG synthesis (liver): "" "- decrease free testosterone, DHEA-S""2. Inhibit 5α-reductase""3. Decrease production of ovarian, adrenal androgens"
"• Lesion count reduction: 40-70%"""" Koo EB et al (2014) JAAD 71:450-459"
Haider A and JC Shaw (2004) JAMA 292:726-735"
Which OCP is best?"• FDA-approved for acne: no superiority data""-Ortho Tri-Cyclen: norgestimate + ethinyl estradiol/ EE"
""-EstroStep: norethindrone acetate + EE ""
""-Yaz: drospirenone + EE"
"""
Arowojolu AO et al (2012) Cochrane Database Syst Rev, 6:CD004425"Haider A and JC Shaw (2004) JAMA 292:726-735"
• High estrogen, low androgenic (progesterone) activity""-norgestimate, desogestrel (3rd gen progestins)""-drosperinone (4th gen progestin)""-nomegestrel acetate (NOMAC)"
My acne patient didn’t respond to OCP. Will adding spironolactone help?"
Effective: non-FDA approved, no placebo-controlled trials""• spironolactone alone or with OCP (50-200mg/day)""• 33-85% reduction in acne"" "- dosing 50-100mg/day: 33% improvement"" "- 100mg + drospirenone: 85% improvement"
""
Brown J et al (2009) Cochrane Database of Sys Rev 2:CD000194"Haider A and JC Shaw (2004) JAMA 292:726-735"
Shaw JC (2000) JAAD 43:498-502"Krunic A et al (2008) JAAD 58:60-2"
Spironolactone: safe, has side effects"
• 8 year safety study in acne: no serious complications"• Main side effects: "menstrual irregularities (22%) "
• monotherapy only at low doses, select patients"• hyperkalemia (minimal rise in K+ in 13%, no sequelae) "• blood pressure reduction: mean 5mmHg SBP, 2.6mmHg DBP"• TERATOGEN: Category C/D"• Black box warning: benign tumors in animal studies"""
Haider A and JC Shaw (2004) JAMA 292:726-735 " ""Shaw JC (2000) JAAD 43:498-502"
Shaw JC, White LE (2002) J Cut Med Surg 6:541-545 ""George R et al (2008) Sem Cut Med Surg 28:188-196"
"""
Spironolactone: the scare over potassium"
Plovanich M et al (2015) JAMA Derm, 151:941-944"
RDA K+: 4700 mg"Low usefulness of screening in healthy
young acne patients""""
425 mg"""
235 mg"""
366 mg"""
30 mg"""
600 mg"""
Do other forms of contraception help acne?"
Vaginal ring: minimal data on efficacy with acne""• etonorgestrel (derivative of 3rd gen progestin)""• Cochrane review (2010): Nuva-users have less acne""• adverse effects: intermediate clotting risk"
""
Ilse JR et al (2008) Cutis, 82: 158"Lopez LM et al (2010) Cochrane Review, CD003552"
Chi IC (1991) Contraception, 44: 573--588"
Intrauterine devices: caution""• levonorgestrel (2nd gen progestin)""• hormone-eluting IUDs may worsen acne (Cutis 2008)""• plasma concentration @ 1 month: 50% of Norplant"
When should I worry about a hormonal disorder?"
• Hirsutism, acanthosis nigricans""• Oligomenorrhea (<8 per year) or amenorrhea""• Virilization: "Deepening voice"" " "Clitoromegaly"" " "Increased muscle mass"" " "Decreased breast size"" " " " " """ ""
"Azziz R et al (2004) J Clin Endo Metab, 89:453-462"
Escobar-Morreale H et al (2012) Hum Reprod Update, 18:146-170"JC Harper (2008) J Drugs Derm 7: 527-530"
Lolis MS et al (2009) Med Clin N Am 93:1161-1181 """"
Virilization = sign of androgen-secreting tumor""""
Hyperandrogenism workup: results"
Escobar-Morreale H et al (2012) Human Repro Update, 18:146-170"
PCOS is #1 cause of androgen excess"Tumors, hormonal disorders are very rare"
Back to our acne patient:10 days after starting doxycycline, your patient develops an itchy generalized
maculopapular rash"
Drug eruptions"
Morbilliform drug eruption"
• common"• erythematous macules, papules "
(can be confluent)"• pruritus"• no systemic symptoms "• begins in 1st or 2nd week"• treatment: ""-D/C med if severe""-symptomatic treatment: "" hydroxyzine, topical steroids"
"
When do the symptoms subside? "Up to 1 week"
Drug eruptions: when to worry"
Potentially life threatening"Require systemic immunosuppression"
Morbilliform drug eruption"""""
Simple"
DRESS"AGEP"
Stevens-Johnson (SJS)"Toxic epidermal necrolysis"
(TEN)"Complex"
Minimal systemic symptoms" Systemic involvement"
Drug eruptions: timing of onset can be helpful"
Potentially life threatening"Require systemic immunosuppression"
"• sun exposed area""• potential to metastasize""• Rx: surgical excision"" "IL 5-FU, MTX"" "in situ -> topical"
SCC on sun-damaged skin" Keratoacanthoma: self-resolving SCC"
Sun-damaged skin = worry""
What is the recommended frequency of skin cancer screening?"
• USPTF: 2015 update""- recommended only for patients with knownhistory of melanoma, NMSC""- no routine screening (including self-exams)""- biopsy in 4.4% screened patients""- 1 in 28 biopsies = melanoma"
Breitbart EW et al (2012) JAAD, 66:201-211
"• SCREEN study (Germany):"
"- 48% reduction in melanoma-related death""- NNT: 100,000 screening to prevent 1 death"
Prevention?Let’s talk about photoprotection"
Ultraviolet radiation"
"UVA: 320-400nm"Photoaging, melanoma"Not blocked by glass, clouds, ozone "
Ultraviolet radiation"
"UVB: 290-320nm"Sunburn, skin cancer, melanoma"Blocked by clouds, ozone "
• Important differential of drug eruption: when to worry""• Changing skin lesions: when to worry""• Acne management in adult women: hormonal therapy is agreat option"""