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Common Dermatologic Conditions . Toby Maurer, MD University of California, San Francisco. Topicals. BP 5% gel (10% - more drying) BP 5% wash-great for comedones back/chest Retin A 0.025% - 0.1% ( vehicle determines strength - start with crème) Cleocin T or erythromycin topically

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common dermatologic conditions

Common Dermatologic Conditions

Toby Maurer, MD

University of California, San Francisco

topicals
Topicals
  • BP 5% gel (10% - more drying)
  • BP 5% wash-great for comedones back/chest
  • Retin A 0.025% - 0.1% ( vehicle determines strength - start with crème)
  • Cleocin T or erythromycin topically
  • Combination topicals good –use qd
    • Use 1 qam and 1qhs

?Not improving after 8 weeks?

p o antibiotics
P.O. Antibiotics
  • TCN - 500 bid x 8 weeks
  • Doxycycline - 100 bid x 8 weeks
  • Minocycline - 100 bid x 8 weeks-too many side effects and high cost
  • Taper - Do NOT STOP ABRUPTLY
alternatives
Alternatives
  • Erythromycin - 500 bid
  • Septra - check WBC’s
  • Keflex-500 tid
spiranolactone
Spiranolactone
  • Diuretic used in cirrhosis of liver
  • Also an anti-androgen
  • Useful in females who have cysts around menstruation
  • 50-100 mg qday continuously
laser treatment for acne
Laser treatment for acne
  • Placebo effect is strong so controlled studies are essential but lacking
  • INFRARED-1320 and 1450nm wavelength-light absorbed by sebaceous glands-results very poor
  • INTENSE PULSE LASER (585 nm)-decreased comedones but not inflammatory papules
  • BLUE LIGHT (415nm)- decreased inflammatorypapules
  • Yeung CK et al Lasers Surg Med 2007 Jan
accutane
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
Acne Rosacea
  • Common in over 40group
  • Often seen in persons of Irish decent
  • Associated with seborrheic dermatitis
acne rosacea16
Acne Rosacea
  • Oral antibiotics for 6-8 weeks clears skin for some amount of time
  • Topicals work less frequently-Metrocreme
perioral dermatitis
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.

acne keloidalis
Acne Keloidalis
  • Not acne, not keloid
  • Hard to treat-IL kenalog/surgical excision
  • Don’t crop hair at back of head!!!!
hair loss
Hair Loss
  • Scarring-refer
  • Non-scarring-work up
non scarring hair loss
Non-scarring Hair Loss
  • 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
If all negative
  • Androgenetic Alopecia-

Minoxidil 5% bid topically (even in women)

Minoxidil 5% foam-use once/day

What about finasteride (propecia)?-equal to minoxidil in men. Does not work in women.

too much hair
Too Much Hair
  • Vaniqa
    • topical cream that breaks the chemical bond of hair
    • apply 2x’s/day forever
    • 30% effective
    • $30/month
hair removal
Hair Removal
  • pigment of hair absorbs the light and is destroyed
  • dark hair responds best
  • 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
Psoriasis
  • What is it?
  • How did I get it?
  • Can I give it to someone else?
  • Is it associated with anything?
  • How can I get rid of it?
psoriasis tx
Decrease the MITOTIC RATE of skin

Tar (LCD 5% in TAC 0.1% oint) ( Tar emulsions)

topical retinoids (Tazarac)

Decrease the INFLAMMATORY RATE of the skin

Steroid Ointment (mid-potency-1st line)

Calcipotriene (Dovonex Creme)-not on face or groin

Clobetasol/Dovonex combination

Ultraviolet light

Psoriasis-Tx:
next step
NEXT STEP
  • Time for referral
  • Methotrexate
  • Oral retinoids (Acitretin)
  • Cyclosporine
  • Biologics (Enbrel, Remicade, Humira)-most benefit in psoriatic arthritis and quick reversal of pustular psoriasis
eczema
Eczema
  • 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
eczema41
Eczema
  • Tacrolimus (Protopic) and Pimecrolimus (Elidel), newer kids on the block
    • Great for facial eczema/eyelid eczema
    • Expensive
    • Efficacy-???better than steroids
    • Black box warning-do not use in children under 2, in sunexposed areas for long periods of time
buttock folliculitis
Buttock Folliculitis
  • Mechanical from clothing
  • Ban roll-on good
  • Topical antibx qd
    • Cleocin/Erythro
keratosis pilaris
Keratosis Pilaris
  • Thickening of hair follicles on the out arms and upper legs
  • Associated with dry skin
  • Lubrication
  • Lachydrin 12% lotion bid
intertrigo
Intertrigo
  • Pendulous breasts or pannus
  • Always component of candida
  • Blow dry area
  • Apply topical antifungals
  • Tucks pads
herpes zoster
Herpes Zoster
  • Zoster vaccine available
  • Study done on 38,000 persons 60 yrs and older (Kimberlin et al NEJM March 2007)
  • INCIDENCE was 51% lower in those that received vaccine vs placebo
  • POST HERPETIC NEURALGIA was 67% lower in vaccinated group
  • Worked best in 60-69 yr olds
  • COST?
bacterial skin infections
Bacterial Skin Infections
  • Most common pathogen is staph aureus
  • More methicillin resistant staph causing skin and soft tissue infections in the community
approach to treatment
Approach to Treatment
  • If pus-culture it
  • If abcess –drain it-NO ANTIBIOTICS
  • Is this true for abcesses with overlying cellulitis ?-designing that study now
if no pus
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, Clindamycin, Cipro/Levofloxacillin

  • Consider adding rifampin 600 qd for 5 days or mupirocin ointment for staph eradication
doc i ve been on doxy for 10 days and no change
Doc-I’ve been on Doxy for 10 days and no change
  • Most likely problem:
  • Could have been strep
  • Wasn’t bacteria
  • It wasn’t infected but INFLAMED
  • Did not treat the underlying dermatologic disease
  • All of the above are equally likely
was it bacterial in the first place
Was it bacterial in the first place?
  • HSV, FUNGUS, MYCOBACTERIA

Consider it, biopsy it and send tissue culture

Diseases that Masquerade as Infectious Diseases Ann Int Med 2005 Jan 4; 142:47-55

hidradenitis supparativa
Hidradenitis Supparativa
  • Not an infectious disease
  • Disease of apocrine glands
  • Treatment
    • IL Kenalog
    • Minocycline
    • Surgery
    • NOT Antibiotics
    • New Biologics
venous insufficiency ulcer
Venous Insufficiency Ulcer
  • Control Edema
    • Elevation of leg above heart 2 hours twice daily
    • Walk, don’t sit
    • Compression-UNNA BOOTS
  • Diuretics overused and not of benefit unless fluid retention due to central problem is present (CHF, CRF)
  • Create healing wound environment-DUODERM
when is a leg ulcer infected
When is a Leg Ulcer Infected?
  • All leg ulcers are colonized with bacteria. Surface culture of little value
  • Suspect infection if:
    • Increasing pain
    • Surrounding erythema, cellulitis
    • Focal area not healing and undermining present
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