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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 l.jpg

Common Dermatologic Conditions

Toby Maurer, MD

University of California, San Francisco


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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?


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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


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Alternatives

  • Erythromycin - 500 bid

  • Septra - check WBC’s

  • Keflex-500 tid


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Spiranolactone

  • Diuretic used in cirrhosis of liver

  • Also an anti-androgen

  • Useful in females who have cysts around menstruation

  • 50-100 mg qday continuously


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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


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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


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Acne Rosacea

  • Common in over 40group

  • Often seen in persons of Irish decent

  • Associated with seborrheic dermatitis


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Acne Rosacea

  • Oral antibiotics for 6-8 weeks clears skin for some amount of time

  • Topicals work less frequently-Metrocreme


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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.


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Acne Keloidalis

  • Not acne, not keloid

  • Hard to treat-IL kenalog/surgical excision

  • Don’t crop hair at back of head!!!!


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Hair Loss

  • Scarring-refer

  • Non-scarring-work up


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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


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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.


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Too Much Hair

  • Vaniqa

    • topical cream that breaks the chemical bond of hair

    • apply 2x’s/day forever

    • 30% effective

    • $30/month


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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


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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?


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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:



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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


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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


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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


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Buttock Folliculitis

  • Mechanical from clothing

  • Ban roll-on good

  • Topical antibx qd

    • Cleocin/Erythro


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Keratosis Pilaris

  • Thickening of hair follicles on the out arms and upper legs

  • Associated with dry skin

  • Lubrication

  • Lachydrin 12% lotion bid


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Intertrigo

  • Pendulous breasts or pannus

  • Always component of candida

  • Blow dry area

  • Apply topical antifungals

  • Tucks pads


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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?


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Bacterial Skin Infections

  • Most common pathogen is staph aureus

  • More methicillin resistant staph causing skin and soft tissue infections in the community


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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


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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


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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



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Strep-may need added coverage withPenicillin, cephalosporins


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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



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Hidradenitis Supparativa

  • Not an infectious disease

  • Disease of apocrine glands

  • Treatment

    • IL Kenalog

    • Minocycline

    • Surgery

    • NOT Antibiotics

    • New Biologics



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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


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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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