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 • Combination topicals good –use qd • Use 1 qam and 1qhs ?Not improving after 8 weeks?
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 • 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
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 • 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 • Common in over 40group • Often seen in persons of Irish decent • Associated with seborrheic dermatitis
Acne Rosacea • Oral antibiotics for 6-8 weeks clears skin for some amount of time • Topicals work less frequently-Metrocreme
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 • Not acne, not keloid • Hard to treat-IL kenalog/surgical excision • Don’t crop hair at back of head!!!!
Hair Loss • Scarring-refer • Non-scarring-work up
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 • 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 • 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 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 • 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?
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 • Time for referral • Methotrexate • Oral retinoids (Acitretin) • Cyclosporine • Biologics (Enbrel, Remicade, Humira)-most benefit in psoriatic arthritis and quick reversal of pustular psoriasis
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
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 • 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 • Pendulous breasts or pannus • Always component of candida • Blow dry area • Apply topical antifungals • Tucks pads
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?