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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

  • 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
  • Erythromycin - 500 bid
  • Septra - check WBC’s
  • Keflex-500 tid
  • 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
  • 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


Topicals: Cleocin T Gel bid

Erythromycin bid

p.o. antibiotics –TCN



- 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
  • 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

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
  • 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
  • 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
  • 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?

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