1. Dermatology Update Katie Fiala, MD Department of Dermatology
Scott and White Memorial Hospital

2. TOPICS Varicella Zoster Psoriasis Acne Lipodermatosclerosis
Hemangiomas
Melanoma
Miscellaneous Updates

3. Varicella Zoster (Shingles)
Reactivation of chickenpox virus along sensory nerve causing a painful blistering skin eruption.

4. Clinical History
70 year old man Recent Hodgkins Disease dx Painful eruption on face Pain is excruciating Blisters erosions

5. Zoster

6. Varicella zoster 20% of healthy adults 50% adults > 85
Induced by stress, fever, XRT, trauma, immunosuppression
Blacks 75% less likely
Transmission via vesicular fluid
4% recurrence rate

8. Zoster: clinical features
Prodrome intense pain
Itch, tingling, or hyperesthesia
Grouped vesicles on erythematous base
Umbilicated, pustular
Sensory dermatome

9. Childhood Zoster
Zoster in 5 year old

11. Diagnosis Confirmation
Viral Culture swab
Viral PCR swab
Aggressively swab base of lesion

12. Management / Treatment
Early treatment, within first 72 hours
Oral anti-virals
Acyclovir 800mg po 5x/day x 7-10 days
Valacyclovir 1gm po TID x 7 days
Famciclovir 500 mg po TID x 7 days $$
IV acyclovir - immunocompromised and disseminated form
Acyclovir 10mg/kg IV q 8hrs x 7-10 days
Oral prednisone (controversial)

13. DISSEMINATED ZOSTER >20 lesions outside of affected dermatome
Can cross midline
2 or more non-contiguous dermatomes
May have internal involvement: hepatitis, encephalitis, pneumonitis

14. Post-herpetic Neuralgia
Post Zoster inflammation/injury to affected nerves
More common >55 years of age
Pain may last for months/year
Rx: Narcotics, Neurotin (gabapentin), Nerve Block, topical lidocaine, topical gabapentin 6%
Prevention?

15. Zostavax Reduced in incidence by 70% 50-59 Live attenuated vaccine
Reduced incidence by 55% in >60yo in a real-world practice
(JAMA 2011;305;160-6)
Effective in pts w/ underlying chronic conditions
Reduced in incidence by 70% 50-59
Reduced incidence of PHN by 67% in >60yo
Okay to receive if previous shingles
Does prevent ophthalmic zoster

16. Contraindications Anaphylaxis to gelatin or neomycin
Immunocompromised: HIV, chemo, chronic steroids, pregnancy, h/o leukemia or lymphoma

17. Psoriasis

22. Treatment Topical steroids Vitamin D analogs – calcipotriene
Phototherapy (Narrowband UVB)
Methotrexate
Cyclosporine
Soriatane
Biologics
**NOT PREDNISONE**

23. Psoriasis & Biologic Agents
Enbrel, Humira, Remicade (TNF-alpha inhibitors)
Stelara (blocks IL-12 and IL-23)
Screening:
TB/HIV/Hepatitis prior
TB yearly
CBC/CMP prior and q6mo
Contraindications: MS, Solid tumor, severe CHF
Paradoxical Psoriasis (palmo-plantar)

24. Biologics and Infections
1 in 10 on biologics will have serious infection/year
10-18 fold increase on biologics
Ways to help
Be aware
Tight control of DM
Education
Vaccines (live given b/f starting tx)

25. Psoriasis Associations
Obesity
Hypercholesterolemia
Hypertension
Diabetes Mellitus II
Depression
Alcohol/Smoking
Psoriatic Arthritis

26. Psoriasis & Metabolic Syndrome
Chronic inflammatory skin condition
Pro-inflammatory cytokines
Diabetes mellitus type II (OR=2.48), arterial hypertension (OR = 3.27), hyperlipidemia (OR = 2.09), and coronary heart disease (OR = 1.95).
Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis , Archives of Dermatological Research , Volume 298, Number 7, , 2006

27. Psoriasis & Metabolic Syndrome
Metabolic syndrome more common in psoriatic patients than controls OR 1.65, >40 yo.
Psoriatic patients - higher prevalence of hypertriglyceridemia and abdominal obesity
Association independent from smoking.
Conclusion: Psoriatic patients have a higher prevalence of metabolic syndrome, which can favor cardiovascular events. We suggest psoriatic patients should be encouraged to correct aggressively their modifiable cardiovascular risk factors
Prevalence of metabolic syndrome in patients with psoriasis: a hospital-based case–control study, British Journal of Dermatology, Volume 157, Issue 1, pages 68–73, July 2007

28. Psoriasis and Cardiovascular Risk
Risk for MI 3.6 for controls, 4.0 for mild psoriasis, 5.1 for severe psoriasis
Younger pts with severe psoriasis have the greatest risk of MI
JAMA 2006;296:1735,41

29. Psoriatic Arthritis

30. Inverse Psoriasis

32. Inverse psoriasis +/- psoriasis elsewhere Treatment
Low-potency topical steroids
Protopic (tacrolimus) 0.1% ointment or Elidel cream
Minimize moisture, careful drying, drying powders (Zeosorb AF)

33. LIPODERMATOSCLEROSIS
Sclerosing panniculitis
Affects lower legs
Secondary to chronic venous insufficiency
2/3 of patients are obese

34. Presentation ACUTE CHRONIC
Erythematous, painful, indurated plaques, swelling
Can be unilateral or bilateral
CHRONIC
Less erythema, significant induration, hyperpigmentation, may ulcerate
“inverted champagne bottle”

38. THERAPY Leg elevation Compression stockings
Potent topical steroids, under occlusion
Aspirin
NSAIDS
Trental 400mg po TID
Weight loss
? Vascular surgery

39. Hemangiomas Natural course Complications Proliferate by 9mo
Involute by 10yo
10% rule
Complications
Beard area
Eye
Diaper area

40. Know when to refer

41. (

42. Diffuse Cutaneous Hemangiomatosis
Liver
Thyroid
High Output Cardiac Failure

43. Treatment Especially if danger zones Prednisone 2-3mg /kg/ day
Propanolol 2-3 mg/ kg/day
Very successful
Risks: Hypotension, hypoglycemia
Pediatric Cardiologist
(Engl J Med 2008;358; )

44. ACNE

45. Topical therapy Non-comedogenic/ non-acnegenic
Topical retinoid – Differin, Retina, Retina Microgel, Tazorac
Topical antibacterial – benzoyl peroxide, topical clindamycin, Benzaclin or Duac (BPO+ clinda)
Azaelic Acid
Topical Dapsone (Aczone)

46. Oral Therapy Minocycline 100mg bid Doxycycine 100mg bid
Clindamycin mg bid
Bactrim DS bid
**Azithromycin mg TIW
Amoxicillin 500mg bid (pregnancy)
**Spironolactone mg daily
Oral contraceptives (Yasmin)
Isotretinoin 1mg/kg bid x 5 -6 mo

47. Isotretinoin Other issues
Depression
Labs: LFTs, lipids
Pseudotumor cerebri: more likely with tetracyclines
Xerosis and cheilitis
Flare
? Inflammatory Bowel Disease

48. Inflammatory Bowel
Crockett SD et al. Isotretinoin use and the risk of inflammatory bowel disease: A case–control study. Am J Gastroenterol 2010 Mar 30
8,189 pts with IBD and 21,832 controls
3664 Crohns & 4428 UC
Isotretinoin use strongly associated with UC (OR 4.36) but not with Crohns
Higher dosage and longer duration increased risk

49. What does this mean? Pts must be made aware of risk
Stop if bowel symptoms develop until cleared by GI
More studies needed
? Association with Tetracyclines

50. Melanoma Barriers to full skin exam Continues to be on the rise
Primary care: time constraints (54%)
Dermatologists: patient embarrassment (44%)
Arch Dermatol 2011;147:36-44
Continues to be on the rise
One American dies of melanoma every hour

51. Melanoma
Asymmetry
Borders
Color
Diameter >6mm
Evolution

54. Lentigo Maligna

55. SEER Age Adjusted Incidence Rates by Race and Sex Melanoma of the Skin, All Ages SEER 9 Registries for

56. Malignant Melanoma 75% of skin cancer deaths 1 American dies/ hour
25-29 yo
Areas of intense, rare sun exposure
Scalp = aggressive
Also: eyes, mouth, genitalia

57. Who’s at Risk Red/blonde hair, blue/green eyes >50 nevi
Dysplastic nevi
First degree relative
H/o melanoma, 9x more likely
Tanning bed
Summer vacations
>5 sunburns doubles risk
Higher SES

58. IPILIMUMAB (Yervoy) FDA approved for metastatic melanoma
Monoclonal antibody (IV)
Median overall survival 10.0 months (both), 10.1 (ipilimumab only) and 6.4 (vaccine only)
N Engl J Med 2010;363;711-23

59. Vitamin D Debate Acknowledge benefits Encourage oral supplementation
Educate about sun protection
Avoid peak hours 10am – 4pm
Broad Spectrum (UVA/UVB) SPF 30, year round
SPF 30 block 97-98% UVB
Adequate amount
Wet white shirt only SPF 4
Special clothing

60. Miscellaneous New, COMB-FREE head lice treatment approved by FDA
Natroba Topical Suspension (spinosad 0.9%)
Approved for children over 4yo
Important not to use <6mo b/c contains benzoyl alcohol

61. Miscellaneous PDT for Actinic Keratoses Photodynamic Therapy
Metvixia (methyl amiolevulinate cream) applied to affected area approx 2 hours under occlusion
Red light for 6-8 minutes
Reaction similar to 5-FU in 1-2 days

62. Miscellaneous BRACYTHERAPY Precise placement of radiation sources
Exposure to radiation of healthy tissues reduced
Tumor can be treated w/ very high doses
Applicator can conform to contour of face/skin
Cure rates comparable to EBRT
Can be completed in less time
Less visits
Less time for cancer cells to divide

63. Thank you!