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

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Presentation on theme: "Dermatology Update Katie Fiala, MD Department of Dermatology Scott and White Memorial Hospital."— Presentation transcript:

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

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

3 Varicella Zoster (Shingles) 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

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

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

9 Childhood Zoster

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

12 Management / Treatment Early treatment, within first 72 hours Early treatment, within first 72 hours Oral anti-virals 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 IV acyclovir - immunocompromised and disseminated form –Acyclovir 10mg/kg IV q 8hrs x 7-10 days Oral prednisone (controversial) Oral prednisone (controversial)

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

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

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

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

17 Psoriasis

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

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

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

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

26 Psoriasis & Metabolic Syndrome Chronic inflammatory skin condition Chronic inflammatory skin condition Pro-inflammatory cytokines 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). 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 Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis, Archives of Dermatological Research, Volume 298, Number 7, , 2006Archives of Dermatological ResearchVolume 298, Number 7Archives of Dermatological ResearchVolume 298, Number 7

27 Psoriasis & Metabolic Syndrome Metabolic syndrome more common in psoriatic patients than controls OR 1.65, >40 yo. Metabolic syndrome more common in psoriatic patients than controls OR 1.65, >40 yo. Psoriatic patients - higher prevalence of hypertriglyceridemia and abdominal obesity Psoriatic patients - higher prevalence of hypertriglyceridemia and abdominal obesity Association independent from smoking. 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 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 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 Volume 157, Issue 1, Volume 157, Issue 1,

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

29 Psoriatic Arthritis

30 Inverse Psoriasis

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

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

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

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

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

40 Know when to refer

41 (

42 Diffuse Cutaneous Hemangiomatosis Liver Liver Thyroid Thyroid High Output Cardiac Failure High Output Cardiac Failure

43 Treatment Especially if danger zones Especially if danger zones Prednisone 2-3mg /kg/ day Prednisone 2-3mg /kg/ day Propanolol 2-3 mg/ 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 Non-comedogenic/ non-acnegenic Topical retinoid – Differin, Retina, Retina Microgel, Tazorac Topical retinoid – Differin, Retina, Retina Microgel, Tazorac Topical antibacterial – benzoyl peroxide, topical clindamycin, Benzaclin or Duac (BPO+ clinda) Topical antibacterial – benzoyl peroxide, topical clindamycin, Benzaclin or Duac (BPO+ clinda) Azaelic Acid Azaelic Acid Topical Dapsone (Aczone) Topical Dapsone (Aczone)

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

47 Isotretinoin Other issues Depression Depression Labs: LFTs, lipids Labs: LFTs, lipids Pseudotumor cerebri: more likely with tetracyclines Pseudotumor cerebri: more likely with tetracyclines Xerosis and cheilitis Xerosis and cheilitis Flare Flare ? Inflammatory Bowel Disease ? 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 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 8,189 pts with IBD and 21,832 controls 3664 Crohns & 4428 UC 3664 Crohns & 4428 UC Isotretinoin use strongly associated with UC (OR 4.36) but not with Crohns Isotretinoin use strongly associated with UC (OR 4.36) but not with Crohns Higher dosage and longer duration increased risk Higher dosage and longer duration increased risk

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

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

51 Melanoma Asymmetry Asymmetry Borders Borders Color Color Diameter >6mm Diameter >6mm Evolution Evolution

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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 75% of skin cancer deaths 1 American dies/ hour 1 American dies/ hour yo yo Areas of intense, rare sun exposure Areas of intense, rare sun exposure Scalp = aggressive Scalp = aggressive Also: eyes, mouth, genitalia Also: eyes, mouth, genitalia

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

58 IPILIMUMAB (Yervoy) FDA approved for metastatic melanoma FDA approved for metastatic melanoma Monoclonal antibody (IV) Monoclonal antibody (IV) Median overall survival 10.0 months (both), 10.1 (ipilimumab only) and 6.4 (vaccine only) 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 Acknowledge benefits Encourage oral supplementation Encourage oral supplementation Educate about sun protection 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 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 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 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 visits Less time for cancer cells to divide Less time for cancer cells to divide

63 Thank you! Thank you!


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