1. Common Dermatologic Conditions
Toby Maurer, MD
University of California, San Francisco

3. Acne Papulopustular Cystic, scarring, keloidal Topicals okay
p.o. antibiotics
Accutane

4. Topicals BP 5% gel (10% - more drying)
Retin A 0.025% - 0.1% ( vehicle determines strength - start with crème)
Cleocin T or erythromycin topically
Use 1 qam and 1qhs
If NO success after 8 weeks, go to p.o.’s

7. P.O. Antibiotics TCN - 500 bid x 8 weeks
Doxycycline bid x 8 weeks
Minocycline bid x 8 weeks
Taper - Do NOT STOP ABRUPTLY

8. Alternatives Erythromycin - 500 bid Septra - check WBC’s
Keflex-500 tid

9. Spiranolactone Diuretic used in cirrhosis of liver
Also an anti-androgen
Useful in females who have cysts around menstruation
mg qday continuously
Increased urination, don’t use during pregnancy, ?electrolyte imbalance

11. 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

13. Acne Rosacea Common in women over 40
Often seen in persons of Irish decent
Associated with seborrheic dermatitis
Characterized by papules, erythema, telangiectasia and rhinophyma (M>F)
Sun exposure, alcohol and spicy foods exacerbate rosacea

14. Acne Rosacea
Oral antibiotics for 6-8 weeks clears skin for some amount of time
Topicals work less frequently

16. 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.

18. Hair Loss Decide if scarring or not: If scarring-refer
If not scarring and diffuse:
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

20. If all negative Androgenetic Alopecia-
Minoxidil 5% bid topically (even in women)
Can make hair oily-may want to start with minoxidil 2% or use 2% by day and 5% at night
Use for at least 6 months for results and what you see after 1 yr. is the effect you can expect.
What about finasteride (propecia)?-equal to minoxidil in men. Does not work in women.

21. Too Much Hair
Vaniqa
topical cream that breaks the chemical bond of hair
apply 2x’s/day forever
30% effective
$30/month

22. Hair Removal pigment of hair absorbs the light and is destroyed
dark hair responds
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

24. Psoriasis-What is it?
Fast growing skin-takes 3 days to come to surface and desquamate
Normal rate is 28 days
Psoriatic skin has a fast mitotic rate
Triggers an inflammatory response in and around affected skin

25. New onset often preceded by strep infection (strep pharyngitis) especially in the younger age group.
In older age group, drugs often unmask psoriasis
Drugs: beta-blockers, lithium, NSAIDS, antimalarials, terbinafine, gemfibrozil-pts on these meds for 3-6 months before onset of psoriasis

29. Psoriasis-Tx: Decrease the mitotic rate of skin
Tar (LCD 5% in TAC 0.1% oint) ( Tar emulsions), topical retinoids (Tazarac)
Decrease the inflammatory response of the skin
Steroid Ointment (mid-potency-1st line)
Calcipotriene (Dovonex Ointment)-not on face or groin
Clobetasol/Dovonex combination
Ultraviolet light (psoralen+ UVA), UVB
NO PREDNISONE

30. NEXT STEP Time for referral
Methotrexate-liver biopsies necessary(don’t give in HEP C pts)
Oral retinoids (Acetretin)-not in persons of reproductive potential -? Okay in liver disease; excellent drug in HIV
Cyclosporine
Biologics (Enbrel, Remicade)-most benefit in psoriatic arthritis and quick reversal of pustular psoriasis

31. 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

33. Eczema
Tacrolimus (Protopic) and Pimecrolimus (Elidel), new kids on the block
Great for facial eczema
$120 for 30gm

34. Topical Immune Modulators and Cancer
Elidel (pimecrolimus 1%) and Protopic (tacrolimus 0.1% and 0.03%) –heavily marketed
29 cases of cancers in children and adults associated with use of these topicals-lymphomas, SCC’s, sarcomas
Causality not proven

35. FDA Response Black Box Warning
Do not use in children under 2 years of age
Do not us in adults or children with “weakened” immune systems: Transplants, HIV, cancer patients, etc.
Limit use—no continuous usage; limit area treated

37. Topical Immunomodulators When to use
Eyelid dermatitis
Refractory psoriasis on upper thighs, scrotum, glans penis
Otherwise use cheaper alternatives first
Protopic=TAC 0.1%
Elidel=HC 2.5%

39. Buttock Folliculitis Mechanical from clothing Ban roll-on good
Topical antibx qd
Cleocin/Erythro

41. Keratosis Pilaris
Thickening of hair follicles on the out arms and upper legs
Associated with dry skin
Lubrication
Lachydrin 12% lotion bid

43. Intertrigo Pendulous breasts or pannus Always component of candida
Blow dry area
Apply topical antifungals
Tucks pads

48. Bacterial Skin Infections
Most common pathogen is staph aureus
More methicillin resistant staph causing skin and soft tissue infections in the community
JAMA-Niami et al Dec 2003

49. Approach to Treatment
Culture where you can-if you have pus, that is great
Incise and drain when appropriate (Abcesses)

50. 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,Cipro/Levofloxacillin), Clindamycin
Consider adding rifampin 600 qd for 5 days or mupirocin ointment for staph eradication

52. Was it bacterial in the first place?
Remember HSV-culture and/or Direct Fleurescent Antibody
Skin biopsy for histology and tissue culture
Diseases that Masquerade as Infectious Diseases Ann Int Med 2005 Jan 4; 142:47-55

55. Hidradenitis Supparativa
Not an infectious disease
Disease of apocrine glands
Treatment
IL Kenalog
Minocycline
Surgery
NOT Antibiotics
New Biologics

57. Inflamed Epidermoid Cysts
Antibiotics-USELESS
If just starting to become inflamed and cyst is small( < 1 cm), can try intralesional Kenalog injection but see them back in few days-you can exacerbate the inflammation
INCISE and DRAIN and PACK
6 weeks later, inspect for residual cyst and excise

60. Recurrent Cellulitis
Recurrent cellulitis knocks out lymph system causing low grade cellulitis and retention hyperkeratosis
Tx. Cellulitis-may need 6 months of tx or more
Tx. Hyperkeratosis-urea crème 40%
Tx. Lymphedema-support stockings with 35mm of pressure or mechanical pumps

63. Venous Insufficiency Ulcer
Compression dressing
Unna boot covered by Coban – this requires a good nursing staff with training and experience
This both provides graded compression AND creates the correct wound environment
Semipermeable dressing (Hydrosorb, Duoderm, etc)
Change dressing weekly
Refer to dermatology if not healing

64. Venous Insufficiency Ulcer
Control Edema
Elevation of leg above heart 2 hours twice daily
Walk, don’t sit
Compression
Diuretics overused and not of benefit unless fluid retention due to central problem is present (CHF, CRF)
Create an appropriate wound environment for healing
Paradigm shift: Ulcers that don’t heal do not have the appropriate biochemical environment to promote healing

65. Complications of Leg Ulcers
Allergic contact dermatitis to applied antibiotics, topical anesthetics
Avoid all topical antibiotics to leg ulcers (except topical metronidazole to prevent odor)
Never apply topical benzocaine, Vitamin E, neomycin, or bacitracin to VI leg ulcer

67. 64 year old man with psoriasis, hypertension, hypercholesterolemia
3 months of ulceration of medial aspect of left lower leg
Vascular evaluation confirms venous insufficiency

69. 3 months of treatment fails to improve ulceration
What is your next step?

70. Skin Biopsy = Squamous Cell Carcinoma
Chronic phototherapy and prior immunosuppressive treatments may have led to skin cancer
If leg ulcer doesn’t heal with appropriate treatment—refer or biopsy