Transcript Skin Conditions as Women Age: What is Normal, What is Not?

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 wavelengthlight absorbed by sebaceous glands-results very
poor
• INTENSE PULSE LASER (585 nm)-decreased
comedones but not inflammatory papules
• BLUE LIGHT (415nm)- decreased
inflammatory papules
• 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 frequentlyMetrocreme
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 AlopeciaMinoxidil 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?
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
NO PREDNISONE
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?
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
• 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:
• 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
•
1)
2)
3)
4)
Most likely problem:
Could have been strep
Wasn’t bacteria
It wasn’t infected but INFLAMED
Did not treat the underlying dermatologic
disease
5) All of the above are equally likely
5) All of the above are equally likely
Strep-may need added coverage with
Penicillin, cephalosporins
Was it bacterial in the first place?
• HSV, FUNGUS, MYCOBACTERIA
Consider it, biopsy it and send tissue
culture
Diseases that Masquerade as Infectious
Diseases Ann Int Med 2005 Jan 4;
142:47-55
INFLAMMATION
Hidradenitis Supparativa
• Not an infectious disease
• Disease of apocrine glands
• Treatment
–
–
–
–
–
IL Kenalog
Minocycline
Surgery
NOT Antibiotics
New Biologics
And what about underling derm
problem???
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 environmentDUODERM
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