DERMATOLOGY Potpourri€¢ Herald Patch: 2-10 cm round-oval lesion appears abruptly (17%) Site: Anyplace (trunk or proximal extremities most common) May be mistaken for tinea • Eruptive

Louis Kuritzky, MDClinical Assistant Professor Emeritus

University of Florida4510 NW 17th Place

Gainesville, Florida 32605(352) 377-3193 Phone/Fax

[email protected]

DERMATOLOGYPotpourri

Disclosure

Louis Kuritzky, MD has NOTHING TO DISCLOSE

in reference to the content of this presentation.

Learning Objectives

By the end of this activity, the participant will be better able to:1. Recognize that HSV is now felt to be a cause of

pityriasis.2. Discuss the utilization of ingenol mebutate for AK

treatment.3. Diagnose Pearly Penile Papules.4. Employ systemic adjunctive treatment for venous

insufficiency ulcers.

What to do about this facial flushing

A 36 y.o. has failed multiple treatments to reduce facial flushing attributed to rosacea. She is frustrated that people keep inquiring about excessive alcohol intake, since she does not drink. She has failed multiple ‘traditional’ treatments. What might help?1. Niacin (as nicotinic acid) 2 g daily p.o. 2. Nifedipine 60 mg po3. She should stop lying about being a non-drinker &

sober-up4. Carvedilol

Pronounced facial flushing and persistent erythema of rosacea effectively treated by

carvedilol, a nonselective β-adrenergic blocker

Chia-Chi Hsu, MD; Julia Yu-Yun Lee, MD

Journal of the American Academy of DermatologyVolume 67, Issue 3, Pages 491-493 (September 2012)

DOI: 10.1016/j.jaad.2012.04.017

Erythematotelangiectatic RosaceaEndorsed Treatments

Severe Erthyematotelangiectatic Rosacea• Β-Blockers• Clonidine• Naloxone• Ondansetron• Endoscopic Thoracic Sympathectomy

HSU CC, Lee JYY, J Am Acad Dermatol 2012;67(3):491-492

ETR: Carvedilol Case Series• Study: ETR Case series (n= 11)• Based upon initial success in 1 case • Previous Failed Rx with ≥1 of

Doxycycline Corticosteroids Propranolol Clonidine Metronidazole

HSU CC, Lee JYY, J Am Acad Dermatol, 2012;67(3):491-492

Ondansetron Tacrolimus/pimecrolimus Thoracic sympathectomy Stellate ganglion block Pulsed dye laser

ETR: Carvedilol Case Series

• Rx: Carvedilol 3.125 mg/d → 31.25 mg/d divided b.i.d.-t.i.d. added to existing Rx x 1 yr

• Metrics: Photo-based facial erythema Cheek temperature VAS 0-10 (pt assessment)


ETR: Carvedilol Case SeriesResults

“All patients experienced significant clinical improvement within 3 weeks (range 3-21

days, mean 10.5 days).”


ETR: Carvedilol Case SeriesResults


Carvedilol Cheek Temperature ↓ 2.20 CVAS: BaselineVAS: End of Rx

8.4/102.1/10

*all results are MEAN

ETR: Carvedilol Case SeriesDiscussion


“Carvedilol appears special among β-blockers in its significant antioxidant and anti-inflammatory properties, which may explain

its efficacy in treating ETR in the current study.”

BASELINE

4 WEEKS

8 thru 12 MONTHS

Carvedilol for ETR

HSU CC, Lee JYYJ Am Acad Dermatol 2012;67(3):491-492

Carvedilol: Rosacea


Recalcitrant Venous Insufficiency

Marcus A is a 62 y.o. man with a venous insufficiency ulcer that has failed elevation, compression, pentoxifylline, and aspirin. What else might help?1. Simvastatin2. Ramipril3. Doxycycline4. Carbamazepine

2014;170:1151-1157

Venous Ulcers: Simvastatin?

“Simvastatin has shown potential wound-healing properties; however, no studies

have investigated its use in venous ulcers.”

Evangelista MTP, et al. Brit J Dermatol 2014;170:1151-1157

Grey JE, Enoch S, Harding KG “Venous and arterial leg ulcers” BMJ 2006;332:Feb 11:347-350

Venous Insufficiency Ulcer

Venous Ulcers & Simvastatin: Putative MOA


Venous Ulcers: Simvastatin?

• Study: RDBPCT venous insufficiency ulcers (n=66)

• Rx: ≤10 wks simvastatin 40 mg/d vs pbo All pts: elevation, compression, etc.

• Outcome: Ulcer healing


Venous Ulcers & Simvastatin: Outcomes


Placebo Simvastatin pAll UlcersHealedTime to Heal

34%8.55 weeks

90%7.53 weeks

*

Ulcer ≤ 5 cm% HealedTime to Heal

50%6.89 weeks

100%8.40 weeks

**

Ulcer > 5 cm% HealedTime to heal

0% 67%9.17 weeks

*

Venous Ulcers & Simvastatin: Outcomes


“…simvastatin 40 mg daily, in addition to standard wound care and compression, is

associated with a significant improvement in healing rate and time, as well as improved patient quality of life when compared with

placebo…”

Elevation: Foundation Rx for Leg Ulcers

Ellen is a 68 y.o. woman with a recalcitrant venous insufficiency ulcer. She has tried elevation for 30 minutes 4 times daily by sitting in her recliner. Are there additional physical therapy maneuvers she might employ?1. No, elevation is elevation and it has failed2. No, 30 minutes is twice as much as she needs3. Yes, but they do not employ elevation4. Yes, but technique of elevation must be clarified

Venous Insufficiency Ulcers:Physical Therapy

Collins L, Seraj S. “Dx and Rx of Venous Ulcers” Amer Fam Phys 2010;81(8):989-996

“Leg elevation…is also considered standard of care. Leg elevation requires raising lower extremities above the level of the heart…”

Asymptomatic Rust‐Colored Spots

A 48 y.o. man seeks advice about asymptomatic spots on both lower legs, gradually progressive for at least 5 years. No other health problems or medications. This is1. Uniformly fatal guttate melanosis. 2. Schamberg’s Disease3. Lamivudine toxicity from

adulterated cocaine4. Venous insufficiency

Schamberg’s Disease

• AKA: Progressive pigmented purpuric dermatosis, Purpura Simplex

• Males > Females• Cause Unknown• Characteristic feature: “orange-brown, pinhead-

sized ‘cayenne pepper’ spots.”• “Lesions persist, but 67% eventually clear.”

Habif T, Clinical Dermatology 6th Edition, Elsevier 2016

Schamberg’s Disease

“But Doc, I am embarrassed to wear shorts, people think I have some weird contagious disease. Isn’t there anything I can do to get rid of it?” You might try1. Pentoxifylline 2. Cryotherapy3. Imiquimod4. Venous insufficiency

J Am Acad Dermatol 1997;36:827-830

Schamberg’s Disease: Pentoxifylline

• Study: Schamberg’s disease patients (n=3)• Rx: Pentoxifylline 300 mg t.i.d. x 8 weeks• Site: Tokyo, Japan• Outcome: all 3 improved; 1 recurrence

responded to re-Rx

Kano Y, et al J Am Acad Dermatol 1997;36:827-830

Schamberg’s: Pentoxifylline Rx x 8 weeks

Kano Y, et al J Am Acad Dermatol 1997;36:827-830

Before After

Schamberg’s Disease: Pentoxifylline

• Study: Schambergs Disease patients (n=30)• Rx: pentoxifylline 400 mg t.i.d. X 9 weeks

• “We conclude that pentoxifylline should be considered as 1st line therapy in all patients with Schamberg’s disease.”

Mild Moderate MarkedImprovement 4 (13.3%) 5 (16.6% 17 (56.6%)

“Improvement was seen in 26 (86.6%) of patients.”

Majid RM, J Pakistan Assoc Dermatologists 2008;18:97-99

Head Lice

A 6 y.o. child was sent home from school because of head lice. Which of the following topical agents has demonstrated the greatest treatment efficacy?1. 1% Permethrin Cream Rinse 2. 1% NaCl3. Mupirocin Cream4. Fluticasone Spray

http://www.fda.gov/Drugs/DrugSafety/ucm245011.htm

Pediculosis Capitis 1% NACL vs 1% Permethrin Creme

PREMISES• Various Rx methods: Physical removal,

combs, topicals, systemic agents• Typical topical: Day 0 and day 7-10

Dose #1: Kills nymphs/adults but not ovae Dose #2: Allows hatched ovae kill

• Resistance problems: permethrin sensitivity 97-99% (1998) → 10-72% > 1999

Serrano L, et al. Pharmacology & Pharmacy 2013;4:266-273

Pediculosis Capitis 1% NACL vs. 1% Permethrin Creme

• Study: Patients (age 6-43) with at least 10 live head lice identified (n = 42)

• Family screened: Enrolled if +• Outcome: Presence of live lice day 8, 15

Serrano L, et al. Pharmacology & Pharmacy 2013;4:266-273

Lice‐Free at Day 15

Serrano L, et al. Pharmacology & Pharmacy, 2013;4:266-273

How Come NaCl Works At all?

Serrano L, et al. Pharmacology & Pharmacy, 2013;4:266-273

“…in vitro data have shown that the ovicidal activity of gelled 1% NaCl formulation is > that of permethrin…the in vivo ovicidal efficacy of

NaCl Spray has yet to be determined…”

Hx

• A 23 y.o. grad student complains of rash for one week. Rash is ‘all over’, and mild-moderately pruritic

• SH/FH/ROS: Nothing contributory• No meds• No known new contacts

What is this rash?

What is this rash?1. Secondary Syphilis2. Guttate Psoriasis3. Severe Rhus Dermatitis (Poison Ivy)4. Pityriasis Rosea

Pityriasis Rosea: Definition

• Pityriasis ion [Greek: pitryon bran + iasis] “A name originally applied to a group of

skin diseases characterized by the formation of fine branny scales, but now used only with a modifier”

Dorland’s Illustrated Medical Dictionary 26th Edition 1981 WB Saunders (Philadelphia)

Pityriasis Rosea

• Common, benign, self-limiting, usually aSx• Etiology? “There is some evidence that it is

viral in origin” (Frat house and military base outbreaks)

• >75% between age 10-35 (mean = 25)• Antecedent URI: 68.8%• DDx: Secondary syphilis, guttate psoriasis,

viral exanthems, drug eruptionHabif T, Clinical Dermatology, 2004 Mosby (Philadelphia)

Pityriasis Rosea: Clinical

• Herald Patch: 2-10 cm round-oval lesion appears abruptly (17%) Site: Anyplace (trunk or proximal

extremities most common) May be mistaken for tinea

• Eruptive phase (mean 7-14 days post HP) Max lesions within 2 weeks Truncal mostly (6% extremity dominant)

Habif T, Clinical Dermatology 2004 Mosby (Philadelphia)

Pityriasis Rosea: Clinical Lesions

• Adults: Oval plaques• Children, PG women, sometimes blacks:

more commonly papular • Lesion coloration

Caucasians: Pink Blacks: Hyperpigmented

• Lesion orientation: Skin lines (‘Xmas tree’)• Fine wrinkled scale (collarette)

Habif T, Clinical Dermatology 2004 Mosby (Philadelphia)

Pityriasis Rosea: Rx

How could you treat this?1. Acyclovir 2. Fluconazole3. Selenium Sulfide Shampoo4. No treatment is required

Rx: 2005

ReassuranceAntipruritics

Potential Rx: 2018 and Beyond

“Use of high-dose acyclovir in pityriasis rosea”Drago F, Vecchio F, Rebora A

Genoa, Italy

Pityriasis Rosea: Acyclovir

• PREMISE: HHV-6/HHV-7 associated• STUDY: Consecutive PR patients (n=87)

Department of Dermatology• Rx: 7 d acyclovir 800mg 5 x/d vs. placebo • LAB (serology):

HHV-6, HHV-7 EBV, V-Z, CMV, Rubella, Parvo 19 Borrelia, Toxo

Drago F, Vecchio F, Rebora A, “Use of high-dose acyclovir in pityriasis rosea” J Am Acad Dermatol, 2006;54-82

Pityriasis & Acyclovir: Demographics

Acyclovir PlaceboAge 28.4 (18-40) 26.5 (18-37)Men 24 25Women 18 20Herald Patch 95% 84%Systemic Sx 45.2% 35.6%IgM HHV-6 2/24 2/19IgM HHV-7 5/24 2/19


Pityriasis: Acyclovir Rx Success

TreatmentPartial Regression

at Day7 14

Complete Regressionat Day

7 14

Placebo 22.2% 40% 4.5% 4.4%

Acyclovir 61.9% 11.9% 28.6% 78.6%


Pityriasis: Acyclovir Rx Success

TreatmentOnset of New

Lesions at Day7 14

Reduction ofSystemic Sx at Day

7 14

Placebo 100% 55.6% 0% 2.2%

Acyclovir 40.5% 9.5% 36.8% 33.3%

Drago F, Vecchio F, Rebora A, “Use of high-dose acyclovir in pityriasis rosacea” J Am Acad Dermatol, 2006;54-82

Those Clever 1950’s TV Ads

“_________ has been shown to be an effective decay-preventive dentifrice that can be of significant value when used as

directed in a conscientiously applied program of oral hygiene and regular

professional care.”

Recurrent Mouth Sores

A 42 y.o. otherwise healthy male physician complains of recurrent multiple aphthous ulcers since he was an adolescent. Non-smoker, no chewing tobacco, no illicit substances or medications. What is causing this? 1. Recurrent herpes virus infections2. Bechet’s syndrome3. Recurrent adenovirus infections4. Sodium Laurel Sulfate (SLS) in toothpaste

Sodium lauryl sulfate (SLS) & Recurrent Aphthous Ulcers

• PREMISE: 1989 study compared SLS-free TP with SLS-TP in allergic stomatitis patients

• STUDY: Compare frequency of multiple minor recurrent aphthous ulcers: SLS TP vs SLS-free TP

• SUBJECTS: 10 healthy volunteers (lab screen WNL) with Hx multiple recurrent aphthous ulcers

Herlofson B, Barkvoll P. “Sodium lauryl sulfate and recurrent aphthous ulcers” Acta Odontol Scand .1994;52:257-259

Sodium Lauryl Sulfate and Recurrent Aphthous Ulcers

• METHOD: 3 month run-in with regular TP (all contained SLS) Rx: SLS-TP vs SLS-free TP X 3 months, then crossover

• RESULTS: Mean ulcers = 17.8 5.1

Herlofson B, Barkvoll P. “Sodium lauryl sulfate and recurrent aphthous ulcers” Acta Odontol Scand. 1994;52:257-259

Sodium Lauryl Sulfate and Recurrent Aphthous Ulcers

“…it appears likely that SLS may denature the mucosal mucin layers. Mucins are principal organic constituents of mucus, the visco-elastic material that covers all mucosal

surfaces.”

Herlofson B, Barkvoll P. “Sodium lauryl sulfate and recurrent aphthous ulcers” Acta Odontol Scand. 1994;52:257-259

Some SLS‐Free Toothpastes

• Hello• Verve• Tom’s of Maine• Himalaya Neem and Pomegranate• Red Seal

Amazon.com Accessed Sept 16, 2018

Recurrent Apthous Ulcers

Goldman EK, “-Blocker Effective in Clearing Recurrent Aphthous Ulcers” Family Practice News. 2002 (Nov 1):24

• Premise: Incidental observation -blocker (for another indication) improvement inaphthous ulcers

• Study: (n=95) Propranolol 30 mg/d X 7d, 20 mg/d X 7 d, 10 mg/d X 65d

• Inclusion: 2-7 Ulcers at baseline, recurrences Q6-8 weeks

• Exclusion: Herpes, Behcets

Recurrent Apthous Ulcers: Results

Goldman EK, “-Blocker Effective in Clearing Recurrent Aphthous Ulcers” Family Practice News. 2002 (Nov 1):24

• Complete resolution: 72/95 (68%) vs. 6/84 (7.7%) placebo

• Partial improvement: 23/95 (32%)• Some patients remain disease free X 3

years• No adverse effects• Subtherapeutic level of Rx for BP impact

Irritating Neck Bumps

A 24 y.o. AA man joined the Army 6 months ago. He has shaved his hair to conform to regulations, but now has irritating bumps on his neck. The bumps represent1. Pseudofolliculitis barbae2. Condyloma acuminata3. Diffuse papilloma infection4. Allergy to his shave cream

Pseudofolliculitis Barbae (Razor Bumps)AKA Acne Keloidalis Nuchae

• Ex: Curving hair growing back into skin• 10-30 X more common in African Americans• Standard Rxs:

D-C shaving Dislodge hair with needle Depilatories (Ba Sulfide, Ca Thioglycolate):

3-10 min application hair shaft sulfide bonds soft fluffy hair tip on breakage

Habif TP. Clinical Dermatology, 3rd Edition,1996 Mosby (St Louis)

Eflornithine for Pseudofolliculitis

• Study: AA men (n = 10) grade 3 Pseudofolliculitis, present at least 2 years

• Rx : eflornithine 13.9% cream b.i.d. X 16 wks• Results: 1 point PB severity scale in 8/10

Tucker ME, “Eflornithine Cream Helps Eliminate ‘Razor Bumps in Black Men” Family Practice News, 2001; October 15: page 9

Cutaneous Stigmata: Other Pathology

“A 71 yo obese woman presented to our clinic with multiple seborrheic keratosis over her entire body. She reported the rapid appearance of the tumors several weeks before an initial diagnosis of…..”1. Herpes Zoster2. Hepatitis C3. Pancreatitis4. Breast Cancer

?

Ghazal PA, et al. Lancet 2013;381(May 11): p 1653


Leser‐Trelat Sign

“It is usually caused by malignancies such as GI adenocarcinoma, but also lung,

kidney, liver, or pancreatic cancer. The exact underlying pathogenesis is unknown.”


Acne: Myth Vs Reality

A college student asks your opinion about acne. Which of the following might actually worsen acne1. Facial cleansing soap < t.i.d.2. Chocolate3. Jelly Beans4. Masturbation

Delost GR, Delost ME, Lloyd JJ Am Acad Dermatol 2016;75(1):220-222

• Study: Single-blind randomized XO study Youngstown State Univ. students (n=60)

• Rx: One Hershey’s milk chocolate bar (= 1.55 oz.) vs. 15 jelly beans (equivalent glycemic load) then cross-over

• Outcome: Acne lesions at 48 hrs. post ‘dose’

Acne Lesions: Chocolate vs. Jelly Beans

Delost GR, Delost ME, Lloyd J, J Am Acad Dermatol 2016;75(1):220-222



60 → 56 students(4 dropouts)

Baseline Photo

15 Jelly Beansn=28

1 Hershey Barn=28

Photo at 48 hrs.

15 Jelly Beansn=28

1 Hershey Barn=28

Photo at 48 hrs.



p < .0001

+4.8 lesions

“…the chocolate consumption group had a statistically significant increase in acne lesions…present across gender, age,

frequency, and severity classifications.”

Acne Chocolate vs. Jelly BeansConclusions


“Netea et al demonstrated that chocolate consumption primed human blood mononuclear cells to release more

proinflammatory cytokines, interleukin1β, and TNFα upon stimulation with Propionibacterium acnes.”

Acne & Chocolate: Why?


Any REAL Hope for Chocolate?A chronologically mature physician (D.O.B. 10/9/1946) has ingested for breakfast every morning since age 18, a Mountain Dew and a Chunky candy bar. Nutrition for other meals is ‘traditional’. He is ostensibly of sound mind and body, though obviously of dubious judgement. Numerous well intended advisors have failed to dissuade him. Scientifically, you might say1. You seem fine, but better nutrition would probably

have made you even healthier2. Perhaps the chocolate helps your brain3. Diet Mountain Dew would be more sensible4. The sodium benzoate ingredient in Mt. Dew says

“Preserves Freshness”; you are already fresh enough

July 19, 1984

July 19, 1984

2012;367(16):1562-1564

Chocolate & Cognitive Function

“A subclass of flavonoids called flavanols, which are widely present in cocoa, green tea,

red wine, and some fruits, seems to be effective in slowing down or even reversing the reductions in cognitive performance that

occur with aging.”

Messerli RH, Chocolate Consumption, Cognitive Function, and Nobel Laureates” NEJM 2012;367(16):1562-1564

Chocolate & Cognitive Function

“Dietary flavanols have also been shown to improve endothelial function and to lower BP

by causing vasodilation in the peripheral vasculature and in the brain.”


Chocolate and Nobel Laureates

Chocolate Consumption kg/yr/capita

Nob

el L

aure

ates

/10

milli

on P

opul

atio

n

Messerli FH, NEJM 2012;367:16:11562-1564

How Much Chocolate, Then?

“The minimally effective chocolate dose seems to hover around 2 kg/year, and the dose-response curve reveals no apparent

ceiling…”


Bumps Where You Don’t Want Bumps

A 22 y.o. male was told “you need those bumps down there burned off” by an urgent care physician. What is his disorder, and what is the preferred treatment?

Bumps Where You Don’t Want Bumps

A 22 y.o. male was told “you need those bumps down there burned off” by an urgent care physician. What is his disorder, and what is the preferred treatment?

1. Condyloma lata: Rx for syphilis2. Condyloma acuminate: Rx for HPV3. Verruca Vulgaris: Rx for warts4. Pearly penile papules: no Rx indicated

EARS?

Which of the following is true about this gent?1. He is probably a better than average listener2. He is probably a long-term, high-volume3. Wax Museum donor4. He has a family history of progeria5. He has increased probability of CAD

Am J Cardiol 2012;109:1283-1287

Frank’s Sign

“Diagonal ear lobe crease (DELC)…is a wrinkle-like line extending diagonally from the

tragus across the lobule to the rear edge of the auricle of the ear…first associated with

CAD…by Frank published in 1973.”

Shmilovich H, et al Am J Cardiol 2012;109:1283-1287

Frank’s Sign: Valid?

“Controversy exists concerning the relation between diagonal ear lobe crease and CAD”


Frank’s Sign: Valid?

• Study: aSx Adults with no Hx CAD (n=430)• Metric: Coronary CT Angiography• Endpoints:

Any CAD Significant CAD (≥50% stenosis) Multivessel disease # segments with plaque


Frank’s Sign: Outcome

“After adjusting for confounders, DELC remained a significant predictor of all 4

measurements of CAD (Odds Ratio 1.8-3.3, p 0.002-0.017).”


Frank’s Sign: Conclusion

“In conclusion, in this study of patients imaged with CT angiography, finding DELC was

independently and significantly associated with ↑ prevalence, extent, and severity of CAD.”


Documents

DERMATOLOGY Potpourri€¢ Herald Patch: 2-10 cm round-oval lesion appears abruptly (17%) Site: Anyplace (trunk or proximal extremities most common) May be mistaken for tinea • Eruptive