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Dermatology Update
Katie Fiala, MDDepartment of DermatologyScott and White Memorial Hospital
TOPICS
Varicella Zoster Psoriasis Acne Lipodermatosclerosis Hemangiomas Melanoma Miscellaneous Updates
Varicella Zoster
(Shingles)
Reactivation of chickenpox virus along sensory nerve causing a painful blistering skin eruption.
Clinical History
70 year old manRecent Hodgkins Disease dxPainful eruption on facePain is excruciatingBlisters erosions
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
Zoster: clinical features Prodrome intense
pain Itch, tingling, or
hyperesthesia Grouped vesicles
on erythematous base
Umbilicated, pustular
Sensory dermatome
Childhood Zoster
Diagnosis Confirmation
Viral Culture swab
Viral PCR swab
Aggressively swab base of lesion
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)
DISSEMINATED ZOSTER >20 lesions outside of affected
dermatome Can cross midline 2 or more non-contiguous
dermatomes May have internal involvement:
hepatitis, encephalitis, pneumonitis
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?
Zostavax
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
Contraindications
Anaphylaxis to gelatin or neomycin
Immunocompromised: HIV, chemo, chronic steroids, pregnancy, h/o leukemia or lymphoma
Psoriasis
Treatment
Topical steroids Vitamin D analogs – calcipotriene Phototherapy (Narrowband UVB) Methotrexate Cyclosporine Soriatane Biologics **NOT PREDNISONE**
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)
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)
Psoriasis Associations
Obesity Hypercholesterolemia Hypertension Diabetes Mellitus II Depression Alcohol/Smoking Psoriatic Arthritis
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, 321-328, 2006
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
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
Psoriatic Arthritis
Inverse Psoriasis
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)
LIPODERMATOSCLEROSIS
Sclerosing panniculitis Affects lower legs Secondary to chronic venous
insufficiency 2/3 of patients are obese
Presentation
ACUTE– Erythematous, painful, indurated
plaques, swelling– Can be unilateral or bilateral
CHRONIC– Less erythema, significant
induration, hyperpigmentation, may ulcerate
– “inverted champagne bottle”
THERAPY
Leg elevation Compression stockings Potent topical steroids, under occlusion Aspirin NSAIDS Trental 400mg po TID Weight loss ? Vascular surgery
Hemangiomas
Natural course– Proliferate by 9mo– Involute by 10yo
10% rule Complications
– Beard area – Eye– Diaper area
Know when to refer
(
Diffuse Cutaneous Hemangiomatosis
Liver Thyroid High Output
Cardiac Failure
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;2649-51)
ACNE
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)
Oral Therapy Minocycline 100mg bid Doxycycine 100mg bid Clindamycin 150 -300mg bid Bactrim DS bid **Azithromycin 250-500mg TIW Amoxicillin 500mg bid (pregnancy) **Spironolactone 100 - 150 mg daily Oral contraceptives (Yasmin) Isotretinoin 1mg/kg bid x 5 -6 mo
IsotretinoinOther issues
Depression Labs: LFTs, lipids Pseudotumor cerebri: more likely
with tetracyclines Xerosis and cheilitis Flare ? Inflammatory Bowel Disease
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
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
Melanoma
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 One American dies of melanoma
every hour
Melanoma
Asymmetry Borders Color Diameter >6mm Evolution
Lentigo Maligna
SEER Age Adjusted Incidence Rates by Race and SexMelanoma of the Skin, All AgesSEER 9 Registries for 1973-2002
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
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
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
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
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
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
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
