Disclosures Common Dermatologic Disorders: Tips for Diagnosis and - PDF document

3/26/2014 Disclosures Common Dermatologic Disorders: Tips for Diagnosis and Management • I have no conflicts of interest to disclose Part 1 Lindy P. Fox, MD Associate Professor Director, Hospital Consultation Service Department of Dermatology University of California, San Francisco foxli@derm.ucsf.edu 1 2 Outline  Part 1  Approach to the itchy patient  Eczemas and approach to treatment Approach to the itchy patient  Fungal infections of the skin  Onychomycosis  Grovers disease  Part 2  Acne, Rosacea, Perioral dermatitis  Drug eruptions  The red leg  Psoriasis as a systemic disease 3 4 1

3/26/2014 Case 1 Question 1: The Best Diagnosis is • 57M with 3 months of 1. Asteatotic dermatitis itch rash 2. Pruritus of renal failure • started on his lower extremities 3. Nummular dermatitis • No response to antifungal creams and 4. Tinea corporis OTC hydrocortisone cream 5. Neuropathic pruritus • He showers 2 x/day with hot water, uses an antibacterial soap, and does not moisturize 5 6 Case 2 Question 2: The Best Diagnosis is 68M with ESRD complains of generalized itch 1. Asteatotic dermatitis 2. Pruritus of renal failure 3. Nummular dermatitis 4. Tinea corporis 5. Neuropathic pruritus 7 8 2

3/26/2014 Pruritus- History Pruritus = the sensation of itch  Suggest cutaneous cause of itch: • Itch can be divided into four categories: 1. Pruritoceptive  Acute onset (days) • Generated within the skin  Related exposure or recent travel • Itchy rashes: scabies, eczema, bullous pemphigoid  Household members affected 2. Neurogenic  Localized itch • Due to a systemic disease or circulating pruritogens Itch “ without a rash ” •  Itch is almost always worse at night 3. Neuropathic  does not help identify cause of pruritus • Due to anatomical lesion in the peripheral or central nervous system  Aquagenic pruritus suggests polycythemia vera • Notalgia paresthetica, brachioradial pruritus  Dry skin itches 4. Psychogenic itch 9 10 Pruritus- Physical Exam Case 1  57M with 3 months of Are there primary lesions present? itch rash  started on his lower extremities  No response to yes no antifungal creams and OTC hydrocortisone cream  He showers 2 x/day with hot water, uses an Pruritoceptive Neurogenic, antibacterial soap, and Neuropathic, does not moisturize or Psychogenic Nummular dermatitis 11 12 3

3/26/2014 Case 2 Causes of Neurogenic Pruritus (Pruritus Without Rash) 68M with ESRD complains of generalized itch • 40% will have an underlying cause: – Dry Skin – Liver diseases, especially cholestatic – Renal Failure – Iron Deficiency – Thyroid Disease – Low or High Calcium – HIV – Medications – Cancer, especially lymphoma (Hodgkin’s) Linear erosions; “Butterfly” distribution of spared skin Pruritus “without rash” 13 14 Neuropathic Pruritus Workup of “ Pruritus Without Rash ” Notalgia Paresthetica and Brachioradial Pruritus • CBC with differential • Localized and persistent area of pruritus, without • Serum iron level, ferritin, total iron binding capacity associated primary skin lesions, usually on the back • Thyroid stimulating hormone and free T4 or forearms • Renal function (blood urea nitrogen and creatinine) • Calcium • Workup= MRI • Liver function tests • Cervical spine disease in ~100% brachioradial pruritus • total and direct bilirubin, AST, ALT, alkaline phosphatase, • Thoracic spine disease in 60% notalgia paresthetica GGT, fasting total plasma bile acids • HIV test • Treatment ‐ capsaicin cream TID, neurontin • Chest X ‐ ray • Surgical intervention when appropriate • Age ‐ appropriate malignancy screening, with more advanced testing as indicated by symptoms 15 16 4

3/26/2014 Notalgia Paresthetica Treatment of Pruritus • Treat the underlying cause if there is one Dry skin care • • Short, lukewarm showers with Dove or soap ‐ free cleanser Moisturize with a cream or ointment BID • • Cetaphil, eucerin, vanicream, vaseline, aquaphor • Sarna lotion (menthol/phenol) Topical corticosteroids to inflamed areas • • Face ‐ low potency (desonide ointment) • Body ‐ mid to high potency (triamcinolone acetonide 0.1% oint) 17 18 Antihistamines for Pruritus Systemic Treatments for Pruritus  Work best for histamine ‐ induced pruritus, but may • Doxepin - 10mg QHS, titrate up to 50 mg QHS – Tricyclic antidepressant with potent H1 and H2 also be effective for other types of pruritus antihistamine properties  First generation H1 antihistamines – Good for pruritus associated with anxiety or depression  hydroxyzine 25 mg QHS, titrate up to QID if – Anticholinergic side effects tolerated • Paroxetine (SSRI)- 25- 50 mg QD • Mirtazepine- 15-30 mg QHS  Second generation H1 antihistamines – H1 antihistamine properties  longer duration of action, less somnolence – Good for cholestatic pruritus, pruritus of renal failure  cetirizine, levocetirizine, loratidine, desloratidine, • Gabapentin- 300 mg QHS, increase as tolerated fexofenadine – Best for neuropathic pruritus, pruritus of renal failure 19 20 5

3/26/2014 Eczemas Eczema (=dermatitis) Group of disorders • Atopic Dermatitis characterized by: • Hand and Foot Eczemas 1. Itching • Stasis Dermatitis 2. Intraepidermal vesicles (= spongiosis) • Asteatotic Dermatitis (Xerotic Eczema) – Macroscopic (you can see) – Microscopic (seen • Nummular Dermatitis histologically on biopsy) 3. Perturbations in the • Lichen Simplex Chronicus skin’s water barrier • Contact Dermatitis (allergic or irritant) 4. Response to steroids 21 22 Asteatotic Dermatitis Hand Eczema (Xerotic Eczema) • Many atopic adults have only hand dermatitis • Caused by loss of the epidermal water • Tinea tends to involve only 1 hand, so if two feet barrier and one hand are involved, think tinea • More common in the elderly • Treatment: • Worsened by hot showers, deodorant – Protect, Moisturize, Medicate soaps • Occupational history • Worse in the winter (dry, heated air) – Consider contact dermatitis and patch testing • Worse after ski trips (altitude, cold) 23 24 6

3/26/2014 Asteatotic Dermatitis (Xerotic Eczema) • Lower legs, flanks, arms • Spares armpits, groin, face • First stage: – flaking of the skin, pruritic • Second stage: – cracking of the skin looking like the bed of a dry lake – itchy and stings • Third stage: Weepy dermatitis, ITCHY 25 26 Asteatotic Dermatitis Nummular Dermatitis (Xerotic Eczema) • Diagnostic clue: • Affects middle aged men most, but also other age groups and women – Itching is relieved by prolonged submersion in bath (20-30 minutes) • Some patients have atopic dermatitis – Then itching starts again 5-30 minutes after • Some patients start with xerotic eczema getting out of the water • Alcoholics predisposed 27 28 7

3/26/2014 Nummular Dermatitis Nummular Dermatitis • Disease lasts 18 months, tending to • Starts as a single lesion of relapse in cleared lesions with minimal the lower leg (90%) or arm irritation or dryness (<10%) • Need to be very aggressive in good skin • Lesion present for months care regimen for 1-2 years after cleared • A few new lesions on that leg • Begins to generalize • Very, very pruritic • May become secondarily infected 29 30 Eczema Lichenification Good Skin Care Regimen Describes lesions that have been rubbed repeatedly • Soap to armpits, groin, scalp only (no soap • Characteristic of any pruritic and on the rash) chronic dermatosis • Short cool showers or tub soak for 15-20 Skin is thickened, with slight scale, minutes excoriations, and ACCENTUATED • Apply medications and moisturizer within 3 skin lines minutes of bathing or swimming Treat with superpotent topical steroids (clobetastol) under occlusion 31 32 8

3/26/2014 Principles of Moisturizers Dermatologic Therapy • Contain oil to seal the surface of the skin and replace the damaged water barrier • The efficacy of any topical medication is • Petrolatum (Vaseline) is the premier and “ gold standard ” moisturizer related to: • Other agents add water to this to make it more 1. The concentration of the medication palatable, OR use glycerin or mineral oil instead 2. The vehicle or in addition 3. The active ingredient (inherent strength) – If the first ingredient is “ water ” , the moisturizer is less effective than if the first ingredient is an oil 4. Anatomic location (hydrophobic) Vehicles Vehicles • Solutions (liquids that are greasy or • Ointment (like Vaseline): alcoholic): – Greasy, moisturizing, messy, most effective. – Can sting, good for hairy areas • Creams (vanish when rubbed in): • Gels (semi solid alcohol-based): – Less greasy, can sting, more likely to cause – Can sting, good for hairy areas or wet lesions allergy (preservatives/fragrances). • Foams (cosmetically elegant): • Lotions (liquid): – For hairy areas – Cooling, liquids that pour. • Sprays: Aerosols (rarely used) 9