Outline Care Practitioner Part 1 Principles of topical therapy - PDF document

Dermatology Pearls for the Primary Outline Care Practitioner‐ Part 1 • Principles of topical therapy • Nummular Dermatitis Lindy P. Fox, MD • Alopecia Professor of Clinical Dermatology • Acne in the adult Director, Hospital Consultation Service • Perioral dermatitis Department of Dermatology University of California, San Francisco lindy.fox@ucsf.edu I have no conflicts of interest to disclose I may be discussing off-label use of medications 1 2 Principles of Dermatologic Therapy Principles of Dermatologic Therapy Moisturizers and Gentle Skin Care Moisturizers and Gentle Skin Care • Emolliate skin • Moisturizers – Contain oil to seal the surface of the skin and – All dry skin itches replace the damaged water barrier • Gentle skin care – Petrolatum (Vaseline) is the premier and “ gold – Soap to armpits, groin, scalp only (no soap on the standard ” moisturizer rash) – Additions: water, glycerin, mineral oil, lanolin – Short cool showers or tub soak for 15-20 minutes – Some try to mimic naturally occurring ceramides (E.g. CeraVe) – Apply medications and moisturizer within 3 minutes of bathing or swimming • Thick creams more moisturizing than pump lotions

Principles of Dermatologic Therapy Vehicles Topical Medications • Ointment (like Vaseline): • The efficacy of any topical medication is related to: – Greasy, moisturizing, messy, most effective. 1. The concentration of the medication • Creams (vanish when rubbed in): 2. The vehicle – Less greasy, can sting, more likely to cause 3. The active ingredient (inherent strength) allergy (preservatives/fragrances). 4. Anatomic location • Lotions (liquid): – Cooling, liquids that pour. Vehicles Topical Corticosteroids • Solutions (liquids that are greasy or • Super-High Potency: Clobetasol alcoholic): • High Potency: Fluocinonide – Can sting, good for hairy areas • Medium Potency: Triamcinolone (TAC) • Gels (semi solid alcohol-based): • Mid-Low: Aclometasone, Desonide – Can sting, good for hairy areas or wet lesions • Lowest Potency: Hydrocortisone • Foams (cosmetically elegant): – For hairy areas • Sprays: Aerosols (rarely used)

Topical Therapy • Choose agent by body site, age, type of lesion (weeping or not), surface area • For Face: – Hydrocortisone 2.5% ointment BID Nummular Dermatitis – If fails, aclometasone (Aclovate), desonide ointment • For Body: – Triamcinolone acetonide 0.1% ointment BID – If fails, fluocinonide ointment • For scalp: – Fluocinonide solution – Fluocinolone oil – Clobetasol foam 9 Nummular Dermatitis Nummular Dermatitis • Affects middle aged men most, but also • Starts as a single lesion of other age groups and women the lower leg (90%+) or arm • Some patients have atopic dermatitis (<10%) • Some patients start with xerotic eczema • Lesion present for months • Alcoholics predisposed • A few new lesions on that leg • Begins to generalize • Very, very pruritic • May become secondarily infected 11 12

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Nummular Dermatitis Nummular Dermatitis Treatment • Emolliation, dry skin care • Disease lasts 18 months, tending to relapse in cleared lesions with minimal • Potent (fluocinonide) or superpotent (clobetasol) topical steroid BID to red irritation or dryness plaques • Need to be very aggressive in good skin • Oral antihistamine care regimen for 1-2 years after cleared • Antibiotic if secondarily infected – bacterial culture • If fails, send to dermatology 17 18 Alopecia = hair loss Non‐Scarring Scarring Traction alopecia Alopecia areata Alopecia Trichotillomania (end stage) Telogen Effluvium Neutrophil mediated Androgenetic alopecia Folliculitis decalvans Dissecting cellulitis of the scalp Lymphocyte mediated Lichen planopilaris Frontal fibrosing alopecia Central centrifugal alopecia Chronic cutaneous lupus Scalp biopsy: 20 • Area ADJACENT to alopecia, ask for TRANSVERSE sections • ALL scarring alopecias OR nonscarring alopecia where diagnosis uncertain 19

Alopecia Areata: Alopecia Areata Round or oval patches of nonscarring alopecia • Affects up to 0.2% US population • Types – Relapsing remitting – Ophiasis (band like along occipital scalp) – Alopecia totalis (all scalp hair) – Alopecia universalis (all scalp and body hair) • Associations – Atopic disease – Autoimmune thyroid disease – Vitiligo – Inflammatory bowel disease – APECED syndrome 21 22 Taken from Dermatology, 2012, Elsevier Alopecia Areata: Alopecia Areat: Ophiasis pattern Exclamation point hairs 23 24 Taken from Dermatology, 2012, Elsevier Taken from Dermatology, 2012, Elsevier

Alopecia Areata Telogen Effluvium • IL triamcinolone • Normal hair cycle – 10mg/ml – Anagen 90‐95% – q month • Immunosuppression (recurs after stopped) – Catagen – Pulse steroids – Telogen 5‐10% – Methotrexate – Cyclosporine – Normal shedding is 50‐100 hairs/day • Contact sensitization • Transient shifting of hair cycle • Minoxidil • Antihistamines • Shedding • Simvastatin/ezetimibe • No scalp itch or rash • Tofacitinib J Investig Dermatol Symp Proc. 2018 Jan;19(1):S25‐S31 J Investig Dermatol Symp Proc. 2018 Jan;19(1):S18‐20 JAAD 2018 Jan; 78(1):15‐24 25 26 Telogen Effluvium‐ Causes Telogen Effluvium • Examination • Postpartum – Diffuse thinning • Chronic (no cause) – Hair pull • Post febrile • Diagnostic > 20% hairs are telogen • Severe infection – Look for bulb at end of hair shaft • Severe chronic illness (SLE, HIV, etc) • Workup • Severe prolonged stress – TSH, Vit D, Fe, ferritin, chemistry • Post major surgery – Biopsy if > 6 mo (r/o AGA) • Endocrinopathy • Treatment – Thyroid, parathyroid – Address underlying etiology • Crash diets, malnutrition, starvation – Replete ferritin if < 40 ng/dl • Medications – Minoxidil – Stopping OCP, retinoids, heparin, PTU, methimazole, anticonvulsants, β‐ blockers, IFN‐α, heavy metals – Reassurance (most regrow almost all lost hair) 27 28

Androgenetic Alopecia • Male or female pattern hair loss • Female – Complain of widening part – Retain anterior hairline – Early onset/severe: workup for hyperandrogenism • F/T testosterone, DHEAS, 17‐OH progesterone • Often “exposed” by telogen effluvium • Treat with – Minoxidil 5% (F QD, M BID) – Spironolactone (female) – Finasteride‐ up to 5mg/d • NOT for women of childbearing potential 29 30 Taken from Dermatology, 2012, Elsevier Traction Alopecia Some scarring alopecias 31 32 Taken from Dermatology, 2012, Elsevier

Chronic Cutaneous LE Lichen Planopilaris 33 34 Taken from Dermatology, 2012, Elsevier Taken from Dermatology, 2012, Elsevier Acne Pathogenesis, Clinical Features, Therapeutics Pathogenesis Clinical features Therapeutics Retinoids, Oily skin Excess sebum spironolactone Approach to the Adult Acne Salicylic acid, Non‐inflammatory Abnormal follicular retinoids open and closed Patient keratinization comedones ( “ blackheads and whiteheads ” ) Benzoyl peroxide Propionibacterium Antibiotics Inflammatory papules (topical and oral) acnes and pustules Spironolactone OCPs Inflammation Isotretinoin Cystic nodules 35 36

Acne Treatment Acne Therapy Guidelines • Mild inflammatory acne • Limit oral antibiotics to 3‐6 mo – benzoyl peroxide + topical antibiotic (clindamycin, erythromycin) • Moderate inflammatory acne • All patients should receive a retinoid for – oral antibiotic (tetracyclines) (with topicals) • Comedonal acne maintenance – topical retinoid (tretinoin, adapalene, tazarotene) – Tretinoin • Acne with hyperpigmentation – azelaic acid – Tazarotene • Acne/rosacea overlap /seborrheic dermatitis- – Adapalene (now OTC) – sulfur based preparations • Hormonal component – oral contraceptive, spironolactone • Cystic, scarring- isotretinoin – Teratogenic, hypertriglyceridemia, transaminitis, cheilitis, xerosis, alopecia (telogen effluvium) 37 38 JAAD 2016; 75: 1142‐50 Topical Retinoids • Side effects –Irritating- redness, flaking/dryness –May flare acne early in course –Photosensitizing –Tazarotene is category X in pregnancy !!! 39 40

41 42 Acne in Adult Women • Often related to excess androgen or excess androgen effect on hair follicles • Other features of PCOS are often not present—irregular menses, etc. • Serum testosterone can be normal • Spironolactone 50 mg-200mg daily with or without OCPs 44 43

Acne Pearls • Retinoids are the most comedolytic • Topical retinoids can be tolerated by most • Start with a low dose: tretinoin 0.025% cream • Wait 20‐30 minutes after washing face to apply Perioral dermatitis • Use 1‐2 pea‐sized amount to cover the whole face • Start BIW or TIW • Tazarotene is category X in pregnancy • Back acne often requires systemic therapy • Acne in adult women‐ use spironolactone – No need to check K + in healthy adult women 45 46 Perioral Dermatitis Perioral Dermatitis: Treatment • Women aged 20‐45 • Stop topical products • Papules and small pustules around the mouth, narrow • Topical antibiotics spared zone around the lips. – Clindamycin • Asymptomatic, burning, • Topical or oral ivermectin itching • Causes • Oral tetracyclines – Steroids (topical, nasal inhalers) – Fluorinated toothpaste • Warn patients of rebound if coming off – Skin care creams with petrolatum topical steroids or paraffin base or Isopropyl myristate (vehicle) • Avoid triggers 47 48