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Dermatology Pearls

Nancy Trzcinski MS, ANP-BC, FNP, DCNP

Conflict of Interest

●Pfizer Speaker Bureau – no conflict with this presentation

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Outline

• Introduction

• Immune Review

• Contact Dermatitis and Allergic Dermatitis

• Tinea and Tinea Mimickers

• Acne

Quick pearls• You are the front line of dermatology...you see skin all day,

every day.

• Skin and nails are a window into many systemic diseases.

• If your treatment is not producing resolution, rethink your diagnosis.

• Don't use combination products...this helps you to evaluate treatment response and therefore diagnostic ability.

• Don't be afraid to use high potency topical corticosteroids.

• Biopsy does not always give a specific answer. It cant tell what one is allergic to.

• Never use a medrol dose pack.

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Immunology Review• Go back to basics, yet the basics have changed

• Histamine is produced by a wide variety of cell types and is found in many physiologic actions...

• Mast cells and basophils store large quantities of histamine. When those cells are degranulated by stimuli either immunologic or non immunologic, the histamine is dumped into the system and begins an inflammatory feedback loop.

• Histamine is known for its effects in immediate-type hypersensitivity responses...increased vascular permeability, smooth muscle contraction, wheal-and flare reactions and the itch response.

• There are now 4 identified histamine receptors H1R and H2R were identified in 1966. H3R in 1999 and H4R in

Immunology pharmacology• 1st generation H1 antihistamines are sedating as they cross the

blood-brain barrier: benadryl, hydroxyzine.

• 2nd generation non-sedating H1 antihistamines cross the blood-brain barrier less: loratadine, cetirizine, desloratadine, fexofenadine and levocetirizine are 1st line treatments. Certirizine can interact with CNS proactive drugs like bupropion and benzodiazepines.

• H2 antihistamines are: cimetadine, ranitidine and famotadine.

• Leukotriene receptor antagonist: montelukast.

• Recently, use of antihistamines are being questioned.

Location, Location, Location

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Allergic Contact Dermatitis

• Allergic contact dermatitis is inflamed skin that happens when something touches the skin to stimulate a reaction. Itching, redness, scaling, a rash and even blisters can result.

• Common allergens: metals, rubber, dyes, antibiotics, preservatives, fragrance, latex and cosmetics.

• Plants and/or natural substances can also cause acute reactions.

Metals

• Metals are in many products. Jewelry, buttons, snaps on clothing, dental fillings, cell phones.

• Metal can also be found in medical equipment such as stents, pacemakers, orthopedic joint repairs.

• Nickel is the most common metal to create a problem. It is in metal alloys in jewelry

Rubber• Natural latex and synthetic rubber products can

cause contact dermatitis.

• Avoid latex gloves.

• Wear shoes with soles that are not rubber

• Avoid underwear without elastic bands even if the are covered with fabric.

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Hair dyes and other dyes

• Hair dyes often contain para-phenylenediamine (PPD). This is found in permanent dyes that are mixed with peroxide.

• Use temporary color for less risk of reaction.

• If allergic to PPD, avoid polyester and other synthetic fabrics as many of the dyes used to color them contain PPD.

Topical antibiotics

• Antibiotics that are applied to the skin are used in wound care. These often cause allergic contact dermatitis.

• These include neomycin, bacitracin, gentamycin kanamycin and polymyxin. The most common is neomycin.

Cosmetics• Makeup can cause a serious problem for men and

women, even the powder base type.

• A careful history and location of the rash is key. You don't need to take the time and have them list all products….I tell patients that I will give you the clues, you now become the detective. I can't tell you what you are allergic to, you will usually figure it down to a couple of possibilities.

• Toothpaste, mouthwash and lip balm are common offenders. It is often the mint flavoring or the whitening component.

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Poison PlantsPoison Ivy, Poison Oak and Poison Sumac

• The entire plant...stem, leaves, flowers, berries, seeds and roots are poisonous during all seasons of the year.

• You may not have a reaction the first time you're exposed.

• An initial reaction occurs within 12-48hrs of exposure. Often the redness, swelling, itching and blisters form in a linear pattern, where the plant brushes up on the skin.

• Touching any object where the sap remains, clothing, dog or cat fur, tools, sports gear and wood in the winter will give you a reaction.

Poison plants●Do not burn the plant...the smoke carries the particles of the sap.

●Wash the exposed are with soap & cold running water as soon as you are able...within 5-10 minutes.

●You can continue to break out in new areas of rash for up to 2 weeks from the initial exposure! You can not spread this to another person from the rash, only from the plant.

●Poison plants belong to the cashew family. Exposure if you are allergic to other members of the cashew family may trigger a reaction. The ginkgo tree, the mango and the cashew nut tree.

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Poison Plant Treatment●Treat the symptoms...itch use antihistamines, cool baths etc.

●Topical corticosteroids...use higher potency and order as ointment as it doesn’t sting on irritated skin. Small tube depending on size of area involved then move to mid potency. Triamcinolone in the 1lb tub is a good choice.

●Never use a medrol dose pack!!!!

●Oral prednisone is a must for diffuse and significant reactions. Must taper over 2 weeks. I use 5-10 mg tabs. Depending on patient profile, I will give 10-20mg per day in one dose in am, for 1 week, then taper to half that dose for the 2nd week. We will often use Depomedrol 40mg/1cc IM.

●If the reaction is severe with big bullae and oozing serous fluid, it is usually on the arms and/or legs, cool wet dressings with non-adherent dressings can help. I will often use silvadene ointment BID, cover with dressing (use of thin maxi-pads are an excellent choice). Cover the area with a white tube sock that you have the patient cut the foot part off.

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Tinea●Capitus: head

●Corporis: ringworm

●Cruris: groin

●Manus: hands

●Pedis: feet

●Versicolar: body

●Seborrheic dermatitis: scalp, face, ears, axilla, groin. Not a true tinea, often treated with anti fungal medications.

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Tinea treatment●Topical anti fungal creams are the mainstay of treatment. Clotrimazole 1%, miconazole 2%, oxiconasole 1%, Ketoconazole 2%, and econazole 2%.

●Ketoconazole has anti-inflammatory effect in seborrheic dermatitis that is comparable to hydrocortisone.

●Ciclopirox 1% is an excellent choice. It covers dermatophytes, yeast, gram+ bacteria, gram– bacteria, is anti-inflammatory and penetrates the nail plate.

●Don't use selenium sulfide shampoo for tinea versicolor. It is difficult to use and patients don't do a complete job.

●Diflucan(fluconazole) is a better choice. 200Mg tablets. 2 po on day 1 followed by 2 po three days later. 4 tabs total. Warn patients that the spots will look lighter after treatment as the fungus lifts off. Remind them that TV is a superficial, non-contagious fungal infection. It also has a seasonal distribution.

Oral Tinea TreatmentLamisil(terbenafine) 250mg tabs:

●Treatment length is based on your judgment and the severity of the tinea. Generally for corporis and cruris, 1 tab po QD for 2-4 weeks. For manus and pedis, 1 tab po QD for 2-6 weeks. Onychomycosis is 1 tab po QD for 3 months. Check LFT's at beginning and end of treatment for onychomycosis.

●Lamisil can also be used in cadidiasis. Treatment is based on severity.

●Tinea capitus: can use oral lamisil(terbenafine) depending on age of patient. Lamisil(terbenafine) is available as granules. Griseofulvin is still a good option for children. Remember food requirements for optimal absorption.

Oral Tinea Treatment

Diflucan(fluconazole) 50mg,150mg,200mg tabs

●Tinea corporis,cruris, pedis and manus: 50mg tab po QD for 1-2 months, or 150mg tab po Q week for 2-6 weeks.

●Onychomycosis: 150mg tab po Q week for 6-9 months.

●Candidiasis: 200mg tab po QD for 2-4 weeks.

●Sporonox(itraconazole) 100mg caps

●I don't use this anymore. It is still a viable option, yet I find the other treatment regimens are easier.

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Perleche' or Angular Chelitis

●This is inflammation of the lips, perioral skin, vermillion border or the labial border.

● The labial border is usually involved in allergic reactions. ● Most commonly this affects the corners of the mouth and

the lips.

●Caused is often multifactoral: dryness as in the winter months and/or sun exposure.

● Most common is the deposition of saliva on the lips or the pooling of saliva in the corners of the mouth during sleep.

Perleche' Treatment

●Educate the patient to cause. Most people are lip

lickers!

●Mycolog II cream. Apply BID to affected area for 2-3 days. It should quiet down or clear. Use it prn.

●Vaseline to lips at bedtime to protect from saliva

●Lip balm or vaseline during the daytime.

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Tinea mimickers

●Granuloma annulare: self-limiting inflammatory condition of the dermis.

● They are often round or annular with central clearing. ● Can be localized or diffuse. Often asymptomatic, but

might be slightly pruritic. ● Treat with topical corticosteroids and reassurance. ● With widespread disease, tetracycline may show some

benefit.

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Tinea Mimickers

Necrobiosis Lipoidica: granulomatous round skin lesions commonly associated with diabetes.

• The lesions start as small, violaceous, round or oval, sharply defined plaques which predominantly affect the shins. The lesions slowly expand with the borders staying red and the central part evolving into a waxy yellowish color. Telangiectasias are often present.

• Treatment of underlying diabetes and topical corticosteroids are the mainstay of therapy. These lesions are very resistant to treatment and often scar.

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Tinea MimickersErythrasma: Erythrasma is a superficial infection caused by a bacteria known as Corynebacterium minutissimum, which naturally resides on the body.

●Erythrasma starts as a pinkish patch of skin that quickly turns brown and scaly as the outer layers start to shed. The infection mainly occurs in so-called intertriginous areas where two skin areas touch or rub together. These include the armpits, groin, navel, under the breasts, and between the toes. The patches may cause mild itching and have regular or irregular borders.

●Most people will experience interdigital erythrasma, primarily in the webbing of the third, fourth, and fifth toes.

●Treat with oral erythromycin, azithromycin, clarithromycin or tetracyclline. May also use topical erythromycin 2% solution(may cause burning sensation), or clindamycin 1% lotion, gel or solution(may cause burning sensation).

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Woods Light

A Wood's lamp can only help diagnose certain infections.

• Corynebacterium minutissimum which causes erythrasma will turn coral-red• Microsporum fungal infections, such as ringworm, will turn a dull blue.• Pseudomonas bacterial infections, such as hot tub folliculitis, will turn green.• Malassezia fungal infections, also associated with folliculitis, will turn a bluish white.• Intertrigo rash, caused by skin-to-skin friction, will also turn green.• Inverse psoriasis, a type of psoriasis found in skin folds, will often turn red.• Tinea versicolor, a fungal infection, will turn a copper-orange.

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4/12/2019

Fig 1

Journal of the American Academy of Dermatology 2016 74, 945-973.e33DOI: (10.1016/j.jaad.2015.12.037)

Copyright © 2016 American Academy of Dermatology, Inc. Terms and Conditions

4/12/2019

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