principles of dermatologic therapy moisturizers and gentle

Dermatology Pearls for the Primary Care Practitioner‐ Part 1

Lindy P. Fox, MD

Professor of Clinical DermatologyDirector, Hospital Consultation Service

Department of DermatologyUniversity of California, San Francisco

[email protected]

I have no conflicts of interest to disclose

I may be discussing off-label use of medications

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Outline

• Principles of topical therapy• Nummular Dermatitis• Alopecia• Acne in the adult• Perioral dermatitis

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Principles of Dermatologic TherapyMoisturizers and Gentle Skin Care

• Emolliate skin– All dry skin itches

• Gentle skin care– Soap to armpits, groin, scalp only (no soap on the

rash)

– Short cool showers or tub soak for 15-20 minutes

– Apply medications and moisturizer within 3 minutes of bathing or swimming

Principles of Dermatologic TherapyMoisturizers and Gentle Skin Care

• Moisturizers– Contain oil to seal the surface of the skin and

replace the damaged water barrier– Petrolatum (Vaseline) is the premier and “gold

standard” moisturizer– Additions: water, glycerin, mineral oil, lanolin– Some try to mimic naturally occurring ceramides

(E.g. CeraVe)• Thick creams more moisturizing than pump lotions

Principles of Dermatologic TherapyTopical Medications

• The efficacy of any topical medication is related to: 1. The concentration of the medication

2. The vehicle

3. The active ingredient (inherent strength)

4. Anatomic location

Vehicles

• Ointment (like Vaseline): – Greasy, moisturizing, messy, most effective.

• Creams (vanish when rubbed in): – Less greasy, can sting, more likely to cause

allergy (preservatives/fragrances).

• Lotions (liquid): – Cooling, liquids that pour.

Vehicles

• Solutions (liquids that are greasy or alcoholic): – Can sting, good for hairy areas

• Gels (semi solid alcohol-based): – Can sting, good for hairy areas or wet lesions

• Foams (cosmetically elegant): – For hairy areas

• Sprays: Aerosols (rarely used)

Topical Corticosteroids

• Super-High Potency: Clobetasol

• High Potency: Fluocinonide

• Medium Potency: Triamcinolone (TAC)

• Mid-Low: Aclometasone, Desonide

• Lowest Potency: Hydrocortisone

Topical Therapy

• Choose agent by body site, age, type of lesion (weeping or not), surface area

• For Face: – Hydrocortisone 2.5% ointment BID – 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

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Nummular Dermatitis

Nummular Dermatitis

• Affects middle aged men most, but also other age groups and women

• Some patients have atopic dermatitis

• Some patients start with xerotic eczema

• Alcoholics predisposed

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Nummular Dermatitis

• Starts as a single lesion of the lower leg (90%+) or arm (<10%)

• Lesion present for months

• A few new lesions on that leg

• Begins to generalize

• Very, very pruritic

• May become secondarily infected

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Nummular Dermatitis

• Disease lasts 18 months, tending to relapse in cleared lesions with minimal irritation or dryness

• Need to be very aggressive in good skin care regimen for 1-2 years after cleared

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Nummular Dermatitis Treatment

• Emolliation, dry skin care• Potent (fluocinonide) or superpotent

(clobetasol) topical steroid BID to red plaques

• Oral antihistamine• Antibiotic if secondarily infected

– bacterial culture

• If fails, send to dermatology

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Alopecia

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Alopecia = hair loss

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Non‐Scarring Scarring

Alopecia areataTelogen EffluviumAndrogenetic alopecia

Traction alopeciaTrichotillomania (end stage)Neutrophil mediated

Folliculitis decalvansDissecting cellulitis of the scalp

Lymphocyte mediatedLichen planopilarisFrontal fibrosing alopeciaCentral centrifugal alopeciaChronic cutaneous lupus

Scalp biopsy:• Area ADJACENT to alopecia, ask for TRANSVERSE sections• ALL scarring alopecias OR nonscarring alopecia where diagnosis uncertain

Alopecia Areata• 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

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Alopecia Areata:Round or oval patches of nonscarring alopecia

22Taken from Dermatology, 2012, Elsevier

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Alopecia Areata:Exclamation point hairs

Taken from Dermatology, 2012, Elsevier

Alopecia Areat: Ophiasis pattern


Alopecia Areata

• IL triamcinolone – 10mg/ml– q month

• Immunosuppression (recurs after stopped)– Pulse steroids – Methotrexate– Cyclosporine

• Contact sensitization• Minoxidil• Antihistamines• Simvastatin/ezetimibe• Tofacitinib

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J Investig Dermatol Symp Proc. 2018 Jan;19(1):S25‐S31J Investig Dermatol Symp Proc. 2018 Jan;19(1):S18‐20JAAD 2018 Jan; 78(1):15‐24

Telogen Effluvium

• Normal hair cycle

– Anagen 90‐95%

– Catagen

– Telogen 5‐10%

– Normal shedding is 50‐100 hairs/day

• Transient shifting of hair cycle

• Shedding

• No scalp itch or rash

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Telogen Effluvium‐ Causes

• Postpartum• Chronic (no cause)• Post febrile• Severe infection• Severe chronic illness (SLE, HIV, etc)• Severe prolonged stress• Post major surgery• Endocrinopathy

– Thyroid, parathyroid

• Crash diets, malnutrition, starvation• Medications

– Stopping OCP, retinoids, heparin, PTU, methimazole, anticonvulsants, β‐ blockers, IFN‐α, heavy metals

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Telogen Effluvium• Examination

– Diffuse thinning– Hair pull

• Diagnostic > 20% hairs are telogen– Look for bulb at end of hair shaft

• Workup– TSH, Vit D, Fe, ferritin, chemistry– Biopsy if > 6 mo (r/o AGA)

• Treatment– Address underlying etiology– Replete ferritin if < 40 ng/dl– Minoxidil– Reassurance (most regrow almost all lost hair)

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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 potential29 30

Taken from Dermatology, 2012, Elsevier

Some scarring alopecias

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Traction Alopecia


Chronic Cutaneous LE


Lichen Planopilaris


Approach to the Adult Acne Patient

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Acne Pathogenesis, Clinical Features, Therapeutics

Oily skin

Non‐inflammatory open and closed comedones(“blackheads and whiteheads”)

Inflammatory papules and pustules

Cystic nodules

Retinoids, spironolactone

Salicylic acid, retinoids

Benzoyl peroxideAntibiotics (topical and oral)SpironolactoneOCPsIsotretinoin

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Excess sebum

Abnormal follicular keratinization

Propionibacteriumacnes

Inflammation

Pathogenesis Clinical features Therapeutics

Acne Treatment• Mild inflammatory acne

– benzoyl peroxide + topical antibiotic (clindamycin, erythromycin)• Moderate inflammatory acne

– oral antibiotic (tetracyclines) (with topicals)• Comedonal acne

– topical retinoid (tretinoin, adapalene, tazarotene)• Acne with hyperpigmentation

– azelaic acid• Acne/rosacea overlap /seborrheic dermatitis-

– sulfur based preparations• Hormonal component

– oral contraceptive, spironolactone• Cystic, scarring- isotretinoin

– Teratogenic, hypertriglyceridemia, transaminitis, cheilitis, xerosis, alopecia (telogen effluvium)

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Acne Therapy Guidelines

• Limit oral antibiotics to 3‐6 mo

• All patients should receive a retinoid for maintenance

– Tretinoin

– Tazarotene

– Adapalene (now OTC)

38JAAD 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 !!!

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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

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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

• 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

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Perioral dermatitis

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Perioral Dermatitis

• Women aged 20‐45

• Papules and small pustules around the mouth, narrow spared zone around the lips.

• Asymptomatic, burning, itching

• Causes – Steroids (topical, nasal inhalers)

– Fluorinated toothpaste

– Skin care creams with petrolatum or paraffin base or Isopropyl myristate (vehicle)

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Perioral Dermatitis: Treatment

• Stop topical products

• Topical antibiotics

– Clindamycin

• Topical or oral ivermectin

• Oral tetracyclines

• Warn patients of rebound if coming off topical steroids

• Avoid triggers

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principles of dermatologic therapy moisturizers and gentle

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