Common skin problems—steven e

COMMON SKIN PROBLEMS—Steven E. Prawer, MD, Clinical Professor of Dermatology, University of Minnesota Medical School, Minneapolis Acne vulgaris: grade 1—comedones (ie, whiteheads, blackheads); most common form;
best treated with comedolytic agents, eg, Retin-A (tretinoin), Differin (adapalene), and
Tazorac (tazarotene); avoid these agents in adults because of drying effects; patients
bathe with mild soap (eg, Cetaphil) and apply lotion in morning; grade 2—characterized
by comedones and papules (pimples); if papules few, have patient use comedolytic agents
at night and apply topical antibiotic (eg, Cleocin T [clindamycin], Benzamycin [benzoyl
peroxide and erythromycin], or BenzaClin [clindamycin and benzoyl peroxide]) in
morning; if patient has many pustules, consider topical antibiotic (eg, tetracycline); if
patient fails to respond, consider doxycycline or minocycline; grade 3—comedones,
papules, and pustules; if not responsive to doxycycline or minocycline, consider
amoxicillin or trimethoprim-sulfamethoxazole (Septra, Bactrim); grade 4 (acne
cystic acne; typically occurs on trunk, chest, and back; lesions can erode into
bone; consider referral to dermatologist for treatment with Accutane (isotretinoin)
Rosacea: presents with telangiectasia; flare factors include sun, cold, spicy foods, and
alcohol ingestion; MetroGel (metronidazole) effective but drying; newer agents include
MetroCream, MetroLotion, and Noritate (varieties of metronidazole); give tetracycline if
papules or blepharitis develop
Psoriasis: typically presents with well-demarcated, scaly plaques; trauma, eg, scratching,
produces lesions (Koebner’s phenomenon); localized to elbow—apply Cordran
(flurandrenolide) tape at night and remove in morning; superpotent corticosteroids (eg,
Temovate [clobetasol], Ultravate [halobetasol], or Diprolene [betamethasone]) often
helpful, but avoid use >1 mo; new treatment combination of Dovonex (calcipotriene)
during week with superpotent corticosteroid on weekend; feet— initially treat with
superpotent steroid, then switch to Lidex (fluocinonide) or Diprosone (betamethasone);
scalp— associated with extensive scaling; Derma-Smoothe (fluocinolone) helpful
(remove in morning and shampoo with Neutrogena T/Gel, Pentrax, or Ionil T Plus
[contain coal tar]) or Neutrogena T/Sal Therapeutic Shampoo (contains salicylic acid);
guttate psoriasis—development of papulosquamous lesions 1-2 wk after streptococcal
infection, especially if family history of psoriasis; generalized psoriasis—treatment
modalities include corticosteroids; if widespread, avoid potent medication by giving
triamcinolone ointment or Dovonex; if patient fails to respond, consider referral to
dermatologist for UV-B, psoralen-UV-A irradiation (PUVA), methotrexate, cyclosporin,
or new retinoid drug (eg, etretinate, Soriatane [acitretin]); children with psoriasis—
speaker uses mild steroid (eg, hydrocortisone [Westcort, Locoid), alclometasone
[Aclovate]); avoid more potent agents because of absorption
Seborrheic dermatitis: associated with greasy scales; typically on preauricular or
postauricular areas (sometimes inside ear), scalp, face, chest, scrotum, or groin;
characterized by pink, scaly patches; treat with steroid without fluoride (can cause
perioral dermatitis), eg, Westcort, Aclovate, or desonide
Pityriasis rosea: thought to be caused by virus; typically lasts 6-8 wk; not contagious;
can improve with exposure to UV light
Lichen planus: demonstrates Koebner’s phenomenon; characterized by small purple
papules; usually responds to steroids (eg, Lidex, Cyclocort [amcinonide])
Xerosis (dry skin): especially common in elderly people who live in cold climates;
characterized by thick scales on skin, pronounced on legs; advise patients to start
applying moisturizer as soon as they begin using heaters in winter; use mild soap (eg,
Cetaphil, Oilatum) and moisturizer (eg, Lac-Hydrin and AmLactin [contain lactic acid]);
associated with nummular eczema (treat with steroid ointment)
Dyshidrotic eczema: caused by plugged eccrine glands; triggers include hot, humid
weather, latex gloves (cause excessive sweating), and stress; treatment includes Lidex or
Cyclocort gel (drying)
Atopic eczema: typically in children 6-9 mo of age; usually starts on face and spreads to
antecubital fossae or popliteal fossae; treat with topical steroids; if no response, consider
use of tacrolimus (Protopic; new immune-system modulator); 25% of atopic eczema may
persist into adulthood (treat with steroid ointment)
Contact dermatitis: due to exposure to poison oak, poison ivy, or poison sumac;
vesicles or papules in line; if localized, give topical steroid (cream or gel, avoid
ointment); if generalized, give systemic prednisone (treat for 2 wk to prevent rebound);
comment—if rash occurs on top of feet, think contact dermatitis, not tinea
Corticosteroids: ultrahigh-potency agentseg, Ultravate, Temovate, Diprolene; should
not be used for more than 2-3 wk; high-potency drugs—indicated if steroids still needed
after course of ultrahigh-potency drug; eg, Elocon (mometasone), Diprosone, Lidex,
Florone (diflorasone), Cyclocort; midpotency or low potency drugs—safe for children
with lesions on face; eg, Westcort, Locoid, Aclovate, Tridesilon (desonide), over-the-
counter (1%) hydrocortisone; side effects include hirsutism, perioral dermatitis (with
potent steroids that contain fluoride), follicular papules in occluded, hair-bearing areas
(eg, groin), skin atrophy in occluded area (eg, axilla, groin), ecchymosis
Tinea versicolor: fungal; lesions typically brown or red in whites and hyperpigmented or
brown in blacks; treat localized lesions with topical antifungal agents (eg, Nizoral
[ketoconazole]); if generalized, give Nizoral tablets (excreted through eccrine glands;
have patient work out 2 hr after dose, and not wash for 12-24 hr to allow medication to
kill fungus in eccrine glands; effect lasts approximately 1 yr)
Tinea pedis: presents as “moccasin skin,” vesicles, or bullae on bottom of feet or
between toes; treat with topical antifungals, alternating shoes from day to day, medicated
powder (eg, Zeasorb-AF [miconazole]) or sprays (eg, Lamisil [terbinafine]) on feet,
shoes, and socks
Topical antifungal drugs: Tinactin (tolnaftate), Halotex (haloprogin) early drugs,
followed by Loprox (ciclopirox); first- generation azole antifungal drugs (1970s; inhibit
ergosterol synthesis) include Lotrimin (clotrimazole) and Micatin (miconazole); second-
generation agents include Spectazole (econ-azole) and Vagistat-1 (tioconazole); third-
generation agents include Nizoral, Exelderm (sulconazole), and Oxistat (oxiconazole);
comments—limit use of Lotrisone (contains betamethasone) to 2 wk to prevent atrophy
Tinea unguium (onychomycosis): distal lateral—most common type; occurs distally
under nail, grows proximally to nail plate; thick, yellow or brown infection; proximal—
starts proximally under lunula of nail fold and grows distally; white; hallmark of HIV
infection; superficial—surface of nail crumbly; may be sign of HIV infection;
granulomatous—rare; seen in patients with chronic mucocutaneous candidiasis or chronic
paronychia; thick granulomas on all nails
Treatment: griseofulvin and Diflucan (fluconazole) hydrophilic, ineffective; newer agents Sporanox (itraconazole) and Lamisil lipophilic, more effective (give for 3 mo, stays in nail for 9 mo); watch for drug-drug interactions with Sporanox Urticaria (hives): difficult to find cause (frequently drug, food, infection); treat with
first- and second-generation antihistamines; speaker uses Vistaril (hydroxyzine) at night
or Claritin (loratadine), Zyrtec (cetirizine), or Allegra (fexofenadine)
Alopecia: alopecia areata—autoimmune disease; autoantibodies attack skin and hair,
causing localized areas of hair loss; sometimes associated with other autoimmune
disorders, eg, thyroid disease; may respond to topical steroids or steroid injections;
alopecia totalis (entire scalp) and alopecia universalis (entire body)—treatment difficult;
try Rogaine (minoxidil) or skin irritant (eg, anthralin)
Impetigo: honey-colored, crusted lesions; frequently seen in spring and summer; due to
staphylococci, streptococci, or both; treat with Bactroban (mupirocin) tid
Folliculitis (sycosis barbae): small pustules in hair-bearing areas; very common; treat
with tetracycline or Cleocin T solution; irritated by shaving, have patient switch to
electric razor
Ecthyma: deep erosion or ulcer in skin; treat with Keflex (cephalexin), second-
generation cephalosporin, or dicloxacillin; for patient with penicillin allergy, use
erythromycin or Zithromax (azithromycin)
Multiple warts: consider referral to dermatologist; Cantharone (cantharidin) works well;
Aldara (imiquimod) approved for genital and rectal warts (and used “off label” for
others); flat warts (verruca plana)—if on face, avoid liquid nitrogen spray due to risk of
scarring; consider Retin-A or Differin gel
Molluscum contagiosum: sexually transmitted in adults; occur near genitalia, especially
in suprapubic area; treat with liquid nitrogen or Cantharone (treatment of choice in
Herpes simplex: group of vesicles on red base; treat adults with Valtrex (valacyclovir) or
Famvir (famciclovir); for children, use Valtrex, Famvir, or consider topical antiviral
Denavir (penciclovir; speaker prefers to Zovirax; must be applied during prodrome)
Herpes zoster: infection in trigeminal nerve; Valtrex and Famvir work well; if
ophthalmic involvement, try prednisone and refer to ophthalmologist; if in child or if >10
lesions beyond dermatome, work up for underlying lymphoma or leukemia; for pain, try
capsaicin, topical lidocaine, antidepressant drugs
Questions and answers: workup for large melanoma on chest for 5 yr, 20-lb weight loss,
no insurance, and negative magnetic resonance imaging (MRI)—if melanoma excised and lymph nodes negative, prognosis excellent; if lymph nodes positive, consider clinical trial of interferon or vaccines; effect of Differin on keratinocytes and aging skin—tretinoin appears more effective in treating wrinkles; sun protection program—sunscreen safe for all infants >6 mo of age; older patients should use sunscreen with sun protection factor (SPF) greater than or equal to 30; sun-sensitive patients should avoid sun from 10 AM to 4 PM ; use sunscreens with both UV-A and UV-B protection ACNE VULGARIS—Lawrence A. Schachner, MD, Professor of Dermatology and Pediatrics, and Director, Division of Pediatric Dermatology, University of Miami School of Medicine, Miami Myths held by teenagers concerning acne
Case of boy 15 yr of age: presented in office with depression; papular, pustular, and
nodular lesions of face and chest beginning at 11 yr of age; now has scarring lesions on
Stages of acne
Etiology: speaker believes distinct anatomic alteration; follicular canal running from
sebaceous gland to skin has “too sticky and retentive a lining” (retention hyperkeratosis;
target of Retin-A); linked to chemotactic substance produced by Propionibacterium

Mechanisms involved in development of acne lesions
What to tell teenagers about acne: dispel myths that certain foods, poor hygiene, or sex
contribute to acne; explain how acne develops; advise therapeutic goal to prevent
physical and psychologic scars; warn about side effects of acne treatments and how to
minimize them; comment—provide personalized handouts
Benzoyl peroxide: “go low” (initial dose 2.5 mg) and “go slow” (15 min at first, then
increase to 1 hour)
Retin-A: “best of the comedolytics”; “low potency, low application”; potential side
effects irritation, photosusceptibility, hyperpigmentation; 0.1% gel or 0.25% cream;
apply at bedtime to minimize photosusceptibility
Cleocin and erythromycin: topical antibiotics; Cleocin associated with rare reports of
bloody diarrhea and pseudomembranous colitis; speaker prescribes frequently
Benzamycin: anti-inflammatory and anticomedonal; must be refrigerated; helps prevent
need for oral antibiotics in papular or pustular acne
Tetracycline: effective against inflammatory acne only; potential side effects
photosensitivity, irritation, vaginal candidiasis
Accutane: effective in treating nodular cystic acne; usual course of therapy 4-5 mo;
benefits may last 6 mo to life; anticomedonal, antipapulopustular, antinodulocystic;
highly teratogenic (requires scrupulous birth control); affects bones, joints, and lipids;
associated with “almost universal” dryness of eyes and skin; speaker doubts drug induces depression or suicide; expensive; decrease incidence of side effects (eg, granulomatous or exacerbated acne) by starting with low dose and increasing to maximum dose in 1 mo; if patient still has significant acne after 2 courses, place him or her on monthly pulses of Accutane; long-term continuous use can result in skeletal changes Approach to therapy: comedonal acne—start with tretinoin; comedone extraction
sometimes indicated; multinodular disease—Retin-A plus benzoyl peroxide; add topical
or oral antibiotic if poor response; severe acne—use benzoyl peroxide, antibiotic (eg,
doxycycline, Minocin [minocycline], Bactrim), and tretinoin; injection of cystic lesions;
severe nodulocystic acne—usually requires Accutane
Problem areas in treating acne: lack of compliance; starting with drug regimens that
are too strong (leads to irritation); comments—dispel illusions of “quick fix”; tell patient
it will take at least 4-6 wk to get better; stress potential drug side effects; provide written
handouts containing treatment schedule
New drugs: Azelex (azelaic acid)—anticomedonal, anti-inflammatory; good agent for
patients who develop hypersensitization or hyperpigmentation while on benzoyl peroxide
or retinoid drug or from their disease; synergistic efficacy with other topical antibiotics;
also effective for treating rosacea; Differin—retinoid derivative; anti-inflammatory,
helpful in reducing comedonal and inflammatory acne; Retin-A Micro Gel—associated
with less irritation and better compliance than Retin-A; “start low”; good drug for
adolescents; Tazorac—acetylenic retinoid derivative; anticomedonal, anti-inflammatory,
and antiproliferative; approved for psoriasis and acne; available in 2 strengths (0.05% and
0.1% gel), less irritation with lower strength; apply to skin for 2 min initially, and
gradually increase length of exposure time (speaker seldom advises >5 min); can be used
as monotherapy or with topical or oral antibiotics


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