SKIN PROBLEMS IN THE YOUNG AND OLD
| ACTINIC KERATOSIS —Glenn D. Goldman, MD, Associate Professor of Dermatology, University of Vermont College of
Medicine and Fletcher Allen Health Care, Burlington, Vermont
|
| Introduction: common; studies show 90% to 100% of screened individuals in Australia have actinic keratoses (AKs);
increasing among fair-skinned individuals in United States; 50 million visits to physicians’ offices per decade in
United States
|
| Reasons to treat: premalignancy; soreness; tenderness; pain; snag on clothing; cosmetic nuisance; national coverage
policy for treatment
|
| AKs and squamous cell carcinoma (SCC): 0.5% to 10.0% of AKs progress to SCC (depends on severity of AK);
AK—lesion has nearly full-thickness atypia with maturing normal epidermis at top of lesion; SCC in situ—atypia fills
epidermis; difficult to distinguish; AK marker for malignancy (progression to SCC uncertain); ≈50% of SCCs arise in
visibly preexisting AK; risk factors—red or blonde hair; fair skin; sun-damaged skin; presence of AKs and nevi
|
| Types of AK: focal—small, well-defined lesion; usually treated with cryotherapy; diffuse—broad patchy lesions
over wide area; usually treated with creams; macular—flat; may be treated with cream; papular—elevated; hypertrophic;
more grittiness and substance; unlikely to resolve with cream; treat by excising; some lesions may resolve or
become difficult to see; hypertrophic AK on ear—common; may be difficult to distinguish from SCC; approach with
caution; SCC on lip and ear more serious than on other areas of face; treat more diligently and conservatively
|
| Fluorouracil (5-fluorouracil, 5-FU; [Carac, Efudex, Fluoroplex]): topical chemotherapeutic agent that inhibits
thymidylate synthetase and destroys rapidly enlarging cells; cure rate high; Fluoroplex used more in Canada;
Efudex used twice daily, Carac used once daily; 5.0% strength maintains cure rate and decreases irritation; educate patients
about profound inflammatory response; 1.0% cream causes less irritation but not as effective; rebound AKs
present 1 to 2 yr later with Efudex; 0.5% Carac cream shown as effective as 5.0% Efudex cream (results in ≈90%
clearance with 4 wk of therapy); treat for 3 wk (patients develop redness; 80%-90% clear) and treat remaining lesions
with cryotherapy; slightly less irritation and absorption with Carac; long-term use of Efudex can result in absorption
and decreased white blood cell (WBC) count; pulse dosing ineffective; use on extremities—ineffective unless patients
pretreated with tretinoin (Retin-A [0.1% cream]) at night; use 5-FU in morning; causes rawness of skin, but results
excellent; useful for patients with history of sun damage (eg, fishermen, golfers); side effects—redness;
crustiness; minimize by applying white petrolatum (Vaseline) several times daily; 5-FU effective for relatively advanced
pervasive macular or patch-like AK; relatively “outpatient unfriendly”; provide patient handouts with Efudex
and Carac; occasional breakthrough AKs present after 1 yr (treat with cryotherapy)
|
| Topical diclofenac (Solaraze): effectiveness lower; nonsteroidal anti-inflammatory agent; cyclooxygenase (COX)-
2 important in angiogenesis and development of neoplasia (particularly in certain types of skin cancer and AK); inhibiting
COX-2 slows down neoplasia; 30% to 50% clearance; 60-day treatment; causes less irritation than Efudex; useful
for patients with public careers (eg, trial attorneys) who cannot go to work with red faces; side effects minimal;
less inflammation
|
| Imiquimod: imidazoquinoline antiviral; results in local generation of interferon and systemic absorption of interferon;
approved for use twice weekly for 12 wk; off-label use—use 50% of packet 3 times weekly for 8 wk (24 treatments);
results in good clearance; indicated only for local treatment (not sufficient to treat broad areas of AK [use Carac]);
more effective than 5-FU for advanced disease (eg, foci of in situ SCC, foci of superficial basal cell carcinomas); effective
for normal AKs; 82% clearance; useful for patients with patchy areas that may be superficial basal cell carcinomas
or in situ SCC; causes irritation; be cautious when using for treatment of basal cell carcinoma; expensive
|
| Photodynamic therapy: involves taking oral photostimulatory agent or applying photostimulatory agent to lesions,
followed by blue-wavelength light (absorbed by porphyrin derivatives and preferentially taken up into precancerous
and early cancerous cells); expensive; performed by few centers in United States; painful; AKs resolve with no scarring
|
| Cryosurgery: effective; cure rates high; fast; usually no cost to patient; disadvantages include temporary pain and hypopigmentation;
AKs on ear—freeze for 20 to 30 sec; results in blistering and crustiness (tell patients not to touch and
to wash hands before applying Vaseline)
|
| Curettage: effective for crusty substantive AK; difficult; for thick AKs on scalp, ring-block scalp and scrape lesions
|
| Chemical peels: speaker prefers using 5-FU; technically challenging; painful; covered by Medicare; performed with
trichloroacetic acid
|
| Thick AKs on backs of hands: 50% early invasive squamous carcinoma; be cautious of tender hypertrophic AKs
on backs of hands, ears, and lips
|
| Local anesthesia: for freezing AK on scalp or forehead
|
| Summary: most AKs treated by destructive methods and few treated by creams; use cream for broad, diffuse, and
shallow lesions; use 5-FU for pervasive lesions; use imiquimod for focal, severe lesions; use cryotherapy for small
number of lesions or keratotic lesions
|
| PEDIATRIC DERMATOLOGOY —James D. Korb, MD, Director of Academic Affairs and Pediatric Residency Program,
Children’s Hospital of Orange County, Orange, California
|
| Tinea capitis: primarily disease of prepubertal children; more common in blacks; transmitted through families,
crowded situations, and fomites; effectiveness of griseofulvin decreasing (success rate 60%); asymptomatic carriers
common
|
| Types of tinea capitis: Trichophyton tonsurans—contracted from people; endothrix infection (ie, spores laid down
inside hair shaft); Microsporum canis—more commonly transmitted through cats than dogs; ectothrix infection (ie,
spores laid down outside hair shaft); easily spread through fomites
|
| Diagnosis: patients present with alopecia or scaling; cervical or occipital adenopathy; kerion—hypersensitivity response
to fungus; more common with T tonsurans; after 8 wk, large pus-filled masses form; patients usually febrile
with tender adenopathy and high WBC count; 50% of cultures show Staphylococcus; scalp abscesses uncommon in
children (if no history of direct trauma or abnormal immune system, suspect tinea capitis until proven otherwise); consider
tinea capitis if child presents with scaling without hair loss; potassium hydroxide (KOH) testing—accuracy
30% to 60%; look for small round spores at base of hair shaft; culture—rub wet sterile toothbrush or throat culture
swab vigorously on skin; results in high cure rate; Wood’s lamp not helpful for identifying T tonsurans
|
| Scalp scaling in prepubertal children: seborrheic dermatitis usually does not occur in children 2 to 10 yr of age
(scalp scaling often indicates tinea capitis until proven otherwise); obtain culture in children with scaling; presumptive
treatment can be started in children with alopecia and scaling and in high-risk children with no alopecia and fine scaling;
wait for culture results for low-risk children
|
| Griseofulvin: safe; inexpensive; duration of treatment long (6 wk to 3 mo); available in microsize and ultramicrosize;
poorly absorbed; 25% to 75% absorption with microsize, 75% to 90% with ultramicrosize; liquid form available only
in microsize; dosage—when using microsize, start at 20 mg/kg per day (cure rates ≤90%; if no improvement after 1
mo, increase to 25 mg/kg per day or switch to alternative agent); when using ultramicrosize, start at 15 mg/kg per day;
no need to follow liver function tests (LFTs) if treating for ≤4 mo; few drug interactions
|
| Itraconazole: nice approach when griseofulvin ineffective; triazole antifungal; fungistatic (duration of treatment
long); due to reservoir effect, continuous application not required; available in 100-mg capsules; liquid preparation
available but contains ingredient known to cause pancreatic cancer in rats; increased absorption with acidic beverages
and food; pulse dosing—1 wk of therapy, stop for 3 wk, and check for improvement; if no improvement, repeat 1-wk
pulse dose and stop for 3 wk; results in high cure rate and lower cost; daily dosing—2-wk course results in 60% to
70% cure rate, 4-wk course 85%; drug interactions—many; drugs that increase risk for prolonged QT syndrome;
other drugs that undergo same hepatic metabolism; review current drug interactions if child has other medical illnesses;
dosage—100-mg capsule opened over food for children ≤29 kg; for children 30 to 39 kg, alternate 100-mg
doses and 200-mg doses daily
|
| Fluconazole: good-tasting liquid preparation available; well tolerated; 6 mg/kg per day for 2 to 3 wk; pulse dosing—
small study found 8 mg/kg once weekly effective; drug interactions similar to itraconazole
|
| Terbinafine (Lamisil): fungicidal; reservoir effect; available in 250-mg scored tablet; dosing—4.5 mg/kg per day;
difficult due to size of tablet; higher dose and longer treatment regimen needed for M canis; use quarter, half, or full
tablet; in children 35 to 37 kg, half tablet may not be sufficient; efficacy compared to griseofulvin—study compared
20 mg/kg per day of griseofulvin for 6 wk to 2-wk course of other agents (additional week of treatment given if no improvement
after 4 wk); griseofulvin drug of choice
|
| Follow-up: see children every month; aim to eliminate scaling and achieve new hair growth; obtain second culture; topical
selenium and ketoconazole shampoo may or may not decrease transmission of spores; kerions—result in bald patch;
prednisone shrinks kerion, but no long-term evidence of effect on scarring; use in asthma-like doses (eg, 2 mg/kg per
day)
|
| Id reaction: often 1 wk into treatment, patients break out in maculopapular eruption; looks like viral exanthem; idiosyncratic
reaction (hyperimmune response); no need to stop therapy; large areas of redness or urticaria could be due to
allergic reaction to drug (discontinue use)
|
| Asymptomatic carriers: following for 3 mo showed 15% develop disease, 50% remain carriers, ≈33% become culture-negative;
asymptomatic carriers usually not treated; consider recommending selenium shampoo
|
| Atopic dermatitis: educate parents about dryness, itchiness, redness, and infection; dryness—bathing hydrates skin,
but moisturizer must be applied within 2 to 3 min after bath; children can be bathed daily; patients with eczema should
apply cream or ointment (thin lotions evaporate and have drying effect); use mild unscented soap and lukewarm water;
do not use bath oil; greater moisturizing effect with ointments, but less cosmetically appealing; use Vaseline;
moisturize twice daily (4-6 times daily for flares); steroids should be applied before moisturizers; itching—in eczema,
not histamine-related; first-generation antihistamines used to sedate children; cetirizine relatively nonsedating
and shown effective
|
| Topical steroid guidelines: steroids do not need to be used more than once or twice daily; use low-potency steroids
(class VI and VII) for face, axilla, and groin and limit to 1 wk of use; use mid-potency steroids for trunk and extremities;
use appropriate vehicle (eg, cream for milder forms of eczema); second-generation topical steroids (eg, mometasone,
prednicarbate, alclometasone) less likely to cause long-term side effects, but topical immunosuppressants used
more commonly
|
| Topical immunosuppressants: do not cause atrophy of skin; no effect on collagen synthesis; can be used on face
and groin; takes 1 wk to see initial improvement; do not decrease in effectiveness over time; useful for thick lichenified
plaques; do not induce cataracts or glaucoma; mild intermittent eczema should be treated with steroids; mild persistent
eczema should be treated with topical immunosuppressants as maintenance, with steroids for flares; long-term
side effects uncertain
|
| Eczema herpeticum: potentially disseminated herpes infection in patient with atopic dermatitis; may be associated
with preceding cold sore; 2- to 4-mm thick-walled vesicles or shallow ulcers form erosive pits; necrotic crusting; fever;
pain; can disseminate to central nervous system (CNS) and liver, resulting in death; can lead to conjunctivitis; risk
factors include abnormal skin barriers, inadequate response to viral infections, deficiency in normal cells that respond
to infections, and deficiency in antimicrobiologic peptides; not seen commonly; can be primary or secondary infection;
can recur; when secondarily infected, large moist lesions form (look for small vesicles); tacrolimus or pimecrolimus
may modify lesions (underlying herpes may be difficult to identify; looks like severe exacerbation that does not
improve with topical steroids; when steroids discontinued, classic lesions appear within 48 hr); laboratory
evaluations—children may have normal WBC count with mild lymphopenia and elevated sedimentation rate; check
for normal renal function when using intravenous (IV) acyclovir; look at LFTs if concerned about dissemination to
liver; if wet or weepy, consider secondary bacterial infection until proven otherwise; infections near eye should be referred;
rapid testing (eg, direct fluorescent antibody [DFA] testing or polymerase chain reaction [PCR] testing) for
herpes simplex virus (HSV); treatment—stop all medications used on skin; acyclovir (IV acyclovir for severe cases);
drugs that allow less frequent dosing more effective; topical antiviral agents useful in eye; methicillin-resistant Staphylococcus
aureus commonly seen; secondary bacterial infections usually Staphylococcus or group A streptococci
|
Educational Objectives
| The goal of this program is to educate the listener about dermatologic problems such as actinic keratoses (AKs) and tinea
capitis. After hearing and assimilating this program, the participant will be better able to:
|
 | 1. Distinguish types of AKs.
|
| 2. Select the appropriate treatment for AKs, based on clinical findings.
|
| 3. Choose effective agents for tinea capitis.
|
| 4. Counsel parents about bathing children with atopic dermatitis.
|
| 5. Describe and identify eczema herpeticum.
|
Discussed on This Program
Acyclovir (acycloguanosine) [Zovirax]
Alclometasone diprorionate [Aclovate]
Cetirizine HCl [Zyrtec]
Diclofenac [Cataflam, Voltaren, Voltaren-XR]
Diclofenac sodium [Solaraze gel]
Fluconazole [Diflucan]
Fluorouracil (5-fluorouracil, 5-FU) [Adrucil, Carac, Efudex, Fluoroplex]
Griseofulvin microsize [Fulvicin U/F, Grifulvin V, Grisactin 250, Grisactin 500]
Griseofulvin ultramicrosize [Fulvicin P/G, Grisactin Ultra, Gris-PEG]
Imiquimod [Aldara]
Itraconazole [Sporanox]
Ketoconazole [Nizoral, Nizoral Cream Shampoo]
Mometasone furoate [Elocon, Asmanex Twisthaler]
Prednicarbate [Dermatop]
Selenium sulfide (several trade names)
Terbinafine HCl [Lamisil, Lamisil DermGel 1%]
Tretinoin (trans-retinoic acid; vitamin A acid) [Altinac, Atragen (investigational), Avita, Renova, Retin-A, Retin-A
Micro, Vesanoid]
Trichloroacetic acid [Tri-Chlor]
White petrolatum [Vaseline]
Suggested Reading
Aste N et al: Tinea capitis caused by Microsporum canis treated with terbinafine. Mycoses 47:428, 2004; Dastghaib
L et al: Therapeutic options for the treatment of tinea capitis: griseofulvin versus fluconazole. J Dermatolog Treat
16:43, 2005; Epstein E: Quantifying actinic keratosis: assessing the evidence. Am J Clin Dermatol 5:141, 2004;
Feldman SR et al: Destructive procedures are the standard of care for treatment of actinic keratoses. J Am Acad Dermatol
40:43, 1999; Foster KW et al: A randomized controlled trial assessing the efficacy of fluconazole in the treatment
of pediatric tinea capitis. J Am Acad Dermatol 53:798, 2005; Gilaberte Y et al: Tinea capitis in infants in their
first year of life. Br J Dermatol 151:886, 2004; Jeffes EW 3rd et al: Actinic keratosis. Current treatment options. Am
J Clin Dermatol 1:167, 2000; Koumantaki-Mathioudaki E et al: Is itraconazole the treatment of choice in Microsporum
canis tinea capitis? Drugs Exp Clin Res 31 Suppl:11, 2005; Mohrenschlager M et al: Pediatric tinea
capitis: recognition and management. Am J Clin Dermatol 6:203, 2005; Novelli VM et al: Eczema herpeticum. Clinical
and laboratory features. Clin Pediatr (Phila) 27:231, 1988; Roberts BJ et al: Tinea capitis: a treatment update.
Pediatr Ann 34:191, 2005; Smith ES et al: Characteristics of office-based visits for skin cancer. Dermatologists have
more experience than other physicians in managing malignant and premalignant skin conditions. Dermatol Surg 24:981,
1998; Swart RN et al: Treatment of eczema herpeticum with acyclovir. Arch Dermatol 119:13, 1983; Thai KE et
al: A prospective study of the use of cryosurgery for the treatment of actinic keratoses. Int J Dermatol 43:687, 2004;
Twersky JM et al: Tinea capitis mimicking dissecting cellulitis: a distinct variant. Int J Dermatol 44:412, 2005;
Whited JD et al: Primary care clinicians' performance for detecting actinic keratoses and skin cancer. Arch Intern
Med 157:985, 1997.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has
been disclosed: Dr. Goldman is a consultant, lecturer, and investigator for 3M Pharmaceuticals.
Dr. Goldman spoke in Rockport, Maine, at Dermatology Update for the Primary Care Physician, presented September
8-10, 2005, by the University of Vermont College of Medicine. Dr. Korb was recorded in Los Angeles at the 32nd
Annual Family Practice Refresher Course, presented May 31 to June 4, 2005, by the David Geffen School of Medicine
at the University of California, Los Angeles. The Audio-Digest Foundation thanks the speakers and the sponsors
for their cooperation in the production of this program.
|
