SKIN DISORDERS
| ATOPIC DERMATITIS —Leslie Storey, MD, Assistant Professor of Dermatology, Loma Linda University School of
Medicine, Loma Linda, CA
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| Introduction: child with atopic dermatitis (AD) typically pruritic; this leads to intense prolonged scratching (especially at
night), which leads to thickening of epidermis (lichenification), and hypopigmentation or hyperpigmentation
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| Essential features: pruritus; eczema; acute or chronic and relapsing; remarks—no cure; some children outgrow problem, but
others do not; management involves controlling disorder; patients tend to flare during illness or stressful events; typical
areas of involvement include elbows, backs of knees, and neck, but AD can involve patient from “head to toe”
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 | Other features supporting diagnosis: early childhood onset (onset occasionally occurs during adulthood); history of food and
seasonal allergies and asthma; IgE reactivity; xerosis
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| Pathophysiology: involves increased synthesis of IgE, proliferation of mast cells (cause itching), excessive T-cell activation,
and hyperactivation of Langerhans cells by T cells; itch-scratch cycle may be started by sensitivity to Staphylococcus aureus
; goals of therapy—stop mast cells and halt itching; remark—50% to 80% of AD patients develop asthma or rhinitis
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| Keys to management: hydration of skin (most important); avoidance of irritants, including anything perfumed; basic
measures—use nonirritant detergents (eg, Dreft, other “chemical-free” brands); use only nonirritant cleansers (eg,
Dove); avoid specific allergens
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| Common food allergies: include milk, tomatoes, and strawberries; cases usually referred to allergist
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| Antiinflammatory drugs: topical corticosteroids “a must” in treating atopic patients; other agents include immunomodulators,
eg, tacrolimus (Protopic), pimecrolimus (Elidel)
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| Moisturizers: include Aquaphor and petroleum jelly, eg, Vaseline (sticky, but best moisturizer; not as hypoallergenic as
Aquaphor); reserve Cetaphil cream for patients who refuse ointment or gel; avoid lotions
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| Management of flares: if involvement confined to elbows and knees, use midpotency corticosteroid; if entire body involved,
start with class 2 steroid, and possibly class 1 steroid if patient under close surveillance and can be trusted to
use it appropriately; points—always prescribe ointment (stronger than cream); steroids come in various strengths
(classes; higher class number, lower strength); hydrocortisone 1% available over-the-counter (OTC); hydrocortisone
2.5% weak agent; can start with triamcinolone (midpotency agent), then progress to class 2 agent (eg, fluocinonide
[Lidex]); clobetasol class 1 steroid; triamcinolone ointment class 4 steroid (triamcinolone cream class 5)
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| What to tell patient: apply corticosteroid first, wait 4 to 5 min, then apply Aquaphor; then apply 2 wraps (one moist), and
keep wraps on for at least 30 min, preferably overnight; if child strongly dislikes wraps, have child wear long-sleeved
cotton pajamas over steroid ointment and Aquaphor overnight; repeat regimen bid for minimum of 1 wk
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| Other measures: take hydroxyzine ≈30 min before nap and at bedtime (or before evening bath); bathe only in warm water
for 3 to 5 min and use only Dove, pat skin dry, then apply steroid ointment, Aquaphor, and wraps
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| When patients start to improve: switch from bid to qd regimen of steroid, or switch to qd immunomodulator (Protopic or
Elidel); Protopic—currently has slight edge over Elidel; available in ointment in 2 strengths, 0.3% and 0.1%; consider
using higher strength initially; other points—consider not applying steroid on “good days”; limit use of potent steroid to
2 wk for most parts of body, but only 3 to 5 days for face, groin, and axilla to avoid skin atrophy and tachyphylaxis; limit
steroid prescription (60 g usually adequate for treating whole body for 1 wk); other problems with use of potent steroids
include telangiectasias, Cushing’s syndrome, glaucoma, and cataracts; advise parents about possible side effects and importance
of following directions exactly
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| Immunomodulators: used orally for transplant patients; action similar to mild steroids when applied topically, but lack
many side effects seen with steroids; main problem reported development of cutaneous T-cell lymphomas in small number
of patients; Food and Drug Administration (FDA) subsequently said these agents should not be used as first-line
drugs for AD, not be used in children <2 yr of age, and not for prolonged periods (“black box” warning); however, no
lymphomas seen in children, and speaker doubts link exists between topical use of these agents and T-cell lymphoma
(some patients receiving these drugs orally for immunosuppression have developed B-cell lymphomas)
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| Antihistamines: sedating agents often used; can use ≤4 times daily; typically given before bedtime or before nap during
flares; can also use nonsedating agents (eg, loratadine [Claritin]) if child allergy prone
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| Case of 74-yr-old man with dry skin: presents with xerotic skin, particularly on extremities; occurs every January
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| Xerosis: typically develops in adults from poor management of skin; can lead to medial malleolus plaque (particularly in
people with venous insufficiency), pruritus, and lichen simplex chronicus; worse in winter; treatment—involves
moisturization; use only Dove or Cetaphil soap; apply AmLactin or Lac-Hydrin (prescription required), or Aquaphor
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| Case of adult with fine vesicles and pruritus: vesicles on hands, particularly on lateral aspects of fingers, palms, and feet;
condition comes and goes; dyshidrotic eczema
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| Dyshidrotic eczema: usually recurrent; if vesicles weeping, apply soak consisting of 1 part vinegar and 4 parts water tid
for 5 min; if patient cannot tolerate regimen advise him/her to use just pinch of vinegar; after soak, apply class 1 steroid
and Aquaphor, then wrap area (can use white cotton gloves on hands or socks on feet); if patient refractory to topical
therapy, try light treatment (eg, UVA, UVB) at least twice weekly; light also used in AD patients who do not respond
to topical treatment
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| Case of 8-mo-old infant with excoriated crusted papules: suspect secondary bacterial infection and treat with antibiotics
(eg, cephalexin [Keflex]); if infant fails to respond, obtain cultures and check for methicillin-resistant S aureus (MRSA);
also apply class 2 steroid and soak oozing lesions
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| WARTS AND MOLLUSCUM CONTAGIOSUM —Cynthia L. Vehe, MD, Head, Department of Dermatology, Health
Partners Medical Group, St. Paul, MN
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| Warts: caused by human papillomavirus (HPV; >125 subtypes); classified by location
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| Types of warts: verruca vulgaris—most common; due to HPV types 2 and 4; characterized by tiny black dots, due to
thrombosed blood vessels; filiform warts—usually on face or around fingernails; flat warts (rubica plana)—usually
due to HPV types 3, 10, and 28; typically occur on face and characterized by slightly brown papules or plaques; usually
occur in multiples; myrmecia warts—deep lesions on palms and soles of feet; usually due to HPV type 1; called mosaic
warts when grouped together; condyloma—genital warts; with certain subtypes, risk for malignant transformation;
butcher’s warts—cauliflower-type lesions on hands in people who handle raw meat; usually due to HPV type 7; Heck’s
disease—focal epidermal hyperplasia of buccal mucosa; due to HPV types 13 and 32; more common in American Indians
and Eskimos; cystic warts—usually occur on bottom of feet, starting with nodules; painful; yield cheesy material
when incised; verrucous carcinoma—warts that transform into cancer
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| Prevalence: warts occur in 10% to 20% of children; peak incidence 13 to 16 yr of age; only 15% of warts develop in people
>35 yr of age; factors contributing to enhanced development—skin trauma (eg, breaks in skin); presence of skin disorders,
eg, eczema, molluscum; immunocompromised state
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| Koebnerization: linear grouping of warts, usually in traumatized areas; linear grouping also seen in contact dermatitis and
lichen planus; lesions usually spread via autoinoculation or contact; HPV types 6, 11, 16, and 18 associated with malignant
transformation (occur in genital area or in immunocompromised patients)
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| Natural history of warts: with no treatment, 50% resolve in 1 yr, 67% in 2 yr, and 75% in 3 yr; point—biopsy indicated if
wart unusual in appearance or presentation
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| Molluscum contagiosum: due to poxvirus; spreads by skin-to-skin contact and autoinoculation; incubation period ranges
from 1 wk to several months; most common in children <5 yr of age; in adults, typically seen in genital area and transmitted
sexually; consists of papule with central umbilication and usually multiple lesions; some patients develop molluscum
dermatitis (eczema-like condition surrounding molluscum lesion); HIV patients can develop large lesions; when treating
adults, consider concomitant venereal disease and always biopsy if lesion appears atypical
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| Management of warts: reasons to treat—warts painful; can spread to others; factors to consider—age of patient; desires
of patient and parents; location and number of lesions; previous treatments; how much discomfort patient can tolerate;
remarks—no perfect treatment for warts; >23 options currently available and most effective ≈50% of time;
treatment modalities divided into destructive and immune-modulating; benign neglect viable option when warts not bothering
child
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| Salicylic acid: available in variety of formulations (eg, liquids, gels, discs); preparations include Compound W and Mediplast;
good for treating thick warts on hands and feet; if patient has extensive warts on bottom of feet, order custom compound
of 40% salicylic acid in petroleum jelly base and have patient apply at night and cover with socks; success rate
ranges from 48% to 87%; pearl—have patient soak wart to soften it up, then file it down, and, finally, apply salicylic
acid 2 to 3 times/day; points—if patient using disc, leave it on 48 hr; can also cover salicylic acid with duct tape
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| Cryosurgery: involves applying liquid nitrogen to wart; pearl—employ rapid freeze and slow thaw, and repeat cycle at
least once; allow for development of 1- to 2-mm halo; ≈60% effective; points—cryosurgery often combined with another
therapy (eg, salicylic acid) after freezing cycle completed; refreezing indicated every 2 to 3 wk; complications include
pigmentation abnormalities, scars, ring warts, nail dystrophies, necrosis of fingers (in patients with cold-sensitive
disorders, eg, Raynaud’s phenomenon), and nerve damage; comment—if blister develops “pop it and drain it”
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| Adhesiotherapy (duct tape): can leave tape on for several days, then soak area and rub it with pumice stone or emery board
(repeat cycle for up to 2 mo or until wart disappears); another approach is to first apply salicylic acid, dry area, then apply
tape
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| Use of cantharidin: extract from blister beetle (“bug juice”); apply directly to wart, including 1- to 2-mm margin of unaffected
skin to prevent ring wart formation; follow with tape occlusion; wash off in 4 to 6 hr, then reapply every 2 to 4 wk;
for stubborn cases, may combine with cryosurgery or mix with 30% salicylic acid and 5% podophyllin in flexible collodion
base; used only for warts on hands and feet; significant risks
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| Cimetidine: use based on observation that immunosuppressed patients taking cimetidine got rid of warts faster; probably
acts by inducing cellular immunity; pearl—need to give 25 to 40 mg/kg daily (maximum 2400 mg/day); usually combined
with another treatment to boost response
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| Imiquimod (Aldara): immune response modifier; stimulates interferon; not approved for nongenital warts; used 3 times
weekly for genital warts; apply 1 to 2 times daily; reported clearance 37% to 90%
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| 5-fluorouracil (Efudex): used by speaker for stubborn warts on hands or feet (off label); applied twice daily with some occlusion;
can cause significant irritation; works ≈50% of time; often combined with other therapies; do not use in women
at risk for pregnancy
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| Hyperthermia: immersion of warts in water at 45°C for 30 min 3 times/wk; anecdotal; compliance poor
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| Excision of warts: not recommended; can cause injury and scarring; generally reserved for filiform warts on face
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| Immunotherapy: involves injecting antigen (eg, Candida) into wart about every 3 wk; clearance rate after 3 injections
50% to 72%; also may cause distal warts to clear
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| Caustic acids: bi- or trichloroacetic acid mostly used for genital warts; painful; requires weekly treatment
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| Uncommon treatments: bleomycin—cancer chemotherapy drug; not FDA-approved for warts; injected directly into warts;
works well, but painful; significant necrotic response; expensive; laser therapy—can use CO2 cutting laser (painful; can
cause significant scarring) or pulsed dye laser; 48% to 93% effective; several treatments needed); squaric acid therapy—
initially applied in office; patient then applies acid at home to lesions for up to 3 mo; systemic retinoids—avoid isotretinoin;
acitretin (Soriatane) used with some success in patients with resistant warts; monitor patients for side effects; topical
retinoids—can use for treating flat warts and molluscum; dinitrochlorobenzene (DNCB) immunotherapy—mutagenic;
use with caution; interferon alfa—requires injection; generally reserved for genital warts; hypnotherapy—used for recalcitrant
warts; HPV vaccine—prevents warts caused by HPV types associated with malignant transformation in genital
area; photodynamic therapy—involves applying photosensitizing agent to area, then exposing it to light (usually blue
light)
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| Molluscum contagiosum: many treatments available; speaker applies cantharidin to lesions with cotton tip applicator (in
study, 90% cleared and 8% improved in 2 visits); cryotherapy preferred in older patients (treat every 2 to 3 wk until lesions
disappear); curettage sometimes indicated for stubborn or very large lesions (first apply lidocaine); electrocautery sometimes
used to desiccate base; imiquimod used, but studies not encouraging; cimetidine 40 mg/kg daily helpful, but watch
for interactions with other drugs (eg, theophylline, phenytoin [Dilantin]; tretinoin [Retin-A]; benzoyl peroxide 10%); other
modalities include covering lesion with tape and surgical tape stripping
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Educational Objectives
| The goal of this program is to educate the listener about common skin problems, including atopic dermatitis, warts, and
molluscum contagiosum. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Recognize the essential clinical features of atopic dermatitis.
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| 2. Pharmacologically treat patients with atopic dermatitis.
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| 3. Distinguish between the various types of warts and recognize those with malignant potential.
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| 4. Evaluate the various forms of therapy for treating warts.
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| 5. Diagnose and treat molluscum contagiosum.
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Discussed on This Program
AmLactin (ammonium lactate, parabens, light mineral oil)
Ammonium lactate [Kerasal AL, Lac-Hydrin]
Aquaphor Natural Healing (ointment containing petrolatum, mineral oil, lanolin, alcohol, panthenol, and glycerin)
Bleomycin sulfate (BLM) [Blenoxane]
Cantharidin (extract from blister beetle)
Cephalexin [Biocef, Keflex]
Cetaphil (soap-free therapeutic cleanser)
Cimetidine [Cimetidine Oral Solution, Tagamet, Tagamet HB 200]
Clobetasol propionate [several trade names]
Dinitrochlorobenzene (DNCB)
Fluocinonide [Lidex, others]
Fluorouracil (5-fluorouracil, 5-FU) [Adrucil, Carac, Efudex, Fluoroplex]
Hydrocortisone (cortisol) [several preparations and trade names]
Hydroxyzine [Atarax, Atarax 100, Vistaril]
Imiquimod [Aldara]
Interferon alfacon-1 [Infergen]
Isotretinoin (13-cis-retinoic acid) [Accutane]
Loratadine [Claritin, others]
Methicillin sodium
Phenytoin [Dilantin Infatab, Dilantin-125]
Pimecrolimus [Elidel]
Podophyllum resin (podophyllin) [Podocon-25, Podofin]
Salicylic acid [Compound W, Mediplast, others]
Tacrolimus (FK506) [Prograf, Protopic]
Triamcinolone (oral) [Aristocort, Atolone, Kenacort]
White petrolatum [Vaseline]
Suggested Reading
Barankin B, Guenther L. Rosacea and atopic dermatitis. Two common oculocutaneous disorders. Can Fam Physician
48:721, 2002; Brown J et al: Childhood molluscum contagiosum. Int J Dermatol 45:93, 2006; Carr J, Gyorfi T: Human
papillomavirus: epidemiology, transmission, and pathogenesis. Clin Lab Med 20:235, 2000; Castro AP: Calcineurin inhibitors
in the treatment of allergic dermatitis. J Pediatr 82(2 Suppl):S166, 2006; Devillers AC, Oranje AP: Efficacy and
safety of “wet wrap” dressings as an intervention treatment in children with severe and/or refractory atopic dermatitis: a
critical review of the literature. Br J Dermatol 154:579, 2006; Dohil MA et al: The epidemiology of molluscum contagiosum
in children. J Am Acad Dermatol 54:47, 2006; Gibbs S, Harvey I: Topical treatments for cutaneous warts. Cochrane
Data Base Syst Rev (3):CD001781, 2006; Gonzales E et al: Bupropion in atopic dermatitis. Pharmacopsychiatry 39:229,
2006; Johnke H et al: Patterns of sensation in infants and its relation to atopic dermatitis. Pediatr Allergy Immunol
17:591, 2006; Kang SH et al: Treatment of molluscum contagiosum with topical diphencyprone therapy. Acta Derm Venerol
85:529, 2005; Kiken DA, Silverberg NB: Atopic dermatitis in children. Part 1: epidemiology, clinical features, and
complications. Cutis 78:241, 2006; Krol A, Krafchik B: The differential diagnosis of atopic dermatitis in childhood. Dermatol
Ther 19:73, 2006; Langan SM et al: What is meant by a “flare” in atopic dermatitis? A systematic review and proposal.
Arch Dermatol 142:1190, 2006; Leslie KS: Topical salicylic acid gel as a treatment for molluscum contagiosum in
children. J Dermatolog Treat 16:336, 2006; Li J et al: Is colposcopy warranted in women with external anogenital warts?
J Low Genit Tract Dis 7:22, 2003; Moore RA et al: Imiquimod for the treatment of genital warts: a quantitative systematic
review. BMC Infect Dis 1:3, 2001; Moses S: Pruritus. Am Fam Physician 68:1135, 2003; Oranje AP, de Waard-van der
Spek FB: Atopic dermatitis: review 2000 to January 2001. Curr Opin Pediatr 14:410, 2002; Osborne S: Caring for each
other, ‘warts and all.’ Nurs N Z 12:5, 2006; Saez M et al: Atypical molluscum contagiosum. J Eur Acad Dermatol Venereol
20:465, 2006; Simon D et al: Benefits from the use of pimecrolimus-based treatment in the management of atopic
dermatitis in clinical practice. Analysis of a Swiss cohort. Dermatology 213:313, 2006; Snoeck R et al: Specific therapies
for human papilloma virus infections. Curr Opin Infect Dis 11:733, 1998; Stulberg DL, Hutchinson AG: Molluscum contagiosum
and warts. Am Fam Physician 67:1233, 2003; Van der Wouden JC et al: Interventions for cutaneous molluscum
contagiosum. Cochrane Database Syst Rev (2)CD004767; Yamamoto T: Bleomycin and the skin. Br J Dermatol
155:869, 2006.
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. For this issue, the faculty reported
nothing to disclose.
Dr. Storey was recorded in Loma Linda, CA, on June 25, 2006, at Family Medicine: Pearls, Perils, and Practice
Guidelines, sponsored by the Loma Linda University School of Medicine. Dr. Vehe spoke in St. Paul, MN on March
9, 2006, at the annual Family Medicine Today course, sponsored by the HealthPartners HMO of MN. The Audio-Digest
Foundation thanks the speakers and the sponsors for making this program possible.
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