THE TROUBLED SKIN
| ROSACEA—Cynthia Vehe, MD, Head, Department of Dermatology, HealthPartners Medical Group, Minneapolis, MN
|
| Introduction: inflammatory disease; more common in fair-skinned individuals and women; granulomatous rosacea more
common in Asians and blacks; children with styes and blepharitis have 3 times greater risk for rosacea into adulthood
|
| Subcategories: erythematotelangiectatic—facial redness; high sensitivity to soaps and lotions; papulopustular—most
common; classic presentation (redness; papules; pustules; central face involvement); phymatous—skin thickening; affects
nose, but also can cause enlargement of eyelid, chin, and ears; more common in men; harder to treat; ocular—patients often
present without typical facial findings; crusting around eyelid margins; inflammation of meibomian glands; redness of conjunctiva;
can lead to ulceration of cornea, vascularization, and scarring; eyes feel gritty, dry or watery, irritated, and have foreign
body sensation
|
| Diagnosis: no specific test available; inquire about flushing and blushing during emotional or stressful times; background
redness over cheeks; papules; pustules; eye symptoms; hypersensitivity to environmental factors; differential diagnosis—
polycythemia vera; connective tissue disease; photosensitivity (especially to medications, eg, hydrochlorothiazide, furosemide);
carcinoid; long-term use of high-potency topical steroids; acne; contact dermatitis
|
| Flare factors: sun; wind; heat; cold; spicy food; alcohol; amiodarone; topical and nasal steroids; high doses of vitamins
B6 and B12
|
| Rosacea vs acne: rosacea—no blackheads or whiteheads; telangiectasia; older patients; affects central face; acne—
adults typically affected in lower half of face
|
| Skin care: nonsoap cleanser (eg, Cetaphil, Dove, Vanicream); wash gently with fingertips; avoid toners, astringents, and
peels; moisturizers—occlusive moisturizers best (eg, petrolatum [eg, Vaseline], mineral oil); silicone- or dimethicone-
containing moisturizers; moisturizers with humectants (eg, lactic acid, urea); sunscreen—products formulated with
physical blockers (eg, zinc oxide, titanium dioxide) less irritating than products formulated with chemical blockers (contain
avobenzone [eg, Parsol]); cosmetics—water-soluble cosmetics with <10 ingredients; green-tinted cover-up for redness;
ocularization—clean eyelids daily with lid scrub or baby shampoo; preservative-free lubricants; glasses to protect
eyes; water-based black mascara
|
| Pharmaceutical management: 1% metronidazole (eg, MetroGel) available for once-daily use; sodium sulfacetamide
and sulfur—eg, Klaron, Novacet, Sulfacet-R Lotion; azelaic acid—Azelex, Finacea; warn patients about higher
risk for burning and stinging; best for papulopustular component of rosacea; clindamycin and erythromycin used for papulopustular
rosacea; retinoids—not approved for rosacea, but many good studies for use on papulopustular component
or background erythema; start slow (eg, once weekly) and increase slowly; consider pretreatment with silicone-containing
moisturizer; benzoyl peroxide for oily papulopustular rosacea (caution, can be irritating); calcineurin inhibitors—
pimecrolimus (Elidel) and tacrolimus (eg, Protopic) approved for treatment of eczema, but may be helpful in rosacea;
may cause irritation in patients with inflammation; helpful adjunct; some reports of rosacea-form dermatitis; expensive;
oral antibiotics—tetracycline; doxycycline; minocycline; amoxicillin in patients with allergy; high risk for side effects
with long-term use of sulfonamides; sub-antimicrobial doxycycline (eg, Oracea)—reduces risk for resistance and side
effects; Oracea approved by Food and Drug Administration (FDA) for use in rosacea; sustained-release formula given
once daily; start with 25 mg qd or bid; in patients with more severe inflammation, start with higher dose and taper; isotretinoin
or tretinoin (eg, Retin-A) used for granulomatous rosacea or pyoderma faciale; β-blockers; clonidine; Demodex
eradication with topical medications; oral contraceptives or spironolactone for women with rosacea flares during menses
|
| Other treatment: surgery for phymatous changes; pulse dye laser—best for telangiectasias and background erythema;
not covered by most insurance; can cause inflammation and hyperpigmentation (transient)
|
| Patient education: rosacea chronic disease with cycles of remission and flares; no cure; may be outgrown; lifestyle
management (avoidance of flare factors); medication compliance; National Rosacea Foundation (www.rosacea.org)
|
| Emerging therapies: photodynamic therapy—approved for actinic keratoses; not covered by insurance; study saw clearance
in 75% to 100% of patients with 1 to 4 treatments; green tea extract cream—study saw improvement in 70%; topical
cyclosporine (eg, Restasis)—≈35% had mild to moderate improvement in ocular rosacea, ≈45% had significant improvement
|
Acne
| Classification: type I—comedones (blackheads and whiteheads); little inflammation; no scarring; type II—pustules;
erythema; no significant risk for scarring; type III—deep, tender, more inflamed nodules; risk for scarring; type IV—acne
conglobata; large, painful, cystic, deep lesions; significant risk for scarring
|
| Other conditions (masqueraders): perioral dermatitis—acne-like eruptions around chin and nose; more common
in women; treated similarly to acne, but resolves more easily; responds to full-dose tetracycline or doxycycline (after
clearance, use once daily for 1 mo and taper slowly to avoid flare); piniform folliculitis—often overlooked; erythematous
papules from top of back to lower back; monomorphous; itchy; patients often have little acne; does not respond to
topical or oral antibiotics; use antifungal agent (eg, itraconazole, terbinafine); recurrence common; pseudofolliculitis
barbae—irritation from razors; inflammation of hairs under skin, typically in beard area; eosinophilic folliculitis—
usually in patients with HIV; itchy; treat with steroids
|
| Exacerbating factors: lithium; look for polycystic ovary disease in women with facial hair and irregular menstrual cycles
|
| Treatment: topical antibiotics—erythromycin; clindamycin; sulfa-containing agents; benzoyl peroxide—eg, PanOxyl;
available in 5% and 10% strengths over-the-counter; inexpensive and effective; azelaic acid effective; retinoids—reduce
keratinization in hair follicles; not to be used as spot treatment (preventive treatment); make sure patients apply pea-sized
amount on entire face; causes dryness and irritation (education important); adapalene, tretinoin, tazarotene (eg, Tazorac) currently
available; after washing face, patients must wait 30 min before applying tretinoin (unless using Retin-A Micro); oral
antibiotics—antibiotic and anti-inflammatory effect; tetracycline; minocycline; doxycycline; erythromycin not recommended
due to increased resistance to Propionibacterium; trimethoprim-sulfamethoxazole (eg, Septra) used less often due
to side effects; patient compliance may be higher with cephalexin; hormone modulation—targets sebum production; ethinyl
estradiol and norgestimate (Ortho Tri-Cyclen) and norethindrone and ethinyl estradiol (Estrostep) approved by FDA for use in
acne; drospirenone and ethinyl estradiol (Yasmin) contains spironolactone analogue; spironolactone—effective in women
with acne around neck and jaw that worsens around menses (start with 50 mg and adjust according to response); side effects
(eg, irregular menses) usually occur with >100 mg daily; can be associated with birth defects (ensure adequate pregnancy prevention);
check potassium levels 1 to 2 mo after starting; isotretinoin (Accutane)—associated with birth defects; no
studies document direct association with depression; elevated liver enzymes and hypertriglyceridemia can occur; 1 mg/
kg per day for 16 to 20 wk; effective in patients with severe acne, in whom other treatments failed; iPLEDGE
program—federal registry of prescribers, pharmacies, and patients; 2 consent forms required; women must have 2 negative
pregnancy tests documented; men required to use 2 forms of pregnancy prevention; every month women must be counseled
and answer questions online about pregnancy prevention; combination medications—benzoyl peroxide and erythromycin
(Benzamycin); benzoyl peroxide and clindamycin (BenzaClin); clindamycin available in pump; clindamycin and benzoyl
peroxide with dimethicone and glycerin (Duac) marketed for reducing irritation; clindamycin and tretinoin (Ziana); new slow-
release and extended-release minocycline (Solodyn) to reduce vestibular side effects; nongreasy clindamycin foam (eg, Evoclin)
for large areas of body (eg, back); benzoyl peroxide and humectants (Benziq); smaller molecules of benzoyl peroxide
(CLENZIderm) for easier absorption; Retin-A Micro available in pump (premeasured but more expensive); benzoyl peroxide
and generic tretinoin not compatible when applied at same time (compatible with Retin-A Micro); higher concentration of
adapalene gel (Differin) awaiting FDA approval; to reduce drug resistance, avoid using antibiotics as monotherapy (incorporate
benzoyl peroxide); Zeno device—triggers heat shock response in microorganisms; ≈$200 for unit; may not be more effective
than benzoyl peroxide; spot treatment; narrow-band UV blue light—twice-weekly treatment for 4 wk; 60%
reduction of acne; causes extreme sensitivity to sun during first 24 to 48 hr; not covered by insurance; not approved by FDA
for acne; faster results; fewer side effects; duration of response unknown; $1000 for 8 to 10 treatments
|
| Approach to treatment: cystic acne not treated topically; determine what patient wants vs what family wants (choose
plan that promotes compliance); hormone modulation in women with jaw or neck acne; oral medications for patients with
back involvement; avoid retinoids in highly sensitive patients; Accutane more likely used in men; aggressive therapy for
patients with positive family history or scarring
|
| CONTACT, STASIS, AND ATOPIC DERMATITIS—Jennifer T. Clarke, MD, Assistant Professor of Dermatology,
Pennsylvania State University Milton S. Hershey Medical Center, Hershey, PA
|
| Dermatitis: skin inflammation; eczema; characteristics include vesicles, papules, plaques, pruritus, and spongiosis
|
| Contact dermatitis: inflammatory reaction in skin precipitated by exogenous agent; irritant—more prevalent; produced
by substances directly toxic to skin (eg, acids, detergents); allergic—≈20% of cases of contact dermatitis; substance
triggers immunologic reaction in susceptible individuals; morphology of irritant and allergic contact dermatitis
identical (use patient history to differentiate); phytophotodermatitis—exposure to phototoxic irritant (found in, eg,
limes) and UV light can lead to inflammation and streaky hyperpigmented macules; in contact dermatitis, lesions linear
or geometric; patient history—ask about personal or positive family history of skin disease (eg, psoriasis) or atopy; ask
about occupation, exposure, hobbies, whether problem improves when patient away from work, and products used routinely
(eg, moisturizers); perform physical examination; if allergy suspected, consider referral for patch testing; use testing
helpful if specific chemical allergy suspected; treatment—avoidance of allergen or irritant; topical steroids;
immunomodulators (eg, topical tacrolimus or pimecrolimus); oral prednisone for severe cases; nickel, fragrances, preservatives,
and medications (particularly neomycin) most common allergens
|
| Stasis dermatitis: eczematous eruption on lower legs due to peripheral venous disease; associated with varicosities,
edema, and pulses; dull brawny erythema; petechiae; scaling; affects both legs; lipodermatosclerosis—fibrosis; lower
extremity resembles inverted champagne bottle; ulcerations; associated with underlying peripheral venous disease; pigmented
purpura—less itchy; not often associated with edema; allergic contact dermatitis can complicate stasis dermatitis;
common cause of autosensitization (id) reactions (ie, patient initially has stasis dermatitis but gradually develops
generalized dermatitis; treating stasis dermatitis clears rest of skin)
|
| Atopic dermatitis: in young children, appears on face or groin; flexural distribution in older children and adults; lapsing
and remitting course; associated with history of atopy and positive family or personal history of hay fever, seasonal allergies,
or asthma; papular or follicular eczema—more common in darker-skinned individuals; dry tiny papules on trunk
and extremities; pityriasis alba—more common in darker-skinned individuals; dry white hypopigmented patches on
face; atopic dermatitis characterized by flares and slow resolution; outgrown by most children; therapy—moisturizers;
topical steroids; antihistamines; macrolide immunosuppressants (eg, pimecrolimus, tacrolimus); UV light for adults; antibiotics
if secondary impetiginization occurs; more systemic immunosuppressants may be indicated; short baths with mild
bar soap and no bubbles, daily or every other day; moisturization important; ointments better moisturizers than creams
(creams better than lotions); petroleum jelly (eg, Vaseline) recommended for pediatric patients; treat flare with medium- or
high-potency topical steroid; use weaker topical steroid during maintenance phase and when treating flexural skin, eyelids,
axilla, or groin; to avoid burning, prescribe ointments for children
|
| COMMON SKIN INFECTIONS—Robert J. Pariser, MD, Professor, Department of Dermatology, Eastern Virginia Medical
School, Norfolk
|
| Staphylococcal pyodermas: some associated with Streptococcus; impetigo—honey-colored crusting; acute; develops
and spreads rapidly; contagious; common in children; usually not severe enough to produce systemic symptoms;
bullous impetigo—less common; superficial peeling with small or large blisters; furunculosis—usually from community-acquired
methicillin-resistant Staphylococcus aureus (MRSA); painful hot tender boils may surface and drain; differential
diagnosis includes ruptured epidermoid cyst; carbunculosis—pathogenesis similar to furunculosis; follicular
staphylococcal abscess; bacterial ecthyma—may resemble psoriasis or neoplasm; indolent crusty hyperkeratotic
plaques; removal of surface crust exposes purulent ulcer that heals with scarring; Streptococcus often involved; acute
paronychia—typically staphylococcal; tenderness; short history; erythema; grossly purulent; folliculitis—many forms;
some not infectious; botryomycosis—resembles deep fungal infection; deep tissue infection from, eg, Staphylococcus
|
| Staphylococcal scalded skin syndrome: superficial lysis of epidermis (peeling and blistering); toxins renally excreted
(higher risk in patients with renal disease); infection usually not cutaneous (eg, conjunctivitis, pharyngitis); fever;
malaise; skin tenderness; little inflammation
|
| Staphylococcal toxic shock: initially highly associated with tampon use, now associated with wound and postpartum
infections, local cutaneous disease, nasal packing, and insulin pumps; features—fever; hypotension; myalgia; headache;
pharyngitis; vomiting; diarrhea; nondiagnostic diffuse toxic erythema; desquamation of palms and soles; mucosal involvement;
epithelial shock; telogen effluvium
|
| Cellulitis: in children, mostly staphylococcal (Streptococcus more common in adults) or Haemophilus influenzae;
features—fever; chills; spreading red edematous eruptions on skin; differential diagnosis includes contact dermatitis
|
| Necrotizing fasciitis: associated with S aureus; often polymicrobial; medical emergency (progresses rapidly); necrosis
and infection of deep tissue; erythema; purpura; patients severely ill; Fournier’s gangrene involves genitalia
|
| Treatment for mild-to-moderate infection: incision and drainage alone may be adequate for abscess or drainable
infection in patients otherwise not at risk; when to consider antibiotics—lesions extensive or rapidly progressing; fever;
toxicity; extremes of age; abscess located in area physically difficult to drain; comorbidities (eg, HIV, diabetes); failure
to respond to conservative treatment
|
| Commonly used antibiotics when MRSA suspected: trimethoprim-sulfamethoxazole—inexpensive; effective;
may result in dermatologic or hematologic side effects; not particularly useful for streptococcal involvement (eg, ecthyma
or cellulitis); clindamycin—effective for Staphylococcus and Streptococcus; risk for pseudomembranous colitis rare
yet present; tetracyclines—fairly effective; inexpensive; not recommended for children due to teeth staining; not particularly
useful for streptococcal involvement; fluoroquinolones—older and less expensive drugs (eg, ciprofloxacin, levofloxacin)
induce resistance quickly; moxifloxacin and gatifloxacin effective; vancomycin for severe infections (consult
with infectious disease colleagues)
|
Suggested Reading
Breuer K et al: Safety and efficacy of topical calcineurin inhibitors in the treatment of childhood atopic dermatitis. Am J
Clin Dermatol 6:65, 2005; Dissemond J et al: Successful treatment of stasis dermatitis with topical tacrolimus. Vasa
33:260, 2004; Eiseman AS: The ocular manifestations of atopic dermatitis and rosacea. Curr Allergy Asthma Rep 6:292,
2006; Gold MH: Acne and PDT: new techniques with lasers and light sources. Lasers Med Sci 22:67, 2007; Izikson L et
al: The flushing patient: differential diagnosis, workup, and treatment. J Am Acad Dermatol 55:193, 2006; Jansen T et al:
Rosacea: classification and treatment. J R Soc Med 90:144, 1997; Krob HA et al: Prevalence and relevance of contact dermatitis
allergens: a meta-analysis of 15 years of published T.R.U.E. test data. J Am Acad Dermatol 51:349, 2004; Langner
A et al: A randomized, single-blind comparison of topical clindamycin + benzoyl peroxide (Duac) and erythromycin + zinc
acetate (Zineryt) in the treatment of mild to moderate facial acne vulgaris. J Eur Acad Dermatol Venereol 21:311, 2007; Nagaraju
U et al: Methicillin-resistant Staphylococcus aureus in community-acquired pyoderma. Int J Dermatol 43:412,
2004; Paydar KZ et al: Inappropriate antibiotic use in soft tissue infections. Arch Surg 141:850, 2006; Sardana K et
al: Bacterial pyoderma in children and therapeutic options including management of community-acquired methicillin resistant
Staphylococcus aureus. Int J Dermatol 46:309, 2007; Wolf JE Jr et al: Efficacy and safety of once-daily metronidazole
1% gel compared with twice-daily azelaic acid 15% gel in the treatment of rosacea. Cutis 77:3, 2006.
www.audiodigest.org
To locate lectures of related interest, or to see a complete listing of Audio-Digest CME Programs, including written summaries.
Educational Objectives
| The goal of this program is to improve the recognition and management of common dermatologic disorders. After hearing
and assimilating this program, the participant will be better able to:
|
 | . Differentiate among types of rosacea, based on patient history and clinical findings.
|
| . Counsel patients with rosacea about skin care and medical therapy
|
| . Select safe and effective treatment for acne and related conditions.
|
| . Describe clinical manifestations of contact, stasis, and atopic dermatitis.
|
| . Choose appropriate antibiotic therapy for common staphylococcal skin infections.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Vehe spoke in Bloomington, MN, on March 9, 2007, at 21st Annual Family Medicine Today, presented by HealthPartners
Medical Group and Clinics. Drs. Clarke and Pariser were recorded in Lancaster, PA, at the 31st Semi-Annual Family
Practice Review, held on March 25-30, 2007, and sponsored by Temple University School of Medicine and Lancaster General
Hospital. The Audio-Digest Foundation thanks the speakers and the sponsors for their support in the production of this
program.
|
