DERMATOLOGY FOR INTERNISTS
Toby A. Maurer, MD, Associate Professor, University of California, San Francisco, School of Medicine, and Chief of
Dermatology, San Francisco General Hospital, San Francisco
| COMMON PROBLEMS IN DERMATOLOGY
|
| Onychomycosis: questionable whether treatment necessary; treat fingernails if patient in public position; toenails can be
painful and portal of entry for recurrent cellulitis, so reasonable to treat
|
| Topical therapy: limited efficacy; use for patches of tinea; ciclopirox (Penlac) has 8.5% cure rate; newer combinations of
imidazoles in urea ointment available in Great Britain have 69% cure rate; may work best as preventive therapy after patients
have used oral medications
|
| Systemic therapy: itraconazole (Sporanox)—pulse at 400 mg/day for 7 days each month for 3 mo; gets into nail matrix
and continues to work after discontinuation; effective until nail grows out (12-18 mo); drug interactions, transaminase elevations,
and congestive heart failure (CHF) reported; terbinafine (Lamisil)—250 mg/day continuously for 3 mo (cannot
be pulsed); side effects include transaminase elevations and CHF; griseofulvan (Grispeg)—250 mg twice daily for
12 to 18 mo; least hepatotoxic, however cure rate not high (50% for fingernails, 17% for toenails); high recurrence rate;
fluconazole (Diflucan)—dosing and duration of use not clear; hepatotoxic; must be used for 18 mo; studies—show
terbinafine more likely to result in cure than itraconazole and superior to itraconazole in remission rates (46% 5-yr remission
vs 13%)
|
| Papular acne: treat topically; for cysts, scars, and keloids, use systemic drugs immediately; topical therapy—2 categories
(1 in morning; 1 in evening); benzoyl peroxide 5% gel works both as anticomedomic and antibiotic; 10% gel more
drying but not more effective; retinoids (Retin A) vary in strength from 0.025% to 0.1%; vehicle determines strength;
cream least irritating, gel most irritating and strongest; clindamycin topical (Cleocin T) or erythromycin; choose one
from each category and use 1 in morning, 1 in evening; if unsuccessful after 8 wk, switch to oral medication; newer
combination drugs (eg, erythromycin 3%-benzoyl peroxide 5% topical gel [Benzamycin], clindamycin 1%-benzoyl peroxide
5% [Benzaclin]); twice daily use irritating, speaker suggests once daily; oral medications—used for patients
with nodules and/or significant scarring; tetracyclines first-line drugs; doxycycline (Vibramycin) most effective but
causes photosensitivity (very light-skinned patients “fry”), taken for 8 wk; do not stop abruptly (causes rebound); treat
until acne clears, then reduce dosage by 1 pill daily; alternatives include erythromycin (E.E.S.) 500 mg bid (watch for
gastrointestinal [GI] disturbances), trimethoprim-sulfamethoxazole (Septra; watch for neutropenia with Septra DS bid);
increased use of cephalosporins (eg, cephalexin [Keflex] 500 mg tid, cefadroxil [Duricef] 500 mg bid) successful, particularly
in patients with liver disease; norgestimate/ethinyl estradiol (Ortho Tri-Cyclen) not superior to other oral contraceptives
(OCs) in treating acne; spironolactone (alone or in combination with tetracycline) used in women with
worsening acne at time of menstruation; 50 mg qd throughout month; do not use in pregnancy; drospirenone and ethinyl
estradiol (Yasmin) contains spironolactone metabolite; questionable whether more effective than other OCs
|
| Documented failure of antibiotics: treat with isotretinoin (Accutane) for 5 mo; difficult to acquire because of teratogenic
effects; Food and Drug Administration (FDA) threatening to remove from market; prescribed only by physician; monthly
tests include complete blood count (CBC), liver function, triglycerides, and cholesterol; counsel men and women about
pregnancy and ensure adequate contraception; drug associated with depression
|
| Acne rosacea: characterized by erythema, pustules, and broken blood vessels; common in women >40 yr of age, in men,
and in persons of Irish descent; often accompanied by seborrheic dermatitis; men often have large nose (rhinophyma
caused by increase in sebaceous glands); exacerbated by sun exposure, alcohol, and spicy foods; treat with oral anti-acne
antibiotics; tetracycline group most effective (remission in 6 to 8 wk); metronidazole topical gel or cream added while
discontinuing antibiotics
|
| Perioral dermatitis: redness, rash, and nodules around mouth and eyes; in patients 30 to 40 yr of age; no history of acne;
treat with oral antibiotics for 6 to 8 wk
|
| Hidradenitis suppurativa: pus and draining sinuses in axilla; inflammatory reaction; considered acne-type condition with
boils, nodules in axilla, groin, and behind neck; minocycline (Dynacin) used as anti-inflammatory shortens course, prevents
recurrence; surgery to marsupialize sinus tracts; allow for granulation from bottom up; infliximab (Remicade) intravenous
[IV] infusion effective but costly
|
| Intertrigo: scrotal redness; bacterial rash with candidal component (tinea affects sides of legs, not scrotum); also appears
in patients with pannus or pendulous breasts; blow dry area first, then apply topical antifungal (eg, clotrimazole topical
[Lotrimin]); Tucks pads work as wet-to-dry dressing to prevent recurrence
|
| Buttock folliculitis: irritation caused by rubbing of pants, combined with perspiration; treat with roll-on deodorant qod;
treat pustules with topical clindamycin or erythromycin
|
| Keratosis pilaris: accentuation of hair follicles on sides of arms or upper thighs; associated with dry skin; treat with lubricants
(Eucerin, Aquaphor); LacHydrin lotion 12% bid diminishes thickness of hair follicle; impossible to eradicate; retinoids
and dermabrasion unsuccessful
|
| Seborrheic dermatitis: common condition; scaly, waxy skin in hair-bearing areas around nose and moustache; inflammatory;
exacerbated by heat and stress; associated with rosacea and yeast (causes inflammatory response); keep scale off
scalp; tar (selenium sulfide) shampoos effective; resistance develops after 2 to 3 mo; rotate treatments; hydrocortisone 1%
ointment (eliminates inflammatory response) and Nizoral bid (no cure)
|
| Eczema: dry, inflamed “weepy” skin; topical steroids still first-line treatment, eg, triamcinolone (Aristocort A); speaker
prefers ointment to cream; pimecrolimus (Elidel cream) and tacrolimus (Protopic ointment) most effective for facial and
eyelid eczema; possible increased risk for skin cancer and for eczema herpeticum
|
| Herpes simplex: consider when nonhealing ulcers not responsive to antibiotics; revealed by direct fluorescent antibody
test; treat with acyclovir (Zovirax); genital herpes simplex—seen in perianal, vulvovaginal, penile, and scrotal areas;
treat with acyclovir (new dosage regimen 800 mg tid for 3 days); herpes zoster (shingles)—dermatomal blisters; treat
with acyclovir within 48 hr of blister onset, 800 mg 5 times daily; in immunosuppressed patient, start acyclovir anytime
during course of zoster (stops dissemination and lessens pain); in disseminated zoster, consider IV acyclovir; involvement
of cranial nerve V1 distribution in immunosuppressed host can result in blindness (use IV acyclovir); for pain, use ibuprofen
(Motrin), amitriptyline (Elavil), capsaicin topical (Capsin; painful to use); nerve blocks; gabapentin (Neurontin)
100 mg tid; prednisone not helpful in postherpetic neuralgia
|
| Warts: vaccine not available for cutaneous warts; exposure in childhood with periodic reactivation; virus remains in top
layer of skin; 60 different treatments, all with same efficacy (50%); be consistent and repetitive (q3wk); use topical salicylate
(eg, Aspercreme) nightly; liquid nitrogen; use mask when performing electrocautery (warts contagious and aerosolize);
podophyllin on mucous membranes (eg, genitalia, mouth); podofilox gel (Condylox) for home treatment; Retin A
for flat warts; imiquimod for genital warts (treat qod); snip excisions and laser work well; trichloroacetic acid not effective
for genital warts; vinegar soaks no longer used to detect genital warts; use duct tape for 6 days, file off dead skin, replace
tape after 12 hr; imiquimod approved for genital warts; combine imiquimod and duct tape for cutaneous warts
|
| Psoriasis: must decrease mitotic rate of skin; can use tar, but steroids (triamcinolone 0.1%) first-line therapy; success with
combining calcipotriene (vitamin D; Dovonex) with more potent steroid (eg, fluocinolone [Lidex], clobetasol); UV light
effective; pustular psoriasis associated with psoriatic arthritis; new concepts of psoriasis—cell-mediated immune disease
involving various cytokines, particularly tumor necrosis factor alpha; biologic agents (eg, infliximab) cleared psoriasis
with 3 infusions; must be on concurrent methotrexate (Rheumatrex); etanercept (Enbrel) less effective for skin, but
effective for psoriatic arthritis
|
| Hair loss: determine whether patient has hair follicles; if patient has scarring alopecia and no hair follicles, refer to dermatologist;
work-up for patients with hair follicles—ask about recent illnesses or surgery; in telogen effluvium, hair goes
into resting state 3 mo after illness, surgery, pregnancy, or starting hormone replacement; hair falls out for 3 mo and stops;
reassure patient; many drugs and conditions associated with hair loss, eg, selective serotonin reuptake inhibitors (SSRIs);
severely restricted diet; hypo- and hyperthyroidism; severe anemia; syphilis; if menses irregular or absent, consider work-
up for polycystic ovary syndrome; if breast discharge present, check prolactin levels; for growth of sideburns in women or
hair on breasts or central abdomen, check dehydroepiandrosterone (DHEA) and free testosterone; must be abnormal 3
times before attribution as cause of hair loss; normal test results indicate androgenic alopecia; occurs in men and women
with family history on both sides; treat with minoxidil 5% (Rogaine) to maintain hair in men and women; finasteride
(Propecia) 1 mg qd orally for men only; must use consistently or hair loss resumes
|
| UPDATE ON INNOVATIVE THERAPIES, SKIN CANCER, AND PSORIASIS
|
| Topical immune modulators: pimecrolimus 1% and tacrolimus (0.1% and 0.03%) associated with 29 cases of cancer in
children and adults, including lymphomas, squamous cell carninomas, and sarcomas; causality not proven; FDA initiated
“black box” warning; do not use in children <2 yr of age, or in adults or children with weakened immune systems (eg,
transplant, HIV-infected, or cancer patients); use on limited areas and not continuously; in animal models, increasing exposure
increases cancer risk, especially squamous cell carcinoma; use for eyelid dermatitis, hard-to-reach psoriasis (eg,
upper thighs, scrotum, glans penis); pimecrolimus equivalent to triamcinolone 0.1%, tacrolimus equivalent to hydrocortisone
2.5%
|
| Skin cancer: study indicates that practitioners good at detecting melanomas and atypical nevi, but not good at detecting
basal cell or squamous cell carcinomas because these lesions have various morphologies; speaker created online learning
module and downloadable PDA program to help practitioners recognize suspicious lesions (www.edermpda.com; accuracy
90%)
|
| Actinic keratoses: feel like sandpaper; men complain of facial bleeding while shaving; nonresolving scale; treatments—
cryotherapy for 1 to 2 lesions; topical therapy for multiple lesions; 5-fluorouracil (5FU) causes most rapid response (4
wk); takes skin layers off (warn patients about appearance and pain); low-dose 5FU works well; use with hydrocortisone;
imiqumod, 5% for 12 to 15 wk, causes severe reactions; diclofenac (topical nonsteroidal anti-inflammatory drug [NSAID]))
takes ≈120 days, does not work as well as other agents, and has more side effects
|
| Topical treatment of skin cancer: patient selection important; invasive basal or squamous cell carcinoma on face must be
surgically excised or else recurrence rate high); confirm with biopsy before treating; can treat superficial basal cell carcinoma
and squamous cell carcinoma in situ with imiquimod 5 times per wk for 6 to 10 wk, depending on host reaction;
high efficacy rate (75%-85%), but not much data at present; since scarring reduced, can use on face, dorsal foot, and in
older people
|
| Immunosuppression and skin cancer: organ transplant recipients at higher risk of developing nonmelanoma and melanoma
skin cancers; sun exposure key risk factor; ongoing debate on relation of immunosuppressive drugs to skin cancer
risk; study found total dose of immunosuppressants in first 3 yr after heart transplantation predicted development of squamous
cell carcinoma; risk for basal cell carcinoma associated with age at transplantation and skin type, not total dose of
immunosuppressant; reduce skin cancer in transplant patients by decreasing total dose of immunosuppressant to minimum
required; absolute sun protection indicated
|
| Psoriasis: bilateral and symmetric scaly silver plaques, often on extensor surfaces (eg, elbows, knees); gluteal pinking
pathognomonic; nail pitting and thickening mimics fungal infection; triggered by—bacterial infections (streptococcal
infections in children), candidiasis (common cause of balanitis in men with psoriasis); medications can unmask condition,
particularly oral or systemic steroid withdrawal, lithium, β-blockers (even drops for glaucoma), terbinafine, gemfibrozil,
but not NSAIDs); HIV (6% of AIDS patients develop psoriasis); rated by—body surface area involved; mild <10%, moderate
10 to 30%, severe >30%; also involves palms and soles; pustular psoriasis severe
|
| Treatment of psoriasis: mild—sequential therapy; phase 1 (induction) uses topical steroid (eg, triamcinolone 0.1% ointment
plus calcipotriene); in phase 2, use calcipotriene twice daily, topical steroids twice daily only on weekends; for
maintenance, calcipotriene twice daily only; moisturize entire body; moderate to severe—phototherapy (UVA and
UVB) treatments 3 times weekly at psoriasis center; systemic therapy uses methotrexate, cyclosporine ≤ 1 yr, or biologic
agents; do not use systemic steroids because withdrawal causes severe pustular flare (deaths reported); biologic
agents—etanercept [Enbrel] for chronic plaque and pustular psoriasis recalcitrant to standard treatments; use 50 mg
twice weekly for first 3 mo, then reduce to 25 mg; studies show 50% improvement by 12 wk, 75% by 24 wk; infliximab
used for severe, pustular flares or refractory psoriasis (with methotrexate or alone); fast, acute treatment to turn off disease
and reverse flares; etanercept replaces infliximab for maintenance
|
Educational Objectives
| The purpose of the program is to provide the listener with information on the nature and management of dermatologic problems.
After hearing and assimilating this program, the clinician will be better able to:
|
 | 1. Discuss the treatment of onychomycosis.
|
| 2. Cite advances in the treatment of acne.
|
| 3. Identify eczema and discuss up-to-date treatments.
|
| 4. Diagnose skin cancers and discuss their treatment.
|
| 5. Review the treatments for psoriasis.
|
Discussed on This Program
Acyclovir (acycloguanosine) [Zovirax]
Amitriptyline HCl Elavil, Endep, Vanatrip]
Ammonium lactate [Lac-Hydrin]
Benzyl peroxide [several trade names]
Calcipotriene [Dovonex]
Capsaicin [Capsin, Capzasin-P, Dolorac, R-Gel, Zostrix, Zostrix-HP]
Cefadroxil [Duricef]
Cephalexin [Keflex, Keftabs, Biocef]
Ciclopirox [Loprox, Penlac Nail Lacquer]
Clindamycin [Cleocin T, Clindagel, ClindaMax, Clinda-Derm Clindets]
Clotrimazole topical [Cruex, Lotrimin AF, Desenex]
Cyclosporine (cyclosporine A) [Neoral, Sandimmune, Gengraf]
Diclofenac [Cataflam, Solaraze, Voltaren, Voltaren-XR]
Doxycycline [several trade names]
Drospirenone and ethinyl estradiol [Yasmin]
Econazole nitrate [Spectazole]
Epinephrine Ophthalmic [Epifrin, Glaucon]
Erythromycin [E-Base, E-Base Caplets and Tablets, E-Mycin, Eryc, Ery-Tab, Erythromycin Filmtabs, PCE Dispertab]
Erythromycin topical [A/T/S, Akne Mycin Ointment, Emgel, Eryderm 2%, Erygel, Ery Pads, Ilotycin, Staticin, T-Stat]
Erythromycin and benzoyl peroxide [Benzamycin, Benzamycin Pak]
Clindamycin and benzoyl peroxide [BenzaClin]
Etanercept [Enbrel]
Ethinyl estradiol and norgestimate [Mononessa, Ortho-Cyclen, Ortho Tri-Cyclen, Ortho Tri-Cyclen Lo, Sprintec]
Finasteride [Propecia, Proscar]
Fluconazole [Diflucan]
Fluocinonide [Fluocinonide “E” cream, Lidex, Lidex-E, Fluonex, Vanos]
Fluorouracil (5-fluorouracil, 5FU) [Adrucil, Carac, Efudex, Fluoroplex]
Gabapentin [Neurontin]
Griseofulvin ultramicrosize [Fulvicin P/G, Grisactin Ultra, Gris-PEG]
Hydrocortisone (cortisol) [several trade names]
Hydroquinone [several trade names]
Ibuprofen [several trade names]
Imiquimod [Aldara]
Infliximab [Remicade]
Isotretinoin (13-cis-retinoic acid) [Accutane]
Itraconazole [Sporanox]
Ketoconazole [Nizoral, Nizoral A-D, Nizoral Cream Shampoo]
Lithium [Eskalith, Eskalith CR, Lithobid, Lithonate, Lithotabs]
Methotrexate (amethopterin; MTX) [Methotrexate LPF, Rheumatrex Dose Pack, Trexall]
Metronidazole [several trade names]
Minocycline HCl (minomycin) [Arestin, Dynacin, Minocin, Minocin IV, Vectrin]
Minoxidil [Loniten, Minoxidil for Men, Rogaine, Rogaine Extra Strength for Men]
Pimecrolimus [Elidel]
Podofilox [Condylox]
Tretinoin (trans-retinoic acid; vitamin A acid) [Altinac, Atragen (investigational), Avita, Renova, Retin-A, Retin-A Micro,
Vesanoid]
Selenium sulfide [Exsel, Head & Shoulders Intensive Treatment Dandruff Shampoo, Selsun, Selsun Blue, Selsun Gold for
Women]
Spironolactone [Aldactone]
Tacrolimus (FK506) [Prograf, Protopic]
Terbinafine HCl [several trade names]
Triamcinolone acetonide [several trade names]
Trichloroacetic acid [Tri-Chlor]
Trimethoprim-sulfamethoxazole (co-trimoxazole; TMP-SMZ) [Septra, others]
Suggested Reading
Carroll CL et al: Better medication adherence results in greater improvement in severity of psoriasis Br J Dermatol
151:895, 2004; Chakrabarty A et al: Recent clinical experience with famciclovir--a "third generation" nucleoside
prodrug Antivir Chem Chemother 15:251, 2004; Curiel-Lewandrowski et al: Use of in vivo confocal microscopy in
malignant melanoma: an aid in diagnosis and assessment of surgical and nonsurgical therapeutic approaches Arch
Dermatol 140:1127, 2004; Dhawan SS et al: Tazarotene cream (0.1%) in combination with betamethasone valerate
foam (0.12%) for plaque-type psoriasis J Drugs Dermatol 4:228, 2005; Gilbert DJ: Treatment of actinic keratoses
with sequential combination of 5-fluorouracil and photodynamic therapy J Drugs Dermatol 4:161, 2005; Gisondi et
al: Pimecrolimus in dermatology: atopic dermatitis and beyond Int J Clin Pract 59:969, 2005; Gupta AK et al: Ciclopirox
topical solution, 8% combined with oral terbinafine to treat onychomycosis: a randomized, evaluator-blinded
study J Drugs Dermatol 4:481, 2005; Herbrecht R et al: Management of systemic fungal infections: alternatives to
itraconazole J Antimicrob Chemother 56S1:139, 2005; Jacob SE et al: Etanercept and psoriasis, from clinical studies
to real life Int J Dermatol 44:688, 2005; Krob AH et al: Terbinafine is more effective than itraconazole in treating
toenail onychomycosis: results from a meta-analysis of randomized controlled trials J Cutan Med Surg 7:306, 2003;
Ling M et al: A randomized study of the safety, absorption and efficacy of pimecrolimus cream 1% applied twice or
four times daily in patients with atopic dermatitis J Dermatolog Treat 16:142, 2005; Mackley CL, Thiboitot DM: Diagnosing
and managing the patient with rosacea Cutis 75S4:25, 2005; O’Mahony C: Genital warts: current and future
management options Am J Clin Dermatol 6:239, 2005; Peris K et al: Imiquimod treatment of superficial and nodular
basal cell carcinoma: 12-week open-label trial Dermatol Surg 31:318, 2005; Poulin Y: Practical approach to the hormonal
treatment of acne J Cutan Med Surg 8S4:16, 2004; Shalita AR: Acne: clinical presentations Clin Dermatol
22:385, 2004; Vender RB, Goldberg O: Innovative uses of imiquimod J Drugs Dermatol 4:58, 2005.
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. Maurer was recorded at Primary Care Medicine: Principles and Practices, held October 13-15, 2004, and at the 33rd Annual
Advances in Internal Medicine, held May 25-28, 2005, both in San Francisco and sponsored by the University of California,
San Francisco, School of Medicine. The Audio-Digest Foundation thanks the speaker and sponsor for their cooperation in the
production of this program.
|
