Dermatology for the General Practitioner - PowerPoint Presentation

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Dermatology for the General Practitioner

Kimberly Dewing, PA-C

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None

Disclosures

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AcnePathogenesis

Types of acne

Treatments

Acne in pregnancy

RashesSkin Cancer

Overview

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95% of individuals ages 12-18

20 to 29 years: 43% (men-M), 51%(women-W)

30-39 years: 20% (M), and 35% (W)

40-49 years: 12% (M), and 26% (W)

50 and older: 7% (M), and 15% (W)

Collier CN, Harper JC,

Cafardi JA, Cantrell WC, Wang W, Foster KW, Elewski BE. The prevalence of acne in adults 20 years and older. Journal of American Academy of Dermatology. 2008;58(1):56.

Acne Prevalence

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Acne scarring – difficult & expensive to treat

Psychological and social effects

Self-esteem

Avoidance of social interactions

Affects interpersonal relationshipsLater in life, affected professionally

Acne - Repercussions

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1) Follicular Epithelial Hyperkeratinization

2) Excessive androgen-driven sebum production

3) Inflammation

4) C Acnes

Pathogenesis of Acne

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Comedonal

Papules

Pustules

Nodules

Cysts

Types of Acne

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Comedonal

Acne

Closed

comedones

Open

comedones

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Papular

& Pustular Acne

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Nodular & Cystic Acne

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Guidelines of Care for Management of Acne Vulgaris

Zaenglein

et al. JAAD 2016;74: 945-73

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1. Topical2. Oral Antibiotics

3. Hormonal

4. Isotretinoin

Categories of Acne Treatments

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Decreases Sebum Production

Normalizes Keratinization or is

Keratolytic

Decreases C Acnes

Decreases

Inflammation

Topical Antibiotic

*

*

Retinoids

*

*

BPO

*

*

*

Oral Antibiotics

*

*

Oral Contraceptive Pills

*

Spironolactone

*

Isotretinoin

*

*

*

*

Target of Treatments

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1. Benzoyl Peroxide 2. Antibiotics: clindamycin, erythromycin, sulfur

sulfacetamide

, minocycline foam

3.

Retinoids: tretinoids

, adapalene,

tazarotene, trifarotene4. Dapsone5. Combination Creams

Topical Treatments for Acne

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Main ingredient in several OTC acne products

Primary effect: antimicrobial, but also

comedolytic

**Recommended IN COMBINATION with topical or oral antibiotic to prevent antibiotic resistance of C Acnes.**

Ranges in concentrations 2.5%-10%

May cause stinging, dryness, redness, peeling of skin

*May bleach linens, clothing, bedding, fabric!Topical: Benzoyl Peroxide (BPO)

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Clindamycin, erythromycin,

sulfacetamide

Two effects: Decrease C Acnes & has anti-inflammatory effects

Applied 1-2 times a day

Recommend pairing with BPO to enhance efficacy & reduce risk of C acnes resistance

**NOT recommended for monotherapy**

More than 50% of C Acne strains are resistant to topical macrolides. Antibiotic Resistance in the topical treatment of acne vulgaris. (Cutis. 2004 Jun;73(6 Suppl):6-10. )

Topical: Antibiotics

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Tretinoin, adapalene,

tazarotene

, and

trifarotene

Chemical compound derived from Vitamin AEffects: Normalize follicular epithelium desquamation, promote clearance of the

comedones

, and anti-inflammatoryMost important: EDUCATION! Expect local cutaneous side effects initiallyMaximal effect takes weeks to months of continuous therapyApply in evening – avoid photo degradation (tretinoins)

Do not apply tretinoin and BPO at the same time (BPO-AM, tretinoin –PM).

Topical:

Retinoids

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Adapalene 0.1% cream

Retin

A Micro 0.04% gel

Adapalene 0.1% gel (OTC)

Retin A Micro 0.1% gelTretinoin 0.025, 0.05, 0.1% cream

*Combo adapalene 0.1% – BPO 2.5% gel

Adapalene 0.3% gelCombo adapalene 0.3% - BPO 2.5% gelTretinoin 0.01, 0.025, 0.05, 0.1% gelTazorac 0.05, 0.1% creamTazorac 0.05, 0.1% gel

Retinoid treatment

Least Drying

Most Drying

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Great anti-inflammatory response as monotherapy.

When combined with topical retinoid, augmented response against

comedonal

lesions

Increased efficacy in females over males

Topical:

Dapsone

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Key to success – target multiple aspects1) Adapalene 0.1% or 0.3% - BPO 2.5% gel:

Epiduo

,

Epiduo

Forte2) Clindamycin/BPO : Duac

,

Onexton, Acanya3) Clindamycin 1.2% - tretinoin 0.025% gel: Ziana**BENEFIT – better compliance with ONE cream versus multiple.**

Topical: Combination therapy

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Plays important role in efficacy, tolerability and compliance!

Vehicles: lotion, cream, gel

Recommend use of moisturizer: Cetaphil or

CeraVe

Before or after topical medication application

Vehicles of

Topicals

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Tetracyclines

: Minocycline &

Doxycyline

*MAINSTAY of antibiotic treatmentOccasional use: sulfamethoxazole/trimethoprim, erythromycin, Amoxicillin, Azithromycin, Cephalexin

Key role in management of inflammatory acne

Mostly – moderate to severe but also when insufficient response to topical therapy alone or when acne is widespread.*NEVER USE AS MONOTHERAPY! Use in combo with topical therapyAntibiotic Treatment for Acne

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Doxycyline

Minocycline

Photosensitivity

Dizziness

GI disturbance

Cutaneous

and mucosal hyperpigmentation

Pseudotumor

cerebri

(rare)

Pseudotumor

cerebri

Primarily metabolized by liver (can be used in renal failure)

Drug-induced

Lupus

Doxycycline vs Minocycline

Dosed 50-200mg in once or twice a day administration

Favored choice of antibiotic for acne over age 8

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Use for moderate to severe inflammatory acne in combination with topical therapy

Use for shortest possible duration, re-evaluate at 3-4 months

As long as effective topical regimen is in place, prompt discontinuation of antibiotic therapy rather than tapering approach is acceptable

Antibiotic Therapy

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Features of hormonal driven acne in females: inflammatory nodules on lower face, jawline, anterolateral neck, menstrual flares, rapid relapse after isotretinoin

Hormonal therapies work by modulating the amount, availability, and action of androgens in the skin

OCO & Spironolactone

Hormonal Treatment of Acne

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Works by binding androgen receptors in the skin, which blocks testosterone and DHT

Dosed 50-200mg daily (higher dose – higher side effects)

May take 3 months to start working

No stopping point (except desires conception)

Side effects: breast tenderness, menstrual irregularities, diuresis, hypotension. Hypothetical risk of teratogenicity.

Hormonal therapy: Spironolactone

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4 COC are FDA approved

1.

ethinyl

estrodiol/norgestimate

2.

ethinyl estrodiol/norethindrone acetate/ferrous fumarate3. ethinyl

estrodiol

/

drospirenone

4.

ethinyl

estrodiol

/

drospirnone

/

levomefolateMOA: decrease androgen production from ovary and also increase sex hormone-binding globulin that binds circulating free testosterone *Concurrent use of common acne antibiotics such as doxycycline & minocycline does not decrease the contraceptive efficacy of COCs Antibiotics have faster onset, but at COCs better long term modality – overlap use.Hormonal Therapy: COCs

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Systemic retinoid FDA approved in 1982 for severe recalcitrant acne vulgaris. Also appropriate for moderate acne that is treatment resistant or producing physical scarring.

IPLEDGE is a risk management program mandated by the FDA. All patients receiving isotretinoin must be enrolled.

Oral Isotretinoin

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Dosed based on weight, and end goal of treatment is an accumulative dose of 120-150mg/kg. Typically 5-6 months.

Occasionally insurance will require prior retinoid, topical antibiotic and oral antibiotic use.

Oral Isotretinoin

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Mostly result of reducing sebum production and size of sebaceous glands

Dry lips, dry skin, dry eyes, nose bleeds

Musculoskeletal pain

Hair loss

PhotosensitivityPseudotumor

Cerebri

Isotretinoin: Side Effects

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Pregnancy category X drug under the previous FDA system

To prescribe and receive isotretinoin, the FDA requires prescribers and patients to register with the

iPLEDGE

program.

iPLEDGE

ensures the fulfillment of appropriate requirements before prescribing Isotretinoin

Abstinence or 2 methods of birth control Negative HCG testing monthlyOnly females that do NOT need birth control methods and monthly HCG monitoring are after hysterectomy or menopause (check FSH, Estradiol, Progesterone)

Isotretinoin Black Box Warnings: Teratogenicity

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FDA warning on packaging:

All patients treated with isotretinoin should be observed closely for symptoms of depression or suicidal thoughts, such as sad mood, irritability, acting on dangerous impulses, anger, loss of pleasure or interest in social or sports activities, sleeping too much or too little, changes in weight or appetite, school or work performance going down, or trouble concentrating; or for mood disturbance, psychosis, or aggression

Meta-Analysis from 2017 posted in the Journal of the American Academy of Dermatology concluded “Isotretinoin treatment for acne does not appear to be associated with increased risk of depression. Moreover, the treatment of acne appears to ameliorate depressive symptoms.”

Isotretinoin treatment of acne and risk of depression:

A systematic

review and meta-analysis.

JAAD. 2017; 76: 1068-1076.

Monitor patients monthly. Also consider following with

pscyh

or counselor regularly.

Isotretinoin & Depression

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In the past, IBD has been controversially linked to isotretinoin use.

2016, a meta-analysis looked at 9 million cases and showed isotretinoin use is not associated with an increased risk of Crohn’s Disease or Ulcerative Colitis.

Does exposure to isotretinoin increase the risk for the development of inflammatory bowel disease? A meta-analysis.

Eur

J

Gastroenterol

Hepatol. 2016: 28; 210-6.

Isotretinoin and Inflammatory Bowel Disease

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Medications to use for acne in pregnancy:

Topicals

: Benzoyl Peroxide, clindamycin,

Azelaic

acidOral medication: Erythromycin & AmoxicillinStop topical

retinoids

, oral antibiotics, spironolactone all 1 month before stopping contraception to try to achieve pregnancyAcne in Pregnancy

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Question due to the hormones found in milk

Insulin-like Growth Factor 1(IGF-1) & androgens found in milk are thought to stimulate oil production and acne

Skim milk has higher concentrations of IGF-1and also whey

Nutrition and Acne: Milk and Diary Products

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Glycemic index- measure of how slowly or quickly a food spikes blood sugar levels

Foods with higher glycemic levels leads to hyperinsulinemia stimulate secretion of androgens & release of IGF-1and leads to

hyperkeratinization

and excess sebum production.

Foods with high glycemic index: soda, white bread, candy, sugar cereal, ice cream,

etc

Nutrition and Acne: Glycemic Index

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How quickly treatment with work - takes time and consistency of use of treatment

Side effects of treatment – EXPECT dryness, redness, flaking for a few days to weeks. Tips to help this.

Take monthly Progress pictures for positive reinforcement.

You have to USE it for it to work.

Make THEM tell you what they are using.

Managing Expectations

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MOISTURIZE, MOISTURIZE, MOISTURIZE

CeraVe

moisturizing cream, Cetaphil cream, or

Vanicream

Topical Steroid Creams – Triamcinolone or mometasone

(kids),

fluocinonide (adults)Non-steroid cream – EucrisaBiologic – Dupixent

(

dupilumab

). Treats moderate to severe eczema 6 years and older.

Common Rashes: Atopic Dermatitis

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Viral, contagious rash often in pediatrics caused by Poxvirus

Self-limited, no treatment needed

Can treat with

cantharidin

, liquid nitrogen, topical retinoid

Common Rashes:

Molluscum

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Abnormal keratinization of the hair follicle – plugged with keratin.

Hereditary, 50% of population

Arms, thighs, buttocks, face

Treatment is

moisturization and salicylic acid, urea, topical steroid, or retinoid.

CeraVe

SA cream BIDCommon Rashes: Keratosis Pilaris

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Inflammatory rash around the mouth, nose and eyes

Monomorphic erythematous papules with background erythema

Slightly itchy or can burn

DO NOT USE topical steroids!

Oral doxycycline or minocycline until resolved – 1 to 2 months. Topical clindamycin or metronidazole.

Common Rashes: Perioral Dermatitis

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Immune-mediated process that speeds up skin cell growth

Common areas: elbows, knees, umbilicus, sacrum, scalp

Can also affect nails and joints. 30% get

PsA

– don’t forget to ask!!Treatments: Topical steroids, Vitamin D analogues,

calcineurin

inhibitors, UVB light, methotrexate, apremilast (Otezla), and biologicsDo not use oral

predisone

–

Risk of Pustular psoriasis

Common Rashes: Psoriasis

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Skin Cancer: Basal Cell Carcinoma

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Topical: 5-fluorouracil, imiquimod

for superficial BCC. Less scarring. Longer treatment time.

Electrodessication and curettage – 93% success rate. Leaves larger scar.

Excision – removes tumor with safety margin

MOHS – for head and neck skin cancer. Harms minimal surrounding healthy tissue while removing all of the skin cancer. Done in stages.

Skin Cancer: BCC treatment

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Skin Cancer: Squamous Cell Carcinoma

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Majority are treated with excisional surgery or MOHS.

If SCC in situ (Bowen’s Disease), then can sometimes use Electrodessication and curettage or topical

imiquimod

or 5-FU.

Skin Cancer: SCC Treatment

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Skin Cancer: Melanoma

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History of Skin Cancer: needs annual full skin check

Family history of first degree relative with melanoma – needs annual full skin check

EVERYTHING you remove – send to pathology

Take photographs prior to biopsy to mark site. (Need landmarks in photograph)

Things to Remember Regarding Biopsies/Skin Cancer

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Thank you for your time!!

Questions!?!