Dermatology Lecture 2

1. Dermatology Lecture 2 Psoriasis Infective Skin Disorders

2. Case Studies • Me-atopic and contact and autoimmune • Patient x with eczema on foot and eyelids • Patient y with history of chronic appendicitis

3. Psoriasis • A hyperprolifitive inflammatory scaling or plaquing skin disease affecting 2-3% of pop. • Lesions are usually well circumscibed red patches with silver or whitish scaling • No known cause but predisposing factors include stress, trauma, infection or as a drug rxn. May be genetically predisposed • Lesions vary in degree of itchiness • Diagnosis is by appearance or scrapings • I have seen overconsumption of alcohol and/or sugar to be a predisposing factor

4. Psoriasis • Considered by some sources to be autoimmune condition. • Basically what is happening is that • a lot of immune cells (activated t-lymphocytes) migrate to an area, sometimes in response to a trauma or infection of the skin, often with no obvious trigger. • Inflammation ensues, disrupting the boundaries between the epidermal layers, and the ability to cement the immature cells in place with lipids. • and immature keratinocytes migrate up to the surface and form a flaky plaque over the erythematous, inflamed underlying tissue

7. Different Types of Psoriasis • Nail Psoriasis-pitting, discoloration of nails ddx fungal infxn, often indistinguishable, but if fungal, will get worse with conventional psoriasis treatment. Tx usually sytemic and unsuccessful. Occasional injection into nail. • Pustular psoriasis of palms and soles-Develops gradually with deep sterile pustules. Can crack and become painful, may become infected. Tx is systemic • Guttate psoriasis-Sudden onset of small lesions (0.5-1.5 cm) often on trunk of kids or teens after a strep throat or suddenly dcing systemic meds. Tx’d with systemic antibiotics, if strep related. Generally resolves completely, but may progress into plaque psoriasis.

10. Guttate psoriasis-Referral may be necessary

11. Guttate psoriasis-Referral may be necessary

12. Types of Psoriais • Psoriatic arthritis- 5-30% of those with psoriasis develop arthritis in the joint associated with psoriaisis • Inverse psoriasis=Psoriasis on the flexor rather than the characteristic extensor surfaces • Erythrodermicpsoriasis-Usually seen in patients who already have plaque psoriasis. Diffuse erythema without plaque, often a response to irritating meds or suddenly dcing systemic steroids. Treated with higher level, immunosuppressive drugs. • Generalized pustular or exfoliative psoriasis-Can be fatal. Sudden widespread erythema with sterile pustules. Tx’d with systemic retinoids.

13. Psoriatic Arthritis • Develops in 5-30% of those with psoriasis • Increasing incidence, but may be due to increasing recognition and diagnosis • Mostly (60-80% of the time) lesions appear before joint pain and deformity • Most often in folks with more severe psoriasis, but also often, sometimes just nails affected • Characteristically the distal interphalangeal (“dips”) joints are affected-helps to differentiate from rheumatoid arthritis. • Also large joints may be involved, esp knee, rarely spine.

14. Differentiating Rheumatoid Arthritis from Psoriatic Arthritis

16. Erythrodermic Psoriasis REFER

17. Exfoliative Psoriasis Refer

18. General Course and treatment of Psoriasis • Waxes and wanes with stresses, especially emotional, hormonal, or climate changes • Considered incurable, but manageable • Topical corticosteroids used for flare-ups • “Systemic corticosteroids are generally ineffective, and they can significantly exacerbate the disease upon withdrawal. Combination therapy with a vitamin D analog (calcipotriol and calcipotriene) or a retinoid such as tazarotene and a topical corticosteroid is more effective than therapy with either agent alone.”(Medscape)

19. Conventional Treatment • “The simplest treatment of psoriasis is daily sun exposure, sea bathing, topical moisturizers, and relaxation. Moisturizers, such as petrolatum jelly, are helpful. Daily application of moisturizing cream to the affected area is inexpensive and successful adjunct to psoriasis treatment. Application immediately after a bath or shower helps to minimize itching and tenderness.” (Medscape) • “Nonprescription tar preparations are available and have therapeutic success, especially when used in conjunction with topical corticosteroids; the newer foams are less messy preparations than some of the older ones. Anthralin, topical corticosteroids, salicylic acid, phenolic compounds, and calcipotriene (a vitamin D analog) also may be effective.” (Medscape)

20. Conventional Treatments • PUVA therapy involves an orally ingested psoralen medication activated by UltraViolet A. • Psoralens are plant derived furanocoumarins most commonly from Queen Anne’s Lace or Heracleumcandicans (bailiang du huo) • There is also therapy using UltraViolet B spectrum light using coal tar ointments • UVA and UVB therapies work best on plaque and guttate psoriasis • It is important not to become sunburn, as this can traumatize and exacerbate the psoriasis. • Higher force medications: Methotrexate, a folic acid inhibitor; cyclosprine, an immunosuppressant; systemic retinoids.

21. More Resources • 2013 MedscapeOverviews of psoriasis: http://emedicine.medscape.com/article/1943419-overview#aw2aab6b2b1aa http://www.rxlist.com/psoriasis_slideshow/article.htm

22. Derm Lecture 2 part 2 Infectious Skin Diseases

23. Infectious Skin issues • Very common • Usually have an age range • Can range in severity from self-limiting to life threatening • Conventional treatment is generally aimed at using a medication that kills off infectious organism. For viral issues often suppression is the goal • Complementary and alternative treatments are based around soothing skin, and increasing immune function, and using natural products to inhibit or kill organism

24. Bacterial Skin issue • Impetigo • Usually seen in very young children or occasionally in the elderly • Very contagious-keep child home • Defined by it’s appearance “honey-colored crust” • Most commonly appears around mouth, nose, knees and elbows • Can be a secondary infection from diaper rash, bug bite or scratch • Usually a coag-positive Staph. aureus or group A betahemolytic Strep • Starts out as a small red macular lesion, which develops into a pustule, which breaks up and spreads.

25. Impetigo

26. Diagnosis and Treatment • Diagnosis by appearance, a swab for culture and sensitivity may be done, WBC’s might be elevated • Conventional treatment includes topical antibiotics, lots of washing with soap and water. Systemic antibiotics (commonly cephalosporins) may be used for extensive cases. • Alternative complementary therapies usually include a wash from a tea of goldenseal, calendula, echinacea, tea tree, or lavender • Red flag issues may include spreading infection, MRSA or rarely streptococcal glomerulonephritis

27. Folliculitis • An infection of a hair follicle usually by Staph aureus • Extremely common • When a group of follicles is involved they will be called a “boil” or “carbuncle”. • Furunculosis occurs when the more superficial folliculitis develops into hard, nodular, painful lesions • Treatment is usually hot compresses and soap and water. Deeper lesions may need to be drained • Red flag issues are MRSA, septicemia

28. Folliculitis-not itchy but sore

29. MRSA • Methicillin Resistant Staph Aureus • A not uncommon antibiotic reistant bacterial infection that can progress quickly to a systemic life threatening or disfiguring infection. • Often, first misdiagnosed as a “boil” or “spider bite” • Refer for a culture/sensitivity, CBC and treatment-Vancomycin, Clindamycin • Alternative treatments of essential oils, Four (or sometimes “Seven”) Thieves vinegar may be effective, but things can go bad quickly, so do not attempt this lightly

30. MRSA Refer

31. Scalded skin syndrome • Named for the appearance of the disorder • Staph aureus is the causative organism and the disorder is sometimes called “SSSS” • Certain strains of the bacteria release toxins which cause an exfoliation of the epidermal layer of the skin, resulting in the scalded appearance. • It is usually seen in children. 62% are less than 2, and 98% younger than 6. Often cases will start out as an impetigo or other infected lesion. • There are only 50 adult cases documented. Immune deficiency, renal insufficiency or other chronic disease were underlying factors • Mortality in children is 1-5%. In adults 50-60%. Refer.

32. Scalded Skin Syndrome • Fluid and electrolyte balance and overwhelming sepsis are usually the cause of death. • Differential diagnosis is another disorder: toxic epidermal necrosis (TEN), a similar disorder but which involves both the skin and the mucous membranes and has a higher mortality rate, also affect adults much more than children and is usually seen in HIV. • Treatment is with systemic antibiotics, either oral or I.V.-Vancomycin, Nafcillin, Clindamycin and rehydration • Often treated in burn centers

34. TineaVersicolor • “Tineaversicolor is a common, benign, superficial cutaneous fungal infection usually characterized by hypopigmented or hyperpigmentedmacules and patches on the chest and the back.” Medscape • Caused by the fungal organisms in the genus Malassezia, formerly known as Pityrosporum, which are considered normal, but opportunistic, skin flora. • Lesions are scaly macular or papular patches that can be white, red or brown (“versicolor”). The fungus messes with pigment production by the melanocytes • Sometimes the hypopigmented patches won’t tan with the rest of the skin, but can burn more easily. Eventually the pigment will return to normal

35. Tinea Versicolor

36. TineaVersicolor • Highest prevalance in people 15-24. Rare before puberty or after 64. The organism is lipophilic, so it is thought that it is most active when the sebaceous glands are most active • Best diagnosed microscopically with skin scrapings mixed in a KOH preparation • Differential dx includes vitiligo, tineacorporis, and seborrheicderm. • Treatment is with topical selenium sulfide lotion or if preferred by patient with oral antifungal drugs, typically ketoconazole, fluconazole, and itraconazole. • Alternative therapies include increasing immune function and decreasing sugar in the diet.

37. Dermatophytosis • Commonly known as a group as tinea. Further designation indicates location of infection • These infections include the commonly known athlete’s foot (tineapedis), jock itch (tineacruris), but also occur on the scalp (tineacapitis), the nails (tineaungum), the trunk (tineacorporis), the bearded face (tineabarbae). • The cause are fungi in the Trichophyton, Microsporum, or Epidermophyton genera • These dermatophytes live normally on the hair, skin and nails and actually require keratin for nutrition • Often called “ringworm”

39. Tinea Diagnosis and Treatment • Appearance-it is circular with scaling on the borders, and sewer shinier skin towards the center of the lesion. • Microscopic study of skin scraping with KOH is preferred method of dx. • Treatment is often with topical antifungals, usually of the –azole class. Occasionally oral antifungals are used, or terbinafine (aka Lamisil) • Alternative therapies, Diet low in simple carbs, probiotics, sometimes applied topically, or herbal vinegar solutions

40. Candidiasis (aka monoliasis) • Common fungal infection of the skin and mucus membranes by Candida albicans or any of the other of the 150 Candida species, which are normal but opportunistic flora. • Infections commonly occur in skin folds where it is moist and warm, also common on the penis, around fingernails and between the fingers. A common cause of diaper rash, vaginitis, and infection of nipple in nursing mom. • Very itchy, often beefy red, can be pustular with crusting or plaquing making it hard to distinguish from psoriasis. • Oral candidiasis (thrush) causes a thick whitish coating on the tongue or mucus membrane that bleeds when scraped off.

41. Candida

42. Diagnosis and treatment • Diagnosis by appearance and a KOH prep of skin scraping • Gentian violet, antifungal topical powders, occasional oral antifungal drugs including nystatin are conventional treatments • Volumes written about the alternative tx • Limiting carbsesp simple or low fiber carbs • Detox or elimination diet common • Some diet also restrict any fungal or fermented food • Lots of antifungal agents: Goldenseal or Oregon Grape, grapefruit seed extract, tea tree or lavender essential oil

43. Other Resources • CDC MRSA Info: http://www.cdc.gov/mrsa/ • Outpatient management of MRSA. CDC PDF: http://www.cdc.gov/mrsa/pdf/Flowchart_pstr.pdf