Dermatology

1. Sebhorrheic dermatitis • Andrea: Case prentation – differential (ddx choose 1) • Yahya: Ddx elimination -treatment • Austin: Treatment, article • Psoriasis • Yahya: case presentation – genogram • Austin: circle of influences - treatment • Andrea: treatment, article • Eczema: • Austin: beginning • Andrea: middle • Yahya: end • Rosacea: • Andrea • Austin • Yahya

2. Dermatology Family Medicine Clerkship Austin Perlmutter Andrea Marcadis Yahya Mohammed

3. Genogram John Smith

4. Case Study – Part I John Smith, a 40 yr old man presents for a several week history of scaling of his scalp and itching and redness in his external auditory canal. He also has erythema with mild scaling in his nasolabial folds. What is the diagnosis?

7. Case Study – Part I HPI: Tried to use dandruff shampoo with little to no effects. PMHx: HTN treated with Amlodipine PSgHx: Appendectomy PScHx: Married to wife with one daughter. Is a truck driver. Is getting depressed due to cosmetic consequences of his condition. FmHx: Mother and Father both smoked cigarettes and died from lung cancer. History of high cholesterol on Mother’s side.

8. Case Study – Part I • P.E.: • Scalp shows scaling and very greasy. • Pt reports itchiness on examination. • Blepharitispresent. • ROS: • Pt has peripheral edema in feet from Amlodipine • Pt reports improvement in symptoms when he goes out into sunlight.

9. Circle of Influence Wife Drinking Too Much Truck Driving Irresponsible Behavior Taking off Wedding Ring Daughter

10. DDx Asteatoic Eczema Atopic Dermatitis Cutaneous Candidiasis Contact Dermatitis Dermatomyositis Drug Eruptions Drug Induced Photosensitivity Erythrasma Extramammary Paget Disease GI Disease Glucagonoma Syndrome Impetigo Intertrigo Langerhans Cell Histiocytosis Lichen Simplex Chronicus Lupus Nummular Dermatitis Omenns Syndrome Pemphigus Erythematosus Pemphigus Foliaceus Perioral Dermatitis PityriasisRosea Psoriasis Rosacea TineaCapitus TineaVersicolor

11. DDx – Choose one Tineacapitis Psoriasis Atopic Dermatitis Seborrheic Dermatitis

12. DDx – Elimination • Tineacapitus • Microscopic examination and culture are diagnostic – KOH test of superficial skin scraping. • Psoriasis • Plaques tend to be thicker and less pruritic • Nails involvement – pitting and onycholysis • Arthritis – 10% of cases • Early facial psoriasis • May be difficult to differentiate • Atopic Dermatitis • Inner elbows and Back of Knees • Possibly dry brittle hair in adults

13. Seborrheic Dermatitis Overview • Common Inflammatory condition of the skin • Presents in areas generally rich in sebaceous glands • Scaling and poorly defined erythematous patches • Occurs in Infants, Adolescents, and Adults 30-60 yrs of age • Very common in the following groups: • Parkinson’s Disease • HIV/AIDS • African Descent • Adolescents

14. Seborrheic Dermatitis Pathology/Histology • Skin biopsy • Typical • Neutrophils in scale crust at margins of follicular ostia • Spongiosis – intercellular edema • Inflammatory infiltrate in Dermis • Psoriasiform Hyperplasia • Parakeratosis around follicular ostia • AIDS associated • Parakeratosis • A few necrotic keratinocytes in epidermis • Plasma cells in dermis

15. Typical Lesion Histology – Acute Phase

16. Circle of Influence Wife Drinking Too Much Truck Driving Irresponsible Behavior Taking off Wedding Ring Daughter

17. Case Study – Part II John Smith, a patient with a history of seborrheic dermatitis, presents with a positive HIV ELISA test confirmed with a positive western blot. How will this diagnosis change the presentation of his skin condition?

20. Seborrheic Dermatitis in HIV • In general population, incidence is ~ 3% • In HIV population, between 34 – 83% • In Mali, seborrheic dermatitis used as a predictor of HIV • More severe presentation than usual and extremities involved. • Become more severe as HIV/AIDS advances • Improves with HAART • Histological differences between AIDS pts and non-AIDS pts • Parakeratosis and keratinocytic necrosis present in AIDS pts

21. Seborrheic Dermatitis in Neurological Disease • Parkinson’s Disease • Pts with Parkinson’s Disease have a high incidence • Endocrine rather than neurotrophic mechanism • Unilateral Parkinson’s -> Bilateral Dermatitis • Facial immobility may result in greater accumulation of sebum • Mood Disorders • Possible due to remaining Indoors

22. Sunlight Exposure • Conflicting Evidence: • Little Exposure to sunlight may be a risk factor • Too much exposure may be a risk factor • Mountain guides • Higher incidence than mainstream population • Psoralen use with phototherapy for Psoriasis • May make it worse

23. Case Study – Part IIIMaking a Rash Decision John Smith very recently had a daughter. His wife gave birth just two months ago. The infant presents with red-yellow plaques covered with scales on her scalp. In addition, there is a generalized rash in the flexural areas around the diaper. What is the diagnosis? What further testing should be performed once the diagnosis is made?

26. Infantile Seborrheic Dermatitis (ISD) • Two primary types of lesions in ISD: • Cradle cap covering the scalp • Diaper Rash – not usually ISD • Other areas affected • Eyebrows, paranasal areas, and flexural sites • Generally disappers by 8 months of age. • Difficult to differentiate between ISD and Atopic dermatitis (AD) • AD generally in antecubital and popliteal fossa • AD more prone to recurrent dermatitis. • If Generalized ISD, then screen for immunodeficiencies

27. Treatments • Anti-Inflammatory Agents • Steroid Shampoos • Steroid Creams • Topical Calcineurin Inhibitors • Anti-Fungal Agents • Creams • Shampoos • Keratolytics • Alternative Meds

28. Treatments – Anti-Inflammatory Agents • Corticosteroids • Often prescribed in combination • Antifungals or Antibiotics • Low potency steroids • Long term effects – skin atrophy, adrenal function, telangiectasias • Examples • Shampoos • Fluocinolone • Topical • Hydrocortisone • Lower potency – good place to start • Fluocinolone • Betamethasone • Desoinide

29. Treatments – Anti-Inflammatory Agents • Topical Calcineurin Inhibitors • Generally adjuvant therapy • Fungicidal and Anti-Inflammatory Properties • Inhibits T – helper Types I and II • Requires one week of use before benefits noticeable • Side Effects • No cutaneous atrophy • Examples • Tacrolimus ointment • Pimecrolimus cream

30. Treatments – Anti-Fungals • Azoles • Mechanism • Attack Malassezia species • Topical Examples: • Ketaconazole • 2% cream, gel, or shampoo most commonly used • No risk of atrophy or telangiectasias • 2% shampoo – excellent prophylactic effect • Fluconazole – 2% shampoo • Miconazole • Bifonazole

31. Treatments – Anti-Fungals • Oral treatments: • If lesions are widespread or refractory to topical treatment • Oral Ketaconazole • 200 mg for 4 weeks + Topical • Oral Itraconazole • 200 mg for 7 days + Topical • Not as hepatotoxic as ketaconazole • Oral Terbinafine

32. Treatments – Anti-Fungals • Other • Examples • Selenium Sulfide Shampoo • Also has a keratolytic activity • Zinc pyrithione • Keratolytic and anti-fungal activity • Equally as effective as selenium sulfide shampoo • Metronidazole • An azole • 1% gel possibly more effective than placebo • Terbinafine – 1% shampoo

33. Treatments - Others • Tea Tree Oil • Antimicrobial and anti-inflammatory activity • TOXIC if ingested • Tar – Whole coal tar and Crude coal tar extract • As effective as selenium sulfide • Lithium succinate - ointment • Possibly anti-fungal or anti-inflammatory effect

34. Prognosis • Treatment may not result in cure • Remission is likely • Prophylaxis may be used • 2% ketaconazole shampoo use once per week or every other week for scalp • 2% ketaconazole cream for remission of facial lesions then once per week.

35. Typical Cost • Typical Regimen: • Initial Treatment • 2% ketaconazole shampoo ($38) twice weekly for 4 weeks • 2% ketaconazole cream ($175) + 1% hydrocortisone cream ($28) twice daily for 4 weeks • TOTAL: $241 • Prophylaxis: • 2% Ketaconazole shampoo once weekly ($5) • 2% Ketaconazole cream once weekly ($25/month) • TOTAL: $30/month • TOTAL: • $241 + $30/month

36. Typical Cost • Oral Medication • Oral Terbinafine • Oral Fluconazole – 800 mg TOTAL • $20 at Walmart

37. Community Resources – Online Forums

38. Community Resources

39. Community Resources

40. Successful treatment and prophylaxis of scalp seborrhoeicdermatitis and dandruff with 2% ketoconazole shampoo:results of a multicentre, double-blind, placebo-controlled trial • R.U. Peter and U. Richarz-Barthauer • University of Munich, Germany • British Journal of Dermatology 1995 • Purpose: Investigate, in the first large scale, double blind placebo controlled study, the effect of 2% Ketaconazole shampoo as treatment and prophylaxis in seborrheic dermatitis of the scalp

41. Article • Phase I: • 575 Patients with moderate to severe dermatitis and dandruff were treated with 2% ketaconazole • Score 0-3 in Categories of erythema, pruritis, and desquamation • Phase II: • 312 Patients who were successfully treated in Phase I of dermatitis and dandruff entered the prophylaxis phase • 4 groups • 2% ketaconazole once weekly • 2% ketaconazole once every other week • 2% ketaconazole alternated with placebo • Placebo

42. Article

43. Article

44. Article • Results: • Phase I: 88% Resolution of dermatitis • 42% Placebo (assumed) • Phase II: only 19% relapse in treated group • 47% relapse in placebo group • Adverse Rxns: • Itching and burning • 6.4% in Phase I; 3.9% in Phase II • Weakness of Study: • No placebo/control group in Phase I

45. Mystery disease ? ? ? ? ? ? ? ? ? ? ? ? ?

46. Ms. K 32 y/o female, mother of 1 with no significant PMH presents at clinic with complaint of non-pruritic, non-painful scaly rash on the back of her elbows for 1 month.

47. Her basics • Sometimes has to work over 24 hour days away from her child • Maintains a strict vegetarian diet for 6 days a week and eats meat on Sundays • Lots of tofu, legumes and variety of dark leafy greens, as well as eggs and hard cheeses • Will have red wine with some meals • Chauffeured when driving is necessary • In the near future, would like to get married, and buy a house in a neighborhood where she can raise a family • Patient is concerned about the appearance of the rash because she thinks it will interfere with her modeling career. She is also concerned about her baby having the disease • Patient is worried that certain foods may make the rash worse • Patient denies any problems with functioning since she’s had the rash • Born October 21, 1980 in LA California, and still lives there • PMH – childbirth by vaginal delivery 6 months ago • Seen by Ob/Gyn, daughter seen by pediatrician • PSx: Medial meniscus repair, Left knee 2002 • Current medications: Multivitamin, topical moisturizer • Social history: Non-smoker, drinks 4-10 alcoholic beverages per week, no recreational drugs • Currently in a monogamous sexual relationship with one male w/o contraceptive protection • Caucasian, catholic • Occupation: Celebrity, model, actress • Education: Marymount high school • Currently living with baby at home with parents in gated community • Member of multiple charities, plays tennis 4x/week with friends • Works 2-3 days a week modeling/making appearances in public/business meetings,

48. OBJECTIVE • Physical exam • BP 122/88, HR 78, Temp 97.8 F, BMI 20 • HEENT normal, with PERRL, EOMI, eyelids clean and non-inflamed, nasal passages normal, trachea midline, thyroid non-palpable • CV normal, S1 S2 normal, no murmurs, thrills, lifts • Respiratory exam normal, no rales, crackles, lung fields clear • Mskel- unremarkable • Derm: Patches of silvery scales on extensor surfaces of both elbows with slight bleeding on manipulation • No other derm findings

49. DDx • Blepharitis • Atopic Dermatitis • Atopic keratoconjunctivitis • Contact dermatitis • Dry eye syndrome • Psoriasis • Gout, pseudogout • Pityriasis (Alba or rosea) • Reactive arthritis • SiccaKeratoconjunctivitis • Tinea

50. And the verdict is.. • Blepharitis • Atopic Dermatitis • Atopic keratoconjunctivitis • Contact dermatitis • Dry eye (syndrome • Psoriasis • Gout, pseudogout • Pityriasis (Alba or rosea) • Reactive arthritis • SiccaKeratoconjunctivitis • Tinea