Charles Edward Mount, MD Co-Director Division of Dermatology

1. 15th Annual Chronic Wound ConferencePearls and Pitfalls from the Medical Dermatologist Perspective Charles Edward Mount, MD Co-Director Division of Dermatology

2. Disclosures Speaker Bureau for AbbVie, Celgene, and Novartis I have no financial disclosures relevant to the material in this presentation.

3. Objectives Illustrate appropriate and more straightforward use of topical steroids Discuss potential sources of contact dermatitis from wound care Review basic points in diagnosis and management of fungal infections Emphasize and encourage the relationship of wound care specialist and dermatologist Provide examples of urgent referrals to dermatology

4. Pre-Test

5. #1 Regarding topical medications of the same drug and concentration which is true? Creams more potent and allergenic Creams more potent, but less allergenic Ointments more potent and allergenic Ointments more potent, but less allergenic

6. #2 If a patient is allergic to a topical steroid you will know immediately or very quickly after application? True False

7. #3 Nystatin is an effective agent against dermatophytes (causative organisms of tinea infections)? True False

8. #4 Which topical antifungal has the best efficacy against the most common dermatophytes? Nystatin Terbinafine Ketoconazole Clotrimazole Econazole

9. #5 Ketoconazole is a safe and effective oral agent for non-life threatening cutaneous fungal infections? True False

10. #6 Which of the following medications have not been reported to cause cutaneous hyperpigmentation? Minocycline Antimalarials Amiodarone Silver Diltiazem Imipramine Hydroquinone Zidovudine Oral contraceptives

11. #7 Naturally occurring medications/chemicals aretypically less allergenic than artificial compounds? True False

12. #8 Which statement is true regarding pyoderma gangrenosum? Tissue for H&E and DIF are necessary It is a diagnosis of exclusion It is typically infected Debridement is helpful to remove the purulent, dead tissue

13. #9 Diagnosis or category

14. #10 Diagnosis or category

15. #11 Diagnosis or category

16. #12 Diagnosis or category

17. #13 Diagnosis or category

18. Considerations in Appropriate Use of Topical Steroids • Potency • Vehicle • Occlusion • Intralesional use • Allergy Class

19. Steroid Potency

20. Potency – Simplify your Life Pick 2 or 3 from different potency categories Even pick from just ultrapotent, medium, lower potency Patient compliance with frequent application dosing – “consider rounding up”

21. Vehicle • Cream • Possibly better on wet lesions • “less mess” • Ointment • More potent than cream equivalent • More occlusive, better on drier lesions • Solution • Liquid, alcohol based • Good for peristomal rash, rash under adhesives/bandages • Gel • Quick absorption • Lotion • Ease of use over larger surfaces

22. Steroid Occlusion and Intralesional Use • Occlusion of any topical agent with plastic wrap, dressing, etc will enhance absorption and therefore its efficacy • Typically have patients use kitchen plastic wrap in the PM/HS • Good for lichenified skin/lichen simplex chronicus (LSC), severe stasis derm • Intralesional injection delivers medication directly to the pathology vs topical agent requiring absorption • Typically triamcinolone 2.5-40mg/mL • Good for thicker dermatoses or conditions where the inflammation is deep within the skin for example lichenified eczema/stasis derm, lichen amyloid, neutrophilic dermatoses, various ulcerating conditions, necrobiosis lipoidica, morphea, discoid lupus, panniculitis

23. Steroid Allergy – When to Suspect Worsening despite adequate use of adequately potent topical steroid Chronic relapsing dermatitis of face, hands, or lower extremities Aggravation of condition with long-term topical steroid Occupational setting: health care, pharmaceutical worker Older patient (supposedly) Also need to consider inactive ingredients

24. Steroid Allergy Classes • Class A • Hydrocortisone • Tixocortol* • Prednisone • Prednisolone • Methylprednisone • Class B • Triamcinolone • Desonide • Budesonide* • Fluocinonide • Fluocinolone • Halcinonide • Class C • Dexamethasone • Desoximetasone* • Fluocortolone • Class D1 • Clobetasol* • Betamethasone diproprionate and valerate • Class D2 • Hydrocortisone butyrate* • Prednicarbate

25. Superficial and Deep Cutaneous Infections Fungus Amongst Us

26. Superficial Fungal Infections – Pearls Tinea corporis, pedis, cruris, manuum, capitis, faciei, barbae, unguium

27. Tinea Cruris vs Intertrigo • Tinea/dermatophytes do not affect the scrotum/penis and advances away from the crease • Look for concurrent t. pedis, onychomycosis • Candidalintertrigo will affect the scrotum and favors the crease • May have satellite pustules/papules

28. Tinea pedis vs eczema/Pso T. Pedis Dermatitis (Ecz/Pso) More isolated, confluent plaques Often favors the arch Pso may have nearly identical changes • Examine the transgradiens zone • Usually favors the thicker surfaces (more keratin) • Look for concurrent nail disease, groin involvement

29. Tinea Incognito • Tinea masked by steroid or other immunosuppression • Look for remnants of annular configuration – “broken up circle/ring” • Look for follicular pustules/papules • Concurrent Majocchi granuloma • Often requires oral treatment • Reasoning for avoiding clotrimazole/betamethasone cream

30. Superficial Fungal Infection Management Topical use usually sufficient in localized disease Terbinafine > azoles Nystatin has no activity against dermatophytes Terbinafine has no activity against candida Use antifungal without corticosteroid if at all possible

31. When to Consider Systemic Therapy • Failed 2-4 week course of adequate topical • Diffuse disease • Tinea manuum • Majocchi granuloma/tinea incognito • Immunosuppressed, compromised patient • Terbinafine 250mg/d for 14-21 days • Fluconazole 200mg/d vs once weekly pulse • Itraconazole 200mg/d vs pulse dosing • AVOID KETOCONAZOLE IN NON-LIFE THREATENING DISEASE

32. Subcutuaneous and Systemic Fungal Infections Aspergillus Histoplasmosis Cryptococcus Coccidiomycosis Blastomycosis Chromoblastomycosis Paracoccidiomycosis ….just to name a few CEM

33. Tissue culture is of utmost importance • Can not reliably diagnose and speciate fungal infections by tissue biopsy alone even with bug stains • Tissue culture (not swab) needed for correlation CEM

34. Tissue Biopsy vs Culture Fontana Masson GMS CEM CEM

35. Tissue Biopsy vs Culture Photos coutesy of Andrej Spec, MD, WUSTL Infectious Disease

36. Alternaria sp. Fontana Masson GMS

37. Hyperpigmentation

38. Hyperpigmentation - Medications • Minocycline • OCPs • Antimalarials • Hydroxychloroquine, chloroquine, quinacrine • Silver • Amiodarone • AZT, zodovudine • Clofazimine • Diltiazem • Tricyclic antidepressants • Hydroquinone (exogenous ochronosis) • Antineoplastic agents • 5FU, Bleomycin, MTX, Cyclophosphamide, doxorubicin, busulfan, carmustine, etc • Targeted therapies • Imatinib • Sclerotherapy

39. Minocycline Hyperpigmentation • Type I • Blue-black within scars • Iron • Type II • Blue-gray in sun protected areas like the shins • Iron or melanin • Type III • Muddy brown in sun exposed skin • Melanin May also affect mucosa, sclera, teeth

40. Contact sensitization and complications of wound care

41. When to Consider… 40-80% of chronic ulcer patients develop epicutaneous reactions to wound treatment products Worsening/spreading of rash on lower legs or skin surrounding wounds Increased itching Increased drainage without infection (negative cultures) Long-term wound care Use of neomycin, bacitracin, OTC topical abx

43. More on Neomycin and Bacitracin 7th and 8th most prevalent allergens in the NACDG 2015-16 Study Neomycin and bacitracin allergy present in 42.1 and 31.6% of patch test patients Although not chemically related there is a high rate of allergic co-reactivity Neomycin allergy cross reacts with gentamicin and tobramycin

44. Neomycin Bandage Aneurysmal bone cyst repair scar Undergoing doxycycline sclerotherapy Prior hardware 3 weeks of betamethasone And d/c neomycin dressing Negative wound cultures

45. Pearls for Worsening Rash Around Wounds Ask what they’ve been putting on it Ask specifically about OTC topical antibiotics (Neosporin) Cream vs ointment? Itch vs pain? Tense blisters or fragile denuding skin? Alternative and homeopathic medicines Essential oils, tea tree oil, etc

46. Allergy to Bandages and Dressings Common sensitizers in bandages Rubber used in the elastic Colophony (pine rosing) Balsam of Peru Acrylates used in adhesives Formaldehyde (releasers) Topical antibiotics embedded in bandages

47. Allergy to Dressings Allergic contact dermatitis (ACD) to adhesives results from hypersensitivity to: Colophony Abitol Abietic acid, benzoyl peroxide, rubber accelerators, antioxidants, and acrylates.

48. Allergy to Dressings More than 50 cases of ACD to Duoderm reported Most to tackifying agent Penalyn – a modified colophony Much of “allergy” to tape may be more ICD than true ACD

49. Allergy to Bandages and Dressings

50. The Skinny of Contact Allergy for You the Wound Specialist • It’s complicated • ACD vs ICD • The culprit is typically in the inactive ingredients • Natural isn’t necessarily less allergenic (sometimes more) • Not all patch testing is created equal