Dermatology Pearls/Pitfalls for Family Practice

2. Dermatology Pearls/Pitfalls for Family Practice A Presentation

3. Dermatology Pearls and Pitfalls Objectives:at the conclusion of the lecture the participant will demonstrate improved understanding of….. • Treatment of resistant or severe eczema • Treatment of mild-moderate acne • Treatment of yeast and dermatophyte (fungal) infections

4. at the conclusion of the lecture the participant will demonstrate improved understanding of….. • Proper selection and safe use of topical steroids • Treatment of pruritus • Selection and use of sunscreens • Treatment of lesions with cryotherapy • Skin biopsy suggestions and precautions

5. Clinical Pearls: Three treatments for severe or resistant eczemarefractory to emollients/steroids • Bleach Baths • Wet Wraps • Eczema Boot Camp

6. Bleach Bath Protocol • Use regular strength – 6 percent – bleach for the bath. Do not use concentrated bleach. • Use a measuring cup or measuring spoon to add the bleach to the bath. Adding too much bleach to the bath can irritate the child’s skin. Adding too little bleach may not help. • For a full bathtub of water, use a 1/2 cup of bleach. For a 1/2-full tub of water, add a quarter cup of bleach. For a baby bathtub, add one teaspoon of bleach per gallon of water.

7. Never apply bleach directly to the child’s eczema. While the tub is filling, pour the bleach into the water. Be sure to wait until the bath is fully drawn and bleach is poured before the child enters the tub. Soak for five- to 10-minutes. Pat the child’s skin dry after the bath. Apply a very mild topical steroid to the child’s skin if prescribed immediately after the bath. Then moisturize the child’s skin. Remember children can absorb a large amount of steroid particularly under occlusion

8. Wet Wraps • After application of steroid (if applicable) then emollient • Damp cotton pajamas covered with dry cotton pajamas (long johns work well) • Repeat nightly until skin healed then 2 times/week prn

9. Eczema Boot Camp • Developed by Sheilagh Maguiness, MD, and Peter A. Lio, MD • Combines bleach bath protocol with wet wrap protocol • Ideally done twice daily, if bleach bath is done once daily, steroid and emollient must be used in the morning as well • Use for up to 2 weeks • Triamcinolone 0.1% cream/ ointment choice for toddlers and older, refer infants to Derm

10. Clinical Pearls: Treatment of mild to moderate acne • Start with retinoid • Adapalene approved for kids as young as 9 years old • Discuss pregnancy safety category with patients and parents and document well. • Tell patients that treatment of acne is a marathon, not a sprint.

11. Pitfalls: Treatment of mild to moderate acne • Use of topical antibiotic without benzoyl peroxide • Use of oral antibiotics without adequate topical treatment • Use of minocycline • Not warning patients over age 21 that medications for treatment of acne may not be covered

13. Clinical Pearls: Treatment of yeast/fungal infections (dermatophyte) • If patient doesn’t respond to treatment within 2-4 weeks, refer to Derm • Culture or biopsy early • KOH vs fungal scraping • Pull hair and place in culture for scalp lesions • Don’t forget to use Wood’s Lamp to aid in diagnosis

14. Clinical Pitfalls: Treatment of yeast/ dermatophyte infections • Never, ever use Lotrisone • Do not mistreat a fungal infection with nystatin, it only works on yeast (candida) • No prolonged course of oral antifungals without diagnosis • Worst case scenario for misdiagnosis

15. Clinical Pitfall: Use of Lotrisone

16. Mycosis FungoidesCutaneous T Cell Lymphoma • Named due to its appearance mimicking tinea corporis infection • Diagnosis often delayed by prolonged treatment with topical/oral antifungals • Punch biopsy confirms diagnosis, but may need to repeat • Misdiagnosis can increase mortality

17. Guidelines for safe use of topical corticosteroids • Prescribe for the appropriate dermatoses. • Use appropriate potency and strength of TC to achieve disease control. • Maintain with a less potent preparation or reduce frequency of application after satisfactory response. • Taper off the treatment upon complete remission of skin diseases. • Be extra careful when prescribing topical steroid over certain locations (e.g. body folds, scrotum, face, and flexures).

18. Guidelines for safe use of topical corticosteroids • Be especially considerate when prescribing to the elderly and children. • Be aware of the adverse effects and act immediately to counteract them. • Avoid prescribing topical corticosteroids in combination with antimicrobials and antifungals. • Resist temptation to use TC for an undiagnosed rash; this makes the possibility of correct diagnosis even bleaker in the future. Indian J Dermatology. 2012 Jul-Aug; 57(4): 251–259. doi: 10.4103/0019-5154.97655

19. Clinical Pearls: Use of Topical corticoSteroids • Seven classes of steroids from super potent (class 1) to least potent (group 1) become familiar with 1 formulation in each group and stick with it to reduce confusion. • Our picks-High Potency • Class 1- Clobetasol Propionate 0.05% • Class 2- Fluocinonide 0.05% • Class 3-Triamcinolone acetonide 0.5%

20. Clinical Pearls: Use of Topical corticoSteroids • Medium potency • Class 4 – Fluocinolone acetonide (alternative to clobetasol) • Class 5- Desonide Ointment 0.05% (minimally atrophic) • Low potency • Class 6- Desonide Cream 0.05% • Class 7- OTC Hydrocortisones 1% prescription Hydrocortisone 2.5%/Pramoxine 1%

21. Clinical Pearls: Use of Topical corticoSteroids • Remember hierarchy of potency based on vehicle • solution-lotion-gel-cream-ointment • Use smallest amount to get the job done (apply sparingly) • Expect steroid will be overused in adults and elderly, underused in children

22. Clinical Pitfalls: Use of Topical corticoSteroids • Follow up not soon enough- 2 weeks for superpotent, 2-4 weeks for potent to mid potent • Underestimating amount needed, FTU method • Prolonged use in high risk areas- face, body folds

23. Clinical Pitfalls: Use of Topical corticoSteroids • Atrophic effects on cutaneous areas of penis and vulva, when attempting to treat mucosal lesions • Use on melasma, urticarial w/o lesions, undiagnosed rash, SK’s • Unintentional occlusion, which can increase potency of steroid 10-100 fold

24. Beware superpotent topical corticosteroid side effects: • Atrophy • Perioral Dermatitis/Acne • Hypopigmentation • Superinfections • Tachyphlaxis • Rare Pituitary Suppression/Cataracts

25. Clinical Pearls: Treatment of Pruritus • Cause of pruritus can be due to skin disease, systemic disease or even psychiatric illness • To determine a primary vs secondary disorder, look at midback where the patient cannot reach. If clear, then lesions are secondary to rubbing, scratching, lichenification (chronic). • Surveillance scraping can rule out dermatophyte or parasites

26. Clinical Pearls: Treatment of Pruritus • History of the pruritus is often the most important clue to cause • After 6 weeks, consider laboratory testing and skin biopsy, referral to Dermatology. • In elderly with chronic pruritus, moisturization most important treatment. Then rule out illness or drug reaction. • With chronic pruritus ( xerosis cutis, chronic prurigo simplex) cure may not be possible, but symptoms can be managed.

27. Pruritus: A Multitude of treatment options to offer • Basics - Cool compresses, cool baths, Cetaphil not Soap • Anesthetics – Lidocaine gel • Antipruritics – Sarna, Pramoxone • Cooling Agents – Menthol, Camphor • Emollients – Aquaphor, Cutemol, Petroleum, Ammonium Lactate • Anti-inflammatory - Sulfasalazine

28. Pruritus: A Multitude of treatment options to offer • Antihistamines – Diphenhydramine Topical, PO Hydroxyzine • Capsaicin • H2 Blocker - Cimetidine • TCA – Doxepin • Anti seizure – Gabapentin • Opioid receptor agonists – Naloxone • Immunologics - Methotrexate

29. Clinical Pitfalls: Treatment of Pruritus • Use of topical steroids in pruritus without skin lesions. • Oral steroid use may result in rebounding • Unrealistic expectations of cure rather than symptom management • Focusing treatment on details rather than process

30. Clinical Pearls: Safe use of sunscreens2013 AAD/FDA Sunscreen Guidelines • Broad spectrum • SPF 30 or higher • Water resistant • Reapply after recommended interval (40-80 minutes). All sunscreens need to be reapplied after no more than 2 hours if you are outside for a long period of time.

31. 2013 AAD/FDA Sunscreen Guidelines • Use separate insect repellent and sunscreen. Apply it more sparingly and less frequently than the sunscreen. • Select lip balm labeled “Broad Spectrum SPF 30” and use it year round.

33. Maine has a large manual labor force with overexposure to UVA/UVB radiation at an early age • Epidemiological studies have revealed a strong association between sun exposure during critical periods of early life and subsequent risk of melanoma during adulthood. • Encourage screening skin exams in high risk individuals Focus on prevention

34. Focus on prevention  Indoor tanning before the age of 35 increases the risk of melanoma by 75 percent. Indoor tanning for minors restricted in Maine, outlawed in other states There is no such thing as a “healthy tan” Hats, protective clothing, avoidance of sun between 10am – 2pm

35. Clinical Pearls: Cryotherapy Appropriate cryotherapy technique: 10 second open spray to achieve “freeze” Appropriate lesions for cryotherapy: • warts, molluscum, isolated actinic keratosis • Palliative treatment of eroded, bleeding SCC in frail patient unable to tolerate flurouracil or excision • AK’s refractory to treatment should be treated with more aggressive method (flurouracil/ excisional biopsy)

36. Clinical Pitfalls: Cryotherapy • Failing to explain risk of scarring and hypopigmentation • Failing to obtain consent for procedure/ABN • Applying cryotherapy to a pigmented lesion • Applying cryotherapy to an eroded/red lesion

37. Clinical Pitfalls: Cryotherapy • Applying cryotherapy to a raised/pink lesion • Applying cryotherapy to seborrheic keratosis (ins. fraud), appropriate treatment curettage and electrodessication with ABN • Recurrence rate of AK with cryotherapy (32.8%) greater than with topical chemotherapeutic agents

38. This Chart blew our minds in derm!!

39. A little better…….

40. Clinical Pearls: Skin Biopsies • Shave, Saucerization, Punch, Excisional/Ellipse – Choose appropriate biopsy type for dermatoses or refer • Dermatology providers like to look at entire lesion to aid in diagnosis, allow pattern recognition with dermoscopy • Some insurances now require a lesion to be biopsy confirmed before they will pay for excision • Pathology report most helpful if you give pertinent history of the lesion • Accurately measure and give location of lesion on path report, also helps locate lesion for future excision

41. Clinical Pearls: Skin Biopsies • Include R/O as well as a couple of differential diagnoses on path report • Pathologists like to look at the whole lesion- patterns, nests of melanocytes, other structures on cellular level to aid diagnosis • Shave or saucerization is preferable to little punch (2-3mm) of large pigmented lesion • Saucerization into deep dermis may be acceptable for certain lesions

42. Clinical Pitfalls: Biopsies • Failing to biopsy promptly • Failing to obtain ABN and consent • Biopsy of small section of a large pigmented lesion (esp. 2mm punch) • Suturing biopsy site closed without clear margins • Failing to send biopsy for pathology • Failing to disclose that “irritated” seborrheic keratosis biopsy may not be covered by insurance if pathology report does not come back as irritated/inflamed

43. Questions??

44. Thank you!

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