Dermatology for the non- Dermatologist. Sanober Amin MD, PhD, FAAD Center for Dermatology, Flower Mound
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1 Dermatology for the non- Dermatologist Sanober Amin MD, PhD, FAAD Center for Dermatology, Flower Mound
2 Disclosure Information Disclosure of Relevant Financial Relationships with industry: None
3 Education BS Biology, International Studies: Loyola University Chicago MD and PhD: University of Illinois at Chicago Dermatology Residency: University of Minnesota
4 Case 1 22 yo otherwise healthy woman presents with a 3 week history of this eruption. Because of the burning, she has tried 1% HC cream with no improvement. Photo courtesy of dermatlas.com
5 Case 1 You diagnose: A. Contact Dermatitis B. Verruca Plana C. Perioral Dermatitis D. Steroid Acne Photo courtesy of dermatlas.com
6 Perioral Dermatitis Common facial dermatitis consisting of fine papules (some with scale) and pustules Key is a fine line of distinction outside of the vermillion border Clinically and histologically, resembles rosacea 90% of cases are in women years old Typical complaint is burning Photo courtesy of dermatlas.com
7 Perioral Dermatitis Cause: Topical steroid use on the face Steroid exposure from asthma inhalers Fluorinated toothpaste Occlusive cosmetics: petrolatum and paraffin Photo courtesy of WebMD.com
8 Perioral Dermatitis cont. Clinical variant is periocular dermatitis May be contiguous with lower facial rash or may be seen in isolation Photo courtesy of Bolognia et al
9 Perioral Dermatitis cont. In children, perioral dermatitis may be more granulomatous appearing This 3 year old boy was treated with numerous topical and oral steroids (which worsened his rash). He resolved with a 6 week course of oral azithromycin Photo courtesy of Bolognia et al
10 Perioral Dermatitis cont. Treatment: Oral antibiotics: Tetracycline family Avoid occlusive cosmetics and topical steroids Patients go through product detox Topical anti-inflammatories Metronidazole, erythromycin, sulfur containing compounds Azelaic acid Topical retinoids (may initially be too irritating) Photo courtesy of Drugstore.com
11 Case 2 18 yo M recently doing well on Doxycycline x 18 months presents with these lesions. He denies missing any of his doxy. He does not use any topicals, because it is too much work. His eruption is getting worse, despite the doxy. Photo courtesy of DermNetNZ.com
12 Case 2 You diagnose: A. Gram-negative folliculitis B. Acne Fulminans C. Perioral Dermatitis D. Sycosis Barbae Photo courtesy of DermNetNZ.com
13 Gram Negative Folliculitis Infection of the hair follicles with gram-negative organisms Include Klebsiella, Serratia, Escherichia, Proteus Occurs as a complication of long term antibiotic use for acne and rosacea. Antibiotics (particularly tetracyclines) alter normal flora Nares serve as reservoir for gram-negative organisms subsequently transferred to the face Uncommon: < 4% of patients with acne treated with oral antibiotics 2 typical scenarios: Acne responding well, but sudden worsening with no change in treatment Inflammatory acne not responding to antimicrobial therapy
14 Gram Negative Folliculitis Key is to notice the extensive pustular lesions, particularly on the infranasal area, cheeks and chin Minimal to no comedones Consider bacterial culture for any extensive pustular eruption Photo courtesy of Dermis.net
15 Gram Negative Folliculitis Treatment 1. Isotretinoin: 1 st line! Reduces sebum production Sebum is reservoir of gram-negative organisms Clearance time of 3 months 2. Systemic antibiotics: 2 nd line Treat based on culture and sensitivity Rarely effective
16 Case 3 73 year old Vietnam vet mentions this eruption casually as you are performing his yearly physical. Oh, by the way doc, I also have these bumps on my scrotum Photo courtesy of WebMD.com
17 Case 3 You diagnose: A. Steroid acne B. Chloracne C. Gram negative folliculitis D. Pyoderma Faciale Photo courtesy of WebMD.com
18 Chloracne Occupational acne caused by exposure to chlorinated aromatic hydrocarbons (commonly known as Dioxin) Insecticides, fungicides, herbicides, electrical conductors, wood preservatives Agent Orange in Vietnam has been linked to the development of chloracne and is a service connected condition May present up to 30 years after exposure Characteristically affects retro auricular area, malar and mandibular area, axillae, and scrotum Oily skin Blackheads Cysts Photo courtesy of VA.gov
19 Chloracne Treatment: Very difficult to treat May partially respond to conventional acne therapies such as topical and oral antibiotics as well as retinoids Prevention is key: wash immediately after exposure to liquid paint, varnish, or cutting oil.
20 Remember Viktor Yushenko? July 2004 December 2004 Photo courtesy
21 Case 4 18 yo M with resistant bumps on chin. Currently being treated with 100 mg minocycline BID and benzoyl peroxide- adapalene x 2 months. He reports that his other small pimple on his forehead have cleared up but the chin is actually worse. Reports itching Has been getting worse during the summer months Photo courtesy of derm101.com
22 Photo courtesy of derm101.com Case 4 Your diagnosis: A. Tinea barbae B. Gram negative folliculitis C. Pyoderma Faciale D. Chloracne
23 Tinea Barbae Superficial dermatophyte infection of the beard area Trichophyton species most common More common in hot/ humid climates Pruritus is key! Referred to as barber s itch Transferred in barber shops with unsanitary razors Hair follicle infection requires oral antifungal therapy Griseofulvin microsize 500 mg qday for 2 weeks until clinical lesions resolve Terbinafine 250 mg po q day x 4 weeks
24 Case 5 19 yo M with new diagnosis of MS admitted to the hospital for pulse dose steroids. He now presents with these facial lesions. Photo courtesy of derm101.com
25 Case 5 You diagnose: A. Steroid Acne B. Tinea Barbae C. Gram Negative Folliculitis D. Verruca Plana Photo courtesy of derm101.com
26 Case 5: Steroid Acne Monomorphic papules that are centro-facial Sudden onset Initial lesions are inflammatory Comedones may or may not be seen Resolves with discontinuation of implicating medication
27 Other medication induced acne Lithium: up to 50% of treated patients develop acne! Cyclosporine Anticonvulsants Antipsychotics TNF alpha inhibitors Anti-tuberculosis meds Quinidine Azathioprine Testosterone
28 Epidermal Growth Factor induced Acne Increased EGFR in solid tumors: head/neck, lung, breast, ovary, prostate, colon Agents include: geftinib, erlotinib, cetuximab, trastazumab, panitumumab Up to 86% of patients may experience an acneiform eruption May portend a good response to treatment Better response with severity of the eruption Mechanism: EGFRi increased cell growth and differentiation of epidermal keratinocytes, sebocytes, and hair follicle outer root sheath hyperkeratosis of the follicular infundibulum acneiform eruption No preferred first line therapy
29 Case 6 24 yo University Minnesota Art History Grad Student presents with this facial eruption. She tells you she has ALWAYS had great skin and this occurred suddenly. Photo courtesy of Bolognia et al
30 Case 6 You diagnose: A. Pyoderma Faciale B. Steroid Acne C. Gram Negative Folliculits D. Tinea Barbae Photo courtesy of Bolognia et al
31 Misnomer- not a pyoderma Early patients misdiagnosed with bacterial infections Typical inflammatory plaque with pustules and cystic lesions EXPLOSIVE onset on nodulocystic lesions and inflammatory plaques Post-adolescent female Little history of acne or rosacea Only affects the face Lesions may be painful Pyoderma Faciale Also known as Rosacea Fulminans Histopathology similar to rosacea Photo courtesy onlinedermclinic.com
32 Pyoderma Faciale Considered a derm emergency because of the potential for scarring Treatment is with isotretinoin +/- concomitant oral steroids (initially) to reduce the inflammatory response Photo courtesy onlinedermclinic.com
33 Case 7 16 yo M presents with these lesions, spreading x 3 months. Proactive has not helped Photo courtesy of Bolognia et al
34 Case 7 Your diagnosis: A. Steroid Acne B. Perioral dermatitis C. Verruca Plana D. Gram negative folliculitis Photo courtesy of Bolognia et al
35 Verruca Plana Skin colored flat-topped papules Often in linear arrays Typically HPV 3 and 10 Treatment: First line: topical retinoids Second line: destructive modalities Caution: scarring and postinflammatory pigment change Third line: imiquimod Photo courtesy of news.com
36 Beware the immunosuppressed Disseminated Cryptococcus in an HIV patient somewhat resembling verruca or molloscum patient Photo courtesy of Bolognia et al
37 Case 8 25 yo African American male presents with bumps in the beard area, worse after shaving Some improvement with OTC benzoyl peroxide wash Photo courtesy of emedicinehealth.com
38 Case 8 Your diagnosis: A. Tinea Barbae B. Pseudofolliculitis Barbae C. Gram negative folliculitis D. Steroid acne Photo courtesy of emedicinehealth.com
39 Pseudofolliculitis Barbae Close shave leads to sharp curly hairs reentering skin Affects 10-80% of AAM Commonly seen in AAM who must shave daily (professionals, military) Treatment: Rx Laser Shaving habits Photo courtesy of emedicinehealth.com
40 Pseudofolliculitis Barbae Rx: Antibiotics PO (tetracycline class) or topical (clindamycin/bpo combo) depending on severity Retinoids +/- steroids Vaniqa blocks enzyme in hair production, slows hair growth Laser Long-pulsed Nd:Yag for laser hair removal Safe for dark skin types Shaving Habits Shave after showering (softens hairs) Medicated shaving gels (BPO, salicylic acid) Do not pull at skin while shaving hairs are cut under skin, can grow into skin, rather than straight out Address PIH Hydroquinone Tazorac Chemical peels
41 Case 9 30 yo F with sudden onset of forehead bumps Itchy No improvement with benzoyl peroxide, retinoids or topical antibiotics Photo courtesy of dermquest.com
42 Case 9 Your diagnosis: A. Gram negative folliculitis B. Verruca Plana C. Pityrosporum Folliculitis D. Comedonal acne Photo courtesy of dermquest.com
43 Pityrosporum Folliculitis Caused by malassezia furfur yeast Overgrowth of yeast plugs hair follicle Monomorphic papules/pustules Itchy Often seen on body Treatment: Oral + topical antifungals (ketoconazole recommended) Continue topical after d/c-ing oral therapy Photo courtesy of dermquest.com
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