April 4April 4thth, 2014 – London, ON, 2014 – London, ON

Denise Wexler MD, FRCPC

Differential Diagnosis: The case of the red face

Top 5 practical tips to take to your clinic tomorrow

1.Comedones are present in acne  2.Perioral dermatitis often spares the area just

beneath the lower lips  3.Telangiectasia don't occur in acne or perioral

dermatitis  4.Age of the patient may help in diagnosing a

red face  5.Rosacea often stings or burns 

Denise Wexler MD, FRCPC

Pediatric and Neonatal Dermatology

Summary

Classification by morphology is a useful way to organize differential diagnosis

Neonates, especially preterm infants, have thinner skin and are more vulnerable to infection

There are many benign, self limited dermatoses that present in the neonatal period, however careful evaluation is needed to rule out infectious causes, systemic disease, and genodermatoses

Top 5 practical tips to take to your practice tomorrow

1. Erythema toxicum neonatorum is self limiting

2. Milia in infants are self limiting 3. Neonatal herpes simplex is a serious disease

and requires systemic treatment 4. Six or more café au lait spots are needed to

make a diagnosis of neurofibromatosis 5. Portwine stains in the trigeminial distribution

require eye examinations and MRIs

Wei Jing Loo MD, FRCPC

Antibiotic Resistance in Acne Treatment: Identifying the threat and minimizing risk

Summary Teaching Points

• Pathogenesis of acne vulgaris is the same at all ages, and the same principles and therapeutic agents apply

• Important considerations for treating younger populations are ease of use (i.e., once daily, combination, etc.), fast onset of action to limit risk of scarring, advanced vehicle to minimize adverse events on young skin

• Limit the duration and/or use of antibiotics (topical and oral) to reduce the risk of antibiotic resistance (ie. <12 weeks)

Summary Teaching Points

• BPO is an extremely efficacious bactericidal agent for managing acne with anti-inflammatory properties, without the risk of antibiotic resistance

• Retinoid-containing agents are essential for comedonal acne and the prevention of comedonal formation

• Adapalene/BPO is now approved in the U.S. for acne patients 9 years and older

Lyn Guenther MD, FRCPC

Red and Bumpy: Managing common manifestations of rosacea

Rosacea: Conclusions

• Rosacea’s chronic, cyclical inflammatory cycle causes progressive damage to skin structure.

• Early recognition and treatment are important to prevent progression and disfigurement.

• The most common features of rosacea (redness, papules/pustules) require specific individualized management approaches.

Millikan L. The Proposed Inflammatory Treatment Pathophysiology of Rosacea: Implications for Treatment

SKINmed 2(1): 43-47, 2003

Baldwin, H. Diagnosis and Treatment of Rosacea: State of the Art. JDD 2(6):725-730, 2012

Top 5 Practical Tips You can Use in Your Clinic Tomorrow

1. Instruct patients to avoid triggers.2. Gentle skin care is important.3. Chronic therapy is required for continued

control.4. Sub-antimicrobial oral doxycycline improves

rosacea without inducing antibiotic resistance.

5. Topical Brimonidine can improve facial redness, but may unmask papules, pustules and telangiectasia.

Baseline Hour 3

Denise Wexler MD, FRCPC

Diagnosis & Treatment of Onychomycosis

• Toenail onychomycosis is common and may present as: – Distal and lateral subungual onychomycosis (DLSO)– Superficial white onychomycosis (SWO)– Proximal subungual onychomycosis (PSO)

• Clinical diagnosis should be confirmed by a diagnosis method to identify causative organism and treatment

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Summary – Diagnosis

• Oral therapies for onychomycosis including terbinafine or itraconazole are recommended: – Involvement of > 50% of distal nail plate/ multiple nail

• Involvement, involvement of nail matrix• Transungual therapies for onychomycosis including

efinaconazole or ciclopirox are recommended:– Involvement of < 50%, or when oral therapy is sub-optimal

• Oral and transungual treatment may be combined to improve efficacy and prevent recurrence

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Summary – Treatment Options

• Recurrence of onychomycosis is frequent and may be due to:– Poor diagnosis, therapeutic failure,

poor prevention– Patient related factors, such as

immunocompromised patients, diabetes etc.

• Maintenance approach is to include: – Regular follow-up and measures to decrease

the risk for reinfection

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Summary – Preventing Recurrence

1. Ketoconozole should not be used to treat onychomycosis

2. Treatment of onychomycosis requires a positive fungal culture

3. Topical therapy for onychomycosis is safe and efficaceous

4. Efinaconozole topically avoids product build up5. Long-term topical treatment for onychomycosis may

be recommended

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HOT TIPS

Moderate to Severe Psoriasis: What should a GP do?

Lyn Guenther MD, FRCPC

Living Well with Psoriasis – Patient ToolsLiving Well with Psoriasis – Patient Tools

Summary commentsSummary comments

• Psoriasis is a life-long systemic inflammatory disease

• Psoriasis has a major impact on quality of life (including work)

• Psoriasis is associated with major co-morbidities (depression, metabolic syndrome, ischemic heart disease, IBD, arthritis)

• Psoriasis treatment options exist for all types and severity levels

• Early initiation of treatment is positively impactful

• Most patients are managed with topicals

• Adherence is challenging

• Systemic agents may be under-utilized

• A thoughtful review of therapeutic options is ideal

5 Tips to take home

1. When making the diagnosis of psoriasis, don’t forget to look at the nails, scalp, natal cleft, elbows, knees and sacrum

2. Check all patients for hypertension, hyperlipidemia, diabetes mellitus and psoriatic arthritis

3. Treat associated Depression and Anxiety.

4. Most psoriasis can be controlled/cleared with appropriate therapy, so treat or refer for treatment.

5. Ask about Adherence at each visit.

Lyn Guenther MD, FRCPC

Chronic Hand Dermatitis: What is it and how should it be treated?

5 tips for Chronic Hand Dermatitis

1. If possible patch test all patients to identify causative allergens.

2. If 2 feet, 1 hand involved, do a KOH smear and take a fungal culture to rule out Tinea pedis and manum.

3. Frequent application of lubricants may prevent fissures.

4. Ceramide or oat containing lubricants may repair the skin barrier .

5. Application of nail glue containing Cyanoacrylate can seal fissures and reduce pain.