Fall CME EventOctober 15, 2019

Reid Masters, MDDermatology

• University of Illinois, 2004-2008

• Navy Medical Center San Diego, 2008-2009

• Undersea Medical Officer, 2009-2013

• University of Iowa Dermatology, 2013-2016

• Private Practice, 2016-2017

• Virginia Mason, 2017-2019

Visual Recognition and Initial Management of Common Dermatoses

• Objectives:

– Review the morphology and distribution of common inflammatory skin diseases.

– Discuss first line diagnostic and therapeutic options.

Dermatologic Therapies

Topical Steroid Vehicle

• White persons scalp – solution

• Black persons scalp – oil

• Otherwise – cream (or ointment if patient prefers)

Topical Steroid Strength

• Face, axillae, groin - hydrocortisone 2.5% (30 grams for $7.39)

• Trunk, arms, legs - triamcinolone 0.1% (30 grams for $4.44)

• Palms and soles - clobetasol 0.05% (15 grams for $20.71)

Topical Steroid Frequency

• Twice a day for 2 weeks, then 2x/d every other day as needed

• Don’t stop the steroid after 2 weeks.

Atopic Dermatitis Treatment

• Repair the skin barrier

• Cream moisturizer applied daily to the entire skin surface after bathing or showering

• Stop hot water, use soap only where needed, and avoid loofahs, scrub brushes, and washcloths

Atopic Dermatitis Treatment

• Calm the inflammation• Topical steroids 2x/d when active• Topical steroids 2x/wk when clear• Hydrocortisone 2.5% cream

– Face, privates, and skin folds

• Triamcinolone 0.1% cream– Trunk, arms, legs

• Clobetasol 0.05% cream– Hands and feet

Atopic Dermatitis Treatment

• Normalize the microbiome

• Swimming pool bleach baths once weekly for 10 to 15 minutes, with 1/4 cup of bleach in a three-quarter full standard bathtub

Seborrheic Dermatitis Treatment

• Yeast overgrowth• Ketoconazole shampoo worked into a lather on the scalp, ears, face, and

neck, left on for at least 5 minutes, 3 times per week• Ketoconazole 2% cream twice daily on non-hairbearing areas that are

affected• Inflammatory response• Clobetasol solution on the scalp, twice daily when active, twice weekly

when clear• Hydrocortisone 2.5% cream twice daily as needed on the face

Scalp Folliculitis

• Clindamycin solution twice daily

• Clobetasol solution twice daily as needed

Acne Treatment

• Benzyl peroxide 4% wash followed by clindamycin lotion each morning• Gentle face wash followed by a pea-sized amount of a topical retinoid each

night • Start with OTC Differin cream, then tretinoin 0.025% cream, then tretinoin

0.05% cream• If there’s a lot of inflammation (redness), add in submicrobial doxycycline 20

mg twice daily• If female, add in Yaz or spironolactone (50 mg for 2 wks, then increase to 100

mg daily). Monitor potassium if >45 y/o, hypertensive, or renal disease.• If cystic and scarring, send to Derm for isotretinoin

Rosacea

• MetroCream apply twice daily

• Doxycycline 20 mg twice daily (submicrobial)

• Derm referral

Periorificial dermatitis

• MetroCream apply twice daily

• Doxycycline 20 mg twice daily (submicrobial)

• Derm referral

Folliculitis

• Open a pustule with an 11 blade, swab, and send for bacterial culture.

• Benzyl peroxide wash daily in the shower followed by clindamycin lotion to the affected areas

• Doxycycline 20 mg twice daily (submicrobial)

Hand dermatitis

• KOH Exam. If can’t KOH, check fingernails and toenails for dystrophy; if nails are funky, treat the hands with over-the-counter Lamisil twice daily while initiating other treatments.

• CeraVe cream (the jar, not the pump), applied to hands after each hand wash

• Nightly, have patient soak hands in lukewarm water, then apply clobetasol ointment to affected areas, followed by Vaseline to the entire hands, then wear thin cotton gloves to bed

• Derm referral

Itch Without Rash

• Test for dermatographism

• Look for dryness

• Refer to Derm

Dry Skin

• Repair the skin barrier

• Cream moisturizer (CeraVe or Cetaphil jar) applied daily to the entire skin surface after bathing or showering

• Stop hot water, use soap only where needed, and avoid loofahs, scrub brushes, and washcloths

Dyshidrotic Eczema

• Clobetasol cream

• Emollients after each hand wash

• 2-3 week prednisone taper.

• If more than 4 or 5 prednisone tapers per year, then send to derm

Hyperhidrosis

• Hyperhidrosis Society Web Page

• Aluminum chloride 20% (available on Amazon) applied to dry skin nightly for 1 week, then 2-3 nights per week.

• Robinul 1 mg daily for 3 days, then increased by 1 mg every 3 days until a max dose of 6 mg/day is reached, or symptoms abate

• Iontophoresis or referral to a cosmetic dermatologist for Botox (out of pocket)

Psoriasis

• Ask about joint swelling or prolonged morning stiffness. If positive, consult rheumatology

• Topical steroids

• Calcipotriene twice a day, every day

• Derm consult

Stasis Dermatitis

• Obtain ABI to assess for arterial insufficiency • If ABI abnormal, consult vascular surgery.• If ABI is normal, start individually fit compression stockings 30 to 40

mmHg worn all day, every day, with frequent leg elevation • Triamcinolone 0.1% ointment twice daily for 2 weeks, then every

other day, alternating with Vaseline• Strict product avoidance, as allergic contact dermatitis is

exceptionally common in these patients

Bed Bugs

• Patient to examine sleeping quarters

– Small, but macroscopic

– Bugs or any black flecks (feces) would indicate infestation

– Love crevices

• If nothing found > derm

• If positive > professional exterminator

Tinea Pedis

• KOH; if not possible, that’s OK – treat anyway

• Butenafine (Lotrimin Ultra) is better than Lamisil, which is better than miconazole/clotrimazole/ketoconazole

• Treat for 2 weeks beyond resolution

Onychomycosis

• Clip a piece of nail, put in formalin, and send to pathology with request to stain for PAS

• Cure rate for topicals is anywhere from 10 to 20%

• Cure rate for oral Lamisil for 3 months is 60-65%

• High recurrence rate: Treat toes with over-the-counter Lamisil cream twice weekly indefinitely following treatment

Warts

• Nightly: Soak wart for 5 minutes, scraped off the scale with a pumice stone or nail file, apply salicylic acid, cover with duct tape, and leave on overnight

• Monthly: Cryotherapy maintaining a freeze ball to include 1 mm of surrounding skin for at least 15 seconds

• After 3 months, send to Derm

• For genital warts, imiquimod 3x/wk

Urticaria

Urticaria

• Zyrtec titrated up to 20 mg in the morning and 20 mg in the early afternoon

• Benadryl titrated up to 50 mg nightly

• If chronic (greater than 6 weeks), perform a physical exam and obtain CBC, CMP, ESR, TSH

• If workup negative and refractory to antihistamines, refer to allergy for consideration of omalizumab, which is the best second line treatment option

Scabies

• Everyone in the house needs to be treated twice, with 1 week between treatments

• Ivermectin orally or permethrin topically; either works

• All clothing and bedding needs to be washed in hot water or put in garbage bags for 3 days

• Warn patients that they will still itch for up to 6 weeks after treatment

Poison Ivy

• Clobetasol

• 3-week prednisone taper

• Avoid the Medrol 5-day Dosepak, as the rebound flare can be worse than the original dermatosis

3 Step Algorithm for Suspicious Moles

Thank you

• Please feel free to epic message me any time for derm help!

Dermatology Clinic

Time Square

660 SW 39th St Ste 150

Renton, WA 98057

Phone: 425.690.3483

Fax: 425.690.9083

Reid_Masters@valleymed.org