“A Rash of Skin Problems” Richard E. Johnson, D.O.

A Rash of Skin Problems Richard E Johnson, DO, FAOCD January 28, 2016

Objectives

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1. Sight recognition of common dermatoses 2. Proper treatment of those conditions 3. Improper use of several common medications

Conflicts

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…my love of seasons vs. my distaste for winter …my enjoyment of patient care vs. my distaste for emr …my realization that electronic prescribing “may” be quicker vs. the human element of talking with the pharmacist is gone. …oh, so many more

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

cc: male child (5yr old )with “fungus causing nails to fall off.”

Pre-examination ideas

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1. Onychomycosis 2. Candidal onycho 3. Psoriasis 4. Trauma 5. Alopecia areata 6. hmmmmm?

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

Physical examination

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What you see is what you get….. No rashes anywhere else No hair loss or scaly scalp

Added information

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Per mom…. Oh, by the way, “Skippy” and his brother and his cousin had hand, foot, and mouth disease about 3 weeks ago.

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

And your answer, please

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1. Onychomycosis 2. Candidal onycho 3. Psoriasis 4. Trauma 5. Alopecia areata 6. hmmmmm?

Onychomadesis

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“My nails are falling off” --painless spontaneous separation of the nail plate from the bed, beginning at the proximal end with subsequent shedding of the nail as the new nail grows --It can occur idiopathically, after trauma, or in association with systemic illnesses, infections and drugs reactions --Other possible mechanisms include inflammation of the nail matrix and intensive hygienic measures resulting in maceration, Candida infection and allergic contact dermatitis. It can be seen with alopecia areata. Patients should be reassured that spontaneous regrowth of a new normal nail is usually seen within a few months.

candidal psoriasis

Alopecia areata

Onychomycosis

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

pitting

Beau’s line

onychomadesis

Extras: Beau’s lines:

Habit tic:

1. 2. 3. 4.

Psoriasis Tinea corporis Darier’s Disease Subacute cutaneous lupus 5. Nummular eczema 6. Cooties

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

Psoriasis

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Generally: 1. Uniform scale 2. Whiter scale 3. Trunk and extremities; symmetrical

Tinea

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Generally: 1. Itchy 2. Advancing leading scale 3. Dark, warm, moist areas

Tinea incognito

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“mis”-treated tinea

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

Darier’s Disease --keratosis follicularis

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Generally: 1. Worse in summer—heat and humidity 2. Inherited—family history 3. Rough, crusty, malodorous 4. Friction areas 5. Seborrheic areas 6. Controlative treatment

Subacute cutaneous lupus

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Generally: 1. Onset with red macule or papules that evolve into hyperkeratotic papulosquamous or annular plaques 2. Photosensitive—sun-exposed areas upper back, dorsum arms, V of neck 3. Typically heal without scarring but may resolve with vitiligo like leukoderma

Cooties

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coot·ie ˈko͞otē/ plural noun: cooties 1. a body louse. 2. a children's term for an imaginary germ or repellent quality transmitted by obnoxious or slovenly people.

Just an observation: …if patient is under 10… ”what you get from touching the opposite sex” …if patient over 14… ”what you get from touching the opposite sex”

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

1. Psoriasis 2. Tinea corporis 3. Darier’s Disease

4. Subacute cutaneous lupus 5. Nummular eczema 6. Cooties

Subacute Cutaneous Lupus

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UV protection Topical steroid for localized disease More widespread disease, in addition to above: Plaquenil® hydroxychloroquine eye exams baseline and q 3-6mos. blood work: cbc, comp

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

1. Tinea corporis 2. Candidal intertrigo 3. Inverse pityriasis rosea 4. Psoriasis

Tinea corporis

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Generally:

1. Advancing leading scale 2. Centrally clears 3. Itchy 4. Recurrent, ongoing tx

Candidal intertrigo

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Generally: 1. 2. 3. 4.

Bright color Satellite lesions ??Painful > itch Mixed flora yeast and dermatophyte

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

Inverse pityriasis rosea

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Generally: 1. PR morphology following scale as opposed to leading scale

2. ?recent URI? 2. Sudden onset with or without herald patch …… ….

Psoriasis

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Generally: 1. Other lesions supportive of diagnosis 2. ?Family history of psoriasis 3. Intertriginous areas-sweat and friction rub off scale leaving a “galled” look

Extras:

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Groin rashes in male: generally will NOT see tinea on scrotum stratum corneum is so thin, no place for fungus to “live.”

rash on scrotum: yeast/candida possible much more common: red angry scrotum syndrome

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

Good time for a transition

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Three No-s to Know

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--welcome to Rick’s soapbox

Lotrisone® poor choice of medicine for where it is often used

Mycolog® ditto

Medrol® Dosepak Dr. Conroy, “If you only need one unit of blood, you don’t need one unit of blood.”

Lotrisone

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Clotrimazole and betamethasone NOT for crease areas or face steroid acne striae ulcers rebound

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

Alternatives

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Antifungal or anti-inflammatory Naftifine (Naftin®) study “last century” showed their product as effective as anti-inflammatory as Lotrisone®

If truly a tinea issue, treating the fungus will treat the itch.

Fungicidal vs fungistatic

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--cidals kill --statics inhibit growth, depending on epidermal turnover to rid the body of fungus. Fungi replicate so slowly, that’s why therapies take a long time. Often patients will d/c med when visually clear, leading to recurrences. Cidals: terbinafine, naftifine, ciclopirox, butenafine, nystatin Statics: clotrimazole, miconazole, ketoconazole, econazole

Several “add-on” points

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Allylamines: terbinafine, naftifine, and butenafine less effective against yeast (candida) than azoles (oral terbinafine NOT effective for tinea versicolor) Azoles: clotrimazole, miconazole, ketoconazole, econazole “better” suited for yeast

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

A couple of more points

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Lotrimin® is clotrimazole, but Lotrimin Ultra® is butenafine You generally don’t need an anti-inflammatory product as “strong” as betamethasone if underlying reason for itch is treated. Econazole comes in an 85 gm tube others in 45 gm or 60gm Ciclopirox comes in a 90 gm tube, other in 30 gm or 60gm

Mycolog®

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Nystatin and triamcinalone (often times NOT needed) Not for crease areas or face striae atrophy ulcers steroid acne ONLY covers candida, NOT dermatophytes most “yeast” infections are mixed flora—treat yeast and dermatophyte with topical antifungal

Alternatives

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See Lotrisone® discussion Nystatin powder ~$60 and still only “covers” candida Miconazole (Zeasorb®) powder better alternative better coverage and cheaper….. but not Rx

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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“A Rash of Skin Problems” Richard E. Johnson, D.O.

Medrol Dosepak®

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1. 21 tablets of methylprednisolone 4mg Medrol = 5mg prednisone 2. Tapered dosing 3. “Convenience” ??

Symptoms without treatment

Rebound! Medrol® started

contact

day

Symptoms WITH treatment

2-4 weeks

Just a thought or two or three 0r four

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**Medrol dosepak® =~ $60++ 30 5mg prednisone =~$10 **Splitting dose is not necessary—adds to patient confusion **Tapering dose is “not” necessary —I still do it though 100mg daily x 3 weeks—no adrenal suppression **“Make up” a dose using 10mg or 20mg tablets

POMA District VIII 29th Annual Winter Seminar January 28-31, 2016

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