Scleroderma Foundation Greater Washington, DC Chapter 2015

Scleroderma and Skin of Color: Unique Problems Christine A. DeWitt MD Georgetown University School of Medicine MedStarWashington Hospital Center Department of Dermatology

Dr. DeWitt has no conflicts of interest to report.

Scleroderma in Skin of Color: Concerns • • • •

Digital ulcerations Dryness & Itch Discoloration Vitamin D needs

Digital Ulcerations • 40% patients with scleroderma

Digital Ulcerations • Control Raynaud phenomenon • Avoid trauma • Infection control – May need rx or antibiotics – Topical antibiotics • OTC triple and double antibiotic ointment (Neo/Polysporin) • Rx bacitracin ointment (effective against MRSA)

• Wound care

Digital Ulcerations Wound care – Daily gentle cleansing – Hydrogen Peroxide • Half strength if crust present (can cause tissue destruction

– Vinegar soaks • Acetic acid is antibacterial, astringent • Symptomatic relief • Soak with cotton, gauze or cloth x 10-15 min Recipe: 1 part white vinegar to 10-40 parts water

– Cover with ointment • Avoid “scabbing over”

– Cover with bandage

Dryness & Itch • Major cause of concern in scleroderma • Very difficult to manage • Chronic, due to inflammation and tightening

Gentle Cleansing The “Rules” – AVOID physical exfoliation • Peach pits, sugars, salts, minerals, crystals • Loofahs, puffs

– Use hands or soft cloth – Gentle soaps or non-soaps • Dove • Cetaphil • CeraVe

– Avoid those with fragrance, added ingredients, colored, or “medicated” soaps

Dryness & Itch

• Dryness (ashy skin)

– Emollient moisturization • Vasoline • Cocoa/shea butters, Eucerin cream, • Gloves in a Bottle, TheraSeal

– Humectants • Exfoliates via loosening skin cell bonds – Opposed to scrubs, is more gentle

• Traps/locks moisture in skin – Best time is immediately after washing when skin is moist

• Lowers pH – Skin is naturally acidic, necessary for immune function

Dryness & Itch

• Dryness (ashy skin)

– Emollient moisturization • Petroleum jelly/Vasoline • Butters, heavy creams, oils • Dimethicone, simethicone

– Humectants- consult with provider first! • Alpha hydroxy acids – Glycolic acid, lactic acid, urea

• Separate needs for face versus body – Face: glycolic acid – Body: » OTC: Eucerin Plus, Amlactin U-lactin » Rx: LacHydrin, Carmol (urea)

Itch Antihistamines • OTC – Benadryl (diphenhydramine) – Non-sedating antihistamines • Zyrtec • Claritin • Allegra (no sedation risk)

• Rx: – Atarax/hydroxyzine – Doxepin

Itch • Cooler, quicker showers • Avoid harsh detergents – Bar soaps, dish detergents

• Use gloves if doing work with chemical or irritatants – Yellow gloves with cloth lining

• Moisturizers with camphor or menthol – Aveeno, Eucerin, Sarna

Discoloration • Greater tendency in skin of color • Post-inflammatory hyperpigmentation • Salt-and-pepper sign – White skin with retention of skin

Discoloration • Sun protection • Retinoids • Hydroquinone

Methods of Sun Protection • • • •

A tan or naturally dark skin is NOT protective Avoid the sun-stay indoors during peak hours Sun protective clothing, hats, and sunglasses Sunscreens for UVA and UVB (“wide spectrum”)protection – High SPF>30

• Physical “barrier” sunscreens – Zinc oxide – Titanium dioxide

Retinoids • Vitamin A derived medication • Available only by prescription – Retinol formulation available OTC

• Evens skin pigment by improving cellular turnover • Can cause irritation so

Hydroquinone • “Bleaching” cream • Turns off the enzyme (tyrosinase) that makes pigment • Essential use of sun protection • Available OTC and by prescription – 2% formulation- otc – 4% forumation- rx

• Overuse can cause oochronosis, a paradoxical darking in the skin

Vitamin D needs • Vitamin D is made in the skin • Because of melanin in skin, higher doses of UV are needed to generate vitamin D in the skin – NOT recommended

• Necessary for: – Bone and muscle health – Healthy heart – Immune system function – Cancer prevention

Vitamin D Deficiency • What is considered deficiency? – >30 ng/ml for bone health – >80 ng/ml for immune health *Toxicity is not seen below serum levels of 100 ng/ml

• Why the “epidemic” of deficiency? – – – – –

Low exposure to sunlight Melanin blocks production in skin of color Genetic polymorphisms (RA, MS, IBD, IDDM) Low nutritional intake Low bioavailability in obese due to sequestration in adipose tissue – (We’re looking for it)

Vit D deficiency & Scleroderma • 156 patients • Insufficient = 10-30 ng/ml • Deficient =