The Red Face and Scalp

The Red Face and Scalp
Misha Miller, MD
Assistant Professor, University of Colorado
Department of Dermatology
Dermatitis
1.1% of All Outpatient Visits
Non-dermatologists
4,793,00
The majority of cases are
seen by NON-dermatologists!
Dermatologists
2,184,000
Types of “Dermatitis”
• Allergic contact dermatitis
• Irritant contact dermatitis
• Atopic dermatitis (“eczema”)
• Nummular dermatitis
• Dyshidrotic dermatitis (pompholyx)
• Seborrheic dermatitis
• Exfoliative dermatitis
Allergic Contact Dermatitis
Pathogenesis
• Topical allergens
• > 85,000 chemicals in the environment
• > 3,700 chemicals are known allergens
• Type IV - DTH reaction
• Initial exp - 5-21 days, (sensitization)
• Subsequent exp - 1-3 days, (elicitation)
Most Common Allergens
• Nickel
14.3%
• Quaternium-15(preservative)
• Neomycin
9.6%
9.0%
• Formaldehyde (preservative)
• Thiuram mix (rubber)
7.8%
7.7%
• Balsam of Peru (fragrance mix)
7.5%
• p-phenylenediamine (hair products)
6.3%
• Carba mix (rubber)
4.8%
Allergic Contact Dermatitis
Clinical Features
• Marked pruritus
• Configurations
• follows contact initially
• may spreads beyond contact site (later)
• Erythema, induration, vesicles, bullae
• New lesions persist for up to 3 weeks!
Allergic Contact Dermatitis
Diagnosis
• Careful history
• Clinical presentation
• Biopsy - helpful but not specific
• Patch testing
Allergic Contact Dermatitis
Treatment
• Withdrawal of offending agent(s)
• Topical corticosteroid (ointment?)
• Antihistamines (sedation?)
• Hydroxyzine (Atarax®) - moderate sedation
• Cetirizine (Zyrtec®) - lesser sedation (? less efficacy)
• Fexofenadine (Allegra®) – little sedation (? lesser efficacy)
• Oral corticosteroids (poison ivy)
Principles of Corticosteroid Therapy
• Ointment > cream > gel > solution > spray
• Occlusion increases potency
• Amount
• 15 grams for whole body one time
• 1 gram for both hands
• Absorption site dependent (scrotum 290x > sole)
• Scrotum>cheek>scalp>back>forearm>palm>sole
• Avoid fluorinated steroids on face
• Superpotent steroids - atrophy in as few as 7 days
Topical Corticosteroid Potency
• Super potent (~ 1500 times > hydrocortisone)
• Clobetasol (Temovate®)
• Halobetasol (Ultravate®)
• Betamethasone diproprionate (Diprolene®)
• High potency (100-500 times > hydrocortisone)
• Amcinonide (Cyclocort®)
• Fluocinonide (Lidex®)
• Mid potency (10-100 times > hydrocortisone)
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Betamethasone valereate (Valisone®)
Fluocinolone (Synalar®)
Hydrocortisone valereate (Westcort®)
Mometasone furoate (Elocon®)
Triamcinolone (Kenalog®, Aristocort®)
• Low potency (1-10 times > hydrocortisone)
• Aclometasone (Aclovate®)
• Desonide (DesOwen®, Tridesilon®)
Irritant Contact Dermatitis
Pathogenesis
• Direct toxic injury to the skin
• More common than ACD (<75%)
• Common causes
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Soaps (bath soap, dishwashing liquids)
Cleansers
Alcohols
Glues/cements
Deodorants
Irritant Contact Dermatitis
Clinical Features
• Strong irritants
• Immediate burning & stinging
• Erythema & edema
• Vesiculation
• Mild irritants
• Hours to days
• Mild erythema
• Scaling & fissuring
Irritant Contact Dermatitis
Diagnosis
• Clinical history
 Strong irritants - self-evident
 Mild irritants - extensive history
• Clinical presentation
• Biopsies - not particularly helpful
• Patch testing - useful to exclude
allergic contact dermatitis
Irritant Contact Dermatitis
Treatment
• Withdrawal of offending irritant
• Withdrawal of other irritants (soaps)
• Moisturizers (Lachydrin®)
• Corticosteroids - mild to moderate
Atopic Dermatitis
Epidemiology
• Atopy is inherited (70% pts with + FH)
• Atopic diathesis (classic triad)
• Allergic rhinitis
• Asthma
• Atopic dermatitis
• Prevalence of atopy in US around 17%
(and increasing)
Atopic Dermatitis
Clinical Features
• Dermatitis
• erythema, excoriations, lichenification
• face/extensors (infants)  flexural (children)
• hand dermatitis in adults
• Xerosis
• Keratosis pilaris
• Ichthyosis vulgaris
• Dennie-Morgan lines
• Pityriasis alba
Atopic Dermatitis
Diagnosis
Three of four major criteria:
• Presence of pruritus
• Morphology & distribution for age group
• Chronic or relapsing dermatitis
• Personal of family history of atopy
Aggravating Factors in 2501 Children Atopic
Dermatitis
Br J Dermatol 2004; 150: 1154-61.
• Sweating
• Hot Weather
• Fabrics (wool)
• Illness
• Dust
33%
• Sea swimming
• Anxiety/stress
• Cold weather
• Animals
• Grass
• Soaps/shampoos 26%
42%
40%
39%
36%
30%
28%
28%
28%
27%
Atopic Dermatitis
Treatment
• Removal of irritants/triggers
• Food elimination diets - controversial
• Lubrication - generous & bland
• Topical corticosteroids (mild to potent)
• alternatives = tacrolimus or pimecrolimus
• Oral antihistamines (hydroxyzine)
Excellent Moisturizers
• Vaseline® (no irritants)
• Cetaphil®
• Aquaphor®
• Eucerin Plus®
• Sodium lactate + urea
• AmLactin®/LacHydrin®
• 12% ammonium lactate
Seborrheic Dermatitis
Adult Presentation
• Appears after puberty
• “Seborrheic” distribution
• scalp, eyebrows, eyelashes, nasolabial folds, auditory
canal, auricular areas, presternal area, umbilicus,
anogenital area
• Erythema, white/yellow, greasy scale
• Pruritus varies - absent to severe
Seborrheic Dermatitis
Diagnosis
•Clinical presentation
•Distribution
•Biopsy usually not indicated
• can be highly suggestive
Seborrheic Dermatitis
Treatment
• Low potency steroids (HC 1-2.5%, desonide)
• Combination agents - (HC + iodoquinol)
• Topical imidazole (ketoconazole)
• Systemic imidazoles - Sporanox®
• 200 mg/day x 7 d then 200 mg/day 2 d/mo
• 19/28 with complete clearing at one year
• expensive & contraindicated in liver disease
Seborrheic Dermatitis
Hair Bearing Skin
• OTC anti-dandruff shampoos
• Keratolytic shampoos (Neutrogena T Sal®)
• Ketoconazole shampoo (Nizoral®)
• J&J Baby Shampoo® - use near eyes
• Steroid solutions (cheap but oily)
• Steroid foams - betamethasone & clobetasol,
wonderful vehicles but very expensive
Exfoliative Dermatitis/Erythroderma
Clinical Presentation
• Diffuse erythema and scaling
100%
• Pruritus
36%
• Malaise
34%
• Palmar/plantar keratoderma
34%
• Lymphadenopathy
26%
Exfoliative Dermatitis
Pathogenesis in 236 Patients
• Idiopathic
• Drug-induced dermatitis
• Pre-existing skin disease
• Lymphoma/leukemia
• Atopic dermatitis
• Psoriasis
• Contact dermatitis
30%
28%
25%
14%
10%
8%
3%
Exfoliative Dermatitis/Erythroderma
Diagnosis
• History - drug use, known skin disorder
• Clinical presentation
• Biopsy definitive in 43% of cases
• CBC - striking eosinophilia favors drug
Exfoliative Dermatitis/Erythroderma
Treatment
• 34% clear spontaneously (~ 7 years)
• Diagnosis known - treat specific entity
• Idiopathic
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lubrication
topical corticosteroids
oral antihistamines
oral prednisone (rarely)
UVB or PUVA therapy
Rosacea
• Disease of unknown cause that results in:
• facial flushing, erythema, and telangiectasias
• acneiform papulopustular eruption
• Common in certain ethnicities
• “Curse of the Celts”
• Differs from acne  no comedones
• Affects only adults
Rosacea
Four Main Subtypes
1. Erythematotelangiectatic
2. Papulopustular
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granulomatous
3. Phymatous
4. Ocular
It is certainly possible to have more than one
subtype or overlapping types.
Rosacea
Patient Education
• Chronic condition (waxing/waning)
• Precise cause unknown
• demodex, H. pylori, ROS, UV damage etc. ?
• Treatments but no cures
• Protect from sun and avoid other triggers
• EtOH, caffeine, tomatoes, wind, etc.
• Use only gentle cleansers & moisturizers
Rosacea
Treatment
• Topical medications
• metronidazole – now qd formulations availablef
• azelaic acid 15% – preferred head:head with MTZ
• sodium sulfacetamide – lowest irritation, least efficacy
• Oral medications
• TCN and macrolide families of antibiotics
• Other
• calcineurin inhibitors (Protopic, Elidel)
• green tinted make-up, “redness relief” formulas
• Papulopustular responds more than
erythematotelangiectatic
Azelaic Acid
(Finacea™ 15% Gel)
• A dicarboxylic acid
• Highest concentration in corn flakes
Bottom Line: Azelaic acid 15% gel had modest benefits over metronidazole
0.75% gel, but was not as well tolerated. Both medications are reasonable
treatment options, and the choice depends upon patient preference/tolerance.
Sub-antimicrobial DCN Dosing
• Oracea (40 mg immediate, 10 mg delayed release)
Brimonidine Topical Gel
• Topical gel, alpha agonist
• Non transient facial erythema
• Vasoconstriction of superficial facial vasculature
• Once daily application, peak erythema redution of ~ 6 hrs
• Return of facial erythema to less severity than prior to use
• Rebound?
Brimonidine Topical Gel
• Side Effects
• Skin irritation, burning sensation
• Flushing
• Redness
• May interact with
• Beta blockers
• Antihypertensives
• MAO inhibitors
Topical Ivermectin
Targets Demodex mites
Anti-inflammatory effects
Treats erythematelangiectatic, papulopustular rosacea
Once daily application
~40 pts reported clear to almost clear
Rosacea Treatment Controversy
Retinoids in Roscea
• Conventional wisdom - ‘avoid retinoids’
• In practice, certain subsets of patients may benefit
from low-strength retinoid:
• patients with patulous follicles
• ‘oily’ patients
• sun-damaged patients whose skin quality will be
improved if the retinoid is tolerated
Acne
• Multi-factorial disease process
• genetics, hormones, environmental factors
• Most Americans affected
• 45 million with acne at any moment
• 70% with enough acne to seek medical care
• 20% with acne severe enough to scar
• direct cost to society exceeds $1 billion USD
Acne
Subtypes
• Comedonal
• whiteheads/blackheads
• Inflammatory
• papules, pustules, nodules, cysts,
sinus tracts
• Most acne is mixed
• Successful treatment interrupts
these processes
Four Tiered Grading Schema
• Grade I – mild acne
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comedones in any number
minor (small) and few papules
no inflammation
• Grade II –moderate acne
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comedones generally in greater numbers
more papules and formation of pustules
slight inflammation of the skin is apparent
• Grade III - severe acne
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increasing amount of inflammation
skin is erythematous and inflamed
papules, pustules and nodules will be present, scarring probable
usually involves other body areas (neck, chest, shoulders, back)
• Grade IV – critically severe nodulocystic
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numerous papules, pustules, nodules, and cysts
pronounced inflammation
often painful
may involve nearly entire back, chest, shoulders, and upper arms
scarring inevitable
Simplest Grading
Scheme for Acne
• Mild - comedones and few papulopustules
• Moderate - comedones, inflammatory papules, and
pustules in greater number
• Severe - comedones, inflammatory lesions, and large
nodules (>5 mm), often with clearly apparent
scarring
Acne Treatments
Targeting Different Points in Pathophysiology
• Comedolytics (salicylic acid, BPO, retinoids)
• improve follicular maturation & reduce plugging
• Topical anti-inflammatory agents
• retinoids comedolytic and block inflammation
• Topical antibiotics (BPO, erythro/clindamycin)
• reduce counts of P. acnes on skin
• Oral antibiotics (mostly TCN & macrolide families)
• likely anti-inflammatory and antibacterial roles
Acne Treatment
Comedolytics
• Salicylic acid (0.5 to 2%)
• pros: OTC, well tolerated
• cons: effective only for mild acne
• Benzoyl peroxide (2.5 -10%)
• pros: OTC, no significant resistance in P. acnes
• cons: bleaches clothing, allergic potential
• Tretinoin (0.025 to 0.1%, gels, creams, other)
• pros: generics available, also anti-inflammatory
• cons: drying, net effect on sun-protection debated
• Adapalene (Differin™) (0.1% cream, 0.1% & 0.3% gel)
• pros: less irritating than other retinoids
• con: underpowered in more advanced acne
Acne Treatment
Comedolytics
• Adapalene 0.1% + BPO 2.5% (Epiduo™ gel)
• pros: dual-action, well-tolerated, other advantages of BPO
• cons: variable coverage, BPO bleaches fabrics
• BPO 5% + 3% erythromycin (Benzamycin™)
• pros: generic available
• cons: supposed to be refrigerated after use
• BPO 2.5% + clindamycin (Acanya™)
BPO 5% + clindamycin (Benzaclin™, Duac™)
• pros: well-tolerated, elegant, once daily indication
• cons: underpowered beyond mild acne, expensive
Acne Treatment
Retinoids - Anti-Inflammatory
• Improve follicular differentiation
• Thinned stratum corneum, prevent plugging
• Also block inflammation
• prevent TLR-2 receptor activation by P. acnes
• Many agents/formulations available:
tretinoin – first, generic available
adapelene – probably least irritating
tazarotene – probably most irritating
Acne Treatment
Antibiotics: Topical & Oral
• Inflammatory acne usually needs antibiotic
• Topical vs. Oral
• Topical abx (erythro/clindamycin)
• for mild inflammatory acne
• use in combination with BPO (prevents resistance)
• Oral antibiotics
• TCN family favored for anti-inflammatory properties
• relative strength: TCN << DCN < MCN
• macrolides useful in preg patients or those unable to take TCNs
• TMP/SMX used in treatment resistant cases
• oral abx must be removed slowly while maintenance tx con’t
Graded Approach (Simplified)
• MILD
Comedonal: topical retinoid
Inflammatory: topical abx/BPO + topical retinoid
Alternatives: salicylic acid, azelaic acid, sulfacetamide
• MODERATE
Papulopustular: oral abx + BPO + topical retinoid
Alternatives: OCP + spironolactone (women only)
• SEVERE
+/- Initial Trial: oral abx + BPO + topical retinoid
Mainstay: place on isotretinoin (Accutane™)
Acne Treatment
Managing Expectations
• Realistic goals are important:
• inform pts that abx effects not immediate
• f/u at 2-3 months, but should call if compliance is not
possible for any reason
• 50% improvement at 3 months = ‘on track’
• acne “not cured” but “managed”
• maintenance Rx needed for years
• scarring dealt with separately after new lesions are no
longer developing
Acne Treatment
Resistance to Antibiotics
• Resistance to erythro/clinda and TCN/DCN is high in
some communities
• “Addition of BPO to any regimen decreases the
development of resistance”
• Monotherapy strongly discouraged
• Avoid PRN use of abx where possible
• Newer regimens of low-dose DCN or
lowdose/extended-release MCN promoted
Acne Treatment
Isotretinoin
• Systemic retinoid
• Difficult to use
(physically/bureaucratically)
• 5 month course
• ~ 25% relapse rate
• Side effects:
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dry lips, eyes, nose
teratogen
hyperlipidemia
? SI/HI ? (controversial)
Acne Treatment
Special Considerations - Women
• “Beard distribution”
• Few comedones
• Described as:
• ‘deep’, ‘no head’,
‘painful’,
‘long lasting’
• Spironolactone
• must follow K+ levels
• Oral contraceptives
• low estrogen
(cyproterone acetate, levonorgestrel)
Acne Case #1
• 13 y/o AA girl
• blackheads x 6 months
• tried OTC BPO and “even
Proactiv”
• minimal benefit
• today is ‘typical’ day
What is next for her?
Acne Case #1
• Mild acne
• mostly comedonal, minimal inflammatory component
• ask about “pomade” component
• Reasonable starting treatment:
• tretinoin cream 0.025 to 0.05% (slow advance to qhs)
• BPO + erythro/clinda ($4 drugs) or combination agent
• Follow-up in 3 mos, goal of 50% improvement
• Poor response  increase retinoid strength
• Inflammatory component  go to oral abx
Acne Case #2
• 15 y/o boy
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acne x 1 yr
no treatment
“average day”
mom believes acne is
related to “lots of burgers
and fries”
• trunk is not involved
What is next for him?
Acne Case #2
• Moderate acne
• mostly inflammatory component
• no evidence that is related to “burgers and fries”
• Reasonable starting treatment:
• oral DCN/MCN 100 mg BID
• topical BPO + retinoid (separately or in combination)
• +/- topical BPO/topical abx in combination (if retinoid separate)
• Follow-up in 2-3 mos, goal of 50% improvement
• Poor response  increase retinoid strength
• Inflammatory component increases  ? isotretinoin
Acne Treatment
Side-Effects of Medication
• Topical comedolytics/retinoids
• all are drying and irritating
• start retinoids slow (2-3 eve/wk), advance to qhs
• watch for bleaching of fabrics with BPO
• Oral abx
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GI upset (avoid dairy with TCN/DCN > MCN)
MCN can cause vertigo (begin qhs only)
UV sensitivity: DCN > MCN
pigmentation & lupus like syndrome with MCN
Acne Treatment
TCN-class Side-Effects
Perioral/Periocular Dermatitis
• Erythematous, monotonous, and slightly exczemaotus
papules around mouth/eyes
• Most common in women 20-45 y/o
• May occur idiopathically or be provoked by use of
strong fluorinated steroid on face
• Fluorinated toothpaste implicated by some
Perioral Dermatitis
Treatment
• Oral tetracyclines for 2 months
• If problem is related to potent steroids
• wean with HC 1-2.5% to replace ‘addiction’
• pimecrolimus showed benefit in one study
• do not use ointments
• “ZERO-THERAPY” likely effective
• requires perfect compliance
• toleration of initial flare
• Oral isotretinoin for rosacea fulminans or treatment
resistant cases
Lupus Erythematosus
Clinical Features
• Discoid lupus erythematosus
• Fixed plaques with variable scarring, follicular
plugs, hyperkeratosis, pigmentary changes
• 2-5% may progress into SLE
• Subacute cutaneous lupus erythematosus
• Nonspecific erythema
• Annular erythema
• Psoriasiform variant
Lupus Erythematosus
Diagnosis
• Clinical presentation
• SCLE - SSA (anti-Ro) antibodies
• Skin biopsy - consistent with or
diagnostic if classic
• Direct immunofluorescence studies
Lupus Erythematosus
Treatment
• Sunscreens- broad spectrum
• Parsol 1789 - Presun Ultra®
• Pure titanium dioxide - Neutragena Sensitive Skin
• Topical corticosteroids - potent
• Intralesional corticosteroids for DLE
• Oral corticosteroids
• Oral antimalarials