Treatment of Early Stage Disease

Treatment of Early Stage Disease
Oleg E. Akilov, MD, PhD
Department of Dermatology,
University of Pittsburgh Medical Center
Early disease
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patches or plaques less than 10% of BSA
No lymphadenopathy
No blood involvement
No lymphoma in internal organs
No. 1 treatment option?
Do nothing!
• Life expectancy at this stage of the disease is
similar to the general population
• Watchful waiting approach is acceptable
• Proper skin care with emphasis on prevention
of dryness, irritations and infection
SKIN CARE
• Ordinarily, the skin is covered with a thin
layer of oil which acts as a protective
agent and seals in water.
• When this is removed, or if you are
producing a deficient amount of oil, your
skin will dry out very quickly.
• Therefore proper water content and oiling
of the skin is most important and may
prevent the development of a rash.
General Sensitive Skin Care
• Temperature:
– Do not let your skin become cold - wear warm clothes
• Humidity
– Humidifiers or flat pans of water on radiators
• Clothing
– Wool and pure synthetic fabrics are very irritating.
– Closely fitting garments such as long-johns and long
stocking may irritate as well.
– The best fabric for sensitive skin is cotton or cottonsynthetic mixtures.
• Bedroom :
– Your bedroom should not be overheated
– Avoid sweating while sleeping.
– Good humidity is particularly important in this room.
• Bed Clothing
– should be smooth cotton or cotton-synthetic mixtures
- not flannel.
– Sheers and pillow cases should not be starched.
• Laundry Detergents:
– Your detergents should be unscented without bleach
– no bleach, fabric softeners, or dryer sheets.
Bathing
• Water must be lukewarm not hot.
– Avoid long baths or showers. Do not let your skin become coldwear warm clothes
• This soap must be used sparingly and not at all
on areas which are dry and/or irritated.
– Use mild, unscented soap.
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Keep the bathroom temperature cool.
- If the room becomes hot and steamy, dry in another room
• Pat yourself dry with a soft towel. DO NOT RUB.
• While still damp, apply a moisturizer/emollient
Soaps and shampoo for sensitive skin
Avoid perfumes and dyes in soaps
Bath
• Oatmeal
• Aveeno: Slowly sprinkle packet of colloidal
oatmeal directly under the faucet into the tub
• Make your own: 1 cup of regular oatmeal into 2 layer
of cheesecloth; tie securely into a small pouch
• Antibacterial
• Clorox bleach or white vinegar
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1/2 cup per one-quarter filled bath
Bath for 5 min;
Do not scrub, do not scratch open skin areas.
Dry skin thoroughly, and generously apply cream
Moisturization
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CeraVe cream
Cetaphil Restoraderm
Eucerin,
Lubriderm
Curel
Aveno
Apply this twice daily and more often if the
skin appears dry and scaly.
Hand cream products
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CeraVe hand cream
Theraplex emollient
Neutrogena
Vaseline
Special conditions
Scales/rough skin
Thickening of the palms
and soles
Fissures on the palms and soles
To smooth the skin:
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Carmol 20/40
Amlactin 12
Lac-Hydrin 12
Salicylic acid 6
can sting and burn initially, gradually improves with continued use
To treat hyperkeratosis of palms
and soles
• Sea salt bath:
– 2 tbs per ½ gallon of water
• Salicylic acid 20 /Urea 40
• Clobetasole 0.01% ointment
• White cotton gloves and
sock o/n under occlusion
under the soaks
• Gel spa gloves and soaks
Home Depot
Walgreens
Gel spa gloves
$6.17 pair
$39.99/24
$1.66 pair
$2.25 pair
~$50
Esafety supplies
$0.69 pair
Allederm
$2.29 pair
To seal the fissure:
• Cyanoacrylates:
– Demabond (J&J
– New-Skin (Med20)
– Nexcare (3M)
• Super glue (Krazy glue)
– Bacroban under/into erosions
– Wipe it out
– Superglue on the top
Therapy of pruritus
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Sarna Lotion
Pramoxine lotion
Zolinza 200 mg qHS
Doxepin/gabapentin/anthisitmins
Therapy of early stage disease
First line Tx:
1. Watchful waiting approach/emollients
Skin-directed therapy (SDT):
1. Topical steroids
2. Nitrogen mustard
3. Light therapy
Second line Tx:
1. Bexarotene gel
2. Imiquimod gel
Topical steroids
-Eliminate malignant lymphocytes
-Modest efficacy
-Can be used a mop-up agent
-Very useful for itching
-Excessive use can cause atrophy
Face/Neck
Armpits/Groin
Trunk
Palms/soles
Thick plaques
Wraps
• After bath
• Apply topicals all over
• Lock the moister in
– Do not dry the skin completely
– smother the topical medication all over
• Wear old cotton clothes (PJs, long
underwear, T-shirts)
• Sleep in it
Nitrogen mustard
• Ointment compounded 0.01-0.04% in
450g of Aquaphor) apply o/n;
• High degree of efficacy
– Usually in 4 to 6 weeks
• Highly irritating
– itching and redness are always present
– Moreover, indicator of proper concentration
• Shower in AM + TAC 0.1% in AM
• May use long-term
• Medicare/Medicaid do not cover
Nitrogen mustard
• Does not get into blood stream
• No systemic toxicities
• BUT: be careful applying this medication
– Wear disposable cotton gloves
– Prevent getting medication under the
fingernails = prevent getting into mouth or
eyes
– Use soap and water afterwards
Light therapy
• Natural sun light
• UVB
• NB UVB
– Excilite
• PUVA
Does not work for thick plaques
May increase a risk for skin cancer
Useful as maintenance therapy
Natural Sun Light
Tan Through Swimwear
www.tanthrough.com
UVB
is more effective than broadband UVB with efficacy approaching PUVA.
-Broad band UVB 290-320 nm
-Narrow band UVB 308-313 nm
-Both wavelengths more selective than the sunlight
PUVA is an acronym
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P = Psoralen – drug required for therapy
U = Ultra
V = Violet
A = A wavelength
PUVA advantages:
• More effective than NB UVB, especially with
regards to duration of therapeutic effect
• Less frequent maintenance schedule
• Penetrates deeper than UVB
Imiquimod
• Irritating
• Comes in small
sachets
• Gradually increase
application: every
other day, daily, BID
by tolerance
• Area after the
treatment may be
more white than the
other skin
In conclusion
• Various topicals exist for treatment of
CTCL
• If you don’t like for some reason your
medication, talk to your doctor – there are
other option
• It is important to rotate medications from
time to time to prevent resistance
• Combination is helpful