dermatology for the non-dermatologist 4/30/2021
TRANSCRIPT
![Page 1: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/1.jpg)
DERMATOLOGYFOR THE
NON-DERMATOLOGIST4/30/2021
Megan N. Landis, MD
Clinical Associate Professor of Dermatology
University of Louisville, Division of Dermatology
Dermatology and Skin Cancer Center of Southern Indiana
Corydon, IN
![Page 2: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/2.jpg)
DISCLOSURES
• Investigator and/or Consultant: Abbvie, Celgene, Cutanea, Dermira, Foamix, Galderma, Incyte, Kadmon, Novartis, Novum, Ortho Dermatology, Pfizer, Regeneron, Sanofi Genzyme, Symbio
•
Information presented is based on evidence-based recommendations and well designed published studies
![Page 3: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/3.jpg)
OBJECTIVE
• To Make Your Life Easier!
• Skin issues frequently seen in primary care, common conundrums, pitfalls to avoid
• High yield clinical pearls
![Page 4: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/4.jpg)
ACUTE ALLERGIC CONTACT DERMATITIS
• Linear vesicles in rash (poison ivy)
• Localized: topical corticosteroids
• Diffuse: long, slow prednisone taper over ~21 days (avoid rebound)
![Page 5: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/5.jpg)
RECURRENT OR CHRONIC ALLERGIC CONTACT DERMATITIS
• Patch testing
![Page 6: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/6.jpg)
CASE #2
Which treatment is absolutely contraindicated for this patient?
A. Topical clobetasol 0.05% ointment
B. Oral corticosteroids
C. Phototherapy (nbUVB)
D. Cyclosporine
![Page 7: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/7.jpg)
PSORIASIS:
TOPICAL THERAPIES
• Topical Anti-inflammatories• Topical steroids
• Topical tacrolimus or pimecrolimus (face, underarms, groin)
• Keratinocyte Proliferation Modulators• Vitamin D analogues (calcipotriene)
• Tazarotene (palmar/plantar involvement)
![Page 8: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/8.jpg)
PSORIASIS:
SYSTEMIC THERAPIES
•NO ORAL/SYSTEMIC STEROIDS: severe flare upon withdraw
• Phototherapy
• Cyclosporine
• Methotrexate
• Biologics
• LOOK for joint involvement: permanent destruction (nails = greater risk PsA)AAD.org
![Page 9: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/9.jpg)
PSORIASIS
• Chronic disease, primarily of skin and joints; may wax and wane
• ~2% of US population
• 30% have family history
• Onset most commonly ages 20-30 and 50-60yrs
• 80% of patients have mild to moderate disease (<5% BSA)
• 20% have moderate to severe disease (>5% BSA OR affecting crucial body areas – hands, feet, face, scalp, or genitals)
AAD.org
![Page 10: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/10.jpg)
PSORIASIS: TYPES
• Plaque (most common)
• Inverse/flexural/genital
• Erythrodermic
![Page 11: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/11.jpg)
PSORIASIS: TYPES
• Guttate (often preceded by strep pharyngitis)
• Palmoplantar pustular
• Generalized pustular (von Zumbusch variant) – severe, life-threatening, often due to systemic steroid withdrawal
• Nail psoriasis
![Page 12: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/12.jpg)
PSORIASIS:COMORBIDITIES
Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol2013;79:10-17
IMPORTANT: -Screen psoriasis patients for joint involvement (30%)
-Monitor psoriasis patients for comorbidities routinely
![Page 13: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/13.jpg)
PSORIASIS
• Localized plaque type often managed by PCP
• All other types of psoriasis often referred to derm
![Page 14: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/14.jpg)
MOLLUSCUM
• BOTE sign: Beginning Of The End
• Inflammatory phenomenon, often precedes resolution
• Tender, inflamed, painful
• 8 patients – cultures with only skin flora
• Symptomatic management only
• No antibiotics needed (unless red streaking or abscess formation) Forbat E, et al. Peditr Dermatol 2017;34(5): 504-515.
Image: Butala N, et al. Pediatrics 2013;131:5.
![Page 15: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/15.jpg)
MOLLUSCUM
• Pox virus: skin contact and fomites
• Self-limited, resolves ~6-24mo without treatment
• Watchful waiting
• Cantharidin, podophyllin, cryo, curettage, topical retinoid, hydrogen peroxide, 2.5-15% KOH
• Imiquimod: NOT effective and potential for high systemic absorption and hematologic abnormalities
Forbat E, Al-Niaimi F, Ali FR. Peditr Dermatol 2017;34(5): 504-515. Katz KA. JAMA Dermatol. 2015;151:125-126.Van der Wouden JC et al. Cochrane Database Syst Rev 2017;5:CD004767.Myhre PE, Levy ML, Eichenfield, et al. Pediatr Dermatol. 2008;25:88-95.Romiti, et al. Pediatr Dermatol. 2000;17:495.Romiti, et al. Pediatr Dermatol. 1999;16:228-231.Teixido C, et al. Pediatr Dermatol 2018;35:336-342.
![Page 16: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/16.jpg)
ATOPIC DERMATITIS (AD)
• Chronic, pruritic inflammatory skin disease; wide range of severity
• Up to 20% of children and 4-10% of adults
• Onset ~3-6mo; 90% diagnosed by age 5
• ~30% persist into adulthood
• Eczema: nonspecific reference to group of inflammatory skin diseases with itching, redness, and scale• Atopic dermatitis is a type of eczematous dermatitis
• Also included in eczematous dermatitis: seborrheic dermatitis, allergic contact dermatitis, irritant dermatitis, etc
![Page 17: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/17.jpg)
ATOPIC DERMATITIS (AD)
• “the itch that rashes”: primary symptom is pruritus
• Scratching to relieve AD-associated itch results in “itch-scratch” cycle that exacerbates the disease
• Infants/Toddlers: Scalp, forehead, cheeks, & extensor arms/legs
• Older children: Flexures of neck, arms, legs, cheeks
Eichenfield LF, et al. J Am Acad Dermatol. 2014 Jul;71(1):116-32
![Page 18: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/18.jpg)
ATOPIC DERMATITIS (AD)
• Cause: not completely known, multifactorial with factors including:
• Skin barrier dysfunction
• Immune dysregulation
• Genetics
• Environment
• Usually not food related
![Page 19: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/19.jpg)
ATOPIC DERMATITIS (AD): TREATMENT
• Puts water in the skin
• But, it will evaporate and take more water with it from skin, UNLESS:
SEAL in the moisture
• Water is GOOD as long as you moisturize afterwards
• Gentle, fragrance-free bar soap at end of bath
• Medicine to rash and moisturize everywhere immediatelyEichenfield LF, et al. J Am Acad Dermatol. 2014 Jul;71(1):116-32
![Page 20: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/20.jpg)
ATOPIC DERMATITIS (AD): TREATMENT
• Topical anti-inflammatories: topical corticosteroids, topical calcineurin inhibitors
• Narrow band UVB treatment
• Immunosuppressive meds: cyclosporine, methotrexate, etc
• Dupilumab (DUPIXENT): 1st biologic for AD, approved 2017, monoclonal antibody directed against IL-4 and IL-13
• 6yrs and above
Eichenfield LF, et al. J Am Acad Dermatol. 2014 Jul;71(1):116-32
![Page 21: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/21.jpg)
SEVERE ATOPIC DERM
• NO SYSTEMIC STEROIDS• Makes disease worse in the long run
• Consensus statement from Peds Derms
• Wet wraps
• DIET: VERY RARELY MATTERS. STRICT DIET RESTRICTIONS NOT recommended
Eichenfield LF, et al. J Am Acad Dermatol. 2014 Jul;71(1):116-32
![Page 22: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/22.jpg)
ATOPIC DERMATITIS: WHEN TO REFER
• Severe or extensive disease
• Symptoms poorly controlled with topical therapy
• Recurrent skin infections
![Page 23: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/23.jpg)
CORTICOSTEROID QUANTITIES
• Commonly available in:
• 15g
• 30g
• 45g
• 60g
• 120g
• 240g
• 454g (1LB jar)
![Page 24: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/24.jpg)
Image: Grepmed.comhttps://image.slidesharecdn.com/seminarpresentation0n04-01-2014-140219112401-phpapp01/95/seminar-principles-of-topical-therapy-10-638.jpg?cb=1392809584
Keys:-prescribe enough but not too much to get them in trouble-~30g to cover adult body once-reassess quantity at follow up
![Page 25: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/25.jpg)
TOPICAL MEDICATIONS:VEHICLE/BASE
• What topical medications are prepared in
• Can optimize for various sites on body and to optimize penetration
Solutions
4
Sprays
Gels
FoamsCreams
Oils
Ointments
Vehicles
Lotion(Not Shown)
Image: AAD.org
![Page 26: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/26.jpg)
TOPICAL MEDICATIONS: VEHICLES
• Ointments (Vaseline): lubricating, greasy, semi-occlusive
• BEST for AD, but sometimes not tolerated
• Cream (vanishes when rubbed in): may sting and irritate open skin areas, more preservatives/fragrances
• Useful when can’t tolerate ointment
• Lotion (pourable liquid): may burn or sting
• Helpful for larger and some hair bearing areas
Indian J Dermatol. 2016 May-Jun; 61(3): 279–287.
![Page 27: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/27.jpg)
TOPICAL MEDICATIONS: VEHICLES
• Foam: more elegant, easy to spread, good for scalp/hair bearing areas, $$$
• Gel: may sting, least occlusive, dries quickly
• Good for acne, hair bearing areas
• Oil: less stinging or burning than solution
• Good for scalp
• Solution: water or alcohol-based lotion containing a dissolved powder
• Good for scalp
Indian J Dermatol. 2016 May-Jun; 61(3): 279–287.
![Page 28: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/28.jpg)
TOPICAL MEDICATIONS: VEHICLE RECOMMENDATIONS
• For eczema (AD): for the body ointment if tolerated, cream if not
• For scalp: oil, solution, or foam
• Acne: cream, gel, foam (for large surfacer area, on back)
![Page 29: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/29.jpg)
TOPICAL CORTICOSTEROIDS
• Do NOT look at percentage: strengthdepends on class
• Recommendation: get familiar and comfortable with a few in a few different classes • High: clobetasol 0.05% (body: severe areas only; DO NOT USE
ON FACE OR. FOLDS)
• Medium: triamcinolone 0.1% (body, NO NOT USE ON FACE OR FOLDS)
• Low: hydrocortisone 2.5% (face and folds)
Department of Dermatology
TCS StrengthPotency Class Example Agent
Super high I Clobetasol propionate 0.05%
High II Fluocinonide 0.05%Mometasone furoate ointment 0.1%
Medium III – V Mometasone furoate cream 0.1%Triamcinolone acetonide ointment 0.1%Triamcinolone acetonide cream 0.1%
Low VI – VIIFluocinolone acetonide 0.01%Desonide 0.05%Hydrocortisone 1% 13
![Page 30: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/30.jpg)
RECOMMENDATION
• Use twice daily until itch free and smooth
• If not improved in 2 weeks, patient to call
• Reassess at follow up
• Transition to nonsteroidal (crisaborale, tacrolimus, pimecrolimus) for maintenance
• If not improving as expected: biopsy or refer (other diagnosis? cutaneous T cell lymphoma? Allergic contact dermatitis?)
![Page 31: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/31.jpg)
AMELANOTIC MELANOMA
• Small minority of melanomas do not have clinically apparent pigment
• All subtypes of melanoma can be amelanotic
• Differential diagnosis: • Basal cell carcinoma (#1)
• Squamous cell carcinoma or verruca when on acral surfaces
• Pyogenic granuloma
• Angioma / angiokeratoma
• Prognosis is same whether melanotic or amelanotic
![Page 32: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/32.jpg)
MELANOMA
A = AsymmetricalB = Irregular BordersC = Multiple ColorsD = Diameter > 6 mmE = Evolving (changing)
![Page 33: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/33.jpg)
MELANOMA
• ABCDEs
• “Ugly Duckling” sign
• Early detection: 99% 5-year survival rate for patients whose melanoma is detected early.
• survival rate drops to 66% if the disease reaches the lymph nodes
• 27% if it spreads to distant organs
Skincancer.org
![Page 34: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/34.jpg)
![Page 35: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/35.jpg)
BUT, BEWARE
![Page 36: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/36.jpg)
CANDIDA INTERTRIGO
• Satellite pustules
• Tinea spares scrotum
• Skin cancers occur EVERYWHERE – if doesn’t respond - biopsy
Bowenoid papulosis, aka squamous cell carcinoma-in-situ
![Page 37: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/37.jpg)
CANDIDA INTERTRIGO
• Erythematous and macerated plaques, peripheral scale, often with peripheral satellite lesions
• Skin folds below the breasts, under the abdomen, axilla, and groin
• Tx:
• decrease moisture to area (powder qAM, loose clothing, sweat wicking material),
• topical ketoconazole (+hydrocortisone), iodoquinol
![Page 38: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/38.jpg)
TINEA CRURIS
• Tinea spares scrotum
• KOH
• Localized: topical terbinafine or clotrimazole bid x 2 weeks (check feet and toenail)
• Generalized: terbinafine 250mg daily x 2 weeks
• Skin cancers occur EVERYWHERE – if doesn’t respond - biopsy
![Page 39: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/39.jpg)
PYODERMA GANGRENOSUM
• Painful, sterile pustule >>> rapidly ulcerates with neutrophilic infiltrate
• Punch biopsy from edge of ulcer to aid diagnosis, with tissue culture
• Association with IBD, RA, some leukemias
• Rule out infection (NOT necrotizing fasc – results in erroneous debilitating amputations!!)
• DO NOT DEBRIDE!!!!
• Treatment: Topical and/or intralesional steroids, immunosuppressive meds/TNF-a-Inhibitors
![Page 40: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/40.jpg)
BIOPSY TECHNIQUE
• Pigmented lesions and moles/nevi: NEVER cryo
• Always send for pathology
• Pathologists need to see entire lesion to fully evaluate
• Site documentation – the more detailed, the better
• Photos
• TriangulateMayoClinic.org
![Page 41: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/41.jpg)
BIOPSY TECHNIQUE
• How to biopsy: Punch? Shave? Excision? Incision?
• Where to biopsy? (ex: LCV - newest lesion, pyoderma gangrenosum – edge of ulcer)
![Page 42: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/42.jpg)
PATHOLOGY REQUISITION FORM
• Specimen location
• Biopsy technique: tangential (shave), punch, excision
• Clinical description of lesion or rash (size, appearance)
• Prior and/or current treatments
• Clinical differential diagnosis (what you think it could be)
Image: dermpathdiagnostics.com
![Page 43: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/43.jpg)
SHAVE BIOPSY SUPPLIES
• Persona blade
• Lidocaine with epi
• Alcohol swab
• Cotton tip applicators
• Hyfrecator ands/or aluminum chloride
• Vaseline and bandage
![Page 44: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/44.jpg)
PUNCH BIOPSY SUPPLIES
• Lido w/ epi
• Alcohol swab
• Punch biopsy blade
• Forceps
• Iris Scissors
• Needle driver
• Suture
• Vaseline and bandage
![Page 45: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/45.jpg)
CARE FOR BIOPSY SITE
• Fold 2 x 2 gauze to make mini pressure dressing
• Paper tape or Coban for sensitive skin
• Keep covered and dry for 24hrs, then gently wash with soap and water, pat dry and recover with Vaseline and bandage until healed
• Erythema around shave and punch biopsy sites is expected
![Page 46: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/46.jpg)
Any time something doesn’t respond as expected = BIOPSY
Differential Diagnosis: • Seborrheic dermatitis• Contact dermatitis• Actinic keratosis• Basal cell carcinoma• Squamous cell carcinoma
![Page 47: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/47.jpg)
BASAL CELL CARCINOMA (BCC)
• Most common type of skin cancer
• Most commonly: sun-exposed areas with history excess sun exposure, burns
• 85% occur on head and neck, BUT found EVERYWHERE
• Additional risk factors: male, increased age
Rogers HW, et al. JAMA Dermatol 2015;151: 1081-1086.
![Page 48: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/48.jpg)
BASAL CELL CARCINOMA:TYPES
• Nodular (most common)
• Superficial
• Sclerosing/morpheaform
• Ill-defined border, more aggressive
• Pigmented
AAD.org
![Page 49: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/49.jpg)
BCC TREATMENT:
SURGICAL AND NON-SURGICAL OPTIONS
• Head and neck, sclerosing subtype: Mohs surgery
• Fellowship trained, Board certified dermatologist
• Real time evaluation of margins for tissue conservation to minimize defect
• Other areas: depends on type, size, location
• Mohs surgery
• Excision
• Electrodessication and curettage
• Non-surgical options (superficial and/or poor surgical candidate): Imiquimod 5% cream, 5-Fluorouracil 5% cream, photodynamic therapy (PDT), radiation AAD.org
![Page 50: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/50.jpg)
BASAL CELL CARCINOMA
• History of one skin cancer = likely to get more
• NEEDS ROUTINE full body skin checks
• Sun protection
• Once monthly self skin exams
![Page 51: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/51.jpg)
ACTINIC KERATOSES
• Slow growing rough, scaly macules/papules on sun damaged skin
• From years of sun exposure
• Face, lips, ears, forearms, scalp, neck or back of the hands
• Usually ages 40 and above
• Reduce your risk by minimizing sun exposure and protecting skin from ultraviolet (UV) rays
• Left untreated, the risk of actinic keratoses turning into a squamous cell carcinoma is about 5% to 10%.
MayoClinic.org
![Page 52: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/52.jpg)
ACTINIC KERATOSES
• Many treatment options
• For few focal lesions: cryotherapy (scar)
• Field treatments: 5-fluorouracil, imiquimod, PDT
![Page 53: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/53.jpg)
PITYRIASIS ALBA
• Mild, often asymptomatic type of atopic dermatitis of the face
• Ill-defined, hypopigmented mildly scaly patches on bilateral cheeks
• Often younger children, spring and summer when skin begins to tan with sun
• Skin care: moisturizer twice daily
• +/-low potency topical corticosteroids or topical calcineurin inhibitors
• Sun protection
• Will fade with time once inflammation resolves
![Page 54: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/54.jpg)
CHERRY ANGIOMAS
• Common, acquired vascular proliferation
• Highest concentration on torso
• Increase in number starting at age 40
• May bleed or thrombose and mimic melanoma
• When in doubt – BIOPSY or REFER it out
![Page 55: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/55.jpg)
NEVI (AKA MOLES)
• Often appear sun exposed areas
• Most commonly acquired nevi begin to appear in early childhood• New lesions over age ~50: biopsy or refer
• Appearance changes with time• Brown macule(s)/papule(s) > brown papule(s) > skin-colored soft papule(s)
• Children & adolescents: change in nevi common, doesn’t necessarily indicate malignancy
![Page 56: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/56.jpg)
NEVI (AKA MOLES)
• Increased risk of melanoma: (refer to dermatology)• Personal history melanoma (5-8% chance of 2nd)• Family hx melanoma (first degree family members)
• More than 100 nevi
• <50yo with few melanocytic nevi at low risk for cutaneous melanoma• Counsel on sun protection and skin self-exams
Goodson AG, et al. J Am Acad Dermatol 2009;60(5): 719-35.Cordoro KM, et al. J Am Acad Dermatol 2013;68:913-25.AAD.org
![Page 57: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/57.jpg)
NEVI (AKA MOLES)
• Evaluate nevi in context of individual patient
• Nevi in one patient tend to resemble one another
• Melanoma often has a different pattern: ”ugly duckling” sign
• ABCDE’s of melanoma
• NEVER use cryotherapy on a pigmented lesion
• If uncertain of what lesion is: biopsy or refer to dermatology
• Biopsy goal: get the breadth and depth of entire lesion
![Page 58: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/58.jpg)
STASIS DERMATITISVS
CELLULITIS
• Stasis Dermatitis• Erythema, scale, pruritus, erosions, exudate
• Typically lower third of legs
• Often with pitting edema
• Bilateral or unilateral (previous vascular injury, etc.)
• +/-varicose veins and orange-red-brown discoloration (hemosiderin deposition)
• Cellulitis• Acute, often fever and pain, more erythema, well-demarcated, without pruritus or scale
![Page 59: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/59.jpg)
• 30-75% of pts admitted for cellulitis actually had stasis dermatitis
• Skin cultures, blood cultures, and leukocytosis: NOT reliable indicators of cellulitis
• Antibiotic prescriptions written for cellulitis shown to be unnecessary for 67% of patients
J Am Acad Dermatol 2015; 73: 70-75JAMA Dermatol 2014; 150: 1056-1061.
CELLULITIS VERSUS
STASIS DERMATITIS
![Page 60: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/60.jpg)
VERRUCA VULGARIS (WART)
• Scaly, hyperkeratotic, exophytic (growing upwards and outwards) plaques (also flat variants)
• Small black dots: thrombosed capillaries at base of lesion
• HPV infection of keratinocytes or mucosal epithelial cells
• HPV ubiquitous in environment
• Skin contact and fomites
• COMMON! • At least 20% overall prevalence in US
![Page 61: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/61.jpg)
DIFFERENTIAL DIAGNOSIS
•Epidermal Nevus
![Page 62: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/62.jpg)
DIFFERENTIAL DIAGNOSIS
• Lichen Planus
![Page 63: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/63.jpg)
DIFFERENTIAL DIAGNOSIS
• Squamous cell carcinoma
![Page 64: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/64.jpg)
VERRUCA VULGARIS: TREATMENT
• Necessary?
• Spontaneous resolution in 2 yrs: >75%• Based on placebo groups in trials with cure rate (20-70%)
• Indications for treatment
• No specific anti-HPV therapy
• Prevent self-inoculation:• Discourage picking, biting, touching: risk spreading to lips,
face
![Page 65: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/65.jpg)
VERRUCA VULGARIS: TREATMENTS
• Cryotherapy
• Cure rates rate from 31-52% after 3 treatments. Pain, blistering, scarring
• Tretinoin 0.025-0.05% cream• Facial flat warts
• 5-FU cream (5-fluorouracil)• +/-Irritating to uninvolved skin• +/- salicylic acid
• Imiquimod
• 3 times weekly, cure rate around 44%
• Intralesional Candida AgBologniaSA Ringin. J Cutan Aesthet Surg. 2020 Jan-Mar; 13(1): 24–30.
![Page 66: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/66.jpg)
SALICYLIC ACID 40% PLASTER: WARTS
• 25 pads for ~$20
• Up to 75% cure rate at 12 weeks with daily use
• Clean skin - Gently pare with nail file (don’t use elsewhere) to remove dead skin – apply plaster cut to fit over wart
• May apply tape over
• Repeat daily
• Good adjunctive home treatmentMadan RK and Levitt J. J Am Acad Dermatol 2014;70:788-92.
![Page 67: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/67.jpg)
LIQUID NITROGEN: -196℃
• Pare, then two 10-15 sec freeze-thaw cycles, allowing to thaw between cycles; 1-3 week intervals
• Margin around lesion correlates to depth of freeze
• Spray until “ice-ball” (white freeze color change) formation spreads from center of wart with a 2mm margin
• Produces most damage to koilocytes (keratinocytes infected with HPV)
• CAUTION in periungual area to avoid nail dystrophy Bolognia
![Page 68: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/68.jpg)
CRYOTHERAPY: POST-OP
• Pain
• Post-inflammatory hyper-/hypo-pigmentation
• Blister formation
• Scarring
• Recurrence
• Multiple treatments likely necessary
![Page 69: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/69.jpg)
HPV VACCINE AND WARTS
• Case reports: resolution of refractory skin warts after receiving HPV vaccination
• Vaccine targets:• 6, 11, 16, 18, 31, 33, 45, 52, 58
• Common HPV types for skin warts:• Common: 1, 2, 4, 7• Plantar: 1• Flat: 3, 10,
• Anogenital: 6, 11
![Page 70: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/70.jpg)
IMPACT OF ACNE
• 85% of teens, at least 12% of adult women
• Lower self-confidence and self-esteem
• More likely to employ a teen without acne
• PCPs likely to be the first the patient sees and may open up to. Patients often ashamed to mention
• Successful treatment improves psychological factors
Cotterill J, Cunliffe W. Br. J Dermaotl 1997;137:246-50.
Dreno B et al. Dermatol Ther 2016;6(2):207-218.
![Page 71: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/71.jpg)
ACNE: TREAT AND/OR REFER SOONER RATHER THAN LATER
![Page 72: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/72.jpg)
LESION TYPES
• Comedones: open and closed
• Papules and pustules
• Cysts and nodules
![Page 73: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/73.jpg)
ACNE SEVERITY
• Mild (topical retinoid, +/-topical Abx, BP)• Mostly comedones
• < 10 papules/pustules
• Moderate (topical retinoid, +/-doxycycline, BP, OCPs, spironolactone, topical Abx)• Comedones
• >10 papules/pustules
• Severe (ISOTRETINOIN)• Comedones
• Many papules/pustules
• +/- nodules/cysts (deeper)
• Active scarring
• **recalcitrant to treatment
• Consider: duration, back
![Page 74: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/74.jpg)
TREATMENT
• Combinational almost always
• CHRONIC disease – set patient expectations
• Timing of results
• Inflammatory/non-inflammatory lesions?
• Mild/moderate/severe?
• Scarring? Chronicity? Previous treatments?
![Page 75: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/75.jpg)
TREATMENT: MILD ACNE
• Topical retinoids
• Mainstay of treatment: EVERYONE
• Comedolytic and anti-inflammatory
• Concentration & vehicle impact tolerability
• Adapalene tends to be better tolerated (**OTC**)
• Older formulations inactivated by sunlight and benzoyl peroxide (BP)
• Patient counseling
• +/-BP
• +/-topical antibiotic
• +/-topical dapsone
Eichenfeld LF, et al. Pediatr 2013;131(3): S163-S186.Leyden JJ. J Am Acad Dermatol 2003;49(3): S200-S210.Bolognia 2018
![Page 76: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/76.jpg)
WHO GETS A RETINOID?
![Page 77: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/77.jpg)
TREATMENT: MODERATE ACNE
• “Many” inflammatory papules
• Oral antibiotic (x3mo MAX)• Evidence supports use of doxycycline, minocycline, erythromycin, TMP-SMX,
TMP, and azithromycin
• + BP (ALWAYS)• + topical retinoid• NO NEED for both oral and topical Abx simultaneously
• Female patients: OCPs, spironolactone
Thiboutot D et al. Arch Dermatol 2006;142:597-602Zaenglein et al. J Am Acad Dermatol 2016;74:945-73
![Page 78: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/78.jpg)
BENZOYL PEROXIDE
• Bactericidal: prevents/eliminates C. acnes resistance
• ALWAYS use in patients on oral or topical antibiotics
• Available in strengths of 2.5-10%
• Concentration dependent irritation
• Contact time can affect efficacy: leave-on vs wash-off –location dependent
• Bleaching and staining of fabric
![Page 79: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/79.jpg)
TREATMENT: MODERATE ACNE (CONT’D)
• Follow-up at 3mo, ideally skin cleared and transition to only topical tx
• +/- inc retinoid strength pending tolerability
![Page 80: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/80.jpg)
SEVERE ACNE
• Scarring
• Nodules, cysts
• Unable to maintain clearance on topical regimen
• *the back
• Treatment: ISOTRETINOIN
![Page 81: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/81.jpg)
ISOTRETINOIN
• Reverses retention hyperkeratosis, reducing comedone formation
• Decreases sebum levels
• Reduces C. acnes
• Decreases inflammation
• Remission and “cure” possible
Layton AM. J Dermatol Treat 4: S2-S5,1993
![Page 82: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/82.jpg)
ISOTRETINOIN
• LIFE-CHANGING
• Baseline labs and repeat at 2mo
• Liver, lipid profile, +/-CK
• I-pledge and birth control or abstinence
• Goal dose
• Controversies
Timothy J, et al. J Am Acad Dermatol. 2016;75(2)323—328.
![Page 83: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/83.jpg)
ACNE TOP 5 PEARLS
1. NEVER use antibiotics (topical or oral) as monotherapy. Limit oral antibiotics to 3 months
2. ALWAYS use topical benzoyl peroxide when using an antibiotic3. EVERYONE gets a retinoid4. It takes a good 3 months of consistent use to see the full effects of acne meds5. Isotretinoin is life-changing and typically well tolerated in patients who are good
candidates
![Page 84: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/84.jpg)
CASE: #22
What is this condition?
A. Scarring from overuse of steroids
B. Lichen planus
C. Hidradenitis suppurativa
D. Deep fungal infection
E. Skin cancer
![Page 85: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/85.jpg)
HIDRADENITIS SUPPRATIVA
• Recurrent painful subcutaneous nodules and draining cysts
• Double comedone(s), sinus tracts, and abscesses
• Occurs in axilla*, inguinal, perianal, perineal, mammary, and inframammary regions
![Page 86: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/86.jpg)
HIDRADENITIS SUPPURATIVA
• Begins ages 20s-30s
• Estimated prevalence 1-4% of population
• Women > Men
• Clinical diagnosis
• Time from disease on set to diagnosis: 7-12 years
![Page 87: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/87.jpg)
HIDRADENITIS SUPPRATIVA
• Painful
• Malodorous discharge, soiling of cloths
• Under-diagnosed
• High incidence of depression
• Negative impact on work and social life
![Page 88: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/88.jpg)
HIDRADENITIS SUPPRATIVA: TREATMENT
• Oral and topical antibiotics
• Biologics: TNF-alpha inhibitor, adalimumab, shown to be effective for moderate to severe HS
• Important: Identify disease early and start appropriate treatment
• Underdiagnosed – patients reluctant to mention and/or seek care
Kimball AB, et al. Ann Intern Med. 2012; 157(12):846-855.
![Page 89: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/89.jpg)
SUMMARY: THE IMPORTANT THINGS
• Any skin lesion or condition that doesn’t respond as expected or diagnosis uncertain: biopsy or refer
• When doing a skin biopsy, clarify (and photo ideally) site, use best technique, know which area is best to sample
• Encourage sun protection and monthly self skin checks
• Don’t underestimate acne and its potential long term impacts. No need for scarring
![Page 90: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/90.jpg)
INTERESTED IN LEARNING MORE DERMATOLOGY?
We have a few spots remaining for the CME/CE course: 9/17/21 @ Huber’s in southern IN
Skinternal Medicine: Dermatology for the Non-Dermatologist
www.skinternalmedicineconference.com
![Page 92: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/92.jpg)
ADDITIONAL REFERENCES
Zaenglein et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016;74:945-73.
Layton AM, et al. Clin Exp Dermatol 1994; 19: 303-308
GouldenV et al. Prevalence of facial acne in adults. J Am Acad Dermatol.1999; 41: 577-8
Levin J. Dermatol Clin 2016(34): 133-145.
Gastroenterol 93:606
Br J Dermatol 123: 653
Cutis 64: 106
Dupre A, et a;. Vitamin B-12 induced acne. Cutis 1979;24(2):210-11.
Layton AM. J Dermatol Treat 4: S2-S5,1993
Timothy et al. JAAD 2016.
Simonart T. Acne and whey protein supplementation among body builders. Dermatol 2012;225:256-8
Huang et al. Isotretinoin treatment for acne and risk of depression: a systematic review and meta-analysis. J Am Acad Dermatol2017;76:1068-76.
![Page 93: DERMATOLOGY FOR THE NON-DERMATOLOGIST 4/30/2021](https://reader033.vdocuments.site/reader033/viewer/2022050306/626f1d79e7fae930421bccba/html5/thumbnails/93.jpg)
ADDITIONAL REFERENCES
Halioau et al. Feelings of stigmatization in patients with rosacea. J Eur Acad DermatolVenereol. 2017;31:163-8
Bewley et al. Erythema of rosacea impairs quality of life: results of a meta-analysis. Dermatol Ther 2016;6:237-47
Egeberg et al. Patients with rosacea have increased risk of depression and anxiety disorders: a Danish nationwide cohort study. Dermatol 2016;232:208-13
Van Zuuren. Rosacea. New Engl J Med. 2017;377,18:1754-64*
Fowler et al. Efficacy and safety of once daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized, double-blind, and vehicle-controlled pivotal studies. J Drugs Dermatol 2013;12:650-6
Rhofade cream prescribing information. Irvine, CA: Allergan, 2017 (https://www.allergan.com)
Deckers and Kimball. The Handicap of Hidradenitis Suppurativa. Dermatol Clin 2016;34:17-22
Alikhan et al. J Am Acad Dermatol 2009;60: 539-61
Woodruff et al. Mayo Clin Proc. 2015:90(12): 1679-1673*
Kimball AB, et al. Adalimumab for the treatment of moderate to severe Hidradenitis supprativa: a parallel randomized trial. Ann Intern Med. 2012; 157(12):846-855.