The Red Face and ScalpMisha Miller, MD

Assistant Professor, University of Colorado

Department of Dermatology

Dermatitis1.1% of All Outpatient Visits

Dermatologists

2,184,000

Non-dermatologists

4,793,00

The majority of cases are

seen by NON-dermatologists!

Types of “Dermatitis”

• Allergic contact dermatitis

• Irritant contact dermatitis

• Atopic dermatitis (“eczema”)

• Nummular dermatitis

• Dyshidrotic dermatitis (pompholyx)

• Seborrheic dermatitis

• Exfoliative dermatitis

Allergic Contact DermatitisPathogenesis

• 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) 9.6%

• Neomycin 9.0%

• Formaldehyde (preservative) 7.8%

• Thiuram mix (rubber) 7.7%

• Balsam of Peru (fragrance mix) 7.5%

• p-phenylenediamine (hair products) 6.3%

• Carba mix (rubber) 4.8%

Allergic Contact DermatitisClinical 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 DermatitisDiagnosis

•Careful history

•Clinical presentation

•Biopsy - helpful but not specific

•Patch testing

Allergic Contact DermatitisTreatment

• 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)• 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 DermatitisPathogenesis

•Direct toxic injury to the skin

•More common than ACD (<75%)

•Common causes• Soaps (bath soap, dishwashing liquids)

• Cleansers

• Alcohols

• Glues/cements

• Deodorants

Irritant Contact DermatitisClinical Features

•Strong irritants• Immediate burning & stinging• Erythema & edema• Vesiculation

•Mild irritants• Hours to days

• Mild erythema

• Scaling & fissuring

Irritant Contact DermatitisDiagnosis

•Clinical history Strong irritants - self-evidentMild irritants - extensive history

•Clinical presentation

•Biopsies - not particularly helpful

•Patch testing - useful to exclude

allergic contact dermatitis

Irritant Contact DermatitisTreatment

•Withdrawal of offending irritant

•Withdrawal of other irritants (soaps)

•Moisturizers (Lachydrin®)

•Corticosteroids - mild to moderate

Atopic DermatitisEpidemiology

• 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 DermatitisClinical 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 DermatitisDiagnosis

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 DermatitisBr J Dermatol 2004; 150: 1154-61.

• Sweating 42%• Hot Weather 40%• Fabrics (wool) 39%• Illness 36%• Dust 33%• Sea swimming 30%• Anxiety/stress 28%• Cold weather 28%• Animals 28%• Grass 27%• Soaps/shampoos 26%

Atopic DermatitisTreatment

• 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 DermatitisAdult 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 DermatitisDiagnosis

•Clinical presentation

•Distribution

•Biopsy usually not indicated• can be highly suggestive

Seborrheic DermatitisTreatment

• 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 DermatitisHair 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/ErythrodermaClinical Presentation

• Diffuse erythema and scaling 100%

• Pruritus 36%

• Malaise 34%

• Palmar/plantar keratoderma 34%

• Lymphadenopathy 26%

Exfoliative DermatitisPathogenesis in 236 Patients

• Idiopathic 30%

• Drug-induced dermatitis 28%

• Pre-existing skin disease 25%

• Lymphoma/leukemia 14%

• Atopic dermatitis 10%

• Psoriasis 8%

• Contact dermatitis 3%

Exfoliative Dermatitis/ErythrodermaDiagnosis

•History - drug use, known skin disorder

• Clinical presentation

• Biopsy definitive in 43% of cases

• CBC - striking eosinophilia favors drug

Exfoliative Dermatitis/ErythrodermaTreatment

• 34% clear spontaneously (~ 7 years)

• Diagnosis known - treat specific entity

• Idiopathic• 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

RosaceaFour Main Subtypes

1. Erythematotelangiectatic

2. Papulopustular• granulomatous

3. Phymatous

4. Ocular

It is certainly possible to have more than one subtype or overlapping types.

RosaceaPatient 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

RosaceaTreatment

• 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 mitesAnti-inflammatory effectsTreats erythematelangiectatic, papulopustular rosaceaOnce daily application~40 pts reported clear to almost clear

Rosacea Treatment ControversyRetinoids 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

• comedones in any number• minor (small) and few papules• no inflammation

• Grade II –moderate acne• comedones generally in greater numbers• more papules and formation of pustules • slight inflammation of the skin is apparent

• Grade III - severe acne• 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• 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 TreatmentsTargeting 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 TreatmentComedolytics

• 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 TreatmentComedolytics

• 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 TreatmentRetinoids - 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 TreatmentAntibiotics: 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 TreatmentManaging 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 TreatmentResistance 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 low-dose/extended-release MCN promoted

Acne TreatmentIsotretinoin

• Systemic retinoid

• Difficult to use (physically/bureaucratically)

• 5 month course

• ~ 25% relapse rate

• Side effects:

• dry lips, eyes, nose

• teratogen

• hyperlipidemia

• ? SI/HI ? (controversial)

Acne TreatmentSpecial 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• 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 TreatmentSide-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• 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 TreatmentTCN-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 ErythematosusClinical 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 ErythematosusDiagnosis

•Clinical presentation

• SCLE - SSA (anti-Ro) antibodies

• Skin biopsy - consistent with or diagnostic if classic

•Direct immunofluorescence studies

Lupus ErythematosusTreatment

• Sunscreens- broad spectrum• Parsol 1789 - Presun Ultra®• Pure titanium dioxide - Neutragena Sensitive Skin

• Topical corticosteroids - potent

• Intralesional corticosteroids for DLE

• Oral corticosteroids

• Oral antimalarials