Jose Dario Martinez, MD, FAADProfessor of Internal Medicine & Dermatology

Chief, Internal Medicine Clinic

University Hospital “ JE Gonzalez”, UANL

Monterrey, Mexico

Pearls from Mexico

Jose Dario Martinez, MD, FAAD

F026 Pearls from Mexico

DISCLOSURES

I do not have any relevant relationships with industry.

DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY

Pearls from Mexico

Jose Dario Martinez, MD, FAADI am going to discuss some FDA approved drugs, and some thatare used off-label.

Number of US residents traveling to

Mexico in 2017: 35.05 millions

Travelers´ maladiesAm J Clin Dermatol 2016 Oct;17(5):451-462

Clinical cases #1

Cutaneous Leishmaniasis: Fast Facts

Neglected tropical disease

Occurs worldwide

CL: 0.7-1.2 million new cases/year

Travelers’ disease

DX: direct smear/biopsy/PCR

Vasievich MP, Martinez JD, Tomecki KJ.

Am J Clin Dermatol 2016 DOI 10.1007/s40257-016-0203-7

Cutaneous Leishmaniasis

RX Pearls L. mexicana: no RX/local or systemic treatment

V. braziliensis, L. panamensis: systemic treatment only

Systemic RX:

Risk of developing MCL

Failure or prior local RX

Size, number and location of lesions

Lymphatic spread

Toxicity of systemic RX LeishMan Recommendations for Treatment of Cutaneous and Mucosal Leishmaniasis in Travelers, 2014

Johannes Blum MD1,2,3,*, Pierre Buffet MD4,5,6, Leo Visser MD3,7, Gundel Harms MD8, et al. Article first published online: 19 DEC 2013

DOI: 10.1111/jtm.12089© 2013 International Society of Travel Medicine

CL RX Pearl

Treatment for travelers Pentavalent antimonials: first line RX

Surgery in case of small lesiones

Itraconazole, 200 mg/PO/day/8 weeks

Amphotericin B, IV (liposomal)

Miltefosine, PO, FDA (2014),

2.5 mg/kg/day/1 month as

an alternative option ($$$$)Curr Treat Options Infect Dis 2015;7(1):52-62

Clinical cases #2

Myasis: Fast Facts Infestation of the skin by fly larvae

Dermatobia hominis & Cordylobia anthropophaga

Boil like lesions, #1-3, furuncular

Painful, movement inside

Travelers’ disease

DX: US, CT scan

RX: topical stuff, surgery, oral ivermectinSeminars in Pediatric Surgery 2012;21:142-150

Furuncular myasis in a traveler:

surgery

Myasis RX Pearl

Prevention & Treatment

Prevented with repelents (DEET)

Vaseline, pork fat, mineral oil, chimo ► top of the furuncle

Topical 1% ivermectin solution

Ivermectin PO: 200 µg/kg/once

Surgical extraction is a good treatment to clean the

wound properly

Vasievich MP, Martinez JD, Tomecki KJ.

Am J Clin Dermatol 2016 DOI 10.1007/s40257-016-0203-7

Myasis in venous ulcers: RX with water + tobacco

Tropical Dermatology

INFESTATIONS AND FUNGAL DISEASES

Tropical dermatology: cutaneous larva migrans, gnathostomiasis,

cutaneous amebiasis and trombiculiasis

José Darío Martínez, MD | Kenneth J Tomecki, MD | Kristian Eichelmann, MD

In today’s world, many people can travel easily and quickly around the globe.

Most travel travel-related illnesses include fever, diarrhea, and skin disease, which

are relatively uncommon in returning travelers. We review four of the most

common emerging infestations and skin infections in the Americas, which are

important to the clinical dermatologist, focusing on the clinical presentation and

treatment of cutaneous larva migrans, gnathostomiasis, cutaneous amebiasis,

and trombiculiasis.

Semin Cutan Med Surg 33:133-135 © 2014 Frontline Medical Communications

Clinical cases #3

Cutaneous larva migransFast facts

Etiology in Mexico: A. caninum

Within 2 weeks from a trip to a beach

More common in the Gulf of Mexico

Beaches with dogs (feces)

Walking barefoot, lying on the beach

Spring break & summer vacations

Creeping eruption, 1-2 cm/day, severe itchSemin Cutan Med Surg 2014;33:133-135

Cutaneous larva migransPearls

20-80 % of larvae die in 2-8 weeks

Diagnosis is clinical

CBC: eosinophilia

High IgE in serum

Dermoscopy can be a useful tool

Confocal microscopy is an expensive tool

RX: ivermectin/albendazol

Topical corticosteroids for inflammation & itchSemin Cutan Med Surg 2014;33;133-135

Cutaneous larva migrans

Dermoscopy

Eichelmann K, Tomecki K, Martinez JD.

Semin Cutan Med Surg 2014;33:133-135

Clinical cases #4

GnathostomiasisFast facts

Gnathostoma (4 species in Mexico)

In Mexico is an emerging disease (Nayarit, Yucatan)

G. binucleatum

Eating “ceviche” (raw fish with lemon)

Freshwater raw fish (tilapia, crapie)

Eating sushi

One month within the trip

Most common clinical form is subcutaneousSemin Cutan Med Surg 2014;33:133-135

Gnathostomiasis

DX & RX Pearls

Visceral: liver, eyes, CNS

Biopsy: eosinophilic panniculitis

DX: CBC (eosinophilia), ELISA

Immunoblot test specific L3 antigen 24 k-Da band

Best treatment: surgery

Semin Cutan Med Surg 2014;33:133-135

Gnathostomiasis

Treatment

First line: albendazole PO: 400-800 mg/BID/4 weeks

Second line: ivermectin PO: 200 µg/kg/2 days

Repeat treatment

Oral corticosteroids

Eichelmann K, Tomecki K, Martinez JD.

Semin Cutan Med Surg 2014;33:133-135

Gnathostomiasis after ivermectin

treatment + oral steroids

Clinical cases #5

Head Lice: Fast Facts

Infestation by Pediculus humanus capitis

Worldwide, 6-12 millions of cases annually

Most commonly in children 4-13 years old

Big economic burden in the U.S.

DX: clinical, nape itch

RX: topical lotions/physical removalJ Med Entomology 2017;54(1):167-172

Lice topical RX: poor efficacy,

toxicity and relapses

Lice RX Pearl: Phase 3, ovicidal

against eggs (not FDA approved)

Lice Pearl: RX & prevention

Clinical cases #6

Kerion: Fast Facts

Is an inflammatory reaction to tinea capitis

Occurs almost exclusively in children

Worldwide, antropophilic/zoophilic infection

T tonsurans (multiple) / M canis (one)

One/multiple tender alopecic nodules/areas

DX: KOH

RX: griseofulvin, terbinafine, itraconazole, fluconazoleFrias MG, Porras C, Martinez JD, et al. Dermatol Rev Mex 2017;61(5):371-378

Kerion

Kerion RX Pearl

T tonsurans: terbinafine (4-5 mg/kg/day/4 weeks)

M canis: fluconazole (5-6 mg/kg/day/4-6 weeks)

Itraconazole everyday/pulse (5 mg/kg/day/2-6

weeks)

Oral steroids can be used to reduce

scaling/itching/pain

Pediatric Dermatology 2011;28(6):655-657

Clinical cases #7

Red scrotum syndrome: idiopathic neurovascular phenomenon or steroid addiction?Tarun Narang, Muthu Sendhil Kumaran, Sunil Dogra, Uma Nahar Saikia, Bhushan Kumar

Sexual Health 2013;10(5):452-5BACKGROUND: Red scrotum syndrome (RSS) is not infrequent but is often misdiagnosed or underdiagnosed, and seldom

reported. The exact etiopathogeneis is still unknown but it almost always follows the prolonged application of topical

corticosteroids and is characterised by persistent erythema of the scrotum, associated with severe itching, hyperalgesia and a

burning sensation.

OBJECTIVE: To evaluate the clinicoepidemiological profile and assess the efficacy of various treatment modalities in addition to corticosteroid abstinence in the treatment of RSS.METHODS: Twelve patients with RSS, who presented to us during 2010 and 2011, were identified, and various aspects of their illness and treatment were studied. Patch testing was performed in all patients. A skin biopsy was done in seven patients.RESULTS: The average age of the patients was 45.83 years (26-62 years). The average duration of illness or the duration of topical steroid use was 27.41 months (6-56 months). Psychiatric comorbidities were seen in 9 (75%) out of 12 patients. Histopathology revealed features resembling erythematotelengiectatic rosacea in four of the biopsied patients. Patch test results were negative. All patients reported improvement of their symptoms within 4 weeks of starting doxycycline with amitriptyline or pregabalin; the treatment had to be continued for 3-4 months.CONCLUSIONS: RSS appears to be a manifestation of corticosteroid misuse rather than a primary disease. We suggest that RSS is a rosacea-like dermatosis or steroid-induced rebound vasodilation based on clinical and histopathological features. Our patients responded to cessation of steroids and doxycycline in combination with amitryptaline or pregabalin.

Red scrotum syndrome: Fast Facts

Under-recognized entity

Prolonged topical corticosteroid therapy (auto-

medication)

Exact pathogenesis is unknown

Intense itching, burning, and pain

Persistent erythema of the scrotum

DX: clinical, skin biopsy is non-specificSexual Health 2013;10:452-455

RSS: RX Pearl

Cessation of topical steroids

Doxycycline + Amitriptyline or pregabalin

Gabapentine

Topical calcineurin inhibitors

Beta blockers: carvedilol*

Ivermectin: 12 mg PO/once a week/4 weeks (personal

observation)Sexual Health 2013;10:452-455

JAAD Case Reports 2017;464-466*

RSS: after 2 months of RX

Clinical cases #8

Erythema dyschromicum perstans: Fast Facts

Rare acquired and chronic dermatosis

Cause unknown

Asymptomatic and progressive disease

Ashy-gray macules, confluent

Upper back & chest, neck, face, limbs

DX: biopsy

RX: clofazimine, dapsoneJAMA Dermatology Letter 2016

Ashy dermatosis RX Pearl

Traditional RX have minimal success

Isotretinoin: anti-inflammatory and

immunomodulatory effects

Dose: start 20 mg/day ► tapered to 10 mg/day

Long-term RX because recurrence occur when

RX is stoppedJAMA Dermatology Letter 2016

Ashy dermatosis: Before isotretinoin

Ashy dermatosis: After 14/4 months of isotretinoin

Clinical cases #9

Leprosy: Fast Facts M leprae / M lepromatosis (DLL in Mexico)

Chronic and progressive disease (LL)

Most common: LL (35%), BL (31%), BT(24%)

Clinical: nodules, plaques, patches (no sensation)

Zoonosis: armadillos as pets in U.S., Mexico

DX: ZN stain, biopsy (FF), Lepromin test, PCR

RX: WHO recommendationsMartinez JD, Cardenas JA. Curr Treat Options Infect Dis 2017

DOI: 10.1007/s40506-017-0127-7

Leprosy DX Pearl

Neglected disease

M lepromatosis causes DLL / LL

In Mexico it´s the leading cause of leprosy

DLL carries higher mortality than LL

PCR (16S rRNA) is the best way to make DX

Int J Dermatol 2012;51(8):952-959

Pearls from MexicoSummary

CL: surgery in small lesions, itraconazole

CLM: ivermectin/albendazol

Gnathostomiasis: albendazol

Myasis: chimo (tobacco)

Lice: Xeglyze®, Cetaphil® skin cleanser & shampoo

Kerion: oral terbinafine

RSS: doxycycline + Amitriptyline or pregabalin, ivermectin

Ashy dermatosis: low dose chronic isotretinoin

Leprosy: is a zoonosis, M lepromatosis (PCR)

Pearls from Mexico…Thank you! Email: jdariomtz@yahoo.com.mx