WM510_Lecture7-part-1.pdf

Western Internal Medicine I WM510 Taran Kermani MD, L.Ac 1 Dermatological Conditions Taran Kermani MD. 2 Acne vulgaris The most common skin condition. More common in younger persons and more severe in males. Almost universal in puberty Comedones are the hallmark. May begin in premenarchal girls and...

Western Internal Medicine I WM510 Taran Kermani MD, L.Ac 1 Dermatological Conditions Taran Kermani MD. 2 Acne vulgaris The most common skin condition. More common in younger persons and more severe in males. Almost universal in puberty Comedones are the hallmark. May begin in premenarchal girls and present or persist into the 4th or 5th decade. Taran Kermani MD. L.Ac 3 Acne vulgaris Acne vulgaris is polymorphic 12% of women and 3% of men over age 25 have acne vulgaris. , D M i Face, neck, and upper trunk an may be a ected. rm e clear It does not alwaysK n spontaneously when maturity is a r reached.a T c A L. Severity varies from purely comedonal to papular or pustular in ammatory acne to cysts or nodules. Taran Kermani MD. L.Ac ff fl 4 The skin lesions parallel sebaceous activity. Pathogenic events include c A L. , D retention of sebum M i (Propionibacterium overgrowth of the acne bacillus n a acnes) with resultant m release of and irritation by r and foreign-body reaction to accumulated fattyeacids, extra-follicularK sebum. n a r Ta plugging of the infundibulum of the follicles Taran Kermani MD. L.Ac 5 Hyperandrogenism may be a cause of acne in women and may or may not be accompanied by hirsutism, irregular menses, or signs of virilism. , D M i an Polycystic ovary syndrome (PCOS) is the most common identi able cause. c A L. rm e K n a r a T Acne may be exacerbated or Acne may develop in patients who use systemic corticosteroids or topical uorinated corticosteroids on the face. caused by cosmetic creams or oils. Taran Kermani MD. L.Ac fl fi 6 Clinical ndings There may be mild tenderness, pain, or itching. c A L. , D M i n white a Comedones tiny, esh-colored, m cial or black non-in amedrsuper e papules that give the skin a rough K n texture or appearance are the a r hallmark a of acne vulgaris. T In ammatory papules, pustules, acne The lesions occur mainly over the face, neck, upper chest, back, and shoulders. cysts, and scarring are also seen Taran Kermani MD. L.Ac 7 Acne may have di erent presentations at di erent ages. Preteens: comedones as their rst lesions. Young teenagers: In ammatory lesions are often found in the middle of the face, extending outward as the patient becomes older. c A L. , D M i an rm e theirK 3rd and 4th Women in n decades:acommonly present r lesions on the a with papular T chin and jawline. Cyst formation, pigmentary changes, scarring, and poor quality of life may result. Taran Kermani MD. L.Ac fi ff fl fl fi fi fl fl 8 Patient Education Because lesions take 4–6 weeks to improve, clinical improvement should be measured by the number of new lesions forming after 6–8 weeks of therapy. Additional time (3–4 months) will be required to see improvement on the back and chest, as these areas are slowest to respond. c A L. , D M i Avoid topical exposure to oils, cocoa butter (theobroma n a including hair products. oil), and greases in cosmetics, m r e with or without the patient Scarring may occur manipulating theK lesions. n a r glycemic diet has been associated with Diet:TAalow improvement and lower incidence of acne. This improvement was associated with a reduction in insulin resistance. Taran Kermani MD. L.Ac 9 Treatment Hygiene plays little role in acne treatment, and a mild soap is almost always recommended. c A.comedonal Topical Retinoids: Tretinoin is very e ective, for L acne or for treatment of the comedonal component of D more severe acne, but its usefulness Mis limited by irritation i n with several other topical Benzoyl peroxide in combination a agents, including adapalene and topical antibiotics m r e phosphate), are available as a (erythromycin, clindamycin K single formulation. n a r (3 weeks to 3 months) with topical or oral BriefTtreatment a antibiotics is the mainstay for treatment of in ammatory acne that does not respond to topical therapy with retinoids or benzoyl peroxide. Taran Kermani MD. L.Ac ff 10 Rosacea c A L. Rosacea is a common condition that presents in adulthood. In ammatory papules may be superimposed on this background and may evolve to pustules , D A chronic disorder a ecting the face. M i n disorder is not known. The pathogenesis of this chronic a rmushing or exacerbation of their Patients frequently report e rosacea due to heat, hot drinks, spicy food, sunlight, K exercise, alcohol, n emotions, or menopausal ushing. a r No comedones Ta are seen. Taran Kermani MD. L.Ac 11 Rosacea , D The patient often complains ofni M burning or stinging with a m episodes of ushing and r e extremely cosmetic-intolerant K skin. n a r aoften misdiagnosed, is Lupus T but the presence of pustules Associated seborrhea may be found. c A L. excludes that diagnosis. Taran Kermani MD. L.Ac fl ff fl fl 12 Treatment Educating patients to avoid the factors they know to produce exacerbations is important. Medical management is most e ective for the in ammatory papules and pustules and the erythema that surrounds them. Rosacea is usually a lifelong condition, so maintenance therapy is required. Rosacea tends to be a persistent process. With the appropriate treatment, it can usually be controlled adequately. c A L. , D M i ncreams, gels, or lotions), Local: Metronidazole (availableaas and ivermectin are e ective topical treatments. Another m r e ective treatment includes topical clindamycin. Response is e K noted in 4–8 weeks. ntetracyclines should be used when topical a Oral r Systemic: ais inadequate. Minocycline or doxycycline are also therapy T e ective. Taran Kermani MD. L.Ac 13 Contact Dermatitis c A L. Contact dermatitis (irritant or allergic) is an acute or chronic dermatitis that results from direct skin contact with chemicals or allergens. , D M exposure to or additive i 80% of cases are due to excessive n e ects of universal irritants a (eg, soaps, detergents, organic solvents) and are called irritant contact dermatitis. rm e K n a r Ta Taran Kermani MD. L.Ac ff ff ff ff ff 14 The most common causes of allergic contact dermatitis are: poison ivy or poison oak Occupational exposure is an important cause of allergic contact dermatitis. c A topically applied antimicrobials (especially bacitracin. L and neomycin), , D anesthetics (benzocaine) M i preservatives n a jewelry (nickel) rm e rubber K n propolis (from bees), vitamin E, and oils, a essential r adhesive Ta tape Taran Kermani MD. L.Ac 15 Clinical ndings Allergic: Intense pruritus, tiny vesicles and weepy and crusted lesions. The lesions consist of erythematous macules, papules, and vesicles and may occur beyond the contact area, distinguishing it from irritant dermatitis. , D M i an c A L. rm e may also be The a ected area K n edematous and warm, simulating a r infection. The location will often a T suggest the cause. Reactions may not develop for 48– 72 hours after exposure. Taran Kermani MD. L.Ac fi ff 16 Clinical ndings Irritant: The rash is erythematous and scaly (but less likely vesicular) and occurs only in the direct sites of contact with the irritant. , D Resolving or chronic contactni M dermatitis presents with scaling, a m erythema, and possibly thickened r e skin. K n and stinging may burning, Itching,ra be severe in both allergic and irritant a T contact dermatitis. c A L. Reactions may develop within 24 hours of contact exposure. Taran Kermani MD. L.Ac 17 Treatment Gram stain and culture will rule out impetigo or secondary infection. c A While local measures are important, severe orLwidespread. involvement is di cult to manage without systemic , D corticosteroids. M i Localized involvement (except on the face) can often be n managed solely with topicalaagents. m r e is treated by protection from the Irritant contact dermatitis K irritant and use of topical corticosteroids. n a rsevere cases, prednisone may be given orally a For acute T days. The key is to use enough corticosteroid to for 12–21 achieve a clinical e ect and to taper slowly over 2–3 weeks to avoid rebound. Taran Kermani MD. L.Ac ff ffi fi 18 c A presentations. Atopic dermatitis (AKA eczema) has distinct L in people of di erent ages and races. , D Diagnostic criteria for atopic dermatitis M must include i n Pruritus a mdistribution rand Typical morphology e K licheni cation, hand eczema, nipple eczema, exuralan and r eyelid eczema in adults a T Onset in childhood, and chronicity. Onset after age 30 is very uncommon. Taran Kermani MD. L.Ac 19 Also helpful are (1) Personal or family history of atopy (asthma, allergic rhinitis, atopic dermatitis), (2) Xerosis-ichthyosis, c A L. , D (4) Elevated serum IgE M i (5) Repeated skin infections an m and may be severe and rfeature Itching is a key clinical e prolonged. K n a red plaques a ect the face, neck, and Ill-de ned,rscaly, a upperT trunk. (3) Facial pallor with infraorbital darkening The exural surfaces of elbows and knees are often involved. Taran Kermani MD. L.Ac ff ff fi fi 20 fl fl Atopic Dermatitis In chronic cases, the skin is dry and licheni ed. In dark-skinned patients with severe disease, pigmentation may be lost in licheni ed areas. , D During acute ares, widespread M i redness with weeping, either n a is di usely or in discrete plaques, m common. r e uncommon Food allergy isnanK a cause of rares of atopic dermatitis in adults. Ta c A L. Eosinophilia and increased serum IgE levels may be present. Taran Kermani MD. L.Ac 21 Treatment Atopic patients have hyper irritable skin. c A L. Anything that dries or irritates the skin will potentially trigger dermatitis. , D M i Soap should be con ned to the armpits, groin, scalp, and n ashould not be used. After feet. Washcloths and brushes m rinsing, the skin shouldrbe patted dry (not rubbed) and then ewith a thin lm of an emollient or a immediately covered K corticosteroidn as needed. a r should be applied sparingly to the a Corticosteroids T dermatitis once or twice daily and rubbed in well Atopic individuals are sensitive to low humidity and often are in the winter Systemic corticosteroids are indicated only for severe acute exacerbations Taran Kermani MD. L.Ac fi fi fi fl fi fl 22 ff fl