10 - Scaly Dermatosis Flashcards by Karlo Sison

Definition + Types of Scaly Dermatoses

Involve epidermis + Scales are primary manifestation

Dandruff -> Seborrheic Dermatitis -> PSORIASIS

increasing Severity + Inflammation

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Seborrheic Dermatitis

NOT a disease of the sebaceous glands
Rate of sebum production is NOT necessarily increased

Found in areas w/ larger or higher amounts of glands

Can be in association with MALASSEZIA

Immunologic + Hyperproliferative

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Malassezia

YEAST found on NORMAL skin
metabolize fatty compounds in sebum

Can be Directly Pathologic:
Pityriasis Versicolor / Systemic Infections

Also Indirectly Pathalogic:
in Dandruff & Seborrheic Dermatitis

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Pathophysiology of SD

Seborrheic Dermatitis

In combination, make an
Exaggerated Immune Response to Malassezia Yeast:

Malassezia
metabolize FATTY compounds, found in LIPID-RICH location

Immunologic
common in immune supressed, more CYTOKINES

HYPERproliferative
Overlap with PSORIASIS, lack of efficacy of antifungals

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Combined PATHWAY of Scaly Dermatosis

Malassezia Fungus influences Dandruff & SD,
not thought to be a factor in Psoriasis

Inflammation
1. varies between diseases
Proliferation + Differentiation
1. also varies between diseases, tied with inflammation:
  1. normal = 25-30 days >> dandruff = 13-15 days
    1. >> SD = 9-10 days >> psoriasis = 4 days
Barrier Disruption

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S/S of Dandruff

Fine / White Flakes

SCALP involvement

Diffuse distribution

Can have Pruritus

Usually NO Erythema

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S/Sx of Seborrheic Dermatitis

Yellow + Greasy scales, can be scalp involved
+ facial & other areas w/ HIGH amounts of sebaceous glands

Pruritus
Presence of Erythema

Seen in adolescents + adults
MORE COMMON in immune compromised + Parkinsons

Well demarcated lesions

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LOOKALIKE Diseases

Atopic Dermatitis

Allergic/Irritant Dermatitis

Rosacea

Cutaneous Fungal Infection

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S/Sx of Psoriasis

SHARPLY Demarcated

SILVERY-WHITE scales

Commonly found on :
scalp / Elbows / Knees / Back

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What Treatment Mechanism do these medications ACT ON?

Pyrithione Zinc / Ciclopirox

Keto/sertaconazole / Selenium Sulfide

Tea Tree Oil

DIRECTLY on the MALASSEZIA FUNGUS

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What Treatment Mechanism do these medications ACT ON?

Corticosteroids

Calcineurin Inhibitors

Tea Tree Oils

INFLAMMATION

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What Treatment Mechanism do these medications ACT ON?

Coal Tar

Selenium Sulfide

Pyrithione Zinc

CYTOSTATIC:

Proliferation + Differentiation

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What Treatment Mechanism do these medications ACT ON?

Salicylic Acid

Keratolytic –> Proliferation & Differentiation

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What ST-Medications are FIRST LINE for

DANDRUFF?

*Selenium Sulfide**
hair discoloration + oily scalp*

Pyrithione Zinc

Ketoconzole 1%

skin irritation / contact dermatitis

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What ST-Medications are Second LINE for

DANDRUFF?

*Coal Tar**
hair discoloration / staining / PHOTOsensitivity / folliculitis*

Salicylic Acid

Natural = Tea Tree Oil*
allergic rxns*

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Treatment Mechanism / MoA / Uses (1st/2nd line?) / AE’s

of (serta)KETOCONAZOLE

Act Directly on Malassezia

Interferes with Membrane Synthesis

ST: 1st line for Dandruff & SD

RX: 1st line for SD
2% Keto Shampoo / Cream / Foam / Gel, BID F8W
photosensitivity
2% Sertaconozole Cream, BID F4W

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Treatment Mechanism / MoA / Uses (1st/2nd line?) / AE’s

of CICLOPIROX?

Act DIRECTLY on the Malassezia Fungus

Disrupt Metabolism

RX Only: 1st Line
1% Shampoo = QD -> Twice a Week
0.77% Gel / Cream = BID for 4 weeks

Treatment Mechanism / MoA / Uses (1st/2nd line?) / AE’s

of PYRITHIONE ZINC?

Act DIRECTLY on the Malassezia Fungus + Cytostatic-Prolif/Differentiation

INCREASED Copper + Disrupt Metabolism

ST: 1st Line for Dandruff + SD

found in head & shoulders

Treatment Mechanism / MoA / Uses (1st/2nd line?) / AE’s

for SELENIUM SULFIDE?

Act on BOTH the Malessezia Fungus + Cytostatic -Prolif+Differentiation

Promote Shedding of the stratum corneum + Anti-Fungal properties

ST: 1st line for Dandruff

1st line Self Treatment for SD

Anti-Malassezia Shampoos
can be used in facial areas as well

Phyrithione Zinc

Selenium Sulfide

Ketoconazole 1%

Self treatment for SD

if patient has ERYTHEMA / yellow or oily lesions

HYDROCORTISONE

Erythema after use of MEDICATED shampoos

along with the medicated shampoos

Self Treatment for Infants/Cradle Cap (Mild cases) for

Seborrheid Dermatitis

Massage w/ BABY OIL

Non-residue / Non-medicated Baby Shampoo, to REMOVE Scales

No medicated shampoos approved for Children
<2 years old

Application + Frequency of use for

MEDICATED SHAMPOOS

Ex. Pyrithione Zinc + Selenium Sulfide + Ketoconazole

*Scalp = Adequate Contact**
Before using medicated shampoo,*
*Use Non-medicated/nonresidue shampoo FIRST**

Massage into scalp and leave it on for 3-5 minutes

2-3x/week for 2-3 Weeks –> 1x/week to control

Ketoconozole = Twice a Week F4W, w/ at least 3 days between each treatment

1st like PRESCRIPTION treatment for

Seborrheic Dermititis

ANTIFUNGALS
burning / contact dermatitis

Ciclopirox 1%

*Ketoconazole 2%**
photosensitivity*

Sertaconazole 2%

**Second Line PRESCRIPTION treatment for** **Seborrheic Dermatitis**

* *_Corticosteroids_** * hypopigmentation / skin atrophy / telangiectasia* * *_Calcineurin Inhibitors_** * *Pimecrolimus 1% ,** BID *HA + URI* * *Tacrolimus 0.1%,** BID *pruritus + flu like symptoms* * burning*

**EX-ST for Dandruff + SD + Psoriasis**

**_\<2 y/o_** Worsening or NO improvement within **_2 weeks of treatment_**

**EX-ST for PSORIASIS**

**_\<2 y/o**_ + no improvement/worse within _**2wks of treatment_** **_\>5%**_ _**BSA_** Lesions **\>Quarter in size** **FACIAL** Lesions / **JOINT Pain**

**Chart for Treating Scaly Dermatosis**

**Risk / Triggers for PSORIASIS**

Genetics **Infections:** Strep Throat = Guttate psoriasis **Skin Trauma** **Smoking / Alcohol** **Obesity / Hormonal Changes / Emotional STRESS** **Medications** Beta Blockers (-olol) + Lithium + Anti-Malarials + Steroid Withdrawal + NSAIDS + Tetracyclines + Ace-I

**Types of Psoriasis:**

**_Chronic Plaque Psoriasis_** most common, erythema + raised + sharply defined **silvery** scales + **asymptomantic,** *some prurtus* **_Pustular Psoriasis_** Erythema + scaling + **pustules** accompanied by **systemic complications --\> life threatening** **Psoriatic Arthritis**, SYSTEMIC involved Other *less common types: Erythrodermic / Inverse / Nail*

**Medications Associated W/ PSORIASIS**

* *_Beta Blockers_** - olol **_Lithium_** **_Anti-Malarials_** Chloroquine + ydroxychloroquine -\> exacerbate psoriasis **_Steroid Withdrawal_** **_Nsaids / Tetracyclines / Ace Inhibitors_**

**Pathophysiology of PSORIASIS**

**_Abnormal Immune Mediation_** 1. **Trigger** = Trauma / Infection / Stress / ?? 2. **Stressed Keratinocytes** 3. **INFLAMMATION** 4. Keratinocyte: 1. **Division + Plaque Formation** 2. Activation -\> **Cytokine Production**

Non-RX, **Self-Treatment for PSORIASIS**

_Appropriate for **MILD**_ **_Psoriasis_** \<5% BSA, lesions

Remove scales w/ soft cloth after bathing

Use of EMOLLIENTS after bathing up to QID

Hydrocortisone ointment, BID

SEE DR AFTER 2 WEEKS of no improvement or worsening

**Topical Prescription Treatment for** **PSORIASIS**

For _MILD - MODERATE Psoriasis_ **_Corticosteroids_** **_Vitamin D Analogs_** Calcipotriene / Calcitriol - BID **_Calcineurin Inhibitor_** Tacrolimus / Pimecrolimus - BID, okay for FACE + Intertriginous **_Vitamin A Derivative_** Tazarotene = QD

**Treatment for Mild-Moderate PSORIASIS**

_**1st**: **Topical Corticosteroids**_ ALT: **Topical Vitamin D Analogs + Topical Retinoids** _Face or Intertriginous_ = **Calcineurin Inhibitors** *Can use corticosteroids + Vitamin D analogs in COMBO or Intermittently*

**Treatment for SEVERE PSORIASIS** **\>5-10% BSA**

**_PHOTOTHERAPY_** Narrow Band UVB \> UVB, both TID Photochemotherapy (PUVA) - TID Excimer Laser - Twice a week **_SYSTEMIC TREATMENTS_** Systemic Retinoid = Acitretin Immune Supression/modulatory = Methotrexate + cyclosporine

**Systemic Treatment for PSORIASIS**

**_Systemic Retinoid_** Acitretin effect **epidermal proliferation + immunomodulation** **_Immune Suppresion / Immunomodulatory_** Methotrexate / Cyclosporine / Apremilast / Biologics

**UV Treatment for PSORIASIS**

MOA = **Anti-Proliferative + Anti Inflammatory** *erythema / blistering / HYPERpigmentation / photodamage / malignancy* **_Narrow Band UVB \> UVB_** both TID, Narrow band is more effective, effects T-cells **_Photochemotherapy = PUVA_** BID, combo oral / topical, deeper **_Excimer Laser_** 2x/week, UVB at targeted area

**Treatment Mechanism / Uses (1st/2nd line?) / AE's** **of _CORTICOSTEROIDS_**

Act on **Inflammation** **_ST for SD: Used AFTER shampoos if ERYTHEMA_** * *1st line for Mild to Moderate Psoriasis** * skin atrophy / hypo pigmentation / acne / bruising*

**Treatment Mechanism / MoA / Uses (1st/2nd line?) / AE's** **for CALCINEURIN INHIBITORS?**

Act on **INFLAMMATION** * *Topical RX treatment for Mild/Moderate PSORIASIS** * *_FACIAL or Intertriginous_** **BID**, Tacrolimus / Pimecrolimus

**Mechanism of Action of Topical Psoriasis Treatments:** **Vitamin D Analogs / Vitamin A Derivatives / Coal Tar**

**_ACT ON CYTOKINE PRODUCTION_** **_Keratinocyte Activation_**