Lecture 37 Rosacea, perioral dermatitis, chronic idiopathic urticaria Flashcards
What is perioral dermatitis (cause, triggers/risk fx)?
impacts female around 20-45, seen in lighter skin types (Fitzpatrick I-II)
Cause: exact unknown, may be infectious (Candida, fusiform, demodex mites), change in microflora, hormonal
Triggers/Risk Fx: topical corticosteroid use, change in flora of skin secondary to corticosteroids, exogenous irritants, hormonal products, facemasks, etc
What is the presentation and S&S of perioral dermatitis?
presents like acneiform eruption, bilaterally in most cases but may also be unilaterally
can affect the eyes, nose, and mouth
S&S: irritation, burning, pruritis
What are differential diagnoses of perioral dermatitis?
Rosacea: usually impacts those older, distribution and lesions differ
rosacea related rhinophyma is excluded
Acne Vulgaris: age of onset is usually younger, distribution is different (T-zone), lesions (comedones, cysts, nodules) differ
Contact Dermatitis: onset secondary to exogenous product, age much more variable, lesions present differently
Seborrheic Dermatitis: distribution typically near the ears and hair bearing areas of face, presents as yellow/scaly lesions that slough off
What is involved in management of perioral dermatitis?
avoiding topical corticosteroids: this condition may be confused with irritant dermatitis or contact and may be prescribed a corticosteroid ⇒ these may settle initial flare but return and cause it to be worse
Non-Pharm: discontinue precipitating products
gentle cleanser and moisturizer, avoidance of fluoride containing toothpastes, avoidance of sodium lauryl sulfate
What are topical products used for management of perioral dermatitis?
Pimecrolimus Cream 1%: calcineurin inhibitor managing erythema,,, Metronidazole gel/cream 0.75-1%: antimicrobial and anti-inflammatory
Azelaic Acid gel 15%: antimicrobial and anti-inflammatory
Clindamycin gel 1%: lincosamide, inhibits 50S ribosome leading to reduced inflammation
Erythromycin gel 2%: macrolide, inhibits 50S ribosome leading to reduced inflammation
Sulfur preps 5-10%: keratolytic, antimicrobial, anti-inflammatory properties
What are systemic products used for management of perioral dermatitis?
Tetracycline: 250-500 mg BID, antibacterial and has anti-inflammatory props
Doxycycline: 50-100 mg QD-BID, more lipophilic than tetracycline resulting in better tissue penetration and better anti-inflammation
Minocycline: 50-100 mg QD-BID, slightly broader spectrum, more CNS penetration which may cause dizziness, pigmentation
What is rosacea (causes)?
chronic inflammatory skin condition which impacts males and females
more common in fair-skin people but can affect darker as well (sx may be masked however)
usually affects 30+ year olds, sometimes called ‘acne of adulthood’
Causes: not well known
may be: imbalance of microbiome in skin and gut (mainly demodex follicorum and S. epidermidis), neurocutaneous mechs including caffeine, spicy foods, alcohol, temp fluctuations, exercise, UV
genetics
What are S&S of rosacea?
flushing, erythema - particularly precipitated by triggers (Caffeine, alcohol, etc)
telangiectasias (persistently dilated capillaries or blood vessels in skin) - nasal region, facial skin, eyelid margins
inflammatory papules and pustules,, thickening of skin (phymatous changes) due to hyperplasia/fibrosis of sebaceous glands - most commonly affects nose (rhinophyma)
What are differential diagnoses for rosacea?
Perioral Dermatitis: usually affects females 20-45, lesions including phymatous changes are not present
Acne Vulgaris: age usually younger, distribution different (T-zone), lesions (comedones, cysts, nodules) differ
Contact Dermatitis: onset secondary to exogenous product, age more variable, lesions present different
Seborrheic Dermatitis: distribution by ears and hair bearing areas, present as yellow/scaly lesions that slough off
What are possible triggers that someone with rosacea should avoid?
climatic influences: sunlight, harsh cold, wind, heat
hot bevs, spicy food, vinegar, exercise, alcohol, use of astringents, emotional stress, topical corticosteroids, niacin (B vitamins), nitrates, CCBs, sildenafil
What are non-pharm measures for rosacea?
buying new cosmetics more often to avoid bacteria
avoid cosmetics with sodium lauryl sulfate, strong fragrances, fruit acids, glycolic acids
avoid products causing burning, stinging, itching, discomfort ⇒ tonics, toners, astringents with alcohol, menthol, peppermint, camphor, witch hazel, eucalyptus oil
waterproof cosmetics may be hard to remove
brushes preferred over sponges to avoid abrasion
cooling neck and mouth
laser tx
What are pharmacological tx for rosacea?
Topical: AVOID steroids as they can exacerbate
Brimonidine, oxymetazoline (for transient flushing), ivermectin, azelaic acid, metronidazole (involving inflammatory papules/pustules)
Oral: tetracyclines (involving inflammatory pustules/papules)
isotretinoin low dose (for refractory/non-responsive)
Mechanical Intervention: vascular laser (telangiectasias)
ablative laser/surgical debulking (non-inflamed phymatous)
What is chronic spontaneous urticaria (CSU) (S&S)?
thought to affect 1% of people, most common in 20-40 years, affects women more, can be severely debilitating and impact QoL
driven by release of mediators from mast cells - histamine, cytokines, etc
S&S: red swollen raised itchy weals (hives), angioedema or both occurring intermittently for >/= 6 weeks
weals can affect any part of body - few mm to cm in diameter, may be white or red with red flare, persist for minutes to hours, will resolve or alter shape within 24 hours
angioedema more localized - can affect any area but common around eyes, lips, hands, feet, genitals
may also affect pharynx, uvula, tongue, soft palate
Tx for chronic spontaneous urticaria (CSU)?
utilizing antihistamines, recommended to dose them up to 4 times daily versus stacking different ones together
1st gen do more harm than good due to AEs - dry mouth, urine retention, increased appetite and weight, increased dizziness, postural hypotension, increased QT, and arrhythmias
2nd Gen are recommended - ex. bilastine, cetirizine, desloratadine, fexofenadine, loratadine, rupatadine
Tx: 2nd gen ⇒ if inadequate response after 2-4 weeks or sx intolerable increase 2nd gen to up to 4x daily ⇒ if inadequate control after 2-4 weeks of sx intolerable add OMALIZUMAB ⇒ if inadequate control after 6 months or sx intolerable add CYCLOSPORINE
