Rosacea and Scaly Dermatoses Flashcards
Questions for the patient
When considering derm conditions:
What do the lesions look like (size, shape, color)?
How have the lesions changed over time?
Does it itch?
Is it painful?
What do you think the problem may be?
Are you having other symptoms (SOB, swelling, fever, or N/V)?
Where did the problem first appear?
Where are you affected?
Did it and how did it spread?
Rosacea
Skin disease that affects the middle third of the face. Causes persistent redness over the areas of the face and nose.
Mainly involves the forehead, the chin, and the lower half of the nose.
No confirmatory laboratory test.
No cure.
Rosacea – predisposing factors
- Between 30 and 50 years old
- Fair-skinned
- Often have blonde hair and blue eyes.
- Likely to have someone in their family with rosacea or severe acne.
- Likely to have had lots of acne — or acne cysts and/or nodules.
- Females more than males, but, males have higher severity
Rosacea Subtypes
Subtype 1: Facial Redness
Subtype 2: Bumps and Pimples
Subtype 3: Skin thickening
Subtype 4: Eye irritation
Rosacea Subtype 1
FACIAL REDNESS
erythematotelangiectatic rosacea
Flushing and persistent redness. Visible blood vessels may also appear.
Rosacea Subtype 2
BUMPS AND PIMPLES
papulopustular rosacea
Persistent facial redness with bumps or pimples. Often seen following or with subtype 1.
Rosacea Subtype 3
SKIN THICKENING
phymatous rosacea
Skin thickening and enlargement, usually around nose
Rosacea Subtype 3
EYE IRRITATION
ocular rosacea
Watery or bloodshot appearance, irritation, burning or stinging.
Rosacea: Clinical presentation
Erythematotelangiectatic (subtype 1)
Persistant erythema of central face
Easily irritated facial skin
Papulopustular (subtype 2)
Above + dome-shaped erythematous papules and some pustules
Phymatous (subtype 3)
Thickened skin with prominent pores +/- Above
Ocular rosacea (subtype 4) Both eyes usually affected Conjunctivitis Blepharitis Styes Keratitis
Rosacea triggers / exacerbating factors
- Prolonged sun / UV light exposure
- Stress / Anxiety
- Humidity / extremes of weather / wind
- Exercise
- Alcoholic beverages
- Smoking
- Hot and spicy foods
- Medications – (eg., vasodilators, calcium channel blockers, opiates)
- Microorganisms
- –Demodex folliculorum (mite)
- –Staphylococcus epidermidis
- –Heliobacter pylori
- –Bacillus oleronius
Rosacea Non-pharmacologic
Basic Skin Care:
- Moisturizer
- Photoprotection
- -SPF 15 or greater
- -Broad Spectrum: UVA and UVB coverage
- Gentle soap-free skin cleanser
- Avoid astringents, toners, waterproof cosmetics
- Avoid potentially exacerbating factors
Rosacea Pharmacologic Treatment (Topical)
Topical agents:
- Metronidazole 0.75% or 1% cream or gel
- Azelaic Acid 15% gel
- Brimonidine 0.33% gel (reduces redness only)
- Sodium Sulfacetamide 10% + Sulfur 5% - (papulopustular)
Benzoyl peroxide 5% + Clindamycin 1% - (papulopustular )
Topical Retinoids – use with or without oral antibiotics in refractory rosacea
- FDA approved
Topical Metronidazole
- Anti-inflammatory agent
- Antimicrobial agent
- Inhibits growth of Demodex brevis (mites)
- Decreases reactive oxygen species generation
Side effects: burning, stinging, dryness, itching
Dosing
0.75% = Applied twice daily (gel, cream, lotion)
1% = Applied once daily
(gel, cream)
Face should be clean before application
Cosmetics may be used 5 minutes after application
Azelaic Acid
15% gel, 20% cream
Anti-inflammatory Antibacterial agent
For mild to moderate papulopustular rosacea
Use twice daily on affected areas
Side effects : burning, stinging, itching, dryness, scaling
Reassess if not improvement after 12 weeks
Face should be clean before application
Cosmetics may be used after application
Brimonidine
Alpha-2 agonist
Reduces facial erythema
Causes vasoconstriction in the smooth muscles of blood vessels in the skin
See effects at 30 minutes after application; persists up to 7 hours
May see rebound facial erythema
Rpsacea Pharmacological Treatment (Systemic)
Oral Agents
- Doxycycline - 40 mg daily – anti-inflammatory dose
Only systemic therapy approved by FDA for rosacea for up to 12 months
Antibiotic / Anti-inflammatory agents
resistance concerns
Azithromycin 250 – 500 mg three times per week for 2 – 6 weeks
Doxycycline 50 – 100 mg/day for 6 – 12 weeks
Minocycline 50 – 100 mg twice daily for 6 – 12 weeks
Metronidazole 200 mg once or twice daily for 4 – 6 weeks
Beta-blockers – to decrease erythema (limited studies w/Carvedilol; concern for CV effects)
Isotretinoin - limited data; Poorly tolerated
!!Not in females of reproductive age
Ocular Rosacea - treatment
Warm water soaks
Twice daily cleaning of base of lashes with no tears baby shampoo or lid cleanser, remove any crusting
Artificial Tear replacement
Topical Metronidazole gel
Oral Doxycycline or alternative antibiotic
Refer severe cases to ophthalmologist
Case 1: 47 year old woman with facial redness and flushing over past year. Eyes itch and are red. Worried about “whiskey” nose.
What is the initial medication treatment for this condition?
What medication can be added to reduce eye symptoms?
For management of rosacea, what is true?
What is the initial medication treatment for this condition?Metronidazole gel BID
What medication can be added to reduce eye symptoms? Doxycycline 40mg daily
For management of rosacea, what is true? should wear sunscreen
Scaly Dermatoses
Dandruff
Seborrhea
Psoriasis
Distinguishing Dandruff
Scalp Generally stable (not exacerabated) but does increase in dry climate
Appears thin, white or grey flakes on scalp
no inflammation
no epidermal hyperplasia (skin increase)
epidermal kinetics 2x faster than normal
less than 5% incompletely keratinized skin
Distinguishing Seborrhea
Head and Trunk
Exacerbated by external factors; Parkinson’s disease
Appears as macules, patches and thin plaques of discrete yellow, oily scales on red skin
Inflammation is present
Has epidermal hyperplasia (skin thickening)
Epidermal kinetics 3x faster than normal
15-25% incompletely keratinized cells
Distinguishing Psoriasis
Scalp, elbows, knees, trunk, lower extremities
Exacerbated by irritation, stress, climate, medications, infection, endocrine
Appears discretely symmetrical, red plaques with sharp borders, silvery white scale
Inflammation is present
Has epidermal hyperplasia (skin thickening)
Epidermal kinetics are 5-6x faster than normal
40-60% incompletely keratinized cells
OTCs for scaly dermatoses
FOR Dandruff, Seborrhea, and Psoriasis:
Coal Tar Ketoconazole (shampoo) Pyrithione Zinc (rinse off) Pyrithione Zinc (residual) Salicylic Acid Selenium Sulfide
FOR dandruff and seborrhea
(NOT psoriasis)
Sulfur
For seborrhea and psoriasis
(NOT dandruff)
hydrocortisone 1%
Dandruff
Chronic, non-inflammatory hyperproliferative epidermal scalp condition
Scales from irregular keratin cracking pattern
Pruritis common
Occurs in 1 – 3 % of population
Puberty onset
Peak occurrence in adulthood
No gender preference
Dandruff Treatment Goals
Reduce epidermal turnover rate of scalp skin
Minimize the cosmetic embarrassment of visible scaling
Minimize itching
Dandruff General Treatment Approach
Mild presentation:
-Non-medicated shampoo
(Daily or every other day)
Moderate to severe presentation :
- OTC medicated shampoos (pyrithione zinc or selenium sulfide)
- Leave on for 3 to 5 minutes
- Rinse well with water
- Use 2 – 3 times weekly for 2 to 3 weeks, then once weekly for control
Seborrheic Dermatitis occurance
Chronic inflammatory disorder occurring in areas of sebaceous gland activity
Chronic condition with no specific cure
Neither harmful nor contagious
Affects 3 – 5% of adults, men more than women
Ages 18 to 40 years
Seborrheic Dermatitis Features
Greasy or dry scaling of the scalp, sometimes a “cradle cap”
Mildly scaling eczematous patches on the face at typical locations (eyebrows, nasolabial creases, “sideburn”area)often with itch and stinging
Itch and inflammation of the ear canal
Blepharitis (eyelid infection)
Well-demarcated eczematous patches
- –on mid-upper trunk
- –at intertrigo areas (skin folds or juxtaposed surfaces of skin)
Seborrhea triggers / causes
- Malassezia (a yeast – like fungus) grows in the sebum along with bacteria
- Hormones
- Physical stress, fatigue, travel
- Zinc deficiency
- Obesity
- Season Change (worse in cold weather)
- HIV infection
- Parkinsonism
Seborrheic Dermatitis Traetment goals
Reduce inflammation and epidermal turnover rate
Minimize or eliminate visible erythema and scaling
Seborrheic Dermatitis General treatment approach / management strategies
- Loosen and remove scales and crusts
- Inhibit yeast colonization (Malassezia)
- Reduce erythema and itching
- Avoid perfumes, aftershave, ointments, soaps
- Control secondary infections
To Loosen and remove scales and crusts and decrease sebum (Seborrhea)
The scales can be softened with:
- -Cream containing salicylic acid and sulphur
- -Wetting and washing
Seborrhoeic skin should be washed more often than twice daily
To Decrease Fungal Growth (Seborrhea)
Washing the scalp
- -Ketoconazole shampoo [first line] or
- -Selenium sulfide shampoo [second line]
Shampoo scalp with medicated shampoo product daily for a week, then 2-3 times a week
leave shampoo on hair, scalp and affected areas for 5 minutes; then rinse
may repeat
After 4 weeks (if see improvement)
may reduce frequency of medicated shampoo to once weekly
If worsens after 1 to 2 weeks on OTC meds/shampoo, refer to physician
Topical treatment with
Imidazole derivative creams
Sometimes ultraviolet light therapy
To Reduce erythema and itching (seborrhea)
Corticosteroid lotion for the scalp (from mild to potent)
Corticosteroid creams for other parts of the body (from mild to potent)
Moisturizing emollients after washing
Ketoconazole shampoo and corticosteroid lotion must often be combined in therapy-resistant cases.
Seborrheic treatment - infants
“Cradle cap”
Remove scaling on scalp:
- Massage scalp with baby oil
- Use non-medicated shampoo
- Soft bristle brush
-For severe cases: Salicylic Acid 3 – 5 % in olive oil or water soluble base
On face – wash with mild soap or cleanser, apply facial emollient – no steroids
A 35 yo man reports itching, redness, and scaling in his scalp, eyebrows and external auditory canal. He has tried several over-the-counter dandruff shampoos, with only temporary relief, and he is increasingly embarrassed by this problem. On exam, greasy scaling on the scalp and erythema with yellowish scales in the nasolabial creases.
Primary problem?
First medication product to suggest?
Primary problem? seborrhea
First medication product to suggest? Ketoconazole shampoo
: A new mom comes to the pharmacy with an infant that looks to be a couple of weeks old. She asks about the scaly appearance of the infant’s scalp, if it is dangerous and what she should do.
Primary problem?
Treatment?
Primary problem? seborrhea, “cradle cap”
Treatment? baby oil with gentle massage
Psoriasis- Patient Assessment
Measures of symptom and involvement:
% Body surface area (BSA) involved
Psoriasis Area and Severity Index (PASI)
Physician’s Global Assessment (static PGA)
Quality-of-life measures:
Dermatology Life Quality Index (DLQI)
Short Form (SF-36) Health Survey
Signs and Symptoms of plaque psoriasis
Lesions (plaques): Erythmatous Red-violet in color At least 0.5 cm in diameter Well demarcated Typically covered by silver, flaking scales
psoriasis skin involvement
Skin Involvement:
Generalized over wide BSA
Mild: less than or = to 5% BSA
Moderate: PASI greater than or = to 8 (psoriasis area and severity index)
Severe: PASI greater than or = to 10 OR DLQI is greater than or = to 10 or BSA is greater than or = to 10. (rule of 10s)
(dermatology quality of life index)
psoriasis pruritis
Pruritis:
More than 50% of patients have itching
May be severe in some patients and require treatment to minimize excoriations from scratching
Other concerns with psoriasis
Other concerns:
Lesions may be physically debilitating or socially isolating
Potential comorbidities: PsA (psoriatic arthritis)
depression, HTN,obesity, diabetes,Chrone’s,anxiety, alcoholism
Psoriasis: Goals of treatment
- -Minimizing or eliminating the signs of psoriasis such as plaques and scales
- -Alleviating pruritus and minimizing excoriations
- -Reducing the frequency of flare-ups
- -Ensuring appropriate treatment of associated conditions such as PsA (psoriatic arthritis), hypertension, dyslipidemia, diabetes, clinical depression, or itching
- -Avoiding or minimizing adverse effects from topical or systemic treatments used
- -Providing cost-effective therapy
- -Providing guidance or counseling as needed (e.g., stress-reduction techniques)
- -Maintaining or improving the patient’s quality of life
All psoriasis patients – Healthy lifestyle recommendations
Reduce stress Regular exercise Weight management (aim for BMI 18.5-24.9) Moderation of alcohol consumption Cessation of smoking
Psoriasis Non-Pharmacologic treatments
For small areas or just a few patches
Moisturizers / Emollients
Oatmeal baths
Sunscreen
Topical therapy options - Psoriasis
Corticosteriods
Vitamin D3 analogue-Calcipotriene
Retinoids-Tazarotene
Anthralin
Coal Tar
Salicylic Acid:
Calcineurin Inhibitors-
Pimecrimolimus:
Psoriasis Systemic Agents
Oral retinoid-Acitretin
Oral Tcell & cytokine suppressor-Methotrexate and Cyclosporin
Oral Tcell Inhibitor-Alefacept (Amevive)
Oral Monoclonal Tcell Inhibitor-Efalizzumab (Raptiva)
Interleukin Inhibitor-Ustekinumab (Stelera)
Biologic Agents-TNFa inhibitors
Corticosteroids for psoriasis
Corticosteriods: (topical)
cream or lotion (day)
ointment (night)
2-4 times daily
Vitamin D3 analogue for psoriasis
Vitamin D3 analogue-Calcipotriene: (topical)
ointment- 1 or 2 times daily or
cream or foam- twice daily
Retinoids for psoriasis (topical)
Retinoids-
Tazarotene: (topical)
Once daily at bedtime
Anthralin for psoriasis
Anthralin: (topical)
Apply only to thick plaque lesions for 2 hrs or less (use zinc oxide around)
Then wipe off
Coal Tar for Psoriasis
Coal Tar: (topical)
Apply in evening
Wash off in morning
Salicylic Acid for Psoriasis
Salicylic Acid:
Shampoo-for scalp lesions
Calcineurin Inhibitors for Psoriasis
Calcineurin Inhibitors-
Pimecrimolimus: (topical)
Apply to intertriginous areas (folds)
Retinoid for psoriasis (oral)
Oral retinoid Acitretin: Not immunosuppressive Max response 3-6 months Do not drink alcohol
Reproductive age women: should not be or plan to get pregnant within 3 years of discontinuing drug
Tcell and cytokine suppressor for psoriasis
Methotrexate (oral)
For psoriasis and psoriatic arthritis
Onset 3-6 weeks
Admin w/ folic acid 1-5mg/day to decrease nausea, bone marrow suppression, hepatic toxicity
Contraindicated:pregnancy, cirrhosis, blood dyscrasias (disorders)
Increases risk of hepatotoxicity (DM, obese, alcoholism, >4g total cumulative dose)
Tcell and cytokine suppressor for psoriasis
Cyclosporin (DMARD)
oral
Not recommended for use over 4 months-nephrotoxic
Dose on ACTUAL body weight
Many drug interactions:major 3A4 substrate, 3A4 & 2C9 inhibitor
Contraindicated:systemic malignancy, untreated HTN, infections
Increases elderly risk of HTN
Tcell inhibitor for psoriasis
Alefacept (Amevive)
Dose: 15mg IM every week for 12 weeks (follow w/ 12 weeks non-treatment)
Contraindicated:HIV
Monitor: CD4 base count, get CD4 counts q 2 wks during therapy (hold for count
Monoclonal Tcell inhibitor for psoriasis
Efalizumab (Raptiva)
Dose: single 0.7 mg/kg SC (conditioning dose) then 1 mg/kg SC weekly (max single dose not to exceed 200 mg)
Monitior: Platelet count monthly, may extend to every 3 mo w/ prolonged course
NO live or attenuated vaccines during therapy
Interleukin inhibitor for psoriasis
Ustekinumab (Stelera)
Dose 0-4 weeks: SC if under 100 kg; 90mh SC if over 100 kg then every 12 wks
Caution: -Avoid in active TB -Do not give concurrently with: ---live vaccines ---BCG ---pimecrolimus ---tacrolimus ---Echinacea (may decrease levels)
Monitor: PPD, CDC, signs of infection, antibody formation
TNFa Inhibitors for psoriasis
Biologic Agents: Adalimumab (Humira) Etanercept (Enbrel) Infliximab (Remicade) Golimumab (Simponi) Certolizumab (Cimzia)
Dose: see insert
TB testing (PPD) on all patients (repeat yearly) HepB screen is recommended
Monitor CBC & LFT
Do not Use:
live vaccine
CHF patients
Patients w/ or family that has demylenating disease or MS
mild-Moderate Psoriasis Treatment algorithm
Topical agents + moisturizers as needed (If controlled step down to lowest effective dose or potency)
Inadequate:
Topical+phototherapy+ moisturizer as needed (If controlled step down to lowest effective dose or potency)
Inadequate:
Topical+systemic+ moisturizer as needed (If controlled step down to lowest effective dose or potency)
Moderate-Sever Psoriasis Treatment Algorithm
Systemic +/- topical or photo+
moisturizer as needed (If controlled step down to lowest effective dose or potency)
Inadequate:
More potent systemic+/- topical + moisturizer as needed (If controlled step down to lowest effective dose or potency)
OR
2 systemics in rotation (rarely done) +/- topical+moisturizer as needed (If controlled step down to lowest effective dose or potency)
Inadequate:
Biologic +/- other agents + moisturizer as needed (If controlled step down to lowest effective dose or potency)
NOTE: may consider biologics earlier or even as first line BUT expensive
Mod-Severe psoriasis treatment (pediatric-no psoriatic arthritis)
Topical agent
If UVB available:
1st line:
UVB phototherapy (monotherapy) or UVB+Methotrexate
If No UVB: 1st line alpha order Adalimumab Cyclosporin Etanercept Infliximab Methotrexate PUVA
Peripheral Psoriatic Arthritis treatment
Nsaids or Local 1A steroids
1st DMARD
2nd DMARD
1st line TNFa inhibitor
2nd line TNFa inhibitor
Axial Psoriatic Arthritis Treatment
Nsaid or local 1A steroid
1st line TNFa inhibitor
2nd line TNFa inhibitor
Photochemotherapy
Last resort
PUVA: Psoralen + UVA light
MOA: Psoralen cross-links with DNA in presence of UVA light; effects immune response in skin and lymphocytes
Reserved for patients with severe, refractory psoriasis
Need skin biopsy of lesion to confirm diagnosis of psoriasis
Efficacy: 90% with oral psoralens + UVA light
Dosing
0.6-0.8mg/kg po every 2 hours before exposure to UVA light
Side effects: Serious burns Blistering Peeling Itching Nausea Potential increase in certain cancer rates
Pharmacoeconomics of Psoriasis Treatments
Costs of psoriasis therapy for moderate to severe disease: Cost of drug Cost of administration Cost of monitoring Cost of adverse effects Cost of failed treatment Cost of days off work Can be significant ($1000s), even with insurance
Psoriasis Patient Education
Fully inform patients / caregivers of benefits and risks of treatment options
www. aad.org
www. psoriasis.org
A 52 year old female, comes into the pharmacy to pick up her refills for enalapril and hydrochlorothiazide.
She shows you two approximately 2 cm plaques on the ulnar surface of each elbow, they are covered with whitish silvery scales.
DC states that these are new and appeared over the past week.
Current meds: Enalapril / HCTZ
NKDA
DC also tells you that 15 years ago she was treated for psoriasis with tar and steroid creams for a couple of months, with good results
She cannot get an appointment with a dermatologist for 8 weeks
She asks your advice about what she can do in the meantime
She has no joint symptoms
risk factors for psoriasis – winter
treatment plan for this patient
Moisturize appropriately, coal tar and steroid cream
Conclusion
Mild to moderate scaly dermatoses can often be effectively managed with topical non-prescription products
Selection of products based on:
Patient’s history
Prior response to treatment
Evaluation of risks vs. benefits of options
Education of patients:
Appropriate application of topical therapy
Appropriate administration of oral therapy
Follow-up should be a week after self-treatment begins
