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Common Diseases and Infections of the SKIN

Toby Maurer, MDUniversity of California, San Francisco

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Onychomycosis

• Topical treatment –use for the right type of lesions

• Naftin gel for small superficial lesions

• Penlac (Ciclopirox 8%) reported to work 35-52% of the time– cost: expensive

Right type of lesions for topicals

• Lunula not affected• Less than 5 nails affected• No thickening of nails• No separation of nail plate on sides

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New ways of overcoming the nail barrier

• Thioglycolic acid followed by Urea-Int J Pharm 2009-brown et al.

• Chemicals that bind to nail and allow delivery of drug

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Dermatophytes or Tinea• Itraconazole (Sporanox)

– VERY effective– Keeps working even after medication is

stopped– Pulse therapy - 400mg q day x 7

dys/mo. for 3 mos.

Dermatophytes or Tinea

• Terbinafine (Lamisil)– VERY effective– Works after medication is stopped– 250 qd x 3 months

– 1 study shows pulse dose (500 mg qd x 1wk/mo for 4 mos) equal effect as continuous-For fingernails only

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What are the chances that I will be cured of fungus if I take terbinafine?a) 75% cure and recurrence 50% of the timeb) 75% cure and recurrence 25% of the timec) 50% cure and recurrence 50% of the time

Answer: aMycologic cure rates for antifungals:Terbinafine: 77%Itraconazole: 70%Griseofulvin: 41%

At 12 months:Terbinafine: 75%Itraconazole: 50%

At 5 yrs:Terbinafine: 50%Itraconazole: 13%

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OnychomycosisA New Approach

• Toenails take 12-18 months to grow• Pulse terbinafine 250 mg per day for 1

week every 2-3 months for one year• Booster dose at 9 months (250 mg qd x 1

month)

Liver toxicity

• Transaminase elevation 0.4% to 1% with terbinafine and intraconazole

• Transaminase elevation does not predict liver failure

• Liver failure 1/100,000• Terbinafine has gone generic

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Candida of Nails

• Look for paronychia (erythema and swelling around nailbed) and green nails

• Green nails represent the co-pathogen which is pseudomonas

Fluconazole 150 mg qd x1 month PLUS Ciprofloxacin 500 bid x 2 weeks

OrThymol 2-4% soak 20 mins bid x 3 months and

tobramycin or gentamycin solution

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Pitted Keratolysis

• May be confused with tinea on foot• See pits• Bad odor• From bacteria-topical erythromycin bid

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Intertrigo

• Under pannus and breasts• Always a component of candida• Blow dry area• Topical antifungals• Tucks pads (wet to dry dressing)

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Erosio interdigitalis blastomycetica

• Candida and bacteria between toes or fingers• On foot, spreads to dorsal foot or can be the

portal of entry for cellulitis and recurrent cellulitis

• Treatment:• Drying agents: Burow’s soaks 20 mins bid

Antibiotics for staph aureusTopical or po antifungalsMild topical steroid for itch

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Tinea VersicolorTreatment:

- for localized areas, topical antifungal otherwise:

– Nizoral 200 mg po daily x 4 days– Sweat x1 hour after taking med– Leave sweat on body for 8-12 hours– Selenium sulfate shampoo 15 mins q week for

prevention

The Many Faces of Strep and Staph Infections

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Approach to Treatment

• Culture where you can-if you have pus• Incise and drain when appropriate

(Abcesses)

If no pus:

• Tx with methicillin sensitive drugs-first line but have pt return to evaluate for resolution

• If recurrent infection, tx with methicillinresitant antibiotics right off the bat -Septra, Doxycycline, Clindamycin

• Consider adding rifampin 600 qd for 5 days or mupirocin ointment for staph eradication

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If not improving

• Was patient treated long enough?Once hair structures are involved or deep

tissues, treatment time may be longer

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Don’t forget strep

• S. pyogenes, S pneumonae, Gp A, B, C strep• Look for skip lesions, culture when possible• Doxycycline and septra resistance is possible

re: strep• Cipro/levo do not cover strep• Add antibiotic that covers strepJacobs et al Diagn Microb Inf Dis 2007, March

Strep-may need added coverage withPenicillin, cephalosporins

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Was it an inflammatory condition and not an infection

• Erythema nodosum• Pyoderma gangrenosum• Hidradenitis suppurativa

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Don’t forget HSV

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Orolabial Herpes Simplex

• No prophylaxis• Treat when sypmtomatic• Sun exposure can activate HSV-ACV 800

mg 1 hour before sun exposure

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Herpes Zoster

• Painful dermatomal lesions with or without blisters

• Culture• Treat with high dose acyclovir (800 mg

5x’s day or high dose valcyclovir/famcyclovir)

• HIV test pts under 50

• Ask about immunosuppressents -prednisone, azathiaprine, mycophenalatemofetil (cellcept) or TNF blockers-particularly infliximab and adilumibab.

• Consider herpes zoster vaccine before initiating therapy

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Acne

• Papulopustular– Topicals okay

• Cystic, scarring, keloidal– p.o. antibiotics– Isotretinoin (accutane)

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Topicals

• BP 5% gel (10% - more drying)• BP 5% wash-great for comedones back/chest• Retin A 0.025% - 0.1% ( vehicle determines

strength - start with crème)• Cleocin T or erythromycin topically

– Use 1 qam and 1qhs– If NO success after 8 weeks, go to p.o.’s

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P.O. Antibiotics

• TCN - 500 bid x 8 weeks• Doxycycline - 100 bid x 8 weeks• Minocycline - 100 bid x 8 weeks• Taper - Do NOT STOP ABRUPTLY

Alternatives

• Erythromycin - 500 bid• Septra - check WBC’s • Keflex-500 tid

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Spiranolactone

• Diuretic used in cirrhosis of liver• Also an anti-androgen• Useful in females who have cysts around

menstruation• 50-100 mg qday continuously• Increased urination, don’t use during

pregnancy, ?electrolyte imbalance

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Acne Rosacea

• Oral antibiotics for 6-8 weeks clears skin for some amount of time

• Topicals work less frequently-Metrocreme

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Perioral Dermatitis

TREATMENTTopicals: Cleocin T Gel bid

Erythromycin bidp.o. antibiotics –TCN

DoxycyclineMinocycline

- bid x 8 wksKeeps pts in remission x 2 yrs.

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Pt says: Hydrocortisone works well but can’t get off it

• What is the problem?a) If using steroids for perioral dermatitis,

use a higher potencyb) Topical steroids exacerbate perioral

dermatitisc) Substitute topical antibiotics for

steroids

Answer: b

• Steroids should not be used to treat perioral dermatitis

• They can bring it on -even HC• Cannot just substitute antibiotics-need to

slowly taper steroids while using antibiotics.

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Psoriasis-What is it?

• Fast growing skin-takes 3 days to come to surface and desquamate

• Normal rate is 28 days• Psoriatic skin has a fast mitotic rate• Triggers an inflammatory response in

and around affected skin

• New onset often preceded by strep infection (strep pharyngitis) especially in the younger age group.

• In older age group, drugs often unmask psoriasis

• Drugs: beta-blockers, lithium, NSAIDS, antimalarials, terbinafine, gemfibrozil-pts on these meds for 3-6 months before onset of psoriasis

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PsoriasisPsoriasis--TxTx::

• Decrease the MITOTIC RATE of skin– Tar (LCD 5% in TAC

0.1% oint) ( Tar emulsions)

– topical retinoids (Tazarac)

• Decrease the INFLAMMATORY RATE of the skin– Steroid Ointment

(mid-potency-1st line)– Calcipotriene

(Dovonex Creme)-not on face or groin

– Clobetasol/Dovonexcombination

– Ultraviolet light

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NO PREDNISONE

Pt has psoriasis and COPD. You need to give him prednisone. What

do you do?a) never give prednisone if pt has psoriasis-

skin most importantb) give prednisone and don’t worry about

it-lungs most importantc) start prednisone and call derm for plan

re: initiating steroid sparing psoriasis drugs

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• Methotrexate• Oral retinoids (Acitretin)• Cyclosporine• Biologics (etanercept, infliximab, humira)

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Poison Oak

• from the oil of the plant• More you are exposed, the worse it is• for localized areas, potent topical steroids• For widespread reaction, this is toxin mediated

reaction-need systemic agents=• Prednisone 60 mg x 10 days, 30 mg x 10 days

(20 days of therapy) otherwise rebound• Ivy block or booze (topically!!) if exposure is

within 40 minutes

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Bed Bugs

• Epidemic in urban areas of the US• Not related to socioeconomics• Bed bugs live in crevices of wood and

mattresses• Come out at night• Hard to eradicate-need professionals• Clobetasol cream bid for relief• Watch for secondary infections