“Dermatological Diagnoses

and Treatment for Primary

Care”

PHILIP LORIA, M.D.

Basics

• Is it Symmetrical?

• Is it Dermatomal?

• Is it scaly?

• Is it in a “Photo Distribution”

• Does it Itch, Burn or Sting

• If it’s Wet Dry it

• If it’s Dry Wet it

Topical Steroids

• Class I Clobetasol, Halbetasol

• Class II Betamethasone, Mometasone

• Class IV Triamcinelone Ointment

• Class VI Desonide

• Class VII OTC Hydrocortisone

How Long to Use

• Face, Groin, Inframammary and “Creases”

• Ears

• Scalp

• Rest of Body

Steroid Alternatives

• Tar

• Salicylic Acid

• Calcineurin Inhibitors

• Others

• Eucrisa

CONTACT DERMATITIS

POISON IVY TYPE

• OFTEN STREAKED VESICLES WITH SCALE

• USUALLY ASYMMETRICAL

OTHER TYPES

• LOOK FOR PATTERNS, ASYMMETRY, VESICLES AND SCALE

HERPES ZOSTER

(SHINGLES)

• PAIN PRIOR TO ERUPTION

• FIRST A RED PLAQUE

• THEN VESICULATION AND CRUSTING

TREATMENT

• VALTREX OR ACYCLOVIR

• SYSTEMIC STEROIDS

KENALOG

• Traimcinelone acetonide

• Safety Profile

• Patient Populations

• Duration and Cost

TINEA VERSICOLA

TREATMENT

• KETOCONAZOLE 400 mg ONCE PER WEEK

FOR 2-3 DOSES

• VARIOUS TOPICALS

• DO NOT USE LAMASIL OR GRISEOFULVIN

TREATMENT OF TINEA

• AVOID CLOTRIMAZOLE-BETAMETHASONE

• NEWER TOPICAL AZOLES

• ORAL KETOCONAZOLE, TERBINAFINE,

FLUCONAZOLE OR GRISEOFULVIN

• PROPYLENE GLYCOL FOR MAINTENANCE

OF CHRONIC TINEA $26 per GALLON AT

TRACTOR SUPPLY

ONYCHOMYCOSIS

• TREATMENT OF FINGERNAILS IS 4-5

MONTHS

• TREATMENT OF TOENAILS IS 6 – 12

MONTHS

• TOENAIL RECURRENCE RATE IS 73%

AT 3 YEARS

TREATMENT OF TINEA CAPITIS

• ORAL TREATMENT ONLY

• 6 WEEKS OF ORAL GRISEOFULVIN AT 7.5

mg/lb/day WITH FATTY FOOD

• TERBINAFINE, FLUCONAZOLE AND

KETOCONAZOLE ARE MUCH LESS

EFFECTIVE

Onycholysis

Granuloma Annulare

Psoriasis

• Triggers

– Strep

– Beta Blockers

– Lithium

– Rarely ACE inhibitors, ARBs, Antimalarials

and NSAIDS

– Others

Inverse Psoriasis

• Scalp

• Ears and Post Auricular Crease

• Belly Button

• Groin

• Palms and Soles

• Look for Candida

TREATMENT

• Remove the trigger

• Topicals

• AVOID PREDNISONE AND DOSE

PACKS

• Kenalog is OK

• ACITRETIN

• METHOTREXATE

• OTEZLA

• TUMOR NECROSIS BLOCKERS

• INTERLEUKIN RECEPTOR ANTIBODIES

TREATMENT OF SEBORRHEA

• TAR, SALICYLIC ACID, SELENIUM, ZINC

AND SULFUR; OTC OR Rx

• TOPICAL ANTI YEAST AGENTS

OFF LABEL

• ELIDEL AND PROTOPIC

• EUCRISA

TREATMENT OF SCABIES

• TOPICAL LINDANE OR ELIMITE NOT

AVAILABLE / DON’T WORK

• 10% PRECIPITATED SULFUR IN AQUAPHOR

OFF LABEL

• ORAL STROMECTOL (IVERMECTIN)

200ug/kg/dose X3 DOSES 5 DAYS APART.

AVAILABLE AS 3 mg TABLETS

TREATMENT FAILURE

• FAILURE TO TREAT ENTIRE HOUSEHOLD

AND CLOSE CONTACTS

Atopic Dermatitis

• Triggers

– Laundry Products

– Tinea Capitis

– Sub Umbilical Contact Dermatitis

– Other Contact Dermatitis

– Staph

Staph

• Tetracycline or Clindamycin

• Ciprofloxin and Trimethoprim /

Sulfamethoxizole less effective

• Gentamycin

• Zyvox & Sivextro $$$$$$$$

Carrier Eradication

• Mupirocin ointment bid x 7 days nose,

ears, umbilical, scrotal, vaginal and rectal.

• Consider treating the entire family

• Rifampin may be added to another

antibiotic 300 bid x 7 days