Common Dermatologic Issues in Family Planning

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Common Dermatologic Issues in Family Planning

• Roli Dwivedi, MD
• Medical Director
• Community University Health Care Center
• (University of Minnesota Medical Center)

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Disclosures and Disclaimers

• This webinar is sponsored by the Region V
  Training Project of HCET.
• Any views or opinions in this presentation are
  solely those of the presenter and do not
  necessarily represent those of the funders.
  Health Care Education and Training, Inc. accepts
  no liability for the content of the presentation
  or for the consequences of any actions taken on
  the basis of the information provided.
• Roli Dwivedi, MD, states that she does not have a
  financial interest in or other relationship with
  any commercial product named in this
  presentation.

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• Technical Support
• 866-229-3239

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Roli Dwivedi, MD

• Medical director and a family physician providing
  a full scope of medical care at the University of
  Minnesota Health Care Center
• Specific interests include womens health,
  adolescent health, and procedures
• Honored by both the American Academy of Family
  Physicians and the Society of Teachers in Family
  Medicine for her teaching in this field
• Graduate of Dr. Vaishampayan Memorial Medical
  College (Maharashtra, India), and served her
  residency at the University of Minnesota Medical
  Center

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Objectives

• Describe common dermatological conditions
  encountered in the family planning context
• Recognize situations warranting referral for
  further evaluation.

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Family Planning Context
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Steps in Dermatology Diagnosis

• Keep your differential simple
• Detailed history
• Detailed exam
• Primary, secondary and tertiary look
• Magnified and tactile look
• Positional look
• Deeper look ( biopsy)

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ACNE
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Prevalence of Acne

• In the US more than 50 million are affected by
  some form of Acne and over 17 million have Acne
  vulgaris
• Women gt Men
• 79-95 of all teens are affected
• May also begin in 20s and 30s and can persist
  in adults
• Most patients are mild to moderate

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Component of Acne development

• Follicular plugging and excessive sebum
  production
• Enlargement of sebaceous glands and development
  of microcomedones
• Propionobacterium acnes in microcomedones
  triggers inflammatory process

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Treatment of Acne

• Topical retinoids
• Tretinoin and Isotretinoin
• Adapalene
• Tazarotene ( only 0.1 for Acne)
• Adapalene is best tolerated , Tazarotene is more
  effective but more irritating
• Use of topical retinoids not recommended in
  pregnancy specially tazarotene is cat X.

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Treatment of Acne

• Topical antimicrobials
• Benzoyl peroxide
• Topical antibiotics
• Erythromycin, Clindamycin, Sulfacetamide and
  Dapsone
• Combination therapy with antimicrobilas and
  topical retinoids is more effective

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Treatment of Acne

• Systemic antibiotics
• Doxycycline 100 mg BID
• Minocycline 100 mg BID
• Tetracycline 500 mg BID
• Bactrim 1 tab Bid
• Erythromycin 500 mg BID
• Azithromycin 250-500 mg QD ( pulses)

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Pulse Dosing of Antibiotics in Acne

• Azithromycin is most often used with various
  dosing regimens
• Comparable efficacy with daily dosing of
  antibiotics.

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Newer Formulations for Acne

• Oracea ( Doxycycline)
• 30 mg immediate release
• 10 mg delayed release
• Periostat
• Doxycycline 20 mg Po BID
• (FDA approved for treatment for Rosacea)

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Newer Formulations of Antibiotics

• Solodyne
• Extended release of Minocycline
• Dosing is weight based
• Lowest effective dose is1mg/kg/day
• 45,90,135 mg daily dosing
• Approved for 12 wks of use.

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Hormonal Therapy for Acne

• Consider for patients with evidence of
  hyperandrogenism
• Can be used for post-menarchal and adults who are
  trying to prevent pregnancy
• Most common therapies are oral contraceptives and
  spiranolactone
• Minimum 3-6 months therapy is required to
  determine efficacy.

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Treatment of Resistant Acne

• Oral Isotretinoin-
• Severe recalcitrant nodular acne
• Scarring Acne
• Acne causing significant psychological distress
• Acne fulminans
• Antibiotic induced gram negative folliculitis in
  patients with acne vulgaris

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Referral to Dermatology

• Laser
• Visible light
• Chemical peel
• Can also refer for Acutane treatment

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ROSACEA
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Rosacea

• Chronic acneiform disorder
• Affects middle age and older adults
• Vascular dilatation of central face
• Flushing reaction is provoked by hot spicy food,
  alcohol ingestion, temperature extremes and
  emotional reactions.
• Varies from simple erythema to papule, nodule,
  cyst but no comedones

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Rosacea look alike

• Acne
• Seborrheic dermatitis
• SLE
• Carcinoid syndrome
• Chronic topical glucocorticoid therapy

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Treatment- Rosacea

• Life style changes
• Mild cleanser and sunblock
• Topical Metronidazole
• Topical Azelaic acid
• Topical Clindamycin,erythromycin or Sulfacetamide
• Benzoyl peroxide
• Topical permethrin cream

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Treatment- Rosacea

• Topical Retinoids- Tretinoin or Adapalene
• Oral antibiotics- Tetracyclin, Doxycyclin,
  Erythromycin and Minocyclin.
• Oral Clonidine and beta blockers can be tried for
  flushing.
• Topical Oxymetazoline for facial Erythema

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Referral to Dermatology

• Severe nodulocystic and recalcitrant Rosacea
• Rhinophyma unresponsive to topical and oral
  therapy
• Pulsed dye vascular laser therapy, Intense pulsed
  light therapy.

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PSEUDOFOLLICULITIS BARBAE
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Pseudofolliculitis Barbae

• Common in African American population
• Papulopustular lesions right next to hair
  follicles.
• Noninfectious, inflammatory condition occurring
  in males with curly hair

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Treatment- Pseudofolliculitis Barbae

• Soften facial hair well with warm water before
  shaving.
• The bearded area should be covered with gentle
  shaving gel before shaving.
• A special razor can be used
• Bump Fighter, the Foil Guard shaver and the PFB
  razor

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Treatment- Pseudofolliculitis Barbae

• Use soft-bristled toothbrush in a circular motion
  on bearded area to dislodge hair tips
• Shave in the direction of beard growth not
  against
• Aftershave lotion should be avoided

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Treatment- Pseudofolliculitis Barbae

• May use very mild steroid lotion for very brief
  period of time
• Steroids on face can lead to skin color changes
  and atrophy
• Topical Retinoids are sometimes helpful.

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HUMAN PAPPILOMAVIRUS
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Warts and HPV facts

• Approximately 20 million people are infected
  with HPV.
• Approximately 50 of sexually active people will
  acquire HPV
• By age 50 ,80 of female will have HPV
• 6.2 million Americans get a new genital HPV
  infection each year
• Females can be diagnosed for HPV.
• No HPV test for men

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Plantar and Palmar Warts

• Painful lesions on the sole of foot or digits
• Caused by certain type of HPV ( type 1)
• Skin to skin contact
• Should be treated only if symptomatic as dermal
  scarring from treatment can itself be painful.

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How to differentiate Corns from Warts

• Corns are maximally painful on direct pressure
• Warts are more painful on pinching.
• Corns do not have dots in it, where as black dots
  in warts are thrombosed capillaries with in them.
• Corns do not disrupt foot prints
• Corns tend to occur at pressure points where as
  warts can grow anywhere

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Treatment- Plantar Warts and Corns

• Liquid nitrogen.
• Salicylic acid
• TCA ( Tri- Chloro acetic acid)
• Cantharidin ( 0.7 )
• Cimetidine
• Imiquimod ( Aldara)
• Tretinoin

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Referral to Dermatology

• Immunotherapy
• Intralesional Bleomycin
• Laser therapy
• Topical treatment with cidofovir
• Oral Acitretin
• Super pharmacologic doses of Zinc.

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GENITAL WARTS (CONDYLOMA ACCUMINATA)

• Genital HPV is STD!! ( type 6, 11, 16 and 18)
• Most people with HPV remain asymptomatic and
  clear infection on their own, yet they can
  transmit virus
• High and low risk
• Low risk may lead to mild abnormality of pap or
  genital warts.
• High risk ( 16 and 18) may cause cancer of
  cervix, vulva, vagina, anus and penis.

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Genital Warts

• Single/ multiple/ cauliflower like growth.
• Soft, moist pink or flesh colored
• Raised or flat

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Condyloma Lata and Accuminata
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Genital Warts treatment

• No treatment is better than other
• No treatment is ideal for all causes
• No cure!!
• Treatment is directed towards changes made by HPV
  virus

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Genital Warts treatment

• TCA ( Tri- Chloro acetic acid)
• Podophylin
• Cryotherapy
• Aldara
• 5 fluorouracil Epinephrine gel.
• Laser
• Intralesional Interferon alfa

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HERPES
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Herpes Classifications

• Primary
• Secondary
• Recurrent

• Herpes labialis
• Herpes genitalis
• Herpes zoster

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Clinical Symptoms

• Fever, bodyache, generalized malaise with primary
  lesions.
• Painful lesions
• Dysuria
• Lymphadenopathy

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Diagnosing Herpes

• Visual inspection
• Serum test for HSV1 and 2 ( high false positive
  test results)
• PCR test
• HSV tissue culture

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Treatment- Herpes

• No treatment
• Episodic therapy
• Chronic suppressive therapy

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Treatment- Herpes

• Acyclovir
• Famciclovir
• Valacyclovir
• Topical therapy
• Sitz bath

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ALOPECIA AREATA
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Alopecia Areata

• Sudden onset of oval to round bald patches on
  scalp.
• Skin of bald spot is completely normal with tiny
  short hair at periphery of patches.
• Autoimmune, familial, stress related.
• Most affected person regrow their hair in 6-12
  months
• Recurrences common

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Treatment- Alopecia Areata

• First line therapy-intralesional steroid, potent
  topical steroid and topical immunotherapy
• Second line therapy- Minoxidil, anthralin and
  photochemotherapy
• Systemic therapy- oral steroid, salfasalzine,
  methotrexate, cyclosporine, biologic agent.
• Other therapies-laser,topical betacarotene,
  fractional photothermolysis

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PPPP vs Condyloma Acuminata
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Pink Pearly Penile Papule

• Normal occurrence in 15 pubertal and
  postpubertal males
• Elongated papilla , 1-3 mm in dia and located
  along coronal margin of penis
• Appear in rows and usually uniform shape and size
• Pearly white
• Treatment- Reassurance

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PPP vs Condyloma Accuminata

• Condyloma accuminata less uniform in shape and
  size
• Changes over time
• Not neatly arranged around corona

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INTERTRIGO
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Intertrigo

• Infectious/ noninfectious inflammatory skin
  disorder
• Involves skin folds mainly under the breasts,
  axilla, underneath abdominal panus, inner side of
  thigh etc
• Most common organism Candida

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Intertrigo

• Risk factors
• Obesity
• Warm moist skin
• Diabetes
• Tight clothing
• Skin on skin rubbing
• Topical or systemic steroid use
• Chronic abx use.

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Intertrigo- Clinical Features

• Erythema
• Macerated plaques
• Satellite papules/pustules
• Peripheral scaling
• Pruritus
• pain

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Intertrigo- Diagnosis

• Clinical feature and presentation
• KOH preparation if doubt

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Treatment- Intertrigo

• Address predisposing factors
• Topical antifungal agent
• Drying agent
• Topical steroids
• Systemic antifungal

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SCABIES
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Scabies

• Infestation of skin by sarcoptes scabiei
• Transmission by person to person
• Itchy and painful lesions.
• Itching more at night
• Characteristic distribution of rash.
• Symptoms usually 3-6 wks after primary
  infestation

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Treatment- Scabies

• Eradication of mites- topical permethrin 5
  cream, Ivermectin, other agents like lindane
• Household and close contact must be treated
• Treatment of itching
• Treatment of infection

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Dermatologic Subspecialties

• Medical dermatology
• Dermatologic surgery and oncology
• Dermatopathology
• Cosmetic dermatology
• Dermatologic research

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Resources

• AAFP
• UpToDate
• Medscape
• Essential Evidence
• NEJM

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