Primary Care Dermatology Update

1. Primary Care Dermatology Update Christina Lewis N.P. Director of Nursing UCLA Arthur Ashe Student Health and Wellness Center ACHA 2009 clewis@ashe.ucla.edu

2. Warts, Hair Loss, and Skin Tags Differential Diagnoses and Evidenced-Based Treatment • Warts (flat, common, plantar, filiform) • Hair Loss, Nonscaring (telogen effluvium, androgenic alopecia) • Skin Tags (acrocordon)

3. Warts Spontaneous Regression 30% in months 78% in 2 years (British Journal of Dermatology, 2001)

4. Warts: Risk factors • Trauma • Communal showers - 146 adolescents, 27% of those who used the communal shower area had warts vs. 1.3% who used the locker changing room only (UBJ Clinical Handbook, 2008). • Immunosuppressed - Renal transplant recipients, after 5 years, 90% had warts (UBJ Clinical Handbook, 2008). • Diet - Low in carotenoids (spinach and other greens, sweet potatoes, and carrots) and high in refined sugar (Rakel, 2007).

5. Thrombosed capillaries in a hyperkeratotic plaque (Fitzpatrick) Dilated capillaries in the wart may bleed during/after shaving. Identified by changes in the skin lines. Dermnet.com

6. Differential Diagnosis • Callus direct pressurehurts (warts hurt with side pressure) • Corn a central hyperkeratotic core • Pitted keratolysis • Seborrheickeratosesflatter, darker, velvety • Pigmented verrucous nevi projections are not dry and rough • Lichen planus • Molluscumcontagiosum

7. Corn Dermnet.com Dermnet.com

8. Pitted keratolysisdermnet.com

9. Lichen planus Dermnet.com

10. Differential Diagnosis (cont) • Verrucous carcinoma -- a low-grade squamous cell carcinoma • Scar tissue • Skin tag • Actinic keratosis • Lichenoidkeratosis • Black heel -warts may be associated with: • Bowenoidpapulosis (premalignant state)

11. Black heel Dermnet.com

12. Bowenoid papulosis (premalignant state) dermnet.com

13. Non-Prescription Treatment for Warts • Duct tape-- Vs. cryotherapy. Resolution: 85% with duct tape, 60% with cryotherapy (Cutis, 1978). • Hypnosis--Small studies, no controls. When comparing hypnosis, placebo, and salicylic acid treatments; results indicated that the hypnotic subjects lost more warts than the treatment controls, but subjects treated with salicylic acid lost the highest percent (Spanos, 1990). • Interactive guided imagery • Garlic extracts--One placebo-controlled study (International Journal of Dermatology, 2005). • Potato, onion, or fresh garlic--Directly to the wart. No data to support, but possible that some direct irritant effect may stimulate the immune response. • Vitamin A, Vit C, Vit E or folic acid--Studies are inconclusive (Rakel, 2007). • Distant healing--A single randomized trial of distant healing for peripheral warts showed no effect (Harkness, 2000). • Acupuncture --Insertion of a needle directly into the wart using a complex “open door” technique has been reported to be beneficial (Rakel, 2007). • Oral zinc sulfate--Increased cure rates compared to placebo--few high quality studies. • Catharidin--from the blister beetle, Cantharis vesicatoria. No longer available in the US. • Folk--Rub a dusty dry toad on warts, and they will disappear. • Folk--Tom Sawyer ”back up against the stump and jam your hand in and say ‘Barley-corn, Barley corn, injun-meal shorts, Spunk water, spunk water, swaller these warts”.

14. Most Effective Treatment Option: Salicylic acid • Soak, emery board, acid, occlusion. • Not on face r/t possible irritation and scarring. • 13 trials using concentrations of 15-26% with or without lactic acid. Data pooled from 6 placebo-controlled trials demonstrated a cure rate of 75% and 48% in placebo arm. • Monotherapy with 5 FU, cryotherapy, podophyllin proved no more effective than salicylic acid (Cochrane, 2003). • Topical salicylic acid may be as effective as cryotherapy (Cochrane, 2003). • After 6 weeks of treatment, 50% of warts resolve (Berger, 1990).

15. Second Line Therapy: Cryotherapy • Contraindicated in Reynaud's if treating hand/foot warts. • Aggressive use over superficial nerves on the volar or lateral aspects of the proximal phalanges of the fingers has caused neuropathy. • White halo for 5-20 sec. improves effectiveness (British Journ of Derm, 2001). • Permanent nail changes may occur if the nail matrix is frozen. • Hypopigmentation is a possible complication. • OTC (Verruca-Freeze) freezes tissue to only -70 degrees, so less effective.

16. Second Line Therapy: Cryotherapy (cont) • Tx every two weeks with cotton swab vs spray gun X 3 months is 47% and 44% respectively, not significant (Baumbach, 2001). • Warts present 6 mo or less cleared at 84%, those longer than 6 mo, 39%. • Freeze thaw technique, no significant different in cure rates at 3 mo for hand warts but was for plantar warts. Possibly due to the callus being a thermal insulator. • Frequency of treatment not related to cure, but number of treatments are. Improvement after 4 treatments not statistically significant (Cochrane database). • Cryotherapy may be less effective than photodynamic treatment or occlusive treatment with duct tape. • 70%-80% of patients with hand warts cured with nonblistering liquid nitrogen cryosurgery within 12 weeks (Bunney, 1976).

17. Dermnet.com

18. Dermnet.com

19. Other Treatment Options • Aldara 5% cream (imiquimod)--Immune modulator. Nightly to three times a week--expensive. • Antigen injection, C. albicans--No randomized controlled studies. Minimal pain and no scarring. 1:1 mixture of C. albicans skin test antigen solution and 1% lidocaine injected intradermally into and at the margins of each wart (genital and facial warts excluded) up to a total of 1.0 ml. Repeat every 4 weeks up to three injections. 72% clearance within 8 weeks of the last injection, without subsequent recurrence (Habif, 2004). • Bleomycin--No controlled studies. Dermajet 1/10cc with each injection (hematoma), nonmed corn pad, debride in 3 weeks X 2-3 treatments, painful. 87% cleared (Salk & Douglas, 2006). • Cautery--Success of 65-85% but scarring and recurrence in up to 30%. • Cimetidine--Studies mixed. Immune modulator, probably blocking type 2 histamine receptors on suppressor T cells.

20. Other Treatment Options (cont) • Dinitrochlorobenzene(DCNB)--Causes allergic reaction and inflammatory response; studies are conflicting regarding wart clearance compared to placebo. Application qd to bid X 4 months. • 5 ALA (aminolevulinic acid) 20% followed by photodynamic therapy. • 5-FU--Immunotherapeutic. Possible hyperpigmentation. Not FDA-approved.

21. Other Treatment Options (cont) • Formalin--pare, soak daily for 30 minutes in 4% formalin solution. Risk of inducing sensitization to formalin (Habif, 2004). • Hot water--45-48 degrees centigrade. • Lasers--2-4 treatments every 2-4 weeks. Careful of plume, hypertrophic scarring. • Pulsed Erbium Laser (Er:Yag) Cleared 75% of patients with one treatment with a 25% relapse. 14% are non-responders. Healing in 7-10 days, but erythema up to 2 months. Shortened wavelength (2940) is absorbed 12-18 times more efficiently by water-containing superficial cutaneous tissues than the CO2 laser. There is a smaller zone of thermal damage so less scarring. • Carbon Dioxide Laser Older therapy. Longer wave length, nonselective thermal tissue destruction, 64-71% cure rate. • Podophyllin--cured 81% in 12 weeks. • Punch excision--60% cure rate. • Retinoic acid 0.1% cream or .25% gel--bid X 4-6 weeks cleared 50% flat warts (Berger, 1990).

22. Other Treatment Options (cont) • Squaric acid dibutylester (SADBE)--Contact immunotherapy. Sensitization by applying 1% or 2% SADBE with or without occlusion to normal skin overnight then washed off. Ninety percent of patients were successfully sensitized after one application of SADBE. Sensitization determined when a second or third dose was applied to a different area causing erythema and pruritus. After sensitization, 0.5% to 5% SADBE applied to the warts every 2-4 weeks. SADBE is not usually used on the face. Clearing in 69% of patients. Mean duration of 4.4 months with a mean of 5.9 treatments. • Trichloroacetic, bichloroacetic, and monochloroacetic acids--A thin coating of petrolatum should be applied to the surrounding normal skin. Repeat after 7 to 10 days. • Surgical excision --Recurrence rates as high as 30% (filiform warts). • Silver nitrate sticks--Chemically cauterize, caution with burns and staining. Clinical efficacy is moderate, clearance 43%, placebo 11%.

23. Summary: Treatments That Have Replicated Studies • Cryotherapy • Duct tape or moleskin • Topical salicylic acid • 5 FU with occlusive dressing • Photodynamic therapy with 5-aminolevulinic acid (Fox, G and Brier, M., Nov 2008)

24. Treatment With Limited or No Clinical Data • Imiquimod • Retinoids • Cantharidin • Bichloroacetic acid • Dinitrochlorobenzene solution • Silver nitrate solution • Alpha-Lactalbumin plus oleic acid • Formic acid • Diphencyprone (diphenylcyclopropenone) • Ciclopirox-containing laquer • Intralesional injection of skin test antigens • Bleomycin • Combination of 5-fluorouracil, lidocaine, and epinephrine • Laser tx • Oral zinc sulfate • Cimetidine • Levamisole • Hypnotic and “suggestion” therapies, including use of “wart tape” • Formaldehyde • Glutaldehyde • Homeopathy • Pulsed dye laser • Surgical procedures (Fox, G and Brier, M., Nov 2008)

25. References • UBJ Clinical Handbook, Fall 2008. • Rakel. Integrative Medicine, 2nd ed. Saunders, An Imprint of Elsevier, 2007. available at: www.psychosomaticmedicine.org. Accessed May 20, 2009. • Fitzpatrick, TB et al. Color Atlas and Synopsis of Clinical Dermatology Common and Serious Diseases. • www.dermnet.com. Accessed May 20, 2009. • Spanos N.H., Williams V, Gwynn M.I. Effects of hypnotic, placebo, and salicylic acid treatments on wart regression.  Psychosomatic Med. 1990;52:109-114. • Harkness EF, Abbot NC, Ernst E.  A randomized trial of distant healing for skin warts.  Am J Med  2000;108:448-452. • Cochrane Database Systems Review. Available at: http://search.cochrane.org/search?restrict=review_abstracts&scso_cochrane_org=this+site&scso_review_abstracts=review+abstracts&scso_registered_titles=registered+titles&scso_evidence_aid=evidence+aid&scso_colloquia_abstracts=colloquia+abstracts&scso_newsletters=newsletters&ie=&site=my_collection&output=xml_no_dtd&client=my_collection&lr=&proxystylesheet=http%3A%2F%2Fwww.cochrane.org%2Fsearch%2Fgoogle_mini_xsl%2Fcochrane_org.xsl&oe=&filter=0&sub_site_name=Cochrane+Reviews+search&q=&btnG=Search+Reviews. Accessed May 2009. • Berger, T. and Elias, P. Manual of Therapy for Skin Diseases. Livingstone :Wintroub,B.Churchill ;1990. • Dermatologic drug therapy . Baumbach, 2001 • Bunney, Nolan and Williams. An Assessment of Methods of Treating Viral Warts by Comparative Treatment Trials Based on a Standard Design. Br. J. Dermatol. 94:667-679, 1976. • Habif , Clinical Dermatology 4th Ed. 2004. Available at: http://www.mdconsult.com/das/book/body/138581598-4/0/1195/85.html. Accessed May 20, 2009. • Fox, G and Brier, M. Stat Consult, Verrucea Vulgaris. The Clinical Advisor, p.95-96, Nov 2008.

26. Hair Loss: Telogen Effluvium • Telogen Effluvium Simultaneous passage of a large number of follicles from antagen (growth) to telogen (resting) phase. Hair loss appears after about 3 months, corresponding to duration of telogen. Most club hairs are retained within the follicle during telogen and shed with new antigen hair. • Scalp paresthesia or pain (trichondynia) 5-30% of pts, esp females. • Hair pull test is diagnostic (often more than 10 hairs). • Shedding of hairs higher than 100, generally 200-300/day. • Pt can remember precisely when hair loss started. • Genetic predisposition and androgen on the follicles. • Finer texture hair, shorter in length and reduced diameter (Tosti and Piraccini, 2006). • Considered normal in middle aged women if lasts greater than 6 months. Frontotemporal thinning worsens with time. Diffuse thinning is uncommon.

27. Telogen Effluvium dermnet.com

28. Hair Loss: Androgenic Alopecia • Androgenic Alopecia Most common form of hair loss affecting up to 80% of men and 50% of women. • Typically after puberty and evident by age 30, about half the population expresses this trait before the age of 50 (Habif, 2004). • Acquired progressive kinking of the hair. • Whisker hair • Variation in the hair shaft diameter

29. Androgenic Alopecia

30. Tests (Habif, 2004) Hair Pull Test Tightly grasp 20 to 40 hairs firmly between the thumb and forefinger above ear. Exert a slow, constant traction to slightly tent the scalp, and slide the fingers up the hair shafts. Normal if fewer than six club hairs extracted. Repeat the count on the opposite side of the head and in two other areas. Daily Hair Counts The patient collects hair lost for 14 days. The patient counts the hairs and records the number for each day. Daily hair shed counts are not necessary if the pull test is positive. It is normal to lose up to 100 hairs daily and 200 to 250 hairs on the day of shampooing. If the hair is shampooed daily, the counts should be less than 100. Part Width Part the hair with a comb over vertex, occipital, and temporal scalp. Compare the part diameters in the different anatomic scalp areas. The hair is less dense in the vertex in both sexes, and thinning increases with age.

31. Lab Tests (Habif, 2004) DHEA-S, dehydroepiandrosterone sulphate; T, total serum testosterone; TeBG, testosterone-estradiol–binding globulin; T/TeBG, androgenic index. † If elevated, suspect pituitary disease (e.g., pituitary prolactin secreting adenoma).

32. Differential Diagnosis for Non-Scarring Hair Loss • Iron deficiency anemia • Thyroid • Excessive circulating androgens. PCOS accounts for 30% of women with hair loss (Tosti, 2006). • Secondary syphilis • SLE • ANA • Genetic disorders • Immune disregulation • Medications (birth control pills) • Chemotherapy • Weight loss (crash diets=inadequate protein) food supplements such as tryptophan, vegetarianism, zinc deficiency • Excessive Vit A • Acute blood loss • Childbirth

33. Differential Diagnosis (cont) • Drugs: retinoids, bromocriptine, aminosalicylic acid, Enalapril, amphetamines, levodopa, Captopril, lithium, carbamazepine, metoprolol, cimetidine, propanolol, Coumadin and others • Stress: emotional, surgery • Weight loss • UV exposure • Cigarette smoking • Diabetes • Pneumonia • TB • Fever

34. DHEA-S, dehydroepiandrosterone sulfate; T, total serum testosterone; TeBG, testosterone-estradiol–binding globulin; T/TeBG, androgenic index.

35. Common Treatment Options-Androgenic Alopecia • Finasteride--Increases about 100 hairs in 1 inch area of vertex. Inhibits 5-alpha reductase, the enzyme that converts testosterone to dihydrotestosterone (DHT). DHT is responsible for male pattern hair loss, prostate enlargement and male acne (Fitzpatrick). Prevents progression in 99% of patients and clinical improvement in 66% after 2 years of tx. Effective in frontotemporal and vertex. Side effects in less than 2%: decreased libido, erectile dysfunction, and diminished ejaculate volume (Tosti, 2006). Solely for use in men. • Minoxidil 5% bid for men. 40% of men show visible improvement after 2 years (Berger, 1990). Side effects include scalp irritation and allergic contact dermatitis. Improvement not seen until 4-6 mo after tx. Minoxidil works better on vertex than bitemporal areas. Mechanism of action unknown. • Minoxidil 2% bid for women, improvement in up to 80% of cases. Side effects include irritation, contact dermatitis, and hypertrichosis (increase facial hair). May be more effective in lower BMI.

36. Common Tx Options Androgenic Alopecia (cont) • Spironolactone; binds to androgen receptors and blocks action of dihydrotestosterone (Fitzpatrick) • Hair transplants • Avoid sun exposure • Avoid sun bed tanning • Avoid smoking • Avoid restrictive diets • Avoid drugs that induce hair loss

37. Common Tx Options Androgenic Alopecia (cont) • Hair Transplants--Have been used successfully to permanently restore hair. Age is not a determining factor. Androgen-independent hairs from the lateral and posterior areas of the scalp are used. The surgeon must have a sense of aesthetics to properly design the anterior hairline. There are many techniques used for harvesting and implanting the graphs. The techniques are constantly changing and improving. • Scalp Reduction and Flaps--An anterior-posterior elliptic excision of bald vertex scalp with primary closure can provide an instant hair effect. The procedure can be repeated every 4 weeks until hair margins converge or scalp tissue becomes too thin. Grafts or flaps may be used later to fill any remaining void. • Hair Weaves--Create a matrix of crisscrossing, transparent fibers, fitted and shaped to the client's thinning area. • Cosmetic measures (hairstyle adjustments, wigs, extensions, hair pieces, hats, scarves) • Cessation of wearing tight braids, buns, pins • In chemical/allergic causes, avoidance of the identified sources

38. References • Tosti, A. and Piraccini, B. Diagnosis and treatment of Hair disorders an Evidence Based Atlas. Taylor and Francis Group, New York. 2006. • Berger, T. Elias, P. Manual of Therapy for Skin Diseases. Livingstone, England. 1990. • Fitzpatrick, TB et al. Color Atlas and Synopsis of Clinical Dermatology: Common and Serious Diseases. • Habif , Clinical Dermatology 4th Ed. 2004. Available at: http://www.mdconsult.com/das/book/body/138581598-4/0/1195/85.html. Accessed May 20, 2009.

39. SKIN TAGS Acrochordons

40. Skin Tags • Obesity, pregnancy, menopause, and endocrine disorders increase skin tags. • Low but detectable levels of HPV are found in 80% of skin tags, subtype 6 and 11 found 98% of the time (Arndt and Bowers, 2002). • If many skin tags develop over a short period of time, consider colonoscopy r/t possible increase in colonic polyps.

41. Differential • Pedunculated seborrheic keratosis • Dermal or compound melanocytic nevus • Neurofibroma • Molluscum contagiosum

42. Seborrheic keratosis Dermnet.com

43. Compound melanocytic nevus

44. Molluscum contagiosum Dermnet.com

45. Skin Tag Treatment • Electrodessication • Grasp with forceps, sever base with sharp scissors or scalpel. Hemostasis by pressure, Monsels solution, 20% aluminum chloride or 30% TCA or cautery. • Grasp base of skin tag with forceps and direct liquid nitrogen spray at lesion until frozen, grabbing minimizes the spread and hyper or hypopigmentation .

46. Neurofibroma Dermnet.com

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50. Dermnet.com