2. Review: Dermatologic Terminology
• Macule – flat (nonpalpable), < 1cm in size
• Patch – flat (nonpalpable), > 1cm in size
• Papule – raised, < 1cm in size
• Plaque – raised (a broad papule), > 1cm in size
• Nodule – similar to a papule but > 1cm and
located in the dermis or subcutaneous fat
• Vesicle – fluid filled, < 1cm in size
• Bulla - fluid filled, > 1cm in size
• Wheal (hive) – edematous papule or plaque
that usually lasts < 24 hours
3. Dermatology Terminology Cont’d
• Scale – dry or greasy laminated masses of
keratin
• Crust – dried serum, pus, or blood
• Fissure – a linear cleft through the epidermis
or into the dermis
• Erosion – loss of all or portions of the
epidermis alone, heals without scarring
• Ulcer – complete loss of the epidermis and
some portion of the dermis, heals with
scarring
17. Warts
• Etiology: Human papilloma virus (HPV)
• Common in children, adolescents, & immunosuppressed pts
• Presentation: verrucous topped papules
• DDx: cutaneous horn, SK, SCC
• Lesions may spontaneously resolve
• Treatment (nongenital warts):
– Cryotherapy (LN2), topical salicylic acid (solution or
plaster applied to wart only once daily), surgical removal
– Refer if no improvement with topicals
• Treatment (genital warts):
– Cryotherapy, imiquimod (M,W,F at bedtime), Podofilox
(bid for 3 days then take 4 days off) , surgical removal
– Refer if no improvement with topicals
18.
19. Molluscum Contagiosum
• Etiology: benign viral infection with a DNA poxvirus
• Most common in children – infection through direct skin-to-
skin contact or indirect skin contact w/ fomites (bath towels)
• In adults, molluscum are sexually transmitted
• Presentation: ~2-5mm, discrete, nontender, flesh-colored,
umbilicated papules
- Generally asymptomatic
- Most common on the face, trunk, and extremities in
children and on the genitalia in adults
• DDx: Milia, keratosis pilaris, wart
• Treatment: spontaneously resolution can occur or can treat
with LN2, curettage, salicylic acid, topical tretinoin, or
imiquimod, podofilox
- Refer if no improvement with topicals and LN2 needed
21. Seborrheic Keratosis (SK)
• Etiology: unknown
• Most common benign lesion in older individuals (often see
these after age 30)
• More common in individuals with white skin
• Presentation:
– Begin as light brown, flat lesions
– Become thicker and appear “waxy and stuck-on”
– May note pseudohorn cysts
• DDx: wart, melanoma, BCC, SCC, lentigo
• Note: acute eruption may be an sign of internal malignancy
• Treatment: None, LN2, curettage, shave removal,
keratolytics (ammonium lactate lotion or urea 20% cream)
- Refer for shave removal or LN2 if lesion is irritated
23. Dermatosis Papulosa Nigra (DPN)
• Variant of seborrheic
keratosis found in
individuals with darker
skin types
• Affect the face (cheeks,
peri-occular)
• Confused with moles
• Treatment:
– None
– Electrodessication
– EXTREME caution with LN2
– Refer if treatment desired
24. Stucco Keratosis
• Variant of SK
• Confused with warts or
“dry skin”
• Affects the legs and feet
• Age > 40, M > F
• Treatment:
– None
– Cyrotherapy
– Keratolytics
(Ammonium lactate
12% lotion or urea
20% cream)
25. Skin Tags (acrochordon)
• Etiology: common, benign lesions thought to be caused by
irritation, aging skin, hormone imbalance
• Reports of 46% in the general population affected;
increase in frequency with age and in obese people
• Presentation: small, soft, pedunculated lesion
– Usually skin- colored or hyperpigmented
– Vary in size from ~2-5 mm in diameter; can grow to 5 cm
– Most frequently located on the neck and the axillae, but any
skin fold may be affected
• DDx: neurofibroma, nevus, SK, wart
• Treatment: None, scissor excision, LN2, electrodessication
– Refer if patient desires removal (we have a skin tag clinic in
the general surgery dept)
26.
27. Epidermal Inclusion Cyst (EIC)
• Etiology: result from the proliferation of epidermal cells within a
circumscribed space of the dermis
• Can occur at any age but most common in 3rd and 4th decades;
twice as common in men
• Presentation: Appear as flesh–colored-to-yellowish, firm,
round, mobile nodules often with central punctum (pore)
– Discharge of a foul-smelling “cheese-like” material is
common
– Occur most frequently on the face, scalp, neck, and trunk
– Usually asymptomatic but may become inflamed or infected
• DDx: lipoma, milia
• Treatment: None required, can refer for tx with ILK or excision
but, if pt’s only skin issue is a cyst, please refer to general
surgery or ENT based on location of cyst
29. Epidermal Inclusion Cyst, inflamed
• Cyst rupture due to trauma
inflammation
• Can become infected
• Treatment:
– warm compresses
– intra-lesional steroids
– +/- oral Abx
• Do NOT squeeze or
excise at this time!
30. Milium (milia)
• Very small epidermal
inclusion cysts
• Face, eyelids
• May be secondary to
acne or trauma
• Treatment:
– Extraction is simple but can
refer for this
– Topical retinoid
• Do NOT confuse with
miliaria = heat rash
31. Dermatofibroma (DF)
• Etiology: unknown
• Can develop at any age, but usually young adulthood; more
common in women
• Presentation: Usually solitary (0.5 to 1 cm) lesions on extremities
– Overlying skin color can range in color
– May feel like a small pebble fixed to the skin surface
– Tethering of overlying epidermis to the underlying lesion with
lateral compression is called the “dimple sign”
– Generally asymptomatic, but can be tenderness or itch
– Historically attributed to a trauma to the skin (e.g., bug bite)
• DDx: Nevus, keloid, melanoma, SCC, prurigo nodule
• Treatment: None, can refer for ILK or excision only if the lesion is
very symptomatic
33. Cherry Hemangioma
• Etiology: benign lesions formed by a proliferation of dilated
venules
• Frequency increases with age in both sexes and all races
• Presentation:
• May be found on all body sites though mucous
membranes are usually spared
• Lesions appearance can range from a small red macule
to a larger dome-topped or polypoid papule
• The color is described as bright cherry red, but lesions
may appear more violaceous at times
• DDx: angiokeratoma, bites, Kaposi’s, melanoma
• Treatment: None, refer for removal through shave biopsy or
electrodessication and curettage only in situations of
irritation or hemorrhage
34.
35. Melanocytic Nevus (mole)
• Etiology: benign neoplasms composed of melanocytes
• Thought to be caused by UV exposure; genetic factors also involved
• Commonly form during early childhood
• Most persons with light skin have a few nevi (common on trunk)
• Lower prevalence in dark-skinned individuals (common on acral sites)
• Presentation:
• Acquired melanocytic nevi – typically < 1cm and evenly colored
• Can be macular or papular
• Usually tan to brown, but coloration can range from skin-colored
(nonpigmented) to jet black
• Not present at birth – incidence increases until ~30 yrs of age
• Congenital melanocytic nevi – present at birth or soon after; vary in size
• Classified as small (< 2 cm), medium (2-20 cm), or large (>20 cm)
• Can commonly see an increase in the number of hair follicles
• Treatment: Removal is only needed w/signs of malignant
transformation – refer if lesion is suspicious!
36.
37. Dysplastic Nevi
• Clinical features:
– > 6 mm
– Macular component
– irregular / indistinct border
– Pigment variegation
• Marker for increased risk of
melanoma
• Refer patients for evaluation
of these lesions
• Histologic grading
– Mild OK
– Moderate +/-excise
– Severe excise (treat as if
melanoma in situ)
39. Atopic Dermatitis
• Etiology: pruritic disease of unknown origin; evidence indicates that
genetic factors are important
• Prevalence - 15-30% of children; 2-10% of adults
• Male-to-female ratio is 1:1.4; affects persons of all races
• 85% of cases occur in 1st year of life; 95% occur before age 5
• Presentation: incessant pruritus
– ill-defined, erythematous, scaly, and crusted (eczematous) patches and
plaques
– Xerosis and lichenification is seen in children and adults
• DDx: contact derm, psoriasis, CTCL, scabies, TV, seb derm
• Treatment: moisturization, topical steroids, topical calcineurin
inhibitors, antihistimines, phototherapy, mild soaps & detergents,
cotton clothing; methotrexate, prednisone, or cyclosporine for
severe cases; antibiotics or antivirals for secondary infections
• Refer if symptoms persistent despite tx or if weird presentation
40. Atopic Dermatitis
Major Features
Pruritus
Typical morphology and
distribution
Facial and extensor
eczema in infants and
children (though can have
flexural involvement in
children)
Flexural eczema in adults
Dermatitis—chronic or
chronically relapsing
Personal or family history or
atopy—asthma, allergic
rhinitis, atopic dermatitis
Minor Features
Xerosis
Ichthyosis/keratosis pilaris/hyperlinear palms
IgE reactivity (immediate skin test reactivity; + RAST)
Elevated serum IgE
Early age of onset
Tendency for cutaneous infection (ie. Staph, HSV)
Nonspecific hand/foot dermatitis
Nipple eczema
Cheilitis
Conjunctivitis (recurrent)
Dennie-Morgan infraorbital fold
Keratoconus
Cataracts
Orbital darkening
Facial pallor/facial erythema
Pityriasis alba
Itch when sweating
Wool intolerance
Perifollicular accentuation
Food hypersensitivity
Influenced by environmental & emotional factors
White dermatographism or delayed blanch to
cholinergic agents
Need: 3 Major + 3 Minor
43. Topical Treatment
• Topical steroids – may alternate high potency
with mid potency to reduce risk or use on
weekends only
– Risks of overuse of topical steroids include: atrophy,
striae, telangiectasias, hypopigmentation (temporary),
can have systemic absorption if using long-term on a
large body surface area
• Topical calcineurin inhibitors (steroid sparing
agents)
– Tacrolimus (Protopic) ointment
– Pimecrolimus (Elidel) cream
44. Steroid Classes
• 7 classes based on vasoconstrictive properties
• Note: ointment form is stronger than cream form
– Class 1 = superpotent
• Clobetasol propionate
• Betamethasone dipropionate
– Class 3 and 4 = mid-strength
• Fluocinonide
• Betamethasone valerate
• Triamcinolone
– Class 6 and 7= low potency
• Fluocinolone
• Desonide
• Hydrocortisone
Scalp, palms, soles
Trunk, extremities
Face, genitals,
intertriginous areas
45. Hygiene Changes/Lubrication
• Avoid barrier disruption
– Harsh soaps (note: we recommend using Dove or Aveeno
soap and cetaphil for a face wash)
– Washcloths
– Bathing too frequently
• Moisturize, moisturize, moisturize!
– The more the better
– Soak and smear technique – soak in tub of luke warm water
for 20 minutes, pat dry, and liberally apply topical
medication or lubricant
– The VA carries derma cerin, aquaphor, ammonium lactate
lotion, mentholated petrolatum
– We have handouts in the derm dept on dry skin care and
soak and smear technique
46. Keratosis Pilaris
• Etiology: benign, genetic disorder of keratinization of hair
follicles
• Affects nearly 50-80% of all adolescents and ~40% of adults;
often improves with age
• Presentation: small folliculocentric keratotic papules
(gooseflesh appearance)
• Most common on outer-upper arms and thighs
• Usually asymptomatic
• Worse in wintertime
• DDx: acne, folliculitis, atopic dermatitis, milia, lichen nitidus
• Treatment: none but ammonium lactate lotion or urea cream
may help
47.
48. Allergic Contact Dermatitis
• Etiology: delayed type of induced sensitivity resulting from cutaneous
contact with a specific allergen to which the patient has developed a
specific sensitivity
• ~25 chemicals are responsible for as many as one half of all cases
• Common culprits: Poison ivy, topical antibiotics (e.g., Neosporin,
neomycin, bacitracin), nickel, rubber gloves, hair dye, textiles,
preservatives, fragrances, benzocaine
• Presentation: pruritic papules and vesicles on an erythematous base
– Acute onset
– Geometric morphology (circles, lines, etc)
– Lichenified pruritic plaques may indicate chronic ACD
– Initial site of dermatitis often provides best clue regarding the potential cause
• DDx: drug rash, nummular dermatitis, seb derm, tinea, urticaria
• Treatment: avoid offending agent, topical steroids or calcineurin
inhibitors, antihistimines, cool soaks, emollients, oral prednisone in
severe cases, can refer for patch testing to help determine allergen
49.
50. Urticaria (hives)
• Etiology: release of histamine and other vasoactive substances
from mast cells and basophils
• 15-20% of the general population is affected at some point during
their lifetime
• May be acute (lasting < 6 wk) or chronic (lasting > 6 wk)
• Can occur at any age, but chronic urticaria is more common in the
40s and 50s
• Acute urticaria – cause unknown in > 60% of cases; known causes
include: infections (ask about recent illness and travel);
caterpillars/moths; foods (e.g. shellfish, nuts); drugs (e.g. PCN,
sulfonamides, salicylates, NSAIDs); environmental factors (e.g.
pollens, chemicals, plants, danders, dust, mold); latex; exposure to
undue skin pressure, cold, or heat; emotional stress; exercise
• Chronic urticaria – cause unknown in 80-90% of patients; known
causes include all of the above as well as: autoimmune disorders;
chronic medical illness; cold urticaria, cryoglobulinemia, or syphilis;
mastocytosis; inherited autoinflammatory syndromes
51. • Presentation: blanching, raised, palpable wheals
• Occur on any skin area and are usually transient (last < 24 hrs)
and migratory
• Dermatographism may occur
• Physical exam should focus on conditions that might precipitate
urticaria or could be life threatening – refer or send to ED if:
• Angioedema of the lips, tongue, or larynx
• Urticarial lesions that are painful, long lasting (> 36-48 hrs),
ecchymotic, or leave residual hyperpigmentation upon
resolution (suggests urticarial vasculitis)
• DDx: Contact or atopic dermatitis, pityriasis rosea, drug reaction,
mastocytosis, urticarial vasculitis
• Treatment: H1 antihistamines (ie Benadryl, hydroxyzine, Zyrtec)
• Add H2 antihistamines (ie ranitidine 150mg bid) for severe or
persistent urticaria
• Glucocorticosteroids for refractory cases
• Zyrtec 10mg dosed bid, Doxepin, or TCAs w/ potent
antihistamine properties may be useful in chronic urticaria
52.
53. Seborrheic Dermatitis
• Etiology: related to a pathologic overproduction of
sebum; may involve an inflammatory reaction to the
yeast Malassezia
• Presentation:
– Erythema with greasy yellowish scale on the “T-zone”
of the face, scalp, behind the ears, central chest
– Dandruff
– Can affect intertriginous areas
• Usual onset occurs with puberty
• Worsens with changes in seasons, trauma, stress,
Parkinson disease, AIDS, certain medications
• DDx: Atopic or contact dermatitis, rosacea, perioral
dermatitis, tinea, impetigo
54.
55. Treatment for Seborrheic Dermatitis
• Shampoo at least every other day (shampoos that contain
salicylic acid, tar, selenium, sulfur, or zinc are especially
helpful) – leave on for 5 minutes before washing off
• Synalar solution, Clobetasol 0.05% solution, or Derma-
Smoothe/FS (mineral/peanut oil + fluocinolone 0.1%) for
severe flaking on the scalp
• Ketoconazole 2% cream twice a day (good for face, ears
chest)
• Hydrocortisone 2.5% cream – for short-term use during
flares
• Tacrolimus ointment or pimecrolimus cream as steroid
sparing agents
56. Psoriasis
• Etiology: Multifactorial
disease that appears to be
influenced by genetic and
immune-mediated
components
• Presentation: Characterized
by red papules and plaques
with adherent silvery scale
• Triggers: Physical trauma,
stress, infection (Strep, HIV),
pregnancy, medications
58. For Each Clinic Visit
• Ask about joint pain
– 10% of patients have Psoriatic Arthritis (PsA)
(Refer to Rheum)
• Estimate body surface area (BSA)
– An average palm = 1%
– Disease Severity:
• Mild <5% BSA
• Moderate = 5-10% BSA (Refer to Derm)
• Severe >=10% BSA (Refer to Derm)
• Note – psoriasis is associated with cardiovascular
disease, smoking, alcohol, metabolic syndrome,
lymphoma, depression, suicide
59. Psoriasis Vulgaris
• Chronic and stationary - lesions can persist for years
• Distribution:
– Elbows
– Knees
– Scalp
– Lumbosacral
– Unbilicus
61. Koebner’s Phenomenon
• Occurs in 20% of patients
• Non-specific trauma can lead to formation of psoriasis in
the area of irritation
62. Inverse Psoriasis
• Involvement limited to skin fold regions
• Usually associated with minimal scaling
• Distribution: axilla, inframammary region, genitocrural
region, neck
• Often confused with intertrigo
63. Topical Treatments for Psoriasis
• Topical steroids
• Hydrocortisone 2.5% ointment (low strength) – good for short term
use on face, penis, and intertriginous areas
• Triamcinolone 0.1% ointment (medium strength)
• Clobetasol 0.05% ointment (high strength)
• Synthetic Vitamin D
• Dovonex (calcipotriene) cream – helps reduce scale
• Topical calcineurin inhibitors – steroid sparing
agents (good for face, penis, intertriginous areas
• Protopic ointment
• Elidel cream
• Common treatment regimen
• calcipotriene bid Mon-Fri and clobetasol oint bid Sat-Sun for lesions
on trunk and extremities; hydrocortisone or calcineurin inhibitor for
face, penis, and intertriginous areas
64. Other Treatments for Psoriasis
• Ultraviolet light (nbUVB and PUVA)
• Systemic therapies
– Conventional – methotrexate, Soriatane
– Biologics – Enbrel, Humira, Remicade
65. Pityriasis Rosea
• Etiology: benign, self-limited disease; considered to be a viral exanthem
• More common in women, children, & young adults
• Presentation: typically begins with a solitary macule that heralds the
eruption (“herald patch”)
• This lesion is usually a salmon-colored macule that enlarges over a
few days to become a patch with a collarette of fine
• Within the next 1-2 weeks, a generalized exanthem usually
appears as bilateral and symmetric salmon-colored macules with a
collarette scale oriented with their long axes along cleavage lines
(creates classic Christmas tree pattern)
• Tends to resolve over a 6 week period, but variability is common
• DDx: syphilis (so important to check RPR if there are risk factors),
nummular dermatitis, psoriasis, lichen planus, tinea corporis
• Treatment: None required but can treat pruritus with topical steroids,
oral antihistamines, topical menthol-phenol lotions
• Refer if skin lesions not resolving in a few months
66.
67. Tinea
• Etiology: superficial fungal infection of skin
• More common in preadolescents and in hot,
humid climates
• Presentation: scaly, ring-shaped,
erythematous plaque that enlarges and
displays central clearing; often mildly itchy
• Confirm diagnosis with KOH prep
• DDx: nummular dermatitis, granuloma
annulare, lupus, psoriasis, pityriasis rosea
69. Tinea Incognito (Majocchi’s Granuloma)
• A deep folliculitis due to a cutaneous dermatophyte infection
• Two types:
1) Follicular type - secondary to trauma or topical corticosteroids
2) Subcutaneous nodular type - occurs in immunocompromised pts
70. Treatment of Dermatophytosis
• Topicals (localized disease)
– Azoles (ketoconazole)
– Allylamines (terbinafine)
– Applied to the lesion and at least 2 cm beyond this
area once or twice/day for at least 2 weeks,
depending on which agent is used
* No Lotrisone!! (topical steroid is too strong)
• Systemic (extensive disease, nail or scalp
involvement, Majocchi’s granuloma)
– Griseofulvin, itraconazole, terbinafine
– May consider referral to dermatology
71. Tinea Versicolor
• Etiology: benign superficial cutaneous fungal infection with
Malassezia furfur (yeast); not contagious
• Most common in persons aged 15-24 years, when the
sebaceous glands are more active
• Presentation: Fine scaling, salmon-pink, hypo- or
hyperpigmented macules and patches
– Chronic, recurrent eruption occurring on upper trunk and proximal
extremities
– Exacerbated by warm, humid conditions
• KOH confirms diagnosis
• DDx: vitiligo, pityriasis alba, guttate psoriasis, CTCL
• Therapy: topical azole antifungals, selenium sulfide (leave
on for 5 min before washing off; weekly maintenance can
help prevent recurrences)
72.
73. Intertrigo
• Etiology: an inflammatory condition of skin folds resulting from heat,
moisture, and friction
• Often colonized by infection - usually candida but can also be
bacterial, fungal, or viral
• A common complication of obesity and diabetes
• Presentation: Erythema, cracking, and maceration with burning and
itching at sites in which skin surfaces are in close proximity (axillae,
perineum, inframammary creases, abdominal folds, inguinal creases)
• DDx: contact dermatitis, seborrheic dermatitis, cellulitis, inverse
psoriasis, acanthosis nigricans
• Treatment: Barrier creams such as zinc oxide paste, compresses with
Burrow solution 1:40 or dilute vinegar, absorbant powders and
moisture-wicking undergarments, exposing the skin folds to air,
topical antifungal agents for secondary infections (e.g., clotrimazole,
econazole, ciclopirox, miconazole, ketoconazole, nystatin)
.
74.
75. Scabies
• Etiology: Sarcoptes scabiei
• In developed countries, scabies occur primarily in institutional settings
and long-term care facilities; also common among children
• Presentation: Extremely itchy, especially at night
– Often involves armpits, groin, umbilicus, wrists, fingerwebs, nipples
– Primary lesions typically include small papules, vesicles, & burrows
**Itchy papules on the penis is scabies until proven otherwise!
• DDx: atopic dermatitis, bug bites, folliculitis, psoriasis
• Treatment: topical antiscabietic agents (e.g., Permethrin 5%) are
applied from the neck down with repeat application in 7 days, oral
ivermectin is also effective
– Pruritus may continue for up to 2 weeks after successful treatment
– Antipruritic agents (e.g. sedating antihistamines) and/or
antimicrobial agents (for secondary infection) may be needed
– All family members and close contacts must be evaluated and
treated for scabies, even if they do not have symptoms
77. Tip about HSV2: vesicles occurring in a sacral dermatomal distribution
can occur in recurrent genital HSV disease and be confused with
herpes zoster – you can do a viral culture to confirm
78. Folliculitis
• Etiology: primary inflammation of the hair follicle resulting from
infections, follicular trauma or occlusion
• Superficial folliculitis is common and often self-limited
• Affects all races, ages, and men and women equally
• Presentation: acute onset of papules and pustules associated with
pruritus or mild discomfort
• Treatment: uncomplicated superficial folliculitis can be treated with
antibacterial soaps (chlorhexidine wash) and good hand washing
technique; refractory or deep lesions that have a suspected
infectious etiology may need empiric treatment with topical
(clindamycin solution or gel) and/or oral antibiotics that cover
gram-positive organisms (choose a drug that covers MRSA in areas
of high prevalence or in predisposed patients); mupirocin ointment
in the nasal vestibule twice a day for 5 days may eliminate the S
aureus carrier state in cases of recurrent folliculitis
79.
80. • Prevalence: Studies have shown ~ 25-30% of the population is
colonized with MSSA (usually on skin or in nasal passages)
• A study in a California ED found 51% of patients presenting for
evaluation of a skin infection had +MRSA cultures
• Presentation: infections usually manifest as folliculitis or a similar
skin infection (patients often present with a “spider bite” or
“infected pimple”)
• Transmission of CA-MRSA is though an open wound or from
contact with a CA-MRSA carrier
• Treatment: I & D of the abscess and tx with appropriate
antibiotics when indicated; wound exudates should be cultured
to determine the causative organism and appropriate antibiotics
Oral antibiotics: Trimethoprim-sulfamethoxazole DS twice daily, w/
or w/o rifampin 600 mg/d; doxycycline 100 mg twice daily;
clindamycin 450 mg 3 times a day (96% sensitive)
Community Acquired MRSA (CA-MRSA)
81.
82. Acne
• Etiology: multifactorial but key factor is genetics (the propensity
for follicular epidermal hyperproliferation with subsequent
plugging of the follicle is inherited)
• Characterized by chronic inflammatory disease of the
pilosebaceous follicles (recurrence and relapse is common)
• Acne is a common skin disease affecting 60-70% of Americans at
some time during their lives
• Key elements in the history:
• Men vs. women
• Menstrual history
• PCOS
• Previous Hx
• Acne as a teenager
• Habits
• Picking or rubbing
• Previous Tx
• How long did you use?
• How did you use?
• Why did you stop?
• Medications
• Dilantin, lithium, prednisone,
etc.
83. The Severity of Acne Varies
• Mild
– Primarily comedones,
pustules and papules (<10)
• Moderate
– Primarily pustules and
papules (10-40), comedones
• Moderately severe
– Numerous papules and
pustules (40-100),
comedones, deeper nodular
lesions
[Refer to derm]
• Severe
– Nodulocystic acne and acne
conglobata
[Refer to derm]
90. Mild Acne
Primary Treatment
• Topical tretinoin (Retin-A) + topical antimicrobial
• Tretinoin (Retin-A) at night
- 0.025%, 0.05%, and 0.1% cream (gel in pts with very oily skin)
• Topical clindamycin 1% gel or lotion in the morning
Adjunctive Treatment
• Salicylic acid 2% wash to entire face up to twice daily
• Benzoyl peroxide (BPO) 2.5-5% gel or lotion in the morning as spot
treatment (note that BPO bleaches clothing/bedding)
Mild Acne (faux pas)
• Topical antimicrobial (e.g., clindamycin) as monotherapy or for >3
months duration encourages antimicrobial resistance
91. Moderate Acne
Primary Treatment
• Topical retinoid + ORAL antibiotic (esp in acute phase)
• Tretinoin (Retin-A) or tazarotene at night
• Oral doxycycline or minocycline once daily (often start 100mg bid
for a month then drop to once daily and get minocycline to 50mg
daily); these should not be taken with dairy but take with food to
prevent stomach upset
- Amoxicillin and Bactrim (low dose) are also options
Adjunctive Treatment
• Salicylic acid 2% wash to entire face up to twice daily
• Benzoyl peroxide 2.5-5% gel in the morning to entire face
• In women, consider oral contraceptive pills and/or spironolactone
92. Moderate-Severe Acne
Primary Treatment
• Referral to dermatology warranted
• Topical retinoid + ORAL antibiotic (high dose)
• Tretinoin (Retin-A) or tazarotene at night
• Oral doxycycline or minocycline twice daily
- Amoxicillin and Bactrim (high dose) are also options
Adjunctive Treatment
• Benzoyl peroxide 2.5-5% gel in the morning to entire face
• Consider Accutane
• In women, highly consider spironolactone (alternative) in
addition to oral contraceptive pills (OCP)
93. Severe Acne
Primary Treatment - Refer to dermatology for tx
• Oral isotretinoin (Accutane) as monotherapy OR
• Potent topical retinoid (e.g., tazarotene) + ORAL antimicrobial
(high dose) + topical benzoyl peroxide
Adjunctive Treatment
• Women are automatically on OCPs
• In women, consider adding spironolactone
• OK to add oral or topical antibiotics but be mindful of drug
interactions
After Accutane
• Bridge to topical retinoids and/or oral antibiotics or
spironolactone
94. Topical retinoids should be 1st line in
maintenance therapy
• Target microcomedo formation
• Topical retinoid monotherapy is effective
• No issue with antimicrobial resistance
• Add BPO and not antibiotics for
maintenance
95. Therapeutic Considerations
• All discussed therapies for acne are pregnancy class C or
worse
• Spironolactone
- Can raise K level so renal function must be normal
• Oral antibiotics should be used to shutdown acute
inflammatory acne over a few months
• If previously on oral antibiotic and patient flares, then restart
on the same oral antibiotic (no need to switch)
• Start Accutane slowly, especially in those with nodulocystic
acne (can paradoxically induce flare)
96. Reducing Antibiotic Resistance
• Concurrent use of oral and topical
antibiotics should be avoided
• Avoid using antibiotics as monotherapy
• Antibiotics should be discontinued as soon
as inflammatory lesions disappear
• Topical antibiotics may be used in mild to
moderate acne but should be used in
combo with a retinoid or BPO
