Disease-a-Month 61 (2015) 297–307

Contents lists available at ScienceDirect

Disease-a-Month journal homepage: www.elsevier.com/locate/disamonth

Clinical pearls in dermatology Rochelle Torgerson, MD, PhD, Scott Litin, MD, John B. Bundrick, MD

Case 1 A 38-year-old mother of three is struggling with moderate, inflammatory facial acne despite using isotretinoin cream nightly  3 months. She is upset with her appearance and frustrated. She asks you for help (Fig. 1).

Question What would the next best additional treatment be? A. B. C. D. E.

Minocycline Isotretinoin Topical dapsone Topical clindamycin Spironolactone

Discussion As many as 40% of adult women in their 30s struggle with acne. One of the pathogenic features of acne is increased androgen sensitivity, leading to increased sebum production and altered keratin plugging of the follicle. This woman has failed an appropriate-duration trial of tretinoin, the first-line therapy for moderate inflammatory acne. For all patients with moderate inflammatory acne, systemic antibiotic therapy would be an appropriate option. However, adult females typically have a hormonally driven form of acne. This can be appreciated by the distribution of lesions on physical exam at the jawline and the cyclic nature of lesions flaring just prior to menses. A recent meta-analysis showed the efficacy of anti-androgen therapy being equal to that of systemic antibiotics at 6 months in adult women. http://dx.doi.org/10.1016/j.disamonth.2015.04.001 0011-5029/& 2015 Mosby, Inc. All rights reserved.

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Fig. 1. 38-year-old woman with acne.

Clinical pearl The use of anti-androgen treatments for moderate inflammatory acne in adult females can be as effective as systemic antibiotic therapy and reduce the need for long-term systemic antibiotic therapy in the treatment of acne. Anti-androgen therapies include drospirenone containing oral contraceptive pills and spironolactone 50–100 mg daily. References 1. Nast A, et al. European evidence-based (S3) guidelines for the treatment of acne. J Eur Acad Dermatol Venereol. 2012; suppl 1:1–29. 2. Koo EB, Petersen TD, Kimball AB. Meta-analysis comparing efficacy of antibiotics versus oral contraceptives in acne vulgaris. J Am Acad Dermatol. 2014;71:450–459. Case 2 A 25-year-old woman has had this facial rash for 8 weeks. She has not made any changes to her facial care program or make-up. Although the skin feels slightly irritated, she is most bothered by the appearance (Fig. 2). Question What topical medication would you prescribe? A. Benzoyl peroxide 5% cream B. Metronidazole 0.75% cream

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Fig. 2. 25-year-old woman with facial rash.

C. Tretinoin 0.025% cream D. Hydrocortisone 2.5% cream E. Triamcinolone 0.1% cream

Discussion The three most common acneiform facial eruptions in adults are acne vulgaris, acne rosacea, and perioral dermatitis. These entities can be distinguished on clinical exam due to differences in primary lesion morphology and lesion distribution. Perioral dermatitis classically presents with erythematous papules, papulovesicles, or papulopustules in a perioral distribution, sparing the vermillion border. Also known as periorificial dermatitis, it can present beneath the nares and around the lateral eyelid. The papules often arise on an eczematous base. The pathogenesis of perioral dermatitis is unknown, but it is often precipitated or aggravated by topical corticosteroid use. Patients have often self-medicated with topical corticosteroids. These need to be tapered off. Antibiotic therapy is effective and the best-studied treatment. A cure of the current episode can be expected, but future recurrence is possible. Clinical pearl Perioral dermatitis should be in the differential of acneiform eruptions in adults. The involvement of skin surrounding the nose and the eyes may provide a clinical clue to the diagnosis. Systemic antibiotics combined with topical antibiotics are very effective. Doxycycline 100 mg BID  3 months þ metronidazole 0.5% cream is a common, successful therapy.

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References 1. Tempark T, Shwayder TA. Perioral dermatitis: a review of the condition with special attention to treatment options. Am J Clin Dermatol. 2014;15:101–113.

Case 3 This 45-year-old woman presents with a 1-year history of pain when brushing her teeth and eating. She has changed toothpaste twice and tried a number of mouthwash products without relief. She smoked for 8 years in her 20s (Fig. 3).

Question What does she have? A. B. C. D. E.

Lichen planus Morsicatio buccarum (chewed cheek) Aphthous ulcers (canker sores) Squamous cell carcinoma Thrush

Discussion Oral lichen planus is an inflammatory dermatosis that affects the mucous membrane surfaces of the mouth. It can present anywhere on the spectrum of mild, hyperkeratotic, asymptomatic plaques on the buccal mucosa to erosive disease affecting all surfaces causing pain, weight loss, and loss of dentition. There is an increased risk of squamous cell carcinoma of the mouth in patients with oral lichen planus. Patients with oral lichen planus need to be screened for involvement in other areas including keratinized skin, scalp, esophagus, genitalia, nails, and less likely eyes and ears. Treatment is catered to disease severity and ranges from observation to systemic therapy (methotrexate, mycophenolate mofetil, and acitretin). The majority of patients with symptomatic mild-to-moderate disease do well with a topical corticosteroid gel.

Fig. 3. 45-year-old woman with painful lesions buccal mucosa.

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Meticulous oral hygiene and regular scaling are key in management. The need for long-term surveillance for squamous cell carcinoma should be stressed.

Clinical pearl Despite the profound disease heterogeneity seen in oral lichen planus, many patients do well with topical corticosteroid gel such as fluocinonide or clobetasol gel applied BID prn several days per week. Treatment can improve patient comfort and theoretically reduce the risk of oral squamous cell carcinoma.

References 1. Davari P, et al. Mucosal lichen planus: an evidence-based treatment update. Am J Clin Dermatol. 2014;15:181–195.

Case 4 A single 32-year-old male complains of 3–5 sores constantly causing pain in the mouth. He is concerned that he may have caught them from kissing one of his dates. They are annoying to him, and he comes to you seeking treatment suggestions (Fig. 4).

Question What is the most effective first-line therapy? A. B. C. D. E.

Nystatin solution Acyclovir Clobetasol gel Chlorhexidine rinse Magic mouth wash

Fig. 4. 32-year-old man with painful oral ulcers.

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Discussion Aphthous ulcers (canker sores) classically present as well-defined ulcers of the mucous membranes with a yellow fibrinous base and erythematous halo. Recurrent aphthous stomatitis (RAS) is the most common condition of the oral cavity. It is a chronic, self-limited condition that disproportionately affects women and individuals with higher socioeconomic and education levels. The pathogenesis is unknown, but well-known inciting factors include trauma, menses, and smoking cessation. Aphthosis can be divided into simple and complex forms. Complex aphthosis is characterized by larger numbers of lesions lasting longer and sometimes big in size. Genital aphthae can be seen in complex aphthosis as well. In the United States, a patient with oral and genital aphthae is much more likely to have complex aphthosis than Behcet Disease. Treatment for RAS is titrated to disease activity. Patients with severe disease should be evaluated for underlying predisposing factors or systemic disease and may require systemic medications such as colchicine, dapsone, and pentoxifylline. In patients with mild to moderate disease, the first-line therapy is the use of a high-potency corticosteroid BID to TID at the first sign of a new lesion. Viscous lidocaine q 3 h can provide pain relief.

Clinical pearl Patients with simple aphthosis can use topical clobetasol gel BID to TID to reduce lesion size and duration. For some patients, high-potency topical corticosteroids can abort lesions. For patients with complex aphthosis, clobetasol gel is continued and systemic medications are added.

References 1. Belenguer-Gualler I. Treatment of recurrent aphthous stomatitis. A literature review. J Clin Exp Dent. 2014;6:e168–e174.

Case 5 A 58-year-old woman presents with this rash. She was diagnosed at a walk in pharmacy clinic with a fungal skin rash. However, it has been continuous June–August despite twice-daily nystatin powder (Fig. 5).

Fig. 5. 58-year-old woman with rash under both breasts.

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Question What is it? A. B. C. D. E.

Intertrigo Allergic contact dermatitis Cellulitis Psoriasis Seborrheic dermatitis

Discussion Psoriasis is common, affecting up to 5% of the population. The most common form of psoriasis is psoriasis vulgaris, which presents as erythematous plaques with an overlying silvery scale. Other forms of psoriasis include guttate, erythrodermic, pustular, and inverse. Inverse psoriasis presents as moist, erythematous plaques in intertriginous areas lacking scale. This lack of scale makes it difficult to differentiate from the more common intertrigo. Associated lesions on the post auricular scalp, umbilicus, or superior gluteal cleft may provide a diagnostic clue. Inverse psoriasis should definitely be considered when intertrigo therapy fails. Psoriasis patients are at risk for inflammatory arthritis, metabolic syndrome, and cardiac disease.

Clinical pearl Inverse psoriasis should be considered in the differential of intertrigo, particularly when treatment resistant. Clues on physical exam may aid in the accurate diagnosis. Identifying patients with psoriasis is important due to the systemic nature of the disease.

References 1. Bolognia JL, Jorrizo JL, Schaffer JV. Dermatology. 3rd ed. Elsevier Saunders; 2012.

Case 6 This 59-year-old woman has complains of severe pruritus of the vulva for the past 9 months. Scratching brings pain not relief. She and her husband have abstained from intercourse due to the discomfort. She comes to you seeking something to relieve her symptoms Fig. 6.

Question What should you prescribe for treatment? A. B. C. D. E.

Testosterone cream Estrace cream Clobetasol ointment Hydrocortisone cream Petrolatum ointment

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Fig. 6. 59-year-old woman with severe pruritus of vulva.

Discussion Vulvar lichen sclerosus (LS) is a chronic inflammatory disease of the modified mucous membranes of the vulva (not vagina) and perianal skin. The pathogenesis is uncertain but thought to be autoimmune. Vulvar LS can affect women of all ages, but peak incidence coincides with low estrogen, and prepubertal and postmenopausal years. The most common presenting symptom is pruritus, but severe disease can lead to skin breakdown and pain. Clinical presentation can range from subtle hypopigmentation to extensive, white atrophic plaques with ecchymoses, and profound architectural alteration. Patients with vulvar LS have an increased 3– 5% lifetime risk of vulvar squamous cell carcinoma. Historically testosterone was used for treatment, but recent studies have shown it to be no better than vehicle. Clobetasol ointment is currently considered to be the gold standard for treatment. Treatment consists of daily to BID application for 2–12 weeks to gain control followed by 2–3 nights per week maintenance application. Modified mucous membranes are quite resistant to topical corticosteroid side effects. Although estrogen is not a treatment for vulvar LS, in some instances local estrogen replacement may be needed to impart more resilience to the tissues. The need for long-term surveillance for squamous cell carcinoma should be stressed.

Clinical pearl Many patients with vulvar lichen sclerosus can be effectively managed using clobetasol ointment. Daily application is used to gain control followed by maintenance application to reduce the frequency of disease flares. Long-term follow-up is needed to monitor for squamous cell carcinoma.

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References 1. Murphy R. Lichen sclerosus. Dermatol Clin. 2010;28:707–715.

Case 7 A 32-year-old woman has had waxing and waning pruritus of the right labium majus for 8 years. She admits to running to the restroom at work to scratch to get relief. She was awaken in the morning with blood on her pajama bottoms from scratching while sleeping. She states that scratching the area brings a great deal of relief (Fig. 7).

Question What does she have? A. B. C. D. E.

Allergic contact dermatitis Psoriasis Recurrent HSV Bacterial vaginitis Lichen simplex chronicus

Discussion Lichen simplex chronicus is a chronic, multifactorial, inflammatory skin condition that can affect the vulva. Disease is often localized or unilateral. Long-standing disease can produce markedly lichenified skin. Scratching can lead to breaks in the epidermal barrier, so superinfections are not uncommon and can be painful. Many patients report an atopic diathesis and a history of sensitive skin. The pathogenesis is hypothesized to be an inciting, nonspecific irritation in predisposed individuals, leading to a deeply entrenched itch–scratch cycle. The itch is unique in that, unlike in other pruritic vulvar diseases, scratching can bring about great relief. Patients will often report scratching at night without waking fully. A treatment approach must address persistent sources of irritation, reduction of inflammation, treatment of superinfections,

Fig. 7. 32-year-old woman with chronic pruritus right labium majus.

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and nighttime sedation to decrease nighttime scratching. Lichen simplex chronicus can be a challenging cycle to break. Patients need to be counseled regarding the chronicity of the disease, so they set their sights on control not cure. Clinical pearl The quality of the itch described by patients with vulvar lichen simplex chronicus, that is scratching can bring about great relief, can be a key diagnostic clue. Effective treatment plans combine, mild vulvar care, high-potency corticosteroid creams, sedating antihistamines at night, and treatment of superinfection. References 1. Rimoin LP, Kwatra SG, Yosipovitch G. Female-specific pruritus from childhood to postmenopause: clinical features, hormonal factors, and treatment considerations. Dermatol Ther. 2013;26:157–167. Case 8 A 25-year-old man desires treatment for painful lesions on the bottom of his soles and toes. They cause pain when walking and exercising (Fig. 8).

Fig. 8. 25-year-old man with warts.

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Question Which of the following when part of the treatment program will be least likely to help him achieve success? A. B. C. D. E.

Dermatology consult Nursing care plan Liquid nitrogen Salicylic acid Duct tape

Discussion Warts are caused by the human papilloma viruses. The viruses are ubiquitous. Microabrasions are all that are required for viral entry. Infection can occur through contaminated surfaces, skin–skin contact, or auto-inoculation. Cutaneous (non-genital) warts have a prevalence of 20% during school years and decrease with age. Prevalence increases with immunosuppression. Warts are benign and self-limited, clearing in 1–2 years spontaneously in most immunocompetent people. Because of this, treatments need to be catered to symptoms, numbers of warts, and psychologic burden, with a goal of avoiding treatments that cause painful scarring. The number of wart treatments available speaks to their inadequacy; most wart treatments work approximately 50% of the time. Successful treatment plans require continuous, uninterrupted treatment for months. Access to a physician calendar over months is unpredictable, thus treatment plans relying on physician intervention tend to fail. Home treatments or care plans using a nurse-run clinic are superior. An effective plan is daily salicylic acid under duct tape occlusion applied at home with cryotherapy every 3–4 weeks in a nurserun wart clinic. In patients with multiple warts, treatment can be focused on one or two lesions. Once immunity to the wart virus is achieved, the body will clear even the untreated warts. Reinfection with the same wart virus is rare. Treatment to cure can take upward of 5–7 months for an average wart. Failure to commit to this duration of therapy is a common reason for treatment failure. Clinical pearl Most wart treatments have equal efficacy. Best results are seen when two treatments are employed simultaneously and these treatments are pursued consistently without break. References 1. Bolognia JL, Jorrizo JL, Schaffer JV. Dermatology. 3rd ed. Elsevier Saunders; 2012. Answers: 1-E; 2-B; 3-A; 4-C; 5-D; 6-C; 7-E; and 8-A See comment in PubMed Commons below.

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