Resident Editor: Michelle Matzko MD, Ph.D.
Faculty Editor: Ryan Arakaki, M.D.
Table 5: Other Common Outpatient Dermatologic Disorders
Condition |
Morphology/Distribution |
Management |
Candida |
Mucous membrane: - Thrush (white adherent exudate) - Chronic atrophic (erythematous patch)
Cutaneous: - Usually in intertriginous areas - Erythematous, erosive patch with satellite pustules
Nails: - Can affect periungual areas and nails - Prolonged water exposure is a risk factor |
Topicals: - Nystatin - Azole antifungals - Note: terbinafine does not cover candida
Systemic: - Fluconazole - Itraconazole
|
Eczema (atopic dermatitis) |
Associated features: - Asthma - Allergic rhinitis - Early-onset - Family history
Infants/children: - Face, neck, extensor surfaces
Adults: - Flexural surfaces
Acute lesions: - Erythematous, ill-defined patches and plaques with serous crust
Chronic lesions: - Hyperpigmented plaques with accentuated skin markings (lichenification) |
Gentle skincare: - Short, lukewarm showers - Pat dry gently - Immediate moisturization with Vaseline or Aquaphor while damp
Topical steroids: - Choice of potency depends on the age of the patient, anatomic site, the severity of the lesion - Refer to the steroids section for choices
Oral immunosuppressants: - For disease resistant to topical treatments
|
Herpes simplex |
Prodrome: - Lesions may be asymptomatic or may sting/itch - Preceding SxS include fever, LAD, anorexia
Skin lesions: - Can be primary or recurrent - Mouth and lips most common sites - Also affects the vulva, vagina, cervix, glans penis, perineum, buttocks - Grouped vesicles on an erythematous base - Quick progression to erosions and crust (may not see vesicles on an exam) - Scalloped borders
|
Genital Primary Infection: - Acyclovir 200 mg 5x/d x10d or 400 mg po tid x 10d - Famciclovir 250 mg po tid x 10d - Valacyclovir 1g po bid x 10d
Genital Recurrent infection: - Acyclovir 200 mg 5x/d x 5d or 400 mg po tid x5d - Famciclovir 1g po bid x 1d or 125 mg po bid x5d - Valacyclovir 500 mg po bid x 3-5d
Suppressive: - Acyclovir 400 mg po bid - Famciclovir 250 mg po bid - Valacyclovir 500 mg po daily
Immunocompromised +/- disseminated: - Acyclovir 5-8 mg/kg IV q8h x 7-10d
|
Herpes zoster |
- Due to reactivation of VZV after primary varicella infection - Prodrome of intense pain, pruritus, hyperesthesia - Distributed along sensory dermatome; respects the midline - Trunk, face, neck, extremities - Crops of grouped vesicles or crusted papules
Complications: - Postherpetic neuralgia - Ophthalmic zoster - Ramsay-Hunt syndrome
Disseminated zoster: - >20 lesions outside primary and two contiguous dermatomes - Occurs in 10% of immunocompromised patients |
Immunocompetent: - Acyclovir 800 mg po 5x/d x 7-10d - Famciclovir 500 mg po tid x 7d - Valacyclovir 1 g po tid x 7d
Immunocompromised +/- disseminated: - Acyclovir 10-12 mg/kg IV q8h x 7-10d
Zoster Vaccine - One-time dose for people older than 60, whether or not they have a history of herpes zoster infection - Reduces zoster incidence, severity, and post-herpetic neuralgia |
Paronychia |
- Swelling, erythema, and pain of nail folds - Acute: most commonly due to Staph aureus or GAS - Recurrent episodes: suspect HSV - Chronic: suspect Candida
|
Acute: - Warm compresses - Drainage of abscess - Oral abx according to culture results - Systemic antivirals if HSV present
Chronic: - Topical steroids +/- antifungal |
Pityriasis rosea |
- Herald patch on trunk - Annular papules and plaques with central fine scaling and collarette of trailing scale - Christmas-tree distribution on the posterior trunk (follows Langer’s lines) |
- Spontaneous remission - Sunlight - Symptomatic treatment with topical steroids - Remember to rule out secondary syphilis |
Condition |
Description |
Management |
Rosacea |
Four major subtypes:
Erythematotelangiectatic: - Central facial erythema - Recurrent skin flushing - Dryness, sensitivity - Telangiectasias
Papulopustular (inflammatory): - Central facial erythema - Erythematous papules and pustules
Phymatous: - Thickening of skin over nose, chin, forehead, ears
Ocular: - Can present as multiple eye symptoms (eg foreign body, burning, stinging, dryness, blurred vision)
|
Prevention: - Avoid triggers (e.g., EtOH, spicy foods, sunlight, extreme temperatures, vasodilatory meds)
Topical therapy (first-line in bold): - Metronidazole 0.75% or 1% daily or bid - Azelaic acid 15-20% bid - Ivermectin 1% cream daily - Benzoyl peroxide/clindamycin daily - Tretinoin 0.025% to 0.1% daily
Systemic therapy (trial 4-12 weeks): - Tetracycline 250-500 mg bid - Doxycycline 50-100 mg bid - Minocycline 50-100 mg bid - If resistant to oral antibiotics, can refer to dermatology for consideration of isotretinoin
For telangiectasias: - Topical and oral therapies mostly ineffective - Vascular-targeted lasers or light therapy effective
For rhinophyma: - Ablative laser or electrosurgery
For ocular: - Refer to ophtho |
Seborrheic dermatitis |
- Limited to periods of life when sebaceous glands are active (infantile and adult forms; rare in prepubertal children) - Distributed over areas rich in sebaceous glands-scalp, face, nasolabial folds, eyebrows, ears, chest, intertriginous areas - Erythematous patches with greasy, diffuse scale - Can rarely be erythrodermic - More common in HIV (can be more extensive and severe) and Parkinson’s |
- First-line: antifungal shampoos ketoconazole 2% or ciclopirox 1% Alternative fungal shampoos include zinc pyrithione 1% or selenium sulfide 2.5%. - Use daily or at least two or three times per week for several weeks until remission achieved; rotate among classes - - Topical Ketoconazole 2% daily or bid x 4 weeks - Topical low dose steroids, calcineurin inhibitors - Severe/refractory: oral itraconazole 200mg qD x 7d
|
Tinea versicolor |
- Distributed over seborrheic areas (neck, trunk, upper arms) - Annular hypo- or hyperpigmented macules with overlying fine scale - KOH prep: “spaghetti and meatballs” representing fungal hyphae & yeast (Malassezia furfur) |
Topicals (first-line): - Selenium sulfide 2.5% shampoo daily for 1 week; leave on for 10 min - Ketoconazole 2% cream daily for 2weeks
Systemic (severe disease): - Itraconazole 200 mg daily x 5 days - Fluconazole 300mg x1; repeat at 1 week |
Verrucae (warts) |
- ~100 different HPV genotypes can cause warts
Cutaneous infection - Common, plantar, palmar, flat, mosaic, and butcher’s warts - Classified by morphology and anatomic location
Mucosal infection - Condyloma acuminata (genital warts) found on the external genitalia, perineum, perianal region - Usually caused by HPV types 6 and 11 - Persistent infection by HPV types 16 and 18 can lead to cervical, vaginal, vulvar, penile, anal cancer
Verrucous carcinomas - Caused by HPV 6 and 11 - Locally invasive and rarely metastasize - Buschke-Lowenstein tumor: giant condyloma acuminata - Oral florid papillomatosis - Epithelioma cuniculatum of the sole |
Overview - Broadly categorize as destructive or immunomodulatory - Everything works about 20% of the time - There is no evidence that treatment prevents subsequent sexual transmission of genital warts - Tools used for paring down warts (eg, nail file, pumice stone, etc.) should not be used on normal skin or nails to avoid spreading the virus
Destructive (first-line in bold) - Cryotherapy - Salicylic acid 20-50% daily x 12 weeks - Bleomycin- refractory (refer to derm) - 5-fluorouracil- refractory - Cantharidin - Laser - Excision
Immunomodulatory - Works poorly in immunosuppressed patients - Squaric acid - DNCB - High dose cimetidine and other H2 antagonists - Imiquimod (genital warts only) |
References
Bolognia, J et al. Dermatology. 3rd Edition. 2011. Elsevier Ltd. Del Rosso JQ, Schlessinger J, Werschler P . Comparison of anti-inflammatory dose doxycycline versus doxycycline 100 mg in the treatment of rosacea. J Drugs Dermatol. 2008;7(6):573.
Gupta AK, Lane D, Paquet M Systematic review of systemic treatments for tinea versicolor and evidence-based dosing regimen recommendations. J Cutan Med Surg. 2014 Mar;18(2):79-90.
Kastarinen H, Oksanen T, Okokon EO, et al. Topical anti-inflammatory agents for seborrhoeic dermatitis of the face or scalp. Cochrane Database Syst Rev. 2014
Table continued next page.
Table 5: Other Common Outpatient Dermatologic Disorders
Condition |
Description |
Management |
Rosacea |
Four major subtypes:
Erythematotelangiectatic: - Central facial erythema - Recurrent skin flushing - Dryness, sensitivity - Telangiectasias
Papulopustular (inflammatory): - Central facial erythema - Erythematous papules and pustules
Phymatous: - Thickening of skin over nose, chin, forehead, ears
Ocular: - Can present as multiple eye symptoms (eg foreign body, burning, stinging, dryness, blurred vision)
|
Prevention: - Avoid triggers (e.g., EtOH, spicy foods, sunlight, extreme temperatures, vasodilatory meds)
Topical therapy (first-line in bold): - Metronidazole 0.75% or 1% daily or bid - Azelaic acid 15-20% bid - Ivermectin 1% cream daily - Benzoyl peroxide/clindamycin daily - Tretinoin 0.025% to 0.1% daily
Systemic therapy (trial 4-12 weeks): - Tetracycline 250-500 mg bid - Doxycycline 50-100 mg bid - Minocycline 50-100 mg bid - If resistant to oral antibiotics, can refer to dermatology for consideration of isotretinoin
For telangiectasias: - Topical and oral therapies mostly ineffective - Vascular-targeted lasers or light therapy effective
For rhinophyma: - Ablative laser or electrosurgery
For ocular: - Refer to ophtho |
Seborrheic dermatitis |
- Limited to periods of life when sebaceous glands are active (infantile and adult forms; rare in prepubertal children) - Distributed over areas rich in sebaceous glands-scalp, face, nasolabial folds, eyebrows, ears, chest, intertriginous areas - Erythematous patches with greasy, diffuse scale - Can rarely be erythrodermic - More common in HIV (can be more extensive and severe) and Parkinson’s |
- First-line: antifungal shampoos ketoconazole 2% or ciclopirox 1% Alternative fungal shampoos include zinc pyrithione 1% or selenium sulfide 2.5%. - Use daily or at least two or three times per week for several weeks until remission achieved; rotate among classes - - Topical Ketoconazole 2% daily or bid x 4 weeks - Topical low dose steroids, calcineurin inhibitors - Severe/refractory: oral itraconazole 200mg qD x 7d
|
Tinea versicolor |
- Distributed over seborrheic areas (neck, trunk, upper arms) - Annular hypo- or hyperpigmented macules with overlying fine scale - KOH prep: “spaghetti and meatballs” representing fungal hyphae & yeast (Malassezia furfur) |
Topicals (first-line): - Selenium sulfide 2.5% shampoo daily for 1 week; leave on for 10 min - Ketoconazole 2% cream daily for 2weeks
Systemic (severe disease): - Itraconazole 200 mg daily x 5 days - Fluconazole 300mg x1; repeat at 1 week |
Verrucae (warts) |
- ~100 different HPV genotypes can cause warts
Cutaneous infection - Common, plantar, palmar, flat, mosaic, and butcher’s warts - Classified by morphology and anatomic location
Mucosal infection - Condyloma acuminata (genital warts) found on the external genitalia, perineum, perianal region - Usually caused by HPV types 6 and 11 - Persistent infection by HPV types 16 and 18 can lead to cervical, vaginal, vulvar, penile, anal cancer Verrucous carcinomas - Caused by HPV 6 and 11 - Locally invasive and rarely metastasize - Buschke-Lowenstein tumor: giant condyloma acuminata - Oral florid papillomatosis - Epithelioma cuniculatum of the sole |
Overview - Broadly categorize as destructive or immunomodulatory - Everything works about 20% of the time - There is no evidence that treatment prevents subsequent sexual transmission of genital warts - Tools used for paring down warts (eg, nail file, pumice stone, etc.) should not be used on normal skin or nails to avoid spreading the virus
Destructive (first-line in bold) - Cryotherapy - Salicylic acid 20-50% daily x 12 weeks - Bleomycin- refractory (refer to derm) - 5-fluorouracil- refractory - Cantharidin - Laser - Excision Immunomodulatory - Works poorly in immunosuppressed patients - Squaric acid - DNCB - High dose cimetidine and other H2 antagonists - Imiquimod (genital warts only) |
References
Bolognia, J et al. Dermatology. 3rd Edition. 2011. Elsevier Ltd.
Del Rosso JQ, Schlessinger J, Werschler P . Comparison of anti-inflammatory dose doxycycline versus doxycycline 100 mg in the treatment of rosacea. J Drugs Dermatol. 2008;7(6):573.
Gupta AK, Lane D, Paquet M Systematic review of systemic treatments for tinea versicolor and evidence-based dosing regimen recommendations. J Cutan Med Surg. 2014 Mar;18(2):79-90.
Kastarinen H, Oksanen T, Okokon EO, et al. Topical anti-inflammatory agents for seborrhoeic dermatitis of the face or scalp. Cochrane Database Syst Rev. 2014