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Essential dermatology for the practicing internist

BOSTON — There is a role for the internist in partnership with the dermatologist to diagnose and treat common dermatological conditions, according to a dermatologist here at the ACP Internal Medicine Meeting.

Julia R. Nunley, MD, FAAD, FACP, who is a dermatologist, nephrologist and an internist, presented to the internist audience many of the common signs and signals for common dermatologic conditions they may see.

“Medical dermatology is alive and well,” Nunley said. “Many of us in dermatology know absolutely nothing about lasers or cosmetics or Botox or fillers.”

The most common dermatologic conditions that patients present with in a primary care office are: inflammatory (acne, rosacea), benign lesions, and malignant lesions. Nunley focused her talk on inflammatory conditions.

Acne

Acne is a disorder of the pilosebaceous unit. The pathobiology is an obstruction of the follicular orifice; an increase in sebum production; and overgrowth of Propionibacterium acnes. There are three lesion types: comedones, papulopustules, nodules and cysts.

“I prefer to categorize acne as whether when we look at it, do we primarily see comedones, or do we primarily see inflammatory papules and pustules. And that’s because this dictates how you will start treatment,” Nunley said.

Nunley said if comedones (blackheads) are present, you must use a retinoid or a keratolytic agent, but choose one based on the patient’s dryness and tolerability of the medication. If the lesion is inflammatory, you must use an antibiotic or an antifungal and can add a retinoid later, she said.

“If you have nodules, you need an oral antibiotic most likely,” she said.

As for the retinoids, adapalene is “less irritating”; tretinoin is “the workhorse”; and tazarotene can “take 3 months to see an improvement.”

Tetracyclines should be used for moderate to severe acne and rosacea. The adverse effects are the potential for photoxicity and esophagitis.

Nunley said there are many OTC keratolytics, such as benzoyl peroxide. Azelaic acid is the “new kid on the block” and inhibits melanin production, which is an advantage for patients of color; and salicylic acid comes in both OTC facial washes and prescription, although the latter tend to be too harsh for facial skin, she noted.

Rosacea

“Its old name is acne rosacea, but it really probably shouldn’t be called acne rosacea because the pathobiology has nothing to do with the pathobiology of acne,” Nunley said of this common inflammatory condition.

Patients with rosacea have a peculiar vascular reactivity process. “They flush and blush easy,” she said.

“There is so little we know about the basic science of rosacea,” she continued. She suggested that internists look at rosacea as four different subtypes: erythematotelangiectatic, papulopustular, phymatous and ocular.

Nunley said when you treat patients, you must educate them on the critical need to sun protect as “all medications one may prescribe will not prevent progression of the disease. It helps manage what they have today.”

She said to avoid topical steroids as they vasoconstrict and will cause thinning. “Short-term of course. Long-term never,” she said. She recommended topical or oral antibiotics and other options such as azelaic acid and sulfacetamide sodium-sulfur.

Other common conditions

Nunley also discussed two other common conditions — seborrheic dermatitis and eczema —which she described as a “garbage bag term.”

Seborrheic dermatitis affects 15% of the population. It has a wide distribution on the body — scalp, behind the ears, under the breast and in the groin. As for the treatment, it is two-fold. “One, go after the fungus and, two, go after the inflammation,” she said.

Eczema can be acute or chronic. If the eczema is acute, it is red, painful, weeping, draining, and blistery. If the eczema is chronic, it is dry, scaly, and thick.

“The good old fashioned therapy is if it’s wet, dry it; if it’s dry, wet it,” she said.

Systemic therapy for chronic eczema is rarely necessary; please try to avoid prednisone because of the rebound phenomenon, Nunley said. Phototherapy and immunosuppressive agents are treatment options.

Patient education is crucial because “patients are going to think that you will cure their eczema like you cured their strep throat,” she said. Be empathetic because of the chronic nature of eczema. “What we have are tools for them to use. We do not have cures,” she said.

Minimize hand washing; modify wet work; adjust bathing habits and products they use. Liberal and immediate use of creams and ointments after water contact of the skin are tools.

“Treatments are within the scope of most of you within the room, at least in the beginning phases of their diseases.” – by Joan-Marie Stiglich, ELS

Reference:

Nunley JR. Essential Dermatology for the Internist. Abstract #SS001. Presented at: ACP Internal Medicine Meeting; April 30-May 2, 2015; Boston.

Disclosure: Nunley reports no relevant financial disclosures.