Definition + Types of Scaly Dermatoses
Involve epidermis + Scales are primary manifestation
Dandruff -> Seborrheic Dermatitis -> PSORIASIS
increasing Severity + Inflammation
Seborrheic Dermatitis
SD
NOT a disease of the sebaceous glands
Rate of sebum production is NOT necessarily increased
Found in areas w/ larger or higher amounts of glands
Can be in association with MALASSEZIA
Immunologic + Hyperproliferative
Malassezia
YEAST found on NORMAL skin
metabolize fatty compounds in sebum
Can be Directly Pathologic:
Pityriasis Versicolor / Systemic Infections
Also Indirectly Pathalogic:
in Dandruff & Seborrheic Dermatitis
Pathophysiology of SD
Seborrheic Dermatitis
In combination, make an
Exaggerated Immune Response to Malassezia Yeast:
Malassezia
metabolize FATTY compounds, found in LIPID-RICH location
Immunologic
common in immune supressed, more CYTOKINES
HYPERproliferative
Overlap with PSORIASIS, lack of efficacy of antifungals
Combined PATHWAY of Scaly Dermatosis
Malassezia Fungus influences Dandruff & SD,
not thought to be a factor in Psoriasis
-
Inflammation
- varies between diseases
-
Proliferation + Differentiation
-
also varies between diseases, tied with inflammation:
- normal = 25-30 days >> dandruff = 13-15 days
- >> SD = 9-10 days >> psoriasis = 4 days
- normal = 25-30 days >> dandruff = 13-15 days
-
also varies between diseases, tied with inflammation:
- Barrier Disruption
S/S of Dandruff
Fine / White Flakes
SCALP involvement
Diffuse distribution
Can have Pruritus
Usually NO Erythema
S/Sx of Seborrheic Dermatitis
Yellow + Greasy scales, can be scalp involved
+ facial & other areas w/ HIGH amounts of sebaceous glands
Pruritus
Presence of Erythema
Seen in adolescents + adults
MORE COMMON in immune compromised + Parkinsons
Well demarcated lesions
LOOKALIKE Diseases
Atopic Dermatitis
Allergic/Irritant Dermatitis
Rosacea
Cutaneous Fungal Infection
S/Sx of Psoriasis
SHARPLY Demarcated
SILVERY-WHITE scales
Commonly found on :
scalp / Elbows / Knees / Back
What Treatment Mechanism do these medications ACT ON?
Pyrithione Zinc / Ciclopirox
Keto/sertaconazole / Selenium Sulfide
Tea Tree Oil
DIRECTLY on the MALASSEZIA FUNGUS
What Treatment Mechanism do these medications ACT ON?
Corticosteroids
Calcineurin Inhibitors
Tea Tree Oils
INFLAMMATION
What Treatment Mechanism do these medications ACT ON?
Coal Tar
Selenium Sulfide
Pyrithione Zinc
CYTOSTATIC:
Proliferation + Differentiation
What Treatment Mechanism do these medications ACT ON?
Salicylic Acid
Keratolytic –> Proliferation & Differentiation
What ST-Medications are FIRST LINE for
DANDRUFF?
- *Selenium Sulfide**
- hair discoloration + oily scalp*
Pyrithione Zinc
Ketoconzole 1%
skin irritation / contact dermatitis
What ST-Medications are Second LINE for
DANDRUFF?
- *Coal Tar**
- hair discoloration / staining / PHOTOsensitivity / folliculitis*
Salicylic Acid
- Natural = Tea Tree Oil*
- allergic rxns*
Treatment Mechanism / MoA / Uses (1st/2nd line?) / AE’s
of (serta)KETOCONAZOLE
Act Directly on Malassezia
Interferes with Membrane Synthesis
ST: 1st line for Dandruff & SD
RX: 1st line for SD
2% Keto Shampoo / Cream / Foam / Gel, BID F8W
photosensitivity
2% Sertaconozole Cream, BID F4W
Treatment Mechanism / MoA / Uses (1st/2nd line?) / AE’s
of CICLOPIROX?
Act DIRECTLY on the Malassezia Fungus
Disrupt Metabolism
RX Only: 1st Line
1% Shampoo = QD -> Twice a Week
0.77% Gel / Cream = BID for 4 weeks
Treatment Mechanism / MoA / Uses (1st/2nd line?) / AE’s
of PYRITHIONE ZINC?
Act DIRECTLY on the Malassezia Fungus + Cytostatic-Prolif/Differentiation
INCREASED Copper + Disrupt Metabolism
ST: 1st Line for Dandruff + SD
found in head & shoulders
Treatment Mechanism / MoA / Uses (1st/2nd line?) / AE’s
for SELENIUM SULFIDE?
Act on BOTH the Malessezia Fungus + Cytostatic -Prolif+Differentiation
Promote Shedding of the stratum corneum + Anti-Fungal properties
ST: 1st line for Dandruff
1st line Self Treatment for SD
Anti-Malassezia Shampoos
can be used in facial areas as well
Phyrithione Zinc
Selenium Sulfide
Ketoconazole 1%
Self treatment for SD
if patient has ERYTHEMA / yellow or oily lesions
HYDROCORTISONE
Erythema after use of MEDICATED shampoos
along with the medicated shampoos
Self Treatment for Infants/Cradle Cap (Mild cases) for
Seborrheid Dermatitis
Massage w/ BABY OIL
Non-residue / Non-medicated Baby Shampoo, to REMOVE Scales
No medicated shampoos approved for Children
<2 years old
Application + Frequency of use for
MEDICATED SHAMPOOS
Ex. Pyrithione Zinc + Selenium Sulfide + Ketoconazole
- *Scalp = Adequate Contact**
- Before using medicated shampoo,*
- *Use Non-medicated/nonresidue shampoo FIRST**
Massage into scalp and leave it on for 3-5 minutes
2-3x/week for 2-3 Weeks –> 1x/week to control
Ketoconozole = Twice a Week F4W, w/ at least 3 days between each treatment
1st like PRESCRIPTION treatment for
Seborrheic Dermititis
ANTIFUNGALS
burning / contact dermatitis
Ciclopirox 1%
- *Ketoconazole 2%**
- photosensitivity*
Sertaconazole 2%
Second Line PRESCRIPTION treatment for
Seborrheic Dermatitis
- *Corticosteroids**
- hypopigmentation / skin atrophy / telangiectasia*
- *Calcineurin Inhibitors**
- *Pimecrolimus 1% ,** BID HA + URI
- *Tacrolimus 0.1%,** BID pruritus + flu like symptoms
- burning*
EX-ST for Dandruff + SD + Psoriasis
<2 y/o
Worsening or NO improvement within 2 weeks of treatment
EX-ST for PSORIASIS
<2 y/o** + no improvement/worse within **2wks of treatment
>5%** **BSA
Lesions >Quarter in size
FACIAL Lesions / JOINT Pain
Chart for Treating Scaly Dermatosis
Risk / Triggers for PSORIASIS
Genetics
Infections: Strep Throat = Guttate psoriasis
Skin Trauma
Smoking / Alcohol
Obesity / Hormonal Changes / Emotional STRESS
Medications
Beta Blockers (-olol) + Lithium + Anti-Malarials + Steroid Withdrawal
+ NSAIDS + Tetracyclines + Ace-I
Types of Psoriasis:
Chronic Plaque Psoriasis
most common, erythema + raised + sharply defined
silvery scales + asymptomantic, some prurtus
Pustular Psoriasis
Erythema + scaling + pustules
accompanied by systemic complications –> life threatening
Psoriatic Arthritis, SYSTEMIC involved
Other less common types:
Erythrodermic / Inverse / Nail
Medications Associated W/ PSORIASIS
- *Beta Blockers**
- olol
Lithium
Anti-Malarials
Chloroquine + ydroxychloroquine -> exacerbate psoriasis
Steroid Withdrawal
Nsaids / Tetracyclines / Ace Inhibitors
Pathophysiology of PSORIASIS
Abnormal Immune Mediation
- Trigger = Trauma / Infection / Stress / ??
- Stressed Keratinocytes
- INFLAMMATION
- Keratinocyte:
- Division + Plaque Formation
- Activation -> Cytokine Production
Non-RX, Self-Treatment for PSORIASIS
Appropriate for MILD Psoriasis
<5% BSA, lesions <quarter></quarter>
<p>Remove scales w/ <strong>soft cloth</strong> after bathing</p>
<p>Use of <strong>EMOLLIENTS</strong> after bathing up to <strong>QID</strong></p>
<p><strong><u>Hydrocortisone ointment</u></strong>, BID</p>
<p> </p>
<p><u><strong>SEE DR AFTER 2 WEEKS of no improvement or worsening</strong></u></p>
</quarter>
Topical Prescription Treatment for
PSORIASIS
For MILD - MODERATE Psoriasis
Corticosteroids
Vitamin D Analogs
Calcipotriene / Calcitriol - BID
Calcineurin Inhibitor
Tacrolimus / Pimecrolimus - BID, okay for FACE + Intertriginous
Vitamin A Derivative
Tazarotene = QD
Treatment for Mild-Moderate PSORIASIS
1st: Topical Corticosteroids
ALT: Topical Vitamin D Analogs + Topical Retinoids
Face or Intertriginous = Calcineurin Inhibitors
Can use corticosteroids + Vitamin D analogs in COMBO or Intermittently
Treatment for SEVERE PSORIASIS
>5-10% BSA
PHOTOTHERAPY
Narrow Band UVB > UVB, both TID
Photochemotherapy (PUVA) - TID
Excimer Laser - Twice a week
SYSTEMIC TREATMENTS
Systemic Retinoid = Acitretin
Immune Supression/modulatory = Methotrexate + cyclosporine
Systemic Treatment for PSORIASIS
Systemic Retinoid
Acitretin
effect epidermal proliferation + immunomodulation
Immune Suppresion / Immunomodulatory
Methotrexate / Cyclosporine / Apremilast / Biologics
UV Treatment for PSORIASIS
MOA = Anti-Proliferative + Anti Inflammatory
erythema / blistering / HYPERpigmentation / photodamage / malignancy
Narrow Band UVB > UVB
both TID, Narrow band is more effective, effects T-cells
Photochemotherapy = PUVA
BID, combo oral / topical, deeper
Excimer Laser
2x/week, UVB at targeted area
Treatment Mechanism / Uses (1st/2nd line?) / AE’s
of CORTICOSTEROIDS
Act on Inflammation
ST for SD: Used AFTER shampoos if ERYTHEMA
- *1st line for Mild to Moderate Psoriasis**
- skin atrophy / hypo pigmentation / acne / bruising*
Treatment Mechanism / MoA / Uses (1st/2nd line?) / AE’s
for CALCINEURIN INHIBITORS?
Act on INFLAMMATION
- *Topical RX treatment for Mild/Moderate PSORIASIS**
- *FACIAL or Intertriginous**
BID, Tacrolimus / Pimecrolimus
Mechanism of Action of Topical Psoriasis Treatments:
Vitamin D Analogs / Vitamin A Derivatives / Coal Tar
ACT ON CYTOKINE PRODUCTION
Keratinocyte Activation