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1

What is Epidermis and what type of cells does it condain?

EXTERNAL layer composed of
layers of KERATINOCYTES

but also containing MELANOCYTE + other cells
(produce melanin)

2

What is the DERMIS and what does it contain?

Area of supportive connective tissue
underneath the epidermis

contains:

Sweat Glands / Hair Roots / Nerve Cells

3

Melanocyte

Cell found in the Epidermis

that produces MELANIN

eumelanin / pheomelanin = biopolymer agent

4

Melanosome vs Melanophage

MelanoSOME = VESICLE that transports melanin

 

MelanoPHAGE = melanin phagocytized by dermal macrophages

5

Hyperpigmentation Pathophysiology

INCREASE in synthesis or desposition of MELANIN 

 

EPIdermal --> Increased Melanin production

Dermal -> does NOT usually have melanin
Transfer / accumalation within melanophages
production by ectopic melanocytes
exogenous pigments

6

Associated Disorders of HYPERpigmentation

Solar Lentigines
age spots, tan-dark-brown macules on sun exposed areas

Maturational Hyperpigmentation
dyschromia, darkening on lateral aspects of face due to sun

Post-inflammatory HYPERpigmentation
darkening of skin after injury / inflammation

Melasma
facial HYPERpigmentation on sun-exposed areas often associatioed w/ hormonal changes

7

Medications that cause HYPERpigmentation

Amiodarone / Anticonvulsants 
 Antimalarial Agents / Antineoplastic agents

HRT / Oral Contraceptives

Heavy Metals

Minocycline / Phenothiazines / TCA's

Zidovudine

8

Tyrosinase Inhibitors

MoA / Treatments

for HYPERpigmentation

Act on Melanocytes @ cytoplasm
Tyrosinase is the enzyme that oxidates this reaction
Tyrosine -/-> DOPA -/-> Dopaquinone -> MELANIN

Treatments:
Hydroquinone / Mequinol

Azelaic/Kojic/Glycolic ACID

Alpha-Arbutin / Licorice Extract

9

Copper Interaction

MoA / Treatments for HYPERpigmentation

In Melanocyte @ cyto, copper interacts
Tyrosine --> DOPA --> Dopaquinone -> MELANIN

 

KOJIC ACID

10

Reduction in Melanosome Transfer

MoA / Treatment for HYPERpigmentation

IN Keratinocyte & melanocyte interface:
Melanosome --/--> Protease activated receptor-2

 

RETINOIDS

NIACINAMIDE

11

INCREASED Keratinocyte TURNOVER

MoA / Treatment for HYPERpigmentation

more keratinocytes turnover / new skin

 

Retinoids

GLYCOLIC Acid

12

RX-treatment for HYPERpigmentation

Retinoids
Tretinoin / Tazarotene

Hydroquinone 3% or 4%

Azelaic Acid 20%

Mequinol/tretinoin = Solage

Fluocinolone/hydroquinone/tretinoin = Tri-Luma

13

Non-Rx Treatment for HYPERpigmentation

SUNSCREEN

Hydroquinone 1.5 / 2%

Azelaid Acid 10%

Glycolic / Kojic Acid

Niacinamide

Botanical combinations = Meladerm

14

Basic treatment ideas for HYPERpigmentation

DAILY SUNSCREEN USE is CRUICIAL

more DIFFICULT to treat DERMAL H-P

Better to use multiple medications for melasma/PIH
beware of use of LASERS --> PIH

some OTC cosmeceuticals contain MERCURY

15

ADR's of HYPERpigmentation Treatments

Generally:
skin Irritation / HYPERsensitivity / SUN sensitivity

BOTH HYPER/hypoPigmentation

 

Hydroquinone: OCHRONOSIS
yellow -> blue/black discoloring

Retinoids: Inflammatory response

16

EX-ST

for HYPERpigmentation

Treatment + Sunscreen with NO improvement in 3 MONTHS

<12 years old

HYPERpigmentation of large BSA

Disease / Drug -induced

Lesions CHANGING 
in size/shape/color

17

Suggested treatment for HYPERpigmentation

As long as NO EX-ST
 >12 yo / large BSA / lesions changing / disease-drug-induced

HYDROQUINONE 2% +/- AHA (acid product)
with SUNSCREEN

after 3 months
improvement
-> continue sunscreenQD/BID treatment prn

no improvement --> SEE MD

 

18

Pathophysiology of WARTS

Caused by HPV = human papilloma virus
various strains are common

Various warts caused by different strains
HPV-1 = plantar

HPV stays on the epidermal layer
proliferation -> WART in about 4-Weeks after infaction

19

Types of cutaneous WARTs that can be SELF TREATED

Common = Hands
often in children/adolescents, skin colored / DOME/ rough surface

Plantar / Mosaic = FEET
adolescents & Young Adults 

 

20

Types of Cutaneous WARTS that we can NOT treat

SEE MD

Flat / Filiform on FACE

Periungual on NAILS

21

Basic Treatment ideas for WARTS

Non-treatment
Most can resolve on OWN (70% in 2years)
less likely if ADULT or IMMUNE compromised

SELF TREATMENT
1) Salicylic Acid = chemical destruction/keratolytic
2) Cryotherapy = physical destruction
Complementary = DUCT TAPE

Micellaneous
Prevention of transmission = important
SEEMD for Physical removal

22

Efficacy & Duration
Salicylic Acid

for WARTS

with NO treatment = 70% resolve, 46% will remain wart free

TAKES WEEKS
Greater efficacy for HANDS > feet

 

Equally effective vs Cryotherapy

23

Efficacy & Duration
CRYOTHERAPY

for WARTS

with NO treatment = 70% resolve, 46% will remain wart free

wart removal after 10 DAYS
single use that will produce a BLISTER --> can be repeated

 

Equally effective vs Salicylic Acid

maybe more effective on hands?

24

Salicylic Acid

ADR

 

used for WARTS, generally well tolerated

Skin irritation

see MD if > 12 weeks

AVOID use in patients with
 PERIPHERAL NEUROPATHY

25

Cryotherapy

ADR

treatment for WARTS, generally well tolerated

Erythema / Blistering / Pain-Tendernes

SEE MD after >3 treatments

Applicator can NOT be used MORE THAN ONCE
to avoid spreading the virus

26

EX-ST for treating WARTS

Ensure that it is actually a wart
not CORNS / CALLUSES / Malignant growth, these show PAIN

<4 years old
Pregnancy / Breast Feeding
>12 weeks SA treatment or >3 Cryotherapy Treatments

Debilitating conditions that affect sensitivity / circulation (blood)

LARGE or MULTIPLE warts
or located on face / breast / armpits / nails / anus / genitalia

Immunosuppressive medications

27

Salicylic Acid 40%

Type of Dosage form / Dosage & Direction 

Treatment of WARTS

Plasters / Pad / Strip
typically used for the FEET

Apply Remove after 48 HOURS
repeat PRN

for 12 weeks
if no improvement --> SEE MD

28

Salicylic Acid 17%

Type of Dosage form / Dosage & Direction 

Treatment of WARTS

Liquid / Gel

in a collodion vehicle

apply QD / BID

for up to 12 weeks
if no improvement --> SEE MD

29

Salicylic Acid 15%

Type of Dosage form / Dosage & Direction 

Treatment of WARTS

PATCH
(Trans-Ver-Sal), in a Kg-g vehicle

Apply for 8 hours, repeat QD

for up to 12 weeks,
if no improvement --> SEE MD

 

30

Cryotherapy

Type of Dosage form / Dosage & Direction 

Treatment of WARTS

Freeze Away / Freeze Off

 

repeat after 10 DAYS PRN

for up to <3 Treatments,
if no improval --> SEE MD