Click here to view next page of this article
Acne. Basically the therapy of acne is one in which we really don’t know the exact cause of the disease but we know that factors play a role. We know that there is an abnormal keratinization leading to plugging of the ducts and the comedo formation, or the comedo formation, and then the rupture of the comedo which produces a chronic granuloma.
Rosacea is the acne of an adult, that came on in their 30’s. When they are in their 30’s to 40’s. They’ve got the erythema of the face. They get the pustules that are present and they get the hypertrophy on the nose.
They also will do good on lower doses of tetracycline and broad spectrum erythromycin. In severe cases, you might put them on Accutane. Again, the use of Accutane throws them into remission as it does in acne, and how long they remain in remission is just an intelligent guess. They on for six months, standard dosage, and they will get better. They will have a silent time where they get just very few pimples or just an occasional, and then suddenly erupt after one year or sometimes it may take them several years, ten years.
Dandruff of course, or seborrhea and its extension onto the face, seborrheic dermatitis, is extremely common. It is so common we are inundated every day with dandruff shampoos by the square metric ton on television. You can have either the dry type in which you see dry scales, or the greasy type. That just means that you happen to produce more oil than the next guy, or the next person. But the scalp is the common site. The ears, the other sites, the bearded areas. The eyebrows in older people, as me, the nasal fold, sometimes the axilla and of course always the sternum.
Impetigo. A very simple form here which never forms scarring by staph or strep. Again, the topical antibiotic - especially now with the new Bactroban or mupirocin - but I like to use systemic antibiotics and one also has to think if staph is involved that one might have a penicillin resistant, or erythromycin resistant form of even staph involvement in this kind of a patient. But that’s a classic. It looks like ringworm but it isn’t.
Erysipelas is a very serious disorder which needs systemic antibiotics immediately. Then of course you get large furuncles like this and this, and one has to be very careful of the surrounding structures that are inside next to these furuncles. The use of systemic antibiotics is absolutely mandatory.
Herpes simplex, of course, fever blisters you see here. Classic. This is the recurrent. All of us have had herpes simplex but the time we are - most of us, a good percentage of us - have had it by the time we are two or three years old. Grandmother gave us a kiss one day when she has a big herpes on her face, which for her are recurrent. And then there are those lucky people among us who get recurrent herpes simplex, and from various forms.
Zoster is chickenpox virus and somehow the virus, after you get it, goes and isolates itself someplace in the body and then you get zoster when you get older, or later, with a flare that follows the dermatome distribution. When I once went to study for a year in Denmark to work in the anatomy.
Wart viruses and warts, verruca vulgaris. The classic periungual wart and of course this is the verruca plana on the leg. You don’t want the patient shaving the legs and spreading the virus. That’s important. The filiform virus, the filiform wart, as you see here, showing this sticking out.
Molluscum contagiosum, and here this is a very different virus, which is very infectious and seems to especially hit the truncal areas. I use topical preparations like Retin-A lotion, benzyl peroxide to irritate them. And in extensive times I sometimes … and topical salicylic acid … but sometimes you have to curette these out and that can be very painful to the patient. Some people use carbon dioxide lasers. If I had an extensive lesion, a patient with many of these, I would probably send them to a dermatologist and let him earn the patient’s eternal hatred for ripping them off. But there’s no really good therapy to wipe them out. Acyclovir has been used in some of these, but again the results are not that clear with this disorder.
Fungus infections. Here again you have inflammatory versus non-inflammatory. People who get fungus infections, tinea pedis as you see here, these individuals have a propensity - anybody who gets a fungus - has a propensity of getting a fungus infection and you will cure them of their disorder with the various preparations that are now available and they’ll get it back in the future.
Tinea versicolor. Here is the so-called Malassezia furfur, or Pityrosporum ovale and this is a bacterial, fungus-like organism that has two phases. Here you see the summertime involvement where the normal skin is pigmented and the area involved with the "spaghetti and meatballs" under the scaling under the microscope is this whitish area. Again, I use Nizoral cream topically - or even orally - and once I get them better I’ll put them on topical Nizoral shampoo once a week to suppress it, or even selenium sulfide shampoo once a week.
Psoriasis and here this is involved now, we think, with the helper T-cells and there is an immunologic process going on here that allows this to take place. These individuals also, there is a hereditary trait. You’ll see this in various forms, from extensive to minimal involvement, especially the knees
Tazarotene can be used, third generation retinoids topically, topical vitamin D-3 can be used. These are extremely expensive drugs. PUVA of course is psoralens plus UVA and that’s usually done by a dermatologist using a large light box. But it is a useful way of turning off DNA metabolism and shutting down the rapid cycle. Remember that these people exfoliate their hides on their sites. These people exfoliate their sites in approximately five days, where your normal turnover time is one month.
Contact dermatitis and here is the classic contact dermatitis, or the primary irritant type. That’s called a thermal burn. It’s a cytotoxic agent. Here is another cytotoxic agent: this is exposure the anhydrous ammonia. This is another cytotoxic agent. It’s called a sunburn. That is a form of contact dermatitis. Here’s the same thing and the patient getting it from an arc-welding. He wore a thin shirt one day while arc-welding, in the summer, and
Primary irritant dermatitis. Diaper rash. Usually complicated with moniliasis and so you have to use a topical preparation like Nystatin and even a little hydrocortisone, and of course changing the diapers often and now allowing them to bake in a plastic wrap. Of course this is now seen in people my age who are in nursing homes, who have got strokes and etc. The same problem is taking place. The skin does not tolerate urine and feces for a
Alopecia areata. The cause of alopecia areata is not known but it tends to run in families. Some people can check these with steroids. Again, this can cause atrophy but I use the potent steroid, but they all grow back. Here of course is what happens with male pattern baldness and the female
Atopic eczema. Lichenification and excoriated lesions scattered here and there. You see it here very extensively, showing the lichenification, the extenuated skin marking and excoriation. Topical steroids have been a real boon to these individuals. You see it here again with thick, localized plaques. Again, topical steroids are very useful. Tars are very useful in these kinds of patients also. One has to treat these patients with sometimes
Chloasma. There is no treatment that is good. The bleaching agent is somewhat helpful. The big thing is to prevent them from going out in the sun by using sunscreens that prevent hyperpigmentation. Vitiligo, not much we can do for vitiligo. So-called PUVA therapy has been useful but not that useful. Here’s a man who came in because he had a sore here from a basal cell, he had a previous basal cell here. He recognized this but he also had
Scabies presents with intense pruritus, scaling between the fingers in a child, involvement of the penis and you know very well what that means. Here’s a close-up. The child has scabies. This will happen to all of you if you have kids. My kids brought it home, along with pediculosis capitis, to
Pyogenic granuloma, which of course is an absolute oxymoron. It is neither pyogenic or granuloma. It is a blood vessel tumor. Simply cutting it off at the base with light cauterization will clear it and the patient will be much better. Here is moles. This is on the sole, and this is supposedly a mole, a
Melanoma. This is the nevus and this is the new elevated lesion that’s only two months duration, which has to be excised. Here of course is the seborrheic keratosis, the big, brown postage stamps on the back that we have on many older individuals. And why we get them, I haven’t the
Stasis dermatitis of the lower leg requires long term therapy. Topical antibiotics, get sometimes sensitization, nutrition is usually a problem. Topical steroids are useful. Protection is absolutely imperative in these kinds of individuals. Luckily we don’t see too many of these.
Hives. What do you do for hives? Most of us have had hives once or twice in our lifetime. I’ve had at least three or four episodes. Never did find out why I had hives at all. Using antihistamine each time to clear me up. Non-sedating agents work quite nicely. Atarax is a good old standby. However, if hives goes on more than two months, one has to think very seriously about the chronic hives syndrome and that’s the kind of patient one