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While local measures are important, severe or widespread involvement is difficult to manage without systemic corticosteroids because even the highest-potency topical corticosteroids seem not to work well on vesicular and weepy lesions Localized involvement (except on the face) can often be managed solely with topical agents Irritant contact dermatitis is treated by protection from the irritant and use of topical corticosteroids as for atopic dermatitis (described above) The treatment of allergic contact dermatitis is detailed below
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PUSTULAR DISORDERS ACNE VULGARIS
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Occurs at puberty, though onset may be delayed into the third or fourth decade Open and closed comedones are the hallmark of acne vulgaris (Plate 15) The most common of all skin conditions Severity varies from purely comedonal to papular or pustular inflammatory acne to cysts or nodules Face and upper trunk may be affected Scarring may be a sequela of the disease or picking and manipulating by the patient
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1 Acute weeping dermatitis Compresses are most often used It is unwise to scrub lesions with soap and water Calamine lotion may be used between wet dressings, especially for involvement of intertriginous areas or when oozing is not marked Lesions on the extremities may be bandaged with wet dressings for 30 60 minutes several times a day High potency topical corticosteroids in gel or cream form (eg, fluocinonide, clobetasol, or halobetasol) may help suppress acute contact dermatitis and relieve itching This treatment should be followed by tapering of the number of applications per day or use of a mid-potency corticosteroid such as triamcinolone 01% cream to prevent rebound of the dermatitis A soothing formulation is 2 oz of 01% triamcinolone acetonide cream in 75 oz Sarna lotion (05% camphor, 05% menthol, 05% phenol) mixed by the patient 2 Subacute dermatitis (subsiding) Mid-potency (triamcinolone 01%) to high-potency corticosteroids (amcinonide, fluocinonide, desoximetasone) are the mainstays of therapy 3 Chronic dermatitis (dry and lichenified) Highpotency to superpotency corticosteroids are used in ointment form
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Acne vulgaris is polymorphic Open and closed comedones, papules, pustules, and cysts are found The disease is activated by androgens in those who are genetically predisposed Acne vulgaris is more common and more severe in males It does not always clear spontaneously when maturity is reached Twelve percent of women and 3% of men over age 25 have acne vulgaris This rate does not decrease until after age 44 The skin lesions parallel sebaceous activity Pathogenic events include plugging of the infundibulum of the follicles, retention of sebum, overgrowth of the acne bacillus (Propionibacterium acnes) with resultant release of and irritation by accumulated fatty acids, and foreign body reaction to extrafollicular sebum The mechanism of antibiotics in controlling acne is not clearly understood, but they may work because of their antibacterial or anti-inflammatory properties When a resistant case of acne is encountered in a woman, hyperandrogenism may be suspected This may or may not be accompanied by hirsutism, irregular menses, or other signs of virilism
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C Systemic Therapy
For acute severe cases, prednisone may be given orally for 12 21 days Prednisone, 60 mg for 4 7 days, 40 mg for 4 7 days, and 20 mg for 4 7 days without a further taper is one useful regimen Another is to dispense seventy-eight 5mg pills to be taken 12 the first day, 11 the second day, and so on The key is to use enough corticosteroid (and as early
Dermatologic Disorders
CMDT 2008
Clinical Findings
There may be mild soreness, pain, or itching The lesions occur mainly over the face, neck, upper chest, back, and shoulders Comedones are the hallmark of acne vulgaris Closed comedones are tiny, flesh-colored, noninflamed bumps that give the skin a rough texture or appearance Open comedones typically are a bit larger and have black material in them Inflammatory papules, pustules, ectatic pores, acne cysts, and scarring are also seen Acne may have different presentations at different ages Preteens often present with comedones as their first lesions Inflammatory lesions in young teenagers are often found in the middle of the face, extending outward as the patient becomes older Women in their third and fourth decades (often with no prior history of acne) commonly present with papular lesions on the chin and around the mouth
topical exposure to oils, cocoa butter (theobroma oil), and greases 2 Diet Foods do not cause or exacerbate acne
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