Tracey Vlahovic, DPM reviews multiple unusual dermatology cases and cases that are difficult to treat. Dr Vlahovic encourages you to think outside the box when developing a treatment plan for your difficult to treat patients.
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Tracey Vlahovic, DPM
Associate Professor of Podiatric Medicine and Orthopedics
Temple University School of Podiatric Medicine
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Female Speaker: Dr. Shainhouse [Phonetic], good morning everyone. Today, I’m going to talk about a lot of the different cases that I see, and I see really interesting variety on a daily basis. But also, different things that you may not have thought of that can treat these various lesions, because I usually am the third or fourth doctor that these patients have seen for these various dermatological conditions. Sometimes, it’s good just to think outside of the box, and that’s something that my dermatology training has certainly showed me. Just so you know, I have served on advisory boards for various pharma companies. Today, we’re going to talk about some nonsteroidal treatment. I know as podiatric physicians, we’re often a little bit hesitant to write for a topical steroid, so we’re going to talk about some nonsteroidal options that you’ll feel more comfortable with prescribing. Talk about some nail issues and my favorite ulcer, pyoderma gangrenosum, which I know sounds a little strange but I do love treating that. Well, first case is a 75-year-old woman who came to me from another podiatrist who said “Fixed her, okay.” What I see when I walked into the room was an acute eczematous reaction, weepy, it was draining, if you can see on the catch-all sheet, itchy, irritated. She was miserable. Now, how did this start? She had used Bactroban on a lesion. You might say, “Bactroban, what’s wrong with Bactroban?” Well, in Bactroban proper, there is a preservative within that vehicle called polyethylene glycol. A lot of patients out there around the country, world, are allergic to this preservative and it’s found in everything, toothpaste, shampoo, you name it. It happens to be within Bactroban itself. She gave me a list when she walked in saying, “You will not give me an oral steroid, an oral antibiotic. You will not give me a topical steroid. You will not give me anything that I would normally want to throw at her, because of this allergy.” So number one, first thing I see is, okay, this is a contact dermatitis. This is an allergic contact dermatitis to the preservative that’s seen within Bactroban. How do we know that? Number one, she has a list of things that she’s allergic to, so I was able to put the pieces together. Number two, contact dermatitis, the allergic kind, typically what you’re seeing is a reaction spread beyond the point of contact. The patient may apply it to one area but it will spread beyond the point of contact, and that is a hallmark of allergic contact dermatitis. Now, you might say, “Well, it’s not bilateral or symmetrical.” It does not have to be to be allergic contact dermatitis on the lower extremity. How did I treat her? Well, she didn’t really leave me a lot of choices. I actually had to go dig into my toolbox and I’ve been trained obviously, western medicine, but I also have an interest in natural medicine and homeopathy. That is actually how I treated this particular patient. Now, how I would have normally approached her was always discontinue the medication, the offending medication that’s caused the allergy. The first thing is stop using Bactroban. The second thing is normally I would throw either a topical steroid or an oral steroid, depending on the severity of the reaction. With her, I would have loved to throw a topical steroid. She would not allow me that. What I did was I recommended an oral homeopathic remedy called cutis compositum. It’s made by a company called Heel. They make Traumeel and Zeel, which are products that some are familiar with the podiatry. They’re anti-inflammatories. I do not work for them but that’s just, again, what I was using for her. As you can see, it took a little bit longer than if I would’ve used topical steroid. But over two months, she had a nice reaction and she was a very happy patient. Again, sometimes patients just limit what I want to do and I want to comply with that, in this case, because I want to get her better. I don’t want to fight with her. I just want to get her better. As I said, typically for inflammatory conditions, the first line is a topical corticosteroid. Now, the thing is I’m very strict about how I prescribe topical steroids. Number one, class I, which are listed at the bottom, clobetasol, betamethasone, diflorasone, halobetasol, fluocinonide, those are my class I superpotents. Patients should only be using those consistently for two weeks. That means, I will prescribe them. You will use them for two weeks. Hopefully, your copay and your life will allow you to come back in two weeks and then I can titrate you down. What I’ll do is I won’t give them a refill. Make sure I prescribe enough of a size of gram 2 that they can use it for two weeks, twice daily. Then when they come back, I’ll say, “Alright, you’re going to use that class I, Monday, Wednesday, Friday and on the alternate other days, you’re going to use a lower class like a triamcinolone or Kenalog until we get you down to where you aren’t inflamed anymore.”
The other hallmark in dermatology right now besides giving a topical steroid prescription is to give you an epidermal barrier function cream. Now, those can be prescription. They’re considered devices, so they might be on the more expensive side. If you do choose to go that route, you do want to look on the website of that pharma company and get coupons. It makes it so much easier for your patient to afford, and I’ll talk about some of them. Or, you can use an over-the-counter, like a CeraVe or a Curel, something like that. But the goal in these inflammatory skin conditions is to use little or no topical steroid ultimately and try to control them with an epidermal barrier function cream, like I said, over-the-counter CeraVe prescription. I would use Neosalus until basically they have a flare. Hopefully, you really calm down the flare process by using that epidermal barrier function cream. What that epidermal barrier function cream does is it reduces transepidermal water loss. The more that you can keep the skin naturally hydrated, the less issues you should have over a long-term, so that’s the thought process. This particular patient came in, lovely lady, said to me, “Help me.” The first thing I thought was, “Okay, this could be a lot of different things. This could be an eczematous reaction. This could be some sort of eczema. This could be psoriasis.” You might say, “Well, that looks like venous stasis dermatitis because it’s on the medial aspect of the foot.” Well, I don’t hold myself to that at all. The first thing is I asked her, “What have you used?” Of course, various doctors have given her antifungals, have given her topical steroids. To me, she’s not responding to a topical steroid. Before I put more of a financial burden on this patient by prescribing an expensive topical, I’m going to do a biopsy. What I did with this particular patient is I did a punch biopsy. I said, “Look, you know, just hold on. By the time you come back and we have the biopsy results, then I’ll give you prescription because I really don’t want to, you know, again, financially burden you.” It came back with psoriasis. Now, you might say, “How”, right? “Psoriasis is that red plaque on a silvery scale.” Well, keep in mind here, she’s had various topicals that are skewing the natural sort of process of psoriasis. She’s excoriated it, so we’re not seeing it in its natural state. So, sometimes again, you have to really think outside the box. The last think I was going to do with this patient is give her another topical steroid. There’s a product on the market that’s actually been on the market for probably seven years. It was basically sold to the dermatology folks and I’ve been using it for seven years because I have a lot of relationships in the derm industry, so I knew about it. How they’ve used it in the derm industry is used it for patients who had laser procedures on their face and had their face burned off with the laser for various rejuvenation procedures. If it’s good enough for the face, it’s good enough for the foot. I gave her a nonsteroidal anti-inflammatory that’s called Bionect. As you can see, her flare went down. Her skin is coming back. I see this patient on a regular basis to this day and you can’t even tell that this was even there. The pigmentation is reduced. Bionect, what that is, it’s a hyaluronic acid. Now, you all know you’re all familiar with hyaluronic acid. Number one, you’re familiar with it getting injected into knees, but it’s also naturally found into your tissue. Hyaluronic acid basically recruits fiberglass through surge in cell. It also absorbs thousand times its water weight, so it’s extremely good to use for the skin. Now, the problem is that there’s different types of hyaluronic acid and you want something that’s actually going to work in your tissues, for skin. Its low molecular weight, which means it can actually penetrate the epidermis. It comes as a spray gel or cream. Now, the spray is really great for our obese patients who maybe can’t bend over because you just can spray it and you don’t have to rub it in. It’s anti-inflammatory. I have used it for both wounds and periwound for my inflamed periwound. This is the same patient on the opposite foot. You can see, just using the Bionect for two weeks gave me the same response that I would get if I would have given her a topical steroid. Again, for my patients who are not responding to topical steroids, this to me is a very good option. Now, again, with this product, depending on the patient’s insurance, I will get a coupon for them, either one that I’ve given or gotten from the rep or that I have downloaded from the internet to make it affordable. But again, this is something that I use extensively in my practice now because I just see too many patients who’ve been seen for so long using the same topical steroid and they’ve hit that threshold where it just doesn’t seem to do anything for them anymore.
Just a little bit more on hyaluronic acid or Bionect, so patients who use it, they showed in the clinical trial that it’s a uniform morphology of the papillary and upper reticular dermis. Basically, what you’re seeing -- let me see if I can -- right here. This is untreated and this is treated. We want to have that uniformity. We don’t want to have everything just to flat and not really healthy. Now, the other product that you could use that’s over-the-counter because Bionect is prescription is something called TriCalm. I was introduced to this at the American Academy of Dermatology Meeting. We’re all excited for it to come out, and then all of a sudden, it came out a year later but it’s over-the-counter. Typically you can find it at CBS but you can also purchase it online. This has been shown that it is useful for patients over the age of two years with minor irritation. It’s an as needed application, and that’s the beauty about these nonsteroidal topicals is that you can use them four to six times a day. They’re not going to cause the side effects that we would have if we use a topical steroid in that manner. After using a topical steroid especially a class I after two weeks, you already get epidermal thinning, so you’re not going to have that with these nonsteroidal topicals. Has this been shown specifically for use in psoriasis and eczema? No, but certainly we can extrapolate it and use it for that. Can it be used with other products? As certainly, again, there’s no clinical trials that have shown that, but certainly it could be. This is another one of my patients. She have wounds and I’m not showing you both legs, but they were extensive on both legs for 20 years. She’d had all manners of various different treatments, hyperbaric oxygen, you name it. When I looked at these wounds, the first thing I said is, “What have people done? Have they debrided this?” She said, “Yes.” I said, “First thing is we’re not going to debride this.” To me, this is a pyoderma gangrenosum. A pyoderma gangrenosum, classically what you’re taught is that it’s associated with rheumatoid arthritis and irritable bowel. Then, it’s a manifestation of something systemic. But to be honest with you, I see a lot of patients who have it idiopathically. The other thing is classically, women develop it more than men. I think I have more men in my practice with this ulcer than women. It’s just one of those things where I don’t see the textbooks. The other thing about pyoderma is that, first of all, it has usually an inflamed periwound border, so it usually has a purple hue. It’s extraordinarily painful. From a dermatology perspective, whenever you have a wound that’s not medial ankle, think pyoderma first. Certainly, that’s another rule of thumb I follow. The other thing is that it may not respond to normal treatment. It typically takes about seven years to diagnose these things. It’s just that something that people are always thinking about, but I really think that we should because I can’t tell you how many patients I’ve had, again, who’ve had these ulcers for multiple years. They come in and like, my gut tells me this is pyoderma. The thing is you can’t biopsy this and get a diagnosis of pyoderma. It’s a diagnosis of exclusion. When I do biopsy these wounds, it’s to make sure that I’m not dealing with squamous cell carcinoma or basal cell. Of course, I’ll biopsy these first before initiating treatment. Anyway, so this is just going through a little bit more. Pyoderma is a misleading name, right? It sounds like we’re having a gangrenous process. Pyoderma means more of a pustular process. Well, what it is, it’s a neutrophilic palisading dermatosis. Now, what that means in real world is that you start out with the collection of neutrophils and the body just can’t shut it down. So, if we were lucky enough to see these patients when they initiated the lesion, it starts out as a pustule and then just evolves into an ulcer. Patients walk and say, “Well, I thought it was a bug bite?” Well, that helps. That gives me a little bit of a clue because never am I going to see this in its initial state. How do we treat PG normally? Well, one of the first things I’ll do depending on what treatments they’ve had previously is I will do an oral prednisone taper. I do not use the Medrol Dosepak for any of my skin conditions because it is too short of a course to have any effect on the skin, so I do prednisone tapers. The dosage of that will depend on the severity of what is presenting. I will use oral doxycycline not as an antibiotic but as an anti-inflammatory if we were to use it for rosacea or acne. Oral cyclosporine, I will use if the patient is confident with their kidneys and I can only use cyclosporine for a year.
Now, cyclosporine is used extensively with patients who have psoriasis to calm down with flare quickly. I will use this, again, as an anti-inflammatory. Infliximab, which you commonly know as Remicade is something that I can use in certain patients who are, again, immunocompetent. If they have irritable bowel or Crohn’s, this would be also a good treatment because you’re treating everything. That’s the only one that’s actually had a clinical trial done with it for pyoderma. And of course, topicals injections, and let me just state this. Putting a topical steroid on an open ulcer, it doesn’t penetrate well. So, you can try that all you want but I’ve never seen it work. One thing that I have done with pyoderma is I have injected the periwound, but I will not go from the periwound into the ulcer. I will go from the ulcer into the periwound. The reason for that is with pyoderma, you can create further ulceration that’s called pathergy. For instance, if a patient hit their leg on a car door or wrapped their leg too tight, they can develop an ulceration in and around that same ulcer. I’m very cautious to think about that and that’s also why I do not debride these ulcers. One of the things that I discovered last year at the American Academy of Dermatology, there were posters. I had a bunch of my students with me and I said, “You got to check this out. There’s a couple of posters on pyoderma,” which of course made me smile, I’m very happy. Again, I’m a strange person who likes to treat pyoderma. The dermatologist who had submitted this poster used Restasis. Now, I’ve seen the commercial for Restasis a million times. I never paid attention to it. I don’t have dry eyes. It’s not really important to me. I thought, “Okay, well what is Restasis?” It’s topical cyclosporine. I thought, “That makes complete sense.” Now, the first thing I did was I looked at the PI on the drug on the internet. Of course, it’s used for the eyes, so there’s no systemic data, alright. So, I am like, okay. Well, if I’m going to use on a patient, I just want to try to follow the rules with oral cyclosporine and make sure that they’re competent kidney wise and just be careful with it because I’ve got no data to help me discern otherwise. What they have shown in that poster was it reduced in pain and size. I thought, “Alright, this is what I’m going to do.” As you can see where it says, first presentation, that’s when the patient first presented to me with pyoderma. In between that and the start of the Restasis, I had used Oasis, the dermal matrix. That had gotten her down very well. You don’t see as much inflammation. You know that this ulcer size has changed. We’re there but she’s still in pain. What I did was as soon as I got home from that conference, I started her on topical Restasis. Now, I had no idea how to prescribe it. What I found out quickly is if you prescribe a month’s worth, that’s one copay. You want to give them at least a month’s worth if you’re going to do this. I had her use it once to twice a day, depending on her inflammation. As you can see, literally within 3 months, how much that ulcer size have gone down, and that’s just using Restasis and a good dressing. The patient is very happy. Again, I see this patient consistently till now and she has had no recurrence of these lesions, and that it’s always something I worry about with pyoderma. She’s doing extremely well. Now, what else could you use? We talked about Restasis. Maybe you don’t want to prescribe that. Well, there’s something that if you work in a wound care center, you’re already familiar with, which is Microcyn. Now, I’ve used Microcyn for years but I just never considered what other properties it had. Microcyn is not only a wound cleanser but it’s also an antimicrobial agent, which they have a lot of beautiful data showing its anti-MRSA. It can be used as a debriding agent, as antihistamine and also as an antipruritic. There’s a lot of interesting things about it. Now, the other thing is that Microcyn, you normally see as a device in a wound care center. They came out with a prescription version of it called Atrapro. They’re the same product. One is a device that you would buy for your center. Atrapro is the prescription version of it that you can write a prescription for your patient. Again, download coupons, it makes it affordable. Just showing that case, this is again not my case. You can see in the bottom, it’s from a Dr. Martinez [Phonetic] who use it as a debriding agent, which I never thought, again, of using at least the hydrogel version of it for. What the dermatologists did, and this was presented at the Caribbean Dermatology, wouldn’t you like to go to that meeting every winter, I know I would, is to use Atrapro gel, which is Microcyn gel and Neosalus. The Neosalus is one of those prescription device epidermal barrier function creams. There’s a cream or foam. What I do in my practice is I have them use Neosalus first. Now, the reason for that is there is Neosalus that shows that it penetrates the epidermis extremely well.
Anything I put on top of Neosalus, it gets pulled through the epidermis even better. I’m taking advantage of the vehicle properties of Neosalus. Having to use Neosalus first and then Atrapro gel and you can see, this is a pediatric derm case. This is the initial presentation. This is two weeks after and then this is four weeks. That was using a nonsteroidal regimen. Again, using this epidermal barrier function along with this nonsteroidal anti-inflammatory, anti-cytotoxic gel or spray worked for these patients. This is a good regimen that I could use and have used for my pediatric patients, especially when their parents are saying, “I really don’t want my child using a topical steroid.” This is a patient who walked in the office, and lovely gentleman who’d never been sick a day in his life, and developed this right after he retired. Isn’t that the way? As soon as you retire, something happens. The only medications he’d been on was aspirin and that was it. In my mind, I look at this and saying, “Okay, I see some sort of vasculitis going on here.” When I pressed on these lesions, this purpura, they didn’t blanch, so I know I’m dealing with purpura. But this is problematic right? We see necrosis and extraordinary pain. The first thing I did was biopsy. I biopsied one of the newest lesions that I could and it came back as leukocytoclastic vasculitis. This is on his lateral aspect of his foot. Of course, I did x-rays and made sure that there was no bony involvement. I admitted him into the hospital because I wanted to start try to curtail this necrotic process as much as possible. This is just showing you, it literally stopped his knee. I mean, it went from his toes to right below his knee. It was nowhere else in his body. No one at the hospital wanted to do it. They said, “Let the podiatrist handle it.” I gave him the million-dollar workup, CBC, ESR, checked in for ANA, complement, you name it, I did it. Then I asked him, “Do you have -- I wanted to rule out all the different causes of vasculitis.” I said, “Have you ever had a colonoscopy?” He’s like, “But Doc, I have blood in my toilet tissue.” I said, “Alright. Well, either it’s hemorrhoids or we’re dealing with colon cancer here that’s manifesting as vasculitis.” He just had hemorrhoids, thankfully. Again, this gentleman had no reason to develop this, so we considered this an idiopathic vasculitis. Now, I did another biopsy in the hospital where I did a new lesion but I also did a periwound lesion, so I did it on affected skin. I sent that for direct immunofluorescence. With that, came back is polyarteritis nodosa. We’re dealing with a mixed vasculitis here. Leukocytoclastic vasculitis is a small vessel disease. Polyarteritis nodosa is medium vessel disease. We’re dealing with both here. Now, again, where this gentleman presented this from or got this from, I have no idea. It’s an unknown etiology and can affect any organ. Typically associated with hepatitis, this gentleman was negative for all of his hepatitis. The thing is with cutaneous or the skin version PAN, it is typically in the lower extremity going to look like that necrotic process. It is something that’s not self-limiting. I had to put him on a steroid taper. The first thing I did before he left the hospital was I put him on a long and slow prednisone taper. Now, the problem with that is that I’m worrying about as I step him down, is flaring. Thankfully, he did not flare. The other thing that I did was I use Santyl for the necrotic areas. This is him about a month after the hospital. You can see that we’re basically left with the wounds, but he was still just feeling he wasn’t able to walk well. I also got him an occupational therapy and physical therapy and everything at home. This was him at his last visit. You can see then, all those ulcerated areas have closed up. He was able to walk again and he had no flare. This is one of the most interesting cases I’ve ever had, my whole thought process was I’ve got to find the source of this vasculitis and we’re going to stop it. And I wasn’t able to do that. Trust me, like I said, we did everything that we could to find it. Sometimes, I just say it’s idiopathic. Alright. I see vasculitis a decent amount I’d say every year. Usually, it’s more associated with the drug interaction. But I also see a lot of bruising. When I say bruising, what I’m seeing is more purpura. I’m seeing what we call senile purpura, which is a terrible name for your skin getting thinner and bruising as you get older.
We see these on areas that are high trauma. For instance, you’re going to see it on the hands, which get easily. You’re going to see it on the front of the legs. This product came out a year ago and it’s sold at CVS, but I found it online both in Amazon and CVS.com. What it is, it’s a barrier restoring cream but that also helps with bruising. I have used this for my patients with senile purpura, but I’ve also used this in patients who are post-op. It’s something that you can sort of, again, extrapolate out from what it’s meant to use and use it for bruising anywhere that you see fit. Now, it has Arnica montana in there, which is commonly used. Arnica is commonly used for bruising. Especially in the plastic surgery world, post eye procedure, they’ll give topical and oral remedy with arnica. It also has retinol and niacinamide, which niacinamide is the hot new molecule in dermatology that help strengthen the skin. So it has all these good things in there to help. It’s, again, something over-the-counter that you can recommend to your patients. Let’s get into another one of my favorite things to talk about, which are nails. There’s a lot of different things that are out there for nails. We all know that, the orals, the topicals. There’s three topicals that should be coming out. Two, tavaborole and efinaconazole, should be coming out this year in 2014. Luliconazole, still being studied and probably will come out 2015, 2016. We’ll see. There’s a lot of different things on the horizon, but what’s out there right now that is something that’s different you may not have heard of. Well, my big passion is saying, you know what, not everything is onychomycosis. A lot of nail lesions that are out there look like onychomycosis but actually aren’t. It’s just either nail dystrophy. It’s nail psoriasis. It’s nail eczema. It’s something, okay. There is a product that has been specifically FDA approved for the signs and symptoms of nail dystrophy. This means, if the patient walks in your office, now, I end up having to do a nail culture on pretty much everyone because of the insurances I’m dealing with in Philadelphia. And just because I want to pair the correct treatment with what’s growing out of that nail. I also want to make sure that I’m actually dealing with onychomycosis. This is something that I feel comfortable prescribing on that first visit after I’ve done the nail culture of KOH or PAS or whatever you like to use because it does not need to be onychomycosis for the patient to use this. Again, the indications are nail splitting, fragility, protection against everyday trauma. Think about your athletes who get the Beau's lines and onychorrhexis from their activity. What Nuvail does, which is poly-ureaurethane is it, number one, it creates a stable flexible structure and it also provides mechanical support. This is also good for your nails that are thickened because of biomechanics. So think about your fifth toe dystrophy, your second toe because they have a hammertoe and it’s just banging down on the ground. You can see what Nuvail does. This is an untreated nail that’s dystrophic and Nuvail makes it nice and smooth. There was a clinical trial that was done with this that was published in the Journal of Drugs in Dermatology where they used it on patients with onychomycosis. Patients had a greater than 60% overall improvement in color, onycholysis and nail thickening. This is one of the nails in that trial. You can see this is what they struggle with. It looks like they almost did a nail procedure here. You can see at the three-month mark that they have a lunula where you weren’t able to see that at baseline. Then six months, you have even less discoloration and less onycholysis. It’s not perfect at six months but it’s certainly better than what they started with. They did a further out study with Nuvail at the 12-month mark. These patients in the study used Nuvail topically every day for six months. They didn’t use any drug between months six and month 12 and had them come back for month 12. You can see, now when I do a lot of clinical trials for onychomycosis, I would never have enrolled this patient. This is called a dermatophytoma. It’s a thick collection of hyphae and it’s really difficult to treat with anything. The fact that here is baseline, here’s three months of using Nuvail, here’s sixth month, the end of the trial, and then at 12 months, that’s still a really nice result. These patients had a drug holiday for six months and still had changes. With Nuvail, that is something certainly that I’ve been using extensively in my practice since it came out. This is one of my patients who, again, came to me. She’s had multiple doctors look at her for her toenails. I said, “You know, I don’t believe this is nail fungus.” I did a culture. It was culture negative.
I have a dermatoscope, looked at it. I think this really is some sort of nail dystrophy that you're dealing with. This is her initial presentation and then this is her a few days ago, whereas you can see how Nuvail has changed her nail. She has a nice healthy nail growing out. That's it. Thank you so much for your attention.