Healthy Skin Women and Dermatology

Healthy Skin Women and Dermatology
By:Suguru Imaeda, M.D.
Chief of Dermatology, Yale University Health Service

Overview
* Normal structures of the skin
* Changes in the skin over time
* Sun and skin
* Skin cancer
* Maintaining healthy skin
Epidermis
the largest organ
* key role in normal healthy functioning of the body
* Disorders range from those limited to the skin to manifestations in the skin of internal disorders
* plays important role in social and psychosocial functioning of the individual
* undergoes changes with aging and in response to external environmental factors and internal hormonal influences
Gender differences
* Fundamental differences in structure and function of the skin
* Differences impact on presentation of skin disease and its management
* Hormonal influences affect common disorders such as acne, rosacea, lupus erythematosus, psoriasis, lichen planus, anogenital pruritus, hidradenitis suppurativa, and atopic dermatitis
Infancy
Toddler to adolescence
Adolescence
Body piercing
* presents risks for multiple possible complications
* nickel allergy
* secondary infection with staphylococcus or streptococcus
* ear cartilage destruction from pseudomonal infection
* candidal infection of the navel or genitalia
* Keloids
* traumatic tears
Tattoos
* Infection
* Granulomatous reaction
* Photodermatitis
* Difficult to remove
Melasma
* Brown patches on forehead and cheeks
* Very sensitive to sun exposure
* More common in Hispanics, Middle Easterners, and Asians
* Most common cause is oral contraceptive use or pregnancy
Melasma management
* Discontinuation of oral contraceptive
* Avoidance of sun/tanning bed
* Daily application of broad spectrum sunscreen
* 4% hydroquinone or 20% azelaic acid
* ? laser
Intrinsic aging
* Changes of chronologic aging gradually become apparent
* Influenced by genetics, gravity, and hormones
* Clinically, the normal aging process leads to fine wrinkles, dryness, sallow color, thinner skin, laxity and purpura
Aging skin
* Decreased function as environmental barrier, sensory organ and immune organ
* Epidermal and dermal atrophy with loss of appendages
* Decreased sweat production leads to dryness
* Decreased body and scalp hair
* Decreased ovarian estrogen production leads to decreased collagen and increased wrinkling
* Overall thinner, paler, drier, with fine wrinkling and decreased elasticity
Histologically
* dermal thinning
* decreased vascularity
* decreased subcutaneous fat
* reduced cellularity of the dermis
* elastic fiber loss
* dermal thinning
* decreased vascularity
* decreased subcutaneous fat
* reduced cellularity of the dermis
* elastic fiber loss

Environmental factors on skin
* create extrinsic damage
* major effect is from photoaging with wrinkling, laxity (sagging), lentigenes, dyschromia, coarseness, sebaceous hyperplasia, and telangiectasia
* 90% of visible skin changes of aging
* Visible as early as age 20
Smoking
* shown to decrease both hyaluronic acid and glycosaminoglycan synthesis
* causes decreased capillary blood flow in the skin
* changes accelerate wrinkling
The twenties
* Skin is smooth and coloring is even
* Little need for emollients
* Skin care is simple - variety of products are tolerated
* May be persistent acne associated with hormonal activity manifest by flaring during the week prior to the menstrual period.

The thirties
* thinning of the skin beneath the eyes
* skin is less elastic
* Fine wrinkles begin to appear around the mouth and lateral periorbital region
* Increased fat and sluggish blood flow contribute to puffiness and darkening of the skin beneath the eyes
The forties
* More sallow and less supple
* Skin surface not as smooth
* Liver spots, solar lentigenes, appear on areas of chronic low grade sun exposure - face, dorsal hands, back or dorsal feet
* Thin red spider angiomas appear on the legs
* Weight gain leads to sagging skin
* Cellulite appears on thighs and buttocks
* Deep furrows develop on forehead and lateral periorbital areas (crow’s feet)
* Skin becomes drier - sweat glands grow smaller and become less effective
The fifties and sixties
* Wrinkles are deeper - skin begins to sag and droop
* Skin tone is lighter from decreased circulation
* More solar lentigines form
* Collagen and elastin are thinner
* Collagen is estrogen dependent therefore skin is both thinner and drier
* Dryness occurs from thickening of the stratum corneum
* Moisturizers help keep the skin moist and supple
* Alpha hydroxy acid-containing products help by reducing the thickness of the stratum corneum, promoting thickening of the epidermis and dermis, and promoting synthesis of collagen, elastin, protein and glycosaminoglycan
Pregnancy
* rosy complexion - increase in vascular circulation
* hyperpigmentation on the nipples, vulva, anus and inner thighs from hormonal stimulation
* Freckles (ephelids) and birthmarks may also darken
* Melasma, the mask of pregnancy, from hormonal changes, sun exposure and genetic factors
* Skin tags develop on the neck, chest, inframammary area, inner thighs, and face
* Spider angiomas, purpura and capillary hemangiomas
* Stretch marks, striae distensae
* Varicosities and hemorrhoids
Sun protection
* Signs of extrinsic photoaging not intrinsic genetic aging usually prompts the visit to the dermatologist
* Therefore, it is most important to incorporate into the daily routine a sun protection regimen
Tan
* Coco Chanel declares tanning “in” in 1920’s
* Suntan seen as symbol of health, youth, status
* Skin’s reaction to damage from UV radiation
* Melanocytes produce melanin
Indoor tanning
* Increasingly popular, esp among young women in 20’s
* Advertised as safe, “healthy glow”, little risk of skin cancer
* Controlled tanning protects against sunburn by building up melanin
* Vitamin D helps prevent breast, prostate, colon cancer
Dripping faucet
* Your skin = empty glass
* Dripping water = ultraviolet radiation
* Rate of drip = amount of sun exposure
* Rate of evaporation of water = skin’s ability to repair DNA damage caused by UV radiation
* Your glass is full = you’ve reached your limit of sun exposure
* Water starts spilling over the top = getting skin cancers
Ultraviolet radiation
Sun myths
Basal cell carcinoma and Squamous cell carcinoma
Melanoma
IARC (International Agency for Research on Cancer)
Sunless tanning
Tanning pills
Sun Protection Factor
In vitro CT FL
New proposed labeling guidelines for sunscreens
Sunscreen
UV Index
Anti-aging treatments
* Prevention
* Retinoids
* Lasers
* Chemical peels
* Dermabrasion
* Botox
* Fillers
* $35 billion/year industry
Prevention
* Daily use of sunscreen or moisturizer with sunscreen SPF 15+
* Clothing
* Avoiding unnecessary UV exposure
* Avoiding sun exposure between 10a-4p
Retinoids
* Tretinoin and tazarotene
* Vitamin A derivatives
* Even out skin tone
* Rebuild collagen
* Repair minor sun damage
* Inhibit tumor growth
* Decrease inflammation
Lasers
Chemical peels
Dermabrasion
Botox
Fillers
General skin care
Skin Care Tips
* Sun protection
* Hydration
* Healthy diet – fruits, vegetables, fish
* Gentle skin care products – soaps
* Moisturize
* Don’t smoke

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Current Obesity Management in Primary Care

Current Obesity Management in Primary Care
By:Eileen L. Seeholzer, M.D., M.S.

Obesity Defined

· Traditionally defined as a weight 20% greater than ideal body weight
· Severe obesity or morbid obesity is defined traditionally defined as a weight 100% greater than ideal body weight

Fat Distribution
Upper-body obesity or abdominal obesity or androgenic obesity: An independent risk factor for diabetes mellitus, cardiovascular disease, hypertension, arthritis, menstrual irregularities and gallbladder disease
(Diabetes mellitus is thirty times higher in highest waist-to-hip ratio (whr)compared to lowest quartile whr)
Clinical Guidelines on the Identification, Evaluation and Treatment of overweight and Obesity in Adults

Body Mass Index Chart
Scope of the problem in the U.S.
Increased Risk for Adult Obesity
* Gender/Ethnicity: Women, blacks, Hispanics and Native Americans
* Family History
* Childhood Obesity
* In lower socioeconomic status
* Sedentary lifestyle
* Increased time-spent watching TV
Local Public Health Data
Associated Medical Problems
Renal: Proteinuria/glomerulosclerosis, CRF
Dermatologic: intertrigo, venous stasis, cellulitis, hidradenitis suppurativa, acanthosis nigricans
Psychiatric: depression, binge eating disorder, night eating syndrome
GU: stress incontinence, PCOS, infertility, pregnancy risk
Rheumatologic: DJD- knee, hip, low back pain
General: fatigue, pain, disability, lower socio- economic status, poorer quality of life
Obesity associated Increased Risks in Pregnancy
* Gestational Diabetes
* Hypertension
* Disordered breathing/Obstructive Sleep Apnea
* Cesarean section rate (RR1.5-1.8)
* Congenital heart defects (OR 1.4-2.0)
* Spina Bifida (OR 3.5)
* Omphalocele (OR 3.3)
* Increased levels of leptin, crp and tnf-alpha

Birth Weight and Obesity
* LBW and (<2000gm)OR2.16 and high birth weight (>4000gm)OR 1.53 increased gestational DM risk
* LBW associated with increased overweight adolescence
* Prolonged breast feeding associated with lower rates of adult obesity
Metabolic Syndrome
Three or more of the following present:
* Abdominal obesity(>102cm M/88cm F)
* Elevated triglycerides (>150mg/dl)
* Low HDL (<40 for men mg/dl; <50 for mg/dl for women)
* Hypertension
* High fasting blood sugar
Neuroendocrine Environment
* Leptin/Leptin receptor resistance (at VMH)
* TNF-α, IL-6, adiponectin (aconitase theory – decreased cellular ATP,increased FFA and glucose, Wlodek, et. Al. 2003)
* CRP
* Dopamine, serotonin, norepinephrine
* Low growth hormone levels observed
* Higher cortisol levels sometimes seen
Ghrelin and Peptide YY
Impact of Weight Loss on Risk Factors
Obesity Treatment Pyramid
Diet
Physical Activity
Lifestyle Modification
Pharmacotherapy
Surgery
Non-Pharmacologic Treatments
Components of Basic Program
* Diet Recommendations
* Exercise Recommendations
* Behavior Therapy
* Regular f/u in maintenance phase
Behavior therapy
Combined therapy
Time (mo)
Assessing Weight Loss Readiness
* Motivation:
* Stress level:
* Psychiatric issues:
* Time availability:
Patient seeks weight reduction
Results from Non-pharmacologic Programs
Pharmacologic Treatments
Other Agents
Experimental Agents - Phase 3
Medications That May Promote Weight Gain
* Antipsychotics: risperidone, clonazepine, olanzepin
* Antidepressants: Tri-cyclics, SSRI
* Antiepileptics: valproic acid, gabapentin, carbemazepine
* Lithium
* DM treatments: Sulfonylureas, insulin
* Progestin steroids
* Cortisone
* Antihistamines
* Beta blockers
Surgical Treatment
Surgical Outcomes
Improvement in Comorbid Conditions s/p Gastric Bypass
Common longer-term Complications after Gastric Bypass
Screening For Obesity in Adults
Weight Management Clinic
Obesity Treatment Guidelines

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Dermatology Review

Dermatology Review
By:Jennifer Best, MD

Acanthosis Nigricans
* Velvety discoloration of skin in flexural creases
* Most commonly seen in insulin resistant states (e.g. DM, PCOS, niacin use), endocrinopathy, malignancy

Xanthelasma
* Soft, polygonal papules and plaques consisting of cholesterol, usually located on upper lids
* When seen in children and young adults, associated with familial hypercholesterolemia
Necrobiosis lipoidica
* Well-demarcated plaque, yellow-orange to tan-pink with thinning and telangiectasia
* Non-painful
* Usually located on shins/feet
* Associated with long-standing, juvenile-onset DM
Molluscum contagiosum
* Centrally umbilicated papules seen in children and sexually active adults
* Viral cause
* More aggressive and common on face in HIV
Angular cheilitis
* Fissuring of corners of mouth
* Associated with thrush, atopic dermatitis, nutritional deficiencies and denture use
Prurigo nodularis
* Pickers’ nodules
* Nodular lesions due to chronic excoriation of the skin
Keratosis pilaris
* Benign sandpaper like bumps (“goosebumps”) on extensor surfaces
* Associated with atopy or a normal variant
Morphea
* Plaques are initially purplish and become ivory in color
* Localized scleroderma
Nikolsky’s sign
* POSITIVE when epidermis is dislodged from the dermis by lateral shearing pressure and blister extends
* Seen in toxic epidermal necrolysis, scalded skin syndrome and pemphigus vulgaris
Seborrheic keratosis
* What is it?
* Does it have malignant potential?
* Warty brown growths seen on aging skin – looks “stuck on”
* No malignant potential, purely cosmetic
Seborrheic dermatitis
* Always think of HIV in seborrheic dermatitis that is extensive or refractory to treatment
Rhinophyma
* Bulbous erythematous enlargement of the nose
* Seen in advanced rosacea
Hidradenitis suppurativa
* Sebaceous cysts seen in follicular areas (e.g. groin, axillae, scalp)
* More common in African Americans
Hereditary Hemorrhagic Telangiectasia
* Other names?
* Dermatologic manifestations?
* Clinical associations?
* Otherwise known as Osler-Weber-Rendu Syndrome
* Autosomal dominant
* Red macular/papular telangiectasias and AVMs on or around mucous membranes/GI tract
* Associated with bleeding tendency
Acrochordon
* Common name?
* Skin tag
Rosacea
* 1. Papules
* 2. Pustules
* 3. Telangiectasias
* Located over cheeks
* May involve nasolabial folds
* Exacerbated by alcohol, hot beverages, spicy foods, sun exposure
Nail pitting
* Associated with?
* Psoriasis
Condyloma lata
* What is it?
* What organism is responsible?
* Flat flesh-colored warts seen in anogenital region
* Representative of secondary syphilis
Condyloma acuminata
* What is it?
* What organism is responsible?
* Human papilloma virus (HPV)
* Genital warts
Whitlow
* Herpes simplex virus infection on finger
* Often seen in health care workers
Tinea versicolor
* Macules with fine scaling on trunk, upper arms, neck, abdomen, axillae with varying pigmentation
* Asymptomatic
* Caused by Malassezia furfur (looks like “spaghetti and meatballs” on KOH prep)
Ascending skin lesions
* Differential diagnosis?
* Mycobacterium marinum
* Sporothrix schenkii
* Nocardia
* Francisella tularensis
Hypopigmented anesthetic macules
* Leading diagnosis?
* Leprosy (Hansen’s Disease)
Yellow-orange skin discoloration
* What should you think of?
* Jaundice
* Increased beta carotene ingestion
* Hypothyroidism (without thyroid hormone, problems metabolizing beta carotene)
* Usually seen best on palms
Argyria
* What is it?
* Silver-gray discoloration of the skin due to intradermal deposition of silver
* Permanent!
Hot tub folliculitis
* What causes it?
* Pseudomonas aeruginosa
Heliotrope lids
* Purplish discoloration around eyes seen in dermatomyositis
* Also associated with…
* Purplish discoloration around eyes seen in dermatomyositis
* Also associated with…Gottron papules
* Recall association of dermatomyositis with malignancy in older patients
Common drug causes of slate-gray discoloration
Common cause of bullous cellulitis in liver disease
Erysipelas
* Responsible organism?
* Group A beta-hemolytic strep
* Raised erythematous plaques, may involve face or extremities
Bullous pemphigoid
* Most common blistering disorder
* Most common in elderly
* Nikolsky negative
* Commonly related to medications (sulfa, furosemide, penicillin
Erythema marginatum
* Pink rings on the trunk and inner surfaces of the arms and legs which come and go for as long as several months - barely raised and non-pruritic. Face is generally spared.
* Associated with rheumatic fever (but only less than 5% of patients)
* Considered a major Jones criterion when it does occur (4 others?)
Erythema nodosum
* Painful, erythematous round plaques, commonly pretibial
* Associated with infection (including strep, fungal, TB), IBD, sarcoidosis, drugs (OCPs, sulfa)
Drug cause of skin necrosis
* Warfarin (1:10,000)
* High doses
* Overweight women
* Breasts, buttocks, thighs, abdomen
Bacillary angiomatosis
* Associated with Bartonella infections (quintana, henselae)
* Cutaneous vascular tumors seen almost exclusively in HIV
Lupus pernio
* Dermatologic manifestation of sarcoidosis
* Indurated violaceous lesions, usually on face
Erythema multiforme
* Strong association with HSV, mycoplasma
* Drug causes (sulfa, phenytoin, PCN, allopurinol)
* Target lesions – can be localized to hands/face or generalized
* On a continuum with Stevens-Johnson
Dermatitis herpetiformis
* Grouped erythematous papules and plaques – seen on extensor areas (elbows, knees, trunk, buttocks, sacrum) as well as scalp, face and hairline
* Associated with celiac sprue
Herpes zoster
* Reactivation of VZV along dermatomal distribution
* Increasing incidence with age and immunosuppression
* Pain precedes rash
Erythema migrans
* “Bulls-eye” lesions seen in 50-70% of patients with Lyme disease (Borrelia burgdorferi).
Serology?
Infectious disease most associated with cryoglobulinemia?
Infectious disease most strongly associated with cryoglobulinemia?
* Hepatitis C virus
* Can cause vasculitic lesions (palpable purpura) commonly on lower extremities
Kaposi’s Sarcoma
* Associated with?
* HIV
* HHV-8
Keratoderma Blenorrhagicum
* Red-brown papules/pustules/vesicles with erosion and crusting on dorsilateral and plantar foot and palms
* Associated with reactive arthritis
Livedo reticularis
* Associated with?
* Vasculitis
* Vascular spasm
* Atheroemboli
* Normal variant (finer pattern)
* Most common on extremities/abdomen
Pyoderma gangrenosum
* Painful, hemorrhagic pustule or macule that breaks down into an ulcer with irregular raised borders and purulent base
* Usually on lower extremities
* Most strongly associated with IBD, but also associated with inflammatory arthritis, hematologic disorders and other GI conditions
Increased skin elasticity
* Ehlers-Danlos
Lichen planus
* Associated with?
* Hepatitis C virus
* Purple, planar, pruritic, polygonal papules on volar wrists, ankles, genitals, mucous membranes and nails
* Wickham’s striae are white lines inside lesions
Peutz-Jeghers
* Cutaneous hyperpigmented macules of lips, perioral and perinasal areas
* Associated with polyps and hamartomas of the GI tract (small bowel, colon and stomach)
* Associated with increased cancer risk
Koebner phenomenon
* What is it?
* With what dermatologic condition is it associated?
* Development of lesions at the site of skin trauma
* Seen in psoriasis (1/3 of patients), but also eczema, vitiligo, lichen planus or sclerosus
Pathergy
* What is it?
* With which disease is it associated?
* Development of pustule at the site of skin breach (i.e. blood draws, injections)
* Seen in Behcet’s Disease
Dermatographism
* With which condition is it associated?
* Development of wheal and flare at site of minor friction
* Seen in urticaria
Eruptive xanthomas
* Yellowish papules located on extensor surfaces (knees, buttocks, elbows)
* Seen in familial hypertriglyceridemia
Urticaria pigmentosa
* Name the disease…
* Flat top papules and brown plaques that for wheal and flare when scratched
* Seen in mastocytosis
Osler’s nodes
* Painful, purplish lesion usually on hands - immune complex deposition
* Seen in endocarditis
Janeway lesions
* Flat , bluish-red, non-painful lesions on palms and soles
* Seen in endocarditis
Cat-scratch disease
* Causative organism?
* Bartonella
* Following cat scratch, development of acute, tender regional lymphadenopathy
“Slapped-cheek” rash
Eosinophilic folliculitis
Koilonychia
Corkscrew hairs and perifollicular hemorrhage
Tophus
Peau d’orange
Actinic keratosis
Porphyria cutanea tarda
Nailfold telangiectasia
Beau’s lines
Clubbing
Oral Hairy Leukoplakia
Pityriasis rosea
Spider angioma
Café au lait spots
Caput medusae
Migratory necrolytic erythema
Acrodermatitis enteropathica
Ecthyma gangrenosum
Sweet’s syndrome

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