Skin Diseases and the Eye - Texas Optometric Association

Dermatology
Skin Diseases
and the Eye
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5th Edition
Wolff, Johnson, Suumond
2005
1000+ pages
857 photographs
largest organ; one of heaviest
Percent of total body weight??
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Reference
Fitzpatrick’s Color Atlas and Synopsis of
Clinical Dermatology
Skin:
k
Just the
h facts
f
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Tammy P. Than, MS, OD, FAAO
UAB School of Optometry
tthan@uab.edu
COPE #28424#28424-SD
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Study of skin, its structure, functions, and
diseases
12--15%
12
20% of GP visits
1-2% of world population has psoriasis
Skin: The Layers
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Epidermis
Dermis
Subcutaneous Fat
Integumentary
System
Epidermis
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Stratum
Germinativum
Stratum Spinosum
Stratum Granulosum
(Stratum Lucidum
Lucidum))
Stratum Corneum
Langerhans Cells
 similar structurally to
melanocyte
 “macrophage of epidermis”
Merkel Cells
 touch receptors
1
Dermis
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Connective tissue
Deep to epidermis
Supports epidermis
Two Parts
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Subcutaneous Fat
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Papillary dermis
Reticular dermis
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Deep to dermis
Made up of lipocytes
Variable thickness
Functions:
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Langer’s Lines
Epidermal Appendages
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Hair Follicles
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Epidermal Appendages
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Hair Erector Muscles
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Sebaceous Glands
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No new follicles after birth
Growth is Cyclic
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lanugo
vellus
terminal
Anagen Phase
Catagen Phase
Telogen Phase
90% of scalp hair is in growth phase
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nail plate does not desquamate
Continuous growth (0.1 mm /d)
0.5
0
5–0
0.75
5 mm thick
function:
protection
scratching
 Grasping
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Diagnostic!!
Pale nail bed – anemia
 White nails – liver disease
sebum
usually attached to hairs but can be free
sweat glands
most on palms, soles, axillae
Apocrine Glands
Dermal Appendages
Nails
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“goose bumps”
Eccrine Glands
Epidermal Appendages
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Insulation
Shock absorber
Nutritional depot
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Blood vessels (reticular)
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Superficial and deep plexus
Originate from subcutaneous fat
flow exceeds nutritional demand
Lymphatics
Nerves
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Somatic sensory
Autonomic motor
Specialized end organs
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2
Factitious Dermatosis
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self-inflicted via mechanical, chemical, or
selfthermal
Differs from Munchausen’s syndrome
F >> M
shape of lesion may be bizarre
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predominate on one side
may persist for years
R/O other causes!!
patient MAY appear normal
management:
Rosacea
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>14 million Americans
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unknown etiology
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NOT related to sebum formation
Demodex folliculorum and Demodex brevis
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Helicobacter pylori?
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78% of Americans – no knowledge of disease
52% with rosacea – avoid public contact
2 factors
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vascular changes
acneform eruptions
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Rosacea
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30-50 years of age
30F > M (3:1)
light complexion
Rosacea – Subjective
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cosmesis
painful
facial heat
exacerbated by:
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heat
alcohol
ocular complaints
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up to 58% have ocular involvement
Trigger Factors?
Rosacea – Objective
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Sun exposure (81%)
Emotional Stress (79%)
Hot weather (75%)
Wind (57%)
Heavy exercise (56%)
Alcohol consumption (52%)
Hot baths (51%)
inflammatory infiltration of upper dermis
no comedones
Stage 1

intermittent flushing
permanent erythema

telangiectasia
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
Stage 2
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Stage 3
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papules
pustules
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rhinophyma
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
Stage 4
3
Ocular Rosacea
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Subjective
Objective
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Alodox
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blepharitis
meibomianitis
conjunctivitis
episcleritis
iritis
chalazion
corneal changes
RCE (up to 15%)
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Cynacon / Ocusoft
20 mg doxycycline
Alodox Convenience Kit
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20 mg doxycycline
Lid scrubs
Tranquileyes Moist Heat Therapy Goggles
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Thermoeyes reusable heat packs
Eye Eco Inc.
Nutridox
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Advanced Vision Research
Meibomian gland health and therapy
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Doxycycline
 75 mg
TheraTears Nutrition
 Fish oil (EPA 450 mg; DHA 300 mg)
 Flaxseed oil 1000 mg
 Vitamin E 183 IU
 3 gel caps qAM
iHeat Warm Compress System
Oracea
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40 mg doxycycline capsules
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q
qd
CollaGenex Pharmaceuticals
“Efficacy beyond 16 weeks and safety
beyond 9 months have not been
established”
$$ ($230 for 30 d)
Doxycycline
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Side Effects:
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GI discomfort
phototoxicity
reversible increased intracranial hypertension
superinfections
not for use in children
reduced efficacy of birth control pills
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Secondary yeast infection
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informed consent!
consent!
30 mg instant
10 mg sustained release
Rosacea - Treatment
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metronidazole 0.75% gel
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Finacea® (azelaic acid 15%) gel
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bid x 9 weeks
Bid x 12 weeks
topical steroids
argon laser
dermabrasion
4
Final Words on Rosacea
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Prognosis
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Seborrheic Dermatitis
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chronic
characteristic patterns
unknown etiology
gy
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dry form
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oily form
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duration varies
can recur
eventually goes away (years)
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Seborrheic Dermatitis
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M>F
more in winter
Subjective
j
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Infants
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+/- pruritis
+/ocular complaints
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Face and trunk
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steroid cream
ketoconazole cream (Nizoral
(Nizoral))
Salicylic acid
Seborrheic Dermatitis – Management
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Scalp treatment
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selenium sulfide (Selsun
(Selsun Blue)
tar preps (Denorex, T/Gel, Tegrin
Tegrin))
 zinc pyrithione (Head & Shoulders)
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Face and trunk
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Rx
Akurza
Salex
 Keralyt (gel)
selenium sulfide (Selsun
(Selsun Blue)
tar preps (Denorex, T/Gel, Tegrin
Tegrin))
 zinc pyrithione (Head & Shoulders)
ionil
Neutrogena Healthy Scalp
Salicylic Topical (6%)
greasy scales with erythematous base
Scalp treatment
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head, presternal area
Salicylic Acid Shampoo (2%)
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“Cradle Cap”
Salicyclic Acid
small powdery scales
Seborrheic Dermatitis – Management
Adults
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Pityrosporon ovale??
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steroid cream
ketoconazole cream (Nizoral
(Nizoral))
Salicylic acid
Eyelids
5
Atopic Dermatitis
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Chronic, relapsing
Not allergic
PHx or FHx of atopy
“the itch that rashes”
Etiology?
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Mastrota Meibomian Paddle
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- CYNACON/OcuSoft
- www.ocusoft.com
IgE
abnormal cellcell-mediated immune response
Atopic Dermatitis
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onset usually between 2 mo and 1 year
M>F
duration: 1515-20 years
y
associated conditions
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Acute
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asthma
hay fever
subjective:
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Atopic Dermatitis
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PRURITIS!!
low cutaneous threshold for drying and itching
erythema
excoriation
papules / vesicles
secondary infections
Chronic
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lichenification
Atopic Dermatitis
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Infants (2 mo – 2 years)
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chest, face, scalp, neck
less exudative
Older Children / Adults
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lichenification
flexural areas
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antecubital, popliteal, neck, periocular
Exacerbating Factors
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Children ((< 10 years)
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Atopic Dermatitis
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foods / irritants
stress / temperature changes
Management
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preventive
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constant temperature
low humidity
hydration (Eucerin
(Eucerin))
tar preps
topical steroids
6
Atopic Dermatitis – Ocular
Atopic Dermatitis – Management
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systemic
steroids
antibiotics
antihistamines
hospitalization
minimize stress
relocate!
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scaling around eyes
Dennie--Morgan line
Dennie
“Allergic Shiner”
conjunctivitis
corneal involvement
Cataracts
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asc and psc
keratoconus
retinal detachment
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Complication of cataract sx
Atopic Dermatitis – Management of Ocular
Manifestations
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Cool compresses / decongestants
topical (lots of options!!)
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antihistamine
mast cell stabilizers
Combos
NSAIDs
steroids
Bepreve ®
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BAK
Bid
Category C
≥ 2 YO
2.5, 5, 10 mL
Newest… 9/8/2009
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Bepreve ®
Bepotastine besilate 1.5%
ISTA Pharmaceuticals
Antihistamine + mast cell stabilizer
Inhibits eosinophil chemotaxis
IND: allergic conjunctivitis - itching
Skin Treatment
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Elidel cream ((pimecrolimus
pimecrolimus))
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skin selective inflammatory cytokine inhibitor
Relatively new NSAID topical for atopic dermatitis
safe for >2 YO
can apply to lids
similar
i il -> Protopic
P t i
FDA Black Box Warning
Cutivate 0.1% ((fluticasone
fluticasone))
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mid-level potency steroid cream
midsafe for >3 months
no reports of skin thinning
recommended 2 weeks or less
7
Impetigo
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superficial skin infection
Staph aureus and/or Strep pyogenes
children and young adults
humid or poor hygiene
contagious
self--limiting but…
self
Vesicular Impetigo
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“Impetigo”
vesicles/pustules -> rupture -> crust
erythema
face and extremities
pruritus
+/-- lymphadenopathy
+/
afebrile
Bullous Impetigo
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Staph aureus
vesicle -> bullae -> crust
no erythema
extremities, face, trunk
Impetigo
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Lab testing
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Gm stain
culture
Treatment
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improve hygiene (Hibiclens
(Hibiclens))
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Impetigo
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Treatment
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systemic antibiotics
treat eye as necessary
http://hibiclens.com/default.html
remove crusts
topical antibiotics
bacitracin or erythromycin
mupirocin 2% tid (Bactroban)
Bactroban)
treat nares
Ocular TRUST
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Ocular Tracking Resistance in U.S
U.S.. Today
The only longitudinal nationwide
antimicrobial susceptibility surveillance
program specific to ocular isolates
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S aureus
S.
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MRSA
MSSA
Coagulase--negative Staph
Coagulase
S. pneumoniae
H. influenzae
Asbell PA, Sahm DF. Longitudinal nationwide antimicrobial susceptibility
surveillance in ocular isolates. Results of Ocular TRUST 2. ARVO 2008.
8
Ocular TRUST: Participating
Sites
Ocular TRUST 2:
Susceptibility Testing
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In vitro susceptibility testing to nine
antimicrobials
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State with
participating
institution
Participating
Eye Centers
(10)
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MSSA
Coagulase--Negative Staphylococci (CNS)
Coagulase
ciprofloxacin
levofloxacin
gatifloxacin
moxifloxacin
azithromycin
trimethoprim
tobramycin
polymyxin B
penicillin
MRSA
Coagulase--Negative Staphylococci (CNS)
Coagulase
9
Streptococcus pneumoniae
Psoriasis
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2-8 million people in US
chronic, unpredictable disease
disorder of proliferation and inflammation
erythematous,, scaly plaque
erythematous
F=M
dominant transmission
association with arthritis
Psoriasis
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unknown etiology
increase mitosis
enlarged,
enlarged tortuous dermal capillaries
can be exacerbated by precipitating
factors
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Psoriasis
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trauma
stress
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initially – red scaling papules
eventually
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round to oval p
plaque
q
adherent silvery, white scale
extensor sites (elbows, knees)
scalp
lumbosacral area
nails
Subjective:
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Psoriasis – Objective
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Location
cosmesis
20% have pruritis
+/-- joint pain
+/
Plaque Psoriasis
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most common
enlarge to certain, stable size
may have residual macule
Koebner reaction
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traumatized normal skin develops
psoriatic lesions
10
Psoriatic Arthritis
Psoriasis – Management
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nail involvement in 80%
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pitting
discoloration
oncholysis
30-50 yo
30F>M
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Minimize precipitating factors
Reassurance
“Psoriasis Therapeutic Ladder”
 lubricants, emollients
 tar cpds
 topical steroids
 Salicylic acid
 PUVA
Two--tiered approach
Two
 Localized therapy
 Systemic and/or phototherapy
Psoriasis – Ocular Complications
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Tear film (decreased TBUT, MGD)
Eyelid – blepharitis,
blepharitis, trichiasis
trichiasis,, ectropion
Conjunctiva
j
/ Cornea
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Acanthosis nigricans
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conjunctivitis, KCS, symblepharon
diffuse, velvety thickening and
hyperpigmentation of the skin
axillae,, other body folds, neck, periocular
axillae
etiology
gy
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Nodular episcleritis
Anterior uveitis
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heredity
endocrine disorders
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associated with insulin resistance
Polycystic ovary syndrome
obesity
drug administration
malignancy
Acanthosis nigricans
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Testing
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Medications
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rule out diabetes, hypothyroidism
Retin-A
Retin15% urea
alpha--hydroxy acid
alpha
salicylic acid
Prognosis
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hereditary – may regress when older
may regress with weight loss
discontinue causative drug will cause resolution
11
Scleroderma
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connective tissue disease
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Scleroderma – Two Forms
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fibrosis
Diffuse – 60%
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progressive
autoimmune
F > M (4:1)
30--50 YO at onset
30
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Limited (CREST) – 20%
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Scleroderma
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Raynaud’s phenomenon – usually first
cutaneous disease
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thickened skin
loss of facial expression / swollen look

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esophagus
lungs
kidneys
heart
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3 Stages
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Stage 1: pallor
Stage
g 2: cyanosis
y
Stage 3: hyperemia
up to 20%
precipitating factors: cold, stress, smoking
PHENOMENON when associated with other
disease or other cause:

Raynaud’s Disease

episodic constriction of digital arteries
usually F

internal organs

Calcinosis
Raynaud’s phenomenon
Esophageal
Sclerodactyly
Telangiectases
CRST, ST, etc.
Raynaud’s Disease


systemic scleroderma
rheumatic disorders, drugs, carpel tunnel
syndrome
Scleroderma – Ocular
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+/- ptosis; +/+/+/- lagophthalmos
KCS
mucous filaments
telangiectasia
cataracts
uveitis
HTN retinopathy
12
Alopecia Areata
Scleroderma – Management
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treat Raynaud’s phenomenon
steroids
ocular:
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lubricants
ointments
tape
ptosis crutch
punctal occlusion

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different than androgenetic alopecia
non--inflammatory
non
inflammatory,, nonnon-scarring hair
loss
idiopathic
M=F
children and young adults
Alopcia Areata
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well demarcated areas (1(1-4 cm)
skin is normal
exclamation points (hallmark)
Sites:
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Scalp
Beard
eyebrows
Alopecia Areata

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Alopecia totalis
Alopecia universalis
DDX:

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Management:

+/-- “hammered brass” nails
+/
fungal infections
secondary syphilis

Prognosis
Therapy
Trichotillomania

Self--inflicted alopecia
Self
Latisse™
Latisse
™




Fractured hairs of unequal lengths
may need therapy


Allergan (Medical Aesthetics)
Approved 12/2008
0 03% bimatoprost
0.03%
Indication:


Hypotrichosis of eyelashes
Caution:


Active intraocular inflammation
Aphakia,, risk factors for CME
Aphakia
13