Therapeutic Strategies

Articles from Therapeutic Strategies in Dermatology are not meant to assign a "definitive" therapy for each disease, but rather to provide a practical approach to treating diseases of the skin as developed by the life experience of two practitioners. This does not represent the intent to develop a consensus about therapies in dermatology. We view the strategies as "recipes," not definitive statements, as dermatologic therapeutics is a rapidly changing field.

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Therapeutic Strategy Articles

Herpes simplex virus (HSV) occurs in 2 common locations: orofacial (usually due to HSV-1) and genital (usually due to HSV-2).

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Seborrheic dermatitis can be limited to the scalp, but it also can involve the face and any hairy or intertriginous area and rarely can even progress to a generalized erythroderma.

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Chancroid

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

The diagnosis of chancroid is usually clinical, although improved culture techniques allow isolation of the causative organism H. ducreyi. The therapeutic strategy is to eliminate the pathogenic microorganism.

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Chronic cutaneous lupus erythematosus (LE) has several morphologic patterns. Subacute cutaneous LE (SCLE) presents with erythematous, annular, or papulosquamous lesions, which tend to heal without scarring. Discoid lupus erythematosus (DLE) causes lesions with significant hyper- and hypopigmentation and follicular plugging, and causes significant scarring. 

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Dermatitis herpetiformis is a chronic, intensely pruritic disorder characterized by symmetrically distributed bullae or erosions, deposition of IgA in the dermal papillae, and evidence of gluten-sensitive enteropathy.

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Although several mycobacterial organisms have been associated with skin lesions, only two, M. fortuitum / chelonei / abscessus (Group IV, rapid growers) and M. marinum, are common pathogens. 

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Superficial chemical peeling is indeed a dermatologic art. It is the skillful use of acidic substances to carefully remove the stratum corneum and superficial epidermis to achieve an improvement in the appearance of the skin.

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Optimal therapeutic regimens for Hansen's disease (HD) have not been established by comparative controlled trials. Therapy is determined primarily by the bacillary load (i.e., multibacillary vs. paucibacillary). Multibacillary patients include all lepromatous and almost all borderline patients (except those near the tuberculoid pole).

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Sweet's syndrome is a skin disease with a sudden onset of fever, leukocytosis, and  well demarcated, erythematous plaques and papules.

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Lichen Planus

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Lichen planus (LP) may be self-limited or chronic and presents as localized or generalized disease, usually with mild to severe pruritus. Occasionally patients have ulcerative, painful mucosal lesions.

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Candidiasis

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Candida albicans causes cutaneous disease in occluded, moist areas: the groin, axilla, inframammary areas, and the glans penis (in uncircumcised males). 

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Gyrate erythemas are reactive processes. The therapeutic strategy is to determine and treat the underlying cause, and the cutaneous reaction is then cured. Gyrate erythemas are divided into superficial and deep types, the superficial types having the classic annular morphology and the "trailing" scale. 

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Borreliosis

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Infection with various Borrelia species will cause cutaneous and systemic infections. Early Lyme disease (erythema migrans) and late Lyme disease (acrodermatitis chronicum atrophicans) are the classic cutaneous complications of these infections. 

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Lesions of transient acantholytic dermatosis (TAD) often are not "transient," and may persist for years. Heat and sweating appear to be triggers, with patients presenting after trips to tropical or semitropical climates, with fever, and after hospitalization or bedrest. 

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Cutaneous larva migrans is due to animal (usually canine) hookworm. It presents as serpiginous papules on the dorsal feet. Larva currens, caused by intestinal infection with Strongyloide stercoralis, presents with serpiginous erythematous papules.

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Deep fungal infections: Sporotrichosis, Coccidioidomycosis, Chromomycosis, Madura Foot, Blastomycosis and Histoplasmosis

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Photosensitivity dermatoses are caused either by an exogenous substance (either topical or systemic), or are idiopathic. These conditions initially present on sun-exposed skin, may be triggered by topical or systemic exposures, and tend to resolve when sun exposure (UV) is avoided.

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Herpes gestationis is a subepidermal bullous disease of pregnancy characterized by pruritic, inflammatory blisters occurring during the second and third trimesters and often recurring during the immediate postpartum period. 

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Bullous Pemphigoid

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Bullous pemphigoid is usually a self-limited inflammatory subepidermal blistering disorder of the elderly, in which circulating auto antibodies to epitopes in the basement membrane zone bind to this region and initiate a cascade of inflammatory events resulting in urticarial and bullous lesions.

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Lymphogranuloma venereum is a chronic sexually transmitted infection that occurs in 3 stages. The primary stage is cervicitis, proctitis, or a transient genital papule. The secondary stage is bilateral inguinal or pelvic adenopathy. If untreated, lymphatic damage can occur, resulting in genital fibrosis and lymphedema. The tertiary stage is very difficult to manage, so identification of infected patients at earlier stages is critical.

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Leishmaniasis

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

As with all infectious diseases, the diagnosis of leishmaniasis should be established by identifying the causative agent in the affected tissue by culture, scrapings, or biopsy. Response to therapy is significantly related to the causative species and geographic area in which the infection was acquired.

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Granuloma Annulare

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

The pathogenesis of granuloma annulare is not known and, for this reason, therapy is empiric. The effectiveness of therapy of granuloma annulare (GA) may be difficult to gauge because spontaneous resolution of individual lesions or the entire disease process is common.

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Pyoderma gangrenosum (PG) is a neutrophilic dermatosis defined by its characteristic morphology. It is a diagnosis of exclusion, and can be simulated by various vascular and infectious conditions.Treatment is determined by the extent and rapidity of the cutaneous process. 

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Behçet Syndrome

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Beh├žet syndrome is a disorder of unknown cause characterized by oral and genital mucous membrane ulceration, erythema nodosum-like lesions, uveitis, and numerous other vascular, rheumatological, and gastrointestinal complications.

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Prurigo Nodularis

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Prurigo nodularis is a morphologic lesion that is a consequence of severe and repeated scratching of one area. In most patients it is secondary to an underlying pruritic condition such as photosensitive dermatitis, renal failure, or neuropathic pruritus due to nerve impingement (brachioradial pruritus). 

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Pruritus Ani

Timothy Berger Bruce Wintroub

Thursday, September 18, 2008

In the absence of a primary cutaneous disorder, pruritus ani is thought to have two probable causes. One is irritation from rectal mucus and fecal material. The other is nerve impingement in the sacral region, causing neuropathic itch.

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Actinomycosis

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Actinomycosis is a chronic bacterial infection that commonly affects the face and neck.

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This condition is a benign and often self-limited lymphocytic vasculitis. Pityriasis lichenoides chronica (PLC) is treated like pityriasis lichenoides et varioliformis acuta (PLEVA). A rare variant of PLEVA, the febrile ulceronecrotic form can be very aggressive and even fatal in adults.

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Palmoplantar keratodermas (PPK) can occur as a primary, inherited disorder of the volar surfaces, or as part of a generalized disorder, such as psoriasis, cutaneous T-cell lymphoma, or ichthyosis.

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Gonococcal infection may remain localized to one or several mucosal surfaces or may become bloodborne, causing a characteristic dermatitis-arthritis syndrome.

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Pemphigus foliaceus is a relatively benign autoimmune bullous disease associated with the deposition of intercellular antibodies directed against desmoglien 1. 

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This common and very pruritic disorder of pregnancy of unknown cause usually begins in the third trimester and resolves with delivery.  Unlike herpes gestationis, postpartum onset or exacerbation is rare.

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The therapy of molluscum contagiosum is divided into three treatment groups: children, adults, and the immunosuppressed. Molluscum contagiosum limited to the genital area in children should raise the possibility of child abuse.

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Hymenoptera Stings

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Hymenoptera stings cause toxic and allergic reactions. Toxic reactions are called local reactions and result from local tissue effects of the venom. These are often mild, lasting several hours, but can be severe or even fatal if many stings occur. 

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Lesions of necrobiosis lipoidica diabeticorum (NLD) are usually, but not always, associated with juvenile-onset diabetes. Tending to occur singly or in crops on the anterior lower legs, they can appear anywhere on the body.

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The diagnosis of Paget's disease or extramammary Paget's is made when Paget cells are identified in histopathologic specimens from involved skin. The term Paget's disease is used when the cutaneous lesion is identified involving the nipple of the breast, whereas extramammary Paget's is used when the skin lesion is identified in an anogenital location.

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Rosacea

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Rosacea is a follicularly based inflammatory process of unknown cause. Those affected by rosacea may have facial erythema, telangiectasia, papules and pustules, or sebaceous hyperplasia of the nose (rhinophyma).

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Papular Urticaria

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

The bites of many arthropods can trigger hypersensitivity reactions in humans. Exposure to penetrating body parts (setae) of certain moths and caterpillars may cause similar reactions.

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Syphilis (Lues)

Timothy Berger Bruce Wintroub

Saturday, December 01, 2012

The treatment of syphilis is based on the duration of infection and the organ systems involved. The treatment of early, late, HIV-associated, and neurosyphilis will be discussed.

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Erythema Nodosum

Timothy Berger Bruce Wintroub

Thursday, December 06, 2012

Erythema nodosum is a reactive inflammatory septal panniculitis produced by multiple agents and underlying conditions.

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Darier's Disease

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

The diagnosis of Darier's disease is dependent on clinical features, family history and a characteristic histopathology. 

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Although bullous systemic lupus erythematosus (bullous SLE) and epidermolysis bullosa acquisita are immunopathologically similar, their clinical behavior is different.

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Stasis dermatitis and ulcers are complications of chronic venous insufficiency.

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Langerhans cell histiocytoses (Class I histiocytosis) are a group of disorders most common in childhood due to the accumulation or proliferation of a clonal population of cells bearing the phenotype of a Langerhans cell that has been arrested at an early stage of activation and is functionally deficient.

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Kaposi's Sarcoma

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Kaposi's sarcoma (KS) results from endothelial cell proliferation caused by infection with human herpesvirus 8 and occurs in four settings: classic KS, African (endemic) KS, immunosuppressive-associated KS, and AIDS-associated KS. 

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Eosinophilic fasciitis is distinguished from scleroderma by its acute onset; its lack of hand and foot or visceral involvement; the characteristic involvement of the extremities (usually distal legs and arms); its tendency to spontaneously remit after 2-5 years, and its exquisite responsiveness to systemic corticosteroid therapy.

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Hidradenitis suppurativa and perifolliculitis capitis are chronic inflammatory processes that affect the groin, axilla, and inframammary areas (hidradenitis suppurativa) and the scalp (dissecting cellulitis).

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Ichthyosis results from abnormal retention and/or production of the stratum corneum layer of the epidermis. Acquired ichthyosis can be a cutaneous manifestation of an underlying disease (eg, malignant neoplasm, metabolic disorder, malabsorption).

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Porphyria cutanea tarda (PCT) is the most common porphyria. It is inherited as an autosomal-dominant disorder in 20% of cases and is acquired in association with other disorders in the remaining 80% of cases.

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Xerosis

Timothy Berger Bruce Wintroub

Friday, September 04, 2009

Xerosis can reflect an inherited tendency toward dry skin as it is seen as a part of the atopic diathesis, or it can occur in normal individuals as a consequence of frequent bathing with excessively hot water and harsh soaps and/or after prolonged exposure to unusually low environmental humidity (as occurs with forced-air heating during winter months in cold climates).

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Contact dermatitis can have either an irritant or an allergic origin. Irritant reactions tend to appear less than 12 hours after exposure and are strictly limited to exposed sites.

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Keratosis pilaris (KP) is an extremely common, often familial disorder that usually does not require treatment. Involvement of the face and upper arms, however, may cause a significant cosmetic problem, and frictional folliculitis not infrequently complicates KP on the buttocks and thighs.

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Inflammatory processes may involve the dorsal or palmar surfaces of the hands. Dorsal hand dermatitis is managed as is dermatitis elsewhere on the body.

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Pseudofolliculitis barbae (PFB) or razor bumps is a condition commonly affecting black men (and women). It is caused by shaving, and it resolves when shaving is stopped.

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Chronic bullous disease of childhood is characterized by the presence of multiple, tense bullae and severe itching in association with linear deposition of IgA at the basement membrane zone. The clinical appearance resembles bullous pemphigoid.

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Alopecia Areata

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Alopecia areata is characterized by nonscarring hair loss of unknown etiology. Manifestations are most frequently limited to a few oval bald patches.

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Atopic Dermatitis

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Therapy of adult atopic dermatitis may be approached as management of either acute or chronic dermatitis. In addition, therapy should be based on the extent of skin involvement (ie, generalized versus localized disease).

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Zinc deficiency may be seen in infants (hereditary or acquired) or adults (acquired). Some breast-fed infants, especially if born prematurely, may develop acrodermatitis enteropathica (AE) due to zinc deficiency in the mother's breast milk.

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Granuloma Inguinale

Timothy Berger Bruce Wintroub

Wednesday, September 08, 2010

This sexually transmitted disease is caused by the gram-negative bacterium Klebsiella granulomatis. Treatment is directed against the causative microorganism.

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Lymphomatoid papulosis (LyP) is an inflammatory disorder affecting primarily the upper dermal blood vessels. It is characterized by the presence of CD30-positive lymphocytes (sometimes large and atypical) in the dermal infiltrate. Individual lesions resolve spontaneously (albeit over months).

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Epidermolysis bullosa is a heterogeneous group of inherited mechanobullous diseases. Three basic forms are recognized, based on the electron microscopic level of the blister formation. The ideal strategy would be to correct the genetic abnormality; however, since this is not yet possible, the strategy is to avoid cutaneous trauma if possible and to heal the wounds that result from injury to the skin. 

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Cheilitis granulomatosa is sudden onset of swelling of the lips, which progresses to chronic enlargement. The Melkersson-Rosenthal syndrome diagnosis is made when lip enlargement is accompanied by facial paralysis or paresis and scrotal tongue. 

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Pityriasis Rosea

Timothy Berger Bruce Wintroub

Wednesday, March 09, 2011

Pityriasis rosea (PR) is a papulosquamous eruption of unknown etiology. A viral pathogenesis has been proposed but is unproven.

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This form of acne is frequently related to the use of moderate-to-potent topical steroids in the affected areas. In addition to the perioral region, the periorbital area is often also affected. A rim of normal skin usually separates the lips from the affected skin of the chin and cheeks.

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Epidermolysis bullosa acquisita (EBA) is an autoimmune disorder due to autoantibodies to Type VII collagen. EBA may present as a noninflammatory bullous lesion with acral distribution that heals with atrophic scarring (similar to porphyria cutanea tarda).

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Pernio/Chilblains

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Chilblains is a recurrent, localized erythema and swelling of the hands, feet, ears, and face. The reaction is an abnormal reaction to cold that occurs most frequently in women, children, and the elderly. 

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Myiasis

Timothy Berger Bruce Wintroub

Wednesday, June 15, 2011

Myiasis is caused by the larvae of certain botfly species whose larvae penetrate and develop in the skin. The larvae may enter the skin from the bites of other insects that carry the botfly eggs (New World), or by direct skin contact with the eggs deposited on beaches or clothing (Africa).

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Scabies

Timothy Berger Bruce Wintroub

Wednesday, November 09, 2011

Scabies is a highly contagious infestation due to the skin mite,Sarcoptes scabiei. Typical sites of infestation are: wrists, ankles, interdigital web spaces, umbilicus, intertriginous sites (axilla, inguinal folds), and genitalia.

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