Management of Common Skin Diseases

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Copyright 2007 by Therapeutic Research Center

Pharmacists Letter / Prescribers Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com

Detail-Document #231011
This Detail-Document accompanies the related article published in
PHARMACISTS LETTER / PRESCRIBERS LETTER
October 2007 ~ Volume 23 ~ Number 231011

Management of Common Skin Diseases

Background
Patients often seek advice from pharmacists on how
to manage skin problems. Some can be managed with
over-the-counter (OTC) preparations. Others require
evaluation by a physician and prescription medications.
The following table includes descriptions and some
online pictures of the most common conditions, as well
as an outline of treatment and special considerations
for patient counseling. A glossary of dermatologic
terms is included below, in addition to a list of
conditions according to body location.

Glossary
1,2,3

Bulla: A large vesicle, greater than 0.5 to 1 cm in
diameter. Example: Second-degree burn.
Comedone: Blackhead or whitehead; plugs of
sebaceous material in follicle. Example: Acne.
Crust: Mass of skin exudate, color varies.
Example: Impetigo.
Erosion: A shallow lesion caused by the loss of
epithelium.
Exanthem: A skin eruption that bursts forth or
blooms. Example: Measles.
Fissures: Sharply-defined linear break in the
skin. Example: Athletes Foot.
Lichenification: Diffuse thickened and scaly area.
Macule: Small flat lesion, up to 0.5 to 1 cm in
diameter. Example: Freckles.
Nodule: Dome-shaped, round lesion, greater than
0.5 to 1 cm in diameter.
Papule: Elevated lesion, up to 0.5 cm in
diameter. Example: Wart.
Patch: Large macule, greater than 0.5 to 1 cm in
diameter. Example: Vitiligo.
Petechiae: A circumscribed deposit of blood less
than 0.5 cm in diameter.
Plaque: A group of papules that are clustered
together, circumscribed, elevated; greater than
1 cm in diameter; flat top. Example: Psoriasis.
Pruritus: Itching.
Pustule: Fluid-filled papule containing pus,
circumscribed, elevated. Example: Acne,
Impetigo.
Scale: Shedding, dead skin cells. Examples:
Dandruff (greasy), Psoriasis (dry).
Telangiectasis: Dilated superficial blood vessels.
Example: Rosacea.
Ulcer: Lesion that is deeper than an erosion,
caused by breakdown of epidermis and dermis.
Urticaria: Hives.
Vesicle: Blister; fluid-filled papule,
circumscribed, elevated, up to 0.5 to 1 cm in
diameter. Example: Early Herpes Zoster, Contact
Dermatitis.
Wheal: Edematous and transitory papule.
Example: Hive.

Common skin disorders by location
Scalp: Seborrheic dermatitis, contact dermatitis,
psoriasis, pediculosis.
Ears: Seborrheic dermatitis, psoriasis, atopic
dermatitis, actinic keratoses.
Face: Acne, rosacea, impetigo, contact
dermatitis, seborrheic dermatitis, herpes simplex,
actinic keratoses.
Eyelids: Contact dermatitis due to fingernail
polish or hairspray, seborrheic dermatitis, atopic
dermatitis.
Posterior neck: Seborrheic dermatitis, psoriasis,
contact dermatitis.
Mouth: Herpes simplex.
Axillae: Contact dermatitis, seborrheic
dermatitis, erythrasma.
Chest and back: Rosacea, acne, seborrheic
dermatitis, psoriasis.
Groin: Tinea, candida, bacterial infection,
scabies, pediculosis.
Penis: Contact dermatitis, fixed drug eruption,
herpes simplex, scabies.
Hands: Contact dermatitis, atopic dermatitis,
psoriasis.
Cubital fossae and popliteal fossae: Atopic
dermatitis, contact dermatitis.
Elbows and knees: Psoriasis, atopic dermatitis.
Feet: Fungal infection, primary or secondary
bacterial infection, contact dermatitis from
footwear or foot care, atopic dermatitis, psoriasis.
(Detail-Document #231011: Page 2 of 17)
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Pharmacists Letter / Prescribers Letter ~ P.O. Box 8190, Stockton, CA 95208
Phone: 209-472-2240 ~ Fax: 209-472-2249

Disease Who gets it?
What is it caused by?
What does it look like? How is it treated? Comments
Acne vulgaris
1,4,5
80% of Americans are affected at
some point in life. Acne may persist
through middle age.

Disorder of sebaceous hair follicles
associated with excess sebum
production, abnormal desquamation,
and presence of Propionibacterium
acnes.
Comedonal acne: No
inflammation, open and/or
closed comedones.
Inflammatory acne: Papules
+/- comedones. Edematous
pustules and plaques, may
have scars.
Nodulocystic: Deep and
severely inflammatory with
cysts, plaques, nodules, and
scars.
Topical:
Tretinoin (Retin-A)
Benzoyl peroxide
Salicylic acid
Azelaic acid (Azelex)
Adapalene (Differin)
Tazarotene (Tazorac)
Clindamycin/erythromycin
Systemic:
Tetracyclines
Erythromycin
TMP/SMX
Isotretinoin (Accutane)
Oral contraceptives with low
androgenic progestin for women
with all types of acne.
Other:
Corticosteroid injection of cysts
can decrease scarring.

Can be caused or worsened
by some drugs (anabolic
steroids, androgens,
corticosteroids).
Refer all but mild
comedonal acne to primary
care provider.
See Detail-Documents:
#220709 (U.S.)-New
Formulations of
Tetracyclines (Solodyn and
Oracea)
#210312-Comparison of
Antimicrobial Treatments
for Mild to Moderate
Acne

Actinic keratoses
6
Most common in middle-aged or
elderly people with fair skin, light
eyes, blonde or red hair, freckles as a
child, and those who sunburn easily.
Risk also related to greater sun
exposure.

Precursor to squamous cell
carcinoma.
Lesions occur on sun-exposed
parts of the body. Dry, scaly
papule up to several cm in
diameter. Color varies from
the same as skin to red-brown
or yellow-black.
Prevention: Limit sun exposure
and wear sunscreen with UVA
and UVB protection.
Treatment:
Cryosurgery/surgical removal
Laser surgery/dermabrasion
Topical retinoids
Topical chemotherapy (5-
fluorouracil [Efudex])
Imiquimod (Aldara)
Topical diclofenac (Solaraze)
Aminolevulinic acid (Levulan
Kerastick)

See Detail-Document:
#200507-Aldara
(Imiquimod) Approved for
Actinic Keratoses

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Atopic dermatitis
7,8

Eczema
Chronic condition. Most common in
children and young adults. Often
develops in infancy.
Has genetic link (more common if
family members have atopic
dermatitis, asthma, hay fever, chronic
allergic rhinitis).
Most patients have dry skin.
Patches with red raised
vesicles; may ooze.
Infants: Typically affects face
and chest first, then forearms,
extensor surfaces of legs, and
ankle flexors.
Older children: Symmetrical
pruritic papules and vesicles
on flexor surfaces of elbows
and knees.
Topical corticosteroids (base
potency on severity of rash)
Topical immunosuppressants
(tacrolimus [Protopic],
pimecrolimus [Elidel])
Topical magnesium salts
Oral immunosuppressants for
severe disease.
Hydrate skin with moisturizers.
Oral antihistamines for pruritus.
Avoid allergens and irritants.
Refer suspected cases to
primary care provider or
dermatologist.
Goal of therapy is control,
not cure. Exacerbated by
irritants like soap,
detergents, extreme
changes in temperature or
humidity, mold, dust, and
pollen. Secondary
infection is common.
#220333 (U.S.)-
Comparison of Topical
Corticosteroids
#210407-FDA Public
Health Advisory Elidel
(pimecrolimus) Cream and
Protopic (tacrolimus)
Ointment

Rosacea
9,10

Peak incidence between 40 and 50
years of age.

Etiology is unknown.
Inflammatory papules and
pustules on central face with
background of erythema and
telangiectases. Flushing and
blushing. Often confused with
acne, but rosacea does not
Prevention: Avoid triggers.
Treatment:
Topical therapy: metronidazole,
azelaic acid, sulfacetamide plus
sulfur, clindamycin
Oral therapy: tetracyclines,
primary care provider or
dermatologist.
Exacerbated by topical
corticosteroids. Triggers
include sunlight, extreme
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Rosacea (cont.) usually affect areas other than
face, has erythema, and does
not have comedones.
metronidazole, macrolides
Tretinoin (Retin-A) and
isotretinoin (Accutane) for
antibiotic-resistant cases.
temperatures, stress, hot
water, alcohol, wind, skin
care products.
#230210-Drug Treatment
for Rosacea
#220709 (U.S.) New
Formulations of
Tetracyclines (Solodyn and
Oracea)
#200553-Ocular Rosacea

Plaque-like or scaly disorders: All are characterized by accelerated epidermal cell turnover.
Psoriasis
11

Usually occurs in adults.
Chronic immune-mediated disorder
with exacerbations and remissions.
Can cause arthritis. Genetic
predisposition with environmental
triggers (stress, injury, infection, and
drugs). Drugs that can trigger or
worsen psoriasis: lithium,
chloroquine, hydroxychloroquine,
quinidine, propranolol, quinacrine,
indomethacin. Severity based on
amount of skin involved: less than
2% is mild, 3% to 10% is moderate,
more than 10% is severe. Plaque is
the most common form, about 80%
of cases.
Plaque: Red patches with
white/silver flakes; often
affects knees, elbows, scalp,
trunk, nails. Pain and pruritus.
Small pinpoint bleeding when
scales removed.
Guttate: Small, red, individual
drop-shaped lesions.
Inverse: No scales; smooth,
dry areas in skin folds/creases.
Pustular: Dermatologic
emergency. Generalized
(rare) or localized (pustules on
hands and feet or finger tips
on background of red plaque).
Erythrodermic: Widespread,
large, red, fiery patches with
severe pain and pruritus.
Topical:
Corticosteroids
Calcipotriene (Dovonvex)
Coal tar
Salicylic acid
Tazarotene (Tazorac)
Anthralin
Tacrolimus (Protopic)
Pimecrolimus (Elidel)
Systemic:
Methotrexate
Oral retinoids (acitretin
[Soriatane])
Cyclosporine
Alefacept (Amevive)
Efalizumab (Raptiva)
Etanercept (Enbrel)
Sulfasalazine (Azulfidine)
Phototherapy:
Adjunctive therapy:
Moisturizers: Greasy
formulations like Eucerin,
Aquaphor, Vaseline,
Neutrogena Norwegian
Formula Hand Cream.
Bath oils
Epsom salts or dead sea
salts to remove scale and
relieve pruritus.
Avoid oral corticosteroids;
withdrawal may exacerbate
psoriasis.
Pustular psoriasis can be
induced in patients with
stable psoriasis by systemic
corticosteroids, infection,
or severe trauma.

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Psoriasis (cont.) Sunlight
UVB
Pulsed dye laser
Excimer laser
PUVA
#220333 (U.S.)-
Comparison of Topical
Corticosteroids
#191213 (U.S.)/#211217
(CAN) New Drug:
Raptiva (Efalizumab)
Injection
#190311 (U.S.)/#201217
(CAN)-New Drug:
Amevive (Alefacept)
#210716 (CAN)-Biologic
Agents for Psoriasis
Seborrheic
dermatitis
1,12

Chronic disorder with exacerbations
and remissions. Usually occurs in
adults. Common in HIV-positive
patients.

Etiology unknown. Characterized by
increased sebaceous gland activity.
Erythema with greasy yellow
scaling on hairline, nasolabial
folds, scalp, axillae, sternum,
groin. Pruritic.
Sicca: Dry, white, flaky,
eczema-like.
Oleosa: Inflammatory form
that occurs in people with oily
skin (may also suffer from
rosacea).
Remove overlying scale with
OTC keratolytic agents:
Salicylic acid, sulfur
Reduce cell turnover with OTC
cytostatic agents:
Selenium sulfide, tar, ciclopirox,
ketoconazole, pyrithione zinc

Topical corticosteroids for
severe eruptions.
Exacerbated by poor
hygiene, warm/humid
climate, high-fat diet,
alcohol, fatigue.
#221009 (U.S.) New
Formulation: Xolegel
(Ketoconazole Gel 2%)
Dandruff
12
Appears at puberty and peaks in
young adults.

Pityrosporum ovale may play a role.
Diffuse shedding of white or
grey, dry scales on scalp.
Wash hair daily or every other
day. If no improvement,
consider shampoo/rinse with:
Pyrithione zinc, Salicylic acid,
Selenium sulfide, Coal tar,
Sulfur, or Ketoconazole.
Coal tar may discolor light
hair, jewelry, and clothing.
Scalp conditions in
children <2 years should be
referred to primary care
provider.
Drug or chemically-induced skin reactions
Allergic contact
dermatitis
1

Delayed hypersensitivity reaction.
Common causes are benzocaine,
neomycin, lanolin, nickel, or chrome.
Vesicular, pruritic, redness at
points of contact with allergen,
but can spread beyond.
Usually occurs within 48
hours of contact with allergen.
Remove allergen.
Can use topical corticosteroids.
Systemic corticosteroids for
severe cases.
Oral antihistamines for pruritus.
Patch testing may help
determine cause.
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Irritant contact
dermatitis
1

Contact with irritant can lead to over-
drying. Often caused by soaps,
detergents, or solvents. Prolonged
exposure to moisture can lead to
maceration.
Patches/plaques with
erythema, pain, erosion,
fissure, lichenification, scale.
Often occurs in finger webs
and on backs of hands. May
worsen over weeks to months.
Avoid irritant.
If skin is overdry, lubricate with
cream. If macerated, avoid
moisture.

Poison ivy/oak
1
Allergic contact dermatitis to
Toxicodendron. Allergen is urushiol.
Erythematous, pruritic
eruption within 2 days of
exposure. Rash may appear as
lines from ends of leaves
scraping across skin.
Treatment:
Wash within 1 hour of exposure
to remove urushiol.
Topical/oral corticosteroids
Prevention:
Recognize and avoid plants.
Protective clothing
Bentoquatam (Ivy-Block)
Mango peel contains
urushiol.
#210706 (U.S.)
Management of Poison
Ivy
Fixed drug
eruption
13

May be a form of delayed
hypersensitivity.

Drugs commonly implicated are
NSAIDs, sulfonamides, tetracyclines.
Lesions recur at same site with
rechallenge. Usually occurs
within 1 to 2 weeks of starting
sensitizing drug. At least one
round, well-demarcated, red,
edematous plaque. May have
central bulla. Most often on
oral/genital mucosa, but also
on hands, legs, face. Hyper-
pigmentation may persist for
several months.
Discontinue drug.
Systemic corticosteroids may be
required for severe reactions.
Antihistamines for pruritus

Maculopapular/
morbilliform drug
eruption
Drug exanthem
13,14

Any drug can cause an exanthem.
The most common agents are beta-
lactam antibiotics, sulfonamides,
gentamicin, anticonvulsants,
allopurinol.
Measles-like rash (bright red
macules, slightly raised
papules) symmetrical on trunk
and proximal extremities.
May occur within 1 week of
starting drug, or as late as 2
weeks after stopping. Benign
course of 1 to 2 weeks.

Discontinue drug. Ampicillin causes maculo-
papular rash in almost all
patients with infectious
mononucleosis. Rash is
not IgE-mediated (unlike
urticaria). Rechallenge
does not cause immediate
hypersensitivity reaction.
15
See Document:#211206-
Beta-lactam sensitivity
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Urticaria and
angioedema
37

Can be type I hypersensitivity
reaction (IgE-mediated, penicillin or
bee sting allergy) or non-
immunologic (radio contrast, ACE
inhibitors, NSAIDs, histamine
release from codeine and morphine).
Some cases of urticaria are
idiopathic. Physical urticaria may
triggered by cold, sun, cholinergic
stimulation.
Well-demarcated, pale to
erythematous papules,
plaques, or wheals. Urticaria
lesions are transient, migrate
(specific wheals last less than
12 hours), and may be
generalized or localized. In
angioedema, large hives have
poorly defined margins and no
color change.

Systemic corticosteroids and
high-dose antihistamines for
severe urticaria/angioedema

Refer suspected cases of
anaphylaxis to emergency
care immediately.

Skin testing may help
determine cause of IgE-
mediated reaction.
Photosensitivity
16
Phototoxic or photoallergic reactions.
Drugs commonly associated with
photosensitivity include
tetracyclines, isotretinoin,
sulfonamides, thiazides,
sulfonylureas, amiodarone,
phenothiazines, lomefloxacin,
ciprofloxacin.
Sun-exposed skin affected.
May look like exaggerated
sunburn or may blister.
Prevention:
Sun avoidance.
Sunscreen with UVA and UVB
protection.
Treatment:
Topical and systemic analgesics
Cooling creams or gels
Antibacterial creams for broken
skin
Oral antihistamines for pruritus
Topical or systemic
corticosteroids

#200509-Drug-Induced
Photosensitivity
Chloasma
2

Melasma
Mask of pregnancy
Usually occurs in young women.
Some cases occur during pregnancy;
others may be related to use of oral
contraceptives, hormone replacement
therapy, hormonal therapy for
infertility.
Etiology unknown.
Symmetrical, irregular brown
macular rash in women;
occurs on forehead, sides of
face, and neck.
Sunscreen (sunlight intensifies
pigmentation) and sun avoidance
Hydroquinone preparations
(Melanex, Lustra)
Tretinoin (Retin-A)
Mequinol plus tretinoin (Solag)
Discontinue oral
contraceptive/HRT.

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Stevens-Johnson
syndrome
35

Occurs most often in children and
young adults, and in those being
treated for seizure disorders. Drugs,
specifically phenytoin, phenobarbital,
sulfonamides, and penicillin, are the
most common cause.
Skin lesions are flat atypical
targets or purpuric maculae
that are widespread or
distributed on the trunk,
palms, and soles.
Bullae appear on the
conjunctivae, mucous
membranes, anorectal
junction, vulvovaginal region,
and urethral meatus.
Ulcerative stomatitis leading
to hemorrhagic crusting is the
most characteristic feature.
Systemic corticosteroids
Burrows compresses
Oral antihistamines
Topical corticosteroids
Suspected cases should
seek medical attention
immediately.
#210408-Ibuprofen and
the Risk of Stevens-
Johnson Syndrome
Bacterial skin infections: Signs include redness, swelling, scaling, and blistering. Symptoms include itching, pain, and burning.
Cellulitis
17,18
Usually occurs near a break in the
skin like a surgical incision, wound,
tinea infection, or ulcer.
Can affect any part of the
body. Inflammation (red,
warm, and swollen) with
poorly-marked, advancing
borders. May have pain,
fever, and elevated white
blood cell count.
Penicillinase-resistant penicillin
First-generation cephalosporin
Amoxicillin-clavulanate
Fluoroquinolones (adults only)
Consider IV second/third-
generation cephalosporin in
diabetics, unresponsive
infections, children, and
immunocompromised patients.
Refer all suspected cases to
primary care provider.

Mild infections can be
treated orally. Severe
infections require IV
antibiotics.
Community-
acquired methicillin-
resistant S. aureus
(CA-MRSA) skin
infection
18

More likely with a break in the skin,
contact with contaminated items and
surfaces (e.g. the gym), in crowded
living conditions, and in those with
poor hygiene.
May present as a pimple, boil, or
abscess. Frequently mistaken for a
spider bite.
Red, swollen, and painful,
may have pus or other
drainage. May have pain,
fever, and elevated blood cell
count.
Primary treatment should be
incision and drainage.
Consider TMP/SMX (high
dose), tetracyclines, linezolid, or
clindamycin according to
sensitivities or for empiric
treatment in those with systemic
symptoms, rapidly progressing
infection, immunocompromised,
or failure to respond to drainage.
Resistance to tetracyclines
and fluoroquinolones may
be increasing in
prevalence. Resistance and
treatment failures have
been documented with
clindamycin.
In locations where the
prevalence of CA-MRSA is
>10%-15%, empiric
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Community-
acquired methicillin-
resistant S. aureus
(cont.)
therapy for skin infections
may be modified to include
coverage for CA-MRSA.
#221008-Community-
Acquired Methicillin-
Resistant Staphylococcus
aureus: An Update

Erysipelas
17

St. Anthonys fire
Not usually associated with a break
in the skin. Pathogen is beta-
hemolytic streptococcus.
Bright red, painful with
sharply-marked borders. May
have prodromal flu symptoms,
lymphatic streaking. Often
affects legs or face.
Oral or IV penicillin Refer suspected cases to
Impetigo
17,19,20
Usually occurs in children 2 to 5
years of age. Primarily caused by
Staphylococcus aureus. Small
vesicle form can be streptococcal.
Spread by direct person-to-person
contact.
Develops rapidly in a local
area. Two types can occur
separately or together.
Bullous: Large thin-walled
vesicle.
Non-bullous: Small vesicles
with adherent/oozing honey-
colored crust.
Oral (if multiple lesions or dont
respond to topical agents):
Macrolides
Penicillinase-resistant penicillin
First-generation cephalosporin
Amoxicillin-clavulanate
Clindamycin
Tetracycline
TMP/SMX
Fluoroquinolone (adults only)
Topical:
Mupirocin (Bactroban)
Retapamulin (Altabax)

Children should stay home
from school until at least
24 hours after antibiotics
have been started.
Nasal carriage of S. aureus
is linked to recurrent
infection; can eliminate
with intranasal mupirocin.
#230605 (U.S.) New
Drug: Altabax
(Retapamulin 1%
Ointment) for Impetigo

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Lyme disease
21
Lyme disease is caused by the bite of
the blacklegged or deer tick, which
can transmit the bacteria Borrelia
burgdorferi to humans.
Erythema migrans is described
as a bulls-eye rash. It is a
round or oval-shaped,
expanding erythematous skin
lesion at the site of a tick bite.
Typically occurs 7 to 14 days
after the bite of the tick.
May be preceded or
accompanied by flu-like
symptoms.
Oral antibiotics (doxycycline,
amoxicillin, cefuroxime, or a
macrolide).
Systemic manifestations may
require IV antibiotics.
Suspected cases should be
instructed to seek medical
attention immediately.

#230711-2006 IDSA
Lyme Disease Guidelines
Rocky Mountain
Spotted Fever
36

Rocky Mountain Spotted Fever is
caused by the bacteria Rickettsia
rickettsii, which is transmitted to
humans by ticks.
The maculopapular, petechial
rash typically begins around
the wrists and ankles but may
start on the trunk or be diffuse
at the onset. Rash on the
palms and soles is considered
characteristic, but it occurs in
only 36% to 82% of patients
who have a rash. The rash is
most likely to occur three to
five days after the onset of
fever and flu-like symptoms.

Tetracyclines
Chloramphenicol
Suspected cases should be
instructed to seek medical
attention immediately.

About 10% to 15% of
patients with Rocky
Mountain Spotted Fever
wont have a rash. This
occurs most frequently in
older patients and in black
patients.
Fungal skin infections
Tinea pedis
12

Athletes Foot

Usually affects white males, in
tropical urban areas. Most common
in adults. Associated with public
swimming pools/showers and sports
that have high-impact on the feet
(moist footwear).

Dermatophyte infection.
Four types that may overlap.
Intertriginous, chronic:
Fissures, scales, or maceration
between toes. May have foul
odor, pruritus, stinging
sensation. May spread to
instep/sole of foot.
Papulosquamous, chronic:
Mild inflammation and
diffuse, moccasin-like scales
on soles of both feet.
Clioquinol/hydrocortisone
Topical antifungals:
Butenafine, Clotrimazole,
Miconazole, Terbinafine,
Tolnaftate, Povidone-iodine, or
Undecylenic Acid.

If deep fissures are present in
wet/soggy type of infection,
apply aluminum chloride.
May develop secondary
bacterial infection,
especially in diabetic
patients.
1

Advise patients to avoid
moisture and occlusion.
1

Beware of brand extensions
(product may not contain
what brand name suggests).

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Tinea pedis (cont.) Vesicular: Small vesicles/
pustules and scales on the
instep and mid-anterior plantar
surface of the foot. More
common in the summer.
Acute ulceration: Macerated,
denuded, weeping ulcers on
the sole of the foot.

#200312 (U.S.) New
Drug: Sertaconazole
Nitrate (Ertaczo)
Tinea corporis
12

Body ring worm
Transmission in day-care setting.
Common in hot and humid climates.

Small, circular, red, scaly
areas that spread peripherally.
May be pruritic. Can occur on
any part of the body.
Clioquinol/hydrocortisone
Topical antifungals (see Tinea
pedis)
Clioquinol not for use in
children <2 years. Concern
is for sub-acute myelo-
optic toxicity due to
systemic absorption across
the skin.
Sprays and powders less
effective than creams.

Tinea capitis
12,22,23

Scalp ring worm
Especially common in black girls.
Spread by direct contact, combs,
hats, telephone, bed linens.
Noninflammatory: Papules
with scale around hair shafts.
Affected hair is dull grey color
and breaks off above scalp.
Inflammatory: Pustules/kerion
(weeping lesions that crust
over). May have fever, pain,
lymphadenopathy.
Black dot: Hairs break off at
scalp and leave black dots.
Favus: Patchy hair loss and
scutula (hairs matted together
with yellow crusts and scales).

Treat with systemic antifungal
therapy:
Griseofulvin
Itraconazole
Fluconazole
Terbinafine

Can cause permanent hair
loss if untreated.
More. . .

Phone: 209-472-2240 ~ Fax: 209-472-2249

Parasites
Head lice
24,25

Pediculosis
Pediculus humanus
capitis infestation
Children 3 to 12 years old are
infested most often, especially girls.
Scalp redness and scaling;
brown/black/gray nits (eggs)
on hair shafts; adult lice on
scalp. Causes pruritus.
Topical:
Permethrin 1%
Pyrethrins plus piperonyl
butoxide
Malathion (Ovide)
Alternatives (Oral):
Ivermectin (Stromectol)
TMP/SMX

Consider retreatment in 7 to 10
days.
Manual nit removal also advised.
Lindane is 2nd-line due to risk
of neurotoxicity (contraindicated
in pregnancy, newborns, use
with extreme caution in children
<50 kg). Never dispense more
than one dose.
Refer to primary care
provider if no dead lice and
if, 8 to 12 hours after
treatment, lice continue to
be as active as they were
before treatment. Wash
clothing and bedding or put
in plastic bags for a week.
#220210-Suffocation-
Based Treatment for Head
Lice
#190509 (U.S.) FDA
Issues Health Advisory
Regarding Labeling
Changes for Lindane
Products
Scabies
27,28

Sarcoptes scabiei
infestation
Children and adolescents infested
most often. Spread by skin-to-skin
contact. Pruritus is caused by
sensitization to parasite. Scabies is
often acquired sexually in adults, but
not in children.
Extreme pruritus. Raised
serpentine lines several cm
long caused by mites
burrowing under the skin.
Inflammatory red papules
between fingers, around wrists
and waist, in armpits, in groin,
and on elbows and knees in
adults. Lesions can be more
widespread in children. Rash
and pruritus may persist for 2
weeks after treatment.
Topical:
Permethrin 5%
Crotamiton (Eurax)
Oral:
Ivermectin (Stromectol)-
alternative especially for crusted
scabies.

Retreat if symptoms persist 1 to
2 weeks after treatment or if live
mites are seen.
Lindane is 2nd-line due to risk
of neurotoxicity (contraindicated
in pregnancy, newborns, use
with extreme caution in children
<50 kg). Never dispense more
than one dose.
Wash clothing and bedding
or remove from body
contact for 72 hours.
Treat sexual and household
contacts.
#190509 (U.S.) FDA
Issues Health Advisory
Regarding Labeling
Changes for Lindane
Products
More. . .

Phone: 209-472-2240 ~ Fax: 209-472-2249

Viral infections
Common warts
29,30
Caused by human papillomaviruses.
Spread by person-to-person contact,
autoinoculation from one part of
body to another, or indirectly in
shower/ swimming pool. Virus
enters through abrasion on skin of
immunologically susceptible person.
Up to 20% of school-age children get
warts; peak incidence is 12 to 16
years of age.
Common warts are rough/
cauliflower-like nodules/
papules, 1 mm to 10 mm in
diameter, either alone or in
groups. Can occur on any skin
surface, but most often on the
hands. Pressure on plantar
warts (on heel or ball of foot)
can cause pain.
Duct tape occlusion
Topical salicylic acid liquid, or
salicylic acid in plaster, karaya
gum-glycol, or collodion
vehicle.
Cryotherapy
Intralesional bleomycin
Immunomodulation with
cimetidine/dinitrochlorobenzene
Warts are contagious.
Wash hands after touching
or treating warts.
About 30% of warts clear
spontaneously within 6
months and 65% within 2
years. See Detail-
Documents:
#190610 (U.S.)-New
Product: Wartner
#181216-Cryotherapy
Versus Duct Tape for
Treating Warts

Herpes zoster
1

Shingles
Usually occurs in adults over 40
years old. May be triggered by
immunosuppression, old age, stress,
nerve trauma. Reactivation of
varicella (chicken pox) virus lying
dormant in dorsal nerve root.
Contagious; can cause chicken pox in
susceptible contacts.

Sudden pain, paresthesia, and
systemic prodromal symptoms
may precede lesions. Rash is
unilateral and follows
dermatome. Tender red
papules become vesicular and
pustular.
Treat as soon as possible after
symptom onset with:
Oral valacyclovir/famciclovir
(dosing regimens more
convenient than acyclovir)
Aggressively manage
postherpetic neuralgia.
Prompt antiviral treatment
may prevent postherpetic
neuralgia. Refer to
ophthalmologist if
ophthalmic dermatome
involved. See Detail-
Documents:
#221201 (U.S.) Issues
with Herpes Zoster
(Zostavax) Vaccine
#220702 (U.S.) Herpes
Zoster (Zostavax) Vaccine

More. . .

Phone: 209-472-2240 ~ Fax: 209-472-2249

Herpes labialis
1

Cold sore
Fever blister
Usually caused by herpes simplex 1.
Virus lays dormant between
outbreaks, which are triggered by
stress, sunlight, acute illness.
Occurs on any mucosal
surface, but usually lips.
Prodromal symptoms of
burning, pruritus, swelling.
Vesicles clustered on
erythematous base which
becomes crusted erosion.
Treat as soon as possible after
symptom onset with:
Topical docosanol (Abreva)
Topical penciclovir (Denavir)

Topical acyclovir (Zovirax) Crm
Oral valacyclovir
Can spread to cornea and
cause scarring; avoid
contact sports.
Infection can become
disseminated in HIV-
infected or
immunocompromised
patients.
Varicella zoster
31

Chickenpox

Onset is at an average age of 5 to 6
years.
Caused by varicella-zoster virus.
Generalized, pruritic rash
progressing from macules to
papules and then vesicles prior
to crusting. They usually
appear first on the head, then
the trunk, and then the
extremities. May also occur
on mucosal surfaces.
Adults may experience a
prodrome of malaise and fever
for 1 to 2 days prior to rash.
Rash may be first sign in
children.
Those over the age of one year
with an increased risk of severe
disease or complications and
women in the third trimester of
pregnancy can be treated with
oral acyclovir.
Patients over the age of 12 years
may be treated with oral
valacyclovir or famciclovir.
Immunocompromised patients
should be treated with IV
acyclovir.
Postexposure varicella
virus vaccine (Varivax)
may be administered to
adults and children over the
age of one year.
Varicella zoster immune
globulin (VariZIG) may be
used under an IND for
patients without immunity
who have been exposed to
varicella, and are at high
risk for severe disease or
complications
(immunocompromised
patients, neonates whose
mothers have signs and
symptoms of varicella
around the time of delivery,
preterm infants born at 28
weeks gestation or later
who are exposed during the
neonatal period and whose
mothers do not have
evidence of immunity,
preterm infants born earlier
than 28 weeks gestation or
who weigh 1000 gm or less
More. . .

Phone: 209-472-2240 ~ Fax: 209-472-2249

Varicella zoster
(cont.)
at birth and were exposed
during the neonatal period
regardless of maternal
history of varicella disease
or vaccination, pregnant
women).
#230901 (U.S.)/
#230915 (CAN)-
Immunization Update
2007
Skin malignancies
Basal cell
carcinoma
32,34

Patients who may be predisposed
include Caucasians with light eye
and hair color, marked freckling on
upper back, family history of basal
cell carcinoma, history of sunburn,
history of arsenic toxicity, outdoor
employment.
Most commonly found on the
head, neck, and trunk. Has
diverse clinical appearances.
Topical fluorouracil (Efudex)
Topical aminolevulinic acid
(Levulan Kerastick)
Topical imiquimod (Aldara)
Excision
Radiation
Melanoma
33,34
upper back, family history of
melanoma, history of sunburn,
history of actinic keratosis, outdoor
employment.
ABCD: (A)symetric lesion
with irregular (B)orders and
(C)olor irregularity with
(D)iameter greater than 7mm.
Removal of lesion
Chemotherapy
Radiation
Squamous cell
carcinoma
34

upper back, family history of
melanoma, history of sunburn,
history of actinic keratosis, outdoor
employment.
Often crusty or scaly and may
occasionally bleed. May also
occur as a non-healing ulcer, or
a white, thickened area in the
mouth. Usually appears on
sun-exposed parts of the body.

Removal of lesion
Chemotherapy
Radiation

More. . .
Pharmacists Letter / Prescribers Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
Users of this document are cautioned to use their own
professional judgment and consult any other necessary
or appropriate sources prior to making clinical
judgments based on the content of this document. Our
editors have researched the information with input
from experts, government agencies, and national
organizations. Information and Internet links in this
article were current as of the date of publication.

Project Leaders in preparation of this Detail-
Document: Jill E. Allen, Pharm.D., BCPS;
Stacy A. Hester, R.Ph., BCPS.

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Cite this Detail-Document as follows: Management of common skin diseases. Pharmacists Letter/Prescribers
Letter 2007;23(10):231011.

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