Medical Dermatology Services
|Acne Treatment||Rosacea Treatment||Eczema Treatment|
|Psoriasis Treatment||Female Baldness Treatment||Vitiligo Treatment||Intralesional Corticosteroids|
Psoriasis is an inherited skin disorder producing red, thickened areas with silvery scales, most often on the scalp, elbows, knees, and lower back. Some cases, of psoriasis are so mild that people don’t know they have it. Severe psoriasis may cover large areas of the body. Pustular psoriasis can be life-threatening. Psoriatic arthritis may occur. Hughes Dermatology can help even the most severe cases.
We have a complete “Psoriasis Center” offering the latest narrow band UVB and PUVA treatments with our state of the art light box with hand & foot units. We have 35 years of experience and interest treating extensive, difficult psoriasis with phototherapy.
Psoriasis Treatments include:
This is a medication developed in England that works well on tough-to-treat thick patches of psoriasis. It can cause irritation and temporary staining of the skin and clothes. Newer preparations and methods of treatment have lessened these side effects. Hughes Dermatology has had many years of experience and success with this useful medication.
Special preparations of anthralin are especially useful for scalp psoriasis. It may be combined with narrow band UVB or PUVA.
Narrow band UVB
This latest phototherapy treatment involves exposing the skin to a wavelength of ultraviolet light called narrow band UVB. It may be used alone or in combination with topical or systemic treatments. Narrow band UVB is administered with our Daavlin light box and hand & foot unit. It takes about 12-24 treatments over a one to two month period for clearing to occur. It may produce a long term remission. Narrow band UVB is generally safe and effective, but it can have unlikely side effects. The risk of skin cancer is actually less than those caused by sun exposure.
Narrow band UVB is almost a effective as PUVA and is less expensive because costly systemic medications are not required. It is safe in pregnancy. Narrow band UVB can be combined with short term cyclosporine, acitretin or methotrexate to speed clearing of psoriasis.
Narrow band UVB is also effective treatment for widespread vitiligo and mycosis fungoides. It is helpful adjunctive therapy for severe atopic dermatitis and erythroderma.
New information: Because biologic treatments slightly increase the risk of contracting TB and with the new worry about drug resistant TB, narrow band UVB is the preferred treatment for severe psoriasis (as long as there is no psoriatic arthritis). It is usually combined with Soriatane for a quicker response.
When psoriasis has not responded to other treatments or is widespread, PUVA is effective in approximately 85% of cases (95% if taken with Soriatane – see below). Patients are given a drug called psoralen which may be taken orally or applied to the psoriasis plaques and then exposed to a carefully measured amount of a special form (UVA) of ultraviolet light with Hughes Dermatology’s new Daavlin phototherapy box and hand and foot unit. The treatment name “PUVA” comes from the combination psoralen + UVA, the two factors involved. It takes approximately 12-24 treatments, over a one or two month period, before clearing occurs. Because psoralen remains in the lens of the eye, patients must wear UVA blocking eyeglasses when exposed to sunlight from the time the psoralen is taken until sunset that day. PUVA treatments over a long period increase the risk of skin aging, freckling, and a slight increase in skin cancer. Hughes Dermatology was an FDA investigator during the development of this most effective treatment and we are experienced with PUVA. Most important, PUVA is one of the few treatments that often produces a long term remission (clearing that persists after the treatment is stopped). PUVA is safe in pregnancy.
A recent (2005) published study concluded that the most costly medications were not the most effective. The new biologic treatments are not as cost-effective as oral systemic agents (methotrexate), the new narrow band UVB phototherapy, UVA and psoralen phototherapy (PUVA) or phototherapy combined with acitretin (re-PUVA). Therefore while sometimes useful, biologic agents are not justified as first-line treatment for moderate to severe psorisis. And more recently, MedWire (10/16/09, Piper) reported that research in the Journal of the American Academy of Dermatology (JAAD) suggests that “psoralen plus ultraviolet A (PUVA) is a highly efficacious treatment for patients with chronic plaque psoriasis.”
With the exception of psoriatic arthritis which responds well to the biologic drugs, narrow band UVB (with acetretin or methotrexate) and re-PUVA remain the most clinically effective as well as cost-effective treatments for extensive psoriasis.
This is an oral anti-cancer drug that can produce dramatic clearing of psoriasis when other treatments have failed. Because it can cause side effects (liver toxicity with long term use), regular blood tests are performed. Other side effects include upset stomach, nausea, and dizziness. Methotrexate should not be used by pregnant women, or by women who are trying to conceive a child. Conception should be avoided for at least 12 weeks after stopping methotrexate. Alcoholic beverages should not be consumed if using methotrexate. Because we use methotrexate for a short period of time (3 months usually) and alternate it with other treatments, methotrexate is a safe and effective treatment.
Soriatane (acetretin), a vitamin A-related drug, may be prescribed alone or especially in combination with narrow band UVB or ultraviolet A (“re-PUVA”) for severe cases of psoriasis. At a recent AAD meeting, acetretin was described as the safest oral psoriasis medication for men and women of non-child bearing potential.
Re-PUVA or narrow band UVB with acetretin are the most successful and cost-effective treatments for severe psoriasis, often producing a long-term remission of the disease (clearing that persists after treatment is stopped). Side effects include dryness of the skin, lips, and eyes; elevation of fat levels in the blood (triglycerides). Oral retinoids should not be used by pregnant women, or women who intend to become pregnant during or within three years of discontinuation of therapy, as birth defects may result. Monitoring of the patient’s triglyceride level is required.
Stelara (ustekinumab) was approved by the FDA on 9/25/09! It is a monoclonal human antibody that is said to be unusually safe and effective for psoriasis. A real bonus: after the initial 2 doses, it is injected subcutaneously only every 3 months! Hughes Dermatology is now prescribing this agent for moderate to severe psoriasis. A TB skin test is required prior to starting. It may turn out to be our favorite biologic agent with 75% of patients experiencing near complete clearing of psoriasis. It is as effective for psoriatic arthritis as the tumor necrosis inhibitors.
These new IL-17A inhibitors are highly effective, with 90% of patients achieving a PASI of
75 by week 12.
This is another expensive biologic agent that blocks tumor necrosis factor-alpha (TNF-a), thereby interfering with a key cytokine that contributes to the development of psoriasis. It is used for psoriatic arthritis and cutaneous psoriasis. Enbrel is injected by the patient sudcutaneously once weekly. We have a registered nurse that teaches patient self-injection. Hughes Dermatology has had success in many patients resistant to other modes of therapy.
As mentioned above, a recent published study concluded that the most costly medications were not the most effective. The new biologic treatments are not as cost-effective as oral systemic agents (methotrexate), phototherapy (PUVA) or phototherapy combined with Soriatane (re-PUVA). Therefore while sometimes useful, biologic agents are not justified as first-line treatment for moderate to severe psorisis unless psoriatic arthritis is present.
Humira is a new TNF inhibitor that is more effective that etancercept. Again, it is expensive. If other regimens fail, Humira is an option. At the 2006 summer AAD meeting, it was stated that it may have the safety of Enbrel and the efficacy of Remicade. It was FDA approved for psoriasis in January 2008. It is a great agent for psoriatic arthritis. It does require a TB skin test every 6 months.
Acne is a chronic inflammatory disease of the sebaceous hair follicles. Each follicle contains a tiny hair and multiple sebaceous glands. Under normal circumstances, sebum, the oily substance made by the sebaceous glands, travels up the hair follicle and out to the skin’s surface. However, with acne, sebum is trapped within the follicle and skin bacteria multiplies within the clogged pores. Acne develops on those areas of the skin where sebaceous glands are most numerous: the face, scalp, neck, chest, back, and upper arms and shoulders. Acne typically begins in adolescence, although onset in the twenties or thirties is not uncommon.
A new trigger for adult acne, especially in women, is testosterone medication. Side effects of testosterone are acne, baldness, increase in facial hair and a 30% increased risk in men of heart attack and stroke.
Hidradenitis suppurativa is a subset of acne that produces acne-like cysts in the underarms and groin. This can be successfully treated by Hughes Dermatology. We are a leader in HS management. Intralesional steroids, medical and surgical therapy can produce a remission. The “Mullins Procedure” (unroofing , curettage and electrodessication and secondary intention healing) is the gold standard of surgical therapy. Dr. Hughes has many decades of experience and was trained by Dr. Mullins during his dermatology residency. Our long pulsed ND:YAG laser can be helpful as an adjunctive treatment. A new study in JAMA Dermatology (2013) presents finasteride as another novel therapeutic option.
The Hidradenitis Suppurative Foundation is a valuable source of information and includes a referral list of physicians with expertise in treatment.
Acne Treatment Options
Depending on the type of acne and the extent of the condition, acne can be treated with oral or topical antibiotics or topical retinoids, which may be used alone or in combination. Low dose (“submicrobial dose”) doxycycline or minocycline can be as effective as standard dose therapy and does not effect normal bacterial flora. There is recent evidence that a diet rich in dairy products (high glycemic content) aggravates acne. Isotretinoin (Accutane), a potent drug that requires close monitoring, is sometimes prescribed for severe cystic acne. Isotretinoin is used for 4-5 months and the majority of patients remain free of acne for life. It was called the “most significant medical advance of the 1980’s” and it remains equally valuable in this new millenium. Hughes Dermatology is a participant in the new (3/1/06) intrusive government iPledge program for isotretinoin treatment. Unfortunately, it is currently difficult for patients to get isotretinoin now because of the cumbersome red tape that affects the doctor, patient and pharmacist. Check out the information in Dermatology Times featuring an interview with Drs. Hughes and Tichy about patient difficulty obtaining isotretinoin in the United States. Following appropriate testing and dermatologic consultation with Hughes Dermatology, some patients have elected to obtain this medication in Canada or Mexico. In a new interesting study, isotretinoin was shown to improve hearing!
If antibiotics and retinoids are not successful in managing acne, Hughes Dermatology can utilize chemical peels to unroof acne pustules and exfoliate the stratum corneum of the skin. This exfoliation allows antibiotics and topical retinoids to penetrate the skin more easily to control acne and prevent further outbreaks. Innovative phototherapy is another helpful adjunct, since UV light destroys the c. acnes bacteria that plays a role in acne.
5-alpha reductase inhibitors are safe useful medications in the management of stubborn acne. These include sprironolactone (Aldactone) and birth control pills that contain a progesterone that has a spironolactone-like effect (eg. Yaz or Yasmin). Other estrogen-dominant birth control pills are also sometimes used (eg. Ortho-tri-cyclen). Female acne patients with irregular menstrual periods should see a gynecologist to r/o polycystic ovaries, which can aggravate acne. See Hughes Dermatology for effective control of your acne!
Adjunctive acne treatments include phototherapy (cold quartz lamp) and mini-chemical peels. These are included in most acne visits at no additional charge. The phototherapy suppresses C. acnes, a bacteria that partially causes acne. The chemical peels unroof comedones and help penetration of topical medication.
Lasers, phototherapy and chemical peels are also being used to successfully treat rosacea, a chronic and often progressive skin disease that causes redness and swelling on the face. As many as 14 million Americans have rosacea, most between the ages of 30 and 50. It most commonly affects fair-skinned individuals. Rosacea may begin as a tendency to flush or blush easily, and progress to persistent redness in the center of the face that may gradually involve the cheeks, forehead, chin, and nose. As the disease progresses, the redness becomes more severe and persistent, and small blood vessels, acne-like pimples, and nodules may become visible on the surface of the skin.
Treatment of rosacea includes avoidance of the factors that may cause flare-ups, as well as utilizing smart sun safety including wearing a broad-spectrum sunscreen, protective clothing and hats, and avoiding the sun. Medical therapy includes oral antibiotics and topical prescription products. Some cases are aggravated by overgrowth of a microscopic mite (“demodex folliculitis”) and treatment requires eradication of this arthropod. The associated telangiectasias (“broken vessels”) are successfully treated with Hughes Dermatology’s 3rd generation pulsed dye laser (Candela Vbeam Perfecta)which does not produce bruising (no purpura). We have had 15 years of experience with this modality.
The terms eczema or dermatitis are used to describe certain kinds of inflamed skin conditions including allergic contact dermatitis and nummular dermatitis. Eczema produces red, blistering, oozing, scaly, brownish, or thickened skin and usually itches severely. A special type is called atopic dermatitis or atopic eczema. Eczema can occur in babies, infants, children, and adults.
Until recently, topical corticosteroids have been the mainstay for treating eczema. Although these medications can be quite effective, their misuse can cause a number of side effects including thinning of the skin, formation of dilated blood vessels, stretch marks and infection. When applied around the eyes, topical corticosteroids can cause cataracts and glaucoma. If enough of the steroid is absorbed into the body, affected children may experience suppressed growth.
Now, a new class of drugs called topical immunomodulators or calcineurin inhibitors have been developed. These steroid-free treatments are sometimes helpful in treating eczema without the side effects of corticosteroids. Unfortunately, these new agents often lack efficacy.
Oral anti-asthma medications (leukotriene receptor antagonists) like Singulair are now often combined with the topical medications for effective and safe relief.
Another recent development, “Xolair” (omalizumab), a synthetic anti-IgE antibody, clears severe atopic dermatitis that is resistant to all other forms of therapy. Xolair is an expensive injection, administered every 2 weeks. It has a good record of safety. Xolair was originally developed for asthma. We have had positive experience with this breakthrough drug in therapy-resistant erythroderma (generalized eczema).
Happily, most children “outgrow” atopic dermatitis during adolescence.
Phototherapy (narrow-band UVB or PUVA) is helpful in severe cases of atopic dermatitis. Hughes Dermatology will utilize the appropriate treatment for your child’s eczema.
Contact dermatitis is characterized by redness, swelling, itching, and scaling caused by an allergic substance that makes direct contact with the skin. The condition can develop at any age. The facial version of the disorder is often seen in young and middle-aged adults due to acne mismanagement.
Patch testing (with the new True Test) is done by Hughes Dermatology to determine the allergen so that it can be avoided. Metal (usually nickel)is one of the most common culprits of allergic contact dermatitis, unfortunately made more common due to the popular trend of “body piercing” which can lead to metal sensitivity and infection in the earlobes, upper ears, lips, nose, tongue, navel, breasts and genitalia. Keloidal scarring can also result, but this can be treated by Hughes Dermatology if it occurs.
Hughes Dermatology can diagnosis and treat most types of female baldness. Following a consultation appointment which will include a hair telogen count and laboratory evaluation, a specific diagnosis will be made (examples: telogen effluvium, female pattern baldness, alopecia areata, tinea capitis, psoriasis, lupus, etc.). Telogen effluvium is treated by recognition and treatment of the underlying medical cause. Pattern baldness, which is genetic, is successfully treated with 5-alpha reductase inhibitors and topical minoxidyl. Please see us for treatment of this psychologically devastating malady!
Vitiligo is an inherited depigmenting disorder that is psychologically disastrous and leaves the vitiligo patient prone to extreme photoaging and skin cancer due to the lack of melanin pigment in the skin.
Vitiligo can be successfully treated with topical calcineurin inhibitors, narrow band UVB or PUVA therapy. New: Localized areas of vitiligo can be repigmented with intralesional injections of a dilute corticosteroid solution (JAAD Aug 2014). Narrow band UVB and PUVA are administered with our Daavlin light box and hand & foot unit. Hughes Dermatology is experienced with all modalities of treatment. A study in the May 2007 Archives of Dermatology discovered that narrow-band UVB provides a more uniform repigmentation than PUVA, and adding topical calcineurin inhibitors enhances the success rate. Please call Dr. Hughes or Dr. Tichy and schedule a consultation visit so successful treatment can be initiated.
An intralesional injection of corticosteroids, like triamcinolone, is a versatile tool. Hughes Dermatology uses this for lipoma shrinkage, keloids, hypertrophic scars, acne cysts, hidradenitis suppurativa cysts, Dupuytren’s contracture, and prurigo nodularis. It can be used for psoriatic fingernail dystrophy and mucous cysts of the finger.