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Presentation

Practical Dermatology Pearls on Measles, HIV, Pruritus, Steroid Overuse, and Treatment Strategies

Description

This dermatology talk offered practical pearls on recognizing and treating common and challenging conditions. Measles was emphasized as still present and reportable, with cough, coryza, conjunctivitis, and rash strongly suggesting the diagnosis regardless of vaccination history. HIV-related skin clues such as verrucous zoster, severe candidiasis, and unusually young zoster were highlighted as signs of undiagnosed infection. The speaker discussed naltrexone for pruritus and inflammatory or acantholytic disorders, NAC and pentoxifylline as low-cost anti-inflammatory adjuncts, and approaches to delusional parasitosis using empathy plus medications like aripiprazole, which was favored for fewer side effects. Severe itch or burning may reflect steroid overuse or steroid atrophy; topical anesthetics, promoxine, short courses of cyclosporine, and attention to contact allergy were recommended. Important triggers for refractory eczema included calcium channel blockers and vehicle or ingredient allergies such as fragrance, preservatives, cocamidopropyl betaine, and sunscreens. The talk also covered eruptive keratoacanthomas, often managed non-surgically with 5-FU, methotrexate, acitretin, or occlusive techniques, sometimes avoiding amputation. Methotrexate monitoring was discussed as better done with procollagen type III peptide testing rather than routine liver biopsy, and hepatitis screening should include total core antibody before biologics or TNF inhibitors because core positivity can predict dangerous reactivation. Finally, for dupilumab-associated facial redness or chronic facial dermatitis, the speaker suggested considering Malassezia overgrowth and using Wood’s lamp evaluation and topical selenium sulfide masks, with recurrence common because the organism is part of normal flora.

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Conclusions

Measles is still circulating, and any patient with cough, coryza, conjunctivitis, and rash should be treated as a reportable case regardless of vaccination history.
Verrucous zoster should prompt strong suspicion for undiagnosed HIV or other immunosuppression.
Low-dose naltrexone appears useful for both acantholytic and inflammatory dermatoses, with dose and timing tailored to the condition.
N-acetylcysteine and pentoxifylline are low-cost adjuncts that may help inflammatory, compulsive, and delusional-parasitosis-related conditions.
Severe pruritus is often driven by steroid atrophy, steroid overuse, contact allergy, or medication effects rather than ongoing primary dermatitis alone.
Topical anesthetics, topical JAKs, promoxine, and short-course cyclosporine can be effective rescue strategies for difficult itchy or burning steroid-damaged skin.
Calcium channel blockers are a common, often overlooked cause of refractory eczematous drug eruptions.
Petrolatum-based ointments and patch testing can help identify and avoid vehicle or steroid contact allergy in persistent eczema.
Mometasone ointment is singled out as a useful steroid option because it is less likely to cross-react with other corticosteroid allergies.
Eruptive keratoacanthomas can mimic aggressive squamous cell carcinoma, but many can be controlled with 5-FU, methotrexate, acitretin, or chemo-wrap approaches, often avoiding surgery or amputation.
Methotrexate can be used safely and cheaply in dermatology without routine liver biopsy when fibrosis is monitored appropriately, especially with procollagen 3 terminal peptide testing.
Procollagen 3 terminal peptide monitoring is presented as superior to liver function tests and many alternative fibrosis tools for detecting hepatic fibrosis risk on methotrexate.
Azathioprine and mycophenolate remain useful options when dosed and monitored correctly, especially by checking TPMT and drug levels as needed.
Biologics and JAK inhibitors should be selected based on the patient’s comorbidities, especially whether they have axial arthritis, inflammatory bowel disease, heart failure, multiple sclerosis, or obesity.
Hepatitis screening for immunosuppressive therapy must include a separate core antibody test, because missing occult hepatitis B can lead to catastrophic reactivation on biologics or rituximab.
For psoriasis with joint involvement, IL-17 agents are favored for axial disease, whereas methotrexate and ustekinumab are less reliable choices for axial arthritis.

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