Common in adults as well as adolescents, acne requires combined medical treatments as well as patient education on home care to control the condition and prevent scars. Dermatologist Timothy Berger, MD, dispels acne myths; clarifies which meds are appropriate for which patients; describes possible underlying issues, such as metabolic syndrome and PCOS; and discusses other serious skin issues, from abscesses to staph infections.
I'm the senior dermatologist here at UCSF. Um I started practicing dermatology in 1980. So This is my 42nd year. Um and I was asked to talk about acne and other hustler inflammatory processes in the skin. So that's what we have here today. Um, So I'm going to show up just a few cases, a lot of this, maybe repetition, but I'll try to emphasize uh some practical aspects that are not clearly outlined in the literature. So case 1 18 year old, healthy adolescent, two years of pimples and here he is with particular populace pustules. And he also has prominent closed and open comma domes, which distinguishes acting vulgaris from acne rosacea in adults. That's an important finding because those diseases can overlap. So this would be grade three acting. Popular, popular acne on the cheeks. And the other aspect of it that is important is it's leaving him with pitted scars. So that makes it more important for us to treat this. So this is an almost universal condition when they have, in large studies followed Children through elementary school. The first sign of going through puberty is the development of acne. It precedes everything else. Um, Most cases resolved by age 25, but unfortunately, you look in women Between the ages of 20 and 45, the prevalence of Acne does not decrease. So women tend to have more persistent acting and all dermatologists have practices of middle aged and professional women with uh actually that hangs on, this is not abnormal and doesn't indicate any significant metabolic problem in most of those patients all races get it. And there's often a family history. So you get blackheads and whitehead's. Those are the comma domes and populous and postural those are the things with us. And then inflammatory nodules which go down deep into the fat. The populist partials insists can be scarring. So he biopsy them. This is a bump. Here are a little papi oh, this is a postural enough neutrophils for this to exit and then a deep assist. You can see that in These latter two cases on the my right side, the correctness debris has ruptured outside the hair follicle and it's caused prominent inflammatory response. So this is how we score acne grade 1234. This is a patient who has commandant lacking primarily with a few posture. Als this is called pomade acting and is in part related to the products that are applied to the hair. This is Grade 2- three. Acne popular. Popular. This is scarring. Great four. This is tropical acne. Grade four. This is more common in men. And then here's severe Nigel assistant acne on the trunk. So what elements are important to ask in this case? Well, you want to talk about patients medications, What about their diet, weight gaining and other supplements or all of the above. When all of the above is an answer. That's always the answer. So we have to go through these. There's medications that are used fairly regularly that cause acne lithium and Dilantin, The anti seizure medicines are two of the big one's any patients on systemic steroids, they can get acne. And if there's exogenous androgen being taken and beyond androgen weight gaining supplements of other types can cause acne to flare as well. The other ingesting that worsens. Acne is iodide. Um and iodide is found in seaweed and other products from the ocean. So when I worked in Korea, it was a common problem that people who snacked on a lot of seaweed would get acne. Many multivitamins are made from seaweed or kelp. And so for patients who have acne and are on multivitamins, I have to take the vitamins without minerals. So there's no iodine in there. So why do we get acne? Well, bacteria in the hair follicle, androgens in the circulation. The hair follicle plugging up and oil and all of these are a problem or a progenitor of the acne. So you need to have hormones first. And those have to be androgens. And those androgens wake up the sebaceous gland and produce sebum. The sea bottom is eaten by the bacteria and they break the seven, which is a triglycerides into free fatty acids and those free fatty acids are what caused the inflammation and this is all happening behind a plug in the hair follicle so that this inflammatory process can't exude and instead stays trapped in the hair follicle ruptures. People who have severe scarring acting may also have sort of wimpy follicles so that with limited inflammation, they rupture more easily and tend to scar. So identifying that patient and being more aggressive in their treatment is important. So what do we use to treat Acne? We use oral antibiotics, we use topical benzoyl peroxide that's over the counter and topical retinoids. Um In general, we're going to try to treat all four of these causes and so we combine agents that work in different ways. So we're going to use topical antibiotics for instance, to treat the bacterial component. And we're going to use topical predniSONE or retin a to treat the follicular plugging components for teenagers. This is a big problem. Um and can generate a fairly poor quality of life. There's a correlation between the mood of a teenager and the presence of their acne and it's and it's pretty regular for us treat teenagers to see a big change in there well being when their acne is under much better control and it's important to recognize that once the scarring occurs, we really don't have that great treatments for it. Um and so preventing the scarring is really critically important. So what antibiotics antibacterials you have? Well, topically, we have a rystrom eyes and clinton mice and we have sulfur, just elemental sulfur benzoyl peroxide, remember rystrom eyes and clintonized and can share resistance. So ah if one of these fails, the other may not work. We have anti com Adonal agents. So that trend known as the most commonly used one adapter lean are different which is over the counter, your patients can just buy it. It's less irritating than retin. A and works pretty well. And then benzoyl peroxide, in addition to killing the bacteria also has some anti com Adonal effect. So um these are helpful in treating that follicular plugging. And then we have Accutane which stops the follicular plugging and also markedly reduces sebum production. If you biopsy someone's facial skin who's on Accutane they have no visible sebaceous plans and the biopsy the stem cells are still there. But the sebaceous plans have just uh sort of shrunk up. And so that's one of the reasons why the patients have a fairly sustained remission. After I said that no one um Benzoyl peroxide now comes in a lot of different combinations. The topical antibiotic with the Benzoyl peroxide. There is a problem if you use a single antibiotic that you get resistance. So it's usually better to use benzoyl peroxide with a topical antibiotic, something like with clinton mice. And plus benzoyl peroxide or with the mason. Plus benzoyl peroxide, there are also combinations of antibiotics with retinoids. You notice that there's no combinations of retinoids and benzoyl peroxide because the two of them in activate each other. So if your patient is using benzoyl peroxide and also using retinoids have to put them on at separate times because they'll interfere with each other. So that's why there's no combination of antibiotics. Uh, Benzoyl peroxide and retinoids. The combinations are more expensive, but for kids, they sometimes are a little bit easier as far as compliance is concerned. Okay, so acne is not related to skin, dirt washing more doesn't help. So if the moms in the room and you know, they're going to be maybe bugging their teenager, it's always helpful to have the patients back and say, you know, really more washing and this cleanliness is not going to really helped the acne. And in fact, excessive scrubbing can trigger acne because in those patients who have these fragile follicles, if they start rubbing and scrubbing, they're going to rupture those follicles under the skin and then get inflammatory lesions. So no scrubs, no myths, no sponges, just gentle washing and in fact friction itself triggers acne. So you see that all the time on the buttocks where people like truck drivers will get frictional follicle itis or acne. You guys may be too young, but Dorothy hamill, if you remember who won the olympic gold medal in figure skating, had this flip of a hair do like this. So all the girls were brushing their hair like this and they all got acne on one half of their forehead from the friction of the hair brushing. So uh, friction is not good for acne. Okay, 32 year old professional woman presents complaining of persistent acne. She had acne and her team, she took two courses of Accutane About seven or 8 years apart, that's about how long of course of Accutane on average will last. Um So most people are not cured, but they do get a sustained remission when asked, she says she has normal Menzies and she's frustrated because she still has acne and she's not a teenager anymore, so she's of normal weight, she doesn't have any evidence of your statism, no excess hair. Um And she has follicular popular's primarily along the jawline and around the mouth. And this is a typical pattern of post teenage acne. So it sort of starts here in the center face and then sort of moves out and ends up sort of persisting along the jawline and up into the temporal area. Ah well into The 20s and 30s. So they said, patient who has somewhat that pattern of action. So when you talk to this patient, several of the lessons I've learned is if the patient says they have regular Menzies, you actually have to be more clear about that because um the patient's normal menstrual cycle may be such that they have a period every three months. So they may actually even meet the criteria for pcos even though they feel that's normal menses for them. I think that you can identify those patients who have uh androgen excess or excess androgen effect if they have an oily t zone. So those are the patients who say that they have to use an astringent on their nose or it gets shiny by the afternoon. And if they if this person goes on Accutane and that's one of the first things you'll notice that gets better. You need to think about pregnancy. If you're going to treat a woman who potentially can become pregnant and then I will often have the patient bring in all their stuff and you'd be surprised what you find and then get rid of all the irritating things um in that bucket. So topical antibiotics I think worked really well in this group in uh sort of women past teenage years and I think clintonized and is more effective. Then a rich from eyes and you can add benzoyl peroxide to that topical retinoids are good for this group, but their skin tends to be a little bit more sensitive. And so I start off very slowly. So I'll give the patient the topical retinoid and having to use a thin small amount twice a week to start and then build up if they use it every day right from the beginning, they may get a flare basil. Lake acid is good for mild acne, but for patients who have natural skin pigmentation persons of color, these electric acid tends to diminish the post inflammatory hyperpigmentation. So it's really a good product for persons who have mild acne but that's leading to pigment terry change. And lastly topical sulfur is safe to use um in everyone. Um and has some good activity against acne, just a little smelly topical retinoids have never been shown to cause any kind of fetal problems, but they are not recommended during pregnancy. Benzoyl peroxide is safe. Okay. And then if the patient doesn't respond or has Grade three or 4 acting will give oral antibiotics. Toxie cycling works better than debt recycling is easier to take. Um, and so that's where we usually start. Mini cycling is more effective than doxycycline. It gets pushed into the hair follicle a little bit better. Mini cycling does have a higher rate of causing lupus. And many cycling also causes uh a inflammatory vasculitis. It's identical to poly arthritis, no dosa. So, um, you can get those unusual side effects from the many cycling. And it also causes hyperpigmentation because it's deposited in the skin with this gray color. So you have to watch for that. Um, in my experience, if you treat patients like this with ISA Trenton Owen As opposed to getting that 7-8 year free period that happens with teenage acne. These patients while they're on Accutane, they're great when they go off Accutane for six months. They're great and then it comes right back. So, um, I have to have another strategy to deal with them. I do two things. Uh one is hormonal therapy, which we'll talk about and the other is in patients who can't become pregnant, I may put them on low dose Accutane chronically. And I have patients who take one Accutane pill every two weeks. So two pills a month completely controls their acne, cost 10 bucks. It's the cheapest treatment that works for this refractory acting so that you can do. It's just if the woman is a a child bearing potential, the system doesn't accommodate for chronic Accutane therapy. And so it's problematic. What I usually do is right for a years worth and then put them back on I pledge again. So it's pretty clear that most women who have actually after teenage years have some form of hormonal imbalance and there are different types of that. But those things that hormonal imbalance, which we'll talk about, the different types all respond to this strategy. So you can give an oral contraceptive and the estrogens reduce even production. Or my favorite spironolactone. Spironolactone. Uh It was noted when it was made in the 50s that women who had fine hair on their upper lip that it got much less prominent while they were in spironolactone. And they then documented that it has an anti androgen effect directly on the sebaceous plan. And the dose you need is somewhere between 25 and 100 mg A day. Um And this is my favorite acne treatment for women who have chronic acne in this post teenage year side side effects are totally minimal. There is now good evidence that you don't have to monitor potassium and you can add all backed onto an oral contraceptive to suppress the hormones more or this hormonal effect More? Ah Most people on al backbone don't get hypertension. I do have marathoners and other people who might be doing exercise where they're going to replace a large portion of their body fluids and they may replace those with high potassium drinks. So I do have them stop their spironolactone the day of Sporting event where they're gonna sweat 2, 3, 4 L maybe. But otherwise I don't monitor, patients don't really have many side effects. And it's a great drug for controlling this and much easier for patients to take And avoids the difficulties of i subtract nine. If the patient is frankly here to the female patient, then you need an endocrine work up um which would include free and total testosterone and ideas. If the patient's menstrual cycles are irregular, you might want to work them up for pcos but by far the most common reason that people have persistent acne after teenage years is that they have metabolic syndrome. Um And what happens is in metabolic syndrome, as you know, there's progressive insulin resistance. And so insulin resistance leads to higher insulin levels and those higher insulin levels induce epidermal growth factor, which enhances follicular plugging. So the Type two diabetes metabolic syndrome like polycystic ovarian syndrome is associated with that. Um And there's some interesting dietary information which we'll talk about. So what about stress and diet and acne um that there's now very good studies that stress triggers flares of acne. It increases particular characterization and then changes inflammation. So people often have flares of acting with stress, high glycemic diets, which is essentially the normal young adult teenage US diet ah will worsen acne. And I was in Okinawa when I was a teenager in the Boy Scouts and we would have native Okinawan young man join our scout troop for camp. And half of those people had to be sent back home because when they switched from their japanese diet to our Western diet, they got full minute acne and had to go back home. So I I personally have seen this and now that the mechanism of all this is kind of understood. So Hi B. M. I. Is associated with worse acne if you're past the age of 18. And this again, has to do with this insulin resistance and in addition to causing particular plugging high levels of insulin increased androgen production and reduce sex hormone binding globulin. So you have more free androgen. So as I tell patients, you know, your mom is right, the hamburger is bad, but it's not the greasy hamburger, it's the bun and the fries that are the problem. So in Australia they did this study where they had two cafeterias in two dorms at a university and they randomized students. So what they did is they changed the food they offered them in the cafeteria. The kids were able to eat as much as they want to take as much as they want. But in one cafeteria all the food had a low glycemic load and in the other they had just like the regular diet. And um those mostly boys who were on the low glycemic diet had a much more rapid improvement of their act. Now all of the patients were counseled about the study and in acne studies. What happens is people get better because they take care of their skin a little bit more. They sort of pay attention. They may be on medicines which they then begin to use. So there was this fairly marked reduction and it turns out going on a low glycemic diet for a young man is as effective as going on an oral antibiotic for treating acne. And here are some before and after pictures before after, before after before after. It's not perfect. But that's that's pretty good result for essentially just being on the right diet to be healthy. Right. So so I do council young men about what they eat. Um The other complicating factor is that way which is in a lot of weight gaining products. W. H. E. Y. Which is the protein from milk also has an adverse effect on acne. So that's another dietary thing to be discussed. What about cosmetics? Cosmetics. Get tested for common Magennis itty. So whether they make acne um But they don't label them because if they labeled them non community genic, then people would say, well, what about this over here? It doesn't have that label. Does that make acne? And then of course, what are you gonna say? So the companies don't do that. Um But if you notice that patient is having acting in areas where they're applying makeup, you may want to talk to them about asking specifically for non community genic uh products, sun blocks and moisturizers in addition should be noncommittal genic again, scrubbing, makes acting worse. Okay, so what do we do? We take a menstrual history? We do a dietary history, Especially in males who are over the age of 18. Although I didn't mention one thing in um the globe glycemic diet. Study Boys under the age of 18 didn't benefit from the low glycemic diet. Only the boys over the 18 over the age of 18. So there appears to be a change. So when you're going through puberty, your hormone levels are really high. And then as you get older, if you're acting as persisting, it becomes more related to these other factors that increase your hormone levels. To take a dietary history. Look for here statism and women talk about metabolic syndrome and wait, you're going to use a topical antibiotic. Use it with benzoyl peroxide. And remember our back tone in the woman who is failing oral antibiotics or doesn't want to take chronic oral antibiotics, which in my experience is this is save my behind many many times. Retinoids, topical retinoids are great that start really slow um and stop rubbing and picking. Okay, so now we're gonna talk a little bit about pie a dermis in the skin. Most pious sermons in the skin are due to staph aureus. 5% of people carry staph aureus. 10% of us carry staff warriors because we're healthcare workers. Um and staph aureus lives in your place where you live. So more and more over time. As I practiced, I'm treating larger and larger segments of people around people who have recurrent staph infections and we'll talk about that. Okay, so first case here 35 year old male, two weeks of blisters on the legs which itch a little and you see these little bumps that start around the hair follicle here which is usually the ingress point of the staff. And then they formed this flaccid blister that ruptured. So this is classic bullets impetigo and bullets impetigo in temperate climates is due to staff in tropical climates, it's due to strep. So there's different bacteria that caused the same pathogenic condition whether you're in the tropics or in temperate climates. That's bullets impetigo. And these are the bacterial infections we think of primarily with Steph impetigo follicular itis abscesses. Excimer. We'll talk about then cellulitis and necrotizing fasciitis toxic shock syndromes which can occur from the toxins that staff makes there are a few interesting things about staff when staff colonize is uh dermatitis, it causes the immune cells in the dermatitis to lose their steroid receptors. So if you have a patient who has eczema and they suddenly are getting worse. One of the reasons can be that their eczema is infected with staph. You have normally antimicrobial peptides that your body makes and these things prevent staff. Those antimicrobial peptides are packaged in the oil that goes to the surface of your skin and that oil delivery to the surface of your skin. And that packaging is vitamin D dependent. So if you have low vitamin D. You can get recurrent infections and if you have eczema and low vitamin D. Your eczema does worse and you get more infections. So one of the things that I checked and monitor and treat is vitamin D. In patients who are having recurrent infections. The Nobel Prize was given in 1906 for the concept of sending people with tuberculosis two sanitary, a high in altitude or in the south. And what happened of course when you did that is they got more sunlight. So their vitamin D. Went up and they're tuberculosis did better. So it took us from 1906 to 2006 to figure out why that was the case. But the Nobel committee was correct. Okay this is also a patient with impetigo and in the center is crusted. But you can see here this superficial blister and this is where you want to take a culture. So you can identify the infectious organism. This is follicular itis, a superficial political itis. So you can see that the staff lights to go down the hair follicle. The groin is another place where staff is carried. Anyone who is cultural positive in the groin is usually culture positive from the nose. So we think the nurseries are the primary place where staff lives when we acquire it. If you take health care workers and you have them stick their hand in a plastic bag with you know, culture media. So you can grow out the staff if they have it, if you treat the patient's nose, their hands become culture negative without treating their hands. So it really does suggest that the neary's is where staff lives. Most antibiotics do not penetrate the Neary's except for revamping so and long term plan to myself. So if you have a patient with recurrent diseases, we'll talk about you really need to pick antibiotics that are going to get rid of them or do something to get rid of the nasal carriage. Okay, this is a timer. Ex seaman in the tropics is due to strep in temporal temperate climates is due to staff. It looks like this punched out ulcer patient. May or may not not say that it started like an impetigo lesion. Um These are pretty difficult to treat. The course of antibiotics is long and the patients tend to be recurrent visitors to your clinic. So it's a little bit more of a difficult to manage thing. So you definitely want to know what the culture and sensitivity is because you're going to be on antibiotics for some time. This is an abscess or her uncle carbuncle on the back cellulitis. So inflammation that then causes erythema usually moves from distal to proximal patients can have systemic symptoms and elevated white count. And this is cellulitis with purpura and bully. Uh In a study that they did and harvard they looked at patients who were diagnosed with bilateral cellulitis. All those patients had stasis dermatitis. None of them had cellulitis. So if you see what looks like cellulitis on both legs, think of another diagnosis and if the patient is going to be admitted to the hospital unless they have an elevated white count or toxic you may not need to give them antibiotics because usually it's a fluid problem. And this is necrotizing fasciitis. So an area of deep infection with necrosis of the overlying skin. So the correct treatment for an abscess is I. N. D. Right. If there's pus get it out and in many studies that have been done additional antibiotics in immuno competent people and even invasions with HIV do not improve the outcome. So the treatment is I. And D antibodies alone or not. The treatment for lock related um areas of infection. So you need to get it out. Okay what's the most common cause of cellulitis of the lower extremity in a healthy person. If they don't have a leg ulcer, a healthy person comes in. They got cellulitis, they didn't have an injury. They don't have an ulcer. The problem is athlete's foot. So they get athlete's foot in between the toes, the bacteria over growing there, they kind of caused a little crack and then the strap get in there. And so um in the like basic training at uh in san Antonio for instance, they, you know, screen all the young guys when they come, they give them a talk about looking in between their toes. They give them powder or other things to treat any athletes foot that's there and they reduced the number of admissions of these young recruits into the hospital just by that kind of intervention. So, uh look in between the toes for that. We had poor young girl who had she was a teenager. And so the pediatricians didn't pick up. She had bad athletes foot. She had been admitted six times for cellulitis. She got a course of oral to benefit and that was it. She was not in the hospital anymore. Okay, what about treating community acquired MRSA? What antibiotics do we use? This is one of the reasons now that I more and more want to culture patients because I want to know what their sensitivities are because I'm going to take antibiotics and they may end up with recurrent infections. So I want to know what antibiotics they're bug is sensitive to whatever antibiotic you're community uses as first line for staff. What will happen over time is that that it will become resistant. So when I was practicing in the Late 80s here in San Francisco, I was at San Francisco General Hospital had a huge HIV population. Um and many of those patients were unsolved myth. Oxydol prime method prim for PCP prophylaxis. You guys may remember those days. Um And all the staff that we cultured was self from a toxic try method from resistance now because everybody uses doxycycline because they're worried about MRSA. All we're culturing is doxycycline resistant staph and all the staff in the community is now sensitive to sell from a Fox's old crime method. So there's antibiotic pressure from the application of antibiotics to the population. And however the treating healthcare workers in the community are using antibiotics that will determine the sensitivity of staff in your community. So you kind of need to monitor that and know what that is. The hospital has that data usually posted somewhere um And you know, once every six months to a year. I look at that just to know if there's been a shift in the antibiotic profile of staff in our environment. Okay, so we can use doxycycline that's become relatively standard. It's really a good drug and it's it's cheap now. Uh self and with ox is all dermatologists are always afraid of the sulfa drugs because they cause bad drug rashes. Quinn alone's. We've had three ruptured achilles tendons in our department. So Cipro has gotten a bad name. But other than that linda, I like but remember if The staff comes back as a rich three minutes and resistant, then it has some likelihood that there will be an induce a ble clintonized and resistance. So you don't want to use clinton if the sensitivity says it's a randomized and resistance. Okay, what's the most common cause of recurrent staph aureus infections? So being a nasal carrier. Right? So activities that lead to the nasal carriage, intravenous drug users. If you get allergy shots, your rate of staff carriage goes up. If you are injecting insulin, your rate of staff carriage goes up. If you have a topic dermatitis, if you're a healthcare worker. So all these things that break the skin barrier or that exposure to staff increase your risk for carrying staff. And that carriage is a source of infections. And they did a study where they took patients who were going into the operating room and they just swabbed and cultured their noses before they went in and then they look after and they looked at the patients who got wound infections. No God infections of their wounds, surgical wound. Right. It was the staff that they took into the O. R. They didn't pick it up from the doctors or from the equipment, it was their own staff that was the problem. So if you have a patient who has had problems with recurrent nasal, I mean with the current staph infections and they're going to have surgery. You probably want to try to eradicate that staph infection. Um And treatment of nasal carriage is required to stop these recurrent episodes. So just giving antibiotics doesn't solve the problem. You've got to get rid of the carriage uh and we'll talk about that. The other thing is that some persons are susceptible to staff. If you have a topic dermatitis. If your immune deficient, I have a patient who's a fireman who got trapped in the building and had 80% 2nd degree burns. So he just has essentially scarf for skin and he gets recurrent staph infections because he has no sebaceous glands, he has no natural protection plus he keeps his skin covered. So he's vitamin D. Deficient. So uh he's getting recurrent staph infections but he's not the carrier then and he was sent to me because they kept culturing his near, he's not finding anything. But then when I treated his dog, his wife and his son, he did much better. Okay so if someone has recurrent staph infections cultural the lesions get sensitivities. If its staff Give five days of revamping with your appropriate oral antibiotic. five days is enough to clear nasal carriage. It's pretty well tolerated. Remember that your family um interact society from P. 4 50 it's the one drugs that really breaks down drugs quickly. So if you have a patient who's on methadone, they'll go through opiate withdrawal. If you put them on refinancing. If you have a woman on oral contraceptives, she might become pregnant uh because of the loss of efficacy. So you you have to pay attention to that. But the risks are easy to avoid. The benefits are great. And so in the person who has recurrent infections, I'm going to culture their nurseries, but I'm also going to be thinking about this group of people around them who may intermittently bring staff into their living space and then infect this person. And especially that's true if this is an immuno suppressed toast and the people coming from outside maybe just delivering the staff. So if you look at kids who have recurrently infected eczema, 60% of the time, one of the parents will be a chronic staph carrier. So, uh do that dogs, cats and many other pets carry staff. I did have a patient who was having recurrent boils and pediatricians couldn't figure it out. So then I went in, I was talking to her and I said, do you have a dog at home. So, yeah, and I said, well, where's the dog sleep? So the dog sleeps in my bed. So they took the dog to the veteran of the dog was carrying staff, they treat the dog and her abscesses go away. So you have to think of a broader circle than just the person. So over time I've changed my approach to staff. And that staph infections are not the person with staph infection, but the environment in which the staph infection is occurring. Okay. Clindamycin orally will clear nasal carriage. But you have to do it for a long time. New Pearson, I think it's a good drug. We use it a lot. Um About 25% of community staff are resistant and there's only one place where that rate is higher And in New Zealand 50% of all staff are resistant to me Pearson. And that's because new Zealand is the only country where me Pearson is sold over the counter and so it's overused and all the staff essentially resistance. So um we like new Pearson for the most refractory, can't clear the carriage problem. 1/2% gentian violet one time painted in the nose gone. So in the patient where you can't give revamp and the Bactrim band has it worked. That's your backup strategy. It always works. You just have to be careful that it doesn't drip down on the patient's lip when they're putting it in their nose because otherwise I'll have a purple lip for a while, gentian violet is great for. Mhm clearing up staff like in between the toes and people with recurrent cellulitis, especially people who can't treat themselves very often like people who are homebound and have a health care worker come once a week or a nurse's aide. And once a week somebody can put that gentian violet in between their toes will dry everything up. It kills the fungus, it kills the bacteria and uh stops these recurrent infections and cellulitis. Okay, what's the sign on physical exam that a cellular lesion could be neck fash? So this is the one thing you're always afraid of, right, This is cellulitis. Is it down in that deep compartment? Isn't really necrotizing fasciitis and that's going to be really serious. So if it's if the tissue is necrotic, that's obviously a concern, right? Something wiped the blood vessels out. So if the patient's hypotensive septic, if there's evidence of random analysis D. I. C. If there's sort of just the tissue has died and the epidermis is sloughing off if you feel air in the tissue. But often the first thing is that there's anesthesia that the infection as it clears through this space right over the fashion. It's knocking off the sensory nerves that go to that skin and the area becomes numb. We had a lawsuit at UCSF where the patient had sally Elias was not getting better. And the medical student kept asking the attendings and writing in the chart the patient can't feel on this spot cellulitis is supposed to be sore. And he kept asking this question and kept asking this question after three days when the patient tubed. Then somebody said ah this was neck fash all along. Right? So, um, so that's a good clue to avoid missing that diagnosis, mm hmm.
