Transcript DMC Facial Rashes 2016

Teledermatology and
One Stop Assessment and Treatment Service (OATS)
Facial Rashes
Dr Tony Downs FRCP
Consultant Dermatologist
DMC Dermatology lead clinician
020 7635 1019
[email protected]
www.dmchealthcare.co.uk
Facial Rashes
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Contact dermatitis
Atopic dermatitis
Seborrhoeic dermatitis
Discoid lupus
Psoriasis
Fungal infection
Acne
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Rosacea
Steroid-induced rosacea
Dermatomyositis
SLE
Erysipelas
Folliculitis
Other infections
Seborrhoeic dermatitis
• Scaly rash worse in
the winter. Feels dry
and sore or itchy
• Affects the skin
around the nose,
nasiolabial fold,
eyebrows, central
(hairy) chest in men
and scalp
• Scalp variant when
mild is called dandruff
Seborrhoeic dermatitis
• Malassezia species feed off lipids
in the skin
• The lipid waste products cause
irritation
• The mild form is called dandruff
• Highly sebaceous skin areas and
oily skin types are more affected
• Drugs (e.g. anti-epileptics) or
conditions (e.g. Parkinsonism or
CVA) that increase sebum
production can aggravate or
precipitate the disease
• Immuno-suppressed states (e.g.
drugs, HIV, old age) can favour
Malassezia and promote the
disease
Treatments for Seborrheic Dermatitis
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1% Hydrocortisone
Ketoconazole cream and/or shampoo
Daktacort cream or ointment
Eumovate cream or ointment
0.1% tacrolimus ointment
Short courses of topical mometasone
2% Sulphur in 1% HC cream
Complications
• HIV patients often are more treatment
resistant. Consider HIV test if status not know
• Rosacea often seen together with seb
dermatitis. Rosacea makes the skin sensitive
and so can be aggravated by treatments to
control the seb dermatitis
• Psoriasis often seen together with seb
dermatitis, which can alter the appearance
and require addition treatment directed at
the psoriasis
Facial psoriasis
• Virtually always
associated with scalp
psoriasis
• Commoner in children
• Like in flexural psoriasis,
treatment products can
irritate
• High DLQI scores
Treatment options
First line
Mild topical steroids
Tacalcitol or calcitriol ointment
Second line
0.1% tacrolimus ointment
Mometasone ointment or cream
Hair Margin
Dithrocream®
Dovobet® gel
0.1% tacrolimus ointment
• Off-label 0.1% tacrolimus
very effective for facial
psoriasis in adults or
children
• May cause stinging for first
two weeks
• Theoretical but unproven
risk of increased incidence
of skin infections or skin
cancers
Acne
Pathogenesis of Acne
Pathogenesis of Acne
1. Androgen
mediated
increased
sebum
production
Pathogenesis of Acne
2. Early inflammation
and
micro-comedone
formation
1. Androgen
mediated
increased
sebum
production
Pathogenesis of Acne
2. Early inflammation
and
micro-comedone
formation
3. P. acnes
colonisation
of follicle
1. Androgen
mediated
increased
sebum
production
Pathogenesis of Acne
2. Early inflammation
and
micro-comedone
formation
4. Late
inflammation +++
3. P. acnes
colonisation
of follicle
1. Androgen
mediated
increased
sebum
production
Actions of Anti-Acne
Therapies
Actions of Anti-Acne
Therapies
Topical retinoids:
 Normalize
desquamation
 Reduce inflammatory
response
Actions of Anti-Acne
Therapies
Topical retinoids:
 Normalize
desquamation
 Reduce inflammatory
response
Antibiotics:
 Kill
microorganisms
 Reduce
inflammatory
response
Actions of Anti-Acne
Therapies
Topical retinoids:
 Normalize
desquamation
 Reduce inflammatory
response
Antibiotics:
 Kill
microorganisms
 Reduce
inflammatory
response
Benzoyl peroxide:
 Kills microorganisms
Actions of Anti-Acne
Therapies
Topical retinoids:
 Normalize
desquamation
 Reduce inflammatory
response
Antibiotics:
 Kill
microorganisms
 Reduce
inflammatory
response
Benzoyl peroxide:
 Kills microorganisms
Hormones:
 Reduce sebum
production
Actions of Anti-Acne
Therapies
Topical retinoids:
 Normalize
desquamation
 Reduce inflammatory
response
Antibiotics:
 Kill
microorganisms
 Reduce
inflammatory
response
Benzoyl peroxide:
 Kills microorganisms
Oral Isotretinoin:
 Reduces sebum
 Normalizes
desquamation
 Inhibits P acnes
 Reduces
inflammatory
response
Hormones:
 Reduce sebum
production
Clinical features
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Blackheads (closed comedones)
Whiteheads (open comedones)
Inflammatory pustules and papules
Inflammatory cysts
Acne scars
Post-inflammatory hyperpigmentation
Acne
• Peaks at the age of 19yrs old
• Effects the face, upper chest, back and upper
arms
• Can cause severe psychological trauma
leading to depression and a withdrawn
personality
• Impacts on career choices and job
opportunities
Treatments
• Self-med benzoyl peroxide (BPO)
• Prescription topical antibiotics, BPO, retinoids,
alazeic acid, nicotinamide and combination
products
• Prescription anti-androgens (for females)
• Prescription oral antibiotics
• Dermatology consultant only isotretinoin
Resistance of P. acnes to antibiotics
62%
49%
38%
20%
20%
1978
USA
Crawford
1988
UK
Eady
1993
UK
Eady
1995
UK
Jones
1996
UK
Jones
E.C.T
E.C.T.
E.T.D.Tr.
E.C.T.
E.C.T.
0%
1976
USA
Leyden
E= Erythromycin C= Clindamycin D= Doxycycline Tr= Trimethoprim
T= Tetracyclines
Eady EA. Dermatology. 1998;196:59-66.
Topical antibiotics
• Should not be prescribed in isolation
• No evidence that the addition of zinc (eg
Zyneryt® lotion) reduces or avoids antibiotic
resistance
• Evidence that bacteria other than P acnes are
acquiring antibiotic resistance with the use of
topical and oral antibiotics used in acne
Oral Antibiotics
Commonly prescribed
• Tetracyclines
• Erythromycin
• Clarithromycin
• Trimethoprim
Advice
• 3 to 6 month courses. Expect 20%
improvement at 2 mths
• No advantage of one tetracycline
over another
• Minocycline side-effects
outweigh its usefulness
• Never prescribe in isolation
(monotherapy)
• Always prescribe with a nonantibiotic topical to avoid or
reduce antibiotic resistance
Combination topical therapies
• Major advantages over single agents
– Better compliance
– Treat different stages of pathogenesis
– More effective than single agents
• Duac®gel twice a day- Clindamycin and BPO (slows antibiotic resistance)
• Epiduo® gel daily- Adapalene and BPO (no antibiotic resistance issues)
• Treclin®gel daily- Tretinoin and Clindamycin (no effect on preventing
antibiotic resistance)
• Isotrexin® gel twice a day – Isotretinoin and Erythromycin (no effect on
preventing antibiotic resistance)
Combination Therapies
• Benzoyl peroxide slows the development
of P acnes drug resistance
• If possible oral or topical antibiotics should
be combined with BPO
• Beware using different topical products
that are not compatible
Combinations
• Apply topical treatment to whole area prone
to acne, not just to the spots
• If mixed lesions:
– Anti-comedonal therapy at night
– Anti-inflammatory therapy in the mornings
Topical Retinoids
• Should be first line after BPO
• Can cause irritation which improves with regular use
or initial intermittent use
• Use a sunscreen during the day and apply at night
• Adapelene less irritant than tretinoin
• Avoid in pregnancy but contraception not required
• Helpful in resolving acne-induced post-inflammatory
hyperpigmentation
20% Alezaic acid
• May cause skin irritation
• Useful to help resolve acne-induced postinflammatory hyperpigmentation in darker
skin types
• Anti-bacterial so a BPO alternative
Nicotinamide gel
• Topical Vit B3 preparation with antiinflammatory effects
• Apply twice a day
• Can cause skin irritation
Benzoyl Peroxide (BPO)
• Self-med or on prescription
• 2.5%, 5% gels and 10% washes
• Ideally used a first line agent for mild to
moderate acne
• Anti-inflammatory and anti-microbial
• Hampered by skin irritation & bleaching of
clothes
Anti-androgens
• Progesterone only and COCs can flare acne
• Contraceptive pills that contain synthetic
progesterone eg Yasmin® and Loesterin®
• Dianette® contraceptive pill and
spironolactone (off-label) are both potent
anti-androgens. In women, these both work
well at controlling acne
Isotretinoin
• Isotretinoin is the only currently available cure
for acne with very high success rates
• Sometimes more than one course is required
• Post treatment with a topical retinoid can
prevent acne relapse
• A single course is for 4-6 mths and must be
completed or the acne will relapse
• The mode of action at preventing relapse
remains unknown
Indications for referral for isotretinoin
• Failure to respond to oral & topical
treatments
• Chronic acne
• Severe acne
• Acne where scarring is beginning to develop
or is established
• Acne where post-inflammatory
hyperpigmentation is beginning to develop or
is established
Light & laser based inflammatory
acne treatments
• For mild to moderate acne, these can work
• Usually provided outside the NHS because of a
lack of robust clinical efficacy and cost-benefit
Light & laser based post-acne scar
and pigmentation treatments
• A number of cosmetic and surgical treatments
can improve acne scarring and postinflammatory hyperpigmentation
• Access as an NHS patient is not always
possible
• Dermatologists that special in laser
treatments would be regarded as the doctor
of choice to treat these patient
Irritant Dermatitis
• Acute
• Cumulative
• All depends on length
or frequency of
exposure & skin barrier
function
Steroid-induced rosacea
• Caused by a moderate
or potent topical steroid
on the face
• Stopping the steroid
usually worsens the
rash
• Treat with an 8 week
course of an oral
tetracycline as well as
stopping the topical
steroid
Facial fungal infections
• Tinea faciei (uncommon in
adults)
• Tinea barbae (often
presents as kerion)
• Trichophyton rubrum –
from other humans or the
feet
• Microsporum canis – from
cats or dogs
• Trychophyton verrucosum –
from cattle
• Trychophyton
mentagrophytes – from
horses
canis and rubrum – always consider when
unilateral/ non-symmetrical
Treatment
• Topical anti-fungal (eg ketoconazole) may be
sufficient, but in widespread disease oral
itraconazole or terbenafine is more
appropriate and effective
• Mycology scrapping prior to treatment should
be taken to confirm disease, confirm
treatment sensitivities and for public health
monitoring of different species
Kerion
• Inflamed & swollen with
lymphadenopathy
• Can lead to scarring and
hair loss
• Patients feels well and the
areas are not excessively
itchy or painful
• Usually fungus contracted
from an animal
• Treat with oral terbenafine
for one month
Tinea barbae
Rosacea
Definition of Rosacea
• Formal definition difficult1,2
– represents a constellation of
clinical symptoms and signs
– Pathogenesis complex and illdefined
• Chronic inflammatory
dermatosis
• associated with altered vascular
tone leading to vasodilatation &
increased blood flow
1.Powell FC. N Engl J Med. 2005; 352(8): 793-803. 2.Liu RH, et al. Arch Dermatol.
2006; 142(8): 1047-52.
Rosacea subtypes 1 - 4
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Erythematotelangiectactic ETTR
Papulopustular PPR
Phymatous PR
Ocular OR
Nat Ros Soc, JAAD 2002; 46: 584-7
Rosacea:subtype I
Erythematotelangiectatic1
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First described at the
start of the 19th century
Flushing & persistent
central facial erythema,
+/- telangiectasia (dilated
superficial blood vessels) 2
Painful symptomatology2
Sparing of the periocular
area and nasolabial
region
May have associated
ocular rosacea
Rhinophyma occasionally
coexists
1. Wilkin J, et al. J AAD 2002; 46(4): 584-7. 2. Crawford GH, JAAD. 2004; 51(3): 327-41
Rosacea:subtype 2
Papulopustular1,2
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Central facial erythema with transient
pustules and/or dome- shaped papules
Frequently accompanied by burning &
stinging
Can be seen in other sites
– Bald heads, pinnae, and chest,
response to treatment very slow
1. Wilkin J, et al. J AAD 2002; 46(4): 584-7. 2. Crawford GH, JAAD. 2004; 51(3): 327-41
Rosacea: subtype 3
Phymatous1
 Thickened skin with prominent pores,
typically on the nose
 chin (gnathophyma), forehead
(metophyma), ears (otophyma) and
eyelids (belpharophyma)2
 May be no other features of rosacea
 More common in males 10:1
 Sebaceous gland & connective tissue
hyperplasia
 surface irregularities,nodules
 once fibrosis developed treatment response
less good
1. Wilkin J, et al. J AAD 2002; 46(4): 584-7. 2. Crawford GH, JAAD. 2004; 51(3): 327-41
Rhinophyma
Commoner in men
Resurfacing
Laser
Surgical
Rosacea: subtype 4
Ocular (usually bilateral)1
50% strongly linked to flushing, may precede
skin problems
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Dry eyes (Shirmers dry eye test), irritation,
crusting, redness, itching, burning, recurrent
styes or infections
Watery or bloodshot conjunctivae
– Foreign body sensation, irritation, light
sensitivity & blurred vision
Blepharo-conjuncitivitis2,3
– Telangiectasia /conjunctival injection,
swelling and scaling of lid margin
Take advice from ophthalmologist for
treatment
1. Wilkin J, et al. JAAD 2002; 46(4): 584-7. 2. Akpek EK, et al. Ophthalmology 1997;104:1863-7.
3.Ghanem VC et at. Cornea 2003;22:230-3.
Rosacea: subtype 4
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Keratitis 5%
 Severe pain, photophobia and blurred
vision
 may lead to corneal inflitrates, thinning,
scarring, vascularisation and perforation
 more common in males
Episcleritis, scleritis, iritis rare1
Sicca syndrome
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Manifestation of malfunction of the meibomian
gland - tear secretion abnormal2
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1. Akpek EK, Ophthalmology 1997;104:1863-7 Bron AJ, Ocul Surf. 2004 Apr;2(2):149-65
Treatment
• Define the various subtypes and treat
them accordingly
• Sunblock is important
• Avoid triggers that flare the rosacea (eg
alcohol, spicy food, sunlight, specific
cosmetics)
• Treat co-existing seborrhoeic dermatitis
Treating inflammatory rosacea
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Topical 0.75% & 1% metronidazole
Topical 15% alezaic acid
Topical 1% ivermectin (Soolantra®)
Oral tetracyclines
Low dose Doxycycline MR
Oral erythromycin or clarithromycin
Oral metronidazole (max 3 mths)
Oral isotretinoin
Topical agents
• Metronidazole & alezaic acid may cause
irritation
• Use for 12-16 wks for maximum response
• If clear at this point, stop treatment and restart if rosacea returns
• Some patients require continuous use
Topical Ivermectin (Soolantra®)
• Anti-inflammatory
• Use daily for 16 wks
• More effective than topical metronidazole or
alezaic acid
• Longer remission after 16 week daily course
than topical metronidazole
• Low irritancy
Oral antibiotics
• No clinical efficacy advantage of different options
• Low dose 40mg slow-release doxycycline cause the least GI
irritation and is the only oral agent actually licensed for
rosacea
• Treat for at least 12 weeks and stop to see if condition is in
remission. Re-start as required
• For non-responsive/aggressive disease, add in a topical agent
and continue that topical agent long-term, after the oral
antibiotic has been stopped
• Oral metranidazole can cause peripheral nerve damage with
prolonged use, so should be limited to 3 mth maximum
• Oral minocycline has a side-effect profile that should limit its
use
Isotretinoin
• Requires referral to community or hospital
dermatology for consultant dermatologist
prescribing
• Long –term remission unlikely. Usual objective
is to modify severe rosacea into mild or
moderate rosacea that this more treatment
responsive
• Length of isotretinoin course and dose is
variable
Treatment of facial erythema
• If confluent and re-active (still flushing and
blushing) then consider 0.03% brimomidine
gel daily
• Intense Pulsed Light (IPL) also works well for
those (but not normal available to NHS
patients)
• If static with visible blood vessels then
vascular laser or IPL indicated (also not readily
available to NHS patients)
Topical 0.03% Brimonidine
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Effective for rosacea erythema
Last for about 12 hours
Not effective for fixed redness and visible thread veins
Inflammation (papules and pustules) must be treated first
Any dry skin or facial eczema must be treated first
Regular application applied thinly is better tolerated than
intermittent application – at least for the first two months
• About 20% of patients experience rebound erythema
Treatment for rhinophyma
• Surgical debridement or CO2 laser ablation
• The inflammatory condition must be
controlled first and long-term oral antibiotics
prescribed after, to prevent re-growth
• Often only done on NHS patients if there is
proof of sleep apnoea
Rosacea:Conclusions
• Enigmatic disease of uncertain
pathophysiology
• Diverse spectrum of signs and symptoms
• Inflammation plays an important role
• Causes significant psychosocial morbidity
• Consideration of clinical subtypes should
be considered in any management
approach
• Refer patients with aggressive and nonresponsive disease
Dermatomyositis- connective tissue disorder
Dermatomyositis
Discoid lupus (DLE)
• Cheeks, nose & ears (also
upper back, scalp, neck &
hands)
• Red scaly patches, white
scarring, post-inflammatory
hyperpigmentation and
scarring alopecia
• Flares caused by sunlight
exposure
• An aggressive inflammatory
condition of unknown cause
DLE dermoscopy images
DLE
Differential diagnosis
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Tinea
Mycosis fungoides
Psoriasis
Sarcoidosis (lupus pernio)
Jessner’s infiltrate
Cutaneous TB (lupus
vulgaris)
• Lichen planus
Investigations
• Biopsy is essential, given the differential
diagnosis
• Biopsy for normal H&E staining, but ideally
also for IMF. Therefore, consider referring to
the community or hospital dermatology team
for this
• ANA and C3 & C4 to exclude SLE
Treatment
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Total sunblock is essential
Topical steroids (eg mometasone)
0.1% tacrolimus ointment
Tapering course of oral steroids
Second line hospital treatments
• Hydroxychloroquine
• Methotrexate
• Dapsone
• Oral gold
• Acitretin
• Azathioprine
In conclusion
• There are many potential facial rashes that require
careful consideration from the patient’s history and
clinical features
• In some cases a skin biopsy is necessary
• Many effective treatments are off-label or need to
be used cautiously on the facial skin
• GPs should be aware of the profound psychological
and social impact of facial rashes. Treatment and
review of that treatment as well as onward referral
should be prompt and efficient
Resources
For the doctor
• www.bad.org.uk
For the patient
• www.rosacea.org
• www.pcds.org.uk
• www.lupus.org.uk
Thank you
Contact details:
020 7635 1019
[email protected]
www.dmchealthcare.co.uk