Transcript files/Dermatology_For_GPs_2x

Primary Care Dermatology
Dr Mick McKernan
Description of skin lesions







Papule
Macule
Nodule
Patch
Vesicle
Bulla
Plaque
Papule


Small palpable circumscribed lesion
<0.5cm
Macule
Flat, circumscribed non-palpable lesion

Pustule

Yellowish white pus-filled lesion
Nodule

Large papule >0.5cm
plaque

Large flat topped elevated palpable
lesion
patch

Large macule >2cm
vesicle

Small fluid filled blister < 1/2cm
Bulla

A large fluid filled blister > 1/2cm
ECZEMA



=dermatitis
10% of population at any one time
40% of population at some time
Features of eczema








Itchy
Erythematous
Dry
Flaky
Oedematous
Crusted
Vesicles
lichenified
Types of eczema







Atopic
Discoid eczema
Hand eczema
Seborrhoeic eczema
Varicose eczema
Contact and irritant eczema
Lichen simplex
Atopic eczema




Endogenous
Atopic i.e asthma, hay fever
5% of population
10-15% of all children affected at some
time
Atopic eczema







individual must have:
An itchy skin condition in the last 12 months+
three or more of:
Onset before 2 years of age
History of flexural involvement
or flexural eczema currently present
History of generally dry skin
History of other atopic disease or FH
Exacerbating factors






Infection
Teething
Stress
Cat and dog fur
? House dust mite
? Food allergens
Clinical features







Itchy erythematous patches
Flexures of knees and elbows
Neck
Face in infants
Exaggerated skin markings
Lichenification
Nail – pitted
complications




Bacterial infection
Viral infections – warts, molluscum,
eczema herpeticum ( refer stat).
Keratoconjunctivitis
Retarded growth
Prognosis



Most grow out of it
15% may come back – often very mildly
Chronic skin dryness common after
Treatment







Avoid irritants especially soap
Frequent emollients
Topical steroids
Sedating antihistamines – oral hydroxyzine
Treat infections
Bandages
Second line agents
Triple combination of therapy



Topical steroid bd as required
Emollient frequently
Bath oil and soap substitute
Principles of treatments





Creams
Ointments
Amounts required
Potential side effects
Soap substitutes
creams




Cosmetically more acceptable
Water based
Contain preservatives
Soap substitutes
ointments




Oil based
Don’t contain preservative
Feel greasy
Good for hydrating
Topical steroids




Mild – “hydrocortisone
Moderate – “eumovate”
Potent – “betnovate”
Very potent – “dermovate”
Amounts required



Emollients – 500g per week for total
body
FTU – steroids- the least potent that
controls the symptoms.
Bath oils – 2-3 capfuls per bath
FTU



Finger tip unit
Helps to give estimation of topical
steroid amount used
To avoid over and under use of steroid
FTU
FTU


2 FTU = nearly 1 gram
Enough for twice size of adult hand







A hand and fingers (front and back) = 1FTU
A foot (all over) + 2FTU
Front of chest and abdomen = 7FTU
Back and buttocks = 7FTU
Face and neck = 2.5 FTU
An entire arm and hand = 4 FTU
An entire leg and foot = 8 FTU
Discoid eczema





Variant of eczema
Easily confused with psoriasis
Well demarcated scaly patches
Limbs
Often infective component (staph
aureus)
Hand eczema



Pompholoyx – itchy vesicles or blisters
of palm and along fingers
Diffuse erythematous scaling and
hyperkeratosis of palms
Scaling and peeling at finger tips
Hand eczema







Not unusual in atopic
More common in non atopics
Cause often uncertain
Irritants
Chemicals
Occupational history
Consider patch testing – 10% positive
Seborrhoeic eczema



Over growth of yeast (pityrosporum
ovale, hyphal form malassezia furfur)
Strong cutaneous immune response
More common in Parkinson’s and HIV
Clinical features



Infancy – cradle cap, widespread rash,
child unbothered, little pruritus
Young adults – erythematous scaling
eyebrows, nasolabial folds, forehead
scalp
Elderly – more extensive
Treatment





Suppressive
Mild steroid and antifungal combination
Ketoconazole or dentinox shampoo
Emollients
Soap substitutes
Venous eczema






Gravitational = stasis eczema
Lower legs
Venous hypertension
Inflammation
Purpura
pigmentation
Clinical features




Older women
Past history DVT
Haemosiderin deposition
often misdiagnosed as cellulitis.
Cellulitis is nearly always unilateral,
tender and has a well demarcated edge
treatment





Emollients
Topical moderately potent steroids
Soap substitutes
Compression – check arterial supply
first
Leg elevation
Champagne bottle appearance
of lipodermatosclerosis
Lipodermatosclerosis
and venous leg ulcer
Cellulitis
– unilateral
painful and
well
demarcated.
Asteatotic eczema







=eczema craquele
Dry skin
Worse in winter
Hypothyroidism
Avoid soap
Emollients
Bath oils
Contact and irritant eczema




Exogenous
Unusual
Worse at workplace
History of exacerbations
irritant



Can occur in any individual
Repeated exposure to irritants
Common in housewives, hairdressers,
nurses –bleaches and chemicals
contact




Occurs after repeated exposure but only
in susceptible individuals
Allergic reaction
Common culprits – nickel, chromates,
latex etc
Patch testing
Lichen simplex





=Neurodermatitis
Cutaneous response to rubbing
Thickened scaly hyperpigmentation
Emotional stress
May need biopsy to diagnose
treatment



Stop rubbing!
Very potent steroids
Occlusion
PSORIASIS
Psoriasis






Affects 2% of population
Well-demarcated red scaly plaques
Skin inflamed and hyperproliferates
Males and females equally
Two peaks of onset (16- 22) and later
(55-60)
Usually family history
Chronic plaque




Extensor surfaces
Sacral area
Scalp
Koebners phenomenon
Guttate psoriasis





Raindrop
Children and young adults
Associated with streptococcal sore
throats
Not all go onto get chronic plaque
May resolve spontaneously over 1-2
months
Guttate psoriasis
Flexural psoriasis






Later in life
Well demarcated red glazed plaques
Groin
Natal cleft
Sub mammary area
No scale
Treatment




Step 1:Prescribe copious emollients - make the skin more
comfortable and reduce the amount of scale
Step 2:Dovobet is the most effective vitamin D analogue Avoid
on areas of thin skin eg the face, flexures and the genitalia. Also
consider dithranol and tar. Flares use topical steroids 2 weekserythroderma or generalised pustular psoriasis if overused.
Step 3 : for hospitals. Phototherapy , cyclosporin , UV,
methotrexate
Step 4: biologicals : Etanercept, Infliximab, Adalimumab and
Ustekinumab belong to the class of biological medicines called
tumour necrosis factor (TNF) blockers. These work by blocking
the activity of TNF.
Erythrodermic and pustular
psoriasis



More severe > 90% involvement
Need dermatologist!
Usually need oral therapy
Associated features


Arthritis
Nail changes- onycholysis, pitting,
discolouration, subungal hyperkeratosis
prognosis


Chronic plaque tends to be lifelong
Guttate – 2/3 further attacks, or
develop chronic plaque
ACNE VULGARIS
Acne Vulgaris



Common facial rash
Usually adolescents
3% may persist after 25yrs especially women.
Clinical features







Increased seborrhoea
Open comedones= blackheads
Closed comedones= whiteheads
Inflammatory papules
Pustules
Nodulocystic lesions
scars
Acne distribution
Treatment






Consider site
Compliance
Inflammatory/non inflammatory lesions
Scarring
Fertility
Psychological effect
Topical treatments




Benzoylperoxidase – OTC, PanOxyl 5 to 10%,
Azelaic acid – skinoren
Antibiotics – clindamycin, erythromycin,
steimycin
Retinoids – adapalene
Oral therapy




Use if topical therapy ineffective or
inappropriate
Anticomedonal topical treatment may be
required in addition
Don’t combine topical with oral antibiotic as
encourages resistance.
3 to 4 months before any improvement
Antibiotics





Oxytetracycline 500mg bd
Tetracycline 500mg bd
Doxycycline 100mg od
Erythromycin 500mg bd
Lymecycline 408mg od
Hormone treatment for acne

Dianette - not if COCP contraindicated


Withdraw when acne controlled
VTE occurs more frequently in women
taking dianette than other COCP – caution
++ at this point.
Oral retinoids





Hospital only
Long list of side effects
Teratogenic
Very effective
Suicide- no proven link
www.pcds.org.uk
Rashes are
difficult!