Dermatology 1
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- Created by: amazingemilyjones
- Created on: 09-04-19 18:12
Dermatology 1
Dermatology 1
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The Skin
- The largest organ of the body
- Complex multilayered organ
- Three major functions:
- Protective - mechanical barrier
- Homeostatic - temperature control
- Sensing - organ of touch
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Skin Structure
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When Things go Wrong
- Dermatological conditions affect up to 1/3 of the population at any one time
- Dermatological conditions make up approximately 10% of GP consultations
- 3 million patients are treated in UK outpatient clinics every year
- Significant psychological impact on patients
- Skin conditions may be the primary disease or may indicate a systemic disease
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Features of Diseased Skin
- Nodule or papule
- e.g. acne, squamous cell carcinoma
- Plaque
- e.g. psoriasis
- elevated flat top lesion, >1cm in diameter, may appear with papsules
- Bullae/blister
- e.g. physical, infection, allergy
- Macule
- flat lesion not elevated, different colour to the surrounding skin, i.e. appearing like a freckle, large macules may be >5mm
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Features of Diseased Skin
- Cyst
- e.g. severe acne
- deep seated mass filled with a semi solid or liquid material, most occur as a result of a blocked gland
- Pustule
- e.g. infection, acne, pustular psoriasis
- lesions containing purulent material, often associated with hair follicles
- Scale
- e.g. dermatitis, eczema
- excess corneocyte production and upset in the desquamation process, dry and whitish scales that flake from the skin surface
- Others: fissure, erosion, ulcer, e.g. bed sore
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Assessing Skin Lesions
- Site
- Shape
- Size
- Symmetry
- Sum
- Shade
- Scratch
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Questions to Ask
- Are there any lesions that you have not examined?
- Has the patient had this skin problem before?
- How old are they?
- How long has the patient been aware of the problem?
- Is it getting worse?
- Has the patient tried any treatment?
- Is the patient taking any medicines currently?
- Did the patient feel unwell before the problem first appeared?
- Does the patient have any other illnesses?
- Does the patient have any allergies?
- Does it itch?
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Dermatological Therapy
- Most skin conditions are treated topically
- Targets the diseased area
- Minimises system side effects
- Stratum corneum acts as a significant barrier to topical therapy
- Need to overcome this barrier to deliver effective treatment
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Topical Over the Counter Products
- Emollients
- Creams/ointments
- Bath additives
- Soap substitutes
- Corticosteroids include
- Hydrocortisone 1%
- Clobetasone butyrate 0.05% (Eumovate)
- Keratolytics include
- Benzoyl peroxide, salicyclic acid, resorcinol, tar
- Antibacterials include
- Benzoyl peroxide, triclosan
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Topical Over the Counter Products
- Antifungals (fungal infections)
- Antiseptics (bacterial infections)
- Antivirals (cold sores and other HSV (Herpes Simplex Virus) infections
- Antihistamines (allergic rashes)
- Parasiticidal preparations (head lice)
- Anaesthetics (teething)
- Antipruritics (reduce itching)
- Skin 'dissolving agents' (warts, verrucae)
- Compound preparations
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Dermatological Therapy
- A number of factors influence drug penetration through the stratus corneum
- Skin
- Anatomical site of application
- Skin temperature
- Skin hydration
- Skin integrity
- Medicine
- Partition coefficient
- Concentration gradient
- Vehicle
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Choice of Vehicle
- The vehicle is the formulation in which the active ingredient is presented (i.e. cream or ointment)
- Choice of vehicle is important because:
- the relative solubility of drug in the vehicle and the stratum corneum influences drug penetration
- vehicles themselves have an important therapeutic role
- Creams
- Use on: moist or dry skin
- Main components: oil/water
- Properties: moisturing, emollient, cooling
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Choice of Vehicle
- Ointments
- Use on: dry, scaly skin
- Main components: water/oil
- Properties: emollient, occlusive, greasy
- Gel
- Use on: greasy, weeping skin
- Main components: usually water and polymers
- Properties: cooling, spreads easily
- Pastes
- Use on: dry, scaly, lichenified skin
- Main components: petroleum derivatives and powders
- Properties: protective, messy
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Choice of Vehicle
- Lotions
- Use on: acute, weeping lesions
- Main components: powder and water
- Properties: soothing, cooling, drying
- Dusting powders
- Use on: skin folds
- Main components: powder
- Properties: reduce friction
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How much to use
- The amount of topical treatment that should be used is dependent on:
- the area being treated (location, size, integrity)
- the active ingredient contained in the vehicle
- the risk of side effects
- Different products have different doses so make sure to counsel on use
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Folliculitis
- Inflammation of the hair follicle, typically associated with infection
- Localised pustules and erythema centred around hair follicles
- E.g. shaving rash, jacuzzis, swimming pools
- Management
- Treatment: antibiotics
- Give lifestyle advice/avoidance tips
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Fungal Skin Infections
- Dermatophyte infection - Tinea/ringworm
- Tinea corporis
- Tinea cruris
- Jock itch/Dhobie itch
- Feet and nails
- Candida infection
- Sweat/nappy rash
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Tinea corporis or Tinea cruris?
- Tinea corporis
- Red/pink, flat or slightly raised
- Ring-shaped lesions with red, scaly borders with a clear central area
- Tinea cruris
- Red-brown, flat or slightly raised plaques
- Active borders (pustules or vesicles)
- Often itch, and in some cases there is uniform scale without central clearing
- Transmission
- Direct contact with an infected person
- Indirect contact with items contaminated with the fungus, e.g. clothing, towels and bed sheets
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Tinea Treatment Strategy
- Treated with imidazole creams (up to 4 weeks)
- Treated with terbinafine cream (1-2 weeks)
- Antifungal powder to reduce perspiration
- Advice: hygiene, drying, towels, loose fitting clothes, feet
- Refer: if severe or topical treatment fails
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Imidazole and Terbinafine Creams: P/GSL
- Imidazole creams
- Clotrimazole 1%, miconazole 2%
- Fungistatic
- Apply 2-3 times daily
- 10-14 days after symptoms resolve
- Up to 4 weeks treatment
- Terbinafine creams
- Lamisil
- Fungicidal
- Binds to keratin
- Apply once daily
- 1 week treatment
- Residency in skin - not for under 16s
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When to Refer
- Persistent
- Recurrent
- Severe
- Immunocompromised
- Treatment failure
- Associated symptoms
- Difficult diagnosis
- POM treatments available include oral tablets
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Other Skin Infections
- Impetigo
- affects around mouth and nose
- Viral Herpes Simplex Virus on skin, especially hands
- not common but very severe so refer immediately if suspected
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Male/Female Pattern Baldness
- Androgenetic alopecia
- First occurs in men between the ages of 20 and 45
- Follows a typical pattern of hair loss
- Usually begins at the temples or on the crown
- Initial thinning progressing to complete loss
- Typical loss is over the top of the head
- Psychological distress and reduced quality of life
- Genetic disposition
- Anagen --> Catagen --> Telogen
- High levels of dihydrotestosterone (DHT) have an adverse effect on the hair follicle cycle
- DHT acts at receptors on hair follicles and slows down growth to produce weaker/shorter hair
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Male/Female Pattern Baldness: Treatment
- Minoxidil (Regaine)
- Potent antihypertensive drug
- Hypertrichosis side effect
- Topical solution 2% (GSL) or 5% (GSL/P)
- Also available as a 5% foam
- Regular application - twice daily
- Patients with pre-existing heart problems should consult their doctor before using minoxidil
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Male/Female Pattern Baldness: Oral Treatment
- Finasteride (Propecia)
- A 5alpha-reductase inhibitor (POM)
- Available on private prescription only
- Dose is 1mg daily
- Daily treatment is required for 3-6 months before any effect is seen
- Reversed following discontinuation
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