Dermatology 2

Dermatology 2

Dermatology 2

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Acne

  • Occurs most commonly in adolescents
  • Puberty --> angrogen production
  • Remission usually follows puberty but up to 5% of women and 1% of men have symptoms as adults
  • Can caused by drugs, e.g. corticosteroids, levonortgestrel, norethisterone
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Acne Vulgaris - Pathogenesis

  • Common inflammatory disorder of sebaceous glands
  • Angrogen increase - seborrhoea (excessive sebum)
  • Abnormal follicular hyperkeratinisation
  • Comedone formation - open (blackheads) or closed (whiteheads)
  • Colonisation - P.acnes and P.granulosum
  • Inflammation
  • Papules, pustules, nodules (inflammatory acne)
  • Hyperpigmentation (redness)
  • Scarring - atrophic (indent), hypertrophic (raised)
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Mild Acne Treatment

  • Treat with a topical drug, usually one drug is sufficient
    • Benzoyl peroxide (P) or topical retinoids (POM) are first-line drugs
    • Azelaic acid (POM) is an alternative is benzoyl peroxide or topical retinoids are not tolerated
    • Combined Oral Contraceptive Pill (POM) can be useful in females requiring contraception
  • Drugs act on one or more of these stages of acne
    • Reduce sebum secretion
    • Clear existing comedones and reduce comedone formation (keratolytic/anti-comedogenic)
    • Reduce P.acnes colonisation and inflammation (antibacterial)
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Benzoyl Peroxide (P)

  • Benzoyl peroxide is both antibacterial at low strength and anticomedogenic at high strengths
  • Used for mild to moderate acne
  • Topical preparations contain 2.5-10% and are normally applied twice daily
  • Select the lowest effective strength
  • Appropriate formulation
  • Wash skin before use to remove excess sebum
  • Apply sparingly to entire area, not just spots
  • Begin at once daily application and increase progressively
  • Skin irritant causing dryness, stinging and erthyema (redness)
  • Bleaching (hair, clothes, bedlinen)
  • Avoid contact with eyes, mouth and mucous membranes
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Topical Treatments

  • Topical treatments should be applied to the entire affected area, not just to current lesions
  • May be little response in the first month
  • Review treatment at 6-8 weeks
  • Topical treatments can cause dry skin/irritant dermatitis
  • Gels and solutions
  • Creams
  • Lotions
  • Combination products are used for moderate and severe acne
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When to Refer

  • Failure of over the counter preparations
  • Severe acne
  • Acne in very young
  • Drug induced acne
  • Scarring
  • Physiologically/psychologically distressed
  • Any associated symptoms
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Eczema/Dermatitis

  • Red, sore, itchy skin
  • Eczema is synonymous (closely associated) with dermatitis 
  • Eczema has an endogenous cause
  • Dermatitis has an exogenous cause
  • Acute - papules, vesicles, erythema (redness), exudation, scaline
  • Chronic - dryness, fissures, excoriation 
  • Prognosis
    • Relapsing condition
    • Depends on type of eczema
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Diagnosis of Atopic Eczema

  • Itchy skin plus three of more of:
    • Onset before 2 years of age
    • History of dry skin
    • History of eczema in skin creases or cheeks in young children
    • Visible flexural eczema (or involvement of cheeks or forehed in children under 4)
    • A personal or immediate family history history of atopic disease
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Emollient Therapy

  • First line treatment for atopic eczema
  • Prescribed but also often available to purchase
  • Ointments, creams and lotions
  • Reduce skin dryness by improving the lipid depleted barrier and therefore prevents water loss from the skin
  • Softens the skin
  • Correct use can reduce flare ups
  • Reduces the need for corticosteroids
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Emollient Selection

  • Consider selection of vehicle/formulation
  • Patient acceptability is of paramount importance
  • Consider the dryness of the skin, the type of the skin and individual preference
    • Lotions: useful on hairy areas of skin
    • Creams: weeping eczema, low-moderate dryness of skin
    • Ointments: moderate to very dry skin, depends on patient preference
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Emollient Application

  • Emollients should be prescribed in sufficient quantities - total emollient therapy

Affected part of body                   Adult quantity for one week

Face                                                     50-100g

Both hands                                           100-200g

Trunk                                                   1000g

  • Frequency of application varies
  • Apply immediately after a bath/shower
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Corticosteroid Potency

  • Mild
    • e.g. hydrocortisone 1% (available over the counter)
  • Moderate
    • e.g. clobetasone butyrate 0.05% (available over the counter)
  • Potent (POM only)
    • e.g. betamethasone valerate 0.1%
  • Very potent (POM only)
    • e.g. clobetasol propionate 0.05%
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Corticosteroid Application

  • Twice daily at most
  • Treatment of flare-up
  • Do not apply an emollient at the same time
  • Apply thinly
  • Apply for as short a time as possible
  • Different steroid potencies used concurrently
  • Specific guidance for over the counter use
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Corticosteroid: Side Effects

  • Patients are anxious about the side effects of topical steroids
  • Side effects occur following improper use of potent steroids for long periods
  • Generally side effects are localised and cutaneous including:
    • skin atrophy
    • telangiectasia ('spider veins')
    • promote secondary infection
    • worsen acne
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The Finger Tip Unit: Corticosteroids

  • 1 FTU (finger tip unit) covers twice the size of the flat of the hand

Application Site           FTUs (Adult)            FTUs (child 6-10)

Face and neck              2.5 (20g)                         2

Front trunk                  7 (50g)                            3.5

Each arm and hand       5 (40g)                           2.5

Each leg and foot          8 (60g)                           4.5

  • The number in brackets is the approximate amount needed for twice daily application for one week
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OTC Corticosteroids

  • Hydrocortisone 1%
    • P medicine: can be sold to the public for the treatment of mild to moderate eczema/dermatitis provided it is not used:
      • for patients less than 10 years of age
      • in a pack size more than 15g
      • on the face, eyes or anogenital region
      • on broken or infected skin
      • more frequently than twice daily
      • for a period longer than 7 days
    • GSL: if for external use, for the treatment of insect bites and stings, in adults and children ages 10 years and over, in a cream with a maximum strenth of 1% and a maximum pack size of 10g
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OTC Corticosteroids

  • Clobetasone 0.05% (Eumovate)
    • P medicine: Can be sold to the public for short term symptomatic treatment and control of small patches of eczema/dermatitis in adults and children over 12 years
    • All other product licence requirements are consistent with that of hydrocortisone cream
  • Lifestyle Advice/Trigger Factors
    • Avoid irritants, e.g. soaps and detergents, toiletries, abrasive clothing, temperature extremes
  • Psychological factors
    • Avoid scratching
    • Stress
    • Drug allergies
    • House dust mite antigens - reduce allergen load
    • Diet - not proven but triggers include cow's milk, eggs, soya, wheat, fish and nuts

 

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Complications of Eczema

  • Psychological problems
    • sleep patterns
    • self esteem
    • isolation
    • development
    • employment
  • Susceptibility to infection
    • bacterial - most likely
    • viral 
    • fungal
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When to Refer

  • Undiagnosed atopic eczema
  • Other eczema types
  • Infection evidence
  • Severe condition (fissured, bleeding)
  • Failed treatment
  • No identifiable cause
  • Dermatitis duration longer than two weeks
  • Unusual rash features
  • Accompanying symptoms
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Irritant Contact Dermatitis

  • Non-immune inflammatory response to irritants
  • Chemicals which directly damage skin
  • Pass through stratum corneum and into epidermal cells and cause inflammatory reactions
  • Common substances in work or at home
    • e.g. handwashes, hair dyes
  • Managment
    • Removal/preventing contact/washing off irritants
    • Maintain skin hydration and barrier function
    • Barrier creams
    • Emollients
    • Hydrocortisone or clobetasone cream/ointment
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Allergic Contact Dermatitis

  • Type IV hypersensitivity reaction
  • Skin is sensitised to a specific allergen
  • Further exposure results in inflammatory response
  • Permanent sensitivity 
    • Nickel
    • Rubber
    • Lanolin
  • Site and pattern depend on site of contact
  • Site is usually indicative of cause
  • Definitive edge to clinical features
  • Distant sites
  • Intense erythema (redness)
  • Weeping, vesiculation 
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Management

  • Identify allergen
  • Allergen avoidance
  • Curative if allergen is avoidance
  • Emollient
  • Application of hydrocortisone or clobetasone cream/ointment
    • Available over the counter
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