Dermatology 2

Dermatology 2

• 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

• 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)

• 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)

• 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

• 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

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

• 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

• 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

• 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

• 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

• 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

• 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%

• 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

• 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

• 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

• 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

• 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

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

• 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

• 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

• 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 

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