Dermatology pearls and pitfalls

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Dermatologypearls and pitfalls

• Dr Keith Freeman FRCP
• Consultant Dermatologist
• CDDFT / STPCT

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Aim

• Highlight a few points
• Stimulate discussion
• Alter practice

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The national picture

• Up to 20 of GP consultations involve skin
  complaints / procedures
• Most GPs have 2 weeks undergraduate training
• 15 children have atopic eczema (5 in 1975)
• Ageing population
• Skin cancer incidence increasing by 5-7 p.a.
  and will continue at least to 2050

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Exclusions agreed with PCTs

• Warts
• Seborrhoeic keratoses
• Skin tags
• Benign lesions - moles, dermatofibromas etc
• Xanthelasmata
• Tattoos
• Sebaceous cysts
• Telangiectases and thread veins
• Mollusca contagiosa

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Exclusions (2)

• Establish local policy prior to referral
• Pressure to manage more dermatology patients in
  primary care is inevitable

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Conditions that seem to cause problems

• Viral warts
• Acne
• Onychomycosis
• Urticaria
• Plaque Psoriasis
• Childhood atopic eczema / topical steroids
• Lumps and bumps (not covered here)

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Viral Warts

• Lesions in elderly are unlikely to be viral and
  should be referred
• No treatment is a viable option
• Painful treatments should not be used in young
  children
• Treatment success only 60-70 at 3 months

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Viral Warts, children

• NO TREATMENT
• Keratolytic plus abrasion for at least 3 mths
• Cryotherapy to filiform warts, if child can take
  the pain
• Plane warts do not respond well to any treatment
  (? lasers)
• Refer intra oral and anogenital warts

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Viral warts, adults

• Keratolytic plus abrasion for at least 3 mths
• Liquid nitrogen cryotherapy, 3 weekly x 5
• ? Formaldehyde soak for plantar warts
• ? Glutaraldehyde soak or gel
• Curettage and cautery risks scarring
• Anogenital warts should be referred to GUM

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Unfunded/unapproved options

• Photodynamic therapy x 3 at monthly intervals
• Pulsed dye or CO2 laser
• Infrared coagulation
• Topical sensitisation (diphencyprone)
• Retinoids
• Bleomycin
• Cimetidine

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Insufficient evidence

• Topical imiquimod
• Folk remedies
• Homeopathy
• Hypnosis
• Intralesional interferon
• Podophyllin

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Acne

• Emphasise possible need for very long term
  treatment and not to expect quick cures.
• Abrasive treatments, picking and very humid
  conditions can worsen things
• Dietary changes do not help

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Mild acne

• Mild cleanser
• Topical treatment to affected area, not just
  spots
• Warn re dryness in first few weeks
• Oil free moisturiser if required
• Avoid very greasy cosmetics, but allow others

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Topical agents

• Benzoyl peroxide
• Retinoids adapalene (Differin), tretinoin
  (Retin-A), isotretinoin (Isotrex)
• Azelaic acid (Skinoren)

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Topical agents (2)

• For inflamed acne, topical antibiotics are best
  used with benzoyl peroxide or azelaic acid, to
  reduce chance of antibiotic resistance
• Combined preparations that can be used once daily
  are preferred ( e.g. Duac benzoyl peroxide
  clindamycin)

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Moderate acne

• Continue topical treatment and add
• Oral antibiotic such as (oxytetracycline)
  lymecycline, doxycycline or erythromycin
• for at least 3 months. Try another if the
  first does not work
• Consider Dianette in women, particularly if
  premenstrual flare and if needing contraception

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Severe and unresponsive acne

• Treat as for moderate acne and consider referral
  for isotretinoin treatment
• Include recent LFTs and fasting lipids in
  referral
• Discuss contraception with females

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Onychomycosis

• Send nail clippings for fungal culture
• Consider no treatment
• Systemic treatment almost always better than
  topical treatment
• Terbinafine is more effective than itraconazole
  or griseofulvin

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Regimes

• Terbinafine 250 mg od for 6-12 weeks
• Griseofulvin in children, 10mg/kg (max 1g) for a
  year or more, with food
• Nails take months to become normal after adequate
  treatment

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Urticaria

• Avoid aspirin, codeine (NSAIDs ACE inhibitors)
• Daily non sedating antihistamines (try at least 2
  and up to 2x recommended dose)
• Add sedating antihistamine at bedtime
• Consider adding H2 antihistamine
• Avoid oral steroids in chronic urticaria
• Most patients do not need referral

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Insufficient evidence

• Ketotifen
• Nifedipine
• Diet
• Phototherapy
• Relaxation techniques
• Topical steroids

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Classic psoriasis
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Plaque Psoriasis (mild to moderate)

• Treatment suppressive not curative
• Topical treatment cannot prevent relapses
• Information and education essential
• Patient perception should influence choice of
  treatment
• Patients prefer non messy, non smelly, rapidly
  effective preparations with long term control

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Psoriasis, general measures

• Soap substitute e.g. Epaderm
• Bath additive e.g. Polytar
• Moisturise after bathing e.g. Diprobase, Oilatum

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Psoriasis, topical options

• Tar, /- steroid
• Mild to moderate steroid
• Dithranol, usually short contact
• Vitamin D analogue, /- steroid
• Site may influence choice of treatment, e.g. face
  or flexures

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Tar, /- steroid

• Long history of use
• Reasonably effective
• Cheap
• Smelly
• Can stain

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Mild to moderate steroid

• Cheap and not messy or smelly
• Efficacy linked to potency
• Side effects linked to potency and amount
• Mild preparations helpful for face / flexures
• Tolerance and allergy may develop
• May lead to rapid relapse and destabilise
  psoriasis

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Dithranol

• Long history of use in hospital, short contact
  more recent
• Cheap and effective, if tolerated
• Irritant
• Stains (skin, clothing, bedding, bath)

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Vitamin D analogues

• Relatively new (1991)
• Not messy or smelly but mildly irritant
• Liked by patients
• Can increase photosensitivity
• Effective and can be used long term
• Excess doses may cause hypercalcaemia
• Synergistic with steroids

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Vitamin D analogues

• Calcipotriol
  Dovonex
• Calcipotriol betamethasone Dovobet
• Calcitriol
  Silkis
• Tacalcitol -
  Curatoderm
• Calcipotriol should not be used on the face.

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Suggested strategy, plaque psoriasis

• General measures and education
• Consider patient preferences, efficacy and safety
• Initiate treatment
• Dovobet, up to 15g daily for 4 weeks, review
• Emollients
• Dovobet for relapses then back to emollients
• Xamiol for scalp
• Refer if not controlled on this regime

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Childhood atopic eczema

• Generous amounts of emollients (500g) to be used
  several times a day
• Soap substitute and bath oil
• Wet wraps
• Mild steroid for face (hydrocortisone)
• Moderate steroid for trunk and limbs

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Topical Steroids

• Mild
• Hydrocortisone 0.5-2.5

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Topical Steroids

• Moderate (2-25 times as potent as
• hydrocortisone)
• Aclometasone dipropionate
• Clobetasone butyrate
• Fluocinolone acetonide
• Triamcinolone acetonide

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Topical Steroids

• Potent (I50-100 times as potent as
  hydrocortisone)
• Betamethasone valerate
• Betamethasone dipropionate
• Diflucortolone valerate
• Fluticasone valerate
• Hydrocortisone 17-butyrate
• Mometasone furoate
• Methylprednisolone aceponate

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Skin absorption of topical steroids

• Steroids are absorbed at different rates from
• different parts of the body. A steroid that works
  on
• the face may not work on the palm. A potent
  steroid
• may cause side effects on the face.
• Eyelids and genitals absorb 30
• Face absorbs 7
• Armpit absorbs 4
• Forearm absorbs 1
• Palm absorbs 0.1
• Sole absorbs 0.05

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Side effects of topical steroids

• Internal side effects
• If more than 50g of clobetasol propionate, or
  500g of hydrocortisone is used per week,
  sufficient steroid may be absorbed through the
  skin to result in adrenal gland suppression
  and/or Cushings syndrome

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Side effects of topical steroids

• Local side effects of topical steroids include
• Skin atrophy and striae
• Easy bruising and tearing of the skin
• Perioral dermatitis
• Telangiectasia
• Susceptibility to skin infections
• Disguising infection e.g. tinea incognito
• Allergy to the steroid

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Steroid skin atrophy
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Striae
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Fingertip unit

• A convenient way to measure how much
• cream to prescribe to a patient with skin
• disease. Accurate prescription is particularly
• important for topical steroids.

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Dose

• Adult male one ftu provides 0.5 g
• Adult female one ftu provides 0.4 g
• Children of four years approximately 1/3 of
  adult amount
• Infants six months to one year approximately 1/4
  of adult amount

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Number of f.t.u.s required

• One hand apply one fingertip unit
• One arm apply three fingertip units
• One foot apply two fingertip units
• One leg apply six fingertip units
• Face and neck apply 2.5 fingertip units
• Trunk, front back 14 fingertip units
• Entire body about 40 units

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3 rules for use of topicals

• The right formulation
• The right potency for site
• The right amount
• Please see www.dermnetnz.org for further
  information

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Childhood atopic eczema (2)

• Pimecrolimus 1 (Elidel) b.d.
• Over 2 yr, acute treatment of mild to moderate
  eczema
• Exclude infection
• Avoid contact with eyes and mucosa
• Can cause local reactions and skin infections

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Childhood atopic eczema (3)

• Tacrolimus 0.03 (Protopic) b.d. for 3 wk. then
  o.d.
• Over 2 yr, moderate to severe, unresponsive to
  conventional therapy
• Exclude infection
• Avoid contact with eyes and mucosa
• Can cause local reactions and skin infections

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Childhood atopic eczema (4)

• Tacrolimus and pimecrolimus may be useful
  long-term in preventing relapses, best regime not
  clear

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Final thoughts

• To treat or not?
• How much to use of which products?
• How long to treat?
• What to refer and when?
• Involve, explain and concur

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Thank you

• keith.freeman_at_suntpct.nhs.uk
• QUESTIONS?