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  • 1. Common Skin Problems Produced by the Department of Dermatology – revised March 2007
  • 2. FORWARD This booklet provides general guidance for G.Ps. on how to manage some of the more common skin problems. The clinical sections have been jointly written by the Consultants at the Royal Liverpool & Broadgreen University Hospitals Trust. It was produced in the hope that by working together we can provide the highest possible quality of care to patients. In addition, it includes information about the Dermatology service at Broadgreen Hospital, which we hope you will find useful. This information should help you to get the most out of the Dermatology Department for your patients. Dr Richard Azurdia Consultant Dermatologist Published with the support of an Educational Grant from Leo Pharmaceuticals
  • 3. THE DERMATOLOGY SERVICE AT THE ROYAL LIVERPOOL & BROADGREEN UNIVERSITY HOSPITALS NHS TRUST The Department of Dermatology at Broadgreen Hospital provides specialist clinical expertise together with a wide range of diagnostic and treatment facilities. In addition to general dermatology clinics the following services are provided. Diagnostic & Therapeutic Services: • Cosmetic Camouflage • Dermatological Surgery & Minor Operations • Dressings • Electrolysis • Iontophoresis & Botulinum toxin for hyperhidrosis • On call SpR for advice on all urgent adult or paediatric cases • Out-patient and In-patient Treatments • Patch Testing (for allergic contact dermatitis) • Photodynamic Therapy (PDT) • Phototherapy – UVB, TLO1, PUVA • Psoriasis – specialist clinic • Rapid Lesion Assessment Clinic (for melanoma and squamous cell carcinoma) • Specialist Nurse Clinics – phototherapy, cytotoxic drug monitoring, skin cancer • Vulval skin disease – specialist clinic 1
  • 4. Consultants Special Interests/Areas of Expertise Whilst all of the Dermatology Consultants undertake general clinics, each have their own areas of expertise as shown below: Consultant Qualifications Areas of Expertise Dr RM Azurdia BMedSci (Hons), Phototherapy for BMBS, MRCPI inflammatory skin disease, PDT, Skin cancer Dr H Bell MB ChB, MRCP Vulval dermatoses, MRCGP, DRCOG, DCCH cutaneous cancer Dr T Clayton MBChB MRCPCH Paediatric dermatology Dr C M King LRCP&SI, FRCP Contact Dermatitis and Patch Testing Dr R A G Parslew MBChB MRCP Inflammatory Skin Disease, Therapeutics and Paediatric Dermatology Dr G R Sharpe MBChB, BA, PhD Cutaneous Malignancies, Clinical Director FRCP, DTM&H Hereditary Disorders, Dermatological Surgery and Paediatric Dermatology Dr N J E Wilson BSc (Hons) MBChB Cutaneous Malignancies & FRCP Histopathology, hyperhidrosis Dr GAE Wong BMedSci (Hons) MBChB Cutaneous adverse drug MRCP reactions, therapeutics, PDT 2
  • 5. Contact Points For appointments please contact RLBUHT Medical Records: (0151) 2826122 For patient enquiries please contact the medical secretaries on the numbers listed below: Designation Name Telephone No Consultant Dr R M Azurdia BGH (0151) 2826858 Consultant Dr H Bell BGH (0151) 2826857 Aintree (0151) 5294785 Consultant Dr C M King BGH (0151) 2826143 Consultant Dr R A G Parslew BGH (0151) 2826144 AHCH (0151) 2525729 Consultant Dr G R Sharpe BGH (0151) 2826144 AHCH (0151) 2525729 Consultant Dr N J E Wilson BGH (0151) 2826856 Consultant Dr GAE Wong BGH (0151) 2826145 Aintree (0151) 5294147 Associate Specialist Dr S Jackson BGH (0151) 2826283 Matron & Directorate Manager Mrs D Baines BGH (0151) 2826319 Fax no: Dermatology Department, Broadgreen (0151) 282 6899 Fax no: Dermatology Department, Aintree (0151) 529 4857 Fax no: Dermatology Department, Alder Hey (0151) 252 5928 3
  • 6. Routine Referrals When you refer patients to the Dermatology Department you may wish to write personally to an individual Consultant. However, we are also happy to receive letters addressed to “The Dermatologist”, as this allows more flexibility in arranging the clinics and appointments. Partial Booking In line with the NHS Plan the service operates a partial booking system for all routine Dermatology appointments. This does not apply to skin cancer referrals or other urgent referrals. • What is Partial Booking? Partial Booking is a new method of booking outpatient appointments which allows patients to choose a convenient time for their appointment. • How does if work? Patients are referred to hospital in the normal way. Referrals are given to Consultants to be prioritised. All routine patients are then added to an outpatient waiting list, a letter is sent to the patient informing them that the referral has been received, added to a waiting list and that we will contact them in due course. Approximately 4 weeks before the appointment a letter is sent to the patient inviting them to contact the hospital to arrange an appointment at a mutually convenient time. Appointments are offered over the following 4 weeks. Once the date is agreed confirmation is sent together with information about the particular clinic. Those patients who do not respond to the invitation letter within 4 weeks will be discharged back to their G.P. • How do patients contact the hospital? A dedicated Telephone Access Centre holds calls in a queue with options to contact the correct department to arrange the appointment. There is voicemail available for those callers who wish to leave a message if they are unable to wait in the queue. The Telephone Access Centre is manned by 6 experienced members of the clerical team and is open Monday to Friday 08.30am to 8.00pm. The busiest times are between 09.00 and 3.00pm. 4
  • 7. • What are the benefits to patients? Because patients choose the day of their appointment there is far less chance of them not attending therefore reducing the number of wasted appointments. As appointments are only booked 4 weeks in advance there should not be a need for the hospital to cancel the appointment. Urgent Referrals For an urgent/emergency dermatological opinion on paediatric or adult problems, please contact the hospital switchboard (0151) 706 2000 and ask for the Dermatology “on call” Registrar. The “on call” Registrar will be able to discuss the problem, advise, and if necessary arrange an urgent appointment. For urgent assessment of lesions suspected to be either a melanoma or squamous cell carcinoma only please refer to the Rapid Lesion Assessment Clinic. Referrals should be made by fax on the appropriate form. Patients will be sent an appointment for a clinic date within 2 weeks of your referral. NB: Please do not abuse the urgent referral service by using it for BCCs. If a BCC is suspected and indicated in the referral letter it will be given appropriate priority. Specialist Nurse Led Clinics • Cytotoxic Drug Monitoring • Phototherapy & PDT treatment & monitoring • Minor surgery & skin cancer • Iontophoresis (for hyperhidrosis) These clinics run in conjunction with a Consultant Led Dermatology Clinic. The Specialist Nurse is available for advice on 706 2000 bleep 296 or 282 6155. The nurses within the Dermatology OPD have a wide experience of knowledge on: • Leg ulcers • Doppler studies • Patch testing • Phototherapy • Minor surgery 5
  • 8. Research and Teaching The department has an active research and development programme thereby ensuring a constant review of practices and procedures and a continuous advancement of knowledge. At any time there are usually a number of clinical trials and investigations ongoing. This will include local studies and multicentre pharmaceutical trials (usually phase III trials). All clinical trials are approved by the Local Ethics Committee and General Practitioners will be fully informed if their patients participate. Particular interests of the department include the treatment of eczema and psoriasis. The department forms an important focus for undergraduate, postgraduate and specialist paediatric dermatology teaching in the Region, and in future years we intend to further develop postgraduate teaching. In this respect we welcome comments and requests from General Practitioners on how to best meet their educational needs. Ward 4 Ward 4 is based on the 2nd floor Alexander Wing, BGH. This is a dedicated 20 bed Dermatology ward and is used for the in-patient management of skin disease egs severe psoriasis, eczema, blistering disorders, cellulitis & leg ulceration; there is also a day care room which can be used for patient treatments not requiring overnight stay. Admission to the ward is arranged via the Dermatology OPD or on call SpR. Phototherapy Unit The Phototherapy unit is based next to ward 4 at BGH. This unit is for out-patient therapies which include broadband UVB, TLO1 narrowband UVB and PUVA for inflammatory skin disease. Patients will be asked to attend 2 or 3 times per week, depending on the treatment, on an appointment basis. As well as UV therapies, topical treatments such as dithranol and tar can be arranged with full private shower facilities. Treatments are performed and monitored by trained nursing staff and all patients will have a baseline assessment and monitoring visits to the Consultant led or Specialist Nurse led Phototherapy Clinics. UVB & TLO1 appointment times 9am – 8pm (Monday, Wednesday, Friday) PUVA appointment times 9am – 5pm (Tuesday, Friday) 6
  • 9. GPwSI In conjunction with the local PCTs the Dermatology Department has trained a number of local GPs who are working as GPs with a Special Interest (GPwSI). There are at present 6 GPs running Community Dermatology clinics. The appropriate PCT will advise about referral pathways and appropriate conditions to refer. Normally referrals are made directly from the GP to the local GPwSI clinic. Each GPwSI has established links with secondary care to refer on when appropriate. 7
  • 10. MANAGEMENT OF COMMON SKIN PROBLEMS • Acne (guidelines) • Bacterial infections • Eczema (guidelines) • Eczema & patch testing • Fungal infections • Infestations • Scabies • Minor surgery • Psoriasis (guidelines) • Solar damage & skin cancer • Urticaria • Venous ulcers • Viral infections 8
  • 11. Management of Acne in Primary Care PATIENT HISTORY Assess: 1. Acne severity and duration 2. Drug/external factor complications 3. Psychological impact 4. Patient expectations with treatment and compliance EXAMINATION Pattern of 1. Check sites 2. Note type of lesions disease 3. Note extent of disease 4. Assess social implications Mild Mainly comedones (blackheads and whiteheads) Some inflammatory papules & pustules Moderate Superficial acne or acne with deeper inflammatory component. Inflamed papules and pustules. Severe Nodulocystic lesions. May be inflamed on the trunk. Scarring Psychological Problems TREATMENT - SEE OVER 9
  • 12. Patient Education Acne Support Group 0208 841 4747 www.stopspots.org Comedonal Acne Mild Acne Moderate Acne Severe Acne Retin A Benzoyl peroxide gel Oral antibiotics cream/gel/lotion 5% once-twice daily Oxytetracycline 500mg bd or Apply twice daily Use aqueous cream Erythromycin 500mg bd Or Differin in between treatment Continue with topical treatments. cream/gel nocte if skin is irritated and Do not prescribe different oral and dry topical antibiotics at the same time to avoid antibiotic resistance. Acne scarring - avoid by treating early + in severe cases refer to plastic surgery 50% improvement not achieved in two months Refer immediately to No No Consultant Dermatologist improvement response Consider Roaccutane Topical antibiotic/combinations treatment Dalacin T solution, Zineryt lotion Change to Tetralysal Zindaclin gel, Duac gel, Benzamycin gel 300mgs daily or Minocin MR No improvement 100mgs daily Add Dianette for girls/women in combination Assess response at 3 months with antibiotics Assess response at 3 months (Dianette takes up to 6 months to show full effect) Improvement Continue antibiotics for at least 1 year - max. 2 years. Tail off and withdraw Continue topical treatments indefinitely Avoid topical antibiotics for more than 6 months SPECIAL CASES Under 10 years Do not use oxytetracycline - permanent discoloration of teeth may occur. Pregnancy and pre-conception Do not use oral antibiotics. Refer to dermatologist if acne moderate-severe. Oral contraceptives Extra precautions on commencing and discontinuing oral antibiotics for 4 weeks. When established on oral antibiotics normal contraception is adequate. Where possible transfer to Dianette from other oral combined contraceptives. Over 25 years Persisting mild-mod acne - refer. Roaccutane may be justified earlier in this age group. 10
  • 13. ACNE - summary Mild Acne Benzoyl peroxide preparations once daily – gel: 2.5%, 5% then 10% as tolerated for 3 months. Improvement – continue topical treatment indefinitely No Improvement – either change to topical antibiotic, e.g. Erythromycin 2 or 4% or Clindamycin 1% twice daily, or alternate topical antibiotic with benzoyl peroxide morning and evening for 3 months. Topical Tretinoin or adapalene for comedonal acne. Moderate Acne Oral antibiotics options include – Oxytetracycline 500mg bd, Erythromycin 500mg bd, Doxycycline 100mg od, Minocycline 100mg od or Lymecycline 408mg od with or without benzoyl peroxide topically bd for 3 - 6 months. In women - consider Dianette as an oral contraceptive (contains cyproterone acetate – anti-androgen) Improvement – stop antibiotic after 6 months or reduce the dose. Continue topical treatment if needed. If relapse – restart antibiotics. No Improvement – refer to Dermatologist. Consideration for Trimethoprim or Isotretinoin (Roaccutane) Severe Acne Refer to dermatologist. Consideration for Isotretinoin Remember • Most topical agents are a little irritant. • Do not combine an oral antibiotic and a different topical antibiotic to avoid antibiotic resistance. • Benzoyl peroxide is a bleach. • Isotretinoin (Roaccutane) is a teratogen. 11
  • 14. • Acne scarring – try to avoid by treating early and stop patients picking spots; in severe cases dermabrasion or laser resurfacing (refer plastic surgery) can be considered once the acne is under control. • Antibiotic resistance can be reduced by combining a systemic antibiotic with either benzoyl peroxide or a topical retinoid 12
  • 15. BACTERIAL INFECTIONS Cellulitis • Streptococcus pyogenes or Staphylococcus aureus most common. • Deep infection and can involve subcutaneous tissue. • Predisposing factors - leg ulceration, Tinea infection, injury, surgery. Management • Penicillin V & flucloxacillin initially but often requires IV benzylpenicillin & flucloxacillin or erythromycin/clarithromycin. Erysipelas • β-haemolytic Streptococcus (often of face or lower leg). • Superficial infection, acute onset. • Unilateral tender erythema and swelling of the face. • High fever and patient unwell. • Usually IV antibiotics – benzylpenicillin and flucloxacillin or erythromycin are required. Impetigo • Staphylococcus aureus or β-haemolytic Streptococcus. • Young children. • Contagious, can spread rapidly. • Predisposing factors – eczema. • Clinically – face involvement with blisters/yellow pus, crusts. • Differential diagnosis - herpes simplex, diagnosis – skin swab. Management • Topical (fucidin cream or mupirocin ointment) and oral antibiotics for 7 days (flucloxacillin or erythromycin). • Emollients as soap substitute and bath additive containing antiseptic. Staphylococcal Scalded Skin Syndrome • Due to the exotoxin of the Staphylococcus. • Occurs mainly in infancy and childhood. • Can vary from localised bullous impetigo to the generalised fulminating form with the scalded appearance of the skin. • Painful skin condition resulting in flaccid blistering and raw areas. • Needs admission to hospital for oral/IV and topical antibiotics, adequate analgesia and good nursing care. 13
  • 16. MRSA Methicillin resistant Staphylococcus aureus (MRSA) is a nosocomial pathogen that affects patients and staff in many hospitals in the UK. MRSA is a Gram-positive bacterium. Like Methicillin sensitive Staphylococcus aureus, it can also be carried harmlessly by many people on their skin and in their noses without causing an infection. MRSA causes a spectrum of illness, ranging from trivial skin infections to life- threatening conditions such as bacteraemia, endocarditis and pneumonia. Some patients can shed MRSA heavily into the environment, and will release airborne particles carrying staphylococci e.g. patients with widespread eczema or upper respiratory infections. There is normally a wide range of antibiotics to treat staphylococcal disease. However, MRSA is resistant to a wide range of antibiotics. Transmission is mainly by direct contact, chiefly via hands. Airborne spread may also be possible over small distances. Further information about the management of MRSA can be obtained from the Infection Control Team at RLBUHT. 14
  • 17. MANAGEMENT OF ATOPIC AND CONTACT DERMATITIS (ECZEMA) IN PRIMARY CARE PATIENT HISTORY 1. Duration EXAMINATION 2. Family history 1. Check sites (face, flexures, trunk, limbs) 3. Possible triggers - irritant or allergy? 2. Character (excoriated, cracked, 4. Occupation impetiginised?) 5. Medical history 3. Extent of cover - well demarcated. Limited 6. Drug history in area? 7. Exclude other causes - eg scabies 4. Assess degree of itching 8. Patient expectations and ability to comply with treatment Pattern of disease Allergic Contact Irritant Contact Try and establish allergen. Avoid irritants and wet work Patch testing may be Use PVC gloves with cotton liners necessary (not for irritant or Atopic food allergy). Assess severity before deciding treatment. Avoid contact with allergen. PATIENT EDUCATION Excoriated, cracked or impetiginised before Otherwise treatment as for 1. Advice at consultation. Pattern of considering treatment options - see over. irritant. disease/cause. Provide patient education and support 2. Leaflets groups. Explain nature of chronic condition. 3. Demonstrate hand care Establish any nursing support if needed. TREATMENT For Treatment see over Dry and Scaly Wet and Weepy Emollients +++ - bath oils, soap substitutes and Consider potent steroid and antibacterial cream, e.g. moisturisers (500g containers). FuciBET, Betnovate C (not on face). Potent steroid ointment - reduce down slowly If infected may need to give a systemic antibiotic with the strength of steroid. topical steroid, eg flucloxacillin/ erythromycin for 10-14 days. Apply Duoderm or Haelan tape to painful fissures if Topical combination can also be used in conjunction. cracked. Swab if no improvement and treat other carrier sites (nasal, Very dry & scaly - wet wraps or Ichthopaste axilla, groin). bandages. Refer to dermatologist if no improvement. Continuing Care Sedation Continue initial measures to avoid irritants Sedating antihistamine (eg hydroxyzine, Continue emollients +++ chlorpheniramine, promethazine) pm for itch. Review regularly to weakest strength steroid (see over) and manage acute episode Indications for Referral Suspected contact allergic factors - patch testing Inability to get back to work Persisting despite treatment 15 Need for second line therapy
  • 18. + PATIENT EDUCATION TREATMENT 1. Advice at consultation. Pattern of disease, pathogenesis, genetics, etc. 2. Leaflets Emollients Frequency for All 3. Support agencies (National Eczema Society - 163 Eversholt Bath oils St, London NW1 1BY. Tel: 0171 388 4097. www.eczema.org) Soap substitutes 4. Nursing support - treatment & techniques Moisturisers Wet and Weepy? Impetiginised? Steroids Babies, the face and in flexures - Mild steroid and antibiotic SEE NOTES BELOW Face - Mild steroid combination, eg Fucidin H cream or ointment. Adults - trunk & limbs: Flexures - Mild steroid + antimicrobial cream, eg Fucidin H cream or ointment Potent steroid and antibacterial cream, eg FuciBET cream. Cotton gauze dressings/bandages. Wet wrapping for children Trunk & limbs - Mild to moderate steroid only when infection is controlled. If infected, may need to give a systemic antibiotic with the Cracked or Excoriated? topical steroid, eg flucloxacillin/erythromycin for 10-14 days. Steroid and antimicrobial ointment, Topical combination can also be used in conjunction. e.g. Fucidin H, Terra-cortril (not Swab if no improvement. Refer to dermatologist. recommended in children), FuciBET, Betnovate C Occlude with paste bandages, eg Ichthopaste/wet wraps Other Measures Avoid irritants, eg soap, wool Minimise exposure to environmental allergens, eg house dust Sedation mite and animal dander Sedating antihistamine hydroxyzine (less sedative for adults). Trimeprazine Second Line Treatments Immunosuppressants: Protopic: 0.03% or 0.1%. Should only be prescribed by Patient Review dermatologists and physicians with extensive experience in 1. Initial treatment period for at least 4 weeks immunoregulators, after conventional therapies for 2. Check compliance (amount/ technique) moderate - severe atopic dermatitis. See SPC. 3. Check expectations compared with results Elidel: 1% cream should be prescribed by physicians with 4. Assess need for nursing support experience in the topical treatment of mild-moderate atopic 5. Consider need for regular review dermatitis. 6. Assess need for referral Short term or intermittent - see SPC NOTE 1. TOPICAL STEROIDS IN ECZEMA Indications for Referral Use preparation containing least potent drug at lowest strength Urgent - worsening despite above which is effective at controlling the eczema. measures I Mild hydrocortisone 1% Routine - If specialist treatment needed, eg II Moderately potent. Clobetasone butyrate 0.05% wet wrapping. If need further patient or (Eumovate), Betnovate 1 in 4 (RD) cream or ointment. III Potent. Betamethosone 0.1% (Betnovate), hydrocortisone parental education and support. butarate (Locoid) IV Very potent - Clobetasol propionate 0.05 (Dermovate) FACE & ARM & LEG & TRUNK TRUNK Fingertip Unit Measurement NECK HAND FOOT (f ront) (back inc. One fingertip unit measurement equals the buttocks) amount of cream or ointment squeezed AGE NUMBER OF FTUs along the index finger starting at the tip 3-6 months 1 1 1½ 1 1½ down to the first joint. 1-2 yrs 1½ 1½ 2 2 3 3-5 yrs 1½ 2 3 3 3½ 6-10 yrs 2 2½ 4½ 3½ 5 Adult 2-5 4 8 7 7 FTU = Fingertip unit. 1 FTU = 1/2 g of cream or ointment. Measurement as expressed from the 30g tube 16
  • 19. ECZEMA & PATCH TESTING Indications for referral • Any chronic eczema, which is unresponsive to treatment e.g. hand eczema or varicose/venous eczema. • Suspicion of allergic contact eczema. • Suspicion of occupational contact dermatitis. Who not to refer for patch tests Patients with urticaria, hayfever, rhinitis, conjunctivitis, asthma. Some of these may need prick testing. Refer to Dr T Dixon or Dr C J Darroch at the Allergy Clinic, Broadgreen Hospital. Patch Test Clinic Patients attend on 3 occasions in one week (Monday, Wednesday and Friday). All topical medicaments, skin products, perfumes, hair products and gloves are required. For occupational contact dermatitis the Health and Safety data sheets and chemicals from work should be supplied in suitable containers (i.e. glass or plastic) and well marked with the name. The back should be clear of eczema and there should be no exposure of the trunk to sun or sunbeds for at least 4 weeks preceding the tests. Secondline treatments for eczema available at BGH: • Phototherapy – UVB, TLO1, PUVA • Drug thearapy – topical immunosuppressants, azathioprine, ciclosporin • In-patient treatment 17
  • 20. FUNGAL INFECTIONS Pityriasis versicolor This is a superficial infection due to the yeast Malassezia furfur. It is particularly common in young people and presents with a slightly scaly eruption of variably coloured macules. This usually affects the trunk and may be complicated by areas of hypopigmentation (as the yeast bleaches the skin) or post inflammatory hypopigmentation. Management • Skin scrapings may confirm diagnosis. • Topical azoles e.g. miconazole cream, ketoconazole shampoo used as a shower gel. • Selenium sulphide shampoo. • Oral itraconazole 200mg daily for 7 days. • After successful treatment repigmentation may take many months. Tinea infections Tinea infections arise due to infection by dermatophytes, which are fungi, which can live on keratin. Classification is related to body site: Tinea capitis - scalp Tinea corporis - body Tinea manuum - hand Tinea cruris - groins Tinea pedis - feet (Athlete’s foot) Tinea unguium - nails Management • Confirm diagnosis by sending scrapings/nail clippings for mycology if the diagnosis is in doubt • Skin infections usually respond to topical treatment. Topical azoles are used as first line whilst topical terbinafine may be used in non- responsive cases. • Scalp and nail infections respond poorly to topical treatment and systemic therapy is indicated. Tinea capitis Tinea capitis occurs predominantly in children. Pustule formation and hair loss are features. Oral antifungals are indicated, if severe urgent referral to dermatologist. Only griseofulvin is licensed for use in children under 12. Terbinafine is more effective than griseofulvin or itraconazole 18
  • 21. Tinea unguium (onychomycosis) Fungal nail infection is over diagnosed. Prolonged courses of antifungal therapy are required but may on occasions be inappropriately prescribed. Correct use of antifungal therapy depends on accurate diagnosis. • This is a true dermatophyte infection of the nail. • Usually only a few nails are involved. • Nails grow slowly, become discoloured and brittle. • Diagnosis is by nail clippings – it is important to send some of the crumbly white material underneath the nail for mycology. Management • 3 months of oral terbinafine; oral itraconazole and griseofulvin may be considered but are less effective. Topical therapy may help in the management of this condition and sometimes in combination with systemic treatment. • Other causes of nail dystrophy include chronic paronychia, inflammatory skin disease and peripheral vascular disease. Chronic paronychia • Very common –arises due to a combination of mechanical factors and candida infection. • Affects finger nails in patients with repeated exposure to irritants and water. • Many nails may be involved with bolstering of the nail folds and loss of the cuticle in addition to nail dystrophy. Management • Avoidance of water, and hand protection; topical treatment of the nail folds with an azole cream may be of help. • In severe cases oral itraconazole may help. Oral terbinafine is of no use. Nail dystrophy due to inflammatory skin disease • Psoriasis and eczema both commonly involve nails. • Nails grow rapidly. • Psoriasis causes nail pitting, onycholysis and patches of discolouration. • Periungual eczema causes nail ridging and dystrophy and may be associated with chronic paronychia. • These conditions do not respond to antifungal treatment. Treatment is directed at the underlying cause. 19
  • 22. Intertrigo • Intertrigo refers to any rash occurring on an area where two skin surfaces are opposed e.g. submammary and groin areas. • Often associated with candida infection. • Areas involved show glazed erythema with surrounding pustules. There is often an associated odour. • This condition responds well to mixtures of topical steroid and antibiotics e.g. Canesten HC cream and Trimovate cream, but is often recurrent. • It is important to avoid irritants and to prescribe emollients to be used as a soap substitute and moisturizer. 20
  • 23. INFESTATIONS Pediculosis capitis (head lice) • Most common in childhood. • Transmitted by contact, combs and brushes. • Scalp itching is the predominant symptom, especially above ears and posterior scalp. Management • Treat index case and all contacts/household members. • Treatments include malathion, permethrin and phenothrin; 2 applications 7 days apart. Carbaryl may be used if other treatments fail. • Resistance to some preparations now exists. • Treat any pre-existing scalp eczema with a steroid / antibiotic cream prior to application of the scalp preparation. Phthiriasis pubis (crab lice) • Most common in adulthood. • Generally transmitted by sexual contact. • Itching is the predominant symptom. Management • Carbaryl or malathion. • Recommend attendance at GUM clinic for full screening to exclude other sexually transmitted diseases. Pediculosis corporis (body lice) • Transmitted by clothing and bedding. • Lice and the eggs can be found in the seams of clothing. • Poor hygiene favours infestation. Management • Malathion and permethrin, but the clothing needs high temperature laundering or incineration. 21
  • 24. INFESTATIONS - SCABIES Scabies is caused by the scabies mite, Sarcoptes scabiei. It is transmitted by skin-to-skin contact. People can be affected for several weeks before they start to itch, and it is therefore important to treat all contacts to prevent the condition spreading. Clinical features There is usually an erythematous scaling rash on the hands, wrists, ankles with more widespread excoriations on the trunk and limbs. The face and scalp are usually spared except in infants. On the trunk a fine red papular rash is often present. Scabies burrows are best seen on the web spaces palms, wrists or ankles (soles in infants). Males tend to develop genital nodules and females involvement of the nipples Choice of anti-scabetic agent The first choice in a majority of cases should be 5% permethrin (Lyclear Dermal Cream) with 0.5% malathion (Derbac M, Quellada M) an alternative. No products are licensed for infants less than 2 months old but Lyclear appears to be safe – medical supervision advised. Benzyl Benzoate (25%) is still available but tends to irritate the skin. Special patient groups Children less than 2 years old, the elderly, immunocompromised, or debilitated patients should have the scalp, face and ears treated as well as the trunk and limbs. Lyclear Dermal creme rinse (1% permethrin) is an appropriate treatment. Dermatologists use Lyclear in pregnancy although the drug is not licenced for this use. Benzyl benzoate is safe. General management information For an average adult, 30g of Lyclear or 50ml malathion is required per application. Lyclear should be effective after a single 8-12 hour overnight application. A bath prior to application is not necessary. Apparent treatment failures are in general NOT due to drug resistance and the commonest causes are: • Failure to cover the skin surface completely (often patients apply it only to the lesions). • Washing off the treatment agent before 12 hours has elapsed. 22
  • 25. • Failure to treat all contacts at the same time. All members of the household must be treated, as must any other close contacts, whether they are symptomatic or not. Following scabies treatment, itch may continue for 6 weeks requiring oral antihistamines and topical steroids. Post-scabetic eczema will be aggravated by further anti-scabetic treatment. Eczema often accompanies scabies and infected eczema may need addressing prior to scabies treatment with emollient, antibiotic and topical steroid. If burrows are still present after 6 weeks, re-treatment is justified. Scabies may be secondarily infected (impetiginised) – especially in children SCABIES IN NURSING HOMES Scabies is caused by the scabies mite, and is transmitted by skin-to-skin contact. People may be affected for several weeks before they begin to itch, and can pass on the mite before they have symptoms themselves. Effective treatment is available but it is essential to treat all contacts to prevent the condition spreading. IF SCABIES IS DIAGNOSED IN ONE OF YOUR RESIDENTS When a single case is diagnosed Make a list of all the people likely to have come into skin-to-skin contact with the patient. This could be staff, relatives or other visitors. Advise the people on the list of the diagnosis, and suggest that they see their GPs for treatment. Explain that they can be affected for weeks before developing symptoms, so they should be treated even if they are not itching. Try to co-ordinate treatments so that contacts are treated as soon as possible after the patient, and ideally on the same day. Any of the contacts’ household should be treated as well. When more than one case is diagnosed Because of the way scabies spreads, we advise that as soon as more than one case is diagnosed in the community such as a nursing or residential home, all patients/residents and staff are treated. This is irrespective of whether they are itching or scratching or not. Relatives and other frequent visitors should also be advised to treat themselves. 23
  • 26. Ideally, everyone should be treated on the same day. If different General Practitioners are involved, the nurse in charge should act as a co- ordinator. Until the outbreak has been successfully controlled, staff should wear gloves whenever they are touching patients or residents. Ideally, patients should not be transferred or discharged and new patients should not be admitted until it is medically confirmed that treatment has been successful. If one of your patients or residents has to be admitted to hospital, the hospital should be informed of the scabies diagnosis. 24
  • 27. MINOR SURGERY Minor-ops room/theatre • Good lighting and ventilation. • Adjustable patient couch. • Nursing assistant. • Hand washing. • Resuscitation equipment. Equipment • Basic minor-ops pack/sterile towels. • Local anaesthetics - plain lignocaine or lignocaine with adrenaline (avoid adrenaline on the fingers, toes, penis and tip of nose). • Scalpel blades (size 15). • Punch biopsies (Stiefel 3, 4 or 5mm). • Curettes (Stiefel 4 or 7mm). • Hyfrecator or electrocautery/chemical haemostasis. (Aluminium chloride alcoholic solution e.g. Driclor). • Stitches - non-absorbable e.g. Ethilon, Novafil and Prolene. • Histological transport medium (formaldehyde)/pots. Procedures • Punch biopsy - rashes, diagnosis of lesions, removal small lesions. • Incisional biopsy - rashes, lesions. • Shave biopsy/snip excision - skin tags, benign fleshy naevi. • Excision biopsy – benign moles, cysts. • Curettage and cautery - warts, seborrhoeic warts, actinic keratoses. • Liquid nitrogen cryotherapy - warts, actinic keratoses. Precautions • Obtain signed informed consent before surgery. • Aspirin stop 10 days pre-op for excisions. (NB. Sometimes aspirin cannot be stopped for medical reasons). • Warfarin - stop 48h pre-op and always check INR on the day of surgery aiming for INR<2.5. (NB sometimes Warfarin cannot be stopped for medical reasons). • Pacemaker - monopolar diathermy more dangerous than bipolar diathermy. • Antibiotic prophylaxis is generally not necessary for skin surgery in patients with pre-existing heart lesions unless skin infection present. 25
  • 28. IMPORTANT • ALWAYS send specimens for histopathogy. • If removing more than one lesion, careful notemaking and labelling of each specimen in separate pots. • ALWAYS use non-alcoholic antiseptics when using electrocautery. • Remember the anatomy of the biopsy site. • Biopsies can scar, warn patients. • Beware of keloid scar and hypertrophic scar sites (especially upper chest and arms). • ALWAYS operate within skill level and facilities available. 26
  • 29. PSORIASIS - summary Patient History • Duration of psoriasis and psychological impact. • Possible triggers – infection, stress, alcohol, cigarettes, drugs. • Family history of psoriasis. • Occupation (including effect of disease). • Medical history. • Drug history. • Patient expectations and ability to comply with treatment. Examination • Check sites (elbows, knees, trunk, scalp, flexures, nails). • Note character of lesions (scales, thickness, erythema, pustules). • Note extent of cover (sometimes PASI score will be given – psoriasis area severity index) • Assess degree of itching. • Assess complications, eg arthropathy. Chronic Plaque Psoriasis • Usually symmetrically distributed. • Large or small plaques. • Often seen on extensor surfaces, scalp. • White silvery scales on a salmon pink base. Management • Encourage emollients – bath oil/soap substitutes and moisturisers. • Vitamin D analogues e.g. calcipotriol ointment bd up to 100g per week in adults, 6-12 years 50g, 12-16 years 75g, (no limit on course length) or tacalcitol ointment od. • Vitamin D analogues + topical steroid - Dovobet® (calcipotriol 50µg/g as hydrate and 500µg/g betamethasone as diproprionate) - maximum weekly dose is 100g or 30% body coverage- so best for localised disease, applied once daily. • Dithranol preparations - short contact Dithrocream 0.1, 0.25, 0.5, 1.0 and 2% strengths (always start with the 0.1% and increase slowly to avoid burning) or Micanol cream 1 & 3% dithranol. • Coal tar preparations – e.g. Alphosyl, Exorex. • Topical retinoids – tazarotene gel od (0.05 & 0.1% strengths); sometimes combined with moderate potency topical steroids to limited areas. • In referral letters, please list all previous treatments. 27
  • 30. Psoriasis at special sites Face/ears – mild or moderate potency steroids bd used sparingly to localised areas. Scalp – Cocois (12%CTS, 4%sulphur, 2%salicylic acid in coconut oil) applied overnight and washed out the following morning with a shampoo e.g. Polytar, T-Gel, Capasal; topical steroid scalp applications or calcipotriol scalp application applied after shampooing. Genitals - mild or moderate potency topical steroids bd used sparingly to localised areas or tacalcitol ointment od. Nails – very difficult to treat; exclude fungal infection; sometimes helped by topical steroids. Secondline treatments for psoriasis available at BGH: • Phototherapy – UVB, TLO1, PUVA • Drug thearapy – hydroxycarbamide, methotrexate, ciclosporin, acitretin • In-patient treatment 28
  • 31. Liverpool - Psoriasis MANAGEMENT OF PSORIASIS IN PRIMARY CARE PATIENT HISTORY 1. Duration of psoriasis 2. Possible triggers - infection, stress, alcohol, drugs, smoking 3. Family history of psoriasis 4. Occupation (including effect of disease) 5. Medical history 6. Drug history 7. Patient expectations and ability to comply with treatment 8. Psychological effect of psoriasis EXAMINATION 1. Check sites (elbows, knees, trunk, scalp, flexures, nails) Pattern of 2. Note character of lesions (demarcation, scales, thickness, disease erythema, pustulation) 3. Note extent of cover 4. Assess degree of itching 5. Assess complications, eg arthropathy Chronic Plaque Psoriasis 1. Usually symmetrically distributed 2. Large or small plaques For treatment see over 3. Often seen on extensor surfaces, scalp 4. White silvery scales on a salmon pink base Emollients plus: a. Mild topical steroid or tar/ Facial Psoriasis steroid combination b. Vit D analogues Guttate Psoriasis 1. Numerous scaly "droplet" lesions over trunk Emollients plus: 2. May follow Streptococcal infection a. Tar preparations 3. Most common in children/adolescents b. Vit D analogues, e.g. Calcipotriol 4. Self limiting 4-6 months c. Topical steroids d. UVB/TL01 if not responding Flexural Psoriasis 1. Smooth glazed shiny red areas of skin, well demarcated (hairline; axillary, submammary, Use moderately potent perineal) steroid/antiyeast and/or 2. More commonly seen in the elderly Vit D analogues 3. May be secondarily infected with yeasts Potent steroids and/or Vit D Psoriatic Nail Dystrophy analogues, e.g. Calcipotriol cream, 1. Severe problems in up to 10% of patients Tazarotene gel 2. Minor signs in 50% of patients But difficult to treat Psoriatic Arthropathy Refer to Rheumatologist Incidence up to 7% of psoriasis patients Pustular Psoriasis palmo-plantar Potent topical steroids 29
  • 32. PATIENT EDUCATION TREATMENT 1. Advice at consultation, eg genetics, 1. Assess practicalities of treatment pathogenesis 2. Assess motivation to use treatment 3. Explain method of application 4. Explain need for compliance and expected time of response (12 weeks) + 2. Leaflets 3. Support agencies (Psoriasis Association, Tel. 01604 - 711129, Psoriatic Arthropathy Alliance, Tel. 01923 672837. www.psoriasis- 5. Calculate amount of topical therapy association.org.uk) needed to treat extent of disease 4. Nursing support - treatment techniques 5. Sunbeds not recommended CHRONIC PLAQUE PSORIASIS MILD SCALP PSORIASIS 1. Encourage emollients - bath oil/soap substitutes & moisturisers +++ 1. Tar based shampoos PLUS 2. Calcipotriol Scalp Solution - 1-2 drops per 2. Active therapy - 1st line: Dovobet once daily - initially for 4 weeks postage stamp area of plaque b.d. and then review. Educate to treat flare-ups only. Vitamin D analogues 3. Steroid scalp lotions - up to 3 times per e.g. Dovonex, Curatoderm, Silkis, tars - e.g. Alphosyl, Exorex week 3. Dithranol preparations (increasing strengths of short contact Moderate scaling Dithrocream) or Micanol Soften scales with overnight application of: Thick scaling 1. Cocois ointment - apply generously to Soften scales with overnight application of: scalp along hair partings. Leave overnight 1. Greasy moisturisers, eg white soft paraffin in liquid paraffin 50/50, and wash out with a tar shampoo am. Do Epaderm this for 3-7 consecutive nights until scale 2. 2% salicylic acid in emulsifying ointment reduced Very thick plaques 1. Consider keratolytic agent, eg 5-10% salicylic acid with emollients PATIENT REVIEW 1. Initial treatment period for at least 12 weeks 2. Check compliance (amounts of treatment used and treatment technique) 3. Check expectations compared with results 4. Consider need for regular review 5. Assess need for referral to hospital CRITERIA FOR REFERRAL TO DERMATOLOGIST 1. Erythrodermic patients - Emergency 2. Unstable/generalised pustular patients - Emergency 3. Extensive/severe or disabling psoriasis 4. Failure to respond or relapse post topical therapies (phototherapy, drug therapy) 5. Recurrent attacks of psoriasis 6. Difficulty with diagnosis 7. Disfiguring nail disease 30
  • 33. SOLAR DAMAGE AND SKIN CANCER Bowen’s Disease Intraepidermal carcinoma is common and typically found on the lower leg in women. Erythematous, scaly plaques occur and there is a small risk of developing SCC. Treatments include liquid nitrogen, cryotherapy, surgery, photodynamic therapy and topical 5-fluorouracil cream (Efudix). Solar or Actinic Keratoses (AK) These present as single or more commonly multiple scaly, erythematous lesions affecting sun exposed sites such as the scalp, ears, face and dorsal hands. Many small solar keratoses will spontaneously involute, especially if patients are given advice concerning the use of high protection factor sunscreens. The vast majority of solar keratoses will never become an SCC but the risk is probably about 5%. Management of Solar Keratoses • Photoprotection – hat, clothing • Sunscreen – high SPF (UVB) and high star rating (UVA); frequent, careful, thick applications • 3% diclofenac gel (Solaraze) applied bd to AKs for 60-90 days – beware of skin irritation, avoid excessive sun exposure • 5-fluorouracil cream (Efudix) applied sparingly to AKs bd for between 1 and 3 weeks; expect irritation and warn patients; if severe, stop applying and may need to use 1% hydrocortisone cream bd to settle; the Efudix cycle can be repeated if the AKs not clear • Liquid nitrogen cryotherapy – 5-10 second freeze; painful and warn patients of blistering and possible scarring at treatment site • Photodynamic therapy (PDT) can be used as a third line treatment for AKs and is performed as an OPD procedure in secondary care • Surgery – either curettage / cautery (C&C) or excision biopsy especially if there is diagnostic doubt or concern of progression to squamous cell carcinoma; remember if SCC considered referral on 2 week fax referral form to skin cancer clinic 31
  • 34. A summary guide to the management of AKs: CRYO Solaraze Efudix PDT Surgery Single AK √√ √ √ √ Multiple AKs √ √√ √√ √√ Failed Rx √ √√ √ Cutaneous horn √ √√ Indurated or √ √√ hyperkeratotic lesion Fast growing ?SCC √√ 32
  • 35. Basal Cell Carcinoma (BCC) or Rodent Ulcer Commonest type of skin cancer seen typically on the face in middle-age and elderly patients. Slow growing, locally invasive tumours, which virtually never metastasize. Nodular lesions are skin coloured papules with telangiectasia and a rolled, pearly edge. Other types – cystic, morphoeic, superficial and pigmented. Excision is the best form of treatment but other treatments are available depending on the size and site of the lesion and age of the patient. BCCs are not included in the 2 week initiative to see suspected cancers but will be given a priority in appointment time. Squamous Cell Carcinoma (SCC) Usually arises on sun damaged skin in elderly males and this tumour may metastasize. It may arise from an actinic keratosis, Bowen’s disease, scar tissue and leg ulceration. Papules grow which can ulcerate and crust. If suspected, requires urgent referral by fax via the skin cancer referral form. Surgery is the treatment of choice but radiotherapy is also utilised depending on the size and site of the lesion and age of the patient. Malignant Melanoma (MM) This is the most serious of the skin tumours and early diagnosis is essential as the prognosis depends on the tumour thickness at time of excision. It is most commonly seen in the fair skinned. In males the commonest site is the back and in females the commonest site is the lower leg. The main types of MM are superficial spreading melanoma, lentigo maligna melanoma, nodular melanoma and acral malignant melanoma (around nails and terminal digits). Other major risk factors include childhood sunburn and familial dysplastic naevus syndrome. Signs of MM: • Asymmetry of shape • Border irregularity • Colour variation with dark and light areas • Diameter increasing and greater than 7mm 33
  • 36. • Other features might include itching, redness or inflammation, bleeding or oozing. Treatment is surgical excision with a wide margin, with regular follow-up and monitoring. If you suspect a malignant melanoma please refer urgently by fax via the skin cancer referral form. Please ensure fax is sent to the number on the form. 34
  • 37. SKIN CANCER REFERRAL FORM FOR SUSPECTED MELANOMA AND SQUAMOUS CELL CARCINOMA ONLY Basal cell carcinomas to be sent by usual referral letter All suspected skin cancers to be referred to Dermatology Department, The Royal Liverpool & Broadgreen University Hospital: Fax 0151 706 5655 PATIENT DETAILS: REFERRING GP: (STAMP) Name: DoB: Address: Phone No: Case Sheet No: DATE SEEN BY GP: …………………….. SUSPECTED DIAGNOSIS: MELANOMA / SCC 1. MELANOMA SITE: ………………………………… SIZE: …………………….. DURATION: ………………… RISK FACTORS CHARACTERISTICS Multiple naevi YES NO Change in size YES NO History of sunburn YES NO Change in shape YES NO Fair skin/freckled YES NO Change in colour YES NO Family history YES NO Irregular outline YES NO Mixed colour YES NO Itch/bleeding YES NO Inflammatory responseYES NO 2. SQUAMOUS CELL CARCINOMA SITE: ………………………………… SIZE: …………………….. DURATION: ………………… RISK FACTORS Previous ultraviolet light exposure YES NO Previous non melanoma skin cancer/actinic keratosis YES NO Immunosuppression YES NO CHARACTERISTICS Evidence of chronic skin damage e.g. actinic keratoses/old burn scar YES NO Crusting/non healing lesion YES NO Documented expansion YES NO Inflammatory response YES NO COMMENTS Other reasons for urgent referral: SIGNATURE: DATE:
  • 38. URTICARIA Urticaria presents as hives, weals or nettle-rash and is very itchy. The cause of an acute attack of urticaria can be fairly obvious, e.g. shellfish, drugs eg ACE inhibitors, or certain fruits / nuts but a ‘well patient’ who has chronic urticaria persisting for more than three months will rarely have an allergy and this has a non-allergic aetiology - detailed investigation is usually unrewarding. Chronic Idiopathic Urticaria • Chronic urticaria is not an allergic rash and skin testing (prick or patch) is not usually indicated. • About 40% of patients with chronic urticaria will be made worse by NSAIDs – so avoid all aspirin containing drugs. Recommend paracetamol as an analgesic if required. • Other aggravating factors may be codeine, azo dyes or preservatives (benzoates) in the diet. Management • Non-sedating antihistamines • Fexofenodine 120 – 180mg od • Desloratidine 5mg od • Levocetirizine 5mg od • Sedating antihistamines • Trimeprazine 10mg tds • Chlorpheniramine 4mg 4-6 hourly • Hydroxyzine 25 mg tds • Promethazine 10mg tds • Others • Topically, aqueous cream or 1% menthol in aqueous cream can be soothing on the skin. • Consider adding ranitidine 150mg bd as sometimes H1 & H2 histamine receptor blockade helps • In emergencies only, short courses of prednisolone may be required in extensive urticaria often associated with angioedema.
  • 39. VENOUS ULCERS First exclude accompanying arterial insufficiency by Doppler Ultrasound examination because ulceration due to venous hypertension is treated with compression bandaging. Keep treatment as sterile as possible: • Clean with water or saline. • Apply liquid paraffin/white soft paraffin 50:50 or Epaderm ointment to the leg to keep the skin well moisturised. • Apply N/A dressing to the ulcers. • Apply 4 layer compression bandaging weekly. • If venous eczema is a problem apply a topical steroid ointment e.g. Betnovate®, Propaderm® or Metosyn® for up to 3 weeks and increase the frequency of dressings until the eczema settles. If secondary infection of eczema occurs steroid combined with an antiseptic e.g. Betnovate C® may be used. 4 layer bandaging available on FP10 – many options: e.g. Profore, K-four, System four, Ultra four. In sensitive patients, rubber bandages must be replaced by rubber-free bandages. Infected Venous Ulceration: Take swabs if there is increasing pain or discomfort, increasing exudate or cellulitis. Do not treat colonisers such as Pseudomonas, Coliforms. Do treat β-haemolytic Streptococcus with penicillin and cellulitis with penicillin and flucloxacillin systemically. Do not use topical antibiotics as they can be sensitisers (e.g. Neomycin). Avoid iodine preparations unless treating MRSA. When to refer to the Dermatology Department • If there is a diagnostic doubt as to the type of ulcer – consider a skin biopsy to exclude malignant pathology • If there is a possibility of allergic contact eczema around the ulcer e.g. to rubber or a topical agent. • Patients unable to tolerate compression bandaging should be referred to a Vascular Surgeon.
  • 40. Information A range of comprehensive guides for the management of leg ulcers including clinical practice guidelines are available from the Royal College of Nursing (www.rcn.org.uk). Graduated compression hosiery Once the ulcer has healed it is vital to continue to maintain compression on the malfunctioning veins to reduce oedema and prevent injury. For most patients Class 2 (medium support) are satisfactory.
  • 41. VIRAL INFECTIONS Herpes zoster (shingles) • Varicella zoster virus. • Virus reactivation in dorsal root ganglia. • Predisposing factors – immunosupression e.g. systemic steroids, AIDS, cancer. • Clinically – pain and paraesthesia, unilateral dermatome distribution, vesicles, scabs and crusts. • Complications – secondary bacterial infection, ophthalmic zoster, Ramsay-Hunt syndrome, disseminated zoster, postherpetic neuralgia. Management • Aciclovir 800mg qids for 7 days, analgesia and bed rest; often becomes secondarily bacterially infected. • In elderly patients it is important to commence amitriptyline 50mg nocte as soon as possible to reduce incidence of postherpetic neuralgia. Herpes simplex • Herpes simplex virus I and II. • Oral/facial and genital infections - recurrent. • Tingling and painful. • Erythema, grouped vesicles. • May cause erythema multiforme; eczema herpeticum. Management • Treatment topical aciclovir qids for 5 days or (if more severe) oral aciclovir 200mg 5xdaily for 5 days. Molluscum contagiosum • Molluscum contagiosum pox virus. • Very common in children. • Contagious. • Flesh coloured dome shaped papules with central umbilication. Management • Cryotherapy, wart preparations containing salicylic acid for a few days only to each lesion, or none as lesions resolve spontaneously (6-18 months). • NB Alder Hey no longer offers a cryotherapy service so we do not recommend referral of viral warts for treatment.
  • 42. Viral warts • Human papilloma virus (HPV). • Very common. • Types – common, plane, periungual, verrucae, mosaic, anogenital. Management • Salicylic acid, glutaraldehyde, podophyllin, cryotherapy, surgery or laser.
  • 43. PATIENT INFORMATION LEAFLETS • Dovobet • 5-Fluorouracil cream (Efudix) • Photoprotection • Urticaria • How to treat your scabies The following patient information leaflets are available on the British Association of Dermatologists web site as follows: http://www.bad.org.uk • Acne • Atopic eczema • Bowen’s disease • Contact dermatitis • Darier’s disease • Dermatitis herpetiformis • Discoid lupus erythematosus • Granuloma annulare • Hailey Hailey disease • Ichthyosis • Keratosis pilaris • Lichen planus / lichenoid eruptions • Lichen sclerosus • Lichen sclerosus in children • Linear IgA • Mycosis fungoides • Oral cortisone • Pemphigoid • Pityriasis lichenoides • Psoriasis • Psoriasis – moderate / severe • Sarcoidosis • Seborrhoeic warts • Strawberry marks / port wine stains • Urticaria and angioedema • Vulval disease
  • 44. DOVOBET® : ADVICE FOR USE Dovobet® (calcipotriol 50µg/g as hydrate and 500µg/g betamethasone as diproprionate) is an effective topical treatment that shows a rapid improvement, even during the first week of use. Maximum weekly dose is 100g or 30% body coverage- so best for localised disease, applied once daily. Dovobet® offers patients an easy way to manage their psoriasis with an opportunity for treatment breaks, by using 1 month at a time. Psoriasis is a common skin disease with characteristic raised, red, scaly plaques. As the patient gets better the plaques lose their scale and reduce in thickness until they are no longer palpable on the skin. During the inflammatory process pigmentation of the skin is disrupted. When the plaque has completely cleared there is, in Day 1 of treatment some patients, a change in the colour of the skin. This colour can be categorised as post inflammatory hyper- or hypo-pigmentation. ¹̉,2 Hyper-pigmentation may be more distressing to the patient and they may feel the desire to continue to treat. These macular (flat area of localized colour change) patches of erythema (redness which blanches on pressure) are shadows of the disease and although secondary to the psoriatic process are not lesions of active psoriasis. At this stage a switch to Dovonex would be advisable to maintain control, saving the Dovobet for flair-ups. Once the skin becomes palpable again it can be re-treated. Dovobet should not be applied to the face. After treatment In short, in terms of psoriasis treatment, this suggests that some simple advice to give a patient would be: “If you can feel it treat it, and if you can’t feel it don’t treat it.” References: 1. Leppard and Ashton, Treatment in Dermatology. 1993, p147 2. Ashton and Leppard, Differential Diagnosis in Dermatology. 1993, p134
  • 45. FLUOROURACIL (5%) CREAM (EFUDIX) Indications: actinic keratoses (AK), Bowen’s disease, superficial basal cell carcinoma (sBCC), others. • Apply the cream thinly twice a day to the affected areas limiting the application to the individual lesions. On occasions you may be instructed to apply the cream more generally to a light exposed area e.g. hands or arms. Be particularly careful not to get the cream near to the eyes. Wash your hands thoroughly after use. Sometimes a cotton bud is a useful applicator. • Apply the cream twice daily for between 1 and 3 weeks; if working, the affected sites will go red / sore and may even weep & blister in some cases. It is important to realise that this ‘reaction’ described is an inevitable and necessary part of the treatment. Once the reaction has started and provided it is not too sore continue the application of cream for a maximum of 3 weeks. If at any time the reaction is really unpleasant and too sore, stop treatment and apply a steroid cream or ointment (usually Hydrocortisone 1% will be prescribed) twice daily to these areas for 2 weeks. • If a severe reaction has occurred it is likely that the lesions will have been effectively treated and no further application will be required. If in doubt, consult your Doctor and he will advise as to whether you should continue treatment. • Once the redness and soreness has settled, check if the lesions are still there. YES - repeat the Efudix cycle again and this can continue on & off until clearance NO – stop treatment but watch for signs of recurrence NOTES • Do not use Efudix Cream without supervision. • Avoid prolonged exposure to sunlight while undergoing treatment. • Continue to protect the exposed skin using clothing and/or an effective high SPF sunscreen. • Always ensure that the Efudix cream is within its expiry date • If a warty lesion appears and appears different, see GP in case a skin cancer has developed
  • 46. PHOTOPROTECTION Use common sense on your holiday and whenever sunbathing. Sunburn can ruin your holiday and age your skin prematurely. Avoiding burning from the first few days helps the skin develop its own protective properties. It seems to be particularly important to avoid sunburn in children. Protect your skin by using sunscreen preparations. Or, if you prefer, cover up and keep in the shade. Always avoid the sun during the middle of the day. And remember the sun is stronger as you get nearer the equator. You should be particularly careful if you have a skin, which always burns or tans only with difficulty. Remember, the fairer your skin, the more important it is to avoid sunburn. In other parts of the world such as Australia, information such as this has reduced the numbers of people developing skin cancer because they protect their skin from excess sun. The Use of Sunscreens The sunscreen should be used in the following way: • Apply before going outside, every day from April to September inclusive. • On days when the sun is out, apply at lunchtime as well. • Use under skin creams or makeup. • Re-apply after swimming – or use a waterproof one. • Use on face/hands/arms/V-neck/ears, as appropriate to all exposed areas. • Sun protection factor (SPF) refers to protection against UVB – the higher the number the better the protection as long as the sunscreen is applied thickly and evenly. • Star **** system refers to protection against UVA – the greater the number of stars, the greater the protection.
  • 47. URTICARIA What is urticaria? Urticaria, ‘hives’, or ‘nettle rash’ is an itchy skin rash consisting of red bumps and weals, which can affect any area of the body. The individual weals come and go within hours, and there may also be swelling of the lips and eyelids. Scratching the skin may cause more weals to form. Some people have only one attack of urticaria in a lifetime, whereas in others it may be a recurrent condition. There are several types of urticaria: Physical Urticaria - Can occur on exercise, exposure to hot or cold temperatures, sunshine or at areas of pressure e.g. bra straps and waist bands. Acute Urticaria – is a short lived and sometimes dramatic condition where weals develop rapidly, within minutes or hours. The cause or trigger may be known. Chronic Urticaria – is urticaria which has been coming and going for several months. It may sometimes last for years, but tends to vary in severity. What causes urticaria? Urticaria develops when special inflammatory cells in the skin release their contents. These include histamine, a chemical, which causes swelling and itching of the skin. The effects of histamine can be blocked, by taking antihistamine tablets. Unknown – in chronic urticaria the cause is usually unknown. Most people are unable to identify any trigger. Drugs – such as penicillin may cause a severe urticarial rash in people who are allergic to them. This is a serious reaction and the drug should not be taken again. Aspirin, other painkillers and over the counter cold and flu remedies may also trigger urticaria or make it worse. Food – sometimes people can identify a foodstuff, which causes their urticaria. Common examples include shellfish, fish, strawberries and nuts. In a few people avoiding additives in the diet can be of help. Infections – such as flu or sinusitis may rarely trigger urticaria.
  • 48. What tests can be done to find the cause? Allergy tests are not usually necessary, and they rarely help to find the cause. If a food trigger is suspected this can be left out of the diet to see if the condition improves. If the urticaria persists, a routine blood test may be necessary, to exclude rare medical conditions which may cause urticaria. Is it serious? Urticaria may look dramatic but in the majority of cases there is no associated risk to general health. In a small number of patients there may be swelling of the tongue and breathing passages, and this requires urgent medical attention. Is there a cure or treatment? Any obvious trigger should be avoided. Regular doses of antihistamine tablets will help settle an attack and these are safe to take over a long period if necessary. Short courses of steroid tablets may be needed for a severe, acute attack. Drugs, which can worsen urticaria should be avoided, such as aspirin or codeine. Paracetamol is safe.
  • 49. HOW TO TREAT YOUR SCABIES Your skin rash has been diagnosed as scabies. You have been prescribed Lyclear Dermal cream (5%). • Treatment is best applied before going to bed. • There is no need to bathe before applying the treatment. • Nails should be cut before treatment and rings removed if feasible. • The creams should be applied thoroughly all over, to the entire skin surface below the chin, whether or not any spots are seen. • The genital area, the finger and toewebs, under the fingernails and the soles of the feet should be treated. • In children under 2 years, Lyclear creme rinse (1%) should be applied to the scalp and face (avoiding eyes). • Wear your usual night clothes overnight. • Only one application, left on for 8-12 hours, should be necessary. • Your hands will need retreating if you wash them during the night. • Bedding, night clothes and day clothes should be changed after the treatment and laundered on a hot wash. • Occasionally, a second application may be recommended by your doctor. Scabies is transmitted by skin to skin contact so all close contacts need to be treated at the same time. Any frequent visitors who are in regular contact with you should also be treated at the same time, even if they do not appear to be affected. The doctor treating you should give advice on other people that should be treated. You may itch for 6 weeks after successful treatment. Do not continue to apply the Lyclear because it may irritate the skin. Your doctor can prescribe creams or antihistamine tables to help the itch.
  • 50. SELF-HELP GROUPS • Acne Support Group • British Red Cross • Hairline International • LUPUS UK • National Eczema Society • The Psoriasis Association • The Vitiligo Society • Wessex Cancer Trust - SCIN
  • 51. Acne Support Group Aims: The Acne Support Group aims to provide information and support to people affected by either acne or rosacea. The group works with health professionals to help improve the quality of information given to patients. Contact: Alison Dudley PO Box 9 Newquay TR9 6WG Tel: 0870-8702263 Website: www.stopspots.org British Red Cross Aims: The aim of the British Red Cross Skin Camouflage Service is to assist people with a disfigurement to cope in their daily lives, with the aid of simple skin camouflage techniques. The service is available to men, women and children through medical referral from a Consultant or GP. Camouflage creams are effective in reducing the impact of scarring, rosacea, birthmarks, vitiligo, tattoos etc. on the face, limbs and torso. The service is available nationally and is provided free of charge to the patient. The creams are normally available on prescription. Information on clinics can be obtained from the local Branch Headquarters of the British Red Cross or see contact below.
  • 52. Contact: Cathy Kingsbury UK Service Development Community Services Unit British Red Cross 9 Grosvenor Crescent London SW1X 7EJ Tel: 020 7201 5172 Website: www.redcross.org.uk Hairline International Aims: Hairline International – The Alopecia Patients’ Society is an international network of patients who have lost, or are losing, their hair through scalp disease or thinning conditions. The society provides information on medical treatment, mutual support and practical help. It is the only national alopecia patients’ support group. Contact: Ms Elizabeth Steel Hairline International – The Alopecia Patients’ Society Lyons Court 1668 High Street Knowle West Midlands B93 0LY Tel: 01564 - 775281 Website: www.hairlineinternational.co.uk LUPUS UK Contact: LUPUS UK St James House Eastern Road Romford Essex RM1 3NH Tel: 01708 - 731251 Website: www.lupusuk.com
  • 53. National Eczema Society Aims: The National Eczema Society exists to eliminate the effects of eczema. It seeks to achieve this by: - Providing information, advice and support to people with eczema and those who care for them both locally and nationally (details from Sarah Ransome). - Managing programmes of patient-focused training courses for GPs, nurses and pharmacists (full information from Mercy Jeyasingham). - Encouraging and supporting research into the causes, effects and treatment of eczema. - Administering and managing the Skin Care Campaign, an alliance of skin patient organisations companies and others interested in skin health. Contact: National Eczema Society Hill House Highgate Hill London N19 5NA Tel: 020 - 7281 3553 Website: http://www.eczema.org The Psoriasis Association Aims: The Association aims to give information on all aspects of Psoriasis upon request. It promotes and funds research particularly into the basic causes. Contact: Gladys Edwards Chief Executive The Psoriasis Association 7 Milton Street Northampton NN3 7JG Tel: 01604 711129 Website: http://www.psoriasis-association.org.uk
  • 54. The Vitiligo Society Aims: A registered charity offering support and advice to people with Vitiligo. Although it is neither painful nor infectious, many who develop it find the experience socially and psychologically devastating. The Society aims to provide information and education about the condition and to encourage and fund research. Contact: Mrs Marion Lesage Information Manager The Vitiligo Society 125 Kennington Road London SE11 6SF Tel: 02078 - 400855 Website: http://www.vitiligosociety.org.uk
  • 55. Wessex Cancer Trust - SCIN (Skin Cancer Information Network) MARC'S LINE (Melanoma and Related Cancers of the Skin) Aims: Marc's Line aims to be of value to patients and their families, health professionals. teachers and others involved in education or prevention of skin cancer. It produces leaflets and information sheets on various types of skin cancer and on sun protection strategies. It has a professional nurse network of voluntary nursing contacts offering psycho-social support for patients and their families living with melanoma. Contact: Jane Freak Clinical Nurse Specialist in Skin Cancer Prevention Marc's Line Resource Centre Dermatology Treatment Centre Level 3 Salisbury District Hospital Salisbury Wiltshire SP2 8BJ Tel: (01722) 415071 Fax: (01722) 415071 Web: www.k-web.co.uk/charity/wct/wct.htm