30/01/1530/01/15 11
DermatologyDermatology
“pearls and pitfalls”“pearls and pitfalls”
Dr Keith Freeman FRCPDr Keith Freema...
30/01/1530/01/15 22
AimAim
 Highlight a few pointsHighlight a few points
 Stimulate discussionStimulate discussion
 Alt...
30/01/1530/01/15 33
The national pictureThe national picture
 Up to 20% of GP consultations involve skinUp to 20% of GP c...
30/01/1530/01/15 44
Exclusions agreed with PCTsExclusions agreed with PCTs
 WartsWarts
 Seborrhoeic keratosesSeborrhoeic...
30/01/1530/01/15 55
Exclusions (2)Exclusions (2)
 Establish local policy prior to referralEstablish local policy prior to...
30/01/1530/01/15 66
Conditions that seem to causeConditions that seem to cause
problemsproblems
 Viral wartsViral warts
...
30/01/1530/01/15 77
Viral WartsViral Warts
 Lesions in elderly are unlikely to be viral andLesions in elderly are unlikel...
30/01/1530/01/15 88
Viral Warts, childrenViral Warts, children
 NO TREATMENTNO TREATMENT
 Keratolytic plus abrasion for ...
30/01/1530/01/15 99
Viral warts, adultsViral warts, adults
 Keratolytic plus abrasionKeratolytic plus abrasion for at lea...
30/01/1530/01/15 1010
Unfunded/unapproved optionsUnfunded/unapproved options
 Photodynamic therapy x 3 at monthlyPhotodyn...
30/01/1530/01/15 1111
Insufficient evidenceInsufficient evidence
 Topical imiquimodTopical imiquimod
 Folk remediesFolk ...
30/01/1530/01/15 1212
AcneAcne
 Emphasise possible need for very long termEmphasise possible need for very long term
trea...
30/01/1530/01/15 1313
30/01/1530/01/15 1414
Mild acneMild acne
 Mild cleanserMild cleanser
 Topical treatment to affected area, not justTopica...
30/01/1530/01/15 1515
Topical agentsTopical agents
 Benzoyl peroxideBenzoyl peroxide
 Retinoids – adapalene (Differin), ...
30/01/1530/01/15 1616
Topical agents (2)Topical agents (2)
 For inflamed acne, topical antibiotics areFor inflamed acne, ...
30/01/1530/01/15 1717
30/01/1530/01/15 1818
Moderate acneModerate acne
 Continue topical treatment and add:Continue topical treatment and add:
...
30/01/1530/01/15 1919
30/01/1530/01/15 2020
Severe and unresponsive acneSevere and unresponsive acne
 Treat as for moderate acne and considerTr...
30/01/1530/01/15 2121
OnychomycosisOnychomycosis
 Send nail clippings for fungal cultureSend nail clippings for fungal cu...
30/01/1530/01/15 2222
RegimesRegimes
 Terbinafine 250 mg od for 6-12 weeksTerbinafine 250 mg od for 6-12 weeks
 Griseofu...
30/01/1530/01/15 2323
UrticariaUrticaria
 Avoid aspirin, codeine (NSAIDs + ACEAvoid aspirin, codeine (NSAIDs + ACE
inhibi...
30/01/1530/01/15 2424
Insufficient evidenceInsufficient evidence
 KetotifenKetotifen
 NifedipineNifedipine
 DietDiet
 ...
30/01/1530/01/15 2525
Classic psoriasisClassic psoriasis
30/01/1530/01/15 2626
30/01/1530/01/15 2727
Plaque Psoriasis (mild to moderate)Plaque Psoriasis (mild to moderate)
 Treatment suppressive not c...
30/01/1530/01/15 2828
Psoriasis, general measuresPsoriasis, general measures
 Soap substitute e.g. EpadermSoap substitute...
30/01/1530/01/15 2929
Psoriasis, topical optionsPsoriasis, topical options
 Tar, +/- steroidTar, +/- steroid
 Mild to mo...
30/01/1530/01/15 3030
Tar, +/- steroidTar, +/- steroid
 Long history of useLong history of use
 Reasonably effectiveReas...
30/01/1530/01/15 3131
Mild to moderate steroidMild to moderate steroid
 Cheap and not messy or smellyCheap and not messy ...
30/01/1530/01/15 3232
DithranolDithranol
 Long history of use in hospital, short contactLong history of use in hospital, ...
30/01/1530/01/15 3333
Vitamin D analoguesVitamin D analogues
 Relatively new (1991)Relatively new (1991)
 Not messy or s...
30/01/1530/01/15 3434
Vitamin D analoguesVitamin D analogues
 Calcipotriol – DovonexCalcipotriol – Dovonex
 Calcipotriol...
30/01/1530/01/15 3535
Suggested strategy, plaque psoriasisSuggested strategy, plaque psoriasis
 General measures and educ...
30/01/1530/01/15 3636
30/01/1530/01/15 3737
Childhood atopic eczemaChildhood atopic eczema
 Generous amounts of emollients (500g) toGenerous am...
30/01/1530/01/15 3838
Topical SteroidsTopical Steroids
MildMild
 Hydrocortisone 0.5-2.5%Hydrocortisone 0.5-2.5%
30/01/1530/01/15 3939
Topical SteroidsTopical Steroids
ModerateModerate (2-25 times as potent as(2-25 times as potent as
h...
30/01/1530/01/15 4040
Topical SteroidsTopical Steroids
PotentPotent (I50-100 times as potent as hydrocortisone)(I50-100 ti...
30/01/1530/01/15 4141
Skin absorption of topical steroidsSkin absorption of topical steroids
Steroids are absorbed at diff...
30/01/1530/01/15 4242
Side effects of topical steroidsSide effects of topical steroids
Internal side effectsInternal side ...
30/01/1530/01/15 4343
Side effects of topical steroidsSide effects of topical steroids
Local side effectsLocal side effect...
30/01/1530/01/15 4444
Steroid skin atrophySteroid skin atrophy
30/01/1530/01/15 4545
StriaeStriae
30/01/1530/01/15 4646
Fingertip unitFingertip unit
A convenient way to measure how muchA convenient way to measure how muc...
30/01/1530/01/15 4747
DoseDose
 Adult male: one ftu provides 0.5 gAdult male: one ftu provides 0.5 g
 Adult female: one ...
30/01/1530/01/15 4848
Number of f.t.u.s requiredNumber of f.t.u.s required
 One hand: apply one fingertip unitOne hand: a...
30/01/1530/01/15 4949
3 rules for use of topicals3 rules for use of topicals
 The right formulationThe right formulation
...
30/01/1530/01/15 5050
Childhood atopic eczema (2)Childhood atopic eczema (2)
 Pimecrolimus 1% (Elidel) b.d.Pimecrolimus 1...
30/01/1530/01/15 5151
Childhood atopic eczema (3)Childhood atopic eczema (3)
 Tacrolimus 0.03% (Protopic) b.d. for 3 wk.T...
30/01/1530/01/15 5252
Childhood atopic eczema (4)Childhood atopic eczema (4)
 Tacrolimus and pimecrolimus may be usefulTa...
30/01/1530/01/15 5353
Final thoughtsFinal thoughts
 To treat or not?To treat or not?
 How much to use of which products?...
30/01/1530/01/15 5454
Thank youThank you
 keith.freeman@suntpct.nhs.ukkeith.freeman@suntpct.nhs.uk
 QUESTIONS?QUESTIONS?
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NE_pearls_and_pitfalls.ppt

  1. 1. 30/01/1530/01/15 11 DermatologyDermatology “pearls and pitfalls”“pearls and pitfalls” Dr Keith Freeman FRCPDr Keith Freeman FRCP Consultant DermatologistConsultant Dermatologist CDDFT / STPCTCDDFT / STPCT
  2. 2. 30/01/1530/01/15 22 AimAim  Highlight a few pointsHighlight a few points  Stimulate discussionStimulate discussion  Alter practiceAlter practice
  3. 3. 30/01/1530/01/15 33 The national pictureThe national picture  Up to 20% of GP consultations involve skinUp to 20% of GP consultations involve skin complaints / procedurescomplaints / procedures  Most GP’s have 2 weeks undergraduateMost GP’s have 2 weeks undergraduate trainingtraining  15% children have atopic eczema (5% in15% children have atopic eczema (5% in 1975)1975)  Ageing populationAgeing population  Skin cancer incidence increasing by 5-7%Skin cancer incidence increasing by 5-7% p.a. – and will continue at least to 2050p.a. – and will continue at least to 2050
  4. 4. 30/01/1530/01/15 44 Exclusions agreed with PCTsExclusions agreed with PCTs  WartsWarts  Seborrhoeic keratosesSeborrhoeic keratoses  Skin tagsSkin tags  Benign lesions - moles, dermatofibromas etcBenign lesions - moles, dermatofibromas etc  XanthelasmataXanthelasmata  TattoosTattoos  Sebaceous cystsSebaceous cysts  Telangiectases and thread veinsTelangiectases and thread veins  Mollusca contagiosaMollusca contagiosa
  5. 5. 30/01/1530/01/15 55 Exclusions (2)Exclusions (2)  Establish local policy prior to referralEstablish local policy prior to referral  Pressure to manage more dermatologyPressure to manage more dermatology patients in primary care is inevitablepatients in primary care is inevitable
  6. 6. 30/01/1530/01/15 66 Conditions that seem to causeConditions that seem to cause problemsproblems  Viral wartsViral warts  AcneAcne  OnychomycosisOnychomycosis  UrticariaUrticaria  Plaque PsoriasisPlaque Psoriasis  Childhood atopic eczema / topical steroidsChildhood atopic eczema / topical steroids  Lumps and bumps (not covered here)Lumps and bumps (not covered here)
  7. 7. 30/01/1530/01/15 77 Viral WartsViral Warts  Lesions in elderly are unlikely to be viral andLesions in elderly are unlikely to be viral and should be referredshould be referred  ““No treatment” is a viable optionNo treatment” is a viable option  Painful treatments should not be used inPainful treatments should not be used in young childrenyoung children  Treatment success only 60-70% at 3Treatment success only 60-70% at 3 monthsmonths
  8. 8. 30/01/1530/01/15 88 Viral Warts, childrenViral Warts, children  NO TREATMENTNO TREATMENT  Keratolytic plus abrasion for at least 3 mthsKeratolytic plus abrasion for at least 3 mths  Cryotherapy to filiform warts, if child canCryotherapy to filiform warts, if child can take the paintake the pain  Plane warts do not respond well to anyPlane warts do not respond well to any treatment (? lasers)treatment (? lasers)  Refer intra oral and anogenital wartsRefer intra oral and anogenital warts
  9. 9. 30/01/1530/01/15 99 Viral warts, adultsViral warts, adults  Keratolytic plus abrasionKeratolytic plus abrasion for at least 3for at least 3 mthsmths  Liquid nitrogenLiquid nitrogen cryotherapy, 3 weekly x 5cryotherapy, 3 weekly x 5  ? Formaldehyde soak for plantar warts? Formaldehyde soak for plantar warts  ? Glutaraldehyde soak or gel? Glutaraldehyde soak or gel  Curettage and cautery risks scarringCurettage and cautery risks scarring  Anogenital warts should be referred to GUMAnogenital warts should be referred to GUM
  10. 10. 30/01/1530/01/15 1010 Unfunded/unapproved optionsUnfunded/unapproved options  Photodynamic therapy x 3 at monthlyPhotodynamic therapy x 3 at monthly intervalsintervals  Pulsed dye or CO2 laserPulsed dye or CO2 laser  Infrared coagulationInfrared coagulation  Topical sensitisation (diphencyprone)Topical sensitisation (diphencyprone)  RetinoidsRetinoids  BleomycinBleomycin  CimetidineCimetidine
  11. 11. 30/01/1530/01/15 1111 Insufficient evidenceInsufficient evidence  Topical imiquimodTopical imiquimod  Folk remediesFolk remedies  HomeopathyHomeopathy  HypnosisHypnosis  Intralesional interferonIntralesional interferon  PodophyllinPodophyllin
  12. 12. 30/01/1530/01/15 1212 AcneAcne  Emphasise possible need for very long termEmphasise possible need for very long term treatment and not to expect quick cures.treatment and not to expect quick cures.  Abrasive treatments, picking and veryAbrasive treatments, picking and very humid conditions can worsen thingshumid conditions can worsen things  Dietary changes do not helpDietary changes do not help
  13. 13. 30/01/1530/01/15 1313
  14. 14. 30/01/1530/01/15 1414 Mild acneMild acne  Mild cleanserMild cleanser  Topical treatment to affected area, not justTopical treatment to affected area, not just spotsspots  Warn re dryness in first few weeksWarn re dryness in first few weeks  Oil free moisturiser if requiredOil free moisturiser if required  Avoid very greasy cosmetics, but allowAvoid very greasy cosmetics, but allow othersothers
  15. 15. 30/01/1530/01/15 1515 Topical agentsTopical agents  Benzoyl peroxideBenzoyl peroxide  Retinoids – adapalene (Differin), tretinoinRetinoids – adapalene (Differin), tretinoin (Retin-A), isotretinoin (Isotrex)(Retin-A), isotretinoin (Isotrex)  Azelaic acid (Skinoren)Azelaic acid (Skinoren)
  16. 16. 30/01/1530/01/15 1616 Topical agents (2)Topical agents (2)  For inflamed acne, topical antibiotics areFor inflamed acne, topical antibiotics are best used with benzoyl peroxide or azelaicbest used with benzoyl peroxide or azelaic acid, to reduce chance of antibioticacid, to reduce chance of antibiotic resistanceresistance  Combined preparations that can be usedCombined preparations that can be used once daily are preferred ( e.g. Duac –once daily are preferred ( e.g. Duac – benzoyl peroxide & clindamycin)benzoyl peroxide & clindamycin)
  17. 17. 30/01/1530/01/15 1717
  18. 18. 30/01/1530/01/15 1818 Moderate acneModerate acne  Continue topical treatment and add:Continue topical treatment and add:  Oral antibiotic such as (oxytetracycline)Oral antibiotic such as (oxytetracycline) lymecycline, doxycycline or erythromycinlymecycline, doxycycline or erythromycin for at least 3 monthsfor at least 3 months. Try another if the. Try another if the first does not workfirst does not work  Consider Dianette in women, particularly ifConsider Dianette in women, particularly if premenstrual flare and if needingpremenstrual flare and if needing contraceptioncontraception
  19. 19. 30/01/1530/01/15 1919
  20. 20. 30/01/1530/01/15 2020 Severe and unresponsive acneSevere and unresponsive acne  Treat as for moderate acne and considerTreat as for moderate acne and consider referral for isotretinoin treatmentreferral for isotretinoin treatment  Include recent LFTs and fasting lipids inInclude recent LFTs and fasting lipids in referralreferral  Discuss contraception with femalesDiscuss contraception with females
  21. 21. 30/01/1530/01/15 2121 OnychomycosisOnychomycosis  Send nail clippings for fungal cultureSend nail clippings for fungal culture  Consider “Consider “no treatmentno treatment””  Systemic treatment almost always betterSystemic treatment almost always better than topical treatmentthan topical treatment  Terbinafine is more effective thanTerbinafine is more effective than itraconazole or griseofulvinitraconazole or griseofulvin
  22. 22. 30/01/1530/01/15 2222 RegimesRegimes  Terbinafine 250 mg od for 6-12 weeksTerbinafine 250 mg od for 6-12 weeks  Griseofulvin in children, 10mg/kg (max 1g)Griseofulvin in children, 10mg/kg (max 1g) for a year or more, with foodfor a year or more, with food  Nails take months to become normal afterNails take months to become normal after adequate treatmentadequate treatment
  23. 23. 30/01/1530/01/15 2323 UrticariaUrticaria  Avoid aspirin, codeine (NSAIDs + ACEAvoid aspirin, codeine (NSAIDs + ACE inhibitors)inhibitors)  Daily non sedating antihistamines (try atDaily non sedating antihistamines (try at least 2 and up to 2x recommended dose)least 2 and up to 2x recommended dose)  Add sedating antihistamine at bedtimeAdd sedating antihistamine at bedtime  Consider adding H2 antihistamineConsider adding H2 antihistamine  Avoid oral steroids in chronic urticariaAvoid oral steroids in chronic urticaria  Most patients do not need referralMost patients do not need referral
  24. 24. 30/01/1530/01/15 2424 Insufficient evidenceInsufficient evidence  KetotifenKetotifen  NifedipineNifedipine  DietDiet  PhototherapyPhototherapy  Relaxation techniquesRelaxation techniques  Topical steroidsTopical steroids
  25. 25. 30/01/1530/01/15 2525 Classic psoriasisClassic psoriasis
  26. 26. 30/01/1530/01/15 2626
  27. 27. 30/01/1530/01/15 2727 Plaque Psoriasis (mild to moderate)Plaque Psoriasis (mild to moderate)  Treatment suppressive not curativeTreatment suppressive not curative  Topical treatment cannot prevent relapsesTopical treatment cannot prevent relapses  Information and education essentialInformation and education essential  Patient perception should influence choicePatient perception should influence choice of treatmentof treatment  Patients prefer non messy, non smelly,Patients prefer non messy, non smelly, rapidly effective preparations with long termrapidly effective preparations with long term controlcontrol
  28. 28. 30/01/1530/01/15 2828 Psoriasis, general measuresPsoriasis, general measures  Soap substitute e.g. EpadermSoap substitute e.g. Epaderm  Bath additive e.g. PolytarBath additive e.g. Polytar  Moisturise after bathing e.g. Diprobase,Moisturise after bathing e.g. Diprobase, OilatumOilatum
  29. 29. 30/01/1530/01/15 2929 Psoriasis, topical optionsPsoriasis, topical options  Tar, +/- steroidTar, +/- steroid  Mild to moderate steroidMild to moderate steroid  Dithranol, usually short contactDithranol, usually short contact  Vitamin D analogue, +/- steroidVitamin D analogue, +/- steroid  Site may influence choice of treatment, e.g.Site may influence choice of treatment, e.g. face or flexuresface or flexures
  30. 30. 30/01/1530/01/15 3030 Tar, +/- steroidTar, +/- steroid  Long history of useLong history of use  Reasonably effectiveReasonably effective  CheapCheap  SmellySmelly  Can stainCan stain
  31. 31. 30/01/1530/01/15 3131 Mild to moderate steroidMild to moderate steroid  Cheap and not messy or smellyCheap and not messy or smelly  Efficacy linked to potencyEfficacy linked to potency  Side effects linked to potency and amountSide effects linked to potency and amount  Mild preparations helpful for face / flexuresMild preparations helpful for face / flexures  Tolerance and allergy may developTolerance and allergy may develop  May lead to rapid relapse and destabiliseMay lead to rapid relapse and destabilise psoriasispsoriasis
  32. 32. 30/01/1530/01/15 3232 DithranolDithranol  Long history of use in hospital, short contactLong history of use in hospital, short contact more recentmore recent  Cheap and effective, if toleratedCheap and effective, if tolerated  IrritantIrritant  Stains +++Stains +++ (skin, clothing, bedding, bath)(skin, clothing, bedding, bath)
  33. 33. 30/01/1530/01/15 3333 Vitamin D analoguesVitamin D analogues  Relatively new (1991)Relatively new (1991)  Not messy or smelly but mildly irritantNot messy or smelly but mildly irritant  Liked by patientsLiked by patients  Can increase photosensitivityCan increase photosensitivity  Effective and can be used long termEffective and can be used long term  Excess doses may cause hypercalcaemiaExcess doses may cause hypercalcaemia  Synergistic with steroidsSynergistic with steroids
  34. 34. 30/01/1530/01/15 3434 Vitamin D analoguesVitamin D analogues  Calcipotriol – DovonexCalcipotriol – Dovonex  Calcipotriol + betamethasone – DovobetCalcipotriol + betamethasone – Dovobet  Calcitriol – SilkisCalcitriol – Silkis  Tacalcitol - CuratodermTacalcitol - Curatoderm  Calcipotriol should not be used on the face.Calcipotriol should not be used on the face.
  35. 35. 30/01/1530/01/15 3535 Suggested strategy, plaque psoriasisSuggested strategy, plaque psoriasis  General measures and educationGeneral measures and education  Consider patient preferences, efficacy and safetyConsider patient preferences, efficacy and safety  Initiate treatmentInitiate treatment  Dovobet, up to 15g daily for 4 weeks, reviewDovobet, up to 15g daily for 4 weeks, review  EmollientsEmollients  Dovobet for relapses then back to emollientsDovobet for relapses then back to emollients  Xamiol for scalpXamiol for scalp  Refer if not controlled on this regimeRefer if not controlled on this regime
  36. 36. 30/01/1530/01/15 3636
  37. 37. 30/01/1530/01/15 3737 Childhood atopic eczemaChildhood atopic eczema  Generous amounts of emollients (500g) toGenerous amounts of emollients (500g) to be used several times a daybe used several times a day  Soap substitute and bath oilSoap substitute and bath oil  Wet wrapsWet wraps  Mild steroid for face (hydrocortisone)Mild steroid for face (hydrocortisone)  Moderate steroid for trunk and limbsModerate steroid for trunk and limbs
  38. 38. 30/01/1530/01/15 3838 Topical SteroidsTopical Steroids MildMild  Hydrocortisone 0.5-2.5%Hydrocortisone 0.5-2.5%
  39. 39. 30/01/1530/01/15 3939 Topical SteroidsTopical Steroids ModerateModerate (2-25 times as potent as(2-25 times as potent as hydrocortisone)hydrocortisone)  Aclometasone dipropionateAclometasone dipropionate  Clobetasone butyrateClobetasone butyrate  Fluocinolone acetonideFluocinolone acetonide  Triamcinolone acetonideTriamcinolone acetonide
  40. 40. 30/01/1530/01/15 4040 Topical SteroidsTopical Steroids PotentPotent (I50-100 times as potent as hydrocortisone)(I50-100 times as potent as hydrocortisone)  Betamethasone valerateBetamethasone valerate  Betamethasone dipropionateBetamethasone dipropionate  Diflucortolone valerateDiflucortolone valerate  Fluticasone valerateFluticasone valerate  Hydrocortisone 17-butyrateHydrocortisone 17-butyrate  Mometasone furoateMometasone furoate  Methylprednisolone aceponateMethylprednisolone aceponate
  41. 41. 30/01/1530/01/15 4141 Skin absorption of topical steroidsSkin absorption of topical steroids Steroids are absorbed at different rates fromSteroids are absorbed at different rates from different parts of the body. A steroid that works ondifferent parts of the body. A steroid that works on the face may not work on the palm. A potent steroidthe face may not work on the palm. A potent steroid may cause side effects on the face.may cause side effects on the face.  Eyelids and genitals absorb 30%Eyelids and genitals absorb 30%  Face absorbs 7%Face absorbs 7%  Armpit absorbs 4%Armpit absorbs 4%  Forearm absorbs 1%Forearm absorbs 1%  Palm absorbs 0.1%Palm absorbs 0.1%  Sole absorbs 0.05%Sole absorbs 0.05%
  42. 42. 30/01/1530/01/15 4242 Side effects of topical steroidsSide effects of topical steroids Internal side effectsInternal side effects  If more than 50g of clobetasol propionate, orIf more than 50g of clobetasol propionate, or 500g of hydrocortisone is used per week,500g of hydrocortisone is used per week, sufficient steroid may be absorbed throughsufficient steroid may be absorbed through the skin to result in adrenal glandthe skin to result in adrenal gland suppression and/or Cushing’s syndromesuppression and/or Cushing’s syndrome
  43. 43. 30/01/1530/01/15 4343 Side effects of topical steroidsSide effects of topical steroids Local side effectsLocal side effects of topical steroids include:of topical steroids include:  Skin atrophy and striaeSkin atrophy and striae  Easy bruising and tearing of the skinEasy bruising and tearing of the skin  Perioral dermatitisPerioral dermatitis  TelangiectasiaTelangiectasia  Susceptibility to skin infectionsSusceptibility to skin infections  Disguising infection e.g. tinea incognitoDisguising infection e.g. tinea incognito  Allergy to the steroidAllergy to the steroid
  44. 44. 30/01/1530/01/15 4444 Steroid skin atrophySteroid skin atrophy
  45. 45. 30/01/1530/01/15 4545 StriaeStriae
  46. 46. 30/01/1530/01/15 4646 Fingertip unitFingertip unit A convenient way to measure how muchA convenient way to measure how much cream to prescribe to a patient with skincream to prescribe to a patient with skin disease. Accurate prescription is particularlydisease. Accurate prescription is particularly important for topical steroids.important for topical steroids.
  47. 47. 30/01/1530/01/15 4747 DoseDose  Adult male: one ftu provides 0.5 gAdult male: one ftu provides 0.5 g  Adult female: one ftu provides 0.4 gAdult female: one ftu provides 0.4 g  Children of four years ­ approximately 1/3 ofChildren of four years ­ approximately 1/3 of adult amountadult amount  Infants six months to one year­Infants six months to one year­ approximately 1/4 of adult amountapproximately 1/4 of adult amount
  48. 48. 30/01/1530/01/15 4848 Number of f.t.u.s requiredNumber of f.t.u.s required  One hand: apply one fingertip unitOne hand: apply one fingertip unit  One arm: apply three fingertip unitsOne arm: apply three fingertip units  One foot: apply two fingertip unitsOne foot: apply two fingertip units  One leg: apply six fingertip unitsOne leg: apply six fingertip units  Face and neck: apply 2.5 fingertip unitsFace and neck: apply 2.5 fingertip units  Trunk, front & back: 14 fingertip unitsTrunk, front & back: 14 fingertip units  Entire body: about 40 unitsEntire body: about 40 units
  49. 49. 30/01/1530/01/15 4949 3 rules for use of topicals3 rules for use of topicals  The right formulationThe right formulation  The right potency for siteThe right potency for site  The right amountThe right amount  Please seePlease see www.dermnetnz.orgwww.dermnetnz.org for furtherfor further informationinformation
  50. 50. 30/01/1530/01/15 5050 Childhood atopic eczema (2)Childhood atopic eczema (2)  Pimecrolimus 1% (Elidel) b.d.Pimecrolimus 1% (Elidel) b.d.  Over 2 yr, acute treatment of mild toOver 2 yr, acute treatment of mild to moderate eczemamoderate eczema  Exclude infectionExclude infection  Avoid contact with eyes and mucosaAvoid contact with eyes and mucosa  Can cause local reactions and skinCan cause local reactions and skin infectionsinfections
  51. 51. 30/01/1530/01/15 5151 Childhood atopic eczema (3)Childhood atopic eczema (3)  Tacrolimus 0.03% (Protopic) b.d. for 3 wk.Tacrolimus 0.03% (Protopic) b.d. for 3 wk. then o.d.then o.d.  Over 2 yr, moderate to severe,Over 2 yr, moderate to severe, unresponsive to conventional therapyunresponsive to conventional therapy  Exclude infectionExclude infection  Avoid contact with eyes and mucosaAvoid contact with eyes and mucosa  Can cause local reactions and skinCan cause local reactions and skin infectionsinfections
  52. 52. 30/01/1530/01/15 5252 Childhood atopic eczema (4)Childhood atopic eczema (4)  Tacrolimus and pimecrolimus may be usefulTacrolimus and pimecrolimus may be useful long­term in preventing relapses, bestlong­term in preventing relapses, best regime not clearregime not clear
  53. 53. 30/01/1530/01/15 5353 Final thoughtsFinal thoughts  To treat or not?To treat or not?  How much to use of which products?How much to use of which products?  How long to treat?How long to treat?  What to refer and when?What to refer and when?  Involve, explain and concurInvolve, explain and concur
  54. 54. 30/01/1530/01/15 5454 Thank youThank you  keith.freeman@suntpct.nhs.ukkeith.freeman@suntpct.nhs.uk  QUESTIONS?QUESTIONS?

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