Embarrassing skin conditions Jan L Bong Consultant Dermatologist Dec 2011

Aims Conditions What can primary care do? What can secondary care do? Hyperhidrosis Hidradenitis Hair disorders Pigment disorders What can primary care do? What can secondary care do?

Hyperhidrosis

Case 1 25 year old woman complains of excessive armpits sweating. What investigations would you consider doing?

Hyperhidrosis Generalise Focal Drugs Systemic diseases propranolol, pilocarpine, tricyclic antidepressants, venlafaxine Systemic diseases Hyperthyroid, diabetes, menopause, Hodgkin's, alcoholism Focal Nerve damage: gustatory Idiopathic

Primary care Treatments AlCl - Driclor or Anhydrol Forte Apply at night until effective, then reduce frequency Irritant, effect may be neutralise by baking soda Consider 1% hydrocortisone Do not shave Anticholinergic - Propantheline or oxybutynin Side effects ++

Secondary care treatment- Axillaries BOTOX NHS treatment Gravimetric test Up to 95% effective within 48 hours Average duration 7 months

Secondary care treatment - Palmer hyperhidrosis Iontophoresis Water and passing direct current across the skin 20-30 minutes alternate day till dry, then maintenance 1-4 weekly ? work by blocking sweat pores Effective in 70-80% £300

Secondary care treatments Glycopyrrolate lotions Topical anticholinergic 1 to 3% Variable results ‘specials’ – hence very expensive

Other secondary care options - Surgery Axillaries Sweat gland removal Palmar Laporscopic Sympathectomy Compensatory hyperhidrosis Not done for plantar due to risk

Hidradenitis suppurativa

Case 2 A 30 year old lady complains of recurrent painful boils under her arms. At any one time, she has at least 3-4 discharging painful lumps. What is the treatment of choice? What investigation(s) will you arrange?

Hidradenitis suppurativa Disorder of apocrine glands Features Comedones Relapsing inflammation Discharges Scarring Sites – axillae, inguinal, perianal

Primary care Treatments Weight loss Dianett for mild disease Local hygiene

Primary care Treatments Antibiotics Treat like acne with cyclical antibiotics No evidence that it alter the natural course Tetracycline, erythromycin and clindomycin

Secondary care Treatments Combination of clindomycin and rifampicin Retinoids >6 months, moderately effective Dapsone Corticosteroid topical Intralesional oral

Treatments Surgery Local excision Wide local excision CO2 laser and secondary intention healing Recurrence rate reported to be >33%

Prognosis Risk of SCC Spontaneously resolution is rare!!

Hair loss

Case 3 - 35 year old with 2 years history of gradual hair loss, worst on vertex

Androgenetic alopecia

More common in post menopausal women

Primary care work up Exclude systemic causes: Check FBC, ferritin, zinc and thyroid function Sex hormones if very young or have signs of virilization Consider differential diagnosis Diffuse alopecia areata Telogen effluvium

Primary care Treatments Minoxidil Need at least 3-4 months to work 2% and 5% Need to continue forever Start early and best for vertex hair loss More effective for women

Secondary care treatments Scalp biopsy if there is diagnostic doubts Anti-androgen – spironolactone or cyproterone acetate Not license Spironolactone may play a dual role in treatment hypertension Finasteride Only for men Need to continue indefinitely Not for women and does not work in post menopause

Patchy hair loss – quiz

Patch alopecia Scarring alopecia Non scarring alopecia Lupus Fungus Lichen planus Traction Non scarring alopecia -Alopecia areata -telogen effluvium

80% has only one single patch. Smooth area of complete hair loss 80% has only one single patch. Smooth area of complete hair loss. Limited form <50% recurred within a few months with or without treatment. >50% has poorer prognosis. Poorer outcome if has atopic dermatitis.

Primary care treatments Potent topical steroids For 2-3 months Intralesional steroids Triamcinolone 10mg/ml Cognitive behavioural therapy

Secondary care treatments UVB Pulse oral steroids Immunosuppressants - ciclosporin

T tonsurans often non inflammatory T tonsurans often non inflammatory. Other trichophytum produced kerion with inflammation and pustules formation

Traction alopecia affects young girls. Need some convincing Traction alopecia affects young girls. Need some convincing. Often partial or near complete.

Trichotillomania – girls, hair of variable length, unusual to have complete alopecia, hair line often maintained

Erythematous plaque with scaling. Older lesions has follicular plugging

Pigmentary disorders

Case 4 A 35 years old lady developed hyperpigmented patches on her face after the birth of her second child. What is your diagnosis? What are the potential primary care treatments?

Chloasma or melasma Contraceptive pills and pregnancy Certain scented products Sun exposure Mainly on foreheads, cheeks and upper lips Epidermal or dermal types Epidermal – dark brown and more obvious under black light, respond well to treatment Dermal – light brown and unchanged under black light, respond poorly to treatment

Primary care treatments for chloasma SUN PROTECTION - everyday Azelaic acid at 20% (Skinoren) Topical retinoid up to 0.1% Hydroquinone

Secondary care treatments Triple therapies – Sheffield, Manchester or Kligman’s formula Topical retinoid, hydroquinone and hydrocortisone Expensive!!

Cosmetic options - chemical peels, dermabrasion, laser

Vitiligo How do I know my patient has it? Colour – white patches Margins – well demarcated Distributions – symmetrical mostly, often on extremities and skin around eyes and mouth Risk factors – other auto immune disease Important differential – pityriasis versicolor, post inflammatory Can occasionally be pale first then white later Occasional segmental one,

Primary care treatments Offer camouflage No Treatments If not acceptable Potent topical steroids for 2 months Stop if no response Continue if working with steroid break

Secondary care treatments 0.1% tacrolimus Narrow band UVB Evidence – 2010 cochrane review no obvious advances

Summary Hyperhidrosis Hidradenitis suppurativa Hair loss Alcl, iontophoresis, botox and surgery Hidradenitis suppurativa Cyclical antibiotics, retinoids Hair loss Androgenetic alopecia Patch hair loss and quiz Pigmentary disorders Chloasma vitiligo