Primary Care Dermatology Dr Mick McKernan

Description of skin lesions Papule Macule Nodule Patch Vesicle Bulla Plaque

Papule Small palpable circumscribed lesion <0.5cm

Macule Flat, circumscribed non-palpable lesion

Pustule Yellowish white pus-filled lesion

Nodule Large papule >0.5cm

plaque Large flat topped elevated palpable lesion

patch Large macule >2cm

vesicle Small fluid filled blister < 1/2cm

Bulla A large fluid filled blister > 1/2cm

ECZEMA =dermatitis 10% of population at any one time 40% of population at some time

Features of eczema Itchy Erythematous Dry Flaky Oedematous Crusted Vesicles lichenified

Types of eczema Atopic Discoid eczema Hand eczema Seborrhoeic eczema Varicose eczema Contact and irritant eczema Lichen simplex

Atopic eczema Endogenous Atopic i.e asthma, hay fever 5% of population 10-15% of all children affected at some time

Atopic eczema individual must have: An itchy skin condition in the last 12 months+ three or more of: Onset before 2 years of age History of flexural involvement or flexural eczema currently present History of generally dry skin History of other atopic disease or FH

Exacerbating factors Infection Teething Stress Cat and dog fur ? House dust mite ? Food allergens

Clinical features Itchy erythematous patches Flexures of knees and elbows Neck Face in infants Exaggerated skin markings Lichenification Nail – pitted

complications Bacterial infection Viral infections – warts, molluscum, eczema herpeticum ( refer stat). Keratoconjunctivitis Retarded growth

Prognosis Most grow out of it 15% may come back – often very mildly Chronic skin dryness common after

Treatment Avoid irritants especially soap Frequent emollients Topical steroids Sedating antihistamines – oral hydroxyzine Treat infections Bandages Second line agents

Triple combination of therapy Topical steroid bd as required Emollient frequently Bath oil and soap substitute

Principles of treatments Creams Ointments Amounts required Potential side effects Soap substitutes

creams Cosmetically more acceptable Water based Contain preservatives Soap substitutes

ointments Oil based Don’t contain preservative Feel greasy Good for hydrating

Topical steroids Mild – “hydrocortisone Moderate – “eumovate” Potent – “betnovate” Very potent – “dermovate”

Amounts required Emollients – 500g per week for total body FTU – steroids- the least potent that controls the symptoms. Bath oils – 2-3 capfuls per bath

FTU Finger tip unit Helps to give estimation of topical steroid amount used To avoid over and under use of steroid

FTU

FTU 2 FTU = nearly 1 gram Enough for twice size of adult hand A hand and fingers (front and back) = 1FTU A foot (all over) + 2FTU Front of chest and abdomen = 7FTU Back and buttocks = 7FTU Face and neck = 2.5 FTU An entire arm and hand = 4 FTU An entire leg and foot = 8 FTU

Discoid eczema Variant of eczema Easily confused with psoriasis Well demarcated scaly patches Limbs Often infective component (staph aureus)

Hand eczema Pompholoyx – itchy vesicles or blisters of palm and along fingers Diffuse erythematous scaling and hyperkeratosis of palms Scaling and peeling at finger tips

Hand eczema Not unusual in atopic More common in non atopics Cause often uncertain Irritants Chemicals Occupational history Consider patch testing – 10% positive

Seborrhoeic eczema Over growth of yeast (pityrosporum ovale, hyphal form malassezia furfur) Strong cutaneous immune response More common in Parkinson’s and HIV

Clinical features Infancy – cradle cap, widespread rash, child unbothered, little pruritus Young adults – erythematous scaling eyebrows, nasolabial folds, forehead scalp Elderly – more extensive

Treatment Suppressive Mild steroid and antifungal combination Ketoconazole or dentinox shampoo Emollients Soap substitutes

Venous eczema Gravitational = stasis eczema Lower legs Venous hypertension Inflammation Purpura pigmentation

Clinical features Older women Past history DVT Haemosiderin deposition often misdiagnosed as cellulitis. Cellulitis is nearly always unilateral, tender and has a well demarcated edge

treatment Emollients Topical moderately potent steroids Soap substitutes Compression – check arterial supply first Leg elevation

Champagne bottle appearance of lipodermatosclerosis

Lipodermatosclerosis and venous leg ulcer

Cellulitis – unilateral painful and well demarcated.

Asteatotic eczema =eczema craquele Dry skin Worse in winter Hypothyroidism Avoid soap Emollients Bath oils

Contact and irritant eczema Exogenous Unusual Worse at workplace History of exacerbations

irritant Can occur in any individual Repeated exposure to irritants Common in housewives, hairdressers, nurses –bleaches and chemicals

contact Occurs after repeated exposure but only in susceptible individuals Allergic reaction Common culprits – nickel, chromates, latex etc Patch testing

Lichen simplex =Neurodermatitis Cutaneous response to rubbing Thickened scaly hyperpigmentation Emotional stress May need biopsy to diagnose

treatment Stop rubbing! Very potent steroids Occlusion

PSORIASIS

Psoriasis Affects 2% of population Well-demarcated red scaly plaques Skin inflamed and hyperproliferates Males and females equally Two peaks of onset (16- 22) and later (55-60) Usually family history

Chronic plaque Extensor surfaces Sacral area Scalp Koebners phenomenon

Guttate psoriasis Raindrop Children and young adults Associated with streptococcal sore throats Not all go onto get chronic plaque May resolve spontaneously over 1-2 months

Guttate psoriasis

Flexural psoriasis Later in life Well demarcated red glazed plaques Groin Natal cleft Sub mammary area No scale

Treatment Step 1:Prescribe copious emollients - make the skin more comfortable and reduce the amount of scale Step 2:Dovobet is the most effective vitamin D analogue Avoid on areas of thin skin eg the face, flexures and the genitalia. Also consider dithranol and tar. Flares use topical steroids 2 weeks- erythroderma or generalised pustular psoriasis if overused. Step 3 : for hospitals. Phototherapy , cyclosporin , UV, methotrexate Step 4: biologicals : Etanercept, Infliximab, Adalimumab and Ustekinumab belong to the class of biological medicines called tumour necrosis factor (TNF) blockers. These work by blocking the activity of TNF.

Erythrodermic and pustular psoriasis More severe > 90% involvement Need dermatologist! Usually need oral therapy

Associated features Arthritis Nail changes- onycholysis, pitting, discolouration, subungal hyperkeratosis

prognosis Chronic plaque tends to be lifelong Guttate – 2/3 further attacks, or develop chronic plaque

ACNE VULGARIS

Acne Vulgaris Common facial rash Usually adolescents 3% may persist after 25yrs especially women.

Clinical features Increased seborrhoea Open comedones= blackheads Closed comedones= whiteheads Inflammatory papules Pustules Nodulocystic lesions scars

Acne distribution

Treatment Consider site Compliance Inflammatory/non inflammatory lesions Scarring Fertility Psychological effect

Topical treatments Benzoylperoxidase – OTC, PanOxyl 5 to 10%, Azelaic acid – skinoren Antibiotics – clindamycin, erythromycin, steimycin Retinoids – adapalene

Oral therapy Use if topical therapy ineffective or inappropriate Anticomedonal topical treatment may be required in addition Don’t combine topical with oral antibiotic as encourages resistance. 3 to 4 months before any improvement

Antibiotics Oxytetracycline 500mg bd Tetracycline 500mg bd Doxycycline 100mg od Erythromycin 500mg bd Lymecycline 408mg od

Hormone treatment for acne Dianette - not if COCP contraindicated Withdraw when acne controlled VTE occurs more frequently in women taking dianette than other COCP – caution ++ at this point.

Oral retinoids Hospital only Long list of side effects Teratogenic Very effective Suicide- no proven link

www.pcds.org.uk Rashes are difficult!