Dermatology in General Practice Dr Lynne Rees

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

vesicle Small fluid filled blister

Bulla A large fluid filled blister

ECZEMA Synonymous with dermatitis Large proportion of skin disease in developed world 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

Exacerbating factors Detergents Infection Teething Stress Cat and dog fur ???? House dust mite ???? Food allergens Theory of protection from parasite

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

complications Bacterial infection Viral infections – warts, molluscum, herpes Keratoconjunctivitis Retarded growth

investigations Clinical ??IgE ??RAST

Prognosis Most grow out of it! 15% may come back – often very mildly

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 Bath oils – 2-3 capfuls per bath

Discoid eczema Variant of eczema Atopic and non atopic 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 Affects body sites rich in sebacceous glands 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 shampoo Emollients Soap substitutes

Venous eczema Lower legs Venous hypertension Endothelial hyperplasia Extravasation of red and white cells Inflammation Purpura pigmentation

Clinical features Older women Past history DVT Haemosiderin deposition

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

Asteatotic eczema Dry skin Repeated soaping 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

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

Lichen simplex 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 Calcipotriol too irritant Steroid

Erythrodermic and pustular psoriasis More severe 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

treatment Suit patient Control rather than cure Topical therapies Light treatments Oral therapy

Topical therapy Emollients Vit D analogues- calcipotriol, calcitriol, tacalcitol (dovonex, silkis, curatoderm) Tazarotene – (zorac) Coal tar – alphosyl, exorex, cocois, polytar Dithranol –dithrocream, dithranol 0.1% to 2% for short contact Steroids – eumovate Combinations – dovobet, alphosyl HC, etc

Light treatments Not the same as sun beds!!!! UVB UVA

ACNE VULGARIS

Cause of acne Common facial rash Usually adolescents May occur in early and mid adult life Blockage of pilosebacceaous unit with surrounding inflammation Androgens lead to increase sebum production Increased colonisation by propionibacterium acnes

Clinical features Increased seborrhoea Open comedones Closed comedones Inflammatory papules Pustules Nodulocystic lesions

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 ,avoid in pregnancy Antibiotics – clindamycin, erythromycin, steimycin Retinoids – adapalene, tretinoin, avoid in pregnancy, avoid uv light, differin, retin-A

Combination topical treatments Antibiotics plus benzoyl peroxidase – benzamycin Retinoid plus antibiotic – isotrexin Antibiotic plus zinc - zineryt

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. Consider side effects and interactions when starting antibiotics 3 to 4 months before any improvement

Antibiotics Oxytetracycline 500mg bd Tetracycline 500mg bd Doxycycline 100mg od Minocycline 100mg od Erythromycin 500mg bd

Hormone treatment for acne Dianette - not if COCP contraindicated Withdraw when acne controlled VTE occurs more frequently in women taking dianette than other cocp.

Oral retinoids Hospital only Long list of side effects Teratogenic Very effective

ROSACEA

Clinical features rosacea Onset middle age Facial flushing / erythema Inflammatory papules Pustules No comedones Telangectasia Blepharitis rhinophyma

Treatment Supressive rather than curative Topical metronidazole 0.075% Tetracycline 500mg bd for 3 months Metronidazole 400mg bd Roaccutane Plastic surgery and some laser therapy for rhinophyma

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