1. GP DERMATOLOGY DR ANITA LOWE MBBS FRACGP

2. GP CASE 1- SAM
12 month old boy with a one week history “very itchy” rash
Has had before several times, diagnosed as eczema
Mostly on face, trunk, arms and legs
Using 1% hydrocortisone cream which is not helping

3. CASE 1- SAM

6. MANAGEMENT

7. MANAGEMENT
Topical steroids? Which one and duration?

8. MANAGEMENT
Topical steroids? Which one and duration?
Antibiotics?

9. MANAGEMENT Topical steroids? Which one and duration? Antibiotics?
General measures for eczema?

10. MANAGEMENT Topical steroids? Which one and duration? Antibiotics?
General measures for eczema?
Allergy testing?

11. TOPICAL CORTICOSTEROIDS
Strength
Vehicle
Amount Required
Adverse Reactions

12. STRENGTH MILD (Group VII) 1% hydrocortisone cream (sigmacort)
MODERATE (Group V)
Triamcinolene acetonide (aristocort)
Betamethasone valerate (celestone)
Methylprednisolone aceponate (advantan)
Clobetasone butyrate (eumovate)

13. STRENGTH STRONG (Group III-IV) Mometasone furoate (elocon)
Betamethasone dipropionate (diprosone)
Betametasone valerate (betnovate)

14. STRENGTH VERY STRONG (Group I) betamethasone dipropionate
(diprosone OV)

15. AVOID WEAKER “SAFE” PREPARATIONS IN FLARED STATES

16. VEHICLE Cream- can be used anywhere but contains alcohol so may sting
Ointment- good for dry areas, do not sting, greasy sensation
Fatty Ointment- better penetration for hands and feets
Lotion/Gel- good for hairy areas including the scalp

17. AMOUNT REQUIRED If applied twice daily for 10 days Trunk- 60grams
One Leg- 60 grams
One Arm- 30grams
Face/Neck- 30grams
One hand- 15grams

18. AMOUNT REQUIRED
Sigmacort- 30 or 50 gram tubes Aristocort/Celestone- 2x 100 gram tubes Advantan/Elocon- 15 gram tubes Diprosone OV- 30 gram tubes CONSIDER AUTHORITY SCRIPT eg. Advantan 4x30 gram tubes with 2 rpts

19. ADVERSE REACTIONS Allergic dermatitis
Burning, irritation, dryness by the vehicle
Hypopigmentation
Skin Atrophy- often reversible
Striae- long term use (over months)
Rosacea, perioral dermatitis, folliculitis

20. Perioral Dermatitis

22. ADVERSE REACTIONS Rebound Phenomenon eg. Psoriasis
Systemic Absorption- unlikely unless prolonged use of group 1 topical steroids over wide areas

23. Educate your patient about Corticosteroid Phobia

24. ANTIBIOTICS Topical eg bactroban, kenacomb
Oral eg cephalexin or di/flucloxacillin
Treat nasal staphylococcus – nasal bactroban

25. TO CONSIDER
Oral antihistamines for itch eg. Phenergan at night and Claratyne during day
Wet dressings
Bleach Baths (White King 12mls per 10L of water)
Elidel (pimecrolimus)

26. GENERAL MEASURES Emollients
Very greasy –liquid paraffin and white soft paraffin (QV intensive)
Moderately greasy- glycerol 10% in sorbolene cream (QV cream, dermaveen)

27. GENERAL MEASURES Slightly greasy- aqueous cream (Cetaphil cream)
Light, non greasy- lotions, not moisterising enough for atopic skin, sting

28. GENERAL MEASURES Avoid excessive bathing/showering and hot temperature
Cool environment
Moisterise after bathing/showering. Add dispersible oil to bath
Avoid soaps, bubble bath and contact irritants

29. GENERAL MEASURES Avoid allergens
Avoid rough fibres and tight clothing-wool and nylon
Avoid sandpits
Avoid emotional stress
Avoid heavily chlorinated pools/spas

30. ALLERGY TESTING??
Consider in moderate to severe atopic dermatitis that does not respond to conventional treatment (especially infants under 12 months age)
Flares after certain foods
Recurrent periorbital and exposed arm and leg areas

31. Allergy Testing for Atopic Dermatitis
Serology and skin prick testing have high rates of false- positives results
Egg’s, cow’s milk, wheat, soy and peanuts
House dust mite, cockroach, pet dander, and pollen
RAST, skin prick testing

32. WHAT WOULD I DO FOR SAM?

33. WHAT WOULD I DO?
Oral cephalexin syrup

34. WHAT WOULD I DO? Oral cephalexin
Body- topical advantin ointment bd until settled then reduce to nocte

35. WHAT WOULD I DO? Oral cephalexin
Body- topical advantin ointment bd until settled then reduce to nocte
Face – topical advantin ointment nocte until settled then change to 1% hydrocortisone ointment nocte

36. WHAT WOULD I DO? Oral cephalexin
Body- topical advantin ointment bd until settled then reduce to nocte
Face – topical advantin ointment nocte until settled then change to 1% hydrocortisone ointment nocte
Sorbolene body wash and QV intensive moisteriser

37. WHAT WOULD I DO?
Write instructions down for parents

38. WHAT WOULD I DO? Write instructions down for parents
Review in one week

39. WHAT WOULD I DO? Write instructions down for parents
Review in one week
At review establish an Action Plan

41. Australasian Society of Clinical Immunology and Allergy

42. GP CASE 2- SALLY
24 year old female G1P0 at 20 weeks gestation with very itchy rash on her hands only for 3 weeks
History of asthma
Using sorbolene cream and paw paw ointment

44. DIAGNOSIS?

45. DIAGNOSIS?
Atopic eruption of pregnancy

46. DIAGNOSIS?
Atopic eruption of pregnancy
Contact dermatitis

47. DIAGNOSIS?
Atopic eruption of pregnancy
Contact dermatitis
Psoriasis

48. DIAGNOSIS? Atopic eruption of pregnancy Contact dermatitis Psoriasis
Scabies

49. Topical corticosteroids in pregnacy
1 % Hydrocortisone ointment (Preg A)
Celestone ointment (Preg A)
Diprosone ointment (Preg A)
Diprosone OV ointment (Preg A)

50. WHAT WOULD I DO FOR SALLY?
Topical diprosone ointment bd until settled and reduced to nocte

51. WHAT WOULD I DO ?
Topical diprosone ointment bd until settled and reduced to nocte
Avoid soap and other chemicals

52. WHAT WOULD I DO ?
Topical diprosone ointment bd until settled and reduced to nocte
Avoid soap and other chemicals
Sorbolene hand wash

53. WHAT WOULD I DO ?
Topical diprosone ointment bd until settled and reduced to nocte
Avoid soap and other chemicals
Sorbolene hand wash
QV intensive moisteriser

54. WHAT WOULD I DO ?
Topical diprosone ointment bd until settled and reduced to nocte
Avoid soap and other chemicals
Sorbolene hand wash
QV intensive moisteriser
Review in one week

55. GP CASE 3- John
22 year old male with a 4 month rash on his glans penis – treated for “thrush” several times, swabs all normal
Topical canestan for the past 2 weeks
Family history of psoriasis

58. PSORIASIS Inflammatory and hyperplastic skin disease
0.5 to 3% of population
Polygenically inherited and environmental triggers
One third have an associated arthritis

59. Psoriasis Presentations in General Practice

64. MANAGEMENT

65. MANAGEMENT Avoid aggravating factors Stress reduction Weight loss
Smoking cesssation

66. MANAGEMENT
Avoid aggravating factors
Emollients
Keratolytics

67. MANAGEMENT Avoid aggravating factors Emollients Keratolytics
Softens and lifts scale
2-10% Salicylic acid in sorbolene cream

68. MANAGEMENT
Tars

69. MANAGEMENT Tars Not well accepted due to colour and smell
LPC 2-10% cream/ointment
Psor- Asist cream (2% salicylic acid, 5% tar and 3% sulphur)

70. MANAGEMENT
Topical corticosteroids

71. MANAGEMENT
Topical corticosteroids
Calcipotriol eg. Daivonex, Daivobet

72. MANAGEMENT Topical corticosteroids Calcipotriol eg. Daivonex, Daivobet
Slow to work >6weeks
Caution in widespread disease - hypercalcaemia

73. MANAGEMENT Scalp Psoriasis
Neutrogena T/Gel Plus (remove scale) plus topical corticosteroid lotion
Daivobet Gel
Elocon Lotion

74. MANAGEMENT Genital Psoriasis
moderately potent topical corticosteroid daily until resolved then add 2% LPC in aqueous cream

75. MANAGEMENT Systemic Therapy Phototherapy
Treatment for nails are limited
Consider secondary bacterial or fungal infection

76. WHAT WOULD I DO FOR JOHN?

77. WHAT WOULD I DO?
Topical advantan bd until settled then reduce to nocte
Review in one week

78. WHAT WOULD I DO?
Topical advantan bd until settled then reduce to nocte
Review in one week
Change to 2% LPC in aqueous cream if tolerates
Action Plan

79. GP CASE 4- LISA 16 year old female worried about her acne
Using proactive and eryacne gel for 3 months without any improvement
History of migraine with aura

81. ACNE MANAGEMENT

82. ACNE MANAGEMENT
Mild- comedomes, some papules and pustules

83. ACNE MANAGEMENT Mild- comedomes, some papules and pustules
Moderate - more widespread, minor scarring

84. ACNE MANAGEMENT Mild- comedomes, some papules and pustules
Moderate - more widespread, minor scarring
Severe – widespread, cystic lesions, extensive scarring

85. MILD ACNE Benzoyl peroxide – antibacterial and mild keratolytic
Benzac AC/Wash
Benzac Gel

86. MILD ACNE
Topical Retinoids – decrease inflammation and decrease comedomal and papule formation

87. TOPICAL RETINOIDS Adapalene eg. Differin gel
Isotretinoin eg. Isotrex gel
Tretinoin eg.Retin- A gel
Tazarotene eg. Zorac gel

88. MILD ACNE Topical Antibiotic Clindamycin eg. Clindatech solution
Erythromycin eg. Eryacne gel

89. Combination Topicals for Acne
Epiduo gel- Benzoyl peroxide and adapalene
Duac gel -clindamycin and benzoyl peroxide

90. MILD ACNE
Benzoyl Peroxide plus Topical Retinoid or Benzoyl Peroxide plus Topical Antibiotic Topical Antibiotic or Topical Retinoid

91. MODERATE ACNE Add Oral Antibiotics (Cease topical antibiotic)
Doxycycline
Erythromycin
Minocycline
Treat for at least 3-6 months

92. MODERATE ACNE
Add Oral Contraceptive Pill in female – anti-androgenic, reduces sebum secretion
Dianne/Brenda/Estelle
Yasmin/Isabelle
Yaz

93. SEVERE ACNE
Oral Isotretinion eg. Roaccutane

94. SEVERE ACNE
Oral Isotretinion eg. Roaccutane
Refer to Dermatologist

95. SEVERE ACNE Oral Isotretinion eg. Roaccutane Refer to Dermatologist
Ensure adequate contraception in females

96. SEVERE ACNE Oral Isotretinion eg. Roaccutane Refer to Dermatologist
Ensure adequate contraception in females
Requires monitering (LFT’s, lipids)
Unable to donate blood during treatment and for 8 weeks after

97. SEVERE ACNE Oral Isotretinion eg. Roaccutane Refer to Dermatologist
Ensure adequate contraception in females
Requires monitering
Unable to donate blood during treatment
Most patients remain disease free after single course (6-8 months)

98. WHAT WOULD I DO FOR LISA?
OCP contra-indicated

99. WHAT WOULD I DO?
OCP contra-indicated
Topical Epiduo gel

100. WHAT WOULD I DO? OCP contra-indicated Topical Epiduo gel
Oral doxycycline 100mg daily

101. WHAT WOULD I DO? OCP contra-indicated Topical Epiduo gel
Oral doxycycline 100mg daily
Refer to Dermatologist

102. WHAT WOULD I DO? OCP contra-indicated Topical Epiduo gel
Oral doxycycline 100mg daily
Refer to Dermatologist
Consider discussing roaccutane and contraception

103. RESOURCES Dermatology Therapeutic Guidelines
Australian Medicines Handbook

104. ANY QUESTIONS?