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GP DERMATOLOGY DR ANITA LOWE MBBS FRACGP
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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
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CASE 1- SAM
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MANAGEMENT
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MANAGEMENT Topical steroids? Which one and duration?
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MANAGEMENT Topical steroids? Which one and duration? Antibiotics?
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MANAGEMENT Topical steroids? Which one and duration? Antibiotics?
General measures for eczema?
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MANAGEMENT Topical steroids? Which one and duration? Antibiotics?
General measures for eczema? Allergy testing?
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TOPICAL CORTICOSTEROIDS
Strength Vehicle Amount Required Adverse Reactions
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STRENGTH MILD (Group VII) 1% hydrocortisone cream (sigmacort)
MODERATE (Group V) Triamcinolene acetonide (aristocort) Betamethasone valerate (celestone) Methylprednisolone aceponate (advantan) Clobetasone butyrate (eumovate)
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STRENGTH STRONG (Group III-IV) Mometasone furoate (elocon)
Betamethasone dipropionate (diprosone) Betametasone valerate (betnovate)
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STRENGTH VERY STRONG (Group I) betamethasone dipropionate
(diprosone OV)
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AVOID WEAKER “SAFE” PREPARATIONS IN FLARED STATES
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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
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AMOUNT REQUIRED If applied twice daily for 10 days Trunk- 60grams
One Leg- 60 grams One Arm- 30grams Face/Neck- 30grams One hand- 15grams
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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
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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
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Perioral Dermatitis
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ADVERSE REACTIONS Rebound Phenomenon eg. Psoriasis
Systemic Absorption- unlikely unless prolonged use of group 1 topical steroids over wide areas
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Educate your patient about Corticosteroid Phobia
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ANTIBIOTICS Topical eg bactroban, kenacomb
Oral eg cephalexin or di/flucloxacillin Treat nasal staphylococcus – nasal bactroban
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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)
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GENERAL MEASURES Emollients
Very greasy –liquid paraffin and white soft paraffin (QV intensive) Moderately greasy- glycerol 10% in sorbolene cream (QV cream, dermaveen)
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GENERAL MEASURES Slightly greasy- aqueous cream (Cetaphil cream)
Light, non greasy- lotions, not moisterising enough for atopic skin, sting
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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
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GENERAL MEASURES Avoid allergens
Avoid rough fibres and tight clothing-wool and nylon Avoid sandpits Avoid emotional stress Avoid heavily chlorinated pools/spas
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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
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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
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WHAT WOULD I DO FOR SAM?
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WHAT WOULD I DO? Oral cephalexin syrup
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WHAT WOULD I DO? Oral cephalexin
Body- topical advantin ointment bd until settled then reduce to nocte
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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
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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
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WHAT WOULD I DO? Write instructions down for parents
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WHAT WOULD I DO? Write instructions down for parents
Review in one week
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WHAT WOULD I DO? Write instructions down for parents
Review in one week At review establish an Action Plan
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Australasian Society of Clinical Immunology and Allergy
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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
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DIAGNOSIS?
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DIAGNOSIS? Atopic eruption of pregnancy
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DIAGNOSIS? Atopic eruption of pregnancy Contact dermatitis
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DIAGNOSIS? Atopic eruption of pregnancy Contact dermatitis Psoriasis
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DIAGNOSIS? Atopic eruption of pregnancy Contact dermatitis Psoriasis
Scabies
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Topical corticosteroids in pregnacy
1 % Hydrocortisone ointment (Preg A) Celestone ointment (Preg A) Diprosone ointment (Preg A) Diprosone OV ointment (Preg A)
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WHAT WOULD I DO FOR SALLY?
Topical diprosone ointment bd until settled and reduced to nocte
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WHAT WOULD I DO ? Topical diprosone ointment bd until settled and reduced to nocte Avoid soap and other chemicals
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WHAT WOULD I DO ? Topical diprosone ointment bd until settled and reduced to nocte Avoid soap and other chemicals Sorbolene hand wash
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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
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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
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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
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PSORIASIS Inflammatory and hyperplastic skin disease
0.5 to 3% of population Polygenically inherited and environmental triggers One third have an associated arthritis
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Psoriasis Presentations in General Practice
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MANAGEMENT
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MANAGEMENT Avoid aggravating factors Stress reduction Weight loss
Smoking cesssation
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MANAGEMENT Avoid aggravating factors Emollients Keratolytics
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MANAGEMENT Avoid aggravating factors Emollients Keratolytics
Softens and lifts scale 2-10% Salicylic acid in sorbolene cream
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MANAGEMENT Tars
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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)
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MANAGEMENT Topical corticosteroids
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MANAGEMENT Topical corticosteroids Calcipotriol eg. Daivonex, Daivobet
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MANAGEMENT Topical corticosteroids Calcipotriol eg. Daivonex, Daivobet
Slow to work >6weeks Caution in widespread disease - hypercalcaemia
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MANAGEMENT Scalp Psoriasis
Neutrogena T/Gel Plus (remove scale) plus topical corticosteroid lotion Daivobet Gel Elocon Lotion
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MANAGEMENT Genital Psoriasis
moderately potent topical corticosteroid daily until resolved then add 2% LPC in aqueous cream
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MANAGEMENT Systemic Therapy Phototherapy
Treatment for nails are limited Consider secondary bacterial or fungal infection
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WHAT WOULD I DO FOR JOHN?
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WHAT WOULD I DO? Topical advantan bd until settled then reduce to nocte Review in one week
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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
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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
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ACNE MANAGEMENT
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ACNE MANAGEMENT Mild- comedomes, some papules and pustules
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ACNE MANAGEMENT Mild- comedomes, some papules and pustules
Moderate - more widespread, minor scarring
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ACNE MANAGEMENT Mild- comedomes, some papules and pustules
Moderate - more widespread, minor scarring Severe – widespread, cystic lesions, extensive scarring
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MILD ACNE Benzoyl peroxide – antibacterial and mild keratolytic
Benzac AC/Wash Benzac Gel
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MILD ACNE Topical Retinoids – decrease inflammation and decrease comedomal and papule formation
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TOPICAL RETINOIDS Adapalene eg. Differin gel
Isotretinoin eg. Isotrex gel Tretinoin eg.Retin- A gel Tazarotene eg. Zorac gel
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MILD ACNE Topical Antibiotic Clindamycin eg. Clindatech solution
Erythromycin eg. Eryacne gel
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Combination Topicals for Acne
Epiduo gel- Benzoyl peroxide and adapalene Duac gel -clindamycin and benzoyl peroxide
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MILD ACNE Benzoyl Peroxide plus Topical Retinoid or Benzoyl Peroxide plus Topical Antibiotic Topical Antibiotic or Topical Retinoid
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MODERATE ACNE Add Oral Antibiotics (Cease topical antibiotic)
Doxycycline Erythromycin Minocycline Treat for at least 3-6 months
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MODERATE ACNE Add Oral Contraceptive Pill in female – anti-androgenic, reduces sebum secretion Dianne/Brenda/Estelle Yasmin/Isabelle Yaz
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SEVERE ACNE Oral Isotretinion eg. Roaccutane
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SEVERE ACNE Oral Isotretinion eg. Roaccutane Refer to Dermatologist
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SEVERE ACNE Oral Isotretinion eg. Roaccutane Refer to Dermatologist
Ensure adequate contraception in females
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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
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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)
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WHAT WOULD I DO FOR LISA? OCP contra-indicated
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WHAT WOULD I DO? OCP contra-indicated Topical Epiduo gel
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WHAT WOULD I DO? OCP contra-indicated Topical Epiduo gel
Oral doxycycline 100mg daily
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WHAT WOULD I DO? OCP contra-indicated Topical Epiduo gel
Oral doxycycline 100mg daily Refer to Dermatologist
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WHAT WOULD I DO? OCP contra-indicated Topical Epiduo gel
Oral doxycycline 100mg daily Refer to Dermatologist Consider discussing roaccutane and contraception
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RESOURCES Dermatology Therapeutic Guidelines
Australian Medicines Handbook
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ANY QUESTIONS?
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