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Embarrassing skin conditions
Jan L Bong Consultant Dermatologist Dec 2011
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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?
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Hyperhidrosis
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Case 1 25 year old woman complains of excessive armpits sweating.
What investigations would you consider doing?
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Hyperhidrosis Generalise Focal Drugs Systemic diseases
propranolol, pilocarpine, tricyclic antidepressants, venlafaxine Systemic diseases Hyperthyroid, diabetes, menopause, Hodgkin's, alcoholism Focal Nerve damage: gustatory Idiopathic
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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 ++
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Secondary care treatment- Axillaries BOTOX
NHS treatment Gravimetric test Up to 95% effective within 48 hours Average duration 7 months
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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
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Secondary care treatments
Glycopyrrolate lotions Topical anticholinergic 1 to 3% Variable results ‘specials’ – hence very expensive
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Other secondary care options - Surgery
Axillaries Sweat gland removal Palmar Laporscopic Sympathectomy Compensatory hyperhidrosis Not done for plantar due to risk
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Hidradenitis suppurativa
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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?
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Hidradenitis suppurativa
Disorder of apocrine glands Features Comedones Relapsing inflammation Discharges Scarring Sites – axillae, inguinal, perianal
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Primary care Treatments
Weight loss Dianett for mild disease Local hygiene
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Primary care Treatments
Antibiotics Treat like acne with cyclical antibiotics No evidence that it alter the natural course Tetracycline, erythromycin and clindomycin
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Secondary care Treatments
Combination of clindomycin and rifampicin Retinoids >6 months, moderately effective Dapsone Corticosteroid topical Intralesional oral
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Treatments Surgery Local excision Wide local excision
CO2 laser and secondary intention healing Recurrence rate reported to be >33%
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Prognosis Risk of SCC Spontaneously resolution is rare!!
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Hair loss
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Case 3 - 35 year old with 2 years history of gradual hair loss, worst on vertex
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Androgenetic alopecia
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More common in post menopausal women
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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
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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
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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
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Patchy hair loss – quiz
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Patch alopecia Scarring alopecia Non scarring alopecia Lupus
Fungus Lichen planus Traction Non scarring alopecia -Alopecia areata -telogen effluvium
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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.
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Primary care treatments
Potent topical steroids For 2-3 months Intralesional steroids Triamcinolone 10mg/ml Cognitive behavioural therapy
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Secondary care treatments
UVB Pulse oral steroids Immunosuppressants - ciclosporin
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T tonsurans often non inflammatory
T tonsurans often non inflammatory. Other trichophytum produced kerion with inflammation and pustules formation
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Traction alopecia affects young girls. Need some convincing
Traction alopecia affects young girls. Need some convincing. Often partial or near complete.
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Trichotillomania – girls, hair of variable length, unusual to have complete alopecia, hair line often maintained
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Erythematous plaque with scaling. Older lesions has follicular plugging
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Pigmentary disorders
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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?
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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
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Primary care treatments for chloasma
SUN PROTECTION - everyday Azelaic acid at 20% (Skinoren) Topical retinoid up to 0.1% Hydroquinone
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Secondary care treatments
Triple therapies – Sheffield, Manchester or Kligman’s formula Topical retinoid, hydroquinone and hydrocortisone Expensive!!
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Cosmetic options - chemical peels, dermabrasion, laser
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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,
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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
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Secondary care treatments
0.1% tacrolimus Narrow band UVB Evidence – 2010 cochrane review no obvious advances
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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
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