Download Wet combing - Manchester GP Training

COMMON
PRESENTATIONS
Dr J Tomkinson
16/10/13
IMPORTANCE
• Around half of consultations
in A&E and 20 – 40% of GP
consultations are for minor
illnesses
• 57 million GP
consultations/yr OR
accounts for over an hour a
day for every GP
• In 90% of cases a
prescription will be issued
costing est £370 million/year
SCABIES
• Highly contagious and often missed as a
diagnosis.
• Diagnosis is based on history and
examination: you don't need to see the
parasite.
• Whole family (and all close contacts) must
be treated, even if asymptomatic.
5% permethrin cream is
recommended 1st line as this
has the best evidence base.
HEAD LICE
• Wet combing is cheapest and can be used for all the household and for
recurrences. Persistence is required, along with cooperation and patience
from all involved
• Insecticides are as effective as wet combing but resistance is common and
many want to avoid chemicals. Ensure patients follow the instructions
above, not those on the packet!
• Non-insecticide based shampoos seem not to be associated with
resistance, and may be more effective than wet combing/insecticides. They
are, however, chemicals, and some may not want to use them for that
reason.
• Patient choice and good compliance are clearly important here!
HYPERHIDROSIS
Primary
Patient may not want a prescription
Non phamacological suggestions
•
•
•
•
Avoid known triggers eg spicy foods and alcohol.
Use antiperspirant spray frequently
Avoid wearing tight, restrictive clothing and man-made fibres
Wearing black or white clothing can help to minimise the signs of
sweating.
• Armpit shields can help to absorb excessive sweat and protect
your clothes.
• Wear socks that absorb moisture
• Buy shoes that are made of leather, canvas or mesh, rather than
synthetic material.
HYPERHIDROSIS
Primary
• First line:
• Second line:
Aluminium chloride antiperspirants
(e.g. Anhydrol forte, Driclor, Odaban).
Iontophoresis
(for hands, feet and axillae).
HYPERHIDROSIS
Primary
For more generalised hyperhidrosis, anticholinergics (e.g. oxybutinin)
and glycopyrronium can be used, but have significant side-effects.
Endoscopic sympathectomy only if all other therapy fails.
Botulinum toxin very effective for the axillae but often not available
on the NHS because of cost (£300–500 per treatment, usually required
3 monthly).
Retrodermal curettage also useful in axillary disease, but again,
usually not available on the NHS
SECONDARY CAUSES OF
HYPERHYDROSIS
The commonest causes are:
• Menopause
• Hyperthyroidism
• Intoxication / withdrawal from drugs / alcohol
• Drugs:
Antidepressants (SSRIs, tricyclics….)
Antipyretics (aspirin, NSAIDs)
Hormonal drugs (tamoxifen, GnRH agonists)
SECONDARY CAUSES OF
HYPERHYDROSIS
Other causes include:
TB
Parkinson's disease
HIV
Neuropathies
Endocarditis
Diabetes
Phaeochromocytoma
Myeloproliferative
Carcinoid syndrome
Lymphoma
Acromegaly
Hyperhidrosis Support Group
www.hyperhidrosisuk.org
1
A
C
2
SORE
THROAT
• 40% of sore throats will be better by
day 3.
• Antibiotics increase re-attendance
rates.
• SIGN advise adequate analgesia
usually all that is required in most
cases.
• Consider using Centor score to aid
diagnostic acumen.
CENTOR CRITERIA
>3y (1 point for each of the following).
•
•
•
•
Tonsillar exudate
Tender anterior cervical lymph nodes
History of fever
Absence of cough
Score 1: 2–23% chance of having group A b-haemolytic strep (GABHS)
Score 4: 25–86% chance of having GABHS
NICE say treat if unwell and score more than ¾
Treatment :
Phenoxymethylpenicillin 500mg qds 10 days (or macrolide)
Analgesia
SORE
THROAT
• Evidence for tonsillectomy in children is
lacking but SIGN provide referral
criteria to determine who to refer to
secondary care.
• Oral steroids have a small evidence
base in adults only. Not yet
recommended.
• Lemierre's syndrome is very rare
but Fusobacterium necrophorum, the
organism responsible, can cause sore
throats and quinsy. Consider FN as a
cause in young adults with sore throat
who are more unwell than expected.
REFERRAL CRITERIA
• Infections must be documented, clinically significant and adequately
treated.
• 7 or more in last 1y OR 5 or more in each of last 2y OR 3 or more in each of
last 3y
• The sore throats are due to acute tonsillitis
• The episodes are disabling and prevent normal function.
• Appropriate stress should be placed on whether the frequency of
episodes is increasing or decreasing and SIGN suggest an ENT surgeon
might consider a six-month period of watchful waiting prior to
consideration of tonsillectomy, particularly if the history is patchy.
If an adult patient has had 4 episodes of sore throat in
12m or 3 in 6 months then…
• If they decide NOT to have the op they would expect
to have 2 episodes in the next 6 months (12 days of
sore throat, 2–3 days of fever)
• If they decide to have the operation they should
expect 13 days of severe pain post-op and an average
of 3 days of sore throat in the next 6 months
• Minor post-op complications are possible, lifethreatening ones are rare.
(BMJ 2007;334:909)
ROLE PLAY
SINUSITIS
• Most people get better on their own
with or without antibiotics.
• Antibiotics have an NNT of 15.
• Although some research suggested
that no clear sub-groups could be
identified who might benefit from
antibiotics more than most, other
research has suggested that those
with multiple symptoms, or
persistent symptoms (>10d) or a
biphasic illness (worsening after 5–
7d) are more likely to have a
bacterial infection.
OTITIS
MEDIA
• 80% of children get better within
3 days without antibiotics.
• NNT runs between 3 and 7
depending upon how you
measure success.
• NNH can be just as high.
• The National Prescribing Centre
does not recommend routine use
of antibiotics.
• Antibiotic use may increase the
risk of future AOM infections.
ONYCHOMYCOSIS
(FUNGAL NAILS)
• Are you sure it is fungal?
• Does any treatment work? If so, which
is better; oral or topical?
• First check that what you are looking at
really is infected!
• Warn patients that treatment is for a long
time (often months) and success rates
are modest to good but with quite
significant relapse rates.
• Nail lacquers are not as effective.
Systemic treatment example:
• Terbinafine 250mg daily
• 12-16 weeks average treatment
• Clinical success 70% but relapse 15%
'BUT I'VE BEEN COUGHING FOR
3 WEEKS DOCTOR; SURELY
YOU CAN DO SOMETHING….'
ACUTE BRONCHITIS
• Acute bronchitis is a self-limiting lower respiratory tract
infection, presenting almost always with a cough
• It is usually viral but can be bacterial
• MeReC recommend that acute bronchitis is a likely
diagnosis in someone presenting with cough, no new focal
chest signs and no systemic upset.
HOW DO I KNOW IT ISN’T PNEUMONIA?
The British Thoracic Society (BTS) defines pneumonia as:
Cough and at least one other lower respiratory tract symptom
AND
New focal chest signs on examination
AND
EITHER sweating, fevers, shivers, aches and pains or fever >38°C
AND
No other explanation for symptoms.
CRP NOT FELT TO BE USEFUL
CXR NOT HELPFUL
COUGH MEDICINES HAVE NO PROVEN BENEFIT
B-AGONISTS HAVE NO EVIDENCE TO SUPPORT
USE
HOW LONG WILL IT LAST?
• The average cough lasted 12 days, although 25% were still coughing 2.5w
later.
• Antibiotics made no impact on duration of cough (or any other
outcome).
• Those given delayed or no antibiotics were less likely to believe in the
benefit of antibiotics next time.
• Those not given immediate antibiotics had slightly lower satisfaction
scores!
(JAMA 2005;293:3029–35):
• Average duration of cough was 3 weeks.
Antibiotics made no difference to the duration of the cough.
(BJGP 2008;58:88–92)
ANTIBIOTICS?
• Neither sputum production nor sputum colour are
good predictors of severity of illness.
• Antibiotics do not offer more than minor and clinically
insignificant benefits e.g. a reduction of cough by half a
day two weeks into the illness.
• Those with more significant illness may benefit from
antibiotics.
NICE guidance on respiratory tract infections
recommends not prescribing or using a delayed
script for acute cough unless:
Co-morbidity or >65y with at least 2 of the following or
>80y with at least 1 of the following:
•
•
•
•
Hospitalised in the last 12m
Diabetes (type 1 & 2)
Heart failure
On steroids
(NICE 2008, CG69)
RCT of over 800 people over the age of 3 with a
LRTI (not URTI) showed that:
• Those offered antibiotics were twice as likely
to re-attend with the next illness.
• Offering a delayed prescription reduced reattendance rates by a whopping 78% compared
to those given immediate antibiotics!
SUMMARY: Acute bronchitis & cough
• There is no evidence for cough mixtures or betaagonists in acute bronchitis.
• The cough with bronchitis lasts, on average, 3
weeks.
• Antibiotics do not make the cough get better more
quickly.
• Neither sputum production, nor sputum colour, are
good markers of severity.
• In children, even if quite unwell, antibiotics do not
speed recovery.
ALOPECIA
Areata
• Autoimmune, non-scarring disorder of hair growth.
Often a genetic link.
• Diagnosis is clinical.
Often you see a circular bald patch with
exclamation hairs (isolated short broken-off hairs
in a patch of baldness). Lifetime prevalence 1.7%.
Alopecia totalis (all of head hair loss) is rarer and
alopecia universalis (loss of all body hair) rarer
still.
• Prognosis
In an initial patch: 33% will have re-grown in 6m,
50% in 12m BUT 33% will never recover. Almost
everyone who gets a first patch will do so again,
but this may be many years later.
TREATMENTS FOR ALOPECIA AREATA
• 50% resolve spontaneously
• Intra-lesional corticosteroids (triamcinolone). This is usually used first line.
• Dithranol. Often used second line in persistent disease. Aim is to induce low-grade
dermatitis.
• Topical immunotherapy. Dinitrochlorobenzene, diphencyprone and SADBC used,
but not in primary care. The aim is to induce a low grade contact dermatitis that
stimulates hair regrowth. The more extensive the hair loss, or the longer it has
been present, the less effective this treatment is.
• Topical super-potent steroids (often under occlusion) or less potent steroids in the
form of a foam. Only small trials, showing limited effectiveness.
• Systemic corticosteroids. Only one tiny RCT showing one third of patients
responded but relapse rates were high. Rarely used because of systemic sideeffects.
• Minoxidil. May be most beneficial in preventing relapse rather than to induce hair
growth initially.
TINEA CAPITIS
(SCALP RINGWORM)
Complications
• Severe hair loss
• Scarring alopecia
• Psychological impact (ridicule, bullying, isolation, emotional
disturbance, family disruption)
Treatments
Topical rx : eg ketoconazole shampoo / terbinafine cream
Systemic rx: eg terbinafine
SHINGLES
How do you explain shingles to a
patient?
SHINGLES
• Shingles is an infection of a nerve area
caused by the varicella-zoster virus
• Causes pain and a rash along a band of skin
supplied by the affected nerve
• Symptoms usually go within 2-4 weeks
• Post herpetic neuralgia: up to 1 in 4 people
with shingles, over the age of 60, has pain
that lasts more than a month
TREATMENTS:
Aciclovir 800mg five times a day if within the first 72
hours
Pain and post herpetic neuralgia
• tricyclic antidepressants
• anticonvulsants such as gabapentin
• Capsaicin, a topical treatment made from chilli
peppers, can be applied to the affected area
several times per day (avoid any mucous
membranes!)
• oxycodone
WARTS AND VERRUCAE
Left untreated, most viral warts will eventually
disappear (some pts happy with this info)
LEARNING POINT:
Not everyone wants a prescription
Remember reassurance / non-pharmacological
treatments
WARTS AND VERRUCAE
Treatment Options:
• Cryotherapy
• Salicylic acid
• Duct tape
• Herbal – eg thuja
WARTS AND VERRUCAE
• An RCT of 240 people with
warts/verrucas compared salicylic acid
with cryotherapy
• There was no difference in cure rates
between the two groups.
• At 12w cure rate was 14% in both groups
and around 33% at 6m. Not that
encouraging…
(BMJ 2011;342:d3271)
IMPETIGO TREATMENTS
Oral or topical antibiotics?
• Topical antibiotics are as effective as, if not more effective than oral
antibiotics & have fewer side-effects. However, oral therapy should be used if
impetigo is widespread.
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•
•
•
•
•
Which antibiotic?
Fusidic acid cream
Flucloxacillin
Macrolides (e.g. erythromycin) and cephalosporins are also effective.
There is no evidence for disinfecting treatments
Retapamulin ointment 1% (Altargo) is a new therapy for impetigo (no clinical
benefit vs fucidin and much more expensive)
Molluscum Contagiosum