Download Inflammatory Skin Conditions in Primary care

Diagnosis and Treatment of
Inflammatory Skin Conditions in
Primary Care
Alexa Shipman
Consultant Dermatologist
Portsmouth
November 2016
Common Inflammatory Skin
Conditions
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Eczema
Seborrhoeic dermatitis
Psoriasis
Acne
Rosacea
Urticaria
Eczema - Cause
• Filaggrin mutations and immune pathways
• Advice on diet is changing
Eczema - Diagnosis
Eczema
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Emollients are imperative to good eczema control
Find one that the patient likes and is happy to use
Ointments contain less preservatives
Prescribe generous amounts
Apply in the direction of the hairs
Warn that they may sting
Use an utensil to scoop out ointments
15-20 minutes between emollient and steroid
Eczema – Treating Flares
• ‘Hit hard' using more potent treatments for a
few days
• Finger tip unit
• Strength of steroid to be determined by the
age of patient, site and severity
Clobetasol
Mometasone
Clobetasone
Hydrocortisone
500
50
5
1
Eczema – If Still Struggling
• Ideally antiseptics instead of antibiotics topically
• If used appropriately steroid atrophy is
uncommon
• Bandages and dressings
• [Clothing]
• Sedating anti-histamines
• Skin swab if not settling
• Check compliance
• Consider contact irritation or allergy
http://www.nottingham.ac.uk/research/gr
oups/cebd/projects/clothes/index.aspx
Eczema – Additional Agents
• Calcineurin inhibitors are Protopic (tacrolimus)
and Elidel (pimecrolimus)
• Stinging (particularly Protopic), and slight
photosensitivity
• Tar-based shampoo or bath oil to wash children’s
hair
• Steroid scalp applications or shampoos
• For scale use Sebco ointment or Cocois
• Patch testing, phototherapy, systemics, biologics
(IL-4 blocker called dupilumab)
Eczema - Conclusions
• Pathophysiology is slowly being understood
• Emollients and steroid creams are mainstay
still, treat aggressively
• No evidence for clothing
• Evidence building up against dietary
exclusions
• New biologic on the cards
Psoriasis - Diagnosis
• Is a disease of increased cell turnover
• Genetic mutations – numerous
Psoriasis - Treatment
• Prescribe copious emollients (use same as in
eczema) - these make the skin more
comfortable and reduce the amount of scale
• Actively treat flares and rotate treatments to
prevent tachyphylaxis
• Atrophy is less of a risk compared to eczema
as the skin is thickening
• Theoretical risk of high calcium with vit D
Psoriasis – Treatment Creams
• Vitamin D - Dovobet gel or ointment,
Dovonex, Enstilar
• Tar preparations e.g. Exorex lotion
• Vitamin A - tazarotene gel 0.05% or 0.1%
• Dithranol preparations
• Steroid creams with or without salicylic acid
Psoriasis – Treating Special Sites
• Flexures - calcitriol (Silkis ) or calcipotriol
(Dovonex ), Eumovate, Protopic
• Scalps – Sebco or Cocois ointments, tar based
shampoos, steroid lotions (e.g. Betacap,
Betnovate or Dermovate), Dovobet gel,
emollients oils to remove scale
• Nails – Dovobet gel or similar watery lotion
Psoriasis – Secondary Care
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Phototherapy
Ciclosporin
Methotrexate
Acitretin
Apremilast
Fumarates
Hydroxyurea
Biologics and biosimilars
Psoriasis Take Home Points
• Emollients and rotation of topical treatments
is first line of treatment – less caution
required compared to eczema
• New licenced medication apremilast trying to
get through NICE
• Patients may start being switched to
biosimilars
• In primary care remember cardiovascular risk
Seborrhoeic Dermatitis - Diagnosis
• Allergic or irritant reaction to yeasts and their
products
Seborrhoeic Dermatitis
• Ketoconazole shampoo or selenium sulphide
shampoo
• Topical steroid scalp application or mousse
• Sebco ointment or Cocois
• Oils to remove scale
• Canestan or Daktarin creams
• Eumovate or Protopic/Elidel
• Itraconazole 100 mg per day for 14 days
• Consider HIV in patients with more severe
symptoms
Seborrhoeic Dermatitis - Points
• Explain aetiology – important patient realises
that this can be lifelong and how to manage
flares
• Minimise topical steroid use in this case
• Anti-yeast agents and emollients with
occasional immunosuppressants should be
sufficient
• Consider immunosuppression in bad cases
Acne Vulgaris - aetiology
• Common, partly genetic
• Lifestyle, drugs, hormonal
Acne – Treatment Continued
• Prevent or minimise scarring,
• Increasing levels of Propionibacterium acnes
resistance to antibiotics
• Although topical retinoids should be avoided in
pregnancy they are safe to use in all other
patients including sexually active women
• Combination treatment reduces bacterial
resistance, e.g. Epiduo gel (adapalene + BPO) or
Duac ® gel (clindamycin + BPO) or Treclin ® gel
(clindamycin and tretinoin) or topicals plus oral
antibiotics
Acne - Treatment
• OCP can be useful, Dianette particularly with PCOS
• During pregnancy use topicals e.g. benzoyl peroxide
preparations, 2% topical erythromycin, azelaic acid
• Antibiotics e.g. lymecycline 408 mg OD, doxycycline
100 mg OD, erythromycin 500 mg BD, clarithomycin
250 mg BD, trimethoprim 300 mg BD
• Atrophic scars – private treatment e.g. lasers, surgery
• Hypertrophic / keloid scars - silicone gels, topical
steroids or intralesional triamcinolone
Acne – Take Home Points
• If scarring or nodulocystic refer straight to
dermatology for isotretinoin whilst starting
treatment – children welcome
• Topical treatments long term are beneficial if
tolerated
• Scarring has to be dealt with privately
Acne Rosacea - Diagnosis
Acne Rosacea - Treatment
• Topicals: ivermectin 10 mg/g, metronidazole gel
or cream, azelaic acid cream, brimonidine 0.33%
gel
• Orals: oxytetracycline 500 mg BD, lymecycline 408 mg OD
- both on an empty stomach, or doxycycline 40 mg OD –
3 month treatment to start
• For flushing propranolol 40 mg BD, or clonidine 50
micrograms BD or laser
• Camouflage – Changing Faces
• Rhinophyma – CO2 laser
• Eyelid and blepharitis – need oral antibiotics
• Isotretinoin
Acne Rosacea - Points
• New topical - ivermectin
• Relatively new topical - brimonidine
• No longer Red Cross for camouflage
Chronic Idiopathic Urticaria Diagnosis
• 6 weeks of spontaneous wheals
• Blood tests - check TFT and autoantibodies
• Almost never need allergy testing
Urticaria - Treatment
• Avoid tight clothing, heat, NSAID/opiate drugs
and alcohol.
• Non-sedating oral antihistamines up to QDS
e.g. fexofenadine 180 mg and loratadine and
desloratadine
• Montelukast or ciclosporin
• Omalizumab
Urticaria – Take Home Points
• Ramp up the non-sedating antihistamine
• Add in montelukast and refer to dermatology
if not working as we have omalizumab now to
help these patients
• Do not send for lots of allergy testing or give
prednisolone or Epipen.
Conclusions
• Only covered a few of the inflammatory skin
disorders
• Lots of new things on market
• Often topicals are sufficient to control a lot of
mild disease – giving patients choice aids
compliance
• A lot of these diseases are chronic so
prescriptions are long term