04. KFP: Case Practice Flashcards
Treatment for chronic stable psoriasis on the trunk and limbs?
Liquor Picis Carbonis (LPC) 4-8% + salicyclic acid 3% cream or ointment topically, BD for 1 month
Management of an acute flare of psoriasis?
Liquor Picis Carbonis (LPC) 4-8% + salicyclic acid 3% cream or ointment topically, BD for 1 month [tar preparation is preferred for maintenance because it is easier to apply over larger surfaces]
PLUS
Methylprednisone aceponate 0.1% cream, ointment or fatty ointment topically, daily until skin is clear (usually two to six weeks)
IF RESPONSE TO TREATMENT IS INADEQUATE AFTER 3 WEEKS, USE A MORE POTENT TOPICAL CORTICOSTEROID:
* betamethasone dipropionate 0.05% cream or ointment topically, daily until skin is clear (usually 2 to 6 weeks)
Management of Psoriasis with only a few scattered plaques that do not respond to a tar preparation, or need longer term control with the topical corticosteroid?
Calcipotriol + betamethasone dipropionate 50 + 500microg/g Topically, daily until skin is clear (usually about six weeks)
When using topical retinoids for the treatment of acne, what kind of topical vehicle do we use for dry and sensitive skin?
Topical retinoid creams
When using topical retinoids for the treatment of acne, what kind of topical vehicle do we use for oily skin?
Topical retinoid gel
What is the treatment for mild acne that is mainly comedonal with minimal inflammation?
Options (topical retinoids):
* adapalene 0.1% gel topically, daily at night for six weeks then review
* Tretinoin 0.025% cream topically, daily at night for six weeks then review
* Trifarotene 0.005% cream topically, daily at night for six weeks then review
Management of:
1) Mild comedonal acne not responding to topical retinoid
2) Mild acne that is mainly comedonal but with some inflammatory papules and pustules
Benzoyl peroxide + adapalene 2.5% + 0.1% gel topically, daily for 6 weeks, then review
Management of:
1) Mild comedonal acne not responding to topical retinoid
2) Mild acne that is mainly comedonal but with some inflammatory papules and pustules
that is not improving but well tolerated on topical combination therapy?
Benzoyl peroxide + adapalene 2.5% + 0.3% gel topically, daily for 6 weeks, then review
Management of mild acne that is mainly inflammatory papules and pustules, with some comedones?
Benzoyl peroxide + Clindamycin 5% + 1% Gel topically, daily for six weeks then review
What is the management of mild acne that is a mix of both comedonal an inflammatory papules and pustules?
Tretinoin + clindamycin 0.025% + 1% gel topically, daily at night for six weeks
What counselling points would you discuss when starting a patient on topical retinoids?
- Introduce gradually because it can irritate the skin initially
- Apply every second night (after washing with a low irritant, ph balance, soap free cleanser) for the first two weeks, then apply every night
- Apply the product to the whole area affected by acne, not just to single lesions
- Remove the product by washing the face in the morning because topical retinoids can increase the skin sensitivity to sunlight
- Choose a cream formulation for patients with dry or sensitive skin, and gel formulation for those with oily skin
What is the management for facial, flexural and scrotal seborrheic dermatitis?
- Use a low irritant skin cleanser
- Hydrocortisone+clotrimazole 1%+1% cream topically, once or twice daily until the skin is clear or for two weeks
- Facial seborrheic dermatitis: wash hair often with an anti yeast shampoo to reduce the yeast burden on the scalp (should contain ketoconazole, selenium sulfide, zinc pyrithione or coal tar)
What’s the difference between the butterfly rash of facial seborrheic dermatitis versus systemic lupus erythematosus?
- Both are associated with erythema and scaling
- Facial seborrhoeic dermatitis: fix the medial aspect of cheeks, the nose and the nasal labial folds
- SLE: The rash usually spares the nasolabial folds
What are reasonable investigations to order in an elderly patient with pruritus without a rash?
- Full blood count
- Renal function and electrolytes
- Liver function
- Fasting glucose
- Thyroid function studies
Management of generalised itch?
- Wet dressings or Quick, cool showers (<2-3 minutes)
- Soap-free substitutes in the shower
- Patting dry skin (hence avoiding vigorous rubbing)
- Liberal use of emolllients on damp skin, after the shower (preferably out of the tub or jar rather than a pump)
- Avoiding excessive heating in winter
- Using a humidifier if possible to enhance ambient indoor humidity, especially in try, cold winter months
- Avoiding use of electric blankets in bed
- Minimising direct contact with woollen and synthetic garments
- Keeping fingernails trimmed short to minimise complications from scratching
- Calamine lotion (contains phenol, which cools the skin) - avoid on dry skin and limit to only a few days
- Topical treatments include antipruritic such as methol 1% in aqueous cream
- Trial antihistamines if predominantly urticarial symptoms
Differentials for itch without rash?
Skin pathology
* Xerosis (dry skin)
* Scabies
* Dermographism
* Urticaria not apparent at time of examination
Nerve compression or neuropathy
* Notalgia paresthetica
* Meralgia paresthetica
* Brachioradial pruritus
* Vulvodynia
Systemic conditions
* End stage kidney disease
* Cholestasis
* Pregnancy
* Thyroid dysfunction
* Iron deficiency
* Coeliac disease
* Intestinal parasitic infections Eg strongyloidiasis (roundworm)
Adverse effects of drugs and topical irritants
* Opioids
* NSAIDs
* Statins
* Angiotensin converting enzyme inhibitors
* Diuretics
* Recreational drugs Eg methamphetamine
* Soaps, detergents, chlorine and other irritants
Malignancy and haematological disease
* Lymphoma, particularly hodgkin’s disease
* Leukaemia
* Polycythemia rubra vera
* Multiple myeloma
* Disseminated carcinoma
Neurological disorders
* Multiple sclerosis
* Brain tumour, abscess, infarct
* Parkinson disease
Psychological and psychiatric conditions
* Stress
* Anxiety
* Depression
* Phobic disorders eg delusional parasitosis
* Obsessive compulsive disorder
* Hypochondriasis
Management of rash caused by dermographism?
Oral antihistamine
Pharmacological management of each without rash in these settings?:
1) Itch without rash on trunk or limbs?
2) Itch without rash on face?
3) Itch without rash persisting despite improving skin consition, topical corticosteroid therapy and trial of oral antihistamine?
1) Itch without rash on trunk or limbs?
* Betamethasone valerate 0.02% cream topically, twice daily for two weeks
2) Itch without rash on face?
* Hydrocortisone 1% cream topically, twice daily for two weeks
3) Itch without rash persisting despite improving skin consition, topical corticosteroid therapy and trial of oral antihistamine?
* Doxepin 10 to 20 mg (adult only) PO, daily at night for 2 weeks - do not mix with a sedating antihistamine because this may result in increased adverse effects eg anticholinergic effects, sedation
What are the indications for acyclovir in the setting of chickenpox?
- Premature neonates
- Neonates less than 7 days of age
- Immunocompromised children
- Children with systemic or central nervous system disease
- Unvaccinated child age > 12 years
- Severe eczema
- Chronic pulmonary disease
- Children on salicylate therapy
- Children on oral steroid therapy
- Secondary cases in household contacts, as these are usually more severe
What is the management for contacts of chickenpox?
- Age 1 month - 1 year: if not at risk of complications, observation. If at risk, consider VZIG
- Age > 1 year: if within 5 days of exposure and no contraindications to vaccine, give VZV vaccine
What is the vaccination course for chickenpox?
- Children <14 years are recommended to receive two doses of varicella containing vaccine (4 or more weeks apart)
- Usually, the first dose is given at 18 months of age as the MMRV vaccine
- But, children can receive varicella-containing vaccine from as young as 12 months of age (incase they are a contact)
- Note: MMRV vaccine is not recommended as the 1st dose of MMR-containing vaccine in children < 4 years due to the small but increased risk of fever
What is the cause of slapped cheek rash (5th disease)?
Parvovirus B19
Signs and symptoms of slapped cheek (5th disease)?
- Prodrome: fever, headache, stomach upsets, aches and pains
- Bright red rash appears on the cheeks after a few days
- Secondary pink lace pattern rash may appear on chest, back, arms and legs
- The rashes can come and go for several weeks, or even months, especially if the skin is exposed to sunlight or after exercise
How long is Slapped Cheek (5th disease) contagious for?
- Infectious period: until 24 hours after the fever has resolved - non-infectious after this period even while having a rash
What is hairy tongue? What are its clinical features? What may cause it?
- It is a harmless condition characterised by a hairy enlargement and discoloration of the filiform papillae of the tongue
- Coloured, usually brown or black, although brown, yellow and green have also been described
- Usually asymptomatic in the main problem is it’s unsightly appearance
- Hairy tongue is due to defective shedding of surface cells
- Potential causes: chlorhexidine mouthwash, after a course of antibiotics or in patients who have limited oral intake
What is the management of hairy tongue?
It is usually self-limiting but treatment options include:
* Avoiding smoking and excessive alcohol intake
* Discontinuing responsible drugs
* Encouraging good oral hygiene
* Gentle tongue debridment, with a tongue scraper or soft toothbrush and solution containing 3% hydrogen peroxide Or baking soda
* Antiseptic mouthwash
* Topical antifungal if candida albicans is present
* Topical retinoid
What is a fixed drug eruption?
- Fixed drug eruption is a distinctive cutaneous allergic reaction that characteristically recurs at the same site on re-exposure
- It is usually due to oral medications, most commonly with antimicrobials and non-steroidal anti inflammatory drugs
What are the clinical features are fixed drug eruption?
Categories based on clinical morphology:
* Localised pigmenting type
* Bullous (localised or generalised)
* Non-pigmenting
* Generalised
- Drug eruption typically presents as a single (or small number of) well defined, round or oval red or violaceous patch or plaque which may blister or ulcerate
- It is usually asymptomatic but can be itchy or painful
- Over days and weeks, the surface may become scaly or crusted before peeling, and the colour fades to leave brown post inflammatory hyperpigmentation
- The patient remains systemically well
- Common sites: Hands and feet, eyelids, and anogenital areas
- On the 1st occasion, eruption may develop after weeks to years of regular ingestion of the drug, but subsequent episodes develope within minutes to hours of recommencing the implicated drug
- With subsequent episodes, the original patch may enlarge and more patches may appear
- The post inflammatory pigmentation darkens with each recurrence
What is the treatment for fixed drug eruption?
- Discontinuation of suspected medication
- Avoiding implicated medication indefinitely
- Topical steroids or systemic corticosteroids
- Generalised bullous fixed drug eruption requires intensive care or burns unit
What is neonatal cephalic pustulosis (AKA neonatal acne)?
- It is a common transient eruption in infants age three to six weeks
- It’s caused by a temporary overgrowth of malassezia species (fungi)
- Appearance: Tiny monomorphic pusutles, often on an erythematous base
What is the difference between neonatal cephalic pustulosis versus infantile acne?
- Although there are tiny monomorphic pustules, often with an erythematous base, neonatal cephalic pustulosis does not have comedones (i.e. blackheads and whiteheads), whereas infantile acne does
- Neonatal cephalic pustulosis is also limited to the face
- Neonatal cephalic pustulosis presents much earlier at 3-6 weeks whereas infantile acne presents 6-16 months
What is the treatment of neonatal cephalic pustulosis?
Resolves in a few weeks without treatment, however responds quickly to a topical imidazole
Options:
* Clotrimazole 1% cream topically, twice daily
* Ketoconazole 2% cream topically, twice daily
If lesions appear very inflamed or itchy, add:
* Hydrocortisone 1% cream topically, twice daily until skin is clear (usually 2-3 days)
What is granuloma annulare and its clinical features?
- Granuloma annulare is common inflammatory skin condition typified clinically by annular, smooth, discoloured papules and plaques, and necrobiotic granulomas on histology
- The surface is smooth and the centre of each ring is often a little depressed
- Localised granuloma annulare usually affects the fingers or the backs of both hands, but is also common on top of the foot or ankle, and over one or both elbows
How would you differentiate between granuloma annulare and other ovoid rashes?
There is a lack of surface scale compared to other scaly rashes such as discoid eczema or psoriasis or tinea
What is the management of granuloma annulare?
Lesions usually clear spontaneously, but may persist for months or years
Options - topical corticosteroid with or without occlusive dressings
* Betamethasone dipropionate 0.05% ointment topically, twice daily for a minimum of four to six weeks
* Mometasone furoate 0.1% ointment topically, twice daily for a minimum of four to six weeks
What is the management of onychomycosis?
- First line: terbinafine 250mg orally, once daily until clinical clearance
- Measure liver function test at baseline and at 4-6 weeks (but earlier at two weeks in high risk patients or if clinically indicated)
- Review after 3 months of treatment (note: most nails with extensive onychomycosis still look abnormal after 3 months of treatment because a new nail takes 9-12 months to grow)
- Make a scratch with a scalpel blade at the proximal end of the dystrophy after three months of treatment so the patient can follow the scratches the nail grows out
What are the clinical features of flexural psoriasis?
- Shiny and smooth due to the moist nature of the skin folds - therefore it is different to the usual silvery scale of plaque psoriasis
- There may be a crack or fissure in the depth of the skin crease
- The deep red colour and well defined borders characteristic of psoriasis may still be obvious
How can you differentiate between flexural psoriasis and seborrheic dermatitis in skin folds?
Seborrheic dermatitis in skin folds tends to present as thin salmon-pink patches that are less well defined than psoriasis
What is the management of flexural psoriasis, including genital psoriasis?
Initial: methylprednisolone aceponate 0.1% ointment or fatty ointment topically, daily until skin is clear (may take several weeks), but for no longer than two weeks in a child wearing nappies
* For a child who was still wearing nappies, add an anticandidal cream to the topical corticosteroid eg nystatin
Maintenance (when there is some rash but no excoriation or inflammation):
* LPC 2% in emulsifying ointment topically, daily
* For a child who was still wearing nappies, LPC can be formulated in zinc cream
What are some differentials for intertrigo (rash in the flexures)?
Flexural psoriasis - well defined, smooth or shiny red patches; symmetrical
Seborrheic dermatitis - ill-defined salmon pink thin patches
Atopic dermatitis - very itchy
Thrush - rapid development, itchy, moist, peeling, red and white skin
Erythrasma - Corynebacterium minutissimum; persistent brown patches
Tinea - slowly spreads over weeks to months; irregular annular plaques
Characteristics of rash: varicella?
- Affects: scalp, eyelids, knows, mouth
- Pleomorphism of rash
- Centripetal distribution - more focused on trunk
- Pruritic rash
