16 - Common Dermatological Conditions Flashcards
What are some of the different types of eczema?
DIFFERENT TYPES CAN CO-EXIST
Endogenous:
- Atopic dermatitis (children)
- Seborrhoeic (more so in adults)
- Varicose
- Discoid
Exogenous:
- Contact dermatitis
What is the pathophysiology of eczema?
- Chronic atopic condition
- Defects in the barrier that the skin provides so there is an entrance for irritants, microbes and allergens that create an immune response (exaggerated IgE response), resulting in inflammation
- Often genetic due to inheritance of FLG (fillagrin) gene that is a protein needed for the skin barrier
How does atopic eczema typically present and what is the disease pattern?
- Relapsing and remitting in infants
- Scaly, itchy, dry and erythematous patches commonly affecting the flexures. Can affect cheeks of infants and in black patients can affect extensors
- Excoriation and lichenification (thickening of skin)
- Areas of hypo/hyperpigmentation after rash
What are some differential diagnoses for atopic eczema?
- Psoriasis (not itchy)
- Seborrhoeic dermatitis
- Fungal infections
- Contact dermatitis
- Scabies
What are some risk factors for developing eczema?
- Family history of atopy
- Personal history of atopy (hayfever, asthma), food allergies or allergic conjunctivitis
How is atopic eczema different in Asian, Black Caribbean and Black African children?
- Often affects extensors rather than flexors
- Discoid and Follicular patterns more common
How is atopic eczema diagnosed?
Under 12s. Have itchy skin plus at least 3 of the following:
- Onset of symptoms was before 2 years old
- Past flexural symptoms
- History of dry skin in the last 12 months
- Personal or first degree family history of atopy
- Visible flexural dermatitis or on cheeks
What area does atopic eczema usually spare?
- Nappy area
- Most children grow out of this eczema by 13 years old
What is an important question to ask in the history when a patient has eczema?
- Is it affecting your sleep?
- How does it affect your life?
Always need to consider if they need a referral to a psychologist for their mental health
How is atopic dermatitis managed in general terms?
Advice to give:
- Identify and avoid triggers e.g soaps, hormones, pets, foods
- Discourage elimination diet
- Report any weeping/oozing rashes as could be eczema herpeticum
- Keep nails short to prevent scratching
Treatment:
- Emollients and Soap substitutes: as maintenance
- Topical corticosteroids: for flares
- Sedating antihistamine: for itch at night
- Oral antibiotics: if secondary infection
- Topical tacrolimus: if not controlled by above
- Systemic immunosuppressants: if severe e.g methotrexate, azathioprine
- Phototherapy: if severe
How would you advise a patient with eczema to use emollients?
- Need to be applying at least 3 times a day very liberally even when eczema not active as provides a barrier
- Use emollients as a soap substitute as normal soaps strip skins oils
- Best emollient is the one the patient likes the most
- Apply 30 minutes before application of steroid
- AVOID NAKED FLAMES DUE TO PARAFFIN CONTENTS
- Wet wrap when severe flare
What are the different preparations of emollient and what are some examples of each?
- Lotions (e.g. Dermol 500, E45): High water content. Spread easily and absorb quick. Not effective at moisturising very dry skin.
- Creams (e.g. Diprobase, Epaderm): Mixture of fat and water. Spread easily. Not as greasy so often preferred by patients
- Sprays (e.g. Emollin): Useful for hard to reach areas.
- Ointments (e.g. Diprobase, Epaderm): Contain minimal water making them thick and greasy. Patients may find them cosmetically displeasing. Very effective at holding water and repairing skin
What advice would you give to an eczema patient when prescribing them topical corticosteroids?
- Apply thin layer 30 minutes after emollient application
- Explain they are safe if used as prescribed
- Only use in active eczema/flares and only up to a week at a time
- 1 Fingertip is enough to cover two adult hands worth of skin
STEP UP AND DOWN DEPENDING ON RESPONSE TO EACH STEROID
What are some side effects of topical steroids?
- Burning sensation
- Thinning of skin
- Contact dermatitis
- Acne
- Depigmentation
What is the steroid ladder?
- Mildly potent: Hydrocortisone
- Moderately potent: Clobetasone (Eumovate)
- Potent: Betamethasone (Betnovate)
- Very potent: Clobetasol propionate (Dermovate)
If eczema is not controlled by emollients and potent topical steroids, what is the next option to try within dermatology?
Topical calcineurin inhibitors (stops activation of T-Lymphocytes) as steroid sparing agents
Tacrolimus: Used aged >2 if moderate-severe and topical corticosteroids have not controlled symptoms and there is a risk of adverse effects from further steroids
Pimecrolimus: Used aged >2 for same reasons as above but on face and/or neck
If topical calcineurin inhibitors are still not controlling eczema, what is the next stage of treatment?
- Phototherapy
- Oral immunosuppressants e.g Azathioprine, ciclosporin, or methotrexate
What are some complications of atopic eczema and what is the prognosis?
Complications:
- Secondary bacterial infections (crusting, oozing, weeping)
- Eczema herpeticum
- Secondary viral infections e.g molluscum
- Poor mental health
Prognosis:
- Tends to improve as child grows up and most grow out of it by 16
How is the presentation of seborrhoeic dermatitis different to atopic dermatitis?
Red, scaly rash affects scalp (dandruff), eyebrows, nasolabial folds, cheeks, and flexures
Due to overgrowth of fungus not atopy
Both can co-exist together
How is seborrhoeic dermatitis treated?
- Mild topical steroid/antifungal preparations, eg Daktacort
- Ketoconazole shampoo