Derm- hair, feet, nails, sweating

Question 1

General measures to manage “pompholyx eczema”

Vesicular hand/foot dermatitis presents as recurrent crops of deep-seated blisters on the palms and soles. They cause intense itch or a burning sensation. The blisters peel off and the skin then appears red, dry and has painful fissures (cracks).

Answer 1

Wet dressings to dry up blisters, using dilute potassium permanganate, aluminium acetate or acetic acid
Cold packs
Soothing emollient lotions and creams
Potent antiperspirants applied to palms and soles at night
Protective gloves should be worn for wet or dirty work
Well-fitting footwear, with 2 pairs of socks to absorb sweat and reduce friction

Question 2

Treatment for cracked heals

(6)

Answer 2

1. Advise patients to avoid soaps and irritants.
2. Advise patients to use a soap-free wash, and to frequently apply a greasy emollient.
3. Wearing closed footwear may help.
4. A cream containing urea 10 to 25%, or salicylic acid 3 to 6%, can be used for treatment.
5. For exfoliation, pumice stone can be used in the shower.
6. Seek podiatrist advice for symptom management, if needed

Question 3

What is this?

How do you treat it?
4 general measures

1 x medication option with full dosing

Answer 3

Pitted keratolysis

General measures
Foot hygiene: clean shoes, socks
Keeping foot dry
Wash regularly with an antiseptic wash
Antiperspirant on foot/feet

If general measures fail then
clindamycin 1% lotion topically, twice daily for 10 days.

Question 4

This condition relapses and remits spontaneously and occurs more so in children.

What is it

How do you manage the following situations?
1. Limited hair loss of recent onset
2. Extensive hair loss OR

Answer 4

Alopecia Areata
Autoimmune condition

1. Can use a potent topical steroid in lotion form
   betamethasone dipropionate 0.05% lotion topically, once or twice daily for 3 to 4 months
2. Refer to dermatology
   and / or discuss acceptance and psychology counselling and camouflage options.

Question 5

What is acute telogen effluvium ?

Answer 5

Excessive shedding of the hair after a stressful life event. (psychological, birth, surgery, crash diets/weight loss, new drugs, severe illness)

Acute version should resolve in 6 months

Question 6

What is Chronic telogen effuluvium?
What are the symptoms?

Answer 6

Excessive hair shedding over 9 months
Can have burning sensation and itching

Cause is idiopathic (spontaneous)

Can refer to derm if unsure
Try to identify trigger and remove
Drugs not usually needed
Some evidence of iron supplementation if iron deficent

Question 7

By the age of 70 years, approximately 80% of Caucasian males and 60% of Caucasian females are affected by this.

What is it?

Answer 7

Androgenetic Alopecia

Question 8

Advice to give patients about the therapy/management for Androgenetic Alopecia?

Answer 8

1. Set realistic expectations
2. Primary aim is to slow down hair loss
3. Secondary aim is to stimulate hair growth
4. Using photography is the best way to assess effectiveness
5. Effects are not immediate. Topical treatments take 3-6 months and oral take 6-12 monhs

Question 9

Treatment available for treating Androgenetic Alopecia?

Answer 9

minoxidil 5% foam 1 g (approximately half a capful) topically to the scalp to cover sparse areas, once or twice daily for at least 6 to 12 months

finasteride 1.25 mg (quarter of a 5 mg tablet) orally, once daily

for NON PREGNANT females
spironolactone 50 to 100 mg orally, once daily, increase to 200 mg daily if no benefit is apparent after 6 to 12 months.

Question 10

Other non medical treatments for androgenetic alopecia?

Answer 10

Evidence for laser treatments, commercially available hair tonics and nutritional supplements to treat hair loss is lacking.

Platelet-rich plasma injections are increasingly used to stimulate hair regrowth in selected patients; however, they are unregulated in Australia

Question 11

what is this?
And what is the cause?

Answer 11

Trichotillomania is an impulse control disorder characterised by compulsive hair pulling or plucking

WIth children, trichotillomania is usually a benign habit that resolves with age, but sometimes it is a response to stress at home or school. Parental help to curb this habit is often adequate, but referral to a child psychologist or psychiatrist may be indicated.

In adults it tends to be associated with a psychological disorder like anxiety / OCD

Question 12

What causes Scaring alopecia?

Answer 12

chronic cutaneous [discoid] lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, folliculitis decalvans

If suspected, refer to dermatologist

Question 13

How do you treat this?

Answer 13

terbinafine 250 mg (child less than 20 kg: 62.5 mg; child 20 to 40 kg: 125 mg) orally, once daily until clinical clearance

Question 14

After starting treatment for onychomyocosis when do you review and refer?

How can you assess continued improvement?

Answer 14

New nails take about 9-12 months to grow.
After 3 months the nail will still look abnormal

if at 3 months there is some proximal improvement i.e healthy nail, then continue treatment

However if there is no improvement then refer to derm.

To assess if treatment is still working, make a scratch with a scalpel blade at the proximal end of the dystrophy after 3 months of treatment. The patient can follow the scratch as the nail grows out. If the dystrophy stays distal to the scratch, continue treatment until clinical clearance. If the dystrophy moves proximal to the scratch, refer to a specialist.

Question 15

Management of an ingrown nail

1st line?

Answer 15

Is actually conservative

1. Avoid environmental factors i.e do not cut the nail to acheive a curve, wearing pointed toe or high heeled shoes, onychomyocosis, repeated trauma and oral retinoids
2. Cut the distal edge in a straight line
3. gently lift the nail edge out of the lateral nail fold. May need to file the distal nail down to make it thin. Pack moistened (in 70% alcohol) cotton wool under the nail to keep it elevated. Repack dailly.
4. Topical antiseptic if appearing infected povidone-iodine 10% ointment topically, under occlusion.

Question 16

what to do if an ingrown toenail

1. has granulation tissue
2. appears infected
3. appears inflammed and swollen

Answer 16

1. curettage, silver nitrate stick for light cautery or potent topical steroid
2. infection; treat as cellulitis. Dicloxacillin 500mg, orally, 6 hourly for 5 days
3. Potent topical steroid like betamethasone dipropionate 0.05% ointment topically, once daily for 3 to 5 days

Question 17

what is acute paronychia?

Answer 17

infection AROUND the finger or toenail

Usually caused by staph. aureus

Question 18

how do you treat this?

Answer 18

acute paronychia

drain pus if visible

if no pus or doesn’t respond to drainage then take a swab and treat as for cellulitis
Dicloxacillin or
clindamycin 450 mg (child 1 month or older: 10 mg/kg up to 450 mg) orally, 8-hourly for 5 days if immediate or severe hypersensitivity

Question 19

what is characteristic of chronic paronychia?

Answer 19

loss of the cuticle
if cuticle is intact consider a different diagnosis.

The waterproofing of the nail is diminished.

Nail dystrophy occurs gradually

Question 20

General advise to treat chronic paronychia?

Answer 20

It can take about 6 weeks for the cuticle to regrow.

avoid pushing back cuticles or manicuring nails
avoid picking at cuticles
avoid inserting objects beneath cuticles to remove debris
keep hands out of water, and wear cotton-lined rubber gloves when washing dishes or doing other wet work
dry hands and nails well after any water or moisture exposure
wear gloves when gardening or exposed to the cold
use a mild soap-free wash
manage any underlying chronic dermatoses

Question 21

medical treatment for chronic paronychia

Answer 21

1 potent topical steroid

2. when the area is not inflamed use
   white soft paraffin topically, 5 to 10 times daily. TO help protect and waterproof the area

Question 22

what is onychoysis?

Answer 22

simple seperation of the nail from the nail bed.

Is not an infection or fungal infection like onychomycosis.

Though sometimes there is a candida colonisation/infection that can be treated.

Question 23

Miliaria is obstruction of the sweat glands.

There are three main types depending on the layer obstructed.
Crystallina - stratum corneum
Rubra - INTRA epidermal obstruction
Profunda- obstruction at dermal-epidermal layer

What is the management?

Answer 23

Prevent sweating
Remove plastic mattresses or mattress protectors on beds, and use a sheepskin underlay and cotton sheets. Wear light breathable clothing and use air-conditioning.

Calamine lotion for itch
Sometimes a mild topical steroid

If the patient continues to sweat, the condition is likely to recur for a few days at a time over several months until the patient becomes acclimatised.

Question 24

Primary Hyperhidrosis affects 1-3% of the population

What is first line management?

What is second line?

Third line?

Answer 24

First
aluminum chlorohydrate as antiperspirant spray or roll-on device topically, once daily in the morning. Available in supermarkets.

Second:
iontophoresis with tap water (cannot use if there is a pacemaker)
Hands and feet are placed on moistened pads in the iontophoresis unit for 15 to 20 minutes.These units can be expensive

Third
Refer to dermatology for
a. sympathetectomy
b. Botulinium toxin injection

Question 25

A 45 year old man living in Darwin, presents with this rash.

He has a history of having dry skin.

What is this rash?
How can he manage this?

Answer 25

A. Grover Disease

B. Take practical measures to reduce heat and sweating

Use an emollient for dry skin

Can use a moderate potency topical steroid for the rash.
triamcinolone acetonide 0.02% cream topically, twice daily for 2 to 6 weeks.

Question 26

What are risk factors for Hidradenitis Supurativa?

Answer 26

Female
ages 20-40
Obesity
Dyslipidemia
Insulin Resistance
Family history
African descent
Inflammatory Bowel Disease

Question 27

what is this?

Answer 27

Hidradenitis Suppurativa

Question 28

General measures to treat this?

Answer 28

Hidradenitis Suppurativa

Wear loss clothing
Lose weight
Stop smoking
Use absorbent dressings
Analgesia
Manage any anxiety and depression

Question 29

Medical treatment for Hidradenitis Suppurativa.

Starting with benzoyl peroxide wash 5%
then?

Answer 29

Second line
Clindamycin 1% applied topically, twice daily for 3 months

Third line
Doxycycline 50 to 100 mg orally, once daily for 6 weeks, then review

Fourth + adjuvant
Refer to Derm
Can whilst waiting for derm or even adjunctivally add Metformin MR 500mg daily at night , taken orally with food

Females can have spironolactone or COPC

Question 30

what is this?

Answer 30

Pearly penile papules are asymptomatic, skin-coloured and dome-shaped.

no treatment needed

Question 31

What is the main difference between prepubertal and adult balantoposthitis?

Answer 31

firstly
Balanitis is inflammation of the glans penis alone
and posthitis is inflammation of the foreskin alone hence balantoposthitis is inflammation of both

In prepubertal males the cause is likely dermatitis (skin inflammation) mainly irritant contact dermatitis.

In adults it is usually due to dermatosis (in this case not inflammatory skin conditions) such as psoriasis or lichen sclerosis.

Question 32

How to treat prepubertal balantophosthitis?

vs adults

Answer 32

Gentle washing with a soap substitute
Soak area in warm salty water
Using a bland emollient (paraffin)
Oral analgesia

If candida is suspected, treat as for nappy rash
hydrocortisone 1% + clotrimazole 1% cream topically both twice daily until resolved.

Adult treatment usually involves referral to a dermatologist

Question 33

What is pruritis Ani?

What exacerbates this
what can it lead to?

Answer 33

itching of perianal skin

Usually stress exacerbates symptoms
Can be caused with dermatosis (lichen planus, psoriasis, lichen sclerosus)
Persistent scratching can cause lichenified skin

Question 34

Differential for pruritis Ani?

Answer 34

Anal pathology (eg anal fissure, anal skin tags, haemorrhoids, fistulas, warts)

Crohn disease,

perianal intraepithelial neoplasia,

extramammary paget disease (rare)

worms (eg threadworms) and perianal streptococcal dermatitis, in children

tinea.

Question 35

General management for Pruritis Ani?

Answer 35

Wear lose clothing/underwear
Use a soap substitute
Clean the perianal area with moistened cotton wool
Apply greasy emollient as a barrier
Use bulk forming laxatives for a bulkier stool

Question 36

If general measures fail to resolve Pruritis Ani, what can be used?

Answer 36

methylprednisolone aceponate (adult, or child 4 months or older) 0.1% fatty ointment topically, once daily, until skin is clear and itch has resolved, or for up to 4 weeks

if skin is lichenified use a potent topical steroid

Question 37

Treating a lichenified Anal area.

Answer 37

1. betamethasone dipropionate 0.05% ointment topically, once daily until skin is clear and itch has resolved
2. afterwards methylprednisolone aceponate (adult, or child 4 months or older) 0.1% fatty ointment topically, once daily for 4 weeks, to prevent recurrence.
3. When the soreness and itch have resolved, use a greasy emollient (eg white soft paraffin) as a barrier indefinitely.
4. if itch reoccurs (without lichenification) then If the condition recurs, repeat treatment with topical methylprednisolone aceponate 0.1% fatty ointment until symptoms resolve