Dermatology Flashcards
Which conditions are associated with chronic spontaneous urticaria in children?
- Nutritional deficiency (iron and vitamin D)
- Coeliac disease
- Thyroid disease
- Systemic lupus erythematosus
- Other autoimmune diseases
What does the image show and how should it be treated?
- Rosacea
- avoid any lifestyle or trigger factors (sunlight, warmth, spicy foods)
- topical brimonidine OD PRN for redness
- mild-moderate papules/pustules: topical ivermectin OD for 8-12 weeks. Alternatives: topical metronidazole or azelaic acid BD.
- if not responding/moderate-severe papules/pustules: topical therapy + oral doxycycline MR OD for 8-12 weeks or erythromycin (pregnant/breast feeding). If little/no improvement - refer derm. Specialist: oral isotretinoin, laser therapy.
- refer pts with Rhinophyma
Which topical corticosteroids are available and what are their potencies?
- Mildly potent — hydrocortisone 0.1%, 0.5%, 1.0%, and 2.5%.
- **Moderately **potent — betamethasone valerate 0.025% (Betnovate-RD®) and clobetasone butyrate 0.05% (Eumovate®).
- **Potent **— betamethasone valerate 0.1% (Betnovate®) and betamethasone dipropionate 0.05% (Diprosone®).Mometasone (Elocon)
- **Very potent **— clobetasol propionate 0.05% (Dermovate®) and diflucortolone valerate 0.3% (Nerisone Forte®)
Which topical corticosteroid should be prescribed for eczema of the face, genitals, axillae?
- hydrocortisone 1% - in children and adults.
Only increase to moderate potency if necessary for max 5 days then refer if insufficient. e.g. betamethasone valerate 0.025% (Betnovate-RD) or clobetasone butyrate 0.05% (Eumovate)
Hydrocortisone = Head
Which topical corticosteroid should be prescribed for eczema of the body?
- Child trunk and limbs: moderate potency e.g. clobetasone butyrate 0.05% (Eumovate®) or betamethasone valerate 0.025% (Betnovate-RD®)
- Adult trunk and limbs: **potent **e.g. betamethasone valerate 0.1%, (Betnovate®) mometasone (Elocon®)
For mild eczema — prescribe a mildly potent topical corticosteroid.
For moderate eczema — prescribe a moderately potent corticosteroid.
For severe eczema — prescribe a potent topical corticosteroid.
Potent corticosteroids should not be used in children under 12 months old.
Very potent corticosteroids should not be used in children of any age, without specialist dermatological advice.
**Very potent **topical corticosteroids should usually only be prescribed by specialists. Clobetasol propionate 0.05% (Dermovate®) and diflucortolone valerate 0.3% (Nerisone Forte®) - may be needed for Palms and soles.
Betamethasone =** B**ody
What can be used for sleep disturbance in children during an eczema flare?
- sedating antihistamine e.g. Chlorphenamine
How often should topical corticosteroid be applied for flares and for maintenance in eczema?
- Flares: no more than twice a day. Continue treatment for 48 hours after the eczema has cleared (if it has not improved after 2 weeks, the person should return for further advice).
- Maintenance of chronic eczema: **weekend therapy **(usual steroid to be used once a day on two days per week). Continue indefinitely (occasional drug holiday advised). If it is the face/genitals/axiallae - mild corticosteroid - if insufficient - refer.
When should topical immunomodulators be considered (prescribed by specialist or GPSI)?
- licensed for children aged 2 and over
- second line for moderate to severe eczema
- Eczema involving the eyelids and peri-orbital skin
- Patients regularly using topical steroids on the face
- Patients regularly using topical steroids on the lower legs in elderly patients and others at risk of leg ulcers
- Any signs of skin atrophy
Should not be used under bandages or dressings.
Avoid direct sunlight, use suncream.
Should not be applied to skin which appears actively infected.
How often should emollients be used, how should they be used, and how much should be prescribed?
- 500g/week
- applied 4 times a day
- pump dispenser if possible
- AVOID aqueous cream - SLS irritants
- Ointments have no preservatives - less reactions
- No evidence for bath additives
- Use emollient before getting into bath as soap substitute. Pat skin dry and apply emollient after.
- Avoid soaps, shampoo, bubble bath (wash hair over sink/at end of bath over the bath - don’t bathe in shampoo)
- Apply steroid 15-30 mins after emollient
- Smooth down in direction of hair growth, no rubbing
- FIRE RISK! Do not smoke or go near naked flames.
How should scalp eczema be treated?
- Children 18 months and under use an emollient bath oil to wash the hair rather than using a specific scalp treatment.
- Use mild tar based shampoo.
- Use water based topical steroid scalp application, e.g. Betacap® OD-BD to eczematous areas until settled.
- If a lot of thick scale is present, before commencing topical steroids, remove the scale with Sebco® ointment.
What does the photo show and how should it be managed?
- eczema herpeticum (extensive eruption of herpes simplex infection)
- most due due to herpes simplex virus types 1 or 2
- Emergency admission - needs systemic aciclovir
- Secondary bacterial infection with staphylococci or streptococci may lead to impetigo and / or cellulitis
.
When should patients presenting with seborrhoeic dermatitis (eczema) be tested for HIV?
- Seborrhoeic dermatitis in areas that are atypical, or is more widespread
- Seborrhoeic dermatitis does not respond to treatment - no or minimal response.
Typical distribution:
* Affects areas rich in sebaceous glands
* Scalp and behind the ears. More extensive involvement of the ears with otitis externa may occur
* Face - medial eyebrows (can be associated with chronic blepharitis), glabella and nasolabial folds. Areas under spectacles or hearing aids may be involved
* Upper trunk - presternal and interscapular regions
* Flexures - axillae, groins, umbilicus, anogenital and submammary regions
What does the image show?
Red, sharply marginated macules / patches covered with greasy-looking yellowish scales
= seborrhoeic dermatitis.
What is the treatment for seborrhoeic dermatitis?
For scalp:
* ketoconazole 2% shampoo - 2-4x per week then once every 2 weeks for maintenance. (leave for 5 mins before washing off)
* For itch & erythema - short course topical steroid scalp mousse (betamethasone valerate 0.1% or mometasone furoate 0.1%)
* For scale and crusts on scalp - olive oil if mild. Sebco ointment massaged & left for 4 hours for thicker scale.
For body & face:
* ketoconazole 2% cream (once or twice a day) or another imidazole cream (clotrimazole or miconazole) for up to 4 weeks. Antifungal shampoo ketoconazole 2% can be used as body wash. Cream once a week/every other week for maintenance.
* Mild-moderate potency topical steroid (up to 2 weeks)
For children >1 year:
* For scalp: ketoconazole 2% shampoo and topical steroids as above
* For body & face: clotrimazole or miconazole cream (ketoconazole cream not licensed). Low-moderate potency topical steroid.
Infants: ‘cradle cap’ - topical emollient massage. Topical clotrimazole or miconazole. Consider low potenct topical steroid if no response.
Nappy area - bathe daily with emollient. Topical antifungal & consider topical steroid.
What are the causes of non-scarring hair loss? Both focal and diffuse:
- Non scarring means the hair follicle is not destroyed - regrowth is possible.
- Surgery, childbirth, fever, sudden weight loss, acute stressor event - can trigger acute diffuse hair loss (telogen effluvium)
- Chemotherapy causes acute hair loss of growing hairs (anagen effluvium).
- Other drugs cause gradual telogen effluvium: TCAs, fluoxetine, isoniazid, lithium, allopurinol, beta blockers (propranolol), nitrofurantoin, retinoids, valproate, warfarin.
What are the causes of scarring hair loss?
Early referral to derm needed - scarring causes irreversible hair loss.
What is alopecia areata, alopecia totalis and alopecia universalis.?
- chronic likely autoimmune inflammatory disease that affects the hair follicle causing patchy non-scarring hair loss on the scalp.
- 20% have family Hx. Occurs in all ethnicities, both sexes.
- Assoc with asthma, rhinitis, eczema, T1DM
- Occurs at all ages - peaks in childhood & adolescence
- Alopecia areata = patchy non-scarring hair loss on the scalp. Short broken hairs (exclamation mark hairs) are often seen around the margins of active expanding patches of alopecia.
- Total loss of scalp hair = alopecia totalis
- Loss of entire scalp and body hair = alopecia universalis.
How should alopecia areata be managed?
- Evidence of hair regrowth - no treatment needed
- No hair regrowth, limited amount affected, stable, no distress - watchful waiting. Spontaneous regrowth occurs after in 80% of people with single small patch (occurs after 3 months, can take years). Extensive hair loss/childhood onset - much less likely to regrow.
- No hair regrowth & wants to treat: trial potent or very potent topical steroid - betamethasone valerate 0.1% for 3 months (not on beard/eyebrows). Refer to paeds dermatologist before starting in children.
- Offer referral to dermatologist if patient wishes to consider medical treatment. Options: intralesional cotricosteroids, oral steroids, biological agents, wigs.
What is telogen effluvium?
- Diffuse hair loss occurring evenly across the scalp.
- Acute telogen effluvium: About 3 months after a significant event (physical or psychological stress): Acute illness with fever, pregnancy and childbirth, major surgery, rapid weight loss.
- Bi-temporal recession is a common sign in women.
- Hair loss lasts for 3–6 months and then the hair regrows. (as long as trigger resolved)
- Gradual telogen effluvium: hair loss can occur as a result of stress, medications, thyroid disorders, iron deficiency anaemia, and malnutrition, but often no cause is found.
- Chronic telogen effluvium - idiopathic hair loss in middle aged women. Shortened hair cycle- does not progress to baldness. Appearance of normal head of hair. Hair falls out during combing.
- Scalp appears healthy - normal dermatoscope appearance.
- Check for underlying cause in all cases: FBC, ferritin, TSH
- Hair regrowth is expected if underlying cause is treated.
What are the causes of acanthosis nigricans?
- symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin.
- T2DM
- Obesity
- PCOS
- Acromegaly
- Cushings disease
- Hypothyroidism
- GI cancer
- Familial
- Prader-willi syndrome
- COCP, nicotinic acid
How is acne graded into mild, moderate and severe?
- Mild acne — predominantly non-inflamed lesions (open and closed comedones) with few inflammatory lesions.
- Moderate acne — more widespread with an increased number of inflammatory papules and pustules.
- Severe acne — widespread inflammatory papules, pustules and nodules or cysts. Scarring may be present.
What is the first line treatment for mild-moderate acne?
A 12-week course of topical combination therapy:
* a fixed combination of topical adapalene with topical benzoyl peroxide
* a fixed combination of topical tretinoin with topical clindamycin
* a fixed combination of topical benzoyl peroxide with topical clindamycin
What is the first line treatment for moderate to severe acne?
A 12-week course of one of the following first-line options:
* a fixed combination of topical adapalene with topical benzoyl peroxide
* a fixed combination of topical tretinoin with topical clindamycin
* a fixed combination of topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline
* a topical azelaic acid + either oral lymecycline or oral doxycycline
- COCP is an alternative to oral ABX in women.
- 3rd or 4th generation
- Co-cyprindiol (Dianette®) or other ethinylestradiol/cyproterone acetate products may be considered where other treatments have failed - stop after acne controlled for 3 months.
When should patients with acne be referred to dermatology?
- acne fulminans - urgent same day referral to hospital derm team
- diagnostic uncertainty
- acne conglobata - urgent referral
- nodulo-cystic acne
- Mild to moderate acne has not responded to two completed courses of treatment.
- Moderate to severe acne has not responded to previous treatment that includes an oral antibiotic.
- They have acne with scarring.
- They have acne with persistent pigmentary changes.
- Their acne of any severity, or acne-related scarring, is causing/contributing to persistent psychological distress or a mental health disorder. (AND consider referral to mental health services if Hx suicidal ideation/self harm/severe depression or anxiety/body dysmorphic disorder)
How should a person starting oral isotretinoin be counselled? What monitoring is required?
- explain side effects of worsening mental health and sexual dysfunction
- 2 independent prescribers must agree to initiate in under 18s
- Can cause serious malformations to unborn fetus - must not get pregnant until 1 month after it is stopped.
- Must be in a pregnancy prevention programme. Pregnancy test every month. User-independent contraception: IUD, implant, or two user-dependent: oral contraceptive +condoms.
- Will need to agree to an acknowledgment of risk form.
- Derm and GP review 1 month after starting: check mental health and sexual funciton (E.D and decreased libido)
- Need baseline LFTs and lipids, at 1 month, then every 3 months. Stop if AST/ALT or lipids persistently raised.
What does this image show? What are the clinical features? How is it managed?
- Bullous pemphigoid is an autoimmune condition causing sub-epidermal blistering of the skin. This is secondary to the development of antibodies against hemidesmosomal proteins
- more common in elderly patients.
- Features include:
- itchy, tense blisters typically around flexures
- the blisters usually heal without scarring
- there is stereotypically no mucosal involvement (i.e. the mouth is spared)
- Patients otherwise appear well.
- Refer derm urgently for biopsy & confirmation of Dx - oral steroids and topical steroids, ABX, immunosuppresants used.
What does the image show? What are the clinical features? How is it managed?
- Pemphigus vulgaris - a rare autoimmune bullous condition.
- most common aged 50-60 but can affect any age
- More common in East than West - especially Ashkenazi Jewish heritage
- vast majority of patients have mucosal lesions, and the mouth is the most common site of presentation
- Bullae are rarely seen
- ill-defined, painful erosions mainly involving the lips, buccal mucosa and palate, which are slow to heal. Lesions on the border of the soft and hard palate are almost pathognomonic
- flaccid blister filled with clear fluid arises on healthy skin or on an erythematous base. Painful, not itchy.
- Blisters are fragile and may rupture, producing painful erosions (the most common skin presentation).
- Lesions heal without scarring
- Urgent Derm referral - oral &topical steroids.
What does the image show? What are the clinical features? How is it managed?
- Porphyria cutanea tarda (PCT) - commonest of all porphyrias
- due to deficiency of liver enzyme - accumulation of porphyrins.
- Mostly acquired - due to liver disease. 25% are due to familial enzyme deficiency (hereditary)
- Symptoms occur due to reaction between porphyrins in the skin and UV light - causes cell damage.
- Skin fragility and blisters on the backs of hands and sometimes bald areas of the scalp. Lesions heal slowly and often leave scars.
- Milia and areas of hyperpigmentation may develop.
- Mild cases - only shedding of the skin over the backs of the hands without blisters.
- Refer derm. Liver screen- Ix cause: haemochromatosis/hepatitic C/alcohol/oestrogens. Hydroxycholoroquine first line.
What does the image show? What are the clinical features? How is it managed?
- (Early) Stevens-Johnson syndrome/Toxic epidermal necrolysis
- Rare serious skin reaction - normally caused by medications
- most common drugs: allopurinol, Sulfa ABX, anticonvulsants, oxicam NSAIDs e.g meloxicam
- Painful / tender erythema with local erosions and blisters - quickly progresses to areas of confluent erythema with sheet-like skin loss
- Mucosal involvement
- Emergency dermatology admission - ITU/burns unit. Stop offending drug.
What does the image show? What are the risk factors? How is it managed?
- Hidradenitis suppurativa
- Chronic follicular occlusive disorder - affects apocrine glands in the axillary, groin, perianal, perineal, and inframammary skin (intertriginous areas).
- Suspect in pubertal or post-pubertal patients who have a diagnosis of recurrent furuncles/boils/abscesses, especially in intertriginous areas.
Risk factors: - heat/sweat/friction - obesity, T2DM
- hormones- women, PCOS
- smoking
- genetics
- stress
- assoc with inflammatory arthritis (esp. axial)
- assoc with IBD
Mx: Aim to treat early. R/V CVS risk Fx - check lipids, HbA1c, BMI, BP, GI/joint syx, mental health.
Acute flares: oral/intralesional steroids. OR AB- flucloxacillin if appears infected. Refer for I&D if tense fluctuant infective abscess/sepsis.
Long term: topical antiseptics
Mild: topical clindamycin / oral doxycycline or lymecycline
Second line: refer derm, consider oral rifampicin and clindamycin.
Refer derm also: severe disease (hurley3), mental impact, scarring, pregnancy.
What does the image show? How is it managed?
pityriasis rosea
A herald patch precedes the main rash by a few days. It is larger than subsequent lesions, usually 2 to 5 cm in diameter, bright-red with fine scale and a sharply demarcated border
self-limiting - unknown cause.
Common in young adults.
Resolves in 6-12 weeks
Emollient / topical steroid if itchy
What does the image show? How is it managed?
Pityriasis versicolor - also called tinea versicolor, is a superficial cutaneous fungal infection
- most commonly affects trunk
- patches may be hypopigmented, pink or brown (hence versicolor). May be more noticeable following a suntan
- scale is common
- mild pruritus
If extensive area: ketoconazole shampoo - OD for 5 days (age >12)
Clotrimazole cream if small areas
Discuss/refer children with derm (less Rdx options)/ topical treatment not resolved it.
* In widespread or resistant cases add in itraconazole 200 mg daily for seven days
* Inform the patient that once the yeast has been eradicated the scale will disappear, however, warn patients that it will take several months for the skin colour to return to its original state. On occasions the discoloration can be very persistent
What does the image show? How is it managed?
- lichen planus
- lichen refers to small bumps on the skin and ‘planus’ means flat, together they refer to the characteristic flat topped papules of lichen planus (LP)
- very itchy
- Most commonly found on the flexural aspects of the wrists, the ankles and the lumbar region. Also the mouth and vulva. Rarely mucosal lesions can lead to SCC.
- Potent / super-potent topical steroids eg 0.1% Betnovate ® cream or Dermovate ® cream once a day, sometimes for several weeks. Benzydamine (Difflam) mouthwash - topical analgesia. Betamethasone gargle (tablet dissolved in water). Refer 2ry care if not responded/unclear Dx.
What does the image show? How is it treated?
- lichen simplex = an eczematous condition characterised by a small number of pruritic, heavily lichenified plaques or, very often, a single lesion.
Itch is very intense.
- address triggers/stress
- regular emollients, sedating antihistamine
- potent/very potent topical steroid - 1-2 weeks - break itch/scratch cycle. Gradually reducing strength and frequency over a few months.
What does the image show? What are the epidemiological and clinical features?
- Chronic plaque psoriasis.
- Psoriasis = chronic inflammatory proliferative skin disorder (autoimmune)
- sharply demarcated, dull-red, scaly plaques, particularly on the extensor prominences and in the scalp.
- Genetic component: 50% have FHx.
- two peaks in incidence — between 20–30 and 50–60 years of age.
- triggers: stress, alcohol, smoking (risk for palmoplantar pustulosis), trauma, streptococcal (throat- triggers guttate psoriasis), HIV, drugs (lithium, antimalarials, NSAIDS, ACEI, terbinafine, beta blockers, improves in pregnancy - worse post partum, sunlight beneficial.
- asymptomatic, some have itch.
- 30% have psoriatic arthritis.
- Nail pitting, oncycholysis
- increased: metabolic syndrome, CVS disease, VTE, non melanoma skin cancer, lymphoma, eye disease, coeliacs.
What are the 2ww criteria for melanoma?
- a suspicious pigmented skin lesion with a weighted 7‑point checklist score of 3 or more
- dermoscopy suggests melanoma of the skin
- pigmented or non‑pigmented skin lesion that suggests nodular melanoma
- nail changes, such as a new pigmented line in the nail (especially if there is associated damage to the nail), or a lesion growing under the nail.
What does the image show? What are the clinical features?
- older patient, unless immunosuppressed/genetic condition (males>females)
- start de novo or from AK/Bowen’s disease/ chronic inflammation
- Pain when touched, bleeding, sensory changes
- Grow quicker than BCC
- most commonly affected areas are the backs of hands and forearms, upper part of the face, lower lip and pinna
- Induration ie firm to palpate -first clinical sign.
- Can be: Nodular
Plaque-like
Verrucous
Ulcerated
2ww referral for people with a skin lesion that raises the suspicion of squamous cell carcinoma.
What does the image show? What are the risk factors? What are the clinical features?
Basal cell carcinoma (BCC) =commonest form of skin cancer (80% of all skin cancers)
Whites of Celtic ancestry have the highest risk for BCC
Men>women
Increasing age
Slow growing, non healing lesions - bleed/produce a scab.
An ulcer with a raised rolled edge; prominent fine blood vessels around a lesion; or a nodule on the skin
Routine referral
Only 2ww if concern re lesion site/size - delay would impact
What does the image show? What are the clinical features? How is it treated?
- Bowen’s disease = an intra-epidermal (in situ) squamous cell carcinoma of the skin.
- The rate of transformation in to invasive squamous cell carcinoma (SCC) is approximately 3%.
- Well-defined pink and scaly patches/plaques.
women>men (lower legs)
fair skin
UV radiation.
- cryosurgery (avoid gaiter area)
- efudix (5-FU) cream OD for 4/52
- FU 3 months
What does the image show? How is it managed?
- actinic keratosis (AK) =a common sun-induced scaly or hyperkeratotic lesion, which has the potential to become malignant.
- consequence of cumulative long-term sun-exposure:
- increasing age, fair skin, UVB, PUVA radiation. Men>women
- usually asymptomatic - if growth/pain/tenderness/ bleeding/ ulceration- transforming into SCC
Rough surface scale - usually white, although in patients with skin type I AK are often more easily felt than seen. Usually <1cm.
What does the image show?
- keratocanthoma = a rapidly evolving skin tumour, composed of keratinising squamous cells originating in pilosebaceous follicles.
- difficult to distinguish clinically and histologically between a Keratocanthoma and an SCC so should be referred urgently 2ww to Secondary Care
- Lesions start to resolve after approximately three months (spontaneously resolve)
What does the image show? What are the clinical features, how is it treated?
- erythema multiforme
- a hypersensitivity reaction usually triggered by infections
- HSV1 is most common cause
- Most common in young adults
- tends to arise on the distal extremities, especially the hands
- typical target lesion with a central dark red zone and lighter outer zones
- Supportive treatment is all that is required for the majority
What does the image show? Which systemic conditions is it associated with?
- erythema nodosum
- an inflammatory disorder of the subcutaneous adipose tissue
- can be idiopathic
- Infective - URTI (streptococcal), TB, GI infections
- Sarcoidosis, IBD, Behcet’s
- Haem malignancy (rare)
- Drugs: COCP, sulphonamides, SSRI, isotretinoin, HepB vaccine
- Pregnancy
What does the image show?
Lentigo maligna
= a melanoma in situ - precursor to lentigo maligna melanoma.
Commonly affects the face or neck, particularly the nose and cheek.
Refer 2ww for removal.
What is this condition? How should it be treated?
Periorofacial dermatitis.
* young women
* vermillon border spared
* triggered by topical steroid/inhaler use
* Do not treat with steroid - will worsen. Use ABX - either topical clindamycin or oral lymecycline for 6 weeks.
What does the image show? how is it treated?
- tinea capitis
- Due to risk of scarring alopecia - oral antifungals.
- take skin scrapings to confirm
- in children - seek derm advice before starting oral antifungal.
- Oral griseofulvin empirically until culture results available (takes 1-2 weeks) - is the only licenced treatment for children. 4-8 wks.
- Consider topical antifungal to reduce transmission to others - ketoconazole shampoo at least twice weekly for 2–4 weeks, or an imidazole cream (in children less than 5 years of age) to be used daily for one week
What does the image show? How is it treated?
- tinea corporis - diagnosed clinically.
- Topical antifungal cream BD - terbinafine (most effective) - 2 weeks, or miconazole cream 2-4 weeks.
- If very extensive or inflammatory (pustules present) - oral terbinafine.
What does the image show? How is it treated?
- Lyme disease = infection caused by the spirochaete Borrelia burgdorferi
- Eythema migrans = characteristic presentation (7-10 days after bite). If present = no Ix needed.
- Tick borne vector.
- mild systemic upset with flu-like symptoms
- then disseminated (days-weeks later) - arthritis, meningitis, polyradiculitis, CN palsy, pericarditis/myocarditis.
- Late stage: chronic lyme arthritis, chronic neuro disorders - cognitive impairment, poor concentration
- Oral ABX: counsel re Jarisch-Herxheimer reaction
- Adults and children >12: Doxycycline 200mg OD for 21 days.
- Children 9-12: doxycycline 21 days
- Children <9: amoxicillin TDS 21 days
What does the image show?
- Acute cutaneous lupus erythematosus - assoc with a flare of SLE. Very photosensitive.
- Malar butterfly rash. sparing the nasolabial folds.
What does the image show?
- livedo reticularis - net like rash.
- Cutaneous feature of SLE
What does the image show? How is it managed?
- urticaria
- pruritic.
- search for cause/triggers and avoid
- NSAID can cause chronic urticaria - stop
- if recurrent/persistent urticaria - Ix - LFT, TFT, FBC, H.pylori, skin prick testing, urinalysis, physical challenge.
- Non sedating antihistamine e.g. cetirizine (can increase to 4x standard dose)- up to 6wks.
- if severe - add short course pred 40mg OD up to 7d
- if chronic spontaneous urticaria - daily antihistamine for 3-6mths.
- refer if syx not well controlled on antihistamine, painful, severe due to food or latex allergy, chronic inducible urticaria (e.g solar/cold)
