Dermatology Flashcards
Eczema: Treatment Options:
What are the **general **measures used in the management of eczema? What are the treatment options for **mild, moderate **and severe eczema?
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General:
- Identify and exclude triggers; irritants (soaps and detergents), contact, food or inhaled allergens, and skin infections
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Mild: dry skin, infrequent itch
- Emollient, mild topical corticosteroid
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Moderate: frequent itching, redness ± excoriations, local skin thickening:
- Body: emollient, moderate topical corticosteroid, tacrolimus, bandages
- Face: emollient, mild or moderate corticosteroids (3-5 days only), tacrolimus
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Severe: incessant itching, widespread, thickening, bleeding / oozing, pigment alteration
- Emollient, potent topical steroids (maximum moderate on face), tacrolimus, phototherapy, consider systemic therapy
Emollients and Soap Substitutes:
What are the indications, examples and adverse effects of emollients and soap substitutes.
- Indications: dry skin, eczema, psoriasis - short lived effects therefore apply liberally and frequently and prescribe in large tubs.
- **Examples: **(Note: choice is patients favourite; offer a selection)
- Light creams: aqueous cream, diprobase, double bass
- Lotion:** **dermol 500
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Adverse effects (uncommon)
- Contact dermatitis; more common in creams (preservatives) than ointments
- Fire hazard
Topical Corticosteroids
What is application advice for topical corticosteroids? What are examples of mild, moderate, potent and very potent topical corticosteroids and what are adverse effects?
- General advice: no more frequently than BD, OD usually sufficient. Spread thinly, only on active areas, about 30mins after emollinet
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Steroid ladder:
- Mild: hydrocortisone (+ antimicrobials; daktacort, fucidin H)
- Moderate: eumovate
- **Potent: **betanovate, elocon
- **Very potent: **dermovate
- **Adverse effects: **for potent / very potent
- Worsening and spread of fungal infections
- Thinning of skin
- Irreversible striae atrophicae and telangectasia
- Acne, or worsening of acne or rosecea
- Delayed diagnosis of more serious problems (e.g. malignancy
Calcineurin Inhibitors
What is the mechanism of calcineurin inhibitors, what are the examples, and what are the dermatological indications?
- Mechanism: prevent IL-2 production in T-cells
- Examples: tacrolimus, pimecrolimus
- Indications: moderate / severe atopic eczema, facial psoriasis
Not considered first line, unless there is a specific reason to avoid / reduce topical corticosteroid. Should avoid sun and UV exposure due to increased risk of skin cancer.
Acne: Treatment Options
What are the definitions and treatment options for mild, moderate and severe acne?
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Mild: predominantly open / closed comodones ± papules and pustules. Poor psychological effect is indication for ↑ treatment
- Benzoyl peroxide, topical retinoid (tretinoin, isotretinoin, adapalene)
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Moderate: predominantly inflammatory papules / pustules. May be widespread, risk of scarring.
- If unlikely to scar: as mild
- If risk of scarring: add in topical antibiotic
- If on back: add oral antibiotic
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Severe: made up of **nodules **and cysts, with papules and pustles. High risk of scarring.
- Refer to specialist → oral isotretinoin
- Contraceptive in women requiring contraception.
Mild Acne: Treatment
What are treatment options for mild acne, and what are the side effects of treatments used?
- **Benzoyl Peroxide **(2.5%, 5%, 10%): effective in acne with comedones. Begin at low concentration and gradually increase → maximal effect takes 2 - 3 months. Adverse effects: skin irritation, bleaching of clothes / towels
- **Adapalene: **topical retinoid, effective for comedonal acne. Adverse effects: burning, erythema, stinging
**Moderate Acne: Treatment **
What are treatment options for moderate acne (papules and pustules), and what are the side effects of treatments used?
- Continue with treatment for mild acne (benzoyl peroxide, topical retinoid)
- Topical antibiotic: erythromycin or clindamycin for 4-6 months are effective in mild inflammatory acne; used with benzoyl peroxide to ↓risk resitance
- Oral antibiotics: tetracycline, lymecycline, erythromycin. Maximal improvement at 4-6 months; controls rather than cures, and often recurs after cessation. Side effects → deposition of **tetracycline **in growing bone and teeth causing staining and dental hypoplasia; avoid below age 12 or in pregnancy.
Severe Acne: Treatment
What are the treatment options for severe acne (pustules and cysts), and what are the adverse effects.
- Continue with treatment, but refer to specialist
- COC → dianette for women with acne refractory to prolonged oral antibiotics. Avoid if history of venous / arterial thrombosis, arterial disease risk or migraine.
- **Oral retinoids (isotretinoin): **given for 16w. Adverse effects:
- Dry skin + mucous membranes, joint pains, nose bleeds.
- Highly teratogenic → written consent before starting; must practice contraception
- Depression and suicide: unproven link, but needs to be discussed with patient
Psoriasis: Treatment Options
What are first, second and third line options for psoriasis?
Note: with a severe presentation, first line topical traetments can be combined with second / third line options)
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First Line: topical treatments
- Potent Corticosteroid (use mild / moderate on face, flexures, genitalia)
- Vitamin D analogues: calcipotriol
- Coal tar preparation (exorex lotion, crude coal tar)
- **Second line: phototherapy **(specialist)
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Third line: **systemic therapy **(specialist)
- Methotrexate
- Ciclosporin
- Acetretin
- Fourth line: biologics - adalimumab, etanercept, infliximab
Psoriasis: First Line Treatment options
First line topical therapies for psoriasis include:
- Corticosteroids
- Topical Vitamin D analogues
- Coal tar preparations
What is relevant information for each?
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Corticosteroids:
- potent (betanovate) for trunk and limbs,
- mild (hydrocortisone) or moderate (eumovate) for face, genitalia and flexures
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Vitamin D Analogues: calcipotriol
- Adverse effects - itching, erythema, burning, paraesthesia, dermatitis. Reduced through combination with corticosteroid.
- **Coal tar preparations: **used in chronic plaque psoriasis:
- Exorex lotion used most frequently for outpatients; no harm of contact with normal skin so appropriate for widespread, small lesions.
- Cocois scalp ointment (coal tar and salicylic acid in coconut oil): useful for scaly scalps of psoriasis, eczema or seborrheic dermatitis.
Dermatophytoses: Treatment Options
What are the treatment options for tinea infections? Note - tinea may affect:
- Body (corporis)
- Groin (cruris)
- Hand (manuum)
- Foot (pedis - athlete’s foot)
- Scalp (capitis) or nail (unguium) - require more aggressive treatment
- Topical imidazole antifungals: clotrimazole, miconazole
- Terbinafine cream - more effective, but more expensive
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Systemic therapy required for tinea capitis or unguium. Options include:
- Terbinafine (fungicidal, most effective)
- Griseofulvin (fungistatic)
Scabies: Treatment
What is the recommended treatment for scabies, and who requires treatment?
- Adult: 5% permethrin cream over whole body - wash off after 8 - 12 hours
- Children, elderly, immunosuppressed: apply to whole bodyincluding face, neck, scalp, ears.
- All members of household, sexual contacts, other close contacts should be treated simultaneously. Itch takes several weeks to settle; treat with sedating antihistamine, emollient, corticosteroid.