Dermatology (B) Flashcards
1
Q
How to categorize eczema?
A
- Clear - if normal skin and no evidence of eczema
- Mild - areas of dry skin and infrequent itching (+/- small areas of redness)
- Moderate - areas of dry skin, frequent itching, redness (+/- areas of excoriation and skin thickening)
- Severe - widespread areas of dry skin, incessant itching and redness (+/- excoriations, extensive skin thickening, bleeding, oozing, cracking and altered pigmentation)
- Infected - weeping, crusted or pustules with fever or malaise
2
Q
Validated tools to assess eczema
A
- Patient orientaed eczema measure (POEM)
- Visual analogue scale (0-10) assessing severity, itch and sleep loss over last 3 days
3
Q
How to assess impact of QOL of eczema?
A
- Ask about sleep, school/work/social life and mood
4
Q
Management mild eczema
A
- Prescribe emolients - frequent and liberal use
- Mild topical corticosteroid eg hydrocortisone 1%
- Continue this for 48hrs after the flare is controlled
5
Q
When to refer eczema as routine derm appt? (mild)
A
- Diagnosis uncertain
- Current management not controlled eczema (one or two flares per month) or reacting to emolients
- Facial eczema not responding to treatment
- Recurrent secondary infection
6
Q
When to refer to clinical psychologist?
A
- Eczema controlled but quality of life and wellbeing has not improved
7
Q
Patient information sources about eczema
A
- British association of dermatologists - eczema
- National eczema society
- Eczema care online website
- NHS pre-payment certificate advice if paying prescription charges
8
Q
Self care advice on eczema
A
- Chronic illness
- Characterised by flares
- Can have significant impact on wellbeing
- Children with eczema - should improve with time but not all children grow out of it
- Children with eczema often develop asthma, allergic rhinitis and food allergy can be related to eczema if very young
- Avoid triggers - detergents, soaps, certain clothing, animals and heat
- Avoid scratching, rub area with fingers to alleviate itch
- Keep nails short in children and babies
- Natural remedies have not been assessed in trials so therefore emolient is best
9
Q
Moderate eczema management
A
- Emolients
- Moderate potent topical corticosteroid eg betamethasone valerate 0.025% or clobetasone butyrate 0.05%
- For delicate areas eg face and flexures consider mild (eg hydrocortisone 1%)
- Aim for maximum of 5 days use
- If severe itch/urticaria - non sedating antihistamine eg loratadine cetirizine or fexofenadine
- Consider corticosteroid maintenance regime or topical calcineurin inhibitors - special interest GPs
10
Q
When to refer to routin derm (moderate eczema)
A
- Same as mild
- if suspect contact allergic dermatitis
11
Q
When to refer to dermatology, immunology or paeds?
A
- If food allergy is suspected and expertise is not available in primary care
12
Q
Management of severe eczema
A
- emolients
- Potent topical corticosteroid - betamethasone valerate 0.1%
- Delicate areas use moderate potency (eg BV 0.025% or clobetasone butyrate 0.05%)
- Do not use potent in children under 1yr
- Occlusive dressings/dry bandages may benefit but if no knowledge refer for this
- Severe itch/urticaria - non sedating antihistamine
- Affecting sleep and severe - sedating antihistamine eg chlorphenamine
- Topical corticosteroid maintence treatment
- Topical calcineurin inhibitors
13
Q
If severe, extensive eczema causing psychological distress consider:
A
- Short course oral corticosteroid
- But refer those under 16yrs
14
Q
When to refer severe eczema?
A
Not responded to optimal treatment within 1 week = urgent derm appt
15
Q
When to admit to hospital with eczema?
A
- Eczema herpeticum - herpes simplex virus infected
16
Q
Treatment for infected eczema
A
- In people who are systemically well do not routinely offer topical or oral antibiotic
- Flucloxacillin is first line if chosen
- Clarithromycin in allergy
- If localised, consider fusidic acid
- Prescribe new emolients and topical corticosteroids
- If not respond to original abx, consider skin swab or specialist advice
17
Q
When to refer infected eczema?
A
- Urgent derm appt if not responded to treatment
- Routine appt if recurrent infections esp deep abscesses and pneumonia
18
Q
Examples of 3 emolients
A
- Epimax
- Zerobase cream
- Zeroderm ointment
19
Q
Advice on topical corticosteroids
A
- They do not cure, just control and reduce inflammation
- Usually once (or twice) daily
- Apply in direction of hair growth - minimises build up of product (which can cause folliculitis)
- Aim is to control flare and then taper down - balance of lowest dose to keep controlled
- Apply in thin layer
- Check finger tip units and how much for each part of the body
- Keep away from fire/naked flames
- Steroid treatment card if very potent steroids for weeks
*
20
Q
Local adverse effects of steroids
A
- Acne vulgaris
- Skin atrophy (thinning)
- Transient burning/stinging
- Permanent stretch marks
- Rarer inc adrenal supression, cushing syndrome, growth supression, visual disturbance
- Loss skin pigment
- Hair growth at site of application
21
Q
Main patient concerns re eczema treatment
A
- Is steroid addiction a problem - commonest problem is under use of steroid, if they are overused esp on face can cause redness which causes increase us and cycle of overuse
- Finger tip amount (from first crease to tip) is enough to cover two hand sizes of skin (with fingers together)
22
Q
Tips from video about emolient use
A
- Emolients rehydrate skin
- Form layer to protect from water loss
- Ointments are oiliest so most effective, then creams then lotions
- Wash and dry hands before
- If comes in tub use spoon/spatula to remove
- Stroke onto skin applying in direction of hairs
- Adult needs around 500-1000g per week if dry skin all over body
23
Q
Advice on steroids from video
A
- reduce inflammation
- Different strengths available
- Ointment and cream form - ointments oilier so better for dryer skin
- Wash and dry hands before and after application
- Finger tip amount - line from crease to tip of finger = amount to cover two flat hands of skin
- Apply to affected skin areas
- Do not apply with emolients at same time = dilutes
- Used for 50yrs in past - similar to natural body steroids
- Skin thinning is low risk if use as directed
24
Q
How does a patient with urticaria present?
A
- Superficial swelling of skin
- Red (initially with pale centre)
- Raised
- Intensely itchy
25
Aspects of history for urticaria to ask
* Time and onset (acute <6 weeks, chronic more) in some it is episodic
* Size, shape and distribution of wheals and if they are itchy
* Severity - urticaria activity score UAS7
* Known causes/triggers - stress, insect bites/stings, exercise, foods
* If IgE mediated, symptoms come on within hr of digesting food
* Tried treatments
* FH
* GI symptoms
* Occurance in relation to menstrual cycle, travel, work, hobbies
26
Correct terminology for urticaria rash
* Wheal and flare (weal is raised hive, erythematous flares surrounding)
* Migratory, well circumscribed, erythematous, pruirtic plaques
27
Management urticaria
* Avoid trigger if indentified
* If need treatment - non-sedating antihistamine (cetirizine, fexofenadine, loratadine)
* If severe, short course of oral corticosteroid
* (can then add LTRA or calamine lotion if itching perist, or sedating antihistamine for sleep)
28
What is this?
* Guttate psoriasis
* Typically 2-3 weeks following strep infection
* Starts with initial lesion and then spreads
29
Description of guttate psoriasis
* Widespread small round-oval erythemtous papules with some associated scaling
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Management of guttate psoriasis
* If strep infection is current, treat this with antibiotics
* Narrowband UVB therapy - refer
* Topical treatment - coal tar preparations eg Exorex ® lotion or Alphosyl-HC ® cream
* Emolients
* Usually clears within 3-4 months even without treatment anyway
* May become persistent and evolve into plaque psoriasis - 25%
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