Dermatology (B)

Question 1

How to categorize eczema?

Answer 1

• 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

Question 2

Validated tools to assess eczema

Answer 2

• Patient orientaed eczema measure (POEM)
• Visual analogue scale (0-10) assessing severity, itch and sleep loss over last 3 days

Question 3

How to assess impact of QOL of eczema?

Answer 3

• Ask about sleep, school/work/social life and mood

Question 4

Management mild eczema

Answer 4

• Prescribe emolients - frequent and liberal use
• Mild topical corticosteroid eg hydrocortisone 1%
• Continue this for 48hrs after the flare is controlled

Question 5

When to refer eczema as routine derm appt? (mild)

Answer 5

• 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

Question 6

When to refer to clinical psychologist?

Answer 6

• Eczema controlled but quality of life and wellbeing has not improved

Question 7

Patient information sources about eczema

Answer 7

• British association of dermatologists - eczema
• National eczema society
• Eczema care online website
• NHS pre-payment certificate advice if paying prescription charges

Question 8

Self care advice on eczema

Answer 8

• 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

Question 9

Moderate eczema management

Answer 9

• 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

Question 10

When to refer to routin derm (moderate eczema)

Answer 10

• Same as mild
• • if suspect contact allergic dermatitis

Question 11

When to refer to dermatology, immunology or paeds?

Answer 11

• If food allergy is suspected and expertise is not available in primary care

Question 12

Management of severe eczema

Answer 12

• 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

Question 13

If severe, extensive eczema causing psychological distress consider:

Answer 13

• Short course oral corticosteroid
• But refer those under 16yrs

Question 14

When to refer severe eczema?

Answer 14

Not responded to optimal treatment within 1 week = urgent derm appt

Question 15

When to admit to hospital with eczema?

Answer 15

• Eczema herpeticum - herpes simplex virus infected

Question 16

Treatment for infected eczema

Answer 16

• 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

Question 17

When to refer infected eczema?

Answer 17

• Urgent derm appt if not responded to treatment
• Routine appt if recurrent infections esp deep abscesses and pneumonia

Question 18

Examples of 3 emolients

Answer 18

• Epimax
• Zerobase cream
• Zeroderm ointment

Question 19

Advice on topical corticosteroids

Answer 19

• 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
  *

Question 20

Local adverse effects of steroids

Answer 20

• 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

Question 21

Main patient concerns re eczema treatment

Answer 21

• 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)

Question 22

Tips from video about emolient use

Answer 22

• 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

Question 23

Advice on steroids from video

Answer 23

• 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

Question 24

How does a patient with urticaria present?

Answer 24

• Superficial swelling of skin
• Red (initially with pale centre)
• Raised
• Intensely itchy

Question 25

Aspects of history for urticaria to ask

Answer 25

• 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

Question 26

Correct terminology for urticaria rash

Answer 26

• Wheal and flare (weal is raised hive, erythematous flares surrounding)
• Migratory, well circumscribed, erythematous, pruirtic plaques

Question 27

Management urticaria

Answer 27

• 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)

Question 28

What is this?

Answer 28

• Guttate psoriasis
• Typically 2-3 weeks following strep infection
• Starts with initial lesion and then spreads

Question 29

Description of guttate psoriasis

Answer 29

• Widespread small round-oval erythemtous papules with some associated scaling

Question 30

Management of guttate psoriasis

Answer 30

• 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%