Dermatology: eczema, acne and psoriasis Flashcards
What is the major form of eczema?
Atopic
What makes the skin barrier dysfunctional in eczema?
Conversion of keratinocytes to protein/lipid scales in INTERRUPTED, causing water loss, hyper-reactivity and infection
- T helper cell dysregulation also thought to be involved
What are the risk factors of eczema?
- stress
- genetics
- pollen and pets
- rough clothes
- contact allergens
- soap and detergent
- extreme temperatures
- house dust mites
- certain foods
- skin infection
- hormones
What sort of disease is eczema?
A chronic disease with flares
What symptoms are experienced with eczema?
- Itchy, inflamed, dry skin (accompanied by scratching)
- Papules and plaques main features
- Can become weeping, crusted, blistered, scaling, thick
- Sleep disturbance common (itching)– big impact
Describe mild eczema and treatments
Some dry skins, some itching, a little redness
- emollients are first line treatment (improve skin barrier, reduce number of flares and have a steroid sparing effect – apply liberally)
- mild topical steroid if inflamed skin, spread thinly using FTU
Describe moderate eczema and treatments
Dry skin, itching, redness, some thickening
- increase emollient use
- moderate potency topical steroid. Start with hydrocortisone on sensitive areas. Aim for max 7-14 day use, 5 if on sensitive areas
- consider trial of non-sedating antihistamine if itch present, review 3 months after
- If needed between flares:
- Use low potency steroid (consider intermittent use)
Topical calcineurin inhibitors (tacrolimus) second line options by specialist
Review use every 3-6 months
Describe severe eczema and treatments
Widespread as above, skin thickening, bleeding, oozing, etc
- treatment: same as moderate +If itch affecting sleep, consider sedating antihistamine
Consider oral corticosteroid (prednisolone)* if severe symptoms and distress.
Consider between flares:
Use lower potency steroid (consider intermittent use)
Topical calcineurin inhibitors (tacrolimus) second line options by specialist
Review use every 3-6 months
Describe infected eczema and treatments
Weeping, crusted, pustules, +/- systemic symptoms Oral antibiotics (flucloxacillin for about 2 weeks) may be required, if localised infection use topical
Name 2 light emollients
E-45
Diprobase
Name 2 moderate emollients
Oilatum
Hydrous crm
Name Greasy emollients
50% white soft/liquid
Epaderm
Emulsifying
Name low potency topical steroids
Hydrocortisone 0.1, 0.5, 1, 2.5%
Name moderate potency topical steroids
Clobetasone butyrate 0.05%
Betamethasone valerate 0.025%
Name potent topical steroids
Betamethasone valerate 0.1%
Betamethasone dipropionate 0.05%
How should emollients be used?
- Use emollients frequently and liberally, even when skin is clear
- apply 30 mins before corticosteroids
- Some contain urea, lanolin, antiseptics. Try to avoid where possible
- Do not prescribe aqueous cream (contains SLS - irritation)
How long should you continue steroids for after inflammation has reduced?
48 hours after inflammation has reduced
What is psoriasis?
- Chronic, inflammatory disorder of skin and joints (relapsing remitting in nature)
- Vulgaris (chronic plaque) 80% of plaque psoriasis sufferers have mild-moderate severity disease managed in primary care using topical therapy.
- more of a systemic illness
What causes psoriasis
Inflammatory cells present in all layers of psoriatic skin leading to epidermal hyper proliferation and vascular changes.
Particularly important role for T cells, TNF alpha and interleukins.
- hyper proliferation of cells - 40x higher turnover
When does psoriasis present?
First presentation between 15-25 years, then 55-60
- mainly effects Caucasian people
What are the risk factors for psoriasis?
- obesity
- smoking
- alcohol
- genetics
- hormones
- medications
- skin injury
- stress
- infection
What symptoms present with psoriasis?
- Commonly affecting the buttocks, lower back, scalp, elbows, knees, nails.
- Thick, scaly skin (acanthosis and hyperkeratosis)
- May bleed if scales scraped off
What are some complications of psoriasis?
- Psoriatic arthritis – screening for symptoms and use of PEST tool
- Depression/anxiety – screening at appointments for symptoms
- Metabolic syndrome and CVD – lifestyle modification, screening
What is included in the treatment of psoriasis?
- Emollients, steroids. See patient advice/practical use sections in eczema
- Ointment for thick scale, cream/lotion/gel for larger areas, lotion/solution for scalp
- Caution with potent/very potent corticosteroids, 4 week break between courses
- Treat for 4 week blocks, importance of regular review must be stressed
What is used on the trunk and limb in psoriasis?
Adults: Potent corticosteroid AND vitamin D analogue (calcipotriol).
Coal tar if above not effective
What is used on the scalp in psoriasis?
Potent corticosteroid.
If not effective try a different formulation and/or salicylic acid/emollients.
Combine steroid with calcipotriol or use vitamin D analogue alone if not effective/tolerated
What is used on the face, flexures and genitals in psoriasis?
Mild-moderate steroid
Short term treatment
If not effective/long term treatment needed, use calcineurin inhibitor
*treat for 2 weeks not 4 weeks
What are the vitamin D analogues?
- calcipotriol
- calcitrol
- tacalitol
What treatments are used for mild psoriasis?
- emollients
- Topical corticosteroid alone or with topical vitamin D analogue
- Calcineurin inhibitor (tacrolimus)
- Coal tar or dithranol
What treatments are used for moderate psoriasis?
- Phototherapy plus topical treatments
- Oral methotrexate or ciclosporin plus topical
- Oral acitretin plus topical
What treatments are used for severe psoriasis?
- add biological agent
- Apremilast, dimethyl fumarate (not examinable)
How long does coal tar take to work?
3-4 weeks
What is the most common type of acne?
Vulgaris - Affects mainly the face, back and chest
What does the epidemiology of acne include?
- Involves pilosebaceous follicles (PSF). Likely to involve:
- Inflammatory action
- Increased production /altered composition of sebum (due to androgens)
- Growth/activity of Cutibacterium acnes within sebum in hair follicles
- Keratinocyte proliferation / differentiation, stimulated by Cutibacterium acnes
What are Comedogenesis and hypercornification key features?
- Leads to blockage of PSF, and acne lesions
- Closed comedones more likely to progress to acne lesions
What are open comedones?
blackheads, melanin interacts with the atmosphere and turns black
what are closed comedones?
whiteheads - lower down, progress to acne regions
What are the risk factors of acne?
- Family members with acne
- High glycaemic index foods – increase androgens
- Medications (not technically acne!) – lithium, anti-epileptics
- Polycystic ovary syndrome (PCOS)
- Smoking?
- Stress
- Cosmetics – look for those that are labelled non-comedogenic
What are symptoms < 5mm in diameter? (mild)
- papules (small red, raised bumps)
- pustules (white pus filled)
What are symptoms > 5mm in diameter? (severe)
- nodules and cysts (deep, big pus filled)
What is the treatment for mild-moderate acne?
- Topical retinoid (adapaline 0.1% gel/cream, isotretinoin)
- Benzoyl peroxide (BPO - 4% cream or 5% gel/wash)
- Azelaic acid (20% cream, 15% gel)
- Topical antibiotic (clindamycin 1%) always with BPO
- Combination products seen
- Emollients to combat dry skin (oil free/non-comedogenic)
- Continue treatment for 6-8 weeks, if no improvement refer to G
What is the treatment for moderate severity acne?
- Oral antibiotic (can use erythromycin) and topical retinoid (avoid in pregnancy)
- Can add BPO (antibacterial and acts using free radical oxidation)
- Treat for 6-8 weeks
What is the treatment for severe acne?
- isotretinoin (oral) 18+
all other treatments 12+
What is some advice regarding retinoids?
- avoid in pregnancy
- apply pea sized amount to entire affected area, wash off after 30-60 mins
