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The Patient Y3 semester 1 > Dermatology lectures - eczema, acne and psoriasis > Flashcards

Dermatology lectures - eczema, acne and psoriasis Flashcards

1
Q

Impact of skin conditions:

A
  • Can be associated with severe psychological impact
  • Emerging evidence: increased risk of cardiovascular disease
  • Development issues in children
  • Many suffers experience low quality of life, bullying
  • Huge burden in society and impact on health services
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2
Q

Name some types of eczema:

A
  • Atopic
  • Gravitational
  • Seborrhoeic
  • Lichen
  • Discoid
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3
Q

Is dermatitis the same as eczema?

A

No - dermatitis relates to an external trigger resulting in rash

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4
Q

What is atopic eczema linked with?

A

Asthma, hay fever, allergies

  • All related to IgE – 60% of those develop asthma – eczema related to allergy based conditions
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5
Q

Epidemiology and pathophysiology of eczema:

A
  • Affects all ages, most commonly in children
    o Most cases before age 5
    o More in urban areas, higher socioeconomic groups
    o Many cases clear in late childhood/adolescence, but not all
  • Dysfunctional skin barrier (altered conversion of keratinocytes to protein/lipid scales)
  • Traced back to a gene that codes for something that forms keratinocytes – if this is dysfunctional it results in a compromised skin barrier.
    o Water loss from skin
    o Hyper-reactivity
    o Infection – higher severity – more colonisation
  • T helper cell dysregulation also thought to be involved (and mast cells) = inflammatory response
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6
Q

Eczema – risk factors and symptoms:

A
  • Stress
  • Genetics
  • Pollen and pets
  • Rough clothes
  • Contact allergens
  • Soap and detergent - alters lipid barrier of skin
  • Extreme temps (sweating can trigger eczema)
  • House dust mites
  • Certain foods
  • Skin infection
  • Hormones
  • Pregnancy
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7
Q

What does an eczema flare look like?

A
  • Itchy, inflamed, dry skin (accompanied by scratching)
  • Papules and plaques main features
  • Can become weeping, crusted, blistered, scaling, thick
  • Sleep disturbance common – big impact
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8
Q

Treatment for mild eczema?

A
  • Some dry skin, some itching, a little redness
  • Emollients
  • Mild topical steroid if inflamed skin, spread thinly using fingertip unit
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9
Q

Treatment for moderate eczema?

A
  • Dry skin, itching, redness, some thickening
  • Emollients. Increase use
  • Moderate potency topical steroid. Start with hydrocortisone on sensitive areas. Aim for maximum 7-14 days use, 5 if on sensitive areas
  • Consider trial of non-sedating antihistamine if itch present, review 3/12 (not much evidence)
  • 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
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10
Q

Treatment for severe eczema?

A
  • Widespread as above, skin thickening, bleeding, oozing, etc.
  • Emollients. Increase use
  • Potent topical steroid. Start with moderate potency on sensitive areas.
    Aim for maximum 7-14 days (5 if sensitive areas)
  • Consider trial of non-sedating antihistamine if itch present, review 3/12
  • If itch affecting sleep, consider sedating antihistamine
  • Consider oral corticosteroid 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
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11
Q

Infected eczema treatment:

A
  • Weeping, crusted, pustules, +/- systemic symptoms

- Oral antibiotics may be required (flucloxacillin), if localised infection use topical

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12
Q

Name some emollients and if they are heavy, moderate or light?

A

E45/diprobase = light
Oilatum, hydrous crm = moderate
50% white soft/liquid
Epaderm emulsifying = Greasy

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13
Q

Example of low potency steroid?

A

Hydrocortisone 0.1,0.5, 1, 2.5%

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14
Q

Examples of moderate potency steroids?

A

Clobestasone butyrate 0.5%

Betamethasone valerate 0.025%

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15
Q

Examples of potent steroids?

A

Betamethasone valerate 0.1%

Betamethasone dipropionate 0.05%

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16
Q

Advice for patients with eczema to optimise medicine use:

A
  • Use emollients frequently and liberally, even when skin is clear
  • Continue steroids for 48 hours after inflammation reduced
  • Avoid scratching (advise to cut nails, rub instead of scratch)
  • Adverse effects of topical corticosteroids, max 1-2 times daily
  • Time course of eczema
  • Link to other allergic conditions
  • Advice to avoid exposure to triggers, e.g. washing powder
  • How to recognise flares / infection and treat promptly
  • Diet alteration under specialist advice only
  • Direct to patient friendly resources
  • Discard old topical products if treating infective episode
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17
Q

Emollient patient advice:

A
  • Creams, bath additives, ointments, gels, lotions, etc etc
  • Some contain urea, lanolin, antiseptics. Try to avoid where possible
  • More than one emollient often needed, tailor to patient preference
    o Inflamed versus dry skin
    o Caution with tubes/sharing preparations
  • Apply corticosteroids 30 minutes later
  • Do not prescribe aqueous cream
  • Caution with soap/wash substitutes
  • Adverse effects
    o If one doesn’t work, try another and check for additives. Consider a small test quantity
    o Watch out for fire warnings!
  • Application technique very important – during/after washing, don’t rub in
18
Q

Name some types of psoriasis:

A
  • Vulgaris (chronic plaque)
  • Nail
  • Guttate
  • Scalp
  • Palmoplantar
  • Flexural
  • Erythrodermic
  • Pustular
19
Q

What is psoriasis?

A
  • Chronic, inflammatory disorder of skin and joints
    o Relapsing remitting in nature
    o Systemic condition
  • Vulgaris (chronic plaque) is the focus in todays lecture
    o 80% of plaque psoriasis sufferers have mild-moderate severity disease managed in primary care using topical therapy.
20
Q

Psoriasis – epidemiology and pathophysiology.

A
  • Prevalence between 1-2% in UK
  • First presentation between 15-25 years, then 55-60
  • Many effects people of Caucasian ethnicity
  • Inflammatory cells present in all layers of psoriatic skin leading to epidermal hyper proliferation and vascular changes. (40 times higher)
    o Particularly important role for T cells, TNF alpha and interleukins.
21
Q

Psoriasis – risk factors and symptoms.

A 
obesity 
smoking
alcohol 
genetics
hormones 
Medications -  beta blockers, lithium, ace inhibitors 
Skin injury 
Stress
Infection
22
Q

Psoriasis appearance:

A

Well marked areas of red plaques with overlying white scale

  • Commonly affecting the buttocks, lower back, scalp, elbows, knees, nails.
  • Thick, scaly skin (acanthosis and hyperkeratosis)
  • May bleed if scales scraped off
23
Q

Psoriasis complications:

A
  • Psoriatic arthritis – screening for symptoms and use of PEST tool
  • Depression/anxiety – screening at appointments for symptoms
  • Metabolic syndrome and CVD – lifestyle modification, screening
24
Q

Brief overview of psoriasis treatment:

A
  • Topical treatments
    o Emollients, steroids. See patient advice/practical use sections in eczema
    o Ointment for thick scale, cream/lotion/gel for larger areas, lotion/solution for scalp
    o Caution with potent/very potent corticosteroids, 4 week break between courses
    o Treat for 4 week blocks, importance of regular review must be stressed
25
Q

How to treat psoriasis in the trunk and limb in adults:

A
  • Adults: Potent corticosteroid AND vitamin D analogue (calcipotriol).
  • Coal tar if above not effective
26
Q

Scalp psoriasis treatment:

A
  • 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
27
Q

Face, flexures, genitals treatment:

A
  • Mild-moderate steroid
  • Short term treatment
  • If not effective/long term treatment needed, use calcineurin inhibitor
28
Q

Name some vitamin D analogues:

A

Calcipotriol, calcitriol, tacalitol

29
Q

Mild psoriasis treatment:

A
  • Emolients
  • Topical corticosteroid alone or with topical vitamin d analogue
  • Tacrolimus (calcineruin inhibitor)
  • Coal tar or dithranol
30
Q

Moderate psoriasis treatment:

A
  • Phototherapy plus topical steroids
  • Oral methotrexate or cyclosporin plus topical
  • Oral acitertin plus topical
31
Q

Severe psoriasis treatment:

A
  • Add biological agent

- Apremilast

32
Q

Psoriasis patient advice/counselling

A
  • How often to apply, how much, warnings with sharing pumps, warnings fire risk
  • Apply emollients before other topical preparations to improve absorption
  • Smooth motion, in direction of hair growth
  • Skin irritation and photosensitivity with vitamin D analogues
  • Several weeks for effect to be seen, persevere
  • Avoid scratching and picking
  • Report joint symptoms immediately
  • Importance of review after 4 weeks – toxicity, adherence, effectiveness
  • Combination steroid and calcipotriol product better than each alone
  • Emollients for daily use, other treatments for flares
  • Treatment break in between steroid courses, in between could use Vit D
33
Q

Different types of acne:

A

o Vulgaris (most common)
o Rosacea
o Conglobata
o Fulminans

34
Q

Acne – epidemiology and pathophysiology

A
  • Affects 90% during teenage years, but can persist
  • Affects more men than women in earlier years
  • Involves pilosebaceous follicles (PSF).
  • Comedogenesis and hypercornification key features
    o Leads to blockage of PSF, and acne lesions
    o Closed comedones more likely to progress to acne lesions (open comedones = blackheads)
35
Q

Pilosebaceous follicles (PSF). Likely to involve:

A

o Inflammatory action
o Increased production /altered composition of sebum (due to androgens)
o Growth/activity of Cutibacterium acnes within sebum in hair follicles
o Keratinocyte proliferation / differentiation, stimulated by Cutibacterium acnes

36
Q

Acne – risk factors and symptoms

A
  • Family members with acne
  • High glycaemic index foods
  • Medications (not technically acne!)
  • Polycystic ovary syndrome (PCOS)
  • Smoking?
  • Stress
  • Cosmetics – look for those that are labelled non-comedogenic (means they don’t block the follicles)
37
Q

Symptoms of acne:

A

<5mm in diameter

  • Papules
  • Pustules

> 5mm in diameter

  • Nodules
  • Cysts

Severity

  • Large area affected
  • Scarring/lesions
  • Treatment failure
  • Severe distress
38
Q

Acne – treatment

Mild-moderate severity acne

A
  • 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 GP
39
Q

Moderate severity acne treatment:

A
  • Oral antibiotic and topical retinoid
  • Can add BPO (helps reduce incidence of resistance)
  • Treat for 6-8 weeks
40
Q

Severe acne treatment:

A
  • specialist involvement

- Isotretinoin (oral)

41
Q

Patient advice for acne sufferers:

A
  • Do not over clean the skin
  • Do not pick/squeeze lesions – scarring risk
  • Use non-comedogenic / no oil products (uncertain benefit for facial cleansers)
  • Bleaching of hair and clothing – BPO
  • Skin irritation, if severe reduce application frequency/switch – all
  • Avoid contact with eyes and mucous membranes - all treatments
  • Sunscreen and avoid sunbeds – retinoids/BPO/oral antibiotics
  • Avoid in pregnancy – retinoids/oral antibiotics
  • Apply to whole affected area, not just individual lesions
  • For gels: apply after washing and then remove a few hours later to avoid irritation
  • For washes: apply and leave on for a few minutes, then rinse off
  • Apply pea sized amount to entire affected area, wash off after 30-60 mins (retinoids)
  • Lifestyle advice important

The Patient Y3 semester 1 (17 decks)

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