Dermatology lectures - eczema, acne and psoriasis Flashcards
Impact of skin conditions:
- 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
Name some types of eczema:
- Atopic
- Gravitational
- Seborrhoeic
- Lichen
- Discoid
Is dermatitis the same as eczema?
No - dermatitis relates to an external trigger resulting in rash
What is atopic eczema linked with?
Asthma, hay fever, allergies
- All related to IgE – 60% of those develop asthma – eczema related to allergy based conditions
Epidemiology and pathophysiology of eczema:
- 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
Eczema – risk factors and symptoms:
- 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
What does an eczema flare look like?
- Itchy, inflamed, dry skin (accompanied by scratching)
- Papules and plaques main features
- Can become weeping, crusted, blistered, scaling, thick
- Sleep disturbance common – big impact
Treatment for mild eczema?
- Some dry skin, some itching, a little redness
- Emollients
- Mild topical steroid if inflamed skin, spread thinly using fingertip unit
Treatment for moderate eczema?
- 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
Treatment for severe eczema?
- 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
Infected eczema treatment:
- Weeping, crusted, pustules, +/- systemic symptoms
- Oral antibiotics may be required (flucloxacillin), if localised infection use topical
Name some emollients and if they are heavy, moderate or light?
E45/diprobase = light
Oilatum, hydrous crm = moderate
50% white soft/liquid
Epaderm emulsifying = Greasy
Example of low potency steroid?
Hydrocortisone 0.1,0.5, 1, 2.5%
Examples of moderate potency steroids?
Clobestasone butyrate 0.5%
Betamethasone valerate 0.025%
Examples of potent steroids?
Betamethasone valerate 0.1%
Betamethasone dipropionate 0.05%
Advice for patients with eczema to optimise medicine use:
- 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
Emollient patient advice:
- 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
Name some types of psoriasis:
- Vulgaris (chronic plaque)
- Nail
- Guttate
- Scalp
- Palmoplantar
- Flexural
- Erythrodermic
- Pustular
What is psoriasis?
- 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.
Psoriasis – epidemiology and pathophysiology.
- 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.
Psoriasis – risk factors and symptoms.
obesity smoking alcohol genetics hormones Medications - beta blockers, lithium, ace inhibitors Skin injury Stress Infection
Psoriasis appearance:
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
Psoriasis complications:
- Psoriatic arthritis – screening for symptoms and use of PEST tool
- Depression/anxiety – screening at appointments for symptoms
- Metabolic syndrome and CVD – lifestyle modification, screening
Brief overview of psoriasis treatment:
- 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
How to treat psoriasis in the trunk and limb in adults:
- Adults: Potent corticosteroid AND vitamin D analogue (calcipotriol).
- Coal tar if above not effective
Scalp psoriasis treatment:
- 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
Face, flexures, genitals treatment:
- Mild-moderate steroid
- Short term treatment
- If not effective/long term treatment needed, use calcineurin inhibitor
Name some vitamin D analogues:
Calcipotriol, calcitriol, tacalitol
Mild psoriasis treatment:
- Emolients
- Topical corticosteroid alone or with topical vitamin d analogue
- Tacrolimus (calcineruin inhibitor)
- Coal tar or dithranol
Moderate psoriasis treatment:
- Phototherapy plus topical steroids
- Oral methotrexate or cyclosporin plus topical
- Oral acitertin plus topical
Severe psoriasis treatment:
- Add biological agent
- Apremilast
Psoriasis patient advice/counselling
- 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
Different types of acne:
o Vulgaris (most common)
o Rosacea
o Conglobata
o Fulminans
Acne – epidemiology and pathophysiology
- 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)
Pilosebaceous follicles (PSF). Likely to involve:
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
Acne – risk factors and symptoms
- 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)
Symptoms of acne:
<5mm in diameter
- Papules
- Pustules
> 5mm in diameter
- Nodules
- Cysts
Severity
- Large area affected
- Scarring/lesions
- Treatment failure
- Severe distress
Acne – treatment
Mild-moderate severity 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 GP
Moderate severity acne treatment:
- Oral antibiotic and topical retinoid
- Can add BPO (helps reduce incidence of resistance)
- Treat for 6-8 weeks
Severe acne treatment:
- specialist involvement
- Isotretinoin (oral)
Patient advice for acne sufferers:
- 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
