Inflammatory skin conditions

Question 1

Name three common inflammatory skin conditions.

Answer 1

Eczema
Psoriasis
Acne

Question 2

What is the management of inflammatory skin conditions?

Answer 2

Control of symptoms

Awareness that complications are primarily due to social and psychological effects

Question 3

What is eczema?

Answer 3

Dermatitis
Characterised by papules and vesicles on an erythematous base
Most common form is atopic eczema (develops in childhood and resolves by teens, but can recur)

Question 4

How prevalent is atopic eczema?

Answer 4

20% in <12y

Question 5

What causes atopic eczema?

Answer 5

Poorly understood
FHx of atopy (eczema, asthma, allergic rhinits)
Primary genetic defect in skin barrier function (loss of filaggrin protein variants) appears to underly

Question 6

What can exacerbate atopic eczema?

Answer 6

Infections
Allergens e.g. chemicals, food, dust, fur
Sweating
Heat 
Severe stress

Question 7

How does atopic eczema present?

Answer 7

Itchy, erythematous dry scaly patches
Common on face and extensor surface in infants/flexor surface in children and adults
Chronic scratching/rubbing can lead to excoriation and lichenification
Nail pitting and ridging of nails may be seen

Question 8

How is atopic eczema managed?

Answer 8

General
-avoid exacerbating agents
-frequent emollient +/- bandages
-bath oil/soap substitute
Topical therapy
-topical steroid for flare ups
-topical immunomodulators (e.g. tacrolimus, pimecrolimus) used as steroid sparing agents
Oral therapy
-antihistamines for symptomatic relief
-abx e.g. flucloxacillin for secondary bacterial infection
-antivirals e.g. acyclovir for secondary herpes infection
Phototherapy and immunosuppressants (e.g. oral pred, azathioprine, ciclosporin) for severe non-responsive cases

Question 9

What complications are associated with atopic eczema?

Answer 9

Secondary bacterial infection (crusted weepy lesions)
Secondary viral infection
-molluscum contagiosum (pearly papules with central umbilication)
-viral warts
-eczema herpeticum

Question 10

What is acne vulgaris?

Answer 10

Inflammatory disease of pilosebaceous follicle

Question 11

What is the prevalence of acne vulgaris?

Answer 11

80% of adolescents 13-18y

Question 12

What causes acne vulgaris?

Answer 12

Hormonal (androgen)
Other contributing factors
-increased sebum production
-abnormal follicular keratinization
-bacterial colonisation (Propionibacterium acnes)
-inflammation

Question 13

How does acne vulgaris present?

Answer 13

Non-inflammatory lesions (mild acne)
-open and closed comedones (blackheads and whiteheads)
Inflammatory lesions (moderate to severe acne)
-papules
-pustules
-nodules
-cysts
Commonly affecting face, chest, upper back

Question 14

How is acne vulgaris managed?

Answer 14

General
-treat for at least 6w to produce affect
-no proven association with diet
Topical (for mild acne)
-benzoyl peroxide
-topical abx (antimicrobial properties)
-topical retinoids (comedolytic and anti-inflammatory properties)
Oral therapy (moderate to severe)
-oral abx
-anti androgens (in females)
Oral retinoids for severe acne

Question 15

What complications are associated with acne vulgaris?

Answer 15

Post-inflammatory hyperpigmentation
Scarring
Deformity
Psychological and social effects

Question 16

What is psoriasis?

Answer 16

Chronic inflammatory skin disease from hyperproliferation of keratinocytes and inflammatory cell infiltration

Question 17

What types of psoriasis exist?

Answer 17

Chronic plaque psoriasis most common
Also
-guttate (raindrop lesions)
-seborrheic (naso-labial and retro-auricular)
-flexural (body folds)
-pustular (palmar-plantar)
-erythrodermic (total body redness)

Question 18

How prevalent is psoriasis?

Answer 18

2% of population

Question 19

What causes psoriasis?

Answer 19

Interaction between genetic, immunological and environmental factors
Precipitating factors
-Trauma (may cause Koebner phenomenon - inflammation in a line)
-infection e.g. tonsillitis
-drugs
-stress
-alcohol

Question 20

How does psoriasis present?

Answer 20

Well demarcated erythematous scaly plaques
Lesions may be itchy, burning or painful
Common on extensor surfaces and scalp
Auspitz sign (scratch and gentle removal of scales causes capillary bleeding)
50% have nail changes (pitting, oncholysis)
5-8% have psoriatic arthropathy
-symmetrical polyarthritis
-asymmetrical oligomonoarthrits
-lone distal interphalangeal disease
-psoriatic spondylosis
-arthritis mutilans

Question 21

How is psoriasis managed?

Answer 21

General 
-avoid precipitants
-emollients to reduce scaling
Topical (localised and mild)
-vitamin D analogues
-topical corticosteroids
-coal tar preparations
-dithranol
-topical retinoids
-keratolytics
-scalp preparations
Phototherapy (extensive disease)
-phototherapy = UVB
-photochemotherapy = psoralen + UVA
Oral therapy (for extensive/severe or for psoriasis with systemic involvement)
-methotrexate
-retinoids
-ciclosporin
-mycophenolate mofetil
-fumaric acid esters
-biologics (infliximab, etanercept, efalizumab)

Question 22

What complications are associated with psoriasis?

Answer 22

Erythorderma

Psychological and social effects