Management

Question 1

What is the general advice you should give to patients with acne?

Answer 1

• Do not squeeze acne lesions—squeezing can increase depth and severity of inflammation, visibly worsening acne and increasing risk of permanent scars.
• Use a mild skin-cleansing regimen—blackheads are not due to dirt, so excessive washing is not helpful and may be counterproductive. Use a low-irritant, pH-balanced, soap-free cleanser twice a day.
• Eat a healthy diet—although diet has not been directly implicated in causing acne, it is reasonable to avoid specific foods that you have linked with flares. Some recent work suggests that dairy products and a high glycaemic index diet may worsen acne in some individuals.
• Avoid overexposure to the sun—ultraviolet light, either natural sunlight or in solariums, should not be used to treat acne.

Question 2

What are the three steps of the principles of treatment of acne?

Answer 2

1. Unblock pores with keratolytics such as salicylic acid or retinoids. Retinoids can be topical (adapalene, isotretinoin, tazarotene, tretinoin) or systemic (isotretinoin)
2. Decrease bacteria in the sebum with systemic antibiotics. These can be topical (benzoyl peroxide, clindamycin, erythromycin) or systemic (tetracyclines, erythromycin)
3. Decrease sebaceous gland activity with oestrogens, spironolactone, cyproterone acetate or **isotretinoin **

Question 3

What are the general management advice for patients with Rosacea?

Answer 3

• Apply cool packs if severe
• Minimise factors that cause flushing or irritation (see aetiology)
• Sun protection plus sun avoidance measures are essential
• Use an emollient soap-free cleanser, combined with a low-irritant sunscreen to reduce irritation
• Some people may use a green-tinted foundation to mask erythrotelangiectatic features

Question 4

What topical therapies are used for rosacea?

Answer 4

Topical therapy – for mild erythema and inflammatory lesions

• 2% sulphur in aqueous cream tds OR
• Metronidazole gel bd OR
• Azelic acid gel OR
• Clindamycin 1% solution bd OR
• Erythomycin 2% gel bd

Topical treatments need to be used for 6 to 12 weeks for maximal response.

Question 5

What systemic therapies are used for Rosacea?

Answer 5

Systemic antibiotics – for more severe cases or when topical therapy unsuccessful

• Doxycycline 50 to 100mg daily
• Erythromycin 250 to 500 mg twice daily
• Minocycline 50 to 100mg daily

An 8-week course is often used and repeated as required.

Question 6

What is the treatment of psoriasis?

Answer 6

General advice

• encourage brief, safe sun exposure
• moisturise

Topical Therapy (CC,DD)

• Corticosteroids (short term)
• Calcipotriol (a vitamin D derivative)
• Dithranol

Systemic Therapy (A,B,C)

• Acitretin (Vitamin A derivative)
• Biological agents
• Chemotherapy agents (MTX and cyclosporins)

Phsyical Therapy

• Phototherapy
• Intra-lesional corticosteroid injections

Prevention

• Screen for psoriatic arthritis
• Increased risk of heart disease

Question 7

What is the management of conjunctivitis?

Answer 7

There are no specific clinical signs to differentiate bacterial and viral conjunctivitis.

• Limit the spread by avoiding close contact with others
• Use of separate towels and good ocular hygiene

Many cases resolve spontaneously within 5 days; however, symptoms can last up to 14 days if untreated. A ‘delayed prescription’ approach is appropriate.

• Mild cases
  
  • Saline irrigation of the eyelids and conjunctiva
  • Antiseptic drop such as propamidine isethionate 0.1%
  • 1-2 drops 6-8 hourly for 5-7 days
• More severe cases
  
  • Chloramphenicol 0.5% eye drops
  • 1-2 hourly for 2 days
  • Decrease to 4 times daily for another 7 days
  • Chloramphenicol 1% eye ointment at night

Question 8

Patient presents with a painful eye, what is your DDx?

Answer 8

Don’t miss/refer today:

1. Herpes zoster
2. Iritis
3. Optic neuritis
4. Corneal ulcer
5. Closed angle glaucoma

Common:

1. Foreign body/corneal abrasion
2. Entropion/ectropion/Trichiasis
3. Blepharitis
4. Dry eye
5. Stye
6. Scleritis

Question 9

What is the management of otitis externa?

Answer 9

• The external ear canal must be kept as dry as possible.
• Remove discharge or other debris from the ear canal by dry aural toilet, not by syringing with water.
• Dry aural toilet involves dry mopping the ear with rolled tissue spears or similar, 6-hourly until the external canal is dry.

After cleaning and drying, insert 10-20cm of 4mm Nufold gauze impregnated with a steroid and antibiotic cream

• For bacterial infection:
  
  • Dexamethasone 0.05% + framycetin 0.5% + gramicidin 0.005% ear drops
  • 3 drops in affected ear tds, for 3-7 days
• For fungal infection
  
  • Triamcinolone acetonide 0.1% + neomycin sulfate 0.25% + gramicidin 0.025% + nystatin
  • 3 drops 3tds for 3-7 days

Systemic antibiotic therapy provides no additional benefit to topical therapy, unless there is fever, spread of inflammation to the pinna, or folliculitis.

Keep the ear dry during, and for 2 weeks after, treatment.

Other measures

• Analgesia
• Prevent scratching and entry of water

Question 10

What is the management of chlamydia?

Answer 10

Public health

• Chlamydia infection (Group C disease) must be notified in writing within five days of diagnosis.
• Advice to cease sexual activity until treated
• Contact tracing
• Sexual partners of individuals with chlamydia should be examined and investigated then treated empirically.

Definitive management

• Azythromycin 1g as a single dose OR
• Doxycycline 100mg BD for 7 days

Long term

• patients should be re-tested 3-4 months after the initiation of antibiotics
• Abstinence from sexual contact is recommended for at least 7 days during and after completion of antibiotic treatment

Question 11

What is the managament of gonorrheoa

Answer 11

Public health

• Gonococcal infection (Group C disease) must be notified in writing within five days of diagnosis.
• Advice to cease sexual activity until treated
• Contact tracing
• Sexual partners of individuals with gonorrhoea should be examined and investigated then treated empirically.

Definitive management

• Ceftriaxone: 250mg IM as a single dose
• It is recommended that all patients with a suspected or confirmed diagnosis of gonorrhoea be treated for Chlamydia if it has not been excluded. As a practical matter, Chlamydia is treated routinely in patients with gonorrhoea.

Long term

• Repeat diagnostic method if want to see if infection has cleared.

Question 12

What is the treatment of syphillus?

Answer 12

Public health

• Syphilis infection (Group C disease) must be notified in writing within five days of diagnosis.
• Advice to cease sexual activity until treated
• Contact tracing

Early syphilis (less than 2 years’ duration)

• benzathine penicillin 1.8 g IM, as a single dose

Late latent syphilis (asymptomatic syphilis of longer than 2 years’ duration, or of unknown duration.)

• benzathine penicillin 1.8 g IM, once weekly for 3 weeks

Tertiary syphilis (syphilis of longer than 2 years’ duration, or of unknown duration, with cardiovascular, central nervous system or skin and bone involvement.)

• Expert advice and referral

Question 14

For how long should one use anti-fungals?

Answer 14

For 2 weeks after the fungal infection has been cleared