Management In FM: Commonly Encountered Problems Flashcards
Ear wax / Cerumen
- Hydrophobic, protective layer against infection, trauma, foreign bodies
- Impaction: 1 in 10 children, 1 in 20 adults, 1 in 3 older adults
Impaction:
1. Obstruction due to ear canal disease
2. Narrowing of ear canal
3. Failure of epithelial migration
4. Overproduction
Clinical features:
- Hearing loss
- Ear ache
- Ear fullness
- Dizziness
- Pruritus
- Tinnitus
Indications of removal:
- Symptoms
Removal methods:
1. Cerumenolytic agents
2. Irrigation
3. Manual removal
- No superiority of one method over another
- Ear drops better than no treatment
- No significant difference in efficacy between types of drops
- Saline and water as effective as more costly commercial products
- Patients with dryness or excessive exfoliation best to use plain mineral oil
Otitis externa
- More common in children
- During summer (humidity, water sports)
- 1st step of pathophysiology: Breakdown of skin-cerumen barrier
Risk factors:
1. Swimming / Water exposure
2. Trauma of ear canal (e.g. prior RT)
3. Devices: Hearing aids, ear phones, ear plugs
4. Underlying dermatologic / systemic condition
Causative agents:
1. Acute bacterial (most common)
- P. aeruginosa > S. epidermidis > S. aureus
2. Anaerobes / Fungal infection
Clinical features:
1. Ear pain
2. Pruritus
3. Discharge
4. Hearing loss
Management:
1. Thoroughly clean ear canal
2. Treat inflammation and infection
3. Control pain
4. Avoid promoting factors
5. FU + Culture if not improving / recurrent cases
Treatment
Topical agents
1. Antibiotics
- Chloramphenicol 5% otic drops, 2-3 drops in affected ear OD for 1/52
- Ofloxacin 0.3% otic drop, 10 drops in affected ear OD for 1/52
2. Antiseptics
3. Glucocorticoids
4. Acidifying solutions
- Single agent / Combination
- No clinically meaningful differences in clinical cure rates between topical therapies except for acetic acid
- Aminoglycoside ototoxicity a concern if tympanic membrane perforation —> Fluoroquinolone
Allergic rhinitis / Rhinosinusitis
- Diagnosis: Clinical (Allergy testing not necessary), Therapeutic trial of medication common
- Seasonal (grass, tree, weed pollens) vs Perennial (house dust mites, cockroaches, animal dander)
- Prevalence increasing world wide (urban areas)
Clinical features:
1. Itchy, runny, sneezy (often paroxysmal), stuffy, post nasal drip
2. Itchy eyes + palate
- Intermittent / Persistent vs Mild / Moderate / Severe
Prevention:
1. Daycare
2. Smoking cessation
3. Breastfeeding, solid foods after 6 months
Management (symptomatic treatment):
1. Avoidance of allergens
2. Pharmacotherapy
3. Allergen immunotherapy
House duct mite avoidance:
1. Physical barriers
2. Minimising upholstery / fabric reservoirs
3. Regulation of humidity
4. Heat treatment
5. Insecticides / Allergen-denaturing agents
- Very low quality evidence though clinical benefit reported
Drugs:
1. Intranasal steroids (2 weeks for peak effect, should be used regularly for >=3-6 months)
- Beclomethasone
- Fluticasone (50mcg aqueous nasal spray 2 sprays in each nostril OD) (Beconase)
- Mometasone
- Oral antihistamines
- Chlorphenamine
- Diphenhydramine (25mg caplets 1 caplet PO bedtime PRN)
- Promethazine
- Loratadine
- Cetirizine - Intranasal antihistamines
- Azelastine - Mast cell stabilizer
- Sodium cromoglicate - Leukotriene receptor antagonist
- Montelukast - Ipratropium bromide
- Sympathomimetic (Decongestant)
- Phenylephrine
- Xylometazoline
- Pseudoephedrine
Intranasal steroids vs Oral antihistamines
- Antihistamines are less effective than topical nasal corticosteroids —> Mild / Intermittent symptoms
- Intranasal steroids most effective single therapy for persistent + significant nasal symptoms
—> Improved global nasal symptoms
—> Superiority demonstrated for both seasonal + perennial allergic rhinitis
Guideline:
1. Mild intermittent allergic rhinitis
- Oral antihistamine / Intranasal antihistamine
- Mild persistent / Moderate intermittent
- Oral antihistamine / Intranasal antihistamine / Intranasal sodium cromoglicate - Moderate / Severe persistent
- Intranasal corticosteroid +/- Intranasal antihistamine
In practice: consider coexistent symptoms, cost, availability, ease of use
Eczema
- Chronic inflammatory skin condition
- Impaired epidermal barrier function (structural / functional)
Clinical features:
- Dry skin + Pruritus (Skin creases)
- Excoriation + Erythema
- Thickened skin + fibrotic papules
- Fissuring + Lichenification
Diagnosis: Clinical
- Subtypes in etiology / morphology
Management:
1. Avoid exacerbating factors
- Temperature, humidity, water, wool, stress, sweat, astringents, detergents, solvents
- Protect / Restore / Hydrate skin
- Cotton, gloves
- Emollients
- Ointments
- Creams > Lotions - Patient education
- Pharmacotherapy (mild - moderate disease)
- Topical corticosteroids
- Oral H1 Antihistamines
- Topical immunosuppressants
Emollients
- Preserve stratum corneum barrier, reducing susceptibility to irritants
- Better clinical outcome when used with topical steroids
- Reduces need for topical steroids
- Available as ointments, oils, creams, lotions
Oral H1 Antihistamines
- Widely used
- Postulated that sedating antihistamines help patients with sleep disturbance due to pruritus
- Currently no high-level evidence to support / refute the efficacy / safety of oral H1 antihistamines used as monotherapy for eczema
- Most of studies allowed use of concomitant medications and involved multi-therapeutic approaches, so meaningful assessments of individual effects of oral H1 antihistamines on eczema not feasible
Topical corticosteroids
- Mainstay of treatment
- Standard of care to which other treatments are compared
- Skin complications limit long term use
- Potential for systemic effects:
- Be aware: Effects of hydration / base / occlusion
Guideline:
- Mild disease: Low potency cream / ointment
- Moderate disease : Medium - High potency cream / ointment
Potency:
1. Superpotent
- Clobetasol 0.05% ointment (Dermovate)
—> Psoriasis, Hand eczema
—> NOT face, groin, axilla, under breasts
- High
- Mometasone 0.1% ointment (Elomet)
—> Adult eczema
—> NOT face, groin, axilla, under breasts - Medium
- Mometasone 0.1% cream (Elomet)
—> Child eczema
—> Limit groin area - Low
- Hydrocortisone 1%
—> Eyelid, Diaper area
Topical immunomodulators: CNI
- Suppress immune response causing symptoms of eczema
- Without SE / risks of steroids
- Expensive
- Possible link to cancer (skin and lymphoma)
Drugs:
1. Tacrolimus (Protopic)
- as effective as topical steroids
2. Pimecrolimus (Elidel)
- better than placebo
Viral gastroenteritis
- One of most common infectious diseases in humans, considerable mortality worldwide
- Norovirus (Calicivirus) > Rotavirus (vaccinations available) > enteric Adenovirus > Astrovirus
- Oral-fecal transmission
- Incubation <48 h
- Seasonality: Tropical vs Temperate climates
Clinical features:
- Nausea > Diarrhoea > Vomiting > Abdominal pain
- URTI symptoms (~10%)
- Dehydration (rare except in young children / elderly)
Treatment:
1. Oral / IV re-hydration fluid
- For severe dehydration
- Careful with children + elderly
- Supportive measures:
- Fluids
- Eat small amount of food as tolerated (limited evidence to support dietary restrictions) - Probiotics
- May shorten duration of the illness
- Beware of products with high sugar content - Antimotility agents / Antiemetics / Antibiotics NOT normally indicated
- Loperamide 2mg tab, 2 tabs PO STAT then 1 tab after each runny bowel movement, max 6 tabs per 24 hours, give 10 tabs
Impetigo management
Fucidin 2% ointment apply sparingly to face QDS for 1 week, give 15g
Bacterial conjunctivitis management
- Lid hygiene
- Baby shampoo
- Antibiotic eye drops
- Chloramphenicol 0.5% eye drops, 2 drops to affected eye, Q2H for 1st day then TDS for 5 days, give 10ml bottle
- Chloramphenicol 1% ophthalmic ointment, apply 2cm ribbon to affected eye at bedtime for 5 days, give 4g tube
Hyoscine butylbromide vs Hyoscine hydrobromide (SpC FM)
Hyoscine: Anticholinergic
Hyoscine butylbromide (Scopolamine butylbromide):
- Buscopan
- Antispasmodic
Hyoscine hydrobromide (Scopolamine):
- Anti-emetic
Dayquil vs Nyquil (SpC FM)
Dayquil:
- Paracetamol
- Guaifenecin
- Phenylephrine
- Dextromethorphan
Nyquil:
- Paracetamol
- Doxylamine (Sedating antihistamine)
- Phenylephrine
- Dextromethorphan
Nappy rash (SpC PP, Murtagh)
Causes:
1. Irritant contact dermatitis
2. Candidiasis (Diffuse, red, raw shiny rash that extend beyond napkin area as satellite lesions)
3. Seborrhoeic dermatitis
4. Bacterial superinfection
5. Psoriasis
6. Atopic dermatitis
Management:
1. Lifestyle
- Keep area dry / Air dry
- Do not use powder which can irritate skin
- Change wet / soiled napkins promptly
- Nappy liners to keep skin dry if use cloth nappies
- Give evening fluids early to reduce night-time wetting / Change nappy before going to bed
- Wash gently with warm water + pat dry
- Avoid excessive bathing + soap
- Moisturisers to keep skin lubricated
- Zinc oxide
- Castor oil cream - Hydrocortisone cream
- Antifungal cream
