Skin Flashcards
Applications
Usually viscous solutions, emulsions or suspensions for application to skin (+ scalp) or nails
Collodions
Painted onto skin, allowed to dry to leave a flexible film over site of application
Creams
Emulsions of oil + water. Generally absorbed well into skin
Gels
High water content - suitable for face and scalp application
Lotions
Have a cooling effect - preferred for hairy areas
Ointments
Greasy + mostly insoluble in water - for chronic dry lesions
Pastes
Stiff preparations - high proportion of finely powdered solids suspended in an ointment
Dusting Powders
Used rarely. Reduce friction between opposing skin surfaces
Excipient and sensitisation: The following excipients in topical preparations are rarely, associated with sensitisation:
- Beeswax
- Benzyl alcohol
- Butylated hydroxyanisole
- Butylated hydroxytoluene
- Certostearyl alcohol (including cetyl and stearyl alcohol)
- Chlorocresol
- Edetic acid (EDTA)
- Ethylenediamine
- Fragrances
- Hydroxybenoates (parabens)
- Imidurea
- Isopropyl palmitate
- N-(3-Chloroallyl)hexaminium chloride
- Polysorbates
- Propylene glycol
- Sodium metabisulfite
- Sorbic acid
- Wool fat and related substances including Ianolin (purified versions of wool fat have reduced the problem)
What does ACBS mean
Preparations marked ‘ACBS’ are regarded as drugs when prescribed in accordance with the advice of the Advisory Committee on Borderline Substances for the clinical conditions listed. Rx issued in accordance with this advice and endorsed ‘ACBS’ are not usually investigated.
Dry + Scaling skin disorders
- Emollients soothe, smooth and hydrate the skin and are indicated for all dry or scaling disorders. Their effects are short lived + should be applied frequently even after improvement.
- Aqueous cream + emulsifying ointment can be used as soap substitutes for hand washing + in the bath
Examples: of emollients
- Anti-microbial bath additive Dermol, Emulsiderm, Oilatum plus
- Anti-microbial cream/ointment Dermol, Hibitane
- Colloidal oatmeal bath additive or cream/lotion Aveeno
- Paraffin-containing bath additive Doublebase & same as cream/ointments
- Paraffin cream/ointment Cetraben, Diprobase, Epaderm, E45, Hydromol, Oilatum, ZeroAQS, Vaseline
- Soya-bean oil bath additives Balneum, Zeroneum
- Tar-containing bath additive Psoriderm
- Urea-containing (urea enhances penetration) Balneum cream, Flexitol, E45 itch relief
Emollients: MHRA warning:
Fire risk with paraffine-containing emollients:
Avoid smoking or going near a naked flame (could cause the dressing or clothing to catch fire).
Clothing and bedding should be changed regularly (e.g. daily) as emollients soak into fabric and can become a fire hazard.
Barrier Creams
(E.g. Sudocrem, Metanium, Conotrane)
- Contain water-repellent substances e.g. Dimeticone or other silicones
- Can be used on skin around stomas, bedsores, and pressure areas in the elderly where the skin is intact.
- Nappy rash Applied with each nappy change & applied after corticosteroids to prevent further damage
Infections of skin: bacterial
Impetigo, Erysipelas, Cellulitis, Animal & Human bites, Mastitis during breast-feeding
Impetigo
- Small areas: Topical Fusidic Acid for 7-10days max. (if MRSA use topical Mupirocin)
- Widespread: Oral Flucloxacillin for 7 days or Clarithromycin is penicillin-allergic
Alternate (if strep): Add Phenoxymethylpenicillin
Erysipelas - A superficial infection with clearly defined edges (and often affecting the face)
- First Line: Oral Phenoxymethylpenicillin Pen V / Benzyl-penicillin Pen G
- Severe Infection: High dose Flucloxacillin 7 days treatment
Alternate Pen allergy: Clindamycin / Macrolide
Cellulitis - Rapidly spreading deeply seated inflammation of the skin and subcutaneous tissue
- First Line: Oral Flucloxacillin
Alternate (if strep): Phenoxymethyl-penicillin / Benzyl-penicillin
Alternate (if gram— / Anaerobes): Broad-spec
Alternate (if pen allergy):Clindamycin / Macrolide / Vancomycin (Teicoplanin)
Animal & Human bites
- Cleanse wound
- Human tetanus immunoglobulin (with tetanus vaccine if necessary)
- Rabies prophylaxis (if animal bite in endemic country)
- Assess risk of blood-borne viruses (HIV, Hepatitis B & C) —> Give prophylaxis
- First Line: Co-amoxiclav
Alternate (if pen allergy): Doxycycline + Metronidazole
Mastitis during breast-feeding
Treat if unwell, nipple fissure or symptoms do not improve after 12-24h of effective milk removal
- First Line: Flucloxacillin for 10-14 days
Alternate (if pen allergy): Erythromycin
- Continue breast-feeding / expressing
Fungal:
To prevent relapse, local antifungal treatment should be
continued for 1–2 weeks after the disappearance of all signs of infection
Ringworm
• Tinea Corporis (Body), Tinea Cruris (Groin), Tinea Pedis (Foot), Tinea Manuum (Hand)
- First Line treatment: Topical e.g. Clotrimazole, Ketoconazole, Miconazole
- Second Line: Systemic e.g. Oral Imidazoles / Triazoles (Itraconazole) / Terbinafine (Available OTC >16y)
Ketoconazole:
15g tube is available OTC to treat tinea pedis, tinea cruris + candidal intertrigo. Can be sold OTC for prevention + treatment of dandruff + seborrhoeic dermatitis of the scalp as a shampoo formulation containing ketoconazole max. 2%, in a pack containing max. 120 mL + labelled to show a max. freq. of application of once every 3 days.
Tinea Capitis (Scalp): Systemic Treatment
- First Line: Systemic Griseofulvin? Terbinafine? depends on fungi (+ topical can be used to reduce transmission)
Tinea Unguium (Onychomycosis – fungal nail infection)
- First Line: Terbinafine. Also: Amorolfine (available OTC to treat max. 2 nails) / Tioconazole
Pityriasis (Tinea) Versicolor:
- Ketoconazole shampoo or alternatively Selenium sulphide shampoo OD for 7 days
Second line: Topical Imidazole. If above treatment fails/infection widespread: Systemic Triazole
Candiasis:
Topical imidazole e.g. clotrimazole or miconazole.
Angular Cheilitis (Candida):
Miconazole (Daktarin oral gel)
Viral: Cold Sores (Labial Herpes Simplex)
- Aciclovir cream (Zovirax: available OTC) 5 times daily for 5-10 days. Applied early as possible in prodromal phase (tingling, irritation in the lip) & before vesicles appear. Mostly heal within 1 week. REFER if > 2weeks
- Systemic for buccal or vaginal infections + for herpes zoster (shingles)
Parasitic
- Scabies: Permethrin or malathion
- Head Lice: Dimeticone, Permethrin (risk of serious burns if treated hair is exposed to open flames or other sources of ignition) or malathion
o Wet combing methods: (probably for at least 30 minutes each time) over the whole scalp at 4-day intervals for min. 2 weeks + continued until no lice are found on 3 consecutive sessions - Crab lice: Permethrin or malathion. An aqueous preparation should be applied, allowed to dry naturally + washed off after 12h; a second treatment is needed after 7 days to kill lice emerging from surviving eggs
Eczema (Dermatitis)
Types:
Irritant Allergic contact Atopic (most common) (children <6 months - 5 years) Venous Discoid
Eczema Treatment Options:
- Skin dryness Emollients (creams/ointments/bath)
- Lichenification (repeated scratching) Topical Corticosteroids (potent)
- Prevent Flare ups (Pt with 2-3 flareups per month) Topical corticosteroids 2 consecutive days per week
- Reduce Pruritus Bandages (ichthammol with zinc oxide): Applied over emollient / topical corticosteroid
- Reduce Pruritus Anti-histamines (sedating if sleep disturbance)
- Prevent scratching Dry wrap dressings
Eczema OTC
Hydrocortisone >10yrs+ Max 1 week use
Clobetasone >12yrs+ Max 1 week use
Infection commonly with staph.aureus (sometimes strep.pyogenes)
- Short-course Antibiotics for 1 week
- Widespread infection: Systemic Antibiotics
- Anti-microbial-containing emollients
Seborrheic Dermatitis
- Associated with species of yeast (Malassezia). Affects the scalp, paranasal areas & eyebrows
- Cradle Cap: Infantile Seborrhoeic Dermatitis (Before 6 months old)
- Treatment Shampoo containing Ketoconazole or Coal Tar + combinations of mild-corticosteroid with suitable antimicrobias
Psoriasis
- Characterised by epidermal thickening and scaling. Silvery-white scales with inflamed, red, patchy plaques
Commonly affects extensor surfaces (elbow, knee, lower back) and the scalp - Exacerbating drugs inc. Lithium, Chloroquine, Hydroxychloroquine, B-blockers, NSAIDs & ACE inhibitors
Psoriasis Treatment Options
- Mild Psoriasis Emollients
- Chronic stable plaque psoriasis Vit D analogues (e.g. Calcipotriol), Coal tar, Dithranol + retinoid tazarotene (do not during inflammatory phase of psoriasis)
- Scalp Psoriasis Tar-based shampoo is 1st line / salicylic acid + coal tar/sulfur preparation
- Facial, Flexural + Genital psoriasis short-term mild (preferred for face) or moderate topical corticosteroid. Vit D analogues (e.g. Calcipotriol and tacalcitol) can be used for long-term treatment
- Specialist Topical Pimecrolimus / Tacrolimus
Topical Corticosteroids
Not recommended in routine treatment of urticaria; specialist use only. Do not use indiscriminately in pruritus (where they will only benefit if inflammation is causing itch). Do not use for acne vulgaris.
Systemic or very potent topical corticosteroids should be avoided in psoriasis. Specialist use only
Mild Topical Corticosteroids
Hydrocortisone 0.1-2.5%
Dioderm
Mildison
Synalar 1 in 10
With antimicrobials Canesten HC Daktacort Econacort Fucidin H Nystaform-HC Terra-Cortil Timodine
Moderate Topical Corticosteroids
Betnovate-RD Eumovate Haelan Modrasone Synalar 1 in 4 Ultralanum Plain
With antimicrobials
Trimovate
With urea:
Alphaderm
Potent Topical Corticosteroids
Beclometasone dipropionate 0.025% Betamethasone valerate 0.1% HC butyrate Locoid/ Locoid Crelo Betacap Metosyn Betesil Mometasone furoate 0.1% Bettamousse Nerisone Betnovate Synalar Cutivate Elocon Diprosone
With antimicrobials: Lotriderm Betamethasone + clioquinol Betamethasone + neomycin Aureocort Synalar N Synalar C With salicylic acid: Fucibet Diprosalic
Very Potent Topical Corticosteroids
Clarelux
Dermovate
Etrivex
Nerisone Forte
With antimicrobials
Clobetamol with neomycin + nystatin
Retinoids and related drugs: (e.g. Acitretin, Alitretinoin, Isotretinoin)
Pregnancy prevention
- Females of child bearing potential should practice effective contraception 1 month before starting treatment, during treatment, and for at least 3 years after stopping treatment. Females should be advised to use at least 1 method of contraception, but ideally two methods should be used.
- Barrier methods should not be used alone but can be used in conjunction with other contraceptive methods. Oral progestogen-only contraception is not effective. Females should seek immediate medical attention, if they become pregnant during treatment or within 3 years of stopping treatment
- Advise patients to avoid alcohol during treatment and for 2 months after stopping treatment.
Benign Intracranial HTN ..
Discontinue if: Severe headache, nausea, vomiting or visual disturbances occur.
Isotretinoin: Oral and topical. SE
Side effects, further information: Risk of pancreatitis if triglycerides are above 9mmol/litre, discontinue if uncontrolled hypertriglyceridemia or pancreatitis.
With oral use: Warn patient to avoid waxing (risk of epidermal stripping), dermabrasion + laser skin treatments during treatment + for at least 6 months after stopping; patient should avoid exposure to UV light (including sunlight) + use sunscreen and emollient (including lip balm) preparations for the start of treatment.
Patients and carers should be told how to recognise signs and symptoms of psychiatric disorders such as depression, anxiety, and rarely suicidal thoughts. Psychiatric side-effects and visual disturbances could require expert referral and possible withdrawal.
With topical use: Patients should be warned that some redness and skin peeling can occur initially but settle with time. If undue irritation occurs, the frequency of application should be reduced, or treatment suspended until the reaction subsides. If skin peeling is severe or haemorrhagic develops, treatment should be discontinued. Several months of treatment may be needed to achieve an optimal response + treatment should be continued until no new lesions develop. If sun exposure is unavoidable, appropriate sunscreen or protective clothing should be used.
Preparations containing salicylates: (e.g. Salicylic acid with zinc oxide)
• Salicylate toxicity may occur particularly if applied on large area of skin or neonatal skin.
Perspiration:
Aluminium chloride hexahydrate is a potent antiperspirant used to treat hyperhidrosis. (Also available OTC)
Pruritus:
Pruritus may be caused by systemic disease (such as obstructive jaundice, endocrine disease, chronic renal disease, iron deficiency, and certain malignant diseases), skin disease (e.g. psoriasis, eczema, urticaria, and scabies), drug hypersensitivity, or as a side-effect of opioid analgesics.
Levomenthol cream can be used to relieve pruritus; it exerts a cooling effect on the skin. Local antipruritics have a role in the treatment of pruritus in palliative care.
Avoid topical antihistamines in eczema + are not recommended for longer than 3 days.
Acne
Mild to moderate acne is generally treated with topical preparations. Systemic treatment with oral antibacterials is generally used for moderate to severe acne or where topical preparations are not tolerated or ineffective or where application to the site is difficult. Another oral preparation used for acne is the hormone treatment co-cyprindiol (cyproterone acetate with ethinylestradiol); it is for women only.
Co-cyprindiol: Cautions, further information:
There is an increased risk of venous thromboembolism in women during first year of use. Likelihood of VTE is 1.5-2 times higher in women taking co-cyprindiol than in women using COC containing Levonorgestrel. Women requiring Co-cyprindiol may have an increased risk of CVD.
Rosacea
is not comedonal (but may exist with acne which may be comedonal). Brimonidine tartrate is licensed to treat facial erythema in rosacea. The pustules + papules of rosacea respond to topical azelaic acid, topical ivermectin or topical metronidazole. Alternatively, oral administration of oxytetracycline, tetracycline or erythromycin can be used. Courses usually last 6–12 weeks and are repeated intermittently.
MHRA: BRIMONIDINE GEL (MIRVASO):
- RISK OF SYSTEMIC CARDIOVASCULAR EFFECTS:
Systemic cardiovascular effects including bradycardia, hypotension + dizziness has been reported after application of gel. To minimise systemic absorption, avoid application to irritated/damaged skin, including after laser therapy. - RISK OF EXACERBATION OF ROSACEA:
Symptom exacerbation has been reported very commonly in patients treated with brimonidine gel. Treatment should be initiated with a small amount of gel (less than the maximum dose) for at least 1 week, then increased gradually, based on tolerability and response. Patients should be counselled on the importance of not exceeding the maximum daily dose and advise to stop treatment + seek medical advice if symptoms worsen during treatment.
Scalp & Hair Conditions
Dandruff - Shampoo with antimicrobial agents such as pyrithione zinc + selenium may be beneficial
Alopecia - Finasteride in men/ Minoxidil
Hirsutism - Eflornithine (antiprotozoal). Hirsutism may result from hormonal disorders or as a side-effect of drugs such as minoxidil, corticosteroids, anabolic steroids, androgens, danazol, and progestogens
Skin cleansing
Antiseptics e.g. chlorhexidine or povidone-iodine are used on intact skin before surgical procedures; their antiseptic effect is enhanced by an alcoholic solvent. Potassium permanganate sol. 1 in 10 000, a mild antiseptic with astringent properties, can be used for exudative eczematous areas; stop when skin gets dry.
Desloughing agents: Alginate, hydrogel and hydrocolloid dressings are effective at wound debridement.
