Skin, head and feet

Question 1

What is the most common skin condition?

Answer 1

Eczema

Question 2

What is the difference between eczema and dermatitis?

Answer 2

Same thing but use dermatitis to describe eczema of external cause

Question 3

How important is the use of emollients in eczema?

Answer 3

The most important pharmacological intervention, but not easy to get right

Question 4

What is the best type of emollient?

Answer 4

Whichever the patient is willing to apply liberally and frequently

Question 5

What is the mainstay treatment for managing flare-ups?

Answer 5

Topical corticosteroids

Question 6

RTS Eczema

Answer 6

Stepped management plan
Foundation for all stages of management plan is:
Identifying and avoiding trigger factors
Irritants
Allergens
Complete emollient therapy
Then step up to TCS and TCI in flare-ups

Question 7

RTS Emollients

Answer 7

Barriers against further water loss

Barrier against penetration by allergens and irritants

Replace lost water

Question 8

RTS Complete emollient therapy

Answer 8

The use of emollients as part of complete emollient therapy:
Clinically proven to significantly reduce the number/severity of flare-ups
Single most important intervention in eczema management outcomes
Reduces amount of treatment needed to stop a flare-up by 75%
Also plays a similarly important role in managing psoriasis

Question 9

RTS Complete emollient therapy

Answer 9

Emollient as leave-on product
4-6 times a day (every 3 hours!) – wipe not rub
0.5-1Kg/week (half of this for child)
Emollient as ‘soap’ substitute
Instead of any Cosmetic acceptability of emollient soap, handwash, shower gel
+0.5Kg/month
Emollient as bath additive
Add directly to bath or apply lightly to skin then wash off, then pat dry and moisturise
+0.5Kg/month

Question 10

Clinical findings for atopic eczema

Answer 10

15% of children develop eczema by the age of 6 months
60% of patients who develop eczema in there life have it by the age of 1 year old
Tends to affect limbs trunk and FACE rather than flexures as it does older patients
Older children and adults presenting with eczema with no history are unlikely to have the atopic form
Atopy – linked to hypersensitivity, check for history of allergies, asthma and allergic rhinitis (including hayfever)
Then refer (with initial support and emollients)

Question 11

Diagnostic criteria for atopic eczema

Answer 11

A child with 3 or more of:
Eczema in skin flexures/creases (or on cheeks and extensor surfaces in children under 18 months old)
Personal history of flexural eczema (or on cheeks and extensor surfaces in children under 18 months old)
Personal history of dry skin in last 12 months
Personal history of asthma or allergic rhinitis (or of these in a first-degree relative in children under 4 years old)
Onset of signs and symptoms under the age of 2 (not applicable if under 4 years old)
In black or Asian patients extensor/discoid presentation of eczema is more common that flexural eczema

Question 12

Atopic eczema presentation in pharmacy

Answer 12

Presentation of flare-ups or atopic eczema for RTS is disproportionately less common in community pharmacy
Parents tend to take children directly to GP with rashes in young children
Patients (of their parents) tend to be prepared and know what flare-ups look like
Contact tends to be to replenish topical corticosteroids
Why does this sometimes lead to conflict?

Question 13

What are contact eczemas and how are they managed

Answer 13

Irritant
Normally have history of eczema
Sometimes occupational link
Common irritants are:
Water or other fluids
Abrasives such as sand/soil
Acids/alkalis e.g. bleach
Solvents or detergents e.g. Shampoo
Allergic
Hypersensitivity reaction which peaks 2-4 days after contact
Common allergens are:
Ingredients in cosmetics
Nickel (jewellery)
Latex/rubber e.g. gloves, condoms
Colophony (an ingredient in some adhesives)
Plants
Cause of eczema often deducible based on where reaction occurred
Treat and advice supporting how to avoid trigger

Question 14

What is asteatotic eczema and varicose eczema, how do they differ and how are they managed?

Answer 14

Common endogenous eczemas in older patients
Asteatotic eczema
Previously/less commonly known as senile eczema
As skin gets older it becomes drier, thinner and more fragile
Varicose eczema
As known as venous/gravitational eczema
Always occurs blow knee
Blood pools in legs due to damaged valves
Blood/plasma accumulates in skin causing irritation
More common in females, post-DVT, people with family/personal history of varicose veins including pregnant women
Management involves the use of compression garments in addition to pharmacological interventions

Question 15

How can we support the management of eczema OTC?

Answer 15

Topical corticosteroids only for flares, for up to 7 days, but not on face or anogenital areas:
Hydrocortisone 1% in 10+ years old – ointment if available
Clobetasone 0.05% in 12+ years old
Emollient, emollient, emollients
Emollients whilst awaiting appointment
Emollients if they don’t like their current emollient
Emollients if their current emollient is too light and they are willing to try richer
Emollients if they are not using enough emollients

Question 16

Topical Corticosteroids (TCS)

Answer 16

No evidence to support applying more than once daily
Match potency of TCS to severity of flare-up
Counsel on finger-tip unit application to:
Minimise risk of therapeutic failure through steroid-phobia
Minimise risk of skin damage (and adrenocortical suppression)

Question 17

What infections can develop in eczema, how can we spot them and what should we do?

Answer 17

Bacterial infection
Normally associated with scratching/excoriation
Staphylococcus aureus often implicated
Eczema worsening in response to treatment which normally works
Weeping, crusting of eczema
Raised temperature
Refer
Viral infection
Herpes simplex infection of eczema - Eczema Herpeticum
Rapid worsening of eczema with fever
Blisters on eczema lesions
Patients/parents should be warned about contact with people who have cold sores
Patients with these presenting symptoms – ask about possible exposure to patients who have cold sores
Refer urgently as can quickly become life threatening

Question 18

differential diagnosis

Answer 18

Scabies
Seborrheic dermatitis
Acne and rosacea
Psoriasis

Question 19

Red flags

Answer 19

No previous diagnosis of Eczema or no identifiable cause
Has lasted over 2 weeks and not responding to treatment
Cracked and bleeding lesions
Failure to thrive
Evidence of infection – fever, weeping/crusting or blisters

Question 20

Who is affected by seborrhea?

Answer 20

Affects 3-5% of the UK population although possibly underdiagnosed due to the potential for differential diagnosis
Cradle cap and dandruff are both types of seborrheic dermatitis
More common in males
More common between 18-40 years old

Question 21

What is the cause of seborrhea?

Answer 21

Normally affects areas rich in sebaceous glands such as scalp, face and centre of chest
Caused by the yeast Malassezia Ovale and Pityrosporum Ovale
Thought to be an inflammatory reaction to fatty acids produced when yeast hydrolyses sebum

Question 22

Differential diagnosis

Answer 22

Can be difficult to diagnose seborrhea from scalp psoriasis, eczema, rosacea, acne, dermophytic infections and urticaria
Marginated red plaques like psoriasis
The ‘tell sign’ is a greasy appearance with yellowish colour to the small scales, especially on the scalp
Also inspect nasolabial fold for inflammation and fine greasy scales with a slight yellowish colour
Explore history of skin conditions
If widespread or systemic symptoms refer
Refer children

Question 23

Managing Dandruff/SD of the scalp OTC

Answer 23

Ketoconazole 2% (Nizoral®) shampoo
Twice a week for 2-4 weeks
Massage in and leave on for 5 minutes
Selenium sulpiride 2.5% (Selsun®) shampoo
Twice a week for 2 weeks
Massage in an leave on for 3 minutes
Coal tar shampoo for scalp ‘sebo-psoriasis’
Twice a week for 4 weeks
Massage in and leave on for 5 minutes
Refer treatment failure to any of above courses

Question 24

Pityriasis amiantacea

Answer 24

Heavy scaling associated with Seb Derm of scalp (also scalp psoriasis and tinea capitis)
Sebco® left on overnight to remove heavy scaling
Massage into scalp for 5 minutes
Leave on under occlusion (showercap) and comb out with fine tooth comb before washing the next morning
For 2 consecutive nights in very heavy scaling
Hairloss can be unavoidable when removing very heavy scaling, this is not permament
Olive oil massaged thoroughly into scalp then washed off for mild crusting/mild cradle cap

Question 25

Managing SD of the skin OTC

Answer 25

Clotrimazole 1% or miconazole 2% cream
Clotrimazole two or three times a day for up to 4 weeks
Miconazole twice a day for up to 6 weeks
Refer cases of treatment failure

Question 26

Demodex

Answer 26

Semi-transparent parasitic mites which live in hair follicles and sebaceous glands
Demodex folliculorum lives in hair follicles ~0.4mm long
Demodex brevis lives in connected sebaceous glands ~0.3mm long
Strong evidence of link to rosacea, growing evidence that Demodex mites may also play a role in acne vulgaris.

Question 27

Complications of acne rosacea

Answer 27

Telangiectasia: ‘Spider-veins’, flushing and erythema can be managed with prescribed topical/oral beta-blockers/alpha-agonists which cause peripheral vasoconstriction

Ocular symptoms: Blepharitis/ conjunctivitis in >50% patients managed with ocular lubricants/antibiotics and cleansing

Rhinophyma: Significant hyperplasia of connective tissue on the nose which can be disfiguring, rare in female patients, may necessitate surgical interventions

Question 28

Over the counter options

Answer 28

Benzoyl peroxide: anti-bacterial properties
Applied once daily, normally at bedtime as bleaches clothing
Hence use old bedding, towel and pyjamas
Irritant to the skin and no evidence to support using stronger preparations but only 5% and 10% available OTC – 5% preparation very expensive
Hence apply none oily moisturiser 30 minutes after use to reduce irritation
If irritation still significant discontinue treatment until settles then reintroduce on alternate nights
Nicotinamide: Vitamin B3 anti-oxidant, anti-inflammatory properties
Applied twice a day
Insufficient evidence to be considered in guidelines
May reduce inflammation of pustules and papules

Question 29

Managing acne OTC

Answer 29

Can only treat non-inflammatory acne vulagris OTC: Comedones and occasional pustule in patients not distressed by condition

Refer all inflammatory acne vulgaris and acne rosacea to GP Treat whilst awaiting appointment sales are not useful due to lack of efficacy and 6-8 week wait for efficacy

Pre-pubescent children do not have the androgenic activity for acne vulgaris, refer cases of acne (not milk spots or occasional lesion) in pre-pubescent children urgently – may be due to androgen producing tumour

Question 30

Acne vulgaris advice and support

Answer 30

Discuss the condition as well as the treatment
Do not trivialise but highlight that normally resolves as they get older
Highlight the importance of adherence in controlling condition
Reassure that not due to poor hygiene or diet
Avoid greasy/heavy/acnegenic makeup or face creams
It takes 6-8 weeks of regular treatment before it starts to work
No evidence that scrubbing skin/abrasive cleaning products reduces acne but it does dry and damage skin
Avoid excessive exposure to UV light (may help acne but Ca risk)
Do not pick or squeeze inflammatory lesions

Question 31

Acne rosacea advice and support

Answer 31

Unlike acne vulgaris rosacea is unlikely to resolve – discuss control and management NOT cure or resolution
Counsel on avoidance of aggravating factors
Tea and coffee, especially taken hot or strong
Alcohol
Mustard, pepper, vinegar, pickles or spicy foods
Excessive heat
Direct sunshine
Topical steroids
Counsel on use of (chilled) emollient for flushing/erythema

Question 32

Aetiology of tinea

Answer 32

Dermophytic skin infections
Dermophytes: Trichophytons, Microsporums and Epidermophtons
Except for Tinea capitis, Trichophyton rubrum is most common in UK
Trichophyton tonsurans and Microsporum canis most common scalp infections
Anthropophilic infections most common (human to human)
From another person or from one place to another on same person
Zoophilic infections can occur (animal to human)
Especially scalp and beard
Associated with more significant inflammation

Question 33

Clinical Findings

Answer 33

Can thrive anywhere with warm, moist conditions
Itchy
Scaly
Leading edge of erythema
Dermophytic skin infection elsewhere?

Question 34

Tina pedis

Answer 34

Most common site for infection
More common in men than women
Most commonly between toes
Increased moisture, skin of toes rubbing together and flexure between toes mean that scales macerate and rub off leaving lesion underneath reddened and skin can break increasing risk of infection
Can lead to infection of nails

Question 35

Advice for patients with Tina pedis

Answer 35

Put sock of before underwear to reduce risk of transmission to groin and genitalia (Tinea cruris)
Wear cotton socks
Wear well-fitting shoes made of non-synthetic upper and soles
Leave shoes off where possible
Do not walk barefoot in communal areas
Wash socks regularly
Dust shoes and socks with fungicidal powder

Question 36

Treatment of Tinea

Answer 36

Clotrimazole 1% or miconazole 2% cream
Clotrimazole two or three times a day for up to 4 weeks
Miconazole twice a day for up to 6 weeks
Terbinafine 1%
Only licensed 16+ years old
Cream: once daily for 2 weeks for Tinea pedis and cruris only
Spray: once daily for 1 week for Tinea pedis and cruris only
Gel: once daily for 1 week for Tinea pedic, cruris and corporis only
Cutaneous solution: single administration, Tinea pedis only, 18+ yo
Refer cases of treatment failure
Do not recommend unopposed topical corticosteroids! Tinea incognito

Question 37

Specific treatments for Tinea unguium

Answer 37

Amorolfine 5% nail lacquer
18+ years old only
Distal/lateral infection of 1-2 nails only
Take 6+ months for hands, 12+ months for feet
Prices vary £15-25 for 3ml (life multifactorial)
http://www.rpharms.com/support-resources/reclassification.asp
Keratolytic
Canespro: https://www.youtube.com/watch?v=WyxgtnIiBBE
Urea 40% ointment Destroys infected nail then treat nail bed with imidazole antifungal
Imidazole antifungals
Clotrimazole or miconazole as before
Either after keratolysis or conditional referral only

Question 38

What is urticaria?

Answer 38

AKA Hives, welts – Red, itchy, bumpy rash
Allergic/autoimmune response
Due to release of inflammatory mediators especially histamine from cutaneous mast cells
Increases blood vessel permeability

Question 39

Aetiology of angioedema

Answer 39

Same mechanism as urticaria
Due to leakage from deep dermal/subcutaneous capillaries
Commonly affect lips/eyelids
Can occur with/without urticaria
Rapid onset and widespread angioedema is an anaphylactic reaction

Question 40

angioedema triggers

Answer 40

Drugs…
Food…
Latex/rubber
Bee/wasp sting
Idiopathic (unidentifiable/unknown)
Exercise – rare unless co-existent food allergy trigger

Question 41

Other urticarias

Answer 41

Spontaneous: chronic idiopathic urticaria lasting over 6 weeks – exclude prolonged exposure to causative of acute urticaria, manage as before
Physical/inducible: In response to specific physical stimulus, manage as before
Contact: A type of inducible urticaria with immediate, transient, localised swelling due to latex, rubber or peri-oral food allergy, manage as before
Urticarial vasculitis: Painful, burning lesions lasting longer than 24 hours associated that leave bruises, associated with vasculitis – do not attempt to manage, refer urgently

Question 42

Physical/inducible urticarias

Answer 42

Delayed pressure: Belts, tight clothes, sitting – 12-72 hours later
Cholinergic: Small urticarial papules on trunk after sweating, exercising, contact with hot water, hot/spicy drink/food
Solar: Rare reaction developing minutes after sun exposure
Cold: Rare reaction developing minutes after cold exposure – urgent refer
Aquagenic: Rare reaction within 30 minutes of exposure to either hot or cold water

Question 43

Epidemiology of warts and verrucae

Answer 43

High incidence in school-age children
Due to high risk of exposure in school and sports facilities, and no immunity
Immunity develops then lesions disappear

Question 44

Aetiology of warts and verrucae

Answer 44

Caused by Human Papillomavirus 2 (HPV2)
Infection by direct/indirect contact
Damaged epidermis increases risk of infection:
From contact with virus on surfaces at swimming pool after skin wet for protracted period and abraded on rough surfaces
Movement of virus from wart to other place on body (e.g. through touch, shaving)
Warts where skin injuries have occurred ‘Koebner phenomenon’
Warts on nail bed in people who bite nails

Question 44

What are verrucae and how does their appearance differ?

Answer 44

Also known as plantar warts
Most commonly occur on weight bearing parts of the feet as this is where the skin most commonly becomes damaged
More likely to be painful as weight pushes the lesion inwards
Commonly develop small black patches due to network of capillaries that supply wart becoming damaged due to pressure

Question 45

Plantar warts without distinctive black points due to damaged capilliaries?

Multiple warts with a central point that can be plugged?

Answer 45

Far more likely to be a callous/corn
Can still be managed OTC with physical/chemical abrasives and dressings

Far more likely to be Molloscum contagiosum
Similarly caused by a viral skin infection
More likely to scar and affect trunk and face
Refer

Question 46

Treatment or referral of warts and verrucae
LOCATION

Answer 46

Warts are most commonly on hands/feet
Treatment is destructive through use of acid
Other areas of skin are more prone to damage and scarring
Do not treat on any other areas – refer
This includes referral of anogenital and facial warts – strongly advise against attempts to self-manage

Question 47

Treatment or referral of warts and verrucae
DURATION

Answer 47

Warts tend to disappear spontaneously within 6 months to 2 years as immunity develops
Immunity tends to develop more quickly the younger the patient
Some skins cancers can look similar to warts
Warts, especially in older patient, where persistent and definitely with changing appearance/shape should be referred urgently

Question 48

Treatment or referral of warts and verrucae
OTHER MEDICATION

Answer 48

Diabetic patients (patients taking antidiabetic medication): Refer as peripheral neuropathy and microvascular changes can lead to delayed healing, ulceration and infection.
Immunosuppressed: Patients with HIV or taking ummunosuppressants (such as ciclosporin or methotrexate) should be referred due to decreased efficacy of treatments and increased risk of complications as above

Question 49

Treatment or referral of warts and verrucae
APPEARANCE

Answer 49

Again main risk is misdiagnosing and patient has skin cancer
Refer is ulcerated or crusted (BCC)
Refer if pigmented (and not on feet) without a history of physical damage, if colour is changing, if there is itching or extrinsic bleeding, if a larger lesion is surrounded by smaller ones, if it has an irregular outline, if it continues to carry on getting bigger after initial emergence

Question 50

Advice on preventing warts and verrucae from spreading

Answer 50

Actual risk of transmission is low
Having warts or verrucae should not exclude children from physical activity including PE and going to sports facilities
A waterproof plaster over the lesion will prevent risk of infection as well as rubber verrucae socks which may carry an element of social stigma
Wear flip flops in communal changing/shower areas
Avoid sharing shoes, socks and towels
Avoid scratching warts
Avoid biting nails/sucking fingers that have warts on
Keep feet dry (except swimming/showering) and change socks daily

Question 51

Treatment of warts and verrucae

Answer 51

Physical destruction by pairing: Soak in warm water for 10 minutes then file with emery board or nail, repeat twice a week
In the US they cover with tape continuously and pair once a week, then replace new piece of tape – may be more effective
Chemical destruction requires pairing prior to each treatment and may not work any more quickly
An occlusive ointment (eg. Vaseline® petroleum jelly) should be applied to surrounding healthy skin to treatment to protect it
All methods can take about 8 weeks – refer if unsuccessful after 12 weeks

Question 52

Treatment of warts and verrucae

Answer 52

Chemical destruction options:
Salicylic acid
Keratolytic
Treatment applied once daily after pairing
i.e. Bazuka®, Salactol®

Formaldehyde/glutaraldehyde
Virucidal
Treatment applied twice daily after pairing
i.e. Glutarol

Question 53

Scabies
Epidemiology

Answer 53

Sarcoptes scabiei infestation
Prevalence peak every 15-20 years
Differential diagnosis in many conditions often found through history taking of prevalence and contacts
From skin to skin contact
Most common transferred through children or sexual contact
Can affect anyone
Only tends to affect face/scalp in children, elderly or immunocompromised
Always refer infants and young children
Rule out pet fleas and manage accordingly

Question 54

Aetiology of scabies

Answer 54

Sarcoptes scabiei infestation
Mite burrows into skin and lives under the surface producing exudates which cause allergic reaction
Itch and erythema/papulopustular rash can take 6-8 weeks to develop
Itch which is usually worse at night

Question 55

Clinical findings in scabies

Answer 55

Intense night time itch
Erythema and papulopustular rash
Most common burrow sites are web space between fingers and toes, wrists, armpits, buttocks and genitals
Burrowing sometimes leaves the ‘tell’ sign of a raised, sometimes wavy line, 5-10mm long
Scratching leads to excoriation
If you get a raised line on wrists or finger webs with rash not hidden by excoriation you are very lucky!
Excoriation can cause crusting and secondary infection - refer

Question 56

Treatment for scabies: Permethrin 5% cream

Answer 56

All household/sexual contacts should be treated simultaneously
Comes in 30G tubes
Larger adults require more than one tube per application
Treatment is repeated after 7 days
Each tube cost approx. £10
Often patients choose to see GP rather than treat OTC

Question 57

Counselling with permethrin 5% cream
What advice would you give to someone who is buying permethrin cream or presents with prescriptions for it?

Answer 57

Apply all over (except face and scalp in adults)
Apply to cool dry skin normally immediately before bedtime
Leave on overnight for at least 8 hours
Treat all household simultaneously
At the same time was all clothing, bedding and linen at 50 degrees C
If cream is rubbed/washed off anywhere in that time (including hands) re-apply immediately
Itching may worsen for first few days after treatment as exudates increase from dead mites – can use oral antihistamines or crotamiton cream (Eurax®/Eurax HC®) if problematic

Question 58

When to refer suspected scabies

Answer 58

Unless you are fairly confident of diagnosis
Crusted scabies – 2ndry infection risk
Children under 2 and elderly patients
If treatment fails – although lack of adherence often the issue