W24 Clinical management of Cellulitis, Acne and Rosacea Flashcards
What is Cellulitis?
What are the symptoms?
- Common
- Acute bacterial infection of dermis & Subcutaneous tissue
Symptoms
* Pain, warmth, swelling, redness of infected area
* Possible blisters
* Fever, malaise, nausea, rigors
* Tracking
Cellulitis is an infection caused by bacteria getting into the deeper layers of your skin
Cellulitis: Which regions of the body does it affect?
Commonly affects lower limbs
Can also affect:
* Face
* Ears
* Trunk
* Upper limbs
What are the causes of cellulitis?(3 microorganisms)
Microorganims entry after after skin barrier broken
* Strep. Pyrogenes
* Staph. Aureus
* Pseudo aeruginosa
What are the risks of cellulitis?
What are the complications?
Risks:
* Lymphoedema
* Leg oedema
* Venous insufficiency
* Hx venous surgery
* Obesity
* Pregnancy
* Diabetes
* Kidney/liver disease
* Chickenpox
* Alcohol misuse
Complications:
* Necrotising fasciitis
* Myositis
* Sepsis
* Subcutaneous abscess
* Post-strep Nephritis
* Leg ulceration
* Lymphoedema
* Recurrent cellulitis
How to diagnose cellulitis?
History
•Symptoms – Duration & severity
•Recent trauma to skin?
•Comorbidities?
•Predisposed conditions?
Examination
•Assessment of area
•Observation & vital signs
•Skin breaks/wounds
•Assess for risk factors
Investigations
•Skin swab
•Skin biopsy
•Ultrasonography
•WCC
•ESR
•CRP
What is the categorisation of cellulitis?
*Class I – No systemic illness or comorbidity
*Class II – Systemically unwell or well with comorbidity
*Class III – Significant systemic illness/upset
*Class IV – Sepsis or sever life threatening illness
Cellulitis – Differential diagnosis
- DVT
- Septic arthritis
- Gout
- Thrombophlebitis
- Cutaneous abscess
- Drug reaction
- Erythema nodosum
- Pyoderma gangrenosum
- Cancer
Cellulitis – Management
When is hospital admission req?
URGENT Hosp admission:
* Class III or Iv suspected
* Class II + serious illness
* Rapid deterioration
* Very young or very frail patients
* Facial cellulitis
* Orbital/periorbital cellulitis
Seek advice
* Wound contaminated by fresh or sea water
* Recurrent episodes
Cellulitis – Management
What medications are used in treatment?
Antibiotic treatment
* Flucloxacillin – 1st line
* Clarithromycin – 1st line in pen. allergy
* Doxycycline
* Erythromycin
* Metronidazole – If anaerobic cause suspected, avoid alcohol
* Co-amoxiclav - Avoid due to high risk c.diff…but 1st line in facial cellulitis
What is Acne?
- Chronic, inflammatory skin condition
- Blocked, inflamed pilosebaceous unit
- Affects areas with high amounts of pilosebaceous units
- Face, back, chest
- Peaks in adolescence but can affect any age
- Non-inflammatory comedones
- Whiteheads (open) & blackheads (closed)
- Papules, pustules, nodules & cysts
What is Acne? (pathophysiology)
- Excess sebum production
- Altered follicular keratinocyte proliferation – follicular plugs
- Bacteria proliferation – Cutibacterium acnes
- Affected follicle becomes inflamed
Acne
What are the contributing factors? (2)
What are the complications? (2)
Contributing factors
* Genetics – Link between identical twins, severe acne in people with FH
* Diet – Link with high GI food/diet
Complications
* Scarring
* Psychological impact – depression, anxiety, low self-esteem
Acne
What to ask when taking a history?
History
* Duration, type, distribution
* Previous treatment
* Exacerbating features
* Systemic features
* Psychological impact
* Family Hx – Endocrine disorders, PCOS, Acne
* Drug Hx – Androgens, ciclosporin, isoniazid, lithium
* Hyperandrogenism
Acne- Differential diagnosis? (5)
- Rosacea
- Perioral dermatitis
- Folliculitis & boils
- Drug-induced acne
- Keratosis pilaris
Acne:
What are the different categories? (5)
- Mild – Predominantly non-inflamed lesions & some inflammatory lesions
- Moderate– More widespread, more inflamed papules & pustules
- Severe – widespread inflammatory papules, pustules, nodules & cysts with scarring
- Conglobate acne – Rare & severe. Extensive inflammatory papules, nodules, cysts on trunk & upper limbs
- Acne fulminans – Rare. Severe inflammatory reactions, deep ulcerations & erosions. Fever & joint stiffness
Acne - Management
nformation & Advice
* Reason/cause of acne
* Therapy options – risks & benefits
* Childbearing potential – Retinoid & tetracyclines contraindicated
* Use of effective contraception or alternative acne treatment
* Impact of acne
* Adherence to treatment – 6-8 weeks before improvement
* Relapses
* Avoid over-cleaning skin – dryness & irritation
* Non-alkaline cleaning products
* Avoid oil based skin products
* Avoid picking/scratching lesions
* Treatment can irritate skin
Acne - Management:
Which medicines are used?
- Benzoyl Peroxide – topical
- Retinoids– topical or oral
- Antibiotics – topical or oral
- Azelaic acid - topical
- Combined oral contraceptive
- Benzoyl peroxide & retinoids available as combination topical products together or with antibiotic e.g. Duac gel
Benzoyl Peroxide
- Licensed from age 12
- Apply OD-BD
- Wash with soap and water before application
- Start at lower strength
- Available as a gel alone or combination with adapalene or clindamycin
- Reduce/stop use until settled & restart at lower strength
- Inc. risk of sunburn – advise on appropriate sunscreen & clothing
- Bleaching of fabrics & hair
Benzoyl PeroxideCautions/Contraindications - Hypersensitivity Hx
- Contact with broken skin, eyes, mouth, nostrils & mucous membranes
Adverse effects - Skin irritation – dryness, redness, peeling, blistering
- Reduce/stop use until settled & restart at lower strength
- Inc. risk of sunburn – advise on appropriate sunscreen & clothing
- Bleaching of fabrics & hair
Topical retinoids
- Adapalene, tretinoin, isotretinoin
- Licensed from age 12
- Isotretinoin only licensed in adults over 18
- OD-BD application
- Start at lower frequency in sensitive skin then increase application
- Apply sparingly and cover whole area not just comedones
- If using due to irritation with other product – allow to settle before starting
Topical retinoids
Cautions/Contraindications
* Hypersensitivity Hx
* Pregnancy – use of effective contraception
* Breastfeeding
* Contact with broken skin, eyes, mouth, nostrils & mucous membranes
* Severe acne, perioral dermatitis, rosacea or HX skin cancer – AVOID
* Avoid/limit UV light exposure
Adverse effects *Risk of systemic absorption – Consider interactions
* Skin & eye irritation
* Increased UV light sensitivity
Topical antibiotics
- Clindamycin & Erythromycin
- OD-BD application
- Prescribe as combination with Benzoyl
Peroxide
Cautions/Contraindications
* Hypersensitivity Hx
* Hx IBD or Antibiotic induced colitis
* Stop if pt., has diarrhoea
* Caution in atopy
* Only use in pregnancy if essential
Adverse effects
* Skin irritation
* GI disturbances
* Pseudomembranous colitis
Interaction with CYP3A4 inducers e.g.
Rifampicin
Oral antibiotics
- Add in if topical preparations fail
- Tetracyclines – Lymecycline & Doxycycline
- OD dosing
- Minocycline – No longer recommended due to adverse effects
- Lupus, skin pigmentation, hepatitis
- Only use Erythromycin if tetracyclines contraindicated
- Co-prescribed with topical retinoid or benzoyl peroxide to reduce risk of resistance
- Do not use topical & oral Abx together
- LFT before Tx, @ 6 weeks and 12 weeks
- Review treatment after 12 weeks
Azelaic Acid
- Licensed from age 12+
- Apply BD – Sensitive skin apply OD for a week then BD
- Avoid contact with broken skin, eyes, mouth, nostrils & mucous membranes
Cautions/Contraindications
* Hypersensitivity Hx
* Contact with broken skin, eyes, mouth, nostrils & mucous membranes
* Caution in pregnancy & breastfeeding
Adverse effects
* Skin irritation
* Worsening of asthma
Combined oral contraceptives
e.g. Co-Cyprindiol
- For use in acne patients with PCOS
- Use if 1st line option not successful
- Co-cyprindiol or other
- Review at 6 months
- Specialist referral
- Counsel on adherence, missed pill, vomiting & diarrhoea, interactions
- Risk of breast and cervical cancer
- Can improve acne symptoms
- Opposite to progesterone only oral contraceptive – worsens acne symptoms
Oral Isotretinoin:
When to use?
Issue?
Consider for age 12+ with severe acne resistant to all other Tx
* Nodulo-cystic acne
* Acne conglobate
* Acne fulminans
* Risk of scarring
Teratogenic
* Pregnancy test before treatment – must be negative to ctu treatment
* Effective contraception or pregnancy prevention programme
Oral Isotretinoin
Dose?
When to stop treatment?
- 0.5-1mg/kg
- Max accumulation of 120-150mg/kg then stop treatment
- Stop treatment if responsive and no new lesions for 4-8 weeks
- Review psych. wellbeing before and during treatment
- Seek help if having MH issues during treatment
Oral Isotretinoin
Contraindications?(6)
Monitor what before commencing tx? (2)
- Children under 12
- Pregnancy or risk of
- Breastfeeding
- Impaired liver function
- High level of fat in blood
- Hypervitaminosis A – high vit A
- Monitor liver function & lipids before Tx, 1 month after starting and every 3 months
-Reduce or stop if liver enzymes or lipids persistently raised
Oral Isotretinoin
Cautions? (5)
- Hx depression/psych. disorder
- Diabetes
- Dry-eye
- Impaired kidney function
- Peanut, soya, sorbitol allergy – some products contain these
Oral Isotretinoin
Adverse effects
- Inflammation & cracking of lips – moisturiser may help
- Dermatitis & dry skin
- Skin scaling
- Itching
- Rec rash
- Fragile skin
- Risk of psych. effects
- depression, anxiety, aggression, mood changes, suicidal ideation
Rosacea
Symptoms?
- Also termed Acne Rosacea
- Chronic inflammatory skin condition
- Affects convexities of centrofacial region
Symptoms - Facial flushing
- Erythema
- Papules
- Pustules
- Telangiectasia
Rosacea
Causes?
Complications?
Risk factors?
Causes:
* Genetics
* Immune system dysregulation
* Vascular neuronal dysfunction
* Demodex folliculorum mite colonisation
* Inflammatory response dysregulation
Complications:
* Psychosocial
* Anxiety
* Depression
* Low self esteem
* Alcoholism?? - linked
* Ocular Rosacea
Risk Factors
* Increasing age
* Photosensitive skin
* UV exposure
* Smoking
* Hold/cold temp. exposure
* Spicy food or hot drinks
* Alcohol
* Emotional stress or exercise
* Drugs – CCBs, Topical steroids
Diagnosis of Rosacea?
What symptoms will lead to a diagnosis?
Diagnostic symptoms?
Clinical symptoms?
- 1 diagnostic or 2 major clinical symptoms
- Diagnostic = Facial skin thickening, rhinophyma*, persistent erythema
- Clinical = Flushing, inflammatory papules/pustules, telangiectasia^, ocular symptoms
*nose enlarges and becomes red, bumpy, and bulbous
- ^ a condition characterized by dilatation of the capillaries causing them to appear as small red or purple clusters, often spidery in appearance, on the skin or the surface of an organ
Ocular Rosacea
symptoms?
- Eye discomfort/irritation
- Tearing, foreign body sensation
- Dryness & itching
- Photophobia, blurred vision
- Telangiectasia on eyelids
Rosacea- Differential diagnoses
- Acne
- Seb. dermatitis
- Contact dermatitis
- Photodermatitis/damage
- Peri-oral or peri-ocular dermatitis
- Mastocytosis
- Steroid induced dermatitis
- Folliculitis
- Lupus
- Erysipelas
- Keratosis pilaris
- Sarcoidosis
Management of Rosacea?
Non-pharmacological treatment?
Which medications are given?
- Info. & support – British Skin foundation, British association of dermatologists. Patient.info
- Self-management -Avoid triggers, sun protection, general skincare
Manage based on clinical phenotype:
* Persistent erythema– Topical Brimonidine gel once daily PRN
- Mild-Moderate papules and/or pustules – Topical Ivermectin OD 8-12 weeks
-Or topical metronidazole 0.75% BD or Azelaic Acid 15% BD - Moderate-Severe papules and/or pustules – Topical Ivermectin and Doxycycline MR 40mg OD for 8-12 weeks
- Alternative topical Metronidazole or Azelaic Acid
- Alternative abx – Oxytetracycline or Tetracycline 500mg BD or Erythromycin 500mg BD
- Clinically inflamed phymatous disease – Doxycycline MR 40mg OD for 6 weeks
Brimonidine
- Α2 adrenoceptor agonist
- Reduces erythema by cutaneous vasoconstriction
- Cautions – Cerebral insufficiency, coronary insufficiency/severe CVD, depression,
postural hypotension, Raynaud’s syndrome, thromboangiitis obliterans, hepatic & renal
impairment, pregnancy, breastfeeding - Side Effects – Dizziness, dry mouth, headache, skin reactions, flushing, angio-oedema, eyelid oedema, nasal congestion, cold peripheries, hypotension, bradycardia,
exacerbation of rosacea symptoms
Ivermectin
Cautions/Contraindications
Side Effects
Drug interactions
Cautions
* Severe hepatic impairment
* Pregnancy
* Breastfeeding
Side Effects
* Skin reactions
Drug interaction with Warfarin – Increases warfarin effect
Also a treatment for parasite infection e.g. Norwegian scabies
Metronidazole
Cautions/Contraindications
Side Effects
Drug interactions
Cautions/Contraindications
* Avoid exposure to strong sunlight/UV light
* Avoid contact with eyes, mouth & mucous membranes
Side Effects
* Skin reactions
* SJS – Stevens-Johnson Syndrome
* TEN – Toxic Epidermal Necrolysis
* AGEP – Acute Generalised Exanthematous Pustulosis
Drug interactions
* Lithium – Inc, concentration of lithium
* Warfarin – inc. effect of warfarin
