W25 CAS Skin Conditions Flashcards
What are the skin related CAS conditions?
- Acne
- Athlete’s foot
- Chickenpox
- Cold sores
- Dry skin
- Ingrowing toenail
- Nappy rash
- Ringworm, tinea cruris & intertrigo
- Scabies
- Warts & Verrucae
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)
- Inflammatory papules, pustules, nodules cysts
Treatment of Acne? (Offered by CAS)
- Mild to moderate acne
1. Benzoyl Peroxide 3 or 5% with clindamycin 1% gel (DUAC Once daily gel)
2. Benzoyl Peroxide 5% gel – only if other options not suitable - 12 week course of 1st line treatment applied once daily in the evening
- 30 or 60g packs
- Products supplied under PGD
What is the Counselling/Self care advice for acne?
- Do not pick or squeeze spots
- Wash area max. twice a day with mild soap/cleanser, avoid hard scrubbing
- Avoid using heavy make –up & cosmetics, avoid oil based products, remove make up at end of day
- Clean skin with non-alkaline skin cleansing product
- Shower after exercise, wash hair regularly
- Apply gel sparingly after washing and drying affected area – pat dry
- Apply to whole affected area (e.g. whole face) OD/BD
- Advise on skin irritation, bleaching effect & light sensitivity – start with alt. days & short contact application
- Benzoyl Peroxide can bleach clothes and hair
- Can take up to 6 weeks to notice effect
When is a GP Referral required for acne?
- Moderate/Severe Acne
- No improvement or worsening within 6 weeks
What is ATHLETE’S FOOT?
- AKA Tinea Pedis
- Fungal/dermatophyte infection affecting feet
- Overgrowth of fungus due to warm, humid, wet conditions in feet –sweaty feet
- Picked up by walking barefoot in areas where someone with athlete’s foot has been
- Itchy, white/red, scaly, blistering, cracking skin between toes
- Can spread to soles of foot and nails
=Can treat with topical corticosteroid if there’s a lot of inflammation or dry skin
What is athlete’s foot treated with? (general)
- Treated with antifungal agents – Clotrimazole, Terbinafine, Miconazole
- Can treat with topical corticosteroid if there’s a lot of inflammation or dry skin
What are 4 treatments for Athlete’s foot?
- Clotrimazole 1% Cream (Canesten)
* up to 3x 20g tubes, max. 2 supplies per year
* Apply 2-3 times daily & use for at least 4 weeks - Miconazole 2% Cream (Daktarin)
* up to 2x30g tubes, max. 2 supplies per year
* Apply BD, continue for 10 days after healing
* Avoid in patient taking Warfarin - Terbinafine 1% Cream
* up to 1x30g tubes, max. 2 supplies per year
* Apply OD-BD for 1 week - Hydrocortisone 1% cream
* 1 x 15g tube, max. 2 supplies per year
* Max 7 days treatment
Athletes foot- what is advice for patients? (From PIL)
- Wash and dry the affected skin before applying treatment and clean your hands afterwards
- Antifungal treatment should be applied to the affected skin and surrounding area
- Do not scratch affected skin as this can spread the infection to other parts of your body
- Seek medical advice if the condition does not improve within a week of treatment
- Wear footwear that keeps the feet cool and dry, leaving shoes and socks off as much as possible when at home
- Change to a different pair of shoes every 2-3 days
Wash the feet daily, then dry them thoroughly, especially between the toes - Avoid using moisturisers between the toes because this may help fungi to multiply
- Antifungal dusting powders may help prevent re-infection
- Do not share towels and wash them frequently
- Avoid going barefoot in public places
ATHLETE’S FOOT - GP referral
Severe or extensive symptoms
* Signs/symptoms of bacterial symptoms – what are these?
* Recurrent episodes – Why?
* No improvement after 1 week
* Pain & discomfort
* Patient is immunocompromised
* Poorly controlled diabetes and not reviewed in last 3 months
What is Chicken pox?
- Acute viral disease
- Caused by varicella-zoster virus
- Common childhood illness but can also affect adults
- Rash – small, red, raised spots, itchy, blisters/vesicles present
- Commonly on face, scalp, trunk and limbs
- Also fever & malaise
- Very infectious – stay off school/nursery until all blisters scabbed over
- Children under 14 under CAS
What are the treatments for chicken pox?
- Paracetamol 120mg/5ml (100ml) or 250mg/5ml SF oral suspension (200ml)
-Not for children under 3 months - Paracetamol 500mg tablets x 32
- Chlorphenamine 2mg/5ml SF oral solution 150ml
-Not to be given to children under 1 - Chlorphenamine 4mg tablets x 28
-Not for children under 6
What is the self management advice for chicken pox?
- Adequate fluid intake
- Appropriate clothing to avoid overheating or shivering – smooth, cotton fabrics
- Keep nails short and clean to minimise skin damage from scratching – mittens for younger children
- Lukewarm/cool bath - dab/pat dry
- Calamine lotion/cream, emollients, cooling gels
- Advise on signs of bacterial infection
Chicken pox
What must you NOT ADVISE OR SUPPLY?
Why-complications?(2)
IBUPROFEN
* increased risks of skin infection & necrotising fasciitis
* Increased pneumonia risk in children with respiratory problems
CHICKEN POX – GP REFERRAL
When to refer?
- Unsure over diagnosis
- Systemically unwell, deterioration, complications, no improvement in 6 days
- Baby less than 4 weeks old – Disseminated/haemorrhagic varicella risk
- Suspected bacterial infection
- Dehydration
- Associated respiratory symptoms – cough, SOB, chest pain/tightness
What are COLD SORES?
- Small vesicles/blisters around the mouth and on lips
- Herpes simplex virus (HSV)
- Exists in a latent state and can remain latent indefinitely, or reactivate to cause clinical infection
- Tingling, itching burning around the mouth before blisters appear
- Self-limiting – can heal in 7-10 days
- Poor evidence for topical antiviral treatment efficacy
What are the triggers for cold sores?
- Illness/infection
- Strong sunlight
- Fatigue
- Stress/upset
- Injury to area
- Periods
Cold sores
Advice only under CAS
What advice to give?
- Minimising transmission
- Avoid touching lesions
- Avoid kissing until completely healed
-newborn babies/immunocompromised - Avoid oral sex until healed
- Do not share lipstick/gloss/balm
- Drink adequate fluids
- Avoid acidic/salty foods
- Eat soft, cool foods
- Risk of recurrence
- Use of sunscreen/sunblock lip balm
Cold sores- When to refer to GP?
- Pregnancy
- Neonates
- Immunocompromised
- Recurrences – 6+/year
- Deterioration – spreading lesions, fever,
dehydration - No improvement after 5-7 days
COLD SORES- What can patients buy OTC?
Advice? (4)
- Patients can purchase OTC Aciclovir cream or cold sore patches
Advise on:
* Avoid touching lesions
* Wash hands before & after use
* Dab on rather than rub in
* Do not share product with others
What is DRY SKIN/DERMATITIS?
What are the triggers?
When to refer to GP? (2)
- Rough, scaly, flaky, cracked skin
- Sometimes red & itchy – atopic dermatitis
Triggers:
* Hot/cold/windy conditions
* Excess washing
* Soaps, detergents, chemicals, alcohol
* Clothing & animal hair
* Foods
* Pollen
* Stress
GP referral – Signs of infection, treatment failure
Dry skin/Dermatitis treatments?
- Aim to maintain skin moisture, barrier function and reduce itching
Emollients – liberal application & often, avoid aqueous cream
* Cetraben, Zerobase, Doublebase, Diprobase, Zerodouble, Hydromol, WSP/LP 50:50
* Creams better for inflamed skin, ointments better for dry skin (Hydromol or 50:50)
* Emulsifying ointment as soap substitute
Topical Corticosteroid – Reduce itching and inflammation
* Hydrocortisone 1%/2.5% cream/ointment
* Not to be supplied for children under 10 or pregnant women
* Use 1% first. 2.5% if patient has established dermatitis and 1% not effective
- First episode as two consultations in order to include trial of therapy. Further episodes as a single consultation.
- First consultation – Provide either a) a choice of up to three different 50–125 g pots as a trial of therapy or to establish
preference or b) a 500 g pot if person already has a preference. - Second consultation – Provide a 500 g pot of preferred product if not supplied at first consultation
What is the advice/self management for
Dry skin/dermatitis?
- Emollient use
- Avoid triggers/exacerbating factors
- Products contain paraffin – advice on smoking/naked flame or heat exposure
- Change/wash bedding regularly
- Keep nails short
- Mittens for younger children
- Keep skin covered with light/loose clothing
What is Ingrown toenail?
treatment? (1)
- Extremely common
- Part of toenail penetrates into the skin
- Pain, redness, heat, tenderness, swelling, pus of nail fold
- No treatment under CAS – ADVICE ONLY
What is the Advice for Ingrowing toenail?
- Analgesia – Paracetamol
- Prevention from getting worse
- Soak in water for 10 minutes to soften skin around nail
- Use cotton wool bud to push skin fold over ingrown nail and away – start at root towards end of the nail
- Repeat daily for a few weeks – give nail room to grow
- As nail grows push a piece of cotton wool or dental floss under the nail to aid growth over skin
- Do not cut the nail until it has grown clear from end of toe
What are the causes of ingrowing toenail?
- Trimming/cutting nail too short
- Tearing off toenail
- Constricting footwear
- Sweaty feet
- Injury to the nail
When is GP Referral required for ingrowing toenail?
- Diabetic
- Infection may need surgical intervention or draining
- Concurrent nail disease
- No improvement within 7 days or worsening
- Abx needed
What is Intertrigo?
2 types?
- Inflammation/rash in body folds
- Under breasts, armpits, groin
- Moist macerated skin, cracking, peeling?
Inflammatory:
* Symmetrical
* Armpits, groin, under breasts, abdominal folds
Infectious:
* Unilateral/asymmetrical
* Bacteria, yeast, fungal growth/cause
Intertrigo
What are the treatment options? (4)
-
Clotrimazole 1% cream 20g
* Supply up to 2 tubes up to twice per year
* min. 6 months since 1st episode
* Apply 2-3 times day for at least 2 weeks for candida infection -
Miconazole 2% cream 30g
* Supply 1 tube up to twice per year
* min. 6 months since 1st episode
* Apply BD & for at least 1 week after rash cleared
* Avoid in warfarin patients -
Terbinafine 1% Cream
* Up to 1x30g tubes, max. 2 supplies per year
* Apply OD-BD for 1 week -
Hydrocortisone 1% cream 15g
* Supply 1 tube up to twice per year
* min. 6 months since 1st episode
* Only use if skin itchy & inflamed
* OD-BD application, OD to groin
Self Management for intertrigo?
- Wash affected area daily & dry thoroughly
- Wash clothes & bed linen frequently
- Do not share towels & wash frequently
- Wear loose-fitting clothing or materials that take moisture away from the skin
When is a GP Referral required for intertrigo? (5)
- Severe/extensive cases
- Signs/symptoms of bacterial infection
- No improvement after 2 weeks treatment
- Recurrent episodes
- Immunocompromised
- Poorly controlled diabetes
What is Nappy rash?
What are the causes?
- Mild rash to nappy area
- Redness over buttocks, genitals, pubic region and upper thighs
- Can be scaly
Causes
* Prolonged skin contact with urine & faeces
* Candida infection
What is the advice for nappy rash?
- Use high absorbency nappies
- Keep nappies off for as long as possible
- Change & clean asap after wetting & soiling
- Use water based/alcohol-free/fragrance free wipes
- Dry gently, avoid rubbing
- Bath daily – avoid more than OD bathing
- Avoid soap, bubble baths or lotion
NAPPY RASH- TREATMENT
What are the 3 options?
Barrier cream/ointment:
* 1 tube, 1 supply per year
* Zinc & castor oil 100g
* Metanium ointment 30g
* Apply thinly at each nappy change
Hydrocortisone 1% cream:
* 1 x 15g tube, 1 supply per year
* From 1 month of age under service
* Max 7 days use
Clotrimazole 1% cream:
* 1 x 20g tube, 1 supply per year
* If suspect candida infection
* Apply 2-3 times per day, ctu for 2 weeks after cleared
When to refer to GP for nappy rash?
- Signs of bacterial infection
- Severe inflammation
- Baby systemically unwell
- Fever
What is Ringworm?
What is it spread by? (4 contacts)
- Common fungal infection
- Circular lesion/patch, inside pale with exterior redness, marked boundary
- Gradually can become larger
Spread by:
* human to human contact
* human to animal contact
* human to object contact
* human to soil contact
What is the self-care advice for ringworm? (5)
- Wash affected skin daily, dry thoroughly afterwards
- Wash clothes, towels & bed linen frequently
- Do not share towels
- Wear loose-fitting clothes made of cotton or a material designed to move moisture away from the skin.
- Take your pet to the vet if they might have ringworm
What is the treatment for ringworm?
- Clotrimazole 1% cream 20g
- Supply up to 2 tubes up to twice per year
- min. 6 months since 1st episode
- Apply 2-3 times day for at least 2 weeks for candida infection
- Miconazole 2% cream 30g
- Supply 1 tube up to twice per year
- min. 6 months since 1st episode
- Apply BD & for at least 1 week after rash cleared
- Avoid in warfarin patients
- Terbinafine 1% Cream
- up to 1x30g tubes, max. 2 supplies per year
- Apply OD-BD for 1 week
- Hydrocortisone 1% cream 15g
- Supply 1 tube up to twice per year
- min. 6 months since 1st episode
- Only use if skin itchy & inflamed
- OD-BD application, OD to groin
When to refer Ringworm to GP?
- Severe/extensive case
- Suspected bacterial infection
- Treatment failure after 2 weeks
- Recurrent episodes
- Immunocompromised
- Poorly controlled diabetes
- Scalp infection
- Ringworm of scalp
What is scabies?
- Intense itching rash, worse at night and in heat
- Burrows seen in webs between fingers - Mites lay eggs in the skin
- Raised rash or spots.
- The spots may look red
- Starts between the fingers but can appear anywhere and spread across whole body
- Rash may then spread and turn into tiny spots
Advice for scabies?
- Wash clothes, bed sheets, towels at high temp (60°C+) then dry in a hot air dryer
- Any clothes that can’t be washed should be sealed in plastic bag for 72 hours
- Treat all people within the household or anyone who has been a close contact e.g.
sexual contacts within last 8 weeks – even if they have no symptoms
When is GP Referral required for Scabies? (6)
- Severe Rash
- Suspected secondary bacterial infection
- Systemically unwell
- Child under 2
- Crusted scabies suspected
- Treatment failure – 2 courses of treatment
Scabies treatment:
What are the options? (3)
Where to apply?
- Insecticide treatment
Permethrin 5% cream 30g (1st line)
* Max. supply 4 packs on 1 occasion
* Apply to whole body especially inbetween webs of fingers, toes and under nails
* Wash off after 8-12 hours
* Reapply if washed off within 8 hours
* 1 x 30g tube should cover whole body
* Apply again 1 week after first application
Malathion 5% Liquid 200ml (2nd line)
* Max 2 packs on one occasion
* Whole body application
* Wash off after 24 hours – reapply if washed off before
* 2nd application after 1 week
Chlorphenamine (significant night-time itch)
* 4mg tablets x 28 – over 6yrs
* 2mg/5ml SF oral solution x 150ml – child age 1+
* For itching
* Itching can persist for 2-4 weeks after successful treatment
What are WARTS & VERRUCAE?
Caused by?
*Small rough growths on skin
*Caused by HPV
*Can appear anywhere on skin but most commonly on hands & feet
*Verruca = wart on sole of the foot
*Unsightly but not harmful, don’t usually cause symptoms and resolve eventually without treatment
*Contagious but the risk of transmission is low.
What is the Advice/Self management for Warts & Verrucae
- Seek medical advice if the wart persists longer than 12 weeks of treatment.
- Reduce risk of transmission:
- Cover with waterproof plaster when swimming
- Wear flip-flops in communal showers
- Avoid sharing shoes, socks and towels
- Avoid scratching lesions, biting nails or sucking fingers that have warts
- Keep feet dry and change socks daily.
Warts & Verrucae - TREATMENT
What is first-line?
Counselling points?
- Salactol Paint (Salicylic Acid 16.7%/Lactic Acid 16.7%)
- Salactac Gel (Salicylic Acid 12%)
- Can be used from age 2+ under CAS
- Apply at night for 12 weeks
- Debride surface with emery board / soften in warm water for up to 10 mins before first application
- Further applications – peel off film then debride/soak
- Avoid applying to surrounding skin – causes inflammation
- Apply Vaseline around surrounding skin to avoid
- Stop treatment for a few days if skin becomes irritated then re-start
- Keep away from heat/source of naked flame
When is GP Referral required for warts & verrucae?
- Wart on face, intertriginous or anogenital regions
- Uncertain diagnosis
- Warts with hair growing out of them
- Bleeding warts
- Changed in appearance
- Wart is associated with significant pain
- Immunocompromised
- Extensive areas are affected
- Persistent and unresponsive to salicylic acid
- Diabetic or have poor circulation to the hands or feet
