ACNE

Common Skin Problems









Produced by the

Department of Dermatology – revised

March 2007

FORWARD



This booklet provides general guidance for G.Ps. on how to manage some

of the more common skin problems. The clinical sections have been

jointly written by the Consultants at the Royal Liverpool & Broadgreen

University Hospitals Trust.



It was produced in the hope that by working together we can provide the

highest possible quality of care to patients.



In addition, it includes information about the Dermatology service at

Broadgreen Hospital, which we hope you will find useful.



This information should help you to get the most out of the Dermatology

Department for your patients.









Dr Richard Azurdia

Consultant Dermatologist









Published with the support of an Educational Grant from

Leo Pharmaceuticals

THE DERMATOLOGY SERVICE



AT



THE ROYAL LIVERPOOL & BROADGREEN



UNIVERSITY HOSPITALS NHS TRUST





The Department of Dermatology at Broadgreen Hospital provides

specialist clinical expertise together with a wide range of diagnostic and

treatment facilities. In addition to general dermatology clinics the

following services are provided.



Diagnostic & Therapeutic Services:



 Cosmetic Camouflage

 Dermatological Surgery & Minor Operations

 Dressings

 Electrolysis

 Iontophoresis & Botulinum toxin for hyperhidrosis

 On call SpR for advice on all urgent adult or paediatric cases

 Out-patient and In-patient Treatments

 Patch Testing (for allergic contact dermatitis)

 Photodynamic Therapy (PDT)

 Phototherapy – UVB, TLO1, PUVA

 Psoriasis – specialist clinic

 Rapid Lesion Assessment Clinic (for melanoma and squamous cell

carcinoma)

 Specialist Nurse Clinics – phototherapy, cytotoxic drug monitoring,

skin cancer

 Vulval skin disease – specialist clinic









1

Consultants Special Interests/Areas of Expertise



Whilst all of the Dermatology Consultants undertake general clinics, each

have their own areas of expertise as shown below:



Consultant Qualifications Areas of Expertise



Dr RM Azurdia BMedSci (Hons), Phototherapy for

BMBS, MRCPI inflammatory skin disease,

PDT, Skin cancer



Dr H Bell MB ChB, MRCP Vulval dermatoses,

MRCGP, DRCOG, DCCH cutaneous cancer



Dr T Clayton MBChB MRCPCH Paediatric dermatology



Dr C M King LRCP&SI, FRCP Contact Dermatitis and

Patch Testing



Dr R A G Parslew MBChB MRCP Inflammatory Skin Disease,

Therapeutics and Paediatric

Dermatology



Dr G R Sharpe MBChB, BA, PhD Cutaneous Malignancies,

Clinical Director FRCP, DTM&H Hereditary Disorders,

Dermatological Surgery and

Paediatric Dermatology



Dr N J E Wilson BSc (Hons) MBChB Cutaneous Malignancies &

FRCP Histopathology,

hyperhidrosis





Dr GAE Wong BMedSci (Hons) MBChB Cutaneous adverse drug

MRCP reactions, therapeutics, PDT









2

Contact Points



For appointments please contact RLBUHT Medical Records:

(0151) 2826122



For patient enquiries please contact the medical secretaries on the

numbers listed below:



Designation Name Telephone No



Consultant Dr R M Azurdia BGH (0151) 2826858



Consultant Dr H Bell BGH (0151) 2826857

Aintree (0151) 5294785



Consultant Dr C M King BGH (0151) 2826143



Consultant Dr R A G Parslew BGH (0151) 2826144

AHCH (0151) 2525729



Consultant Dr G R Sharpe BGH (0151) 2826144



AHCH (0151) 2525729



Consultant Dr N J E Wilson BGH (0151) 2826856



Consultant Dr GAE Wong BGH (0151) 2826145

Aintree (0151) 5294147



Associate Specialist Dr S Jackson BGH (0151) 2826283



Matron & Directorate Manager

Mrs D Baines BGH (0151) 2826319







Fax no: Dermatology Department, Broadgreen (0151) 282 6899

Fax no: Dermatology Department, Aintree (0151) 529 4857

Fax no: Dermatology Department, Alder Hey (0151) 252 5928









3

Routine Referrals

When you refer patients to the Dermatology Department you may wish to

write personally to an individual Consultant. However, we are also happy

to receive letters addressed to “The Dermatologist”, as this allows more

flexibility in arranging the clinics and appointments.



Partial Booking

In line with the NHS Plan the service operates a partial booking system

for all routine Dermatology appointments. This does not apply to skin

cancer referrals or other urgent referrals.



 What is Partial Booking?

Partial Booking is a new method of booking outpatient

appointments which allows patients to choose a convenient time

for their appointment.



 How does if work?

Patients are referred to hospital in the normal way. Referrals are

given to Consultants to be prioritised. All routine patients are

then added to an outpatient waiting list, a letter is sent to the

patient informing them that the referral has been received, added

to a waiting list and that we will contact them in due course.

Approximately 4 weeks before the appointment a letter is sent to

the patient inviting them to contact the hospital to arrange an

appointment at a mutually convenient time. Appointments are

offered over the following 4 weeks. Once the date is agreed

confirmation is sent together with information about the

particular clinic. Those patients who do not respond to the

invitation letter within 4 weeks will be discharged back to their

G.P.



 How do patients contact the hospital?

A dedicated Telephone Access Centre holds calls in a queue with

options to contact the correct department to arrange the

appointment. There is voicemail available for those callers who

wish to leave a message if they are unable to wait in the queue.

The Telephone Access Centre is manned by 6 experienced

members of the clerical team and is open Monday to Friday

08.30am to 8.00pm. The busiest times are between 09.00 and

3.00pm.









4

 What are the benefits to patients?

Because patients choose the day of their appointment there is far

less chance of them not attending therefore reducing the number

of wasted appointments. As appointments are only booked 4

weeks in advance there should not be a need for the hospital to

cancel the appointment.



Urgent Referrals

For an urgent/emergency dermatological opinion on paediatric or adult

problems, please contact the hospital switchboard (0151) 706 2000 and

ask for the Dermatology “on call” Registrar. The “on call” Registrar will

be able to discuss the problem, advise, and if necessary arrange an urgent

appointment.



For urgent assessment of lesions suspected to be either a melanoma

or squamous cell carcinoma only please refer to the Rapid Lesion

Assessment Clinic. Referrals should be made by fax on the appropriate

form. Patients will be sent an appointment for a clinic date within 2

weeks of your referral.



NB: Please do not abuse the urgent referral service by using it for

BCCs. If a BCC is suspected and indicated in the referral letter it

will be given appropriate priority.



Specialist Nurse Led Clinics

 Cytotoxic Drug Monitoring

 Phototherapy & PDT treatment & monitoring

 Minor surgery & skin cancer

 Iontophoresis (for hyperhidrosis)



These clinics run in conjunction with a Consultant Led Dermatology Clinic.

The Specialist Nurse is available for advice on 706 2000 bleep 296 or

282 6155.



The nurses within the Dermatology OPD have a wide experience of

knowledge on:

 Leg ulcers

 Doppler studies

 Patch testing

 Phototherapy

 Minor surgery



5

Research and Teaching

The department has an active research and development programme

thereby ensuring a constant review of practices and procedures and a

continuous advancement of knowledge. At any time there are usually a

number of clinical trials and investigations ongoing. This will include local

studies and multicentre pharmaceutical trials (usually phase III trials).

All clinical trials are approved by the Local Ethics Committee and General

Practitioners will be fully informed if their patients participate.

Particular interests of the department include the treatment of eczema

and psoriasis.



The department forms an important focus for undergraduate,

postgraduate and specialist paediatric dermatology teaching in the

Region, and in future years we intend to further develop postgraduate

teaching. In this respect we welcome comments and requests from

General Practitioners on how to best meet their educational needs.



Ward 4

Ward 4 is based on the 2nd floor Alexander Wing, BGH. This is a

dedicated 20 bed Dermatology ward and is used for the in-patient

management of skin disease egs severe psoriasis, eczema, blistering

disorders, cellulitis & leg ulceration; there is also a day care room which

can be used for patient treatments not requiring overnight stay.

Admission to the ward is arranged via the Dermatology OPD or on call

SpR.



Phototherapy Unit

The Phototherapy unit is based next to ward 4 at BGH. This unit is for

out-patient therapies which include broadband UVB, TLO1 narrowband

UVB and PUVA for inflammatory skin disease. Patients will be asked to

attend 2 or 3 times per week, depending on the treatment, on an

appointment basis. As well as UV therapies, topical treatments such as

dithranol and tar can be arranged with full private shower facilities.

Treatments are performed and monitored by trained nursing staff and all

patients will have a baseline assessment and monitoring visits to the

Consultant led or Specialist Nurse led Phototherapy Clinics.

UVB & TLO1 appointment times 9am – 8pm (Monday, Wednesday, Friday)

PUVA appointment times 9am – 5pm (Tuesday, Friday)









6

GPwSI

In conjunction with the local PCTs the Dermatology Department has

trained a number of local GPs who are working as GPs with a Special

Interest (GPwSI). There are at present 6 GPs running Community

Dermatology clinics. The appropriate PCT will advise about referral

pathways and appropriate conditions to refer. Normally referrals are

made directly from the GP to the local GPwSI clinic. Each GPwSI has

established links with secondary care to refer on when appropriate.









7

MANAGEMENT OF COMMON SKIN

PROBLEMS



 Acne (guidelines)

 Bacterial infections

 Eczema (guidelines)

 Eczema & patch testing

 Fungal infections

 Infestations

 Scabies

 Minor surgery

 Psoriasis (guidelines)

 Solar damage & skin cancer

 Urticaria

 Venous ulcers

 Viral infections









8

Management of Acne in Primary Care



PATIENT HISTORY

Assess:

1. Acne severity and duration

2. Drug/external factor complications

3. Psychological impact

4. Patient expectations with treatment and compliance





EXAMINATION

Pattern of 1. Check sites

2. Note type of lesions

disease

3. Note extent of disease

4. Assess social implications









Mild

Mainly comedones

(blackheads and whiteheads)

Some inflammatory papules

& pustules









Moderate

Superficial acne or acne with

deeper inflammatory

component. Inflamed papules

and pustules.









Severe

Nodulocystic lesions. May be

inflamed on the trunk.

Scarring









Psychological Problems







TREATMENT - SEE OVER



9

Patient Education

Acne Support Group 0208 841 4747

www.stopspots.org







Comedonal Acne Mild Acne Moderate Acne Severe Acne







Retin A Benzoyl peroxide gel Oral antibiotics

cream/gel/lotion 5% once-twice daily Oxytetracycline 500mg bd or

Apply twice daily Use aqueous cream Erythromycin 500mg bd

Or Differin in between treatment Continue with topical treatments.

cream/gel nocte if skin is irritated and Do not prescribe different oral and

dry topical antibiotics at the same time

to avoid antibiotic resistance.

Acne scarring - avoid by treating

early + in severe cases refer to

plastic surgery

50% improvement not

achieved in two months

Refer immediately to

No No

Consultant Dermatologist

improvement response

Consider Roaccutane



Topical antibiotic/combinations treatment

Dalacin T solution, Zineryt lotion Change to Tetralysal

Zindaclin gel, Duac gel, Benzamycin gel 300mgs daily or Minocin MR









No improvement

100mgs daily

Add Dianette for

girls/women in combination

Assess response at 3 months with antibiotics







Assess response at 3 months (Dianette

takes up to 6 months to show full effect)

Improvement Continue antibiotics for at least 1 year -

max. 2 years. Tail off and withdraw



Continue topical treatments

indefinitely

Avoid topical antibiotics for

more than 6 months





SPECIAL CASES

Under 10 years

Do not use oxytetracycline - permanent discoloration of teeth may occur.

Pregnancy and pre-conception

Do not use oral antibiotics. Refer to dermatologist if acne moderate-severe.

Oral contraceptives

Extra precautions on commencing and discontinuing oral antibiotics for 4 weeks. When

established on oral antibiotics normal contraception is adequate. Where possible transfer

to Dianette from other oral combined contraceptives.

Over 25 years

Persisting mild-mod acne - refer. Roaccutane may be justified earlier in this age group.

10

ACNE - summary







Mild Acne Benzoyl peroxide preparations once daily – gel:

2.5%, 5% then 10% as tolerated for 3 months.

Improvement – continue topical treatment

indefinitely

No Improvement – either change to topical

antibiotic, e.g. Erythromycin 2 or 4% or

Clindamycin 1% twice daily, or alternate topical

antibiotic with benzoyl peroxide morning and

evening for 3 months.

Topical Tretinoin or adapalene for comedonal

acne.



Moderate Acne Oral antibiotics options include –

Oxytetracycline 500mg bd, Erythromycin

500mg bd, Doxycycline 100mg od, Minocycline

100mg od or Lymecycline 408mg od with or

without benzoyl peroxide topically bd for 3 - 6

months.

In women - consider Dianette as an oral

contraceptive (contains cyproterone acetate –

anti-androgen)

Improvement – stop antibiotic after 6 months

or reduce the dose. Continue topical treatment

if needed. If relapse – restart antibiotics.

No Improvement – refer to Dermatologist.

Consideration for Trimethoprim or Isotretinoin

(Roaccutane)



Severe Acne Refer to dermatologist. Consideration for

Isotretinoin



Remember

 Most topical agents are a little irritant.

 Do not combine an oral antibiotic and a different topical antibiotic to

avoid antibiotic resistance.

 Benzoyl peroxide is a bleach.

 Isotretinoin (Roaccutane) is a teratogen.









11

 Acne scarring – try to avoid by treating early and stop patients picking

spots; in severe cases dermabrasion or laser resurfacing (refer

plastic surgery) can be considered once the acne is under control.

 Antibiotic resistance can be reduced by combining a systemic

antibiotic with either benzoyl peroxide or a topical retinoid









12

BACTERIAL INFECTIONS



Cellulitis

 Streptococcus pyogenes or Staphylococcus aureus most common.

 Deep infection and can involve subcutaneous tissue.

 Predisposing factors - leg ulceration, Tinea infection, injury, surgery.

Management

 Penicillin V & flucloxacillin initially but often requires IV

benzylpenicillin & flucloxacillin or erythromycin/clarithromycin.



Erysipelas

 -haemolytic Streptococcus (often of face or lower leg).

 Superficial infection, acute onset.

 Unilateral tender erythema and swelling of the face.

 High fever and patient unwell.

 Usually IV antibiotics – benzylpenicillin and flucloxacillin or

erythromycin are required.



Impetigo

 Staphylococcus aureus or -haemolytic Streptococcus.

 Young children.

 Contagious, can spread rapidly.

 Predisposing factors – eczema.

 Clinically – face involvement with blisters/yellow pus, crusts.

 Differential diagnosis - herpes simplex, diagnosis – skin swab.

Management

 Topical (fucidin cream or mupirocin ointment) and oral antibiotics for

7 days (flucloxacillin or erythromycin).

 Emollients as soap substitute and bath additive containing antiseptic.



Staphylococcal Scalded Skin Syndrome

 Due to the exotoxin of the Staphylococcus.

 Occurs mainly in infancy and childhood.

 Can vary from localised bullous impetigo to the generalised fulminating

form with the scalded appearance of the skin.

 Painful skin condition resulting in flaccid blistering and raw areas.

 Needs admission to hospital for oral/IV and topical antibiotics,

adequate analgesia and good nursing care.









13

MRSA

Methicillin resistant Staphylococcus aureus (MRSA) is a nosocomial

pathogen that affects patients and staff in many hospitals in the UK.

MRSA is a Gram-positive bacterium. Like Methicillin sensitive

Staphylococcus aureus, it can also be carried harmlessly by many people

on their skin and in their noses without causing an infection. MRSA

causes a spectrum of illness, ranging from trivial skin infections to life-

threatening conditions such as bacteraemia, endocarditis and pneumonia.

Some patients can shed MRSA heavily into the environment, and will

release airborne particles carrying staphylococci e.g. patients with

widespread eczema or upper respiratory infections. There is normally a

wide range of antibiotics to treat staphylococcal disease. However, MRSA

is resistant to a wide range of antibiotics. Transmission is mainly by

direct contact, chiefly via hands. Airborne spread may also be possible

over small distances.

Further information about the management of MRSA can be obtained

from the Infection Control Team at RLBUHT.









14

MANAGEMENT OF ATOPIC AND CONTACT DERMATITIS (ECZEMA) IN

PRIMARY CARE





PATIENT HISTORY

1. Duration EXAMINATION

2. Family history 1. Check sites (face, flexures, trunk, limbs)

3. Possible triggers - irritant or allergy? 2. Character (excoriated, cracked,

4. Occupation impetiginised?)

5. Medical history

3. Extent of cover - well demarcated. Limited

6. Drug history in area?

7. Exclude other causes - eg scabies 4. Assess degree of itching

8. Patient expectations and ability to comply with treatment









Pattern of

disease

Allergic Contact Irritant Contact

Try and establish allergen. Avoid irritants and wet work

Patch testing may be Use PVC gloves with cotton liners

necessary (not for irritant or

Atopic

food allergy).

Assess severity before deciding treatment.

Avoid contact with allergen.

PATIENT EDUCATION Excoriated, cracked or impetiginised before

Otherwise treatment as for

1. Advice at consultation. Pattern of considering treatment options - see over.

irritant.

disease/cause. Provide patient education and support

2. Leaflets groups. Explain nature of chronic condition.

3. Demonstrate hand care Establish any nursing support if needed.







TREATMENT For Treatment see over





Dry and Scaly Wet and Weepy

Emollients +++ - bath oils, soap substitutes and Consider potent steroid and antibacterial cream, e.g.

moisturisers (500g containers). FuciBET, Betnovate C (not on face).

Potent steroid ointment - reduce down slowly If infected may need to give a systemic antibiotic with the

strength of steroid. topical steroid, eg flucloxacillin/ erythromycin for 10-14 days.

Apply Duoderm or Haelan tape to painful fissures if Topical combination can also be used in conjunction.

cracked. Swab if no improvement and treat other carrier sites (nasal,

Very dry & scaly - wet wraps or Ichthopaste axilla, groin).

bandages. Refer to dermatologist if no improvement.







Continuing Care

Sedation Continue initial measures to avoid irritants

Sedating antihistamine (eg hydroxyzine, Continue emollients +++

chlorpheniramine, promethazine) pm for itch. Review regularly to weakest strength steroid (see

over) and manage acute episode







Indications for Referral

Suspected contact allergic factors - patch testing

Inability to get back to work

Persisting despite treatment

15 Need for second line therapy

PATIENT EDUCATION

TREATMENT





Emollients Frequency for All

+ 1. Advice at consultation. Pattern of disease, pathogenesis,

genetics, etc.

2. Leaflets

3. Support agencies (National Eczema Society - 163 Eversholt

Bath oils St, London NW1 1BY. Tel: 0171 388 4097. www.eczema.org)

Soap substitutes 4. Nursing support - treatment & techniques

Moisturisers



Wet and Weepy? Impetiginised?

Steroids

Babies, the face and in flexures - Mild steroid and antibiotic

SEE NOTES BELOW

combination, eg Fucidin H cream or ointment.

Face - Mild steroid

Adults - trunk & limbs:

Flexures - Mild steroid + antimicrobial cream,

Potent steroid and antibacterial cream, eg FuciBET cream.

eg Fucidin H cream or ointment

Cotton gauze dressings/bandages. Wet wrapping for children

Trunk & limbs - Mild to moderate steroid

only when infection is controlled.

If infected, may need to give a systemic antibiotic with the

Cracked or Excoriated? topical steroid, eg flucloxacillin/erythromycin for 10-14 days.

Steroid and antimicrobial ointment, Topical combination can also be used in conjunction.

e.g. Fucidin H, Terra-cortril (not Swab if no improvement. Refer to dermatologist.

recommended in children), FuciBET,

Betnovate C

Occlude with paste bandages, eg

Ichthopaste/wet wraps Other Measures

Avoid irritants, eg soap, wool

Minimise exposure to environmental allergens, eg house dust

Sedation mite and animal dander

Sedating antihistamine hydroxyzine (less

sedative for adults). Trimeprazine Second Line Treatments

Immunosuppressants:

Protopic: 0.03% or 0.1%. Should only be prescribed by

Patient Review dermatologists and physicians with extensive experience in

1. Initial treatment period for at least 4 weeks immunoregulators, after conventional therapies for

2. Check compliance (amount/ technique) moderate - severe atopic dermatitis. See SPC.

3. Check expectations compared with results Elidel: 1% cream should be prescribed by physicians with

4. Assess need for nursing support experience in the topical treatment of mild-moderate atopic

5. Consider need for regular review dermatitis.

6. Assess need for referral Short term or intermittent - see SPC





NOTE 1. TOPICAL STEROIDS IN ECZEMA

Indications for Referral Use preparation containing least potent drug at lowest strength

Urgent - worsening despite above which is effective at controlling the eczema.

measures I Mild hydrocortisone 1%

Routine - If specialist treatment needed, eg II Moderately potent. Clobetasone butyrate 0.05%

(Eumovate), Betnovate 1 in 4 (RD) cream or ointment.

wet wrapping. If need further patient or

III Potent. Betamethosone 0.1% (Betnovate), hydrocortisone

parental education and support.

butarate (Locoid)

IV Very potent - Clobetasol propionate 0.05 (Dermovate)







FACE & ARM & LEG & TRUNK TRUNK

Fingertip Unit Measurement NECK HAND FOOT (f ront) (back inc.

One fingertip unit measurement equals the buttocks)



amount of cream or ointment squeezed AGE NUMBER OF FTUs

along the index finger starting at the tip 3-6 months 1 1 1½ 1 1½

down to the first joint. 1-2 yrs 1½ 1½ 2 2 3

3-5 yrs 1½ 2 3 3 3½

6-10 yrs 2 2½ 4½ 3½ 5

Adult 2-5 4 8 7 7



FTU = Fingertip unit. 1 FTU = 1/2 g of cream or

ointment.

Measurement as expressed from the 30g tube

16

ECZEMA & PATCH TESTING



Indications for referral

 Any chronic eczema, which is unresponsive to treatment e.g. hand

eczema or varicose/venous eczema.

 Suspicion of allergic contact eczema.

 Suspicion of occupational contact dermatitis.



Who not to refer for patch tests

Patients with urticaria, hayfever, rhinitis, conjunctivitis, asthma.

Some of these may need prick testing. Refer to Dr T Dixon or Dr C J

Darroch at the Allergy Clinic, Broadgreen Hospital.



Patch Test Clinic

Patients attend on 3 occasions in one week (Monday, Wednesday and

Friday).



All topical medicaments, skin products, perfumes, hair products and

gloves are required.



For occupational contact dermatitis the Health and Safety data sheets

and chemicals from work should be supplied in suitable containers (i.e.

glass or plastic) and well marked with the name.



The back should be clear of eczema and there should be no exposure of

the trunk to sun or sunbeds for at least 4 weeks preceding the tests.





Secondline treatments for eczema available at BGH:

 Phototherapy – UVB, TLO1, PUVA

 Drug thearapy – topical immunosuppressants, azathioprine,

ciclosporin

 In-patient treatment









17

FUNGAL INFECTIONS



Pityriasis versicolor

This is a superficial infection due to the yeast Malassezia furfur. It is

particularly common in young people and presents with a slightly scaly

eruption of variably coloured macules. This usually affects the trunk and

may be complicated by areas of hypopigmentation (as the yeast bleaches

the skin) or post inflammatory hypopigmentation.

Management

 Skin scrapings may confirm diagnosis.

 Topical azoles e.g. miconazole cream, ketoconazole shampoo used as a

shower gel.

 Selenium sulphide shampoo.

 Oral itraconazole 200mg daily for 7 days.

 After successful treatment repigmentation may take many months.



Tinea infections

Tinea infections arise due to infection by dermatophytes, which are fungi,

which can live on keratin. Classification is related to body site:

Tinea capitis - scalp

Tinea corporis - body

Tinea manuum - hand

Tinea cruris - groins

Tinea pedis - feet (Athlete‟s foot)

Tinea unguium - nails

Management

 Confirm diagnosis by sending scrapings/nail clippings for mycology if

the diagnosis is in doubt

 Skin infections usually respond to topical treatment. Topical azoles

are used as first line whilst topical terbinafine may be used in non-

responsive cases.

 Scalp and nail infections respond poorly to topical treatment and

systemic therapy is indicated.



Tinea capitis

Tinea capitis occurs predominantly in children. Pustule formation and hair

loss are features. Oral antifungals are indicated, if severe urgent

referral to dermatologist. Only griseofulvin is licensed for use in children

under 12. Terbinafine is more effective than griseofulvin or itraconazole









18

Tinea unguium (onychomycosis)

Fungal nail infection is over diagnosed. Prolonged courses of antifungal

therapy are required but may on occasions be inappropriately prescribed.

Correct use of antifungal therapy depends on accurate diagnosis.



 This is a true dermatophyte infection of the nail.

 Usually only a few nails are involved.

 Nails grow slowly, become discoloured and brittle.

 Diagnosis is by nail clippings – it is important to send some of the

crumbly white material underneath the nail for mycology.



Management

 3 months of oral terbinafine; oral itraconazole and griseofulvin may be

considered but are less effective. Topical therapy may help in the

management of this condition and sometimes in combination with

systemic treatment.

 Other causes of nail dystrophy include chronic paronychia,

inflammatory skin disease and peripheral vascular disease.



Chronic paronychia

 Very common –arises due to a combination of mechanical factors and

candida infection.

 Affects finger nails in patients with repeated exposure to irritants

and water.

 Many nails may be involved with bolstering of the nail folds and loss of

the cuticle in addition to nail dystrophy.

Management

 Avoidance of water, and hand protection; topical treatment of the nail

folds with an azole cream may be of help.

 In severe cases oral itraconazole may help. Oral terbinafine is of no

use.



Nail dystrophy due to inflammatory skin disease

 Psoriasis and eczema both commonly involve nails.

 Nails grow rapidly.

 Psoriasis causes nail pitting, onycholysis and patches of discolouration.

 Periungual eczema causes nail ridging and dystrophy and may be

associated with chronic paronychia.

 These conditions do not respond to antifungal treatment. Treatment

is directed at the underlying cause.







19

Intertrigo

 Intertrigo refers to any rash occurring on an area where two skin

surfaces are opposed e.g. submammary and groin areas.

 Often associated with candida infection.

 Areas involved show glazed erythema with surrounding pustules.

There is often an associated odour.

 This condition responds well to mixtures of topical steroid and

antibiotics e.g. Canesten HC cream and Trimovate cream, but is often

recurrent.

 It is important to avoid irritants and to prescribe emollients to be

used as a soap substitute and moisturizer.









20

INFESTATIONS



Pediculosis capitis (head lice)

 Most common in childhood.

 Transmitted by contact, combs and brushes.

 Scalp itching is the predominant symptom, especially above ears and

posterior scalp.

Management

 Treat index case and all contacts/household members.

 Treatments include malathion, permethrin and phenothrin; 2

applications 7 days apart. Carbaryl may be used if other treatments

fail.

 Resistance to some preparations now exists.

 Treat any pre-existing scalp eczema with a steroid / antibiotic cream

prior to application of the scalp preparation.



Phthiriasis pubis (crab lice)

 Most common in adulthood.

 Generally transmitted by sexual contact.

 Itching is the predominant symptom.

Management

 Carbaryl or malathion.

 Recommend attendance at GUM clinic for full screening to exclude

other sexually transmitted diseases.



Pediculosis corporis (body lice)

 Transmitted by clothing and bedding.

 Lice and the eggs can be found in the seams of clothing.

 Poor hygiene favours infestation.

Management

 Malathion and permethrin, but the clothing needs high temperature

laundering or incineration.









21

INFESTATIONS - SCABIES



Scabies is caused by the scabies mite, Sarcoptes scabiei. It is

transmitted by skin-to-skin contact. People can be affected for several

weeks before they start to itch, and it is therefore important to treat all

contacts to prevent the condition spreading.



Clinical features

There is usually an erythematous scaling rash on the hands, wrists, ankles

with more widespread excoriations on the trunk and limbs. The face and

scalp are usually spared except in infants. On the trunk a fine red

papular rash is often present. Scabies burrows are best seen on the web

spaces palms, wrists or ankles (soles in infants). Males tend to develop

genital nodules and females involvement of the nipples



Choice of anti-scabetic agent

The first choice in a majority of cases should be 5% permethrin (Lyclear

Dermal Cream) with 0.5% malathion (Derbac M, Quellada M) an

alternative. No products are licensed for infants less than 2 months old

but Lyclear appears to be safe – medical supervision advised. Benzyl

Benzoate (25%) is still available but tends to irritate the skin.



Special patient groups

Children less than 2 years old, the elderly, immunocompromised, or

debilitated patients should have the scalp, face and ears treated as well

as the trunk and limbs. Lyclear Dermal creme rinse (1% permethrin) is an

appropriate treatment.



Dermatologists use Lyclear in pregnancy although the drug is not licenced

for this use. Benzyl benzoate is safe.



General management information

For an average adult, 30g of Lyclear or 50ml malathion is required per

application. Lyclear should be effective after a single 8-12 hour

overnight application. A bath prior to application is not necessary.



Apparent treatment failures are in general NOT due to drug resistance

and the commonest causes are:



 Failure to cover the skin surface completely (often patients apply it

only to the lesions).

 Washing off the treatment agent before 12 hours has elapsed.



22

 Failure to treat all contacts at the same time. All members of the

household must be treated, as must any other close contacts,

whether they are symptomatic or not.



Following scabies treatment, itch may continue for 6 weeks requiring oral

antihistamines and topical steroids. Post-scabetic eczema will be

aggravated by further anti-scabetic treatment. Eczema often

accompanies scabies and infected eczema may need addressing prior to

scabies treatment with emollient, antibiotic and topical steroid. If

burrows are still present after 6 weeks, re-treatment is justified.

Scabies may be secondarily infected (impetiginised) – especially in

children



SCABIES IN NURSING HOMES



Scabies is caused by the scabies mite, and is transmitted by skin-to-skin

contact. People may be affected for several weeks before they begin to

itch, and can pass on the mite before they have symptoms themselves.

Effective treatment is available but it is essential to treat all contacts to

prevent the condition spreading.



IF SCABIES IS DIAGNOSED IN ONE OF YOUR RESIDENTS



When a single case is diagnosed

Make a list of all the people likely to have come into skin-to-skin contact

with the patient. This could be staff, relatives or other visitors.



Advise the people on the list of the diagnosis, and suggest that they see

their GPs for treatment. Explain that they can be affected for weeks

before developing symptoms, so they should be treated even if they are

not itching. Try to co-ordinate treatments so that contacts are treated

as soon as possible after the patient, and ideally on the same day. Any of

the contacts‟ household should be treated as well.



When more than one case is diagnosed

Because of the way scabies spreads, we advise that as soon as more than

one case is diagnosed in the community such as a nursing or residential

home, all patients/residents and staff are treated. This is irrespective

of whether they are itching or scratching or not. Relatives and other

frequent visitors should also be advised to treat themselves.









23

Ideally, everyone should be treated on the same day. If different

General Practitioners are involved, the nurse in charge should act as a co-

ordinator.



Until the outbreak has been successfully controlled, staff should wear

gloves whenever they are touching patients or residents.



Ideally, patients should not be transferred or discharged and new

patients should not be admitted until it is medically confirmed that

treatment has been successful. If one of your patients or residents has

to be admitted to hospital, the hospital should be informed of the scabies

diagnosis.









24

MINOR SURGERY



Minor-ops room/theatre

 Good lighting and ventilation.

 Adjustable patient couch.

 Nursing assistant.

 Hand washing.

 Resuscitation equipment.



Equipment

 Basic minor-ops pack/sterile towels.

 Local anaesthetics - plain lignocaine or lignocaine with adrenaline

(avoid adrenaline on the fingers, toes, penis and tip of nose).

 Scalpel blades (size 15).

 Punch biopsies (Stiefel 3, 4 or 5mm).

 Curettes (Stiefel 4 or 7mm).

 Hyfrecator or electrocautery/chemical haemostasis. (Aluminium

chloride alcoholic solution e.g. Driclor).

 Stitches - non-absorbable e.g. Ethilon, Novafil and Prolene.

 Histological transport medium (formaldehyde)/pots.



Procedures

 Punch biopsy - rashes, diagnosis of lesions, removal small lesions.

 Incisional biopsy - rashes, lesions.

 Shave biopsy/snip excision - skin tags, benign fleshy naevi.

 Excision biopsy – benign moles, cysts.

 Curettage and cautery - warts, seborrhoeic warts, actinic keratoses.

 Liquid nitrogen cryotherapy - warts, actinic keratoses.







Precautions

 Obtain signed informed consent before surgery.

 Aspirin stop 10 days pre-op for excisions. (NB. Sometimes aspirin

cannot be stopped for medical reasons).

 Warfarin - stop 48h pre-op and always check INR on the day of

surgery aiming for INR<2.5. (NB sometimes Warfarin cannot be

stopped for medical reasons).

 Pacemaker - monopolar diathermy more dangerous than bipolar

diathermy.

 Antibiotic prophylaxis is generally not necessary for skin surgery in

patients with pre-existing heart lesions unless skin infection present.







25

IMPORTANT

 ALWAYS send specimens for histopathogy.

 If removing more than one lesion, careful notemaking and labelling of

each specimen in separate pots.

 ALWAYS use non-alcoholic antiseptics when using electrocautery.

 Remember the anatomy of the biopsy site.

 Biopsies can scar, warn patients.

 Beware of keloid scar and hypertrophic scar sites (especially upper

chest and arms).

 ALWAYS operate within skill level and facilities available.









26

PSORIASIS - summary



Patient History

 Duration of psoriasis and psychological impact.

 Possible triggers – infection, stress, alcohol, cigarettes, drugs.

 Family history of psoriasis.

 Occupation (including effect of disease).

 Medical history.

 Drug history.

 Patient expectations and ability to comply with treatment.



Examination

 Check sites (elbows, knees, trunk, scalp, flexures, nails).

 Note character of lesions (scales, thickness, erythema, pustules).

 Note extent of cover (sometimes PASI score will be given – psoriasis

area severity index)

 Assess degree of itching.

 Assess complications, eg arthropathy.



Chronic Plaque Psoriasis

 Usually symmetrically distributed.

 Large or small plaques.

 Often seen on extensor surfaces, scalp.

 White silvery scales on a salmon pink base.

Management

 Encourage emollients – bath oil/soap substitutes and moisturisers.

 Vitamin D analogues e.g. calcipotriol ointment bd up to 100g per week

in adults, 6-12 years 50g, 12-16 years 75g, (no limit on course length)

or tacalcitol ointment od.

 Vitamin D analogues + topical steroid - Dovobet® (calcipotriol 50µg/g

as hydrate and 500µg/g betamethasone as diproprionate) - maximum

weekly dose is 100g or 30% body coverage- so best for localised

disease, applied once daily.

 Dithranol preparations - short contact Dithrocream 0.1, 0.25, 0.5, 1.0

and 2% strengths (always start with the 0.1% and increase slowly to

avoid burning) or Micanol cream 1 & 3% dithranol.

 Coal tar preparations – e.g. Alphosyl, Exorex.

 Topical retinoids – tazarotene gel od (0.05 & 0.1% strengths);

sometimes combined with moderate potency topical steroids to limited

areas.

 In referral letters, please list all previous treatments.





27

Psoriasis at special sites

Face/ears – mild or moderate potency steroids bd used sparingly to

localised areas.



Scalp – Cocois (12%CTS, 4%sulphur, 2%salicylic acid in coconut oil)

applied overnight and washed out the following morning with a shampoo

e.g. Polytar, T-Gel, Capasal; topical steroid scalp applications or

calcipotriol scalp application applied after shampooing.



Genitals - mild or moderate potency topical steroids bd used sparingly to

localised areas or tacalcitol ointment od.



Nails – very difficult to treat; exclude fungal infection; sometimes helped

by topical steroids.









Secondline treatments for psoriasis available at BGH:

 Phototherapy – UVB, TLO1, PUVA

 Drug thearapy – hydroxycarbamide, methotrexate, ciclosporin,

acitretin

 In-patient treatment









28

Liverpool - Psoriasis



MANAGEMENT OF PSORIASIS IN PRIMARY CARE

PATIENT HISTORY

1. Duration of psoriasis

2. Possible triggers - infection, stress, alcohol, drugs, smoking

3. Family history of psoriasis

4. Occupation (including effect of disease)

5. Medical history

6. Drug history

7. Patient expectations and ability to comply with treatment

8. Psychological effect of psoriasis





EXAMINATION

1. Check sites (elbows, knees, trunk, scalp, flexures, nails)

Pattern of 2. Note character of lesions (demarcation, scales, thickness,

disease erythema, pustulation)

3. Note extent of cover

4. Assess degree of itching

5. Assess complications, eg arthropathy





Chronic Plaque Psoriasis

1. Usually symmetrically distributed

2. Large or small plaques For treatment see over

3. Often seen on extensor surfaces, scalp

4. White silvery scales on a salmon pink base

Emollients plus:

a. Mild topical steroid or tar/

Facial Psoriasis

steroid combination

b. Vit D analogues

Guttate Psoriasis

1. Numerous scaly "droplet" lesions over trunk Emollients plus:

2. May follow Streptococcal infection a. Tar preparations

3. Most common in children/adolescents b. Vit D analogues, e.g. Calcipotriol

4. Self limiting 4-6 months c. Topical steroids

d. UVB/TL01 if not responding

Flexural Psoriasis

1. Smooth glazed shiny red areas of skin, well

demarcated (hairline; axillary, submammary, Use moderately potent

perineal) steroid/antiyeast and/or

2. More commonly seen in the elderly Vit D analogues

3. May be secondarily infected with yeasts



Potent steroids and/or Vit D

Psoriatic Nail Dystrophy

analogues, e.g. Calcipotriol cream,

1. Severe problems in up to 10% of patients

Tazarotene gel

2. Minor signs in 50% of patients

But difficult to treat



Psoriatic Arthropathy

Refer to Rheumatologist

Incidence up to 7% of psoriasis patients





Pustular Psoriasis

palmo-plantar Potent topical steroids

29

PATIENT EDUCATION

TREATMENT 1. Advice at consultation, eg genetics,

1. Assess practicalities of treatment pathogenesis

2. Assess motivation to use treatment

3. Explain method of application

4. Explain need for compliance and

expected time of response (12 weeks)

+ 2. Leaflets

3. Support agencies (Psoriasis Association,

Tel. 01604 - 711129, Psoriatic Arthropathy

Alliance, Tel. 01923 672837. www.psoriasis-

5. Calculate amount of topical therapy association.org.uk)

needed to treat extent of disease 4. Nursing support - treatment techniques

5. Sunbeds not recommended









CHRONIC PLAQUE PSORIASIS MILD SCALP PSORIASIS

1. Encourage emollients - bath oil/soap substitutes & moisturisers +++ 1. Tar based shampoos

PLUS 2. Calcipotriol Scalp Solution - 1-2 drops per

2. Active therapy - 1st line: Dovobet once daily - initially for 4 weeks postage stamp area of plaque b.d.

and then review. Educate to treat flare-ups only. Vitamin D analogues 3. Steroid scalp lotions - up to 3 times per

e.g. Dovonex, Curatoderm, Silkis, tars - e.g. Alphosyl, Exorex week

3. Dithranol preparations (increasing strengths of short contact Moderate scaling

Dithrocream) or Micanol Soften scales with overnight application of:

Thick scaling 1. Cocois ointment - apply generously to

Soften scales with overnight application of: scalp along hair partings. Leave overnight

1. Greasy moisturisers, eg white soft paraffin in liquid paraffin 50/50, and wash out with a tar shampoo am. Do

Epaderm this for 3-7 consecutive nights until scale

2. 2% salicylic acid in emulsifying ointment reduced

Very thick plaques

1. Consider keratolytic agent, eg 5-10% salicylic acid with emollients









PATIENT REVIEW

1. Initial treatment period for at least 12 weeks

2. Check compliance (amounts of treatment used and treatment

technique)

3. Check expectations compared with results

4. Consider need for regular review

5. Assess need for referral to hospital









CRITERIA FOR REFERRAL TO DERMATOLOGIST

1. Erythrodermic patients - Emergency

2. Unstable/generalised pustular patients - Emergency

3. Extensive/severe or disabling psoriasis

4. Failure to respond or relapse post topical therapies (phototherapy,

drug therapy)

5. Recurrent attacks of psoriasis

6. Difficulty with diagnosis

7. Disfiguring nail disease









30

SOLAR DAMAGE AND SKIN CANCER





Bowen’s Disease

Intraepidermal carcinoma is common and typically found on the lower leg

in women. Erythematous, scaly plaques occur and there is a small risk of

developing SCC.



Treatments include liquid nitrogen, cryotherapy, surgery, photodynamic

therapy and topical 5-fluorouracil cream (Efudix).



Solar or Actinic Keratoses (AK)

These present as single or more commonly multiple scaly, erythematous

lesions affecting sun exposed sites such as the scalp, ears, face and

dorsal hands. Many small solar keratoses will spontaneously involute,

especially if patients are given advice concerning the use of high

protection factor sunscreens. The vast majority of solar keratoses will

never become an SCC but the risk is probably about 5%.

Management of Solar Keratoses

 Photoprotection – hat, clothing

 Sunscreen – high SPF (UVB) and high star rating (UVA); frequent,

careful, thick applications

 3% diclofenac gel (Solaraze) applied bd to AKs for 60-90 days –

beware of skin irritation, avoid excessive sun exposure

 5-fluorouracil cream (Efudix) applied sparingly to AKs bd for

between 1 and 3 weeks; expect irritation and warn patients; if

severe, stop applying and may need to use 1% hydrocortisone cream

bd to settle; the Efudix cycle can be repeated if the AKs not clear

 Liquid nitrogen cryotherapy – 5-10 second freeze; painful and warn

patients of blistering and possible scarring at treatment site

 Photodynamic therapy (PDT) can be used as a third line treatment

for AKs and is performed as an OPD procedure in secondary care

 Surgery – either curettage / cautery (C&C) or excision biopsy

especially if there is diagnostic doubt or concern of progression to

squamous cell carcinoma; remember if SCC considered referral on

2 week fax referral form to skin cancer clinic









31

A summary guide to the management of AKs:



CRYO Solaraze Efudix PDT Surgery

Single AK    

Multiple AKs    

Failed Rx   

Cutaneous horn  

Indurated or  

hyperkeratotic

lesion

Fast growing ?SCC 









32

Basal Cell Carcinoma (BCC)

or Rodent Ulcer

Commonest type of skin cancer seen typically on the face in middle-age

and elderly patients. Slow growing, locally invasive tumours, which

virtually never metastasize. Nodular lesions are skin coloured papules

with telangiectasia and a rolled, pearly edge. Other types – cystic,

morphoeic, superficial and pigmented. Excision is the best form of

treatment but other treatments are available depending on the size and

site of the lesion and age of the patient. BCCs are not included in the 2

week initiative to see suspected cancers but will be given a priority in

appointment time.



Squamous Cell Carcinoma (SCC)

Usually arises on sun damaged skin in elderly males and this tumour may

metastasize. It may arise from an actinic keratosis, Bowen‟s disease,

scar tissue and leg ulceration. Papules grow which can ulcerate and crust.

If suspected, requires urgent referral by fax via the skin cancer

referral form. Surgery is the treatment of choice but radiotherapy is

also utilised depending on the size and site of the lesion and age of the

patient.



Malignant Melanoma (MM)

This is the most serious of the skin tumours and early diagnosis is

essential as the prognosis depends on the tumour thickness at time of

excision. It is most commonly seen in the fair skinned. In males the

commonest site is the back and in females the commonest site is the

lower leg.



The main types of MM are superficial spreading melanoma, lentigo maligna

melanoma, nodular melanoma and acral malignant melanoma (around nails

and terminal digits).



Other major risk factors include childhood sunburn and familial dysplastic

naevus syndrome.



Signs of MM:

 Asymmetry of shape

 Border irregularity

 Colour variation with dark and light areas

 Diameter increasing and greater than 7mm







33

 Other features might include itching, redness or inflammation,

bleeding or oozing.



Treatment is surgical excision with a wide margin, with regular follow-up

and monitoring.





If you suspect a malignant melanoma please refer

urgently by fax via the skin cancer referral form.

Please ensure fax is sent to the number on the

form.









34

SKIN CANCER REFERRAL FORM

FOR SUSPECTED MELANOMA AND SQUAMOUS CELL CARCINOMA ONLY

Basal cell carcinomas to be sent by usual referral letter

All suspected skin cancers to be referred to Dermatology Department, The Royal

Liverpool & Broadgreen University Hospital: Fax 0151 706 5655

PATIENT DETAILS: REFERRING GP: (STAMP)



Name:



DoB:



Address:



Phone No:



Case Sheet No: DATE SEEN BY GP: ……………………..



SUSPECTED DIAGNOSIS: MELANOMA / SCC

1. MELANOMA

SITE: ………………………………… SIZE: …………………….. DURATION: …………………

RISK FACTORS CHARACTERISTICS

Multiple naevi YES NO Change in size YES NO

History of sunburn YES NO Change in shape YES NO

Fair skin/freckled YES NO Change in colour YES NO

Family history YES NO Irregular outline YES NO

Mixed colour YES NO

Itch/bleeding YES NO

Inflammatory responseYES NO

2. SQUAMOUS CELL CARCINOMA

SITE: ………………………………… SIZE: …………………….. DURATION: …………………



RISK FACTORS

Previous ultraviolet light exposure YES NO

Previous non melanoma skin cancer/actinic keratosis YES NO

Immunosuppression YES NO







CHARACTERISTICS

Evidence of chronic skin damage e.g. actinic keratoses/old burn scar YES NO

Crusting/non healing lesion YES NO

Documented expansion YES NO

Inflammatory response YES NO



COMMENTS



Other reasons for urgent referral:

SIGNATURE: DATE:

URTICARIA



Urticaria presents as hives, weals or nettle-rash and is very itchy. The

cause of an acute attack of urticaria can be fairly obvious, e.g. shellfish,

drugs eg ACE inhibitors, or certain fruits / nuts but a „well patient‟ who

has chronic urticaria persisting for more than three months will rarely

have an allergy and this has a non-allergic aetiology - detailed

investigation is usually unrewarding.



Chronic Idiopathic Urticaria

 Chronic urticaria is not an allergic rash and skin testing (prick or

patch) is not usually indicated.

 About 40% of patients with chronic urticaria will be made worse by

NSAIDs – so avoid all aspirin containing drugs. Recommend

paracetamol as an analgesic if required.

 Other aggravating factors may be codeine, azo dyes or preservatives

(benzoates) in the diet.



Management

 Non-sedating antihistamines

 Fexofenodine 120 – 180mg od

 Desloratidine 5mg od

 Levocetirizine 5mg od



 Sedating antihistamines

 Trimeprazine 10mg tds

 Chlorpheniramine 4mg 4-6 hourly

 Hydroxyzine 25 mg tds

 Promethazine 10mg tds



 Others

 Topically, aqueous cream or 1% menthol in aqueous cream can be

soothing on the skin.

 Consider adding ranitidine 150mg bd as sometimes H1 & H2 histamine

receptor blockade helps

 In emergencies only, short courses of prednisolone may be required in

extensive urticaria often associated with angioedema.

VENOUS ULCERS



First exclude accompanying arterial insufficiency by Doppler Ultrasound

examination because ulceration due to venous hypertension is treated

with compression bandaging.

Keep treatment as sterile as possible:

 Clean with water or saline.

 Apply liquid paraffin/white soft paraffin 50:50 or Epaderm ointment

to the leg to keep the skin well moisturised.

 Apply N/A dressing to the ulcers.

 Apply 4 layer compression bandaging weekly.

 If venous eczema is a problem apply a topical steroid ointment e.g.

Betnovate, Propaderm or Metosyn for up to 3 weeks and

increase the frequency of dressings until the eczema settles. If

secondary infection of eczema occurs steroid combined with an

antiseptic e.g. Betnovate C may be used.



4 layer bandaging available on FP10 – many options:

e.g. Profore, K-four, System four, Ultra four.



In sensitive patients, rubber bandages must be replaced by rubber-free

bandages.



Infected Venous Ulceration:

Take swabs if there is increasing pain or discomfort, increasing exudate

or cellulitis.

Do not treat colonisers such as Pseudomonas, Coliforms.

Do treat -haemolytic Streptococcus with penicillin and cellulitis with

penicillin and flucloxacillin systemically.

Do not use topical antibiotics as they can be sensitisers (e.g. Neomycin).

Avoid iodine preparations unless treating MRSA.



When to refer to the Dermatology Department



 If there is a diagnostic doubt as to the type of ulcer – consider a skin

biopsy to exclude malignant pathology

 If there is a possibility of allergic contact eczema around the ulcer

e.g. to rubber or a topical agent.

 Patients unable to tolerate compression bandaging should be referred

to a Vascular Surgeon.

Information

A range of comprehensive guides for the management of leg ulcers

including clinical practice guidelines are available from the Royal College

of Nursing (www.rcn.org.uk).



Graduated compression hosiery

Once the ulcer has healed it is vital to continue to maintain compression

on the malfunctioning veins to reduce oedema and prevent injury. For

most patients Class 2 (medium support) are satisfactory.

VIRAL INFECTIONS



Herpes zoster (shingles)

 Varicella zoster virus.

 Virus reactivation in dorsal root ganglia.

 Predisposing factors – immunosupression e.g. systemic steroids, AIDS,

cancer.

 Clinically – pain and paraesthesia, unilateral dermatome distribution,

vesicles, scabs and crusts.

 Complications – secondary bacterial infection, ophthalmic zoster,

Ramsay-Hunt syndrome, disseminated zoster, postherpetic neuralgia.

Management

 Aciclovir 800mg qids for 7 days, analgesia and bed rest; often

becomes secondarily bacterially infected.

 In elderly patients it is important to commence amitriptyline 50mg

nocte as soon as possible to reduce incidence of postherpetic

neuralgia.



Herpes simplex

 Herpes simplex virus I and II.

 Oral/facial and genital infections - recurrent.

 Tingling and painful.

 Erythema, grouped vesicles.

 May cause erythema multiforme; eczema herpeticum.

Management

 Treatment topical aciclovir qids for 5 days or (if more severe) oral

aciclovir 200mg 5xdaily for 5 days.



Molluscum contagiosum

 Molluscum contagiosum pox virus.

 Very common in children.

 Contagious.

 Flesh coloured dome shaped papules with central umbilication.

Management

 Cryotherapy, wart preparations containing salicylic acid for a few days

only to each lesion, or none as lesions resolve spontaneously (6-18

months).

 NB Alder Hey no longer offers a cryotherapy service so we do not

recommend referral of viral warts for treatment.

Viral warts

 Human papilloma virus (HPV).

 Very common.

 Types – common, plane, periungual, verrucae, mosaic, anogenital.

Management

 Salicylic acid, glutaraldehyde, podophyllin, cryotherapy, surgery or

laser.

PATIENT INFORMATION LEAFLETS

 Dovobet

 5-Fluorouracil cream (Efudix)

 Photoprotection

 Urticaria

 How to treat your scabies



The following patient information leaflets are available on the British

Association of Dermatologists web site as follows:

http://www.bad.org.uk

 Acne

 Atopic eczema

 Bowen‟s disease

 Contact dermatitis

 Darier‟s disease

 Dermatitis herpetiformis

 Discoid lupus erythematosus

 Granuloma annulare

 Hailey Hailey disease

 Ichthyosis

 Keratosis pilaris

 Lichen planus / lichenoid eruptions

 Lichen sclerosus

 Lichen sclerosus in children

 Linear IgA

 Mycosis fungoides

 Oral cortisone

 Pemphigoid

 Pityriasis lichenoides

 Psoriasis

 Psoriasis – moderate / severe

 Sarcoidosis

 Seborrhoeic warts

 Strawberry marks / port wine stains

 Urticaria and angioedema

 Vulval disease

DOVOBET® : ADVICE FOR USE

Dovobet® (calcipotriol 50µg/g as hydrate and 500µg/g betamethasone as

diproprionate) is an effective topical treatment that shows a rapid

improvement, even during the first week of use. Maximum weekly dose is

100g or 30% body coverage- so best for localised disease, applied once

daily. Dovobet® offers patients an easy way to manage their psoriasis

with an opportunity for treatment breaks, by using 1 month at a time.



Psoriasis is a common skin disease with characteristic raised, red,

scaly plaques. As the patient gets better the plaques lose their

scale and reduce in thickness until they are no longer palpable on

the skin.

During the inflammatory process pigmentation of the skin is

disrupted. When the plaque has completely cleared there is, in

some patients, a change in the colour of the skin. This colour can Day 1 of treatment

be categorised as post inflammatory hyper- or hypo-pigmentation.

,2



Hyper-pigmentation may be more distressing to the patient and

they may feel the desire to continue to treat. These macular (flat

area of localized colour change) patches of erythema (redness

which blanches on pressure) are shadows of the disease and

although secondary to the psoriatic process are not lesions of

active psoriasis. At this stage a switch to Dovonex would be

advisable to maintain control, saving the Dovobet for flair-ups.

Once the skin becomes palpable again it can be re-treated.

Dovobet should not be applied to the face.







After treatment







In short, in terms of psoriasis treatment, this suggests that some

simple advice to give a patient would be:



“If you can feel it treat it, and if you can’t feel it don’t treat it.”



References:

1. Leppard and Ashton, Treatment in Dermatology. 1993, p147

2. Ashton and Leppard, Differential Diagnosis in Dermatology. 1993,

p134

FLUOROURACIL (5%) CREAM (EFUDIX)



Indications: actinic keratoses (AK), Bowen‟s disease, superficial basal cell

carcinoma (sBCC), others.



 Apply the cream thinly twice a day to the affected areas limiting the

application to the individual lesions. On occasions you may be

instructed to apply the cream more generally to a light exposed area

e.g. hands or arms. Be particularly careful not to get the cream near

to the eyes. Wash your hands thoroughly after use. Sometimes a

cotton bud is a useful applicator.



 Apply the cream twice daily for between 1 and 3 weeks; if working, the

affected sites will go red / sore and may even weep & blister in some

cases. It is important to realise that this „reaction‟ described is an

inevitable and necessary part of the treatment. Once the reaction

has started and provided it is not too sore continue the application of

cream for a maximum of 3 weeks. If at any time the reaction is really

unpleasant and too sore, stop treatment and apply a steroid cream or

ointment (usually Hydrocortisone 1% will be prescribed) twice daily to

these areas for 2 weeks.



 If a severe reaction has occurred it is likely that the lesions will have

been effectively treated and no further application will be required.

If in doubt, consult your Doctor and he will advise as to whether you

should continue treatment.



 Once the redness and soreness has settled, check if the lesions are

still there. YES - repeat the Efudix cycle again and this can

continue on & off until clearance

NO – stop treatment but watch for signs of recurrence



NOTES

 Do not use Efudix Cream without supervision.

 Avoid prolonged exposure to sunlight while undergoing treatment.

 Continue to protect the exposed skin using clothing and/or an

effective high SPF sunscreen.

 Always ensure that the Efudix cream is within its expiry date

 If a warty lesion appears and appears different, see GP in case a skin

cancer has developed

PHOTOPROTECTION



Use common sense on your holiday and whenever sunbathing. Sunburn can

ruin your holiday and age your skin prematurely. Avoiding burning from

the first few days helps the skin develop its own protective properties.

It seems to be particularly important to avoid sunburn in children.



Protect your skin by using sunscreen preparations. Or, if you prefer,

cover up and keep in the shade.



Always avoid the sun during the middle of the day. And remember the

sun is stronger as you get nearer the equator.



You should be particularly careful if you have a skin, which always burns

or tans only with difficulty. Remember, the fairer your skin, the more

important it is to avoid sunburn.



In other parts of the world such as Australia, information such as this

has reduced the numbers of people developing skin cancer because they

protect their skin from excess sun.



The Use of Sunscreens

The sunscreen should be used in the following way:



 Apply before going outside, every day from April to September

inclusive.

 On days when the sun is out, apply at lunchtime as well.

 Use under skin creams or makeup.

 Re-apply after swimming – or use a waterproof one.

 Use on face/hands/arms/V-neck/ears, as appropriate to all exposed

areas.

 Sun protection factor (SPF) refers to protection against UVB – the

higher the number the better the protection as long as the sunscreen

is applied thickly and evenly.

 Star **** system refers to protection against UVA – the greater the

number of stars, the greater the protection.

URTICARIA



What is urticaria?

Urticaria, „hives‟, or „nettle rash‟ is an itchy skin rash consisting of red

bumps and weals, which can affect any area of the body. The individual

weals come and go within hours, and there may also be swelling of the lips

and eyelids. Scratching the skin may cause more weals to form. Some

people have only one attack of urticaria in a lifetime, whereas in others it

may be a recurrent condition.



There are several types of urticaria:



Physical Urticaria - Can occur on exercise, exposure to hot or cold

temperatures, sunshine or at areas of pressure e.g. bra straps and waist

bands.

Acute Urticaria – is a short lived and sometimes dramatic condition

where weals develop rapidly, within minutes or hours. The cause or

trigger may be known.

Chronic Urticaria – is urticaria which has been coming and going for

several months. It may sometimes last for years, but tends to vary in

severity.



What causes urticaria?

Urticaria develops when special inflammatory cells in the skin release

their contents. These include histamine, a chemical, which causes

swelling and itching of the skin. The effects of histamine can be blocked,

by taking antihistamine tablets.



Unknown – in chronic urticaria the cause is usually unknown. Most people

are unable to identify any trigger.

Drugs – such as penicillin may cause a severe urticarial rash in people who

are allergic to them. This is a serious reaction and the drug should not

be taken again. Aspirin, other painkillers and over the counter cold and

flu remedies may also trigger urticaria or make it worse.

Food – sometimes people can identify a foodstuff, which causes their

urticaria. Common examples include shellfish, fish, strawberries and nuts.

In a few people avoiding additives in the diet can be of help.

Infections – such as flu or sinusitis may rarely trigger urticaria.

What tests can be done to find the cause?

Allergy tests are not usually necessary, and they rarely help to find the

cause. If a food trigger is suspected this can be left out of the diet to

see if the condition improves. If the urticaria persists, a routine blood

test may be necessary, to exclude rare medical conditions which may

cause urticaria.



Is it serious?

Urticaria may look dramatic but in the majority of cases there is no

associated risk to general health. In a small number of patients there

may be swelling of the tongue and breathing passages, and this requires

urgent medical attention.



Is there a cure or treatment?

Any obvious trigger should be avoided. Regular doses of antihistamine

tablets will help settle an attack and these are safe to take over a long

period if necessary. Short courses of steroid tablets may be needed for

a severe, acute attack. Drugs, which can worsen urticaria should be

avoided, such as aspirin or codeine. Paracetamol is safe.

HOW TO TREAT YOUR SCABIES



Your skin rash has been diagnosed as scabies. You have been prescribed

Lyclear Dermal cream (5%).



 Treatment is best applied before going to bed.

 There is no need to bathe before applying the treatment.

 Nails should be cut before treatment and rings removed if feasible.

 The creams should be applied thoroughly all over, to the entire skin

surface below the chin, whether or not any spots are seen.

 The genital area, the finger and toewebs, under the fingernails and

the soles of the feet should be treated.

 In children under 2 years, Lyclear creme rinse (1%) should be applied

to the scalp and face (avoiding eyes).

 Wear your usual night clothes overnight.

 Only one application, left on for 8-12 hours, should be necessary.

 Your hands will need retreating if you wash them during the night.

 Bedding, night clothes and day clothes should be changed after the

treatment and laundered on a hot wash.

 Occasionally, a second application may be recommended by your

doctor.



Scabies is transmitted by skin to skin contact so all close contacts need

to be treated at the same time. Any frequent visitors who are in regular

contact with you should also be treated at the same time, even if they do

not appear to be affected. The doctor treating you should give advice on

other people that should be treated.



You may itch for 6 weeks after successful treatment. Do not continue to

apply the Lyclear because it may irritate the skin. Your doctor can

prescribe creams or antihistamine tables to help the itch.

SELF-HELP GROUPS

 Acne Support Group



 British Red Cross



 Hairline International



 LUPUS UK



 National Eczema Society



 The Psoriasis Association



 The Vitiligo Society

 Wessex Cancer Trust - SCIN

Acne Support Group



Aims: The Acne Support Group aims to provide information and

support to people affected by either acne or rosacea. The

group works with health professionals to help improve the

quality of information given to patients.



Contact: Alison Dudley

PO Box 9

Newquay

TR9 6WG



Tel: 0870-8702263

Website: www.stopspots.org









British Red Cross



Aims: The aim of the British Red Cross Skin Camouflage Service is

to assist people with a disfigurement to cope in their daily

lives, with the aid of simple skin camouflage techniques.



The service is available to men, women and children through

medical referral from a Consultant or GP. Camouflage

creams are effective in reducing the impact of scarring,

rosacea, birthmarks, vitiligo, tattoos etc. on the face, limbs

and torso.



The service is available nationally and is provided free of

charge to the patient. The creams are normally available on

prescription. Information on clinics can be obtained from

the local Branch Headquarters of the British Red Cross or

see contact below.

Contact: Cathy Kingsbury

UK Service Development

Community Services Unit

British Red Cross

9 Grosvenor Crescent

London SW1X 7EJ

Tel: 020 7201 5172

Website: www.redcross.org.uk



Hairline International



Aims: Hairline International – The Alopecia Patients‟ Society is an

international network of patients who have lost, or are

losing, their hair through scalp disease or thinning

conditions. The society provides information on medical

treatment, mutual support and practical help. It is the only

national alopecia patients‟ support group.







Contact: Ms Elizabeth Steel

Hairline International – The Alopecia Patients‟ Society

Lyons Court

1668 High Street

Knowle

West Midlands B93 0LY



Tel: 01564 - 775281

Website: www.hairlineinternational.co.uk



LUPUS UK



Contact: LUPUS UK

St James House

Eastern Road

Romford

Essex

RM1 3NH



Tel: 01708 - 731251

Website: www.lupusuk.com

National Eczema Society



Aims: The National Eczema Society exists to eliminate the effects

of eczema. It seeks to achieve this by:



- Providing information, advice and support to people

with eczema and those who care for them both locally

and nationally (details from Sarah Ransome).

- Managing programmes of patient-focused training

courses for GPs, nurses and pharmacists (full

information from Mercy Jeyasingham).

- Encouraging and supporting research into the causes,

effects and treatment of eczema.

- Administering and managing the Skin Care Campaign,

an alliance of skin patient organisations companies and

others interested in skin health.



Contact: National Eczema Society

Hill House

Highgate Hill

London N19 5NA



Tel: 020 - 7281 3553

Website: http://www.eczema.org







The Psoriasis Association



Aims: The Association aims to give information on all aspects of

Psoriasis upon request. It promotes and funds research

particularly into the basic causes.



Contact: Gladys Edwards

Chief Executive

The Psoriasis Association

7 Milton Street

Northampton NN3 7JG



Tel: 01604 711129

Website: http://www.psoriasis-association.org.uk

The Vitiligo Society



Aims: A registered charity offering support and advice to people

with Vitiligo. Although it is neither painful nor infectious,

many who develop it find the experience socially and

psychologically devastating. The Society aims to provide

information and education about the condition and to

encourage and fund research.



Contact: Mrs Marion Lesage

Information Manager

The Vitiligo Society

125 Kennington Road

London

SE11 6SF



Tel: 02078 - 400855

Website: http://www.vitiligosociety.org.uk

Wessex Cancer Trust - SCIN

(Skin Cancer Information Network) MARC'S LINE (Melanoma and

Related Cancers of the Skin)

Aims: Marc's Line aims to be of value to patients and their

families, health professionals. teachers and others involved

in education or prevention of skin cancer. It produces

leaflets and information sheets on various types of skin

cancer and on sun protection strategies. It has a

professional nurse network of voluntary nursing contacts

offering psycho-social support for patients and their

families living with melanoma.



Contact:

Jane Freak

Clinical Nurse Specialist in Skin Cancer Prevention

Marc's Line Resource Centre

Dermatology Treatment Centre

Level 3

Salisbury District Hospital

Salisbury

Wiltshire SP2 8BJ

Tel: (01722) 415071

Fax: (01722) 415071

Web: www.k-web.co.uk/charity/wct/wct.htm