ACNE Common Skin Problems Produced by

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					 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 2 nd 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. Nor mally 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 Ly mecycline 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 sy mptom.
Management
 Carbaryl or malathion.
 Recommend attendance at GUM clinic for full screening to excl ude
  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 sy mptoms 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 sy mptoms, 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 REFERRA L FORM
     FOR SUSPECTED MELANOMA AND SQUAMOUS CELL CA RCIN OMA ONLY
              Basal cell carcinomas to be sent by usual ref erral 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:        MELAN OMA / SCC
1.       MELAN OMA
SITE: …………………………………              SIZE: …………………….. DURATION: …………………
        RISK FACTORS                                CHARACTERISTICS
Mul tiple 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 hi story       YES   NO               Irregular outline     YES NO
                                             Mixed colour          YES NO
                                             Itch/bleeding         YES NO
                                             Inflamma tory responseYES NO
2.       SQUAMOUS CELL CARCINOMA
SITE: …………………………………              SIZE: …………………….. DURATION: …………………

                                      RISK FACTORS
Previous ul traviolet light exposure                                       YES   NO
Previous non melanoma skin cancer/ac tinic kera tosis                      YES   NO
Immunosuppression                                                          YES   NO



                                   CHARACTERISTICS
Evidence of chronic skin da mage e.g. ac tinic kera toses/old burn sca r   YES   NO
Crusting/non healing lesion                                                YES   NO
Documented expansion                                                       YES   NO
Inflamma tory 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 ap plied
    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

				
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