Docstoc

Plaques

Document Sample
Plaques Powered By Docstoc
					                     Plaques
• Emollient
• Calcipotriol (dovonex)
  – No smell
  – No staining
  – Occasional irritation
  – Use b.d (>2 weeks)
  – Be liberal (not more
    than 100g per week)
  – It’s a cream
                Plaques
            Elbows and Knees


• Emollient
• Diprosalic Oint
  – Diprosone plus
    salicylic acid 3%
  – 60g £6.60
• Dovobet Oint
  – Calcipotriol and
    diprosone
  – 60g £35
                  DOVOBET
• Calcipotriol (dovonex) and betamethasone
  diproprionate (diprosone)

• Once daily intermittent use for months is usually
  OK if not on large surface areas

• Initial results promising but

• Subsequently reports of rebound and pustulation
  (debated)
             Dithrocream at Home
• Dithrocream 0.1 to 2%
• Wash off after 30 mins to
  1 hour
• Good for small number of
  isolated plaques
• ‘Non Steroid’
• Can be used on the scalp
• Messy. Needs motivation
  and careful explanation
• Micanol less messy
                     Scalps
• Soften scale e.g olive
  oil, emulsiderm even
  overnight with shower
  cap
• Cocois or sebco for 1
  hour or often longer
• Shampoo e.g. Polytar,
  Aphosyl 2:1 or Tgel
• Betacap scalp
  application or
• Bettamousse or
  diprosalic lotion
• Xamiol
• Etrivex
                  Hairline


• Synalar
  (fluocinolone)
  gel o.d nocte up to 4
  weeks
• Dithrocream
               Facial Psoriasis


•   Emollient
•   (Alphosyl HC)
•   Calcitriol (Silkis)
•   Eumovate Oint
•   ? Tacrolimus
                  Genital


•   Emollient
•   Eumovate Oint
•   Trimovate Cream
•   Betnovate Oint
•   Dermovate Oint
    (max 7 days)
                     Feet
• Emulsifying oint
• Epaderm
• Diprosalic Oint
• Dermovate daily for a
  month
• Dermovate with
  propylene glycol
• Cling film wrapping
• Local PUVA
                   Hands
• Emulsifying oint
• Epaderm
• Diprosalic Oint
• Dermovate daily for a
  month
• Dermovate with
  propylene glycol
• Cling film wrapping
• Local PUVA
    Topical Treatments Summary
•   Emollients for all patients
•   Bath Emollients e.g. Polytar or Balneum
•   Coal tar preparations e.g Exorex lotion
•   Vitamin D analogues
•   Dithrocream & (Dithranol)
•   Retinoids (seldom used)
•   Steroids ( short course for 4 weeks usually)
•   Vitamin D analogues and steroids (Dovobet)
• Failure of topicals
• Failure of phototherapy
• Rapid relapse after
  phototherapy
• Phototherapy
  contraindicated
• First line in pustular
  psoriasis
• Cheap!
         Ciclosporin (Neoral)
• Good for short term
  control of severe
  disease
• Toxicity a problem
• Careful monitoring
• Expensive
• Often flare ups when
  discontinued
              When to Refer
• Diagnostic confusion
• Failure of appropriately used topical treatments
  for a reasonable period of time e.g. 1 month
• Widespread disease such that topical
  application becomes impractical
• Quality of Life Issues
• Erythrodermic
• For education including demonstration of topical
  treatments (nurse-led)
• Pustulating psoriasis
                Differentials
•   Discoid eczema
•   Pityriasis Rosea
•   Inverse pattern eczema
•   Bowen’s disease
•   Mycosis fungoides
•   Seborrhoeic dermatitis scalp
•   Erythrasma and tinea groin
•   Tinea infections
•   Dermatomyositis
•   Secondary syphilis
      Systemic Treatments
• Methotrexate
• Ciclosporin
• BIOLOGICALS
     Biologicals in Psoriasis Costs
            and Outcomes
                        • Agents targeting
• Agents targeting T-     Cytokines
  Cells and APCs
                        • Etanercept
• Alefacept CD2/LFA-3     £9500 per annum 25mg
  £10 000 per annum       x2/w
  PASI-75 24%             PASI-75 34% 12/52
                                     44% 24/52
• Efalizumab            • Infliximab
  £14 000 per annum       £13000 per annum
  PASI-75 27% 12/52       PASI-75 82%
  PASI-75 44% 24/52
                        •   Humira (adalimumab)
               For Patients
  www.psoriasis-association.org.uk
  The Psoriasis Association
  7 Milton Street
  Northampton
  NN2 7JG
  Tel. 0845 676 0076

www.bad.org.uk
RUH website too (Dermatology Section)
        Atopic Dermatitis Criteria
• Itchy skin plus 3 of the following:-

   –   Onset before 2 years old
   –   History of involvement of skin creases or cheeks
   –   Dry skin
   –   Family history of asthma, eczema or hayfever
   –   Visible flexural eczema ( or facial eczema in children
       under 4 years old)
  Dry skin results from lack of water in the outer layer
  of skin, the stratum corneum. When this layer
  becomes dehydrated it loses its flexibility and
  becomes cracked, scaly and sometimes itchy.

  Emollients have three basic properties:
• Occlusion - providing a layer of oil on the surface of
  the skin to slow water loss and thus increase the
  moisture content of the stratum corneum
• Humectant - increasing the water-holding capacity of
  the stratum corneum
• Lubrication - adding slip or glide across the skin.
               NICE
www.nice.org.uk/Guidance/CG57

Atopic eczema in children
Management of atopic eczema in children
from birth up to the age of 12 years.
Guidance type: Clinical guideline
      Treatment: emollients
•Emollients should be used continuously,
even when skin is clear and:
  – suited to the child’s needs and preferences
  – unperfumed
  – used every day
  – prescribed in large quantities (250–500
  g/week)
  – easily available to use at nursery, pre-
  school
    or school.
         Aggravating Factors

•   House dust mite
•   Animal dander
•   Pollens
•   Moulds
•   Detergents and soaps
•   Woollen clothing
•   Central heating
•   Carpets
•   Staphylococcus aureus
         Specialist Treatments
•   Prednisolone
•   Azathioprine
•   Phototherapy TL01 or PUVA
•   Cyclosporin
•   Behavioural Therapy (for the habitual
    rubbing and scratching)
      Photosensitive Eczema
• Photoallergic contact dermatitis
  (sunscreens)
• Drugs
• Chronic Actinic Dermatitis
• Airborne Contact (Plants)
• Light exacerbated
  – atopic
  – Seborrhoeic
                Treatments
• Emollients (patient preference important)
• Bath Oils
• Topical Steroids (reassure and explain how to
  use)
• Topical Immunomodulatory drugs

• SEE http://www.ruh-bath.swest.nhs.uk
  – Wards and departments
  – Clinical departments
  – Dermatology unit
  RUH SITE FOR TREATMENT GUIDELINES
         Failure of Treatment
• Non-compliance e.g.
  – Steroid phobia
  – Lack of instructions
  – Poor doctor-patient relationship
• Semi-compliance (under-treatment)
• Aggravating Factors
• Severe Refractory Eczema
        Useful Internet Sites

•   http://www.bad.org.uk
•   http://www.dermnet.org.nz
•   http://www.skincarecampaign.org
•   http://www.ruh-bath.swest.nhs.uk
    – Wards and departments
    – Clinical departments
    – Dermatology unit
    RUH SITE FOR TREATMENT GUIDELINES
Comparison Studies of Tacrolimus
          in Eczema
• One month treatment

  – Adults (n=570) moderate to severe eczema equal
    outcome between Locoid and 0.1% tacrolimus

  – Children (n=560 age 2-15) both 0.03 and 0.1%
    tacrolimus significantly better than 1%
    hydrocortisone

  In J Allergy and Clin Immunol 2002; 109: 539-54
        Particular indications for
          Tacrolimus ointment
• Facial involvement

• Peri-ocular involvement

• Flexural involvement

• Requirement for maintenance treatment with
  moderately potent or potent topical steroids

• Presence of topical steroid-induced
  cutaneous
  atrophy or striae
     Important instructions to patients
• Warn about sensation of burning and stinging following
  application which will spontaneously resolve

• 2 week break before immunisations

• No excessive sun exposure during treatment

• Advise to avoid application after a hot bath or shower

• If erythromycin allergic (rare) shouldn’t prescribe
• Tried topical and oral
  antibiotics for 1-year with
  no benefit

• No past medical history.
  No drug history

• She is fed up and needs
  your help. Outline 2
  treatment plans
26-year-old male


        • Progressively worse
          despite
          oxytetracycline for 4-
          months
        • Lesions all over his
          back too
        • Suggest a treatment
          plan
26-year-old female
         • Erythromycin and
           tetracyclines ‘don’t
           work’
         • Retin-A cream
           irritates
         • N-lite laser ‘a waste of
           money’
         • Tearful and
           desperate!

         • 2 treatment plans
               Questions
• What will you advise a patient who starts a
  tetracycline for their acne regarding their
  combined oral contraceptive pill efficacy?
               Questions
• What will you advise a patient who starts a
  tetracycline for their acne regarding their
  combined oral contraceptive pill efficacy?

• What advice will you give regarding the
  use of cosmetics in patients with acne?
           Pathogenesis
   Acne is a chronic inflammatory
  disorder of the pilosebaceous unit

Androgen-mediated seborrhoea
Microcomedone formation
Propionibacterium acnes proliferation
Inflammation
                Comedones
•   Topical retinoids
•   More topical retinoids
•   Benzoyl Peroxide
•   20% Azelaic Acid
•   Salicylic acid (Acnisal) very minor effect
                     Topicals
            Remember pathogenesis
         Androgen-mediated seborrhoea
     Microcomedone formation, bacteria and
                  inflammation

• No effect on sebum production but
  – Lessen ductal hypercornification (retinoids)
  – Reduce bacterial load (antibiotics & benzoyl
    peroxide))
  – Anti-inflammatory (retinoids and antibiotics)
         Topical Retinoids
• Act on the microcomedone reversing the
  process of follicular keratinisation
• Theoretical risk in pregnancy
• ALL acne apart from very severe
  inflammatory disease
• At night
• Need a good reason not to prescribe!
          Benzoyl Peroxide
• Oxidising agent that is bactericidal for
  P.acnes and a keratolyic
• Creams, gels and lotions 2.5% to 10 %
• Use it as part of a treatment plan to
  decrease resistant strains of P.acnes at
  least
• Bleaches clothing and hair
• No real benefit of strengths above 5%
           Topical Antibiotics
•   Dalacin T (clindamycin)
•   Duac (Clindamycin and benzoyl peroxide)*
•   Stiemycin (erythromycin)
•   Zineryt (Zinc acetate and erythromycin)*
•   Benzamycin (benzoyl peroxide and
    erythromycin)*
 Topical Retinoids (nearly always)
• Adapalene
  – Differin cream and gel
• Tretinoin
  – Retin A 0.01 & 0.025% cream, gel and lotion
  – Aknemycin Pus (tretinoin 0.025% & erthyromycin
    4%)
• Isotretinoin
  – Isotrex (isotretinoin 0.05%)
  – Isotrexin (isotretinoin 0.05% & erythromycin
    2%)
          Systemic Treatment
•   Poor response to topical
•   Moderate to severe disease
•   Post inflammatory changes
•   Acne excoriee
•   Dysmorphophobia
•   USE WITH TOPICALS
               Oral Antibiotics
Minimum 4-months treatment (AND topicals)
• Oxytetracycline
• Erythromycin

•   Lymecycline
•   Doxycycline
•   (Minocycline)
•   Trimethoprim
   P.acnes Resistance to
        Antibiotics

‘Resistance to antibiotics constitutes a
major threat to public health’

We who treat acne have a responsibility
to play our part in reducing risk of
antibiotic resistance
                    Antibiotics
• Always optimise topicals
• Strict cross infection
  control measures
• Try and wean off after 6
  to 8 months
• Use topical retinoids
  nocte
• Use benzoyl peroxide
  twice-a week
• Never use different
  topical and systemic
  antibiotics simultaneously
      Tetracyclines and Acne
• BJD 2008; 158: 208-16
  – Subclinical doses of doxycycline at 40mg
    seem to be as good
  – No evidence one tetracycline is better than
    another
  – Probably anti-inflammatory effect most
    important
  – No justification for minocin
  – Oxytetracycline or lymecycline or
    doxycycline?
         Hormonal Therapy
• AND topical treatment
• Dianette (ethinyloestradiol and cyproterone
  acetate)

• Avoid most progesterone only pills &
  norethisterone or levonorgestral (?Cerazette
  OK has desogestrel)

• Use COP with new generation progesterones
  e.g. gestodene (femodene & Minulet),
  desogestrel (Marvelon) and norgestimate
  (Cilest)
      Isotretinoin (Roaccutane)
•   Nodulocystic acne
•   Failure of antibiotics
•   Rapidly progressive disease
•   Severe dymorphophobia
•   Acne conglobata and fulminans
•   Gram-negative folliculitis
•   Beware pushy patients
                Isotretinoin
• Halts sebum production
• Reduces comedone formation
• Anti-inflammatory
• Reduces P.acnes colonisation
BUT
• Major teratogen (pregnancy prevention
  programme)
• Many potential side-effects e.g. mucocutaneous,
  ??depression, CNS, musculoskeletal and
  biochemical
                   Isotretinoin
• Some epidemiological evidence of depression
• Many anecdotal reports however
• Depression is well recognised in acne anyway

     Archives of Dermatology 2005; 141: 557-61
   101 patients 50: 50 split re. isotretinoin or antibiotics.
   No difference in depression in the two groups

    Archives of Dermatology 2000; 136: 1231-36
   No increase in relative risk of depression
                       But
J Clin Psychiatry 2008; 69(4): 526-32
Editorial in Arch Dermatol 2008; 144: 1197-99

Does Isotretinoin Increase the Risk of
Depression?
Conclusion from a case-crossover study was a
relative risk of 2.68

The first controlled study to find a statistically
significant association between isotretinoin and
depression therefore
do warn patients there is a possible association
between isotretinoin and depression
N-lite (Low-Fluence Pulsed-dye laser)
           Lancet 2003; 362: 1347-52
• Small study (only 41
  patients)
• Mild and moderate acne
• Probably no better than
  topicals
• Expensive
• Not repeatable in USA
  study of 40 patients
  JAMA 2004; 291: 2834-
  39
• But not an antibiotic!
• No significant side-
  effects
             Reference
• Management of Acne. A report from a
  global alliance to improve outcomes in
  acne.
  Supplement to Journal American Academy
  of Dermatology July 2003 Vol. 49

				
DOCUMENT INFO