Dermatology in General Practice

Dr Lynne Rees

Description of skin lesions

Papule Macule Nodule Patch Vesicle Bulla Plaque

Papule

Small palpable circumscribed lesion <0.5cm

Macule

Flat, circumscribed non-palpable lesion

Pustule

Yellowish white pus-filled lesion

Nodule

Large papule >0.5cm

plaque

Large flat topped elevated palpable lesion

patch

Large macule

vesicle

Small fluid filled blister

Bulla

A large fluid filled blister

ECZEMA

Synonymous with dermatitis Large proportion of skin disease in

developed world 10% of population at any one time 40% of population at some time

Features of eczema

Itchy Erythematous Dry Flaky Oedematous Crusted Vesicles lichenified

Types of eczema

Atopic Discoid eczema Hand eczema Seborrhoeic eczema Varicose eczema Contact and irritant eczema Lichen simplex

Atopic eczema

Endogenous Atopic i.e asthma, hay fever 5% of population 10-15% of all children affected at some

time

Exacerbating factors

Detergents Infection Teething Stress Cat and dog fur ???? House dust mite ???? Food allergens Theory of protection from parasite

Clinical features

Itchy erythematous scaly patches Flexures of knees and elbows Neck Face in infants Exaggerated skin markings Lichenification Nail – pitted ridged

complications

Bacterial infection Viral infections – warts, molluscum,

herpes Keratoconjunctivitis Retarded growth

investigations

Clinical ??IgE ??RAST

Prognosis

Most grow out of it! 15% may come back – often very mildly

Treatment

Avoid irritants especially soap Frequent emollients Topical steroids Sedating antihistamines – oral hydroxyzine Treat infections Bandages Second line agents

Triple combination of therapy

Topical steroid bd as required Emollient frequently Bath oil and soap substitute

Principles of treatments

Creams Ointments Amounts required Potential side effects Soap substitutes

creams

Cosmetically more acceptable Water based Contain preservatives Soap substitutes

ointments

Oil based Don’t contain preservative Feel greasy Good for hydrating

Topical steroids

Mild – “hydrocortisone Moderate – “eumovate” Potent – “betnovate” Very potent – “dermovate”

Amounts required

Emollients – 500g per week for total body

FTU – steroids Bath oils – 2-3 capfuls per bath

Discoid eczema

Variant of eczema Atopic and non atopic Easily confused with psoriasis Well demarcated scaly patches Limbs Often infective component (staph

aureus)

Hand eczema

Pompholoyx – itchy vesicles or blisters of palm and along fingers

Diffuse erythematous scaling and hyperkeratosis of palms

Scaling and peeling at finger tips

Hand eczema

Not unusual in atopic More common in non atopics Cause often uncertain Irritants Chemicals Occupational history Consider patch testing – 10% positive

Seborrhoeic eczema

Over growth of yeast (pityrosporum ovale, hyphal form malassezia furfur)

Strong cutaneous immune response More common in Parkinson’s and HIV

Clinical features

Affects body sites rich in sebacceous glands

Infancy – cradle cap, widespread rash, child unbothered, little pruritus

Young adults – erythematous scaling eyebrows, nasolabial folds, forehead scalp

Elderly – more extensive

Treatment

Suppressive Mild steroid and antifungal combination Ketoconazole shampoo Emollients Soap substitutes

Venous eczema

Lower legs Venous hypertension Endothelial hyperplasia Extravasation of red and white cells Inflammation Purpura pigmentation

Clinical features

Older women Past history DVT Haemosiderin deposition

treatment

Emollients Topical moderately potent steroids Soap substitutes Compression – check arterial supply

first Leg elevation

Asteatotic eczema

Dry skin Repeated soaping Worse in winter Hypothyroidism Avoid soap Emollients Bath oils

Contact and irritant eczema

Exogenous Unusual Worse at workplace History of exacerbations

irritant

Can occur in any individual Repeated exposure to irritants Common in housewives, hairdressers,

nurses

contact

Occurs after repeated exposure but only in susceptible individuals

Allergic reaction Common culprits – nickel, chromates,

latex etc Patch testing

Lichen simplex

Cutaneous response to rubbing Thickened scaly hyperpigmentation Emotional stress May need biopsy to diagnose

treatment

Stop rubbing! Very potent steroids Occlusion

PSORIASIS

Psoriasis

Affects 2%of population Well-demarcated red scaly plaques Skin inflamed and hyperproliferates Males and females equally Two peaks of onset (16- 22) and later

(55-60) Usually family history

Chronic plaque

Extensor surfaces Sacral area Scalp Koebners phenomenon

Guttate psoriasis

Raindrop Children and young adults Associated with streptococcal sore

throats Not all go onto get chronic plaque May resolve spontaneously over 1-2

months

Guttate psoriasis

Flexural psoriasis

Later in life Well demarcated red glazed plaques Groin Natal cleft Sub mammary area No scale

Treatment

Calcipotriol too irritant Steroid

Erythrodermic and pustular psoriasis More severe Need dermatologist! Usually need oral therapy

Associated features

Arthritis Nail changes- onycholysis, pitting,

discolouration, subungal hyperkeratosis

prognosis

Chronic plaque tends to be lifelong Guttate – 2/3 further attacks, or develop

chronic plaque

treatment

Suit patient Control rather than cure Topical therapies Light treatments Oral therapy

Topical therapy

Emollients Vit D analogues- calcipotriol, calcitriol,

tacalcitol (dovonex, silkis, curatoderm) Tazarotene – (zorac) Coal tar – alphosyl, exorex, cocois, polytar Dithranol –dithrocream, dithranol 0.1% to 2%

for short contact Steroids – eumovate Combinations – dovobet, alphosyl HC, etc

Light treatments

Not the same as sun beds!!!! UVB UVA

ACNE VULGARIS

Cause of acne

Common facial rash Usually adolescents May occur in early and mid adult life Blockage of pilosebacceaous unit with

surrounding inflammation Androgens lead to increase sebum

production Increased colonisation by propionibacterium

acnes

Clinical features

Increased seborrhoea Open comedones Closed comedones Inflammatory papules Pustules Nodulocystic lesions

Acne distribution

Treatment

Consider site Compliance Inflammatory/non inflammatory lesions Scarring Fertility Psychological effect

Topical treatments

Benzoylperoxidase – OTC, PanOxyl 5 to 10%,

Azelaic acid – skinoren ,avoid in pregnancy Antibiotics – clindamycin, erythromycin,

steimycin Retinoids – adapalene, tretinoin, avoid in

pregnancy, avoid uv light, differin, retin-A

Combination topical treatments

Antibiotics plus benzoyl peroxidase – benzamycin

Retinoid plus antibiotic – isotrexin Antibiotic plus zinc - zineryt

Oral therapy

Use if topical therapy ineffective or inappropriate

Anticomedonal topical treatment may be required in addition

Don’t combine topical with oral antibiotic as encourages resistance.

Consider side effects and interactions when starting antibiotics

3 to 4 months before any improvement

Antibiotics

Oxytetracycline 500mg bd Tetracycline 500mg bd Doxycycline 100mg od Minocycline 100mg od Erythromycin 500mg bd

Hormone treatment for acne

Dianette - not if COCP contraindicated– Withdraw when acne controlled– VTE occurs more frequently in women

taking dianette than other cocp.

Oral retinoids

Hospital only Long list of side effects Teratogenic Very effective

ROSACEA

Clinical features rosacea

Onset middle age Facial flushing / erythema Inflammatory papules Pustules No comedones Telangectasia Blepharitis rhinophyma

Treatment

Supressive rather than curative Topical metronidazole 0.075% Tetracycline 500mg bd for 3 months Metronidazole 400mg bd Roaccutane Plastic surgery and some laser therapy

for rhinophyma

COFFEE

TIME