Complications of Topical C.Steroid Rx

Tachyphalaxis (reduction in efficacy over time)

• Stop using c.steroid and recommence after 7 days

Skin atrophy

Striae

Rosacea

Alteration of infection

Topical steroid allergy

Glaucoma

Disruption of HPA axis

What & How Much?

Dermatitis

Consider

• What to prescribe?
• Region/s affected
• Face/Neck and flexures
• 1% HC cream (Egocort 1%)
• For palms and soles
• Diprosone 
• For other regions
• Celestone-M
• Lichen planus; discoid lupus; granuloma annulare
• Diprosone OV [optimum vehicle]

• How much to use?
• Consider the 'finger tip' measure
• Face and neck                    --> 2.5 units
• Trunk front and back          --> 14 units
• Hands and feet                   --> 1.5 units
• Upper limb                         --> 3.5 units
• Lower limb                         --> 5.5 units

• How to use?
• Apply thin layer, ideally straight after a bath or shower
• 'Pulse therapy' helps prevent tachyphylaxis 

• How long to use?
• Need to balance strength of c.steroid with anticipated Rx time-horizon
• Optimise beneficial effects
• Avoid local side effects
• Avoid suppression of HPA axis
• Adult
• Child

1 finger tip (from Wiki)





Psoriasis

Calciptriol 0.05% cream bd

• Up to 100g per week

Compounding

Styptic Agents

• 20% aluminium chloride
• Monsel's solution
• Ferric subsulfate

For psoriasis

• Tar Cream
• 3% salicylic acid + 3% lpc (liquor picis carbonatum)

In Case of Psoriasis

Always examine

• Scalp
• Joints (& associated tissue)
• Nails

Tips for Procedures

Minor bleeding post-op

• 20% aluminium chloride
• Monsel's solution

EMLA

• Apply to post-cryoRx to reduce pain

Dark skinned people

• Those most likely to develop keloid

Liquid N2

• Spray = -195.8 C
• Dipped swab --> much less cold

UV

• C - penetrates epidermis only
• B - penetrates superficial dermis
• A - penetrates deep dermis

For laser Rx

• CO2 - resurfacing - deep
• Erbium:YAG - resurfacing - superficial
• Argon-pumped - telangiectasia/port wine stain
• Or other that target oxyHb
• Doubled Nd:YAG - pigmented lesions (epidermal)
• For tattoos
• doubled Nd:YAG - red tattoos
• Q.Switched - blue/black/green tattoos

Atypical Nevi

AKA dysplastic nevi


Usually

• >0.5cm diameter
• Irregular border
• Shades of pink & brown
• Always have a macular component

Not present at birth

Prevalence 5%

Increased risk of melanoma

Several or many lesions
=> ?Atypical Nevus Syndrome
=> Accounts for 5% of melanomas in US
Consider the familial syndrome
=> >50 dysplastic nevi; FHx of melanoma, esp. 1st or 2nd degree relative
Subtle histological differences for non- versus familial

Mx for multiple dysplastic nevi should include

• Total cutaneous survey at least every 12/12
• Screen family members
• Educate re self-examination
• Excise suspicious lesions

Nevus vs. Lentigo | Melanocyte | Mole

Nevus

• Tumor made up of nevus cells, derived from melanocytes
• Most derived in the first 20 years of life
• Sometimes referred to as melanocytic nevus or 'mole'
• May or may not be pigmented

Lentigo

• Increased pigment in basal layer
• Melanocytes may be increased in number, but don't form nests
• More prevalent in older age

Congenital Nevus

• A hamartoma: a benign, but disorganized, growth of normal tissue elements in its region and which grows at a normal rate
• Possible risk of melanoma (especially if >20cm diameter)

Melanocyte

• Produce melanin
• Numerous stimuli, including UV and ACTH
• Located in the bottom layer of the epidermis
• Also found in the CNS, bones and heart

Mole

• As above, a common name for a (melanocytic) nevus
• Sometimes reserved specifically as a label for an intra-epidermal nevus, many non-pigmented

Melanoma

Mimics

• Compound nevus (with irregular border)
• Seborrheic keratosis
• Hemangioma
• Dermatofibroma (pigmented)

Prognosis

• Two most important determinants
• Tumor thickness
• Ulceration: present or not
• Recurrence/survival
• Sample sentinel lymph node
• 1st node in lymphatic basin that drains lesion
• Bx if depth of lesion >=1mm

Risk Factors

• Complexion (fair skin; red or blond hair)
• PHx
• Atypical nevus
• 1 lesion         --> 2* risk
• >=10 lesions --> 12* risk
• Melanoma
• Non-melanoma skin cancer
• Congenital nevus >20cm diameter

70% are superficial-spreading melanomas and slow-growing


15% are nodular melanoma and fast-growing




Any changing skin lesion (pigmented or non-pigmented)
--> must consider melanoma




Stage

• Sample sentinel group of lymph nodes
• # affected
• Tumor burden within node
• FBC; LFTs; serum LDH
• CXR; ?CT chest?
• ?CT or MRI brain?

Rx

• Surgical
• Excision margin
• <1mm thick   --> 1cm
• >=1mm thick --> 2cm
• Medical
• Interferon-alfa
• Improves outcomes in Stage IIB - IIIC

Congenital Vascular Malformations

Congenital vascular lesions

• hemangiomas  - 40% present @birth
• common on face
• mostly arterial
• rapid neonatal growth; slow involution
• malformations  - 99% present @birth
• common on limbs
• mostly venous
• grows in proportion to child
• result from inborn errors of vascular morphogenesis

Watch out for eroded or ulcerated skin

--> N.saline compresses; paraffin gauze; Rx infection

Consider potential for other system compromise, including psycho-social difficulties


Any extensive facial hemangioma or any midline spinal hemangioma

-->brain imaging: US scan; CT scan


Vascular malformations associated with more congenital abnormalities vs. hemangiomas

Another Initial Approach

Hx must always consider:

1. Timeline (acute; sub-acute; chronic)?
2. Similar in past (new; recurrent)?
3. Medication/drug history
4. PHx
5. Symptoms: 
• Direct: itch or pain
• Indirect: fever; URTI; joint pain; headache; weight loss; fatigue; malaise

1. For examination of the lesion or rash
• Number: single lesion; several lesions; or rash?
• 'First impression':macro characteristics
• Flat or raised?
• Furthermore
• Scaly (=> epidermis)
• Non-scaly (=> dermis)
• Pustular
• Blisters
• Skin intact or broken?
• Distribution/region
• Morphology
• 'Closer inspection":
• macular; papular; patch; plaque
• erosion; ulcer
2. For the Hx
• Symptoms, as above
• Drug Hx: prescribed; over-the-counter; recreational
• Occupational Hx: work; hobbies/pastimes/activities/sports
• Contacts: rash; itching; hospitalization
• PHx:
• .. medical: other skin disease; diabetes; auto-immune; immunosuppression; rheumatic fever
• ...  surgical
• FHx: eczema; psoriasis

NB:

If single lesion

--> ?is lesion or region affected prone to complications?

e.g.

SCC from venous stasis ulcer on lower leg;

Cavernous sinus thrombosis from infected 'danger zone' on the face

If rash

--> ?does it conform to a dermatomal distribution?

e.g.

Herpes zoster ('shingles')

--> ?is it symmetrical?

e.g. Acne rosacea on the face

--> ?is confined to a particular region?

e.g. Venous stasis dermatitis on lower leg

--> ?does it affect a particular cutaneous feature?

e.g. The nails in onychomycosis

Heavy Snow: Basel 2006

Wood's lamp

Erythrasma

= coral pink

Pityriasis versicolor

= yellow-green

Porphyria cutanea tarda

= coral pink urine

Scabies

--> rub fluorescine into skin

--> ?burrows

Head lice

= white - unborn lice

= grey - empty nits

Acne rosacea

Demodex mites live in or close to hair follicles and are thought to contribute to the development of rosacea

Variations to be Rx as per rosacea

• peri-oral dermatitis
• peri-orbital dermatitis

Avoid factors that can aggravate (not cause)

• cosmetics
• hot food
• spicy food
• alcohol

Ocular rosacea is common (so always ask re eye symptoms) and includes

• Blepharitis
• Chalazion or hordeolum (styes)
• Dry eyes
• (mild) conjunctivitis
• Keratitis (inflamed cornea; cornea ulceration) 
• Light sensitivity
• Scarring --> blindness

Seborrheic dermatitis

Lipophilic yeasts from Malassezia genus has been implicated in the development of this disorder

• Pityrosporum ovale

Often associated with acne rosacea

Rx

•  reduce inflammation/Rx discomfort
• 1% HC cream tds for face/axilla/groin
• or Advantan or Elocon for first 5-7 days
• remove scale
• 3% sulfur + 3% salicylic acid in emulsifying ung or similar keratolytic
• tar-based product
• target Malassezia
• Hyrdrozole cream (1% HC + 1% clotrimazole)
• Nizoral cream (ketoconazole)
• Selsun shampoo (for scalp and body)

For recalcitrant or severe disease

--> oral azole e.g. ketoconazole (daily for 1/52); fluconazole (weekly for 2/52)

--> isotretinoin

Impetigo

Common and contagious, particularly amongst children.

Strep., Staph. or combination.


Bullous or non-bullous forms

Self-limiting, but may last weeks or months.

Post-strep. g.nephritis may following acute infection, but usually resolves completely without Rx

Rheumatic fever has not been reported.

Serology not routine, but:

- ASO titre doesn't increase; 

- anti-DNase B increases to high levels => best indicator of Strep. impetigo

Bullous

- usually due to Staph. epidermolytic toxin

- lesions can heal with hyperpigmentation on black skin

- regional lymphadenopathy uncommon

Non-bullous

- satellite lesions beyond periphery are common

- regional lymphadenopathy common

Recurrent impetigo is usually caused by Staph. aureus

--> Rx Bactroban ung to nares bd for 5 days

Rx

- Bactroban ung 2% = as safe and effective as oral erythromycin

- Isolate children until Rx commenced

- penicillin - Diclox

- cephalosporin - Keflex

- macrolide - EES

- often require 10-day course (5-day minimum)

- erythromycin less effective
- consider hot-washing bed linen and clothing that will tolerate this

An Approach to Dx Ix & Rx

1. Solitary lesion or multiple lesions

• Solitary --> consider using dermatoscope for pigmented and non-pigmented lesions

2. Multiple

• Distribution
• Pruritic or not?
• Painful or not?

3. Time scale

• Acute
• Sub-acute
• Chronic

4. Similar in past?

5. Primary or secondary skin condition

• e.g. eczema with secondary Staph. infection

6. Main feature

• Red scaly
• => epidermis affected
• Red non-scaly
• => dermis affected
• Blisters
• Pustules

7. Muco-cutaneous symptoms


8. Contact?

9. General condition

• Presenting complaint
• Systematic enquiry
• PHx
• Symptoms
• RS - URTI/LRTI
• GI - infection; inflammation
• GU - UTI; STI
• NS - headache
• Pysch - stress; mood disorder
• Other
• Medications
• OTC preparations
• Vaccinations
• Diet
• Weight
• Examination
• Scalp
• Oral cavity
• Axilla
• Groin
• Palms & soles
• Lymph nodes
• neck
• axilla
• groin
• epitrochlea

10. Febrile?

11. Ix

• Clinical
• Wood's lamp
• Magnifier
• Dermoscope
• Lab
• Swab
• mcs
• PCR
• Throat ?Strep.
• Scrape
• KOH micro
• Bxi
• +/- DIF
• +/- special stains
• Exc
• +/- DIF
• +/- special stains
• Special stains
• Standard
• H&E
• Consider other or additional stain in inflammatory and neoplastic disease
• Bacteria
• Gram (gram -ve difficult to demonstrate)
• Ziehl-Neilson (most mycobacteria (ZN or AFB)
• Cutaneous lymphoma
• cytogenetics
• Fungi
• Periodic acid-Schiff (PAS)
• 
  
• DIF
• IgG; IgA; IgM; C3
• Blood/serology
• Blood
• FBC
• LFTs
• UCEs
• F.BSL & lipids
• Serology
• CRP
• RF
• ANA
• Complement
• IDIF
• IgE
• RAST
• Strep.
• FTA-ABS
• Hep B/C
• HIV
• QuantiFERON

11. Rx

• Reduce symptoms
• Reduce excessive moisture
• Hydrate dry skin
• Prevent recurrence
• Cure
• Palliate
• Rx secondary condition/s (incl. infection)
• General skin care
• Clothing
• 100% not always best as may contain allergens
• may be finished with formaldehyde resin
• Consider
• 100% cotton or linen that wrinkles easily
• 100% polyester
• 100% wool
• 100% silk
• 100% denim
• Silver Shield/4H gloves
• Soap alternative
• Dermaveen Shower & Bath Oil
• Emollient
• Dermeze ung
• Aqueous cream
• Shampoo
• Don't use everyday if skin dry
• Hypo-allergenic
• Head & Shoulders Clean Balance
• Selsun
• Sebitar/Sebirinse
• Topical

• Rx
• PBS
• Private
• Compound
• OTC
• Systemic
• antibiotics
• c.steroids
• Ig
• Vaccine
• Address psychological issues

Diabetes mellitus

Classic rash = necrobiosis lipoidica (shins)

Can make most chronic skin disease worse

More prone to infection

Can be associated with many skin diseases/conditions

Acanthosis nigricans is considered a risk factor for diabetes mellitus (axilla; nape of neck)

Red scaly rash

Always consider as a possibility

• Lupus (discoid; systemic)
• T-cell lymphoma; Mycosis fungoides
• Syphilis (secondary)

Usually

• Psoriasis
• Eczema
• Tinea

Hot-washing

Always in scabies

Consider in recalcitrant impetigo

Psoriasis

Never Rx with systemic cortico-steroids as this can result in a severe rebound effect

Acne vulgaris

Acne

• Any scarring --> refer ASAP to specialist dermatologist for consideration of oral isotretinion and/or laser resurfacing
• Do not Rx tetracyclines for children under 8 years of age 

Psycho-social impact

Always consider the potential psycho-social and occupational impact of dermatoses

Tinea

If suspect tinea
--> skin scrapings for KOH micro & culture
--> if no fungal elements seen or culture is -ve and Dx uncertain
---->  Biopsy and ask for periodic acid-Schiff stain --> fungal elements appear red