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