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