Molluscum contagiosum Rx

Rx

• EMLA cream 60 mins prior to Rx (especially in children)

• Curettage

• or

• Umbilicate

Other topical Rx messy, expensive and far less effective

NB:

• In cases of dermatitis, ensure this is treated too as MC more likely to spread
• Also, avoid baths to reduce risk of spread

Vit D Deficiency

People with dark skin at higher risk for vitamin D deficiency versus people with light skin

The Common Systemic Therapies

In psoriasis

• 1. methotrexate
• 2. acitretin
• 3. cyclosporin
• DON'T USE SYSTEMIC STEROIDS

In dermatitis (atopic)

• 1. prednisolone
• 2. methotrexate
• 3. cyclosporin
• 4. azothioprine - but evidence-base for efficacy and side effects is weak

Prednisolone

• side-effects
  • endocrine or metabolic
    • osteoporosis
    • diabetes
    • e.lyte imbalance
    • acute adrenal insufficiency (on withdrawal)
  • hypertension
  • ocular
    • glaucoma
    • cataracts

Methotrexate

• not sure how it works ?immune suppression
• taking folic acid tabs. for part of week may help ↓anemia incidence

• side-effects
  • nausea
  • diarrhoea
  • mouth ulcers
  • skin side-effects uncommon
  • More serious
    • hepatitis
    • cytopenia
    • teratogenesis
• Pre-Rx check
  • FBC
  • LFTs
  • UCEs
  • eGFR

Acitretin

• ↓cell proliferation
• LFT changes uncommon
• TG changes common (↑serum TGs)

• side-effects
  • skin side-effects common
    • dry, red skin/nose;eyes; lips
      • →artificial tears for eyes
      • cheilitis --> consider barrier ung; UV protection
  • alopecia
  • photosensitivity
  • more serious
    • hepatitis
    • cytopenia
    • teratogenesis

In pregnant woman or woman planning pregnancy or breastfeeding

• don't use
  • MTX
    • and until 3/12 after MTX ceased
  • tetracyclines
  • oral retinoid
    • isotretinoin
    • acitretin (and no pregnancy within 2 years)

Cyclosporin

• ↓inflammation
• only use under guidance of specialist experienced in its use
• side-effects
  • hepatitis
  • renal dysfunction
  • gum hyperplasia: swollen or bleeding gums can occur --> dental hygiene
  • hirsuitism
  • Pre-Rx check
    • FBC
    • LFTs
    • UCEs
    • eGFR
    • F.lipids
    • Blood pressure
  • If BP raised --> consider calcium antagonist to prevent renal loss

So, for MTX, retinoids and cyclosporin

- Pre-Rx check

• BP
• FBC
• LFTs
• UCEs
• eGFR
• (F.lipids)
• (pregnancy test in females)

- during Rx check

• BP
• FBC
• LFTs
• UCEs
• eGFR

So, for prednisolone

- Pre-Rx check (ideally)

• BP
• UCEs
• eGFR
• F.lipids and F.BSL
• Intra-ocular pressure

- during long-term Rx check

• BP
• UCEs
• F.lipids and F.BSL
• bone density
• eyes
  • intra-ocular pressure
  • lens ?cataracts

Biological Rx

• target T-cells or tumour necrosis factor alfa (TNF alfa)
• expensive and strictly limited
• can reactivate TB
• → before Rx → QuantiFERON-TB Gold test
  • indirect test for M.tuberculosis

Preg code X

• oral retinoids
  • isotretinoin
  • acitretin
• MTX

In case of skin cancer

In case of melanoma or non-melanoma skin cancer
- check local/draining lymph nodes

In case of melanoma
- refer to local melanoma unit

Dermoscopy: non-pigmented lesions & vessels

BCC
- serpentine branched vessels (arborizing telangiectasia)

SCC
- diffuse coiled vessels (glomerular) & red dots

Confocal clinical microscopy probably better than dermoscopy

Must use polarized AND non-polarized light

Don't Rx aspirin/NSAID/ACE inhibitor

In cases of angioedema

Case: Rash on Sweating

Often quite itchy

Miliaria

• rubra variant ('prickly heat'; 'heat rash')
• small red papules; some may appear more like vesicles
• sometimes looks like folliculitis
• but rash not related to hair follicles
• dermoscope may help distinguish
• itchy (look for scratch marks)
• ?clothing distribution/friction
• epidermal
• sweat may leak into dermis
  --> very itchy lumps
• may get secondary infection
  = miliaria pustulosa
• Rx
• reduce heat/sweating
• cold compresses
  calamine lotion
• topical c.steroid
• not antihistamine as = not related to histamine release

Cholinergic urticaria (a physical urticaria)

• Rx
• reduce heat/sweating
• antihistamine (non-sedating)
• oral c.steroid

Polymorphous Light Eruption

Often triggered by short UVB and long UVA


If by UVA

• Sun block not very effective
• Can be triggered by light through windows

Genital Ulcer

Painful
=> Herpes simplex (I or II)

Painless
=> Syphilis (primary; chancre)

Poorly-defined
=> Chancroid

Hemorrhagic
=> Granuloma inguinale (Donovanosis)

Tinea or Pityriasis?

Fungi <--> Tinea
But "tinea" generally reserved to describe circinate lesions => 'ring worm'
- in particular, those caused by a dermatophyte

So, tinea => dermatophyte
Generally followed by the region it affects e.g. tinea pedis (foot); tinea corporis (trunk) etc.


Candida albicans and Malassezia furfur
- are yeast-like and not dermatophytes

Candida --> candidiasis
Mallassezia furfur --> pityriasis versicolor (misnomer = tinea versicolor)


Important reason for understanding this

• Tinea, including onychomycosis (nails)
• responds to terbinafine (e.g. Lamisil) and griseofulvin (e.g. Grisovin)
  &
  responds to the "azoles"
• Candidiasis and pityriasis versicolor
• do not respond to terbinafine or griseofulvin
  but
  respond to the "azoles"

So 

• Tinea                                      --> terbinafine or griseofulvin or an azole
• Candidiasis                          --> an azole
• Pityriasis versicolor             --> an azole

Elidel and Protopic

PBS Listing

For eczema on face where topical c.steroids have failed to control disease or where intermittent topical c.steroids are contraindicated


Intermittent use only


Don't use for more than 2 years as no safety data yet


Children 3/12 to 2 years old

• Apply to smallest practical area
• Max 3/52 episode

Topical C.Steroid vs. Elidel or Protopic

In adults:                topical c.steroids are more effective

In children:             unknown

Contraindications to Topical Steroid

Relative

• Region (re potency)
• Face
• Intertriginous regions
• Extensor surfaces arms, legs, hands & feet

• Condition (re aggravation of disease)
• Acne rosacea; perioral dermatitis
• Rx for cutaneous infection
• Folliculitis

• Extent of disease (re ? for systemic steroid-sparing Rx) 

• Age (re increased absorption)
• Young children
• Elderly

Absolute

• Allergy to corticosteroid (5% of cases with allergic dermatitis)

• Steroid atrophy

Not an exhaustive list, but important issues highlighted

Acne Vulgaris

Rx in Practice

• Patient education
• Combination Rx best for all degrees of acne
• Consider psychological impact - especially if scarring present
• Reduce cosmetic use and use non-greasy or water-based products

If female, consider

• Impact of Rx on pregnancy - present or planned
• Anti-androgen
• COCP + anti-androgen
• e.g. Diane
• Spironolactone

Consider oral prednisolone in severe cases or if acne fulminans --> short-term relief

Before Any Systemic Rx

• Check
• BP
• FBC
• LFTs; UCEs; eGFR
• Fasting TGs (for isotretinoin and prednisolone)

Systemic Rx in Eczema & Psoriasis

For eczema

1. Prednisolone
2. Methotrexate
3. Cyclosporin

For psoriasis

1. Methotrexate
2. Acitretin
3. Cyclosporin

NB: Prednisolone in psoriasis could increase severity

Pregnancy Test Pre-Rx

Methotrexate

A retinoid

Cyclosporin

Re Systemic Acitretin & Side Effects

Potential side effects

• Dry inflamed skin and mucous membranes - lips
• Alopecia
• Raised serum TGs

Pre-Rx

• LFTs; UCEs; eGFR; FBC
• Fasting lipids
• Pregnancy test

Re Systemic Cyclosporin & Side Effects

Only use in conjunction with a specialist experienced in its use

Potential side effects

• Raised BP
• Hepatic dysfunction
• Renal dysfunction

Pre-Rx check

• BP
• FBC; LFTs; UCEs; eGFR; lipids
• Pregnancy test

If BP raised, consider 

• Rx calcium-antagonist to prevent renal loss

Do Not Use if Pregnant or Planning Pregnancy

Systemic agents

• Methotrexate
• Acitretin (Neotigason)
• Isotretinoin (RoAccutane)
• Tetracyclines

Further more

• Acitretin & Isotretinoin
• No pregnancy within 2 years of Rx cessation

Re Systemic Methotrexate & Side Effects

Potential side effects

• Hepatitis
• Cytopenia
• Teratogenesis

Pre-Rx check

• LFTs; FBC; UCEs; eGFR
• Pregnancy test

Re Systemic Prednisolone & Side-Effects

Short-term

• Raised intra-occular pressure
• Adrenal insufficiency

Long-term

• As / short-term
• Hypertension
• Osteoporosis
• Occular
• Glaucoma
• Cataracts
• Endocrine
• Diabetes
• Electrolyte imbalance
• Weight gain; tends to be trunk and face

Pre-Rx check

• BP
• Intraoccular pressure
• LFTs; UCEs; eGFR; fasting lipids & BSL

Long-term Rx check

• BP
• Eyes - intraoccular pressure; cataracts
• Bone density
• UCEs; fasting lipids & BSL

Milia or Miliaria

Milia

• Keratin-filled cysts

Miliaria

• Blocked sweat ducts

Compression Bandages & Stockings for Wounds

Pressure

• 18-24 mmHg
• Jobst stockings
• Varicose veins
• Ulcer prevention
• Mild edema

• 25-35
• Venosan stockings
• Varicose veins (severe)
• Post limb DVT
• 14-17
• If discomfort an issue with higher pressure / patient compliance

Should be properly measured

Wound Dressings

Examples of Brand Dressings for Different Types of Wounds


Venous

• Zinc oxide
• FlexiDress
• Steripaste

Xs bacterial burden / Excessive moisture

• Calcium alginate with antiseptic component (e.g. weak povidine-iodine)
• Algisite M
• Kaltostat

Hypergranulation

• Hypertonic saine
• Mesalt
• Curasalt