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