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)