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«INTRODUCTION Dermatology – Does it Matter? SECTION 1 - Conditions Acne vulgaris Actinic keratosis (solar keratosis) Alopecia Basal cell papillomas ...»

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Skin Deep

Revised Version 2013

CONTENTS

INTRODUCTION

Dermatology – Does it Matter?

SECTION 1 - Conditions

Acne vulgaris

Actinic keratosis (solar keratosis)

Alopecia

Basal cell papillomas (seborrhoeic keratoses/warts)

Benign melanocytic naevi (moles)

Benign skin lesion

Bowen’s disease

Bullous eruptions

Chondrodermatitis nodularis helicis chronicus (CDNH)

Drug reactions Eczema – Atopic Eczema – Discoid (Nummular) Eczema – Hand Eczema – Seborrhoeic Eczema – varicose Fungal skin infection Hirsutism Latex allergy Leg ulcers Lichen planus Local hyperhidrosis (excess sweating) Malignant melanoma Molluscum contagiosum Nail disorders (onychodystrophies and onychomycosis) Non melanoma skin cancers Patch testing Photosensitive rashes Pityriasis rosea Pityriasis versicolor Pruritus Pruritus ani Psoriasis – Chronic Plaque Psoriasis - Guttate Rosacea Scabies Urticaria Vascular birthmarks Viral warts Vitiligo Xeroderma SECTION 2 - Treatments Cryotherapy (cutaneous cryosurgery) Dermatological therapy Skin surgery SECTION 3 – Online Educational Resources Section 4 - Patient Support Groups

DERMATOLOGY

The demographics of skin disease

DEFINITIONS

Dermatology is the study, investigation and management of diseases of the skin, hair and nails.

There are over 2000 diagnoses ranging from rare genodermatoses to the ubiquitous acne.

Most presentations are for the 10 commonest skin diseases.

For the purpose of presenting data, the numbers below relate to a NHS primary care cluster or clinical commissioning group (CCG) covering a population of 100,000.

PREVALENCE AND INCIDENCE

In any year, about 50% of the population will develop a problem with their skin and 25% will develop a skin condition that necessitates a consultation with their GP. 95% of this group have always been managed in primary care with approximately 5% being referred to secondary care services (1-2% of GP list referred per year). The commonest dermatology conditions presenting in the general population are shown in table 1.' Table 1 Prevalence of skin conditions in the general population expressed as rates per 1000 (to nearest unit).

Diagnostic category Rate per 1000 Population All Grades Moderate and severe Eczema 90 61 Prurigo and allied conditions 82 39 Acne 86 35 Scaly dermatoses 85 29 Erythematous and other dermatoses 75 21 Nail disorders 33 19 Tumours and vascular lesion 205 14 Scalp and hair disorders 82 14 Infective and parasitic conditions 46 7 Psoriasis 16 6 Warts 34

–  –  –

Demand

1. In any NHS CCG serving a population of 100,000 people it has been estimated that 25,000 people will have some form of skin disease.

2. Nearly a third of these sufferers (7,500) will treat themselves, and nearly two-thirds (14,550) will consult a GP.

3. Over the last 20 years there has been a sustained, up to 20% increase in the incidence of chilfhood atopic dermatitis

4. There is a consistent year on year increase in melanoma and non melanoma skin cancer

5. the increase in the number of elderly in the population poses its own challenges in managing age related skin problems, asteatosis, pruritus, leg ulcers, skin cancer immunobullous disease etc etc.

6. Of all GP consultations, 15% are for skin problems (table 2).

7. Table 2 Proportion of people with skin conditions among people consulting their GP

–  –  –

GPs classify a third of these conditions as 'minor' - equating to 4,550 minor skin conditions receiving GP advice in our CCG population of 100,000.

Despite the immense workload generated by skin disease the total NHS expenditure is only £2bn.

SECTION 1 CONDITIONS

ACNE VULGARIS

DEFINITION This common skin disease affects virtually all adolescents to some extent and is a chronic inflammatory disease of the pilo-sebaceous apparatus. It can also be a significant problem in some adults particularly women in there late 20s early 30s. Only a small minority of sufferers will seek medical advice.

CAUSE

The condition is probably hormone driven causing an increase in sebum production, an abnormal proliferation and differentiation of ductal keratinocytes leading to occlusion and colonisation with the commensal bactrium Proprionobacterium acnes leading to an inflammatory reaction.

Exacerbating factors may include: Hormonal factors – some females will experience a flare around their periods.

 Diet - there is no evidence that diet has any role in the aetiology of acne.

 Stress may be an aggravating factor.

 Drugs – topical and oral steroids, anabolic steroids and lithium may exacerbate.

UV exposure may help acne (especially comedonal), but do NOT advise the use of sunbeds

CLINICAL FEATURES

Formerly considered a disease of teenagers, more and more adults, particularly females, in their 20s and 30s are presenting with and seeking treatment for their acne. Though predominantly occurring on the face, acne will also affect the back and chest to a certain degree. The treatment of acne depends upon the lesions the patient presents with and may require combination of topical and systemic agents.





Lesions include: comedones – blackheads (open) and whiteheads (closed) (Fig 1)  papules/pustules (Fig 2)  nodules (Fig 3)  cysts (Fig 3)  scars- keloidal or atrophic (ice pick)

DIFFERENTIAL DIAGNOSIS

Although usually a straightforward diagnosis in the adolescent, gram negative folliculitis may occur after long term antibiotic treatment and may present as treatment resistant acne. In the adult the differential diagnosis may include rosacea. If an adult woman suddenly gets devastating acne and hirsutism one should consider a hormonal tumour.

INVESTIGATIONS

 None for most patients. Hormone profile for older female with hirsutism, menstrual irregularity etc.

 Liver function tests and fasting lipids.. For females of childbearing age being considered for Isotretinoin please arrange a serum pregnancy test less than 7 days before the appointment. Availability of these will minimize appointments.

MANAGEMENT The majority of people with acne will self medicate with over the counter preparations from the pharmacy.

Comedonal acne Managed with topical agents, usually a topical Retinoid, Benzoyl peroxide, Adapalene, Azelaic acid or Nicotinamide. Many of these products can be quite irritant to the skin so advise patient to build up length of and frequency of application. They must be used for at least 6 weeks before seeing any benefit.

Agents recommended in the Wirral formulary include:First choice Benzoyl Peroxide 5% gel - Apply once or twice daily Second choice Tretinoin (Retin-A®) 0.025% cream - Apply thinly once or twice daily Or Adapalene (Differin®) 0.1% cream/gel - Apply once daily at night Mild inflammatory acne (with papules and a few pustules).

Initially try topical antibiotics or topical antibiotics in combination with benzyl peroxide or adapalene (1 at either end of the day) or as combination products. Treatment is to be applied twice daily to all potentially affected areas for a minimum of 3 months. These agents may also be used after a course of oral antibiotics or Retinoids if small comedones of pustules persist. Topical treatment can be maintained for prolonged periods.

Agents recommended in the Wirral formulary include:First choice Benzoyl peroxide 5% / clindamycin 1% (Duac Once Daily®) - Apply once daily in the evening Or Isotretinoin 0.05% / erythromycin 2% (Isotrexin®) - Apply thinly once or twice daily Adapalene 0.1%/benzoyl peroxide 2.5% (Epiduo®) Inflammatory acne (with papules pustules and more inflammatory nodules).

Usually requires oral antibiotics such as tetracyclines, erythromycin or occasionally trimethoprim (minocyclines are rarely used because of risk of hepatotoxicity and lupus like syndrome). Treatment must be given for a minimum of 3 months before moving to another agent if no response. Efficacy can be improved if oral antibiotics are combined with topical anti comedonal treatments if both comedonal and inflammatory lesions exist. Some research suggests using Benzoyl peroxide in conjunction with oral antibiotics reduces the development of antibiotic resistant propionobacterium acnes.

Oral antibiotics recommended on the Wirral formulary are:First choice - severe inflammatory acne Oxytetracycline 500mg, orally, twice daily. (emphasis to the patient that this must be taken on an empty stomach) However, to increase compliance Lymecycline 408 mg, orally, daily may be a better first choice Second choices Erythromycin 500 mg, orally, twice daily Or Doxycycline 100 mg, orally, daily Third choice Trimethoprim 300 mg, orally, twice daily (unlicensed dose – check FBC 2 x year and warn re possibility of drug reaction) Females with moderately severe acne, seborrhoea and a pre menstrual flare may benefit from Dianette (Ethinyloestradiol 35 micrograms, cyproterone acetate 2 mg), Co-cyprindiol, non-proprietory.. This would also serve as a contraceptive should the patient require Isotretinoin.

If there is no response of inflammatory acne to the above then patients should be referred for consideration of Isotretinoin. An alternative for some females is spironolactone.

Severe nodulo-cystic acne Those with severe inflammatory acne and especially those with significant scarring should be referred immediately for consideration of Isotretinoin. They should be started on an oral antibiotic whilst awaiting their appointment.

Acne Variants Macrocomedones These comprise large ‘whiteheads’ and usually affect the chin and cheeks. They do not respond to conventional treatment and require cautery before receiving isotretinoin otherwise a sever inflammatory response can occur.

Acne Fulminans Sudden occurrence of severe inflammatory acne on the trunk and face with associated fever arthritis and lethargy. These patients require urgent referral and often require systemic steroids followed by isotretinoin.

Acne Conglobata Usually found in males with clustered blackheads, sinus tracts, tender lesions and usually extensive scarring. Hidradenitis can sometimes co-exist. Treatment is difficult and patients should be referred immediately to secondary care.

Acne Excoriee Usually affects young females who tend to have mild acne which has been ‘picked’. In most a simple explanation of the deleterious effect of this is all that is required but in some patients this forms part of a spectrum including dermatitis artefacta/dysmorphophobia.

Treat with the less irritant topical agents.

Persistent acne in the adult.

If an adult over 25 continues with acne even mild to moderate in severity then consider referral for specialist advice as these patients often require isotretinoin.

WHEN AND WHERE TO REFER

Refer Early  Severe acne  Moderate acne which is only partially responded to treatment mand starting to scar  Inadequate response to at least 2 systemic antibiotics given for a minimum of 4 months each  Patients with associated and severe psychological symptoms regardless of severity of acne Patients with acne who have failed two full courses of oral antibiotic treatment combined with appropriate topical treatment, all patients with severe nodulo-cystic, conglobate acne and acne occurring in the adult should be referred for consideration of Isotretinoin.

Include FBC, biochemical profile and lipids with referral and a negative pregnancy test within 7 days of the appointment if isotretinoin is to be considered in a female of childbearing age to minimise appointments required.

Fig 1 Comedonal Acne Fig 2 Papules and Pustules Fig 3 Nodules

ACTINIC KERATOSIS (SOLAR KERATOSIS)

DEFINITION Dysplastic epidermal cell changes with superficial redness and scaling of the skin in sun exposed areas. Some can be hyperkeratotic. Squamous cell carcinoma (SCC) risk is low withan annual incidence of transformation estimated at 1%. The risk is higher in immunocompromised patients.

CAUSE Sun induced.

CLINICAL FEATURES

 Often multiple, discrete red scaling lesions on sun exposed areas.

 Commonly found on backs of hands, face and scalp (especially in men with male pattern baldness).Fig 1  May develop into a cutaneous horn. Fig 2

DIFFERENTIAL DIAGNOSIS

1. Seborrhoeic keratosis/basal cell papilloma, these are usually larger and often pigmented and not restricted to sun exposed areas.

2. Bowen's disease, often larger, erythematous and scaly.

3. Squamous cell carcinoma – usually and indurated or nodular lesion which may ulcerate.

4. Viral warts are usually more hyperkeratotic with less redness.

INVESTIGATIONS

 None required  If SCC is suspected refer urgently via 2 week pathway MANAGEMENT

1. Emollient and observation - an option if there are not very many lesions and the patient is educated to return if lesions change or become nodular.

2. Sun protection – avoidance, sunscreens, hats and clothing.

3. Liquid nitrogen cryotherapy, one freeze/thaw cycle of 10 seconds usng the ‘C’ nozzle of the Cryac® usually sufficient.

4. Efudix cream (5 Fluorouracil), useful especially if multiple lesions with field change.

 Apply once or twice daily to affected areas for 3 weeks – can cause quite marked local irritation or inflammation to the lesions and surrounding skin. In the 4th week, 1% Hydrocortisone or Nystaform-Hydrocortisone ointment can be applied to reduce the inflammation.

5. Topical Diclofenac (3% gel, Solaraze). This is to be applied twice daily for 3 months usually not such a brisk inflammatory reaction as with Efudix but the prolonged treatment is sometimes difficult for compliance. Efficacy probably less than Efudix.

6. 5% Imiquimod (Aldara). Useful for resistant lesions or field change not responding to Efudix. Use 3 times weekly for 6 weeks. Causes significant morbidity.

7. 2% Imquimod (Zyclara). Use for 2 weeks, 2 weks off and then a further 2 weeks.



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