CommonSkinProblems When%to%refer% - Dr. … • Consider mycology" Pompholyx" •...

Common  Skin  Problems  When  to  refer  

Dr  Paul  Farrant  Consultant  Dermatologist  &  Clinical  Lead,  

Brighton  &  Sussex  University  Hospitals  Trust  

What is eczema /dermatitis?���

•  Inflammation of epidermis causing swelling between the cells (Spongiosis)

•  Barrier dysfunction •  New genetic information points to

defect in the filament aggregating protein (Filagrin)

Sub-Types of Eczema •  Infantile •  Atopic •  Seborrhoeic

•  Discoid

•  Pompholyx

•  Venous

•  Asteatotic •  Lichen Simplex Chronicus / Nodular Prurigo

•  Irritant

•  Contact

Infantile Eczema

•  Presents 3-6 months old •  Cheeks commonly involved •  Can be very widespread •  Allergy frequently suspected by parents •  Limited role for allergy tests

•  Failure to thrive

•  Strong history

Infantile Eczema

•  Majority of children grow out of eczema •  50% by 5 years and 90% by 10 years •  Those with widespread disease + asthma +

hayfever poorer prognosis •  If continues into adolescence likely to have

on & off through adult life

Infantile Eczema

•  Education is key •  Address daily routine •  Avoid soaps, hand wash & anything that

foams •  Emollients

•  Topical steroids •  Immunomodulators for steroid phobic

parents and sensitive sites • Water softeners?

Discoid Eczema

•  Discrete discoid lesions •  Very itchy •  Requires very potent topical steroids •  If not sure a small biopsy can help confirm

diagnosis

•  Consider mycology

Pompholyx

•  Blistering beneath the skin on the palms •  Very debilitating •  Requires very potent topical steroids •  PUVA •  New retinoid - Alitretinoin

Contact Eczema •  Type IV delayed hypersensitivity to

specific antigen •  Very specific •  Preservatives •  Fragrances

•  Plants •  Metals •  Rubber derivatives

Topical Steroids

•  Need to use appropriate strength for site •  Body - Potent / Super Potent •  Flexures / Face - Mild / Moderate

•  Short blasts on intermittent basis

•  Combination steroids - good for sites prone to secondary infection

1%  

 HydrocorGsone  

Eumovate  ointment  

Betnovate  RD  ointment  

Elocon  ointment  

Betnovate  Ointment  

Dermovate  ointment  

Immunomodulators

•  Tacrolimus (ointment) / Pimecrolimus (cream)

•  Second line •  Good for sensitive sites / steroid phobic •  Preventative?

Eczema  –  When  to  refer  

•  DiagnosGc  doubt  •  Poor  response  •  Allergy  suspected  •  Widespread    

– Phototherapy  – Systemic  therapy  

Localised patchy hair loss

Non-Scarring Alopecia Areata

Localised, non scarring hair loss

•  Alopecia Areata – Autoimmune condition against hair follicle – Patchy hair loss –  ! Hairs around edge – Can become widespread – totalis or

universalis

Localised, non-scarring hair loss

•  Alopecia Areata –  Poor prognosis if:

•  Early onset (childhood) •  Atopy •  Family history •  Hair line affected •  Other autoimmune

conditions

•  Treatments: –  Can do nothing –  Topical Steroids –  Intralesional Steroids –  Systemic Steroids –  Contact

immunotherapy –  Hair pieces

http://www.alopeciaonline.org.uk

Psoriasis  •  2-­‐3  %  UK  populaGon  •  Two  peaks  of  incidence  

–  2nd/3rd  Decade  –  6th/7th  Decade  

•  M=F  •  Epidermal  cell  turnover  accelerated  4  days  cf  28  •  GeneGc  predisposiGon  35%  Family  history  •  10-­‐15%  Joint  involvement    

Psoriasis  •  Chronic  Plaque  Psoriasis  •  Gu_ate  •  Scalp  •  Nail  •  Flexural  •  Palmar-­‐Plantar  pustulosis  •  Erythrodermic  •  Pustular  

Chronic  Plaque  Psoriasis  Elbows  Knees  Bu_ocks  /  Lower  back    Thickened  Well  demarcated,  sharp  cut  off  Scaly    Koebner  phenomen  –  comes  up  in  areas  of  trauma    Can  become  quite  widespread  RelaGvely  stable  

Gu1ate  Rain  Drop  like  Acute  May  follow  sore  throat  (strep)  Young  adults    If  acute  swab  throat  or  ASO  Gtre  and  treat    Responds  well  to  phototherapy    DifferenGal:  Pityriasis  Rosea  Secondary  Syphilis  Drug  

Scalp  50-­‐80  %  paGents  will  have  scalp  involvement    Very  embarassing  “The  Brighton  snow  shower”  Difficult  to  treat    Ask  about  dandruff  Check  hair  line,  behind  the  ears  and  throughout  scalp    Be  proacGve  as  paGents  oien  embarassed  

ContribuGng  factors  •  Stress  •  Alcohol  •  Smoking  •  Drugs  –  β  Blockers,  Lithium  •  Post-­‐pregnancy  •  Sunlight  10%  

Psoriasis  CVS  risk  

•  Co-­‐morbidiGes  – Obesity  – ETOH  – Smoking  – Dyslipidaemia  

•  Systemic  Inflammatory  condiGon  –  Increased  CVS  risk,  independent  of  the  above  factors  

Topical  treatments  

•  CombinaGon  Products  – Topical  steroids  +  Vit  D  –  Dovobet  – Topical  steroids  +  Salicylic  acid  -­‐  Diprosalic  – Topical  steroids  +  anGbioGcs  +  anGfungal  –  Trimovate  

– Very  effecGve  – All  suscepGble  to  steroid  side  effects,  thinning  and  occasionally  de-­‐stabilisaGon  of  psoriasis    

Topical  Treatments  •  Immunomodulators  

– Tacrolimus  – Pimecrolimus  – Useful  for  facial  psoriasis  

Beyond  Topical  Treatments  Informing  paGents  about  management  opGons    

•  Phototherapy  •  Systemic  therapy  •  Biologics  

– “What  about  this  injec/on  I  read  about  in  the  Daily  Mail?”  

Phototherapy  •  When  to  refer?  

– Widespread  psoriasis  or  mulGple  small  areas  where  topical  treatment  difficult  

–  30%  –  Psoriasis  on  exposed  sites  (not  flexural  or  scalp)  –  Fed  up  with  topicals  &  need  a  break  

•  When  not  to  refer:  –  Busy  professional  or  those  who  will  struggle  to  get  to  appointments  3x  weekly  

–  Skin  type  1  or  previous  skin  cancer  – Mild  disease  or  severe  disease  with  joint  involvement  

Systemics  Treatments  •  AcitreGn  

•  Ciclosporin  

•  Methotrexate      •  Dose:  2.5mg  &  10mg,  weekly  •  InteracGons:  Aspirin  and  NSAIDS  

Whats  new  in  psoriasis?  •  The  Biologics!  

– Targeted  proteins,  AnG-­‐TNF,  AnG-­‐IL12  and  Il  23  – PaGents  with  moderate  to  severe  psoriasis  who  fail  on  systemics  &  phototherapy  

–  Increased  chance  of  infecGon  – Cost  £10K  

Psoriasis  Management  When  to  refer  

•  Primary  Care  –  Soap  avoidance  –  Emollients  –  Topical  Treatments  

•  Secondary  Care  –  DiagnosGc  doubt  –  Requiring  phototherapy  or  nurse  educaGon  

–  Requiring  systemic  therapy  including  Biologics  

Psoriasis  affects  2-­‐3%  of  populaGon  80%  Managed  with  topicals  alone  Psoriasis  represents  5%  of  new  referrals  to  secondary  care  New:FU  1:5.5    

Epidermal  vs  Dermal  

•  Surface  Change  (Look  and  Feel)  – Scale  /  HyperkeratoGc  /  KeraGn  horn  – Warty  or  textural  change  – UlceraGon  

•  Deep  PalpaGon  – Soi  vs  Firm  vs  Hard  – Fixed  to  overlying  skin  or  mobile?    

Epidermal  Lesions  

Seborrhoeic  Keratoses  

Seborrhoeic  Warts  

Basal  Cell  Papillomas  

Warty  /  Rough  

Stuck  on  appearance  

Usually  Brown  

Red  or  irritated  lesions  can  confuse  

Dermoscopy  can  be  very  useful  

KeraGn  cysts  

Pseudofollicular  openings  

Pitfall The Thickened Keratosis

•  Widespread AKs very common

•  Flat ones of little concern

•  Can come and go •  Small Potential to

change

•  Beware of the thickened lesion

•  Thickened AKs are persistent and more likely to represent Squamous change

Pearls & Pitfalls

3rd April 2014

AK New treatments Pearls & Pitfalls

3rd pril 2014

Pearls & Pitfalls AKs – Topical treatments

●  Solaraze – still commonest prescribed in primary care – least inflammatory

●  Efudix – Commonest in secondary care ●  Consider twice daily to non-face sites

●  Imiquimod – alternative to efudix ●  Actikerall – like efudix + salicylic acid – good

for thickened lesions ●  Picato – the new kid, good for rapid

treatment ●  150 mcg x 3 tubes for face ●  500 mcg x 2 body

Pearl – The Pinch Pearls & Pitfalls

Pearl – The vessels and stretch

Lesions with blood vessels: Spider naevi Telangiectasia Haemangiomas Intradermal naevus BCCs

BCC vessels: Arborising Irregular Angulated “Wiggly”

Pearls & Pitfalls

A Scab with a rolled edge and arborizing vessels = BCC

Keratoacanthoma  =  

Well  DifferenGated  Squamous  Cell  Carcinoma  

Come  up  very  quickly  –  2-­‐3  weeks,  plateau  and  then  spontaneously  regress    or  do  they?  

Superficial Spreading Malignant Melanoma

•  Commonest type •  Irregular pigmentation •  Black •  Blue/Grey •  Milky Red •  Multiple Shades of Brown

•  Irregular edge •  Asymmetrical •  Enlarging

Nodular Melanoma

•  Less common •  Present as a nodule •  Black, eroded and red with surrounding pigmentation •  Rapid growing

•  Deeper

•  Poor prognosis

If in doubt photo and see again

Improving diagnosis

•  Assess risk factors and stratify risk •  Take time to examine the skin as a whole and not just the

lesion •  Take note of the ugly duckling

•  Use a bright light, or natural light, and magnifying glass •  Touch

•  Photograph, measure and bring back at 3 months and 6 months

•  Dermoscopy?????? Needs training but I wouldn’t be without mine!

Lesions  –  When  to  refer  

•  Aks,  Bowen’s,  Benign  lesions  should  be  managed  in  primary  care    

•  Head  and  Neck  BCCs  should  be  referred  for  management  by  your  local  LSMDT  (Soon,  not  TWW)  

•  Probable  Melanoma  and  SCC  –  TWW  

Questions?

•  Dr Paul Farrant •  paul.farrant@bsuh.nhs.uk •  NHS secretary: Linda Gardiner •  01444 441881 ext 5998