Dermatology Protected Learning Time · Picato® (Ingenol mebutate): Is a 2-3 day topical treatment...

Dermatology Protected

Learning Time Dr Amir Ghazavi & Dr Anand Patel

02 & 09 December 2014

Agenda

• 12.30pm-1.30pm Registration

• 1.30pm-1.40pm City Care - Urgent Care Service - Steve Upton

• 1.40pm-1.50pm Actinic Keratosis Guidelines - Dr Anand Patel

• 1.50pm-2.05pm Hidradenitis Suppurativa - Dr Amir Ghazavi

• 2.05pm-2.15pm Hyperhidrosis - Dr Anand Patel

• 2.15pm-2.30pm Urticaria - Dr Amir Ghazavi

• 2.30pm-2.45pm Skin Cancer - Dr Anand Patel

• 2.45pm-3.00pm Patch Testing - Dr Anand Patel

• 3.00pm-3.15pm Break

• 3.15pm-3.50pm Pigmentation and Quiz - Dr Amir Ghazavi

• 3.50pm-4.00pm Teledermatology - Dr Amir Ghazavi

• 4.00pm Close

City Care – Urgent Care

Services

Steve Upton

Actinic Keratosis

Guideline Dr Anand Patel

Dermatologist

Nottinghamshire Solar Keratosis Primary Care Treatment Pathway

(Adapted from the Primary Care Dermatology Society Treatment Pathway)

Crusted, indurated and inflamed lesion could turn out to

be early SCC-urgent 2-week referral

Early solar keratosis needs

no treatment

Single solar keratosis

consider cryotherapy

Lesion with rapid onset, indurated

inflamed base, critical sites,

immunosuppressed patient or >1cm

Urgent 2-week referral

Sun avoidance advice including

sunscreen. Skin cancer info

sheets

Impalpable or barely palpable

Palpable but not

indurated

Does the patient want

treatment? No

Yes Single lesion or

Hyperkeratotic

lesion*

Cryotherapy with

liquid nitrogen

1x15sec freeze

thaw cycle.

Histofreezer® Not

recommended as

no evidence.

Multiple lesions

Offer topical treatment- 1st line - 5-Fluorouracil cream (Efudix®) (Amber 3 – GP can initiate in

line with this guideline) Apply once or twice daily for 3 to 4 weeks, depending on site. Counsel

regarding skin reaction (give Eumovate® if symptomatic). Patient Information sheet (with

photographs of reactions) available here

2nd line - Ingenol mebutate gel (Picato® ▼) (Amber 3 – GP can initiate in line with this

guideline) For patients unable to tolerate/comply with Efudix

• on face and scalp lesions, apply 150 micrograms/g gel once daily for 3 days

• on trunk and extremities, apply 500 micrograms/g gel once daily for 2 days Patient Information

sheet (with photographs of reactions) available here

3rd line – imiquimod 3.75% cream (Zyclara ®) (Amber 3 – GP can initiate in line with this

guideline) To be used if Efudix® and Picato® are not tolerated or used earlier if the lesions cover a

large area or if there is field change (refer to specialist if needed). Apply up to 2 sachets (250mg per

sachet) once daily before bedtime to the affected treatment field (full face or balding scalp) for two

treatment cycles of 2 weeks each separated by a 2- week no-treatment cycle.

Review 4-weeks after stopping treatment. If no response, review diagnosis +/-

referral

If not available

*Actikerall®

(See next page

for instructions)

Dr A N Patel & Dr W Perkins, Dermatology Department, Nottingham University Hospitals NHS Trust (updated September 2014)

***The Medicines Management Teams can also provide copies of the patient information leaflet. Actinic/Solar Keratosis Epidemiology

Chronic or repeated sun exposure is a major association >80% appear on the face, head or back of the hands, especially, but not exclusively, in those with fair skin.

Caucasians previously living in hot climates or working outside are at highest risk. Prevention is better than cure (see national skin cancer prevention & sunscreen advice)

Prevalence in UK (Merseyside) age>40

Diagnosis Red or white lesions with a gritty or sandpaper like texture on palpation but no induration at the base of the lesion, meaning there is epidermal thickening or dermal

infiltration, both manifested as a thickened red base.

Efudix® (5-Fluorouracil -Amber 2 – GP can initiate in line with this guideline)

once or twice daily for 3 to 4 weeks, depending on site. Counsel regarding skin reaction (give Eumovate® if symptomatic). Give patient Information sheet (with

photographs of reaction). http://www.nottspct.nhs.uk/images/stories/My_PCT/How_we_work/areaprescribing/solar%20keratosis%20-

%20patient%20information%20leaflet.pdf Actikerall® (0.5% 5-Fluorouracil. 10% Salicylic acid ): Due to the unavailability of cryotherapy in primary care as well as the inefficacy of Effudix® on

hyperkeratotic actinic keratoses, Aktikerall® provides an alternative treatment option with better results when used on thicker lesions in primary care and will save on

secondary care referrals. Use once daily for 6-12 weeks. Counsel regarding mild to moderate skin reaction.

Picato® (Ingenol mebutate): Is a 2-3 day topical treatment for AK with background field change for an area of 25cm2 0.015% gel should be used on scalp and face

lesions in a 25cm2 area for 3 consecutive days. 0.05% gel should be used for 2 consecutive days on the body. Counsel on moderate skin reaction. Zyclara® (3.75% Imiquimod): For the topical treatment of face and scalp AK with field change up to an area of 100cm2 . Treatment regime is a single application once

a day for two weeks followed by a 2 week rest period and then a further two weeks active treatment. Fewer side effects seen than with 5% imiquimod cream.

Bibliography Actinic Keratosis Primary Care Treatment Pathway published by Primary Care Dermatology Society (available from http://www.pcds.org.uk or NHS Evidence - National

Library of Guidelines)

Guidelines for the management of actinic keratoses. D. de Berker, J.M. McGregor and B.R. Hughes - on behalf of the British Association of Dermatologists Therapy

Guidelines and Audit Subcommittee British Journal of Dermatology 2007 156, pp222–230

(Available from www.bad.org)

NICE Guidance on Cancer Services. Improving outcomes for People with Skin Tumours including Melanoma. February 2006.

Stockfleth E et al. Low-dose 5-fluorouracil in combination with salicylic acid as a new lesion directed option to treat topically actinic keratoses-histological and clinical

study results. Br J Dermatol. 2011 Nov;165(5):1101-8.

Authors Dr A N Patel & Dr W Perkins, Dermatology Department, Nottingham University Hospitals NHS Trust (updated September 2014)

***The Medicines Management Teams can also provide copies of the patient information leaflet.

all Age>70

males 15.4% 34.1%

females 5.9% 18.1%

Skin cancer risk

Actinic keratoses (AK) are a risk factor for skin cancer as they are very closely linked to sun

exposure. Therefore patients with actinic keratoses should be educated in the signs of common

skin cancers and asked to present if any new/ different lesions develop.

Less than 1 in 1000 actinic keratoses will transform into squamous cell carcinoma (SCC) in any one

year therefore, treatment is dependent on patient preference, symptoms and the need to clear the

sun damaged area in order to be able to see if any more sinister lesions such as basal cell

carcinoma (BCC) or SCC are developing.

Progression of very early AK lesions and AK recurrence are reduced by daily use of an appropriate

sunscreen (SPF factor 15+ or higher, available on prescription, annotate “ACBS”) if clinically

indicated i.e. recurrent or multiple AK lesions.

The treatment guideline can be followed again if new lesions develop.

Hidradenitis Suppurativa Dr Mohammad Ghazavi

Dermatologist

Hidradentis Suppurativa

• Prevalence of 1-4%

• F/M: 2/1-5/1

• Rare onset before puberty and after menopause

• Persistence into menopause not uncommon

• Genitofemoral involvement more common in women

Association

• Genetic

• Androgen effect

• Obesity and current smoking

• Common microorganisms: S aureus and coagulase negative staph.

Diagnostic criteria

• Active disease with 1 or more primary lesions in a designated site, plus a history of 3 or

more discharging or painful lumps (not specified) in designated sites since age 10 years

• Inactive disease with a history of 5 or more discharging or painful lumps (unspecified) in

designated sites since age 10 years, in the absence of current primary lesions

Questions to ask

• Is there more than a single inflamed lesion?

• Is the course chronic, with new and recurrent lesions?

• Are the lesions bilateral?

• Where are the lesions located primarily?

Hurley staging

• First stage: Solitary/multiple, isolated abscess formation without scarring or sinus tracts

• Second stage: Recurrent abscesses, single/multiple widely separated lesions, with sinus

tract formation and cicatrization

• Third stage: Diffuse/broad involvement, with multiple interconnected sinus

tracts/abscesses

Hyperhidrosis Dr Anand Patel

Dermatologist

What is it?

• Excessive and uncontrollable sweating

• Sweat is produced by the eccrine sweat glands. These are distributed over the entire body

but are most numerous on the palms and soles (with about 700 glands per square

centimetre).

Hyperhidrosis

• Localised hyperhidrosis affects the armpits, palms, soles or face.

• Generalised can affect the whole body

Primary or Secondary

• Primary

• Childhood/adolescence

• Persist lifelong/improve with age

• Family history

• Armpits, palms or soles symmetrically

• Reduces at night and stops when asleep

• Secondary

• Less common

• Unilateral or asymmetrical

• Can occur at night or during sleep

• Due to endocrine/neurological conditions

Triggers

• Hot weather

• Exercise

• Spicy food

• Fever

• Anxiety

Causes of secondary localised

• Stroke

• Spinal nerve damage

• Peripheral nerve damage

• Surgical sympathectomy

• Neuropathy

• Brain tumour

• Anxiety disorder

Causes of secondary generalised

• Obesity

• Diabetes

• Menopause

• Overactive thyroid

• Respiratory failure

• Endocrine tumours

• Parkinson’s disease

• Drugs (caffeine, corticosteroids, TCA, SSRI, opiods)

Tests that should be done

• Not needed in primary hyperhidrosis

• Needed to ascertain underlying cause in secondary HH

• Depends on clinical features but should be a minimum

• Blood sugar/TFT

Management-General

• Loose fitting clothing

• Change clothing when damp

• Absorbant insoles

• Talc powder

• Antiperspirant

• Avoid caffeine/drugs

Management-topical

• Antiperspirant

• Driclor-aluminium salts-cream/spray/roll on

• Apply to dry skin after cool shower before bed

• Wash off in morning

• Use once/twice a week and build up to daily if necessary

• Beware as irritant

Iontophoresis

• For palms, soles and armpits

• Affected area is immersed in water or an electrolyte solution or gylcopyrronium solution

• Gentle electric current is passed across the skin for 10-20 mins

• Repeat daily for several weeks then less frequently

• Not always effective

Oral Medications

• Oral anticholinergic drugs:

• Propantheline, oxybutynin, glycopyrolate

• Can cause blurred vision, dry mouth, constipation, dizziness, palpitaions.

• Should not be taken in those with urinary retention/glaucoma

• Beta blockers:

• Block effects of anxiety

Botulinum Toxin

• Approved for axillary hyperhidrosis

• Reduce/stop sweating for 3-6 months

• Used off license for localised hyperhidrosis at other sites (palms)-effective.

Sympathectomy

• Division of spinal sympathetic nerves (chemical/surgical)

• Reserved for the most severe cases/resistant to other treatments

• Potential risks and complications

• Hyperhidrosis can recur in 15%

• Accompanies with skin warmth and dryness

• New onset of hyperhidrosis in other site in 50%

• Horner syndrome, pneumonia, pneumothorax and persistent pain

Outlook

• Primary hyperhidrosis tends to improve with age

• Secondary hyperhidrosis depends on the cause

Urticaria Dr Mohammad Ghazavi

Dermatologist

Urticaria

• Red

• Non scaly

• Mostly itchy, can be painful or

asymptomatic

• Lasts from 30 minutes to 36 hours

• Acute in 20% and chronic in 0.5% of

population

• 45% of chronic form are autoimmune

Acute urticaria

• IgE related and not IgE related

• Complement-mediated urticarias include viral and bacterial infections, serum sickness, and transfusion reactions.

• Certain drugs (opioids, vecuronium, succinylcholine, vancomycin, and others) as well as radiocontrast agents cause urticaria due to mast cell degranulation through a non—IgE-mediated mechanism.

• Urticaria from nonsteroidal anti-inflammatory drugs may be IgE-mediated or due to mast cell degranulation, and there may be significant cross-reactivity among the nonsteroidal anti-inflammatory drugs (NSAIDs) in causing urticaria and anaphylaxis

Acute urticaria

• Recent illness

• Medication use

• IV radiocontrast media

• Travel

• Foods

• New perfumes, hair dyes, detergents, lotions, creams, or clothes

• Exposure to new pets (dander), dust, mold, chemicals, or plants

• Pregnancy (usually occurs in last trimester and typically resolves spontaneously

soon after delivery)

• Contact with nickel, rubber, latex, industrial chemicals, and nail polish

• Sun or cold exposure

• Exercise

• Alcohol

Chronic urticaria

• Autoimmune disorders (SLE, rheumatoid arthritis, polymyositis, thyroid autoimmunity, and other connective tissue diseases); probably up to 50% of chronic urticaria is autoimmune

• Cholinergic urticaria induced by emotional stress, heat, or exercise; examine for other signs of cholinergic stimulation including lacrimation, salivation, and diarrhea

• Chronic medical illness, such as hyperthyroidism, amyloidosis, polycythemia vera, malignant neoplasms, lupus, lymphoma, and many others

• Cold urticaria, cryoglobulinemia, cryofibrinogenemia, or syphilis

• Mastocytosis

• Inherited autoinflammatory syndromes

• The etiology of chronic urticaria is undetermined in at least 80-90% of patients.

Recurrent urticaria

• Sun exposure -solar urticaria, occurring only on skin exposed to the sun[29]

• Exercise (cholinergic urticaria)

• Emotional or physical stress

• Water (aquagenic urticaria)

Urticaria work up

• Acute urticaria: laboratory studies generally are not indicated. The patient's history and

physical examination should direct any diagnostic studies

• Chronic or recurrent urticaria: basic laboratory studies prompted by signs and symptoms

but may include a CBC, erythrocyte sedimentation rate, TSH, and an ANA looking for

possible causes of the urticaria

Cancerous Lesions Dr Anand Patel

Dermatologist

Pre-cancerous lesions

• Actinic Keratoses

• Bowen’s disease (intra-epidermal carcinoma)

• Superficial BCC

• Lentigo Maligna

Bowen’s Disease

BCC

Management

• 5 Fluoro-uracil

• Imiquimod

• PDT

• Cryotherapy

• Surgery- C&C or excision

• Watch and wait

LM

Management

• Excision with conventional 5mm margin

• Staged excision-’Square technique’

• Imiquimod-poor evidence

Basal cell carcinoma

• Nodular Basal cell carcinoma

• Ulcerated Basal cell carcinoma

• Pigmented basal cell carcinoma

• Morphoeic basal cell carcinoma

Nodular BCC

BCC left without treatment

Ulcerated BCC

Pigmented BCC

Morphoeic BCC

Morphoeic BCC

Management

• Surgery

• Mohs micrographic surgery

• Radiotherapy

• Chemotherapy-Vismodegib

• Watch and wait/conservative

Mohs surgery

Squamous cell carcinoma

• Squamous cell carcinoma

• (multiple histological subtypes-desmoplastic)

• High risk factors

• Keratoacanthoma

Keratoacanthoma

Management

• Surgical excision

• Radiotherapy

• Watch and wait for KA

Risk factors

• Poor differentiation

• Size of lesion x> 2cm

• Thickness of tumour >4mm

• Immunosuppressed

• Site of tumour-lip, ear

• Vascular/peri-neural invasion

• Sub type-desmoplastic

Malignant Melanoma

• Lentigo Maligna melanoma

• Superficial spreading melanoma

• Nodular melanoma

• Amelanotic melanoma

• Acral melanoma

LMM

SSMM

Nodular MM

Amelanocytic MM

• <>

Acral MM

Management

• Excision biopsy

• Wide local excision

• Lymph node clearance

• Chemotherapy for advanced MM-Ipilimumab

Surgical margins

Breslow Thickness Excisions margins

<1mm 1cm

1-2mm 1-2cm

2-4mm 2-3cm

>4mm 3cm

Other skin cancers

• Merkel cell cancer

• Angiosarcoma

• Dermatofibroma sarcoma protuberans

• Cutaneous T-Cell Lymphoma

MCC

Angiosarcoma

DFSP

Management

• Mohs Micrographic surgery

• Radiotherapy

• Wide local excision

Mycosis fungoides

• Subset of cutaneous T cell lymphoma

• Patch, plaque and tumour stages

• May look like dermatitis or psoriasis

• Protracted clinical course

• Treatment depends on stage

• topical steroid

• Phototherapy-PUVA/TLO1

• Superficial radiotherapy

• Chemotherapy-Bexarotene, MTX, extracorporeal photopheresis.

Contact Dermatitis

Dr Anand Patel

Dermatologist

atopic

irritantallergic

infection infection

infection

endogenous

Irritant contact dermatitis

• Skin damaged directly by the irritant

• Soaps, detergents, water, solvents, dry atmosphere etc – depends upon degree of exposure

• Very, very common

• 10 % of the population suffer from hand dermatitis

• Treated with emollients/moisturisers and exposure reduction

Stratum Corneum Barrier Function

Dermis

Epidermis

Dermatitis present

Subclinical dermatitis

A series of cumulative irritant episodes of vary degree of severity leading eventually to

dermatitis. Often the patient does not link the weaker exposures with the dermatitis.

Impa

irm

ent

(log

sca

le)

Time

Threshold for ICD

What Is Diagnostic Patch Testing?

• To diagnose allergic contact dermatitis not irritant contact dermatitis

British Standard Series 1-7

DICHROMATE Leather, cement etc 3.0

NEOMYCIN Topical antibiotic 4.8

THIURAM MIX Rubber additive 5.0

Paraphenyldiamine Permanent hair dye 3.4

COBALT Metal 6.7

CAINE MIX Local anaesthetic 1.2

FORMALDEHYDE Biocide 2.6

British Standard Series 8-14

ROSIN Colophony, resin from spruce trees 5.9

QUINOLINE MIX Antiseptic 1.2

BALSAM OF PERU Fragrance 8.2

Isopropyl-phenyl-paraphenylenediamine Industrial rubber additive 0.4

WOOL ALCOHOLS Lanolin 4.8

MERCAPTO MIX Rubber additive 1.2

EPOXY RESIN Two part adhesive 1.4

British Standard Series 15-21

PARABEN MIX Preservative 1.1

Paratertiarybutyl Phenol Formaldehyde Resin Adhesives 1.2

FRAGRANCE MIX Fragrance 12.4

QUATERNIUM-15 Biocide 1.7

NICKEL Metal 19.5

Methylchloroiso thiazolinone + Methylisothiazolinone Biocide 2.1

Mercaptobenzothiazole Rubber additive 1.0

British Standard Series 22-28

PRIMIN Primula 0.6

SESQUITERPENE LACTONE MIX Compositae plant allergy 1.6

CHLOROCRESOL Preservative 0.5

2-BROMO-2-NITROPROPANE-1,3-DIOL Biocide 1.1

CETEARYL ALCOHOL Whitening agent/emulsifer 1.3

FUCIDIC ACID Antibiotic 0.4

TIXOCORTOL PIVALATE Hydrocortisone allergy 2.0

British Standard Series 28-35

BUDESONIDE Steroid 1.0

IMIDAZOLIDINYL UREA Biocide 1.2

DIAZOLIDINYL UREA Biocide 1.3

METHYLDIBROMO GLUTARONITRILE Biocide 4.1

ETHYLENEDIAMINE Stabiliser/emulsifier 2.2

PCMX Antiseptic in Dettol 0.6

CARBA MIX

Rubber additive 3.7

Specialised Series

• cosmetic/facial

• medicament

• steroid

• hairdressing

• dental

• oil & cooling fluid

• glues & plastics

• shoe

• textile colours & finishes

• meth(acrylate)

• photographic chemicals

• isocyanates

ICDRG Grading System

?+ = doubtful reaction; faint erythema only

+ = weak positive reaction; erythema, infiltration, possibly papules

++ = strong positive reaction; erythema, infiltration, papules, vesicles

+++ = extreme positive reaction; intense erythema and infiltration and coalescing vesicles or a bulla

IR = irritant reaction

NT = Not tested

Relevance (COADEX)

Current relevance

Old or past relevance

Actively sensitised

Do not know the relevance

Exposed but no dermatitis

Cross reaction

Indications for Patch Testing

• Hand eczema

• Treatment resistant eczema

• Stasis eczema

• Occupational contact dermatitis

Patch test Database 2004.mdb

Disorders of

pigmentation Dr Mohammad Ghazavi

Dermatologist

Hypopigmentation

Vitiligo

• Well defined with normal surface

• 0.3-0.5% of population

• Segmental, acro-facial, localised, mix

• Any age, any skin type

• Usually asymptomatic

• Other autoimmune conditions

• No preceding rash

Pityriasis versicolour

• Well defined patches/ macules

• Upper torso

• Might be itchy/ scaly

Post inflammatory hypopigmentation

• More in darker colour skin

• Preceding rash

• Ill defined, irregular border

• Anywhere, any age

• Can be scaly

Pityriasis alba

• Darker skin colour

• Children

• Symmetric

• Mostly on face

• Can be scaly/ slightly itchy

• Ill defined

Hyperpigmentation

Post inflammatory hyperpigmentation

• More in darker skin colour

• Irregular border

• Preceding rash (eczema, psoriasis, lichen planus…)

LPP

• Grey brown pigmentation

• On sun exposed area (face, neck, flexures)

• Darker skin colour

• Can be itchy

Melasma

• Female (rare in male)

• Face (forehead, cheeks, chin)

• Not scaly

• Irregular border

• Link to pregnancy, OCP…

Ashy dermatosis (Erythema Dyschromicum Perstans)

• Rare condition

• Ashy grey-blue pigmentation

• First few decades of life

• Non exposed area

• Varying size coalescing macules

• With or without an erythematous rim

Teledermatology Dr Amir Ghazavi

Teledermatology

What is Teledermatology?

Teledermatology is a subspecialty in the

medical field of dermatology and

probably one of the most common

applications of telemedicine and e-

health.

Generic Process

When a GP sees a skin complaint/lesion

which they are unsure about, instead of

referring the patient in, they take a series

of photos.

This is then sent to a dermatologist to

interpret.

The dermatologists replies with the

diagnosis and course of action for the

GP/patient.

Teledermatology at Circle Nottingham

Background

• Oct/Nov 2013 started taking to Nottingham City CCG about a pilot of Teledermatology.

• The CCG looked at a number of ways of doing this, including using the Mole Clinic.

• However they ideally wanted locum Dermatologists to interpret the photos.

• We considered a number of different ways of facilitating the process, but wanted something

which the GPs were already comfortable using, therefore making the process as simple as

possible.

• Choose and Book seemed to be the simplest way of the GPs referring in for this service, as

both the GPs and ourselves are confident with this system.

• So far, we have tested the process both live in clinic and via Choose and Book with test

patients. A number of hiccups have been ironed out.

Teledermatology at Circle Nottingham

Next steps

The process is designed to be as simple as possible.

Our process

The GP sees a patient and decides that advice via Teledermatology is suitable option.

Photos are taken, (advice on how to take the photos will be available via Youtube or similar).

Patient is referred in via Choose and Book and an appointment is created in Proxima.

The photographs are transferred from Choose and Book into the portal and the referral accepted

on Choose and Book.

The Portal – Select patient

The Portal – Doctor review

The Portal – Doctors findings

The Portal – Report

The Portal – Letter

Any questions?

Thank you.