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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 • [email protected] • NHS secretary: Linda Gardiner • 01444 441881 ext 5998
