3rd april 2014 pearls and pitfalls of dermatology · 2014. 4. 3. · 3rd april 2014 pearls &...
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Pearls and Pitfalls of Dermatology
3rd April 2014
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3rd April 2014
Pearls & Pitfalls The Basics
● AVOID SOAP – Use Aqueous cream as a soap substitute, i.e. apply before bath/ shower and rinse off
● Bath oils – Oilatum/Balneum
● LIBERAL EMOLLIENTS – 500g tubs, Diprobase/Doublebase/E45 Epaderm/Hydromol/Emulsifying ointment 50:50 WSP:LP
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3rd April 2014
Pearls & Pitfalls Topical Steroids
● Ointments better than creams unless weeping
● Choose appropriate strength for condition and site
● Most patients have fear of steroids and under use but must warn them that steroids are not for continuous use
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1%
Hydrocor*sone
Eumovate ointment
Betnovate RD ointment
Elocon ointment
Betnovate Ointment
Dermovate ointment
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3rd April 2014
Pearls & Pitfalls The Pulse
● Used to get rapid control of inflammatory conditions e.g. eczema
● Think longer and stronger e.g. 3 weeks daily ● The taper – cut down the potent steroids and
alternate with weaker or alternatives
● The maintenance – the twice weekly
● http://www.drpaulfarrant.co.uk/resources-patients/#therapies
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3rd April 2014
Pitfall – The localised eczema
• Localised eczema • Confined to an area • Resistant to treatment • Recurs in same area • May worsen on each re-
exposure
• Consider a contact allergen • Hair dye PPD allergy • Sofa dermatitis –
Dimethylfumarate • Methylisothiazolinone • Metals, Fragrance, Rubber
Pearls & Pitfalls
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3rd April 2014
Pearl – Auto-sensitisation
• Eczema may start in localised area
• Becomes widespread • Rest of body comes up in
sympathy • Focus on underlying
cause for long term success
• If leg (common site) address oedema
• Consider compression • Leg elevation • ABPI >0.8
Pearls & Pitfalls
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3rd April 2014
Pitfall – the spreading rash
• Unilateral rash • Itchy • Red • Dry/Scaly • Topical steroid helps
symptoms and lessen redness and get rid of scale
• May have pustules • Rash is spreading
Tinea Incognito
Pearls & Pitfalls
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3rd April 2014
Patchy hair loss with broken hairs +/- pustules
Page Title
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Pearls and Pitfalls
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3rd April 2014
Patchy hair loss with broken hairs +/- pustules Pearls and Pitfalls
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3rd April 2014
Pearls & Pitfalls Tinea Capitis
● High incidence in urban environments
● Always suspect in setting of localised hair loss
● Low threshold for taking skin scrape or
brushings and don’t forget family members
● Treatment 4/52 Terbinafine systemically
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The Scaly Scalp
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3rd April 2014
Pearls & Pitfalls Pearls - Seborrhoeic Dermatitis
● Manage Expectations!
● Regular anti-fungal shampoo – ketoconazole, twice weekly + /- Selsun
● Ketoconazole cream, Daktocort, Tacrolimus/ Pimecrolimus
● Treatment 4/52 Terbinafine or Pulsed
Itraconazole (1 week per month) systemically
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NON SCARRING
SCARRING
Non-‐Scarring Follicular openings s*ll present, with or without a hair shaD Hairs may be smaller (Vellus) or non-‐pigmented Varia*on of hair follicle diameter
Scarring Shiny Absent follicular openings May have surrounding redness or scale Hair shaDs may be tuDed and grouped together
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3rd April 2014
Pearls & Pitfalls Pearls –Scalp Psoriasis
● Hair – makes topical treatments physically more difficult
● Hair – has important cosmetic function, and messy treatments and treatments with odour are unacceptable
● Hair – causes retention of scale, allowing it to build up and act as a barrier preventing absorption of topical treatments
● Hair – protects from useful exposure to UV light
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Condi*oning Treatments Descaling Treatments Ac*ve Treatment
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3rd April 2014
Pearls & Pitfalls Pearls –Scalp Psoriasis Conditioning treatments
● Need to be used regularly as part of on going treatment
● Aim is to hydrate the scalp epidermis, and soften scale and facilitate it’s removal
● Coal tar based (Polytar, T Gel, alphosyl 2 in1)
● Antidandruff shampoos (Head and Shoulders, Nizoral, Meted etc)
● Olive oil, Arachis oil, Epaderm
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Scalp Psoriasis - Treatments • Targeting Scale:
– Salicylic acid – Glycolic acid – Zinc – Coal tar – Sulphur
– Combinations: Sebco / Cocois (Coal tar, salicylic acid, sulphur)
– Physical removal of scale with combing
Common Ingredients in shampoos, but need to stay on for minutes, most get washed down the drain!
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Scalp Psoriasis - Treatments • Active Treatment
– Steroids • Lotions • Mousse • Gels • Short contact shampoos • Ointments/Creams – too messy
– Vit D • Calcipitriol
– Combinations • Salicylic acid and betamethasone diproprionate (diprosalic) • Calcipitriol and Betamethasone (ie like dovobet)
Etrivex Clarelux Dovobet gel
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3rd April 2014
Pearls & Pitfalls Pearls –Scalp Psoriasis Take home messages
● The active treatments will not work unless scale has been removed
● The conditioning treatments will not work on their own
● Combination approach is required
● Control not cure
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3rd April 2014
Guttate Psoriasis
Typically acute widespread and may follow sore throat Pitfall: If palmer plantar macules consider secondary syphilis If large patch first may be atypical pityriasis rosea
Pearl: Coal tar lotion, followed 30 mins by emollients Phototherapy and Ciclosporin very effective
Pearls & Pitfalls
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3rd April 2014
Palmar plantar pustulosis
Pitfall: If unilateral suspect fungus
Pearl: Need super-potent steroids e.g. clobetasol Wrap feet in clingfilm after application
Pearls & Pitfalls
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Onychomycosis vs Psoriasis
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3rd April 2014
Oncyhomycosis vs Psoriasis
Pearls: • Toes > Fingers • Isolated nails rather than all • Discoloured and thickened • Crumbly debris underneath
nail plate
Pearls: • Nails Pits & Onycholysis
commonest signs • Subungual hyperkeratosis • Trial of diprosalic ointment
around nail folds and distal nail plate daily for 3 months
Pearls & Pitfalls
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3rd April 2014
Pearl – The itchy patient – No rash
• Scars = Chronic • Linear = scratch • Round = picked
• Is skin dry? > Urea based emollients
• Hb, Ferritin, TFTs, U&Es, LFTs, ESR/CRP
• Any new drugs? > Trial off 3/12
• Tetracycline antibiotics • Phototherapy
Pearls & Pitfalls
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3rd April 2014
Pitfall – The itchy patient with a rash Pearls & Pitfalls
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3rd April 2014
Page Title Pearls and Pitfalls
• Papule on the penis = Scabies
• Web spaces, axillae, flanks
• Look for the trail of scale • Can see triangular head
with dermatoscope
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3rd April 2014
Pearls & Pitfalls Scabies – The pitfall
● Was it scabies? ● Was treatment done properly? http://www.bad.org.uk/site/871/Default.aspx ● Post scabies itch is very common ● Resistance is possible but avoid endless re-
treating with topicals
● Ivermectin is an option
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3rd April 2014
Non-Healing Ulcer
Pitfall – Neoplastic ulcer
• Most commonly BCC • Bowen’s occasionally will
ulcerate • SCC is usually the main
differen*al Pitfall – Pyoderma
• Inflammatory ulcer • Assoc inflammatory bowel
disease, Rh A, • Rolled purple edge • Painful
Pearls and Pitfalls
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Odd location in young patient – take a travel history
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4th April 2014
Pearl – The Pinch Pearls & Pitfalls
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3rd April 2014
Pitfall 4
• 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
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3rd April 2014
AK New treatments Pearls & Pitfalls
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3rd April 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
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3rd April 2014
Pearl The Black Nail
• Trauma to the nail is almost never recalled
• Sudden • Uniform • Splatter – globules • No Nail fold involvement
• Does it involve the lunula? • Is there a proximal curve? • Cut nail back and see if debris
– scraped away • Can photograph and review
3/12
Pearls & Pitfalls
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4th April 2014
Pearl 4 The Black Nail
Parallel curve of pigment = haematoma
Pearls & Pitfalls
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3rd April 2014
Pearl – Lesion helps Pearls & Pitfalls
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3rd April 2014
Pearl – Lesion helps Pearls & Pitfalls
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3rd April 2014
Pearl – Remove scabs Pearls & Pitfalls
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3rd April 2014
Pearl – The vessels and stretch
Lesions with blood vessels: Spider naevi Telangiectasia Haemangiomas Intradermal naevus BCCs
BCC vessels: Arborising Irregular Angulated “Wiggly”
Pearls & Pitfalls
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A Scab with a rolled edge and arborizing vessels = BCC
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If in doubt photo and see again
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Thank you Dr Paul Farrant FRCP Consultant Dermatologist Tel 01444 412273 Email [email protected] Web drpaulfarrant.co.uk