Acne, Eczema and Psoriasis. Dr Rebecca Clapham

Transcription

1 Acne, Eczema and Psoriasis Dr Rebecca Clapham

2 Aims Classification of severity Management in primary care tips and tricks When to refer Any other aspects you may want to cover?

3 Acne First important aspect is to assess severity and type of lesions as this alters management

4 1. Androgen-induced seborrhoea (excess grease) 2. Comedone formation abnormal proliferation of ductal keratinocytes 3. Colonisation pilosebaceous duct with Propionibacterium acnes (P.acnes) esp inflammatory lesions 4. Inflammation lymphocyte response to comedones and P. acnes Acne - Aetiology

5 Factors that influence acne Hormonal 70% females acne worse few days prior to period PCOS UV Light can benefit acne Stress evidence weak, limited data Acne excoriee habitually scratching the spots Diet Evidence weak People report improvement with low-glycaemic index diet Cosmetics Oil-based cosmetics Drugs Topical steroids, anabolic steroids, lithium, ciclosporin, iodides (homeopathic)

6 Skin assessment Comedones Blackheads and whiteheads Inflammed lesions Papules, pustules, nodules Scarring atrophic/ice pick scar or hypertrophic Pigmentation Seborrhoea (greasy skin)

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8 Comedones Blackheads Open comedones Whiteheads Closed comedones

9 Inflammatory lesions Papules/pustules Nodules

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11 Scarring Ice-pick scars Atrophic scarring

12 Acne Grading Grade 1 (mild) a few whiteheads/blackheads with just a few papules and pustules Grade 2 (moderate)- Comedones with multiple papules and pustules. Mainly face. Grade 3 (moderately severe) Large number of papules and pustules and occasional inflammed nodule. May affect back and chest affected. Grade 4 (severe) Large number of large painful pustules and nodules

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14 Mild Moderate Severe

15 Treatment 1 Comedonal Acne 1 st Line Topical retinoid 2 nd Line Adapalene (Differin) Adapalene with benzoyl peroxide(bpo) 2.5% (Epiduo) Isotretinoin (Isotrex) Azelaic acid BPO and topical retinoids dry the skin, local irritation and bleaching. Retinoids in evening Inflammatory Acne (mild/mod) Use combination treatment ideally with BPO (reduces bacterial resistance) with either a topical retinoid or abx: 1 st Line Adapalene +BPO (Epiduo gel) 2 nd Line Clindamycin+BPO (Duac) Others Clindamycin+tretinoin (Treclin gel) Erythromycin combinations (Aknemycin, Isotrexin)

16 Treatment 2 Not responding or more severe/widespread: Oral abx + topical (preferably BPO to reduce resistance, if not Differin): 1 st Line oral abx Lymecycline 408mg OD 2 nd Line Doxcycline 100mg OD (photosensitivity + teratogenicity) (tetracycline or oxytetracycline 500mg BD also options) Macrolides Avoid due to high levels of P.acnes resistance 1 st line in pregnancy or <12yrs Adult dose - Erythro 500mg BD or Clarith 250mg BD Trimethoprim concerns re resistance Minocycline DO NOT USE due to risk of pigmentation Review at 6-8 weeks, if no response within 3/12 try a 2 nd abx. If some response continue for up to 6 months

17 Treatment 3 COCP: Consider adding in COCP as adjunctive treatment in women. Dianette licensed for severe acne, refractory to prolonged oral abx but advice is to stop within 3-4 cycles after acne resolved! VTE risk 1.5-2x higher than levonorgestrel-containing pills. Oral Isotretinoin: Failure to 2 oral abx (3 month courses) Scarring

18 Any questions on Acne?

19 Psoriasis 3% population Large numbers of T-cells trigger release cytokines -> inflammation Proliferative skin disorder scaly plaques FH present in 40-50% (up to 75% if onset <20yrs) Lifetime risk: 4% if no FH 28% if 1 parent affected 65% if both parents affected

20 Triggers Stress Alcohol Smoking Trauma (köebner phenomenon) Infection (strep throat -> guttate) Drugs (lithium and hydroxychloroquine) Pregnancy (most likely to improve) Sunlight (usually helps)

21 Comorbidities Psoriatic Arthropathy Approx 30% with psoriasis have psoriatic arthropathy Strong link with nail disease Early intervention required refer rheum CVD More relevant in severe psoriasis Target modifiable risk factors Assess every 5 years

22 Morphology Usually large or small plaque (90%) Ruby-red Well defined Silvery surface scale Auspitz sign bleeding occurring if scales picked off

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24 Severity Assessment

25 Severity Mild <3% body surface area (BSA<10 and PASI<10 and DLQI<10) Moderate 3-10% body surface area Severe >10% body surface area (BSA>10, PASI>10 and DLQI>10)

26 Referral For diagnosis Severe or extensive (e.g. >10%) Not controlled with topicals Acute guttate needing phototherapy Nail disease with functional or cosmetic impact If having major impact on life Refer rheum if psoriatic arthritis suspected

27 Treatments General Measures Emollients Formulations: Widespread -> Cream/lotion/gel Scalp/hairy areas -> Lotion/solution/gel Thick adherent scale -> Ointment Lifestyle measures: Lipid modification Obesity Preventing T2DM Preventing CVD Alcohol advice Smoking cessation Increase physical activity

28 Preparations Vit D and analogues Calcipotriol Dovonex (30g= 5.78) Dovobet (calcipotriol with betamethasone dipropionate) (30g= 19.84) Calcitriol Silkis (100g= 18.06) Tacalcitol Curatoderm lotion (30ml= 12.73) Curatoderm ointment (30g= 13.40) Tars Cocois (scalp ointment coal tar 12% and salicylic acid 2%) Exorex (skin or scalp lotion coal tar 5% in emollient) Psoriderm (skin or scalp cream coal tar 6% and lecithin 0.4%) Sebco (scalp ointment coal tar 12% and salicyclic acid 2%) Alphosyl-HC (Cream coil tar 5%, allantoin 2% and hydrocortisone 0.5%) Other non-proprietary combinations e.g. zinc or calamine with coal Bath preparations Dithranol Dithrocream dithranol 0.1% cream (50g = 3.77) Micanol dithranol 1% cream (50g= 16.18) Psorin dithranol 0.11%, coal tar 1%, salicylic acid 1.6% ointment (50g= 9.22) Salicylic acid Often in a combination with dithranol, tar or zinc

29 NICE guidelines Potent topical steroid OD and vit D or Vit D analogue OD (dovonex/calcipotriol) (applied one in the morning and one in the evening) for 4/52 (trunk or limb) If does not result in clearance/satisfactory control after 8/52 offer Vit D or Vit D analogue alone BD If this doesn t result in clearance after 8-12/52 offer either: Potent topical steroid BD for 4/52 A coal tar prep OD or BD If above cannot be used, can use combined calcipotriol monohydrate and betamethasone OD (dovobet) for 4/52 Can use VERY potent steroids if: specialist setting other topicals failed max 4/52 If treatment resistant offer short-contact dithranol in specialist setting

30 Reality 1 st Line Often start with combination therapy: Dovobet (calcipotriol with betamethasone dipropionate) gel, ointment or spray foam (enstilar) Give good amounts - 2x60g Discontinue when skin smooth (even if pink/red) then ongoing treatment with a vit D analogue: Calcipotriol (dovonex) Calcitriol (silkis) OR emollients Dovobet gel for scalp Calcitriol (Silkis) for face and flexures as calcipotriol (dovonex) can be irritant here Tar Exorex lotion for large thin plaques De-scaling e.g. diprosalic may help initially if thick scale

31 Treatments 2 nd Line If mod/severe or not responding to topicals refer for: Phototherapy (Narrowband UVB/TL01) Ciclosporin acts quickly but not long-term Methotrexate can help arthropathy also Acitretin very good for hand/foot psoriasis?fumarates Biologics

32 Guttate Psoriasis Multiple small tear-drop lesions, mainly trunk and limbs 7-10 days after strep throat Children/young adults Good chance of spontaneous resolution in 2-4/12 in 60% 1/3 don t have a FH and don t go on to develop psoriasis as an adult Use of abx to treat underlying throat infection is controversial Emollients Exorex lotion Alphosyl-HC Phototherapy if widespread(>10%)/unresponsive

33 Palmoplantar Psoriasis Hyperkeratotic Thick scale Palmoplantar pustulosis Erythema and yellow pustules, that become brown macules

34 Palmoplantar Psoriasis Hyperkeratotic Emollients If scale salicylic acid Erythema diprosalic Under occlusion Consider patch testing as often degree or irritant contact dermatitis Acitretin (Neotigason) or alitretinoin (Toctino) Palmoplantar pustulosis Potent topical steroids Betnovate 0.1% or Dermovate consider clingfilm for occlusion Consider referral for phototherapy or systemics

35 Any questions on psoriasis?

36 Eczema 15-20% school children 2-10% adults If it does not itch very unlikely to be eczema Scabies a common differential Atopic eczema if itchy skin plus 3 or more: Past involvement of skin creases PMH or FH (immediate) of asthma or HF Tendency to generally dry skin Flexural eczema Onset<2yrs

37 General Principles Avoid extremes in temp, irritating clothing, soaps and detergents, keep nails short Avoid irritants Need 3 aspects: Topical emollient Bath additive/oil Soap substitute Liberal use of emollients 3-4x a day best when skin moist (600g a week adult, 250g a week child) ratio 10:1 emollient:steroid. Apply in direction of hair growth Paraffin based can be flammable. Food allergy rarely the cause but could involve dietician Do not prescribe aqueous cream as leave-on emollient or soap substitute

38 First Line First line: Simple creams and ointments Topical corticosteroids

39 Emollients

40 Topical Steroids Few days to a week for acute eczema 4-6 weeks to gain control of chronic eczema Can use twice weekly for maintenance if mod/severe with frequent relapses Ideally once daily Weaker on face and flexures Very potent can be used in resistant severe hand and feet eczema Avoid emollients for 30mins after steroid application SIGN (2011) did not specify order of application, nor do they mention timings. The current BNF (2014) and BNFC (2014), NICE CKS (2013) continues to advise against mixing topical preparations and states several minutes should elapse between applications of different preparations. The PCDS & BAD (2014) now tell patients to let the moisturiser dry for 20 minutes before applying steroid. Side-efffects: Thinning of the skin (atrophy) Skin thickening (lichenification) Stretch marks (striae) Darkening of the skin

41 Fingertip Unit

42 2 nd Line Second line : Ensure enough emollients used complex emollients - Humectant (urea or glycerol) emollients or additional ingredients Topical calcineurin inhibitors (mod/sev)

43 Emollients added ingredients Some emollients contain added ingredients: Antimicrobials Humectants (propylene glycol, lactic acid, urea and glycerol) draw water into the epidermis. These only need to be applied every 6 8 hours. Anti-itch ingredients are found in a couple of creams in the form of lauromacrogols, a local anaestheic which helps to relieve itch. Ceramides are found in some leave-on creams and lotions. They may re-establish the balance of fats necessary for the appropriate functioning of the skin barrier. Oatmeal is found in one cream and lotion. It has anti-itch properties

44 Topical Calcineurin Inhibitors If intolerant or failed with steroids or risk of skin atrophy not first line Apply twice daily or twice weekly for prevention Transient burning sensation build up, start with small areas. Long-term effects unknown Can get flushing if drink alcohol Pimecrolimus (Elidel) licenced mild/mod eczema, short-term use or intermittent to prevent flares. Chose over protopic if younger Tacrolimus (Protopic) 0.03% (weaker) and 0.1% (stronger) for mod/severe eczema Greasier, stronger but doesn t penetrate as deeply 0.1% licenced for >16yrs 0.03% licenced >2yrs

45 TCS = Topical corticosteroid TCI = Topical calcineurin inhibitor

46 3 rd Line Phototherapy Immunosuppresives Other treatments: Antihistamines sedating to reduce itch-scratch Bacterial infections if crusting, weeping, pustulation, cellulitis or sudden worsening 7 day fluclox or erythro. Swab if not responding.

47 Referral If uncertain diagnosis Severe eczema herpeticum Severe/not responding/excessive steroids Infected and not responding to abx + topical steroids Psychosocial problems sleeplessness, school absence Bandaging techniques required Contact dermatitis suspected patch testing Dietary factors suspected (rare)

48 Any questions on Eczema? Thank you!