ALL THINGS DERMATOLOGY

Transcription

1 ALL THINGS DERMATOLOGY Dr Aravind Chandran Dermatologist Auckland District Health Board and Skin Specialist Centre Honorary Lecturer University of Auckland

2 ALL THINGS DERMATOLOGY PITFALLS & PRACTICAL TIPS Dr Aravind Chandran Dermatologist Auckland District Health Board and Skin Specialist Centre Honorary Lecturer University of Auckland

3 Outline Pitfalls and practical tips in managing skin conditions Use of Steroids Liquid Nitrogen/Cryotherapy Diagnosing Pigmented lesions Clinical Photography

4 Steroids in dermatology

5 Steroids in dermatology Topical Formulations ointment, cream, lotions, gel, foam Combinations : antifungals, antimicrobial, antibacterial Compounded Oral Standard course Slow taper Mini-pulse Intra-lesional Intramuscular Intravenous

6 Topical Steroids in Dermatology Pillar of skin therapeutics Ease of use Less systemic effects Safe in pregnancy ( class I III) Potency and steroid step ladder

7 Topical Steroids - Pitfalls Suboptimal medication use Wrong potency scalp vs vs hands and feet vs face vs body vs flexures Improper formulation Insufficient dosage Steroid phobia patient and practitioner Under use more common than overuse Lack of patient adherence as a result of inadequate patient education or adverse drug events The use of combination steroid/antifungal formulations

8 Topical Steroids Practical Tips: Familiarize topical steroids potencies Finger tip units FTU Consider formulation Location weeping? Contact sensitivity Occlusion Wet wraps Tachyphylaxis Weekend therapy - for prevention frequent flares Patient education, written plans, information leaflets

9 ORAL Steroids Used for inflammatory skin disease Often over prescribed Long-term use associated with significant side effects PITFALLS No formal diagnosis Repeated course short and sharp Lack of bone protection and immunization in longer term use TIPS: - Establish a diagnosis before committing to treatment course - Slower taper and supplementing with potent topical to prevent rebound - Plan for early switch to steroid sparing agents - AVOID in psoriasis may de-stabilise and result in erythroderma or pustular psoriasis - Medical alert bracelets - Bone protection

10 Intramuscular steroids Under utilised IM vs PO steroids Equally effective Better compliance especially with need for long tapering doses Greater efficacy and safety Lower total dose when used long-term fewer side effects Adverse effects (as per oral ) PLUS IM can result in lipoatrophy at injection site Dysmenorrhea in females

11 LIQUID NTROGEN CRYOTHERAPY

12 LN - Cryotherapy Effective, simple and inexpensive treatment Suitable for outpatient setting and poor surgical candidates most commonly used actinic keratoses warts, molluscum benign, premalignant lesions malignant (superficial) lesions Destruction of benign lesions requires temperatures of 20 C to 30 C Effective removal of malignant tissue often requires temperatures of 40 C to 50 C.

13 Mechanism of action

14 Cryotherapy - PITFALLS Treating undiagnosed lesions Avoid in pigmented lesions If unsure biopsy first Do not treat thickened or raised lesion Under treating malignant lesions Poor cosmetic results in exposed sites Single/long cycles Swelling, blistering, ulceration Caution on special sites: Pretibial lesions prone to ulceration Eyelids- swelling, haemorrhage Hair-bearing skin may result in scarring and alopecia

15 CRYOTHERAPY- TIPS Cone tip Reduces contamination and focuses treatment Feathering at edged to avoid abrupt cut off Overlapping treatment areas for large areas De-bulking hyperkeratotic areas Use nozzles and attachments In malignant lesion Draw a margin Repeated freeze thaw cycles Medscape image

16 PIGMENTED LESIONS - DIAGNOSIS

17 Biopsy of pigmented skin lesions 2010 NZMA Audit by Rademaker et al 37% of cases referred had no useful clinical information OUTPUT results = INPUT of information provided 40% of lesions where a melanoma was considered, and 32.5% of lesions identified as pigmented lesions, were punch biopsied 2470 patients with melanoma, punch and shave biopsy significantly increased the odds of misdiagnosis by and 2.6-fold respectively, compared to excisional biopsy. Punch biopsy increased the risk of a misdiagnosis with adverse outcome by 20-fold (p < 0.001). Smaller the percentage of lesion removed by biopsy, the greater the degree of inaccuracy was likely to occur Whole lesion if possible Serial punch or representative incisional bx not single punch biopsy

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22 CLINICAL PHOTOGRAPHY

23 Clinical Photography Documentation rash, lesions, cosmetic procedures Treatment progress Monitoring/Self observation with selfies Professional development/learning Medico-legal Referrals Tele-dermatology opinions

24 Pitfalls and TIPS Consents informed consent - verbal or written Patient identification or de-identification in with facial photos Lesion observation Macro +/- Dermoscopy (not ONLY dermoscopic images) Location/distribution shot waist up/down/front back/arms and legs Close-up macro Dermoscopy if available Taking the photograph Get to know your equipment Composition Storage and handling of images patient privacy

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26 Lighting AppwoRx

27 POSITIONING AppwoRx

28 BACKGROUND AppwoRx

29 Clinical Photography apps Picsafe Epitomyze capture Rx Photo

30 END