OSPAP Programme Skin Disorders

Transcription

1 OSPAP Programme Skin Disorders Slide 1 of 43 MPHM14 OSPAP Dermatology

2 History taking general considerations Where did the problem first appear Are there any other symptoms Occupational history General medical history Travel Family and household contact history Patient view on cause of the problem Slide 2 of 43 MPHM14 OSPAP Dermatology

3 History taking Itch -Ask specifically about How long? Better or worse? Any rash or spots? Anybody else in the family? Any partners Rash and spots -Ask about How long? Getting better or worse? Distribution? Does it itch? What tablets they take (POM and OTC) Is it painful? Slide 3 of 43 MPHM14 OSPAP Dermatology

4 Types of lesion Slide 4 of 43 MPHM14 OSPAP Dermatology

5 Examples of lesions Now that you know the different types of lesions, can you identify the following Slide 5 of 43 MPHM14 OSPAP Dermatology

6 Examples of lesions Slide 6 of 43 MPHM14 OSPAP Dermatology

7 Examples of lesions Slide 7 of 43 MPHM14 OSPAP Dermatology

8 CASE STUDY FEEDBACK Slide 8 of 43 MPHM14 OSPAP Dermatology

9 Case study 1 Miss KG is presenting with what appears to be plaques of red raised skin on her knees and elbows, skin is broken and weeping. She is feeling a little down. She has had this for about a week, since her boyfriend broke up with her. Slide 9 of 43 MPHM14 OSPAP Dermatology

10 Psoriasis Caused by an increase in the cell turnover Raised large red scaly plaques with silvery appearance Exact cause is unknownimmunological, genetic? Types of psorasis: Plaque, guttate, inverse, pustular TRIGGER FACTORS: Emotional stress (Miss KG) Ultraviolet light Infection Trauma Medicines Lifestyle factors (cause or consequence?) Slide 10 of 43 MPHM14 OSPAP Dermatology

11 Case study 1: Miss KG Miss KG has a psoriasis possibly caused by emotional stress but this needs a formal diagnosis She also reports weeping of the skin Refer to GP could counsel on emollient use to soften plaques Assess impact on well-being (depression?) General counselling: Lifestyle modification: Smoking cessation Alcohol intake Reducing stress levels Slide 11 of 43 MPHM14 OSPAP Dermatology

12 Case study 2 Mr BA presents with a red, painful rash on his back and abdomen. He is 56 years old and the tingling sensation started about 2 days ago with the rash following. The pain is dull and throbbing. He takes lisinopril, atenolol, furosemide and aspirin. Slide 12 of 43 MPHM14 OSPAP Dermatology

13 Shingles Caused by reactivation of the Herpes Zoster virus Symptoms appear in 3 stages: 1) Pre- eruptive phase: pain described as burning, itching, tingling in the absence of rash 2) Eruptive phase: erythematous, swollen unilateral rash, with vesicles which crust over 3) Chronic phase: pain that persists after acute infection, when rash has resolved (Post Herpetic Neuraligia) Slide 13 of 43 MPHM14 OSPAP Dermatology

14 Symptoms Headache, general malaise Fever Burning, tingling sensation in affected area Crops of vesicles, may initially present as red blotches and then develop into itchy blisters Pain Slide 14 of 43 MPHM14 OSPAP Dermatology

15 Treatment In a healthy individual: Symptomatic Tx: paracetamol for pain/ fever sedating antihistamines for itching??? calamine aqueous cream to help soothe and cool the skin Aciclovir indicated if: Over 50 Weakened immune system Rash/Pain that is moderate to severe Slide 15 of 43 MPHM14 OSPAP Dermatology

16 Risk factors/counselling The following are risk factors for complications: Elderly Neonates or very young children Immunocompromised Pregnancy Counselling: Maintain fluid intake Avoid scratching Painful rash can be eased by: Cooling the affected area Cool baths Apply wet dressings Avoid contact with pregnant women and the immunocompromised Vaccination available for patients over the age of 70 years Slide 16 of 43 MPHM14 OSPAP Dermatology

17 Case study 2: Mr BA Mr BA is presenting with shingles Because he is over 50, oral antiviral medication is indicated therefore REFER for review and suitability of treatment Paracetamol for pain (OTC) In general, it s important to see the GP once you notice signs of shingles as early Tx can decrease severity and risk of complications Slide 17 of 43 MPHM14 OSPAP Dermatology

18 Case study 3 Mrs Wen approaches the counter and asks to buy something for acne. You find out it is for her niece who is 18. She had it in the past and used something called PanOxyl 5. She takes paracetamol. The patient isn t present but is described as having a few whiteheads and blackheads. Slide 18 of 43 MPHM14 OSPAP Dermatology

19 Causes/Triggers of acne Exact cause is unclear Four clear factors to its development: increased sebum production follicular hyperkeratinisation bacterial colonisation Inflammation Greasy cosmetics Androgens Puberty Medication Menstruation Stress Slide 19 of 43 MPHM14 OSPAP Dermatology

20 Symptoms Comedones (whiteheads (closed) and blackheads (open)) Papules Pustules Nodules Appear on the face, chest and back Skin is reddened and looks greasy Slide 20 of 43 MPHM14 OSPAP Dermatology

21 OTC Treatment Benzoyl peroxide Start low strength and increase over time Entire face should be treated Irritant effects in first few days likely, counsel patient Apply od or alternate days, build up to bd Applying a light moisturizer mins after benzoyl peroxide to reduce irritation It bleaches clothes, bed linen and hair Wash hands thoroughly after use Improvement is gradual, Tx may be needed for several months Slide 21 of 43 MPHM14 OSPAP Dermatology

22 Case study 3- Mrs Wen Mrs Wen is not the patient- careful questioning required here Need to question Mrs Wen re severity of acne seems relatively mild The patient used benzoyl peroxide beforehow long for? One week? Three months? Can supply assuming patient has gradually increased application from the lowest strength so may need to give lower strength Slide 22 of 43 MPHM14 OSPAP Dermatology

23 Counselling points Reassure patients acne is not caused by poor hygiene Manage expectations and continue using Txresults take time Avoid heavy greasy make up Gentle washing of the skin using mild products, avoid abrasives Avoid trigger factors Do not squeeze spots, this can make them worse Slide 23 of 43 MPHM14 OSPAP Dermatology

24 Red flags No improvement after 8 weeks of Tx Severe acne Drug induced acne Anxious/ depressed about spots Slide 24 of 43 MPHM14 OSPAP Dermatology

25 Case study 4 Ms Jones asks to speak to the pharmacist. She would like to buy something for her hands. She is presenting with red papules on her hands; redness, burning and soreness present. She started a new job as a cleaner recently. She has no broken skin or signs of infection. She has tried E45 itch relief cream but this hasn t helped. Slide 25 of 43 MPHM14 OSPAP Dermatology

26 Case study 4 Ms Jones has occupational contact dermatitis Due to contact with chemicals Careful history taking is key Contact dermatitis: Can be caused by: Allergen: substance causes an immune response in the body which affects the skin Irritant: substance that causes direct damage to skin Areas exposed to a substance become: Red, inflamed, dry, blistered, thickened and cracked Symptoms usually appear within 48hrs+ of contact but can appear immediately in some cases Slide 26 of 43 MPHM14 OSPAP Dermatology

27 Treatment Avoid trigger! Use of gloves Wash hands after contact Protect skin using emollient Will help reduce water loss and moisturise any dry skin Topical corticosteroid cream: Hydrocortisone 1% Licensed contact dermatitis Max 7 days use Over 10 years Counsel on application : thinly!!!! Check skin regularly Slide 27 of 43 MPHM14 OSPAP Dermatology

28 When to Refer: Signs of infection Widespread reaction Failure to respond to treatment Slide 28 of 43 MPHM14 OSPAP Dermatology

29 Case study 5 Mr Newton would like to buy something for an intense itch. The itching is worse at night and tiny burrows are evident on either side of the wrist flexure. He takes loratadine and sodium cromoglicate eye drops as he has hayfever. He has tried an antihistamine cream but it hasn t solved the problem. He has a wife aged 28, (no medication) and a son who is 2 months old. Slide 29 of 43 MPHM14 OSPAP Dermatology

30 Scabies Caused by the scabies mite Burrows into skin, lives under the skin and lays eggs Exudate and insect coats cause the allergic reaction Spread by close contact with infected person Symptoms can occur weeks after initial infection SYMPTOMS Scabies tunnels (burrows), thread-like lines Itch, usually worse at night Rash Scratching Aggravation of existing skin conditions Slide 30 of 43 MPHM14 OSPAP Dermatology

31 Treatment Everyone (sexual partners, close contacts, family members) must be treated at the same time Permethrin 5% cream (Lyclear) Malathion lotion (Derbac- M) Applied to whole body in accordance with manufacturers instructions Repeated after 7 days If unsure REFER for diagnosis by GP as they can assess and rule out any other conditions Lyclear is licensed from 2 months but OTC treatment of young children under 2 years should be avoided OTC if possible. Refer so that treatment is under the supervision of the GP. Slide 31 of 43 MPHM14 OSPAP Dermatology

32 Counselling points Children/adults need to be kept from school/ nursery/work until first application is complete Clothes, bed linen, towels, etc need to be washed at a hot temperature after first application Antihistamines/crotamiton cream etc for itch Itch may persist for weeks after eradication of parasite due to presence of dead mites etc Slide 32 of 43 MPHM14 OSPAP Dermatology

33 Case study 6 Mrs Long comes into your community and asks you for something to treat her foot. She presents with a small hard lump under the foot. She has tried bazuka gel for a week and this has helped a bit but the lump is still there. She takes lisinopril, bendroflumethiazide, metformin and simvastatin. She has never had it before until a couple of weeks ago when it first appeared. Slide of 43 MPHM14 OSPAP Dermatology

34 Plantar warts (verrucas) Viral infection Localised thickening of the skin occurring: on the soles and toes often involve the weight-bearing areas Different appearance to warts as lesion is pushed inwards due to body weight therefore, can cause pain Small black dot may be visible Blocked blood vessels Slide 34 of 43 MPHM14 OSPAP Dermatology

35 Treatment Treatment is not always necessary Verrucae are self limiting But may take a long time to clear Successful treatment does not prevent further verruca developing. Most traditional treatments take up to 12 weeks to work, therefore counsel patient on this Cryotherapy treatments are much faster acting OPTIONS OTC: Salicylic acid/lactic acid preparations Soften and destroy the skin Counsel on application Bazuka Cryotherapy Freeze the verruca Scholl freeze Verruca and Wart remover Bazuka Sub Zero Not for pregnant or BF As this patient is diabetic - should be referred! Slide 35 of 43 MPHM14 OSPAP Dermatology

36 Counselling points Never try to cut it out or burn it off yourself Wear comfortable shoes that do not press on it Keep feet clean and dry, and change your socks daily Do not go barefoot in public places Protect the surrounding skin to avoid burning healthy skin and help avoid spread of infection If you have children, check their feet periodically Slide 36 of 43 MPHM14 OSPAP Dermatology

37 Red flags Bleeding warts/ verrucae Changes in appearance Facial/ genital warts Warts/ verrucae causes you significant pain Diabetic patients should not self-treat Immunocompromised patients Slide 37 of 43 MPHM14 OSPAP Dermatology

38 Case study 7 Gail comes into your pharmacy. She would like something for her toe nails. She shows you her nail and it is thick and discoloured. She was using clotrimazole 1% cream to treat athletes foot recently. Three of her nails are affected. Slide 38 of 43 MPHM14 OSPAP Dermatology

39 Fungal nail infection Onychomycosis Caused by: Dermatophyte e.g athletes foot Non-dermatophyte moulds Yeasts They can involve any part of the nail, including the plate, bed and root Toenails are much more commonly affected than fingernails. Slide 39 of 43 MPHM14 OSPAP Dermatology

40 Symptoms Discolouration of the nail Turns yellow or white Distal - Starts at the tip and spreads towards the base Proximal Starts at the base and spreads up.this should be referred Nail starts to become: distorted thick eventually crumble Slide 40 of 43 MPHM14 OSPAP Dermatology Proximal subungual onychomycosis DISTAL AND PROXIMAL ONYCHOMYCOSIS

41 Treatment OTC amorolfine nail lacquer Licensed from 18 years Maximum of two nails infected Directions: nail must be filed and swabbed before applying Tx, allowed to dry and repeated weekly Recovery can take up to one year False nails or nail varnish cannot be applied during this time Patient should be reviewed every three months In this case the patient has 3 nails affected=> refer! Slide 41 of 43 MPHM14 OSPAP Dermatology

42 Counselling Treatment will not cure condition overnight- persevere!! Wash and thoroughly dry feet everyday To try to prevent the infection spreading to other toes avoid tight fitting or occlusive shoes Rest shoes periodically to limit exposure to infectious fungi Do not file infected nails and healthy nails with same file Keep nails short Use antifungal powders once a week to help keep shoes free from pathogens Exercise good nail care and be alert for recurring infection Visit a chiropodist regularly Slide 42 of 43 MPHM14 OSPAP Dermatology

43 Red flags Patients aged under 18 years People with diabetes Pregnant or breastfeeding women Patients in whom more than two nails are affected Failed OTC treatment Immunosuppressed patients Those with fully destroyed nails Slide 43 of 43 MPHM14 OSPAP Dermatology