Itchy, Scratchy, Red and Patchy: Derm tips for primary care Robert Gniadecki, MD
Faculty/Presenter Disclosure Faculty: Robert Gniadecki Relationships with financial sponsors: Grants/Research Support: N/A Speakers Bureau/Honoraria: Therakos; Mallincrodt; Janssen; Abbvie; Novartis; Leo Pharma Consulting Fees: N/A Patents: N/A Other: Mallincrodt; Janssen; Amgen; Abbvie; Eli Lilly; Sanofi; Novartis; Leo Pharma
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Urtica dioica urticaria Smooth, slightly elevated papules or plaques (wheals) that are erythematous and that are often attended by severe pruritus. Individual lesions resolve without scarring in several hours. Most cases of urticaria are self-limited and of short duration (acute urticaria). Chronic urticaria is > 6 weeks Most cases are NOT allergic Causes: A. foods B. medications (especially aspirin, NSAIDs, antibiotics, over-thecounter (OTC) medications, herbs, and supplements) C. infections D. physical stimuli (eg, heat, cold, pressure, vibration) E. insect bites or stings
International EAACI/GA 2 LEN/EDF/WAO guidelines: definition and classification of chronic urticaria Zuberbier T, et al. Allergy 2018;73:1393 1414; Zuberbier T, et al. Allergy 2009:64:1417 26..
Urticaria may coexist with angioedema Angioedema: Swelling of the subcutaneous tissue Painful rather than itchy Common areas involved: face, lips, eyelids, genitals, hands and feet Usually resolves in less than 72 hours Zuberbier T, et al. Allergy 2018;73:1393 1414
Work-up Differential blood count ESR or CRP Omission of suspected drugs (e.g. ACE-I, NSAIDs)
Directed investigations Causes Description Tests Infectious diseases Type I allergy Bacterial, viral, parasitic, or fungal infections have been implicated to be underlying causes of CIU Frequency / relevance varies between patient groups and regions Rare but can be considered in patients with intermittent symptoms H. pylori, Streptococci, Staphylococci, Yersinia, Giardia lamblia, Mycoplasma pneumonia, Hepatitis virus, Norwalk, Parvovirus B19, Herpes simplex, Entamoeba ssp., Blastocystis spp. Skin tests, including physical tests (eg, cold provocation) Pseudo-allergy Pseudo-allergen-free diet Avoidance of NSAIDs for 3 weeks to rule out non-allergic hypersensitivity reaction Functional autoantibodies Thyroid causes Malignancy Severe systemic disease Autoantibodies against IgE or FcεR1 Not recommended routinely, but warranted if suggested by patient history Tryptase Autologous serum skin test Thyroid hormones and autoantibodies directed (PET-CT, markers, other) Zuberbier T, et al. Allergy 2018;73:1393 1414
CSU - treatment algorithm 1. Second generation antihistamines (2 weeks) (bilastine* cetirizine*, desloratadine*, ebastine, fexofenadine*, levocetirizine* and rupatadine*) 2. Increase dose x2 and then x4 (max 4 weeks) 3. Add Omalizumab 4. finally, as fourth line, consider ciclosporin. For exacerbations consider Prednisone *-can be safely used in children Loratadine can safely be used in pregnant women based on the metaanalysis data and EAACI recommendation (not in label) (Schwarz, Drug Safety 2008;31:775-788) Zuberbier T, et al. Allergy 2018;73:1393 1414
H 1 -antihistamine Cetirizine (Reactine ) Standard daily dose 10 mg Fexofenadine (Allegra ) 60 mg bid Loratadine (Claritin ) 10 mg Desloratadine (Aerius, Clarinex ) 10 mg bid Levocetirizine (Xyzal ) 10 mg bid Rupatadine 10 mg Bilastine 20 mg
Are 1st generation antihistamines of any value? NO drowsiness, bad quality sleep, anticholinergic effects, QT interval prolongation,.. Zuberbier T, et al. Allergy 2018;73:1393 1414
Urticaria - derm tips It is a clinical diagnosis If >6 weeks - chronic urticaria. Look for drugs (NSAID) as triggers Ask for possible inducible urticaria (cold, heat, pressure, scratching, cholinergic (sweating), sunlight) and try to provoke All remaining cases will likely be chronic idiopathic urticaria Don t do extended workup Treat with 2nd generation antihistamines, if failure increase the dose x2 and x4 Refer resistant cases to dermatology
How to recognize AD? Itchy Pink Slightly scaly https://jamanetwork.com/journals/jama/fullarticle/ 1829686
How to diagnose? What is prognosis? age, location, scaly-itchy-red rash 80% spontaneous remission 5% persists to adulthood food - environment - climate affect AD What are the complications? hand eczema and allergic eczema 20% asthma infections: impetigo, herpes, molluscum
Treatment of pediatric patients: Mild AD Moisturizers (creams, fragrance- and parabene free) Bath (short) Dilute bleach bath 0.5 cups sodium hypochlorite per 40 gallons bathtub Trigger avoidance (soaps, wool, cold weather) Exacerbation: mild corticosteroids (1% - 2 % Hydrocortisone) for 7-14 days with slow tapering Eichenfield LF, et al. Pediatrics 2015;136:554-565
How many grams of cream should be prescribed weekly for sufficient therapy (whole body, used twice daily)? - infant? - child? - adult? 100-200 - 300 g Eichenfield LF, et al. Pediatrics 2015;136:554-565
Treatment of pediatric patients: Moderate AD Moisturizers (creams, fragrance- and parabene free) Bath (short) Dilute bleach bath 0.5 cups sodium hypochlorite per 40 gallons bathtub Trigger avoidance (soaps, wool, cold weather) Maintenance: non-steroid calcineurin inhibitor (tacrolimus or pimecrolimus) / mild corticosteroid on: medium oids (e.g. sone fuorate) for slow tapering Exacerbation: medium potency corticosteroids (e.g. 0.1% mometasone fuorate) for 7-14 days with slow tapering Exacerbation potency corticosteroi 0.1% mometason 7-14 days with slo a As tolerated during flare; direct use of moisturizers on inflamed skin may be poorly tolerated; however, bland petrolatum is often tolerated when skin is inflamed.. Eichenfield LF, et al. Pediatrics 2015;136:554-565.
Atopic dermatitis - tips It is a clinical diagnosis - age and lesion distribution Moisturize, moisturize, moisturize Infection control Calcineurin inhibitor as maintenance Intermittent steroids for exacerbations Think of risk of occupational hand eczema in adolescents Insufficient control - refer
SKIN DISEASE JOINT DISEASE DITIES Spondyloarthropathy Periphe ral arthrop athy Soft tissue inflamm ation Psoriasis reduces life expectancy by 5 years Diabetes and metabolism Renal COinsuf- 44% Nail of deaths in psoriasis are ficiency related to disease cardiovascular disease MORBI- vs 36% in the Depression normal MS Hepatic population Psychological Cardiovascular Cancer IBD Gulliver W, et al. Br J Dermatol 2008;159(Suppl 2):2 9.
Practice gap: Suboptimal medical management of coronary risk factors in patients with psoriasis Ahlehoff O, Skov L, Gislason G, Lindhardsen J, et al. (2012) Pharmacological Undertreatment of Coronary Risk Factors in Patients with Psoriasis: Observational Study of the Danish Nationwide Registries. PLoS ONE 7(4):
Psoriasis - derm tips Screen your patients for CVD Severe psoriasis has the same weigh as diabetes when calculating CVD risk
Efficacy of sunscreen in real world
Sunscreens - derm tips Sunscreen DO protect against skin cancer and skin aging Sunscreens DO NOT have appreciable hormonal side effects SPF30 is sufficient, but must be applied 2mg/cm 2 One application daily is enough
Strategy 1: Apply before sun exposure and reapply once within1 h. People apply usually a mean quantity of sunscreen of 0.71 mg/cm 2 at first application and 1.27 mg/cm2 at second application Strategy 2: Use higher SPF than necessary. There is a linear relationship between application density and the actual SPF Sunscreens labeled SPF 70 and 100 applied at 0.5 mg/cm 2 provided an actual SPF value of, respectively, 19 and 27.