Pearls and Pitfalls of Dermatology

3rd April 2014

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

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

1%  

 Hydrocor*sone  

Eumovate  ointment  

Betnovate  RD  ointment  

Elocon  ointment  

Betnovate  Ointment  

Dermovate  ointment  

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

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

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

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

3rd April 2014

Patchy hair loss with broken hairs +/- pustules

Page Title

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Pearls and Pitfalls

3rd April 2014

Patchy hair loss with broken hairs +/- pustules Pearls and Pitfalls

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

The  Scaly  Scalp  

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

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    

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

Condi*oning  Treatments  Descaling  Treatments    Ac*ve  Treatment  

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

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!

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

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

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

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

Onychomycosis  vs  Psoriasis  

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

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

3rd April 2014

Pitfall – The itchy patient with a rash Pearls & Pitfalls

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  

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

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

Odd location in young patient – take a travel history

4th April 2014

Pearl – The Pinch Pearls & Pitfalls

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

3rd April 2014

AK New treatments Pearls & Pitfalls

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

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

4th April 2014

Pearl 4 The Black Nail

Parallel curve of pigment = haematoma

Pearls & Pitfalls

3rd April 2014

Pearl – Lesion helps Pearls & Pitfalls

3rd April 2014

Pearl – Lesion helps Pearls & Pitfalls

3rd April 2014

Pearl – Remove scabs Pearls & Pitfalls

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

A Scab with a rolled edge and arborizing vessels = BCC

If in doubt photo and see again

Thank you Dr Paul Farrant FRCP Consultant Dermatologist Tel 01444 412273 Email secretary@drpaulfarrant.co.uk Web drpaulfarrant.co.uk