Dermatology 538/17 Flashcards
(33 cards)
- Rosacea- History and examination
- Are there any triggers that exacerbate the flushing or redness? - any treatment for the redness or the bumpiness, in particular, has she been using topical corticosteroids? - Does she have any ocular symptoms? Examine face closely, looking for - background erythema, - telangiectasia and - superimposed papules and pustules. These changes are usually more apparent on the nose, cheeks and chin.
- Rosacea- types
The clinical presentation for rosacea is varied. There are four primary subtypes: Inflammatory papulopustular rosacea - inflammatory papules and pustules consistent with - erythrotelangiectatic rosacea and papulopustular rosacea often co-exist. Erythrotelangiectatic rosacea - characterised by chronic background erythema, facial flushing and telangiectasia, particularly of the central face. Ocular rosacea - dry, gritty and inflamed eyes - Patients with ocular rosacea often report a sense of dryness or pain, and - ocular manifestations may precede cutaneous signs. - Blepharitis and conjunctivitis are the most common findings. Phymatous rosacea - characterised by tissue hyperplasia after chronic inflammation (eg rhinophyma) - This subtype occurs mainly in older men. Persistent erythema of the central portion of the face lasting for at least three months is an important primary feature of rosacea. Other characteristic findings of rosacea that are often present but not needed for diagnosis, include - oedema, - rhinophyma or - hyperplasia of the connective tissue
- Rosacea- Ddx
Other skin conditions to consider, which have features similar: Seborrhoeic dermatitis – This chronic inflammatory condition is characterised by erythema and scaling of the eyebrows, nasolabial folds, scalp and chest. Rosacea is usually not scaly. The erythrotelangiectatic subtype of rosacea can at times coexist with rosacea (sebo-rosacea). Periorofacial dermatitis – This condition most commonly presents with inflammatory papules around the mouth, eyes and nasal area, and is sometimes caused by the prolonged use of potent topical steroids on facial skin. Acne vulgaris – This is typically seen in a younger age group and is characterised by comedonal lesions, inflammatory papules, pustules, nodules, cysts and scarring. Rosacea does not present with comedones and seldom scars. Keratosis pilaris – This facial disease can be difficult to differentiate from rosacea and may occur simultaneously with rosacea in patients. It is characterised by a fixed blush appearance, especially on the lateral cheeks, and fine follicular keratotic plugs. Keratosis pilaris most commonly affects the extensor surface of the upper arms. Systemic lupus erythematous (SLE) – Patients with SLE may have a malar erythema, which is difficult to differentiate from rosacea, and are often extremely photosensitive. Patients with SLE may also have other systemic symptoms, such as arthritis.
- Rosacea- population
Rosacea is most commonly seen in individuals with - fair skin, - blue eyes and - of European and Celtic origin. However, patients of any ethnic group may experience rosacea. Typically, symptoms of rosacea peak in those aged 30–50 years. Most studies report it to be more common in women; however, phymatous rosacea develops most frequently in males.
- Rosacea - aetiology
The aetiology of rosacea is multifactorial. - the number of facial sebaceous glands, - the innervation and vasculature of the skin all contribute to the pathophysiology of rosacea. - demodex mites may also be implicated in the pathogenesis of rosacea.
Triggers of rosacea that may initiate or aggravate the clinical manifestations…
- Rosacea- management
Rosacea is managed mainly with general measures and pharmacological treatments targeted at the specific presenting symptoms.
The pharmacotherapy goals for rosacea are to reduce morbidity and symptoms. However, rosacea is not curable and symptoms often recur on cessation of treatment.
First-line pharmacological treatment is with topical agents, including:
- metronidazole 0.75% gel or cream daily
- ivermectin 1% gel
- azelaic acid 15%12
Treatment should be reviewed after four to six weeks and, if there is no improvement, oral antibiotics can be prescribed for six to eight weeks to reduce the inflammatory lesions (papules and pustules) and ocular symptoms of rosacea. Antibiotics that can be used include the following, given orally:
- doxycycline 50–100 mg daily
- erythromycin (ethyl succinate formulation) 400–800 mg twice daily
- minocycline 50 mg twice daily
- Rosacea- recurrent management
Recurrent papulopustular rosacea, the following line of treatment should be considered:
- Topical ivermectin 1% gel daily, initially for three months, as an anti-inflammatory agent to control demodex mites
- Repeat course of oral antibiotics: doxycycline 100 mg daily for two to three months at a time
- Trial a different oral antibiotic (eg minocycline 100 mg daily for two to three months at a time).
- Referral to specialist dermatologist for consideration of oral isotretinoin at a low dose of 10–20 mg daily, which is particularly useful for inflammatory lesions and refractory nodules. It is also useful for preventing the progression of rhinophyma. Isotretinoin is not Pharmaceutical Benefits Scheme (PBS)-subsidised for rosacea.
For erythrotelangiectatic rosacea, vascular laser therapy could be considered. It is an effective treatment for background erythema and telangiectasia; however, these tend to recur with time.
Episodes of papulopustular rosacea would require episodic therapy described above.
- Scabies- History
- location of the rash
- onset of symptoms
- subsequent spread
- aggravating/associated factors
- any identified relievers.
- treatment tried to date, including any local medicine.
Past history should consider
- previous similar episodes,
- how they were treated and responded.
Social history would include whether anyone else in the household currently has, or previously had, symptoms.
Ideally, management of this patient should be done with knowledge of the local context, including:
current outbreaks of skin infections and infestations
local disease patterns, including common skin conditions, incidence/prevalence of possible infectious sequelae, such as post- streptococcal glomerulonephritis (PSGN) and acute rheumatic fever (ARF)/rheumatic heart disease (RHD)
commonly occurring bacteria and known antibiotic susceptibility
local health literacy levels.
- Scabies examination
Examination should incorporate a full set of observations and a complete head-to-toe skin examination.
Look for scratches and sores around the fingers, wrists, elbows, knees and ankles. In particular, include external genitalia, head and face, and inguinal region and axillae for nodules if permitted.
Where appropriate, a complete health check may also be considered, including checking growth, vision, oral health, nutrition and physical activity. In some settings, it may be appropriate to give six-monthly albendazole stat dose and investigate for anaemia.
Examination specific to Scabies
- excoriated skin on both of her hands and wrists.
- track marks and burrows.
- crusted pustules present on the anterior surface of both wrists.
- webbing between fingers, you may also see significant excoriation.
- Scabies DDx
- insect bites,
- papular dermatitis,
- skin infections,
- dermatitis,
- urticarial and bullous pemphigoid.
- Scabies Inx
Scabies is a parasitic infection of the skin caused by a mite, Sarcoptes scabiei.
The impetigo occurs as a result of bacterial infection secondary to scratching from the pruritis.
Scabies is typically a clinical diagnosis; however, it is possible to confirm the diagnosis.
- using dermatoscopy, it may be possible to see the typical ‘hang-glider’ appearance
- Alternatively, a skin scraping from the end of a burrow may reveal mites on microscopy. Ideally, this skin scraping should be performed using dermatoscopy to improve accuracy.
- Response to treatment may also be used as a confirmation of diagnosis.
In severe cases of scabies, patients may also develop eosinophilia.
- Scabies Rx
Treatment of scabies infection
- permethrin 5% applied late in the evening. It should be left on overnight (minimum eight hours) and washed off in the morning.
- Application should be from head to toe, from the hairline down, avoiding the face.
- It is important to include the webbings, soles of the feet, beneath the nails, behind the ears and around the groin and genitalia. Note that in infants and elderly, it may also be appropriate to apply to the face and hair, avoiding contact with mucous membranes.
Treatment of concurrent impetigo:
oral treatment using trimethoprim plus sulphamethoxazole 8/40 mg/kg oral daily for five days; OR
benzathine penicillin (by weight) stat dose intramuscular
- Scabies Mx
To prevent re-infection:
Household contacts should be treated concurrently. As scabies has a long incubation period, contacts may be infected but asymptomatic. Treatment for contacts is the same as those confirmed:
permethrin 5% (or crotamiton 10% daily for two to three days if any contacts are <2 months of age) applied as described above.
Fomites need to be managed concurrently with application of the scabicide. Ensure that towels, clothes and bedding are either exposed to heat (eg washing at 50–60°C) or separated from contacts for a minimum of three days to let any mites on them die.
Eggs may hatch up to one week later, hence any scabies treatment given to the patient and their contacts should be repeated seven days later to ensure any eggs that have subsequently hatched have also been dealt with.
- Scabies; community Mx
Scabies has been hypothesised to contribute to streptococcal infections and their sequelae of PSGN and ARF. Community control of scabies has been shown to reduce the prevalence of impetigo.
Current recommendations for impetigo are to exclude from school until 24 hours after treatment has commenced.
Any weeping sores that are present should be covered before she goes to school. Current National Health and Medical Research Council (NHMRC) guidelines recommend excluding school until after initiation of appropriate treatment for scabies.
In some locations, there are trials or localised protocols using oral ivermectin 200 µg/kg as a stat dose and repeated seven to 14 days later to reduce community outbreaks.
In the event of a high community-wide prevalence, a public health intervention could be considered in this way.
- Scabies- persistent Sx
Persistent itch is common after treatment for scabies and may occur for some weeks afterwards. It is thought to be linked to the immune- mediated response to the dead mites. This can be treated in a number of ways including use of an emollient, topical steroids or oral antihistamines.
In the event of itch and recurrent signs of infection, consider the following possibilities:
Inadequate treatment:
Is there resistance to the treatment given?
Was it applied incorrectly or removed prematurely?
Did it not penetrate (eg because of crusting)?
Supervised treatment may be required, or changing to an alternative such as benzyl benzoate or ivermectin.
Incorrect diagnosis:
Use dermatoscopy and scrapings to confirm the diagnosis.
Re-infestation:
In some locations, once topical treatment has failed twice, a home visit may be done to perform a ‘mini-skin’ day. This includes treatment as mentioned above to patient, identification and treatment of all contacts, and clearance of household items.
On occasion, an insecticide bomb may be used in each bedroom.
Directly observed treatment to the entire household, which is repeated seven to 14 days later, improves coverage.
A home visit may also include promotion of home hygiene practices, and reviewing the household’s access to adequate washing facilities and bathrooms.
- Penile Lumps- Pearly papules
Pearly penile papules are normal anatomical variants. They classically present as papillae arranged in rows around the coronal sulcus and may be mistaken for warts. Laser ablation or shave excision is a possible approach to treatment, but the main management is reassurance of their normality and advice to leave them alone.
- Balinitis
- is an inflammation of the glans penis
- may be associated with other dermatological conditions, such as dermatitis or psoriasis
Non-specific balanitis refers to an irritant reaction to bacteria (eg Pseudomonas, anaerobes) and yeasts (eg Candida albicans)
management would be
- encourage to keep his skin clean and dry, and not to use soaps to wash his genitalia (try lukewarm water or sorbolene cream instead).
- salt water baths may help soothe the itch and discomfort.
- Treat any obvious underlying cause (eg candidal balanitis can be treated with clotrimazole 1% cream).
- Genital warts
Growths or bumps that may be raised or flat, single or multiple, small or large.
Some are clustered together, forming a cauliflower-like shape.
Warts are caused by human papillomavirus (HPV); approximately 90% are caused by HPV types 6 and 11. These HPV types are different from the oncogenic types (HPV 16 and 18) that are associated with HPV-related (ie cervical, anal, oropharyngeal) cancers.
- Genital warts Rx
The HPV infection will usually resolve within 12–24 months. It is important to note that treatment will not get rid of the HPV virus but only treats the visible warts.
Treatment options include patient-applied methods:
- podophyllotoxin cream 0.15% or 0.5% paint applied topically twice daily for three days in a row, then no application for four days, repeated every week for up to four weeks and review; OR
- imiquimod 5% cream once a day, three times a week for 4–16 weeks.
In general, warts that are soft, mucosal, vulval or perianal, or are on or under the prepuce respond well to these topical agents.
Keratinised or longstanding warts usually need ablative therapies. These include clinician-applied cryotherapy, laser, diathermy, electrocautery or excision (only for very large warts). Long-term complications of treatment are very rare and may include hypopigmentation or hyperpigmentation.
- Genital Herpes
Suggestive sexual history and combination of symptoms (including his flu-like symptoms), the likely diagnosis now is primary genital herpes.
Genital herpes is caused by Herpes simplex virus (HSV) 1 or 2. This may be acquired from symptomatic or asymptomatic partners.
Sexually acquired manifestations include genital ulceration, gingivostomatitis, urethritis, cervicitis and proctitis.
- Genital Herpes- Inx
The most sensitive and specific investigation would be to do a swab for viral HSV polymerase chain reaction (PCR).
It is advisable to also request testing for syphilis PCR from the same swab, particularly for men who have sex with men, as syphilis rates in Australia are rising rapidly.
Further, the majority of sexually acquired genital ulcers in Australia are caused by HSV or syphilis, which may present with overlapping symptoms and signs.
Note that serology should not be used to screen for HSV as it lacks positive predictive value in low prevalence populations and antibody results are not specific to anatomical sites of infection.
- Genital Herpes Rx
Education, patient information leaflets and referral for counselling where necessary.
Antiretroviral treatment:
• valaciclovir 500 mg, twice daily for 7–10 days; OR
• acyclovir 400 mg, three times a day for 7–10 days.
Oral valaciclovir and acyclovir are equally effective treatments. Topical antivirals are ineffective.
Lignocaine 2% jelly topically may be useful if the lesions are particularly painful.
Simple analgesics (paracetamol, codeine) may also be considered for pain relief.
- Atopic dermatitis (eczema) Hx
- onset of symptoms
- symptoms and severity in childhood.
- clinical course of the disease, which tends to follow a chronic, relapsing pattern over months to years.
- periods of flares and remission, and whether remission is ever achieved without treatment.
Patients with mild disease may experience intermittent flares and spontaneous remission, but those with moderate-to- severe disease rarely experience remission without direct treatment.
Documenting fully failed therapies is important for directing treatment.
Establish whether general measures, topical therapy and systemic therapy have been trialed, and whether remission was achieved.
Lack of adherence to treatment is the most common reason for poor response to treatment.
More than 50% of patients (and parents) with atopic dermatitis do not administer therapy as directed. The most common reasons for poor compliance include concerns about side effects, dislike of topical preparations and insufficient education by practitioners about skin care.
- Atopic dermatitis- Examination
A full-body examination is required. Acute atopic dermatitis is characterised by intensely pruritic, erythematous papules and vesicles, with exudation and crusting. Chronic atopic dertmatitis is characterised by dry, scaly or excoriated erythematous papules.
Other signs of chronic atopic dertmatitis are skin thickening from itching (lichenification) and fissuring. Infants and young children typically present with lesions on the extensor surfaces, cheeks and scalp. The diaper region is usually spared.
Older children and adolescents typically present with lesions in the antecubital and popliteal fossae, volar aspect of the wrists, ankles and neck.
Adults typically present with lesions in skin flexures and, less commonly, on the face, neck and hands.
