Treatment pathways

Question 1

Describe the treatment regime for an acute flare of atopic dermatitis / eczema [6]

Answer 1

1. Emollients (warn patients about fire hazard risk)
2. Consider topical steroid cream / ointment. Start on low to medium potency and go up
3. Consider topical calcineurin inhibitor; tacrolimus; pimecrolimus. Useful for long term tx of pruritis without giving steroids for long time
4. Consider Phototherapy: Narrow Band UVB (NB-UVB) small part of the UVB light spectrum is used to tx; where UVA radiation is combined with a chemical called psoralen that increases the effect of UVA on the skin). PUVA (UVA + psoralen)
5. Systemic therapies: methotrexate (1x week medication, given with folic acid); ciclosporin (shorter time for treatment to work; can only use for 1 or 2 years before moving to biologics
6. Biologics: JAK inhibitors - Baricitinib, Upadacitinib; IL-13/4 – Dupilumab, Tralokinumab.

Question 1

Describe the tx algorithm for plaque psoriasis

Answer 1

Topical treatments:
- Emollients
- Steroids - dont use alone - combine with vitamin D analogue e.g. Dovabet (combination tx)
- Salicylic acid - breaks down keratin
- Coal tar - effective anti-inflam

Phototherapy: 3x week for 3 months
- NB-UBV
- PUVA

Systemics - Oral immunosuppression
- Methotrexate
- Ciclosporin

Systemics - retinoids:
- Acitretin - Its use is restricted, generally only for those who have failed other systemic options or in whom they are inappropriate.

Biologics

Question 2

Describe the tx algorithm for guttate psoriasis [5]

Answer 2

1. Most cases resolve spontaneously within 2-3 months
2. Phototherapy
3. Ciclosporin
4. Methotrexate
5. Acitretin

Question 3

State side effects of using the following treatments for psoriasis:

• Methotrexate [4]
• Ciclosporin [2]
• PUVA [2]
• Acitretin [2]

Answer 3

Methotrexate
- Mucosal damage: ulcers
- Neutropaenia from bone marrow suppression
- Nausea
- Chronic use: cirrhosis and lung fibrosis

Ciclosporin
- HTN
- Nephrotoxicity

PUVA
- Skin cancer
- Ageing

Acitretin:
- Hyperlipidaemia
- Hepatoxicity

Question 4

Describe the management plan for a patient with psoriasis

Answer 4

Mild to moderate psoriasis:
- Vitamin D analogues (e.g., calcipotriol) and corticosteroids
- Tar preparations and dithranol may be considered for chronic plaque psoriasis.

Moderate to severe disease not responding to topical treatments:
- Narrowband UVB therapy (psoralen plus UVA (PUVA) therapy may be utilised if narrowband UVB is ineffective or contraindicated)
- Methotrexate, ciclosporin or acitretin can be considered in patients with severe disease or when topical treatments and phototherapy have failed

Severe disease who have failed traditional systemic therapies:
- etanercept (TNF-inhibitors)
- ustekinumab (interleukin-12/23 inhibitors)
- secukinumab (interleukin-17 inhibitors)

Question 5

Management of psoriatic arthritis should be holistic, addressing symptoms, disease progression and potential complications and disability.

Describe the treatment regime of PsA

Answer 5

NSAIDs - First line symptomatic relief
Intra-articular corticosteroid injections - may be used alone or in combination with oral medication

DMARDs:
- if there is a failure of response to initial medical treatment or if there is severe disease at diagnosis
- 1st line: standard DMARDs (methotrexate, leflunomide or sulfasalazine)
- 2nd line: biological agents (etanercept, infliximab, apremilast)

Question 6

Describe the mangement of mild, moderate and severe acne vulgaris [+]

Answer 6

Mild: 12 week topical combination of any of the following:
* a fixed combination of topical adapalene with topical benzoyl peroxide
* a fixed combination of topical tretinoin with topical clindamycin
* a fixed combination of topical benzoyl peroxide with topical clindamycin

Moderate to severe acne: a 12-week course of one of the following options:
* a fixed combination of topical adapalene with topical benzoyl peroxide
* a fixed combination of topical tretinoin with topical clindamycin
* a fixed combination of topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline
* a topical azelaic acid + either oral lymecycline or oral doxycycline

Severe - not responding to treament
- Oral isotretinoin (derived from vitamin A and is a powerful anti-inflammatory agent)

Question 7

What risks occur with isotretinoin prescription? [5]

Answer 7

Teratogenicity
hyperlipidaemia
hepatotoxicity
Sexual side effects: erectile disfunction, loss of libido, vaginal dryness
Photosensitivity
Depression & ? suicide ideation

Question 8

What monitoring should you perform when prescribing isotretinoin? [3]

Answer 8

Liver function tests
Lipids
Pregnancy tests in female patients

Question 9

Management is complex and guided by the Melanoma Multidisciplinary Team (MDT).

Describe the different treatment options

Answer 9

Surgical:
- WLE represents the standard treatment for primary melanoma. Involves removal of the biopsy scar with a surrounding margin of ‘healthy’ skin, with fat, down to muscular fascia. This margin is determined by the Breslow thickness.
- Sentinel Lymph Node Biopsy (SLNB)
- Electrochemotherapy is a relatively new therapy for patients with locally advanced melanoma.

Medical (typically adjuvant therapy)
- Chemotherapy
- Radiotherapy
- Immunotherapy

Question 10

Describe the different treatment options for low and high risk BCC [+]

Answer 10

The main goal of treatment is the complete removal of the tumour with preservation of the function and cosmesis of the affected area.

The type of treatment depends on whether the BCC is low or high risk

Low risk:
- complete surgical removal or electrodesiccation and curettage (ED&C)
- Superficial BCCs – 5-flourouracil or imiquimod cream

High risk
- Mohs micrographic surgery is a specialist removal method for non-melanoma skin cancers with high recurrence risk
- As an alternative for high-risk lesions, simple resection with adjunct radiotherapy has been recommended

Question 11

Describe the management of squamous cell skin cancer [3]

Answer 11

Surgical excision with 4mm margins if lesion < 20mm in diameter.

If tumour >20mm then margins should be 6mm.

Mohs micrographic surgery may be used in high-risk patients and in cosmetically important sites.

Question 12

For Bowen’s disease, therapies such as [] or therapies like [] are first-line management

Answer 12

For Bowen’s disease, destructive therapies such as cryotherapy or topical therapies like 5-fluorouracil are first-line management.8

Question 13

Describe the management options for Actinic Keratoses [4]

Answer 13

Management options include:
- prevention of further risk: e.g. sun avoidance, sun cream
- fluorouracil cream: typically a 2 to 3 week course. The skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation
- topical diclofenac: may be used for mild AKs. Moderate efficacy but much fewer side-effects
- Imiquimod can be used for lesions on the face and scalp when cryotherapy or other topical treatments cannot be used.

Question 14

Describe the topical treatments [4] and systemic therapy [5] used to treat Bullous Pemphigoid

Answer 14

Topical Treatments
* Super potent topical steroid
* Non adhesive dressings
* Potassium per manganate soaks
* Pop large blisters

Systemic therapy
* Antihistamines
* Tetracycline antibiotic vs oral steroid (BLISTER trial)
* Methotrexate
* Mycophenolate Mofetil
* Biologic therapy - Rituxumab

Question 15

Tx of Pemphigus Vulgaris? [4]

Answer 15

First-Line Treatment
- oral corticosteroid ± azathioprine or mycophenolate

Second line:
- Rituximab

Intravenous immunoglobulin (IVIG) and plasmapheresis are adjunctive therapies for severe or refractory cases.

Patients on high-dose steroids or other immunosuppressants should receive prophylaxis against Pneumocystis jirovecii pneumonia with co-trimoxazole.

Notes: BMJ BP

Question 16

Tx for Eczema Herpeticum? [2]

Answer 16

Acyclovir
Flucoxacillin

Question 17

What is the management for EM? [3]

Answer 17

Management

• EM typically develops over 3-5 days and improves over 2 weeks. Some patients may get persistent or recurrent episodes.
• Stop the drug
• Treat the underlying infection
• Treat with a week of oral prednisolone if severe mucosal pain/ difficulty eating

Question 18

Erythrasma is a superficial bacterial skin infection caused by [1]

How do you dx erythrasma? [1]

What is the treatment? [1]

Answer 18

Erythrasma is a superficial bacterial skin infection caused by Corynebacterium minutissimum

Examination with Wood’s light reveals a coral-red fluorescence.

Topical miconazole or antibacterial are usually effective. Oral erythromycin may be used for more extensive infection

Question 19

Which drugs are used for fungal nail infection, for both fingernails and nails, if:

• Limited involvement
• Extensive involvement
• Extensive involvement due to Candida infection

Answer 19

Limited involvement: - Topical treatment with amorolfine 5% nail lacquer
- Fingernails: 6 months
- Toe nails: 9-12 months

Extensive involvement - : oral terbinafin
- Fingernails: 6 weeks-3 months
- Toe nails: 3-6 months

Candida:
- oral itraconazole is recommended first-line;
- ‘pulsed’ weekly therapy is recommended

Question 20

Treatment of acute and chronic Hidradenitis suppurativa?

Answer 20

Acute flares:
- can be treated with steroids (intra-lesional or oral) or flucloxacillin.
- Surgical incision and drainage may be needed in some cases.

Long-term disease:
- can be treated with topical (clindamycin) or oral (lymecycline or clindamycin and rifampicin) antibiotics.

Question 21

Hyperhidrosis describes the excessive production of sweat.

What are 4 managment options? [4]

Answer 21

1. topical aluminium chloride preparations are first-line. Main side effect is skin irritation
2. iontophoresis: particularly useful for patients with palmar, plantar and axillary hyperhidrosis
3. botulinum toxin: currently licensed for axillary symptoms
4. surgery: e.g. Endoscopic transthoracic sympathectomy. Patients should be made aware of the risk of compensatory sweating

Question 22

What is the treatment algorithm for impetigo? [3]

Answer 22

Tx:
- Hydrogen peroxide 1% cream for ‘people who are not systemically unwell or at a high risk of complications’
- topical antibiotic creams: topical fusidic acid; topical mupirocin should be used if fusidic acid resistance is suspected
- Extensive disease: oral flucloxacillin; oral erythromycin if penicillin-allergic

Question 23

Management of LP? [2]

Answer 23

potent topical steroids are the mainstay of treatment
benzydamine mouthwash or spray is recommended for oral lichen planus

Question 24

How do you treat lichen sclerosus? [2] Why do you follow up patients? [1]

Answer 24

**Treatment**: * topical steroids and emollients Follow up due to risk of **vulval cancer**

Question 25

Describe the tx for rosacea - simple measures - for predominant erythema or flushing? [2] - Mild/moderate papules [2] - Moderate/severe papules [2] - Telangiectasia that hasn't resolved despite treatment [1]

Answer 25

**Simple**: - recommend daily application of a **high-factor sunscreen** - **camouflage** **creams** may help conceal redness **Flushing**: - Topical brimonidine gel (alpha adrenergic agonist) - as required basis' to temporarily reduce redness' **Mild/moderate papules**: - topical **ivermectin** is first-line (CKS) - alternatives include: **topical metronidazole** or **topical azelaic acid** **Moderate / severe papules**: - combination of **topical ivermectin + oral doxycycline** - **isotretinoin** **refractory, prominent telangiectasia**: - **laser therapy** ## Footnote NB: steroids not used in rosacea

Question 26

How do you manage Class III/IV Cellulitis? [2]

Answer 26

**Eron Class III-IV** * **admit** * NICE recommend: **oral/IV co-amoxiclav, oral/IV clindamycin, IV cefuroxime or IV ceftriaxone** **General points** * mark the area of erythema to detect spreading cellulitis * if possible elevate the leg * consider paracetamol or ibuprofen for pain or fever

Question 27

How do you prevent / manage pressure sores [4]

Answer 27

**Regular repositioning** every **2 hours** for **bed-bound** patients and **hourly** for those in **chairs**. **Maintain skin integrity** by keeping skin clean and dry. Use **mild soap** and **warm** (not hot) **water** for cleaning **Dressings**: - **Alginate dressings** are useful for **exuding** **wounds**; - **Hydrocolloid dressings** can be used for **non-exuding wounds**. **Administer analgesics as required**. Regularly reassess pain levels.

Question 28

Treatment algorithm for folliculitis? [2]

Answer 28

**Topical treatments** * Mild cases can often be managed with topical antiseptics (e.g., **chlorhexidine**) or antibiotics (e.g., **fusidic acid**). * If fungal infection suspected (e.g., Pityrosporum folliculitis), consider **antifungal** **creams** or **shampoos** containing **ketoconazole**. **Systemtic treatments**: - In severe or recurrent cases, consider oral antibiotics that cover Staphylococcus aureus (e.g., **flucloxacillin**).

Question 29

How do you manage urticaria? [3]

Answer 29

I**t is critical that all patients presenting with urticaria are assessed for a more systemic allergic reaction (e.g. anaphylaxis) or angio-oedema affecting the airway due to laryngeal oedema** **non-sedating antihistamines** (e.g. **loratadine** or **cetirizine**) are first-line - NICE Clinical Knowledge Summaries suggest **continuing these for up to 6 weeks** following an episode of acute urticaria CKS **a sedating antihistamine** (e.g. **chlorphenamine**) may be considered for night-time use (in addition to day-time non-sedating antihistamine) for troublesome sleep symptoms CKS **prednisolone** is used for severe or resistant episodes