W24 Clinical management of Cellulitis, Acne and Rosacea Flashcards
(38 cards)
What is Cellulitis?
What are the symptoms?
- Common
- Acute bacterial infection of dermis & Subcutaneous tissue
Symptoms
* Pain, warmth, swelling, redness of infected area
* Possible blisters
* Fever, malaise, nausea, rigors
* Tracking
Cellulitis is an infection caused by bacteria getting into the deeper layers of your skin
Cellulitis: Which regions of the body does it affect?
Commonly affects lower limbs
Can also affect:
* Face
* Ears
* Trunk
* Upper limbs
What are the causes of cellulitis?(3 microorganisms)
Microorganims entry after after skin barrier broken
* Strep. Pyrogenes
* Staph. Aureus
* Pseudo aeruginosa
What are the risks of cellulitis?
What are the complications?
Risks:
* Lymphoedema
* Leg oedema
* Venous insufficiency
* Hx venous surgery
* Obesity
* Pregnancy
* Diabetes
* Kidney/liver disease
* Chickenpox
* Alcohol misuse
Complications:
* Necrotising fasciitis
* Myositis
* Sepsis
* Subcutaneous abscess
* Post-strep Nephritis
* Leg ulceration
* Lymphoedema
* Recurrent cellulitis
How to diagnose cellulitis?
History
•Symptoms – Duration & severity
•Recent trauma to skin?
•Comorbidities?
•Predisposed conditions?
Examination
•Assessment of area
•Observation & vital signs
•Skin breaks/wounds
•Assess for risk factors
Investigations
•Skin swab
•Skin biopsy
•Ultrasonography
•WCC
•ESR
•CRP
What is the categorisation of cellulitis?
*Class I – No systemic illness or comorbidity
*Class II – Systemically unwell or well with comorbidity
*Class III – Significant systemic illness/upset
*Class IV – Sepsis or sever life threatening illness
Cellulitis – Differential diagnosis
- DVT
- Septic arthritis
- Gout
- Thrombophlebitis
- Cutaneous abscess
- Drug reaction
- Erythema nodosum
- Pyoderma gangrenosum
- Cancer
Cellulitis – Management
When is hospital admission req?
URGENT Hosp admission:
* Class III or Iv suspected
* Class II + serious illness
* Rapid deterioration
* Very young or very frail patients
* Facial cellulitis
* Orbital/periorbital cellulitis
Seek advice
* Wound contaminated by fresh or sea water
* Recurrent episodes
Cellulitis – Management
What medications are used in treatment?
Antibiotic treatment
* Flucloxacillin – 1st line
* Clarithromycin – 1st line in pen. allergy
* Doxycycline
* Erythromycin
* Metronidazole – If anaerobic cause suspected, avoid alcohol
* Co-amoxiclav - Avoid due to high risk c.diff…but 1st line in facial cellulitis
What is Acne?
- Chronic, inflammatory skin condition
- Blocked, inflamed pilosebaceous unit
- Affects areas with high amounts of pilosebaceous units
- Face, back, chest
- Peaks in adolescence but can affect any age
- Non-inflammatory comedones
- Whiteheads (open) & blackheads (closed)
- Papules, pustules, nodules & cysts
What is Acne? (pathophysiology)
- Excess sebum production
- Altered follicular keratinocyte proliferation – follicular plugs
- Bacteria proliferation – Cutibacterium acnes
- Affected follicle becomes inflamed
Acne
What are the contributing factors? (2)
What are the complications? (2)
Contributing factors
* Genetics – Link between identical twins, severe acne in people with FH
* Diet – Link with high GI food/diet
Complications
* Scarring
* Psychological impact – depression, anxiety, low self-esteem
Acne
What to ask when taking a history?
History
* Duration, type, distribution
* Previous treatment
* Exacerbating features
* Systemic features
* Psychological impact
* Family Hx – Endocrine disorders, PCOS, Acne
* Drug Hx – Androgens, ciclosporin, isoniazid, lithium
* Hyperandrogenism
Acne- Differential diagnosis? (5)
- Rosacea
- Perioral dermatitis
- Folliculitis & boils
- Drug-induced acne
- Keratosis pilaris
Acne:
What are the different categories? (5)
- Mild – Predominantly non-inflamed lesions & some inflammatory lesions
- Moderate– More widespread, more inflamed papules & pustules
- Severe – widespread inflammatory papules, pustules, nodules & cysts with scarring
- Conglobate acne – Rare & severe. Extensive inflammatory papules, nodules, cysts on trunk & upper limbs
- Acne fulminans – Rare. Severe inflammatory reactions, deep ulcerations & erosions. Fever & joint stiffness
Acne - Management
nformation & Advice
* Reason/cause of acne
* Therapy options – risks & benefits
* Childbearing potential – Retinoid & tetracyclines contraindicated
* Use of effective contraception or alternative acne treatment
* Impact of acne
* Adherence to treatment – 6-8 weeks before improvement
* Relapses
* Avoid over-cleaning skin – dryness & irritation
* Non-alkaline cleaning products
* Avoid oil based skin products
* Avoid picking/scratching lesions
* Treatment can irritate skin
Acne - Management:
Which medicines are used?
- Benzoyl Peroxide – topical
- Retinoids– topical or oral
- Antibiotics – topical or oral
- Azelaic acid - topical
- Combined oral contraceptive
- Benzoyl peroxide & retinoids available as combination topical products together or with antibiotic e.g. Duac gel
Benzoyl Peroxide
- Licensed from age 12
- Apply OD-BD
- Wash with soap and water before application
- Start at lower strength
- Available as a gel alone or combination with adapalene or clindamycin
- Reduce/stop use until settled & restart at lower strength
- Inc. risk of sunburn – advise on appropriate sunscreen & clothing
- Bleaching of fabrics & hair
Benzoyl PeroxideCautions/Contraindications - Hypersensitivity Hx
- Contact with broken skin, eyes, mouth, nostrils & mucous membranes
Adverse effects - Skin irritation – dryness, redness, peeling, blistering
- Reduce/stop use until settled & restart at lower strength
- Inc. risk of sunburn – advise on appropriate sunscreen & clothing
- Bleaching of fabrics & hair
Topical retinoids
- Adapalene, tretinoin, isotretinoin
- Licensed from age 12
- Isotretinoin only licensed in adults over 18
- OD-BD application
- Start at lower frequency in sensitive skin then increase application
- Apply sparingly and cover whole area not just comedones
- If using due to irritation with other product – allow to settle before starting
Topical retinoids
Cautions/Contraindications
* Hypersensitivity Hx
* Pregnancy – use of effective contraception
* Breastfeeding
* Contact with broken skin, eyes, mouth, nostrils & mucous membranes
* Severe acne, perioral dermatitis, rosacea or HX skin cancer – AVOID
* Avoid/limit UV light exposure
Adverse effects *Risk of systemic absorption – Consider interactions
* Skin & eye irritation
* Increased UV light sensitivity
Topical antibiotics
- Clindamycin & Erythromycin
- OD-BD application
- Prescribe as combination with Benzoyl
Peroxide
Cautions/Contraindications
* Hypersensitivity Hx
* Hx IBD or Antibiotic induced colitis
* Stop if pt., has diarrhoea
* Caution in atopy
* Only use in pregnancy if essential
Adverse effects
* Skin irritation
* GI disturbances
* Pseudomembranous colitis
Interaction with CYP3A4 inducers e.g.
Rifampicin
Oral antibiotics
- Add in if topical preparations fail
- Tetracyclines – Lymecycline & Doxycycline
- OD dosing
- Minocycline – No longer recommended due to adverse effects
- Lupus, skin pigmentation, hepatitis
- Only use Erythromycin if tetracyclines contraindicated
- Co-prescribed with topical retinoid or benzoyl peroxide to reduce risk of resistance
- Do not use topical & oral Abx together
- LFT before Tx, @ 6 weeks and 12 weeks
- Review treatment after 12 weeks
Azelaic Acid
- Licensed from age 12+
- Apply BD – Sensitive skin apply OD for a week then BD
- Avoid contact with broken skin, eyes, mouth, nostrils & mucous membranes
Cautions/Contraindications
* Hypersensitivity Hx
* Contact with broken skin, eyes, mouth, nostrils & mucous membranes
* Caution in pregnancy & breastfeeding
Adverse effects
* Skin irritation
* Worsening of asthma
Combined oral contraceptives
e.g. Co-Cyprindiol
- For use in acne patients with PCOS
- Use if 1st line option not successful
- Co-cyprindiol or other
- Review at 6 months
- Specialist referral
- Counsel on adherence, missed pill, vomiting & diarrhoea, interactions
- Risk of breast and cervical cancer
- Can improve acne symptoms
- Opposite to progesterone only oral contraceptive – worsens acne symptoms
