W24 Clinical management of eczema and psoriasis

Question 1

What is Eczema?

Answer 1

a.k.a. Atopic Eczema/Atopic Dermatitis
Chronic inflammatory skin condition
Affects all ages but presents most often in early childhood

Dry, itchy, inflamed skin
Skin can become infected
Episodes of flare up/exacerbation with periods of remission

Atopic – Increased immune response to an allergen or trigger
Common for patients to have Hx of Family Hx of other atopic conditions e.g. asthma

Question 2

What is the cause of eczema?
(fil)

Answer 2

*Complex condition
* Many factors affect it’s development
* Genetic Link
-70% patients have FH of atopic disease – asthma, hayfever, allergy, eczema
-Mutation of Filaggrin gene in 50% of cases
* Filaggrin – converts keratinocytes to protein/lipid squames that make up stratum corneum
* Loss of Filaggrin function = Dysfunction of skin barrier
Skin barrier dysfunction = water loss, allergen/pathogen entry

Question 3

Triggers of eczema?

Answer 3

Soap/Detergents/Chemicals
Animal hair
Dust mites
Extremes of Temperature
Clothing
Pollen
Foods
Infection
Stress

Question 4

What is the Itch-scratch cycle?

Answer 4

1. Itch- In people with atopic dermatitis, immune cells in the deeper layers send inflammatory signals to the surface, causing the itchy rash
2. Scratch- Scratching breaks down the outer layer of the skin, which allows germs, viruses and allergens to get in
3. Release of Inflammatory signals - In response to these invaders, the immune system continues to send even more redness and itching.
4. Damaged skin- The more scratching, the more the skin barrier breaks down, and the itch-scratch cycle continues

Question 5

Diagnosing Eczema
History

Answer 5

Itching
Pattern
Time & age of onset
Hx of rash
Tx tried? & response
Dry skin in last 12 months
Asthma or allergic rhinitis

Question 6

Diagnosing Eczema:
What are the features of the Rash?

Answer 6

• Dryness
• Itching
• Primary manifestation on hands
• Presence in limb flexures
• Infants -Face, scalp, limbs nappy areas
• Acute – Fluid vesicles, scaling, crusting of skin
• Chronic – Thickened skin due to scratching, Keratosis pilaris
• Weeping, crusting, pustules, fever & malaise – suspect bacterial infection

Question 7

What is the differential diagnosis of Eczema? (8)

Answer 7

Psoriasis
Allergic Contact Dermatitis
Seborrhoeic Dermatitis
Fungal infection
Scabies
Food allergy
Fungal infection

Question 8

Management of Eczema
How is it assessed? (brief)
What are the categories of eczema? (5)

Answer 8

Assessment of Severity
Assess severity to determine the best treatment
Examine all areas
Itching??

Categorization
Clear – normal, no active eczema
Mild – Dry skin, infrequent itching
Moderate – Dry skin, frequent itching, redness +/- excoriation & thickening
Severe – Widespread dry skin, incessant itching & redness. Excoriation, extensive thickening, bleeding, oozing, cracking, altered skin pigmentation
Infected – Weeping, crusting, pustules, fever, malaise

Question 9

What is Eczema Herpeticum?

Answer 9

• Herpes Simplex infection (HSV)
• Widespread lesions
• Usually on face and neck but can extend over whole body
• Possible association with Staph/Strep skin infection
• Cluster of small blisters - itchy and painful
• Blisters are red, purple or black
• Blisters can ooze pus when broken open
• Fever
• Generally unwell
  MEDICAL EMERGENCY – URGENT REFERRAL

Question 10

Psychological impact of eczema

Answer 10

Assess impact of symptoms on school, work, social life, sleep & mood:
None
Mild
Moderate
Severe

Assessment Tools:
Visual analogue scales
Patient Oriented Eczema Measure
Infants Dermatitis Quality of Life
Children’s Dermatology Life Quality Index
Dermatitis Family Impact

Question 11

Management of Eczema- Self care

Answer 11

Correct use of emollients
Maintenance of skin, reduce risk of flare ups
Avoid exacerbating triggers
Do not change diet unless advised by specialist
Complementary remedies not advised – Homeopathy, Chinese, herbal
Information and support sources – British Association of Dermatologists (BAD), National Eczema Society, Eczema Care Online

Question 12

Mild Eczema- management

Answer 12

Emollients – Frequent and liberal use, maintain skin moisture
Mild potency topical corticosteroid for red areas e.g. Hydrocortisone 1%
Continue for 48hrs after flare up controlled
Information & advice on maintenance of skin, reducing flare ups
Follow up – if persisting symptoms review emollient use

Question 13

Moderate Eczema- management
1st line?
2nd line?

Answer 13

• Identify trigger factors or infection
• Emollients – Frequent and liberal use, maintain skin moisture
• Moderate potency topical corticosteroid
  Betamethasone val. 0.025% or Clobetasone but. 0.05%
• Use mild potency for delicate skin areas Continue for 48hrs post flare up control, max. 5 days use on face
• Occlusive dressings/bandages – specialist recommendation
• Non-sedating antihistamine – to help with itching
  =Cetirizine, Loratadine, Fexofenadine
• Information & support – maintenance of skin, reducing flare ups
• Consider maintenance regime of topical steroid
• Follow up – persistent symptoms, review emollient use

Topical Calcineurin inhibitors:
2ND Line preventative option
Tacrolimus
Pimecrolimus
Only recommended by Specialist
Dermatologist or GP with Special Interest (GPSI)

Question 14

Severe Eczema:
What are the steps in management?

Answer 14

• Identify trigger factors or infection
• Emollients – Frequent and liberal use, maintain skin moisture
• Potent/Very Potent topical corticosteroid e.g. Betamethasone val. 0.1%
  -Moderate potency for delicate skin areas, max. 5 days use
  -DO NOT USE in children under 12 months old
• Occlusive dressings/bandages
• Antihistamine to help with itching
  -Cetirizine, Loratadine, Fexofenadine, Chlorphenamine (if affecting sleep)
• Extensive & distressing – Consider short oral corticosteroid (Pred 30mg 7/7), Refer under 16s to specialist
• Consider topical steroid maintenance regime

Question 15

Infected Eczema

Answer 15

• If systemically well aim not to routinely offer Abx – limited benefit, risk of resistance
• If offered Abx
  -Flucloxacillin 1st line
  -Clarithromycin if penicillin allergy
  -Poor response - consider alternative, skin swabs
• Localised infection – Topical Fusidic Acid

Question 16

Emollients

Answer 16

Creams, ointments, gels, lotions, sprays, washes, bath & shower additives
Brands - Epimax, Cetraben, Diprobase, Epaderm, Hydromol
Most are Paraffin based products e.g. White Soft Paraffin

Some contain active ingredients:
Urea – Eucerin Intensive
Lauromacrogols – Balneum Plus
Lanolin - Oilatum
Antiseptic – Dermol (only recommended in cases of skin infection)

Question 17

Emollients

Answer 17

• All available on NHS
• Some classified as Borderline Substances – Endorsed ACBS
• Aveeno & E45 products – Avoid E45
• Creams & Lotions better for red, inflamed areas
• Ointments better for dry skin that’s not inflamed
  -Greasy, poorly tolerated
• Patients may need several different preps
• DO NOT OFFER Aqueous Cream due to poor evidence
• Can be used as soap substitutes
• Evidence for bath additives is limited
• Prescribe in high quantities (2000g) due to liberal application (QDS) – pump dispensers

Question 18

Emollients- Use and application

Answer 18

Use liberally and frequently, as much and as often as possible even when skin clear, Minimum QDS application
Apply during or after washing
Smooth into the skin along the line of hair growth
Apply 15-30 mins before topical corticosteroid

Contain paraffin – fire hazard
Avoid smoking or being near naked flames
Build up on clothes & bedding – wash at high temperatures to reduce build up

Question 19

Emollients- Adverse Effects

Answer 19

• Skin reactions/sensitivity to ingredients
  -Perfumes, preservatives, lanolin
• Stop emollient and use alternative if reaction occurs
• Previous issue with reaction/sensitivity – consider patch test before full application
• Prescribe a product with few additives if known sensitivity
• Folliculitis with ointments
• High risk of reactions with Aqueous Cream – MHRA 2013

Question 20

TCS- 4 Potencies

Answer 20

4 Potencies
Mild – Hydrocortisone 0.1-2.5%
Moderate – Betamethasone Valerate 0.025%, Clobetasone 0.05%
Potent – Betamethasone Valerate 0.1%, Betamethasone Dipropionate 0.05%
Very Potent – Clobetasol 0.05%, Diflucortolone 0.3% - Only to be prescribed by Specialist

Cream, ointment, lotion, scalp application

Hydrocortisone 1% cream available for OTC purchase or through CAS

Question 21

TCS Flare up treatment

Answer 21

• Normal skin – Prescribe a potency to match the severity of eczema
• Once to Twice daily for 7-14 days
• Mild – Mild, moderate - moderate, severe - potent
• Face, genitals, axillae
  -Mild potency
  -Max. 5 days use

Question 22

TCS- Maintenance regimen:
What potency is used for flare up/usually?
What are the 2 regimens that patients use to apply the tcs?

Answer 22

• Use lowest potency that controls eczema
• Potency lower than that used for flare up e.g. mild for maintenance if moderate during flare
• Use mild potency for thin skin areas
• 2 regimens
  -Weekend application
  -Twice weekly application – Most commonly used

Question 23

Adverse Effects TCS

Answer 23

Rare serious adverse effects from topical steroids

Inc. likelihood of adverse effects when:
Long duration of treatment
Application to large area of skin
Skin condition – thin skin?
Use of higher potency
Occlusion/use under dressings & bandages
Age – Children & elderly – thinner epidermis

=Increased exposure & risk of systemic absorption

Question 24

What are local adverse effects of topical corticosteroids?

Answer 24

• Burning & stinging
• Worsening/spreading of infection
• Skin thinning/Steroid induced atrophy
• Striae
• Allergic contact dermatitis
• Acne & Rosacea
• Skin depigmentation
• Excess hair growth

Question 25

Application/Counselling TCS:

Answer 25

* Apply sparingly/thinly to affected area(s) * Apply as FTUs – Finger Tip Units * 1 FTU roughly 500mg of drug – will treat an area 2 x size of flat hand * Apply 15-30 mins **before** emollient * Apply at most convenient time of day e.g. at night before sleep * Continue application for 48hrs post flare up clearance

Question 26

Topical Calcineurin inhibitors: When are they used? What are examples? (2)

Answer 26

* 2nd line in moderate-severe atopic eczema – only on specialist recommendation * Lower risk of skin thinning than corticosteroids * Useful in failed steroid therapy or risk of serious adverse effects from prolonged use Tacrolimus ointment: -0.03% - Licensed from age 2+ -0.1% - Licensed from Age 16+ Pimecrolimus 1% Cream: -Licensed from Age 3+

Question 27

Topical Calcineurin inhibitors Application/Counselling

Answer 27

Apply thinly BD to affected areas DO NOT apply to skin that looks infected Not to be used under bandages or dressings Avoid skin exposure to sunlight

Question 28

What is Psoriasis? Why do lesions arise?

Answer 28

* Systemic, immune-mediated, inflammatory skin disease * Common disorder, underreported * Can also involve nails and joints (Psoriatic arthritis) * Well-defined, erythematous, scaly papules or plaques Lesions arise due to: * Skin cells multiplying too quickly (hyperproliferation) * Skin cells not maturing normally (abnormal differentiation) * Presence of cells causing inflammation

Question 29

Psoriasis: What are the different forms/classification? (8)

Answer 29

Chronic Plaque Psoriasis Scalp psoriasis Localised/Generalised Pustular Psoriasis Flexural Psoriasis Guttate Psoriasis Erythrodermic Psoriasis Nail Psoriasis Psoriatic Arthritis

Question 30

Psoriasis- Diagnosis

Answer 30

Diagnosis Site & extent Symptoms – itch, irritation, burning, pain, bleeding, scaling Triggers? Joint symptoms? – swelling, stiffness, pain Nail changes Associated conditions – IBD, Obesity Physical, psychological, social impact Severity – PASI score (Psoriasis Area and Severity Index)

Question 31

Psoriasis Triggers

Answer 31

Strep infection – guttate psoriasis Drugs e.g. Lithium, antimalarials, NSAIDs (Diclofenac, Ibuprofen, Naproxen) UV light exposure Trauma Hormonal changes HIV infection/AIDS Psychological stress Smoking Alcohol Obesity

Question 32

Psoriasis- Differential Diagnosis

Answer 32

* Seborrheic Dermatitis (dandruff/eczema) * Fungal skin/nail infection * Candidal intertrigo * Norwegian scabies * Secondary syphilis * Bacterial infection * Eczema * Lichen planus * Lichen simplex chronicus * Discoid lupus erythematosus * Cutaneous T-cell lymphoma * Viral exanthems * Pityriasis rosea * Drug eruptions * Pyogenic infections * Vasculitis

Question 33

Vitamin D preparations -Use/Counselling Calcipotriol Frequency? Max doses? Freq with betamethasone? Dose?

Answer 33

* Once/Twice a day application **Max. 100g ointment, cream or gel per week or 60mL scalp solution** * **Max. 5mg per week** if using ointment **and** scalp solution in **combination** Cream/ointment 30g plus 60ml scalp sol. Cream/ointment 60g plus 30ml scalp sol. * With Betamethasone Once daily for 4 weeks for foam/ointment 1-4g OD for 4 weeks for gel Do not exceed 30% of body surface

Question 34

Salicylic acid Contraindications? Cautions? Adverse effects? Application?

Answer 34

* Usually given as combination product with coal tar -Keratolytic agent * Contraindications – Aspirin allergy, inflamed skin, local infection, pustular psoriasis * Cautions – Application over large area, pregnancy & breastfeeding, risk of neuropathic ulcers, peripheral neuropathy * Adverse effects – Irritation, skin dryness, salicylate toxicity Application: - Part hair in sections - Rub preparation along exposed areas & work around hair - Leave on for 1 hour then wash off - Apply once daily for 3-7days if severe psoriasis the once per week - Leave on overnight if there is thick scaling

Question 35

Coal Tar What is it used to treat? Possible moA? Cautions? C/I? Adverse effects? How is it applied?

Answer 35

* Used to treat scalp psoriasis * Alphosyl, Capasal, Polytar T/Gel shampoos, Psoriderm cream Exorex lotion, Sebco, Cocois ointments * Possible action - suppresses DNA synthesis and inhibits of keratinocyte proliferation * Cautions – Face & flexure application, Pregnancy trimester 2 & 3, breastfeeding * Contraindications – Broke/inflamed skin, pregnancy trimester 1, genital psoriasis * Adverse effects – Photosensitivity, skin irritation, folliculitis, skin, hair & fabric staining * Application Wipe onto plaque area BD Scalp applications - apply once a week, leave on for 1hr then wash off Shampoo – use once daily to twice weekly

Question 36

Dithranol **specialist treatment** Used? What is the MoA? Contraindications? Adverse effects?

Answer 36

(Subacute and chronic plaque psoriasis) * Available as ointment/paste * Range of strength 0.1-2% Inhibits keratinocyte hyperproliferation, granulocyte function and possible immunosuppressive effect Contraindications – Acute/pustular psoriasis, inflamed psoriasis, facial psoriasis, sensitive skin Adverse effects – Irritation, burning, staining of hair, skin & fabrics

Question 37

Dithranol- Application (psorias)

Answer 37

* Start at lowest strength (0.1%) * Increase over 4 weeks to highest tolerated strength * Up to 6 weeks before improvement seen * Apply OD to affected area for 1 week * Leave on for 30-60 minutes then wash off * Weekly increases – 0.25%, 0.5%, 1%, 2% * **STOP if inflammation to the applied area & restart at lower strength once settled** * Apply 30 mins after emollient application * **STOP once lesions feel flat**

Question 38

Systemic Treatment When should it be offered? Which medications are given?

Answer 38

To be commenced only by specialist Consider pt demographics and preference before prescribing Offer if: - Topical therapy unsuccessful - Significant impact on physical, psychological and social wellbeing - Extensive psoriasis, phototherapy ineffective or localised psoriasis causing significant distress * Methotrexate – 1st line, teratogenic, blood monitoring under shared care * Ciclosporin – Good for rapid/short term control, palmoplantar psoriasis or considering conception * Acitretin – Consider if MTX or ciclo not effective or not appropriate, good for pustular psoriasis

Question 39

What is Photherapy? Used how freq? Disadvantage?

Answer 39

* Use of UV light therapy – UVA, UVB * Used alone (UVB) or alongside Psoralens (PUVA) * Psoralens increase skin sensitivity to light * Periodic use, long term use not suitable * Offered when topical therapy failed or can be given alongside topical therapy * Use 2-3 times a week * Cancer risk – Inc. risk of skin cancer -Carefully monitor treatment -Not to be used in pts @ high risk of cancer -Discuss risk with patients before treatment