Cookie policy notice

By continuing to use this site you agree to our cookies policy below:
Since 26 May 2011, the law now states that cookies on websites can ony be used with your specific consent. Cookies allow us to ensure that you enjoy the best browsing experience.

This site is intended for health professionals only

At the heart of general practice since 1960

Key learning points- dermatology

Key questions – eczema

+ Traditional eczema management strategies – starting with low steroid doses and moving up – have led to undertreatment

+ Current practice is to start with a moderately potent, or potent, topical steroid for a short time and then tail down the dose

+ An alternative to using a lower daily dose is the ‘weekender regime' – using a steroid one or two days a week

+ Lotions are best for the scalp and other hairy areas and for mild dryness on the face, trunk and limbs. Ointments are prescribed for drier, thicker, more scaly areas

+ Antimicrobials such as benzalkonium chloride and triclosan can combat infection, especially staphylococcal, and help to prevent flares

+ Fusidic acid resistance is now 50% in the general population and 78% in dermatology inpatients

+ Fusidic acid preparations should be prescribed for 10-14 days' use only

+ Pimecrolimus is very useful for facial eczema, particularly on the eyelids

+ There have been reports of cataracts developing from long-term use of just 1% hydrocortisone on eyelids

+ The treatment for varicose eczema is good compression hosiery, mild-to-moderate steroids and lots of moisturisers

+ Children who have hyperlinear palms are more likely to develop severe and persistent eczema into adulthood

+ Becoming familiar with a small selection of steroids is better than prescribing from the whole range

+ The most potent topical steroids are needed on the soles and palms, while the eyelids and genitals need much milder steroids

Dermatology dilemmas

1 Acne excoriée

+ Acne excoriée patients are most typically female and aged 20 to 40 years – older than the typical range for acne

+ The picking produces atrophic round or stellate scars, typically with an angulated border and a white centre

+ Effective management is two-pronged: aggressively bringing the acne under control and addressing behavioural issues

+ Adapalene and topical antibiotics are useful and not irritants

+ Dianette is especially helpful in young women, ideally in combination with isotretinoin

+ Explaining the disease process and how picking exacerbates the problem can address the behaviour in some patients

2 Chronic urticaria

+ In chronic urticaria it's worth checking for aggravating factors, such as use of NSAIDs

+ A non-sedating antihistamine is a useful first-line treatment and should be taken daily if it works

+ Double the dose or add in an H2 blocker like ranitidine if there's no response

3 Itch in the elderly

+ About 30% of itch in the elderly is caused by metabolic problems

+ The mainstay of treatment is emollients and moderately potent, or potent, topical steroids

+ Moisturisers containing menthol can help cool and soothe the skin

+ Suspect scabies if there is a history of severe itch, especially at night or after a bath

+ Itch can precede the development of pemphigus or pemphigoid

+ Itch can be a manifestation of anxiety, depression or loneliness

4 Recurrent boils

+ Primary treatment for most boils is heat application, usually with hot soaks or hot packs

+ Recurrent lesions should be swabbed to check for resistance

+ Recommended oral antibiotics are flucloxacillin or erythromycin 250mg or 500mg qds for adults for 10-14 days

+ Nasal carriage can be treated topically by Naseptin cream or Bactroban nasal ointment

5 Scalp psoriasis

+ Shampoos should be used long term

+ A topical agent such as Xamiol can be added if shampoos are not effective on their own

+ Thick scale needs to be removed before using a topical treatment

Clinical curio

+ Pitted keratolysis commonly affects those whose feet sweat a lot

+ Key characteristics are macerated skin over the pressure areas with pits in the skin and an unpleasant odour

+ Topical antibiotics are the first-line treatment

+ In resistant or severe cases, oral treatment – typically erythromycin – is required

Dermoscopy in diagnosis

+ Dermoscopy helps distinguish pigmented, melanocytic lesions from non-melanocytic lesions

+ It also helps differentiate benign and malignant melanocytic lesions

+ Stored dermoscopic images are particularly valuable in the surveillance of patients with many naevi

+ Characteristic features of malignant melanoma include atypical pigment network, a few scattered dots, asymmetrical blotches and white scar-like depigmentation

+ A dermascopic view of a basal cell carcinoma typically shows structureless brownish areas

Red legs in the elderly

+ Eczema, whether varicose, asteatotic, discoid or other, is the most common cause of red legs in the elderly and usually responds to appropriate treatment

+ Effective management relies on differentiating between skin disease and the results of underlying circulatory disorder

+ Varicose eczema responds to emollients, topical steroids (if there is inflammation) and compression

+ Excessive bathing caused by primary asteatotic eczema can lead to a misdiagnosis of scabies

+ Discoid eczema is more common after late middle age and is often misdiagnosed as fungal infection or psoriasis

+ Cellulitis is typically unilateral, painful, confluent and associated with pyrexia and malaise

+ Strongly inflamed, steroid-responsive skin disease should be treated with a potent, or very potent, topical steroid once or twice daily for a week or so and then reviewed

Click here to start the CPD assessment This CPD article is worth an estimated 1.5 hours

Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say