Dermatology dilemmas

Five dermatology GPSIs tackle some of the trickiest dermatology problems in primary care

Acne excoriée

Minor picking in acne is extremely common1 but here the distress caused, and degree of skin trauma, is totally out of proportion to the severity of the acne lesions – making this a very challenging form of acne. Even minor eruptions are picked at as soon as they present, resulting in permanent scarring. Invariably the face is involved predominantly, with bilateral involvement, but interestingly it can be more severe on the non-dominant side.

Patients are most typically female, but the age range – at between 20 and 40 years – is often older than is usual for acne.

The picking produces atrophic, round or stellate scars that typically have an angulated border and a white atrophic centre. There is often some post-inflammatory peripheral hyperpigmentation or hypopigmentation.

Management demands a two-pronged approach. First, it is essential to control the acne aggressively.

Topical treatments can be dismissed by the patient as ‘too irritating' but I've found adapalene is not very irritating and can help prevent new lesions even when used only twice a week. Topical antibiotics are also useful and are not irritants. A six-month trial of oral antibiotics is certainly worth a go but the response is often disappointing.

The scarring lowers my threshold for considering oral isotretinoin. Unless contraindicated, Dianette is especially helpful in young women and is ideal when used in combination with isotretinoin.

Secondly, it's important to address the behaviour. It's extremely useful to explain the pathogenesis of acne. I describe how the fundamental problem – the open comedone – starts deep in the dermis around the hair bulb. The hair shaft penetrates through the epidermis to the surface, but a closed comedone, papule or more inflammatory acne lesion remains deep in the dermis. A physical attack will never express the blockage but disrupts and permanently scars the epidermis. This alone can help to modify patient behaviour.

It's important to address why the patient has developed this obsessive behaviour. It may be a manifestation of disturbed body image or part of a self-mutilating spectrum. Management of any psychological comorbidity such as depression, anxiety, obsessive compulsive disorder, borderline personality disorder or history of abuse is essential. Early referral for a psychiatric opinion should be offered if appropriate and treatments including cognitive behaviour therapy, SSRIs or even neuroleptics, such as olanzapine, may be necessary.

Dr George Moncrieff is a dermatology GPSI in Bicester, Oxfordshire

Competing interests None declared

Chronic urticaria

Chronic urticaria can be a real problem and patients need to be reassured that it will be brought under control. They often want to hear a single allergen is responsible but it's more frequently a holding game – aiming for symptomatic relief until the patient's own immune system perfects a cure.

A good history is essential. Most urticaria is probably idiopathic or autoimmune, but you should check for other possible causes. It can be related to exercise, cholinergic urticaria for example, or pressure – delayed pressure urticaria. Dermatographism is similar to urticaria, but comes more quickly. Test for this by gently pressing the skin with a blunt spatula.

It's worth looking for aggravating factors. Drugs are a frequent culprit – for example aspirin, codeine and NSAIDs. Check if the patient is on an ACE inhibitor and if so switch them to an ARB. A good history may tease out a possible food allergy but enthusiastic patients can keep a food diary.

Check TFTs and thyroid antibodies, as treating thyroid disease improves urticaria. It is probably worth checking FBC, ESR, U&Es and LFTS. If there is a history of angioedema then check the C4. If low, further immunological tests are required.

If lesions are prolonged – beyond 24 hours – and associated with bruising, consider urticarial vasculitis. Ask if there has been any laryngeal oedema or previous anaphylactic problems as these need specialist advice.

Try a non-sedating antihistamine as first-line treatment – it's worth finding one that the patient finds acceptable. It should then be taken daily and not just with each attack. When the patient has been asymptomatic for a while, try stopping it to see if the urticaria returns. Double the dose if there's no response, but warn the patient of possible drowsiness and check for interactions.

An alternative is to add in an H2 blocker such as ranitidine or to add in a small evening dose of sedating antihistamine. Chlorpheniramine, although sedating, is often worth a try. It's probably the best choice if you have to prescribe in pregnancy.

Topical aqueous cream with 1% menthol can provide some symptomatic relief.

Short courses of oral steroids are used in severe refractory urticaria but, although easy to initiate, can be difficult to withdraw.

Dr Thomas Poyner is a GP and honorary lecturer at the University of Durham

Competing interests None declared

Itch in the elderly

When an older person complains of itch, consider two points.

First, is it really a skin disease? When skin is scratched, rubbed and then secondarily infected it can be very difficult to determine what was going on before. Look between the shoulder blades, which may be the only place that is unscratched, and you might see an untouched plaque or patch.

Second, is there an underlying disease that could be causing this itch? About 30% of cases of itch in the elderly are caused by metabolic problems – low iron is common and thyroid and renal problems can present in this way, as can underlying malignancy. If the cause of itch is not apparent after taking a history, a thorough examination and a urinary dipstick, arrange what's called a pruritus screen: FBC, ferritin, LFTs, U&E and TFTs. If clinically indicated, a PSA can be added and a chest X-ray could be considered.

Whatever the cause, the mainstay of treatment is emollients and moderately potent or potent topical steroids to make the patient comfortable. Topicals need to be applied thickly and patients should be told to ignore possible advice from the pharmacist and use generous quantities of the topical steroids for two weeks.

For application of emollients to the back the use of a ‘Norfolk sausage' can be very helpful. This is a metre length of tubular bandage filled with emollient and used as you would use a towel for drying the back.

Another useful tip is to use menthol in a moisturiser to help cool and soothe the skin. There is now a propriety preparation called Dermacool, which is available in three strengths – 0.5%, 1.0% and 2.0% – and is available on prescription.

It is also worth considering if this could be scabies or a blistering problem.

Suspect scabies if there is a history of severe itch, especially at night or after a bath. Scabies burrows are not easy to see, though a good place to look is the lateral border of the feet. Also, papules around or on the areola in women and on the scrotum or shaft of the penis in men can be presumed to be scabies until proven otherwise. The clincher is when itch is also reported in a close relative.

Itch can also precede the development of either pemphigus or pemphigoid.

Other tips for patients are to avoid excessive bathing or very hot baths, to keep nails short, to avoid synthetic clothing and to use a soap substitute.

Sometimes all tests draw a blank as the itch can be a manifestation of anxiety, depression or loneliness. This is where knowing the social background of the patient is key. Daycare, outings and joining clubs can help more than medication.

Dr Elizabeth Ogden is associate specialist in dermatology in Hertfordshire

Competing interests None declared

Recurrent boils

A boil is a localised abscess, usually caused by a staphylococcal infection, centred on one or more hair follicles. Recurring boils are referred to as furunculosis.

If small they usually resolve over 10 days. Some develop points and discharge pus, at which time they cease to be so tender. The most common sites are the face, axillae, buttocks, arms and legs.

A carbuncle describes multiple abscesses occurring together. They are less common, but necks of men over 40 are more at risk.

The primary treatment for most boils is heat application, usually with hot soaks or hot packs. Most small boils drain on their own with soaking. On occasion, and especially with larger boils, the boil will need to be lanced. Oral antibiotics are only used to eliminate the infection of the surrounding skin. Topical antibiotics are not usually beneficial but antiseptics or topical antibiotics may be helpful for recurrent lesions.

For cellulitic and recurrent lesions, swabs should be taken from the lesion and the nose to check for resistance and possible nasal carriage. The pick-up rate will improve if the swab is first dipped into the charcoal transport medium.

If the condition requires oral antibiotics, use 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 three times daily for five to 10 days. In my experience, generic flucloxacillin syrup tastes unpleasant and is poorly tolerated by young children.

Further treatment using antiseptic washes such as chlorhexidine (Hibiscrub) or iodine (Betadine) for groins, axillae and the scalp for several weeks may be beneficial.

Consider the possibility of diabetes and, even more rarely, immune deficiency.

Dr Stephen Kownacki is a dermatology GPSI in Wellingborough.

Competing interests None declared

Scalp psoriasis

Patients present with scaly plaques often separated by normal areas of scalp. At times the scale can be very thick (pityriasis amiantacea). Scalp margins and the areas above the ears are frequently affected.

Shampoos should be used long-term, for example tar-based products like Capasal or non-tar preparations such as Dermax. These are useful when scale is present – patients should massage them into the scalp for five minutes to penetrate the scale and then wash them out.

Add in a topical application if shampoos are not effective on their own. Xamiol gel combines a topical steroid with a vitamin D analogue, and is better than either agent alone. It should be massaged into a dry scalp and washed out the following morning with shampoo. It can leave the scalp feeling greasy, so it is recommended that shampoo is massaged into the treated areas of the scalp and left on for about five minutes before being washed off.

There are a number of alternatives to Xamiol, such as Betacap scalp application. It is best to avoid alcohol-based solutions.

Some patients present with thick scale, which needs to be removed before using a topical treatment. Sebco scalp ointment is very effective – massage into affected areas of the scalp for five minutes and leave on for at least two hours, or overnight before washing out with shampoo. But some patients cannot tolerate the treatment for more than a few hours. It may need to be used for a few days until the scale diminishes and then used as needed as the scale builds up. For psoriasis of the hair margins consider 1% hydrocortisone ointment/Eumovate ointment.

Patients not responding adequately to treatment should be referred for consideration of other treatments, such as methotrexate or intralesional steroid injections. The latter is the less effective of the two.

Dr Tim Cunliffe is a GPSI in dermatology and skin surgery in Middlesborough

Competing interests None declared

The PCDS was formed in 1994 by a group of GP skin specialists who recognised the need for a forum for GPs in the UK and Ireland to exchange views on primary care dermatology, hone skills and develop clinical research.
The society also provides a voice and support forum for GPSIs in dermatology.
Our key objectives are:
• To provide an innovative forum for GPs and GPSIs with
a common interest in dermatology to exchange views and
ideas, encourage research, improve patient management and promote education both for the GP and the healthcare team.
• To encourage an interest in and provide an arena to promote and establish a clearer understanding of dermatology in primary care.
• To create wider awareness and appreciation of the benefits of shared care and to encourage strong links with specialist groups such as the British Association of Dermatologists (BAD)
The Society holds a series of educational meetings around the country from dermoscopy to surgical training to general dermatological subjects, all delivered by both GPs and consultant dermatologists.