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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

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