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Dermatology Protected Learning Time Dr Amir Ghazavi & Dr Anand Patel 02 & 09 December 2014 Agenda

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Dermatology Protected Learning Time Dr Amir Ghazavi & Dr Anand Patel 02 & 09 December 2014 Agenda Dermatology Protected Learning Time Dr Amir Ghazavi & Dr Anand Patel 02 & 09 December 2014 Agenda • 12.30pm-1.30pm Registration • 1.30pm-1.40pm City Care - Urgent Care Service - Steve Upton • 1.40pm-1.50pm Actinic Keratosis Guidelines - Dr Anand Patel • 1.50pm-2.05pm Hidradenitis Suppurativa - Dr Amir Ghazavi • 2.05pm-2.15pm Hyperhidrosis - Dr Anand Patel • 2.15pm-2.30pm Urticaria - Dr Amir Ghazavi • 2.30pm-2.45pm Skin Cancer - Dr Anand Patel • 2.45pm-3.00pm Patch Testing - Dr Anand Patel • 3.00pm-3.15pm Break • 3.15pm-3.50pm Pigmentation and Quiz - Dr Amir Ghazavi • 3.50pm-4.00pm Teledermatology - Dr Amir Ghazavi • 4.00pm Close City Care – Urgent Care Services Steve Upton Actinic Keratosis Guideline Dr Anand Patel Dermatologist Nottinghamshire Solar Keratosis Primary Care Treatment Pathway (Adapted from the Primary Care Dermatology Society Treatment Pathway) Early solar keratosis needs Single solar keratosis Crusted, indurated and inflamed lesion could turn out to no treatment consider cryotherapy be early SCC-urgent 2-week referral Lesion with rapid onset, indurated Palpable but not inflamed base, critical sites, indurated immunosuppressed patient or >1cm Does the patient want No treatment? Urgent 2-week referral Impalpable or barely palpable Yes Single lesion or Multiple lesions Hyperkeratotic lesion* *Actikerall® (See next page Offer topical treatment- 1st line - 5-Fluorouracil cream (Efudix®) (Amber 3 – GP can initiate in for instructions) line with this guideline) Apply once or twice daily for 3 to 4 weeks, depending on site. Counsel regarding skin reaction (give Eumovate® if symptomatic). Patient Information sheet (with photographs of reactions) available here 2nd line - Ingenol mebutate gel (Picato® ▼) (Amber 3 – GP can initiate in line with this guideline) For patients unable to tolerate/comply with Efudix • on face and scalp lesions, apply 150 micrograms/g gel once daily for 3 days Cryotherapy with • on trunk and extremities, apply 500 micrograms/g gel once daily for 2 days Patient Information liquid nitrogen sheet (with photographs of reactions) available here 1x15sec freeze 3rd line – imiquimod 3.75% cream (Zyclara ®) (Amber 3 – GP can initiate in line with this If not available thaw cycle. guideline) To be used if Efudix® and Picato® are not tolerated or used earlier if the lesions cover a Histofreezer® Not large area or if there is field change (refer to specialist if needed). Apply up to 2 sachets (250mg per recommended as sachet) once daily before bedtime to the affected treatment field (full face or balding scalp) for two no evidence. treatment cycles of 2 weeks each separated by a 2- week no-treatment cycle. Sun avoidance advice including sunscreen. Skin cancer info sheets Review 4-weeks after stopping treatment. If no response, review diagnosis +/- referral Dr A N Patel & Dr W Perkins, Dermatology Department, Nottingham University Hospitals NHS Trust (updated September 2014) ***The Medicines Management Teams can also provide copies of the patient information leaflet. Actinic/Solar Keratosis Epidemiology Chronic or repeated sun exposure is a major association >80% appear on the face, head or back of the hands, especially, but not exclusively, in those with fair skin. Caucasians previously living in hot climates or working outside are at highest risk. Prevention is better than cure (see national skin cancer prevention & sunscreen advice) Prevalence in UK (Merseyside) age>40 Skin cancer risk all Age>70 Actinic keratoses (AK) are a risk factor for skin cancer as they are very closely linked to sun exposure. Therefore patients with actinic keratoses should be educated in the signs of common males 15.4% 34.1% skin cancers and asked to present if any new/ different lesions develop. Less than 1 in 1000 actinic keratoses will transform into squamous cell carcinoma (SCC) in any one females 5.9% 18.1% year therefore, treatment is dependent on patient preference, symptoms and the need to clear the sun damaged area in order to be able to see if any more sinister lesions such as basal cell carcinoma (BCC) or SCC are developing. Progression of very early AK lesions and AK recurrence are reduced by daily use of an appropriate sunscreen (SPF factor 15+ or higher, available on prescription, annotate “ACBS”) if clinically indicated i.e. recurrent or multiple AK lesions. The treatment guideline can be followed again if new lesions develop. Diagnosis Red or white lesions with a gritty or sandpaper like texture on palpation but no induration at the base of the lesion, meaning there is epidermal thickening or dermal infiltration, both manifested as a thickened red base. Efudix® (5-Fluorouracil -Amber 2 – GP can initiate in line with this guideline) once or twice daily for 3 to 4 weeks, depending on site. Counsel regarding skin reaction (give Eumovate® if symptomatic). Give patient Information sheet (with photographs of reaction). http://www.nottspct.nhs.uk/images/stories/My_PCT/How_we_work/areaprescribing/solar%20keratosis%20- %20patient%20information%20leaflet.pdf Actikerall® (0.5% 5-Fluorouracil. 10% Salicylic acid ): Due to the unavailability of cryotherapy in primary care as well as the inefficacy of Effudix® on hyperkeratotic actinic keratoses, Aktikerall® provides an alternative treatment option with better results when used on thicker lesions in primary care and will save on secondary care referrals. Use once daily for 6-12 weeks. Counsel regarding mild to moderate skin reaction. Picato® (Ingenol mebutate): Is a 2-3 day topical treatment for AK with background field change for an area of 25cm2 0.015% gel should be used on scalp and face lesions in a 25cm2 area for 3 consecutive days. 0.05% gel should be used for 2 consecutive days on the body. Counsel on moderate skin reaction. Zyclara® (3.75% Imiquimod): For the topical treatment of face and scalp AK with field change up to an area of 100cm2 . Treatment regime is a single application once a day for two weeks followed by a 2 week rest period and then a further two weeks active treatment. Fewer side effects seen than with 5% imiquimod cream. Bibliography Actinic Keratosis Primary Care Treatment Pathway published by Primary Care Dermatology Society (available from http://www.pcds.org.uk or NHS Evidence - National Library of Guidelines) Guidelines for the management of actinic keratoses. D. de Berker, J.M. McGregor and B.R. Hughes - on behalf of the British Association of Dermatologists Therapy Guidelines and Audit Subcommittee British Journal of Dermatology 2007 156, pp222–230 (Available from www.bad.org) NICE Guidance on Cancer Services. Improving outcomes for People with Skin Tumours including Melanoma. February 2006. Stockfleth E et al. Low-dose 5-fluorouracil in combination with salicylic acid as a new lesion directed option to treat topically actinic keratoses-histological and clinical study results. Br J Dermatol. 2011 Nov;165(5):1101-8. Authors Dr A N Patel & Dr W Perkins, Dermatology Department, Nottingham University Hospitals NHS Trust (updated September 2014) ***The Medicines Management Teams can also provide copies of the patient information leaflet. Hidradenitis Suppurativa Dr Mohammad Ghazavi Dermatologist Hidradentis Suppurativa • Prevalence of 1-4% • F/M: 2/1-5/1 • Rare onset before puberty and after menopause • Persistence into menopause not uncommon • Genitofemoral involvement more common in women Association • Genetic • Androgen effect • Obesity and current smoking • Common microorganisms: S aureus and coagulase negative staph. Diagnostic criteria • Active disease with 1 or more primary lesions in a designated site, plus a history of 3 or more discharging or painful lumps (not specified) in designated sites since age 10 years • Inactive disease with a history of 5 or more discharging or painful lumps (unspecified) in designated sites since age 10 years, in the absence of current primary lesions Questions to ask • Is there more than a single inflamed lesion? • Is the course chronic, with new and recurrent lesions? • Are the lesions bilateral? • Where are the lesions located primarily? Hurley staging • First stage: Solitary/multiple, isolated abscess formation without scarring or sinus tracts • Second stage: Recurrent abscesses, single/multiple widely separated lesions, with sinus tract formation and cicatrization • Third stage: Diffuse/broad involvement, with multiple interconnected sinus tracts/abscesses Hyperhidrosis Dr Anand Patel Dermatologist What is it? • Excessive and uncontrollable sweating • Sweat is produced by the eccrine sweat glands. These are distributed over the entire body but are most numerous on the palms and soles (with about 700 glands per square centimetre). Hyperhidrosis • Localised hyperhidrosis affects the armpits, palms, soles or face. • Generalised can affect the whole body Primary or Secondary • Primary • Secondary • Childhood/adolescence • Less common • Persist lifelong/improve with age • Unilateral or asymmetrical • Family history • Can occur at night or during sleep • Armpits, palms or soles symmetrically • Due to endocrine/neurological conditions • Reduces at night and stops when asleep Triggers • Hot weather • Exercise • Spicy food • Fever • Anxiety Causes of secondary localised • Stroke • Spinal nerve damage • Peripheral nerve damage • Surgical sympathectomy • Neuropathy • Brain tumour • Anxiety disorder Causes of secondary generalised • Obesity • Diabetes • Menopause • Overactive thyroid • Respiratory failure • Endocrine tumours • Parkinson’s disease • Drugs (caffeine, corticosteroids, TCA, SSRI, opiods) Tests that should
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