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 be done
• Not needed in primary hyperhidrosis • Needed to ascertain underlying cause in secondary HH • Depends on clinical features but should be a minimum • Blood sugar/TFT Management-General
• Loose fitting clothing • Change clothing when damp • Absorbant insoles • Talc powder • Antiperspirant • Avoid caffeine/drugs
Management-topical
• Antiperspirant • Driclor-aluminium salts-cream/spray/roll on • Apply to dry skin after cool shower before bed • Wash off in morning • Use once/twice a week and build up to daily if necessary • Beware as irritant
Iontophoresis
• For palms, soles and armpits • Affected area is immersed in water or an electrolyte solution or gylcopyrronium solution • Gentle electric current is passed across the skin for 10-20 mins • Repeat daily for several weeks then less frequently • Not always effective
Oral Medications
• Oral anticholinergic drugs: • Propantheline, oxybutynin, glycopyrolate • Can cause blurred vision, dry mouth, constipation, dizziness, palpitaions. • Should not be taken in those with urinary retention/glaucoma • Beta blockers: • Block effects of anxiety
Botulinum Toxin
• Approved for axillary hyperhidrosis • Reduce/stop sweating for 3-6 months • Used off license for localised hyperhidrosis at other sites (palms)-effective.
Sympathectomy
• Division of spinal sympathetic nerves (chemical/surgical) • Reserved for the most severe cases/resistant to other treatments • Potential risks and complications • Hyperhidrosis can recur in 15% • Accompanies with skin warmth and dryness • New onset of hyperhidrosis in other site in 50% • Horner syndrome, pneumonia, pneumothorax and persistent pain Outlook
• Primary hyperhidrosis tends to improve with age • Secondary hyperhidrosis depends on the cause Urticaria Dr Mohammad Ghazavi Dermatologist Urticaria
• Red • Non scaly • Mostly itchy, can be painful or asymptomatic • Lasts from 30 minutes to 36 hours • Acute in 20% and chronic in 0.5% of population • 45% of chronic form are autoimmune
Acute urticaria
• IgE related and not IgE related • Complement-mediated urticarias include viral and bacterial infections, serum sickness, and transfusion reactions. • Certain drugs (opioids, vecuronium, succinylcholine, vancomycin, and others) as well as radiocontrast agents cause urticaria due to mast cell degranulation through a non—IgE- mediated mechanism. • Urticaria from nonsteroidal anti-inflammatory drugs may be IgE-mediated or due to mast cell degranulation, and there may be significant cross-reactivity among the nonsteroidal anti-inflammatory drugs (NSAIDs) in causing urticaria and anaphylaxis
Acute urticaria
• Recent illness • Medication use • IV radiocontrast media • Travel • Foods • New perfumes, hair dyes, detergents, lotions, creams, or clothes • Exposure to new pets (dander), dust, mold, chemicals, or plants • Pregnancy (usually occurs in last trimester and typically resolves spontaneously soon after delivery)
• Contact with nickel, rubber, latex, industrial chemicals, and nail polish • Sun or cold exposure • Exercise • Alcohol Chronic urticaria
• Autoimmune disorders (SLE, rheumatoid arthritis, polymyositis, thyroid autoimmunity, and other connective tissue diseases); probably up to 50% of chronic urticaria is autoimmune • Cholinergic urticaria induced by emotional stress, heat, or exercise; examine for other signs of cholinergic stimulation including lacrimation, salivation, and diarrhea • Chronic medical illness, such as hyperthyroidism, amyloidosis, polycythemia vera, malignant neoplasms, lupus, lymphoma, and many others • Cold urticaria, cryoglobulinemia, cryofibrinogenemia, or syphilis • Mastocytosis • Inherited autoinflammatory syndromes • The etiology of chronic urticaria is undetermined in at least 80-90% of patients. Recurrent urticaria
• Sun exposure -solar urticaria, occurring only on skin exposed to the sun[29] • Exercise (cholinergic urticaria) • Emotional or physical stress • Water (aquagenic urticaria) Urticaria work up
• Acute urticaria: laboratory studies generally are not indicated. The patient's history and physical examination should direct any diagnostic studies
• Chronic or recurrent urticaria: basic laboratory studies prompted by signs and symptoms but may include a CBC, erythrocyte sedimentation rate, TSH, and an ANA looking for possible causes of the urticaria
Cancerous Lesions Dr Anand Patel Dermatologist
Pre-cancerous lesions • Actinic Keratoses • Bowen’s disease (intra-epidermal carcinoma) • Superficial BCC • Lentigo Maligna
Bowen’s Disease BCC Management
• 5 Fluoro-uracil • Imiquimod • PDT • Cryotherapy • Surgery- C&C or excision • Watch and wait LM Management
• Excision with conventional 5mm margin • Staged excision-’Square technique’ • Imiquimod-poor evidence Basal cell carcinoma • Nodular Basal cell carcinoma • Ulcerated Basal cell carcinoma • Pigmented basal cell carcinoma • Morphoeic basal cell carcinoma Nodular BCC
BCC left without treatment Ulcerated BCC Pigmented BCC Morphoeic BCC Morphoeic BCC Management
• Surgery • Mohs micrographic surgery • Radiotherapy • Chemotherapy-Vismodegib • Watch and wait/conservative Mohs surgery
Squamous cell carcinoma • Squamous cell carcinoma • (multiple histological subtypes-desmoplastic) • High risk factors • Keratoacanthoma
Keratoacanthoma Management
• Surgical excision • Radiotherapy • Watch and wait for KA
Risk factors • Poor differentiation • Size of lesion x> 2cm • Thickness of tumour >4mm • Immunosuppressed • Site of tumour-lip, ear • Vascular/peri-neural invasion
• Sub type-desmoplastic Malignant Melanoma • Lentigo Maligna melanoma • Superficial spreading melanoma • Nodular melanoma • Amelanotic melanoma • Acral melanoma LMM SSMM Nodular MM Amelanocytic MM
• <> Acral MM
Management
• Excision biopsy • Wide local excision • Lymph node clearance • Chemotherapy for advanced MM-Ipilimumab Surgical margins
Breslow Thickness Excisions margins
<1mm 1cm
1-2mm 1-2cm
2-4mm 2-3cm
>4mm 3cm Other skin cancers • Merkel cell cancer • Angiosarcoma • Dermatofibroma sarcoma protuberans • Cutaneous T-Cell Lymphoma
MCC Angiosarcoma DFSP Management
• Mohs Micrographic surgery • Radiotherapy • Wide local excision
Mycosis fungoides
• Subset of cutaneous T cell lymphoma • Patch, plaque and tumour stages • May look like dermatitis or psoriasis • Protracted clinical course • Treatment depends on stage • topical steroid • Phototherapy-PUVA/TLO1 • Superficial radiotherapy
• Chemotherapy-Bexarotene, MTX, extracorporeal photopheresis.
Contact Dermatitis
Dr Anand Patel Dermatologist infection infection endogenous
atopic
allergic irritant
infection Irritant contact dermatitis
• Skin damaged directly by the irritant • Soaps, detergents, water, solvents, dry atmosphere etc – depends upon degree of exposure • Very, very common • 10 % of the population suffer from hand dermatitis • Treated with emollients/moisturisers and exposure reduction Stratum Corneum Barrier Function
Epidermis
Dermis Threshold for ICD
Dermatitis present Impairment (log (log scale) Impairment
Subclinical dermatitis
Time
A series of cumulative irritant episodes of vary degree of severity leading eventually to dermatitis. Often the patient does not link the weaker exposures with the dermatitis.
What Is Diagnostic Patch Testing?
• To diagnose allergic contact dermatitis not irritant contact dermatitis British Standard Series 1-7
DICHROMATE Leather, cement etc 3.0
NEOMYCIN Topical antibiotic 4.8
THIURAM MIX Rubber additive 5.0
Paraphenyldiamine Permanent hair dye 3.4
COBALT Metal 6.7
CAINE MIX Local anaesthetic 1.2
FORMALDEHYDE Biocide 2.6 British Standard Series 8-14
ROSIN Colophony, resin from spruce trees 5.9
QUINOLINE MIX Antiseptic 1.2
BALSAM OF PERU Fragrance 8.2
Isopropyl-phenyl-paraphenylenediamine Industrial rubber additive 0.4
WOOL ALCOHOLS Lanolin 4.8
MERCAPTO MIX Rubber additive 1.2
EPOXY RESIN Two part adhesive 1.4 British Standard Series 15-21
PARABEN MIX Preservative 1.1
Paratertiarybutyl Phenol Formaldehyde Resin Adhesives 1.2
FRAGRANCE MIX Fragrance 12.4
QUATERNIUM-15 Biocide 1.7
NICKEL Metal 19.5
Methylchloroiso thiazolinone + Methylisothiazolinone Biocide 2.1
Mercaptobenzothiazole Rubber additive 1.0 British Standard Series 22-28
PRIMIN Primula 0.6
SESQUITERPENE LACTONE MIX Compositae plant allergy 1.6
CHLOROCRESOL Preservative 0.5
2-BROMO-2-NITROPROPANE-1,3-DIOL Biocide 1.1
CETEARYL ALCOHOL Whitening agent/emulsifer 1.3
FUCIDIC ACID Antibiotic 0.4
TIXOCORTOL PIVALATE Hydrocortisone allergy 2.0 British Standard Series 28-35
BUDESONIDE Steroid 1.0
IMIDAZOLIDINYL UREA Biocide 1.2
DIAZOLIDINYL UREA Biocide 1.3
METHYLDIBROMO GLUTARONITRILE Biocide 4.1
ETHYLENEDIAMINE Stabiliser/emulsifier 2.2
PCMX Antiseptic in Dettol 0.6
CARBA MIX Rubber additive 3.7
Specialised Series
• cosmetic/facial • shoe • medicament • textile colours & finishes • steroid • meth(acrylate) • hairdressing • photographic chemicals • dental • isocyanates • oil & cooling fluid
• glues & plastics
ICDRG Grading System
?+ = doubtful reaction; faint erythema only + = weak positive reaction; erythema, infiltration, possibly papules ++ = strong positive reaction; erythema, infiltration, papules, vesicles +++ = extreme positive reaction; intense erythema and infiltration and coalescing vesicles or a bulla IR = irritant reaction NT = Not tested
Relevance (COADEX)
Current relevance Old or past relevance Actively sensitised Do not know the relevance Exposed but no dermatitis Cross reaction
Indications for Patch Testing
• Hand eczema • Treatment resistant eczema • Stasis eczema • Occupational contact dermatitis Patch test Database 2004.mdb Disorders of pigmentation Dr Mohammad Ghazavi Dermatologist Hypopigmentation
Vitiligo
• Well defined with normal surface • 0.3-0.5% of population • Segmental, acro-facial, localised, mix • Any age, any skin type • Usually asymptomatic • Other autoimmune conditions • No preceding rash
Pityriasis versicolour
• Well defined patches/ macules • Upper torso • Might be itchy/ scaly
Post inflammatory hypopigmentation
• More in darker colour skin • Preceding rash • Ill defined, irregular border • Anywhere, any age • Can be scaly
Pityriasis alba
• Darker skin colour • Children • Symmetric • Mostly on face • Can be scaly/ slightly itchy
• Ill defined
Hyperpigmentation
Post inflammatory hyperpigmentation
• More in darker skin colour • Irregular border • Preceding rash (eczema, psoriasis, lichen planus…)
LPP
• Grey brown pigmentation • On sun exposed area (face, neck, flexures) • Darker skin colour • Can be itchy
Melasma
• Female (rare in male) • Face (forehead, cheeks, chin) • Not scaly • Irregular border • Link to pregnancy, OCP…
Ashy dermatosis (Erythema Dyschromicum Perstans)
• Rare condition • Ashy grey-blue pigmentation • First few decades of life • Non exposed area • Varying size coalescing macules
• With or without an erythematous rim
Teledermatology Dr Amir Ghazavi Teledermatology What is Teledermatology?
Teledermatology is a subspecialty in the medical field of dermatology and probably one of the most common applications of telemedicine and e- health. Generic Process When a GP sees a skin complaint/lesion which they are unsure about, instead of referring the patient in, they take a series of photos. This is then sent to a dermatologist to interpret. The dermatologists replies with the diagnosis and course of action for the GP/patient.
Teledermatology at Circle Nottingham Background
• Oct/Nov 2013 started taking to Nottingham City CCG about a pilot of Teledermatology.
• The CCG looked at a number of ways of doing this, including using the Mole Clinic.
• However they ideally wanted locum Dermatologists to interpret the photos.
• We considered a number of different ways of facilitating the process, but wanted something which the GPs were already comfortable using, therefore making the process as simple as possible.
• Choose and Book seemed to be the simplest way of the GPs referring in for this service, as both the GPs and ourselves are confident with this system.
• So far, we have tested the process both live in clinic and via Choose and Book with test patients. A number of hiccups have been ironed out. Teledermatology at Circle Nottingham Next steps
The process is designed to be as simple as possible. Our process The GP sees a patient and decides that advice via Teledermatology is suitable option. Photos are taken, (advice on how to take the photos will be available via Youtube or similar). Patient is referred in via Choose and Book and an appointment is created in Proxima. The photographs are transferred from Choose and Book into the portal and the referral accepted on Choose and Book.
The Portal – Select patient The Portal – Doctor review The Portal – Doctors findings The Portal – Report The Portal – Letter Any questions? Thank you.