Common Skin Problems When to refer

Dr Paul Farrant Consultant Dermatologist & Clinical Lead, Brighton & Sussex University Hospitals Trust

What is eczema /dermatitis?

• Inflammation of epidermis causing swelling between the cells (Spongiosis) • Barrier dysfunction • New genetic information points to defect in the filament aggregating protein (Filagrin)

Sub-Types of Eczema

• Infantile • Atopic • Seborrhoeic • Discoid • Pompholyx • Venous • Asteatotic • Lichen Simplex Chronicus / Nodular Prurigo • Irritant • Contact Infantile Eczema

• Presents 3-6 months old • Cheeks commonly involved • Can be very widespread • Allergy frequently suspected by parents • Limited role for allergy tests • Failure to thrive • Strong history

Infantile Eczema

• Majority of children grow out of eczema • 50% by 5 years and 90% by 10 years • Those with widespread disease + asthma + hayfever poorer prognosis • If continues into adolescence likely to have on & off through adult life Infantile Eczema

• Education is key • Address daily routine • Avoid soaps, hand wash & anything that foams • Emollients • Topical steroids • Immunomodulators for steroid phobic parents and sensitive sites • Water softeners? Discoid Eczema

• Discrete discoid lesions • Very itchy • Requires very potent topical steroids • If not sure a small biopsy can help confirm diagnosis • Consider mycology

Pompholyx

• Blistering beneath the skin on the palms • Very debilitating • Requires very potent topical steroids • PUVA • New retinoid - Alitretinoin

Contact Eczema • Type IV delayed hypersensitivity to specific antigen • Very specific • Preservatives • Fragrances • Plants • Metals • Rubber derivatives

Topical Steroids

• Need to use appropriate strength for site • Body - Potent / Super Potent • Flexures / Face - Mild / Moderate • Short blasts on intermittent basis • Combination steroids - good for sites prone to secondary infection Dermovate ointment

Betnovate Ointment

Elocon ointment

Betnovate RD ointment

Eumovate ointment

1% Hydrocorsone Immunomodulators

• Tacrolimus (ointment) / Pimecrolimus (cream) • Second line • Good for sensitive sites / steroid phobic • Preventative? Eczema – When to refer

• Diagnosc doubt • Poor response • Allergy suspected • Widespread – Phototherapy – Systemic therapy

Localised patchy hair loss Non-Scarring Alopecia Areata

Localised, non scarring hair loss

• Alopecia Areata – Autoimmune condition against hair follicle – Patchy hair loss – ! Hairs around edge – Can become widespread – totalis or universalis Localised, non-scarring hair loss

• Alopecia Areata • Treatments: – Poor prognosis if: – Can do nothing • Early onset (childhood) – Topical Steroids • Atopy – Intralesional Steroids • Family history – Systemic Steroids • Hair line affected • Other autoimmune – Contact conditions immunotherapy – Hair pieces

http://www.alopeciaonline.org.uk Psoriasis • 2-3 % UK populaon • Two peaks of incidence – 2nd/3rd Decade – 6th/7th Decade • M=F • Epidermal cell turnover accelerated 4 days cf 28 • Genec predisposion 35% Family history • 10-15% Joint involvement Psoriasis • Chronic Plaque Psoriasis • Guate • Scalp • Nail • Flexural • Palmar-Plantar pustulosis • Erythrodermic • Pustular Chronic Plaque Psoriasis Elbows Knees Buocks / Lower back

Thickened Well demarcated, sharp cut off Scaly

Koebner phenomen – comes up in areas of trauma

Can become quite widespread Relavely stable

Guate Rain Drop like Acute May follow sore throat (strep) Young adults

If acute swab throat or ASO tre and treat

Responds well to phototherapy

Differenal: Pityriasis Rosea Secondary Syphilis Drug Scalp 50-80 % paents will have scalp involvement

Very embarassing “The Brighton snow shower” Difficult to treat

Ask about dandruff Check hair line, behind the ears and throughout scalp

Be proacve as paents oen embarassed Contribung factors • Stress • Alcohol • Smoking • Drugs – β Blockers, Lithium • Post-pregnancy • Sunlight 10% Psoriasis CVS risk

• Co-morbidies – Obesity – ETOH – Smoking – Dyslipidaemia • Systemic Inflammatory condion – Increased CVS risk, independent of the above factors Topical treatments

• Combinaon Products – Topical steroids + Vit D – Dovobet – Topical steroids + Salicylic acid - Diprosalic – Topical steroids + anbiocs + anfungal – Trimovate

– Very effecve – All suscepble to steroid side effects, thinning and occasionally de-stabilisaon of psoriasis Topical Treatments • Immunomodulators – Tacrolimus – Pimecrolimus – Useful for facial psoriasis Beyond Topical Treatments Informing paents about management opons • Phototherapy • Systemic therapy • Biologics – “What about this injecon I read about in the Daily Mail?” Phototherapy

• When to refer? – Widespread psoriasis or mulple small areas where topical treatment difficult – 30% – Psoriasis on exposed sites (not flexural or scalp) – Fed up with topicals & need a break • When not to refer: – Busy professional or those who will struggle to get to appointments 3x weekly – Skin type 1 or previous skin cancer – Mild disease or severe disease with joint involvement Systemics Treatments • Acitren

• Ciclosporin

• Methotrexate • Dose: 2.5mg & 10mg, weekly • Interacons: Aspirin and NSAIDS Whats new in psoriasis? • The Biologics! – Targeted proteins, An-TNF, An-IL12 and Il 23 – Paents with moderate to severe psoriasis who fail on systemics & phototherapy – Increased chance of infecon – Cost £10K Psoriasis Management When to refer • Primary Care • Secondary Care – Soap avoidance – Diagnosc doubt – Emollients – Requiring phototherapy – Topical Treatments or nurse educaon – Requiring systemic therapy including Biologics Psoriasis affects 2-3% of populaon 80% Managed with topicals alone Psoriasis represents 5% of new referrals to secondary care New:FU 1:5.5

Epidermal vs Dermal

• Surface Change (Look and Feel) – Scale / Hyperkeratoc / Keran horn – Warty or textural change – Ulceraon

• Deep Palpaon – So vs Firm vs Hard – Fixed to overlying skin or mobile?

Epidermal Lesions

Seborrhoeic Keratoses Seborrhoeic Warts Basal Cell Papillomas

Warty / Rough Stuck on appearance Usually Brown Red or irritated lesions can confuse

Dermoscopy can be very useful Keran cysts Pseudofollicular openings Pearls & Pitfalls Pitfall The Thickened Keratosis

• Widespread AKs very common • Flat ones of little concern • Can come and go • Small Potential to change

• Beware of the thickened lesion • Thickened AKs are persistent and more likely to represent Squamous change 3rd April 2014

Pearls & Pitfalls AK New treatments 3rd pril 2014

Pearls & Pitfalls AKs – Topical treatments

● Solaraze – still commonest prescribed in primary care – least inflammatory ● Efudix – Commonest in secondary care ● Consider twice daily to non-face sites ● Imiquimod – alternative to efudix ● Actikerall – like efudix + salicylic acid – good for thickened lesions ● Picato – the new kid, good for rapid treatment ● 150 mcg x 3 tubes for face ● 500 mcg x 2 body Pearls & Pitfalls Pearl – The Pinch

Pearls & Pitfalls Pearl – The vessels and stretch

Lesions with blood vessels: Spider naevi Telangiectasia Haemangiomas Intradermal naevus BCCs

BCC vessels: Arborising Irregular Angulated “Wiggly” A Scab with a rolled edge and arborizing vessels = BCC Keratoacanthoma = Well Differenated Squamous Cell Carcinoma Come up very quickly – 2-3 weeks, plateau and then spontaneously regress or do they?

Superficial Spreading Malignant Melanoma

• Commonest type • Irregular pigmentation • Black • Blue/Grey • Milky Red • Multiple Shades of Brown

• Irregular edge • Asymmetrical • Enlarging

Nodular Melanoma

• Less common • Present as a nodule • Black, eroded and red with surrounding pigmentation • Rapid growing • Deeper • Poor prognosis If in doubt photo and see again Improving diagnosis

• Assess risk factors and stratify risk • Take time to examine the skin as a whole and not just the lesion • Take note of the ugly duckling • Use a bright light, or natural light, and magnifying glass • Touch • Photograph, measure and bring back at 3 months and 6 months • Dermoscopy?????? Needs training but I wouldn’t be without mine! Lesions – When to refer

• Aks, Bowen’s, Benign lesions should be managed in primary care

• Head and Neck BCCs should be referred for management by your local LSMDT (Soon, not TWW)

• Probable Melanoma and SCC – TWW Questions?

• Dr Paul Farrant • [email protected] • NHS secretary: Linda Gardiner • 01444 441881 ext 5998