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Home , Calcipotriol, Psoriasis

Acne, Eczema and

Dr Rebecca Clapham Aims

• Classification of severity • Management in primary care – tips and tricks • When to refer

• Any other aspects you may want to cover?

• First important aspect is to assess severity and type of lesions as this alters management

Acne - Aetiology

• 1. Androgen-induced seborrhoea (excess grease) • 2. Comedone formation – abnormal proliferation of ductal • 3. Colonisation pilosebaceous duct with Propionibacterium acnes (P.acnes) – esp inflammatory lesions • 4. – lymphocyte response to comedones and P. acnes Factors that influence acne

• Hormonal – 70% females acne worse few days prior to period – PCOS • UV Light – can benefit acne • Stress – evidence weak, limited data – Acne excoriee – habitually scratching the spots • Diet – Evidence weak – People report improvement with low-glycaemic index diet • Cosmetics – Oil-based cosmetics • – Topical steroids, anabolic steroids, , , iodides (homeopathic) Skin assessment

• Comedones – Blackheads and whiteheads • Inflammed lesions – , pustules, nodules • Scarring – atrophic/ice pick or hypertrophic • Pigmentation • Seborrhoea (greasy skin)

Comedones

Blackheads Whiteheads • Open comedones • Closed comedones Inflammatory lesions

Papules/pustules Nodules

Scarring

Ice-pick Atrophic scarring Acne Grading

• Grade 1 (mild) – a few whiteheads/blackheads with just a few papules and pustules • Grade 2 (moderate)- Comedones with multiple papules and pustules. Mainly face. • Grade 3 (moderately severe) – Large number of papules and pustules and occasional inflammed nodule. May affect back and chest affected. • Grade 4 (severe) – Large number of large painful pustules and nodules

Mild

Moderate

Severe Treatment 1

Comedonal Acne Inflammatory Acne (mild/mod) • 1st Line • Use combination treatment ideally with BPO (reduces – Topical bacterial resistance) with • Adapalene (Differin) either a topical retinoid or abx: • Adapalene with benzoyl • 1st Line peroxide(BPO) 2.5% (Epiduo) – Adapalene +BPO (Epiduo gel) • Isotretinoin (Isotrex) • 2nd Line • 2nd Line – Clindamycin+BPO (Duac) • Others – Azelaic acid – Clindamycin+ (Treclin gel) BPO and topical dry the – Erythromycin combinations skin, local irritation and bleaching. (Aknemycin, Isotrexin) Retinoids in evening Treatment 2

• Not responding or more severe/widespread: • Oral abx + topical (preferably BPO to reduce resistance, if not Differin):

• 1st Line oral abx – Lymecycline 408mg OD • 2nd Line – Doxcycline 100mg OD (photosensitivity + teratogenicity) (tetracycline or oxytetracycline 500mg BD also options)

• Macrolides – Avoid due to high levels of P.acnes resistance – 1st line in or <12yrs – Adult dose - Erythro 500mg BD or Clarith 250mg BD • Trimethoprim – concerns re resistance • Minocycline – DO NOT USE due to risk of pigmentation • Review at 6-8 weeks, if no response within 3/12 try a 2nd abx. • If some response continue for up to 6 months Treatment 3

• COCP: – Consider adding in COCP as adjunctive treatment in women. – Dianette licensed for severe acne, refractory to prolonged oral abx but advice is to stop within 3-4 cycles after acne resolved! VTE risk 1.5-2x higher than levonorgestrel-containing pills. • Oral Isotretinoin: – Failure to 2 oral abx (3 month courses) – Scarring Any questions on Acne? Psoriasis

• 3% population • Large numbers of T-cells trigger release -> inflammation • Proliferative skin disorder – scaly plaques • FH present in 40-50% (up to 75% if onset <20yrs) • Lifetime risk: – 4% if no FH – 28% if 1 parent affected – 65% if both parents affected Triggers

• Stress • Alcohol • Smoking • Trauma (köebner phenomenon) • Infection (strep throat -> guttate) • Drugs (lithium and ) • Pregnancy (most likely to improve) • (usually helps)

Psoriatic Arthropathy CVD • Approx 30% with psoriasis • More relevant in severe have psoriatic arthropathy psoriasis • Strong link with disease • Target modifiable risk • Early intervention required factors – refer rheum • Assess every 5 years Morphology • Usually large or small plaque (90%) • Ruby-red • Well defined • Silvery surface scale • Auspitz sign – bleeding occurring if scales picked off

Severity Assessment Severity

• Mild <3% body surface area (BSA<10 and PASI<10 and DLQI<10)

• Moderate 3-10% body surface area

• Severe >10% body surface area (BSA>10, PASI>10 and DLQI>10)

Referral

• For diagnosis • Severe or extensive (e.g. >10%) • Not controlled with topicals • Acute guttate needing phototherapy • Nail disease – with functional or cosmetic impact • If having major impact on life • Refer rheum if psoriatic suspected

Treatments – General Measures

• Emollients • Formulations: – Widespread -> Cream/lotion/gel – /hairy areas -> Lotion/solution/gel – Thick adherent scale -> Ointment • Lifestyle measures: – Lipid modification – – Preventing T2DM – Preventing CVD – Alcohol advice – Smoking cessation – Increase physical activity

Preparations

• Vit D and analogues – • Dovonex (30g=£5.78) • Dovobet (calcipotriol with dipropionate) (30g=£19.84) – • Silkis (100g=£18.06) – • Curatoderm lotion (30ml=£12.73) • Curatoderm ointment (30g=£13.40) • Tars – Cocois (scalp ointment – 12% and 2%) – Exorex (skin or scalp lotion – coal tar 5% in emollient) – Psoriderm (skin or scalp cream – coal tar 6% and lecithin 0.4%) – Sebco (scalp ointment – coal tar 12% and salicyclic acid 2%) – Alphosyl-HC (Cream – coil tar 5%, allantoin 2% and 0.5%) – Other non-proprietary combinations e.g. zinc or calamine with coal – Bath preparations • – Dithrocream – dithranol 0.1% cream (50g =£3.77) – Micanol – dithranol 1% cream (50g=£16.18) – Psorin – dithranol 0.11%, coal tar 1%, salicylic acid 1.6% ointment (50g=£9.22) • Salicylic acid – Often in a combination with dithranol, tar or zinc NICE guidelines

• Potent OD and vit D or Vit D analogue OD (dovonex/calcipotriol) (applied one in the morning and one in the evening) for 4/52 (trunk or limb) • If does not result in clearance/satisfactory control after 8/52 offer Vit D or Vit D analogue alone BD • If this doesn’t result in clearance after 8-12/52 offer either: – Potent topical steroid BD for 4/52 – A coal tar prep OD or BD – If above cannot be used, can use combined calcipotriol monohydrate and betamethasone OD (dovobet) for 4/52 • Can use VERY potent steroids if: – specialist setting – other topicals failed – max 4/52 • If treatment resistant offer short-contact dithranol in specialist setting

Reality 1st Line

• Often start with combination therapy: • Dovobet (calcipotriol with betamethasone dipropionate) gel, ointment or spray foam (enstilar) • Give good amounts - 2x60g • Discontinue when skin smooth (even if pink/red) then ongoing treatment with a vit D analogue: – Calcipotriol (dovonex) – Calcitriol (silkis) – OR emollients • Dovobet gel for scalp • Calcitriol (Silkis) for face and flexures as calcipotriol (dovonex) can be irritant here • Tar – Exorex lotion for large thin plaques • De-scaling e.g. diprosalic may help initially if thick scale Treatments – 2nd Line

• If mod/severe or not responding to topicals refer for: – Phototherapy (Narrowband UVB/TL01) – Ciclosporin – acts quickly but not long-term – – can help arthropathy also – – very good for hand/foot psoriasis – ?Fumarates – Biologics

Guttate Psoriasis • Multiple small tear-drop lesions, mainly trunk and limbs • 7-10 days after strep throat • Children/young adults • Good chance of spontaneous resolution in 2-4/12 in 60% • 1/3 don’t have a FH and don’t go on to develop • Emollients psoriasis as an adult • Exorex lotion • Use of abx to treat • Alphosyl-HC underlying throat infection • Phototherapy if is controversial widespread(>10%)/unresponsive Palmoplantar Psoriasis

Hyperkeratotic Palmoplantar pustulosis • Thick scale • and yellow pustules, that become brown macules Palmoplantar Psoriasis

Hyperkeratotic Palmoplantar pustulosis • Emollients • Potent topical steroids • If scale – salicylic acid • Betnovate 0.1% or • Erythema – diprosalic Dermovate – consider • Under occlusion clingfilm for occlusion • • Consider patch testing as Consider referral for often degree or irritant phototherapy or systemics contact • Acitretin (Neotigason) or alitretinoin (Toctino) Any questions on psoriasis? Eczema

• 15-20% school children • 2-10% adults • If it does not very unlikely to be eczema • a common differential • Atopic eczema if itchy skin plus 3 or more: – Past involvement of skin creases – PMH or FH (immediate) of asthma or HF – Tendency to generally dry skin – Flexural eczema – Onset<2yrs

General Principles

• Avoid extremes in temp, irritating clothing, soaps and detergents, keep nails short • Avoid irritants • Need 3 aspects: – Topical emollient – Bath additive/oil – Soap substitute • Liberal use of emollients – 3-4x a day best when skin moist (600g a week adult, 250g a week child) ratio 10:1 emollient:steroid. • Apply in direction of hair growth • Paraffin based can be flammable. • Food allergy rarely the cause but could involve dietician • Do not prescribe aqueous cream as leave-on emollient or soap substitute First Line

• First line: – Simple creams and ointments – Topical

Emollients Topical Steroids • Few days to a week for acute eczema • 4-6 weeks to gain control of chronic eczema • Can use twice weekly for maintenance if mod/severe with frequent relapses • Ideally once daily

• Weaker on face and flexures • Very potent can be used in resistant severe hand and feet eczema

• Avoid emollients for 30mins after steroid application • SIGN (2011) did not specify order of application, nor do they mention timings. • The current BNF (2014) and BNFC (2014), NICE CKS (2013) continues to advise against mixing topical preparations and states “several minutes should elapse between applications of different preparations”. • The PCDS & BAD (2014) now tell patients to let the moisturiser dry for 20 minutes before applying steroid.

• Side-efffects: – Thinning of the skin (atrophy) – Skin thickening (lichenification) – (striae) – Darkening of the skin

Fingertip Unit 2nd Line

• Second line : – Ensure enough emollients used – “complex emollients” - Humectant ( or glycerol) emollients or additional ingredients – Topical inhibitors (mod/sev)

Emollients – added ingredients

• Some emollients contain added ingredients: – – Humectants (propylene glycol, lactic acid, urea and glycerol) draw water into the . These only need to be applied every 6–8 hours. – Anti-itch ingredients are found in a couple of creams in the form of lauromacrogols, a local anaestheic which helps to relieve itch. – are found in some leave-on creams and lotions. They may re-establish the balance of fats necessary for the appropriate functioning of the skin barrier. – Oatmeal is found in one cream and lotion. It has anti-itch properties

Topical Calcineurin Inhibitors

• If intolerant or failed with steroids or risk of skin atrophy – not first line • Apply twice daily or twice weekly for prevention • Transient burning sensation – build up, start with small areas. • Long-term effects unknown • Can get flushing if drink alcohol • (Elidel) – licenced mild/mod eczema, short-term use or intermittent to prevent flares. – Chose over protopic if younger • (Protopic) 0.03% (weaker) and 0.1% (stronger) – for mod/severe eczema – Greasier, stronger but doesn’t penetrate as deeply – 0.1% licenced for >16yrs – 0.03% licenced >2yrs • http://www.bad.org.uk/shared/get-file.ashx?id=155&itemtype=document

TCS = Topical TCI = Topical calcineurin inhibitor 3rd Line

• Phototherapy • Immunosuppresives

• Other treatments: – Antihistamines – sedating to reduce itch-scratch – Bacterial infections – if crusting, weeping, pustulation, or sudden worsening – 7 day fluclox or erythro. Swab if not responding.

Referral

• If uncertain diagnosis • Severe eczema herpeticum • Severe/not responding/excessive steroids • Infected and not responding to abx + topical steroids • Psychosocial problems – sleeplessness, school absence • Bandaging techniques required • suspected – patch testing • Dietary factors suspected (rare) Any questions on Eczema?

Thank you!