clinical features

treatment

therapeutic tips

Mild to moderate acne should be managed in primary care. Several different agents may need to be tried alone or in combination. Do not use combinations of agents with similar properties or actions e.g. topical plus systemic antibiotics. Inform patient that response is usually slow and allow at least 12 weeks before review.

Mild

Comedonal

Papular/Pustular

Moderate

Greater number or more extensive inflamed lesions.

Topical retinoid

• Adapalene - Differin

• Isotretinoin - Isotrex

Topical retinoid + Topical antimicrobial

• Benzoyl peroxide/Brevoxyl cream 4%

  Panoxyl gel 2.5, 5 & 10%

• Benzoyl peroxide/Erythromycin -

  Benzamycin

• Isotretinoin/Erythromycin-Isotrex

• Erythromycin/zinc-Zineryt

• Dalacin T lotion

Topical therapy as for mild plus oral antibiotics

1. Oxytetracycline 500mg bd

2. Erythromycin 500mg bd

3. Lymecycline 408mg od

Often cause irritation therefore reduce frequency or duration of application and build up to daily over 2-3 weeks. Advise additional non-comedogenic moisturiser.

Start at lowest strength to avoid irritation

Assess after 3 months.  If poor response, check compliance and treat as moderate acne

Assess after 3 months.  Good response, continue for 6 months.  If inadequate response, check compliance.

Milk, minerals and antacids can reduce absorption. Advise patients to take doses 2 hours apart.

Not contra-indicated in pregnancy

NB. Prone to cause gastro-intestinal upset.

Patients should be advised to avoid

direct sunlight and to wear a suitable sun block when going outside.

Moderate - Severe

Papules/pustules with deeper inflammation and some scarring.

Severe

Confluent or nodular lesions

usually with significant scarring.

Maintenance

Topical treatment as above

plus 2^nd line antibiotics

1.  Lymecycline 408 mg od or bd (unlicensed at higher dose)

2.  Minocycline 100 mg od or bd

3. Trimethoprim 200/300 mg bd

Commence systemic therapy and

refer immediately for systemic

isotretinoin treatment.

Topical retinoid therapy e.g.

• Adapalene (Differin)

Consider additional hormone therapy in women, e.g. Ethinyloestradiol/ Cyproterone acetate – (Dianette)

If inadequate response, refer to secondary care for Isotretinoin or second opinion.

clinical features

treatment

therapeutic tips

• Flushing often made worse by alcohol,

  spicy foods, hot drinks, temperature

  changes or emotion

• Telangectasia

• Papules on an erythematous

  background

• Pustules

• Facial disfigurement intermittent or

  permanent

• Rhinophyma

• Absence of comedones

Ocular Rosacea

Topical Treatment

Metronidazole 0.75%

1.  Rozex gel/cream bd

2.  Zyomet bd

Systemic Treatment – continue topical treatment

1. Oxytetracycline 500mg bd

2. Lymecycline 408mg od

3. Erythromycin 500mg bd

•Oxytetracycline 500 mg bd

Early treatment of rosacea is considered to be important as each exacerbation leads to further skin damage and increases the risk of more advanced disease.

Intermittent therapy can be considered for those with very occasional flare-ups but as detailed later frequency of recurrences can be reduced by maintenance therapy.

Mild to moderate cases or where systemic treatment is contraindicated.

May be introduced at the end of a course of oral antibiotics to allow their tapering and withdrawal.

Preparations with a cellulose base (e.g. Metrogel) tend to be less cosmetically acceptable to patients.

Avoid Topical Steroids.

Continue therapy for 12 weeks minimum

NB. Tetracyclines are contra-indicated in pregnancy, lactation and renal disease.

Not contra-indicated in pregnancy

NB. Prone to cause gastro-intestinal upset.

Advise patient on lid hygiene to manage blepharitis.

Surgical Treatment

(hospital only)

Patient Counselling

Electrocautery

Vascular Laser

Dermabrasion

Surgical shaving

Laser therapy

Useful in the treatment of telangectasia.

For the treatment of rhinophyma.

Patients can be advised on a number of issues: heat and cold, alcohol and cosmetics all of which can provoke flushing. Stress management may also be considered.

clinical features

treatment

therapeutic tips

A. Endogenous Eczema (eg. atopic)

B. Exogenous Eczema

   (i) Contact Irritant Eczema

Due to substances coming into       contact with the skin, usually repeatedly, causing damage and irritation.

       Substances such as

       • Water

       • Detergents

       • Shampoos

       • Household cleaning products

    (ii) Contact Allergic Dermatitis

Due to type IV allergic reaction to a substance the skin is in contact with.

All types of endogenous and exogenous eczema can present with either ‘wet’ (blistering and Weeping) or ‘dry’ (hyperkeratotic and fissured) eczema.

Avoidance of irritants

Soap substitutes such as Aqueous cream should be used. Gloves e.g. household PVC gloves should be used for wet work such as dishwashing. Gloves may also be required for dry work e.g. gardening.

Emollients

These should be applied frequently. There are a variety of emollients available, which vary in their degree of greasiness. Different patients will prefer different preparations.

Topical Steroids

The strength of topical steroid required varies from case to case. However, often it is necessary to use a potent topical steroid short term. Prescribe a cream formulation if ‘wet’ and ointment if ‘dry’.

Potassium permanganate

1:10000 soaks for fifteen minutes 2 to 3 times daily for acute wet eczema until blistering weeping has dried.  Make up a pale pink/rose colour using crystals tablets or liquid in warm water.  Ignore manufacturers instruction as too strong.

Antibiotics (topical/systemic)

Exclude secondary infection and

treat if appropriate.

Other skin conditions can mimic eczema and should be kept in mind. It is usually worth examining the patient’s skin all over as this can provide clues to other diagnoses e.g. plaques in extensor distribution in psoriasis, scabetic nodules.

If contact dermatitis is suspected a careful occupational and social history should be taken and the patient will require Patch Testing.

Patch Testing is only of value in patients with eczema. It is of no use with type 1 reactions (e.g. food allergies causing anaphylaxis or urticaria). In practice the cause of eczema is often multifactorial with external factors precipitating eczema in a constitutionally predisposed individual.

If eczema is present on only one hand a fungal infection needs to be excluded by taking skin scrapings for mycology.

clinical features

treatment

therapeutic tips

Explain the condition to the patient and reassure that it is benign and usually self-limiting.

Minimise:

• Overheating

• Stress

• Alcohol

• Caffeine

Review:

• Drug history

Both prescribed and non-prescribed,

 as many drugs have been reported to cause Urticaria such as penicillins, statins and NSAID’s in particular  aspirins.  Additionally opiates and NSAID’s may exacerbate existing urticaria.

Exclude:

• C1 Esterase Deficiency

   (If angioedema is the only sign)

• Insect bites

Antihistamines

There is little to choose between different antihistamines but individuals may vary in their response to different agents.

Sedative or non-sedative antihistamine choice depends on the need for sedation. Many antihistamines block histamine wheals and itching but do not

suppress the rash completely. Use

continuous medication if attacks

occur regularly. Use fast acting

antihistamines as required for sporadic attacks. If there is no response to one agent after six weeks, try a second and then a third agent.

In some cases of severe acute urticaria such as a Penicillin reaction, a short reducing course of Prednisolone starting at 30mgs – 40mgs od may be useful.

• Systemic steroids should never be  

   used in chronic urticaria.