Acne, Eczema and Psoriasis

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?

Acne

• 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 keratinocytes

• 3. Colonisation pilosebaceous duct with Propionibacterium acnes (P.acnes) – esp inflammatory lesions

• 4. Inflammation – 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

• Drugs – Topical steroids, anabolic steroids, lithium, ciclosporin, iodides (homeopathic)

Skin assessment

• Comedones – Blackheads and whiteheads

• Inflammed lesions – Papules, pustules, nodules

• Scarring – atrophic/ice pick scar or hypertrophic

• Pigmentation

• Seborrhoea (greasy skin)

Comedones

Blackheads

• Open comedones

Whiteheads

• Closed comedones

Inflammatory lesions

Papules/pustules Nodules

Scarring

Ice-pick scars 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

• 1st Line – Topical retinoid

• Adapalene (Differin)

• Adapalene with benzoyl peroxide(BPO) 2.5% (Epiduo)

• Isotretinoin (Isotrex)

• 2nd Line – Azelaic acid

Inflammatory Acne (mild/mod)

• Use combination treatment ideally with BPO (reduces bacterial resistance) with either a topical retinoid or abx:

• 1st Line – Adapalene +BPO (Epiduo gel)

• 2nd Line – Clindamycin+BPO (Duac)

• Others – Clindamycin+tretinoin (Treclin

gel) – Erythromycin combinations

(Aknemycin, Isotrexin) BPO and topical retinoids dry the skin, local irritation and bleaching. 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 pregnancy 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 cytokines -> 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 hydroxychloroquine)

• Pregnancy (most likely to improve)

• Sunlight (usually helps)

Comorbidities

Psoriatic Arthropathy

• Approx 30% with psoriasis have psoriatic arthropathy

• Strong link with nail disease

• Early intervention required – refer rheum

CVD

• More relevant in severe psoriasis

• Target modifiable risk factors

• 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 arthritis suspected

Treatments – General Measures

• Emollients • Formulations:

– Widespread -> Cream/lotion/gel – Scalp/hairy areas -> Lotion/solution/gel – Thick adherent scale -> Ointment

• Lifestyle measures: – Lipid modification – Obesity – Preventing T2DM – Preventing CVD – Alcohol advice – Smoking cessation – Increase physical activity

Preparations

• Vit D and analogues – Calcipotriol

• Dovonex (30g=£5.78) • Dovobet (calcipotriol with betamethasone dipropionate) (30g=£19.84)

– Calcitriol • Silkis (100g=£18.06)

– Tacalcitol • Curatoderm lotion (30ml=£12.73) • Curatoderm ointment (30g=£13.40)

• Tars – Cocois (scalp ointment – coal tar 12% and salicylic acid 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 hydrocortisone 0.5%) – Other non-proprietary combinations e.g. zinc or calamine with coal – Bath preparations

• Dithranol – 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 topical steroid 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

– Methotrexate – can help arthropathy also

– Acitretin – 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 psoriasis as an adult

• Use of abx to treat underlying throat infection is controversial

• Emollients • Exorex lotion • Alphosyl-HC • Phototherapy if

widespread(>10%)/unresponsive

Palmoplantar Psoriasis

Hyperkeratotic

• Thick scale

Palmoplantar pustulosis

• Erythema and yellow pustules, that become brown macules

Palmoplantar Psoriasis

Hyperkeratotic

• Emollients

• If scale – salicylic acid

• Erythema – diprosalic

• Under occlusion

• Consider patch testing as often degree or irritant contact dermatitis

• Acitretin (Neotigason) or alitretinoin (Toctino)

Palmoplantar pustulosis

• Potent topical steroids

• Betnovate 0.1% or Dermovate – consider clingfilm for occlusion

• Consider referral for phototherapy or systemics

Any questions on psoriasis?

Eczema

• 15-20% school children • 2-10% adults • If it does not itch very unlikely to be eczema • Scabies 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 corticosteroids

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) – Stretch marks (striae) – Darkening of the skin

Fingertip Unit

2nd Line

• Second line :

– Ensure enough emollients used

– “complex emollients” - Humectant (urea or glycerol) emollients or additional ingredients

– Topical calcineurin inhibitors (mod/sev)

Emollients – added ingredients

• Some emollients contain added ingredients: – Antimicrobials – Humectants (propylene glycol, lactic acid, urea and

glycerol) draw water into the epidermis. 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.

– Ceramides 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 • Pimecrolimus (Elidel)

– licenced mild/mod eczema, short-term use or intermittent to prevent flares. – Chose over protopic if younger

• Tacrolimus (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 corticosteroid TCI = Topical calcineurin inhibitor

3rd Line

• Phototherapy

• Immunosuppresives

• Other treatments:

– Antihistamines – sedating to reduce itch-scratch

– Bacterial infections – if crusting, weeping, pustulation, cellulitis 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 • Contact dermatitis suspected – patch testing • Dietary factors suspected (rare)

Any questions on Eczema?

Thank you!