Common Dermatological Conditions in Adults in Ghana

Margaret Lartey FWACP

Outline

• Introduction

• Two Common disorders

• Discussion

Case 1

• 34 yr old female

• C/o pruritus of 2 months duration

• First episode

• Seen GP

• Prescribed ceterizine for 2 weeks

• Completed tablets but still itching

• Referred dermatologist

Pruritus

• Epidemiology

• Very common

• Pathophysiology

• Complex, interplay of peripheral and central receptors and many chemical agents

• Pattern of itching

• Localised or generalised but ear canals, eyelids, nostrils perianal and genital areas more susceptible to pruritus

Aetiology

• Dermatological causes – Eczema – Lichen planus – Scabies – Pediculosis – Insect bites – Cutaneous Larva Migrans – Urticaria – Drug eruptions – Dermatitis herpetiformis – Bullous pemphigoid – Prurigo – + localized ones like pruritus vulvae or ani

• Non dermatological causes – Drugs-opiates and derivatives, chloroquine

– Haem-primary polycythaemia, IDA

– Hepatic-extra hepatic obstruction, cholestasis of pregnancy, drugs, PBC

– Renal disease-CKD

– Malignancy-lymphomas, leukaemia

– Endocrine-hyper/hypothyroidism

– psychological

• History

• Basic Minimum

– Duration

– Site

– With or without rash

– Aggravating/releasing factors

• Physical examination

• Examination in well lit room

• Good exposure

• General exam if indicated

• Systemic examination

• Normal skin-dermographism

Laboratory investigations

• Battery of Investigations??

• Focused investigations??

Treatment Modalities

• Not all pruritus responds to antihistamines which are very useful in urticatia and histamine mediated pruritus

• Topical/Systemic steriods have limited value and should be used when indicated.

• Topical antihistamines • Lotions containing phenol, menthol or camphor may

be effective • Amitriptyline, doxepin • Naloxone • Cholestyramine

Urticaria

• Definition-Transient, itchy, (red) swellings of the skin and mucous membranes secondary to the release of histamine and other vasoactive agents from granules within mast cells

• Histology-vasodilatation, dermal odema with mild perivascular infiltrates

• Clinical Features-itchy, varying colour and sizes of wheals not lasting more than few hours, occurring in crops and worse in areas of pressure.

Causes

• Anything under the sun!!!

Types

• Acute<2months, chronic>2 months

• Physical Urticarias

– Pressure

– Solar, cold, heat

– Aquagenic

– Cholinergic-very tiny wheals sometimes difficult to see in response to exercise, emotion sweating and hot food. Common in young people

Diagnosis

• If wheals are not present can be demonstrated by the presence of dermographism

Laboratory investigations

• Most often non rewarding and DEFINITELY NOT STOOL MICROSCOPY (Routine Examination)

Management

• Prophylactic Antihistamines

• Must be taken regularly and NOT prn or when the rash appears

• Doses can be stepped up

• After urticaria has cleared COMPLETELY tail off antihistamines watching carefully for recurrence.

Acne Vulgaris

• Epidemiology • common inflammatory skin disorder commonly

occurring during adolescence. • It is a disorder of the pilo-sebaceous gland (oil

glands in the skin). • It can range from very mild to very severe forms • common in adolescents and teenagers due the

following reasons: – There are higher levels of sex hormones at puberty than in younger

children. – These hormones stimulate oil glands in the skin to enlarge.

Pathophysiology

• Androgenic stimulation of sebacceous glands

• Impaction and distension of the follicles with tightly packed horny cells

• Proliferation of propionibacterium acnes which metabolize sebum to FFA, also staph epidermidis

• Disruption or rupture of follicle into dermis releasing FFA and other irritants resulting in inflammation

• Can occur in anybody, neonates to adults

• Scarring disease- atrophic, hypertrophic and keloids

• Primary and secondary forms

• Can be exacerbated by steroids (both topical and systemic)

AGGRAVATING FACTORS

• Genetic factors • Hormonal factors (higher levels of androgenic

hormones) • Diseases of the ovaries (Polycystic ovaries) • Pregnancy • Psychological stress and depression • Certain medications e.g. steriods-creams and tablets • Cosmetics application especially certain moisturizers,

foundation and pomades (watch out for lanolin, petrolatum, vegetable oils, butyl stearate, lauryl alcohol and oleic acid)

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Acne myths

• Diet- nuts, chocolate

• If you did not have acne as an adolescent you cannot have acne as an adult

• Acne and pimples are different diseases

• Acne does not require treatment

• Washing your face often and with cleansers will get rid of acne

Physical examination

• Lesions commonly of face, upper chest(anterior and posterior) and upper arms

• Closed and open comedomes, papules, pustules, nodules, cysts, scars, hyper and hypo pigmentary changes

Laboratory diagnosis

• If history suggestive of secondary acne

Principles of Treatment

• Treatment depends on severity

• Multi drug treatment

• Patient education and buy in

• Treatment is long term

• Plan for complications-scars and pigmentary changes

Treatment Options

• Long term antibiotics-topical and systemic

• Salycilic acid and azelaic acids-topical

• Hormonal Therapy- oestrogen therapy and anti androgens ((OCP) and high dose oestrogen

• Benzoyl peroxide

• Retinoids- topical

• Steriods- intralesional and acne fulminans

• Systemic retinoids- ISOTRETINION

Acknowledgements

• Fiesta Organisers

• Dr. S B Ofori for some of photographs

• Thank you