50
CHAPTER 11
Common skin conditions Dr Marjorie Ridley, MA, FRCP Dr Margaret Safranek, MB BS
SUMMARY Four common conditions: acne, psoriasis, eczema and urticaria are considered. Guidance is given on appropriate topical and systematic treatment for the different types and degrees of these conditions, with notes on management in general and criteria for referral to hospital outpatient departments. Where there are different types of the condition, with varying aetiology, for example in urticaria and eczema, management of the common types is outlined.
ACNE Acne is a rash primarily on face, chest and back characterized by combinations of pustules, papules, comedones and cysts.
Aetiology There is a suggestion that there is some defect of the pilosebaceous apparatus leading to excessive sebum secretion and damming back of the sebum. In addition, acne bacilli act on the sebum and irritant compounds lead to perpetuation of inflammation. Circulating androgens and/or increased local sensitivity are probably involved.
Age range Acne occurs mainly in the teens and twenties; however, it may be encountered in childhood and also in the thirties and forties. Differential diagnosis Rosacea occurs in older women (peaking in the thirties) and mainly affects the central part of the face with papules, pustules and flushing but no comedones. Assessment of problems Patients' views of their problem are perhaps as important as objective assessment of severity. A classification of mild/moderate/severe acne which is suitable for treatment in general practice is given below. Mild Mild acne is usually limited to small areas around the chin and cheeks with a small number of lesions. Local applications of drying and antiseptic lotions or gels like benzoyl peroxide in aqueous or alcoholic solutions may be sufficient, strengths varying from 2.5% to 10%. These may be bought over the counter and the patient may already
have tried them. Patients should be warned that some drying and reddening of the skin may be expected, but if excessive, applications should be reduced to once a day or less. If local applications are not sufficient, add an oral antibiotic; the cheapest is oxytetracycline 250 mg qid for 3-6 months. The patient should be warned to take pills on an empty stomach, to stop in the event of pregnancy (treatment can harm fetal teeth) and to persevere (no results can be expected for 4 to 6 weeks). Iron and milk can both hinder absorption. Further courses may be necessary if the patient relapses. If the patient is on oral contraceptives, one containing more androgenic progestagen like norgestrel or ethinyloestradiol diacetate could aggravate acne - it is best to change to one containing norethisterone or desogestrel. Moderate to severe Moderate to severe acne involves more widespread and marked non-inflamed lesions which often cause scarring. Local applications should be used as above. If comedones are preponderant, Retin-A gel may be the best choice since it modifies keratin production, but patients should be warned of possible photosensitivity. Local antibiotic lotions are claimed by manufacturers to work faster than systemic ones. They include clindamycin (Dalacin-T), tetracycline (Topicycline) and erythromycin (Stiemycin). They work out dearer than the cheaper oral generics but cheaper than minocycline and doxycycline except when the area of acne is very big. Topicycline is probably least effective. They are of benefit if patients are reluctant to take oral therapy. If oral oxytetracycline is ineffective, erythromycin 250 mg qid, or doxycycline 50 mg od, or minocycline 50 mg bd should be considered. The last is the most expensive - about £17 per month compared with about £1 for oxytetracycline. Minocycline can be taken with meals whereas oxytetracycline (and tetracycline) should be taken on an empty stomach. Minocycline can (rarely) cause pigmentation with prolonged administration. It does, however, have the advantage of a superior bacterial action leading to a reduced incidence of bacterial resistance compared with tetracycline (Eady et al., 1990). For women, Dianette should be considered, a contraceptive pill that combines 35 mcg oestrogen and 2 mg of the anti-androgen cyproterone acetate. Some women respond equally well to Minilyn, a (much cheaper) 50 mcg oestrogen pill but this is to be discontinued. Severe Severe acne should be treated as above, but if it is resistant or very widespread, a course of Roaccutane (isotretinoin, a Vitamin A derivative) should be considered. This can reduce sebum production and modify pilosebaceous blockage and
51
produce a long-term improvement after a few months. It is only available on hospital prescription and is teratogenic, so girls must be on effective contraception. It may affect lipid levels adversely, so these must be checked during and after treatment.
Future trends Roaccutane may be used more readily, its great efficacy making it potentially justifiable on both medical and financial grounds. When to refer Patients with severe or persistent acne resistant to treatment should be referred. In an older woman, acne, especially if combined with hirsutism, may be an indication of polycystic ovaries or a steroid-producing tumour and, even in the absence of menstrual irregularities, endocrinological investigations (sex hormone binding globulin, FH, LH, testosterone levels) and referral should be considered. Women on both oral contraception and oral antibiotics should be warned that, though direct interference with the oral contraception is extremely rare, diarrhoea associated with the tablets may lead to inactivation of the contraceptive.
Self-help measures Most patients think diet important and blame their acne on eating chocolate and chips. In fact, there is little to support this belief and they should be reassured. Heavy make-up and oils can exacerbate acne, and hair oils often used by Afro-Caribbeans can be a cause of acne confined to the forehead. Ordinary make-up, however, is safe, particularly if a range for greasy skins is chosen. Some people may find that sunshine makes their acne better, but this is by no means universal.
Audit 1. Repeat prescriptions for oral antibiotics in moderate to severe cases of acne could be monitored to check for patient compliance. Reference Eady E A, Cave J H, Holland K T et al. (1990) Superior antibacterial action and reduced incidence of bacterial resistance in minocycline compared with tetracycline-treated acne patients. British Joumal ofDennatology 122, 233-44.
Reading for patients Marks R (1984) Acne. Advice on Clearing Your Skin. Practical Health
Guide. London, Martin Dunitz.
PSORIASIS Psoriasis is a skin condition of unknown origin characterized by an accelerated turnover of skin cells and, though it is rarely combined with systemic symptoms, there is a hereditary component - around 50% of patients have a positive family history - and 1-2% of the UK population are affected.
Age of onset Psoriasis most commonly occurs in the third decade, but quite often in children and in the middle-aged or elderly. It varies widely in severity and clinical pattern, both in individual patients from time to time and between patients. Chronic plaque psoriasis Chronic plaque psoriasis affects especially the scalp, knees and elbows. Nail changes (pitting or loosening) are common. It comprises well demarcated bright red lesions with silvery scale. It is usually easy to recognize, though if it only affects the scalp it may be confused with seborrhoeic dermatitis, or if there are only one or two lesions in untypical areas it may resemble discoid eczema; but psoriasis is usually better defined and never moist. It may or may not itch. Guttate psoriasis Guttate psoriasis is a clinical variant of the psoriatic diathesis and may be associated with, or develop into, other forms of psoriasis. It is a widespread rash of small psoriatic lesions on trunk and proximal limbs. It is often precipitated by streptococcal infections and therefore has a relatively good prognosis, resolving at least partly in a few weeks. Differential diagnosis: pityriasis rosea, usually distinguished by 'firtree distribution' and herald patch, and rash of secondary syphilis (but this usually involves systemic upset).
Flexural psoriasis Flexural psoriasis affects axillae, groins, genitocrural and submammary areas. Scale is absent, and there are well demarcated bright pink lesions. Differential diagnosis: candida and tinea infections (if in doubt, microscopy or culture will help), seborrheic dermatitis, and banal intertrigo in relation to sweating and obesity.
Palmar and plantar pustulosis Palmar and plantar pustulosis involve confluent, localized sterile pustules on the palms and soles, or well defined scaly hyperkeratotic areas. Differential diagnosis: tinea and eczema. Psoriasis is often more clearly demarcated. In some patients psoriasis may on occasion become unstable and proceed to erythrodermic or generalized pustular psoriasis, with systemic upset.
Generalized pustular psoriasis Generalized pustular psoriasis may arise in 'ordinary psoriasis' or spontaneously. Precipitating factors include: drugs, pregnancy, excessive topical steroids and injudicious use of dithranol in unstable psoriasis.
Management Patients with psoriasis need long-term support, sympathy and practical help, for example with dressings.
52 Tar preparations
Used for many years, tar in a cream or soft white paraffin base can be applied to plaques in gradually increasing strengths of preparations and is usually effective. The disadvantages are that tar preparations are messy and smelly, stain skin and clothes, and irritate normal skin. Commercial preparations combining tars with hydrocortisone creams (Tarcortin, Carbo-cort, Alphosyl HC) are milder and may be more acceptable and effective for mild plaque and guttate psoriasis. Tar shampoos, such as Polytar, are helpful for scalp psoriasis.
Dithranol Dithranol, the most potent topical agent, and used traditionally in combination with Lassar's paste (zinc and salicylic acid), can, like tar, irritate and stain normal skin and intensive treatment is usually given on an inpatient basis in strengths of from 0.1 % to 1 or even 2%. But some patients can control their psoriasis with daily short contact therapy which involves applying gradually increasing strengths of dithranol cream for 30-60 minutes each night starting at 0.1%. This means that mess and staining are kept to a minimum. Some people find dithranol in a wax stick (Antraderm) easier to use (though more expensive). It can be prescribed in strengths of 0.5%, 1% or 2%. More acceptable dithranol preparations, for example Dithrocream, tend to be less effective than dithranol in Lassar's paste. Under supervision, steroid and dithranol mixtures can be effective.
Salictlic acid preparations Useful for hyperkeratotic plaques, topical treatments may contain salicylic acid alone or in combination with steroids (Diprosalic) or coal tar (Gelcosal). A keratolytic is particularly important in scalp psoriasis where scale is not easily shed. Cocois is a preparation containing tar and salicylic acid which may be more readily available than the traditional Ung. Cocois Co. Corticosteroids Mild corticosteroid creams and ointments are the treatment of choice for flexural psoriasis. Stronger steroid preparations may be very effective in chronic plaque psoriasis but run the risk of a rebound aggravation of the condition on stopping treatment, sometimes even precipitating severe pustular psoriasis. Make sure the patient understands that topical steroid preparations should be carefully applied to the lesions only.
Calcipotriol (Dovonex) This preparation is a vitamin D derivative, newly available and as yet very expensive. If used in the recommended way there appears to be no risk of inducing hypercalcaemia. It helps many patients with moderately severe, stable psoriasis; it is more cosmetically acceptable than dithranol and in the short term often more effective, though relapse appears to be more rapid when the treatment is discontinued. In a few patients it leads to buming and spreading of the lesions. It should be avoided in all patients on the face and in flexures.
UVB Sunny holidays or UVB help many but not all patients. UVB is best given in conjunction with tar and dithranol. Excessive exposure to sunlight may worsen psoriasis.
Infection In people whose psoriasis appears to be precipitated by infections, it is important to avoid re-infection. Occasionally, recurrent streptococcal tonsillitis may prove a problem, and tonsillectomy may be indicated.
When to refer Patients should be referred: 1. When they appear to be developing joint involvement (occurs in about 7% of cases). Referral here is most appropriate to a rheumatologist. 2. When local applications are not controlling the condition. 3. When there is rapid worsening with pustule formation.
Systemic treatments Systemic treatments, including PUVA, are best supervised by a dermatology department, at least initially. PUVA PUVA, which involves ultraviolet light treatment combined with a psoralen (available only in hospital), is effective in most patients if given 3-4 times weekly for 4-6 weeks. But long term there may be an increased risk of squamous and basal cell carcinomas and possibly melanoma which must be weighed against the benefit. Etretinate (Tigason) This is a vitamin A derivative that is relatively non-toxic but often has minor side-effects, like drying of mucous membranes. It can raise blood lipid levels, so regular checks are necessary, and hyperostosis has followed long-term use. It is also teratogenic and women must have effective contraception during and for two years after therapy. Etretinate is available only in hospitals.
Chemotherapeutic agents (immunosuppressives) Chemotherapeutic agents, especially methotrexate, are treatments of last resort that often work when all else fails, especially when there is arthropathy. Again, adequate contraception is important up to 6 months after stopping treatment. Main risks are marrow suppression (short term) and liver toxicity (long term). They must be given intermittently. Cyclosporin and hydroxyurea are occasionally used: cyclosporin promises to be of great value. Self-help measures Some patients find that stressful situations can spark off exacerbations, so self-help methods like relaxation therapy may help.
53
Aetiology When an eczematous eruption has been diagnosed, its features, pattern and course will enable one to categorize it further: Endogenous: atopic, seborrheoic, discoid, venous, asteatotic, pompholyx. Exogenous: allergic contact dermatitis, irritant dermatitis. In practice eczema is often multifactorial (a common example is chronic hand eczema of any type with an allergic contact dermatitis superimposed).
antiseptics and antibiotics are useful even in the absence of florid infection. When infection is obvious an oral broad spectrum antibiotic is indicated. Dressings are often helpful because they encourage absorption of the ointment into the skin and give protection from scratching. The texture of the skin can be treated as follows: oozing areas need lotion and thin creams, dry and thicker lesions creams and ointments; pastes give protection from scratching. Patients can react to preservatives, hence ointments, which rarely contain them, are safer than creams. The following are points to remember in particular types: 1. Atopic: management is long term; the help of the Eczema Society (see below) is particularly valuable in patients with chronic atopic eczema. Parental anxiety often leads to a wish to try various 'alternative' treatments and these need not be discouraged if it is certain they are not harmful. Diet is only very occasionally of importance; if elimination diets are tried, it is important to ensure that the diet is adequate. Evening primrose oil is now being promulgated. This does seem to help some patients but probably not many and, particularly as it is very expensive, it is certainly not recommended for routine use. Herbal remedies are of uncertain composition. Tar-impregnated occlusive bandages are useful for limbs. Eczema vaccinatum is not now seen but eczema herpeticum should be suspected if the patient becomes ill and if viral-like vesicles are seen. 2. Seborrhoeic dermatitis: some patients do better with ketoconazole cream than with steroids. If seborrhoeic dermatitis is atypical and severe in a patient at risk, it should be remembered that this can be a manifestation of AIDs. 3. Venous eczema: contact allergies to medicaments are common and patients should be patch tested. Support from toe to knee when the patient is up, and elevation of leg when in bed, are vital. 4. Pompholyx: acute attacks of blisters on palms and soles may need systemic steroids. 5. Allergic contact dermatitis: where this is suspected the patient should be patch tested. 6. Irritant dermatitis (for example housewives with frequent wetting of the hands): needs care and emollients rather than, or as well as, steroids. Protective gloves should be of thin disposable polythene type or heavier plastic (Glovelies), not rubber, which is a sensitizer.
Management The first essential is to use bland emollients in the bath and after washing. Emulsifying ointment and aqueous cream are cheap and reliable. Proprietary creams and ointments such as E45, Oilatum, and Diprobase are sometimes preferred. Antihistamines in the main act by virtue of their sedative properties so in adults are best given at night, for example hydroxyzine. Non-sedating preparations such as terfenadine do, however, sometimes appear to help and can be given by day. Topical steroids are invaluable. It is best to use a limited range of different strengths and become familiar with them. The amounts used of stronger ones, and of any applied on the face, should be monitored. The British National Formulary gives helpful notes on strengths and on amounts needed as regards area and periods of application. Topical
When to refer If diagnosis is in doubt. In acute severe outbreaks, possibly needing admission or steroids, for example erythrodermic atopics. In infants where there is much parental anxiety. If patch testing appears to be indicated. (This is suggested by the history or distribution of the rash, for example 'jean button rash' near the umbilicus.) In addition, patients with chronic venous eczema, otitis externa and hand eczema should probably be tested because of the possibility of allergies to compounds in medicaments (eg preservatives and lanolin). If problems are arising in relation to work.
The Psoriasis Association, 7 Milton Street, Northampton, NN2 7JG, runs contact and self-help groups, produces a newsletter, and dispenses general advice as well as pursuing education of the public and fundraising for research.
Audit 1. Monitor repeat prescriptions for regular medication. 2. Review patients on topical steroids regularly to ensure correct usage of the applications and to check that those used are the minimum potency which are effective for the condition.
Further reading Zachariae H (1990) Management of Difficult Psoriasis - Recent Advances in Dermatology. Ed. Champion R H and Pye R J. London, Churchill Livingstone.
ECZEMA Eczema and dermatitis may be regarded as synonymous (patients however often think of dermatitis as either infective or related to work). Eczema is characterized by inflammation and vesicle formation. Vesicular changes may be masked by secondary infection, thickening in response to rubbing, hyperkeratosis and fissuring, leading to a variable clinical picture which it may be difficult to differentiate from other conditions, particularly psoriasis. However, the sharp outline, bright redness and silvery scaling of the latter are helpful points.
1. 2.
3. 4.
5.
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Self-help The Eczema Society gives support and information to all, particularly atopics. The address is: National Eczema Society, Tavistock House East, Tavistock Square, London, WClH 9SR. Audit Read as for psoriasis. Further reading Drug and Therapeutics Bulletin (1990) Evening primose oil. 28, 69.
URTICARIA Urticaria is an acute or chronic condition characterized by a rash of weals and surrounding erythema which is very itchy and may be associated with swelling, especially of the mouth and round the eyes; individual lesions rarely last longer than 48 hours or are often very short-lived. Deeper subcutaneous swelling is referred to as angio-oedema. The reaction involves the release of histamine and possibly other mediators such as kinins and prostaglandins.
Differential diagnosis It is difficult to mistake the evanescent itchy lesions of urticaria although there may be difficulty if the rash has disappeared by the time the patient presents. In papular urticaria, a reaction to bites, there are usually unequivocal bites to be seen as judged by site, pattern, and so on. Classic urticaria Classic urticaria may consist of a solitary attack, or several over a few weeks or months or years, or a state where the patient is never without lesions; in a few individuals it may be possible to establish a cause and avoid it. History should cover:
Drugs: especially aspirin, sulphonamides Foods: strawberries and shellfish are best known but nuts, eggs, chocolate, yeast, pork, and so on, may be relevant Food additives: especially tartrazine Infections: especially hepatitis, but parasites (stool samples and blood test are advisable in patients recently returned from exotic parts) and possibly candidal infections. Classic uriticaria may also be related to a viral infection, especially in children. Contact with animals or with other substances, including pollen, some plants, chemicals, and foods like chicken and egg, may also spark off the contact urticarial variant. When a patient has urticaria, from whatever cause, other substances like aspirin may act as aggravating agents and should be avoided.
Physical urticarias often chronic over a period of months
These are Causes include:
or years.
Dermographism: firm stroking leads to weals. It may be very chronic. Small doses of antihistamines give good control. Pressure (rare): sustained pressure on the skin produces the weal and flare response. Cholinergic urticaria: so-called because the response can be blocked by anti-cholinergic drugs like atropine. This type of urticaria can be sparked off by exercise, heat or emotional stress and is common in young patients where it appears as small itchy weals, often with sweating. Solar urticaria (rare): arises within a few minutes of exposure to intense sunlight. It should be distinguished from other types of actinic reaction which take longer to appear. Cold urticaria (familial or acquired): varies in severity and duration. Swimming in cold water may be dangerous.
Treatment Antihistamines remain the mainstay of treatment, though they are not successful in all cases. Often a good combination is a sedating type like chlorpheniramine (Piriton) at night with terfenadine (Triludan) during the day. In resistant cases hydroxyzine (Atarax) 25 mg bd or i mane ii nocte may be effective. Some patients, particularly those with physical urticarias, are helped by the addition of an H2 blocker such as cimetidine and severe angio-oedema may warrant a course of systemic steroids. It is only possible to establish the main precipitating cause in a small minority of patients and, since the urticarial reaction is often not a true allergy, patch or prick testing is not usually helpful. Topical treatments with steroid creams are not useful since the skin surface is intact. Patients may be encouraged to learn that the most chronic urticarias will usually resolve eventually.
Self-help measures Precipitating factors, such as hot baths, should be avoided. In some cases a diary of food intake and other activities may pinpoint the cause. In the cholinergic urticarias, when exercise sets off an attack, the athlete may think it worth provoking an attack deliberately some time before an important event, since there is a refractory period of around 12 hours when another attack is unlikely to occur. In some individuals emotional stress may be a factor, and techniques such as relaxation therapy may help. When to refer Patients should be referred: * When attacks are severe, with swelling of mouth and eyes. Occasionally urticarias with angio-oedema may merge with anaphylactic shock and sufferers may even need to carry adrenaline. * When there is systemic illness. Urticaria may be associated with autoimmune disease, especially LE or lymphoma. Bruising in association with weals is an indicator of urticarial vasculitis, an important clue to such causes.
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* When there is a history that may suggest hereditary angiooedema - these patients are especially at risk from anaesthetics. The Cl esterase inhibitor is deficient or inactive. Referral is necessary to establish this important diagnosis. Hereditary angio-oedema is rare and transmitted as a dominant characteristic. Swellings start in childhood or later and are often associated with abdominal symptoms. In some, the course is severe and patients die of laryngeal obstruction. Antihistamines and steroids are ineffective. Treatment is now with danazol or tranexamic acid; in an acute episode or before surgery fresh frozen plasma is helpful or when available the concentrated C 1 esterase extract. Though expensive, the Cl esterase extract is an important advance. Patients may keep vials at home and arrange for the accident and emergency department or admission ward of their local hospitals to have it available.
Further reading Champion R H, Greaves M W, Kobza Black A et al. (1985) The Urticarias. London, Churchill Livingstone.
Further reading (general) Clement M and Du Vivier A (1986) Topical Steroids for Skin Disorders. London, Blackwell Scientific. Gawkrodger D J (1992) Dermatology - An Illustrated Colour Text. Edinburgh, Churchill Livingstone. Launer J M (1988) A Practical Guide to the Management of Eczema for General Practitioners. London, National Eczema Society. McKie R (1991) Clinical Dermatologist: An Illustrated Textbook. 3rd ed. Oxford, Oxford Medical Publications. Wilkinson J D, Shaw S and Fenton D (1987) Colour Aids. Dermatology. London, Churchill Livingstone. (Currently being revised.)
CHAPTER 11
Common skin conditions Dr Marjorie Ridley, MA, FRCP Dr Margaret Safranek, MB BS
SUMMARY Four common conditions: acne, psoriasis, eczema and urticaria are considered. Guidance is given on appropriate topical and systematic treatment for the different types and degrees of these conditions, with notes on management in general and criteria for referral to hospital outpatient departments. Where there are different types of the condition, with varying aetiology, for example in urticaria and eczema, management of the common types is outlined.
ACNE Acne is a rash primarily on face, chest and back characterized by combinations of pustules, papules, comedones and cysts.
Aetiology There is a suggestion that there is some defect of the pilosebaceous apparatus leading to excessive sebum secretion and damming back of the sebum. In addition, acne bacilli act on the sebum and irritant compounds lead to perpetuation of inflammation. Circulating androgens and/or increased local sensitivity are probably involved.
Age range Acne occurs mainly in the teens and twenties; however, it may be encountered in childhood and also in the thirties and forties. Differential diagnosis Rosacea occurs in older women (peaking in the thirties) and mainly affects the central part of the face with papules, pustules and flushing but no comedones. Assessment of problems Patients' views of their problem are perhaps as important as objective assessment of severity. A classification of mild/moderate/severe acne which is suitable for treatment in general practice is given below. Mild Mild acne is usually limited to small areas around the chin and cheeks with a small number of lesions. Local applications of drying and antiseptic lotions or gels like benzoyl peroxide in aqueous or alcoholic solutions may be sufficient, strengths varying from 2.5% to 10%. These may be bought over the counter and the patient may already
have tried them. Patients should be warned that some drying and reddening of the skin may be expected, but if excessive, applications should be reduced to once a day or less. If local applications are not sufficient, add an oral antibiotic; the cheapest is oxytetracycline 250 mg qid for 3-6 months. The patient should be warned to take pills on an empty stomach, to stop in the event of pregnancy (treatment can harm fetal teeth) and to persevere (no results can be expected for 4 to 6 weeks). Iron and milk can both hinder absorption. Further courses may be necessary if the patient relapses. If the patient is on oral contraceptives, one containing more androgenic progestagen like norgestrel or ethinyloestradiol diacetate could aggravate acne - it is best to change to one containing norethisterone or desogestrel. Moderate to severe Moderate to severe acne involves more widespread and marked non-inflamed lesions which often cause scarring. Local applications should be used as above. If comedones are preponderant, Retin-A gel may be the best choice since it modifies keratin production, but patients should be warned of possible photosensitivity. Local antibiotic lotions are claimed by manufacturers to work faster than systemic ones. They include clindamycin (Dalacin-T), tetracycline (Topicycline) and erythromycin (Stiemycin). They work out dearer than the cheaper oral generics but cheaper than minocycline and doxycycline except when the area of acne is very big. Topicycline is probably least effective. They are of benefit if patients are reluctant to take oral therapy. If oral oxytetracycline is ineffective, erythromycin 250 mg qid, or doxycycline 50 mg od, or minocycline 50 mg bd should be considered. The last is the most expensive - about £17 per month compared with about £1 for oxytetracycline. Minocycline can be taken with meals whereas oxytetracycline (and tetracycline) should be taken on an empty stomach. Minocycline can (rarely) cause pigmentation with prolonged administration. It does, however, have the advantage of a superior bacterial action leading to a reduced incidence of bacterial resistance compared with tetracycline (Eady et al., 1990). For women, Dianette should be considered, a contraceptive pill that combines 35 mcg oestrogen and 2 mg of the anti-androgen cyproterone acetate. Some women respond equally well to Minilyn, a (much cheaper) 50 mcg oestrogen pill but this is to be discontinued. Severe Severe acne should be treated as above, but if it is resistant or very widespread, a course of Roaccutane (isotretinoin, a Vitamin A derivative) should be considered. This can reduce sebum production and modify pilosebaceous blockage and
51
produce a long-term improvement after a few months. It is only available on hospital prescription and is teratogenic, so girls must be on effective contraception. It may affect lipid levels adversely, so these must be checked during and after treatment.
Future trends Roaccutane may be used more readily, its great efficacy making it potentially justifiable on both medical and financial grounds. When to refer Patients with severe or persistent acne resistant to treatment should be referred. In an older woman, acne, especially if combined with hirsutism, may be an indication of polycystic ovaries or a steroid-producing tumour and, even in the absence of menstrual irregularities, endocrinological investigations (sex hormone binding globulin, FH, LH, testosterone levels) and referral should be considered. Women on both oral contraception and oral antibiotics should be warned that, though direct interference with the oral contraception is extremely rare, diarrhoea associated with the tablets may lead to inactivation of the contraceptive.
Self-help measures Most patients think diet important and blame their acne on eating chocolate and chips. In fact, there is little to support this belief and they should be reassured. Heavy make-up and oils can exacerbate acne, and hair oils often used by Afro-Caribbeans can be a cause of acne confined to the forehead. Ordinary make-up, however, is safe, particularly if a range for greasy skins is chosen. Some people may find that sunshine makes their acne better, but this is by no means universal.
Audit 1. Repeat prescriptions for oral antibiotics in moderate to severe cases of acne could be monitored to check for patient compliance. Reference Eady E A, Cave J H, Holland K T et al. (1990) Superior antibacterial action and reduced incidence of bacterial resistance in minocycline compared with tetracycline-treated acne patients. British Joumal ofDennatology 122, 233-44.
Reading for patients Marks R (1984) Acne. Advice on Clearing Your Skin. Practical Health
Guide. London, Martin Dunitz.
PSORIASIS Psoriasis is a skin condition of unknown origin characterized by an accelerated turnover of skin cells and, though it is rarely combined with systemic symptoms, there is a hereditary component - around 50% of patients have a positive family history - and 1-2% of the UK population are affected.
Age of onset Psoriasis most commonly occurs in the third decade, but quite often in children and in the middle-aged or elderly. It varies widely in severity and clinical pattern, both in individual patients from time to time and between patients. Chronic plaque psoriasis Chronic plaque psoriasis affects especially the scalp, knees and elbows. Nail changes (pitting or loosening) are common. It comprises well demarcated bright red lesions with silvery scale. It is usually easy to recognize, though if it only affects the scalp it may be confused with seborrhoeic dermatitis, or if there are only one or two lesions in untypical areas it may resemble discoid eczema; but psoriasis is usually better defined and never moist. It may or may not itch. Guttate psoriasis Guttate psoriasis is a clinical variant of the psoriatic diathesis and may be associated with, or develop into, other forms of psoriasis. It is a widespread rash of small psoriatic lesions on trunk and proximal limbs. It is often precipitated by streptococcal infections and therefore has a relatively good prognosis, resolving at least partly in a few weeks. Differential diagnosis: pityriasis rosea, usually distinguished by 'firtree distribution' and herald patch, and rash of secondary syphilis (but this usually involves systemic upset).
Flexural psoriasis Flexural psoriasis affects axillae, groins, genitocrural and submammary areas. Scale is absent, and there are well demarcated bright pink lesions. Differential diagnosis: candida and tinea infections (if in doubt, microscopy or culture will help), seborrheic dermatitis, and banal intertrigo in relation to sweating and obesity.
Palmar and plantar pustulosis Palmar and plantar pustulosis involve confluent, localized sterile pustules on the palms and soles, or well defined scaly hyperkeratotic areas. Differential diagnosis: tinea and eczema. Psoriasis is often more clearly demarcated. In some patients psoriasis may on occasion become unstable and proceed to erythrodermic or generalized pustular psoriasis, with systemic upset.
Generalized pustular psoriasis Generalized pustular psoriasis may arise in 'ordinary psoriasis' or spontaneously. Precipitating factors include: drugs, pregnancy, excessive topical steroids and injudicious use of dithranol in unstable psoriasis.
Management Patients with psoriasis need long-term support, sympathy and practical help, for example with dressings.
52 Tar preparations
Used for many years, tar in a cream or soft white paraffin base can be applied to plaques in gradually increasing strengths of preparations and is usually effective. The disadvantages are that tar preparations are messy and smelly, stain skin and clothes, and irritate normal skin. Commercial preparations combining tars with hydrocortisone creams (Tarcortin, Carbo-cort, Alphosyl HC) are milder and may be more acceptable and effective for mild plaque and guttate psoriasis. Tar shampoos, such as Polytar, are helpful for scalp psoriasis.
Dithranol Dithranol, the most potent topical agent, and used traditionally in combination with Lassar's paste (zinc and salicylic acid), can, like tar, irritate and stain normal skin and intensive treatment is usually given on an inpatient basis in strengths of from 0.1 % to 1 or even 2%. But some patients can control their psoriasis with daily short contact therapy which involves applying gradually increasing strengths of dithranol cream for 30-60 minutes each night starting at 0.1%. This means that mess and staining are kept to a minimum. Some people find dithranol in a wax stick (Antraderm) easier to use (though more expensive). It can be prescribed in strengths of 0.5%, 1% or 2%. More acceptable dithranol preparations, for example Dithrocream, tend to be less effective than dithranol in Lassar's paste. Under supervision, steroid and dithranol mixtures can be effective.
Salictlic acid preparations Useful for hyperkeratotic plaques, topical treatments may contain salicylic acid alone or in combination with steroids (Diprosalic) or coal tar (Gelcosal). A keratolytic is particularly important in scalp psoriasis where scale is not easily shed. Cocois is a preparation containing tar and salicylic acid which may be more readily available than the traditional Ung. Cocois Co. Corticosteroids Mild corticosteroid creams and ointments are the treatment of choice for flexural psoriasis. Stronger steroid preparations may be very effective in chronic plaque psoriasis but run the risk of a rebound aggravation of the condition on stopping treatment, sometimes even precipitating severe pustular psoriasis. Make sure the patient understands that topical steroid preparations should be carefully applied to the lesions only.
Calcipotriol (Dovonex) This preparation is a vitamin D derivative, newly available and as yet very expensive. If used in the recommended way there appears to be no risk of inducing hypercalcaemia. It helps many patients with moderately severe, stable psoriasis; it is more cosmetically acceptable than dithranol and in the short term often more effective, though relapse appears to be more rapid when the treatment is discontinued. In a few patients it leads to buming and spreading of the lesions. It should be avoided in all patients on the face and in flexures.
UVB Sunny holidays or UVB help many but not all patients. UVB is best given in conjunction with tar and dithranol. Excessive exposure to sunlight may worsen psoriasis.
Infection In people whose psoriasis appears to be precipitated by infections, it is important to avoid re-infection. Occasionally, recurrent streptococcal tonsillitis may prove a problem, and tonsillectomy may be indicated.
When to refer Patients should be referred: 1. When they appear to be developing joint involvement (occurs in about 7% of cases). Referral here is most appropriate to a rheumatologist. 2. When local applications are not controlling the condition. 3. When there is rapid worsening with pustule formation.
Systemic treatments Systemic treatments, including PUVA, are best supervised by a dermatology department, at least initially. PUVA PUVA, which involves ultraviolet light treatment combined with a psoralen (available only in hospital), is effective in most patients if given 3-4 times weekly for 4-6 weeks. But long term there may be an increased risk of squamous and basal cell carcinomas and possibly melanoma which must be weighed against the benefit. Etretinate (Tigason) This is a vitamin A derivative that is relatively non-toxic but often has minor side-effects, like drying of mucous membranes. It can raise blood lipid levels, so regular checks are necessary, and hyperostosis has followed long-term use. It is also teratogenic and women must have effective contraception during and for two years after therapy. Etretinate is available only in hospitals.
Chemotherapeutic agents (immunosuppressives) Chemotherapeutic agents, especially methotrexate, are treatments of last resort that often work when all else fails, especially when there is arthropathy. Again, adequate contraception is important up to 6 months after stopping treatment. Main risks are marrow suppression (short term) and liver toxicity (long term). They must be given intermittently. Cyclosporin and hydroxyurea are occasionally used: cyclosporin promises to be of great value. Self-help measures Some patients find that stressful situations can spark off exacerbations, so self-help methods like relaxation therapy may help.
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Aetiology When an eczematous eruption has been diagnosed, its features, pattern and course will enable one to categorize it further: Endogenous: atopic, seborrheoic, discoid, venous, asteatotic, pompholyx. Exogenous: allergic contact dermatitis, irritant dermatitis. In practice eczema is often multifactorial (a common example is chronic hand eczema of any type with an allergic contact dermatitis superimposed).
antiseptics and antibiotics are useful even in the absence of florid infection. When infection is obvious an oral broad spectrum antibiotic is indicated. Dressings are often helpful because they encourage absorption of the ointment into the skin and give protection from scratching. The texture of the skin can be treated as follows: oozing areas need lotion and thin creams, dry and thicker lesions creams and ointments; pastes give protection from scratching. Patients can react to preservatives, hence ointments, which rarely contain them, are safer than creams. The following are points to remember in particular types: 1. Atopic: management is long term; the help of the Eczema Society (see below) is particularly valuable in patients with chronic atopic eczema. Parental anxiety often leads to a wish to try various 'alternative' treatments and these need not be discouraged if it is certain they are not harmful. Diet is only very occasionally of importance; if elimination diets are tried, it is important to ensure that the diet is adequate. Evening primrose oil is now being promulgated. This does seem to help some patients but probably not many and, particularly as it is very expensive, it is certainly not recommended for routine use. Herbal remedies are of uncertain composition. Tar-impregnated occlusive bandages are useful for limbs. Eczema vaccinatum is not now seen but eczema herpeticum should be suspected if the patient becomes ill and if viral-like vesicles are seen. 2. Seborrhoeic dermatitis: some patients do better with ketoconazole cream than with steroids. If seborrhoeic dermatitis is atypical and severe in a patient at risk, it should be remembered that this can be a manifestation of AIDs. 3. Venous eczema: contact allergies to medicaments are common and patients should be patch tested. Support from toe to knee when the patient is up, and elevation of leg when in bed, are vital. 4. Pompholyx: acute attacks of blisters on palms and soles may need systemic steroids. 5. Allergic contact dermatitis: where this is suspected the patient should be patch tested. 6. Irritant dermatitis (for example housewives with frequent wetting of the hands): needs care and emollients rather than, or as well as, steroids. Protective gloves should be of thin disposable polythene type or heavier plastic (Glovelies), not rubber, which is a sensitizer.
Management The first essential is to use bland emollients in the bath and after washing. Emulsifying ointment and aqueous cream are cheap and reliable. Proprietary creams and ointments such as E45, Oilatum, and Diprobase are sometimes preferred. Antihistamines in the main act by virtue of their sedative properties so in adults are best given at night, for example hydroxyzine. Non-sedating preparations such as terfenadine do, however, sometimes appear to help and can be given by day. Topical steroids are invaluable. It is best to use a limited range of different strengths and become familiar with them. The amounts used of stronger ones, and of any applied on the face, should be monitored. The British National Formulary gives helpful notes on strengths and on amounts needed as regards area and periods of application. Topical
When to refer If diagnosis is in doubt. In acute severe outbreaks, possibly needing admission or steroids, for example erythrodermic atopics. In infants where there is much parental anxiety. If patch testing appears to be indicated. (This is suggested by the history or distribution of the rash, for example 'jean button rash' near the umbilicus.) In addition, patients with chronic venous eczema, otitis externa and hand eczema should probably be tested because of the possibility of allergies to compounds in medicaments (eg preservatives and lanolin). If problems are arising in relation to work.
The Psoriasis Association, 7 Milton Street, Northampton, NN2 7JG, runs contact and self-help groups, produces a newsletter, and dispenses general advice as well as pursuing education of the public and fundraising for research.
Audit 1. Monitor repeat prescriptions for regular medication. 2. Review patients on topical steroids regularly to ensure correct usage of the applications and to check that those used are the minimum potency which are effective for the condition.
Further reading Zachariae H (1990) Management of Difficult Psoriasis - Recent Advances in Dermatology. Ed. Champion R H and Pye R J. London, Churchill Livingstone.
ECZEMA Eczema and dermatitis may be regarded as synonymous (patients however often think of dermatitis as either infective or related to work). Eczema is characterized by inflammation and vesicle formation. Vesicular changes may be masked by secondary infection, thickening in response to rubbing, hyperkeratosis and fissuring, leading to a variable clinical picture which it may be difficult to differentiate from other conditions, particularly psoriasis. However, the sharp outline, bright redness and silvery scaling of the latter are helpful points.
1. 2.
3. 4.
5.
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Self-help The Eczema Society gives support and information to all, particularly atopics. The address is: National Eczema Society, Tavistock House East, Tavistock Square, London, WClH 9SR. Audit Read as for psoriasis. Further reading Drug and Therapeutics Bulletin (1990) Evening primose oil. 28, 69.
URTICARIA Urticaria is an acute or chronic condition characterized by a rash of weals and surrounding erythema which is very itchy and may be associated with swelling, especially of the mouth and round the eyes; individual lesions rarely last longer than 48 hours or are often very short-lived. Deeper subcutaneous swelling is referred to as angio-oedema. The reaction involves the release of histamine and possibly other mediators such as kinins and prostaglandins.
Differential diagnosis It is difficult to mistake the evanescent itchy lesions of urticaria although there may be difficulty if the rash has disappeared by the time the patient presents. In papular urticaria, a reaction to bites, there are usually unequivocal bites to be seen as judged by site, pattern, and so on. Classic urticaria Classic urticaria may consist of a solitary attack, or several over a few weeks or months or years, or a state where the patient is never without lesions; in a few individuals it may be possible to establish a cause and avoid it. History should cover:
Drugs: especially aspirin, sulphonamides Foods: strawberries and shellfish are best known but nuts, eggs, chocolate, yeast, pork, and so on, may be relevant Food additives: especially tartrazine Infections: especially hepatitis, but parasites (stool samples and blood test are advisable in patients recently returned from exotic parts) and possibly candidal infections. Classic uriticaria may also be related to a viral infection, especially in children. Contact with animals or with other substances, including pollen, some plants, chemicals, and foods like chicken and egg, may also spark off the contact urticarial variant. When a patient has urticaria, from whatever cause, other substances like aspirin may act as aggravating agents and should be avoided.
Physical urticarias often chronic over a period of months
These are Causes include:
or years.
Dermographism: firm stroking leads to weals. It may be very chronic. Small doses of antihistamines give good control. Pressure (rare): sustained pressure on the skin produces the weal and flare response. Cholinergic urticaria: so-called because the response can be blocked by anti-cholinergic drugs like atropine. This type of urticaria can be sparked off by exercise, heat or emotional stress and is common in young patients where it appears as small itchy weals, often with sweating. Solar urticaria (rare): arises within a few minutes of exposure to intense sunlight. It should be distinguished from other types of actinic reaction which take longer to appear. Cold urticaria (familial or acquired): varies in severity and duration. Swimming in cold water may be dangerous.
Treatment Antihistamines remain the mainstay of treatment, though they are not successful in all cases. Often a good combination is a sedating type like chlorpheniramine (Piriton) at night with terfenadine (Triludan) during the day. In resistant cases hydroxyzine (Atarax) 25 mg bd or i mane ii nocte may be effective. Some patients, particularly those with physical urticarias, are helped by the addition of an H2 blocker such as cimetidine and severe angio-oedema may warrant a course of systemic steroids. It is only possible to establish the main precipitating cause in a small minority of patients and, since the urticarial reaction is often not a true allergy, patch or prick testing is not usually helpful. Topical treatments with steroid creams are not useful since the skin surface is intact. Patients may be encouraged to learn that the most chronic urticarias will usually resolve eventually.
Self-help measures Precipitating factors, such as hot baths, should be avoided. In some cases a diary of food intake and other activities may pinpoint the cause. In the cholinergic urticarias, when exercise sets off an attack, the athlete may think it worth provoking an attack deliberately some time before an important event, since there is a refractory period of around 12 hours when another attack is unlikely to occur. In some individuals emotional stress may be a factor, and techniques such as relaxation therapy may help. When to refer Patients should be referred: * When attacks are severe, with swelling of mouth and eyes. Occasionally urticarias with angio-oedema may merge with anaphylactic shock and sufferers may even need to carry adrenaline. * When there is systemic illness. Urticaria may be associated with autoimmune disease, especially LE or lymphoma. Bruising in association with weals is an indicator of urticarial vasculitis, an important clue to such causes.
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* When there is a history that may suggest hereditary angiooedema - these patients are especially at risk from anaesthetics. The Cl esterase inhibitor is deficient or inactive. Referral is necessary to establish this important diagnosis. Hereditary angio-oedema is rare and transmitted as a dominant characteristic. Swellings start in childhood or later and are often associated with abdominal symptoms. In some, the course is severe and patients die of laryngeal obstruction. Antihistamines and steroids are ineffective. Treatment is now with danazol or tranexamic acid; in an acute episode or before surgery fresh frozen plasma is helpful or when available the concentrated C 1 esterase extract. Though expensive, the Cl esterase extract is an important advance. Patients may keep vials at home and arrange for the accident and emergency department or admission ward of their local hospitals to have it available.
Further reading Champion R H, Greaves M W, Kobza Black A et al. (1985) The Urticarias. London, Churchill Livingstone.
Further reading (general) Clement M and Du Vivier A (1986) Topical Steroids for Skin Disorders. London, Blackwell Scientific. Gawkrodger D J (1992) Dermatology - An Illustrated Colour Text. Edinburgh, Churchill Livingstone. Launer J M (1988) A Practical Guide to the Management of Eczema for General Practitioners. London, National Eczema Society. McKie R (1991) Clinical Dermatologist: An Illustrated Textbook. 3rd ed. Oxford, Oxford Medical Publications. Wilkinson J D, Shaw S and Fenton D (1987) Colour Aids. Dermatology. London, Churchill Livingstone. (Currently being revised.)
