Dermatology Protected
Learning Time Dr Amir Ghazavi & Dr Anand Patel
02 & 09 December 2014
Agenda
• 12.30pm-1.30pm Registration
• 1.30pm-1.40pm City Care - Urgent Care Service - Steve Upton
• 1.40pm-1.50pm Actinic Keratosis Guidelines - Dr Anand Patel
• 1.50pm-2.05pm Hidradenitis Suppurativa - Dr Amir Ghazavi
• 2.05pm-2.15pm Hyperhidrosis - Dr Anand Patel
• 2.15pm-2.30pm Urticaria - Dr Amir Ghazavi
• 2.30pm-2.45pm Skin Cancer - Dr Anand Patel
• 2.45pm-3.00pm Patch Testing - Dr Anand Patel
• 3.00pm-3.15pm Break
• 3.15pm-3.50pm Pigmentation and Quiz - Dr Amir Ghazavi
• 3.50pm-4.00pm Teledermatology - Dr Amir Ghazavi
• 4.00pm Close
City Care – Urgent Care
Services
Steve Upton
Actinic Keratosis
Guideline Dr Anand Patel
Dermatologist
Nottinghamshire Solar Keratosis Primary Care Treatment Pathway
(Adapted from the Primary Care Dermatology Society Treatment Pathway)
Crusted, indurated and inflamed lesion could turn out to
be early SCC-urgent 2-week referral
Early solar keratosis needs
no treatment
Single solar keratosis
consider cryotherapy
Lesion with rapid onset, indurated
inflamed base, critical sites,
immunosuppressed patient or >1cm
Urgent 2-week referral
Sun avoidance advice including
sunscreen. Skin cancer info
sheets
Impalpable or barely palpable
Palpable but not
indurated
Does the patient want
treatment? No
Yes Single lesion or
Hyperkeratotic
lesion*
Cryotherapy with
liquid nitrogen
1x15sec freeze
thaw cycle.
Histofreezer® Not
recommended as
no evidence.
Multiple lesions
Offer topical treatment- 1st line - 5-Fluorouracil cream (Efudix®) (Amber 3 – GP can initiate in
line with this guideline) Apply once or twice daily for 3 to 4 weeks, depending on site. Counsel
regarding skin reaction (give Eumovate® if symptomatic). Patient Information sheet (with
photographs of reactions) available here
2nd line - Ingenol mebutate gel (Picato® ▼) (Amber 3 – GP can initiate in line with this
guideline) For patients unable to tolerate/comply with Efudix
• on face and scalp lesions, apply 150 micrograms/g gel once daily for 3 days
• on trunk and extremities, apply 500 micrograms/g gel once daily for 2 days Patient Information
sheet (with photographs of reactions) available here
3rd line – imiquimod 3.75% cream (Zyclara ®) (Amber 3 – GP can initiate in line with this
guideline) To be used if Efudix® and Picato® are not tolerated or used earlier if the lesions cover a
large area or if there is field change (refer to specialist if needed). Apply up to 2 sachets (250mg per
sachet) once daily before bedtime to the affected treatment field (full face or balding scalp) for two
treatment cycles of 2 weeks each separated by a 2- week no-treatment cycle.
Review 4-weeks after stopping treatment. If no response, review diagnosis +/-
referral
If not available
*Actikerall®
(See next page
for instructions)
Dr A N Patel & Dr W Perkins, Dermatology Department, Nottingham University Hospitals NHS Trust (updated September 2014)
***The Medicines Management Teams can also provide copies of the patient information leaflet. Actinic/Solar Keratosis Epidemiology
Chronic or repeated sun exposure is a major association >80% appear on the face, head or back of the hands, especially, but not exclusively, in those with fair skin.
Caucasians previously living in hot climates or working outside are at highest risk. Prevention is better than cure (see national skin cancer prevention & sunscreen advice)
Prevalence in UK (Merseyside) age>40
Diagnosis Red or white lesions with a gritty or sandpaper like texture on palpation but no induration at the base of the lesion, meaning there is epidermal thickening or dermal
infiltration, both manifested as a thickened red base.
Efudix® (5-Fluorouracil -Amber 2 – GP can initiate in line with this guideline)
once or twice daily for 3 to 4 weeks, depending on site. Counsel regarding skin reaction (give Eumovate® if symptomatic). Give patient Information sheet (with
photographs of reaction). http://www.nottspct.nhs.uk/images/stories/My_PCT/How_we_work/areaprescribing/solar%20keratosis%20-
%20patient%20information%20leaflet.pdf Actikerall® (0.5% 5-Fluorouracil. 10% Salicylic acid ): Due to the unavailability of cryotherapy in primary care as well as the inefficacy of Effudix® on
hyperkeratotic actinic keratoses, Aktikerall® provides an alternative treatment option with better results when used on thicker lesions in primary care and will save on
secondary care referrals. Use once daily for 6-12 weeks. Counsel regarding mild to moderate skin reaction.
Picato® (Ingenol mebutate): Is a 2-3 day topical treatment for AK with background field change for an area of 25cm2 0.015% gel should be used on scalp and face
lesions in a 25cm2 area for 3 consecutive days. 0.05% gel should be used for 2 consecutive days on the body. Counsel on moderate skin reaction. Zyclara® (3.75% Imiquimod): For the topical treatment of face and scalp AK with field change up to an area of 100cm2 . Treatment regime is a single application once
a day for two weeks followed by a 2 week rest period and then a further two weeks active treatment. Fewer side effects seen than with 5% imiquimod cream.
Bibliography Actinic Keratosis Primary Care Treatment Pathway published by Primary Care Dermatology Society (available from http://www.pcds.org.uk or NHS Evidence - National
Library of Guidelines)
Guidelines for the management of actinic keratoses. D. de Berker, J.M. McGregor and B.R. Hughes - on behalf of the British Association of Dermatologists Therapy
Guidelines and Audit Subcommittee British Journal of Dermatology 2007 156, pp222–230
(Available from www.bad.org)
NICE Guidance on Cancer Services. Improving outcomes for People with Skin Tumours including Melanoma. February 2006.
Stockfleth E et al. Low-dose 5-fluorouracil in combination with salicylic acid as a new lesion directed option to treat topically actinic keratoses-histological and clinical
study results. Br J Dermatol. 2011 Nov;165(5):1101-8.
Authors Dr A N Patel & Dr W Perkins, Dermatology Department, Nottingham University Hospitals NHS Trust (updated September 2014)
***The Medicines Management Teams can also provide copies of the patient information leaflet.
all Age>70
males 15.4% 34.1%
females 5.9% 18.1%
Skin cancer risk
Actinic keratoses (AK) are a risk factor for skin cancer as they are very closely linked to sun
exposure. Therefore patients with actinic keratoses should be educated in the signs of common
skin cancers and asked to present if any new/ different lesions develop.
Less than 1 in 1000 actinic keratoses will transform into squamous cell carcinoma (SCC) in any one
year therefore, treatment is dependent on patient preference, symptoms and the need to clear the
sun damaged area in order to be able to see if any more sinister lesions such as basal cell
carcinoma (BCC) or SCC are developing.
Progression of very early AK lesions and AK recurrence are reduced by daily use of an appropriate
sunscreen (SPF factor 15+ or higher, available on prescription, annotate “ACBS”) if clinically
indicated i.e. recurrent or multiple AK lesions.
The treatment guideline can be followed again if new lesions develop.
Hidradenitis Suppurativa Dr Mohammad Ghazavi
Dermatologist
Hidradentis Suppurativa
• Prevalence of 1-4%
• F/M: 2/1-5/1
• Rare onset before puberty and after menopause
• Persistence into menopause not uncommon
• Genitofemoral involvement more common in women
Association
• Genetic
• Androgen effect
• Obesity and current smoking
• Common microorganisms: S aureus and coagulase negative staph.
Diagnostic criteria
• Active disease with 1 or more primary lesions in a designated site, plus a history of 3 or
more discharging or painful lumps (not specified) in designated sites since age 10 years
• Inactive disease with a history of 5 or more discharging or painful lumps (unspecified) in
designated sites since age 10 years, in the absence of current primary lesions
Questions to ask
• Is there more than a single inflamed lesion?
• Is the course chronic, with new and recurrent lesions?
• Are the lesions bilateral?
• Where are the lesions located primarily?
Hurley staging
• First stage: Solitary/multiple, isolated abscess formation without scarring or sinus tracts
• Second stage: Recurrent abscesses, single/multiple widely separated lesions, with sinus
tract formation and cicatrization
• Third stage: Diffuse/broad involvement, with multiple interconnected sinus
tracts/abscesses
Hyperhidrosis Dr Anand Patel
Dermatologist
What is it?
• Excessive and uncontrollable sweating
• Sweat is produced by the eccrine sweat glands. These are distributed over the entire body
but are most numerous on the palms and soles (with about 700 glands per square
centimetre).
Hyperhidrosis
• Localised hyperhidrosis affects the armpits, palms, soles or face.
• Generalised can affect the whole body
Primary or Secondary
• Primary
• Childhood/adolescence
• Persist lifelong/improve with age
• Family history
• Armpits, palms or soles symmetrically
• Reduces at night and stops when asleep
• Secondary
• Less common
• Unilateral or asymmetrical
• Can occur at night or during sleep
• Due to endocrine/neurological conditions
Triggers
• Hot weather
• Exercise
• Spicy food
• Fever
• Anxiety
Causes of secondary localised
• Stroke
• Spinal nerve damage
• Peripheral nerve damage
• Surgical sympathectomy
• Neuropathy
• Brain tumour
• Anxiety disorder
Causes of secondary generalised
• Obesity
• Diabetes
• Menopause
• Overactive thyroid
• Respiratory failure
• Endocrine tumours
• Parkinson’s disease
• Drugs (caffeine, corticosteroids, TCA, SSRI, opiods)
Tests that should be done
• Not needed in primary hyperhidrosis
• Needed to ascertain underlying cause in secondary HH
• Depends on clinical features but should be a minimum
• Blood sugar/TFT
Management-General
• Loose fitting clothing
• Change clothing when damp
• Absorbant insoles
• Talc powder
• Antiperspirant
• Avoid caffeine/drugs
Management-topical
• Antiperspirant
• Driclor-aluminium salts-cream/spray/roll on
• Apply to dry skin after cool shower before bed
• Wash off in morning
• Use once/twice a week and build up to daily if necessary
• Beware as irritant
Iontophoresis
• For palms, soles and armpits
• Affected area is immersed in water or an electrolyte solution or gylcopyrronium solution
• Gentle electric current is passed across the skin for 10-20 mins
• Repeat daily for several weeks then less frequently
• Not always effective
Oral Medications
• Oral anticholinergic drugs:
• Propantheline, oxybutynin, glycopyrolate
• Can cause blurred vision, dry mouth, constipation, dizziness, palpitaions.
• Should not be taken in those with urinary retention/glaucoma
• Beta blockers:
• Block effects of anxiety
Botulinum Toxin
• Approved for axillary hyperhidrosis
• Reduce/stop sweating for 3-6 months
• Used off license for localised hyperhidrosis at other sites (palms)-effective.
Sympathectomy
• Division of spinal sympathetic nerves (chemical/surgical)
• Reserved for the most severe cases/resistant to other treatments
• Potential risks and complications
• Hyperhidrosis can recur in 15%
• Accompanies with skin warmth and dryness
• New onset of hyperhidrosis in other site in 50%
• Horner syndrome, pneumonia, pneumothorax and persistent pain
Outlook
• Primary hyperhidrosis tends to improve with age
• Secondary hyperhidrosis depends on the cause
Urticaria Dr Mohammad Ghazavi
Dermatologist
Urticaria
• Red
• Non scaly
• Mostly itchy, can be painful or
asymptomatic
• Lasts from 30 minutes to 36 hours
• Acute in 20% and chronic in 0.5% of
population
• 45% of chronic form are autoimmune
Acute urticaria
• IgE related and not IgE related
• Complement-mediated urticarias include viral and bacterial infections, serum sickness, and transfusion reactions.
• Certain drugs (opioids, vecuronium, succinylcholine, vancomycin, and others) as well as radiocontrast agents cause urticaria due to mast cell degranulation through a non—IgE-mediated mechanism.
• Urticaria from nonsteroidal anti-inflammatory drugs may be IgE-mediated or due to mast cell degranulation, and there may be significant cross-reactivity among the nonsteroidal anti-inflammatory drugs (NSAIDs) in causing urticaria and anaphylaxis
Acute urticaria
• Recent illness
• Medication use
• IV radiocontrast media
• Travel
• Foods
• New perfumes, hair dyes, detergents, lotions, creams, or clothes
• Exposure to new pets (dander), dust, mold, chemicals, or plants
• Pregnancy (usually occurs in last trimester and typically resolves spontaneously
soon after delivery)
• Contact with nickel, rubber, latex, industrial chemicals, and nail polish
• Sun or cold exposure
• Exercise
• Alcohol
Chronic urticaria
• Autoimmune disorders (SLE, rheumatoid arthritis, polymyositis, thyroid autoimmunity, and other connective tissue diseases); probably up to 50% of chronic urticaria is autoimmune
• Cholinergic urticaria induced by emotional stress, heat, or exercise; examine for other signs of cholinergic stimulation including lacrimation, salivation, and diarrhea
• Chronic medical illness, such as hyperthyroidism, amyloidosis, polycythemia vera, malignant neoplasms, lupus, lymphoma, and many others
• Cold urticaria, cryoglobulinemia, cryofibrinogenemia, or syphilis
• Mastocytosis
• Inherited autoinflammatory syndromes
• The etiology of chronic urticaria is undetermined in at least 80-90% of patients.
Recurrent urticaria
• Sun exposure -solar urticaria, occurring only on skin exposed to the sun[29]
• Exercise (cholinergic urticaria)
• Emotional or physical stress
• Water (aquagenic urticaria)
Urticaria work up
• Acute urticaria: laboratory studies generally are not indicated. The patient's history and
physical examination should direct any diagnostic studies
• Chronic or recurrent urticaria: basic laboratory studies prompted by signs and symptoms
but may include a CBC, erythrocyte sedimentation rate, TSH, and an ANA looking for
possible causes of the urticaria
Cancerous Lesions Dr Anand Patel
Dermatologist
Pre-cancerous lesions
• Actinic Keratoses
• Bowen’s disease (intra-epidermal carcinoma)
• Superficial BCC
• Lentigo Maligna
BCC
Management
• 5 Fluoro-uracil
• Imiquimod
• PDT
• Cryotherapy
• Surgery- C&C or excision
• Watch and wait
LM
Management
• Excision with conventional 5mm margin
• Staged excision-’Square technique’
• Imiquimod-poor evidence
Basal cell carcinoma
• Nodular Basal cell carcinoma
• Ulcerated Basal cell carcinoma
• Pigmented basal cell carcinoma
• Morphoeic basal cell carcinoma
BCC left without treatment
Morphoeic BCC
Morphoeic BCC
Management
• Surgery
• Mohs micrographic surgery
• Radiotherapy
• Chemotherapy-Vismodegib
• Watch and wait/conservative
Mohs surgery
Squamous cell carcinoma
• Squamous cell carcinoma
• (multiple histological subtypes-desmoplastic)
• High risk factors
• Keratoacanthoma
Keratoacanthoma
Management
• Surgical excision
• Radiotherapy
• Watch and wait for KA
Risk factors
• Poor differentiation
• Size of lesion x> 2cm
• Thickness of tumour >4mm
• Immunosuppressed
• Site of tumour-lip, ear
• Vascular/peri-neural invasion
• Sub type-desmoplastic
Malignant Melanoma
• Lentigo Maligna melanoma
• Superficial spreading melanoma
• Nodular melanoma
• Amelanotic melanoma
• Acral melanoma
LMM
SSMM
Nodular MM
Amelanocytic MM
• <>
Management
• Excision biopsy
• Wide local excision
• Lymph node clearance
• Chemotherapy for advanced MM-Ipilimumab
Surgical margins
Breslow Thickness Excisions margins
<1mm 1cm
1-2mm 1-2cm
2-4mm 2-3cm
>4mm 3cm
Other skin cancers
• Merkel cell cancer
• Angiosarcoma
• Dermatofibroma sarcoma protuberans
• Cutaneous T-Cell Lymphoma
Angiosarcoma
Management
• Mohs Micrographic surgery
• Radiotherapy
• Wide local excision
Mycosis fungoides
• Subset of cutaneous T cell lymphoma
• Patch, plaque and tumour stages
• May look like dermatitis or psoriasis
• Protracted clinical course
• Treatment depends on stage
• topical steroid
• Phototherapy-PUVA/TLO1
• Superficial radiotherapy
• Chemotherapy-Bexarotene, MTX, extracorporeal photopheresis.
Contact Dermatitis
Dr Anand Patel
Dermatologist
atopic
irritantallergic
infection infection
infection
endogenous
Irritant contact dermatitis
• Skin damaged directly by the irritant
• Soaps, detergents, water, solvents, dry atmosphere etc – depends upon degree of exposure
• Very, very common
• 10 % of the population suffer from hand dermatitis
• Treated with emollients/moisturisers and exposure reduction
Stratum Corneum Barrier Function
Dermis
Epidermis
Dermatitis present
Subclinical dermatitis
A series of cumulative irritant episodes of vary degree of severity leading eventually to
dermatitis. Often the patient does not link the weaker exposures with the dermatitis.
Impa
irm
ent
(log
sca
le)
Time
Threshold for ICD
What Is Diagnostic Patch Testing?
• To diagnose allergic contact dermatitis not irritant contact dermatitis
British Standard Series 1-7
DICHROMATE Leather, cement etc 3.0
NEOMYCIN Topical antibiotic 4.8
THIURAM MIX Rubber additive 5.0
Paraphenyldiamine Permanent hair dye 3.4
COBALT Metal 6.7
CAINE MIX Local anaesthetic 1.2
FORMALDEHYDE Biocide 2.6
British Standard Series 8-14
ROSIN Colophony, resin from spruce trees 5.9
QUINOLINE MIX Antiseptic 1.2
BALSAM OF PERU Fragrance 8.2
Isopropyl-phenyl-paraphenylenediamine Industrial rubber additive 0.4
WOOL ALCOHOLS Lanolin 4.8
MERCAPTO MIX Rubber additive 1.2
EPOXY RESIN Two part adhesive 1.4
British Standard Series 15-21
PARABEN MIX Preservative 1.1
Paratertiarybutyl Phenol Formaldehyde Resin Adhesives 1.2
FRAGRANCE MIX Fragrance 12.4
QUATERNIUM-15 Biocide 1.7
NICKEL Metal 19.5
Methylchloroiso thiazolinone + Methylisothiazolinone Biocide 2.1
Mercaptobenzothiazole Rubber additive 1.0
British Standard Series 22-28
PRIMIN Primula 0.6
SESQUITERPENE LACTONE MIX Compositae plant allergy 1.6
CHLOROCRESOL Preservative 0.5
2-BROMO-2-NITROPROPANE-1,3-DIOL Biocide 1.1
CETEARYL ALCOHOL Whitening agent/emulsifer 1.3
FUCIDIC ACID Antibiotic 0.4
TIXOCORTOL PIVALATE Hydrocortisone allergy 2.0
British Standard Series 28-35
BUDESONIDE Steroid 1.0
IMIDAZOLIDINYL UREA Biocide 1.2
DIAZOLIDINYL UREA Biocide 1.3
METHYLDIBROMO GLUTARONITRILE Biocide 4.1
ETHYLENEDIAMINE Stabiliser/emulsifier 2.2
PCMX Antiseptic in Dettol 0.6
CARBA MIX
Rubber additive 3.7
Specialised Series
• cosmetic/facial
• medicament
• steroid
• hairdressing
• dental
• oil & cooling fluid
• glues & plastics
• shoe
• textile colours & finishes
• meth(acrylate)
• photographic chemicals
• isocyanates
ICDRG Grading System
?+ = doubtful reaction; faint erythema only
+ = weak positive reaction; erythema, infiltration, possibly papules
++ = strong positive reaction; erythema, infiltration, papules, vesicles
+++ = extreme positive reaction; intense erythema and infiltration and coalescing vesicles or a bulla
IR = irritant reaction
NT = Not tested
Relevance (COADEX)
Current relevance
Old or past relevance
Actively sensitised
Do not know the relevance
Exposed but no dermatitis
Cross reaction
Indications for Patch Testing
• Hand eczema
• Treatment resistant eczema
• Stasis eczema
• Occupational contact dermatitis
Patch test Database 2004.mdb
Disorders of
pigmentation Dr Mohammad Ghazavi
Dermatologist
Hypopigmentation
Vitiligo
• Well defined with normal surface
• 0.3-0.5% of population
• Segmental, acro-facial, localised, mix
• Any age, any skin type
• Usually asymptomatic
• Other autoimmune conditions
• No preceding rash
Pityriasis versicolour
• Well defined patches/ macules
• Upper torso
• Might be itchy/ scaly
Post inflammatory hypopigmentation
• More in darker colour skin
• Preceding rash
• Ill defined, irregular border
• Anywhere, any age
• Can be scaly
Pityriasis alba
• Darker skin colour
• Children
• Symmetric
• Mostly on face
• Can be scaly/ slightly itchy
• Ill defined
Hyperpigmentation
Post inflammatory hyperpigmentation
• More in darker skin colour
• Irregular border
• Preceding rash (eczema, psoriasis, lichen planus…)
LPP
• Grey brown pigmentation
• On sun exposed area (face, neck, flexures)
• Darker skin colour
• Can be itchy
Melasma
• Female (rare in male)
• Face (forehead, cheeks, chin)
• Not scaly
• Irregular border
• Link to pregnancy, OCP…
Ashy dermatosis (Erythema Dyschromicum Perstans)
• Rare condition
• Ashy grey-blue pigmentation
• First few decades of life
• Non exposed area
• Varying size coalescing macules
• With or without an erythematous rim
Teledermatology Dr Amir Ghazavi
Teledermatology
What is Teledermatology?
Teledermatology is a subspecialty in the
medical field of dermatology and
probably one of the most common
applications of telemedicine and e-
health.
Generic Process
When a GP sees a skin complaint/lesion
which they are unsure about, instead of
referring the patient in, they take a series
of photos.
This is then sent to a dermatologist to
interpret.
The dermatologists replies with the
diagnosis and course of action for the
GP/patient.
Teledermatology at Circle Nottingham
Background
• Oct/Nov 2013 started taking to Nottingham City CCG about a pilot of Teledermatology.
• The CCG looked at a number of ways of doing this, including using the Mole Clinic.
• However they ideally wanted locum Dermatologists to interpret the photos.
• We considered a number of different ways of facilitating the process, but wanted something
which the GPs were already comfortable using, therefore making the process as simple as
possible.
• Choose and Book seemed to be the simplest way of the GPs referring in for this service, as
both the GPs and ourselves are confident with this system.
• So far, we have tested the process both live in clinic and via Choose and Book with test
patients. A number of hiccups have been ironed out.
Teledermatology at Circle Nottingham
Next steps
The process is designed to be as simple as possible.
Our process
The GP sees a patient and decides that advice via Teledermatology is suitable option.
Photos are taken, (advice on how to take the photos will be available via Youtube or similar).
Patient is referred in via Choose and Book and an appointment is created in Proxima.
The photographs are transferred from Choose and Book into the portal and the referral accepted
on Choose and Book.
The Portal – Select patient
The Portal – Doctor review
The Portal – Doctors findings
The Portal – Report
The Portal – Letter
Any questions?
Thank you.