Facial Rashes

Acne, Rosacea and other red facesSteve Goldthorp

CDLE or Rosacea or?1

2

What lesions are demonstrated? (1)What is the condition? (1)Quizz: Max 20

1 what lesions are demonstrated? (1) 2 name the condition (1)

1 what lesion is demonstrated? (1)2 can it occur alone? (1)1 - Would you refer this patient? (1)2 - What treatment would be considered? (1)

1 What is the diagnosis? (1)2 What are the two diagnostic clues? (1)

1 Give three diagnostic features (1)2 and the diagnosis (1)

1 Give a name to the complication affecting his nose? (1)2 Name two ocular manifestations (1)

1 - Diagnosis please? (1)2 What microorganism is implicated? (1)

1 List two classical features of this process (1)2 Give the diagnosis (1)

1 Name the process? (1)2 Give two precipitants? (1)

Diagnosis?

www.gpminorsurgery.com

National Patient Pathwayswww.pathways.scot.nhs.uk/dermatology.htm

http://www.pathways.scot.nhs.uk/dermatology.htmWe will cover:AcneRosaceaSeborrhoeic dermatitisPerioral dermatitisTouch on SLE as part of the aboveDLEActinic keratosesJuvenile Spring EruptionPLEMelasma

Look elsewhere!Look at nails, hair, mucus membranes, hands, feetnail pitting for psoriasisscalp may be clue to seborrhea elsewherelichen planus may show a white lacy pattern in the mouth/penis/vulvaAcne of back/chest

AcneSelf limiting, inflammatory condition of pilosebaceous unitStarts puberty because of androgenic stimulation and increased keratinization at follicular orificeFollicular hyperkeratinization with blockage of PSU (comedone)Incr. sebum production and PSU distension (whitehead)Sebum bursts into tissues with triglicaride breakdown by P. acnes all leads to inflammatory reactionGives erythematous papules pustules and nodulesEventual healing with possible scarring

Closed comedones whiteheads

Open comedones or blackheads

Wide range of disease few comedones to severe nodulocysticAreas of greatest density of PSUs, face/back/upper chest, rarely buttocks/upper arms

No racial differencesBenign but physical and psychological scarringReluctance to seek helpAcne prevalencePuberty to adulthood, occasionally prepubertalWomen more likely -> 20s and 30s

25 85% of 12 24 yr olds8 10% 25 34 yr olds3 8% 35 44 yr oldsPsychological ProblemsQuality of life threatened esp mod/severe acneFeelings of insecurity & inferiorityReduced self esteem/confidence/body imageEmbarrassment & social withdrawl, depression/angerLifestyle limitationsHigher rates of unemploymentAdults>adolescents

Rubbing/overcleansing may exacerbate50% makeups comedogenicOccupations kitchen environmentsSports equipment eg helmets/sweat bandsDrugs levonorgestrel/progesterone/steroids/some anticonvulsants, lithiumPCOSCong adrenal hyperplasia

Cardinal sign is the comedone, closed or openLater papules and pustulesDeeper involvement gives nodules and cystsHealing -> scarringDepressed scars > ice-pick Hypertrophic scars -> keloids

PrognosisEventually disappears after many yearsMinority into 20s, 30s or later

SequelaeScarringPsychological

TreatmentNeed to reduceMicrocomedonesMicro-organismsInflammationAndrogenic stimulationExternal irritantsTreatmentUseful to think

Mild

Moderate

Severe

TreatmentComedones non inflammatoryPeeling agent to remove surface keratinbenzoyl peroxide (2.5%, 5%, 10%)retinoic acid gel/cream/lotionisotretinoin gelazaleic acid creamUV light has similar effectTreatment inflammatory lesionsPapules/pustules or nodules need systemic treatmentThese are:AntibioticsOxytetracycline 500mgs bd cheap and effectiveEmpty stomach 30mins before food or 2 hrs afterChelates with iron/antacids/calciumImprovement slow and not seen for 2-3/12 with ongoing improvement for 6-12/12Maintenance at 250mg bd for a long as it takesAvoid tetracyclinesUnder 12PregnantLactatingImpaired renal function

Side effects fewDiarrhoea, candidiasis

OCP - contraception x 3/52 then in happy symbiosishttp://www.gpnotebook.co.uk/simplepage.cfm?ID=101056582 37If tetracyclines dont work?

Check compliance empty stomach and taking it!Try erythromycin 250mgs bdDoxycycline 50mgs odLymecycline 400mgs od(minocycline discoloration of skin/teeth and a rare lupus like syndrome)TopicalsWork well but ?resistance ?contact dermatitis expensiveApply dailyNegligible systemic absorption

If combine with oral antibiotic use the same agent eg erythromycin with zineryt

TretinoinInfluences desquamationAlters microclimateResolves mature comedonesPrevents new lesionsEnhances penetration of other drugs

Topical or systemicTopicals tretinoin: Retin A, adapalene (Differin)Benzoyl peroxide 2.5 10%Antibacterial and reduces keratinizationImproves comedones/papulopustulesReduces P. acnes, butCan induce irritationBleaches hair, towels etc

Topical antibioticsErythromycin & clindamycinReduce P. acnesDecrease neutrophilic activity

Azelaic Acid (Skinoren)Antikeratinizing, antibacterial and antiinflammatory effectsMild to moderate acneUse with oral antibiotics

Absence of resistance or systemic side effects

Anti-androgens

Anagen bulb in hair follicle and sebaceous gland contain androgen receptors

Influenced by gonadotrophins, insulin, glucocorticoidsOestrogen, TSH

Cyproterone acetate as co-cyprindiol containing 35mcg oestrogenUseful for women wishing contraceptionAvoid over 35 increased risk of cardiovasular and thromboembolic diseaseMax effect not seen for 2-3/12 and continue long term, not just 6 months

83% improvement at 6/12 (placebo 63%)

Severe or no response?Nodules/cystsScarringnot controlled by >6/12 oral antibioticspersisting over 25 yrsSignificant psychological effects

Refer for oral isotretinoin ie roaccutaneProduces long term remission 85%Single dose daily for 4 monthsSide effects of roaccutaneDryness and splitting of lipsDry eyesEpistaxesMyalgiaMenstrual irregularitiesIncreased lipidsMay temporarily worsen acneMay rarely induce depressionPotent teratogen, must not become pregnant on it or for one month afterwards

Scarring?Ice pick scars: Dermabrasion Laser resurfacingPunch grafting for deep scars Subcision: a surgical technique in which the fibrous band under the scar is divided, allowing the skin to return to its normal position Larger scars can be excisedSoft tissue augmentation techniques such as hyaluronic acid, collagen, gelatin matrix & fat implantsAtrophic scars: Dermabrasion Hypertrophic scars: Potent topical steroids for a few weeks Intralesional steroid injections Silicone gel dressings Cryotherapy Surgical revision Unfortunately, hypertrophic or keloid scars are particularly prone to recur even after apparently successful treatment.

EducationPatient expectationsTime frame when to expect improvement!Discuss complianceAdverse effectsDuration of treatment

Return visitHand outs?

www.stopspots.org www.m2w3.com/acnewww.bad.org.uk Click here for printable PDF version

Perioral DermatitisUsually young female adultsTopical steroids although may develop withoutGradual onset small itchy spots around mouth, given topical steroids which at first helpand then aggravate

often sparing the vermillion border of the lipsUsually around the mouth

Remember

Papules, pustules No comedonesSparing of vermillion area

Examine elsewhereMay coexist with other pathology

..and may be around the eyes

..and can be subtle!

TreatmentWithdraw steroidsMay get temporary aggravationReassure patient use bland moisturiser rather than top steroids 6 wks oral oxytetracyclineFurther courses seldom required, although may be persistent