primary care dermatology n.
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Primary Care Dermatology
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  1. Primary Care Dermatology Dr Bess Barrett Dr Louise Moss Dr Liz Riches

  2. Aims • What more can be done in primary care • Improve confidence in diagnosing and managing skin lesions – particularly actinic keratoses • Hopefully…reduce referrals to secondary care

  3. Hardwick dermatology Reducing referrals

  4. Aims Reduce referrals but offer patients as good or better dermatology Peer support from consortium. Building positive relationships Value is in problem based learning and the discussion resulting from the consultation (what happens to the next patient and not just to this one) Legacy of improved knowledge and confidence

  5. Method Own GP remains clinically responsible Role is teaching (clinicians and patients) Patients know they can still be referred to hospital Own GP follows up patient Works best if most of the clinicians in the practice attend

  6. Practice requirements Generate enough patients to make the visit worthwhile Organise the clinic so that patients come and that they know what is going on Ensure that doctors/nurses are free to be there Desire to learn and be involved in the discussions

  7. Statistics 9 practices referring in excess of SAR (out of 16 practices) 1st OPD appt taken as an activity proxy Ranging from 4.1 xs to 115.8 xs of SAR Highest spending practice accounted for half of the total ‘above SAR’ spend) = £22,581 (1st appt taken as proxy of activity) Assumption of £120 per 1st OPD appt and £64 for f/u

  8. Kit Liquid Nitrogen Fungal scrapings kit Dermatoscope Cautery Photos

  9. Joint surgeries 7 surgeries booked from August to March Total of 59 patients seen Between 6 and 8 patients per surgery Surgery lasting 2 hours

  10. Clinical mix Eczema mainly Prurigo Actinic keratoses BCCs 2 x Lentigo Maligna (2 ww) 1 x SCC (2 ww) Acne Leg ulcers

  11. Main learning points Eczema – start high, get control, follow up to work out management plan Most itchy rashes are eczema! Detailed instructions on how to use treatment Looking at sun damage – treating with Efudix Patients pick up lack of confidence DermNet NZ and BAD

  12. Challenges for me Explaining my role clearly Need a lot of experience to be confident on one’s own in front of other clinicians and their patients Not knowing diagnosis Patients whose skin is normal Finding creative ways of saying ‘I don’t know’!

  13. What GPs could do more of.. Biopsies to distinguish between diagnoses Curettage and cautery Share LN? Review and management planning

  14. £ Cost per hour of my time £80 7 sessions = £1600 approx 50 patients at approx £200 = £10,000 But – not all of these patients would have been referred. Some were referred who wouldn’t have been 1st OPD appt underestimates the actual cost of the total OPD package Long term legacy is what really matters

  15. Could it fly? All stats are 3 months behind. Long term legacy as yet not assessed Other specialties could offer the same (eg. Headache clinic) Visiting clinicians/consultants need to aim to leave a lasting legacy of knowledge/confidence.

  16. Top tips for primary care management

  17. ECZEMA – Squeezing the most out of treatment Practical Aspects of Topical Therapy

  18. Why Might Topical Therapies Fail? Wrong diagnosis Wrong choice of treatment Inadequate explanation of method and frequency of application Inadequate prescription Cosmetically unacceptable to patient Fear of side effects Patient / doctor’s unrealistic expectations Untreated secondary infection Patient continuing to use an irritant

  19. EMOLLIENTS • Should be prescribed in all cases • Should be applied frequently – at least twice a day • The greasier the emollient, the more effective it generally is • The best emollient for a patient is the one they prefer to use • Most can be used as a soap substitute • Well controlled eczema will require at least • Approx 500g topical emollient/month • Approx 500mls bath oil/month

  20. Topical Steroids Extremely effective treatment for inflammatory skin disorders Potency needs to be adequate to treat Start high and step down, once daily treatment Should be applied for as long as it takes the inflammation to come under control then the potency and frequency should be reduced. Wet weepy eczema - use creams Dry scaly eczema – use ointments Leave ½ hr between different products

  21. Weekender method for frequent flares • Elocon ointment daily for 2 weeks then alternate days for 2 weeks • Once the eczema is under control use elocon on 2 consecutive days of each week ( weekends) to the areas that tend to flare

  22. Quantities • Fingertip Units (FTUs) • One FTU is the amount of topical steroid that is squeezed out from a standard tube along an adults fingertip from the very end of the finger to the first crease • One FTU is enough to treat an area of skin twice the size of the flat of an adults hand with fingers together • One FTU is about 0.5g

  23. Finger tip units (adult) 4 FTUs = 2 g per dose = 30g per week if used twice a day

  24. Fingertip units (child)

  25. Using Occlusion • Wet wraps / Comfifast suits • Efficient means of delivering emollients • Occludes and therefore protects the skin • Maintains a constant temperature and therefore reduces the tendency to scratch • Occlusion of topical steroid increases effective potency • Don’t suit every child • Avoid until infection is controlled

  26. Elasticated viscose stockinette size chart • Comfifast is cheaper than Tubifast • Comfifast garments easier to use for children • Greasy emollient at night under cotton gloves very good for difficult hand dermatitis

  27. Take Home Messages Take a detailed history of exactly what the patient is doing Prescribe sufficient quantities Prescribe adequate potency Give it time to work Make sure patient/parent knows how much to use /when to use it Remind patients to avoid soap Don’t forget about occlusion Treat infection especially in children

  28. Useful Websites

  29. ACNE

  30. History • Duration of acne/ treatments tried/ response/ psychological effects/ possibility of pregnancy Examination • Assess and record sites affected/ types of lesion/ severity Treatment aims • Decrease severity/ prevent scarring/ reduce psychosocial impact • May take up to 6 months for full benefit • Treat the different causes- Seborrhoea/ microcomedone formation/ inflammation/ infection p. acnes

  31. Mild acne Comedonal Topical Retinoid – Adapalene/ Retin A applied at night- build up over 2-3 weeks Inflammatory Epiduo ( adapalene + benzoylperoxide) once daily Or Topical antibiotics in combination with benzoyl peroxide Apply to whole area not just individual lesions

  32. Moderate AcneMore widespread- more inflamed lesions Systemic antibiotics – at least 4/12 course 1st Line Doxycycline 100mg od 2nd Line Lymecycline 408mg od 3rd Line Erythromycin 500mg bd Trimethoprim 200- 300mg bd Ideally + topical retinoid at night ( adapalene) / benzoyl peroxide wash 10% at least twice weekly Consider Co-cyprindiol in women Until control achieved then 2-3 cycles more- switch to skin friendly pill- e.g cilest

  33. Severe – Widespread Inflamed lesions, papules,pustules, nodules, scarring Optimise antibiotic treatment Doxycycline 200mg daily/ Trimethoprim 300mg daily Discuss referral for oral isotretinoin if failed response to 2 4/12 courses of different antibiotics ( sooner/urgently if severe nodulocystic lesions/ scarring)

  34. If referring to secondary care... • Ensure 2 different antibiotics have been tried for at least 4/12 each • Counsel patients re side effects of Roaccutane • Skin dryness, mood changes, muscle aches, minimal alcohol, need for blood test monitoring • Establish 2 forms of contraception if female • Check Fasting Lipids, LFT, FBC

  35. Consider audit of acne prescribing Are there any patients still on Minocycline? How many have been on Dianette for >6/12? Are any patients on oral and topical Abx? Are patients on oral antibiotic co-prescribed a retinoid and benzoyl peroxide? In patients referred with acne how many went on to have roaccutane ?- had primary care been optimised prior to referral?

  36. Troublesome Scaly scalps • Step 1: Remove Scale • Step 2: Suppress the underlying condition

  37. Step 1:Removing stubborn scale Agents: Sebco ointment 10% urea in Unguentum M Apply at night to scalp cover with shower cap Wash off next morning May need to do this 2-3 nights before other Rx Nightly for a week, repeat weekly thereafter

  38. Step 2: Suppressing the underlying condition Agents- apply immediately after washing Non/low alcohol preps reduce stinging: Synalar gel 30g/60g Betnovate lotion 100ml Bettamouse 100g Clarelux Foam 100g Other preparations: Betacap 100ml Mometasone 30ml Calcipotriol scalp application ( 2nd line in psoriasis) Try to avoid Dovobet gel due to cost - £36/60g

  39. PSORIASIS Mr Anderson, you have Psoriasis. Pso?

  40. Stable Plaque Psoriasis • Most common variant • May be widespread – up to 90% BSA • Genitalia involved in up to 30% of patients • Patient Complaints • Unsightliness of the lesions • Low self-esteem • Feelings of being socially outcast • Excessive scale

  41. Stable Plaque Psoriasis • Emollients • Corticosteroids • Medium potency, stronger agents can be used on palms and soles or on the scalp • Abrupt withdrawal can cause rebound and risk of erythroderma • Vitamin D3 Analogues (Calcipotriol, Dovobet) • Try calcipotriol in combination with steroid – one in the morning, the other at night • With dovobet improvement should be seen after 4 weeks

  42. Coal Tar based treatments (Carbodome 10%, Exorex cream/ lotion5%) • Avoid face and flexures • May take 6-12 weeks • Dithranol (0.1% - 0.3%) • Use only in stable psoriasis • Avoid face and flexures • Short contact treatment starting with lowest strength and increasing every few days • Side effects • Skin irritation • Staining

  43. Scalp Psoriasis • Can occur in isolation • Management options • Tar shampoos (capasal/ polytar/ T-Gel) • Potenttopical steroids • Vit D analogue scalp soln • Creams can be used in small areas • 10% urea in Unguentum merk

  44. Flexural Psoriasis • Plaques often shiny without scale • Steroid creams with antibiotic and antifungal agents work best • Trimovate • Timodine • Daktacort

  45. Guttate Psoriasis • Occurs most frequently after a streptococcal throat infection – so swab and treat • Usually resolves spontaneously within 12 weeks • If treatment desired • Emollients helpful • Coal tar (1-10% in WSP ) or Psoriderm or Alphosyl HC • (Phototherapy )

  46. Remember...... Can start at any age but peaks in 2nd and 6th decades Always check fingernails as can aid diagnosis in early disease Often overlaps with seborrhoeic dermatitis Beware making diagnosis of psoriasis when pt has only a solitary scaly erythematous patch Manage expectations and lifestyle factors Caution with oral steroids

  47. Urticaria

  48. Urticaria • Chronic urticaria often idiopathic – cause not found. May relapse / remit over several years • Few investigations necessary – fbc/tfts/esr • Ask specifically about Aspirin/Nsaid/ACE/codeine use • Management • dispel myths • Explain prognosis/aim is to control not cure • Avoid triggers/ exacerbating factors • Antihistamines – can use higher than standard dose( cetirizine 20mg) or in combination of sedating and non-sedating ( hydroxyzine/doxiepin 10-50mg at night) • Patient information – BAD leaflet ‘ urticaria and angioedema’ • Referral rarely helpful – refer if concern re urticarial vasculitis, at least 2 antihistamines not helpful or troublesome angioedema

  49. Perioral Dermatitis