Reducing Unnecessary Referrals Bill Tucker Tues 25th Feb

How to define ‘unnecessary’ Still Important to patient Can be dealt with in primary care Treatment no different in 2ndry care Quicker speed of access Diagnosis not a problem Agreed treatment pathway ( as per guidelines)

Eight examples Acne Rosacea Actinic Keratoses Seborrhoeic keratoses Urticaria Hyperhidrosis Psoriasis Eczema and Dermatitis

Acne Leeds Grading: 1-2 - Normal 3-4 - mild-moderate 5-6 – moderate – severe 6 + severe, scarring etc.

Acne Rx Topicals Benzoyl peroxide Topical retinoids Azeleic acid Topical antibiotics- alone or combination ( Zineryt, dalacin) Oral Tetracyclines- oxy, lymecycline, doxycycline Erythromycin Trimethoprim OCP –dianette, or equiv, Yasmin, other combined Spironolactone

Acne – when to send for Isotretinoin Should be reserved for severe (above Leeds 5) or scarring acne Failure of adequate oral antibiotics and topical RX Scarring , truncal, male * needs to join armed forces – timing important Psychological ( lay) assessment

Rosacea and perioral dermatitis Why treat? Rosacea ‘curse of celts’ POD may be self limiting In reality- embarassing, distressing for many Avoid Rhinophyma Approx half have detectable ocular symptoms

POD Stop or reduce with help of therapy, topical steroids Oxytet 1g daily, doxycycline 100mg daily, lymecline 408mg daily, erythromycin 500mg bd – for 2 months Zineryt or dalacin t lotion probably better than metrogel for minor recurrences

Rosacea Diet - no coffee, tea , chocolate, cheese, marmite, spices, booze, - boiled potatoes, lamb, veg…. OXYTET - 1g day, reduced to 250mg long term Doxycycline 100mg day, reduced to 50mg, or 40mg long term Erythromycin 500mg od Metrogel/ Rozex - cream or gel Finacea – Azeleic acid

Actinic Keratoses Practically universal in middle aged/elderly skin type 1-2 males on face, hands Outdoor workers, Golfers, Sailors, Horse riders etc. Dysplastic/ pre-cancerous – but what ratio? Some types hyperkeratotic – can resemble Sq cell Carcinoma

Actinic keratoses If we treat, ( and argument for not,) – how? Simple moisturising with urea based emollients Cryotherapy- OK for less than ? 10 lesions Specific topical agents - all relatively expensive, all require patient selection

AK treatments Efudix – 5% 5FU Actikeral - 5 FU and salicylic acid Solaraze gel - diclofenac The ‘daddy’ regime varies from 2- 3 weeks daily - For Hyperkeratotic lesions 6 – 12 week regime, no need to be selective

AK treatments (2) Imiquimod – Aldara Imiquimod - Zyclara Tiny sachets, 3 x a week for 4 weeks – ferocious reaction plus ‘flu like symptoms etc Tiny sachets daily for 2 weeks, repeat after a month( or not )

AK treatments (3) Picato – euphorbia Face and body concentration- separate Apply to area once daily for 3 days- Begins to react by day 2- pain, then swelling, then becomes crusted. By the time patient realises - job done! Speedy recovery

Seborrhoeic keratoses Cryo – 10 – 20 sec Curette and cautery/ Ag No3 Urea based cream and topical steroids if sore

Urticaria Acute – may be drugs ( aspirin/NSAID), contacts –( wash powder), allergy ? CIU - over 3 months - basic urticaria . Lesions move about during day, don’t last longer than 24-48 hours. May have dermographism, angioedema Autoimmune CIU ….. Physical urticarias-

Physical urticarias Cholinergic Dermographism Cold Aquagenic

Treating urticaria Non-sedating antihistamines - loratidine, cetirizine. - dose 20mg- bd, up to 6 or 8 a day. Fexofenadine 180mg bd Rupatidine H2 s - Ranitidine 150mg bd, Cimetidine 200mg bd Monteleukast Oral steroids

Hyperhidrosis Primary - secondary Localised – generalised Perceived – real Embarassing Bodies

Principles of local Rx Block the duct - chemicals, electrical Block Secretion - Drugs, Botox, surgery Remove sweat glands Disguise odour and moisture (antiperspirants v deodorants)

Antiperspirant use Needs to get where it’s needed – Roll on Aluminium salt - chloride ( 15-20% ) Works best on dry skin( less irritant) Works best overnight Can apply deodorant in morning Can cause soreness , but once dried up , only needed every 1 -2 weeks

iontophoresis Damp pad applied to area, DC current applied Cooks sweat ducts – stings £ 350 for machine Motivation vital

Botox for sweating Axillae, hands, scalp Axillae -30 plus injections -50 units in N/saline per axilla. Repeat 4 -6 months Hands – gives ‘dry grip’ finger tips, palms. May need sedation, or just cooling! Scalp – either – 1cm apart around hair line, and or 1-2cm apart all over scalp

Anticholinergics* Propantheline 15mg bg MR oxybutinin 20 -30mg daily * Pzotifen

B blockers 10-40mg propanolol bd

Best option is combination MR oxybutinin for special events or induction Al Chloride for daily May need Hydrocortisone for soreness

Starch Iodine test Cornflour ( maize starch ) dusted over axilla already painted with aqueous alcohol. Black dots and pools if sweating

Psoriasis What’s new in Rx topically? Dovobet gel . - advantage – not sticky/ greasy

Eczema / Dermatitis Treatment for chronic hand eczema dermatitis –Toctino-alitretinoin Retinoid , so still care in women, watch lipid, lft etc ‘Global assessment – generous measure Prolonged remission Nice says needs to be Derm or GPwSI