Management in primary care Acne Vulgaris Management in primary care

Why treat Massive psychosocial impact Leaves life long scarring Effective treatments

Severity Mild Moderate Severe

Mild acne

Mild comedonal

mild acne Over the counter products to treat and prevent recurrence Use oil free products eg make up Advise low glycaemic index, Zinc and less dairy Avoid picking/ squeezing (acne excoriee)

Consider predominant lesions Inflammatory – benzoyl peroxide (2.5-5%) Comedonal – retinoid gel/cream Tips Needs 2-3 months to show improvement If irritation reduce dose, frequency of application, change formulation

Moderate acne

Moderate acne Use combination products (minimum 2-3/12) epiduo (BPO + retinoid) Duac ( AB +BPO) treclin (AB + retinoid ) Zineryt (AB plus zinc) – in pregnancy For women (especially PCOS) consider dianette (can be used for 3-4 cycles after acne clears)

Progress to oral antibiotics First choice doxycycline and lymecycline Always use a non-AB topical Use for 3 months only then continue topical 2nd line trimethoprim 300mg bd Erythromycin 500mg bd for pregnant women and children

When to refer

When referring Make sure women are on two forms contraception if sexually active Arrange bloods to be done 2 weeks prior to appointment (FBC UE LFT and lipids)

ECZEMA Currently around 6 million in UK (underestimate) Increasing 1in 5 children 27 million + prescriptions a year

eczema A massive impact on QOL 90% itch or pain 70% sleeplessness and fatigue 74% stress was a trigger – vicious cycle Social embarrassment and bullying

Investing time with patient at the start has massive impact on patient self management and reducing GP attendances

A problem with barrier of skin

treatment Moisturisers and soap substitutes work at this level so should always be used even between flares Avoid triggers (from history) Steroids are required when the eczema flares

steroids Try to remember one from each group Potent – mometasone / Betnovate Moderate - eumovate Mild - hydrocortisone 1% Creams / ointments ?

Fear of steroids Widespread sub- optimal management of eczema in primary care due to unfounded fears Need to educate both practitioners (esp pharmacists) and patients HC1% does not cause atrophy but should be avoided on eyelids where absorption can occur

Flare require potent steroids see hand outs i finger tip = 2 palms

Eyelids Consider tacrolimus ointment (protopic 0.1% and 0.03%) and pimecrolimus cream ( elidel ) once flare is under control with steroid Should be applied bd for one month then od for one month and try tailing off. Consider twice weekly long term as well No long term adverse effects seen

Triggers and irritants Avoid extreme temperature changes Irritant clothing – wear cotton Perfumes, soaps, skin irritants etc Animal dander, pollen, dust mite etc – triggers vary Pollution Stress

Recurrent infections Takes wet swabs (skin and nose) Use dermol as soap during infections only Oral antibiotics may help but often not required if eczema is treated adequately

When to refer Routine referral Diagnosis uncertain Eczema is associated with severe recurrent infections Contact allergic eczema suspected Causing serious social or psychological problems for child or carers Eczema not controlled to the satisfaction of carers or child

Case scenario Rapid development of numerous monomorphic, punched-out erosions with haemorrhagic crusting ± vesicles

Eczema Herpeticum Widespread herpes simplex infection on a background of eczema Refer to secondary care urgently