1. Reducing Unnecessary Referrals
Bill Tucker Tues 25th Feb

2. 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)

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

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

7. 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

9. 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

10. 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

11. 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

13. 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

15. 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

16. 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

17. 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

18. 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 )

19. 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

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

24. 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 hours. May have dermographism, angioedema
Autoimmune CIU …..
Physical urticarias-

25. Physical urticarias
Cholinergic
Dermographism
Cold
Aquagenic

26. 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

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

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

29. 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

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

31. 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

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

33. B blockers
10-40mg propanolol bd

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

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

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

37. 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