1. Management in primary care
Acne Vulgaris
Management in primary care

2. Why treat Massive psychosocial impact Leaves life long scarring
Effective treatments

3. Severity
Mild Moderate Severe

4. Mild acne

6. Mild comedonal

7. 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)

8. 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

9. Moderate acne

12. 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)

13. 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

14. When to refer

18. 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)

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

20. 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

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

22. A problem with barrier of skin

23. 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

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

25. 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

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

27. 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

28. 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

29. 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

30. 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

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

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