Acne Vulgaris

1. 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 steroidssee 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