Common Medical Problems during Adolescence

1. Common Medical Problems during Adolescence Updated July 2016 1

2. Learning objectives • To describe the range of common medical problems that young people present with in clinical practice including skin problems, musculoskeletal conditions and fatigue. • To describe the adolescent-specific aspects of these conditions • To demonstrate the skills in assessment, diagnosis and management of the conditions highlighted.

3. Outline • Intro • Dermatology • Fatigue and Sleep • MSK

4. Multiple health complaints@ 15 years www.hbsc.org (2013/2014 survey)

5. Multiple Health Complaints www.hbsc.org.uk, England 2014 survey

6. When to Worry • Co-occurrence of multiple symptoms • Chronicity > 3 months •  School attendance • Isolation • Recent family, school, psychological problems

7. Presentations of Adolescents to primary care • 16-24 year olds (Australia) • Respiratory 13.8% • MSK - back pain 11.1% • Skin – acne 10.4% • 13-15 year olds (UK) • Respiratory conditions 35.1% • Skin (acne and eczema) 28.9% • Musculoskeletal conditions (including trauma, sports injuries, and joint problems) 22.1%

8. Common Somatic Symptoms • Passport symptoms • Hidden agendas • Windows of opportunity

9. AcneTypes of lesions • Non-inflammatory Mild acne • Comedones • Closed (whiteheads) • Open (blackheads) • Inflammatory Moderate acne • Papules • Pustules Severe Acne • Nodules • Cysts • Scars

10. Acne • 85% of adolescents have acne to some degree • Due to  androgen-induced sebum production  Abnormal keratinisation leading to ductal obstruction + Proliferation of propionibacterium acnes  Inflammation! • Important psychosocial consequences • Impact on self-esteem and body image of the developing adolescent • May affect social interactions

11. Psychosocial judgements and perceptions of adolescents with acne vulgaris: A blinded, controlled comparison of adult and peer evaluations Ritvo E et al, Biopsychosocial Medicine 2011

12. Q. Which of the following are the effect of having acne? Not shown in the graph above; None of these = 14%, Other = 4%.

13. Acne Management • Explore perceptions regarding impact on self-image and social relationships • Address myths and misconceptions Eg the central discloration of blackheads is not dirt but oxidised melanin • Emphasise “it takes time” • Self-management skills including adherence

14. Topical Therapy • Benzyl Peroxide 2.5-10% • Bacteriocidal, mild comedolytic, anti-inflammatory • Night use • Gels better than alcohol • Often worse before gets better • ADR: peeling and irritation; contact dermatitis; bleaching of towels and clothing • Antibiotics • Tetracycline, erythromycin, clindamycin

15. Topical Therapy • Retinoids (vitamin A derivatives) • Decreases folllicular plugging • Alternate nights initially • Cream less irritating than gel • Avoid sun exposure (sunblock) • NB Contraception advice

16. Systemic Therapy • Antibiotics • (avoid combination with topical antibiotic therapy as resistance) • Minocycline, Doxycycline, Tetracycline, Erythromycin • Isoretinoin • Specialist supervision • For nodulocystic acne • Teratogenic • Significant toxicity • Hormonal • Oral contraceptive pill • Antiandrogens Eg in Polycystic Ovary syndrome

17. Acne @ 2013! • Dawson AL, Dellavalle RP. Acne vulgaris BMJ. 2013 May 8;346:f2634.  • Eichenfield LF, Krakowski AC, Piggott C et al; American Acne and Rosacea Society. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics. 2013 May;131 Suppl 3:S163-86.

18. Pityriasis Rosea • herald patch 2-6cm, 2-21 days before the rash (DDx eczema) • maculopapular rash • Oval, sl. scaly lesions 1-2cms • Rash follows Langer's lines (cleavage lines; Xmas tree pattern) • Not painful or itchy. • Trunk and extremities • Lasts 1-2 months then fades • No treatment

19. Tinea Versicolor • hypopigmented or hyperpigmented macules or patches • upper trunk and arms: occasionally on the face and neck. • Pityrosporum orbiculare. • usually asymptomatic • Predisposing factors: Humidity, hyperhidrosis, heredity, diabetes mellitus and corticosteroids Diagnosis: observation of hyphae and spores (spaghetti and meatballs) on potassium hydroxide wet mount. Wood's light - shows yellow/brown fluorescence Rx: topical antifungals , daily for 2 weeks

20. Acanthosis Nigricans • gray-brown thickening of the skin. • symmetrical, velvety, papulomatous plaques, with increased skinfold markings. • base of the neck, axilla, groin, and antecubital fossa. Associations • obesity • insulin resistance • Malignancy (adults) Management • Screen for diabetes • Encourage weight loss

21. Erythema nodosum • Wide Differential • Includes • Infections – viral, strep, TB • Drugs inc Oral contraceptive pill, codeine • Systemic disease inc Inflammatory bowel disease, SLE, sarcoidosis

22. SLE • Photosensitive malar rash of SLE • Many “classic teenage complaints” eg • Fatigue • Anorexia • Raynauds • Mouth ulcers • MSK pain • Headaches • Moodiness!

23. Raynauds • Classical • White  blue  red • Discomfort on re-warming • Triggers – cold, anxiety • Differential diagnosis • Underlying Connective tissue disease (unlikely if ANA negative and normal nail fold capillaries)

24. Nail Fold Capillaries in SLE

25. Raynauds • Gloves and socks! • Moisturisers and emollients • Avoidance of triggers, smoking • Advice for PE teachers at school • Trial of Calcium blockers eg Nifedipine slow release

26. Outline • Intro • Dermatology • Fatigue and Sleep • MSK

27. Young People, Sleep and Fatigue http://www.sleepscotland.org/sound-sleep/

28. Adolescent Sleep Important as • A cause and the result of health problems • 2 independent but related processes • A daily circadian rhythm • The sleep-wake pressure (homeostatic) system, (sleep “urge”)

29. Adolescent sleep“he won’t get out of bed in the morning!” • The Pubertal phase delay • Pubertal slowing of the circadian timing system • Sleep pressure system changes during puberty - easier to stay awake longer in later puberty • Found in adolescents of other species so has an evolutionary purpose (?!) • During puberty, variation in alertness across the day (young children have less variation)

30. Too sleepy OR too tired? • Sleepiness =  tendency to fall asleep • Fatigue = abnormal exhaustion after normal activities

31. www.hbsc.org (England, 2014)

32. Limited Awareness Documentation in Case-Notes of Adolescents with JIA in 10 UK centres • 8% • Improved to 29% post implementation of a Transition programme (p<0.001) Robertson L et al, 2006

33. Key Sleep Diagnoses (i) Delayed Sleep Phase syndrome (DSPS) • Most common sleep disorder • Up to 7% of adolescents • Difficulty falling asleep (2-4am then wake late) • Disrupted circadian rhythm • NB different from YP who choose to stay up late but fall asleep very quickly! (ii) Obstructive Sleep Apnoea

34. Other Sleep Disorders • Night terrors • Sleep walking (pre-pubertal) • Sleep-onset anxiety • Restless legs syndrome • Narcolepsy

35. Antecedents of Adult Health • Adolescent sleep disturbances predicted adult sleep disturbances If problems at 16 • A third still had problems at 23 years • 10% at 42 years Dregan A & Armstrong D 2010

36. Sleep History Sleep • Habitual bedtime and rise time • Sleep duration • Sleepiness • Difficulties falling asleep (sleep-onset latency) • No of night wakings • No of daytime naps • Subjective opinion • Fatigue • Other sleep problems • Beliefs

37. Sleepy HEADSS! • Home: Bed room environment • Education: Schoolday vs weekend (sleep irregularities) School achievement • Activities:Cell phone/computer use;competing demands • Drug use include caffeine/energy drinks • Safety – Injuries, Driving • Suicide – mood; anxiety

38. Sleeping BEARS! (Jones JA & Dalzell V, 2005)

39. Sleep Promotion!! • “Crash in Bed – Instead”; “ Sleep Smart” • Positive benefits of Sleep Education Programmes James SL, 1998; Rossi CM 2002; Cortesi F, 2004 Young Person’s Perspective! • 87% - good/excellent • 90% - felt it useful Cortesi F et al, 2004

40. The Energy Debt during Adolescence Physiological demands of growth Social and educational demands

41. Fatigue: Definitions Important to distinguish • Physical fatigue, • physiological • refreshing AND • Psychological fatigue • “I don’t like doing anything” “I’m tired” may mean “I’m depressed”.

42. Epidemiology of Fatigue Rimes KA et al, 2007

43. Chronic Fatigue Syndrome Persistent debilitating severe fatigue for ≥ 6m (? 3m in adolescents) Plus CFS related Symptoms • Un-refreshing sleep • MSK: Muscle and/or joint pain • Headaches • ENT: Sore throat, Tender cervical/axillary lymph nodes • Neuropsych: Concentration, Memory problems Which cannot be explained by another medical or psychiatric illness

44. Differential Diagnosis • Infections • Medications and substance misuse • Anaemia • POTS – postural orthostatic tachycardia syndrome (may be 20 to CFS) • Endocrine • Chronic disease eg SLE • Neurological • Psychological inc depression, eating disorders, refusal syndromes

45. Assessment • TIME++++ • Acknowledge distress and disability • “Symptoms are REAL” • Thorough history • Thorough examination (inc MSK, neuro, lying and standing HR and BP) • Assessment of psychological well-being, family functioning, social and educational development

46. Baseline Investigations • FBC • Acute phase response markers (ESR, CRP) • Basic biochemistry • Thyroid function • Muscle enzymes (CK,AST, LDH) • Immunoglobulins • Autoantibodies (ANA, coeliac) • ? Re Addisons • ? EBV and Lyme disease

47. Factors suggesting an organic cause • Increase fatigue over the day • Reduce with rest • Associated physical symptoms eg weight loss, fever, etc

48. Management • Invest time in giving the diagnosis • Acknowledge the reality of the symptoms • Enable ownership of the management programme by the YP as well as engagement of the family • Multidisciplinary approaches • Focus on functional improvement and symptom control

49. Think of a young person with chronic fatigueand imagine what aspects of their lives they would use to create their fatigue/energy spider… Energy/ Fatigue

50. Management • Energy Spider! • Goal setting with YP with regular review • Activity Diary • Activity management • Graded Activities and Exercise programme • Graded re-integration programme • Sleep hygiene • Dietary • Rx depression and mood disorders • CBT • Simple analgesia and non-pharmacological pain relief • ? Role of SSRI, melatonin • Management of relapse • Family support • Regular review (GP/paed team)