ALL THINGS DERMATOLOGY

Dr Aravind ChandranDermatologist

Auckland District Health Board and Skin Specialist Centre

Honorary LecturerUniversity of Auckland

ALL ∧ THINGS DERMATOLOGY

PITFALLS & PRACTICAL TIPS

Dr Aravind ChandranDermatologist

Auckland District Health Board and Skin Specialist Centre

Honorary LecturerUniversity of Auckland

Outline

■ Pitfalls and practical tips in managing skin conditions

Use of Steroids

Liquid Nitrogen/Cryotherapy

Diagnosing Pigmented lesions

Clinical Photography

Steroids in dermatology

Steroids in dermatology

– Topical

■ Formulations – ointment , cream, lotions, gel, foam

■ Combinations : antifungals, antimicrobial, antibacterial

■ Compounded

– Oral

■ “Standard” course

■ Slow taper

■ Mini-pulse

– Intra-lesional

– Intramuscular

– Intravenous

Topical Steroids in Dermatology■ “Pillar” of skin therapeutics

– Ease of use

– Less systemic effects

– Safe in pregnancy ( class I –III)

■ Potency and steroid step ladder

Topical Steroids - Pitfalls

■ Suboptimal medication use

– Wrong potency –

■ scalp vs vs hands and feet vs face vs body vs flexures

– Improper formulation

■ Insufficient dosage

– Steroid phobia – patient and practitioner

– Under use more common than overuse

■ Lack of patient adherence as a result of inadequate patient education or adverse drug events

■ The use of combination steroid/antifungal formulations

Topical Steroids■ Practical Tips:

– Familiarize topical steroids potencies

– Finger tip units FTU

– Consider formulation

■ Location

■ weeping?

■ Contact sensitivity

– Occlusion

– Wet wraps

– Tachyphylaxis

– “Weekend” therapy - for prevention frequent flares

– Patient education, written plans, information leaflets

ORAL Steroids■ Used for inflammatory skin disease

– Often over prescribed

■ Long-term use associated with significant side effects

■ PITFALLS

– No formal diagnosis

– Repeated course – short and sharp

– Lack of bone protection and immunization in longer term use

■ TIPS:

- Establish a diagnosis before committing to treatment course

- Slower taper and supplementing with potent topical to prevent rebound

- Plan for early switch to steroid sparing agents

- AVOID in psoriasis – may de-stabilise and result in erythroderma or pustularpsoriasis

- Medical alert bracelets

- Bone protection

Intramuscular steroids■ Under utilised

■ IM vs PO steroids

– Equally effective

– Better compliance especially with need for long tapering doses

■ Greater efficacy and safety

– Lower total dose when used long-term – fewer side effects

– Adverse effects (as per oral ) PLUS

■ IM can result in lipoatrophy at injection site

■ Dysmenorrhea in females

LIQUID NTROGEN CRYOTHERAPY

LN - Cryotherapy

■ Effective, simple and inexpensive treatment

■ Suitable for outpatient setting and poor surgical candidates

■ most commonly used

– actinic keratoses

– warts, molluscum

– benign, premalignant lesions

– malignant (superficial) lesions

■ Destruction of benign lesions requires temperatures of −20°C to −30°C

■ Effective removal of malignant tissue often requires temperatures of −40°C to −50°C.

Mechanism of action

Cryotherapy - PITFALLS■ Treating undiagnosed lesions

– Avoid in pigmented lesions

– If unsure biopsy first

■ Do not treat thickened or raised lesion

■ Under treating malignant lesions

■ Poor cosmetic results in exposed sites

■ Single/long cycles

– Swelling, blistering, ulceration

■ Caution on special sites:

– Pretibial lesions – prone to ulceration

– Eyelids- swelling, haemorrhage

– Hair-bearing skin – may result in scarring and alopecia

CRYOTHERAPY- TIPS

– Cone tip

■ Reduces contamination and focuses treatment

– Feathering at edged to avoid abrupt cut off

– Overlapping treatment areas for large areas

– De-bulking hyperkeratotic areas

– Use nozzles and attachments

– In malignant lesion

■ Draw a margin

■ Repeated ‘freeze – thaw’ cycles

Medscape image

PIGMENTED LESIONS -DIAGNOSIS

Biopsy of pigmented skin lesions■ 2010 NZMA Audit by Rademaker et al

■ 37% of cases referred had no useful clinical information

■ OUTPUT results = INPUT of information provided

■ 40% of lesions where a melanoma was considered, and 32.5% of lesions identified as pigmented lesions, were punch biopsied

■ 2470 patients with melanoma, punch and shave biopsy significantly increased the odds of misdiagnosis by 16.6- and 2.6-fold respectively, compared to excisional biopsy. Punch biopsy increased the risk of a misdiagnosis with adverse outcome by 20-fold (p < 0.001).

■ Smaller the percentage of lesion removed by biopsy, the greater the degree of inaccuracy was likely to occur

■ Whole lesion if possible

■ Serial punch or representative incisional bx – not single punch biopsy

CLINICAL PHOTOGRAPHY

Clinical Photography

■ Documentation – rash, lesions, cosmetic procedures

■ Treatment progress

■ Monitoring/Self observation with “selfies”

■ Professional development/learning

■ Medico-legal

■ Referrals

■ Tele-dermatology opinions

Pitfalls and TIPS

■ Consents – informed consent - verbal or written

■ Patient identification or de-identification in with facial photos

■ Lesion observation Macro +/- Dermoscopy (not ONLY dermoscopic images)

– Location/distribution shot – waist up/down/front back/arms and legs

– Close-up macro

– Dermoscopy if available

■ Taking the photograph

– Get to know your equipment

– Composition

■ Storage and handling of images – patient privacy

Lighting

©AppwoRx

POSITIONING

©AppwoRx

BACKGROUND

©AppwoRx

Clinical Photography apps

■ Picsafe

■ Epitomyze capture

■ Rx Photo

END

enquiry@skinspecialistcentre.co.nz