itchy, scratchy, red and patchy: derm tips for primary care · desloratadine*, ebastine,...

Itchy, Scratchy, Red and Patchy: Derm tips

for primary care Robert Gniadecki, MD

Faculty/Presenter Disclosure

•  Faculty: Robert Gniadecki

•  Relationships with financial sponsors:

•  Grants/Research Support: N/A

•  Speakers Bureau/Honoraria: Therakos; Mallincrodt; Janssen; Abbvie; Novartis; Leo Pharma

•  Consulting Fees: N/A

•  Patents: N/A

•  Other: Mallincrodt; Janssen; Amgen; Abbvie; Eli Lilly; Sanofi; Novartis; Leo Pharma

Disclosure of Financial Support

•  This program does not receive financial support.

•  This program is presented by the ACFP without financial support.

•  The ACFP provides a speaker fee and expense support for presenting at the event.

•  This program does not receive in-kind support.

•  This program is presented by the ACFP without in-kind support.

Mitigating Potential Bias

•  Material/Learning Objectives and/or session descriptions were developed and reviewed by the Planning Committee composed of experts/family physicians/allied care professionals responsible for overseeing the program’s needs assessment and subsequent content development to ensure accuracy and fair balance.

•  Consideration was given by the Planning Committee to identify when speakers’ personal or professional interests may compete with or have actual, potential, or apparent influence over their presentations.

•  Information and/or recommendations in the program are evidence- and/or guidelines-based, and the opinions of the independent speakers will be identified as such.

urticaria •  Smooth, slightly elevated papules or plaques (wheals) that are

erythematous and that are often attended by severe pruritus. •  Individual lesions resolve without scarring in several hours. •  Most cases of urticaria are self-limited and of short duration

(acute urticaria). Chronic urticaria is > 6 weeks •  Most cases are NOT allergic •  Causes:

A. foods B. medications (especially aspirin, NSAIDs, antibiotics, over-the-

counter (OTC) medications, herbs, and supplements) C. infections D. physical stimuli (eg, heat, cold, pressure, vibration) E.  insect bites or stings

Urtica dioica

International EAACI/GA2LEN/EDF/WAO guidelines: definition and classification of

chronic urticaria

Zuberbier T, et al. Allergy 2018;73:1393–1414; Zuberbier T, et al. Allergy 2009:64:1417–26..

Urticaria may coexist with angioedema

Angioedema:

Swelling of the subcutaneous tissue

Painful rather than itchy

Common areas involved: face, lips, eyelids, genitals, hands and feet

Usually resolves in less than 72 hours

Zuberbier T, et al. Allergy 2018;73:1393–1414

Work-up

Differential blood count

ESR or CRP

Omission of suspected drugs (e.g. ACE-I, NSAIDs)

Directed investigations Causes Description Tests

Infectiousdiseases

Bacterial,viral,parasitic,orfungalinfectionshavebeenimplicatedtobeunderlyingcausesofCIUFrequency/relevancevariesbetweenpatientgroupsandregions

H.pylori,Streptococci,Staphylococci,Yersinia,Giardialamblia,Mycoplasmapneumonia,Hepatitisvirus,Norwalk,ParvovirusB19,Herpessimplex,Entamoebassp.,Blastocystisspp.

TypeIallergy Rarebutcanbeconsideredinpatientswithintermittentsymptoms

Skintests,includingphysicaltests(eg,coldprovocation)

Pseudo-allergy Pseudo-allergen-freediet AvoidanceofNSAIDsfor3weekstoruleoutnon-allergichypersensitivityreaction

Functionalautoantibodies

AutoantibodiesagainstIgEorFcε�R1 Autologousserumskintest

Thyroidcauses Thyroidhormonesandautoantibodies

Malignancy Notrecommendedroutinely,butwarrantedifsuggestedbypatienthistory

directed(PET-CT,markers,other)

Severesystemicdisease

Tryptase


CSU - treatment algorithm 1.  Second generation antihistamines (2 weeks) (bilastine* cetirizine*,

desloratadine*, ebastine, fexofenadine*, levocetirizine* and rupatadine*)

2.  Increase dose x2 and then x4 (max 4 weeks)

3.  Add Omalizumab

4.  finally, as fourth line, consider ciclosporin. For exacerbations consider Prednisone

*-can be safely used in children

Loratadine can safely be used in pregnant women based on the metaanalysis data and EAACI recommendation (not in label) (Schwarz, Drug Safety 2008;31:775-788)


H1-antihistamine Standarddailydose

Cetirizine (Reactine®) 10 mg

Fexofenadine (Allegra®) 60 mg bid

Loratadine (Claritin®) 10 mg

Desloratadine (Aerius®, Clarinex®) 10 mg bid

Levocetirizine (Xyzal®) 10 mg bid

Rupatadine 10 mg

Bilastine 20 mg

Are 1st generation antihistamines of any value?


NO drowsiness, bad quality sleep, anticholinergic effects, QT interval prolongation, …..

Urticaria - derm tips ●  It is a clinical diagnosis ●  If >6 weeks - chronic urticaria. ○  Look for drugs (NSAID) as triggers ○  Ask for possible inducible urticaria (cold, heat, pressure,

scratching, cholinergic (sweating), sunlight) and try to provoke

○  All remaining cases will likely be chronic idiopathic urticaria

○  Don´t do extended workup ●  Treat with 2nd generation antihistamines, if failure increase

the dose x2 and x4 ●  Refer resistant cases to dermatology

https://jamanetwork.com/journals/jama/fullarticle/1829686

Itchy

Pink

Slightly scaly

How to recognize AD?

How to diagnose?

age, location, scaly-itchy-red rash

What is prognosis?

80% spontaneous remission

5% persists to adulthood

food - environment - climate affect AD

What are the complications?

hand eczema and allergic eczema

20% asthma

infections: impetigo, herpes, molluscum

★  Exacerbation: mild corticosteroids (1% - 2 % Hydrocortisone) for 7-14 days with slow tapering

Treatment of pediatric patients: Mild AD

Eichenfield LF, et al. Pediatrics 2015;136:554-565

★  Moisturizers (creams, fragrance- and parabene free)

★  Bath (short)

★  Dilute bleach bath 0.5 cups sodium hypochlorite per 40 gallons bathtub

★  Trigger avoidance (soaps, wool, cold weather)

How many grams of cream should be prescribed weekly for sufficient therapy

(whole body, used twice daily) ? - infant? - child? - adult?

100 - 200 - 300 g

Eichenfield LF, et al. Pediatrics 2015;136:554-565

Exacerbation: medium potency corticosteroids (e.g. 0.1% mometasone fuorate) for 7-14 days with slow tapering


Treatment of pediatric patients: Moderate AD

aAs tolerated during flare; direct use of moisturizers on inflamed skin may be poorly tolerated; however, bland petrolatum is often tolerated when skin is inflamed. . Eichenfield LF, et al. Pediatrics 2015;136:554-565.

★  Moisturizers (creams, fragrance- and parabene free)

★  Bath (short)

★  Dilute bleach bath 0.5 cups sodium hypochlorite per 40 gallons bathtub

★  Trigger avoidance (soaps, wool, cold weather)

★  Maintenance: non-steroid calcineurin inhibitor (tacrolimus or pimecrolimus) / mild corticosteroid


Atopic dermatitis - tips

●  It is a clinical diagnosis - age and lesion distribution ●  Moisturize, moisturize, moisturize ●  Infection control ●  Calcineurin inhibitor as maintenance ●  Intermittent steroids for exacerbations ●  Think of risk of occupational hand eczema in adolescents ●  Insufficient control - refer

SKINDISEASE

JOINTDISEASE

CO-MORBI-DITIES

Psycho-logical

Hepatic

Cardio-vascular

Diabetesand

metabo-lism

Depres-sion

Cancer

Renalinsuf-ficiencyNail

disease

Spondylo-arthro-pathy

Peripheral

arthropathy

Softtissueinflammation

IBD

MS

Psoriasis reduces life expectancy by 5 years

GulliverW,etal.BrJDermatol2008;159(Suppl2):2–9.

44% of deaths in psoriasis are related to cardiovascular disease vs 36% in the normal

population

Practice gap: Suboptimal medical management of coronary risk factors in patients with psoriasis

AhlehoffO,SkovL,GislasonG,LindhardsenJ,etal.(2012)PharmacologicalUndertreatmentofCoronaryRiskFactorsinPatientswithPsoriasis:ObservationalStudyoftheDanishNationwideRegistries.PLoSONE7(4):e36342.

Psoriasis - derm tips

●  Screen your patients for CVD ●  Severe psoriasis has the same weigh as diabetes when

calculating CVD risk

Efficacy of sunscreen in real world

Sunscreens - derm tips

●  Sunscreen DO protect against skin cancer and skin aging ●  Sunscreens DO NOT have appreciable hormonal side

effects ●  SPF30 is sufficient , but must be applied 2mg/cm2 ●  One application daily is enough

Strategy 1: Apply before sun exposure and reapply once within1 h.

People apply usually a mean quantity of sunscreen of 0.71 mg/cm2 at first application and 1.27 mg/cm2 at second application

Strategy 2: Use higher SPF than necessary.

There is a linear relationship between application density and the actual SPF

Sunscreens labeled SPF 70 and 100 applied at 0.5 mg/cm2 provided an actual SPF value of, respectively, 19 and 27.

itchy, scratchy, red and patchy: derm tips for primary care · desloratadine*, ebastine,...

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