Dermatologycases

SarahMulligan2ndyearGPtrainee

•  23yoman•  2/7hxofrashle=shoulder/neck–  dischargingperianalfistula

•  BG:CrohnsDisease•  Humira4omgs/cweekly•  Azathioprine125mgOD

•  Whatelsedoyouwanttoknow?

•  Whatitis?•  Howwouldyoumanagethis?

•  Isthereanyevidencefortreatment?

•  What’syourdifferenRaldiagnosis?

DifferenRaldiagnosisforvesicularrashinthisman

•  InfecRon:– Viral\Bacterial

•  Autoimmuneblisteringdisorder– Mostlikelybullouspemphigoid

•  BlisteringdrugerupRon•  ContactdermaRRs

HerpesZoster

•  ReacRvaRonoflatentvaricellazostervirus

•  Lasts7-10days,completehealingin3-4weeks

•  Commonlythoracic/cervical/lumbar/trigeminal–  Specificsyndromes:–  RamsayHunt(CranialnerveVII)–  HerpesZosteropthalmicus

•  Immunocompromised–  Mayhavemorethan1

dermatome–  DisseminaRon

TreatmentofZosterAnRvirals

•  EarliertxanRvirals=greaterpainreducRon,fasterresoluRonofrash,reduceriskofPHN

•  Recommendforpts:–  <72hrsa=eronsetofrash

•  >/=50yrs•  Severerash•  Mod-severepain•  Nontruncalinvolvement

–  ComplicaRonsofzoster(egopthalmic)–  Immunosupressed

•  IVaciclovir–  Visceral,CNSordisseminateddisease

•  ValacyclovirandfamciclovirmaybeassociatedwithgreaterpainreducRonthanaciclovir–  SystemaRcreview–  Reference-AnRvirTher2012;17(2):255

.

Liveafenuatedvaccines•  (EgMMR,varicella,andherpeszostervaccines)•  AnypaRentwhoisanRcipaRngimmunosuppressivetherapywithintheensuing6weeksshouldavoidMMRvaccinaRon.

•  waiRngatleast4–12weeksbetweenadministeringthevaricellaorherpeszostervaccinesandiniRaRonofimmunosuppressivetherapyhasalsobeenrecommended.

Ref:1.IharaT,KamiyaH,TorigoeS,SakuraiM,TakahashiM.Viremicphaseinaleukemicchilda=erlivevaricellavaccinaRon.Pediatrics1992;89:147--9.2.www.cdc.gov

HZvaccineinIBD

•  AdvisoryCommifeeonImmunizaRonPracRcesstatesthatpaRentson– short-termcorRcosteroidtherapy(<14days),–  lowdosesofmethotrexate(<0.4mg/kg/week),–  lowdosesof6-MP(<1.5mg/kg/day)/azathioprine(<3.0mg/kg/day)

–  ..canreceiveHZvaccine

Zostervaccine

•  Notably,evidenceofthebenefitandsafetyofimmunizingpaRentswithzostervaccineandreceivinganR-TNFtherapyisaccruing.

•  InaddiRon,anadjuvantsubunitvaccinejustcompletedaphase3trialinwhichtherewas97%efficacyintheprevenRonofzosterinolderindividuals.–  Immunosuppressedindividualsmightbeeligibleforthisvaccinea=erclinicalstudiesinthispaRentpopulaRon.

–  Fornow,allIBDpa'ents50yearsofageandolderonlowimmunosuppressionregimensorplanningtostartimmunosuppressionshouldbevaccinatedwiththezostervaccine.

Reference-NEnglJMed2015May28;372(22):2087,

•  73yowoman•  Rashx4/12lowerlegs•  TreatedwithoralandIVabx•  Itchy•  Whatelsedoyouwantto

know?•  Howwouldyoumanage

this?

Photosfromgoogleimages

Clinicalfeaturesofeczema

•  ClinicalmanifestaRonsvarywithage:

•  Typicallystartsinearlyinfancywitheczematous,erythematouspapulesand

vesiclesonthecheeksandscalp;scratchingcausescrustederosions(o=ennon-flexuralareas)

•  A=erinfancyitiso=enlimitedtotheflexuresbutmayalsoaffectthenapeoftheneckandextensorsurfacesofthelimbs;moderatetosevereeczemacanbemuchmoreextensive

•  InfecRonswithStaphylococcusaureusarecommonandcausetypicalhoneyyellowcrusts

•  EczemapresentsdifferentlyinAsian,African,andAfro-Carribeanchildren:

–  Skincanappeardarkenedratherthanerythematous

•  ExtensivelichenificaRonandprurigolesionscanoccur

–  Follicularanddiscoidpafernsofatopiceczemaaremorecommoninchildrenwithdarkerskin

Approachtomanagement

•  Treatmentaimstoreducethesymptoms,improvequalityoflife,and

decreasethedegreeandfrequencyofflares.

•  Treatmentmaymodifytheoveralldiseasecourse–  andpossiblyreduceatopiccomorbidiRes,althoughmoreevidenceisneededto

determineifthisisarobusteffect.

–  ApersonalisedmanagementplanessenRaltoensureadherencetotreatmentrecommendaRonsandtreatmentsuccess.

–  Themanagementofsevereeczemainchildreno=enrequiresamulRdisciplinaryteamapproach.

•  Managingeczemainprimarycare

•  MildeczemacanbemanagedinprimarycarewithpaRenteducaRon,regularuseofemollients,andtopicalcorRcosteroidsofmildormoderatepotency

•  PaRenteducaRon–  PaRenteducaRonisanessenRalandimportantprimaryintervenRon.Ithasbeen

showntoreducediseaseseverityandimprovequalityoflifeatleastoveraoneyearperiod

Managementofdifficultandsevereeczemainchildhood,McAleeretal,BMJ2012345,

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Bathingandemollients

•  Dailyuseofemollientstocounteractdryskinisoneofthecornerstonesof

management.

–  BathinghydratesandcleansestheskinandemollientbasedsoapsubsRtutesmoisturisetheskinandavoidskinirritaRonassociatedwithstandardsoaps.

–  Bathingisusuallyrecommendedonceadayandemollientsoncetotwiceaday,orevenmoreo=en,dependingontheclinicalsesng

–  OintmentscontainhigherconcentraRonsoflipidsandaregenerallymoreeffecRvemoisturisersthancreams.

–  TopicalpreparaRonsshouldbefreeofdyes,fragrances,andfoodderivedallergenssuchaspeanutprotein

–  DespitetheuniversalrecommendaRonoftheuseofemollientsandbathaddiRves,norobustevidencefromRCTssupportsthis.

–  Ofnote,the2007NICEguidelinesrecommendedthataqueouscreamshouldnotbeusedbecauseitcancauseirritantreacRons.•  Morerecently,aqueouscreamwasshowntoincreasetransepidermalwaterlossinhealthy

subjectsandthosewithahistoryof

Managementofdifficultandsevereeczemainchildhood,McAleeretal,BMJ2012345,

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UKrefinementoftheHanifinandRajkadiagnosRccriteria

•  ToqualifyashavingatopicdermaRRs/eczema,thechildmusthave

hadanitchyskincondiRoninthepast12monthsplusthreeormoreofthefollowingcriteria:

•  Onsetbelowage2years*•  Historyofflexuralinvolvement

•  Historyofagenerallydryskin•  Personalhistoryofotheratopicdisease**•  VisibleflexuraldermaRRs

•  *Notusedinchildrenunder4years.**Inchildrenunder4years,ahistoryofatopicdiseaseinafirstdegreerelaRvemaybeincluded.

Managementofdifficultandsevereeczemainchildhood,McAleeretal,BMJ2012345,

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•  Localadverseeffects,suchasskinatrophy,striae,andtelangiectasia,canoccurwithinappropriateuseoftopicalcorRcosteroids,especiallyonsensiRveareassuchastheface,neck,orgroin.

•  Systemicadverseeffectsarerare.

•  AsystemaRcreviewof10RCTsfoundnoevidencethatapplicaRonoftopicalcorRcosteroidstwicedailyismoreefficaciousthanoncedailyapplicaRon.

•  Furthermore,oncedailyapplicaRonmayincreaseadherencetotreatmentandreducesideeffectsandcosts.

•  WheneczemaisnotcontrolleddespitepotenttopicalcorRcosteroidsandfulladherencetotheprescribedemollientandbathingregimen,orwhenunsafeamountsofpotenttopicalcorRcosteroidsareneeded,addiRonaltherapeuRcapproachesarerequired.

Managementofdifficultandsevereeczemainchildhood,McAleeretal,BMJ2012345,

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•  Eczemaflaresareo=enafributabletoinfecRon,mostcommonlywithStaphylococcusaureus.

•  TheseinfecRonscanbeclinicallysubtle.

•  SignsofbacterialinfecRonincludeweeping,crusts,pustules,failuretorespondtotreatment,andrapidlyworseningeczema.

•  However,althoughskininfecRonundoubtedlyplaysaroleineczemaflares,twoCochranereviewsofanR-staphylococcalmeasures(prophylacRcandtreatment)inrouRneeczemacarefoundnoclearevidenceofaddiRonalclinicalbenefit.

•  itissRllacceptedclinicalpracRcetouseanRmicrobialmeasuresinpaRentswithfrequentskininfecRons.

•  CombinedcorRcosteroidandanRmicrobialointmentscanbeusedforshortperiodsininfectedeczema,buta

•  ChildrenwithsevereeczemaarealsoatincreasedriskofeczemaherpeRcum(whichcanberecurrent.

–  EarlydiagnosisandprompttreatmentareessenRal,andparentsshouldbeeducatedabouttheclinicalsignsandtheneedtoseekmedicaladvice.Managementofdifficultandsevereeczema

inchildhood,McAleeretal,BMJ2012345,e4770