Embarrassing skin conditions

1. Embarrassing skin conditions Jan L Bong Consultant Dermatologist Dec 2011

3. Aims • Conditions • Hyperhidrosis • Hidradenitis • Hair disorders • Pigment disorders • What can primary care do? • What can secondary care do?

5. Hyperhidrosis

6. Case 1 • 25 year old woman complains of excessive armpits sweating. • What investigations would you consider doing?

7. Hyperhidrosis • Generalise • Drugs • propranolol, pilocarpine, tricyclic antidepressants, venlafaxine • Systemic diseases • Hyperthyroid, diabetes, menopause, Hodgkin's, alcoholism • Focal • Nerve damage: gustatory • Idiopathic

8. Primary care Treatments • AlCl - Driclor or Anhydrol Forte • Apply at night until effective, then reduce frequency • Irritant, effect may be neutralise by baking soda • Consider 1% hydrocortisone • Do not shave • Anticholinergic - Propantheline or oxybutynin • Side effects ++

9. Secondary care treatment- Axillaries BOTOX • NHS treatment • Gravimetric test • Up to 95% effective within 48 hours • Average duration 7 months

10. Secondary care treatment - Palmer hyperhidrosis • Iontophoresis • Water and passing direct current across the skin • 20-30 minutes alternate day till dry, then maintenance 1-4 weekly • ? work by blocking sweat pores • Effective in 70-80% • £300

11. Secondary care treatments • Glycopyrrolate lotions • Topical anticholinergic • 1 to 3% • Variable results • ‘specials’ – hence very expensive

12. Other secondary care options - Surgery • Axillaries • Sweat gland removal • Palmar • Laporscopic Sympathectomy • Compensatory hyperhidrosis • Not done for plantar due to risk

14. Hidradenitis suppurativa

15. Case 2 • A 30 year old lady complains of recurrent painful boils under her arms. At any one time, she has at least 3-4 discharging painful lumps. • What is the treatment of choice? • What investigation(s) will you arrange?

16. Hidradenitis suppurativa • Disorder of apocrine glands • Features • Comedones • Relapsing inflammation • Discharges • Scarring • Sites – axillae, inguinal, perianal

18. Primary care Treatments • Weight loss • Dianett for mild disease • Local hygiene

19. Primary care Treatments • Antibiotics • Treat like acne with cyclical antibiotics • No evidence that it alter the natural course • Tetracycline, erythromycin and clindomycin

20. Secondary care Treatments • Combination of clindomycin and rifampicin • Retinoids • >6 months, moderately effective • Dapsone • Corticosteroid • topical • Intralesional • oral

21. Treatments • Surgery • Local excision • Wide local excision • CO2 laser and secondary intention healing • Recurrence rate reported to be >33%

22. Prognosis • Risk of SCC • Spontaneously resolution is rare!!

23. Hair loss

24. Case 3 - 35 year old with 2 years history of gradual hair loss, worst on vertex

25. Androgenetic alopecia

26. More common in post menopausal women

27. Primary care work up • Exclude systemic causes: • Check FBC, ferritin, zinc and thyroid function • Sex hormones if very young or have signs of virilization • Consider differential diagnosis • Diffuse alopecia areata • Telogen effluvium

28. Primary care Treatments • Minoxidil • Need at least 3-4 months to work • 2% and 5% • Need to continue forever • Start early and best for vertex hair loss • More effective for women

29. Secondary care treatments • Scalp biopsy if there is diagnostic doubts • Anti-androgen – spironolactone or cyproterone acetate • Not license • Spironolactone may play a dual role in treatment hypertension • Finasteride • Only for men • Need to continue indefinitely • Not for women and does not work in post menopause

31. Patchy hair loss – quiz

32. Patch alopecia Scarring alopecia • Lupus • Fungus • Lichen planus • Traction Non scarring alopecia -Alopecia areata -telogen effluvium

34. Primary care treatments • Potent topical steroids • For 2-3 months • Intralesional steroids • Triamcinolone 10mg/ml • Cognitive behavioural therapy

35. Secondary care treatments • UVB • Pulse oral steroids • Immunosuppressants - ciclosporin

40. Pigmentary disorders

41. Case 4 • A 35 years old lady developed hyperpigmented patches on her face after the birth of her second child. • What is your diagnosis? • What are the potential primary care treatments?

42. Chloasma or melasma • Contraceptive pills and pregnancy • Certain scented products • Sun exposure • Mainly on foreheads, cheeks and upper lips • Epidermal or dermal types

43. Primary care treatments for chloasma • SUN PROTECTION - everyday • Azelaic acid at 20% (Skinoren) • Topical retinoid up to 0.1% • Hydroquinone

44. Secondary care treatments • Triple therapies – Sheffield, Manchester or Kligman’s formula • Topical retinoid, hydroquinone and hydrocortisone • Expensive!!

45. Cosmetic options - chemical peels, dermabrasion, laser

49. Vitiligo • How do I know my patient has it? • Colour – white patches • Margins – well demarcated • Distributions – symmetrical mostly, often on extremities and skin around eyes and mouth • Risk factors – other auto immune disease • Important differential – pityriasis versicolor, post inflammatory

50. Primary care treatments Offer camouflage No Treatments If not acceptable Potent topical steroids for 2 months Stop if no response Continue if working with steroid break