GP gauntlet #5 (dermatology, palliative care)

elliptic's version from 2018-06-26 11:25

Fungal treatments #1

Question Answer
Dermatophyte infection / tinea (other than tinea capitis), rx1. Confirm diagnosis --scrapings/clippings & consider ddx.
2. Education (hot wash socks/stockings, wipe out shoes with formalin, observe hygeine).
3. Topical antifungals, eg. terbinafine 1% cream/gel, od-bd for 7-14d.
4. Oral antifungals if required, eg. terbinafine 250mg daily for 2 weeks (different dosage for kids).
Tinea capitis including kerion1. Confirm diagnosis before treatment. 2. Terbinafine 250mg (halve dose if under 40kg, quarter dose if under 20kg), daily for 4 weeks. 3. At the completion of treatment, repeat the culture; resume treatment for another 4-6 weeks if positive, and continue retesting and retreating. Stop treatment when culture is negative.
Tinea unguium (onychomycosis)1. Confirm diagnosis, distinguish from candidal onychomycosis or moulds. 2. Weigh advantages and disadvantages of treatment. 3. Terbinafine 250mg daily for 12 weeks (toenails) or 6 weeks (fingernails).
Cutaneous candidiasisclotrimazole 1% cream, top bd for 2 weeks. If required, add hydrocortisone 1% cream bd. If topical rx is ineffective or impractical, fluconazole 150mg po stat.
Acute vulvovaginal candidiasisclotrimazole vaginal cream; 10% for one night, 2% for 3 nights, 1% for 6 nights. nystatin 100,000 units/5g can be used daily before bed for 14 nights. OR fluconazole 150mg po stat.
Chronic candidal vulvovaginitisfluconazole 50mg daily until better (2w-6m), or if pregnant/can't tolerate azoles, nystatin 100,000u/5g intravaginally daily before bedtime until symptoms resolve.

Fungal treatments #2

Question Answer
Candidal balanoposthitishydrocortisone + clotrimazole 1%+1%, bd until 2 weeks after skin is clear; alternatively, fluconazole 150mg po stat.
Pityriasis versicolorselenium sulfide 2.5% shampoo, once daily to wet skin, leave on for at least 10 minutes or overnight, for 7-10 days. In unresponsive cases, fluconazole *400mg* po stat.
Oral candidiasisamphotericin 10mg lozenge sucked (then swallowed), qid after food, for 7-14 days
Scalp seb derm1. Normal shampoo daily.
2. Failing that, selenium sulfide 2.5% shampoo, 2-7 times/weekly.
3. Failing that, add betamethasone diproprionate 0.05% lotion top, applied nightly for 7 nights.
Other seb dermhydrocortisone+clotrimazole 1%+1% cream topically, once or twice daily until skin is clear or for up to 2 weeks

Annular lesions & scaly plaques

Question Answer
Tinea corporisround erythematous scaly plaques, slowly enlarging; annular raised edge, central healing
Discoid eczema / nummular dermatitisscattered dry or exudative round or oval plaques, sometimes with more pronounced edge, may or may not be itchy, may or may not be atopic
Psoriasisred scaly plaques which may be annular, often signs elsewhere such as scalp, elbows, knees, flexures, nails
Pityriasis rosealarger initial herald patch, symmetrical oval plaques on trunk with dry centre and trailing scale
Granuloma annularedermal skin coloured or violaceous plaques, often over joints, slightly tender on knocking
Annular erythemasslowly extending rings with trailing scale


Question Answer
Tinea crurisscaly raised red border, spreading asymmetrical down the inguinal folds or scrotum; often very itchy
Candida infectionacute onset, bright red skin, satellite pustules, peeling surface
Psoriasischronic, bright red, minimal symptoms, often signs elsewhere such as scalp, elbows, knees, flexures, nails
Erythrasmachronic, dry, brownish, asymptomatic patches
Dermatitisespecially seborrhoeic, irritant contact, allergic contact variants can cause intertrigo.

Management of psoriasis, seborrheic dermatitis

Question Answer
Chronic stable plaque psoriasis or hyperkeratotic psoriasis of palms/solesCoal tar 6% + salicylic acid 3% in aqueous cream bd for 1 month. Failing that -- or if only a few scattered plaques -- daivobet gel (calcipotriol 50mcg/g + betamethasone 500mcg/g) daily until skin is clear (~6 weeks).
Scalp psoriasisMethylpred aceponate 0.1% (advantan) daily for at least 2 weeks. If no results, switch to clobetasone shampoo (clobex) - massage onto dry scalp and leave on for 15 minutes before adding water and rinsing/lathering. Use for up to 4 weeks. When symptoms control, add coal-tar based shampoo.
Face/flexural genital psoriasisMethylpred aceponate 0.1% (advantan) daily until clear. Use LPC 2% + SA 2% in aqueous when withdrawing from steroids.
Risk factors for psoriasisstrep infection; sunlight usually beneficial but may exacerbate in some; local trauma to skin; post-pregnancy; stress; etoh/smoking; HIV/AIDS; change in climate
Scalp seb derm1. Standard shampoo daily. 2. Antiyeast shampoo twice weekly. 3. Add Advantan for 7 days. 4. Add coal tar emulsion/gel 1-2 times/week. 5. Replace antiyeast shampoo with clobex (clobetasone) shampoo.
Non-scalp seb derm1. Hydrocortisone 1% + miconazole nitrate 2% (Resolve plus 1.0) cream 1-2 times/day for 2 weeks. 2. Advantan + clonea (clotrimazole 10mg/g) cream 1-2 times/day for 2 weeks. 3. Tar cream (LPC 1-2% in aqueous for face/flexures genitals, LPC/salicylic 5+5% elsewhere) daily for 2 weeks.

Nonmelanoma skin cancer treatments

Question Answer
Excision margins4mm SCC, 3mm BCC
Cryotherapy (SCC? BCC? Bowen? Solar keratosis?)SCC - usually not. BCC - superficial away from head and neck; long term followup essential. Bowen: single 30 second FTC + 3mm margin. Solar k: single 5-10s FTC.
Curettage (SCC? BCC? Bowen? Solar keratosis?)For a primary, well-defined superficial or nodular BCC. Bowen's, solar K.
Imiquimod 5% creamSuperficial BCC, Bowen: 5 times/week for 6 weeks. Solar K: 3 times/week for 4 weeks, then review prior to continuing treatment.
Ingenol mebutateFor solar keratosis. Face/hands: 0.015% gel daily for 3 days. Trunk/limbs 0.05% gel daily for 2 days.
5-fluorouracilFor (localised) Bowen or (field) actinic keratosis. Twice daily for 2 weeks.
Diclofenac gelFor actinic keratosis, twice daily for 90 days.
Photodynamic therapyAll but SCC; not on nose/around eyes.
Superficial x-ray therapyAn option for SCC/BCC where surgery unacceptable.

Palliative care

Question Answer
Pall care planning mnemonicPhysical, Emotional, Personal, Social, Information/communication, Control, Out of hours/continuity, Late, Afterwards.
Name the five 'core' palliative medications for community pall care patients (according to SA expert working group)Morphine, Metoclopramide, Haloperidol, Clonazepam, Hyoscine butylbromide.
Example PRN order for subcut morphineMorphine 2.5-5 mg sc 1hrly PRN for pain or dyspnoea
Example PRN order for subcut metoclopramideMetoclopramide 10 mg sc 4hrly PRN for nausea or vomiting
Example PRN order for subcut haloperidolHaloperidol 0.5 mg sc 4hrly PRN for agitation or delirium
Example PRN order for clonazepam liquid dropsClonazepam 2-6 drops sublingually PRN for severe agitation or if sedation required in delirium
Example PRN order for hyoscine butylbromideHyoscine butylbromide 20 mg sc 4hrly PRN for excess secretions