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Dermatology - Coggle Diagram

- - - - Corticosteroids
      - Anticonvulsants
  - - - Most severe form
      - Many comedones
      - Marked by suppuration, cysts, sinuses and scarring
  - - - Predominant comedonal facial acne
    - - Mild to moderate papulopustular acne
    - - Severe papulopustular acne / moderate nodular acne
    - - Severe nodular/conglobate acne
  - - - Manage disease according to severity
      - Maintain remission
      - Prevent scarring of the skin
    - - Acne is a chronic disease that may rewuire therapy for months to years
      - May take 2-3 months for improvement
      - Initial treatment may need to be changed
    - - Reduce proliferation of sebum
      - Nomalise keratinasation
      - Clear existing comedomes
      - Reduce C. acnes colonisation
      - Prevent the development of new comedomes
      - Clear existing lesions
  - - - Benzoyl Peroxide
        
        MOA
        
        Anti-microbial
        
        Anti-inflammatory
        
        Comedolytic
        
        Adverse Effects
        
        Skin irritation
        
        Pruritus
        
        Dryness
        
        Staining and bleaching of skin
      - Topical Retinoids
        
        Tretinoin
        
        Adapalene
        
        MOA
        
        Anti-inflammatory
        
        Comedolytic
        
        Anticomedogenic
        
        Adverse Effects
        
        Skin irritation
        
        Dryness
        
        Burning sesation
        
        Erythema
        
        Contact dermatitis
        
        Photosensitivity
      - Azelaic acid
        
        MOA
        
        Anti-microbial
        
        Anti-inflammatory
        
        Comedolytic
        
        Similar to benzoyl peroxide w/ less irritant
        
        Adverse Effects
        
        Dryness
        
        Pruritus
        
        Rash
      - Topical Antibiotics
        
        Clindamycin
        
        Erythromycin
        
        MOA
        
        Anti-microbial
        
        Anti-inflammatory - only to be used in combination with other topical agents
        
        Should not be used in combination with oral antibiotics
        
        Adverse Effects
        
        Skin irritation
        
        Urticaria
        
        Resistance
        
        GI upsets
        
        Rare reports of pseudomembranous colitis (clindamycin)
    - - Oral Antibiotics
        
        Aims
        
        Suppress growth of Cutibacterium acnes
        
        Reduce inflammatory mediators
        
        Lack of Response
        
        Inadequate duration of treatment
        
        Pt complinace
        
        Resistance to antibiotics
        
        Regimen
        
        Combo with topical therapies (not A/B)
        
        Max 4-6months
        
        Change if no improvement after 6-8 weeks
        
        Tetracyclines 1st Line
        
        Lymecycine (1st Line)
        Doxycyclin (2nd line)
        Minocycline (specialist care)
        
        Pharmacokinetics
        
        Absorption affected by
        food
        Antacids
        Milk
        Calcium (not minocycline
        
        Adverse Effects
        
        N+V 🤢
        
        Diarrhoea 💩
        
        Oesophagitis
        
        Hepatotoxicity 🐄
        
        Skin reaction 🦒
        
        Doxy - Photosensitivity 📸
        
        Minocycline - SLE
        
        Trimethoprim (alteranative therapy)
        
        Adverse Effects
        
        Stevens Johnson syndrome 👺
        
        Contraindications
        
        Pregnancy
      - Hormonal Therapy (FEMALES)
        
        Cyproterone Acetate (AC)
        
        MOA
        
        Progestin (synthetic progesterone) with strong anti-androgenic affect
        
        Adverse Effects
        
        C/I in hx of DVT
        
        Higher risk of thromboembolism than combined oral contraceptives
        
        Combined Ethinylestradiol and Cyproterone Acetate (AC)
        
        MOA
        
        Indications
        
        Severe acne
        
        Androgen dependant acne not reponding to topic and/or oral antibiotics
        
        Adverse Effects
        
        Increased risk of thromboembolism
      - Combined Oral Contraceptives (COC)
        Not authorised
        
        MOA
        
        Reduce lesions and severity of acne
        
        Newer progestogens (Norgestimate, gestodene, desogestrel) have anti-androgenic properties
        
        Adverse Effects
        
        Risk of Thromboembolism
      - Spironolactone
        Not Authorised
        
        Emerging evidence of benefit
      - Isotretinoin (Vit A analogue)
        
        Use
        
        Affects 4 main pathological factors
        
        Most effective anti-acne treatment
        
        Reserved for management of severe acne resistant to other treatments
        
        Prescribed by experts
        
        Regimen
        
        16-24 weeks achieve remission in 85% of cases
        
        Acne often deteriorates after treatment starts
        
        Need baseline fasting lipi and liver fx
        
        Adverse Effects
        
        Teratogenicity 🕷️
        
        Prevention programme
        
        All women of childbearing potential
        
        Prescription 30 days
        
        Neg pregnancy test before and during treatment
        
        Use of effective contraception (2 forms) during tx and 1 mnth post
        
        Psychiatric reactions 🤪
        
        Cracked lips, nose bleeds, dry skin
        
        Increased liver enzyme and triglycerides (monitoring required)
        
        Allergic reactions
        
        Decreased bone marrow activity
        
        DDI with tetracyclines
      - Indications
        
        Moderate to Severe acne
        
        Acne which has failed to respond to optimal therapy with topical agents
        
        Acne causing psychological difficulty for pt
  - - - 1st line combonations
        
        Topical adapalene w/ topical BPO
        
        Topical tretinoin w/ topical BPO
        
        Topical tretinoin w/ topical clindamycin
        
        Topical BPO w/ topical clindamycin
    - - 1 and 2 above
      - Fixed combo of topical adaplene and BPO + either oral lymecycline OR oral doxycycline
      - Topical azelaic acid + either oral lymecycline or oral doxycycline
    - - Acne fulminans - same day on call dermatology team
      - Uncertainty about acne, acne conglobate, nodulocysticacne
- - - - Epidermal barrier dysfunction
      - Cutaenous inflammation - heightened immune response
    - - House dust mite
      - Pollen
      - Air pollution
    - - Fam hx of atopic disease
  - - - Onset before 2 yrs
      - Visible flexural dermatitis involving ckin creases
      - Hx of flexural dermatitis
      - Hx of dry skin in last 12 mnth
      - Hx of asthma or allergic rhinitis
  - - - Continous epidermal barrier repair with emollients
      - Avoidance of triggers
      - Anti-inflammatory therapy w/ topical corticosteroids or topical calcineurin inhibitors
      - Systemic therapy for severe cases
  - - - Emollients
        
        MOA
        
        Restores epidermal barrier fx
        
        Forms occlusive layer
        
        Reduces transepidermal water loss
        
        Reduces exposure to bacteria and sensitising agents
        
        Improves symptoms of itch and pain
        
        Prolongs time to flare, number of flares
        
        Reduces amounts of TCS needed to control
      - Topical Corticosteroids
        
        Treatment of Exacerbations Regimen
        
        Adults
        
        Face, Genitals & Flexures: Mildly potent TCS
        
        Palms, Soles of Feet, and Scalp: Potent TCS
        
        Trunk and Limbs: Lowest potency likely to produce effect within 7-14 days
        
        Children
        
        All Skin Areas: Mildly potent TCS
        
        Areas other than Face, Genitals & Flexures: Moderately potent (only on specialist advice)
        
        Special Considerations: Potent TCS only on specialist advice
        
        General Recs
        
        Duration of Treatment: Mildly potent TCS may be used for 7-14 days; monitor effectiveness
        
        Secondary Infections: If a mild or moderately potent TCS has not controlled the AE within 7 to 14 days, exclude secondary bacterial or viral infection.
        
        MOA
        
        Ati-inflammatory
        
        Immunosuppressive
        
        Drugs
        
        Hydrocortisone
        
        Aclomethasone dipropionat
        
        Clobetasone butyrate
        
        Betamethasone valerate 0.1%
        
        Betamethasone dipropionate
        
        Hydrocortisone butyrate
        
        Mometasone furoate
        
        Clobestasol Propionate
      - Topical Calcineurin Inhibitors
        
        MOA
        
        Anti-inflammatory agents that inhibit calcineurin-dependent T-cell activation.
        
        Efficacy
        
        Safe and effective for adults and children with moderate to severe atopic eczema.
        
        Guidelines
        
        Second-line treatment for short and intermittent use.
        
        Patients usually respond within 1 week.
        
        Tacrolimus 0.1% and 0.03% for adults and children >16 years. Only 0.03% is recommended for children >2 years.
        
        Useful for delicate skin areas such as the face and groin.
        
        Can be used as maintenance therapy in patients with frequent flares.
        
        Adverse Effects
        
        Localised skin reactions
        
        Avoid in congenital / aquired immunodeficiencies, immunosuppressed, phototherapy
        
        Malignancies ass with tacrlimus - no causal relationship established
    - - Systemic Immunomodulatory Treatments - Ciclosporin
        
        Ciclosporin
        Authorised
        
        MOA
        
        Inhibitor of T cell dependent immune reponse
        
        Inhibitor of IL-2 production
        
        Efficacy
        
        Effective in severe disease in pts w/ refractory disease
        
        Improvement within 4 weeks up to 1 years
        
        Not a long term solution
        
        Careful monitoring required
        
        Adverse Effects
        
        Infx
        
        Hypertention ⛺
        
        Nephrotoxicity 🫘
        
        Immunosuppression 🛡️
        
        Risk of lymphoma + malignancies 🦀
        
        Methotrexate
        Unauthorised
        
        Monitoring Required
        
        Azathiopine
        
        Monitoring Required
      - Targeted therapy
        
        Dupilumab
        
        Type
        
        Monoclonal antibody
        
        MOA
        
        Targets IL-4 and IL-13 to block immune response
        
        Admin
        
        Subcutaneous
        
        Adverse Effects
        
        Conjunctivitis 👁️
        
        Herpes simplex 🦠
        
        Headache 🤕
        
        Injection site reaction 💉
        
        Tralokinumab
        
        Type
        
        IgG4 monoclonal antibody
        
        MOA
        
        Targets IL-13
        
        Admin
        
        Subcutaneous
        
        Adverse Effects
        
        Conjunctivitis 👁️
        
        Herpes simplex🦠
        
        Headache🤕
        
        Injection site reactions 💉
        
        Upadacitinib
        
        Type /MOA
        
        Reversible Janus kinase (JAK) inibitor
        
        Admin
        
        Oral prolonged release
        
        Adverse Effects
        
        Serious infx
        
        Immunosuppression 🛡️
        
        Venous thromboembolism (VTE)
        
        Drug interactions
      - UV Phototherapy
        
        Efficacy
        
        Some pts
        
        Adverse Effects
        
        Skin itching
        
        Skin burning
        
        Regimen
        
        3 sessions / week for 10 weeks
        
        Effect lost in unfinished treatment
- - - - Emollients
      - Vit D Analogues
      - Topical Corticosteroids
      - Dithranol
      - Coal Tar
    - - Methotrexate
      - Ciclosporin
      - Acitretin (Vit A analogue)
      - Apremilast (PDE Type 4 Inhibitor)
      - Dimethyl Fumarte
      - Biologics
        
        Anti TNF-α Agents
        
        Interleukin inhibitors