EBMT Education Day for Nurses and AHPs April 2012 Skin care: not every rash is GVHD

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1 EBMT Education Day for Nurses and AHPs April 2012 Skin care: not every rash is GVHD Eileen Parry Consultant Dermatologist Tameside Hospital Foundation Trust

2 Overview How to assess a patient with a rash Common skin conditions Drug reactions Skin care

3 Assessment of patient with rash History Duration Site onset, spread Time course Associated symptoms Previous skin disease Family history Drug history Examination Good light Whole skin, scalp, nails Mucous membranes Size, shape, colour lesions Pattern, distribution

4 Dermatological terms Primary lesions Macule Papule Nodule Plaque Vesicle Bulla Pustule Cyst Weal Purpura Secondary changes Crust Scale Lichenification Atrophy Erosion Ulcer Excoriation EBMT website: definition / examples

5 Diagnosis of patient with rash Differential diagnosis History/examination Pattern recognition Terminology Investigation/Treatment

6 Common skin conditions Eczema Psoriasis Infection

7 Eczema Atopic eczema Seborrhoeic Varicose Discoid Contact Asteototic Pompholyx

8 Atopic eczema Itchy rash Flexural distribution Diffuse erythema, vesicles, scale, crust, excoriation Chronic: lichenification 20% children, 1/3 adult Family history atopy 2/3 rds Genes/environment

9 Atopic eczema

10 Seborrhoeic eczema

11 Varicose eczema

12 Discoid eczema

13 Eczema variants

14 Psoriasis Chronic plaque psoriasis Guttate Flexural Pustular Erythrodermic

15 Psoriasis Extensor distribution Well demarcated plaques Salmon-pink, silvery scale 2% population Family history 1/3 rd Genetic predisposition Environmental triggers

16 Chronic plaque psoriasis

17 Psoriasis variants

18 Psoriasis variants

19 Infection Bacterial Viral Yeast / fungal

20 Staphylococcal infections

21 Streptococcal infection

22 Herpes Zoster

23 Candida infections

24 Pityriasis versicolor

25 Fungal infection

26 Steroid treated fungal infection

27 Skin care How you can help Emollients Topical corticosteroids

28 Emollients Essential part of treatment program Underused by professionals and patients Bath/shower oils, soap substitute, moisturiser Treat skin dryness, repair barrier function Best emollient is one which patient will use

29 Generic emollients Aqueous cream Emulsifying ointment Hydrous ointment White soft paraffin Yellow soft paraffin Liquid and white soft paraffin, 50:50 mix British National Formulary Sept 2011

30 Proprietary emollients Aquamol Aveeno Cetraben Dermamist Diprobase Doublebase E45 Emollin Epaderm Hydromol Lipobase Oilatum QV Ultrabase Unguentum M ZeroAQS Zerobase Zerocream Zeroguent British National formulary Sept 2011

31 Emollient tips Apply frequently Thin layer, whole skin Direction of hair growth Gently smooth on Avoid rubbing - itch Use enough - skin shiny Adult: 500g week Child: 250g week

32 Topical corticosteroids Skin inflammation Potency: age, body site, frequency, duration Vehicle: cream, ointment, lotion Quantity: fingertip units Contraindications Steroid phobia

33 Topical corticosteroids Potency x 2.5 x 10 x 40 Mild Moderate Potent Super potent

34 Finger tip units Fingertip Unit = 0.5g Trunk (front & back) Arm Hand Leg Foot 14 units 3 units 1 unit 6 units 2 units Whole body 40 units = 20g

35 Topical corticosteroid tips Apply thinly Cover area, shiny film Once daily is enough Cream/lotion: weepy Ointment: dry/scaly Step up/down potency Different time to emollient

36 Drug reactions Commonest pattern of drug reaction Drug rash or GVHD? Less frequent / rare drug reactions

37 Drug reactions Common side effect 2-3% of medical admissions May be difficult to determine cause Clinical pattern of rash is rarely a clue Patients often taking several drugs Patients may be ill: other diagnoses?

38 Drug reactions Commonest Maculopapular rash

39 Differential diagnosis Reactive condition Infection: EBV, CMV, HHV6, PV B19 Toxin: Staph aureus ETA, ETB Inflammation: Still s disease Drug induced Graft versus host disease

40 Acute GVHD or drug rash? Acute GVHD 59% facial rash 36% face, palms/soles 73% diarrhoea 41% diarrhoea, bilirubin Onset within 2-3 days Adverse drug rash 24% facial rash None face, palms/soles 12% diarrhoea None diarrhoea, bilirubin Study 39 patients allo-hct Byun et al. J Am Acad Dermatol 2011; 65: maculopapular rash d100

41 Drug reactions Less frequent Urticaria/angioedema Erythema multiforme Fixed drug reactions Phototoxic Vasculitis SDRIFE Hand and foot syndrome

42 Urticaria / angioedema

43 Erythema multiforme

44 Fixed drug eruption

45 Phototoxic reaction

46 Vasculitis

47 Symmetrical drug related intertriginous and flexural exanthema (SDRIFE)

48 Chemotherapy induced hand and foot syndrome

49 Rare drug reactions SCAR: Severe cutaneous adverse reactions SJS TEN AGEP DRESS Stevens-Johnson syndrome Toxic epidermal necrolysis Acute generalised exanthematous pustulosis Drug reaction with eosinophilia and systemic symptoms

50 Stevens-Johnson Syndrome

51 Toxic epidermal necrolysis

52 Acute generalised exanthematous pustulosis

53 Drug reaction with eosinophilia and systemic symptoms Drug rash Facial oedema Fever Eosinophilia Lymphadenopathy Liver abnormalities Arthralgia

54 Drug reactions- what can you do? Identify and stop culprit Drug: within 14 days SCAR: within 3 months Refer for investigation Supportive care Antihistamines Emollients Topical anti-pruritic Topical corticosteroids D.E.R.M. SCAR: expert help

55 Topical anti-pruritic Calamine: lotion, oily lotion, Aqueous cream Crotamiton: cream, lotion Menthol in aqueous cream: 0.5%, 1%, 2% Doxepin cream (Topical anaesthetics/antihistamines)

56 Cause of drug rash 40 % antibiotic 21 % anti-inflammatory 8 % contrast media 31 % others: antidiabetic, antimycotic, antipsychotic, antiepileptic Heinzerling et al. Brit J Dermatol 2012; 166: year study, 612 patients suspected ADR; 107/141 patients full work up: 76% confirmed drug cause

57 Summary Common rashes: eczema, psoriasis, infections Drug reactions: clinical patterns, drug or GVHD? Skin care: emollients, topical corticosteroids

58 Thank you References: EBMT website

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