When treating moderate acne that doesn’t respond to topical treatments, it may be appropriate to add an oral antibiotic like lymecycline or doxycycline for up to three months. If there is no improvement, the acne worsens, or the patient cannot tolerate side effects, a different antibiotic can be tried. However, if the patient doesn’t want to try a different antibiotic, combined oral contraceptives can be considered as long as there are no contraindications. Second or third-generation combined oral contraceptives are typically preferred, such as Microgynon. It is important to note that Cerelle, a progesterone-only contraceptive, can worsen acne due to its androgenic activity. Dianette (co-cyprindiol) is a second-line contraceptive option for moderate to severe acne, but it comes with an increased risk of VTE and should only be used after careful discussion of the risks and benefits with the patient. It should be discontinued three months after acne has been controlled. Similarly, Cerazette is not a suitable option due to its androgenic activity.

Acne vulgaris is a common skin condition that usually affects teenagers and is characterized by the obstruction of hair follicles with keratin plugs, resulting in comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the number and type of lesions present. Treatment for acne typically involves a step-up approach, starting with single topical therapy and progressing to combination therapy or oral antibiotics if necessary. Tetracyclines are commonly used but should be avoided in certain populations, and a topical retinoid or benzoyl peroxide should always be co-prescribed to reduce the risk of antibiotic resistance. Combined oral contraceptives can also be used in women, and oral isotretinoin is reserved for severe cases under specialist supervision. Dietary modification has no role in the management of acne.

Hirsutism is a known side effect of phenytoin, while alopecia is not commonly associated with it.

Understanding the Adverse Effects of Phenytoin

Phenytoin is a medication commonly used to manage seizures. Its mechanism of action involves binding to sodium channels, which increases their refractory period. However, the drug is associated with a large number of adverse effects that can be categorized as acute, chronic, idiosyncratic, and teratogenic.

Acute adverse effects of phenytoin include dizziness, diplopia, nystagmus, slurred speech, ataxia, confusion, and seizures. Chronic adverse effects may include gingival hyperplasia, hirsutism, coarsening of facial features, drowsiness, megaloblastic anemia, peripheral neuropathy, enhanced vitamin D metabolism causing osteomalacia, lymphadenopathy, and dyskinesia.

Idiosyncratic adverse effects of phenytoin may include fever, rashes, including severe reactions such as toxic epidermal necrolysis, hepatitis, Dupuytren’s contracture, aplastic anemia, and drug-induced lupus. Finally, teratogenic adverse effects of phenytoin are associated with cleft palate and congenital heart disease.

It is important to note that phenytoin is also an inducer of the P450 system. While routine monitoring of phenytoin levels is not necessary, trough levels should be checked immediately before a dose if there is a need for adjustment of the phenytoin dose, suspected toxicity, or detection of non-adherence to the prescribed medication.

If fusidic acid resistance is suspected or confirmed, mupirocin is the appropriate treatment for impetigo. Advising the person and their carers about good hygiene measures is important to aid healing and reduce the spread of impetigo, but it is not a treatment for the condition itself. Oral flucloxacillin is typically used for widespread non-bullous impetigo or in cases of bullous impetigo, systemic illness, or high risk of complications, none of which apply to Timothy’s localized impetigo.

Understanding Impetigo: Causes, Symptoms, and Management

Impetigo is a common bacterial skin infection that is caused by either Staphylococcus aureus or Streptococcus pyogenes. It can occur as a primary infection or as a complication of an existing skin condition such as eczema. Impetigo is most common in children, especially during warm weather. The infection can develop anywhere on the body, but it tends to occur on the face, flexures, and limbs not covered by clothing.

The infection spreads through direct contact with discharges from the scabs of an infected person. The bacteria invade the skin through minor abrasions and then spread to other sites by scratching. Infection is spread mainly by the hands, but indirect spread via toys, clothing, equipment, and the environment may occur. The incubation period is between 4 to 10 days.

Symptoms of impetigo include ‘golden’, crusted skin lesions typically found around the mouth. It is highly contagious, and children should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment.

Management of impetigo depends on the extent of the disease. Limited, localized disease can be treated with hydrogen peroxide 1% cream or topical antibiotic creams such as fusidic acid or mupirocin. MRSA is not susceptible to either fusidic acid or retapamulin, so topical mupirocin should be used in this situation. Extensive disease may require oral flucloxacillin or oral erythromycin if penicillin-allergic. The use of hydrogen peroxide 1% cream was recommended by NICE and Public Health England in 2020 to cut antibiotic resistance. The evidence base shows it is just as effective at treating non-bullous impetigo as a topical antibiotic.

Distinguishing Scabies from Other Itchy Skin Conditions

Scabies is a highly contagious skin condition caused by Sarcoptes scabiei mites. It is characterized by intense itching, particularly in the finger webs, wrists, elbows, perineum, and areolar regions. The rash may appear as erythematous papules, diffuse dermatitis, or urticated erythema. The pathognomonic sign of scabies is the presence of burrows, which are intraepidermal tunnels created by the female mite.

When differentiating scabies from other itchy skin conditions, it is important to consider the location and appearance of the rash. Contact dermatitis, for instance, doesn’t typically present with an eczematous rash on the hands. Lichen planus, on the other hand, is characterized by violaceous papules and tends to affect the wrists more than other areas. Pompholyx eczema is limited to the hands and soles of the feet, while psoriasis is characterized by white, scaly plaques and mild itching. By carefully examining the symptoms and physical presentation, healthcare providers can accurately diagnose and treat scabies.

Understanding Sunscreens: Protection Against UV Radiation

Sunscreens are essential in protecting the skin from the harmful effects of ultraviolet (UV) radiation from the sun. UVB causes sunburn, while UVA contributes to long-term photodamage, skin cancer, and aging. Sunscreens come in two types: chemical absorbers and physical blockers. Chemical absorbers absorb UVA or UVB, while physical blockers reflect or scatter UV radiation. The ideal sunscreens are those that provide the most effective protection against both UVA and UVB, but they may produce a white appearance when applied to the skin.

The sun protection factor (SPF) indicates the degree of protection against UVB. A higher SPF means longer protection against burning. However, users often do not apply enough sunscreen, resulting in lower protection than what is indicated in experimental studies. The EU Commission recommends that the UVA protection factor should be at least one-third of the SPF, and products that achieve this will be labelled with a UVA logo.

Sunscreens should be applied liberally to all exposed areas and reapplied every 2 hours, especially after swimming, sweating, or rubbing off. Allergic reactions to sunscreen are rare. Sunscreens can be prescribed and marked as ACBS drugs for individuals with genetic disorders, photodermatoses, vitiligo, changes resulting from radiotherapy, and chronic or recurrent herpes simplex labialis precipitated by sunlight. Sunscreens with SPF less than 30 should not normally be prescribed.

In summary, understanding sunscreens and their proper use is crucial in protecting the skin from the harmful effects of UV radiation.

Since the topical preparation did not work for the patient, the next step would be to try an oral antibiotic. The recommended first-line options are lymecycline, oxytetracycline, tetracycline, or doxycycline. Lymecycline is preferred as it only needs to be taken once a day, which can improve the patient’s adherence to the treatment.

Acne vulgaris is a common skin condition that usually affects teenagers and is characterized by the obstruction of hair follicles with keratin plugs, resulting in comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the number and type of lesions present. Treatment for acne typically involves a step-up approach, starting with single topical therapy and progressing to combination therapy or oral antibiotics if necessary. Tetracyclines are commonly used but should be avoided in certain populations, and a topical retinoid or benzoyl peroxide should always be co-prescribed to reduce the risk of antibiotic resistance. Combined oral contraceptives can also be used in women, and oral isotretinoin is reserved for severe cases under specialist supervision. Dietary modification has no role in the management of acne.

First Aid and Management of Burns

Burns can be caused by heat, electricity, or chemicals. Immediate first aid involves removing the person from the source of the burn and irrigating the affected area with cool water. The extent of the burn can be assessed using Wallace’s Rule of Nines or the Lund and Browder chart. The depth of the burn can be determined by its appearance, with full-thickness burns being the most severe. Referral to secondary care is necessary for deep dermal and full-thickness burns, as well as burns involving certain areas of the body or suspicion of non-accidental injury.

Severe burns can lead to tissue loss, fluid loss, and a catabolic response. Intravenous fluids and analgesia are necessary for resuscitation and pain relief. Smoke inhalation can result in airway edema, and early intubation may be necessary. Circumferential burns may require escharotomy to relieve compartment syndrome and improve ventilation. Conservative management is appropriate for superficial burns, while more complex burns may require excision and skin grafting. There is no evidence to support the use of antimicrobial prophylaxis or topical antibiotics in burn patients.

Managing Psoriasis with Topical Treatments

Psoriasis patients are advised by NICE to take a break of at least 4 weeks between courses of treatment with potent or very potent corticosteroids. During this period, patients should consider using topical treatments that are not steroid-based, such as vitamin D or vitamin D analogues, or coal tar to maintain psoriasis disease control. These topical treatments can help manage psoriasis symptoms and prevent flare-ups. It is important for patients to work closely with their healthcare provider to determine the best treatment plan for their individual needs. By incorporating non-steroid topical treatments into their psoriasis management plan, patients can achieve better control of their symptoms and improve their overall quality of life.

Chondrodermatitis Nodularis Chronica Helicis: A Benign Tender Lump in the Ear Cartilage

Chondrodermatitis nodularis chronica helicis is a common condition characterized by a benign tender lump in the cartilaginous portion of the ear, specifically in the helix or antihelix. It is often caused by pressure between the head and pillow during sleep, particularly in individuals who predominantly sleep on one side. Minor trauma, exposure to cold, and tight headgear or telephone headsets can also trigger the condition.

The lesion rarely resolves on its own and conservative measures such as using a soft pillow or sleeping on the opposite side may be attempted. Wearing a protective pressure-relieving device, using topical and intralesional steroids, or applying topical glyceryl trinitrate may also provide relief. Cryotherapy is sometimes used as well.

Excision of the damaged cartilage area is often successful, but recurrence can occur at the edge of the excised area. The distinctive feature of chondrodermatitis nodularis chronica helicis is the associated pain and tenderness, which sets it apart from painless cutaneous tumors and non-tender actinic keratoses.

It is important to note that tophi, which contain a white pasty material and are usually not painful or tender, typically develop around 10 years after the first attack of gout in untreated patients and are commonly found around the elbows, hands, and feet.

Assessing Pigmented Skin Lesions and Identifying Risk Factors for Melanoma

When assessing a pigmented skin lesion, it is important to consider any risk factors for melanoma. The number and characteristics of naevi are the greatest risk factors for melanoma, with individuals who have more than 50 melanocytic naevi, of which 3 or more are atypical in appearance, classified as having atypical mole syndrome. This syndrome occurs in about 2% of the population and increases the risk of developing melanoma by 7 to 10 fold. The risk is further increased if there is a family history of melanoma in a first or second degree relative, known as familial atypical mole syndrome. Other risk factors include light-colored eyes, unusually high sun exposure, and red or light-colored hair.

It is important to understand the extent of risk associated with these factors, as identifying high-risk patients presents an opportunity to advise them accordingly. Patients at moderately increased risk of melanoma should be taught how to self-examine, including those with atypical mole phenotype, previous melanoma, and organ transplant recipients. Patients with giant congenital pigmented naevi also require long-term follow-up by a specialist, usually a dermatologist. By understanding these risk factors and providing appropriate guidance, healthcare professionals can help prevent and detect melanoma in high-risk patients.