Therapeutic Guidelines Dermatology

And I have to say that for acne, I was pretty much doing the same thing for everybody. So this was a little bit of extra discrimination, a little bit more finessing, which hopefully will lead to better patient outcomes.

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Hi, and welcome to this Australian Prescriber Podcast. I'm Dr Justin Coleman. I'm a GP with Fitzpatrick Type 1 skin, freckles and white, and I used to lie on the beach burning a lot. For that, I blame my parents. With me on this Dermatology Therapeutic Guidelines podcast, I have another GP, Dr Lee Fong from Newcastle. Lee, good morning, and how's your skin?

Thanks for having me on, Justin. My skin's not great. Probably a Type 3. Was generally discouraged from hanging out in the sun. I think we never went to the beach. My parents told me, I think an apocryphal story about a cousin that got eaten by a shark, so generally stayed out of the sun.

Wonderful. Well, when we get to the melanoma section we can thank your parents and their shark story. Unfortunately, mine I think just used to get rid of me and say, ‘Spend a few hours on the beach and don't come back till dinnertime.’ But moving straight on to the newest updated Therapeutic Guidelines on dermatology, and there's lots to get through, so we might get started straight away talking about topical corticosteroids. Now, we're not going to go through all the different types and brands of steroids because you can look them up and most GPs are fairly familiar. But one thing which did strike me was a nice little chart looking at how much cream you get on your fingertip, and the fact that we should be slathering it on rather than dabbing it on.

Yeah, look, that's a really interesting point, and I have to say one that I wasn't particularly au fait with, that there's actually a lot of concern amongst the dermatologists about underuse rather than overuse, with underuse leading to treatment failure.

The same could be said of sunscreen too. I think there's also an understanding that people tend to save a bit of money on sunscreen and not put enough on, and so I tell my patients to, rather than buy a little expensive tube, go and buy a huge big tub of sunscreen and tell the kids to lather it all over them. There really are very few problems I think with creams and ointments, putting on lots of them, virtually no matter what you're putting on.

Yeah, no, absolutely. I think that's probably the general takeaway message here, which is that in general, steroid creams are outstandingly safe. I was only just having a bit of a Google to see how much, well, disinformation, misinformation is out there. And there's actually a heap. There's whole websites dedicated to concerns about steroid creams, and I think that's led to a reluctance or a fear from a lot of patients, which is not really supported by the evidence. So I think the point of this section here is to say, actually you can use it safely, you can use it liberally, and don't underdo it.

A couple of other conditions where we tend to use creams mainly, although antibiotics as well, occasionally, acne and rosacea. The acne section has been updated with some newer topical products, trifarotene, and tretinoin and clindamycin, and there's also some flow charts looking at deciding early for both acne and rosacea, what subtype it is, for example comedonal or inflammatory, and tailoring your treatment fairly early depending on those subtypes.

That's right. So, there's a particular chart that's in there now under treatment of acne, where, when you look at the different subtypes, comedonal versus inflammatory, you've got a few different options, a few different pathways you can follow, which lead you to different endpoints. And I have to say that for acne, I was pretty much doing the same thing for everybody. So this was a little bit of extra discrimination, a little bit more finessing, which hopefully will lead to better patient outcomes. So, that I thought was good. Those two new agents you talked about trifarotene and tretinoin plus clindamycin, both of them are used for mild acne and that's in those pathways, so there's a good little guide there about how to use those.

And also the rosacea section does have that, depending on the patient's presenting symptoms, whether there's flushing, erythema, inflammation, hyperplasia, that sort of thing. I encourage listeners to go and look it up when they face someone who comes in with rosacea, because yeah, it's just nice to get the correct treatment early on. Another condition, which I think you've had a bit of experience in recently, is urticaria. Urticaria, of course, being a very alarming condition, I find for patients, because they worry that going from normal skin to suddenly having these quite dramatic welts and things, they worry that awful things are going on inside them. And usually we can reassure them that's not the case, but on the other hand, it's not necessarily easy to treat. Tell us about your recent times with urticaria.

Yeah, look, I was recently, well, maybe a year or so ago, was one of the GPs working in one of those state-based COVID-19 vaccination centres. So we had large volumes of patients coming through getting their COVID-19 vaccinations, and part of our role as medical officers there was to see patients who may have had an adverse reaction. And so, you can get urticaria after any vaccination, whether it's hepatitis, hep B shot, or influenza, and including COVID. So, we'd have a few patients coming through. But given the concerns that were already running around regarding COVID vaccines then, there was heightened anxiety around this sort of thing.

So, it was really instructive for me to be working in that setting, working closely with our immunology people from the local health district and to see that the treatment pathway was actually pretty straightforward. It involved the use of antihistamines, sometimes in higher doses than I was used to using. Say, for cetirizine, instead of using 10 mg once a day, you go straight to, say, 10 mg twice a day for an adult. And in fact, there's leeway to go up to even triple or quadruple the normal dose as a divided dose. But then also besides using antihistamines, there's an additional step of using a leukotriene antagonist like montelukast. So there's plenty of options there. It's relatively, well, not an uncommon symptom to be having, but it's something that we can readily treat in general practice with agents that are readily available.

Wonderful. I'm talking with Lee Fong. I always like talking to you, Lee, because as a GP you tend to use words I can understand. We are moving on to the sweating disorders, and I must say I've always had trouble pronouncing some of these things. I perhaps sweat when I try to say them on a public podcast, but hidradenitis suppurativa. Have I nailed that one?

That's as good as I would do, I reckon, Justin. That's an interesting one from the perspective of, when I was sitting on this guideline review group, I was usually the guy in the room going, ‘What? Oh, no. How many patients have I not recognised with a particular condition or not treated appropriately?’ And hidradenitis suppurativa is one of those conditions. This is one of those ones where you get recurrent modules, abscesses in the axillae or the inguinal regions, for example. It can be anogenital or  inframammary as well. I think we've all had a bunch of these patients. It varies in severity, so sometimes you just get a few little pimple-like things that might only happen every few months or so, but in severe cases you can get heaps of scarring.

I think the trap that I probably slipped into with all of these patients is throwing dicloxacillin at everybody, when in fact the appropriate treatment, if it's recognised, is probably more along the lines of topical antiseptics, sometimes topical antibiotics. But then, recognising it early and probably referring them on for specialist treatment, particularly if it's not responding to what we're doing conservatively in general practice, particularly if it’s developing into more complicated things with sinuses and lots of scarring, and all that sort of stuff.

Yeah, Lee, I used to always recommend I think aluminium chloride, it was, Driclor, which I also used to use sometimes after skin excisions to stop bleeding. But it's no longer on the market. Is there anything new these days in that area?

For sweating disorders, so particularly for using in localised areas, so whether that might be the palms or the soles or in the axillae, then I think the one that we all used to reach for was Driclor. But that's not available locally in your corner pharmacist anymore. An alternative is, thanks to the wonders of the internet, you can jump onto Amazon or eBay and get your hands on Driclor, or at least your patients can get their hands on Driclor. There is another option over the counter though at the chemist, which is another quite concentrated aluminium salt, which goes under the brand name of No More Sweat.

And you were telling me about a new treatment, which sounded a bit dodgy to me, but you convinced me that it has entered Therapeutic Guidelines and it does have an evidence base. And it sounded a bit like a trick you used to play on your little brother, which was electrocuting his hands with a battery.

Oh, the 9-volt battery trick?

Yeah, but this is perhaps a bit more targeted and scientific than what I used to do to my little brother.

This was just as the group was going through this particular issue of primary hyperhidrosis, looking at hands or palms and feet in particular, this was just something I was unfamiliar with. So there's a treatment called iontophoresis, and it's one of those ones where it's like, who knows how it works? But it seems to. Basically, you pop your hands and feet on some moistened pads, and there's a particular iontophoresis unit, and batteries generate this current that stimulates ions to migrate across the skin barrier. And if you do that for 15 to 30 minutes, and you do it daily, apparently it makes quite a difference. And then over time, sometimes a single treatment will be good enough for 1 to 2 weeks. So that was completely news to me. Sounds so weird, but it's in Therapeutic Guidelines, so got to be true.

Well, my brother has more to thank me for than he knew at the time. Let's move on to scabies. Scabies is one of my favourite skin things because I've seen so much of it over time, and seen so much of it fail treatment over time too. To be fair, look, I have lived in remote Aboriginal communities for 7 years of my career in 3 different stints, so I guess that's where I had that experience, but certainly you get whole households with scabies and it's very hard to eradicate. What's the new message in scabies in the new updated guidelines?

Well, I think it's very much in line with what you just said, which is, you've seen the treatment failures, and the treatment failures, I'm guessing, would probably tend to occur more with the topical treatments. That whole idea of coating somebody from top to toe and not missing anything out, it always struck me as being a tricky thing to do, especially if, like me, you have an aversion to slathering yourself in creams and so forth. So, to probably reflect that concern, there's that oral treatment option of ivermectin, where you have a single dose and you follow up with another dose a week later. So, that's been upgraded to equal first-line, first option status with topical permethrin for the treatment of scabies and adults in children who are 15 kg or more.

Melanoma. Now, I talked about our skin types early on. Melanomas are certainly covered in Therapeutic Guidelines, although of course, treatment there is surgical rather than anything topical or oral for 99% of cases, until you get into the more complex spreading melanomas. One particular chart I like, and there's a handout for patients and for doctors, but the ABCDEFG rule. That's a hell of an acronym.

But a very useful one. Acronyms are often useful as long as you don't mix them up. A to G, there's a new diagram that's there as a PDF that you can print out and hand to your patients, that describes and shows in a pictorial representation what exactly does asymmetry, border, colour, diameter, evolving, elevated, firm, and growing look like. And so there's a handy bit of education for your more sun-exposed patients.

We finish now with psoriasis. Psoriasis, yeah, one of those conditions I think which all GPs will have some patients with psoriasis. We're sometimes not hugely familiar with the types of treatments. But happily for psoriasis, I find that a lot of them tend to be proprietary treatments, where the manufacturers themselves add in two things, like a corticosteroid and a coal tar or a calcipotriol. The main new message when I was looking through this section seems to be about rotating the treatments.

So, rotation of the combinations of the different treatments. So there's, again, just a handy little chart that gives you a bit of a guide about how to potentially go through different types of monotherapy or combination therapy in the various combinations. So, just a handy little chart, and also a little bit of a guide to what point you might on refer to a dermatologist for specialist treatments, phytotherapy, methotrexate. There's a new drug, apremilast. So again, just a little guide at what point you might say, ‘Time to move on.’

Lee Fong, it is time to move on, so that's well-timed. It's been wonderful talking to you. Thanks so much for helping us and our listeners with the new Therapeutic Guidelines: Dermatology update.

You're very welcome, Justin. Thanks for having me.

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My guests’ views are their own and don't represent Australian Prescriber, and my views are certainly all mine.