Acne Vulgaris
- chronic, inflammatory skin condition affecting face, back and chest. It’s characterised by blockage and
inflammation of the hair follicle, hair shaft and sebaceous gland and presents with lesions which can be
inflamed. Non-inflammatory lesions (comedones) may be open (blackheads) or closed (whiteheads).
Inflammatory lesions can include papules and pustules.
Causes: high glycaemic diets, proliferation of Propionibacterium acnes and increased sebum production
Complications: scarring, post-inflammatory hyperpigmentation, risk of suicide, depression, anxiety
Clinical features: comedones, inflammatory lesions, scarring, pigmentation, seborrhoea
Management
General advice:
o Avoid overcleaning the skin as this can cause dryness and irritation
o Twice daily washing with gentle soap and fragrance-free cleanser is adequate
o For make-up/cleansers/emollients, non-comedogenic preps with a pH close to the skin are advised
o Avoid picking and squeezing spots which may increase the risk of scarring
o Maintain a healthy diet
o Treatments are effective but take time to work (usually up to 8 weeks) and can irritate the skin
Mild-to-moderate acne:
1. Topical retinoid i.e. adapalene alone or in combination with benzoyl peroxide
Adapalene and tretinoin are licensed for use in >12yrs
AVOID retinoids in pregnancy, BF, severe acne and exposure to excessive UV light
2. Topical antibiotic i.e. clindamycin 1% with benzoyl peroxide to prevent bacterial resistance
If 2 separate products are used, they should be applied 12hrs apart.
Benzoyl peroxide is applied at night and the topical antibiotic in the morning
AVOID using 2 products with an alcoholic base as this can increase skin irritation
Topical benzoyl peroxide and erythromycin are safe in pregnancy
3. Azelaic acid 20% - usually twice daily
Moderate acne not responding to topical treatment:
1. Consider adding oral tetracycline i.e. lymecycline or doxycycline for a max 3 months
Oral antibiotics should always be prescribed with topical retinoid or benzoyl peroxide to
reduce the risk of antibiotic resistance
AVOID macrolides like erythromycin due to high levels of P. acnes resistance but can be
used if TCs are contraindicated (i.e. in pregnancy, <12yrs (tetracycline), <8yrs (lym.))
Change to an alternative antibiotic if there’s no improvement after 3 months
2. Combined oral contraceptives in combination with topical agents as an alternative to systemic ABs
2nd and 3rd gen COCS are preferred over oral progesterone-only contraceptives or progestin
implants as these have androgenic activity and can exacerbate acne
Co-cyprindiol (‘Dianette’) can be considered in moderate-to-severe acne. Discontinue 3
months after acne has been controlled
,Allergic Rhinitis (Hayfever)
- an IgE-mediated inflammatory disorder of the nose, which occurs when the nasal mucosa becomes
exposed and sensitised to allergens. This triggers the release of histamine, which acts on cells, nerve
endings and blood vessels to produce symptoms of sneezing, nasal itching, rhinorrhoea (discharge) and
congestion
Causes: house dust mites, pollen, moulds, animal dander, occupational, family history
Complications: impaired quality of life, impaired school performance, asthma, sinusitis
Differential diagnosis: autonomic/irritant rhinitis (due to changes in temp/humidity or with exercise,
chemical exposure and odours), drugs (ACE inhibitors, beta-blockers, aspirin, cocaine, NSAIDs, etc),
hormones, alcohol, spicy foods, deviated nasal septum.
Refer: blood-stained nasal discharge, recurrent epistaxis, nasal pain, predominant nasal obstruction
Management:
Allergen avoidance techniques
o Avoid walking in grassy, open spaces, especially during early morning/evening
o Avoid drying washing outdoors, especially when pollen count is high
o Shower or wash hair following high pollen exposures
o Use synthetic pillows and acrylic duvets, and keep furry toys off the bed
o Wash all bedding at least once weekly at high temperatures
o Choose wooden/hard floor surfaces instead of carpets
o Fit blinds that can be wiped clean instead of curtains
o Wash the animal and any surfaces they are in contact with, regularly
Initial drug treatment
1. Mild-to-moderate, intermittent or mild, persistent symptoms:
o 1st line = intranasal antihistamine on ‘as-needed’ basis i.e. azelastine
o 2nd line = non-sedating oral antihistamine i.e. loratadine, cetirizine
o 3rd line = intranasal chromone on ‘as-needed’ basis i.e. sodium cromoglicate
2. Moderate-to-severe, persistent or initial drug Tx is ineffective:
o Regular intranasal corticosteroid i.e. mometasone or fluticasone
Onset of action is 6-8hrs post first dose, but max effect may not be seen until after
2wks
Nasal drops may be preferred if there’s severe nasal obstruction
Treatment failure and referral
1. If nasal congestion is the main problem;
o Intranasal decongestant (i.e. ephedrine or xylometazoline) for up to 5-7 days
2. If there’s persistent, watery rhinorrhoea;
o Combined therapy – intranasal corticosteroid, oral antihistamine and intranasal
anticholinergic (i.e. ipratropium bromide)
3. If there’s persistent nasal itching and sneezing, options include;
o Use oral antihistamine regularly
, o Dymista spray – intranasal azelastine with intranasal fluticasone
o Using oral and intranasal antihistamine together is not recommended
4. If Pt has ongoing symptoms plus a history of asthma;
a. Add leukotriene receptor antagonist (i.e. montelukast) to an oral or intranasal antihistamine
Prescribing information
Azelastine nasal spray is the only intranasal antihistamine licensed for treating allergic rhinitis
- for >6yrs, one spray twice daily into each nostril
- S/Es = bitter taste, irritation of nasal mucosa, rash, pruritus
Cetirizine and loratadine are not licensed for children <2yrs
- Cetirizine in >12yrs = 10mg OD, for 6-12yrs = 5mg BD, for 2-5yrs = 2.5mg BD
- Loratadine in >2yrs = 10mg OD
- S/Es = blurred vision, dry mouth, diarrhoea, urinary retention, drowsiness (some)
- take caution with both in pregnancy and breastfeeding
- AVOID cetirizine in severe renal impairment (eGFR = <10ml/min/1.73m2)
Intranasal sodium cromoglicate is licensed for use in children
- one spray, 2-4 times daily into each nostril
- not known to be harmful in pregnancy and breastfeeding
Ephedrine HCl 0.5% nasal drops are licensed for nasal congestion in >12yrs
- apply 1-2 drops up to QDS as required for a max 7 days, into each nostril
Xylometazoline HCl nasal drops/spray is licensed for nasal congestion in >6yrs
- 6-11yrs = 1-2 nasal drops applied 1-2 times daily as required for max 5 days
- >12yrs = 2-3 nasal drops applied 2-3 times daily as required for max 7 days
- caution in diabetes, hypertension, hyperthyroidism, CVD and angle closure glaucoma
(xylometaz.)
- S/Es (both) = rebound nasal congestion upon withdrawal, headache, transient visual
disturbance
- S/Es especially with xylometaz. = hallucinations, restlessness, sleep disturbance in small
children
- AVOID both in pregnancy and breastfeeding
Intranasal ipratropium bromide is used to manage rhinorrhoea in >12yrs
- 2 sprays 2-3 times daily, into each nostril
- caution in cystic fibrosis, BPH and those at risk of angle-closure glaucoma
- S/Es = epistaxis, nasal dryness, headache, nausea
- only use in pregnancy and breastfeeding if potential benefits outweigh risks
- AVOID spraying near eyes to reduce risk of ocular complications
Oral montelukast is licensed for the symptomatic relief of seasonal allergic rhinitis in asthmatics aged
>15yrs
- 10mg OD, to be taken in the evening
- be alert to the development of eosinophilia, cardiac complications (Churg-Strauss syndrome)
, Amenorrhoea
- absence or cessation of menses.
1° = failure to establish menstruation by 16yrs with normal sex characteristics (by 14yrs with no char.)
2° = absence of menstruation for at least 6 months in women with previously normal + regular menses
Oligomenorrhoea = menses occurring less frequently than every 35 days
Causes:
Physiological – pregnancy, constitutional delay
Pathological – genito-urinary defect, absent vagina, ovarian failure, hypothalamic-pituitary
dysfunction
Progestogen methods of contraception, chemotherapy
Drugs = hyperprolactinaemia – antipsychotics, metoclopramide, methyldopa, cimetidine, opiates
Diseases – PCOS, Cushing’s, TB, head injury, tumour
Hypothalamic dysfunction – weight loss, eating disorders, excessive exercise, depression, stress
Complications: osteoporosis, CVD, infertility, psychological distress
Management
Primary amenorrhoea
Weight-related – encourage weight gain and refer to a dietician if needed
Exercise-related – reduce exercise, increase calorie intake and weight gain
Stress-related – consider measures to manage stress and improve coping strategies like CBT
Secondary amenorrhoea
Hypothalamic amenorrhoea or hyperprolactinaemia
o Treat underlying cause and assess their fragility fracture risk
o Consider HRT or COC pill if amenorrhoea persists for more than 12 months
o Review at least annually
Dysmenorrhoea
- painful cramping, usually in the lower abdomen, occurring before or during menstruation, or both
1° = occurs in the absence of any identifiable underlying pelvic pathology usually due to production of
uterine prostaglandins during menstruation.
2° = caused by underlying pelvic pathology like endometriosis, fibroids or endometrial polyps
Refer: abnormal cervix on exam, persistent intermenstrual bleeding, palpable abdominal or pelvic mass
Management
1. NSAID i.e. ibuprofen, naproxen or mefenamic acid or paracetamol (if NSAIDs contraindicated)
Mefenamic acid is licensed for dysmenorrhoea but it can cause seizures in overdose
2. Hormonal contraception for 3-6 months as a trial
1st line = monophasic COC (30-35mcg of ethinylestradiol + norethisterone or levonorgestrel)
2nd line = oral desogestrel 75mcg, parenteral ‘Depo-Provera’ or intrauterine ‘Mirena’
3. Non-drug treatments – local application of heat (i.e. hot water bottle) or TENS at a high frequency
- chronic, inflammatory skin condition affecting face, back and chest. It’s characterised by blockage and
inflammation of the hair follicle, hair shaft and sebaceous gland and presents with lesions which can be
inflamed. Non-inflammatory lesions (comedones) may be open (blackheads) or closed (whiteheads).
Inflammatory lesions can include papules and pustules.
Causes: high glycaemic diets, proliferation of Propionibacterium acnes and increased sebum production
Complications: scarring, post-inflammatory hyperpigmentation, risk of suicide, depression, anxiety
Clinical features: comedones, inflammatory lesions, scarring, pigmentation, seborrhoea
Management
General advice:
o Avoid overcleaning the skin as this can cause dryness and irritation
o Twice daily washing with gentle soap and fragrance-free cleanser is adequate
o For make-up/cleansers/emollients, non-comedogenic preps with a pH close to the skin are advised
o Avoid picking and squeezing spots which may increase the risk of scarring
o Maintain a healthy diet
o Treatments are effective but take time to work (usually up to 8 weeks) and can irritate the skin
Mild-to-moderate acne:
1. Topical retinoid i.e. adapalene alone or in combination with benzoyl peroxide
Adapalene and tretinoin are licensed for use in >12yrs
AVOID retinoids in pregnancy, BF, severe acne and exposure to excessive UV light
2. Topical antibiotic i.e. clindamycin 1% with benzoyl peroxide to prevent bacterial resistance
If 2 separate products are used, they should be applied 12hrs apart.
Benzoyl peroxide is applied at night and the topical antibiotic in the morning
AVOID using 2 products with an alcoholic base as this can increase skin irritation
Topical benzoyl peroxide and erythromycin are safe in pregnancy
3. Azelaic acid 20% - usually twice daily
Moderate acne not responding to topical treatment:
1. Consider adding oral tetracycline i.e. lymecycline or doxycycline for a max 3 months
Oral antibiotics should always be prescribed with topical retinoid or benzoyl peroxide to
reduce the risk of antibiotic resistance
AVOID macrolides like erythromycin due to high levels of P. acnes resistance but can be
used if TCs are contraindicated (i.e. in pregnancy, <12yrs (tetracycline), <8yrs (lym.))
Change to an alternative antibiotic if there’s no improvement after 3 months
2. Combined oral contraceptives in combination with topical agents as an alternative to systemic ABs
2nd and 3rd gen COCS are preferred over oral progesterone-only contraceptives or progestin
implants as these have androgenic activity and can exacerbate acne
Co-cyprindiol (‘Dianette’) can be considered in moderate-to-severe acne. Discontinue 3
months after acne has been controlled
,Allergic Rhinitis (Hayfever)
- an IgE-mediated inflammatory disorder of the nose, which occurs when the nasal mucosa becomes
exposed and sensitised to allergens. This triggers the release of histamine, which acts on cells, nerve
endings and blood vessels to produce symptoms of sneezing, nasal itching, rhinorrhoea (discharge) and
congestion
Causes: house dust mites, pollen, moulds, animal dander, occupational, family history
Complications: impaired quality of life, impaired school performance, asthma, sinusitis
Differential diagnosis: autonomic/irritant rhinitis (due to changes in temp/humidity or with exercise,
chemical exposure and odours), drugs (ACE inhibitors, beta-blockers, aspirin, cocaine, NSAIDs, etc),
hormones, alcohol, spicy foods, deviated nasal septum.
Refer: blood-stained nasal discharge, recurrent epistaxis, nasal pain, predominant nasal obstruction
Management:
Allergen avoidance techniques
o Avoid walking in grassy, open spaces, especially during early morning/evening
o Avoid drying washing outdoors, especially when pollen count is high
o Shower or wash hair following high pollen exposures
o Use synthetic pillows and acrylic duvets, and keep furry toys off the bed
o Wash all bedding at least once weekly at high temperatures
o Choose wooden/hard floor surfaces instead of carpets
o Fit blinds that can be wiped clean instead of curtains
o Wash the animal and any surfaces they are in contact with, regularly
Initial drug treatment
1. Mild-to-moderate, intermittent or mild, persistent symptoms:
o 1st line = intranasal antihistamine on ‘as-needed’ basis i.e. azelastine
o 2nd line = non-sedating oral antihistamine i.e. loratadine, cetirizine
o 3rd line = intranasal chromone on ‘as-needed’ basis i.e. sodium cromoglicate
2. Moderate-to-severe, persistent or initial drug Tx is ineffective:
o Regular intranasal corticosteroid i.e. mometasone or fluticasone
Onset of action is 6-8hrs post first dose, but max effect may not be seen until after
2wks
Nasal drops may be preferred if there’s severe nasal obstruction
Treatment failure and referral
1. If nasal congestion is the main problem;
o Intranasal decongestant (i.e. ephedrine or xylometazoline) for up to 5-7 days
2. If there’s persistent, watery rhinorrhoea;
o Combined therapy – intranasal corticosteroid, oral antihistamine and intranasal
anticholinergic (i.e. ipratropium bromide)
3. If there’s persistent nasal itching and sneezing, options include;
o Use oral antihistamine regularly
, o Dymista spray – intranasal azelastine with intranasal fluticasone
o Using oral and intranasal antihistamine together is not recommended
4. If Pt has ongoing symptoms plus a history of asthma;
a. Add leukotriene receptor antagonist (i.e. montelukast) to an oral or intranasal antihistamine
Prescribing information
Azelastine nasal spray is the only intranasal antihistamine licensed for treating allergic rhinitis
- for >6yrs, one spray twice daily into each nostril
- S/Es = bitter taste, irritation of nasal mucosa, rash, pruritus
Cetirizine and loratadine are not licensed for children <2yrs
- Cetirizine in >12yrs = 10mg OD, for 6-12yrs = 5mg BD, for 2-5yrs = 2.5mg BD
- Loratadine in >2yrs = 10mg OD
- S/Es = blurred vision, dry mouth, diarrhoea, urinary retention, drowsiness (some)
- take caution with both in pregnancy and breastfeeding
- AVOID cetirizine in severe renal impairment (eGFR = <10ml/min/1.73m2)
Intranasal sodium cromoglicate is licensed for use in children
- one spray, 2-4 times daily into each nostril
- not known to be harmful in pregnancy and breastfeeding
Ephedrine HCl 0.5% nasal drops are licensed for nasal congestion in >12yrs
- apply 1-2 drops up to QDS as required for a max 7 days, into each nostril
Xylometazoline HCl nasal drops/spray is licensed for nasal congestion in >6yrs
- 6-11yrs = 1-2 nasal drops applied 1-2 times daily as required for max 5 days
- >12yrs = 2-3 nasal drops applied 2-3 times daily as required for max 7 days
- caution in diabetes, hypertension, hyperthyroidism, CVD and angle closure glaucoma
(xylometaz.)
- S/Es (both) = rebound nasal congestion upon withdrawal, headache, transient visual
disturbance
- S/Es especially with xylometaz. = hallucinations, restlessness, sleep disturbance in small
children
- AVOID both in pregnancy and breastfeeding
Intranasal ipratropium bromide is used to manage rhinorrhoea in >12yrs
- 2 sprays 2-3 times daily, into each nostril
- caution in cystic fibrosis, BPH and those at risk of angle-closure glaucoma
- S/Es = epistaxis, nasal dryness, headache, nausea
- only use in pregnancy and breastfeeding if potential benefits outweigh risks
- AVOID spraying near eyes to reduce risk of ocular complications
Oral montelukast is licensed for the symptomatic relief of seasonal allergic rhinitis in asthmatics aged
>15yrs
- 10mg OD, to be taken in the evening
- be alert to the development of eosinophilia, cardiac complications (Churg-Strauss syndrome)
, Amenorrhoea
- absence or cessation of menses.
1° = failure to establish menstruation by 16yrs with normal sex characteristics (by 14yrs with no char.)
2° = absence of menstruation for at least 6 months in women with previously normal + regular menses
Oligomenorrhoea = menses occurring less frequently than every 35 days
Causes:
Physiological – pregnancy, constitutional delay
Pathological – genito-urinary defect, absent vagina, ovarian failure, hypothalamic-pituitary
dysfunction
Progestogen methods of contraception, chemotherapy
Drugs = hyperprolactinaemia – antipsychotics, metoclopramide, methyldopa, cimetidine, opiates
Diseases – PCOS, Cushing’s, TB, head injury, tumour
Hypothalamic dysfunction – weight loss, eating disorders, excessive exercise, depression, stress
Complications: osteoporosis, CVD, infertility, psychological distress
Management
Primary amenorrhoea
Weight-related – encourage weight gain and refer to a dietician if needed
Exercise-related – reduce exercise, increase calorie intake and weight gain
Stress-related – consider measures to manage stress and improve coping strategies like CBT
Secondary amenorrhoea
Hypothalamic amenorrhoea or hyperprolactinaemia
o Treat underlying cause and assess their fragility fracture risk
o Consider HRT or COC pill if amenorrhoea persists for more than 12 months
o Review at least annually
Dysmenorrhoea
- painful cramping, usually in the lower abdomen, occurring before or during menstruation, or both
1° = occurs in the absence of any identifiable underlying pelvic pathology usually due to production of
uterine prostaglandins during menstruation.
2° = caused by underlying pelvic pathology like endometriosis, fibroids or endometrial polyps
Refer: abnormal cervix on exam, persistent intermenstrual bleeding, palpable abdominal or pelvic mass
Management
1. NSAID i.e. ibuprofen, naproxen or mefenamic acid or paracetamol (if NSAIDs contraindicated)
Mefenamic acid is licensed for dysmenorrhoea but it can cause seizures in overdose
2. Hormonal contraception for 3-6 months as a trial
1st line = monophasic COC (30-35mcg of ethinylestradiol + norethisterone or levonorgestrel)
2nd line = oral desogestrel 75mcg, parenteral ‘Depo-Provera’ or intrauterine ‘Mirena’
3. Non-drug treatments – local application of heat (i.e. hot water bottle) or TENS at a high frequency
