Inflammatory dermatoses

Risk factors: Triggers: soap/detergents, overheating, rough clothing, stress, skin infection; less often allergens.

Features: Infants: face then flexures. Itch, redness, scale/crust, papulovesicles, excoriation, lichenification. Afro-Caribbean patients may show more extensor disease.

Management: Complete emollient therapy is the mainstay (more emollient means less steroid). Apply emollient then topical steroid after 15-20 minutes. Soap substitutes. Antiseptic emollients (for example Dermol) if frequent infection; do not overuse if irritating. Topical steroids: lowest appropriate potency, thinly, to inflamed skin only. Avoid routine combined steroid/antibiotic preparations. Potency by site: child face mild (1% hydrocortisone); child trunk/limbs moderate (for example clobetasone / dilute betamethasone); adult face mild to moderate; adult trunk/limbs potent (for example betamethasone 0.1%, mometasone); palms/soles potent or very potent. Flares: moderate to potent steroid once daily until settled (avoid lingering on mild steroid alone). Sleep disturbance: short sedating antihistamine. Not settling: swab. Review in 1-2 weeks. Frequent flares: check adherence; weekend steroid regimen (2 consecutive days/week to flare-prone areas once settled); consider topical calcineurin inhibitors. Steroid potency ladder (UK brands): mild hydrocortisone 0.5-1%; moderate clobetasone butyrate 0.05% (Eumovate), betamethasone 0.025% (Betnovate RD); potent betamethasone 0.1% (Betnovate), mometasone 0.1%, fluticasone 0.05%, hydrocortisone butyrate 0.1%; very potent clobetasol propionate 0.05% (Dermovate).

AKT pearl: hand 1 | foot 2 | face/neck 2.5 | arm 3 | leg 6 | trunk front 7 | trunk back 7.

Red flags: diagnostic doubt; severe eczema; moderate to severe with partial response; steroid atrophy/concerns; possible contact allergy. Secondary care: phototherapy, systemics (MTX, ciclosporin, azathioprine, MMF), biologics/JAK inhibitors.

Features: TCI: no atrophy; useful on eyelids/face and with frequent facial steroids. Local sting/burn common; sun protection; stop if infected.

Management: Scalp: mild tar shampoo; steroid scalp application until itch settles; alcohol-free gel if stinging; soft scale with keratolytic ointment before steroid.

Management: Acute: short potent topical steroid. Long-term: regular emollient plus steroid for flares.

Features: Patterns: dry/scaling; wet/weeping with or without vesicles; pompholyx (itchy palm/finger vesicles with or without bullae); hyperkeratotic palms/soles. Differentials include psoriasis.

Management: Protection (gloves), emollient soap substitutes, potent/super-potent steroids, potassium permanganate soaks for weeping bullae, steroid-impregnated tape for fissures. Severe: short oral prednisolone with or without antibiotics if infected.

Management: Scalp: ketoconazole 2% shampoo 2-3 times per week then weekly. Face/body: topical azole with or without short mild steroid. Extensive/refractory: short oral itraconazole; maintain with intermittent shampoo.

Advice: Relapses common. Check HIV if severe/recalcitrant.

Management: Same-day action: admit if systemically unwell, infant, widespread, or any eye signs. Start aciclovir promptly (IV if severe/child/eye). Swab HSV PCR with or without bacterial culture. Hold topical calcineurin inhibitors; avoid potent steroid on infected skin. Urgent ophthalmology if peri-ocular symptoms.

Red flags: Face/eye involvement or infants are high risk - treat as an emergency.

Management: Frequent changes, gentle cleaning, thick barrier, nappy-free time. Inflamed: hydrocortisone 1% for up to 7 days. Candida: clotrimazole/miconazole twice daily continue 7-10 days after clear. Bacterial: consider fusidic acid; swab if severe/recurrent.

Red flags: ulcers, fever, cellulitis, unwell neonate, perianal strep; refer if not settling in 1-2 weeks.

Risk factors: Triggers: stress, strep, Koebner trauma, alcohol/smoking; drugs (lithium, antimalarials, beta-blockers, NSAIDs, ACEIs, interferon); postpartum flares. Severe disease: consider HIV test.

Features: Nails: pitting, onycholysis, subungual hyperkeratosis, oil-drop sign. Complications: psoriatic arthritis (about 10%), metabolic syndrome, CVD/VTE, psychosocial burden.

Management: Primary care ladder: emollients for all; then 4 weeks potent steroid once daily plus vitamin D analogue once daily (morning/evening); next 8 weeks vitamin D analogue twice daily; then potent steroid twice daily or coal tar. Short-contact dithranol optional. Scalp: potent steroid once daily for 4 weeks; descaling if needed. Face/flexures/genital: mild to moderate steroid for up to 2 weeks.

AKT pearl: Vitamin D analogues maximum about 100 g/week in adults; avoid in pregnancy. Potent steroid courses typically up to 8 weeks; very potent up to 4 weeks; 4-week break between courses; avoid strong steroids on face/flexures.

Red flags: failed topicals; extensive/unstable disease; diagnostic doubt; urgent rheumatology for psoriatic arthritis. Secondary care: NB-UVB, PUVA, MTX, ciclosporin, acitretin, biologics.

Features: Sudden teardrop scaly papules on trunk/limbs. Self-resolves in 2-3 months.

Management: Emollients with or without mild steroid/vitamin D; NB-UVB if extensive. Treat concurrent strep throat as usual; antibiotics do not clear the rash. Recurrent: ENT review case-by-case.

AKT pearl: STREP then DROPS (strep precedes teardrop spots).

Management: Self-limiting 6-12 weeks. Reassure; emollients, mild steroid/antihistamine for itch; NB-UVB if severe.

Advice: Atypical sites (palms/soles), systemic symptoms, or pregnancy: reconsider diagnosis (syphilis serology if indicated).

Risk factors: Lichenoid drugs: gold, antimalarials, thiazides, beta-blockers, ACEIs, NSAIDs.

Features: Course months to 2 years; post-inflammatory hyperpigmentation common. Erosive oral LP: small SCC risk. Oral LP: reticular (painless lacy buccal striae) versus erosive (painful ulcers).

Management: Primary care: potent topical steroid (for example clobetasol 0.05%). Oral: topical steroid in Orabase or steroid mouthwash; analgesia; add azole if candida. Photo and review 6-12 months; biopsy unilateral/indurated/persistent change.

Referral: Refer widespread/erosive genital or oral, nail disease, or refractory cases.

Risk factors: Triggers: heat/sun, alcohol, hot drinks, spicy food, stress, exercise; topical steroids worsen.

Management: General: trigger diary, SPF 30 or higher, gentle care; avoid steroids. Flushing/erythema: brimonidine gel as needed. Mild to moderate papulopustular: topical ivermectin 1% first-line (or metronidazole/azelaic acid). Moderate to severe: oral doxycycline/lymecycline 6-12 weeks.

Red flags: failed optimal topicals, significant ocular disease, marked telangiectasia, rhinophyma, diagnostic doubt.

Features: Diagnosis: skin biopsy plus DIF (granular IgA at dermal papillae). Coeliac serology (tTG-IgA with or without EMA; check total IgA).

Management: Lifelong gluten-free diet. Dapsone for rapid control (G6PD, FBC/LFT monitoring). Refer dermatology and GI.

Management: 12-week courses then review. Pick one regimen matching severity; never antibiotic monotherapy. Mild to moderate topical: fixed adapalene plus BPO, or tretinoin plus clindamycin, or BPO plus clindamycin, or azelaic acid. Moderate inflammatory/trunk: oral doxycycline or lymecycline plus fixed retinoid/BPO (no topical antibiotic at the same time). Limit oral antibiotics to about 3 months. Severe/scarring/high psychosocial impact/failed above: dermatology for isotretinoin; continue topical retinoid/BPO while waiting if tolerated. Maintenance: topical adapalene or BPO; stop continued antibiotics. Pregnancy: avoid tetracyclines and all retinoids; use azelaic acid or BPO (with or without topical erythromycin).

Red flags: severe/nodulo-cystic/scarring; failed two optimised regimens (one with oral antibiotic); major distress; suspected acne fulminans (urgent).

Management: Stop exposure (may need 8-12 weeks), emollient plus soap substitute, appropriate-potency topical steroid; patch testing/occupational referral if persistent.