Great outcomes for urticaria (“hives”) patients with new injectable medication!

 

Spontaneous urticaria (hives) is such a common condition but can be difficult to manage. Patients describe itchy welts, swollen and red skin, and sometimes swollen eyes and lips too. The rash typically resolves within 24 hours but then the cycle repeats itself and new rash appears on other areas of the body. It can be incredibly itchy or even painful and can be frustrating to treat.

I myself suffer from urticaria too but mine is set off by temperature changes (“cold-induced urticaria”) and friction (“delayed-pressure urticaria”).  Any of my urticaria patients will attest to my empathy with their skin rash; as I have first hand knowledge of how frustrating it can be to manage! When patients present with urticaria, it is important to find out the triggers (heat, sweat, friction, stress, medication etc) and also exclude any other underlying medical conditions that can contribute to their urticaria flaring. This means taking a detailed history for other symptoms and blood tests may be needed. Typically urticaria treatments might involve creams, UV therapy and tablets.

Now a new injectable biologic medication, Omalizumab, is available under the PBS for our patients with chronic spontaneous urticaria since late 2017. Only some dermatologists are able to prescribe this medication (Dr Georgina Lyons and myself satisfy PBS criteria to prescribe this medication). Omalizumab works by binding to circulating IgE; a molecule responsible for setting off an inflammatory cascade, leading to the symptoms of itch and rash. Omalizumab has been on the PBS for a while for the indication of asthma but has been a recent addition to the PBS under dermatology for the indication of Chronic Spontaneous Urticaria (or CSU for short). In the past, patients with CSU have used various combinations of H1 (histamine 1) blockers and H2 blockers, UV therapy, Plaquenil (an anti-malarial tablet that acts to reduce inflammation), mast-cell stabiliser medications and then immunosuppression – all in a bid to control their rash and itching. Now we are finding that patients are able to transition straight from the H1 and H2 blocker combination, to Omalizumab straight away and these patients are reporting great outcomes.

Omalizumab is given as a monthly injection and PBS gives patients 3 months worth of medication at a time. After the 3-month period of medication is up, patients then make an assessment as to whether they need another round of injections or they can take a trial period off the injections and monitor their symptoms to see if there is a flare. If they need another period of treatment, then their dermatologist can apply for another 3 months.

It is a well tolerated medication and some patients with a history of very difficult to control urticaria have had a great response to this medication. We would be happy to offer you an appointment with our team to fully assess and manage your urticaria.

Acne and early treatment

In this blog we would like to discuss one of our lovely patient’s journey with acne and share with you some very impressive before and after photo’s.

Our patient is a 25yo gentleman who has been struggling with cystic acne since the age of 14. Over the course of 11 years he experienced large cystic lesions to his chest, back, face and neck that are typically associated with significant atrophic (pitted) scarring. He found his acne would increase with consumption of certain foods and had tried many different types of skincare with little change to his skin.

The lesions were painful, red and visible.

He came to us with a pre-conceived notion of treatment options and their side effects and efficacy and had avoided medical treatment for many years because of this.  After a thorough consultation, with skin education and encouragement he was happy to try treatment and commenced on oral isotretinoin, oral antibiotic cover and anti-inflammatories to reduce flare-up which can occur with this type of acne. He received a detailed consultation regarding appropriate skincare and acne aetiology (causal factors).

The images pictured are only 4 weeks post commencement of treatment and this gentleman is so thrilled with his results he has provided his very own ‘before and after’ images that he has previously shared on social media personally and was more than happy for us to share on this platform for the benefit of others. We are thrilled to join him on his journey to great skin!

He told us he wanted to share his images as (in his own words) “I put up with my acne for so long and if my “before and after” pictures can help patients make the decision to see a dermatologist and get treatment early, then I’m happy to help.”

 

For more images please follow the links to Instagram and Facebook from our home page!

Treating freckles and pigmentation

Autumn is officially here! And with the cooler weather, lots of our patients are wanting laser and treatment for their pigmented and blotchy skin. Our laser nurse Kristie gives us an overview of pigmentation…Freckles, pigment, sunspots…

What’s the difference!?

 

Kristie Phillips - Hope Dermatology

“In my 18 years of lasering I have often been asked this very question, and frequently in general conversation the terms “freckle”, “pigment” and “age spot” get bandied around interchangeably.

Whilst as a consumer, you probably don’t need to know the ins and out of what constitutes a freckle versus a sun spot, or whether you have sun damage or melasma it is important to understand there IS a difference and this can be VERY important when it comes to treatment”.

 

PIGMENT essentially refers to the colour of the skin and is determined by the level of melanin, produced by melanocytes. Melanin production is determined by racial origin and sun exposure. People with dark skin produce more melanin than those who are fair skinned, and exposure to sun and UV stimulates our melanocytes to produce more melanin, resulting in a tan. Generally when people are seeking treatment for their pigmentation, we are referring to excess and uneven pigment.

MELASMA is a chronic skin disorder that results in a symmetrical, blotchy, darkening of the skin that can be both difficult to treat and distressing for sufferers. It commonly affects women more so than men, manifesting around the ages of 20-40. It results from the production of melanin by melanocytes, as with a tan, but is an overstimulation of melanin that persists long term (often despite our best efforts!) The cause of melasma can be complex and can have a genetic predisposition. Common triggers can include sun exposure, pregnancy, hormone therapy such as the oral contraceptive pill, other medications and inflammation from cosmetics such as perfumes or soaps and so strict avoidance of these is vital in treatment.

FRECKLES (medically we call them ephelides just to add another term into the mix) present as small, flat brown lesions on sun exposed areas of the body such as the face, shoulders, arms etc and are common in people with fair skin and red heads. Freckles are the result of sun exposure which again is stimulating our melanocytes to produce melanin, which then accumulates locally in the superficial skin cells (keratinocytes). They typically darken in summer (with sun exposure) and fade in winter (due the natural exfoliation and replacement of the keratinocytes).

SUN SPOTS / AGE SPOTS / LIVER SPOTS etc etc are all terms used to describe SOLAR LENTIGINES. Like freckles, solar lentigines are benign dark patches in the skin, as a result of sun induced melanin production and localised proliferation within the keratinocytes.   Unlike freckles, they do not fade in winter and tend to present in people over the age of 40 and accumulate with continued sun exposure, hence the terms “sun damage” and “aged spots”. They have NOTHING to do with your liver.

So how do we treat them? Well first I would always suggest a skin check with the dermatologist to diagnose your skin condition and rule out the myriad of OTHER brown spots and skin lesions and potential skin cancers.

Beyond that…

Prevention – with daily (rain, hail or shine) use of an SPF 50+.

Repair  – with good quality, cosmeceutical skincare (think AHA, Vit A, Vit B, Vit C etc etc).

Remove – generally with laser. There are a variety of lasers available to treat various types of pigment irregularities and a consultation is a must.

 

Kristie Phillips, RN

 

New medications for eczema – an update from the American Academy of Dermatology annual conference 2018

 

Dr Georgina Lyons - Hope Dermatology

 

 

Dr Georgina Lyons talks all new things in eczema.

Reporting from the AAD meeting San Diego 

 

“I have just returned from sunny San Diego, where the American Academy of Dermatology held their annual scientific meeting this year. As the largest dermatology conference in the world the AAD meeting is always a wonderful opportunity to hear from the best dermatologists in America and catch up on all the latest advances in dermatology (many of which are released in the U.S. first before making their way to Australia).

This year there were several exciting developments in terms of new treatments available for eczema, including the biologic Dupilimumab for widespread recalcitrant eczema and the new non-steroid topical cream Crisaborole. Whilst not yet on the PBS these medications were approved for use in Australia by the TGA earlier in the year, and will hopefully soon be government subsidised for treatment of eczema in Australia.

Also, it turns out that vinegar doesn’t just go well with fish and chips – vinegar baths for eczema were discussed as a simple and effective alternative or adjunct to bleach baths in treating flares and preventing secondary infection. I am looking forward to trying this out with some of my patients!”

Eczema in babies

 

 

And just like that in the blink of an eye my youngest is nearly 8 months. Trawling through old videos and photos, I came across this video that was shot when I was pregnant with him. I am talking about eczema in the video and little did I know that he would also have infantile eczema, like his older sister (eczema tends to run in families). And little did I know I would have many a sleepless night with him scratching and irritable!

Today I was asked about suggestions for eczema management for a medical colleague’s baby. She was having trouble managing her 4 month old’s eczema. Here is the conversation, almost verbatim….

{Sleepless mum of 4-monther}  Eczema runs in my family. Bub has eczema and dribble rash and also heat rash on the trunk. He is scratching at night and I really want to help him. I have been putting on greasy moisturiser on the dribble rash and barrier cream containing zinc but I think this has made it worse. I have been applying bath oils in the bath, moisturising creams and 1% hydrocortisone cream for the body rash but am getting no where and no one in my house in getting sleep. HELP!

{Me} Don’t bother with 1% hydrocortisone on the body. This over-the-counter cream is really only for the mildest of eczema rashes. It does have its place but when the eczema is severe enough that no one in the family is getting any sleep, you need to bring in the medium/strong potency topical steroids for the body eczema. I would suggest topical steroids such as methylprednisolone aceponate 0.1% daily for about 2-3 weeks until the rash settles considerably and then downgrade to the 1% hydrocortisone for maintenance.

{Sleepless mum of 4-monther} But the 0.1% cream you’ve suggested must be weaker than the 1% hydrocortisone that I have been using.

{Me} This is a common misconception. The percentage that is displayed on the topical steroid cream does not in any way correlate with potency strength. It is a bit confusing but as dermatologists we are used to figuring out which potency strength patients are going to need to sort out their rashes. A lot of people ask me about steroid atrophy (thinning of the skin)  but if you apply the steroid cream only to the rash areas and not on normal skin, and apply for short periods of time to control the rash, you would rarely get skin thinning. You should go with your gut and if bub is unhappy and itching away, then he needs active cream treatments.

{Sleepless mum of 4-monther} What about his heat rash? I’m doing all the right things; avoiding overheating; using lukewarm baths…

{Me} Here are some additional things that you might want to make sure you are doing for the heat rash/eczema….If you have a mattress protector, consider ditching it for the short while until the rash resolves. Most mattress protectors will be quite “plasticky” and trap heat. As you have a young 4 monther that is not yet able to roll over, he might get too hot in the cot but he won’t be able to roll over or get himself in a more comfortable position. I have found with my 8 monther, once he was rolling and sitting up by himself, a lot of his eczema settled down as he is able to “air himself” out more. If bub co-sleeps in bed with you, he may also be overheated. Also if he uses a sleeping bag, try and opt for a light cotton one rather than a heavy duty style. Try and use 100% cotton sheets in bedding rather than poly/cotton blend to keep him cool, avoid any clothes that might irritate his skin – wool, clothes with irritating zips and tags (consider cutting off tags even!), ribbed singlets..

{Sleepless mum of 4-monther} **SMS’ me a picture of the heat rash**

{Me} ….bub’s skin does look irritated in the pic. I would also steer clear of occlusive ointments. So if you are using topical steroids, go for the cream preparation rather than the greasy ointment as ointments can be too “sticky” and make the heat rash worse. Get bub reviewed if the above don’t help. Sometimes eczema can become secondarily infected and then there might be a need for topical or oral antibiotics or anti-septic washes. Good luck! Most kids will grow out of eczema but hopefully by doing all of the above, you can make the transition easier….and hopefully get some more zzzzzz in the meantime.