What are the general recommendations and treatments for common dermatological conditions, such as acne, psoriasis, eczema, and skin cancers, in patients with a history of skin conditions or those taking medications that may affect the skin?

General Dermatology Management: Evidence-Based Recommendations

Acne Vulgaris

For patients with acne, multimodal topical therapy combining benzoyl peroxide with topical retinoids represents the strongest evidence-based first-line approach, with systemic antibiotics reserved for moderate-to-severe disease and isotretinoin for severe or refractory cases. 1

Topical Treatment Algorithm

• Benzoyl peroxide is strongly recommended as a foundational therapy for all acne patients, applied once daily (typically before bedtime after skin is completely dry for 20-30 minutes) 1, 2, 3
• Topical retinoids (tretinoin, adapalene) are strongly recommended and should be applied once nightly to the entire affected area, not just individual lesions 1, 2
• Fixed-dose combinations are preferred over monotherapy: retinoid + benzoyl peroxide or retinoid + topical antibiotic (with concurrent benzoyl peroxide to prevent resistance) 1
• Topical antibiotic monotherapy should never be used due to resistance concerns 1

Systemic Treatment Escalation

• For moderate-to-severe acne, doxycycline (strong recommendation) or minocycline (conditional recommendation) should be initiated at standard doses (doxycycline 100mg twice daily) 1
• Systemic antibiotics must be combined with benzoyl peroxide and limited in duration to reduce resistance 1
• For female patients, spironolactone or combined oral contraceptives are conditionally recommended, with potassium monitoring unnecessary in healthy patients without risk factors 1
• Isotretinoin is recommended for severe acne, treatment failures, or patients with psychosocial burden/scarring, with monitoring limited to liver function tests and lipids only 1

Critical Management Points

• Expect initial worsening at 3-6 weeks as deep lesions surface; this is not treatment failure 2
• Therapeutic benefit typically appears by 12 weeks; continue treatment for 6-12 weeks minimum before declaring failure 2
• Avoid excessive washing, harsh scrubbing, and alcohol-containing products that worsen xerosis 2, 3
• Apply moisturizers with sunscreen (SPF 15+) every morning during retinoid therapy 2

Psoriasis

Topical corticosteroids remain first-line therapy for localized psoriasis, with narrowband UV-B phototherapy strongly recommended for moderate-to-severe disease requiring systemic management. 1, 4

Treatment Hierarchy

• Topical corticosteroids (moderate-to-high potency) applied to lesional skin twice daily for initial control 1, 5
• Topical vitamin D3 analogs (calcipotriene) are as effective as medium-potency steroids without steroid side effects, though doses must not exceed 100g/week to avoid hypercalcemia 4
• Narrowband UV-B phototherapy (TL-01) has strong evidence for efficacy in psoriasis with initial dosing at 50-70% of minimal erythema dose 1
• For severe disease, methotrexate, cyclosporine, or biologic agents (TNF inhibitors) are appropriate systemic options 4

Special Populations

• For children and pregnant women, narrowband UV-B is first-line systemic treatment when topicals are insufficient 4
• Equipment calibration annually and recording of cumulative doses are essential audit points 1

Atopic Dermatitis (Eczema)

Topical corticosteroids combined with aggressive moisturization form the foundation of eczema management, with topical calcineurin inhibitors serving as steroid-sparing alternatives for sensitive areas. 1, 4

Stepwise Management

• Alcohol-free moisturizers containing 5-10% urea applied at least twice daily to restore skin barrier function 1, 5
• Low-to-moderate potency topical corticosteroids for active inflammation, with hydrocortisone 1-2.5% or alclometasone 0.05% for facial/intertriginous areas 1
• Topical calcineurin inhibitors (tacrolimus preferred over pimecrolimus) for adults and children >2 years requiring steroid-sparing therapy 4
• Diluted bleach baths may delay need for systemic therapy by reducing bacterial colonization 4
• Narrowband UV-B phototherapy has strong evidence for chronic atopic eczema 1

Systemic Options

• Oral cyclosporine is appropriate when systemic management needed, though oral corticosteroids often required for severe acute flares 4

Immune Checkpoint Inhibitor Dermatologic Toxicities

For patients on immune checkpoint inhibitors, dermatologic toxicity management requires grade-based escalation from topical therapies to systemic corticosteroids, with permanent discontinuation mandatory for grade 4 reactions, Stevens-Johnson syndrome, or DRESS. 1

Grade-Based Management

Grade 1 (rash <10% body surface area):

• Continue immunotherapy 1
• Topical emollients and mild-to-moderate potency topical corticosteroids 1
• Avoid skin irritants 1

Grade 2 (rash 10-30% BSA or >30% with mild symptoms):

• Consider holding immunotherapy, monitor weekly 1
• Medium-to-high potency topical corticosteroids 1
• Oral antihistamines 1
• Consider prednisone 0.5-1 mg/kg with 4-week taper 1

Grade 3 (rash >30% BSA with moderate-severe symptoms):

• Hold immunotherapy 1
• Dermatology consultation required 1
• Prednisone 1-2 mg/kg daily 1
• High-potency topical corticosteroids 1
• May consider phototherapy for severe pruritus 1

Grade 4 or life-threatening reactions (SJS/TEN, DRESS):

• Permanently discontinue immunotherapy 1
• Immediate specialist referral mandatory 1
• Intravenous corticosteroids 1

Preventive Strategies

• Patients with pre-existing psoriasis, bullous pemphigoid, or lupus require baseline dermatologic assessment before initiating checkpoint inhibitors 1
• Dermatologic assessment within first month of therapy and as needed thereafter 1

EGFR Inhibitor Papulopustular Rash

Prophylactic oral tetracyclines (doxycycline 100mg twice daily or minocycline 100mg daily) significantly reduce grade 2 rash incidence and should be initiated with EGFR inhibitor therapy. 1

Preventive Management

• Oral tetracyclines prophylactically for antimicrobial and anti-inflammatory properties 1
• Urea-containing moisturizers (5-10%) at least twice daily 1
• Sun protection (SPF 15+) 1
• Avoid frequent hot water washing, skin irritants, and over-the-counter anti-acne medications 1

Therapeutic Management by Grade

Grade 1-2:

• Initiate or escalate topical corticosteroid potency 1
• Oral tetracyclines for minimum 6 weeks 1

Grade 3:

• Short-course systemic corticosteroids (prednisone 0.5-1 mg/kg for 7 days with 4-6 week taper) 1
• Interrupt EGFR inhibitor until grade 1 1
• If infection suspected (painful lesions, yellow crusts, pustules on extremities), obtain bacterial culture and treat based on sensitivities for ≥14 days 1

Critical Distinction

This is an inflammatory process, not acne vulgaris—avoid alcohol-containing gels and aggressive anti-acne treatments that worsen xerosis. 1

Bullous Pemphigoid

For localized or mild bullous pemphigoid, very potent topical steroids applied to lesional skin represent first-line therapy, while moderate-to-severe disease requires systemic corticosteroids 0.5-1.0 mg/kg daily with bone protection. 1

Treatment Selection

Localized/Mild Disease:

• Very potent topical steroids to lesional skin (strength of recommendation A) 1
• Alternative: systemic corticosteroids 0.3 mg/kg daily with weaning 1
• Anti-inflammatory antibiotics (doxycycline 200mg/day, oxytetracycline 1g/day) with or without topical steroids 1

Moderate-to-Severe Disease:

• Systemic corticosteroids 0.5-1.0 mg/kg daily with weaning 1
• Very potent topical steroids 5-15g twice daily to whole skin surface if patient/carer capable 1
• Bone protection mandatory for all patients on oral corticosteroids 1

Refractory Disease:

• Consider azathioprine 1-2.5 mg/kg daily, methotrexate 5-15mg weekly, or dapsone 50-200mg daily 1

Essential Monitoring

• Document diabetes and hypertension status before treatment 1
• Pretreatment tests: complete blood count, liver function, glucose, renal function, blood pressure 1
• Patient satisfaction with symptom control should be assessed 1

Melanoma Surveillance During Systemic Therapy

Patients receiving BRAF inhibitor monotherapy require dermatologic assessment every 2-4 weeks for the first 3 months due to high risk of squamoproliferative neoplasms, though combination BRAF/MEK inhibition is now standard with reduced skin toxicity. 1

Monitoring Schedule

• BRAF inhibitor monotherapy: every 2-4 weeks for first 3 months in patients with numerous squamoproliferative lesions 1
• Immune checkpoint inhibitors: within first month, then as needed for side effect management 1
• Patients with atopic dermatitis, psoriasis, or autoimmune dermatoses: pre-treatment dermatology consultation for preventive counseling 1