What are the appropriate treatment plans for common skin conditions in an adult patient with no significant medical history?

Treatment Plans for Common Skin Conditions in Adults

For acne vulgaris, initiate multimodal topical therapy combining a topical retinoid (adapalene 0.1-0.3%) with benzoyl peroxide 5% applied once daily, as this addresses multiple pathogenic mechanisms and represents the evidence-based standard of care. 1, 2

Acne Vulgaris

Mild Acne (Primarily Comedonal)

• Topical retinoid monotherapy is the cornerstone treatment, with adapalene 0.1-0.3% gel or tretinoin 0.025-0.1% applied once nightly to completely dry skin 1, 2
• Adapalene is preferred over tretinoin because it can be applied simultaneously with benzoyl peroxide without oxidation concerns and lacks photolability restrictions 2
• Benzoyl peroxide 2.5-10% can be added as monotherapy or in combination for additional antibacterial effects 1

Moderate to Severe Acne (Mixed or Inflammatory)

• Fixed-dose combination products are strongly recommended: topical retinoid + benzoyl peroxide OR topical retinoid + topical antibiotic (with concurrent benzoyl peroxide to prevent resistance) 1
• Never use topical antibiotics as monotherapy due to bacterial resistance risk; clindamycin 1% or erythromycin 3% must always be combined with benzoyl peroxide 1, 2
• For females with hormonal patterns, spironolactone 50-100 mg daily provides excellent long-term control without antibiotic resistance concerns 1, 2
• Oral antibiotics (doxycycline 50-100 mg daily or minocycline) should be limited to 3-4 months maximum and always combined with topical benzoyl peroxide 1

Severe or Refractory Acne

• Isotretinoin is indicated for severe acne, treatment failures, or patients with psychosocial burden or scarring 1
• Monitor only liver function tests and lipids; CBC monitoring is unnecessary in healthy patients 1
• Pregnancy prevention is mandatory for persons of childbearing potential 1
• Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease with isotretinoin 1

Adjunctive Measures

• Azelaic acid 15-20% is useful for post-inflammatory hyperpigmentation and provides mild anti-inflammatory effects without resistance concerns 1, 2
• Intralesional triamcinolone acetonide 2.5-5 mg/mL for large, painful nodules provides rapid relief and prevents scarring 1, 2

Maintenance Strategy

• Continue topical retinoid indefinitely after achieving clearance, reducing to 2-3 times weekly for long-term maintenance 2

Psoriasis (Chronic Plaque Type)

Mild to Moderate Disease

• Topical corticosteroids (moderately potent, BNF grade III) with regular clinical review and no unsupervised repeat prescriptions 1
• Maximum 100 g per month of moderately potent preparations, with periods each year using alternative treatments 1
• Calcipotriene (calcipotriol) ointment 0.005% is FDA-approved for plaque psoriasis in adults 3
• Coal tar preparations: start with 0.5-1.0% crude coal tar in petroleum jelly, increasing every few days to maximum 10% 1
• Cruder tar extracts are messier but generally more effective than refined products 1

Dithranol (Anthralin) Protocol

• Start at 0.1-0.25% concentration and increase in doubling concentrations as tolerated 1
• Provide adequate explanation of irritancy and staining of skin and clothes 1
• Exercise great care on sensitive sites (face, flexures, genitalia) 1

Severe Disease Requiring Systemic Therapy

• Patients requiring systemic agents should be under continuing supervision of a consultant dermatologist due to potential toxicity 1

Critical Medication Warnings

• Avoid or use extreme caution with beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine, as these may precipitate or cause severe deterioration 1

Eczema and Pruritus

Generalized Pruritus Without Underlying Dermatosis

• First-line topical therapy: emollients with high lipid content, particularly in elderly patients 1
• Topical doxepin can be prescribed but limit to 8 days, 10% body surface area, and 12 g daily 1
• Topical clobetasone butyrate or menthol may provide benefit 1
• Avoid crotamiton cream, topical capsaicin, and calamine lotion as they are ineffective 1

Systemic Options for Refractory Pruritus

• Non-sedative antihistamines: fexofenadine 180 mg or loratadine 10 mg, or mildly sedative cetirizine 10 mg orally 1
• Consider H1 and H2 antagonist combination (e.g., fexofenadine + cimetidine) 1
• Second-line agents: gabapentin, pregabalin, paroxetine, fluvoxamine, mirtazapine, naltrexone, or ondansetron 1
• Sedative antihistamines (hydroxyzine) only for short-term or palliative settings 1

Pruritus in Elderly Skin

• Initially treat with emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema 1
• Gabapentin may provide benefit if initial treatment fails 1
• Do not prescribe sedative antihistamines in elderly patients 1

Hyperpigmentation

Diagnostic Approach

• Wood's lamp examination differentiates epidermal from dermal pigmentation, especially in fair-skinned patients 4
• Dermoscopy aids in characterizing pigmented lesions 4
• Serial photographs monitor changes over time 4

When to Refer

• Immediate dermatology referral for atypical presentations, concern for malignancy, or diagnostic uncertainty 4
• Consider multidisciplinary approach with endocrinology or genetics if systemic disease suspected (e.g., Addison's disease) 4

Dermatologic Conditions in Cardio-Facio-Cutaneous Syndrome

At-Risk Manifestations

• Keratosis pilaris, ulerythema ophryogenes, eczema, progressive multiple pigmented nevi, dystrophic nails, lymphedema, hemangiomas, hyperkeratosis, and generalized hyperpigmentation 1

Management Protocol

• Dermatology consultation at diagnosis with evaluation of hemangiomas and pigmented nevi 1
• Frequent dermatology visits for management of xerosis, hyperkeratosis, and eczema 1
• Annual evaluation of pigmented nevi 1
• Referral to podiatrist for dystrophic nails or hyperkeratosis if needed 1
• If lymphedema present, refer to vascular specialist with meticulous skin care and early treatment of skin infections 1
• Sun protection as recommended for general population (sunscreen, hats) 1

Critical Pitfalls to Avoid

• Never use topical antibiotics as monotherapy for acne—always combine with benzoyl peroxide to prevent bacterial resistance 1, 2
• Avoid unsupervised repeat prescriptions of topical corticosteroids for psoriasis without regular clinical review 1
• Do not prescribe sedative antihistamines for elderly patients with pruritus due to fall risk and cognitive effects 1
• Limit systemic antibiotics for acne to 3-4 months maximum and always use with topical benzoyl peroxide 1
• Avoid crotamiton cream, topical capsaicin, and calamine lotion for generalized pruritus as evidence shows they are ineffective 1