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Psychiatric emergencies
https://t.me/med1917
Major Minor Medical
• Suicidal patients (30%)
• Agitated/violent patients
1. ASSESSMENT
History: need to rule out organic cause e.g. infection
• Establish any diagnoses & medication
• Any previous similar episodes & cause/Tx
• Consider medication compliance or SEs
• Use of alcohol / illicit drugs
• Recent changes in social life e.g. employment/relationships
• History of self-harm/suicide attempt/violence – risk assess
2. NON-PHARMACOLOGICAL MANAGEMENT
• Encourage patient to move to area away from others
• Speak confidently, slowly, clearly
• Non-threatening body language, give space
• Explore & acknowledge concerns with patient – try to build rapport
• Grief reaction
• Rape
• Panic attacks
• Neuroleptic malignant syndrome
• Serotonin syndrome
• Delirium
• Overdose/withdrawal
Chapter 6: Psychiatry 217
40% of psychiatric emergencies need admission to
hospital
Factors to consider when deciding need
for treatment/admission
• Severity of illness
• Level of insight
• Risk of harm to self or others
• Other support available
3. PHARMACOLOGICAL MANAGEMENT / PHYSICAL RESTRAINT
Rapid tranquilisation → calm the patient without full sedation
• BZDs, antipsychotics, promethazine – minimum dose, PO if possible
AETIOLOGY: RARE (<1%), adverse
reaction to antipsychotics (DA blockade
causes hyperactivity of SNS)
→ Hard to predict
SYMPTOMS:
• Fever, diaphoresis (sweating)
• Rigidity
• Confusion, fluctuating consciousness
• Autonomic instability (fluctuating BP,
HR, salivation, incontinence)
INVESTIGATIONS
• Raised CK – may be >1000
• Raised leucocytes
• Deranged LFTs
MANAGEMENT: withdraw
antipsychotic medication
• Rehydration
• Monitor temperature, BP, pulse
• Consider BZDs to muscle activity &
temperature (lorazepam, diazepam)
LINE!
AETIOLOGY: increased serotonin due to synthesis, uptake/metabolism or
direct receptor activation → more predictable
SYMPTOMS
Psychiatric: restlessness, confusion, agitation
Autonomic: hyperthermia, diarrhoea, HR, hypo-/hypertension, mydriasis
Neuromuscular: myoclonus, rigidity, tremors, hyperreflexia, ataxia, convulsions
MANAGEMENT: stop precipitating medicine → restart cautiously after 48h
• Rehydration
• May need cyproheptadine (anti-serotonergic)
• BZDs if agitated (lorazepam, diazepam)
Will need close medical monitoring afterwards
Risk factors for NMS:
Hx: previous NMS, brain damage, alcoholism
Mental state: agitation, hyperactivity, catatonia
Physical: dehydration
Treatment: recent or dose, high dose,
IM injections
more likely with 1st generation APs
If severe:
• Bromocriptine
• Dantrolene ( rigidity)
• ICU, intubation + ventilation
Common causes of serotonin syndrome:
• Switching antidepressant
• Combining antidepressants
(with other ADs or supplements)
May need ICU, intubation + ventilation if severe
218 Chapter 6: Psychiatry
https://t.me/med1917
Risk of suicide is 66× greater if self-harmed
Factors predicting repetition of self-harm
• Number of previous episodes
• Personality disorder
• History of violence
• Alcohol misuse
• Unmarried
Factors indicating suicidal intent
• Trying to avoid intervention
• Feelings of hopelessness about the future
• Planning suicide
• Leaving a note
• Anticipatory acts (leaving a will, settling
debts)
• Use of violent methods
Risk assessment
• Impulsive or
planned?
• Ongoing or resolved
trigger?
• Precautions to avoid
discovery
• Preparations (note/
will written)
• Do they regret it?
want to try again?
• Use of alcohol/
drugs?
• Any protective
factors?
• Social support
network?
• Willing to engage
in Tx?
Neuroleptic malignant
syndrome
Associated
treatment
Onset Slow (days–weeks) Rapid
Progression Slow (24–72h) Rapid
Muscle rigidity Severe (lead pipe) Less severe rigidity, clonus present
Activity Bradykinesia Hyperkinesia
Blood results
Antipsychotics
Idiosyncratic/normal dose
CK & WCC or normal CK
EPIDEMIOLOGY: F>M, ⅔ are aged <35y
RISK FACTORS
Biological Psychological Social
• Genetics
• Age (teens/young adults)
• Personality disorder
(particularly EUPD)
• Abuse: sexual, physical,
emotional
• Bullying
• Bereavement
• Relationship breakdown
• Endings/changes
MANAGEMENT:
1. Assessment
• Physical & mental health
• Safeguarding concerns
• Further self-harm and suicide risk
2. Treatment
• Of physical injuries
• Specialist psychosocial assessment
• Monitor in a healthcare setting to reduce risk of recurrence
• Consider need for admission to mental health ward
Serotonin syndrome
Serotonergic medications
Overdose/combinations
(involuntary rhythmic muscle contractions)
Overdose & cutting are the
most common forms
• Substance misuse
• Friends who self-harm
• Financial/living concerns
• Work/school pressures
• Isolation/loneliness
Divorced > Single > Widowed > Married
EPIDEMIOLOGY: second leading cause of death in those aged 15–29y
RISK FACTORS
• History of self-harm or suicide attempt
• Severe depression
• Occupation (farmers, doctors)
• Social isolation
• Anorexia
• Unemployed
• Alcohol
• Male
Safety plan: identify support, recognise early
warning signs, avoid alcohol/drugs, identify
emergency contacts
Hanging/strangulation is
most common method
Chapter 6: Psychiatry 219
https://t.me/med1917
Child & adolescent psychiatry
↳ Mental illness affects 10% children
↳ 50% present to GPs
Children: neurodevelopmental disorders
Adolescents: mood/anxiety disorders*, eating disorders, substance misuse
*self-harm is common
• History, MSE, risk assessment → SAFEGUARDING ISSUES?
• Consider impact on family/carers
Legally presumed that those ≥16y have capacity to make decisions
regarding their care BUT encourage discussion with family.
• However, must assess capacity on an INDIVIDUAL BASIS (some <16y may
have competence)
• If deemed to have competence, a child can consent to treatment BUT parents
can still override refusal of treatment if it is in child’s best interests (avoid if
possible)
• If a child lacks competence, a parent can consent to treatment on their
behalf if it is within scope of parental responsibility
• If a parent refuses treatment that is in child’s best interests, further advice
should be sought from courts.
There is no age restriction for Mental Health Act.
Summary of consent
Capacity/competence No capacity /competence
16–17y Can consent/refuse admission or
treatment
<16y Can consent, but if refuse can use
MHA
↳ Impacts development, education,
relationships
Parental consent may be adequate, may
need MHA
Parental consent may be adequate, may
need MHA
Child <16y
Young person 16–17y
Adult ≥18y
If ≥16y, capacity is presumed. If concerns
regarding capacity to make a decision, this
can be assessed under the MCA.
If <16y, capacity is not presumed & MCA
does not apply. Instead ‘Gillick competence’
must be assessed to decide whether child
understands enough to make the decision.
Capacity depends on the decision – a child
may be competent to consent/refuse a simple,
low risk procedure, but not more complex,
riskier ones
May lack competence/capacity due
to age or a mental health disorder
If child has competence, should respect their decisions regarding
confidentiality/disclosure of information unless:
• There is overriding public interest in the disclosure
• Disclosure is required by law
If child lacks competence and refuses disclosure of information to parents you
should:
• Firstly try to persuade them to involve parents/carers
• Disclose information to parents/authorities if you deem it necessary in child’s
best interests
Biological: usually less common/limited evidence as 1st-line treatment
→ consider in ADHD and depression
Psychological: most commonly used are CBT and family therapy
Social: very important – especially regarding education and social services
→ need good intra-agency working
Should encourage child to involve family/carers
in their care if possible
Use of antidepressants in children/
adolescents
• Concerns of suicidal behaviour in teens taking
SSRI
• Only prescribed by specialist (child
psychiatrist)
• FLUOXETINE = ONLY ANTIDEPRESSANT
LICENSED FOR PAEDIATRIC USE (although
others sometimes used)
220 Chapter 6: Psychiatry
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Eating disorders
Prevalence = 0.6% → most common in adolescent girls.
General risk factors
• Perfectionism
• Body image disturbances
• Weight stigma / teasing / bullying
• Low self-esteem
• Early sexual development
• History of abuse
• Personality disorder
• FHx of eating disorders
• Exposure to ‘diet culture’
• Higher socioeconomic status
• Comorbid mental illness
(e.g. anxiety disorders)
Peak onset = adolescence. F:M = 10.1
FEATURES
• BMI <17.5
• Persistent restriction of energy intake
• Fear of gaining weight / becoming fat
• Often excessive exercise (to compensate for food)
• Lack of insight into seriousness of low BMI
• Menstrual abnormalities
SYMPTOMS
DDx anorexia nervosa
• Hyperthyroidism
• Depression, anxiety, OCD
• Psychosis, substance misuse
• Body dysmorphic disorder
Poor prognostic factors
• Low body weight
• Late onset
• Bulimic features
• Family difficulties
• Personality disorder
• Longer illness duration
• Poor support/relationships
• Comorbid mental illness
10-year prognosis
50% recovered
40% chronic problem
10% mortality (1/3 suicide)
Indications for hospitalisation
Psychiatric: brain atrophy
• Inflexible thinking
• Obsessions/habits
• Poor concentration
• Irritable / flattened mood
• Interests centre around
food
Heart
• Low BP & pulse
• Risk of arrhythmias &
heart failure
Metabolic disturbances: hypokalaemia, cortisol, GH & cholesterol, hormone levels
MANAGEMENT
Biological
• Weight restoration – risk refeeding syndrome
• Regular monitoring – weight, FBC, U&Es, LFT, glucose, bone profile, Mg2+,
CK, B12
• ± DEXA scan
• ± ECG – prolonged QTc, HR <50, arrhythmias
Psychological*
• Psychotherapies: CBT, motivational interviewing, compassion-focused,
interpersonal, family therapy
• Family therapy if <18y
Social
• Education: dietar y advice / multivitamins
• Involve family/friends for support
• Carer support
12
Reproductive:
hypothalamic changes
• Reduced libido
• Amenorrhoea (females)
• Low testosterone (males)
• Reproductive dysfunction
Muscles
• Wasting/cramp
Bones: irreversible
• Osteopenia/osteoporosis
↱
Hair/skin
• Broken skin, dry & brittle hair
• Hair over face/body (lanugo)
Other
• Cold extremities /
hypothermia
• Infections
• Iron-deficiency anaemia
• Leucopenia,
thrombocytopenia
• Metabolic disturbances
BIOPSYCHOSOCIAL APPROACH
Treat coexisting mental
health illness
e.g. SSRI for depression
*Psychological Tx has limited
effect if BMI <13, so restore
weight first
• BMI <13.5
• Very deranged bloods
• Syncope/arrhythmias
12
NICE (2017, updated 2020) Eating disorders [NG69]
FEATURES
https://t.me/med1917
• Recurrent binge eating (no prominent weight changes)
• Recurrent compensatory behaviour (vomiting, laxatives,
diuretics, fasting, exercise)
SYMPTOMS
Chapter 6: Psychiatry 221
Prevalence = 1% → often a
history / coexisting anorexia nervosa
for 3m
Psychiatric
• Poor concentration
• Irritable
Mouth
• Tooth decay/erosion
• Hoarse voice
• Bleeding
• Swollen parotid glands
(‘chipmunk face’)
Hands
• Russell sign: calluses,
scars, abrasions on backs
of fingers due to selfinduced vomiting
Electrolyte imbalance:
can be life-threatening
• Seizures
• Muscle paralysis
Abdomen
• Swollen/painful stomach
• Constipation
• Delayed gastric emptying
• Reflux/oesophagitis
• Rectal prolapse
• Renal failure
• Arrhythmias
↳
MANAGEMENT13
Biological
• Antidepressant – SSRI (usually fluoxetine)
• Advise laxative and alcohol cessation
• Regular monitoring – weight, FBC, U&Es, LFT, glucose and electrolytes
Psychological
• Psychoeducation: regarding coping mechanisms
• Psychotherapies: CBT, compassion-focused, interpersonal, family therapy
Social
• Involve family/friends for support
• Carer support
BIOPSYCHOSOCIAL
APPROACH
10-year prognosis
70% recovered
1% mortality
Poor prognostic factors
• Low body weight
• Comorbid depression
13
NICE (2017, updated 2020) Eating disorders [NG69] & NICE BNF Fluoxetine
222 Chapter 6: Psychiatry
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Intellectual disability
↳ Significantly sub-average intellectual
functioning (IQ <70)
↳ Impaired adaptive behaviour
↳ Onset of intellectual impairment
before 18y
Mild (85% cases) Moderate Severe Profound
IQ 50–69 35–49 20–34 <20
Prevalence 1.5–3% 0.5% 0.5% 0.05%
Functioning Only need help if
problems arise
• Often not recognised as ID
• prevalence in lower socioeconomic groups • M>F
• Association with overcrowding, poverty, irregular/unskilled employment
IQ tests are subjective – performed by clinical psychologists
May need supervision
in some elements of daily
living / work
Need help with many ADLs
• Often physical disability
• Limited communication
Extensive/total help
with ADLs
• Minimal communication
30% have no identifiable cause
GENETIC/CHROMOSOMAL CAUSES
Down syndrome
= trisomy 21
• Most common chromosomal cause
• Characteristic physical abnormalities
• risk of deafness, cataracts,
hyperthyroidism, Alzheimer’s
Phenylketonuria
= autosomal recessive: 1 in 10,000 births
• High serum phenylalanine
• Epilepsy, hyperactivity, irritability
• Short stature, hypopigmented, eczema
NB Intellectual disability (ID) is not same as
autism spectrum disorders (ASD)
→but often exist as comorbid conditions,
along with epilepsy
Cri du chat syndrome
= deletion of short arm of
chromosome 5
Fragile X syndrome
= abnormality on long arm of
X chromosome
• Most common genetic cause
• More common in males
• Elongated face / protruding
ears / microcephaly
• Delayed development of speech &
language by age 2y
Neurofibromatosis
= mutation on chromosome 7
• Usually mild ID
• Café au lait spots
• Skin, bone, soft tissue, nervous system
abnormalities
Tuberous sclerosis
= mutated tumour suppressor gene chr 9
or 16
• Results in autism & epilepsy with ID
• Skin changes, brain/other tumours
PRENATAL, PERINATAL, POSTNATAL FACTORS
Prenatal Perinatal Postnatal
• Fetal alcohol syndrome (most prevalent)
• Congenital hypothyroidism
• Pre-eclampsia
• Placental insufficiency
• TORCH infections
• Birth trauma /
hypoxia
• Intraventricular
haemorrhage
• Hyperbilirubinaemia
• Brain infection/tumour
• Head injury
• Chronic lead poisoning
• Malnutrition
• Neglect/abuse
>50% of patients with ID have coexisting mental
health problems
may present differently / patient has difficulty describing symptoms
→
↳ Psychological therapies may need to be adapted/simplified
DIFFERENCES IN PRESENTATION:
Mania/bipolar
• Challenging behaviour
• Giggling
• Delusions less elaborate
Depression
• Exaggerated need for routine
• Suicidal ideas rare & poorly planned
• Less likely to complain of low
mood
Schizophrenia:
• Delusions/hallucinations less
elaborate
• Persecutory delusions / thought
disorder rare
• Earlier onset
• Presents as fear/withdrawal,
challenging behaviour, sleep
disturbance
Perinatal psychiatry
https://t.me/med1917
Chapter 6: Psychiatry 223
• All women should be screened at antenatal clinic for previous/current/FHx
of psychiatric disorder
• Refer necessary cases for psychiatric assessment & referral
• Regularly monitor mental state of all peri-/postnatal women, regardless
of whether they’ve been referred
WHO TO REFER?
1. PHx ± FHx of:
• Schizophrenia/psychosis
• Bipolar disorder
• Puerperal psychosis
• Severe depression i.e. required secondary care input (depression treated by
GP doesn’t need referral)
2. On mood stabilisers
Pregnant/postpartum women should have
priority in psychiatric service pathways
NORMAL PSYCHIATRIC SYMPTOMS → Due to hormonal changes ±
physical & emotional exhaustion
‘The Pinks’: within 48h postpartum
Excitement, euphoria, overtalkative,
overactive, insomnia
→ spontaneous resolution
‘The Blues’: day 3–10 postpartum
Emotional lability, tearful, anxious, irritable
Does not affect functioning (most do not
develop PPD)
→ spontaneous resolution after 48h
POSTPARTUM DEPRESSION (PPD) → bipeak onset at 2–4w & 3m
postpartum
Symptoms:
Similar to normal depressive illness with more prominent anxiety
→ guilt & concerns over parental ability = common
→ anxious preoccupation with baby’s health
→
reduced affection for baby / impaired bonding
→ obsessional phenomena (ego-dystonic in nature e.g. harming baby)
Edinburgh Postnatal Depression Scale: used to assess Sx during & after pregnancy
Puerperium: period of about 6w after childbirth
Important to identify at-risk women
antenatally so we can effectively manage risks
Assess risk to baby
• Obsessional/delusional Sx
• Determine baby’s location & carer
Prevalence of PPD: 10%
Risk factors for postpartum depression
• Previous episode of PPD / FHx of PPD
• Depression during pregnancy
• Hx of major depressive disorder
Management
• Psychotherapy: CBT
• SSRIs = 1st line (sertraline/paroxetine) – may give prophylactically after birth
if high risk
Prognosis
With Tx: 2/3 resolve within 2–3m
No Tx: can take >6m to recover
→ children of treated mother experience fewer psychiatric symptoms/disorders
→ if untreated, can result in insecure attachments, psychiatric problems in child, child less
compliant with their own health visits
POSTPARTUM BIPOLAR DISORDER → highest risk 9–14d postpartum
Often affects those with Hx of bipolar disorder
→ high risk of relapse in pregnancy due to discontinuation of teratogenic mood
stabilisers
→ should consider continuing mood stabilisers that are safer to use in pregnancy
14
NICE (2014, updated 2020) Antenatal and postnatal mental health [CG192]
RISK ASSESS
Predictors of PPD
• Anxiety in pregnancy
• Stressful life events
• Marital discord
• Povert y
Small amounts transferred in
breast milk but can still breastfeed
e.g. lamotrigine
224 Chapter 6: Psychiatry
https://t.me/med1917
Prevalence: 0.2%
Risk factors for postpartum psychosis
• Previous PPP
• Hx of bipolar disorder
Other RFs: primiparity, unmarried, obstetric
complications
PUERPERAL/POSTPARTUM PSYCHOSIS (PPP) → onset normally within
2–3w postpartum
Symptoms:
• sudden onset behavioural disturbances
• hallucinations/delusions – often a religious context
Management15: treat as EMERGENCY
• Admission to mother & baby unit – may need MHA
• High intensity physical & psychological care including:
▶ mood stabiliser ± antipsychotic
▶ treatment of anxiety & insomnia
• Support services: support groups, help with childcare/housework etc.
Prevention of PPP and BPAD
• If treatment for ongoing BPAD/psychosis stopped during pregnancy, restart immediately after
delivery
• If history of BPAD, continue treatment during pregnancy and postpartum
• If history of PPP/BPAD in postpartum only, start treatment immediately after delivery
prophylactically
↳
RISK ASSESS
Prognosis
Good short-term progress if treated early: most severe symptoms last 2–12w, most make
full recovery within 12m
BUT associated with significant morbidity & mortality
Valproic acid Avoid in pregnancy & breastfeeding
Lithium Avoid in breastfeeding
Lamotrigine Safe in pregnancy & breastfeeding
Atypical antipsychotics Safe in pregnancy & breastfeeding
Sertraline/paroxetine Safe in pregnancy & breastfeeding (low levels in breast milk)
Fluoxetine Safe in pregnancy & breastfeeding (higher levels in breast milk)
15
NICE (2014, updated 2020) Antenatal and postnatal mental health [CG192]
225
https://t.me/med1917
DERMATOLOGY
Psoriasis ...................................................................................... 226
Acne vulgaris
Eczema.........................................................................................228
Skin infestations
Bacterial skin infections
Viral skin infections
ABBREVIATIONS
ABPI – Ankle brachial pressure index
ACEi – Angiotensin-converting enzyme
inhibitor
BCC – Basal cell carcinoma
DLQI – Dermatology Life Quality Index
EASI – Eczema Area & Severity Index
HHV – Human herpes virus
HPV – Human papillomavirus
HSV – Herpes simplex virus
IBD – Inflammatory bowel disease
.......................................................................... 227
..................................................................229
................................................. 230
...........................................................232
ICU – Intensive care unit
LN – Lymph node
OCP – Oral contraceptive pill
PASI – Psoriasis Area & Severity Index
PCOS – Polycystic ovary syndrome
PDT – Photodynamic therapy
SA – Surface area
SCC – Squamous cell carcinoma
SJS – Stevens–Johnson syndrome
07
Fungal skin infections
Melanocytic (pigmented) lesions
Non-melanocytic lesions
Dermatological manifestations ofsystemic
disease
Drug eruptions
.................................................................................. 238
...................................................................... 240
...................................................... 234
............................236
................................................ 237
SSMDT – Specialised Skin Multidisciplinary
Team
TEN – Toxic epidermal necrolysis
TNF – Tumour necrosis factor
UC – Ulcerative colitis
URTI – Upper respiratory tract infection
UVA – Ultraviolet A
UVB – Ultraviolet B
VZV – Varicella zoster virus
Definitions of terms
Term Description
Eruption Rash
Lesion Any small area of skin disease
Macule Flat (non-palpable) area of colour change <0.5cm
Patch Flat (non-palpable) area of colour change >0.5cm
Papule Raised (palpable) lesion <0.5cm – usually dome-shaped
Nodule Raised (palpable) lesion >0.5cm – usually dome-shaped
Cyst Fluctuant papule/nodule containing fluid/pus/keratin
Plaque Palpable, flat-topped lesion
Vesicle Fluid-filled lesion/papule <0.5cm
Bulla Fluid-filled lesion/papule >0.5cm
Pustule Pus-filled lesion
Wheal/weal Smooth, skin-coloured superficial swelling lasting <24h (often surrounded by erythema)
Erosion Partial break in skin: loss of epidermis only
Ulcer Complete break in skin: dermis included
Fissure Small, slit-like break in skin
Excoriation Erosion or ulcer due to scratching
Lichenification Thickening of skin and increased markings due to chronic scratching/rubbing
Scale Visible white loosening of outermost skin layer
Crust Golden deposit on skin due to dried plasma
226 Chapter 7: Dermatology
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Psoriasis
Bi-peak onset: early 20s & 50s
2% population (M=F)
Things that impact the patient:
Chronic, relapsing inflammatory skin disorder ( skin turnover & epidermal
thickening)
Presentation
• Red, scaly plaques with sharp demarcation – extensor surfaces + scalp
• Psoriatic arthritis – in around 30%
• Symptoms: pain, itching, bleeding
• Psychological: self-esteem
• Treatment: time-consuming & messy
• Complications:
risk CVD, metabolic syndrome, lymphoma
Linked with other inflammatory
conditions:
cardiovascular disease, metabolic syndrome,
NASH (non-alcoholic steatohepatitis)
Other diseases associated with HLA gene:
lymphoma, asymmetric anterior uveitis, IBD
Fig. 7.1
Risk factors
1. Genetics: FHx, HLA-CW6, HLA-B27, HLA-B13, HLA-B17 genes
2. Environmental:
• Strep throat infection, HIV
• Medications – BBs, antimalarials, lithium, TNF-α inhibitors
• Stress, alcohol, smoking, trauma (Koebner phenomenon)
Management
→ depends on severity & impact on patient*
1. EDUCATION: avoid lifestyle triggers e.g. smoking/alcohol/stress
2. TOPICAL TREATMENTS
• Emollients e.g. E45
• Corticosteroids + vit D analogues (mild/moderate ifsensitive area)
• Keratolytics e.g. 5% salicylic acid → for thick plaques
• Coal tar products (used on scalp)
3. PHOTOTHERAPY = needs 2° care referral
• Narrow band UVB = superficial (good if pregnant)
• PUVA (psoralen tablets + UVA) = deeper (not if pregnant)
4. SYSTEMIC TREATMENTS
Therapy Side-effects Monitoring
Methotrexate Teratogenic, hepatotoxic, bone marrow suppression,
Acitretin
Ciclosporin
1
GI upset/nausea
Teratogenic, hepatotoxic, lipids
Nephrotoxic, BP, tingling peripheries
*PASI/DLQI scores assess severity & impact
Avoid vit D analogues in pregnancy
or breastfeeding!
LFTs, FBC
LFTs & fasting lipids
BP, U&Es
5. BIOLOGICS (monoclonal antibodies) for severe or recalcitrant disease
Topical steroid use
Mild 1% hydrocortisone Any
Moderate Eumovate (clobetasone) Caution on face
Potent Betnovate (betamethasone) Adults
V. potent Dermovate (clobetasol)
age
only
Anywhere
Not face/
genitals
Phototherapy
• UV light exposure causes immunosuppression & skin inflammation → UVB
or PUVA
• 2–3 × a week for 15–30 episodes
• Base starting dose on skin type & gradually
time of exposure
Indications: acne, vitiligo, psoriasis, lichen planus
Side-effects
Of UV: erythema/pruritus, cold sores, skincancer
Of tablets: nausea & headaches
1
NICE (2012, updated 2017) Psoriasis [CG153]
Side-effects
• Skin thinning
• Can trigger acne/rosacea
• Withdrawal can cause erythroderma
Reassure
→ Only very short
exposure (secs–minutes)
→ Dose is carefully
calculated for skin type
→ Goggles protect eyes
& genitalia covered
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