The Australasian College of Dermatologists: tests, treatments and procedures clinicians and consumers should question

Bilateral lower leg cellulitis is very rare. Most commonly the redness is due to an underlying inflammatory skin disorder such as venous eczema or a more deeply extending inflammation involving the subcutaneous fat known as lipodermatosclerosis. This condition, which occurs more frequently in patients with venous disease, who are overweight and immobile, may initially present as bilateral redness and swelling, and then progresses over time to produce scarring and hardening of the underlying tissues. A careful history and physical examination should be undertaken. An entry point for infection should be looked for, and swabs taken from open skin wounds. However, microbiological testing from intact overlying skin is usually of little value.

Supporting evidence

  • Hirschmann JV, Raugi GJ. Lower limb Cellulitis and its mimics: part I. Lower limb cellulitis. Journal of the American Academy of Dermatology 2012;67(2):163e1-163e12.
  • Hirschmann JV, Raugi GJ. Lower limb Cellulitis and its mimics: part II. Conditions that simulate lower limb cellulitis. Journal of the American Academy of Dermatology 2012; 67(2):177.e1-177.e9. 
  • Levell NJ, Wingfield CG, Garioch JJ. Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. British Journal of Dermatology 2011;164(6):1326-8. 
  • Arakaki RY, Strazzula L, Woo E, Kroshinsky D.  The impact of dermatology consultation on diagnostic accuracy and antibiotic use among patients with suspected cellulitis seen at outpatient internal medicine offices: a randomized clinical trial. JAMA Dermatology 2014;150(10):1056-61.

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The inflammation is secondary to an intense foreign body reaction to the cyst contents leaking into adjacent tissues and will respond to incision and drainage. The use of intralesional corticosteroid injections has been suggested, but there are no formal studies to support this practice. Although oral antibiotics are often prescribed, there is no evidence on which to base recommendations for their routine use in this setting.

Supporting evidence

  • Diven D, Dozier S, Meyer, D, Smith EB. Bacteriology of inflamed and uninflamed epidermal inclusion cysts. Archives of Dermatology 1998; 134(1):49-51.

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The individual weals of acute urticaria and angioedema can be widespread and variable in appearance, resolving in 24 hours leaving normal skin. In children, upper respiratory tract and viral infections are the most common cause of acute urticaria. Foods and medications such as antibiotics and nonsteroidal anti-inflammatory drugs are possible triggers in all age groups. Thus the cause of acute urticaria is usually suggested by a patient’s history without the need for routine blood investigations.

Supporting evidence

  • Frigas E, Park MA. Acute urticaria and angioedema: diagnostic and treatment considerations. Am J Clin Dermatol 2009;10(4):239-50.
  • Schaefer P. Urticaria: evaluation and treatment. Am Fam Physician 2011;83(9):1078-84. 
  • Grattan CEH, Humphreys F. and on behalf of the British Association of Dermatologists Therapy Guidelines and Audit Subcommittee. Guidelines for evaluation and management of urticaria in adults and children. British Journal of Dermatology 2007;157(6):1116-23. 

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Fifty percent of thickened distorted toenails are caused by age, pressure from footwear (onychogryphosis) or other trauma, or associated with inflammatory disorders such as psoriasis or lichen planus, and are not due to a fungal infection.

Supporting evidence

  • de Berker D. Fungal nail disease. N Engl J Med 2009;360:2108-16.
  • Ameen M, Lear JT, Madan V, et al. British Association of Dermatologists’ guidelines for the management of onychomycosis 2014;171(5);937-58. 
  • Eisman S, Sinclair R. Fungal nail infection: diagnosis and management. BMJ 2014;348:g1800. 

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In light of concerns about antibiotic resistance, the treatment of acne with topical or oral antibiotics should be in combination with agents such as benzoyl peroxide or retinoids and prolonged use should be avoided.

Supporting evidence

  • Eady EA, Gloor M, Leyden JJ. Propionibacterium acnes resistance: A worldwide problem. Dermatology 2003;206 (1):54-6.
  • Earnshaw S, Mendez A, Monnet DL, et al. Global collaboration to encourage prudent antibiotic use. The Lancet Infectious Diseases 2013;13(12):1003-4. 
  • Archer CB, Cohen SN, Baron SE and on behalf of British Association of Dermatologists and Royal College of General Practitioners. Guidance on the diagnosis and clinical management of acne. Clin Exp Dermatol 2012; 37(s1)1:1-6. 
  • Laxminarayan R, Duse A, Wattal C, et al. Antibiotic resistance—the need for global solutions. The Lancet Infectious Diseases 2013;13(12):1057-98. 
  • Zaenglein A, Pathy AL, Schlosser BJ, et al. Guidelines of care  for the management of acne  vulgaris. J Am Acad Dermatol 2015; http://dx.doi.org/10.1016/j.jaad.2015.12.037. 

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A long-standing College Fellow, in consultation with the Honorary Secretary has prepared 5 recommendations. All ACD members were invited to choose three out of the five recommendations. Following an NPS Representatives meeting, it was noted that five recommendations are needed. Therefore the remaining two recommendations were selected.

Last reviewed 01 August 2016