The Australasian College of Dermatologists
Recommendations from the Australasian College of Dermatologists on leg cellulitis, epidermal cysts, urticaria, distorted toenails & acne, advice on systemic non-sedating antihistamines and topical corticosteroids for skin conditions. The Australasian College of Dermatologists (ACD) is the sole medical college accredited by the Australian Medical Council for the training and continuing professional development of medical practitioners in the specialty of dermatology. As the national peak membership organisation, we represent over 550 dermatologist Fellows (FACD) and 100 trainees. We are the leading authority in Australia for dermatology, providing information, advocacy and advice to patients, communities, government and other stakeholders on skin health and dermatological practice.
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Acute urticaria (i.e. of less than 6 weeks duration) does not routinely require investigation for an underlying cause. Where clinical history and examination suggest the possibility of a bacterial infection or food as a likely trigger, further testing may be warranted. If individual lesions (weals) persist for longer than 24 hours an alternative diagnosis may need to be considered.
Acute urticaria (i.e. of less than 6 weeks duration) does not routinely require investigation for an underlying cause. Where clinical history and examination suggest the possibility of a bacterial infection or food as a likely trigger, further testing may be warranted. If individual lesions (weals) persist for longer than 24 hours an alternative diagnosis may need to be considered.
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.
- Antia C, Baquerizo K, Korman A, Bernstein JA, Alikhan A. 2018. Urticaria: A comprehensive review: Epidemiology, diagnosis, and work-up. J Am Acad Dermatol. 2018 Oct;79(4):599-614. (Fee for access)
- Schaefer P. 2017. Acute and Chronic Urticaria: Evaluation and Treatment. Am Fam Physician. 2017 Jun 1;95(11):717-724.
- Kayiran MA and Akdeniz N. 2019. Diagnosis and Treatment of Urticaria in Primary Care. North Clin Istanb. 2019 Feb 14;6(1):93-99.
How this list was made
College’s Expert Advisory Committee, comprising seven longstanding Fellows considered four potential recommendations, together with supporting evidence, and agreed to proceed with three of them. The Committee then refined and finalised the recommendations. These were reviewed by the NPS Representatives Committee and finalised in response to the feedback received.
- 1 Do not assume that bilateral redness and swelling of both lower legs is due to infection unless there is clinical evidence of sepsis such as malaise, fever and neutrophilia, plus an expanding area of redness or swelling over a period of hours to days.
- 2 Do not routinely prescribe antibiotics for inflamed epidermoid cysts (formerly called sebaceous cysts) of the skin.
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Acute urticaria (i.e. of less than 6 weeks duration) does not routinely require investigation for an underlying cause. Where clinical history and examination suggest the possibility of a bacterial infection or food as a likely trigger, further testing may be warranted. If individual lesions (weals) persist for longer than 24 hours an alternative diagnosis may need to be considered.
- 4 Do not prescribe topical or systemic anti-fungal medication for patients with thickened, distorted toenails unless mycological confirmation of a dermatophyte infection has been obtained.
- 5 Monotherapy for acne with either topical or systemic antibiotics should be avoided.
- 6 Do not recommend that patients take systemic non-sedating antihistamine for itchy rashes, i.e. eczema, psoriasis. Non-sedating antihistamines can be prescribed for urticaria according to the ASCIA guidelines.
- 7 Do not routinely prescribe or recommend topical steroids Class II and above on the face including periorbital areas, or flexural areas of skin (axilla/groin and natal cleft).
- 8 Review your diagnosis and/or treatment/adherence if patient has not responded to adequate prescribed topical steroids after two weeks.