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.
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.
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.
- 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.
- Ghannoum M, Mukherjee P, Isham N, Markinson B, Rosso JD, Leal L. 2018. Examining the importance of laboratory and diagnostic testing when treating and diagnosing onychomycosis. Int J Dermatol. 2018 Feb;57(2):131-138. (Fee for access)
- Lipner SR and Scher RK. 2019. Onychomycosis: Clinical Overview and Diagnosis. J Am Acad Dermatol. 2019 Apr;80(4):835-851. (Fee for access)
- Saunte DML, Piraccini BM, Sergeev AY et al. 2019. A Survey Among Dermatologists: Diagnostics of Superficial Fungal Infections – What is Used and What is Needed to Initiate Therapy and Assess Efficacy? J Eur Acad Dermatol Venereol. 2019 Feb;33(2):421-427. (Fee for access)
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.
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.