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.
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.
Non-sedating antihistamines are only of value if treating pruritus in a setting of urticaria (Hives). There is strong evidence to support the impact of non-sedating antihistamines on the quality of life of patients with urticaria and their productivity in daily activities. Furthermore, non-sedating antihistamines exhibit favourable efficacy and safety profiles.
The Australasian Society of Clinical Immunology and Allergy (ASCIA) treatment guidelines for urticaria state that increasing second-generation H1 antihistamines (non-sedating antihistamines) up to four times the standard packaging dose may be required to obtain a clinical improvement. These non-sedating antihistamines include cetirizine, levocetirizine, loratadine, desloratadine and fexofenadine.
All other itchy rashes such as eczema and psoriasis are not mediated by histamine. Therefore, these agents are of no clinical value and should not be recommended. Rather, these itchy rashes should be managed with topical anti-inflammatory therapies and/or systemic immunomodulation.
The use of a sedating antihistamine which causes central sedation and helps induction of sleep/drowsiness may be helpful in breaking the itch/scratch cycle with all itchy rashes.
Supporting evidence
- Metz M, Wahn U, Gieler U et al. 2013. Chronic Pruritus Associated with Dermatologic Disease in Infancy and Childhood: Update from an Interdisciplanry Group of Dermatologists and Pediatricians. Pediatr Allergy Immunol. 2013 Sep;24(6):527-39
- Radonjic-Hoesli, S., Hofmeier, K.S., Micaletto, S. et al. 2018. Urticaria and Angioedema: an Update on Classification and Pathogenesis. Clinic Rev Allerg Immunol (2018) 54: 88
- Metz M. 2019 Treatments for Chronic Pruritus Outside of the Box. Exp Dermatol. 2019 Jul 16. Doi: 10. 1111/exd. 14007
- McEwen MW, Fite EM, Yosipovitch G and Patel T. 2018. Drugs on the Horizon for Chronic Pruritus. Dermatol Clin. 2018 Jul;36(3):335-344
- ASCIA 2019. ASCIA Treatment Guidelines for Chronic Spontaneous Urticaria AU 2019. Available at https://www.allergy.org.au/hp/papers/chronic-spontaneous-urticaria-csu-guidelines
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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3
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.