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uh, OK, recording. I'm probably So it's I'm happy to present today inflammatory skin conditions. My name is Ahmed and I work outdoors. Come to hospital. It's very down south in Dorchester. And so you guys, I like this session TV interactive. So please feel free to interrupt me. Ask me or, you know, mention your your opinion or anything at any point you want. You don't have to chat in the box. Just, um, feel free to address me directly. Um, and also, there is no right or wrong. So we all have learning. So I'll discuss three topics today. These are the most common topics. Um, and from try skin conditions, I'll start with eczema, followed by psoriasis and a few points about acne. All right, so, eczema. Have you guys ever encountered patient's with eczema? Maybe family members or yourself or patient's If anyone encounter, um, eczema. Can you just say yes or raise your hand or anything? Yes. Amazing. And what's your experience with eczema? Like, um, how was it? And what did you have? I have eczema on my hands. Okay. Perfect. So you know quite well what we are talking about, and hopefully, um we can add some some value. Or also, you can add some value to our chat. Ok, brilliant. So, um, there are many types of eczema. Some people they divide them into, um uh, you know, regarding the positive factors so indigenous and exogenous causes. And then according to that, we will divide it. Or you can just have numerous types. You just enumerate them like a topic. Dermatitis, suburb, dermatitis, etcetera. I like to divide it to be more obvious and easy to remember. So we have to causative factors. Basically indigenous and exogenous. One of the most common type is a topic dermatitis. And as we all know, the topic dermatitis usually happen in Children and as well as they grow into adults. Um, those patients' sometimes have a history of asthma, hay fever, and obviously, family history of eczema. Mom, dad or granddad? Another type of aximum would be seborrheic dermatitis and subject dermatitis. Um, I'll show you guys photos and the knee so we can link the information with so in seborrheic dermatitis. In short, sometimes we call it subbed. Um, um, this usually affects the PSA Borick areas. For example. You can see here around the nose and around the eyebrows around the ears behind the ears as well. You can see, um, around the flexors as well, especially armpits. It's actually quite common, and then patient's when they have on their scalp. You know, they find it difficult sometimes clinically, to differentiate the seborrheic dermatitis here from psoriasis scalp psoriasis. So sometimes we just, like, treat it all in one go as if it's mixture. That would be, um, clinically challenging, um, other types of eczema what is called discoid dermatitis, which you can see like annular patches, pink or purpose patches. This type of eczema. Actually, it's very difficult to treat, especially with topical steroids. It's challenging to treat, and I'll show you a few photos about it, and we have and dermatitis hand dermatitis. It could be multi factorial, so it could be endogenous and exogenous factors by put it just in the indigenous. Obviously, sometimes again, it can be difficult to know, Um, when you're treating this or if it's, um, hand psoriasis. This type of hand ax, um, also can be infected. A blistering type of it or a physical type is called palm flux, which we're going to also just explain about the treatment a little bit. Another form is called ST A Topic dermatitis or a fancy name, which is called Eczema Crackly. I'll show you photos. Usually this happens in elderly patient, especially malnourished and dehydrated patient's. It has, like a really nice pattern, which you're gonna see in which we terms as crazy pay, ving pattern and venous dermatitis, which is shockingly. Some clinicians, they call it, um, bilateral cephalitis when they see patient's, um, and the wards or in in any and unfortunately, some patient's being treated as bilateral cephalitis. But in fact, it's just, um um status dermatitis. Now, a few points about the exogenous, which means that there is some element that is irritating. The skin or the skin would be allergic to, um, such as rubber, you know, latex nickel as well. Um, so interestingly for females also, acrylic, which is, um, used for, um, nails and also glitters and stuff, which is used for cosmetics. They actually contain nickel on them. So we've seen patient's, um, that allergic to those products as well. And then we have other irritants. Um, such as cement or oil. Uh, you know, so we'll see with handed mints or people who work in car industries and factories, etcetera. They would have these kinds of trouble. Or maybe people who are working in oil refineries. I have few patient's um, They have a a written contact dermatitis, um, drug induced dermatitis, which is basically the rush that appears after, um, drug allergies. It's itching and then causes dermatitis. Okay, I just want to quickly through those. But don't worry about it. Now is the real deal. So this is the atopic dermatitis, and as you can see, a photo of baby, then we can see it's usually aximum. How we define it is that it affects the Flexeril areas basically, while psoriasis usually affects, um, Extensors. But of course, there is a type which is called Flector a psoriasis. And as you can see here, you guys can see them. I was moving. OK, Brennan. So you can see how if you want to describe it, it's this looks like an erythematosus pink patch. And as you can see, it's clearly there is an excoriation science Can Can you see those little dots here? Okay, so this is happening with nails. These are excoriation signs and you can see her. The baby. It's very classical pattern here when you see, um, when you do pediatric dermatology, it's a classical pattern. We see these areas are are involved. Okay. Any questions about it? Nope. Great. Okay, now this one. Anyone wants to describe what is going on here? I know the title that shows us to break dermatitis, but anyone wants to volunteer to describe what happening? What is happening here? There is no right or wrong. Just anything. Just mention anything. All right? We'll start with or set. Yeah, on the left. Is that like, it's, um, erythematosus and flaky over the nasal labial thongs. Perfect. In here. Can you see the flakes here as well? Yeah. Yeah. Perfect. And what about the skull? I mean, he was like, I was struggled to distinguish that from, like, really bad dandruff. Exactly. And even if you see, um, Psoriasis, you would say this is psoriasis isn't so. It's not. It's not always clear cut to say, Is it psoriasis? Is it eczema? You know, um, uh, like, suburb dermatitis or not. Okay. Um, so this is the trick a bit, but we can see with psoriasis. It's usually very well demarcated. You will see a demarcation line while with sub them, or subject dramatizes. It does not have, like, a clear demarcation. As you can see here, it just extends to the edge, like grows to the end. Okay. And of course, these can be infected because of the itching again, all types of inflammatory skin condition always keep in mind that there is a possibility of infection. You know, super added infection happens there. All right, Now, this is a script dermatitis anyone wants to describe. Describing legion is very important. And you can just describe whatever you are. You know anything in front of you. Just any words. What you see from your point of view, anyone Shall I pick someone? So someone's asked in the chat box? Um, they've asked, Maybe a silly question. But how do we distinguish between discoid dermatitis and ringworm? Exactly. A very good question. So, um, so for ring ones, how many? Um, patches or plaques you will have. And then for discard dermatitis. How many? Um uh, plaques you will have. Or or patches? That's number one. Number two with the wrong one. Or it's basically, um, you would have a unilateral rather than bilateral, while with described dermatitis is usually bilateral number two, we will have with tinea, which is ring Guan. It's basically we will have a very demarcated patch or plaque, and then it shouldn't be that erythema tous. Basically, the center is usually not the erythematosus. And then on the periphery we will have fine scaling there. And it's usually not angry like this. It can be angry like this if sometimes, um, ring one treated with steroids. That's why they call it Tina incognito, if you guys heard of that one. Have you guys ever heard of Tina Incognito? No. So, Tina incognito is basically if you have a penial fungal infection, right? And then instead of your fungal, um, antifungals they put steroid treatment because they see a pink patch probably is going to respond to steroid, but actually, it got worse with the steroid. So also, this is like a test for you. It indicates this is not an an eczema. This is a fungal infection. If it gets worse if it gets red, Um, these are the futures and forth. You can do what's called skin scraping. You just, um a piece of paper and you scrape the edges. Do not go to the center. You go to the edges, and then you have that flakiness, and then you just send it to mycology and you'll have the results. So those four features, um, hoping this would help you. Um, they just also asked whether, uh, just a clarification, whether it was angry or angular about angry, right? Angry, right? You know, with the herald patch that you get before pityriasis rosacea. Rosacea? Yeah, that would be the same kind of thing. Here. Do you see them getting treated with steroids and things and they're not. So, um, it's interesting question. So with pityriasis rosea, you don't have to treat it at all. It just disappears by itself. I've seen a patient two days ago, actually with pityriasis rosea to, um, it's called Fairy Tree. So you start with them herald patch somewhere in the in the in the body, either chest or back. And then after a few days, um, lesion start to appear like this. And then there are very distinguished futures. They don't look like these. They are not crusty and not looking like this. Um, the demarcation is better. And they would involve the chest and back and a very, um, distinguished pattern. I'm happy to show you guys at later stage. Maybe in another session. These, um, interesting skin presentations. Um, but it's highly distinguishable. It's basically just the depart Earn of garage is completely different from described eczema The pattern. Once you see it, once you like. Once you see it in the text work or an ANA patient, you will immediately notice it with another patient because once they take the top off, you will immediately see the the departure and just like like this. Then when you ask them, you say, did it start as one patch and then quickly you develop these patches, they say, Yes, that is your That is your your answer. You You just say you don't need to to treat it with anything. It should disappear by itself. If it didn't, then you can use topical steroid. But ideally, it should just go by itself. Amazing. Thank you. Know it's any other question, guys. Mm. Okay. So this is your area, Seth, Do you wanna do you want to describe it? Anyone wants to describe what can we see here? Shall I pick someone to It Looks like scabbed over peeling skin, areas of contact with chemicals. That sort of thing is what it looks like to me. Excellent. So, yeah, you can you can see it's first of all we if we want to describe what we can see. The skin is very dry, isn't it? You can see it's very, very dry. Correct? Yep. And then you can see these cracks cracks here, multiple cracks and then, in addition to the cracks, you can just describe and you say so. These are patches here, erythema dispatches so you can just say generally dry skin, multiple erythematosus, scaly or just patches. Erythema dispatches with multiple skin cracks, especially here. You can see the crux very, very obvious. And even in these photos, these could be also infected, especially this one in here, because these gets infected very quickly. You know, the skin would be open and you those type, you know, those patients'. Actually, they just carry on with, um, irritant on their hands, like Simon or or oil or anything like this. And they just carry on day and day until the skin will become thickened and infected, and it looks like this, and it's actually very painful, and it's very interesting. It's irritant and burning and painful more than it's itchy. But because of the itching as well, they tend to scratch. And on top of the with the scratching, this would make things worse and worse. It's like a vicious cycle until you stop it with the correct treatment. And this would require potent or even super potent topical steroids, usually with, um, antibiotics with it, such as, um, button of etc. Okay, and this is a cirrhotic dermatitis. So I told you will see a very interesting pattern. You don't see anywhere else in, uh, eczema, and this is called the Crazy pay Ving. This is called eczema crackly, so you can see, um, an elderly people who have, um, producing nutrition, dehydration. And I've seen it, actually, in one young patient, they were, like, 27 or something, but they had extreme diet. Um, so they lost so much weight, and then aximum was really evident on the legs. Any questions about it? Um, yeah. Does it Is it still like, um, you know, does it still have the clinical symptoms of eczema, was it? Yes, but it's just, you know, the presentation when you look at it. If you know, if you do not have the knowledge about the eczema crackly, then you would be like, Okay, so what Rush would look like this. What Rush could be bilateral, Uh, itchy, dry eczema. Could be one of your differential diagnoses. As long as you know how it looks like. Thank you. All right. And this one, the clinical dilemma of lots of medical doctors. So, you guys, um, when you start, um, working any words on anywhere when a patient presents like this that usually went to the G P, they would refer them to, um, any with bilateral sterile itis, and then they get treated. I have antibiotics with bilateral sterile itis. So I want a volunteer to describe what is going on with the legs and also what is going on with the rush Anyone wants to describe Sorry. Just before that, someone's asked if there's a link between eight a. P and contact dermatitis from irritants. There is what is called sometimes when you have HRP. So that is what's called order sensitization for For example, if you have upper limp. Okay, so let's assume that your dermatitis or eczema is gonna is just limited your upper limp and you start scratching and scratching and an itching with the frequency of that. Then it's called auto sensitization. Your whole skin start to itch and scratch, and then more and more errors will be involved. This is just a spread of your HP, but with irritant and contact dermatitis, they can overlap. So just because someone we know that they have a topic dermatitis doesn't mean that they can't have like, uh, an irritant or allergic contact dermatitis, for example. We know they have a to be, and then they are wearing for, for example, a new ring. And then it's a gold ring or any type of offering like, um silver. Okay. And then they have noticed that just around that area, it becomes red. When they take it off, it improves by itself. That I start of their skin is extremely well controlled, with the usual, um, daily regime, whether it's just moisturizers or stars with moisturizers. Now, if they notice only this area is involved, this could raise the suspicion it could be, um um contact dermatitis. Um, and good days. Previously, we used to do the patch testing just to see if there are any irritants or allergens that can cause these things. But after covid, um, they're these services are not available, like like before, But some hospitals, they still carry on with these, But we would do them only for extreme cases rather than just mild forms. So, yes, things can overlap with eczema, but still, the treatment would be the same. I don't know if this answers your question, or I made it more difficult. Yeah. All good. All good. All right. So, um, anyone wants to describe this slide? The first one on the on the left, This one. Should we pick one of the bosses? Okay, Becky, want to go for it? Oh, I did not think I would be. Okay. You will. You will definitely see those patients'. And you will remember this this session. Believe me, each one of you going to see one of those patient's in your life at least 56 times at least. Oh, that's a good point. I've actually seen a couple of patient's like this already. I'm describing the image on the left? Yes. And then. So, first of all, we start with the general. Look, what is going on with the legs. Then we talk about the rush. So do you wanna describe? Yeah. So, uh, they look to have, uh They look like they have bilateral edema. Um, they've got a little bit of a champagne bottle appearance of the legs. Um, bilateral edema extending potentially up to the knees. Maybe a bit higher than that, but a picture doesn't allow us to see. Um uh, you've got, uh there seems to be bilateral, um, erythema present on the legs as well. Maybe a bit darker. Doesn't seem. It seems like I forgot what the word is, but it sort of when iron I think breaks down and then, like leaves. Yes. Yeah, he was citrine. Correct. I think that that seems to be Yeah, that seems to be responsible for a lot of the coloring present. Um and so the earth, the erythematous patches seem to extend sort of too right right to the level of the tibial tuberosity, maybe slightly below it. And, um, you can, like, literally draw a line the okay. And yes, you are correct bilateral edema, and then we have the reverse champagne. But if you just have a look at the nails, always when When you look at patient's always look at the nails, not just the hand, the toes. Okay, if What What is the most? If you look at the nails, the kind that there is signs of fungal infection, you have no idea how many patient's have fungal infections and their toes. It's just like a bread and butter. Oh, is that the black? This is the second. I think the second two of the left foot there seems to be a little bit of black at the base of it. Oh, so here, this one is really obvious. A fungal infection there. Okay, Okay, So you have bilateral leg swelling. We have, um, correct, which is an erythema. Dispatches punches of him aside, drain and also post inflammatory hyperpigmentation. Um, and the treatment is just, you know, you can just give them steroids and you give them moisturizers and leg elevation and compressing, stocking and get rid of the cause that is causing the leg swelling, you know, rather than treat them with antibiotics, because antibiotics will not touch that at all. And then if we look here, it's very obvious and a similar similar presentation, and we can see here varicose veins really obvious. Can you see them guys? I'm moving them also on them. Yeah. Sorry. Just wondering. Um, if I wasn't Edie, if I was a, you know, Reggie needy. And I saw that, you know, would I not in anyway, give, You know something IV? Some sort of antibiotic, maybe flu o'clock or something? Yeah, because you can't risk it regardless. So, what would you do for this patient? Because you can't just say to being stem a tightest, and then you let them get, you know, yeah, Sally, like the sepsis. Sepsis? Yeah, correct. So you will see those patient's come to e. D. And then they tries to medicine for, for example, if you have, like, really good features, which is first of all, bilateral cephalitis is extremely rare entity. Extremely rare. I don't think you will see it. Um, in in in real practice, there is no by bilateral Sal lattice. It's just theoretical, as far as I know. And that's why I was you know, um, my my teachers taught me. Um, you will see unilateral cellulitis, and maybe one of the legs maybe is infected, so you need to apply the rules or cellulitis. Is it tender? Is it hot? Um, is a really swollen Okay, um, these you know, these patches. So if you examine this patient, these are not tender, not swollen, not hot. So no signs of infection because satellite is basically you are just infection that's happening under the skin. So it's going to be really, really tender to the patient while this patient, when you when you do like when you want to just examine it with your thumb or you just want to feel it, they're absolutely fine. Now you can see some patients might have inflammatory markers are high. But if these legs are fine, maybe these inflammatory markers are high. Maybe for another reason, just infection tonsils, urine. You have so many other problems rather than they just pick the easy route and just say, yeah, the legs so you can you can challenge them even if they are seniors. You can always challenge, and you can just say like I read about this. This is what I'm thinking. What do you think? Shall we visit the diagnosis? It's a It's a matter of discussion, you know, if they're if they were like, No, let's start the antibiotics. Just carry on. It's a it's a cephalitis. We are definite then they you know. But I deal with with cellulitis after a few days of a treatment. If you follow these patient's and in particular this patient for, for example, if you follow them up after 23 weeks time, you will see the same discoloration is that it did not disappear. Why? But if you have sort of like this, ideally, it should improve. Correct or not? Yeah, yeah, it might have a positive inflammatory pigmentation. That's fine. I'm happy with that. But even if you start your antibiotics, you do. You do everything, and you will have it the same features. And unfortunately, some patient's they just become regular. Two G, P and E. D. Bilateral satellite is every single time, but maybe there is another source, which got treated with IV antibiotics and then inflammatory markers come down. But maybe it's not this one, so we just need to be mindful about it, you know, just to keep it at the back of your head. Like bilateral. Um, brush doesn't look like it's cellulitic. What could it be? Shall we just, you know, do further investigation? Shall we do it? Just just x ray, rather than just immediately just say Yeah, I've reflux. Excellent. You know something? Just to keep it in your differential diagnosis. Thank you, Doctor. No, we just got a couple more questions. So, uh, someone's asking whether venous dermatitis predisposes to cellulitis. Um, and the second question is what causes venous dermatitis? Is it related to edema? Yes. So I'm going to ask for the second question before the first. So the second, which is is it predisposing to, um, like edema? Venus? Yes. So the bars like what causes venous dermatitis like, Is it related to a demo or not? Yes, correct. So it can be related to that. So when you have the venous status, it means basically low blood supply to the lower limb. So our lower limbs, they have, you know, because the the geography of of the body, so they would receive the least amount of blood supply. And those patient's not like in a normal, healthy, healthy patient. So that is number one, number two because, um, low blood supply you will have, um, poor vasculature and, um, poor, um, skin health. And then these will gradually start to develop. So join us, and then dryness will lead to itching and then irritation there, all these multifactorial, they will lead to Venus status or venous dermatitis. Okay, I don't know if it if it helps. So it's basically a Dema. Also can cause that stretching of the skin so the skin will be dry. In addition to that swelling of the leg again would compromise the blood supply and eventually you will have similar similar presentation. And on top of that, unfortunately, for example, if we do skin surgery on on a patient with this presentation, it would take very long time to heal because of poor blood supply and swelling. So that's why moisturizing skin is really, really, really important. Just keeps the the skin integrity just improve the skin integrity and where in compressing, stocking, if suitable, you know, if the blood supply, if the rt our supply is good so they can wear them and like elevation, these simple measures actually would make a huge difference and speaking of skin integrity. So if a person's got being a stem Matitis, they're more at risk of compromising that sort of skin barrier. So that does that mean they're more at risk of developing cellulitis? So what? The cellulitis? You need to have a root for infection to happen. So usually when you have a patient with sterile itis like you are, expect you are diagnosing sterile itis. Okay, then you need. First of all, look at their feet. Look at the Web spaces, especially patient's with athlete's foot, because one of the most common causes of sterile itis is that you will have a source of infection coming from athlete foot. That's very important. Second, you'll have patience because their skin is really dry and itchy. And then, while you know you would see them a lot if there are any your clinic while they're sitting, they just do. They just itch their their their legs, and you can see them in front of you and you. You can just tell the moments that just avoid that's really not not good for your skin so that itching and scratching will cause, um, damage to the to the skin, and then this would be also route for infection. So to have cellulitis, you need to have route for for infection, whether a trauma, whether lacerations or whether they just not there the leg or maybe previously not treated well, um, sterile itis just happens like a record. Encephalitis or one of the most common causes would be athlete foot and then ascending of of an infection. Does that help by any chance? Um, yeah. I think you've answered all the questions. I think if the person has any more, they'll just send it and we'll ask it. Yeah, yeah, No worries. So some of the most important differential diagnosis when we see, um, these rushes. So we had a look at all these rushes that have different presentations. So we need to keep in mind some of the most important differential diagnosis that shouldn't be missed. One of them is obviously infection, which you know. Could it be fungal? As you guys rightly said, How would we know Kenya, Um, from Oximetry answered that one bacterial infection, which is cellulitis. We also explained, or it could be just disseminated infection, blistering disease, which I'm keen also for you. guys to have, um, a like a session about blistering diseases. These are very common and and not very common. These are common in elderly patient, especially nowadays, I don't know. A clinic last week, I've seen three. So, um and then we have if you heard of my courses. Fungoid is which is key Tina's T cell lymphoma. These patient's usually have slowly progressing rush, which is longstanding and now responding to topical treatment. One need to think about, um, t cell lymphoma and piece of advice. Always, Always when you examine the skin, always check lymph notes. The general examination of peripheral lymph nodes. You know, um, exactly had a neck area and groins always check those. You might save a patient's life, you know, when they come with with a rush and then you check the lymph node and you find out maybe they have, like a cancer presented as a as a rush, because we see them in the indicating, um, connective tissue diseases such as Lupus and skin cancer. Skin cancer especially, you know, when we have, like dis create lesion's uh, these are are are important because sometimes we need to biopsy them. Is not always crystal clear what's diagnosis. So we actually do biopsy good number of patient's now, The, uh, important bits of the treatment is that we have a general advice which is very important, as we said, avoid the irritants and triggering factor. So when we see the patient and the clinic, we start just questioning them about anything. You know, um, air fresheners, flowers, dogs, cats, dust mite. Um, all these like perfumes, glitter, Nell acrylics all these stuff or ask them about their their job and then ask them if they started something new, such as hair sprays or new shampoo. All these can be trigger factors, which we usually advise to stop. And then after a few weeks time, we can introduce one by one gradually to see which one is because of the factor. Okay, No topical treatments. Mainstay of the treatment is emollients emollients. We have creams and we have appointments. So creams prefer to be used during the day and ointments usually early in the day and during the night because they're really messy. But they are extremely helpful, especially with severe types of accident. Then we have steroids now, steroids, uh, you will see some patient's. Actually, they are. You know, um, they say I'm afraid to use steroids. They're constraining of the skin. I'm not keen to it. But in fact, um, prednisolone, which is the all all steroids this is the one is actually causing more thinning of the skin way, way more than using even potent topical steroids. So therefore, when you have, uh, moderate or severe type of of axum, at least if you want to control it for from the below the neck area, you can use, um, for example, potent steroids. But never, never on the face never use potent steroids. Okay? Never, ever. Maybe maximum. We can use humor of eight, which is a moderate strengths, uh, steroids. And for a short term. All right, Um, just got a question. Sorry. Yes. Uh, we've just got a question about whether parabens like Vaseline work. Oh, these are amazing. I love them. So we have. You will see on shelves. You know, if you go to boots or anywhere else, we'll see what's called 50 50. So this one contain paraffin, and then those are amazing. Really, really helpful. Sometimes in advanced cases of eczema, if you heard of it. You just apply those and you do wrapping wet wrapping. These are very helpful during the night. So, yes, these are very helpful. Um, duration of the treatment and strength just depends on the severity. You can just gauge it clinically. And of course, there are scores would help you out. But you will just see the area. Would it be suitable for moderate or higher strength and dermatology? We usually do not use hydrocortisone because when patient's see us, they actually need something more stronger. There are other topical treatments called council union inhibitors such as Protopic. If you heard of it, Um, and it comes as an ointment. These are safe to use as a steroid alternative, even for long term. And even you can use it on the face as a steroid sparing agent. The problem with those they can be irritant in the beginning, especially in the first few weeks until the patient's tolerates them. Um, what else? We have any questions? None. So we go to big guns. Now we have systemic treatment. So you have your patient's that come back to you. They're not responding. The eczema is worse. And then it's really, really bad. In the meantime, you can control it, at least with an oral steroid, a short course of, um, Prednisolone. And again you can gauge according to the patient's for it. And according to the severity, you can gauge it, and then you will think about something for the future or something for, you know, for the next visit what you're gonna do, you start work up for one of the really old fashioned treatment, such as methotrexate or azathioprine. These are really effective. Methotrexate is cheap and needs blood monitoring. Cyclosporin is very quickly, um, effective, but the problem with it it can affect the kidneys, and it can cause hypertension and causes trouble as a therapy. Brilliant medication, but associated with, um, skin cancers, non melanoma skin cancers. Therefore, patient's shouldn't be on long term with it. And I've seen a patient developed more than 10 square muscle carcinomas. And if you're aware of, um, so we do not use um, threatening ones. We do not use them for, uh, for, um, eczema, but exception only for hand, which is the palm flocks. We use electricity known. It's effective and it's fairly safe medication, but again. It needs, um, follow ups. If those patient's still not improving very severe, um, and affecting their life, then we'll go to biologics if ahead of, um, the pill a mob which is very effective and is currently being used. We have Barry sitting, which has recently been licensed for, um, eczema, and you have a bra sitting up as well. This one is, um, more recently licensed. Of course, you will see a lot of people. They use anti estimates, but in fairness, these are used for their sedative effects. So if you want to prescribe them, it's just for their sedating. Do not bother prescribing nonsedating. And if you do that, please let the patient's know that they shouldn't be operating heavy machinery. They shouldn't be driving, so it's preferable to use them before sleep to help them. And this would let them avoid itching and scratching. Another option. We would have like therapy soap UVA. It's usually for a limited one. For instance, if you have hand eczema, you just put them in the, um, prove approve a machine, but you've UVB is more, uh, more generalized. Any question Good? How are we on time? Um we have 15 minutes left. Yes, but I mean, I don't mind, um you taking your time? I think if anyone else has an issue, they can let us know. And, you know, I mean, we'll share everything with everyone. Anyways, if anyone needs to leave early, just let us know. You guys just let me know. But I didn't anticipate we'll have a discussion when with, uh, I'm I'm I'm more than happy to to carry on even after, um, seven. But if you guys are, if you have plans or anything, just feel free to, uh, you know, leave. I think definitely, I think feel free to carry on. Doctors wane. If anyone needs to leave early, just let let us know in the child will send you the feedback form link. So you can just use that and get access to the slides and everything afterwards anyway, so it should be fine. Amazing. So we'll move forward to psoriasis. Anyone seen any patient with psoriasis or complaining from for psoriasis or family members? It's Come on. So, yeah, my friend's got quite bad. Psoriasis, bad psoriasis. Where is it affecting him? It's on his hands. Um, his scalp is quite bad as well. Um, and I think it's his elbows. Well, okay, so you are quite familiar with that? You've You've seen it clinically. So you will have some idea what we are talking here. Brilliant. So there are various types of psoriasis. One of them, Actually. It's an acute form which is called guttate psoriasis. I'm going to show you photos. The most common type is chronic plaque psoriasis, which I'll show you again. I'll show you photos about the common ones. We have scalp psoriasis, which, as I said, sometimes it is difficult to distinguish it. Um uh, from seborrheic dermatitis. And then we have, um, nail psoriasis, um, which can be associated with the chronic plaque, psoriasis, or maybe not. Or maybe just with the psoriatic arthritis, you will have just nail fitting. And we have a lecturer. Psoriasis, as I told you, Usually flexes are are affected by eczema and extensors affected by psoriasis. Having said that, psoriasis can be in flex iss, and this is called difficult side psoriasis. Because these areas can be infected or can have a mixture of psoriasis and eczema and maybe also some fungal infection on top So that's why sometimes it's challenging and that is attempt See both psoriasis, which means you we can't distinguish, Really. We can't distinguish between both of them. And even if we have a biopsy under microscope, is not that straightforward to distinguish between them, because I do also helps to pathology for dermatology. And in our hospital we do it, Um and you have palmoplantar. So it just affects palms and and, uh, and soles as well. And we have the severe form which is called Aretha Dynamic psoriasis. Let's see some photos. So this has got it. OK, it's very easy to diagnose. And you can just immediately when you see the patient like this, you can immediately um no, the the diagnosis, having excluded others and then listening to the patient, they would just tell you. Actually, I recently had sore throat, and this itchy, flaky rush just appeared. And then light bulb immediate film. Could it be cut a psoriasis as one of the presentations? Plaque. Psoriasis. They call them salmon pink. They're not deep pink. They're not red, that salmon pink. If they look really angry. Red, please think about something else. Do not be fixated to psoriasis, even if if they have crossed or or or or anything, so just keep an open mind. But again, you know the side. If you see them on the elbows and stuff again, you should think about psoriasis Scout. If you guys remember the photo that we showed about seborrheic dermatitis and can you see how it's very well demarcated? It's not even not crossing to hear. See? It can draw a line. It's very obvious. Yeah, And when you examine the patient clinically, you will see the plaques you see, like a real obvious plaques. There. Now, can you see the pitting here? Ok, regin. Okay. And again, this is structural psoriasis. Okay. As you can see, the features are different from the block. You can see that looks like patchy. Actually, very few cross there and one would say, Okay, how can I differentiate this from subject dermatitis? Or maybe from eczema? It's difficult. It's challenging, even clinically. But you need to look at other areas. You need to look at journals. You need to look at the symptoms. You need to look at the family history of the patient's got any 80. P or anything like this or family history of psoriasis. Do they have, like, involvement of other extensile areas? Belly button these things. So it's not just looking at one area, and you can make your diagnosis because the skin is a whole organ. You need to look around flu's so you can diagnose your your your patient's correctly. And in fairness, in the beginning, the the treatment is more or less the same. And then here is palmoplantar again. Sometimes it's it's difficult to say. Okay, why? This is not, er Litton contact dermatitis, which is correct. You know, it's very difficult sometimes to to distinguish, however, with irritant contact dermatitis. You will have more fish hering of the skin really obvious fishing, and it's extremely, you know, banning sensation there. But with psoriasis, you have involvement of the palm, and if you go to defeat, you can see the soul, and you can see that it's well demarcated here. If you see the mouse going, it does not go to the doors, um, of the foot and you can see here at teeny tiny Plock. And if you go to the if you guys see the mouse on the left photo. Can you see this like? It's a well demarcated as if there is a line here just separating normal from abnormal skin. And it's really thick, scaly scan with fishery and erythema tous blocks. Sometimes it's it. It poses challenges to treatment. Actually, not always response to treatment nicely. An Ortho dynamic psoriasis, as you can see. Right? Okay, so this patient needs to see dermatology. Same day, at least. Okay, hopefully you will not see those patients'. They're really not in a good place now with psoriasis such as an eczema eczema. We said that our exogenous and indigenous factors here that are triggering factors and hopefully all of us know that injuries with patient's with psoriasis can cause what's called koebner phenomenon. Have you guys ever heard of coq? 10 are phenomena? Yeah, perfect. So do you. Anyone who does not know it's koebner phenomenon is basically when you have a trauma or, for example, like if you have psoriasis here and you damage the skin just around it by scratching, you'll develop psoriasis along the way. Koebner not pathognomonic for psoriasis. It can happen, for example, with lichen planus, so it's not just for psoriasis. Can happen with others. Um, again, infection can trigger psoriasis. As we said, um, streptococcal infection can cause, um, trigger gutted psoriasis. Obesity? Um, it can make psoriasis worse. Smoking make it worse. And medications. Uh, a well known medications beta blockers, lithium and antimalarials are, um, really, really triggering psoriasis and make it worse stress. We see a lot of patient's stress with triggered a psoriasis. For example, you have a patient very nicely controlled. And if they have new stress in their life, any situation, it just kind of triggers it very, very quickly. And then, ideally, we do not use, um, steroids orally for psoriasis. We use them for ex, um, not for psoriasis. I don't know. Some patient's they say in the US they would give them prednisolone. But we, um usually we we do not give it. We do not give prednisolone for, um, psoriasis. Um, sunlight, actually. Um, most of patient's. They would respond nicely to sunlight, but unfortunately, some few patient's sunlight actually triggering to them. And that's really not helpful because psoriasis patients', they really enjoy the summer because their skin would become better assessment tools. We have d l Q. I we love that tool. You can use it to majority of skin skin. Problem is basically how the patient perceive, Um, they're, uh, skin skin presentation, so it's not us assessing them. It's the patient assessing themselves, and it's their way to tell us how their skin presentation is affecting their lives. And usually we use posse and for eczema, use easy, which is eczema area and severity index. And there is, um, the P G A as well in BSA. BSA especially would be helpful when you have, um, Erythroderma. It can just say that amount of what the surface area is involved associations. Um, psoriasis. It can be associated with arthritis, so called psoriatic arthritis. So basically, not every patient with psoriatic arthritis have psoriasis. Vice versa. Not every patient with psoriasis will develop psoriatic arthritis, but it's a question ourselves, um, ask patient's when they come and rheumatologists. When they see a patient with psoriatic arthritis, they also check for skin lesions. If they have, they will refer them to to us. And if I see patient's whose got joint problems, you know, small joints of their hands, morning stiffness, lower back pain, neck pain, and it's really affecting their their life. This might trigger, um, uh, referral to rheumatologists f needed. There is a score. Court past, score, past score. And then there is a criteria. When they referred to rheumatology, it can be associated with inflammatory bowel disease. And here this is a new pot topic is metabolic syndrome, which is happe lipidemia obesity and cardiovascular problems. Um, which is a new thing. And I and I published actually research about it. Uh, this is my publication, which is a problem. It cited, um, about the association between psoriasis and cardiovascular disease. I've attached the link. If you want to read about it, we explain a lot of psoriasis and, um, pathogenesis and pathways. And then how it affects the heart. So far, so good. Or any questions? Yep. That just in time once popped up. So someone's asking. Is there a link between psoriatic arthritis and metabolic syndrome, too? Uh, that I to be honest, I don't know, because psoriatic arthritis. Basically, it is a rheumatological, um, diagnosis. But I don't know. In fairness, um, yeah, I'm really sorry. That question I do not have answer tea, but I know psoriasis itself. It is associated with metabolic syndrome. Perhaps it could be related or not. It's it's, it's difficult to say because it's, um, psoriatic. Arthritis is usually it's related to hep HLA Um, so but I don't know about the link with metabolic syndrome, but I cannot comment on rheumatology. All right, thank you. Know, um so you have important things. Always, lifestyle changes are very, very, very important. And as we said, with maximum avoidance of exposure and positive factor the same thing here and in addition to that is lifestyle modification such as weight loss, cessation of alcohol, cessation of smoking and interestingly, when we see patient's with inflammatory skin conditions, we should always ask few questions for future treatments. For example, if I see a patient with moderate psoriasis or excellent, but I need to look into the future, I say maybe in the future, this patient's might need to be on methotrexate or, um, as a threatened or anything like this, so we know the side effects these medications can affect on the lipid and can affect on the blood and also can affect the liver. So a few questions we need to ask the patient's is that how much alcohol they drink if they take any contraceptive pills or not. Because these medications, um, basically affects, um, these cost birth defects or patient shouldn't be pregnant. So all these you know, you have future questions in your mind. You can ask them in the first visit, or at least in the second visit, to establish a baseline. For example, if you have a patient to drink like four units, um, a week, that's a no no for methotrexate. You need to from the beginning, tell them you need to cut down really significantly gradually, bit by bit. This would improve your skin condition and also with open new horizons for further treatment. Because when they have all these medical problems and the liver is involved, this would really, really limit future treatment. So just to keep it in your in your mind when you cancel those patient's in the clinic and again similar with eczema um, Orleans, our mainstay of treatments, you have no idea how many patient's you will see. They don't for Anyim Orleans, and then they have plaques this thick, and then they put steroid on it, and they tell you, actually, steroids do not help But that steroid they put on the plaque is just moisturizing. The the plaque is not doing anything. It's not doing its job. Steroids should be on on fresh skin. So the way around it to get rid of these flux What moisturizers? Plenty of them increase the frequency if they don't like, um, you know, if the if they don't like the consistency compromise Say okay, you screams during the day, but use, um ointments during during the night and moisturize as many times as you want because moisturizers, they're just nutrition to your, you know, the nutrition to your skin. They keep the skin integrity and then they keep the skin barrier. Um called our preparations such as polyta different. All used to be used in the past, but just stains and or okay, so not many people use it Now. Sala Sala Kasit is very nice, and it's basically used to d scale so you can use it for the scalp. You can use it for any plucks you can. You can use it and it's a very effective. You can also combine it with steroid later on, so you can just d scale with it and then you can apply any types of steroid, depending on the severity. You have vitamin D and the rocks. These are called Cal Sectorial, and this is, um, the brand. It's called Dovonex, but, um, I'll talk about the combinations later on, and there are plenty of names you don't need to worry about the names. But if you are interested in the future, you can just research them just to know about them. Because when you see patient's in a any or in the medical world, they tell you I have the Prozelic. I have install a phone, but you don't know what is it. You can just research them and just find out what they are. And again, we have the topical steroids. Strength ranges from mild up too potent, uh, sorry of super potent steroids. And we have calcineurin inhibitors, Um, such as the Protopic. As I mentioned for Exelon, uh, combination Treatment's. These are very, very common. We use them here. Uh, one of a nice combinations is insular, insular. It can be, um, as a topical or can be as foam, and it's actually very effective and patients' like it because it's foam and it's easier for them to to apply. A similar one is Dover beds. So if you look here, that is Dover. Next, a Dovonex does not have any steroid ends with the next, but ends with the bet Dover Bet that contains better metha zone. This is a potent stellar Sorry. Just wondering. Yes. Does that does Vaseline help or not? Oh, yes, it does help. But the be wary of one thing tell the patient's if you put Vaseline, this is highly flammable, so they can catch fire if they are using a stove or something like this so they might and or if they if they smoke because if if they, you know, plaster themselves with Vaseline and go out for a smoke, they might catch fire. So that is very, very important, like from the medical, legal and for the patient themselves. But because it is beautiful. Okay, thank you. No worries, and especially if they use it more frequently and put it during the night and comes the morning the scales removed, and then they can put their steroids there. That's the idea. You need to do the scale. Then you can put your steroids. Never, ever put your steroids on thick scales because they would not do anything. And so many patient's come to your clinic and they just say nothing works for me. I put this and I put that. And when you ask them, do you use any moisturizers? They say, yes, we use Nivea. Nivea is not a moisturizer. Maybe you can use Navia. You know, if you're scared incredibly nice and does not have any any issues, you can use navy, a lotion or whatever, or Ceraview or anything. But when you have a skin condition that cause thickening and scaling, you need to have, like, a proper stuff, greasy stuff and thick. Okay. And then we have the press. Elik Also beautiful treatment. This disk ALS and also contains steroid. It's called, um depress. Elik. Any questions? None so far. Okay, Again. Similar to eczema, we have systemic treatment in the form of, uh, methotrexate, similar to, um, psoriasis. So you need the blood investigations deliver initially with these medications, we need to also to assess some for TB and HIV. Um, and hepatitis C etcetera. Um, it's easily just hepatitis. Uh, sorry. Um, TV and, um, HIV. These are very important because that can be reactivation. And also these mitigation or immune immune suppressant. So patient's should aware of be aware of those. And, you know, when they have infection covid, etcetera, just infection. They need to postpone these treatments because a lot of them they just carry on. I'll take it while I have my infection. Actually, pausing that treatment one or two weeks would not kill them, but taking them along with their current with their current pneumonia this can make like a a massive difference can be life threatening. Um, as a threaten, we have also phototherapy as we mentioned. And we have biologics, plenty of biologics. And there are lots and lots of lots. I just put like a flavor or a few of them. And then this is just, um I mentioned the pathways here on how they work. We have Adelina Mob. If people know it, it's called Humira. That is the original brand. But nowadays we have biosimilar the cheap brands. Um and you have? Yeah, loads. We have risen Kizza mob. Um, so kicking them up a lot. Lots of mabs and but it just depends on their presentation. Do they have purely psoriasis. Do they have psoriasis with psoriatic arthritis? Are they responding? Um, and and how quick we want. Um, the treatment is affected because some of these biologics, they take a few weeks time and some of them really quicker, and there is a lot of research about them, so I will not bother you guys about them at the moment. Any questions about psoriasis? None. Okay. Favorite topic for everyone. Acne vulgaris. Everyone had acne. Very rare people. They don't have acne. Um, so we are quite familiar with from the presentation point of view, and it affects the pilot seditious system. And there will be some plugging and then development of, uh, an infection there, so the it will be colonized by bacteria. Research says there is also an genetic element. Family history, element, lots of stuff. Even the research, the gut mucosa and, um, probiotic. So lots of lots of stuff going on with with acne. But this is just an overview about this situation and how we so far no, it, um, the acne is also involved. Usually, uh, affect. Age group is 16 to 18. I've seen it in very young people and I've seen it in older people. Um, so it's not, um, just, um, related to people like teenagers? Not really. So it can be like, 12, 10 years old. They can present 30 40. They also can still present, So never say never. There are triggering factors or that are associated factors. I just mix them together, uh, one of those steroids. So if you guys see some of those, um, guys who go to the gym and then they take anabolic steroids and actually we see them a lot in the in the clinic, and then they develop, like, really severe acne or some of them. They have, like, uh, mild to moderate acne by affecting big surface area, especially the back and upper chest and face, uh, white and black head comedones. You will see. I don't know if you guys seen such patient's. You can see them on when when they walk on the street, you know, like big muscles and stuff. But there is loads of acnida. So, you know, they literally they they took steroids for their muscles. Um, and then we have some, um occlusive cosmetics. So exclusive cosmetics. Um, not all the cosmetics they are nice to the skin, even if they look fine. So, um, their structure is not correct. Um, So some of them should be called comedogenic, which means, like, they should be suitable for for skin. They do not cause plugging or occlusion of the skin and very important washing. Um uh, cosmetics early on, the on the face once it's not needed. That's why we do not recommend, like sleeping with makeup and stuff like this, um, hypoglycemic diet. And also, you have the polycystic ovarian syndrome PCOs. Um, um, have you guys seen patients with polycystic ovarian syndrome? Or have you heard of it? Yeah, it's very common. Yeah, very common. Correct. And then you'll you'll see patient's. Some of them have her citizen I'm or hormonal disturbances. Or if they have minister irregularities and also on top of that, they would have acne. So, um, their treatment maybe just similar to normal acne Or sometimes we can add also, um, other medications such as or conservative pills or even spironolactone. Now presentations. Um, there is a non inflammatory stage, which is the initial stage, which we have the comedones and then the inflammatory stage. When things get even worse, which is you. They would develop small, popular's or even they might contain past, so these are called postural. And then, if it gets bigger and more severe, it would develop nodules. Unfortunately, when things get worse, when they resolve, they will form acne, scarring, acne. Scarring can be caused by the severity of acne, or even when they pick up. You know, they just pick off their arm lesion's and then they keep doing this. This would cause scarring, actually, and you will see a lot of patient's. They have scarring, and this treatment of that scarring really difficult. It's not. Not easy, and then some might develop post inflammatory hyperpigmentation or hyperpigmentation. Depends very, um, important is the psychological and psychosocial with all skin presentations. It's very important to assess how this situation is affecting the patient from the psychological psychosocial family. Um, where all these very important to assess with the with the patient's? Because actually, we can help them, Um, and then we can refer them to the G P or steps of well, being something like this. So these might be helpful just to spend a few minutes with the patient to assess and I will connect that to something else, which is the treatment as a threat knowing. But, um, once we reach it now we have types of acne. Um, it could be mild, moderate, severe or even very severe. And it depends on the lesion's as usually, Um, sometimes you can just assess it clinically when you see the patient's and see the surface area that's involved. And what are the types of, um, acne lesions? Are they inflammatory or non inflammatory? As it's mentioned, you know, to assessment tools are very beneficial. D l Q. I. So we would know how this is affecting the patient's from their point of view. And from our point of view, you can just do cardi, which is the Cardiff Acne Disability Index. This is a photo of it. Don't worry about this number. You can just do your story from there, and here it tells you the grade of your score. Nothing mild, moderate or severe. So far, so good. Any questions? No. Okay, now treatment like any other skin condition. Lifestyle changes. And, as you can see most of, um, skin problems, we talk about lifestyle changes because it's just skin and lifestyle. They just go hand and hand together. Sometimes it's things that we do to our health that can affect our skin. That's why it's very important. So avoiding, including cosmetics and very, very, very important. Avoid popping Lesion's. That's one of the most important advice to tell your patient's because what they do, they just press them and all that pause and all these problems, which is wrong when the Because popping them and picking them this would cause, um, risk of infection, risk of scarring. Um, and we have treatment wise. So have you guys heard of any of these treatments such as benzoyl peroxide as, like, asset or different or tretinoin anything? Yeah. Which one you heard, though, Um, train. Oh, in at benzoyl peroxide. Yeah. So it's usually the first line of treatment. They use benzoyl peroxide, which is, um, effective, but it can be irritant as well. Um, so not all patient's like it. And sometimes when there is no response, then we just up the treatment to a tretinoin or different. Also, we would use and be aware that treatment response would take time. So unfortunately, patient's would stop using the treatment after a couple of weeks time. So when we cancel them, we say treatment would take months, not not weeks nowadays. So they should be fully aware that treatment will take a long time until there is improvement and needs sometimes just continuation. No. Yes. All right. I just wanted to ask questions come up about whether, um, acne can sort of come on, just be treated quite acutely and then just disappear after a week or so Or is it more of a chronic thing? Know it takes time. It takes time to improve. Uh, most of the times, it takes time to improve in depending if there is a positive fact that it might improve quickly. But especially like if we have, like, a teenage without any positive fact, that it just happens like any other teenage that happened. Uh, and, um, it takes time, especially if there are other limiting factors, such as they would pop up there. The lesion's, maybe they have PCOS. Maybe they have formal disturbances. Hypoglycemic diet. Also, these are you know, uh would limit your your treatment. But ideally, when you use the creams, it takes time to improve even whatever modality are using treatment of acne months. It's not. It's not a matter of weeks or or days, which I'm gonna explain in the moderate and the moderate. We can use a combination, that combination. It could be a topical combination or a topical with oral okay, or maybe just oral so you can see sometimes patient's. And when you do G P practice, they would just start them on llama cycling. And then they give them llama cycling in four months. There is some improvement in the beginning. Then they stop the treatment. Everything comes back, or even there is no improvement at all. Now, at that point, it's better to combine things. So if you go back just one step backwards, we either combine um, any of the mild treatment here. Mild treatment line. We can combine them with topical antibiotics, one of very beautiful combinations which are really like as track Langil patient's. They have some good response for multi moderate acne. I had some positive feedbacks about it. It's basically clindamycin and tretinoin. Then if your head of Epiduo as well, which is adapalene and benzoyl peroxide, Um, this one is more irritant. So what we tell the patient's because they want, they use them. They just immediately stop after a week or two. And this is not good. So we just need to build a good relationship. We tell them, start using them once or twice a week at night, then gradually increase using them after a week or two. Once you feel it's better, then start using them maybe three times. Then increase it to four and then increase it every day and carry on with it and then see how it goes after, like 34 months time if things are better. So that is also one way around those medications. Most of these topical treatments there are written to the skin. Like, for instance, we have the Tretin int. They can cause dryness, irritation, redness of the skin, Um, and then the their skin will will become dry and flaky. They should be fully aware of that. So part of your acne treatment is not just prescribing treatment is counseling them. Half of the consultation is just counselling them about the the treatment options. These are very important steps, Um, and again you can combine um, any of the topicals with the oral antibiotics such as llama cycling. You can combine it with a Dapple in or if you want, sometimes for difficult cases, you can combine even trickling with llama cycling. We did such combination, so it depends again. You need to tell you all your patient's I'm giving you an oral antibiotics or putting on your face. Um, threaten him with the clindamycin. Be aware of that one. Okay? And then we need to tell them their side effects as well. Very important is telling the side effects. Never, ever hide anything from the patient, especially activations. They need, You know, every single thing, because they would stop their treatment very quickly. And then once they stop, it's It's very difficult to restart the cycle. You need to start from the from the beginning and have new consultation and, um, explain things further. We have, yes, sorry, we've just got two questions. So, firstly, if someone's got like popular Bastion, every lesion's, um, that looks like acne. But then I guess, you know, disappear within, like, a couple of weeks. What? What sort of differentials would we have for that if it wasn't acne? It's difficult to say what is unless it's seemed to be honest. It could be just a question. Maybe an infected hair follicle there. Uh, when it when it's get infected, it becomes really big and like a like a popular there. There is a differential diagnosis of acne, which is not popular pasture, but, um, do we hope that can could look like like, a popular pasture? Very, very few lesions that disappear quickly if they look like acne, unless something infected that happens. They're like infection of the hair. Follicle itself can look like this because we are dealing with acne is basically pilosebaceous unit. Uh, and, um, another question is, at what age would you expect hormonal acne to have stopped in males and females before it becomes problematic in adulthood? Uh, sorry. So at what age would we expect? Hormonal acne? Um, like caused by puberty to stop in males and females. There is no age limit. So some people say once you become an adult like, especially once you enter your twenties, it should improve. But I've, uh, telling you from clinical point of view, like clinical practice, not just reading. So you can You can still see an inpatient when they are like 27 or even 30 or 35. You will have what's called adult acne. Or some, um, I have, like a couple of patient's. Actually, they're actually improved. And then after 30 acne just came back. But it was way, way mild, milder than than before, which was treated with topicals only, and it was very successful quickly. Um, so usually things would improve by the twenties, hopefully, but there is a possibility it can carry on. So there is no, like certain age limit. Understood. Thank you. No worries. And then lastly have as of threatening when if you heard of it. Guys, have you heard about as a threat now? And I'm quite sure everyone about it. Okay, it's called Truvada Threaten. It's the bread and butter of acne, but it comes with a price. The price is side effects, so we need to tell the patient's Definitely definitely they can't be pregnant, and then they should opt for pregnancy prevention program. And then they need to have two forms of form contraception, and if they decided not to go through it, they need to sign a form for it as well. Um, also, um, they need to be aware of, um, some of the side effects. So a lot of patient's, they come to the clinic and they said, I've Googled it And then they said it can cause depression, so you need to explain to them that it's not every patient on it. With develop depression, it can cause, um um, some mental health issues, um, it's not necessarily to be severe, Um, and we will monitor the patient's while they're on the treatment when they come for their visits. Even if it's over the phone call consultation, we ask them. Have you noticed any behavioral changes? Do you feel that your mood is getting worse? Anyone else in the family notice? Yeah, Your mood is different. Your personality is different. So once that happened, we might reduce the dose we might discuss with psychologist as well. Another dilemma is that when a patient comes to, they already have mental health diagnosis. Already, they are diagnosed with mild, moderate or severe depression. They're already on antidepressant again. You need to have an open and really honest discussion with them. What could be the side effects? Sometimes you even have to contact the psychiatric. You refer to them. And you say I have this patient. They are under your care. They have severe acne. I'm planning to start them. This those etcetera, etcetera. Then you wait for them to give you the green light. One of the side effects as well is they can have some joint pains. Please let them know, especially for gym enthusiasts and patient's who will do running and cycling. Please let them know that initially they might have some joint problems, so they might feel tired, and then they can't do their exercise. And I have seen patients. They stop the treatment because of that. And again, the treatment is a cumulative dose, and it can be for a few months time. Few blood investigations either three or four times across the treatments, period. And then it will be according to the body weight, um, two, um, in a formula. And then females. We usually give them the treatment, um, each month. And then also, we need to have a negative pregnancy test before we sign them. Next, uh, prescription. Um, is that help? In terms of as a tretinoin? Of course, it does have, like, further side effects and how it shouldn't be combined with Detrol Cycling's If you guys know from your medicine because it's if you combine things together, it can increase intracranial pressure. So you can't give both of them together that recycling and as a tretinoin together. If you remember from your medicine as well. Any questions? No, we're good. Get okay. Uh, let's see. We do have Oh, yeah. Any questions? I think I'm finished. Sorry. Uh, my name is Oh, gosh, I'm 20 minutes of of time. So hopefully the session was, um, informative to you guys. Too much information. I try to make it as easy as possible. You can pick and choose what you wanna use for now and how it helps you in your practice. You can use some of this information.