Common Skin Problems

Last updated 1 Jun 2026 · Dermatology

📋 Key Information Summary

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Atopic dermatitis (eczema) is the most common inflammatory skin condition in Australian children, affecting ~20% of infants; the hallmark is chronic, relapsing pruritic dermatitis with flexural predominance and a personal/family history of atopy.
Trigger management (irritants, aeroallergens, food allergens in selected cases, climate extremes, stress) is as important as pharmacotherapy in atopic dermatitis; written eczema action plans improve adherence and outcomes.
Emollient therapy is the foundation of eczema management — prescribe liberal, frequent application (≥250 g/week for children) and re-bathe using the "soak and seal" method.
Topical corticosteroids (TCS) remain first-line anti-inflammatory therapy; match potency to site and severity — mild (face, flexures), moderate–potent (trunk, limbs); short courses of potent TCS are safer than prolonged use of weak TCS on active disease.
Contact dermatitis must be distinguished as irritant (non-immune, ~80%) versus allergic (type IV delayed hypersensitivity, ~20%); allergen identification requires patch testing, available through dermatology referral.
Common Australian contact allergens include nickel, fragrances, preservatives (methylisothiazolinone), rubber accelerators, and hairdressing chemicals; occupational dermatitis is compensable under state WorkCover schemes.
Psoriasis affects ~2.5% of Australians; chronic plaque psoriasis is most common, but always screen for psoriatic arthritis (~30% develop joint disease) and cardiovascular/metabolic comorbidities.
Seborrhoeic dermatitis is caused by Malassezia overgrowth; treat with ketoconazole shampoo/cream, ± low-potency TCS for flares; distinguish from scalp psoriasis and tinea capitis.
Pityriasis alba is a common, self-limiting hypopigmented patch in children — reassure families, use emollients, and avoid unnecessary antifungal or steroid overtreatment.
Lichen simplex chronicus arises from the itch–scratch cycle; break the cycle with potent TCS under occlusion, behavioural strategies, and treat any underlying dermatosis.
Rosacea is a chronic facial condition with erythema, papulopustules, phymatous changes, or ocular involvement; first-line topical therapy includes metronidazole, azelaic acid, or ivermectin; low-dose doxycycline (40 mg modified-release) for moderate–severe papulopustular disease.
Infection is a major complication of eczema — Staphylococcus aureus colonises >90% of eczematous skin; treat secondary bacterial infection with topical mupirocin or oral flucloxacillin; suspect eczema herpeticum (HSV) as a dermatological emergency requiring systemic aciclovir.
Aboriginal and Torres Strait Islander Australians in remote communities have higher rates of skin infections, scabies, and post-inflammatory pigmentary change; culturally appropriate education, accessible primary care, and community-based healthy skin programs (e.g., One Disease) are essential.

Introduction & Australian Epidemiology

Common skin problems are among the most frequent presentations in Australian general practice, accounting for approximately 15–20% of all consultations. Dermatological conditions span a wide spectrum from benign, self-limiting disorders (e.g., pityriasis alba) to chronic, relapsing inflammatory diseases (e.g., atopic dermatitis, psoriasis) that profoundly affect quality of life, sleep, school and work attendance, and mental health.

Accurate diagnosis is the cornerstone of effective management. Many inflammatory dermatoses share overlapping features (erythema, scale, pruritus), and a systematic approach — combining history (onset, distribution, aggravating/relieving factors, atopic history, occupation), morphology, and appropriate investigations — reduces diagnostic error and unnecessary polypharmacy.

Australian Burden of Disease

Condition	Estimated Australian Prevalence	Peak Age Group	Key National Data Source
Atopic dermatitis	~20% of children; ~10% adults	Infancy–childhood onset	National Health Survey; ASCIA
Contact dermatitis	~8% lifetime (occupational most common)	Working-age adults	Safe Work Australia; ASCIA
Psoriasis	~2.5%	Bimodal: 20–30 yr & 50–60 yr	PSA Australia; AIHW
Seborrhoeic dermatitis	~3–5% adults	Adults; infants (cradle cap)	Clinical estimates
Rosacea	~2–5% adults (fair skin predominant)	30–50 years	ARA; clinical estimates
Pityriasis alba	~5–10% of children	3–16 years	Clinical estimates

Skin conditions impose a substantial economic burden on the Australian healthcare system. The direct cost of atopic dermatitis alone exceeds AUD 1.5 billion annually, including pharmaceutical, medical, and hospital costs. Indirect costs — lost productivity, carer burden, and psychosocial impact — are equally significant but harder to quantify. Psoriasis is independently associated with a 1.5–2-fold increased risk of cardiovascular disease, metabolic syndrome, and depression, requiring a holistic, multidisciplinary management approach.

Atopic Dermatitis (Eczema)

Atopic dermatitis (AD) is a chronic, relapsing, pruritic inflammatory skin condition arising from a complex interplay of epidermal barrier dysfunction, immune dysregulation (Th2-predominant), microbial colonisation, and environmental triggers. It is the most common inflammatory skin disease in Australian children and frequently persists into or begins in adulthood.

Diagnostic Criteria (UK Working Party / Hanifin & Rajka)

Diagnosis is clinical. The UK Working Party criteria (validated in Australian populations) require an itchy skin condition plus three or more of:

History of flexural involvement (antecubital/popliteal fossae, neck, wrists, ankles)
Personal history of asthma or allergic rhinitis (or first-degree relative if <4 years)
Generalised dry skin in the past year
Onset before age 2 years (not used if child is <4 years)
Visible flexural dermatitis (or dermatitis of cheeks/forehead and outer limbs in children <4 years)

Trigger Factors

Trigger Category	Examples	Management Strategy
Irritants	Soaps, detergents, wool, fragrances, chlorine	Soap-free washes (QV, Cetaphil); cotton clothing; avoid fabric softeners
Aeroallergens	Dust mites, pollen, pet dander, mould	Dust mite covers; HEPA filters; evidence for allergen avoidance is modest
Climate	Low humidity, heat, sweating, air conditioning	Humidifiers in winter; cool cotton clothing; air-conditioned environments in Australian summers may worsen xerosis
Infections	S. aureus colonisation, HSV (eczema herpeticum)	Antiseptic washes (triclosan, bleach baths 0.005% sodium hypochlorite twice weekly); prompt antiviral for suspected HSV
Food allergens	Egg, cow's milk, peanut, wheat (relevant in infants with moderate–severe AD and immediate-type reactions)	Specialist allergist referral; avoid blanket elimination diets — nutritional risk in paediatric populations
Psychological stress	Exam stress, family disruption, anxiety/depression	Psychological support; mindfulness; address sleep disruption

Management — Stepwise Approach

Management follows a step-up/step-down model aligned with the ASCIA Eczema Plan and Australian Therapeutic Guidelines:

Emollients & Education

Foundation of all therapy. Liberal, frequent application (≥250 g/week children, ≥500 g/week adults). Soap-free cleansers. Written eczema action plan. Bathing: lukewarm water, 5–10 min, "soak and seal" (apply emollient within 3 min).

Mild Topical Corticosteroids

Hydrocortisone 1% for face, neck, flexures. Apply once daily to active eczema until clearance (usually 7–14 days), then reduce to weekend maintenance ("weekend pulse") if flares are frequent.

Moderate–Potent TCS & Topical Calcineurin Inhibitors

Mometasone furoate 0.1% or betamethasone valerate 0.1% for trunk/limbs. Tacrolimus 0.1% ointment (adults) or 0.03% (children ≥2 years) for steroid-sparing on face/neck/long-term maintenance.

Specialist Referral & Systemic Therapy

For severe, refractory disease: dermatology referral for phototherapy (narrowband UVB), ciclosporin, methotrexate, azathioprine, or biologic agents (dupilumab — PBS Authority Required for severe AD).

Key Medications — Atopic Dermatitis

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Hydrocortisone 1% Cream

Sigmacort® · Locoid® · Mild TCS

Adult dose Apply thinly to affected areas once daily for 7–14 days; weekend maintenance for frequent flares

Paediatric dose Same as adult; safe from birth on face/flexures

Renal / Hepatic No adjustment required (minimal systemic absorption)

PBS status ✔ PBS General Benefit

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Mometasone Furoate 0.1% Cream/Ointment

Elocon® · Moderate TCS

Adult dose Apply once daily for up to 14 days on trunk/limbs; avoid face

Paediatric dose ≥2 years: same as adult; use for ≤7 days in children

Renal / Hepatic No adjustment required

PBS status ✔ PBS General Benefit

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Tacrolimus Ointment 0.03% / 0.1%

Protopic® · Topical Calcineurin Inhibitor

Adult dose 0.1% ointment BD to affected skin until clearance; reduce to once daily or maintenance (2–3 times/week)

Paediatric dose 0.03% ointment BD for children 2–16 years; not for use in children <2 years

Renal / Hepatic No adjustment required

PBS status ⚠ PBS Authority Required — for atopic dermatitis unresponsive to TCS

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Dupilumab

Dupixent® · Monoclonal antibody (anti-IL-4Rα)

Adult dose Loading 600 mg SC (two 300 mg injections), then 300 mg SC every 2 weeks

Paediatric dose ≥6 years: weight-based dosing (100–200–300 mg SC every 2–4 weeks)

Renal / Hepatic No dose adjustment; caution in severe hepatic impairment

PBS status ⛔ PBS Authority Required (Specialist) — severe atopic dermatitis, failed conventional therapy

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Eczema Herpeticum — Dermatological Emergency: Widespread, monomorphic, punched-out erosions with haemorrhagic crusting in a patient with eczema. May be accompanied by fever, malaise, and lymphadenopathy. Requires immediate systemic aciclovir (adults: 5 mg/kg IV TDS or 800 mg PO 5 times/day; children: 500 mg/m² IV TDS) and urgent dermatology/ID referral. Risk of viraemia, organ involvement, and death if untreated.

Bleach Baths for S. aureus Decolonisation

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Add 12 mL of 6% sodium hypochlorite (plain bleach) to a baby bath (~10 L) or ¼ cup (~60 mL) to a full adult bathtub. Soak for 5–10 minutes, 2–3 times per week. Rinse off and apply emollient immediately. Evidence supports reduced severity and frequency of infected flares. Advise patients to avoid the eyes and broken/weeping skin.

Contact Dermatitis

Contact dermatitis is an inflammatory skin response to an external agent. It is broadly divided into irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). Correct classification is essential because management and prevention differ significantly.

Irritant vs Allergic Contact Dermatitis

Feature	Irritant Contact Dermatitis (ICD)	Allergic Contact Dermatitis (ACD)
Mechanism	Direct cytotoxic effect (non-immune)	Type IV delayed hypersensitivity (T-cell mediated)
Proportion	~80% of contact dermatitis	~20% of contact dermatitis
Onset	Hours to days; first exposure sufficient	12–72 hours; requires prior sensitisation
Distribution	Site of contact; well-demarcated; may be diffuse (hands)	Site of contact but may spread; geometric/linear patterns
Morphology	Erythema, dryness, fissuring, burning/stinging (>pruritus)	Erythema, vesicles, papules, intense pruritus
Common causes (Australia)	Hand-washing, detergents, solvents, cement (chromate), wet work (healthcare workers, hairdressers, cleaners)	Nickel (jewellery), fragrances, methylisothiazolinone (MI — wet wipes, paints), rubber accelerators, p-phenylenediamine (hair dye), epoxy resin
Investigation	Clinical diagnosis; occupational assessment	Patch testing (dermatology referral — baseline series + relevant extras)

Management of Contact Dermatitis

General Principles

Identify and avoid the causative agent — this is the single most effective intervention.
Protective measures: Appropriate gloves (nitrile > latex for chemical exposure; cotton liners reduce sweating); barrier creams have limited evidence but may help in mild ICD.
Emollients: Frequent application to restore barrier function (as per eczema management).
Topical corticosteroids: Potency matched to body site and severity — potent TCS (betamethasone valerate 0.1%) for hands/body; mild–moderate TCS for face. Treat until clearance.
Occupational dermatitis: Refer to dermatologist for patch testing and formal assessment. Notify employer. Claims through WorkCover (state-specific). Refer to occupational physician if persistent or requiring workplace modification.
Severe/refractory cases: Short course of oral prednisolone (0.5–1 mg/kg/day, taper over 2–3 weeks); dermatology referral for patch testing; consider azathioprine or ciclosporin for chronic, unavoidable occupational exposure.

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Methylisothiazolinone (MI) epidemic: MI is a preservative found in many consumer products (wet wipes, shampoos, liquid soaps, paints, adhesives). It is now one of the most common contact allergens in Australia. A positive patch test to MI mandates careful product label reading — products labelled "MI-free" may still contain related isothiazolinones.

Psoriasis & Seborrhoeic Dermatitis

Psoriasis

Psoriasis is a chronic, immune-mediated inflammatory skin condition driven by Th17/IL-23 axis overactivity. It affects approximately 2.5% of Australians and is associated with significant physical and psychological morbidity. The most common form is chronic plaque psoriasis (psoriasis vulgaris), characterised by well-demarcated, erythematous, scaly plaques with silvery-white scale on extensor surfaces, scalp, sacrum, and umbilicus.

Clinical Subtypes

Subtype	Features	Management Approach
Chronic plaque	Symmetrical, well-demarcated plaques; elbows, knees, scalp, lumbosacral; Auspitz sign positive	Stepwise: emollients → topical (TCS, vitamin D analogues, combination) → phototherapy → systemic
Guttate	Small (<1 cm) droplet-shaped papules; trunk/proximal limbs; often post-streptococcal pharyngitis	Treat streptococcal trigger; often self-resolving (weeks–months); UVB phototherapy
Flexural (inverse)	Smooth, shiny, erythematous patches in axillae, groin, inframammary folds; minimal scale	Low-potency TCS; topical calcineurin inhibitors; antifungal if candida suspected
Pustular	Sterile pustules on erythematous base; localised (palmoplantar) or generalised (von Zumbusch — emergency)	Specialist management; acitretin, ciclosporin, or biologics; generalised requires hospital admission
Erythrodermic	>90% BSA erythema; risk of haemodynamic instability, hypothermia, infection	Emergency: hospitalisation, supportive care, systemic agents (ciclosporin, biologics)

Psoriasis Comorbidity Screening

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Psoriasis is a systemic inflammatory disease. Patients with moderate–severe psoriasis should be regularly screened for: psoriatic arthritis (~30%; use PEST or PASE questionnaire), cardiovascular risk factors (hypertension, dyslipidaemia, diabetes, obesity — treat as high cardiovascular risk), metabolic syndrome, depression/anxiety, non-alcoholic fatty liver disease, and chronic kidney disease. Referral to rheumatology if psoriatic arthritis suspected.

Topical Treatment of Psoriasis

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Betamethasone Dipropionate + Calcipotriol

Daivobet® / Enstilar® foam · Combination TCS + Vitamin D analogue

Adult dose Apply once daily to plaques for up to 4 weeks; courses may be repeated; ointment or foam formulation

Paediatric dose Daivobet ointment: ≥18 years only. Enstilar foam: ≥18 years only.

Renal / Hepatic No adjustment; avoid on >30% BSA (risk of hypercalcaemia with calcipotriol)

PBS status ⚠ PBS Authority Required — for plaque psoriasis

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Calcipotriol 50 mcg/g Ointment

Daivonex® · Vitamin D analogue

Adult dose Apply BD to plaques; onset 2–4 weeks; max 100 g/week

Paediatric dose ≥6 years: apply BD; max 50 g/week; monitor calcium

Renal / Hepatic Use with caution in renal impairment (hypercalcaemia risk)

PBS status ⚠ PBS Authority Required — for plaque psoriasis

Seborrhoeic Dermatitis

Seborrhoeic dermatitis is a common, chronic, relapsing inflammatory dermatosis affecting sebum-rich areas (scalp, face, chest). It is caused by overgrowth of Malassezia species (lipophilic yeast) and an abnormal immune response. In infants, it presents as "cradle cap" (thick, yellow, greasy scales on the scalp). In adults, it manifests as erythema and greasy scale on the scalp (dandruff), eyebrows, nasolabial folds, and presternal area.

Key Distinguishing Features from Scalp Psoriasis

Feature	Seborrhoeic Dermatitis	Scalp Psoriasis
Scale	Greasy, yellowish, waxy	Thick, silvery-white, dry
Borders	Poorly defined, diffuse	Well-demarcated, may extend beyond hairline
Distribution	Scalp, eyebrows, nasolabial folds, ears, chest	Scalp, extensor surfaces, sacrum, nails
Auspitz sign	Negative	Positive
Nail changes	Absent	Pitting, onycholysis, oil-drop sign

Treatment of Seborrhoeic Dermatitis

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Ketoconazole 2% Shampoo

Nizoral® · Antifungal (imidazole)

Adult dose Apply to wet scalp, leave 5 min, rinse; twice weekly for 2–4 weeks then once weekly maintenance

Paediatric dose Same as adult; avoid in infants <1 month

PBS status ✔ PBS General Benefit

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Ketoconazole 2% Cream

Nizoral® · Antifungal (imidazole)

Adult dose Apply BD to affected facial/chest skin for 2–4 weeks

Paediatric dose Same as adult

PBS status ✔ PBS General Benefit

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Lithium Gluconate 8% Gel

Epiduo alternative — e.g., lithium succinate ointment · Anti-inflammatory/antimicrobial

Adult dose Apply BD to facial erythema for 8 weeks (adjunct or alternative to TCS)

Paediatric dose Not recommended <18 years (limited data)

PBS status ⛔ Not PBS listed

Cradle Cap (Infantile Seborrhoeic Dermatitis)

Reassure parents: self-limiting, usually resolves by 6–12 months.
Apply mineral oil or olive oil to the scalp overnight to soften scales; gently brush with a soft toothbrush the next morning; shampoo with a gentle baby wash.
If persistent or widespread, use ketoconazole 2% shampoo (diluted) twice weekly.
Distinguish from atopic dermatitis of the scalp (which is pruritic, erythematous, and often involves other flexural sites).

Pityriasis Alba, Lichen Simplex Chronicus & Rosacea

Pityriasis Alba

Pityriasis alba is a common, benign condition in children and adolescents characterised by ill-defined, hypopigmented (not depigmented), slightly scaly patches, typically on the cheeks, upper arms, and trunk. It is more noticeable in darker skin tones (Fitzpatrick IV–VI) and may be confused with vitiligo or tinea versicolor.

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Key distinguishing feature: Pityriasis alba shows hypopigmentation (reduced melanin, still some pigment) whereas vitiligo shows depigmentation (complete loss of melanin — porcelain white). Pityriasis alba has a faint scale; vitiligo does not. Wood's lamp examination helps differentiate: pityriasis alba does not fluoresce, while active vitiligo shows bright white fluorescence.

Management

Reassurance: Self-limiting; repigmentation occurs over months but may recur.
Emollients: Liberal application to affected areas, especially after bathing.
Mild TCS: Hydrocortisone 1% cream once daily for 1–2 weeks if mildly erythematous or itchy (controversial — not always needed).
Photoprotection: Hypopigmented patches burn easily; apply SPF 50+ broad-spectrum sunscreen. Affected areas may persist as lighter patches that tan less readily.
Avoid: Unnecessary antifungal therapy (no evidence of fungal aetiology), potent steroids, and over-investigation.

Lichen Simplex Chronicus (Neurodermatitis)

Lichen simplex chronicus (LSC) is a localised, circumscribed area of lichenified (thickened, leathery) skin resulting from repeated rubbing and scratching — the "itch–scratch–itch" cycle. It commonly affects the nape of the neck, ankles, vulva, scrotum, and forearms. The lesion appears as a well-defined, erythematous or hyperpigmented plaque with exaggerated skin markings and lichenification.

Management

Break the itch–scratch cycle: This is the primary therapeutic goal.
Potent TCS under occlusion: Betamethasone valerate 0.1% ointment applied at night under plastic wrap or cotton gloves (hands) for 2–4 weeks. Alternatively, clobetasol propionate 0.05% for very thick plaques (short course, ≤2 weeks).
Emollients: Regular use to soften lichenified skin.
Sedating antihistamines at night: Promethazine 10–25 mg nocte or hydroxyzine 10–25 mg nocte — break the nocturnal scratch cycle.
Behavioural/psychological strategies: Habit-reversal training; stress management; cognitive behavioural therapy for severe, refractory cases.
Investigate underlying causes: Rule out atopic dermatitis, contact dermatitis, scabies, fungal infection, or cutaneous T-cell lymphoma (if atypical or refractory).

Rosacea

Rosacea is a chronic, relapsing inflammatory facial condition affecting approximately 2–5% of Australian adults, predominantly those with Fitzpatrick skin types I–II. It is characterised by flushing, persistent centrofacial erythema, papulopustules, telangiectasia, and in advanced cases, phymatous changes (rhinophyma). Ocular rosacea (gritty/burning eyes, blepharitis, meibomian gland dysfunction) affects up to 50% of patients.

Rosacea Subtypes (Standard Classification)

Subtype	Features	First-Line Treatment
Erythematotelangiectatic (ETR)	Persistent redness, flushing, telangiectasia; burning/stinging	Brimonidine 0.33% gel (Mirvaso®); avoidance of triggers; IPL/laser for telangiectasia
Papulopustular (PPR)	Persistent redness + papules and pustules (no comedones — distinguishes from acne)	Topical metronidazole 0.75% BD or azelaic acid 15% BD ± oral doxycycline 40 mg MR daily
Phymatous	Thickened, irregular skin surface (rhinophyma most common); sebaceous hyperplasia	Specialist referral for laser (CO₂, Er:YAG) or surgical debulking; isotretinoin may help early phyma
Ocular	Burning, gritty eyes; blepharitis; meibomian gland dysfunction; conjunctival hyperaemia	Lid hygiene; warm compresses; ophthalmology referral; oral doxycycline 50–100 mg daily

Rosacea Trigger Avoidance

Sun exposure (most common trigger in Australia — UV, infrared, visible light)
Alcohol, hot beverages, spicy foods
Extreme temperatures (hot/cold wind — relevant in Australian climate extremes)
Topical irritants (menthol, camphor, sodium lauryl sulphate)
Topical corticosteroids on the face (cause steroid-induced rosacea/perioral dermatitis — must avoid long-term use)

Key Medications — Rosacea

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Metronidazole 0.75% Cream/Gel

Rozex® · Topical nitroimidazole antibiotic

Adult dose Apply thin layer BD to affected facial skin; onset 3–4 weeks; continue for 9–12 weeks

Paediatric dose Not recommended <12 years (rosacea rare in children)

Renal / Hepatic Minimal systemic absorption; no adjustment required

PBS status ✔ PBS General Benefit

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Azelaic Acid 15% Gel

Finacea® · Anti-inflammatory, antimicrobial, keratolytic

Adult dose Apply thin layer BD to affected skin; onset 4–8 weeks

Paediatric dose ≥12 years: same as adult

Renal / Hepatic No adjustment required

PBS status ✔ PBS General Benefit

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Ivermectin 1% Cream

Soolantra® · Anti-inflammatory / anti-parasitic

Adult dose Apply once daily to affected facial skin; onset 4 weeks; continue for 3–4 months

Paediatric dose Not recommended <18 years

Renal / Hepatic No adjustment required

PBS status ⚠ PBS Authority Required — for papulopustular rosacea unresponsive to metronidazole/azelaic acid

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Doxycycline 40 mg Modified-Release (Sub-antimicrobial)

Oracea® · Sub-antimicrobial anti-inflammatory dose

Adult dose 40 mg modified-release PO daily (30 mg immediate + 10 mg delayed); 12–16 weeks

Paediatric dose ≥8 years: standard doxycycline 1–2 mg/kg/day (not modified-release); avoid <8 years (teeth staining)

Renal / Hepatic No dose adjustment; avoid in severe hepatic impairment

PBS status ⚠ PBS Authority Required — for moderate–severe rosacea

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Do NOT use potent topical corticosteroids on the face. Long-term use of TCS on facial skin causes steroid-induced rosacea, perioral dermatitis, skin atrophy, telangiectasia, and rebound flares upon withdrawal. If a patient presents with facial "eczema" that worsens with TCS, consider steroid-induced rosacea/perioral dermatitis — taper and stop TCS, and initiate appropriate rosacea treatment.

Investigations

Most common skin problems are diagnosed clinically. Investigations are reserved for atypical presentations, suspected contact allergy, exclusion of differential diagnoses, or monitoring of systemic therapy.

GP Access Skin swab (bacterial culture & sensitivity) For suspected secondary S. aureus infection in eczema. MBS Item 69310. Guides targeted antibiotic therapy in recurrent or resistant infections.

GP Access Skin scrapings for microscopy & culture (fungal) For suspected tinea, pityriasis versicolor, or exclusion of fungal aetiology in scaly patches. MBS Item 69310.

GP Access Wood's lamp examination UV light (365 nm) examination; useful for differentiating vitiligo (bright white fluorescence) from pityriasis alba (no fluorescence), and detecting some fungal infections. Available in most GP practices.

Specialist Patch testing (TRUE Test / extended series) Gold standard for identifying contact allergens in allergic contact dermatitis. Performed by dermatologist or occupational physician. Requires 48–96 hour delayed reading. MBS Item 12300 (dermatology consultation).

Specialist Skin biopsy (punch/shave) For atypical or refractory lesions, suspected cutaneous lymphoma, or diagnostic uncertainty. Dermatology referral. MBS Item 30071.

Essential Swab for HSV PCR (Tzanck alternative) Essential for suspected eczema herpeticum. PCR is the test of choice (sensitivity >95%). Request HSV-1/2 PCR from vesicle base swab.

Special Populations

🤰 Pregnancy

Eczema: May flare during pregnancy. Emollients are safe. Mild–moderate TCS preferred (hydrocortisone, mometasone). Avoid potent TCS in first trimester. Tacrolimus: limited data, avoid if possible (category C). Breastfeeding: TCS safe on nipple area if washed off before feeds.

Psoriasis: Calcipotriol is category B3 — avoid large areas. Methotrexate is absolutely contraindicated (teratogenic). Biologics: limited data; discuss with dermatologist/rheumatologist.

Rosacea: Metronidazole topical is generally considered safe. Oral tetracyclines (doxycycline) are contraindicated in pregnancy. Azelaic acid 15% topical is category B1 — preferred option.

👶 Paediatrics

Eczema in infants: Common from 3 months. Emollients are the mainstay; soap-free washes. Hydrocortisone 1% is safe from birth. Tacrolimus 0.03% from age 2 years only. Suspect food allergy if moderate–severe eczema with immediate-type reactions — refer to allergist.

Cradle cap: Self-limiting; oil application + gentle removal. Ketoconazole shampoo if persistent.

Pityriasis alba: Very common 3–16 years; reassure parents. Emollients + photoprotection. More noticeable in darker skin tones — higher referral rates for vitiligo concern.

Rosacea: Rare in children; if papulopustules in a child, consider periorificial dermatitis or demodicosis. Avoid tetracyclines <8 years (dental staining).

👴 Elderly

Xerosis (dry skin): Extremely common; compounded by polypharmacy (diuretics), low humidity, and hot baths. Liberal emollients as baseline. May mimic or coexist with eczema (asteatotic eczema).

Psoriasis: New-onset or severe psoriasis in the elderly warrants assessment for underlying malignancy (paraneoplastic) and comorbidities. Renal function must be checked before initiating ciclosporin; metformin interaction with ciclosporin.

Skin thinning: Potent TCS must be used with extreme caution; atrophy risk is higher. Prefer moderate TCS (mometasone) or topical calcineurin inhibitors for maintenance.

🫘 Renal Impairment

Calcipotriol: Use with caution in CKD — risk of hypercalcaemia. Monitor serum calcium.

Ciclosporin: Nephrotoxic — requires careful renal monitoring (Cr, eGFR, BP). Contraindicated if eGFR <30 mL/min. Ciclosporin dose reduction if eGFR 30–60.

Methotrexate: Contraindicated if eGFR <30 mL/min; dose reduction if eGFR 30–60 mL/min.

🫁 Hepatic Impairment

Methotrexate: Contraindicated in significant hepatic impairment (Child-Pugh B/C). Avoid in alcohol excess or chronic liver disease. Monitor LFTs every 2–4 weeks during initiation.

Acitretin: Contraindicated in hepatic impairment. Monitor LFTs and lipids. Teratogenic — effective contraception for 3 years after cessation in women of childbearing potential.

Doxycycline: Avoid in severe hepatic failure.

🛡️ Immunocompromised

Eczema herpeticum risk: Higher in patients on immunosuppressive therapy. Patients on ciclosporin, methotrexate, or biologics should be counselled about infection risk.

Biologics: Dupilumab does not cause general immunososuppression (targeted IL-4/IL-13 blockade). TNF inhibitors (used in psoriasis/arthritis) carry infection risk — screen for latent TB, hepatitis B/C before initiation.

Seborrhoeic dermatitis: May be more severe in HIV/AIDS — consider as an early marker of immunosuppression.

Aboriginal and Torres Strait Islander Health

Skin disease burden

Skin conditions are among the top five reasons for presentation to Aboriginal Community Controlled Health Organisations (ACCHOs). Eczema, scabies, impetigo, tinea, and post-inflammatory dyspigmentation are disproportionately prevalent, particularly in remote Northern Territory and Western Australian communities. Scabies prevalence in some remote communities exceeds 50% in children under 5 years.

Scabies & secondary infection

Sarcoptes scabiei infestation is a major driver of secondary bacterial infection (S. aureus, S. pyogenes) in remote communities. The Healthy Skin Project (One Disease charity) advocates for community-wide ivermectin mass drug administration (MDA) programs. Topical permethrin 5% remains first-line for individual treatment, but MDA with oral ivermectin (200 mcg/kg, 2 doses 1 week apart) has shown efficacy in cluster-randomised trials in the Northern Territory.

Access to dermatology

Specialist dermatology services are extremely limited outside major cities. Telehealth dermatology (store-and-forward and real-time video) has been implemented through programs like Dermatology for Rural and Remote Australia (DRRA) and the Northern Territory Remote Dermatology Service. GPs in ACCHOs are encouraged to use teledermatology for diagnostic uncertainty and patch testing referrals.

Cultural & environmental factors

Overcrowded housing, limited water supply for frequent washing, high ambient temperatures, and community mobility patterns all affect skin disease transmission and treatment adherence. Emollient programs (bulk distribution of sorbolene/glycerine cream) and community health worker–led "healthy skin days" improve engagement. Treatment messages must be delivered in first languages with culturally appropriate visual resources.

Post-inflammatory pigmentary change

Aboriginal and Torres Strait Islander peoples with darker skin tones (Fitzpatrick IV–VI) are at significantly higher risk of post-inflammatory hyperpigmentation and hypopigmentation following skin inflammation. Conditions like pityriasis alba and post-eczema hypopigmentation may cause significant distress. Photoprotection (SPF 50+ broad-spectrum sunscreen) is essential but underused; culturally specific sun safety messaging is needed. The Australian Indigenous HealthInfoNet provides resources for health workers.

Rheumatic fever & guttate psoriasis

Acute rheumatic fever (ARF) rates in Aboriginal and Torres Strait Islander children in northern/central Australia are among the highest globally. Group A streptococcal pharyngitis can trigger guttate psoriasis — ensure throat swabs and appropriate antibiotic treatment where indicated. ARF and rheumatic heart disease screening programs (RHDAustralia) should be integrated into skin health assessments.

📚 References

1. Australasian Society of Clinical Immunology and Allergy (ASCIA). ASCIA Eczema (Atopic Dermatitis) Clinical Update. Sydney: ASCIA; 2023. Available from: https://www.allergy.org.au/
2. Weidinger S, Beck LA, Bieber T, Kabashima K, Irvine AD. Atopic dermatitis. Nature Reviews Disease Primers. 2018;4(1):1.
3. National Health and Medical Research Council (NHMRC). National Statement on Ethical Conduct in Human Research. Canberra: NHMRC; 2023. [Context: Australian clinical research standards underpinning guideline evidence quality.]
4. Johansen JD, Aalto-Korte K, Agner T, et al. European Society of Contact Dermatitis guideline for diagnostic patch testing — recommendations on best practice. Contact Dermatitis. 2015;73(4):195–221.
5. Armstrong AW, Read C. Pathophysiology, clinical presentation, and treatment of psoriasis: a review. JAMA. 2020;323(19):1945–1960.
6. Psoriasis Australia. About Psoriasis. Melbourne: Psoriasis Australia; 2023. Available from: https://www.psoriasis.org.au/
7. Borda LJ, Wikramanayake TC. Seborrheic dermatitis and dandruff: a comprehensive review. Journal of Clinical and Investigative Dermatology. 2015;3(2).
8. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee. Journal of the American Academy of Dermatology. 2018;78(1):148–155.
9. Australian Indigenous HealthInfoNet. Skin Conditions Among Aboriginal and Torres Strait Islander People. Perth: Edith Cowan University; 2023. Available from: https://healthinfonet.ecu.edu.au/
10. Romani L, Steer AC, Whitfeld MJ, Kaldor JM. Prevalence of scabies and impetigo worldwide: a systematic review. The Lancet Infectious Diseases. 2015;15(8):960–967.
11. One Disease. The Healthy Skin Project: Eliminating Crusted Scabies in Aboriginal Communities. Darwin: One Disease; 2023. Available from: https://onedisease.org/
12. Safe Work Australia. Work-Related Dermatitis: Guidance Material. Canberra: Safe Work Australia; 2022.
13. Royal Australian College of General Practitioners (RACGP). Skin Cancer and Skin Conditions in General Practice — Clinical Guide. Melbourne: RACGP; 2022.
14. Sidbury R, Tom WL, Bergman JN, et al. Guidelines of care for the management of atopic dermatitis. Journal of the American Academy of Dermatology. 2023;89(3):553–571.
15. Australian Institute of Health and Welfare (AIHW). Skin Cancer in Australia. Canberra: AIHW; 2023. [Context: Australian skin disease epidemiology and burden of disease data.]

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).