2 - Atopic & Contact Dermatitis Flashcards
What are topical corticosteroids effective at treating?
Skin conditions with hyperproliferation, inflammation, and immunologic involvement
What do topical corticosteroids provide symptom relief for?
Itching and burning
How many categories of topical corticosteroids are there?
7, ranging from low to very high potency
How do topical corticosteroids get rid of inflammation?
By decreasing formation, release, and activity of inflammatory mediators
How do topical corticosteroids cause vasoconstriction?
Prevent cell migration and decrease access to affected area, thereby reducing swelling
How can topical corticosteroids be immunosuppressive?
Inhibit action of cells involved in the immune response
How are topical corticosteroids anti-proliferative?
They interfere with DNA synthesis and mitosis and obstruct fibroblast activity and the development of collagen
What does hyperproliferation mean?
Rapid cell turnover
What is the main guideline for topical corticosteroids?
The least potent effective dosage should be used for the shortest duration to reduce the likelihood of adverse effects
Which areas of the body is low potency topical corticosteroids used?
Thin skin areas such as face and folds
Which areas of the body is medium potency topical corticosteroids used?
Medium thickness skin such as body and scalp
Which areas of the body is high potency topical corticosteroids used?
Thick skinned areas such as palms and soles
Response to topical corticosteroids depends on _____
Condition being treated
What is the difference between clobetasol and clobetasone?
- Clobetasol is an ultra-high potency topical corticosteroid
- Clobetasone is a moderate potency topical corticosteroid
____ affects potency of topical corticosteroids
Formulation
Can the same concentration of a steroid have different potencies?
Yes, depending on vehicle
What is significant about propylene glycol in topical corticosteroids?
Propylene glycol enhances absorption creating an ultra-high potency
What are advantages to topical corticosteroid ointments?
- Occlusive
- Provide lubrication
- Good for dry, scaly lesions
What is a disadvantage of topical corticosteroid ointments?
Greasy, which tend to decrease patient compliance
What are advantages to topical corticosteroid creams?
- Good lubrication
- Cosmetically appealing
What are disadvantages to topical corticosteroid creams?
- Generally less potent than ointments
- Often contain preservatives
Which type of topical corticosteroids are helpful in hairy areas?
Lotions or gels
What are common adverse effects of topical corticosteroids?
Dryness, itching, burning, and local irritation
How often should you apply a topical corticosteroid?
1-2 times daily
Does applying a topical corticosteroid more often improve the results?
No
What is an advantage to less frequent application of topical corticosteroids?
Reduced risk of side effects
____ may be helpful to prevent rebound flares where potent or prolonged treatment is needed
Tapering (decrease potency and/or decrease frequency)
What are the 3 OTC treatments for atopic or contact dermatitis?
1) Hydrocortisone 0.5%
2) Hydrocortisone 1.0%
3) Clobetasone butyrate 0.05%
What is the age group for OTC hydrocortisone?
Anyone over 2 years
What is the duration of treatment for hydrocortisone?
7-14 days
What schedule is hydrocortisone 0.5%
1 or 3
What schedule is hydrocortisone 1.0%
1 or 3
What schedule is clobetasone butyrate 0.05%?
2
What is the age group for OTC clobetasone butyrate?
Anyone over 12 years
What is the duration of treatment for clobetasone butyrate?
7 days
What are the 2 subcategories of contact dermatitis?
1) Irritant contact dermatitis
2) Allergic contact dermatitis
What causes irritant contact dermatitis?
When the skin undergoes mechanical or chemical trauma on exposure to an irritating substance
What causes allergic contact dermatitis?
Exposure to an allergen
What are symptoms of contact dermatitis?
- Inflammation, redness, itching
- Burning, stinging
- Vesicle and pustule formations
What is one significant difference between irritant and allergic contact dermatitis with respect to the cause?
- Everyone who is exposed to the irritant will experience a reaction
- Not everyone exposed to the allergen will have a reaction b/c not everyone has a sensitization to the antigen
What are symptoms of acute contact dermatitis?
Red, edematous papules which become vesicles that ooze if reaction is severe enough
What are symptoms of chronic contact dermatitis?
Secondary changes such as dryness, lichenification (formation of thick, leathery patches), pigment changes, and thickening
What is the primary symptom in acute and chronic contact dermatitis?
Itching
What are signs and symptoms of irritant contact dermatitis?
- Erythema
- Vesiculation and oozing
- Blistering
- Linear fashion
What are signs and symptoms of allergic contact dermatitis?
- Mild form similar to irritant
- Severe - edema in face, periorbital, and genital areas
When a patient presents with a red, inflamed area, what do you first want to do?
Rule out infection
What are common irritants for contact dermatitis?
- Poison ivy (aka rhus)
- Kiwi, bananas, peanuts
- Fertilizers and weed killers
- Cosmetics
- Latex
- Metals (nickel and copper)
- Lanolin
Poison ivy consists of __ leaflets
3
What is the allergen found in poison ivy?
Urushiol
Are men or women more frequently exposed to contact dermatitis?
Women because of cosmetic use
When do you want to refer for contact dermatitis?
- More than 30% of body
- Edema persists or increases within a few days
- Discomfort in genitalia
- Involvement of mucous membranes of mouth, eyes, nose, or anus
- Younger than 2
When do you want to refer for an acute case of contact dermatitis?
If it has been nonresponsive for a few days
When do you want to refer for a chronic case of contact dermatitis?
If it has been nonresponsive for 7-10 days
What is atopic dermatitis?
A genetic based, chronic relapsing skin disorder
When does atopic dermatitis usually begin?
In infants or early childhood
Who does atopic dermatitis affect the most?
Children
What is the cause of atopic dermatitis?
Unknown
What is the pathophysiology of atopic dermatitis?
- Chronic inflammatory skin disease associated with cutaneous and mucous membrane hyper-reactivity
- Most people have high levels of IgE
What is significant about atopic dermatitis presenting in infants?
It may be a prelude to the development of other atopic disorders later in life
What is the expected cause of atopic dermatitis?
Genetic impairment of epidermal barrier
What are signs and symptoms of atopic dermatitis?
- *Itching is always first symptom, which then leads to a rash
- Skin is dry and lesions are scaly; may be vesicular, weeping, or oozing
What is the typical location of atopic dermatitis in infants under 6 months?
Chest, face, and scalp
What is the typical location of atopic dermatitis in children under 2 years?
Scalp, neck, and extensor surface of extremities
What is the typical location of atopic dermatitis in children aged 2-6 years?
Neck, wrist, elbow, knee, hands, feet, and back of thigh
What is the typical location of atopic dermatitis in people over 12 years?
Flexors, hands and upper body
What is the diagnostic criteria for atopic dermatitis?
Itching and at least 3 of the following:
- onset before 2 years old
- history of skin crease involvement
- history of generally dry skin
- personal history of atopic disease
- visible flexural dermatitis
Is a pharmacist expected to diagnosis atopic dermatitis?
No, but we can suspect it and refer
What are the top 5 risk factors for atopic dermatitis?
1) Genetics
2) Environmental allergens
3) Climate
4) Sweating
5) Physiologic stress
When should you refer for atopic dermatitis?
- if the child is younger than 2 and hasn’t been diagnosed
- If dermatitis is acute and vesicular
- Appearance of infection
- Large area of body
- Severe condition with intense itching
How should you asses a patient for dermatitis?
- Ask questions regarding signs and symptoms, onset, progression, timeframe, location, and previous occurrence
- Determine urgency
- Medication history
What are the goals of treatment for atopic and contact dermatitis?
- Eliminate trigger factors or contact exposure to irritants and allergens
- Provide symptomatic relief wile decreasing skin lesions
- Implement preventative measures
- Develop coping strategies
What are some non-pharms for contact dermatitis?
- Immediately wash with soap and water
- Avoid or remove allergen
- Take cold soapless showers
- Avoid scrubbing affected area
- Remove and wash all clothing exposed to irritant/allergen
What is the recommended treatment of contact dermatitis?
- Identify and avoid irritant
- Wet compresses for 20 minutes 4-6 times/day
- Topical steroids (on a short term basis)
- May want to add an oral antihistamine
Why should topical anesthetics and topical antihistamines be avoided for contact dermatitis?
Can sometimes cause or aggravate the contact dermatitis
What is the recommended treatment of poison ivy?
- Shower after exposure
- Wash all items that have been exposed
- To treat the itch and rash apply topical corticosteroid and oral antihistamine (if needed)
Why are baths not recommended for treatment of poison ivy?
Uroshiol will spread in the water and may infect other areas of the body
How long can it take a poison ivy rash to appear?
Up to 9 days after exposure
How can poison ivy be prevented?
- Total avoidance of plant
- Protective clothing
- Wash objects that have come into contact w/ plant
- Wash skin w/in 10 minutes of exposure
- Do not burn the plant
Which type of corticosteroids can pharmacists prescribe?
Topical, not oral
Which topical corticosteroids are available for sale in Canada?
- Hydrocortisone
- Clobetasone
- Desonide
- Triamcinolone
What are some non-phrms for atopic dermatitis?
- Bathe in lukewarm water for 5 minutes using non-soap cleansers
- Pat skin dry
- Trim nails short and smooth
- Avoid occlusive, tight clothing
- Avoid triggers, allergens, and irritants
- Keep skin hydrated
____ is a common trigger to an atopic dermatitis flare
Dry skin
What is the recommended treatment for atopic dermatitis when the skin is dry with mild itch and no patches of dermatitis?
Emollient or barrier repair treatment twice daily and after bathing
What is the recommended treatment for atopic dermatitis during an acute flare?
- Topical corticosteroid or barrier repair therapy
- Reinforce emollient use for prevention
What are the 2 goals of treatment for atopic dermatitis?
- Treat the current condition
- Increase the time between flares
How is atopic dermatitis prevented?
Prevent dry skin
What is a prescription product that is used for the long term therapy of atopic dermatitis?
- Topical calcineurin inhibitors (tacrolimus or pimecrolimus)
What does tacrolimus (protopic) do and where can it be used?
- Reduces itching and inflammation
- Can be used on children older than 2 on the face and neck
Is tacrolimus (protopic) or pimecrolimus (elidel) better?
Pimecrolimus has a lower cost and causes less burning and itching than protopic
What are some OTC skin protectants that can help atopic dermatitis?
- Calamine lotion
- Zinc oxide
- Colloidal oatmeal
- Sodium bicarbonate
Why are oral antihistamines recommended for atopic dermatitis?
They act by blocking H1 receptors, therefore decreasing itch caused by histamine
What is the recommended oral antihistamine for atopic dermatitis?
25-50mg diphenhydramine (benadryl)
What are the most useful moisturizers for people with atopic dermatitis?
Emollients with humectants added
Are astringents more effective than saline when used as a wet dressing for atopic dermatitis?
No, saline or tap water is preferred
What are 7 OTC products that you can recommend to a patient with atopic dermatitis?
1) Hydrocortisone cream
2) Calamine lotion
3) Zinc oxide
4) Colloidal oatmeal (aveeno baths)
5) Sodium bicarbonate (baking soda)
6) Aluminum acetate
7) Diphenhydramine (benadryl)
What are the 4 R’s of management of atopic dermatitis?
1) Recognize condition and seek treatment early
2) Remove triggers
3) Restore moisture to skin
4) Regulate
