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6 - Atopic & Contact Dermatitis (AD + ICD/ACD) Flashcards

1
Q

Dermatitis

A

non-specific term

Generally characterized by erythema & inflammation
Skin may blister / ooze / crust / flake

Known causes:
Allergens / Irritants / Infections

Usually SELF TREATED

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2
Q

Atopic Dermatitis

AD

A

Primarily driven by GENETIC FACTORS

Usually develops in infantry, all over the body
especially in skin folds

Physical Contact with irritant / allergen may exacerbate

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3
Q

Contact Dermatitis

A

Driven mainly by EXTERNAL FACTORS

Develips @ site of physical contact w/ irritant or allergen

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4
Q

What is the “Atopid Triad”

or Atopic March

A

AD + Asthma + Allergic Rhinitis

Atopy = exaggerated skin & mucosal reactivity
in response to environmental stimuli
genetically predipsosed

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5
Q

Pathophysiology of AD

A

Skin is inflammed with and expression of CYTOKINES
IL-4, IL13, TNF

FLG = Fliggrin Mutation, INCREASES risk of AD

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6
Q

Diagnostic Criteria for AD

A

Essential Features:
Pruritis / Eczema

Important Features:
Early Age of Onset
Atopy / Xerosis / FMH

Possible Lab Findings:
Elevated IgE levels & peripheral blood eosinophilia

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7
Q

Characteristics of Atopic Dermatitis by AGE

A
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8
Q

3 Stages of AD

A

ACUTE AD
INTENSELY Pruritic + Papules/vesicles over erythematous skin
often associated with an exudate, pus/leak

  • *SUB-ACUTE AD**
  • *Red** / scaling papules / plaques

Chronic AD
Thickened plaques of skin
accentuated skin markings

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9
Q

Complications of AD

A

S/Sx = Pustules / Vesicles / Yellow Crusting

Secondary BACTERIAL infections
>90% of skin lesions harbor staph

Secondary VIRAL infections
Herpes simples or molluscum

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10
Q

Exacerbating Factors of AD

A

Allergens

Irritants

Temperature Changes

Airborn Irritants
Pollution / Cigarette Smoke / Traffic Exhaust

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11
Q

Goals of Therapy for AD

A

*CAN NOT be cured; symptom control is key

Stop Itch-scratch cycle
Topical steroids

Maintain skin hydration + barrier function
Emollients + Moisturizers

Avoid or Minimize exacerbating factors

prevent 2ndary infections

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12
Q

Bathing Procedures for AD

A

Bathe in lukewarm water for limited duration

Fragrance-Free bath oils (Aveeno)

Use hypoallergenic cleanser (Cetaphil)

Skin should be patted dry or air-dried

Application of moisturizer within 3 minutes of bathing

Use lubricating ointment for excessively dry areas

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13
Q

What type of moisturizers for LESS severe cases?

Atopic Dermatitis treatments

A

EMOLLIENTS

Aquaphor / Nivea

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14
Q

What type of moisturizers are used for MORE SEVERE cases?

Atopic Dermatitis treatments

A
  • *HUMECTANTS**
  • *Eucerin + Urea**

UREA increases water uptake in the stratum corneum
giving it high-water binding

RX Strength Urea acts as a KERATOLYTIC agent

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15
Q

Creams

Atopic Dermatitis treatments

A

Usually Oil-in-Water emulsions (O/W)

LESS occlusive than ointments

common mistake = using too much and/or not rubbing in fully

Cetaphil / Nivea

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16
Q

Ointments

Atopic Dermatitis treatments

A

W/O emulsions

Act primarily by leavan an oily film on the skin surface
that moisture can NOT readily escape

MOST OCCLUSIVE vehicle
relives dryness / brittleness / protects fissures

  • AVOID ON*:
  • Inflammed skin / interinous areas / hairy areas*

WEEPING LESIONS

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17
Q

Topical Steroids

Dose / MoA / ADR

Atopic Dermatitis treatments

A
  • *STANDARD OF CARE**
  • *Hydrocortisone** 0.5% & 1%
  • low potency*

MOA: Supresses cytokines​ associated with the development of inflammation and itching
minimal systemic absorption (~1%)

During flare ups: AAA BID
prior to application of moisturizers

AVOID use if skin is infected / open / cracked

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18
Q

Wet Wraps

AD Treaments

A

INCREASES Skin Hydration
decreases _scratching_

Apply steroid or emollient to affected area
then wrap MOIST dressing to AA
then wrap a DRY dressing OVER the wet one
put over nighttime clothing -> LEAVE WRAP OVER NIGHT

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19
Q

Astringents

Atopic Dermatitis treatments

A

Aluminum Acetate & Witch Hazel

Cause vasoCONSTRICTIOn & reduce Bloodflow to inflammed tissue
slow oozing / discharge / bleeding

  • *Wet Dressing**
  • *Cool & dry** skin through EVAPORATION

(Burrows solution / Domeboro)

20
Q

Burow’s Solution

Directions / Duration

Type of Atopic Dermatitis treatments

A

Category 1 ASTRINGENT
Dissolve 1-3 packets in a PINT (16oz) of cool/warm water -> dissolve

for use as SOAK:
soak AA for 15-30 min Q8H PRN, or AD by a doctor

for use as COMPRESS or WET DRESSING:
soak a clean/soft cloth in the solution
apply cloth looselyto the AA for15-30 min, reapply PRN

21
Q

How to PREVENT / MANAGE Infections

Atopic Dermatitis treatments

A

Topical Antibiotics NOT routinely recommended

  • *Bleach Bath_ & _IntraNASAL MUPIROCIN**
  • BID** used to *_decrease disease severity_

Bleach bath for ECZEMA:
1/2 cup for a FULL TUB or 1/4 cup for HALF tub
soak for 10 minutes -> Dry -> Lotion -> WRAP w/ eczema clothing

22
Q

EX-ST

for ATOPIC DERMATITIS

A

SEVERE condition with INTENSE PRURITIS

Involvement of LARGE AREA of the body

< 2 years old

Skin appears to be INFECTED

No improvement after 2-3 days of self care

23
Q

Important notes on AD

A

Most AD cases are MILD and can be treated with NON-RX products
for patients >2 y/o

Need to be counseled on potential exacerbating factors

Errors in BATHING / Moisturizing procedures are THE MOST COMMON FACTORS in persistant AD

Treatment should involve focus on skin care / moisturization in order to enhance/restore barrier properties

OTC therapies can be recommended for symptomatic treatment of dermatosies to reduce inflammation / pruritis

24
Q

What Characterizes CONTACT DERMATITIS?

A

Inflammation / Redness / Itching / Burning / Stinging

  • *VESICLE + PUSTULE** formation on dermal areas that are
  • *Exposed to irritant / antigenic agents**

2 Main types:
Irritant & Allergic

25
What are the **3 possible mechanisms** that cause **Irritant Contact Dermatitis?** ## Footnote **ICD**
*Caused by **exposure to an irritant**:* **_DISRUPTION_** of **skin barrier** Irritant may **_DIRECTLY DAMAGE_** the **epidermis** Release of **_CYTOKINES_** as a result of **chemical exposure**
26
Common **IRRITANTS** associated with **ICD**
**Acids / Alkalis** **Detergents** / soaps / hand sanitizers **Oxidants / Solvents** **Urine / Feces** Epoxy Resins / Ethylene Oxide / Oils Wood dust / products
27
**Symptoms / Clinical Presentation** **of ICD**
Skin becomes **inflammed / swollen / red** on **exposure to IRRITANTS** *symptoms may be DELAYED*, often limited to **_hands & forearms_** Presents as **DRY / MACERATED / PAINFUL / CRACKED** skin that often induces: ***Itching / stinging / burning*** Generally **resolves within a few days,** *if AVOIDING irritant* CHRONIC EXPOSURE -\> develop FISSURES / SCALES / Pigmentation
28
**3 Treatment goals of ICD**
* *_REMOVE / PREVENT_** * *exposure** to the **irritant** **_RELIEVE_ inflammation** / tenderness / irritation **_EDUCATE_** patient on **self-management** to PREVENT recurrence
29
What to **AVOID** in treating **ICD**
***_AVOID:_*** topical **CAINE-type** anesthetics **Salicylic / Lactic ACID** **UREA** **PROPYLENE GLYCOL**
30
**TREATMENTS** for **ICD**
**_Cleansing_** area of exposure with **tepid water** & ***hypoAllergenic soap*** (Cetaphil) **_Protective**_ _**clothing / equipment_** to *avoid further exposure* **_Emollients / Moisturizers_** to assist in **REPAIRING** **epidermal barrier** **_Corticosteroids_** to *reduce **_inflammation_*** & *relieve* ***_itching_*** * *_Colloidal OATMEAL Bath_** * also to relieve ITCHING*
31
What is **Allergic Contact Dermatitis** = **ACD**? and what are **common allergens?**
**Inflammatory dermal RXN** related to exposure to **allergen** Activites sensitized **T-Cells** Usually *does **NOT*** *appear* on **first contact** **Poison ivy/oak/sumac** = MOST COMMON CAUSE **Metal Allergy** (NICKEL) **LATEX**
32
**STEPS** to developing **ACD**
* *_Induction phase_** * *INITIAL exposure** to antigen --\> **sensitizes** the immune system **_Next Contact_** induces **type 4** IV delayed **hypersensitivity reaction** cell mediated IMMUNE rxn --\> **24hours - 21 days** to develop **_Dermatitis_** along with associated symptoms *if **_previously sensistized_***, may appear between **24-48hours** after exposure
33
**_Urushiol-Induced_** **ACD**
Caused by Toxicodendron species = **Poison IVY** can occur in a **BROADER AREA** 80% of people are sensitive to it & it **INCREASES into adulthood** *declining sensitivity with **_advanced age_*** but with **prolonged duration** & **severity** of **symptoms**
34
**Symptoms / CLinical Presentation of ACD**
Can ocur **ANYWHERE** on the body after contact with antigen * *Rash is limited** to the **area of antigen contact** * Urushiol-induced ACD* can occur on BROADER area Presents w/: **Papules** / **Small vesicles** / **Large Bullae** over inflammed / swollen skin **_SIGNIFICANT ITCHING_** Heals in **_10-21 days_** as a result of our own immune system
35
**Treatment Goals of ACD**
**REMOVE** offending agent **TREAT inflammation** **RELIEVE itching** & excessive scratching Relieve **accumulation** of **debris** **PREVENT** secondary skin **infection**
36
What to **AVOID** when **treating ACD**
use of _TOPICAL_: **Anesthetics** **Antihistamines** **Antibiotics** known SENSITIZERS --\> can cause ***_drug-induced ACD_*** superimposed on the existing AC
37
**Treatments for ACD**
**_REMOVE the known antigen_** w/ **mild soap** & **tepid water** + **Zanfel / Tecnu** for **Urushiol** **_Rash w/ pruritis & erythema_** treat with **Hydrocortisone 1%** , CREAM\>ointment for WEEPING lesions **_Oozing Vesicles_** use **Astringents** or **cool water compress** to **DRY** * *_Non-Weeping**_ _**Lesions_** * *Calamine Lotion** -\> **Drying** / **Colloidal Oatmeal** --\> **Itching**
38
**TECNU** **ACD Treatments**
**Skin cleanser** used to REMOVE KNOWN ANTIGEN for **_URUSHIOL_**-induced ACD use **ASAP** up to **\<8 hours** after exposure * *Cleanse** the contaminated area for **\>2minutes** * *Wipe away** with cloth or rinse with water *EQUAL efficacy between Tecnu / dish soap / GOOP grease remover*
39
**Zanfel** ACD Treatments
**Skin cleanser** used to **REMOVE KNOWN ANTIGEN** for **URUSHIOL**-induced ACD Can be used at **_any time_** following exposure, *even **after rash develops*** because it provides **RELIEF** from **PAIN & ITCHING** MoA: **bonds with urushiol** within the dermal layer to create an **aggregate** that can be **washed away w/ water**
40
**Ivy Block** **ACD Treatment**
**Lotion** that is the **only FDA approved _BARRIER PRODUCT_** provides **protection** **against exposure** to: **poison ivy / oak / sumac** **_BENTOQUATAM_** active ingredient believed to **physically block** urushiol from being **absorbed** into the skin when applied **_\<15 minutes_** PRIOR to exposure _REAPPLY once **Q4HOURS**_
41
**EX-ST** / **Refer to MD** for **ACD**
Children **_\<2 years old_** Involvement of **Eyes / eyelids / mouth / genitals** or **\>20% of skin surface** Rash does not improve in **_1-2 weeks_** or *failure of Self management **_\>7 days_*** **S/Sx of INFECTION** Presence of **numerous LARGE Bullae** SWELLING of body / impairment of daily activities
42
Important **Patient counseling** for **ACD**
**Bathing Procedure** **AVOID triggers/allergens** **Humidifyer** + adequate HYDRATIOn ***_Minimize SCRATCHING_*** fingernail hygiene Correct use of **moisturizers + OTC products**
43
**Important notes on CONTACT DERMATITIS** **ICD / ACD**
should **resolve** within **_10-21 days_** W or W/O therapy knowing the **surrounding circumstances** for the occurance helps leading cause of **ICD** = **frequent / unprotected exposure** to **WET environments** that may contain irritant **ACD** is produced through **sensitization** to antigen Discuss **preventative therapies** **Washing** (remove) \> **Hydrocortisone** (itching) \> **Astringents** (weeping/oozing lesions) \> **Emollients** (restore barrier)
44
**Zanfel INSTRUCTIONS for use**
1. **Wet** affected area 2. Measure **1 ½ inches** **of the product** into one palm 3. **Wet both hands and rub the product into a paste** 4. Rub both hands on the **affected area until there is no sign of itching (up to 3 minutes)** 5. **Rinse the affected area thoroughly** 6. If itching returns after several hours, **the product may be used again**
45
**Inflammation** How to treat this SYMPTOM in ACD?
**_HYDROCORTISONE_ Most effective NON-RX** therapy for mild-moderate ACD, that *does NOT involve edema/extensive areas* Urushiol ACD *may require RX-strength* corticosteroid **AAA TID-\> QID** ***_DO NOT USE DRESSINGS / BANDAGES_** when self-care*
46
**ITCHING** How to treat this SYMPTOM in ACD?
**Cold** or **tepid** ***_soapless_*** **SHOWERS** or use ***_hypoallergenic soap_*** (cetaphil) you can use **oral antihistamines**, *not topical* **Topical hydrocortisone** will help the itching through **vasoconstriction**
47
**Oozing Lesions** How to treat this SYMPTOM in ACD?
* *_ASTRINGENTS_** * *Aluminum Acetate = Burow's Solution** used as a **wet dressing or compress** applied to unhealthy skin to ***_decrease: weeping_ / oozing / discharge / bleeding***

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