Atopic Dermatitis (Eczema) Flashcards
Eczema
pathogenesis
s/sx
demographics
- filaggrin deficiency, normally produced by differentiating keratinocytes, filaggrin is broken down inside cells to produce natural moisturizer factor (NMF), genetic disposition
- dry skin and severe pruritis, “the itch that rashes”, papules zand vesicles that exudate, dry scaly excoriated erythematous papules if chronic AD
- FHx 70% eczema, asthma, allergic rhinitis, increased IgE and eosinophilia
- 30-80% have specific allergies to certain foods, hard water
- more liekly to affect black children, presentation is darker brown, purple, swollen, warm itchy, dry, scaly, drier, nodules on torso, arms and legs
eczema sx mild
infrequent itching, little impact on every day activities, sleep and psychosocial well being
eczema sx moderate
frequent itching and redness, moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep
eczema sx severe
widespread areas of dry skin, incessant itching, redness, severe limitation of everyday activities and psychosocial fxn, nightly loss of sleep
AD tx non-pharm
elim exacerbating factors (stress, anxiety, heat, low humidity, contact allergens)
bathing (warm soaking baths or showers, soap free or mild cleansers)
maintain hydration (avoid lotions w high w/o content)
avoiding pruritis in AD
po antihistamines
H1 - benadryl, hydroxizine, cypoheptadine sedating
H2 - fexofenadine, loratidine, cetirizine - may need high dose
topical doxepin
topical CNi - tacrolimus cream (Protopic 0.03% and 0.1%) and pimecrolimus cream (Elidel)
mild and mod AD 1st line tx
(not involving face, eyelids, neck or flexures)
(not 2 yo +) (for each mild and moderate
alternative?
mild - low potency cream/ointment
desonide 0.05% crm/oint BID x2-4wks
moderate - high potency creams tapered to low
triamcinolone acetonide oint 0.5% x1-2wks
face, flexures - low pot steroids qd x5-7d
alt is CNi (Tacro, Pimecro)
alt in mild to mod -OR- mild to mod involving face, eyelids, neck, or flexures
Tacro 0.03% or 0.1%
or Pimecrolimus 1% BID
topical tx of mild-mod AD in pts 2 yo+
Crisaborole (Eucrisa) BID
PDE-4 inhibitor
Severe AD
non-pharm
pharm tx
non pharm:
- soak in water for 15 min and smear topical steroid (dont dry)
- wet wraps (mid-super potency steroids in an ointment base), wet pjs covered by dry pjs minimum4 hours BID
- phototherapy 2-3x a week, sometimes combo w coal tar solns
pharm
- Dupilumab (Dupixent) ; can also be for refractory mod-sev;SQ inj
- Cyclosporine
- Methotrexate
- Azathioprine
- MMF
Seborrheic Dermatitis (SD)
cause
occurance
inflam rxn to yeast
imm syst over reacts–> inflam and skin changes
35% among patients with early HIV infection, up to 85% in patients with AIDS, also common in Parkinsons
SD s/sx
well-demarcated erythematous plaques
greasy-looking, yellowish scales
distributed on areas rich in sebaceous glands (scalp, external ear, center of face, upper trunk)
worsens w stress, cold, dry heat of winter
SD tx options overview
Topical antifungals topical Cs topical CNi Systemic antifungals Systemic antifungals (severe)
SD non pharm
selinium sulfinde, zinc pyrithione
SD
topical antifungal agents
Ketoconazole 2% shampoo BIW x4wks w 3+ d btwn tx, leave in for 3 min, can then do qwk for maintenance
Ciclopirox 0.77% gel BID x4wks
or 1% shampoo BIW x4wks w >3d btwn txs
*can cause dermatitis or hair discoloration
SD alternative to topical antifungal agents
Coal Tar Solution 0.5-5%
- limited usefullness
- qd hs, bathe in morning
cradle cap s/sx
tx
asx and non-inflam accumulation of greasy scales, dark to yellowish on the scalp
sometimes eruptions start on the face
tx - often spontaneously resolves
baby shampoo, remove scales with soft brush (qd, then q 2-3d once resolves)
emollient cream (mineral oil, petroleum jelly) then baby shampoo
Conjunctivitis
s/sx
prevention
bacterial tx
NO extravascated blood or opacifications
bacterial: s. aureus, s. pneumo, h infl, m catarrhalis, morning crusting that continues throughout the day, eye stuck shut
bacterial tx: erythromycin 5mg/g ointment 1/2” QID x5-7d
trimethoprim/polymixin B 0.1%-10,000units/g drops 1-2 drops QID x5-7d
save FQ for if pt has contact lend\ses (pseud)
viral conjunctivitis
s/sx
tx
most contagious self limiting burning, sandy, gritty feeling enlarged, tender pre-auricular nodes HSV and VZV have different tx
tx
-OTC antihistamines/decongestants (only tx sx:/)
-Vasoconstrictor/antihistamine combo Naphazoline/Pheniramine 1-2gtt qid
-antihistamines w mast cell stabilizing properties
(Azelastine 1gtt bid, Ketotifen [Zaditor] 1gtt bid, Olopatidine [Patanol])
Allergic Conjunctivitis
s/sx
tx
Type 1 HS rxn, can be acute, seasonal or perennial
tx
- refrigerated artificial tears, coo, compress, allergen avoidance
- vasoconst/antihistamine max 2 wks
- antihistamine w mast cell stabilizing abilities (Azelastine 1gtt bid, Ketotifen [Zaditor] 1gtt bid, Olopatidine [Patanol]) like pink eye viral
non-allergic conjunctivitis
ex)
dx
tx
piece of sand in eye, no damage
resolves in 24h
dry eye has similar sx
tx: lubricant drops 1-2gtts up to 6/d
lubricant ointment 1/2"qid prn or hstoxic conjunctivitis time? dx s/sx tx
direct damage to ocular tissues from preservatives or meds
takes years to develop
contact lens soln, topical eye meds (AG, antivirals, glaucoma meds, topical anesthetics)
redness, edema, mucous discharge, swollen eyelids, thickened eyelids
dx- injection
tx - d/c topical meds with preservatives (BAK), short course loteprednol
fleas tx
avoid scratching
wash area
ice packs/calamine
po antihistamines, topical corticosteroids
bed bugs tx
inject anesthetic and anticoagulant
washing at 60C, dry at >40C x 30min, freezing -17Cx2hours
to tx bites - low or med potency topical CS, systemic antihistamine
pediculosis humanus capitis (head lice) tx
> 2mo = Permethrin 1%, leave on hair for 10 min, rinse, CAN repeat on day 9, wash hair without conditioner FIRST
AE: irritation, avoid if chrysanthemum allergy
2 yo = Pyrethrins and piperonyl butoxide, leave on hair for 10 min, rinse, MUST repeat on day 9, apply to DRY hair
wet combing, Lindane (second line only), Bactrim po + permethrin topical in resistant cases
pediculosis corporis (body lice)
s/sx
RF
tx
heavily bitten areas of skin thickened and discolored around midsection of the body
RF: lower socioeconomic status, direct physical contact, contant w infested fomites
tx: regularly changing into clean clothes, thorough bathing, wash clothes in hot water, iron clothign w hot iron, vacuum area well
pubic lice
tx
topical permethrin 1% or pyrethrins+piperonyl butoxide and retreatment at 9-10days
tx all sexual partners
eval for STDs
Ciliaris tx
lice in eyelashes
manual removal or apply ophthalamic grade vaseline bid-qid x 10d
scabies
dx
tx
and who to tx
dx - finding mite or burrow
tx - Permethrin 5% (Elimite) applied from neck to soles of the feet, under fingernails and toenails, 30g per avg adult, wash of after 8-14 hours, reapply 1-2wks later
can give antihistamines to help w itching
other options - Ivermectin 200mcg/kg x1 repeat at 2 wks later, take w food
Crotamiton 10% cream or lotion (Crotan)
tx all members of teh family too or those with skin to skin contact
Chiggers
s/sx
tx
clustered skin disease secondary to bites of mites most common in summer or fall
tx: vigorous soap and water (repel with DEET), if sx topical antipriuritics like menthol or calamine lotion, topical corticosteroids, po sedating antihistamines
mosquitoes
tx
antihistamine (cetirizine, loratidine, fexofenadine), topical GC x5-10d, po GC prednisons 1mg/kg x5-7d
DEET
repellents, available in sprays, solutoins, creams and wipes every 4-8 hours minimum
children need [ ] <30%
10-30% for most situations anyway
need >20% [ ] for ticks
self care for bites
do not use…?
wash with soap and water, ice 30 min, on off for 60
camphor/menthol x7d
DO NOT USE: dibucaine in large quantities or on open areas, topical diphenhydramine >7d, hydrocortisone on scabies bact infxns or fungal infxns
