Atopic Dermatitis (Eczema)

Question 1

Eczema
pathogenesis
s/sx
demographics

Answer 1

• 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

Question 2

eczema sx mild

Answer 2

infrequent itching, little impact on every day activities, sleep and psychosocial well being

Question 3

eczema sx moderate

Answer 3

frequent itching and redness, moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep

Question 4

eczema sx severe

Answer 4

widespread areas of dry skin, incessant itching, redness, severe limitation of everyday activities and psychosocial fxn, nightly loss of sleep

Question 5

AD tx non-pharm

Answer 5

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)

Question 6

avoiding pruritis in AD

Answer 6

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)

Question 7

mild and mod AD 1st line tx
(not involving face, eyelids, neck or flexures)
(not 2 yo +) (for each mild and moderate

alternative?

Answer 7

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)

Question 8

alt in mild to mod -OR- mild to mod involving face, eyelids, neck, or flexures

Answer 8

Tacro 0.03% or 0.1%

or Pimecrolimus 1% BID

Question 9

topical tx of mild-mod AD in pts 2 yo+

Answer 9

Crisaborole (Eucrisa) BID

PDE-4 inhibitor

Question 10

Severe AD
non-pharm
pharm tx

Answer 10

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

Question 11

Seborrheic Dermatitis (SD)

cause
occurance

Answer 11

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

Question 12

SD s/sx

Answer 12

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

Question 13

SD tx options overview

Answer 13

Topical antifungals
topical Cs 
topical CNi
Systemic antifungals 
Systemic antifungals (severe)

Question 14

SD non pharm

Answer 14

selinium sulfinde, zinc pyrithione

Question 15

SD

topical antifungal agents

Answer 15

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

Question 16

SD alternative to topical antifungal agents

Answer 16

Coal Tar Solution 0.5-5%

• limited usefullness
• qd hs, bathe in morning

Question 17

cradle cap s/sx

tx

Answer 17

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

Question 18

Conjunctivitis
s/sx
prevention
bacterial tx

Answer 18

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)

Question 19

viral conjunctivitis
s/sx
tx

Answer 19

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])

Question 20

Allergic Conjunctivitis
s/sx
tx

Answer 20

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

Question 21

non-allergic conjunctivitis
ex)
dx
tx

Answer 21

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 hs

Question 22

toxic conjunctivitis
time?
dx
s/sx
tx

Answer 22

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

Question 23

fleas tx

Answer 23

avoid scratching
wash area
ice packs/calamine
po antihistamines, topical corticosteroids

Question 24

bed bugs tx

Answer 24

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

Question 25

pediculosis humanus capitis (head lice) tx

Answer 25

> 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

Question 26

pediculosis corporis (body lice)
s/sx
RF
tx

Answer 26

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

Question 27

pubic lice

tx

Answer 27

topical permethrin 1% or pyrethrins+piperonyl butoxide and retreatment at 9-10days
tx all sexual partners
eval for STDs

Question 28

Ciliaris tx

Answer 28

lice in eyelashes

manual removal or apply ophthalamic grade vaseline bid-qid x 10d

Question 29

scabies
dx
tx
and who to tx

Answer 29

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

Question 30

Chiggers
s/sx
tx

Answer 30

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

Question 31

mosquitoes

tx

Answer 31

antihistamine (cetirizine, loratidine, fexofenadine), topical GC x5-10d, po GC prednisons 1mg/kg x5-7d

Question 32

DEET

Answer 32

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

Question 33

self care for bites

do not use…?

Answer 33

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