Ch. 33 - Atopic Dermatitis

Question 1

Functions of Skin

Answer 1

1. Protecting the body against trauma 2. Regulating body temperature 3. Maintaining water and electrolyte balance 4. Sensing painful and pleasant stimuli 5. Participating in vitamin D synthesis

Question 2

Epidermis

Answer 2

Outer most thin layer of the skin, provides waterproof barrier

Question 3

Dermis

Answer 3

Beneath epidermis, contains touch connective tissue, hair follicles, and sweat glands

Question 4

Hypodermis

Answer 4

Deeper cutaneous tissue made of fat and connective tissue

Question 5

Transdermal Drug Absorption

Answer 5

• Drug absorption is often through passive diffusion through the stratum corneum, followed by transport through deeper epidermal regions and then the dermis - Stratum corneum often the rate-limiting barrier to absorption -Hydration status can affect drug diffusion - Occlusion increases hydration increased transfer of most drugs - Wounds, burns, inflammation can alter the stratum corneum and cause increased drug absorption - Pediatric concerns: newborns and infants have underdeveloped stratum corneum, increased skin hydration, and largest ratio of body surface area to body weight which causes increased systemic exposure to topical drugs - Geriatric concerns: often have thinning of stratum corneum which causes increased systemic exposure to topical drugs

Question 6

Macule

Answer 6

Flat, nonpaplpable discoloration <1 cm (brown, blue, red, or hypopigmented)

Question 7

Papule

Answer 7

Superficial solid elevated, ≤0.5 cm, color varies

Question 8

Vesicle

Answer 8

Circular collection of free fluid, ≤ 0.5 cm

Question 9

Pustule

Answer 9

Vesicle containing pus

Question 10

Bulla

Answer 10

Fluid-filled blister, >0.5 cm

Question 11

Patch

Answer 11

Circumscribed flat discoloration, > 1 cm

Question 12

Plaque

Answer 12

Elevated, superficial, solid lesion, > 1 cm

Question 13

Scale

Answer 13

Flakes or plates of compacted layers of stratum corneum

Question 14

Lichenification

Answer 14

Thickening of epidermis seen with exaggeration of skin lines

Question 15

Crust

Answer 15

Dried serum or exudates on skin

Question 16

Nodule

Answer 16

Palpable, solid lesion, >1 cm

Question 17

Wheal/uriticaria

Answer 17

Transient elevation due to dermal edema, often with erythematous borders and pale centers

Question 18

Fissure

Answer 18

Crack or split in the skin

Question 19

Erosion

Answer 19

Loss of some or all of the epidermis

Question 20

Ulcer

Answer 20

Loss of the epidermis and at least part of the dermis

Question 21

Atopic Dermatits (AD)

Answer 21

-Genetic mutation in protein in the epidermal differentiation complex (filaggrim) -Increased penetration of allergens -Decrease in skin barrier proteins -Decreased ability to retain moisture -People can have unique triggers that cause flare ups

Question 22

Possible AD Triggers

Answer 22

-Food allergens -Aeroallergens -Stress -Airborne irritants -Cosmetics, fragrances, astringents -Exposure to temperature extremes -Electric blankets -Excessive hand or skin washing -Use or irritating soaps, detergents, or scrubs -Tight-fitting or irritating clothes -Dyes and preservatives

Question 23

Atopic Skin Cycle

Answer 23

1. Disturb skin barrier function 2. Penetration of irritants/allergens 3. Inflammation 4. Itching 5. Scratching **Then starts back at 1**

Question 24

Essential Diagnostic Features

Answer 24

-Pruritis -Eczema and age-specific distribution patterns -Chronic or relapsing course

Question 25

Important Diagnostic Features

Answer 25

-Onset in infancy or early childhood -Personal and/or family history of atopy -Xerosis

Question 26

Clinical Presentation - Infants

Answer 26

-Starts around 2-3 months -Erythema, pruritis, and scaling on cheeks that can spread to other areas -Scalp, face, arms, and legs are common sites in infants and toddlers -Crust and pustules may form from scratching and running -Remission may occur by 2 y.o.

Question 27

Clinical Presentation: Kids and Adults

Answer 27

-Chronic, relapsing dermatitis -Pruritis is hallmark symptom -Asthma and allergic rhinitis can be seen in up to 80% of people with AD -AD or xerosis can continue into adulthood in about 30% of patients

Question 28

Xerosis

Answer 28

-Dry skin -Frequently seen in AD along with dehydration, malnutrition, physical damage, etc. -Results from decreased water content in the skin which causes an abnormal loss of cells from stratum corneum -Related to loss of ceramides (help form skin barrier and retain moisture) -Frequently causes pruritis in winter -Goals: restore skin hydration and barrier function -Treat with nonpharmacologics

Question 29

Infected AD Signs/Symptoms

Answer 29

-Severe itchiness -Burning sensation -Blistered skin -Fluid drainage (clear or yellow) -White or yellow pus -Flu-like symptoms

Question 30

AD Treatment Goals

Answer 30

1. Stop itch-scratch cycle 2. Maintain skin hydration and barrier function 3. Avoid/minimize factors that trigger or aggravate the disorder 4. Prevent secondary infections

Question 31

AD Nonpharmacologics

Answer 31

-Avoid triggers -Tepid, short baths with non-soap cleansers -Pat dry after bathing -Apply moisturizer immediately after bathing -Apply cool, tap water compress for 5-20 minutes 4-6 times a day to dry weeping lesions -Keep fingernails short, smooth, and clean -Use cotton gloves at night to prevent scratching

Question 32

Non-Soap Cleansers

Answer 32

-Soap can increase skin pH to undesirably levels and worsen AD -Non-soap cleansers usually don't have sodium lauryl sulfate and have lower pHs to prevent this -Often also hypoallergenic and fragrance free

Question 33

Colloidal Oatmeal

Answer 33

-Available in body washes, moisturizing creams, and bath treatments -Provides moisturization, barrier protection, and anti-inflammatory activity -In many Aveeno products -Three studies supporting its efficacy in improving quality of life and reducing clinical signs of AD in adults and kids as young as 8 months

Question 34

Occlusives

Answer 34

- Physically block transepidermal water loss - Enhance penetration of ingredients - More oil, more occlusive - Ex: petrolatum, lanolin, mineral oil, silicones

Question 35

Emollients

Answer 35

- Oil in water or water in oil preparation - Soften the skin by filling the spaces between desquamating skin cells - Includes fatty acids, cholesterol, and ceramides

Question 36

Humectants

Answer 36

- Water-attracting substances that actively pull water from dermis and hydrate the stratum corneum - Ex: glycerin, propylene glycol, alpha hydroxyl acids, urea

Question 37

Other Moisturizer Components

Answer 37

- Vitamins - no-known clinical effects - Fragrances - avoid in sensitive skin - Exotic oils - Preservative - enhance product elegance and stability but can cause irritation or dermatitis (Ex: parabens, benzyl alcohol)

Question 38

Lotions

Answer 38

-Thinner in consistency, easy to spread - Contain more water - High water content lotions can have drying effect - May be preferred in milder cases of dryness or in warm weather - Useful in hairy areas - Good for skin folds Ex: Lubriderm, Cetaphil

Question 39

Creams

Answer 39

- Usually half water and half oil - Heavier than lotion - Less greasy than an ointment - Good for skin folds - Good for daily use for winter months Ex: Eucerin, Cetaphil

Question 40

Ointments

Answer 40

- Often contain petrolatum - Useful if occlusion is desired - Good for dry, thick, or scaly lesions - Can be greasy and staining - Avoid on oozing lesions - Avoid in intertriginous areas to prevent maceration - May be too occlusive in very warm weather - Good for palms and soles - Not good for oily skin Ex: CeraVe, Vaseline

Question 41

Pharmacologic Therapy

Answer 41

-Topical Hydrocortisone -0.5% or 1% OTC -MOA: suppress cytokines associated with the development of inflammation and itching -Don't use in patient \< 2 y.o. -Apply twice a day during AD flare ups prior to applying moisturizer -Cream is acceptable for mild, dry skin -Ointment is preferred on areas of thick skin or if skin is dry, lichenified, or scaly -Avoid if lesions are weeping -Avoid all products if skin is infected, open, or cracked -Intermittent course of therapy decreases likelihood of tachyphylaxis -ASE: local atrophy after prolonged use

Question 42

When to seek medical attention...

Answer 42

-Moderate to severe condition with intense pruritus -Involvement of large area of the body -\<1 y.o. -Skin appears to be infected -Involvement of face or intertriginous areas -AD doesn't improve or worsens after 2-3 days of treatment -Dry skin doesn't improve or worsens after 7 days