Ch. 34 - Scaly Dermatoses Flashcards
1
Q
Scaly Dermatoses
A
- Chronic Dermatoses: dandruff, sehorrheic dermatitis (SD), and psoriasis
- Involve uppermost skin layer: epidermis
- Dandruff - less inflammatory form with fine scaling limited to scalp
- SD - involves dace, scalp, and chest with significant inflammation
- Psoriasis - highly inflammatory skin condition with raised plaques and adherent thick scales, profound physical, psychological, and economic consequences
- Non-Rx usually good for dandruff and SD
- Mild psoriasis may respond to non-Rx, but initial diagnosis and management of flares requires a dermatologist
2
Q
Dandruff
A
- Chronic, mildly inflammatory scalp disorder
- Character: excessive scaling
- Cosmetic concern with social stigma
- Less inflammatory end of SD
- Not sure if inadequate shampooing makes it worse, but consistent washing is important with this condition
- 1-3% prevalent in population
- Uncommon in children, usually occurs in puberty and reaches peak in early adulthood
- Levels off at middle age and drops off in elderly
- No gender preference and bald spots are usually dandruff free
- Also less severe in summer
- Malassezia (Mala.) species agreed to cause accelerated cell turnover and inflammation seen in both dandruff and SD
3
Q
Dandruff Pathophysiology
A
- Hyperproliferative epidermal disorder
- Accelerated cell turnover (2x), irregular keratin breakup pattern causing shedding of large, nonadherent white scales
- Crevices occur deep in strum corneum causing cracking and the large scale generation
- If broken down to smaller units the dandruff becomes less visible
- Thought to be due to irritant inflammatory effects of fatty acids and cytokines produced by Mala
4
Q
Dandruff Presentation
A
- Diffuse, minimally inflammatory
- Scaling is the only visible part, large white or gray scales
- Pruritus is common as well
- Crown of head often prime location
5
Q
Dandruff Treatment Goals
A
- Decrease epidermal turnover rate by decreasing Mala
- Minimize cosmetic embarrassment of visible scaling
- Minimize itch
6
Q
Dandruff General Treatment
A
- Washing with general purpose, non-medicated shampoo daily or every other day
- If not effective, can provide non-Rx medicated dandruff shampoo
- Massage shampoo into scalp and leave in for 3-5 minutes before rinsing
- If shampoo contains selenium, additional rinsing is suggested since it can discolor especially light hair
- Medicated shampoos should be used daily for a week, then 2-3 times a week for 2-3 weeks, and then once weekly or every other week to control condition
- Scalp scrubbers help ensure adequate contact with scalp especially with long hair
- An agent that decreases Mala. is recommended initially or a non-Rx ketoconazole with anti-Mala. activity can be useful
- Shampoos containing cytostatic agents are second line therapy with limited efficacy and potential to discolor
- Keratolytic shampoos containing salicyclic acid or sulfur may also be used but need longer treatment periods for efficacy
- If resistant after 4-8 weeks of use, refer to PCP to get a high concentration of selenium sulfide or ketoconazole
7
Q
Seborrheic Dermatitis (SD)
A
- Subacute or chronic inflammatory disorder occuring mainly from areas of greatest sebaceous gland activity
- Chronic red, scaly, itchy rash typically seen within first 3 months of like and in the fourth to seventh decades
- Common in infants and 2-5% of adults
- Typically more severe in winter, may also be aggravated by emotional stress
8
Q
SD Pathophysiology
A
- More inflammatory than dandruff and marked by accelerated epidermal proliferation in areas with dense distribution of sebaceous glands from increased Mala levels
- 9-10 days for SD cell turnover rates (13-15 in dandruff, 25-30 for normal)
- Accelerated cell turnover, enhanced sebaceous gland activity, prominent yellow greasy scales
9
Q
SD Presentation
A
- Scalp, eyebrows, glabella eyelif margins, cheeks, paranasal areas, central back, nasolabial folds, head area, presternal area, retroauricular creases, in and around external ear canal
- Typically presents as dull, yellowish, oily, scaly areas on red skin
- Pruritis is common
- Infantile form: greasy scales and scale crusts on bright erythematous base on scalp, lateral neck, and areas mentioned earlier
- Usually clears in 8-12 months and doesn’t resurface until puberty
- Adult form: yellow, greasy scales on scalp and extended to middle third of face with eyebrow involvement
- Frequently seen with Parkinson’s patients
- Lasts years to decades with improvements in warmer season and exacerbations in cold
10
Q
Adult Form + Presentation Areas
A
- Scalp: Greasy, scaling patches or plaques, exudation, and thick crusting
- Face: Flaky scales or yellowish scaling patches on red, itchy skin in eyebrows/glabella
- Ear canals, aud. meatus, and postauricular areas: red scaling, fissures, swelling
- Chest and Back: V-shaped areas
11
Q
SD Treatment Goals
A
- Decrease inflammation and cell turnover from Mala
- Minimize or eliminate visible erythema/scaling
- Minimize itch
12
Q
SD General Treatment
A
- Similar to dandruff but more aggressive due to inflammation
- Therapy controls but doesn’t cure
- Aims to loosen and remove scales/crusts, inhibit yeast colonization, control secondary infection, and decrease erythema/itching
- Same shampoo recommendations except use it 2-3 times a week for FOUR weeks after first week of use
- In infants, usually self limiting and can be treated by massaging scalp with baby oil and using unmedicated shampoo
- Refer to pediatrician if these methods don’t work
- In adults, shampooing is the foundation of treatment and can be applied to the face and body
- Can use cosmetically acceptable shampoo afterwards if smell is objectable
- Can use topical corticosteroids for inflammation and erythema post-shampoo
- Hydrocortisone can be used no more than twice daily due to a reservoir effect
- Don’t use non-Rx hydrocortisone for more than 7 days in a row
- Refer to doctor if SD worsens or persists after 7 days
13
Q
Psoriasis
A
- Chronic inflammatory disease effecting 1-3% of Americans
- Lesions usually local, but can be general too
- Remissions/exacerbations are unpredictable
- Can cause enough psychological distress to effect the quality of life
- Moderate to severe forms can also cause significant physical and economic burdens
- Equal effects men and women
- All races and geographical areas but shown to have lower instances closer to the equator
- Cause is unknown
- Exacerbation factors: environment, infections, drug use, psychological stress, endocrine/hormone changes, obesity, alcohol and tobacco use
14
Q
Psoriasis Pathophysiology
A
- Accelerated cell turn over causing excessive scaling on raised plaques, turnover is about 4 days
- Lesions lasts lifetimes or disappear quickly
- Can leave skin hypo or hyperpigmented after lesion fades
- Tends to be chronic and relapsing with spontaneous exacerbations/remissions
15
Q
Psoriasis Clinical Presentation
A
- Usually symmetrical
- Plaque is most common symptom (90%)
- Start as small papules that grow and unit to form plaques
- Lesions are well-circumscribed, shaply demarcated, light pink/bright red/maroon, overlying opaque, thick, adherent white scales that can be pulled off in layers
- Punctate bleeding points can occur when scales are removed
- Common locations: elbows, knees, lumbar region, scalp, posterior auricular areas, external auditory canal, and glans penis
16
Q
Psoriasis Treatment Goals
A
- Control/eliminate signs and symptoms
2. Prevent/minimize likelihood of flare-ups
17
Q
Psoriasis General Approach
A
- Only VERY MILD approved for self treatment
- Larger areas, face involvement, or joint pain should be referred to the dermatologist
- Moderated to severe cases covering >5% of the body should be referred to the dermatologist
- Not responding emollients and non-Rx hydrocortisone should be referred to the dermatologist
- <2 y.o. should be referred to the dermatologist
- Non-Rx can be helpful with symptoms but not likely to control the condition alone
- Avoid UV, physical, and chemical drama
- Remove scales: encourage to bathe with lubricating agents in tepid water 2-3 times a week, gently rub the lesions with a wash cloth to remove, apply emollients minutes after bathing (especially on dry skin)
- Lubricate skin after baths and showers DAILY (essential), can also decrease fissure formation within plaques and increase skin flexibility
- Apply emotions up to 4 times a day
- Hydrocortisone 1% = preferred for acute lesions along with emollients
- Severe to moderate cases need Rx treatment
- Not curable, but can control flare-ups
- Educations increases compliance and can decrease emotional stress and psychological exacerbations
- Minimize emotional stress, skin irritaiton, and physical trauma
18
Q
SD Treatment
A
- Usually medicated shampoos with different MOA
- Also hydrocortisone ointment for inflammation
- Should shampoo with non-medicated, non-residue shampoos (like J&J Baby Shampoo) to remove scalp and hair dirt, oil, and scales BEFORE using medicated shampoo
- Can use non-medicated shampoo after to eliminate unpleasant smells
- Use medicated shampoo until controlled then use 2-3x weekly and reduce eventually to once a week or every other week
19
Q
Pyrithione Zinc
A
- Anti-Mala agent
- MOA: reduce yeast count in scalp and skin
- Binds to hair and external skin layers, more binding is more performance
- 0.3-2% for dandruff
- 0.95-2% for SD
- Shampoos and soaps currently are 1% or 2%
- Well tolerated, no major SE when used properly
- Avoid contact with eyes, stinging
20
Q
Selenium Sulfide
A
- Anti-Mala agent
- Similar MOA as Pyrithione Zinc
- More effective with larger contact time so apply in similar manner
- Rinse thoroughly since it can discolor
- Can make scalp oily and leave an unpleasant odor with recurrent use
- Non-Rx: 1% for dandruff and SD
- Rx: 2.5% lotion for resistant cases or topical fungal infections
- Minimal risk of mucus membrane/scalp irritation and no ADR with routine use
- Avoid eye contact due to irritation
21
Q
Ketoconazole
A
- Anti-Mala agent
- Synthetic azole antifungal, non-Rx shampoo
- 1% active for most fungi, specifically for Mala.
- Treats dandruff and SD of the scalp
- Use twice a week for 4 weeks, space out uses by at least 3 days
- Apply weekly once controlled to prevent relapse
- Hair loss, skin irritation, abnormal hair texture, dry skin are possible, rare SE
- Avoid eye contact, causes irritation
22
Q
Cytostatic Agent
A
- MOA is not completely understood
- Decreases epidermal cell replication
- Increases time for epidermal cell turnover, slowly declines visible scales
- Limited efficacy and other issues makes it second line therapy
23
Q
Coal Tar
A
- Cytostatic agent
- Popular for dandruff, SD, and psoriasis
- Many available dosage forms but limited use due to cosmetic and efficacy issues
- Cross-links to DNA and arrests excessive skin proliferation
- 0.5-5% creams, ointments, pastes, lotions, bath oils, shampoos, soaps, and gels created to try to mask odor, smell, and staining
- SE: Folliculitis, staining skin/hair, photosensitization, irritant contact dermatitis, can rarely worsen condition too
- Apply to body, arms, and legs before bed and then bathe in the morning to remove residue and scales
- Avoid sun exposure 24 hours after use
24
Q
Keratolytic Agents
A
- Salcylic acid and sulfur used in dandruff and SD to loosen and lyse keratin aggregates
- Dissolve the “cement” that holds cells together
- Vehicle composition, exposure time, and concentration are all important factors to its efficacy
- Takes weeks to months to see improvements
- May cause many ASE, limited efficacy, and slow acting, so counsel on these points
- Concentration dependent irritant effect, can alter hair appearance
25
Q
Salicylic Acid
A
- Keratolytic agent
- Decreases skin pH and increases keratin hydration to facilitate its loosening and removal
- Helpful in psoriasis for thick scales
- Avoid using extensively for psoriasis
- 1.8-3%f for dandruff, SD and psoriasis
- Takes 7-10 days for effects at those concentrations to be noticed
26
Q
Sulfur
A
- Increasing sloughing of cells and reduces corneocyte counts
- 2-5% for self treatment of dandruff ONLY
- Often combined with salicylic acid and used for SD
- No significant ASE
27
Q
Topical Hydrocortisone
A
- 0.5 or 1% for non-Rx
- FDA approved for inflammatory skin conditions
- Good for inflamed SD not responding to medicated shampoos and preferred for psoriasis
- Multiple effects to reduce redness and itching
- Most potent and effective dosage form is ointment
- Enhance activity by waiting 30 minutes after its application then covering plaque with greasy emollient like petrolatum as a dressing
- ASE: local atrophy with prolonged use, aggravation of certain cutaneous infection
- Systemic sequalae possibilities exist and are increased by more potent compounds, occlusive dressings, or applying to larger areas of the body
28
Q
Assessment
A
- Appearance of scales at the start is not always definitive
- Presence and nature of symptoms are additional clues
- Factors that help or exacerbate the condition also help define the disorder
29
Q
Counseling
A
- Rarely cured, but non-Rx can help control
- Emotion, physical, or environment factors can effect SD and psoriasis severity
- Explain proper use and duration of products, possible SE, and when to seek medical attention
30
Q
Evaluation
A
- Follow-up: 1 week after self-treatment starts
- If symptoms have worsened, send to PCP
- If it hasn’t worsened, ask to return in 1 week
- If worsened or persists after 2 weeks, send to PCP
