Derm - Dermatitis - Exam 1 Flashcards
What is the primary symptoms of atopic eczema?
Itchy skin
What is the atopic triad?
Combination of the following:
- Atopic dermatitis
- Allergic rhinitis (hay fever)
- Asthma
What is the clinical presentation of atopic eczema? Include appearance and location.
- Ranges from ill-defined, erythematous, scaling patches to edematous papules and vesicles
- Located on cheeks, scalp, and extensor surfaces in infants
- Located on flexural surfaces, hands, and feet in older children/adults
In pediatric patients, what is an important indicator that can help you determine if the presentation is atopic eczema or another rash?
The diaper area will be spared
What are essential/required features of atopic eczema in order to make the diagnosis?
- Pruritis
- Eczema
- Typical morphology and age-specific patterns
- Chronic or relapsing history
What are important features that are observed in the majority of cases and add support to the diagnosis of atopic eczema?
- Early age of onset
- Atopy (either personal or family history)
- IgE reactivity
- Xerosis
What are complications of atopic eczema?
- Excoriations
- Lichenification (thickened, dry, irritated skin due to chronic scratching / accentuated skin lines)
- Fissures (palms, fingers, soles) which can be very painful
- Secondary cellulitis as skin is often highly colonized with Staph aureus
- Eczema Herpeticum (disseminated viral infection - typically primary infection of HSV1)
What is Pityriasis Alba?
Inflammation that when it subsides/resolves, it causes and leaves hypopigmentation in those areas.
How is Eczema Herpeticum, a complication of Atopic eczema, typically treated?
Prompt treatment with antiviral needed (acyclovir or valacyclovir) as it is a dermatological emergency.
In general, what does optimal management of Atopic Eczema include?
Patient education which includes:
- Avoiding exacerbating factors (allergens/irritants) - - Hydrate the skin and restore skin barrier function
Pharmacologic treatment of skin inflammation:
- Topical/oral steroids
- Calcineruin inhibitors
- Antihistamines for itching
- Antibiotics
What should an individual avoid if diagnosed with atopic eczema?
- Common triggering irritants (fragrances, bleach, wool clothing, heat, low humidity)
- Animal dander, dust mites
- Excessive bathing/swimming
- Scented bath oils, lotions
How can an individual restore skin barrier function if diagnosed with atopic eczema?
- Avoid rubbing/scratching
- Treat stress and anxiety
What is the gold standard in regards to moisturizers?
Petroleum (Vaseline)
How often should a moisturizer be applied in cases of atopic eczema?
Two times daily and immediately after bathing
If prescribing topical corticosteroids for atopic eczema, what potency and how often should the patient apply it for mild disease?
Low potency applied 1-2x daily for 2-4 weeks
If prescribing topical corticosteroids for atopic eczema, what potency and how often should the patient apply it for moderate disease?
Medium to high potency applied 1-2x daily for 2-4 weeks
If prescribing topical corticosteroids for atopic eczema, what potency and how often should the patient apply it for acute flares?
Intermediate to super high potency may be used for up to 2 weeks, then replaced with a lower potency until lesions resolve
Where should one generally avoid applying topical corticosteroids? Why?
Thinned-skin areas such as the face, neck, and skin folds.
These areas have a higher absorption rate and risk of adverse effects.
What specific body regions have the highest percutaneous absorption rates?
- Forehead
- Mandible
- Genitalia
What are the potential adverse effects of topical corticosteroids?
- Skin atrophy
- Acneiform or rosacea-like eruptions
- Straie (thick red lines on skin)
- Bruising
- Telangiectasias
- Hypertrichosis (increased hair growth)
What are the two common topical calcineurin inhibitors that are prescribed?
- Pimecrolimus (Elidel) cream
- Tacrolimus (Protopic) ointment
What are topical calcineurin inhibitors prescribed for and how often are they applied?
- Prescribed for mild to moderate eczema of the face, eyelids, neck, and skin folds (thinned-skinned areas in which you avoid steroids). Applied twice daily.
- Maintenance therapy in adults and children 2-15 years old. Applied 2-3 times per week to recurrent sites of involvement to reduce relapse.
What is the topical calcineurin inhibitor formulation for adults? Patients 2-15 years old?
Adults: 0.1% formulation
2-15 years old: 0.03% formulation
What are side effects of topical calcineurin inhibitors?
- Burning
- Stinging
- Pruritis
(Note that these effects are most common during the 1st week of application and then subside)
What are oral antihistamines recommended for in atopic eczema?
Pruritis to break the itch-scratch-itch cycle
When would you prescribe antibiotics in atopic eczema?
If the complication of a secondary infection occurs
When would you prescribe oral steroids in atopic eczema?
Only in severe cases
What is the general population affected by Lichen Simplex Chronicus “Neurodermatitis”?
Females ages 30-50 years old
What are common areas in which you would observe Lichen Simplex Chronicus “Neurodermatitis”?
- Scalp
- Back of neck
- Wrists
- Forearms
- Lower legs
- Genitals (seen more in males)
What are common characteristics of Lichen Simplex Chronicus “Neurodermatitis”?
- Lichenified plaque caused by excessive scratching or rubbing
- Exaggerated skin markings, dry, leathery appearance, pigmentation
- Pruritis often worse at night
What are causes of Lichen Simplex Chronicus “Neurodermatitis”?
- Atopic dermatitis
- Contact dermatitis
- Psoriasis
- Lichen Planus
- Fungal infection
- Insect bite
- Neuropathy (DM)
- Anxiety/stress
What are treatment options for Lichen Simplex Chronicus “Neurodermatitis”?
- Stop itching/rubbing
- High potency topical steroids
- Moisturizers
- Antidepressants: SSRI - Paroxetine (Paxil), Sertraline (Zoloft) or tricyclic antidepressants
- 1st generation antihistamine, Hydroxyzine (Vistaril), or tricyclic antidepressant (Doxepin) can be used for nocturnal pruritis
What are common characteristics of Dyshidrotic Eczema “dyshidrosis/pompholyx”?
- Deep seated vesicles with tapioca-like appearance which can coalesce and rupture
- Intensely pruritic
Where is Dyshidrotic Eczema typically observed?
- Hands (80%)
- Sides of fingers
- Palms and soles
What are precipitating factors for Dyshidrotic Eczema?
Emotional stress and hot weather.
Also found in those with nickel allergy
What is the duration of Dyshidrotic Eczema?
Episodes are usually weeks to months apart with spontaneous remission after 2-3 weeks
What is the management for Dyshidrotic Eczema?
- Reassurance
- Wet dressings which draw fluid out of the vesicles (Burow’s soaks/Domeboro solution)
- Topical steroids
What is Keratosis Pilaris?
Disorder of keratinization causing the formation of horny plugs in hair follicles
What are common characteristics of Keratosis pilaris?
- Rough, raised papules (flesh, red or brownish)
- Usually worse in winter months
Where is Keratosis pilaris typically observed?
- Outer upper arms
- Thighs
- Cheeks
- Upper back
What is the treatment for Keratosis pilaris?
Individuals can try creams, exfoliating scrubs, topical retinoids, urea, salicylic acid, alpha-hydroxy acids, but there is not much one can do for it and typically improves with age.
What is the presentation associated with Allergic Contact Dermatitis?
- Dominant symptom is itch
- Localized to skin areas that came in contact with the allergen
- Hands, face, and eyelids are common
- Erythematous, papular dermaitis with indistinct margins; often blisters and edema
- Can take 1-3 days to appear after contact with allergen
What is the presentation associated with Irritant Contact Dermatitis?
- Burning, stinging pain
- Hands are most common
- Erythema, chapped skin, dryness, and fissuring
- More immediate onset (minutes to hours)
What are typical examples of Allergic Contact Dermatitis?
What are some other allergenic agents?
- Poison ivy, Oak, Sumac
- Nickel, Rubber, Latex, Preservatives, Cosmetics, Neomycin
What is a common Irritant Contact Dermatitis which involves saliva?
Lip licker’s dermatitis
What is the treatment for contact dermatitis?
- Topical steroids 1-2 times daily for 7-14 days
- Discontinue exposure to allergen OR irritant
- Decreased frequency of hand-washing if that is playing a role
- Use mild soap
- Wear gloves or protective clothing
- Apply bland emollient (Vaseline, Aquaphor)
- Consider an oral corticosteroids for Allergic Contact Dermaitis involving face or greater than 20% of body surface area
If prescribing an oral corticosteroids for Allergic Contact Dermaitis involving the face or greater than 20% of body surface area, what could you prescribe?
Prednisone 0.5-1 mg/kg per day (max 60 mg/day) for 7 days
Is a drug allergy Type I, II, III, or IV reaction?
Type I immune reaction mediated by IgE
What accounts for the large majority of all adverse cutaneous drug reactions?
Drug-induced exanthems
How long does it take for a drug-induced exanthem to develop?
Within 5-14 days of exposure
What are the common characteristics associated with Drug-induced exanthems?
- Morbilliform rash - erythematouse macules, papules (measle-like rash)
- Involves trunk and proximal extremities
- Mucosal involvement is absent
What commonly causes Drug-induced exanthems?
Penicillins and sulfonamides
What are common characteristics associated with urticaria “hives”?
- Intensely pruritic
- Circumscribed, raised erythematous eruption with central pallor
What is angioedema?
Swelling deeper in the dermis and subcutaneous tissue of the face and lips
What can lead to airway obstruction in angioedema?
Tongue swelling and laryngeal edema
When does urticaria and angioedema typically occur in a drug reaction?
Most commonly occurs during the first weeks of therapy, but can happen at any time, even months to years after being on the medication
What are examples of medications that commonly cause urticaria or angioedema?
- ACE inhibitors
- Antibiotics (penicillins, cephalosporins, sulfonamides)
What is the treatment for common cutaneous drug reactions?
When do these reactions typically resolve once treatment has started?
Treatment:
- Discontinue the offending drug
- Supportive and/or symptomatic care such as systemic corticosteroids, topical steroids, or antihisamines
Resolution:
Typically within 5-14 days
What are examples of severe cutaneous drug reactions?
- Drug-induced hypersensitivity syndrome (DIHS)
- Steven-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN)
What are common characteristics associated with Drug-induced hypersensitivity syndrome (DIHS)?
- Fever (100.4-104 F)
- Facial edema
- Rash (morbilliform eruption)
- Lymphadenopathy
- Blood abnormalities
- Visceral involvement (heart, kidney, liver)
What are causes of Drug-induced hypersensitivity syndrome (DIHS)?
- Antiepileptic agents
- Allopurinol (used for gout)
- Sulfonamides
What is SJS/TEN?
A rare, acute, potentially life threatening mucocutaneous reaction in which there is epidermal necrosis and sloughing off of the mucous membranes and skin due to Fas/Fas ligand-induced apoptosis
Which population is at a greatly increased risk for SJS/TEN?
HIV-infected individuals
What medications are commonly implicated in SJS/TEN?
What is another cause of SJS/TEN?
Medications:
- Allopurinol
- Anticonvulsants (phenobarbital, phenytoin, carbamazepine, and lamotrigine)
- Sulfonamides
- NSAIDS
Other:
Mycoplasma pneumoniae
What are the most common causes of SJS/TEN in pediatrics?
Medications:
- Anticonvulsants (phenobarbital, carbamazepine, and lamotrigine)
- Sulfonamides
Other:
Mycoplasma pneumoniae
What is Nikolsky Sign and what disorders is it commonly associated with?
Nikolsky Sign is the elicitation of skin blistering as a result of gentle mechanical pressure on the skin.
Commonly associated with SJS/TEN and Pemphigus
What is the common clinical presentation of SJS/TEN?
- Fever often greater than 39C/102.2F
- Flu-like symptoms 1-3 days before lesions develop
- Tender erythematous skin lesions, purpuric macules –> Vesicles/bullae form –> Skin sloughing
- Mucosal involvement
- Erythema and edema of lips
- Intraoral bullae –> painful friable raw surfaces and hemorrhagic crusts
- Oral, genital, and/or ocular involvement (conjunctival itching, burning, pain, corneal ulceration, and photophobia
What classifies SJS versus TEN?
SJS - skin detachment of less than 10% of total body surface area
TEN - skin detachment of greater than 30% total body surface area
How is SJS/TEN diagnosed?
Clinical initially, followed by skin biopsy and cultures
What is the treatment for SJS/TEN?
- Discontinue offending medication
- Hospital admission if extensive skin sloughing; ICU/burn unit depending on severity
- Supportive care
- Nutritional and fluid replacement
- Temperature maintenance
- Pain relief
- Ocular management
- Wound care/sterile handling
What is the typical cause of death associated with SJS/TEN?
Septicemia (S. aureus and P. aeruginosa)
What are the long-term complications associated with SJS/TEN?
- Cutaneous
- Mucosal
- Ocular
- Pulmonary
What is drug hypersensitivity?
Immune-mediated response to a drug in a sensitized patient
