Derm wk 4 Flashcards
1
Q
Most skin drug reactions are
A
Inflammatory
Generalized
Symmetric
2
Q
Immediate drug reactions
A
occur within 1 hour!
Urticaria (hives), Angioedema, Anaphylaxis
3
Q
Delayed drug reactions
A
Often occur after 6 hours, sometimes even weeks- months after starting med
Exanthematous, Fixed drug eruption, Systemic (DIHS, SJS/TEN), Vasculitis
4
Q
Most of the time, allergy testing is useless for med reactions, BESIDES with
A
PCN
PCN skin testing is preferred when evaluating possible type I, IgE mediated PCN allergy
5
Q
Test for PCN allergy
A
PCN skin testing
look for IgE mediated PCN allergy
6
Q
Risk factors for drug rxns
A
Female Prior drug rxn Recurrent drug exposure HLA gene Certain dz states- Mono or HIV positive
7
Q
HIV positive often have dermatologic rxns to
A
Sulfa
8
Q
Drug timeline
A
Onset of rash as day 0, then work backwards and forwards
9
Q
Widespread, symmetric
Confluent erythematous macules and papules on trunk and extremities, AKA
A
“Morbilliform” measles-like eruption
10
Q
macule
A
circumscribed, FLAT, discoloration that is <10 mm
11
Q
Most common skin drug eruption
A
Exanthematous Drug Eruption
12
Q
Details on Exanthematous Drug Eruption
A
Limited to Skin
Red macules and papules starting on the TRUNK and spread centrifugally to the arms/legs in symmetric fashion
13
Q
What might be present along with the Exanthematous Drug Eruption classic mac-pap rash?
A
Mild fever
Itchiness
Rash starts 7-10 days after drug if 1st time, and 1-2 days after drug if recurrent
14
Q
Papules
A
small also, <10 mm
but RAISED
15
Q
Can you keep taking the drug if you get an Exanth Drug Eruption rash?
A
Yes but only if eruption is not severe and med can’t be subbed
16
Q
How soon does Exanth Drug Erup last after stopping the med?
A
Clears up in a few days- week after med is stopped
17
Q
Tx for Exanth Drug Eruption rash
A
Topical steroids
Oral antihistamine
Reassurance
18
Q
Oral erythematous plaque with central bulla
A
Fixed drug eruption
19
Q
FDE- Fixed drug eruption
A
Formation of one or more round or oval patches or plaques that recur at same site with re-exposure to the drug
20
Q
Common culprits of FDE- fixed drug eruption
A
Laxatives Tetracyclines Metro Sulfa Barbs NSAIDs Salicyates (ASA) Food coloring
21
Q
Where do FDE often occur?
A
Mouth, genitalia, face, fingers, toes
but can occur anywhere
22
Q
How quickly do FDE show up?
A
In prev sensitized ppl, as soon as 30 min- 8 hours after taking drug
23
Q
Early lesions of FDE are sharply demarcated red macules (flat) —->
A
become raised, forming plaques, which may –> bullae then erosions
24
Q
In the healing phase, lesions from FDE
A
violet hue followed by post inflammatory hyperpigmentation
25
Tx for FDE
Non-eroded: Potent topical steroid ointment
Eroded: Protective or antimicrobial ointment + dressing
26
Pt presents with combo of:
Rash + Facial edema
suspect drug rxn with Eosinophilia and Systemic sx
| DRESS
27
If you suspect DRESS, what next
Order CBC- look for Eisinophilia, and LFT and Renal(kidney) fx test to evaluate for end organ damage
28
Normal platelet count
150-450
29
Normal Hematocrit
36-48%
30
Drug Induced Hypersensitivity Syndrome (DIHS) is AKA
DRESS- Drug Rxn w Eisinophilia and Systemic Sx
31
Skin eruption with systemic sx and internal organ involvement (Liver, Kidney, Heart)
DRESS
or
DIHS
32
Typical signs of DRESS or DIHS
Rash, red centrofacial swelling, fever, malaise, lymphadenopathy, involvement of other organs
33
Most pts experiencing DRESS/DIHS have what on labs
Eosinophilia
>70% have this
34
How long does it take for DIHS/DRESS sx to occur?
in the 3rd week (but range 1-12 weeks) after starting the medication
Sx can persist and recur for many weeks after stopping drug
35
What is fatality rate for DRESS/DIHS?
up to 10%
36
Common meds causing DIHS/DRESS
```
Allopurinol
Abx- Sulfa, PCN, Mino, Metro
AntiTB- Isoniazid
Anticonvulsant- Phenytoin, Carbamazepine, Lamotrigine
NSAIDs
Anti-HIV- Abacavir
```
37
Approach to pt with suspected DIHS
Stop (or sub) all culprit meds and discontinue non-essential meds
38
Tx for DIHS
mild: topical steroids + systemic antihistamines
severe: systemic steroids (prednisone) and taper gradually weeks- months
severely ill: ICU
39
"Sloughing rash"
On Sulfa and Bactrim for UTI
SJS/TEN!!
Widespread erosions on face, upper trunk, and arms
Begin as painful flaccid blisters
40
How do SJS and TEN differ?
BSA- % body surface area that is involved
41
Mortality rate of SJS
5-12 %
42
Mortality rate of TEN
>20%
worse!
43
SATANN is a mnemonic to help remember common meds that can cause SJS/TEN!
```
Sulfa
Allopurinol
Tetra, thiacetazone
Anticonvulsant
NSAIDs
Nevirapine
```
44
What precedes the rash of SJS/TEN?
Fever
HA
Runny nose
Myalgias by 1-3 days
45
How soon after taking med does SJS/TEN start?
within 8 wks after drug initiation
46
Red, irregularly shaped, dusky red to purple macules,
that progressively coalesce
SJS/TEN rash description
47
Dark center of atypical target lesion may blister
SJS/TEN
48
Classifying SJS/TEN
SJS <10 % BSA
SJS/TEN 10-30%
TEN >30%
49
Mucous membrane involvement associated with SJS/TEN
Red --> painful erosions of the buccal, ocular, and genital mucosa
Mouth, Eyes, Genitals
50
Whats the worst part of Eye involvement with SJS/TEN
Many will suffer permanent Eye sequelae, even blindness
51
SJS/ TEN complications
```
Eye damage
Oral cavity sicca synd and pain
GU damage
Pulmonary- bronchitis, bronchiectasis
Fluid/electrolyte disturbance
Nutrition requirements
Secondary INFECTION
```
52
SJS/TEN Tx
consult Dermatology and Ophthalmology
Burn unit
IV steroids, IVIG, Cyclosporine, or Etanercept are given variable at diff centers
53
Prevention of SJS/TEN
FDA recommends
Test for HLA-B 1502 for all pts SOUTHEAST ASAIN starting Carbamaz
Test for HLA-B 5701 for ALL PTS starting Abacavir
54
Another gene association
HLA-B 5801 genetic screening for some Southeast Asain, Japanese, European patients starting Allopurinol
55
Genes and associations
HLA 1502: Carbamazepine
HLA 5701: Abacavir
HLA 5801: Allopurinol
56
1502
Carbamazepine
57
5701
Abacavir
58
5801
Allopurinol
59
Cardinal sx of Urticaria
Pruritis
60
Urticaria is caused by
swelling of the upper dermis
61
Angioedema
Same mechanism as hives, but in the DEEP DERMIS and SUBQ
swelling is the major manifestation
62
Angioedema and/or Urticaria can be the ________ of Anaphylaxis
Skin portion
assessment of the Respiratory and Cardiovascular sx are vital!
63
Course of hives
Appear within minutes, enlarge, and then disappear in hours
Rarely last longer than 12 hours
64
Urticaria can be Acute or Chronic
Acute: <6 weeks
Chronic: recurrent more than 2 days per week longer than 6 weeks
65
Common cause of Acute Urticaria
```
Idiopathic
Infection- URI, strep, worms
Food- shellfish, nuts, fruit
Drug rxns
IV products- contrast or blood products
```
66
Cholinergic Urticaria
triggered by heat and emotion
67
Dermatographism
most common form of physical urticaria- sharply localized edema/wheal within seconds-min of skin being rubbed
68
Urticaria Multiforme
Kiddos
| Polycyclic or Annular lesions with dusky and ecchymotic centers along with acral edema (fingers and toes= acral)
69
Urticaria Multiforme
improves w Antihistamines
70
Immunologic urticaria
related to IgE
Antigen binds to IgE on the mast cell causing degranulation and release of Histamine
71
Non-Immunologic urticaria
not dependent on the binding of IgE receptors
i.e. ASA induced hives
72
Diffuse red papules coalescing into plaques
Wheals
73
Is lab testing required for ACUTE Urticaria?
No
74
Common causes of hives via the IgE mediated mechanism
PCN
| Other Abx
75
Common cause of NON-IgE mediated mechanism
ASA
76
30% of Chronic Urticaria is MADE WORSE BY
ASA/NSAID use
77
Evaluating chronic urticaria
Encourage pt to take picture to show you
Often, no external cause can be identified
If physical trigger suspected, a challenge test with the trigger may be performed
78
IgE mediated food allergy more common with
Acute urticaria
79
Average duration of Chronic Urticaria
2-5 years,
but can extend beyond this
80
What can someone with Chronic Urticaria try
Avoid tight triggers
Stop Ibuprofen or other NSAID use
Start 1st gen Antihistamine i.e. Hydroxyzine
81
Reassurance for chronic urticaria
About 1/2 patients undergo remission within 1 year
82
1st line tx for Acute and Chronic Hives
Oral H1 Anthistamine
83
What types of ppl may require Renal dosing when taking H1 Antihistamines
Children
Elderly
Pts w Kidney or Live impairment
84
CAUTION in using H1 Antihistamines in
Glaucoma
Prostatic hyperplasia
Respiratory dz
85
1st Gen Antihistamine
Diphenhydramine
Hydroxyzine
Chlorpheniramine
86
2nd Gen Antihistamine
Cetirizine
Loratadine
Fexofenadine
87
Refer to derm if Hives have 1 of the following:
- last more than 48 hrs
- painful and burning
- systemic sx
- no response to Antihis
- leave pigment change upon resolution
88
Tx for Anaphylaxis
Epi
IVF
Oxygen
89
Adult dosage for Epi treating Anaphylaxis
0.3-0.5 mL in 1:1000 epi dilution IM
repeat every 10-20 min as necessary
90
Child <30 kg dosage for Epi treating Anaphylaxis
0.01 mL/kG
91
Most common cause of urticaria in kids is
Viral illness
92
"itchy red rash" waxing and waning, involving her face
mother has hx of Asthma and Allergic Rhinitis
sounds like ATOPIC DERMATITIS (eczema) case
93
Chronic, pruritic, inflammatory skin disease
Atopic Dermatitis
one of the most commin skin disorders in developed countries
94
Onset of Atopic Derm
usually b/w 3-6 mo
90% diagnosed by age 5
95
How often does Atopic Derm persist into adulthood?
30%
96
"The itch that rashes" bc Atopic Derm is itchy and then pts scratch it which makes it
WORSE
97
Distribution of Atopic Derm
Symmetric
98
Lesions are red and scaly
| May display vesiculation, oozing, and crusting
More chronic lesions can even become lichenified
99
Lichenification
epidermal thickening with accentuated skin lines from chronic irritation
100
Atopic Derm for INFANTS and TODDLERS affects what body parts
Scalp
forehead
cheeks
Extensor surfaces
(back of arms, back of legs)
101
Atopic Derm for Older children affects what body parts
FLEXORAL areas
| neck, elbows, knees, wrists, ankles
102
Eczema is a nonspecific term encompassing
Itchy
Erythema
Scale
103
Atopic Dermatitis is a more specific type of
Eczematous dermatitis
104
Factors thought to contribute to Atopic Dermatitis
Genetic pre-D
Skin barrier dysfx
Immune dysregulation
Environment
105
Best tx for a child's face with Atopic Dermatitis
Hydrocortisone 2.5% ointment
106
Super high potency steroid
Clobetasol
like a CLUB, super STRONG
107
High potency steroid
Fluocinonide
108
Medium potency steroid
Triamcinolone
109
Low potency steroid
Desonide
| Hydrocortisone
110
Bathing rec for someone with Atopic Derm
Apply moisterizer after bathing
Limit use of soap/cleanser
Dilute bleach baths
111
Refer pt with Atopic Derm to Dermatology when
Recurrent skin infection
Extensive/severe dz
Sx poorly controlled w topical therapy
112
Systemic therapy for Atopic Derm
```
Light therapy w NbUVB
Immunosupp meds:
-Cyclosporine
-Mycophenolate mofetil
-MTX
-Azathioprine
```
113
Biologic drug for Atopic Derm
Dupilumab
monoclonal antibody directed against IL-4 and IL-3
114
If low dose steroid is not working to control flare
Increase dose, then taper off once sx are controlled
115
How is food related to AD
Food allergy is a known trigger in 20-30% of pts w Mod-Sev AD
116
Atopic march
Atopic derm --> Rhinitis --> Asthma
117
Explaining Atopic Derm boy's foot
Lichenified red plaques with overlying scale, fissuring, hemorrhagic and brown crust
118
What do you need to consider in pts that have Weepy flares of AD?
i.e. when Pustules, Erosions, or Crusting are present- yellow, brown, hemorrhagic
Skin Bacterial Culture
bc secondary infection from Staph or Group A Strep is common
119
Way to describe the boy
| s face that had white spots
Poorly defined HYPOPIGMENTED patches w fine scale on the face
120
Pityriasis Alba may present as
Poorly defined hypopigmented patches w fine scale on the face
121
What is Pityriasis Alba?
Mild, often no sx, form of Atopic Derm of the face
122
Poorly marginated, hypopigmented, slightly scaly patches on the CHEEKS
Pityriasis Alba
123
Who is Pityriasis Alba usually found in?
Young children w darker skin
often in spring or summer when the unaffected skin tans, becomes more noticeable
124
Tx for Pityriasis Alba
Moisterizer BID
| Sun protection
125
If no improvement of Pityriasis Alba after moisterizing and sun protection, consider
- Low strength topical steroid
| - Topical calcineurin inhibitor
126
Long term tx for AD vs Acute care
Emollients and gentle care
| Acute flare: topical steroids
