Dermatitis Flashcards
ATOPIC DERMATITIS (AD): AKA ECZEMA
Complications
- Secondary cutaneous infections (scratching, “itch that rashes”) (bacterial: staph. aureus: yellow crusting lesions/eczematous lesions)
- Poor sleep/insomnia: waking up to itch
REFER if bacterial infection
ATOPIC DERMATITIS: WHEN TO REFER
1 Moderate to severe condition with intense pruritis
2 Involvement of large area of body (> 20%)
3 < 1 year of age
4 Secondary Infection
5 Involvement of face / intertriginous areas (armpits/groin)
6 If Sx worsen during treatment
ATOPIC DERMATITIS: PREVENTION
Identify/avoid triggers:
- allergens, chemicals, cosmetics, etc
- use cotton sheets
- launder new clothes before wearing
Skin hydration
- moisturize with emollients BID
ATOPIC DERMATITIS: NON-PHARMACOLOGIC TREATMENT
Limit bath/shower time
- first 5 min hydrates the skin, > 5 min dehydrates the skin when water is hot
- lukewarm water
- daily or every other day (QOD) baths
- avoid soap (use non-soap cleansers)
- pat skin dry (do not rub)
- apply moisturizer to skin immediately after bathing
Keep fingernails short, smooth and clean
- wear cotton gloves/socks on hands to bed at night if itching at night
Keep room humidity high
- humidifier in bedroom at night
TREATMENT: PHARMACOLOGIC-ACUTE AD + refer
If its wet, dry it” : For weeping
- Astringents: Al acetate 5%, USP: dilute
- Witch hazel (hamamelis water)
- Less expensive: Isotonic saline solution, Tap water, Diluted white vinegar
REFER:
- If lesions continue to weep after TWO days of treatment
Pharm Tx of Acute AD: CS dosing/admin, poor sleep, what to avoid
OTC hydrocortisone 0.5-1% cream
- Apply BID-QID prn to affected area for up to 7 days
- Avoid use over large surface areas, prolonged use (> 7 days)
- Avoid use on infected site or eyes/face, avoid ointment
Itching/Poor Sleep
- Oral, sedating antihistamine
AVOID
- Topical anesthetics (benzocaine), topical antihistamines (diphenhydramine) , topical antibiotics (containing neomycin)
- May cause sensitization leading to drug-induced ACD
TREATMENT: PHARMACOLOGIC: CHRONIC AD
“ If it’s dry, wet it”: Chronic AD
Moisturization:
Bath Oils: mineral/veg oil w. a surfactant
- May also contain colloidal oatmeal
- Can add to bath water at end of bath or applied as a wet compress (1 tsp in 1⁄4 cup warm water)
- Can make tub slippery; safety hazard for children and elderly patients
Cleansers
- Avoid typical soaps that contain long chain fatty acids (oleic, palmitic, stearic acid) and alkali metals (Na, K): remove natural lipids that keep skin soft and pliable + increase skin pH
- Glycerin soaps: Transparent, higher oil content because addition of castor oil
- Mild cleansers (Cetaphil Restoraderm): Contain shea butter, glycerin + maintains skin pH
Moisturization: Chronic AD
Emollients and Moisturizers
- Petrolatum 100% USP: effective/inexpensive when applied at bedtime and covered with wet wraps/clothes
- Greasy; less cosmetically appealing
- Do not apply over puncture wounds or laceration
- Mineral Oil
- Dimethicone
- Lanolin (rxn from wool fraction)
Humectants: help skin retain water (glycerin, hyaluronic acid, etc)
Ceramides
DRY SKIN (XEROSIS): Signs and Sx
DUE TO: winter, low humidity, windy/cold/dry climates, hot showers/excessive soap, prolonged detergent use, malnutrition, dehydration, hypothyroidism, advanced age
1 Roughness 2 Scaling 3 Loss of flexibility 4 Fissures 5 Inflammation 6 Pruritis 7 “Cracked” appearance, esp on arms and legs
DRY SKIN (XEROSIS): TREATMENT
Treatment similar to Chronic Dermatitis
Bathing
- Limits baths/showers to 3-5 minutes 2-3x/week
- Can add bath oil to baths. Tepid water baths, not hot
- Bath products: avoid soap-use non-soap cleansers
- Pat body dry, and apply body moisturizer within 3 minutes of leaving bath
Moisturization: Apply at least TID
If itching
- Apply a more lubricating moisturizer, and/or
- Topical hydrocortisone 0.5-1% ointment BID-QID for up to 7 days if needed
- See PCP if no resolution within 1-2 weeks
Stay well hydrated
Increase room humidity with a humidifier
IRRITANT CONTACT DERMATITIS (ICD): Sx
Acute
1 Inflammation, redness, swelling
2 Itching, burning, stinging
3 Crusting may occur within days
*If remove irritant, resolution in several days
*If chronically exposed to irritant, inflammation can persist and lead to fissures, scales, hyper-and hypo-pigmentation
Chronic
- Lichenification
IRRITANT CONTACT DERMATITIS: Tx (prev, non-pharm, pharm, avoid)
Prevention
- Using protective clothing, gloves or other equipment
- Frequent changes in coverings
Non-pharmacologic Treatment
- Immediate washing of area if exposed to an irritant
Pharmacologic Treatment
- Liberal application of emollients
- Assist in restoring moisture and protect stratum corneum from further damage
If itching: Colloidal oatmeal baths or Topical Hydrocortisone
AVOID: caine-type anesthetics, salicylic acid, lactic acid, urea, propylene glycol
ALLERGIC CONTACT DERMATITIS (ACD): Sx
Distribution and presentation of rash
Acute
- Rash presents as papules, small vesicles, sometimes large bullae over inflammed , swollen skin
- Significant itching
Chronic
- Lichenification
ALLERGIC CONTACT DERMATITIS (ACD): REFER
1 < 2 years of age
2 Dermatitis present for > 2 weeks
3 Involvement of > 20% of body surface area
4 Presence of numerous bullae
5 Extreme itching, irritation, or severe vesicle/bulla
6 Swelling of body/extremities/eyes
7 Involvement / discomfort of genitalia or mucus membranes
8 Signs of infection
9 Failure of self-management after 7 days
10 Low tolerance for pain, itching, or sx discomfort
11 Impairment of daily activities
ALLERGIC CONTACT DERMATITIS (ACD): Non-pharm
Removal of antigen
- Wash exposed area with soap and water
- Can use an urushiol cleanser: contains mineral spirits, water, soap, and a surface active agent
- Rub into area as soon as possible after exposure
- Aims to limit exposure to other areas of the body
- Cleanse area for a minimum of 2 minutes
Avoid cleaning with alcohol
ALLERGIC CONTACT DERMATITIS (ACD): PHARM
- Aluminum acetate 5% (Burow’ solution)
- Aluminum sulfate 1347mg (Domeboro astringent solution)
- Calcium acetate 952mg (astringent powder packets)
- Isotonic saline solution, or diluted white vinegar, or tap water
Itch relief
- Calamine Lotion: skin protectant that provides relief from itch, pain, discomfort and dries weeping and oozing
- Caladryl Lotion: shake well, leaves a pink/white residue on skin
- Hydrocortisone 0.5-1% cream TID-QID prn: Don’t use ointment if weeping, oozing lesions. Cream is preferred
- Colloidal oatmeal baths
ALLERGIC CONTACT DERMATITIS (ACD): AVOID
- Caine-type anesthetics
- Topical diphenhydramine and other topical antihistamines
- Topical antibiotics containing neomycin
- All are known sensitizers and can cause drug-induced ACD and worsen the problem
WOUND INFECTIONS: Sign and Sx
LOCAL
- Erythema
- Edema
- Pain
- Crepitation
- Purulent / odorous exudate in affected area
SYSTEMIC - Fever - Flu-like sx - Leukocytosis > REFER
CLASSIFICATION OF WOUNDS: STAGES
SELF CARE
- Stage 1: no loss of skin, warmth, redness
- Stage 2: superficial lesion, epidermis/dermis damage
REFER
- Stage 3: full-thickness skin loss, damage to entire epidermis
- Stage 4: deep full thickness skin loss, tissue necrosis
PHARMACOLOGIC TREATMENT OF WOUNDS
Antiseptics:
• Chemical substances used to disinfect
• Designed for application to INTACT skin up to the
EDGES of a wound
• In open wounds antiseptics can cause harm by:
- leukocytotoxic action
- increasing intensity and duration of inflammation; causes tissue necrosis
• Normal saline or water is sufficient for irrigation to remove dirt and debris with a wound
FIRST AID TOPICAL ANTIBIOTICS
Act to prevent infection in minor cuts, wounds, scrapes, and burns, especially useful if wound contains debris or foreign matter
If healing has not occurred within 7 days, refer patient to PCP
Products:
- Some contain a triple antibiotic formulation:
- Bacitracin
- Neomycin (sensitizing. Avoid using alone)
- Polymyxin B
