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PHARM 130 - Exam > Dermatitis > Flashcards

Dermatitis Flashcards

1
Q

What are the characteristics of acute atopic dermatitis (AD)?

A
  • Pruritus
  • Xerosis
  • Erythema, edema
  • Blistering, oozing and crusting
  • scratching
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2
Q

What are the characteristics of chronic AD?

A
  • Thickening
  • Lichenification
  • Excoriations (picking at the skin)
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3
Q

Where does AD effect infants and younger children, older children and adults?

A

Infants/younger children –> face and extensor areas

Older children –> flexural areas

Adults –> face and hands

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4
Q

What are the characteristics of acute stasis dermatitis (SD) and where is it found?

A
  • inflammation
  • erythema, edema
  • pigmentation
  • ulceration

Typically found on any part of the lower leg but in most cases is proximal to the medial malleolus

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5
Q

What are the characteristics of chronic SD?

A
  • Scaling
  • Linchenification
  • Edema
  • Discolouration
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6
Q

What are the characteristics of acute contact dermatitis (CD)?

List for both allergic and irritant

A

Allergic

  • intensely pruritic
  • pain with scratching or infection
  • signs may range from transient erythema to severe swelling with bullae and/or ulceration

Irritant:

  • more painful than pruritic
  • signs may range from mild erythema to crusting, pustules, bullae, hemorrhage and erosions
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7
Q

What are the characteristics of chronic CD?

A
  • thickening
  • xerosis
  • discolouration
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8
Q

What areas are typically effected by CD?

A

Areas in contact with the allergen or irritant; in some cases allergic CD may be generalized

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9
Q

What are the red flags that warrant further assessment of both AD and CD?

A
  • affects more than 30% BSA
  • involves the palms of hands or soles of feet
  • may be infected
  • involves edema that persists or worsens over time
  • significantly interferes with sleep or daily activities
  • fails to improve within 7 days of pharmacologic and non-pharmacologic treatment or does not resolve within 14 days
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10
Q

What are the goals of therapy for treating AD or CD?

A
  1. Provide adequate relief while attempting to resolve lesions
  2. Restore barrier function of skin
  3. Reduce risk of secondary infection
  4. Identify and eliminate triggers
  5. Implement strategies to prevent/minimize recurrence
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11
Q

What are the non-pharmacologic options for the treatment of dermatitis?

A
  • keep environment temperate (mild) with moderate humidity
  • choose swimming as a sport
  • wear loose-fitting cotton or cotton blend clothing
  • bathe using lukewarm water and a mild soap/soapless cleanser
  • do NOT restrict diet in absence of a confirmed food allergy
  • use wet dressings
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12
Q

What are the 3 types of wet dressings that can be used to treat dermatitis and when are they indicated?

A
  1. Compresses –> when oozing and crusting is present
  2. Soaks –> when hardened crusts and scaling are present (chronic)
  3. Wraps –> moderate to severe AD and/or resistant cases
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13
Q

What are the mechanisms and instructions for use for a compress?

A

Mechanism: cool and dry skin through evaporation

Instructions:

1) soak gauze or a thin cloth with solution
2) wring gently so it remains wet but not dripping
3) Apply to the skin, remove, remoisten, and reapply every few minutes for 20-30 minutes, 4-6x day
4) lotion may be applied after but avoid occluding with ointment

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14
Q

What are the mechanisms and instructions for use for a soak?

A

Mechanism: softens hardened crusts and hydrates skin

Instructions:

1) saturate gauze or cloth with solution
2) apply to area for 15-20 minutes without removal

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15
Q

What are the mechanisms and instructions for use for a wrap?

A

Mechanism: increase penetration of topical agent, decrease water loss and provide physical barrier against scratching

Instructions:

1) topical agent is covered by a wetted layer of tubular bandages or gauze
2) second layer is applied
3) can be worn for several hours depending on patient tolerance

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16
Q

What is the solution that can be used for the different wet dressings?

A

Tap water, saline or pharmacologic solution containing astringents and/or antiseptics

Cold solution can be used for itch relief

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17
Q

What are the non-pharmacological options in the treatment of SD?

A
  • compresses or soaks
  • avoid applying non-essential topical agents to avoid concurrent CD
  • avoid ointment/occlusive bases

MOST IMPORTANT: treating the underlying CVI

  • graduated compression stockings between 20-40mmHg facilitate blood flow
  • daily walking or exercise
  • weight reduction
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18
Q

What is the general approach to treatment for AD?

A

Moisturizer therapy and non-pharmacologic strategies are used in conjunction with topical corticosteroid.

To step up therapy:
topical corticosteroid –> topical calcineurin inhibitors OR topical phosphodiesterase 4 inhibitors –> phototherapy or systemic therapy

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19
Q

What are the non-Rx bath products available for the treatment of dermatitis and what are their mechanisms? (2)

A

Bath oils –> slow water loss from the skin, improve xerosis and soothe irritated skin (more effective than oatmeal in trapping water)

Colloidal oatmeal –> decreases pruritus (useful when large BSA is affected but does not significantly improve xerosis)

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20
Q

What are the different non-Rx moisturizers available for the treatment of dermatitis and what are their mechanisms? (4)

A

Emollients –> slow water loss and lubricate the skin; o/w products also decrease pruritus

Hydrating products –> decrease water loss from skin

Occlusive agents –> delay water evaporation from skin and protect against irritants (generally causes less stinging than emollients/hydrating products but is not appropriate on inflamed or oozing lesions)

Barrier repair products –> restore ceramide balance in the skin (tingling may occur for 10-15 minutes after application)

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21
Q

What are the non-Rx topical corticosteroids used for the treatment of dermatitis, what schedule are they and what are some important counselling points to communicate to patients? (2 products)

A

Hydrocortisone 0.5% or 1% –> lowest potency TCS (NHP)
Clobetasone butyrate 0.05% –> medium potency TCS (schedule 2)

Counselling points:

  • Hydrocortisone not recommended for <2 years
  • Clobetasone butyrate not recommended for <12 years
  • can be applied BID-TID for MAXIMUM 2 weeks
  • may cause stretch marks, spider veins and atrophy but uncommon when used for under 2 weeks
22
Q

What is the lowest potency Rx TCS and what is it indicated for?

A

Hydrocortisone 2.5% –> mild dermatitis, safe for application to face

23
Q

What is the low potency Rx TCS and what is it indicated for?

A

Desonide 0.05% cream –> mild dermatitis

24
Q

What is the lower-medium potency Rx TCS and what is it indicated for?

A

Hydrocortisone Balerate 0.2% –> mild to moderate dermatitis

25
Q

What are the medium potency Rx TCS and what are they indicated for?

A

Betamethasone valerate 0.05% or 0.1% –> moderate dermatitis

Mometasone furoate 0.1% –> moderate dermatitis

26
Q

What are the high potency Rx TCS and what are they indicated for?

A

Betamethasone dipropionate 0.05% –> moderate dermatitis

Fluocinide 0.05% –> moderate dermatitis

27
Q

What are the very high potency Rx TCS and what are they indicated for?

A

Clobetasol propionate 0.05% –> severe dermatitis

Halobetasol propionate 0.05% –> severe dermatitis

28
Q

What are the instructions for use, limitations and cautions of Rx TCS?

A

Instructions: applied QD or BID depending on product and body area being treated

Cautions:

  • may cause stretch marks, spider veins and atrophy (uncommon when used for under 2 weeks)
  • risk of HPA axis suppression (rare when used appropriately)
29
Q

What are the second line or “step up” Rx therapies in the treatment of dermatitis and what are their indications and mechanism?

A

Topical Calcineurin Inhibitors: cyclosporine analogue with anti-inflammatory effects

  • Primecrolimus 1% cream (Elidel) –> mild to moderate AD
  • Tacrolimus 0.03% or 0.1% ointment (Protopic) –> moderate to secere AD

Topical PDE-4 Inhibitors: boron-based molecule that blocks PDE-4
- Crisaborole 2% ointment (Eucrisa) –> mild to moderate AD

30
Q

What are the cautions and limitations associated with topical calcineurin inhibitors? (ages, contraindications, SE)

A
  • Primecrolimus 1% not recommended for <3 months
  • Tacrolimus 0.03% not recommended for <2 years, 0.1% is reserved for >16
  • contraindicated in immunocompromised patients
  • may cause transient burning
  • alcohol ingestion may cause redness & burning at the site of application
  • unnecessary UV exposure should be avoided
31
Q

What are the cautions and limitations associated with topical PDE-4 inhibitors?

A
  • not indicated <3 months

- may cause mild stinging/burning

32
Q

When are oral antihistamines indicated in patients with dermatitis? What type of OAH should they use and what will it help with?

A

Indicated as a step-up to help with sleep and possibly decreasing itching

Not recommended as a substitute for better disease control, TAH not recommended either

Second generation agents are longer lasting and better tolerated but do not really have value in AD/CD –> use 1st gen (Diphenhydramine)

33
Q

What are 1st line treatments for irritant CD?

A

TCS and moisturizers

Topical barrier products can be used to protect the skin against irritants

34
Q

What effect does zinc sulfate have on the treatment of dermatitis?

A

Oral administration may improve allergic CD due to nickel sensitivity

35
Q

What are the considerations for TCS in special populations? (geriatric, children and pregnant/breastfeeding)

A

Children and older adults: greater systemic absorption of topical products, higher risk of HPA axis suppression and other steroid-related side effects

Pregnancy: systemic absorption of TCS is low and use has reported no risk in pregnancy or breastfeeding (if applied to breasts, carefully remove before feeding)

36
Q

What is corticophobia?

A

Negative feelings and beliefs related to topical corticosteroid use resulting in poor adherence and treatment response

37
Q

What are the pros and cons of lotions?

A

Pros: less greasy, good for large or hairy areas

Cons: alcohol based and higher water content may dry area

38
Q

What are the pros and cons of creams?

A

Pros: cosmetically acceptable, good for weeping areas

Cons: less absorption

39
Q

What are the pros and cons of ointments?

A

Pros: excellent penetration, emollient effects (good for dry and scaly areas), less irritating

Cons: less cosmetically acceptable, may cause irritation in hot, humid environments

40
Q

What are the FTU needed to cover the face, trunk/front/back, arm/hand, and leg/foot?

A

Face & neck = 2.5

Trunk, front, back = 14

Arm & hand = 4

Leg & foot = 8

41
Q

What are the monitoring parameters for the patient and when should follow up be with the RPh?

A

Inflammation & pruritus –> decrease by 50%
Area involved –> no progression
Sleep and daily activities –> may take several weeks to return to normal
AE –> none/minimal

Patients should monitor daily
RPh to follow up in 1 week

42
Q

What is the appearance and location of irritant diaper dermatitis?

A

Mild erythema, shiny patches with deep erythema, papules, vesicles and ulcers

Found on convex surfaces

43
Q

What is the appearance and location of allergic diaper dermatitis?

A

Grouped linear tense vesicles and blisters with marked edema in severe cases

Generally limited to areas in contact with the allergen

44
Q

What is the appearance and locations of candidal diaper dermatitis?

A

Beefy red plaques with satellite pustules and early maceration of skin

Almost always involves inguinal folds

45
Q

What are the red flags associated with diaper dermatitis?

A
  • acute onset with pus, vesicles, or ulceration
  • frequent recurrences
  • moderate or severe presentation
  • rash or skin lesions outside the diaper area
  • complicated secondary infection or comorbid UTI
  • significant behavioural changes
  • signs of abuse or neglect
  • significant behavioural changes
  • patient is immunocompromised
  • fails to improve in 7 days despite appropriate treatment or dose not resolve after 14 days
46
Q

What are the goals of therapy for diaper dermatitis?

A
  1. Relieve symptoms
  2. Resolve dermatitis
  3. Prevent complications
  4. Prevent recurrences
47
Q

What are the non-pharmacologic strategies for treating diaper dermatitis? (ABCDEs)

A

A –> air, absorptive; encourage air drying
B –> barriers; apply barrier product with each diaper change, avoid powders
C –> cleansing, compression; clean area gently after urination/defication, apply wet dressings
D –> diapers; change q3-4h and whenever there is wetness/BM, wash in mild detergent
E –> education; educate patients and caregivers on prevention and treatment

48
Q

What is the general approach to treatment for diaper dermatitis?

A
  1. Ensure adherence to ABCDE measures and change protectant barrier to zinc oxide 20-40%
  2. If ineffective, determine whether DD is predominantly inflammatory or if Candida infection is suspected
    - -> if Candida suspected, add topical antifungal
    - -> if inflammatory, add hydrocortisone 0.5-1%
  3. follow up in 7 days, if resolved continue ABCDEs, if improved but not resolved, continue treatment for 7 more days, if worsened, refer
49
Q

What are the options for non-Rx barrier products for prevention of DD?

A

Ceramide-based, petrolatum, and silicone based

50
Q

What are the options for non-Rx barrier-absorptive products for the treatment and prevention of DD?

A

Zinc Oxide –> also has astringent and antiseptic properties, prevention at lower % and treatment at higher %

51
Q

What are the topical anti-fungals that can be used for candidal DD? (nonRx - 3, Rx - 2)

A

Non-prescription:

  • Clotrimazole 1%
  • Miconazole 2%
  • nystatin (slightly less effective than imidazole therapy)

Prescription:

  • Ciclopirox 1% (inferior to imidazoles)
  • Ketonazole 2%

PHARM 130 - Exam (10 decks)

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