Dermatitis Flashcards
What are the characteristics of acute atopic dermatitis (AD)?
- Pruritus
- Xerosis
- Erythema, edema
- Blistering, oozing and crusting
- scratching
What are the characteristics of chronic AD?
- Thickening
- Lichenification
- Excoriations (picking at the skin)
Where does AD effect infants and younger children, older children and adults?
Infants/younger children –> face and extensor areas
Older children –> flexural areas
Adults –> face and hands
What are the characteristics of acute stasis dermatitis (SD) and where is it found?
- inflammation
- erythema, edema
- pigmentation
- ulceration
Typically found on any part of the lower leg but in most cases is proximal to the medial malleolus
What are the characteristics of chronic SD?
- Scaling
- Linchenification
- Edema
- Discolouration
What are the characteristics of acute contact dermatitis (CD)?
List for both allergic and irritant
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
What are the characteristics of chronic CD?
- thickening
- xerosis
- discolouration
What areas are typically effected by CD?
Areas in contact with the allergen or irritant; in some cases allergic CD may be generalized
What are the red flags that warrant further assessment of both AD and CD?
- 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
What are the goals of therapy for treating AD or CD?
- Provide adequate relief while attempting to resolve lesions
- Restore barrier function of skin
- Reduce risk of secondary infection
- Identify and eliminate triggers
- Implement strategies to prevent/minimize recurrence
What are the non-pharmacologic options for the treatment of dermatitis?
- 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
What are the 3 types of wet dressings that can be used to treat dermatitis and when are they indicated?
- Compresses –> when oozing and crusting is present
- Soaks –> when hardened crusts and scaling are present (chronic)
- Wraps –> moderate to severe AD and/or resistant cases
What are the mechanisms and instructions for use for a compress?
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
What are the mechanisms and instructions for use for a soak?
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
What are the mechanisms and instructions for use for a wrap?
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
What is the solution that can be used for the different wet dressings?
Tap water, saline or pharmacologic solution containing astringents and/or antiseptics
Cold solution can be used for itch relief
What are the non-pharmacological options in the treatment of SD?
- 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
What is the general approach to treatment for AD?
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
What are the non-Rx bath products available for the treatment of dermatitis and what are their mechanisms? (2)
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)
What are the different non-Rx moisturizers available for the treatment of dermatitis and what are their mechanisms? (4)
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)
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)
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
What is the lowest potency Rx TCS and what is it indicated for?
Hydrocortisone 2.5% –> mild dermatitis, safe for application to face
What is the low potency Rx TCS and what is it indicated for?
Desonide 0.05% cream –> mild dermatitis
What is the lower-medium potency Rx TCS and what is it indicated for?
Hydrocortisone Balerate 0.2% –> mild to moderate dermatitis
What are the medium potency Rx TCS and what are they indicated for?
Betamethasone valerate 0.05% or 0.1% –> moderate dermatitis
Mometasone furoate 0.1% –> moderate dermatitis
What are the high potency Rx TCS and what are they indicated for?
Betamethasone dipropionate 0.05% –> moderate dermatitis
Fluocinide 0.05% –> moderate dermatitis
What are the very high potency Rx TCS and what are they indicated for?
Clobetasol propionate 0.05% –> severe dermatitis
Halobetasol propionate 0.05% –> severe dermatitis
What are the instructions for use, limitations and cautions of Rx TCS?
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)
What are the second line or “step up” Rx therapies in the treatment of dermatitis and what are their indications and mechanism?
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
What are the cautions and limitations associated with topical calcineurin inhibitors? (ages, contraindications, SE)
- 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
What are the cautions and limitations associated with topical PDE-4 inhibitors?
- not indicated <3 months
- may cause mild stinging/burning
When are oral antihistamines indicated in patients with dermatitis? What type of OAH should they use and what will it help with?
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)
What are 1st line treatments for irritant CD?
TCS and moisturizers
Topical barrier products can be used to protect the skin against irritants
What effect does zinc sulfate have on the treatment of dermatitis?
Oral administration may improve allergic CD due to nickel sensitivity
What are the considerations for TCS in special populations? (geriatric, children and pregnant/breastfeeding)
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)
What is corticophobia?
Negative feelings and beliefs related to topical corticosteroid use resulting in poor adherence and treatment response
What are the pros and cons of lotions?
Pros: less greasy, good for large or hairy areas
Cons: alcohol based and higher water content may dry area
What are the pros and cons of creams?
Pros: cosmetically acceptable, good for weeping areas
Cons: less absorption
What are the pros and cons of ointments?
Pros: excellent penetration, emollient effects (good for dry and scaly areas), less irritating
Cons: less cosmetically acceptable, may cause irritation in hot, humid environments
What are the FTU needed to cover the face, trunk/front/back, arm/hand, and leg/foot?
Face & neck = 2.5
Trunk, front, back = 14
Arm & hand = 4
Leg & foot = 8
What are the monitoring parameters for the patient and when should follow up be with the RPh?
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
What is the appearance and location of irritant diaper dermatitis?
Mild erythema, shiny patches with deep erythema, papules, vesicles and ulcers
Found on convex surfaces
What is the appearance and location of allergic diaper dermatitis?
Grouped linear tense vesicles and blisters with marked edema in severe cases
Generally limited to areas in contact with the allergen
What is the appearance and locations of candidal diaper dermatitis?
Beefy red plaques with satellite pustules and early maceration of skin
Almost always involves inguinal folds
What are the red flags associated with diaper dermatitis?
- 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
What are the goals of therapy for diaper dermatitis?
- Relieve symptoms
- Resolve dermatitis
- Prevent complications
- Prevent recurrences
What are the non-pharmacologic strategies for treating diaper dermatitis? (ABCDEs)
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
What is the general approach to treatment for diaper dermatitis?
- Ensure adherence to ABCDE measures and change protectant barrier to zinc oxide 20-40%
- 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% - follow up in 7 days, if resolved continue ABCDEs, if improved but not resolved, continue treatment for 7 more days, if worsened, refer
What are the options for non-Rx barrier products for prevention of DD?
Ceramide-based, petrolatum, and silicone based
What are the options for non-Rx barrier-absorptive products for the treatment and prevention of DD?
Zinc Oxide –> also has astringent and antiseptic properties, prevention at lower % and treatment at higher %
What are the topical anti-fungals that can be used for candidal DD? (nonRx - 3, Rx - 2)
Non-prescription:
- Clotrimazole 1%
- Miconazole 2%
- nystatin (slightly less effective than imidazole therapy)
Prescription:
- Ciclopirox 1% (inferior to imidazoles)
- Ketonazole 2%
