Dermatitis Flashcards
Two types of dermatitis discussed in this lecture
1) contact dermatitis
2) atopic dermatitis
Atopic dermatitis = ?
eczema
Pharmacological treatment for dermatitis?
topical corticosteroids
*this is the first line medication for dermatitis
What are topical corticosteroids effective for treating?
skin conditions of: hyperproliferation
inflammation
immunologic involvement
Topical corticosteroids provide symptomatic relief of ?
itching and burning
topical corticosteroids are classified into __ categories
7
- classified into 7 categories based on potency, ranging from low to very high potency.
- relates to the amount of vasoconstriction the formula induces
List the 4 components of the mechanism of action for topical corticosteroids
1) anti-inflammatory
2) vasoconstrictive
3) immunosuppression
4) anti proliferative
Explain the MOA for topical corticosteroids:
-anti-inflammatory
decreases formation, release and activity of inflammatory mediators
Explain the MOA for topical corticosteroids:
-vasoconstrictive
prevents cell migration and decreased access to affected area thereby reducing swelling
Explain the MOA for topical corticosteroids:
-immunosuppression
inhibits action of cells involved in the immune response
Explain the MOA for topical corticosteroids:
-antiproliferative
able to interfere with DNA synthesis and mitosis and obstruct fibroblast activity and the development of collagen
Topical corticosteroids:
low potency used where?
on skin areas such as face and folds
*b/c these areas of thin skin have increased absorption
Topical corticosteroids:
medium potency used where?
on medium thickness skin such as body and scalp
Topical corticosteroids:
high potency used where?
used on thick skinned areas such as palms and soles
When do you stop using a topical corticosteroid product?
as soon as the skin is clear!
-do not continue use as it will continue to thin your skin and make it more prone to infections, cuts, or damage
Topical corticosteroids that Mb Pharmacists can prescribe: What class and schedule is clobetasone 17-butyrate in?
class IV (considered moderate potency)
schedule 2 (behind the counter, but do not need an Rx)
Topical corticosteroids that Mb Pharmacists can prescribe:
What class and schedule is
triamcinolone actonide in?
class IV (considered moderate potency)
schedule = ?
Topical corticosteroids that Mb Pharmacists can prescribe:
What class and schedule is
desonide in?
class VI (low potency)
schedule = ?
Topical corticosteroids that Mb Pharmacists can prescribe:
What class and schedule is
hydrocortisone in?
class VII (low potency)
schedule 1 or 3
Topical corticosteroids that Mb Pharmacists can prescribe:
What class and schedule is
hydrocortisone acetate in?
class VII (low potency)
schedule 1 or 3
As the classes increase (1-7) does potency increase or decrease?
decrease
Class 1 = ultra high potency
Class 2 = high potency
Class 3, 4, 5 = moderate potency
Class 6, 7 = low potency
Describe the effect of vehicle on potency
optimized vehicle > ointment or gels > creams or lotions
Describe ointments
- occlusive and provide lubrication
- good for dry, scaly lesions
- greasy, which may tend to decrease patient compliance
Describe creams
- generally less potent than ointments
- good lubrication
- can contain preservatives
- cosmetically appealing
Describe lotions or gels
-helpful in hairy areas
Why do ointments have the highest potency?
- they seal skin and create an occluded area which:
- increases temp
- increases absorption
- increases potency
What are the adverse effects of topical corticosteroids?
- dryness
- itching
- burning
- local irritation
- infections
- ocular changes (ocular hypertension, glaucoma, cataracts)
- suppression of the hypothalamic-pituitary-adrenal (HPA) axis
- steroid rebound
- steroid addiction
- tachyphylaxis
What are the adverse effects usually a rxn to?
most likely due to the vehicle that the corticosteroid is in
List some atrophic changes that may occur as an adverse effect from a topical corticosteroid
steroid atrophy (thinning of skin/redness) telangiectasia (spider veins) striae (stretch marks) purpura ulceration easy bruising
Frequency of application for topical corticosteroids?
apply once or twice daily
Does a more frequent application of a topical corticosteroid provide better results?
no man
- applying it more often is just as effective as not as often
- less frequent application reduces risk of side effects
OTC treatments for atopic dermatitis
Corticosteroids!
-hydrocortisone 0.5% (schedule 1 or 3)
-hydrocortisone 1.0% (schedule 1 or 3)
(these are not recommended in children <2 years old)
7-14 day therapy
-clobetasone butyrate 0.05% (Schedule 2)
(not recommended in children <12 years old)
7 day therapy
Describe contact dermatitis
inflammatory skin condition with two subcategories:
- irritant contact dermatitis
- allergic contact dermatitis
Describe irritant contact dermatitis
occurs when skin undergoes mechanical or chemical trauma on exposure to an irritating substance
How much % of cases does irritant contact dermatitis make up?
it makes up 80% of contact dermatitis cases
Describe allergic contact dermatitis
occurs when skin is exposed to an allergen
What is contact dermatitis characterized by?
inflammation redness itching burning *all of these can be relieved by use of a topical corticosteroid
stinging
vesicle and pustule formation on skin areas that are exposed
What is the difference between irritant and allergic contact dermatitis?
irritant
-will be inflamed on very 1st exposure
allergic
-needs to have a prior interaction with the allergen
There can be acute rxns and chronic rxns:
Describe acute
red, oedematous papules in early phase, which become vesicles and bull that ooze if the rxn is severe enough
There can be acute rxns and chronic rxns:
Describe chronic
primary lesions are minimal, and secondary changes such as dryness, lichenification, pigment changes, hyperkeratosis or thickening, excoriation and fissuring predominate
What is the primary symptom in both acute and chronic?
itching
Signs and symptoms of ICD (irritant contact dermatitis)
mild irritants produce erythema, gesticulation and oozing while strong irritants produce blistering, erosions and ulcers
Signs and symptoms of ACD (allergic contact dermatitis)
mild form similar to the irritant exposure. A typical allergic rxn consists of grouped or linear tense vesicles and blisters. Severe = edema, especially in the face and periorbital and genital areas
Types of Irritants
plants (poison ivy) foods (peanuts) chemicals cosmetics latex metals
Describe poison ivy
- perennial
- 3 leaves
- edges may be smooth or toothed
- leaves vary in size (8-55 mm long)
- reddish in spring
- green in summer
- orange/red in autumn
- allergen = urushiol
What is the allergen for poison ivy?
urushiol
Risks/aggravating factors include ?
- gender (women wear jewellery and cosmetics)
- area on the body susceptible to different types of irritants (ex. jewellery)
- seasonal (poison ivy)
- occupational (irritation through contact with chemicals)
- UV light (phytotoxic rxns when taking medications)
When do you refer contact dermatitis?
- if dermatitis spreads to distant sites or becomes generalized to more than 30% of BSA
- acute and non responsive with a few days
- edema persists or increases within a few days/swelling of body
- discomfort in genitalia from itching, redness, swelling or irritation
- involvement and/or itching of mucous membranes of the mouth, eyes, nose, anus
- chronic and or non responsive within 7-10 days
- interferes with quality of life
- < 2 yrs of age
- presence of numerous vullae
- extreme or low tolerance to itching, irritation, or severe vesicle and bullae formation
Describe atopic dermatitis
- genetic based
- chronic relapsing skin disorder
- usually begins in infants or early childhood and may last into adulthood
**most common dermatological condition in children
**exact cause is unknown
atopic dermatitis causes a __% incidence people with 2 parents that have eczema
70
atopic dermatitis causes a __% incidence in the general population
17
Describe the pathophysiology of atopic dermatitis
chronic inflammatory skin disease associated with cutaneous and mucous membranes hyper-reactivity toward environmental triggers that are innocuous to normal, non-atopic individuals
80-85% of people with atopic dermatitis have high levels of ____
IgE
Signs and symptoms of atopic dermatitis (eczema)
- pruritus (itching)
- no primary skin lesion
- skin dry and lesions are scaly (although they may be vesicular, weeping and oozing in the acute stage)
If Pts have reacted to wool before, don’t recommend creams with ______
lanolin
Can we diagnose eczema?
no
-but we can recommend treatment for already diagnosed eczema
What is the diagnostic criteria for atopic dermatitis (eczema)
- onset before 2 years old
- history of skin crease involvement
- history of generally dry skin
- personal history of other atopic disease (or history of any atopic disease in 1st degree relative in children <4 yrs)
- visual flexural dermatitis
What is a 1st degree relative?
parent or sibling
What are some risk factors for atopic dermatitis?
- genetics
- environmental allergens
- climate (cold, dry weather)
- sweating
- physiologic stress
- dietary influences
- irritants
- infections
- itch-scratch cycle
When do you refer atopic dermatitis? (eczema)
- if dermatitis is acute and vesicular
- if it is a severe condition with intense pruritus
- if moderate to severe defined as:
- large area of the body
- remains unresponsive
- skin appears to be infected
- <2 years of age
- interferes with activities of daily life or sleep patterns
Explain atopic triad
If you have one atopic condition, you are at risk of developing other atopic conditions
*so you want to be sure to document in their file somewhere that they have this atopic condition so other HCPs are aware of it
Goals of treatment for dermatitis
- eliminate trigger factors or contact exposure to irritants and allergens
- provide symptomatic relief
- decrease skin lesions
- implement preventative measures
- develop coping strategies
non-pharmacological treatment for contact dermatitis?
-immediatley wash with soap and water
-avoid or remove the allergen
(tips on reducing exposure)
-take cold or tepid soapless showers
-avoid scrubbing affected area
-remove and wash all clothing exposed to irritant/allergen
-use wet compresses for acute keeping or oozing lesions
Treatment for contact dermatitis
- identify and avoid irritant
- wet compresses for 20 minutes 4-6 times per day
- topical steroid may be used to treat symptoms on a short term basis
- acute symptoms should resolve within 7-10 days
- in addition, an oral antihistamine may be added to therapy
Treatment of poison ivy
- shower after exposure
- wash all items exposed to plant using oil free soap
- application of topical corticosteroid
- oral antihistamines PRN (For itching)
When can initial rash of poison ivy appear?
can appear up to 9 days after exposure
but with previous exposure (like you’ve had the rash before) the rash may appear within 1-2 days after contact
What 4 things do a corticosteroid do?
- suppresses immune system
- decreases IS response
- decrease inflammation
- relieve itch
How do you prevent poison ivy?
- total avoidance of plant
- wear protective clothing that can be removed
- wash objects that have come into contact with the plant
should you burn poison ivy?
NO! - can cause rash/rxn in respiratory tract if the smoke is inhaled
SEE MONITORING ON PAGE 698 OF TEXT BOOK
table 7
okay man no need to yell
Non-pharmacological treatment for atopic dermatitis?
- bathing in lukewarm water for 5 mins, every other day with tepid water - use mild non-soap cleansers
- pat skin dry, don’t rub
- trim nails short and smooth
- avoid occlusive, tight clothing
- wash new clothing before wearing
- limit exposure to sudden temperature changes, maintain moderate humidity
- avoid triggers
- use wet compresses for acute weeping or oozing lesions
- keep skin hydrated
Treatment for atopic dermatitis
when skin is dry with mild itch or irritation:
-emollient or barrier repair treatment recommended twice daily and after bathing
in an acute flare:
- topical corticosteroid or barrier repair therapy applied to the affected area
- skin lesion should resolve in two weeks
- if effective - reinforce emollient use for prevention
- if not effective - refer to physician
Topical calcineurin inhibitors are another Rx product - they are used for long-term therapy for atopic: Describe tacrolimus (protopic)
- can be used on face and neck
- only used in children older than 2
- reduces itching and inflammation
Topical calcineurin inhibitors are another Rx product - they are used for long-term therapy for atopic: Describe pimecrolimus (Elidel)
- causes less burning and itching than Protopic
- lower cost
- only used in children older than 2
OTC treatments for atopic dermatitis include: -skin protectants -oral antihistamines -moisturizers -skin cleansers -astringents: List some skin protectants
calamine lotion
zinc oxide
colloidal oatmeal
sodium bicarbonate
How do oral antihistamines work?
by blocking H1 receptors therefore decreasing itch caused by histamine
- cause drowsiness
eg. diphenhydramine 25-50 mg (Benadryl)
Histamine is not really involved so oral antihistamines aren’t really effective but they can make you drowsy and allow you to sleep & heal
List the 4 R’s of management of atopic dermatitis
Recognize - diagnose condition and seek treatment early
Remove - triggers
Restore - moisturizers/ointments
Regulate - treatment (OTC & RX)
-follow up
See monitor therapy for atopic, contact or stasis dermatitis on pg 698 of text
OOOOOO TAY
