Dermatitis and Eczematous Eruptions - Exam 1 Flashcards
What is atopic dermatitis? ** It is _____ mediated
Atopic dermatitis is an acute, subacute and chronic, relapsing, pruritic condition
**IgE mediated
What pt population is MC affected by atopic dermatitis? What areas on the body?
Infants and children are most often affected
MC: face, scalp, torso, and extensors
What pt population is more likely to have the follicular pattern of atopic derm?
MC in persons with darker skin phototypes
**What is the atopic triad?
eczema
asthma
hay fever
What is the itch scratch cycle characterized by?
Characterized principally by dry skin and pruritus; consequent rubbing leads to increased inflammation and lichenification and to further itching and scratching
What causes the decreased barrier function in atopic dermatitis?
Decrease in barrier function due to impaired filagrin production, reduced ceramide levels, and increased trans-epidermal water loss; dehydration of skin
What interleukins cause the acute inflammation in atopic derm?
Acute inflammation in AD is associated with a predominance of interleukin (IL) 4 and IL-13 expression
What are the different categories of atopic derm?
acute
subacute
chronic eczema
What category of atopic derm? ______ erythema, vesicles, bullae, weeping, crusting
acute
What category of atopic derm? ______ lichenification, scaling, hyper- and hypopigmentation
chronic eczema
What category of atopic derm? ______ scaly plaques, papules, round erosions, crusts
subacute
**“itch that rashes” is characteristic for _____. What increases risk?
atopic derm
family history
What common foods may cause a flare of atopic derm? There may be a relationship between atopic derm and development of ________
Allergy to eggs, cow’s milk, or peanuts is common
ASA related respiratory diseases
**What is the hallmark symptom of atopic derm? What does the scratching lead to ____ and ???
intense itching!!!
lichenification
impaired barrier function that leads to increased water loss and cutaneous infections
What should you look for when evaluating a pt for potential atopic derm?
Scaly, erythematous papules and plaques involving the flexural surfaces, particularly the antecubital fossae and popliteal fossae, face, neck, and extremities in general
What are some facial findings that are associated with atopic derm? Will periorbital be hyper or hypo pigmented?
Facial findings include periorbital scaly plaques and thinning of the lateral eyebrows
periorbital is HYPERpigmentated
What is keratosis pilaris?
a common, benign skin condition that causes small, rough bumps on the skin
What is often in the patients history with atopic derm?
Adequate history of child and family history of allergies, asthma, and skin disorders
What are 4 common PE findings in kids associated with atopic derm?
dennie morgan lines
allergic shiners
nasal crease
open mouth with recessed lower jaw
What are the testing options when diagnosing atopic derm?
Family and Personal history is key to diagnosis
Serum IgE (not necessary but can be done)
Culture suspected infection
Skin biopsy can help
What is the general overall management in atopic derm?
avoid triggers
appropriate skin care with gentle cleansers and moisturizing cream with ceramides
steroid cream at the lowest strength that clears symptoms
control itch with oral antihistamine
**What are two important pt education points with regards to showering and atopic derm?
**avoid soap except in body folds
**apply moisturizes within 60 seconds of patting dry post shower
Desonide bid
low potency steroid
Triamcinolone cream or ointment – BID
medium
Mometasone cream or ointment – BID
medium
Fluocinolone cream or ointment – BID
medium
Tacrolimus ointment BID
IMMUNOMODULATORS: CALCINEURIN INHIBITOR
used in atopic derm
Pimecrolimus cream BID
IMMUNOMODULATORS: CALCINEURIN INHIBITOR
used in atopic derm
Crisaborole ointment BID
IMMUNOMODULATORS: CALCINEURIN INHIBITOR
used in atopic derm
Dupilumab (Dupixent)
How old do you have to be?
systemic injectable drug used in atopic derm
at least 6 months old
What are the 2 sedating antihistamine options?
Diphenhydramine hydrochloride
Hydroxyzine
What are the 2 non-sedating antihistamine options?
Cetirizine
Loratadine
What is the difference between irritant contact derm and allergic contact derm?
Irritant contact dermatitis- (ICD) occurs after a SINGLE exposure to the offending agent that is toxic to the skin. It is confined to the area of exposure and is therefore always sharply marginated and never spreads
Allergic contact dermatitis- (ACD) is caused by an antigen (allergen) that elicits a type IV (cell-mediated or delayed) hypersensitivity reaction. immunologic reaction that tends to involve the surrounding skin (spreading phenomenon) and may spread beyond affected sites
What are the 2 important factors to remember about irritant contact derm? What is one alternative way it can present?
occurs after ONE exposure
Well demarcated suggestive of an “outside job” or external contact
It can also present as a systemic contact reaction with widespread lesions such as in an ingested or implanted device
What are the 3 important factors to remember about allergic contact derm?
Repeat exposures
24-48 hours post exposure
topical agents, ingested, implanted devices, airborne
Allergic contact dermatitis is a delayed-type _______ = allergens activate antigen-specific _____ in a sensitized individual
(type IV) hypersensitivity reaction
T cells
Airborne contact derm usually affects the _______, ______, _______, _______ and the ______
Airborne contact dermatitis affects the:
face (particularly the upper eyelids)
neck (including the submandibular region)
the upper chest
the forearms
the hands (especially palmar surfaces)
What am I?
contact derm
What am I?
contact derm
What 3 occupations should raise concern for contact derm?
health care professionals
machinists
construction workers
contact derm is also prevalent in the _____ and ______ populations
pts with an allergy to adhesives (think wound care)
pts with implanted biomedical devices
What are the 2 best tests to dx contact derm?
history/ PE
patch testing to verify the allergen
T/F: A positive patch allergy test is adequate to a diagnosis of ACD
FALSE!
A positive patch test does NOT always equate to a diagnosis of ACD, and clinical correlation is key
T/F: Skin prick testing is used frequently in the diagnosis of contact derm
Skin prick tests are used to diagnose type I hypersensitivity reactions and are NOT used for testing for contact dermatitis
What specific cell type is responsible for allergic contact derm? What is it due to?
ACD- is defined by hapten specific T cell-mediated inflammation
Due to a reexposure to a substance that a patient has been sensitized.
What is the visual “flow” of worsening lesions in allergic contact derm?
Erythema — > papules — > vesicles — > erosions — » crusts — » scaling
What am I?
allergic contact derm
What am I?
allergic contact derm
What is the management of contact derm?
review meds!
no HOT water
animals??
find and avoid offending agent!!
topical steroids
oral steroids
What is the pt education with regards to topical steroid application in contact derm?
(max 2 weeks on, 2 weeks off, repeat cycle)
Hydrocortisone 1% and 2.5 % cream,
low potency steroid
Clobetasol cream, ointment – Apply every 12 hours
high potency
Halobetasol cream, ointment – Apply every 12 hours
high potency
Betamethasone dipropionate cream, ointment – Apply every 12 hours
high potency
Fluocinonide cream, ointment – Apply every 12 hours
high potency
Desoximetasone cream, ointment – Apply every 12 hour
high potency
Besides steroids, what other tx method can be used in contact derm?
Phototherapy can also be used
PUVA
What am I? What are the 3 causes? Who is the MC pt population?
diaper derm
cutaneous candidiasis, ICD, and miliaria
3 weeks old 2 years in age (and geriatric population)
What are miliaria?
blocked sweat ducts
How would you describe diaper derm in words?
Shiny erythema with dull margins
+/- papules/vesicles/erosions
Candidiasis can be present
What is the tx for diaper derm?
frequent diaper changes while keeping the area dry
allow air flow if possible
barrier creams: Zinc oxide / petroleum jelly
treat the candidiasis
**What is the tx for candidiasis associated with diaper derm?
Nystatin x 2 weeks
Clotrimazole x 2 weeks
Econazole x 2 weeks
______ is characterized by pruritic, coin-shaped, scaly plaques. What is it associated with?
nummular eczema
frequent bathing, low humidity, irritating and drying soaps, skin trauma, interferon therapy for hepatitis C, and exposure to irritating fabrics such as wool
_____ is a predisposing factor to developing nummular eczema lesions on the legs
Venous stasis
What is the MC pt population for nummular eczema?
50-65 year old men
What am I?
nummular eczema
What locations are the body are more common to find nummular eczema? Where are you likely to NOT find them
Trunk and extremities +/- hands and feet
NOT face and scalp
What is the best test to dx nummular eczema?
Culture if bacteria suspected
Skin scraping if fungus suspected
Biopsy if necessary
What am I? What is the MC organism? Where are the MC body parts?
seborrheic derm
Pityrosporum (Malassezia) yeast
Face!!, scalp, neck, upper chest, and back
What am I? How can it affect pigmentation? _____ can exacerbate it
seborrheic derm
can be darker hypo or hyperpigmentation
stress can exacerbate it!!
What 2 comorbid contitions do you also find seborrheic derm in?
HIV and Parkinsons patients
What am I? What will it look like in lighter vs darker skin pts?
Seborrheic derm
Lighter skin yellow to red to pink
Darker skin hypo or hyperpigmentation
What will the pt complain of with seborrheic derm?
Asymptomatic or may complain of pruritus or burning in affected areas
Facial seborrheic dermatitis may be associated with _____. _____ frequently co-exist
rosace
Psoriasis
What is the best test for seborrheic derm?
Clinical dx
Biopsy may help
KOH if thinking fungal
What is the pt education for seborrheic derm? **Which one is first line?
NO CURE!!!
waxes and wanes
use shampoo:
Salicylic Acid
Selenium Sulfide
Tar shampoos
Pyrithone Zinc
Ketoconazole 2% shampoo (1st line)**
topical steroids
NOT FACE:
Clobetasol solution
Betamethasone
Fluocinolone Scalp Oil
FACE:
hydrocortisone / desonide
Which steroids are safe to use on the face?
LOW potency only!!
hydrocortisone / desonide
______ Inflammatory skin condition occurring on lower extremities. What is the underlying cause?
STASIS DERMATITIS
chronic venous insufficiency
What am I? What are the 3 symptoms?
stasis dermatitis
Pruritus
Heaviness
Edema
What am I? Describe it in words.
stasis derm
reddish-brown discoloration with erythematous, scaling, patches, weeping and crusting with LOSS OF HAIR and shiny skin
Loss of hair and shiny skin, what should you think?
stasis derm
What is the tx for stasis derm? What is the lesion is weeping?
treat underlying chronic venous insufficiency and topical steroids (triamcinolone or clobetasol)
Weeping lesions = wet compresses
What are the 2 complications of stasis derm?
cellulitis and non-healing wounds
need to consult vascular or wound clinic
_____ happens from excessive rubbing and scratching. What are the 3 predisposing factors?
Lichen simplex chronicus
chronic skin conditions (atopic derm)
emotional stress
habit forming scratching
What am I? Describe it in words
lichen simplex chronicus
thick, plaques, lichenified with hyperpigmentation and excoriations
What is the tx for lichen simplex chronicus?
need to stop the scratch itch cycle!!
antihistamines
Triamcinolone
steroid injections into effected skin
emollients
Where is perioral derm typically found? Where is it NOT found? What is the MC pt pop?
Erythematous papular and pustular eruption involving the nasolabial folds, the upper and lower cutaneous lip, and the chin. may be around the lower and lateral eyelids. may have fine scaling
NOT around the immediate lip margin and immediate circumoral area
MC women aged between 18 and 40
What am I? What will the pt complain of?
perioral derm
may complain of burning itching or pruritis
What are 2 common triggers of perioral derm? **What is a important medication point?
mid-high potency steroids
fluorinated toothpaste
NEED TO TAPER STEROIDS!! switch to low potency steroid and then wean. If not, they will flare
pt need to be warned likely to flare up after steroids are stopped, will get worse before it gets better
What is the tx for perioral derm?
taper then d/c topical steroids
Topical pimecrolimus 1% or azelaic acid (20% cream) has been shown to be beneficial in these patients
Topical and oral antibiotics may also be used
(example in class was metronizadole topical and oral doxy)
What vehicle need to be avoided if prescribing for something around the eye?
avoid use of gels, solutions, or lotions on the eyelid as inadvertent intraocular application may occur
What am I? Where is it MC found? What age range? What will the pt complain of?
dyshidrotic eczema
hands and feet
20-40 years old
itching, burning and pain
**“tapioca like vesicles” is associated with ______. What is the diagnostic test?
DYSHIDROTIC ECZEMA
biopsy is diagnostic
What am I? What is the tx? What if severe?
DYSHIDROTIC ECZEMA
Topical Steroids: Under occlusion x 2 weeks
severe: high dose PO prednisone 2 week taper and PUVA therapy
What are 2 important pt education points for dyshidrotic eczema?
Avoid allergens/irritants
Excessive hand washing (and moisturize hands after!!)
**What is the pt education when selecting an emollient? How do they apply it?
**needs to be without anti-aging ingredients and unscented
IMMEDIATELY after bathing and 3x throughout the day
apply in direction of hair growth
avoid excessive rubbing
CONTINUE to use after flare is controlled
Compare cream vs lotion vs ointment. Which one is the best option for most?
cream: mixture of fat and water, cooling effect on skin, MODERATE moisturizing effect
lotion: more WATER than fat, less effective moisturising skin but better for HAIR COVERED AREAS
ointment: GREASY, good for dry/thickened skin
What are the 4 processes that topical steroids work? MOA, know these!!
- stabilizes leukocyte/macrophage/histamine activity
- constriction of the capillaries and reduced capillary wall permeability - improving and preventing edema formation
- decreases activation of complement cascade
- reduces fibroblast proliferation and collagen deposition which leads to reduced scar formation
What are the 2 CI to topical steroids? What are the cautions? What preg category?
underlying bacterial infections
ophthalmic use
cautions:
chronic use may inhibit growth in children
chronic use induced Cushing syndrome, Kaposi sarcoma
preg category C
What are the different classes of topical steroids?
Class I-VII:
I-highest
VII- lowest
**_______ is the most potent topical steroid vehicle
ointment!
semi-occlusive, petroleum based
_____ topical steroid vehicle has the best cosmetic absorption. ______ is the least potent but leaves minimal residue and good for thick hair bearing areas and large areas
cream
lotion
Besides ointment, cream and lotion, list 4 additional forms topical steroids come in
gels
powders
foam
solution
____ is a mixture of oil in water with alcohol base and has a drying effect with minimal residue. Good for scalp or acne
gels
_____ is good to absorb excess moisture and protects against skin chafing
powders
______ gaseous bubbles in matris of liquid film
easy to spread, w/o residue but is more expensive
foal
______ is low viscosity and is a powder in water/alcohol. Good drying effect. Good for scalp or hairy areas
solution
What is the dosing for topical steroids? What are 2 important pt education points?
gradual reduction in potency and frequency of application
1-2 week intervals between each reduction in dose
What is the maximum duration of treatment for topical steroids based on the class?
Class I - < 3wk
Class II-IV - < 6-8 wk
Class V-VII - chronic intermittent therapy
face, intertriginous, genital limit to 1-2 wk intervals of therapy
______ is a progressive decrease in clinical response to same dose. results from repetitive use of same drug. How do you prevent/tx it?
Tachyphylaxis
drug free intervals (“holidays”)
switch to alternative agent
What are the 2 IMMUNOMODULATORS: CALCINEURIN INHIBITOR? What are the vehicle options for each?
pimecrolimus (Elidel) and tacrolimus (Protopic)
pim: cream
tacrolimus: ointment
What is the MOA for IMMUNOMODULATORS: CALCINEURIN INHIBITOR?
inhibits T-lymphocyte activation via calcineurin inhibition
prevents release of inflammatory cytokines/mediators
What is the dosing for IMMUNOMODULATORS: CALCINEURIN INHIBITOR? How long can you use each?
BID until clearing is noted
pimecrolimus (Elidel) - 2 yrs
tacrolimus (Protopic) - 4 yrs
**What is the BBW for immunomodulators? **What is the important pt education point?
rare case of lymphoma and skin malignancy (tumors) and to avoid long term use!
lymphoma and skin malignancy (tumors) was only noted when the product was EATEN!! so dont eat it and you should be fine
What is the age restriction on immunomodulators? **What are the 2 cautions? What preg category?
CI if under the age of 2
cautions:
**do not use with occlusive dressing
reassess if no improvement in 6 weeks
preg category C
Is it safe to use immunomodulators on the face?
YES! safe for use on face/eyelids
What is the active ingredient in Head and Shoulders? When is it indicated?
selenium sulfide
seborrheic dermatitis
tinea versicolor
What areas on the body is selenium sulfide CI? What vehicle do they come in?
oral, ophthalmic, anal or intravaginal use
shampoo, lotion, foam
What are the dosing instructions for selenium sulfide in seborrheic derm?
Seborrheic dermatitis: apply to affected area for 2-3 minutes, rinse thoroughly, repeat 2x/wk initially; maintenance therapy once q 1-2 wks
What are the dosing instructions for selenium sulfide in tinea versicolor?
shampoo/lotion: apply to affected area , lather, leave for 10 minutes, rinse thoroughly; apply QD x 7 days
foam: rub into affected area q12 hr x 7 days
_____ MOA binds to hair/skin- reduces cell turnover. Where is it found?
pyrithione zinc
Head and Shoulders, Selsun, T/Gel
A 75-year old with a history of Parkinson’s disease presents with minimally pruritic facial lesions presenting for 1 week. Exam reveals scattered discrete macules approximately 1 cm in size, with an orange-red greasy scale on the cheeks and nasolabial folds. What is the most appropriate treatment?
sebhorreic derm
hydrocortisone cream
A 22-year old female is complaining of a rash around her mouth. She describes a feeling of mild burning or tension but denies pruritus. Exam reveals papulospustules on erythematous bases, the vermillion border is spared. A culture is negative. What is the recommended management?
perioral derm
topical metronidazole and oral doxy if severe
