Dermatitis, Burns, Cellulitis Flashcards
Atopic Dermatitis: What is it?
- most common form of dermatitis
- AKA eczema
- affects between 10-15% of children in U.S.
- 90% of patients experience remission by puberty
- common in those with other atopic illnesses (asthma, allergic rhinitis)
- usually begins before age 5 in children
Atopic Dermatitis: Risk Factors
- family history of atopy
- repeated skin infections
Atopic Dermatitis: Assessment Findings
Pruritic, ill-defined, red scaly plaques often seen on the face, neck, and upper trunk, and flexural surfaces of knees and elbows
** In patients with dark skin, the pigmentation may be lost in areas of lichenification when severe disease is present
Atopic Dermatitis: Diagnostic Tests
- clinical exam
- may also see increased IgE levels and eosinophils
- may need a culture to rule out staph
** New diagnoses should not be made in those 30 and older without consultation with a dermatologist.
Atopic Dermatitis: Non-Pharmacologic Management
- gentle skin cleansing
- avoid low-humidity environments (flares common in winter)
- only bathe once daily and confine soap to armpits, groin, scalp, and feet in adults
- pat skin dry; do not rub
- immediately apply a thin film of emollient after bath/shower
- avoid wools and acrylics, sweating, and heat
Atopic Dermatitis: Pharmacological Therapy for Mild Disease
** Antihistamines and topical steroids are mainstay
1. Low-potency topical corticosteroids (TCS) [triamcinolone] once daily for 2-4 weeks.
- If improvement is seen, use emollients and intermittent use of TCS.
- If there is no improvement, assess triggers, adherence to treatment, check for infection, or switch to a topical calcineurin inhibitor (TCI) such as tacrolimus (if the child is> 2 years old).
- If still no better after 2-4 weeks, switch to a medium-to-high-potency TCS twice daily for 2-4 weeks (in consultation with and probable referral to a dermatologist).
Atopic Dermatitis: Tapering Steroids
- In general, for treatment of lesions on the body (excluding genitalia, axillary or crural folds), one should begin withtriamcinolone0.1% or a stronger corticosteroid
- then taper tohydrocortisoneor another slightly stronger mild corticosteroid (alclometasone,desonide).
- It is vital that patients taper off corticosteroids and substituteemollientsas the dermatitis clears to avoid side effects of corticosteroids.
- Tapering is also important to avoid dermatitis flares that may follow abrupt cessation
Atopic Dermatitis: Pharmacologic Management in Moderate to Severe Disease
- Medium to high potency topical corticosteroids to affected areas BID for 2-4 weeks
- Use low to medium potency topical corticosteroids or topical calcineurin inhibitor (TCI) for areas at increased risk of skin atrophy (face, neck, skin folds)
THEN… - Reassess after 2-4 weeks
IF NO IMPROVEMENT… - Refer
Non-Steroidal Pharmacological Treatment for Atopic Dermatitis
- tacrolimusointment (Protopic 0.03% or 0.1%)
- pimecrolimuscream (Elidel 1%)
- crisaborole(Eucrisa 2%)
- ruxolitinib(Opzelura 1.5%)
** may be effective in managing atopic dermatitis when applied twice daily
** burning with application occurs in about 50% of patients using Protopic and 10–25% using Elidel but may resolve with continued treatment.
Seborrheic Dermatitis: What is it?
- AKA cradle cap
- a chronic, superficial, papulosquamous disorder affecting the hairy areas of the body, such as the scalp, eyebrows, and face
- possible causes include genetics and environment
Seborrheic Dermatitis: Risk Factors
- common throughout the lifespan
- affects men more often
- emotional stress
- family history
- Parkinson’s
- HIV
- cold/dry weather
Seborrheic Dermatitis: Assessment Findings
- the mildest and most common form of seborrheic dermatitis is dandruff
- blepharitis with redness of the free margin of the eyelids and yellow crusting between the eyelashes may be the sole manifestation of seborrheic dermatitis or may accompany its more classic distribution.
- well demarcated erythematous plaques with greasy-looking, yellowish scales most commonly on oily areas of the skin such as:
- scalp
- external ear
- center of the face
- upper part of the trunk
- interiginous areas
Seborrheic Dermatitis: Diagnostic Studies
Usually clinical exam
Seborrheic Dermatitis: Scalp Treatment Mild Disease
- ketoconazole shampoo 2% 2-3 times per week
THEN… - Reassess after 4 weeks
IF NO IMPROVEMENT… - Add a high-potency topical corticosteroid once daily until symptoms subside or up until 4 weeks
IF STILL NO IMPROVEMENT… - Systemic antifungal (itraconazole 200 mg PO QD x 7 days)
** If still no improvement, reconsider diagnosis
** If improvement is seen at any point, use the shampoo once or twice a week to prevent relapse
Seborrheic Dermatitis: Scalp Treatment Moderate to Severe Disease
- Ketoconazole shampoo 2-3 times per week
AND - High-potency topical corticosteroid QD until symptoms improve or up to 4 weeks
** If improvement is seen at any point, use the shampoo once or twice a week to prevent relapse
Seborrheic Dermatitis: Non-Scalp Treatment Mild Disease
- Topical antifungal once or twice daily
THEN… - Reassess at 4 weeks
IF NO IMPROVEMENT… - Add a low potency TCS cream/gel once or twice daily until symptoms subside or up to 2 weeks
IF STILL NO IMPROVEMENT… - Switch to a TCI (tacrolimus) and reassess after 4 weeks
** If no improvement after all this, reconsider diagnosis
Seborrheic Dermatitis: Non-Scalp Treatment Moderate to Severe Disease
- Low-potency TCS once or twice daily until symptoms subside or up to 2 weeks
- Topical antifungal once or twice daily
IF NO IMPROVEMENT… - Switch to TCI plus antifungal, reassess at 4 weeks
IF STILL NO IMPROVEMENT… - Systemic antifungal (itraconazole 200 mg PO QD x 7 days), reassess at 4 weeks
** If no improvement after all this, reconsider diagnosis
Allergic/Irritant Contact Dermatitis: What is it?
- an allergic reaction
- an acute inflammation of the skin due to contact with an irritant
Allergic/Irritant Contact Dermatitis: Common Culprits
- Nickel
- Rubber
- Essential oils
- Anesthetics
- Adhesive tape
- Latex
- Soaps
- Detergents
- Poison ivy or oak
- Antibiotics
Allergic/Irritant Contact Dermatitis: Diagnostic Tests
- clinical exam
- gram stain and culture (will rule out impetigo or secondary infection)
- patch test (after the episode of allergic contact dermatitis has cleared, patch testing may be useful if the triggering allergen is not known)
Allergic/Irritant Contact Dermatitis: Clinical Findings
- redness
- itching
- bullae
- macules
- papules
- vesicles
- lines of demarcation
- scaling
- crusting
- oozing
Allergic/Irritant Contact Dermatitis: Prevention
- avoid contact with offending substance
- if contact occurs, wash skin within 30 minutes with soap and water and rinse well
- colloidal oatmeal baths
- soaks with cool water for burning/irritation
- tepid bath may help with pruritis
- use protective gear when contact with offending substance is possible
Allergic/Irritant Contact Dermatitis: Acute Treatment Localized to hands, feet, and nonflexural areas
- High potency TCS once or twice daily until resolution (up to 4 weeks)
- then taper over 2 weeks
Allergic/Irritant Contact Dermatitis: Acute Treatment Localized to face or flexural areas
- Medium-or-low potency TCS once or twice daily for 1-2 weeks, then taper over 2 weeks
OR - Topical tacrolimus (TCI) ointment until resolution, then taper (if treatment beyond 2 weeks)
Allergic/Irritant Contact Dermatitis: Treatment for Acute Extensive-Severe Disease Course
- short course of systemic corticosteroids (Prednisone 0.5-1mg/kg/day max of 60 mg/day) x 7days
- then, reduce dose by 50% over next 7 days
- then, taper over 2 weeks
Allergic/Irritant Contact Dermatitis: Treatment for Chronic-Intermittent Disease Course
- Intermittent (2-3 times per week) high-potency TCS
OR - Intermittent topical tacrolimus 0.1% ointment
OR - NPUVB phototherapy if feasible plus frequent and liberal use of allergen-free emollients
Allergic/Irritant Contact Dermatitis: Generalized Treatment Considerations
- Use lowest potency in children and shortest treatment time
- Topical, oral or injectable steroids can be used, but avoid systemic during 1st trimester of pregnancy.
- Use only low-to-medium potency during 2nd and 3rd trimesters and while breastfeeding
- Monitor for secondary bacterial infections and treat as needed
- Calamine lotion for itching
- Zinc oxide for moisture barrier
Burns: Causes
- chemicals
- thermal energy
- radiation
- electricity
- abuse
Methods for Assessing the Percentage of TBSA
- Lund-Browder
- Rule of Nines
- Palm Method
Lund-Browder
- is the most accurate method for estimating TBSA for both adults and children
- children have proportionally larger heads and smaller lower extremities, so the percentage TBSA is more accurately estimated using this method
Rule of Nines
** Best for adult assessment of burns
- The head represents 9 percent TBSA
- Each arm represents 9 percent TBSA
- Each leg represents 18 percent TBSA
- The anterior and posterior trunk each represent 18 percent of TBSA
Palm Method
- Small or patchy burns can be approximated by using the surface area of the patient’s palm
- The palm of the patient’s hand, excluding the fingers, is approximately 0.5 percent of total body surface area, and the entire palmar surface, including fingers, is 1 percent in children and adults
Burns: Minor Thermal Injury Treatment
- Remove clothing, jewelry, debris, if necessary
- Cooling with room temperature or cool tap water
- Pain management with tylenol, ibuprofen, or opioids
- Clean with mild soap and water daily
- Tetanus prophylaxis
- Bacitracin ointment or aloe vera
- Dressings
** Ruptured blisters should be debrided, but intact small blisters <2 cm in diameter should be left alone.
** Basic burn dressings include application of a topical antibiotic, a nonadherent dressing, covered by a dry gauze dressing and a gauze roll if needed.
** Individually wrap and separate all toes and fingers.
** When assessing the burn, observe for any signs that there could be an inhalation injury or a more severe burn, if so send them to the ER.
Cellulitis: What is it?
- a non-necrotizing inflammation of the skin and SQ tissues, usually resulting from acute infection
- usually affects the lower extremities or face/head
Cellulitis: Possible Causes
- staph aureus
- MRSA
- Group A strep
- H. influenza
Cellulitis: Risk Factors
- tinea pedis fissures (unilateral, lower extremities affected)
- venous insufficiency
- chronic edema
- prior cellulitis
Cellulitis: Assessment Findings
- small, tender, erythematous patch that grows larger and larger over the next 36 hours
- painful, lymphadenopathy, chills, fever, malaise
Cellulitis: Diagnostic Tests
- clinical exam
- leukocytosis with increased neutrophils
- possible C&S
Cellulitis: Treatment for Mild Course
- Oral dicloxacillin for 5-10 days
OR - Oral cephalexin for 5-10 days
Cellulitis: Treatment for Severe Course
If the patient appears toxic with severe local signs and symptoms, signs of sepsis, or failure to respond to oral antibiotics, admit to the hospital for IV antibiotics
** It is very important to rule out necrotizing fasciitis because if it is NF, it needs to be surgically debrided very quickly. Suspect NF if the patient appears toxic (bullae, crepitus or anesthesia of the involved skin, overlying skin necrosis, and lab evidence of rhabdomyolysis (elevated CK) or DIC).
General Considerations before Prescribing Steroids
- Use low-potency steroids for face.
- Using topical steroids for longer than 2 weeks can lead to atrophy and changes in skin color.
- Use lowest potency steroid that produces desired effect.
- Max amount for high and super-high potency steroids is 50 GM/wk
