Dermatitis & Eczema Flashcards
an acute, subacute and chronic, relapsing, pruritic condition that is often associated with allergic rhinitis and/or asthma
dx?
atopic derm
atopic derm is Ig-___ mediated
IgE
atopic derm is MC affects in what pt demographic?
Infants and children
atopic derm MC is found where in the body?
- face, scalp, torso, and extensors
- MC flexures
___ patterns of atopic dermatitis are MC in persons with darker skin phototypes
Follicular
what is the itch-scratch cycle?
Characterized principally by dry skin and pruritus; consequent rubbing leads to increased inflammation and lichenification and to further itching and scratching
atopic derm - Decrease in barrier function due to ?
- impaired filagrin production
- reduced ceramide levels
- increased trans-epidermal water loss; dehydration of skin.
Acute inflammation in AD is associated with a predominance of what markers/cytokine?
interleukin (IL) 4
IL-13 expression
describe the 3 categories of atopic derm
- Acute – erythema, vesicles, bullae, weeping, crusting
- Subacute – scaly plaques, papules, round erosions, crusts
- Chronic eczema – lichenification, scaling, hyper- and hypopigmentation
- “itch that rashes”
atopic derm Environmental triggers:
- Heat
- Humidity
- Detergent
- Soaps
- Abrasive clothing
- Chemicals
- Smoke
- Stress
- Allergy to eggs, cow’s milk, or peanuts is common
- possible relationship between atopic dermatitis and the development of ASA-related rsp disease
hallmark of atopic derm
Intense pruritus (itching)
scratching can lead to ____ aka skin thickening
lichenification
atopic derm - Impaired barrier function leads to ___ and ____
increased water loss and cutaneous infections
impaired barrier function in atopic derm can lead to impetiginization of what pathogen?
Staphylococcus aureus
Secondary infections with HSV (eczema herpeticum), Coxsackie viruses (eczema coxsackium), or vaccinia virus (eczema vaccinatum) may transpire
Scaly, erythematous papules and plaques involving the flexural surfaces, particularly the antecubital fossae and popliteal fossae, face, neck, and extremities in general
dx?
atopic derm
s/s of chronic cases of atopic derm
Lichenification, scaling, and dyspigmentation may be seen
- Facial findings include periorbital scaly plaques and thinning of the lateral eyebrows
- Periorbital hyperpigmentation if darker
- Hyperlinear palms
- Keratosis pilaris
tests for 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
tx for atopic derm
- avoid triggers
- appropriate skin care - gentle cleansers, fragance free
- low-strength steroid
SE of steroid in atopic derm
- Atrophy
- Hypopigmentation
- Striae
- Ointment without preservatives
- Damp skin or under occlusive dressing
- AVOID soap except in the body folds
medium potency meds for localied topic derm
- Triamcinolone cream or ointment – BID
- Mometasone cream or ointment – BID
- Fluocinolone cream or ointment – BID
low potency meds for atopic derm
desonide
3 nonsteroidal tx for localized atopic derm?
who is this not recommended for?
- Tacrolimus ointment BID
- Pimecrolimus cream BID
- Crisaborole ointment BID
not recommended in <2 years old
systemic tx for atopic derm
Dupilumab (Dupixent)
what med can be given for pruritis in atopic derm?
antihistamines
- Diphenhydramine hydrochloride
- Hydroxyzine
- Cetirizine hydrochloride
- Loratadine
generic term applied to acute or chronic inflammatory reactions to substances that come in contact with the skin.
contact derm
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
Well demarcated suggestive of an “outside job” or external contact
can also present as a systemic contact reaction with widespread lesions
Ingested or implanted device
dx?
Irritant contact dermatitis- (ICD)
- 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
- Repeat exposures
- 24-48 hours post exposure
- topical agents, ingested, implanted devices, airborne
dx?
Allergic contact dermatitis- (ACD)
s/s of acute contact derm
Erythema, vesicles, and bullae
s/s of chronic contact derm
Scaling, lichenification, fissures, and cracks
Geometric shapes with well-demarcated borders may be seen
airborne contact derm affects what parts of the body?
- face (particularly the upper eyelids)
- neck (including the submandibular region)
- upper chest
- forearms
- hands (esp palmar surfaces)
how does cumulative contact derm occur? examples of certain agents?
after repeated exposure
- Soaps, detergents, waterless hand cleaners
- Acids and alkalis 3: hydrofluoric acid, cement, chromic acid, phosphorus, ethylene oxide, phenol, metal salts
- Industrial solvents: coal tar solvents, petroleum, chlorinated hydrocarbons, alcohol solvents, ethylene glycol, ether, turpentine, ethyl ether, acetone, carbon dioxide, DMSO, dioxane, styrene
- Plants: Euphorbiaceae (spurges, crotons, poinsettias, manchineel tree), Ranunculaceae (buttercup), Cruciferae (black mustard), Urticaceae (nettles), Solanaceae (pepper, capsaicin), Opuntia (prickly pear)
- Others: fiberglass, wool, rough synthetic clothing, fire-retardant fabrics, “NCR” paper
Occupational ACD should be considered, particularly in ?
- health care professionals, machinists, and construction workers
- Consider allergy adhesive, wound dressings, and/or antimicrobial tx in pts with chronic wounds including stomas
- Implanted devices: Pacemakers, orthopedic implants, and endovascular stents
best tests for contact derm
- H&P
- patch testing to verify the allergen (if necessary)
- Allergy referral
- (+) test does not always equate to a diagnosis; clinical correlation is key
- Skin prick tests: used to dx type I hypersensitivity reactions and not used for testing for contact dermatitis
hapten specific T cell-mediated inflammation
Due to a reexposure to a substance that a patient has been sensitized.
Allergens are found in jewelry, personal care products, topical medications, plants, house remedies, and chemicals the individual may come in contact with at work.
Allergic contact dermatitis
process of the development of lesions in Allergic contact dermatitis
Erythema — > papules — > vesicles — > erosions — » crusts — » scaling
management for contact derm
Review of medications
- OTC/RX/Homeopathic
- Hot water
- Humidifier
- Antihistamines (Hydroxyzine vs Benadryl)
- Animals
tx for contact derm
- Avoid offending agents
- Topical steroids (max 2 weeks on, 2 weeks off, repeat cycle)
- Oral steroids
low potency tx for contact derm
- Hydrocortisone 1% cream, ointment
- Hydrocortisone 2.5% cream, ointment
- Desonide ointment twice daily
medium potency tx for contact derm
- Triamcinolone cream, ointment – Apply every 12 hours
- Mometasone cream, ointment – Apply every 12 hours
- Fluocinolone cream, ointment – Apply every 12 hours
hgih potency tx for contact derm
- Clobetasol cream, ointment – Apply every 12 hours
- Halobetasol cream, ointment – Apply every 12 hours
- Betamethasone dipropionate cream, ointment – Apply every 12 hours
- Fluocinonide cream, ointment – Apply every 12 hours
- Desoximetasone cream, ointment – Apply every 12 hour
alt therapy intervention for severe contact derm
phototherapy - PUVA
Psoralen, ultra, violet, a solar spectrum 320-400 um in wavelength
- Generalized term used to describe a rash in the buttocks
- Causes cutaneous candidiasis, ICD, and miliaria
- miliaria = blocked sweat ducts
- Combo of wet, dark, friction, urine, feces and microorganisms
- MC in infants
- 3 weeks old 2 years in age
diaper derm
- Fussiness
- Crying during diaper changes
- Diarrhea typically multiple
- Shiny erythema with dull margins
- +/- papules/vesicles/erosions: Candidiasis can be present
- Miliaria: Multiple papulovesicular lesions/pruritus
dx?
diaper derm
mangement for diaper derm
- Discuss proper diaper changes (frequency/wipes) - Disposable; Avoid tight fitting
- Keep area dry; allow air flowl After bathing use blow drier
- Barrier creams - Zinc oxide / petroleum jelly
-
Candidiasis
- Nystatin x 2 weeks
- Clotrimazole x 2 weeks
- Econazole x 2 weeks
Dermatitis characterized by pruritic, coin-shaped, scaly plaques
frequent bathing, low humidity, irritating and drying soaps, skin trauma, interferon therapy for hepatitis C, and exposure to irritating fabrics such as wool
nummular eczema
predisposing factor to developing nummular eczema on the legs?
Signs and symptoms associated with classic atopic dermatitis
MC in who?
venous stasis
Men - 50-65 y
- Round or coin-shaped erythematous scaly plaques; PIH, often with minute fissures, round erosions, or crusts located within
- Erythema may be less prominent in patients with darker skin phototypes
- Plaques may begin as papules or vesicles, which then coalesce
- Trunk and extremities MC
- May involve the hands and feet, but not the face and scalp
dx?
nummular eczema
best tests for nummular eczema
Culture if bacteria suspected
Skin scraping if fungus suspected
Biopsy if necessary
tx for nummular eczema
same as AD
Common inflammatory papulosquamous condition
Affects the sebum-rich areas of the body
Face, scalp, neck, upper chest, and back
Pityrosporum (Malassezia) yeast, a common skin flora
seb derm
Simple dandruff fulminant rash
Dryness, pruritus, erythema, fine greasy scaling
Scalp, eyebrows, glabella, nasolabial folds, the beard area, upper chest, external ear canal, posterior ears, eyelid margins (blepharitis), and intertriginous areas
Anogenital involvement has also been reported
Stress can exacerbate
Crusted plaques are seen
Lighter skin yellow to red to pink
Darker skin hypo or hyperpigmentation
Asx or may complain of pruritus or burning in affected areas
dx?
MC affects who?
best tests?
- seb derm
- immunocomp - HIV, parkinsons
- Clinical dx, bx, KOH if fungal
management for seb derm
- No cure
- Waxes and wanes
- Shampoos - Salicylic Acid, Selenium Sulfide, Tar shampoos, Pyrithone Zinc
Ketoconazole 2% shampoo (TOC), Vanicream Zbar
- Steroids - Clobetasol, Betamethasone, Fluocinolone Scalp Oil; Face hydrocortisone / desonide
Inflammatory skin condition occurring on lower extremities
Cause chronic venous insufficiency
Symptoms - Pruritus, Heaviness, Edema
dx?
stasis derm
Reddish-brown discoloration
Erythematous
Scaling
Patches
Weeping
Crusting - MC area medial ankle; Hyperpigmentation late; Lichenification; Loss of hair shiny skin
dx?
stasis derm
management for stasis derm
- Treat underlying VI
- Weeping lesions = wet compresses = Clean water and burrows
- Topical steroids - Triamcinolone, Clobetasol
Lichenified plaques excessive rubbing and scratching
Predisposing factors: Chronic skin conditions, Emotional stress, Habit forming scratching (ANXIETY)
dx?
lichen simplex chronicus
complications of stasis derm
- Cellulitis
- Non healing wounds (wound clinic referral)
Consult vascular
MC chronic skin condition that predisposes for lichen simplex chronicus
AD
- Thick
- Plaques
- Lichenified - Small papules; Hyperpigmentation; Excoriations
- MC areas: Scalp, ankles, lower legs, upper thighs, forearms, vulva, pubis, anal region, scrotum, groin
dx?
lichen simplex chronicus
tx course in lichen simplex chronicus
- Chronic pts typically aren’t happy
- Stop the itch scratch cycle
- Antihistamines?
- avoid scratching - Nails/pressure; Occlusive dressings/gloves
- Topical steroids - TAC
- ILK
- Emollients
- Erythematous papular and pustular eruption involving the nasolabial folds, the upper and lower cutaneous lip, and the chin
- lip margin and the immediate circumoral area are typically spared
- Periorbital involvement, predominantly the lower and lateral eyelids, may occur - Fine scaling may be seen
- eruption may be asx, but burning or itch may be encountered
- MC women 18-40
dx?
best tests?
- perioral derm
- clinically, bx may help
If the perioral dermatitis was triggered by the use of mid- or high-potency topical steroids, then use _____ because the disorder will flare if corticosteroids are discontinued abruptly
low-potency to taper
Patients must be warned that they will likely flare before they improve after the topical steroid is stopped
therapy regimen for perioral derm
- DC topical steroids (taper)
- Topical pimecrolimus 1%
- Topical and oral abx may also be used - avoid use of gels, solutions, or lotions on the eyelid as inadvertent intraocular application may occur
medication options for perioral derm (6)
- erythromycin
- metronidazole
- pimecrolimus
- azelaic acid
- clindamycin
- Oral abx: Doxy if necessary
- Common on the hands and feet
- Pruritic vesicular rash; Classic “tapioca like vesicles”
- Typically history of AD
- MC between 20-40 years old
- Itching, Burning, Pain
dx?
tests?
tx?
- dyshidrotic eczema
- C&S if unsure if there is infection or not
- Patch testing (not always necessary)
- Biopsy – diagnostic
- topical steroids under occulsion x 2 wks; severe: high dose PO prednisone, PUVA
pt ed for dyshidrotic eczema
Avoid allergens/irritants like excessive hand washing
5 medications for dermatitis & eczema
- Emollients
- Topical Steroids
- Immunomodulators: pimecrolimus (Elidel)
- selenium sulfide
- pyrithione zinc
benefits of emollients
Non-cosmetic moisturizers
increases skin moisture, flexibility and prevents cracking/fissures
use unscented & without anti-aging ingredients
application of emollients
- apply immediately after bathing and frequently throughout the day (3x/d)
- apply in direction of hair growth
- avoid excessive rubbing
- continue use after flare up is controlled
which emollient is the best option for most dermatoses
mixture of fat and water
cooling effect on skin
moderate moisturizing effect
cream
which emollient has more water, less fat than cream
less effective at moisturising skin
useful for hair covered areas
lotion
which emollient is greasy; avoid on weeping eczema
preferable for dry/thickened skin
ointment
indications for topical corticosteroids
- atopic/seborrheic, contact dermatitis
- lichen simplex
- pruritus ani
- nummular eczema
- stasis dermatitis
- psoriasis
MOA of topical corticosteroids
decreases immune response by 4 different processes:
- 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
CI of topical corticosteroids
- underlying bacterial infections
- hypersensitivity
- ophthalmic use
cautions with chronic use of topical corticosteroids
- chronic use may inhibit growth in children
- chronic use induced Cushing syndrome, Kaposi sarcoma
classification of potency of topical corticosteroids
Class I-VII
I-highest
VII- lowest
SE of topical corticosteroids
- skin atrophy
- striae
- easy bruising
- telangiectasias
- change in skin pigmentation
- corticoid rosacea
- steroid acne
- adrenal suppression
- glaucoma (periorbital use)
SE of topical corticosteroids are more likely to happen with:
- continuous long term use
- high potency steroids/vehicles
- facial, intertriginous, genital dermatoses
pros vs cons of corticosteroid ointment
- semi-occlusive
- petroleum based
- most potent topical steroid vehicle
- benefits: superior lubrication, prevention of moisture loss, increase active ingredient absorption
- disadvantage: greasy, avoid hairy areas
benefit of corticosteroid cream
- semisolid emulsions of oil in 20-50% water
- less potent (than ointment) vehicle
- benefits - cosmetic absorption
benefit of corticosteroid lotion
- powder in water- requires shaking of container prior to use
- least potent vehicle
- benefits: minimal residue, cooling/soothing to skin, covers large area, good for thick hair bearing areas
benefit of corticosteroid gels
- mixture of oil in water with alcohol base
- drying effect with minimal residue
- great for scalp dermatitis or acne
- no residue
benefit of corticosteroid powders
- absorb excess moisture
- protect skin-skin chafing
- covers large area
benefits of corticosteroid foam
- gaseous bubbles in matris of liquid film
- easy to spread, w/o residue
- more expensive
benefit of corticosteroid solution
- low viscosity
- powder in water/alcohol
- alcohol = drying effect
potency classification table of topical corticosteroids
Maximum Duration of corticosteroid tx based on classification
- 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
what is Tachyphylaxis
tx/prevention?
- a progressive decrease in clinical response to same dose
- results from repetitive use of same drug
- prevention/treatment: drug free intervals (“holidays”); switch to alternative agent
pimecrolimus (Elidel) and tacrolimus (Protopic) are what drug class
immunomodulators - calcineurin inhibitor
what meds inhibit T-lymphocyte activation via calcineurin inhibition
prevents release of inflammatory cytokines/mediators
pimecrolimus (Elidel) and tacrolimus (Protopic)
indications for pimecrolimus (Elidel) and tacrolimus (Protopic)
atopic dermatitis
Off-label - intertriginous and facial psoriasis, oral lichen planus; Vitiligo
which meds have a BBW for
rare case of lymphoma and skin malignancy
pimecrolimus (Elidel) and tacrolimus (Protopic)
avoid long term use; limit to areas of AD only , with minimal application to achieve control
CI of pimecrolimus (Elidel) and tacrolimus (Protopic)
hypersensitivity
< 2 y/o
cautions with pimecrolimus (Elidel) and tacrolimus (Protopic)
- do not use with occlusive dressing
- reassess if no improvement in 6 wks
- Pregnancy cat. C
SE of pimecrolimus/tacrolimus
- burning sensation (MC) - resolves with continued use
- HA
- URI symptoms, fever
pros and cons of pimecrolimus/tacrolimus
Pros: no skin atrophy/striae; safe for use on face/eyelids
Cons: more expensive; BBW - tumorigenicity
An ingredient found in Head and Shoulders, Selsun
MOA not fully known; reduction in corneocyte production
what med?
selenium sulfide
indications for selenium sulfide
seborrheic dermatitis
tinea versicolor
CI of selenium sulfide
- hypersensitivity
- oral, ophthalmic, anal or intravaginal use
dosing for seb dern with selenium sulfide
apply to affected area for 2-3 minutes, rinse thoroughly, repeat 2x/wk initially; maintenance therapy once q 1-2 wks
dosing of selenium sulfide for tinea vesicolor
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
Se of selenium sulfide
transient burning, stinging
An ingredient found in Head and Shoulders, Selsun, T/Gel
binds to hair/skin- reduces cell turnover
what med?
pyrithione zinc
indications of pyrithione zinc
seb derm
SE of pyrithione zinc
- transient stinging/burning
- desquamation
what is the triad of atopic derm?
- eczema
- asthma
- hay fever
