Dermatitis (Exam 1) Flashcards
Forms of contact dermatitis
irritant
allergic
in contract dermatitis, lesions are found
only in the area of exposure
irritant contact dermatitis
non-immune modulated irritation of the skin by a substance
can be acute or chronic
acute irritant contact dermatitis
irritant exposure to oxidizing agents, strong acids, detergents or solvents
effect in minutes to hours
chronic irritant contact dermatitis
continuous skin exposure to liquids
prolonged wearing of slices
hand washing/disinfectant
difference in appearance of acute and chronic irritant contact dermatitis
acute - erythema
chronic - cracks/skin fissures
allergic contact dermatitis
delayed hypersensitivity reaction
foreign substance comes into contact with the skin
immune modulated
examples of allergic contact dermatitis
poison ivy
nickel
fragrance exposure
what is the dominant feature of allergic contact dermatitis
pruritis
chronic allergic contact dermatitis symptoms
dry, scaly and thicker
lichenification and fissuring
what type of hypersensitivity reaction is contact dermatitis?
what about eczema?
type IV
type I (also type IV)
goals of therapy for contact dermatitis
restoration of normal epidermal barrier
treatment of inflammation of skin
control of itching
the mainstay of therapy in dermatitis are
topical corticosteroids
when prescribing topical corticosteroids, the ____________ potent topical agent that is effective for the patient should be used for the _______________________
least
shortest possible time
topical corticosteroids are classified according to
potency
which type of corticosteroids are more potent?
why?
fluorinated steroids (groups 1-3)
they penetrate the skin better than non fluorinated steroids
why are fluorinated steroids not used mostly first?
more local complications
may be associated with systemic absorption and side effects
the choice of steroid based on potency is determined by the ________________ to be treated.
low potency agents treats __________
Higher potency agents treats __________
area of skin
thinner stratum corneum (face, scrotum, skin folds)
palms and soles, crusting and thickened conditions
________________ are the most potent and most lubricating and have ____________ properties
ointments and gels
occlusive
what type of formulation in most desirable?
lotions and creams - less greasy
what formulations are useful for treating the scalp
foam sprays and solutions
correct usage of topical corticosteroids
use sparingly to affected areas 2-4 times a day
tolerance is common
repository effect (1 or 2 applications/day may be as effective as 3 or more)
what type of topical corticosteroids are preferred in children?
low potency
super high potency topical corticosteroids should generally not exceed
2 consecutive weeks due to increased risk of immunosuppression
topical corticosteroids should not be _______________ because a __________ effect may occur
abruptly discontinued
rebound
topical corticosteroids should not be applied to
wet or weeping lesions
adverse effects of topical corticosteroids
local tissue atrophy, skin degeneration and striae
thinning of the epidermis
risk of suppression of HPA axis
development of cushingoid features
first line for irritant contact dermatitis
mild to moderate potent topical steroid
oral antihistamine as needed
second line for irritant contact dermatitis
more potent topical corticosteroid for up to 14 days
first line for allergy contact dermatitis
moderate potent topical steroids
oral antihistamine as needed
second line for allergy contact dermatitis
systemic corticosteroids, taper to no medication by 2 weeks
atopic dermatitis
chronic disorder due to defective skin barrier
similar presentation to allergic contact dermatitis but more widespread
pathogenesis of atopic dermatitis
IgE dysregulation
defects in the cutaneous cell mediated immune response
genetic factors
cytokines that cause inflammation in atopic dermatitis
IL4 and IL13
atopic dermatitis severity scale we need to know is
United Kingdom National Institute for Health and Care Excellence
mild atopic dermatitis
areas of dry skin
infrequent itching
little impact on everyday activities
sleep and psychological well being
moderate atopic dermatitis
areas of dry skin
frequent itching and redness
moderate impact on everyday activities
frequently disturbed sleep
severe atopic dermatitis
widespread areas of dry skin (incessant itching, redness, bleeding, oozing, etc)
severe limitation of everyday activities
nighyly loss of sleep
goals of therapy for atopic dermatitis
restoration of normal epidermal barrier
treatment of inflammation of skin
control of itching
remission
first line treatment for mild-moderate atopic dermatitis
emollients/moisturizers, education
when acute control of pruritis and inflammation is needed in mild-moderate atopic dermatitis
low potency topical corticosteroid
second line treatment for mild-moderate atopic dermatitis
switch to topical calcineurin inhibitors or crisaborole
third line treatment for mild-moderate atopic dermatitis
medium-high potency topical corticosteroid
low potency topical corticosteroid or topical calcineurin inhibitors on areas of increased risk of atrophy
maintenance therapy for mild to moderate atopic dermatitis
topical calineurin inhibitors (2 consecutive days/week) or crisaborole
include intermittent topical corticosteroids prn
adjunctive therapy for mild to moderate atopic dermatitis
avoidance of trigger factors
antihistamine as needed
newer options that can be used as maintenance for mild to moderate atopic dermatitis
topical roflumilast
tapinarof
ruxolitinib
examples of emollients/moisturizers
eucerin
lubriderm
lac-hydrin
vaseline
the thicker the preparation,
the more effective the product
Eucrisa (crisaborole)
topical phosphodiesterase 4 inhibitor
mild-moderate atopic dermatitis
can be used in infants 3 months and older
examples of topical immunosuppressants
Protopic (tacrolimus)
Elidel (pimecrolimus)
topical immunosuppressants
inhibit calcineurin which normally initiates T cell activation
acute or maintenance
ages 2 and up
adverse effects of topical immunosuppressants
stinging, itching, burning (common)
flu like symptoms
muscle pain
swollen glands
skin infections
Vtama(Tapinarof)
topical immunosuppressant
modulation of T helper cytokines
alternative to topical steroids/ineffective treatments
adults
Zoryve (roflumilast)
inhibits PDE4
topical immunosuppressant
alternative to topical steroids/ineffective treatments
ages 6 and up
Opzelura (Ruxollitinib)
topical immunosuppressant
JAK inhibitor
inhibits cytokines IL4 and 13
ages 12 and up
when using Opzelura (Ruxollitinib), when signs and symptoms resolve
discontinue use
Opzelura is approved for
short term treatment only
First line treatment for moderate/severe atopic dermatitis
Dupixent (dupilumab)
inhibits IL4 and 13
ages 6 months and up
alternate treatments to the first line treatment for moderate/severe atopic dermatitis in adults
tralokinumab (Adbry)
Lebrikizumab (Ebglyss)
second line treatment for moderate/severe atopic dermatitis
oral JAK (janus kinase) inhibitors:
Rinvoq(upadacitinib)
Cibinqo (abrocitinib)
phototherapy
can topical corticosteroids or other topical agents still be used in a person who has moderate/severe atopic dermatitis on maintenance treatment?
yes!
only as needed
biologic agents adverse effects
conjunctivitis and keratitis
eosinophilia
antibody development
viral infection
injection site reactions
biologics inhibit the
binding of one or more cytokines, by either binding the cytokine or receptor causing changes that trigger inflammation
biologics are ____________ while JAK inhibitors are ______________
genetically engineered proteins from living organisms
synthetic
JAK inhibitors block
enzymes which decrease inflammation from INSIDE the cells
are biologics or JAK inhibitors preferred when treating atopic dermatitis?
why?
while JAK inhibitors provide more rapid improvement,
BIOLOGICS are preferred
there is potential risk for serious adverse events when using JAK inhibitors
when to use JAK inhibitors
control of seasonal flares
eczema that does not respond to biologics
JAK inhibitors are considered _____________ due to their serious adverse effects
last line agents
phototherapy
use of UV light to slow the rapid growth of new skin cells in atopic dermatitis
JAK inhibitors warnings/precautions
cerebrovascular accidents
MI
hypotension
arrhythmias
hematologic toxicities
severe hepatic reactions
reactivation of HBV
active TB
non targeted oral immunosuppressive agents for moderate/severe atopic dermatitis
cyclosporine (Neoral, Sandimmune)
methotrexate
cyclosporine (Neoral, Sandimmune)
blocks calcineurin activation inhibiting T cell activation and non targeted cytokine production
Methotrexate
inhibits folic acid reductase resulting in the inhibition of cellular DNA replication
leads to suppression of inflammation
methotrexate is often combined with
folic acid
methotrexate is contraindicated in
pregnancy (X)
treatments for scalp seborrhea
topical corticosteroids in conjunction with a shampoo: either selenium sulfide (Selsun) or ketoconazole (Nizoral)
salicylic acid
coal tar products
treatments for diaper rash
occlusive agents (zinc oxide, petrolatum)
low potency topical corticosteroid
if secondary Candida infection is present in diaper dermatitis, the treatment should include
anti fungal agents (nystatin, clotrimazole, miconazole, ketoconazole)
super high potency topical corticosteroids (group 1)
betamethasone dipropionate augmented
clobetasol propionate
fluocinonide
halobetasol propionate
high potency topical corticosteroids (group 2)
halcinonide
medium potency topical corticosteroids (group 4)
mometasone furoate
lower mid potency topical corticosteroids (group 5)
hydrocortisone butyrate
hydrocortisone probutate
hydrocortisone valerate
low potency topical corticosteroids (group 6)
alcometasone dipropionate
desonide
least potent topical corticosteroids (group 7)
hydrocortisone (base less than 2%)
