Dermatitis Pt 2

Question 1

what is the first line treatment for contact dermatitis

Answer 1

TCS are first line treatment for localized ACD

• use moisturizers as an adjunct, esp for chronic ACD
• can use TCI as an alternative to TCS when ACD is unresponsive, invovles skin folds or when thought to be caused by topical corticosteroids

Question 2

what is the first line treatment when large BSA or when the face, hands, feet or genitalia are involved and quick relief is desired

Answer 2

oral corticosteroids

prednisone

Question 3

when ACD is unresposnive to topical or oral corticostoerids what do you do

Answer 3

use phototherapy

Question 4

when would you use systemic therapy

Answer 4

rarely used in resistance cases of ACD

ex: cyclosporine azathiopine

Question 5

what is the mainstay treatment for ICD

Answer 5

TCS and moisturizers

• mostly based on empirical data -> TCI have not ven proven to be effective in ICD and not current recommended

Question 6

what can be used to protect skin against irritants and occupational settings (ICD)

Answer 6

topical barrier products (containing silicone and/or zinc related compounds)

Question 7

with of colloidal oatmeal

Answer 7

evidence is limtied

• can be used in both allergic and ICD to reduce itch and soothe the skin

Question 8

use of frist gen antihistamiesn for contact derm

Answer 8

avoid

maybe can be used to help with sleep i young healthy patients

Question 9

use of moisturizers and soap in patients with stasis dermatitis

Answer 9

improve skin hydration and restore normal barrier function of the skin

mild soap or soapless cleanser should be used during bathing

Question 10

first line to reduce inflammationa and itch during acure SD flares

Answer 10

TCS are frst line to reduce inflammation and itch during fales

• but prolonged use of higher potency CS is not recommended due to risk of akin atrophy and consequently inc risk of ulceration

* use short course of systemic therapy with an oral corticosteroid like prednisone if not responsing to topical corticosteroid therapy

Question 12

use of antibotics, TCI for SD

Answer 12

• antibiotics (topical or systemic_ used when secondary bacterial infection is present
• some evidence for use of TCI but not normally indicated
• systemic therapy (pentoxifylline) bay be considered for treating underlying CVI when non pharm strategies are insufficient

Question 13

non pharm treatments for atopic and contract dermatitis

Answer 13

* first like is avoding allergens and irritants

• envirnment
  
  • home/work in temperate moderate humidity
• Phyiscal activity
  
  • swimming may be tolerated bc less sweating and can remove allergens from skin & reduce colonization by staphylococcus aureus
  • despite drying swimming in chlorinated pools shown to help some atopic patients -> use gentle cleanser after
• Clothing
  
  • loose fiting cotton or cotton blend
  • avoid occllusive clothing fabrics like nylon ro wool
  • avoid fabric softener, bleach or dryer sheets
  • use liquid detergent over powder
• Personal hygiene
  
  • bathe in lukewarm water and mild soap or soapless cleanser
  • limit 5 min for shower and 15 for baths, abths generally preferred bc shown to rehydrate skin
  • pat dry w/ towel

Question 14

wet dressings for treatment of atropic and contact derm

Answer 14

* non pharm method

• Compress
  
  • when oozing and crusting present
  • cools and drys skin through evaporation
• Soaks
  
  • when hardens crusts or scallign is present (chronic AD)
  • softends hardened crusts and hydrates the skin
• Wraps
  
  • Moderate to severe AD and/or resistant cases
  • increases penetration of topical agents, dec water loss and provides a physical barrier against scratching

Question 15

how to use a compress

Answer 15

Soak gauze or a thin cloth with room temperature solution

Wring gently so it remains wet, but not dripping

Apply to the skin, remove, remoisten and reapply every few minutes for 20-30 mins, 4-6x/day

May apply a lotion after, but avoid occluding with an ointment

Question 16

how to use a soak

Answer 16

Saturate the gauze or cloth with solution

Apply to area for 15-20 mins without removal

Question 17

how to use a wrap

Answer 17

A topical agent is covered by a wetted layer of tubular bandages, gauze, or other material

A second dry layer is then applied

Wraps can be worn for several hours, depending on patient tolerance

Question 18

using compresses in stasis dermatitis

Answer 18

• can use wet dressings as compresses or soaks, will cool and dry weeping skin through evaporation
• soid applying non essential topical agents bc they are readily sensitized and at risk of developing CD

* esp ointment bases which tend to be irritating in SD

Question 19

non pharm measures for treatment of SD

Answer 19

• treat underlying CVI
• lifelong compression theapy needed -> gradient compression stockings
• facillitates blood flow to heart, reduces capillary leakage itno tissue and supports lymphatic drainage of interstitial fluid
• general rec is 20-40 mmHg
• other non pharm strategies = daily walking or exercise, weight reduction, or ablation therapy.

Question 20

contraindications of compression therapy

Answer 20

peripheral artery disease,

severe peripheral neuropathy,

massive leg edema or pulmonary edema from congestive heart failure,

local skin or soft tissue conditions (e.g., a recent skin graft, severe cellulitis, gangrene),

allergy to stocking material,

or an extreme deformity of the leg that would prevent proper stocking fit.

Question 22

NHP for treatment of atopic dermatitis

Answer 22

• little evidence
• probiotics durin preg or breastfeeding may prevent AD in child
• evening primrose oil and borage oil are widely used but clinically unsubstantiated
• traditional chinese medicines have been sued for years but safety and efficaccy not well stuided in clincial treils
• acupuncture or massage therapy may improve sigsn and sympoms but studies have been small and of limited quality

Question 23

NHP for contact derm

Answer 23

few studies

• soem evidence that oral admin of sinc sulfate may imporve ACD due to nikle sensitivity

Question 24

NHP for stasis dermatitis

Answer 24

• micronized purified flavonoid fraction (MPFF), a mix of diosmin an hesperidin can be useful ad adjunct to compression therapy to impove small ulcer healing, edema, trophic changes of the skin, and subjective symptoms of CVI
• NPFF associated with few side effects, so given the potential gbenefits and favourable safety can consider for management of underlying CVI in patients with CD

Question 25

product selection guidelines for dermatitis in children and older adults

Answer 25

• systemic abs of TCS is increased due to hgiher sin surface area to boy weight ratio and age related skin changes respectively
• use lowest potency topical corticotoerid that is effectie for shortest duration possible
• risk of hypothalamic pituitary adrenal axis suppression and other stoerid related side effects greater in these pop

Question 26

product selection considerations for dermatitis in pregnant/breastfeeding

Answer 26

• used lowest potency TCS for shortest duration possibe
• systemic abs of TCS is low and use is reported to pose no risk to baby when used in preg, and unlieky it would be passed on via breastmilk
• TCI are also poorly abs folloing topical admin so can consider in second line therapy
• if topical corticosteroid or calcineurin inhibitor is applied to the breast, remove before feeding
• safety of crisaborole ointment has not been evaluated in human pregnancy
• phototherapy and UV is fine
• systemic therapy with agents like methotrexate is generally contraindicated

Question 27

what clinical pearls are associated with topical corticosteroids

Answer 27

“corticophobia” negative feelings and beliefs related to TCS use

• results in poor adherence and treatment
• only apply CTS to intact skin
• avoid occluding the treated areas unless directed to do so by HCP
• seek reassessment for skin lesions that do not improve after 2 weeks of therapy

Question 28

pros and cons for topical agents

Answer 28

• Lotion
  
  • pro: less greasy and good for large or hairy areas
  • con: alc based, hgiher water content
• Cream
  
  • Pro: cosmetically accetable, good or weeping areas
  • cons: less abs
• Ointment
  
  • Por: excellent penetration, emollient effects, good for dry scaly skin, less irritating
  • Cond: less cosmetically acceptable, may cause skin irritation in hot humid env

Question 29

how much FTU to apply to

Face & neck

Trunk, front and back

arm and hand

leg and foot

Answer 29

Face & neck: 2.5 FTU

Trunk, front and back: 14 FTU

arm and hand: 4 FTU

leg and foot: 8 FTU

Question 30

monitoring and follow up for

inflammation and pruritis

area involved

sleep and/or daily activities

adverse effects of therapy

Answer 30

inflammation and pruritis: dec by 50% in 7-10 days

area involved: no progression

sleep and/or daily activities: may take several weeks to return to normal

adverse effects of therapy: none/minimal

*patient monitor daily, RPh in 7 days for acute cases