dermatologic disorders Flashcards
when to refer to MD
multiple or extensive burns Human or animal bites Multiple or extensive cuts, bruises, or abrasions Rash that is extensive, weeping, or infected Tumors or growths Yellow skin Deep infection (cellulitis) Large blisters of unknown origins Exposed deep tissue, muscle, or bone
anatomy of the skin
epidermis
dermis
subQ
primary skin lesions
flat, nonpalpable changes in skin color: macule, patch
elevation formed by a fluid in a cavity: vesicle, bulla, pustule
elevated, palpable solis masses: papule, plaque, nodule, tumor, wheal
secondary skin lesions
material on skin surface: scale, crust, keloid
loss of skin surface: erosion, ulcer, excoriation, fissure
vascular skin lesions
cherry angioma, telangiectasia, petechiae, eccyhmosis
basic vehicles for derm products
ointment, cream, lotion, gel, soln/spray
very important to realize basic properties
ointments
Semi-solid preparations intended for external application to skin and mucous membranes.
Four classes: Hydrocarbon, Absorption, Water-removable, Water-soluble
Advantages: Hydrates, Removes scales, Greatest bioavailability of active ingredient
Disadvantages: Greasy
Preferred Area of Use: Smooth skin with short or sparse hair
properties of ointments
Occlusive: promotes retention of water in the skin, forms a hydrophobic barrier that prevents moisture in the skin from evaporating.
Humectant: causes water to be retained because of its hygroscopic properties.
Emollient: Softens the skin, Soothes irritation in skin or mucous membranes
Protective: Protects injured or exposed skin surfaces from harmful or annoying stimuli
application of creams/ointments
finger tip units - 1/2 gram of cream/ointment
amount needed depends on area of patient, area being applied to, how often and how long
creams and lotions
Ointment bases of the water-removable class Consisting of oil-in-water emulsions or aqueous microcrystalline dispersions of long fatty acids or alcohols Water washable and more cosmetically and aesthetically acceptable than ointments*** LOTIONS are basically watered-down creams
lotions solutions or sprays
Advantages: Easy to apply to hairy areas, scalp, High patient acceptance
Disadvantages: Drying, Lower bioavailability
Preferred Area of Use: Intertriginois and hair-bearing skin, face
cream properties
Advantages: Good cosmetic appearance, High patient acceptance
Disadvantages: Not as hydrating as ointments
Preferred Area of Use: Smooth or hair-bearing skin, Intertriginous areas
gels
semi-solid systems consisting of either suspensions made up of small inorganic particles or large organic molecules interpenetrated by a liquid
Advantages: Non-greasy, Easy to apply to hairy areas, High patient acceptance
Disadvantages: Drying
gels/lotions/solution/foam preferred area of use
hair bearing skin
oleaginous bases
white petrolatum, vaseline, plastibase
absorbs NO water, not water washable - soap is required
absorption bases
aquaphor, aquabase, polysorb
can absorb* several times it;s weight of water*
not water washable
water-in-oil emulsion bases
nivea, eucerin, hydrocerin
absorbs less water than absorption bases
not water washable
oil-in-water emulsion bases
hydrophilic ointment, dermabase, hydrocerin, unibase, cetaphil lotion, vanicream
water washable***
add water = lotion
water soluble base
polyethylene glycol ointment
water washable
minimal therapeutic effect
primarily used for drug delivery
choice of bases
Condition of the skin - Desired effect** from the base
Area of application
Patient acceptability
The nature of the incorporated medication - Bioavailability, Stability, Compatibility
drug-induced skin disorders
Hypersensitivity/allergic rxn - rash, hives, scarlet fever
Photosensitivity
Toxic Reaction: Erythema multiforme, Stevens-Johnson Syndrome, toxic Epidermal Necrolysis
treatment of ADRs
stop the drug!
systemic antihistamines, systemic or topical CSs, soothing baths or soaks
derm SEs
photosensitivity,
treatment of photosensitivity
Prevention*** with sunscreens/clothing - SPF ≥ 30 Systemic analgesics Systemic antihistamines for itching Prevent infection Moisturizers Cooling creams and gels (Aloe)
drug-induced skin disorders
Toxic Skin Reactions: Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis
Characteristics: Epidermal detachment, Erosive mucosal lesions
Underlying mechanism: Drug protein complex reaction leads to T-cell activation which migrates to the dermis and releases cytokines
drugs associated with SJS/TEN
Sulfonamides, Cephalosporins, Penicillins, Fluoroquinolones, Anticonvulsants***, Allopurinol, NSAIDs, Others…
features of SJS/TEN
Usually occurs within first 4 weeks of tx
Prodromal NVD, myalgias, sore throat, arthralgias - Flu-like symptoms
Involvement of mucous membranes
Widespread blisters and lesions
Full thickness epidermal detachment - Risk of infection
treatment of SJS/TEN
Stop offending agent***, IV fluids / nutrition, Pain control, Eye carem, Nasal saline, Oral hygiene and anesthetics, Topical antiseptics, Wound care
questions to ask a patient who presents with a skin rash or lesion
Onset, duration, getting better or worse
Parts of body involved
Symptoms
Exposure to new drugs or irritants
cellulitis
infection near break in skin
Red, warm, swollen
Refer to PCP**
Tx with… Oral antibiotics, IV antibiotics in severe cases
imeptigo
Topical Staph skin infection Most common in children Direct spread Refer to PCP** Tx with… Topical or oral antibiotics
topical candida infection
Common in moist areas in humid conditions
Tx with… Topical antifungals, Dry affected areas
tinea pedis
Often spread in pools/showers
Moist environments promote growth
Dermatophyte infection
Tx with… Topical antifungals
tinea corporis
body ring worm Commonly transmitted in day-care Hot/humid environments promote growth Small, circular, red scaly areas Tx with… Topical antifungals
head lice
Children 3-12 yo
Scalp redness and scaling
Pruritus
Refer to PCP
tx with… Permethrin 1%, Malathion (Ovide), Oral Ivermectin (Stromectol), Spinosad (Natroba), Topical Ivermectin (Sklice)
Other considerations! Somewhat expensive OTC medications (Make sure patient knows how to use); Prevention! (Others in house, Washing everything!)
scabies
Sarcoptes scabiei infestation
Primarily in children and adolescents (LTCF)
Raised lines caused by mites burrowing under skin***
Extreme pruritus
Refer to PCP
Tx with… Permethrin 5%, Crotamiton (Eurax Cream), Oral Ivermectin (Stromectol)
herpes zoster (shingles)
Adults > 40 yo
Especially in pts who previously had chicken pox
Potentially contagious while blisters are present
Triggered by stress, old age, immunosuppression
Extreme pain along dermatome
Tender red papules - progresses to scabs
Refer to PCP
Tx with…
-Oral valacyclovir or famciclovir
-Manage acute pain and postherpetic neuralgia - Oral opioids for acute pain, Gabapentin for PHN, Lidoderm patches - once lesion have healed
skin cancer
Better screening tests means its becoming more “prevalent” Patients becoming more aware of it Lots of prevention education available Basal cell carcinoma (most common) Squamous cell carcinoma (sun-exposed) Melanoma (most deadly) Caucasians w/ light eye and hair color Refer to PCP Tx with… Removal of lesion, Chemotherapy, Radiation
xerosis
dry skin
Common features: Fall and winter, Feet, lower legs, Hands, elbows, face, Rough, dry, scales, cracks, Itching is common Sx
who is at risk - elderly (decreased activity of sweat and sebaceous glands; very warm, dry environments) and frequent bathing
treatment options: emollients (first line for itching, restores barrier and skin function), agents for itching, alter bathing habits (no more than 3 times/week, tepid water (3-5 degrees above body temp), for 3-5 minutes, pat dry, apply copious amounts of emollients within 3 minutes, apply at least 3 times daily)
emollients for xerosis
Vaseline, Nivea, Keri, Lubriderm, AmLactin, Eucerin
Ointments vs. Creams vs. Lotions
agents to reduce itching for xerosis
Menthol and camphor - ½ to 1%, Create a sensation of cooling
Pramoxine - 1%, Local anesthetic
Aluminum Acetate - 0.2%, Alter C-fiber nerve transmission
Hydrocortisone - 0.5% and 1%, Anti-inflammatory
acute dermatitis
red patches or plaques
Pebbly surface or blisters (vesicles)
Itching is common
subacute dermatitis
dry, less red than acute, crusting, oozing, mild thickening
Red scaling, fissured, patches or plaques
Slight to moderate pruritis, pain, stinging or burning
chronic dermatitis
Epidermal thickening Exaggerated skin markings lichenification Scaling Less itching Well demarcated, lichenified, thichened plaques Excoriations, fissures, scaling Itching predominates - Minor irritations or trauma worsens itching Treatment – same as subacute Use emollients (ointments for dry lesions) Avoid long-term corticosteroids UV light
acute contact dermatitis
Look at pattern
Look at part of body involved
Main symptom is itching
Two types: Allergic and Irritant
acute contact dermatitis - irritant
Non-immunologic reaction to frequent contact with everyday substances
Reaction within a few hours
Common irritants ???
More common than allergic
poison ivy
example of acute dermatitis
Direct exposure: Broken plant, Resin – 2 weeks
Indirect exposure: Clothing, dog, smoke, Does not spread from lesions
Prevention is the key: Ivy-Block (Protectant; barrier, Re-apply every 4 hours)
Dermatitis occurs 24 to 48 hrs after exposure.
Pruritis is intense - secondary infections, cool water
Wash skin and nails within 10 minutes. - wash clothing as well
Topical therapy OK if less than 10% BSA involved.
treatment options: Remove source, Soaks, Calamine Lotion, Topical antihistamines, Oral Antihistamines, Topical Corticosteroids, Oral Corticosteroids
soaks for treating acute dermatits
For oozing, weeping, crusting lesions
Wet dressings useful for drying acutely inflammed, wet areas
treatment of acute dermatits
Domeboro (5% aluminum acetate) - Packets in cool water
Acetic Acid: 60 ml vinegar in 1 qt warm water
Saline: 1 tsp salt in 2 cups water
Water
Apply linen or cheesecloth for 30 minutes bid – qid; remove when dry
topical corticosteroids for treatment of acute dermatitis
MOA: Anti-inflammatory, Anti-pruritic, Suppress immune response
Apply bid to qid x 3 – 14 days
choice of vehicle based upon: Location of lesions, Type of lesion, Severity of lesion/degree of inflammation, Degree of skin penetration desired
Classified according to potency which corresponds to anti-inflammatory activity and vasoconstrictive potency
-Very-high - High – Mid – Low (Grades I to VII)
Vehicle impacts delivery and potency of corticosteroids
Only 1% is absorbed when applied to normal intact skin
Occlusion enhances penetration** - Plastic wrap + T-shirt / bandage, Increases penetration 10X, Leave on for six hours
topical corticosteroids side effects
Thinning of skin Dilated blood vessels Bruising Skin color changes Risk of HPA suppression with long-term use of high-potency agents Development of tolerance (tachyphylaxis)
low potency topical CSs
grades 5 - 7 Examples: Hydrocortisone; Desonide Use on face, groin, genitals, axilla Mild anti-inflammatory effect Safest for long-term maintenance use
mid-potency topical CSs
Grades 3 - 5
Examples: Betamethasone, Triamcinolone, Mometasone
Used on most skin surfaces for exacerbations
Moderate anti-inflammatory effect
Safer for longer usage than high potency
high/very-high potency topical CSs
Grades 1 -2
Examples: Fluocinolide, Halobetasol, Clobetasol
Used for very severe lesions and on thicken skin when maximum penetration is needed - Psoriasis
Do NOT use on face.
Avoid using super-potent agents for > 2 wks.
Limit to no more than 50 grams per week.
topical calcineurin inhibitors
MOA: blocks pro-inflammatory cytokine genes Can be used on any area Equivalent to mid-potency corts No risk of atrophy Few side effects - burning \$\$\$\$$ Now considered 2nd-line tx Intermittent use only** Recent concern regarding long -term use - Risk of malignancies, Risk of resp infect in children under 2 yrs
crisaborole 2% ointment
Phosphodiesterase-4 Inhibitor (non-steroidal) Alternative to TCS and TCIs Mild or moderate AD BID for 28 days \$\$$
