Dermatology 2 Flashcards
1
Q
Phyto-Photo Dermatitis
Overview
A
- Occurs after contact with photosensitizing compounds in plants and exposure to sunlight.
- Mistaken for atopic dermatitis, type IV hypersensitivity reaction (contact dermatitis) or a chemical burn
- Primary skin lesion of PhytoPD may range from delayed erythema (24-48 hours) to frank blisters
- Go out into sun and get an erythema
2
Q
Phyto-Photo Derm Triggers
A
- Furocoumarins (e.g., 5- methoxypsoralen) found in limes, lemons, oranges, celery, fig, parsnip, parsley, carrots, dill, and perfumes, are commonly implicated
- Citric fruits
3
Q
Phyto-Photo Dermatitis
Clinical Findings
A
- A post-inflammatory pigment alteration may follow the acute phase of this phototoxic reaction.
- Melanin, which is normally found in the epidermis, “falls” into the dermis and is ingested by melanophages.
- An increased number of functional melanocytes and melanosomes distributed in the epidermis following PPD also account for the hyperpigmentation
- Greater number of melanocytes and have hypopigmentation
- Some kids after varicella – some kids have a lot and some nothing; depends on skin
- Post-inflammatory hyperpigmentation
4
Q
Overview of Atopic Dermatitis
A
- AD affects approximately 10% to 12% of the childhood population in the U.S. with higher incidence in other countries.
- AD develops in 85% of children within the first 12 months of life, and in 95% of children before age 5 years.
- Approximately 0.9% of adults have AD; some of whom had an adult onset but the majority had AD as a child.
- AD is often the first manifestation of the “atopic march” with asthma and Allergic Rhinitis following.
- Asthma also develops in approximately 30% and AR develops in 35% of those with AD. The incidence of AD is increasing in the U.S. (Schneider et al., 2013).
5
Q
The Atopic Triad
A
Asthma
Atopic Derm
Allergic Rhinitis
6
Q
Atopic Derm: The Basics
A
- Chronic, pruritic, inflammatory skin disease with a wide range of severity
- Diagnostic characteristics
- Pruritus
- Chronic or relapsing eczematous lesions with typical morphology and distribution
7
Q
Primary Symptom of AD
A
- Primary symptom is pruritus (itch)
- AD is often called “the itch that rashes” chronic, relapsing
- Scratching to relieve AD-associated itch gives rise to the ‘itch-scratch’ cycle and can exacerbate the disease
- Patients experience periods of remission and exacerbation
8
Q
Pathogenesis of AD
A
- The cause of AD is multifactorial and not completely understood
- The following factors are thought to play varying roles:
- Genetics
- Skin Barrier Dysfunction
- Impaired Immune
- Response
- Environment
- Prone to terrible secondary infection
- Dry vs. Wet – more likely to have exacerbations in dry
9
Q
Pathophysiology of AD
A
- Increased serum IgE levels are common and correlate with disease severity
- AD is in part initiated by skin barrier defects. These barrier defects can be acquired or genetic.
- Inadequate innate immune response to epicutaneous microbes is partially responsible for
- Increased susceptibility to infections
- Colonization with Staphylococcus aureus and a number of viruses
- Susceptibility to infection****
10
Q
Clinical Findings AD
Infants and Toddlers
A
- Lesions typically begin as erythematous papules, which then coalesce to form erythematous plaques that may display weeping, crusting, or scale
- Distribution of involvement varies by age:
- Infants and toddlers: eczematous plaques appear on the cheeks forehead, scalp and extensor surfaces
- THINK ABOUT EXTENSOR SURFACES
- Infants and toddlers: eczematous plaques appear on the cheeks forehead, scalp and extensor surfaces
- Affects the cheeks, forehead, scalp, and extensor surfaces
- Erythematous, ill-defined plaques on the cheeks with overlying scale and crusting
- Not well demarcated
11
Q
Clinical Findings AD
Older children (older than 2) and adolescents
A
Older children and adolescents: lichenified, eczematous plaques in flexural areas of the neck, elbows, wrists, and ankles
Flexed areas*
- Lichenified, erythematous plaques behind the knees
- Erythematous, excoriated papules with overlying crust in the antecubital fossa
12
Q
Clinical Findings of AD
Adults
A
Adults: lichenification in flexural regions and involvement of the hands, wrists, ankles, feet, and face (particularly the forehead and around the eyes)
Xerosis is a common characteristic of all stages = DRY SKIN
13
Q
Allergens and Atopic Dermatitis
A
- The role of allergy in AD remains controversial
- Many patients with AD have sensitization to food and environmental allergens
- However, evidence of allergen sensitization is not proof of a clinically relevant allergy
- Food allergy as a cause of, or exacerbating factor for, AD is uncommon
- Identification of true food allergies should be reserved for refractory AD in children in whom the suspicion for a food allergy is high
- Infants with AD and food allergy may have additional findings that suggest the presence of food allergy, such as vomiting, diarrhea, and failure to thrive
- Elimination of food allergens in patients with AD and confirmed food allergy can lead to clinical improvement
14
Q
Understanding the Clinical Presentation
Acute/subacute skin lesions vs. Chronic AD
A
- Acute and subacute skin lesions
- Characterized by intensely pruritic, erythematous papulovesicular lesions with excoriation and serous exudate in young children
- Chronic AD
- Characterized by lichenification, papules, and excoriations
15
Q
Treatment for AD
Clinical Guidelines
A
- Clinical Guidelines
- Clinicians should use a systematic, multipronged approach that includes skin hydration, topical anti-inflammatory medications, antipruritic therapy, antibacterial measures, and elimination of exacerbating factors.
- Clinicians should evaluate the success of the approach and modify the treatment plan, if needed. (A)
- HYDRATION HYDRATION HYDRATION
- Hydroxyzine
- 10mg per 5mL
16
Q
- Intensity of Atopic dermatitis treatment depends on
A
- Severity of illness
- Effect on the quality of life The clinician should establish treatment
- The clinician should establish treatment
- Establish goals with the patient
17
Q
What is a characteristic of AD?
A
- Reduced skin barrier is characteristic of AD
- Leads to enhanced water loss and dry skin;
- Hydration of the skin with warm soaking baths for at least 10 minutes followed by the application of a moisturizer
18
Q
- SOAK AND SEAL
A
- Shower
- Rub with cream and ointment
19
Q
First Line for AD?
Exacerbated in what months?
A
- MOISTURIZER IS FIRST LINE!
- Xerosis contributes to the development of epithelial microfissures and cracks, which allow entry of microbes and allergens.
- Exacerbated during the dry winter months and aggravated in certain work environments.
- Addition of oatmeal or baking soda to the bath water can have a soothing antipruritic effect for certain patients but does not increase water absorption.
20
Q
Moisturizers in AD
A
- Help control pruritus
- Maintaining a soft texture to the skin.
- When applied to dry skin and after bathing to maintain hydration of the epidermis.
- Consistent use has a corticosteroid-sparing effect
- HELPS TO SPARE USE OF STEROIDS
21
Q
Other anecdotes for AD
A
- Baking soda
- ½ cup of regular oatmeal, use ¼ Crisco, add a cup of water
- Mix in clean jar and then you put a tablespoon or 2 in every bath – hydrates and soothes skin
22
Q
- TYPES OF MOISTURIZERS for AD
A
- Emolliate with a moisturizer.
- Lubricants maintain the skin’s hydration
- An ointment-based emollient
- Eucerin cream, Crisco (plain, not butter flavored), Aveeno, Moisturel,
- Neutrogena, Dermasil, Curel, or petroleum jelly (an occlusive agent).
- If a child is sensitive to fragrances, scented creams, such as Nivea and Vaseline
- Intensive Care, should be avoided.
- TriCeram is a moisturizer that repairs the stratum corneum barrier function.
- Prescription
- Like Cereve, it is a ceramide-dominant, lipid-based emollient.
- For DRY skin
- Urea-containing products, such as Aquacare cream or lotion and Ureacin Crème,
- Soften and moisturize dry skin.
- Stinging is a side effect when using urea containing product on fissured or flaring skin.
- Comes back if you stop using creams
23
Q
AD:
- An ointment-based emollient
A
- e.g., Vaseline, petrolatum jelly, Crisco, vegetable oil, whipped petrolatum, Aquaphor) can be applied just before getting out of the bath water or just after getting out of the bath while still damp.
- If patients do not like the greasy feel of an ointment, other topical creams (e.g., Vanicream, Cereve, Cetaphil) can be used.
- Vanicream – contains no chemicals and its great that way
- This is also a good time to apply TCPs because absorption of the agent is more effective if the skin is hydrated.
24
Q
Bathing with AD
A
- Frequent bathing may exacerbate their pruritus and thus aggravate their skin problems.
- Bathing must be limited in these patients and emollients used.
- If a child experiences stinging when bathing during acute exacerbations, adding 1 cup of table salt into the bath may reduce the stinging sensation.
