dermatology Flashcards
Ointments
consist mainly of water suspended in oil and exellent lube, most potent vehicles, occulsive effect, not hairy areas to to greasiness-
use: dry, lichenified lesions
creams
less potent than ointments but stronger than lotions, semisolid emulsion of oil in water, washed off with water, nonhairy areas such as palms and soles
lotions
powder in water preparation, less potent vehicle
use: moist areas, dermatoses, pruritius, hairy areas, lg areas, cooling effect on skin
solutions
water in combo with various meds/substances
coolness and aid in drying of exudative lesions
use: closed dsg, infected dermatoses or hairy areas
gel
oil in water, semisolid emulsion with alcohol in the base, transparent and colorless and liquefies on contact with the skin
use: hairy body areas and combine the advt of ointments with cosmetic adv of creams
corticosteroids GROUP 1 (most potent)
Clobetasol propionate (Temovate; cream, ointment 0.05%) Betamethasone dipropionate (Diprolene; ointment 0.05%) Halobetasol propionate (Ultravate; cream, ointment 0.05%)
corticosteroids GROUP 2
Fluocinonide (Lidex; cream, ointment, gel, solution 0.05%) Mometasone furoate (Elocon; ointment 0.1%) Betamethasone dipropionate (Maxivate; ointment 0.05%) Amcinonide (Cyclocort; ointment 0.1%) Desoximetasone (Topicort; cream, ointment 0.25%; gel 0.5%)
corticosteroids GROUP 3
Triamcinolone acetonide (Kenalog, Aristocort; ointment 0.1%) Amcinonide (Cyclocort; cream, lotion 0.1%) Betamethasone dipropionate (Diprosone; cream 0.05%) Betamethasone valerate (Valisone; ointment 0.1%) Fluticasone propionate (Cutivate; ointment 0.005%)
corticosteroids GROUP 4
Mometasone furoate (Elocon; cream, lotion 0.1%) Triamcinolone acetonide (Kenalog, Aristocort; cream 0.1%)
corticosteroids GROUP 5
Fluticasone propionate (Cutivate; cream 0.05%) Fluticasone acetonide (Synalar; cream 0.025%) Betamethasone valerate (Valisone; cream 0.1%) Hydrocortisone valerate (Westcort; cream 0.2%) Betamethasone dipropionate (lotion 0.05%) Prednicarbate (Dermatop; cream 0.1%)
corticosteroids GROUP 6
Fluocinolone acetonide (Synalar; solution 0.01%) Betamethasone valerate (Diprolene lotion 0.05%) Triamicinolone acetonide (Aristocort, Kenalong; cream 0.1%) Desonide (DesOwen; cream, ointment, lotion 0.05%, Tridesion; ointment 0.05%) Alclometasone dipropionate (Aclovate; cream, ointment 0.05%)
corticosteroids GROUP 7 (least potent)
Hydrocortisone (Hytone; cream, ointment, lotion 2.5%, generic cream 0.1%, 2.5% Pramoxine hydrochloride (HC Pramoxine; cream 0.1%, 2.5%)
group 1 and II used for
Groups 1-2 (severe): psoriasis, discoid lupus, severe eczema, resistant adult atopic dermatitis
group III- V used for
Groups 3-5 (intermediate): atopic derm, eczema, seborrheic derm, intertrigo, tinea, scabies (after scabicide), severe dermatitis of face
group VI- VII used for
Groups 6-7 (mild): derm of eyelids, diaper area, face, mild intertrigo.
group I-II use these to tx
Groups 1-2 (severe): psoriasis, discoid lupus, severe eczema, resistant adult atopic dermatitis
group 3-5 use these to tx
Groups 3-5 (intermediate): atopic derm, eczema, seborrheic derm, intertrigo, tinea, scabies (after scabicide), severe dermatitis of face
group 6-7 use these to tx
Groups 6-7 (mild): derm of eyelids, diaper area, face, mild intertrigo.
psoriasis s&s
Scaly plaques & papules
well demarcated, elevated, erythematous, silvery white plaques
pitting on nail beds
most psoriatic lesions are asymptomatic, but can be pruritic. Picking & scratching can worsen lesions (produce Koebner’s response?)
Skinfold lesions more likely to itch (axilla, groin, genitals = inverse proriasis)
differential dx of psoriasis
gout pseudogout reactive arthritis syphilis squamous cell CA nummular eczema lichen simplex chronicus
management of psoriasis
meds = Oral retinoids i.e. methotrexate, Cyclosporine
phototherapy- uvb
topical- reduce epidermal proliferation and decrease inflammation wiht steroids (ointments pref), shampoo help, coal tar prep or vit D prep
methotrexate
oral retinoids for psoriasis
use with caution of childbearing age
effective in treating severe, recalcitrant psoriasis involving a large body area
CI: pregnancy, liver/kidney disease, anemia, colitis or debility
cyclosporine
oral retinoids for psoriasis
limited because of its potential nephrotoxicity
monitor BP, and serum creat.
Dermatologist should manage/co-manage
referral of psoriasis
medication management, pt with re-calcitrant or unresponsive psoriasis
education to pt on psoriasis
understand chronic nature, adherence with meds/ointments, avoid injury sunburn/trauma, triggers BB ASA chloroquines
Acne Vulgaris patho
before puberty- androgenic stimulation which increases sebaceous gland production, abd adherent keratinization (plugged follicles)
acne vulgaris management
tx comedone (retinoids), topical keratolytics (retin A) salicylic acid, inflam/bacteria with benozyl peroxide & ABX for severe acne i.e. doxy/minocycline or estrogen/spironolactone suppress the androgenic stimualtion of sebum
acne vulgaris s&s
primary lesion (comedone)
open- blackhead closed- whitehead
inflam rx to sebum, fatty acids, and gm + propionibacerium acnes (cytokines causing papules and pustules)
acne vulgaris referral
cystic acne unresponsive to std therapy systemic isotretinoin (accutane)
contact dermatitis overview
eczematous dermatitis- irritant or allergic type
hands and ACD most common
ICD vs ACD
irritant CD- acute- well demarcated area of erythema, scaling or crusting at site of exposure
cumulative ICD- weak irritants (cosemetics)
occurs months after continual exposure (not as ACD)
ACD_ typically acute with itch, inflam, vesicles
differential dx of CD
atopic derm dyshidrotic eczema bacterial or candida infection phytophotodermatitis herpes zoster
distribution dx - for CD
scalp/ears: shampoo, hair dyes, eyeglasses
eyelid- nail polish, contact lens
face- airborne allergens, cosmetics, sunscreen
neck- necklace, airborne allergen, perfumes
trunk- meds, sunscreen , plants, clothing
axillae- deodorant, clothing
arms- same as hands, watch
hands- soap detergents, foods, plants, metal, gloves
genitals- poison ivy, rubber condoms
anal region- hemorrhoid prepartions, nystatin,
lower legs- topical meds, socks
feet - shoes
CD patient education
avoid offending agent- dont use personal product until healed, domeboros solition for soothing inflammed/crusted lesions, reduce handwashing, liberal use of emollinets, anithistamines to help sleep not ithc, urushiol resin( poison oak) remains on clothing/tools for months
CD referral
refractory cases, dx in ??, patch test to determine allergy
CD tx
topical medium to high potency corticosteroids( group 1-5) ointments pref (less preservative)- steroid allergy use topical calcineurin inhibitors
oral prednisone- when periorbital/gential regions or >20% body SA involved
atopic dermatitis
chronic DO c/o exacerbation and remissions of dry, itchy, red skin
can start in infancy (a/w asthma, allergic rhinitis, urticaria, acute reactions to foods)
FH
itch and rash develops rash followed by lichenification if untreated
pruritic, erythematous, dry patches of skin, often w/ scale. linear excoriations. ill defined borders, crusting and oozing are common
Infants: cheeks, scalp, forehead, extensor extremities
Adults: generalized typically on face, neck, flexural folds, wrists, and dorsa of feet.
atopic dermatitis triggers
Aggravating factors
dry skin, sweating, heat, dry environments, occlusion(athletic equipment, dressings, gloves)
topical agents (soap, laundry detergents) and wool make it worse
exacerbated by infections, stress, allergies
atopic dermatitis differential dx
seborrheic derm: psoriasis: Scabies: Molluscum contagiousum: tinea:
atopic dermatitis tx
moisturize for dryness
antihistamines for itching and sleep aid.
hydration w/ tepid water bath immediately followed by emollient like petrolatum
Topical mild corticosteroid ointment for inflam
discontinue once inflam has reduced but continue lubricants and emollients
Nonsteroidal calcineurin inhibitors (tacrolimus and pimecrolimus) for chronic mod to severe AD
Treat secondary bacterial, fungal, or viral infection
Systemic corticosteroids reserved for extreme cases.
atopic dermatitis education
Must avoid rubbing and scratching
Avoid known triggers; continuous use of lubricants and emollients to decrease need for topical corticosteroids.
use mild soaps and laundry detergents
scabies s&S
itching, (esp at night)
lesions at site of infestation & lesions secondary to hypersensitivity to mite
intraepidermal burrows are linear or serpiginousNOT “typical”
common sites: interdigital spaces (web spaces), wrist, arms, genitals, feet, buttucks, axillae
scabies differential dx
contact dermatitis asteatotic dermatitis insect bites animal scabies seborrheic dermatitis psoriasis
scabies tx
Apply Permethrin 5% head (neck) to toe (sparing face); leave on for 8-12 hrs; and then wash off
May use antihistamines & corticosteroids after permethrin for itching
Ivermectin off-label is PO med used as well
patient education on scabies
all household contacts must be identified and treated
all clothing & bedding must be washed in hot water and dried on hot cycle
stuffed sofas & chairs should be vacuumed
materials that cannot be washed should be placed in a plastic bag for 1 week
seborrheic dermatitis s&S
dry, flaky scales
greasy, erythematous, sharply marginated plaques
FYI: (this is Cam’s two cents) often in adults nasolabial folds & eyebrows. Golden dry flaky hue & on scalp (aka dandruff & in infants = cradle cap)
Unknown cause, over reaction to normal yeast on skin ?? (hence use anti-fungal cream to treat yeast, and then stop over reaction)
seborrheic dermatitis differential dx
dandruff scabies asteatotic eczema psoriasis ** in particular this is hard candidal infection intertrigo
seborrheic dermatits tx
topical 2% ketoconazole
10% sodium sulfacetamide wash daily
if above doesn’t work, topical steroid
shampoo = Nizoral 1% OTC
patient education on seborrheic dermatitis
this is chronic & recurrent
monitor for early flares (and Cam’s two cents: avoid triggers - sun, ETOH etc)
fungal infections
dermatophytes most common fungi tinea capitis tinea corporis tinea cruris tinea pedis tinea manus tinea unguium
tinea capitis
head/scalp - patchy, scaly, nonscarring areas of hair loss
tinea corporis
body-erythematous plaques and papules in annular or arciform pattern=elevated borders w/ central clearing
tinea cruris
jock itch- groin and upper thigh, gluteal folds: erythematous scaling patches w/ raised borders. often spares scrotum.
tinea pedis
athletes foot- interdigital scaling, maceration, and fissuring, also scaling eruption on sole and sides of foot
tinea manus
hand- dry, diffuse, scaly eruption of palms, w/ shrp marginated plaques on dorsum.
tinea unguium
nail aka onychomycosis
begins in distal nail bed and spreads to infect nail plate=thickened/yellowed nail
patient education on fungal infections
caution use of OTC steroid creams for long-term use (causes skin thinning and striae)
absorbent powders help reduce moisture and prevent reinfection.
Tinea capitis: clean combs, towels and bedding; don’t share
refer if start ORAL ANTIFUNGALS
canidiadisis
appearance depends on location
thrush (oral cavity): white or gray membranous plaques w/ base-macerated and brightly erythematous
lesions can extend down esophagus, lips.
skin: axillary, gluteal, interdigital, perianal/diaper region, panniculus foldes, shaved areas (folliculitis of beard), vagina, glans penus.
Treatment: powders, vaginal douches, oral suspensions, creams and tablets
tinea versicolor
chronic, asymptomatic, superficial lesions
white or light pink in hypopigmented version or tan and brown in hyperpigmented version; pigment returns w/ treatment.
slightly scaly, round/oval coalescing papules and plaques.
sternum, sides of chest, abdomen, or back, pubis, intertriginous areas.
Treatment
antifungal creams (imidazoles), shampoos w/ selenium sulfide or pyrithione zinc x 7-14 days consecutively
management of most tinea
Acute, exudative lesions - drying agent like aluminum 1)sulfate (Domeboro) soaks
2) topical antifungal solutions and creams
3) keratolytic agents remove thick scales on hands and feet allowing topical antifungal agent to penetrate.
4) Oral antifungals: for widespread tinea or infections involving scalp and nails. consult
Onychomycosis: terbinafine 250mg daily x 6wks for fingernail and 12wks for toenail
**monitor liver fx and CBC for SE of neutropenia
most fungal infections application of steroids
BID- tx for 2 weeks , tinea pedis, tinea unguium and tinea capitis require 6 weeks or more of tx
