Dermatology Flashcards
1
Q
Dermatitis
A
- Dermatitis or eczema is a pattern of cutaneous inflammation that presents with erythema, vesiculation, and pruritus in its acute phase
- The chronic phase is characterized by dryness, scaling, lichenification, fissuring, and pruritus
2
Q
Multiple types of dermatitis:
A
o 1. Seborrheic
o 2. Atopic
o 3. Dyshidrotic
o 4. Nummular
3
Q
Seborrheic Dermatitis
A
- Affect person in post puberty
- Pityrosporum Ovale, lipophilic yeast of Malassezia genus
- May induce inflammatory response
- Present on all person
- Responds to antifungal
- Infancy and adolescence
4
Q
CLINICAL PRESENTATIONS of Seborrheic Dermatitis
A
Affect area where sebaceous blends in high frequency and are most active
♣ Scalp
♣ Eyebrows
♣ Eyelashes
♣ Forehead
♣ Nasolabial fold (common in kids with CP)
♣ External ear canal
Also found near umbilicus, under breast
5
Q
Treatment for Seborrheic Dermatitis (4)
A
- Under androgen control - responds well to anti-fungal shampoo
- Frequent cleansing with soap removes oils
- Outdoor recreation improve seborrhea
- Avoid sun damage
6
Q
Antidandruff Shampoo
A
- 2.5% percent selenium sulfide
- 1-2% pyrithione zinc
- Head and Shoulders
- Coal Tar
- OTC Ketoconazole shampoo treats the fungus infection; can rotate with Coal Tar
7
Q
Some popular name brands - Antidandruff shampoo
A
OTC with salicylic acid –> X-Seb, Scalpicin Pyrithione Zinc 1% –> Head and shoulder, Zincon, Dandex Pyrithione Zinc 2% –> DHS zinc, Theraplex Z Prescription medicine selenium sulfide Selsun, Exsel) or pyrithione zinc DHS Zinc, Head & Shoulders Shampoos with coal tar DHS Tar, Neutrogena T/Gel, Polytar may be used 3 times a week Carmol HC ♣ Contains urea smoothing agent; takes top layers of skin and smooth them down ♣ Not aesthetic because urea burns Elidel off-label use; calcium inhibitor and very good for seborrhea (BBW and high lymphoma risk)
8
Q
TREATMENT: Special Considerations for African Americans Seborrheic Derm
A
- Use of daily shampooing not applicable
- Weekly shampooing
- Fluocinolone acetonide in oil as pomade
- Other option
- Moderate to mid potency topical
- Corticosteroid in ointment base
- Some AA children do not wash hair everyday because it would dry out
- Use with mid-strength steroid to clear it up
9
Q
Contact Dermatitis 2 types
A
Skin condition created by a reaction to an externally applied substance
Types of contact dermatitis:
o Irritant Contact Dermatitis (ICD)
o Allergic Contact Dermatitis (ACD)
10
Q
Allergic Contact Dermatitis Overview
A
- ACD occurs when contact with a particular substance elicits a delayed hypersensitivity reaction
- The sensitization process requires 10-14 days
- Upon re-exposure, dermatitis appears within 12-48 hrs
- The most common cause is Rhus dermatitis, from poison ivy, poison oak, or poison sumac (all contain the resin – urushiol) T-cell mediated***
11
Q
Other common causes of A Contact Derm (9)
A
o Fragrances
o Formaldehyde
o Preservatives
o Neosporin
o Benzocaine
o Vitamin E
o Rubber compounds
o Nickel – Number 1 contact dermatitis
o Balsam of Peru – ALL MAKE-UP**
12
Q
Clinical Findings of Atopic Contact Dermatitis
A
- Main symptom of ACD is pruritis
- Weepy, huge amounts of vesicles Bilateral
- Presents as eczematous, scaly edematous plaques with vesiculation distributed in areas of exposure
- ACD is bilateral if the exposure is bilateral (e.g., shoes, gloves, ingredients in creams, etc.)
13
Q
Poison oak leaves are usually (5)
A
o Are 3‐7cm in length
o Lobulated notched edges
o Groups of 3, 5, or 7
o Grows on bush‐like plants
o Turn colors in autumn
14
Q
Poison Ivy leaves are usually
A
o Are 3‐15cm in length
o Notched edges o Groups of 3s
o Grows on hairy‐stemmed vines or low shrubs
o Turn colors in autumn
LEAVES OF 3 LET THEM BE
15
Q
Rhus Allergy Initial episode
Subsequent outbreaks
Total length Initial episode
A
- The initial episode occurs 7-10 days after exposure
- On subsequent outbreaks the rash may appear within hours of exposure and usually within 2 days
- Individual sensitivity is variable so the eruption may be mild to severe
- Rhus dermatitis lasts from 10-21 days depending on the severity
- Initial episode is the longest (up to 6 weeks!)
16
Q
What should you use for drying weeping allergic contact derm?
A
BURROWS solution – covered under medicaid phenomenal for drying up weeping allergic contact dermatitis
17
Q
Linear Streaks
A
Koebner phenomenon
18
Q
Fomites can be contaminated by…
A
the plant oil and lead to recurrent eruptions
19
Q
Contact dermatitis; topical steroid level
A
3 along with anti-itch medication (aveeno, eucerin)
20
Q
Rhus Dermatitis Mimics of Lesions – Bullous insect bites (3)
A
o Usually scattered
o Not linear or grouped
o No history of multiple bites
21
Q
Rhus Dermatitis Mimics of Lesions – Cellulitis
A
- Spreading erythematous, non-fluctuant tender plaque
- Can be associated with fever
22
Q
Rhus Dermatitis Mimics of Lesions – Herpes Zoster
A
Painful eruption of grouped vesicles in a dermatomal distribution
23
Q
Rhus Dermatitis Mimics of Lesions – Urticaria
A
o MOVING edematous plaques, not vesicles
o Early lesions of allergic contact dermatitis could be mistaken for urticaria
24
Q
Rhus Dermatitis Treatment
A
- Most patients need minor supportive care
- Topical steroids for localized involvement
- Topical or oral antihistamines may improve pruritus
- Oatmeal soaks/calamine lotion may soothe weeping erosions
- Severe involvement may require oral steroids
- In cases of failing potent topical steroids, or widespread
- If given for less than 2-3 weeks, patients may relapse
- Do not give short bursts of steroids for this reason
25
Rhus Allergy Prevention
* Avoid the plants
* Wash clothing, shoes, and objects after exposure (within 10 minutes if possible)
* Apply barrier: clothing, OTC products which bind resin more than skin
26
Eyelid Allergic Contact Dermatitis Common Causes
Intensely pruritic
* Scaling red plaques on upper \> lower eyelids
* Allergic contact dermatitis of the eyelid is often caused by transfer from the hands
* Common causes:
* Nail adhesive/polish
* Fragrances and preservatives in cosmetics -- Balsam of Peru
* Nickel
27
Evaluation of Dermatitis
* • Important to take a comprehensive history
* Ask questions about possible culprit
* Think about what they might be doing
* Complete dermatologic assessment of the patient
* Shape, configuration, and location of the dermatitis are useful clues in identifying the culprit allergen
* Elimination of a suspected trigger may be both diagnostic and therapeutic
* In chronic cases, patch testing is necessary to identify specific allergens
28
HISTORY TAKING FOR Dermatitis
o In addition to the dermatitis-specific history (e.g., onset, location, temporal associations, treatment), be sure to ask about:
* Daily skin care routine
* All topical products
* Occupation/hobbies
* Regular and occasional exposures (e.g. lawn care products, animal shampoos)
Are they washing their dog with flea shampoo? Hobby, recreation
29
Steroid Potency
Regular use of Class 1, 2, or 3 steroids on thin skin will lead to steroid atrophy (thinning and easy bruising/purpura)
o Also hypopigmentation in darker skin types
If topical steroids are to be used on the eyelid for a period of more than one month, refer to an ophthalmologist for monitoring of intraocular pressure and the development of cataracts
30
Steroid Potency FOR THE FACE
For the face:
* Class 6, 7 steroids (e.g., desonide) can safely be used intermittently during flares
* Hydrocortisone cream 1%
* Elidel and protopic (Black Box Warnings) ELIDEL -- Works for contact derm around eyes
31
PATCH testing (6)
* Patch testing is used to determine which allergens a patient with allergic contact dermatitis reacts against
* A series of allergens are applied to the back, and they are removed after 2 days
* On day 4 or 5, the patient returns for the results
* Positive reactions show erythema and papules or vesicles
* Identification of specific allergens helps the patient find products free of those allergens
* Example of a patient with patches (allergens) placed on the back o Best test for allergic contact dermatitis
32
POSITIVE PATCH TEST
Positive patch test reactions at 96-hour reading
This patient had three positive reactions
♣ Nickel, Balsam of Peru, and Fragrance Avoidance of these allergens should improve their rash
33
Identifying Allergens
* Not all patients with ACD need patch testing
* Refer patients when the allergen is unclear or the dermatitis is chronic
* A positive reaction on patch testing does not mean that the patient’s rash is due to that specific allergen
* Elimination of the rash with removal of the allergen confirms the clinical relevance of the positive patch test
34
ACD Treatment
* Avoid exposure to offending substance
* Treatment of the acute phase depends on the severity of the dermatitis
* In mild to moderate cases, topical steroids of medium to strong potency for a limited course is successful
* A short course of systemic steroids may be required for acute flares
* Oatmeal baths or soothing lotions can provide further relief in mild cases
* Wet dressings are helpful when there is extensive oozing and crusting BURROWS\*
35
Chronic cases or patients with dermatitis involving over _____ of the BSA should be referred to a dermatologist
10%
36
Latex Allergy
* Delayed hypersensitivity: Patients develop an allergic contact dermatitis
* Often presents on the dorsal surface of the hands
* Immediate hypersensitivity: May present with immediate symptoms such as burning, stinging, or itching with or without localized urticaria on contact with latex proteins
* May include disseminated urticaria, allergic rhinitis, and/or anaphylaxis #1 allergen that will go from a localized reaction to systemic reaction
* Can get type 1 reaction after years of having a type 4 T-cell mediated allergic reaction
37
S from SCRATCH
* stands for symmetrical.
* Commonly affected areas include exposed surfaces such as the face, neck, arms, and legs
* Covered areas such as the abdomen, palms, soles, diaper area, etc. are spared. C stands for cluster.
* Lesions usually appear in a “meal cluster,” that is often described as “breakfast, lunch, and dinner.” This grouping of lesions are characteristic of bedbug bites, but also are seen in flea bites and with IBIH.
* Appear in a meal cluster; breakfast, lunch and dinner
38
R stands for
* Rover
* Is there is a family pet where the child could come into contact with fleas?
39
A stands for
* age.
* IBIH is rarely seen in babies, and these reactions peak after the age of 2.
40
T stands for
* Target and time.
* Target lesions are characteristic for IBIH, particularly in dark‐pigmented patients. Time refers to the chronic nature of this condition.
41
C stands for
* confused.
* Patients and their parents are often confused/surprised that these reactions are due to bugs.
42
H stands for
* history.
IBIH is not often associated with family history, unlike with scabies and atopic dermatitis where we see a strong family history correlation
43
3 P's for Insect Bites
* Prevention
* Wearing protective clothing for outdoor play with use of insect repellents.
* Patience
* Pruritis control
* Topical steroids may help
* Due to depth of inflammatory, topical agents can ineffective.
* Use of antihistamine
* Little evidence to support due to the predominance of T**‐**cell–mediated response and a lack of histamine**‐**mediated lesions.
44
Irritant Contact Dermatitis
Overview
* Inflammatory reaction in the skin resulting from exposure to a substance that can cause an eruption in most people who come in contact with it
* Strictly on hands – most likely irritant contact dermatitis
* No previous exposure is necessary
* May occur from a single application with severely toxic substances
* Most commonly results from repeated application from mildly irritating substances (e.g., soaps, detergents)
45
Multifactorial disease where...
Most important exogenous factor for ICD
Areas that are most susceptible
* Multifactorial disease where both exogenous (irritant and environmental) and endogenous (host) elements play a role.
* Most important exogenous factor for ICD is the inherent toxicity of the chemical for human skin
* Site differences in barrier function, making the face, neck, scrotum, and dorsal hands more susceptible
46
Major Risk Factor for Irritant Hand Derm
* **Atopic dermatitis** is a major risk factor for irritant hand dermatitis because of impaired barrier function and lower threshold for skin irritation
* **More likely to get irritant CD**
* **When you go to apply a moisturizer for atopic derm you need to be careful because if they do travel – using a moisturizer that doesn’t have a lot of chemicals in it**
47
ICD Clinical Findings
* Mild irritants produce
* Erythema
* Chapped skin
* Dryness
* Fissuring after repeated exposures over time
* Pruritus can range from mild to extreme
* Pain is a common symptom when erosions and fissures are present
* Severe cases present with edema, exudate, and tenderness
* Potent irritants produce painful bullae within hours after the exposure
48
What to use for Itch (5)
* Topical steroids
* Antihistamines
* Only provide relief when pruritus is mediated by antihistamine as in case of urticaria
* Eczema—anti histamine does not work
* Pramoxine
* Topical anesthetic
* Aveeno anti itch
* Eucerin calming cream
* Pramasone
* Capsaicin
* Capzasin cream activate the TRP-V1 channel to produce mildly painful sensation and interferes with itch
* Used for bug bite\*
* Menthol
* Topical ant-itch product—**Sarna**, and aveeno
* Activates TRP channels to create a competitive sensation to itch
* Vicks vapor rub
49
ICD Evaluation and Treatment
* Identification and avoidance of the potential irritant is the mainstay of treatment
* Need to avoid whatever causes it
* Topical therapy with steroids to reduce inflammation and emollients to improve barrier repair are usually recommended
* Referral to a dermatologist should be made for patients who are not improving with removal of the irritant or in severe cases
* Patch testing should be performed in occupational cases with suspected chronic irritant dermatitis to exclude an allergic contact dermatitis
* PATCH to ALLERGY
50
ICD prevention
* Patient Education about things the irritant is included in
* Need to read and be able to look for it
* Use personal protective equipment (e.g. protective gloves should be worn for any wet work)
* Instead of soap, use less irritating substances, such as emollients and soap substitutes when washing
* Only recommend: White Dove for soap
* Care should be taken for several months after the dermatitis has healed, as the skin remains vulnerable to flares of dermatitis for a prolonged period
51
Take Home Points
* Allergic contact dermatitis (ACD) and Irritant contact dermatitis (ICD) are the two types of contact dermatitis.
* ACD occurs when contact with a particular substance elicits a delayed hypersensitivity reaction.
* ACD = delayed T-cell hypersensitivity reaction
* Most patients need minor supportive care, but some cases will require oral steroids.
* Patch testing is used to determine which allergens a patient with allergic contact dermatitis reacts against.
* Not all patients with ACD need patch testing.
* Latex allergy may present as a delayed or immediate hypersensitivity.
* Can go from type 4 to type 1 anaphylaxis
* ICD is an inflammatory reaction in the skin resulting from exposure to a substance that can cause an eruption in most people who come in contact with it.
* Inflammatory
* Identification and avoidance of the potential irritant is the mainstay of treatment.
* Patch testing may be performed in cases with suspected chronic irritant dermatitis to exclude an allergic contact dermatitis.
* If a rash is due to an exposure at work, the medical evaluation may be covered by worker’s compensation.
* Important to ask about the patient’s occupation/school related activity
* Referral to a dermatologist should be made for patients with contact dermatitis who are not improving with the removal of the allergen/irritant or severe cases.
