Dermatology Dermatitis, Autoimmune Flashcards
Dermatitis Types
Acute (2)
Chronic (5)
- Urticaria (Hives)
- Contact dermatitis
- Eczematous or atopic dermatitis
- Seborrheic dermatitis
- Psoriasis
- Acne Vulgaris
- Rosacea
Transient, pruritic, erythematous, edematous, papules, plaques, and wheals
Affects 20% of general population
Usually occurs over 1-2 hours, uncommon for lesions to remain on skin >24hrs
Urticaria (Hives)
Urticaria (Hives)
- Common triggers =
- Often the trigger is (1)*
- May be accompanied by (1)*→ monitor (1)*
- (1) = consider if lesions continue to appear more than 6 weeks
- Foods, meds, cold, infection, stress, contact w substances, water
- Idiopathic
- Angioedema (lips, throat, eyes) → Monitor airway
- Chronic urticaria
- Angioedema d/t severe allergic reactions. Occurs often in African Americans who take ACE inhibitors*
- Chronic urticaria is much more difficult to find a cause for*
What condition is shown in these pictures?
Dermatographia
(Urticaria)
Urticaria Treatment
Treatment is symptomatic
Rx (4)
Pregnant Rx (2)
Nursing Rx (1)
-
H1 Antihistamines
- 1st generation (sedating) - Diphenydramine 50mg, Hydryzine (Atarax) 10, 25, 50mg
- 2nd generation (first line bc less sedating) - Cetirizine (Zyrtec) 10mg, Loratidine (Claritin) 10mg, Fexofenadine (Allegra) 180mg, Levocetirizine (Xyzal) 5mg
-
H2 Antihistamines
- Combo with H1 is more effective (urticaria often occurs when too much histamine is released)
-
H2 Blockers
- Famotidine (Pepcid)
-
Glucocorticoids
- Only if initial sx are severe, as with prominent angioedema
- ADD to antihistamines and H1 blockers as need those to stabilize mast cells
Pregnant (Chlorpheniramine 4mg Q4-6h PRN or Benadryl)
Loratidine 10mg QD
Any dermatitis arising from direct contact to a substance
(2) Types + Associated symptom of each (2)
Contact Dermatitis
- Allergic Dermatitis (pruritis) = occurs when substance triggers delayed type IV, T-cell mediated hypersensitivity response
- Irritant Dermatitis (burning) = trigger substance directly damages skin causing cutaneous inflammation
Contact Dermatitis: Allergic Type
- S______ requires 10-14 days
- Upon re-exposure → ______ released dermatitis within 12-48 hours
- Examples: Poison I___/O___/S____, Ni___, Dy__, Fr_____, Balsam of P____, OTC topical antibiotics (2), Ru_____
- Sensitization requires 10-14 days
- Upon re-exposure → cytokines released dermatitis within 12-48 hours
- Examples: Poison Ivy/Oak/Sumac, Nickel, Dyes, Fragrances, Balsam of Peru, OTC topical antibiotics (Neosporin, Bacitracin), Rubber
Contact Dermatitis
What substance in Poison Ivy, Mangoes, and Ginkgo lead to a reaction?
Assess for ____ streaks which is common in poison ivy
Oleoresin Urushiol
Linear streaks common in poison ivy (vesicles, bullae, and edema are present)
What is causing the contact dermatitis in these images?
Nickel from earrings/belt, Rubber from sandals
Poison Ivy Non-Pharm Treatment
- First ____ offending agent!
- Gently _____ everything that may have had contact with it w soap and water including skin
- _____ baths and ____ wet compresses may soothe
- Weepy blisters: (1) solution on wet occlusive dressing
- First remove offending agent!
- Gently wash everything that may have had contact with it w soap and water including skin
- Oatmeal baths and cool wet compresses may soothe
- Weepy blisters: Domborows solution on wet occlusive dressing
Poison Ivy Pharm Treatment
- 1st line = (1) (clobetasol, fluocinonide)
- NOT on (2) places → due to skin atrophy
-
(1)??—commonly used, not well studied
- Sedating may help with sleep if pruritus keeping awake
-
(1) if severe or large BSA affected
- 60 mg/day starting dose (1mg/kg/day)
-
Gradually _____ over 2-3 weeks to prevent rebound sx
- __ MEDROL OR STEROID PACKS – not long enough treatment
- High potency steroid creams 1st line (clobetasol, fluocinonide)
- NOT on face, genitals → due to skin atrophy
- Antihistamines ??—commonly used, not well studied
- Sedating may help with sleep if pruritus keeping awake
- Systemic steroids if severe or large BSA affected
- 60 mg/day starting dose (1mg/kg/day)
-
Gradually taper over 2-3 weeks to prevent rebound sx
- NO MEDROL OR STEROID PACKS – not long enough treatment
Testing you could do to help find out what is causing contact dermatitis?
Patch Testing
Latex Allergy
Latex natural product from rubber tree H____ br_____
- Common allergen to people w/ _____ latex exposure
- nonspecific sx & lack of knowledge → _____ diagnosis
- exposure may be _____ → powders used in gloves
- may progress rapidly and unpredictably to ______
- Dx =
- Rx =
Hevea Brasiliensis
- Common allergen to people w cumulative latex exposure
- nonspecific sx & lack of knowledge → missed diagnosis
- exposure may be airborne → powders used in gloves
- may progress rapidly and unpredictably to anaphylaxis
- Dx = made by history - may confirm with skin testing
- Rx = educate, avoidance, antihistamines, Epipen prn
Contact Dermatitis Treatment
The KEY is?
Work with patient to help them be their own _____ OR ____ testing
- Topicals for symptomatic treatment
- (1) = Mainstay of treatment
- (1) = May be preferred for persistent facial particularly periocular dermatitis
- (1) = May help diminish pruritis caused by allergic contact dermatitis
- TCI’s has block box warning but not for topical
Removal of Offending Agent
Work with patient to help them be their own detective or patch testing
- Topicals for symptomatic treatment
- High potency topical glucocorticoids (not for face)
- Topical Calcineurin Inhibitors (immunomodulators) - Pimecrolimus (Elidel) or Tacrolimus
- Oral antihistamines
Commonly Prescribed Corticosteroids
Strength based on (2) of rash
Strength based on location and severity of rash
38 yo male with pruritic rash for several weeks; sx are intermittent. Well-circumscribed scaly erythematous patch area or erythema and with excoriations. What is the most likely diagnosis?
- Tinea corporis
- Contact dermatitis
- Urticaria
- Herpes simplex
- Herpes Zoster
What is the most critical aspect of managing this?
What is the first line medical therapy for symptom relief?
- Acyclovir 5% cream
- Econazole 1% cream
- Diphenhydramine (Benadryl) tabs 50 mg
- Triamcinolone acetonide ointment 0.1%
- Tinea corporis
- Contact dermatitis
- Urticaria
- Herpes simplex
- Herpes Zoster? - no vesicles, and usually gone within 7-10 days
Minimizing contact with the offending agent
- Acyclovir 5% cream
- Econazole 1% cream
- Diphenhydramine (Benadryl) tabs 50 mg
- Triamcinolone acetonide ointment 0.1%
Chronic, inflammatory condition causing overproduction of skin cells, sebum, and normal yeast
debate re: if belongs in fungal section vs idiopathic
- Typically areas w/many _____ glands (___-producing glands)
- Commonly affected areas (5)
- _______ is mild form
Seborrheic Dermatitis
- Typically areas w/many sebaceous glands (oil-producing glands)
- Scalp (appears weepy), upper chest, back, face (eyebrows, NLFs, hairline), ears
- Dandruff is a mild form
Seborrheic Dermatitis Characteristics
- Symptoms are in_____, s_____, st___-related
- Pruritic o____, r___ patches with significant y____ and w____ sc____
- Note: POC may exhibit ___pigmented scaly patches
- Dx =
- DDx =
- Symptoms are intermittent, seasonal, stress
- Pruritic orange, red patches with significant yellow and white scales
- POC may exhibit hypopigmented scaly patches
- Dx = based on exam and history (rarely skin biopsy)
- DDx = eczema, psoriasis, PR, contact derm, lupus, rosacea, tinea capitus
Seborrheic Dermatitis Treatment
First line agent (1)
+ (1) if moderate or severe or PRN for pruritis
Alternative to anti-fungal (1)
Topical Antifungals (if mild)
+/- low potency topical steroids for mod-severe inflammation and pruritis
Anti-seborrhea shampoos (helps control itch, scaling, and dandruff)
Seborrheic Dermatitis Topical Antifungals
- (1): cream; gel; shampoo (Nizoral) 2% (prescription) or 1% (OTC);
- (1) (Loprox)- Cream/lotion/gel: 0.77%; Shampoo: 1%
How frequent to use Creams? How frequent to use Shampoos? OTC anti-seborrhea shampoos how often?
- Ketoconazole cream, gel, or shampoo
- Ciclopirox cream, lotion, gel
Creams BID, Shampoos 3x weekly, OTC anti-seborrhea every other day
Anti-Seborrhea Shampoos Instructions
- Requires min __ weeks
- Leave on for _ - _ minutes then rinse well (3-4x/wk)
Examples of Anti-Seborrheic Shampoos (3)
- Requires min 4 weeks
- Leave on for 5-10 min, then rinse well (3-4x/wk)
OTC Anti-seborrheic/Anti-inflammatory shampoo
- Tar (Z-tar, T-gel)
- Selenium sulfide (Selsun, Exelderm)
- Zinc pyrithione (Head and shoulders, Zincon)
If 1 shampoo doesn’t work after 4-6 wks, try 1 w/diff active ingredient, combo antifungal + anti-inflammatory
Seborrheic Dermatitis Cradle Cap Considerations
- Affects (1), most cases will resolve (1)
- Apply (2) oil gently to scales prior to bathing
- Do not ____ scalp, gently remove scales with a (1)
- Can use (2) shampoos
- Low potency (1) ie 1% hydrocortisone cream or lotion for a few days if severe and itchy
- Very young infants, most cases will resolve on their own
- Mineral oil or baby oil before bathing
- Selenium Sulfide or Ketoconazole shampoo
- Low potency corticosteroids (1% hydrocort) if severe and itchy
Chronic inflammatory, pruritic skin disease, usually appears in childhood
“The rash that itches”
- Caused by both (1) and (1) factors that lead to a disruption in the epidermal barrier
- Is chronic: with (1) and (1) for most
- Associated with the Triad of (3) called “atopics”, will see elevated (1), often (1) bc has a large genetic component
Atopic Dermatitis (Eczema)
- Genetic and Environmental factors
- Exacerbations and Remissions for most
- Eczema, Allergies, Asthma, elevated IgE, often familial bc has large genetic component
What is happening to cause Eczema to appear like this? What is this condition called?
Pt is scratching so much that it caused erosion, trauma and secondary bacterial infection - impetiginization
Atopic Dermatitis in Black Patients
(1) common
Pruritic Papules common in Black pts
Treatment for Ear Dermatitis
- May treat this with topical or corticosteroid otic solution—depending on how proximal sx are
- Hydrocortisone/acetic acid 3 drops Q4-6hrs
Periocular Dermatitis Treatment
(1)-(2)
Topical calcineurin inhibitors (immunomodulators)
- Pimecrolimus (Rx) – Elidel
- Tacrolimus ointment (Rx) - Protopic
So much itching, doing it sleep, so probably need more long term tx
Atopic Dermatitis (Eczema) Prevention
Preventative measures are key!!
- (1) at least __ times/day & hydration
- (1) NOT soaps (includes lauryl sulfate)
- _____ frequent bathing
- NO hot baths/showers- _____ water only
- (2) especially after bathing (no lotion)
- Avoid products with fr_____, sc____, or d___ (includes soaps, lotions, detergents, scented candles)
- Emollients at least 3 times/day & hydration
- Gentle cleansers NOT soaps (includes lauryl sulfate)
- Less frequent bathing
- NO hot baths/showers- lukewarm water only
- Ointments and thick creams especially after bathing (no lotion)
- Avoid products with fragrances, scents, or dyes (Includes: soaps, lotions, detergents, scented candles)
Form of atopic dermatitis that occurs on hands, feet, or both
Characterized by “tapioca-like vesicles”
- Patients will report small, very itchy bumps
- In several weeks the vesicles resolve and skin appears, dry, erythematous, and scaly
Dyshidrotic Eczema
Dyshidrotic Eczema
Education and Prevention are Key
- Wear _____ when doing dishes
- Avoid contact with harsh cleaning ______
- May be characterized by small, painful fissures → Liberal use of em______ especially with (1) at bedtime
- Wear gloves when doing dishes
- Avoid contact with harsh cleaning chemicals
- May be characterized by small, painful fissures → Liberal use of emollients especially with (1) at bedtime
Dishydrotic Eczema DDx
(3)
Keep in mind secondary (1)
allergic contact derm, herpetic whitlow, pustular psoriasis
secondary syphilis (not vesicles, no fluid)
Chronic, multisystem inflammatory dx, abnormal immune response leads to inflammation
(breakdown of immune system causing hyperkeratizination of the skin, diff inflammatory cytokines/interleukins than atopic derm)
- Characterized by well defined**, circumscribed, erythematous **plaques** with a **classic silver or whitish scale
- Favors extensor surfaces (opposite of atopic derm)
Psoriasis
- (bottom left 2 pics) Psoriasis on extensor surfaces (most common elbows, knees, scalp, trunk), note the symmetry of plaques with silvery scale
- Bottom right pic: severe plaque psoriasis, note well defined borders, often requires systemic treatment if >30% BSA affected
Psoriasis on Scalp
Treat with solutions, sh____, o__, and f____
These plaques can be extremely persistent and may require intralesional (1) to soften plaques and reduce localized inflammation, nbuvb, systemic medications
solutions, shampoos, oils, foams
These plaques can be extremely persistent and may require intralesional injections to soften plaques and reduce localized inflammation, nbuvb, systemic medications
Psoriasis Guttate
Guttate =
- In addition to (1), the following may trigger an attack of guttate psoriasis:
- (2) infections, including upper respiratory infections
- (1) to the skin, including cuts
- Some medicines, including those used to treat (1) and certain (1) conditions
- St____, sun____, excessive a_____ consumption
Guttate = tear drop
- In addition to strep throat, the following may trigger an attack of guttate psoriasis:
- Bacteria or viral infections, including upper respiratory infections
- Injury to the skin, including cuts
- Some medicines, including those used to treat malaria and certain heart conditions
- Stress, sunburn, excessive alcohol consumption
All common triggers of psoriasis, pathogenesis not well known/understood
Psoriasis of the Nails
Always assess the nails and ask about any hx of ____ pains if you suspect dx of psoriasis, will see ____ of nails
Always assess the nails and ask about any hx of joint pains if you suspect dx of psoriasis, will see pitting of nails
Psoriasis Treatment
Mainstay (1)
- Administration instructions: ___ daily dosing until (1) or up to __ weeks
- Tx varies according to s_____, l_____, and B_ _
- Helpful adjuncts (2)
- Atrophy not an issue until?
Topical corticosteroids*
- Administration instructions: twice daily dosing until sx respond or up to 4 weeks
- Tx varies according to severity, body location, and BSA
- Emollients and hydration, and thick creams especially after bathing
- Atrophy not an issue until you get past the plaque down to healthy skin
Healthy 22 y.o. with tender lesion on great toe for 9 months, increasing size x several weeks. What is the most likely diagnosis?
- Tinea pedis (athletes foot)
- Verruca plantaris (plantar wart)
- Common callus or corn
- Squamous cell carcinoma (verrucous carcinoma)
- Tinea pedis (athletes foot)
- Verruca plantaris (plantar wart)
- Common callus or corn
- Squamous cell carcinoma (verrucous carcinoma)
Acne Patho
- Starts with increased (1)
- Colonization of (1)
- Increased proliferation and sebum creates (1) of sebaceous unit then (1)
- (1) develops as a white or black head, then mixing with bacteria can create an (1) response = a PIMPLE
- Starts with increased sebum production in our pilosebaceous unit
- Colonization of P. acnes
- Increased proliferation and sebum creates widening of sebaceous unit then clogging
- Comedones develop as a white or black head, then mixing with bacteria can create an inflammatory response = a PIMPLE
Comedonal Acne (Noninflammatory)
-
(1) open comedones
- Due to (1) NOT dirt, combo of (3) occludes the pilosebaceous unit
-
(1) closed comedones
- distended follicle, but ____ stays intact
-
“Black heads” open comedones
- Due to oxidized lipid NOT dirt, combo of keratin, cornified cells, and oil occludes the pilosebaceous unit
-
“White heads” closed comedones
- distended follicle, but epidermis stays intact
Cystic Acne (Inflammatory)
Proprionobacterium Acnes → activation of (1) and (1) cells → _____
- Proprionobacterium Acnes → activation of cytokines and immune cells → inflammation*
- A comedo may become progressively larger and eventually be gigantic. In time, the ever-expanding plug of cornified cells causes the wall of an infundibulum to become so thin that eventually it is breached, spewing into the dermis cornified cells, sebaceous secretion, and microorganisms*
Treatment for Inflammatory Acne
(1) helps reduce inflammation and P. acnes
Rx (1) or (1) 50-100mg qd-bid
SE (3)
(1) pregnancy category D, enters breast milk
Never give < __ yo
Often will not see effects up to (1), and often course is for (1) long → if no improvement refer to derm to consider isotretinoin
Systemic antibiotics helps reduce inflammation and P. acnes
Minocycline or Doxcycline 50-100mg qd-bid
SE: GI, photosensitivity (doxy), HA/dizziness (mino)
TCN pregnancy category D, enters breast milk
Never give <8 yo
Often will not see effects up to 10d, and often course is for 3m long → if no improvement refer to derm to consider isotretinoin
Inflammatory Acne Treatment cont.
- _____ tx alone if mild or moderate
- (1) if pustules, cysts, large area, and is moderate to severe
- Topical tx alone if mild or moderate
- PO Abx if pustules, cysts, large area, and is moderate to severe
- Always have a plan to discontinue PO Abx; Explain resistance and importance of pregnancy prevention*
- Biggest concern in latin/black post inflammatory hyperpigmentation (dark spots) - retinoids and sunscreen can help the PIH get worse*
Nodulocystic Acne
- Can result in permanent scarring so important to (1) ASAP
- May need Rx (1) - KEY IS EARLY TX TO PREVENT PERMANENT SCARRING!
- Only providers who have gone through specialized ______ can prescribe
- ______ is major issue w its use - severe teratogen
- Can result in permanent scarring so important to refer to derm ASAP
- May need Rx Isotretinoin (Accutaine) - KEY IS EARLY TX TO PREVENT PERMANENT SCARRING!
- Only providers who have gone through specialized training can prescribe
- Contraception is major issue w its use - severe teratogen
4 Types of Rosacea
(1) flushing w or w/o stinging or burning
(1) (most common)
(1) overgrowth of affected sebaceous glands, large, bulbous erythematous nose/thickening - almost exclusively in men
(1) blepharitis and conjunctivitis
Erythematotelangiectatic
Papulopustular
Phymatous
Occasionally Ocular
Rosacea DDx
- (1) but has to have comedones
- (1) (cousin of rosacea, may hae similar triggers but fluorinated toothpastes, and wearing masks during covid, i usually do a sulfa wash and elidel)
- (1) autoimmune disorder
- (1) dermatitis
- Acne
- Perioral Dermatitis
- SLE
- Seborrheic Dermatitis
Malar Rash of Lupus
What makes it different from other skin conditions?
Found in % of pts, no ____ like in rosacea
Spares the Nasolabial Folds
20% of pts, no telangiectasia
Discoid Rash of Lupus
Only found in 20% of pts with SLE
Discoid Lupus Erythematous typically presents in the __ or __ decade of life
If patient presents just with discoid rash, no systemic symptoms, do they have lupus?
DLE 4th or 5th decade of life
Can have discoid rash and NO SLE
Pruritic rash on torso for a couple weeks; annular lesion with scaly, erythematous border, central clearing. Asx otherwise. What is the most likely diagnosis?
- Tinea corporis
- Pityriasis rosea
- Discoud lupus
- Erythema migrans
- Tinea corporis
- Pityriasis rosea
- Discoud lupus
- Erythema migrans
