Dermatology II Flashcards
What is the epidermis?
The outer layer, stratum corneum at the surface
What is the dermis?
Contains nerve endings, vasculature, and hair follicles
What is the hypodermis?
Provides nouishment and cushioning for the upper two layers
What is pruritus?
Sensation to scratch
How does drug absorption with topical work?
- Most of the drug that gets absorbed in the skin is from passive diffusion (when applied topically)
- Drug absorption can vary depending on the thickness of the skin, thinner = more permeable, allowing more substance to get through
- Thick part of the skin is in the hands and sole
- thin parts are like the eye lids
What are creams and lotions?
- Oil in water emulsion
- Less greasy
- Cooling effect
What are ointments?
- Water in oil emulsions
- Greasy feeling
- Long lasting
- Occulusive effect
Describe irritant contact dermatitis (ICD).
- Inflammatory skin, direct damage to the epidermal layer
- Mostly on hands and forearms
Describe allergic contact dermatitis (ACD).
- Immunologic skin reaction, contact with allergenic substance.
- Can affect any part of the body.
Describe contact dermitis.
- 3 steps: irritation and disruption of the skin barrier, stimulations of epidermal cells, release of proinflammatory cytokines
- Substance commonly associated with irritant contact dermatitis
- Acids, alkalis, detergents, disinfectants/antiseptics, foods, oils, radiation, sunscreen, urine/feces, water, and wood dust.
What are the ICD goals of contact dermatitis?
- Prevent contact with irritant
- Prevent reoccurence and secondary infection
- Relieve inflammation and irritation
- Educate the patient on self-management
What are signs of infection for contact dermatitis?
- Fever
- Increase redness
- Swelling
- Increase pain or tenderness
- Pus or discharge
What are preventative measures for contact dermatitis?
- Frequent changes in coverings, avoiding the irritant
- Applying a barrier to the skin can be helpful as well
- Ointments are better to use if the irritant is aqueous solution
- Lotion and creams are better for lipophilic materials
What are non-pharm treatments for contact dermatitis?
- Remove contact with irritant
- Washing with hypoallergenic soap
What are pharmacological treatments for contact dermatitis?
- Burow’s solution (aluminum acetate 5% solution)
- Cooling, anti-inflammatory, and antibacterial effects
What is the role of petrolatum jelly (Gold Standard)?
- Prevents water loss due to its ointment properties
What is contact dermatitis- ACD?
- Delayed hypersensitivity reaction form exposure to a foreign substance–Type IV
- Delayed hypersenesitivity reaction, occurs between 1-21 days
What are common substances that cause ACD?
- Poison ivy, poison oak, poison sumac, kewelry, clothing, and electronics
- Nickel, fragrances, rubber, neomycin
What are ACD allergens?
- Toxicodendron, poison ivy, oak and sumac (Urushiol)
- General appearance is three leaves growing from a central stem.
- Poison Ivy – grown in central and northeastern part of the states
- Poison Oak – located along the west coast and southern areas of the states
- Poison Sumac – mid west and some parts of the east in the states
What are key presentation characteristics of allergic dermatitis?
- Ballae
- Vesicles
- Oozing/Weeping
What are the goals of contact dermatitis ACD?
- Remove and avoid contact from offending agent
- Treat inflammation and relieve itching/scratching
- Relieve accumulation of debris from oozing, crusting, and scaling
What are non-pharm treatments for ACD?
Prevent contact with urushiol
* Eradication of Toxicodendron plants
Prevent spread of urushiol
* Inanimate objects can carry
* Handwashing to prevent transfer
* Wash exposed area with water and a mild soap
Relief of itching
* Cold or lukewarm soap-less showers
Products that remove urushiol
* Zanfel and Tecnu
* Both are not FDA approved
* Zanfel – removes Toxicodendron induced ACD
* Tecnu – chemical deactivator removes the urushiol oil on the skin
* Applied to skin ASAP and repeated as needed
What are pharmacological treatments of ACD?
Pruritus (itching)
* Topical anesthetics, antihistamine (diphenhydramine), or antibiotics should NOT be used
* Known to cause drug-induced ACD which could mask existing symptoms
* First generation oral antihistamine may be used for sedation at bedtime
Weeping
* Aluminum acetate solution (Burrow’s solution)
Inflammation
* OTC Hydrocortisone cream (0.5% and 1%)
* RX Hydrocortisone cream (2% and 2.5%)
* Low potency steroid to reduce inflammation and pruritus
* For mild to moderated symptoms of ACD
What are exclusions to self-care for contact dermatitis?
- <2 years of age
- Dermatitis present >1 week (with self-care)
- Chronic dermatitis symptoms
- Body Surface Area (BSA) Greater than: 10% (ICD) or 20% (ACD)
- Extreme itching, irritation, or severe vesicle formation
- Swelling of the body, extremities or eyelids/area around the eye
- Discomfort in mouth, nose, eyes, anus or genital area from itching, redness, swelling, or irritation
- Signs of infection
- Involvement of face scalp or neck
What is the background for scaly dermatitis?
- Includes dandruff, seborrheic dermatitis, and psoriasis
- Increasing amount of inflammation and scaliness: Dandruff, seborrheic, and then psoriasis
- Really only effect the top layer of the skin (epidermis)
What is scaly dermatitis caused by?
- Malassezia yeast
How does scaly dermatitis present?
Presentation: mild inflammation, flaking, and pruritus.
* Small white or gray loosely bound flakes
* Typically, the least likely to be inflamed
What is the seborrheic background?
- More severe form of dandruff Malassezia species
- More common in areas with dense distribution of sabaceous glands (head, face, chest, eyebrows, eye lids)
What is the pathophysiology of psoriasis?
- Immunologic mechanism: T-cell induction, keratinocyte and epidermal proliferation
- Genetic predisposition
How does psoriasis present?
- Starts as small papules which grows and unites to form plaque
- Commonly on elbows, knees, lumbar region, scalp, and trunk
What are psoriasis triggers?
- Environmental factors, physical, ultraviolet, and chemical injury
- Various infections
- Rx drug use and withdrawal of systemic corticosteroids
- Emotional and psychological stress
- Use of alcohol and tobacco
What are the goals of treatment for scaly dermatitis?
- Redice the epidermal turnover rate, decrease Malassezia fungi
- Minimize the cosmetic embarrassment of visible scaling
- Minimize itch
What is the first line of treatment for scaly dermatitis?
- Pyrithione zinc (0.1% - 0.25%)
- Selenium sulfide (1%)
- Important to have long enough contact time of 3-5 mins
How long do you use dandruff medication?
- Use daily for 1 week
- Used for maintenance after initial treatment (2-3 times a week)
How long do you use medication for seborrheic dermatitis?
- Used daily for 1-2 weeks
- Slowly decrease frequency
What are psoriasis treatment options?
Topical steroids or emollients
Removal of scales
* Continues to cause further growth of plaque
* Less penetration with topical agents
* Daily lubrication of the skin after bath to remove scales
Cytostatic agent
* Coal tar (Creams, ointments, pastes, lotions, bath oils, shampoos)
* Applied to selected area
* Discoloration
Antifungal agents
* Ketoconazole 1% (OTC) for Malassezia
* AW- hair loss, skin irritation
Keratolytic agents
* Salicylic acid
* 1.8-3% for self-care for all three conditions
* MOA: decreases the skin pH, making it easier to remove the keratin
Sulfur (dandruff only)
* 2-5% concentration
Topical hydrocortisone
* Inflammation treatment only (SB and Psoriasis)
What is Cradle Cap?
- Scaly Dermatitis
- Usually occurs in the first three months of life
- Yellow-brown greasy scales on the scalp
- Can go to the face, neck, and trunk
- Treatment: Gently massaging baby oil into the affected area followed by a non-medicated shampoo
- Refer to pediatrician if therapy fails (after 7 days)
What are exlusions to self-care for scaly dermatitis?
Dandruff, seborrheic, and psoriasis:
* <2 years old
* Worsening symptoms or no improvement after 2 weeks of proper OTC treatment
Psoriasis Only:
* >5% BSA (Lesions larger than a size of a quarter)
* Involvement of the face
* Presence of joint pain
* More than a few lesions
What is the pathophysiology for acne?
Overview
* Sebum production by the sebaceous gland
* Follicular colonization (cutibacterium acnes)
Etiology:
* Condition, genetics, diet, gender
Different types of presentation:
* Close comedo (whiteheads) or open comedo (blackheads)
* Papule and Nodule
What are exacerbating factors?
- Acne cosmetica
- Acne excoriee (excoriated)
- Acne mechanica
- Drug-induced acne
- Hormone-induced acne
- Hydration-induced acne
- Occupational acne
- Stress/Extreme-emotion induced acne
What are the goals of acne care?
- Eliminate visible lesions
- Maintaining treatments ro prevent relapse
- Treat scarring or other complications
What are non-pharmacological treatments for acne?
- Identifying the type of acne
- Eliminating exacerbating factors
- Cleanse with a mild soap and water
- Hydration
- Dietary changes (fruits and vegetables)
Whan are Non-Rx Pharm Treatment for Acne?
Different formulations:
* Cleansers – removes dirt, makeup, or oil from the area
* Creams – Mostly water based, allows easier absorption
* Gels – water based, lighter compared to ointments
* Astringents – causes tissues to contract/shrink
What are pharmacological treatments for acne?
- Adapalene 1% (OTC) – higher strength requires Rx
- MOA: modulate cellular differentiation, keratinization, and inflammatory process
- AE: Redness, drying, scaling, and burning
- Typically, in front month of therapy
- Acne may worsen if the first few weeks
- Therapeutic effects occurs with 8-12 weeks of therapy
- Avoid excessive sun exposure
- Benzoyl Peroxide 2.5%-10% (OTC)
- MOA: keratolytic and inhibits C. Acnes
- AE: Burning, skin peeling, scaling
- Apply 1-2 small amounts onto affect area once daily x 3 days
- May increase to 2-3 a day if able to tolerate symptoms
- Decrease frequency if unable to tolerate
- Avoid excessive sun exposure
- Salicylic acid (beta hydroxyl acid)
- MOA: lowers skin pH to break up the epidermis layer (unclog pores)
- AE: burning sensation, redness
- May take up to 8 weeks to see efficacy
- Applied 1-3 times a day
- Cleanser or topical gel
- Gel formulation, only on affected areas
- Avoid excessive sun exposure
- Azelaic Acid
- MOA: Inhibits C. acnes growth
- Used twice daily (gels, creams, or lotion)
- Less irritation than salicylic acid
Sulfur - MOA: Inhibits C. acnes growth
- Used 1-3 times daily
- Unpleasant odor/chalky consistency
- Do not use in sulfa allergy patients
What are exclusions to self-care for acne?
- Moderate to severe acne
- Exacerbating factors
- Possible rosacea
Severe Acne: extensive pustules, multiple nodules with inflamed skin
What is the background for diaper dermatitis?
- Most known as diaper rash
- Most occurs from the first few years of life from build up of urine and feces with occlusion
Prevention:
* Frequent changes in diaper for infants (every 2 hours)
* Keeping area clean and dry
Clinical presentation – bright red and moist area
What are the goals of diaper dermatitis?
- Relieve symptoms
- Prevent reoccurrence
- Prevent secondary infection
What are the treatments for diaper dermatitis?
- Air
- Barrier
- Cleansing
- Diaper Change
- Education
What are treatment options for diaper dermatitis?
Non-pharmacological
* Frequent diaper changes, keeping area dry and clean, contact with air
Pharmacological – apply a skin protectant
* Allows a barrier between skin and diaper to treat or prevent further irritation
* Calamine
* Cocoa butter
* Petrolatum
What are treatments for diaper dermatitis?
Contraindications
* Anti-fungal agents
* Anti-bacterial agents
* Hydrocortisone
If fungal or bacterial infection – refer to PCP
Patient unable to communicate any changes
What are the exclusions to self care for diaper dermatitis?
- Lesions present >7 days
- Lack of improvement despite appropriate care (7 days)
- Secondary infection
- Lesions cause by another disease state
- Presences of diaper dermatitis outside of diaper region
- Oozing, blood, vesicles, or pus at legion site
- Significant behavioral change
- Comorbid conditions (HIV, organ transplant)
What is the background for prickly heat?
Pathophysiology- caused by partially clogged sweat glands.
Hallmark presentation- pinpoint sized lesions that are raised and red or maroon.
What are goals of prickly heat treatment?
- Eliminate occlusions of the skin
- Protect the skin from further irritation
- Promote healing of the skin
What are non-pharm treatments for prickly heat rash?
- Cooling down area
- Remove occlusions to the skin
- Washing and drying skin
What are pharm treatments for prickly heat treatment?
- Emollients, Skin Protectants, and Antipruritic
- Hydrocortisone (adults only)
What are exclusions for self-care for prickly heat rash?
- High fever without sweating
- Heat Exhaustion–> Heat Stroke
- Slow or weak pulse
- Lethargy
- Cold and pale clammy skin
- Absence of fever
- If patient is experiencing heat stroke, move to cool area and call 911.
Describe the pathophysiology of atopic dermatitis.
- Barrier dysfunction: can be caused by environmental triggers or altered immunity
- Abudance of CD4 T-helper cells and mass production of cytokines
- Inability to retain moisture
- More susceptible to allergens
List the steps of atopic dermatitis.
- Inflammation
- Itching
- Scratching
- Damages skin barrier
- Irritant/Allergen penetrates skin
What are triggers of atopic dermatitis?
- Aeroallergens (pollen, dusts, grass, etc.)
- Clothes that are tight fitting
- Dyes and preservatives
- Excessive hand washing or bathing
- Food allergen
- Psychological stress
- Electric blankets
- Irritating soaps and detergents/scrubs
Weather
What are the treatment goals of atopic dermatitis?
- Sop the itch-scratch cycle
- Maintain skin hydration and barrier function
- Avoid aggravating factors
- Prevent secondary infection
What are non-pharm treatments of atopic dermatitis?
- Moisturizers are the first line treatment
- Cleansers – removes many substance from the skin, also hydrates the skin
- Bath soaps – removes skin, oil, and debris
- Emulsifiers – helps lipids and water maintain a continuous phase
- Humectants – helps the skin retain water
- Avoid triggers
- Short bath/showers (lukewarm water)
- Moisturizers applied 3 mins after a shower
- Increase humidity to prevent evaporation in the skin
How do we apply hydrocortisone for atopic dermatitis?
- Topical hydrocortisone 0.5% or 1% (OTC)
- Apply to affected area 1-2 times daily
- Limit to 7 days for use
- Possible rebound or withdrawal symptoms
- Itch/redness returns
What are exclusions for self-care for atopic dermatitis?
- Moderate-severe condition with intense pruritis
- Involvement of large area of the body
- Less than ONE years of age
- Skin appears to be infected
- Involvement of fave or intertriginous areas
