Exam 1 Flashcards
Atopic Dermatitis (Eczema)
Manifestations:
Pathogenesis;
epidemiology**:
Types (Severity):
Manifestations:
a. dry skin and severe pruritic (itching)
b. acute: erythematous papule and vesicles with exudate/ crusting
c. chronic: Dry, scaly excoriated (removal of skin) erythematous papules.
Pathogenesis:
a. Filaggarin deficiency (substance produced by keratinocytes that is broken down to produce natural moisturize factor(NMF)
b. family history of Atopy (eczema, asthma, allergic rhinitis, increased IgE, food allergies, hard water [Calcium carbonate]
epidemiology: more likely to affect black children. les likely to affect black adults. asians least likely to experience
Severity:
a.mild: areas of dry skin, infrequent itching (w. or w.o small areas of redness), little impact on everyday activities, sleep, and psychosocial wellbeing
b. moderate: areas if dry skin, frequent itching, redness (w. or w.o excoriation and localized skin thickening), moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep
severe: widespread dry skin, incessant (continuous) itching, redness (w. or w.o excoriation aextensive skin thickening, bleeding oozing, cracking, and alteration of pigmentation), Severe limitation of everyday activities and psychosocial functioning, nightless loss of sleep
Atopic Dermatitis (eczema)
non pharm/ OTC
Non Pharm:
- Eliminate Exacerbating factors
(i. e stress, anxiety, heat, low humidity, contact allergens) - Bathing
a. warm soaking bath or showers
b. soap free or mild cleansers - maintain skin hydrations
a. use lotions with higher oil content (avoid high water to oil content lotions
4.Avoiding Pruritis
a.oral antihistamines-especially if concurrent urticaria/ rhinoconjunctivitis
H1: diphenhydramine, hydroxyzine
H2: fexofenadine, loratadine
b. Topical Doxepin
c, Topical Calicineurin inhibitors
Atopic Dermatitis (Eczema) Treatment
Mild/ Moderate:
a. first line
Severe:
a. non pharm
b. pharm
mild-moderate: a: FIRST LINE:TOPICAL STEROIDS I. Denoside 0.05% cream/ung *low potency creams/ung for mild *BID x 2-4 weeks with emollients
II. Triamcinolone Acetonide oint. 0.5%
- high potency
- for moderate
- 1-2 weeks, taper to low potency creams
III. Face, Flexures
* low potency steroids qd 5-7 days
Severe:
a. Soak and smear
* soak affected area in water for 15 min.
* do not dry, apply high potency steroid (except in face, groin, axillae)
b. Wet wraps
* mid-super potency steroids in an ung. base
* treated areas occluded with wet wraps. Wet pajamas covered by dry pajamas min 4 hrs BID
c. Photo therapy
* 2-3 times weekly
* sometimes combined with coal tar solutions
Allergic Contact dermatitis (General)
Causes: (8 listed)
Manifestations:
General management
:
Causes:
- Latex
- poison ivy, poison sumac, Poison Oak, Mango (CONTAIN URUSHIOL)
- metals (nickel, cobalt, cold chromium
- topical ABX (neomycin, polymyxin B and bacitracin)
- Topical steroids
- topical anesthetics (benzocaine, procaine, tetracaine)
- propylene glycol
- fragrance
Manifestation:
Erythematous, indurated, scaly plaques
General management:
- identify and avoid offending products
- treat the skin infammation
- restore the skins natural barrier
- protect the skin
Allergic Contact dermatitis (General)
Treatment
a. General
b. pharm
c. non pharm
a. general
* identify and avoid offending agent
* treat the skin inflammation
* restore the skins natural barrier
* protect the skin
b. PHARM
1. Topical corticosteroids
* first line
* high potency on thick skin or non-face/ flexural areas
* medium potency on face or flexures- no longer than 2 weeks
2. Topical calcineurin inhibitors (TCI)- for chronic localized ACD or ACD involving face or intergrigenous areas.
3. systemic corticosteroids- for patients with ACD >20% of BSA or for acute ACD of face, hands, feet or genetalia
4. drying agents for weeping vesicles
5. soothing agents: oatmeal baths, calamine lotion
Allergic Contact Dermatitis (ACD)
Toxicodendron Dermatitis
What is it: Cross reactivity: Presentation: Prevention: Treatment: (also, what will not help)
Toxicodendron Dermatitis
What is it: an ACD that occurs after exposure to urushiol, a skin irritating oil produced by members of plant genus toxicodendron.
Causative agent: poison ivy, oak, sumac
Cross reactivity: mango rind, cashew nutshell, etc.
Presentation: redness, itching, swelling, blisters
Prevention:
a. avoidance; protective clothing
b. washing clothes and pets after exposure
c. barrier creams (controversial)
Treatment:
*ANTI HISTAMINES WILL NOT HELP ITCH
*TCI not effective
*but can use..
a. soothing measures, oatmeal baths and cool and wet compress
*calamine lotion for symptomatic relief
b. topical astringents (drying agents)
aluminum acetate: Burows solution
Aluminum sulfate (domeboro)
c.high potency topical steroids for up to a week
d. systemic steroids- for severe facial and genital exposures
Allergic Contact Dermatitis (ACD)
Latex Allergy
Management/prevention
non pharm:
pharm:
- avoidance (most effective, least expensive
Pharm treatment
a. steroids
b. self admin-epic pen to treat acute reactions
Immunotherapy
a. sub q immunotherapy
b. sub lingual immunotherapy
Seborrheic Dermatitis
Causes:
epidemiology**:
Manifestations
Causes: (theory) inflammatory reaction to Malassezia (yeast)
yeast in oil secretion
immune system overeats and causes inflammation and skin changes
epidemiology:
* biphasic incidence: infants btw ages of 2 weeks and 12 months (CRADLE CAP).
* 35% among pts. with early HIV infection, 85% among pts. with aids
manifestations:
- well-demarcated erythematous plaques
- worsens e. stress, cold, dry heat of winter
- greasy yellow scales
- distributed on areas rich in sebaceous glands such as
a. scalp
b. external ear
c. center of the face
d. upper part of the trunk
Seborrheic Dermatitis
pharm Management
a. Topical anti fungal agents
* ketoconazole 2%
* selenium sulfide 2.5%
* Zinc Pryithione 1% shampoos
* ciclopirox 1% shampoo, 0.77% ung.
b. topical steroids for symptom management
c. Systemic antifungals (severe)
* itroconazole, ketoconazole, fluconazole, terbinafine
Seborrheic Dermatitis
Selenium sulfide
Class:
Adverse effects:
Formulations:
Notes:
Class: Anti-Malessezia activity
Adverse effects: well tolerated with no adverse events
Formulations:
*1% is OTC: >2y.o BIW: apply to wet hair, massage into scalp for several min, rinse
*2.5% is rx: >2y.o BIW: apply to wet hair, massage into scalp for several min. BIW for 2 week. once a week or less there after
Notes:
- contact time important
- discoloration of blonde, gray or died hair may occur
- if pt< 2 y.o consult pediatrician.
Seborrheic Dermatitis
Zinc Pyrothione
Class:
Adverse effects:
Formulations:
Notes:
Class: anti-malassezia activity. reached yeast count in scalp and skin and binds exclusively to skin of scalp and hair
Adverse effects: well tolerated, no AE
Formulations:
>2.yo: BIW apply to wet hair, massage into scalp for several min. rinse
Notes: absorption increases w, contact time, temp, conc. and freq. of application.
Seborrheic Dermatitis
Cradle Cap
Causes:
Manifestation:
Treatment
Causes: asymptomatic and non inflammatory accumulation of greasy scales (dark to yellowish) on the scalp.
manifestations: can start on face, with erythematous , scaly salmon colored plaques
* in forehead, retroauricular areas, eyebrows, eyelids, cheeks, nasolabial folds
Treatment: a. often spontaneously resolves
b. concervative measures
* baby shampoo, remove scales w. soft brush
* emolient cream (mineral oil, or petroleum jelly), then baby shampoo
Conjunctivitis (pink eye)
What is it:
Types:
what is it: inflammation of the conjunctiva of the eye (aka pink eye)
types: bacterial allergic viral toxic
Conjunctivtis
General prevention
wash hands
keep eyes clean (wash hands b4 changing contacts)
change pillow cases frequently during infection
don’t share eye makeup
avoid allergens
avoid rubbing eyes
Bacterial conjunctivitis
causes:
manifestation:
Treatment:
causes: S. aureus, S. Pneumoniae, H influenzae, M catarrhalis
manifestation:
- starts in one eye, but can spread in both
- thick pus (meow, white green) at lid margins and corner of eye
- morning crust that continues throughout the day
- purulent discharge
Treatment:
- Erythromycin 5mg/gram of ung.
* Dosing: 1/2 inch pid x 5-7 days - Trimethroprim/ polymyxin B 0.1%-10,000 units/ g drops
* 1-2 drops bid x 5-7 days - IF PT HAS CONTACTS, must possibly cover for pseudomonas. can consider fluoroquinolones.
- for special new born ocular bacterial infections such as neisseria gonnorhea and chalmydia trachmatis, use SYSTEMIC TREATMENT.
Viral conjunctivitis
causes:
manifestation:
Treatment:
Counseling points:
Viral conjunctivitis
causes:
*most contagious
adenovirus serotypes
manifestation:
- self limiting. 1-2 weeks
- apart of viral prodrome: fever, pharyngitis, URI
- burning, sandy, grit feeling
- watery or mucous discharge
- enlarged tender pre-auricular nodes
Treatment:
- Vasocontrictor/ antihistamine combo
* NAphazoline/ Pheniramine (Naphcon-A, Opcon-A)
* 1-2 gtt bid - antihistamines with mast cell stabilizing properties (only treat symptoms. systemic doesn’t work)
* Azelastine (Optivar) 1 gtt bid
* Ketotifen (Zaditor) 1gtt bid
* olopatadine (Patanol) dose cared by strength - Counseling points
*symptons get worse b4 they get better
3 days or so, and may persist
Allergic conjunctivitis
SS:
types:
non pharm/ prevention:
Pharm:
SS: intense itching, hyperemia, tearing,chemosis, and eyelid edema
types:
* acute allergic Con. (AAC): fast onset. ends in ~24h
* seasonal acute. con. (SAC): SIMILAR TO AAC+rhinitis. slower onset and takes days-weeks associated w. pollen seasons.
* Perenniam allergic. con. (PAC): mild chronic waxingg and year round symptoms. dust, dandy,mold. etc.
non pharm/ prevention: *refrigerated artificial tears
- cold compress and avoid contacts if possible
- allergen reduction: frequent clean, limit outdoor exposure, replace/clean/cover pillows, blankets, mattresses, carpets, curtains
Pharm:
- vasoconstrictors/ antihistamines: max of 2 weeks due to rebound problems
- antihistamines w. mast cell stabilizing properties (TOPICAL)
Non allergic conjunctivitis
what is it:
causes:
Treatment
what is it: catch all for all other potential causes of conjunctivitis
causes: transient chemical or mechanical grit
* resolves within 24hrs
* dry eye has similar SS
Treatment:
- eye lubricant drops: 1-2 gtts up to 6x per day
- eye lubricant ung.: 1/2 inch qid pen or hs.
Toxic conjunctivitis
what is it:
causes:
SS:
Treatment:
what is it: direct contact to ocular tissues from preservatives or meds
causes:
- contact lens solutions
- artificial tears
- topical eye meds such as
a. amino glycoside abx
b. antiviral meds
c. glaucoma meds
d. topical anesthetics
SS:redness, edema, mucus discharge, swollen eyelids, thickened eyelids
Treatment:
- discontinue topical meds containing preservatives (benzalkonium chloride)
- use of short course loteprednol (topical corticosteroid) qid.
- use non BAK containing formulations
Flea bites
TReatments
a. non pharm
b. pharm
treatment:
- avoid scratching
- wash area
- oral antihistamines such as cetirizine, loratadine, fezofenadine
- topical steroids
Bed bug bite
Treatments
- avoid scratching
- low or medium potency topical steroid
- systemic antihistamine
Pediculosis humanus captious (head lice)
transmission:
manifestation:
Treatment:
transmission: head ot head. hand to head
vectors. hats, pillows
manifestation: itching
Treatment:
- Permethrin 1%
- Pyrethrins and piperonyl butoxide
- Wet combing
Permethrin (Nix)
indication: MOA: age group: Regimen: Precautions: general treatment guidance:
indication: Head lice MOA: neurotoxin age group: >/=2 months Regimen: *wash hair * do NOT use conditioner *leave on hair for 10 min, rinse *repeat on day 9
Precautions:
- skin irritation
- induc difficulty breathing in pts . ragweed allergy
- avoid in chrysanthemum allergy
general treatment guidance: * do not use conditioners Rinse over sink instead of in shower rinse w. warm water not hot to prevent vasodilation *treat bedmates prohpyllactly
Pyrethin/ piperonyl butoxide (Rid)
indication: MOA: age group: Regimen: Precautions: general treatment guidance:
indication: head lice MOA: neurotoxin age group:>/= 2 years Regimen: *apply to dry hair or other affected area *don't use conditioner *leave o hair for 10 min *rinse with warm water * repeat in 7-10 days
Precautions: skin irritation
general treatment guidance: * do not use conditioners Rinse over sink instead of in shower rinse w. warm water not hot to prevent vasodilation *treat bedmates prohpyllactly
Wet combing
what is it used for:
how to do it:
what is it used for:
alternaive to meds for removal lice
how to do it:
- wash hair w. shampoo
- apply conditioner
- detangle
- use head lice detection *comb, draw comb to ends of hair starting from roots
- wipe and rinse comb
- work in sections
- repeat
- can take 10-30 min
Body Lice (pediculosis corporis)
general treatment:
- ensure regular change of clean clothes
- throughly bathe
- wash clothing in hot water or throw away
- ironing with hot flat iron
- vacuums area well
Pubic Lice (phthirus pubs)
transmission:
SS:
treatment: (including household contacts)
also what is ciliaris, and what is the pharm treatment
transmission: sexual contact
SS: usually asymptomatic . if ss, USUALLY urticaria in pubic areas, maculae ceruleae (red macule)
CILARIS: reddish crusting
Treatment: Pubis *topical permethrin 1% or pyrethrins+ piperonly butoxide a. apply on cool and dry skin b. apply. wash off after 10min c. put on clean clothing d.treat after 9-10 days
Ciliaris:
1. manual removal or apply ophthalmic grade Vaseline bid-qid x 10 days
household contacts:
a. avoid sex contact until both partners treated
b. don’t need to treat non sex contacts
c. evaluate for other std’S
d. machine wash clothes w. hot water
e. fumigation not necessary
Scabies
what is it: manifestations : Dx: treatment: Counseling: control of transmission
what is it: itchy skin condition caused by a burrowing mite
manifestations :
- intense pruritis, worse at night. w. onset of SS 3-6 weeks after infestation.
- burrow: slightly elevated 1-2 mm long
- crusted/ Norwegian area: pathes-> fissures->secondary bacterial, sepsis
Dx: finding mite or burrow
treatment:
NO OTC
a.Mites
1. Permethrin 5% (Elimite) cream (kills mites and eggs)
2. crusted scabies: Permethrin 5% cream + oral ivermectin
b. itching: antihistamines for up to 2 weeks
Counseling:
- Permethrin 5%
* aply throughout body into skin from neck to soles of feet
* include under fingernails and toes
* 30g per average adult
* include hairline, neck, temples, and forehead in geriatrics and infants
* remove by washing after 8-14 hrs
* apply 1-2 weeks later
* >2 mo. old
* if breast feeding, D/c breast feeding temporarily.
control of transmission: *treat all members of family or ppl w. close ocntact
- machine wash fomites
- place items in plastic bags x3 days (mites cant survive w.o human contact more than 2 days
- fumigation not indicated
Chiggers
What is it:
Treatments:
what is it: skin disease secondary to bite of mites most common in summer and fall
fun fact: cluster of bites in certain areas due to barriers of migration such as belts, waist bands, etc.
precludes wandering
treatment:
1. vigorous soap and water
2. Repel with DEET
3. symptomatic treatment; topical antipyretics such as menthol or calamine, topical steroids, oral sedating antihistamines
Mosquitos
transmission:
treatment:
transmission: inject anticoagulant saliva: welt, pain, and itching. some pts get symptomatic fever and joint swelling
treatment: (if needed)
1. antihistamine (cetirizine, loratadine, fexofenadine)
2. topical glucocorticoid x 5-10 days
3. oral glucocorticoid
Ticks
what is it:
disease transmission:
How to remove tick:
Treatment:
what is it: parasite
disease transmission: feed on blood of humans and animals. takes about 36 hrs to transmit lyme disease
a. rocky mountain spotted fever: headache, rash, high fever, extreme exhaustion
Lyme disease: erythema migrant (bulls eye) transmitted by spirochete
long term complications: neurologic, cardiovascular, musculoskeletal, arthritis
How to remove tick: 1. sanitize bite area and tweezers 2. grab tick close to head pull up slowly and carefully sanitize bite area again
Treatment:
insect repellents
1. Topical N,N- diethyl-m-toluamide, commonly called DEET (most efficacious repellant
DEET
indication:
available dosage forms and strength:
how to use:
age indication
DEET
indication: repellant
available dosage forms and strength: sprays, solutions, creams, and wipes conc. 10-35 % for most situations conc. >/= 20% for ticks conc. <30% for children
how to use: usually no ore frequently than q4-8hrs
age indication: > 2 months old
Exclusions for self-treatment for bites
- hypersensitivity to insect bites. resulting in systemic symptoms or symptoms away from bite area
- <2 years of age
- hx tick bite and systemic c effects indicating possible infection
- suspected spider bite requiring medical attention
- SS of secondary infection of bite area
Exclusions for self-treatment for stings
- Hives, excessive swelling, dizziness, weakness, N&V, difficulty breathing
- significant allergic response away from site of sting
- previous sting by honeybee, wasp or horney ( need to evaluate possible development of hypersensitivity
- previous severe reaction to insect bites
- Personal or family hx significant allergic reactions (eg. hay fever)
- <2 y.o
Patho of acne
- excess keratin cells and blockage of folic entrance due to sebum
- blockage of pore due to sweat, makeup, etc.
- WBC flow to cause inflammation
pH of health skin
~4.7-5.7
types of acne lesions
- white head (close comedones
- black head (open comedones)
- papules (pinhead)
- cysts
- nodules
- pustules (pimple)
Acne Treatment:
Mild:
Moderate:
Severe:
Mild:
a. first line: Benzoyl peroxide (BP) OR topical retinoid
Moderate:
1st line: Topical combo therapy
ex: BP+ retinoid
Severe: Oral isotretinoin
acne classifications
mild:
moderate:
severe:
mild: few -several papules/ pustules (generally <10) and no nodules
moderate: several- many papules/ pustules (10-40) along with comedones (10-40) and few to several nodules
severe: numerous or extensive papules/ pustule and many nodules
Home care of acne
gentle synthetic clearers twice a day
wash with fingers not cloths
avoid scrubs- apricot or otherwise
use water-based lotions, cosmetics, and hair products
don’t pick at lesions
skin should be dry before applying topicals
vehicles used for skin types
dry skin: oily skin: hairy areas: also... solutions: pledgets:
dry skin: lotions or creams
oily skin: gels or foams
hairy areas: foams
also. ..
solutions: drying but cover large areas
pledgets: cover large areas
Targeted treatment Factors for acne
Follicular/ hyperpoliferation
oral/ topical retinoids
azalea acid
salicylic acid
hormonal therapies
Targeted treatment Factors for acne
Increased sebum production
oral retinoids
hormonal therapies
clascoterone cream
Targeted treatment Factors for acne
C. acnes proliferation
benzoyl peroxide
ABX
azaleic acid
dapsone topical
Targeted treatment Factors for acne
inflammation
oral/opical retinoids
oral tetracyclines
azalea acid
clascoterone cream
dapsone topical
Targeted treatment Factors for acne
androgen receptor inhibitor
clascoterone cream
Topical Retinoids
ex:
effects:
side effects:
notes:
ex: Tretinoin, Tazarotene, etc.
effects: decrease cohesiveness of keratinocytes
side effects: irritation dryness flaking of skin transient worsening of acne "photosensitivity avoid OTC irritating products
avoid use in pregnancy (especially tazarotene)
allergy info: atralin -soluble fish proteins
notes: start low, go slow
Clascoterone cream
class:
ADVERSE EFFECTS
class: androgen receptor inhibitor
Adverse effects: HPA suppression has been reported (concern w. occlusive dressings)
topical antimicrobials for treatment of acne
action:
adverse effects:
how to use;
product:
action: decrease number of C. acnes colonizing skin. comedolytic
reduce inflammatory response
adverse effects: may bleach hair or clothing
erythema, scaling, xerosis, stinging/ burning
reports of life threatening hypersensitivity
how to use: apply qd, may be increased to bid or did after 2 weeks if tolerated.
benefits w.in 3 weeks max within 12 weeks
products: DIFFERIN CLEANSER: BP cleanser (don’t confuse with differin gel which is adapalene)
oral abx for acne
ex:
adverse effects
ex. tetracycline, doxycycline, minocycline.
ae:
TETRA + DOXY: photosensitivity, GI distress, CI in pregnancy and young children
mino: dizziness, drug induced lupus, skin discoloration, ci in pregnancy and young children
