Exam 1: eyes & skin Flashcards
1
Q
exacerbating factors for atopic dermatitis (eczema)
A
stress, anxiety, heat, low humidity, contact allergens
2
Q
mild/moderate tx for atopic dermatitis
A
1st line: topical corticosteroids
Low potency: Desonide 0.05% BID x2-4 weeks
High potency: Triamcinolone acetonide ointment 0.5% 1-2 weeks & taper down
For face/flexures: low potency qd x5-7 days or Tacrolimus 0.03% & 0.1% or Pimecrolimus 1% BID
-Crisaborole: use in pts 2+ yrs
3
Q
Severe disease tx for atopic dermatitis
A
1- soak & smear then apply high potency steroid
2- wet wraps
Drugs: Dupilumab, cyclosporine, methotrexate, Azathioprine, MMF mycophenolate mofetil
4
Q
characteristics of allergic contact dermatitis
A
erythematous, indurated, scaly plaques
-can be caused by latex, poison ivy, poison sumac or oak, metals, topical antibiotics,
5
Q
Treatment of allergic contact dermatitis
A
1st line: topical corticosteroids
- high potency on thick skin or non face/flexural areas
- medium potency on face or flexures - NOT LONGER THAN 2 WEEKS
6
Q
when do you use topical calcineurin inhibitors in allergic contact dermatitis?
A
for chronic, localized ACD or ACD involving face or intertriginous areas (does NOT work for urushiol rashes)
7
Q
when are systemic corticosteroids used in allergic contact dermatitis?
A
for pts with ACD >20% of BSA or for acute ACD of face, feet, hands or genitalia
8
Q
what are some drying and soothing agents that are used in allergic contact dermatitis?
A
- drying: aluminum acetate soaks
- soothing: oatmeal baths, calamine lotion
9
Q
what is toxicodendron dermatitis caused by?
A
-poison ivy, oak, sumac = redness, itching, swelling & blisters (URUSHIOL)
10
Q
How to treat toxicodendron dermatitis:
A
-soothing measures
-calamine lotion
-topical astringents (aluminum acetate, aluminum sulfate calcium acetate)
-high potency topical corticosteroids
-for severe, facial, genital exposures: prednisone taper over 2-3 weeks
DO NOT use antihistamines or topical CIAs
11
Q
What is seborrheic dermatitis caused by?
A
- inflammatory reaction to Malassezia (yeast)
- incidence: in infants 2weeks-12 months
12
Q
Management of seborrheic dermatitis
A
- topical anti-fungal agents: ketoconazole 2%, selenium sulfide 2.5%, zinc pyrithione 1% shampoos, ciclopirox 1% or .77% ointment
- systemic anti-fungals: (severe) itraconazole, ketoconazole, fluconazole & terbinafine
13
Q
what is cradle cap and how do you treat it?
A
- asymptomatic & non-inflammatory accumulation of greasy scales on the scalp
- treat with baby shampoo & remove the scales with a soft brush or used mineral oil and then baby shampoo
14
Q
What are causes/signs of bacterial conjunctivitis?
A
(s aureus, s pneumoniae, h influenzae & m catarrhalis)
-morning crusting–> thick “pus”, yellow, white or green
15
Q
What are the treatment for bacterial conjunctivitis?**
A
1-Erythromycin 5 mg/g oint 1/2 inch QID x 5-7 days
2-Trimethoprim/polymyxin B .1%-1000 u/g drops: 1-2 drops qid x5-7 days
(for contact wearers: ofloxacin 0.3% or ciprofloxacin 0.3%)
16
Q
New born ocular infections: Neisseria gonorrhoeae
A
-purulent conjunctivitis, profuse exudate, swelling of eyelid
SYSTEMIC tx: single dose IV or IM ceftriaxone
17
Q
Newborn ocular infections: Chlamydia trachomatis
A
SYSTEMIC tx: PO erythromycin 50mg/kg/day in 4 divided doses x 14 days or azithromycin 20mg/kg/day x 3 days
18
Q
Viral conjunctivitis (pink eye) signs& symptoms
A
- fever, pharyngitis, URI
- burning, sandy, gritty feeling
- injection, watery or mumcoserous discharge
19
Q
Viral conjunctivitis (pink eye) treatment**
A
- Naphazoline/Pheniramine 1-2 gtt qid
- azelastine (optivar) 1 gtt bid
- ketotifen (zaditor). 1 gtt bid
- olopatadine (patanol)
20
Q
allergic conjunctivitis signs
A
-intense itching, hyperemia, tearing, chemises & eyelid edema
21
Q
allergic conjunctivitis treatment
A
(same as pink eye)
- na/ph
- AKO
22
Q
toxic conjunctivitis signs & tx
A
- direct damage to the ocular tissues : redness, edema, mucus discharge, swollen/thickened eyelids
- treat with: loteprednol
23
Q
treatment for fleas
A
-ice pack, calamine, oral antihistamines & topical corticosteroids
24
Q
treatment of bedbugs
A
- low or medium potency topical corticosteroid
- systemic antihistamine
25
treatment of pediculuc humanus capitis (head lice)**
- permethrin 1% (> 2 month olds)
- Pyrethrins & piperonyl butoxide: > 2 year old
- trimethoprim-sulfamethoxazole + permethrin (oral, for resistant cases)
26
treatment of pubic lice
- topical permethrin 1% or pyrethrins + piperonyl butoxide (retreat 9-10 days after)
* treat sexual partner as well
27
treatment of ciliaris lice (eyelashes)
- manual removal or ophthalmic grade vaseline bid-qid x 10days
- alts: oral ivermectin, permethrin 1% cream rinse, lindane 1% lotion, malathion 1% shampoo
28
classical scabies treatment*
- permethrin 5% cream (apply 1-2 weeks later)
| alts: ivermectin 200 mcg/kg x1 (repeat 14 days later), crotamiton 10% cream
29
crusted/norweigian scabies treatment*
-permethrin 5% cream + oral ivermectin
30
Chiggers treatment
-skin disease secondary to the bites of mites
-treat with vigorous soap & water (repel with DEET)
sytemic treatment: topical menthol or calamine lotion, topical corticosteriods, oral sedating antihistamines
31
Mosquitoes
- inject anticoagulant saliva = welts, pain & itching
- vectors for spreading west nile, chikugunya and zika virus
- treat (if needed) with antihistamines, topical and oral glucocorticoids
32
Ticks
- takes ~36 hours to transmit lymes disease
- rocky mounted spotted fever: headache, rash, high fever, extreme exhaustion
- long term complications: neurologic, cardiovascular, musculoskeletal & arthritis
33
DEET
- do not use for more than 4-8 hours
- children use concentrations less than 30%
- age indications for use > 2 months old
34
Bites (self care things)
- wash with soap&water then ice for 10 mins
- camphor/menthol: do not use < 2yo or more than 7 days
- can use pramoxine and benzyl alcohol
- do not use dibucaine, hydrocortisone or topical diphenhydramine (for more than 7 days)
35
Exclusions for self care (bites)
- hypersensitivity to bites
- < 2 years old
- suspected spider bite
- signs of secondary infection
36
Stings (self care things)
- -can use camphor/menthol, pramoxine and benzyl alcohol
| - diphenhydramine po 15-50mg may help with itching
37
Exclusions for self care (stings)
- hives, swelling etc
- previous sting by honeybee, wasp or hornet
- previous severe reaction to insect bites
- fam hx of allergies
- < 2 year old
38
what is the normal pH of skin?
~4.75-5.7
39
drugs that cause "acne-like" lesions
lithium, phenytoin, glucocorticoids, oral contraceptives, androgens, high dose vitamin B & D, valproic acid, Isoniazid, cyclosporine, Azathioprine, disulfiram, phentermine, Iodides, bromides, danazol
40
Mild acne treatment
- <10 papules
| - topical benzoyl peroxide/retinoid
41
moderate acne treatment
10-40 papules
| -topical bp + oral antibiotic
42
Severe acne treatment
40+ papules
| -oral Isotretinoin
43
Targeted treatment factors: follicular hyper proliferation
-oral/topical retinoids, azelaic acid, salicylic acid, hormonal therapies
44
Targeted treatment factors: increased sebum production
-oral retinoids, hormonal therapies, clascoterone cream
45
Targeted treatment factors: C. acnes proliferation
-benzoyl peroxide, antibiotics, azelaic acid, dapsone topical
46
Targeted treatment factors: Inflammation
-oral/topical retinoids, oral tetracyclines, azelaic acid, clascoterone cream, dapsone topical
47
Clascoterone cream
- androgen receptor inhibitor
| - store at 2-8C prior to dispensing, discard 180 days after dispensing or 30 days after opening
48
topical retinoids
- included as initial management in most pts
- normalize follicular hyperkeratosis
- may take up to 8-12 weeks to work
- use a pea sized amount to entire affected area
* tretintoin NOT applied at the same time as benzoyl peroxide
49
topical retinoids (drugs)
Atralin 0.05%, Adapalene, tazarotene, TWYNEO (tretinoin/bp), trifarotene, Epiduo Forte (adapalene and BP), & veltin (clinda + tretinoin)
50
topical antimicrobials
- decrease inflammation & # of C. acnes colonizing skin
- combo therapy with topical retinoid = more effective
- to prevent resistance, use with benzoyl peroxide
* *BP in combo with many things --> if skin/hair bleaching occurs, use clindamycin 1.2%/tretinoin 0.025%
51
Azelaic acid
- helps improve inflammation
- limits melanin production via inhibitory effect on tyrosine
- use once daily - burning, itching, redness, hives, anaphylaxis (v rare)
52
Oral antibiotics
- limit duration, if stopped- restart the same one if effective, don't combine oral & topical, use with BP or other topical retinoids
- -> tetracycline, doxycycline (both cause photosensitivity)
53
Benzoyl Peroxide
- comedolytic & antibacterial
- benefits 3-12 weeks
- start at 2.5% and increase if needed
- AEs: erythema, scaling, xerosis, stinging/burning, bleaching of hair
54
salicylic acid
- desquamating agent: able to penetrate pilosebaceous follicle
- synergistic effect with benzoyl peroxide
55
alpha hydroxy acids
- remove top layer of dead skin cells, improve post-inflammatory properties
- may work synergistically with retinoids
56
tea tree oil
melaleuca alternifolia 5%
- toxic if used internally
- slower mechanism of action than BP
57
Ethinyl Estradiol/Progestin
- suppress androgen production
- used to suppress/inhibit sebum production
- side effects = embolism
- abx (rifampin) decreases COC efficacy
58
Spironolactone & Drospirenone
- competitively inhibit the binding of androgens to receptors on pilosebaceous unit
- AEs: menstrual irregulatities, breast tenderness,
- CI with renal insufficiency --> monitor K+ 4-6 weeks later
59
examples of isotretinoin
zenatane, amnesteem, claravis, sotret, absocrica, absorical LD
-used for severe and recalitrant acne
60
CIs of Isotretinoin
pregnancy!, underlying psychiatric conditions, concomitant use with tetracyclines/doxycycline/minocycline --> pseudotumor cerebri
- do not take vitamin supplement = vitamin A toxicity
- take a baseline LFT & FLP
61
Doses of oral Isotretinoin
-0.5 to 1 mg/kd/day in divided dose with food
| Micronized dose: 0.4-0.8 mg/kg/day in divided doses
62
iPledge things
- rxs that are more than 30 days beyond the date of the office visit or more than 7days beyond the pregnancy test date will NOT be approved
- no automatic refills & no more than 30 day supply
- # of prego tests over course of therapy = n+4 (n = months on drug)
- must be on TWO forms of contraception
63
acne conglobata
- inflammatory, acne nodules & cysts grow together deep below skin = severe scarring
tx: isotrentinoin, systemic abx, steroids
64
Acne fulminans
- rare, severe, painful, ulcerating, hemorrhagic, +/- fever or polyarthritis, +/- bone lesions
- can occur spontaneously or after Isotretinoin
tx: stop isotretinoin, systemic oral steriods
65
Post inflammatory hyperpigmentation (PIH)
- hypermelanosis of skin d/t inflammation commonly from acne, eczema or burn
- grey/blue when in dermis
66
1st line tx for PIH
first line: hydroquinone 2% BID --> reduces formation & melanization of melanosomes
AEs: halo of hypopogmentation around affected area, exogenous ochronosis "sooty pigmentation*
67
2nd line meds for PIH
- retinoids (tretinoin, tazarotene or adapalene)
- azelaic acid 20%
- Tri-lima cream
- chemical peels or laser resurfacing
68
Maculopapular Rash
-most common type
-starts within 7-10 days of drug & resolved within 7-14 days when drug is stopped
offending agents: penicillins/cephalosporins, sulfonamides, anticonvulsants
69
DRESS: drug reaction with eosinophilia & systemic symptoms
-exanthematous eruption + FEVER, lymphadenopathy, hematologic abnormalities
-multiorgan involvement: liver, kidneys, lungs
-delayed onset of 1-6 weeks after starting drug
Offending agents: ALLOPURINOL, sulfonamides, anticonvulsants (lamotrigine), dapsone
70
DRESS caused by allopurinol
risk factors: excessive allopurinol dose, renal dysfunction, thiazide diuretic use, hypertension, Chinese
kidney dosing: 1.5mg x eGFR
71
DRESS treatment
-stop offending drug
-valproic acid is good alt for lamotreigene
-fluid, electrolyte & nutrition management
-no organ involvement: high potency topical steroids
organ involvement: systemic, .5-2mg/kg.day prednisone tapered over 8-12 weeks
72
high class of steriods
- flucinonide 0.05%
- halcinonide 0.1%
- betamethasone diproprionate 0.05%
- triamcinolone cream 0.5%
- desoximetasone 0.05%
73
medium class of steroids
- triamcinolone cream 0.1%
| - mometasone 0.1%
74
Urticaria
- type 1 hypersensitivity- IgE
- onset within min to hours
- offending agents: penicillins, sulfonamides, aspirin, opiates, latex
75
Serum Sickness-like reaction
- urticaria, FEVER, arthalgias
- onset 1-3 weeks after starting drug, symptoms will resolve 1-2 weeks after stopping drug
- offending agents: penicillins/cephalosporins, sulfonamides
76
Fixed drug eruptions
- SAME spot, simple eruptions with pruritic, erythematous, raised lesions that can blister
- offending agents: tetracyclines, barbiturates, sulfonamides, codeine, phenolphthalein, acetaminophen & NSAIDs
77
SJS/TEN
- severe, life-threatening - painful bulbous formations with fever, headache, respiratory symptoms, mucous membrane involvement
- onset 7-14 days after drug exposure
78
SJS/TEN risk factors/ offending agents
risk factors: HIV infection, lupus, malignancy, UV light
Offending agents: #1: sulfonamides (Bactrim), penicillins, anticonvulsants, NSAIDS (-oxicams), allopurinol
Sequelae: fluid loss, electrolyte imbalance, hypotension, secondary infections
79
SJS/TEN drug options
1- prednisone 1-2mg/kg/day from 3-5 days --> risk is infection, use early on
2- IVIG: does not increase risk of infection, may benefit
3-cyclosporine: 3-5mg/kg/day had been shown to slow down progression- used as 2nd line to pts intolerant of IVIG
80
hyperpigmentation
- phenytoin: increased melanin
- tetracyclines, silver, mercury, antimalarials: direct deposit
- AMINODARONE: direct deposition and/or dermal lipofucsinosis
81
photosensitivity
- offending agents: sulfonamides, tetracyclines, amiodarone, coal tar
- prevention! : education and spf 30
82
1st gen cephalosporins
- cefazolin
- cefalothin
- cefaloridine
- cefadroxil
- cephalexin
- cephradine
83
2nd gen cephalosporins
- cefoxitin
- cefprozil
- cefotitan
- cefmetazole
- cefaclor
- cefuroxime
84
primary open angle glaucoma risk factors
- elevated IOP (>21)
- age (>60, >40 for blacks)
- family hx
- ethnicity
- increased cup-to-disc ratio (>.5)
- central corneal thickness
- ocular perfusion pressure
- type 2 diabetes
- myopia
85
goals of POAG therapy
- treat all pts with elevated IOP & confirmed disc changes/field defects
- want to lower IOP >25% below pretreatment IOP
86
Prostaglandin analogs (for glaucoma)
- all reduce IOP 25-33%
- bimatoprost (worst side effects, best efficacy), latanoprost (cheap)
- AEs: hyperemia, hypertrichosis, infection, headaches
- CIs: ocular inflammation/infection (keratitis, iritis, uveitis, macular edema)
87
Beta blockers (for glaucoma)
-decrease aqueous humor production --> reduce IOP 20-25%
-betaxolol (highly selective for the eye), carteolol, levobunolol, metipranolol & timolol (QD med)
AEs: irritation, cardiac, pulmonary & CNS, tachyphylaxis
CIs: sinus bradycardia, HF, heart block (absolute), pulmonary disease (ralative)
88
A2- adrenergic agnostic
- use in combo, 20-25% IOP reduction
- AEs: hyperemia, irritation, allerdic reactions, drowsiness, xerostomia & tachyphylaxis
- -> Brimonidine-Timolol combo- lantoprost sill cheaper
89
Carbonic Anhydrase Inhibitors
- use as add on drug
- reduce IOP 15-20% (20-30% oral)
- acetazolamide, brinzolamide, dorzolamide, methazolamide,
- -> Dorzolamide/timolol: bimatoprost still more poppin tho
90
progression of glaucoma risk factors
- IOP- getting higher
- older age
- disc hemorrhage
- larger cup to disc ratio
- thinner central cornea
- lower ocular perfusion pressure
- poorer adherence to meds!
- progression in fellow eye
91
ocular hypertension- who should be treated:
- all pts with elevated IOP & confirmed disc changes/field defects
- those with OH & risk factors: ethnicity, family hx, thin central cornea, large cup to disc ration, IOP > 25 mmHg
92
normal tension glaucoma: who should be treated
- all pts with elevated IOP & confirmed disc changes/field defects
- those with OH & risk factors: ethnicity, family hx, thin central cornea, large cup to disc ration, IOP > 25 mmHg
- those with NTG & documented progression of visual field loss
93
primary angle-closure glaucoma
- usually due to lens contacting iris at pupillary margin
1) normal/high IOP, no/subacute attacks --> most cases have no issues
2) normal/high IOP with infrequent AACC --> medical emergency! (wild IOP #s, rapid vision loss, unilateral)
94
AACC signs
- can be caused by rapid mydriasis
- halo around light, edematous cornea
- pain, headache, n/v
- emergency!
95
treatment options for AACC - INITIAL
1- IV or PO CAI (acetazolamide)
1- topical beta blocker (timolol OU)
1- topical alpha-agonist (apraclonidine OU)
1- topical pilocarpine OU
96
treatment options for AACC- AFTER 1 HR
-hyperosmotics (PO glycerin or. isosorbide, IV mannitol- in hospital setting)
-repeat doses of BB, AA & pilocarpinre (timolol & apraclonide)
~may add ophthalmic steroid if there is inflammation
97
Chronic PACG
- use opthalmic prostaglandins & BBs
- iridotomy (prophylactic)
- counsel on importance of acute attacks and avoid using OTC drugs that cause pupil dilation
