Exam 1: eyes & skin Flashcards
exacerbating factors for atopic dermatitis (eczema)
stress, anxiety, heat, low humidity, contact allergens
mild/moderate tx for atopic dermatitis
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
Severe disease tx for atopic dermatitis
1- soak & smear then apply high potency steroid
2- wet wraps
Drugs: Dupilumab, cyclosporine, methotrexate, Azathioprine, MMF mycophenolate mofetil
characteristics of allergic contact dermatitis
erythematous, indurated, scaly plaques
-can be caused by latex, poison ivy, poison sumac or oak, metals, topical antibiotics,
Treatment of allergic contact dermatitis
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
when do you use topical calcineurin inhibitors in allergic contact dermatitis?
for chronic, localized ACD or ACD involving face or intertriginous areas (does NOT work for urushiol rashes)
when are systemic corticosteroids used in allergic contact dermatitis?
for pts with ACD >20% of BSA or for acute ACD of face, feet, hands or genitalia
what are some drying and soothing agents that are used in allergic contact dermatitis?
- drying: aluminum acetate soaks
- soothing: oatmeal baths, calamine lotion
what is toxicodendron dermatitis caused by?
-poison ivy, oak, sumac = redness, itching, swelling & blisters (URUSHIOL)
How to treat toxicodendron dermatitis:
-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
What is seborrheic dermatitis caused by?
- inflammatory reaction to Malassezia (yeast)
- incidence: in infants 2weeks-12 months
Management of seborrheic dermatitis
- 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
what is cradle cap and how do you treat it?
- 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
What are causes/signs of bacterial conjunctivitis?
(s aureus, s pneumoniae, h influenzae & m catarrhalis)
-morning crusting–> thick “pus”, yellow, white or green
What are the treatment for bacterial conjunctivitis?**
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%)
New born ocular infections: Neisseria gonorrhoeae
-purulent conjunctivitis, profuse exudate, swelling of eyelid
SYSTEMIC tx: single dose IV or IM ceftriaxone
Newborn ocular infections: Chlamydia trachomatis
SYSTEMIC tx: PO erythromycin 50mg/kg/day in 4 divided doses x 14 days or azithromycin 20mg/kg/day x 3 days
Viral conjunctivitis (pink eye) signs& symptoms
- fever, pharyngitis, URI
- burning, sandy, gritty feeling
- injection, watery or mumcoserous discharge
Viral conjunctivitis (pink eye) treatment**
- Naphazoline/Pheniramine 1-2 gtt qid
- azelastine (optivar) 1 gtt bid
- ketotifen (zaditor). 1 gtt bid
- olopatadine (patanol)
allergic conjunctivitis signs
-intense itching, hyperemia, tearing, chemises & eyelid edema
allergic conjunctivitis treatment
(same as pink eye)
- na/ph
- AKO
toxic conjunctivitis signs & tx
- direct damage to the ocular tissues : redness, edema, mucus discharge, swollen/thickened eyelids
- treat with: loteprednol
treatment for fleas
-ice pack, calamine, oral antihistamines & topical corticosteroids
treatment of bedbugs
- low or medium potency topical corticosteroid
- systemic antihistamine
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)
treatment of pubic lice
- topical permethrin 1% or pyrethrins + piperonyl butoxide (retreat 9-10 days after)
- treat sexual partner as well
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
classical scabies treatment*
- permethrin 5% cream (apply 1-2 weeks later)
alts: ivermectin 200 mcg/kg x1 (repeat 14 days later), crotamiton 10% cream
crusted/norweigian scabies treatment*
-permethrin 5% cream + oral ivermectin
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
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
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
DEET
- do not use for more than 4-8 hours
- children use concentrations less than 30%
- age indications for use > 2 months old
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)
Exclusions for self care (bites)
- hypersensitivity to bites
- < 2 years old
- suspected spider bite
- signs of secondary infection
Stings (self care things)
- -can use camphor/menthol, pramoxine and benzyl alcohol
- diphenhydramine po 15-50mg may help with itching
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
what is the normal pH of skin?
~4.75-5.7
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
Mild acne treatment
- <10 papules
- topical benzoyl peroxide/retinoid
moderate acne treatment
10-40 papules
-topical bp + oral antibiotic
Severe acne treatment
40+ papules
-oral Isotretinoin
Targeted treatment factors: follicular hyper proliferation
-oral/topical retinoids, azelaic acid, salicylic acid, hormonal therapies
Targeted treatment factors: increased sebum production
-oral retinoids, hormonal therapies, clascoterone cream
Targeted treatment factors: C. acnes proliferation
-benzoyl peroxide, antibiotics, azelaic acid, dapsone topical
Targeted treatment factors: Inflammation
-oral/topical retinoids, oral tetracyclines, azelaic acid, clascoterone cream, dapsone topical
Clascoterone cream
- androgen receptor inhibitor
- store at 2-8C prior to dispensing, discard 180 days after dispensing or 30 days after opening
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
topical retinoids (drugs)
Atralin 0.05%, Adapalene, tazarotene, TWYNEO (tretinoin/bp), trifarotene, Epiduo Forte (adapalene and BP), & veltin (clinda + tretinoin)
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%
Azelaic acid
- helps improve inflammation
- limits melanin production via inhibitory effect on tyrosine
- use once daily - burning, itching, redness, hives, anaphylaxis (v rare)
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)
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
salicylic acid
- desquamating agent: able to penetrate pilosebaceous follicle
- synergistic effect with benzoyl peroxide
alpha hydroxy acids
- remove top layer of dead skin cells, improve post-inflammatory properties
- may work synergistically with retinoids
tea tree oil
melaleuca alternifolia 5%
- toxic if used internally
- slower mechanism of action than BP
Ethinyl Estradiol/Progestin
- suppress androgen production
- used to suppress/inhibit sebum production
- side effects = embolism
- abx (rifampin) decreases COC efficacy
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
examples of isotretinoin
zenatane, amnesteem, claravis, sotret, absocrica, absorical LD
-used for severe and recalitrant acne
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
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
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
acne conglobata
- inflammatory, acne nodules & cysts grow together deep below skin = severe scarring
tx: isotrentinoin, systemic abx, steroids
Acne fulminans
- rare, severe, painful, ulcerating, hemorrhagic, +/- fever or polyarthritis, +/- bone lesions
- can occur spontaneously or after Isotretinoin
tx: stop isotretinoin, systemic oral steriods
Post inflammatory hyperpigmentation (PIH)
- hypermelanosis of skin d/t inflammation commonly from acne, eczema or burn
- grey/blue when in dermis
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*
2nd line meds for PIH
- retinoids (tretinoin, tazarotene or adapalene)
- azelaic acid 20%
- Tri-lima cream
- chemical peels or laser resurfacing
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
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
DRESS caused by allopurinol
risk factors: excessive allopurinol dose, renal dysfunction, thiazide diuretic use, hypertension, Chinese
kidney dosing: 1.5mg x eGFR
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
high class of steriods
- flucinonide 0.05%
- halcinonide 0.1%
- betamethasone diproprionate 0.05%
- triamcinolone cream 0.5%
- desoximetasone 0.05%
medium class of steroids
- triamcinolone cream 0.1%
- mometasone 0.1%
Urticaria
- type 1 hypersensitivity- IgE
- onset within min to hours
- offending agents: penicillins, sulfonamides, aspirin, opiates, latex
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
Fixed drug eruptions
- SAME spot, simple eruptions with pruritic, erythematous, raised lesions that can blister
- offending agents: tetracyclines, barbiturates, sulfonamides, codeine, phenolphthalein, acetaminophen & NSAIDs
SJS/TEN
- severe, life-threatening - painful bulbous formations with fever, headache, respiratory symptoms, mucous membrane involvement
- onset 7-14 days after drug exposure
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
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
hyperpigmentation
- phenytoin: increased melanin
- tetracyclines, silver, mercury, antimalarials: direct deposit
- AMINODARONE: direct deposition and/or dermal lipofucsinosis
photosensitivity
- offending agents: sulfonamides, tetracyclines, amiodarone, coal tar
- prevention! : education and spf 30
1st gen cephalosporins
- cefazolin
- cefalothin
- cefaloridine
- cefadroxil
- cephalexin
- cephradine
2nd gen cephalosporins
- cefoxitin
- cefprozil
- cefotitan
- cefmetazole
- cefaclor
- cefuroxime
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
goals of POAG therapy
- treat all pts with elevated IOP & confirmed disc changes/field defects
- want to lower IOP >25% below pretreatment IOP
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)
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)
A2- adrenergic agnostic
- use in combo, 20-25% IOP reduction
- AEs: hyperemia, irritation, allerdic reactions, drowsiness, xerostomia & tachyphylaxis
- -> Brimonidine-Timolol combo- lantoprost sill cheaper
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
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
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
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
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)
AACC signs
- can be caused by rapid mydriasis
- halo around light, edematous cornea
- pain, headache, n/v
- emergency!
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
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
Chronic PACG
- use opthalmic prostaglandins & BBs
- iridotomy (prophylactic)
- counsel on importance of acute attacks and avoid using OTC drugs that cause pupil dilation
