Exam 4 Flashcards
Xerosis
Dry skin
-Skin functions to protect the body and control moisture loss
Ability to protect depends on:
-Age
-Immunologic status
-Underlying health conditions
Xerosis etiology
External/environmental factors
-Dry air and wind
-Long and hot showers
-Prolonged use of detergents and soaps
Internal factors
-
-Malnutrition
-Hypothyroidism
Presenting symptoms for Xerosis
-Roughness
-Scaling
-Cracking
-Fissuring
-Erythema
-Pruritis
Do not self treat for Xerosis when
-Severe dry skin
-Large body surface area
-Intense itching
-Infected skin
Goals of therapy Xerosis
-Improve skin hydration and minimize water loss
-Restore skin’s barrier function
-Educate patient: prevention and treatment
General treatment approach:
-Modify environmental factors and bathing habits
-Bath oils and moisturizers
-Topical hydrocortisone - Only if Puritis and erythema
Complementary and non otc options for Xerosis
-Moisturizers
-Oil based emollients
-Apply
*Within 3 minutes of bath/shower
-Frequent reapplication during daytime
-Humidify air
-Drink water
OTC:
-Moisturizers
-Cleansers
-Hydrocortisone ointment/cream
*Follow up after 1 week if not resolved
Atopic dermatitis (eczema)
An inflammatory condition of the epidermis and dermis characterized by episodic flares and periods of remission
*caused by genes/mutations
Presenting Sx:
-Redness and scaling
-Often cheeks initially
-Crusts, pustules
-Remissions and flares
-Lichenification
-Secondary infections
Don’t self treat for eczema when
-Severe dry skin
-Large body surface area
-Intense itching
-Infected skin
-Less than 1 year old
-Face or intertriginous areas
Goals of therapy Eczema
-Stop the itch scratch cycle
-Maintain skin hydration and barrier function
-Avoid or minimize triggers
-Prevent secondary Infections
General treatment approach:
-Manage symptoms
-Nonpharmacologic first
-Hydration
-Skin barrier support/moisture
-Topical hydrocortisone for itch/inflammation
Complementary options for eczema
-Trigger avoidance
-Oral and skin hydration
-Trim fingernails short, keep clean
-Wear cotton gloves at night
-Wet wrap compresses
-Moisturizers (avoid lotions, use creams/ointments, coconut oil)
Moderate to severe eczema: diluted bleach baths
-2x daily; max 3x per week
-1/2 cup of 5% household bleach in 40 gallons/full bathtub; soak for 10 minutes
-Rinse with fresh water, and apply moisturizer within 3 minutes
OTC treatment options for eczema
-Bath oils (FF)
-Cleansers (FF)
-Moisturizers (FF)
-Hydrocortisone ointment/cream
*FF = Fragrance Free
Follow up if symptoms worsen or not improved after 1 week
-Pruritis not improved after 1 week topical hydrocortisone
Bath oils and skin cleansers
Bath oils
-Ingredients: mineral or vegetable oil + surfactant
-Mechanism: lubricate dry skin
-Considerations: safety hazard
Cleansers:
-Ingredients: glycerin, castor oil
-Mechanism: reduce skin drying
-Considerations: little evidence
Moisturizers
Emollients: Glycol, glyceryl stearate
MOA - Fill spaces between desquamating skin scales with
Occlusives: Petrolatum, mineral oil, dimethicone
MOA - Prevent evaporation of water from the skin
Humectant: Gylcerol, lactic acid, urea
MOA - Attract and hold water in the skin
How to use moisturizers
- Liberal and frequent application
-At least twice daily and up to 4 times daily - Pat dry + must apply within 3 minutes of toweling off
Considerations:
1. Vehicle choice
b. Creams
C. Ointments
Hydrocortisone 0.5% or 0.1%
MOA: suppresses cytokines involved in inflammation and itching
-Pharmacokinetics
Onset is very fast and duration is very long
SE: skin atrophy/thinning
Avoid: weeping lesions, cracked/open or infected skin
Ointment preferred to cream
Hydrocortisone dosing
- Apply before moisturizers
- Twice daily during flares only
- Fingertip rule
- Use sparingly
- Maximum 7 days
Warts or “verrucae”
-Affect 7-10% of the pop
-More common in children/teens
*Children age 12-16
-Caused by HPV infection
-3 criteria (presence of HPV, opening in skin, susceptible immune system)
-Resolve on their own
Risk factors for Warts
-History of warts
-Immunocompromised
-Chronic skin condition
-Walking barefoot
-Use of public bathing areas/swimming pools
-Nail biting
-Working at meat handling facility
Clinical presentation of warts
Common warts
-Skin colored or brown lesions
-Rough, cauliflower texture
-Usually painless
Plantar warts
-Skin colored lesions appearing on the feet
-Extend deeper into skin
-May be painful
-Not a special kind of wart
(named after plantar –> bottom of the foot)
Do not self treat warts when
Age under 3 (SA)
Age under 4 for freezing
-Unable to follow instructions
-Pregnancy and lactation
-Immunocompromised
-Chronic conditions
-Large/and or multiple concentrated warts
-Bleeding, painful or discolored warts
-Warts found on sensitive areas of the body
-No/little improvement after 12 weeks of self-treatment
Complementary options for warts
Wait and see approach
-Main focus is preventing the spread of HPV
OTC options for warts
Salicylic Acid
Cryotherapy
Occlusion therapy (duct tape)
Follow up:
-Expect some improvement in 1-2 weeks
-May self treat for a max of 12 weeks
Salicylic acid
MOA: keratolytic agent
Indication: common or plantar warts
Pharmacodynamics:
quick onset and clearance within 6-12 weeks
Efficacy: Better than placebo
SE: skin irritation, potential systemic toxicity
DI: none
Avoid: under 3 years old, allergy, immunosuppressed, pregnancy/lactation
Dosing:
-Apply
-Every 48 hours
Cryotherapy
MOA: destroys warts by freezing them off with nitrous oxide or a mix of dimethyl ether and propane
Indication: common or plantar warts
Pharmacodynamics: Onset is as soon as blister forms, ~10 days wart falls off
Efficacy:
-No more effective than salicylic acid or placebo
SE:
-Blistering
-Pain/tenderness
-Scarring or burns
-Hypo or hyperpigmentation
-Tendon or nerve damage
Avoid: < 4 yr old
Dosing: can repeat after 2 weeks
Cryotherapy cautions
-Treat only one side of the finger/toe at a time
-Treat one wart at a time
-Apply directly to wart only
-Protect eyes during use
-Do not ingest or inhale chemicals
-Keep away from children
-Avoid areas with thin skin
-Avoid irritated or infected skin
-Do not use for moles or birthmarks
-Avoid in pregnancy or lactation
Occlusion therapy
MOA: unclear - local irritation causing stimulation of immune response
Indication: warts at any location
Pharmacodynamics: Duration up to two months or until resolved
SE:
-Left over sticky residue
-Adhesive rash
DI: none
Avoid: if sensitive to duct tape
*Use silver duct tape only
*Apply and leave on wart for 6 days
Corns and calluses
-Affect 5% of the population
-caused by increased friction and pressure
*leads to increased growth of the basal cell skin layer
*As cells reach the outer surface a thicker layer of skin is produced
corns
Small, raised lesion with a central core and defined border appearing on bony joints
Hard corns = found on the tops of toes near joints
Soft corns = found between toes
Calluses
-Thickening of skin with an indefinite border
-Found at the bottom/sides of the foot
-Usually somewhat raised and dull yellow color
Do not self treat corns and calluses
-Age < 3 years (if using SA)
-Chronic conditions
-History of rheumatoid arthritis
-Fault in body weight distribution
-Bleeding or oozing purulent material
-Painful or extensive in nature
-Self care is ineffective
Complementary options for corns and calluses
-Soak affected area in warm water for at least 5 minutes daily and then remove dead tissue
-Circular foam cushioning pads
-Wear appropriately fitted shoes
-Arch supports
-Surgical correction
-Avoid trimming tissue
OTC treatment options for corns and calluses
Soft corns: Salicylic acid in collodion vehicle 1-2x/day for 3-6 days
Hard corns/calluses: Salicylic acid in collodion vehicle 1-2x/day OR plaster/pad every 48 hours for 14 days
Follow up recommendations:
-May take up to several days to months to disappear
-May self treat for up to
Minor Burns
80% of minor burns occur in the home
*Most frequently in children < 5 y.o and adults > 64 y.o
Etiology (based on how the burns occur)
-Thermal (inhalation of hot vapors, contact with heat)
-Electrical
-Chemical (acidic, or alkaline substances)
-Sunburns
Pathophysiology for Minor Burns
Superficial - 1st degree
Superficial partial thickness - 2nd degree
Deep Partial thickness
Full thickness - 3rd degree
Minor burns nonpharmacological treatment
Cool moisture (no ice)
Cleansing
Protect the area - non adherent dressing
*Avoid further injury, reduces pain by sealing off nerve exposure to the air
-Plastic/saran wrap
-Sterile gauze
-Tegaderm
-Duoderm
Minor burns OTC treatment
OTC oral analgesics - APAP, ibuprofen, naproxen, etc.
Topical anesthetics
Ointments, creams, lotions/solutions, aerosols
Topical Hydrocortisone
Antimicrobials
Vitamins
Counterirritants
Aloe Vera
Topical anesthetics/OTC strengths for Minor Burns
Benzocaine 5-20%
Lidocaine 0.5-4%
Pramoxine 0.5-1%
Dibucaine 0.25-1%
Tetracaine 1-2%
Butamben 1%
Topical Anesthetics
-Inhibit transmission of pain signals from reaching the brain
-Application
*Apply to small areas no more than x 3-4 per day
*Use higher concentrations on intact skin only
Duration: 15-45 min
Caution: if someone has hypersensitivity
Ointments, creams, lotions/solutions, aerosols
Ointments - Minor burns with intact skin
Creams - Better for minorly broken skin because they are thinner
Lotions and solutions - Even thinner than creams so good for minorly broken skin and large burn areas (powdery = avoid (calamine))
Aerosols - Large painful burn areas
Topical Hydrocortisone for minor burns
Not FDA approved for treatment of burns
Antimicrobials for minor burns
Infection prevention
-Always used for major burns (usually Rx)
-OTC antibiotic creams, ointments, solutions, not especially beneficial for minor burns, especially if skin is intact
Vitamins for minor burns
No real benefit if good dietary intake
Significant deficiencies in vitamins A,B, and C may impair/retard wound healing
Counterirritants and Aloe Vera for minor burns
Not FDA-recommended (counterirritants)
Aloe Vera (no scientific proof)
Minor burns when to refer
-Moderate to severe burns
-Deep or full thickness
- > 2% BSA involvement
-Involvement of eyes, ears, face, hands, feet, joints, genitals, or perineum
-Chemical, electrical or inhalation burns
-Elderly, diabetic, immunocompromised, etc. patients
-Burns don’t heal after 5+ days
-Signs/symptoms of an infection
Allergic contact dermatitis
-Poison ivy, oak, sumac
Etiology
-Leaves of 3 let it be
All contain urushiol which binds to skin proteins
Pathophysiology for Allergic Contact dermatitis
Type IV delayed hypersensitivity reaction to urushiol
Usually occurs within24-48 hours after exposure
Rashes last from 1 to 4 weeks
Signs and symptoms of Allergic contact dermatitis
-Erythematous, intensely itchy patches on the affected exposure areas of the body
-Formation of vesicles and bullae (blisters)
-Scratching can lead to urushiol spread, open the sores which can lead to infection
Allergic contact dermatitis preventative
-Avoid plant
-Ivy Block: organic clay lotion that blocks urushiol
Directions –> apply 15 minutes before exposure and repeat every 4 hours as needed
-Protective clothing
Allergic contact dermatitis non OTC options
-Wash with mild soap and cool water immediately (within 5-10 minutes)
-No scrubbing
-Trim fingernails
Wash exposed clothing, tools, and pets
Allergic contact dermatitis OTC options
Zanfel
Hydrocortisone
Topical anesthetics
Astringents
Zanfel Allergic contact dermatitis OTC
-Soap mixture of 2 active ingredients
-Binds with urushiol to prevent binding to skin and rash formation
-No known SE to date
-Small studies have shown some potential benefit up to 6 days after exposure
Hydrocortisone cream/ointment for Allergic Contact dermatitis
-Considered 1st line treatment to relieve pruritis & inflammation
-0.5 and 1%
*APPLY TO AFFECTED AREAS UP TO 3-4 TIMES A DAY FOR NO MORE THAN 7 DAYS
-Keep out of eyes and eyelids
SE: Local skin atrophy, aggravation of current skin infections, no systemic SE unless occlusive dressing is used, heat is applied
Topical anesthetics Allergic Contact dermatitis
-Decrease itching and protect area from further injury
-Generally considered 2nd line therapy
- 3 to 4 x daily
- Avoid if you’re hypersensitive
Astringents Allergic Contact dermatitis
Aluminum acetate, zinc oxide, zinc acetate, sodium bicarbonate, calamine, witch hazel
-Promote drying of wet oozing dermatitis, and reduce inflammation
-Used as soaks or compresses applied several times a day
-Aid in cleansing and removing crusting or debris
SE: Products can become caked on skin and excessive drying of skin
When to refer Allergic Contact dermatitis
-Symptoms become worse
-Rash becomes more widespread
-Rash covers large areas of the face or other sensitive areas
-Signs or symptoms of infection
-No resolution after 3+ weeks
Diaper dermatitis (diaper rash)
Etiology
-Occlusion
-Moisture
-Bacteria
-Alkaline pH
-Mechanical chafing and friction
-Proteolytic enzymes and bile salts
Signs and symptoms:
-Skin atrophy
-Red to bright red, wet looking patches or lesions
-Severe: maceration, papule formation, oozing, erosion, and ulceration of the skin
Diaper dermatitis non OTC options
Preventative:
-Increased diaper changes
-Not wiping infant with any part of dirty diaper
-Use chemically bland baby wipes and soaps
-Wash cloth diapers in hypoallergenic detergent
-Dry thoroughly after changing/bathing
Diaper dermatitis OTC treatments
Skin Protectants
Topical Corticosteroids
Antifungal agents - Suspected Candidal infection
Topical Maalox
Skin protectants Diaper dermatitis
MOA: provide a physical barrier to protect skin and provide lubrication to reduce friction
Administration:
-Apply sufficient amount to cover entire affected area(s)
-Wash/wipe products off at every diaper change
Time to effect: relief with each application
Duration: while its on the skin
Adverse reactions: Irrigation from inactive ingredients
Common ingredients: Zinc oxide, petrolatum & white petrolatum, Talc (avoid), Topical Cornstarch (avoid)
Antifungal agents Diaper dermatitis
-Suspected Candidal infection
-Only recommended under physician supervision
Well define beefy red plaques
Scaly, slightly raised borders
-Lasts > 2 days despite appropriate treatments(s)
Topical corticosteroids Diaper dermatitis
Only recommended under physician supervision
Anti-inflammatory and anti-pruritic
Administration: use low potency (0.5%) hydrocortisone for a short period of time and on a small surface area
Topical Maalox Diaper dermatitis
-Recommended by some physicians despite no scientific evidence of efficacy
-Aluminum component may act as an astringent
-Acids in stool/urine may be “neutralized”
-Concern for aluminum and magnesium absorption in infants
Agents to avoid with Diaper dermatitis
Boric acid and baking soda
-Toxicity from absorption
-Skin irritants
External analgesics
-Alter sensory perception
-Might retard healing and/or irritate skin
-Methemoglobinemia concern
When to refer Diaper dermatitis
-No improvement after 5-7 days of treatment
-Fever, nausea, vomiting, diarrhea,
-Suspected Candida infection
-Affected skin ruptures or pus forms
-Pain on urination or defecation
-Incessant crying
-Concurrent dermatitis on other body parts
-Recurrent rash
Bugs and Bites
- Mosquito: Welt, pruritis
- Flea: reddened, pruritic area around puncture; usually grouped bites
- Chigger: intensely pruritic
- Deer tick & bite; wood or dog tick
- Bedbugs
- Spiders
Do not self treat bug bites when
-History of hypersensitivity to insect bites or symptoms distant from area of bite
-Younger than 2 years of age
-Infected bite area
-DEER tick bite (possible LymE disease)
-Brown recluse or northern black widow spider bite
Goals of therapy bites
-Prevent bites
-Relieve symptoms
-Prevent secondary bacterial infections
Preventions of bites
-Cover skin with clothing
-Avoid infested areas
-Remove standing water around home
-Limit time outside at dawn/dusk
-Window screens
-Pet “prevention”
-Avoid wearing scents/perfumes
Non-OTC options for bites
-Ice pack (10 min at a time)
-Avoid scratching
-Comfortable clothing
-Nail polish over chigger location (cut off air flow)
-Tick removal
-Skin cleansing
Tick removal
- Use clean, fine-tipped tweezers to grasp tick as close to the skin’s surface as possible
- Pull upward with steady, even pressure. Don’t twist or jerk the tick
- After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol or soap and water
- Never crush a tick with your fingers
How to dispose of a tick
Put it in alcohol
Placing it in a sealed bag/container
Wrapping it tightly in tape
Flushing it down the toilet
OTC options
Insect repellents
-Pre treat clothing with permethrin
Skin-safe repellents
Treatments:
External analgesics
-Local anesthetics
-Counterirritants
Topical hydrocortisone (doesn’t work quickly)
Skin protectants
Follow up recommendations:
-Symptoms of infection develop around bite location
-Symptoms not resolved after 7 days
-Lyme disease “bullseye”
DEET
*May block insect’s sensors or serve as olfactory repellant
-Apply as needed
-Regulated by the EPA (so not Nonrx drugs)
-Works for MOSQUITOES, BLACKFLIES, MIDGES, MITES, TICKS, CHIGGERS
Safe to use on skin, fabrics (nylon, natural fibers)
Less safe to use on rayon, spandex, polyester, paints, vinyl products
DEET efficacy and toxicity
Duration is 6-8 hours (25% DEET)
Toxicity:
Rare: < 50 case reported since 1960
Local reactions: eyes, skin
Systemic reaction: GI, CNS, anaphylatic
DEET cautions
-Avoid if history of sensitivity
-Avoid direct eye, nose or hand application
-Stop if dermatitis occurs
*Safe in pregnancy and use sparingly
-Avoid unintended removal
Children: minimal use
6 months to 2 yrs: 1 application/day
2 to 12 yrs: 3 applications/day
Max of 10% or less (efficacy of 2-3 hrs per application)
Picardin
Can use on children older than 2 months
-Odorless
-Will not damage plastic or fabric
-Most common repellent in Australia & Europe
Picardin efficacy and toxicity
Concentrations up to 20% = effective 8-10 hrs
Effective against Biting flies , Mosquitoes, Ticks
MOA: vapor barrier to prevent arthropods from biting
-Nongreasy, nonsticky
-Less skin irritation
-No significant toxicity in children or adults when used as recommended
-Safe in pregnancy
Permethrin
MOA: contact repellant
Used for Ticks, Fleas, Blackflies
Remains on clothing after washing
*Use only on clothing not on skin
Permethrin efficacy and toxicity
Compared to DEET:
More effective against ticks
Less effective against mosquitoes
*No signs of significant toxicity
Cautions:
-Avoid eye and nose contact
-Wash hands after use
DI: Don’t use in combo with DEET
