L3 Dermatitis and other Itchy disorders Flashcards
Atopic Eczema/dermatitis
-Common allergic skin disease that usually starts in childhood
-Majority of cases have an onset before age 5
-Primary symptom is ITCHY
-Chronic, non-contagious, inflammatory skin disease
-Disruption of skin barrier: Filaggrin(FLG) gene mutation and allergens or other triggers
-Type 1 hypersensitivity (IgE)
-Viscous cycle of pruritis and disruption of the skin surface “the itch that rashes”
-genetic defects/family history 70%
-Environment: foods, dust mites, molds, pollens, animal dander, season(winter/low humidity) clothing, emotional stress
ATOPIC triad:
-atopic dermatitis(1st), allergic rhinitis(hay fever), and asthma(3rd)
-this is considered atopy meaning more easily allergic to common allergens
- ill defined rash, erthematous, scaling patches to edematous papules and vessicles
- Cheeks, scalp and extensor surfaces common in INFANTS
- Flexural surfaces, hand/foot (older children/adults)
Treatment:
-avoid exacerbating factors (allergens/irritants)
-Hydrate the skin and restore skin barrier function
-topical/oral steroids
-calcineuron inhibitors
-+/- antihistimines/antibiotics
-avoid rubbing/scratching
-treat stress and anxiety
-hydrate the skin with emollients: gold standard= petroleum (vaseline)
-apply 2x daily and immediately after bathing
-topical corticosteroids:
mild disease: low potentcy applied 1-2x daily for 2-4 weeks
Moderate disease: medium to high potency
Acute flares: intermediate to super high potency preparations may be used for up to 2 weeks then replaced with a lower potency until lesions resolve
-be careful about using steroids on thin areas of the skin
What are essential features and important features when diagnosing atopic dermatitis?
Essential: (required) -pruritis -eczema (acute, subacute, chronic) -typical morphology and age specific patterns (area) -chronic or relapsing history Important features: (observed in majority of cases; adds support to diagnosis) - early age of onset -atopy: personal/family history; IgE -xerosis (dry skin)
What are some complication with atopic eczema/dermatitis
- excoriations (scratches from being very itchy)
- Lichenification (thickened, dry, irritated skin due to chronic scratching; skin lines are accentuated)
- fissures (palms, fingers, soles)
- Skin lines are accentuated
- Secondary cellulitis: skin is often colonized with Staph. aureus
- eczema herpeticum: disseminated viral infection, typically primary infection of HSV1 (herpes simplex 1); treat promptly with antiviral (acyclovir or valacyclovir)
What is pityriasis alba?
Inflammation of the skin then it will go away leaving that area of the skin hypopigmented. Pigment will return. Recommend staying out of the sun
What is the difference between group 1 and group 7 corticosteroid classification?
Group 1 is super hight potency
Group 7 is least potent such as OTC
Different regions can have differences in percutaneous absorption. What ares have high absorption and where you should use caution?
- Forhead 6%
- Mandible 13%
- Genitalia 42%
What are some adverse effects of topical corticosteroids?
- skin atrophy
- acneiform or rosacea-like eruptions
- striae- thick red lines
- bruising
- telangiectasias
- hypertrichosis: hair growth
What type of treatment should you use for thinner areas?
Topical calcineurin inhibitors
- pimecrolimus (elidel) cream and Tacrolimus (protopic) ointment
- steroid-sparing, anti-inflammatory agents
- efficacious for acute flares and maintenance therapy in adults and children 2 years and older
- 0.1% formulation for adults
- 0.03% formulation for patients 2-15 years old
- MOA- inhibits calcineurin-dependent T cell activation, impeding production of pro-inflammatory cytokines
- Apply 2x daily for mild to moderate eczema of the face, eyelids, neck and skin folds
- Maintenance- apply 2-3 per week to recurrent sites of involvment to reduce relaple
- Side effects: burning, stinging and pruritis (most common during 1st week)
What are other pharmacologic treatments for acute eczema/dermatitis other than corticosteroids and topical calcineurin inhibitors?
- Oral antihistimines PRN pruritis (to break the itch-scratch-itch cycle)
- Antibiotics if secondary infection
- Oral steroids reserved for severe cases
Lichen simplex chronicus
- aka “neurodermatitis”
- Affects F>M age 30-50 years old
- Secondary skin condition: lichenified plaque caused by excessive scratching or rubbing
- exaggerated skin markings, dry, leathery appearance, pigmentation
- common areas: scalp, back of neck, wrists, forearms, lower legs, and genitals
Causes include:
- atopic dermatitis
- contact dermatitis
- psoriasis
- lichen planus
- insect bite
- neuropathy DM
- anxiety/stress
Treatment
- High potency topical steroids
- Moisturizers
- Antidepressants: SSRIs- paroxetine(paxil), sertraline(zoloft) or tricyclic antidepressants
- 1st generation antihistime, hydroxyzine(vistaril), or tricyclic antidepressant (doxepin) can be used for nocturnal pruritis.
Dyshidrotic Eczema
- aka dyshidrosis or pompholyx
- NOT a problem with the sweat glands
- deep seated vesicles with “tapioca-like” appearance
- vesicles coalesce and repture
- location: hands (80%), sides of fingers, palms and soles
- INTENSELY PRURITIC
- Emotional stress & hot weather precipitating factors, also found in those with NICKEL allergy
- Episodes usually weeks to months apart, spontaneous remission after 2-3 weeks
- management- REASSURANCE, wet dressings (burrows soaks, aka domeboro solution), TOPICAL STEROIDS
Keratosis Pilaris
- Disorder of keratinization
- Forms horny plugs in hair follicles
- Rough, raised papules (flesh, red or brownish)
- Usually worse in winter months
- outer upper arms, thighs, cheeks, upper back
- improves with age
- can try creams,exfoliating scrubs, topical retinoids (avoid in children), urea, salicylic acid, alpha-hydroxy acids
- these help with skin turnover but there’s not much we can do
Contact Dermatitis
-Allergic Contact dermatitis- a delayed-type hypersensitivity reaction (can be up to a couple days later) ex. poison ivy, nickel, etc
-Irritant contact dermatitis- 80% of all dermatitis
household duties: hands in water, detergents, solvents, etc.
-The most common occupational skin disease
-healthcare workers, chemical industry workers, hairdressers, construction workers, etc.
What are some differences in presentation of allergic contact dermatitis and irritant contact dermatitis?
Allergic contact dermatitis:
- dominant symptom is ITCH
- localized to skin areas that came in contact with the allergen
- hands, face and eyelids are common
- erythematous, papular dermatitis with indistinct margin; often blisters and edema
- can take 1-2days to appear
Irritant contact dermatitis
- Burning, stinging pain
- hands are most common
- erythema, chapped skin, dryness and fissuring
- more immediate onset (minutes to hours)
Examples of allergic contact dermatitis
Poison ivy, oak, and sumac
-Urushiol oil
- nickel
- rubber/latex
- preservatives/cosmetics
- neomycin- in topical cream/ointments
- shampoo, lotion, sunscreen allergy
