Lecture 18: Dermatology III Flashcards
Causes of Hair Loss
- Chronic Illnesses
- Dietary Changes or Deficiencies
- Genetics
- Hormonal Changes
- Local Trauma
- Medications
- Physiologic stress
Chronic Illnesses
Autoimmune disorders, eating disorders, endocrine disorders,
hepatic failure, infections, renal failure
Dietary Changes or Deficiencies
Protein restriction/deficiency, rapid weight loss, strict
vegetarian diet, zinc/biotin/iron deficiency
Hormonal Changes
Hyperandrogenic conditions, menopause, post-partum,
pregnancy
Local Trauma
Hair care practices, tinea capitis, trichotillomania
Medications
ACE inhibitors, androgenic medication, anticoagulants,
anticonvulsants, antidepressants, beta blockers, chemotherapeutics, et
Physiologic Stress
Fever, infection, hemorrhage, surgery, trauma
Androgenetic Alopecia (AGA)
Most common form of hair loss • Only form of hair loss approved for self-care therapy - Etiology • Hereditary • Hormonal
Androgenetic Alopecia (AGA) Pathophysiology
Changes in hair follicle cycle
• Shorter time in active growth
• Shorter transitional/resting period before hair sheds
Androgenetic Alopecia (AGA) Clinical Presentation for Males
Gradual onset with progression of patterned hair loss
Frontal hairline
○ Occipital regions
○ Top rear of head (vertex)
Androgenetic Alopecia (AGA) Clinical Presentation for Women
Gradual onset with progression of patterned hair loss
Central portion of scalp
○ Wide midline part on crown with progression
to diffuse thinning over crown
Androgenetic Alopecia (AGA) exclusions
● <18 years of age
● Pregnancy or breastfeeding
● Recent discontinuation of oral contraceptives
● Hair loss in patient with no family history of hair loss
● Hair loss related to history of endocrine dysfunction,
medical treatments, or dietary deficiencies
● Sudden or patchy hair loss
● Evidence of fever or inflammation (typically occurring 3-6
months before hair loss begins)
Androgenetic Alopecia (AGA) exclusions to self-care pt 2
Skin lesions that indicate autoimmune disease or infection
● Scaling, sunburn, or other damage to scalp
● Broken off hair shafts that resemble those cause by fungal
infection or trichotillomania
● Loss of eyebrows or eyelashes
● Changes in nails
● Women with sudden or severe hair loss
● Postpartum women with hair loss
Androgenetic Alopecia (AGA) Non-Pharm Therapy
● Cosmetic ○ Camouflage ○ Surgical transplantation ●Hair care ○ Avoid hairstyles that pull; avoid heat or oily products ● Proposed, but ineffective ○ Electrical stimulation ○ Frequent shampooing ○ Scalp massage ●Unknown efficacy ○ Low-level light therapy
Androgenetic Alopecia (AGA) Pharm-Therapy
Minoxidil
Minoxidil Brand Name
Rogaine
Minoxidil MOA
Increases cutaneous blood flow directly to hair follicles
Minoxidil Indications for Use
Men: baldness at the crown of head
Women: hair thinning at the frontoparietal area
Minoxidil Warnings/ Precautions
Do not use in heart disease unless recommended by primary care
provider
Minoxidil Adverse effects
Local: itching, irritation, dryness, or scaling at the application site
Long-term use: transient hypertrichosis
Systemic: hypotension, tingling/numbness, vision changes - RARE
Minoxidil Drug Interactions
Hair chemicals (colors, perms, relaxants); oral minoxidil; topical corticosteroids, petrolatum, or retinoids
Minoxidil Dosage Forms
○ Hydroalcoholic solution: 2%, 5%
○ Solvent-free foam: 5%
Minoxidil Applications methods
○ Dropper
○ Foam
○ Rub-on
○ Spray
Minoxidil Application
Ensure scalp and hair are clean and dry
▪ Apply and massage 1 mL solution or ½ capful foam to
affected scalp area twice daily (men) or once daily (women)
▪ Wash and dry hands after application
▪ Allow product to dry completely and penetrate the scalp (2-4
hours)
▪ Do not use a hairdryer
▪ May stain clothing/linens
Minoxidil Patient Education/Follow Up
● Increased hair loss may occur within the first few weeks of
use
●Must continue use indefinitely to maintain new hair growth
● Consider discontinuation if hair density does not increase after 4 months of treatment
Wounds Acute
typically caused by trauma and tend to heal within one month
Wounds Chronic
any wound that does not heal properly through the normal
stages of tissue repair (longer than 2-3 weeks)
Abrasions
rubbing or friction that affects the epidermis
● May extend to uppermost portion of dermis
Burns
caused by chemical, electrical, thermal, or ultraviolet radiation
(UVR) exposure
Lacerations
result from a sharp-edged object cutting through the
various skin layers
Punctures
piercing of epidermis by a sharp-pointed object
Risk Factors for Poor Wound Healing
● Bacterial contamination and infection ● Inadequate nutrition ● Medications ○ Chemotherapeutics, systemic steroids ● Poor vascularization → poor oxygenation ○ Congestive heart failure, diabetes, hypotension, peripheral vascular disease, severe anemia ●Unfavorable wound characteristics ○ Foreign bodies, necrotic tissue, scab ● Advanced age ●Obesity
Exclusions to Self-Care - General
● Chronic wounds (> 2-3 weeks)
● Contains foreign matter after irrigation
● Caused by an animal or human bite
● Signs of infection
● Involvement of face, mucous membrane, or genitalia
● Deep wound (extending below dermis)
● Patients with immunocompromising conditions
Exclusions to Self-Care - Burns/Sunburns
● Burns to BSA ≥2%
● Burns involving eyes, ears, face, hands, feet, or perineum
● Chemical, electrical, or inhalation burns
○ Use first-aid measures then seek medical attention
● Older age
● Immunocompromised patients or those with multiple medical
disorders
Non-Pharmacologic Therapy for Wounds
First-aid measures to relieve pain, prevent contamination, and
promote healing
● Wound Irrigation
○ Remove dirt/debris by flushing with normal saline or water
○ Mechanical removal with clean gauze
● Soaking in water
● Covering
○ Nonadherent, hypoallergenic dressing may be applied
○ Create a moist wound environment
● Do NOT pull at or peel off loose or burned skin
Pharmacologic Therapy for Wounds – Systemic Analgesics
● Recommended for short term use
● Preferably an agent with anti-inflammatory properties
● NSAIDs
● Ibuprofen 200-400 mg PO every 4-6 hours as needed
● Naproxen 220 mg PO every 8-12 hours as needed
● Acetaminophen
● 325-1000 mg PO every 4-6 hours as needed
Wounds- Pharmacologic Therapy – Skin Protectants
Protects from mechanical irritation caused by friction and rubbing
• Prevent drying/provide lubrication
- Apply as often as needed
Skin protectants common ingredients
- Allantoin
- Cocoa butter
- Petrolatum
- Shark liver oil
- White petrolatum
Wounds-Pharmacologic Therapy – First-aid antiseptics
Chemical substances applied to intact skin up to edges of damaged skin area
for disinfection purposes
-Apply to intact skin only
First-aid antiseptics common ingredients
- Camphorated phenol
- Ethyl alcohol
- Hydrogen peroxide
- Iodine
- Isopropyl alcohol
- Povidone/iodine
Pharmacologic Therapy – First-aid antibiotics
Help prevent infection • Ingredients • Bacitracin • Neomycin • Hypersensitivity reactions in 3.5-6% of patients • Polymyxin B sulfate
Pharmacologic Therapy – First-aid antibiotics Directions
Use after cleansing wound bed
• Apply 1-3 times daily
General Treatment Approach
● Clean the wound carefully
● Selective use of antiseptics and antibiotics
● Systemic analgesics for pain as needed
● Close/cover the wound with an appropriate dressing
Minor Burns Approach
- Actively cool burns with cool tap water continuously for first 10 minutes
- Cleanse the area with water and a mild soap
- Apply a non-adherent dressing or skin protectant
- If skin is broken, use topical antibiotics to prevent infection
- Systemic analgesics for pain as needed
- Reassess after 24-48 hours
- Inflammatory response to a burn evolves
- Initial appearance may lead to underestimation of actual severity
Follow-up/Monitoring
REFER if infection suspected or wound or burn does not show signs of healing in 7 days
Dermatomycoses
Fungal Skin Infections
One of the most common skin infections – occur in 10-20% of the
population
• “Tinea” refers to dermatophyte infections
Tinea corporis
Body Often involves smooth bare skin ● Begins as small, circular, erythematous, scaly areas that spread peripherally ● May also be referred to as “ringworm” ○ Ring-shaped lesions with clear centers and red, scaly borders ● Self-Care? ○ YES
Tinea pedis
Feet Also known as “athlete’s foot” ● Risk Factors ○ High impact sports with chronic trauma to feet (long distance running) ○ Occlusive footwear ○ Public pools/bathing facilities ○ Warm/humid environment ● Self-Care? ○ YES
Tinea cruris
Groin Also known as “jock itch” ● Occurs more often in men than women ● Occurs on medial upper parts of thighs and pubic area ○ Usually spares the penis and scrotum ● Well-demarcated lesions, slightly elevated and erythematous ● Associated with significant pruritus ● Self-Care? ○ YES
Tinea unguium
Nails Tinea infection of the nails ● Loss of shine, become opaque ● Can progress to thick, rough, yellow, friable ● Self-Care? ○ NO
Tinea capitis
Scalp Fungal infection of the scalp ●Often presents with pruritic scaling areas of hair loss ● Primarily occurs in children ● Self-Care? ○ NO
Dermatomycoses Risk factors
- Diabetes
- Human immunodeficiency virus (HIV)
- Immunosuppressive medication use
- Occlusive clothing/footwear
- Sweating/humidity
Dermatomycoses Exclusions to Self-Care
●Unsuccessful initial treatment or worsening of condition
●Nails or scalp involved
● Face, mucous membranes, or genitalia involved
● Signs of secondary bacterial infection
● Large area, seriously inflamed, or debilitating
● Immunocompromization
Dermatomycoses Clincal Presentation
Often occurs in areas of body where excess moisture accumulates
(feet, groin, scalp, under the arms)
●Usually localized to a single region of the body, but can spread
● Signs/symptoms
○ Soggy malodorous thickened skin, acute vesicular rash, or fine
scaling
○ Varying degrees of inflammation
○ Itching and pain
Dermatomycoses Non-Pharmacologic Therapy
●Use a separate towel to dry the affected area
● Avoid sharing personal articles
● Launder contaminated towels and clothing in hot water and
dry them on a hot dryer setting
● Cleanse skin daily with soap and water
● Avoid contact with infected fomites or persons with a fungal
infection
●Do not wear clothing/shoes that cause the skin to stay wet
Dermatomycoses: Pharmacologic Therapy: Topical Antifungals
● Apply once or twice daily (depends on formulation)
● Length of treatment depends on formulation and infection
Pharmacologic Therapy: Topical Antifungals
Various treatment options available OTC:
● Clotrimazole 1% ● Miconazole nitrate 2% ● Terbinafine hydrochloride 1% ● Butenafine hydrochloride 1% ● Tolnaftate 1% ● Also approved to PREVENT tinea infection
Dermatomycoses: Pharmacologic Therapy: Formulation Considerations
Creams/solutions
● Most efficient/effective for delivery of active ingredient to epidermis
● Sprays/powders
● Less effective – not rubbed into the skin
● Used as adjuncts or prophylactic agents
Dermatomycoses: Follow Up
There should be some relief of itching, scaling, and/or
inflammation within 1 week
● If improvement seen, continue treatment for 1-3
weeks depending on type of tinea infection and
medication being used
● REFER if no improvement or condition has worsened
Warts Pathophysiology
● Common benign skin disorder caused by human papillomaviruses
(HPV)
● Transmitted via person-to-person contact, autoinoculation, or fomites
on contaminated surfaces
● May affect any skin and mucous membranes
● 1-24 month incubation period following inoculation
Warts Risk factors
- Biting fingernails
- Depressed immune system
- Going barefoot, especially on wet surfaces (public pools, showers)
- Meat handling occupation
- Previous or existing warts
Warts Clinical Presentation
• Can appear on any skin • Hands and feet are most common • Raised lesions, typically 1-3 mm • May present as slight scaly, rough papules or nodules or even cauliflower-like in appearance • May have black spots • May appear in groups or alone • Begin as minute skin-colored lesions that enlarge over time • May be painful if pressure is applied
Warts Exclusions to self-care
● <4 years of age
● Pregnancy or breastfeeding
● Chronic, debilitating conditions that affect sensitivity or circulation of
the hands or feet
○ Diabetes, peripheral vascular disease (PVD), neuropathy
● Immunocompromization
● Large or multiple warts located on one area of body
● Painful plantar warts
● Warts located on the face, breasts, armpits, fingernails, toenails,
anus, genitalia, or mucous membranes
Warts Non-Pharm therapy
Focus on prevention of spread of HPV
○ Autoinoculation
■ Avoid cutting, shaving, or picking warts
■ Keep feet clean and dry
■ Use designated towel to dry warts
■ Wash hands before/after treating or touching warts
○ Transmission to others
■ Avoid sharing towels, razors, socks, shoes, etc.
■ Do not walk barefoot
■ Keep wart covered
• Duct tape
OTC treatment options cannot treat/cure HPV, they only remove the wart
Warts Pharm-therapy
Salicylic Acid
Salicylic Acid Brand Names
Compound W®, Dr. Scholl’s Clear Away®, TransVer-Sal®
Salicylic Acid MOA
May induce an immune response secondary to
mild irritation
Salicylic Acid Indications
Common and plantar warts
Salicylic Acid Adverse Effects
Skin irritation
Salicylic Acid Dosage Forms
- Liquid (colloidion vehicle) – 17%
- Patches (karaya gum glycol plaster vehicle) – 15%
- Pads/strips (plaster vehicle) – 12 - 40%
Salicylic Acid - Keratolytic Agent
slowly destroys virus-infected cells
Salicylic Acid Note
Should see some improvement in 1-2 weeks
• Can use up to 12 weeks of treatment
• REFER if not cleared after 12 weeks
Salicylic Acid Application Collodion Vehicle Liquid
Wash/soak and dry affected area
○ Apply one drop at a time to cover wart
○ Allow solution to dry completely and cover with occlusive tape
○ Repeat 1-2 times daily
Salicylic Acid Application Karaya gum glycol vehicle Patch
Wash/soak and dry affected area
○ Use file to gently remove keratinous surface and apply drop of warm
water to wart
○ Apply patch at bedtime and remove after at least 8 hours
○ Repeat daily
Salicylic Acid Application Plasters/Pads/Strips
Wash/soak and dry affected area
○ Apply appropriate size to wart and remove after 48 hours
Pharmacologic Therapy: Cryotherapy
●Destroy warts by freezing the wart tissue
● Blister will form under the wart
● Warts may fall off within 10 days
● If not cleared after 12 weeks or 4 treatments, REFER
Cryotherapy Application
- Wash hands before/after use
- Soak wart in warm water for 5 minutes
- Use a file or pumice stone to remove wart’s keratinous surface
- Apply applicator to center of wart
- Keep in contact with skin for no more than 40 seconds
- Discard applicator after use
- Repeat use after 14 days if needed
