Lecture 18: Dermatology III Flashcards
1
Q
Causes of Hair Loss
A
- Chronic Illnesses
- Dietary Changes or Deficiencies
- Genetics
- Hormonal Changes
- Local Trauma
- Medications
- Physiologic stress
2
Q
Chronic Illnesses
A
Autoimmune disorders, eating disorders, endocrine disorders,
hepatic failure, infections, renal failure
3
Q
Dietary Changes or Deficiencies
A
Protein restriction/deficiency, rapid weight loss, strict
vegetarian diet, zinc/biotin/iron deficiency
4
Q
Hormonal Changes
A
Hyperandrogenic conditions, menopause, post-partum,
pregnancy
5
Q
Local Trauma
A
Hair care practices, tinea capitis, trichotillomania
6
Q
Medications
A
ACE inhibitors, androgenic medication, anticoagulants,
anticonvulsants, antidepressants, beta blockers, chemotherapeutics, et
7
Q
Physiologic Stress
A
Fever, infection, hemorrhage, surgery, trauma
8
Q
Androgenetic Alopecia (AGA)
A
Most common form of hair loss • Only form of hair loss approved for self-care therapy - Etiology • Hereditary • Hormonal
9
Q
Androgenetic Alopecia (AGA) Pathophysiology
A
Changes in hair follicle cycle
• Shorter time in active growth
• Shorter transitional/resting period before hair sheds
10
Q
Androgenetic Alopecia (AGA) Clinical Presentation for Males
A
Gradual onset with progression of patterned hair loss
Frontal hairline
○ Occipital regions
○ Top rear of head (vertex)
11
Q
Androgenetic Alopecia (AGA) Clinical Presentation for Women
A
Gradual onset with progression of patterned hair loss
Central portion of scalp
○ Wide midline part on crown with progression
to diffuse thinning over crown
12
Q
Androgenetic Alopecia (AGA) exclusions
A
● <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)
13
Q
Androgenetic Alopecia (AGA) exclusions to self-care pt 2
A
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
14
Q
Androgenetic Alopecia (AGA) Non-Pharm Therapy
A
● 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
15
Q
Androgenetic Alopecia (AGA) Pharm-Therapy
A
Minoxidil
16
Q
Minoxidil Brand Name
A
Rogaine
17
Q
Minoxidil MOA
A
Increases cutaneous blood flow directly to hair follicles
18
Q
Minoxidil Indications for Use
A
Men: baldness at the crown of head
Women: hair thinning at the frontoparietal area
19
Q
Minoxidil Warnings/ Precautions
A
Do not use in heart disease unless recommended by primary care
provider
20
Q
Minoxidil Adverse effects
A
Local: itching, irritation, dryness, or scaling at the application site
Long-term use: transient hypertrichosis
Systemic: hypotension, tingling/numbness, vision changes - RARE
21
Q
Minoxidil Drug Interactions
A
Hair chemicals (colors, perms, relaxants); oral minoxidil; topical corticosteroids, petrolatum, or retinoids
22
Q
Minoxidil Dosage Forms
A
○ Hydroalcoholic solution: 2%, 5%
○ Solvent-free foam: 5%
23
Q
Minoxidil Applications methods
A
○ Dropper
○ Foam
○ Rub-on
○ Spray
24
Q
Minoxidil Application
A
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
25
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
26
Wounds Acute
typically caused by trauma and tend to heal within one month
27
Wounds Chronic
any wound that does not heal properly through the normal
| stages of tissue repair (longer than 2-3 weeks)
28
Abrasions
rubbing or friction that affects the epidermis
| ● May extend to uppermost portion of dermis
29
Burns
caused by chemical, electrical, thermal, or ultraviolet radiation
(UVR) exposure
30
Lacerations
result from a sharp-edged object cutting through the
| various skin layers
31
Punctures
piercing of epidermis by a sharp-pointed object
32
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
```
33
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
34
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
35
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
36
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
37
Wounds- Pharmacologic Therapy – Skin Protectants
Protects from mechanical irritation caused by friction and rubbing
• Prevent drying/provide lubrication
- Apply as often as needed
38
Skin protectants common ingredients
* Allantoin
* Cocoa butter
* Petrolatum
* Shark liver oil
* White petrolatum
39
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
40
First-aid antiseptics common ingredients
* Camphorated phenol
* Ethyl alcohol
* Hydrogen peroxide
* Iodine
* Isopropyl alcohol
* Povidone/iodine
41
Pharmacologic Therapy – First-aid antibiotics
```
Help prevent infection
• Ingredients
• Bacitracin
• Neomycin
• Hypersensitivity reactions in 3.5-6% of patients
• Polymyxin B sulfate
```
42
Pharmacologic Therapy – First-aid antibiotics Directions
Use after cleansing wound bed
| • Apply 1-3 times daily
43
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
44
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
45
Follow-up/Monitoring
REFER if infection suspected or wound or burn does not show signs of healing in 7 days
46
Dermatomycoses
Fungal Skin Infections
One of the most common skin infections – occur in 10-20% of the
population
• “Tinea” refers to dermatophyte infections
47
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
```
48
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
```
49
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
```
50
Tinea unguium
```
Nails
Tinea infection of the nails
● Loss of shine, become opaque
● Can progress to thick, rough, yellow, friable
● Self-Care?
○ NO
```
51
Tinea capitis
```
Scalp
Fungal infection of the scalp
●Often presents with pruritic scaling areas of
hair loss
● Primarily occurs in children
● Self-Care?
○ NO
```
52
Dermatomycoses Risk factors
* Diabetes
* Human immunodeficiency virus (HIV)
* Immunosuppressive medication use
* Occlusive clothing/footwear
* Sweating/humidity
53
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
54
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
55
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
56
Dermatomycoses: Pharmacologic Therapy: Topical Antifungals
● Apply once or twice daily (depends on formulation)
| ● Length of treatment depends on formulation and infection
57
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
```
58
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
59
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
60
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
61
Warts Risk factors
* Biting fingernails
* Depressed immune system
* Going barefoot, especially on wet surfaces (public pools, showers)
* Meat handling occupation
* Previous or existing warts
62
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
```
63
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
64
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*
65
Warts Pharm-therapy
Salicylic Acid
66
Salicylic Acid Brand Names
Compound W®, Dr. Scholl’s Clear Away®, TransVer-Sal®
67
Salicylic Acid MOA
May induce an immune response secondary to
| mild irritation
68
Salicylic Acid Indications
Common and plantar warts
69
Salicylic Acid Adverse Effects
Skin irritation
70
Salicylic Acid Dosage Forms
* Liquid (colloidion vehicle) – 17%
* Patches (karaya gum glycol plaster vehicle) – 15%
* Pads/strips (plaster vehicle) – 12 - 40%
71
Salicylic Acid - Keratolytic Agent
slowly destroys virus-infected cells
72
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
73
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
74
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
75
Salicylic Acid Application Plasters/Pads/Strips
Wash/soak and dry affected area
○ Apply appropriate size to wart and remove after 48 hours
76
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
77
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
