Med classes- Skin Quiz 2 Flashcards
What are the 2 layers of the skin and what do they do?
- Epidermis: is the protective layer—its outer most surface (the stratum
corneum) contains lipids & keratin - Dermis: lies between the epidermis and SQ fat layer—it is composed of
connective tissue and contains sweat glands, sebaceous glands, hair follicles and vessels
Key factors in a skin exam
-Perform in well-lit room
-Use hand-held light for illumination
-Wood’s lamp helpful for fluorescing certain types of lesions
-Skin scrapings may be needed
-KOH (potassium hydroxide) and/or 5% acetic acid prep may be needed for certain pathogens
-Assess appearance of patient and VS
-With ANY suspicious lesion, skin cancer must be ruled out
What to know about steroids on the face
-Use lowest strength possible,
starting with a potency that is less than the standard dosage
-NO fluorinated steroids on the face or perineum—can cause striae and
permanent thinning of the tissue
Why does the “vehicle” choice matter in terms of skincare?
-Therapeutic effect can depend on whether the vehicle is water or oil based
-The efficacy of the topical agent can depend on the thickness of the stratum corneum, drug concentration and permeability, and frequency of application
What does the sun do to our skin?
-Maintains the body’s supply of Vitamin D (positive effect)
-The photoreceptors on the skin [forearms/legs], when uncovered and without sunscreen absorb Vitamin D2 from the sun rays
-This form of Vitamin D is converted to Vitamin D3 in the kidney and then to its active form in a second renal
conversion
What are the two main types of UV radiation?
- UVB [bad]: are the rays that burn us, cause wrinkling and skin cancers
- UVA can cause some wrinkling and with many decades of “lead time” may manifest itself as BCC later in life
-NOTE: Small amounts of UV exposure daily can help maintain our bone and teeth stability
Derm Terms to know
- MED—minimal erythemal dose—minimum amount of UV radiation that produces evident erythema
after one exposure - SPF—describes the amount of UVB protection (i.e., protection against sunburn) that a sunscreen provides. SPF values are not related to time but rather to the amount of UV exposure [MED on protected skin ÷ MED on unprotected skin]; gives direction for how long one will be protected before burning
- Broad Spectrum—effective against both UVA & UVB radiation; these protect against sunburn, skin cancer
and photoaging - Water Resistant—sunscreen is effective for 40-80 minutes while a person is swimming [or is sweating]
Sunblock
Sunblock:
-Usually contains Zinc oxide/Titanium dioxide
-Block ALL sun rays, not just protect from sun’s burning rays
Per chat:
-Works by reflecting/ scattering rays
-Works as physical blocker
-Thicker, may have a white cast
-Better for use on sensitive/ reactive skin
Sunscreen
Need to double check what she’s looking for for SPF
-Per chat:
-Contains chemical ingredients like avobenzone, oxybenzone, octisalate, and homosalate.
-Absorbs UV rays chemically
-Works by chemical filter
-Usually lightweight/ transparent and can be used for all skin types
-Use of sunscreens with SPFs of >16 for 5 years will decrease malignant melanoma risk by 50%
-Educate your patient about what an SPF of a 2, 20, 15, 30 would mean…for a person who burns in 1 minute in the sun without sunscreen??????
-Recommended Use: 3 tablespoons [to cover all BSA] every 120 minutes
Special considerations for sunscreen
-Apply sunscreen, then wait 30 minutes to apply insect repellant
-Use a broad-spectrum sunscreen with an SPF of at least 15 (per FDA) or 30 (per the American Academy of Dermatology and Health Canada)
-Limit time in the sun, especially between 10AM and 2PM when the sun’s rays are the strongest
-Apply sunscreen 15 minutes before sun exposure for best effectiveness
-Reapply sunscreen at least every two hours, as well as right after sweating or swimming
-Use a lip balm with SPF 30 or higher to protect the lips
-For infants less than 6 months—use small amounts of SPF 15 or less sparingly
-Sunscreen expires 36 months after date manufactured date
Damage from sun exposure
-Photoaging (refers to damage done to skin from prolonged exposure to UV radiation throughout one’s life)
-Normal skin changes of aging are exacerbated by sun exposure
-Photoaging includes—dark spots, wrinkles, droopy skin, yellowish tint to the skin, blood vessels that are
fragile and break easily, leathery skin, skin cancers
Skin phototype
Type 1: Porcelain Pale white skin,
blue/hazel eyes; blonde/ red hair
Always burns; does not tan
Type 2: Fair skin with blue eyes Burns easily, tans rarely
Type 3: Darker white skin Tans after an initial burn
Type 4: Light brown skin Burns minimally; tans easily
Type 5: Brown skin Rarely burns; tans darkly with ease
Type 6: Dark brown or black skin Never burns; tans darkly
Glucocorticoids: How they work on the skin
-Steroids work via intracellular receptors; they initiate several transcriptions—inhibition of
arachidonic acid cascade, decrease production of many cytokines and inflammatory cells
-Potency is based on vasoconstriction—most potent [VII] to least potent [I]
-Occlusive dressings can significantly increase absorption and may also increase side effects
-Applying topical steroids to wet skin may improve effectiveness
-Total dose for very high potency steroids should generally not exceed 50 grams per week because of the potential for adrenal suppression
Glucocorticoides: ADE
-Acneiform eruptions, dermatitis, local infections, hypopigmentation
-In children, applying potent steroids to large BSA can cause systemic toxicity—depression of HPA axis and growth retardation
-Skin changes such as atrophy (thinning), telangiectasias (red or purple clusters on the skin from dilated capillaries), and striae (discolored ridge or groove like a stretch mark)
-Though mild atrophy usually resolves after stopping the steroid, telangiectasia and striae are less likely to resolve with discontinuation.
Acne Vulgaris
Patho: Excess sebum, Comedones, Propionibacterium acnes overgrowth, Inflammation
-How its classified:
-Comedones, pustular/papular and nodular
-Disease further subdivided as→
-Mild—comedonal, pustular/papular
-Moderate—pustular/papular, small nodules [up to 1 cm]
-Severe—nodular, cystic/pustular [also called acne conglobate]
Retinoids
-Derivatives of Vitamin A
-Influence cell proliferation, immune function, inflammation & sebum production
-These agents are comedolytic and anti-inflammatory
MOA: mediated through nucleic
retinoic acid receptors
ADE’s: irritation, dryness, skin peeling, photosensitivity, dry MM &
eyes
Tretinoin (Prototype drug for retinoids) vs other retinoids
-Tretinoin: 1 st generation agent
-Other agents:
-Isotretinoin—1 st generation
agent—category X agent (must be prescribed by licensed providers—I Pledge Program)
-Oral agent
-Used in scarring acne and in
severe disease
-Adapalene / Tazorac—3rd
generation agent—less irritating
-1st line for comedonal and
inflammatory acne
Benzoyl Peroxide fo Acne
-1 st line for mild to moderate acne with NO inflammation
-MOA: antiseptic against P acnes and opens pores
ADE’s:—dry skin, peeling, irritation, eyebrow discoloration
Salicylic Acid for acne
-Is a Beta hydroxy acid, penetrates pilosebaceous unit
MOA: exfoliates to clear comedones; mild antiinflammatory activity and is keratolytic at high concentrations
-Usually for mild disease
-ADE’s: peeling, dryness, local irritation
Azelaic Acid for acne
-Antibacterial against P acnes and it has antiinflammatory actioins
-Normalizes keratinization and its anticomedogenic
-Used in mild to moderate inflammatory acne
-ADE: skin irritation
Antibiotics for acne
-P acnes is a gram + rod associated
-For moderate to severe acne with inflammatory lesions, topical or oral antibiotics can inhibit this bacteria’s
growth (Erythromycin and Clindamycin are available and used)
-Topical antibiotics best when combined with Benzoyl peroxide or
retinoids
-Topical Dapsone [a sulfonamide] is available (MOA is unknown)
ADE: methylhemaglobinemia (PERMANENT DONT GIVE)
-Moderate to severe acne requires ORAL antibiotics— Doxycycline [preferred] or Minocycline
How to know which acne treatment to use
For mild acne:
-If mainly comedones—treatment of
choice is topical retinoid
-If mainly is papular/pustular—treatment of choice is topical retinoid + benzoyl peroxide [BPO] OR topical retinoid + BPO/antibiotic combination
For moderate acne:
-For papular/pustular disease—topical retinoid + oral antibiotic & BPO (or OCP)
-For nodular disease— topical retinoid + oral antibiotic & BPO [or
BPO/antibiotic]
-Alternative—Isotretinoin orally
For severe disease:
-For nodular—oral antibiotic and topical retinoid + BPO (can add
OCP)
-For cystic/pustular—oral
Isotretinoin [Accutane]
-Alternative is high dose
oral antibiotic and topical
retinoid + BPO (& OCP)
Isotrentinoin important warnings
-Requires prescribers be trained and registered— have a federal ID number [based on your NPI and
completion of training]
-Category X pregnancy
-The iPLEDGE program is a mandatory, FDA-regulated initiative for isotretinoin prescribing to prevent fetal exposure. Key components include:
-Monthly doctor visits for pregnancy tests and counseling.
-Strict rules for contraception (two forms of birth control or abstinence).
Limited prescription fills (usually for 30 days).
Rosacea
-Chronic acne-like inflammation of central area of face, yet no comedones are present
-Etiology:
-Cutaneous vascular disorder of capillaries
» Increased reaction to heat causes “flushing”
» Ocular symptoms may include blepharitis, conjunctivitis
-Incidence/Demographics:
-Common in fair skinned, middle aged to elderly people
