Pediatric Dermatology - Block 4 Flashcards
What are the layers of the skin?
Epidermis: stratum basale, spinosum, granulosum, corneum
Dermis: connective tissue layer containing sweat glands, sebaceous glands, hair, nails, nerves, blood vessels
Subcutis: fatty layer
Human skin is normally ____?
Acidic which becomes a natural antimicrobial
Functions of the epidermis?
Keratinocytes, corneocytes and melanocytes:
1. Keep water and vital fluids in
2. Keeps foreign elements out
3. Vit D production and absorption
Function of the dermis?
Provides resilency
Functions of sebaceuous glands?
Produce sebum for supple skin
Functions of the subcutis?
Body temp reg and protects bones and muscles
Factors examined during a skin exam?
- Lesions
- Moles
- Freckles
What is diaper dematitis?
Affects the buttocks, genital, and perineum regions leading to Erythematous that may have vesicles or oozing
Secondary infection: Candida-induced plaques, paupules, and pustules, and macerations in inguinal folds
How do you manage diaper rashes?
- Frequent diaper changes
- Air drying
- Gentle clensing
- Topicals
What are the topicals used for diaper rash?
- Barriers
- Topical antifungal
- Topical CS
Barriers and its indication as a diaper rash topical?
Zinc oxide: ultra high potency containing astringent and absorbents
Petrolatum: Water impermeable layer but traps water
Antifungal and its indication as a diaper rash topical?
Imidazoles (clotrimazole, metronidazole): Cover with a barrier product
Only for secondary infection
A red, itchy, weepy reaction where the skin has come into contact with a substance that the immune system recognizes as foreign, such as poison ivy or certain preservatives in creams and lotions
Allergic contact eczema (dermatitis)
A chronic skin disease characterized by itchy, inflamed skin.
Atopic dermatitis
A localized reaction that includes redness, itching, and burning where the skin has come into contact with an allergen (an allergy-causing substance) or with an irritant such as an acid, cleaning agent, or other chemical.
Contact eczema (dermatitis)
Irritation of the skin on the palms of hands and soles of the feet characterized by clear, deep blisters that itch and burn.
Dyshidrotic eczema
Scaly patches of the skin on the head, lower legs, wrists, or forearms caused by a localized itch (such as an insect bite) that become intensely irritated when scratched.
Dyshidrotic eczema
Yellowish, oily, scaly patches of skin on the scalp, face, and occasionally other parts of the body.
Seborrheic eczema
A skin irritation on the lower legs, generally related to circulatory problems
Stasis dermatitis
Coin-shaped patches of irritated skin (arms, back, buttocks, lower legs) that may be crusted, scalling, and itchy
Nummular eczema
What is the atopic triad?
Atopic dermatitis (1st to occur)
Allergic rhinitis
Asthma
What are the RF of AD?
- Urban environment
- Higher sociaoeconomic status
- High family ed
- Family hx
- Female (after 6)
- Smaller family size
- Functional mutations in the FLG gene
What are the predisposing factors that put a child at risk for developing AD?
- Climate
- Infection
- Genetics
- Environmental aeroallergens
- Urban versus rural living
- Breastfeeding and weaning
- Obesity
- Pollution/tobacco smoke
- Food/diet
What is the cause of AD?
Neuropeptides, irritation, or pruritis-induced scratching -> proinflammatory cytokines from keratinocytes
* T-cell mediated but IgE-independent reactions
* Skin barrier dysfunction and immune deviation
* Reduced antimicrobial peptides (AMPs)
How do we diagnose AD?
Earliest onset of AD usually occurs between 3 and 6 months of age or before 5YO
* Presentation will vary with age
Clincial diagnosis: atopy, pruritus, eczema, altered vascular
Required sx for AD diagnosis?
Uncontrollable itching that causes irritability, sleep disruptions, and excoriation
AD presentations during infancy?
Facial eruptions that progress to red, scaling, oozing:
* Nose is spared (headlight sign)
* Eybrows are thin or absent (Herthoge’s sign)
* Lesions on flexor surfaces
AD presentations in toddlers?
Extension of lesions to the lower legs, then to the entire body
* exclusion of the groin, axillary, and nose
AD presentations throughout childhood?
Dry, flakey, rough, cracked:
* Bleeding or lichenifications
* Increased folds under eyes (Dennie-Morgan folds)
AD presentations in adults?
Lesions with underlying erythema: brown macular ring around neck
What are the triggers for pruritus?
- Heat and sweating
- Wool
- Stress
- Foods
- ALcohol
- Upper respiratory infection
- DUst mites
What is allokinesis?
Sensation where stimulus hause itching but normally doesn’t evoke itching
Scoring tools for AD?
SCORAD (Scoring of Atopic Dermatitis): score >50 = severe AD, and <25 = mild AD
Patient-Oriented SCORAD (PO-SCORAD)
EASI (Eczema Area and Severity Score) - subjective
POEM (Patient-Oriented Eczema Measures) - Objective
What are the complications associated with AD?
- Sleep dysfunction
- Secondary infection from Staph or Strep
- Disseminated infection with herpes simplex or vaccinia virus
Smallpox vaccine (live) is CI
What are treatment goals for AD?
- Symptomatic relief
- Control
- Eliminate tirggers
- Prevent future exacerbations
- Support
- Minimize ADRs
- Treat secondary infection if present
Non Phar for AD?
- Moisturize (apply after bathing)
- Lukewarm bath
- Non soap cleanser
- Wet wrap
- Keep fingernails short
- SOft cotton clothes
- Sedating antihistamine for scratching at night
- Keep cool
- Treat promptly
- Attempt to distract the child with activities
- Identify and remove irritants
What are the types of moisturizers used?
- Occlusives
- Humectants (not recommended in AD)
- Emollients
Function of occlusives?
Provides an oily layer on the skin to slow transepidermal water loss -> increasing moisture content of the stratum corneum
FUnction of humectants?
Increase water holding capacity
Function of emollients?
Smooth out the surface of the skin by filling the spaces with droplets of oil, less effective than occlusives
What is the difference between reactive and proactive tx?
Reactive: anti-inflammatory agents for acute flares and mild AD
Proactive: Long term anti-inflammatory tx with scheduled follow up to control mod-severe AD (not for active flares)
What is the standard of care for AD?
TCS: Daily or BID until flare up is controlled and requires tapering
* Then may stop use or go to once to twice weekly on commonly afflicted areas
What are reactive TCS tx?
- Low-potency TCS (hydrocortisone 1%)
- Medium-potency TCS (betamethasone valerate 0.1%)
- Mid-strength and high-potency TCS
- Ultrahigh- and high-potency TCS (betamethasone dipropionate 0.05% or clobetasone propionate 0.05%)
What are proactive TCS?
Low-potency TCS (hydrocortisone 1%)
Medium-potency TCS (betamethasone valerate 0.1%)
What are the uses for low potency TCS?
Hydrocortisone 1% for the face
What are the uses for medium potency TCS?
Betamethasone valerate 0.1% for body
Use of mid-high potency TCS?
Short term management of exacerbations
Uses of ultra high-high potency TCS?
Betamethasone dipropionate 0.05% or clobetasone propionate 0.05%): SHort term tx of lichenified areas in adults
Local ADR of TCS?
- Striae distendae (stretch marks)
- Skin atrophy
- Acne
- Rosacea
- Dirty neck
- Skin irritations
ADRs of long term TCS use?
Red face or CS addiction syndrome: rosacea-like disease with erythema, burning, and stinging
Systemic ADRs of TCS?
Usually from high- ultrahigh potency or increased BSA exposure: HPA axis suppression, hyperglycemia, cataracts, glaucoma, growth retardation in children
MOA and Products of topical calcineurin inhibitors?
Tacrolimus ointment (Protopic) and pimecrolimus cream (Elidel)
MOA: Inhibit the activation of T cells and mast cells -> blocking production of proinflammatory cytokines and mediatory
Indications and ADRs of topical calcineurin inhibitors?
Indication: >2YO
* Not for immunocompromised patients
BBW: Potential cancer risk -> skin protection is recommneded
ADR: burning sensation at app, transient worsening of skin condition before it gets better
Topical options apart from calciurin inhibitors and CS? Indications
- Coal tar: staining/malodoraous, not for acute inflammation
- Selective phosphodiesterase 4 inhibitors: crisaborole and apremilast
- JAK inhibit: ruxolitinib and tofacitinib
What is second line for AD?
Phototherapy
MOA and Indications for phototherapy?
MOA: UV has immunosuppressive, modulating, anti-inflam, and antipruritic effects
Eye protection is required
What is photochemo?
UV therapy with drugs or topical ointments (coal tar or psoralens)
What are the uses of systemic AD therpaies?
Not well studied, but most meds are for immune modulation
Monitoring and follow up for AD tx?
- Improvement in a few days (pruritis)
- Follow up in 1-2 weeks after initiation
- Monitor ADR
- Ensure preventative measures are being implemented
What are the main cause of acne?
- Increased sebum production, due to hormonal influences
- Alteration in the keratinization process and hyperproliferation of ductal epidermis
- Bacterial colonization of the duct with Propionibacterium acnes
- Production of inflammation with release of inflammatory mediators in acne sites
What are the dietary influences of developing acne?
- Dairy and GF in milk
- Whey protein in milk
- Hyperglycemic-load diets
Describe the cascade of acne?
- White head
- Blackhead
- Papule
- Pustules
- Cysts
What are the acne lesion types?
Noninflam: open and closed comedones
Inflam: Papulopustular and/or nodular lesions
Scarring: Result of nodules and deep lesions
What is the location of most acne cases?
Face, back, neck, shoulders, chest
* rarely buttocks and extremities
What is the assessment tool used for acne severity?
FDA Investigator Global Assessment
What is type 1 acne?
Almost clear: rare noninflammatory lesions with no more than 1 small IL
What is type 2 acne?
Mild, some noninflammatory lesions, no more than a few inflammatory lesions (papules/pustules only, no nodules)
What is type 3 acne?
Moderate: many noninflammatory lesions, some inflammatory, no more than 1 nodule
What is type 4 acne?
Severe: many noninflammatory and inflammatory lesions, no more than a few nodules
What is the differential diagnosis of acne?
Rosacea, perioral dermatitis, gram-negative folliculitis, and drug-induced acne
Palliating facotrs of acne?
Sunlight
Provoking facotrs of acne?
Premenstrual flares, humid environments, excessive sweating; exposure to chemicals; occlusive clothing; friction; oily cosmetics; manual manipulation; stress; diet
What is monomorphinc acne?
comedonal with some inflammation or papular–pustular
What are some drugs that cause comedonal/inflammatory acne?
- TUberculostatic drugs (isoniazine, ethambutal)
- Lithium
- ANtiepileptics (phenytoin)
- Cyclosporine
- AZA
Drugs that cause Papular–pustular reactions?
- NSAIDs
- Bactrim
- Cephalosporins
- Diltiazem
What are the goals of acne tx?
- Reduce number or leasions improvign appearance
- SLow progression
- Prevent scarring and hyperpigmentation
- Avoidance of psychological suffering
What are the principles of acne tx?
- Target microcomedones
- Cleansing, reducing triggers, and combination therapy targeting all four pathogenic mechanisms
- Regimens may be titrated and tapered
Nonpharm for controlling acne?
- Cleansing
- Shaving
- Comedone extraction (with tool not fingers)
- UV not recommended
- Avoid oil-containing cosmetics (oil free not water based)
How do you properly shave?
Direction of hair growth and each area only once
How do you properly clense?
BIS with mild, nonfragranced opaque or glycerin soap or a soapless cleanser
* Avoid cream based cleansers and exfoliants
Describe the pharm options for acne?
What is first line for comedonal, noninflam acne?
- Topical retinoids (adapalene, tretinoin) alone or in combination
- Benzoyl peroxide, azelaic acid, and salicylic acid are alternatives
Tx for Mild-to-moderate papulopustular inflammatory acne?
Fixed-dose combination (adapalene and benzoyl peroxide) or benzoyl peroxide or topical retinoid or azelaic acid
Tx for Moderately severe or severe papulopustular or moderate nodular acne?
- Fixed-dose combination with an oral antibiotic
- Oral isotretinoin or oral hormonal therapy may be added
- Oral antiandrogens are an alternative
First line for very severe acne?
Males: Oral isotretinoin
Females: Oral isotretinoin + antiandrogenic hormonal therapy
What is the maintenace tx for acne?
- 12-week induction and continues for 3 to 4 months
- Topical azelaic acid is an alternative to topical retinoids
- Long-term therapy with antibiotics is not recommended
What is the tx for mild scarring?
nonprescription α-hydroxy acids
What is the tx for severe scarring?
- Dermabrasion
- Collagen implants
- Chemical peels
- Laser therapy
Short term goal of acne tx?
Lesion count, comedones, inflammatory lesions, anxiety/depression
Long term goal for acne tx?
Progression of severity, recurrent episodes, scarring or pigmentation
General safety of acne tx?
Dermatitis, increased dryness, gastrointestinal upset, photosensitivity
What are the types of topical retinoids?
- Tretinoin
- Adapalene
Types of topical antibiotics?
- Clindamycin
- Erythromycin
- Minocycline
ANtiandrogen?
- Clascoterone
- Spiranolactone
PO Abx?
- Doxycycline
- Minocycline
- Erythromycin
- Bactrim
- Sarecycline
What is used for severe and aggressive acne?
Isotrentinoin
