PHRM 825: Dermatology Flashcards
What 2 primary lesions are flat, nonpalpable changes in skin color
- Macule
- Patch
What 3 primary lesions are elevated and formed by a fluid in a cavity (no color change)
- Vesicle
- Bulla
- Pustule
What 5 primary lesions are elevated, palpable solid masses?
- Papule
- Plaque
- Nodule
- Tumor
- Wheal
What primary lesion are most drug rashes made of?
Macules
What 3 secondary lesions have material on the skin surface?
- Scale
- Crust
- Keloid
What 4 secondary lesions have loss of skin surface?
- Erosion
- Ulcer
- Excoriation
- Fissure
What are the 4 vascular lesions?
- Cherry angioma
- Telangiectasia
- Petechiae
- Ecchymosis
What does occlusive mean in regards to ointments?
Promotes retention of water in the skin
What does humectant mean in regards to ointments?
Causes water to be retained because of its hygroscopic properties
What does emollient mean in regards to ointments?
- Softens the skin
- Soothes irritation in skin or mucous membranes
What does protective mean in regards to ointments?
Protects inured or exposed skin surfaces from harmful or annoying stimuli
What form of topical agent has the greatest bioavailability of active ingredient?
Ointment
What topical agent is essentially a watered-down cream?
Lotion
What 4 topical vehicles are preferred for hair bearing skin?
- Gel
- Lotions
- Solution
- Foam
Characteristics of oleaginous bases
- Absorbs no water
- Not water washable (requires soap)
Characteristics of absorption bases
- Can absorb several times it’s weight of water
- Not water washable
Characteristics of water-in-oil emulsion bases
- Absorbs less water than absorption bases
- Not water washable
Characteristics of oil-in-water emulsion bases
- Water washable
- Add water=lotion
What base is most commonly used therapeutically to treat skin disorders?
Creams
What are 3 drug-induced skin disorders?
- Hypersensitivity/allergic reaction
- Photosensitivity
- Toxic Reaction
How do you treat drug-induced skin disorders?
- Stop the drug
- Systemic antihistamines
- Systemic or topical corticosteroids
- Soothing baths or soaks
What are the 2 types of photosensitivity reactions?
- Phototoxic
- Photo allergic
What causes a phototoxic skin reaction?
Drug or its metabolite accumulates in the skin, absorbs light and undergoes a photochemical reaction resulting in local tissue damage
What causes a photo allergic reaction?
Drug or its metabolite induces a cell mediated immune response which on exposure to light (longer wave length) produces a papular or eczematous contact dermatitis like picture
How do you prevent photosensitivity reactions?
Sunscreen SPF >30 and clothing
How do you treat photosensitivity reactions?
- Systemic analgesics
- Systemic antihistamines for itching
- Prevent infection
- Moisturizers
- Cooling creams and gels (Aloe)
What are characteristics of toxic skin reactions?
- Epidermal detachment
- Erosive mucosal lesions
What causes a toxic skin reaction?
Drug protein complex reaction leads to T-cell activation which migrates to the dermis and releases cytokines
What drug is most commonly responsible for Steven Johnsons Syndrome?
Anti-convulsants
What is cellulitis and should you treat or refer?
- Infection near break in skin
- Red, warm, swollen (fever?)
- Refer
How do you treat cellulitis?
- Oral antibiotics
- IV antibiotics in severe cases
What is impetigo and should you treat or refer?
- Topical staph skin infection
- Most common in children
- Direct spread
- Refer
How do you treat impetigo?
Topical or oral antibiotics
Where is topical candida infection most common?
- Moist areas in humid conditions
- Obese patients
How do you treat topical candida infection?
- Topical antifungals
- Dry affected area
What is Tinea pedis?
- Athlete’s foot
- Dermatophyte infection
- Often spread in pools/showers
- Moist environments promote growth
How is tinea pedis (athlete’s foot) treated?
Topical antifungals
What is tinea corporis?
- Body ring worm
- Commonly transmitted in day-care
- Hot/humid environments promote growth
- Small, circular, red scaly areas
How is tinea corporis/body ring worm treated?
Topical antifungals
What is Pediculosis and do you treat or refer?
- Head lice
- Children 3-12 years old
- Scalp redness and scaling
- Pruritus
- Refer
How is head lice/pediculosis treated?
- Permethrin 1%
- Malathion
- Oral Ivermectin
- Spinosad
- Topical Ivermectin
- $$$
What is scabies and do you treat or refer?
- Sarcoptes scabiei infestation
- Primarily in children and adolescents (LTCF)
- Raised lines caused by mites burrowing under the skin
- Extreme pruritus
- Refer to PCP
How is scabies treated?
- Permethrin 5%
- Crotamiton
- Oral Ivermectin
What is Herpes zoster and do you treat or refer?
- Shingles
- Adults >40 yo
- Especially in pts who previously had chicken pox
- Potentially contagious while blisters are present
- Triggered by stress, old age, immunosuppression
- Extreme pain along dermatome
- Tender red papules that progress to scabs
- Refer to PCP
How do you treat herpes zoster/shingles?
- Oral valacyclovir or famciclovir
- Manage acute pain and postherpetic neuralgia (oral opioids for acute pain, gabapentin for PHN, lipoderm patches once lesions have healed)
What is the most common type of skin cancer?
Basal cell carcinoma
What is the most deadly type of skin cancer?
Melanoma
How is skin cancer treated?
- Removal of lesion
- Chemotherapy
- Radiation
What is xerosis?
Dry skin
Who is at risk for xerosis?
Elderly
-decreased activity of sweat and sebaceous glands
-very warm, dry environments
Frequent bathing
How is xerosis treated?
- Emollients (first line for itching/restores barrier and skin function)
- Agents for itching
- Alter bathing habits
Dr. Martin’s Rules of 3’s for xerosis
- Bathe 3 times per week
- tepid water (3-5 degrees above body temp)
- Bathe for 3 mins
- Apply emollient within 3 mins
- Apply emollients 3 times daily
What agents reduce itching?
- Menthol and camphor
- Pramoxine
- Aluminum acetate
- Hydrocortisone
What is dermatitis?
Inflammatory process of the upper two layers of skin
What are the 3 stages of dermatitis?
- Acute
- Sub-acute
- Chronic
What characterizes acute dermatitis?
- Red patches or plaques
- Pebbly surface or blisters (vesicles)
- Itching is common and intense
What characterizes sub-acute dermatitis?
- Dry
- Less red than acute dermatitis
- Crusting, oozing
- Mild thickening
- Red scaling, fissured, patches or plaques
- Slight to moderate pruritis, pain, stinging, or burning
- Itching is common but less intense than acute dermatitis
What characterizes chronic dermatitis?
- Epidermal thickening
- Exaggerated skin markings
- Lichenification
- Scaling
- Less itching
What is the main symptom of acute contact dermatitis?
Itching
What are the 2 types of contact dermatitis?
Allergic and irritant
What is the itch-scratch cycle?
Inflammation/excitation of C-nerve fibers leads to itching which leads to scratching and repeat
What is an irritant?
Non-immunologic reaction to frequent contact with everyday substances
Which is more common: allergic or irritant contact dermatitis?
Irritant
What is the main symptom of poison ivy?
Intense pruritis
How is poison ivy treated?
Topical therapy
If >10% BSA involved, oral therapy
What are poison ivy treatment options?
- Remove source
- Soaks
- Calamine lotion
- Topical antihistamines
- Oral antihistamines
- Topical corticosteroids
- Oral corticosteroids
When are soaks used to treat acute dermatitis?
For oozing, weeping, crusting lesions
When are wet-to-dry dressings useful?
For drying acutely, inflamed, wet areas
What is the MOA of topical corticosteroids?
- Anti-inflammatory
- Anti-pruritic
- Suppress immune response
How are topical corticosterois classified?
According to potency corresponding to anti-inflammatory activity
(very high-low corresponds with grades I to VII)
What technique enhances penetration of topical agents?
Occlusion
What are side effects of topical corticosteroids?
- Thinning of skin
- Dilated blood vessels
- Increased bruising
- Skin color changes
- Risk of HPA suppression with long-term use of high-potency agents
- Development of tolerance (tachyphylaxis)
What is the MOA of topical calcineurin inhibitors?
Blocks pro-inflammatory cytokine genes
What are 2 topical calcineurin inhibitors
-Pimecrolimus and tacrolimus
What class of medications can be used for systemic treatment of acute dermatitis?
Corticosteroids
What non-sedating antihistamines are used as systemic therapy for acute dermatitis?
- Loratadine
- Desloratadine
- Fexofenadine
What sedating antihistamines are used as systemic therapy for acute dermatitis?
- Diphenhydramine
- Cetirizine
- Hydroxyzine
- Doxepin
What is atopic dermatitis and its characteristics?
- Most common form of eczema
- Usually presents in infancy
- 1 in 5 children
- 1 in 12 adults
- 80% mild and 20% mod-severe
- Significant QOL issues (sleep, depression, anxiety, lack of productivity)
What is included in the atopic triad?
- Atopic dermatitis
- Asthma
- Allergic rhinitis
What is the first diseases of atopic/allergic triad to be observed?
Atopic march
What is atopic dermatitis and its characteristics?
- Pruritis
- Symmetrical red papules or plaques
- Scaling excoriations
- Overall dryness of skin
- Redness and inflammation
- History of allergic disease
- Risk of 2nd infection
What are triggers for atopic dermatitis?
- Detergents
- Infections
- Allergens
- Chemicals
- Bathing
- Soaps
- Smoke
- Dust
What is dupilumab and what is its MOA?
- First biologic indicated for moderate to severe AD (not well controlled with other therapies
- Human monoclonal antibody against IL-4 receptor alpha (inhibits signaling of IL-4 and IL-13 (Th2 cytokines)
What is stasis dermatitis and what are it’s characteristics?
- Patients > 50yo
- Poor circulation
- Most common around ankles
- Aching, swelling, edema, discomfort
- Red, scaly, crusted plaques
- Secondary infection and ulcers common
- Hyperpigmentation (retention of iron in skin)
How is stasis dermatitis treated?
- Topical corticosteroids (for itching)
- Emollients (for all pts)
- Oral antibiotics for local infections (cephalexin)
- Support/compression stockings to relieve edema
What is chronic dermatitis and what are it’s characteristics?
- Well documented lichenified, thickened plaques
- Excoriations, fissures, scaling
- Itching predominates (minor irritations or trauma worsens itching)
How is chronic dermatitis treated?
- Emollients
- Avoid long-term corticosteroids
- UV light
What patients are at risk for topical fungal infections?
- Obese!
- Infants
- Elderly
- Immunosuppressed
- Incontinence
- Warm and humid climates
- Usually a combination of risk factors
Should you treat or refer topical fungal infections?
- Most can be treated with OTC
- Refer if systemic symptoms
- Refer if patient is immunocompromised
OTC products for topical fungal infections
- Miconazole
- Clotrimazole
- Terbinafine
Rx products for topical fungal infections
- Nystatin
- Ciclopirox
- Ketoconazole
Treatment options for diaper rash
- Remove irritant (frequent diaper changes)
- Air dry
- Keep clean
- Antifungal agents +/- corticosteroids
What is seborrhic dermatitis?
- Erythema with greasy yellow scaling
- Hairline, scalp, nose, neck, ears, back
- Itching
- Includes cradle cap in infants
How to treat cradle cap
- Baby oil to soften
- Baby shampoo
- No drug tx usually required
Treatment options for seborrhic dermatitis
- Medicated shampoos (contact time is critical)
- Topical corticosteroid (low strength ideal for lesions on face and ears)
Acne definition
Chronic inflammatory disease of the sebaceous glands and hair follicles of the skin characterized by comedones, papules, and pustules
What percentage of the adolescent population experiences acne?
90%
Corresponds to increased androgen production
80% of patients with acne are within what age range?
- 12-30
- Males more severe during puberty
- Females more severe during adulthood
Factors that exacerbate acne
- Oil-based cosmetics
- Emotional stress
- Irritation/physical pressure
- Drugs
What drugs exacerbate acne?
- Androgenic steroids!!!
- Corticosteroids
- Lithium
- Anti-epileptics (phenytoin)
- Tuberculostatic drugs
- Oral contraceptives
What is a comedone?
Hair follicle plugged with sebum, keratin, and dead skin
What bacteria naturally colonizes the skin and sebaceous glands and causes acne?
Propionibacterium acnes
What are the 2 classes of acne?
Non-inflammatory and inflammatory
What are the non-inflammatory lesions of acne?
Whiteheads and blackheads
What are the inflammatory lesions of acne?
- Papules
- Pustules
- Ruptured contents
What constitutes a whitehead?
Trapped contents in a closed comedo
What constitutes a blackhead?
- Trapped contents
- Dilated opening
- Open comedo
- Melanin accumulates
What is the difference between a papule and a pustule?
Papules are red and inflamed while pustules are yellow and inflamed
What are complications of acne?
- Excoriations
- Erythematous macules
- Hyperpigmented macules
- Scars
What are treatment options for complications of acne?
- Dermabrasion
- Chemical peels
- Laser resurfacing
- $$$
What are the goals for treatment of acne?
- Long-term control
- Prevent scars
- Relieve discomfort
- Improve skin appearance
- Minimized psychological stress
What oral antibiotics are used for acne?
- Minocycline
- Doxycycline
- Erythromycin
- Azithromycin
- TMP/SMX
What type of therapy is ideal for females who’s acne flares during the menstrual cycle?
Hormone treatment/oral contraceptive
What is isotretinoin and what is it used for?
Used for severe acne or when patients have failed other treatments or when it relapses soon after discontinuing other therapies
How long must someone wait to determine if an acne treatment regimen has been successful?
2-4 months
What is rosacea?
- Chronic, progressive inflammatory dermatosis based upon vascular instability
- Primarily affects central part of face
- Characacterized by facial flushing/bluching, facial erythema, papules, pustules, and telangiectasia
- 25-75 years of age
- Women > men
What characterizes telangiectatic rosacea?
- Visibly dilated blood vessels
- Very red skin
What characterizes papulopustular rosacea?
- Resembles acne
- Often referred to as “adult acne”
What characterizes phytmatous rosacea?
- Enlarged sebaceous glands
- Especially the nose
- More common in males
What characterizes ocular rosacea?
- Watery eyes
- Bloodshot eyes
What are triggers for rosacea?
- Temperature!
- Drugs!
- Foods
- Weather
- Beverages
- Medical conditions
- Emotional influences
- Physical exertion
- Skin products
What drugs are the main trigger for rosacea?
Vasodilators
What is psoriasis and how does it present clinically?
- Chronic autoimmune inflammatory skin disorder
- T-lymphocyte mediated disease
- Keratinocyte proliferation
- Thickened, red patches covered by silvery-white scales
- Results from rapid skin growth (7x faster than normal)
How do you treat psoriasis?
- Not curable!
- Attempt long remissions
What is psoriatic arthritis?
- Usually in joint area
- Defined with red patches on skin topped with silvery scales
- Usually psoriasis diagnosed first and then psoriatic arthritis
- Joint problems can begin before skin lesions appear
What is guttate psoriasis?
- Usually in children or young-adults
- Small, pink-red spots often appearing on trunk, upper arms, thighs, scalp due to URI, stress, skin injury, or commonly beta-blockers
What is erythrodermic psoriasis?
- Inflammatory form of psoriasis, often affects most of body surface
- Usually rare, and usually develops from pustular psoriasis or unstable plaque psoriasis
- Characterized by redness and severe itching throughout the entire body
What is inverse psoriasis?
- Develops in body’s skin folds: armpits, genitals, under breasts, buttocks
- Painful and difficult to treat
What BSA% characterizes “limited psoriasis”
<5%
What BSA% characterizes “moderated psoriasis”
5-10%
What BSA% characterizes “severe psoriasis”
> 10%
What are comorbidities of psoriasis?
- Psoriatic arthritis
- Crohn’s disease
- Psychiatric disorders
- Metabolic syndrome (CV disease/stroke)
When is topical therapy most effective to treat plaque psoriasis?
When it covers <20% of BSA
What technique enhances penetration of topical therapies?
Occlusion (increases penetration by 10x)
What is goeckerman therapy?
All day occlusive coal tar followed by light therapy
What infection can biologic therapy activate?
TB
