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DEENT Exam 4 > Rosacea and Scaly Dermatoses > Flashcards

Rosacea and Scaly Dermatoses Flashcards

1
Q

Questions for the patient

A

When considering derm conditions:

What do the lesions look like (size, shape, color)?
How have the lesions changed over time?
Does it itch?
Is it painful?
What do you think the problem may be?
Are you having other symptoms (SOB, swelling, fever, or N/V)?
Where did the problem first appear?
Where are you affected?
Did it and how did it spread?

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2
Q

Rosacea

A

Skin disease that affects the middle third of the face. Causes persistent redness over the areas of the face and nose.
Mainly involves the forehead, the chin, and the lower half of the nose.
No confirmatory laboratory test.
No cure.

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3
Q

Rosacea – predisposing factors

A
  • Between 30 and 50 years old
  • Fair-skinned
  • Often have blonde hair and blue eyes.
  • Likely to have someone in their family with rosacea or severe acne.
  • Likely to have had lots of acne — or acne cysts and/or nodules.
  • Females more than males, but, males have higher severity
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4
Q

Rosacea Subtypes

A

Subtype 1: Facial Redness
Subtype 2: Bumps and Pimples
Subtype 3: Skin thickening
Subtype 4: Eye irritation

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5
Q

Rosacea Subtype 1

A

FACIAL REDNESS

erythematotelangiectatic rosacea
Flushing and persistent redness. Visible blood vessels may also appear.

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6
Q

Rosacea Subtype 2

A

BUMPS AND PIMPLES

papulopustular rosacea
Persistent facial redness with bumps or pimples. Often seen following or with subtype 1.

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7
Q

Rosacea Subtype 3

A

SKIN THICKENING

phymatous rosacea
Skin thickening and enlargement, usually around nose

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8
Q

Rosacea Subtype 3

A

EYE IRRITATION

ocular rosacea
Watery or bloodshot appearance, irritation, burning or stinging.

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9
Q

Rosacea: Clinical presentation

A

Erythematotelangiectatic (subtype 1)
Persistant erythema of central face
Easily irritated facial skin

Papulopustular (subtype 2)
Above + dome-shaped erythematous papules and some pustules

Phymatous (subtype 3)
Thickened skin with prominent pores +/- Above

Ocular rosacea (subtype 4)  Both eyes usually affected
Conjunctivitis
Blepharitis
Styes
Keratitis
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10
Q

Rosacea triggers / exacerbating factors

A
  • Prolonged sun / UV light exposure
  • Stress / Anxiety
  • Humidity / extremes of weather / wind
  • Exercise
  • Alcoholic beverages
  • Smoking
  • Hot and spicy foods
  • Medications – (eg., vasodilators, calcium channel blockers, opiates)
  • Microorganisms
  • –Demodex folliculorum (mite)
  • –Staphylococcus epidermidis
  • –Heliobacter pylori
  • –Bacillus oleronius
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11
Q

Rosacea Non-pharmacologic

A

Basic Skin Care:

  • Moisturizer
  • Photoprotection
  • -SPF 15 or greater
  • -Broad Spectrum: UVA and UVB coverage
  • Gentle soap-free skin cleanser
  • Avoid astringents, toners, waterproof cosmetics
  • Avoid potentially exacerbating factors
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12
Q

Rosacea Pharmacologic Treatment (Topical)

A

Topical agents:

  • Metronidazole 0.75% or 1% cream or gel
  • Azelaic Acid 15% gel
  • Brimonidine 0.33% gel (reduces redness only)
  • Sodium Sulfacetamide 10% + Sulfur 5% - (papulopustular)

Benzoyl peroxide 5% + Clindamycin 1% - (papulopustular )
Topical Retinoids – use with or without oral antibiotics in refractory rosacea

  • FDA approved
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13
Q

Topical Metronidazole

A
  • Anti-inflammatory agent
  • Antimicrobial agent
  • Inhibits growth of Demodex brevis (mites)
  • Decreases reactive oxygen species generation

Side effects: burning, stinging, dryness, itching

Dosing
0.75% = Applied twice daily (gel, cream, lotion)
1% = Applied once daily
(gel, cream)

Face should be clean before application
Cosmetics may be used 5 minutes after application

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14
Q

Azelaic Acid

A

15% gel, 20% cream

Anti-inflammatory Antibacterial agent
For mild to moderate papulopustular rosacea

Use twice daily on affected areas

Side effects : burning, stinging, itching, dryness, scaling
Reassess if not improvement after 12 weeks

Face should be clean before application
Cosmetics may be used after application

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15
Q

Brimonidine

A

Alpha-2 agonist

Reduces facial erythema
Causes vasoconstriction in the smooth muscles of blood vessels in the skin

See effects at 30 minutes after application; persists up to 7 hours

May see rebound facial erythema

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16
Q

Rpsacea Pharmacological Treatment (Systemic)

A

Oral Agents

  • Doxycycline - 40 mg daily – anti-inflammatory dose
    Only systemic therapy approved by FDA for rosacea for up to 12 months

Antibiotic / Anti-inflammatory agents
resistance concerns

Azithromycin 250 – 500 mg three times per week for 2 – 6 weeks
Doxycycline 50 – 100 mg/day for 6 – 12 weeks
Minocycline 50 – 100 mg twice daily for 6 – 12 weeks
Metronidazole 200 mg once or twice daily for 4 – 6 weeks

Beta-blockers – to decrease erythema (limited studies w/Carvedilol; concern for CV effects)

Isotretinoin - limited data; Poorly tolerated
!!Not in females of reproductive age

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17
Q

Ocular Rosacea - treatment

A

Warm water soaks

Twice daily cleaning of base of lashes with no tears baby shampoo or lid cleanser, remove any crusting

Artificial Tear replacement

Topical Metronidazole gel

Oral Doxycycline or alternative antibiotic

Refer severe cases to ophthalmologist

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18
Q

Case 1: 47 year old woman with facial redness and flushing over past year. Eyes itch and are red. Worried about “whiskey” nose.

What is the initial medication treatment for this condition?

What medication can be added to reduce eye symptoms?

For management of rosacea, what is true?

A

What is the initial medication treatment for this condition?Metronidazole gel BID

What medication can be added to reduce eye symptoms? Doxycycline 40mg daily

For management of rosacea, what is true? should wear sunscreen

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19
Q

Scaly Dermatoses

A

Dandruff
Seborrhea
Psoriasis

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20
Q

Distinguishing Dandruff

A 
Scalp
Generally stable (not exacerabated) but does increase in dry climate

Appears thin, white or grey flakes on scalp

no inflammation

no epidermal hyperplasia (skin increase)

epidermal kinetics 2x faster than normal

less than 5% incompletely keratinized skin

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21
Q

Distinguishing Seborrhea

A

Head and Trunk

Exacerbated by external factors; Parkinson’s disease

Appears as macules, patches and thin plaques of discrete yellow, oily scales on red skin

Inflammation is present

Has epidermal hyperplasia (skin thickening)

Epidermal kinetics 3x faster than normal

15-25% incompletely keratinized cells

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22
Q

Distinguishing Psoriasis

A

Scalp, elbows, knees, trunk, lower extremities

Exacerbated by irritation, stress, climate, medications, infection, endocrine

Appears discretely symmetrical, red plaques with sharp borders, silvery white scale

Inflammation is present

Has epidermal hyperplasia (skin thickening)

Epidermal kinetics are 5-6x faster than normal

40-60% incompletely keratinized cells

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23
Q

OTCs for scaly dermatoses

A

FOR Dandruff, Seborrhea, and Psoriasis:

Coal Tar
Ketoconazole (shampoo) Pyrithione Zinc (rinse off)
Pyrithione Zinc (residual)
Salicylic Acid
Selenium Sulfide

FOR dandruff and seborrhea
(NOT psoriasis)
Sulfur

For seborrhea and psoriasis
(NOT dandruff)
hydrocortisone 1%

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24
Q

Dandruff

A

Chronic, non-inflammatory hyperproliferative epidermal scalp condition

Scales from irregular keratin cracking pattern

Pruritis common

Occurs in 1 – 3 % of population

Puberty onset

Peak occurrence in adulthood

No gender preference

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25
Q

Dandruff Treatment Goals

A

Reduce epidermal turnover rate of scalp skin

Minimize the cosmetic embarrassment of visible scaling

Minimize itching

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26
Q

Dandruff General Treatment Approach

A

Mild presentation:
-Non-medicated shampoo
(Daily or every other day)

Moderate to severe presentation :

  • OTC medicated shampoos (pyrithione zinc or selenium sulfide)
  • Leave on for 3 to 5 minutes
  • Rinse well with water
  • Use 2 – 3 times weekly for 2 to 3 weeks, then once weekly for control
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27
Q

Seborrheic Dermatitis occurance

A

Chronic inflammatory disorder occurring in areas of sebaceous gland activity

Chronic condition with no specific cure

Neither harmful nor contagious

Affects 3 – 5% of adults, men more than women

Ages 18 to 40 years

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28
Q

Seborrheic Dermatitis Features

A

Greasy or dry scaling of the scalp, sometimes a “cradle cap”

Mildly scaling eczematous patches on the face at typical locations (eyebrows, nasolabial creases, “sideburn”area)often with itch and stinging

Itch and inflammation of the ear canal

Blepharitis (eyelid infection)

Well-demarcated eczematous patches

  • –on mid-upper trunk
  • –at intertrigo areas (skin folds or juxtaposed surfaces of skin)
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29
Q

Seborrhea triggers / causes

A
  • Malassezia (a yeast – like fungus) grows in the sebum along with bacteria
  • Hormones
  • Physical stress, fatigue, travel
  • Zinc deficiency
  • Obesity
  • Season Change (worse in cold weather)
  • HIV infection
  • Parkinsonism
30
Q

Seborrheic Dermatitis Traetment goals

A

Reduce inflammation and epidermal turnover rate

Minimize or eliminate visible erythema and scaling

31
Q

Seborrheic Dermatitis General treatment approach / management strategies

A
  • Loosen and remove scales and crusts
  • Inhibit yeast colonization (Malassezia)
  • Reduce erythema and itching
  • Avoid perfumes, aftershave, ointments, soaps
  • Control secondary infections
32
Q

To Loosen and remove scales and crusts and decrease sebum (Seborrhea)

A

The scales can be softened with:

  • -Cream containing salicylic acid and sulphur
  • -Wetting and washing

Seborrhoeic skin should be washed more often than twice daily

33
Q

To Decrease Fungal Growth (Seborrhea)

A

Washing the scalp

  • -Ketoconazole shampoo [first line] or
  • -Selenium sulfide shampoo [second line]

Shampoo scalp with medicated shampoo product daily for a week, then 2-3 times a week
leave shampoo on hair, scalp and affected areas for 5 minutes; then rinse
may repeat

After 4 weeks (if see improvement)
may reduce frequency of medicated shampoo to once weekly

If worsens after 1 to 2 weeks on OTC meds/shampoo, refer to physician

Topical treatment with
Imidazole derivative creams

Sometimes ultraviolet light therapy

34
Q

To Reduce erythema and itching (seborrhea)

A

Corticosteroid lotion for the scalp (from mild to potent)

Corticosteroid creams for other parts of the body (from mild to potent)

Moisturizing emollients after washing

Ketoconazole shampoo and corticosteroid lotion must often be combined in therapy-resistant cases.

35
Q

Seborrheic treatment - infants

A

“Cradle cap”
Remove scaling on scalp:

  • Massage scalp with baby oil
  • Use non-medicated shampoo
  • Soft bristle brush

-For severe cases: Salicylic Acid 3 – 5 % in olive oil or water soluble base

On face – wash with mild soap or cleanser, apply facial emollient – no steroids

36
Q

A 35 yo man reports itching, redness, and scaling in his scalp, eyebrows and external auditory canal. He has tried several over-the-counter dandruff shampoos, with only temporary relief, and he is increasingly embarrassed by this problem. On exam, greasy scaling on the scalp and erythema with yellowish scales in the nasolabial creases.

Primary problem?
First medication product to suggest?

A

Primary problem? seborrhea

First medication product to suggest? Ketoconazole shampoo

37
Q

: A new mom comes to the pharmacy with an infant that looks to be a couple of weeks old. She asks about the scaly appearance of the infant’s scalp, if it is dangerous and what she should do.

Primary problem?
Treatment?

A

Primary problem? seborrhea, “cradle cap”

Treatment? baby oil with gentle massage

38
Q

Psoriasis- Patient Assessment

A

Measures of symptom and involvement:
% Body surface area (BSA) involved
Psoriasis Area and Severity Index (PASI)
Physician’s Global Assessment (static PGA)

Quality-of-life measures:
Dermatology Life Quality Index (DLQI)
Short Form (SF-36) Health Survey

39
Q

Signs and Symptoms of plaque psoriasis

A 
Lesions (plaques):
Erythmatous
Red-violet in color
At least 0.5 cm in diameter
Well demarcated
Typically covered by silver, flaking scales
40
Q

psoriasis skin involvement

A

Skin Involvement:
Generalized over wide BSA

Mild: less than or = to 5% BSA
Moderate: PASI greater than or = to 8 (psoriasis area and severity index)
Severe: PASI greater than or = to 10 OR DLQI is greater than or = to 10 or BSA is greater than or = to 10. (rule of 10s)
(dermatology quality of life index)

41
Q

psoriasis pruritis

A

Pruritis:
More than 50% of patients have itching
May be severe in some patients and require treatment to minimize excoriations from scratching

42
Q

Other concerns with psoriasis

A

Other concerns:
Lesions may be physically debilitating or socially isolating

Potential comorbidities: PsA (psoriatic arthritis)
depression, HTN,obesity, diabetes,Chrone’s,anxiety, alcoholism

43
Q

Psoriasis: Goals of treatment

A
  • -Minimizing or eliminating the signs of psoriasis such as plaques and scales
  • -Alleviating pruritus and minimizing excoriations
  • -Reducing the frequency of flare-ups
  • -Ensuring appropriate treatment of associated conditions such as PsA (psoriatic arthritis), hypertension, dyslipidemia, diabetes, clinical depression, or itching
  • -Avoiding or minimizing adverse effects from topical or systemic treatments used
  • -Providing cost-effective therapy
  • -Providing guidance or counseling as needed (e.g., stress-reduction techniques)
  • -Maintaining or improving the patient’s quality of life
44
Q

All psoriasis patients – Healthy lifestyle recommendations

A 
Reduce stress
Regular exercise 
Weight management (aim for BMI 18.5-24.9)
Moderation of alcohol consumption 
Cessation of smoking
45
Q

Psoriasis Non-Pharmacologic treatments

A

For small areas or just a few patches

Moisturizers / Emollients
Oatmeal baths
Sunscreen

46
Q

Topical therapy options - Psoriasis

A

Corticosteriods

Vitamin D3 analogue-Calcipotriene

Retinoids-Tazarotene

Anthralin

Coal Tar

Salicylic Acid:

Calcineurin Inhibitors-
Pimecrimolimus:

47
Q

Psoriasis Systemic Agents

A

Oral retinoid-Acitretin

Oral Tcell & cytokine suppressor-Methotrexate and Cyclosporin

Oral Tcell Inhibitor-Alefacept (Amevive)

Oral Monoclonal Tcell Inhibitor-Efalizzumab (Raptiva)

Interleukin Inhibitor-Ustekinumab (Stelera)

Biologic Agents-TNFa inhibitors

48
Q

Corticosteroids for psoriasis

A

Corticosteriods: (topical)
cream or lotion (day)
ointment (night)
2-4 times daily

49
Q

Vitamin D3 analogue for psoriasis

A

Vitamin D3 analogue-Calcipotriene: (topical)
ointment- 1 or 2 times daily or
cream or foam- twice daily

50
Q

Retinoids for psoriasis (topical)

A

Retinoids-
Tazarotene: (topical)
Once daily at bedtime

51
Q

Anthralin for psoriasis

A

Anthralin: (topical)
Apply only to thick plaque lesions for 2 hrs or less (use zinc oxide around)
Then wipe off

52
Q

Coal Tar for Psoriasis

A

Coal Tar: (topical)
Apply in evening
Wash off in morning

53
Q

Salicylic Acid for Psoriasis

A

Salicylic Acid:

Shampoo-for scalp lesions

54
Q

Calcineurin Inhibitors for Psoriasis

A

Calcineurin Inhibitors-
Pimecrimolimus: (topical)
Apply to intertriginous areas (folds)

55
Q

Retinoid for psoriasis (oral)

A 
Oral retinoid
Acitretin:
Not immunosuppressive
Max response 3-6 months
Do not drink alcohol

Reproductive age women: should not be or plan to get pregnant within 3 years of discontinuing drug

56
Q

Tcell and cytokine suppressor for psoriasis

A

Methotrexate (oral)
For psoriasis and psoriatic arthritis

Onset 3-6 weeks

Admin w/ folic acid 1-5mg/day to decrease nausea, bone marrow suppression, hepatic toxicity

Contraindicated:pregnancy, cirrhosis, blood dyscrasias (disorders)

Increases risk of hepatotoxicity (DM, obese, alcoholism, >4g total cumulative dose)

57
Q

Tcell and cytokine suppressor for psoriasis

A

Cyclosporin (DMARD)
oral

Not recommended for use over 4 months-nephrotoxic

Dose on ACTUAL body weight

Many drug interactions:major 3A4 substrate, 3A4 & 2C9 inhibitor

Contraindicated:systemic malignancy, untreated HTN, infections

Increases elderly risk of HTN

58
Q

Tcell inhibitor for psoriasis

A

Alefacept (Amevive)

Dose: 15mg IM every week for 12 weeks (follow w/ 12 weeks non-treatment)

Contraindicated:HIV

Monitor: CD4 base count, get CD4 counts q 2 wks during therapy (hold for count

59
Q

Monoclonal Tcell inhibitor for psoriasis

A

Efalizumab (Raptiva)

Dose: single 0.7 mg/kg SC (conditioning dose) then 1 mg/kg SC weekly (max single dose not to exceed 200 mg)

Monitior: Platelet count monthly, may extend to every 3 mo w/ prolonged course

NO live or attenuated vaccines during therapy

60
Q

Interleukin inhibitor for psoriasis

A

Ustekinumab (Stelera)

Dose 0-4 weeks: SC if under 100 kg; 90mh SC if over 100 kg then every 12 wks

Caution: 
-Avoid in active TB
-Do not give concurrently with:
---live vaccines
---BCG
---pimecrolimus
---tacrolimus
---Echinacea
(may decrease levels)

Monitor: PPD, CDC, signs of infection, antibody formation

61
Q

TNFa Inhibitors for psoriasis

A 
Biologic Agents:
Adalimumab (Humira)
Etanercept (Enbrel)
Infliximab (Remicade)
Golimumab (Simponi)
Certolizumab (Cimzia)

Dose: see insert

TB testing (PPD) on all patients (repeat yearly)
HepB screen is recommended

Monitor CBC & LFT

Do not Use:
live vaccine
CHF patients
Patients w/ or family that has demylenating disease or MS

62
Q

mild-Moderate Psoriasis Treatment algorithm

A

Topical agents + moisturizers as needed (If controlled step down to lowest effective dose or potency)

Inadequate:
Topical+phototherapy+ moisturizer as needed (If controlled step down to lowest effective dose or potency)

Inadequate:
Topical+systemic+ moisturizer as needed (If controlled step down to lowest effective dose or potency)

63
Q

Moderate-Sever Psoriasis Treatment Algorithm

A

Systemic +/- topical or photo+
moisturizer as needed (If controlled step down to lowest effective dose or potency)

Inadequate:
More potent systemic+/- topical + moisturizer as needed (If controlled step down to lowest effective dose or potency)
OR
2 systemics in rotation (rarely done) +/- topical+moisturizer as needed (If controlled step down to lowest effective dose or potency)

Inadequate:
Biologic +/- other agents + moisturizer as needed (If controlled step down to lowest effective dose or potency)

NOTE: may consider biologics earlier or even as first line BUT expensive

64
Q

Mod-Severe psoriasis treatment (pediatric-no psoriatic arthritis)

A

Topical agent

If UVB available:
1st line:
UVB phototherapy (monotherapy) or UVB+Methotrexate

If No UVB:
1st line alpha order
Adalimumab
Cyclosporin
Etanercept
Infliximab
Methotrexate
PUVA
65
Q

Peripheral Psoriatic Arthritis treatment

A

Nsaids or Local 1A steroids

1st DMARD

2nd DMARD

1st line TNFa inhibitor

2nd line TNFa inhibitor

66
Q

Axial Psoriatic Arthritis Treatment

A

Nsaid or local 1A steroid

1st line TNFa inhibitor

2nd line TNFa inhibitor

67
Q

Photochemotherapy

A

Last resort
PUVA: Psoralen + UVA light

MOA: Psoralen cross-links with DNA in presence of UVA light; effects immune response in skin and lymphocytes

Reserved for patients with severe, refractory psoriasis

Need skin biopsy of lesion to confirm diagnosis of psoriasis

Efficacy: 90% with oral psoralens + UVA light

Dosing
0.6-0.8mg/kg po every 2 hours before exposure to UVA light

Side effects:
Serious burns
Blistering
Peeling
Itching
Nausea
Potential increase in certain cancer rates
68
Q

Pharmacoeconomics of Psoriasis Treatments

A 
Costs of psoriasis therapy for moderate to severe disease:
Cost of drug
Cost of administration
Cost of monitoring
Cost of adverse effects
Cost of failed treatment
Cost of days off work
Can be significant ($1000s), even with insurance
69
Q

Psoriasis Patient Education

A

Fully inform patients / caregivers of benefits and risks of treatment options

www. aad.org
www. psoriasis.org

70
Q

A 52 year old female, comes into the pharmacy to pick up her refills for enalapril and hydrochlorothiazide.
She shows you two approximately 2 cm plaques on the ulnar surface of each elbow, they are covered with whitish silvery scales.
DC states that these are new and appeared over the past week.
Current meds: Enalapril / HCTZ
NKDA
DC also tells you that 15 years ago she was treated for psoriasis with tar and steroid creams for a couple of months, with good results
She cannot get an appointment with a dermatologist for 8 weeks
She asks your advice about what she can do in the meantime
She has no joint symptoms

A

risk factors for psoriasis – winter

treatment plan for this patient
Moisturize appropriately, coal tar and steroid cream

71
Q

Conclusion

A

Mild to moderate scaly dermatoses can often be effectively managed with topical non-prescription products

Selection of products based on:

Patient’s history
Prior response to treatment
Evaluation of risks vs. benefits of options
Education of patients:

Appropriate application of topical therapy
Appropriate administration of oral therapy

Follow-up should be a week after self-treatment begins

DEENT Exam 4 (6 decks)

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