Scaly Dermatitis Flashcards
What is Coal Tar?
- Keratolytic, antiseptic,
- reduces local swelling and inflammation
- has minimal anti fungal activity
Side effects of Coal Tar?
acne folliculitis stains to skin and hair photosensitization irritant contact dermatitis
What is Zinc Pyrithione? (ingredient in Head & Shoulders)
- cytostatic and keratolytic agents
- effective likely due to non-specific toxicity for epidermal cells
- has bacteriostatic and fungistatic properties
- few side effects, rare cases of contact dermatitis have been reported when this is used on broken or abraded skin
Describe Selenium Sulfide (ingredient in Selsun Blue)
- Keratolytic, slows down scale production and epidermal proliferation
- has fungicidal/static effect
- must be rinsed from hair thoroughly because discolouration may result
- frequent use tends to leave a residual odor, an oily scalp, and hair loss
- irritation is minimal when used topically but toxic if ingested
Describe Ketoconazole 2% shampoo
- antifungal
- MOA: cytostatic and fungistatic
- OTC 2% shampoo
- causes minimal scalp and skin irritation, greasy or dry hair/scalp, itching or stingingg
Is there a potential for discolouration of hair when using ketoconazole 2%?
no way jose
Describe salicylic acid
- keratolytic agent
- decreases skin pH which will increase hydration of keratin facilitating loosening and removal
*not to be used in patients with greater than 20% BSA (body surface area) involvement as may cause salicylate toxicity
salicylate toxicity symptoms?
- tinnitus (ringing in the ears)
- fatigue
- GI symptoms
What is psoriasis?
- life-long chronic inflammatory disease of the skin
- characterized by recurrent exacerbations and remissions
Compare cell turnover rate of normal cells compared to psoriasis
normal cell turnover rate = 28 days
psoriasis turnover rate = 3-4 days
Psoriasis:
is it contagious?
no
Psoriasis:
rare in ??
children under 5
Psoriasis:
Onset
typical onset between 16-22 (more severe) and 57-60 (less severe)
Psoriasis:
____ psoriasis is the most common form
plaque (80-90%)
Psoriasis:
primarily found on?
scalp, buttocks, arms, legs, elbows, knees, ears, palms, and soles
da dry crusty areas man
Psoriasis:
describe the genetic pre-disposition to this condition
1 parent = 16-25%
both parents = 50%
identical twins = 70%
fraternal twins = 25%
Psoriasis:
List 5 risks/aggravating factors
- genetic pre-disposition
- skin trauma
- environmental
- medications
- infections
Psoriasis:
List environmental risk factors
alcohol ingestion
obesity
stress
pregnancy
Psoriasis:
List medications that are risk factors for this condition
beta blockers
NSAIDs
anti-malarial
lithium
Psoriasis:
List infections that are risk factors for this condition
respiratory infections
HIV
streptococcal infection
Does sunlight help or hurt psoriasis?
helps
Psoriasis:
signs and symptoms of plaque psoriasis
- thickened red plaque with silvery-white scales
- bleed easily
- most have symmetrical lesions
- minimal itching
Psoriasis:
Assessment Questions
How severe are the symptoms? Duration of irritation? Area of involvement? How often do symptoms occur? Medical history? Has anything been tried yet?
Psoriasis:
Red Flags - When to refer?
-under 2 yrs old
-if diagnosis has not been made
PSORIASIS NEEDS A REFERRAL IN ORDER TO GET DIAGNOSIS FOLKS
-no improvement of symptoms after 2 weeks
->3% of BSA (body surface area) involved
-if hands, forearms, and/or face are locations of lesions (for quality of life kids)
Psoriasis:
is it curable
no
Psoriasis:
treatment goals
- control or eliminate the signs and symptoms (inflammation, scaling and itching)
- prevent or minimize the likelihood of flares
*want to decrease length of flares and increase time in between flares
Psoriasis:
Is it self treatable?
only mild cases are man
Psoriasis:
Choice of treatment depends on?
- severity
- location of plaques
- convenience
- patient compliance
- financial considerations
- physical accessibility to treatment
Psoriasis:
non-pharmacologic treatment
-don’t rub, scratch, or pick skin (can cause bleeding and lead to infection, avoid rubbing medication - just dab it in)
-mild cleansers and warm water used for cleansing (avoid fragrances, irritating chemicals)
-moisturize skin (rehydration of skin)
-avoid triggers-reduces risk for infections (smoking, alcohol, stress)
-moisturize air in home
(use a humidifier and avoid electrical heat)
Psoriasis:
first line of therapy for mild to moderate psoriasis?
topical therapy
Psoriasis:
Types of therapy?
- topical therapy - first line treatment for mild to moderate psoriasis
- phototherapy - narrow band UVB or UVA light used
- systemic therapy - various prescription products are used
- biologic therapy - target the immunological causes of psoriasis
- combination therapy
Psoriasis:
Describe the suggested approach for the treatment of psoriasis on pg 921 of CTMA 2
1) Use topical corticosteroids on:
-scalp
trunk
-extremeties
-face - hydrocortisone only
-folds - hydrocortisone only
If ineffective:
-add intralesional corticosteroids
If ineffective:
-use light therapy (UVB and PUVA)
If Ineffective:
-use systemic therapy
PLUS
2) Use steroid-sparing modalities :
- petrolatum
- tar
- vitamin D3 derivatives
- salicylic acid
- anthralin
- tazarotene
Psoriasis:
Rx topical products
- corticosteroids (medium, high potency)
- compounds with coal tar or salicylic acid
- tazarotene
- calcipotriol (alone or combined with a corticosteroid)
Psoriasis:
Rx oral therapies
various immunosuppression medications
Psoriasis:
What are Rx biologics used for?
for chronic moderate to severe plaque psoriasis
Psoriasis: OTC Treatment (4)
- Corticosteroids
- Coal tar products
- Keratolytic agents
- Rehydration with moisturizers
Psoriasis: Describe corticosteroids (OTC treatment)
- Hydrocortisone 0.5% and 1% available OTC therefore only used for mild cases. Could be used on face and skin folds.
- Clobetasone 0.05% cream available as schedule 2 - it is moderate potency
Psoriasis:
Describe coal tar products (OTC treatment)
mild to moderate psoriasis in combination with other treatments
Psoriasis:
Describe keratolytic agents (OTC treatment)
mild to moderate psoriasis in combination with other treatments
Psoriasis:
Describe rehydration with moisturizers (OTC treatment)
- ointments (most effective)
- creams (less greasy)
- lotions (relieves itching)
Psoriasis:
Examples of OTC Products:
Coal Tar
- Denorex Regular
- Denorex Extra Strength
- Targel
Psoriasis:
Examples of OTC Products:
Salicylic acid
- Dermarest Medicated Shampoo
- Sebcur
- Psoriasin S/A Therapeutic Shampoo
Psoriasis:
Examples of OTC Products:
Combination Products of salicylic acid and coal tar
- Polytar AF Shampoo
- Sebcur/T
- Tardan Shampoo
- Targel SA
Psoriasis:
Examples of OTC Products:
Corticosteroids
- Hydrocortisone 0.5% cream (generic)
- Hydrocortisone 1% (pretty sure this is OTC as well even though these notes don’t include it)
Psoriasis:
Monitoring Parameters
- thickness of scales
- scaling
- itching
- redness
- side effects of treatment
Psoriasis:
Monitoring Parameters:
thickness of scales
monitor daily for 50% decrease for 6-8 weeks
Psoriasis:
Monitoring Parameters:
scaling
monitor daily for 50% decrease for 7-10 days
Psoriasis:
Monitoring Parameters:
itching
monitor daily for relief for 1-2 weeks
Psoriasis:
Monitoring Parameters:
redness
monitor daily for 50% decrease for 8-12 weeks
Psoriasis:
Monitoring Parameters:
side effects of treatment
monitor daily for side effects, allergic rxns or treatment failure
Describe Seborrhea Dermatitis
- sub-acute or chronic inflammatory disorder
- characterized by accelerated cell turnover (9-10 days)
- remember normal cell turnover is 28 days
Seborrhea Dermatitis:
primarily found on?
scalp, face, and trunk
*also seen in eyebrows, eyelid margins, cheeks, external ear canal, central back
Seborrhea Dermatitis:
Which gender does it affect more?
men > women
Seborrhea Dermatitis:
There may be a possible abnormality of ?
the oil glands and hair follicies
Seborrhea Dermatitis:
May be associated with a yeast infection - ?
Malassezia
Seborrhea Dermatitis:
Required Reading Q:
According to Gary Goldenberg, when completing the differential diagnosis of seborrhoea, what other conditions should you consider?
psoriasis, rosacea, Demodex dermatitis, atopic eczema, pityriasis versicolor, contact dermatitis, and tinea infections
Seborrhea Dermatitis:
risk/aggravating factors
- HIV/AIDS Pts at higher risk
- genetic pre-disposition
- medical conditions (parkinsons, depression, mood disorders)
- environmental (low humidity and temp, stress)
- medications (lithium, cimetidine, haloperidol, methyldopa)
Seborrhea Dermatitis:
signs and symptoms
- mild, greasy scaling of the scalp area
- starts as small patches and spreads
- dull, yellowish, oily, scaly areas on red skin
- obvs itching
- groin area, axillae show lesions that are bright red, without scaling
- “cradle cap in infants” - thick, dry, yellowish-brown scales on the face, forehead, ears, or entire scalp
Seborrhea Dermatitis:
Red flags/ when to refer
- under 2 yrs of age
- no improvement with OTC treatment after 2 weeks
- if symptoms are severe
- if symptoms spread to other parts of the body (groin)
- signs of infections (pus or drainage from areas, crust formation)
Define: self-limiting
will usually resolve without treatment
Seborrhea Dermatitis:
treatment goals
- reduce inflammation and the epidermal turnover rate of the scalp skin
- minimize or eliminate visible erythema and scaling
Seborrhea Dermatitis:
Non-pharmacological treatment:
- Remove triggers/aggravating factors
- Wash hair with general, non-medicated shampoo every other day or daily
- Control stress
Seborrhea Dermatitis:
Non-pharmacological treatment:
Remove triggers/aggravating factors
- avoid irritating soaps, gels, greasy creams, and hair products
- avoid excessive hot water
- avoid or decrease exposure to cold, dry air
- use a cool air humidifier
- warm compresses to area (eyelids)
Seborrhea Dermatitis:
OTC treatment options - Initial treatment
Initial treatment with an agent that reduces Malassezia is recommended: -zinc pyrithione -selenium sulfide OR -ketoconazole shampoo
Seborrhea Dermatitis:
OTC treatment options - Second line treatment
Second line treatments reduce scaling by decreasing epidermal turnover:
- keratolytic agent (salicylic acid)
- antiproliferative agent (coal tar)
- Hydrocortisone cream (Once or twice daily until symptoms clear for 1-2 weeks. Apply after shampooing to enhance absorption)
Seborrhea Dermatitis:
Required Reading Q:
Which anti fungal shampoo is most effective for the treatment of scalp seborrhoea? (Gary Goldenberg)
Ketoconazole 2%
Seborrhea Dermatitis:
OTC treatment options
medicated shampoos need to be used only 2-4 times weekly for until controlled (approximately 4-5 weeks) then reduce to once a week to prevent relapse
What can pharmacists prescribe for sebborhea dermatitis? (this excludes paediatric)
Salicylic acid Ciclopirox Terbinafine Tolnaftate Combinations
N.B. Combined preparations are classified in this group if mycosis is the main indication. As well, combined preparations containing salicylic acid, which are used as antifungals (e.g. dusting powders), are included.
Seborrhea Dermatitis:
We can prescribe ciclopirox. Describe it.
- broad spectrum agent
- effective against dermatophytes, yeast, and some bacteria
Seborrhea Dermatitis:
Ciclopirox:
Available as?
1-available as a 1% cream or lotion (Loprox):
-has a low incidence of side effects, may cause some itching or burning
2-available as a 1.5% shampoo (Stieprox):
- used 2-3 times per week for treatment of fungal infections associated with seborrheic dermatitis until remission, then once weekly to prevent relapse
- contains coconut diethanolamide (POSSIBLE ALLERGY THAT YOU MUST ASK ABOUT FOLKS)
- may discolour hair
- adverse effects include pruritus (itching) and irritation
Seborrhea Dermatitis: Monitoring Parameters (4)
Scaling
Redness
Thickness of Plaques
Itching
Seborrhea Dermatitis:
Monitoring Parameters:
Scaling
monitor daily for improvement within 7-10 days
Seborrhea Dermatitis:
Monitoring Parameters:
Redness
monitor daily for improvement within 8-12 weeks
Seborrhea Dermatitis:
Monitoring Parameters:
Thickness of plaques
monitor daily for improvement within 6-8 weeks
Seborrhea Dermatitis:
Monitoring Parameters:
Itching
monitor for improvement within 1-2 weeks
Cradle Cap:
Is it self limiting ?
yeah man, you bet your ass it is
Cradle Cap:
Describe it
- Usually starts in infants within 1st month after birth
- Usually resolves by age 3-4 months
Cradle Cap:
Is there a proven relationship between experiencing cradle cap and the development of seborrhoea dermatitis as an adult?
nope
Cradle Cap:
Presentation?
yellowish, greasy scale on scalp
Cradle Cap:
treatment
- wash hair daily with mild baby shampoo
- loosen the scales with a soft brush before rinsing
- gently massage in mineral oil or baby oil to loosen scales, then washed with baby shampoo
*if it’s on the face, use mild soap and moisturizer
Dandruff:
describe it
- chronic, non-inflammatory scalp condition
- excessive scaling of the scalp, characterized by accelerated epidermal cell turnover (13-15 days)
Dandruff:
common in children?
no
Dandruff:
when does it generally appear?
during puberty (10-20 yrs old)
Dandruff:
less prominent after ?
75 yrs of age
Dandruff:
less severe during ?
summatime
-a magical time where all I did was eat Reese’s ice cream and not learn about flaky shit falling off people’s heads
Dandruff:
risks/aggravating factors
- environmental (dry climate, extremes in weather)
- increased stress
- obesity
- inadequate hair washing
- possibly caused by the fungus Malassezia furfur
Dandruff:
signs and symptoms
- dry, white , or silver-grey flakes
- scaling from accumulation of flakes
- detached by combing the hair
- some itching
- usually symmetrical
- may be in patches but most often not
Dandruff:
treatment goals
1) reduce or eliminate flaking and associated symptoms
2) minimize cosmetic embarrassment of visible flakes
3) prevent recurrences
Dandruff:
non-pharm treatment
- remove triggers/aggravating factors
- wash hair with general, non-medicated shampoo every other day or daily
- controll stress
See:
Fig 1: Treatment of Dandruff and Seborrheic Dermatitis of the Scalp
Fig 2: Treatment of Nonscalp Seborrheic Dermatitis
(Pg. 742 of CTMA 2)
i don’t want to but ok
Dandruff: pharmacological treatment (initial)
Initial treatment with an agent that reduces Malassezia is recommended:
- zinc pyrithione
- selenium sulfide
- ketoconazole shampoo
Dandruff:
pharmacological treatment
(second line treatment)
Second line treatments reduce scaling by decreasing epidermal turnover:
- Keratolytic agent (salicylic acid)
- Antiproliferative agent (coal tar)
Dandruff:
What would you educate the patient on?
- contact time is vitally important for the effectiveness of medicated shampoos
- medicated shampoos need to be used only 2-4 times weekly until controlled (approx 2-3 weeks) then reduce to once a week or every other week to maintain control of dandruff
Dandruff:
Examples of OTC products:
Zinc pyrithione
Head & Shoulders
Pantene Anti-Dandruff
Dandruff:
Examples of OTC products:
Selenium Sulfide
Selsun
Selsun Blue
Head & Shoulders Clinical Strength
Dandruff:
Examples of OTC products:
Ketoconazole
Nizoral Shampoo
Dandruff:
Examples of OTC products:
Salicylic acid
Secure
Selsun Blue Deep Cleaning
Dandruff:
Examples of OTC products:
Coal Tar
Neutrogena T-Gel
Denorex
PolyTar
Secure/T
Dandruff:
Examples of OTC products:
Efficacy comparison
Ketoconazole = hydrocortisone > selenium sulfide > zinc pyrithione > coal tar
Dandruff:
Rx Products
Ciclopirox (Stieprox)
- antifungal
- used 2-3 times a week
- used for prophylaxis or treatment
Dandruff:
Monitoring for?
Scaling
Redness
Thickness of plaques
Itching
*monitoring parameters are the exact same as seborrhoea dermatitis so just look at those
