Self care for the skin (3) Flashcards
Roles of layers of the skin
Epidermis
-outer most thin layer
-regulates the water content of skin
Dermis
-thicket layer under the dermis
-contains nerve endings, vasculature, and hair follicules
Hypodermis
-under the dermis
-provides nourishment and cushioning for epidermis and dermis
Functions of skin
To protect the body from external harmful agents, pathogenic organisms, and chemicals
Also important in hydro-regulation (controls moisture movement into and out of the body)
What is xerosis
dry skin
Xerosis pathophysiology/etiology
result of decreased water content (causes abnormal cell loss) … disruption of skin turn over - keratinization and desquamation
various etiologies
can be caused by long hot showers or not enough water intake
common in older adults - older people have inadequate water content, decrease in fatty substances in skin, and hormonal changes - allowing them to be more susceptible to dry skin
can also be caused by detergent use, malnutrition, and damage to stratum carenum
Xerosis (dry skin) presentation
One or more of the following…
Pruritis (most common cause of itchiness)
Scaling
Loss of flexibility
Fissures (opening in the skin)
Inflammation
Dry skin (xerosis) goals of therapy
Restore skin hydration
Restore barrier function
Educate about prevention and treatment
Dry skin (xerosis) treatment
Modify environment (add humidity)
Modify bathing habits (use tepid, not hot water)
Restore barrier function (emollients/moisturizers - apply on moist skin to lock in moisture)
Reduce itching and redness (add topical hydrocortisone if needed)
What is atopic dermatitis
Inflammatory condition of the epidermis and dermis
Episodic flares with periods of remission
Effects 10-20% of children, many of whom will have symptoms into adulthood
80% of AD is classified as mild and can be treated with OTC products
Atopic triad
Atopic dermatitis and atopic rhinitis occur in 80% of people who have atopic asthma
Atopic dermatitis pathophysiology
Large genetic components
-filaggrin protein mutation
Inflamed skin
Decreased moisture retention
What is used to determine severity of atopic dermatitis?
SCORAD index
-used to determine if mild, moderate or severe
(most is mild and can be treated OTC)
Atopic dermatitis presentation in children vs adults
Children
-typically occurs within first year (often 2-3 months of age)
-initially redness/scaling on cheeks, may progress to affect face, neck, forehead, and extremities
-crusts/pustules can form from scratching and rubbing
-remission usually occurs by the end of the second year with xerosis often continuing into adulthood
Adults
-may be less severe, often environmental cause
-pruritis is the hallmark symptom … “the itch that rashes”
Atopic dermatitis complications
Secondary infections
-present as yellowish crusting of eczematous lesions
-bacterial infections are difficult to prevent and can aggravate AD (scratching skin can open it up making it susceptible to infections)
Patients with AD may also develop herpes simplex or Molluscum contagiosum
Any signs of this means they are not eligible for self care
Atopic dermatitis exclusions for self care (5)
- moderate/severe condition with intense pruritis
- involvement of large area of body
- less than 1 year of age
- skin appears to be infected
- involvement of face of intertriginous area (skin folds)
Atopic dermatitis general treatment approach
Counsel patients!
AD can NOT be cured but can be managed
Enhance hydration
-non pharm measures and use of emollients/moisturizers
Relieving itching and inflammation
-hydrocortisone and weeping vesicles with cool compresses
Minimize exposure to triggering factors
Atopic dermatitis bathing tips
Bathing can help hydrate stratum corneum
Bathe for 3-5 minutes every other day in tepid water
Use mild soaps
Pat skin dry and apply moisturizers to seal in water
Atopic dermatitis and dry skin pharmacologic therapy options (5)
- Occlusive agents
-reduce moisture loss by creating a barrier/seal (preventing it from escaping)
e.g. petrolatum - Humectants
-attract water from environment and brings to skin like a magnet
e.g. glycerin, lanolin, urea - Emollients
-add hydration from their formulations to soften and sooth skin
e.g. mineral oil, dimethicone, cetyl palmitate - Keratolytic agents
-soften keratin
e.g. allantoin, lactic and salicylic acid - Antipruritics
-relieve itching
-local anesthetics, local and topical antihistamines
-should be avoided… use moisturizers instead - but oral antihistamines can be used short term if patient is struggling
What is the standard of care topical product for AD/dry skin, how often should they be used?
Emollients
-creams and ointments are preferred over lotions (they lock in moisture better, lotion is thinner and needs to be applied more frequently)
Twice daily use is recommended
E.g. Eucerin (active ingredient is mineral oil)
What is the active ingredient in Aquaphor?
Petrolatum
Bath oil and cleanser considerations for AD and dry skin
Bath oils
-mineral oil
-minimally effective
-should be cautioned with older patients - slippery floors/fall risk
Cleansers
-glycerin soaps (higher oil content less drying)
-Cetaphil or pHisoDerm - if soap is to be avoided
-evidence of benefit over soaps is lacking
Which OTC agent is used for itch relief in AD and dry skin?
Hydrocortisone 0.5% or 1%
Hydrocortisone for AD/dry skin considerations (5)
-safe in children over 2 years
-apply before moisturizers
-creams are okay for mild dry skin, for drier, thicker skin - ointment base may be better, but it is less favorable because of the greasiness
-AVOID ointments (use creams) if lesions are weeping (we want the stuff to come out, and the ointment would lock it in)
-AVOID hydrocortisone if skin is opened/cracked or has signs of infection
AD/dry skin OTC treatment effect/follow up?
Resolution or improvement occurs within 1 week
-initial improvement is seen within 24-48 hours
Follow up in 5-7 days
Advise patients with self-treatable symptoms to contact their primary care provider if symptoms worsen or do not improve within 7 days.
What is scaly dermatoses?
Includes 3 disorders:
Dandruff, seborrheic dermatitis, and psoriasis
They all involve the epidermis and are inflammatory disorders with varying degrees if inflammation (dandruff the least, psoriasis the most)
What are exclusions of self care for scaly dermatoses
For all 3 (dandruff, seborrheic dermatitis and psoriasis) …
-less than 2 years of age
-worsening or no improvement after 2 weeks of proper OTC treatment
Psoriasis only
-involvement of > 5% BSA
Dandruff pathophysiology
Accelerated epidermal cell turnover & irregular keratin break up pattern results in shedding of white scales
-the accelerated epidermal cell turnover is caused by Malassezia sp of yeast (also responsible for seborrheic dermatitis)
Dandruff presentation
Diffuse - not patchy
Minimal inflammation
Pruritis is common
Occurs on the crown of the head
Dandruff treatment approach
Wash hair and scalp with regular non-medicated shampoo every other day
If regular shampoo doesn’t work -> OTC medicated shampoo which suppress yeast species … first - selenium sulfide or pyrithione zinc Then if that doesn’t work –> ketoconazole
If dandruff is resistant after 4-8 weeks -> referral is needed
Dandruff treatment counseling points
Use scalp scrubber
Contact time with scalp is important! - leave on for 3-5 minutes
Repeated rinsing is needed with selenium sulfide to prevent discoloration
Use daily for 1 week then 2-3 times per week
(if no improvement after 4-8 weeks –> referral)
Second line agents for dandruff treatment
Coal tar
-causes discoloration, limited effectiveness
Salicylic acid or sulfur
-longer treatment time required
Where does seborrheic dermatitis most commonly occur?
Areas with greatest sebaceous gland activity - scalp, face, and chest
Seborrheic dermatitis pathophysiology
Accelerated epidermal cell turnover caused by Malassezia yeast (same as dandruff, but there is more inflammation than dandruff)
Seborrheic dermatitis presentation in infants vs adults
In infants - aka cradle cap
-self limiting in infants - usually clears by 8-12 months
In adults
-scales on scalp that extend to middle face
-can last from years to decades
-exacerbations occur in colder months
Adult Seborrheic dermatitis treatment
More aggressive than dandruff because more inflammation
ketoconazole
-leave on for 3-5 minutes
-use 2 times a week for 4 weeks with 3 days between treatment
-once controlled use once a week for prevention
Or cytostatic agents - selenium sulfide, pyrithione zinc
-leave on for 3-5 minutes
-use daily for 1-2 weeks then 2-3 times a week for 4 weeks
Note - coal tar, salicylic acid, and sulfur should NOT be used - have limited effectiveness and take a long time to work
Adult Seborrheic dermatitis treatment that presents with erythema (redness)
Hydrocortisone 1% topical ointment
-use max twice daily
-treat until symptoms subside for up to 7 days
-if not controlled after that refer for more potent steroid
Adult General seborrheic dermatitis counseling points/tips
If medical shampoo odor is a problem can follow up with usual shampoo product
Can use dish soap to soften and remove crusts
Shampoos are not just for hair - can be used in other places
Infant seborrheic dermatitis treatment
It is self limiting in infants
Gentle massaging with baby oil
Removal of scales with non medicated shampoo
Refer if no response
Psoriasis OTC therapy considerations
Psoriasis has the most aggressive inflammation, not usually treated with OTC products, but if they are newly diagnosed hydrocortisone 1% ointment can be used covered with petrolatum (Vaseline) 30 minutes after application to enhance activity by creating occlusive dressing
But, usually requires prescription products
Difference between the 3 scaly dermatoses conditions
They vary in degree of skin turnover rate and inflammation
Dandruff = minimal inflammation and slowest skin turnover rate (13-15 days)
Seborrheic dermatitis = more inflammation than dandruff and faster skin turnover rate (9-10 days)
Psoriasis = most inflammation and fastest skin turnover rate (4 days)
Irritant Contact dermatitis
Occurs due to direct skin exposure to irritants
-when agents get on skin they cause break down of cells and release of cytokines (the severity depends on the quantity and concentration of offending agent)
Following exposure the skin becomes inflamed and red
-symptoms are typically delayed (but can be immediate)
Irritant contact dermatitis treatment
First: IMMEDIATELY wash exposed areas
-reducing contact time with irritant helps to localize exposure
Then…
-emollients
-colloidal oatmeal baths
Note - topical steroids and anesthetic agents should NOT be used in patients with irritant contact dermatitis
Allergic contact dermatitis pathophysiology/etiology
This is when the skin is exposed to an allergen, and then a delayed immune response occurs (type IV delayed hypersensitivity reaction - t cell mediated) … symptoms appear after 24-48 hours
-initial exposure sensitizes the immune system, subsequent exposure results in delayed hypersensitivity
commonly caused by ivy, oak, sumac, nickel, latex, cosmetics, and fragrances
Urushiol induced allergic contact dermatitis presentation
Urushiol is the oil found in the plants that often cause allergic contact dermatitis reactions
Enters the skin quickly - within 10 minutes
Presentation is highly variable
Intense itching followed by erythema
Vesicles or bullae form; may break open
Oozing and weeping (note this is NOT antigenic = cannot cause further transfer)
Development of crusts
Urushiol induced allergic contact dermatitis severity considerations
Can be mild, moderate, or severe
Mild can be treated OTC
Mild is localized, has linear streaks and minimal itching
Moderate has erythema, bullae, papules, inflammation, and pruritus
Severe has extensive area involvement, edema, involves extremities and/or face, swelling of eyelids, and extreme itching
Allergic contact dermatitis self care exclusions (7)
- more than 20% of BSA affected
- present > 2 weeks
- extreme itching or severe bullae
- swollen eyes or eyelids
- involvement of mucus membranes
- signs of infection
- failure of self care after 7 days
Allergic contact dermatitis course of disease
Naturally resolves within 10-24 days on its own, whether or not it is treated
(so we treat to reduce inflammation, itching, oozing, and crusting)
Allergic contact dermatitis treatment approach
Remove antigen
Wash affected area with mild soap and tepid water
Relieve itching and excessive scratching
Relieve accumulation of debris from oozing and crusting
Ivy Block (Bentoquatam)
This is used for poison ivy prevention
-creates a protective barrier, prevents urushiol from penetrating skin
Applied 15 minutes before exposure, reapply after 4 hours
Not for children under 6
Zanfel
Used once you have been exposed to treat urushiol induced allergic contact dermatitis
First wash effected area (soap and water) - urushiol is water insoluble but washing immediately after exposure may reduce severity of rash
Squeeze Zanfel onto palm, wet, and rub palms together until it forms a paste (activating the ingredients) - then rub into affected area (up to 3 minutes until there is no itching), then rinse thoroughly
-can use again if itch returns
Tecnu
Used for urushiol induced allergic contact dermatitis
Should be rubbed into affected areas ASAP (but up to 8 hours later) and cleansed for 2 minutes (water is not required)
Allergic contact dermatitis pharmacologic therapy (aside from urushiol induced)
Topical ointments should NOT be used for itching - oral antihistamines can be used instead
(ointments trap things that are trying to come out of the openings)
-oatmeal baths can help with itching
For weeping - astringents - aluminum acetate (no ointments)
For inflammation - hydrocortisone CREAM (not ointment) 2-4 times a day for up to 7 days
-can be applied to all parts of body except for eyes and eyelids
Calamine lotion can help with drying lesions
